AB|abortion|AB.|231|233||_%#NAME#%_ _%#NAME#%_ is a 29-year-old gravida 3, para 2-0-0-2, who presented to the Emergency Room complaining of increasing vaginal bleeding since approximately 6 a.m. The patient does have a known history of having had a missed AB. She had been followed at another clinic and was told that she had a missed AB shortly after Christmas. The patient at that time had been counseled to undergo a D&C and was even offered misoprostol to help complete a miscarriage, however, patient declined at that time to schedule a D&C or to take the misoprostol.
AB|abortion|AB.|249|251||She is now bleeding quite heavily. Ultrasound this morning demonstrated a missed AB consistent with a 6 week pregnancy with blood clots in the uterine cavity, as well as continued bleeding from the cervical os. This is consistent with an incomplete AB. The patient presents now for a suction D&C. Medical history is negative. Surgical history is negative. CURRENT MEDICATIONS: Include prenatal vitamins.
AB|abortion|AB|223|224|PAST OB HISTORY|ALLERGIES: Heparin and Imitrex. PAST OB HISTORY: 1. 1992 full term primary section for breech presentation. 2. 1995 full term successful VBAC, no complications. 3. _%#1999#%_ full term repeat C-section. 4. 2005 spontaneous AB followed by suction D&C. PAST GYN HISTORY: The patient denies any history of abnormal Pap smears except for her most recent Pap performed _%#MM2006#%_.
AB|abortion|AB.|194|196|HISTORY OF THE PRESENT ILLNESS|She had a pelvic ultrasound at Park Nicollet on _%#MMDD#%_ that showed six weeks, six days gestation sac which is empty with no pole or cardiac activity consistent with blighted ovum and missed AB. The patient waited and did not miscarry on her own and she desires suction curettage of uterus. She is scheduled to undergo suction curettage on _%#MMDD2007#%_ under general anesthesia.
AB|abortion|AB|114|115|PAST OB-GYN HISTORY|On _%#MMDD2007#%_, normal anatomy with anterior placenta. No evidence of previa. PAST OB-GYN HISTORY: 1. Elective AB in the first trimester x 2. 2. NSVD at 36 weeks in 1996. 3. No STIs or abnormal Pap smears. PAST MEDICAL HISTORY: None. MEDICATIONS: None. ALLERGIES: NKDA. SOCIAL HISTORY: No tobacco, alcohol or drugs.
AB|ankle-brachial|AB|329|330|SIGNIFICANT FINDINGS|7. Laryngospasm. CONSULTANTS: 1. Nephrology. 2. GI. 3. ENT. SIGNIFICANT FINDINGS: An 81-year-old woman is admitted to the emergency room where she was found to have hemoglobin of 10.4, sodium 139, potassium 4, BUN 44, creatinine 3.4. She was quite nauseated. She had been recently diagnosed with peripheral vascular disease with AB index and Doppler findings. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was admitted and Nephrology consult was undertaken.
AB|abortion|AB|98|99|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 27-year-old female, gravida 1, now para 0, AB 0, at 25 weeks gestation, well-documented pregnancy, who was seen at Methodist Hospital by urologists because of pain in the right flank and right upper quadrant. She had an ultrasound of her gallbladder and evaluation which was then felt that she had no gallbladder disease, but because of the pain on the right side and going towards the right flank, evaluation showed hydronephrosis on the right side and a ureteral stent was placed at that time.
AB|blood group in ABO system|AB|292|293|PATIENT IDENTIFICATION|PATIENT IDENTIFICATION: _%#NAME#%_ _%#NAME#%_ is a 31-year-old female who is now para 2-0-2-2, who is status post a vacuum curettage on _%#MMDD2006#%_ for a missed abortion at 9 weeks gestational age. That was an uncomplicated procedure performed by Dr. _%#NAME#%_. The patient is blood type AB positive, so did not receive RhoGAM appropriately. Pathology report showed products of conception with no trophoblastic proliferation. At the time of her postoperative visit on _%#MMDD2006#%_, the patient was still spotting and had a positive urine pregnancy test, therefore, a quantitative beta HCG was checked which came back at 667.
AB|abortion|AB|236|237|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: None except car accident with neck, shoulder, back, and arm pain. Previous surgeries: C-section times two in 1995 and 2000. She had an ectopic pregnancy in 1997 treated with methotrexate, and she had a spontaneous AB in 1999. ALLERGIES: No known allergies. MEDICATIONS: None. PHYSICAL EXAMINATION: On exam, the HEENT is normal.
AB|abortion|AB|65|66||_%#NAME#%_ _%#NAME#%_ is a 25-year-old female gravida 3, para 0, AB now 3. She had a previous ectopic pregnancy on the left side, had laparoscopy, and was told that her tube and pelvis were in excellent condition at that time.
AB|abortion|AB|172|173|HISTORY|He ordered a quantitative HCG and a pelvic ultrasound. The quantitative HCG from _%#DDMM#%_ was greater than 5,000. The pelvic ultrasound from _%#MMDD#%_ revealed a missed AB at 6 weeks, 2/7th days, without cardiac activity. She wished confirmation and at Fairview Southdale Hospital she had a confirmatory ultrasound with the identical diagnosis.
AB|blood group in ABO system|AB|155|156|PLAN|_%#NAME#%_ _%#NAME#%_ was the 1375 gm product of a 31 week pregnancy complicated by cervical incompetence. He was born to a 24-year-old gravida 2, para 1, AB positive mother. His EDC was _%#MMDD2006#%_. The family lives in _%#CITY#%_, Nebraska and they were in the _%#CITY#%_ area visiting relatives when mother had onset of labor.
AB|abortion|AB.|227|229|PAST OB HISTORY|She is at 40 plus 2. The patient presents complaining of contractions, which have increased in frequency. No loss of fluid. Normal fetal movement. PAST OB HISTORY: Significant for an SVD without complications and 1 spontaneous AB. PAST GYN HISTORY: Negative. PRENATAL CARE: With Dr. _%#NAME#%_. She is AB positive, GBS negative, hemoglobin 12.6, RPR negative, hepatitis B surface antigen negative.
AB|abortion|AB|102|103|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 28-year-old Russian female, gravida 1, para 0, AB 0, who has excellent dates and is followed for the pregnancy from the beginning with early ultrasounds by 11 weeks gestation. She has a 5 cm fibroid, and at that time, a marginal previa.
AB|abortion|AB|137|138|HOSPITAL COURSE|She had a miscarriage in _%#MM#%_ of 2000 at seven weeks gestation. Had elective AB at six weeks gestation in _%#MM2001#%_, and elective AB at seven weeks gestation in _%#MM#%_ of 2001. Otherwise has a history of some allergies. Status post MVA in 2001. Also a history of an abnormal pap smear. For the rest of the details of medications, allergies, social history, review of systems, physical exam, etc.
AB|abortion|AB|196|197|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 31-year-old Caucasian female who was followed for her pregnancy with early ultrasounds, and has a history of habitual abortion. She is now a gravida 2, para 0, AB 3, because of her recent fetal demise. The patient was followed until 9 weeks gestation, and had ultrasounds weekly which were showing good growth.
AB|abortion|AB|205|206|PREOPERATIVE STATUS AND JUDGMENT|She is morbidly obese at 300 pounds, and at that time in _%#MM#%_ of 2001, she defined a dysfunction, irregular bleeding pattern and has a history of a vacuum curettage in _%#MM2001#%_ for an early missed AB at approximately 7 weeks gestation. That was accomplished without difficulty. The patient's blood type is AB positive. She has continued to do well on previous Provera cycling which she has been undergoing.
AB|blood group in ABO system|AB|265|266|PAST SURGICAL HISTORY|ALLERGIES: PENICILLIN. MEDICATIONS: None. PAST SURGICAL HISTORY: Only notable for the outpatient vacuum curettage which was accomplished in _%#MM#%_ of 2001 for a missed AB at approximately 7 weeks gestation. This was accomplished without difficulty. Blood type is AB positive. Confirmation of products of conception was demonstrated. REVIEW OF SYSTEMS: In fact, she has been in otherwise good health except for the weight issues.
AB|abortion|AB|141|142|PREGNANCY HISTORY|Preterm labor beginning at 27 weeks, treated with magnesium sulfate and bedrest. 2) _%#MMDD1999#%_; 6 to 7 weeks gestation, with spontaneous AB without complications. LABORATORY DATA: O-positive, antibody screen negative. Rubella immune. RPR is negative.
AB|blood group in ABO system|AB|129|130|DATE OF DISCHARGE|_%#NAME#%_ received phototherapy for a peak bilirubin level of 11.5 mg%. Her blood type was AB positive; maternal blood type was AB positive. Antibody screening tests were negative. The last bilirubin level prior to discharge was 8.3 mg% on _%#MMDD2005#%_. The most likely etiology for the hyperbilirubinemia was physiologic. This problem has resolved.
AB|abortion|AB|154|155|HISTORY OF PRESENT ILLNESS|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, MD (Soteria Family Health Center) HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a gravida 7 para 5 AB 2 who desires hysterectomy for relief of her very irregular periods, tremendous pain with her periods that has been ongoing for years, and hopes of relieving constant mild low back pain that has been significantly aggravated with her periods.
AB|abortion|AB|111|112|SUMMARY OF HOSPITAL COURSE|SUMMARY OF HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 27-year-old African-American female, gravida 4, para 1, AB 2, plus one ectopic. Ectopic pregnancy was in 2004 and she had a right salpingectomy at that time. I had been seeing her for chronic pelvic pain and the patient was noted to have pelvic adhesions.
AB|abortion|AB|66|67||_%#NAME#%_ _%#NAME#%_ is a 40-year-old female, gravida 4, para 2, AB 2, who had a previous cesarean section, originally for breech presentation. History of lymphocyte incompatibility and was treated with prednisone and baby aspirin for her entire pregnancy, because of her recurrent pregnancy loss.
AB|abortion|AB|65|66||_%#NAME#%_ _%#NAME#%_ is a 40-year-old female, gravida 5 para 2, AB 3, who had her two pregnancies conceived by in vitro fertilization. She has a history of tubes that were damaged previously.
AB|blood group in ABO system|AB|164|165|PRENATAL LABS|Hemoglobin 11.7. Hepatitis B negative. Pap smear was LSIL and was requested to undertake a colposcopy 3 months postpartum. Antibody screen was negative. Blood type AB positive. HIV negative, rubella immune, and RPR negative. PAST OB HISTORY: She had in _%#MM2004#%_, a C-section of 7 pounds 5 ounce male secondary to preeclampsia, gestational diabetes, and a failed induction.
AB|blood group in ABO system|AB|215|216|ASSESSMENT|At the time of discharge, the infant's corrected gestational age was 38 weeks and 2 days. He was the 2985 gm, 38 1/7 week gestational age male infant born at University of Minnesota Medical Center to a 22-year-old, AB positive, gravida 1, para 0-0-0-0, single Caucasian female whose LMP was _%#MMDD2005#%_ and whose EDC was _%#MMDD2006#%_. The mother's pregnancy was complicated by hypertension and obesity. The mother also has a seizure disorder, and a history of pulmonary emboli, HSV, depression.
AB|abortion|AB,|166|168|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 37-year-old white female gravida 3, para 1-0-1-1, status post suction curettage in _%#MM2004#%_ for incomplete AB, status post low segment transverse cesarean section _%#MMDD2005#%_ for arrest of labor, whose last menstrual period was sometime in _%#MM2006#%_, who presents for evaluation of vaginal bleeding. The vaginal bleeding started in earnest on Thursday _%#MMDD2006#%_. She is blood group O Rh positive.
AB|abortion|AB.|347|349|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Left lower quadrant abdominal pelvic pain. HISTORY OF PRESENT ILLNESS: The patient is a 30-year-old white female gravida 3, para 0,0,2,0, blood group A, RH positive, who is status post right salpingectomy for ruptured ectopic gestation, an ectopic that had been treated with methotrexate prior. She has had a previous spontaneous AB. Her last menstrual period was _%#MMDD2006#%_. The patient was evaluated on _%#MMDD2006#%_ for suboptimal rise in quantitative beta HCGs. She had vaginal bleeding that began on _%#MMDD2006#%_. The patient initially had some left lower quadrant discomfort at that time, but had subsided.
AB|abortion|AB|79|80|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 38-year-old female, gravida 1, now para 0, AB 1, who was seen by me for early pregnancy, and when an ultrasound was performed was noted to have a blighted ovum. The uterus was approximately nine weeks size but her ultrasound showed a gestational sac of approximately 7-1/2 weeks.
AB|blood group in ABO system|AB|110|111|LABORATORY DATA|PELVIC: Cervix is fingertip dilated, 60% effaced and -2 station. LABORATORY DATA: Hemoglobin 12.5, blood type AB positive, antibody screen is negative, rubella immune, RPR nonreactive, hepatitis B surface antigen nonreactive, Pap smear, gonorrhea, Chlamydia and urine culture all negative.
AB|abortion|AB|58|59||_%#NAME#%_ _%#NAME#%_ is a 43-year-old gravida 4, para 3, AB 1, who initially presented in _%#MM#%_ 2001 with complaints of menometrorrhagia. She had a hysteroscopy performed in _%#MM#%_ 2001, revealing a slightly enlarged, anteverted uterus with no evidence of submucosal fibroids or endometrial polyps.
AB|abortion|AB|209|210|PREGNANCY COMPLICATIONS|Urine culture 10,000-50,000 GBS, one hour GCT 112, triple screen abnormal with an increased risk of Down's 1:100. Last hemoglobin 11.1 at 32 weeks gestation. PREGNANCY COMPLICATIONS: 1. History of spontaneous AB times three. 2. Advanced maternal age 37 year old at delivery. 3. During the pregnancy had a triple screen with an increased Down's syndrome risk of 1:100.
AB|abortion|AB|136|137|GYNECOLOGIC HISTORY|b. 1995 - status post D&C for vaginal bleeding. PAST SURGICAL HISTORY: Negative except for D&C. GYNECOLOGIC HISTORY: Gravida 7, para 7, AB 0, vaginal deliveries. HISTORY OF THE PRESENT ILLNESS: This is a 62-year-old woman who was diagnosed with cervical cancer in 1991.
AB|abortion|AB|136|137|REVIEW OF SYSTEMS|GI: History of peptic ulcer disease, 25 years ago. Has been under reasonable control with good medications. GU: Gravida 6, para 2, with AB times four. Two living children. No bladder or kidney problems. No bleeding tendencies until the present bout. No history of thrombophlebitis or pulmonary infarction. PHYSICAL EXAMINATION: GENERAL: The patient is alert and comfortable at the present time.
AB|abortion|AB|276|277|SURGEON|The patient states that she has had dizziness, nausea, some heartburn, and some change in her vision since her dose of Tambocor or flecainide was increased from 50 to 150 mg b.i.d. The patient has had past surgeries including right knee arthroscopy. She is gravida 6, para 4, AB 2. She has no history of adverse reaction to anesthesia. Her family history reveals that there are heart attacks in the family.
AB|abortion|AB|162|163|ASSESSMENT|ABDOMEN: Soft and nontender. Bowel sounds present. PELVIC: Cervix is closed. Uterus is retroverted and feels 10 week size. ASSESSMENT: Status post D&C for missed AB with retained products of conception. PLAN: D&C _%#MMDD2002#%_.
AB|abortion|AB|64|65||_%#NAME#%_ _%#NAME#%_ is a 32-year-old female, gravida 1 para 1 AB 0 who was followed for her entire pregnancy with excellent dates and early ultrasound because of Clomid-induction pregnancy. The patient was noted to have a frank breech presentation at about 35 weeks gestation.
AB|abortion|AB|85|86|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 28-year-old, gravida 2 para 0 AB 1, with estimated date of confinement (EDC) of _%#MMDD2006#%_ at 37-2/7 weeks' gestation with a twin pregnancy who presents for a primary cesarean section. The patient has very good dates due to being on Clomid and undergoing an insemination to achieve this pregnancy.
AB|blood group in ABO system|AB|168|169|LABORATORY  DATA|ABDOMEN: Gravid with estimated fetal weight of 6-6/12 pounds. LOWER EXTREMITIES: No edema. LABORATORY DATA: Laboratory tests include a CBC which is normal. Blood Type: AB positive. Rubella: Immune. VDRL: Nonreactive. Hepatitis C surface antigen: Negative. HIV: Negative. One-Hour Glucose: 117. Group B strep has not been done as yet.
AB|type A, type B|AB|224|225|LABORATORY DATA|Official reading pending. White blood cell count is elevated at 24.8 with 96% neutrophils and hemoglobin of 12.4. Electrocardiogram shows atrial fibrillation with a rapid ventricular response. No sign of ischemia. Influenza AB swab is pending at this time. ASSESSMENT: 1. Pneumonia, right lower lobe, possible sepsis. Aspiration is possible.
AB|abortion|AB|203|204|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. As noted, the congenital birth defect involving her right hand and then subsequently no right breast development and had implantation of a right breast in 1974. 2. G6-P2032 with AB x3 and then 2 kids by cesarean section secondary to severe toxemia, and then subsequent tubal ligation. 3. Urethral dilation as a child. She has not had any bladder problems since.
AB|abortion|AB|63|64||_%#NAME#%_ _%#NAME#%_ is a 53-year-old female gravida 3 para 2 AB 1 who had two babies by Cesarean section. She also has a history of endometriosis and now has been having menorrhagia 3+/4 for the last number of months.
AB|blood group in ABO system|AB|117|118|LABORATORY|Soft, nontender, and nondistended. Extremities: No hip clicks. LABORATORY: On admission, bilirubin 96. Blood type is AB positive, Coombs negative. ASSESSMENT AND PLAN: A 4-day-old term infant female admitted for jaundice, under bili lights.
AB|abortion|AB|175|176|COMPLICATIONS|PAST MEDICAL HISTORY: Obstetrical history is remarkable for NSVD x1 at term in _%#MM#%_ 2004 and that was uncomplicated. In addition, the patient has a history of spontaneous AB x1 in the first trimester. The patient's gynecologic history is remarkable for one abnormal Pap smear with subsequently a negative colposcopy.
AB|blood group in ABO system|AB|170|171|PRENATAL LABS|Total weight gain during her pregnancy was 17.6 pounds. First trimester blood pressure was 136/86. The patient had a total of five plus visits. PRENATAL LABS: Blood type AB positive, antibody negative, hemoglobin 12.4, 11.2, Rubella nonimmune, RPR negative, hepatitis B surface antigen negative, Pap within normal limits, GCT 122.
AB|blood group in ABO system|AB|229|230|PLAN|At the time of discharge, the infant's corrected gestational age was 31 weeks and 3 days. He was the 1345 gm, 30 + 0 week gestational age male infant born at the University of Minnesota Medical Center, Fairview to a 29-year-old, AB positive, gravida 1, para 0-0-0-0, married Caucasian female whose EDC was _%#MM#%_ _%#DD#%_, 2006. The mother's pregnancy was complicated by pancreatitis, gestational diabetes mellitus, and severe pre-eclampsia.
AB|abortion|AB|148|149|PAST MEDICAL HISTORY|She also notes that her cholesterol has been high in the past. PAST MEDICAL HISTORY: Remarkable for hypertension, status post NSVD x 6, spontaneous AB x 1. She is status post tubal ligation, status post right ankle surgery x 2 due to fracture and torn ligaments (first surgery included plate and screws, second screws to remove this).
AB|blood group in ABO system|AB|179|180|HISTORY OF PRESENT ILLNESS|DOB: _%#MMDD2002#%_ FINAL DISCHARGE DIAGNOSIS: Physiologic hyperbilirubinemia. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a term newborn male, born at 39-weeks, to a G3, P1-0-2-1, AB Positive, serology negative, 27-year- old mother. He was delivered by cesarean section secondary to failure to progress. Apgars were 9 at one minute and 9 at five minutes.
AB|blood group in ABO system|AB|152|153|HOSPITAL COURSE|Hospital course has been consistent with physiologic hyperbilirubinemia. HOSPITAL COURSE: 1. Physiologic hyperbilirubinemia. _%#NAME#%_ was found to be AB Positive, Coomb's negative. Bilirubin peaked on _%#MMDD2002#%_ at 19.4, at which point phototherapy was started. Bilirubin at discharge was 13.5. Newborn metabolic screen was negative.
AB|blood group in ABO system|AB|192|193||In general, the patient is in good health. She is on no medications other than her prenatal vitamin and was on progesterone. She has no known drug allergies. She is a nonsmoker. Blood type is AB positive. PHYSICAL EXAMINATION: This is a healthy appearing female.
AB|type A, type B|AB|102|103|LABORATORY DATA|HEART: Regular rhythm without murmurs. ABDOMEN: Normal EXTREMITIES: Normal LABORATORY DATA: Influenza AB nasopharyngeal smear negative. Basic metabolic profile showed a glucose of 124, otherwise normal. White count 10,900, hemoglobin 12.7. Myoglobin and troponin were negative.
AB|abortion|AB|226|227|PAST MEDICAL HISTORY|Total weight gain 40 pounds. The patient has had mild ankle edema without elevation in blood pressure, proteinuria, or other problems with this pregnancy. PAST MEDICAL HISTORY: Caesarian section in 1999, D&C after spontaneous AB in 1998, she is gravida 3, para 1-0-1-1. ALLERGIES: No known drug allergies. MEDICATIONS: Prenatal vitamins. HABITS: No smoking, no alcohol, no drug use.
AB|blood group in ABO system|AB|133|134|HISTORY OF PRESENT ILLNESS|We did discuss with her the tubal ligation and she does not want that. Diabetes screen was negative. Her prenatal profile show blood AB rh negative. She is rubella immune status and VDRL hepatitis, HIV is negative. She is rh negative and she received RhoGAM at 28 weeks.
AB|abortion|AB|200|201|HISTORY OF PRESENT ILLNESS|The ultrasound demonstrated an intrauterine gestational sac. A fetal pole was visualized. However, fetal cardiac pulsation or cardiac activity was not visualized. The impression was a probable missed AB at 7 weeks 3 days. These findings were discussed with the patient and her options were discussed. She was offered observation/expectant management vs Cytotec vs suction dilation and curettage.
AB|abortion|AB|146|147|PAST OBSTETRICAL HISTORY|3. She had a cesarean delivery for twins in _%#MM1996#%_. 4. She had a repeat cesarean delivery in _%#MM2000#%_. 5. She is previously status post AB x 3. PAST MEDICAL HISTORY: None. ISSUES THIS PREGNANCY: 1. Difficult social situation. 2. Subchorionic hemorrhage.
AB|blood group in ABO system|AB|132|133|PLAN|South Lake Pediatrics at Children's West, pediatrician. 2. Mother is a 34-year-old gravida 6 [sic] para 2-0-1-2, A positive with an AB positive infant. 3. This was a precipitous delivery with 19 minutes of second stage. 4. The baby delivered at Fairview Southdale Hospital with Apgars of 8 and 9, birth weight 8 pounds 6 ounces and being formula fed on _%#MMDD2003#%_.
AB|abortion|AB|145|146|PAST OB HISTORY|3. Tobacco abuse. 4. ASCUS pap smear. 5. Trichomonas diagnosed during pregnancy. PAST OB HISTORY: In _%#MM2000#%_, the patient had a spontaneous AB at 5 weeks, not requiring a D and C. PAST GYN HISTORY: The patient had an abnormal Pap smear this pregnancy, being ASCUS, but denies a history of Pap smears in the past.
AB|blood group in ABO system|AB|119|120|1. FEN|We anticipate the bili should continue to decrease as long as _%#NAME#%_ continues to eat well. 4. Heme: _%#NAME#%_ is AB + Discharge medications, treatments and special equipment: TriViSol with iron 1 ml po q day Discharge measurements: Weight 2790 gms; length 48 cm; OFC 33.5 cm.
AB|abortion|AB.|241|243|OB-GYN HISTORY|4. In _%#DD2002#%_, the patient had a primary cesarean section for failure to progress secondary to macrosomia for a 9-pound 9-ounce male. This was a surrogate pregnancy and delivery of a male child. 5. In 1998 the patient had a spontaneous AB. _%#NAME#%_, _%#NAME#%_ Hospital #: _%#MRN#%_ LABORATORY HISTORY: Blood type A-positive.
AB|blood group in ABO system|AB|211|212|PAST MEDICAL HISTORY|She was admitted to Special Care at 7 hours of age because of apnea desaturations and some temperature instability. PAST MEDICAL HISTORY: Mother is a 31-year-old, gravida 6, para 3-0-2-3. Maternal blood type is AB positive. Antibody screen is negative. Rubella immune. VDRL negative, but Hepatitis B surface antigen positive, HIV negative, and GBS negative on 6-2-06.
AB|abortion|AB.|149|151||_%#NAME#%_ _%#NAME#%_ is a 35-year-old gravida 2, para 1-0-0-1 female who is being admitted on an emergency basis from our office with an incomplete AB. The patient's blood type is O positive. She has had a previous full-term pregnancy. This pregnancy she was seen early on _%#MMDD2006#%_. She had no problems initially during this pregnancy, had an ultrasound done on _%#MMDD2006#%_ consistent with an EDC of _%#MMDD2007#%_.
AB|abortion|AB|59|60||_%#NAME#%_ _%#NAME#%_ is a 35-year-old, gravida 6, para 2, AB 4, who entered the hospital at 39 weeks gestation with a phospholipid syndrome of lymphocyte incompatibility treated with heparin and then switched back and forth from Lovenox. Also had prednisone. She also had a placenta previa that was partial.
AB|abortion|AB|174|175|SUMMARY OF ADMISSION|The patient had good ultrasounds and last ultrasound approximately at 8 weeks of gestation. At 11 weeks, she came in for some vaginal spotting and was found to have a missed AB with crown-rump length measuring 7-5/7 weeks. The patient underwent an office dilatation and curettage with resultant blood clot formed in the uterus measuring 6 x 5 cm in size.
AB|abortion|AB|92|93|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 40-year-old female, gravida 6 para 4 AB 1, who was followed for her entire pregnancy and has had four previous cesarean sections. She had done very well with this pregnancy, started on metformin prior to the pregnancy and stopped it at about 16 weeks' gestation.
AB|abortion|AB|155|156|PAST MEDICAL HISTORY|This was done in 1995 and was uncomplicated. The patient's history is also remarkable for an ectopic in 1993 at approximately 12 weeks as well as elective AB x2 in 2004 and 2005. 2. Gynecologic History: Remarkable for abnormal Pap smears. There is no note of treatment of these by cone, LEEP or cyrotherapy.
AB|abortion|AB|130|131|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Surgeries: 1. Laparoscopic tubal ligation in 1995. 2. Reversal of tubal ligation in 2004. 3. D&C for missed AB in 2004. 4. Laparoscopy, 2005, to rule out ectopic pregnancy with normal pelvis. Medical illnesses: 1. Gestational hypertension with her most recent pregnancy.
AB|blood group in ABO system|AB|160|161|PRENATAL LABORATORIES|First trimester blood pressures were in the 90s/50s. PRENATAL LABORATORIES: Hemoglobin of 10.8. Urine toxin negative. GC and Chlamydia negative. Pap is normal. AB positive with antibody negative. Hepatitis B surface antigen negative. Rubella immune and RPR negative. PAST OB HISTORY: In _%#MM2004#%_, SAB at 8 weeks. In _%#MM2005#%_, an SVD at 34 weeks with gastroschisis.
AB|blood group in ABO system|AB|177|178|HOSPITAL COURSE|She received ampicillin and gentamicin for 48 hours. Her blood culture was negative at 48 hours, so the IV antibiotics were discontinued. 5. Hematology/GI. Mom's blood type was AB positive. _%#NAME#%_ does have an older sibling that had some difficulties with jaundice. Her TCB at approximately 44 hours of age was 11.0. Her TCB at 50 hours of age was 12.2 and her TCB at 70 hours of age, prior to discharge, was 13.3. This 13.3 put her in the percentile of 75th for age.
AB|blood group in ABO system|AB|115|116|PLAN|His weight at the time of discharge was 3630 gm (50 %). Problem #2: Hyperbilirubinemia. _%#NAME#%_'s blood type is AB negative; maternal blood type is A negative. Antibody screening tests were negative. Silas had a bilirubin of 13.2 mg% on _%#MMDD2007#%_ and 15.0 on _%#MMDD2007#%_.
AB|abortion|AB.|146|148||_%#NAME#%_ _%#NAME#%_ is a 46-year-old gravida 1, para 0, with missed AB, approximately 6 weeks gestational age. She is to undergo D&E for missed AB. Risks of the procedure were explained to her. PAST MEDICAL HISTORY: Negative ALLERGIES: Sulfa and codeine. PAST SURGICAL HISTORY: Previous bowel resection SOCIAL HISTORY: Negative FAMILY HISTORY: Noncontributory PHYSICAL EXAMINATION: Height 5' 4 1/4", weight 137, blood pressure 130/74.
AB|abortion|AB,|106|108|IMPRESSION|Abdomen is soft and nontender. Uterus was just mildly enlarged with no adnexal masses. IMPRESSION: Missed AB, for D&E. The patient's blood type is O positive.
AB|abortion|AB.|255|257|PAST OB HISTORY|Total weight gain 14 pounds. She is 0-positive, antibody screen negative, HIV nonreactive, RPR negative, hepatitis B surface antigen negative, rubella immune. PAST OB HISTORY: 1. Term NSVD, 9 pounds, epidural, induced, no preterm labor. 2. Early elective AB. PAST GYN HISTORY: No abnormal Paps, cryotherapy, or LEEPs; no infertility or STDs.
AB|abortion|AB.|199|201|HISTORY OF PRESENT ILLNESS|The yolk sac is echogenic, suggesting partial calcification, and compared to the _%#MM#%_ _%#DD#%_ study there was no growth. Measurements are consistent with 7 weeks 1 day. The impression is missed AB. The patient's blood type is Rh positive. She had the options of doing spontaneous miscarriage on her own or do the dilation and curettage; the patient opted for dilation and curettage.
AB|abortion|AB|64|65||_%#NAME#%_ _%#NAME#%_ is a 32-year-old female, gravida 1 para 1 AB 0 who has triplets and had a Cesarean section for her only pregnancy. She is currently using condoms and has regular menses, but has a history of endometriosis, her last laparoscopy done in 2001.
AB|blood group in ABO system|AB|131|132|DOB|Patient was counseled regarding this decision and decision was made to proceed with surgery as recommended. Prenatal screen showed AB positive blood type, immunity to rubella, nonreactive serology, normal Pap smear. Hepatitis B surface antigen testing was negative. Alpha-fetoprotein testing was declined.
AB|abortion|AB|170|171|HISTORY OF PRESENT ILLNESS|She has had 2 ultrasounds at 15 and 18 weeks. PAST MEDICAL HISTORY: She has a history of scabies with this pregnancy which has been treated. PAST OB HISTORY: Spontaneous AB in 2003 and NSVD in 2000, a 7-pound 12-ounce infant delivered precipitously. GYN HISTORY: She has an uncertain LMP. She has a history of trichomonas which has been treated, never gonorrhea or Chlamydia and ASCUS.
AB|blood group in ABO system|AB|148|149|PRENATAL CARE|She had a total of 6 weeks. She was transferred at 31 weeks gestational age. Her total weight gain from 31 weeks on was 2 pounds. She is blood type AB positive, GCT of 112 and hemoglobin 12.3. OB HISTORY: None. PAST GYN HISTORY: She denies any sexually transmitted infections or abnormal Pap smears.
AB|abortion|AB|207|208|COMPLICATIONS|PROCEDURE: Repeat cesarean section. ESTIMATED BLOOD LOSS: 750 cc. FINDINGS: 7 pound 15 ounce female infant with Apgars 9 and 9. COMPLICATIONS: None. _%#NAME#%_ _%#NAME#%_ is a 29-year-old gravida 3, para 1, AB 1 white female admitted at 37 weeks in active labor following an uncomplicated antepartum course. She had been previously scheduled for a cesarean section several weeks from the date of admission.
AB|abortion|AB|129|130|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 43-year-old Caucasian female, gravida 4, para 1, AB 3 (two tubal pregnancies included in the AB 3). The patient did have one in vitro pregnancy which resulted in twins by cesarean section. She was complaining of menorrhagia and severe dysmenorrhea, and after much counseling, and going through bouts of depression and increasing PMS, the patient decided that she wanted definitive surgery.
AB|type A, type B|AB|136|137|HOSPITAL COURSE|A herpes simplex virus swab was sent on his lower lip lesion, although the results were erroneously canceled on the computer. Influenza AB was sent and was negative. He had several blood cultures during his hospitalization, as well as a urine culture, which all remained negative, with no growth.
AB|abortion|AB|92|93|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 33-year-old black female, gravida 1, para 0, AB 1, who was seen by me because of endometriosis and fibroids. The patient had laparoscopy by me performed in _%#MM#%_ 2001 because of her history of endometriosis, and a laparoscopy by someone else in 2000 which showed abnormal pelvic conditions.
AB|blood group in ABO system|AB|230|231|HISTORY OF PRESENT ILLNESS|Arterial pH was 7.26. EBL was 800 ml. The patient's postoperative course was fairly unremarkable. She remained afebrile throughout her entire postoperative course. Her postoperative hemoglobin was 10.8. She was Rubella immune and AB positive. The patient was discharged to home on postoperative day 3. She was ambulating, had good pain control, passing flatus, and wanted to go home.
AB|abortion|AB|117|118|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 35-year- old, Caucasian female, gravida 1, para 0, AB 1, who is known by me for many years with tubal damage. Had her original laparoscopy by me in 1998, was noted to have bilateral tubal damage.
AB|abortion|AB.|137|139|PAST OB HISTORY|PAST MEDICAL HISTORY: 1. Syphilis, diagnosed 10 years ago. 2. Hypertension, which is untreated. PAST OB HISTORY: NSVD x4 and spontaneous AB. PAST SURGICAL HISTORY: 1. Surgeries on her left shoulder in 2004.
AB|abortion|AB|75|76|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 55-year-old female, gravida 2, para 1, AB 1, who was seen by me for many years and has been in menopause for approximately three years. The patient was noted to have a left ovarian cyst approximately one year ago.
AB|abortion|AB|109|110|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 27-year-old African-American female, gravida 4 para 1 AB 2 and also ectopic 1. She had a right ectopic pregnancy in 2004 with a right salpingectomy. The patient has seen me for chronic pelvic pain more on the right than on the left and her surgery that took place in 2004 was performed because of an ectopic pregnancy.
AB|abortion|AB.|109|111|REASON FOR ADMISSION|REASON FOR ADMISSION: This is a 31-year-old female, gravida 2, para 1 with an ultrasound finding of a missed AB. She has been bleeding for a few days and she and her husband are choosing to perform a suction D&C. The risks and complications were discussed in detail. PAST OBSTETRICAL HISTORY: NSVD x1.
AB|abortion|AB.|173|175|PLAN|ASSESSMENT: Missed AB at approximately 6 weeks 2 days by ultrasound. PLAN: 1. A thorough discussion was done with the patient regarding her options for treating this missed AB. Her options include conservative management with observation and allowing her body to proceed with the miscarriage on its own, versus medical management with Cytotec, versus proceeding with a suction D&C.
AB|blood group in ABO system|AB|189|190|HOSPITAL COURSE|Bilirubin continued to rise to a max of 13.1 on the evening of _%#MMDD2007#%_, was down to 12.8 on the a.m. of _%#MMDD2007#%_, day of discharge. She remained on phototherapy. Blood type is AB positive, Coombs negative. She continued to eat well throughout the hospital course, had weight of 9 pounds 1 ounce at the time of discharge.
AB|blood group in ABO system|AB|187|188|HISTORY OF PRESENT ILLNESS|The patient's postpartum course was without complications. Her vital signs were stable, and her physical examination was within normal limits during her hospital stay. She was blood type AB positive, rubella immune, and was breast-feeding her infant during her hospitalization. Her postpartum hemoglobin was 12.4. The patient was discharged to home on postpartum day #2, which was _%#MM#%_ _%#DD#%_, 2002.
AB|type A, type B|AB|264|265|PROBLEM #2|PROBLEM #2: Cough. The patient presented with aggressive cough. She had a chest CT done, which showed minimal central ______ passage to upper lobes bilaterally, a nonspecific finding. The patient had cultures done. At the time of discharge, they were negative for AB by stain. However, cultures will be called several weeks after culture. PROBLEM #3. Hypertension. The patient will continue her medications she was on, which includes Norvasc and hydrochlorothiazide.
AB|blood group in ABO system|AB|343|344|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 5-1/2- day-old newborn girl who was admitted to Fairview Southdale Hospital via Metropolitan Pediatric Specialists, PA for elevation of bilirubin drawn this morning. She was born here at Fairview Southdale Hospital at 36-3/7 weeks' gestation to a 38-year-old, gravida 2 para 2 AB negative mom following an uncomplicated pregnancy. She was delivered with Apgar scores of 7 at 1 minute and 9 at 5 minutes, birth weight 8-pounds- 3-ounces.
AB|blood group in ABO system|AB|131|132|HISTORY OF PRESENT ILLNESS|She was delivered with Apgar scores of 7 at 1 minute and 9 at 5 minutes, birth weight 8-pounds- 3-ounces. The baby's blood type is AB negative with a negative direct antigen. She had elevation of bilirubin to 17.4 on _%#MMDD2004#%_. Triple light phototherapy was initiated and over the course of the next three days her bilirubin decreased to 13.5 yesterday, _%#MMDD2004#%_.
AB|blood group in ABO system|AB|154|155|HISTORY OF PRESENT ILLNESS|ADMISSION MEDICATIONS: Prenatal vitamins. ALLERGIES: NO KNOWN DRUG ALLERGIES. PRENATAL CARE: Previously complicated by advanced maternal age. LABORATORY: AB positive, rubella immune, GBS negative, RPR negative, HIV negative, hepatitis B negative. HOSPITAL COURSE: The patient was admitted and found to have a cervical exam of 1 cm/50%/negative 2 and fetal heart tones that showed good long-term variability and good acceleration.
AB|abortion|AB|193|194|REVIEW OF SYSTEMS|Breasts: No lumps, normal mammogram _%#MM#%_ of 2004. Respiratory: No cough or shortness of breath. Cardiovascular: No chest pain, palpitations. GI: No GI upset or constipation. GU: Gravida 4, AB 1. A set of twins. Neuropsyche: Mood is good. Musculoskeletal: Hip and knee pain has been persistent. Endocrine: Hypothyroid.
AB|abortion|AB|63|64||_%#NAME#%_ _%#NAME#%_ is a 56-year-old female gravida 4 para 3 AB 1 seen for many years and had menopausal treatment with Fem-HRT. The uterus was approximately 10 cm, consistent with a fibroid uterus.
AB|abortion|AB|65|66||_%#NAME#%_ _%#NAME#%_ is a 30-year-old teacher, gravida 2 para 1 AB 0 who had her first pregnancy in 2004, ending at 39 weeks gestation with an emergency Cesarean section by another physician because of failure to progress secondary to cephalopelvic disproportion. She had a transverse Cesarean section at that time. She has now been followed for her entire pregnancy with excellent dates starting with ultrasounds in the first trimester and with excellent growth.
AB|abortion|AB|250|251|OB HISTORY|She received RhoGAM on _%#MM#%_ _%#DD#%_, 2006. Rubella immune, RPR negative, hepatitis C surface antigen negative, HIV negative, GC/chlamydia negative, EC negative. PAP showed CIN 2, GBS negative. OB HISTORY: In _%#MM#%_ 2005, she had a spontaneous AB which required a suction D and C. PAST GYN HISTORY: No history of abnormal Pap smears. She did have HPV in this pregnancy with a Pap with CIN 2.
AB|blood group in ABO system|AB|162|163|PRENATAL LABORATORY|CURRENT MEDICATIONS: Prenatal vitamins. ALLERGIES: Sulfa. FAMILY HISTORY: Hypertension in her father and her grandparents. PRENATAL LABORATORY: She is blood type AB positive. Rubella immune. Antibody screen negative. OBJECTIVE: VITAL SIGNS: The patient's vital signs are stable.
AB|abortion|AB|66|67||_%#NAME#%_ _%#NAME#%_ is a 39-year-old female, gravida 4, para 1, AB 3, who had one cesarean section in 2004 and has had a history of recurrent endometriosis, chronic pelvic pain, dyspareunia and dysmenorrhea. She was brought for definitive surgery and had a total abdominal hysterectomy, bilateral salpingo-oophorectomy and enterocele repair and fulguration of endometriosis.
AB|blood group in ABO system|AB|291|292|PROBLEMS ENCOUNTERED IN THE HOSPITAL|6. Head ultrasound. He had a head ultrasound done secondary to a possible intracranial cyst; however, the study was normal and had the presence of a normal corpus callosum. He had one follow up head ultrasound done which was normal as well. 7. Hyperbilirubinemia. _%#NAME#%_'s blood type is AB positive, maternal blood type was A positive, antibody screens negative. He received phototherapy for one day with a peak bilirubin of 8.7.
AB|abortion|AB,|147|149|PAST OB HISTORY|PAST OB HISTORY: 1. In 1988, the patient had an elective AB, less than 12 weeks. 2. In 1990, elective AB, less than 12 weeks. 3. In 1998, elective AB, less than 12 weeks. PAST GYN HISTORY: 1. History of HSV. 2. Uterine fibroids.
AB|blood group in ABO system|AB|128|129|PRENATAL LABS|Pregnancy via in vitro fertilization. Second trimester blood pressures were in the 120s-130s/70s-80s. PRENATAL LABS: Blood type AB positive, antibody screen negative, rubella immune, HIV negative, hepatitis B surface antigen, RPR negative, UA/UC negative, GCT 95, GBS negative.
AB|blood group in ABO system|AB|158|159|HISTORY OF PRESENT ILLNESS|Prenatal care at University Specialists. First visit was at 4+ weeks for a total of 13 visits. Total weight gain was 15 pounds. Prenatal laboratories: She is AB positive, antibody negative. Hemoglobin was noted to be at 13 and 12.9. Serology non-reactive. Rubella immune. Triple screen within normal limits. She had an Ascus Pap smear with a colposcopy consistent with CIN-II.
AB|abortion|AB|65|66|DISCHARGE MEDICATIONS|_%#NAME#%_ _%#NAME#%_ is a 33-year-old female gravida 1, para 1, AB 0, who has had a known history of endometriosis, the last scope being in the year 2000. At that time the patient had a right ovarian cyst and recurrent endometriosis.
AB|abortion|AB.|133|135|PAST MEDICAL HISTORY|Past history: Menarche age 12. Interval normally 28 to 30 days with 5 to 7 days of moderate flow. Pregnancies: In 1975 a spontaneous AB. In 1976 a boy 8 pounds 6 ounces complicated by toxemia. In 1977 a stillborn girl at about 6 months. In 1978 a spontaneous AB.
AB|abortion|AB|222|223|PAST MEDICAL HISTORY|Ultrasounds confirm the presence of large fibroids, as did physical examination. PAST MEDICAL HISTORY: Usual childhood diseases. Denies serious illnesses. Surgery history - Breast biopsy, D&C many years ago for incomplete AB spontaneous, and carpal tunnel surgery. ALLERGIES: None known. BLOOD TRANSFUSIONS: None. REVIEW OF SYSTEMS: Denies headache, shortness of breath, or chest pain.
AB|abortion|AB|167|168|GYN HISTORY|On _%#MM#%_ _%#DD#%_ she underwent a pelvic ultrasound that demonstrated the absence of any fetal cardiac activity with a collapsed yolk sac, consistent with a missed AB at approximately seven weeks. The patient denied any vaginal bleeding or cramping. The patient was examined on _%#MM#%_ _%#DD#%_. PHYSICAL EXAMINATION: LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm.
AB|abortion|AB|185|186|PAST OBSTETRICAL HISTORY|In 1998 she had a full term normal spontaneous vaginal delivery, and this child developed mild cerebral palsy and was felt due to injury as a child. She has also had an 8-week elective AB and an early SAB in the past. GYNECOLOGICAL HISTORY: Normal Pap smears. No STDs. Yeast infections in the past.
AB|abortion|AB|117|118|PAST HISTORY|Weight has been stable. She has had no new other complaints. PAST HISTORY: Reveals that she is Gravida VIII, Para 7, AB 1 with 7 healthy children. She is a nondrinker who is married, lives with her husband. She is retired from working at Northwest Airlines in office work.
AB|blood group in ABO system|AB|240|241|HISTORY OF PRESENT ILLNESS|She was subsequently discharged when there was no progress. She returned on the day of admission complaining of vaginal discharge. She was also having irregular contractions q. 6 to 7 minutes. Prenatal record reveals that her blood type is AB positive, antibody negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, hemoglobin 12.8, GC and chlamydia cultures negative, urine culture was also negative.
AB|abortion|AB|171|172|PAST SURGERIES|5. She also notes past history of sexual abuse and probable PTSD. PAST SURGERIES: 1. Left breast lumpectomy, which was being. 2. C section x 3. 3. Status post spontaneous AB x 1, and EAB x 1. MEDICATIONS: Effexor XR 150 mg daily, trazodone 150 mg q.h.s. p.r.n., Protonix when she remembers, and aspirin very infrequently, like if she has a headache or something.
AB|type A, type B|AB|225|226|HOSPITAL COURSE|Blood cultures remained negative throughout her hospital stay. Rapid strep culture on admission, as above, was done and was negative. Cultures were followed, and remained negative. An influenza panel was also sent. Influenza AB negative. Respiratory viral cultures were also sent and were pending at the time of discharge. No positive results were reported. Again, at the time of discharge, _%#NAME#%_ was afebrile, and without complaints of sore throat or cough/rhinorrhea.
AB|blood group in ABO system|AB|115|116|DOB|DOB: _%#MMDD2005#%_ _%#NAME#%_ _%#NAME#%_ was born on _%#MMDD2005#%_ at 2003 hours to a 37-year-old female, who is AB positive, rubella immune, VDRL negative, hepatitis B negative, HIV negative, group B Strep positive in the urine. Mother was gravida II, para I-0-0-I. Membranes ruptured at 0230 on _%#MMDD2005#%_, approximately 17.5 hours prior to delivery.
AB|blood group in ABO system|AB|165|166|DOB|Hemoglobin initially was 12.7, white count 9800, platelet count 163,000. Lab work was otherwise unremarkable. INR was 1.16, alcohol, level was 0.13. The patient was AB positive blood typing. EKG was unremarkable and it was felt that he had a major UGI bleed. He was admitted to the ICU and started on Protonix IV and GI consultation was requested.
AB|blood group in ABO system|AB|149|150|PRENATAL LABS|ALLERGIES: No known drug allergies. SOCIAL HISTORY: No smoking, alcohol or other drug use. She is married and lives with her husband. PRENATAL LABS: AB negative, antibody negative, rubella immune, hemoglobin 11.2, hepatitis B surface antigen non-reactive, RPR non-reactive, Pap smear NILM, urine culture negative, GCT 122, GBS negative, phosphatidylglycerol present, LS ratio 5.5, disaturated lecithin 1750.
AB|abortion|AB|155|156|PAST SURGICAL HISTORY|She acknowledges a history of STDs, specifically chlamydia, gonorrhea and genital warts. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: D&C for missed AB in 2001. MEDICATIONS: Oral contraceptive pills. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is currently single, however in a single monogamous relationship.
AB|blood group in ABO system|AB|155|156|PRENATAL LABS|Prenatal care was with Fairview _%#CITY#%_ Women's Clinic. Her weight gain was 31 pounds. Pregnancy appears to be uncomplicated. PRENATAL LABS: Blood type AB positive, antibody negative, hepatitis B surface antigen negative, HIV negative, RPR negative, GBS negative, hemoglobin 13.4, rubella immune. PAST OB HISTORY: The patient is a primigravida. PAST GYN HISTORY: The patient's Pap smear was in _%#MM2007#%_ and no history of abnormal Paps or STD.
AB|abortion|AB|83|84|HISTORY|HISTORY: 32-year-old female, gravida 3, para 2 who has been found to have a missed AB on an ultrasound. She is being brought in for suction D&C. PAST OBSTETRICAL HISTORY: NSVD x2. PAST SURGICAL HISTORY: None. PAST MEDICAL HISTORY: Negative. ALLERGIES: Penicillin.
AB|blood group in ABO system|AB|249|250|DISCHARGE MEDICATIONS|At the time of discharge, the infant's postmenstrual age was 34 weeks and 1 day. She is a 1530 gram, 31 2/7 week gestational age female infant born at University of Minnesota Children's Hospital to a 38 year old, gravida 4, para 2-0-1-2, blood type AB positive, African American female whose LMP was unknown and whose EDC was _%#MMDD2007#%_. The mother's pregnancy was complicated by primary hypertension, type 2 diabetes, and absent end diastolic flow to the baby.
AB|abortion|AB|204|205|HISTORY OF PRESENT ILLNESS|She states that her mother had a ruptured ectopic in the past, and she is quite apprehensive about this situation. At this point, it is unclear whether the patient has an ectopic pregnancy or a completed AB or a missed AB. We discussed surgical treatment or methotrexate treatment if it is an ectopic pregnancy. The patient was shocked by this pregnancy and does not want any future children.
AB|blood group in ABO system|AB|195|196|LABORATORY DATA|Apparently adequately qualitative amniotic fluid volume noted. LABORATORY DATA: Ultrasound obtained _%#MMDD2004#%_ was compatible with 23 weeks gestation, or EDC of _%#MMDD2004#%_. Blood type is AB positive, antibody screen negative, Pap smear negative, rubella immunity present, serology nonreactive, urine and hepatitis screening negative. She declined HIV screening. Normal MSAFP screening, done _%#MMDD2003#%_. Normal screening for gestational diabetes at a level of 92 on _%#MMDD2004#%_.
AB|blood group in ABO system|AB|126|127|HISTORY OF PRESENT ILLNESS|Previous C-section is in Mexico. Prenatal care at Green Central beginning at 8 weeks for a total of 16 visits. Prenatal labs: AB positive. Antibody screen negative, hemoglobin of 13.2, rubella immune, RPR nonreactive. Hepatitis B surface antigen negative. Urine culture positive for GBS, treated.
AB|blood group in ABO system|AB|137|138|HOSPITAL COURSE|Blood glucose was 84. AST was 26, ALT of 16, uric acid of 4.7, LDH of 838, INR of 1.13, PTT of 28, and fibrinogen of 342. The patient is AB positive. With the help of a Somali interpreter, Dr. _%#NAME#%_ discussed with the patient on the risks and benefits of the C-section and consent was obtained.
AB|abortion|AB.|206|208|HISTORY OF PRESENT ILLNESS|The patient went for another ultrasound on _%#MMDD2005#%_ and that showed nonviable pregnancy, fetal pole is same size, has not grown from _%#MM2005#%_ and no heartbeat was detected, consistent with missed AB. We presented this diagnosis to the patient and we gave her the options of doing suction D&C or abort on her own.
AB|abortion|AB|65|66||_%#NAME#%_ _%#NAME#%_ is a 41-year-old female, gravida 3 para 3, AB 0, who has had severe dysplasia by endocervical curettage but no lesion outside of the cervix. When I did her colposcopy she had this performed because she had a Pap smear that showed low-grade squamous epithelial lesion.
AB|abortion|AB|97|98|HOSPITAL COURSE|HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 30-year-old Caucasian female, gravida 1, now para 1, AB zero, who entered the hospital at 39 weeks gestation in active labor, and was started on Pitocin augmentation. She progressed quickly. Within five hours, she was complete, complete, +2 station, with a large amount of moulding of the baby's head.
AB|abortion|AB|64|65||_%#NAME#%_ _%#NAME#%_ is a 35-year-old female, gravida 2 para 1 AB 0 who had her first baby in 1989 at 41 weeks with a Cesarean section for failure to progress secondary to cephalopelvic disproportion. The patient also had a LEEP procedure in her life and has had laparoscopies which showed endometriosis, the last one being in 2003.
AB|abortion|AB.|209|211|PAST OBSTETRICAL HISTORY|Prenatal labs, blood type O positive, antibody screen negative, rubella immune, RPR, hepatitis B and HIV, all negative. PAST OBSTETRICAL HISTORY: Two previous low transverse cesarean sections, one spontaneous AB. PAST MEDICAL HISTORY: Significant for asthma. CURRENT MEDICATIONS: 1. Prenatal vitamins.
AB|abortion|AB|200|201|HISTORY OF PRESENT ILLNESS|PREOPERATIVE DIAGNOSIS: Retained products of conception. PROCEDURE: Suction curettage. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 19-year-old, gravida 1, para 0, who underwent an elective AB on Monday, _%#MMDD2007#%_. She had this done at Midwest Center for Reproduction. She was bleeding like a normal period, but on Thursday, _%#MMDD#%_, began having worsening cramping.
AB|abortion|AB|170|171|PAST MEDICAL HISTORY|Of note, her CT of her chest was unchanged, and because of that, she is brought to the Emergency Room and admitted today. PAST MEDICAL HISTORY: She is gravida 9, para 5, AB 4 and has had D&Cs for spontaneous ABs, otherwise no surgeries. Other procedures last admission included bronchoscopy in _%#MM2005#%_ along with sputum cytology, which made the diagnosis and attempted colonoscopy followed by a barium enema because of iron deficiency anemia, which turned out to be nutritional.
AB|blood group in ABO system|AB|212|213|PLAN|Blood cultures obtained on admission were negative. Urine CMV DNA quantitation was sent on _%#MMDD2007#%_ because of IUGR. These results were negative. Problem # 4: Hyperbilirubinemia. _%#NAME#%_'s blood type is AB positive, DAT negative. Maternal blood type is B positive. _%#NAME#%_ received phototherapy for a total of two days for a peak bilirubin level of 9.5 mg/dL.
AB|blood group in ABO system|AB|228|229|HISTORY|She had regular prenatal care from 11-27 weeks gestation. At 18 weeks she did receive 2 doses of terbutaline for cramping but did not require continued therapy. Laboratory data obtained in her previous prenatal care: Blood type AB negative, antibody screen negative, RPR nonreactive, HIV negative, hepatitis B negative. One hour glucose was reportedly normal. Rubella immune. Pap was normal.
AB|abortion|AB|185|186|ASSESSMENT/PLAN|LABORATORY & DIAGNOSTIC DATA: Blood type A-positive. ASSESSMENT/PLAN: Pregnancy at 12+ weeks menstrual age, 9 1/7 weeks by ultrasound age, without cardiac activity, diagnosis of missed AB was made. She will have a suction ________. Blood type Rh- positive and she will not need RhoGAM.
AB|abortion|AB|66|67|PLAN|_%#NAME#%_ _%#NAME#%_ is a 38-year-old female, gravida 1, para 1, AB 0, who was seen by me because of menometrorrhagia. When first seen she had failed birth control pills and had been on different types.
AB|blood group in ABO system|AB|180|181|PHYSICAL EXAMINATION|Supplemental oxygen was discontinued on _%#MMDD2005#%_. Problem #3: Hyperbilirubinemia. _%#NAME#%_ received phototherapy for a peak bilirubin level of 12.1 mg%. His blood type was AB positive; maternal blood type was B positive. Antibody screening tests were negative. The last bilirubin level prior to discharge was 8.1 mg% on _%#MMDD2005#%_.
AB|blood group in ABO system|AB|159|160|DOB|Bilirubin slowly came down and over three days came down to 8.8. Off lights, it slowly increased again to 10.0 and stabilized there. The baby's blood type was AB positive. The Coombs was negative. Blood smear was done, which came back essentially normal. A few spherocytes were seen, which is normal and were not increased in number, and there were some subtle signs of possible very mild hemolysis, but again, very small amounts and within normal range.
AB|blood group in ABO system|AB|124|125|FOLLOW UP|Problem #6: Hyperbilirubinemia. _%#NAME#%_ received phototherapy for a peak bilirubin level of 14.9 mg%. His blood type was AB positive; maternal blood type was A positive. Antibody screening tests were negative. The last bilirubin level prior to discharge was 8.0 mg% on _%#MMDD2006#%_.
AB|abortion|AB.|198|200|ASSESSMENT/PLAN|ABDOMEN: Soft and nontender. PELVIC: Deferred but performed by nurse practitioner at first visit. ASSESSMENT/PLAN: The patient is a 27-year-old G1, P0 at approximately 6 weeks gestation with missed AB. The patient has been counseled on her options of expectant management versus misoprostol versus D&C. All risks, benefits and alternatives have been reviewed. The patient wishes to proceed with suction D&C under general anesthesia.
AB|abortion|AB|76|77||_%#NAME#%_ _%#NAME#%_ is a 37-year-old black female who is gravida 3 para 1 AB 0. The patient has been followed for her entire pregnancy, achieved without medications. She has a history of having a myomectomy in 2002 by myself and two laparoscopies.
AB|abortion|AB|70|71||_%#NAME#%_ _%#NAME#%_ is a 25-year-old female, gravida 1, now para 1, AB 0, at 38 weeks gestation with ruptured bag of water in active labor who was admitted to the hospital, had Pitocin infusion and an intrauterine catheter for controlled contractions. Uterine contractions were difficult to stay on any particular pattern.
AB|abortion|AB|139|140|PAST OB HISTORY|PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: D and C for elective AB. PAST OB HISTORY: She had three fullterm NSVDs, one spontaneous AB and one elective AB. MEDICATIONS: 1. Prenatal vitamins. 2. Iron. ALLERGIES: None known. SOCIAL HISTORY: Significant for smoking half a pack per day of cigarettes, but denied alcohol or other drug use.
AB|abortion|AB|176|177|ADMISSION DIAGNOSES|PAST SURGICAL HISTORY: Significant for remote history of tonsillectomy and appendectomy. PAST OB HISTORY: Significant for elective termination of pregnancy x 1 and spontaneous AB x 2 with D&C. The patient did receive RhoGAM during the current pregnancy. ADMISSION MEDICATIONS: 1. Budesonide nebulizers b.i.d. 2. Singular 10 mg p.o. q.day.
AB|blood group in ABO system|AB|192|193|REASON FOR HOSPITALIZATION|2. Perinatal jaundice. 3. Poor feeder. 4. Sepsis workup. REASON FOR HOSPITALIZATION: This patient is a 33-week infant born to a 36-year-old married mother, gravida 2, para 1-0-0-1. Blood type AB positive, rubella immune, VDRL negative, hepatitis negative. Group B status unknown. Issues during the pregnancy included some polyhydramnios, gestational diabetes.
AB|blood group in ABO system|AB|229|230|HISTORY|Her obstetric care has been unremarkable. She has had a weight gain from her initial weight of 170 to a current weight of 207. She has met all of her scheduled OB visits. Her laboratory data has been unremarkable with blood type AB positive, antibody screen negative, initial platelet count of 221,000, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, vaginal culture negative, Pap smear normal in _%#MM#%_ 2004.
AB|abortion|AB|202|203|PAST OB HISTORY|Total weight gain of 40 pounds. Blood type O-positive, rubella immune, HIV, GBS, RPR, and hepatitis B surface antigen negative. Chlamydia/gonorrhea negative per patient. PAST OB HISTORY: 1. Spontaneous AB in 2002. 1. Previous C-section at 38 plus 3 weeks on _%#MM#%_ _%#DD#%_, 2004. Female. C- section performed secondary to nonreassuring fatal heart tones.
AB|abortion|AB.|273|275|HISTORY OF PRESENT ILLNESS|She had ultrasound on _%#MMDD2005#%_ that showed intrauterine pregnancy, 6.1 weeks pregnant, with no fetal pole or cardiac activity, consistent with missed abortion. We gave the diagnosis to the patient and they had interpreter with them, and we explained about the missed AB. She had the options of doing spontaneous miscarriage or doing suction curettage, the patient opted for suction curettage of uterus, and she was scheduled at the endoscopy room at Fairview Southdale Hospital to do suction curettage of uterus under IV sedation and paracervical block.
AB|blood group in ABO system|AB|319|320|PLAN|She was born on _%#MMDD2005#%_ at 22:45 hours, transferred to the NICU on _%#MMDD2005#%_ and discharged on _%#MMDD2005#%_. At the time of discharge, the infant's corrected gestational age was 41 weeks and 2 days She was the 3930 gm, term female infant born at Fairview _%#CITY#%_ Hospital, _%#CITY#%_ to a 34-year-old, AB positive, gravida 5, para 2-0- 2-2, married Somalian female whose EDC was _%#MMDD2005#%_. The mother's pregnancy was complicated by an episode of herpes zoster.
AB|abortion|AB.|239|241|HISTORY OF PRESENT ILLNESS|She continued to have bleeding and cramping and went to the Emergency Department at Fairview Southdale Hospital on _%#MMDD2005#%_. She was seen by the Emergency Department physician _%#NAME#%_ _%#NAME#%_ and was told she had an incomplete AB. She was given pain medication, 2 mg of Dilaudid, and was discharged home with Percocet tablets. The patient came in to _%#CITY#%_ Clinic on _%#MMDD#%_ to see me, and during the examination there was a moderate amount of bleeding coming through the uterus, suggestive of incomplete AB.
AB|blood group in ABO system|AB|157|158||Baby Boy _%#NAME#%_ was born _%#MMDD2005#%_ at 1721 hours, Twin #1 born by cesarean section to a 29-year-old married Caucasian mother, gravida 1, blood type AB positive, rubella immune, hepatitis B status negative, group B strep status unknown. Estimated date of confinement was _%#MMDD2005#%_. Pregnancy was complicated by twin gestation as well as by gestational diabetes, which was diet controlled.
AB|abortion|AB|75|76|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 38-year-old female, gravida 5, para 3, AB 2, who is brought into the hospital for cesarean section. She had intrauterine pregnancy at 38 weeks gestation, had a double cerclage with a history of incompetent cervix and preterm labor.
AB|abortion|AB|75|76|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 28-year-old female, gravida 2, para 1, AB 0, who has been followed for this current pregnancy with ultrasounds every week to watch for growth and now is at about 14 weeks gestation. The patient was counseled about a history of incompetent cervix and in a first pregnancy she had preterm labor with treatment by another physician and delivered at 32 weeks gestation.
AB|abortion|AB|51|52|HISTORY|HISTORY: Patient is a 30-year-old gravida 2 para 1 AB 1 who is being admitted to Fairview Ridges Hospital on Saturday _%#MMDD2007#%_ for a suction dilatation & curettage of the uterus. The reason for the procedure is that there are probable retained products of conception.
AB|abortion|AB.|131|133|PAST SURGICAL HISTORY|MEDICATIONS: Lexapro 10 mg daily, multivitamin. PAST SURGICAL HISTORY: 1. Laser treatment to the cervix in 1994. 2. D&C for missed AB. SOCIAL HISTORY: The patient is married. She is a nonsmoker.
AB|abortion|AB|111|112|PAST MEDICAL HISTORY|6. She had a Z-plasty of her right knee in 1969. 7. Tennis elbow surgery in 1975. 8. She is gravida 3, para 2, AB 1. 9. Cholecystectomy in 1979. 10. Tubal ligation in 1983. 11. Breast cancer with mastectomy in 1988. 12. Multiple fractures to her wrist in 1989.
AB|abortion|AB|224|225|PAST MEDICAL HISTORY|No dysuria, urgency, or frequency. She has not noted if her urine is any different color because she is menstruating. PAST MEDICAL HISTORY: She takes no known medicines. She has no known allergies. She is gravida 3, para 2, AB 1. No previous surgeries. SOCIAL HISTORY: The patient is married. Does not use any tobacco.
AB|abortion|AB|130|131|PAST MEDICAL HISTORY|2) Left total hip. 3) Bunionectomy. 4) Hysterectomy for benign reasons. 5) Thyroidectomy for benign reasons. 6) Gravida 5 para 4, AB 1. SOCIAL HISTORY: The patient does not drink to any extent.
AB|abortion|AB|394|395|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 21-year-old Gravida 2, Para 1-0-2-1 at approximately 7 weeks gestation by dates who was admitted through the emergency room with complaints of 3 weeks of spotting and approximately 2 hours of heavier bleeding soaking one pad an hour. The patient states she was seen at an outside ER in _%#CITY#%_, Minnesota, 2 weeks ago and diagnosed with a missed AB but failed follow up with a local physician. Upon arrival to the emergency room, the patient was stable, bleeding was moderate, blood type was checked and found to be Rh positive, hemoglobin 13.7. Ultrasound showed a very small fluid collection in the lower uterine segment consistent with a sac of less than 5 weeks with no fetal pole or yoke sac consistent with incomplete AB.
AB|abortion|AB|119|120|ASSESSMENT|ABDOMEN: Soft, nontender. PAST MEDICAL HISTORY: None. SOCIAL HISTORY: Positive for tobacco use. ASSESSMENT: Incomplete AB at less than 5 weeks. I did discuss with the patient options. I did not feel that she emergently needed surgery given that she is hemodynamically stable.
AB|blood group in ABO system|AB|145|146|ASSESSMENT|She had a negative Beta strep test and the patient desires a repeat cesarean section. This is scheduled for _%#MM#%_ _%#DD#%_. Her blood type is AB positive. Her last baby was a male weighing 9 pounds 7 ounces. She has no known allergies. PHYSICAL EXAMINATION: On physical exam her blood pressure is 120/72.
AB|blood group in ABO system|AB|280|281|HISTORY OF PRESENT ILLNESS|The patient's first pregnancy was complicated by preeclampsia late in the pregnancy, and the patient underwent a caesarian section at 36 weeks for breech presentation. The patient declined genetic testing for advanced maternal age. She did get Rhogam during this pregnancy for an AB negative blood type. HOSPITAL COURSE: The patient was admitted to the hospital on _%#MM#%_ _%#DD#%_, 2002 for elevated blood pressures and 3+ proteinuria.
AB|abortion|AB|117|118|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Heavy periods HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 48-year-old gravida 5, para 4, AB 1, white female being admitted for a D&C. The patient is on hormone replacement therapy and for the past couple of months has had heavy periods.
AB|abortion|AB.|227|229||She had follicle studies performed earlier this cycle. The patient denies nausea, vomiting or fever. She had no pain up until the middle of the night last night and has been no sign of any bleeding consistent with a threatened AB. PHYSICAL EXAMINATION: VITAL SIGNS: Her blood pressure is 110/70, pulse 72, respiratory rate 16.
AB|abortion|AB.|156|158|OB HISTORY|2. In 1996, 39-week NSVD 7 pound 14 ounce female. 3. In 1996, 4-week SAB. 4. In 1997, 40-week C-section 8 pound 12 ounce male. 5. In 2001, 10-week elective AB. GYN HISTORY: History of abnormal Pap in 1997 with no procedures.
AB|abortion|AB|56|57||_%#NAME#%_ _%#NAME#%_ is a 35-year-old gravida 3 para 1 AB 1, EDC _%#MMDD2006#%_ at 31-5/7 weeks gestation who presents in preterm labor. She was 3 cm dilated, 70% effaced and 0 station. She noted increased uterine contractions on the morning of _%#MMDD2006#%_ and in my office she was noted to be 3 cm dilated, 70% effaced and 0 station with contractions occurring every 6 minutes.
AB|blood group in ABO system|AB,|145|147|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 28-year-old white female who is a gravida 1/para 0-0-0-0 with an EDC of _%#MMDD2006#%_, blood group AB, Rh negative and Rubella status immune. She was seen in Labor and Delivery on _%#MMDD2006#%_ for evaluation of preterm uterine irritability and contractions.
AB|abortion|AB|63|64||_%#NAME#%_ _%#NAME#%_ is a 32-year-old female gravida 1 para 0 AB 0 who was seen by me for her entire pregnancy. She saw me at seven weeks. She had multiple ultrasounds with perfect dates for the pregnancy.
AB|abortion|AB|56|57||_%#NAME#%_ _%#NAME#%_ is a 69-year-old gravida 5 para 2 AB 3 who presented to my office on _%#MMDD2006#%_ regarding an ovarian cyst that was found on CT scan. The patient has been followed by a urologist for hematuria and a CT scan was performed, revealing a 3.5 cm septated left adnexal cyst and also a 3.5 cm uterine fibroid.
AB|blood group in ABO system|AB|155|156|PRENATAL LABS|Prenatal care began at 8 weeks x7 appointments with CRPC, then transferred to (_______________)CNM at 36 weeks x4 visits for a total of 11. PRENATAL LABS: AB negative. Antibody negative, rubella immune. RPR nonreactive, hepatitis B surface antigen nonreactive. Sickledex negative, Pap was within normal limits, urine culture negative, GC/chlamydia negative x2, 1-hour GCT was 108.
AB|blood group in ABO system|AB|320|321|PRESENTING INFORMATION|DISCHARGE DIAGNOSIS: Physiologic newborn jaundice, hyperbilirubinemia. PRESENTING INFORMATION: _%#NAME#%_ _%#NAME#%_ was admitted at 8 days of age for evaluation and treatment of hyperbilirubinemia. Evaluation revealed no evidence of blood group incompatibility. The baby's blood type is A negative, mother's blood type AB positive, direct Coombs (DAT) was negative. Bilirubin on admission was 20.7. Fractionated bilirubin revealed a total of 19.9 and a conjugated of 0.3. Neonatal bilirubin decreased under phototherapy to 14.4 by _%#MMDD2006#%_.
AB|blood group in ABO system|AB|83|84|MEDICATIONS|ALLERGIES: No known drug allergies. MEDICATIONS: Prenatal vitamins. The patient is AB positive, rubella immune, VDRL, hepatitis and HIV negative. Group B strep was negative. Glucose screen was done at Dr. _%#NAME#%_'s office. The patient declined a C-section until her due date and presented to L&D in labor during the night of _%#MMDD2006#%_.
AB|blood group in ABO system|AB|260|261|HISTORY AND HOSPITAL COURSE|Postpartum course was essentially uncomplicated. By postpartum day number 2 the patient was ambulating, tolerating a house diet, and voiding without difficulty. She was discharged to home with follow-up to be in the office to be in 6 weeks. Her blood type was AB positive and she was Group B strep negative.
AB|abortion|AB|120|121|PAST OBSTETRICAL HISTORY|Level II ultrasound done _%#MMDD2001#%_ at 17 + 6 weeks was within normal limits. PAST OBSTETRICAL HISTORY: 1. Elective AB x 2. 2. 1997: Normal spontaneous vaginal delivery, 7 pounds 8 ounces, complicated by A1 gestational diabetes. PAST MEDICAL HISTORY: 1. The patient has a history of bipolar disorder, and was on Depakote, but is now off since getting pregnant.
AB|abortion|AB|202|203||She underwent an ultrasound two days later. Unfortunately, the ultrasound revealed that the gestational sac was irregular and there was debris noted with no fetal pole identified. A diagnosis of missed AB has been made. _%#NAME#%_ has been counseled. She was given her options of either going through a suction D&C to clean out her uterus or to wait until natural miscarriage occurs.
AB|abortion|AB.|73|75|ASSESSMENT|EXTREMITIES: Unremarkable. DERMATOLOGICAL: Clear. ASSESSMENT: Incomplete AB. Patient with a known A positive blood type. Discussed sending portions of the placenta for genetic evaluation because of the patient's age as well as this being her third consecutive miscarriage.
AB|abortion|AB|201|202|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old white female para 1-1-3-3, status post tubal sterilization, who had an emergency cesarean section with twins at 28 weeks gestation, spontaneous AB x3, whom I initially evaluated on _%#MMDD2007#%_ for dysfunctional uterine bleeding. Prior to _%#MM2006#%_ she had very regular periods every 28 days.
AB|blood group in ABO system|AB|124|125|TELEPHONE INTERACTION|Problem #3: Hyperbilirubinemia. _%#NAME#%_ received phototherapy for a peak bilirubin level of 16.5 mg%. His blood type was AB positive; maternal blood type was B positive. Antibody screening tests were negative. The last bilirubin level prior to discharge was 9.5 mg% on _%#MMDD2006#%_.
AB|abortion|AB.|188|190|OB HISTORY|Labor was induced for placental insufficiency. _%#MMDD1996#%_, vaginal birth, 6 pounds, 8 ounce male 39 weeks with spontaneous rupture of membranes with induction of labor. 1995, elective AB. No complications. LABORATORY DATA: Blood type is A negative. Antibody screen negative X2. HSV negative. HIV negative. Sickle cell negative.
AB|abortion|AB|58|59|PLAN|_%#NAME#%_ _%#NAME#%_ is a 35-year-old gravida 2, para 0, AB 1, who was admitted in early labor several days past term. She experienced spontaneous rupture of membranes. She had an epidural placed and at that point it became clear that the patient's baby was in a breech presentation.
AB|abortion|AB.|128|130|PAST MEDICAL HISTORY|The prenatal course has been otherwise uncomplicated. PAST MEDICAL HISTORY: Significant for 3 vaginal deliveries, 1 spontaneous AB. No history of hypertension, diabetes, cardiac disease, or asthma. PAST SURGICAL HISTORY: Significant for cholecystectomy and left wrist surgery.
AB|abortion|AB|116|117|CHRONIC DISEASE/MAJOR ILLNESS|3. She has chronic migraine headaches that occur about once a week. 4. She is gravida 4 para 1 with one spontaneous AB and two therapeutic ABs. 5. Long-standing rheumatoid arthritis. REVIEW OF SYSTEMS: Regular periods, last period was three weeks ago.
AB|blood group in ABO system|AB|96|97|LABS|The cervix is closed and high. EXTREMITIES: Are unremarkable. LABS: The patient's blood type is AB negative with a negative antibody screen, rubella immune, VDRL non-reactive. Hepatitis B. surface antigen is negative. HIV negative. Triple test was normal and glucose was normal at 131 and a group B.
AB|abortion|AB.|285|287|PAST OB HISTORY|PAST OB HISTORY: The patient had a normal spontaneous vaginal delivery following induction of labor at 38 weeks in _%#MM#%_ 2001. That pregnancy was also complicated by insulin-dependent gestational diabetes. The patient also has a history of an elective termination and a spontaneous AB. PHYSICAL EXAMINATION: Today the patient is 39 weeks 4 days.
AB|abortion|AB.|195|197||She was seen in the office. She had an ultrasound done this morning that shows a gestational sac present. There is no yolk sac and there is no fetus present. Ultrasound is consistent with missed AB. Options for management were discussed with the patient and she decided to proceed with vacuum curettage and D&C. Risks and complications have been discussed with the patient and her husband and they understand these.
AB|abortion|AB|66|67||_%#NAME#%_ _%#NAME#%_ is a 23-year-old female, gravida 1, para 1, AB 0 who had excellent dates after induction of ovulation with Clomid. She conceived twins and was followed for her entire pregnancy with early ultrasound confirmation of growth and was started on iron therapy at about 17 weeks because her hemoglobin was 10.7. She had major complications of pregnancy, with morbid obesity.
AB|abortion|AB|136|137|HISTORY|The patient is to have a duodenal switch procedure done by Dr. _%#NAME#%_ _%#NAME#%_. HISTORY: This is a 37-year-old gravida 4, para 2, AB 2 white female who is being admitted by Dr. _%#NAME#%_ for a duodenal switch procedure. The patient weighs 258 pounds.
AB|abortion|AB|88|89|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 40-year- old, gravida 2, para 1, AB 1, who presents for total abdominal hysterectomy, bilateral salpingo-oophorectomy, and incisional hernia repair. The patient is a long-established patient of Dr. _%#NAME#%_ _%#NAME#%_.
AB|abortion|AB|75|76|CHIEF COMPLAINT|CHIEF COMPLAINT: _%#NAME#%_ _%#NAME#%_ is a 49-year-old gravida 4, para 3, AB 1 female who is being admitted for surgery for symptomatic pelvic relaxation. The patient gave a history of having mild urinary stress incontinence several years ago.
AB|abortion|AB|133|134|OB HISTORY|Mild asthma, myomatous uterus, CF mutation in the patient with FOB negative, an elevated GCT and normal GTT. OB HISTORY: 1. Elective AB x1. 2. SAB x1 in the first trimester. 3. IUFD at 18 weeks followed by D&E. 4. NSVD at 39 weeks, 7 pound 8 ounce infant with postpartum hemorrhage.
AB|abortion|AB|133|134|HISTORY OF PRESENT ILLNESS|An ultrasound was performed on _%#MMDD2003#%_ which confirmed fetal demise at 7 3/7 weeks. Note that she has had a history of missed AB in 1998. PAST MEDICAL HISTORY: Major Medical Problems: 1. History of thrombophlebitis postpartum.
AB|abortion|AB|87|88|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 35-year- old gravida 3, para 0, AB 1, ectopic 1 with a last menstrual period of _%#MMDD2003#%_, currently at 10.5 to 11 weeks gestation who presents for a suction D&C, possible laparoscopy. An intrauterine pregnancy was documented as late as _%#MMDD2003#%_ with a crown rump length measuring 8 weeks and 3 days.
AB|abortion|AB|150|151|PAST MEDICAL HISTORY|This is done through a Dr. _%#NAME#%_ in _%#CITY#%_. She is status post C section x 4 (two of the children were born dead), NSVD x 1, and spontaneous AB x 1. She has three living children. She is status post hysterectomy due to a growth on her uterus. She believes that she has had an appendectomy with one of her C sections.
AB|abortion|AB|249|250|PAST OBSTETRICAL HISTORY|In _%#MM1999#%_ she had a cesarean section at 41 weeks gestational age of a viable female infant weighing 8 pounds 13 ounces secondary to arrest of labor at 3 cm dilated. 2. On _%#MMDD2002#%_ she had a dilatation and curettage secondary to a missed AB at 13 weeks gestational age, which was complicated by an intraoperative hemorrhage. FAMILY HISTORY: The father of the baby is recovering from alcoholism.
AB|abortion|AB|58|59||_%#NAME#%_ _%#NAME#%_ is a 34-year-old gravida 3, para 1, AB 1, EDC _%#MMDD2003#%_ based on a 6-7 week ultrasound, who presents for repeat cesarean section. Her first cesarean section was performed in 1997 for low amniotic fluid and fetal distress.
AB|abortion|AB|325|326|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 34-year- old, gravida 5 para 2-0-2-2, female who is being admitted to Fairview Southdale Hospital for vacuum curettage and dilation and curettage (D&C) with chromosome evaluation of tissue for recurrent missed abortion (AB). The patient had a previous missed AB in early 2003 and had a vacuum curettage. She subsequently became pregnant. Last menstrual period was _%#MMDD2003#%_. She had an ultrasound done on _%#MMDD2003#%_ consistent with 8-weeks-1-day and the pregnancy was viable at that time.
AB|abortion|AB|75|76|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 29-year-old female, gravida 2, para 0, AB 2 - both VIP's. The patient is an esthetician who is complaining of dysmenorrhea and dyspareunia. She has regular menses with 2+ out of 4 dysmenorrhea associated with diarrhea and 2+ pain on deep penetration with intercourse.
AB|abortion|AB|191|192|HISTORY|PRENATAL CARE: Prenatal care was with Dr. _%#NAME#%_ _%#NAME#%_, first visit at 11 weeks. Total visits 13. First trimester blood pressures 120/81, weight gain 30 pounds. PRENATAL LABORATORY: AB Positive, antibody negative. Hemoglobin 13.8 and 11.9. GBS negative. Pap within normal limits in _%#MM#%_ 2003. RPR nonreactive. HIV nonreactive.
AB|abortion|AB,|168|170|MEDICATIONS|16. Vicodin as needed for pain. She has had a flu shot this year. Previous hospitalizations have included back surgery in 1992. She is gravida 6, para 4,1 stillbirth 1 AB, cholecystectomy, fractured right arm with open reduction and internal fixation and then another operation to remove the hardware, umbilical hernia repair times two, eye surgeries likely Lasix surgeries, carpal tunnel release x2.
AB|abortion|AB.|201|203|PAST OBSTETRICAL HISTORY|2. 2001 39 weeks, 7 pounds 12 ounces, cesarean section secondary to arrest of dilatation at 7 centimeters. This was complicated by a postpartum hemorrhage with hemoglobin down to 6.9. 3. 1997 elective AB. 4. 1998 elective AB. 5. 1998 spontaneous AB. PAST MEDICAL HISTORY: None. SURGICAL HISTORY: Cesarean section as noted above.
AB|abortion|AB|153|154|PAST OBSTETRICAL HISTORY|3. _%#MM#%_ 1991, 38-week primary cesarean section secondary to arrest of dilatation, 8 pounds 4 ounces. This was a twin gestation, however, spontaneous AB of Twin A occurred at 5 weeks. 4. _%#MM#%_ 1992, spontaneous AB at 4 weeks. 5. _%#MM#%_ 1993, 37 week, repeat cesarean section, 8 pounds 3 ounces male, this was done secondary to a failed trial of labor and arrest of dilatation.
AB|abortion|AB|203|204|PAST OB HISTORY|_%#MM#%_ 1994: Delivered a 3.5-kg male infant at 40 weeks by vaginal delivery in Somalia. _%#MM#%_ 1995: At 40 weeks, delivered a viable female weighing 2.5 kg in Somalia. In 1998, she had a spontaneous AB with a D and C. PAST MEDICAL HISTORY: Positive PPD, negative chest x-ray. She has not received INH.
AB|abortion|AB|122|123|PAST SURGICAL HISTORY|Normal Pap since. History of Depo Provera use for three years. PAST MEDICAL HISTORY: Unremarkable. PAST SURGICAL HISTORY: AB x 8. C-section x 1. MEDICATIONS: Tylenol and prenatal vitamins. ALLERGIES: No known drug allergies.
AB|abortion|AB.|228|230|PAST OB HISTORY|4. In _%#MM1998#%_, she had normal spontaneous vaginal delivery of a 9 pound, 14 ounce infant at 37 weeks. This pregnancy was also complicated by gestational diabetes mellitus, Type A1. 5. In _%#MM2000#%_, she had a spontaneous AB. 6. In _%#MM2001#%_, she had a spontaneous AB. 7. In _%#MM2001#%_, she had normal spontaneous vaginal delivery of an 8 pound, 15 ounce infant at 33 weeks.
AB|abortion|AB.|138|140|PAST MEDICAL HISTORY|This was felt to be secondary to a history of an arcuate uterus. PAST MEDICAL HISTORY: Illnesses none. Surgery - S&C times two for missed AB. MEDICATIONS: Prenatal vitamins. ALLERGIES: None. OB HISTORY: As mentioned above.
AB|blood group in ABO system|AB|162|163|HOSPITAL COURSE|Postpartum, Ms. _%#NAME#%_ did very well. By the afternoon of postpartum day #1, she was desiring discharge. Her postoperative hemoglobin was 13+. Again, she was AB positive and Rubella immune. She desired circumcision for her baby, and this was done prior to discharge. She desired birth control pills. When we started discussing Micronor since she was breast- feeding, the patient stated that she knew herself and did not think she would be breast-feeding in two weeks when she would be starting the birth control pills and, thus, she wanted to go with the combination pill.
AB|abortion|AB|74|75||_%#NAME#%_ _%#NAME#%_ is a 49-year-old Russian female, gravida 5, para 2, AB 3, seen for a number of years with known fibroid uterus. Her uterus was irregular in size and was growing from an eight week size when first being followed a couple of years ago, to now 13-14 weeks' size; a large growth spurt.
AB|blood group in ABO system|AB|136|137|PLAN|3. Hyperbilirubinemia - patient's total bilirubin level on day of life 3 was 12.7 and direct bilirubin level was 0. Mom's blood type is AB + and baby's blood type is A + with a negative antibody and Coomb's tests on day of life 3. _%#NAME#%_ was treated with 3 days of phototherapy. Last total bilirubin level on day of life 7 was 7.5 and direct bilirubin level of 0.
AB|abortion|AB|96|97||_%#NAME#%_ _%#NAME#%_ is a 27-year-old female who has been shown by ultrasound to have a missed AB at 11 weeks 2 days. She is being brought in for suction D&C. Blood type is pending. Past OB history is negative. PAST MEDICAL HISTORY: Mild asthma.
AB|blood group in ABO system|AB|175|176|HISTORY OF PRESENT ILLNESS|Rubella is reported to be 20, and upon further check with the laboratory, this is immune. RPR is negative. Hepatitis C is negative. Antibody screen is negative. Blood type is AB positive. Hemoglobin is 13.1, and platelets are 272. Ultrasound done three weeks prior to admission, it is unclear what the results are, due to the fact that we do not have the official report.
AB|abortion|AB|67|68|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 46-year-old gravida 6, para 3, AB 3 female seen in consultation because of menorrhagia, stress urinary incontinence, pelvic relaxation, and fibroid uterus. The patient was counseled about her situation when first seeing me because of her menorrhagia that was lasting for 5 to 7 days associated with some menstrual migraine.
AB|blood group in ABO system|AB|218|219|HOSPITAL COURSE|Labs were drawn on admission. Hemoglobin was 12.9, white blood cell count 9.5, platelets 77, hematocrit 36.5, ALT was 274, AST 109, BUN 7, creatinine 0.61. Fibrinogen was 636. D-dimer was 3.3. Magnesium level was 4.6. AB positive blood type was confirmed. PTT 35, INR 0.94. Bilirubin conjugated 0.0, delta bilirubin was 0.1, and total bilirubin 0.3. EKG showed normal sinus rhythm, normal EKG.
AB|abortion|AB|252|253|ASSESSMENT/PLAN|LABORATORY DATA: Patient's blood type is A positive. Hemoglobin on _%#MMDD#%_ was 13.9, hematocrit 42.7, white count 7.7 and platelets 312. Antibody screen was negative. ASSESSMENT/PLAN: The patient is a 34-year-old gravida 3, para 2-0-1-2 with missed AB at approximately 8 weeks EGA. Options were discussed with the patient including expectant management versus suction D&C. The patient elects to proceed with the suction D&C secondary to fear of uncontrolled bleeding and desire for definitive management.
AB|abortion|AB,|229|231|PAST OBSTETRICAL HISTORY|PAST OBSTETRICAL HISTORY: 1. 1998, incomplete AB. 2. 2000, cesarean section at 34 + 2 weeks secondary to abruption. 3. 2001, cesarean section at 35 + 4 weeks secondary to abruption; this ended in neonatal demise. 4. 2003, missed AB, treated with D and C. PAST GYNECOLOGIC HISTORY: The patient has a history of a bicornuate uterus.
AB|abortion|AB|85|86|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 39-year-old Caucasian female, gravida 2, para 1, AB 0, who is an Emergency Department physician. She has been followed through her entire pregnancy with excellent dates and early ultrasounds.
AB|blood group in ABO system|AB|107|108|PRENATAL LABS|The patient declined breech version and a Cesarean section has been scheduled for 39 weeks. PRENATAL LABS: AB positive, antibody screen negative, serology nonreactive, hepatitis B surface antigen nonreactive, rubella immune. PAST MEDICAL HISTORY: Asthma. SURGICAL: Dilation and curettage in 1990 and 1992.
AB|blood group in ABO system|AB|151|152|DOB|DOB: _%#MMDD2002#%_ _%#NAME#%_ was born on _%#MMDD2002#%_ at 1634 hours to a 24-year-old Caucasian female who was gravida 1 para 0. Her blood type was AB negative. She was rubella immune, VDRL negative, hepatitis B surface antigen negative, group B strep negative, HIV negative. Estimated date of delivery was _%#MMDD2002#%_ giving a gestational age of 37-5/7 weeks.
AB|abortion|AB|182|183|REVIEW OF SYSTEMS|She has no chest pain. EKG is abnormal, stable. Gastrointestinal: She had a colonoscopy in _%#MM#%_, 1996 which was normal. Note: Father died of colon cancer. GYN: Gravida 7 para 6, AB 1. Endocrine: Diabetes, monitors her blood sugars, runs between 140 and lowest of 86. She is on Amaryl 2 mg daily. She has not been seen in the office for three years.
AB|abortion|AB|176|177|PLAN|This was done at 33 weeks for pregnancy-induced hypertension and asymmetric intra-uterine growth retardation. This delivery required cesarean section. In 1996 she had a missed AB with a D&C. In 2002 she had a fetus with holoprosencephaly and electively terminated the pregnancy at 14 weeks. Since then she has had secondary infertility with intrauterine insemination and IVS, however, her current pregnancy was conceived spontaneously.
AB|abortion|AB|362|363|LABORATORY|The right groin site was inspected with no ecchymosis or bruit auscultated. Extremities were free of peripheral edema. LABORATORY: Sodium 141, potassium 4.1, CO2 33, chloride 102, BUN 19, creatinine 1.73, white blood cell count 5.7, hemoglobin 13.6, hematocrit 40.5, platelets 196, and troponin-I is 0.10. An EKG showed a normal sinus rhythm with a first degree AB block with no significant ST or T-wave changes. DISPOSITION: At this time, the patient will be discharged to home as he is doing very well.
AB|abortion|AB|117|118|PAST OBSTETRICAL HISTORY|Hemoglobin 12.0. Pap within normal limits. Urine culture was in normal limits. PAST OBSTETRICAL HISTORY: Spontaneous AB x2 at 6 and 8 weeks' gestation. PAST GYNECOLOGICAL HISTORY: Denies.
AB|blood group in ABO system|AB|165|166|OB HISTORY|Total visits 7. First visit was at 12 weeks. Total weight gain 9 pounds. Blood pressures have been normal throughout the pregnancy. Prenatal labs are the following: AB negative; antibody screening negative; rubella immune nonapparent, nonreactive; hepatitis B surface antigen negative; HIV negative; triple screen abnormal, 1:50 risk of Down's; and one-hour GCT 125.
AB|abortion|AB|60|61||_%#NAME#%_ _%#NAME#%_ is a 35-year-old gravida 3 now para 2 AB 1 with intrauterine pregnancy at 37 1/2 weeks gestation, who was admitted to labor and delivery at Fairview Southdale Hospital on _%#MMDD2005#%_ due to strong, regular uterine contractions and a diagnosis of early labor. Because of her history of previous cesarean section, it was decided to go ahead with a repeat low transverse cesarean section.
AB|abortion|AB|130|131|PAST OBSTETRICAL HISTORY|Pap within normal limits. Triple screen within normal limits. HIV unknown. Hemoglobin 13.9. PAST OBSTETRICAL HISTORY: Spontaneous AB first trimester requiring D and C, _%#MM2003#%_. GYNECOLOGICAL HISTORY: The patient denies any history of sexually transmitted diseases or abnormal Pap smears.
AB|abortion|AB.|151|153|PAST OB HISTORY|PAST OB HISTORY: In _%#MM#%_ 1994, 40 plus 2 weeks C-section for breech presentation. In _%#MM#%_ 2000, 39 weeks C-section elective. In 1997, elective AB. In 1994, elective AB. ADMISSION MEDICATIONS: Prenatal vitamins. ALLERGIES: No known drug allergies.
AB|abortion|AB|79|80|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 40-year-old female, gravida 1, now para 0, AB 1, who has had an invitro fertilization cycle with Dr. _%#NAME#%_, and unfortunately had a blighted ovum. She had perfect dates and was seen by Dr. _%#NAME#%_ at the beginning of the pregnancy and realized that there was a blighted ovum.
AB|blood group in ABO system|AB|222|223|PLAN|Exogenous surfactant was not administered. Problem #3: Hyperbilirubinemia. _%#NAME#%_ received phototherapy for a peak bilirubin level of 8.7 mg/dL on _%#MMDD2005#%_. His blood type was A positive; maternal blood type was AB positive. Antibody screening tests were negative. The last bilirubin level prior to discharge was 6.4 mg/dL on _%#MMDD2005#%_. _%#NAME#%_ received phototherapy on days of life 2-5 and days of life 8-9 of life.
AB|blood group in ABO system|AB|160|161|FOLLOWUP CARE|Problem # 2: Hyperbilirubinemia. _%#NAME#%_ received phototherapy for a peak bilirubin level of 6.7 mg%. His blood type was B positive; maternal blood type was AB positive. Antibody screening tests were negative. _%#NAME#%_ required phototherapy for 3 days. The last bilirubin level prior to discharge was 4.0 mg% on _%#MMDD2005#%_.
AB|blood group in ABO system|AB|222|223|REASON FOR PRESENTATION|REASON FOR PRESENTATION: This patient was born at 3374 grams, 39-week's gestation AGA, male infant, at 9:30 in the morning on _%#MMDD2005#%_. Mother is a 30-year-old Cambodian, gravida 4, para 2-2-1-2. Mother's blood type AB positive, serology negative, Hepatitis B Antigen negative, Group B strep unknown, and rubella immune. Pregnancy uncomplicated. Labor and delivery were complicated by failure to progress.
AB|blood group in ABO system|AB|214|215|DISCHARGE MEDICATIONS|At the time of discharge, the infant's corrected gestational age was 39 weeks and 4 days. _%#NAME#%_ was the 3389 gram, 37 2/7 week gestational age male infant born at Fairview Southdale Hospital to a 39-year-old, AB negative, gravida 5, para 0-2-3-1, married Caucasian female whose LMP was _%#MMDD2005#%_ and whose EDD was _%#MMDD2005#%_. The mother's pregnancy was complicated by preterm labor. A cerclage was placed at 14 weeks, she was placed on bed rest at 24 weeks, and had a terbutaline pump started at 29 weeks.
AB|abortion|AB|70|71||_%#NAME#%_ _%#NAME#%_ is a 25-year-old accountant, gravida 1, para 0, AB 0, who is seen by me for her entire pregnancy with early ultrasounds of perfect dates. The patient had anatomy screen at 22 weeks which had excellent anatomy and this was checked more than once.
AB|abortion|AB|103|104|HISTORY|PROPOSED PROCEDURE: Cesarean section. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 42-year-old gravida 3 para 1 AB 1, EDC _%#MMDD2005#%_ at 38.5 weeks gestation who presents for primary Cesarean section. _%#NAME#%_ has a history of a fourth-degree perineal laceration from a vaginal delivery in _%#MM#%_, 1995.
AB|blood group in ABO system|AB|151|152|HISTORY|Prenatal care was at Fairview Lakes with Dr. _%#NAME#%_ since 12 weeks. The patient has attended approximately 15 visits during this pregnancy. She is AB negative and status post Rhogam 2 weeks ago. Her 1 hour GCT was normal at 82, she is known to be HIV negative, antibody screen negative, rubella immune, RPR negative, hepatitis B surface antigen negative as well.
AB|abortion|AB|128|129|PAST OBSTETRICAL HISTORY|Her GCT was 141. GTT was as follows: Fasting 87, at 1 hour 161, 2 hours 130, 3 hours 121. PAST OBSTETRICAL HISTORY: Spontaneous AB x2 in the first trimester. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: None. MEDICATIONS: Prenatal vitamins.
AB|blood group in ABO system|AB|121|122|LABORATORY|EFW 7-1/2 pounds. Vaginal Exam: 300 and -1 with a bulging bag of water. Legs have 2+ edema with reflexes 2+. LABORATORY: AB positive, antibody negative, rubella immune, RPR negative, hepatitis B surface antigen negative, HIV negative. Platelets on _%#MMDD#%_ were 85, and this is stable for this patient.
AB|blood group in ABO system|AB|199|200|POSTOPERATIVE COURSE|NICU was present at the delivery. COMPLICATIONS: Postpartum hemorrhage, as stated above. DISPOSITION: Stable to the PAR. POSTOPERATIVE COURSE: The patient's postoperative hemoglobin was 11.6. She is AB positive and rubella immune. She is breast feeding her infant and plans to use the progesterone only pill for contraception.
AB|blood group in ABO system|AB|71|72|PRENATAL LABS|Total weight gain is 50 pounds, from 210 to 260 pounds. PRENATAL LABS: AB positive, antibody screen negative. Rubella immune. Varicella immune. Hepatitis B surface antigen-negative. Pap negative on _%#MM#%_ _%#DD#%_, 2005. GC and chlamydia both negative. RPR nonreactive. HIV negative. Quad screen reportedly was no increased risk.
AB|abortion|AB|75|76|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 29-year-old female, gravida 2, para 2, AB 0, who had been followed for her entire pregnancy as a high-risk pregnancy. She had a history of idiopathic thrombocytopenic purpura that had been stable.
AB|blood group in ABO system|AB|180|181|FOLLOW UP|At the time of discharge, the infant's corrected gestational age was 39 weeks and 2 days. She was the 3225 gm, 39 week gestational age female infant born at UMMC to a 47-year-old, AB positive, gravida 4, para 2-0-1-2, married female whose LMP was _%#MMDD2005#%_ and whose EDC was _%#MMDD2006#%_. The mother's pregnancy was complicated by h/o previous c-section for suspected macrosomia.
AB|abortion|AB|103|104|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 65-year-old female, gravida 6 para 5 AB 1, who is known by me for many years and had a total abdominal hysterectomy (TAH) and bilateral salpingo- oophorectomy (BSO) in 1991. I operated on her in 1996 because of stress incontinence, did a Burch procedure and Halban vault suspension.
AB|abortion|AB.|173|175|ADMISSION HISTORY AND PHYSICAL|This pregnancy secondary to Clomid. PAST OB HISTORY: In 1996, she had a primary low transverse cesarean section. She's had 2 vaginal births after cesarean and 3 spontaneous AB. Prenatal care was at Fairview _%#CITY#%_. Her prenatal labs are significant for a GCT of 113, and she is blood type A positive, rubella immune.
AB|abortion|AB.|111|113|PAST GYN HISTORY|PAST OB HISTORY: Gestational diabetes with prior pregnancy, diet controlled. PAST GYN HISTORY: One spontaneous AB. No STDs or abnormal Pap smears. ADMISSION MEDICATIONS: Prenatal vitamins. ALLERGIES: SULFA, penicillin, azithromycin. SOCIAL HISTORY: No tobacco, alcohol, or drug use.
AB|abortion|AB|190|191|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient had a routine UOB on _%#MMDD2005#%_ at which she was six weeks 5 days. An ultrasound was ordered secondary to the fact that she had a previous missed AB at 6 weeks in _%#MM#%_ 2004. Ultrasound at that time showed a 1 week lag in the fetus growth of only being 5 weeks 5 days, and a fetal heart rate of 80.
AB|blood group in ABO system|AB|145|146|HISTORY|She has had a 34 pound weight gain over the course of her measured prenatal visits. She has had normal laboratory testing, to include blood type AB positive, antibody screen negative, initial hemoglobin 12.1, platelet count 190,000, rubella immune, RPR nonreactive, hepatitis B nonreactive. Initial exam did reveal yeast, and this was treated in the first trimester.
AB|abortion|AB|119|120|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 27-year-old female from India, gravida 3, para 0-0-2-0, had a spontaneous AB in _%#MM2003#%_, had an ectopic gestation in her right tube in _%#MM2005#%_, who had an LMP on _%#MMDD2005#%_ with positive ovulation by LH kit on _%#MMDD#%_ and _%#MMDD#%_, who presents today for admission after speaking with Dr. _%#NAME#%_ for questionable ectopic gestation. The patient had a scant traces spotting on Saturday, _%#MMDD#%_ and on Monday, _%#MMDD#%_ with whipping on one occasion each day.
AB|abortion|AB|91|92|PAST OB HISTORY|She has had normal ultrasound since. PAST MEDICAL HISTORY: None. PAST OB HISTORY: Elective AB at 8 weeks in 1993. Spontaneous abortion at 8 weeks on _%#MMDD2001#%_ and on _%#MMDD2003#%_, the patient had NSVD at 34 weeks, delivered a 5-pound male.
AB|abortion|AB,|225|227|POSTOPERATIVE DIAGNOSES|OB HISTORY: 1. First pregnancy cesarean section, secondary to failed induction for pregnancy-induced hypertension. 2. _%#MM#%_ 2002, she had a spontaneous abortion. 3. Third pregnancy on _%#MM#%_ 2005, first trimester missed AB, D & C done. PAST MEDICAL HISTORY: History of hypothyroidism, currently on Synthroid. History of infertility.
AB|abortion|AB,|172|174|HISTORY|There was a large, irregular-shaped sac with debris within the uterus, no fetal pole, no yolk sac visible, and both ovaries are normal. It was clear that this was a missed AB, perhaps in the blighted ovum category. The patient now presents for a vacuum curettage D&C under MAC general anesthesia.
AB|abortion|AB|253|254|HISTORY|The patient just went through IVF with Dr. _%#NAME#%_ who confirmed with ultrasound on _%#MMDD#%_ a small gestational sac that was consistent with 5 weeks. Repeat ultrasound a week later showed no growth. The patient has had a previous D&C for a missed AB similar to this and wants to proceed with another one. She understands the alternatives of medical induction versus expectant management but she is anxious to do another IVF cycle.
AB|abortion|AB|180|181|PAST OB HISTORY|She also had an MRA which revealed no evidence of an aneurysm. The cerebral infarction was thought to be due to a preeclampsia with abruption and massive DIC. 4. 2005, spontaneous AB in the first trimester. 5. Prenatal care with _%#NAME#%_'s Clinic. She is A positive, antigen antibody screen negative, rubella immune, varicella immune.
AB|abortion|AB|198|199|PRENATAL LABORATORIES|All preeclamptic labs within normal limits on _%#MM#%_ _%#DD#%_, 2004, _%#MM#%_ _%#DD#%_, 2005, and _%#MM#%_ _%#DD#%_, 2005. OBSTETRIC HISTORY: Elective AB x2, early first trimester. First elective AB with postoperative infection and repeat D&C. MEDICAL AND SURGICAL HISTORY: 1. D&C x3. 2. In 1998, foot surgery. ADMISSION MEDICATIONS: Prenatal vitamins and iron. ALLERGIES: NKDA. FAMILY HISTORY: Mother with cervical cancer and hypertension.
AB|blood group in ABO system|AB|180|181|CHIEF COMPLAINT|CHIEF COMPLAINT: The patient is a 36-week estimated gestational male delivered via C-section due to fetal distress and twin pregnancy, born to a 34-year-old mother who was G2, P1, AB negative, rubella immune, VDRL negative, Hepatitis B negative. Upon delivery, Apgars were noted to be 8 and 9. At admission, the birth weight was 6 lb 15 oz.
AB|blood group in ABO system|AB|194|195|ADMISSION DIAGNOSIS|FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient does not smoke, use drugs, or alcohol. MEDICATIONS: Prenatal vitamins. ALLERGIES: No known drug allergies. PRENATAL LABS: Blood type AB positive, rubella immune, GBS negative. HIV, RPR, and hepatitis-B surface antigen negative. PHYSICAL EXAMINATION: On admission, the patient was afebrile.
AB|blood group in ABO system|AB|194|195|DISCHARGED 10/19/05|DISCHARGED _%#DDMM2005#%_ _%#NAME#%_ _%#NAME#%_ was a 33-week gestation, second of twins born by cesarean section due to uncontrolled labor to a 34-year-old, gravida 2, para 1-0-1-0, blood type AB positive, group B strep unknown, hepatitis B negative, HIV negative mom. The child initially was noted to have transient tachypnea in newborn and was quickly weaned to room air.
AB|blood group in ABO system|AB|197|198|PRENATAL CARE|PAST OB HISTORY: None. PAST GYN HISTORY: No abnormal Pap smears or sexually transmitted diseases. PRENATAL CARE: Dr. _%#NAME#%_ _%#NAME#%_ in _%#CITY#%_, North Dakota. Labs revealed the patient is AB positive, antibody screen negative, rubella nonimmune, RPR negative, hepatitis C surface antigen negative, and HIV negative. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: Right knee arthroscopy x2.
AB|blood group in ABO system|AB|131|132||Her pregnancy has been healthy. Her weight gain has been approximately 24 pounds. Her blood pressures have remained stable. She is AB negative, rubella immune, hepatitis surface B antigen negative, and HIV screen nonreactive. Glucose screen was within normal limits. Triple screen is not listed here in her papers.
AB|blood group in ABO system|AB|94|95|PRENATAL LABS|MEDICATIONS: Prenatal vitamins. ALLERGIES: No known drug allergies. PRENATAL LABS: Blood type AB positive, antibody screen negative. Gonorrhea and Chlamydia negative. Hepatitis B surface antigen negative. HIV negative. RPR negative. Rubella immune. Pap smear was within normal limits.
AB|blood group in ABO system|AB|202|203|DISCHARGE MEDICATIONS|At the time of discharge, the infant's corrected gestational age was 37 weeks and 0 days. He was the 2240 gm, 36 week and zero days gestational age male infant born at UMMC _%#CITY#%_ to a 26-year-old, AB positive, gravida 1, para 0-0-0-0, married white female whose LMP was _%#DDMM2005#%_ and whose EDC was _%#DDMM2006#%_. The mother's pregnancy was complicated by twin gestation, pre-term labor necessitating modified bedrest and also received several doses of betamethasone.
AB|abortion|AB|231|232|PAST OB HISTORY|PRENATAL LABS: She is blood type O positive. GBS positive, hepatitis B negative, VDRL negative, rubella immune, antibody screen were negative, GC negative, chlamydia negative, and HIV negative. PAST OB HISTORY: She had an elective AB in 1999 at 16 weeks. She had a primary C-section at 41 weeks for fetal distress, 8-pound 13-ounce infant in 2003.
AB|abortion|AB|66|67||_%#NAME#%_ _%#NAME#%_ is a 34-year-old female, gravida 2, para 1, AB 1 who had in vitro fertilization five different times and this is the only pregnancy she achieved and has been successful. She has a history of rheumatoid arthritis that was severe and has been on medication for many years for that.
AB|abortion|AB|132|133|LABORATORY STUDIES|LABORATORY STUDIES: Her hemoglobin was 12.4, blood type was O positive. At this time the patient was admitted for likely incomplete AB with possible molar pregnancy.
AB|abortion|AB|123|124|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Missed AB. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 29-year-old, G2 P0-0-1-0, with a missed AB at 11 +4 weeks gestation by an LMP of _%#DDMM2007#%_, presents to clinic to discuss the options of treating her missed AB. This is a much-desired pregnancy. The patient has been trying to get pregnant for a year.
AB|abortion|AB|114|115|PAST OB HISTORY|MEDICATIONS: Prenatal vitamins. ALLERGIES: Amoxicillin and Flagyl. PAST OB HISTORY: In 1988, patient had elective AB at less than 12 weeks. In 1990, she had elective AB at less than 12 weeks. In 1998, she had an elective AB of less than 12 weeks.
AB|abortion|AB.|114|116|HISTORY OF PRESENT ILLNESS|She has no dysuria or constipation. The patient was seen in the clinic and had an ultrasound that showed a missed AB. She presents for a suction D&C. MEDICATIONS: None. ALLERGIES: Sulfa drugs. PAST OB HISTORY: She had one vaginal delivery and two missed ABs.
AB|abortion|AB|66|67||_%#NAME#%_ _%#NAME#%_ is a 28-year-old female, gravida 1, para 1, AB 0, who was sent to me for consultation by Dr. _%#NAME#%_ _%#NAME#%_. She is a Spanish speaking female who is 41 1/2 weeks gestation with early ultrasonic dating.
AB|abortion|AB|114|115|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Back pain. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 25-year-old gravida 5, para 2, AB 2 with estimated date of confinement of _%#MM#%_ _%#DD#%_, 2006 or _%#MM#%_ _%#DD#%_, 2006. The patient is unsure. She has limited prenatal care from _%#COUNTY#%_ County and is admitted through the Emergency Room Department for back pain.
AB|blood group in ABO system|AB|246|247|PRENATAL PROFILE|PAST MEDICAL HISTORY: Significant for one normal delivery, two cesarean sections, past rupture of uterus, summer allergies, laser to the cervix, and gestational diabetes in her last pregnancy, diet-controlled. PRENATAL PROFILE: Her blood type is AB positive, no antibodies detected. Rubella status was immune. Negative VDRL, hepatitis and HIV screening. FAMILY HISTORY: Negative. PHYSICAL EXAMINATION: VITAL SIGNS: Her blood pressure was 120/60.
AB|blood group in ABO system|AB|305|306|HISTORY|HISTORY: Baby Girl _%#NAME#%_ was born at Fairview Southdale Hospital premature at 35 plus 6 weeks estimated gestational age with respiratory distress, transient tachypnea in the newborn, hypotension with hypoperfusion and a question of sepsis. She was born to a G-3, P-1-1-0-3 female, who was blood type AB positive, rubella immune, VDRL negative, hepatitis B negative, HIV negative, Group B strep unknown, with a history of hypertension and pre-eclampsia near the end of her pregnancy.
AB|abortion|AB|97|98|CHIEF COMPLAINT|CHIEF COMPLAINT: _%#NAME#%_ _%#NAME#%_ is a 30-year-old gravida 1 para 0 diagnosed with a missed AB on _%#MMDD2006#%_. She presents today for suction dilation and curettage vacuum curettage. The patient should be approximately 12 weeks by an earlier scan.
AB|abortion|AB|94|95|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 38-year-old female, gravida 5, para 3, AB 2, whose husband has had a vasectomy, and she saw me for a consultation because of dysmenorrhea and dyspareunia. The patient stated that this has been increasing over the last few years, and she had endometrial ablation in 2004 by another physician because of her bleeding at that time.
AB|abortion|AB.|154|156|PAST SURGICAL HISTORY|PAST MEDICAL HISTORY: Para 0-0-2-0, asthma, hypertension and chronic sinus trouble. PAST SURGICAL HISTORY: Abdominal myomectomy, infection D&C for missed AB. CURRENT MEDICATIONS: 1. Allegra. 2. Nasonex. 3. Albuterol. 4. Advair.
AB|abortion|AB.|180|182|OBSTETRIC HISTORY|2. On _%#MMDD2003#%_, she had spontaneous AB requiring a D and C. 3. On _%#MMDD2005#%_, she had a full term NSVD, 8 pounds 5 ounces, uncomplicated. 4. In _%#MM2006#%_, an elective AB. PAST GYNECOLOGIC HISTORY: Significant for history of herpes and Chlamydia in the past, also history of ASCUS and low-grade SIL Pap smears.
AB|abortion|AB|243|244|PAST OB HISTORY|She was sent for a repeat ultrasound to evaluate the pregnancy further and the ultrasound was done today and thus she was found to have a missed AB. ALLERGIES: No known drug allergies. MEDICATIONS: None. PAST OB HISTORY: She did have a missed AB in _%#MM2007#%_ and did undergo a suction D&C at that time. PAST GYN HISTORY: The patient denies any history of abnormal Pap smears.
AB|abortion|AB|103|104|IMPRESSION|PELVIC: Pelvic examination is deferred until under anesthesia. EXTREMITIES: Normal. IMPRESSION: Missed AB with non-rising hCG levels, light vaginal spotting, no evidence of ectopic pregnancy. PLAN: The patient was informed that we recommend an examination under anesthesia, hysteroscopy, suction vacuum curretage and/or sharp curretage, evaluation for products of conceptions and monitoring of hCG titers following the procedure.
AB|abortion|AB|275|276|GYN HISTORY|The patient had been spotting at that time. Her bleeding and spotting continued so ultrasound was performed again on _%#MMDD2006#%_. Ultrasound demonstrated intrauterine gestational sac and fetal pole with yolk sac with no evidence of cardiac activity consistent with missed AB at 7 weeks and 2 days. EXAMINATION: Performed on _%#MMDD2006#%_. LUNGS: Clear to auscultation bilaterally. HEART: Had a regular rate and rhythm.
AB|blood group in ABO system|AB|229|230|PLAN|At the time of discharge, the infant's corrected gestational age was 35 weeks and 2 days . He was the 2380 gm, 33 + 3 week gestational age male infant born at University of Minnesota-Fairview, _%#CITY#%_ Campus to a 20-year-old, AB positive, gravida 1, para 0, single caucasian female whose LMP was uncertain and whose EDC was _%#MMDD2006#%_. The mother's pregnancy was uncomplicated, except for preterm labor treated with magnesium.
AB|abortion|AB|201|202|ADMISSION HISTORY|Her pregnancy was complicated only by this blood pressure issue as well as history of HSV and she was on Valtrex suppression since the recent weeks. The patient's OB history is complicated by a missed AB in 2003 followed by an IUFD at 8 weeks which was notable for trisomy 21. She then delivered a term female infant weighing 6 pounds 5 ounces in 2004 and then this present pregnancy.
AB|abortion|AB|61|62||_%#NAME#%_ _%#NAME#%_ is now P0-0-2-0 status post incomplete AB second emergency room visit in 36 hours prompted definitive intervention. On _%#MMDD2006#%_, she underwent dilation and curettage under MAC anesthesia.
AB|abortion|AB|84|85|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 38-year-old gravida 3 para 1 AB 1 with estimated date of confinement (EDC) of _%#MMDD2006#%_ at 38-6/7 weeks' gestation who presents for repeat cesarean section. Her pregnancy has been complicated by uterine fibroids, however, there has been no compromise of fetal growth.
AB|blood group in ABO system|AB|132|133|PRENATAL LABS|The patient gained 13 pounds during the pregnancy. First trimester blood pressure is unavailable. PRENATAL LABS: Include blood type AB positive, antibody negative, Rubella immune, RPR nonreactive. Hepatitis B surface antigen negative, gonorrhea and chlamydia negative. Urine culture negative.
AB|blood group in ABO system|AB|225|226||The infant was admitted after being delivered in the car on the way to the Emergency Department and brought up and placed in the warmer. Initial vital signs were stable. Oxygen saturation was 92 to 95%. The mom was G-3, P-2, AB negative, prenatal labs were within normal limits. GBS status unknown. He was placed on IV fluids and near tube feedings were started in the first 24 hours.
AB|blood group in ABO system|AB|158|159|MEDICATION|Blood, urine, and CSF cultures obtained on admission were negative. Problem #4: ABO blood type. _%#NAME#%_'s blood type is A positive; maternal blood type is AB positive. Antibody screening tests were positive. _%#NAME#%_'s last bilirubin level was 6.6 on _%#MMDD2007#%_. He never became jaundiced. Problem #5: Possible Seizures. Seizure-like activity was not noted throughout his hospitalization.
AB|blood group in ABO system|AB|263|264|OTHER PROCEDURES|At the time of discharge, the infant's postmenstrual age was 35 weeks and 2 days. He is a 2410 gram, 33 1/7 week gestational age male infant born at University of Minnesota Medical Center, Fairview _%#CITY#%_ to a 29 year old, gravida 7, para 1-2-3-1, blood type AB positive, Caucasian female whose LMP was _%#MMDD#%_ and whose EDC was _%#MMDD2007#%_. The mother's pregnancy was complicated by preterm bleeding and methamphetamine use.
AB|blood group in ABO system|AB|204|205|IMPRESSION|We discussed the potential to try and do a version and the patient and her husband elected to go ahead with a scheduled cesarean section. The pregnancy has been otherwise uncomplicated. Her blood type is AB positive, she is rubella immune. Hepatitis screen is negative. Her HIV is negative. Her pap smear is normal. She plans to breast feed. She has an abnormal gestational diabetes screen.
AB|abortion|AB|76|77|PLAN|_%#NAME#%_ _%#NAME#%_ is a 42-year-old Caucasian female, gravida 1, para 0, AB 1 who was seen by me for endometriosis. The patient had a history of endometriosis after I laparoscoped her in 1999.
AB|type A, type B|AB|112|113|ASSESSMENT/PLAN|Will change Albuterol with atrovent Nebs to q 4 hours p.r.n. for shortness of breath. Labs for tomorrow include AB and P and CBC. We will follow this patient accordingly and treat as needed.
AB|type A, type B|AB|270|271|LABORATORY DATA|LABORATORY DATA: Hemoglobin 13.4. Hematocrit 39.8. Platelet count 308. White blood cell count 22.6 with 80% neutrophils, 15% lymphocytes, and 4% monocytes. Sodium 134. Potassium 3.5. Chloride 99. Bicarbonate 24. Glucose 99. BUN 8. Creatinine 0.8. Calcium 8.9. Influenza AB rapid antigen was negative. Rapid strep A screen was also negative. RADIOLOGY: Chest x-ray showed possible right middle lobe infiltrate, increased interstitial signs.
AB|abortion|AB|133|134|PAST OB HISTORY|PAST OB HISTORY: 1. In 2002, NSVD at term of a 7-pound infant. 2. NSVD at term in 2004, of a 6-pound 14-ounce infant. 3. Spontaneous AB x1. PAST MEDICAL HISTORY: Infertility. PAST SURGICAL HISTORY: None.
AB|abortion|AB|73|74|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 37-year-old female, gravida 7 para 3 AB 4, who was seen by me because of dyspareunia and dysmenorrhea and chronic left pelvic pain. When I first saw the patient, she said that her menses have been regular with just a few irregular cycles, she had dysmenorrhea 3+/4, she had pelvic pain usually at mid-cycle on the left and usually lasted for almost two weeks, it seems like it was mostly ovary.
AB|abortion|AB|66|67||_%#NAME#%_ _%#NAME#%_ is a 35-year-old female, gravida 3, para 1, AB 1, who had 1 ectopic on the right side in 2003. She had a right salpingectomy by another physician at that time.
AB|blood group in ABO system|AB|302|303|LABORATORY DATA|Her pregnancy had been complicated by a parvovirus infection during pregnancy and abnormal one hour glucose screening of 164 but a normal three hour test, positive bacterial vaginosis on her first OB visit, and borderline post- dates gestation. LABORATORY DATA: Antepartum laboratory tests: Blood type AB positive, antibody screen negative. Rubella, RPR, hepatitis B and HIV were all within normal limits with rubella being immune. Cervical culture, urine culture at early OB visits were normal.
AB|blood group in ABO system|AB|144|145|COMPLICATIONS|Did note occasional contractions. Prenatal care was initiated at 29+6 weeks. She had a total of 2 visits. Weight gain is unknown. Her labs were AB positive, antibody negative, hemoglobin 11.8, and urine culture was negative, hepatitis B negative, HIV negative, GC and Chlamydia are negative.
AB|blood group in ABO system|AB|151|152|PRENATAL CARE|Her care began at 8 weeks. Dating is by sure LMP and an 8-week ultrasound. She has had six visits prior to her admission to the hospital. Her labs are AB positive, antibody negative. Rubella immune serology nonreactive. Hepatitis B negative. Pap was benign. Alpha fetoprotein was declined. UA/UC negative. GC/Chlamydia was ....... ....... COMPLICATING ISSUES: 1. Advanced maternal age.
AB|blood group in ABO system|AB|156|157|LABS|She was discharged home postoperative day #2 in good condition. LABS: Preoperative hemoglobin 14.6, postoperative hemoglobin 11.2, 11.3. Patient blood type AB positive, antibody screen negative. PROCEDURES: Laparoscopy/laparotomy, left salpingo-oophorectomy. DISCHARGE MEDICATIONS: Over-the-counter pain medications. PATHOLOGY: Pending at the time of discharge.
AB|abortion|AB|100|101|NARRATIVE|DOB: _%#DDMM2002#%_ NARRATIVE: Newborn infant delivered at 0816 by cesarean section to a gravida 2, AB 1, 28 year old woman after developing chorioamnionitis during her labor. The patient did receive one dose of Ampicillin at 6:30, approximately one hour before delivery.
AB|abortion|AB|57|58|PLAN|_%#NAME#%_ _%#NAME#%_ is a 39-year-old gravida 1 para 0, AB 1, with a history of uterine fibroids. She underwent a laparotomy with myomectomy in _%#MM#%_ 2000. That fibroid was right-sided, fundal and posterior and measuring 6x8 cm.
AB|abortion|AB,|174|176|PAST OB HISTORY|A second ultrasound at 21 weeks, Level II ultrasound prior to her cerclage, revealed normal anatomy with funneling to the end of her cervix. PAST OB HISTORY: 1991 - Elective AB, no complications. PAST MEDICAL HISTORY: 1. Depression. She had been on Effexor prepregnancy. She denied any symptoms of depression during this pregnancy.
AB|type A, type B|AB|178|179|MEDICINES AT DISCHARGE|The patient presented with dyspnea, shortness of breath, and low grade temperature. A chest x-ray raised the possibility of infiltrate in the right lower lung. A rapid influenza AB antigen screen in the nasal mucosa was positive. Blood culture was sterile after one day. White count was 17,800 with left shift.
AB|arteriovenous:AV|AB|144|145|PAST MEDICAL HISTORY|No vision changes. no abdominal pain, with some occasional rectal incontinence. No shortness of breath. No chest pain. PAST MEDICAL HISTORY: 1. AB fistula placement on _%#MM#%_ 2002 in her right forearm for vascular access. 2. End stage renal disease as above. 3. Paranoid schizophrenia for 25 years controlled on medications.
AB|blood group in ABO system|AB|140|141||Initial glucose was 68. There were some retractions and flaring shortly after birth, but this resolved within an hour. Maternal serology is AB positive blood type, B Strep negative. Hepatitis B negative, VDRL negative, rubella immune, HIV negative. SOCIAL HISTORY: The parents are married.
AB|abortion|AB|160|161|PAST OBSTETRICS HISTORY|Recently she has also developed a pressure feeling. PAST OBSTETRICS HISTORY: 1. Mid forceps delivery 15 years ago, 8 pound 7 ounces, high fever post partum. 2. AB times one, lots of pain afterwards. 3. SAB. PAST MEDICAL HISTORY: 1. Swollen joints 10 years ago, possibly related to previous strep.
AB|abortion|AB|311|312|PAST OB HISTORY|ULTRASOUND: _%#MMDD2002#%_ at 25+3 weeks: Anterior placenta. COMPLICATIONS OF PREGNANCY: Spanish-speaking only, father of the baby is not involved, late prenatal care, urinary tract infection _%#MMDD2002#%_-treated with Macrobid, 19-year-old. PAST OB HISTORY: 1. _%#MM#%_ 1998 at 8 weeks: She had an incomplete AB and had a D and C in Mexico. 2. _%#MM#%_ 2001: She had a spontaneous loss at 4 months, and was told that the baby was 2 months.
AB|abortion|AB|138|139|PAST OB HISTORY|PAST SURGICAL HISTORY: She had shoulder surgery in 1985, and a cesarean section in _%#MM#%_ of 2000. PAST OB HISTORY: She had an elective AB in 1986 and 1989. In _%#MM#%_ of 2000 she had a primary low-transverse cesarean section for breech presentation following spontaneous rupture of membranes at 32 weeks.
AB|blood group in ABO system|AB|167|168||Her pregnancy has been healthy. Her weight gain has been approximately 31 pounds, her blood pressures have remained stable. Her hemoglobin has remained stable. She is AB positive, rubella immune, hepatitis surface B. antigen negative and HIV screen nonreactive. Glucose test done at 28 weeks was 89. The patient's past medical history is remarkable for no medical problems.
AB|abortion|AB|76|77||_%#NAME#%_ _%#NAME#%_ is a 33-year-old Caucasian female, gravida 2, para 1, AB 0, who has a history of having a documented pregnancy with early ultrasound and now is at approximately 13 weeks gestation. She was followed carefully and had negative group B strep, negative DNA probe, and GEN probe.
AB|abortion|AB|137|138|PAST OB HISTORY|One-hour GCT is 161, and then three-hour GCT is 74, 107, 112, and 106. UC is negative. PAST OB HISTORY: She had a history of spontaneous AB in the first trimester. PAST MEDICAL HISTORY: Healthy. PAST SURGICAL HISTORY: None. SOCIAL HISTORY: Smokes three cigarettes per day.
AB|X-ray finding|AB|352|353|LABORATORIES|His electrolyte panel revealed sodium 143, potassium 4.0, chloride 107, bicarbonate 25, BUN slightly elevated at 35 with a creatinine of 1.2. His calcium was 7.6, but I anticipate his albumin is also low, so this may correct. A chest x-ray was performed and is reportedly improved when compared to his previous chest x-ray. No pleural effusion, Kerley AB lines, or notable infiltrate seen. IMPRESSION: 1. Non-small cell lung cancer with metastasis on chemotherapy - The patient's last chemotherapy was approximately 12 days ago and he is not neutropenic.
AB|abortion|AB|174|175|SOCIAL HISTORY|No family history of diabetes. SOCIAL HISTORY: This is her second marriage. Her first husband died of a cerebral bleed. She has been married for 12 years. Gravida 2, para 2, AB x 0. No tobacco history. Occasional wine intake. She is currently not working. No drug history. REVIEW OF SYSTEMS: She wears glasses. Last exam in _%#MM#%_ 2002 was normal.
AB|blood group in ABO system|AB|146|147|PHYSICAL EXAMINATION|RESPIRATORY: Clear to auscultation. ABDOMEN: Gravid and nontender. EXTREMITIES: Unremarkable. GU: Cervix is long, thick and closed. Blood type is AB positive. Antibody screen is negative. Rubella screen is immune. Most recent hemoglobin was 13.3 in the office. IMPRESSION: Healthy female to undergo an elective repeat caesarian section at term.
AB|abortion|AB|64|65||_%#NAME#%_ _%#NAME#%_ is a 32-year-old female, gravida 2 para 0 AB 1 who is a state patrol officer; she has a positive pregnancy at approximately five and a half weeks gestation with beta HCG that has gone up in a step-wise fashion but slower than what would be expected and doubled in approximately the last three days; it is now 1,074. Ultrasound was performed and showed no changes in the uterus, no gestational sac, no yolk sac and a questionable mass at the right ovary and tube.
AB|blood group in ABO system|AB|134|135|PRENATAL LABS|No steroid use this pregnancy. 3. Gestational diabetes mellitus, moderately well-controlled with twice- a-day insulin. PRENATAL LABS: AB positive, antibody negative, serology nonreactive. Abnormal three hour GTT. GBS negative. BRIEF PHYSICAL EXAM: Patient is in early labor, contracting every three minutes.
AB|abortion|AB|73|74|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 33-year-old G1 P0 AB 1 with a history of polycystic ovarian syndrome and infertility. She was admitted with ovarian hyperstimulation syndrome. She had hyperstimulation with her first stimulated cycle and the cycle was shut down.
AB|abortion|AB|163|164|DISCHARGE PLAN|Now, she has no limp and denies any discomfort in the hip. She is really quite happy with the results. She was hospitalized in _%#MM#%_ of 1991 with a spontaneous AB and in _%#MM#%_ 1999, she had a term pregnancy which ended up with a cesarean section because of cephalopelvic disproportion secondary to the pelvic fractures and _______________ in the pelvis.
AB|abortion|AB|97|98|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 32-year- old, gravida 6 para 1 AB 4, with estimated date of confinement (EDC) of _%#DDMM2003#%_ at 38-4/7 weeks' gestation by excellent dates, who presents for a repeat cesarean section. Her first cesarean section was performed in _%#MM#%_ of 2001 for active phase arrest.
AB|blood group in ABO system|AB|106|107|PRENATAL LABS|She does not smoke, drink, or use drugs. MEDICATIONS: Prenatal vitamins. PRENATAL LABS: She is blood type AB positive and rubella immune. VDRL negative. Hepatitis B surface antigen negative. GBS negative. PHYSICAL EXAMINATION: On admission, she is afebrile.
AB|blood group in ABO system|AB|315|316|PHYSICAL EXAMINATION|FAMILY HISTORY: Is unremarkable. ALLERGIES: None. CURRENT MEDICATIONS: Prenatal vitamins PHYSICAL EXAMINATION: Height is 5 feet 0 inches, weight is 191, prepregnancy weight is 138, for a total weight gain of 43 pounds. Blood pressure is 122/72, urinalysis is negative. Hemoglobin is 13.3. Prenatal labs, blood type AB positive, antibody screen negative. Rubella immune, RPR - non-reactive. Hepatitis B. non-reactive, HIV non- reactive. Pap smear is normal. Gonorrhea and Chlamydia and urine culture is negative.
AB|abortion|AB|124|125|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Pelvic relaxation. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 68-year- old, gravida 5, para 4, AB 1, who is being admitted for vaginal hysterectomy and anterior and posterior repair. The patient states that over the last year or so she has noted a gradual protruding of tissue in the vagina.
AB|abortion|AB,|168|170|PAST OB HISTORY|2. 1997, male, normal spontaneous vaginal delivery, Princeton, no complications, 8 pounds. 3. 1990, elective AB. 4. Unsure date, approximately around 1995, spontaneous AB, did not require dilatation and curettage. PAST GYNECOLOGIC HISTORY: Regular menses. History of Chlamydia in 1993.
AB|abortion|AB|56|57||_%#NAME#%_ _%#NAME#%_ is a 31-year-old gravida 3 para 2 AB 1, last menstrual period _%#MM#%_ _%#DD#%_, 2003, who presents for an operative hysteroscopy. The patient has a history of losing a pregnancy at 25 weeks gestation.
AB|abortion|AB|146|147|REVIEW OF SYSTEMS|Neurologic; As noted above, she has been evaluated for hypesthesias of her face but this spontaneously resolved. Genitourinary: Gravida 3 para 2, AB 1, two Cesarean sections. PHYSICAL EXAMINATION: GENERAL: She is acutely ill. VITAL SIGNS: Blood pressure lying down is 106/58, sitting it drops to 80, pulse 75 and regular, afebrile.
AB|abortion|AB|159|160|REVIEW OF SYSTEMS|No claudication. GI: Has dyspepsia, has been on Prevacid. Is trying to get pregnant now so it not currently taking that. No colon problems. Gravida 1, para 0, AB 1, had a miscarriage at three months. Endocrine: Overweight. Musculoskeletal: Rheumatoid/ankylosing spondylitis, chronic arthritis. Sees Dr. _%#NAME#%_, rheumatologist.
AB|blood group in ABO system|AB|235|236|PLAN|He was born at Fairview-_%#CITY#%_ Birthplace on _%#MMDD2004#%_ at 11:38 hours, transferred to the NICU on the same day, and discharged on _%#MMDD2004#%_. He was a 1856 gm, 34+0 week gestational age male infant born to a 21-year- old, AB positive, gravida 1, para 0 - 0 - 0 - 0, female whose LMP was 2 years ago (secondary to Depo-Provera) and whose EDC was _%#MMDD2004#%_.
AB|abortion|AB|191|192|OB HISTORY|In 1998, she had an ectopic pregnancy for which she underwent the salpingostomy. In _%#MM#%_ 2001, she had a viable male infant, birthweight 6 pounds 9 ounces. In 2002, she had a spontaneous AB at 12 weeks. GYN HISTORY: Regular cycles, no history of sexually transmitted diseases or pelvic inflammatory disease.
AB|blood group in ABO system|AB,|153|155|HOSPITAL COURSE|Discharge instructions were reviewed with her prior to leaving the hospital. Bowel and bladder function were adequate and documented. She is blood group AB, Rh positive and Rubella status immune. DISCHARGE MEDICATIONS: Include oral analgesics. I'll see her back in the office in 10-14 days and again in six weeks.
AB|blood group in ABO system|AB|159|160|HOSPITAL COURSE|He was born at 37-week's estimated gestational age. His weight was 5 lb 4 oz. His length was 18 inches. His OFC 12-1/4 inches. Born to a G5, P5, mother who is AB negative, VDRL negative, Hepatitis B negative, GBS positive, and HIV negative. Upon delivery, the patient was noted to have some difficulty with maintaining temperatures and also with maintaining blood glucose.
AB|abortion|AB.|130|132|PAST OBSTETRICAL HISTORY|Pyelonephritis in _%#MM2004#%_. Anorexia in 1994. ALLERGIES: No known drug allergies. PAST OBSTETRICAL HISTORY: 1. 2001. Elective AB. No complications. 2. 2003. Elective AB. No complications. HOSPITAL COURSE: The patient was admitted and noted to have cervical exam of 1.0 to 2.0 cm, 80%, and 0 station with reassuring fetal heart tones and an estimated fetal weight of 8-1/2 pounds.
AB|abortion|AB|63|64||_%#NAME#%_ _%#NAME#%_ is a 36-year-old female gravida 4 para 1 AB 3 who was brought to the hospital for primary cesarean section. She had a history of habitual miscarriages, was on heparin and switched to Lovenox for most of the pregnancy and then switched the heparin back in the last four weeks of pregnancy.
AB|abortion|AB|75|76|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 32-year-old female, gravida 3, para 1, AB 2, who had her last baby by cesarean section in 2004 and had tubal ligation at that time. She has a history of endometriosis. Her last laparoscopy was in 2003.
AB|blood group in ABO system|AB|271|272|DESCRIPTION|He was born on _%#MM#%_ _%#DD#%_, 2004 at 16:30 hours, transferred to the NICU on _%#MM#%_ 23 and discharged to the newborn nursery on _%#MM#%_ _%#DD#%_, 2004. He was the 4119 gram, 40 week gestational age male infant born at FUMC- _%#CITY#%_ Hospital to a 36 -year-old, AB positive, gravida 2 , para 0010, married Ethiopian female whose LMP was _%#MM#%_ _%#DD#%_, 2004 and whose EDC was _%#MM#%_ _%#DD#%_, 2004.
AB|blood group in ABO system|AB|171|172|HOSPITAL COURSE|3. Infectious Disease. The mother was a 30-year-old with one other child at home. She had Group B strep test which was negative. Hepatitis B negative, rubella immune, and AB positive was blood type. The baby was started on ampicillin and gentamicin and a blood culture and CBC was drawn. The blood culture remained negative throughout the hospital course and antibiotics were discontinued at 48 hours of age.
AB|abortion|AB.|113|115|IMPRESSION|No dilation of the cervical os. EXTREMITIES: Without clubbing, cyanosis or edema SKIN; Clear. IMPRESSION: Missed AB. Plan is for suction D&C. The patient to call should she experience increasing cramping or bleeding and may need to have the procedure performed earlier on an emergency basis.
AB|abortion|AB|178|179|COMPLICATIONS|On _%#MM#%_ _%#DD#%_, 2005, at 29 plus 5 weeks, fetus was small for gestational age. AFI was 16. Vertex with normal anatomy. PAST OB HISTORY: Includes a first trimester elective AB in _%#MM#%_ 2002. PAST GYN HISTORY: Negative for sexually transmitted diseases or PID. The patient has normal menses. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: None.
AB|abortion|AB|212|213|PAST OBSTETRICAL HISTORY|PAST MEDICAL HISTORY: The patient's past history reveals that she had a toxic reaction to sulfonamides with usage of sulfa in 1948 and kidney reaction. PAST OBSTETRICAL HISTORY: The patient is gravida 6, para 6, AB 0. PAST SURGICAL HISTORY: She has had a hysterectomy and excision of bilateral fractured patellae.
AB|abortion|AB.|223|225|OB HISTORY|OB HISTORY: She is a gravida 4, para 1-0-2-1. First child in _%#MM#%_ 2003, delivered at 42 weeks, primary cesarean section for face presentation, a female infant, 8 pounds 8 ounces. Following that, she had two spontaneous AB. Please note, the patient had prenatal care in this pregnancy starting at 10 weeks at _%#CITY#%_ _%#CITY#%_ People's Center and transfer of care was done at 22 weeks.
AB|blood group in ABO system|AB|142|143|HISTORY OF PRESENT ILLNESS|Prenatal care was followed with Fairweeks CNM since 6 weeks. Total of 12 visits. Normotensive during prenatal care. PRENATAL LABORATORY DATA: AB positive, antibody screen negative, HIV negative, RPR negative, hepatitis B negative. Hemoglobin 14.2, rubella immune, GBS negative. PAST MEDICAL HISTORY: Migraines and herpes simplex infection.
AB|abortion|AB.|235|237|PAST OBSTETRIC HISTORY|PAST OBSTETRIC HISTORY: 1. On _%#MM#%_ _%#DD#%_, 1990, C-section for failure to progress, PPROM failure to progress. The patient also had PPROM and pregnancy induced hypertension during this pregnancy. 2. On _%#MM#%_ 1989, spontaneous AB. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: C-section x1. ADMISSION MEDICATIONS: Prenatal vitamins. ALLERGIES: No known drug allergies.
AB|abortion|AB|155|156|HISTORY OF PRESENT ILLNESS|The quantitative HCG were 63,000 and her RH type is A Rh positive, no antibodies. Hemoglobin was 11.8. We explained to the patient the diagnosis of missed AB and she was offered suction curettage or other option would be to miscarry on her own. The patient now waited for a few weeks and has not miscarried on her own and decided to have suction curettage of the uterus for which she is scheduled at Fairview Southdale Hospital.
AB|abortion|AB|63|64||_%#NAME#%_ _%#NAME#%_ is a 41-year-old female gravida 5 para 0 AB 5 who had in vitro fertilization, approximately four and a half weeks gestation, who had some pain on the right side and had a beta HCG of 2847 on _%#MM2006#%_. Ultrasound showed no evidence of intrauterine pregnancy, small cystic area near the right adnexa, ill defined.
AB|abortion|AB.|222|224|PATIENT IDENTIFICATION|The findings were consistent with a fetal demise. The HCG was 27,194. The patient's blood type is A positive. The patient was encouraged to schedule an appointment at our office for evaluation and management of her missed AB. The patient presents today for evaluation. At the present time, she is no longer having bleeding and is not cramping.
AB|abortion|AB,|93|95|IMPRESSION|There are no adnexal masses. Bimanual exam confirms. EXTERMITIES: Normal. IMPRESSION: Missed AB, 9+ weeks gestation by dates, 6+ weeks gestation confirmed by ultrasound on _%#MMDD2006#%_ at Fairview Ridges Hospital. Blood type A positive. The patient requests suction vacuum curettage.
AB|abortion|AB.|129|131||She was pregnant with her first pregnancy recently. Approximately 2 weeks ago she had an ultrasound which showed probable missed AB. She was seen one week later in _%#CITY#%_ which confirmed missed AB. She states an hCG level was obtained, but she does not know that number.
AB|abortion|AB.|203|205|PAST MEDICAL HISTORY|She did have A1 gestational diabetes although had excellent blood sugar control with diet alone. PAST MEDICAL HISTORY: Noncontributory. SURGICAL: Cesarean section and dilation and curettage for elective AB. SOCIAL HISTORY: Occupation: The patient is a business analyst for Wells Fargo and is married.
AB|abortion|AB|223|224|PAST SURGICAL HISTORY|She then continued through a normal prenatal course and was found to be Rh positive and rubella immune, and GBS positive. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: Dilation and curettage in _%#MM2005#%_ for missed AB at seven weeks. FAMILY HISTORY: Hypertension in parents. MEDICATIONS; Prenatal vitamins. SOCIAL HISTORY: The patient is married and is a housewife.
AB|abortion|AB|132|133|PAST SURGICAL HISTORY|She was then transferred to the postoperative ward. PAST MEDICAL HISTORY: Hypertension and obesity. PAST SURGICAL HISTORY: Elective AB and D and C x3 due to miscarriages. ALLERGIES: PENICILLIN AND SULFA. SOCIAL HISTORY: The patient denies tobacco, alcohol, or drug usage.
AB|blood group in ABO system|AB|109|110|LABORATORY|SOCIAL HISTORY: The patient does use tobacco. She denies any alcohol or illicit drug use. LABORATORY: She is AB positive, antibody screen negative, rubella immune, hemoglobin of 11, VDRL negative, HIV negative, hepatitis B negative, GCT 99, and a GBS negative.
AB|blood group in ABO system|AB|87|88|PRENATAL LABS|She was seen by Dr. _%#NAME#%_ at Fairview Southdale. PRENATAL LABS: She is blood type AB positive. Fetal fibronectin positive on _%#MM#%_ _%#DD#%_, 2006. UA showed large blood, 5 wbc, and negative ketones. PAST GYN HISTORY: Clomid pregnancy. No history of STDs. No abnormal Pap smears.
AB|abortion|AB|196|197|ASSESSMENT AND PLAN|BLOOD TRANSFUSIONS: Denies. PHYSICAL EXAMINATION: Pending to a.m. of admission, vital signs pending to a.m. of admission. Height 5 feet 5 inches Blood type A positive. ASSESSMENT AND PLAN: Missed AB at 7 weeks by size and 6 weeks by last menstrual period. The patient was offered expectant management; she wishes to proceed with suction vacutage.
AB|abortion|AB|133|134|CHIEF COMPLAINT|Ultrasound demonstrated an intrauterine gestational sac with fetal pole and no evidence of cardiac activity consistent with a missed AB at 9 weeks. The patient has denied any cramping or bleeding. She presents today for suction D&C. PAST MEDICAL HISTORY: Significant for history of endometriosis. PAST SURGICAL HISTORY: The patient has had a previous laparoscopy for endometriosis in 2005.
AB|abortion|AB|118|119|PAST SURGICAL HISTORY|PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: 1. Cesarean section in _%#MM#%_ of 2004. 2. Suction D&C for missed AB in _%#MM#%_ of 2006. MEDICATIONS: Prenatal vitamins. ALLERGIES: No known drug allergies. SOCIAL HISTORY: She is married.
AB|abortion|AB|70|71||_%#NAME#%_ _%#NAME#%_ is a 35-year-old female, gravida 2, now para 2, AB 0, who had a first baby by cesarean section and now at 37 weeks gestation was brought in for repeat cesarean section because of previous cesarean section. Also, had pregnancy-induced hypertension that was stable, but with no improvement.
AB|abortion|AB|70|71||_%#NAME#%_ _%#NAME#%_ is a 32-year-old female, gravida 2, now para 2, AB zero. First, cesarean section was done in 2003 with a 9 pound 5 ounce baby because of failure to progress, the patient was followed her entire pregnancy and was scheduled for a repeat cesarean section at 39 weeks gestation with a floating vertex and unfavorable cervix.
AB|blood group in ABO system|AB|188|189|DISCHARGE MEDICATIONS|At the time of discharge, the infant's corrected gestational age was 37 weeks and 5 days. She was the 1488 gm, 34 1/7 week gestational age female infant born at UMMC, FV to a 30-year-old, AB positive, gravida 3, para 3-0-0-3, married Somali female whose EDC was _%#MMDD2007#%_. The mother's pregnancy was complicated by pre-eclampsia. The infant was delivered by cesarean section with Apgar scores of 4 at one minute and 8 at five minutes.
AB|blood group in ABO system|AB|216|217|HOSPITAL COURSE|Cardiolipin antibody negative, IgM and IgG Kleihauer-Betke was elevated at 5.7%, fetal cells seen. However, this is consistent with her status as a beta thalassemia carrier. Antibody screen was negative . Blood type AB positive, direct antiglobulin negative.
AB|MISTAKE:abduction|AB|184|185|PHYSICAL EXAMINATION|This has significantly improved. NEUROLOGIC: Sensory exam is within normal limits. His muscle strength reveals slight proximal weakness remaining. Hip flexors are 4/5 bilaterally. Hip AB and AD duction are 5/5 bilaterally. Distally in lower extremity he is 5/5 this has significantly improved from admission.
AB|abortion|AB|263|264|ASSESSMENT|I have reviewed with them the findings, the risks, the benefits and the alternative forms of therapy, I have answered all their questions, their H&P has been updated, and no further changes in her exam was noted from one week ago. ASSESSMENT: Intrauterine missed AB consistent with approximately 5 weeks gestational age, no evidence of ectopic gestation. PLAN: Proceed with suction curettage under MAC anesthetic.
AB|abortion|AB|67|68|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 42-year-old gravida 4, para 0, AB 3, last menstrual period _%#MMDD2001#%_, estimated date of confinement _%#MMDD2002#%_, who presented for her first trimester ultrasound following some vaginal spotting. The ultrasound was performed on _%#MMDD2002#%_ when she would have been 8 weeks and 3 days by excellent dates.
AB|abortion|AB,|291|293|HISTORY OF PRESENT ILLNESS|The patient was seen for a scheduled nonstress test, and had a spontaneous deceleration, which spontaneously resolved. On admission, a Perinatology consult was obtained, and a biophysical profile was performed, which was 10/10, but significant for confirming an intrauterine growth retarded AB, weighing approximately 5 pounds, associated with polyhydramnios, with an AFI of 28.4, and a grade 3 placenta. The plan at admission for induction of labor. The patient's past obstetrical history does not involve any prior pregnancies.
AB|blood group in ABO system|AB|145|146|ALLERGIES|She is a pre-law student. MEDICATIONS: 1. Prozac. 2. Albuterol inhalers. ALLERGIES: She has no known drug allergies. LABORATORY DATA: Blood type AB positive. Antibody screen negative. Rubella immune. HIV negative. Hepatitis B surface antigen negative. On evaluation to labor and delivery she was afebrile with stable vital signs.
AB|blood group in ABO system|AB|98|99|LABS|PRENATAL CARE: She was seen by the Family Practice physicians. She had a total of 6 visits. LABS: AB positive, antibody negative, rubella not immune, RPR negative, hepatitis C negative, hemoglobin 11.9, gonorrhea and Chlamydia negative, UA/UC negative, Pap smear with benign cellular changes, HIV negative, GCT 71.
AB|abortion|AB|76|77||_%#NAME#%_ _%#NAME#%_ is a 30-year-old Caucasian female, gravida 3, para 1, AB 2, who has had an episode of an ovarian cyst on the left side that seemed to be functional when evaluated originally in _%#MM#%_ of 2002. At that time, her ultrasound showed a 75 mm by 55 mm left ovarian cyst and the right side had a 3 by 3 cm cyst.
AB|abortion|AB.|136|138|PAST SURGICAL HISTORY|PAST SURGICAL HISTORY: 1. In 1986, a 40-week 7-pound 8-ounce NSVD female. 2. In 2000, a 36-week 8-pound 15-ounce NSVD male. 3. Elective AB. 4. Spontaneous AB. PAST MEDICAL HISTORY: She has had Lasik eye surgery.
AB|blood group in ABO system|AB|121|122|LABORATORY DATA|The patient was sent to labor and delivery following this. ALLERGIES: Aspirin. LABORATORY DATA: Prenatal: The patient is AB positive, serology non-reactive, rubella immune, antibody screen is negative, hepatitis B surface antigen is negative, HIV non-reactive, pap smear from _%#MMDD2001#%_ is within normal limits.
AB|abortion|AB|206|207|HISTORY OF PRESENT ILLNESS|Fetal pole was visualized. The yolk sac was visualized. However, fetal cardiac pulsation or cardiac activity was not visualized. Both ovaries were visualized and normal in size. The impression was a missed AB at 6 weeks 6 days. These findings were discussed with the patient. Her options were discussed including observation vs Cytotec vs suction D&C.
AB|blood group in ABO system|AB|175|176|HISTORY OF PRESENT ILLNESS|She is already on Macrobid for a suspected urinary tract infection. She has had no fevers. No other specific complaints. Her prenatal laboratories showed her to be blood type AB positive, antibody negative, Rubella immune, and negative for all screened diseases including syphilis, hepatitis B, HIV, GC, and Chlamydia. Her blood sugars were normal on her three hour GTT as she failed the one hour screen.
AB|blood group in ABO system|AB,|190|192|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 29-year-old primigravida with last menstrual period of _%#MMDD2002#%_ and estimated date of confinement by early ultrasound of _%#MMDD2002#%_, blood type AB, Rh positive. She was admitted to labor and delivery at 05:00 hours on _%#MMDD2003#%_ at term gestation in early labor. She had been followed for prenatal care since _%#MMDD2002#%_ at 10 weeks gestation and the prenatal course was entirely uncomplicated.
AB|abortion|AB|344|345|PAST SURGICAL HISTORY|She does have secondary infertility as described above and a history of endometriosis. ALLERGIES: Codeine. MEDICATIONS: Prenatal vitamins. PAST SURGICAL HISTORY: Laparoscopy with pelviscopy in _%#MM#%_, 2000, laparotomy with left salpingo-oophorectomy and fulguration of endometriosis in _%#MM#%_ of 2001, vacuum suction curettage for a missed AB in _%#MM#%_, 2001. HEALTH HABITS: Tobacco and alcohol: None. FAMILY HISTORY: Significant for mother with hypertension, grandfather with colon cancer, and a grandfather with heart disease.
AB|blood group in ABO system|AB|247|248|1. F/E/N|This was initiated secondary to her being in the same environment as her twin sister who was clinically worse upon admission. Blood cultures were negative upon discharge. 6. Heme. Admission CBC was within normal limits. _%#NAME#%_'s blood type is AB positive, her mother is B negative and did receive Rhogam. DAT was negative. Ongoing problems and suggested management: 1. _%#NAME#%_ will need continued monitoring of nutritional support and growth evaluation.
AB|abortion|AB|166|167|HISTORY OF THE PRESENT ILLNESS|The options were given to her for spontaneous abortion versus dilatation and curettage. She has a active life style at work. She did not want to wait for spontaneous AB and she wanted to do the dilatation and curettage and this is scheduled for _%#MM#%_ _%#DD#%_ at Fairview Southdale Hospital.
AB|blood group in ABO system|AB|184|185|HOSPITAL COURSE|The patient's Apgars were 5 and 8. Mother was negative for Hepatitis B, negative for Group B strep, negative for HIV, negative for BDRL and was rubella immune. Mother's blood type was AB Positive. Birth weight was 3375 grams. The patient was on ampicillin and gentamicin and then switched to ampicillin and cefotaxime.
AB|abortion|AB.|136|138|PAST OBSTETRICAL HISTORY|Screen for ANA and anticardiolipin antibody and antiphospholipid antibody normal. PAST OBSTETRICAL HISTORY: In 1987 she had an elective AB. In _%#MM#%_ 2002 she had a 10 week spontaneous AB. PAST GYNECOLOGICAL HISTORY: Significant for a dermoid cyst that was removed in 1999.
AB|abortion|AB|328|329|OB HISTORY|PAST MEDICAL HISTORY: Hypertension. PAST SURGICAL HISTORY: 1. Status post bilateral knee replacements, the last one in 2000. 2. Appendectomy in 1938. 3. Cataract surgeries OU. OB HISTORY: She is gravida 5 para 4 with one child dying as a premature, she said the delivering physician decided the child should not live and also 1 AB spontaneous. MEDICATIONS: 1. Atenolol 50 mg q.a.m. 2. Hydrochlorothiazide 50 mg q.a.m.
AB|abortion|AB|110|111|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 34-year-old gravida 6 para 2-0-3-2 with a known missed AB at 7 weeks gestation. It was discussed with patient her options. The patient desires a suction D&C. The patient would also like the tissue sent for chromosome analysis as this is her third miscarriage this year.
AB|abortion|AB.|195|197|PAST OBSTETRICAL HISTORY|She use to smoke three to four cigarettes a day prior to pregnancy. PAST OBSTETRICAL HISTORY: 1. _%#MM1999#%_, 40 weeks, 9 1/2 pounds, cesarean section in _%#CITY#%_. 2. _%#MM2000#%_ spontaneous AB. 3. _%#MM2001#%_, 39 weeks, 8 pounds 9 ounces, cesarean section at _%#CITY#%_. PAST GYNECOLOGICAL HISTORY: The patient has irregular menses. Denies any sexually transmitted diseases in the past.
AB|blood group in ABO system|AB|173|174|LABORATORY DATA|We discussed the options of an external version attempt vs cesarean section and the patient has elected to proceed with cesarean section. LABORATORY DATA: Her Blood Type is AB negative. All the rest of her labs were normal. Her hepatitis screen was negative. Her Bell titer is immune. Her beta strep culture was negative. Her hemoglobin was 12.1. PAST SURGICAL HISTORY: LEEP procedure.
AB|abortion|AB|68|69|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 36-year-old, gravida 4, para 0, AB 3, who was admitted at term in active labor. Her antepartum course was complicated by gestational diabetes. She was monitored with twice weekly nonstress tests for three to four weeks.
AB|abortion|AB|87|88|BRIEF HISTORY|BRIEF HISTORY: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 34-year-old, gravida 2 para 2 now AB 0 who is brought at 38-1/2 weeks for elective induction of labor with a cervix that was 3.0-cm. She was started on Pitocin brought up in a stepwise fashion until she reached up to 20 mL/minute, having contractions at that time every 4 minutes. At about 1355 hours in the afternoon ruptured bag of water was performed showing clear fluid.
AB|blood group in ABO system|AB|187|188||She had a pregnancy that was complicated by herpes gestationis and has been on prednisone for that. She also had low platelets which had been followed by hematologist. Her blood type was AB positive. She is rubella immune, hepatitis B surface antigen, RPR and HIV were all negative. She had a normal three hour glucose tolerance test. Her triple screen was normal.
AB|abortion|AB|151|152|PAST OBSTETRICAL HISTORY|Delivery was reported as "difficult," with possibly a shoulder dystocia, as well as the use of both a vacuum and forceps. 2. She has also had elective AB in 1996, at 7-8 weeks. 3. In _%#MM2002#%_, she had a 6 week spontaneous miscarriage. 4. In _%#MM2002#%_, she had an 8 week elective termination.
AB|abortion|AB|173|174|ASSESSMENT|ABDOMEN: Soft. Uterus not palpable. GU: The patient has had no vaginal bleeding this pregnancy and has history of 1 miscarriage with her first pregnancy. ASSESSMENT: Missed AB at 10 weeks by LMP with fetus at 6 weeks, by crown-rump length. PLAN: CBC and ABO Rh was done and review of previous prenatal records shows the patient is A positive.
AB|abortion|AB|75|76|OBSTETRICAL HISTORY|11. EFW of 2920 g and a VP of 8/8. OBSTETRICAL HISTORY : 1. 1986, elective AB at 8 weeks. No complications. 2. In _%#MM#%_ 1991 at 40 weeks, Cesarean section for fetal distress and no complications.
AB|blood group in ABO system|AB|106|107|LABS|Cervix closed. Uterus mid-position, freely mobile, 6-7 week size, soft. LABS: The patient's blood type is AB positive. Hemoglobin 11.6, WBC 10,000, platelets 215,000. IMPRESSION: Missed abortion, status post outpatient dilatation and curettage, retained products of conception.
AB|abortion|AB|142|143|SURGERY|She has been on a Betaseron long term. Followed by Dr. _%#NAME#%_ _%#NAME#%_ from neurology. SURGERY: None. The patient is gravida 1, para 0, AB one. The patient denies heart disease, hypertension, asthma, diabetes, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, thyroid disease, seizure, tuberculosis or anemia.
AB|abortion|AB|140|141|PAST SURGICAL HISTORY|5. History of Hashimoto's thyroiditis, not requiring Synthroid replacement. PAST SURGICAL HISTORY: 1. Tubal ligation. 2. Gravida 3, para 3, AB 0. 3. Bilateral breast reduction surgery in 1997. She denies heart disease, diabetes, hypertension, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, seizure, tuberculosis, or anemia.
AB|abortion|AB|75|76|ASSESSMENT|Small complex cysts in both ovaries, no free fluid. ASSESSMENT: Threatened AB vs. ectopic pregnancy. PLAN: The patient was given the three scenarios of a normal pregnancy that continues to term, a miscarriage and an ectopic pregnancy.
AB|abortion|AB|163|164|PAST SURGICAL HISTORY|PAST MEDICAL HISTORY: 1. Depression (details per Psychiatry). 2. History of pneumonia (remote). PAST SURGICAL HISTORY: Wisdom teeth extraction. Gravida 4, para 4, AB 0. Denies heart disease, diabetes, hypertension, asthma, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, thyroid disease, seizure, tuberculosis, or anemia.
AB|abortion|AB|300|301|IMPRESSION|3. Questionable distal filling defects in the right lower lobe: Radiologist not definitive for this with no evidence of proximal filling defects. 4. Marginally increased D-dimer. 5. Some risk factors for thromboembolic disease including the use oral contraceptives, recent smoker, recent spontaneous AB and a family history of father and paternal grandmother with strokes at an early age (unclear as to whether or not these were hemorrhagic or thromboembolic).
AB|abortion|AB|171|172|HISTORY OF PRESENT ILLNESS|Ms. _%#NAME#%_ _%#NAME#%_ is a 25-year-old female who stopped smoking approximately one week ago. She has recently started oral contraceptive pills. She had a spontaneous AB within the last few weeks. The patient had a two- to three-day history of gradually worsening left-sided pleuritic chest pain that increased to the point where she required evaluation in the Emergency Department.
AB|abortion|AB.|203|205|PAST MEDICAL HISTORY|No central chest discomfort. No lower extremity swelling. No recent periods of immobility or being sedentary. PAST MEDICAL HISTORY: Medical history is remarkable for the following: 1. Recent spontaneous AB. 2. Prior history of cigarette smoking. 3. No previous history of thromboembolic disease. FAMILY HISTORY: Positive for stroke on the part of her father when he was in his early 30s.
AB|abortion|AB|212|213|IMPRESSION/RECOMMENDATIONS|The parents claim that autopsy was negative. Although we did not see an autopsy report in her records that we received, karyotype was performed and was 46, XY (normal male). 2. In _%#MM#%_ of 2006, a spontaneous AB at about 4 weeks' gestation. The patient claims that there was a possible gestational sac, but cardiac activity was never noted.
AB|antipyrine benzocaine|AB|122|123|ASSESSMENT|4. Psoriasis. The patient will be started on triamcinolone as well as lotion. 5. Right ear wax. The patient will continue AB otic solution. 6. Constipation. The patient will consider continue Colace. 7. Flatus. The patient will have simethicone on a p.r.n. basis.
AB|abortion|AB|275|276|INFORMANT SOURCES|CHIEF COMPLAINT: Osteopetrosis, developmental assessment. INFORMANT SOURCES: Old medical records, discussion of team, interview with father, personal review of the cranial CT and x-rays on the PAC system. _%#NAME#%_ was a 2.015 kg product of a 35-week gestation to a G3, P0, AB 2 female with pregnancy complicated by polysubstance abuse of methadone, Xanax, marijuana, clonazepam and tobacco with a 5 month attempt at getting her into drug rehab, finally successful at 8 days prior to delivery, who presented with oligohydramnios and IUGR and delivered by cesarean section without antenatal steroid doses.
AB|abortion|AB|187|188|RECOMMENDATIONS|She stated that she was not certain what she would in the event there was an abnormality found, but was interested in first trimester screening. As stated earlier, unfortunately a missed AB was seen on ultrasound today. If we can be of any further assistance or support for this patient during this time please feel free to contact me at _%#TEL#%_.
AB|abortion|AB|316|317|TELEPHONE CONVERSATION|TELEPHONE CONVERSATION: The conversation was with _%#NAME#%_ _%#NAME#%_ who represented herself as her mother and stated that she had had permission from her daughter to discuss specific medical concerns. The patient, _%#NAME#%_ _%#NAME#%_, is a young woman who is 11 days status post suction curettage for a missed AB by Dr. _%#NAME#%_. Today she has noted worsening lower back pain and cramping. She continues to use a pad, which needs to be changed 2 to 3 times a day.
AB|abortion|AB.|142|144|PLAN|She was offered a suction D&C with repeat beta hCG afterwards to check for decreasing quantitative beta hCG levels for complete versus missed AB. She understands the pathology from the suction D&C may be negative due to early gestation, but understands that even with negative pathology, with an intrauterine pregnancy, beta hCG levels should decrease after a suction D&C.
AB|abortion|AB|179|180|ASSESSMENT|4. Distal upper extremity tremor likely related to medication effect, ie, Zyprexa. 5. Remote history of syncope. 6. Status post spine surgery for scoliosis. 7. Gravida 3, para 3, AB 0. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Hold further Zyprexa pending review by Psychiatry.
AB|abortion|AB|163|164|SURGERIES|SURGERIES: 1. Total abdominal hysterectomy and bilaterally salpingo-oophorectomy for endometriosis 8 years ago. 2. Status post bladder "tuck". 3. Gravida 2 para 2 AB 0. Denies known history of heart disease, hypertension, diabetes, asthma, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, thyroid disease, seizure, tuberculosis, or anemia.
AB|abortion|AB|63|64||_%#NAME#%_ _%#NAME#%_ is a 28-year-old female gravida 2 para 2 AB 0 who lives in _%#CITY#%_ and has a very complex reproductive history with a history of endometriosis and a very difficult last pregnancy because of incompetent cervix and pregnancy-induced hypertension, and cerclage with preterm labor in her last pregnancy. She was induced and delivered after the cerclage was cut and had a normal infant female at 8 pounds 3 ounces.
AB|atrioventricular:AV|AB|126|127|LABORATORY DATA|Myoglobin 39. Troponin less than 0.7. Electrolytes were normal. WBC 12.1. Glucose 137. Hemoglobin was 13.1. EKG: First degree AB block with left bundle branch block previously on old EKGs. ASSESSMENT/PLAN: _%#NAME#%_ _%#NAME#%_ is a pleasant 46-year-old female who has been seen currently for intermittent palpitations, has been monitored for over a hour while she states she has had symptoms, had no significant arrhythmia as seen on the monitor.
AB|abortion|AB|176|177|ASSESSMENT|There is normal flow to both ovaries. The left ovary is entirely normal. ASSESSMENT: This is a 26-year-old female who is likely undergoing miscarriage. This may be a completed AB at this point or an incomplete AB. She is clinically stable. PLAN: 1. She should follow up in the Women's Health Clinic in approximately 2 days for repeat beta HCG and further evaluation.
AB|abortion|AB|158|159|PAST MEDICAL HISTORY|New crop of varicosities involving the right medial thigh distally. No increase in lower extremity pain or edema. PAST MEDICAL HISTORY: 1. Gravida 3, para 2, AB 0; uncomplicated. 2. Lower extremity varicosities, right greater than left leg, as above. No history of DVT. Surgeries: None. Other known serious illness: None.
AB|abortion|AB.|232|234|IMPRESSION|There is no cervical motion tenderness. Adnexa are both negative confirmed by rectovaginal exam. LAB STUDIES: The patient is Rh positive. IMPRESSION: A 22-year-old G2, P1-0-0-1 at 5 plus 1 week by LMP _%#MMDD2007#%_ with incomplete AB. PLAN: 1. Incomplete AB: Options were given to the patient regarding management at this time; given her bleeding and pain, expected management was offered, but not recommended.
AB|abortion|AB|155|156|PAST SURGICAL HISTORY|Denies suicidal ideation. PAST MEDICAL HISTORY: Major depressive disorder, as above (details per Psychiatry). PAST SURGICAL HISTORY: 1) Gravida 2, para 2, AB 0. 2) Tubal ligation. 3) Appendectomy. Denies heart disease, diabetes, hypertension, asthma, renal disease, peptic ulcer disease, hepatitis or gallbladder disease, thyroid disease, seizure, tuberculosis, or anemia.
AB|abortion|AB|294|295|HISTORY OF PRESENT ILLNESS|The patient has significant obstetric history for two previous ectopic pregnancies; one treated with methotrexate in 2001 followed by a second requiring laparoscopy secondary to rupture in 2004 at which time the patient believes she her lost her right tube and ovary. She also has one elective AB with her obstretical history. The patient was seen at the Face to Face Clinic in hopes that this was a viable IUP. No labs were done. However, the patient was informed to return at approximately 10 weeks gestation as she is 5+3 by her LMP of _%#DDMM2006#%_ today.
AB|abortion|AB.|172|174|IMPRESSION|This appears to be separate from the ovary. The ovaries were both normal, and the uterus was of normal size and a normal endometrial stripe. IMPRESSION: 1. Likely complete AB. 2. Right adnexal mass, possibly a hydrosalpinx. PLAN: The patient is not a surgical candidate, and it does not appear that she is pregnant anymore.
AB|abortion|AB|133|134|PLAN|Also, given her exam, I do not believe that she is a surgical candidate. The patient understands that she most likely had a complete AB and that this ultrasound finding is incidental. I did suggest that she follow up at the Fairview _%#CITY#%_ Women's Clinic in four to six weeks for a follow-up ultrasound.
AB|abortion|AB|142|143|ASSESSMENT|Negative trich. She did have clue cells and wet prep was asymptomatic. ASSESSMENT: A 41-year-old gravida 4, para 3-0-0-3 with either a missed AB or a viable IUP. This is reviewed with the patient that it is very concerning to know where she is in her pregnancy because there is always a concern for choriocarcinoma.
AB|abortion|AB|144|145|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ presented to the emergency room on _%#MMDD2005#%_ for evaluation. She is a gravida 5, para 4, AB 1, who has a known positive pregnancy test. Her last menstrual period had started in early _%#MM#%_, but she had some bleeding following the period.
AB|abortion|AB|227|228|PLAN|Transvaginal ultrasound revealed a slightly irregular gestational sac that was 9.7 x 12.6 x 9.0 mm, corresponding to a gestational age of 5 weeks 1 day plus/minus 1 day. The patient was told that this was a possible threatened AB versus early pregnancy. Plans were made for her to have a beta HCG drawn in the hospital, followed by a second value 48 hours later, and follow-up was scheduled.
AB|abortion|AB|180|181|HISTORY OF PRESENT ILLNESS|The patient took an over-the-counter yeast infection medication and that has resolved as of yesterday. PAST OB HISTORY: Three cesarean section deliveries at term and 1 spontaneous AB at 7 weeks. First cesarean section was due to nonreassuring fetal heart tones, the second cesarean section sounds like it was due to a placenta previa.
AB|abortion|AB,|180|182|PHYSICAL EXAMINATION|There is a trace of fluid in the cul-de-sac. There is a nabothian cyst present in the cervix. The findings are discussed with the patient. I certify that she is having spontaneous AB, and that she is not experiencing an ectopic pregnancy. I offered her a D and C here versus expectant management with follow up in _%#CITY#%_, and that she may travel today.
AB|abortion|AB|146|147|PROBLEM|PROBLEM: Abdominal pain. HISTORY OF PRESENT ILLNESS: Patient is a 25-year-old G1, P0, approximately 12-weeks pregnant who has a known spontaneous AB and presents to the ER this morning with abdominal pain. She was seen in the emergency room at _%#CITY#%_ Hospital on _%#MM#%_ _%#DD#%_, 2005, with vaginal bleeding and cramping.
AB|arterial blood|AB|199|200|ASSESSMENT AND PLAN|Electrolytes were normal. Creatinine 0.4, INR 1.24. ASSESSMENT AND PLAN: 43-year-old gentleman status post HeartMate XV LVAD is ready for extubation once we see an ABG gas, once we see a CPAP trial, AB arterial blood gas, continue diuresis with Lasix. We will also get a speech evaluation prior to instilling oral feeding.
AB|abortion|AB|132|133|ASSESSMENT|ASSESSMENT: 27-year-old gravida 1 para 0 female at 10+5 weeks' estimated gestational age by last menstrual period with known missed AB now status post passage of tissue and cramping. Physical examination suggestive of complete passage of all products of conception as the patient is now without vaginal bleeding.
AB|abortion|AB|171|172|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Included a hysterectomy and cholecystectomy, bilateral carpal tunnel surgery. She has had a T&A and an appendectomy. She is also gravida 10, para 9, AB 1, all vaginal deliveries. MEDICATIONS: She takes the diabetic medicines as noted above. In addition to that, she is on amitriptyline 25 mg at hs, Atenolol 50 mg q.a.m., Kay Ciel 40 mEq a day, 20 mg of Lasix b.i.d., Prinzide 20-12.5 q.a.m., 81 mg of aspirin a day, Zocor 40 mg a day in addition to the Avandia, 70/30 insulin and Glucotrol.
AB|UNSURED SENSE|AB|225|226|SOCIAL HISTORY|It was not associated with nausea, shortness of breath, dizziness, palpitations or radiation into the neck, jaw or arms but he was mildly clammy during it. SOCIAL HISTORY: He is a retired printing press repairman working for AB Company. He is married with 3 children and 4 grandchildren. REVIEW OF SYSTEMS: Shows that he does use Tums morning and evening for muscle cramps rather than for GI distress and tends toward diarrhea rather than constipation and has an occasional ache and pain is his usual.
AB|atrioventricular:AV|AB|395|396|ASSESSMENT/PLAN|I suspect this is related to implantation of his AICD and this was also shown in the MADIT II trial that, despite a survival benefit, many of the patients had worsening congestive heart failure and this is most likely due to the fact that he has a fair amount of pacing which is wide complex which is less efficient. We will have his pacemaker reprogrammed to decrease the rate and increase the AB delay such that he paces less frequently. 4. He appears to be responding to Lasix already. I will, as he is in the hospital with decreased left ventricular function, put him on a course of Natrecor to tune him up.
AB|abortion|AB|202|203|PRIOR SURGERY|ALLERGIES: None. MEDICATIONS: On admission was taking lithium, Seroquel, clotrimazole, and topical TMC as well as Depo-Provera injections. PRIOR SURGERY: Had a therapeutic AB in 2005. Had a spontaneous AB in 2006. No other hospitalizations or surgery. CHRONIC DISEASE/MAJOR ILLNESS: History of bipolar disease.
AB|abortion|AB,|234|236|IMPRESSION|Appears as though it may be an embryonic pregnancy with her last menstrual 3 weeks ago, actually was most likely bleeding during early pregnancy rather than a true menstrual period. It appears as though this may end up to be a missed AB, given a sac size measuring 6 weeks without fetal pull and a quant of 16,000. 2. Laboratory evaluation is suggesting a urinary tract infection, which may be the cause of her diffuse pelvic tenderness.
AB|abortion|AB|239|240|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: I was consulted by Dr. _%#NAME#%_ _%#NAME#%_ from the Department of Obstetrics for the purpose of evaluation and management of diabetes mellitus. HISTORY OF PRESENT ILLNESS: The patient is a 36-year-old gravida 2, para 2, AB 0 white female who was admitted and delivered by cesarean section at 33 and 5/7 weeks for a non-reassuring fetal heart rate monitoring strip.
AB|abortion|AB|81|82|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 19-year-old black female, gravida 2, para 1, AB 1, who presented to the ER with hemorrhage, low blood pressure, hemoglobin 8.9 and platelets of 56,000. The patient had had a D & E at Meadowbrook Abortion Clinic today earlier in the day and then when she was at home started bleeding and passing large clots.
AB|abortion|AB.|219|221|HISTORY OF PRESENT ILLNESS|She has also had light-headedness upon standing, with graying of vision, intermittently for the past month. The patient is status post suction curettage on _%#MMDD2004#%_ at Fairview Ridges Hospital for probable septic AB. She had originally been admitted on _%#MMDD2004#%_ with what appeared to be sepsis. Following the suction curettage, the patient improved rapidly. Her initial hCG on _%#MMDD2004#%_ had been 37,877.
AB|abortion|AB|125|126|PAST OBSTETRIC HISTORY|The patient reports normal fetal movement, no bleeding, no loss of fluid. PAST OBSTETRIC HISTORY: In 2003, NSVD. Spontaneous AB x1. PAST GYNECOLOGIC HISTORY: Negative. PRENATAL CARE: The patient is A positive, rubella immune, RPR negative, hepatitis B surface antigen negative, hepatitis B surface antibody negative.
AB|abortion|AB,|184|186|PRIOR SURGICAL HISTORY|4. Congenital defect left kidney. 5. Hypertension. 6. History of hepatitis B. PRIOR SURGICAL HISTORY: 1. Surgical correction of a renal defect. 2. Gravida 4, para 0 with 1 spontaneous AB, one tubal pregnancy, three therapeutic AB. 3. Multiple surgeries on her left leg after a traumatic fracture. 4. She has no history of cardiopulmonary disease or diabetes.
AB|abortion|AB.|149|151|PRIOR SURGICAL HISTORY|PRIOR SURGICAL HISTORY: 1. Surgical correction of a renal defect. 2. Gravida 4, para 0 with 1 spontaneous AB, one tubal pregnancy, three therapeutic AB. 3. Multiple surgeries on her left leg after a traumatic fracture. 4. She has no history of cardiopulmonary disease or diabetes.
AB|abortion|AB|76|77|TBA 7/24/03|TBA _%#MMDD2003#%_ _%#NAME#%_ _%#NAME#%_ is a 44-year-old gravida 5 para 3, AB 2, who presented on _%#MMDD2003#%_ with complaint of severe dysmenorrhea and pelvic pain, desiring a hysterectomy. She has a history of endometriosis which was diagnosed back in 1998 by laparoscopy.
AB|blood group in ABO system|AB|197|198|PLAN|She had no further cardiovascular instability during her hospitalization. Problem #4: Hyperbilirubinemia. _%#NAME#%_ received phototherapy for a peak bilirubin level of 5.4 mg%. Her blood type was AB positive; maternal blood type was A positive. Antibody screening tests were negative. The last bilirubin level prior to discharge was 8 mg% on _%#MMDD2005#%_.
AB|abortion|AB.|201|203|PAST OBSTETRICAL HISTORY|4. In 1995 she had a normal spontaneous vaginal delivery at term of a female infant weighing 9 pounds 8 ounces. No complaints of hypertension or diabetes at that time. 5. In 2001 she had a spontaneous AB. PAST GYNECOLOGICAL HISTORY: The patient denies any history of abnormal Pap smears or STDs.
AB|abortion|AB|218|219|SOCIAL HISTORY|Last hospitalization as noted was _%#MMDD#%_ to _%#MMDD2006#%_ and evidently had a stress test around that time which was reported as negative. SOCIAL HISTORY: The patient is widowed for 7 years, is gravida 1, para 0, AB 1, has a sister and niece who are her closest relatives. Sister is legally blind. She does not drink any alcohol and now is living in her apartment by herself for the last couple days.
AB|blood group in ABO system|AB|170|171|FAX (952) 985-8299|Problem # 3: Hyperbilirubinemia. _%#NAME#%_ received phototherapy for a peak bilirubin level of 13.7 mg/dL. His blood type was B, Rh positive. The maternal blood type is AB positive. Antibody screening tests were negative. The most likely etiology for the initial hyperbilirubinemia was physiologic. His direct bilirubin was also elevated for a time with a peak direct bilirubin of 2.1mg% on _%#MMDD2006#%_.
AB|blood group in ABO system|AB|127|128|LABORATORY DATA|An INR and PTT were obtained on admission and revealed an INR of 2.09 and a PTT of 46. The patient was typed and screened with AB negative blood type with negative antibodies. A urine pregnancy test was negative. A CA-125 was drawn at the outside hospital but results were pending.
AB|abortion|AB|165|166|PAST MEDICAL HISTORY|She has had a lot of trouble with dyskinesia. PAST MEDICAL HISTORY: 1. Remote hysterectomy for benign reasons. 2. Remote left knee arthroscopy. 3. Gravida 10 para 6 AB 4, all vaginal deliveries. 4. Cataract extractions, both eyes. 5. Pneumonia about a year ago. 6. Parkinson's disease for a number of years. CURRENT MEDICATIONS: She takes no other medicines.
AB|abortion|AB|176|177|PAST OB HISTORY|This was apparently due to suspected retained products of conception, and there is no mention of D and C being done at that time. 2. _%#MM#%_ 2000, the patient had spontaneous AB at 6 weeks gestational age. ALLERGIES: The patient is allergic to sulfa, which leads to a rash.
AB|blood group in ABO system|AB|124|125|DISCHARGE FOLLOW-UP|Problem #4: Hyperbilirubinemia. _%#NAME#%_ received phototherapy for a peak bilirubin level of 14.8 mg%. His blood type was AB positive; maternal blood type was A positive. Antibody screening tests were negative. The last bilirubin level prior to discharge was 2.1 mg% on _%#MM#%_ _%#DD#%_, 2006.
AB|blood group in ABO system|AB|209|210|DISCHARGE MEDICATIONS|At the time of discharge, the infant's corrected gestational age was 39 weeks and 6 days. She was the 2418 gm, 345 week gestational age female infant born at Altru Hospital in _%#CITY#%_, ND to a 21-year-old, AB positive, gravida 2, para 0-1-0-1, partnered white female whose EDC was _%#MMDD2006#%_ (by 6+6 week dating US). The mother's pregnancy was complicated by ultrasounds showing a cardiac anomaly consistent with Ebstein's anomaly as well as dolichocephaly, nuchal thickening, kidney sinus separation and IUGR.
AB|blood group in ABO system|AB|124|125|DISCHARGE MEDICATIONS|Problem #4: Hyperbilirubinemia. _%#NAME#%_ received phototherapy for a peak bilirubin level of 14.8 mg%. His blood type was AB positive; maternal blood type was A positive. Antibody screening tests were negative. The last bilirubin level prior to discharge was 2.1 mg% on _%#MM#%_ _%#DD#%_, 2006.
AB|abortion|AB|199|200|PAST SURGICAL HISTORY|4. Benign breast biopsies. Underwent mammography yesterday 5. Status post melanoma excision, left upper extremity, approximately 10 years ago. No evidence for disease activity. 6. Gravida 3, para 3, AB 0. 7. Without known coronary artery disease, diabetes, intrinsic renal disease, hepatitic, peptic ulcer disease, gallbladder disease, seizure, tuberculosis or anemia.
AB|blood group in ABO system|AB|127|128|POSTOP COURSE|_%#NAME#%_ received phototherapy for a peak bilirubin level of 5.6 mg%. Her blood type was B positive; maternal blood type was AB negative. Antibody screening tests were negative. The last bilirubin level prior to discharge was 1.6 mg% on _%#MMDD2006#%_. The most likely etiology for the unconjugated hyperbilirubinemia was physiologic.
AB|blood group in ABO system|AB|207|208|HISTORY OF PRESENT ILLNESS|At the time of discharge, the infant's corrected gestational age was 42 weeks and 3 days. She was the 4205 gm, 41+2/7 week gestational age female infant born at Fairview Ridges, _%#CITY#%_ to a 19-year-old, AB positive, gravida-1, para-0, married Hispanic female whose LMP was unknown and whose EDC was _%#MMDD2006#%_. The mother's pregnancy was uncomplicated. The infant was delivered vaginally via vacuum extraction with Apgar scores of 9 at one minute and 9 at five minutes.
AB|blood group in ABO system|AB|470|471|LABORATORY|He comprehends well with nodding his head, but at this point he was easily agitated with the NG tube. LABORATORY: His INR on _%#MMDD#%_ is 2.0, but INR today is 2.77. His electrolytes show sodium 138, potassium 4.2, chloride 96, CO2 29, glucose 171, BUN 21, creatinine 1.09, calcium 8.7, troponin less than 0.04, myoglobin 59, and his CBC showed WBC 18.6, RBC 5.15, hemoglobin 13.6, hematocrit 42.5, MCV 83, platelets 263, neutrophils 84, absolute neutrophils 16.5, and AB positive blood group. Urinalysis showed cloudy urine with glucose of 300, specific gravity 1.01, large blood, protein is 100, WBC 69, RBC more than 182 which is a cathed specimen, many bacteria and mucous present.
AB|blood group in ABO system|AB|121|122|ANC = 21.2|After phototherapy was discontinued, her bilirubin rose to a peak of 10.9 and spontaneously resolved. Her blood type was AB positive; maternal blood type was B positive. Antibody screening tests were negative. The last bilirubin level prior to discharge was 9.6 mg% on _%#MMDD#%_.
AB|blood group in ABO system|AB|363|364|* FEN|She required dopamine from _%#DDMM#%_/ to _%#DDMM#%_ at maximum doses of 10 micrograms/kilogram/minute and dobutamine from _%#DDMM#%_/ to _%#DDMM#%_ at maximum doses of 20 micrograms/kilogram/minute and numerous fluid flushes, as well as hydrocortisone at stress doses on several occasions. This issue has resolved. 14. Hyperbilirubinemia: Maternal blood type is AB positive. _%#NAME#%_'s blood type is also AB positive. Direct antiglobulin test was negative. She was started on phototherapy on _%#MMDD2005#%_ at one day of age for an indirect bilirubin level of 4.0 mg/dL.
AB|blood group in ABO system|AB|269|270|DISCHARGE MEDICATIONS|At the time of discharge, the infant's postmenstrual age was 37 weeks and 4 days. He is a 1370 gram, 30 3/7 week gestational age male infant, first of twins, born at University of Minnesota Medical Center, Fairview to a 29 year old, gravida 2, para 0-0-1-0, blood type AB positive, Caucasian female whose LMP was _%#MMDD2007#%_ and whose EDC was _%#MMDD2007#%_. The mother's pregnancy was complicated by twin pregnancy and hypertension.
AB|abortion|AB|131|132|SURGERIES|6. History of herpes simplex virus. SURGERIES: 1. Laparoscopic cholecystectomy _%#MM#%_ 2003. 2. D and C 2003. 3. Gravida 1 para 1 AB 0. She denies heart disease, hypertension, renal disease, peptic ulcer disease, hepatitis, thyroid disease, seizures, tuberculosis, or anemia.
AB|blood group in ABO system|AB|225|226|HOSPITAL COURSE|Postpartum course uncomplicated. Discharged to home on postpartum day #1 tolerating a regular diet with pain well controlled with oral pain medication and ambulating without difficulty. Discharge hemoglobin 10.3, recorded as AB positive and rubella immune. DISCHARGE MEDICATIONS: Ibuprofen only, 800 mg p.o. q.8h. p.r.n. pain.
AB|blood group in ABO system|AB|148|149|LABORATORY DATA|CARDIAC: Regular rate and rhythm. RESPIRATORY: Clear to auscultation. ABDOMEN: Soft and nontender. PELVIC: Deferred. LABORATORY DATA: Blood Type is AB positive. ASSESSMENT AND PLAN: The patient is a 28-year-old with an eight week fetal demise who presents for suction and curettage.
AB|abortion|AB.|150|152|PRIMARY PROCEDURE|PAST MEDICAL HISTORY: Her past medical history is only significant for the gestational diabetes. SURGICAL HISTORY: LEEP. PAST OB HISTORY: Spontaneous AB. MEDICATIONS: Prenatal vitamins and Tylenol No. 3 p.r.n. ALLERGIES: CEPHALOSPORIN. FAMILY HISTORY: Significant for hypertension and diabetes. SOCIAL HISTORY: Negative for tobacco, alcohol, and drugs. PHYSICAL EXAMINATION VITAL SIGNS: Blood pressure was 135/92.
AB|abortion|AB|191|192|PAST MEDICAL HISTORY|3. Tonsillectomy and adenoidectomy as a child. 4. Hysterectomy at age 27 for endometriosis. 5. Breast cancer with left mastectomy five years ago with radiation therapy. 6. Gravida 2, para 1, AB 1. ALLERGIES: She has allergies to the old tetanus serum and to kiwi fruit.
AB|abortion|AB.|187|189|PAST SURGICAL HISTORY|She strongly desires delivery by primary cesarean section. PAST MEDICAL HISTORY: Exercise induced asthma which has been stable. PAST SURGICAL HISTORY: A D&C in _%#MM#%_ 2003 for a missed AB. PAST GYN HISTORY: D&C for a missed AB. No abnormal Pap smears.
AB|abortion|AB|136|137|PAST OB HISTORY|Endometrial thickness was 9 mm. The patient has no history of sexually transmitted diseases or abnormal paps. PAST OB HISTORY: Elective AB X3, uncomplicated. PAST MEDICAL HISTORY: 1. Diabetes mellitus, in good control. 2. Hypertension, on medications.
AB|abortion|AB.|24|26|CHIEF COMPLAINT|CHIEF COMPLAINT: Missed AB. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 35-year-old white female multiparous, blood group O, Rh positive with an ultrasonographically confirmed missed AB at approximately 11 1/2 weeks gestation. By gestational age and ultrasound, this pregnancy measures approximately 7 weeks size.
AB|abortion|AB.|115|117|OB HISTORY|At the time of admission, her cervix was noted to be 3-4 cm dilated, 80% effaced at -2 station. OB HISTORY: Missed AB. GYN HISTORY: History of abnormal Pap smears, status post colpo.
AB|abortion|AB|180|181|PAST OB HISTORY|2. Spinal meningitis as a child. PAST SURGICAL HISTORY: Exploratory laparoscopy as well as cochlear implant. ADMISSION MEDICATIONS: Prenatal vitamins. PAST OB HISTORY: Spontaneous AB 2. PAST GYN HISTORY: Patient does have a history of herpes.
AB|abortion|AB.|226|228|PAST SURGICAL HISTORY|This pregnancy complicated by AMA, previous history of rescue cerclage and then prophylactic cerclage this pregnancy. PAST MEDICAL HISTORY: GDA, GDMA-1 prior pregnancy, and asthma. PAST SURGICAL HISTORY: Cerclage x2, elective AB. OB HISTORY: 2001, NSVD at 38 weeks, after rescue cerclage at 27 weeks, SAB x1, AB x1.
AB|abortion|AB|135|136|IMPRESSION|The uterus itself is small, anterior and mobile. There is a palpable mass in the right adnexa measuring 3-4 cm. IMPRESSION: Threatened AB versus ectopic pregnancy. PLAN: Possible suction D&C, possible diagnostic laparoscopy and removal of ectopic pregnancy.
AB|abortion|AB.|186|188|HISTORY OF PRESENT ILLNESS|PAST OBSTETRICAL HISTORY: 1. _%#MM#%_ 2001, cesarean section, 5 pounds 8 ounces, female, 39 weeks, cesarean section secondary to breech with failed version at 36 weeks. 2. 2002 elective AB. HOSPITAL COURSE: The patient was taken to the operating room on _%#MM#%_ _%#DD#%_, 2004, where she underwent repeat low transverse cesarean section without complications.
AB|abortion|AB.|114|116|IMPRESSION|Cervix is closed. Uterus is anteverted, 6 weeks size, both adnexae clear, no masses were felt. IMPRESSION: Missed AB. PLAN: The patient is undergoing suction curettage of the uterus.
AB|abortion|AB|213|214|PAST OBSTETRICAL HISTORY|PAST MEDICAL HISTORY: Inappropriate sinus tachycardia managed with atenolol during pregnancy, and the patient is followed electrophysiologist at Abbott Northwestern Hospital. PAST OBSTETRICAL HISTORY: An elective AB in the past. PAST GYN HISTORY: She denies sexually transmitted infections or abnormal Pap smears.
AB|abortion|AB|433|434|OBSTETRIC HISTORY|Good fetal movement. Prenatal care started at 10 weeks in _%#CITY#%_ with first trimester blood pressure 116/58, total weight gain was 24 pounds. PRENATAL LABORATORIES: Blood type A positive, antibody screen negative, hepatitis B surface antigen negative, HIV negative, RPR negative, rubella immune, GC/Chlamydia negative, Pap NILM, urine culture showed contamination, hemoglobin 13.1. OBSTETRIC HISTORY: She has had one spontaneous AB in the first trimester. PAST GYNECOLOGIC HISTORY: She does have a history of abnormal Pap smear and had a cold knife cone in 2002.
AB|abortion|AB|105|106|OBSTETRICAL HISTORY|Urine culture within normal limits. Hemoglobin 11.9, 10.7, 11.4. Hemoglobin A1C 5.4 OBSTETRICAL HISTORY: AB x2. On _%#DDMM1991#%, normal spontaneous vaginal delivery, female 7 pounds 11 ounces. PAST MEDICAL HISTORY: History of secondary infertility. ALLERGIES: No known drug allergies.
AB|abortion|AB.|92|94|CHIEF COMPLAINT|DOB: PREOP HISTORY AND PHYSICAL AND EMERGENCY ROOM CONSULTATION CHIEF COMPLAINT: Incomplete AB. HISTORY OF PRESENT ILLNESS: The patient is a 20-year-old white female Gravida I, Para 0-0-0-0 blood group and Rh status pending who I am asked to see by Dr. _%#NAME#%_ _%#NAME#%_ in the Emergency Room to evaluate for incomplete AB.
AB|abortion|AB.|167|169|ASSESSMENT|LUNGS: Clear. ABDOMEN: Soft. PELVIC: External cervical os open, internal os closed. LABORATORY STUDIES: Hemoglobin 13.8, blood type B positive. ASSESSMENT: Incomplete AB. PLAN: Proceed with suction curettage.
AB|abortion|AB|123|124|OB HISTORY|PRENATAL CARE: She received at the Native American Clinic. No antepartum complications. OB HISTORY: She has had 1 elective AB in the past. GYN HISTORY: She has had no abnormal Pap smears and no history of sexually transmitted infections.
AB|abortion|AB|140|141|PAST SURGICAL HISTORY|3. Rubella immune. 4. Hepatitis B, HIV and RPR are all nonreactive. 5. GBS negative. PAST SURGICAL HISTORY: C-sections x3 and a spontaneous AB x1. Past GYN history, past medical and past surgical history are all noncontributory.
AB|abortion|AB.|58|60|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Ectopic pregnancy versus spontaneous AB. DISCHARGE DIAGNOSIS: Resolving spontaneous AB. PROCEDURES: Transvaginal ultrasound. COMPLICATIONS: None. BRIEF HISTORY: The patient is a 32-year-old G2, P0-0-1-0 who presented to the emergency room on _%#MMDD2007#%_ with severe right lower quadrant abdominal pain.
AB|abortion|AB|230|231|OB HISTORY|LABORATORY DATA: Blood type A positive, antibody screen negative, rubella immune, hep B negative, HIV negative, RPR negative, Pap negative, GC chlamydia negative, GCT 111, hemoglobin 12.1 and GBS negative. OB HISTORY: Spontaneous AB x1. GYN HISTORY: Positive for history of herpes simplex virus No history of abnormal Paps or other STDs.
AB|abortion|AB.|154|156|IMPRESSION|The fetus, however, showed no cardiac activity and no fetal movement, and size-wise was estimated at approximately 8 weeks and 6 days. IMPRESSION: Missed AB. The patient and her family were apprised of the findings.
AB|abortion|AB|199|200|ASSESSMENT|Again, the ultrasound results from today was done to confirm viability and what was found was a 14+4-week fetal demise with no cardiac activity transabdominally or transvaginally. ASSESSMENT: Missed AB at 14+4-weeks. PLAN: After all possibilities were reviewed with the patient, she very strongly wishes for a D&C procedure as soon as possible, even today.
AB|abortion|AB.|24|26|CHIEF COMPLAINT|CHIEF COMPLAINT: Missed AB. HISTORY OF PRESENT ILLNESS: The patient is a 33-year-old G2, P1-0-0-1, with missed AB, diagnosed fetal demise on ultrasound _%#MMDD2004#%_ at 8 weeks' gestation. The patient presented for a follow-up ultrasound today which demonstrates continued retained endometrial products consistent with products of conception and pregnancy test is again positive at today's visit.
AB|abortion|AB|136|137|OB/GYN HISTORY|PAST SURGICAL HISTORY: 1. Cholecystectomy. 2. Hysterectomy. 3. Rectal prolapse repair, 1994. 4. T&A. OB/GYN HISTORY: Gravida 3, para 2, AB 1. ALLERGIES: She has no true drug allergies, but codeine causes chest discomfort and makes her lightheaded.
AB|abortion|AB|346|347|OB HISTORY|Given the history of classical C-section by her report and therefore having an unknown scar, she was consented for a repeat C-section on _%#MM#%_ _%#DD#%_, 2006, after the risks, benefits, and alternatives were discussed with her. OB HISTORY : 1. _%#MM#%_ _%#DD#%_, 2004, emergency C-section at 24 weeks secondary to PROM. 2. History of elective AB x1. PAST MEDICAL HISTORY: Asthma, diabetes, and possible chronic hypertension.
AB|abortion|AB|119|120|OB HISTORY|3. GBS negative on _%#MM#%_ _%#DD#%_, 2006. 4. A 1-hour GCT was 97 on _%#MM#%_ _%#DD#%_, 2005. OB HISTORY: Spontaneous AB in the first trimester in 1996. GYN HISTORY: No history of STDs or abnormal Pap smears.
AB|abortion|AB|119|120|PAST OB HISTORY|PAST SURGICAL HISTORY: 1. Status post ovarian cystectomy. 2. Status post cholecystectomy. PAST OB HISTORY: Spontaneous AB x2. PAST GYNECOLOGIC HISTORY: The patient has a history of abnormal Pap smears consistent with HPV, but otherwise no STDs or PID.
AB|abortion|AB|31|32|PREOPERATIVE DIAGNOSIS|PREOPERATIVE DIAGNOSIS: Missed AB at 8-plus weeks SCHEDULED PROCEDURE: Suction dilation and curettage. SURGEON DOING HISTORY AND PHYSICAL: _%#NAME#%_ _%#NAME#%_ SURGEON FOR SCHEDULED SURGERY: _%#NAME#%_ _%#NAME#%_ HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 31-year-old gravida 2 para 1-0-0-1 who presented for an initial prenatal visit on _%#MMDD2007#%_ at approximately 9-plus weeks.
AB|abortion|AB|136|137|PAST OBSTETRICAL HISTORY|Urine culture 10-50,000 Staph. Hepatitis B surface antigen negative, HIV negative. Platelets of 374. PAST OBSTETRICAL HISTORY: Elective AB in 1994. ISSUES THIS PREGNANCY: First trimester bleeding and rubella indeterminate. Hypertension at 29 weeks, which subsequently resolved.
AB|abortion|AB|232|233|PAST OB HISTORY|1. A1 gestational diabetes. 2. Polycystic ovarian syndrome with infertility. This pregnancy was a spontaneous pregnancy. MEDICATIONS: Prenatal vitamins. ALLERGIES: No known drug allergies. PAST OB HISTORY: _%#MM2003#%_, spontaneous AB at 8 weeks. PAST GYNECOLOGY HISTORY: Irregular menses, no birth control used recently.
AB|abortion|AB|87|88|PAST OB HISTORY|She is having contractions every 6 minutes that are mild. PAST OB HISTORY: Spontaneous AB x1. PAST MEDICAL HISTORY: Positive PPD with a negative chest x-ray.
AB|abortion|AB|123|124|PAST OBSTETRICS HISTORY|She was admitted on _%#MMDD2003#%_ for spontaneous rupture of membranes and early labor. PAST OBSTETRICS HISTORY: Elective AB in 1987. PAST MEDICAL HISTORY: Genital herpes. PRENATAL CARE: The patient's prenatal care began at 11 weeks with Dr. _%#NAME#%_ _%#NAME#%_, for a total of seven visits.
AB|abortion|AB.|100|102|IMPRESSION|No hepatosplenomegaly. PELVIC: Deferred to surgery. IMPRESSION: Normal physical examination. Missed AB. PLAN: Suction D&C. Risks and complications discussed.
AB|abortion|AB|158|159|PAST OBSTETRICS HISTORY|3. Low-lying placenta and third-trimester bleeding. 4. The patient requested a primary cesarean section. PAST OBSTETRICS HISTORY: Significant for an elective AB x 1. GYNECOLOGIC HISTORY: History of infertility with tubal adhesions noted on laparoscopy.
AB|abortion|AB|130|131|PAST SURGICAL HISTORY|1. Psychiatric illness (as above). Details per Dr. _%#NAME#%_. 2. Serious illness none. PAST SURGICAL HISTORY: Gravida 1, para 1, AB 0. Denies heart disease or murmur, diabetes, asthma, hypertension, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, thyroid disease, seizure, tuberculosis or anemia.
AB|abortion|AB|184|185|ASSESSMENT|1. This is a 26-year-old G3, P0-0-2-0, at 6 weeks 0 days by last menstrual period with vaginal bleeding and abdominal pain. 2. Stable. 3. History of ectopic x2. 4. Rule out threatened AB versus complete AB versus early IUP versus ectopic pregnancy. PLAN: The risks, benefits and alternatives of continued observation with serial beta hCGs versus therapeutic suction D&C were discussed with the patient and her husband.
AB|abortion|AB|138|139|PAST SURGICAL HISTORY|2. History of iron deficiency anemia during her teenage years. PAST SURGICAL HISTORY: 1. Bartholin's cyst excision. 2. Gravida 3, para 3, AB 0. Denies other surgery or known serious illness. Without heart disease, diabetes, asthma, hypertension, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, thyroid disease, seizure, tuberculosis or anemia.
AB|abortion|AB|169|170|PAST SURGICAL HISTORY|Raised the question regarding possible seizure. Evaluated by Dr. _%#NAME#%_ from neurology. Normal EEG. No subsequent events. PAST SURGICAL HISTORY: 1. Gravida 2 para 2 AB O. Denies heart disease or murmur, diabetes, asthma, hypertension, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, thyroid disease, seizure, tuberculosis, or anemia.
AB|abortion|AB.|56|58|CHIEF COMPLAINT|CHIEF COMPLAINT: Vaginal bleeding, probable spontaneous AB. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 22-year-old G2, P1-0-0-1 at 5 plus 1 week by last menstrual period _%#MMDD2007#%_ who presented to the ER on _%#MMDD2007#%_ after increased vaginal bleeding and cramping pain that had persisted throughout the course of the last 48 hours. She has been seen approximately 2 other times at the United Hospital Emergency Department for similar complaints.
AB|NAME|_%#NAME#%_.|133|143|HISTORY OF PRESENT ILLNESS|The patient was asked to be seen for an Internal Medicine consult per Dr. _%#NAME#%_ _%#NAME#%_. HISTORY OF PRESENT ILLNESS: Patient _%#NAME#%_. is a 46-year-old female admitted to station 10-North from Fairview Ridges ER. The parents state that the patient has been having increasing symptoms of anxiety, paranoia and agitation the past several weeks.
AB|abortion|AB|152|153|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Psychiatric illness: As above. Details per Dr. _%#NAME#%_. 2. Serious illness: None. 3. Surgeries: None. 4. Gravida 1, para 1. AB 0. Denies heart disease, murmur, diabetes, asthma, hypertension, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, thyroid disease, seizure, tuberculosis, or anemia.
AB|abortion|AB|125|126|PAST SURGICAL HISTORY|6. Topamax 100 mg at h.s. ALLERGIES: Vistaril which causes a rash. PAST SURGICAL HISTORY: Tubal ligation. Crystal is G7, P5, AB 2. SOCIAL HISTORY: Crystal lives in a townhouse with her children.
AB|abortion|AB|259|260|SURGERIES|5. Remote history of pneumonia and pleurisy. 6. History of mild hypertension, treated in the past with antihypertensive medication; she is able to come off medication with diet and exercise. SURGERIES: 1. Appendectomy. 2. Tonsillectomy. 3. Gravida 2, para 2, AB 0. NOTE: She denies heart disease, diabetes, asthma, renal disease, peptic ulcer disease, gallbladder disease, hepatitis, seizure, tuberculosis, or anemia.
AB|abortion|AB|187|188|PAST SURGICAL HISTORY|1. Anxiety disorder (details per Psychiatry). 2. Polysubstance abuse with drugs of choice alcohol and marijuana. PAST SURGICAL HISTORY: 1. Benign breast lumpectomy. 2. Gravida 1, para 1, AB 0. Denies heart disease, hypertension, asthma, diabetes, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, thyroid disease, seizure, tuberculosis or anemia.
AB|abortion|AB|169|170|OB HISTORY|She has a partner in her room with her at all times, therefore, a history of STDs was not pursued secondary to protecting the patient's privacy. OB HISTORY: Spontaneous AB in the first trimester in 2004. PAST MEDICAL HISTORY: None. SURGICAL HISTORY: None. ALLERGIES: NKDA. FAMILY HISTORY: Mother with type 2 diabetes.
AB|abortion|AB.|217|219|OB HISTORY|She says that the second day of her period is very heavy flow but it tapers off significantly by the third or fourth day. OB HISTORY: Para 3-0-1-3 status post 3 normal spontaneous vaginal deliveries and a spontaneous AB. MEDICAL HISTORY: Headaches. The patient states she has migraines; however, she takes aspirin and Tylenol intermittently for headaches whenever she gets tired.
AB|abortion|AB.|31|33|PREOPERATIVE DIAGNOSIS|PREOPERATIVE DIAGNOSIS: Missed AB. POSTOPERATIVE DIAGNOSIS: Missed AB. PROCEDURE: Suction D&C. DESCRIPTION: _%#NAME#%_ _%#NAME#%_ was placed under satisfactory general anesthesia and prepped and draped in the dorsal lithotomy position.
AB|abortion|AB|214|215|PAST OBSTETRICAL HISTORY|Hemoglobin 11.8 to 12.6, platelets of 239, 000. ALT 17, AST is 31, BUN is 6, uric acid is 4.1, GTT of 139 and GBS positive. TSH of 3.58, 1.73 to 1.52 to 2.04. PAST OBSTETRICAL HISTORY: NSVD x2 in 1985 and 1998 and AB x2. PAST MEDICAL HISTORY: Hypothyroidism, anxiety, sinusitis and esophageal reflux. PAST SURGICAL HISTORY: Breast reduction, treatment of ankle fracture and dilation and curettage.
AB|abortion|AB|193|194|PAST OBSTETRICAL HISTORY|PRENATAL CARE: Prenatal care was initiated at 19 + 4 weeks for a total of seven visits. Total weight gain: 34 pounds. First-trimester blood pressure: 102/60. PAST OBSTETRICAL HISTORY: Elective AB x 3. PAST GYNECOLOGICAL HISTORY: 1. History of abnormal Pap, with cryo surgery.
AB|abortion|AB|243|244|DOB|She is not allergic to any medications. The past history reveals right rotator cuff surgery as well as hysterectomy and bowel and bladder repair, abdominal hernia repair, and some throat surgeries in the remote past. She is gravida 3, para 3, AB 0. She is a nonsmoker and nondrinker who was recently widowed.
AB|abortion|AB.|489|491|PAST OB HISTORY|She had a total weight gain of 31 pounds. PRENATAL LABS: Blood type O positive, antibody screen negative, rubella immune, VDRL is nonreactive, HIV negative, hepatitis B surface antigen negative, Pap within normal limits, urine culture negative, GC/Chlamydia negative, quad screen within normal limits and GBS negative, hemoglobin 13.2 and11.4 and GCT 101. Amniocentesis performed on _%#MMDD2006#%_ showed 46 XY, negative deletion for 22q11.2. PAST OB HISTORY: In 1999, she had an elective AB. PAST GYN HISTORY: No history of abnormal Pap smears or sexually transmitted infections.
AB|blood group in ABO system|AB|200|201|PAST MEDICAL HISTORY|SURGICAL: 1) Knee surgery x 3. 2) Cesarean section. 3) Tonsillectomy. ANESTHESIA COMPLICATIONS: Denied. SMOKING: Denies. ALCOHOL: Denies. STREET DRUGS: Denies. BLOOD TRANSFUSIONS: Denies. BLOOD TYPE: AB positive. MEDICATIONS: Prenatal vitamins. PHYSICAL EXAMINATION: VITAL SIGNS: Height 5 feet 3 inches, prepregnant weight 143, now 183, blood pressure 138/70.
AB|abortion|AB.|183|185|CHIEF COMPLAINT|She is scheduled for vacuum curettage at Fairview Ridges Hospital this afternoon _%#MMDD2006#%_. CHIEF COMPLAINT: Intrauterine pregnancy 9 weeks by dates, 7 weeks by size, incomplete AB. HISTORY OF PRESENT ILLNESS: The patient is a 21-year-old white female, gravida 2, para 0-0-1-0, LMP of _%#MMDD2005#%_, blood group is A, Rh negative who began having vaginal bleeding on _%#MMDD2006#%_.
AB|abortion|AB|162|163|PAST MEDICAL HISTORY|Pacemaker was considered, but it was elected to continue monitoring and she, overall, has done well. Arthritis. She is status post NSVD times one and spontaneous AB times one. PAST SURGERIES: Include cataract surgery. Also has had a history of a fractured shoulder in four places _%#MM#%_, 2002.
AB|abortion|AB|331|332|PAST MEDICAL HISTORY|It was slightly more irregular, and because of the possibility of rare malignant change plus having difficulty following such a patient with mammographic screening, we recommended excisional biopsy to remove this lesion. PAST MEDICAL HISTORY: Medical illnesses - history of Crohn's disease. Obstetrical history: Gravida 3, para 2, AB 1. ALLERGIES: None MEDICATIONS: Premarin 0.625, Ativan at hs, atenolol 1 a day, Celexa p.r.n. PAST SURGICAL HISTORY: Shoulder repair in 1998, hysterectomy in 1994.
AB|abortion|AB|104|105|SUMMARY OF HOSPITAL COURSE|SUMMARY OF HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 45-year-old Registered Nurse, gravida 2, para 0, AB 2, followed by me for endometriosis. She had moderate endometriosis and the right ovary was attached to the cul-de-sac. The rectum was attached to the uterus. She has had severe pelvic pain an discomfort.
VBG|vertical banded gastroplasty|VBG,|119|122|PAST MEDICAL HISTORY|2. Esophageal candidiasis. PROCEDURE PERFORMED: Endoscopy. PAST MEDICAL HISTORY: 1. Morbid obesity, status post failed VBG, converted to Roux-en-Y gastric bypass. 2. Ventral hernia repair. 3. Diabetes mellitus. 4. Hypercholesterolemia.
VBG|venous blood gas|VBG|133|135|PHYSICAL EXAMINATION|ALT and AST are moderately elevated. Alkaline phosphatase is elevated as is chronic for her. Albumin is low. Urinalysis is negative. VBG completed in the emergency department showed a PV of 232, PVCO2 of 35, and pH of 7.34. ASSESSMENT: This is a markedly disoriented, morbidly obese, and deconditioned female.
VBG|vertical banded gastroplasty|VBG|237|239|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Abdominal pain. DISCHARGE DIAGNOSIS: Abdominal pain. OPERATIONS/PROCEDURES PERFORMED: IV fluid hydration. HISTORY OF PRESENT ILLNESS: The patient is a 36-year-old female with a past medical history significant for a VBG done in _%#MM#%_ of 2003, who presents with worsening epigastric pain and right upper quadrant pain. Patient reports no radiation. There is associated nausea and vomiting.
VBG|vertical banded gastroplasty|VBG|172|174|ADMISSION DIAGNOSIS|Per the patient's report, post VBG she had lost approximately 70 pounds and, then, in recent months regained 50 pounds. PAST MEDICAL HISTORY: 1. Morbid obesity status post VBG _%#MM#%_ of 2003. 2. Esophagitis. 3. GERD. 4. Peptic ulcer disease. 5. History of ectopic pregnancy. 6. Hypothyroidism, now hyperthyroidism. 7. Depression. 8. Status post cholecystectomy 1997.
VBG|venous blood gas|VBG:|132|135|ADMISSION LABORATORY DATA|SKIN: No rash. NEUROLOGIC: Positive for grasp, suck and Moro reflexes. Reflexes are +2 DTRs bilaterally. ADMISSION LABORATORY DATA: VBG: 7.37, 41, 36, 23 and 78%. CBC: White blood cell count 27.4, hemoglobin 16.3, platelets 284. HOSPITAL COURSE: PROBLEM #1: Shortly after being admitted, the patient was taken to the Cardiac Catheterization Laboratory and underwent a Rashkind procedure.
VBG|venous blood gas|VBG|252|254|LABORATORY DATA|Neuro exam: Grossly intact with mental status intact. LABORATORY DATA: CBC showed white blood cell count 10.5, hemoglobin 8.4, platelet count 216,000. CSF negative for white blood cells, normal protein at 44 and glucose at 54. RSV tests were negative. VBG was within normal range with pH at 7.3, CO2 38, bicarbonate 18. CHEST X-RAY: Remarkable for streaky opacities at right and left upper lobes.
VBG|vertical banded gastroplasty|VBG|136|138|HISTORY OF PRESENT ILLNESS|She had previously undergone vertical banded gastroplasty in 1993 with approximately 100-pound weight loss. She then had a breakdown of VBG with a leak. Previous attempt at buttressing this failed, she regained the weight. Her comorbidities include arthritis, back pain, reflux.
VBG|vertical banded gastroplasty|VBG|93|95|PAST MEDICAL HISTORY|Her comorbidities include arthritis, back pain, reflux. PAST MEDICAL HISTORY: 1. Status post VBG in 1993. 2. GERD. 3. Arthritis. 4. Status post ventral hernia repair with mesh. 5. Status post cholecystectomy. ALLERGIES: Patient has no known drug allergies. HOSPITAL COURSE: The patient was admitted and underwent a modified duodenal switch procedure and liver biopsy.
VBG|vertical banded gastroplasty|VBG|115|117|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Inability to keep down food. HISTORY OF PRESENT ILLNESS: This is a 54-year-old female status post VBG in _%#MM#%_ 2001. She is also status post reversal of jejunoileal bypass in _%#MM#%_ 2001. She was last hospitalized earlier in the month of _%#MM#%_ for food particle outlet obstruction of the VBG.
VBG|vertical banded gastroplasty|VBG.|176|179|HISTORY OF PRESENT ILLNESS|She is also status post reversal of jejunoileal bypass in _%#MM#%_ 2001. She was last hospitalized earlier in the month of _%#MM#%_ for food particle outlet obstruction of the VBG. On _%#MM#%_ _%#DD#%_, 2002, she presented with a 24-hour history of inability to keep foods, particularly solids and liquids, down but able to tolerate small sips of liquids without difficulty.
VBG|vertical banded gastroplasty|VBG.|108|111|PAST MEDICAL/SURGICAL HISTORY|She has flatus currently. No nausea, fevers or chills. No abdominal pain. PAST MEDICAL/SURGICAL HISTORY: 1. VBG. 2. Status post reversal of jejunoileal bypass. 3. Prior hospitalization as described in the HPI. 4. Status post cholecystectomy. 5. Status post appendectomy. 6. History of kidney stones. MEDICATIONS ON ADMISSION: None.
VBG|vertical banded gastroplasty|VBG|308|310|HISTORY OF PRESENT ILLNESS|PRIMARY DIAGNOSIS: Morbid obesity. OPERATIONS/PROCEDURES THIS ADMISSION: On _%#MMDD2002#%_, the patient had a revision of her vertical banded gastroplasty, liver biopsy, and bilateral tubal ligation. HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ is a 30-year-old female with a history of obesity status post a VBG in _%#MM#%_ 2000 as well as _%#MMDD2000#%_. The re-do VBG was for an adhesive obstruction with Dr. _%#NAME#%_. The patient has lost approximately 120 pounds. In _%#MM#%_ 2001, the patient had increasing amounts of nausea and vomiting which had not resolved through the past year.
VBG|vertical banded gastroplasty|VBG|166|168|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ is a 30-year-old female with a history of obesity status post a VBG in _%#MM#%_ 2000 as well as _%#MMDD2000#%_. The re-do VBG was for an adhesive obstruction with Dr. _%#NAME#%_. The patient has lost approximately 120 pounds. In _%#MM#%_ 2001, the patient had increasing amounts of nausea and vomiting which had not resolved through the past year.
VBG|vertical banded gastroplasty|VBG|251|253|HISTORY OF PRESENT ILLNESS|The patient has lost approximately 120 pounds. In _%#MM#%_ 2001, the patient had increasing amounts of nausea and vomiting which had not resolved through the past year. She continues to have acid reflux and the patient has agreed on a revision of her VBG on an elective basis. ALLERGIES: Penicillin and morphine. MEDICATIONS: Paxil and birth control pills.
VBG|vertical banded gastroplasty|VBG,|146|149|HOSPITAL COURSE|9. History of oral surgery. SOCIAL HISTORY: Negative X3. FAMILY HISTORY: Non-contributory. HOSPITAL COURSE: The patient underwent revision of her VBG, liver biopsy, and bilateral tubal ligation on _%#MMDD2002#%_ and was admitted to the floor shortly afterwards where she stayed a total of four postoperative days.
VBG|vertical banded gastroplasty|VBG|195|197|HOSPITAL COURSE|6. Lansoprazole suspension 30 mg p.o. q.a.m. ALLERGIES: Penicillin and erythromycin. HOSPITAL COURSE: The patient was admitted on _%#MMDD2002#%_ and was taken the operating room for laparoscopic VBG changed to gastrointestinal bypass. The procedure went well. The patient was stable and was transferred to the postanesthesia care unit.
VBG|venous blood gas|VBG|174|176|HOSPITAL COURSE|His chest x-ray showed no infiltrate, and his sputum culture was negative, but given his sputum color change, he was also started on doxycycline. He did refuse an ABG, but a VBG was significant for pCO2 of only 52. Influenza nasal swab and viral cultures are currently pending. He was re-started on his Spiriva prior to discharge.
VBG|vertical banded gastroplasty|VBG|139|141|HISTORY OF PRESENT ILLNESS|2. Upper GI with small bowel followthrough. HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old female who is status post revision of VBG to Roux-en-Y gastrointestinal bypass. The patient has been readmitted multiple times in the past month for complaints of nausea and vomiting.
VBG|venous blood gas|VBG|477|479|ADMISSION LABS|ADMISSION LABS: Sodium 137, potassium 4.0, chloride 105, bicarbonate 25, BUN 5, creatinine 0.33, glucose 147, calcium 9.2, magnesium 1.8, phosphorus 12.9. White blood cell count was 9.8, hemoglobin 11.4, platelets 273, and eosinophils 9.0 with a differential of 92% neutrophils, 7% lymphocytes and 0% monocytes and INR was normal at 1.15. PTT was normal at 32. Admission ABG showed a pH of 7.35 with PCO2 of 42, PO2 of 96, and a bicarbonate of 23 and total CO2 correlated with VBG of 44. HOSPITAL COURSE: 1. FEN. _%#NAME#%_ was initially kept n.p.o. and hydrated with IV fluids while he was on the ventilator.
VBG|vertical banded gastroplasty|VBG|232|234|HOSPITAL COURSE|5. Vertical banded gastroplasty with cholecystectomy. 6. Appendectomy. 7. Ventral hernia repair. HOSPITAL COURSE: The patient was admitted to the hospital on _%#MM#%_ _%#DD#%_, 2006. The patient underwent an uneventful laparoscopic VBG to Roux-en-Y gastric bypass surgery. Please refer to the operative note dated _%#MM#%_ _%#DD#%_, 2006, for complete details of the procedure.
VBG|venous blood gas|VBG:|103|106|LABORATORY DATA|No hepatosplenomegaly. Extremities: No clubbing or edema. Skin: Without rash. LABORATORY DATA: Initial VBG: pH 7.29. After intubation, he has a venous pH of 7.30. Chest x-ray shows diffuse interstitial alveolar infiltrates with near whiteout of his lungs.
VBG|vertical banded gastroplasty|VBG.|91|94|PAST SURGICAL HISTORY|PAST MEDICAL HISTORY: 1. Chronic pain. 2. Migraines. 3. Obesity. PAST SURGICAL HISTORY: 1. VBG. 2. Ventral hernia repair in 1995. 3. Bladder suspension in 1996. 4. Umbilical hernia repair in 1997. 5. Arthroscopy of left knee in 2000. FAMILY MEDICAL HISTORY: The mother has diabetes mellitus.
VBG|vertical banded gastroplasty|VBG|196|198|HOSPITAL COURSE|Heart regular rate and rhythm. Abdomen nontender and nondistended. Extremities: Full of range of motion, no edema. HOSPITAL COURSE: The patient was in good condition and taken to the OR where the VBG was converted to a GIB by Drs. _%#NAME#%_, _%#NAME#%_, and _%#NAME#%_ without complications and a liver biopsy was performed. Postoperatively, the patient was extubated and taken to the postoperative recovery area where she remained stable and was eventually transferred to 7B where she remained stable.
VBG|vertical banded gastroplasty|VBG|164|166|PAST MEDICAL HISTORY|The patient was scheduled for hernia repair earlier in the week; however, it was postponed due to no available operating room. PAST MEDICAL HISTORY: 1. Status post VBG as above. 2. Status post incisional herniorrhaphy with mesh approximately two years ago. 3. Status post right TKA. 4. History of morbid obesity.
VBG|vertical banded gastroplasty|VBG|212|214|HOSPITAL COURSE|The surgical service, as well as GI. Endoscopy was done on the morning of the day of discharge. It revealed banded gastroplasty and gastric bypass in the gastric fundus. Suture material and staples were visible. VBG size was easily traversed with the endoscope. The pouch was estimated to be 100 cc in volume. Fluid residue was mild found in the gastric fundus. Removal of the fluid was accomplished.
VBG|vertical banded gastroplasty|VBG|172|174|ALLERGIES|EKG was normal. ASSESSMENT: A 53-year-old, morbidly obese female presenting for VBG surgery. HOSPITAL COURSE: Patient was taken to the O.R. on _%#MM#%_ _%#DD#%_, 2002, and VBG and liver biopsy were performed without complication. Postoperatively, the patient did well, and patient was ambulating a lot and was tolerating it, had no complaints.
VBG|venous blood gas|VBG|144|146|POST-EXTUBATION LABORATORY DATA|Neuro: Deep tendon reflexes 4/4 in all extremities. ADMISSION LABORATORY DATA: Hemoglobin 11.9. Platelets 216. POST-EXTUBATION LABORATORY DATA: VBG 7.28, 52, 71, 24, 90%. Sodium 143. Potassium 4.7. Chloride 106. Bicarbonate 27. Glucose 122. BUN 15. Creatinine 0.6. Calcium 8.3. HOSPITAL COURSE: PROBLEM #1: Fluids, Electrolytes, and Nutrition.
VBG|vertical banded gastroplasty|VBG|167|169|HOSPITAL COURSE|The patient had laboratory tests that were not remarkable, and then had an EEG performed that did reveal a foreign body found in the gastric pouch. The orifice of the VBG was 5-6 mm in diameter. This was removed and the patient was started back on a diet. The patient then was discharged home early in the morning on _%#MM#%_ _%#DD#%_.
VBG|vertical banded gastroplasty|VBG|225|227|HISTORY OF PRESENT ILLNESS|She has a previous vertical banded gastroplasty but continues to be obese and unsatisfied with her weight loss. After the discussion of the risks, benefits, and alternatives, the patient wished to proceed with conversion for VBG to Roux-en-Y gastric bypass. PAST MEDICAL HISTORY: 1. Migraines. 2. Status post vertical banded gastroplasty in 2000.
VBG|vertical banded gastroplasty|VBG|254|256|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSES : 1. Morbid obesity. 2. Status post vertical banded gastroplasty OPERATIONS/PROCEDURES PERFORMED: An Open VBG to Roux-en-Y conversion, liver biopsy HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 31-year-old female who is status post VBG in 2000. The patient was seen in followup clinic with Dr. _%#NAME#%_, in _%#MM#%_ 2006 with complaints of persistent nausea and vomiting.
VBG|venous blood gas|VBG|409|411|HISTORY OF PRESENT ILLNESS|Her last hemoglobin A1C in _%#MM#%_ was 12. She also has a history of diastolic heart dysfunction, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease with creatinine baseline of 1.5-2. She presented to the ER on _%#MMDD2006#%_ with complaints of significant fatigue and weakness. On presentation, her blood sugar was found to be 724. Her bicarbonate on admission was 8. A VBG was obtained with a pH of 7, pCO2 of 33, pO2 of 49 and bicarbonate of 8. She was admitted to the ICU for an insulin drip and a bicarbonate drip for overnight correction of her acidosis and her hyperglycemia.
VBG|venous blood gas|VBG|199|201|LABORATORY DATA|SKIN: Shows acanthosis nigricans on the neck. MUSCULOSKELETAL: Shows full range of movement. NEUROLOGIC: Intact. LABORATORY DATA: On admission, her lipid panel is pending. Her blood ketones are 0.2. VBG is pH is 7.4, PCO2 of 41, PO2 of 53 and bicarbonate of 25. Her BMP on admission was remarkable for sodium 137, potassium 3.9, chloride 103, bicarbonate 23, BUN 8, creatinine 0.72, glucose of 361, calcium of 9.4. UA showed glucose greater than 1000, was negative for ketones and bilirubin, moderate blood, 9 white blood cells and 35 red blood cells.
VBG|vertical banded gastroplasty|VBG|103|105|PAST SURGICAL HISTORY|PAST MEDICAL HISTORY: 1. Morbid obesity. 2. Arthritis. 3. Depression. 4. MS. PAST SURGICAL HISTORY: 1. VBG in 2001. 2. Hysterectomy in 2005. MEDICATIONS: 1. Celexa. 2. MS drugs. 3. Sudafed. 4. The patient will be started on Prilosec 40 mg b.i.d. for 2 weeks.
VBG|vertical banded gastroplasty|VBG|195|197|HOSPITAL COURSE|HOSPITAL COURSE: The patient was admitted on _%#MMDD2002#%_. The patient underwent an upper GI with endoscopy on _%#MMDD2002#%_. Those studies showed no obstruction but some residual food in the VBG outlet. Her diet was advanced to clears, then to juices, and then to puree, as tolerated. By the second day after admission, the patient experienced some left shoulder pain, with sudden onset.
VBG|vertical banded gastroplasty|VBG|124|126|ADMISSION DIAGNOSIS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 38-year-old female with a long history of morbid obesity. The patient had a VBG performed by Dr. _%#NAME#%_ in _%#MM#%_ of 2000. The patient did have some weight loss after the procedure but started to regain weight and underwent an endoscopy on _%#MM#%_ _%#DD#%_, 2002, that found the pouch size to be approximately 100 mL, and the outlet was over 1 cm.
VBG|vertical banded gastroplasty|VBG|50|52|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Nausea and vomiting after VBG revision. 2. Malnutrition. PROCEDURE ON THIS ADMISSION: Placement of a PICC line, _%#MMDD2003#%_.
VBG|vertical banded gastroplasty|VBG.|152|155|HISTORY OF PRESENT ILLNESS|2. Exploratory laparotomy. HISTORY OF PRESENT ILLNESS: This is a 57-year-old morbidly obesity female who presented to Dr. _%#NAME#%_ to undergo an open VBG. The patient has attempted several diet and exercise modalities, which have not been successful. PAST MEDICAL AND PAST SURGICAL HISTORY: Limited. Obesity comorbidities.
VBG|vertical banded gastroplasty|VBG|154|156|HOSPITAL COURSE|No signs of organomegaly. EXTREMITIES: Moving all extremities appropriately. Strong peripheral pulses x 4. HOSPITAL COURSE: The patient underwent an open VBG on _%#MMDD2003#%_. Please see the operative dictation for details. Following surgery, the patient had a postoperative bleed from which she lost several liters of blood.
VBG|vertical banded gastroplasty|VBG|140|142|PAST MEDICAL HISTORY|However, he presented to the emergency room because he was unable to reduce the hernia. PAST MEDICAL HISTORY: 1. Gastric bypass in 1976. 2. VBG in 1984. 3. Panniculectomy in 1978. 4. Chronic ventral hernia. 5. Hypertension. 6. High cholesterol. 7. GERD. 8. Restless leg syndrome. ALLERGIES: No known drug allergies.
VBG|vertical banded gastroplasty|VBG.|213|216|HISTORY OF PRESENT ILLNESS|3. Status post percutaneous drainage of perihepatic collection. HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old male who was recently discharged from FUMC status post removal of silastic ring of a failed VBG. The patient was discharged on _%#MM#%_ _%#DD#%_, 2003. The patient did well for a few days, but developed abdominal pain and persistent nausea and vomiting.
VBG|vertical banded gastroplasty|(VBG)|147|151|HOSPITAL COURSE|1. Vaginal hysterectomy. 2. Cholecystectomy. HOSPITAL COURSE: Ms. _%#NAME#%_ was admitted by ambulatory surgery for a vertical banded gastroplasty (VBG) and liver biopsy on _%#MMDD2003#%_ with Dr. _%#NAME#%_. Please see the dictated operative report for full details of her surgery.
VBG|vertical banded gastroplasty|VBG.|132|135|HOSPITAL COURSE|Ms. _%#NAME#%_ had her Foley catheter removed and her diet advanced in a timely manner as expected in the postoperative course of a VBG. By _%#MMDD2003#%_ her pain was entirely controlled with p.o. pain medication. She remained afebrile and vital signs stable in the postoperative period.
VBG|venous blood gas|VBG|135|137|LABORATORY|SKIN: No skin rash. MENTAL STATUS: Alert, oriented, in no acute distress. LABORATORY: Labs drawn in the emergency department include a VBG which was 7.25, PCO2 23, PO2 54, bicarbonate 10. Sodium 137, potassium 4.3, chloride 108, bicarbonate 9. BUN 9, creatinine 0.8. Glucose 229.
VBG|vertical banded gastroplasty|VBG|213|215|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Abdominal pain. OPERATIONS/PROCEDURES PERFORMED: Panniculectomy. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 47-year-old female with a distant history of morbid obesity. The patient had a VBG in 1999. The patient has since lost a significant amount of weight. The patient has now complained of low back pain due to extra skin and occasional rashes in her skinfold.
VBG|vertical banded gastroplasty|VBG.|262|265|ADMISSION DIAGNOSIS|After explanation of risks and benefits, including the significant complication of flap infection, the patient elected to undergo panniculectomy. PAST MEDICAL HISTORY: 1. Gastroesophageal reflux disease. 2. Morbid obesity status post VBG. PAST SURGICAL HISTORY: VBG. ALLERGIES: No known drug allergies. HOSPITAL COURSE: The patient was admitted on _%#MM#%_ _%#DD#%_, 2003. Informed consent was obtained for a panniculectomy. The patient was taken to the operating room.
VBG|venous blood gas|VBG|161|163|INITIAL LABORATORY DATA|Peripheral pulses 2+ bilaterally. Capillary refill less than one second in the extremities. INITIAL LABORATORY DATA: Bicarbonate 16. Sodium 148. Creatinine 0.6. VBG showed a pH of 7.35 with a pCO2 of 20. White blood cell count 15.4. 89% neutrophils. Lactic acid 2.5, slightly elevated.
VBG|vertical banded gastroplasty|VBG|184|186|HISTORY OF PRESENT ILLNESS|The patient's comorbidities include asthma, skin fold rashes, and osteoarthritis. She was evaluated in bariatric surgery clinic and was felt to be a good candidate for revision of her VBG to Roux-en-Y gastric bypass. The patient's preoperative weight was 279 pounds. HOSPITAL COURSE: On _%#MM#%_ _%#DD#%_, 2006, the patient underwent revision of her VBG to Roux-en-Y gastric bypass as well as a liver biopsy.
VBG|vertical banded gastroplasty|VBG|133|135|HOSPITAL COURSE|The patient's preoperative weight was 279 pounds. HOSPITAL COURSE: On _%#MM#%_ _%#DD#%_, 2006, the patient underwent revision of her VBG to Roux-en-Y gastric bypass as well as a liver biopsy. She tolerated the procedure well, and there were no immediate postoperative complications.
VBG|vertical banded gastroplasty|VBG|169|171|HISTORY OF PRESENT ILLNESS|OPERATIONS/PROCEDURES PERFORMED: Chest CT. Negative workup, including troponin, D-dimers. HISTORY OF PRESENT ILLNESS: The patient is a 33-year-old woman who underwent a VBG gastric bypass in 2004 by Dr. _%#NAME#%_ with a history of multiple admissions for nausea, abdominal pain and vomiting with negative workups.
VBG|vertical banded gastroplasty|VBG,|163|166|OPERATIVE FINDINGS|This was identified and repaired with multiple 5-0 Tevdek sutures in Lembert fashion. In the process of lysis of adhesions, we identified the Silastic ring of the VBG, and the staple line of the VBG pouch. We then dissected the angle of His free from the diaphragm and created a small window at the angel of His.
VBG|vertical banded gastroplasty|VBG|109|111|OPERATIVE FINDINGS|In the process of lysis of adhesions, we identified the Silastic ring of the VBG, and the staple line of the VBG pouch. We then dissected the angle of His free from the diaphragm and created a small window at the angel of His. In a similar fashion, we created a small window in the medial surface of the lesser curvature of the stomach just inferior to the left gastric vascular bundle, and the dissection was carried down with Metzenbaum scissors posteriorly connected to the angle of His.
VBG|venous blood gas|VBG|137|139|PROBLEM #2|The patient remained on nasal cannula oxygen. When the patient did not show improvement she was switched to DuoNeb q.4 h. scheduled. Her VBG on the day of admission showed pH of 7.32 and PCO2 of 72. Pulmonary was consulted after two days of hospitalization. When the patient still complained of shortness of breath, however, her VBG remained stable.
VBG|venous blood gas|VBG|196|198|PROBLEM #2|Her VBG on the day of admission showed pH of 7.32 and PCO2 of 72. Pulmonary was consulted after two days of hospitalization. When the patient still complained of shortness of breath, however, her VBG remained stable. Pulmonary recommended increasing frequency of Duonebs to every 2 hours scheduled which the patient reported slight improvement, however, later the patient refused this frequency of nebulizer treatment.
VBG|venous blood gas|VBG|1302|1304|LABS|6. propofol gtt 7. vecuronium PRN 8. midazolam PRN REVIEW OF SYSTEMS: could not be obtained due to unresponsiveness/sedation VITALS: Vent Settings CMV, Vt 850, R 12, PEEP 5 FiO2 100% Ppeak 30 T 98.1 BP 73/60 HR 78 RR 12 O2 >95% PHYSICAL EXAM: General: intubated/sedated Eye: pupils 3 mm, minimally reactive, no scleral icterus ENT: MMM, large anterior tongue hematoma, ET tube in place, moderate serosanguionois fluid in oral cavity, trachea midline Neck: supple, unable to appreciate JVP Chest: coarse BS bilaterally, diminished at bases Heart: regular, obscured by IABP sounds Abdomen: obese, limited exam; no masses GU: normal male, mild scrotal edema Groin: PA catheter in R groin, site mildly ecchymotic without evidence of hematoma or active bleeding MSK/lymph: extremities cool, pale; faint DP pulses, 1+ pitting pedal edema Skin: no rashes/petechiae/ulcers noted Neuro: limited exam; slight movement of all extremities to verbal command; unable to completely assess GCS (likely 8-9). Pupils reactive, no corneal reflex, toes downgoing LABS: AM from _%#CITY#%_ _%#CITY#%_: ABG 7.417/33.8/83.2/22.8/96.6% 100% FiO2 Na 134, K 3.9, Cl 101, CO2 22, BUN 34, Cr 2.34, Glucose 117, Ca 8.6 Hgb 14.9, Hct 44.3%, WBC 10.6, Plt 99 INR 1.78 TSH 5.79, FT4 0.99 Admission Labs: ABG 7.33/42/61/22/86% 80% FiO2 VBG sVO2 44% Na 134, K 4.5, Cl 100, CO2 21, BUN 34, Cr 2.43, ICa 4.7 Hgb 14.9, Hct 45.0%, WBC 11.7, Plt 117 INR 1.47, PTT 58, fibrinogen 481 PA catheter readings: PA 45, PAWP 25 TTE: severe akinesis CXR: pending ASSESSMENT/PLAN: 67 year old gentleman with ICM transferred from outside hospital with refractory ventricular arrhythmias/arrests, decompensated heart failure, respiratory failure and renal failure (acute vs. chronic kidney disease).
VBG|vertical banded gastroplasty|VBG|276|278|HISTORY OF PRESENT ILLNESS|PROCEDURES PERFORMED: Repair of huge ventral hernia, lysis of severe intra-abdominal adhesions, resection of distal small bowel and ascending colon, closure of the ventral hernia with mesh. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 57-year-old female who is status post VBG for weight loss. The patient had a long history of ventral hernia and had two previous repairs. HOSPITAL COURSE: On _%#MMDD2007#%_, the patient was admitted to the hospital.
VBG|vertical banded gastroplasty|VBG|186|188|PAST MEDICAL HISTORY|Because of the patient's failed primary surgery, she was determined to be an appropriate candidate for revision to Roux-en-Y gastric bypass surgery. PAST MEDICAL HISTORY: 1. Status post VBG performed 2000. 2. Status post tubal ligation. 3. Status post total abdominal hysterectomy and salpingo-oophorectomy secondary to endometriosis.
VBG|vertical banded gastroplasty|VBG|113|115|DISCHARGE DIAGNOSES|ADMITTING DIAGNOSES: Nausea and vomiting secondary to VBG. DISCHARGE DIAGNOSES: Nausea and vomiting secondary to VBG status post VBG removal. PROCEDURES: VBG removal with pyloroplasty on _%#MMDD2007#%_ with pyloroplasty without complications.
VBG|vertical banded gastroplasty|VBG|113|115|DISCHARGE DIAGNOSES|ADMITTING DIAGNOSES: Nausea and vomiting secondary to VBG. DISCHARGE DIAGNOSES: Nausea and vomiting secondary to VBG status post VBG removal. PROCEDURES: VBG removal with pyloroplasty on _%#MMDD2007#%_ with pyloroplasty without complications.
VBG|vertical banded gastroplasty|VBG|188|190|HISTORY AND PHYSICAL|PROCEDURES: VBG removal with pyloroplasty on _%#MMDD2007#%_ with pyloroplasty without complications. HISTORY AND PHYSICAL: _%#NAME#%_ _%#NAME#%_ is a 52-year-old female who is status post VBG in 199. She has lost significant weight since the surgery. She has had resolution of her diabetes and is at ordinary ideal body weight.
VBG|venous blood gas|VBG|251|253|COURSE IN HOSPITAL|1. Acidosis with low bicarbonate. Of note, he is on sodium bicarbonate 2600 mg p.o. t.i.d. at home but his bicarbonate does not seems to be adequately replaced with this regimen. On admission, his bicarbonate level was 8 on a Chem-7 and was 12 on the VBG on the same day. His anion gap on Chem-7 was 22 and his pH on the VBG was 7.25. We did get the urine pH which was 6 and urine sodium on admission was 19.
VBG|venous blood gas|VBG|142|144|COURSE IN HOSPITAL|On admission, his bicarbonate level was 8 on a Chem-7 and was 12 on the VBG on the same day. His anion gap on Chem-7 was 22 and his pH on the VBG was 7.25. We did get the urine pH which was 6 and urine sodium on admission was 19. We thought the reason for this bicarbonate is either type 1 or type 2 renal tubular acidosis.
VBG|venous blood gas|VBG,|155|158|HOSPITAL COURSE|Abdomen was otherwise soft, nontender, nondistended. HOSPITAL COURSE: He was admitted on _%#MMDD2003#%_, underwent conversion of a jejunoileal bypass to a VBG, liver biopsy, and J-tube placement. Attending surgeon was Dr. _%#NAME#%_ _%#NAME#%_, assisted by Dr, _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_. His estimated blood loss was 200 cc intraoperatively.
VBG|vertical banded gastroplasty|VBG|154|156|HISTORY OF PRESENT ILLNESS|Negative for fevers and chills. Positive for nausea. The patient denies any emesis and has been having normal bowel movements. The patient is status post VBG and has a long history of peptic ulcer disease. This has been treated with Nexium to no avail. Multiple upper GIs in the past have shown evidence of gastritis and ulcer disease.
VBG|vertical banded gastroplasty|VBG|139|141|DIAGNOSIS|HISTORY OF PRESENT ILLNESS: This is a 44-year-old gentleman with a history of jejunoileal bypass which was taken down and converted into a VBG in _%#MM#%_ of 2003. That hospital stay was complicated by ileus and coagulopathy. He presents to the hospital today with a several-day history of abdominal pain and pressure, nausea and dry heaving.
VBG|vertical banded gastroplasty|VBG|259|261|DIAGNOSIS|PAST MEDICAL HISTORY: Significant for hypertension, gastroesophageal reflux disease, morbid obesity, kidney stones, jejunoileal bypass in 1970 with a subsequent cholecystectomy, surgery for small-bowel obstruction in 1987, viral myocarditis, and history of a VBG in _%#MM#%_ of 2003. ADMISSION MEDICATIONS: Coumadin 7.5 mg p.o. q. day, Altace 10 mg p.o. q. day, Protonix 40 mg p.o. q. day, folate and Zofran.
VBG|vertical banded gastroplasty|VBG|165|167|HOSPITAL COURSE|HOSPITAL COURSE: This is a 51-year-old male who underwent an open gastrointestinal bypass and hernia repair in _%#MM#%_ of 2003. The patient has had previous failed VBG in the past in _%#MM#%_ of 2000, as well as a prolonged hospital course with leak and sepsis at that time.
VBG|vertical banded gastroplasty|VBG|135|137|HOSPITAL COURSE|ADMISSION MEDICATIONS: None. ALLERGIES: No known drug allergies. HOSPITAL COURSE: He was admitted to bariatric service and underwent a VBG and liver biopsy on _%#MM#%_ _%#DD#%_, 2004. A liver biopsy was done at the time of surgery and showed moderate steatosis, no inflammation or fibrosis.
VBG|vertical banded gastroplasty|VBG|124|126|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Morbid obesity. DISCHARGE DIAGNOSIS: Morbid obesity. OPERATIONS/PROCEDURES PERFORMED: 1. Conversion of VBG to Roux-en-Y gastric bypass. 2. Ventral hernia repair x2, primary. 3. Extensive lysis of adhesions on _%#MM#%_ _%#DD#%_, 2004. HISTORY OF PRESENT ILLNESS: This is a 59-year-old female who is status post a vertical banded gastroplasty in _%#MM#%_ 1999, with a weight loss of approximately 80 pounds.
VBG|venous blood gas|VBG|225|227|HOSPITAL COURSE|Cultures grew out stenotrophomonas maltophilia and staph aureus. She was started on antibiotics _%#MMDD2007#%_ and should complete a 14 day course. Please see below. She has been tolerating the vent well with the most recent VBG of pH 7.43, PCO2 40, PO2 34, FiO2 21, bicarb 26. In relation to her pneumonia she has remained afebrile with a normal white count.
VBG|venous blood gas|VBG|158|160|LABORATORY DATA|LABORATORY DATA: On admission white blood cell count 17.6 with hemoglobin 13.5 and platelet count of 374,000. Liver function tests were within normal limits. VBG was 7.39, 34, 45, 20. Basic metabolic panel was within normal limits with BUN of 21 and creatinine of 0.6.
VBG|venous blood gas|VBG|118|120|LABORATORY AND IMAGING DATA|FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Negative except as noted in the HPI. LABORATORY AND IMAGING DATA: VBG showed a pH of 7.42, pCO2 39, pO2 85, bicarbonate 25. Sodium 139, potassium 3.9, glucose 84. CBC showed WBC 16.3, hemoglobin 19.4, platelets 271.
VBG|vertical banded gastroplasty|VBG|153|155|ADMISSION DIAGNOSIS|She did have some anxiety related to her job situation and the procedure itself. PAST MEDICAL HISTORY: 1. VBG in 1988 for morbid obesity. 2. Revision of VBG to Roux-en-Y in _%#MM#%_ 2004, complicated with leak and sepsis. 3. Exploratory laparotomy with subsequent intracutaneous fistula. 4. Status post appendectomy.
VBG|vertical banded gastroplasty|VBG|305|307|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 39-year-old female who had a vertical banded gastroplasty in 2003; however, the patient most recently within the past 4-5 months has been having abdominal pain that is becoming increasingly intolerant in nature for the past few months. Following her VBG in 2003, the patient has gained a significant amount of weight. The patient underwent an upper GI endoscopy on _%#MMDD2007#%_ with her paraesophageal hernia was noted to have no evidence of any incarceration or strangulation.
VBG|vertical banded gastroplasty|VBG|114|116|PAST SURGICAL HISTORY|2. Prilosec 2 tabs daily. SOCIAL HISTORY: She denies any significant alcohol abuse. PAST SURGICAL HISTORY: Gastro VBG banding back in 1999. FAMILY HISTORY: Both her father and brother had diabetes mellitus type 2.
VBG|vertical banded gastroplasty|VBG|177|179|HOSPITAL COURSE|However, the patient still had not had a satisfactory weight loss. Upon further examination as an outpatient in the Obesity Clinic, it was determined by Dr. _%#NAME#%_ that the VBG had not held, and it was therefore decided to revise the VBG on an elective basis. The patient was brought to the Operating Room on _%#MMDD#%_.
VBG|venous blood gas|VBG|248|250|LABORATORY DATA|Cerebellum: abnormal finger to nose. LABORATORY DATA: Chem-7 normal; creatinine 0.6; BUN 13; WBC 6,100; hemoglobin 11.0; MCV 85; platelets 390,000; differential normal. ESR 60; CRP 3.88 (normal 0-0.8); C3 149 (normal 90-200); C4 23 (normal 15-50); VBG pH 7.34; pCO2 50; pO2 24; SVO2 36% on room air. Urinalysis: normal. WBC negative. RBC negative. CT: Bilateral phrenic nerve pacemakers.
VBG|vertical banded gastroplasty|VBG|236|238|HISTORY OF PRESENT ILLNESS|OPERATIONS/PROCEDURES PERFORMED: Upper endoscopy and removal of food in the gastric pouch. HISTORY OF PRESENT ILLNESS: This is a 54-year-old female status post revision of a prior gastrointestinal bypass which essentially amounted to a VBG inside a gastric bypass who now presents for the second time in about 3 weeks with nausea and vomiting. She complains of no chills, no fevers, no abdominal pain, some minor constipation, no shortness of breath, no chest pain, and no dysuria nor lower abdominal pain.
VBG|vertical banded gastroplasty|VBG.|167|170|PAST SURGICAL HISTORY|ADMISSION MEDICATIONS: Synthroid, digoxin, verapamil, olanzapine, hydroxyzine, and aspirin. ALLERGIES: PENICILLIN. PAST SURGICAL HISTORY: 1. Ventral herniorrhaphy. 2. VBG. 3. Appendectomy. 4. Jejunoileal bypass. 5. Takedown of the jejunoileal bypass. 6. Stroke. 7. Depression. 8. Inflammatory or irritable bowel disease.
VBG|vertical banded gastroplasty|VBG,|146|149|HISTORY OF PRESENT ILLNESS|DIAGNOSES: 1. Wound infection. 2. Non-cardiac chest pain. HISTORY OF PRESENT ILLNESS: This is a 40-year-old male with morbid obesity, status post VBG, with reversal of VBG on _%#MMDD#%_ due to postop nausea and vomiting. He is now transferred from his nursing home to F-UMC with chest pain and wound infection.
VBG|vertical banded gastroplasty|VBG.|200|203|PROCEDURES PERFORMED DURING THIS HOSPITALIZATION|ADMIT DIAGNOSIS: Morbid obesity. DISCHARGE DIAGNOSES: Same. PROCEDURES PERFORMED DURING THIS HOSPITALIZATION: Open VBG and umbilical hernia repair. The patient was admitted on _%#MMDD2003#%_ for open VBG. The patient was taken to the OR on this date. OR course was uneventful. The patient was then temporarily transferred to post anesthesia care Unit.
VBG|vertical banded gastroplasty|VBG|283|285|HISTORY OF PRESENT ILLNESS|ADMITTING DIAGNOSIS: Abdominal pain. DISCHARGE DIAGNOSIS: Same. HISTORY OF PRESENT ILLNESS: The patient is a 25-year-old female who presented to the ER secondary to increasing abdominal pain. From the ER, the patient was admitted to 7B for further workup. The patient is status post VBG on _%#MMDD2003#%_. On approximately postoperative day #6, the patient began developing abdominal pain. The pain increased, and it was on postoperative day #7 that she presented to the ER.
VBG|vertical banded gastroplasty|VBG|142|144|HISTORY OF PRESENT ILLNESS|He has tried several dieting and exercise modalities to no avail. After being seen in clinic, it was deemed he should undergo revision of his VBG to a gastric bypass. PAST MEDICAL HISTORY: 1. Coronary artery bypass graft x3 vessels.
VBG|vertical banded gastroplasty|(VBG)|146|150|PAST MEDICAL HISTORY|She returned to clinic 7 days later with complaints of fevers and some mild abdominal pain. PAST MEDICAL HISTORY: 1. Vertical-banded gastroplasty (VBG) in 1994; redo of VBG at some point later. 2. Revision of vertical-banded gastroplasty to Roux-en-Y bypass on _%#MMDD2004#%_.
VBG|vertical banded gastroplasty|VBG|180|182|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Morbid obesity. PROCEDURES PERFORMED: Revision of VBG to Roux-en-Y gastrointestinal bypass. HISTORY OF PRESENT ILLNESS: This is a 43-year-old female who had a VBG procedure done in 2002 and she initially lost some weight but stopped losing weight for the last several years. She presents to F- UMC for revision of VBG and change to Roux-en-Y gastric bypass procedure.
VBG|vertical banded gastroplasty|VBG|132|134|PAST SURGICAL HISTORY|PAST MEDICAL HISTORY: 1. Bipolar disorder. 2. Anxiety. 3. Obesity. 4. Nephrolithiasis. 5. B12 deficiency. PAST SURGICAL HISTORY: 1. VBG in 2002. 2. Status post hysterectomy. 3. Status post tympanoplasty of the right ear. 4. Status post cholecystectomy. 5. Status post tubal ligation. ALLERGIES: CODEINE, BACTRIM, AND SEPTRA.
VBG|vertical banded gastroplasty|VBG|211|213|ALLERGIES|4. Status post cholecystectomy. 5. Status post tubal ligation. ALLERGIES: CODEINE, BACTRIM, AND SEPTRA. HOSPITAL COURSE: The patient was admitted to F-UMC and was taken to the operating room for revision of the VBG and change it to a Roux-en-Y gastrointestinal bypass. The patient tolerated the procedure very well and was taken to 7B for postoperative medical care.
VBG|vertical banded gastroplasty|VBG,|142|145|ADMISSION DIAGNOSIS|HISTORY OF PRESENT ILLNESS: This is a 44-year-old female with a complicated past medical history of morbid obesity that has been treated with VBG, stomach unstapling, and partial duodenal switch with 50 cm common channel. She presents for sleeve gastrectomy to decrease her stomach pouch.
VBG|vertical banded gastroplasty|VBG,|241|244|ADMISSION DIAGNOSIS|PAST MEDICAL HISTORY: Candidiasis, irregular menstruation, kidney stones, anemia, diarrhea, myalgia and myositis, urticaria, endocrine disorder, intestinal malabsorption, osteoarthritis. PAST SURGICAL HISTORY: Cesarean section x2, VBG, undo VBG, partial duodenal switch, right wrist fusion, spinal fusion L4 and L5 and L5 to S1 with postoperative infection, nephrolithotomy and lithotripsy, lumbar laminectomy, colposcopy, laparoscopy, bowel resection.
VBG|vertical banded gastroplasty|VBG|122|124|PAST SURGICAL HISTORY|1. Bowel obstruction. 2. Spinal stenosis. 3. History of hypertension. 4. History of PE in 1986. PAST SURGICAL HISTORY: 1. VBG in _%#MM#%_ 2003. 2. Revision of VBG in _%#MM#%_ of 2004 with resection of intestinal adhesions. 3. Cholecystectomy in 1986. 4. Spinal stenosis surgery, cervical, in _%#MM#%_ 2002.
VBG|vertical banded gastroplasty|VBG|159|161|PAST SURGICAL HISTORY|1. Bowel obstruction. 2. Spinal stenosis. 3. History of hypertension. 4. History of PE in 1986. PAST SURGICAL HISTORY: 1. VBG in _%#MM#%_ 2003. 2. Revision of VBG in _%#MM#%_ of 2004 with resection of intestinal adhesions. 3. Cholecystectomy in 1986. 4. Spinal stenosis surgery, cervical, in _%#MM#%_ 2002.
VBG|vertical banded gastroplasty|VBG|145|147|HOSPITAL COURSE|5. Breast lump resection in 1988. HOSPITAL COURSE: Patient was admitted on _%#MM#%_ 5, 2004; was taken to the operating room for revision of the VBG to gastrointestinal bypass procedure. Her wound, large keloid scar was also excised during the procedure. She tolerated procedure well and was transferred to 7B for postoperative care.
VBG|venous blood gas|VBG|165|167|ADMISSION LABORATORY DATA|ADMISSION LABORATORY DATA: Sodium 134, potassium 4.5, chloride 101, bicarbonate 18, BUN 16, creatinine 0.7, glucose 470, calcium 9.5, magnesium 1.7, phosphorus 4.3. VBG 7.33, 34, 72 and 17. Positive blood and urine ketones. HOSPITAL COURSE: PROBLEM #1. Endocrine: _%#NAME#%_'s insulin regimen was adjusted throughout his hospital stay, by the endocrine service, until his blood sugars were under good control.
VBG|vertical banded gastroplasty|VBG|145|147|HOSPITAL COURSE|6. Intermittent edema of the ankles and legs. 7. Tobacco abuse, less than 1 pack per day. HOSPITAL COURSE: Ms. _%#NAME#%_ underwent a conversion VBG to gastrointestinal bypass on _%#MM#%_ _%#DD#%_, 2004, along with a liver biopsy, cholecystectomy for gallstones, and primary repair of a ventral hernia.
VBG|vertical banded gastroplasty|VBG|370|372|HOSPITAL COURSE|However, he is experiencing a lot of vomiting and after an upper GI endoscopy which demonstrated significant restriction throughout the band, a decision was made to revise the vertical banded gastroplasty into a Roux-en-Y gastric bypass. Mr. _%#NAME#%_ has a past medical history significant for type 2 diabetes, gastroesophageal reflux disease, hypertension, the above VBG in 1994, knee surgery x3, and appendectomy. Socially, he works as an probation officer, he is married.
VBG|venous blood gas|VBG|123|125|LABORATORY DATA|Coags with INR 1.73, PTT of 46 and fibrinogen 170. ABG with a pH of 7.34, CO2 of 41, O2 of 245, bicarb 21, lactate at 2.1, VBG with a pH of 7.19, CO2 of 66, O2 of 27, bicarb of 24. Mixed venous sat of 40%. BMP with sodium of 146, potassium 3.7, chloride 116, CO2 23, BUN 19, creatinine 0.53, glucose 92, calcium 9.5, magnesium 2.2, phosphorus 6.8. LFTs with an ALT of 45, AST of 65.
VBG|vertical banded gastroplasty|VBG.|123|126|DISCHARGE DIAGNOSES|The plan was for the patient to come back to University of Minnesota Medical Center, Fairview, in a week for a revision of VBG. The patient is discharged home with TPN and clear liquids as tolerated. DISCHARGE INSTRUCTIONS: The patient is to be on a clear liquid diet.
VBG|vertical banded gastroplasty|VBG.|133|136|DISCHARGE DIAGNOSES|Activity is ad lib. The patient is to call if increased nausea or vomiting. The patient is to return in a week for a revision in the VBG. DISCHARGE MEDICATIONS: Wellbutrin SR 150 mg p.o. b.i.d., Effexor 75 mg p.o. q. day, Lipitor 10 mg p.o. q. day, Protonix 40 mg p.o. b.i.d., Roxicet elixir one or two teaspoon q.4 hours p.r.n. for pain, milk of magnesia 30 mL q.6 hours p.r.n. for constipation.
VBG|vertical banded gastroplasty|VBG|192|194|PROCEDURES PERFORMED DURING THIS HOSPITALIZATION|The patient underwent an upper GI endoscopy on _%#MMDD2007#%_, her paraesophageal hernia was noted to have no evidence of any incarceration or strangulation. The patient underwent her revised VBG to Roux-en-Y and paraesophageal hernia repair on _%#MMDD2007#%_ without any complications. The patient's hospitalization has also been without complications postoperatively. The patient's NG tube was pulled on postoperative day #4 and has since then tolerated bariatric clear diet.
VBG|vertical banded gastroplasty|VBG|101|103|HISTORY|HISTORY: The patient is a 19-year-old female who currently weighs 238 pounds. The patient did have a VBG surgery at age 16 by Dr. _%#NAME#%_. The patient's weight at that time was 260 pounds. Her lowest weight was 113 pounds, however she then began to not be able to tolerate food and so approximately 1 year ago Dr. _%#NAME#%_ did revision of surgery and put in a larger VBG ring.
VBG|vertical banded gastroplasty|VBG,|171|174|HISTORY|At the time of her second surgery, the patient was 138 pounds and today the patient is approximately 238 pounds. The patient has gained approximately 101 pounds since her VBG, which is very concerning for the patient. It was then decided that the patient should undergo a revision to a Roux-en-Y gastric bypass.
VBG|vertical banded gastroplasty|VBG|110|112|PAST SURGICAL HISTORY|Comorbidities due to her morbid obesity include GERD, depression and anxiety. PAST SURGICAL HISTORY: Includes VBG in 2005, revision VBG in 2006. PAST MEDICAL HISTORY: Significant for morbid obesity, GERD, depression and anxiety.
VBG|vertical banded gastroplasty|VBG|149|151|HOSPITAL COURSE|PAST MEDICAL HISTORY: Significant for morbid obesity, GERD, depression and anxiety. HOSPITAL COURSE: The patient proceeded to have a revision of her VBG to Roux-en-Y gastric bypass, a liver biopsy and lysis of adhesions on _%#MMDD2007#%_ without any complications. The patient then proceeded to have uncomplicated hospital course. DIET: The patient will be discharged on full bariatric liquid diet.
VBG|vertical banded gastroplasty|VBG|213|215|HISTORY OF PRESENT ILLNESS|An upper GI from _%#MMDD2007#%_ showed findings consistent with a breakdown of a vertical banded gastroplasty. The patient's past surgical history is significant for gastric bypass surgery united in 1989, an open VBG to Roux-en-Y gastric bypass with Dr. _%#NAME#%_ in 2002, appendectomy in 1955, a C-section in 1987, total abdominal hysterectomy in 1981, multiple hernia repairs without mesh.
VBG|vertical banded gastroplasty|VBG|137|139|HISTORY OF PRESENT ILLNESS|The patient has been morbidly obese for numerous years and has tried multiple attempts at weight loss and weight reduction including the VBG to Roux-en-Y gastric bypass. Her highest weight after her 2002 VBG was 360. Comorbidities include bladder cancer and lower back pain, seizure disorder and stroke with left-sided residuals, weakness and brain surgery in 1999.
VBG|venous blood gas|VBG|177|179|LABS ON ADMISSION|GU: Tanner I. MUSCULOSKELETAL EXAM: Bilateral clubbed feet. NEURO: Good suck and tracking. LABS ON ADMISSION: White blood cell count 17.1, hemoglobin 9.8 and platelets 663,000. VBG of pH 7.41, pCO2 of 63, p02 of 38, and bicarbonate 39. Lactic acid 2.0, basic metabolic panel within normal limits with exception of elevated bicarbonate of 39.
VBG|venous blood gas|VBG|240|242|ASSESSMENT AND PLAN|He will also be started on regular insulin. We will initially give him a bolus of 10 units and then run insulin at 10 units per hour. We will be initially drawing a STAT chem-10, CBC with differential, amylase, lipase, LFTs, serum ketones, VBG and serum osmolality. We will also be getting an EKG and troponin from this patient. We will be continuously checking his blood sugar q.1 hr. along with a chem-10 and serum osmolality q.2 h.
VBG|vertical banded gastroplasty|VBG|190|192|ADMITTING HISTORY AND PHYSICAL|ADMITTING DIAGNOSIS: Ventral hernia. DISCHARGE DIAGNOSIS: Ventral hernia. ADMITTING HISTORY AND PHYSICAL: _%#NAME#%_ _%#NAME#%_ is a 63-year-old female who is status post open revision of a VBG in 2004 with open conversion to a Roux-en-Y gastric bypass in _%#MM2006#%_ with a several month history of an asymptomatic ventral incisional hernia. In the past several weeks however the patient has noticed increased pain with hernia particularly at night when she lies down.
VBG|vertical banded gastroplasty|VBG,|143|146|PAST SURGICAL HISTORY|7. Hypothyroidism. 8. Ventral hernia. 9. Epilepsy. 10. Nephrotic syndrome. PAST SURGICAL HISTORY: 1. Appendectomy. 2. Cholecystectomy. 3. Open VBG, with revision in 2002. 4. Tonsillectomy and adenoidectomy. 5. Bilateral tubal ligation. FAMILY HISTORY: Non-contributory. ADMISSION MEDICATIONS: 1. Levoxyl 25 mcg q.d. 2. Vasotec 5 mg q.d.
VBG|vertical banded gastroplasty|VBG|139|141|HOSPITAL COURSE|DISCHARGE DIAGNOSES: Wound infection. PROCEDURES PERFORMED: None. HOSPITAL COURSE: The patient is an 18-year-old female who is status post VBG in _%#MM#%_ of 2003 with a wound infection. She is on chronic dialysis for renal failure. She was admitted on _%#MM#%_ of 2003 when her mother found that the patient's wound had "greenish pus" in it.
VBG|vertical banded gastroplasty|VBG|254|256|HISTORY OF PRESENT ILLNESS|Her diet was advanced to the _%#NAME#%_ pureeds. On the evening of postoperative day three, the patient was discharged to home. DISPOSITION: The patient was discharged to home on _%#MMDD2003#%_. PRINCIPAL DIAGNOSIS: Morbid obesity. MAJOR TREATMENT: Open VBG by Dr. _%#NAME#%_ _%#NAME#%_. DISCHARGE MEDICATIONS: 1. Roxicet elixir 5 ml p.o. q.6h. p.r.n. pain. 2. Motrin elixir 400 mg p.o. q.6h. p.r.n. pain.
VBG|vertical banded gastroplasty|VBG|161|163|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Obstructive sleep apnea requiring C-PAP. 2. Bursitis. 3. Sciatica of the right lower extremity. 4. PVCs. 5. Bradycardia. 6. Status post VBG six years ago. 7. Tonsillectomy during childhood. 8. Adenectomy in childhood. 9. Open appendectomy. 10. Cholecystectomy with the VBG. 11. Lipoma excision in the right neck.
VBG|vertical banded gastroplasty|VBG|145|147|HISTORY|2. Status post open vertical banded gastroplasty. 3. Increased BUN and creatinine. HISTORY: The patient is a 50-year-old male who underwent open VBG in _%#MM#%_ of 2003. The patient had a fairly unremarkable postoperative course. However, the patient was readmitted to F-UMC, on _%#MMDD2003#%_, with a diagnosis of dehydration secondary to poor PO intake x 3 to 4 days.
VBG|vertical banded gastroplasty|VBG|150|152|PAST MEDICAL HISTORY|The patient denied any nausea, vomiting, or diarrhea. Furthermore, the patient denied any fevers or chills. PAST MEDICAL HISTORY: 1. Status post open VBG in _%#MM2003#%_. 2. Bilateral knee arthroplasty. 3. Angioplasty x 3. 4. Tonsillectomy. 5. Chronic venostasis. 6. Cardiac heart disease. HOSPITAL COURSE: The patient was admitted to F-UMC, on _%#MMDD#%_, with the above diagnosis.
VBG|vertical banded gastroplasty|VBG|223|225|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Vomiting. DISCHARGE DIAGNOSIS: Gastric pouch outlet obstruction and status post vertical banded gastroplasty revision. HISTORY OF PRESENT ILLNESS: The patient is an 18-year-old female who had undergone VBG in _%#MM#%_ 2004. Following that time, she had lost a significant amount of weight, but unfortunately over the past several months she has been experiencing persistent nausea and vomiting after oral intake.
VBG|vertical banded gastroplasty|VBG|148|150|ADMISSION DIAGNOSIS|She was hospitalized in _%#MM#%_ 2006 for dehydration and inability to tolerate pill intake. At that time, she was found to have a stricture at the VBG site, as well as friable mucosa in the gastric fundus. At that time, she was treated with IV Protonix and her symptoms did improve.
VBG|vertical banded gastroplasty|VBG|159|161|ADMISSION DIAGNOSIS|She was discharged in stable condition. Unfortunately, she did continue to experience vomiting following p.o. intake. At that time it was felt revision of her VBG would be necessary. PAST MEDICAL HISTORY: Significant for diabetes which has resolved, depression and gastric reflux. PAST SURGICAL HISTORY: Significant for VBG and an umbilical hernia repair.
VBG|vertical banded gastroplasty|VBG|202|204|ADMISSION DIAGNOSIS|At that time it was felt revision of her VBG would be necessary. PAST MEDICAL HISTORY: Significant for diabetes which has resolved, depression and gastric reflux. PAST SURGICAL HISTORY: Significant for VBG and an umbilical hernia repair. HOSPITAL COURSE: On _%#MM#%_ _%#DD#%_, 2006, the patient underwent an open revision of her vertical banded gastroplasty.
VBG|venous blood gas|VBG,|251|254|ASSESSMENT AND PLAN|We have already ordered STAT labs as above. We will change the patient's IV fluids to 1/2 normal saline with 20 mEq of potassium run at 500 mL/hr. for 2 hours and then decrease it, depending on the patient's hydration status. We will be checking BNP, VBG, serum ketones q.2 h. and make sure that the patient's anion gap is resolving and her acidosis is resolving. We will also check a glucose q.1 h. as well as neuro checks q.1 h. as well to make sure the patient's blood sugar is dropping at an appropriate 50-75 per hour.
VBG|venous blood gas|VBG|119|121|HOSPITAL COURSE|During this hospitalization, ipratropium was added to his regimen. He also was started on BiPAP each day at bedtime. A VBG was checked before and after the BiPAP and did show improvement with his hypercapnic respiratory failure with the use of BiPAP.
VBG|venous blood gas|VBG|180|182|LABORATORY DATA|A CMP demonstrates an elevated creatinine of 2.0 with a BUN of 106. This is significantly changed compared to _%#MM#%_ _%#DD#%_ when her creatinine was 0.9. Her UA was negative. A VBG was drawn which demonstrates a pH of 7.23, pCO2 of 38, pAO2 of 41, and bicarb of 16. Troponin is 0.38. Abdominal CT with only oral contrast demonstrates no convincing evidence of bowel wall edema or ischemia.
VBG|venous blood gas|VBG,|150|153|ASSESSMENT|She is noted to be profoundly dehydrated with an elevated creatinine. This is acute compared to last week, and I suspect this may be prerenal. On her VBG, she does have a metabolic acidosis which may be represented by her acute renal failure plus or minus diffuse hypoperfusion from her Raynaud's phenomenon.
VBG|vertical banded gastroplasty|VBG|81|83|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old woman with a history of VBG in _%#MM2001#%_. Since then she has had persistent vomiting and presented for conversion of VBG to Roux-en-Y. She was referred to Dr. _%#NAME#%_ _%#NAME#%_ for _%#MMDD2004#%_. PAST MEDICAL HISTORY: Tension headaches, CHF, hypothyroidism, CAD, Raynaud's, history of angioplasty in 1991 and 1994.
VBG|vertical banded gastroplasty|VBG|177|179|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old woman with a history of VBG in _%#MM2001#%_. Since then she has had persistent vomiting and presented for conversion of VBG to Roux-en-Y. She was referred to Dr. _%#NAME#%_ _%#NAME#%_ for _%#MMDD2004#%_. PAST MEDICAL HISTORY: Tension headaches, CHF, hypothyroidism, CAD, Raynaud's, history of angioplasty in 1991 and 1994.
VBG|vertical banded gastroplasty|VBG|185|187|PAST MEDICAL HISTORY|She was referred to Dr. _%#NAME#%_ _%#NAME#%_ for _%#MMDD2004#%_. PAST MEDICAL HISTORY: Tension headaches, CHF, hypothyroidism, CAD, Raynaud's, history of angioplasty in 1991 and 1994. VBG in _%#MM2001#%_. History of hysterectomy. ADMISSION MEDICATIONS: 1. Glucosamine. 2. Aspirin 81 mg p.o. q.day. 3. Cozaar 50 q.day.
VBG|vertical banded gastroplasty|VBG|137|139|HOSPITAL COURSE|11. Klor-Con 20 mEq 2 p.o. q.day. ALLERGIES: Morphine causes nausea and vomiting. HOSPITAL COURSE: The patient underwent revision of the VBG to gastric bypass on _%#MMDD2004#%_ with a liver biopsy. Postoperatively, the patient did well. Pain was controlled with IV pain medications and then p.o. pain meds.
VBG|vertical banded gastroplasty|VBG.|175|178|OPERATIONS/PROCEDURES PERFORMED|HISTORY OF PRESENT ILLNESS: Patient is a 42-year-old female status post a gastric stapling in 1990. She has gained significant amounts of weight and presented for revision of VBG. PAST MEDICAL HISTORY: 1. Status post vaginal hysterectomy in 1993. 2. Status post gastric stapling in 1990. 3. Status post left shoulder surgery 2001.
VBG|vertical banded gastroplasty|VBG|176|178|ALLERGIES|1. Aciphex 20 mg p.o. q. day. 2. Advil 200 mg p.r.n. ALLERGIES: Iodine and Toradol. HOSPITAL COURSE: The patient was admitted to the bariatric service, underwent a revision of VBG and hiatal hernia repair and liver biopsy on _%#MM#%_ _%#DD#%_, 2004. Pain was initially controlled with PCA. Nausea was controlled with Zofran.
VBG|venous blood gas|VBG:|275|278|ADMISSION LABORATORY DATA|She had adequate bowel sounds. Cranial nerves were intact. She had no lymphadenopathy. ADMISSION LABORATORY DATA: White count 7.3, hemoglobin 13.2, platelets 211, hematocrit 38.8, sodium 133, potassium 4.0, chloride 100, bicarbonate 22, BUN 11, creatinine 0.59, glucose 499, VBG: pH 7.35, pCO2 36, pO2 61, calculated bicarbonate 21.0. Urine hCG was negative. Urinalysis showed glucose greater than 1000. No ketones. The patient was admitted to the general medicine service for management of her hyperglycemia and persistent cough.
VBG|vertical banded gastroplasty|VBG|192|194|HISTORY OF PRESENT ILLNESS|Unfortunately, she had had issues with nausea and inability to tolerate solid foods. This had gone on for some time following her surgery, and ultimately, she was to undergo a revision of her VBG to a Roux-en-Y. HOSPITAL COURSE: On _%#MM#%_ _%#DD#%_, 2006, the patient underwent an open revision of her vertical banded gastroplasty to a Roux-en-Y gastric bypass and liver biopsy.
VBG|venous blood gas|VBG|172|174|ASSESSMENT AND PLAN|We will start an insulin drip at 10 units/h and monitor his glucose hourly and adjust the rate. We will check serum ketones. We will monitor the patient's electrolytes and VBG every 2 h. We will check blood cultures, urinalysis and urine culture to look for evidence of infection. Also check a urine toxicology screen, ethanol level, acetaminophen level, and salicylate levels as well as amylase and lipase to look for other causes of diabetic ketoacidosis.
VBG|venous blood gas|VBG|156|158|LABORATORY DATA|INR was elevated at 1.98. Troponin was negative at less than 0.04. Ammonia and hepatic panel were completely normal. CK 115, which is within normal limits. VBG showed a pH of 7.49, pCO2 of 33, pO2 of 164, and bicarbonate of 25. This was on 100% FIO2. Ionized calcium 4.6. Lactate 1.4.
VBG|venous blood gas|VBG|144|146|HOSPITAL COURSE|He states that in the past when this has happened to him, he knew to come in sooner than later, otherwise he would start to feel sick. He had a VBG in the emergency room, which showed a pH of 7.28 with a pCO2 of 46. He had bicarbonate at that time of 24. Ketones were deducted in his blood at 1.5. The patient was given IV fluids with normal saline.
VBG|vertical banded gastroplasty|VBG|169|171|DISCHARGE APPOINTMENTS|2. No driving while taking narcotics. DISCHARGE APPOINTMENTS: Followup with Dr. _%#NAME#%_ _%#NAME#%_ in Bariatric Surgery in 2 weeks time. She is scheduled to have her VBG converted to a Roux-en-Y gastric bypass in the next few months.
VBG|venous blood gas|VBG,|207|210|LABORATORY RESULTS|EXTREMITIES: Plus 1 pitting edema in his lower extremities but no cyanosis or clubbing. LABORATORY RESULTS: On admission laboratories patient's white count was 12.4, hemoglobin 12.4, platelets 369. He had a VBG, which showed pH of 7.49, a pCO2 of 42, a pO2 of 24 and a bicarb of 32. He had a chem 10 with sodium 127, potassium 4.6, chloride 90, bicarb 28, BUN of 30, creatinine 1.37 and glucose of 116, calcium 9.3. He had a TSH of 0.42. Troponins were checked and were negative x2.
VBG|venous blood gas|VBG|191|193|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1: Shortness of breath: The patient was found to be significantly short of breath on admission. His initial O2 sat was 80% on 5 liters O2 nasal cannula. His initial VBG was 7.35/79/21/42/5 liters nasal cannula. Given the patient's prior history of severe pulmonary hypertension and recent outside echo report in 2005 showing right ventricular systolic pressure of 70 plus PAP.
VBG|venous blood gas|VBG|163|165|HOSPITAL COURSE|Diet was advanced on _%#MMDD2006#%_. Fluid balance was monitored closely, and he was net positive at the time of discharge. 2. Cardiovascular/pulmonary: Admission VBG was significant for normal pH with mildly low bicarbonate and pCO2. His respiratory status remained stable throughout the hospitalization. Dips in heart rate were noted towards the end of hospitalization on _%#MMDD2006#%_ in the early a.m. He was hemodynamically stable, neurologically appropriate and in a normal rhythm at that time.
VBG|venous blood gas|VBG,|226|229|ASSESSMENT|Electrolytes do not seem to be altered. Will draw some further lab tests including a peripheral smear, iron panel, B12 and folate, as well as a reticulocyte count to evaluate his anemia and possible confusion. Will also get a VBG, venous blood gas to evaluate for possible hypercapnia, check a TSH for thyroid disease. Will check one further troponin at 7:00 this evening although does not have any heart symptoms at this time.
VBG|venous blood gas|VBG|231|233|PROCEDURES PERFORMED DURING HOSPITALIZATION|Chest x-ray which showed clear lungs with hyperinflation cardiomegaly compared to a chest x-ray on _%#MMDD2007#%_ but no vascular congestion. Multiple laboratory tests were performed. No significant acute abnormalities were found. VBG did show a pCO2 that was minimally elevated at 50. Troponins were negative at less than 0.04. MRI of the brain showed no evidence of acute ischemic injury and moderate nonspecific white matter changes, likely representing sickle of chronic small vessel ischemic disease.
VBG|vertical banded gastroplasty|VBG|155|157|PAST SURGICAL HISTORY|PAST MEDICAL HISTORY: 1. Colorectal cancer. 2. Morbid obesity. 3. Hypertension. 4. Degenerative joint disease. PAST SURGICAL HISTORY: 1. _%#MM#%_ 1995. 2. VBG 1998 with cholecystectomy and stomal revision. 3. Incisional hernia repair in 1998. 4. C-section 1989. 5. Tonsillectomy. 6. VBG revision 2004. ALLERGIES: No known drug allergies.
VBG|venous blood gas|VBG.|191|194|HOSPITAL COURSE|She was stable in the MICU. The diagnosis was upper airway obstruction. The patient was transferred to the floor, then sating in the mid-90s on trach dome without difficulty. She underwent a VBG. It showed a pH of 7.4, pCO2 of 37. She underwent a bronchoscopy on _%#MMDD2005#%_ by the pulmonary service.
VBG|vertical banded gastroplasty|VBG|272|274|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old female who presented to the emergency department in the evening of _%#MM#%_ _%#DD#%_, 2005, complaining of nausea, vomiting, and left upper quadrant pain. The patient had a recent history of an open conversion of a VBG to Roux-en-Y gastric bypass with repair of a large ventral hernia on _%#MM#%_ _%#DD#%_, 2005. The patient reported that her pain had begun 5 days earlier with progressive emesis, unable to keep any food down on the day prior to her admission.
VBG|venous blood gas|VBG,|209|212|HISTORY OF PRESENT ILLNESS|Cranial nerves grossly intact and motor grossly intact. LABORATORY: Labs on admission, basic metabolic panel was normal except for a low glucose of 66. Bicarbonate was normal at 25. The patient has also had a VBG, which showed a normal pH of 7.4, and a bicarbonate of 22. Serum ketones were elevated at 1.3. CBC showed a slightly low white blood cell count of 4.7 with a differential of 44 neutrophils, 36 lymphocytes, and 20 monocytes.
VBG|vertical banded gastroplasty|VBG|78|80|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: Morbid obesity. OPERATIONS/PROCEDURES PERFORMED: An open VBG with a liver biopsy was done on _%#MM#%_ _%#DD#%_, 2006. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 49-year-old female who is referred for evaluation of bariatric surgery.
VBG|venous blood gas|VBG|243|245|HISTORY OF PRESENT ILLNESS AND BRIEF HOSPITAL COURSE|She was continued on BiPAP at night. Her symptoms gradually improved, and at the time of discharge she was only on a nasal cannula. On _%#MM#%_ _%#DD#%_, 2006, her ABG showed a pH of 7.32, PCO2 91, bicarb 46, and on _%#MM#%_ _%#DD#%_, 2006, a VBG was done which showed a pH of 7.34, PCO2 94, PO2 47, and bicarb 49 on 3 liters of oxygen. She was also seen by a Pulmonary Team on the floor who ordered a home BiPAP even on discharge.
VBG|vertical banded gastroplasty|VBG|173|175|PAST MEDICAL HISTORY|6. Hypertension. 7. Iron deficiency anemia. 8. Decreased haptoglobin, probably secondary to valve. 9. Obstructive sleep apnea, not tolerating CPAP. 10. Gastric stapling and VBG in 1995 with chronic nausea and vomiting. 11. Cholecystectomy in _%#MM1998#%_. 12. Left breast biopsy, benign. 13. Ventral hernia repair in 2005. 14. Hyperlipidemia. 15. Hepatitis C, status post blood transfusion in 1963.
VBG|vertical banded gastroplasty|VBG|137|139|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 49-year-old female, status post takedown of duodenojejunostomy done 31 years ago and conversion to VBG six months ago in _%#MM#%_ of 2001. Approximately three weeks after discharge from this procedure, the patient was readmitted for small bowel obstruction secondary to intra- abdominal abscess most likely due to small bowel anastomosis leak and fistula.
VBG|venous blood gas|VBG,|184|187|PLAN|Will also check isopropyl alcohol level which is much more likely in the setting of this osmolal gap and no anion gap. Will check a lactic acid level, serum ketones. Will also check a VBG, venous blood gas, at this time. Again, it is very unlikely that the patient has ingested methanol or ethylene glycol, although isopropyl alcohol is a very real possibility.
VBG|venous blood gas|VBG|124|126|LABORATORY AND DIAGNOSTICS|Motor exam with the upper and lower extremities without focal deficit. Otherwise nonfocal exam. LABORATORY AND DIAGNOSTICS: VBG obtained: pH 7.34, pCO2 43, pO2 87, bicarbonate 23. Chest x-ray obtained demonstrates increased density in the right lung base, possibly consistent with pneumonitis.
VBG|vertical banded gastroplasty|VBG,|95|98|DISCHARGE DIAGNOSIS|ADMISSION DIAGNOSIS: Obesity status post VBG, no weight gain. DISCHARGE DIAGNOSIS: Status post VBG, no weight gain. OPERATION PERFORMED: Conversion of VBG to open duodenal switch.
VBG|vertical banded gastroplasty|VBG.|216|219|BRIEF HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSIS: Status post VBG, no weight gain. OPERATION PERFORMED: Conversion of VBG to open duodenal switch. BRIEF HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 44-year-old lady who 10 years ago underwent VBG. Initially, she had a good weight loss, but recently had again problems with weight gain. She tried nonsurgical options first, however, failed to lose her weight.
VBG|vertical banded gastroplasty|VBG|283|285|HISTORY OF HOSPITALIZATION|PAST MEDICAL HISTORY: VBG in 1998 with tubal ligation, uterine ablation, 2007 right knee replacement surgery in 1982 and tonsillectomy and tummy tuck in 2000. MEDICATIONS: None. HISTORY OF HOSPITALIZATION: The patient was admitted on _%#MMDD2007#%_. She underwent open conversion of VBG to a duodenal switch. Intraoperatively and postoperatively, the patient had no complications. Her pain was initially well controlled on PCA. She was ambulating. The patient had return of bowel functions.
VBG|venous blood gas|VBG|258|260|LABORATORY DATA|LYMPHATICS: No edema. SKIN: Intact. NEUROLOGICAL STATUS: Alert, awake and oriented x3. EXTREMITIES: No edema and no calf tenderness. LABORATORY DATA: Sodium 134, potassium 4.7, chloride 97, bicarbonate of 17, glucose of 478, BUN of 14 and creatinine of 0.7. VBG of 7.36/35/32/19. Ketones of 5.8. UA had more than 150 ketones. ASSESSMENT AND PLAN: A 41-year-old female patient with insulin-dependent diabetes mellitus admitted after 2 days of crampy abdominal pain, nausea, vomiting and diarrhea.
VBG|venous blood gas|VBG|206|208|LABORATORY DATA|LABORATORY DATA: From _%#MMDD#%_, sodium 136, potassium 4.3, chloride 100, bicarbonate 27, glucose 86, BUN 19, creatinine 0.5, hemoglobin 14.5, white blood cell count 4.4, platelet count 178. Postoperative VBG 7.31+62. POSTOPERATIVE CHEST X-RAY: Shows decreased right lower lobe consolidation, no change in the opacities on the left.
VBG|vertical banded gastroplasty|VBG.|240|243|HOSPITAL COURSE|On that day, the patient was taken to the operating room by the bariatric surgery service where she underwent a lysis of adhesion and conversion of her VBG to a Roux-en-Y gastric bypass surgery. Notable intraoperative findings were a tight VBG. The procedure was without complications, and the patient tolerated the procedure well. The patient's postoperative course was unremarkable. Throughout the patient's hospital stay, she remained afebrile and hemodynamically stable.
VBG|vertical banded gastroplasty|VBG|103|105|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: Morbid obesity, wound infection. OPERATIONS/PROCEDURES PERFORMED: Conversion of a VBG to an open Roux-en-Y gastric bypass. HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old male with morbid obesity status post VBG.
VBG|vertical banded gastroplasty|VBG.|238|241|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: Morbid obesity, wound infection. OPERATIONS/PROCEDURES PERFORMED: Conversion of a VBG to an open Roux-en-Y gastric bypass. HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old male with morbid obesity status post VBG. The patient apparently had a gastroplasty in 1998 and has continued to be obese and has had weight gain since the surgery.
VBG|vertical banded gastroplasty|VBG|240|242|DISCHARGE DIAGNOSIS|The patient apparently had a gastroplasty in 1998 and has continued to be obese and has had weight gain since the surgery. After the risks and benefits of the procedure were explained, the patient decided to go ahead with conversion of the VBG to an open Roux-en-Y gastric bypass. PAST MEDICAL HISTORY: Diabetes mellitus type 2 insulin dependent, hypertension, dyslipidemia, morbid obesity, sleep apnea, L5- S1 compression, depression, peripheral neuropathy, diabetic nephropathy, diabetic proliferative retinopathy, erectile dysfunction, cervical disk degeneration.
VBG|venous blood gas|VBG:|211|214|LABORATORY DATA|SKIN: Warm and dry, no rashes. LABORATORY DATA: WBC 12.2, hemoglobin 11.5, platelets 272. Glucose slightly elevated at 139, otherwise chemistry panel normal. LFTs essentially normal. Prealbumin 24, albumin 3.3. VBG: pH 7.40, pCO2 48, pO2 33. ASSESSMENT AND PLAN: The patient is a 32-year-old female with cystic fibrosis now in for desensitization to Bactrim for treatment of Achromobacter.
VBG|vertical banded gastroplasty|VBG.|126|129|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: The patient was scheduled with an appointment with a dietitian to discuss dietary habits, status post VBG. She was also told to call with any concerns, worsening pain or fevers, the resident on call at _%#TEL#%_. Follow up with Dr. _%#NAME#%_.
VBG|venous blood gas|VBG|184|186|HISTORY OF PRESENT ILLNESS|An UVC line was placed. The patient developed worsening apnea and bradycardia at approximately 2:30 a.m. and therefore was intubated and placed on a ventilator. Prior to intubation, a VBG was drawn and showed a pH of 7.16, pCO2 of 71, pO2 of 30 and bicarbonate of 24 and post intubation, his VBG showed a pH of 7.34, pCO2 of 38, pO2 of 48 and bicarbonate of 20.
VBG|venous blood gas|VBG|455|457|ADMITTING LABORATORY DATA|SPINE: No defects. LYMPHATICS: No edema. MUSCULOSKELETAL: Moves all extremities, warm and well perfused. SKIN: Slight jaundice. ADMITTING LABORATORY DATA: His BMP showed a sodium of 131, potassium of 5, chloride 105, bicarbonate 21, BUN 21, creatinine 1.1, glucose 68 and calcium of 3.4. He has a total bilirubin of 4.6 and direct bilirubin of 0.2. His CBC showed a white blood cell count of 16.6, hemoglobin 15.6, platelets 260,000 and ANC of 8.817. His VBG pH of 7.34, pCO2 of 28, pO2 of 48 and bicarbonate of 20 and saturating 90%. HOSPITAL COURSE: 1. Fluids, electrolytes and nutrition. The patient was kept n.p.o. on admission to the PICU.
VBG|vertical banded gastroplasty|VBG|209|211|HISTORY AND PHYSICAL EXAMINATION|HISTORY AND PHYSICAL EXAMINATION: The patient is a 38-year-old female who has had chronic abdominal pain associated with nausea and vomiting and has got worse over the last 2 weeks. The patient is status post VBG in 2003. The patient has been admitted 2 times now for the same problem, once in 2003 and another in 2005. The workups during the 2 hospitalizations for negative for any anatomical reasons for her symptoms.
VBG|venous blood gas|VBG|141|143|LABORATORY ASSESSMENT UPON ADMISSION|LABORATORY ASSESSMENT UPON ADMISSION: Her white count was 5.3, hemoglobin 12.6, CRP was 12.5, which decreased to 7.9 within 1 day. She had a VBG indicating 7.33, 74, 28 and 38. Electrolyte panel was unremarkable. FVC was 37% predicted, FEVI 28% predicted. Chest x-ray indicates a large bronchiectasis with air fluid levels no acute infiltrate.
VBG|venous blood gas|VBG|368|370|HOSPITAL COURSE|She was initiated on levofloxacin antibiotic therapy along with the burst of steroids 1 mg/kg b.i.d. She was continued on all her home regimens of nebulizers including albuterol q.i.d., Atrovent b.i.d., hypertonic 7% saline b.i.d., tobramycin 300 mg b.i.d. along with q.i.d. VEST treatments. Her BiPAP was provided with settings of 15/8 for use when she slept. Repeat VBG was obtained at 5:00 a.m. and before she went to sleep on both evenings. A continuous pulse oximetry was also obtained during her sleep.
VBG|venous blood gas|VBG|200|202|HOSPITAL COURSE|A continuous pulse oximetry was also obtained during her sleep. She had no headache during the hospitalization. Her VBGs improved significantly after treatment with antibiotics and steroids. Her last VBG before discharge was 7.37, PCO2 of 58, PO2 52, bicarbonate of 32. Again, the patient had a complete resolution of her headache once the PCO2 was brought down to a level closer to normal.
VBG|vertical banded gastroplasty|VBG|151|153|HISTORY OF PRESENT ILLNESS|The patient presents for an elective paniculectomy scheduled with Dr. _%#NAME#%_ _%#NAME#%_. PAST MEDICAL HISTORY: 1. History of hypertension prior to VBG that has been resolved to a small extent. 2. Symptoms due to weight that have been resolved. 3. GERD, on Aciphex. Was diagnosed in _%#MM#%_ 2002. 4. History of depression.
VBG|vertical banded gastroplasty|VBG|141|143|PAST SURGICAL HISTORY|3. GERD, on Aciphex. Was diagnosed in _%#MM#%_ 2002. 4. History of depression. Completed treatment in _%#MM#%_ 2000. PAST SURGICAL HISTORY : VBG in _%#MM#%_ 2000. ADMISSION MEDICATIONS: Aciphex 1 tablet p.o. q.d. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.8, pulse 58, blood pressure 116/58, weight 161 pounds.
VBG|venous blood gas|VBG|208|210|LABORATORY STUDIES ON ADMISSION|Her heart had a regular rate and rhythm with a 2/6 systolic murmur heard at the left upper sternal border. LABORATORY STUDIES ON ADMISSION: White count 20.4, hemoglobin 10.1, 83% neutrophils, 9% lymphocytes. VBG as 7.31, 46, 34. Electrolytes were within normal limits. LFTs were also within normal limits. CRP was 29.8.
VBG|vertical banded gastroplasty|VBG|187|189|PAST SURGICAL HISTORY|4. Osteoporosis and chronic pain. 5. Gastroesophageal reflux disease. 6. Depression. PAST SURGICAL HISTORY : 1. Cholecystectomy in _%#MM#%_ of 2001. 2. Duodenal switch, _%#MM#%_ 1999. 3. VBG revision in 1991; original VBG in 1979. MEDICATIONS ON TRANSFER: 1. DuoNeb. 2. Calcitonin. 3. Calcium carbonate.
VBG|vertical banded gastroplasty|VBG|324|326|HOSPITAL COURSE|However, it was noted she did, after some social stressors in her life, begin eating excessively, and it was found on her upper GI that there was a broken staple, as well as endoscopy showing about 100 ml pouch with 2 mm outlet. It was decided, therefore, by Dr. _%#NAME#%_ to take the patient back to surgery to revise her VBG as well as repair an incisional ventral hernia. The patient's surgery was without complication. The patient was brought to the floor on the first postoperative day.
VBG|venous blood gas|V.B.G.|128|133|PROBLEM #4|We thought that tracheomalacia might be playing a role in her symptoms because of the history of the tracheoesophageal fistula. V.B.G. at the time of admission was pH 7.37, PCO2 43 on 2 liters per minute of O2. CBC showed a white count of 15,200 and hemoglobin 13.5 with a platelet count of 804,000.
VBG|vertical banded gastroplasty|VBG|147|149|BRIEF HISTORY OF PRESENT ILLNESS|BRIEF HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 45-year-old patient with long history of morbid obesity of approximately ten years. He had a VBG performed by Dr. _%#NAME#%_ in _%#MM#%_ of 2000, and after this lost approximately a 160 pounds. He began to regain this weight around _%#MM#%_ of 2001 and he was thought to have a staple line leak by outside film that was performed.
VBG|vertical banded gastroplasty|VBG|182|184|BRIEF HISTORY OF PRESENT ILLNESS|A repeat upper GI was performed at the Fairview-University Medical Center that showed small pouch and no leak. Options were discussed for possible surgical revision of the patient's VBG and that the decision was made to go ahead with a revision of the VBG. The patient's BMI is 51 at the time of evaluation.
VBG|vertical banded gastroplasty|VBG|145|147|PAST SURGICAL HISTORY|ALLERGIES: No known drug allergies. MEDICATIONS: 1. Verapamil. 2. Aspirin. PAST MEDICAL HISTORY: Hypertension. PAST SURGICAL HISTORY: Other than VBG is a tonsillectomy. HOSPITAL COURSE: The patient was assessed by the Anesthesia Service and taken to the operating room on _%#MM#%_ _%#DD#%_.
VBG|vertical banded gastroplasty|VBG.|179|182||Patient complains of right upper quadrant pain with meals. PAST MEDICAL HISTORY: Hypothyroidism, depressions, obesity, status post VBG, GERD, hypertension. PAST SURGICAL HISTORY: VBG. ALLERGIES: INCLUDE BIAXIN, CODEINE, EPINEPHRINE. FAMILY HISTORY: Significant for coronary artery disease and diabetes mellitus. SOCIAL HISTORY: Denies tobacco use. PHYSICAL EXAMINATION: On exam, patient was afebrile.
VBG|vertical banded gastroplasty|VBG|52|54|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Morbid obesity, status post VBG in 1985. 2. Failure to lose weight, status post revision of VBG. HISTORY OF PRESENT ILLNESS: This patient is a 49-year-old Native American female with a history of morbid obesity.
VBG|vertical banded gastroplasty|VBG|125|127|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This patient is a 49-year-old Native American female with a history of morbid obesity. She had a VBG in Montana in 1985, and initially lost approximately 80 pounds of weight. She regained weight following the second pregnancy, and has tried several attempts to lose weight without success.
VBG|vertical banded gastroplasty|VBG|29|31|FINAL DIAGNOSIS|FINAL DIAGNOSIS: Status post VBG 3 years ago, presented with nausea and vomiting of 1 week duration. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 53-year-old female who is status post VBG approximately 3 years ago.
VBG|vertical banded gastroplasty|VBG|187|189|HISTORY OF PRESENT ILLNESS|FINAL DIAGNOSIS: Status post VBG 3 years ago, presented with nausea and vomiting of 1 week duration. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 53-year-old female who is status post VBG approximately 3 years ago. She presented with vomiting of about 1 week duration. On presentation, she denied fevers, chills or abdominal pain.
VBG|vertical banded gastroplasty|VBG.|128|131|BRIEF HISTORY OF PRESENT ILLNESS|Unfortunately, she did not succeed. She was evaluated by Dr. _%#NAME#%_ in clinic and she decided she was going to undergo open VBG. The patient's comorbidities include hypertension, cardiac dysrhythmia and depression. HISTORY OF HOSPITALIZATION: The patient was hospitalized on _%#MMDD2007#%_.
VBG|vertical banded gastroplasty|VBG.|181|184|HISTORY OF HOSPITALIZATION|The patient's comorbidities include hypertension, cardiac dysrhythmia and depression. HISTORY OF HOSPITALIZATION: The patient was hospitalized on _%#MMDD2007#%_. She underwent open VBG. Her pediatric operative BMI was 106. Intraoperatively and postoperatively, the patient did well. Her pain initially was controlled on PCA. Further after the return of bowel function, the patient was started on liquid pain medication, plus the patient was started on a full liquid diet.
VBG|venous blood gas|VBG,|192|195|LABORATORY DATA|LUNGS: Clear. ABDOMEN: Soft, benign, no rebound or guarding. SKIN: Without rashes. LABORATORY DATA: White count 13.9, hemoglobin 16.2, bicarbonate level is less than 5 on the chemistry but on VBG, estimated at around 5. PH of 7.11. His initial glucose is 499. UA demonstrates significant glucosuria with 30+ protein.
VBG|vertical banded gastroplasty|VBG|301|303|BRIEF HISTORY OF HOSPITALIZATION|The patient had a history of ventral banded gastroplasty. However, given the persistent weight gain, the patient decided to undergo the procedure for duodenal switch. BRIEF HISTORY OF HOSPITALIZATION: The patient was admitted on _%#MMDD2007#%_. She underwent tubal ligation, liver biopsy, revision of VBG to duodenal switch and lysis of adhesions. Postoperatively, the patient did well. Her pain was controlled on PCA. Initially, she had a bump in her white blood cell count and upper GI was obtained.
VBG|venous blood gas|VBG|175|177|COURSE|He does have a fine tremor consistent with his long term cyclosporin use. Respiratory: The patient is currently on 4 liters nasal cannula. His oxygen saturation is at 95-97%. VBG is essentially within normal limits. He did have some hypercapnia that is now resolved now with a PCO2 of 49. From a cardiac standpoint, he is on the normal standard transplant cardiac medications.
VBG|venous blood gas|VBG|199|201|HOSPITAL COURSE|HOSPITAL COURSE: 1. Metabolic acidosis/hypokalemia: Upon presentation to the emergency room, the patient was found to have a sodium level of 128 and potassium level of 1.9, chloride level of 51. Her VBG at that time showed pH of 7.58, PCO2 of 58, PO2 of 42, with oxyhemoglobin of 65% and bicarbonate of 55.
VBG|venous blood gas|VBG|165|167|HOSPITAL COURSE|The patient had a short course in the ICU and was transferred out after her potassium was replaced and her electrolytes were more balanced. The patient had a repeat VBG which showed a pH of 7.46, PCO2 of 57, PO2 of 39, and bicarbonate of 40. The patient did have some hypophosphatemia as well and this did require replacement for this as well.
VBG|venous blood gas|VBG|220|222|HOSPITAL COURSE|The patient did feel much better throughout her MICU course and was actually transferred to the Medicine Service for further care. The patient's phosphorus remain low at 1.1 and continuous replacement was placed. Repeat VBG showed normalizing values with still likely metabolic acidosis with the pH of 7.49, PCO2 of 45, PO2 of 62 and bicarb at 34. The patient's basic metabolic panel on the day of discharge was sodium level 136, potassium 4.1, chloride of 103, CO2 of 27, BUN of 12, creatinine 0.7, and calcium low at 7.8, magnesium at 2.3, and phosphorus at 2.5. The patient was discharged with phosphorus replacement and Nutraphos 1 pack p.o. t.i.d.
VBG|vertical banded gastroplasty|VBG|282|284|HISTORY OF PRESENT ILLNESS|Her last revision of VBG was 2 years ago. Following that revision, she has been unable to eat solid foods and has been eating only ice cream and protein shakes. She was also experiencing episodes of vomiting following p.o. intake. Due to this, she ultimately sought revision of her VBG to a Roux-en-Y gastric bypass. HOSPITAL COURSE: On _%#MM#%_ _%#DD#%_, 2006, The patient underwent revision of VBG to a Roux-ne-Y gastric bypass and liver biopsy.
VBG|vertical banded gastroplasty|VBG|165|167|HOSPITAL COURSE|Due to this, she ultimately sought revision of her VBG to a Roux-en-Y gastric bypass. HOSPITAL COURSE: On _%#MM#%_ _%#DD#%_, 2006, The patient underwent revision of VBG to a Roux-ne-Y gastric bypass and liver biopsy. She tolerated the procedure well, and there were no immediate postoperative complications.
VBG|vertical banded gastroplasty|VBG.|36|39|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: 1. Status post VBG. 2. Gastric outlet stricture. 3. Dehydration. DISCHARGE DIAGNOSIS: 1. Status post VBG. 2. Gastric outlet stricture.
VBG|vertical banded gastroplasty|VBG|151|153|HISTORY OF PRESENT ILLNESS|The patient was initially admitted on _%#MM#%_ _%#DD#%_, 2006, at _%#CITY#%_ with dehydration and was fluid resuscitated. The patient has a history of VBG in the past done at St. Joseph Hospital in 1997. On consultation with bariatric team, it was deemed appropriate for the patient to be transferred to University of Minnesota Medical Center, Fairview, Bariatric Service for a continued care.
VBG|vertical banded gastroplasty|VBG|227|229|PAST MEDICAL HISTORY|On consultation with bariatric team, it was deemed appropriate for the patient to be transferred to University of Minnesota Medical Center, Fairview, Bariatric Service for a continued care. PAST MEDICAL HISTORY: 1. Status post VBG in 1997 performed at St. Joseph Hospital. 2. History of chronic headaches. 3. History of neck and left shoulder pain. 4. Dental caries. 5. History of gunshot wound to the left chest.
VBG|venous blood gas|VBG:|257|260|LABS ON ADMISSION|GU: ND. Skin: Right triple-lumen catheter. LABS ON ADMISSION: Chem 10: Sodium 134, potassium 2.8, chloride 79, bicarb 25, BUN 76, creatinine 2.5, glucose 673. LFTs: Bilirubin 1.1, AST 22, ALT 14(?), ALT 150(?), albumin 4.4. Serum ketones: Small. Lipase 59. VBG: pH 7.44(?), pCO2 28, pO2 44, bicarb 19. Beta HCG: Negative. UA: Glucose greater than 1000, ketones 15, blood small, nitrates negative, leukocyte esterase negative.
VBG|vertical banded gastroplasty|VBG.|185|188|HISTORY OF PRESENT ILLNESS|The patient relates over the past 15 years doubling her weight, which is currently 300 pounds. The patient has tried multiple diet and exercise programs, and has now elected to undergo VBG. PAST MEDICAL HISTORY: 1) Morbid obesity (see above). 2) History of cholecystectomy.
VBG|venous blood gas|VBG|112|114|LABORATORY DATA|Cranial nerves II through XII are all intact. Motor is 5/5. Reflexes are intact and symmetric. LABORATORY DATA: VBG initially was 7.27 with pCO2 of 62 and a pO2 of 63. Subsequent measurements were pH of 7.33, pCO2 of 57, pO2 of 37, and then subsequently 7.37 with pCO2 of 48 and pO2 of 43.
VBG|venous blood gas|VBG|193|195|HOSPITAL COURSE|Bronchial cultures grew out Hemophilus influenza, sensitive to ampicillin. After extubation, the patient was switched to Bi-PAP 10/5. The patient continues to have severe hypoventilation, with VBG on discharge showing a pH of 7.29, pCO2 94, pO2 22, bicarbonate 44, and SV02 31%. The patient has extremely severe underlying acidosis. The patient has no respiratory reserve.
VBG|venous blood gas|VBG|226|228|PROBLEM #6|She had intermittently noted some right flank pain, which appeared musculoskeletal in nature, although a U/A and U/C were obtained, which were both normal in terms of infection. PROBLEM #6: Endocrinology. _%#NAME#%_'s initial VBG was significant for a pH of 7.38. Upon arrival to F-UMC, she was on a regular insulin drip. This was transitioned to a combination of NPH and Humalog.
VBG|vertical banded gastroplasty|VBG|140|142|SURGICAL HISTORY|4. Hypertension. SURGICAL HISTORY: 1. Jejunoileal bypass in 1978 and cholecystectomy. 2. Takedown of jejunoileal bypass and conversion to a VBG in _%#MM#%_ of 2003. ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: 1. Metoprolol 50 mg po q day.
VBG|venous blood gas|VBG|248|250|X-RAY/LAB RESULTS|She does answer questions appropriately when you can awaken her to do so. X-RAY/LAB RESULTS: White count of 10.1 with 88% neutrophils, hemoglobin 15, platelets 212, troponin #1 is negative, her terminal BMP is 7630, phenytoin level is less than 3, VBG in the ER is 7.5, CO2 20, O2 of 108, bicarb 15, oxy hemoglobin is 99%. Her lactic acid is 1.1. Electrolyte panel revealed some hyponatremia at 129.
VBG|vertical banded gastroplasty|VBG|172|174|HISTORY OF HOSPITALIZATION|MEDICATIONS: Include atenolol, lisinopril, Zoloft and multivitamin. HISTORY OF HOSPITALIZATION: The patient was hospitalized on _%#MMDD2007#%_. She underwent conversion of VBG to long limb Roux-en-Y gastric bypass. Postoperatively, the patient did well. She had return of bowel function and had multiple bowel movements.
VBG|vertical banded gastroplasty|VBG.|108|111|OPERATION PERFORMED|ADMISSION DIAGNOSIS: Morbid obesity. DISCHARGE DIAGNOSIS: Morbid obesity. OPERATION PERFORMED: Laparoscopic VBG. BRIEF HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 29-year-old gentleman with a history of morbid obesity who was evaluated by Dr. _%#NAME#%_ in clinic.
VBG|vertical banded gastroplasty|VBG.|203|206|BRIEF HISTORY OF HOSPITALIZATION|The risks and benefits were discussed with the patient and he decided to undergo laparoscopic VBG. BRIEF HISTORY OF HOSPITALIZATION: The patient was admitted on _%#MMDD2007#%_. He underwent laparoscopic VBG. Intraoperatively, the patient did well. Postoperatively, there were no complications. The patient tolerated clear liquid diet. His pain was well controlled on oral medications.
VBG|vertical banded gastroplasty|VBG|239|241|HISTORY OF PRESENT ILLNESS|ADMISSION DIAGNOSIS: Wound infection. DISCHARGE DIAGNOSIS: Wound infection. PROCEDURE PERFORMED: Incision and drainage of the wound, VAC placement. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 50-year-old lady status post conversion of VBG to gastric bypass on _%#MMDD2007#%_. She presented to the Emergency Department with erythema around the abdominal wound and drainage.
VBG|vertical banded gastroplasty|VBG|251|253|HISTORY OF PRESENTING ILLNESS|She has multiple psychiatric illness and other comorbidities. An upper endoscopy was performed to confirm the fact that she has had a restricted diet. The patient was seen in the clinic and she was found suitable. She was evaluated from conversion of VBG to Roux-en-Y bypass. The patient presented to the hospital on the day of procedure. The patient had endoscopy, which showed severe regurigtation secondary to VBG and had an upper GI showing GERD.
VBG|vertical banded gastroplasty|VBG|160|162|PROCEDURE PERFORMED|ADMISSION DIAGNOSIS: Chronic vomiting, status post VBG. DISCHARGE DIAGNOSIS: Replacement of vertical banded gastroplasty ring. PROCEDURE PERFORMED: Revision of VBG and replacement of VBG ring. Liver biopsy. SURGEON: Dr. _%#NAME#%_.
VBG|venous blood gas|VBG|190|192|HISTORY OF PRESENT ILLNESS|She is quite sure there was no head injury as she was found still sitting on the toilet. Initial laboratory data in the emergency department showed elevated blood sugar greater than 500 and VBG showing pH 7.2. she had elevated anion gap of 25 and bicarbonate was 17. Thus she was given 2 liters of IV fluids, started on 7 units of IV insulin, and brought to the Intensive Care Unit for management of diabetic ketoacidosis.
VBG|vertical banded gastroplasty|VBG|246|248|HISTORY OF PRESENT ILLNESS|ADMISSION DIAGNOSIS: Morbid obesity. DISCHARGE DIAGNOSIS: Morbid obesity. OPERATIONS/PROCEDURES PERFORMED: Open conversion from VBG to Roux-en-Y and splenectomy. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 41-year-old female who had a VBG approximately 16 years ago who developed chronic cholecystitis and cholelithiasis. The patient underwent a laparoscopic cholecystectomy which was complicated postoperatively by a common bile duct stone.
VBG|vertical banded gastroplasty|VBG|114|116|HISTORY OF PRESENT ILLNESS|She was sent to Minnesota GI for postoperative ERCP. They were unable to do the ERCP secondary to the size of her VBG site. They attempted multiple dilations with no success. She then underwent a common bile duct exploration with T-tube placement.
VBG|vertical banded gastroplasty|VBG|261|263|HOSPITAL COURSE|The patient has had continued problems with difficulty with weight loss, recurrent episodes of nausea and intractable emesis requiring multiple dilations, most recently as stated above. HOSPITAL COURSE: On _%#MMDD2007#%_, the patient underwent an open revision VBG to Roux-en-Y gastrointestinal bypass, extensive lysis of adhesions and a splenectomy. She tolerated the procedure well and was transferred to the floor with stable vital signs.
VBG|vertical banded gastroplasty|VBG|130|132|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a Russian native patient who previously had a vertical band gastroplasty and was admitted for VBG revision. PAST MEDICAL HISTORY: Vertical band gastroplasty. ADMISSION MEDICATIONS: 1. Coumadin 7.5 mg q.d.
VBG|venous blood gas|VBG|130|132|PHYSICAL EXAMINATION ON ADMISSION|Chest film was significant for slight pulmonary edema bilaterally with atelectasis in the right upper lobe and right middle lobe. VBG was found to be 7.43/40/47/26/79%. Coags were INR of 2.45 and PTT of 33. EKG revealed sinus tachycardia and complete right bundle branch block.
VBG|vertical banded gastroplasty|VBG.|169|172|BRIEF HISTORY|BRIEF HISTORY: The patient is a 50-year-old female with a history of morbid obesity that has been unsuccessfully treated with diet and exercise. She presented now for a VBG. PAST MEDICAL HISTORY: Significant for asthma and long history of smoking.
VBG|vertical banded gastroplasty|VBG|194|196|BRIEF HISTORY|1. Open conversion of vertical banded gastroplasty. 2. Roux-en-Y gastric bypass. 3. Liver biopsy. BRIEF HISTORY: Ms. _%#NAME#%_ is a 31-year-old female with morbid obesity. She originally had a VBG in _%#MM#%_ 1999 by Dr. _%#NAME#%_. She did manage to lose approximately 140 pounds. Within the last 7 or 8 months, this patient has started to gain weight again.
VBG|vertical banded gastroplasty|VBG.|175|178|BRIEF HISTORY|This started in _%#MM#%_ 2003, and was accelerated by _%#MM#%_ 2003. An upper GI was performed in _%#MM#%_ 2003, and they were unable to pass the scope beyond the ring of the VBG. At the time of this admission, her BMI was 31. PAST MEDICAL HISTORY: 1. L4-5 disc herniation. 2. Episodic GERD.
VBG|venous blood gas|VBG|88|90|LABORATORY DATA|Sensation and muscular strength grossly intact. Alert and oriented x3. LABORATORY DATA: VBG 7.41/33/26/20. Sodium 138, potassium 3.5, chloride 106, bicarbonate 21, BUN 9, creatinine 0.51, glucose 98, ionized calcium 4.7. CK 107. IMAGING: Chest x-ray is read as clear. ASSESSMENT AND PLAN: 4-year-old male with URI symptoms as well as vomiting and diarrhea with past medical history significant for mitochondrial trifunctional protein deficiency, most likely viral URI, gastroenteritis.
VBG|venous blood gas|VBG|151|153|LABORATORY DATA/DIAGNOSTICS|NEUROLOGIC: Cranial nerves II-XII are grossly intact. Alert and oriented x3. Sensation and motor strength grossly intact. LABORATORY DATA/DIAGNOSTICS: VBG 7.31/47/31/23. Sodium 138, potassium 4.2, chloride 99, bicarb 25, BUN 16, creatinine 0.47, glucose elevated at 205. Ionized calcium 5. CK of 120. Chest x-ray read as streaky perihilar opacities.
VBG|vertical banded gastroplasty|VBG|187|189|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a massively obese female with type 2 diabetes, dyslipidemia and iron deficiency anemia who has severe obesity. Plan for conversion of VBG to Roux-en-Y gastrointestinal bypass, the plan was to do this case open. Preoperatively, her most recent weight was 355 pounds. HOSPITAL COURSE: On _%#MMDD2007#%_, the patient was brought to the operating room where she underwent an open Roux-en-Y gastrointestinal bypass, she tolerated the procedure well and was transferred to the floor.
VBG|venous blood gas|VBG|175|177|ADMISSION LABORATORY DATA|She does report these as being itchy. ADMISSION LABORATORY DATA: Chest x-ray showed no change since _%#MM2007#%_. White count was 6000, hemoglobin 12.6 and platelets 227,000. VBG showed a pH of 7.30 and CO2 level of 70. Rapid RSV influenzae were negative. HOSPITAL COURSE: PROBLEM #1: Respiratory: _%#NAME#%_ was admitted and continued on her 4 times daily vest treatments with her DuoNebs and TOBI nebs.
VBG|venous blood gas|VBG|278|280|HOSPITAL COURSE|We reduced her BiPAP settings from 15/8 to 10/6 and she reported that she is able to use it much more comfortably and was using it at night. Her clinical status improved during her hospital stay. Her lung exam improved, her oxygen needs remain returns to baseline, and a repeat VBG on hospital day #3 showed a pH of 7.37 and CO2 of 47. She did have a repeat pulmonary function testing on hospital day #4, which showed minimal improvement.
VBG|venous blood gas|VBG|238|240|ASSESSMENT AND PLAN|3. Acute respiratory failure with aspiration. He has copious secretions which are the same color as his NG aspirate and is also hypoxic. He was started on Levaquin and clindamycin in the emergency department. He has a sputum pending. His VBG showed a metabolic acidosis with a pH of 7.24, a carbon dioxide of 49 and a bicarbonate of 20. We will go ahead and change the ventilator to give him slightly better respiratory compensation and the ETT was noted to be slightly high and will be adjusted accordingly.
VBG|venous blood gas|VBG|166|168|LABORATORY DATA|No rashes or other bruising noted. NEUROLOGIC: Sedated. LABORATORY DATA: White count 1.7, hemoglobin 8.1, platelets 93. INR 1.2. BUN 31, creatinine 4.7, glucose 156. VBG 7.46, 41, 36, 29. Ionized calcium 6.8. IMAGING: Chest x-ray demonstrates severe pulmonary edema.
VBG|venous blood gas|VBG|98|100|LABS ON ADMISSION|As stated previously, on neuro exam, he was intubated, sedated, and paralyzed. LABS ON ADMISSION: VBG with a pH of 7.22, pCO2 of 58, pO2 of 35, and bicarbonate of 23, with 80% saturation. Sodium was 130, creatinine 0.3. Other electrolytes were normal. White count was 17.8, hemoglobin 9, platelets 616,000.
VBG|vertical banded gastroplasty|VBG|203|205|BRIEF HISTORY|ADMISSION DIAGNOSIS: Bowel obstruction. DISCHARGE DIAGNOSIS: Same. PROCEDURES PERFORMED: G tube placement on _%#MM#%_ _%#DD#%_, 2002. BRIEF HISTORY: The patient is a 60-year-old male with a history of a VBG who presented on _%#MM#%_ _%#DD#%_, 2002, with a one-day history of nausea and vomiting. The patient's last bowel movement and flatus was the day prior to admission.
VBG|vertical banded gastroplasty|VBG|162|164|BRIEF HISTORY|The patient had increased abdominal pain since the day prior. He had no chest pain or shortness of breath. The patient's past medical history was significant for VBG on _%#MM#%_ _%#DD#%_, 2000. The patient has a history of being at a Methadone Clinic. He is status post cholecystectomy. He had sleep apnea, arthritis, hepatitis C, an irregular heartbeat and a history of ventral hernia repair on _%#MM#%_ _%#DD#%_, 2001.
VBG|vertical banded gastroplasty|VBG,|160|163|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Hypertension. 2. Diabetes. 3. Gastroesophageal reflux disease. 4. Hyperlipidemia. 5. Arthritis. 6. Many previous surgeries including a VBG, multiple laparotomies, appendectomy, hernia repair, cholecystectomy, and hysterectomy. ALLERGIES: Morphine, atropine, codeine, penicillin, sulfa, and Keflex.
VBG|venous blood gas|VBG:|197|200|ADMISSION LABORATORY DATA|LUNGS: Decreased breath sounds in the right middle and lower lobe, and some dependent crackles in the left lower lobe. She also had mild subcostal retractions. ADMISSION LABORATORY DATA: WBC 29.9. VBG: normal, with pH of 7.4; carbon dioxide level of 31. HOSPITAL COURSE: _%#NAME#%_ was admitted for IV antibiotics and further observation.
VBG|vertical banded gastroplasty|VBG.|104|107|HOSPITAL COURSE|HOSPITAL COURSE: Mr. _%#NAME#%_ is a 43-year-old white male who presented on _%#MMDD2003#%_ for an open VBG. The patient was taken to the OR as stated earlier on _%#MMDD2003#%_. OR course was largely uneventful. The patient was then transferred to the PACU.
VBG|venous blood gas|VBG|194|196|LABORATORY STUDIES|LABORATORY STUDIES: Reviewed by me, and were significant for a white blood cell count of 14.1, hemoglobin 10.2, platelets 350, INR 115, PTT 32. Sodium 136. Potassium 4.3. BUN 9. Creatinine 0.5. VBG showed pH of 7.43 and a pCO2 of 42. IMPRESSIONS: A 70-year-old male with a new subcarinal mass.
VBG|vertical banded gastroplasty|(VBG)|85|89|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Recurrent small bowel obstruction, vertical banded gastroplasty (VBG) outlet obstruction. DISCHARGE DIAGNOSIS: Recurrent small bowel obstruction, vertical banded gastroplasty (VBG) outlet obstruction. OPERATIONS/PROCEDURES PERFORMED: 1. Laparotomy. 2. Lysis of adhesions approximately 1 hour.
VBG|vertical banded gastroplasty|(VBG)|196|200|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Recurrent small bowel obstruction, vertical banded gastroplasty (VBG) outlet obstruction. DISCHARGE DIAGNOSIS: Recurrent small bowel obstruction, vertical banded gastroplasty (VBG) outlet obstruction. OPERATIONS/PROCEDURES PERFORMED: 1. Laparotomy. 2. Lysis of adhesions approximately 1 hour. 3. Reduction/detortion of small bowel volvulus. 4. Internal hernia repair.
VBG|vertical banded gastroplasty|VBG|201|203|ADMISSION DIAGNOSIS|OPERATIONS/PROCEDURES PERFORMED: 1. Laparotomy. 2. Lysis of adhesions approximately 1 hour. 3. Reduction/detortion of small bowel volvulus. 4. Internal hernia repair. 5. Appendectomy. 6. Restapling of VBG gastric pouch. 7. Removal/replacement of Silastic ring. 8. Liver biopsy. These procedures were performed on _%#MM#%_ _%#DD#%_, 2004.
VBG|vertical banded gastroplasty|VBG|299|301|ALLERGIES|4. Lorazepam 1 mg p.o. b.i.d. 5. Vioxx p.r.n. 6. Vicodin p.r.n. ALLERGIES: PENICILLIN. HOSPITAL COURSE: The patient was admitted to the bariatric service and underwent a laparotomy, lysis of adhesions, reduction detortion of small bowel volvulus, internal hernia repair, appendectomy, restapling of VBG gastric pouch, removal and replacement of Silastic ring, and liver biopsy on _%#MM#%_ _%#DD#%_, 2004. She tolerated the procedure well. There were no apparent complications.
VBG|vertical banded gastroplasty|VBG|136|138|PROCEDURES PERFORMED|ADMITTING DIAGNOSIS: Obesity. DISCHARGE DIAGNOSIS: Same. PROCEDURES PERFORMED: 1. Duodenal switch. 2. Sleeve gastrectomy. 3. Removal of VBG Marlex. 4. Drainage of right ovarian cyst. 5. Liver biopsy. 6. Adhesiolysis. HISTORY OF PRESENT ILLNESS: The patient is a 28-year-old female with a history of morbid obesity who was evaluated at Dr. _%#NAME#%_'s clinic for a revision of her vertical-banded gastroplasty.
VBG|vertical banded gastroplasty|VBG.|142|145|HISTORY OF PRESENT ILLNESS|She has been unsuccessful with nonsurgical means of weight loss. After discussion of the risks and benefits, she elected to go ahead with her VBG. HOSPITAL COURSE: On _%#MMDD2007#%_, the patient was brought to the operating room where she underwent a vertical banded gastroplasty and Tru-Cut liver biopsy.
VBG|vertical banded gastroplasty|VBG|108|110|PAST MEDICAL HISTORY|She had a BM this morning. Denies dyspnea, denies chest pain, denies fever or chills. PAST MEDICAL HISTORY: VBG on _%#MM#%_ _%#DD#%_, 2002, hypertension, hypothyroid, depression, pericardial stripping. MEDICATIONS: Aldactone 50 mg p.o. q.d., verapamil 120 mg p.o. q.d., Reglan 10 mg p.o. t.i.d., Protonix 40 mg p.o. q.d., Paxil 60 mg p.o. q.d., Remeron 60 mg p.o. q.d., Prempro 1 tablet q.d., Zyprexa 10 mg q.d., Xanax 0.25 plus 0.5, Synthroid 0.375 mg p.o. q.d. ALLERGIES: Penicillin, erythromycin, sulfa, tetracycline and bacitracin.
VBG|venous blood gas|VBG:|213|216|LABORATORY DATA|Skin: Scattered ecchymoses on his arms. Neuro: He moves all extremities equally. LABORATORY DATA: Pertinent labs included sodium of 138, potassium 3.5, chloride 84, bicarb greater than 40, BUN 75, creatinine 0.9. VBG: Ph of 7.36. White count is 16.3, hemoglobin 9.0, INR 1.4, PTT 47, platelets 257, troponin less than 0.3. Chest x-ray shows hyper-expanded lungs, tracheostomy in place and with ET tube in place.
VBG|vertical banded gastroplasty|VBG|261|263|HOSPITAL COURSE|At that time, oral medications were resumed and her heparin drip was stopped once her INR reached a level greater than 2. GI endoscopy was scheduled for _%#MM#%_ _%#DD#%_, 2002, which showed normal esophagus. It showed changes consistent with being status post VBG with GE junction to anastomosis for a space of 8 cm. To note, the anastomotic opening appeared tight measuring approximately 5 to 6 mm, although the scope was able to be passed with mild resistance.
VBG|vertical banded gastroplasty|VBG|371|373|HISTORY OF PRESENT ILLNESS|The patient is a 42-year-old morbidly obese female with multiple comorbidity including sleep apnea, hypertension, and joint pain evaluated by Dr. _%#NAME#%_ and underwent an elective vertical banded gastroplasty after discussion with the patient. The patient was admitted to Fairview- University Medical Center Bariatric Service on _%#MM#%_ _%#DD#%_, 2004, and underwent VBG open and liver biopsy. The patient had an unremarkable postoperative course. Liver biopsy was normal. She had a Hemovac suction to drainage 2 days postoperatively.
VBG|vertical banded gastroplasty|VBG|158|160|PAST MEDICAL HISTORY|1. Hypertrophic cardiomyopathy. 2. Asthmatic bronchitis. 3. Obstructive sleep apnea. 4. Morbid obesity. 5. Chronic obstructive pulmonary disease. 6. He had a VBG in _%#MM2001#%_ per Dr. _%#NAME#%_. 7. Status post appendectomy. 8. Right lower lobe lobectomy. MEDICATIONS: 1. Advair. 2. Furosemide. 3. Atrovent inhaler. On _%#MMDD2004#%_ the patient was taken to the operating room where under general anesthesia a revision vertical banded gastroplasty was performed.
VBG|venous blood gas|VBG|151|153|LABORATORY DATA|LABORATORY DATA: CBC shows a hemoglobin of 14.2, white count 6.6, platelet count 384,000. Electrolytes are within normal limits. Creatinine is 0.84. A VBG completed in the emergency department indicates a pH of 7.38, pCO2 30, pVO2 of 24, PCHO of 17. Chest x-ray reviewed by me during this hospitalization is negative.
VBG|venous blood gas|VBG|162|164|PROBLEM #4|PROBLEM #4: Miscellaneous. On admission, the patient had a urinalysis and urine culture which were negative, so she was not treated for UTI. Also on admission, a VBG was done which showed that she had carbon dioxide pressure of 32. Her ventilatory settings were changed and her tidal volume was brought from 600 mL to 550 mL and the repeat VBG done showed normal VBG physiology and the patient was discharged on tidal volume of 550.
VBG|venous blood gas|VBG|199|201|PROBLEM #4|Also on admission, a VBG was done which showed that she had carbon dioxide pressure of 32. Her ventilatory settings were changed and her tidal volume was brought from 600 mL to 550 mL and the repeat VBG done showed normal VBG physiology and the patient was discharged on tidal volume of 550. DISCHARGE MEDICATIONS: The patient was discharged on the same medications that she was taking prior to her hospitalization.
VBG|venous blood gas|VBG|149|151|ALLERGIES|Cranial nerves II through XII were grossly intact. The patient could not bear weight on the right lower extremity. LABORATORY STUDIES ON ADMISSION : VBG was pH 7.40. PCO2 51. PO2 31. Bicarbonate 31. Sodium 137, potassium 3.7, chloride 95, bicarbonate 34, BUN 17, creatinine 0.9, glucose 97, magnesium 2.2, phosphorus 2.0, calcium 8.7. Liver function tests were normal.
VBG|venous blood gas|VBG|147|149|ALLERGIES|This has been tapered since his last hospitalization. The plan is to keep him at his current dose until he is seen as an outpatient in clinic. His VBG on admission revealed a CO2 of 51. His chest x-ray on admission was not significantly changed from previous films.
VBG|venous blood gas|VBG|182|184|ALLERGIES|Had gasping respirations at 30 minutes of age. He was transferred to the SCN at Southdale Hospital and placed on a ventilator with rate 60, PIP 24, EEP 4, and 100% FiO2. His initial VBG was 6.90/63/57/12. He was maintained on mechanical ventilation during transport and throughout his NICU stay. 2. Cardiovascular - FHTs before delivery were noted to be in the 60s.
VBG|vertical banded gastroplasty|VBG|56|58|DISCHARGE DIAGNOSIS|ADMISSION DIAGNOSIS: Obesity. DISCHARGE DIAGNOSIS: Redo VBG converted to modified duodenal switch. HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old female with a history of morbid obesity, with a history of a conversion of VBG to gastric bypass.
VBG|vertical banded gastroplasty|VBG|231|233|HISTORY OF PRESENT ILLNESS|ADMISSION DIAGNOSIS: Obesity. DISCHARGE DIAGNOSIS: Redo VBG converted to modified duodenal switch. HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old female with a history of morbid obesity, with a history of a conversion of VBG to gastric bypass. PAST MEDICAL HISTORY: 1. Morbid obesity. 2. Chronic sinusitis.
VBG|vertical banded gastroplasty|VBG|148|150|CHIEF COMPLAINT|CHIEF COMPLAINT: The patient is a 44-year old white female with a significant history of morbid obesity. The patient presents on _%#MMDD2003#%_ for VBG to GIB conversion on _%#MMDD2003#%_. HISTORY OF PRESENT ILLNESS: The patient has a history that is significant for vertical banded gastroplasty in 1987 and, over the past several years, has begun once again, to gain weight and suffer medical problems as a consequence, which includes hypertension and sleep apnea.
VBG|venous blood gas|VBG|134|136|HOSPITAL COURSE|His electrolytes on admission were significant for a bicarb of 18, potassium of 3, and a creatinine of 0.8 with a glucose of 361. His VBG on admission was 7.35, 33, 37, and 18. After rehydration and therapy with insulin, his electrolytes did normalize. PROBLEM #2: Endocrine. On admission, his urine was significant for greater than 1000 glucose, greater than 80 ketones, with trace blood.
VBG|vertical banded gastroplasty|VBG|339|341|HOSPITAL COURSE|HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old white female with morbid obesity, height 167 cm, weight 124 kg, with comorbidities, including depression, joint pain, back pain, skin, and swelling problems, who wishes to undergo vertical banded gastroplasty for weight loss. HOSPITAL COURSE: The patient was admitted and underwent VBG and liver biopsy on _%#MMDD2003#%_. The patient tolerated the procedure well and was transferred to the floor postoperatively. On postoperative day #1 the patient's Foley was discontinued. The patient had an unremarkable course on the floor.
VBG|vertical banded gastroplasty|VBG.|62|65|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Morbid obesity. 2. Status post failed VBG. 3. Ventral hernia. DISCHARGE DIAGNOSES: 1. Morbid obesity. 2. Status post repair of ventral hernia.
VBG|vertical banded gastroplasty|VBG|128|130|DISCHARGE DIAGNOSES|3. Ventral hernia. DISCHARGE DIAGNOSES: 1. Morbid obesity. 2. Status post repair of ventral hernia. 3. Status post take-down of VBG with conversion to RNY gastric bypass surgery. 4. Status post EGD. SERVICE: Minimally Invasive Surgery at Fairview-University Medical Center.
VBG|vertical banded gastroplasty|VBG|148|150|HOSPITAL COURSE|6. Hyperlipidemia. 7. History of left tibial fracture. 8. Ventral hernia repair x 2 in 2001. HOSPITAL COURSE: The patient underwent revision of the VBG and ventral hernia repair on _%#MMDD2003#%_ without intraoperative complication. The patient was admitted to the SICU for hemodynamic monitoring secondary to his complex surgery and his cardiac history.
VBG|vertical banded gastroplasty|VBG,|304|307|HOSPITAL COURSE|HOSPITAL COURSE: This is a 32-year-old female who was seen in clinic in follow-up by Dr. _%#NAME#%_ after having undergone a vertical- banded gastroplasty in 1999, and has recently regained weight. Preoperative studies did show a break in her staple line. The patient wished to undergo a revision of her VBG, and this was performed on _%#MMDD2003#%_. Intraoperatively, the broken staple line was noted, as well as an enlarged VBG pouch; a silicone ring had also migrated distally along the pouch.
VBG|vertical banded gastroplasty|VBG|170|172|HOSPITAL COURSE|The patient wished to undergo a revision of her VBG, and this was performed on _%#MMDD2003#%_. Intraoperatively, the broken staple line was noted, as well as an enlarged VBG pouch; a silicone ring had also migrated distally along the pouch. This was revised in such a way that a small pouch was created with a new Silastic ring.
VBG|vertical banded gastroplasty|VBG|164|166|DIAGNOSES|The patient was recommended to be admitted to the hospital for definitive management. PAST MEDICAL HISTORY: Significant for hypertension, peptic ulcer, status post VBG in 1999, status post conversion of the VBG to a Roux- en-Y gastric bypass on _%#MM#%_ _%#DD#%_, 2004, which was complicated by a parasplenic hematoma, status post bilateral knee and hip replacement.
VBG|venous blood gas|VBG|194|196|HOSPITAL COURSE|The evening prior to discharge he was changed over to his home ventilator, which he tolerated well. Over the first two nights there was access problems to check blood gases. Multiple peripheral VBG showed pH in 7.2 range, pCO2 of over 80-90, and bicarbonate of 34. When a capillary blood gas muscle was checked it revealed PH of 7.31 with pCO2 of 75.
VBG|vertical banded gastroplasty|VBG|253|255|HOSPITAL COURSE|PAST MEDICAL HISTORY: Morbid obesity, depression, reflux, and arthritis. HOSPITAL COURSE: She underwent revision of her gastric bypass on _%#MM#%_ _%#DD#%_, 2005. She had an extensive lysis of adhesions. She had a takedown of her jejunoileal bypass and VBG and converted into a Roux- en-Y gastric bypass. She tolerated this well. Postoperatively, she had a prolonged course with nausea and vomiting.
VBG|venous blood gas|VBG|156|158|HOSPITAL COURSE|In addition, she can use BIPAP as needed during the day. She is to follow up with Dr. _%#NAME#%_ in approximately 2 weeks for these issues and is to have a VBG checked prior to that. 2. Nutrition. While she was here we were somewhat concerned with the patient's oral intake.
VBG|venous blood gas|VBG|164|166|LABORATORY DATA|LABORATORY DATA: On admission and transfer was hemoglobin of 9.3, MCV 110, white blood cell count 7.9, platelet count 97,000. Electrolytes: BUN 15, creatinine 0.8. VBG showed 7.34/54/48/28, 82%. Ammonia of 24. CHEST X-RAY: Shows left lower lobe opacity.
VBG|vertical banded gastroplasty|VBG,|198|201|ASSESSMENT/PLAN|Peripheral pulses within normal limits. NEUROLOGIC: Nonfocal. ASSESSMENT/PLAN: 1. This is a 42-year-old female here with abdominal pain and vomiting and diarrhea for three days with past history of VBG, most likely obstruction. I went ahead and did abdominal x-ray in the clinic which does show multiple air fluid levels.
VBG|vertical banded gastroplasty|VBG|47|49|ADMITTING DIAGNOSIS|ADMITTING DIAGNOSIS: Morbid obesity and failed VBG (vagotomy and Billroth gastroenterostomy.) DISCHARGE DIAGNOSES: 1. Morbid obesity. 2. Failed VBG (vagotomy and Billroth gastroenterostomy).
VBG|venous blood gas|VBG|217|219|1. FEN|Labs from _%#MMDD2004#%_: Na 143/ K 3.6/ Cl 107/ Glucose 102/ total Calcium 9.2/ Phos 5.7/ Mg 1.8/ Triglycerides 109. 2. RDS: Noah continues to require supplemental oxygen via nasal to keep his sats greater than 92%. VBG on _%#MMDD2004#%_: 7.38/ pCO2 44/ pO2 30/ HCO3 29. 3. Vascular access: He has a patent UVC that was placed upon admission to the NICU, noted to be at the T8 level on CXR from _%#MMDD2004#%_.
VBG|vertical banded gastroplasty|VBG|162|164|ADMISSION DIAGNOSIS|Her comorbid conditions include gastroesophageal reflux disease, depression, and osteoarthritis. After complete evaluation, she was scheduled for revision of the VBG to open wound via gastric bypass. REVIEW OF SYSTEM: The patient's review of systems preoperatively was fairly unremarkable.
VBG|vertical banded gastroplasty|VBG.|239|242|ADMISSION DIAGNOSIS|She came here for revision of her VBG. HOSPITAL COURSE: After preoperative evaluation and clearance, the patient presented on _%#MM#%_ _%#DD#%_, 2005. On that day, the patient was taken to the operating room where she underwent a revision VBG. Intraoperative findings were a leak at the gastric staple line. Procedure was without complications and the patient tolerated the procedure well.
VBG|vertical banded gastroplasty|VBG|226|228|BRIEF HISTORY OF PRESENT ILLNESS|BRIEF HISTORY OF PRESENT ILLNESS: The patient is a 48-year- old female who presented to the hospital with approximately 2 days' history of abdominal pain, nausea, and some dry heaves. The patient has underwent a conversion of VBG to Roux-en-Y gastrointestinal bypass approximately 1 month ago. The review of systems at the time of admission was fairly unremarkable.
VBG|vertical banded gastroplasty|VBG|200|202|PAST MEDICAL HISTORY|The patient was admitted to our service for further evaluation and care. PAST MEDICAL HISTORY: 1. Morbid obesity. 2. Depression. 3. Osteoarthritis. 4. Status post open cholecystectomy. 5. Status post VBG in 1995. 6. Status post colectomy in 1993. 7. Status post appendectomy. 8. Status post left hip replacement. 9. Status post right hip replacement.
VBG|vertical banded gastroplasty|VBG|168|170|PAST MEDICAL HISTORY|6. Status post colectomy in 1993. 7. Status post appendectomy. 8. Status post left hip replacement. 9. Status post right hip replacement. 10. Status post conversion of VBG to Roux-en-Y gastric bypass on _%#MM#%_ _%#DD#%_, 2005. HOSPITAL COURSE: While the patient was in the ER, she underwent a CT scan of her abdomen and pelvis.
VBG|venous blood gas|VBG,|80|83|LABORATORY DATA|He has a vigorous cry. He appears bright and alert when awake. LABORATORY DATA: VBG, BNP, and CBC are pending. Chest x-ray on admission revealed a normal cardiac silhouette, clear lung fields, no bony abnormalities, essentially clear.
VBG|venous blood gas|VBG|330|332|ADMISSION LABORATORY DATA|GENITOURINARY: Unremarkable. SKIN: Unremarkable. ADMISSION LABORATORY DATA: Electrolytes were all within normal limits with the exception of a slightly elevated creatinine at 6.3. Admission CBC showed a hemoglobin of 11.3 and a white blood cell count of 14.1. Platelets were 185. INR was 1.14, PTT 32, and fibrinogen 269. Initial VBG was acidotic. However, this was thought to be secondary to air leak and agitation with blood draw. Repeat cap gas showed a pH of 7.39, PCO2 51, bicarb 30, and PO2 of 39.
VBG|vertical banded gastroplasty|VBG|112|114|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Morbid obesity. OPERATIONS/PROCEDURES PERFORMED: Laparoscopic takedown of VBG. Has had the VBG done in 1997 and has had problems for the last year. PAST MEDICAL HISTORY: Morbid obesity and intolerance of VBG, as well as urinary frequency, depressive disorder, vaginal hysterectomy, and laparoscopic cholecystectomy.
VBG|vertical banded gastroplasty|VBG,|125|128|ADMISSION DIAGNOSIS|Has had the VBG done in 1997 and has had problems for the last year. PAST MEDICAL HISTORY: Morbid obesity and intolerance of VBG, as well as urinary frequency, depressive disorder, vaginal hysterectomy, and laparoscopic cholecystectomy. ADMISSION MEDICATIONS: Nexium, Prozac, and Advil. ALLERGIES: DEMEROL TABS. HOSPITAL COURSE: The patient presented for the takedown of the VBG.
VBG|vertical banded gastroplasty|VBG.|138|141|ADMISSION DIAGNOSIS|ADMISSION MEDICATIONS: Nexium, Prozac, and Advil. ALLERGIES: DEMEROL TABS. HOSPITAL COURSE: The patient presented for the takedown of the VBG. Procedure was otherwise uncomplicated though did have stenosis at the ring site. The patient had an upper GI and when this came back normal her diet was advanced and she was discharged to home when she was ambulating well, tolerating p.o. diet, and otherwise feeling well.
VBG|vertical banded gastroplasty|VBG.|62|65|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: Chronic nausea and vomiting, status post VBG. OPERATIONS/PROCEDURES PERFORMED: Revision of VBG to VBG new ring. HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old female who is being evaluated for ongoing inability to tolerate an oral diet.
VBG|vertical banded gastroplasty|VBG|119|121|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: Chronic nausea and vomiting, status post VBG. OPERATIONS/PROCEDURES PERFORMED: Revision of VBG to VBG new ring. HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old female who is being evaluated for ongoing inability to tolerate an oral diet.
VBG|vertical banded gastroplasty|VBG|230|232|DISCHARGE DIAGNOSIS|OPERATIONS/PROCEDURES PERFORMED: Revision of VBG to VBG new ring. HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old female who is being evaluated for ongoing inability to tolerate an oral diet. The patient has a history of VBG revision and was seen recently at _%#CITY#%_, Minessota for difficulties with ability to tolerate diet. The patient was scoped twice at _%#CITY#%_, Minnesota recently and also had a scope here, via EGD, the patient was found to have a nonbleeding ulcer.
VBG|vertical banded gastroplasty|VBG|214|216|DISCHARGE DIAGNOSIS|The patient was still not tolerating a p.o. diet and was sent home on nutritional supplement. The patient now returns for revision of her VBG. On _%#MM#%_ _%#DD#%_, 2006, the patient underwent a revision of VBG to VBG new ring. HOSPITAL COURSE: The patient's hospital course was uncomplicated. The patient was started on oral pain medications and the PCA discontinued as the patient's bowel function returned.
VBG|vertical banded gastroplasty|VBG|179|181|OPERATIONS/PROCEDURES PERFORMED|ADMITTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD ADMISSION DIAGNOSIS: 1. Morbid obesity. 2. Failed VBG. OPERATIONS/PROCEDURES PERFORMED: Revision gastric bypass surgery, VBG to Roux-en-Y. HISTORY: The patient is a 57-year-old female who is referred by a primary care physician for revision of a failed VBG.
VBG|vertical banded gastroplasty|VBG|134|136|HISTORY|At the time of presentation, the patient was 5 feet 2 inches tall and weighed 243 pounds. Her BMI was 44. The patient had undergone a VBG in 1996 at United Hospital. She had initially lost approximately 7 pounds but over the intervening years had regained all of her lost weight.
VBG|vertical banded gastroplasty|VBG|158|160|HOSPITAL COURSE|3. Tubal ligation. HOSPITAL COURSE: The patient was admitted to the hospital on _%#MM#%_ _%#DD#%_, 2006. On that day, the patient underwent a revision of her VBG to her Roux-en-Y gastric bypass surgery. The procedure was without complications and the patient tolerated the procedure well. Please refer to the operative note dated _%#MM#%_ _%#DD#%_, 2006, for complete details of the procedure.
VBG|venous blood gas|VBG:|169|172|PERTINENT LABORATORY DATA|Chemistry panel: Sodium 137, potassium 4.9, BUN 37, creatinine 1.1, glucose 105. Troponin less than 0.07. Urinalysis: 89 white blood cells and large leukocyte esterase. VBG: pH 7.31, pCO2 54, pO2 31. X-ray: Consistent with emphysema. Bilateral pleural effusion. Pleural air space opacity in the lower lobes.
VBG|venous blood gas|VBG|198|200|LABORATORY|LABORATORY: On admission, white count was 11,000, hemoglobin 14.3, platelets 390,000. Sodium was 140, potassium 4.3, chloride 100, bicarb 13, BUN 12, creatinine 1.04, glucose 417. Calcium 10.4. Her VBG was 7.20, 22, and 35. Urinalysis showed greater than 1000 glucose, greater than 80 ketones, trace blood. Her urine pregnancy test was negative. AST was 18, ALT 6, alkaline phosphatase 144.
VBG|vertical banded gastroplasty|VBG|223|225|HISTORY OF PRESENT ILLNESS|1. Conversion of a vertical banded gastroplasty. 2. Roux-en-Y gastrointestinal bypass on _%#MM#%_ _%#DD#%_, 2004. HISTORY OF PRESENT ILLNESS: This is a 53-year-old female with a history of morbid obesity and is status post VBG in 2000. She initially had weight loss but is now with failure to lose weight. Her calculated BMI is 39.4.
VBG|vertical banded gastroplasty|VBG|216|218|HISTORY OF PRESENT ILLNESS|An upper GI series was obtained, revealing the presence of a staple line leak. The patient was evaluated by Dr. _%#NAME#%_ in bariatric surgery clinic and was deemed to be an appropriate candidate to have her failed VBG converted to a Roux-en-Y gastric bypass. PAST MEDICAL HISTORY: 1. Morbid obesity. 2. Schizoaffective disorder, depressive type.
VBG|venous blood gas|VBG|128|130|DISCHARGE DIAGNOSES|LABORATORY DATA: On admission hemoglobin was 11.8, white count was 12.3, platelet count was 210,000. INR was 1.4, PTT was 32. A VBG after intubation revealed a pH of 7.31, PCO2 of 44. Electrolytes on admission were completely within normal limits with the exception of BUN of 40 and a creatinine of 6.1. First troponin was less than 0.07. His EKG on admission revealed old anterior and inferior myocardial infarctions but no change from his baseline.
VBG|venous blood gas|VBG|187|189|LABORATORY|Deep tendon reflexes were 2+ and equal bilaterally. Musculoskeletal: He was able to move all extremities equally. LABORATORY: Blood culture was pending and eventually came back negative. VBG 7.24/33/34/14. White blood cell count was 30.6, hemoglobin 16, and platelets 576. Sodium 138, potassium 5.0, magnesium 1.4, phosphorous 4.5, calcium 10.2, and lactic acid 1.3. PROBLEM 1: Endocrine: _%#NAME#%_ was admitted initially to the pediatric ICU.
VBG|venous blood gas|VBG|169|171|ALLERGIES|Sputum culture grew out Streptococcus pneumoniae and was otherwise negative at 48 hours. An acid-fast bacilli stain and culture were pending at the time of discharge. A VBG drawn on admission was normal with a pH of 7.39, pCO2 of 42, and a bicarbonate of 25. HOSPITAL COURSE: 1. Fluid, electrolytes, and nutrition: _%#NAME#%_ continued on a regular diet with her home G-tube feeding regimen overnight.
VBG|vertical banded gastroplasty|VBG|119|121|OPERATIONS/PROCEDURES PERFORMED|DISCHARGE DIAGNOSIS: Obesity, failed vertical banded gastroplasty. OPERATIONS/PROCEDURES PERFORMED: Open conversion of VBG to long limb gastric bypass. HISTORY OF PRESENT ILLNESS: Patient is a 36-year-old female with morbid obesity.
VBG|vertical banded gastroplasty|VBG|239|241|HISTORY OF PRESENT ILLNESS|Her preop weight at that time was 329 and her lowest weight after the VBG was 217 and the patient is currently, prior to this surgery, 245. The patient has tried numerous dietary attempts of weight reduction without success, including the VBG surgery, NutriSystem diet, Optifast diet, and Weight Watchers. The patient has also tried pharmacological approaches to weight loss, including Xenical and Phen-Fen for approximately 1 year in 1996.
VBG|vertical banded gastroplasty|VBG|162|164|HOSPITAL COURSE|SOCIAL HISTORY: Patient denies tobacco, denies alcohol, denies illicit street drugs. HOSPITAL COURSE: On _%#MMDD2005#%_, the patient underwent open conversion of VBG to long limb gastric bypass. Postoperatively, the patient had some edema, which is not new. The patient's dose of Lasix was increased, which controlled the edema.
VBG|venous blood gas|VBG|177|179|HOSPITAL COURSE|Throughout this time, vital signs remained stable with no signs of tachycardia, tachypnea, hypertension, shortness of breath, or syncope. Sean complains of little to no pain. A VBG obtained on the day of admission showed pH of 7.36, CO2 of 54, PO2 of 53, and bicarbonate 30. On _%#MM#%_ _%#DD#%_, 2005, a repeat VBG following placement of chest tube showed pH of 7.30, CO2 of 64, O2 41, and bicarbonate 31.
VBG|venous blood gas|VBG|180|182|HOSPITAL COURSE|_%#NAME#%_ complains of little to no pain. A VBG obtained on the day of admission showed pH of 7.36, CO2 of 54, PO2 of 53, and bicarbonate 30. On _%#MM#%_ _%#DD#%_, 2005, a repeat VBG following placement of chest tube showed pH of 7.30, CO2 of 64, O2 41, and bicarbonate 31. There was concern that this was an inaccurate blood gas, perhaps due to delayed transport, so a repeat VBG on _%#MM#%_ _%#DD#%_, 2005, was obtained.
VBG|vertical banded gastroplasty|VBG,|322|325|HISTORY OF PRESENT ILLNESS|The patient presents now for cholecystectomy, revision of vertical banded gastroplasty which is found to have a hole in the staple line per endoscopy, and the patient also presents for repair of the large ventral hernia. On _%#MM#%_ _%#DD#%_, 2006, the patient underwent an exploratory laparotomy takedown/revision of the VBG, cholecystectomy, repair of the ventral hernia, and a liver biopsy. HOSPITAL COURSE: The patient's hospital course was uncomplicated. Postoperatively, the pain was well controlled.
VBG|vertical banded gastroplasty|VBG|180|182|HOSPITAL COURSE|She wishes to undergo revision of VBG to Roux-en-Y gastric bypass in order to attempt weight loss. HOSPITAL COURSE: On _%#MM#%_ _%#DD#%_, 2006, the patient underwent a revision of VBG to Roux-en-Y gastric bypass with the laparoscopic approach. The evening following the surgery, the patient did experience some tachycardia.
VBG|vertical banded gastroplasty|VBG.|141|144|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Mitral valve replacement. 2. Status post cholecystectomy. 3. Status post ventral hernia repair. 4. Status post open VBG. 5. Status post revision VBG. 6. Hypertension. 7. History of atrial fibrillation. 8. Hypercholesterolemia. HOSPITAL COURSE: The patient was admitted to the hospital and IV hydration was started.
VBG|vertical banded gastroplasty|VBG.|156|159|DISCHARGE DIAGNOSES|ADMITTING DIAGNOSES: 1. Cystic duct obstruction. 2. Abdominal pain. DISCHARGE DIAGNOSES: 1. Choledocholithiasis. 2. Ascending cholangitis. 3. Dehiscence of VBG. HISTORY OF PRESENT ILLNESS: This is a pleasant 53-year-old gentleman who on _%#MM#%_ _%#DD#%_, 2006, was awakened by abdominal pain.
VBG|vertical banded gastroplasty|VBG|243|245|HISTORY OF PRESENT ILLNESS|Findings on the ERCP showed choledocholithiasis with stones, which were retrieved. He had a biliary sphincterotomy. He was also found to have ascending cholangitis with pus running out of the papillae, and a 10-mm dehiscence at the top of the VBG pouch which was found to be large enough to pass an upper scope through. The patient was sent to the SICU following his ERCP, where he remained intubated overnight.
VBG|venous blood gas|VBG|188|190|HOSPITAL COURSE|No changes were made to her home feeding regimen/water regimen and her primary care physician will continue to make changes if necessary as an outpatient. 2. Respiratory. She has a normal VBG and no signs of respiratory distress on admission. She was maintained on home ventilator settings and no changes were made.
VBG|venous blood gas|VBG|172|174|CHEST X-RAY|Troponin was 0.20. BNP was 668. Lipase 63. CHEST X-RAY: Showed elevated left hemidiaphragm unchanged from previous studies with stable interstitial fibrosis. The patient's VBG showed a pH of 7.31, pCO2 of 54, pO2 of 62. EKG: Revealed a normal sinus rhythm without any ST segment changes.
VBG|vertical banded gastroplasty|VBG|150|152|BRIEF HISTORY AND HOSPITAL COURSE|BRIEF HISTORY AND HOSPITAL COURSE: This is a 62-year-old female with past medical history significant for morbid obesity. The patient had undergone a VBG in the past by Dr. _%#NAME#%_ and had significant weight loss. She presented to the Emergency Department with acute onset of abdominal pain and had a lipase of greater than 20,000.
VBG|venous blood gas|VBG|108|110|LABS ON ADMISSION|Sensory exam was limited given the age of the patient, however, grossly appeared intact. LABS ON ADMISSION: VBG reveals pH 7.31/46/54/23/80%. Potassium was 2.6. Hemoglobin 15.4. Please make note that the above labs were done precardiac catheterization.
VBG|vertical banded gastroplasty|VBG|193|195|HISTORY AND PHYSICAL|SERVICE: Bariatric surgery. PROCEDURE: None. HISTORY AND PHYSICAL: The patient is a 52-year-old female who is status post ventral hernia repair by Dr. _%#NAME#%_ on _%#MMDD2007#%_, status post VBG in 2004. She presents to the ER with severe abdominal pain. She states she has had severe abdominal pain intermittently since her operation.
VBG|venous blood gas|VBG|203|205|PROBLEM #3|The patient ultimately opted not to pursue feeding tube in light of this information. PROBLEM #3: Respiratory failure. As noted above, the patient presented with some degree of respiratory distress. His VBG a week into his admission was 7.29 pH, pCO2 of 72 and pO2 on 3 L. This was despite undergoing a trial of aggressive BiPAP therapy.
VBG|venous blood gas|VBG|150|152|PROCEDURES|4. CBC, white count is 7, hemoglobin 12.9, platelets 335, 000. Basic metabolic panel was within normal limits. Initial emergency department blood gas VBG showed 7.42-35-272-22. HISTORY OF PRESENT ILLNESS: Briefly, this is a 4-1/2-month-old male, ex-29 week primi who presented to the emergency department with respiratory distress.
VBG|venous blood gas|VBG|374|376|LABORATORY DATA|Glucose 626. BUN 21. Creatinine 1.04. Calcium 9.9. Total bilirubin 0.9. Albumin 5.1. Total protein 8.8. Alkaline phosphatase, ALT, and AST were within normal limits. Amylase and lipase were also normal. A urinalysis was also sent which showed straw-colored clear urine with glucose in urine being greater than 1000, ketones greater than 150, specific gravity 1.020, pH 5.0. VBG was done on the patient which showed his pH to be 7.28, pCO2 46, pO2 28, bicarbonate 24, and a ketone level on whole blood was done which was elevated at 1.5. ASSESSMENT AND PLAN: This is a 19-year-old gentleman with a past medical history significant for diabetic ketoacidosis.
VBG|venous blood gas|VBG:|206|209|LABORATORY DATA|Chem-7: Sodium 140, potassium 4.3, chloride 105, bicarbonate 29, BUN 13, creatinine 1.0, glucose 83. LFTs: ALT 30, AST 24, alk phos 96, T-bili 1.0. INR 1.07. D-dimer 1.6. TSH 1.14. Troponin less than 0.04. VBG: 7.35/53/16. EKG: Right bundle branch block with converted T waves in II, III and AVF as well as V1 consistent with a repolarization abnormality.
VBG|vertical banded gastroplasty|VBG.|190|193|HISTORY OF PRESENT ILLNESS|She has tried multiple weight loss mechanisms without success, and there is also a strong history of obesity in her siblings and parents. The patient presents on _%#MMDD2002#%_ for elective VBG. PERTINENT PAST MEDICAL HISTORY: None. FAMILY HISTORY: Hypertension, diabetes, hypercholesterol, asthma, and alcoholism. SOCIAL HISTORY: Negative x 3.
VBG|vertical banded gastroplasty|VBG.|181|184|HISTORY OF PRESENT ILLNESS|Today, patient reports sharp epigastric pain, followed by nausea and vomiting. She reports fevers and chills. Denies dyspnea or chest pain. She reports a 60-pound weight loss since VBG. The patient had flatus and bowel movements during this episode. PAST MEDICAL HISTORY: Status post VBG, status post 5 C-sections.
VBG|venous blood gas|VBG|178|180|ADMITTING LABS|Skin: No rash. No digital swellings on the extremities. The neurological exam was grossly intact. ADMITTING LABS: Electrolytes were within normal limits. BUN 10, creatinine 0.6, VBG 9.6/53/48/23. Hemoglobin was 8.9, white blood cell count 13.6, platelets 425. Reticulocyte count 3.1% with absolute reticulocyte count of 11.3. LFTs were all within normal limits.
VBG|venous blood gas|VBG|221|223|CLOSING|He was bagged and eventually intubated. _%#NAME#%_ received 1 dose of surfactant at Southdale prior to transfer to our facility. Laboratory values obtained at Southdale included a glucose of 45, hemoglobin 14.2, WBC 6.2, VBG 7.37/44/87/26. The physical examination upon transfer was significant for an intubated and sedated infant male with a UVC in place. He was also noted to have bilateral undescended testicles. The remainder of the exam was within normal limits.
VBG|vertical banded gastroplasty|VBG|91|93|DIAGNOSES|DIAGNOSES: 1. End-stage CHF secondary to idiopathic dilated cardiomyopathy. 2. Status post VBG in 1999. 3. Insulin-dependent diabetes. 4. Chronic renal insufficiency. 5. AICD placed in _%#MM1998#%_. 6. Morbid obesity. PROCEDURES PERFORMED: 1. Intra-aortic balloon pump placed on _%#MMDD2002#%_.
VBG|vertical banded gastroplasty|VBG.|225|228|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 44-year-old male with a long history of obesity. He has not been able to loose weight by dieting, exercise, or multiple medications and presents on _%#MMDD2002#%_, for elective VBG. PAST MEDICAL HISTORY: 1. Non-insulin dependent diabetes mellitus. 2. Hypercholesterolemia.
VBG|vertical banded gastroplasty|VBG|164|166|MEDICATIONS|This is a 54-year-old female that previously had vertical banded gastroplasty for morbid obesity and successfully lost over 100 pounds. She now has difficulty with VBG outlet obstruction. ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: Wellbutrin 150 mg b.i.d., Klonopin 1.5 mg at bedtime, Roxicet 1 tablet prn for pain, Pulmicort 4 puffs b.i.d., Serevent 2 puffs b.i.d., Albuterol prn.
VBG|vertical banded gastroplasty|VBG|196|198|HISTORY OF PRESENT ILLNESS|She also has a history of bipolar disorder and borderline personality disorder, and is taking antipsychotic medications for these. The patient reports losing 50 pounds in the first year after her VBG and an additional 100 pounds over the past year. She complains of lightheadedness and hair loss, and denies any history of peptic ulcer disease, gastroesophageal reflux disease, cholelithiasis, or inflammatory bowel disease.
VBG|vertical banded gastroplasty|VBG|212|214|PAST MEDICAL HISTORY|She has had intermittent episodes of diarrhea over the last few months but does deny any hematemesis, melena, or hematochezia. PAST MEDICAL HISTORY: 1. Bipolar. 2. Borderline personality disorder. 3. Status post VBG performed in _%#MM#%_ 2001. MEDICATIONS: Paxil, trazodone, Depakote, Protonix, and Zyprexa.
VBG|vertical banded gastroplasty|VBG.|215|218|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Morbid obesity. HISTORY OF PRESENT ILLNESS: I saw this 52-year-old black female in clinic at _%#CITY#%_ Bandana on _%#MMDD2003#%_ and _%#MMDD2003#%_ for a preoperative evaluation prior to a planned VBG. This is scheduled with Dr. _%#NAME#%_ on _%#MMDD2003#%_. She has been obese all her life and has been steadily gaining.
VBG|vertical banded gastroplasty|VBG|167|169|OPERATIVE PROCEDURES PERFORMED DURING THIS ADMISSION|DATE OF DISCHARGE: _%#MMDD2003#%_ ADMITTING DIAGNOSIS: Morbid obesity. DISCHARGE DIAGNOSIS: Morbid obesity. OPERATIVE PROCEDURES PERFORMED DURING THIS ADMISSION: Open VBG revision with a liver biopsy. HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old female with a past medical history of vertical banded gastroplasty for obesity in _%#MM#%_.
VBG|venous blood gas|VBG:|190|193|ADMISSION LABORATORY DATA|Urine specific gravity: 1.008. Urine sodium: 85. TSH: 0.58. Folic acid: 10.2. Vitamin B12: 159 (normal: greater than 211). LFTs: albumin 3.0; otherwise, normal. LDH: 385. am cortisol: 14.9. VBG: pH 7.4, pCO2 48, pO2 26, SpO2 48%. HOSPITAL COURSE: PROBLEM #1: Diarrhea of acute onset and onset of abdominal pain.
VBG|vertical banded gastroplasty|VBG|141|143|HOSPITAL COURSE|PAST MEDICAL HISTORY: 1. Please see above for comorbid conditions. 2. Gout. 3. Lower extremity edema. HOSPITAL COURSE: The patient underwent VBG and liver biopsy without any complications on _%#MMDD2003#%_. On postoperative day #1, he was encouraged to ambulate, and his home medications were restarted.
VBG|vertical banded gastroplasty|VBG|166|168|PAST MEDICAL HISTORY|He complained of constant mild epigastric pain intermittently worse. He stated he wanted his surgery undone if this pain were to continue. PAST MEDICAL HISTORY: Open VBG _%#MMDD2002#%_. MEDICATIONS AT ADMISSION: None. PHYSICAL EXAMINATION: Alert and oriented x 3 in no acute distress, regular rate and rhythm, no murmurs, rubs or gallops.
VBG|vertical banded gastroplasty|VBG.|292|295|OPERATIONS/PROCEDURES PERFORMED|The patient was having menses at the time. Potassium 3.8, sodium 139, CR2 22, anion gap 12.0, chloride 105, PT 9.6, INR 1.0, PTT 23.9. EKG: Normal sinus rhythm with a ventricular rate of 69. Chest X-ray: None. HOSPITAL COURSE: The patient was admitted on _%#MM#%_ _%#DD#%_, 2002, for an open VBG. The procedure was performed by Doctors _%#NAME#%_ and _%#NAME#%_. The procedure was without complication. The patient was transported to the PACU in stable condition.
VBG|venous blood gas|VBG|226|228|DISCHARGE DIAGNOSIS|There were multiple well-healed scars from his previous surgeries. Neurologically his exam revealed a patient who sits in bed unassisted with normal sensation. He could move all extremities. LABORATORY: On admission reveals a VBG 7.41, PCO2 50, PO2 55, bicarbonate 31. His hemoglobin was 10.8, platelet count 38, white count 8.1 with 57 neutrophils, 25 lymphocytes, 4 monocytes.
VBG|vertical banded gastroplasty|VBG|21|23|ADMITTING DIAGNOSIS|ADMITTING DIAGNOSIS: VBG with outlet obstruction. PROCEDURE PERFORMED: _%#MM#%_ _%#DD#%_, 2002, vertical banded gastroplasty takedown and chest tube placement. ATTENDING SURGEON: Dr. _%#NAME#%_. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 49-year-old female that had a VBG performed by Dr. _%#NAME#%_ and was unhappy with the restrictions it made on her diet, and came to clinic to request having this procedure removed.
VBG|venous blood gas|VBG|198|200|FOLLOW UP|9. Augmentin 1 tab b.i.d. x 10 days. FOLLOW UP: A follow up appointment was set with the patient' pulmonary specialist within two to four weeks after discharge. At that time, the patient may need a VBG and pulmonary function test to follow up on his old data. Thank you for allowing us to participate in the care of Mr. _%#NAME#%_.
VBG|vertical banded gastroplasty|VBG|245|247|HOSPITAL COURSE|ADMISSION DIAGNOSIS: Broken lap band port. PROCEDURES ON THIS TREATMENT: Repositioning of lap band performed _%#MMDD2003#%_. HOSPITAL COURSE: This is a 69-year-old female patient who presents on _%#MMDD2003#%_ for an elective repositioning of a VBG band. Her past medical history includes hypertension, osteoarthritis, depression and anxiety, chronic incontinence, chronic edema. Her surgical history includes a vertical banded gastroplasty _%#MMDD2002#%_. She is also status post cholecystectomy, appendectomy, and repair of her rotator cuff.
VBG|vertical banded gastroplasty|VBG.|97|100|ADMISSION DIAGNOSIS|HOSPITAL COURSE: This is a 38-year-old female patient with a history of obesity who presents for VBG. PAST MEDICAL HISTORY: Migraine headaches. PAST SURGICAL HISTORY: Tubal ligation. ALLERGIES: She had no drug allergies. MEDICATIONS: She uses Imitrex p.r.n. at home.
VBG|vertical banded gastroplasty|VBG|236|238|HISTORY OF PRESENT ILLNESS|ADMISSION DIAGNOSIS: Morbid obesity. DISCHARGE DIAGNOSIS: Morbid obesity. OPERATIONS/PROCEDURES PERFORMED: Vertical banded gastroplasty, liver biopsy. HISTORY OF PRESENT ILLNESS: This is a 58-year-old female patient who presented for a VBG on _%#MM#%_ _%#DD#%_, 2003. PAST MEDICAL HISTORY: Hypertension, obesity, osteoarthritis, hyperlipidemia, depression, gout. She is status post hysterectomy and cholecystectomy.
VBG|vertical banded gastroplasty|VBG|151|153|HOSPITAL COURSE|ALLERGIES: She has no allergies. HOSPITAL COURSE: On _%#MM#%_ _%#DD#%_, 2003, the patient was taken to the OR, where under general anesthesia, an open VBG and liver biopsy were performed without complications. The patient was taken to the floor postoperatively where he course was unremarkable.
VBG|venous blood gas|VBG|192|194|LABORATORY ON ADMISSION|ABDOMEN: Positive bowel sounds, soft, non-tender, non-distended, without hepatosplenomegaly. Also of note, he has some wide spaced eyes with a flattened nasal bridge. LABORATORY ON ADMISSION: VBG of 7.33, pCO2 of 47, bicarbonate of 24, sodium of 140, potassium 4.2, chest x-ray showed some mild hyperexpansion without infiltrates.
VBG|vertical banded gastroplasty|VBG|163|165|HOSPITAL COURSE|DISCHARGE DIAGNOSIS: Morbid obesity, status post revision of vertical-banded gastroplasty (VBG). HOSPITAL COURSE: This is a 34-year-old female who had undergone a VBG by Dr. _%#NAME#%_. However, the patient regained the weight and was found, after a preoperative workup, to have had a breakdown in her staple line.
VBG|vertical banded gastroplasty|VBG|213|215|HOSPITAL COURSE|However, the patient regained the weight and was found, after a preoperative workup, to have had a breakdown in her staple line. Therefore, the patient was taken back to the operating room where a revision of the VBG and liver biopsy were performed. Please see operative note for details of this procedure. The patient tolerated the procedure well, and the remainder of her postoperative course was unremarkable.
VBG|venous blood gas|VBG:|86|89|ADMISSION LABORATORY DATA|He had good motor strength in upper and lower extremities. ADMISSION LABORATORY DATA: VBG: pH was 7.18, pCO2 22, pO2 53, bicarbonate 8. Electrolytes: Sodium 132, potassium 4.1, chloride 100, bicarbonate 7, BUN 4, creatinine 0.3, glucose 423.
VBG|vertical banded gastroplasty|VBG|203|205|HISTORY OF PRESENT ILLNESS|2. Cholecystectomy. 3. Hiatal hernia repair. HISTORY OF PRESENT ILLNESS: After referral and workup to Dr. _%#NAME#%_ _%#NAME#%_, it was determined that the patient would benefit from a conversion of her VBG to Roux-En-Y gastric bypass. The patient had a VBG in 2000 but over the past approximately 6 months to a year has been gaining weight and no longer feels as well as she did when she initially had her surgery.
VBG|venous blood gas|VBG|180|182|LABORATORY DATA|CARDIOVASCULAR: Tachycardic without murmur or gallop. ABDOMEN: Soft, nontender. EXTREMITIES: No clubbing or edema. SKIN: Dry. LABORATORY DATA: Sodium 166. Glucose 492. Lipase 1.9. VBG pH 7.48. Potassium 3.4. RADIOLOGY: Chest x-ray personally reviewed by me shows slight cardiomegaly, some cephalization, and no opacities.
VBG|vertical banded gastroplasty|VBG;|54|57|PROCEDURES PERFORMED|DIAGNOSIS: Morbid obesity. PROCEDURES PERFORMED: Open VBG; liver biopsy. PAST MEDICAL HISTORY: 1. Morbid obesity. 2. Orbital cellulitis in 1986.
VBG|vertical banded gastroplasty|VBG.|102|105|DISCHARGE DIAGNOSES|ADMISSION DIAGNOSES: 1. Failure of VBG. 2. Possible hiatal hernia. DISCHARGE DIAGNOSES: 1. Failure of VBG. 2. Exploratory laparotomy with removal of silastic ring. ATTENDING: Dr. _%#NAME#%_ and Dr. _%#NAMW#%_. BRIEF HISTORY: Mr. _%#NAME#%_ is a 56-year-old gentleman with a history of morbid obesity.
VBG|vertical banded gastroplasty|VBG|265|267|ADMISSION DIAGNOSIS|OPERATIONS/PROCEDURES PERFORMED: Minimally invasive surgery at Fairview-University Medical Center. HISTORY OF PRESENT ILLNESS: Patient is a 50-year-old female with a complex gastric bypass surgery history. Patient has gone through multiple revisions of her initial VBG approximately 11 years ago. Furthermore, patient has also had multiple ventral hernia repairs. Patient was seen by Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_ with abdominal pain, fevers, chills, night sweats, tingling hands, and diarrhea.
VBG|vertical banded gastroplasty|VBG|162|164|REVIEW OF SYSTEMS|PAST MEDICAL HISTORY: 1. Please see above. 2. Ventral hernia repair on _%#MM#%_ _%#DD#%_, 2003. 3. Duodenal switch in _%#MM#%_ of 2002 by Dr. _%#NAME#%_. 4. Open VBG repair in 2000 by Dr. _%#NAME#%_ _%#NAME#%_. 5. Ventral hernia repair and cholecystectomy in 1999 by Dr. _%#NAME#%_ _%#NAME#%_. 6. Bladder surgery for incontinence in 1998.
VBG|vertical banded gastroplasty|VBG|136|138|REVIEW OF SYSTEMS|5. Ventral hernia repair and cholecystectomy in 1999 by Dr. _%#NAME#%_ _%#NAME#%_. 6. Bladder surgery for incontinence in 1998. 7. Open VBG in 1992 by Dr. _%#NAME#%_. 8. Angina diagnosed in 1999. 9. GERD diagnosed in 1997. 10. Asthma diagnosed in 1993. 11. History of tuberculosis, patient was PPD positive in the 1960s, it is non-active.
VBG|vertical banded gastroplasty|VBG,|44|47|PROCEDURES|DIAGNOSIS: Severe obesity. PROCEDURES: Open VBG, liver biopsy. HISTORY: Mr. _%#NAME#%_ is a 55-year-old male who has had longstanding history of obesity.
VBG|vertical banded gastroplasty|VBG.|412|415|HISTORY OF PRESENT ILLNESS|Mrs. _%#NAME#%_ is a 61-year-old female with morbid obesity and a BMI of 37.4, multiple comorbidity including hypertension, chronic ischemic heart disease, diabetes mellitus, osteoarthritis, mild pulmonary hypertension, hyperlipidemia, low back pain with a past history of coronary artery bypass graft done on _%#MMDD#%_. The patient after explaining risks and benefits the patient consented to undergo the open VBG. PAST MEDICAL HISTORY: 1. Diabetes. 2. Coronary artery disease.
VBG|vertical banded gastroplasty|VBG|150|152|HOSPITAL COURSE|1. Levaquin. 2. Sulfa. HOSPITAL COURSE: The patient was admitted on _%#MMDD2003#%_. The patient was taken to the operating room and underwent an open VBG and liver biopsy, see operative note for details. The patient tolerated the procedure well and was transferred back to 6A. The patient did well postoperative, she had good pain control.
VBG|venous blood gas|VBG|162|164|1. FEN|ABGs are followed q8 hours and are remarkable for mild respiratory alkalois and pO2 in 40's. O2 saturations on room air range from 84-91%. A simultaneous ABG and VBG oxygen saturations were obtained to evaluate cardiac index and were 84% and 56% respectively. 4. ID: Blood cultures were obtained and ampicillin and gentamycin started for a 48 hour rule out sepsis.
VBG|vertical banded gastroplasty|VBG|167|169|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSES: 1. Wound infection. 2. UTI. 3. C. diff colitis. PROCEDURES: None. HISTORY OF PRESENT ILLNESS: This is a 65-year-old female who has a history of a VBG done on _%#MMDD2004#%_ who returns to the hospital with a history of fevers. The patient comes from a nursing home where she resides secondary to her cerebral palsy and left hemiparesis.
VBG|vertical banded gastroplasty|VBG|130|132|PAST SURGICAL HISTORY|3. Obesity. 4. Seizure disorder. 5. Aortic stenosis. 6. History of CHF. 7. DJD. 8. Depression. 9. COPD. PAST SURGICAL HISTORY: 1. VBG _%#MMDD2004#%_. 2. Open cholecystectomy. 3. Left lower extremity surgery. 4. ORIF of the left wrist fracture. HOSPITAL COURSE: The patient was admitted on _%#MMDD2004#%_ for fever.
VBG|vertical banded gastroplasty|VBG|216|218|HISTORY OF PRESENT ILLNESS|She was subsequently transferred to F-UMC and was admitted for further treatment and management. PAST MEDICAL HISTORY: 1. Vertical banded gastroplasty 1988 with development of a gastrogastric fistula. 2. Revision of VBG to divided Roux-en-Y gastric bypass _%#MM#%_ _%#DD#%_, 2004, with G-tube and JP placement. 3. Development of an enterocutaneous fistula, secondary to above.
VBG|vertical banded gastroplasty|VBG|148|150|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 55-year-old female who was referred for evaluation of revision of her vertical-banded gastroplasty. She had a VBG in _%#MM1999#%_, and has been experiencing emesis, which has become progressively worse over the year, and has difficulty eating solid foods.
VBG|venous blood gas|VBG|318|320|LABORATORY DATA|LABORATORY DATA: The patient's labs on admission showed a WBC of 20.6, hemoglobin 14.1, platelets count of 326. The differential on the WBC showed 88% neutrophils. The patient did have electrolytes that were completely normal including a BUN of 8 and a creatinine of 0.32. The patient's blood gases as mentioned was a VBG showing pH of 7.26, pCO2 of 55, pO2 of 52, and a bicarb of 24. The patient did also have liver enzymes checked and they were normal.
VBG|venous blood gas|VBG|139|141|DISCHARGE DIAGNOSIS|2. Respiratory. His respiratory status was stable throughout his hospitalization. He did not require any oxygen or assisted ventilation. A VBG was obtained on admission and was within normal limits. 3. Cardiovascular. An echocardiogram was performed during this admission secondary to concerns for muscle breakdown because of the elevated CK level.
VBG|vertical banded gastroplasty|VBG|131|133|ADMITTING PHYSICIAN|3. Lysis of adhesions. ADMITTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD BRIEF HISTORY: The patient is a 51-year-old female who had a VBG performed 12 years ago at Fairview University Medical Center. She had some success with weight loss at the time; however, in recent years had been steadily gaining weight.
VBG|venous blood gas|VBG:|271|274|LABORATORY DATA|NEUROLOGIC: Cranial nerves intact, awake and alert. LABORATORY DATA: Sodium 137, potassium 5.3, chloride 101, bicarbonate 22, BUN 9, creatinine 0.41, glucose 306, calcium 8.9. AST 29, ALT 33, alkaline phosphatase 182, total bilirubin 0.2, total protein 6.6, albumin 3.2. VBG: pH 7.34, CO2 48, O2 38, bicarbonate 25, saturation 69%. INR 1.17, PTT 34. WBC elevated at 23.3, hemoglobin 8.6, platelets low at 15, differential 66% neutrophils.
VBG|vertical banded gastroplasty|VBG|89|91|OPERATIONS/PROCEDURES PERFORMED|DISCHARGE DIAGNOSIS: Morbid obesity. OPERATIONS/PROCEDURES PERFORMED: Open conversion of VBG to Roux-en-Y gastric bypass, liver biopsy, lysis of adhesions. HISTORY OF PRESENT ILLNESS: The patient is a 22-year-old female who has had a prior vertical banded gastroplasty in 2002.
VBG|vertical banded gastroplasty|VBG|212|214|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 22-year-old female who has had a prior vertical banded gastroplasty in 2002. The patient has been seen in the bariatric clinic multiple times for consideration of the VBG to a Roux-en-Y gastric bypass. After discussion the risks and benefits of the procedure, the patient decided to undergo an open conversion of the VBG to a Roux-en-Y gastric bypass.
VBG|venous blood gas|VBG|193|195|PROBLEM #4|However, the emergency room physician felt it was necessary to do a workup. He did have a chest x-ray, which was read as clear. The patient also had a legionella antigen, which was negative. A VBG showed slightly decreased PO2 at 78 with a slightly low CO2 and bicarbonate. It was felt the patient was likely hyperventilating. His pH was 7.41. BNP was also checked, which was less than 5.
VBG|vertical banded gastroplasty|VBG,|199|202|HISTORY OF PRESENT ILLNESS|The patient has diabetes and hypercholesterolemia as comorbidities. Her preoperative weight was 272 pounds. As the patient has failed numerous weight loss attempts in the past in addition to failing VBG, she was evaluated in bariatric surgery clinic and ultimately did elect to undergo conversion of her VBG to a Roux-en-Y gastric bypass.
VBG|vertical banded gastroplasty|VBG|304|306|HISTORY OF PRESENT ILLNESS|The patient has diabetes and hypercholesterolemia as comorbidities. Her preoperative weight was 272 pounds. As the patient has failed numerous weight loss attempts in the past in addition to failing VBG, she was evaluated in bariatric surgery clinic and ultimately did elect to undergo conversion of her VBG to a Roux-en-Y gastric bypass. HOSPITAL COURSE: On _%#MM#%_ _%#DD#%_, 2006, the patient underwent open revision of a vertical banding gastroplasty to a Roux-en-Y gastric bypass and liver biopsy, as well as ventral hernia repair.
VBG|vertical banded gastroplasty|VBG|136|138|PAST MEDICAL HISTORY|After discussion of the risks and benefits, she wished to proceed. PAST MEDICAL HISTORY: 1. Hypertension. 2. Morbid obesity status post VBG in 2001. 3. Status post breast reduction surgery in 2002. 4. Status post cholecystectomy in 1995. 5. Status post low back surgery in 1995. 6. Status post tubal ligation in 1980.
VBG|vertical banded gastroplasty|VBG|196|198|PAST MEDICAL HISTORY|I was unable to find records of this at this time of night. PAST MEDICAL HISTORY: Notable for: 1. Vertical banded gastroplasty by Dr. _%#NAME#%_. 2. Laparoscopic cholecystectomy. 3. Conversion of VBG to Roux-en-Y gastric bypass by myself in _%#MM2005#%_. 4. In _%#MM2006#%_ reversal of a tubal ligation here at _%#CITY#%_. ALLERGIES: None. MEDICATIONS: 1. Prilosec. 2. Calcium. 3. Multivitamin. SOCIAL HISTORY: He denies tobacco, alcohol, or drug abuse.
VBG|vertical banded gastroplasty|VBG|208|210|DISCHARGE DIAGNOSIS|The patient had a similar episode a month ago which was resolved by emesis. PAST MEDICAL HISTORY: GERD. ALLERGIES: MORPHINE. RASH, NAUSEA, VOMITING; PENICILLIN, RASH AND HIVES. PAST SURGICAL HISTORY: 1. Open VBG on _%#MM#%_ _%#DD#%_, 2005. 2. Cholecystectomy 15 years ago. 3. Appendectomy 20 years ago. FAMILY HISTORY: Mother with a 3-vessel CABG and also breast cancer.
VBG|venous blood gas|VBG|171|173|HOSPITAL COURSE|HOSPITAL COURSE: 1. Diabetic ketoacidosis: Upon admission, the patient had a bicarb level of 10 and an anion gap of 27 along with an elevated blood sugar of around 300. A VBG was also performed and it was found that the patient had a pH of 7.12, therefore, she was initially admitted into the intensive care unit for close monitoring.
VBG|vertical banded gastroplasty|VBG|106|108|PAST SURGICAL HISTORY|6. Gastroesophageal reflux disease. 7. Pinched nerve with sciatica on the left. PAST SURGICAL HISTORY: 1. VBG 2000. 2. Revision 2000. 3. Takedown of VBG 2001. 4. Hiatal hernia repair 2001. 5. Cholecystectomy 2001. 6. Appendectomy. 7. Ear tubes x 8.
VBG|vertical banded gastroplasty|VBG|149|151|PAST SURGICAL HISTORY|6. Gastroesophageal reflux disease. 7. Pinched nerve with sciatica on the left. PAST SURGICAL HISTORY: 1. VBG 2000. 2. Revision 2000. 3. Takedown of VBG 2001. 4. Hiatal hernia repair 2001. 5. Cholecystectomy 2001. 6. Appendectomy. 7. Ear tubes x 8. 8. Tonsillectomy/adenoidectomy. 9. Hiatal hernia repair x 2. 10. Knee surgery x 4 on the right.
VBG|vertical banded gastroplasty|VBG|173|175|HISTORY OF PRESENT ILLNESS|SURGEON: _%#NAME#%_ _%#NAME#%_ MD. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 27-year-old female presented to Dr. _%#NAME#%_'s clinic with history of VBG. Preoperative VBG weight was 327. Her weight was decreased down to 214. However, over the past year her weight increased to 294. The patient had the VBG operation in 2003. The patient was evaluated for gastric bypass surgery and she was admitted under the care of Dr. _%#NAME#%_.
VBG|vertical banded gastroplasty|VBG|115|117|HISTORY OF PRESENT ILLNESS|Her weight was decreased down to 214. However, over the past year her weight increased to 294. The patient had the VBG operation in 2003. The patient was evaluated for gastric bypass surgery and she was admitted under the care of Dr. _%#NAME#%_. PAST MEDICAL HISTORY: Eczema, abnormal Pap smear in 2003 status post cryo.
VBG|venous blood gas|VBG|178|180|LABORATORY|NEUROLOGIC: Grossly intact. LABORATORY: White count is 7.4, hemoglobin 11.5, platelets 481, INR 1.0, PTT 30. Reticulocyte count 1.5%. Troponin is less than 0.04. D-dimer is 0.2. VBG is 7.37, 46, 31, 26. Urinalysis is negative for leukocyte esterase and nitrites with few bacteria and 6 squamous epithelials.
VBG|vertical banded gastroplasty|VBG|407|409|FOLLOW-UP|Started on clears diet, tolerated well. Post admission day #5, the patient continued to tolerate clears well without any nausea, vomiting; hemodynamically stable with having her blood sugars well controlled on insulin sliding scale, and seemed suited for discharge. DISPOSITION: She was discharged home. FOLLOW-UP: _%#NAME#%_ _%#NAME#%_, MD, Minimal Invasive Surgery Clinic, in 1 week, status post revision VBG to Roux-en-Y bypass. DISCHARGE INSTRUCTIONS: 1. She is discharged on a clear liquid diet.
VBG|venous blood gas|VBG|243|245|HISTORY OF PRESENT ILLNESS AND BRIEF HOSPITAL COURSE|She was continued on BiPAP at night. Her symptoms gradually improved, and at the time of discharge she was only on a nasal cannula. On _%#MM#%_ _%#DD#%_, 2006, her ABG showed a pH of 7.32, PCO2 91, bicarb 46, and on _%#MM#%_ _%#DD#%_, 2006, a VBG was done which showed a pH of 7.34, PCO2 94, PO2 47, and bicarb 49 on 3 liters of oxygen. She was also seen by a Pulmonary Team on the floor who ordered a home BiPAP even on discharge.
VBG|venous blood gas|VBG|178|180|HISTORY OF PRESENT ILLNESS AND BRIEF HOSPITAL COURSE|Chest x-ray did not show any cute infiltrate or any acute disease. On labs, her white count was 9.4, hemoglobin 11.9, platelets 314, chem panel was normal, CRP 22.7, BNP 116, on VBG her pH was 7.42, PCO2 42, PO2 67, oxygen saturation 91% on 2 L. The blood cultures were negative. She was initially treated with IV Zosyn.
VBG|venous blood gas|VBG|194|196|LABORATORIES|LABORATORIES: White count 9.3. Hemoglobin 14.0. MCV 92. Platelet counts 257. Normal differential. Troponin is less than 0.04. Lipase 117. Lactate 0.8. CRP is less than 3. Sedimentation rate 10. VBG is 7.45/33. Albumin 4.3. Total bilirubin 0.1. Total protein is 7. Alkaline phosphatase 113. ALT 36. AST 25. Sodium 139. Potassium 3.8. Chloride 106.
VBG|vertical banded gastroplasty|VBG|223|225|PROCEDURES|ADMISSION DIAGNOSIS: Morbid obesity. DISCHARGE DIAGNOSIS: Morbid obesity. ATTENDING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_. SERVICE: Bariatric Surgery. PROCEDURES: On _%#MMDD2007#%_, the patient underwent an open revision of VBG to Roux-en-Y gastric bypass surgery by Dr. _%#NAME#%_. For details of this procedure, please refer to the dictated operative note.
VBG|vertical banded gastroplasty|VBG|182|184|HISTORY AND PHYSICAL EXAM|For details of this procedure, please refer to the dictated operative note. HISTORY AND PHYSICAL EXAM: Mr. _%#NAME#%_ is a 56-year-old male who presented for evaluation for revision VBG to Roux-en-Y gastric bypass surgery. The patient has had a history of obesity for quite some time now. He previously had a vertical banded gastroplasty that had failed.
VBG|vertical banded gastroplasty|VBG.|248|251|PROCEDURES|ADMISSION DIAGNOSIS: Morbid obesity. DISCHARGE DIAGNOSIS: Morbid obesity. SERVICES: Bariatric surgery. PROCEDURES: On _%#MMDD2007#%_, the patient underwent an exploratory laparotomy with extensive lysis of adhesions, liver biopsy and a takedown of VBG. HISTORY AND PHYSICAL: Ms. _%#NAME#%_ is a 59-year-old female who had a vertical banding gastroplasty 8 years ago with Dr. _%#NAME#%_.
VBG|vertical banded gastroplasty|VBG|139|141|DISCHARGE DIAGNOSIS|ADMISSION DATE: _%#MMDD2007#%_ DISCHARGE DATE: _%#MMDD2007#%_ ADMISSION DIAGNOSIS: Nausea, vomiting. DISCHARGE DIAGNOSIS: Open revision of VBG to Roux-en-Y gastric bypass. ATTENDING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_. PROCEDURES: On _%#MMDD2007#%_, the patient underwent a revision of VBG to Roux-en-Y gastric bypass.
VBG|vertical banded gastroplasty|VBG|145|147|HISTORY OF PRESENT ILLNESS|DIAGNOSIS: Upper gastrointestinal bleed. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 48-year-old female underwent revision of her VBG to Roux-en-Y GB on _%#MMDD2007#%_. The patient states that she has had black tarry formed stools since her operation. One day prior to presentation she began to have diarrhea with bright red blood mixed in her stools.
VBG|vertical banded gastroplasty|VBG|218|220|PROCEDURE|ADMISSION DIAGNOSIS: Morbid obesity. DISCHARGE DIAGNOSIS: Morbid obesity. ATTENDING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_. SERVICE: Bariatric Surgery. PROCEDURE: On _%#MMDD2007#%_ the patient underwent open revision of VBG to Roux-en-Y gastric bypass surgery. For details of this procedure, please refer to the operative note. HISTORY AND PHYSICAL: Mrs. _%#NAME#%_ is a 43-year-old female who is status post VBG in 1996 at outside hospital.
VBG|venous blood gas|VBG|396|398|LABORATORY DATA|His UA showed a specific gravity of 1.02, trace glucose, bilirubin negative, ketone 1, blood 2, albumin 3. Urine was normal in 2003. A renal panel on admission, sodium 131, potassium 5.7, chloride 87, bicarb 11, BUN 234, creatinine 15.2. Urine glucose 116, calcium 4.5, phosphorous 15.3, magnesium 1.1, total protein 6.6, AFT was 76, ALT 41, alkaline phosphatase 189 and total bilirubin 0.3. His VBG showed 7.18/37/64/13. HOSPITAL COURSE: 1. Fluids, electrolytes and nutrition and his lytes were consistent with hyperphosphatemia, hyp0calcemia on admission.
VBG|vertical banded gastroplasty|VBG,|23|26|DIAGNOSIS|DIAGNOSIS: Revision of VBG, admitted on _%#MMDD2002#%_ and discharged on _%#MMDD2002#%_. PROCEDURES PERFORMED: Revision of vertical-banded gastroplasty on _%#MMDD2002#%_. HISTORY OF PRESENT ILLNESS: This is a 47-year-old lady who has had two previous vertical-banded gastroplasties who presents for revision.
VBG|vertical banded gastroplasty|VBG|127|129|ADMISSION DIAGNOSIS|CHIEF COMPLAINT: Obese. HISTORY OF PRESENT ILLNESS: This is a 57-year-old female with history of obesity x 20 years. She had a VBG done in _%#MM#%_ of 1994 with revision in _%#MM#%_ of 1999. However, she has gained 40 pounds due to a breakdown of the staple line.
VBG|vertical banded gastroplasty|VBG|164|166|PAST SURGICAL HISTORY|1. Hypertension. 2. Cholecystitis. PAST SURGICAL HISTORY: 1. Hysterectomy in _%#MM#%_ of 1989. 2. Repair of a left inguinal hernia and umbilical hernia in 1987. 3. VBG in 1994. 4. VBG in 1999 with bilateral oophorectomy, cholecystectomy and appendectomy at that time. 5. Umbilical hernia repair again in _%#MM#%_ of 1998. FAMILY HISTORY: Not available.
VBG|vertical banded gastroplasty|VBG|213|215|BRIEF HISTORY|PHYSICAL EXAM: Significant for blood pressure of 168/82. The patient weighed 316.8 pounds. Otherwise, her abdominal exam was unremarkable. HOSPITAL COURSE: Patient was admitted on _%#MM#%_ _%#DD#%_, 2002, for the VBG with liver biopsy. The patient tolerated the procedure well. Please see operative note for details. On postop day number one, the patient's Foley was removed.
VBG|venous blood gas|VBG:|177|180|LABORATORIES|Neurologically, she moves all of her extremities. Her DTR are 1+ bilateral, symmetric. LABORATORIES: Sodium 144, potassium 5.1, chloride 112, bicarb 16, BUN 115, creatinine 29. VBG: pH at 7.29. PTT 33, white count less than .5, hemoglobin 9.6, platelets less than 10. Calcium 8.2, bili 18, AST 39, alk phos 382. CHEST X-RAY: My interpretation is clear diaphragms, no obvious opacities.
VBG|vertical banded gastroplasty|VBG|177|179|PAST MEDICAL HISTORY|The patient does relate anorexia and he also relates that he had similar episodes of this in the past secondary to small bowel obstruction. PAST MEDICAL HISTORY: 1. Status post VBG in 1981 secondary to morbid obesity. 2. History of open cholecystectomy in 1980. 3. Status post adhesiolysis with repair of a large incisional hernia with mesh X2.
VBG|vertical banded gastroplasty|VBG|225|227|ADMISSION MEDICATIONS|6. History of reactive airways disease. 7. Depression. 8. Hyperlipidemia. ADMISSION MEDICATIONS: Premarin, Altace, Zoloft, Theo-Dur, Advair, and Vioxx. ALLERGIES: Erythromycin. HOSPITAL COURSE: The patient underwent revision VBG on _%#MM#%_ _%#DD#%_, 2002, tolerated the procedure well, and was admitted to the floor where she remained for 4 postoperative days.
VBG|vertical banded gastroplasty|VBG|199|201|PHYSICAL EXAMINATION|There was left upper quadrant tenderness, induration and erythema evident at one of the port sites. There was also an appreciable seroma which appears just right of midline to the patient's previous VBG scar. At this time the patient was admitted to the hospital for monitoring as well as secondary to GI side effects of Augmentin due to the nausea and the vomiting.
VBG|vertical banded gastroplasty|VBG|75|77|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 34-year-old male patient status post VBG on _%#MMDD2002#%_, who came in complaining of early satiety, nausea, and vomiting over the last three weeks. The patient also reported a recent cat bite and was started on Augmentin five days ago.
VBG|vertical banded gastroplasty|VBG.|140|143|HOSPITAL COURSE|1. Hydrate, and keep NPO. 2. Follow up with labs. HOSPITAL COURSE: Medical Nutrition Therapy was consulted, and the patient was educated on VBG. Previously, per their note, the following guideline was given: chewing foods well. The patient was chewing foods well, per their note, and had multiple problems with vomiting.
VBG|vertical banded gastroplasty|VBG|199|201|HOSPITAL COURSE|An EGD to investigate the cause of this patient's symptoms and to remove the obstructing food particle, if it was present was done. Results of the EGD came back negative. It revealed a normal postop VBG stomach, with acute angulation of the stomach. They were unable to examine all of the antrum or the pylorus. DISPOSITION: The patient was discharged on _%#MMDD2002#%_. He was discharged to home in stable condition.
VBG|vertical banded gastroplasty|VBG|143|145|ADMISSION DIAGNOSIS|5. Stenosis of L1 to L4 of her back as well as scoliosis. 6. History of depression. 7. Hypertension. 8. History of strabismus. 9. History of a VBG and liver biopsy on _%#MM#%_ _%#DD#%_, 2001, as above. 10. Multiple EGDs over the last 6 weeks. SOCIAL HISTORY: Negative for tobacco, occasional ethanol, no IV drug abuse.
VBG|vertical banded gastroplasty|VBG|141|143|PAST MEDICAL HISTORY|The service is Gold Surgery, and the attending physician is _%#NAME#%_ _%#NAME#%_, MD. This is a 48-year-old female scheduled for conversion VBG to gastric bypass with liver biopsy and ventral hernia repair. PAST MEDICAL HISTORY: Includes apnea, hypertension, morbid obesity, mild depression, ventral hernia, anemia, hereditary edema of the legs.
VBG|venous blood gas|VBG:|222|225|LABS ON ADMISSION|Extremities: No pedal edema. LABS ON ADMISSION: White count 7.6, hemoglobin 13.6, platelets 167. Sodium 141, potassium 4.1, chloride 102, bicarbonate 25, BUN 34, creatinine 4.3, glucose 123, magnesium 1.9, phosphorus 2.8. VBG: 7.54/39/38/34. HOSPITAL COURSE: PROBLEM #1: Right eye blindness, most likely arterial emboli from possibly a PFO.
VBG|venous blood gas|VBG|488|490|ADMISSION LABS|ADMISSION LABS: Admission labs revealed a normal basic metabolic panel, with a BUN of 19 and a creatinine of 0.6, phosphate 6.2, calcium 9.1, albumin 3.2, AST 90, ALT 46, alkaline phosphatase 699, total bilirubin 1.1, and direct bilirubin 0.0. A hemoglobin was 9.8, white count 9.0, with a differential of 81% neutrophils, 4% lymphocytes, 14% monocytes, and 1% eosinophils. ANC was 7.3 and platelets 248. A nasal wash was positive for influenza A, and negative for influenza B and RSV. A VBG revealed a pH of 7.33, PC02 30, P02 40, bicarbonate 15, and an oxygen saturation of 69% on room air. HOSPITAL COURSE: 1. FEN: _%#NAME#%_ was placed on maintenance IV fluids around the clock to be alternated with her TPN given every other night.
VBG|venous blood gas|VBG|147|149|DISCHARGE INSTRUCTIONS|It was necessary to give boluses of Ativan and Dilaudid in order to make _%#NAME#%_ comfortable. On admission, on _%#MM#%_ _%#DD#%_, 2003 he had a VBG done with blood gas of 7.34 and a CO2 of 47. At approximately 9 p.m. on _%#MM#%_ _%#DD#%_, 2003 he had a blood gas of 7.12 with CO2 of 53.
VBG|vertical banded gastroplasty|VBG.|129|132|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Dehydration. 2. DVT. 3. Status post jejunoileal bypass, status post revision of a jejunoileal bypass. 4. VBG. 5. Acute renal failure. HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old gentleman who was admitted for severe dehydration, status post revision of a jejunoileal bypass.
VBG|vertical banded gastroplasty|VBG|240|242|HISTORY OF PRESENT ILLNESS|4. VBG. 5. Acute renal failure. HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old gentleman who was admitted for severe dehydration, status post revision of a jejunoileal bypass. The patient had revision of a jejunoileal bypass to a VBG on _%#MMDD2003#%_. His postoperative course was complicated by a prolonged ileus and postoperative coagulopathy, requiring SFP and ............transfusions, again due to malabsorption.
VBG|vertical banded gastroplasty|VBG.|165|168|HOSPITAL COURSE|2. Liver biopsy. HOSPITAL COURSE: The patient is a 56-year-old female with a weight of 276 pounds and a height of 5 feet 4 inches who is here for morbid obesity for VBG. The patient was admitted and underwent vertical banded gastroplasty and liver biopsy. Her weight was 126 kg with height of 165 cm.
VBG|vertical banded gastroplasty|VBG|171|173|HISTORY|SERVICE: Minimally Invasive Surgery at F-UMC. ATTENDING: _%#NAME#%_ _%#NAME#%_, MD. HISTORY: The patient is a 48-year-old African-American female with history of previous VBG in the 1980s. She had failure of this operation and had regained most of her weight. The patient was seen by Dr. _%#NAME#%_ at his clinic for evaluation of possible revision.
VBG|vertical banded gastroplasty|VBG|119|121|PAST MEDICAL HISTORY|The patient was medically cleared and readied for an operation on _%#MMDD2003#%_. PAST MEDICAL HISTORY: 1. Status post VBG in 1980s, which failed. 2. History of asthma. 3. Hypertension. 4. Significant history of tobacco use. 5. Depression. 6. Status post amputation of finger and thumb in the 1960s.
VBG|vertical banded gastroplasty|VBG|134|136|HOSPITAL COURSE|5. Depression. 6. Status post amputation of finger and thumb in the 1960s. HOSPITAL COURSE: The patient underwent the revision of her VBG on _%#MMDD2003#%_ without any intraoperative complications. While in the postoperative holding area, anesthesia found it difficult to extubate the patient.
VBG|vertical banded gastroplasty|VBG|153|155|PAST MEDICAL HISTORY|She is admitted to F-UMC for further evaluation and work up of these concerns of these symptoms. PAST MEDICAL HISTORY: 1. Morbid obesity. 2. Status post VBG _%#MM2003#%_. 3. PTSD. 4. Diabetes mellitus type 2. 5. Hypertension. 6. GERD. HOSPITAL COURSE: Ms. _%#NAME#%_ underwent an upper GI with small bowel through which was unremarkable.
VBG|venous blood gas|VBG|235|237|HISTORY OF PRESENT ILLNESS|He was recently discharged on _%#MMDD2003#%_ from F-UMC. He was re-admitted from _%#CITY#%_ Health Center with shortness of breath and somnolence. He was in the ICU from _%#MMDD2003#%_ to _%#MMDD2003#%_. Initially, he presented with a VBG of pH 7.16, pCO2 of 76, pO2 of 52, and saturations of 79%. He was initially supported with BI-PAP, and improved and transferred to 7A.
VBG|vertical banded gastroplasty|VBG|142|144|PAST MEDICAL HISTORY|The patient vomited approximately 3 times before being seen in the ER. PAST MEDICAL HISTORY: 1. Status post cholecystectomy. 2. Status post a VBG revision to a modified duodenal switch approximately 2 years ago. 3. Multiple orthopedic surgeries. 4. History of gunshot wound injury to the chest.
VBG|vertical banded gastroplasty|(VBG)|62|66|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Status post vertical banded gastroplasty (VBG) _%#MMDD2004#%_, presented with nausea and vomiting. Rule out obstruction. DISCHARGE DIAGNOSIS: Work up was negative for obstruction.
VBG|vertical banded gastroplasty|VBG|245|247|HISTORY OF PRESENT ILLNESS|ADMISSION DIAGNOSIS: Ventral band gastroplasty ring stenosis/adhesions. OPERATIONS/PROCEDURES PERFORMED: Ventral band gastroplasty ring revision and replacement; liver biopsy. HISTORY OF PRESENT ILLNESS: This is a 33-year-old female status post VBG that was unable to keep any solids down for several months and presented for VBG procedure revision. PAST MEDICAL HISTORY: 1. Borderline personality disorder versus bipolar.
VBG|vertical banded gastroplasty|VBG|326|328|HISTORY OF PRESENT ILLNESS|ADMISSION DIAGNOSIS: Ventral band gastroplasty ring stenosis/adhesions. OPERATIONS/PROCEDURES PERFORMED: Ventral band gastroplasty ring revision and replacement; liver biopsy. HISTORY OF PRESENT ILLNESS: This is a 33-year-old female status post VBG that was unable to keep any solids down for several months and presented for VBG procedure revision. PAST MEDICAL HISTORY: 1. Borderline personality disorder versus bipolar.
VBG|venous blood gas|VBG|205|207|LABORATORY DATA|SKIN: Multiple tattoos, no rash. NEUROLOGIC: Alert, fluent speech, normal gait. LABORATORY DATA: Sodium 142, potassium 3.4, bicarb 37, AST 21, alk phos 35, white count 10.6, hemoglobin 9.8, platelets 311, VBG showed a pH of 7.29. ASSESSMENT/PLAN: A 27-year-old man who is noncompliant with cystic fibrosis and worsening hypoxia and hypercapnia.
VBG|venous blood gas|VBG|216|218|HISTORY OF PRESENT ILLNESS|An echocardiogram showed critical pulmonary stenosis with bidirectional shunting through the PFO. An EKG did not show WPW. With worsening apnea and bradycardia, _%#NAME#%_ was intubated and placed on a ventilator. A VBG prior to intubation showed a PH of 7.16, PCO2 71, PO2 30 and bicarbonate 24. Arrangements were then made for _%#NAME#%_'s transfer to the Pediatric Intensive Care Unit at the University of Minnesota Medical Center Children's Hospital, Fairview, for further management.
VBG|venous blood gas|VBG|251|253|LABORATORY DATA|CBC on _%#MMDD2004#%_: White count 7.5. Platelet count 260. CBC on _%#MMDD2004#%_: White count 7.7. Hemoglobin 10.3. Platelet count 321. CRP on _%#MMDD2004#%_ is 5.7; on _%#MMDD2004#%_ it is 5.41. BUN and creatinine on _%#MMDD2004#%_ are 13 and 0.41. VBG 7.44/42/39/28. Blood cultures on _%#MMDD2004#%_, _%#MMDD2004#%_, _%#MMDD2004#%_, and _%#MMDD2004#%_ are all no growth so far. Urine cultures from _%#MMDD2004#%_ and _%#MMDD2004#%_ are all on growth so far.
VBG|venous blood gas|VBG|175|177|LABORATORY DATA|SKIN: Exam unremarkable with abdominal scar. NEUROLOGIC: Normal with normal tone and level of alertness. LABORATORY DATA: Hemoglobin 11.4, potassium 2.9, ionized calcium 4.7, VBG 7.33/60/28/31. Basic metabolic panel from yesterday unremarkable. Newborn screen remarkable for a delta 508 mutation x 2. IMAGING: Chest x-rays showing peribronchial cuffing, otherwise normal. ASSESSMENT: _%#NAME#%_ is an 11-day-old girl with cystic fibrosis and status post surgical repair of ileal atresia, currently without apparent respiratory issues and doing well, although her only stool output has been 3 mL of stool on _%#MMDD2007#%_ and _%#MMDD2007#%_ and 1 mL on _%#MMDD2007#%_.
VBG|venous blood gas|VBG|143|145|LABORATORY RESULTS|Despite this intervention the baby continued to have multiple spells with duration of less than a minute. LABORATORY RESULTS: From last night, VBG showed blood pH 7.42, CO2 of 39, O2 31. INR 1.22, PTT 35, ALT and AST were normal. Lumbar puncture was performed, showed white blood count 18 and red blood cells 260.
VBG|venous blood gas|VBG|159|161|HISTORY OF PRESENT ILLNESS|He was treated with 2 doses of Narcan, after which limb twitching was noted. His pupils responded became less pinpoint, the respirations increased. The repeat VBG showed little improvement. He was subsequently reintubated with normalization of blood gases. Horizontal nystagmus was noted in this interval. The twitching movements continued. Cranial CT scan with and without contrast was ordered and an EEG was postponed until the following day.
VBG|vertical banded gastroplasty|VBG|142|144|PAST SURGICAL HISTORY|He also has an ostial circumflex lesion that is 40-50%. His ejection fraction is well preserved at 63%. PAST SURGICAL HISTORY: 1. Status post VBG in _%#MM#%_ of 2000 with postoperative exploratory lap. 2. He had a ventral hernia repair done in _%#MM#%_ of 2001 and attempts were made twice to do this.
VBG|vertical banded gastroplasty|VBG.|175|178|PAST SURGICAL HISTORY|4) Depression. 5) History of obesity. 6) Hypertension. 7) Asthma. PAST SURGICAL HISTORY: 1) Cesarean section. 2) Total abdominal hysterectomy with unilateral oophorectomy. 3) VBG. 4) Arthroscopic right knee surgery. 5) Lipoma removal. 6) Bilateral carpal tunnel. 7) Appendectomy. 8) Cholecystectomy.
VBG|venous blood gas|VBG|160|162|PHYSICAL EXAMINATION|The sternal wound has healed well, with no evidence of infection instability. RESPIRATORY: Intermittent ventilatory support. His last blood gas was as follows: VBG _%#MMDD2005#%_ is 7.29, 70, PC02 45, 3375 cc. We will increase his ventilatory support. ABDOMEN: Soft. Bowel sounds present.
VBG|vertical banded gastroplasty|(VBG)|246|250|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Schizoaffective disorder. 2. History of prior gastroesophageal reflux disease (GERD) controlled with proton pump inhibitor (PPI). 3. History of morbid obesity treated with gastric surgery. a. Vertical banded gastroplasty (VBG) performed by Dr. _%#NAME#%_ _%#NAME#%_ at United Hospital on _%#MMDD2002#%_. Review of the surgical report indicates the patient had a vertical banded gastroplasty with a Silastic ring.
VBG|vertical banded gastroplasty|(VBG)|614|618|IMPRESSION|No appreciable hepatosplenomegaly, masses, guarding, or rebound. EXTREMITIES: Right and left lower extremities are negative for edema. NEUROLOGIC: Neurologically the patient is alert. LABORATORY DATA: Laboratory data from _%#MMDD2003#%_ reveals a sodium of 140, potassium 4.3, chloride 113, bicarbonate 20, glucose 72, BUN 8.0, creatinine 1.0. Albumin 3.3, alkaline phosphatase 67, calcium 8.2, ALT 27, AST 21, total bilirubin 0.3, lipase 46, total protein 6.4. Thyrotropin 1.63. Hemoglobin 12.0, MCV 92, platelet count 217, white count 4.0. IMPRESSION: Adult female with a history of vertical banded gastroplasty (VBG) with a Silastic ring who presents with an episode of nausea and vomiting and intolerance to oral diet. The presence of a Silastic vertical banded gastroplasty would make endoscopic dilatation extremely difficult as balloon dilatation should not be able to significantly alter the shape and size of the Silastic ring.
VBG|venous blood gas|VBG|163|165|HISTORY OF PRESENT ILLNESS|At the outside hospital, grunting and retraction were noted with O2 desat in the 70% range with cardiomegaly by silhouette. She was, subsequently, intubated, with VBG showing pH 7.19, pO2 23. A cardiac echo demonstrated hypoplastic left heart syndrome. She was started on prostaglandins and transported to F-UMC PICU for further management.
VBG|venous blood gas|VBG:|245|248|LABORATORY DATA|Skin: Without rash. Neurologically, she moves all extremities equally. Lymph: No cervical or supraclavicular lymphadenopathy. LABORATORY DATA: Sodium 149, potassium 4.0, chloride 112, bicarbonate 20, BUN 24, creatinine 0.9, calcium ionized 5.2. VBG: pH 7.44, white count 19.8, hemoglobin 13.8, platelets 200. Her tacrolimus drug level this morning is 10.7. Chest x-ray shows clear lung fields bilaterally with bilateral chest tubes.
VBG|venous blood gas|VBG|167|169|LABORATORIES|LABORATORIES: White count is 8.6, hemoglobin 6.6, platelet count 91, differential is 96.6, two lymphs to monos. INR is 2.22. D-dimer is 14.6. BUN 62, creatinine 1.27. VBG is 7.42, pCO2 36, bicarb 23. Cultures from _%#MMDD#%_, ET tube have a growth of Streptococcus pneumoniae, Hemophilus influenzae, light grown of Candida albicans.
VBG|venous blood gas|VBG:|369|372|LABORATORY DATA|SKIN: Sedated with tracheostomy. LABORATORY DATA: White count of 0.1, hemoglobin 9.0, platelets 56, hematocrit 26.1, albumin 3.6, total protein 6.9, AST is 55, ALT is 48, alk phos 121, albumin 4.1. Sodium is 144, potassium 3.2, chloride 96, carbon dioxide 34, BUN is 93, creatinine 1.57, glucose 103, calcium 9.2, magnesium 2.0, phosphorus 3.4. INR is 1.47, PTT is 35. VBG: 7.46 pH, pCO2 is 47, pO2 is 54, bicarb 33. Hemoglobins read from _%#MMDD#%_: 11.5-9.8-9.3-9.1-9.0. Those are all TO. _%#MMDD#%_ ABDOMINAL X-RAY: No free air and paucity of bowel gas.
VBG|vertical banded gastroplasty|VBG|225|227|FAMILY HISTORY|PAST SURGICAL HISTORY: 1. She had a D&C in 1996. 2. She also had her wisdom teeth removed. FAMILY HISTORY: Her father is unknown in his medical Her mother suffered from obesity, as well as her grandmother and they both had a VBG done at United Hospital. SOCIAL HISTORY: The patient is married. She has two children ages 5 and 9 months full.
VBG|venous blood gas|VBG:|158|161|LABORATORY DATA|LYMPHATICS: no left supraclavicular or axillary lymphadenopathy. LABORATORY DATA: Sodium 138, potassium 3.8, chloride 104, bicarb 30, BUN 12, creatinine 1.0. VBG: pH 7.42. White count 12.6, hemoglobin 11.9, platelets 279. Chest x-ray personally reviewed by me shows left lower lobe atelectasis, cannot rule out pneumonia and an opacity at the right base.
VBG|venous blood gas|VBG|178|180|LABORATORY  DATA|5. UA: Specific gravity 1.020, 100 of glucose, 100 of protein, positive nitrite, moderate leukocyte esterase, greater than 100 white cells, many bacteria and 10-25 red cells. 6. VBG 7.32/34/38/63/17. DIAGNOSTIC STUDIES: 1. On her monitor she looks like she has peaked T waves.
VBG|venous blood gas|VBG|149|151|LABORATORY DATA|LABORATORY DATA: Additional information: ABG performed 1 hour on BiPAP with a pressure of _%#MMDD#%_ and 50% FIO2: pH 7.27, pCO2 54, pAO2 is 76. His VBG drawn at the same time is pH 7.24, pCO2 64, pO2 55 with 85% saturation of the tissue. Blood cultures drawn _%#MMDD2007#%_ are no growth to date less than 24 hours.
VBG|vertical banded gastroplasty|VBG|131|133|HISTORY OF PRESENTING PROBLEMS|She has attended the introductory class here at Fairview Southdale and is well versed about weight loss surgery, as her mother had VBG surgery about four years at another site. She describes a seven year struggle with her weight and has been through Weight Watchers, has done herbal supplements and over-the-counter medications with very little success in weight loss.
VBG|venous blood gas|VBG|160|162|ADMISSION LABORATORY DATA|Basic metabolic panel is within normal limits except for chloride which is slightly low at 97 and bicarbonate which is slightly high at 32. Troponin I is 0.08. VBG is 7.35, 55, 41 with bicarbonate of 30 and venous oxyhemoglobin of 71% on one sixteenth of a liter O2 via nasal cannula.
VBG|venous blood gas|VBG|178|180|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1: Respiratory. The patient is presently ventilating spontaneously on the trach-dome 24 hours a day. FIO2 35%. His oxygen requirements have diminished. VBG _%#MMDD2003#%_: pH 7.37, pCO2 38, pO2 53, SVO2 86%. The patient has perfuse purulent secretions. A sputum gram stain and culture is pending.
VBG|venous blood gas|VBG,|167|170|PLAN|Possible etiologies include fungemia or other intraabdominal process with elevated liver function tests and lipase. 3. Respiratory. Respiratory failure. We will check VBG, lactate, and MVO2 q. 12h. We may need to intubate. 4. Shock liver. Check ultrasound of abdomen, also include Dopplers of the liver, possible clot, coagulopathy possibly related to sepsis versus DIC versus clot.
VBG|venous blood gas|VBG|200|202|HISTORY OF PRESENT ILLNESS|Will cry with needle sticks. LABORATORY: On laboratory studies on admission, sodium 135, potassium 5.1, chloride 112, bicarb 15, BUN 18, creatinine 0.4, glucose 135, calcium 8.5, ionized calcium 5.3. VBG was 7.29/33/65/16, satting 89% on 1.5 L. CBC revealed a white blood cell count of 4.1, hemoglobin 10.5, hematocrit 32.9, platelets 346.
VBG|vertical banded gastroplasty|VBG|144|146|PAST MEDICAL HISTORY|11. Status post tonsillectomy and adenoidectomy. 12. Status post bilateral breast reduction. 13. Status post left knee surgery. 14. Status post VBG x 3, see history. MEDICATIONS: 1. Prednisone 2.5 mg p.o. q.d. 2. Protonix 80 mg p.o. q.d.
VBG|vertical banded gastroplasty|VBG|529|531|ASSESSMENT|Her vital signs were all within normal limits. On physical exam, remarkable characteristics were positive for abdomen that was obese, two small areas in the midline of superficial ulceration, one was approximately 4 centimeters below the xiphoid process approximately 0.75 centimeters deep with pink granulation tissue, the second area was approximately a 1 centimeter dime-sized ulcer in the midabdomen. The patient does have a blunted affect. ASSESSMENT: This is a 47-year-old female status post endoscopy which showed a small VBG lumen of approximately 5 mm, recent history of increased nausea and vomiting. The plan was to admit the patient for IV hydration, obtain nutrition laboratories, and possible TPN before scheduling the patient's surgery.
VBG|vertical banded gastroplasty|VBG|351|353|HOSPITAL COURSE|The next day a PICC line was placed, and the patient was started on TPN after nutrition laboratory values showed the patient had an albumin of 2.1 as well as decreased transferrin and total protein. The patient remained in the ward approximately 10 days until _%#MMDD2002#%_ where she underwent exploratory laparotomy, lysis of adhesions, reversal of VBG with removal of silastic ring, and gastric pouch dilation with Maloney dilators. The patient tolerated the procedure well. There was a small splenic laceration during the lysis of adhesions that was repaired primarily.
VBG|venous blood gas|VBG|155|157|BLOOD GASES|SPECIALITY LABS: She had a troponin on _%#MMDD2003#%_, which was negative, less than 0.07. BLOOD GASES: She had numerous blood gases done. Her most recent VBG was on _%#MMDD2003#%_, 7.24373615. DRUG LEVELS: Most importantly, her tacrolimus level had been followed very closely.
VBG|venous blood gas|VBG|265|267|LABORATORY DATA ON ADMISSION|INR 1.6, total bilirubin 1.1, albumin 2.5, total protein 6.7. Troponins were negative. Alkaline phosphatase was 90, ALT 22, AST 38, lactic acid 1.4. Sodium was 138, potassium 4.4, chloride 102, bicarb 20, BUN 88, creatinine 7.34, glucose 91, total calcium 8.1, and VBG in the emergency department was 7.37/39/40% on unknown oxygen. ASSESSMENT AND PLAN: Suspected recurrent upper-GI bleed due to portal gastropathy given past history.
VBG|venous blood gas|VBG|134|136|PROBLEM #2|Chest x-ray from admit was reviewed by Dr. _%#NAME#%_ and was reported to be overall worse with increased hyperinflation. She had one VBG during hospitalization which showed a pH of 7.35 and a pCO2 of 51. Her pulmonary function tests on _%#MM#%_ _%#DD#%_, 2002, showed a vital capacity of 82% and a peak flow of 41%.
VBG|venous blood gas|VBG|186|188|PROBLEM #3|PROBLEM #3: Resp. _%#NAME#%_ was stable on room air until his third spacing problems developed. Oxygen supplementation was started on _%#MM#%_ _%#DD#%_, 2004, and was closely monitored. VBG was done. He did not tolerate a trial of BiPAP on _%#MM#%_ _%#DD#%_, 2004. His clinical status continued to decline, and he was intubated on _%#MM#%_ _%#DD#%_, 2004.
VBG|venous blood gas|VBG|171|173|HOSPITAL COURSE|Since then the patient has been on BiPAP predominantly, but in the past 2 days has been tolerating trach-dome intermittently during the day up to about 2 hours at a time. VBG today shows a pH of 7.36, pCO2 of 49, pO2 46 and bicarbonate of 27 that is on room air at this point.
VBG|venous blood gas|VBG|148|150|LAB TESTS|LAB TESTS: On admission _%#MM#%_ _%#DD#%_ show chem 7 shows sodium 135, potassium 4.1, BUN 24, creatinine 1.6, chloride 103, bicarb 19, glucose 94. VBG shows a pH of 7.4, CO2 31, O2 45. Liver function tests show ALT 38, AST 32, alkaline phosphatase 98, total bili 1.2, direct 0, _________________ 0.4, albumin 3.4, total protein 6.8. Coag profile shows INR 1.04, PTT 39.
VBG|venous blood gas|VBG|163|165|LABORATORY FINDINGS ON ADMISSION|SKIN: Mottled with capillary refill time of 4-5 seconds. NEUROLOGIC: Not recorded, however the patient is noted to be irritable. LABORATORY FINDINGS ON ADMISSION: VBG showing pH of 7.06, pCO2 76, pIO2 37, bicarbonate 21 with saturation of 46% and FiO2 environment of 100%. VRP 0.74, sodium 148, potassium 5.8, chloride 109, bicarbonate 24, glucose 118, BUN 30, creatinine 0.58, calcium 8.8, INR 1.73, PTT 32, fibrinogen activity 254.
VBG|venous blood gas|VBG|170|172|ASSESSMENT AND PLAN|Will also get a CBC, basic metabolic panel, liver function tests every four hours for the next 24 hours, an ABG is ordered, a cortisol level was ordered. Will get serial VBG after initial ABG. Also, we will perform a cosyntropin stim test at low dose to evaluate adrenal response will order serial troponins to evaluate for ischemic heart disease.
VBG|venous blood gas|VBG|184|186|BRIEF HISTORY OF PRESENT ILLNESS|On presentation, the patient stated that he had had a 1-2 day history of worsening shortness of breath. His saturations on presentation were 60-70% on high flow oxygen and his initial VBG showed a pH of 7.2, CO2 56, oxygen of 32 and bicarbonate 21. Additional history was that the patient had initially had his Coumadin held in mid _%#MM#%_ for an elective bronchoscopy.
VBG|venous blood gas|VBG|217|219|PROBLEM #1|HOSPITAL COURSE: PROBLEM #1: Acute hypoxic respiratory failure/pulmonary embolus. On presentation to the Emergency Department, the patient was significantly hypoxic with saturations down to 60% on 100% FIO2 mask. His VBG and ABG were consistent with hypoxic respiratory failure with a pH of 7.2. Initially, there was a concern for pulmonary embolus given his past history of PE and recently being off his Coumadin therapy; however, there was also consideration of infectious etiology.
VBG|venous blood gas|VBG|450|452|DISCHARGE DIAGNOSES|On _%#MMDD2002#%_, he had a tracheostomy tube placed and on _%#MMDD2002#%_, he was transferred to the Medical Intensive Care Service for further management of ventilator weaning. This is his hospital course in brief. His laboratory data on the day of discharge shows a white count of 8.7, hemoglobin 10.8, MCV 89, platelets 409, sodium 148, potassium 4.3, chloride 121, bicarb 21, BUN 68, creatinine 1.6, glucose 144, calcium 9.0, mag 2.9, phos 3.0. VBG shows a pH of 7.38 and a pCO2 of 38 on 30% FIO2. Chest x-ray shows slight hazing of the left cardiac border but otherwise overall greatly improved since admission.
VBG|venous blood gas|VBG.|197|200|FOLLOWUP|Additionally he shou ld use his BiPAP machine for 6 hours per day with setting of 8/4. He will have twice weekly blood draws by home health nurse with BMP with magnesium and phosphorous as well as VBG. His primary MD will follow up on the VBG. We instructed the patient that if his VBG showed a PCO2 of greater than 100 he should call his primary MD and go to the local ER.
VBG|venous blood gas|VBG|195|197|FOLLOWUP|He will have twice weekly blood draws by home health nurse with BMP with magnesium and phosphorous as well as VBG. His primary MD will follow up on the VBG. We instructed the patient that if his VBG showed a PCO2 of greater than 100 he should call his primary MD and go to the local ER. Additionally he should go to the emergency room if he has any new increased oxygen demands, increased work of breathing, shortness of breath or altered mental status.
VBG|venous blood gas|VBG|168|170|HOSPITAL COURSE|6. Pulmonary: _%#NAME#%_ was found to have a high bicarbonate level on admission. This continued to increase and he also had an increased carbon dioxide as well when a VBG was checked, maximum pCO2 was 61, maximum bicarbonate 37, pH was 7.41. A pulmonary consult was obtained. I feel that he does not have any lung problems per se that likely this carbon dioxide retention is the result of his neurologic disease and discoordinated breathing and possibly some decreased drive, they are recommending possible EEG and sleep study as well as five-channel sleep study as an outpatient.
VBG|venous blood gas|VBG|161|163|PROBLEM #1|When she came in to the hospital, she was found to be severely hypoxemic and had sats that were in 60s. She was started on BiPAP in the ER and she improved. Her VBG at the time of admission showed a pCO2 of 108 and a pO2 of 72. She was started on BiPAP and was transferred to MA Medical ICU.
VBG|venous blood gas|VBG|285|287|PROBLEM #2.   ENT|PROBLEM #2. ENT: We will follow the ENT Service's recommendations and do no dressing changes or alteration to her thyrotomy site, and will access them readily should any problems arise. PROBLEM #3. Respiratory: _%#NAME#%_ is ventilating well on her current vent settings. I will get a VBG to evaluate the satisfactory nature of these settings, and wean her oxygen as tolerated. She will need to be fully supported with ventilation, as she will be paralyzed for at least 3 days.
VBG|venous blood gas|(VBG)|164|168|ALLERGIES|Since the sleep study demonstrated that _%#NAME#%_ has good central drive, his backup respiratory rate on his BiPAP machine was decreased to 10. A venous blood gas (VBG) demonstrated that his PCO2 is 51, which is relatively unchanged from his previous admission. _%#NAME#%_ will follow up with Dr. _%#NAME#%_ in 2 weeks after discharge for evaluation of his pulmonary status.
VBG|venous blood gas|VBG|172|174|PATIENT'S CLINICAL COURSE|7. Neurology: The patient was noted to be floppy with the small conical-shaped head. _%#NAME#%_ was especially listless after extubation and developed elevated CO2 and the VBG in the 60s with the pH around 7.25. There was a question of perhaps _%#NAME#%_ has underlying other genetic anomalies besides Trisomy 21.
VBG|venous blood gas|VBG:|204|207|LABORATORY DATA|Troponin negative. Alcohol 0.26, down to 0.15 later. Serum osmolality 380, calculate osmolality with correction for alcohol level about 350 giving an osmolal gap. _________ level less then 1. Most recent VBG: pH 7.24, pCO2 37, pO2 88, FiO2 21%, bicarbonate 15. Lactic acid 2.6. IMAGING: Chest x-ray and abdominal x-ray unremarkable.
VBG|venous blood gas|VBG|277|279|DISCHARGE MEDICATIONS|Her discharge chemistries are significant for CHF findings, including sodium of 131 (improved from _%#MMDD2006#%_), potassium 4.5, chloride 94, and bicarbonate 28. Her glucose is improved at 163. Her BUN is 53 and her creatinine is stable at 0.79. Her total calcium is 8.2 Her VBG on 2 liters nasal cannula is 7.36 with a pCO2 of 60, pO2 of 27, a bicarbonate of 33, venous oxyhemoglobin of 44.
VBG|venous blood gas|VBG|169|171|LABS ON ADMISSION|White blood cell count 13.7 with 81% neutrophils, hemoglobin 14.8 and platelets 397,000. Urinalysis with greater than 1000 glucose, trace blood, 2-5 WBCs and 0- 2 RBCs. VBG with pH 7.29. EKG - is sinus, 100 without acute ST-T wave changes.
VBG|venous blood gas|VBG|164|166|HISTORY OF PRESENT ILLNESS|On the morning of admission, she was found by the nursing home staff to be less responsive than usual. Laboratory evaluation in the emergency department revealed a VBG of 7.27/66/77/29, BUN of 46 and the creatinine of 2.0. Per discussion with the nursing home nursing staff, the patient had received "plenty" of narcotics, including morphine and oxycodone and had been getting Ativan p.r.n. as well.
VBG|venous blood gas|VBG|295|297|ADMISSION LABORATORY DATA|Differential: 87% neutrophils, 7% lymphocytes and 5% monocytes. Electrolytes: Sodium 136, potassium 3.5, chloride 97, bicarbonate greater than 40, BUN 12, creatinine 0.5, glucose 111, ionized calcium 4.7, magnesium 1.3, phosphorus 3.0. Chest x-ray showed no infiltrate. EGD tube was in place. A VBG showed a pH of 7.53, a pCO2 of 31, a pO2 of 36 and a bicarbonate of 25. HOSPITAL COURSE: PROBLEM #1: Fluid, electrolytes and nutrition. In the PICU, an NJ was placed.
VBG|venous blood gas|VBG|213|215|PERTINENT LABS AND DIAGNOSTICS ON ADMISSION|Differential showed 62% neutrophils, 37% lymphocytes, 1% mono and few atypical lymphocytes were noted. Rapid strep was negative with culture pending. Monospot was positive at an outside institution. CRP was 34.2. VBG was checked, which revealed 7.31/28/45/14. HOSPITAL COURSE: PROBLEM #1: FEN/GI/Renal: On admission, given poor p.o. intake, _%#NAME#%_ was started on IV fluids and strict I's and O's were monitored.
VBG|venous blood gas|VBG|162|164|HOSPITAL COURSE|G-tube intact. EXTREMITIES: No peripheral edema. SKIN: No rash. HOSPITAL COURSE: PROBLEM #1: Hyperglycemia. At the time of admission, we checked a urinalysis and VBG looking for any signs of acidosis. Her urinalysis showed 40 ketones and no glucosuria. Her pH was 7.42 on venous gas. These findings suggest that she did not have a new-onset type 1 diabetes but rather hyperglycemia related to her cystic fibrosis.
VBG|venous blood gas|VBG,|195|198|EMERGENCY DEPARTMENT COURSE|He was back to his pre-procedural state in the middle of the LP, as noted, and was completely out of his post-ictal state within ten minutes of completing the LP. We attempted to obtain a repeat VBG, but were unsuccessful, as the child was now completely wide awake and fighting. I deferred further attempts, as he obviously is not experiencing CO2 retention.
VBG|venous blood gas|VBG|261|263|ADMISSION PHYSICAL EXAMINATION|ADMISSION LABORATORY DATA - (From the outside Emergency Department): White count 7.3 with 80% neutrophils, 13% lymphocytes, hemoglobin 11.4, platelet count 282. Sodium 140, potassium 3.4, chloride 101, bicarb 28, BUN 7, creatinine 0.3, glucose 94, calcium 8.8. VBG revealed a pH of 7.45, pCO2 of 41, bicarb of 15. INR 1.12. PTT 29. The pleural fluid was sent for gram stain and cell count.
VBG|venous blood gas|VBG|249|251|ADMISSION LABORATORY DATA|INR 1.25. Electrolytes revealed sodium 142, potassium 4.0, chloride 100, bicarbonate 31, BUN 22, creatinine 1.1, glucose 165. BNP 352. Troponin 0.42. Troponin peaked at 4.48, TSH 4.12. Blood cultures were negative. Sputum culture grew normal flora. VBG 7.33/49/52/25/86% on 50% FIO2. Urinalysis positive for protein 100, large blood with RBCs 250. Urine culture negative, albumin 2.8, prealbumin 12, transferrin 117. Repeat sputum culture revealed MRSA.
VBG|venous blood gas|VBG|129|131|LABORATORY RESULTS|Urine tox screen was done and that was negative. EKG was done which showed normal sinus rhythm. No ST segment or T-wave changes. VBG showed a pH of 7.39, PCO2 64, PO2 21, and bicarb 38. IMAGING: Chest x-ray shows decreased lung volumes. Supine technique may explain pulmonary vascularity fuzziness.
VBG|venous blood gas|VBG|180|182|ASSESSMENT/PLAN|He had a negative troponin and negative EKG indicating that this was unlikely to be an MI. There is no evidence of infection or intoxication. We will use CPAP at night and recheck VBG in the morning. We will ask RT to make sure that the patient has functioning CPAP at home, although he does state that this has been fixed.
VBG|venous blood gas|VBG|231|233|PROBLEM #2|He is on an FiO2 of 30% with a PEEP of 6, a tidal volume of 22, a rate of 40, pressure support of 10, which has been giving him peak pressures of 18 to 19 and a mean airway pressure of 10. His I-time is set as .43 or 29%. His last VBG was at 11 o'clock today, and is 740 with a pCO2 of 46, a pO2 venous of 32, a venous bicarb of 28, which gave him an oxyhemoglobin of 66% on the aforementioned vent settings and an FiO2 of 30%.
VBG|venous blood gas|VBG|135|137|DISCHARGE LABORATORY DATA|Sodium 133, potassium 3.9, chloride 103, bicarbonate 30, BUN 13, creatinine 0.63, glucose 141, calcium 7.6, magnesium 2, phosphorus 2. VBG pH was 7.43, and pCO2 was 42. Chest x-ray showed possible right lower lobe infiltrate unchanged from previous. HOSPITAL COURSE: PROBLEM #1: Amyotrophic lateral sclerosis with respiratory compromise.
VBG|vertical banded gastroplasty|VBG|103|105|PROCEDURE PERFORMED|DIAGNOSIS AT ADMISSION: Morbid obesity. DIAGNOSIS AT DISCHARGE: Same. PROCEDURE PERFORMED: Revision of VBG and liver biopsy. CHIEF COMPLAINT: Morbid obesity. HISTORY OF PRESENT ILLNESS: This is a 62-year-old female, status post VBG who now presents for a revision of the VBG secondary to weight gain.
VBG|vertical banded gastroplasty|VBG|158|160|HISTORY OF PRESENT ILLNESS|PROCEDURE PERFORMED: Revision of VBG and liver biopsy. CHIEF COMPLAINT: Morbid obesity. HISTORY OF PRESENT ILLNESS: This is a 62-year-old female, status post VBG who now presents for a revision of the VBG secondary to weight gain. PAST MEDICAL HISTORY: 1. Depression 2. Previous failure of VBG.
VBG|vertical banded gastroplasty|VBG|201|203|HISTORY OF PRESENT ILLNESS|PROCEDURE PERFORMED: Revision of VBG and liver biopsy. CHIEF COMPLAINT: Morbid obesity. HISTORY OF PRESENT ILLNESS: This is a 62-year-old female, status post VBG who now presents for a revision of the VBG secondary to weight gain. PAST MEDICAL HISTORY: 1. Depression 2. Previous failure of VBG.
VBG|vertical banded gastroplasty|VBG.|202|205|PAST MEDICAL HISTORY|HISTORY OF PRESENT ILLNESS: This is a 62-year-old female, status post VBG who now presents for a revision of the VBG secondary to weight gain. PAST MEDICAL HISTORY: 1. Depression 2. Previous failure of VBG. PAST SURGICAL HISTORY: 1. Significant for previous VBG. 2. Prior rectal surgery and placement of an artificial rectal sphincter.
VBG|vertical banded gastroplasty|VBG.|115|118|PAST SURGICAL HISTORY|PAST MEDICAL HISTORY: 1. Depression 2. Previous failure of VBG. PAST SURGICAL HISTORY: 1. Significant for previous VBG. 2. Prior rectal surgery and placement of an artificial rectal sphincter. FAMILY MEDICAL HISTORY: Not available. SOCIAL HISTORY: The patient smoked in the past.
VBG|venous blood gas|VBG|197|199|LABORATORIES AT TIME OF INTERIM SUMMARY|There is no specific consolidation noted. LABORATORIES AT TIME OF INTERIM SUMMARY: White count 9.5, hemoglobin 9.2, platelets 274, sodium 141, creatinine 3.8, creatinine 1.9, BUN 4.6, glucose 133. VBG 7.46, 47, 31, with an O2 hemoglobin of 58%. Blood cultures have been no evidence of any to date. Swan tip cultures are negative to date. UAs have been negative to date.
VBG|vertical banded gastroplasty|VBG|144|146|HISTORY OF PRESENT ILLNESS|PAST MEDICAL HISTORY: 1. Pancreatitis, idiopathic, chronic, status post distal pancreatectomy, splenectomy. 2. Status post ERCP. 3. Status post VBG in the 1990s. 4. Pulmonary embolism as well as DVT postoperatively. 5. Status post appendectomy. 6. Status post cholecystectomy. 7. Status post bilateral breast reduction.
VBG|venous blood gas|VBG|211|213|HOSPITAL COURSE|Initial blood gas showed an acute respiratory alkalosis with pH of 7.5, pCO2 of 28, and bicarb 22 with a measured bicarb of 22. Over the course of the subsequent 24 hours his respiratory alkalosis improved. His VBG on the morning of discharge was 7.49, pCO2 of 39, and bicarb of 29. Initial salicylate acid level was 50, this was 14 hours after ingestion and salicylate level on the morning of discharge was 27, which was just above therapeutic range of up to 20.
VBG|venous blood gas|VBG|146|148|CHIEF COMPLAINT|His saturations have remained 96% to 100% on room air. During the middle of his admission, however, he did develop some tachypnea. At that time a VBG was drawn which was within normal limits. His lungs at that time remained clear to auscultation. His tachypnea has resolved since that time and at the time of this dictation, his respiratory rate was within the normal range.
VBG|venous blood gas|VBG|213|215|LABORATORY DATA|Sodium 138, potassium 4.4, chloride 109, bicarbonate 22, BUN 54, creatinine 2.94, glucose 117, calcium 9.3, mag 2.5, alkaline phosphatase 4.6. ALT 77, AST 145. Alkaline phosphatase 185, T bili 0.5. ESR was 87 and VBG was 3.37 for pH, pCO2 33, pO2 59, bicarbonate 19. IMAGING: Chest x-ray showed a return of his right-sided effusion, but was otherwise clear without any acute changes.
VBG|venous blood gas|VBG|140|142|ADMISSION LABORATORY|CRP was less than 0.2. Pyruvate was normal at 0.05. Liver function tests were normal with the exception of a slightly elevated AST at 72. A VBG was normal. Blood cultures grown on admission was normal. His G-tube aspirate grew coag negative staphylococcus and Enterobacter. A urinalysis was unremarkable with urine culture that grew 10 to 50,000 colonies of non-lactose fermenting Gram negative rod.
VBG|venous blood gas|VBG|262|264|PROBLEM #4|The patient has had confusion since his admission to the hospital thought secondary to his underlying pulmonary disease versus underlying infection. He has shown some significant clearing, however, on _%#MMDD2005#%_ was noted to be more confused than usual. The VBG obtained showed a pCO2 elevated at 88. This was secondary to oversedation during the night and underventilation. He subsequently cleared after being placed on a higher amount of pressure support, which drove the pCO2 down.
VBG|venous blood gas|VBG|136|138|ADMISSION DIAGNOSIS|She also had one additional episode with a low bicarbonate at 16. This was rechecked and was in the normal range. Her lactate level and VBG were also checked and were normal. 5. Neuro. Peds Neurology was asked to see her in the hospital. She has a history of a left parietal stroke and a history of chorea.
VBG|venous blood gas|VBG|180|182|HISTORY OF PRESENT ILLNESS|Upon admission to of floor, he subsequently had sats in the 70s on room air. Rapid flu and RSV were initially negative. On _%#MMDD2007#%_, he had increased work of breathing and a VBG showed a CO2 of 88 and 100 on repeat VBG. Because of this, he was transferred to the PICU at that time where he was subsequently intubated.
VBG|venous blood gas|VBG.|144|147|HISTORY OF PRESENT ILLNESS|Rapid flu and RSV were initially negative. On _%#MMDD2007#%_, he had increased work of breathing and a VBG showed a CO2 of 88 and 100 on repeat VBG. Because of this, he was transferred to the PICU at that time where he was subsequently intubated. Viral cultures did come back at that time and were noted to be positive for RSV.
VBG|venous blood gas|VBG|136|138|ASSESSMENT/PLAN|The patient is on metformin. However, there is a concern that acidosis could be contributing to the patient's symptoms. We will check a VBG to assess for this. Hold his metformin at this time. However, we will resume this should the patient's laboratory values return to normal.
VBG|venous blood gas|VBG|191|193|PROBLEM #3|She maintained good perfusion throughout his stay. PROBLEM #3: Pulmonary: He was maintained on his home vent, which was at his bedside, with his home vents nothing was changed. He did have a VBG checked which was 744, 49, 37. He remained completely stable pulmonary wise and did not require any extra oxygen during his stay.
VBG|venous blood gas|VBG|146|148|PROBLEM #2|PROBLEM #2: Endocrine. At this time the patient has numerous lab results which would be very consistent with diabetic ketoacidosis. The patient's VBG does demonstrate acidemia and the patient also with significant anion gap and a low bicarb. Due to this suspicion the patient will be initiated on IV therapy with insulin, along with an insulin drip.
VBG|venous blood gas|VBG|215|217|PROBLEM #5|She initially received a workup which included an LDH which was high at 1,306 and a uric acid level which was low at 0.6. She had a normal bone survey and a normal alpha 1 antitrypsin level. Ammonia level and a gas VBG were also normal. She then underwent bone marrow examination which was felt to be essentially normal. She did have chromosomes performed which eventually showed a ring chromosome 21, replacing one normal chromosome 21.
VBG|venous blood gas|VBG|235|237|PROBLEM #6|PROBLEM #6: Pulmonary. The patient's tachypnea has improved from a high rate of 40 to between 16-22 at the present time. No infiltrates were recognizable on both CT and x-rays of lungs. His overall metabolic acidosis has improved. His VBG on _%#MMDD#%_ demonstrated compensated metabolic acidosis. His chest CT on _%#MMDD#%_ showed no acute airspace opacities identifiable. He had an unchanged 5-mm left lower lobe pulmonary nodule.
VBG|venous blood gas|VBG:|392|395|LABORATORY DATA|No other significant rashes or jaundice were noted. LABORATORY DATA: On admission: White cell count 1.2, hemoglobin 5.6, platelets 153, MCV 87. Sodium 136, potassium 4.4, chloride 113, bicarb 17, BUN 28, creatinine 1.36, calcium 7.0, magnesium 1.8, phosphorus 3.5. INR 1.73, PTT 49, total bilirubin 1.8, ALT 36, AST 31, alkaline phosphatase 81, albumin 1.8, LDH 307, reticulocyte count 3.9%. VBG: pH 7.35, PCO2 33, PO2 32, bicarb 18, lactic acid 2.0. UA showed specific gravity of 1.004, 1 white blood cell, 0 red blood cell, otherwise negative for infection.
VBG|venous blood gas|VBG|194|196|LABORATORY DATA ON ADMISSION|LYMPHATICS: No lymphadenopathy. LABORATORY DATA ON ADMISSION: His white count was 3.7. hemoglobin 14, platelets 34, 94% neutrophils, 4% lymphocytes, 2% monocytes. His ANC was 3.5. INR was 0.90. VBG was 7.43/52/35. Total bilirubin was 0.3, albumin 3.4, total protein 6, alkaline phosphatase 95, ALT 345, AST 94. Sodium 133, potassium 3.6, chloride 89, bicarb 34, BUN 15, creatinine 0.56, glucose 160.
VBG|venous blood gas|VBG.|180|183|IMPRESSION AND PLAN|In the meantime, we will continue him on 14/4 settings with a backup rate of 10 at bedtime but also whenever he is napping during the day. I am also obtaining a followup admission VBG. Currently his mental status appears at baseline. 5. Pancreatic exocrine insufficiency: By history the patient has adequate enzyme replacement and will continue on his Creon.
VBG|venous blood gas|VBG|353|355|LABORATORY DATA|GENITOURINARY: Not examined. LABORATORY DATA: Sodium 140, potassium 6.4, chloride 100, CO2 31, BUN 63, creatinine 2.42. AST 45, ALT 11, alk phos 200, total protein is 8, albumin is 4, calcium 9.8, BNP 1130, lactate 1.8, UA is yellow clear urine with a few bacteria, 27 white blood cells and 4 red blood cells. WBC is 7.2, hemoglobin 12.9, platelet 177. VBG pH 7.28, CO2 70, O2 29, bicarbonate 33. EKG illustrating first-degree heart block and sinus bradycardia, no peak T-wave, no ST elevations or depressions.
VBG|venous blood gas|VBG|148|150|PROBLEM #2|A venous blood gas showed a pH of 7.44, pCO2 of 42, pO2 of 34, bicarbonate 28 on 4 liters. Following nebs and IV antibiotic treatments, a follow-up VBG ten hours later showed a pH of 7.48, pCO2 of 42, pO2 of 40, bicarbonate of 30 on room air. The patient was weaned off oxygen on his second day of admission.
VBG|venous blood gas|VBG|147|149|LABORATORY DATA|Hemoglobin 14.6. Platelets 165. MCV 100. Sodium 144. Potassium 4.4. Chloride 92. Bicarbonate greater than 40. BUN 27. Creatinine 1.6. Glucose 151. VBG revealed: pH 7.34, pCO2 77. Troponin less than 0.07. BNP 163. INR 2.29. Total bilirubin 1.2. Albumin 4.1. Total protein 8.
VBG|venous blood gas|VBG|243|245|IMPRESSION|She reports recent prolonged hospitalization at Abbott Northwestern. It would be useful to get records from that hospitalization as well as from her pulmonologist to get a clear idea of her underlying disease and recent course. I will check a VBG to get a sense of her acid based status and whether she is retaining CO2 to get a clear idea of the severity of her lung disease.
VBG|venous blood gas|VBG,|128|131|LABORATORY STUDIES|Plantar responses were down. Reaching for objects, gait and station could not be assessed. LABORATORY STUDIES: Remarkable for a VBG, pH 7.25, albumin 2.9. Chest x-ray showed mediastinal drainage. IMPRESSION: 1. A 3-year-old with status post heart transplant with worsening cardiac function and developmental delay.
VBG|venous blood gas|VBG|153|155|LABORATORY DATA|LABORATORY DATA: White count 4.6, hemoglobin 11.9, platelets 68. Sodium 142, potassium 3.9, chloride 102, bicarb 25, BUN 46, creatinine 1.1, glucose 69. VBG this morning was 7.33 with pCO2 of 52. Bilirubin is 18.3 with 13.0 direct. Alk phos 414, ALT 147, AST 87, total protein 5.7, albumin 2.6. Amylase and lipase are normal.
VBG|venous blood gas|VBG|178|180|LABORATORY STUDIES|Plantar responses down. He had brisk reflexes in upper extremities in the normal range. Essentially, examination was normal. LABORATORY STUDIES: Remarkable for a glucose of 290. VBG was normal. Comprehensive urine tox was pending. I reviewed the EEG as well. It shows mostly a sleep record with spindles and some technical artifact.
VBG|vertical banded gastroplasty|VBG|175|177|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Morbid obesity. HISTORY OF PRESENT ILLNESS: This is a 39-year-old female with a history of obesity of chronic pain who presents for an elective conversion of VBG to gastric bypass. She has no recent illnesses, fevers and chills, or coughs, no nausea and vomiting, chest pain, or shortness of breath.
VBG|vertical banded gastroplasty|VBG.|182|185|PAST MEDICAL HISTORY|Incision is clean, dry, and intact with Steri-Strips. EXTREMITIES: The patient has a mild trace pitting pretibial edema. PAST MEDICAL HISTORY: 1. Morbid obesity. 2. Status post open VBG. 3. Depression. 4. Hypothyroidism. 5. Hypertension. 6. Sleep apnea. 7. Chronic back pain. 8. C-section x 1 - along with tubal ligation.
VBG|vertical banded gastroplasty|VBG.|221|224|DISCHARGE DIAGNOSIS|Comorbidities include congestive heart failure, anxiety, depression, hypertension, migraine headaches, obesity central, and elevated cholesterol. HOSPITAL COURSE: On _%#MM#%_ _%#DD#%_, 2006, the patient underwent an open VBG. She tolerated the procedure well, and there were no immediate postoperative complications. Following the surgery, the patient was kept NPO and had an NG tube.
VBG|vertical banded gastroplasty|VBG.|141|144|BRIEF HISTORY OF PRESENT ILLNESS|Options were discussed for possible surgical revision of the patient's VBG and that the decision was made to go ahead with a revision of the VBG. The patient's BMI is 51 at the time of evaluation. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Verapamil. 2. Aspirin.
VBG|venous blood gas|VBG|392|394|LABS|His white count is 8.6, hemoglobin 14.4, platelets 194. Initial sodium was 125, potassium 4.5, chloride 85, CO2 22, BUN 35, creatinine 1.80, calcium 9.5. Repeat check of electrolytes 4-1/2 hours later shows a sodium of 138, potassium 4.0, chloride 99, CO2 25, BUN 30, creatinine 1.5, glucose 44, calcium 9.4, bilirubin 1.2, albumen 4.4, protein 8.3, alkaline phosphatase 133, ALT 33, AST 31. VBG is pH of 7.42, PCO2 39, PO2 53. His hemoglobin is 84 percent, bicarb 26. Pending labs is a hemoglobin A1c. ASSESSMENT: This is a 47-year-old gentleman with new onset diabetes with critical high glucoses that have come down with insulin.
VBG|vertical banded gastroplasty|VBG|171|173|HISTORY OF PRESENT ILLNESS|The patient is 5 feet 2 inches tall and prior to the procedure weighed 245 pounds and had a BMI calculated out to be 44.8. The patient has been obese for 20 years and had VBG surgery in _%#MM#%_ 2000. Her preop weight at that time was 329 and her lowest weight after the VBG was 217 and the patient is currently, prior to this surgery, 245.
VBG|vertical banded gastroplasty|(VBG)|129|133|PAST SURGICAL HISTORY|At the time of presentation, the patient denied nausea, vomiting, fevers. PAST SURGICAL HISTORY: 1. Vertical-banded gastroplasty (VBG) approximately six years ago. 2. Duodenal switch approximately two years ago. 3. Hernia repair _%#MM2003#%_. PAST MEDICAL HISTORY: 1. Morbid obesity. 2. Gastroesophageal reflux disease.
AC|(drug) AC|AC|278|279||At this point in time he also does have belching and gas symptoms that seemingly are not necessarily related to his anginal pain. I think at this point in time we will also treat this with simethicone and Maalox and start him on Protonix as he has required a fair bit of Pepcid AC in the last 2 or 3 weeks. At this point in time Mr. _%#NAME#%_ looks very comfortable.
AC|acromioclavicular|AC|132|133||3. Humerus x-ray done, right side, showed no evidence of fractures or other joints seen. There was degenerative changes seen in the AC joint and the glenohumeral joint. 4. EKG was done and multiple lab studies, which were all within normal limits. She had no abnormalities noted. Her creatinine is 0.94, liver function tests are all within normal limits, and hemoglobin was 13.5. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is an 81-year-old female who was admitted on _%#NAME#%_ _%#NAME#%_.
AC|adriamycin cyclophosphamide|AC|461|462||In talking with Dr. _%#NAME#%_, he feels that cytoreductive therapy would be helpful and we will see if Dr. _%#NAME#%_ agrees, but the patient will undergo bilateral mastectomies when that time comes, but sentinel lymph nodes will be done bilaterally regardless of whether the chemotherapy is done before or after the surgery. I have addressed all of these issues with the patient, discussed why those will be necessary, and the patient will be a candidate for AC chemotherapy at a minimum, and if there are nodes involved, either Taxol or Taxotere. I have gone over all of this again with the patient.
AC|adriamycin cyclophosphamide|AC.|188|190||She eats well, maintains weight. LABS: Normal. X-rays were all done in _%#MM#%_. SOCIAL/FAMILY HISTORY: No change. CHEMOTHERAPY TREATMENT: Her last chemo was three years ago, when she had AC. Now she is on tamoxifen. ALLERGIES: Penicillin. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 120/72, pulse 88, respirations 18, temperature 98.6, weight 186.
AC|(drug) AC|AC|616|617||Only change will be digoxin is now 0.125 mg p.o. q. day instead of 0.25, Anbesol to the lip q. 2 to 4 hour p.r.n., Lexapro 10 mg p.o. q. day, Norvasc 10 mg p.o. q. day, bupropion 150 mg SR 1 p.o. b.i.d., Actos 30 mg p.o. q. day, Protonix 40 mg p.o. b.i.d., Imdur 60 mg p.o. q. p.m., clonazepam 0.5 mg p.o. q. day, Lipitor 10 mg p.o. q. day, bromocriptine 2.5 mg p.o. q. p.m., nitroglycerin 0.4 mg sublingual p.r.n. chest pain, lorazepam 0.5 mg 1 to 2 p.o. q. 8 hours p.r.n., Oxycontin 10 mg p.o. q. 4 to 6 hour p.r.n., aspirin 81 mg p.o. q. day, Spiriva 1 puff q. day, Advair Diskus 5/500 1 puff b.i.d., Cheratussin AC 1 to 2 tsp q. 4 hours p.r.n., Flonase nasal spray 2 sprays each nostril q. a.m., Vicodin 2 tabs q.i.d. p.r.n., oxygen p.r.n., Ambien 10 mg p.o. q. h.s. p.r.n., Prevent rinse mouth 2 tsp, SF 500 Plus cream 51 grams four times a day, regular insulin sliding scale.
AC|adriamycin cyclophosphamide|AC.|196|198||LABORATORY DATA: Bone scan and labs normal. FAMILY HISTORY/SOCIAL HISTORY: No change, except that her father-in-law died of small cell carcinoma of the lung. Chemotherapy history - four cycles of AC. She is on Femara currently. ALLERGIES: Sulfa PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 130/88, pulse 80, respirations 16, temperature 97.3, and weight 153.
AC|adriamycin cyclophosphamide|AC|200|201||CHEMO & RADIATION THERAPY HISTORY: With all of her lymph nodes, we elected to put her on Zometa, and will continue that for at least another three months until we do a re-scan. She had four cycles of AC and 12 weekly doses of Taxotere. She had a history of Premarin in the past. Currently, she is just on Zometa. ALLERGIES: Penicillin, cephalexin, erythromycin, Neupogen. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 114/80, pulse 82, respirations 16, temperature 98.2, weight 152.
AC|(drug) AC|AC|204|205||3. Loratadine 10 mg PO daily. 4. Augmentin 875 mg PO b.i.d. x 8 more days to complete a 10-day course of antibiotics. 5. Prednisone 60 mg PO daily. Dr. _%#NAME#%_ to discuss tapering doses. 6. Robitussin AC 10 to 20 mL PO q.4h. p.r.n. cough. 7. Oxycodone 5 mg PO q.6h. p.r.n. for leg pain. 8. Albuterol nebulizers or inhaler q.4h. p.r.n. wheezing or shortness of breath..
AC|assist control|AC|156|157||Respiratory rate 18. He was supported on eight m/kg/minute of Dopamine at that time. His temperature was 98.3. His saturation was 94% with vent settings of AC of 12, tidal volume of 700, FI 02 60%, a peak of 5. On physical exam, he was an elderly appearing male intubated, only minimally responsive to deep stimuli, but appeared comfortable and in no acute distress.
AC|(drug) AC|AC,|262|264||4. Hypothyroidism. 5. Hypertension. 6. Hypercholesterolemia. PLAN: Will rule out for myocardial infarction with serial troponins and EKGs. Assuming that he will rule out, I will order a stress test for tomorrow morning. For his cough, will treat with Robitussin AC, and for secondary bronchitis with Zithromax. He has a history of developing problematic bronchitis and pneumonia after colds.
AC|(drug) AC|AC,|157|159||Change antihistamine to Zyrtec 10 mg q. day, which the patient thinks is better for her. Continue Nasonex, atenolol, triamterene/hydrochlorothiazide, Pepcid AC, Macrobid, aspirin daily, Fosamax 35 mg q. week. The patient will need to say what day she takes this. The patient was interested in going off Neurontin, so start wean at 200 mg p.o. q. h.s. while in the hospital.
AC|adriamycin cyclophosphamide|AC.|169|171||IMMUNE: Negative. PSYCHIATRIC: Negative. SLEEP: Negative. PAIN: Negative. SOCIAL/FAMILY HISTORY: No change. CHEMO & RADIATION THERAPY HISTORY: She has had two cycles of AC. She will have four cycles of AC, Taxotere, radiation, and Arimidex. LABS: MUGA is 65%. ALLERGIES: No known allergies. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 116/76, pulse 80, respirations 16, temperature 98.2, weight 132.
AC|adriamycin cyclophosphamide|AC,|168|170||LABS: Pending from today. SOCIAL HISTORY/FAMILY HISTORY: No change. CHEMO & RADIATION THERAPY HISTORY: She has had three AC. Today, she is due for her fourth and final AC, and then she will get started on radiation, and go on Arimidex after that. ALLERGIES: No known allergies. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 130/80, pulse 83, respirations 18, temperature 98.5, weight 152.
AC|adriamycin cyclophosphamide|AC,|92|94||ASSESSMENT: The patient has no evidence of recurrent disease. PLAN: She will get her fourth AC, and then she will get radiation and Arimidex. I will see her in three months. If her cough does not get better, we will get pulmonary function tests within the next month, but this may be Cytoxan-related.
AC|(drug) AC|AC|113|114||5. Prednisone 40 mg p.o. x 5 days. 6. Levaquin 500 mg p.o. x 5 days. 7. Claritin 10 mg p.o. daily. 8. Robitussin AC 10 mL p.o. at bedtime p.r.n. cough, dispense 240 mL. 9. Piroxicam 20 mg p.o. daily. OPERATIONS/PROCEDURES PERFORMED: Patient had chest x-ray on date of admit that was read infiltration both mid-lungs, most marked on the right.
AC|adriamycin cyclophosphamide|AC.|204|206||She was diagnosed in _%#MM#%_ 2006; T1, M0, N0; 3 positive lymph nodes which were ER positive; PR and HER-2 negative. She is status post mastectomy. She is receiving adjuvant dose-dense chemotherapy with AC. She received her last dose on _%#MM#%_ _%#DD#%_, 2006. She did receive Neulasta support on _%#MM#%_ _%#DD#%_, 2006. Prior to her admission, she was experiencing a sore throat for 2 days.
AC|adriamycin cyclophosphamide|AC|228|229||1. The patient will have a followup appointment with Dr. _%#NAME#%_, her medical oncologist, on _%#MM#%_ _%#DD#%_, 2006, at 1 p.m. with a chemotherapy appointment to follow. The patient will receive another cycle of dose- dense AC pending her clinical exam with Dr. _%#NAME#%_. 2. The patient has been asked to call renal transplant in followup for management of her continued immunosuppression and coordinating with Dr. _%#NAME#%_ with her dose-dense chemotherapy.
AC|acromioclavicular|AC|116|117||DATE OF SURGERY: _%#MMDD2002#%_ SURGEON: Dr. _%#NAME#%_ PLANNED PROCEDURE: Left shoulder subacromial decompression, AC repair, and left shoulder manipulation. HISTORY: _%#NAME#%_ is a 27-year-old gentleman who has been having problems with his left shoulder for some years.
AC|before meals|AC.|125|127||1. Aspirin 81 mg PO q day to be held until after skin biopsy next week. 2. Calcitriol 0.25 mg PO q AM. 3. Phoslo 667 mg PO q AC. 4. Calcium with vitamin D 650 mg PO b.i.d. 5. Erythropoietin 10,000 units subcu q Monday and Thursday. 6. Metoprolol 25 mg PO b.i.d.
AC|(drug) AC|AC|157|158||2. OsCal with vitamin D 500 mg p.o. t.i.d. (new medication). 3. Synthroid 0.125 mg p.o. q.d. 4. Zantac 150 mg p.o. b.i.d. (patient can substitute for Pepcid AC as she prefers). 5. Zocor 20 mg p.o. q.d. (new medication). FOLLOW UP: The patient will follow-up 1 day after admission with previously scheduled primary care physician, Dr. _%#NAME#%_.
AC|(drug) AC|AC|151|152||He eats fast food frequently. DETAILED REVIEW OF SYSTEMS: Reveals the patient has chronic heartburn about five times per week for which he uses Pepcid AC regularly, but continues to have waking from sleep due to this. He has the left shoulder pain which radiates towards his neck, but otherwise no musculoskeletal pain.
AC|adriamycin cyclophosphamide|AC.|148|150||The patient underwent a modified mastectomy, with 2 of 35 nodes positive, ER - PR positive, her two new positive; followed by Taxol/Herceptin, then AC. The course was completed in _%#MM#%_ 2000. The patient also underwent an oophorectomy _%#MM#%_ 2000. She is presently on tamoxifen. The patient now presents with ongoing neck and shoulder pain, with spasms since _%#MM#%_ 2002.
AC|(drug) AC|AC|321|322||DERMATOLOGIC: Without rash. LABORATORY DATA: WBC 15.4, hemoglobin 9.6, platelets 255,000, sodium 134, potassium 3.5, bicarbonate 28, BUN and creatinine 19 and 1.1. Glucose 100. ASSESSMENT: The patient is a 78-year-old woman with diabetes mellitus admitted with pneumonia. 1. Pneumonia. Start IV levofloxacin, guaifenesin AC p.r.n. 2. Diabetes mellitus poorly controlled, we will increase Latus to 15 subcu q.a.m., increase Avandia to 2 mg twice daily.
AC|acromioclavicular|AC|152|153||I am able to abduct the patient's bilateral upper extremities fully without tenderness. No tenderness to full range of motion of the wrists, elbows. No AC joint tenderness. No bilateral knee joint tenderness. SKIN: Negative for rashes. NEUROLOGIC: Shows patient to be alert and oriented times three.
AC|(drug) AC|AC|179|180||She was hospitalized 3 or 4 times in the past in _%#CITY#%_ for this. ALLERGIES: Sulfa. CURRENT MEDICATIONS: 1. Paxil 20 mg per day. 2. Celebrex. 3. Medrol dosepak. 4. Robitussin AC which she has just used in the last 3 or 4 days. FAMILY HISTORY: Mother died of "uterine cancer" at age 29.
AC|(drug) AC|AC,|170|172||NEW MEDICATIONS: 1. For her to resume her Avelox which was originally given to her as an outpatient, 400 mg a day with the Avelox for 5 days. 2. Resumption of Robitussin AC, 5 cc p.o. q h.s. as needed. The patient was told to hold her Metformin until follow up with her primary care provider in one week.
AC|(drug) AC|AC|168|169||8. Colace 2 tablets b.i.d. 9. Levaquin 250 mg daily for 7 days. 10. Ferrous gluconate 324 mg 1 tablet daily. 11. Multivitamins with iron 1 tablet daily. 12. Robitussin AC 10 mL q.6h. p.r.n. 13. Warfarin as at home. 14. Advair 500/50 mg 1 inhalation b.i.d. Rinse mouth after use. 15. Albuterol neb or inhaler 4x a day and q.4h. p.r.n. She will resume home care services and will have physical therapy for her neck pain.
AC|(drug) AC|AC|125|126||2. Prednisone taper 40 mg x4 days, 30 mg x4 days, 20 mg x4 days, 10 mg x4 days, 10 mg every other day x4 days. 3. Robitussin AC 2 tsp p.o. q. 6 hours p.r.n. 4. Lasix 20 mg p.o. q. day. 5. Albuterol 2 nebs q. 4-6 hours p.r.n. 6. Advair 250/50 1 inhalation b.i.d.
AC|acetate|AC|165|166||5. Singulair 10 mg inhaler q. day. 6. Kadian 60 mg p.o. b.i.d. 7. Protonix 40 mg p.o. q. day. 8. Phenylephrine hydrochloride 1 drop right eye b.i.d. 9. Prednisolone AC 1% one drop right eye b.i.d. 10. Azmacort 2 puffs inhaler b.i.d. 11. Lasix 20 mg p.o. b.i.d. for 4 days. 12. Potassium chloride 20 mEq p.o. b.i.d. x4 days.
AC|(drug) AC|AC|191|192||DISCHARGE MEDICATIONS: 1. Diovan 80 mg p.o. b.i.d. 2. Toprol XL 75 mg p.o. b.i.d. 3. Lasix 40 mg p.o. daily. 4. Senokot one p.o. daily. 5. Ambien 5 mg p.o. q h.s. for insomnia. 6. Robitussin AC 5-10 ml q six hours p.r.n. cough. DISPOSITION: Fairview Southdale Hospital for catheterization by Minnesota Heart.
AC|(drug) AC|AC.|112|114||He denies use of other chemicals except marijuana. PAST MEDICAL HISTORY: None. ADMISSION MEDICATIONS: 1. Pepcid AC. 2. Zantac. SOCIAL HISTORY: His drug of choice is alcohol and states he has used marijuana in the past.
AC|(drug) AC|AC|172|173||2. Prednisone taper 20 mg tab one q.d. times three days and then one-half q.d. times four days. 3. Albuterol MDI two puffs q.i.d. 4. Diltiazem CD 180 mg q.d. 5. Robitussin AC 10 cc q4h prn. Discharge follow-up will be with his PMD, Dr. _%#NAME#%_ in one to two weeks. He is urged again to be compliant with his medications and he seems to appreciate the importance of this.
AC|(drug) AC|AC.|158|160||The patient is localized on the left side of his chest. He rates the pain 6-7 out of 10. Initially, the patient thought that it was dyspepsia and took Pepcid AC. Pepcid AC did not help with pain relief. Therefore, his wife, who is a nurse, took the patient to the hospital. By the time he got to the emergency room, the pain gradually resolved.
AC|(drug) AC|AC|114|115||6. Vitamin E 400 International Units PO Q day 7. Coumadin 2.5 mg PO Q day 8. Avalox 400 mg PO Q day 9. Robitussin AC one teaspoon PO Q 6 hours prn. 10. Soma 350 mg PO t.i.d. prn. The patient is instructed to call _%#TEL#%_ for a follow up visit with Dr. _%#NAME#%_ _%#NAME#%_, his primary care MD within 7-10 days.
AC|(drug) AC|AC|252|253||It was felt on _%#MM#%_ 8, that she was ready and stable enough to be transferred there. DISCHARGE PLANS: Discharged and transferred to Southview TCU. DISCHARGE MEDICATIONS: Tequin 400 mg p.o. q day for seven more days, Lasix 400 mg b.i.d., Robitussin AC 10 ml every 4-6 hours p.r.n., Tessalon Perles 200 mg t.i.d. p.r.n., potassium chloride 20 meq p.o. b.i.d., albuterol nebs q 2-4 hours p.r.n. She was to be on four liters of oxygen to keep her in the low 90's.
AC|acromioclavicular|AC|160|161||The previous acromioplasty is noted and there is good decompression there. The rotator cuff is intact. The only remaining abnormality on the MRI relates to the AC joint arthrosis. There is some fluid in the subacromial bursa and edema in the muscle bellies. The patient has seen a number of physicians. Most recently she has been consulting Dr. _%#NAME#%_ who had asked me to see her for further consultation at this time.
AC|(drug) AC|AC|184|185||I would like to start him on prednisone 50 mg p.o. daily times five days and on albuterol MDI to help with the cough and occasional wheezing. Also, given a prescription for Robitussin AC 10 ml p.o. q.4-6h. p.r.n. to help suppress cough. Take it easy over the week and call return with any problems. 3. Follow up with Dr. _%#NAME#%_ by call or clinic visit next week.
AC|(drug) AC|AC|172|173||DISCHARGE MEDICATIONS: 1. Lisinopril 20 mg daily. 2. Digoxin 125 mcg daily. 3. Multivitamin 1 tablet daily. 4. Warfarn 5 mg daily. 5. Metoprolol 25 mg b.i.d. 6. Robitussin AC 10 ml p.o. q4-6h p.r.n. 7. Lyrica 12.5 mg q.h.s. 8. Furosemide 60 mg b.i.d. 9. Oxycodone 5 mg t.i.d. 10. Oxycodone 5 mg, 1-2 tablets q4-6h p.r.n.
AC|(drug) AC|AC|135|136||9. Amitriptyline 50 mg p.o. daily. 10. Calcium acetate 2 tabs p.o. b.i.d. 11. Percocet 1-2 tabs p.o. q.6h. p.r.n. pain. 12. Robitussin AC 5-10 mL p.o. q.6h. p.r.n. cough. 13. Prednisone taper: 60 mg p.o. daily x2 days, then 40 mg p.o. daily x4 days, then 20 mg p.o. daily x4 days, then 10 mg p.o. daily x4 days, then 5 mg p.o. daily x4 days, then discontinued.
AC|acromioclavicular|AC|78|79||ADMITTING DIAGNOSIS: Left distal clavicle nonunion. PROCEDURE PERFORMED: Left AC joint reconstruction with allograft. HOSPITAL COURSE: _%#NAME#%_ was admitted to the inpatient ward on 8A following an uneventful surgery.
AC|before meals|AC|153|154||It is asked that the patient follow up with her primary care physician within one to two weeks' time. DISCHARGE MEDICATIONS: 1. Lactinex one tablet p.o. AC for seven days. 2. Artificial tears 2 drops both eyes p.r.n. 3. Xalatan one drop right eye q. day. 4. Claritin 10 mg p.o. q. day. 5. Multivitamin one tablet p.o. daily.
AC|acromioclavicular|AC|142|143||HOSPITAL COURSE: The patient was taken to the operating room on _%#MMDD2003#%_, at which time he underwent open right shoulder acromioplasty, AC joint resection, and rotator cuff repair. At surgery, he had a large tear of the supraspinatus, with involvement of the infraspinatus.
AC|acromioclavicular|AC|159|160||She had also previously been seen for rotator cuff repair on the left side. She was a smoker. She was seen in the emergency room with radiographs showing mild AC joint degenerative changes. She was discharged with Percocet and follow up with her primary care physician. She has the social situation of reporting that she is here for a funeral.
AC|before meals|AC|195|196||6. Potassium chloride in 20 mEq. packets, 11 packs a day and this varies depending upon her potassium level. 7. Humulin N. 60 units in the a.m. and 16-20 units in the p.m. 8. Humalog at 20 units AC t.i.d. 9. Aspirin 81 mg QD. 10. Spironolactone 25 mg two tablets q.i.d. 11. Calcium D. 600 plus 200 mg Vitamin D. one tablet daily
AC|adriamycin cyclophosphamide|AC|158|159||ASSESSMENT AND PLAN: The patient has a 1.2 cm infiltrating ductal grade 3/3 ER/PR and HER-2/neu negative with 0 of 3 lymph nodes positive, is a candidate for AC or CMF chemotherapy. We went through the pros and cons of each of the therapies. The patient has currently elected for AC in an accelerated fashion, every two weeks for four doses and then she will get set up for her radiation therapy.
AC|adriamycin cyclophosphamide|AC|155|156||HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her adenocarcinoma of the breast. The patient is due for her third cycle of AC chemotherapy. REVIEW OF SYSTEMS: GENERAL: Fatigue - she gets insomnia after chemotherapy.
AC|adriamycin cyclophosphamide|AC,|145|147||LABORATORY DATA: Pending from today FAMILY HISTORY/SOCIAL HISTORY: No change. CHEMOTHERAPY /RADIATION THERAPY HISTORY: She has had two cycles of AC, third today. ALLERGIES: Codeine, sulfa, Adderall, Band-Aids PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 118/60, pulse 92, respirations 18, temperature 97 , and weight 133.
AC|adriamycin cyclophosphamide|AC,|216|218||The radiologist saw some air bronchograms, and thinks that all of the nodules are associated with pneumonia, and the patient is gradually getting better. CHEMO & RADIATION THERAPY HISTORY: She has had four cycles of AC, four cycles of Taxotere. She has been on Arimidex. She has had radiation. ALLERGIES: Demerol. VITAL SIGNS: Currently, her vital signs show a blood pressure of 110/60, pulse 72, respirations 18, temperature 98.1, weight 144.
AC|(drug) AC|AC,|111|113||6. Alphagan P, one drop to the right eye t.i.d. 7. Os-Cal with vitamin D 625 mg, one p.o. b.i.d. 8. Robitussin AC, 5 ml of syrup p.o. q.h.s. p.r.n. cough. 9. Levsin 0.375 mg p.o. q.h.s. 10. Xalatan 0.005%, one drop to the right eye q.h.s.
AC|(drug) AC|AC.|247|249||There is a port-a-cath present. IMPRESSION: The patient is a 42-year-old woman with a history of breast cancer who presents with dyspnea, pleuritic chest pain and fever. PLAN: 1. Pneumonia: IV levofloxacin. Blood cultures are pending. Guiafenesin AC. 2. Dehydration: Start IV fluids. 3. Breast cancer: As noted above she finished chemotherapy _%#MM#%_ 2006 and radiation therapy in _%#MM#%_ of 2006.
AC|before meals|AC.|127|129||10. Peri-Colace two tabs p.o. bid prn. 11. Tylox 1-2 tabs p.o. q4-6h prn. 12. Insulin ....... 3 units subcu tid with meals and AC. 13. Insulin NPH 10 units subdue bid. The patient will resume an American Diabetic Association diet and will increase her activity gradually with no lifting more than 10 pounds for two weeks.
AC|acromioclavicular|AC|292|293||Cowpoke maneuver was not performed. During the exam the patient was able to sit-up with assistance, but her symptoms would recur with these movements and then slowly resolve. X-rays of the right humerus were revealing for no fractures or soft tissue swellings. Right clavicle was normal. The AC joint was intact. CT of the head without contrast revealed no masses.
AC|before meals|AC|163|164||He is neurologically stable and ready for discharge. MEDICATIONS ON DISCHARGE: 1. Atenolol 50 mg po q day. 2. Catapres TTS 3. One patch per week 4. Glipizide 5 mg AC b.i.d. 5. Lisinopril 10 mg po q day 6. Percocet one to two tablets po q3h prn pain 7. Regular insulin sliding scale, subq q.i.d. with blood sugar checks as follows: blood sugar less than 70 no coverage but treat for hypoglycemia, blood sugar 70-180 no coverage, blood sugar 181-250 nine units of regular insulin, blood sugar 251-300 12 units, blood sugar 301-350 15 units, blood sugar 351-400 18 units and blood sugar greater than 400 21 units and please call medical physician.
AC|(drug) AC|AC|198|199||LOWER EXTREMITIES: Skin warm, dry, intact. DISCHARGE MEDICATIONS: Protonix 40 mg p.o. q. day, iron gluconate 325 mg p.o. t.i.d., Combivent 2 puffs q.i.d., Flovent 110 mg, 2 puffs b.i.d.; Robitussin AC 10 cc q. 4 hours p.r.n., aspirin on hold x 7 days, labetolol continue, lisinopril on hold. I suggest gemfibrozil continued, azithromycin 250 mg p.o. q. day x 4 days.
AC|assist control|AC,|216|218||The patient will need tracheostomy care, tube feedings, and TLC home care for chaplain and social worker. The patient will have Isosource tube feeds at 70 cc per hour. The patient's LP10 settings will have a mode of AC, respiratory rate 14 per minute, tidal volume 450, PEEP of 5, and FIO2 of 30%. DISCHARGE MEDICATIONS: 1. Decadron 8 mg through G-tube q.day.
AC|(drug) AC|AC.|232|234||She has had an upper GI which shows moderate to large size hiatal hernia, and a pH study which is positive, with manometry which shows essentially normal esophageal body function. ALLERGIES: 1. Vioxx. 2. Bextra. 3. Sulfa. 4. Pepcid AC. 5. Amoxicillin. 6. Halcion. 7. Butalbital. 8. Sulindac. 9. Depakote. ADMISSION MEDICATIONS: 1. Albuterol nebulizer 3 cc q.6h p.r.n.
AC|before meals|AC|285|286||14. Mycelex Troche 1 p.o. q.i.d. 15. Combivent inhaler 4 puffs q.i.d. 16. Novalog insulin sliding scale: Blood Sugar Dose 120-150 Give 1 unit 151 - 200 Give 2 units 201 - 250 Give 4 units 251-300 Give 6 units 301-350 Give 8 units 351-400 Give 10 units ( 401 Give 12 units and cover at AC and HS. 17. Depakote 2 g p.o. q.h.s. for bipolar disorder.
AC|(drug) AC|AC.|242|244||SECONDARY DIAGNOSES: 1. Hypertension. 2. Hypothyroidism. _%#NAME#%_ _%#NAME#%_ is an 86-year-old female who lives at home with her son, was initially treated at my office for respiratory infection. She was prescribed Zithromax and Robitussin AC. Two or three days down the line the patient came back to my office. She was worse. She had generalized aching, fever, increasing cough and also had developed diarrhea.
AC|adriamycin cyclophosphamide|AC|189|190||IMMUNE: Negative. PSYCHIATRIC: Negative. SLEEP: Negative. PAIN: Negative. LABS: Her MUGA was 71%. Labs are normal. SOCIAL/FAMILY HISTORY: No change. CHEMO HISTORY: She is due for her third AC today. ALLERGIES: Sulfa, Ceclor, erythromycin, Percocet, Compazine. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 116/67, pulse 73, respirations 16, temperature 96.5, weight 141, height 5 feet 6 inches.
AC|(drug) AC|AC|110|111||2. Aspirin 325 mg daily. 3. Celexa 10 mg daily. 4. Prednisone 5 mg daily. 5. Lipitor 10 mg daily. 6. Mytussin AC 10 ml p.r.n. 7. Nystatin powder to groin p.r.n. 8. Nizoral cream applied to groin p.r.n. 9. Multivitamin. ALLERGIES: There are no known drug allergies.
AC|acromioclavicular|AC|284|285||PRIMARY CARE PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_ CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 57 year male who has had on and off chest pains now for about a week, he developed first of all about a week ago and was centered more near the right AC joint area but a dull sort of pain of mild to moderate severity which did not radiate much but did not seem to vary with movement or palpation of that area.
AC|(drug) AC|AC|123|124||2. Advair 500/50 one puff b.i.d. 3. Albuterol inhaler one to two puffs q2-4h p.r.n. 4. Claritin 10 mg p.r.n. 5. Robitussin AC one teaspoon q4h p.r.n. 6. Lantus 23 units at bedtime. 7. Novalog with five units at breakfast, ten at lunch and ten at dinner.
AC|(drug) AC|AC|173|174||5. Nicotine patch 21 mcg #14. Also given a prescription for 14 mcg #14 and 7 mcg #14 with 2 refills of each. 6. Omnicef 300 mg p.o. q.12h. #20 with no refills 7. Robitussin AC 1-2 teaspoons q.i.d. p.r.n. 8 ounces with 1 refill 8. Also resume home medications: Estrogen p.o. q. day 9. Bel-Phen-Ergot 1 p.o. q.a.m.
AC|before meals|AC|112|113||Zantac 150 mg b.i.d. Neurontin 300 mg. Levaquin 500 mg q.i.d. for 10 days. Tylenol 650 mg. Colace 100 mg b.i.d. AC 325 mg. Celexa 20 mg. Vioxx 25 mg. Synthroid 0.1 mg. Vitamin E 400 mg. SOCIAL HISTORY: The patient lives in a nursing home, and she really cannot provide a family history.
AC|(drug) AC|AC|166|167||2. Multivitamin 1 p.o. q.d. 3. Gemfibrozil 600 mg p.o. q.d. (he was not aware that he was supposed to be taking this twice). 4. Pravachol 40 mg p.o. q.h.s. 5. Pepcid AC 10 mg p.o. b.i.d. 6. NPH insulin 27 units SQ q.a.m., 17 units SQ q.p.m. 7. Regular insulin 15 units SQ q.a.m., 9 units SQ q.p.m.
AC|adriamycin cyclophosphamide|AC.|168|170||EXTREMITIES: She still has a cord in her right arm. NEUROLOGIC: Cranial nerves II-XII are intact. ASSESSMENT & PLAN: No evidence of recurrent breast cancer. Tolerating AC. That will be followed by tamoxifen. The patient will need to see the lymphedema therapist and get some exercises for stretching.
AC|adriamycin cyclophosphamide|AC|195|196||EXTREMITIES: The patient has full range of motion. There is no lymphedema. NEUROLOGIC: Cranial nerves II-XII are intact. ASSESSMENT AND PLAN: The patient is undergoing chemotherapy. We will hold AC for a week. I put her on Ventolin and Keflex. Decrease her dose by 25%. I will see her in a week if she is stable.
AC|adriamycin cyclophosphamide|AC|186|187||EXTREMITIES: The patient has full range of motion. There is no lymphedema. NEUROLOGIC: Cranial nerves II-XII are intact. ASSESSMENT AND PLAN: I have recommended that the patient undergo AC chemotherapy. She is thinking about whether she wants prophylactic mastectomies with reconstruction or just to go with a lumpectomy and radiation. Plan will be to start chemotherapy next week and she can address her decisions regarding the future of her breasts after that.
AC|adriamycin cyclophosphamide|AC,|166|168||LABS: Labs were normal. The patient had a repeat CT of the chest that showed the nodule to be stable. SOCIAL/FAMILY HISTORY: No change. CHEMO HISTORY: Four cycles of AC, four cycles of Taxotere. She was on tamoxifen for a little over two years. ALLERGIES: To food only. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 122/72, pulse 84, respirations 16, temperature 96.8, weight 159.
AC|(drug) AC|AC|146|147||DISCHARGE MEDICATIONS: 1. Zithromax 250 mg one daily for one day only. 2. Lasix 40 mg one p.o. in the morning and 20 mg at bedtime. 3. Robitussin AC 5 to 10 ml p.o. q 6h p.r.n. for cough. 4. Synthroid 100 mcg one daily. 5. Lopressor 50 mg one p.o. b.i.d.
AC|(drug) AC|AC.|168|170||A sister died of pancreatic cancer. MEDICATIONS 1. Hydrochlorothiazide 25 mg daily. 2. Citalopram 20 mg daily. 3. Atenolol 25 mg daily. 4. Aspirin one daily. 5. Pepcid AC. 6. Vitamins. REVIEW OF SYSTEMS: As above, all other systems negative.
AC|acromioclavicular|AC|184|185||He also underwent MRI of his left shoulder, which showed a partial-thickness tear along the articular surface of the distal supraspinatus tendon as well as degenerative changes to his AC joint. His hemoglobin remained stable in the hospital (he does have a history of chronic anemia requiring Procrit. He did respond well to physical therapy. He was subsequently discharged to _%#CITY#%_ Health Care Center for additional therapy.
AC|(drug) AC|AC|126|127||11. Left hip surgery. 12. Falls in the past, multiple. MEDICATIONS: 1. Tylenol 500 mg every 6 hours as needed. 2. Cheratussin AC 5 mL 4 times a day as needed. 3. Vicodin 1 tab every 6 hours as needed. 4. Imodium 2 mg as needed. 5. Prilosec 20 mg daily.
AC|before meals|AC.|137|139||2. Some type of lung procedure at age 3. ALLERGIES: None known. MEDICATIONS: (At nursing home). 1. Carafate oral suspension 10 gm t.i.d. AC. 2. Folic acid 1 mg daily. 3. Lisinopril 20 mg daily. 4. Multivitamin q. daily. 5. Neurontin 100 mg t.i.d.
AC|(drug) AC|AC|176|177||DISCHARGE MEDICATIONS: P.r.n. : 1. Nitroglycerin p.r.n. 0.4 mg 2. Trazodone 25 to 50 mg as needed for sleep 3. Azmacort 3 puffs as needed for shortness of breath 4. Robitussin AC 5 cc every 8 hours as needed for cough 5. Glucagon emergency kit for hypoglycemia 6. Zaroxolyn 10 mg 7. Extra potassium for weight gain Routine medications: 8. Torsemide 80 mg 2 times per day
AC|acromioclavicular|AC|384|385||He is exquisitely tender over the AC joint. LABORATORY DATA: CBC was within normal limits and hemoglobin is 14.7. The patient has had an MRI dated _%#MMDD2003#%_ showing full-thickness tearing of supraspinatus tendon and tearing of the posterior/superior aspect of the glenoid labrum. Also mild arthrosis of the AC joint. ASSESSMENT: Left shoulder rotator cuff tear, labral tear, and AC arthrosis. PLAN: No contraindication to planned procedure. This has also been reviewed by the supervising physician and signed as well; that has been faxed.
AC|(drug) AC|AC|120|121||15. Combivent metered dose inhaler two puffs q.i.d. 16. Fioricet two tablets Q 6 hours prn. for migraine 17. Robitussin AC two teaspoons Q 4 hours prn. for cough 18. Compazine 10 mg PO Q 6 hours prn. for nausea. 19. Ibuprofen 600 mg QHS prn. for osteoarthritis pain.
AC|(drug) AC|AC|116|117||DISCHARGE MEDICATIONS: 1. Ceftin 250 mg p.o. bid for 7 days 2. Zithromax 500 mg p.o. daily for 7 days 3. Robitussin AC 2 tsp po every 4 to 6 hours prn cough 4. Calcium Carbonate 1250 mg p.o. 3 times a day DISCHARGE FOLLOW UP: The patient is to follow up with Dr. _%#NAME#%_ as needed.
AC|(drug) AC|AC|138|139||Patient was discharged on _%#MM#%_ _%#DD#%_, 2005. DISCHARGE MEDICATIONS: 1. Tylenol 650 mg 2 p.r.n. 2. Duonebs q4h. p.r.n. 3. Robitussin AC 1 tsp. q.4h. p.r.n. 4. Levaquin 500 mg daily for 10 days. 5. Metamucil 1T. daily. 6. Mevacor 20 mg daily with 40 mg q.p.m.
AC|adriamycin cyclophosphamide|AC,|190|192||No dizziness, headache or weakness. IMMUNE: Negative. PSYCHIATRIC: Negative. SLEEP: She is sleeping okay. LABS: Labs today. SOCIAL/FAMILY HISTORY: No change. CHEMO HISTORY: She has had four AC, and this will be her second Taxol. ALLERGIES: No known allergies. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 116/65, pulse 102, respirations 16, temperature 95.8, weight 177.
AC|acromioclavicular|AC|345|346||HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is an 83-year- old white male with a history of elevated cholesterol, hypertension, frequent PVCs, status post right rotator cuff repair on _%#MM#%_ 1 by Dr. _%#NAME#%_ (specifically the patient had right shoulder arthroscopy with arthroscopic subacromial decompression, arthroscopic AC joint excision and right shoulder arthroscopically-assisted mini-arthrotomy rotator cuff repair) and remote history of cigarette use who is followed by Dr. _%#NAME#%_ _%#NAME#%_. The patient has also been seen in Cardiology for several months for shortness of breath.
AC|adriamycin cyclophosphamide|AC.|135|137||SLEEP: Negative. LABS: Pending from today. SOCIAL/FAMILY HISTORY: No change. CHEMO & RADIATION THERAPY HISTORY: She had four cycles of AC. She has been on progesterone liquid and Arimidex, started _%#MM#%_ 2004. She had tamoxifen briefly, but discontinued it because it exacerbated her seizures.
AC|(drug) AC|AC|162|163||He is scheduled to have pinning of this region. ALLERGY: He is allergic to Biaxin. CURRENT MEDICATIONS: 1. Calan SR 240 mg daily. 2. Altace 5 mg daily. 3. Pepcid AC p.r.n. PAST MEDICAL HISTORY: 1. Whooping cough about 5 years ago.
AC|(drug) AC|AC|148|149||2. Tessalon Perles. 3. Colace. 4. Senna. 5. Aspirin 81 mg p.o. daily. 6. Zocor 20 mg p.o. at bedtime. 7. Diltiazem 120 mg p.o. daily. 8. Robitussin AC 1-2 teaspoons q. 4-6h. p.r.n. for cough. SOCIAL HISTORY: The patient lives alone and is retired.
AC|acromioclavicular|AC|284|285||Dr. _%#NAME#%_ from psychiatry came by to see her over in Fairview University Transitional Services, but she refused and had him come back at a later date which has not happened as of yet. PROCEDURES: ORIF of the right ankle, she had an x-ray of the right shoulder, which showed some AC degeneration, which was otherwise unremarkable. REHAB COURSE: Please see Dr. _%#NAME#%_'s consultation note for the hospital admission.
AC|adriamycin cyclophosphamide|(AC|172|174||Her hospital course was also significant for placement of a Tenckhoff catheter to facilitate drainage at home by a home nurse for her ascites. She received carboplatin and (AC = 4) and Taxol at 125 mg per meter squared prior to discharge. She received Neulasta injection at MOHPA prior to discharge as well.
AC|(drug) AC|AC|148|149||8. Coumadin 2.5 mg p.o. Wednesday and Friday. 9. Trazodone 50 mg each day at bedtime. 10. Prednisone 20 mg p.o. q. daily for 4 days. 11. Robitussin AC 10 mL p.o. q. day. 12. Robitussin AC 10 mL p.o. q. p.r.n. 13. Advair Diskus 100 mcg/50 two puff q. daily.
AC|acetate|AC|130|131||3. Lotrel _%#MMDD#%_ p.o. daily. 4. Atenolol 50 mg p.o. daily. 5. Baby aspirin 81 mg p.o. daily. 6. Metamucil daily. 7. Megestrol AC 40 mg 2 teaspoons p.o. daily. 8. B12 liquid, unknown dose. 9. Folic acid 1 mg p.o. daily. 10. Caltrate plus D, 500 mg p.o. daily. 11. Iron supplement 1 p.o. daily.
AC|adriamycin cyclophosphamide|AC|183|184||NEUROLOGIC: Cranial nerves II-XII are intact. ASSESSMENT AND PLAN: The patient with a stage II-B infiltrating ductal carcinoma of the breast. She is a candidate for chemotherapy with AC if her ejection fraction is normal. She is at high risk for recurrence but she is also 72 years old with fairly significant lung and heart disease and may elect to have no therapy but alternative therapy.
AC|adriamycin cyclophosphamide|AC|183|184||EXTREMITIES: The patient has full range of motion. There is no lymphedema. NEUROLOGIC: Cranial nerves II-XII are intact. ASSESSMENT AND PLAN: The patient is status-post six cycles of AC and Taxol. Last radiation therapy was in 1998, bilateral chest wall over implants have not given her any problem. The plan will be to see her again in four months when she is due for labs and x-rays.
AC|(drug) AC|AC|76|77||1. Dapsone 150 mg p.o. daily. 2. Prednisone 10 mg p.o. daily. 3. Robitussin AC 1-2 tsp p.o. q.4h p.r.n. cough. 4. Ultram 50 mg p.o. q.6-8 hours p.r.n. pain. 5. Imodium 2 mg p.o. after each loose stool, maximum 16 mg/24 hours.
AC|(drug) AC|AC|157|158||Also Refresh ointment, a small strip to be placed in both eyes at bedtime. 13. For macular degeneration, Ocuvite 1 tab p.o. b.i.d. 14. For cough, Robitussin AC 10 cc p.o. q 4 hours as needed. 15. For pain, Tylenol #3, 1 every 6 hours as needed. LABORATORY DATA: A chest x-ray showed no pneumonia, no pneumothorax, normal size heart, lungs were clear.
AC|(drug) AC|AC|147|148||7. Tear drops 1 drop in both eyes 3 times daily. 8. Baza cream to peri area as needed. 9. Loperamide 2 mg every 4 hours as needed. 10. Cheratussin AC 5-10 mL every 4 hours as needed. 11. Ranitidine 150 mg twice daily as needed. 12. Tylenol 325 mg every 4 hours as needed.
AC|before meals|AC.|172|174||4. Lisinopril 20 mg daily. 5. _______________herbal supplement 1 t.i.d. 6. Cranberry supplement 1 t.i.d. 7. Multivitamin 1 daily. 8. Protonix 40 mg b.i.d. 9. Carafate 1 gm AC. 10. Trazodone 50 mg q h.s. 11. Levaquin 250 mg daily x 5 more days. 12. Caltrate 600 mg 1 p.o. b.i.d.
AC|(drug) AC|AC|178|179||5. Vitamin K 5 mg daily. 6. Vitamin E 400 international units daily. 7. Multivitamin daily. 8. Lactinex 4 tabs three times a day with meals. 9. Humalog sliding scale. 10. Benzac AC Wash to affected areas daily. 11. Differin cream to affected areas on face nightly. 12. Cetaphil cleanser to face twice daily. 13. NPH Insulin 30 units subcu q.p.m.
AC|(drug) AC|AC|150|151||9. Prednisone 2.5 daily. 10. Repaglinide 1 mg t.i.d. 11. Tacrolimus 1 mg b.i.d. 12. Acetaminophen 325-650 mg PO q.6h. p.r.n. pain/fever. 13. Guiatuss AC 15 mL PO daily p.r.n. 14. Oxycodone 5 mg q.4h. p.r.n. pain. 15. Albuterol with Mucomyst nebs 1 nebulizer inhaled q.4-6h. p.r.n. shortness of breath.
AC|adriamycin cyclophosphamide|AC|131|132||SLEEP: Negative. LABS: Normal. SOCIAL/FAMILY HISTORY: No change. CHEMO & RADIATION THERAPY HISTORY: The patient had four cycles of AC and four cycles of Taxol in 2002. She had radiation after chemo. ALLERGIES: IV contrast. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 110/72, pulse 72, respirations 16, temperature 98.0, weight 163.
AC|adriamycin cyclophosphamide|AC|172|173||She also has a pelvic abnormality on PET scan that is negative on CT scan, that we are monitoring closely. At any rate, the patient has been started on adjuvant dose dense AC followed by Taxol chemotherapy. Her first dose of chemotherapy was quite complicated by severe intractable nausea and vomiting immediately post chemotherapy.
AC|(drug) AC|AC|166|167||12. Propranolol 80 mg p.o. q. day. 13. Zanaflex 2 mg p.o. q.i.d. 14. Topamax 25 mg p.o. b.i.d. 15. Trospium 20 mg b.i.d. 16. Calcium carbonate q. day. 17. Robitussin AC 5 mg q.4h. p.r.n. for cough. FOLLOW-UP: The patient should follow up with her primary physician in 1-2 weeks.
AC|(drug) AC|AC|148|149||2. Celexa 40 mg q.a.m. 3. Klonopin 0.5 mg q.a.m. and 1.5 mg each day at bedtime. 4. Colace 200 mg b.i.d. 5. Estratest 1 tablet daily. 6. Robitussin AC q. 4 hours p.r.n. cough. 7. Lamictal 300 mg each day at bedtime. 8. Multivitamin 1 tablet daily. 9. Nicotine patch 14 mg per 24 hour apply 2 patches q. 24 hours.
AC|assist control|AC|176|177||A spiral CT was negative. Dopplers were negative. He was slowly weaned off his nitrous oxide and discontinued on _%#MM#%_ _%#DD#%_, 2001. He was then supported and weaned from AC to SIMV to pressure support and extubated on _%#MM#%_ _%#DD#%_, 2001. He also had a chest tube placed at Mercy after open lung biopsy and after discontinuation the patient developed a pneumothorax four days later.
AC|(drug) AC|AC|199|200||2. We will continue to hydrate, although we will decrease IV fluids as he is urinating quite frequently to 15 cc a hour. 3. Anxiety: Will continue Librium as needed. 4. Cough: We will add Robitussin AC to be taken mostly at night for his sleep. 5. The patient does complain of some constipation, so we will make Milk of Magnesia, Fleet's enemas, and Colace available if needed.
AC|acromioclavicular|AC|188|189||NEUROLOGIC: Power is 5/5 throughout, cranial nerves are normal, sensation is normal. MOOD: No anxiety or depression. MUSCULOSKELETAL: He does have some tenderness to palpation of the left AC joint. Otherwise, palpation of the chest wall does not cause any tenderness. LABORATORY AND X-RAYS: Reviewed all of his lab work. His electrolytes look fine.
AC|acromioclavicular|AC|162|163||3. GERD. He was kept on his PPI. 4. Asthma; he was kept on the same regimen. He was not wheezing during his stay. 5 AC joint arthritis. He was bit tender in both AC joints. This may contribute to why he is having chest pain; he will use Tylenol as needed. 35 minutes spent in discharge planning time today.
AC|adriamycin cyclophosphamide|AC,|139|141||LABS: Labs and mammogram were normal. SOCIAL/FAMILY HISTORY: No change. CHEMO HISTORY: She is on her 93rd Herceptin today. She has been on AC, Taxol, Navelbine currently. ALLERGIES: Benadryl. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 124/80, pulse 80, respirations 18, temperature 97.3, weight 183, height 5 feet 5 inches.
AC|acromioclavicular|AC|277|278||Originally had an MRI _%#MMDD2000#%_ that had revealed a partial supraspinatus tear. Surgery at that time had been deferred. Following recent activity installing a floor, he had increasing symptoms of pain, and repeat MRI of _%#MMDD2005#%_ revealed degenerative changes of the AC joint that had progressed since _%#MM2000#%_, and a shallow partial thickness tear along the bursal surface of the anterior distal supraspinatus tendon with additional surrounding tendinosis and tendonopathy.
AC|(drug) AC|AC|182|183||12. Multivitamin one tablet p.o. q. day. 13. Iron tablets one tablet p.o. q. day. 14. Insulin 10 Units subcutaneous b.i.d. or on a p.r.n. basis based on blood sugars. 15. Robitussin AC 1-2 teaspoons p.o. b.i.d. p.r.n. 16. Prednisone 40 mg p.o. q. day on a six-day taper. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 120/70 with a pulse of 70, respiratory rate 18.
AC|(drug) AC|AC|118|119||6. Aspirin 325 mg p.o. daily. 7. Senna two tablet p.o. each at bedtime. 8. Persantine 75 mg p.o. b.i.d. 9. Robitussin AC 5 ml p.o. q. 4 hours p.r.n. FAMILY HISTORY: Mother died of coronary artery disease.
AC|assist control|AC|185|186||REVIEW OF SYSTEMS: Unable to obtain. PHYSICAL EXAMINATION: Afebrile, blood pressure 120s/70s, heart rate 70s to 80s. Respirations 20-22, 95-98% saturation on vent support. Vent setting AC mode, TV 700, rate 12, PEEP 5 and FI02 50%. GENERAL: The patient is intubated and sedated in no apparent distress.
AC|(drug) AC|AC|126|127||ALLERGIES: No known drug allergies. MEDICATIONS: 1. Glipizide XL 7.5 mg p.o. q.a.m. 2. Neurontin 300 mg p.o. t.i.d. 3. Pepcid AC 10 mg p.o. b.i.d. 4. Epivir 150 mg p.o. daily. 5. Ambien CR 12.5 mg p.o. daily at bedtime 6. Tylenol PM 1-2 tabs p.o. daily at bedtime p.r.n. for insomnia.
AC|(drug) AC|AC.|374|376||HISTORY OF PRESENT ILLNESS: This is a 26-year-old female who has been obese since the age of 14 and has tried numerous dietary attempts at weight reduction without success including Weight Watchers, exercise, low carb and no carb diet, and fruit diet. In addition, she has also tried Metabolite and Dexatrim without success. Obesity includes GERD for which she takes Pepcid AC. PAST MEDICAL HISTORY: Medical: Chickenpox. Surgery: None. ALLERGY: NKDA. PHYSICAL EXAMINATION: Temperature 98.1, pulse 68, blood pressure 127/68, weight 213 pounds.
AC|acromioclavicular|AC|142|143||PAST MEDICAL HISTORY: Includes a history of nephrectomy as a donation of kidney to a friend. He had a lumbar disc surgery. He has had a right AC separation of his shoulder. He has hypertension, gout and GERD and hypercholesterolemia. The patient was detoxed with Ativan and did well.
AC|(drug) AC|AC|235|236||At that time, she had reported a 3 to 4 day history of high fevers to 102, severe body aches and some shortness of breath. Her CBC at that time was completely normal. She was discharged home with ibuprofen 800 mg t.i.d. and Robitussin AC to be used for her cough. She was in clinic subsequently on _%#MMDD2007#%_ with persistent fever to 102. She looked fatigued and had bodyaches and had some increasing shortness of breath.
AC|acromioclavicular|AC|205|206||4. Prevacid 30 mg daily 5. Lexapro 10 mg daily 6. Lisinopril 10 mg daily 7. Levothyroxine I do not have a dose HISTORY OF PRESENT ILLNESS: Gary Asti is a man with a previous surgical correction of both an AC joint abnormality with arthrosis as well as an ulnar nerve entrapment in the left elbow. These were corrected by Dr. _%#NAME#%_ in _%#MM#%_ 2005. The patient returns now with elbow symptoms where the elbow seems to lock on him with full extension.
AC|before meals|AC|128|129||6. Will maintain the patient on her current insulin and diabetic treatment. 7. Will try a trial of low dose Ativan 0.25 mg p.o. AC p.r.n. nausea and vomiting. I am hopeful that this may help with not only the nausea, in that benzodiazepines could also be effective in his nausea but may also help with what I perceive to be an anxiety component.
AC|(drug) AC|AC|154|155||4. Lasix 20 mg p.o. daily 5. Imdur 15 mg p.o. daily 6. Cozaar 50 mg p.o. daily 7. Aldactone 12.5 mg. p.o. daily 8. Aciphex 20 mg p.o. daily 9. Robitussin AC one teaspoon p.o. q 6 hours p.r.n.
AC|before meals|AC|119|120||5. aspirin 81 mg p.o. q. day. 6. Norvasc 5 mg p.o. q. day. 7. Synthroid 0.125 mg 1/2 p.o. q. 8. Reglan 5 mg 30 minutes AC p.r.n. 9. multivitamins 1 p.o. daily 10. Ritalin 10 mg q.i.d. 11. vitamin B12 1000 mcg IM every 3 weeks 12. Caltrate 600+ D b.i.d.
AC|(drug) AC|AC.|170|172||He denies a history of surgery or other chronic illnesses. MEDICATIONS ON ADMISSION: 1) Coumadin. 2) Effexor. 3) Multi-vitamin. 4) Vicodin. 5) Tylenol #3. 6) Cheratussin AC. ALLERGIES: The patient denies allergies to medications.
AC|(drug) AC|AC,|155|157||DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Gemfibrozil 600 mg p.o. b.i.d. 3. Glyburide 5 mg p.o. q.d. 4. Losartan 50 mg p.o. q.d. 5. Robitussin AC, 2 tsp. p.o. q. 4h. p.r.n. FOLLOW UP: The patient should follow up with her primary physician, Dr. _%#NAME#%_, in one to two weeks.
AC|adriamycin cyclophosphamide|AC|231|232||Ms. _%#NAME#%_ _%#NAME#%_ is a 42-year-old para 4-0-0-4 who was diagnosed with left breast cancer in 1998. This was a stage II, T2 N0 Mx infiltrating ductal carcinoma. She underwent lumpectomy followed by radiation and 4 cycles of AC chemotherapy. She was without evidence of recurrence until _%#MM2007#%_ when she was found to have a stage I, high grade invasive ductal carcinoma on the right.
AC|abdominal circumference|AC|261|262||The patient's prenatal care was done at Southdale Ob-Gyn with labs of O positive, and serology nonreactive. Concerns for size less than dates were noted in the third trimester and patient at 37 weeks was found to have an EFW of less than 10th percentile and an AC less than 2nd percentile. The patient underwent induction of labor secondary to IUGR. HOSPITAL COURSE: The patient was admitted on the morning of _%#MMDD2007#%_.
AC|(drug) AC|AC|134|135||2. Paxil 10 mg p.o. daily. 3. Allopurinol 300 mg daily. 4. Tenormin 50 mg p.o. daily. 5. Fenofibrate 160 mg p.o. daily. 6. Robitussin AC 10 ml p.o. q.4-6h p.r.n. 7. Lisinopril 20 mg p.o. daily. 8. Nitroglycerin sublingually as needed. 9. Prednisone 20 mg p.o. daily.
AC|(drug) AC|AC|306|307||Not having any significant dyspnea with ambulation. It was felt that based on this, as well as the fact that she felt significantly better since coming in that she could be treated further on an outpatient basis. DISCHARGE MEDICATIONS: 1. Levaquin 750 mg p.o. daily. Complete a 7 day course. 2. Robitussin AC as needed for cough. 3. Effexor 150 mg daily. 4. Ambien 5 mg as needed daily. 5. Lorazepam 0.5 mg daily. 6. Midrin as needed. 7. Gabapentin 300 mg t.i.d.
AC|(drug) AC|AC|200|201||We also performed a sputum culture. Will maximize his oxygenation with supplemental O2 and continued inhalers. He is on Spiriva and Advair at home. We can also give him Tessalon Perles and Robitussin AC for help with his cough. 2. Infectious Disease: Pneumonia, see above discussion. C diff colitis, his increasing diarrhea is very suspicious for C diff colitis recurrence.
AC|(drug) AC|AC|116|117||She has a history of a second-degree heart block, Mobitz type II, first noted in _%#MM#%_ 2000. MEDICATIONS: Pepcid AC p.r.n. Imitrex 50 mg p.r.n. for migraine headaches. She is on Cipro 500 b.i.d. for recent infection with her last dose having been last night.
AC|adriamycin cyclophosphamide|AC.|254|256||3. Nutritional deficits. 4. Neutropenia. HISTORY OF PRESENT ILLNESS: This is a 48-year-old female with left breast cancer diagnosed in _%#MM#%_ 1999. The patient received 1 cycle of AC Chemotherapy, followed by a lumpectomy, followed by 3 more cycles of AC. She then received 6480 GrayXRT between _%#MMDD#%_ and _%#MMDD1999#%_. Following the radiation therapy, the patient received 4 cycles of Taxol, then daily tamoxifen.
AC|(drug) AC|AC|191|192||Chest x-ray did not reveal any pathology. She wished to go home and I thought it was reasonable. She was afebrile. I placed her on Cipro 500 mg p.o. b.i.d. for seven days and also Robitussin AC for the cough. She will have her counts checked on Monday and will be seen by my nurse practitioner on Wednesday of next week.
AC|(drug) AC|AC.|242|244||3. Hyperlipidemia. 4. Barrett's esophagus. _%#NAME#%_ _%#NAME#%_ was admitted as a rule out MI. His enzymes were all negative. His ECG was unremarkable, and the patient was discharged to home on his usual medications plus Allegra and Robaxin AC.
AC|(drug) AC|AC|165|166||FAMILY HISTORY: Positive for ASHD. His father had MI in his 50s and died of an aneurysm at age 62. ALLERGIES: He has no drug allergies. MEDICATIONS: He takes Pepcid AC and Excedrin for headaches. REVIEW OF SYSTEMS: The chest pain is a new feature.
AC|before meals|AC|142|143||12. Tylenol on a p.r.n. basis 13. Aspirin 81 mg p.o. q. day. 14. Glyburide 5 mg p.o. b.i.d. 15 Lantus insulin 12 units subq q.h.s 16. Insulin AC and q.h.s. on a sliding scale, medium resistance.
AC|acromioclavicular|AC|142|143||She was seen by Orthopedics. This was felt to be a referred pain. She did have shoulder x-rays, which showed some degenerative changes in the AC joint. She subsequently had an MRI of her shoulder, which showed tendinosis in the distal supraspinatus tendines, acromioclavicular degenerative changes, some mild thickening of the coracoacromial ligament and medial displacement of the bicipital groove.
AC|acromioclavicular|AC|147|148||STUDIES: Ultrasound studies of the upper limb venous duplex were performed in clinic. Diameters were: 1. Left cephalic: uppermost 3.8, midarm 4.1, AC fossa 4.7, mid forearm 3.4, and wrist 2.7. 2. Left basilic: uppermost 1.8, midarm 2.0, AC fossa 1.8. 3. Right cephalic: uppermost 2.7, midarm 2.5, AC fossa 2.6, mid forearm 3.6, and wrist 3.9.
AC|(drug) AC|AC|413|414||She denies any urinary symptoms. Her vital signs are stable with no further fever and blood pressure is in the range of 130/60's. At the time of discharge, her medications will be as follows: Levaquin 500 mg daily times 10 days then stop, Avapro 150 mg once daily (replace lisinopril), Lasix 40 mg daily, potassium chloride 20 meq daily, Liquibid 600 mg taking two pills b.i.d. for one week then stop, Robitussin AC cough syrup p.r.n., Duoneb by nebulizer machine q.i.d. for one week then p.r.n., metoprolol 25 mg b.i.d., Imdur 30 mg daily, Celebrex 200 mg, and insulin 70/30 15 units b.i.d. Her previous lisinopril was stopped in case there was a factor with her cough.
AC|(drug) AC|AC|203|204||PAST MEDICAL HISTORY: Significant for multiple orthopaedic surgeries to his feet secondary to fall as well as a history of hypertension. MEDICATIONS ON ADMISSION: 1. Atenolol 50 mg p.o. daily. 2. Pepcid AC daily. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He is a nonsmoker.
AC|before meals|AC.|106|108||5. Lisinopril 25 mg po q d. 6. Loratadine 10 mg po q d. 7. Zocor 10 mg po q hs. 8. Imodium 2 tablets po q AC. 9. Combivent MDI 2 puffs qid prn. 10. Tylenol 1 tablet po qid prn. FOLLOW UP: The patient will be discharged to Transitional Care at Ebenezer Ridges.
AC|acromioclavicular|AC|236|237||There is thought to be either a very nearly complete partial thickness tear or a small full thickness tear involving the supraspinatus tendon. Lateral sloping of the acromion is also noted together with mild degenerative changes in the AC joint. This produces only minimal narrowing of the supraspinatus outlet. She is now admitted for an arthroscopic decompression of the right shoulder together with a mini rotator cuff repair of the right shoulder.
AC|adriamycin cyclophosphamide|"AC"|304|307||DOB: _%#MMDD1941#%_ CHIEF COMPLAINT: Bilateral leg and back pain. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 62-year-old female, whose history is significant for breast cancer, status post left- sided lumpectomy with subsequent sentinel node lymph node dissection, status post four cycles of "AC" chemo, and now status post first of four cycles of Taxol just two days ago. She presents with significant bilateral pain in her feet as well as her back.
AC|(drug) AC|AC.|155|157||No shortness of breath, cough or wheezing. GASTROINTESTINAL: She has decreased appetite. She has increased heartburn issues, for which she is using Pepcid AC. GENITOURINARY: Negative. No urgency, frequency or hematuria. SKIN: Dryness. MUSCULOSKELETAL: Her legs and back ache. LYMPHATIC: Negative. No enlarged lymph nodes or lymphedema. ENDOCRINE: Negative.
AC|acromioclavicular|AC|254|255||He has a type II acromial morphology in his right shoulder with some intrasubstance and deep surface tendinopathy and tendinitis, with some deep surface fraying on the supraspinatus, but no area of full thickness tearing or muscle atrophy. There is some AC joint arthrosis and mild osteoarthritis in the glenohumeral joint. He had an injection most recently on _%#MMDD2002#%_, and received 70% relief of pain for about one month.
AC|acromioclavicular|AC|156|157||This demonstrates a full thickness tear of the rotator cuff including the supraspinatus tendon and the infraspinatus tendon. In addition, there is advanced AC joint arthrosis with moderate inferior hypertrophic changes. In addition to these findings, there is tearing and deformity of the superior labrum extending from about 10 o'clock to 2 o'clock.
AC|(drug) AC|AC|194|195||Culture of the ear discharge did not reveal any organism, and the patient improved during her hospital stay, and will be discharged home today on _%#MMDD2002#%_. DISCHARGE MEDICATIONS: 1. VoSol AC four drops to each ear four times a day. 2. The patient already had some Percocet at her halfway house where she is currently staying.
AC|(drug) AC|AC.|234|236||Clinically, the patient developed mild symptoms of withdrawal. Followup pulmonary exam demonstrated sonorous upper airway rhonchi with diminished breath sounds at the bases. Continuation of nebs, antibiotics, steroids, and Robitussin AC. Psychiatry consultation with Dr. _%#NAME#%_ _%#NAME#%_ regarding issue of depression and alcohol dependency, as well as need for probable commitment based on underlying health issues and placing the patient at significant risk with continued alcohol use.
AC|adriamycin cyclophosphamide|AC|206|207||She was found to have a hormone receptor negative, HER-2/neu negative breast cancer, but has unfortunately since gone on to metastatic disease to the lung with a malignant pleural effusion despite adjuvant AC and Taxol chemotherapy. She has since been treated with Taxotere, Xeloda, Gemzar, Navelbine, Doxil, Taxol with carboplatin and on _%#MM#%_ _%#DD#%_ received her first dose of retreatment with Taxotere.
AC|acromioclavicular|AC|140|141||Most recent EKG showed no acute changes. Respiratory: Negative. Musculoskeletal: The patient has a rib fracture, as noted above. History of AC joint inflammation. GU: Positive for prostatism. Positive for BPD. The patient had a transurethral resection of the prostate by Dr. _%#NAME#%_ in 1985. GI: Positive for gastroesophageal reflux disease. Neurological: Positive for sleep apnea.
AC|(drug) AC|AC|196|197||Her medications at the time of discharge were similar to those on admission with the addition of Megace 400 mg orally q. day to increase appetite. She was also given a prescription for Robitussin AC cough syrup 1 to 2 tsp every 3 to 4 hours p.r.n. and also Zofran 8 mg 1 every 8 to 12 hours p.r.n. for severe nausea and vomiting.
AC|acromioclavicular|AC|152|153||He was subsequently transferred to Fairview Southdale Hospital for medical evaluation. PAST MEDICAL HISTORY: Unknown. From his exam, he has an old left AC separation. MEDICATIONS: Unknown. ALLERGIES: Penicillin (reaction unknown). HEALTH HABITS: Unknown, although I see that he has a pack of cigarettes.
AC|acromioclavicular|AC|183|184||Walk only with assistance. Seizure and aspiration precautions. We will lumbar puncture if elevated temperature, or change in exam. Chemical dependency consult in morning. 2. Old left AC separation. 3. Tobacco abuse with wheezing: It is unclear whether he truly has asthma, or whether his wheezing is from smoking.
AC|(drug) AC|AC|163|164||8. Advair 500/50 one puff b.i.d. 9. Percocet one tablet p.o. q.i.d. prior to vest therapy. 10. Tylenol 325 mg one to two tablets p.o. q. 6 h p.r.n. 11. Robitussin AC one to two teaspoons q.h.s p.r.n. cough. 12. Dornase 2.5 mg nebulized b.i.d. 13. Albuterol 2.5 mg nebulized q.i.d. 14. Acetylcysteine/Mucomyst 10% solution 4 cc nebulized q.i.d. 15. Tobramycin nebulizer 300 mg nebulized b.i.d.
AC|adriamycin cyclophosphamide|AC,|133|135||FAMILY HISTORY/SOCIAL HISTORY: No change, except expecting her second child. CHEMOTHERAPY /RADIATION THERAPY HISTORY: Four cycles of AC, finished in _%#MM2002#%_. No hormone therapy, no radiation. ALLERGIES: No known allergies PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 132/72, pulse 72, respirations 18, temperature 96.4, and weight 152.
AC|adriamycin cyclophosphamide|AC|211|212||Maintaining weight: Yes. LABORATORY DATA: Mammogram, bone scan and bone density were all normal. FAMILY HISTORY/SOCIAL HISTORY: No change CHEMOTHERAPY /RADIATION THERAPY HISTORY: The patient had three months of AC and three months of Taxol, was on tamoxifen but because of increased endometrial stripe, she was switched over to Arimidex and is on Lupron.
AC|adriamycin cyclophosphamide|AC,|193|195||LABORATORY DATA: Normal. Chest x-ray, mammogram and bone scan were done this summer. FAMILY HISTORY/SOCIAL HISTORY: No change CHEMOTHERAPY /RADIATION THERAPY HISTORY: History of four cycles of AC, prior to that she had six cycles of CMF and Arimidex. ALLERGIES: No known allergies PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 104/62, pulse 60, respirations 18 , temperature 96.4, and weight 159.
AC|(drug) AC|AC|124|125||DISCHARGE MEDICATIONS: 1. Flumadine 100 mg b.i.d. to complete his course of treatment over the next four days 2. Robitussin AC expectorant, one to two teaspoons q four hours p.r.n. for cough, eight ounces. 3. He will continue on his usual home medications: Prevacid 30 mg per day 4.
AC|adriamycin cyclophosphamide|AC|166|167||FAMILY HISTORY/SOCIAL HISTORY: No change CHEMOTHERAPY /RADIATION THERAPY HISTORY: She has had 12 cycles of Gemzar and Taxotere. She has had Navelbine, Xeloda, Taxol, AC in the past. She has had radiation. ALLERGIES: Codeine and sodium pentothal. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 102/70, pulse 92, respirations 16, temperature 98.6, and weight 124.
AC|before meals|AC|137|138||5. Vitamin E 400 IU daily. 6. Multivitamin daily. 7. Flomax 0.4 mg daily. 8. Lisinopril 20 mg daily. 9. Chromium daily. 10. Reglan 10 mg AC 11. Zyrtec 10 mg daily. 12. Lipitor 10 mg daily. 13. Zoloft 100 mg daily. 14. Lorazepam 0.5 mg as needed for sleep or anxiety.
AC|adriamycin cyclophosphamide|AC.|151|153||HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is seen today for follow-up of her adenocarcinoma of the breast. She is finished with four cycles of AC. She will start Taxotere in four weeks. REVIEW OF SYSTEMS: GENERAL: She has a low-grade fever of 99.3. Weight: Retaining fluids.
AC|adriamycin cyclophosphamide|AC|157|158||PSYCHIATRIC: Negative. SLEEP: Negative. PAIN: Negative. LABS: Normal. SOCIAL/FAMILY HISTORY: No change. CHEMOTHERAPY HISTORY: The patient had four cycles of AC in 2001, followed by tamoxifen. ALLERGIES: No known allergies. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 110/70, pulse 75, respirations 14, temperature 98.2, weight 175, height 5 feet 5 inches.
AC|(drug) AC|AC|124|125||DISCHARGE MEDICATIONS: 1. Neurontin 300 mg p.o. t.i.d. 2. Elavil 150 mg p.o. q.h.s. 3. Ambien 10 mg p.o. q.h.s. 4. Mytussin AC 2 ml p.o. q.4-6h. p.r.n. 5. Tylenol #3 30/300 mg p.o. 1-2 tabs q.4-6h. p.r.n. 6. Flovent inhaler 220 mcg inhaled 1 puff b.i.d. 7. Serevent 2 puffs b.i.d.
AC|adriamycin cyclophosphamide|AC.|119|121||She is eating well, maintaining weight. LABORATORY DATA: Drawn today. Her MUGA went from 63% to 54% with two cycles of AC. CURRENT TREATMENT: AC. She has finished two cycles; is due for her third today.
AC|adriamycin cyclophosphamide|AC.|72|74||Her MUGA went from 63% to 54% with two cycles of AC. CURRENT TREATMENT: AC. She has finished two cycles; is due for her third today. ALLERGIES: NO KNOWN ALLERGIES. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 104/66, pulse 88, respirations 18, temperature 97.1, and weight 146.
AC|adriamycin cyclophosphamide|AC,|153|155||There is no lymphedema. NEUROLOGIC: Cranial nerves II-XII are intact. ASSESSMENT AND PLAN: No evidence of recurrent disease. The patient will finish her AC, and then will try and decide on surgical vs radiation options. We will also recheck her MUGA, as it did drop fairly significantly; will do this before the fourth cycle.
AC|(drug) AC|AC|140|141||Therefore, will symptomatically treat her. She will be given Tessalon Pears for cough suppression as she says that Robitussin or Robitussin AC does not help. Also may try Mucomyst nebs as needed. In addition will try albuterol and Atrovent nebs as needed for shortness of breath or cough.
AC|abdominal circumference|AC|195|196||At the latter part of her pregnancy ultrasound showed the EFW of the fetus to be greater than the 88th percentile initially at 33 weeks, at 37 weeks the EFW was greater than 90th percentile with AC greater than 97th percentile. These findings were discussed with the patient and after extensive review of the pros and cons, she elected to proceed with a primary caesarian section for suspected fetal macrosomia.
AC|adriamycin cyclophosphamide|AC,|167|169||PAIN MANAGEMENT: Fair control of right hip pain with Tylenol and Advil. LABS: Pending. SOCIAL/FAMILY HISTORY: No change. CHEMO HISTORY: The patient had four cycles of AC, and four cycles of Taxotere. ALLERGIES: Generic Prozac, penicillin. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 103/50, pulse 66, respirations 16, temperature 98.3, weight 121.
AC|adriamycin cyclophosphamide|AC|164|165||It was treated in _%#MM#%_ 2002. He has felt a chest wall nodule. CHEMO & RADIATION HISTORY: He was originally treated with four cycles of Taxol and four cycles of AC and radiation because he had 3 of 14 lymph nodes involved. REVIEW OF SYSTEMS: GENERAL: He has a good appetite. He has had problems with sleep apnea, so he is fatigued.
AC|adriamycin cyclophosphamide|AC.|93|95||SOCIAL/FAMILY HISTORY: Her daughter has been sick. TREATMENT HISTORY: She had four cycles of AC. She was started on tamoxifen. ALLERGIES: Aspirin, Cipro. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 120/68, pulse 80, respirations 18, temperature 97.3, weight 147.
AC|adriamycin cyclophosphamide|AC|180|181||SLEEP: Negative. LABS: Labs were normal. MRI of the breast was normal. SOCIAL/FAMILY HISTORY: No change. CHEMO HISTORY: Her last chemo was in _%#MM#%_ 2004. She had four cycles of AC with four cycles of Taxotere. She has had tamoxifen 10 mg p.o. b.i.d., started in _%#MM#%_ 2004. ALLERGIES: Amoxicillin, ampicillin, Septra, NSAIDs. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 122/82, pulse 100, respirations 16, temperature 97.1, weight 240.
AC|acromioclavicular|AC|187|188||HEART: Regular rate and rhythm, normal S1, S2, without any murmurs, rubs or gallops. ABDOMEN: Positive bowel sounds, soft and nontender, nondistended. EXTREMITIES: Tenderness to the left AC joint. The patient is unable to move shoulder greater than 30 degrees. Positive for Tinel's. Muscle strength 4/5 bilaterally. DTRs were 2+ throughout.
AC|acromioclavicular|AC|147|148||Positive for Tinel's. Muscle strength 4/5 bilaterally. DTRs were 2+ throughout. As far as her right shoulder, she also had tenderness to the right AC joint with negative Tinel's. Again, she was unable to move her arm greater than 30 degrees. LAB AND DIAGNOSTIC DATA: EKG was obtained and that was normal sinus rhythm without any ST changes.
AC|acromioclavicular|(AC)|203|206||An x-ray was done which showed deformity of her right humeral head and neck with the appearance of an old healed fracture. There was the appearance of degenerative joint changes in the acromioclavicular (AC) joint. Once again were identified. DISPOSITION: The patient is being discharged to Minnesota Masonic Home transitional care unit.
AC|before meals|AC|115|116||DISCHARGE MEDICATIONS: 1. Neurontin 600 mg p.o. b.i.d. 2. Nexium 20 mg p.o. q. day. 3. Viokase 2 to 3 tablets p.o. AC t.i.d. 4. Sandostatin LA 20 mg IM q. 3 weeks. 5. Sandostatin 100 to 300 mcg subcu q. 2 hours p.r.n. carcinoid symptoms. 6. Periactin 2 mg p.o. b.i.d.
AC|assist control|AC|202|203||PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.9, pulse 91, respiratory rate 22, blood pressure currently 110/60, previously on admission was 150/80. She is currently intubated with vent settings of AC tidal volume 450, respiratory rate 12, PEEP of 5, FiO2 55%. Her peak pressures are running in between 25 and 33. GENERAL: The patient is currently intubated and sedated. HEENT: Eyes - normal conjunctivae/lids.
AC|(drug) AC|AC|171|172||1. Splenic infarction. 2. Left lobe pneumonia. DISCHARGE MEDICATIONS: 1. Azithromycin 250 mg p.o. daily x 4 days (1st dose of 500 mg was given in hospital). 2. Robitussin AC 10 mL p.o. q.4 h. p.r.n. cough; 140 mL was given to the patient. CONSULTATIONS: Hematology-Oncology, Dr. _%#NAME#%_ attending. PROCEDURES: 1. CT of abdomen done on date of admit, _%#DDMM2005#%_, that showed a 5-cm wedged-shaped area of decreased or absent perfusion in the middle spleen, and fatty infiltration of the liver.
AC|(drug) AC|AC|205|206||The patient has been given his 1st dose of azithromycin, and is expected to continue as an outpatient. The patient remained afebrile throughout his hospital stay. He did have a cough, for which Robitussin AC was effective. A prescription for Robitussin AC was given to him for outpatient use. DISCHARGE DISPOSITION: Stable; discharged to home. FOLLOW-UP: 1. Dr. _%#NAME#%_ _%#NAME#%_ at the patient's new identified clinic as Fairview Uptown, for initial visit on Friday at 9:30 a.m.
AC|acromioclavicular|AC|135|136||The episode before which happened in _%#MM#%_ of 2004 did not have any other recurrence. X-ray of his right shoulder showed a possible AC joint separation. He is going to be discharged home. DISCHARGE MEDICATIONS: 1. Atenolol 50 mg twice daily 2. Flomax 0.4 mg once daily
AC|(drug) AC|AC|135|136||Had a chronic cough for which she had tried various medications including prednisone which was not resolving. She was using Robitussin AC intermittently but not having success with that. She was fatigued to the point of not being able to care for herself and felt to be dehydrated.
AC|(drug) AC|AC|182|183||HOSPITAL COURSE: The patient was admitted and started on IV fluids and given potassium as well IV as she was low normal with that. We started her on albuterol nebs plus a Robitussin AC and prednisone to help with her cough, and did gradually improve. Her weakness also gradually improved throughout the course of hospitalization.
AC|before meals|AC.|172|174||MEDICATIONS: 1. Phoslo 667 mg po t.i.d. 2. Aspirin 81 mg po q day. 3. Lasix 80 mg q day 4. Lisinopril 20 mg po q day. 5. Nephrocaps one po q day. 6. Renagel one tab t.i.d. AC. 7. Atenolol 25 mg po q day. 8. Lipitor 10 mg po q day. ALLERGIES: Labetalol causes hives. FAMILY HISTORY: Notable for a mother who died of thyroid carcinoma with bone mets, however, there is no history of hypertension, hyperlipidemia, diabetes, coronary artery disease or renal failure in the family.
AC|adriamycin cyclophosphamide|AC.|187|189||REVIEW OF SYSTEMS: GENERAL: Fevers - she has not had a fever but she has had a cold and some chills. Sweats - she has hot flashes. Weight is up two pounds. Fatigue is better than when on AC. EYES: Dry. EARS: Negative. NOSE: She has some nose drainage and upper respiratory infection. THROAT: Negative. No sore throat or hoarseness. CARDIOVASCULAR: Negative for cardiac pain or irregular heartbeat.
AC|adriamycin cyclophosphamide|AC|151|152||Sleeping well, eating well, maintaining weight. LABS: Labs, chest x-ray and bone scan are all normal. SOCIAL/FAMILY HISTORY: No change. CHEMO HISTORY: AC x 4. Taxotere x 4. Still on tamoxifen. ALLERGIES: No known allergies. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 130/78, pulse 80, respirations 18, temperature 97.2, weight 213.
AC|(drug) AC|AC|73|74||3. Nebulizer treatments will be offered on a p.r.n. basis. 4. Robitussin AC will be offered for cough suppression. 5. At some point she may benefit from a course of systemic steroids, but I would like to see how she does over the next day or so before deciding this.
AC|acromioclavicular|AC|166|167||4. Distal clavicle excision, right shoulder. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is 53-year-old female with a right glenoid labral tear, impingement syndrome, and AC joint arthrosis. She was taken to the operating room on _%#MM#%_ _%#DD#%_, 2005, for a right shoulder examination under anesthesia, arthroscopy with debridement of a labral tear, subacromial decompression and distal clavicle excision on the right shoulder.
AC|(drug) AC|AC|131|132||13. Neurontin 300 mg p.o. three times a day. 14. Synthroid 75 mg p.o. every day. 15. Furosemide 80 mg p.o. twice a day. 16. Pepcid AC 10 mg p.o. every day. 17. Diazepam 10 mg p.o. three times a day. 18. Lanoxin 0.125 mg p.o. daily. 19. Humulin R.
AC|(drug) AC|AC|151|152||4. Multivitamin 1 p.o. daily. 5. Toprol-XL 25 mg tablet to take 2 p.o. daily. 6. Fish oil 1200 mg p.o. daily. 7. Oxybutynin 5 mg p.o. b.i.d. 8. Pepcid AC 1 tablet p.o. b.i.d. 9. Lipitor 40 mg tablet p.o. daily at bedtime. 10. Nitrofurantoin 100 mg p.o. q.6h. with food. Last dose should be in the morning of _%#MMDD2005#%_.
AC|(drug) AC|AC,|215|217||He was feeling stronger by the _%#DD#%_. His medications were Zosyn as well as ceftriaxone. Again, appearing to continue to improve over several days. Switched to oral medication on _%#MMDD#%_, Levaquin, Robitussin AC, albuterol inhalers. Diagnosis of pneumonia with abscess anemia of chronic disease, cough, ethanol abuse. Told to return to clinic within a week. Also, he was to be admitted for inpatient alcohol treatment, to be set up by the county.
AC|adriamycin cyclophosphamide|AC|106|107||Her bone density was normal. SOCIAL/FAMILY HISTORY: No change. CHEMO & RADIATION THERAPY HISTORY: She had AC x 4. She was on tamoxifen for two years, and then switched over to Arimidex. She had radiation in 1998 with her original breast cancer.
AC|(drug) AC|AC|108|109||There was no further investigation of his abdominal pain during this stay. DISCHARGE MEDICATIONS: 1. Pepcid AC 20 mg daily. 2. Celebrex 200 mg daily. DISCHARGE PLANS: The patient is being discharged directly to inpatient psychiatry at Fairview Southdale Hospital.
AC|(drug) AC|AC|146|147||10. Zofran 8 mg p.o. q.8 h. p.r.n. for nausea. 11. Compazine 5 mg p.o. q.6 h. p.r.n. for nausea. 12. Synthroid 25 mcg p.o. q. day. 13. Robitussin AC 10 mL p.o. q.6 h. p.r.n. for cough. 14. Benzonatate 100 mg p.o. t.i.d. p.r.n. for cough. 15. Levofloxacin 400 mg p.o. q. day x 10 days.
AC|acromioclavicular|AC|186|187||This demonstrates an intact rotator cuff. He has no evidence of labral tear. There is subacromial spur formation resulting in narrowing of the acromiohumeral space and there is moderate AC joint arthrosis with inferior hypertrophic changes. He is now admitted for an arthroscopic decompression of the right shoulder together with an open distal clavicle excision of the right shoulder.
AC|(drug) AC|AC,|189|191||She had no complications during hospitalization and was much improved by _%#MMDD2006#%_ as we would expect with a gastroenteritis. She is discharged to home. I have written for some Pepcid AC, which she can take over-the-counter if she has any residual gastritis. She will continue on her Ortho Tri-Cyclen. The patient had no abdominal pain on the day of discharge.
AC|(drug) AC|AC|161|162||2. Aspirin 81 mg p.o. daily. 3. Plavix 75 mg p.o. daily. 4. Imdur 30 mg p.o. daily. 5. Metformin ER 500 mg p.o. daily. 6. Furosemide 20 mg p.o. daily. 7. Pepcid AC 10 mg p.o. daily p.r.n. 8. Calcium carbonate p.r.n. 9. Potassium chloride 20 mEq p.o. daily. 10. Vitamin B12 100 mcg p.o. daily. 11. Pindolol 5 mg p.o. daily.
AC|before meals|AC|156|157||9. Lotemax 0.5%, 1 drop left eye daily. 10. Norvasc 10 mg p.o. q. day. 11. Timolol 0.5%, 1 drop left eye daily. 12. Monitor blood sugars b.i.d. Very timing AC and h.s. 13. Seroquel 25 mg q.h.s. FOLLOW-UP: Return to the clinic to see Dr. _%#NAME#%_ in 1-2 weeks. We need to follow up on echocardiogram report and chest x-ray at that time.
AC|adriamycin cyclophosphamide|AC,|192|194||NEUROLOGIC: Cranial nerves II-XII are intact. ASSESSMENT AND PLAN: Stage III cancer. She is a candidate for cytoreduction. Given her the option of Xeloda Taxotere study with Herceptin vs. the AC, Taxol and Herceptin. She is going to think about it overnight and we will arrange for her treatment once she has decided where she wants to go.
AC|acromioclavicular|AC|182|183||Also, during this hospital stay she developed E. coli UTI and that was managed with Levaquin. Also, during the hospital course the patient developed left wrist pain, as well as left AC joint pain. Orthopedics was consulted, aspiration of the left wrist joint was done and cultures grew also MSSA. The patient clinically has improved. Echocardiogram was done as well which showed possible strain or vegetations on the valves which is suspicious for endocarditis per ID, therefore the patient will be treated for a total of six weeks of antibiotics for presumed infective endocarditis.
AC|(drug) AC|AC|197|198||3. Hypertension. 4. Lower extremity stasis dermatitis. 5. History of stroke and left carotid artery occlusion. DISCHARGE MEDICATIONS: 1. Augmentin 875 mg p.o. b.i.d. with food x10 days. 2. Aquacel AC dressings over the left heel and lower extremity ulcers daily. Cover this with gauze. 3. Pressure reduction AFO brace to the left lower extremity with need to take complete weight off the posterior aspect of the left heel, giving this a chance to heal.
AC|(drug) AC|AC|312|313||The patient, who had been initiated on oral antibiotic on _%#MMDD2006#%_ for his upper respiratory infection was maintained on that and discharged home, pain-free, hemodynamically normal and stable. DISCHARGE MEDICATIONS: Same as that prior to admission with the addition of: 1. Zetia 10 mg daily. 2. Robitussin AC 5-10 cc p.o. q.6h. p.r.n. cough. PLAN: Patient will follow-up with his primary provider, Dr. _%#NAME#%_ _%#NAME#%_ at Fairview Cedar Ridge Clinic, in 2 weeks.
AC|(drug) AC|AC|131|132||24. Coly-Mycin nebs 150 mg b.i.d. 25. Ventolin 2.5 mg neb q.i.d. 26. Tylenol 325 to 650 mg p.o. q. 6h. p.r.n. pain. 27. Robitussin AC 5-10 mg p.o. 1-2 times a day as needed. 28. Levofloxacin 750 mg p.o. daily. 29. Imipenem 750 mg IV q. 8h. 30. Vancomycin 1.4 g IV q. 8h. 31. Prednisone taper decrease by 5 mg every 7 days: 40 mg p.o. daily _%#MMDD#%_, _%#MMDD#%_; 35 mg p.o. daily, _%#MMDD#%_ to _%#MMDD#%_; 30 mg p.o. daily, _%#MMDD#%_ to _%#MMDD#%_; 25 mg p.o. daily, _%#MMDD#%_ to _%#MMDD#%_; 20 mg p.o. daily, _%#MMDD#%_ to _%#MMDD#%_; 15 mg p.o. daily, _%#MMDD#%_ to _%#MMDD#%_; 10 mg p.o. daily, _%#MMDD#%_ to _%#MMDD#%_; 5 mg p.o. daily, _%#MMDD2007#%_.
AC|acetate|AC|131|132||1. Bactroban applied to face 3 times a day. 2. Enbrel 15 mg subcutaneous 2 times a week on Tuesdays and Saturdays. 3. Prednisolone AC one drop right eye twice a day, one drop left eye, once a day. 4. Solu-Tab 30 mg G-tube twice a day. 5. Reglan 1.5 mL G-tube three times a day.
AC|adriamycin cyclophosphamide|AC,|230|232||Unfortunately, around 1998 the patient developed evidence of progressive disease and she has since been found to have bony metastases, lung metastases and brain metastases. She had multiple courses of chemotherapy, including CMF, AC, Taxol with Herceptin, but for the last three-plus years has done extremely well on Herceptin alone. Her CNS metastases have been treated with radiation and radiosurgery.
AC|(drug) AC|AC|122|123||He was put on oxygen to keep his oxygen saturation between 88 and 94. He was given Tessalon for his cough with Robitussin AC and Ativan as well 1 mg p.o. t.i.d. His Prinivil was continued at 20 mg once a day. Amaryl was continued at 2 mg once a day. Regarding his heart condition, a chest x-ray showed that he had pulmonary edema.
AC|acromioclavicular|AC|189|190||Neck exam is normal. Thyroid not enlarged. No jugular venous distention. Lungs are clear, with good air movement. Oxygen saturations running 97% on 1 liter. There is deformity of the right AC joint area. Abdomen is benign. Extremities show no edema. There are some abrasions on the left knee and contusion/ecchymosis of the left medial thigh.
AC|(drug) AC|AC|142|143||MEDICATIONS: 1. Lisinopril 5 mg one PO Q day 2. Apresoline 5 mg per patient at HS. 3. Zantac over the counter 75 prn. heartburn 4. Robitussin AC one teaspoon, Q 4 hours prn. 5. Azithromycin 500 mg on Monday and then 250 mg PO Q day ALLERGIES: Biaxin and Sulfa.
AC|(drug) AC|AC|131|132||9. Provigil 400 mg per os twice a day. 10. Paxil 20 mg per os every day. 11. Mirapex 0.125 mg per os three times a day. 12. Pepcid AC one per os twice a day. 13. Neurontin 300 mg per os three times a day. 14. Isosorbide 30 mg per os every day. 15. Enalapril 10 mg per os every day.
AC|acromioclavicular|AC|157|158||He thinks that perhaps at one time he may have strained his shoulder when lifting weights. A recent MRI of the left shoulder showed impingement syndrome and AC joint arthrosis, but no rotator cuff tear. PAST MEDICAL HISTORY: 1. Had a right shoulder surgery in 2000.
AC|(drug) AC|AC|249|250||He was discharged on Ceftin per gastrostomy tube b.i.d. with meals, guiafenesin liquid 100 mg/5 cc four teaspoons per gastrostomy tube q. 4hours while awake for seven days, Rilutec and Sanoft daily as previously, Prozac 60 mg p.o. daily, Robitussin AC one or two teaspoons per gastrostomy tube q. 4 to 6hours p.r.n. cough, Tylenol #3 one to two p.o. q. 4 to 6hours p.r.n. per gastrostomy tube for neck discomfort, Ambien 5 mg per gastrostomy tube q.h.s. p.r.n. insomnia.
AC|alternating current|AC|140|141||The patient should keep the vent filter free from fluid or obstructions and should keep the PVU in a properly grounded three-prong 110 volt AC outlet. The patient will get dressing supplies from Midwest Medical (_%#TEL#%_). 6. If the patient notes any drainage, pain, swelling, fever greater than 101.5, or problems around the drive line or sternal incision, she should call the doctor.
AC|acromioclavicular|AC|146|147||2. Cocaine abuse. SECONDARY DIAGNOSIS: 1. History of atrial fibrillation 1 year ago status post cardioversion. 2. Status post surgery to the left AC joint, posttraumatic. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 58-year-old male who previously had an episode of atrial fibrillation and was cardioverted about a year to a year and a half ago and since cardioversion was put on Coumadin, propafenone, and metoprolol.
AC|before meals|AC|242|243||The patient improved significantly with the IV narcotics, but then again developed problems every time attempts were made to either decrease the dose or switch him to oral medicine. The patient was subsequently started on Bentyl 20 mg po qid AC and hs. This did not provide much relief on the first day but, after the second day, the patient began to have much less of a problem with bowel pain.
AC|before meals|AC|103|104||3. Klonopin 0.5 mg po bid. 4. Seroquel 100 mg po q hs. 5. Asacol 800 mg po tid. 6. Bentyl 20 mg po qid AC and hs. 7. Zofran 8 mg po q8h prn nausea and vomiting. 8. Dilaudid 6 mg po q3h prn pain. 9. _______ one tablet po tid AC.
AC|assist control|AC|136|137||PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 122/78, pulse of 106, respiratory rate 23. Her oxygen saturations were 100%. Vent was AC at tidal volume of 350, PEEP of 5, 40% FiO2, respiratory rate 17. IN GENERAL: The patient is a thin pale-appearing female on the ventilator, intubated, sedated, and in no acute distress.
AC|(drug) AC|AC|120|121||1. Spastic paraparesis. 2. Congenital paralysis. 3. Cerebral palsy. MEDICATIONS: 1. Trazodone 100 mg p.o. qd. 2. Pepcid AC 20 mg p.o. qd. 3. Claritin 10 mg p.o. qd. 4. Dulcolax suppositories prn. HOSPITAL COURSE: On _%#MMDD2002#%_ the patient underwent ileal conduit urinary diversion.
AC|assist control|AC|113|114||EXAMINATION: VITAL SIGNS: The patient's blood pressure was 98/54, his pulse is 114, respiratory rate is 12 on an AC mode ventilator support with 50% Fi02. Tidal volume of 750 cc. The patient is afebrile. GENERAL: He is a middle-aged white male who is resting comfortably on a propofol drip and ventilator support.
AC|(drug) AC|AC|160|161||14. Diovan 160 mg b.i.d. 15. Tequin 200 mg daily to conclude a 10-day course on _%#MMDD2003#%_ 16. Kay Ciel 20 mEq daily 17. Avandia 4 mg b.i.d. 18. Robitussin AC p.r.n. 19. Nitro p.r.n. 20. A regular insulin sliding scale depending on her blood sugars: She gets 0 insulin with a blood sugar of 0-150; 3 units 151-200; 5 units 201- 250; 7 units 251-300; 12 units 301-400; and 15 units greater than 400.
AC|assist control|AC|110|111||5. Furosemide 20 mg p.o. b.i.d. 6. Metoprolol of unclear dosage. OBJECTIVE: The patient is on a ventilator on AC of 12, 5 of PEEP, 40% FiO2, and a tidal volume of 650. Temperature 103.3, heart rate 80, blood pressure 96/47, and on 6 mcg/kg per minute of dopamine.
AC|assist control|AC|198|199||FAMILY HISTORY/SOCIAL HISTORY: Per the chart. PHYSICAL EXAMINATION (HLI): On physical examination, the patient's blood pressure was 137/84, heart rate of 99, respirations 23. He was on a ventilator AC of 12. Tidal volume 750. FI02 of 40%, peak of 5. In general, he was an elderly appearing male, appearing comfortable on the vent, with no evidence of distress.
AC|(drug) AC|AC,|149|151||PAST MEDICAL HISTORY: Denies. PAST SURGICAL HISTORY: Status-post intussusception repair as an infant. MEDICATIONS: Levaquin 500 mg PO qd. Robitussin AC, 1 tsp q 4-6 hours p.r.n. ALLERGIES: None known. SOCIAL HISTORY: The patient is married. Works as a research director at Carmichael Advertising in downtown _%#CITY#%_.
AC|(drug) AC|AC.|139|141||2. Cough/fever. Will check a rapid influenza. There have been some ill exposures with a child with pneumonia. Will place her on Robitussin AC. Her chest x- ray is negative. Will continue her home medications of omeprazole and Zoloft.
AC|(drug) AC|AC|129|130||HOSPITAL COURSE: The patient was admitted and initially placed on IV Tequin and then on po Tequin. She was also given Robitussin AC orally. She has had improvement in her cough. Her O2 saturations with exercise have been 94%. She has been ambulatory without difficulty with a cane.
AC|(drug) AC|AC|114|115||PLAN: Will discharge the patient to home. She will be discharged on seven days of Tequin 400 mg daily, Robitussin AC 8 ounces 1-2 teaspoons q4-6 hours prn for cough control. She will be given an Albuterol MDI 1-2 puffs q2-4h prn for any shortness of breath or wheezing and will be instructed on use prior to discharge.
AC|(drug) AC|AC|338|339||DISCHARGE MEDICATIONS: Include Estrace 2 mg p.o. q. day, Zocor 10 mg p.o. q.h.s., aspirin 325 mg p.o. q. day, Colace 100 mg p.o. b.i.d. p.r.n., nitroglycerin 0.4 mg sublingual p.r.n. for chest pain, Protonix 40 mg p.o. b.i.d. (new medication this hospitalization), ibuprofen 800 mg p.o. t.i.d., p.r.n. for pain and some cough, Robitussin AC 10 mL q.4h. p.r.n. for cough (new medication), albuterol MDI 2 puffs q.i.d. p.r.n. (new medication). DIET: The patient is to follow a regular diet as tolerated.
AC|(drug) AC|AC.|198|200||The patient had been diagnosed with a gastritis on her last visit and was prescribed Prilosec for discharge, but she has not apparently been taking the Prilosec. Instead, she has been taking Pepcid AC. She does note that pain seems worse after eating, and particularly worse after her medications. Currently, the patient's pain is much improved after receiving some Zofran and Protonix in the ER, but no other pain medications.
AC|acromioclavicular|AC|243|244||GENITOURINARY and RECTAL were not done. EXTREMITIES: She has some ecchymosis over her forehead in the bridge of her nose where she fell and also has some painful range of motion in the left arm, but no obvious deformity of the clavicle or the AC joint. NEUROLOGICALLY, she is oriented times three. LABORATORIES AVAILABLE FOR REVIEW: Chest x-ray not available.
AC|adriamycin cyclophosphamide|AC|222|223||_%#NAME#%_ _%#NAME#%_ is a 54-year-old woman with metastatic breast cancer to the brain, being admitted for additional radiosurgery. She was initially diagnosed with breast cancer in 1996 and had a mastectomy, followed by AC chemotherapy. She has since gone on to develop brain metastases and bony metastases. She has had hip surgery and radiation to the right hip.
AC|adriamycin cyclophosphamide|AC|112|113||LABORATORY DATA: Labs show her CA27.29 to be down to 249. CHEMOTHERAPY/RADIATION TREATMENT: The patient has had AC Taxol with recurrent disease. She is on Herceptin, taxotere and on Aredia. She has been on tamoxifen, Arimidex and Faslodex.
AC|adriamycin cyclophosphamide|AC|168|169||She is maintaining weight. LABORATORY DATA: Pending from today. FAMILY HISTORY/SOCIAL HISTORY: No change. CHEMOTHERAPY/RADIATION THERAPY: The patient had two cycles of AC (Adriamycin and cyclophosphamide) chemotherapy and then stopped. She was on tamoxifen from _%#MM#%_ 2002 until _%#MM#%_ 2003. ALLERGIES: She has no known allergies. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 102/78, pulse 80, respirations 16, temperature 97.5, and weight 121.
AC|acromioclavicular|AC|262|263||Saw one orthopedic surgeon who recommended AC joint stabilization. He sought out second opinion because the pain was not just to that area. I saw him and felt most of the pain was rotator cuff interval, and I did not detect any instability or any evidence of an AC separation. Recent MRI done shows significant AC joint arthrosis and some subacromial impingement pain compatible with his symptoms.
AC|acromioclavicular|AC|135|136||Left shoulder chronically painful. Recent MRI shows partial rotator cuff tearing vs. severe tendinosis and hypertrophic changes of the AC joint and subacromial space as well. Injection was done in the office without good relief and with the partial tearing of rotator cuff his recommendation is that it is a surgical decompression, possible open repair if there is a significant issue there.
AC|acromioclavicular|AC|222|223||No murmurs heard. ABDOMEN: No rebound or guarding. Bowel sounds present. NEUROLOGIC: Nonfocal. Motor and sensory reflexes intact. SPINAL: Normal. MUSCULOSKELETAL: Left shoulder very positive impingement sign. Hypertrophic AC joint per rocket impingement pain is present. Rotator cuff strength 5-/5. Range of motion full and stable. Right shoulder negative. Right hand finger-to-finger ______________ flexion at the A1 pulley is tender.
AC|adriamycin cyclophosphamide|AC,|176|178||FAMILY HISTORY/SOCIAL HISTORY: She had a grandchild in _%#MM#%_ 2004. She is stressed. CHEMOTHERAPY/RADIATION THERAPY: She is taxotere, carboplat, and Zometa. She has had CMS, AC, Taxol, ________, Xeloda in the past. ALLERGIES: Codeine and sodium pentothal. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 108/72, pulse 106, respirations 18, temperature 98.3, and weight 122 pounds.
AC|(drug) AC|AC|175|176||9. Ferrous sulfate 325 mg t.i.d. 10. Lasix 20 mg daily. 11. Metformin 850 mg b.i.d. 12. Fosamax. 13. Claritin 10 mg daily. 14. Calcitonin. 15. Nicotine patch. 16. Cheratussin AC p.r.n. 17. Tylenol No. 3 three pills b.i.d. 18. NPH insulin 45 units q.a.m. and 30 units q.p.m. 19. Regular insulin sliding scale. ALLERGIES: NO KNOWN DRUG ALLERGIES. FAMILY HISTORY: The patient has a sister who has had a myocardial infarction and a mother with emphysema.
AC|(drug) AC|AC|175|176||She was changed then to Levaquin 500 mg on _%#MMDD2005#%_ and will be discharged home with Avalox 400 mg daily for 10 days, which is required for her insurance and Robitussin AC 1 to 2 tsp every 4 to 6 hours. She will continue her previous medications, Tegretol and Keppra, push fluids and she will follow-up in clinic as needed.
AC|(drug) AC|AC|212|213||2. Percocet two tabs every 4-6 hours as needed. His regular meds include: 1. Ecotrin 325 mg daily. 2. Plavix 75 mg daily. 3. Hydrochlorothiazide/triamterene 37.5/25 one daily. 4. Lisinopril 5 mg daily. 5. Pepcid AC 20 mg daily. 6. Fish oil one tab daily. 7. Nortriptyline 75 mg at bedtime. 8. Lipitor 40 mg daily. 9. Tylenol 500 mg three times a day. 10. Nitroglycerin 0.4 mg sublingually p.r.n., chest pain.
AC|adriamycin cyclophosphamide|AC,|119|121||SLEEP: Negative. PAIN: Negative. LABS: Labs, chest x-ray and bone scan show no evidence of cancer. CHEMO HISTORY: Four AC, four Taxol, Evista. ALLERGIES: No known allergies. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 142/74, pulse 78, respirations 20, temperature 96.9, weight 152.
AC|(drug) AC|AC|159|160||2. GERD, and has had a chronic cough ALLERGIES: Dust and molds MEDICATIONS: 1. Fosamax 70 mg one a week for osteoporosis 2. Multi-vitamin 3. Occasional Pepcid AC 4. Injection of iron supplement recently SOCIAL HISTORY: She is a nonsmoker, does not consume alcohol.
AC|adriamycin cyclophosphamide|AC|311|312||PSYCH: Working on her depression but cries daily. SLEEP: Ativan helps. PAIN: 2/10 in the left shoulder, just taking over-the-counter medications LABORATORY DATA: Normal FAMILY HISTORY/SOCIAL HISTORY: No change CHEMO/RADIATION TREATMENT HISTORY: She is due for Taxol and Herceptin today, finished four cycles of AC ALLERGIES: No known allergies PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 110/64, pulse 89, respirations 18, temperature 98.2, and weight 160.
AC|before meals|AC.|151|153||5. Plavix 75 mg PO 6. Gemfibrozil 600 mg b.i.d. 7. Lantus insulin two units at breakfast and four units at bedtime. 8. Novalog three units subQ t.i.d. AC. 9. Synthroid 175 mcg. 10. Avapro 300 mg per day 11. Famotidine 20 mg PO b.i.d. 12. Trazodone 75 mg POHS 13. Nephrocaps one PO Q day
AC|(drug) AC|AC,|190|192||1. Flovent metered dose inhaler, one puff b.i.d. 2. Albuterol metered dose inhaler two puffs q.i.d. and q two hours p.r.n. 3. Aspirin 81 mg p.o. q day 4. The patient is asked to take Pepcid AC, one tablet p.o. q day while on the prednisone He is asked to maintain an 1800 calorie ADA diet while on the prednisone and can be active as tolerated.
AC|(drug) AC|AC|145|146||DISCHARGE MEDICATIONS: She was discharged home on: 1. Augmentin 875 mg q.12 x10 days. 2. Zithromax 250 mg daily for two more days. 3. Robitussin AC 1-2 teaspoons p.o. q.4h. p.r.n., x4 ounces. 4. She is take some Mucinex over-the-counter. DISCHARGE INSTRUCTIONS: She may not return to work until _%#MMDD#%_, and no swimming from _%#MMDD#%_ through _%#MMDD#%_, related to her job.
AC|(drug) AC|AC|135|136||She was placed on albuterol nebs with racemic nebs q six hours as needed. She was placed back on her Advair. She also takes Robitussin AC at homes at times which helps break the cough and stops some of the spasm that she gets and she was placed on this even though it was noted in the chart she is allergic to CODEINE, she says she takes Robitussin with codeine without a problem on a fairly regular basis when she gets the cough.
AC|(drug) AC|AC.|193|195||13. Flonase 1-2 sprays each nostril daily. 14. Ativan 1 mg as needed q four to six hours. 15. Spiriva inhaler. 16. Advair diskus 250/50 one puff b.i.d. 17. Darvocet-N 100 p.r.n. 18. Robitussin AC.
AC|acromioclavicular|AC|137|138||MUSCULOSKELETAL: Left shoulder shows vague discomfort in the subacromial area. Good passive and active range of motion. Mild pain in the AC joint, across the anterior shoulder. Right side negative. Elbows and wrists normal. Good grip. Lower extremities, left lower extremity, hip, knee and ankle examined and benign at this time.
AC|(drug) AC|AC|141|142||She denies any chest pain. Her appetite is still good and she is able to eat and drink without any difficulty. She has been using Robitussin AC for suppression as well as Delsym without much luck. Her husband and daughter have been sick with bronchitis. She denies any recent travel.
AC|(drug) AC|AC|141|142||She will require frequent Xopenex nebs to help open up those airways and I will prescribe Mucomyst every 8 hours. I will also use Robitussin AC and benzonatate for her cough suppression. Although, her chest x-ray was normal and this could be a viral bronchitis in setting of the bronchospasm, I will finish off her 10-day course of the Levaquin.
AC|(drug) AC|AC|165|166||At this point she does not appear to be in significant exacerbation. I hear no wheezes on her exam. 3. History of peptic ulcer disease. She reports she takes Pepcid AC at home. I will put her on Protonix here in the hospital. 4. Hypothyroidism. She will be continued on her home dose of Synthroid.
AC|(drug) AC|AC|221|222||He was discharged to home in stable condition. 2. Hepatitis B: The patient continued his oral treatment during his hospitalization stay. DISCHARGE MEDICATIONS: 1. Albuterol inhaler 2 puffs to inhale t.i.d. 2. Cheratussin AC 2 tablespoons orally t.i.d. 3. Effexor 75 mg orally daily. 4. Trazodone 100 mg orally at bedtime. 5. Epivir-HBV 100 mg orally daily.
AC|before meals|AC|130|131||2. Follow-up appointment _%#MMDD2006#%_ at 2:30 p.m. with Dr. _%#NAME#%_ at the Oncology Clinic. 3. She needs to check Accu-Cheks AC and HS at home and bring a list of these sugars to Dr. _%#NAME#%_ appointment for reviewal of insulin needs, as she may need an increase of her Lantus or may need to be put on some routine Lispro before meals.
AC|before meals|AC|272|273||At the time of discharge he was to avoid smoking although he is using a 7-mg nicotine patch per day, and no alcohol, caffeine or nonsteroidal anti-inflammatory drugs (NSAID) at all. DISCHARGE MEDICATIONS: He will be placed on omeprazole 20 mg b.i.d., Carafate 1-g q.i.d., AC and h.s., ferrous sulfate daily; his previous Neurontin 600 mg t.i.d. and multiple vitamin daily. DISCHARGE PLAN: He is to follow up with Dr. _%#NAME#%_ in 6 weeks.
AC|(drug) AC|AC|160|161||He is currently on Bactrim and is finishing a course of Avelox. He is still taking the Advair and the albuterol. He is using Tessalon up to q.i.d. and Mytussin AC p.r.n. He reports that he has had a mild runny nose since yesterday. He complains of fits of cough, usually not productive, or produces only scant amounts of clear sputum.
AC|acromioclavicular|AC|163|164||CHEST: Clear. CARDIAC: Normal without rub or murmur. She does have tenderness on the left parasternal area on palpation, and she has significant tenderness at the AC joint on the left distal clavicle. The pain is not present when this is pressed on. There is no evidence of inflammation or rash noted. ABDOMEN: Soft, obese, protuberant, and perhaps slightly tender in the right upper quadrant epigastric area.
AC|acromioclavicular|AC|207|208||3. MRI of upper extremity joints with and without contrast on the right, which shows large glenohumeral effusion with synovitis with expansion into the bicipital tendon sheath. It also shows widening of the AC joint with fluid enhancement. These changes could represent septic arthritis versus degenerative changes versus trauma. 4. MRI of the T-spine on _%#MMDD2006#%_, which shows progressive erosion of the vertebral endplates at T11-T12 consistent with discitis and vertebral osteomyelitis.
AC|(drug) AC|AC|191|192||4. Dehydration. Appears dry clinically with flat neck veins. He does have some poor skin turgor also. PLAN: At this time, continue course of Z-Pack for now. Check sputum cultures. Robitussin AC for supportive cares. Also gentle NS hydration at 50 ml per hour. Will have PT and OT evaluate and treat, and consider proper disposition.
AC|acromioclavicular|AC|46|47||DIAGNOSES: 1. Left rotator cuff tear. 2. Left AC joint arthrosis. 3. Left biceps tendinosis. 4. Left glenohumeral osteoarthrosis. 5. Atrial fibrillation. PROCEDURES: 1. Left arthroscopic rotator cuff repair. 2. Left shoulder subacromial decompression.
AC|acromioclavicular|AC|196|197||EXTREMITIES: No edema. Peripheral pulses are intact. Right shoulder has limited range of motion. He reports discomfort with holding his arm with only against gravity. Some point tenderness in the AC joint. He does have some limited range of motion with extensive flexion or extension of the shoulder. PSYCHIATRIC: No evidence to suggest anxiety or depression. LABORATORY: Hemoglobin 16.1. Chest x-ray was done, and results will be forwarded.
AC|acromioclavicular|AC.|243|245||Impression was right lower lobe pneumonia. 2. Chest x-ray on _%#MMDD2007#%_ showing there is increasing bibasilar density worrisome for worsening pneumonia. Impression was worsening lower lobe pneumonia. A PICC line catheter tip is low as the AC. HISTORY OF PRESENT ILLNESS: Please see the admission history and physical dated _%#MMDD2007#%_ for further details.
AC|(drug) AC|AC|99|100||9. Hospitalization in _%#MM#%_ and _%#MM#%_ of 2007 for pneumonia, treated. MEDICATIONS: 1. Evoxac AC 30 mg t.i.d. 2. Beclomethasone nasal spray 2 sprays each nostril b.i.d. p.r.n. 3. Prilosec 20 mg a day. 4. Zetia 10 mg a day.
AC|(drug) AC|AC.|170|172||She does have allergic rhinitis and does have a strong family history of penicillin allergy. PRESENT MEDICATIONS: 1. Tessalon Perles as needed along with h.s. Robitussin AC. 2. Oral iron b.i.d. 3. Multiple vitamins. 4. Valtrex for genital herpes prophylaxis. 5. Oral contraceptives. PAST SURGICAL HISTORY: Include a septoplasty in _%#MM#%_ 1993.
AC|acromioclavicular|AC|177|178||HEENT: Negative. NECK: Normal. LUNGS: Clear to A&P. CARDIOVASCULAR: Normal S1 and S2 without murmurs. ABDOMEN: Negative. EXTREMITIES: The right shoulder has a prominence at the AC joint and mild tenderness. There is also tenderness anteriorly and laterally. Range is 170 degrees of abduction and 80 degrees of flexion bilaterally.
AC|before meals|AC,|256|258||DISPOSITION: This patient is discharged to home eating fairly well. I fear another relapse, but hope not. DISCHARGE MEDICATIONS: Glipizide 10 mg 1/2 tablet b.i.d., diltiazem 180 mg p.o. b.i.d., hydralazine 50 mg one p.o. b.i.d., Viokase two tablets t.i.d. AC, Zantac 150 mg at h.s. Timolol 0.5% ophthalmic drops, one drop OU q day, Tylenol 1,000 mg every six hours as needed for pain.
AC|(drug) AC|AC|173|174||3. Chronic hepatitis C (Dr. _%#NAME#%_ _%#NAME#%_) 4. Gastroesophageal reflux disease CURRENT MEDICATIONS: 1. Triphasil 1 p.o. q. day 2. Serafim 10 mg p.o. b.i.d. 3. Pepcid AC 20 mg p.o. q. day ALLERGIES: None known. SOCIAL HISTORY: The patient has not smoked cigarettes for many years.
AC|(drug) AC|AC,|131|133||The cultures are pending at the time of dictation, and the rapid swab is negative. She was treated symptomatically with Robitussin AC, and felt somewhat better at the time of discharge. PROBLEM #2: GI. The patient has a history of cholelithiasis, per CT scan.
AC|acromioclavicular|AC|368|369||_%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 74-year-old patient who was admitted to Fairview Southdale Hospital after he fell and complained of pain in the left hip and left shoulder. X-rays failed to reveal evidence of fractures, but it was noted that he had heterotopic ossification of the left hip following a total hip arthroplasty plus some degenerative changes of the AC joint left shoulder. A radioisotope bone scan was obtained to rule out an occult fracture but there was no evidence of fracture on the scan.
AC|(drug) AC|AC|301|302||For her age and height, predicted peak flow would be about 400 to 440, but I think she has significant asthma and this is probably never going to be there. Anyway, we are discharging her home. Her medications are as follows: Cozaar 100 mg p.o. q day., hydrochlorothiazide 25 mg p.o. q day, Robitussin AC as needed, Singulair 10 mg p.o. q day, and Advair 500/50 one puff b.i.d. I am also providing prescriptions for Tequin 400 mg p.o. q day for three days and prednisone 40 mg per day for week, then 20 mg for four days, then 10 mg for three days, then discontinue.
AC|acromioclavicular|AC|32|33||ADMIT DIAGNOSIS: Right grade IV AC joint dislocation. DISCHARGE DIAGNOSIS: Right grade IV AC joint dislocation. ATTENDING SURGEON: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD
AC|acromioclavicular|AC|135|136||On the opposite side, he does hyperextend at his MP joint but he has good stability to radial and ulnar deviation. IMPRESSION: Grade 3 AC joint separation and a right thumb ulnar collateral ligament rupture. PLAN: Right thumb collateral ligament repair. The surgery is scheduled for Friday, _%#MMDD2003#%_ under Bier block anesthetic.
AC|(drug) AC|AC|190|191||DISCHARGE MEDICATIONS: 1. Prograf 2.5 mg p.o. b.i.d. 2. CellCept 500 mg p.o. q.i.d. 3. Bactrim SS one tablet p.o. q.d. 4. Lopressor 25 mg p.o. b.i.d. 5. Lipitor 20 mg p.o. q.h.s. 6. Aspirin AC 81 mg p.o. q.d., on hold. 7. Synthroid 0.2 mg p.o. q.d. 8. Premarin 0.9 mg p.o. q.d. 9. Protonix 40 mg p.o. q.d. 10. Dulcolax 5 mg one to two tablets p.o. q.h.s. p.r.n.
AC|acromioclavicular|AC|103|104||ADMITTING DIAGNOSIS: Impingement of shoulder. OPERATIVE PROCEDURE PERFORMED: Scope decompression, open AC joint resection. COMPLICATIONS THIS ADMISSION: Respiratory distress. HOSPITAL COURSE: On _%#MMDD2004#%_ the patient was admitted and underwent the procedure.
AC|(drug) AC|AC|235|236||FOLLOW-UP: Primary physician, Dr. _%#NAME#%_, on _%#MM#%_ _%#DD#%_, 2004. DISCHARGE MEDICATIONS: 1. Clonidine 0.1 mg p.o. b.i.d. 2. Lasix 120 mg p.o. daily. 3. Spironolactone 50 mg p.o. daily. 4. K-Dur 10 mEq x 2 p.o. b.i.d. 5. Pepcid AC 10 mg p.o. daily. 6. Hydrocodone. 7. Sinemet 25/10 p.o. q.h.s. 8. Quinine 250 mg p.o. q.h.s.
AC|(drug) AC|AC|248|249||3. History of cigarette smoking. 4. Cough and paroxysms. PLAN: Continue community-acquired pneumonia pathway with Rocephin and azithromycin in addition to her oxygen. She will be given albuterol and Atrovent nebs q. 2-4 hours as needed. Robitussin AC is ordered, 10 cc q. 4 hours p.r.n. for cough. Dr. _%#NAME#%_ will be asked to see the patient in the a.m. The lab work done in the ER shows a normal CBC and normal basic metabolic panel.
AC|(drug) AC|AC.|166|168||She was seen at her primary care clinic this past Thursday. She had a chest x-ray and was diagnosed as having bronchitis. She was started on Zithromax and Robitussin AC. Despite this, she has been getting steadily worse. She now notes that she is so short of breath, she has difficulty walking 5-10 feet.
AC|(drug) AC|AC,|349|351||Last night, she states that she had such a bad night with the heavy chest pain, pain in her chest going radiating down to both shoulders, worse at night with laying down, rest kind of made it better, exertion kind of made it worse too. She states that initially she thought that it was indigestion, felt nauseated with that too. She took one Pepcid AC, it helped a little, but the patient waited until 6 am. today and called the clinic and she was asked to call 911 and following that she was brought into the emergency room by the paramedics.
AC|adriamycin cyclophosphamide|AC|155|156||HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her adenocarcinoma of the breast. The patient is due for her third cycle of AC today. REVIEW OF SYSTEMS: GENERAL: No fevers, sweats, weight change, or fatigue.
AC|adriamycin cyclophosphamide|AC|162|163||There is no lymphedema. NEUROLOGIC: Cranial nerves II-XII are intact. ASSESSMENT AND PLAN: No evidence of recurrent breast cancer. The patient will finish up her AC today, get started with radiation in about three weeks or so. Will start her on hormone therapy after her radiation.
AC|adriamycin cyclophosphamide|AC,|175|177||Maintaining weight. LABORATORY DATA: Chest x-ray and mammogram all normal. FAMILY HISTORY/SOCIAL HISTORY: No change. CHEMO/RADIATION TREATMENT: The patient had four cycles of AC, started on tamoxifen as of _%#MM2004#%_ when she finished her radiation. ALLERGIES: Zofran. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 130/80, pulse 72, respirations 20, temperature 97.4, and weight 223 pounds.
AC|adriamycin cyclophosphamide|AC|157|158||HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 47-year-old woman who is in today for followup of her adenocarcinoma of the breast, and for her third AC chemotherapy. REVIEW OF SYSTEMS: GENERAL: Fatigue on and off with chemo.
AC|(drug) AC|AC|184|185||DISCHARGE MEDICATIONS: 1. Metoprolol 25 mg p.o. b.i.d. 2. Altace 2.5 mg p.o. daily. 3. Prednisone 10 mg p.o. daily. 4. Aspirin 81 mg p.o. daily. 5. Zelnorm 12 mg p.o. b.i.d. 6. Pepcid AC 10 mg chew and swallow 1 tablet p.o. daily. 7. Nefazodone HCL 300 mg p.o. nightly. 8. Effexor XR 225 mg p.o. daily.
AC|adriamycin cyclophosphamide|AC,|145|147||LABS: Her labs, chest x-ray and bone scan show no evidence of recurrent disease. SOCIAL/FAMILY HISTORY: No change. CHEMO HISTORY: Four cycles of AC, four cycles of Taxotere, then followed by Femara. She had tamoxifen for nine months and Arimidex for a year without being able to tolerate them, but is tolerating Femara.
AC|adriamycin cyclophosphamide|AC,|244|246||SOCIAL/FAMILY HISTORY: No change. CHEMO & RADIATION THERAPY HISTORY: The patient had her University of Minnesota protocol with epirubicin instead of adriamycin. Previously, she has had Taxotere and Xeloda x 6 cycles. She has had four cycles of AC, four cycles of Taxol. She had tamoxifen for two years. She has had radiation to her chest wall and to her right hip.
AC|before meals|(AC)|173|176||17. Vicodin 1 to 2 p.o. 4 hours p.r.n. pain. 18. Tylenol 650 mg p.o. q. 4 hours p.r.n. pain/fever (do not take with Vicodin). 19. Humalog insulin sliding scale subcu t.i.d. (AC) p.r.n. hyperglycemia: 120-150 1 unit, 151-200 3 units, 201-250 5 units, call MD. DISCHARGE: The patient was told to restrict lifting to less than 10 pounds for 6 weeks from the time of surgery.
AC|before meals|(AC,|172|175||14. Lantus insulin 16 units subcu tonight, then discontinue. 15. Lantus insulin 12 units subcu q. h.s., begin _%#MMDD2005#%_ 16. Humalog insulin sliding scale subcu t.i.d. (AC, p.r.n. hyperglycemia: 0 for less than 150, 2 units for 150-200, 4 units for 201-250, 6 units greater than 250 and contact Transplant Service).
AC|before meals|(A.C.)|155|160||9. Aspirin 81 mg p.o. daily. 10. Calcium carbonate with vitamin D 500 mg p.o. t.i.d. 11. Ferrous sulfate 325 mg p.o. t.i.d. 12. Renagel 800 mg p.o. t.i.d. (A.C.) 13. Protonix 40 mg p.o. daily. 14. Zelnorm 6 mg p.o. t.i.d. 15. Compazine 10 mg p.o. q6h p.r.n. nausea. 16. Prednisone 5 mg p.o. daily.
AC|before meals|(A.C.)|225|230||15. Tylenol 650 mg p.o. q.4-6h p.r.n. pain/fevers and Thymoglobulin pre-medication. 16. Benadryl 25 to 50 mg IV/p.o. q.4-6h p.r.n. itching/rash and Thymoglobulin pre-medication. 17. Humalog insulin sliding-scale subcu t.i.d. (A.C.) p.r.n. hyperglycemia: less than 120 equals 0, 120-150 equals 2 units, 151-200 equals 4 units, 201-250 equals 6 units, 251-300 equals 8 units, 301-350 equals 10 units, 351-400 equals 12 units, greater than 400 equals 14 units and call MD.
AC|adriamycin cyclophosphamide|AC.|110|112||No axillary disease. Exam: Well-healed scar in right breast. Assessment and Plan: Plan to receive 4 cycles of AC. We would recommend radiation to right breast. Benefits and side effects were discussed and consent form was signed.
AC|(drug) AC|AC,|136|138||CURRENT MEDICATIONS: 1. Tylenol on a p.r.n. basis. 2. Lorazepam on a p.r.n. basis. 3. Zofran 4 mg four times daily p.r.n. 4. Robitussin AC, 1 tsp. every 4 hours p.r.n. 5. Effexor 150 mg twice a day. 6. Furosemide 20 mg a day. 7. Glucosamine chondroitin 1 capsule 3 times a day.
AC|acromioclavicular|AC|200|201||She is quite thin. Examination of her left shoulder reveals no ecchymosis, erythema, or focal swelling. There is no obvious deformity. She has no tenderness to palpation along the SC joint, clavicle, AC joint. She has some mild coracoid tenderness. No tenderness along the spine of the scapula. She does have tenderness to palpation at the paracervical and paraspinous musculature, especially on the left.
AC|adriamycin cyclophosphamide|AC|177|178||She was also asking about a prosthesis right after the mastectomy. Assessment and Plan: T2, N1, M0 infiltrating ductal carcinoma of the right breast, status post four cycles of AC and three cycles of Taxol. She is scheduled for a mastectomy. We may recommend post-mastectomy chest wall radiation after her surgery, since she has multiple lesions, as well as at least one lesion being T2 in size, which did not disappear with chemotherapy.
AC|angiotensin-converting enzyme:ACE|AC|193|194||She does desaturate at night. 3. Diuretics are not contraindicated if true volume excess can be documented. 4. Afterload reduction. 5. Close monitoring of renal function. 6. Consider alternate AC inhibitors if creatinine continues up. (Would not change at this point.) HISTORY: _%#NAME#%_ _%#NAME#%_ is a 71-year-old woman who has had a couple of admissions here for acute shortness of breath.
AC|acromioclavicular|AC|188|189||Examination of both shoulders showed no atrophy of the shoulder girth. The skin was intact without lesions, masses, or ecchymosis. Palpation of the shoulders revealed no tenderness of the AC joint. However, the patient did have tenderness of the anterolateral rotator cuff, anterior glenohumeral joint, as well as posterior glenohumeral joint.
AC|acromioclavicular|AC|147|148||He has full active extension. He has normal thumb to index finger tip pinch. He is tender over the proximal humerus. He has no tenderness over his AC joint. He has no pain with adduction across his chest. Review of his x-ray show a nondisplaced proximal humerus fracture.
AC|acromioclavicular|AC|171|172||Exam showed no atrophy of the right shoulder girdle. Skin was intact without lesions, masses, or ecchymosis. Palpation of the right shoulder revealed no tenderness of the AC joint, anterolateral rotator cuff, anterior or posterior glenohumeral joint. Passive range of motion of the right shoulder showed external rotation 40 out of 70, internal rotation about L2 out of T7, abduction about 90 out of 100, elevation 120 out of 180.
AC|(drug) AC|AC|188|189||Indicates weight has been stable over the last few years within a couple of pounds. Treated with Prevacid and Prilosec without relief. Has taken Gas-X, Maalox, Zantac, Tagamet, and Pepcid AC and Pepto-Bismol without definitive benefit. Bowel movements are typically soft to diarrheal. Occasional stringy stool. Bright red blood in the stool prior to admission correlating with diarrhea.
AC|acromioclavicular|AC,|217|219||No murmur, gallop, or rub. ABDOMEN: Quiet. EXTREMITIES: The following joints were examined and found to be without synovitis or effusion and had full range of motion: Finger DIP, PIP, MCP, wrist, elbow, glenohumeral, AC, TMJ, SC, hip, knee, subtalar, tibiotalar, toe MTP, IP bilaterally. NEUROLOGIC: Deep tendon reflexes were 2+ bilaterally both in upper and lower extremity and her strength was 5/5 in all major muscle groups.
AC|(drug) AC|AC.|212|214||EXTREMITIES: Without edema. LABORATORY DATA: Currently pending. ASSESSMENT/PLAN: 1. Depression. Diagnosis and treatment per Dr. _%#NAME#%_. 2. HIV. The patient does have a chronic cough and would like Robitussin AC. Given his positive cocaine on urinalysis, I will write for Robitussin DM. He also requested a Boost three times a day with meals, which I think is reasonable.
AC|adriamycin cyclophosphamide|AC|197|198||She will certainly get more information once she decides to proceed with the clinical trial. If she is either not a candidate or wishes an alternative treatment, we would consider either CEF X6 or AC X4 followed by taxotere X4. When she has completed her chemotherapy she will go on hormonal ablation treatment, either with tamoxifen, or if she has stopped menstruating, we would chose Arimidex.
AC|(drug) AC|AC|125|126||5. Lisinopril 40 mg by mouth once daily 6. Nitroglycerin patch 0.4 mcg/hour 7. Toprol XL 50 mg by mouth once daily 8. Niacin AC 500 mg by mouth daily 9. Protonix 40 mg by mouth once daily PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 35.9, pulse 62, blood pressure 147/79 (he has not yet received his blood pressure medications).
AC|acromioclavicular|AC|203|204||X-rays of the right shoulder (two views) taken at Fairview Southdale Hospital today and interpreted by me reveal significant osteopenia. There is no evidence of any fracture or dislocation. She has mild AC joint arthrosis but none in the glenohumeral joint. Of most note is no residual subacromial space (humeral-acromial distance of 0).
AC|(drug) AC|AC|179|180||PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Complete MSSA withdrawal protocol. Thiamine as ordered. 3. Protonix 40 mg daily p.r.n. symptoms of acid reflux. Pepcid AC subsequent to discharge. 4. Clinical observation. Thank you for the consultation. We will follow along as indicated.
AC|adriamycin cyclophosphamide|AC,|226|228||The closest margin was 2 mm. The tumor was ER negative and PR negative, as well as HER-2 negative by FISH. The patient was seen by Dr. _%#NAME#%_ after surgery and was offered adjuvant chemotherapy in the form of a dose dense AC, followed by Abraxane due to hypersensitivities. She has completed all but her last of 4 cycles of Abraxane and has tolerated chemotherapy quite well.
AC|adriamycin cyclophosphamide|AC,|122|124||SLEEP: Negative. LABS: She has had no screening since _%#MM#%_. CHEMO & RADIATION THERAPY HISTORY: She had four cycles of AC, and on Arimidex. ALLERGIES: No known allergies. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 120/75, pulse 60, respirations 16, temperature 96.0, weight 183.
AC|adriamycin cyclophosphamide|AC|208|209||PROBLEM: Brain metastasis from breast cancer. HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old female patient who is known to have breast cancer, right side. She had surgery and chemotherapy finished AC four cycles and continued with Taxotere and Herceptin weekly, and then the Herceptin was continued every three weeks. She was doing well until _%#MM2002#%_ when she started having headaches.
AC|adriamycin cyclophosphamide|AC|172|173||She had a 1.3. and 1.2 cm sized primary lesion with a DCIS and one of two axillary nodes positive. The sentinel node with extracapsular extension. She received a course of AC and two cycles of Taxol of a planned dose of four cycles. Exam: Status post right mastectomy. There are no abnormal palpable lymph adenopathy.
AC|acromioclavicular|AC|145|146||Ms. _%#NAME#%_ saw Dr. _%#NAME#%_ _%#NAME#%_ about two weeks later. She received an injection in her right shoulder which she localizes near the AC joint. That gave her fairly good relief for a short period of time, but it has now recurred. At the present time, this patient is having difficulty raising her arm over her head without pain.
AC|acromioclavicular|(AC)|106|109||Otherwise, these films appear fairly unremarkable. IMPRESSION: 1. Osteoarthritis, right acromioclavicular (AC) joint. 2. Neck pain, likely the result of osteoarthritis. I see that Dr. _%#NAME#%_ has ordered some x-rays of the cervical spine to evaluate his neck better.
AC|acromioclavicular|AC|140|141||I will review those once they are available. In regard to the shoulder, I believe that Mr. _%#NAME#%_ would benefit from injection into his AC joint with some steroid. I will stop by later today and do that for him. I would anticipate pain relief within 7-10 days.
AC|acromioclavicular|AC|133|134||The ordering clinician was aware of the finding. Chest x-ray showed fracture of the left clavicle with additional abnormality of the AC joint on the sternoclavicular joint on the left side. There is an infiltrate of the right middle lobe. No other abnormalities were seen.
AC|adriamycin cyclophosphamide|AC.|175|177||Exam: Post-op change of left breast Assessment and Plan: Patient is going to receive adjuvant chemotherapy first, followed by radiation. We will see patient after 4 cycles of AC.
AC|acromioclavicular|AC|180|181||In regards to shoulder, eventually if things are not imperfect, we will get an MRI of the shoulder and evaluate the rotator cuff. He is very, very tender in the subacromial space. AC joint was benign though and it would not be alarming or surprising to see a significant rotator cuff problem. Right now, get the clavicle to heal, mobilize, get the bruising down and follow serial hemoglobins.
AC|acromioclavicular|AC|161|162||He has no significant pain with internal and external rotation. He has a passive flexion rotation to approximately 40 degrees. There is some tenderness over the AC joint and minimal anterior tenderness. He has marked weakness of the right shoulder to forward flexion and external rotation.
AC|acromioclavicular|AC|203|204||LABORATORY DATA: X-rays were obtained yesterday, AP and axial of the right shoulder, which revealed some general osteopenia. There was no obvious lytic lesion in the proximal humerus. There was moderate AC joint arthrosis. He has high riding humeral head consistent with a rotator cuff tear. He has some mild degenerative changes of his glenohumeral joint.
AC|adriamycin cyclophosphamide|AC|180|181||After surgery she was seen by Dr. _%#NAME#%_ and they discussed chemotherapy regimens including AC plus Taxol, plus tamoxifen and other regimens. Ms. _%#NAME#%_ elected to receive AC in six cycles and tamoxifen. Total estrogen ablation was also discussed and she opposed an oophorectomy. When her breast cancer had been diagnosed, she was nursing her 2-year- old child and now has five children.
AC|acromioclavicular|AC|167|168||IMAGING: X-rays of the right shoulder (multiple views) taken in the emergency room on _%#MMDD2006#%_ reveal no fractures or dislocations. He has mild arthritis of the AC joint. X-rays of the right hip (two views) also done yesterday reveal a completely displaced femoral neck fracture. IMPRESSION: 1. Displaced unstable right femoral neck fracture. 2. Right shoulder contusion.
AC|acromioclavicular|AC|135|136||Her hand is well perfused. Her neck range of motion is normal without discomfort. There is no tenderness about the SC joint, clavicle, AC joint or coracoid. No tenderness about the scapula or spine. She does have obvious bony deformity at the anterior shoulder, where the proximal portion of her humeral shaft is prominent anteriorly.
AC|acromioclavicular|AC|237|238||There are no signs of instability. Examination of both shoulders shows no significant atrophy about the shoulder girdle. The skin is intact without lesions, masses, or ecchymosis. Palpation of both shoulders reveals no tenderness at the AC joint, anterolateral rotator cuff, anterior glenohumeral joint, or posterior glenohumeral joint. Passive range of motion of the left/right shoulder shows external rotation of 70/70, internal rotation of T7/T7, abduction of 100/100, and elevation of 180/180.
AC|adriamycin cyclophosphamide|AC,|313|315||The patient subsequently has done well. Apparently, her lab work has been normal, but recently in _%#MM#%_, she was found to have some ovarian masses, and she had metastatic infiltrating lobular carcinoma to her ovaries. She had a hysterectomy and oophorectomy. She subsequently has been on almost five cycles of AC, Taxol and carboplatin chemotherapy. She had some complications with low counts. She was started on Femara on _%#MMDD2004#%_. FAMILY HISTORY: Her mother died at 64 of metastatic breast cancer.
AC|before meals|AC|125|126||5. Synthroid 0.125 mg daily. 6. Cytomel 5 mcg daily. 7. Seroquel 25 mg b.i.d. to t.i.d. p.r.n. 8. Reglan 10 mg q.i.d. 1 hour AC and h.s. 9. Carafate 1 gram q.i.d. AC and h.s. 10. Metamucil daily. 11. MiraLax 17 grams daily. FAMILY HISTORY: Grandparents died from heart disease in their 80s.
AC|acromioclavicular|AC|154|155||A head CT scan was negative. Very likely a diabetic-related problem, but the EEG has been done, and we will see those results. 2. Left shoulder fracture, AC joint equivalent, but it is the distal clavicle. Treatment is sling for a few weeks. 3. Cervical fracture. Treatment is a Philadelphia collar. We will obtain an x-ray with flexion and extension views.
AC|(drug) AC|AC|178|179||PAST MEDICAL HISTORY: Does not include any gallbladder problems. Her gallbladder is in and her only medical problem is scoliosis. She takes no medication but did try some Pepcid AC which did not help her and she is allergic to penicillin. REVIEW OF SYSTEMS: She denies fevers chills or sweats except the chills on _%#MM#%_ _%#DD#%_.
AC|acromioclavicular|AC|215|216||She points to volar aspect for the worst discomfort. The amount of bruising is compatible with something that is a few days old. She denies any other injuries except some vague left shoulder pain. She points to the AC joint. She denies radiculopathy, primary neck pain, but there is some complaints in the trapezius rhomboid area. The patient has been in the hospital here for a neurological evaluation and apparently is being cleared for discharge now.
AC|acromioclavicular|AC|127|128||Pulses normal and symmetric. Median, radial and ulnar nerve functions intact. Left shoulder, she gets some vague discomfort in AC joint but she is able to fully elevate it and says the pain is mild. There is no bruising noticed. Distally in the left arm, elbow, wrist and fingers are normal.
AC|acromioclavicular|(AC)|155|158||16. Left shoulder motion 135/90/ L2/ 60. There is no significant swelling or ecchymosis. She has very well localized tenderness over the acromioclavicular (AC) joint with less tenderness laterally over the subacromial space. A minimal tenderness in the trapezial musculature. Negative impingement sign.
AC|acromioclavicular|AC|167|168||We do not have the MRI studies to review to confirm or refute that at this time. 1. We will obtain plain films to rule out osteoarthritis of the glenohumeral joint or AC arthrosis. She had a cortisone injection that provided minimal relief. The injection sounded to be subacromial. If she has glenohumeral arthritis, she may benefit from a steroid injection of the glenohumeral joint.
AC|adriamycin cyclophosphamide|AC|310|311||She has normal liver function tests. ASSESSMENT AND PLAN: Right breast cancer, infiltrating, lobular and ductal carcinoma with multiple primary, T2 N2 M0 stage IIIA right breast cancer, status post mastectomy and axillary node dissection with instant saline expander. Status post chemotherapy using dose dense AC and Taxol. The patient was recommended to use to receive radiation to her right chest wall as well as nodal chains.
AC|adriamycin cyclophosphamide|AC|172|173||This was fully evaluated by a urologist according to patient. PAST MEDICAL HISTORY: 1. Previous history of breast cancer, right side, which was treated with mastectomy and AC chemotherapy. 2. Tubal ligation in 1987. 3. Bladder problem. FAMILY HISTORY: Father had prostate cancer. Paternal aunt had breast cancer. SOCIAL HISTORY: The patient used to smoke and quit 20 years ago, now using nicotine gum.
AC|acromioclavicular|AC|182|183||2. Severe osteoarthritis of the right knee. X-rays taken three views of shoulders stated showing type III acromion process, mild arthritic change of the joint and moderate to severe AC joint changes. AP of the both knees was also taken showing moderate to severe arthritic changes to the knee patellar joint.
AC|acromioclavicular|AC|215|216||Extremities: Right shoulder is without atrophy or deformity. It is intact without erythema, edema, or ecchymoses. The patient denies pain in the scapula on palpation. The patient admits to mild pain on palpation of AC joint. Admits to "tightness" on elevation and internal rotation. Denies acute pain with active range of motion or passive range of motion.
AC|(drug) AC|AC|189|190||ALLERGIES: None known to medications. Intolerance to latex. CURRENT MEDICATIONS: Include, MSSA withdrawal protocol using Ativan Thiamine 100 mg q.d. times 3, Effexor XR 225 mg q.d., Pepcid AC 10 mg b.i.d. with p.r.n. Tylenol, Milk of Magnesia, and Maalox. A multivitamin 1, p.o. q.d. FAMILY HISTORY: Remarkable for hypertension, diabetes, myocardial infarction, stroke and cancer.
AC|acromioclavicular|AC|202|203||Her internal rotation on the right compared with the left is about L5 and on the left side it is about T12. Her external rotation is about 30 degrees of the right shoulder. She has no tenderness at the AC joint. Review of an MRI shows she has a full thickness supraspinatus tear consistent with a rotator cuff tear. Examination of the left lower extremity reveals a black subcutaneous wound.
AC|acromioclavicular|AC|148|149||All major joints with normal alignment, contour, without atrophy. Good strength with the exception of the left shoulder, very positive impingement. AC joint mildly tender. Strength 5-/5, passive range of motion with assistance 140/80/70/60. Fairly prominent spasms in rhomboid, levators. Elbows with full range of motion, stable, no obvious deformity or pain.
AC|(drug) AC|AC|193|194||RECOMMENDATION: The patient's respiratory symptoms will be monitored. She will be given intravenous fluids and intravenous potassium. Albuterol nebulizer treatments will be started. Robitussin AC will be started. Further electrolytes will be repeated in the morning. Further respiratory evaluation will be predicated on her clinical course.
AC|acromioclavicular|AC|165|166||She had significant worsening pain and redness, however, and was seen by Dr. _%#NAME#%_ in consultation. Scan was done which apparently showed infection in her left AC joint. She has now been admitted, Levaquin was started and I&D was done with cultures now pending. PAST MEDICAL HISTORY: Prior deep venous thrombosis and pulmonary embolism.
AC|adriamycin cyclophosphamide|AC|207|208||There was one sentinel lymph node positive. This did not have extracapsular extension. No other lymph nodes were positive on full axillary dissection. She had a13 total lymph nodes removed. She is receiving AC chemotherapy times four cycles. Her last cycle is scheduled to begin _%#MMDD2003#%_. PLAN: As per Dr. _%#NAME#%_'s note, it seems like the patient is planed to be on Arimidex.
AC|acromioclavicular|AC|198|199||Normal skin. Normal neurovascular function. Radiographs of the right shoulder dated _%#MMDD2005#%_ were evaluated. There is fracture involving the distal clavicle approximately 5 cm proximal to the AC joint. There is evidence of a radiolucent lesion within the bone at that level consistent with pathologic fracture. IMPRESSION: Pathologic fracture, right distal clavicle. Unknown primary neoplasm. PLAN: My recommendation is completion of the metastatic workup.
AC|adriamycin cyclophosphamide|AC|157|158||The tumor size was 6 x 5.8 x 1.8 cm with positive lymphangitic involvement. The patient then went on to have adjuvant chemotherapy consisting of 4 cycles of AC followed by Taxol and Herceptin. The patient says that she tolerated the chemotherapy fairly well aside from nausea and fatigue.
AC|adriamycin cyclophosphamide|AC|111|112||PROBLEM: T2, N2 infiltrating ductal carcinoma of her left breast, status post modified mastectomy, status post AC chemotherapy x 4, status post Taxol chemotherapy x 2 of a planned four cycles. The patient was seen in consultation by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_.
AC|adriamycin cyclophosphamide|AC|254|255||_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Left breast cancer, T2, N2, M0 infiltrating ductal carcinoma, status post modified radical mastectomy, status post four cycles of AC chemotherapy, status post two cycles of Taxol of the planned dose of four cycles. HPI: 54-year-old female patient who was found to have a left breast mass and left axillary lymph node which was diagnosed in _%#MM2003#%_ as cancer.
AC|(drug) AC|AC|100|101||No purulence or signs of deep space infection was noted. I recommend wound care as follows: Aquacel AC dressing changes every day. Cover this with gauze. Also recommend pressure reduction AFO to the left lower extremity. He needs to take complete weight off the posterior aspect of the left heel so this has a chance to heel.
AC|adriamycin cyclophosphamide|AC|303|304||The patient was seen by Dr. _%#NAME#%_ _%#NAME#%_ at Fairview-University Medical Center on _%#MMDD2004#%_ and the patient was eventually started on chemotherapy with Taxol to which she developed an allergic reaction. Therefore, chemotherapy was changed to AC and she has finished her scheduled cycle of AC chemotherapy. The patient is seen by us for radiation therapy post chemotherapy. PAST MEDICAL HISTORY: Essentially unremarkable. She has a history of depression and has used Prozac and Zoloft.
AC|before meals|AC|184|185||2. Status post Whipple procedure for excision of adenocarcinoma of the head of the pancreas. RECOMMENDATIONS: 1. No insulin following discharge at least initially. 2. Test blood sugar AC and HS and record in log book. 3. Call if blood sugars rise to greater than 200 so that Lantus insulin could be reinitiated.
AC|acromioclavicular|AC|322|323||Examination of the cervical area indicates no pain between the spinous processes, no pain in the right paraspinal muscles, no pain in the right suboccipital area, no pain over the supraspinatus or the scalenes on the right. On the left she has specific tenderness over the supraspinatus on the left. She has pain over the AC joint, pain over the bicep tendon, negative arc, negative flexion, negative Adson maneuver. Examination of her suboccipital area indicates point tenderness there but nonradicular and I palpated all along the base of the skull to see if there was any pain radiating off the occipital nerve and it did not.
AC|acromioclavicular|AC|210|211||Both were tender to palpation in the posterior aspect of the glenohumeral joint as well as she states they were also tender deep within the joint. She is nontender to palpation along the clavicle and scaphoid. AC joint is nontender. She is nontender over her rotator cuff bilaterally. Strength and sensation are intact bilaterally. Strength is noted to be 5/5 bilaterally.
AC|acromioclavicular|AC|340|341||He has full range of motion of both elbows without pain or tenderness to palpation and a normal neurologic exam distally, with normal strength in groups tested. Normal sensation to light touch posterior radial pulse. LABORATORY DATA: X-rays were reviewed, including three views of the right shoulder, which showed type II acromion and mild AC joint arthritis and subsequent ____ greater tuberosity, consistent with chronic impingement. ASSESSMENT/PLAN: Right shoulder rotator cuff tendonitis with impingement. I explained to _%#NAME#%_ his diagnosis and my recommended treatment, which would include ice, anti-inflammatories, and exercises, which I demonstrated for him in the office today.
AC|acromioclavicular|AC|170|171||Findings on that show tendinosis of the supraspinatus but no other problems are noted. The patient is coming in for surgical intervention, presumably ASD, debridement of AC joint, and possibility open rotator cuff repair if clinically one is found. ALLERGIES: SULFA, NOT ANAPHYLACTIC. CODEINE--NAUSEA.
AC|adriamycin cyclophosphamide|AC|181|182||SLEEP: Negative PAIN: Negative. LABORATORY DATA: Normal. CHEMO/RADIATION TREATMENT HISTORY: She is having her second Taxol today and her third Herceptin. She has had four cycles of AC ALLERGIES: No known allergies PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 108/64, pulse 69, respirations 18, temperature 97.5, and height 67 inches.
AC|acromioclavicular|AC|135|136||The patient complains of ongoing difficulty with right shoulder pain secondary to an injury to his right shoulder when he sustained an AC separation some months ago. He has since that time re- injured the shoulder at least two different times. He has been seen by a surgeon, who recommended surgical intervention at some point in the future, although it was felt that a more stable living environment would be required before he could plan to undergo this surgery.
AC|(drug) AC|AC|143|144||1. GERD well controlled with Pepcid AC over the counter. He does not get the GERD very often, but when he does he just takes one of his Pepcid AC pills and he does fine. 2. Alcohol abuse. 3. Depression. 4. Paranoia. MEDICATIONS: Admission medications: Chart says he is taking Protonix 40 mg a day and Abilify 15 mg a day and Seroquel 25 mg b.i.d. has been initiated in the hospital, but the patient denied taking any of these medications in fact says he has been taking no medications at all.
AC|(drug) AC|AC.|148|150||PAST MEDICAL HISTORY: 1. Psychiatric history of depression with psychoses. 2. Mild gastroesophageal reflux disease (GERD) for which he takes Pepcid AC. Currently has no symptoms of GERD. 3. Prior suicide attempt in 2002. 4. Chemical dependency issues with treatment for alcohol in 1994 and 1995.
AC|acromioclavicular|AC|285|286||FAMILY HISTORY: Not obtainable. PHYSICAL EXAMINATION: The patient is a 62-year-old gentleman who is pleasant, alert and oriented, appears fairly healthy. He has some deterioration of his posterior shoulder girdle muscle, tenderness along the glenohumeral joint line, tenderness in the AC joint. The AC joint does not appear enlarged or disproportionate compared to the left shoulder. Elevation is to 40 degrees, external rotation 40 degrees, internal rotation TIO.
AC|adriamycin cyclophosphamide|AC|95|96||She has had progressive bilateral forefoot problems and acquired flatfoot deformities. Current AC status approximately six days status post surgery. She has developed a low-grade temperature and increased pain and swelling of both feet and a foul odor regarding the dressings and cast.
AC|acromioclavicular|(AC)|149|152||Shoulder motion per se does not cause any pain. Resisted supraspinatus function does not cause pain. She is mildly tender over the acromioclavicular (AC) joint and when I forcibly adduct her shoulder with her shoulder flexed in 90 degrees it does cause some pain, but the majority of the pain occurs after I move the shoulder around rather than during the shoulder movement.
AC|adriamycin cyclophosphamide|AC|222|223||PSYCH: Anxiety with patient exam today but otherwise normal. SLEEP: Negative PAIN: Negative. LABORATORY DATA: Pending from today FAMILY HISTORY/SOCIAL HISTORY: No change CHEMO/RADIATION TREATMENT HISTORY: She has had four AC and we are going to go on to Arimidex. ALLERGIES: Aspirin, sulfa PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 118/80, pulse 88, respirations 20, temperature 98.5, and weight 174.
AC|adriamycin cyclophosphamide|AC.|262|264||No palpable axillary lymphadenopathy. LUNGS: Essentially clear. HEART: Regular sinus rhythm. ABDOMEN: Unremarkable. EXTREMITIES: Unremarkable. ASSESSMENT/PLAN: 61-year-old female patient who has most likely Stage 2 or 3 breast cancer, status post four cycles of AC. The patient is going to be seen by Dr. _%#NAME#%_ and her surgical procedure will be decided upon.
AC|acromioclavicular|AC|182|183||He denies lightheadedness. PAST MEDICAL HISTORY: 1. Mild intermittent asthma. 2. Diverticulosis. 3. Hyperlipidemia. 4. Osteoarthritis. 5. Status post acromioplasty in 1982. 6. Right AC joint repair. 7. Status post right elbow arthroscopy of the tendon groove in 1994. 8. Status post left elbow arthroscopy of the tendon groove in 1992.
AC|acromioclavicular|AC|266|267||LABORATORY DATA: X-rays today, multiple views of the left knee do show some mild to moderate degenerative joint disease. No evidence for fracture on plain films. Three views of her left shoulder, shoulder is located in good position, no degenerative change, minimal AC degeneration. Labs, white count is 13.7. Cultures are negative. Crystalline exam pending, uric acid 10.9 which is elevated.
AC|acromioclavicular|AC|131|132||We were consulted secondary to the fact that three days ago, he fell on his right shoulder and has had a significant pain near the AC joint. X-rays on admission showed a fracture of the distal one-third clavicle. Orthopedic consultation was requested. He is right hand dominant. He denies previous shoulder injury it is a deep achy pain.
AC|adriamycin cyclophosphamide|AC|162|163||The patient had two sentinel lymph nodes which were negative. ER and PR were negative. Her-2/neu was negative. The patient is scheduled to received six cycles of AC chemotherapy by Dr. _%#NAME#%_. The patient had a prolonged third and fourth cycle because of low blood counts. The patient did not have any hospitalizations or infections. The patient is receiving dose #5 for cycle #5 of chemotherapy today.
AC|adriamycin cyclophosphamide|AC|120|121||Has been on AC chemotherapy. Exam: Well-healed lumpectomy site. Assessment and Plan: She is planned to receive 6 cycles AC and is at 5th cycle; will see her after her chemotherapy. Post-chemotherapy radiation treatment was recommended.
AC|acromioclavicular|AC|239|240||Her mood and affect are normal. Examination of her right shoulder demonstrates some mild ecchymosis along the proximal biceps. She is tender to palpation in her biceps tendon proximally. She has no tenderness at the SE joint, clavicle, or AC joint. Her passive range of motion is forward flexion 165, abduction 150, external rotation 10. Active range of motion is slightly less. Her sensation to light touch is fully intact over her hand and forearm.
AC|acromioclavicular|AC|239|240||AAROM (active assisted range of motion) passively 120s-140s, 90/80/40. There is no effusion of the joint. Referred subdeltoid pain is present. External rotators are weak as are internal. Bicipital groove is nontender. Sternoclavicular and AC joint benign. Opposite shoulder was examined for comparison; elbow, wrist, good grip, negative exam for acute problems. X-rays reviewed, three views of the shoulder on the hospital computer.
AC|(drug) AC|AC|122|123||2. Right IHR. 3. UHR. 4. Several other spinal surgeries. 5. Tonsillectomy. 6. Vasectomy. ADMISSION MEDICATIONS: 1. Pepcid AC 10 mg p.o. q. day. 2. Vitamin C 1 tablet p.o. q. day. 3. Multivitamin 1 tablet p.o. q. day. 4. Fiber tablets 1 tablet p.o. q. day.
AC|adriamycin cyclophosphamide|AC.|219|221||At that time, she had a lumpectomy on _%#MMDD2003#%_. She had a primary size of 3.9 x 1.8 cm, ER positive, PR negative and HER-2/neu positive. The sentinel node showed 5/7 positive lymph nodes. She received 4 cycles of AC. At that time, we recommended radiation treatment which she declined, as well as tamoxifen. Unfortunately, she developed recurrence on the same side and had a bilateral mastectomy with grade 3, 4.5 cm tumor with extensive lymphatic invasion.
AC|acromioclavicular|AC|246|247||Chest and abdomen show no subcutaneous crepitation or emphysema. He has normal bowel sounds, normal airway pattern. The left hemithorax demonstrates tenderness at the mid-shaft clavicle without significant rotational or shortening deformity. The AC and SE joints are nontender with normal findings. His motor function is otherwise unremarkable in the upper extremity with normal deltoid, bicep, tricep and distal motor function.
AC|before meals|AC|92|93||5. Hypothyroidism a. By history, well controlled. 6. Morbid obesity. SUGGESTIONS: 1. Sugars AC and h.s. in hospital as well as at 0200 to watch for hypoglycemia 2. Maintain usual regimen of NovoLog 70/30 but at decreased doses due to controlled environment and decreased calories.
AC|acromioclavicular|(AC)|156|159||At first she stated that her shoulder pain was on the right and so shoulder exam was performed on that side. She had no tenderness at the acromioclavicular (AC) joint and no pain with abduction across her chest. She had full forward flexion in internal and external rotation without pain.
AC|(drug) AC|AC|160|161||2. Alprazolam 0.25 mg p.r.n. 3. Toprol XL 100 mg q.d. 4. Estradiol 0.5 mg q.d. 5. Allegra 60 mg b.i.d. 6. Flonase 15 mcg q.d. 7. Celebrex 200 mg q.d. 8. Pepcid AC 10 mg b.i.d. 9. Multivitamins q.d. 10. Tums one to three tabs q.d. ALLERGIES: Penicillin, MSG, sulfides, grass, pollen, smoke, red dye in foods and dust.
AC|acromioclavicular|AC|167|168||Initially close margin medially of 1 mm was re-excised for a negative margin. She had an Oncotype DX tested, which yielded a score of 13 and the patient opted to have AC chemotherapy. She is scheduled to have her 4th and final AC chemotherapy on _%#MMDD2007#%_. The patient, aside from some fatigue, is continuing to work one of her jobs.
AC|anticoagulation|AC|229|230||EXTREMITIES: Ankle edema, 1+. NEURO: No obvious focal signs. SKIN: No petechiae, purpura, or nodularity. LAB DATA: Hemoglobin was 8.4 prior to transfusion and now is 10.6. PTT initially was greater than 240 (she had been getting AC for DVT previously), INR 1.9. Sodium 136, potassium 3.7, chloride 100, CO2 17, creatinine 4.0 (versus 3.8 versus 2.8 versus 1.8 versus 1.2 versus 0.7 on _%#MMDD2004#%_).
AC|acromioclavicular|(AC)|93|96||DOB: _%#MMDD1995#%_ ORTHOPEDIC CONSULTATION CHIEF COMPLAINT: Rule out left acromioclavicular (AC) joint injury, shoulder. HISTORY: The patient is a 9-year-old boy whom I was asked to consult upon by Dr. _%#NAME#%_ for an evaluation of his left shoulder.
AC|acromioclavicular|AC|162|163||The left shoulder has a mild abrasion posteriorly. There is no ecchymosis or swelling specifically about the AC joint. There is absolutely no tenderness over the AC joint. He is moving his shoulder well in the hospital bed without pain. There is a question of slight instability of the left AC joint versus the right, but again it is completely nontender and I suspect that this is a nonspecific nonpathologic finding.
AC|acromioclavicular|AC|194|195||X-rays reviewed from the Emergency Room include two AP views, as well as an axillary view. The glenohumeral joint is well reduced. There are no views of the right shoulder for comparison of the AC joint. It is difficult to make any definitive statements regarding the x-rays until comparison views of the right shoulder are made, and I do not believe that that is indicated at this time.
AC|acromioclavicular|AC|127|128||On the left shoulder impingement tests are negative. Abdominal compression tests are negative. There is no tenderness over the AC joint in either shoulder. I have reviewed the MRI study obtained on _%#DDMM2002#%_. There is evidence for tendinitis and partial thickness tearing involving the articular surface of the mid and distal supraspinatus tendon without evidence of full thickness tearing.
AC|acromioclavicular|AC|204|205||Palpation of reveals no tenderness of the left shoulder, however, there is generalized tenderness over the anterolateral and posterior aspects of the right shoulder girdle. There is no bony tenderness or AC joint tenderness bilaterally. Passive range of motion of the left shoulder shows external rotation of 70 degrees, internal rotation to T7, adduction to 100 degrees and elevation of 180 degrees.
AC|acromioclavicular|AC|188|189||ABDOMEN: Soft and not tender. No hepatosplenomegaly, and bowel sounds are present. MUSCULOSKELETAL: Examination of the left clavicle does with palpation does not elicit pain nor along the AC joint. She has no pain with palpation all along the left elbow. Turning her on her back reveals with the 2 Duragesic patches.
AC|acromioclavicular|AC|179|180||This motion is somewhat improved from her exam of _%#MMDD2002#%_. She has fairly well localized tenderness over the right coracoclavicular arch and anterior shoulder capsule. The AC joint is not tender. Impingement sign is negative. There is no rotator cuff weakness. Neurovascular exam is intact in the right upper extremities.
AC|acromioclavicular|AC|162|163||LYMPHATIC: Negative. Range of motion is symmetric. She has good cuff strength. Radiographs were taken. I reviewed the report. There appears to be effusion of the AC joint and no other diagnostic abnormality. No arthrosis or fracture is seen. My diagnostic impression at this time is impingement syndrome, right shoulder.
AC|before meals|AC,|184|186||Goal in the 2 to 3 range, particularly with the patient's known valve replacement. 4. Encourage p.o. fluids. 5. Tylenol p.r.n. for now for knee discomfort. 6. Monitor Accu-Ceks q.i.d. AC, with staff to call p.r.n. blood sugar less than 80 or consistently greater than 200. Thank you for the consultation. Will follow along with you.
AC|(drug) AC|AC.|248|250||She denies any recent new medical problems. PAST MEDICAL HISTORY: Notable for prior CVA with residual left- sided weakness, atrial fibrillation, hip fracture and she has a Greenfield filter. CURRENT MEDICATIONS: 1. Atenolol. 2. Prinivil. 3. Pepcid AC. ALLERGIES: Aspirin. REVIEW OF SYSTEMS: CARDIOVASCULAR: Denies any chest pain. Does have occasional shortness of breath.
AC|before meals|AC,|146|148||Adequate control. 12. Surgeries, as above. 13. Nicotine addiction. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Accu-Cheks q.i.d., AC, and h.s. Continue regimen of Glucophage. Moderate in intensity carbohydrate diet. NovoLog correction factor using very low scale. 3. Add hemoglobin A1c to labs. 4. Review/resume home meds as appropriate.
AC|acromioclavicular|AC|168|169||LABORATORY & DIAGNOSTIC DATA: I reviewed radiographs. The x-rays were actually of the right shoulder, did not show any evidence of fracture. He has a very degenerative AC joint. ASSESSMENT/PLAN: He has AC joint arthritis on the right, which is not currently symptomatic.
AC|(drug) AC|AC.|202|204||Indicates a similar sensation since early childhood. Asymptomatic with lesser activity. No orthopnea or PND, no cough. Denies nausea or vomiting. Indicates daily dyspepsia, usually relieved with Pepcid AC. No abdominal pain, diarrhea or constipation. No signs of GI blood loss. Voiding symptoms as above. No arthralgias or rash. No focal neurologic complaint. OBJECTIVE: A mildly overweight young adult male in no distress.
AC|adriamycin cyclophosphamide|AC|145|146||HISTORY OF RADIATION: 5940 centigrade to the left chest wall adjuvantly completed _%#MM2005#%_ at MRO (Dr. _%#NAME#%_). HISTORY OF CHEMOTHERAPY: AC x4, Taxol weekly x12, Xeloda, as above. KPS score: 60-70 approximately. ASSESSMENT: Ms. _%#NAME#%_ is a 75-year-old Caucasian female with metastatic breast cancer, manifested with a cutaneous metastasis and skin involvement, which have now progressed on chemotherapy.
AC|acromioclavicular|AC|221|222||NEUROLOGIC: Intact sensation and motor. LYMPHATIC: No epitrochlear nodes. He has limited active range of motion of the right shoulder. Limited passive range of motion. He has a prominence about the superior aspect of the AC joint about the size of a large super ball. Examination of his contralateral shoulder reveals intact skin and intact neurovascular status.
AC|acromioclavicular|AC|244|245||He has diminished median nerve sensation bilaterally. IMPRESSION: 1) Clinical evidence of rather severe carpal tunnel syndrome bilaterally. 2) History of rotator-cuff disease right shoulder with probable rotator- cuff arthropathy, degenerative AC joint disease and overlying synovial cyst formation. DISCUSSION: The patient does plan to be discharged tomorrow. We do not have the results of the EMGs from _%#MM#%_ of this year.
AC|adriamycin cyclophosphamide|AC,|197|199||CHANGE IN FAMILY HISTORY/SOCIAL HISTORY: No change in social/family history except her son is depressed. Her daughter had some cutting problems. CHEMO/RADIATION TREATMENT HISTORY: She has had four AC, tamoxifen, and radiation. ALLERGIES: No known allergies. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 120/70, pulse 72, respirations 16, temperature 97.8, and weight 131.
AC|antecubital|AC|210|211||PHYSICAL EXAMINATION: VITALS: The patient is afebrile. Blood pressure is 135/66, respiratory rate 8, and heart rate 70. Last bowel movement prior to admission. Current IV access is right subclavian line, right AC line, left AC line. Vent per RT. Pulse ox is 96%. HEENT: Intubated. No excessive oral secretions. Neck: Left positive jugular venous distention. No carotid bruits. LUNGS: Diminished throughout bilateral, silent bases laterally.
AC|acromioclavicular|AC|155|156||NEUROPSYCHE: Normal. Cranial nerves II-XII were intact and equal. NECK: The left side of his neck is tight with some spasm. MUSCULOSKELETAL: Clavicles and AC joints benign. The entire left shoulder girdle is very swollen. No open wounds. Scrapes and moderate bruising, apex. Right shoulder negative.
AC|acromioclavicular|AC|216|217||He is alert and oriented, answering questions appropriately. RIGHT UPPER EXTREMITY: Examination of his right shoulder reveals no ecchymosis, bruising or lesions. He complains of some tenderness to palpation over the AC joint. He has greater pain over the deltoid area. He cannot lift the arm actively against gravity, but passively he can bring it up to full range of motion.
AC|adriamycin cyclophosphamide|AC|233|234||Patient was asked to see us by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ for locally advanced breast cancer post-chemotherapy and surgery. PROBLEM: Left breast cancer, T4 N1 M0 status post neoadjuvant chemotherapy with AC and Taxol status post modified radical mastectomy and axillary node dissection sampling on the left side and simple mastectomy of the right side.
AC|acromioclavicular|AC|173|174||He has tenderness to palpation over the superior posterior shoulder that is diffuse. He is otherwise neurovascularly intact distally with no rashes or skin breakdown and no AC joint tenderness to palpation. IMAGING STUDIES: Radiographs are unremarkable with respect to the right shoulder. IMPRESSION: Question re-injury of right shoulder. DISPOSITION: At this point we will get an MRI on him when he is medically able.
AC|acromioclavicular|AC|261|262||Please see consultation note from _%#MMDD2007#%_ by me. Very briefly, again, she is a 50-year-old right-handed woman with osteoporosis and lupus who fell at home 4 nights ago. She sustained a distal left clavicular fracture, mildly displaced, not involving the AC joint and also a distal left fibular avulsion fracture with superior retraction of the fragment. In addition, she had a left mildly displaced fracture of the mid body of the calcaneus.
AC|acromioclavicular|AC|98|99||DOB: _%#MMDD1949#%_ PREOPERATIVE DIAGNOSIS: Right shoulder rotator cuff tear with impingement and AC joint arthrosis. POSTOPERATIVE DIAGNOSIS: Right shoulder rotator cuff tear with impingement and AC joint arthrosis.
AC|acromioclavicular|AC|144|145||The ............. were assessed. Anterior acromion was resected with acromioplasty with ...... ..................and a two-step excision of the AC joint was performed, conserving the ..............capsule. A ..............bursectomy was performed, ......................of the rotator cuff were debrided, and the rotator cuff was repaired back to hold on to the anterior tuberosity.
AC|acromioclavicular|AC|155|156||During the exam today, is somewhat of a forward head position. No pain along the supraspinatus and the muscles does not feel tight there. No pain over the AC joint of the biceps tendon, negative arc and she has good range of motion to her left arm and is able to follow the command of raising her arm up.
AC|(drug) AC|AC|129|130||6. Prinivil 10 mg q day. 7. Lasix 40 mg q day. 8. KCL 20 meq q day. 9. Neurontin 300 mg b.i.d. with 600 mg at HS. 10. Robitussin AC 1 to 2 teaspoons q 4 hours p.r.n. cough. 11. Nitroglycerine sublingual p.r.n. chest discomfort, may repeat times three. 12. Morphine sulfate 5 mg per 5 cc q 2 hours p.r.n. chest pain unrelieved with Nitroglycerine.
AC|acromioclavicular|AC|137|138||Her muscle strength is supraspinatous 4+ and external rotation 4+, limited mainly by pain. She has tenderness to palpation both over the AC joint and over the subdeltoid bursa. No evidence for instability. At the left hip there is no erythema, ecchymoses or other rashes.
AC|acromioclavicular|AC|165|166||There is a displaced distal clavicle fracture. There was elevation of the medial component of the fracture. There is approximately 2 cm of distal bone intact at the AC joint. The glenohumeral joint is located. There is arthritic narrowing of the AC joint. Diffuse osteopenia. IMPRESSION: Closed left displaced distal clavicle fracture. PLAN: I had a long discussion with the patient and his daughter regarding the shoulder.
AC|acromioclavicular|AC|138|139||There is approximately 2 cm of distal bone intact at the AC joint. The glenohumeral joint is located. There is arthritic narrowing of the AC joint. Diffuse osteopenia. IMPRESSION: Closed left displaced distal clavicle fracture. PLAN: I had a long discussion with the patient and his daughter regarding the shoulder.
AC|acromioclavicular|AC|119|120||She did note that she had mild headache and indicated the front of her forehead. PAST MEDICAL HISTORY: Significant for AC joint separation suffered when she was hit by a car in _%#MM2003#%_. She denied any associated head injury or other severe injury.
AC|adriamycin cyclophosphamide|AC.|149|151||LABS: Labs are today. Her MUGA was 64%. SOCIAL/FAMILY HISTORY: No change. CHEMOTHERAPY HISTORY: She has had two AC to date, and is due for her third AC. She will go on to Taxol when she is finished. ALLERGIES: Bee stings. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 124/75, pulse 90, respirations 10, temperature 97.4, weight 149.
AC|acromioclavicular|AC|195|196||TBA _%#MMDD2002#%_. _%#NAME#%_ _%#NAME#%_ is a 49-year-old gentleman who has been followed in my office for evaluation of his left shoulder. He has undergone an MRI examination which showed some AC arthrosis. There was no evidence of rotator cuff tearing. He has had impingement findings and had an injection in the subacromial space which gave him 50% relief up until recently.
AC|acromioclavicular|AC|183|184||Examination of the left shoulder demonstrates mild degree of ecchymosis over the superior aspect of the shoulder. The skin is intact. Tender to palpation over the distal clavicle and AC joint. No palpable crepitance. There is no tenting of the skin. Range of motion of the shoulder was not performed due to the patient's discomfort.
AC|acromioclavicular|AC|204|205||I reviewed the chest film and I do not see any obvious glenohumeral pathology on the left. I think it is appropriate to get the MRI scan mainly because I am concerned about this soft tissue change at the AC joint. I suspect there is going to be some fluid, probably related to degenerative AC changes. He has no obvious external signs of infection which is also a possibility.
AC|acromioclavicular|AC|199|200||I think it is appropriate to get the MRI scan mainly because I am concerned about this soft tissue change at the AC joint. I suspect there is going to be some fluid, probably related to degenerative AC changes. He has no obvious external signs of infection which is also a possibility.
AC|adriamycin cyclophosphamide|AC|269|270||NEUROLOGIC: Cranial nerves II-XII are intact. ASSESSMENT AND PLAN: The patient with a 1.2 cm infiltrating ductal cancer, strongly ER/PR positive with one lymph node at 1.1 cm, HER-2/neu negative. The patient will get the rest of her workup; will plan on four cycles of AC followed by tamoxifen. She will get post- radiation once her chemotherapy is complete. Will get her started once the drain is out and her incision is healed, probably in one and a half weeks.
AC|acromioclavicular|AC|197|198||X-RAY: I reviewed several of the patient's x-rays. Films of the left shoulder (three views) taken in the emergency room earlier today revealed no fractures. He does have some mild arthrosis of the AC joint. X-rays of the right knee, right lower leg and right ankle (multiple views) reveal a fracture of the proximal fibula at the neck level, nondisplaced.
AC|acromioclavicular|AC|211|212||PHYSICAL EXAMINATION: GENERAL: In no acute distress, very pleasant. VITAL SIGNS: Blood pressure 168/82, pulse 64, respirations 18, afebrile. Sats on room air 94%. HEAD AND NECK; Atraumatic. SHOULDERS: Crepitus, AC joint tenderness but no specific abnormalities. Passive range of motion is good. CHEST WALL: Negative. ABDOMEN: No rebound or guarding.
AC|adriamycin cyclophosphamide|AC.|172|174||After four cycles of Taxotere, her chemotherapy has changed to AC which gave her a satisfactory response and a regression of the tumor. She received a total of 6 cycles of AC. She underwent a modified radical mastectomy on the left side with a left axillary node dissection at level 1 and 2. She also had a prophylactic mastectomy on _%#MMDD2004#%_. The specimen from the left modified radical mastectomy reveals no evidence of invasive or intraductal carcinoma.
AC|adriamycin cyclophosphamide|AC,|223|225||She was ER/PR and HER- 2/neu negative. CHEMO & RADIATION THERAPY HISTORY: The patient underwent a study with cytoreductive, and was given taxotere initially. After four cycles, she had no shrinkage, and she was switched to AC, and had six cycles of AC, and had seen shrinkage. She had breast irradiation from _%#MM#%_ 2004 to _%#MM#%_ 2004.
AC|(drug) AC|AC.|170|172||1. Hypercholesterolemia. 2. Status post wisdom tooth extraction 30 years ago. 3. Status post tonsillectomy as a teenager. MEDICATIONS: 1. Percodan. 2. Lipitor. 3. Pepcid AC. ALLERGIES: No known drug allergies. HABITS: The patient has smoked less than 1 pack of cigarettes per day for 40 years on and off.
AC|acromioclavicular|AC|212|213||PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 120/80. HEENT: Negative. NECK: Supple. UPPER EXTREMITIES: Both shoulders exhibit evidence of chronic arthritic changes and probable rotator cuff arthropathy, and AC joint arthrosis. Upper extremity strength is good with no long tract signs. LOWER EXTREMITIES: Right lower extremity is very tender. Knees are benign.
AC|acromioclavicular|AC|255|256||When I palpate along the scalene, he does have pain that goes beyond the area that I am palpating and he defines it as a burning-prickling sensation. I palpated along the brachial plexus; he denies any pain. I examined the left shoulder. No pain over the AC joint. No pain of the biceps tendon. Negative arc, negative flexion. Good range of motion to flexing both shoulders up against resistance, good strength to abduction, adduction, flexion, extension, and hand grasp is equal and strong.
AC|acromioclavicular|AC|312|313||His right upper extremity is quite spastic. He has pain with any motion of his right shoulder and he is tender, especially over the anterior, superior aspect of his shoulder. There is no obvious deformity. There is no swelling. X-ray examination of the right shoulder shows some mild degenerative changes in the AC joint, but is, otherwise, normal. ASSESSMENT: Right shoulder pain consistent with subacromial bursitis and rotator cuff tendonitis secondary to a recent fall.
AC|adriamycin cyclophosphamide|AC,|147|149||The patient also had some fibrocystic changes and terminal duct hyperplasia on her right breast. She underwent a lumpectomy, and had two cycles of AC, but did not tolerate that. She had some problems with her blood counts, and it was stopped on _%#MMDD2007#%_. She had radiation to her left breast on _%#MMDD2007#%_. The patient had a hemoglobin of 12.2 in _%#MM#%_, with a white count of 5.2. When she started chemo, her hemoglobin dropped.
AC|adriamycin cyclophosphamide|AC|216|217||We then talked about the possibility of either adriamycin/Cytoxan every three weeks, for a total of four cycles versus taxotere/Cytoxan also given every three weeks for four cycles, which is probably superior to the AC regimen. If one wished to be a little more aggressive, another alternative would be to use FEC every three weeks for three cycles followed by taxotere every three weeks for four cycles.
AC|before meals|AC.|113|115||2. Flomax, 0.4 mg p.o. q. day at h.s. 3. Ditropan XL, 10 mg p.o. q. day at h.s. 4. Prevacid, 30 mg q. day q.a.m. AC. 5. Warfarin, 2 mg q. day q.a.m. 6. Lasix, 40 mg q.a.m. 7. Advair, 500/50 one inhalation b.i.d. 8. Combivent, 2 puffs q. 4-6 hours p.r.n. 9. Xopenex/Atrovent nebulizer treatments, as needed up to every 4 hours.
AC|acromioclavicular|AC|180|181||SKIN: Without obvious lesions. LYMPHATICS: Negative. EXTREMITIES: Pulses 4+ and equal as best able to check with the well splinted foot. The shoulder is tender _________; shoulder AC joint. Scapula itself is negative. Elbows, wrists normal grip. Movement of the neck is normal. NEUROLOGICAL including motor, sensory and reflexes, as best able to be checked are normal.
AC|(drug) AC|AC.|239|241||ASSESSMENT: 1. Schizoaffective disorder exacerbation. 2. Apparent obsession versus delusion regarding body odor. 3. History of intermittent constipation. 4. Hyperlipidemia currently being treated. 5. Episodic heartburn treated with Pepcid AC. RECOMMENDATION: Routine labs were ordered and will be followed if abnormal.
AC|acromioclavicular|AC|150|151||O2 sats are adequate at 90+% at room air. HEAD AND NECK: Atraumatic. Scalp is tender but no bleeding or lacerations. Neck is supple. Sternoclavicular AC joint is negative. Shoulders negative. The cervical and thoracic spine is somewhat tight in the trapezius rhomboid area but no acute problems are noted.
AC|acromioclavicular|(AC)|191|194||There is also diffuse swelling apparent on the CT scan. IMPRESSION: 1. Left scapula fracture, nondisplaced. 2. Left greater tuberosity fracture, minimally displaced. 3. Old acromioclavicular (AC) joint instability, chronic in nature, not acute. RECOMMENDATIONS: Based on his findings on clinical examination as well as findings on his studies I do not think this is a true scapulothoracic dissociation.
AC|acromioclavicular|AC|128|129||She has no pain between the spinous processes of the thoracic area or along the mid scapula border. She does have pain over the AC joint bilaterally and it is worse on the right than the left, but her verbal report is equal in intensity. She has pain over the biceps tendons. Range of motion I am not able to get from her because of severe pain and then she has pain over the deltoid groove and that is bilateral.
AC|acromioclavicular|AC|155|156||VASCULAR: Palpable pulses. LYMPH: No trochlear nodes. NEURO: Intact sensation. Radiographic evaluation is taken on the right shoulder. This shows that his AC joint is patent. There are some degenerative changes around it, but there is really quite a patent joint space here. The glenohumeral joint shows no evidence of arthritic changes. There is an old-appearing ____ overlying the greater thoracic consistent with an old rotator cuff repair.
AC|(drug) AC|AC|145|146||2. Furosemide 20 mg p.o. q.d. 3. Premarin 0.625 mg q.d. 4. Elavil 25 mg q.d. 5. Aspirin 325 mg q.d. 6. Lovenox 40 mg subcutaneous q.d. 7. Pepcid AC 20 mg 1 tablet b.i.d. 8. Atenolol 50 mg q.d. FAMILY HISTORY: The patient's father died from a blood clot at 54.
AC|acromioclavicular|AC|262|263||She complains of some ache in the forearm. The right shoulder is seen on chest x-ray and x-ray of the shoulder, consisting of AP, internal and external rotation. No fractures are present. There is diffuse osteoporosis. There are some degenerative changes in the AC joint. The glenohumeral relationship is uncertain on AP x-rays. DISCUSSION: I feel further imaging studies are indicated to make a definitive diagnosis.
AC|(drug) AC|AC|210|211||She will restart extra-strength Tylenol as needed or pain. I will recheck the TSH and T4 Monday and will be notified if it is abnormal. The patient will be continued on her Humalog and she will have Robitussin AC p.r.n. cough. We will do Accu-Checks q.i.d. I do realize that the patient does have a chemical dependency history but given the fact that she has such bad coughing spells, I feel it is warranted to use a narcotic to decrease her coughing until her bronchitis is treated.
AC|acromioclavicular|AC|137|138||It does not radiate. Then she has tightness along the supraspinatus on the left, tightness on the scalenes on the left. No pain over the AC joint, no pain over the biceps tendon, negative arc, negative flexion. Good range of motion to her arms to. Good strength to shoulder shrug, abduction and adduction, flexion and extension of her upper extremities.
AC|acromioclavicular|AC|225|226||Symptoms of numbness and tingling down the arm. MUSCULOSKELETAL: Right shoulder full range of motion stable, passively. Actively is obviously quite weak. LEFT UPPER EXTREMITY: Inspection shows no obvious redness. Very tender AC joint and subcoracoid. Glenohumeral joint is benign. Bicipital groove is negative. Passive movement of the shoulder and forward flexion is difficult because of pain.
AC|acromioclavicular|AC|216|217||NEUROPSYCH PROFILE: Normal. Does not appear to be in any acute distress secondary to shoulder pain. Normal alignment and contour is noted. Opposite left shoulder has similar contour and alignment. I see no bruising. AC joint is normal contour somewhat prominent, but nontender. Active range of motion right shoulder is full, strength 5/5, there is no winging.
AC|before meals|AC|150|151||4. While in-hospital in addition to the glimepiride, I recommend medium NovoLog correction scale and I have written for that. 5. We will obtain BGMs, AC and h.s. while in hospital as well. 6. Now that Ms. _%#NAME#%_ is more than 40 years out from her original diagnosis of thyroid cancer and has had no evidence of recurrence, I do not think she requires as suppressive a dose of thyroid hormone.
AC|adriamycin cyclophosphamide|AC|174|175||Metastatic workup, including bone scan and chest/abdominal CT were negative for metastasis. The patient then underwent the Baylor protocol, with randomization to neoadjuvant AC or Taxotere, and was randomized to Taxotere x 4 cycles. After this, the patient had a right modified radical mastectomy on _%#MMDD2003#%_, which showed a 4.5 x 3.2 x 3.0 cm grade 2/3 invasive lobular carcinoma.
AC|adriamycin cyclophosphamide|AC,|299|301||Light touch is symmetric and intact in all four extremities. Gait is smooth and symmetric. ASSESSMENT: 68-year-old female with stage T3, N1, M0 invasive lobular carcinoma of the right breast, status post four cycles of neoadjuvant Taxotere, modified radical mastectomy, and three cycles of adjuvant AC, with her last cycle scheduled for _%#MMDD2004#%_. RECOMMENDATIONS: Ms. _%#NAME#%_ would make an excellent candidate for radiation therapy for the treatment of her invasive lobular carcinoma of her right breast.
AC|adriamycin cyclophosphamide|AC.|199|201||The patient states that she understands these side effects and wishes to be treated. We have scheduled her for simulation. She will begin her radiation two to three weeks following her last cycle of AC. _%#NAME#%_ _%#NAME#%_, MD Resident Physician __X Patient seen and examined by me and resident.
AC|adriamycin cyclophosphamide|AC|155|156||The patient had an ultrasound-guided biopsy in _%#MM2003#%_, which showed a 7 cm invasive lobular carcinoma. The patient had neoadjuvant chemotherapy with AC and Taxotere, which resulted in partial response of the breast mass. The patient underwent a modified radical mastectomy in _%#MM2003#%_, which showed a 4.3 x 3.2 x 3.0 cm grade 2/3 invasive lobular carcinoma.
AC|adriamycin cyclophosphamide|AC|112|113||The tumor was ER positive, PR negative, and HER-2 positive. She is status post chemotherapy with four cycles of AC followed by four cycles of Taxol, which she completed at the end of _%#MM#%_. She has also been receiving Herceptin and started Femara on _%#MMDD2007#%_.
AC|adriamycin cyclophosphamide|AC,|189|191||Would use a large cuff with the patient's obesity. Suspect may normalize with time. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Check a CMT. 3. Accu-Cheks four times daily, AC, and HS. If blood sugars are consistently elevated we will resume Lantus in that setting. ADA diet. 4. Selenium sulfide lotion q.h.s. to the anterior chest eruption for 2 weeks then q. monthly for 3 weeks.
AC|adriamycin cyclophosphamide|AC|177|178||My key findings: CC: Left breast cancer, stage IIIA . HPI: This patient was seen in consultation on _%#MMDD2004#%_. The patient has neoadjuvant chemotherapy with four cycles of AC and Taxol and underwent left sided mastectomy and axillary node sampling on _%#MMDD2004#%_. Pathology of the post chemotherapy revealed extensive residual invasive breast cancer especially in the upper-outer quadrant of the breast specimen.
AC|(drug) AC|AC.|114|116||He also thinks he might have been treated for H. pylori, but is not sure. More recently he has been taking Pepcid AC. He began smoking again and came in. PAST MEDICAL HISTORY: His past medical history is otherwise negative.
AC|acromioclavicular|AC|112|113||Passively, I am able to bring her forward flexion up to 140, abductor to 140. There is mild tenderness over the AC joint from over the anterior lateral shoulder. She gets tenderness when the arm is brought from an elevated position down to her waist level.
AC|acromioclavicular|AC|207|208||Sensation is intact to light touch, 2+ radial pulse, capillary refill less than 2 seconds. X-RAYS: Reviewed including AP, lateral and axillary views. There is no significant degenerative change or some mild AC joint sclerosis. She has some mild superior migration of the humeral head. MRI was reviewed. She appears to have a large to massive rotator cuff tear with retraction to the 1 o'clock position on the glenoid.
AC|acromioclavicular|AC|168|169||X-rays show comminuted fracture, right shoulder. It is not dislocated as best we can see. He appears to have a greater tuberosity fragment fractured off with some mild AC joint arthrosis. No other problems are noted. I do not detect __________ changes on films. Chest x-ray was done and apparently negative.
AC|acromioclavicular|AC|204|205||Two views of the left shoulder, AP internal rotation AP external rotation were reviewed. They demonstrate no evidence of fracture dislocation or other worrisome pathology. There is slight widening of the AC joint but no elevation of the distal clavicle as compared to the acromion. IMPRESSION: Left shoulder contusion. PLAN: My recommendation is conservative care.
AC|(drug) AC|AC|154|155||He reports the stones to his recollection were calcium oxalate stones. He also has a history of gastroesophageal reflux disease for which he takes Pepcid AC with resolution of his symptoms. HISTORY OF THE PRESENT ILLNESS: The patient is a 33-year-old gentleman with a limited past medical history who presents for evaluation of significant abdominal pain, diarrhea, and nausea.
AC|acromioclavicular|AC|148|149||Base issues pain with moving, coughing or breathing. He came to the hospital on _%#MM#%_ 7. His only previous orthopedic problems were in his right AC joint years ago. He is in sales, in a newer job for the last three months. He denies abdominal complaints, urinary problems, voiding problems in general or any progressive neurologic changes.
AC|acromioclavicular|AC|223|224||_%#NAME#%_ _%#NAME#%_ is 65 years of age and is seen today in followup for her left shoulder. She has completed the left shoulder MRI. She has a type II acromial morphology with mild degenerative changes present within the AC joint as well, with some minimal inferior hypertrophic spurring. She does have mild to moderate tendinopathy involving the distal supraspinatus tendon.
AC|acromioclavicular|AC|276|277||The plain x-rays do show significant degenerative arthrosis in the AC joint with a type II+ and almost type III acromial morphology. His MRI shows partial-thickness tearing of the supraspinatus. There is increased signal in defect indentation of the supraspinatus beneath the AC joint, and also at the insertional point at the greater tuberosity. IMPRESSION: 1. Severe impingement syndrome, left shoulder, with partial-thickness rotator cuff tear.
AC|adriamycin cyclophosphamide|AC|161|162||My key findings: CC: Right breast CA, post chemo, post lumpectomy and levels 1-11 dissection. HPI: Presented with 12 cm right breast CA. Received pre-op chemo - AC X4 and Taxol X4. Had lumpectomy with residual disease, 2.6 cm with 1 mm margin in posterior margin. Exam: Post-op second day. Assessment and Plan: Recommend radiation. Case to be discussed at the Breast Cancer Conference.
AC|acromioclavicular|AC|233|234||Active right shoulder motion with 60 degrees of forward flexion, 45 of abduction, internal rotation to the lateral side at 30 of external. She has fairly specific, well localized tenderness over the anterior coracoacromial arch. The AC joint is nontender. She does not have significant tenderness in the bicipital groove. Rotator cuff strength is full in external rotation and AB duction.
AC|(drug) AC|AC.|139|141||He had a carotid endarterectomy at that point. He is status post appendectomy. MEDICATIONS: Outpatient medications included: 1. Robitussin AC. 2. Zaditor 0.25% one drop in each eye b.i.d. 3. Hydrochlorothiazide 25 mg a day. 4. Norvasc 10 mg po qday. 5. Atenolol 100 mg po qday. 6. Accupril 40 mg po b.i.d.
AC|acromioclavicular|AC|120|121||EXAMINATION: Today there is some visible swelling in the area of the AC joint of the right shoulder compatible with his AC joint injury. He remains locally tender in this area. We will plan on having physical therapy see him and try to assist with transfers and ambulation.
AC|adriamycin cyclophosphamide|AC,|180|182||SLEEP: She sleeps pretty well, but intermittently has problems, and requests Ambien. LABS: Normal. SOCIAL/FAMILY HISTORY: No change. CHEMOTHERAPY HISTORY: The patient has had four AC, four Taxol. She was put on tamoxifen for about six months, and switched to Arimidex which she is currently on. ALLERGIES: Codeine. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 120/80, pulse 80, respirations 20, temperature 96.3, weight 132.
AC|adriamycin cyclophosphamide|AC|134|135||Histopathology showed Nottingham grade 3 of 3. The patient also had ANCA type DX score of 32. The patient underwent chemotherapy with AC and the patient finished her third cycle of AC chemotherapy so far. The patient was asked to see us for post chemotherapy/post lumpectomy radiation treatment.
AC|adriamycin cyclophosphamide|AC|154|155||The patient finished 12 or 15 weeks of weekly doxorubicin and daily cyclophosphamide per protocol S_%#PROTOCOL#%_. She is supposed to receive Taxol after AC chemotherapy. She has been tolerating chemotherapy reasonably well with some fatigability and low blood count. The patient was last seen by the Mayo Clinic on _%#MMDD2006#%_, and she is planning to continue her chemotherapy per protocol.
AC|adriamycin cyclophosphamide|AC,|165|167||Node was ......and also extracapillary extension into the soft tissue. The patient was treated on the SWOG protocol S_%#PROTOCOL#%_, arm 2. She receives 15 weeks of AC, doxorubicin, and cyclophosphamide with the support of filgrastin followed by every 2 weeks of Taxol with support of PEG-G, which is pegfilgrastim and G-CSF.
AC|(drug) AC|AC|69|70||MEDICATIONS: Medications at the time of this transfer: 1. Robitussin AC p.r.n. 2. Enteric coated aspirin 325 mg p.o. daily. 3. Synthroid 75 mcg p.o. daily. 4. Fosamax 75 mg p.o. q. Saturday. 5. Klonopin 0.25 mg p.o. t.i.d.
AC|adriamycin cyclophosphamide|AC|120|121||PAST MEDICAL HISTORY: 1. Status post adenoidectomy. 2. Depression. CHEMOTHERAPY: The patient is status post 3 cycles of AC regimen and will receive her last cycle of AC on _%#MMDD2004#%_. PAST RADIATION HISTORY: None. MEDICATIONS: Prozac 20 mg p.o daily.
AC|adriamycin cyclophosphamide|AC.|155|157||ASSESSMENT: 50-year-old Caucasian female with stage I, T1c N0 M0 infiltrating ductal carcinoma of the right breast, status post lumpectomy and 3 cycles of AC. The tumor is grade 1, ER PR positive, sentinel node negative, margin negative. Because there is no axillary node involvement, we will treat the right breast with a total of 5040 cGy with 1400 cGy boost to the tumor bed.
AC|acromioclavicular|AC|130|131||X-rays reviewed and my review of the shoulder on clinical exam. IMPRESSION: 1. Rotator cuff impingement. 2. Rotator cuff tear. 3. AC joint arthrosis. All contributing to the same area of pain. Wrist fracture has healed. Clinically we will get x-rays as the patient is desirous of this.
AC|acromioclavicular|AC|154|155||BILATERAL SHOULDERS: No significant atrophy of the right shoulder as compared to the left. There is a small cyst-like fluid collection superficial to the AC joint. There is no erythema, ecchymoses or other lesions or masses noted on the right shoulder as compared to the left. Range of motion: The patient does have full range of motion of her right shoulder as compared to left with flexion of the left/right shoulder reveals flexion of 180 degrees/180 degrees and abduction of 100/100, internal rotation to T7/T7.
AC|acromioclavicular|AC|225|226||There were no signs of instability. Examination of both shoulders showed no atrophy of the shoulder girdle. The skin was intact without lesions, masses or ecchymosis. Palpation of both shoulders revealed no tenderness to the AC joint, anterolateral rotator cuff, anterior glenohumeral joint and posterior glenohumeral joint. The patient was unable to flex, abduct or elevate her left shoulder due to pain.
AC|acromioclavicular|AC|150|151||The skin on the patient's left shoulder was intact without lesions, masses, or ecchymoses. Palpation of the left shoulder showed no tenderness of the AC joint, anterolateral rotator cuff, anterior glenohumeral joint, and posterior glenohumeral joint. The patient did, however, have tenderness to palpation over the proximal humerus on the left side.
AC|angiotensin-converting enzyme:ACE|AC|179|180||We can also add aspirin 81 mg p.o. daily and see how she does, but she does have a history of GI bleeding in the past. Her blood pressure is high enough that I would increase her AC inhibitor somewhat. 2. COPD, more stable on oxygen. 3. Question alcohol abuse and dementia.
AC|(drug) AC|AC|129|130||3. Serevent 2 puffs b.i.d. 4. ________________ 24 200 mg 2 capsules b.i.d. 5. Claritin-D 12 hours 1 tablet p.o. b.i.d. 6. Pepcid AC p.r.n. 7. Singulair 10 mg q.day. 8. Flovent inhaler 2 puffs b.i.d. ALLERGIES: PENICILLIN. FAMILY HISTORY: Bipolar. The patient's mother and grandmother suffer from hypertension but the patient believes that his mother's hypertension is secondary to stress due to the patient's behavior and drug use.
AC|(drug) AC|AC|138|139||The Prevacid certainly helped. However after stopping it the pain recurred. In 1997 he discovered that he could treat himself with Pepcid AC 1 before each meal. He remained on this for the next 4 years or so. In the year 2001 the patient was seen again in a clinic and had a Helicobacter pylori serology which was apparently positive.
AC|acromioclavicular|AC|175|176||X-rays in the ER show a distal clavicle fracture with reasonable alignment with intact coracoclavicular ligaments relatively nondisplaced, but slight angulation dorsally. The AC joint was very arthritic. The rest of the joint looks intact. Sternoclavicular joint as best able to check looks okay. CT of the head is negative per report.
AC|before meals|AC|182|183||ALLERGIES: Listed include stainless steel. MEDICATIONS: Medications on record include: 1. Creon 6 caps before meals 812 and 1700 with 3 capsules before snack. 2. P.r.n. Reglan 10 mg AC and bedtime (question for gastroparesis). 3. Omeprazole 20 mg b.i.d. 4. Vitamin D 50,000 units q. Friday. 5. Oxycodone 5 mg 1 p.o. q. 4-6 h p.r.n. pain.
AC|acromioclavicular|AC|150|151||SI joints bilaterally and trapezius rhomboid. Base of the paraspinals in the neck, but really nothing alarming here. Shoulders are mildly tender over AC joint, but good range of motion and good grip both hands. No long tract signs. LOWER EXTREMITIES: Lower extremities, right ankle splinted.
AC|acromioclavicular|AC|215|216||LYMPHATICS: Negative. ABDOMEN: Negative. Pulses normal and symmetric. No winging of scapula either side. Cervical spine exam including cranial nerves II through XII normal. Left shoulder normal to palpation. Tender AC joint. Shoulder stable sitting in supine with negative sulcus sign. Passive range of motion with assisted is 140/120/90/40 with full extension.
AC|before meals|AC|249|250||7. Lexapro 10 mg G-tube daily. 8. Furosemide 40 mg IV daily as of _%#MMDD2005#%_ with reassessment daily as patient appears to be nearing dry weight. 9. Heparin 5000 units subcu t.i.d. 10. Insulin NPH 25 mg subcu b.i.d. 11. Insulin sliding scale q. AC and q. h.s. 12. Magnesium oxide 2 tablets G-tube b.i.d. 13. Metoprolol 75 mg G-tube b.i.d. 14. Multivitamin 1 G-tube daily.
AC|before meals|(A.C.)|197|202||24. Magnesium oxide 400 mg p.o. t.i.d. 25. Aranesp 100 mcg subcutaneous SQ weekly (Thursdays). 26. Lantus insulin 5 units subcutaneous q. p.m. 27. NovoLog insulin sliding scale subcutaneous t.i.d. (A.C.) p.r.n. hyperglycemia: Less than 120 = 0, 120-150 = 1 unit, 151-200 = 2 units, 201-250 = 3 units, 251-300 = 5 units, 301-50 = 7 units, greater than 350 = 9 units and call M.D.
AC|(drug) AC|AC,|229|231||PAST MEDICAL HISTORY: Is notable for the above mentioned esophageal cancer, arthritis, osteopenia, and hypercholesterolemia. CURRENT MEDICATIONS: Include Prevacid, Oxybutynin, Celexa, Miacalcin nasal spray and Ativan, Robitussin AC, Levaquin, Fluconazole THERE ARE NO KNOWN ALLERGIES. SOCIAL HISTORY: The patient is widowed and does live with her son.
AC|(drug) AC|AC|188|189||8. Ambien 5 mg p.o. q. bedtime as needed. 9. Vitamin B12 1000 mg subcu q. month, last given _%#MMDD2005#%_. 10. Klor-Con 10 mEq p.o. q. day. 11. Protonix 40 mg p.o. q. day. 12. Robitussin AC one to two teaspoons q.i.d. as needed. 13. Zelnorm 6 mg one to three times a day as needed for IBS. 14. Zofran 8 mg q.8h as needed for nausea.
AC|(drug) AC|AC|191|192||FAMILY HISTORY: Coronary artery disease. No DVT, PE or sudden unexplained death. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Toprol-XL 100 mg every night. 2. Aspirin a day. 3. Pepcid AC 1 q day over-the-counter. SOCIAL HISTORY: He is married. He does not smoke or drink alcohol.
AC|(drug) AC|AC|136|137||8. Clozapine 100 mg p.o. q.a.m. and 200 mg p.o. q.h.s. 9. Hydralazine 50 mg p.o. t.i.d. 10. Metformin 500 mg p.o. daily. 11. Robitussin AC 10 ml p.o. q.h.s. 12. Prilosec 20 mg p.o. daily. 13. Nasacort to both nostrils daily. 14. Paxil 30 mg 1 1/2 tablets p.o. daily.
AC|acetate|AC|118|119||5. Nitro spray prn. 6. Plavix 75 mg PO daily 7. Prednisolone eye drops 1% one drop two left eye daily 8. Prednisolone AC 1% one drop to the right eye b.i.d. 9. Lasix 40 mg daily. The patient is not taking this however. 10. Lipitor 10 mg daily 11. Prednisone 5 mg PO daily
AC|(drug) AC|AC|593|594||She also is on Zoloft 200 mg daily for depression, Ditropan XL 100 mg daily for incontinence, Imdur 30 mg daily for angina, lisinopril 10 mg daily for hypertension and protection of kidney and eye from her diabetes, atenolol 25 mg daily for angina and hypertension, quinine sulfate 325 mg, q in the morning, 2 in the evening for leg cramps; Os-Cal 500 mg with vitamin D, 1 b.i.d.; Miralax 1 scoop in water daily, Actonel 35 mg weekly orally as well as Coumadin 5 mg daily, and recently Restoril 15 mg h.s. p.r.n. sleep as well as Tessalon Perles 200 mg orally t.i.d. for cough, and Robitussin AC 5-10 cc orally q. 4 hours p.r.n. for cough, Compazine 10 mg q. 6 hours p.r.n. nausea. ALLERGIES: Ampicillin and contrast dye is what is listed on her medical record.
AC|before meals|AC|192|193||5. Endocrine. Consider tighter control of glucose levels, which were elevated on multiple BMPs during hospitalization. Consider starting Actos at 5 mg p.o. q.d., with blood glucose monitoring AC and HS. Continue to monitor this condition at FUT S and will make recommendations to primary care physicians to consider new onset diabetes as diagnosis.
AC|(drug) AC|AC|148|149||The patient also reports mild increase in constipation lately. ALLERGIES: The patient has no known drug allergies. ADMISSION MEDICATIONS: 1. Pepcid AC p.r.n. 2. Multivitamin. 3. Celexa 20 mg daily. 4. Gabapentin 600 mg daily. 5. Oxycodone 5 mg 1-2 q.6h. p.r.n. pain. 6. Fluconazole 200 mg daily. 7. Acyclovir 800 mg 5 times daily.
AC|acromioclavicular|AC|221|222||Upon admission, the patient was hemodynamically stable. PROCEDURES: 1. Shoulder x-ray on _%#MMDD2005#%_ of the left shoulder, which showed no evidence of acute osseous injury, mild to moderate degenerative changes of the AC joint, diffuse osteopenia. 2. Left elbow x-ray, which showed a likely small fracture of the left radial head. Recommend repeat radiographs in one week. 3. Thoracic spine x-ray.
AC|(drug) AC|AC|142|143||8. Calcium and vitamin D, 1 tablet twice a day. 9. Psyllium powder or vegetable powder 1 spoonful before meals and at bedtime. 10. Robitussin AC 2 tsp q. 4 hours p.r.n. 11. Fosamax 70 mg 1 tablet weekly. 12. Omega-3 fatty acid 1000 mg t.i.d.
AC|before meals|A.C.|176|179||7. Bactrim SS 1 p.o. q day 8. Valcyte 900 mg p.o. q day X3 months, then discontinue 9. Lipitor 10 mg p.o. q.h.s. 10. Aspirin 81 mg p.o. q day 11. Domperidone 20 mg p.o. q.i.d. A.C. and h.s. from patient's own supply as prescribed by Canadian physician 12. Prilosec 20 mg p.o. q day 13. Peri-Colace 1-2 p.o. b.i.d. p.r.n. constipation
AC|(drug) AC|AC|156|157||1. Metoprolol 25 mg p.o. twice a day. 2. Indapamide 2.5 mL p.o. once a day. 3. Enala pril 10 mg p.o. once a day. 4. Flomax 0.04 mg p.o. at night. 5. Pepcid AC 10 mg p.o. at night. 6. Aspirin 81 mg p.o. once a day. 7. Cranberry fruit 500 mg p.o. b.i.d. 8. Vitamin E 400 international units p.o. once a day.
AC|acromioclavicular|AC|352|353||In the right upper extremity the patient has full range of motion of the wrist, elbow and he has range of motion of the shoulder and there is obvious, somewhat tenderness around the acromioclavicular joint, but there is no tenting. There is no clavicular tenderness to palpation. LABORATORY DATA: A chest x-ray reveals no evidence of pneumothorax. The AC joint could not be seen on the right. The patient's white blood count was 14.1, hemoglobin 16.7, hematocrit 48, platelets 225,000.
AC|(drug) AC|AC|158|159||5. Combivent inhaler 2 puffs q.i.d. 6. Flovent inhaler. 7. Novolin N insulin 25 units b.i.d. and sliding scale Humalog. 8. Prilosec 30 mg q.d. 9. Cheratussin AC syrup 2 tsp q.4h. p.r.n. PAST MEDICAL HISTORY: 1. Insulin-dependent diabetes mellitus for 10 years. Originally this was controlled with oral hypoglycemics, but he has been insulin-dependent for 7-8 years.
AC|acromioclavicular|AC|250|251||No pain over the SI joint, no pain over the piriformis. EXTREMITIES: On the upper extremity, strength: she has good strength to shoulder shrug, abduction, adduction, flexion, extension, and examination of the left shoulder indicates no pain over the AC joint, no pain of the biceps tendon, no crepitation with range, negative arc, negative flexion and I am examining the shoulder because she has been jostled around quite a bit.
AC|before meals|AC|143|144||PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Replace KCl, check a.m. magnesium, potassium and white count. 3. Accu-Cheks q.i.d. AC and bedtime. Continue present insulin regimen. 4. Hypoglycemic protocol. 5. Empiric thiamine 100 mg daily for 3 days. 6. Follow up liver function to assess trend. 7. Clinical observation/staff to call p.r.n. recurrent fever.
AC|acromioclavicular|AC|147|148||Nonfocal neurologic exam. Recommendation on rectal manometry and urodynamic studies. Associated issue of chronic right shoulder pain subsequent to AC separation with what sounds like secondary infection. Required prior surgical intervention x 3. Right total knee arthroplasty six to seven months ago.
AC|adriamycin cyclophosphamide|AC|186|187||The tumor was reportedly ER positive and PR negative. We do not have the results of her continued testing available. She was treated as per CALGB adjuvantly (trial 9741) with dose dense AC x 4 followed by a dose dense Taxol x 4. There was an interval after this during which she was not under the direct care of an oncologist; however, she was reinitiated on adjuvant therapy one year later and received a total of three years of Arimidex.
AC|adriamycin cyclophosphamide|AC|192|193||2. Bartholin's cyst excised in 1976. 3. Status post tonsillectomy in 1952. 4. History of fibromyalgia. 5. Osteopenia. 6. Osteoarthritis of the knees and low back. 7. Chemotherapy, status post AC x4 followed by weekly Herceptin and Taxol for 12 weeks. She is to have her Herceptin continued for a total of 1 year.
AC|adriamycin cyclophosphamide|AC|279|280||This is compared to patients who received only four cycles of adriamycin and Cytoxan preoperatively who showed a clinical response rate of 85%, a complete clinical complete response rate of 40%, and a pathological complete response rate of 13%. Thus, the combined four cycles of AC followed by four cycles of taxotere is superior in terms of resulting in an increased pathological complete response rate.
AC|adriamycin cyclophosphamide|AC|190|191||With regards to her current and recent symptomatology, the patient states that she feels like she is doing quite well. She did experience some nausea as well as significant fatigue with the AC chemo, however, this has resolved. She also endorses a tingling of the fingers and toes with Taxol. She has not experienced frank progressive dyspnea, or focal neurologic symptoms.
AC|acromioclavicular|AC|186|187||Active Motion: Only flexes to 20 degrees and 30 degrees because of pain. Abducts 30-40 degrees because of pain. Passive angle range is 140/100/80/50. There is quite a bit of discomfort. AC joint is tender. LEFT SHOULDER: There is much less crepitus. It is painful and weak but nowhere near as weak as the right shoulder.
AC|before meals|AC|109|110||2. Contact the group home to confirm Lantus and NovoLog insulin dose as well as a diet. 3. Accu-Cheks q.i.d. AC and h.s. with Lantus/NovoLog coverage as per group home. 4. Continue Keflex 250 mg a q.i.d. for 5 days. Topical wound care as above. 5. Contact group home regarding tetanus status.
AC|acromioclavicular|AC|267|268||No crepitation with range of motion on the knees. She does not have any pain along the lateral medial joint line, no lateral medial laxity, negative drawer's, smooth patella slide, negative apprehension bilaterally. Examination of the shoulder shows no pain over the AC joint. She does have some pain over the biceps tendon, though very minimal and slight amount of tenderness over the deltoid groove and this is bilaterally negative.
AC|before meals|AC|205|206||ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: 1. Triamcinolone cream 0.1% b.i.d. to the face 2. Prevacid 30 mg p.o. b.i.d. 3. Detrol 4 mg LA p.o. b.i.d. 4. Reglan 5 mg p.o. q.i.d. one half hour AC and h.s. 5. Florinef 0.1 mg one half tab p.o. b.i.d. 6. Klor-Con 20 mEq p.o. b.i.d. for tendency toward hypokalemia (presumably related to Florinef)
AC|adriamycin cyclophosphamide|AC|139|140||26/28 axillary nodes were involved with disease. The patient's hormonal receptor was negative and HER- 2/neu was positive. The patient had AC and Taxol chemotherapy and a mastectomy. She had postmastectomy radiation to her right chest wall. Unfortunately, the patient recurred in _%#MM2004#%_.
AC|acromioclavicular|AC|190|191||9. History of hyperlipidemia. 10. History of a right thyroid nodule. 11. History of thyroidism 12. History of chronic anemia. 13. History of mild chronic renal insufficiency. 14. History of AC separation. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Effexor XR.
AC|acromioclavicular|AC|205|206||HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old right-handed woman who fell at home two nights ago and sustained a distal left clavicle fracture which is mildly displaced and does not involve the AC joint. She also sustained a left distal fibular avulsion fracture with superior retraction of the fragment. In addition, she has a mildly displaced fracture of the mid body of the calcaneus.
AC|adriamycin cyclophosphamide|AC|151|152||IMPRESSION: Ms. _%#NAME#%_ is a 60-year-old female with stage I, T1a N0 M0, infiltrating ductal carcinoma of the right breast, status post dose- dense AC and Taxol chemotherapy and lumpectomy. PLAN: This patient was seen and examined by Dr. _%#NAME#%_ _%#NAME#%_. The patient is believed to be an excellent candidate for external beam radiation to the right breast.
AC|adriamycin cyclophosphamide|AC|215|216||Instead, she had a saline implant reconstruction. At the same time, the patient underwent a left prophylactic mastectomy, also with reconstructive surgery with the saline implant. At that time, the patient received AC times 4, followed by Arimidex. In _%#MM2004#%_, the patient again noted a lump in her right breast which measured about 2 cm in size at the 10 o'clock position.
AC|adriamycin cyclophosphamide|AC|238|239||At the time of mastectomy, she was found to have 6 mm residual tumor nodule along the previous lumpectomy site. This was found to be cutaneous margin of the previous breast cancer. Post mastectomy, the patient underwent chemotherapy with AC 4 cycles between _%#MM2001#%_, and _%#MM2001#%_. Shortly thereafter chemotherapy, the patient developed chest wall recurrence along the incisional scar with a 7 mm nodule.
AC|adriamycin cyclophosphamide|AC.|157|159||She also had an axillary dissection on that right side. She reports that the lymph nodes were negative. She did report, however, receiving chemotherapy with AC. She was then on tamoxifen for almost 5 years time. The tamoxifen was discontinued secondary to abnormal liver enzymes. On _%#MMDD2004#%_, the patient underwent a laparoscopically assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, and pelvic and para- aortic lymph node dissection and omentectomy by Dr. _%#NAME#%_.
AC|angiotensin-converting enzyme:ACE|AC|110|111||His wife is able to get him up only through the use of a Hoyer lift. ALLERGIES: Renal dysfunction with use of AC inhibitors and nonsteroidal anti-inflammatory agents. MEDICATIONS ON ADMISSION: 1. Isosorbide 45 mg b.i.d. 2. Hydralazine 10 mg t.i.d.
AC|acromioclavicular|AC|885|886||She has pain at the insertion of the nuchal muscles into the occiput bilaterally, pain in the upper trapezius at the mid point bilaterally, pain in the pectoralis muscle just lateral to the second costochondral junction bilaterally, pain 2 cm below the lateral epicondyle bilaterally, pain in upper gluteal region bilaterally, pain 2 cm posterior to the greater trochanter bilaterally, pain in the medial knee there in the anserine bursa bilaterally, pain in the paraspinous 3 cm lateral to the midline at the level of the midscapula bilaterally and then above the scapular spine near the medial border and the pressure, the PSI pressure a ____________ just away my nailbed and she had pain pretty specifically throughout those areas. Examination of the left shoulder, as she does complain of tingling in the left hand, shows she does have pain over the bicep tendon, no pain over the AC joint, good range, no crepitation and negative arc, negative flexion and negative Adson's maneuver for thoracic outlet syndrome and same on the right upper extremity.
AC|adriamycin cyclophosphamide|AC|210|211||She did sign a consent for treatment as well as informed consent dated _%#MMDD2005#%_. She was scheduled for a follow-up simulation on _%#MMDD2005#%_. The patient will continue with her remainder two cycles of AC and may be possibly receive Taxol. This case will be discussed by Dr. _%#NAME#%_ and Dr. _%#NAME#%_ at the Breast Conference. Thank you for the opportunity to assist in the care of this pleasant patient.
ALD|ad lib on demand|ALD.|238|241|3. FEN|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2006#%_. _%#NAME#%_ was discharged on breastmilk or Enfamil 20 cal/oz taking 10-44 ml every 2-3 hours and/or breast-feeding every 2-3 hours ALD. The parents have scheduled an appointment to see you next Tuesday, _%#MMDD2007#%_. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|147|150|P|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on breast milk ALD. The parents were asked to make an appointment for their child to see you on _%#MMDD2004#%_. Home Care nurse will visit _%#MMDD2004#%_ and check a bilirubin level.
ALD|adrenoleukodystrophy|ALD.|190|193|FAMILY HISTORY|ALLERGIES: No known drug allergies. FAMILY HISTORY: _%#NAME#%_'s family history is remarkable for 2 first cousins who died from ALD in 1992 and 1997. _%#NAME#%_'s 2 older brothers also have ALD. His mother is positive for increased very long-chain fatty acids. SOCIAL HISTORY: _%#NAME#%_'s family is from _%#CITY#%_, Ohio. His father works for GM as a press technician.
ALD|ad lib on demand|ALD|176|178|* FEN|She passed the ABR hearing screening test on _%#MMDD2006#%_. Immunizations: Hepatitis B vaccine was given on _%#MMDD2006#%_. Baby Girl _%#NAME#%_ was transferred breastfeeding ALD and bottling Enfamil 20 ALD taking 55 to 70 ml every 2-4 hours. Thank you again for allowing us to share in the care of your patient.
ALD|alanine aminotransferase:ALT|ALD|162|164|ADMISSION LABORATORY DATA|No rashes. NEUROLOGIC: No focal deficits. ADMISSION LABORATORY DATA: Hemoglobin 16.6. WBC 5.9. Platelets 136. Blood sugar 602. Potassium 3.7. Sodium 134. ASD 32. ALD 32. Alkaline phosphatase 279. Urinalysis showed glucose. ASSESSMENT/PLAN: 1. 38-year-old Somali gentleman with past medical history significant for major depressive disorder, with psychological features, admitted with hyperglycemia.
ALD|ad lib on demand|ALD.|134|137|1. FEN|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was not given. Vivian was transferred on breast-feeding ALD. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|207|210|1. FEN|_%#NAME#%_ was circumcised on _%#MMDD2004#%_. _%#NAME#%_ was discharged on breast milk fortified with Enfacare 24kcal and Promod 4 gm/kg taking 35-60 ml every 3-4 hours and/or breast-feeding every 3-4 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include NICU at four months CGA and ophthalmology in 3-4 months.
ALD|ad lib on demand|ALD|180|182|1. FEN|His feeds were advanced to a 60cc q 3 hour schedule and he tolerated this reasonably well though still with significant amounts of emesis. At discharge he was taking good PO on an ALD schedule. 2. Pulmonary: _%#NAME#%_ was intubated secondary to respiratory distress and given a single dose of Survanta. He was weaned off the ventilator and successfully extubated to room air on _%#MMDD2002#%_.
ALD|ad lib on demand|ALD.|120|123|1. FEN|Her parents were given instructions on how to arrange follow-up testing. _%#NAME#%_ was discharged on Similac with iron ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD,|120|123|NONE.|He passed the ABR hearing-screening test. Immunizations: NONE. _%#NAME#%_ was discharged breast-feeding every 3-4 hours ALD, he is being supplemented with a bottle after each feed. The parents were asked to make an appointment for their child to see you within one week.
ALD|ad lib on demand|ALD,|199|202|GI|Immunizations: None. _%#NAME#%_ was discharged on breastmilk and supplemental bottle feeds. His bottle feeds are breastmilk fortified with Enfacare to 24kcal/oz. He is breast-feeding every 2-3 hours ALD, and taking 1-2 supplemental bottles per day. The parents were asked to make an appointment for their child to see you within one week.
ALD|ad lib on demand|ALD.|176|179|GI|He passed the ABR screening test on _%#MMDD2005#%_. Immunizations: Hepatitis B vaccine was given on _%#MMDD2005#%_. _%#NAME#%_ was discharged on breast-feeding every 2-4 hours ALD. The parents were asked to make an appointment for their child to see you on _%#MMDD2005#%_. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|163|166|1. FEN|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2005#%_. _%#NAME#%_ was discharged breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you early next week. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include an appointment with the NICU Follow-Up Clinic at 4 months corrected age.
ALD|alanine aminotransferase:ALT|ALD,|191|194|LABORATORY|CBC done of _%#MM#%_ _%#DD#%_, 2005, revealed a WBC count of 19.4, hemoglobin 10.4, and platelets of 143,000. LFT's done on _%#MM#%_ _%#DD#%_, 2005, which were alkaline phosphatase, AST, and ALD, were normal. Albumin was 2.7. HOSPITAL COURSE: The patient is an 82-year-old Korean lady with past medical history significant for chronic bronchiectasis/COPD/left pleural effusion, who was admitted to University of Minnesota Medical Center, Fairview transitional services for physical rehabilitation after undergoing a left anterior thoracotomy and pericardectomy on _%#MM#%_ _%#DD#%_, 2005.
ALD|ad lib on demand|ALD.|180|183|1. FEN|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2005#%_. _%#NAME#%_ was discharged on breast milk, bottle-feeding every 2-4 hours ALD. The parents were asked to make an appointment for their child to see you within two to four days.
ALD|ad lib on demand|ALD.|119|122|1. FEN|Immunizations: Hepatitis B vaccine was given on _%#MMDD2006#%_. _%#NAME#%_ was discharged on breastmilk, breastfeeding ALD. The parents were asked to make an appointment for their child to see you on _%#MMDD2006#%_. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|149|152|1. FEN|He passed the ABR hearing screening test. Immunizations: _%#NAME#%_ was discharged on formula taking 50 -55 ml every 3-4 hours and/or breast-feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|236|238|1. FEN|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending at discharge. He passed the ABR hearing screening test. Immunizations: none _%#NAME#%_ was discharged on Enfamil formula ALD taking a minimum of 180 ml every 12 hours .The parents were asked to make an appointment for their child to see you within one week.
ALD|ad lib on demand|ALD.|137|140|1. FEN|He passed the ABR hearing screening test. _%#NAME#%_ was discharged on breast milk, breast or bottle feeding approximately every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|130|133|5. F/E/N|He passed the ABR hearing screening test on _%#MMDD2002#%_. Immunizations: none given _%#NAME#%_ was discharged on breast-feeding ALD. It is understood at discharge that _%#NAME#%_ will see you in clinic tomorrow at 4 pm. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|129|132|3. FEN|He has been stable on room air during his stay. 3. FEN: Breast feeding has progressed well, and he was discharged breast feeding ALD. 4. Neurology: _%#NAME#%_ has periods of mild tremors that are extinguished by holding the affected limb, suggesting that it is not seizure activity.
ALD|ad lib on demand|ALD.|102|105|3. FEN|He Passed the ABR hearing screening test Immunizations: none _%#NAME#%_ was discharged breast feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Follow- up clinic appointments scheduled at Fairview-University Children's Hospital include Cardiology with Dr. _%#NAME#%_ in three months.
ALD|ad lib on demand|ALD,|113|116|3. FEN|She passed the ABR hearing screening test. Immunization: none given. _%#NAME#%_ was discharged on breast-feeding ALD, with total intake not to fall below 180cc every 12 hours. The parents were asked to make an appointment for their child, and it was known at the time of discharge that _%#NAME#%_ will see you this Thursday, _%#MM#%_ _%#DD#%_.
ALD|ad lib on demand|ALD,|238|241|4. F/E/N|4. F/E/N: _%#NAME#%_ was initially started on both TPN and enteral feeds with either breast milk or Enfamil with iron at 10cc q3hrs. The TPN was slowly tapered off as we went up on her scheduled feeds. The scheduled feeds were changed to ALD, but _%#NAME#%_ had trouble meeting her goals secondary to excessive sleepiness. A workup of UA/UC and ammonia was started to r/o UTI and metabolic diseases as causes of _%#NAME#%_'s excessive sleepiness that was sometimes difficult to arouse.
ALD|ad lib on demand|ALD.|131|134|6. GU|She passed the ABR hearing screening test on _%#MMDD2002#%_. Immunizations: none given _%#NAME#%_ was discharged on breast-feeding ALD. The parents were asked to make an appointment to see on Monday, _%#MM#%_ _%#DD#%_, 2002. Public health nurses will follow-up with the parents and _%#NAME#%_ to make sure that she continues to feed adequately and is gaining weight.
ALD|ad lib on demand|ALD.|128|131|6. GU|Physical exam was normal except for oral candidiasis. Immunizations: none _%#NAME#%_ was discharged on Enfamil with iron taking ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|164|167|6. GU|Physical exam was completely normal, including equal breath sounds bilaterally. Immunizations: none _%#NAME#%_ was discharged _%#MMDD2002#%_, on Enfamil with iron, ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|160|163|1. FEN|He passed the ABR hearing screening test. Immunizations: None _%#NAME#%_ was discharged on breast milk taking at least 150 ml every 12 hours and breast-feeding ALD. The parents were asked to make an appointment for their child to see you by the end of the week Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|243|246|GI|They will continue to follow this patient with you. Discharge medications, treatments and special equipment: Ranitidine 7.5 mg po BID Nystatin 2 ml po swish and spit QID Discharge exam was normal. _%#NAME#%_ was discharged on Prosobee formula ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|adrenoleukodystrophy|(ALD)|249|253|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 6-year-old boy with cerebral adrenoleukodystrophy and adrenal insufficiency, who was admitted for HLA-matched sibling donor bone marrow transplant (BMT). _%#NAME#%_ was diagnosed with adrenoleukodystrophy (ALD) in _%#MM#%_ 2002, after several hospital admissions for headache, fever, and emesis. A head CT on _%#MMDD2002#%_ was significant for parietooccipital hypodensity, consistent with demyelination.
ALD|adrenoleukodystrophy|ALD.|271|274|HISTORY OF PRESENT ILLNESS|1. Adrenoleukodystrophy (ALD). 2. Dehydration secondary to decreased p.o. intake. HISTORY OF PRESENT ILLNESS: The patient is a 8-1/2-year-old boy with ALD biochemically diagnosed at age 2-1/2 years when he was screened secondary to maternal great nephew with symptomatic ALD. He was enrolled in Lorenzo's oil study from age 2 years to the summer of 2000 when the study was discontinued.
ALD|adrenoleukodystrophy|ALD|251|253|PAST MEDICAL HISTORY|On the day of admission the patient did not ambulate well and he seemed agitated and uncomfortable for the past day evident by his moaning, kicking, hitting, and sleep difficulty. PAST MEDICAL HISTORY: 1. Lorenzo's oil study from initial diagnosis of ALD at age 2-1/2 years until the summer of 2002. 2. Enrollment and treatment of advanced childhood onset of cerebral ALD by intensive immunotherapy starting _%#MM#%_ 2003.
ALD|ad lib on demand|ALD|137|139|PAST MEDICAL HISTORY|Ongoing problems and suggested management: 1. Feeding problems: _%#NAME#%_ will have a feeding goal of 160cc/kg/day. He will breast feed ALD through the day at home, and supplement daytime breast feeding with gavage after every 2nd or 3rd breast feeding attempt (up to 55cc per time).
ALD|ad lib on demand|ALD.|151|154|1. FEN|She passed the ABR hearing screening test. Immunizations: None. _%#NAME#%_ was discharged on Enfamil with Iron 20 Kcal taking 30-35 ml every 2-4 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit per arranged for OB follow up.
ALD|ad lib on demand|ALD.|143|146|1. FEN|She passed the ABR hearing screening test. Immunizations: None given. _%#NAME#%_ was discharged on breast milk and Enfamil with iron 20kcal/cc ALD. The parents were asked to make an appointment for their child to see you within one week Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|126|129|4. GI|He passed the ABR hearing screening test. Immunizations: None given _%#NAME#%_ was discharged on maternal breast milk feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit in 2 days for a weight check.
ALD|ad lib on demand|ALD.|152|155|2. GI|The ABR hearing screening test will need to be performed. _%#NAME#%_ was discharged on total parenteral nutrition and has just initiated breast-feeding ALD. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|161|164|1. FEN|The ABR hearing screening test was not yet performed upon transfer to the newborn nursery. _%#NAME#%_ was discharged on Prosobee taking 40-55 mL every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Follow-up clinic appointments include Dr. _%#NAME#%_ _%#NAME#%_ in 2 weeks for cardiology follow-up.
ALD|ad lib on demand|ALD.|176|179|1. FEN|Repeat echocardiogram and a follow-up appointment with Dr. _%#NAME#%_, Pediatric Cardiology, in 2 weeks. 2. Nutrition: _%#NAME#%_ was discharged on a schedule of breastfeeding ALD. Discharge medications, treatments and special equipment: 1. Tri-vi-sol 1 ml PO Daily Discharge measurements: Weight 3770 gms; length 54.25 cm; OFC 36 cm.
ALD|ad lib on demand|ALD.|162|165|1. FEN|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2006#%_. _%#NAME#%_ was discharged on NeoSure 22 every 2-4 hours ALD. The parents were asked to make an appointment for their child to see you in 2 days. Home Care nurse will visit on the day after discharge for weight check and to answer any questions.
ALD|ad lib on demand|ALD|161|163|* GU|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2006#%_. _%#NAME#%_ was discharged breast-feeding every 3 hours ALD with supplemental bottles offered after each feed. The parents were asked to make an appointment for their child to see you within three days.
ALD|ad lib on demand|ALD.|120|123|* GU|He passed the ABR hearing screening test. Immunizations: None. _%#NAME#%_ was discharged breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|124|126|LUSB.|_%#NAME#%_ was discharged on Enfamil with Fe 20 kcal/oz thickened with Thick & Easy (1/2 tsp. added to 60 ml of formula) on ALD schedule. The parents were asked to make an appointment for their child to see you within one week. Follow-up clinic appointments scheduled at Fairview- University Children's Hospital include Dr. _%#NAME#%_ from Pediatric Cardiology in 3 weeks as well as a repeat swallow study with speech pathology 3-4 weeks after discharge.
ALD|ad lib on demand|ALD.|134|137|1. HEME|He passed the ABR hearing screening test. Immunizations: None. _%#NAME#%_ was discharged on breast-feeding and bottling every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. A Home Health Care nurse will visit _%#NAME#%_ on _%#MMDD2002#%_ for weight and feeding checks.
ALD|ad lib on demand|ALD|124|126|1. FEN|She remained on TPN until day of life 11. Enteral feeds were initiated on day of life #3 and at discharge she was taking BM ALD successfully. She also received intermittent diuretics for fluid overload. _%#NAME#%_ was started on iron supplements on day of life 18. 2. RESP: _%#NAME#%_ was initially intubated and received surfactant replacement therapy for respiratory distress prior to transport to FUMC.
ALD|ad lib on demand|ALD|252|254|1. FEN|Physical exam was normal. PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are normal at discharge. She passed the ABR hearing screening test. _%#NAME#%_ was discharged breast-feeding every 3 hours ALD but supplementing with bottled breast milk. The parents were asked to make an appointment for their child to see you within one week.
ALD|ad lib on demand|ALD|216|218|2. F/E/N|Problems during the hospitalization included the following: 1. FEN. Upon admission (_%#MMDD2003#%_) _%#NAME#%_ was started on D10 at 10cc/hr. On _%#MMDD2003#%_, his IV was heplocked and he was allowed to breast-feed ALD with Enfamil supplementation ALD when breast- feeding was unavailable. At the time of discharge (_%#MMDD2003#%_) _%#NAME#%_ was meeting all of his nutritional needs through a combination of breast and bottle feeding ALD every 2-3 hours.
ALD|ad lib on demand|ALD|249|251|2. F/E/N|Problems during the hospitalization included the following: 1. FEN. Upon admission (_%#MMDD2003#%_) _%#NAME#%_ was started on D10 at 10cc/hr. On _%#MMDD2003#%_, his IV was heplocked and he was allowed to breast-feed ALD with Enfamil supplementation ALD when breast- feeding was unavailable. At the time of discharge (_%#MMDD2003#%_) _%#NAME#%_ was meeting all of his nutritional needs through a combination of breast and bottle feeding ALD every 2-3 hours.
ALD|ad lib on demand|ALD|145|147|2. F/E/N|At the time of discharge (_%#MMDD2003#%_) _%#NAME#%_ was meeting all of his nutritional needs through a combination of breast and bottle feeding ALD every 2-3 hours. 2. Respiratory. A chest xray was obtained and arterial blood gas was sampled at admission on _%#MMDD#%_: both of these were normal.
ALD|ad lib on demand|ALD.|141|144|2. F/E/N|On day 3 of life, _%#NAME#%_ began breast feeding ad lib demand. _%#NAME#%_ took approximately 30 cc/kg/d on the first day of breast feeding ALD. _%#NAME#%_'s mother worked with a lactation consultant to improve breast feeds.
ALD|ad lib on demand|ALD.|106|109|1. FEN|He passed the ABR hearing screening test Immunizations: None. _%#NAME#%_ was discharged on breast feeding ALD. The parents were asked to make an appointment for their child to see you tomorrow. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|228|231|1. GU|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending at discharge. He passed the ABR hearing screening test. _%#NAME#%_ was discharged breast-feeding every 2-4 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include: pediatric surgery in 1 month.
ALD|ad lib on demand|ALD.|137|140|1. CV|Newborn metabolic screen sent by HCMC. Immunizations: None given during hospitalization. _%#NAME#%_ was discharged on enfamil 24 kcal/oz ALD. The parents were asked to make an appointment for their child to see you within two weeks. Home Care nurse will visit on _%#MMDD2003#%_ to follow up on jaundice and feeding.
ALD|ad lib on demand|ALD.|296|299|1. GI|Physical exam was normal except for mild/moderate jaundice. PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending at discharge. He passed the ABR hearing screening test. He was discharged on breast milk or Enfamil with iron 20 kcal/oz ALD. The parents were asked to make an appointment for their child to see you on Friday, _%#MMDD2003#%_. He will need a recheck bilirubin at that time. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|279|281|1. FEN|He had no further episodes. 6. Musculosceletal: _%#NAME#%_ has increased hair on his upper back, such that a Spinal ultrasound was obtained and found to be normal. Ongoing problems and suggested management: 1. Nutrition: _%#NAME#%_ is breast-feeding and continues breast-feeding ALD such that mom was educated regarding breast-feeding. 2. Urinary out put was 0.7 cc /kg/ hr on the day of discharge, so mom was educated regarding the need for _%#NAME#%_ to have increased fluid intake.
ALD|ad lib on demand|ALD.|197|200|1. FEN|Physical exam was normal except for a birthmark on right upper back and increased hair on mid upper back. _%#NAME#%_ passed the ABR hearing-screening test. _%#NAME#%_ was discharged breast-feeding ALD. The parents were asked to make an appointment for their child to see you on Friday of this week. Home Care nurse will visit tomorrow to assess the feeding and nutritional status of the child.
ALD|ad lib on demand|ALD.|181|184|3. ID|Physical exam was normal except for slight continued nasal congestion. _%#NAME#%_ was discharged on Enfamil 20 taking 80-90 ml every 3-4 hours and/or breast-feeding every 3-4 hours ALD. The parents were asked to make an appointment for their child to see you within the next 3-4 days. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|227|230|4. NEURO|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending at discharge. He passed the ABR hearing-screening test. _%#NAME#%_ was discharged on breast milk breast-feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include an appointment with Dr. _%#NAME#%_ _%#NAME#%_ (Pediatric Neurology) in 6 weeks.
ALD|ad lib on demand|ALD|145|147|2. ID|She passed the ABR hearing screening test. Immunizations: No immunizations were given. _%#NAME#%_ was discharged on breast-feeds every 2-3 hours ALD with supplemental Enfamil 20, taking 40 ml every 2-3 hours, until mom's milk comes in. The parents were asked to make an appointment for their child to see you within one week.
ALD|ad lib on demand|ALD.|246|249|1. TTN.|Physical exam was normal. PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending at discharge. She passed the ABR hearing screening test. _%#NAME#%_ was discharged on Enfamil 20 with Fe ALD. The parents have made an appointment for their child to see you on _%#MMDD2003#%_. A Home Health nurse will also be seeing _%#NAME#%_ early next week.
ALD|ad lib on demand|ALD.|225|228|1. GI|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on Enfamil 20/Breast milk taking 26-55 ml every 3 hours and/or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit on _%#MMDD2004#%_ to ensure appropriate weight gain.
ALD|ad lib on demand|ALD.|163|166|1. FEN|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2005#%_. _%#NAME#%_ was discharged breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you early next week. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include an appointment with the NICU Follow-Up Clinic at 4months corrected age.
ALD|ad lib on demand|ALD|249|251|1. FEN|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent previously, and the results are pending at the time of discharge. Immunizations: Hepatitis B vaccine has not been given. _%#NAME#%_ was discharged breast-feeding ALD and supplementing with breast milk and/or formula by bottle approximately 50 - 60 mL every three hours. The parents were asked to make an appointment for their child to see you on Friday, _%#MM#%_ _%#DD#%_.
ALD|ad lib on demand|ALD|179|181|* FEN|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was not given. _%#NAME#%_ was transferred taking 30-40 ml of Enfamil with iron every 2-4 hours on an ALD schedule. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|111|114|1. FEN|He passed the ABR hearing screening test Immunizations: none given _%#NAME#%_ was discharged on breast-feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|231|234|4. ID|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending at discharge. He passed the ABR hearing screening test. _%#NAME#%_ was discharged breast-feeding every 3 to 4 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Follow-up clinic appointments scheduled at Fairview- University Children's Hospital include an appointment with the geneticist in one month.
ALD|adrenoleukodystrophy|ALD,|211|214|PAST MEDICAL HISTORY|ALLERGIES: No known drug allergies. IMMUNIZATIONS: Up to date prior to the bone marrow transplant. DIET: Regular. PAST MEDICAL HISTORY: 1. Adrenal leukodystrophy. In _%#MM2003#%_, his brother was diagnosed with ALD, and shortly thereafter _%#NAME#%_ was also diagnosed. He is status post a matched sibling bone marrow transplant on _%#MMDD2003#%_.
ALD|ad lib on demand|ALD.|122|125|1. FEN|Physical exam was normal except for jaundice to the mid-abdomen. _%#NAME#%_ was discharged breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you on Monday _%#MM#%_ _%#DD#%_. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|210|213|1. FEN|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending at discharge. She passed the ABR hearing screening test. Xochitl was discharged on breast milk ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|152|154|2.) FEN/GI|By day of life three he was on full enteral feeds. By 16 days of age _%#NAME#%_ moved to cue based feeds. Having done well with this he was switched to ALD on day 17. Having continued to gain appropriate weight, he was deemed ready for discharge on day 18. 2. Resp- _%#NAME#%_ was intubated for respiratory distress and high pCO2.
ALD|ad lib on demand|ALD.|266|269|1. FEN|Physical exam on discharge was normal. PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are normal at discharge. He passed the ABR hearing screening test. _%#NAME#%_ was discharged breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include an appointment in the neurology clinic with Dr. _%#NAME#%_ in one month.
ALD|ad lib on demand|ALD.|373|376|1. FEN|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are normal at discharge, with the exception of a borderline CAH screen, which was re-sent (including 17-hydroxy-progesterone) and is pending at discharge. She passed the ABR hearing screening test. _%#NAME#%_ was discharged on breast milk breast-feeding every 2-3 hours ALD. Laboratory studies including sodium and potassium levels were to be drawn _%#MMDD2003#%_ at follow-up appointment with Dr. _%#NAME#%_ at Fairview Lakes lab. The parents were asked to make an appointment for their child to see you or Dr. _%#NAME#%_ within one week, and this was scheduled for _%#MMDD2003#%_.
ALD|ad lib on demand|ALD.|213|216|1. FEN|She passed the ABR hearing screening test. Immunizations: none _%#NAME#%_ was discharged on breast milk fortified to 22kcal (with Enfacare) or Enfacare itself taking 50-60 ml every 3-4 hours and/or breast-feeding ALD. The parents were asked to make an appointment for their child to see you within one week Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|196|199|FOLLOW-UP|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on Enfacare 22 kcal formula, bottle feeding about every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include NICU follow-up clinic at 4 months corrected gestational age.
ALD|ad lib on demand|ALD;|147|150|1. FEN|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on breast milk ALD; the parents do plan to offer occasional bottle feedings of breast milk as well, in order to allow _%#NAME#%_'s father to feed him.
ALD|ad lib on demand|ALD.|147|150|1. GI|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on breast milk ALD. The parents were asked to make an appointment for their child to see you within one week. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital should include follow-up with the surgery clinic in 1 month..
ALD|ad lib on demand|ALD.|134|137|1. FEN|_%#NAME#%_ was discharged on breast milk or enfacare 22 taking a minimum of 150 ml every 12 hours and/or breast-feeding every 4 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Follow-up clinic appointments scheduled at Fairview- University Children's Hospital include a 4 month check-up.
ALD|ad lib on demand|ALD|195|197|1. FEN|* He passed the ABR hearing screening test. * Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on Similac PM 60/40 formula with Kayexalate as above on an ALD schedule. The parents were asked to make an appointment for their child to see you within one week. _%#NAME#%_ will need weekly labs drawn at the clinic near his home (Na, K, HCO3, BUN/CR, Ca, Phos, Hgb).
ALD|left anterior descending:LAD|ALD,|232|235|HOSPITAL COURSE|HOSPITAL COURSE: 1. Chest pain. The patient is a 67-year-old gentleman with known coronary artery disease status post stenting of the right posterolateral branch artery. Angiogram in _%#MM#%_ showed 30 to 50 percent stenosis in the ALD, circumflex and RCA. See previous discharge summaries for angiogram report. 2. Patient has had poorly controlled hypertension. Patient has had medication adjustments through his primary M.D. Over the last several weeks, however, he has had increasing substernal and right-sided chest discomfort, described as a pressure without radiation.
ALD|ad lib on demand|ALD.|167|170|FOLLOW-UP APPOINTMENTS|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2005#%_. _%#NAME#%_ was discharged on breast-feeding every 3-4 hours ALD. The parents were asked to make an appointment for their child to see you within 3-5 days. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|129|131|ASSESSMENT AND PLAN|We started Lovenox, nitro, beta blocker and also Abilify 30 mg at nighttime to be continued. We will probably start some sort of ALD once a day. 2. Otherwise for her other problems of asthma, cholesterol problem, bipolar and hypertension, her home medications will be continued.
ALD|ad lib on demand|ALD.|176|179|ASSESSMENT AND PLAN|He passed the ABR hearing screening test. Immunizations: none _%#NAME#%_ was discharged on Enfamil20 formula and breast milk taking 40- 50 ml every hours and/or breast-feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit 2 times the first week after discharge and then re-assess.
ALD|ad lib on demand|ALD.|127|130|ASSESSMENT AND PLAN|She passed the ABR hearing screening test _%#NAME#%_ was discharged on Enfacare 22 calories taking about 30 ml every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you on friday. Millacs Co.Home Care nurse will visit _%#MMDD#%_ and _%#MMDD#%_. The parents were asked to keep a record of the _%#NAME#%_'s intake and output to show the PHN.
ALD|ad lib on demand|ALD.|270|273|1. FEN|Physical exam was normal at time of discharge. PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are normal at discharge. He passed the ABR hearing screening test. _%#NAME#%_ was discharged on regular Enfamil formula ALD. The parents were asked to make an appointment for their child to see you within one week. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include Neonatology at 4 months CGA.
ALD|ad lib on demand|ALD|109|111|1. FEN|He passed the ABR hearing screening test. Immunizations: None given _%#NAME#%_ was discharged breast feeding ALD with bottle supplementation of breast milk vs. Enfamil 20 to achieve a goal of 220-240 cc/12 hours. The parents were asked to make an appointment for their child to see you within one week.
ALD|ad lib on demand|ALD.|118|121|1. FEN|She passed the ABR hearing screening test. Immunizations: None _%#NAME#%_ was discharged breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit on Friday _%#MMDD2002#%_. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|100|103|3.  FEN|He did not need any IV rehydration during hospitalization. _%#NAME#%_ was discharged breast-feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you for allowing us to participate in the care of _%#NAME#%_.
ALD|ad lib on demand|ALD.|195|198|PICU|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. . _%#NAME#%_ was discharged on Breast milk and Enfamil 20 cal/oz with iron taking feeds ALD. The parents were asked to make an appointment for their child to see you within one week. She will need to follow-up with ENT as directed post-operatively Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|224|227|PICU|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on breastmilk from a bottle taking 60 ml every 3 hours and/or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit from Fairview Lakes Home Care.
ALD|ad lib on demand|ALD.|209|212|PICU|He passed the ABR hearing screening test. Immunizations: _%#NAME#%_ was vaccinated for Hepatitis B on _%#MMDD2004#%_. _%#NAME#%_ was discharged on Enfamil with iron, taking approximately 55 ml every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will make a couple visits early this week.
ALD|ad lib on demand|ALD.|193|196|1. FEN|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. . _%#NAME#%_ was discharged on breast milk taking and breast-feeding every 2- 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit in 2-3 days. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include Pediatric Surgery with Dr. _%#NAME#%_ in 2 weeks and Neurosurgery with Dr. _%#NAME#%_ in 4-6 weeks.
ALD|ad lib on demand|ALD.|178|181|1. FEN|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD#%_. _%#NAME#%_ was discharged on breast and bottle feeding about every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|112|115|2. ID|He passed the ABR hearing screening test (administered in the NBN). _%#NAME#%_ was discharged on breast milk PO ALD. The parents were asked to make an appointment for their child to see you Tuesday _%#MMDD2004#%_. At this appointment the Hgb, retic count and bilirubin should be checked.
ALD|adrenoleukodystrophy|(ALD)|119|123|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 9-year-old boy, soon to be 10, who was diagnosed with adrenoleukodystrophy (ALD) in 1999. He underwent an unrelated donor bone marrow transplant in _%#MM2000#%_ and had a relatively uncomplicated post-transplant course.
ALD|ad lib on demand|ALD.|165|168|1. FEN|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was not given. _%#NAME#%_ _%#NAME#%_ was transferred on Enfamil 20 kcal/oz with iron at ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|179|182|1. FEN|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was not given. _%#NAME#%_ was discharged on breast milk breast-feeding approximately every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include Pediatric Surgery in 2-3 weeks.
ALD|ad lib on demand|ALD.|196|199|1. FEN|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2003#%_. Baby _%#NAME#%_ was discharged on breast milk and Enfamil 20 kcal feeding every 1-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|285|288|1. FEN|Physical exam was normal except for mild jaundice. PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending at discharge. She passed the ABR hearing screening test. _%#NAME#%_ was discharged on Enfamil 20 and/or breast-feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD,|133|136|1. FEN|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was not given. _%#NAME#%_ was discharged on Enfamil 20 ALD, and working on breast feeding. The parents were asked to make an appointment for their child to see you within one week.
ALD|ad lib on demand|ALD.|191|194|1. FEN|Immunizations: Hepatitis B vaccine was not given. _%#NAME#%_ was discharged to the newborn nursery on Enfamil and breast milk taking 30-45ml every 3 hours and/or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|170|173|1. FEN|Physical exam was normal except for persistent jaundice in an awake, alert baby and a Grade II/VI systolic murmur. _%#NAME#%_ was discharged breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Follow-up clinic appointments scheduled at The University of Minnesota Children's Hospital include the Pediatric Metabolism clinic on Wednesday _%#MMDD2005#%_.
ALD|adrenoleukodystrophy|ALD|179|181|FAMILY HISTORY|1. Diagnosed with X-linked adrenal leukodystrophy soon after birth, progressive white matter changes were evident on MRI. 2. Reactive airway disease. FAMILY HISTORY: Positive for ALD on mother's side of the family with several members succumbing to the disease and the mother is currently staying at the Ronald McDonald House.
ALD|ad lib on demand|ALD.|202|205|PROBLEM #8|He passed the ABR hearing screening test on _%#MMDD2002#%_. Immunizations: due _%#MMDD2002#%_ _%#NAME#%_ was discharged on Enfamil Premature Formula, 24 calories/ounce taking 30-70 cc's every 3-4 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit on _%#MMDD#%_ or _%#MMDD#%_.
ALD|ad lib on demand|ALD|204|206|2. PPROM|He passed the ABR hearing screening test on _%#MMDD2002#%_. Immunizations: Comvax: _%#MMDD2002#%_ IPV: _%#MMDD2002#%_ DTaP: _%#MMDD2002#%_ _%#NAME#%_ was discharged bottle feeding, every 3 1/2 to 4 hours ALD taking 40-90 cc. He is feeding breast milk fortified with neosure and ProMod to equal 24 calories per ounce and 4 grams/kg/day of protein.
ALD|ad lib on demand|ALD.|160|163|1. FEN|Discharge measurements: Weight 4015 gms; OFC 35 cm. Physical exam was normal except for a sacral dimple. _%#NAME#%_ was discharged breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you for her two month well child visit. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|272|275|1. FEN|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were NOT sent and will need to be drawn from outpatient clinic this week. _%#NAME#%_ did NOT have a newborn hearing screen. _%#NAME#%_ _%#NAME#%_ was discharged on breast-feeding every 2-3 hours ALD. The parents have made an appointment with you _%#MMDD2003#%_ at 1:30 p.m. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|261|263|1. FEN|The transition from gavage feeding to full bottle feeding was very slow and gradual; his final gavage feed occurred on _%#MMDD2003#%_ (day 26 of life). He was fed with EPF 24 and will be discharged on EnfaCare 22. At the time of discharge, _%#NAME#%_ was on an ALD schedule, and satisfactorily meeting nutritional requirements with bottle feeding. 2. Respiratory. Shortly following birth, _%#NAME#%_ developed mild respiratory distress; he was intubated for transport to the NICU on _%#MMDD2003#%_, and extubated later that same day.
ALD|ad lib on demand|ALD.|129|132|1. FEN|He passed the ABR hearing screening test. Immunizations were not given. _%#NAME#%_ was discharged breast-feeding every 2-3 hours ALD. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|103|105|1. FEN|He passed the ABR hearing screening test. Immunizations: None. _%#NAME#%_ was discharged on breastmilk ALD with breastmilk bottle supplementation as needed (no scheduled bottling). Breastmilk that is given with the bottle will be supplemented to 24 kcal using Enfacare 22 kcal powder to improve _%#NAME#%_'s caloric intake and growth.
ALD|ad lib on demand|ALD|213|215|1. FEN|Hearing: Passed both ears. Immunizations: Hepatitis B vaccine was not given, but should be administered prior to discharge home. Ongoing problems and suggested management: 1. FEN: BG _%#NAME#%_ was breast feeding ALD at time of transfer. Enfamil 20kcal/oz formula was added to her feeds, in the case that she would need more than mother can offer at present time.
ALD|ad lib on demand|ALD|125|127|1. FEN|Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on Enfamil 20 and breastfeeding on ALD schedule. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|154|157|1. F/E/N|She passed the ABR hearing screening test. _%#NAME#%_ was discharged on Enfamil with Fe taking 40-80 ml every 3 hours and/or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit by _%#MMDD2003#%_.
ALD|ad lib on demand|ALD.|134|137|1. F/E/N|She passed the ABR hearing screening test. Immunizations: none given during hospitalization. _%#NAME#%_ was discharged breast-feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|144|147|4. ID|_%#NAME#%_ was discharged on formula (iron fortified Enfamil 20) and breast milk taking 56 ml every 3 hours and/or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit 2 times per week for 2 weeks.
ALD|ad lib on demand|ALD.|214|217|1. ID|Problems during the hospitalization included the following: 1. FEN - _%#NAME#%_ was initially made NPO until his respiratory distress resolved. He was given IV fluids. He then began breast feeding with the plan of ALD. Shortly after his first breastfeed, his mother had a post- partum hemorrhage, necessitating gavage feeding until she was able to resume breastfeeding on _%#NAME#%_'s DOL#1.
ALD|ad lib on demand|ALD.|122|125|1. FEN|He passed the ABR hearing screening test. Immunizations: None _%#NAME#%_ was discharged breast-feeding every 2 to 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|107|110|1. FEN|Immunizations: Hepatitis B vaccine was not given. _%#NAME#%_ was discharged breast-feeding every 3-4 hours ALD. The parents were asked to make an appointment for their child to see you on _%#MMDD2006#%_ for lab work and examination. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|215|218|1. FEN|He passed the ABR hearing screening test. No follow up is required Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. . _%#NAME#%_ was discharged on Enfamil 20 with iron taking 40-50 ml every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|231|233|3. ID|Physical exam was normal except for mild jaundice. PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent at birth and the results were normal. Immunizations: none given _%#NAME#%_ was discharged on ALD feeds breast feeding and supplemental bottles. The parents were asked to make an appointment for their child to see you early the week of _%#MM#%_ _%#DD#%_.
ALD|ad lib on demand|ALD.|192|195|1. FEN|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_ . _%#NAME#%_ was discharged on both formula and breast milk, feeding every 2- 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit within one to two days..
ALD|ad lib on demand|ALD.|156|159|1. GU|He also received 1 dose of Synagis prior to discharge. _%#NAME#%_ _%#NAME#%_ was discharged on breast-feeding fortified to 22Kcal per ounce every 3-4 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include the NICU clinic in 4 months.
ALD|ad lib on demand|ALD.|228|231|1. ID|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was not given prior to transfer to the newborn nursery. _%#NAME#%_ was transferred to the newborn nursery on breast milk breast- feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|198|201|1. FEN|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ _%#NAME#%_ was discharged on Enfamil 20 with iron taking bottles every 3-4 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|228|231|WCC.|He passed the ABR hearing screening test on _%#MMDD#%_. Immunizations: Hepatitis B vaccine was declined by parents until first WCC. _%#NAME#%_ _%#NAME#%_ was discharged on breast milk breast-feeding every at least every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week for suture removal. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include follow-up with Dr. _%#NAME#%_, Neurosurgery in 4-6 weeks.
ALD|ad lib on demand|ALD.|214|217|1. FEN|She passed the ABR hearing-screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on breast milk taking 50-60 ml every 3 hours and/or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit _%#MMDD2004#%_. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|230|233|1. FEN|He passed the ABR hearing screening test _%#MMDD2006#%_. Immunizations: Hepatitis B vaccine was not given. _%#NAME#%_ was discharged on Enfamil 20 kcal infant formula taking 60 ml every 4 hours and/or breast-feeding every 4 hours ALD. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|162|164|1. FEN|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. . _%#NAME#%_ was discharged on Enfamil with Lipil on an ALD schedule. The foster parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit from _%#COUNTY#%_ _%#COUNTY#%_. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|121|124|3. ID|Immunizations: Hepatitis B vaccine was given on _%#MMDD2005#%_. _%#NAME#%_ was discharged breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|162|165|1. FEN|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2005#%_. _%#NAME#%_ was discharged breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Dr. _%#NAME#%_ from Heme/Onc will work with you to manage _%#NAME#%_'s thrombocytopenia and to continue the work up.
ALD|adrenoleukodystrophy|ALD|139|141|FAMILY HISTORY|SOCIAL HISTORY: _%#NAME#%_ lives in a group home and the family is involved. Please note CODE STATUS IS DNR/DNI. FAMILY HISTORY: Mom is an ALD carrier. Mom and sister have factor IV Leiden, as does _%#NAME#%_. PAST MEDICAL HISTORY: 1. Adrenoleukodystrophy diagnosed in 2004 after staring spells and impaired attention, detected late after it had progressed.
ALD|adrenoleukodystrophy|ALD.|160|163|ASSESSMENT/PLAN|She will have neuro checks q 4 hours overnight. Will have a Neuro consult from _%#CITY#%_ Clinic of Neurology. 8. Will continue to do symptomatic cares for her ALD. 9. Will continue the Macrobid for the UTI. 10. Continue her atenolol, Maxzide for hypertension. 11. Continue Levoxyl for her thyroid. 12. DNR/DNI per requests.
ALD|ad lib on demand|ALD.|131|134|ASSESSMENT/PLAN|He pPassed/Failed the ABR hearing screening test. Immunizations: none given _%#NAME#%_ was discharged breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|229|232|GI|Problems during the hospitalization included the following: 1. FEN- _%#NAME#%_ was placed NPO on admission but the next day advanced to po. Breast feeding progressed well and on discharge she was gaining weight and breastfeeding ALD. 2. Respiratory - CXR and ABG done on admission were both within normal limits.
ALD|ad lib on demand|ALD.|104|107|NONE|She passed the ABR hearing screening test. Immunizations: none _%#NAME#%_ was discharged breast-feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|146|149|NONE|Problems during the hospitalization included the following: 1. FEN - Baby bottled well on Enfamil 20 kcal with iron , and was discharged bottling ALD. 2. CV/RESP - a CR scan was conducted to evaluate but was inadequately performed, with no results. 3. GI - UGI/SBFT was consistent with reflux. Reflux precautions were initiated in hospital and no further spells were noted.
ALD|ad lib on demand|ALD.|252|255|NONE|Discharge medications, treatments and special equipment: Zantac 7.5 mg po Q 12 hours Discharge measurements: Weight 3530 gms; length 49.5 cm; OFC 35.5 cm. Physical exam was normal . _%#NAME#%_ was discharged on Enfamil 20 kcal with iron formula taking ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|306|309|NONE|Physical exam was normal except for subtle decrease in tone, consolidating hematoma on posterior skull, and reduced endurance to suck and grasp. _%#NAME#%_ was transferred to the Newborn Nursery on pumped breast milk with supplemental Enfamil 20 formula taking 4 ml every three hours and/or breast-feeding ALD. Thank you again for allowing us to share in the care of your patient.
ALD|adrenoleukodystrophy|ALD|33|35||_%#NAME#%_ was a 9-year-old with ALD who received double umbilical cord blood transplant with 2 5/6 antigen matched cords. The patient had multiple complications after transplant including mostly irreversible encephalopathy secondary to cyclosporin toxicity, hypertension, graft versus host disease and multiple postitive tests for adenovirus in blood and stools.
ALD|ad lib on demand|ALD.|110|113|GI|He passed the ABR hearing screening test. Immunizations: none _%#NAME#%_ was discharged on breast milk taking ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|129|132|1. CV|He passed the ABR hearing screening test. Immunizations: None given. _%#NAME#%_ was discharged on breast-feeding every 2-4 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Follow-up clinic appointments: 1. Appointment with Dr. _%#NAME#%_ on Wednesday, _%#MM#%_ _%#DD#%_, 2002.
ALD|ad lib on demand|ALD|137|139|2. CV|He passed the ABR hearing screening test. Immunizations: none given _%#NAME#%_ was discharged on 24Kcal BM fortified with Enfacare on an ALD schedule. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit after the other sibling is discharged.
ALD|ad lib on demand|ALD.|241|244|4. GI|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are normal. He Passed the ABR hearing screening test. _%#NAME#%_ was discharged on breastmilk, breast-feeding with supplemental bottles s ALD. The parents were asked to make an appointment for their child to see you at the end of this week. Home Care nurse will visit within one week of discharge.
ALD|ad lib on demand|ALD.|146|149|1. FEN|He passed the ABR hearing screening test. Immunizations: None given. _%#NAME#%_ was discharged on Enfamil 20 with Iron taking 54 ml every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|adrenoleukodystrophy|ALD.|204|207|HISTORY OF PRESENT ILLNESS|DIAGNOSIS: Bone marrow donation for his brother. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 13-year-old boy who presented today for donation of bone marrow for his brother, _%#NAME#%_ who has ALD. He was seen in bone marrow transplant clinic prior to his donation. His only past medical history is significant for some mild intermittent epistaxis and nasal congestion, which resolved approximately 1-1/2 weeks ago.
ALD|ad lib on demand|ALD|212|214|LABORATORY DATA|_%#NAME#%_ was initially maintained on parenteral nutrition from _%#MMDD2007#%_ until _%#MMDD2007#%_. Feedings were started on _%#MMDD2007#%_ with attempts at breast feeding. He progressed to breastfeeding on an ALD schedule. His weight at the time of transfer was 3530 gm (50th-90th %tile). Problem #2: Respiratory Distress. His clinical and radiologic course was most consistent with respiratory distress syndrome / transient tachypnea of the newborn.
ALD|ad lib on demand|ALD.|216|219|1. FEN|_%#NAME#%_ passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2006#%_. _%#NAME#%_ was discharged breast-feeding and/or bottling breast milk taking 20-40 ml. every 2-3 hours ALD. The parents have an appointment to see you on Friday, _%#MMDD2006#%_. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|176|179|1. FEN|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2006#%_. _%#NAME#%_ _%#NAME#%_ was discharged, breast-feeding every 2-3 hours ALD. She has an appointment to see you on _%#MM#%_ _%#DD#%_, 2006. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|162|165|1. FEN|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2006#%_. _%#NAME#%_ was discharged on Enfacare 22kcal/oz formula ALD. The parents were asked to make an appointment for their child to see you on Monday _%#MMDD2006#%_. Home Care nurse will visit _%#MMDD2006#%_. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|175|178|2. ID|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending at discharge. _%#NAME#%_ was breast-feeding every 3-4 hours ALD. The parents were asked to make an appointment for their child to see you on Monday _%#MMDD2002#%_. Children's Home Care will be making a visit to the home Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|121|123|FEN|_%#NAME#%_ passed the ABR hearing screening test. Immunizations: none given _%#NAME#%_ was discharged taking breast milk ALD with adequate weight gain. Her weight was 2030 gms, length 46.5 cm, and OFC 30 cm. Physical exam was entirely normal. The parents were asked to make an appointment for their child to see you within two days.
ALD|ad lib on demand|ALD.|234|237|FEN|He passed the ABR hearing screening test. _%#NAME#%_ received no immunizations during his hospitalization. _%#NAME#%_ was discharged gavaging breast milk fortified to 22kcal/oz with HMF taking 40ml every 3 hours and/or breast-feeding ALD. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|213|216|1. ID|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending at discharge. She passed the ABR hearing screening test. _%#NAME#%_ was discharged breast-feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|177|179|1. ID|His last exam was on _%#MMDD2003#%_, with follow- up recommended around _%#MMDD2003#%_. Ongoing problems and suggested management: 1. FEN. Currently doing well with EnfaCare 22 ALD feeding. 2. GI. a) Follow-up ileostomy take-down with Dr _%#NAME#%_ _%#NAME#%_ in Peds Surgery Clinic in 4-6 weeks. b) Zantac for reflux. Follow clinically; if appropriate weight gain in 1-2 months it is reasonable to consider discontinuation of this therapy.
ALD|ad lib on demand|ALD.|108|111|2. IPV		1/14/03|Synagis administration has been contracted to Children's Homecare. _%#NAME#%_ was discharged on EnfaCare 22 ALD. The parents were asked to make an appointment for their child to see you within one week. His follow-up NICU appointment should still be scheduled at Fairview- University Children's Hospital at 4 months corrected gestational age.
ALD|ad lib on demand|ALD.|127|130|3. ID|He passed the ABR hearing screening test Immunizations: _%#NAME#%_ was discharged on breast milk, breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit _%#MMDD2003#%_.
ALD|ad lib on demand|ALD.|168|171|3. ID|He passed the ABR hearing screening test. Immunizations: none _%#NAME#%_ was discharged on breast milk taking 35 ml every 3 hours and/or breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit in 24 hours to follow-up his weight gain.
ALD|ad lib on demand|ALD.|141|144|1. FEN|The only abnormality was the previously mentioned right clavical fracture. BB _%#NAME#%_ was discharged on Enfamil with iron 20 kcal formula ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|332|335|1. FEN|Physical exam was normal. PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending at discharge. She passed the ABR hearing screening test. Immunizations: None _%#NAME#%_ was discharged on breast milk plus Enfamil 20 with iron, taking 75 ml every 3 hours and breast-feeding ALD. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|175|178|CUHCC|Feeds were initially gavaged (_%#NAME#%_ was still slightly tachypneic and would tire quickly). Full PO feeds were tolerated by DOL 3 and soon thereafter he was bottling well ALD. 2. CV. _%#NAME#%_ was cardiovascularly stable throughout hospitalization. 3. Resp. _%#NAME#%_ was admitted for respiratory distress on DOL 1. Blood cultures were drawn.
ALD|ad lib on demand|ALD.|141|144|CUHCC|He passed the ABR hearing screening test. Immunizations: None given during hospitalization _%#NAME#%_ was discharged on Enfamil 20 with iron ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|212|215|3. ENDO|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending at discharge. He passed the ABR hearing screening test. _%#NAME#%_ was discharged on breast milk ALD. The parents were asked to make an appointment for their child to see you early the following week. Home Care nurse will visit the patient the next 2-3 days to check weights, heart rate, remind parents of follow up appointments.
ALD|ad lib on demand|ALD.|133|136|1. FEN|He passed the ABR hearing screening test. No further follow-up is necessary. Immunizations: _%#NAME#%_ was discharged breast-feeding ALD. Further evaluation, management, and follow-up to be arranged per newborn nursery protocol. Thank you again for allowing us to share in the care of your patient.
ALD|adrenoleukodystrophy|ALD|24|26|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. ALD status post bone marrow transplant. 2. Mental status changes. DISCHARGE DIAGNOSES: 1. ALD status post bone marrow transplant.
ALD|adrenoleukodystrophy|ALD|114|116|DISCHARGE DIAGNOSES|ADMISSION DIAGNOSES: 1. ALD status post bone marrow transplant. 2. Mental status changes. DISCHARGE DIAGNOSES: 1. ALD status post bone marrow transplant. 2. Status epilepticus. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a seven-year-old boy with adrenal leukodystrophy diagnosed _%#MM2002#%_, status post matched 6/6 sibling bone marrow transplant on _%#MMDD2002#%_, who presented to clinic on the day of admission with mental status changes.
ALD|ad lib on demand|ALD.|169|172|DISCHARGE MEDICATIONS|Total fluids were initially run at 100 mL/kg/day because of concern for polycythemia. IV fluids were discontinued on _%#MMDD2007#%_ and she was changed to breastfeeding ALD. She fed poorly so was placed on scheduled feedings. Because of fluid sensitivity she remained on scheduled feeds and fluid restricted until _%#MMDD#%_ just prior to discharge when she was allowed to ALD with a minimum goal of 320mls/day ( 125 ml/k/day).
ALD|ad lib on demand|ALD|199|201|DISCHARGE MEDICATIONS|She fed poorly so was placed on scheduled feedings. Because of fluid sensitivity she remained on scheduled feeds and fluid restricted until _%#MMDD#%_ just prior to discharge when she was allowed to ALD with a minimum goal of 320mls/day ( 125 ml/k/day). Her weight at the time of discharge was 2590 grams. Problem # 2: Respiratory Distress. Her clinical and radiologic course was most consistent with hypoxia secondary to congenital heart disease.
ALD|ad lib on demand|ALD.|230|233|GI|Both parents have had infant CPR teaching. Immunizations: None. _%#NAME#%_ was discharged on MBM and MBM supplemented with Enfacare to 24 kcal/oz (to be continued at your discretion, depending on growth), eating every three hours ALD. The parents were asked to make an appointment for their child to see you within one week. Follow-up clinic appointments at Fairview-University Children's Hospital include NICU follow-up clinic in three months.
ALD|ad lib on demand|ALD.|263|266|6. F/E/N|_%#NAME#%_ tolerated the feeds without difficulties, so the feeds were rapidly increased to 45 cc every 3 hours by _%#MMDD2002#%_. Full feeds were advanced on _%#MMDD2002#%_, which he also tolerated. At discharge, _%#NAME#%_ was breast-feeding and bottle-feeding ALD. Ongoing problems and suggested management (see above) Discharge medications, treatments and special equipment: none Discharge measurements: Weight 3390 gm; length 54 cm; OFC 36 cm; abdominal girth 35 cm.
ALD|ad lib on demand|ALD.|292|295|1. FEN|She passed the ABR hearing screening test. Immunizations: _%#NAME#%_'s mother was negative for Hepatitis B surface antigen and therefore no immunizations were given during her hospital stay. _%#NAME#%_ was discharged on formula and breast milk taking approximately 50-70 ml every three hours ALD. The parents were asked to make an appointment for their child to see you on Thursday, _%#MM#%_ _%#DD#%_, 2002. Home Care nurse will visit Tuesday, _%#MM#%_ _%#DD#%_ and Wednesday, _%#MM#%_ _%#DD#%_ with further follow-up at your discretion.
ALD|ad lib on demand|ALD|212|214|1. FEN|His admission exam was significant for mild yellow drainage and crusting of the right eye but was otherwise normal. Problems during the hospitalization included the following: 1. FEN: _%#NAME#%_ was continued on ALD breast and bottle feeds as at home. 2. RESP: _%#NAME#%_ was continued on his caffeine as at home. A caffeine level was obtained on admission and was within therapeutic range; therefore, no dosing changes were made.
ALD|ad lib on demand|ALD.|164|167|GI|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was not given. _%#NAME#%_ was transferred on formula taking 20-40mL ml every 3-4 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|233|236|A.|As discussed above, hemoglobinopathy screen was remarkable for a low level of Hemoglobin A. _%#NAME#%_ was transferred on Enfacare 24 formula/breast milk fortified to 24 kcal with HMF taking 36 ml every 3 hours and/or breast-feeding ALD. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|268|271|1. FEN|Physical exam was normal. PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending at discharge. She passed the ABR hearing screening test. _%#NAME#%_ was discharged on breastmilk, breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|149|151|1. FEN|Ongoing problems and suggested management: 1. FEN: Amani demonstrated excellent oral intake and weight gain on her home regimen of Similac with Iron ALD throughout hospitalization. 2. RESP/ID: _%#NAME#%_ still has some upper airway congestion at time of discharge. While a Pertussis PCR study is still pending at time of discharge, her clinical picture is consistent with a viral respiratory infection.
ALD|ad lib on demand|ALD|158|160|1. FEN|In addition, _%#NAME#%_ continues to have some white plaques over her buccal mucosa bilaterally. _%#NAME#%_ was discharged on Similac with Iron formula on an ALD schedule. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|187|190|1. FEN|She passed the ABR hearing screening test. Immunizations: none _%#NAME#%_ was discharged on both Enfamil and breast milk taking 30-40 ml every 3 hours and/or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit in 48 hours to assess feedings and follow weight gain.
ALD|ad lib on demand|ALD.|140|143|1. RESP|Immunizations: To receive Hepatitis B vaccine prior to discharge. Baby Boy _%#NAME#%_ was transferred to newborn nursery on breast- feeding ALD. The parents were asked to make an appointment for their child to see you within 48 hours of discharge to home. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|375|377|1. RESP|6. Physiologic Hyperbilirubinemia - _%#NAME#%_'s bilirubin level on day 4 of life was 9.1 and she was given phototherapy for 2 days (peak 10.10). Her last bilirubin level on _%#MMDD2003#%_ was 4.5. Mom's blood type is AB + and _%#NAME#%_'s blood type is A + with a negative Coomb's and a negative antibody screen. Ongoing problems and suggested management: 1. FEN - Continue ALD feeds and follow weight gain closely to assess need for adjustment in volume or concentration.. 2. Heme - Continue iron supplementation; may need to adjust dosing given amount of formula and breast milk taken.
ALD|ad lib on demand|ALD.|218|221|3. FEN|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on bottled breastmilk taking 35 ml every 3 hours and/or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit the day following discharge. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|172|175|1. FEN|_%#NAME#%_ passed the ABR hearing screen test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. . _%#NAME#%_ was discharge on breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|197|200|4. FEN|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MM#%_ _%#DD#%_, 2004. _%#NAME#%_ was discharged on breast milk bottle or breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you this week. _%#NAME#%_ is to follow-up with the University of Minnesota Pediatric Surgery Clinic two weeks after discharge.
ALD|ad lib on demand|ALD.|221|224|4. FEN|He passed the ABR hearing screen test on _%#MMDD2004#%_ Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. No other immunizations were given. _%#NAME#%_ was discharged on formula taking 50 ml every 3-4 hours ALD. The parents were asked to make an appointment . Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|278|281|1. FEN|Physical exam was normal. PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent from the newborn nursery and the results are pending at discharge. She passed the ABR hearing screening test. _%#NAME#%_ was discharged breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you on Friday, _%#MMDD2003#%_. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|183|185|1. FEN/GI|Maternal blood type was O positive. A blood type on the baby was not done. Ongoing problems and suggested management: 1. Growth and nutrition: _%#NAME#%_ was discharged breastfeeding ALD and being supplemented with a bottle twice a day. He has not gained weight since his admission, but has been feeding fairly well.
ALD|ad lib on demand|ALD.|128|131|1. FEN/GI|Immunizations: Hepatitis B vaccine was given on _%#MM#%_ _%#DD#%_, 2004. _%#NAME#%_ was discharged breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|185|188|4. GERD|He passed the ABR hearing screening test. Immunizations: _%#MMDD2003#%_ DtaP, Comvax, Polio _%#MMDD2003#%_ Synagis (RSV) _%#MMDD2003#%_ _%#NAME#%_ _%#NAME#%_ was discharged on Enfacare ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit 2-3 days. A follow-up NICU clinic appointment should be scheduled at Fairview-University Children's Hospital in 4 months.
ALD|ad lib on demand|ALD|334|336|1. FEN|She is very concerned and states that she "has never taken care of a baby before and I don't know what to do." The admission physical examination was significant for slightly tacky mucous membranes, weight gain to 6 grams less than birth weight. Problems during the hospitalization included the following: 1. FEN: He was placed on an ALD schedule of breast feeding along with Enfamil Lipil per mom's request if needed. He ate well during this admission and maintained his hydration orally.
ALD|ad lib on demand|ALD|269|271|1. FEN|Following extubation on _%#MM#%_ _%#DD#%_ he was restarted on oral feeding, first with bottled Enfamil 20, and then with rapid transition back to breast-feeding. At the time of discharge on _%#MM#%_ _%#DD#%_, _%#NAME#%_ was meeting his nutritional needs breast-feeding ALD (q 1-2 hrs) and was not requiring formula supplementation. 2. Resp. _%#NAME#%_ was intubated prior to transport from Fairview Northland Hospital on _%#MM#%_ _%#DD#%_.
ALD|ad lib on demand|ALD.|161|164|1. FEN|Problems during the hospitalization included the following: 1. FEN. Upon arrival in the NICU, _%#NAME#%_ was allowed to continue his regular diet of EnfaCare 22 ALD. 2. Pulmonary. _%#NAME#%_ had a single episode of apnea with bradycardia on the evening of admission (_%#MMDD2003#%_; mild, self-resolving).
ALD|ad lib on demand|ALD|188|190|2. IPV 1/13/03|Physical exam was normal. Immunizations: 1. Hib _%#MMDD2003#%_ 2. IPV _%#MMDD2003#%_ 3. HepB _%#MMDD2003#%_ 4. DTaP _%#MMDD2003#%_ _%#NAME#%_ was discharged on Enfacare 22kcal formula and ALD schedule. The parents were asked to make an appointment for their child to see you within one week. His follow-up NICU appointment should still be scheduled at Fairview-University Children's Hospital at 4 months corrected gestational age.
ALD|ad lib on demand|ALD.|118|121|RA.|He passed the ABR hearing screening test. No immunizations were given: _%#NAME#%_ was discharged breast-feeding every ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|196|199|1. FEN|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was not given. _%#NAME#%_ was discharged on breast milk taking 40 ml every 3 hours and/or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within 2-3 days. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|126|129|1. FEN|He passed the ABR hearing screening test. Immunizations: None given _%#NAME#%_ was discharged on breastmilk/Enfamil with Iron ALD. The parents were asked to make an appointment for their child to see you on _%#MM#%_ _%#DD#%_, 2003. Home Care nurse will visit on either _%#MM#%_ _%#DD#%_, 2003 or _%#MM#%_ _%#DD#%_, 2003.
ALD|ad lib on demand|ALD.|255|258|1. FEN|Physical exam was normal except . PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are normal at discharge. He passed the ABR hearing screening test. Owen was discharged breast-feeding every 3-4 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include Peds Urology with Dr. _%#NAME#%_ in 4-6 weeks.
ALD|ad lib on demand|ALD.|178|181|1. FEN|She passed the ABR hearing screening test. Immunizations: None given during this hospitalization _%#NAME#%_ was discharged on Breast milk or Enfacare 22, bottling ever 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit _%#MM#%_ _%#DD#%_ or _%#DD#%_. She should be seen in the NICU follow-up clinic at 4 months corrected gestational age.
ALD|adrenoleukodystrophy|ALD.|183|186|PROBLEM #3|His pressures have remained stable since the change. PROBLEM #3: Neurologic. From a neurologic standpoint, _%#NAME#%_'s baseline status is severe developmental delay secondary to his ALD. He is non-verbal, but does vocalize with agitation and excitement. During his stay he developed seizures which eventually became status epilepticus and brought him to the Pediatric Intensive Care Unit for two days.
ALD|ad lib on demand|ALD|165|167|5. HEME|6. ID: he has been afebrile over the course of this hospitalization with no signs of sepsis. Discharge medications, treatments and special equipment: 1. Breast milk ALD and breast milk fortified to 26 cal with neosure, 2. Tri Vi Sol with Iron 1 ml PO Q day 3. Zantac 5.5 mg PO BID 4. Atropine sulphate ophthalmic sol 1 drop left eye QOD _%#NAME#%_ is a good candidate to receive Synagis during the upcoming RSV season.
ALD|ad lib on demand|ALD.|158|161|DOL # 6.|He passed the ABR hearing screening test. _%#NAME#%_ was discharged on breast milk and formula taking 45 ml every 3 hours and/or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit this weekend _%#MMDD#%_-_%#MMDD2003#%_ and they will check on feeds and weights.
ALD|ad lib on demand|ALD.|232|235|1. FEN|He Passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on both formula and breast milk, taking 60 ml every 2-3 hours and/or breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit within 1-2 days of discharge.
ALD|ad lib on demand|ALD.|211|214|1. F/E/N|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on breast milk taking 60 ml every 3 hours and/or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within 3-5 days. Home Care nurse will visit on _%#MMDD2004#%_ for a bilirubin check.
ALD|ad lib on demand|ALD.|195|198|1. FEN|Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on MBM fortified with Enfamil 22 kcal taking 20- 60 ml every 3 hours and/or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit for a weight check and to monitor feeding within 2-3 days after discharge.
ALD|ad lib on demand|ALD.|128|131|2. FEN/GI|Immunizations: Hepatitis B vaccine was not given while in the NICU. _%#NAME#%_ was discharged on breast-feeding every 2-3 hours ALD. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|196|198|* FEN|* Synagis: _%#NAME#%_ does not meet the AAP criteria for receiving Synagis this current RSV season. Ongoing problems and suggested management: * FEN: _%#NAME#%_ was transferred on a breastfeeding ALD schedule. * ID: Blood culture is negative at the time of discharge. Discharge measurements and exam: Weight 3500 gm (20%). Physical exam was normal.
ALD|ad lib on demand|ALD.|273|276|1. FEN|Physical exam was normal. PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are normal at discharge. _%#NAME#%_ passed the ABR hearing screening test. _%#NAME#%_ was discharged on regular Enfamil fortified to 22 kcal/oz ALD. The parents were asked to make an appointment for their child to see you within one week. Follow-up clinic appointments scheduled at Fairview- University Children's Hospital include ophthalmology exam on _%#MMDD2002#%_.
ALD|ad lib on demand|ALD.|140|143|OPHTHO|Physical exam was normal except for a left-sided hydrocele. _%#NAME#%_ was discharged on Enfacare concentrated to 24 kcal/oz formula taking ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|153|156|1. FEN|Physical exam was normal. Immunizations: None given during this hospitalization. _%#NAME#%_ was discharged on Enfacare 22 cal formula taking 90 - 110 ml ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|227|229|HEME|Her placental was separated from her twin's thus twin-to twin transfusion is unlikely. Follow up hemoglobin the week of discharge was19.1. Ongoing problems and suggested management: Feeding: Will continue Enfamil 20 kcal/oz on ALD schedule Discharge measurements: Weight 1955 gms; length 44.5 cm; OFC 29.5 cm.
ALD|ad lib on demand|ALD,|131|134|4. F/E/N|She passed the ABR hearing screening test on _%#MMDD2002#%_. Immunizations: none given _%#NAME#%_ was discharged on breast-feeding ALD, with a minimum intake of 120cc every 12 hours. The parents had decided to pump and bottle feed _%#NAME#%_ at home.
ALD|ad lib on demand|ALD|138|140|4. F/E/N|The cause of _%#NAME#%_'s jaundice was felt to be physiologic and did not require further treatments. 4. F/E/N: _%#NAME#%_ was started on ALD breastfeeds on admission, but he was made NPO for the bronchoscopy. Post-operatively _%#NAME#%_ tried breastfeeding again but experienced episodes of oxygen desaturations with each attempt.
ALD|ad lib on demand|ALD|229|231|4. F/E/N|Post-operatively _%#NAME#%_ tried breastfeeding again but experienced episodes of oxygen desaturations with each attempt. Breastfeeding was briefly held, and _%#NAME#%_ was fed via gavage with breastmilk or Enfamil with iron. PO ALD was attempted again, and _%#NAME#%_ was feeding well at the time of discharge. Ongoing problems and suggested management: see above Discharge medications, treatments and special equipment: home monitor Discharge measurements: Weight 3745 gms; length 53.5 cm; OFC 34.5 cm.
ALD|ad lib on demand|ALD.|112|115|4. F/E/N|He passed the ABR hearing screening test. Immunizations: none given _%#NAME#%_ was discharged on breast-feeding ALD. It was understood that _%#NAME#%_ will see you in clinic tomorrow. Dr. _%#NAME#%_ will see _%#NAME#%_ in his office next Friday, _%#MMDD2002#%_.
ALD|ad lib on demand|ALD.|132|135|1. FEN|It will need repeating. She passed the ABR hearing screening test. _%#NAME#%_ was discharged bottling Enfamil 20 and breast-feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit once to evaluate weight and feeding regimen.
ALD|ad lib on demand|ALD|150|152|SGA.|She passes the ABR hearing screening test. Immunizations: none were given. _%#NAME#%_ was discharged breast-feeding approximately every 3 hours on an ALD schedule. She has also been supplemented with Enfacare 22 after some feedings where she has been sleepy. She has been taking anywhere from 20-60 mL every 3 hours.
ALD|ad lib on demand|ALD.|183|186|3. GU|She Passed the ABR hearing screening test. Immunizations: None _%#NAME#%_ was discharged on Enfacare 22 and breast milk taking 45 ml every 3 hours and/or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital will not be necessary..
ALD|ad lib on demand|ALD.|139|142|1. FEN|Problems during the hospitalization included the following: 1. FEN: _%#NAME#%_ was continued on his current diet of breast or bottle feeds ALD. 2. Heme: Admission hemoglobin was 8.3. He received a 15ml/kg transfusion of PRBCs with increase of Hgb to 13.6. He was continued on his Folate supplement.
ALD|ad lib on demand|ALD.|164|167|2. ID|He passed the ABR hearing screening test during his previous admission. Immunizations: none given _%#NAME#%_ was discharged on Similac with iron and/or breast milk ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|116|119|INTRODUCTION|She passed the ABR hearing screening test. Immunizations: _%#NAME#%_ was discharged on breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week Follow up appointment with Dr. _%#NAME#%_ _%#NAME#%_, neonatologist, in Fairview University PWB clinic in 4 months.
ALD|ad lib on demand|ALD.|163|166|1. FEN|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit in 2 days. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|209|212|1. FEN / GI|He passed the ABR hearing screening test. Immunizations: _%#NAME#%_ was vaccinated for Hepatitis B on _%#MMDD2004#%_. _%#NAME#%_ was discharged on Enfamil with iron, taking approximately 55 ml every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will make a couple visits early this week.
ALD|ad lib on demand|ALD.|121|124|3. FEN|Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged breast-feeding every 3-4 hours ALD. The parents were asked to make an appointment for their child to see you on _%#MMDD2004#%_ for hospital follow-up and bilirubin check.
ALD|ad lib on demand|ALD.|153|156|3. FEN|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on Enfamil with iron ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|135|138|3. FEN|_%#NAME#%_ was discharged on Similac 20 with iron and breast milk taking 20- 40 ml every 3 hours and/or breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you Friday, _%#MM#%_ _%#DD#%_. Home Care nurse from Children's Home Care will visit Thursday, _%#MM#%_ _%#DD#%_ to weigh _%#NAME#%_ and monitor feedings.
ALD|ad lib on demand|ALD.|165|168|3. FEN|He was subsequently switched to breastmilk as mom's milk supply came in. At the time of discharge, he was bottling / breastfeeding all of his feedings of breastmilk ALD. His weight at the time of discharge was 2825 gm with a head circumference of 33 cm and length of 52 cm. Problem #2: Respiratory Distress. His clinical and radiologic course was most consistent with transient tachypnea of the newborn.
ALD|ad lib on demand|ALD.|127|130|1. ID|_%#NAME#%_ passed the ABR hearing screening test. Immunizations: none _%#NAME#%_ was discharged breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit in 1-2 days to check his weight.
ALD|ad lib on demand|ALD.|121|124|2. FEN|She passed the ABR hearing screening test. Immunizations: None. _%#NAME#%_ was discharged breast-feeding every 3-4 hours ALD. She will be supplemented with bottle-feeds as needed. The parents were asked to make an appointment for their child to see you within one week.
ALD|ad lib on demand|ALD.|262|265|1. FEN|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent from _%#CITY#%_ _%#CITY#%_ and the results are pending at time of transfer. He passed the ABR hearing screening test. _%#NAME#%_ was discharged breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|211|214|1. ID|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending at discharge. _%#NAME#%_ was transferred to the newborn nursery, breast-feeding every 2-3 hours ALD. His continued hospital care will be assumed by the Smiley's Family Practice group. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|212|215|1. FEN|He was started on feeds on DOL#2 with gavage and attempted breast- feeding but didn't do well. On DOL # 3 he attempted bottle-feeds. Since then he has been bottle-feeding well and discharged home on bottle feeds ALD. Mother plans to work on breast-feeding at home, with bottle supplements. 2. RESP: Initially he was on oxygen but after a few hours after transfer to the NICU he was off oxygen and since then he has been doing fine on RA.
ALD|ad lib on demand|ALD|144|146|2. CV|Cardiac murmur can be followed clinically until resolution. 3. Discharge medications, treatments and special equipment: 4. Enfamil 20 with iron ALD or Breast milk ALD Discharge measurements: Weight 5190 gms; length 55 cm; OFC 37 cm.
ALD|ad lib on demand|ALD.|128|131|2. CV|He passed the ABR hearing-screening test. Immunizations: None. _%#NAME#%_ was discharged on Enfamil 20 with iron or breast milk ALD. The parents are asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|134|137|1. IDM|Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. . _%#NAME#%_ was discharged on breast milk fortified with Enfacare 22 ALD. She was attempting breast feeding several times per day as well, although taking less than one ounce at a time. The parents were asked to make an appointment for their child to see you within three days.
ALD|ad lib on demand|ALD.|211|214|1. FEN|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on Enfacare taking 145 ml every 12 hours and/or breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include Pediatric Hematology/Oncology with Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2004#%_.
ALD|ad lib on demand|ALD.|136|139|1. RESP|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was not given. _%#NAME#%_ was discharged on bottle feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|131|134|1. RESP|_%#NAME#%_ was discharged on Enfamil w/Fe 20 kcal (finger feeds) taking 20-50 ml every 3 hours and/or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit 1-2 days after discharge. Follow-up appointment with you should be scheduled for _%#MMDD2004#%_.
ALD|ad lib on demand|ALD.|129|132|ACMC|_%#NAME#%_ was discharged on Neosure or fortified breast milk, taking 40-60 ml every 3 hours and/or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit on _%#MMDD2004#%_ to follow-up on breastfeeding and check her weight.
ALD|ad lib on demand|ALD.|139|142|DOL #5.|Immunizations: Hepatitis B vaccine was not given per mother's request. _%#NAME#%_ _%#NAME#%_ was discharged on breast milk, breast-feeding ALD. The parents were asked to make an appointment for their child to see you within one week (on Monday, _%#MMDD#%_, or Tuesday _%#MMDD#%_).
ALD|ad lib on demand|ALD.|127|130|1. FEN|He passed the ABR hearing screening test. Immunizations: None given. _%#NAME#%_ was discharged on breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|161|164|1. FEN|She passed the ABR hearing-screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD#%_. _%#NAME#%_ was discharged, breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Parents are to follow up at the _%#CITY#%_ Clinic _%#MMDD#%_ for weight and bilirubin check.
ALD|ad lib on demand|ALD.|284|287|1. FEN|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were not yet sent. He did not yet have the ABR hearing screening test Immunizations: Hepatitis B vaccine was not given. Baby-boy _%#NAME#%_ was discharged to the newborn nursery breast-feeding every 3 hours ALD. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|214|217|3. FEN/GI|He passed the ABR hearing-screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2005#%_. _%#NAME#%_ was discharged on breast milk taking 40-50ml every 2-3 hours and/or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|196|199|3. FEN/GI|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were not sent at time of transfer. BB _%#NAME#%_ was transferred back to the newborn nursery with plans to breast-feed ALD. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|149|152|3. FEN/GI|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was not given. Baby boy _%#NAME#%_ was discharged on Enfamil 20 kcal/oz ALD. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|212|215|1. FEN/GI|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending at discharge. He passed the ABR hearing screening test. _%#NAME#%_ was discharged breast-feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|159|162|1. FEN|_%#NAME#%_ passed the ABR hearing screening test. Immunizations: _%#NAME#%_ received no immunizations. _%#NAME#%_ was discharged on breast milk breast-feeding ALD. The parents were asked to make an appointment for him to see you within one week. Home Care nurse will visit this weekend. _%#NAME#%_ will have a follow-up clinic appointment with Pediatric Cardiology at Fairview-University Children's Hospital in 4-6 weeks.
ALD|ad lib on demand|ALD.|135|138|1. FENGI|During this time, maintained fluids and calories on TPN. Initiated feeds on D8. He tolerated increasing feeds well and is now on feeds ALD. 2. Respiratory: _%#NAME#%_ was on the ventilator for 8 days. Extubated to room air without complications. 3. Cardiovascular: On admission an EKG was obtained that showed biventricular hypertrophy and some ST-T wave changes, and in normal sinus rhythm.
ALD|ad lib on demand|ALD|125|127|1. FENGI|She tolerated these feeds well and was at full feeds by day 6. She is currently on feeds of breast milk or Enfacare 22 on an ALD schedule. Mom is also breast feeding ad lib. _%#NAME#%_ has had small amounts of emesis (spit up) and was placed on reflux precautions for several days.
ALD|ad lib on demand|ALD.|145|148|1. RESP|She passed the ABR hearing screening test. Immunizations: none. _%#NAME#%_ was discharged on breast milk and Enfacare 22 kcal/oz every 3-4 hours ALD. The parents were asked to make an appointment for their child to see you within one week, (scheduled for _%#MM#%_ _%#DD#%_, 2003 Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|139|142|1. FEN|He passed the ABR hearing screening test. Immunizations: None given. _%#NAME#%_ was discharged on breast milk taking feeds every 2-4 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit on _%#MM#%_ _%#DD#%_, 2003.
ALD|ad lib on demand|ALD.|195|198|1. FEN|He passed the ABR hearing screening test on _%#MMDD2003#%_. Immunizations: Hepatitis B and HBIG on _%#MMDD2003#%_. _%#NAME#%_ was discharged on Enfamil with iron taking 40-60 ml every 2- 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. A _%#CITY#%_ Children's Home Nurse will visit _%#MMDD#%_ to check a bilirubin level and assess infant.
ALD|ad lib on demand|ALD.|126|129|1. FEN|He has not had the hearing screening test yet. Immunizations: None. _%#NAME#%_ was discharged on breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. There are no follow-up clinic appointments scheduled at Fairview-University Children's Hospital at this time.
ALD|adrenoleukodystrophy|(ALD)|98|102|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 6-year-old male with history of adrenoleuko-dystrophy (ALD) who is status post umbilical- cord blood transplant on _%#MMDD2003#%_. The transplant was a five of six HLA-matched, and _%#NAME#%_ is now day +30 following transplantation.
ALD|ad lib on demand|ALD|162|164|DISCHARGE MEDICATIONS|He will need follow-up with audiology after discharge. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. . _%#NAME#%_ was discharged on breast milk ALD fortified to 22 calorie/ounce when not breast fed. The parents were asked to make an appointment for their child to see you within one week.
ALD|ad lib on demand|ALD|189|191|5. ID|_%#NAME#%_ passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. . _%#NAME#%_ was discharged on breast milk, breast-feeding every 2-3 hours ALD with some supplemental bottle feeds as necessary. The parents were asked to make an appointment for their child to see you within one week.
ALD|ad lib on demand|ALD.|182|185|5. ID|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MM#%_ _%#DD#%_, 2004. . _%#NAME#%_ was discharged breast/bottle feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|179|182|2. ID|He passed the ABR hearing screening test on _%#MMDD2004#%_. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_ _%#NAME#%_ was discharged breastfeeding every 3-4 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|146|148|3. FEN|_%#NAME#%_ was discharged on breast milk or PM 60/40 24 calorie/ounce, each of which is treated with Kayexelate 3.6 Gm/600 ml. He is eating on an ALD schedule. The parents were asked to make an appointment to see you and for daily lab draws.
ALD|ad lib on demand|ALD.|171|174|3. FEN|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on breast milk and formula supplement ALD. The parents were asked to make an appointment for their child to see you within one week. . Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|206|209|3. FEN|He passed the ABR hearing screening test on _%#MMDD2005#%_. Immunizations: Hepatitis B vaccine was given on _%#MMDD2005#%_. _%#NAME#%_ was discharged on fortified breastmilk or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include NICU clinic at 4 months corrected gestational age.
ALD|ad lib on demand|ALD.|161|164|1. FEN|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2005#%_ _%#NAME#%_ was discharged breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|162|165|4. ID|_%#NAME#%_ was transferred to the newborn nursery on Enfamil 20 + Lipil and expressed breast milk taking a minimum of 150 ml every 12 hours and/or breast-feeding ALD. The parents were asked to make an appointment for their child to see their primary care doctor within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|196|199|4. ID|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2005#%_. _%#NAME#%_ was discharged on breast milk and Enfamil 20 cal taking 26-80 ml every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|107|110|4. ID|Immunizations: Hepatitis B vaccine was not given. _%#NAME#%_ was discharged breast-feeding every 2-4 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit early next week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|211|214|1. CV|He will need to be re-tested by Audiology before discharge. Immunizations: Hepatitis B vaccine was not given. _%#NAME#%_ was discharged on Enfamil and breast milk feeding approximately 60-70 mLs every 2-3 hours ALD. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|187|190|3. FEN|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on Similac 20 w/ Iron taking 45-75 ml every 3 hours or ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit within one-two days of d/c.
ALD|ad lib on demand|ALD.|153|156|3. FEN|Immunizations: none _%#NAME#%_ was discharged on Enfacare 24 taking 55-60 ml every 3-4 hours (as well as 20 mls of Prune juice with every other feeding) ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit on _%#MMDD2004#%_.
ALD|ad lib on demand|ALD.|124|127|3. FEN|Immunizations: Hepatitis B vaccine was given on _%#MMDD2005#%_. _%#NAME#%_ was discharged on breast-feeding every 3-4 hours ALD. The parents were asked to make an appointment for their child to see you within 3-5 days Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|137|140|3. FEN|At the time of discharge, she was bottling and breastfeeding all of her feedings of Breastmilk fortified to 22 kcal/ounce with Enfacare, ALD. Her weight at the time of discharge was 2425 gm with a head circumference of 30 cm and length of 48 cm. Problem #2: Hyperbilirubinemia. _%#NAME#%_ received phototherapy for a peak bilirubin level of 10.3 mg%.
ALD|adrenoleukodystrophy|ALD.|159|162|* FEN|_%#NAME#%_ is a 10-year-old male with a 5-week-old diagnosis of cerebral adrenal leukodystrophy admitted for high-dose IV Mucomyst therapy of radical trap for ALD. History was provided by the parents. I saw him on Friday per consultation request from Dr. _%#NAME#%_ _%#NAME#%_ from Wayne State University in _%#CITY#%_. He was in his usual state of health until _%#MM#%_ 2005 when he developed changes in hearing and vision.
ALD|ad lib on demand|ALD.|194|197|PLAN|She passed the ABR hearing-screening test Immunizations: Hepatitis B vaccine was given on _%#MMDD2005#%_. _%#NAME#%_ was discharged on Enfacare 24 calories/ounce taking 30-50 ml every 2-4 hours ALD. The parents were asked to make an appointment for their child to see you within one week.
ALD|ad lib on demand|ALD|135|137|PLAN|_%#NAME#%_ was discharged on BM or Enfamil 20 with Fe taking 15-60 ml every 2-3 hours and/or attempting breast-feeding every 2-3 hours ALD with minimal volumes. The parents were asked to make an appointment for their child to see you within one week. Children's home Care nurse will visit tomorrow _%#MMDD2005#%_.
ALD|ad lib on demand|ALD.|95|98|1. FEN|Physical exam was normal except for the sacral divot. _%#NAME#%_ was discharged breast-feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|148|151|1. FEN|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2005#%_. _%#NAME#%_ was discharged breast-feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit in two days. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|269|272|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 5-year-old male with family history of adrenoleukodystrophy who was enrolled in the _%#NAME#%_ _%#NAME#%_ Institute, Lorenzo Oil trial and followed for the last 2 years for the effect of Lorenzo Oil in prevention of cerebral ALD. As part of a yearly visit, an MRI scan was performed in _%#MM2005#%_ in _%#CITY#%_, which showed changes in the corpus callosum.
ALD|ad lib on demand|ALD|166|168|PAST MEDICAL HISTORY|ALLERGIES: No known drug allergies. PAST MEDICAL HISTORY: 1. Adrenoleukodystrophy diagnosed 2-1/2 years ago when mother had a heart attack and she was found to be an ALD carrier. Mother's cousin had previously died of ALD. 2. Serial MRIs showing progression of his disease in _%#MM#%_ 2006. 3. Bone marrow transplant on _%#MMDD2006#%_ per protocol M2 _%#PROTOCOL#%_.
ALD|ad lib on demand|ALD.|178|181|* FEN|Immunizations: Hepatitis B vaccine was not given. _%#NAME#%_ was discharged on Similac PM 60/40 and breast feeding taking 70 ml every 3 hours and/or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you this week. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include Endocrinology CAH clinic with Dr. _%#NAME#%_ during the second week of _%#MM#%_.
ALD|ad lib on demand|ALD|150|152|PAST MEDICAL HISTORY|Prior to his admission he had a mild cough and runny nose for one day without any fever. ALLERGIES: No known drug allergies. PAST MEDICAL HISTORY: 1. ALD diagnosed at age 4. 2. Mild adrenal insufficiency. 3. Mild obstructive pulmonary disease. 4. History of nocturnal diuresis HOME MEDICATIONS: 1. Cortef 12.5 mg qam; 7.5 mg qpm.
ALD|ad lib on demand|ALD.|149|152|5. GI|She passed the ABR hearing screening test. Immunizations: due in clinic at 2 months of age. _%#NAME#%_ was discharged on Enfacare formula 22 kcal/oz ALD. The foster parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit _%#NAME#%_ to evaluate feeding, weight gain and home environment.
ALD|ad lib on demand|ALD,|129|132|2. GI|She passed the ABR hearing screening test. Immunizations: None given _%#NAME#%_ was discharged breast-feeding every 2 to 3 hours ALD, followed by supplemental bottles of breast milk. The parents were asked to make an appointment for their child to see you within one week.
ALD|ad lib on demand|ALD.|132|135|1. FEN|He passed the ABR hearing screening test. Immunizations: None given _%#NAME#%_ was discharged on Enfacare 22 taking 60cc or more PO ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit on _%#MMDD2002#%_. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|189|192|1. CV|She passed the ABR hearing screening test. Immunizations: She did not receive immunizations during her stay in the NICU. _%#NAME#%_ was discharged breast-feeding followed by bottle feeding ALD. Bottle feeds are breast milk supplemented with Enfamil Enfacare to 22kcal. The parents were asked to make an appointment for their child to see you within one week.
ALD|ad lib on demand|ALD.|189|192|1. CV|However, the PKU screen will need to be repeated since it was obtained within the first 24 hours of life. He passed the ABR hearing screening test. _%#NAME#%_ was discharged breast-feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit on _%#MMDD2002#%_ to assess weight gain and feeding issues.
ALD|ad lib on demand|ALD.|119|122|1. CV|He passed the ABR hearing screening test Immunizations: None _%#NAME#%_ was discharged on breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Follow-up clinic appointments scheduled at _%#CITY#%_ Children's within one week.
ALD|ad lib on demand|ALD|204|206|1. CV|She was placed on Ranitidine and reflux precautions secondary to emesis, however, since that time, she did well with a supine trial and precautions and Ranitidine were discontinued. On _%#MMDD2002#%_, an ALD trial of feeds was initiated and _%#NAME#%_ met minimum requirements. Resp- _%#NAME#%_ was intubated in the NICU for increasing hypercarbia.
ALD|ad lib on demand|ALD.|167|170|1. CV|_%#NAME#%_ was discharged on MBM and MBM supplemented with Enfacare to 24 kcal/oz feeding (to be continued at your discretion, based on weight gain) every three hours ALD. The parents were asked to make an appointment for their child to see you within one week. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include NICU follow up clinic in three months.
ALD|ad lib on demand|ALD|248|250|1. CV|Physical exam was normal. PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending. He passed the ABR hearing screening test. Immunizations: None _%#NAME#%_ was discharged on breast-feeding ALD with supplementation of Enfamil with Iron at 20 kcal as needed, 30-45 mL per bottle feed. The parents were asked to make an appointment for their child to see you within one week.
ALD|ad lib on demand|ALD.|111|114|4. F/E/N|She passed the ABR hearing screening test. Immunizations: none given _%#NAME#%_ was discharged bottle feedings ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|208|210|5. F/E/N|At the time of discharge, she had spent more than 24 hours in a crib without difficulties. 5. F/E/N: _%#NAME#%_ was initially kept NPO and started on 60cc/kg/day of D10W IV fluid. However, she was started on ALD feeds within 24 hours with either breast milk or Enfamil with iron if the former is not available. _%#NAME#%_ tolerated the feeds well, and she was consistently able to reach our set 12-hour minimum of 140 cc at the time of discharge.
ALD|ad lib on demand|ALD|240|242|5. F/E/N|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending at discharge. She passed the ABR hearing screening test. Immunizations: none given _%#NAME#%_ was discharged bottle feedings ALD with Neosure 24 cal and with breast milk fortified to 24 cal with Neosure. Home nurse visit was arranged and at that time the nurse will evaluate the need for further visits.
ALD|ad lib on demand|ALD.|133|136|5. UTI|Comvax on _%#MMDD2002#%_ 4. Synagis on _%#MMDD2002#%_ _%#NAME#%_ was discharged on Enfacare 22 taking at least 200 ml every 12 hours ALD. The parents were asked to make an appointment for their child to see you within one week Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include ophthalmology in 2 weeks and NICU follow up clinic.
ALD|ad lib on demand|ALD.|138|141|1. FEN|He passed the ABR hearing screening test. Immunizations: Hep B on _%#MMDD2002#%_ _%#NAME#%_ was discharged breast-feeding every 3-4 hours ALD. The parents were asked to make an appointment for their child to see you within two days for a weight check and bilirubin level Thank you again for allowing us to share in the care of your patient.
ALD|adrenoleukodystrophy|ALD.|262|265|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Adrenoleukodystrophy. The patient was initially diagnosed attention- deficit/hyperactivity disorder and had a trial of Ritalin. However, he has developed hearing loss and an MRI in _%#MM2001#%_ revealed changes that were consistent with ALD. This was confirmed biochemically by very long chain fatty acids. IQ in _%#MM2001#%_ was 70 versus 104 in 1997. BMT performed on _%#MMDD2001#%_ was a 5/6 unrelated, CMV positive, HSV negative donor.
ALD|ad lib on demand|ALD.|168|171|BP=73/54|Afebrile, P=120, R=50, BP=73/54 Physical exam on discharge was normal. He passed the ABR hearing screening test. _%#NAME#%_ was discharged breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit _%#MMDD2002#%_. A follow-up appointment with the Apnea Program at Fairview-University Children's Hospital will be scheduled by telephone.
ALD|ad lib on demand|ALD.|111|114|1) FEN|He passed the ABR hearing screening and car seat tests. _%#NAME#%_ was discharged bottle-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you on _%#MMDD2002#%_. Home Care nurse will visit on _%#MMDD2002#%_ and assess the need for future visits.
ALD|ad lib on demand|ALD.|147|150|ID|Physical exam was normal. Immunizations: none given _%#NAME#%_ was discharged on Neosure 22 kcal formula taking approximately 100 ml every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|267|270|ID|Physical exam was entirely normal. PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending. No Immunization were given. _%#NAME#%_ was transferred back to the newborn nursery on day of life 4 breast- feeding ALD. The parents were asked to make an appointment for their child to see you within one week of discharge home. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|239|241|ID|Discharge medications, treatments and special equipment: Caffeine 13 mg PO q day Ranitidine 5 mg PO BID Physical exam at the time of discharge was normal, except for the jaundice that was previously described. _%#NAME#%_ was discharged on ALD breastfeeding. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|101|104|3. FEN|He passed the ABR hearing screening test. Immunizations: Hepatitis B Warsame was bottling Enfamil 20 ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|232|235|1. FEN|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on breast milk and Enfamil 20 taking 20-90 ml every 2-3 hours and/or breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|239|241|1. FEN|Problems during the hospitalization included the following: 1. FEN: He was initially kept NPO for approximately 2 hours and received IV fluids. Once his respiratory status was stable he was allowed to take feeds of Enfamil with Iron on an ALD schedule. 2. RESP: He initially required oxygen via headbox to maintain his oxygen saturation. He was rapidly weaned to nasal canula and then room air within 2 hours of admission.
ALD|ad lib on demand|ALD.|188|191|1. FEN|By _%#MM#%_ _%#DD#%_, _%#NAME#%_ was fully transitioned to breast feeding, taking 30-40cc per 3hrs. At discharge, he successfully continues to meet nutritional requirements breast feeding ALD. 2. Respiratory. _%#NAME#%_ was intubated and mechanically ventilated on day of life one. He was given one dose of Survanta. A chest x-ray was obtained and was consistent with hyaline membrane disease.
ALD|ad lib on demand|ALD.|200|203|1. FEN|He passed the ABR hearing screening test. Immunizations: Needs regular 2mo immunizations. _%#NAME#%_ was discharged on breast milk, taking 40-60 ml every 3-4 hours and/or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you for a follow-up weight check on Monday, _%#MM#%_ _%#DD#%_, 2003.
ALD|ad lib on demand|ALD|159|161|1. GU|He passed the ABR hearing screening test. Immunizations: Synagis on _%#MMDD2003#%_ _%#NAME#%_ was discharged on breast milk and Neosure 22 Kcal formula taking ALD with a minimum of 160 ml every 12 hours. The parents were asked to make an appointment for their child to see you within one week.
ALD|ad lib on demand|ALD.|110|113|2. ID|She passed the ABR hearing screening test. Immunizations: _%#NAME#%_ was discharged on formula and breast mil ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit _%#MMDD2003#%_ days for a weight check.
ALD|ad lib on demand|ALD.|120|123|1. FEN|He passed the ABR hearing screening test. Immunizations: None. _%#NAME#%_ was discharged breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit in 2 days.
ALD|adrenoleukodystrophy|ALD|200|202|PAST MEDICAL HISTORY|Diagnosed in the summer of 2002. Treated with Florinef and prednisolone. 3. In _%#MM2003#%_, his brother was diagnosed with adrenoleukodystrophy and, shortly thereafter, _%#NAME#%_ was diagnosed with ALD and underwent a matched-sibling bone marrow transplant on _%#MMDD2003#%_. _%#NAME#%_ tolerated that procedure well and had no major complications. He did, however, have pansinusitis on admission, and was treated with long-term antibiotics.
ALD|adrenoleukodystrophy|ALD.|215|218|PAST MEDICAL HISTORY|4. _%#NAME#%_ has no known drug allergies. 5. _%#NAME#%_'s growth and development are significant for delays in both motor and speech, for which he receives therapy. The etiology of this is thought to be due to his ALD. On admission, _%#NAME#%_ was on a regular diet. He was not requiring TPN.
ALD|ad lib on demand|ALD|211|213|1. FEN|Additionally, _%#NAME#%_ has recently started taking some of his feeds by mouth as opposed to gavage. When he is able to take the majority of his feeds by mouth, he should be considered for cue-based feeding or ALD feeding. Discharge medications, treatments and special equipment: _%#NAME#%_ should have a repeat head ultrasound at one month of age.
ALD|ad lib on demand|ALD|155|157|1. FEN|Ongoing problems and suggested management: 1. Anemia: _%#NAME#%_ will continue on iron supplementation with Trivisol/Iron as an outpatient. 2. Continue on ALD feeds by breast milk and/or Neosure 22 Kcal/oz transitional formula. Her weight will need to be monitored closely in the following months.
ALD|ad lib on demand|ALD.|238|241|1. FEN|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are normal at discharge. She passed the ABR hearing screening test. _%#NAME#%_ was discharged on Neosure 22 Kcal/oz and/or breast milk ALD. The parents were asked to make an appointment for their child to see you within 3 days. Home Care nurse will visit in the ensuing 3 days for weight measurements.
ALD|ad lib on demand|ALD.|149|152|4. ID|Immunizations: none during this admission _%#NAME#%_ was discharged on breast milk taking 50-70 ml every 3 hours and/or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit within the next few days.
ALD|ad lib on demand|ALD.|114|117|4. ID|She passed the ABR hearing screening test. Immunizations: _%#NAME#%_ was discharged on Enfacare 22 taking-feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit in 2-3 days after discharge.
ALD|ad lib on demand|ALD.|277|280|2. GI|Physical exam was normal. PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending at discharge. He passed the ABR hearing screening test. _%#NAME#%_ was discharged on breastmilk/Enfamil 20cal with iron every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|222|224|1. FEN|Problems during the hospitalization included the following: 1. FEN: _%#NAME#%_ was placed on IVF with oral formula feeds advanced on day two of life. He tolerated these well and was discharged home on Enfamil 20 with iron ALD 2. ID: Blood cultures were drawn and subsequently negative. Antibiotics were started on admission and discontinued after cultures were negative for 48 hours.
ALD|ad lib on demand|ALD.|177|180|1. FEN|He passed the ABR hearing screening test. _%#NAME#%_ was discharged on breast milk and Enfamil 20 kcal with iron, taking 65 ml every 3 hours and/or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within 3-4 days. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|257|260|1. GI|Physical exam was normal except for mild jaundice. PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent on initial admission and the results are normal at discharge. _%#NAME#%_ was discharged on breast milk, breast-feeding ALD. The parents were asked to make an appointment for their child to see you in 2 days. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|286|288|1. GI|On day 24 of life, bottle feeding was added as a supplement to breast feeding, and the wean from gavage was slowly begun; her final gavage feed occurred on _%#MMDD2003#%_ (day 29 of life). She switched from HMF24 to EnfaCare 24 on day 30. At the time of discharge, _%#NAME#%_ was on an ALD schedule, and satisfactorily meeting nutritional requirements by alternating breast feeding with bottle feeding. 2. Respiratory. _%#NAME#%_ was on room air from day 0 of life.
ALD|adrenoleukodystrophy|ALD.|161|164|PAST MEDICAL HISTORY|He had a head CT on _%#MM#%_ _%#DD#%_, 2002, that showed parietooccipital hypodensity consistent with demyelination. He also had an MRI that was consistent with ALD. As noted above, he had a 6/6 match sibling bone marrow transplant on _%#MMDD2002#%_. 2. Adrenal insufficiency diagnosed in _%#MM#%_ 2002. 3. PE tubes in _%#MM#%_ 2000 and _%#MM#%_ 2002.
ALD|ad lib on demand|ALD.|104|107|1. RESP|He passed the ABR hearing-screening test. Immunizations: None. _%#NAME#%_ was discharged breast feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|259|262|1. FEN/GI|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending at discharge. The ABR hearing-screening test has not been done. Immunizations: _%#NAME#%_ was discharged on Enfamil 20 with iron or breast milk ALD. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|247|249|1. FEN/GI|The admission physical examination was significant for jaundice. Problems during the hospitalization included the following: 1. F/E/N - On admission he was clinically dehydrated. We initiated a bolus and then rehydrated with D10W 1/5NS. Tolerated ALD breast feeding schedule well by discharge. Adam was also hypernatremic on admission. We fluid resuscitated him and checked the sodium BID. The sodium decreased slowly and returned to normal 30 hours after admission.
ALD|ad lib on demand|ALD.|117|120|1. FEN/GI|He passed the ABR hearing screening test. Immunizations: _%#NAME#%_ was discharged on breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|245|248|1. FEN/GI|He passed the ABR hearing screening test on _%#MMDD2003#%_. _%#NAME#%_ was discharged on breast milk with HMF fortified to 24 kcal/oz or Enfacare Premature Formula 24 kcal/oz taking 30-50 ml every 2-3 hours and/or breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit over the weekend of _%#MM#%_ _%#DD#%_-_%#DD#%_, 2003 for a weight check.
ALD|ad lib on demand|ALD|135|137|1. FEN|He was initially started on maintenance IVF, but after a few hours he began to breastfeed more avidly and was changed to breastfeeding ALD with IV hep locked between medications. Admission electrolytes were WNL and urine output remained excellent. 2. ID: A CBC and differential and CRP were WNL. Blood culture remained negative throughout admission.
ALD|ad lib on demand|ALD.|134|137|1. F/E/N|2. Hep B IgG (_%#MMDD2003#%_) _%#NAME#%_ was discharged on breast milk taking 45 ml every 3 hours and/or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit within the next few days.
ALD|ad lib on demand|ALD,|205|208|1. RESP|She passed the ABR hearing screening test. Immunizations: _%#NAME#%_ received her first Hepatitis B immunization on _%#MMDD2004#%_. _%#NAME#%_ was discharged on breast milk, breast-feeding every 2-3 hours ALD, and breastmilk fortified to 24 kcal to be offered every other feed. The parents were asked to make an appointment for their child to see you within one week.
ALD|ad lib on demand|ALD.|181|184|5. ID|She passed the ABR hearing screening test. Immunizations: Hepatitis B #1 _%#NAME#%_ was discharged on breast milk taking 150 ml every 12 hours and/or breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|192|195|1. GI|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on breast milk breast-feeding and bottling every 2- 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|148|151|1. GI|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was not given. _%#NAME#%_ was discharged on breastmilk, breast-feeding ALD. The parents were asked to make an appointment for their child to see you on Monday _%#MMDD2004#%_. Follow-up clinic appointments scheduled at Fairview- University Children's Hospital include pediatric surgery in 2-3 weeks.
ALD|ad lib on demand|ALD|179|181|1. FEN|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on breast milk, breast-feeding every 2-3 hours ALD with a small amount of supplemental bottling of formula. The parents were asked to make an appointment for their child to see you within one week.
ALD|ad lib on demand|ALD.|98|101|3. ID|He passed the ABR hearing screening test. Immunizations: _%#NAME#%_ was discharged on breast milk ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|140|143|FEN|Problems during recent hospitalization included the following: FEN: During _%#NAME#%_'s stay, we continued _%#NAME#%_ on Enfamil-20 with Fe ALD. He did very well with feedings and never required supplementation. Viral Meningitis: After obtaining blood cultures, CSF, and a urine culture, _%#NAME#%_ was started on Ampicillin and Gentamicin.
ALD|ad lib on demand|ALD.|214|217|1. ID|He passed the ABR hearing screening test. Immunizations: Hepatitis B on _%#MMDD2003#%_ done; will need a second Hepatitis B vaccine at 1 month of chronological age. _%#NAME#%_ was discharged on Enfacare 22 kcal/oz ALD. The parents were asked to make an appointment for their child to see you within one week. _%#NAME#%_ will have follow-up with Dermatology, who will contact the mother with the appointment and with Dr. _%#NAME#%_ _%#NAME#%_ mid _%#MM#%_.
ALD|ad lib on demand|ALD.|148|151|1. FEN|Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. . _%#NAME#%_ was discharged on breast milk bottle or breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you on _%#MMDD2004#%_ or _%#MMDD2004#%_. Home Care nurse will visit on _%#MMDD2004#%_. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|120|123|1. FEN|Immunizations: Hepatitis B vaccine was not given. _%#NAME#%_ was discharged on Enfamil / breastmilk by bottle or breast ALD. The parents were asked to make an appointment for their child to see you _%#MM#%_ 5th. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|151|154|CUHCC|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on breast-feeding ALD. The parents were asked to make an appointment for their child to see you within 2 days after discharge. Pt should see neurosurgery for a follow up appointment within 2 weeks of discharge.
ALD|ad lib on demand|ALD.|162|165|1. CV|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you on _%#MMDD2004#%_. Home Care nurse will visit on _%#MMDD2004#%_ to check her total bilirubin.
ALD|ad lib on demand|ALD.|185|188|1. CV|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on Enfacare 24 kcal taking 45-65 ml every 3 hours or ALD. The parents were asked to make an appointment for their child to see you within one week. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include NICU follow-up; appointment will be set for 4 months CGA.
ALD|ad lib on demand|ALD|240|242|1. FEN|Discharge measurements: Weight 3700 gms. Physical exam was normal except for jaundice to approximately 3 cm above the level of the umbilicus. He passed the ABR hearing screening test. _%#NAME#%_ was discharged on breast milk breast-feeding ALD with supplementation with a bottle of pumped breast milk if not satisfied after breast feeds. The parents were asked to make an appointment for their child to see you within two days.
ALD|ad lib on demand|ALD|214|216|4. GI|He passed the ABR hearing screening test. Immunizations: 1. Synagis given on _%#MMDD2004#%_ 2. Hepatitis B #1 on _%#MMDD2004#%_ 3. _%#NAME#%_ _%#NAME#%_ was discharged on breast milk 22Kcal feeding every 2-3 hours ALD for a minimum goal of 180mL per 12 hours. The parents were asked to make an appointment for their child to see you within one week.
ALD|ad lib on demand|ALD.|174|177|FEN|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. . _%#NAME#%_ was discharged on breast milk, feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|183|186|1. FEN|Immunizations: Hepatitis B vaccine was given. _%#NAME#%_ was transferred to the NB Nursery on Enfamil and breast milk taking 30-40ml every 3 hours and/or breast-feeding every 3 hours ALD. Thank you again for allowing us to share in the care of your patient. If questions arise, please contact us as _%#TEL#%_ (NICU) or _%#TEL#%_ (office).
ALD|ad lib on demand|ALD.|157|160|1. FEN|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was declined by the parents. _%#NAME#%_ was discharged on breastmilk or Similac ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|172|175|1. ID|He passed the ABR hearing screening test. Immunizations: None. _%#NAME#%_ was circumcised on _%#MMDD2002#%_. _%#NAME#%_ was discharged on breast milk feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Patient is to see Dr. _%#NAME#%_ (Peds GI) on _%#MM#%_ _%#DD#%_.
ALD|ad lib on demand|ALD.|130|133|2. CV|_%#NAME#%_ was discharged on breast milk/Enfamil with Iron taking 40-50 ml every 3-4 hours and/or breast-feeding at least 8 times ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|150|153|1. FEN|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was not given. _%#NAME#%_ was discharged breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|182|185|1. FEN|She passed the ABR hearing screening test. Immunizations: None given. _%#NAME#%_ was discharged on Enfamil 24 kcal/oz. taking 50 ml every 3 hours and/or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week.
ALD|ad lib on demand|ALD.|154|157|FEN|Ongoing problems and suggested management: * Nutrition: _%#NAME#%_ was discharged breast-feeding/ bottle-feeding expressed breast milk every 2 to 4 hours ALD. The parents were asked to make an appointment for their child to see you on Tuesday, _%#MMDD2005#%_. Discharge medications, treatments and special equipment: * Tri-Vi-Sol with Iron 0.5 ml daily by mouth.
ALD|ad lib on demand|ALD.|258|261|1. FEN|Physical exam was normal. PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending at discharge. She passed the ABR hearing screening test. _%#NAME#%_ was discharged on breast-feeding every 2-4 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit in 1-2 days. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|163|166|1. FEN|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2006#%_. _%#NAME#%_ was discharged breast-feeding every 2-4 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|adrenoleukodystrophy|(ALD)|100|104|DISCHARGE DIAGNOSES|DISCHARGE INFORMATION: DISCHARGE DATE: _%#MMDD2006#%_. DISCHARGE DIAGNOSES: 1. Adrenoleukodystrophy (ALD) status post 6/6 matched unrelated single umbilical cord blood transplant. 2. Adrenal insufficiency. 3. Attention deficit
ALD|adrenoleukodystrophy|ALD.|173|176|DISCHARGE DIAGNOSES|ADMISSION DIAGNOSES: 1. Adrenoleukodystrophy. 2. Adrenal insufficiency secondary to ALD. DISCHARGE DIAGNOSES: 1. Adrenoleukodystrophy. 2. Adrenal insufficiency secondary to ALD. 3. Transplant day #26, status post unrelated donor umbilical cord transplant. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 5-year-old male diagnosed with adrenoleukodystrophy in _%#MM#%_ 2004 who is transplant day #26, status post unrelated donor umbilical cord transplant done on ._%#MMDD2006#%_. _%#NAME#%_ was initially diagnosed with a work up done secondary to positive family history including 2 first cousins who died from this disease.
ALD|adrenoleukodystrophy|ALD.|147|150|FAMILY HISTORY|4. Traumatic right eye injury in _%#MM#%_ 2005 leading to superior rectus palsy but normal vision. FAMILY HISTORY: Significant for 2 brothers with ALD. Cousin with neurofibromatosis type 1, maternal grandmother with hypothyroid, paternal uncle with ADHD and obsessive compulsive disorder. SOCIAL HISTORY: _%#NAME#%_'s family is from _%#CITY#%_, Ohio. His father works for GM as a press technician.
ALD|adrenoleukodystrophy|ALD.|168|171|HOSPITAL COURSE|He is receiving cyclosporin and MMF for GVH prophylaxis. He is also on oral Mucomyst. PROBLEM #7 Endocrine. _%#NAME#%_ does have adrenal insufficiency secondary to his ALD. He was initially placed on stress dose hydrocortisone and Florinef. He is now on oral Cortef and Florinef. PROBLEM #8 Neurologic.
ALD|adrenoleukodystrophy|ALD.|24|27|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. ALD. 2. Aspiration pneumonia. 3. Altered mental status. DISCHARGE: Patient is to be discharged to his group home care, Group Home Creative Care Resource.
ALD|ad lib on demand|ALD.|180|183|1. FEN|His results are pending at discharge. Immunizations: Hepatitis B was given while _%#NAME#%_ was in the newborn nursery. _%#NAME#%_ was discharged breast-feeding and bottle feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|180|183|1. FEN|He passed the ABR hearing screening test. Immunizations: _%#NAME#%_ did not receive immunizations while hospitalized. _%#NAME#%_ was discharged on 20Kcal Enfamil with iron formula ALD. The parents were aware that an appointment with you has been scheduled for _%#MMDD2002#%_. Home Care nurse will visit daily to administer Methadone doses and assess feeding and growth.
ALD|ad lib on demand|ALD.|148|151|ID|She passed the ABR hearing screening test. Immunizations: None _%#NAME#%_ was discharged on formula Enfacare 22 taking about 60 mls every 3-4 hours ALD. The parents were asked to make an appointment for their child to see you on _%#MMDD2002#%_. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include at four months corrected gestational age at NICU follow-up clinic.
ALD|ad lib on demand|ALD.|146|149|1. FEN|He passed the ABR hearing screening test. _%#NAME#%_ was discharged bottling with breast milk supplemented with Enfacare to 22kcals every 3 hours ALD. The mother plans to try to breastfeed in the future. The parents were asked to make an appointment for their child to see you within one week.
ALD|ad lib on demand|ALD.|117|120|CV|She passed the ABR hearing screening test Immunizations: none _%#NAME#%_ was discharged breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Follow-up clinic appointments scheduled at Central Pediatrics. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|113|116|INTRODUCTION|She passed the ABR hearing screening test. Immunizations: _%#NAME#%_ was discharged breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|182|184|5. F/E/N|1. FEN - Began feeding right away 20cc q 3 hours Enfamil 20, or breast milk po/gavage. She tolerated feedings well and was advanced over the next few days to 60cc q 3 hours and then ALD for a goal of 150 cc/kg/d. Was slow to po with the Haberman, but adjusted gradually to take all of her feeds by bottle.
ALD|ad lib on demand|ALD.|125|128|5. F/E/N|Left ear is nonfunctional. Immunizations: none _%#NAME#%_ was discharged on Enfamil with iron 20 cal formula and breast milk ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit next week to check on feedings.
ALD|ad lib on demand|ALD,|158|161|5. F/E/N|He failed the newborn hearing screening test, he will be referred for repeat ABR. _%#NAME#%_ was discharged breastfeeding and bottling with Enfamil with iron ALD, with a minimum of every three hours. The parents were asked to make an appointment for their child to see you within one week.
ALD|ad lib on demand|ALD.|152|155|1. FEN|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was not given. _%#NAME#%_ was discharged on breast-feeding every 2-4 hours ALD. The parents were asked to make an appointment for their child to see you on _%#MMDD2006#%_. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|103|106|1. FEN|He passed the ABR hearing screening test. Immunizations: none _%#NAME#%_ was discharged breast feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Follow- up clinic appointments scheduled at Fairview-University Children's Hospital include Endocrine at the beginning of next week.
ALD|ad lib on demand|ALD.|111|114|2. FEN|She passed the ABR hearing screening test. Immunizations: none _%#NAME#%_ was discharged on breast milk taking ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|121|124|2. FEN|She passed the ABR hearing screening test. Immunizations: None. _%#NAME#%_ was discharged breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit in 1-2 days to assess breastfeeding and check her weight.
ALD|ad lib on demand|ALD.|119|122|2. FEN|She passed the ABR hearing screening test. Immunizations: None. _%#NAME#%_ was discharged breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|122|125|1. FEN|Discharge measurements: Weight 3628 gms. Physical exam was normal. _%#NAME#%_ was discharged on Enfamil with iron feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|121|124|ID|She passed the ABR hearing screening test. Immunizations: None. _%#NAME#%_ was discharged breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. They were also asked to follow up in the NICU clinic in four months.
ALD|ad lib on demand|ALD,|151|154|3. F/E/N|Post extubation, he was started on tube feeds of breast milk or Enfamil with iron while adjusting the TPN rate. He was then switched to breast feeding ALD, and showed weight gain on the day of discharge. Ongoing problems and suggested management (please see above) Discharge medications, treatments and special equipment: none Discharge measurements: Weight 3700 gm; length 51 cm; OFC 36.5 cm.
ALD|ad lib on demand|ALD.|190|193|3. F/E/N|The admission physical completely unremarkable, including an admission temp of 37.3. Problems during the hospitalization included the following: 1. FEN - Began po feeds of enfamil with iron ALD. She tolerated her feeds well and advanced appropriately. 2. ID - Cultures were drawn at her home hospital prior to transport.
ALD|ad lib on demand|ALD.|133|136|3. F/E/N|Newborn hearing exam was completed and was normal. Immunizations: none _%#NAME#%_ was discharged on enfamil with iron 20 cal formula ALD. The parents were asked to make an appointment for their child to see you on Friday, _%#MMDD2002#%_. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|130|133|1. FEN|_%#NAME#%_ was discharged on breast milk/Enfamil 20 with Fe taking 40-60 ml every 2-4 hours and/or breast-feeding every 2-4 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit next day after discharge. Follow-up appt with you on Monday, _%#MM#%_ _%#DD#%_, 2002.
ALD|ad lib on demand|ALD.|169|172|1. F/E/N|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on breast milk feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|118|121|1. ID|He passed the ABR hearing screening test. Immunizations: None. _%#NAME#%_ was discharged breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you tomorrow (_%#MMDD2002#%_). Home Care nurse will visit from MHVA. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|114|116|2. FEN|He did not have an initial diuresis, and was placed on bid lasix for 3 days beginning on DOL # 3. He went home on ALD breast and bottle feeds. 3. Heme: _%#NAME#%_ was started on supplemental iron as per routine for prematurity. 4. ID: _%#NAME#%_ was started on antibiotics after birth for his respiratory distress, but they were stopped after his blood culture was negative at 48 hours.
ALD|ad lib on demand|ALD|143|145|2. FEN|He passed the ABR hearing screening test. Head ultrasound was normal. No immunizations were provided. _%#NAME#%_ was discharged on breast milk ALD by either bottle or breast. The parents were asked to make an appointment for their child to see you within one week and intend to schedule the appointment for _%#MMDD2002#%_.
ALD|ad lib on demand|ALD.|115|118|1. FEN|He passed the ABR hearing screening test on _%#MMDD2003#%_. _%#NAME#%_ was discharged breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include NICU follow-up in four months.
ALD|ad lib on demand|ALD.|215|218|1. FEN|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending at discharge. He passed the ABR hearing screening test. _%#NAME#%_ was discharged on breast-feeding ALD. The parents were asked to make an appointment for their child to see you on _%#MMDD2003#%_. Home Care nurse will visit this week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|176|179|3. ID|He passed the ABR hearing screening test. Immunizations: None. _%#NAME#%_ was discharged on Enfamil with Iron 20 Kcal and expressed breast milk taking 40-45 ml every 2-4 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit as per arranged for OB follow up.
ALD|ad lib on demand|ALD.|193|196|3. ID|Discharge measurements: Weight 4975 grams Physical exam was normal except for oral candidiasis, slight scleral icterus and jaundice to the chest. _%#NAME#%_ was discharged on Similac with Iron ALD. The mother was instructed on the importance of ensuring good oral intake and monitoring his urine output over the next week or so.
ALD|ad lib on demand|ALD.|268|271|1. FEN|Physical exam was normal on discharge. PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending at discharge. He passed the ABR hearing screening test _%#NAME#%_ was discharged on breastmilk and breast-feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|320|323|1. FEN|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are significant for borderline CAH (17 hydrocyprogesterone level of 59--nl is <50, positive screen for CAH if >80). He passed the ABR hearing screening test. _%#NAME#%_ was discharged on Enfacare 22 and breastfeeding ALD. The parents were asked to make an appointment for their child to see you within four days for his two week well-baby check.
ALD|ad lib on demand|ALD.|222|225|2. FEN|It is unknown whether _%#NAME#%_ passed or failed the ABR hearing screening test at HCMC Immunizations: None. _%#NAME#%_ was discharged on Breastmilk/Enfamil 20 kcal with Iron taking 70 ml every 3 hours and breast-feeding ALD. Thank you again for allowing us to share in the care of your patient.
ALD|adrenoleukodystrophy|ALD,|160|163|FAMILY HISTORY|_%#NAME#%_ is a 6-year-old brother who is a donor. The family lives at the Ronald McDonald house. FAMILY HISTORY: As mentioned above, a 9-year-old brother with ALD, a 6-year-old brother, _%#NAME#%_, who is healthy. PHYSICAL EXAMINATION ON ADMISSION: The examination was unremarkable except for a grade 2/6 systolic ejection murmur, a murmur heard at the right upper sternal border, small bruises on the body, and difficulty walking.
ALD|adrenoleukodystrophy|ALD|195|197|DISCHARGE DIAGNOSES|CSA levels from _%#MMDD2003#%_ are pending PROBLEM #10: Access. He has a Hickman placed, which was placed on _%#MMDD2003#%_. It was working fine at the time of discharge. DISCHARGE DIAGNOSES: 1. ALD status post matched sibling 6/6 transplant. 2. Adrenal insufficiency. 3. Hypertension. 4. Dysarthria and delays in handwriting.
ALD|adrenoleukodystrophy|ALD.|101|104|DISCHARGE DIAGNOSES|The gatifloxacin is on hold while he is on the clindamycin. DISCHARGE DIAGNOSES: 1. Pansinusitis. 2. ALD. 3. Status post bone marrow transplant. DISCHARGE MEDICATIONS: 1. Nifedipine XL 30 mg p.o. b.i.d.
ALD|adrenoleukodystrophy|ALD,|38|41|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Pneumonia. 2. ALD, status post bone marrow transplant. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a five-year-old male, now day +66, status post bone marrow transplant for adrenal leukodystrophy, who presents with a fever and purulent rhinorrhea.
ALD|adrenoleukodystrophy|ALD,|211|214|PAST MEDICAL HISTORY|ALLERGIES: No known drug allergies. IMMUNIZATIONS: Up to date prior to the bone marrow transplant. DIET: Regular. PAST MEDICAL HISTORY: 1. Adrenal leukodystrophy. In _%#MM2003#%_, his brother was diagnosed with ALD, and shortly thereafter _%#NAME#%_ was also diagnosed. He is status post a matched sibling bone marrow transplant on _%#MMDD2003#%_.
ALD|adrenoleukodystrophy|ALD|189|191|REVIEW OF SYSTEMS|He has two brothers. He enjoys playing with power ranges. Both parents work outside of the home. REVIEW OF SYSTEMS: Significant for rhinorrhea, tachypnea, abdominal pain, fever, history of ALD and Addison's. PHYSICAL EXAMINATION: Temperature 103.3, heart rate 160, respiratory rate 20, saturation 96% on room air, blood pressure 84/48.
ALD|ad lib on demand|ALD.|168|171|DISCHARGE MEDICATION|He passed the ABR hearing screening test. Immunizations: None given during this hospitalization. _%#NAME#%_ _%#NAME#%_ was discharged on formula (Enfamil 20 with iron) ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit _%#MMDD2003#%_. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|190|193|3. GI|_%#NAME#%_ the passed ABR hearing screening test. Immunizations: None _%#NAME#%_ was discharged on Enfacare 22 and breast milk taking 60 ml every 3 hours and/or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit from _%#CITY#%_ Lake Home Health.
ALD|ad lib on demand|ALD.|172|175|1. F/E/N|She passed the ABR hearing screening test. Immunizations: None BG _%#NAME#%_ was discharged on Enfamil 20 kcal/ounce premature infant formula taking 45-65 ml every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. She will need a recheck of her electrolytes, including glucose and ionized calcium at that time.
ALD|ad lib on demand|ALD.|112|115|1. HEENT|He passed the ABR hearing screening test. Immunizations: None _%#NAME#%_ was discharged on Enfamil 20 with iron ALD. The parents were asked to make an appointment for their child to see you within the week.
ALD|ad lib on demand|ALD.|108|111|1. HEENT|She passed the ABR hearing screening test. Immunizations: _%#NAME#%_ was discharged on Neosure 22 taking it ALD. Mom is pumping breast milk at this time also. The parents were asked to make an appointment for their child to see you Friday.
ALD|ad lib on demand|ALD.|280|283|1. FEN|Physical exam was normal except for fine crackles bilaterally and syndactyly of the 2nd and 3rd toes bilaterally. She passed the ABR hearing screening test. Immunizations: none _%#NAME#%_ was discharged on breast milk by gavage feeds taking 40 ml every 3 hours and breast-feeding ALD. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|162|165|1. FEN|She passed the ABR hearing screening test. Immunizations: _%#NAME#%_ was discharged on Enfacare 22 kcal/oz and breast-feeding taking 40-70 ml total every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|229|232|1. F/E/N|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending at discharge. She passed the ABR hearing screening test. _%#NAME#%_ was discharged breast-feeding every 2-4 hours ALD. The parents were asked to make an appointment for their child to see you later this week to check her weight and jaundice.
ALD|ad lib on demand|ALD|158|160|5. GI|His discharge bilirubin level was 13.6 from a high of 14.2. Ongoing problems and suggested management: 1. Oral intake: The plan is to have Matteo breast feed ALD with bottles of Similac 20 with Iron given to optimize his nutritional intake and weight gain. 2. _%#NAME#%_ will be discharged on Trivisol drops, 0.5 ml by mouth once a day while breast feeding.
ALD|ad lib on demand|ALD.|294|297|1. FEN|Physical exam was normal. PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were normal. She passed the ABR hearing screening test. Immunizations: none _%#NAME#%_ _%#NAME#%_ was discharged on breast milk breast-feeding every 3 hours and supplementing with Similac 20 ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit on _%#MMDD2003#%_. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|120|123|1. FEN|Immunizations: NONE _%#NAME#%_ was discharged on breast milk by bottle or breast taking 45 ml every 110 hours 3-4 hours ALD. The parents were asked to make an appointment for their child to see you within one week.
ALD|ad lib on demand|ALD.|145|148|1. FEN|_%#NAME#%_ passed the ABR hearing screening test. Immunizations: none were given. _%#NAME#%_ was discharged on breast-feeding every 3 to 4 hours ALD. The parents were asked to make an appointment for their child to see you within a week. Home Care nurse will visit Monday _%#MM#%_ _%#DD#%_, 2003. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD|125|127|1.  FEN|He passed the ABR hearing screening test. _%#NAME#%_ was discharged on Similac 20 kcal with iron, taking 75 ml every 3 hours ALD via both bottle and g-tube. The parents were asked to make an appointment for their child to see you within one week.
ALD|ad lib on demand|ALD|174|176|1. FEN|He was moved to ALD breastfeeding and did well with this, nearly meeting his goal of 140 cc/kg/day by day 19. Although _%#NAME#%_ failed to gain weight over the first day on ALD feeds, the lactation specialist saw _%#NAME#%_ and his mother and concluded that _%#NAME#%_ was feeding appropriately. 2. Hyperbilirubinemia- An initial total bilirubin was elevated to 5.8. His peak bilirubin was 7.7 on _%#MMDD#%_.
ALD|ad lib on demand|ALD.|196|199|1. FEN|Children's Home Care has been contacted to administer future doses. _%#NAME#%_ was discharged on Enfacare 22 added to breastmilk to make 22calorie breastmilk and/or breast-feeding every 3-4 hours ALD. The parents were asked to make an appointment for their child to see you within one week (scheduled for _%#MMDD2003#%_).
ALD|ad lib on demand|ALD.|106|109|1. CV|She will be due for her first series at two months of age. _%#NAME#%_ was discharged on Enfamil with Iron ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit this week.
ALD|ad lib on demand|ALD.|140|143|1. FEN|Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. . _%#NAME#%_ was discharged on breast milk taking up to 30 ml every 3 hours ALD. The parents were asked to make an appointment for their child to see you on Monday, _%#MMDD2004#%_. Home Care nurse will visit on Saturday, _%#MMDD2004#%_. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|118|121|4. FEN|She passed the ABR hearing screening test. Immunizations: none _%#NAME#%_ was discharged breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you on _%#NAME#%_. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|296|299|6. CNS|Problems during the hospitalization included the following: 1. Fluids, electrolytes, and nutrition: _%#NAME#%_ was initially started on a D10W peripheral IV drip with daily fluid estimates of 60 ml/kg. By mid-morning on the day of admission, he was very active and was allowed to take oral feeds ALD. 2. Respiratory: Due to grunting, _%#NAME#%_ was initially placed on nasal CPAP, which helped improve color and reduce his work of breathing.
ALD|ad lib on demand|ALD.|228|231|2. ID|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending at discharge. He passed the ABR hearing screening test. _%#NAME#%_ was discharged breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you on Wednesday, _%#MM#%_ _%#DD#%_ for weight check and bilirubin check.
ALD|ad lib on demand|ALD.|173|176|1. FEN|Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. . _%#NAME#%_ was discharged on Enfacare 22kcal per ounce formula, taking approximately 30 ml every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|157|160|1. FEN|Synagis was also given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on breastmilk fortified to 24kcal/oz with enfacare taking at least 140 ml every 12 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include NICU follow-up at four months corrected gestational age, about five months from now.
ALD|ad lib on demand|ALD.|270|273|1. FEN|Physical exam was normal.. PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending at discharge. He passed the ABR hearing screening test. _%#NAME#%_ was discharged on breast milk breast-feeding every 2-3 hours ALD. The parents had and appointment to see you on _%#MMDD#%_ for a bilirubin check and on _%#MMDD#%_ for the newborn check.
ALD|ad lib on demand|ALD,|243|246|1. FEN|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are normal at discharge. She passed the ABR hearing screening test. _%#NAME#%_ was discharged on breast milk breast-feeding every 2-3 hours ALD, to be supplemented with pumped and bottled breast milk. The parents were asked to make an appointment for their child to see you within one week.
ALD|ad lib on demand|ALD.|465|468|4. FEN|Physical exam was normal except for slight respiratory retractions. PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent on _%#MMDD2002#%_ and the results are pending at discharge. She passed the ABR hearing screening test. Immunizations: None. _%#NAME#%_ was transferred on TPN: D12.5, 1 mEq/kg/day Na+, 3 gm/kg/day amino acids, and 3 gm/kg/day lipids, and Enfamil 20 taking 5 ml every 3 hours and/or breast-feeding every 3 hours ALD. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|145|148|1. GI|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was not given. _%#NAME#%_ was transferred to the NBN breast-feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|162|165|3. ID|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged breast-feeding every 2 hours ALD. The parents were asked to make an appointment for their child to see you within one week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|166|169|1. FEN|Problems during the hospitalization included the following: 1. FEN: Normal glucose on admission. Patient started on D10W and allowed to advance to full enteral feeds ALD. 2. Respiratory: NG passed into stomach and bilaterally through choanae without difficulty. 3. Cardiovascular: Normal cardiac exam with hemodynamic stability. An ECHO cardiogram revealed normal anatomy and function with a tiny PDA and PFO.
ALD|ad lib on demand|ALD|147|149|1. FEN|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on breastmilk ALD attempting nursing every 2 to 4 hours. The parents were asked to make an appointment for their child to see you within one week.
ALD|ad lib on demand|ALD.|164|167|3. CV|He failed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged on Enfamil 24 with Iron formula ALD. Parents were trained to feed him with the Haberman Feeder. The parents were asked to make an appointment for their child to see you within one week Mom made an appointment for _%#MM#%_ 1.
ALD|ad lib on demand|ALD.|161|164|1. FEN|She passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. _%#NAME#%_ was discharged breastfeeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you within one week. ._%#NAME#%_ is to follow up with Pediatric Neurologist Dr. _%#NAME#%_- _%#NAME#%_ at Fairview-University Medical Center in one month.
ALD|ad lib on demand|ALD.|164|167|1. FEN|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was not given. _%#NAME#%_ _%#NAME#%_ was discharged on Enfamil 20 kcal/oz with iron at ALD. The parents were asked to make an appointment for their child to see you early this week. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|209|212|3. FEN|He passed the ABR hearing-screening test. Immunizations: Hepatitis B vaccine was not given. Mother had negative Hepatitis B surface antigen. Upon transfer, Baby _%#NAME#%_ was breast-feeding every three hours ALD. Thank you again for allowing us to share in the care of your patient.
ALD|ad lib on demand|ALD.|173|176|* FEN|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2005#%_. _%#NAME#%_ was discharged breast-feeding every three to four hours ALD. He will be supplemented with two bottles per day of expressed breast milk fortified to 24 calories/ounce with Enfacare powder.
ALD|adrenoleukodystrophy|ALD.|252|255|* FEN|_%#NAME#%_ _%#NAME#%_, M.D. Child Neurology _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#ADDRESS#%_ _%#CITY#%_ _%#CITY#%_, CA _%#90000#%_ Dear Dr. _%#NAME#%_: _%#NAME#%_ _%#NAME#%_ is now four months status post unrelated donor cord blood transplant for ALD. _%#NAME#%_ has had a stable week. His problems have consisted mainly of gagging with feeds. We are attempting to increase his feeds by increasing intake overnight.
ALD|adrenoleukodystrophy|ALD|139|141|HISTORY OF PRESENT ILLNESS|He subsequently developed infantile spasms, mental retardation and cerebral palsy. _%#NAME#%_ has a twin brother who developed symptoms of ALD which led to the diagnosis in _%#NAME#%_ in _%#MM#%_, 2001. He was evaluated at the Fairview-University Medical Center in _%#MM#%_, 2001 where he had neuropsychological evaluation and MRI scan with a Loes-score of 2.5. He was reevaluated in _%#MM#%_, 2002 when his MRI Loes score increased to 8.0. He has been otherwise healthy.
ALD|adrenoleukodystrophy|ALD.|370|373|HISTORY OF PRESENT ILLNESS|He was evaluated at the Fairview-University Medical Center in _%#MM#%_, 2001 where he had neuropsychological evaluation and MRI scan with a Loes-score of 2.5. He was reevaluated in _%#MM#%_, 2002 when his MRI Loes score increased to 8.0. He has been otherwise healthy. _%#NAME#%_'s mother is interested in pursing a bone marrow transplant to stop the progression of the ALD. He has no suitable sibling donors, however, a matched umbilical cord blood is available for transplant.
ALD|adrenoleukodystrophy|ALD,|344|347|FAMILY HISTORY|SOCIAL HISTORY: _%#NAME#%_ lives with his parents and siblings in _%#CITY#%_, California where he attends a nongraded county school in Special Education FAMILY HISTORY: Brother _%#NAME#%_ with end-stage ALD who is bed- ridden and is fed through a gastrostomy tube. Maternal cousin died of ALD. A distant maternal cousin has been diagnosed with ALD, another with the adult form of ALD. REVIEW OF SYSTEMS: General: _%#NAME#%_ currently is feeling well. Skin: Increased hyperpigmented areas, particularly on the feet, knees and fingers.
ALD|adrenoleukodystrophy|(ALD)|248|252|IMPRESSION|RADIOGRAPHIC STUDIES: Chest x-ray revealed no acute infiltrates. LABORATORY DATA: White blood cell count 3.6, hemoglobin 12.6, platelet count 363,000, creatinine 0.5, total bilirubin less than 0.1. PATHOLOGY: None. IMPRESSION: Adrenoleukodystrophy (ALD) currently asymptomatic.
ALD|adrenoleukodystrophy|ALD|224|226|LABORATORY DATA|LABORATORY DATA: Currently, she has a creatinine of 4.24, white count 2.9, hemoglobin of 9.6, and platelet count of 160. She was recently transfused. Previous hemoglobin was 8.5. She had a negative direct Coombs. She has an ALD of 379 and heptoglobin of 200, retic count of 29.7 absolute. ASSESSMENT AND PLAN: 1. Neutropenia. The etiology of her neutropenia is somewhat elusive, but some of the possibilities include reaction to drugs, atypical Felty syndrome.
ALD|adrenoleukodystrophy|ALD|153|155|MR#|_%#NAME#%_ reports several first cousins once removed who are also affected with the condition. _%#NAME#%_ was familiar with the X-linked inheritance of ALD and reports that her family is followed at Mayo. _%#NAME#%_ states that genetic testing has been performed on most of the family members.
ALD|adrenoleukodystrophy|ALD|169|171|MR#|This family hiostory was not _%#NAME#%_'s main concern, as she knows that there is no risk to her pregnancy because she is not a carrier. Nevertheless, the diagnosis of ALD has affected her life in many ways. One of _%#NAME#%_'s maternal uncles was severely affected with the condition and raped her when she was a young teen.
ALD|adrenoleukodystrophy|ALD,|238|241|HISTORY OF PRESENT ILLNESS|PROBLEM: Adrenoleukodystrophy (ALD). HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an almost 4- year-old boy who was diagnosed prenatally with adrenoleukodystrophy because of a family history (two uncles have had the adult form of ALD, and the maternal grandmother and maternal great-grandmother were all carriers). He has undergone several MRI scans of the brain which recently began showing disease progression.
ALD|adrenoleukodystrophy|ALD|300|302|FAMILY HISTORY|7. Lorazepam. 8. Florinef 0.1 mg daily. SOCIAL HISTORY: He has been moved from behavior home to the _%#ADDRESS#%_ group home, which has RN nurses on staff with the understanding that he will likely progress in his disease. Previous social history is documented in notes. FAMILY HISTORY: Mother is an ALD carrier. The disease has been tracked back as far as can be identified on her side with subsequent identification of all persons at risk.
ALD|adrenoleukodystrophy|ALD|147|149|PAST HISTORY|Repeat admission several weeks later with left hip pyomyositis, on antibiotics. Previous surgeries include herniorrhaphy as an infant secondary to ALD and changes in behavior leading to the diagnosis in _%#MM2004#%_. He was recently seen in the clinic by me on _%#MMDD#%_ with a review.
ALD|adrenoleukodystrophy|ALD|182|184|UNIT|PAST MEDICAL HISTORY: Prior hospitalizations included one last week. He was hospitalized at Minnesota Epilepsy Group. In _%#MM#%_ 2004 for staring spells leading to the diagnosis of ALD because of impaired attention, Addison disease secondary to ALD, and herniorrhaphy as an infant. CURRENT MEDICATIONS: 1. Cortef 5 mg t.i.d. 2. Florinef 0.1 mg q. day.
ALD|adrenoleukodystrophy|ALD|190|192|SOCIAL HISTORY|FAMILY HISTORY: Remarkable for mother who was an ALD carrier and has factor V Leiden. _%#NAME#%_ has not been tested for factor V Leiden. There was no previous family history of symptomatic ALD in the family. REVIEW OF SYSTEMS: Remarkable for weight gain about 4 pounds since admission until the symptoms beginning yesterday and the fever.
ALD|adrenoleukodystrophy|ALD.|244|247|PAST MEDICAL HISTORY|REVIEW OF SYSTEMS: Positive for skin rash and fever as per HPI, otherwise as per past medical history. All other systems are negative. PAST MEDICAL HISTORY: 1. Adrenoleukodystrophy diagnosed prenatally secondary to a family history of X-linked ALD. Several male cousins and uncles have had this diagnosis. The patient has had serial head MRIs with the last MRI on _%#MM#%_ 2005 showing worsening inactive demyelination which lead to a cord blood transplantation.
ALD|adrenoleukodystrophy|ALD|201|203|FAMILY HISTORY|2. Hospitalized in _%#MM#%_ 2001 for pneumonia. PAST SURGICAL HISTORY: Central line placements. FAMILY HISTORY: Mom with seasonal allergies. Mom has a cousin who had a myocardial infarction at age 33. ALD in multiple male family members. Mother had a sister who died as an infant of SIDS. SOCIAL HISTORY: The patient lives with his mother and a 13-year- old sister in Michigan.
ALD|adrenoleukodystrophy|ALD.|102|105|FAMILY HISTORY|_%#NAME#%_ enjoys swimming, hockey, water polo, video games and Gameboy. FAMILY HISTORY: Negative for ALD. REVIEW OF SYSTEMS: GENERAL: _%#NAME#%_ parents indicate that he is currently feeling well aside from the symptoms of ALD.
ALD|adrenoleukodystrophy|ALD.|151|154|REVIEW OF SYSTEMS|FAMILY HISTORY: Negative for ALD. REVIEW OF SYSTEMS: GENERAL: _%#NAME#%_ parents indicate that he is currently feeling well aside from the symptoms of ALD. VITAL SIGNS: His weight is 70 pounds, his height is 52 inches. SKIN: He has no rashes or bruises. HEENT: Has visual and hearing impairments.
ALD|alanine aminotransferase:ALT|ALD|162|164|LABORATORY DATA|PET CT and bone scan: Scheduled. LABORATORY DATA: White blood cell count 2.9, hemoglobin 10.7, platelets 323,000. Creatinine 0.76, total bilirubin 0.6. TSH 0.57. ALD 803. PATHOLOGY: UHH06-561 (2/28/06) No evidence lymphoma.
ALD|adrenoleukodystrophy|(ALD),|216|221|RECOMMENDATIONS|_%#NAME#%_ _%#NAME#%_, MD Dartmouth-Hitchock, _%#CITY#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_, NH _%#03100#%_ Dear Dr. _%#NAME#%_, As you know, _%#NAME#%_ is a 10-year-old male with adrenoleukodystrophy (ALD), who was recently referred to University of Minnesota Medical Center, Fairview, in anticipation of umbilical cord-blood transplantation.
ALD|adrenoleukodystrophy|ALD.|204|207||_%#NAME#%_ is an 8-1/2-year-old male with cerebral adrenal leukodystrophy well known to the Pediatric Neurology Service. He presented in _%#MM#%_ with new-onset seizure leading to a diagnosis of cerebral ALD. He came to Minnesota in _%#MM#%_ and was transplanted in late _%#MM#%_. His initial transplant course was complicated by partial complex seizure with speech arrest but awareness.
ALD|adrenoleukodystrophy|ALD,|122|125|IMPRESSION|Toes down. He was able to walk when pulled along. He cannot cooperate with more detailed testing. IMPRESSION: 1. Cerebral ALD, presentation with seizures. 2. Status post bone marrow transplant with lost graft. 3. New-onset loss of responsiveness with apparent diverse eye movement and head turning.
ALD|adrenoleukodystrophy|ALD|223|225|HISTORY OF PRESENT ILLNESS|During that period, he received hydrocortisone and mineralocorticoid treatment for Addison disease. In 2004 he noted decreased mental acuity and subsequently went on to develop seizures activity. The diagnosis of X- linked ALD was made in _%#MM2004#%_. He was evaluated and deemed to be a candidate for bone marrow transplantation, and was done with umbilical cord blood in _%#MM2004#%_.
ALD|adrenoleukodystrophy|ALD.|137|140|SOCIAL HISTORY|SOCIAL HISTORY: The patient is a 22-year-old male originally from Georgia. He was a junior in college prior to his diagnosis of X-linked ALD. He is attended currently by his mother, father, and grandfather. He does not smoke or use alcohol presently. FAMILY HISTORY: Noncontributory.
ALD|adrenoleukodystrophy|ALD|139|141|HISTORY OF PRESENT ILLNESS|He has history of six admissions for headache and vomiting since the age of 11 months. _%#NAME#%_ underwent a workup and was found to have ALD as confirmed by increased very- long chain fatty acids. He was also found to have adrenal insufficiency. An MRI scan revealed a Loes score of 10 and also revealed characteristic demyelination pattern.
ALD|adrenoleukodystrophy|(ALD),|173|178|IMPRESSION|LABORATORY DATA: White blood cell count 7.6, hemoglobin 14.5, platelet count 378,000, creatinine 0.4, total bilirubin 0.4. PATHOLOGY: None. IMPRESSION: Adrenoleukodystrophy (ALD), currently asymptomatic.
ALD|adrenoleukodystrophy|ALD|122|124|HISTORY OF PRESENT ILLNESS|PROBLEM: Adrenal leukodystrophy (ALD). HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is an 8-year-old boy who was diagnosed with ALD in _%#MM#%_ 2007. This was preceded with symptoms first noticed in _%#MM2007#%_ when his mother noticed right eye deviation, and an increase in tripping and falling.
ALD|adrenoleukodystrophy|ALD|254|256|HISTORY OF PRESENT ILLNESS|In _%#MM2007#%_ while vacationing in Puerto Rico, _%#NAME#%_ underwent an MRI, which showed abnormalities which were further worked up back in _%#CITY#%_ _%#CITY#%_ _%#CITY#%_. He was found to have abnormal very long chain fatty acids and a diagnosis of ALD was made. His mother indicates that the ALD effects are primarily hypertrophy of his gums, vision changes (described as that there can be something right in front of him and he does not see it), hearing changes (he does not always hear his mother), and balance problems.
ALD|adrenoleukodystrophy|ALD|121|123|HISTORY OF PRESENT ILLNESS|He was found to have abnormal very long chain fatty acids and a diagnosis of ALD was made. His mother indicates that the ALD effects are primarily hypertrophy of his gums, vision changes (described as that there can be something right in front of him and he does not see it), hearing changes (he does not always hear his mother), and balance problems.
ALD|adrenoleukodystrophy|ALD|148|150|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Remarkable for being a full-term infant born in Air Force base in northern Japan with normal development. His diagnosis of ALD was suspected on _%#MMDD2007#%_ due to an abnormal MRI scan, but in retrospect symptoms for present for at least 9 months beginning with changes in handwriting, going to decreased responsiveness and shyness.
ALD|adrenoleukodystrophy|ALD.|170|173|FAMILY HISTORY|Her mother reports no siblings, mother or father who had multiple sclerosis or symptoms suggestive of adrenal myeloneuropathy or early male child deaths suggestive of an ALD. This workup is proceeding. PHYSICAL EXAMINATION: VITAL SIGNS: Weight 27.5 kilograms, respiratory rate 41, pulse 111, blood pressure 98/64, repeat pulse was 72, O2 saturation 98% to 100%.
ALD|adrenoleukodystrophy|ALD|118|120|HISTORY OF PRESENT ILLNESS|PROBLEM: Adrenal leukodystrophy (ALD). HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 10-year-old who was diagnosed with ALD in _%#MM2007#%_ after a 8 month history of progressive neurological symptoms. His parents first noticed that _%#NAME#%_ seemed to slow down, his gait was slow, he became quiet and shy, he develop episodes of urinary incontinence.
ALD|adrenoleukodystrophy|ALD.|204|207|HISTORY OF PRESENT ILLNESS|His parents first noticed that _%#NAME#%_ seemed to slow down, his gait was slow, he became quiet and shy, he develop episodes of urinary incontinence. In _%#MM#%_ an abnormal MRI led to the diagnosis of ALD. _%#NAME#%_'s parents indicate that the affects of the ALD include changes in gait, changes in swallowing, drooling, and intermittent incontinence of urine and stool.
ALD|adrenoleukodystrophy|ALD|263|265|HISTORY OF PRESENT ILLNESS|His parents first noticed that _%#NAME#%_ seemed to slow down, his gait was slow, he became quiet and shy, he develop episodes of urinary incontinence. In _%#MM#%_ an abnormal MRI led to the diagnosis of ALD. _%#NAME#%_'s parents indicate that the affects of the ALD include changes in gait, changes in swallowing, drooling, and intermittent incontinence of urine and stool. _%#NAME#%_ is not talking, has experienced a partial complex seizure, is inconsistent with following commands, has developed left elbow contracture and cries most days.
ALD|adrenoleukodystrophy|(ALD)|244|248|HPI|Pediatric Palliative Care Consult _%#MMDD2007#%_ Reason for consult: worsening nausea, continued vomiting Consulting physician: Dr. _%#NAME#%_ _%#NAME#%_, BMT attending HPI: _%#NAME#%_ is an 8-year-old Hispanic male with adrenal leukodystrophy (ALD) admitted on _%#MMDD2007#%_ for HLA identical carrier sibling related transplant currently day -4. Prior to admission _%#NAME#%_ was diagnosed with ALD _%#MM2007#%_, initiated on acetylcysteine, noted to have worsening of vision and dragging the left foot with an episode of stumbling and hitting his nose.
ALD|adrenoleukodystrophy|ALD|1092|1094|PE|PMHx: ALD diagnosed _%#MM2007#%_ Medications: Zofran IV 1 mg/hour Phenergan 20 mg IV Q 4 hour Kytril 400 mg IV Q 12 hour Decadron 6 mg IV x1 yesterday and today Protonix 20 mg IV Qday Morphine sulfate IV 0.06 mg/kg/hour and 1 mg Q 15 min prn Ativan 0.25 mg IV Q 6 hour prn nausea Ceftazidine 1259 mg IV Q 8 hour Ancef 625 mg IV Q hour Fluconazole 75 mg Q day Bactrim 80 mg TMP BID Q Mon/Tues Acyclovir 250 mg Q 8 hour Florinef 0.1 mg Q day po Urosodiol 300 mg TID MMF 400 mg Q 8 hour Selenium 200 mcg Qday Clofarabine 37.6 mg IV ROS: a 12 point review of systems was negative other than noted in the HPI Family Hx: Social Hx: lives with parents and sister _%#NAME#%_ (donor) in _%#CITY#%_ Nebraska PE: weight 24.6 kg Sleeping initially. Woke up uncomfortable but easily consoled by parents. No acute distress HEENT deferred chest CTA CV no murmur Abd + bs, soft, nontender, nondistended, no organomegaly Labs: BMP unremarkable other than gluc 129 ALT 508, AST 340, t bili 0.5 lipase 54, amylase 62 Abdominal xray: stool in colon, no obstruction Impression and recommendations: 8 year old boy ALD day - 4 HLA identical carrier sibling related transplant Potential contributing factors to nausea and vomiting include chemotherapy and morphine sulfate.
ALD|adrenoleukodystrophy|ALD|174|176|HISTORY OF PRESENT ILLNESS|An MRI late in _%#MM#%_ showed white matter changes which led to the diagnosis of ALD. _%#NAME#%_'s parents indicate that the symptoms that he is currently experiencing with ALD include his eye deviation, a decrease in hearing acuity, a decrease in his balance, stiffness in his legs, occasional crankiness, brief staring spells, sensation of heaviness in his extremities.
ALD|adrenoleukodystrophy|ALD.|102|105|FAMILY HISTORY|_%#NAME#%_ enjoys swimming, hockey, water polo, video games and Gameboy. FAMILY HISTORY: Negative for ALD. REVIEW OF SYSTEMS: GENERAL: _%#NAME#%_ parents indicate that he is currently feeling well aside from the symptoms of ALD.
ALD|adrenoleukodystrophy|ALD.|168|171|IMPRESSION|LABORATORY DATA: White blood cell count 5.1, hemoglobin 13.8, platelet count of 248,000, creatinine 0.56, total bilirubin 0.5. PATHOLOGY: None. IMPRESSION: Symptomatic ALD. RECOMMENDATIONS: _%#NAME#%_ was seen with Dr. _%#NAME#%_ _%#NAME#%_ who agrees the patient appears to be a suitable candidate for total body irradiation prior to hematopoietic stem cell allogeneic transplant per protocol number _%#PROTOCOL#%_.
ALD|adrenoleukodystrophy|ALD.|258|261|FAMILY HISTORY|FAMILY HISTORY: Remarkable for a sister who is healthy. Father died of myocardial infarction. Mother has a history of breast cancer. Although she denies symptoms of adrenomyeloneuropathy, she states that blood tests confirmed her to be a carrier of X-linked ALD. REVIEW OF SYSTEMS: No chest pain, palpitations, shortness of breath, pneumonia, nausea, or vomiting.
ALD|adrenoleukodystrophy|ALD.|115|118|PAST MEDICAL HISTORY|He had significant developmental delay, including loss of ability to understand speech and language as a result of ALD. He attended school through the fourth grade without problems prior to his diagnosis. He underwent matched sibling donor bone marrow transplant on _%#MMDD2005#%_ with CMV/HSV negative.
ALD|ad lib on demand|ALD.|183|186|1. FEN|She Passed the ABR hearing-screening test. Immunizations: _%#NAME#%_ was discharged on breast milk fortified to 24 kcal with Enfacare taking 35 ml every 3 hours and/or breast-feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Mom and baby remained in _%#CITY#%_ at Ronald McDonald House due to transportation problems.
ALD|ad lib on demand|ALD|236|238|1. FEN|He continued to require nutritional support from TPN until _%#MMDD2004#%_ when he was finally tolerating full volume feeds enterally. We found that his ostomy output was significantly better on Progestimil, and he is now on Progestimil ALD and gaining weight well. Xavier was also on either PRN or scheduled diuretics during most of his hospitalization.
ALD|adrenoleukodystrophy|ALD|173|175|PAST MEDICAL HISTORY|Normal growth and development. Immunizations are up to date. He has a regular diet. No major childhood illnesses aside from what follows. He was diagnosed with asymptomatic ALD at 4 years of age. He had an older brother with ALD who died. The patient is followed as an outpatient.
ALD|adrenoleukodystrophy|ALD|138|140|FAMILY HISTORY|He currently has mild adrenal insufficiency and is treated with Florinef and hydrocortisone. FAMILY HISTORY: Significant for brother with ALD who died following a bone marrow transplant. REVIEW OF SYSTEMS ON ADMISSION: No headache. Mild rhinorrhea. Pulmonary: Occasional cough.
ALD|adrenoleukodystrophy|ALD|297|299|FAMILY HISTORY|7. Clindamycin 300 mg G-tube q. 12. 8. Hydrocortisone 5 mg solution G-tube t.i.d. SOCIAL HISTORY: _%#NAME#%_ has been moved due to behavioral difficulties to _%#ADDRESS#%_ Group Home, in which he has RN, nurses on staff, which understand the prognosis of his disease. FAMILY HISTORY: Mother is an ALD carrier. The disease has been tracked back as far as can be identified on her side and with subsequent identification of all persons at risk and his mother also has a factor V Leiden.
ALD|adrenoleukodystrophy|ALD.|163|166|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: In _%#MM2004#%_, he was having staring spells leading to the diagnosis of ALD because of impaired attention and Addison disease secondary to ALD. He had a herniorrhaphy as an infant. In _%#MM2006#%_, he had a left hip pyomyositis and an MRI which showed a progression of ALD as well.
ALD|adrenoleukodystrophy|ALD|125|127|PAST MEDICAL HISTORY|He had a herniorrhaphy as an infant. In _%#MM2006#%_, he had a left hip pyomyositis and an MRI which showed a progression of ALD as well. On _%#MMDD2006#%_, he was admitted for aspiration pneumonia. He was recently seen by his pediatric neurologist, Dr. _%#NAME#%_ on _%#MMDD2006#%_. The family had noted on that occasion that he was initiating more, but continued to be n.p.o., not eating, with oral thrush and nystatin swish and swallow had been started.
ALD|ad lib on demand|ALD.|145|148|3. IPV|PCV-7: _%#MMDD2003#%_ 6. Synagis: _%#MMDD2003#%_ _%#NAME#%_ was discharged on 2 bottles of Neosure 22 kcal per day in addition to breast feeding ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit within one week following discharge to assess weight gain and inguinal hernia.
ALD|ad lib on demand|ALD.|207|210|3. IPV|He had the ABR hearing screening test performed on _%#MMDD2003#%_ which he passed. Immunizations: None. _%#NAME#%_ was discharged on breast milk fortified to 22 kcal/oz and/or breast-feeding every 3-4 hours ALD. The parents were asked to make an appointment for their child to see you on _%#MMDD2003#%_. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include NICU follow up appointment at 4 months of age (parents call to schedule).
ALD|ad lib on demand|(ALD)|191|195|1. FEN|_%#NAME#%_ was started on TPN on _%#MMDD2002#%_. She was started on enteral feeds on _%#MMDD2002#%_. She was able to advance to full feeds by _%#MMDD2002#%_. She was changed to ad lib demand (ALD) feeding schedule on _%#MMDD2002#%_. At time of discharge, she was tolerating full feeds on an ALD schedule. 2. Respiratory: _%#NAME#%_ had cardiopulmonary arrest at the time of birth.
ALD|ad lib on demand|ALD|133|135|1. FEN|She was changed to ad lib demand (ALD) feeding schedule on _%#MMDD2002#%_. At time of discharge, she was tolerating full feeds on an ALD schedule. 2. Respiratory: _%#NAME#%_ had cardiopulmonary arrest at the time of birth. As noted above, she was intubated immediately after birth. Once transferred to the NICU she was placed on a high-frequency oscillating ventilator and nitric oxide to treat pulmonary hypertension and improve oxygenation.
ALD|ad lib on demand|ALD|134|136|1. FEN|She passed the ABR hearing screening test on _%#MMDD2002#%_. Immunizations: none _%#NAME#%_ was discharged on Enfamil with Iron on an ALD schedule. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit two days after discharge. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include an appointment with Dr. _%#NAME#%_ in Pediatric Neurology in 1 month after a CT venogram and an appointment with the NICU follow-up clinic at 4 months of age.
ALD|adrenoleukodystrophy|ALD.|197|200|PAST MEDICAL HISTORY|He denies sore throat, ear pain, chest pain, cough and URI symptoms. PAST MEDICAL HISTORY: 1. ALD status post unrelated donor umbilical cord blood transplant. 2. Adrenal insufficiency secondary to ALD. 3. Traumatic right eye injury in _%#MM#%_ 2005 leading to superior rectus palsy, but normal vision. FAMILY HISTORY: Significant for 2 brothers with ALD, cousin with neurofibromatosis type 1, maternal grandmother with hypothyroid, paternal uncle with ADHD and obsessive-compulsive disorder.
ALD|adrenoleukodystrophy|ALD.|167|170|ALLERGIES|PAST MEDICAL HISTORY: 1. Adrenoleukodystrophy, status post 5/6 unrelated cord blood transplant in _%#MM#%_ 1999. Subsequent left-sided "desensitized" secondary to his ALD. 2. Status post chemotherapy and full-body XRT. 3. Hypothyroidism. 4. Seizure disorder. 5. Cortical blindness. 6. Adrenal insufficiency. SOCIAL HISTORY: The patient currently lives with his grandparents in Kansas and is home-schooled due to inability to go to school because of the noise aggravating his headaches.
ALD|adrenoleukodystrophy|ALD:|165|168|PROBLEM #4|PROBLEM #3: Graft vs Host Disease. The patient continues to tolerate his prednisone taper with recurrence of GVHD. Stool output was normal. No vomiting. PROBLEM #4: ALD: The patient continued to remain stable neurologically and was continued on his Mucomyst as directed. PROBLEM #5: Hyperglycemia: The patient's blood glucose was well controlled on his Lantus and NovoLog.
ALD|ad lib on demand|ALD.|204|207|5. ID|She passed the ABR hearing screening test. Immunizations: None _%#NAME#%_ was discharged on breast milk fortified with Enfamil to 24 kcal/oz taking 75 ml every 3 hours and/or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you on Wed _%#MMDD2003#%_.
ALD|ad lib on demand|ALD,|117|120|8. ENT|He passed the ABR hearing screening test bilaterally. _%#NAME#%_ was discharged enfamil with iron and/or breast milk ALD, using a habernman nipple. The parents were asked to make an appointment for their child to see you on Monday, _%#MM#%_ 9.
ALD|adrenoleukodystrophy|ALD.|155|158|FAMILY HISTORY|The patient was discharged to home on _%#MMDD2003#%_. Also, during that hospitalization, a PICC line was placed. FAMILY HISTORY: Mom is a known carrier of ALD. The maternal grandmother has diabetes. SOCIAL HISTORY: The patient lives with mother and two stepsisters in _%#CITY#%_, Wisconsin.
ALD|adrenoleukodystrophy|ALD|205|207|HISTORY OF PRESENTING ILLNESS|Parents also reported a recent loss of strength in his left leg and complaints of left-sided tightness. The patient had an MRI on _%#MMDD2007#%_ to workup the above-mentioned symptoms and the diagnosis of ALD was made particularly affecting the posterior brain. Upon diagnosis, the patient was sent here for evaluation of potential bone marrow transplant and was seen by Neurology, Neuropsychology, BMT, Pulmonology, Cardiology, Eye clinic, Audiology and Radiology/Oncology.
ALD|adrenoleukodystrophy|ALD|272|274|PROBLEM #5|By the time of discharge, he was not utilizing any of his p.r.n. and therefore will not be sent home on any Phenergan or _____ (8:32). With respect to Neurology, we appreciate the Neurology consultation provided by Dr. _%#NAME#%_ _%#NAME#%_. The patient was continued per ALD on Mucomyst, ursodiol and per mother's request was also continued on omega-3 fatty acids and vitamins C. Otherwise, Dr. _%#NAME#%_ continues to follow him and has made a recommendation that he receive an MRI on day plus 30 after transplant.
ALD|adrenoleukodystrophy|ALD|213|215|HISTORY OF PRESENT ILLNESS|He presented for a 4/6 unrelated umbilicus cord blood transplant per protocol MT_%#PROTOCOL#%_, with preparative regimen Busulfan, Cytoxan, and ATG. Of note, his older brother, _%#NAME#%_, was also diagnosed with ALD and underwent a cord blood transplant in _%#MM2003#%_ and is doing well. PAST MEDICAL HISTORY: The patient has no known previous allergies but was found to have a sensitivity to codeine, which caused hallucinations in the hospital.
ALD|adrenoleukodystrophy|ALD.|192|195|PAST MEDICAL HISTORY|Past hospitalizations occurred in _%#MM2001#%_ with dehydration and during that hospitalization was found to have increase in the very long chain fatty acid level and therefore diagnosed with ALD. He also has had bronchitis approximately yearly but is on no medications and has not been diagnosed with asthma. ADMISSION MEDICATIONS: 1. Cortef 5 mg p.o. b.i.d. 2. Florinef 0.1 mg p.o. q.d. SOCIAL HISTORY: He lives in Michigan with his mother, mother's roommate, maternal grandmother, and brother on a farm.
ALD|ad lib on demand|ALD.|175|178|1. FEN|She passed the ABR hearing screening test. Immunizations: None _%#NAME#%_ was discharged alternating breast-feeding with bottle EnfaCare 22kcal/ounce formula, every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you during this coming week. The current plan is to have the Home Care nurse visit twice per week for the first three weeks, and once per week thereafter.
ALD|ad lib on demand|ALD.|209|212|HCM|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are normal at discharge. _%#NAME#%_ was discharged on Neosure 24 Kcal/oz taking 300-400 ml every 24 hours ALD. The parents have an appointment for their child to see you on _%#MM#%_ _%#DD#%_. Home Care nurse will visit on _%#MM#%_ _%#DD#%_. He should follow up at the Fairview NICU clinic at 4 months corrected gestational age.
ALD|ad lib on demand|ALD|183|185|HCM|Recipe for 24 hours period: * 6 ounces Breastmilk (180ml) * 3 1/2 teaspoons Neosure Powder * 2 teaspoons Beneprotein Powder Taking 30-60 ml every 2 1/2- 3 1/2 hours of these feedings ALD and breast-feeding. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit on Friday _%#MM#%_ _%#MMDD2005#%_. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include: * NICU follow-up clinic in two weeks.
ALD|ad lib on demand|ALD.|229|232|4. PULM|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are normal at discharge. She passed the ABR hearing screening test. _%#NAME#%_ was discharged on Enfamil with iron 20 kcal/oz ALD. The parents were asked to make an appointment for their child to see you within one week. Home Care nurse will visit in the next few days to assess weight, proper administration of medications, and to remind parents of follow up appointments.
ALD|ad lib on demand|ALD.|180|183|1. FEN/GI|He passed the ABR hearing screening test. Immunizations: Hepatitis B vaccine was given on _%#MMDD2004#%_. . _%#NAME#%_ was discharged on breastmilk, breast-feeding every 2-3 hours ALD. The parents were asked to make an appointment for their child to see you by Friday _%#MMDD2004#%_. Thank you again for allowing us to share in the care of your patient.
ALD|adrenoleukodystrophy|ALD|19|21|PRIMARY DIAGNOSIS|PRIMARY DIAGNOSIS: ALD posterior forearm, late stage, status post 6/6 matched sibling bone marrow transplant _%#MMDD2007#%_. SECONDARY DIAGNOSES: 1. CMV pneumonia/pneumonitis. 2. CMV viremia. 3. Visual agnosia.
ALD|adrenoleukodystrophy|ALD|191|193|PROBLEM #5|LFTs have been monitored twice weekly and have improved on ganciclovir therapy. PROBLEM #5: Neuro. On hospital day #2 _%#NAME#%_ had significant anxiety. Neurology was consulted since, as an ALD patient, protocol states that he cannot receive benzodiazepines for anxiety. This facet of protocol was found to be untrue and _%#NAME#%_ was started on benzodiazepines for anxiety.
ALD|adrenoleukodystrophy|ALD|125|127|HPI|_%#NAME#%_ has a history of seizures, unclear of some "muscle twitching" is seizure. Followed by neuro Past Medical History: ALD diagnosed _%#MM#%_ 07 Seizures Visual Hearing deficits Skin Gut GVHD Adenvirus Pancreatitis resolved secondary to VPA Hypertension with PRES Hyperglycemia related to steroids ROS: Pertinent findings outlined in HPI from following areas reviewed: (Pain, Respiratory, CV, GI, GU, Constitutional, Psychiatric, Neurological, Skin, Musculoskeletal, Eyes, ENT) Medications: Anti-infectives: Cidofovir 45 mg 3X/week with Probenecid 375 mg, Voriconazole 200 mg BID Bactrim PCP prophylaxis 80 mg BID qMON &Tues, Ribovarin 400 mg po via NG qday, Ancef 750 q8h, Meropenem 500 q8h BP Meds: Prazosin 4 q8, clonidine 0.1 mg q10pm, Amlodipine 7.5 q12h, Nifidepine prn 4mg q8h Hydralazine IV prn, Diltiazem 15 q6h, Lasix 15 IV qd, labetolol 30 q4h Anti-GVHD meds: Methylprednisolone 15 mg q12h, CSA IV drip 4.5 mg/hr, HCT 1% cream, Triamcinolone to face Endocrine: Hydrocortisone 30 mg IV for Addison disease, Florinef 0.05 mg, Insulin drips Analgesics/Antipyretics:acetaminophen prn MISCELLANEOUS: Ditropan 5 mg BID,aranesp 12.5 mcg IV qweek CNS active meds: Gabapentin 167 mg q8h, Keppra 300 mg BID, Melatonin 15 mg qhs, Risperdal 0.375 mg q2 am GI/GU meds: Pantoprazole 30 mg IV Social History: _%#NAME#%_'s family consists of parents _%#NAME#%_ and _%#NAME#%_, and siblings _%#NAME#%_ 20, _%#NAME#%_ 12, and _%#NAME#%_'s twin _%#NAME#%_ Physical Exam Weight 32.8 kg exam deferred Summary of Discussion Overall Goals of Care/Concerns _%#NAME#%_ shared that her greatest concern for _%#NAME#%_ is his overall quality of life.
ALD|adrenoleukodystrophy|ALD|333|335|HPI|Reviewed history with Dr. _%#NAME#%_, Dr. _%#NAME#%_, _%#NAME#%_ (covering SW), _%#NAME#%_ (case coordinator), and _%#NAME#%_ (Children's hospice) prior to meeting Members Present at Meeting: _%#NAME#%_ (mother), _%#NAME#%_ (sister), _%#NAME#%_ (pediatric palliative care physician) HPI: _%#NAME#%_ is a 9 year 11 month old boy with ALD S/P double cord blood transplant with complications including skin gut GVHD, Adenovirus, Pancreatitis resolved presumed to be secondary to VPA, hearing visual deficits from ALD, hypertenstion with PRES, hyperglycemia likely steroid responsive, and behavioral disregulation.
ALD|adrenoleukodystrophy|ALD,|175|178|CHIEF COMPLAINT|CHIEF COMPLAINT: _%#NAME#%_ has bilateral hip pain right greater than left secondary to avascular necrosis. He is currently on 4A recuperating from bone marrow transplant for ALD, and he is having difficulty participating in his recovery for multiple reasons, including his hip pain and is also having difficulty sleeping and waking up frequently at night.
ALD|acetyl lysergic acid diethylamide|ALD,|190|193|HISTORY|He indicates he is compliant with medication. He has no present act of self-harm. He does have an issue of polysubstance abuse dating back to age 11, with drugs of choice including cocaine, ALD, and TSH. He was involved in chemical dependency treatment on at least 12 occasions. He was most recently admitted on _%#MMDD2002#%_ by Dr. _%#NAME#%_ for detoxification with subsequent transfer to Lodging Plus.
ALD|ad lib on demand|ALD|147|149|1. FEN|These were discontinued after 48 hours of a negative blood culture. Ongoing problems and suggested management: 1. FEN: _%#NAME#%_ is doing well on ALD feeding with Enfamil 20 with iron. Discharge medications, treatments and special equipment: None Discharge measurements: Weight 3.33 kilos; length 52 cm; OFC 37 cm.
ALD|ad lib on demand|ALD.|107|110|4. GI|She passed the ABR hearing screening test. Immunizations: None. _%#NAME#%_ was discharged on breastfeeding ALD. The parents were asked to make an appointment for their child to see you on Monday, _%#MM#%_ _%#DD#%_. A follow-up chest film is not necessary unless _%#NAME#%_ has symptoms of respiratory distress.
AMA|against medical advice|AMA.|253|256|ASSESSMENT AND PLAN|4. Alcohol intoxication. At this point, I will not put him on the alcohol detox protocol, as he does not use alcohol excessively on a daily basis. 5. Hold situation. The emergency room doctor had to put him on a hold because he was threatening to leave AMA. I explained to him that he does need further testing, but assuming all the testing goes fine tomorrow, I would think the hold could be released and he could be discharged.
AMA|against medical advice|AMA|137|139|HOSPITAL COURSE|HIV antibodies were negative as was hepatitis B surface antigen HCV antibody. The rest of the tests were still pending. The patient left AMA on the morning of _%#MMDD2007#%_. She was hemodynamically and clinically quite stable. On-Q pump was removed. We tried to encourage her to stay but she refused.
AMA|against medical advice|AMA|175|177|PLAN|2. Cholelithiasis associated with hereditary spherocytosis. a. Cholecystectomy b. Incidental appendectomy. 3. Chemical abuse. 4. Chronic tobacco abuse. PLAN: Patient has left AMA therefore we have no specific follow-up scheduled for her.
AMA|antimitochondrial antibody|AMA.|249|252|PAST MEDICAL HISTORY|LABORATORY DATA: A positive antibody negative, GCT 113, GBS negative, hepatitis B surface antigen, RPR and HIV negative, rubella immune, quad screen within normal limits, GC and Chlamydia negative. PAST MEDICAL HISTORY: 1. History of depression. 2. AMA. PAST SURGICAL HISTORY: 1. Primary low transverse cesarean section. 2. Bunionectomy. 3. Umbilical hernia repair as an infant.
AMA|against medical advice|AMA.|103|106|DISCHARGE  MEDICATIONS|3. Tobacco abuse. 4. Diagnosis of bipolar disorder and PTSD. DISCHARGE MEDICATIONS: Craig Nystrom left AMA. Prior to admission he was supposed to be on Depakote 1000 b.i.d. b.i.d. but had not been taking it for several days.
AMA|against medical advice|AMA|157|159|DISPOSITION|He apparently was having some complex psychosocial issues in his home setting and felt that he needed to be at home to deal with those issues. He signed out AMA on _%#MM#%_ _%#DD#%_, 2006, which was 5 days after admission. Arrangements were made for the patient to receive Zosyn, tobramycin, and vancomycin IV in addition to his previous home p.o. medicines.
AMA|advanced maternal age|AMA|239|241|HISTORY OF PRESENT ILLNESS|The patient did drink occasional alcohol prior to pregnancy. OB HISTORY: Significant for cesarean section on _%#MM#%_ _%#DD#%_, 2002, at 40 weeks at _%#CITY#%_ for OT presentation in which she stalled at 5 cm. Prenatal care complicated by AMA declined amniocentesis. Also history of macrosomia with previous infant. PHYSICAL EXAMINATION: Vital signs are stable. Afebrile. She is in no acute distress.
AMA|advanced maternal age|AMA.|131|134|ISSUES OF PRENATAL CARE|HIV negative. Quad screen within normal limits. Level 2 ultrasound within normal limits. GBS negative. ISSUES OF PRENATAL CARE: 1. AMA. The patient was counseled and declined amniocentesis. 2. Anemia. 3. Elevated GCT. Normal GTT. 4. Recent spontaneous abortion. PAST MEDICAL HISTORY: Medical history is unremarkable. SURGICAL HISTORY: The patient had a 7 week spontaneous abortion in _%#MM#%_ 2003.
AMA|against medical advice|AMA|114|116|HOSPITAL COURSE|2. Contusion to chest and abdominal walls, mild. 3. SVT - mild. HOSPITAL COURSE: 1. This patient decided to leave AMA when she was told that she had no concerning physical exam findings for extensive trauma. When narcotics and sedatives were not offered to the patient, she decided to leave the hospital against medical advice.
AMA|against medical advice|AMA.|188|191|HOSPITAL COURSE|He has done numerous jail sentences and prison time. As a result of the information from prepetition, as well as the denial of commitment, the decision was made to discharge Mr _%#NAME#%_ AMA. When he was told that he would be discharged he was not surprised. He did willingly dressed and was discharged. Security did escort him from the building.
AMA|against medical advice|AMA|253|255|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 42-year-old female with a 25-year history of chronic abdominal pain who was actually discharged from our service on the day of admission. On the morning of _%#MMDD2004#%_ the patient was threatening to leave AMA because she had "things to do" and no longer wanted to stay in the hospital. As noted in my previous discharge summary, we did prepare her paper work so as to avoid the patient having problems with her insurance leaving AMA, and the patient did leave without any complaints of pain at that time.
AMA|advanced maternal age|AMA,|101|104|COMPLICATIONS|PRENATAL CARE: At Fairview _%#CITY#%_ Women's Clinic. Total weight gain 33 pounds. COMPLICATIONS: 1. AMA, increased risk of Down syndrome on quad screen with a normal level II ultrasound. 2. Rubella not immune. 3. Elevated von Willebrand's factor. However, workup negative for von Willebrand's disease.
AMA|against medical advice|AMA|176|178|HOSPITAL COURSE|HOSPITAL COURSE: The patient was recommended to have an echo to evaluate for any evidence of pericarditis and wall motion abnormalities, however, the patient left the hospital AMA and declined any medical intention. Troponin on admission was 0.09. Repeat troponins was 0.07 and then two troponins before discharge were less than 0.04.
AMA|against medical advice|AMA,|139|142|FOLLOW-UP APPOINTMENTS|3. Zoloft 200 mg p.o. daily. 4. Haldol 2 mg p.o. q.p.m. 5. Remeron 30 p.o. q.p.m. FOLLOW-UP APPOINTMENTS: As the patient left the hospital AMA, there were no follow-up appointments made, however, the patient sees physicians at HCMC for his psychiatric care and his general medical care and it would be advisable for him for followup there.
AMA|advanced maternal age|AMA.|176|179|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: 1. Intrauterine pregnancy at 36 plus one week. 2. Class B diabetes. 3. Abnormal fetal Dopplers. 4. Infant large for gestational age. 5. Morbid obesity. 6. AMA. DISCHARGE DIAGNOSIS: 1. Intrauterine pregnancy at 36 plus one week.
AMA|advanced maternal age|AMA.|203|206|DISCHARGE DIAGNOSIS|5. Morbid obesity. 6. AMA. DISCHARGE DIAGNOSES: 1. Intrauterine pregnancy at 36 plus one week. 2. Class B diabetes. 3. Abnormal fetal Dopplers. 4. Infant large for gestational age. 5. Morbid obesity. 6. AMA. 7. Now delivered. PROCEDURES PERFORMED: Cervidil for induction of labor, insulin drip, primary cesarean section for failed induction and presumed LGA baby.
AMA|against medical advice|AMA|290|292|HISTORY OF PRESENT ILLNESS|Lipase was not checked. The patient was given symptomatic treatment including morphine and fluids with her amylase coming down from 1900 to 200 today. The patient was scheduled to have an ultrasound to rule out gallstones but because she had to wait for another day, the patient signed out AMA and came into Fairview Southdale Hospital. In the emergency department, the patient received morphine for resumption of this pain which was only mild this time.
AMA|against medical advice|AMA.|230|233||He was trying to get off of a methadone maintenance program, and weaned himself down to 30 or 40 mg. He came in here to detox off of the last part of the methadone maintenance, but when this withdrawal became too painful, he left AMA. He did this twice. One time when he left, he returned to his methadone maintenance program, but when he left AMA a week ago, he found out that the methadone maintenance program that he was going to would not take him back.
AMA|against medical advice|AMA|243|245||He came in here to detox off of the last part of the methadone maintenance, but when this withdrawal became too painful, he left AMA. He did this twice. One time when he left, he returned to his methadone maintenance program, but when he left AMA a week ago, he found out that the methadone maintenance program that he was going to would not take him back. He then had to search in the streets to find heroin, which he did.
AMA|against medical advice|AMA.|192|195|ADDENDUM|4. The patient will be continued on PPI for gastroesophageal reflux disease. ADDENDUM: _%#NAME#%_ _%#NAME#%_ refused further medical evaluation including an adenosine stress thallium. He left AMA. He was aware that his leaving early before medical evaluation was completed especially with his significant history of ASCVD and cardiac risk factors, he could suffer repeat myocardial infarction and/or die.
AMA|against medical advice|AMA.|148|151|HOSPITAL COURSE|Unfortunately, the patient left the hospital against medical advice. The Urology and Pulmonary Services were contacted prior to the patient leaving AMA. They recommended followup in the near future. The patient was advised on the consequence of him leaving AMA in light of active pericarditis, urethral stone with stent being in place, as well as right lower lobe pneumonia.
AMA|against medical advice|AMA,|158|161|DISCHARGE MEDICATIONS|2. Acute renal failure on top of chronic renal failure. 3. Hematuria of unknown etiology. 4. Left ankle sprain. DISCHARGE MEDICATIONS: None, the patient left AMA, he does have a Prevpac in his possession. MEDICATIONS: (Normally takes). 1. Remeron 15 mg p.o. q.h.s.
AMA|against medical advice|AMA.|290|293|HOSPITAL COURSE|The opiate withdrawal protocol was started. See chart. In addition, phenobarbital 90 mg 3 times daily and then tapered by 30 mg daily until discontinuation was ordered to cover possible withdrawal symptoms from Valium. On _%#MM#%_ _%#DD#%_, 2005, initially Mr. _%#NAME#%_ asked to sign out AMA. He did not do that and the 72-hour hold continued. On _%#MM#%_ _%#DD#%_, 2005, he was seen by medical staff and a UA, UC was ordered because of lab values on admission.
AMA|against medical advice|AMA.|173|176|DISPOSITION|His constipation is due to high dose narcotics. The patient was given laxative and stool softener, including Senna, Sorbitol, and enema p.r.n. DISPOSITION: The patient left AMA. The patient was still on significant high dose of Dilaudid IV 10 mg every 2 hours. He was also on narcotic medication, including Fentanyl patch 200 mcg.
AMA|against medical advice|(AMA),|177|182|DISPOSITION|The patient was still on significant high dose of Dilaudid IV 10 mg every 2 hours. He was also on narcotic medication, including Fentanyl patch 200 mcg. On the day of discharge (AMA), the patient was competent, awake, alert, oriented and he was able to understand that he was taking a big health risk, leaving the hospital AMA.
AMA|against medical advice|AMA|228|230|DISCHARGE MEDICATIONS|On the day of discharge (AMA), the patient was competent, awake, alert, oriented and he was able to understand that he was taking a big health risk, leaving the hospital AMA. DISCHARGE MEDICATIONS: The patient will be sent home AMA with antibiotic medication including Gatifloxacin 400 mg p.o. daily and Flagyl 500 mg p.o. q.i.d. to finish 2-week course of treatment.
AMA|against medical advice|AMA.|166|169|HOSPITAL COURSE|She initially refused and was going to leave AMA. She then relented. However, when told she would not be able to drink coffee she again refused and left the hospital AMA. It appears that at home her family convinced her that she really needed to have this test. She called the cardiology clinic and when asked, told them that she had further chest pain.
AMA|against medical advice|AMA.|182|185|AXIS I|He denied any suicidal ideation prior to his going out on passes to apply at sober houses. DISCHARGE MEDICATIONS: None were ordered as he did not return from pass and was discharged AMA. DISCHARGE STATUS: When he had been seen on _%#MM#%_ DD, 2005, prior to his pass, he was alert and oriented. His speech was regular in rhythm and rate and normal in volume and tone.
AMA|against medical advice|AMA|162|164|LABORATORY DATA|The patient is currently on a CSA taper, receiving 70 mg PO t.i.d. through _%#MMDD2002#%_, then switching to 55 mg PO t.i.d. starting _%#MMDD2002#%_. Problem #4: AMA discharge. After admission labs and exam, the patient's father inquired about the possibility of doing the Ribavirin therapy at home.
AMA|against medical advice|AMA|203|205|HISTORY OF PRESENT ILLNESS|One day prior to admission, she actually presented to the North Memorial Medical Center Emergency Department where she was given morphine for pain and was recommended to be admitted. She apparently left AMA feeling that she could handle her pain better at home. She then went back to the emergency department at Fairview-University Medical Center today due to continued incapacity from pain.
AMA|against medical advice|AMA|160|162|HOSPITAL COURSE|The patient was to be transferred to Psych to await the Rule 25 evaluation because of significant suicidal ideation and because of depression. The patient left AMA because he was not interested in any further in patient treatment.
AMA|against medical advice|AMA.|154|157|PROBLEM BASED HOSPITAL COURSE|They recommended continuing him on antibiotics and adding Fluconazole to prevent a systemic Candidiasis given his immunosuppressed state. 5. Patient left AMA. On _%#MM#%_ _%#DD#%_, Mr. _%#NAME#%_ decided to leave AMA. He had been unhappy with his admission from the date of arrival on.
AMA|against medical advice|(AMA)|251|255|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSIS: Gastrointestinal bleed, spontaneously resolved. HISTORY OF PRESENT ILLNESS: The patient is a 28-year-old man with a history of hepatitis C, asthma, and depression, who is status post gastric bypass. He left against medical advice (AMA) from _%#COUNTY#%_ _%#COUNTY#%_ Medical Center and presented to Fairview-University Medical Center. The patient reported hematemesis on _%#MMDD2002#%_ and was taken to _%#COUNTY#%_ _%#COUNTY#%_ Medical Center.
AMA|against medical advice|AMA|234|236|HOSPITAL COURSE|The patient also refused labs and EKG. It was discussed with the patient that only with EKG changes or with an enzyme rise that morphine would be given. The patient was given nitroglycerin without significant relief. The patient left AMA on hospital day #1.
AMA|against medical advice|AMA.|199|202|HOSPITAL COURSE|He had a negative prior stress test in the past, as well as a negative angiogram 1 month prior, at Abbott-Northwestern. The patient is well known to this service after a prior admission, having left AMA. 2. Narcotics. The patient demanded narcotics for his chest pain. He was told that he would not receive these unless he had objective evidence of ischemia, e.g., ECG changes or elevated troponin.
AMA|against medical advice|AMA|185|187|HOSPITAL COURSE|In the future, would recommend not giving any intravenous narcotics for chest pain without objective evidence of ischemia or injury. Discharge orders were not done, as the patient left AMA and refused to sign AMA paperwork. Thus, no changes could be made in his medication regimen. On prior hospital AMA discharge, we had started a calcium channel blocker, if this is any evidence of Prinzmetal angina.
AMA|against medical advice|AMA.|215|218|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 24-year-old male with a history of opiate dependence. He has a long history of admission. He has a history of using while in treatment and a history of leaving AMA. He has had no long-term sobriety. He also has a history of being extremely dishonest regarding his use and about kinds, amounts, and frequencies.
AMA|against medical advice|(AMA)|325|329|PAST MEDICAL HISTORY|3. Longstanding history of personality disorder. She has been on numerous psychotropic medications having generally stopped all those medications as soon as she is able or not being supervised. She has been admitted on several occasions for problems with dizziness, weakness. She has left the hospital against medical advice (AMA) on two occasions and has left a rehab center AMA in the past as well. She has been treated with Tranxene and Remeron in the past, having stopped those medications.
AMA|against medical advice|AMA|182|184|PAST MEDICAL HISTORY|She has been admitted on several occasions for problems with dizziness, weakness. She has left the hospital against medical advice (AMA) on two occasions and has left a rehab center AMA in the past as well. She has been treated with Tranxene and Remeron in the past, having stopped those medications.
AMA|against medical advice|AMA;|371|374|HISTORY OF PRESENT ILLNESS|The patient's blood type was B positive and her hemoglobin went from 14.5 preoperatively to 8.1 postoperatively, and the plan was to offer this patient a blood transfusion; however, given her poor peripheral access and inability to place a PICC on postoperative day #4 in the morning, this was never achieved. Again, I stressed this with the patient prior to her leaving AMA; however, she refused blood products. Her incision was clean, dry, and intact with staples; these were removed prior to her discharge.
AMA|against medical advice|AMA.|244|247|DISPOSITION|Her incision was clean, dry, and intact with staples; these were removed prior to her discharge. DISPOSITION: A 48-year-old para 8-0-0-7, postoperative day #4, status post primary C-section secondary to arrest of dilation, IUFD, who is leaving AMA. DISCHARGE INSTRUCTIONS: 1. The patient was instructed to call or return directly to the emergency room if she develops a fever of 100.4 or greater, pain in her abdomen, or feelings of shortness of breath, dizziness, chills, nausea, or vomiting.
AMA|against medical advice|AMA|133|135|ADMISSION DIAGNOSIS|His current history is precisely the same as it always has been at _%#CITY#%_ Children's as well as his prior admission when he left AMA approximately 24 hours ago. There are no changes. For past medical history, family history, social history, allergies, and current medications, please see my dictation dated _%#MM#%_ _%#DD#%_, 2005, in FCIS.
AMA|against medical advice|(AMA)|212|216|HISTORY OF PRESENT ILLNESS|The risks, complications and long-term effects that could be potentially life-threatening were all discussed with her and outlined in Dr. _%#NAME#%_'s Discharge Summary. She was discharged against medical advice (AMA) and went home. After being at home the family members had noticed that the patient had decreased oral intake and most recently has had some problems with a little bit of nausea and apparently vomiting per family but denied by patient.
AMA|against medical advice|AMA|181|183|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Significant for previous laparoscopic surgery at _%#COUNTY#%_ _%#COUNTY#%_ Medical Center in _%#MM2002#%_ for abdominal pain. The patient at that time left AMA 1 day later and later went to University of Minnesota Medical Center, Fairview University campus where a laparoscopy was done and the patient was found to have a hemorrhagic corpus luteum.
AMA|against medical advice|AMA|27|29||The patient was discharged AMA on _%#MM#%_ _%#DD#%_, 2006. DISCHARGE DIAGNOSES: 1. Abdominal pain, nausea, and vomiting. 2. Gastric reflux disease.
AMA|against medical advice|AMA|151|153|HISTORY OF PRESENT ILLNESS|8. Senna 1 p.o. b.i.d. 9. Vicodin 1 p.o. q.4 h. p.r.n. pain. HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old man, initially left the hospital AMA after being hospitalized for several days for treatment of cardiomyopathy and urinary retention. He was readmitted due to ongoing complaints of malaise and recurrent urinary retention.
AMA|against medical advice|AMA,|209|212|HOSPITAL COURSE|The patient was scheduled to have the ultrasound earlier in the morning of the day of discharge, but it was not done and his patience level was tested, and he actually left AMA. Unfortunately with him leaving AMA, he was not able to get his medications, which included new medication of Coumadin to have an INR of 1.6 to 2.4 for 3 months.
AMA|against medical advice|AMA.|202|205|PHYSICIAN FOLLOWUP|LABORATORY TESTS: Pending at discharge: None. The patient refused blood draws on the morning of discharge. DIET AND ACTIVITY: As tolerated by the patient. PHYSICIAN FOLLOWUP: As noted, the patient left AMA. Dr. _%#NAME#%_ was informed as well as, _%#NAME#%_ _%#NAME#%_, the GI nurse practitioner about his leaving. Transplant coordinator, _%#NAME#%_ _%#NAME#%_ was also notified as well as his primary care physician, Dr. _%#NAME#%_ _%#NAME#%_.
AMA|against medical advice|AMA|181|183||Please see discharge summary dated _%#MM#%_ _%#DD#%_, 2006, for complete details on this hospitalization. Addendum to discharge instructions and followup: The patient left hospital AMA prior to receiving her discharge paperwork and medications. The patient was contacted at home and told that she had a prescription for Lovenox to pick up at the hospital which she could fill here for the next 3 days.
AMA|against medical advice|AMA.|175|178|HOSPITAL COURSE|While recovering from acute pancreatitis, her lipase level has gone down to 751. While switching the patient from one room to the other, the patient had gotten upset and left AMA. I did not have a chance to see the patient before she left.
AMA|against medical advice|AMA.|261|264|DISCHARGE MEDICATIONS|The patient is leaving AMA with his wife and he is to follow up with his rheumatologist and primary care physician, _%#NAME#%_ _%#NAME#%_, CV surgery and Minnesota Heart. The patient understands the risks of leaving and the nurse was the witness in him signing AMA. The patient to return if he has further chest pain.
AMA|against medical advice|AMA|207|209|HISTORY OF PRESENT ILLNESS|I have advised her of the possible risks of GI bleed versus pancreatitis and the possibilities that these conditions may worsen and lead to possible sudden death. To this, she stated that she would like her AMA papers and she will sign out and leave. She refused to participate in further history taking, or to allow me to conduct a physical exam.
AMA|against medical advice|AMA.|222|225|PHYSICAL EXAMINATION|Nutrition noted that she had a little recent weight gain, but is still far below her pre-gravid value. The author was called to the bedside by staff on _%#MMDD2007#%_ in the evening because the patient was asking to leave AMA. A Somali interpreter was summoned and over 45 minutes was spent in discussion at approximately 1800 on _%#MMDD2007#%_. It was a revealing interview. The patient stated that her child was ill, that her husband has to miss school to care for that child and she wants to go home to be that care provider.
AMA|against medical advice|AMA|107|109|PHYSICAL EXAMINATION|To all she verbalizes understanding via the excellent interpreter available throughout. The patient leaves AMA this evening following prescriptions for Dilantin 300 mg daily, Remeron 15 mg p.o. each day at bedtime x1 week, 30 mg each day at bedtime (I did another slow progression given the fact that I doubt the patient has been taking it at all, although she did report to psychiatry that she has missed only a few doses, given her non-existent Dilantin levels and previous history), Zelnorm 6 mg p.o. b.i.d. and folic acid 1 g daily.
AMA|against medical advice|AMA.|460|463|PHYSICAL EXAMINATION|The patient was put on aspirin and her potassium was replaced on admission, but she was insistent on going home, though, I have gone over in detail with her was all the risk factors involving the low sodium and the low potassium, and the enlarged liver and the fact that she should not drink at all, or if she would start vomiting she would have similar symptoms. But still after explaining all of that, the patient still insisted on going home and she signed AMA. I have given her a prescription of potassium supplement, thiamin, and multiple vitamin. FINAL DIAGNOSIS: This patient has nausea and vomiting mainly due to increased alcohol intake and the fact that she has not been eating for two days apart from alcohol lead her to the hyponatremia and the hypokalemia.
AMA|against medical advice|AMA|320|322|PROBLEMS PRESENTED AT ADMISSION|The patient has a previous history of treatment with two admissions to the STOP program, one previous outpatient chemical dependency treatment during which he continued to use, an admission to the inpatient dual program, and an admission to the Fairview _%#CITY#%_ _%#CITY#%_ Lodging Program. The patient was discharged AMA from his last STOP admission by his mother. The patient does have a history of legal problems and it was stated that he is court ordered to the chemical dependency evaluation.
AMA|against medical advice|AMA|163|165|HOSPITAL COURSE|In fact, there continued to be an improvement in the background EEG rhythm. On the date of transfer to psychiatry, the patient was actually about to be discharged AMA by her parents. The plans were to take her back to _%#CITY#%_, Wisconsin, even though Wisconsin and _%#CITY#%_ had refused her transfer request.
AMA|advanced maternal age|AMA.|139|142|COMPLICATIONS OF PREGNANCY|PRENATAL CARE: Pregnancy care started at 6 weeks for a total of 20+ visits. Total weight gain is 14 pounds. COMPLICATIONS OF PREGNANCY: 1. AMA. 2. Previous C-section. 3. Latex allergy. 4. Lactating. 5. History of LGA macrosomia. 6. History of low progesterone. 7. Obesity. 8. History of borderline normal EKG. 9. Pregnancy-induced hypertension.
AMA|against medical advice|AMA|241|243|HOSPITAL COURSE|We also met with her mother and the Native American patient advocate to discuss the recommended transfer to _%#CITY#%_ Regional Treatment Center that was also recommended to her the last time she was discharged. Last time she was discharged AMA and since she was unable to function outside of a structured setting over the weekend, we believe that at this time a transfer to _%#CITY#%_ would be necessary.
AMA|against medical advice|AMA.|175|178|IDENTIFICATION|His wife works as a CPA. He is unemployed. He entered with a long history of addiction. Heroin and crack-cocaine were his drugs of choice. He moved here in _%#MM#%_, but left AMA. He admitted to daily use of above. On admission his physical examination was essentially normal. He was started on bromocriptine for cocaine craving and buprenorphine for heroin withdrawal.
AMA|against medical advice|AMA|346|348|IDENTIFICATION|Plavix prescription was given to him at my request. Patient also complained of back pain secondary to "osteomyelitis" but I have no background for this although he states he is on chronic antibiotics which we did continue while in the hospital and I filled a prescription for Oxycodone in anticipation of discharge today. As stated, patient left AMA last evening. For other details, please see my admission history and physical, my cardiac catheterization report. I do not have the chart available at this time for my perusal for details of lab.
AMA|against medical advice|AMA,|166|169|HISTORY OF PRESENT ILLNESS|She has been through treatment here. She has been to Wayside House and Transformation House, but was discharged from each. She was recently here a month ago and left AMA, as she was not in withdrawal. She did not stay sober and started using again immediately. She now enters for further detox. She wants to get back on methadone maintenance.
AMA|against medical advice|AMA|196|198|HOSPITAL COURSE|Again, the patient expressed understanding of these. Discussion was also done in front of her husband and he also expressed understanding of this. She still wished to leave. The patient signed an AMA form and left AMA. 3. Anemia. The patient was anemic on exam. Her hemoglobin dropped to 8.7 on the day discharge.
AMA|against medical advice|AMA|212|214|HOSPITAL COURSE|He was advised against it because of the risk of fall for his alcoholism. There would be an increased risk of him getting subdural hematoma, but the patient did not want to stay in the hospital, and he signed an AMA form and wanted to leave. RESULTS PENDING: TSH. DISCHARGE MEDICATIONS: The patient was discharged on metoprolol 25 mg twice a day, thiamine 100 mg once a day, multivitamins 1 tablet once a day, aspirin 325 mg once a day, Combivent 1 puff twice a day, and nicotine patch which he was not using.
AMA|against medical advice|AMA,|150|153|PHYSICIAN FOLLOWUP|DIET: No restriction. ACTIVITY: No restriction. ADVANCE DIRECTIVES: Not discussed. PHYSICIAN FOLLOWUP: At this time, the patient since he was leaving AMA, he did not want any followup to be done. He does have a followup with his primary care doctor arranged on _%#MM#%_ _%#DD#%_, 2006, and he does plan to follow up with his primary care doctor.
AMA|against medical advice|AMA.|179|182|PLAN|The patient needs a Rule 25 evaluation for chemical-dependency treatment, which will not be done until early next week. The patient is on a 72-hour hold because he tried to leave AMA. I will get a 1:1 sitter for overnight.
AMA|against medical advice|AMA|246|248|HOSPITAL  COURSE|I then received a phone call later on the evening of _%#MMDD2006#%_ after the patient had been seen by psychiatrist, nursing notes indicate the patient's son came out and said that his mother wanted to sign out AMA. The patient apparently signed AMA papers, I could not find these in the chart currently. Nursing tried to instruct the patient that she would be at risk for withdrawal symptoms, but the patient's son and the patient kept interrupting stating its "better than staying here".
AMA|against medical advice|AMA|345|347|BRIEF HISTORY OF PRESENTING ILLNESS|Global LV function was normal. BRIEF HISTORY OF PRESENTING ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 51-year-old Hmong with end-stage renal disease on dialysis and being considered for transplant, diabetes mellitus type 2, hypertension, coronary artery disease, recently had left circumflex and OM-1 stented with procedural complication of OM-3. Left AMA during last hospitalization; however, echocardiogram at that time on multiple occasions did not show any pericardial effusion, presented back with midsternal chest pain that was radiating to her back.
AMA|against medical advice|AMA|151|153|HISTORY  OF PRESENT ILLNESS|He received Dilantin. He was loaded with fosphenytoin and subsequently given Dilantin with a therapeutic level. Unfortunately, the patient left either AMA or without discharge advisement. Since that time he has received home care and/therapy. Details are very sketchy as far as how well he has been doing and it unclear exactly what the patient has been taking.
AMA|against medical advice|AMA.|258|261|ADMITTING HISTORY AND PHYSICAL|This had been found in the second floor women's room. The patient's belongings were taken out of the closet in her room, she was paged overhead, security was notified, patient representative was notified and the patient did not return, presumed to have left AMA. After having stressed on daily rounds, the need for further evaluation of her condition and the potential seriousness of her intravenous infection, the patient left without notifying staff or physician.
AMA|against medical advice|AMA.|166|169|HOSPITAL COURSE|She stated that she understood all of this and that she would rather go home and find out the results of the MRCP from there. She elected to sign the paper and leave AMA. She left the hospital at around 1730 on the evening of _%#MMDD2003#%_. She has since been called with the results of her MRCP.
AMA|against medical advice|AMA|172|174|CLINICAL HISTORY|2. History of severe and moderate depression. 3. History of asthma. 4. History of diabetes mellitus since 2002. 5. Paranoid schizophrenia. 6. History of non-compliance and AMA medical leave. 7. History of 72-hour hold. CURRENT MEDICATIONS: The patient denied the use of medications at this time.
AMA|against medical advice|AMA,|163|166|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 33-year-old woman with a long history of alcohol abuse who went into the _%#CITY#%_ emergency room yesterday and left AMA, she states, due to their inability to treat her chemical dependency. She came to Fairview- University Medical Center after having a couple drinks and emesis at home.
AMA|against medical advice|AMA|330|332|OPERATIONS/PROCEDURES PERFORMED|The patient did allow us to redraw her hemoglobin, which came back at 14.4; and when the result was going to be explained to the patient by me, it was found that she was not in her room, her monitor had been taken off, and all of her belongings were gone. Please note that the patient had another admission here, and she has left AMA once again. The patient appears stable and there is no concern or reason to hold her for any psychiatry and no medical reason at this point.
AMA|against medical advice|AMA.|177|180|SOCIAL HISTORY|Rare alcohol use. He lives with his daughter in an apartment. Apparently there have been attempts to get him into nursing homes in the past and he has left at least one of them AMA. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Again recently discharged from Methodist.
AMA|advanced maternal age|AMA.|161|164|OPERATIONS/PROCEDURES PERFORMED|Clear fluid was noted. The patient was scheduled for a repeat cesarean section on _%#MM#%_ _%#DD#%_, 2004. PRENATAL CARE: The patient had regular visits. She is AMA. She had a CBS that was normal. XY baby with nephrogenic diabetes insipidus. PAST OB HISTORY: 1. In _%#MM#%_ 2000, the patient had a cesarean section for arrestive dilatation with a 9-pound infant.
AMA|against medical advice|(AMA)|312|316|ADMIT DATE|ADMIT DATE: _%#MMDD2004#%_ DISCHARGE: _%#MMDD2004#%_ Left without notification. DISCHARGE DIAGNOSIS: The patient presented with chest pain, but left without notification. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 51-year-old gentleman with history of multiple admissions and leaving against medical advice (AMA) and request for narcotics in the past, who was admitted on _%#MMDD2004#%_ with chest pain, left AMA on _%#MMDD2004#%_, and came back on the evening of _%#MMDD2004#%_ to the ER for chest pain evaluation.
AMA|against medical advice|AMA|230|232|HISTORY OF PRESENT ILLNESS|Of significance, we know Mr. _%#NAME#%_ has had four admissions at Fairview Southdale Hospital since _%#MM2002#%_ all of them with alcohol related disease including ascites. The patient's last admission on _%#MMDD2004#%_, he left AMA when he came in with intoxication and left when he sobered up without further therapy. He is supposed to be on spironolactone, furosemide, Protonix, and neomycin, although, it does not appear he has been taking this of late.
AMA|advanced maternal age|AMA,|149|152|COMPLICATIONS|DISCHARGE DIAGNOSES: 1. Intrauterine pregnancy at term. 2. Active labor. 3. Status post cesarean section. COMPLICATIONS: Fetal intolerance of labor, AMA, infertility, with artificial insemination. OPERATIONS/PROCEDURES PERFORMED: Primary cesarean section. PRENATAL CARE: Nurse midwives, began at 11 weeks, 9 visits, weight gain was 13 pounds.
AMA|against medical advice|AMA.|184|187|DISCHARGE FOLLOWUP|The patient agreed to this plan and left the hospital. DISCHARGE MEDICATIONS: None. DISCHARGE FOLLOWUP: The patient will follow up for outpatient stress test as he agreed upon leaving AMA.
AMA|against medical advice|AMA,|166|169|HISTORY OF PRESENT ILLNESS|He went to the emergency department the night before admission, and the pain was not resolved with sublingual nitrate, but it improved with Toradol. The patient left AMA, but returned back after the pain recurred. He denied any shortness of breath, palpitation, lightheadedness or dizziness.
AMA|against medical advice|AMA|194|196|HOSPITAL COURSE|This discussion was not obtained with the patient due to the patient's social situation, needed to stay at home. The patient refused to stay overnight in the hospital, and would have signed out AMA should she not have been allowed to go home. Thus, it was decided this lymphadenopathy should be worked up on an outpatient basis.
AMA|against medical advice|AMA.|255|258|HISTORY OF PRESENT ILLNESS|The patient was evaluated at a local hospital one week ago, and CT scan without contrast had been performed, which showed no acute bleed, but an old left caudate lacunar infarct. The patient was advised to be admitted, but she declined and she signed out AMA. Because of the progressive weakness and numbness of her left lower extremity, she came here evaluation.
AMA|against medical advice|AMA|131|133||She was admitted for detoxification on _%#MMDD2002#%_. She had been using daily. She had a previous treatment for one day but left AMA three years ago. On admission, she had a swollen left knee. She was started on three days of methadone for detoxification.
AMA|against medical advice|AMA|255|257|FAMILY AND SOCIAL HISTORY|A CT scan was done, however, and it showed thickening of the gastric wall and small bowel, consistent with gastritis/gastroenteritis-so this was felt to be gastroenteritis or gastritis. The patient was put on a once-per-day PPI. However, the patient left AMA before his prescriptions were filled. DISCHARGE MEDICATIONS: 1. MS Contin 50 mg p.o. q.12h. 2. Flexeril 10 mg p.o. b.i.d. 3. Protonix 40 mg p.o. q.d. FOLLOW-UP PLAN: The patient is to follow up with Dr. _%#NAME#%_ at his scheduled appointment.
AMA|against medical advice|AMA.|211|214|HISTORY OF PRESENT ILLNESS|The patient's prenatal course was fairly unremarkable. She was cared by the physicians at Fairview _%#CITY#%_ Women's Clinic, particularly Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_. Issues with her pregnancy: She is AMA. She had a normal level II ultrasound and declined amniocentesis. The patient's 1st prenatal visit was at 11 weeks. First trimester blood pressure was at 112/74.
AMA|against medical advice|AMA|114|116|DISCHARGE DISPOSITION|Patient was alert and oriented and competent to make the decision and still elected to leave AMA. He did sign out AMA and was discharged to home. HOSPITAL COURSE: 1. Acute respiratory failure. Patient presented to the hospital on _%#MM#%_ _%#DD#%_, 2004, with acute respiratory failure.
AMA|against medical advice|AMA|209|211|HISTORY OF PRESENT ILLNESS|6. Chronic pain. 7. Tobacco abuse. HISTORY OF PRESENT ILLNESS: A 48-year-old Native American female readmitted to the Smiley's Teaching Service after leaving the Fairview-University Transitional Services Unit AMA on _%#MMDD2004#%_. She is returning to the hospital to finish her course of IV vancomycin for her Mersa positive foot ulcers.
AMA|against medical advice|AMA,|226|229|HISTORY OF PRESENT ILLNESS|In her absence from the Fairview System she received 2 doses of vancomycin through her PICC line at the _%#COUNTY#%_ _%#COUNTY#%_ Medical Center Emergency Room. The patient has noticed some new ulcers developing since leaving AMA, mainly around the calf edges at her right shin and mid-calf, as well as on her left great toe. Otherwise, she has had no change in symptoms from her previous admission.
AMA|against medical advice|AMA|121|123|BRIEF HISTORY AND HOSPITAL COURSE|On my presentation, she had improved significantly. She was actually requesting to go home and actually would be leaving AMA if we tried to keep her. Her O2 was titrated to room air and she was 98% prior to discharge. There was only occasional wheezes on her discharge exam. She was instructed to continue prednisone 60 mg p.o. once daily for three days starting in the a.m. on _%#MMDD2004#%_, with a taper as directed.
AMA|against medical advice|AMA|183|185|DISCHARGE MEDICATIONS|_%#NAME#%_ was a term AGA male infant, 3352gm at 40 weeks gestation, with a length of 50cm and head circumference of 33cm. No jaundice was noted at birth, and his parents left Abbott AMA on _%#MMDD2005#%_. They did follow-up in clinic at _%#CITY#%_ Children's Hospital on _%#MMDD2005#%_ where _%#NAME#%_ was diagnosed with jaundice.
AMA|against medical advice|AMA.|240|243|DISCHARGE DIAGNOSIS|The patient does have a history of elevated pressures but gives a history now that she was in Illinois and had elevated pressures and protein in her urine. At that time, she was given magnesium and steroids for fetal lung maturity and left AMA. Here, the patient received a second dose of steroids and was monitored for three days. Her blood pressures remained within the mild preeclampsia category as well as a urine protein of 3.36 g per 24 hours.
AMA|against medical advice|AMA,|188|191|HOSPITAL COURSE|However, had only been using Levaquin p.r.n. On admission, he was started on Unasyn as well as continued on linezolid. Prior to any repeat imaging could be obtained, the patient did leave AMA, so further imaging to evaluate the status of osteo was not obtained, he will continue on linezolid and Levaquin as an outpatient.
AMA|against medical advice|AMA|274|276|HOSPITAL COURSE|PROBLEM #3. Schizophrenia: The patient has a history of schizophrenia that was currently untreated, although he was disheveled and, we did not feel that he could be held as he was not actively psychotic or acute harm to himself or others. Therefore, he was discharged on an AMA basis as he insisted on leaving. FOLLOWUP INSTRUCTIONS: The patient should continue on linezolid and Levaquin as needed for his osteomyelitis.
AMA|against medical advice|AMA.|140|143|DISCHARGE FOLLOWUP|DISCHARGE FOLLOWUP: She will follow up with Dr. _%#NAME#%_ and also with Dr. _%#NAME#%_, her psychiatrist in a week. The patient discharged AMA.
AMA|against medical advice|AMA|158|160|BRIEF HISTORY OF PRESENT ILLNESS|The patient is homeless and has been admitted to the hospital several times in the past for the same reason, but has refused various antibiotics and has left AMA before he can be discharged on appropriate treatment. At his most recent hospitalization, the patient had been started on antibiotics and the plan was to discharge him to a rehab facility, which he was initially agreeable to.
AMA|against medical advice|AMA,|220|223|PROBLEM #1|It was determined that the patient probably needs IV antibiotic treatment for approximately 6 to 8 weeks and a PICC line was ordered. However, the patient did leave AMA before we were able to place this. As he did leave AMA, he did not leave with any medications. PROBLEM #2: CHF exacerbation. The patient has a known cardiomyopathy with ejection fraction of approximately 25%.
AMA|against medical advice|AMA.|144|147|HISTORY OF PRESENT ILLNESS|She had a Lyme test that was positive. She was started on doxycycline. At that time she had a headache and they wanted to do an LP but she left AMA. She came back today with persistent symptoms. She has been sent for an LP. The results are pending. She is having severe headache and is being admitted for pain control and for further evaluation and treatment of possible meningitis and possible Lyme's disease.
AMA|against medical advice|AMA|174|176|HOSPITAL COURSE|His vital signs were all stable overnight and into the next morning. His coags were all within normal limits. He was discharged the next morning after he threatened to leave AMA and did not wait to be seen by staff. Both Drs. _%#NAME#%_ and _%#NAME#%_ agreed to see him in clinic on _%#MMDD2007#%_.
AMA|against medical advice|AMA.|181|184|DISCHARGE DISPOSITION|GTT was 20, TSH was 0.71, CBC was normal, urine drug screen was positive for cannabis, cocaine and opioids. DISCHARGE DISPOSITION: The patient went home. The patient was discharged AMA. DISCHARGE MENTAL STATUS EXAMINATION: The patient was alert, oriented and cooperative.
AMA|against medical advice|AMA|148|150|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 46-year-old white male who was recently hospitalized between _%#MMDD#%_ and _%#MMDD#%_ at which point he left AMA where he had been treated with IV Ancef for right-sided cellulitis and lymphedema. He returned to seek medical care on _%#MMDD#%_ with recurrent of lymphedema and recurrent cellulitis that was worsening.
AMA|against medical advice|AMA|160|162|BRIEF HISTORY|BRIEF HISTORY: This is a 32-year-old white male admitted with cellulitic infection of his foot. He was originally admitted to Fairview Southdale. He left there AMA due to apparent mistreatment according to the patient. He came here for re-evaluation. He was admitted for treatment. He did well. He was initially treated with IV antibiotics and this was switched to po without difficulty.
AMA|against medical advice|AMA.|378|381|HOSPITAL COURSE|The patient was able to void independently. On the late afternoon of _%#MM#%_ _%#DD#%_, 2004, the patient decided to leave AMA, despite primary team expressing the need for her to continue monitoring following the procedure to ensure both good p.o. intake and adequate pain control. The patient was informed of the risks of leaving AMA; however, she chose to leave the hospital AMA. It was discussed with the patient that she should keep her followup appointment with Dr. _%#NAME#%_ dated _%#MM#%_ _%#DD#%_, 2004, (Thursday) for continued followup. The patient was agreeable to this.
AMA|against medical advice|AMA|186|188|DISCHARGE MEDICATIONS|His affect had been congruent. His mood had improved. His insight and judgment were obviously impaired. DISCHARGE MEDICATIONS: None were sent, as the patient did not return prior to his AMA discharge. DISCHARGE PLAN: None, as the patient did not return to hospital.
AMA|against medical advice|AMA|275|277|HOSPITAL COURSE|We shall see him back in Dr. _%#NAME#%_'s neurosurgery clinic in about 5 days when his incision will be inspected and also for followup. Because the patient is leaving against medical advice of transferring to acute rehabilitation center, the discharge will be designated as AMA (against medical advice) discharge.
AMA|against medical advice|AMA.|17|20|DIAGNOSIS|The patient left AMA. The patient was admitted on _%#MM#%_ _%#DD#%_, 2004, and left AMA on _%#MM#%_ _%#DD#%_, 2004. DIAGNOSIS: Acute renal failure secondary to Wegener granulomatoses.
AMA|against medical advice|AMA|196|198|PAST OB HISTORY|Postoperative hemoglobin was 8.4. Patient remained afebrile, vital signs stable. Patient was placed on iron for blood loss anemia. Pain was controlled with Percocet and th On-Q pump. Patient left AMA on _%#MM#%_ _%#DD#%_, 2004. Patient was instructed that she would need a 6-week postpartum visit. Staples were removed prior to patient leaving. Patient was given prescriptions for Azmacort and albuterol inhaler prior to leaving AMA.
AMA|against medical advice|AMA.|185|188|IMPRESSION|In point of fact, should she decline any form of treatment or diagnostic procedures, I would not admit her to the hospital and in fact ask her to sign out from the Emergency Department AMA. At this point, the patient will think about this and let me know. It is my hope that she will allow for a proper work-up to include a CT scan of the abdomen with contrast as well as basic metabolic panel, comprehensive panel, liver enzymes, INR, blood cultures and sedimentation rate.
AMA|against medical advice|AMA|262|264|DISCHARGE PLAN|His abdominal exam was unremarkable. He had no diarrhea with any of this, and my concern is that this may have been a gastroenteritis, but it is possible that none of these symptoms had any substantiation in fact. DISCHARGE PLAN: The patient threatened to leave AMA if not released, he was released. I had not had a chance to talk to him afterwards and I have no idea what his planned follow-up is.
AMA|against medical advice|AMA.|155|158|HISTORY OF PRESENT ILLNESS|This is the second admission. He is married. He has 3 children. He recently lost his job. Alcohol was his drug of choice. He was here a year ago, but left AMA. He has had 2 public detoxes in the past year. He has had outpatient treatment but relapsed. On admission, the patient was tremulous and diaphoretic.
AMA|against medical advice|AMA,|237|240|HISTORY OF PRESENT ILLNESS|Therefore, she presented to the ER. Here, she initially had a chest x-ray, EKG, troponins, all of which did not suggest heart disease. The ER physician wanted to bring her in, but the patient did not want to come in, and ultimately left AMA, but then out in the parking lot she felt quite diaphoretic, started having some nausea, and had presyncope and near-syncope, and therefore the patient came back in, was reevaluated with another EKG without any new changes, and then repeated a troponin without any new changes, but given the patient's ongoing symptoms and new symptoms, the patient was willing to come into the hospital.
AMA|advanced maternal age|AMA.|141|144|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Intrauterine pregnancy at 38 plus 1 week. 2. Premature rupture of membranes. 3. Gestational diabetes mellitus A1. 4. AMA. 5. Suspected macrosomia. DISCHARGE DIAGNOSES: 1. Intrauterine pregnancy at 38 plus 1 weeks.
AMA|advanced maternal age|AMA.|152|155|HISTORY OF PRESENT ILLNESS|She noted loss of clear fluid. Denied any contractions or vaginal bleeding and reported good fetal movement. Her pregnancy was complicated by GDMA1 and AMA. She had been scheduled for cesarean section at 39 weeks for suspected macrosomia. ` PRENATAL LABORATORY DATA: Blood type 0 positive, antibody screen negative, hepatitis B surface antigen negative.
AMA|against medical advice|AMA|240|242|ASSESSMENT AND PLAN|Give him aspirin. I did just speak with the ER HUC who had talked with regions for the fifth time tonight and it sounds like he actually has not had a stress test yet. He had planned on having it this morning or on _%#MMDD#%_ and thus left AMA before he ever had the stress test. They do have a stress test results from him from _%#MM#%_ and they are planning on sending those results to us.
AMA|against medical advice|AMA.|138|141|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|Apparently, patient was admitted at Regions Hospital for chest pain 2 days ago where before doing the stress test, patient had signed out AMA. According to the patient, stress test was done over there; however, results cannot be obtained from there. Patient also had slightly elevated D-dimers for which CT of the chest was done which was negative for PE.
AMA|against medical advice|AMA.|82|85|DISPOSITION|DISCHARGE MEDICATIONS: Lansoprazole 30 mg p.o. q.d. DISPOSITION: The patient left AMA. She said that she will follow up with her outpatient speech therapist. Upon discharge the patient was comfortable, breathing normally, and not in any respiratory distress.
AMA|against medical advice|AMA.|184|187|LAB RESULTS|No psychiatric diagnosis. The decision was being made about where she would go. The patient became quite angry and refused to stay longer and demanded to leave. So, she was signed out AMA. She was advised to continue her current medications, follow up if she had any increased symptoms. ADDENDUM: The patient was noted that she had quite a bit of services as an outpatient and we recommended that she continue these and contact her nurse.
AMA|against medical advice|AMA|165|167|ASSESSMENT AND PLAN|Therefore, I did call Dr. _%#NAME#%_ at _%#TEL#%_. When he returned my call, he did express the concern for her leaving, however, he did state that she may sign out AMA after expressing concerns for inpatient ECT is recommended. The patient at this time would like to proceed with AMA discharge and will return to her parent's house with her husband and children as they can provide a 24-hour care for her.
AMA|against medical advice|AMA|361|363|ASSESSMENT AND PLAN|She would like to proceed with outpatient ECT treatment, although this may not be a valuable option for her as she may need to initiate this. Inpatient precautions were given to the patient that if she does begin to have a decompensation in anyway, suicidal or homicidal intention she should call and return immediately to the hospital that despite her leaving AMA does not mean that we will not proceed to care for her. The patient demonstrates the understanding of above as well as her husband.
AMA|against medical advice|AMA|224|226|HISTORY OF PRESENT ILLNESS|His MRI, EEG, and head CT were normal. The patient was loaded with Dilantin in the emergency department and was on Dilantin during the hospitalization. On Friday afternoon the patient left the _%#CITY#%_ _%#CITY#%_ Hospital AMA as he was not happy with the care that he was getting in _%#CITY#%_ _%#CITY#%_. The next morning the patient had another spell and came to Fairview-University Medical Center Emergency Department.
AMA|against medical advice|AMA.|218|221|OPERATIONS/PROCEDURES PERFORMED|9. She is not to report to the emergency department. 10. She is to also call if she is having any increased pain or temperature greater than 101.5. This has been fully discussed with the patient and she is signing out AMA.
AMA|against medical advice|AMA|181|183|HISTORY OF PRESENT ILLNESS|Of note, the patient has had CVAs in the past and was working in Washington where he possibly had another cerebrovascular accident. He was to be admitted at that point, but he left AMA because he and his wife both wanted to make their cruise to Hawaii. After the cruise, the patient returned for checkup and then came back to his home here in _%#CITY#%_.
AMA|against medical advice|AMA.|214|217|HISTORY OF PRESENT ILLNESS|It was noted at that time that it likely esophageal irritation versus gastritis causing this persistent pain. It was recommended that she have a comprehensive GI work-up, including endoscopy, before she signed out AMA. She again complains of similar- type pain that is affected by inspiration, change in position, and swallowing. She denies nausea, vomiting, diaphoresis, or shortness of breath. She denied any suicide attempt after she took the OxyContin and states that she is feeling fine now.
AMA|against medical advice|AMA,|188|191|PAST MEDICAL HISTORY|Rubella immune antibody screen negative. RPR negative. Hepatitis B surface antigen negative. HIV negative. GC-chlamydia negative. GCT is 127. PAST MEDICAL HISTORY: Significant for asthma, AMA, history of previous preterm delivery, low back pain, and allergies. PAST SURGICAL HISTORY: In 1980 she had a laparoscopic cholecystectomy.
AMA|against medical advice|AMA|170|172|HISTORY OF PRESENT ILLNESS|She was noted in mid _%#MM#%_ to have left upper extremity and left facial weakness. She presented to _%#COUNTY#%_ _%#COUNTY#%_ Medical Center on _%#MMDD2005#%_ and left AMA readmitted to Fairview-University Medical Center on _%#MMDD#%_. Head MRI showed a right basal ganglia abnormality, lumbar puncture with cultures at that time were negative.
AMA|against medical advice|(AMA)|468|472|HISTORY OF PRESENT ILLNESS|Laboratory tests were checked. His initial troponin I was less than 0.07, myoglobin 21, white blood cell count 7.3, hemoglobin 17.1, hematocrit 50.7, platelets 292,000, sodium 141, potassium 3.7, chloride 101, bicarbonate 28, anion gap 12, glucose 110, BUN 13, creatinine 0.8, calcium 9.0. The patient was told that he was in the process of having a myocardial infarction (MI). He was told that he needed to be admitted to the hospital. He left against medical advice (AMA) stating that it was just as easy to sleep at home as to sleep in the hospital. Mr. _%#NAME#%_'s wife is a nurse. She urged him to come to the cardiology clinic today for further evaluation.
AMA|against medical advice|AMA|70|72||He was admitted to this institution yesterday after having signed out AMA from Abbott Northwestern to which he was admitted with respiratory distress on _%#MM#%_ _%#DD#%_. Since his admission here on IV Levaquin and intravenous Solu-Medrol with in addition a continuation of usual medications, the patient's symptoms have improved.
AMA|advanced maternal age|AMA,|259|262|HOSPITAL COURSE|HOSPITAL COURSE: Ms. _%#NAME#%_ is a 37-year-old female, gravida 6, para 5-0-0-5 who presented at 41 weeks estimated gestational age for planned cesarean section. She had a prior cesarean section x2. Her pregnancy was complicated by a prior cesarean section, AMA, late prenatal care and anemia. Her scheduled cesarean section went well without complications. On post-operative day #1, she was noted to be doing well, eating, ambulating without difficulty.
AMA|against medical advice|AMA.|121|124|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|He was admitted with GI work up. IV fluids, Protonix IV. Meanwhile before the GI work up could be done, the patient left AMA. The patient does not have any PCP. Upon discharge his hemoglobin had been 14.6 and he had stopped vomiting. The patient also had a chemical dependency evaluation order which he refused.
AMA|against medical advice|AMA|230|232|HISTORY OF PRESENT ILLNESS|The patient is a 19-year-old female with a history of cystic fibrosis who was recently hospitalized for pulmonary exacerbation, hyperglycemia. The patient was placed on ceftazidime, tobramycin, levofloxacin at that time, but left AMA within 3 days of her hospitalization. She had presented with persistent chest pain, worsening cough, nausea, malaise, and hyperglycemia again.
AMA|against medical advice|AMA.|165|168|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|Given the fact that she is denying any further workup for anemia or any GI consultation and she is very adamant to go back to the nursing home we will ask her to go AMA. I have talked to Dr. _%#NAME#%_ about the condition and he is aware of the situation that refusal of further treatment or investigation of anemia can lead to severe anemia and then patient could die from this condition.
AMA|against medical advice|AMA,|184|187|HOSPITAL COURSE|Please review the admission note by Dr. _%#NAME#%_ on _%#MMDD2007#%_ for further details about admission. HOSPITAL COURSE: The patient initially was very irritable and wanted to leave AMA, but after talking with his family he agreed to stay. He then was detoxed using buprenorphine. He was up to 6 mg of sublingual buprenorphine and he had an uneventful detox.
AMA|against medical advice|AMA|355|357|PROBLEM #2|As noted above, if he returns to the ED the lower for readmission in the near future, he should have social work evaluate his case to deem whether he is a candidate for more supervised care to prevent recurrent ER visits and readmissions. Please do not hesitate to page me at _%#TEL#%_ for further questions regarding Mr. _%#NAME#%_'s brief admission and AMA discharge.
AMA|against medical advice|AMA|180|182|HOSPITAL COURSE|The patient had no further convulsive activity during the hospitalization and was deemed competent prior to discharge. He was quite eager to be discharged and stated he will leave AMA if we do not give him his paper work, so we decided to discharge the patient home with refills of his antiepileptics.
AMA|against medical advice|AMA|469|471|BRIEF HISTORY OF PRESENT ILLNESS|PERTINENT PROCEDURES AND/OR IMAGING: None. BRIEF HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old male with a past medical history of CHF (EF of 25%), coronary artery disease being medically managed, severe COPD, pulmonary hypertension paranoid personality disorder with noncompliance multiple admissions with resulting leaving against medical advice who presented to the emergency department with a worsening shortness of breath. Of note, the patient had left AMA just 2 days prior. Physical exam was remarkable for her rate of one teens and slight respiratory distress with coarse crackles, 3+ lower extremity edema.
AMA|against medical advice|AMA|88|90|HOSPITAL COURSE|HOSPITAL COURSE: The patient is a 46-year-old man who is admitted to FUTS after leaving AMA from the hospital 8 hours previously. The patient had a chronic pain issue. He had had a BKA for a nonhealing cadaveric transplanted tibia.
AMA|against medical advice|AMA.|228|231|HISTORY OF PRESENT ILLNESS|The patient initially stated that upon refusing the test, the nurse brought her the AMA papers without a chance to talk to the doctor, then later the patient claimed that she just wanted Xanax, but was not given any so she left AMA. The patient was given a prescription for Cipro, which she did not fill due to cost. Her last dose of antibiotics was in the hospital yesterday a.m. The patient went home yesterday, took a Xanax, and slept through the night.
AMA|advanced maternal age|AMA.|63|66|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Intrauterine pregnancy at 38 weeks. 2. AMA. 3. Insulin-dependent diabetes mellitus. 4. Rh negative. DISCHARGE DIAGNOSES: Same. PROCEDURES PERFORMED: 1. Cervical ripening. 2. Induction of labor with Pitocin.
AMA|against medical advice|AMA|158|160|PLAN|3. GBS culture, treat with penicillin prophylactically until culture is available. 4. I am refusing to give the patient narcotics. She may very well sign out AMA due to this, however. I have discussed at length the risks using narcotics and importance of safety for her baby.
AMA|against medical advice|AMA|342|344|HOSPITAL COURSE|HOSPITAL COURSE: Intractable headache. The patient is a 41-year-old gentleman with known history of coronary artery disease and cardiomyopathy, idiopathic, history of V-tach with inducible V-tach by EP study and status post AICD placement with a recent hospitalization at Fairview Ridges Hospital. In fact, this was the day he was discharged AMA several hours before his readmission for headache. His he was discharged AMA with working diagnosis at that time of noncardiac chest pain.
AMA|against medical advice|AMA|419|421|HOSPITAL COURSE|HOSPITAL COURSE: Intractable headache. The patient is a 41-year-old gentleman with known history of coronary artery disease and cardiomyopathy, idiopathic, history of V-tach with inducible V-tach by EP study and status post AICD placement with a recent hospitalization at Fairview Ridges Hospital. In fact, this was the day he was discharged AMA several hours before his readmission for headache. His he was discharged AMA with working diagnosis at that time of noncardiac chest pain. The patient came back with intractable headache. The patient does have a history of headaches.
AMA|against medical advice|AMA|158|160|PAST MEDICAL HISTORY|2. Depression-using Celexa. 3. Status post GI bleed on _%#MM2006#%_ (the patient was drinking alcohol in the hospital while he was staying as a patient. Left AMA and was not scoped at that time). 4. Status post ACL repair. SOCIAL HISTORY: The patient is not a smoker. He has a chronic history of alcohol abuse. Denied any use of drugs.
AMA|against medical advice|AMA|236|238|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: 51-year-old man with known history of coronary artery disease. Multiple ER presentation and admissions for chest pain. Noncompliance with medical therapy and leaving the hospital AMA on several occasions. He has been in the Emergency Room already this month 4 times and admitted twice. On _%#MMDD2007#%_ he left the Emergency Room AMA and on _%#MMDD#%_ he threatened to leave AMA when they told him he needs to go to Southdale for an angiogram.
AMA|against medical advice|AMA.|256|259|HOSPITAL COURSE|He was put on telemetry and he had a serial troponins, which were negative. Also, he was advised that he should see cardiologist as an outpatient and he needs to continue to better blood care and also he should be on aspirin daily but he left the hospital AMA. 4. Anemia, probably secondary to chronic blood loss. He has a history of 1 episode of blood-tinged vomiting before the admission.
AMA|against medical advice|AMA.|243|246|HOSPITAL COURSE|He also denies having any hematemesis. His hemoglobin on the _%#MMDD#%_ was 12.2. He was advised that he needs to have a coloscopy as an outpatient and endoscopy as an outpatient. We wanted to start him on ferrous sulfate but the patient left AMA. 5. Rhabdomyolysis. Because of chronic alcohol drinking and history of a fall, his CK was initially elevated at 900.
AMA|against medical advice|AMA.|186|189|HOSPITAL COURSE|However, the patient decided to leave AMA, because he did not want to stay until he came out of detox. His scores at the time of discharge were coming down, however, he decided to leave AMA. The patient discharged AMA. The patient was educated about complications of alcohol withdrawal including reoccurrence of withdrawal seizures, delirium tremens and other side effects.
AMA|against medical advice|AMA.|111|114|HOSPITAL COURSE|His scores at the time of discharge were coming down, however, he decided to leave AMA. The patient discharged AMA. The patient was educated about complications of alcohol withdrawal including reoccurrence of withdrawal seizures, delirium tremens and other side effects.
AMA|against medical advice|AMA|348|350|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 59-year-old male with a history of diabetes, cardiomyopathy, chronic right foot ulcers and osteomyelitis with multiple hospitalizations and recent discharge AMA on _%#MMDD2007#%_ for foot ulcers who presented with a complaint of increasing foot swelling. Please note the patient after he left AMA on _%#MMDD#%_ subsequently went to a hospital in North Dakota where he was treated with IV antibiotics and then discharged to a nursing home on Zyvox, per patient.
AMA|against medical advice|AMA|232|234|HISTORY OF PRESENT ILLNESS|Please note the patient after he left AMA on _%#MMDD#%_ subsequently went to a hospital in North Dakota where he was treated with IV antibiotics and then discharged to a nursing home on Zyvox, per patient. He then left the hospital AMA and subsequently returned here to live in a shelter. He presented with increasing foot pain. Upon evaluation on the floor he is resting comfortably.
AMA|against medical advice|AMA|144|146|HISTORY OF PRESENT ILLNESS|This scan apparently also demonstrated the presence of an incarcerated hernia. The patient left the hospital, where she was initially evaluated AMA stating she would return to hospital more near her home. The patient was seen at a Unity Hospital, where an NG tube was placed and abdominal x-rays were taken that showed the presence of multiple loops of dilated small bowel.
AMA|against medical advice|AMA.|185|188|HOSPITAL COURSE|She was being stabilized her mood, energy, sleep, appetite and interest were all returning. She was cout of detoxification. The patient was not interested on any treatment and she left AMA. The patient left AMA before an EGD scheduled . The patient decided to leave AMA did not want to do any treatment. DISCHARGE MENTAL STATUS EXAMINATION: The patient is a 33-year-old Caucasian female who has good grooming, good hygiene, good eye contact, clear coherent speech with normal rate, rhythm and volume.
AMA|against medical advice|AMA|484|486|HOSPITAL COURSE|The patient was very intimidating to the clinician as well threatening and clenching his fists, glaring, and looking rather intensely, increase in the volume and talking in a threatening tone. During the hospitalization, he was a veteran and when asked about wanting to go to the VA, he was very abusive and began to use profanity saying that he did not want to do that treatment.He was clonazepam 0.5 mg po bid for the past 5 days whwn he was asked to come off he threatned to leave AMA .The case was discusses extensively with the team including his rn _%#NAME#%_ _%#NAME#%_ , Dr _%#NAME#%_.As he was on clonazeapm fo a short period there was alittle hance of withdrawl seizure.He is on antiseizure medication also.It was not therapuetic to discharge pt on clonazepam so it was discontnued.The case was discusses extensively with the team including his rn _%#NAME#%_ _%#NAME#%_ several collateral sources all indicated pt was not suicidal /homicidal at teh time of discharge.
AMA|against medical advice|AMA|185|187|HISTORY OF PRESENT ILLNESS|The patient will be admitted to the hospital for further evaluation of an apparent pancreatitis, presumed gallstone pancreatitis. It was noted that patient did leave the emergency room AMA to go home to take care of his cats and then reported back to the hospital floor to be admitted. PAST MEDICAL HISTORY: 1. Anxiety. 2. Depression. 3. Gastroesophageal reflux disease.
AMA|against medical advice|(AMA)|176|180|HOSPITAL COURSE|As we did not have an etiology for the pancreatitis we recommended the patient remain in the hospital for further investigation. She elected to sign out against medical advice (AMA) in the afternoon of _%#MM#%_ _%#DD#%_, 2005. This was discussed with staff. The patient will sign out AMA.
AMA|against medical advice|AMA.|190|193|HISTORY OF PRESENT ILLNESS|The patient did well and was subsequently discharged on _%#MM#%_ _%#DD#%_, 2005, to rehab. The patient spent approximately 1 to 2 hours in rehab and complained of it being too warm and left AMA. The patient was subsequently at home for a few days prior to presenting on _%#MM#%_ _%#DD#%_, 2005, with above stated sternal infection.
AMA|against medical advice|AMA|124|126|IMPRESSION|He did tell me that he may want to leave in the morning. I said that he is free to do so, but we would ask that he sign out AMA and he amenable to this. He is agreeable to stay overnight for further testing. At this point he is hemodynamically stable and symptom free.
AMA|against medical advice|AMA,|253|256|HOSPITAL COURSE|He continued to be very confrontational regarding this and several other issues, and demanded to be discharged from the hospital. When we explained that we would not discharge him because he was not appropriate to go home, he stated that he would leave AMA, but then changed his mind once he realized that the insurance company would likely not pay for this stay if he were to do so.
AMA|against medical advice|AMA|200|202|HOSPITAL COURSE|She will continue on these for approximately 12 days for a total of a 14 day course. I would doubt anything like ARDS given her excellent oxygen saturations. I thought that she was likely to sign out AMA so I worked with her in trying to create a good plan for discharge. Her problems are as follows: 1. Pneumonia, unclear etiology, aspiration versus community-acquired pneumonia versus septic type picture secondary to recent abortion and products of conception.
AMA|against medical advice|AMA|248|250||The history was obtained through a deaf interpreter. He has had a problem throughout his life with depression and alcohol abuse. He was recently hospitalized at Fairview _%#CITY#%_ psychiatric hospital for alcohol abuse earlier this month but left AMA on _%#MM#%_ _%#DD#%_, 2006. Apparently the patient was in a hotel characterized by the police as a flop house where he shot up some heroin.
AMA|against medical advice|AMA,|163|166|IDENTIFICATION|She is separated. She is the mother of 3 children and currently lives in _%#CITY#%_, Minnesota. She has had 6 prior chemical dependency treatments. She left detox AMA, her last admission on _%#MM#%_ 2006. Her drug of choice is heroin. She has had multiple prior psychiatric exams with a diagnosis of depression.
AMA|advanced maternal age|AMA|173|175|HISTORY OF PRESENT ILLNESS|Confirmatory ultrasound at MSM Clinic showed gross at the less than the second percentile. Dopplers also showed absent end-diastolic flow. Pregnancy had been complicated by AMA and increased risk of Down syndrome based on echogenic focus in the left ventricle and fetal renal pelvis were noted 3-mm in an 18-week ultrasound.
AMA|against medical advice|AMA.|182|185|HISTORY OF PRESENT ILLNESS|Urinalysis showed a possible urinary tract infection. She received a head CT which was unremarkable. Plan was to pursue a lumbar puncture but patient refused this and was discharged AMA. She, I believe, was discharged with Bactrim. She has continued to take Bactrim. She denies, however, any urinary tract infection symptoms such as dysuria, frequency, hematuria.
AMA|against medical advice|AMA|94|96|DISCHARGE MEDICATIONS|DISCHARGE DIAGNOSIS: Gastric ulcer disease. DISCHARGE MEDICATIONS: Due to the patient leaving AMA prior to the completion of discharge paper work nor formal discharge medications were written, however, the patient is presumed to still be on the medications that she was on at the time of admission and these include the following. 1. Omeprazole 40 mg p.o. b.i.d. 2. Oxycodone 5 to 10 mg p.o. q. 6h. p.r.n.
AMA|against medical advice|AMA.|184|187|HISTORY OF PRESENT ILLNESS|He ruled out CHF by negative chest x-ray, however, had atrial fibrillation on the EKG with a rate of 30s-40s patient. It was suggested hospital admission, however, he refused and left AMA. Today patient comes back for the same complaints and on Doppler study on the left leg was found to have an extensive DVT.
AMA|against medical advice|AMA|143|145|HOSPITAL COURSE|2. Anemia. The patient did receive 2 units of PRBCs on the day of admission. His hemoglobin following transfusion was 9.5, the morning he left AMA hemoglobin was stable at 9.7. Iron studies did show a low iron level at 28 and a low iron saturation of 7% and a low ferratin of 18.
AMA|against medical advice|AMA.|218|221|HISTORY OF PRESENT ILLNESS|He has been admitted three times in the past six months with significant alcohol withdrawal. He has been poor with following through with treatment recommendations. He has left Lodging Plus residential treatment twice AMA. He has had a history of alcoholic liver disease and an alcohol withdrawal seizure. He has a history of depression and hypertension. HOSPITAL COURSE: On admission, the patient had a large ecchymoses on each hip and thigh.
AMA|against medical advice|AMA|195|197|HOSPITAL COURSE|It was also noted that he had some hyperglycemia and probable upper-respiratory infection. Approximately one to two hours after being admitted, the patient left AMA. The patient prior to leaving AMA was warned about the risks of leaving without knowing whether or not his symptoms were caused by a possible stroke versus an arrhythmia and getting the proper care and follow-up that was needed for these possible conditions.
AMA|antimitochondrial antibody|AMA|271|273|PROBLEMS|The patient was seen in consultation during this time by gastroenterology and Dr. _%#NAME#%_ felt that the proper plan would be to leave the tube in place unclamped and recheck the bilirubin again down the line, perhaps as an outpatient. She had hepatitis serologies and AMA drawn but these are pending at the time of this dictation. The drainage has been about 300-900 cc per shift. 2. Thrombus. She had a PIC line placed in the right arm on _%#MMDD#%_ and developed right arm pain on _%#MMDD#%_.
AMA|advanced maternal age|AMA.|251|254|HOSPITAL COURSE|HOSPITAL COURSE: Ms. _%#NAME#%_ is a 39-year-old G1, P0 at 33 plus 0 weeks, who presented as a transfer of care from Northland Hospital and Dr. _%#NAME#%_ with preterm premature rupture of membranes. The patient's pregnancy complicated by Rh negative AMA. She also had a history of preterm labor with this pregnancy and received betamethasone on _%#MMDD2007#%_ and _%#MMDD2007#%_.
AMA|against medical advice|AMA.|188|191|PROBLEM #1|His blood glucose was thought to be under good control on the new regimen. The patient was very noncompliant and he wanted to leave the hospital so on the night of _%#MMDD2007#%_, he left AMA. PROBLEM #2: Hypertension. The patient was off all the antihypertensive as he said that he is allergic to multiple medications.
AMA|against medical advice|AMA.|149|152|PROBLEM #2|It may be due to congestion of the liver due to intermittent atrial fibrillation. However, before this could be further worked out, the patient left AMA. The LFTs were found to be increasing more so the enzymes than the alkaline phosphatase. PROBLEM #3: Atrial fibrillation with tachybrady syndrome. The patient's metoprolol dose was halved from 100 mg b.i.d. to 50 mg b.i.d. on the day of admission due to her presenting heart rate in the 30s.
AMA|against medical advice|AMA,|139|142|PROBLEMS|Vascular supply was intact. Neurologic function and sensation were intact. An MRI demonstrated evidence of osteomyelitis. The patient left AMA, after having received 1 day of oral levofloxacin, with the thought of conversion to IV antibiotics if osteomyelitis was confirmed.
AMA|against medical advice|AMA|232|234|PROBLEMS|An MRI demonstrated evidence of osteomyelitis. The patient left AMA, after having received 1 day of oral levofloxacin, with the thought of conversion to IV antibiotics if osteomyelitis was confirmed. Unfortunately, the patient left AMA on day 2 of his hospitalization, without a prescription for antibiotics. Of note, the ESR on _%#MM#%_ _%#DD#%_, 2005, was 18. 3. Psychiatric problem, not otherwise specified. Psychiatry consult was obtained, as there were significant indicators that this patient was psychiatrically disturbed.
AMA|against medical advice|AMA.|212|215|PHYSICAL EXAMINATION|His mood was positive about therapy progress. He was receiving his medications and felt that his pain control was adequate. On the morning of _%#MMDD2006#%_, I was informed that the patient had left the facility AMA. His concern at the time of followup telephone call was that he was not receiving his HIV/AIDS medications in a timely manner and felt that the staff should be aware of the time of administration of his medications without his having to tell us.
AMA|against medical advice|AMA|60|62|HOSPITAL  COURSE|I do not believe the patient is competent enough to sign an AMA and we will have her son sign this before discharge. DISPOSITION: The patient is discharged to her son and the patient should follow up with her primary care physician, Dr. _%#NAME#%_, early next week and with Dr. _%#NAME#%_ from urology later on next week for outpatient cystoscopy.
AMA|against medical advice|AMA.|221|224|HOSPITAL COURSE|The patient was very tearful and anxious throughout the day on _%#MMDD2007#%_. In the morning of _%#MMDD2007#%_ pressures again were 140/90. Throughout the morning, they became elevated and the patient requested to leave AMA. The patient was counseled on the risks of leaving with elevated pressures.
AMA|against medical advice|AMA|176|178|HOSPITAL COURSE|The patient does report that she has a significant supply of Aldomet at home, which she has never been taking this in her pregnancy as she was instructed. The patient did sign AMA papers endorsing that she is taking responsibility for risk for herself and for the child, possible poor outcomes for the mother and child.
AMA|against medical advice|AMA|219|221|ADMISSION MEDICATIONS|The patient was thought to be prerenal from self-induced dehydration from vomiting, as well as having the ACE inhibitor on board. The ACE inhibitor was not continued upon admission. The patient was advised when he left AMA not to take his ACE inhibitor for the next 1 week. The patient was also advised that he did need to follow up with someone knowledgeable in cardiology and renal function for evaluation of his ACE inhibitor.
AMA|against medical advice|AMA.|121|124|ASSESSMENT AND PLAN|She will sign an AMA form. I will give her Vicodin and Coumadin to take with her as a precaution. She has agreed to sign AMA.
AMA|against medical advice|AMA|139|141|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|She was having significant pain, however, and this was treated with IV Dilaudid as she has an allergy to morphine. On the night before her AMA discharge, she was having significant amount of pain and received some Dilaudid. She then began to act somewhat paranoid and bizarre, stating that the room was upside down, the TV was upside down, etc, etc.
AMA|against medical advice|AMA|401|403|HISTORY OF PRESENT ILLNESS, HOSPITAL COURSE, AND SIGNIFICANT FINDINGS|5. Disruptive behavior with threatening manifestations towards care providers. HISTORY OF PRESENT ILLNESS, HOSPITAL COURSE, AND SIGNIFICANT FINDINGS: _%#NAME#%_ _%#NAME#%_ is a 45-year-old man with a long-standing history of chronic back pain issues, with several admissions to Fairview University Medical Center as well as Fairview Southdale Hospital. The patient was admitted on _%#MMDD#%_ and left AMA in the middle of the night because of "inadequate pain control." The patient thereafter returned to the hospital on _%#MMDD#%_ with abnormal CT findings, and was admitted for further evaluation, management and intervention.
AMA|against medical advice|AMA|195|197|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 7-year-old girl with severe malnutrition secondary to feeding problems who was brought to the hospital by Police escort after having left the hospital AMA on _%#MMDD2007#%_. Her mother originally had brought her to the hospital on _%#MMDD2007#%_ due to her concern for her daughter's weight loss.
AMA|against medical advice|AMA|206|208|HISTORY OF PRESENT ILLNESS|At that time, her complaints had been constipation for the week prior to admission and then subsequent diarrhea at the time of admission. Her mother was dissatisfied with care and removed her daughter from AMA on _%#MMDD2007#%_. Due to concerns about the child's wellbeing at home, she was brought back to the hospital for complete workup of her malnutrition to ensure that she could adequately take nutrition and gain weight.
AMA|against medical advice|AMA,|181|184|DISCHARGE PLANNING AND FOLLOWUP|We were able to arrange for a 7-day supply of medications and instructed the patient to follow up with his primary care physician. DISCHARGE PLANNING AND FOLLOWUP: The patient left AMA, his current residence is in _%#CITY#%_ Place Nursing Home.
AMA|against medical advice|AMA.|207|210|SUMMARY OF HOSPITAL COURSE|I did at that point make tramadol available to him as this had been prescribed to him in the past through the pain clinic. Shortly after that, I was contacted by the nurse stating that he was going to leave AMA. I was currently involved with a patient and thus was not able to see Mr. _%#NAME#%_. I then called back as soon as I could and at that point, the patient had already left AMA.
AMA|against medical advice|AMA.|171|174|SUMMARY OF HOSPITAL COURSE|I was currently involved with a patient and thus was not able to see Mr. _%#NAME#%_. I then called back as soon as I could and at that point, the patient had already left AMA.
AMA|against medical advice|AMA.|199|202|HOSPITAL COURSE|HOSPITAL COURSE: During the hospital course, the patient reports that he was not really interested in being clean from alcohol and drugs and he wanted to go back to using. The patient was discharged AMA. He was initially started on suboxone to taper, however, he refused to take it. While he was in the hospital, he was seen by Dr. _%#NAME#%_.
AMA|against medical advice|AMA.|162|165|HOSPITAL COURSE|She also contacted _%#CITY#%_. The patient reported that she wants to leave AMA and wants to go to methadone clinic StS to be put back on methadone. Patient left AMA. DISCHARGE MENTAL STATUS EXAMINATION: The patient is alert, oriented x3, good grooming, good hygiene, good eye contact, clear coherent speech, linear thought process with no loosening of associations.
AMA|against medical advice|AMA|227|229|HOSPITAL COURSE|He was made NPO and was given IV fluids. He was initially treated with IV Dilaudid and then converted to oral Dilaudid. His pain was tolerable. His diet was advanced to regular and he was anxious to leave the hospital. He left AMA and did not have any of his pain medications filled at that the time he left. He should refrain from alcohol to avoid further episodes of acute pancreatitis.
AMA|against medical advice|AMA|165|167|HOSPITAL COURSE|He has had multiple admissions for this. He had gone through treatment programs in the past. He was placed on the alcohol withdrawal protocol and on the day he left AMA was still requiring 11 mg of Ativan. He did not have any withdrawal seizures during this admission. It was recommended that he go through inpatient treatment and he was initially in agreement with this, but left prior to this being established.
AMA|against medical advice|AMA:|87|90|HOSPITAL COURSE|Again he should refrain from alcohol to avoid further damage to his liver. Problem #4. AMA: On _%#MMDD2006#%_, the patient was very anxious to go home and the team told him this may be a possibility; however, when his Ativan use was reviewed it was felt he was not appropriate for discharge.
AMA|against medical advice|AMA.|205|208|HISTORY OF PRESENT ILLNESS|She was going to be discharged with Doxycycline, prednisone and home oxygen, but was unable to get the home oxygen arranged. She was then going to be admitted due to her need for oxygen, but actually left AMA. Apparently she became confused and had perhaps some chest pain or shortness of breath and she came back to the Emergency Room.
AMA|against medical advice|AMA.|170|173|ASSESSMENT AND PLAN|Plan obtain the Fairview emergency room CT scan results which did show a colitis apparently in the emergency room records somewhere there is a notation that patient left AMA. He was treated outpatient with Cipro and Flagyl, apparently he has failed that. His symptoms continues. He seems to be having worsening of symptoms.
AMA|against medical advice|AMA|229|231|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: Heroin dependence. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 40-year-old male with heroin dependence. He was previously admitted to Fairview Recovery Services a few days ago but left after 1 day AMA because he had to take care of some family matters. He used on _%#MM#%_ _%#DD#%_, 2006, and _%#MM#%_ _%#DD#%_, 2006, and was readmitted on _%#MM#%_ _%#DD#%_, 2007.
AMA|against medical advice|AMA,|129|132|HOSPITAL COURSE|2. Chronic pain. The patient was given IV Dilaudid for the first 24 hours, then switched to oral oxycodone. Prior to her leaving AMA, she did report she had adequate control of her chest pain. She was given no medications for this treatment. 3. CF-related diabetes.
AMA|against medical advice|AMA.|264|267|HOSPITAL COURSE|The AMA was discussed with this patient and the possibility of issues that she may continue to do poorly and the risks involved with her leaving AMA. She was also advised that the hospitalization may not be completely paid for by insurance because she was leaving AMA.
AMA|against medical advice|AMA,|434|437|HOSPITAL COURSE|In summary, the patient had a number of presentations, with inconsistency of her behavior during this hospitalization, such as requesting narcotics for pain, and when was told that we were to investigate the etiology of the pain the patient exhibited behaviors such as self-discontinuing her IV and locking herself in the bathroom. This did raise the question of possible secondary gains versus personality disorder. PROBLEM #2: Left AMA, on 72 hour hold. When the patient did not receive her narcotics the patient threatened to leave AMA and states "I have a stash of Percocet and Darvocet at home".
AMA|against medical advice|AMA|149|151|ADMISSION MEDICATIONS|Again, a stress test was offered to the patient, and she refused and had left AMA. 2. Possible psychiatric disorder. Given that the patient has left AMA 3 times, this will be her third within the past 6 months, and in lieu of her risk factors, unsure of her insight and her questionable behavior during her hospital stay and multiple complaints regarding her stalker and physical abuse.
AMA|advanced maternal age|AMA,|214|217|HISTORY OF PRESENT ILLNESS|She presented complaining of rupture of membranes and was found to be grossly ruptured. Her pregnancy was complicated by bicornuate uterus, prior cesarean section x2, prior preterm delivery at 34 weeks' for PPROM, AMA, and Rh negative blood type. PRENATAL CARE: The patient was seen at Fairview _%#CITY#%_ Women's Clinic, starting at 9 weeks with a total of 9 visits.
AMA|against medical advice|AMA.|155|158|HOSPITAL COURSE|HOSPITAL COURSE: During the hospital course, the patient was detoxed using the buprenorphine. He required up to 8 mg. The patient was threatening to leave AMA. He was very impatient to go to Lodging Plus. The patient was discharged over the weekend to Lodging Plus. During hospitalization, he was seen by Dr. _%#NAME#%_, please review the detailed note.
AMA|against medical advice|AMA|224|226|COURSE|The patient had a stable course until the evening of _%#MMDD2007#%_, when the patient elected to leave the hospital against medical advice. Again, she was counseled regarding the risk of her condition and the patient signed AMA papers and left the hospital.
AMA|against medical advice|AMA|188|190|HOSPITAL COURSE|She had good amount of pain control. She requested a Lidoderm patch for her back. On postop day #1, she was started on a clear liquid diet, which she tolerated well. She did plan to leave AMA on postop day #1, however decided to come back to the hospital. On postop day #3 she was stable, did not have any abdominal pain.
AMA|against medical advice|AMA|207|209|HOSPITAL COURSE|The patient presented to Fairview Ridges hospital, where she was admitted for this problem. She was placed on clindamycin but had an allergic reaction; this was on _%#MMDD2006#%_. She then left the hospital AMA on _%#MMDD2006#%_. Her doctor did call in a prescription for ciprofloxacin, however this was not effective. The patient returned to Fairview Southdale Hospital on _%#MMDD2006#%_ with an even worse infection.
AMA|against medical advice|AMA|17|19||The patient left AMA on _%#MMDD2006#%_. DISCHARGE DIAGNOSES: 1. Line infection. 2. End-stage renal disease. 3. Diabetes. 4. Atrial fibrillation.
AMA|against medical advice|AMA.|194|197|HOSPITAL COURSE|The patient was given IV Solu-Medrol. The patient's secondary plan was to titrate it. The patient was also given BiPAP and inhaler treatment. However, this was not completed as the patient left AMA. DISPOSITION: On _%#MMDD2006#%_, approximately p.m., the patient left AMA. The patient was advised that his medical condition could deteriorate.
AMA|against medical advice|AMA.|182|185|DISPOSITION|The patient was also given BiPAP and inhaler treatment. However, this was not completed as the patient left AMA. DISPOSITION: On _%#MMDD2006#%_, approximately p.m., the patient left AMA. The patient was advised that his medical condition could deteriorate. However, the patient did not listen to any medical advice and left against medical advice.
AMA|against medical advice|AMA|179|181|HPI|He had transferred from Regions for consideration of liver transplant. He was recently treated _%#MM#%_ _%#DD#%_ at St. Joe's Hospital for right knee cellulitis. The patient left AMA on _%#MM#%_ _%#DD#%_. He is admitted to Regions on _%#MM#%_ _%#DD#%_, after developing abdominal pain and becoming difficult to arouse.
AMA|against medical advice|AMA,|153|156|HISTORY OF PRESENT ILLNESS|She received a chest CT which showed a dissection of her thoracic aorta. Despite this information, the patient decided against admission. She signed out AMA, knowing full well that she could have serious complications including paralysis, limb loss, kidney failure, and death. When she got home, she called Dr. _%#NAME#%_ _%#NAME#%_ who had done carotid artery surgery for her, wanting to get his opinion and he strongly stressed the serious nature of her problem and was able to convince her to return to the Emergency Room where she accepted admission.
AMA|against medical advice|AMA|150|152|HOSPITAL COURSE|9. Hypothyroidism. CONSULTANTS: Dr. _%#NAME#%_. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 65-year-old woman who was admitted after recently leaving AMA from the hospital. She found that she just could not breathe well. Her previous admission had also been for COPD exacerbation.
AMA|against medical advice|AMA.|36|39||_%#NAME#%_ _%#NAME#%_ actually left AMA. DATE OF ADMISSION: _%#MMDD2007#%_. DATE OF DISCHARGE: _%#MMDD2007#%_. TIME OF DISCHARGE: 5:20 p.m.
AMA|against medical advice|AMA|141|143|HISTORY OF PRESENT ILLNESS|Additionally, it was quite painful and caused some infections. Previously, she did get admitted to the hospital for resection and later left AMA when she was quite nervous. She was rescheduled for this hospitalization and definitive surgery. Much of the history is covered by the fact that the patient has schizoaffective disorder and lives at a Hathaway House.
AMA|advanced maternal age|AMA.|86|89|COMPLICATIONS|Total weight gain 14 pounds. First trimester blood pressure 110/70. COMPLICATIONS: 1. AMA. 2. Asthma. 3. History of preterm labor with previous pregnancy and this pregnancy. 4. Rh negative status. PRENATAL LABS: O negative. Antibody negative.
AMA|against medical advice|AMA|279|281|POSTPARTUM COURSE|She decided she was leaving against medical advice. The patient was counseled regarding the importance of being in or near the hospital with the appropriate neobnatal abilities to take care of her infant, if she wants to deliver early. She understood this risk and chose to sign AMA papers and be discharged to home. She was given preterm labor precautions and asked to maintain bed rest at home. She stated that she will continue to take her nifedipine as prescribed.
AMA|against medical advice|AMA|188|190|AMENDMENTS|I also spent from 4:25pm to 7:30pm coordinating care together with social work, child protection services, the home county's health department, and the pulmonary service. The patient left AMA without signing out. During this time, the county health department was eventually able to confirm that the patient's infected contacts had pan-sensitive mycobacterial isolates.
AMA|against medical advice|AMA.|209|212|CHIEF COMPLAINT/REASON FOR ADMISSION|3. Chronic neck pain. 4. Possible narcotic-seeking behavior. CHIEF COMPLAINT/REASON FOR ADMISSION: The patient was readmitted to the hospital through the emergency room after she left our service the same day AMA. Please refer to my previous dictation from _%#MMDD2001#%_ for history of present illness, past medical history, social history, and family history.
AMA|against medical advice|AMA|218|220|CHIEF COMPLAINT/REASON FOR ADMISSION|Please refer to my previous dictation from _%#MMDD2001#%_ for history of present illness, past medical history, social history, and family history. Briefly, the patient returned to the hospital, because after she left AMA she tried to eat some chicken at home and again vomited. At this time, she again had some confrontation with the Emergency Department staff and was verbally abusive to them.
AMA|against medical advice|AMA|151|153|OPERATIONS/PROCEDURES PERFORMED|The patient was in the ICU until _%#MM#%_ _%#DD#%_, 2003, when the patient left AMA. However, she returned to the _%#CITY#%_ ED shortly after she left AMA complaining about abdominal pain and a cough, positive nausea and vomiting. Positive fevers, chills, and shortness of breath.
AMA|against medical advice|AMA.|145|148|HOSPITAL COURSE|2. Diabetes Type 2. 3. Hypertension. 4. Opioid dependence with opioid withdrawal syndrome. The patient was seen by psychiatrist prior to signing AMA. The patient does have a psychiatrist outside that she follows. The psychiatrist felt that the patient was stable enough to be signed out AMA and that in the future if she does come back that a 72-hour hold and commitment with immediate Psych evaluation would be warranted.
AMA|against medical advice|AMA,|331|334|HOSPITAL COURSE|On the second day of admission, the patient received another 50 mg of Solu-Medrol and received a total of three doses of IV Solu-Medrol. During the course of his hospitalization, the patient eventually became very depressed regarding his situation of non-improving myasthenia gravis and expressed several times his intent to leave AMA, and then upon returning home, to attempt suicide with firearms, which he has at home. At that time, Psychiatry was consulted, and they felt that his psychiatric status was secondary mostly to frustration regarding the myasthenia gravis.
AMA|against medical advice|AMA.|206|209|HOSPITAL COURSE|As part of his work up the carotids were evaluated with significant stenosis on the right and left side. Neurosurgery was going to intervene and perform an endarterectomy as well. However, the patient left AMA. DISPOSITION: We contacted the Bell Hill Recovery Center where the patient was being treated, and they reported that he had contacted them and was just overwhelmed.
AMA|against medical advice|AMA,|193|196|HISTORY OF PRESENT ILLNESS|We explained that we would still take care of her, even though she left against medical advice. Social worker was called who will check to see if CPS is involved and report the patient leaving AMA, despite the fact that she was on magnesium for her preterm labor. This patient does not live with either of her other two children, although per her report, she does have full custody of both of them.
AMA|against medical advice|AMA.|396|399|DISCHARGE MEDICATIONS|The patient's labs on _%#MMDD2002#%_ showed sodium 144, potassium 4.4, chloride 112, bicarb 24, BUN 11, creatinine 0.8, glucose 87, calcium 8.7, magnesium 2.2, phosphate 3.6. The patient's hemoglobin was stable at 6.0 (the patient's baseline hemoglobin is 6.7), WBC count of 18.4, and platelets of 296. DISCHARGE MEDICATIONS: The patient did not get any discharge medications because he has left AMA. The patient signed the AMA form and will follow up with his primary care physician.
AMA|against medical advice|AMA,|138|141|HISTORY OF PRESENT ILLNESS|The patient was admitted and subsequently was not prescribed pain medications that he felt were adequate, and he was threatening to leave AMA, although now he has decided to stay until discussion with me. At this time, he is requesting to go home regardless of how he feels, although clinically he appears to be improved.
AMA|against medical advice|AMA|183|185|HISTORY OF PRESENT ILLNESS|He now enters for that purpose. The patient has had multiple chemical dependency treatments in the past. He has had a history of anxiety and depression. He has left treatment centers AMA in the past. PAST MEDICAL HISTORY: 1. History of seizures. He is not currently on an anticonvulsant.
AMA|against medical advice|AMA|206|208|DISPOSITION|He was advised to follow up as soon as possible with his primary care doctor for further work-up of his heart condition and urinary tract infection, with possible STD testing. DISPOSITION: The patient left AMA in guarded condition to home with instructions to follow up with his primary physician as soon as possible.
AMA|against medical advice|(AMA)|174|178|DISPOSITION|We attempted to arrange chemical dependency assessment but they could not complete their assessment in a timely fashion. DISPOSITION: The patient left against medical advice (AMA) and it was not felt we could place him on a hold and therefore he was allowed to leave. He declined follow-up.
AMA|against medical advice|AMA|249|251|HOSPITAL COURSE|The reason why the patient could not make these phone calls from his hospital room, were that they were "private," and he did not want to do them in the hospital. In spite of multiple conversations, the patient was insistent upon leaving and signed AMA papers. PROBLEM #1: Esophageal cancer with possible lung metastases. The patient declined further follow up in the University Hematology/Oncology Clinic and will establish a relationship with an oncologist in another care system.
AMA|against medical advice|AMA|191|193|HOSPITAL COURSE|Her lipase was 268 yesterday, 360 today. I have recommended one more day in the hospital but the patient is quite insistent on leaving. I feel she is certainly competent to do so and that an AMA discharge is not called for. Furthermore, the patient was offered chemical dependency evaluation and treatment. She declined this and again I feel that she is competent and within her rights to do so.
AMA|against medical advice|AMA.|235|238|MEDICATIONS AT ADMISSION|MEDICATIONS AT ADMISSION: Include Fosamax 70 mg weekly, Lisinopril 20 mg daily, Amaryl 1 mg daily, atenolol 50 mg daily, and magoxide 400 mg daily. She was also supposed to be on Pravachol but did not get this prescription as she left AMA. ALLERGIES: Include penicillin which causes hives, aspirin which causes stomach upset as do NSAIDS.
AMA|against medical advice|AMA.|179|182|OPERATIONS/PROCEDURES PERFORMED|He on the 4th day of admission insisted on attending a hip hop concert at the Target Center despite being warned that it could seriously jeopardize his health. The patient signed AMA. At that juncture, he had not had any improvement in his pulmonary function tests. He returned later that night and was admitted through the emergency department.
AMA|against medical advice|AMA|121|123|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Multiple visits to the emergency department for kidney stones in 2001, chest pain in 2002. He left AMA at that time. Chest pain in 2003. Admitted to the hospital, had a stress echo which was suboptimal. Recommended that he get a nuclear medicine test which he never followed up for.
AMA|antimitochondrial antibody|AMA,|157|160|DIAGNOSIS|Hepatitis C was negative. HIV was negative. CMV IgM and IgG were negative. EBV was negative. Serial creatinine was negative. His ferritin was negative. ANA, AMA, SMA were negative. Gallbladder ultrasound showed no obstruction. CT of the abdomen showed minimal spleen enlargement. No hepatomegaly.
AMA|advanced maternal age|AMA,|155|158|HOSPITAL  COURSE|HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 41-year-old female, Gravida 1, Para 0, who presented for induction at 40-1/7 weeks EGA secondary to postdates, AMA, and gestational diabetes - diet controlled. The patient was given approximately two doses of Cytotec over the evening of _%#MM#%_ _%#DD#%_, 2004.
AMA|against medical advice|AMA.|310|313|HOSPITAL COURSE|Allergy was consulted and they did come to see the patient, they did recommended a serum C3, C4, CH50, C1Q, C1 esterase inhibitor functionality, and they also requested checking an alpha and beta tryptase, as well as a 24-hour urine PGD2 histamine. However, during his examination the patient decided to leave AMA. He did not let the allergist continue the consultation, and the staff physician was unable to see the patient. They did say that they would be happy to see him in clinic if he returned, but they were unable to comment on other allergies.
AMA|against medical advice|AMA.|158|161|DISPOSITION|If that has been set-up through Oncology then the patient should go to that, and although I am not sure if it was. DISPOSITION: The patient left the hospital AMA. He was supposed to follow up with Oncology as normal on the _%#DD#%_, with a CT on the _%#DD#%_. Again, I am unsure if that has been scheduled. We did not find the cause of his allergic reaction because the patient would not let us continue to evaluate him.
AMA|against medical advice|AMA.|289|292|PLAN|She is currently stable at this time. Also, we will obtain a carotid Doppler in the morning to assess the extent of the carotid bruit and a stress echocardiogram will be obtained in the morning as well. The patient is concerned about the hospital bill at this time and she wanted to leave AMA. I explained to her as well as the nurses if she leaves the hospital it will be against medical advice. The patient is aware of that at this time. She will decide later on if she needs to stay or not.
AMA|against medical advice|AMA|132|134|HOSPITAL COURSE|4. Tobacco use/abuse. The patient has significant smoking history as well. The patient on a number of occasions threatened to leave AMA if he was not allowed to smoke. The patient was escorted occasionally to go and smoke. The patient was counseled on trying to quit the tobacco, as well as the alcohol and that likely success of him quitting both are better now than sequentially.
AMA|against medical advice|AMA|365|367|ADDENDUM|It was felt that this was likely due to this Depakote, and the Depakote was stopped, and he was started on Keppra 500 mg p.o. q.12h. The patient was also started on 3% sodium chloride; however, before the serum sodium stabilized, the patient demanded to go home, and wanted to go home against medical advice. The patient was directed regarding the risks of leaving AMA including but not limited to seizures, decreased mental status, mental status changes. The patient understands these risks and still wishes to go home against medical advice.
AMA|against medical advice|AMA.|158|161|PAST PSYCHIATRIC HISTORY|He had one past psychiatric hospitalization. Records not available at this time. That was _%#MM#%_ 2004 at Fairview-Southdale Hospital and he apparently left AMA. Precipitant to that was that his brother had been murdered and his son was in jail and his mother had breast cancer.
AMA|advanced maternal age|AMA.|183|186|OPERATIONS/PROCEDURES PERFORMED|Prenatal care was with Fairview _%#CITY#%_ Women's Clinic for a total of more than 15 visits beginning at 8 weeks' estimated gestational age. Issues during this pregnancy include, 1. AMA. The patient had genetic counseling and declined amniocentesis. 2. History of asthma, used albuterol inhaler during this pregnancy. 3. Suspected fetal macrosomia. Recent ultrasound on _%#MM#%_ _%#DD#%_, 2005, suspected an estimated fetal weight of 4134 g, and the patient has gestational diabetes.
AMA|against medical advice|AMA|135|137|HOSPITAL COURSE|He did strongly recommend that she stay, but if she did leave, recommend that she use oral antibiotics. The patient signed herself out AMA then on _%#MMDD2005#%_. She was given prescriptions for Avelox 400 mg daily for seven days and Flagyl 500 mg three times a day for seven days and also was given some Vicodin to use one to two every six hours as needed.
AMA|against medical advice|AMA|242|244|PAST MEDICAL HISTORY|Bacteria was found to be methicillin Staph aureus from tissue of her first rib, as well as cultures of the abscess. In _%#MM2005#%_ she was initially treated with vancomycin during her hospitalization in early _%#MM2005#%_; however, she left AMA on _%#MMDD2005#%_. 3. Cesarean section x2. 4. Status post appendectomy in 1989. 5. History of crack use. HOSPITAL COURSE: PROBLEM #1. First rib osteomyelitis on the left side and sternocostal abscess with methicillin sensitive Staph aureus.
AMA|against medical advice|AMA.|168|171|HOSPITAL COURSE|In the hospital, she was asking for her pain medication, benzodiazepine, and threatened to leave if jpain medications are not provided. At the end, she wanted to leave AMA. She left AMA on _%#MM#%_ _%#DD#%_, 2005, without signing the AMA sheet. She was not given any prescriptions, and she was explained in detail about the risks of the decision she is making.
AMA|against medical advice|AMA|234|236|HOSPITAL COURSE|In the hospital, she was asking for her pain medication, benzodiazepine, and threatened to leave if jpain medications are not provided. At the end, she wanted to leave AMA. She left AMA on _%#MM#%_ _%#DD#%_, 2005, without signing the AMA sheet. She was not given any prescriptions, and she was explained in detail about the risks of the decision she is making.
AMA|against medical advice|AMA|193|195|DISCHARGE MEDICATIONS|7. Combivent inhaler two puffs b.i.d. p.r.n. 8. Albuterol 2.5 mg nebulization q.i.d. p.r.n. 9. Multivitamin tablet one tab p.o. daily. The patient was discharged against medical advice, and an AMA form was signed. The patient will be returning to his hometown of _%#CITY#%_, Wisconsin where he will undergo dialysis, most likely on Friday.
AMA|against medical advice|AMA.|205|208|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient was recently discharged from a 57 day stay at Fairview Southdale for renal failure, sepsis. She was discharged to _%#CITY#%_ Methodist Rehab and last night she left AMA. She had dialysis last evening and just had the driver bring her home instead of back to _%#CITY#%_ Methodist. She says she did have all her home meds at home except for her insulin.
AMA|against medical advice|AMA|190|192|HISTORY OF PRESENT ILLNESS|She had a glucose of 285 at that point in time, and evaluation was completed. The transfer was arranged to St. Vincent in _%#CITY#%_ _%#CITY#%_, Wisconsin which the patient refused and left AMA to come back home with her daughter. In route she apparently had no problems. She had persistent right side arm and leg weakness with some facial drooping on the left and slurring of speech, apparently none of which changed.
AMA|against medical advice|AMA|239|241|HISTORY OF PRESENT ILLNESS|He states that he was staying at the Ebenezer Nursing Home due to his status post L4-L5 spinal fusion and subsequent wound infection treated with IV vancomycin. He began to become paranoid during his nursing home stay and decided to leave AMA and arrived in the FUMC _%#CITY#%_ emergency room on the day after leaving Ebenezer Nursing Home and was subsequently admitted to station 12 due to psychotic features and delirium.
AMA|against medical advice|AMA|238|240|HISTORY OF PRESENT ILLNESS|He was admitted on Monday evening. A CT scan at that time was consistent with another 4 mm stone and hydronephrosis in the right kidney. At that time he had a cystoscopy and a double-J ureteral stent was placed on the right side. He left AMA from Fairview Ridges as his pain was not adequately controlled on _%#MMDD2005#%_. He now has a burning with urination and blood in his urine.
AMA|against medical advice|AMA|177|179|HISTORY OF PRESENT ILLNESS|The patient was readmitted at this time after a clinic visit at which time her cervix exam showed that she continued to have further cervical change. The patient had signed out AMA earlier in the week from her hospitalization for the same. The patient had been followed for cervical shortening and funneling, was maintained on Indocin therapy, which was discontinued on _%#MM#%_ _%#DD#%_, 2005, secondary to ductal constriction.
AMA|against medical advice|AMA|200|202|HISTORY OF PRESENT ILLNESS|The patient developed fatigue, sore throat and malaise this weekend. He has two children with viral URIs. Sunday he was admitted to _%#COUNTY#%_ _%#COUNTY#%_ Medical Center with DKA. The patient left AMA on Monday evening. Today he noted persistent elevation in blood sugars and while walking down stairs became light headed and fell down 8 stairs.
AMA|against medical advice|AMA,|177|180|DISCHARGE MEDICATIONS|He was markedly tremulous and did have some asterixis. Sensory exam, cerebellar exam and station and gait were all normal. DISCHARGE MEDICATIONS: None. Since the patient's last AMA, he was recommended to continue to take multivitamin and thiamine. SPECIFIC DISCHARGE INSTRUCTIONS: Full code status. The patient is full code.
AMA|against medical advice|AMA.|121|124|FOLLOWUP DISCHARGE INSTRUCTIONS|Oxygen requirement is none. Seizure precautions. Wound care none. FOLLOWUP DISCHARGE INSTRUCTIONS: The patient did leave AMA. He did sign out.
AMA|against medical advice|AMA|190|192|HISTORY OF PRESENT ILLNESS|The patient states that the abdominal pain had begun earlier that evening, and he is also complaining of knee and back pain. The patient had recently left Fairview University Medical Center AMA previously after he was told he needed an ERCP for his right upper quadrant pain. Of note, the patient had a cholecystectomy in _%#MM#%_ 2004, and the patient was noted to have a fever of 101 at home.
AMA|against medical advice|AMA|292|294|HOSPITAL COURSE|Hemodynamically, the patient was stable throughout this hospitalization. She will follow up with her primary care physician for any further workup or evaluation. It was very difficult to try and examine this patient or perform any further questioning, as the patient was threatening to leave AMA and pull out all of her IV lines and, therefore he could not further evaluate the patient on date of discharge.
AMA|against medical advice|AMA|196|198|PHYSICAL EXAMINATION|She was given IV hydration and was started on Reglan 10 mg orally q.i.d. and a clear liquid diet. She is feeling significantly better this morning and is anxious to leave and said she would leave AMA if we did not discharge her. At this point she is comfortable and medically stable for discharge on Reglan 10 mg q.i.d., as well as Protonix 40 mg daily.
AMA|against medical advice|AMA.|288|291|ADDENDUM|ADDENDUM: The patient denied any hallucinations or delusions, seemed a bit anxious and slightly unreasonable as far as her course of judgment and elicited some mild lack of insight into the importance of her rectal bleeding on admission. She exhibited the same at the time of her leaving AMA. However, she did not seem to be acutely psychotic, was not of acute mind to harm herself at the time of discharge, so, therefore, I did not think, again, that she was medically or psychologically holdable at this time.
AMA|against medical advice|(AMA)|362|366|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 24-year- old lady with history of depression and anorexia nervosa for the past 1 year, who was admitted on _%#MMDD2005#%_ from the Star Clinic where she usually follows up for her eating disorder. She was recently admitted to Methodist Hospital for episodes of blacking out. She left against medical advice (AMA) after she was given a meal to eat. The patient now presents with a 4-day history of no oral intake. According to the Star Clinic notes, it looks like the patient had anorexia and purging behavior for the past 1 year, which was apparently brought on by breakup with her boyfriend.
AMA|against medical advice|AMA.|229|232|HOSPITAL COURSE|They did note that the patient is significantly constipated and recommended to continue regimen as currently being conducted. The patient subsequently requested discharge from the hospital and actually requested to be discharged AMA. The patient is otherwise without significant medical complaints. DISPOSITION: The patient discharged to home on current bowel regimen.
AMA|against medical advice|AMA|183|185|HISTORY OF PRESENT ILLNESS|The patient's lab work was sent which was essentially normal other than a blood sugar of 400, and his chronic anemia. The patient kept on complaining of abdominal pain and signed out AMA because he was not being given any narcotics. On leaving the emergency room about 45 minutes later the patient reportedly collapsed and his wife called 911.
AMA|advanced maternal age|AMA|104|106|PRENATAL CARE|ALLERGIES: Sulfa. MEDICATIONS: Prevacid 30 mg p.o. daily. PRENATAL CARE: Forty-pound weight gain, GERD, AMA with declined amnio, placenta previa. No bleeding during pregnancy. The patient had prenatal care at Fairview _%#CITY#%_ Women's Clinic with Dr. _%#NAME#%_, beginning at 10 weeks for 7 visits.
AMA|against medical advice|AMA|349|351|HISTORY OF PRESENT ILLNESS|It is unapparent what her FEV-1 is as I am unable to find pulmonary function tests and the patient states that they were checked 10 years ago but were scheduled to begin recently in Dr. _%#NAME#%_'s office and then she developed an episode of tachycardia to the 180's and was sent to the emergency room for evaluation at that time. She did sign out AMA at that time. She has just recently begun seeing Dr. _%#NAME#%_ for her asthma and they were trying to work on some different control issues.
AMA|antimitochondrial antibody|AMA|328|330|HOSPITAL COURSE|The results back at the time of discharge are significant for CMV IgG being positive, IgM being negative with CMV antigenemia also being negative, hepatitis B and C negative, mononucleosis screen being negative, Parvovirus IgG being positive, however, IgM being negative, EBV IgG positive, however, IgM negative. Complement and AMA levels were found to be normal. C- reactive peptides was found to be positive however. A CT of the abdomen was significant for a 6.6-mm round mass noted in the right kidney.
AMA|against medical advice|AMA|175|177|HOSPITAL COURSE|In addition, we had recommended she again go to TCU for physical therapy to help with this back pain. However, the patient opted on the day of discharge to leave the hospital AMA without any medications. It was not clear what her motives were, but she appeared anxious to leave the hospital and did not want physical therapy or any medications and chose to leave AMA.
AMA|against medical advice|AMA|121|123|PROBLEM #2|It was recommended that she take oral Protonix twice a day for the next six weeks. However, again, she left the hospital AMA without any of her medications. MEDICATIONS ON DISCHARGE: 1. Amitriptyline 100 mg p.o. q.h.s.
AMA|against medical advice|AMA.|257|260|HISTORY|He had a positive stress echo at that time and was transferred to Fairview Southdale, where he underwent angiography that demonstrated right coronary artery disease which was stented and no other significant lesions. He was discharged to TCU, which he left AMA. He was readmitted on _%#MM#%_ _%#DD#%_, again on _%#MM#%_ _%#DD#%_, just discharged _%#MM#%_ _%#DD#%_. He has not followed up in clinic after any of these hospital stays, either no-showing appointments or not making appointments despite discharge requests.
AMA|against medical advice|(AMA)|129|133|HISTORY OF PRESENT ILLNESS|She was admitted recently with similar symptoms, and was found to have an elevated lipase. She signed out against medical advice (AMA) 3 days ago, but yesterday her lipase remained elevated and she was therefore readmitted for further evaluation. PAST MEDICAL HISTORY: Ulcerative colitis. PAST SURGICAL HISTORY: 1. Total proctocolectomy.
AMA|against medical advice|AMA|181|183|HISTORY OF PRESENT ILLNESS|He has had some chills but no fevers. He was hospitalized here _%#MM#%_ _%#DD#%_ and _%#DD#%_ with bright red blood per rectum. He was transfused and treated with steroids. He left AMA without completing his treatment and without undergoing subsequent colonoscopy. PAST MEDICAL HISTORY: 1. Ulcerative colitis. 2. Anemia secondary to GI bleeding with transfusion on _%#MMDD2005#%_.
AMA|against medical advice|(AMA)|460|464|HOSPITAL COURSE|He has maintained a normal sinus rhythm. I have advised the patient and his wife that he should stay one more day for observation but they decline stating that given his long history of alcoholism and his current determination to reform he would be best served by being at home. We did discuss this at length and ultimately I have decided that the patient is of sound mind and I did not feel it would be appropriate to make him sign out against medical advice (AMA) given his stability. DISCHARGE MEDICATIONS: 1. BuSpar 30 mg p.o. b.i.d. 2. Trazodone 100 mg p.o. q.h.s.
AMA|against medical advice|AMA|229|231|DISCHARGE DIAGNOSIS|In fact, during that hospitalization, an EGD was performed which revealed a widely patent vertical banded gastroplasty with normal esophagus and normal examined stomach and duodenum. During that hospitalization, the patient left AMA and subsequently has returned with similar symptoms. PAST MEDICAL HISTORY: 1. Hypertension. 2. Reported history of deep venous thrombosis since _%#MM#%_ 2004 diagnosed in North Memorial Medical Center.
AMA|against medical advice|AMA.|168|171|HOSPITAL COURSE|It was recommended to him, when he is medically stable that he go to detox. However, there are questions of his insurance covering this. He in the end decided to leave AMA. 2. Anxiety and depression. The patient was restarted on his p.o. medications prior to discharge. 3. Mild hypernatremia, resolved by the end of his stay.
AMA|against medical advice|AMA.|184|187|SERVICE|On the evening of _%#MM#%_ _%#DD#%_, 2006, the on-call doctor was called as the patient had gone outside to smoke and never returned. The patient was therefore considered to have left AMA. He did not sign any of the discharge paperwork stating this. No changes in medications therefore were prescribed. Medications for complete list, see admission note.
AMA|against medical advice|AMA.|159|162|HISTORY OF PRESENT ILLNESS|TTE, transthoracic echocardiogram was negative for vegetation and previous team over TEE, transesophageal echocardiogram. However, the patient's left hospital AMA. and we lost connection with the patient. Apparently, she was hospitalized and managed in institutions including _%#COUNTY#%_ _%#COUNTY#%_ Medical Center and Community University Health Care Center.
AMA|against medical advice|AMA|104|106|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 19-year-old female well known to our service after leaving AMA just a few days ago. At which time she had been hospitalized for hyperglycemia and pulmonary exacerbation. She re-presented on _%#MMDD2006#%_ with similar symptoms. She said that she had initially responded to her IV therapy.
AMA|against medical advice|AMA.|159|162|HOSPITAL COURSE|Per discussion with the surgical services and myself the decision was made that she was not stable for discharge, however, the patient subsequently signed out AMA. As far as her laboratory results and hospital course, the patient presented to the Emergency Department on _%#MMDD#%_ and had a normal CBC, normal electrolytes, normal liver function tests, an amylase of 67, lipase 78 and negative blood pregnancy test, myoglobin 26, troponin less than 0.07. The patient had a negative abdominal ultrasound.
AMA|against medical advice|AMA.|229|232|DISCHARGE DIAGNOSIS|HOSPITAL COURSE: Patient was admitted. Urology consult was called, and they recommended a cystoscopy to evaluate the obstruction. The patient, through a translator, was unsure if she wanted this at this time and decided to leave AMA. She did have a urine that was dirty and started on Levaquin, and that was continued at the time she left. Patient was advised to come back if symptoms recurred. Her pain had left significantly prior to discharge, and it was believed that is why she felt she did not need any more tests.
AMA|against medical advice|AMA.|183|186|PREVIOUS MEDICAL HISTORY|PREVIOUS MEDICAL HISTORY: 1. Patient with sickle cell disease. 2. Recent history of admits in _%#MM#%_ with low-grade temperatures, IM Dilaudid therapy, OxyContin therapy and leaving AMA. Multiple other previous histories with much of the same. Multiple clinic visits that were no-shows. 3. History of right proximal vein DBT to the right upper extremity in _%#MM2006#%_.
AMA|against medical advice|AMA.|231|234|IMPRESSION|I will check serial troponins and follow him on telemetry, given his cardiac history, but I would like to turn our focus towards possible cholelithiasis. Unfortunately, his workup was not completed last hospitalization and he left AMA. At this point, I would like to recheck the abdominal ultrasound and ask for surgical consultation in the morning. We will treat his symptoms with Dilaudid. The patient has an elevated digoxin level, possibly related to excessive digoxin use.
AMA|against medical advice|AMA|130|132|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Dyspnea. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 47-year-old gentleman who is well known to leave AMA at different facilities presents here with progressive increasing dyspnea. He has history remarkable for obstructive sleep apnea, COPD, atypical chest pain despite known cardiac risk factors.
AMA|against medical advice|AMA|150|152|HOSPITAL COURSE|He required 5-point restraints, received Haldol and that was at about 1:30 in the morning. He continued to be angry and decided to leave the hospital AMA at 3 in the morning. The physician did see the patient and had discussed with him earlier that day why it was important for him to stay and continue his treatment, and the patient chose to sign out against medical advice.
AMA|advanced maternal age|AMA,|155|158|COMPLICATIONS|She denied any loss of fluid, vaginal bleeding, headache, visual changes, or right upper quadrant pain. The patient's pregnancy was complicated by GDM A2, AMA, obesity, GERD, first trimester bleeding, yeast infection, and pyelo on _%#MM#%_ _%#DD#%_, 2006. At the time of admission, the patient's cervix was found to be 5 cm dilated, 80% effaced, and at a high station.
AMA|against medical advice|AMA.|139|142|HOSPITAL COURSE|The patient left on the evening of _%#MMDD2006#%_. He was seen by the covering hospitalist for our service that evening and chose to leave AMA. The covering hospitalist did provide the patient a prescription for prednisone on discharge.
AMA|against medical advice|AMA.|265|268|HISTORY  OF PRESENT ILLNESS|He was seen recently at Fairview Ridges Emergency Room with these complaints. They recommended that he be admitted for evaluation, but it was a Friday afternoon and he was not going to be able to have his stress test done until several days and he elected to leave AMA. Mr. _%#NAME#%_ describes a substernal dull hollow aching chest discomfort which comes on with exertion and is relieved with rest.
AMA|against medical advice|AMA.|206|209|HOSPITAL COURSE|It was recommended to the patient that he remain as an inpatient and to undergo stress testing. Approximately an hour after this discussion, the 6-C in charge nurse notified me that the patient was leaving AMA. Upon my arrival 10 minutes later, the patient had already left and was not available to sign an AMA form. Attempts to contact the patient were unsuccessful. Of note, he did leave with peripheral IV in place.
AMA|against medical advice|AMA|211|213|HOSPITAL COURSE|Approximately an hour after this discussion, the 6-C in charge nurse notified me that the patient was leaving AMA. Upon my arrival 10 minutes later, the patient had already left and was not available to sign an AMA form. Attempts to contact the patient were unsuccessful. Of note, he did leave with peripheral IV in place. 2. Tobacco use disorder. Shortly after admission, the patient was counseled on his one-and-half per day smoking habit.
AMA|advanced maternal age|AMA.|142|145|PREGNANCY ISSUES|Hemoglobin 12.12, first trimester blood pressure is 112/81, GCT at 115, GBS positive, Pap NILM, urine cultures negative. PREGNANCY ISSUES: 1. AMA. 2. Obesity. 3. History of LVA. 4. Grand multipara. OBSTETRIC HISTORY: Ten spontaneous vaginal deliveries all at term between the years of 1988 and 2005, largest infant was 9 pounds 6 ounces.
AMA|against medical advice|AMA|285|287|HISTORY  OF PRESENT ILLNESS|CHIEF COMPLAINT: Nausea, vomiting, diarrhea, dehydration and urticaria. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 40-year-old male who is known to me from an admission earlier this week. At that time he was admitted for symptoms quite similar to this and ended up leaving AMA the night of admission. He states that he continued having the symptoms. He was evaluated at the Fairview Southdale Emergency Department two days ago and diagnosed with a probable ongoing allergic reaction.
AMA|against medical advice|AMA.|132|135|LABORATORY DATA|On the evening of discharge, she announced that she was going home. She had no reasons, she just was leaving. She was allowed to go AMA. She has prednisone at home, albuterol at home-she has no other medicines. Whether or not she plans to make any follow-up appointments is not clear.
AMA|against medical advice|AMA|210|212|PROBLEM #1|It was noted at the last admission, _%#MMDD2007#%_ that her urine tox was positive for cocaine. The goal of treatment was to optimize the patient on medications. However, the patient made the decision to leave AMA before this could fully be established. She was informed of the risks of leaving AMA and her need for the medications and our concerns including death, however, the patient made the decision still to leave AMA.
AMA|advanced maternal age|AMA.|124|127||The patient was admitted via the ER. The ER did not perform any evaluation. The patient's pregnancy has been complicated by AMA. She declined first trimester screening, amnio or other genetic counseling. She has a history of precipitous labor, postpartum hemorrhage last delivery and history of fetal macrosomia with her last baby weighing 9 pounds 14 ounces.
AMA|against medical advice|AMA|179|181|DISCHARGE FOLLOWUP|She should continue her home medications as previously scheduled and was advised to take MiraLax when she has issues of constipation. DISCHARGE FOLLOWUP: Because the patient left AMA we were unable to set her up any followup appointments. She should followup with her primary care physician as previously scheduled and should also followup with her physician in her Pain Clinic as previously scheduled.
AMA|advanced maternal age|AMA.|150|153||_%#NAME#%_ _%#NAME#%_ is a 37-year-old G3 P2, EDC _%#MMDD#%_, admitted for elective induction today per her request. Pregnancy was complicated by: 1. AMA. 2. Fractured nose requiring surgery at 18 weeks gestation 3. Positive GBS for which she received IV penicillin in labor. 4. History of postpartum depression x 2 with a plan to consider putting her on Celebrex postpartum.
AMA|against medical advice|AMA|141|143|PROBLEM #3|Per psychiatric recommendations as the patient agreed we did a CT evaluation for him. CT evaluation is pending right now. NOTE: Patient left AMA before this assessment was done. PROBLEM #4: Endocrinology: Diabetes type 2: Controlled. His last hemoglobin A1c was done on _%#MMDD2007#%_, which showed 6.3. The patient is on Lantus 10 units subcutaneously twice daily.
AMA|against medical advice|AMA.|174|177|MISCELLANEOUS|MISCELLANEOUS: The patient was doing well while in the hospital and was comfortable with the care that he had this time but unfortuately, become agitated that night and left AMA. Social Worker spoke with his case worker at _%#COUNTY#%_ _%#COUNTY#%_ regarding his frequent admissions and the fact that he is leaving AMA.
AMA|against medical advice|AMA,|204|207|HISTORY|In any event, _%#NAME#%_ presented to Fairview Southdale ER last night with complaints of worsening pain. Of note, he was recently admitted at Fairview University Hospital and left against medical advice AMA, "because he felt he was not getting the care that he deserved". In my reviewing the records, I can see multiple blood draws were obtained and he was recently transfused, not by exchange method with PRBCs for a hemoglobin below 8.
AMA|against medical advice|AMA.|173|176|HISTORY|Central stenosis and thrombosis was suggested and a catheter CT or MR venography was recommended. Obviously, those procedures had not been performed as he left the hospital AMA. Despite my recommendations that David be potentially discharged with more pain medications, ongoing Lovenox and his regular Hydrea and folic acid doses, he was unwilling to leave the emergency room and I somewhat grudgingly admitted him to the hospital.
AMA|against medical advice|AMA|167|169|HOSPITAL COURSE|The patient was seen by the smoking cessation people; however, his behavior became quite unacceptable while he was here in the hospital, and he threatened to sign out AMA by 10:00 a.m. on the day after his angiogram. He told the nurse that he was not planning on taking his usual medications or the newly prescribed one.
AMA|against medical advice|AMA|149|151|DISCHARGE MEDICATIONS|The patient should followup in her Pain Clinic as previously scheduled for further pain medications. DISCHARGE MEDICATIONS: Because the patient left AMA she was not discharged on any medications. She should continue her home medications as previously scheduled and was advised to take MiraLax when she has issues of constipation.
AMA|against medical advice|AMA|179|181|DISCHARGE FOLLOWUP|She should continue her home medications as previously scheduled and was advised to take MiraLax when she has issues of constipation. DISCHARGE FOLLOWUP: Because the patient left AMA we were unable to set her up any followup appointments. She should followup with her primary care physician as previously scheduled and should also followup with her physician in her Pain Clinic as previously scheduled.
AMA|against medical advice|AMA|145|147|DISCHARGE MEDICATIONS|3. Nasacort 2 sprays each nostril daily. 4. Singulair 10 mg p.o. q. day at bedtime. This patient is at very high risk for readmission as he left AMA without prescriptions. If you have any questions, please feel free to contact me at _%#TEL#%_.
AMA|against medical advice|AMA|88|90||The patient was a 32-year-old male admitted to Fairview Recovery Services after leaving AMA a few days previously. He had a history of alcohol dependence. He had a history of withdrawal and a history of withdrawal seizures.
AMA|against medical advice|AMA,|124|127|PAST MEDICAL HISTORY|She has been admitted three times in the last year for chest pain. The patient always left without any significant work up, AMA, and she has been refusing coronary catheterization. She also has a history of hyperlipidemia. CURRENT MEDICATIONS: She was on Plavix, Lipitor, ibuprofen, Flexeril, and Trazodone.
AMA|against medical advice|AMA,|139|142|PROBLEM #3|The right upper quadrant ultrasound did show hydronephrosis and a renal cyst and did recommend an IVP or renal CT. Before the patient left AMA, we discussed that she needed renal follow-up and notified her primary MD. PROBLEM #4: Diabetes. The patient was maintained on a sliding scale of insulin while she was in-house and then changed over to her regular dose upon discharge.
AMA|against medical advice|AMA|189|191|HISTORY OF PRESENT ILLNESS|She states that she was short of breath, but denied syncope radiation, lightheadedness. In her past medical record of note, patient has had multiple episodes for chest pain, where she left AMA prior to having any sort of work-up, including stress test or angiogram. ALLERGIES: The patient is allergic to aspirin, codeine, penicillin, and sulfa.
AMA|against medical advice|AMA,|175|178|PAST MEDICAL HISTORY|4. She had an echocardiogram in _%#MM#%_ 2000, which showed a normal ejection fraction and a small amount of valvular regurgitation. 5. A long history of leaving the hospital AMA, prior to being worked up after being there for an evening. PHYSICAL EXAMINATION (HLI): Admission vitals were stable. She is afebrile.
AMA|against medical advice|AMA.|223|226|HOSPITAL COURSE|She was very upset at having to put up with lab draws and having to deal with the possibility of having a stress test done. A cardiac angiogram was not even mentioned at the time. She was very angry and threatened to leave AMA. I reassured her that this was not necessary; however, she persisted. After much abuse of the staff and physicians, she left with her IV in place from the Telemetry Unit.
AMA|against medical advice|AMA|229|231|HOSPITAL COURSE|I also informed her that there was a possibility that she could die, if she left without medical treatment, and patient stated that she assumed those responsibilities and understood what I was saying to her. She did not sign the AMA paperwork, but insisted on leaving anyway, with the full knowledge and full responsibility for her own medical care. DISCHARGE MEDICATIONS: There were no discharge medications, as the patient eloped.
AMA|against medical advice|AMA.|200|203|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Alcohol abuse complicated by hepatitis and gastritis. Recently evaluated by Dr. _%#NAME#%_ _%#NAME#%_ from Gastroenterology on _%#MM#%_ _%#DD#%_, 2002 before the patient left AMA. She felt nauseated. Emesis was due to her alcohol hepatitis. Given that patient had no hematemesis or symptoms of upper GI bleeding, she did not have EGD.
AMA|advanced maternal age|AMA.|332|335|PROBLEM LIST|She is status post repeat low-segment transverse cesarean section on _%#MM#%_ _%#DD#%_, 2003, at 3:10 in the morning, and the baby was transferred to the Fairview University Medical Center NICU with question of seizures. PROBLEM LIST: Pregnancy, gastritis, prior C-section, history of diabetes mellitus, history of positive GBS and AMA. PRENATAL LABS: GCG 169, past GGT this pregnancy. O-positive antibody negative.
AMA|against medical advice|AMA.|264|267|HISTORY OF PRESENT ILLNESS|At this point, the patient elected to refuse further workup and treatment, specifically refusing biopsies, CT scans, MRIs, any IV therapies or intubation. At this point, the risks were explained to the patient and the patient did elect to sign out of the hospital AMA. We did send the patient home on his current medications including a 10-day course of gatifloxacin for treatment of pneumonia as well as high-dose prednisone that was used to empirically treat ossifying interstitial pneumonitis.
AMA|against medical advice|AMA.|190|193|CHIEF COMPLAINT|His hemoglobin has been stable although GI felt that he should be provided with an EGD, the patient refused because of his sensitivity to sedation. He refused completely, he wanted to leave AMA. We finally persuaded him to stay so he could actually be evaluated by the renal team and Dr. _%#NAME#%_. The patient will require eventually hemodialysis and he will have to follow up with the renal clinic next week.
AMA|against medical advice|AMA|169|171|HOSPITAL COURSE|She was consistently blowing 320 to 330 before discharge and was clinically improved as far as lung sounds and remained afebrile throughout her admission. She did leave AMA on _%#MMDD2003#%_ due to a court date that was important enough for her to attend regarding her daughter and some sexual molestation that her daughter had been a victim of in the past.
AMA|against medical advice|AMA|334|336|HISTORY OF PRESENT ILLNESS|Please refer to his H&P for details. She also had an MRI of the head at North Memorial which revealed no significant abnormalities of the brain except for thickening of the mucosa in the sinuses consistent with chronic sinusitis. She was asked to have complete psychiatric evaluation at North Memorial but declined. In fact, she went AMA yesterday and went back home. Since going back home, she had two more syncopal episodes and was brought in by her boyfriend.
AMA|against medical advice|AMA|183|185|SUBJECTIVE|She notes that she quit these because of no money, not because of no need or side effects. She does admit to being hospitalized briefly about a month ago, but it sounds like she left AMA because someone was bothering her there. According to her history, she was not given any medication or follow up. She has not seen anyone since then. PAST MEDICAL HISTORY: Remarkable for status post NSVD x 1.
AMA|advanced maternal age|AMA|117|119|COMPLICATIONS OF PREGNANCY|A CVS on _%#MMDD2003#%_ that shows an XY normal male. Normal triple screen. Normal male. COMPLICATIONS OF PREGNANCY: AMA with her testing done as previously stated. MEDICATIONS: Prenatal vitamins. ALLERGIES: Sulfa drugs. PAST OB HISTORY: In 2001, a 40-week Pitocin induction, 7 pounds, NSVD.
AMA|against medical advice|AMA|123|125|HISTORY OF PRESENT ILLNESS|They got a CT scan and thought that they possible say appendicitis and wanted to bring her into the hospital, but she left AMA due to babysitting concerns. Today, she returns to our emergency department now with the same pain, no nausea, vomiting, or change in bowel habits, no bloody stool.
AMA|against medical advice|AMA|237|239|HOSPITAL COURSE|Infectious Disease was consulted, who recommended an ENT evaluation for upper airway sources of the hemoptysis. The patient also was started empirically on a PPI for symptoms of gastroesophageal reflux disease. However, the patient left AMA before evaluation could be completed. One sputum Gram's stain was obtained, which was unremarkable and revealed only moderate PMNs and mixed gram-positive and gram- negative bacteria.
AMA|against medical advice|AMA,|158|161|HOSPITAL COURSE|It was recommended that the patient stay one more night for further observation of this, however, patient was very anxious to go home. She was not discharged AMA, rather she was discharged with instructions to seek emergent medical attention should she have similar lower abdominal discomfort as she may be in urinary retention possibly related to her Benadryl ingestion.
AMA|against medical advice|AMA.|83|86|DISCHARGE DISPOSITION|DISCHARGE CONDITION: Unstable. Patient psychotic. DISCHARGE DISPOSITION: Discharge AMA. The patient's mother was informed that the patient left AMA. The patient's pediatric endocrinologist is Dr. _%#NAME#%_ at _%#TEL#%_.
AMA|against medical advice|AMA.|189|192|HISTORY OF PRESENT ILLNESS|The patient was seen at _%#CITY#%_ _%#CITY#%_ Urgent Care Center yesterday and was told to go to the Ridges Emergency Department for admission, however, the patient declined and signed out AMA. He did receive a dose of Unasyn as well as oral fluoroquinolone. The patient decided today to show up at the Ridges Emergency Room for admission.
AMA|against medical advice|AMA|166|168|HOSPITAL COURSE|The patient could not be convinced to continue bladder irrigations and home IV therapies, and wished to leave against medical advice on _%#MMDD2004#%_. He signed out AMA and was discharged that day. Of note, we did attempt to secure home bladder irrigations for this patient. However, his insurance denied that claim. PROBLEM #2: Small bowel obstruction.
AMA|against medical advice|AMA|198|200|HOSPITAL COURSE|HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 31-year-old male with history of almost ten admissions in the last year who presents with DKA. He has had behavioral issues in the past and has also left AMA from our hospital. He says that he had been doing everything right in terms of his diabetes, although when I asked him about carb counting, he did not seem to know much about carb counting.
AMA|against medical advice|AMA.|219|222|HOSPITAL COURSE|3. Bipolar disorder. She was seen by psychiatry. She was initially placed on a 72-hour hold and this was re-started for another 72 hours. At the time of discharge, the patient was not deemed holdable and was discharged AMA. 4. Hepatitis C. The patient was noted to be hepatitis C positive during her hospitalization. DISCHARGE MEDICATIONS: Zyvox for 12 days and Depo-Provera shots. DISPOSITION: The patient is discharged AMA.
AMA|against medical advice|AMA.|172|175|HOSPITAL COURSE|The patient left AMA shortly before noon on _%#MMDD2005#%_ at which time he was on no medications. Failure to give discharge instructions were giving because again he left AMA. FINAL DIAGNOSES: Alcoholic cardiomyopathy, small myocardial infarction during the hospital stay, hallucinations due to alcohol abuse, no evidence of methanol toxicity, history of dialysis x1 and I believe history of pancytopenia resolving.
AMA|against medical advice|AMA.|160|163|HISTORY OF PRESENT ILLNESS|He had a cardiac echo at that time, which was reportedly negative. He had a stress adenosine set up, but he did not want to wait a day in the hospital and left AMA. He now returns for similar symptoms. He has not changed any of his medications, had any other recent illnesses or problems.
AMA|against medical advice|AMA|232|234|HISTORY OF PRESENT ILLNESS|On numerous occasions on the ward, the nurses report that the patient did not appear to be in any substantial pain but was requesting recurring narcotic administration. At one point there was some question about the patient leaving AMA to receive medications that she did not feel she was getting here in the hospital. At no point was there evidence that the patient was obtaining narcotics outside of the hospital during her hospital stay.
AMA|against medical advice|AMA.|218|221|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|In the past, she has been on stress doses, especially when she was originally on her pre bone marrow transplant chemotherapy regimen. Apparently, prior to a full workup, the patient became agitated and wished to leave AMA. The following team did offer her a plan for her syncope consisting of working her up for orthostatic hypotension, arrhythmia or possibly seizure.
AMA|against medical advice|AMA|222|224|PROBLEM #3|We planned to continue tapering the dose and informed the patient that she will likely be ready for discharge in several days. On _%#MMDD2006#%_ the patient left the hospital against medical advice. She refused to sign an AMA form. DISCHARGE MEDICATIONS: The patient did not wait to receive discharge orders with the recommended discharge medications.
AMA|against medical advice|AMA|150|152|DISPOSITION/FOLLOWUP|10. Benadryl 25 mg p.o. q. 4-6h. p.r.n. for itching. DISPOSITION/FOLLOWUP: The patient left the hospital against medical advice, refusing to sign the AMA form. She is to follow up with her primary care physician, Dr. _%#NAME#%_ _%#NAME#%_. Please do not hesitate to contact us should you have any questions or concerns.
AMA|against medical advice|AMA|246|248|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 58-year-old female who was readmitted for further evaluation and treatment of multiple medical problems. The reader is referred to my original dictation on _%#MMDD#%_. The patient signed out AMA despite being well aware that she had gram-negative central venous catheter infection with bacteremia and sepsis, as well as end-stage renal disease without any existing hemodialysis access.
AMA|against medical advice|AMA.|149|152|HOSPITAL COURSE|After negotiation, did agree to discontinue the hold second day. On agreement, the patient saw detox and discussed detox treatment. Ended up leaving AMA. Discussed with family pursuing commitments, this would have to happen outpatient. As the patient had no insurance, would have had to be regardless for rule 25 assessment.
AMA|against medical advice|AMA.|142|145|HOSPITAL COURSE|His plan was to follow up with another primary that he noted Dr. _%#NAME#%_ at Marilynn Clinic. Discharge Planning: As noted the patient left AMA. Recommended follow up with primary, uncertain as to his primary, Dr. _%#NAME#%_ at Marilynn Clinic or Dr. _%#NAME#%_ in _%#CITY#%_ _%#CITY#%_ with Health Partners as noted above.
AMA|against medical advice|AMA|387|389|DISCHARGE PLAN|He has a long history of antisocial behaviors of thievery. DISCHARGE PLAN: Originally, we planned to send him to CD treatment, he was not compliant, so we plan to discharge him on Monday, _%#MM#%_ _%#DD#%_, 2006; however, the patient has signed a 12-hour intent to leave on Friday, _%#MM#%_ _%#DD#%_, 2006, at about 3:30 in the afternoon, so a decision was made to discharge the patient AMA at that time with a 30- day supply of the patient's medication (_______________).
AMA|against medical advice|AMA|232|234|HISTORY OF PRESENT ILLNESS|Diabetes mellitus: The patient had a significantly high glucose of 268. An insulin drip was started for tight control. The patient pulled out the IV and therefore stopped insulin drip and was not sent home on any insulin as he left AMA before the patient could be given medications.
AMA|against medical advice|AMA.|104|107||_%#NAME#%_ _%#NAME#%_ is a 31-year-old female with heroin dependance. She was here a month ago but left AMA. She admits to daily usage of heroin. Se has a daughter and is about to lose custody unless she can complete treatment and maintain sobriety.
AMA|against medical advice|AMA|258|260|BRIEF  HISTORY AND HOSPITAL COURSE|She had been failing home nebulizer treatments. She was treated in the ER with Heliox continuous nebs and was given a one-time dose of IV Solu-Medrol. She is well known to our service. She seems to know the healthcare delivery system quite well and has left AMA at institutions multiple times. Given her encouragement to stay with her prior intubations for her asthma, she still is a very difficult patient.
AMA|against medical advice|AMA.|120|123|BRIEF  HISTORY AND HOSPITAL COURSE|I did start her on Allegra to assist with the allergic component of her asthma. Shortly, an hour or two later, she left AMA. She remained otherwise stable on room air with good oxygenation. I do not suspect that she will decompensate on an outpatient basis.
AMA|against medical advice|AMA|157|159|HOSPITAL COURSE|I informed her the possibility of death related if she leaves because her INR is still low. She states that she knows and she wants to go anyway. She signed AMA and she left the hospital today. She will be following up with warfarin clinic and her INR today was 1.48, and she will be taking the Coumadin as an outpatient.
AMA|antimitochondrial antibody|AMA|294|296|HOSPITAL COURSE AND PLAN|Her liver enzymes were trending downwards everyday. On the day of discharge, her AST was 79, ALT 304, and ALK was 312, INR was 0.91. The patient did not have abdominal pain or other symptoms of hepatic dysfunction. GI involved who ordered other viral labs like CMV, IgM, IgG, ANA antibody, and AMA which were all negative. So the hepatitis looks probably from drug induced given the downward trend of the enzymes after stopping the offending medications and negative labs.
AMA|against medical advice|AMA|199|201|HISTORY OF PRESENT ILLNESS|The patient was hospitalized at Fairview _%#CITY#%_ Psychiatric Hospital for depression and alcohol abuse early this month. Apparently he was to be hospitalized for 4 weeks, but he left the hospital AMA on _%#MMDD2006#%_. Upon leaving he did have blood work including a basic metabolic panel and a CBC, as well as LFTs that were all normal.
AMA|against medical advice|AMA.|305|308|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|The patient was started on cardiac medications. Meanwhile the patient decided to leave AMA. I explained to the patient about his serious condition and the need to have a proper discharge with proper medications in the morning after each specialist has evaluated him, however he refused then later on left AMA. Also, patient had a nocturnal pulse oximetry which showed severe hypoxia.
AMA|against medical advice|AMA|215|217|HISTORY OF PRESENT ILLNESS|EGD showed 5 small antral ulcers. The patient was put on Protonix b.i.d. Her second admission was on _%#MMDD2006#%_ where she was readmitted for another episode of hematemesis. GI was consulted but the patient left AMA before she was seen. Today, when she presented to the emergency room, workup at the emergency room was negative. The emergency room physician was planning to discharge her home, but she refused.
AMA|against medical advice|AMA.|195|198|HISTORY OF PRESENT ILLNESS|During my evaluation I discussed the need for psychiatry consult after which patient refused to talk with me and would not allow me to examine her. She wants to discharge or otherwise will leave AMA. PAST MEDICAL HISTORY: 1. Upper GI bleed admitted twice in _%#MM2006#%_. Her initial admission was _%#MMDD2006#%_ when she was hospitalized through _%#MMDD2006#%_.
AMA|against medical advice|AMA|318|320|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 42-year-old Hispanic male, well known to me, who was recently admitted to the Fairview Smiley's Teaching Service with acute intoxication and pneumonia and was being treated for the pneumonia, as well as bright red blood per rectum, when he decided to leave the hospital AMA on Christmas Eve. The patient apparently got home and found that he was not able to take care of himself as he thought he might be able to and consequently returned to our health care facility.
AMA|against medical advice|AMA.|164|167|REASON FOR HOSPITALIZATION|Following that, the hold was released and right away after the hold was released, patient decided that he wanted to leave the hospital for his work issues, he left AMA. Following that, his complete workup was not completed, as patient had left the hospital. He does have a history of known alcohol and drug abuse.
AMA|advanced maternal age|AMA|463|465|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 46-year-old white female, gravida 3, para 2002, EDC of _%#MMDD2006#%_, blood group O, Rh positive, rubella status immune, one hour blood sugar screen 89, who has a past history of White's classification A2 gestational diabetes with her second pregnancy, White's classification A1 gestational diabetes with her first pregnancy, with a history of chronic hypertension who is today 36-5/7 weeks gestation. Because of her AMA status, chronic hypertension, gestational diabetes, she has been undergoing weekly antenatal testing.
AMA|against medical advice|AMA.|202|205|HOSPITAL COURSE|He is also warned of the risk of decreased outflow of the venous drainage of the central nervous system in brain including symptoms of stroke. Again the patient declined further inpatient care and left AMA. 3. Fever. This is possibly due secondary to septic thrombi involving the new nonocclusive thrombi in the internal jugular veins versus infection including endovascular etiologies.
AMA|against medical advice|AMA|240|242|DISCHARGE DIAGNOSES|However, she presented to an outside hospital, Regions Hospital to be specific, with acute onset of abdominal pain. The patient had a CT scan obtained that revealed possible gastric remnant dilatation. The patient had left Regions Hospital AMA after prolonged wait in the ED. The patient came to Fairview University Hospital ED after our contacting her to do so, so we could examine her and ensure that there was no ongoing problem.
AMA|against medical advice|AMA.|160|163|PAST MEDICAL HISTORY|CHIEF COMPLAINT: Chest pain. PAST MEDICAL HISTORY: 1. Chest pain evaluation at Park Nicollet in 2003. The patient was offered admission, however, he signed out AMA. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 49-year-old man who presented to Fairview Southdale Hospital ER for evaluation of chest pain.
AMA|advanced maternal age|AMA,|147|150||_%#NAME#%_ _%#NAME#%_ is a 37-year-old gravida 3, para 2, EDC _%#MMDD#%_, admitted for induction of labor at term. Pregnancy was complicated by 1. AMA, 2. Fractured nose requiring surgery at 18 weeks gestation. 3. Positive GBS for which she received IV Penicillin in labor. 4. History of postpartum depression and the plan was to put her on Celexa post partum.
AMA|against medical advice|AMA|367|369|HOSPITAL COURSE|The morphology of platelets is within normal limits. Based on this, hemo-pathology report the Hematology service recommended that most likely this is from the chronic alcoholism and bone marrow suppression and they recommended to transfuse the patient to get the platelet count about 50,000 before the ERCP, it could be done safely. Please note that the patient left AMA before further study would be done for her pancreatitis.
AMA|against medical advice|AMA.|286|289|PROBLEM #6|Despite patient's elevated baseline creatinine of 1.6 on _%#MM#%_ _%#DD#%_, 2007, and 1.44 on _%#MM#%_ _%#DD#%_, 2007, she maintained adequate and clear urine output. On _%#MM#%_ _%#DD#%_, 2007, in the evening, the patient indicated to staff that she was planning to leave the hospital AMA. 20 minutes of face-to-face time was spent discussing the risks of doing so, and she expressed full understanding.
AMA|against medical advice|AMA|300|302||Mr. _%#NAME#%_ decided to leave the hospital against medical advice on _%#MMDD2007#%_ despite being counseled on the need to stay to have his EGD performed to assess his hematemesis and to be seen by Ophthalmology for the anisocoria. He apparently felt that he needed to leave and agreed to sign the AMA paperwork and stated that he would not hold any of us responsible if he were to become more ill and even potentially as a result of prematurely leaving the hospital.
AMA|against medical advice|AMA.|352|355|DISPOSITION|Discussed with the patient regarding the concerns that primary team as regarding his tumor in his chest and the risk of going home/leaving the hospital were discussed with the patient including possibility of death from exsanguination secondary to tumor erosion of his pulmonary vessels. The patient was adamant about leaving and still wishes to do so AMA. It was at that point that the patient was given discharge paper work and sent home. He was set up to be the first available followup appointments, Dr. _%#NAME#%_ first available.
AMA|against medical advice|AMA|136|138|BRIEF HISTORY OF PRESENT ILLNESS|At these admissions, the patient has been advised to be on IV antibiotics for 6-8 weeks in the past but he has bene discharged and left AMA before he was able to complete these courses. The patient notes that he only gets relief from taking oral linezolid as an outpatient for this osteomyelitis and come into the hospital today because he has run out of this medication and wants to be on this further.
AMA|against medical advice|AMA,|160|163|HISTORY|HISTORY: A 32-year-old white male who has had several recent bouts of right foot cellulitis. He was hospitalized _%#MMDD2002#%_ at Southdale, left the hospital AMA, was rehospitalized _%#MMDD2002#%_ at Ridges Hospital for right foot cellulitis, and then he was readmitted again on _%#MMDD2002#%_ for five days at Ridges Hospital for cellulitis.
AMA|against medical advice|AMA,|164|167|HISTORY OF PRESENT ILLNESS|She denied any nausea, vomiting, diarrhea, lower extremity pain or swelling, or pleurisy. The patient currently is requesting to go home and does not want to leave AMA, but I think that in her best interest, we should at least watch her for a good portion of the morning to early afternoon.
AMA|antimitochondrial antibody|AMA|194|196|INDICATIONS|She now desires and request repeat cesarean section at term and does not desire a trial of labor. Her antepartum course was essentially uncomplicated though she did give a history of a positive AMA in _%#MM#%_ of 2002, but subsequently had another AMA performed that was negative. She has been taking baby aspirin throughout her pregnancy and will stop this approximately 48 hours before surgery.
AMA|against medical advice|AMA|242|244|HOSPITAL COURSE|She was covered initially with broad-spectrum antibiotics in the form of imipenem; was kept on IV fluids; was given thiamine, multivitamins, and the MSSA Protocol; and was given morphine for pain, with Ativan for sedation. At the time of her AMA discharge, she was on a clear-liquid diet and seemed to have a marked improvement in her abdominal symptoms. Apparently, she became insistent that she be allowed to go outside to smoke, and also began to act out with the Nursing Staff.
AMA|against medical advice|AMA|226|228|HISTORY OF PRESENT ILLNESS|She presented for evaluation. She had recently been admitted to the hospital just yesterday for similar symptoms. She was admitted to the coronary special care area, was ruled out with three negative troponin enzymes but left AMA before her stress echo. For further information regarding that admit, see H&P from yesterday dated _%#MMDD2003#%_. Cardiac risk factors include positive smoker, elevated lipids that are not treated and positive family history.
AMA|against medical advice|AMA|180|182|PLAN|She does not require amoxicillin prophylaxis prior to procedures. 6. Social: There are multiple concerns with respect to this family. They have threatened to take this infant home AMA since admission and are currently taking her home essentially AMA. However, due to the family circumstances and the infant's improvement and relative stability, we are releasing her, but suggesting that the family seek care immediately upon arrival in California.
AMA|advanced maternal age|AMA|274|276|HISTORY OF PRESENT ILLNESS|Her total weight gain was 30 pounds. LABORATORY: Prenatal Labs: She is 0 negative, antibody negative, RPR negative, rubella immune, HIV negative, hepatitis surface antigen negative, GBS negative, all other labs within normal limits. ISSUES DURING THIS PREGNANCY: Patient is AMA and declined amniocentesis. Also, patient is followed closely for a suspected sacrococcygeal teratoma approximately 3-cm in size and stable. Patient does have a history of preeclampsia with borderline hypertension.
AMA|against medical advice|AMA|145|147|HISTORY OF PRESENT ILLNESS|She went to the urgent care yesterday and was sent to the Emergency Department where she had an I&D with the abscess area packed. She signed out AMA after being recommended she be admitted. She was sent home with clindamycin and Cipro. She took a few doses of that but continued to have significant pain today, so returned to the Emergency Department for admission.
AMA|against medical advice|AMA|219|221|PROBLEM #2|This was discussed with the patient during her admission. The patient wanted a Chemical-Dependency consult as well as possible placement in the Chemical-Dependency Program after discharge. However, the patient had left AMA on Sunday, _%#MMDD2003#%_, prior to obtaining a Chemical-Dependency consult. PROBLEM #3: Hematuria. As mentioned above, the patient has a history of stent placement due to ureteral obstruction secondary to her cervical carcinoma.
AMA|against medical advice|AMA,|152|155|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: The patient should follow up with the GI Clinic in one two weeks. She was provided with a telephone number prior to walking out AMA, and she was also instructed to follow up with her primary-care physician in two to three weeks as well at Smiley's Clinic.
AMA|against medical advice|AMA|179|181|HISTORY|During this recent hospitalization, he underwent EGD yesterday (Dr. _%#NAME#%_), which demonstrated duodenitis. On the evening of _%#MMDD2003#%_, the patient left Ridges Hospital AMA because of "family business." He returned to the Emergency Department at 1 a.m. this morning (5-6 hours after he left) with complaints of recurrent and persistent nausea and vomiting.
AMA|against medical advice|AMA|293|295|HOSPITAL COURSE|We had extensive discussions outlining why this would be undesirable, including the fact that we might not be able to get him over onto an oral regimen that would maintain adequate pain control, but he is insistent on going home. I plan to let him go home, because I think making him sign out AMA would interfere with his pursuing future care for his underlying esophageal carcinoma. During this hospitalization we also had a very extensive, 90-plus minute discussion with the patient, his mother, his father, and another relative who did not identify herself, about the diagnostic and treatment options available for management of his metastatic esophageal carcinoma.
AMA|against medical advice|AMA,|161|164|ASSESSMENT/PLAN|Continue Thiamin, multiple vitamins, IV fluids. Check U- tox, chemical dependency and psych evaluation. I do feel that he is impaired and if he chooses to leave AMA, I will place a 72 hour hold unless psychiatry feels otherwise. 2. Possible depression. I favor an SSRI, although I am not sure the patient will take it.
AMA|against medical advice|AMA|183|185|HOSPITAL COURSE|The patient signed the AMA forms and has left the hospital. The patient was given medical advise by the nursing staff of his medical conditions but the patient refused and signed the AMA forms.
AMA|against medical advice|AMA|210|212|FOLLOW UP|The tapering schedule was called to Dr. _%#NAME#%_'s office to alert her to the need for continuous care. Remeron, Klonopin, Neurontin, and Seroquel were not provided to the patient at discharge because of her AMA departure. Future psychiatric medicines from Dr. _%#NAME#%_. FOLLOW UP: A followup appointment was made with Dr. _%#NAME#%_ _%#NAME#%_ for _%#MM#%_ _%#DD#%_, 2003, at 1 p.m.
AMA|against medical advice|(AMA)|181|185|DISCHARGE DISPOSITION|3. Chronic alcoholism. 4. Hypertension. 5. Chronic tobaccoism. DISCHARGE DISPOSITION: Per chart dated _%#MMDD2003#%_ at 1330 hours _%#NAME#%_ _%#NAME#%_ left against medical advice (AMA) with my partner, Dr. _%#NAME#%_ _%#NAME#%_, being contacted. No follow-up as per my knowledge was entertained. DISCHARGE MEDICATIONS: Due to the fact that this patient left against medical advice (AMA), I do not see any medications ordered on discharge.
AMA|against medical advice|(AMA),|135|140|DISCHARGE MEDICATIONS|No follow-up as per my knowledge was entertained. DISCHARGE MEDICATIONS: Due to the fact that this patient left against medical advice (AMA), I do not see any medications ordered on discharge. BRIEF HISTORY: _%#NAME#%_ _%#NAME#%_ is a 45-year-old white male who was admitted to Fairview Southdale Hospital with a one-month history of severe right leg pain for which he was using Tylenol and ibuprofen.
AMA|against medical advice|AMA|134|136|HOSPITAL COURSE|She was eventually convinced to do so, but once again refused shortly before the test was to be begin. The patient agreed to sign the AMA form and left without receiving formal discharge orders.
AMA|against medical advice|AMA|202|204|HOSPITAL COURSE|1. Cellulitis of the right upper extremity. 2. Unspecified psychiatric concerns. HOSPITAL COURSE: 1) Cellulitis. Ms. _%#NAME#%_ is a 34-year-old female who presented here one day after being discharged AMA from Regions Hospital. She presented with a right arm cellulitis in an area of an old IV site. She had erythema and swelling of the right upper extremity and she was treated with vancomycin and Tequin.
AMA|against medical advice|AMA,|294|297|HISTORY OF PRESENT ILLNESS|On the morning of _%#MMDD2004#%_ the patient was threatening to leave AMA because she had "things to do" and no longer wanted to stay in the hospital. As noted in my previous discharge summary, we did prepare her paper work so as to avoid the patient having problems with her insurance leaving AMA, and the patient did leave without any complaints of pain at that time. Apparently the patient was feeling fine throughout the rest of that day but then had some pizza in the afternoon and had acute onset of excruciating epigastric pain.
AMA|against medical advice|AMA.|159|162|ADDENDUM|In fact, she was afebrile and when the nurses went to soak her foot, it was apparent that she had applied make- up to foot and ankle region. Patient then left AMA. I believe this strongly supports the diagnosis of Munchausen's syndrome or drug- seeking behavior. I alerted the patient advocate, _%#NAME#%_ _%#NAME#%_ to the situation and they will likely draw up a care plan for this patient.
AMA|against medical advice|AMA,|110|113|SUMMARY|She was started on liquids, and stoma output was slowly increasing. She at that point was wanting to sign out AMA, as she was frustrated with her slow recovery. I reviewed with her in detail the signs and symptoms of obstruction and dehydration.
AMA|against medical advice|AMA.|242|245|HOSPITAL COURSE|He has a history of chemical dependence, including drug and alcohol use, and is currently under a commitment from _%#COUNTY#%_ _%#COUNTY#%_. HOSPITAL COURSE: I went to evaluate the patient on the Medical floor, and he apparently already left AMA. He left with his IV in. After speaking with care coordinator and social worker, it was determined that the patient is currently still under commitment at _%#COUNTY#%_ _%#COUNTY#%_.
AMA|against medical advice|AMA.|136|139|HISTORY OF PRESENT ILLNESS|She has lost most things in her life. She was here a month ago, but did not stay for treatment. She was only here for 24 hours and left AMA. She has a history of methamphetamine dependence. She uses large amounts. She uses daily. She snorts it. She does not use needles.
AMA|against medical advice|AMA|150|152|HISTORY OF PRESENT ILLNESS|The patient enters Fairview Recovery Services at this time on his own volition. He admits to an addiction to heroin. He was here a month ago but left AMA after a short period of time because he could not smoke. He came back in now realizing that he cannot smoke, and is more willing to proceed through the program.
AMA|against medical advice|AMA.|257|260|PLAN|Advised the patient of the risk of leaving before detox is complete; that is worsening withdrawal, seizures, and delirium tremens. The patient is alert and oriented and cannot be kept against his will. He desires to leave against medical advise. Discharged AMA. DISCHARGE DIAGNOSIS: Alcohol dependence.
AMA|against medical advice|AMA.|130|133|PRESENT ILLNESS|He has a history of alcohol dependence. He was here earlier this year but relapsed. He was here a couple weeks ago but left detox AMA. He then signed up for the MICD outpatient program but it was recommended that he go to Lodging Plus because he lives alone.
AMA|against medical advice|AMA.|153|156|HISTORY OF PRESENT ILLNESS|He has been here twice. The first time he left AMA. The second time he completed detox and then went to Lodging Plus but left Lodging Plus after a 1 day AMA. He says he did not like groups, does not like hanging around with other people. He would prefer to be by himself. He does not like anything to do with recovery meetings, support, spirituality, etc.
AMA|against medical advice|AMA|139|141|HOSPITAL COURSE|On her postop day #5, the patient had made plans to return to Alabama without any follow up. The patient was informed that she could leave AMA or remain until she had a followup appointment and a confirmation from her hematologist that he would be willing to manage her hemolysis.
AMA|against medical advice|AMA|254|256|PLAN|He will be detoxed using the MSSA protocol. The patient will be restarted back on his medications, which include Luvox 100 mg, Prozac. The patient will have an Internal Medicine consultation. He will have labs done. The patient initially wanted to leave AMA but he reconsidered and wants to go to Lodging Plus. He will be given Remeron 15 mg at bedtime to help with sleep.
AMA|against medical advice|AMA.|161|164|HISTORY|He was given sublingual Nitroglycerin which seemed to help alleviate most of his pain but not completely. The patient was told he should be admitted but he left AMA. He had mild discomfort since that time until yesterday when he was mowing the lawn. He noted nausea without vomiting and had diaphoresis and shortness of breath yesterday.
AMA|against medical advice|AMA|199|201|PAST MEDICAL HISTORY|She would like to continue her inhalers for her asthma and her blood pressure medication. PAST MEDICAL HISTORY: 1. History of presumed seizure X1 with negative EEG in _%#MM#%_ 2001. The patient left AMA but per the discharge summary there was a question that the patient had seizure vs. a syncopal event. 2. Temporomandibular joint disorder. 3. Hypertension.
AMA|against medical advice|AMA.|183|186|HISTORY OF PRESENT ILLNESS|He was recently hospitalized for laceration of the perineal/penile area related to a fall, and had this surgically repaired. He was sent to a nursing home for convalescence, and left AMA. HABITS: The patient is a non-smoker; he quit smoking six weeks ago.
AMA|antimitochondrial antibody|AMA,|223|226|RECOMMENDATIONS|5. Workup for anemia and elevated total bilirubin including iron studies, peripheral smear, hemolysis labs. 6. Workup for the elevated alkaline phosphatase would include fractionation of the alkaline phosphatase, GGT, ANA, AMA, anti-smooth muscle antibody, PSA, as well as a CT scan of his abdomen and pelvis to work up for cancer. 7. He may require colonoscopy for the anemia and the blood in his ostomy.
AMA|against medical advice|AMA|137|139|DISCUSSION|She did have an MRI/MRA which revealed chronic changes from a past CVA. No acute processes were noted. _%#NAME#%_ did leave the hospital AMA on _%#MMDD2002#%_. She was readmitted because of complaints of depression. She also noted a several-day history of right leg pain. _%#NAME#%_ had recounted that she had fallen down a week ago but did not indicate any injuries related to this fall.
AMA|antimitochondrial antibody|AMA,|109|112|LABORATORY AND DIAGNOSTIC DATA|Right upper quadrant ultrasound showed hepatomegaly. No ascites. No duct dilation. Pending labs include ANA, AMA, hepatitis screen. A hepatobiliary scan was ordered but patient was not cooperative. ASSESSMENT/PLAN: 1. Increased alkaline phosphatase several points over normal and transient increase in ALT and AST.
AMA|against medical advice|AMA|269|271|DISCUSSION|DISCUSSION: _%#NAME#%_ _%#NAME#%_ is a 58-year-old white female with a history of bipolar affective disorder who has been off her medications for the last two weeks. She was admitted on _%#MMDD2002#%_ for evaluation of suicidal ideation. _%#NAME#%_ was just discharged AMA from Mercy Hospital apparently without any diabetic medications. I have been asked to see her by Dr. _%#NAME#%_ to assess diabetes and hypertension.
AMA|against medical advice|AMA,|205|208|HISTORY|Medical therapy was tried, but he continued to have ongoing chest pain and therefore he was scheduled for an angiogram on _%#MMDD#%_ with me. The lab was running late and he refused to stay and walked out AMA, never called our office back and never scheduled another heart catheterization. Reviewing the chart, apparently there has been some other issues about stressors in his life and noncompliance and, in fact, the internist tells me even on this admission he was starting to make some "early waves".
AMA|against medical advice|AMA.|193|196|PHYSICAL EXAMINATION|Gait is within normal limits. Reflexes: He has deep tendon reflexes that are equal and present in all four extremities. MENTAL STATUS: At this time, the patient was strongly contemplated going AMA. LABORATORY DATA: Basic metabolic profile was normal. Albumin was 3.1. A U/A showed trace albumin in the urine.
AMA|against medical advice|AMA|146|148|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Hypertension. 2. Asthma and COPD for which she is on chronic inhalers. 3. Chemical dependency with a history of frequent AMA departures from both medical and chemical dependency treatments stays. The patient last received antibiotics probably about a week ago. She left while she was in chemical dependency treatment and immediately starting drinking again and then came back and requested readmission for chemical dependency treatment.
AMA|antimitochondrial antibody|AMA|168|170|ASSESSMENT/PLAN|Also cirrhosis, await the pathology report. GI is also following and they are suspicious for malignancy. GI also ordered hepatitis serologies as well as ferritin, ANA, AMA and S pep. 2. Probable CHF. She seems to have cardiomegaly on chest x-ray with some interstitial edema as well as crackles on exam and elevated neck veins.
AMA|against medical advice|AMA|148|150|RECOMMENDATIONS|This includes insurance information. There has been clinical suspicion that none of his history is actually true and valid and that he may sign out AMA if he is challenged to produce any of this information. For now, I am willing to take him at face value and do the angiogram.
AMA|against medical advice|AMA.|160|163|RECOMMENDATIONS|3. I will try to withhold from using narcotics as much as possible. It is possible again if we withhold narcotics for his chest pain that he may still sign out AMA. I have told him that we will wait for his papers to arrive, which he has promised to our social workers and the nursing staff for the last 36 hours, but he says now will be here by the end of this afternoon.
AMA|against medical advice|AMA.|156|159|HISTORY OF PRESENT ILLNESS|Plan during last hospitalization for discharge to a halfway house. The patient left on a pass _%#MMDD2007#%_ to get his clothes. Did not return. Discharged AMA. Subsequently, stayed with friends. Relapsed on alcohol, consuming 1/2 pint of cognac on _%#MMDD2007#%_. Smoked approximately 7 grams of crack cocaine on _%#MMDD2007#%_. Associated increase in despondency with alleged suicidal ideation.
AMA|against medical advice|AMA.|130|133|HISTORY OF PRESENT ILLNESS|The patient had a PPD test that was 11 mm. He was recommended to undergo bronchoscopy to evaluate for the mass, but he signed out AMA. The patient remained with pulmonary symptoms since that time. He recently had left shoulder pain for approximately 3 months. In view of this, the patient underwent a biopsy of the left humerous, which showed metastatic adenocarcinoma consistent with lung origin (U07-6198).
AMA|against medical advice|AMA|92|94|HISTORY OF PRESENT ILLNESS|She actually was found to have an abscess and had an I&D done yesterday. Patient left Unity AMA due to patient's upset about not receiving her psychiatric medications. Patient overall is feeling somewhat improved. There is a lot of tenderness in the incision site in the I&D of the left upper quadrant of the abdomen.
AMA|against medical advice|(AMA)|142|146|IMPRESSION|3. Status post open reduction and internal fixation (ORIF) of left clavicle nonunion in 2002. Reportedly he signed out against medical advice (AMA) on the night following that surgery. 4. Admitted now with open wound over the left clavicle with exposed metal which has been present for several months.
AMA|against medical advice|AMA|245|247|HISTORY|The patient with a past mental health diagnosis of schizoaffective disorder. Past mental health hospitalizations at Abbott Northwestern and Fairview _%#CITY#%_. Recent mental health hospitalization Fairview _%#CITY#%_ _%#MMDD2007#%_. Discharged AMA _%#MMDD2007#%_ after patient left on pass to get a Rule 25 without return. In the interim, patient indicates that she did take Risperdal.
AMA|against medical advice|(AMA)|149|153|HISTORY OF PRESENT ILLNESS|The patient was discharged from Fairview Ridges on _%#MMDD2004#%_ to a nursing facility. She was not happy there and had left against medical advice (AMA) without any set up for BIPAP or feeding tube delivery. She was at home. Her condition gradually worsened, and she was subsequently instructed by the on-call doctor to come back into the Ridges ER, where she was admitted to the floor.
AMA|antimitochondrial antibody|AMA,|368|371|PLAN|However, would prefer confirmation with hepatitis C PCR. Given the young age of the patient it would be reasonable to rule out other etiologies of elevated liver chemistries including autoimmune hepatitis, PBC, PSC, celiac disease, Wilson's disease, hemachromatosis, etc. PLAN: 1. Abdominal ultrasound. 2. Hepatitis C PCR. 3. Rule out autoimmune diseases with an ANA, AMA, ASMA. 4. Check TTG and IgA levels to rule out celiac disease. 5. Check cellular plasma. 6. Check ferritin and iron studies to rule out hemachromatosis.
AMA|against medical advice|AMA|169|171|HISTORY OF PRESENT ILLNESS|Her prior primary physician apparently is in _%#CITY#%_, Illinois, but she has had multiple physicians either fire her or alternatively fire them. She has recently left AMA from Olmstead Medical Center in LaCrosse and from the Mayo Clinic. The patient has a history of ongoing right lower extremity cellulitis since _%#MM#%_.
AMA|antimitochondrial antibody|AMA|295|297|IMPRESSION|Fatty liver present presentation would be atypical. At the present time, an MRCP will be done. Because of her anxiety, she will be given sedation. If this is negative, while we are waiting serology, I think she will probably need a transjugular biopsy to better assess the liver problems, ANA , AMA , protein electrophoresis, hepatitis serologies, peripheral smear all pending at this point. Further recommendations can be made pending the above studies.
AMA|against medical advice|AMA.|171|174|PAST MEDICAL HISTORY|6. Recently diagnosed with hyperthyroidism with thyromegaly. She arteriosclerotic heart disease a thyroid scan done on her last admission, but the patient apparently left AMA. She had a thyroid ultrasound that showed a 3.5 cm solid right thyroid nodule and thyromegaly. On _%#MMDD2005#%_, her TSH was less than 0.02. Her T3 was 135.
AMA|against medical advice|AMA|207|209|ASSESSMENT|Our plan was to increase his beta-blockade and repeat a transesophageal echocardiogram in 3 days. At this point, the patient stood up and left the hospital, or at least the immediate area of 4E. He signed a AMA (or Against Medical Advice) form prior to leaving the ward. TIME SPENT: I spent over 2 hours dealing with this patient.
AMA|antimitochondrial antibody|AMA.|147|150|RECOMMENDATIONS|2. Agree with empiric antibiotics. 3. Test all acute viral hepatitis serologies as well as serologies for CMV, HSV and EBV. 4. Check ANA, ASMA and AMA. 5. Check TTG and IgA. 6. Check TSH. 7. Consider checking a serum protein electrophoresis. 8. Check blood and urine cultures. 9. Continue to monitor mental status, liver chemistries and INR.
AMA|against medical advice|AMA|115|117|IMPRESSION|I will decrease the titration at this time and try to work with this young man. He certainly might choose to leave AMA and in that particular case, I will have security come up and wait until an appropriate interval for him to be clear of any IV opioid medications.
AMA|against medical advice|AMA|139|141|PAST MEDICAL HISTORY|No coughing. No constipation. No urinary symptoms. PAST MEDICAL HISTORY: Recent CD treatment on 2 rehab in _%#MM#%_ 2002. The patient left AMA at this time. He denies any other past medical history. No diabetes, hypertension, heart disease, asthma or seizures. PAST SURGICAL HISTORY: Only known surgery is a tonsillectomy.
AMA|against medical advice|AMA|151|153|HISTORY OF PRESENT ILLNESS|He is reported to be a significantly noncompliant gentleman with limited insight into his severe medical condition. He has checked out of the hospital AMA during two his recent hospitalizations. He now returns because he cannot walk due to severe swelling. He has also been having symptoms of shortness of breath, chest discomfort which typically occurs with walking, and has not been able to sleep.
AMA|antimitochondrial antibody|AMA,|152|155|PLAN|PLAN: 1) Increase diuretics. 2) Consider Natrecor. 3) Repeat chest x- ray on Monday to follow up after therapy has been augmented. 4) Consider checking AMA, ESR, ANCA to screen for interstitial lung disease if no better after congestive heart therapy augmentation. HISTORY OF PRESENT ILLNESS: This patient is an 80-year-old male who was admitted on _%#MMDD2004#%_ with one-month history of worsening fatigue and breathlessness with activity.
AMA|against medical advice|AMA.|144|147|IMPRESSION|I described the procedure, she states that she has eight children at home. She cannot stay and she is going home and she is willing to sign out AMA. I am more concerned about her anemia. While certainly the differential highest on the list would be iron deficiency, we need to include thalassemia or sickle cell trait, etc.
AMA|against medical advice|AMA|204|206|ASSESSMENT AND PLAN|He immediately became very, very angry in that we did not have a clear diagnosis for his pain. He at that point began to rip out his IVs and his other therapeutic instruments, and then signed himself out AMA (against medical advice). 2. If the patient does return or decides to stay, I would continue IV resuscitation and observation.
AMA|antimitochondrial antibody|AMA,|248|251|PLAN|2. We will obtain an outpatient ultrasound with special attention to the liver evaluating for cirrhosis or fatty infiltration. 3. We will check labs including HB surface antibodies. B-surface antigen, B core antibody. 4. Also obtain anti HCV, ANA, AMA, ASMA, Serial plasmin, alpha 1 antitrypsin, iron, ferritin, percent sat, IVC, and alpha-fetoprotein. From our standpoint he may be started on a statin We would like to see him in follow-up outpatient to review these results with him.
AMA|against medical advice|AMA.|144|147|PAST MEDICAL HISTORY|1. History of seasonal allergies. 2. Asthma. 3. Broken nose. 4. Broken left hand. 5. Broken jaw. 6. Seen at Fairview on _%#MMDD2004#%_ and left AMA. Labs were drawn then, and the patient was positive for hepatitis C. The patient was not aware of that result until notified at this visit.
AMA|against medical advice|AMA|145|147|DISCUSSION|The patient was admitted here 2 months ago with hematemesis and anemia. She had a documented iron deficiency anemia at that time, she signed out AMA after 24 hours of refusing gastrointestinal diagnostic studies. She has a history of chronic renal failure apparently to a mild to moderate degree with baseline creatinine 2 months ago in the 1.2 to 1.5 range.
AMA|antimitochondrial antibody|AMA.|180|183|LABORATORY AND DIAGNOSTIC DATA|LFTs as described above. Of note, HCB was negative. Hepatitis B, surface antibody, surface antigen and core antibody all negative. Labs pending yet are hepatis A, antibody ANA and AMA. Ultrasound demonstrated no liver abnormality. IMPRESSION: 1. This is a woman who had a fall secondary to increased Tegretol level.
AMA|antimitochondrial antibody|AMA|323|325|ASSESSMENT/PLAN|INR 1.47. ASSESSMENT/PLAN: 1. Liver disease with coagulopathy. At this time the patient denies further alcohol use, yet he is really unsure of the workup he has had as an outpatient for any liver disease. a. I think the workup needs to include hepatitis B and C serologies, iron TIBC, ferritin, alpha-fetoprotein, ANA, and AMA and an ultrasound of the liver. His liver functions and his platelet count and his white blood cell count are all pending at this time.
AMA|antimitochondrial antibody|AMA,|193|196|RECOMMENDATIONS|In addition should hold any other diuretics and his Ace inhibitor at this time. RECOMMENDATIONS: 1. Doppler ultrasound to rule out Budd-Chiari. 2. Liver workup including iron panel, ANA, ASMA, AMA, S-pep, alpha I antitrypsin level and AFP. 3. Consider albumin and fluid administration.
AMA|against medical advice|AMA,|141|144|DOB|CT scan of the head was obtained and was found to be normal. His INR was 2.31. He was to be admitted to the hospital; however, he signed out AMA, wanting to be admitted to Fairview Ridges Hospital. He states that since that time, his symptoms have persisted. He notes that prior to the onset of his current symptoms, he was doing well, and he had no neurologic problems.
AMA|against medical advice|AMA|140|142|IMPRESSION AND PLAN|If the patient does not get better in the next 24 to 36 hours, colonoscopy may be warranted. Nevertheless, I suspect the patient will leave AMA today.
AMA|against medical advice|AMA|355|357|HISTORY|Mr. _%#NAME#%_ is a 42-year-old man whose past medical history is significant for heroin abuse, an injury to the right femoral artery, fasciotomies in the right lower leg, and anesthesia in the right lower leg below the mid calf He was recently admitted to Fairview Southdale Hospital for care of a wound on his right plantar foot. He checked himself out AMA and was recently admitted to the Fairview Ridges Hospital. Mr. _%#NAME#%_ does not know how long the lesion has been present on the plantar surface of his foot.
AMA|against medical advice|AMA|154|156|DIAGNOSTIC IMPRESSION|I told him that in my professional opinion, this is the least optimal in terms of her safety for fall risk. In that regard, I request that she signed out AMA should she wish to go home with her son. They understand that and she will consider what she wants to do. I will check in with her tomorrow. Thank you very much for allowing me to participate in Ms. _%#NAME#%_'s care.
AMA|against medical advice|AMA.|161|164|HISTORY|He was seen in the emergency room yesterday and administered IV Lasix and oxygen as well as nebulization treatment. He felt improved and left the emergency room AMA. He returned at 5 p.m., again short of breath but not nearly as severe as the previous visit. Additionally, he was having urinary hesitancy and wound up having 800 cc of catheterized urine.
AMA|against medical advice|AMA|126|128|SUGGESTIONS|He does have some left leg radiation pain. On his past admission he was suppose to see Chronic Pain, but having left the unit AMA he did not do this. He of course has a history of substance abuse and his pain treatment is complicated because of that.
AMA|antimitochondrial antibody|AMA|195|197|PLAN|We are ordering a CT scan of the chest, abdomen and pelvis, and an MRI or the orbits. Rheumatologic factor with erythrocyte sedimentation rate 1 to V titer, complete metabolic profile, LDH, CBC, AMA test. The patient was also going to be referred to Dr. _%#NAME#%_ and Dr. _%#NAME#%_ for their input regarding this patient's care.
AMA|against medical advice|AMA|221|223|IMPRESSION|Hopefully this will slow down his heart rate should he go into supraventricular tachycardia again as well as offering him blood pressure control. I also advised him that if he wants to be discharged he will be signed out AMA and his insurance company may not cover the cost of this hospitalization. He understands. Total care time was in excess of one hour.
AMA|against medical advice|AMA|154|156|HISTORY|Last hospitalized at Fairview _%#CITY#%_ _%#MMDD2002#%_ for alleged suicidal ideation and ongoing chemical abuse at that time. The patient was discharged AMA on _%#MMDD2002#%_. Subsequent daily intake of a six-pack of beer with three "bottles of whisky" on _%#MMDD2002#%_. Subsequent to that time evaluated in the Crisis Intervention Center where blood alcohol level was 0.101. Referred to Mission Detox on _%#MMDD2002#%_ where the patient detoxified with Librium.
AMA|antimitochondrial antibody|AMA|300|302|IMPRESSION|He does have a history of sclerosing cholangitis. Given that his abnormality of recent CT and chronically elevated alkaline phosphatase are secondary to that, it is unclear how this diagnosis has been made. Given his underlying ulcerative colitis, it is most likely sclerosing cholangitis, but if an AMA has not been done, this could be done, at the least. Could consider ERCP/MRCP liver biopsy, but this will be reviewed by Dr. _%#NAME#%_ at his visit later today.
AMA|against medical advice|AMA.|136|139|PLAN|Again, he called me an ass-hole, told me that I had an attitude, and that he did not want me to take care of him. Consequently, he left AMA.
AMA|against medical advice|AMA.|194|197|HISTORY|Longest sobriety was 2 years. CD intervention on approximately 4 occasions. She was most recently admitted to the adult chemical dependency unit at Fairview _%#CITY#%_ in _%#MM2004#%_. She left AMA. She relapsed 2 to 3 weeks following discharge. Intermittent use to the present time. She indicates $200 to $300 of crack cocaine daily, and a pint of hard liquor with a 24-pack of beer daily over the last 1-1/2 to 2 months.
AMA|against medical advice|AMA|155|157|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a right-hand dominant 28-year-old male who was admitted recently to North Memorial Medical Center where he left AMA secondary to an abscess believed to be secondary to possible IV drug use. He presented to the Emergency Department last night with increasing pain.
AMA|against medical advice|AMA.|233|236|SUMMARY OF CASE|He was seen, urgently admitted and had consultation by his orthopedic surgeon who did an I&D procedure earlier today. He had apparently been evaluated and even hospitalized at North Memorial Medical Center earlier this week and left AMA. He tells me that he was using Minocin for acne on a daily basis at the time that the current infection problem developed.
AMA|against medical advice|AMA|223|225|HISTORY OF PRESENT ILLNESS|The patient had a history of multiple hernia repairs, the last approximately four months ago in New Jersey. At that time admission was recommended and she was briefly seen by Dr. _%#NAME#%_, however, the patient signed out AMA before the consult was completed. The patient's last bowel movement was on _%#MMDD#%_. She vomited one time with her pain. She did have a nasogastric tube placed in the emergency room last night with a significant decrease in pain.
AMA|against medical advice|AMA.|113|116|SUBJECTIVE|He was recently discharged on _%#MMDD2006#%_ after being admitted on _%#MMDD2006#%_. The patient apparently left AMA. He came in with the same suicidal ideation with a plan to cut his wrists. An internal medicine consult was requested for a general medical evaluation and to follow this patient regarding a history of COPD.
AMA|against medical advice|AMA|150|152|MEDICATIONS|3. Seroquel 300 mg at h.s. 4. Risperdal 9 mg at h.s. 5. Navane 30 mg at h.s. Again, the patient has not been compliant with his medications since his AMA discharge. FAMILY AND SOCIAL HISTORY: (As per the chart). PHYSICAL EXAMINATION: He is a sleepy, obese male who is in no acute distress.
AMA|against medical advice|AMA|145|147|HISTORY|Unaware of alcohol- related liver disease, pancreatitis, upper GI hemorrhage. Denies knowledge of DT's. Denies other chemical use. Subsequent to AMA discharge, the patient resumed intake of one liter of brandy daily, up until the time of present admission. Significant clinical issues of E. coli urinary tract infection documented _%#MMDD2002#%_ for which patient never received antibiotics, thrombocytopenia attributed to alcohol.
AMA|against medical advice|AMA.|227|230|IMPRESSION|Again, we have not seen family here, though mother has been called and she is unable to come in, and no other family members have been here patient. Please see my note in the progress notes about patient's threatening to leave AMA. We continue to work as a collaborative care team to try to give her optimal comfort and safety as well as reconciling her original admission criteria of pain management for sickle cell anemia.
AMA|against medical advice|AMA.|191|194|HISTORY OF PRESENT ILLNESS|He does not recall a recent history but my understanding is that he had a seizure yesterday afternoon and was taken to St. Joseph's Hospital. After recovering from the seizure, he signed out AMA. He then went home and had seizures in his sleep according to his friend. He was brought to the emergency room in the early morning hours and started on Dilantin.
AMA|against medical advice|AMA|188|190|CONSULTS|ADMISSION DIAGNOSES: 1. Headache. 2. Chest pain. SERVICE: Smiley's Family Practice - Dr. _%#NAME#%_ CONSULTS: 1. Psychiatric, completed. 2. ENT and CD requested, however, the patient left AMA prior to their arrival. OPERATIONS/PROCEDURES PERFORMED: None. HISTORY: Ms. _%#NAME#%_ is a 46-year-old woman with a history of numerous hospitalizations for alcoholism, benzodiazepine abuse, and psychiatric health, who presents to the emergency room with a headache for 3-4 weeks and recurrent acute chest pain.
AMA|against medical advice|AMA.|271|274|HOSPITAL COURSE|The patient subsequently left AMA. The patient was to be on aspirin 81 mg q day, Plavix 75 mg q day, metoprolol 50 mg b.i.d., lisinopril increased to 20 mg q day, Lipitor 40 mg q.h.s., nitropatch 0.4 mg q hour off at h.s., Gemfibrozil 600 mg p.o. b.i.d. The patient left AMA. Doubt that chest pain was related to his coronary artery disease, though this may be possible. Our recommendation was going to be to discharge with follow-up with Cardiology and continue his regimen as indicated above.
AMA|against medical advice|AMA.|171|174|HOSPITAL COURSE|The plan was for the patient to have a hold placed for transportation and be placed in inpatient psychiatric unit on a locked unit. This was the plan prior to him leaving AMA.
AMA|against medical advice|AMA,|225|228|HOSPITAL COURSE|She was counseled regarding this and the patient signed the appropriate paperwork stating that she was leaving against medical advice. Dr. _%#NAME#%_ was informed of this. The patient was also informed that as she is leaving AMA, her hospitalization would not be covered. The patient was informed that at any point she should come back for fever, increasing pain, nausea, vomiting, or no output from her colostomy.
AMA|antimitochondrial antibody|AMA|170|172|HOSPITAL COURSE|She will need a followup urine culture to ensure clearing of the hematuria as the patient had a prior hospitalization for this issue. We will also ensure that a FANA and AMA and a quantitative IgG are also sent. We will also make sure that an Epstein-Barr virus will be sent. DISCHARGE EXAMINATION: Vital signs: temperature 98.5, pulse 49 to 71, respiratory rate 18, blood pressure 88 to 106, and O2 saturation 99 percent on room air.
AMA|antimitochondrial antibody|AMA|201|203|HOSPITAL COURSE|When we looked at her bilirubin fractions, we have noted that the large fraction of her bilirubin was conjugated and we started a workup for hemolytic anemias. Her direct Coombs test was negative. Her AMA was negative as well. Peripheral smear, however, showed spherocytosis and a suggestion was made that patient might be suffering from spur cell hemolytic anemia which is a type of hemolytic anemia associated with alcohol-induced liver disease and cirrhosis.
AMA|against medical advice|AMA|169|171|PAST SURGICAL HISTORY|She was started on IV antibiotics, ceftriaxone, as her last culture and sensitivity was sensitive to this. The patient was cultured, both blood and urine, and on day of AMA the patient was noted to have a positive urine culture and a positive blood culture. Urine culture positive for non-lactose and lactose fermenter, sensitivities pending, as well as a blood culture positive for gram-positive cocci in clusters.
AMA|against medical advice|AMA.|200|203|PAST MEDICAL HISTORY|She has also been admitted here to Fairview Southdale Hospital and seen by Dr. _%#NAME#%_. Dr. _%#NAME#%_ did a urgent psychiatric consult on _%#MMDD2002#%_, when the patient was leaving the hospital AMA. At that time, Dr. _%#NAME#%_' impression of Axis I was major depressive disorder, recurrent by history, posttraumatic stress disorder, by history, rule out malingering, rule out Munchausen syndrome, rule out somatization disorder, rule out benzodiazepine abuse.
AMA|against medical advice|AMA.|178|181|HISTORY OF PRESENT ILLNESS|The patient was seen actually on _%#MMDD2004#%_ for the same condition, but was found to be hyperglycemic and was treated with insulin. The patient at that time decided to leave AMA. The patient returns today with similar complaints of fatigue, dizziness, and elevated biopsy. Today, the son-in- law noticed blood sugar was running high on glucose meter, which usually indicates blood sugars above 550.
AMA|against medical advice|AMA,|376|379|DISCHARGE MEDICATIONS|He was explai ned how his medical condition was very delicate and how he might require a future intubation if he does not follow with primary care physician and how important it will be for him to follow up with pulmonary for sleep study and pulmonary functions as well as a possible chronic need of BiPAP at night at home. DISCHARGE MEDICATIONS: None, since the patient left AMA, unable to write for any scripts. The patient would have been prescribed on discharge; albuterol q.4 h. for the following 7 days and then p.r.n., Prednisone taper 50 mg for one more day, and Protonix 40 mg p.o. daily.
AMA|advanced maternal age|AMA.|141|144|ISSUES WITH PREGNANCY|11. Triple screen showing an elevated risk of neural tube defect but a normal level-2 ultrasound. 12. GBS unknown. ISSUES WITH PREGNANCY: 1. AMA. 2. Elevated ASP. 3. Recurrent candidiasis. 4. Previa. 5. Tobacco use. OB HISTORY: In _%#MM#%_ of 1992 the patient had and NSVD at 40 weeks after ten hours of labor delivering a 6 pound 8 ounce male.
AMA|against medical advice|AMA.|218|221|HISTORY OF PRESENT ILLNESS|He has been hospitalized twice since the time of his stent without finding any significant coronary disease. He has had a colorful social history in which he had been placed in TCU after his coronary stent but he left AMA. Following his most recent admission he was admitted to a nursing home but per the patient he "just left." It is unsure at this time whether his discharge willingly or just left AMA from there.
AMA|against medical advice|AMA|177|179|HISTORY OF PRESENT ILLNESS|Following his most recent admission he was admitted to a nursing home but per the patient he "just left." It is unsure at this time whether his discharge willingly or just left AMA from there. He had home nursing set up but they had not been to his house. Evidently the patient had been refusing their help. He has not been taking his routine medications for approximately the last two weeks except for his atenolol.
AMA|against medical advice|AMA|251|253|HISTORY OF PRESENT ILLNESS|He had an additional complaint of left-sided chest pain, which increased with inspiration and movement, and he was producing greenish sputum and was dehydrated. He was discharged to _%#CITY#%_. The history was unclear if the patient was discharged or AMA from _%#CITY#%_ _%#CITY#%_ Hospital. ALLERGIES: No known allergies. ADMISSION MEDICATIONS: At home he uses an insulin sliding scale and Lantus 20 U in the p.m. SOCIAL HISTORY: He said that he smokes, but not sure about the quantity.
AMA|against medical advice|AMA|241|243|ON ARRIVAL IN THE EMERGENCY ROOM|In addition, the patient has had multiple ER visits over the last couple of years at Fairview, especially in the year 2004 and 2005. In addition, the patient was subsequently admitted to Unity Hospital 1 week ago in which the patient signed AMA when she was unable to get her Vicodin and her Clonazepam. The patient stated she had multiple knee and arthroscopic surgeries, and also had bilateral ..........and also back problems from injuries.
AMA|against medical advice|AMA|263|265|HISTORY OF PRESENT ILLNESS|A chest CT done at that time showed a large mass, deep to the pectoralis major muscle in the right anterior chest wall, most consistent with a hematoma. It was recommended to the patient at that time to be admitted overnight for observation, but the patient left AMA over a disagreement about pain medications. The patient then came back later that day feeling lightheaded, with worsening anterior chest wall pain throughout the day.
AMA|against medical advice|AMA|120|122|PRIMARY CARE PHYSICIAN|PRIMARY CARE PHYSICIAN: Dr. _%#NAME#%_, Allina Medical West, nephrologist is Dr. _%#NAME#%_. The patient was discharged AMA (against medical advice). DISCHARGE DIAGNOSES: 1. Right atrial clot. 2. End-stage renal disease on dialysis. 3. Hypertension. 4. Hyperkalemia. 5. Staphylococcus aureus bacteremia. 6. Coronary artery disease status post stenting of the right coronary artery.
AMA|against medical advice|AMA.|188|191|PROCEDURES PERFORMED|His hemoglobin was followed and was stable. Heparin was discontinued for 1 day due to hematoma but was resumed the next day after hematoma stopped bleeding. DISCHARGE DISPOSITION: To home AMA. DISCHARGE MEDICATIONS: 1. Baby aspirin 81 mg PO daily. 2. Atenolol 100 mg PO daily. 3. Lipitor 20 mg PO daily. 4. Cefazolin 2 grams IV daily for 4 weeks. Cephazolin was started on _%#MM#%_ _%#DD#%_, 2004.
AMA|against medical advice|AMA|203|205|PROBLEM #7|GI and ID consults were done, please refer to consults above PROBLEM #7: Polysubstance abuse: CD consult and psych consults were done. Consider CD evaluation and treatment. The patient left the hospital AMA on _%#MMDD2007#%_. MEDICATIONS WHILE IN THE HOSPITAL: 1. Nadolol 120 mg p.o. daily.
AMA|against medical advice|AMA|168|170|HISTORY OF PRESENT ILLNESS|She signed out against medical advice, and was to follow up with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_ for a stent study, as well as with Dr. _%#NAME#%_ 1 week after her AMA leave. PAST MEDICAL HISTORY: Breast cancer as well as cervical cancer. PAST SURGICAL HISTORY: Exploratory laparotomy x3. Multiple stent changes for her right kidney, as well as a total pelvic exoneration.
AMA|against medical advice|AMA.|207|210|PROBLEM #2|She was discharged against medical advise with likely ongoing infection.She was warned about her recurrent fevers, elevated white count, and lack of known cause for her fevers. Despite this, she checked out AMA. PROBLEM #3: Cirrhosis and steatohepatitis. Most likely secondary to alcohol consumption in a patient with known cirrhosis.
AMA|against medical advice|AMA.|14|17|PLAN|Discharge was AMA. ADMISSION DIAGNOSES: 1. Right upper quadrant abdominal pain. 2. Nausea and vomiting. 3. Alcoholic hepatitis. 4. Cholelithiasis.
AMA|against medical advice|AMA|155|157|PROBLEM #4|He stated she was yelling and felt that she was being unreasonable, but she did not want to elaborate further about the situation. She refused to sign the AMA papers because she wanted her visit to be covered by insurance. Discharge medicines were not given to her by the team. This was discussed with the attending and the senior on duty.
AMA|against medical advice|AMA|436|438|PROBLEMS|D-dimer 1.3. Sodium 139, potassium 3.2, chloride 99, bicarbonate 30, BUN 5, creatinine 0.6, glucose 90, calcium 9.4. The patient had a Breathalyzer of 0.39, but then subsequent blood alcohol level of 0.01. On _%#MM#%_ _%#DD#%_, 2003, the patient had a B12 level of 484, folate of 8.8, and a TSH of 1.7. PROBLEMS: 1. Cellulitis: The patient never received a full course of antibiotic treatment for her cellulitis given that she had left AMA 2 separate times within the past approximately 1 month, and she has had poor compliance with p.o. antibiotics. A lower extremity ultrasound was done and revealed no DVT.
AMA|advanced maternal age|AMA|160|162|HISTORY OF PRESENT ILLNESS|Her first trimester blood pressure was 102/70. Issues of pregnancy include: 1. ITP. 2. Elevated anti-C antibodies with nil titer on _%#MM#%_ _%#DD#%_, 2004. 3. AMA ultrasound revealed possible echogenic focus in the left ventricle and echodense bowels. The patient asked to consider chromosomal analysis, also amniocentesis for anti-C antibodies.
AMA|against medical advice|AMA|135|137|HOSPITAL COURSE|We stopped the fluids again and it remained in the 470s and then went down to the 350s again. At discharge or at the time when he left AMA his last lipase level was 350. We, however, were not too concerned about this level because on his admission in _%#MM#%_ his lipase levels did not get down below 400 although he was deemed treated and ready to go home.
AMA|against medical advice|AMA|112|114|DISPOSITION|He called the following day asking if he could pick up his things and I told him that he would have to sign out AMA in order to do this. He also asked if he would be able to get some pain medications on discharge, and I told him no that he would not since he left AMA, but I did encourage him to continue treating his alcohol dependence and to continue treating his hepatitis C or to be aware of his hepatitis C and stressed the importance of stopping alcohol abuse and dependency with the diagnosis of hepatitis C.
AMA|against medical advice|AMA,|264|267|DISPOSITION|He called the following day asking if he could pick up his things and I told him that he would have to sign out AMA in order to do this. He also asked if he would be able to get some pain medications on discharge, and I told him no that he would not since he left AMA, but I did encourage him to continue treating his alcohol dependence and to continue treating his hepatitis C or to be aware of his hepatitis C and stressed the importance of stopping alcohol abuse and dependency with the diagnosis of hepatitis C.
AMA|against medical advice|AMA.|147|150|DISCHARGE INSTRUCTIONS|17. Prometrium days 1 through 10 of the month. 18. Augmentin 500 - 125 one tablet t.i.d. for 10 days. DISCHARGE INSTRUCTIONS: 1. Discharge to home AMA. The patient did consent to return in the event of persistent fever. 2. Follow-up appointment with Dr. _%#NAME#%_ _%#NAME#%_ in approximately one week.
AMA|against medical advice|AMA.|172|175|HISTORY OF PRESENT ILLNESS|However, he does have a history of cognitive impairment, anxiety and personality disorder, and was put on a 72 hour hold by Dr. _%#NAME#%_ when he was threatening to leave AMA. During his admission in _%#MM#%_, the patient was evaluated by Dr. _%#NAME#%_ and felt that he should have cognitive testing done.
AMA|against medical advice|AMA.|338|341||Mr. _%#NAME#%_ is a 51-year-old gentleman with a past medical history significant for known coronary artery disease, history of medical noncompliance, cocaine use, question of drug seeking behavior, tobacco abuse, multiple hospital and ER visits; this is his 18th since his original myocardial infarction and multiple episodes of leaving AMA. This is his fourth ER visit this month for chest pain. Cardiac history dates back to _%#MMDD2006#%_ when the patient suffered a lateral wall myocardial infarction while using cocaine.
AMA|antimitochondrial antibody|AMA|169|171|HISTORY OF PRESENT ILLNESS|There was some mild fibrosis noted. Iron stains were unremarkable. Hepatitis serologies were negative for hepatitis A, B and C and autoimmune serologies were normal for AMA antimitochondrial antibody, ANA, antinuclear antibody and ASMA antismooth muscle antibody. Serum alpha 1 antitrypsin was within normal limits. The patient had undergone bone marrow biopsy that showed no iron overload
AMA|antimitochondrial antibody|AMA|167|169|ASSESSMENT AND PLAN|Would also recommend obtaining the liver biopsy specimen from St. Vincent's Hospital for review here. It would be reasonable to recheck the autoimmune markers such as AMA antimitochondrial antibody, ANA antinuclear antibody and ASMA antismooth muscle antibody. Would check a TSH as well. Will discuss with Dr. _%#NAME#%_ in the morning as well as with Dr. _%#NAME#%_.
AMA|against medical advice|AMA.|183|186|HISTORY|Signed out AMA. She is being treated with Zyvox for an additional 12 days. Re-hospitalized subsequently at St. Joseph's for persistent bilateral upper extremity infection. Again left AMA. Recollects being treated with IV vancomycin at that facility. Apparently did not obtain medical follow up until _%#MMDD2005#%_when the patient presented to University of Minnesota Medical Center Emergency Department .
AMA|against medical advice|AMA|241|243|ASSESSMENT|He suffered a small myocardial infarction in _%#MM#%_ 2001. He has had multiple admissions to several hospitals including the Mayo Clinic and _%#CITY#%_ Hospital as well as Fairview Southdale and Fairview Ridges since that time. He has left AMA several times. He was last admitted to Fairview Southdale Hospital _%#MM#%_ _%#DD#%_, with coronary angiography showing 20-percent LAD, 30 to 40-percent circumflex, and 40-percent right coronary artery stenosis proximally.
AMA|against medical advice|AMA.|465|468|HISTORY OF PRESENT ILLNESS|Urine drug screen has been performed although the patient denies using any medications and it shows the patient is negative for amphetamines, negative for methamphetamine, negative for barbiturates, positive for benzodiazepines, positive for cannabinoids, positive for cocaine, positive for opiates, negative for PCP, negative for tricyclic antidepressants. The patient initially was offered admission when narcotics were not given to him and he was going to leave AMA. He has subsequently been convinced to stay in the Emergency Department for a second troponin. He has been given Ibuprofen. The patient on further questioning states that he has been buying narcotics off the street and he has not taken any cocaine and they must have been laced with cocaine because he does not use cocaine.
AMA|antimitochondrial antibody|AMA,|131|134|RECOMMENDATIONS|3. Patient is already having her thyroid function test checked as well as celiac serologies and I agree with those. 4. Check ASMA, AMA, ANA 5. Patient is already having iron studies checked. 6. Consider checking ceruloplasmin level. 7. Recheck amylase/lipase tomorrow.
AMA|against medical advice|AMA,|145|148|ASSESSMENT/PLAN|6. I will empirically put him on some Prevacid, as his pain did wake him up during the night. 7. I would not be surprised if this patient leaves AMA, or refuses any further evaluation or changes in his medications. It appears that he is very controlling, and will determine what he is going to take or not take.
AMA|against medical advice|AMA|143|145|RELEVANT HISTORY/REASON FOR REFERRAL|Most recently, she was hospitalized on _%#MMDD2003#%_ after telling a counselor that she wanted to kill herself. She left that hospitalization AMA on _%#MMDD2003#%_. On _%#MMDD2003#%_, she was committed to Metro Residential Treatment Center and will be transferred there upon discharge. Ms. _%#NAME#%_ denied a history of loss of consciousness, seizures, or neurological symptoms, such as unilateral weakness or numbness or changes in balance or coordination.
AMA|against medical advice|AMA.|204|207|PROBLEM #1|She did agree to take oral Keflex 500 mg q.i.d., and was given a prescription for this. She also did agree to see Dr. _%#NAME#%_, her primary physician, in clinic tomorrow for follow-up. She did sign out AMA. PROBLEM #2: Diabetes. Her blood sugars were running high in the 200s during her hospital course.
AMA|against medical advice|AMA.|244|247|PROBLEM #2|It was decided that the patient does need at least two weeks of Vancomycin, and a PICC line was advised for this. After multiple attempts to obtain a PICC line on the day of discharge, it could not be achieved, and the patient decided to leave AMA. PROBLEM #3: Possible heart failure as an etiology of shortness of breath.
AMA|against medical advice|AMA.|111|114|DISCHARGE MEDICATIONS|There was no legal cause, legal reasons to hold the patient. DISCHARGE MEDICATIONS: The patient was discharged AMA. She has her own supplier for Effexor 150 mg daily, which she reports will continue to take.
AMA|against medical advice|AMA|55|57|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Acute respiratory distress. 2. AMA discharge. BRIEF HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 58-year-old male with a history of severe COPD, CHF (EF 25% by TEE in _%#MM2007#%_), paranoid personality disorder and multiple admissions and ER visits for COPD and CHF complicated by persistent medical noncompliance who returns to the ED on the eve of admission with complaints of shortness of breath.
AMA|against medical advice|AMA|279|281|PROBLEM #2|If he presents for future admission in the next days to weeks, it would be prudent to get social work involved immediately to free him to his possible leaving AMA and medical noncompliance issues. PROBLEM #2: AMA discharge. As discussed above, the patient was competent to leave AMA and he decided to do so. As noted above, if he returns to the ED the lower for readmission in the near future, he should have social work evaluate his case to deem whether he is a candidate for more supervised care to prevent recurrent ER visits and readmissions.
AMA|against medical advice|AMA.|182|185|DISCHARGE PLANS|DISCHARGE DIAGNOSIS: 1. Dehydration. 2. Increasing slurred speech, rule out TIA. 3. Hyperglycemia. 4. Hypertension. 5. Upper-respiratory infection. DISCHARGE PLANS: The patient left AMA. PROCEDURES PERFORMED: The patient received a head CT in the ER without contrast, which was negative.
AMA|advanced maternal age|AMA.|146|149|ISSUES THIS PREGNANCY|Rubella immune, VDRL negative, urine culture no growth, hepatitis B surface antigen negative, HIV negative. Platelets 361. ISSUES THIS PREGNANCY: AMA. Declined amniocentesis. ______ spines. Migraines. Level 2 choroid plus assist, with cardiac echogenicity, subsequently resolved on follow-up ultrasound.
AMA|against medical advice|AMA.|118|121|DISCHARGE FOLLOWUP|DISCHARGE DISPOSITION: The patient reports that she will go back home. DISCHARGE FOLLOWUP: The patient was discharged AMA.
AMA|against medical advice|AMA|17|19||The patient left AMA _%#MMDD2007#%_. HISTORY OF PRESENT ILLNESS, HOSPITAL COURSE AND SIGNIFICANT FINDINGS: _%#NAME#%_ _%#NAME#%_ is a 30-year-old homeless woman who presented to the emergency room with complaints of shortness of breath and cough as well as chest pain. She was admitted with the working diagnosis of pneumonia and was started on antibiotics appropriately as per the protocol.
AMA|against medical advice|AMA|239|241|IDENTIFICATION|At that time, she was asked to stay in the hospital until Sunday because on Monday, she could get medications from the doctor's office. She declined that plan and demanded that she will leave the hospital. She was discharged at that point AMA without medications. DISCHARGE STATUS: She was alert and oriented. Her thought process was organized. Her cognitive process impaired. The thought content negative for suicidal ideation or plan.
AMA|against medical advice|AMA|148|150|DISCHARGE MEDICATIONS|2. Anxiety disorder with panic attack. 3. Mild substance abuse, tetrahydrocannabinol found in urine screen. DISCHARGE MEDICATIONS: The patient left AMA without medications. DISCHARGE PLAN: After the patient left, the patient's mother was informed.
AMA|against medical advice|AMA.|162|165|DISPOSITION|3. End-stage Renal Disease: Patient was continued on hemodialysis as per his schedule. Did not have any further issue. DISPOSITION: The patient left the hospital AMA. DISCHARGE MEDICATIONS: His medication included Dilantin 100 mg p.o. q.i.d. and Keppra 750 mg p.o. b.i.d. His last level of (_______________) on _%#MM#%_ _%#DD#%_, 2003, was 26.1. FOLLOW UP: As the patient left AMA, no further recommendations were able to be given to him.
AMA|against medical advice|AMA.|99|102|DISCHARGED|Please do not hesitate to contact me if you have any questions or concerns. DISCHARGED: 0823 hours AMA.
AMA|against medical advice|AMA.|243|246|INITIAL EVALUATION|Tegretol was added. Continued with delusional symptoms, and the client's Abilify and Tegretol were discontinued, and Zyprexa and Depakote were initiated. Commitment services were pursued. Commitment was not obtained. The client was discharged AMA. DISCHARGE DIAGNOSES AXIS I: Bipolar disorder with psychosis. AXIS II: Deferred.
AMA|against medical advice|AMA.|259|262|PROBLEM #2|It is unclear if that actually was given because orders were written to transfer the patient to the Adolescent Psychiatry floor when a bed was available. However, later on that day, the patient did escape from the floor down a back door and left the hospital AMA. DISCHARGE CONDITION: Unstable. Patient psychotic. DISCHARGE DISPOSITION: Discharge AMA. The patient's mother was informed that the patient left AMA.
AMA|against medical advice|AMA.|211|214|DISCHARGE MEDICATIONS|DISCHARGE STATUS: He was discharged against medical advice. He did deny suicidal ideation prior to discharge. DISCHARGE MEDICATIONS: He refused any supply of medications on discharge. DISCHARGE PLAN: Discharged AMA.
AMA|against medical advice|AMA|319|321|HOSPITAL COURSE|He will also have followup with his ophthalmologist. I discussed at length the importance of him maintaining close followup and taking his medications regularly as he is at risk for renal failure, blindness, and significant heart failure. The patient was anxious to be discharged home, and rather than being discharged AMA we decided to discharge him home as his blood pressure was reasonably controlled and his workup was essentially complete at this time.
AMA|against medical advice|AMA.|211|214|HOSPITAL COURSE|At the same time I got a page from a fifth floor patient whose heart rate was 170, hence I prioritized the patient with tachycardia and went to see that patient. By the time I went upstairs the patient had left AMA. LABORATORY DATA AT DISCHARGE: Anion gap has resolved, bicarb 26, sodium 139, blood sugar 151, ketones negative now, magnesium 1.8. Hopefully the patient will follow up with his endocrinologist at Park Nicollet.
AMA|antimitochondrial antibody|AMA,|249|252|PLAN|3. Current symptoms are not thought to be secondary to his blood pressure medication as typically with lisinopril there would be more of a cholestatic type picture with increased alkaline phosphatase. 4. We will, therefore, check iron studies, ANA, AMA, SMA, B12, and folic acid. 5. Viral serologies have already been requested. 6. Liver biopsy will be entertained, however, that after repeated liver studies over the next few weeks.
ASA|acetylsalicylic acid|ASA|124|126|CURRENT MEDICATIONS|1. Allopurinol 200 mg p.o. daily. 2. Accupril 40 mg p.o. daily. 3. Plavix 75 mg p.o. daily. 4. Indocin 50 mg p.o. p.r.n. 5. ASA 81 mg p.o. daily. 6. Isosorbide 5 mg p.o. p.r.n. 7. Toprol 100 mg p.o. daily. 8. Fish oil one cap q day. 9. Zocor 40 mg each day at bedtime. 10. Excedrin for headaches p.r.n.
ASA|American Society of Anesthesiologists|ASA|258|260|PLAN|NEUROLOGIC: Cranial nerves II through XII are grossly intact SKIN: Within normal limits ASSESSMENT: Mammary hyperplasia, chronic neck and shoulder pain secondary to above. PLAN: I see no contraindication to the proposed surgical procedure; the patient is an ASA I. I will have her return to our clinic later this week. Will recheck a blood pressure and forward this to the hospital.
ASA|acetylsalicylic acid|ASA|130|132|MEDICATIONS|4. Xalatan eye drops 0.005% 5. Alphagan eye drops 0.2%. 6. Vitamin D 400 international units daily, 7. Lisinopril 10 mg daily, 8. ASA 81 mg daily. 9. Vytorin 10/20 mg daily. 10. Metformin 500 mg 2 b.i.d. FAMILY HISTORY: Negative for allergic reactions to anesthesia or bleeding tendency.
ASA|acetylsalicylic acid|ASA|153|155|MEDICATIONS|5. Status post ORIF left hip 10/04. MEDICATIONS: 1. Duragesic patch 25 mcg patch q.72 h. 2. Toprol XL 50 mg p.o. daily. 3. Protonix 20 mg p.o. daily. 4. ASA 325 mg p.o. daily. 5. Indocet 5/325 one p.o. q.6 h. p.r.n. 6. Tylenol #3 one to two p.o. q.4-6 h. p.r.n. 7. Ambien 10 mg p.o. q.h.s. p.r.n. 8. In addition, the patient was discharged on prednisone 1 mg p.o. daily, Lasix 20 mg p.o. q.a.m. and Flomax.
ASA|acetylsalicylic acid|ASA|121|123|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Atenolol 100 mg daily. All medicines given through the G-tube by the way. Synthroid 75 mcg daily, ASA 81 mg daily, Prinivil 20 mg daily, Colace 100 mg daily with liquid. Benefiber 2 tablespoons full and water 4 times a day, hydrochlorothiazide 25 mg daily, doxycycline suspension 100 mg b.i.d. until _%#MM#%_ _%#DD#%_, 2004, and glipizide 10 mg given through the G-tube at the beginning of the tube feeding and some 8 hours later and home care was to be continued.
ASA|American Society of Anesthesiologists|ASA|79|81|ASSESSMENT|LOWER EXTREMITIES - with just trace edema. NEURO - grossly normal. ASSESSMENT: ASA 1 for postpartum tubal ligation and there have been no problems with this. Patient will be kept n.p.o. after midnight, epidural catheter in place, and she can use some I.V. morphine through the night, and Dr. _%#NAME#%_ will arrange for OR time in the morning.
ASA|acetylsalicylic acid|ASA,|243|246|DISCHARGE MEDICATIONS|She dialyzed routinely while she was here with her perm cath and was discharged to home on _%#MMDD2002#%_ with instructions to follow-up in two weeks. DISCHARGE MEDICATIONS: Prinivil, metoprolol, Adalat, Prevacid, Nephrocaps, Premarin, Zocor, ASA, Tylenol, and minoxidil.
ASA|acetylsalicylic acid|ASA|216|218|PHYSICAL EXAMINATION|Deep tendon reflexes +2/4 equal upper and lower extremities. MRI report from the outside hospital is essentially normal. EKG is normal sinus rhythm without ectopy. U-tox screen is positive for opiates. Alcohol 0.01. ASA and APAP are both negative. Troponins are 0.07. BNP is less than 5. Hemoglobin is 13.6 with a white blood cell count of 9100, platelet count 356,000.
ASA|acetylsalicylic acid|ASA,|150|153|ALLERGIES|3. Atrial fibrillation. 4. Chronic renal failure. 5. Chronic obstructive pulmonary disease. 6. Anemia of chronic disease. 7. Osteoporosis. ALLERGIES: ASA, codeine, Demerol, Vasotec, Novocain (for dental work produced shaking, tolerates lidocaine). HABITS: Nonsmoker. MEDICATIONS: 1. Protonix 40 mg q. day.
ASA|acetylsalicylic acid|A.S.A.|163|168|HISTORY AND PHYSICAL|5. Lisinopril 10 mg one time daily. 6. Zyprexa 10 mg one time daily. 7. Metformin ER 1500 mg daily. 8. Seroquel 25 to 50 mg up to q.i.d. for anxiety as needed. 9. A.S.A. 300 mg one time daily. 10. Phenobarbital per taper. See chart. DISCHARGE PLAN: 1. He is to continue the prescribed medications.
ASA|acetylsalicylic acid|ASA|155|157|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1. Lipitor 20 mg p.o. daily. 2. Enalapril 10 mg p.o. b.i.d. 3. Carbamazepine 200 mg p.o. b.i.d. 4. Cimetidine 400 p.o. b.i.d. 5. Baby ASA once a day. 6. Glucosamine chondroitin sulfate 100 mg p.o. b.i.d. 7. Zetia 10 mg p.o. daily. 8. She also takes a multivitamin and calcium.
ASA|acetylsalicylic acid|ASA|113|115|MEDICATIONS ON DISCHRAGE|3. Multivitamin with Iron one p.o. daily. 4. Celexa 10 mg p.o. daily. 5. Ativan 0.5 mg one p.o. b.i.d. p.r.n. 6. ASA 325 mg p.o. daily. 7. Diltiazem ER 60 mg p.o. daily given 30 with two refills. 8. Acetaminophen 650 mg p.o. q.4h p.r.n. pain and fever.
ASA|acetylsalicylic acid|ASA|129|131|DISCHARGE MEDICATIONS|2. Vasotec 5 mg 1 p.o. b.i.d. 3. Lasix 60 mg p.o. daily. 4. Cilostazol 100 mg p.o. b.i.d. 5. Spironolactone 25 mg 1 daily. 6. EC ASA 325 mg one daily. 7. Lipitor 20 mg p.o. daily. 8. Nicotine patch 21 mg replace daily. 9. Albuterol MDI 2 puffs q.4 h. p.r.n. SOA.
ASA|American Society of Anesthesiologists|ASA|170|172|PLAN|II-XII are grossly intact. SKIN: Is within normal limits. ASSESSMENT: Intimal tear. PLAN: I see no contraindication to the proposed surgical procedure. The patient is an ASA I
ASA|acetylsalicylic acid|ASA|179|181|MEDICATIONS|3. Bilateral cataract removal with follow up lasers. ALLERGIES: Duricef causes a rash. She tolerates penicillin MEDICATIONS: 1. Dyazide 25 mg daily 2. Premarin cream vaginally 3. ASA AC Q day 81 mg 4. Timoptic one gtt OU QD. 5. Klor-Con 10 mEq daily 6. Calcium supplement 7. Temazepam 50 mg at HS and recently she has been taking Vicodin for arthritic pain.
ASA|acetylsalicylic acid|ASA|121|123|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1. Prinivil 5 mg daily 2. HCTZ 25 mg daily 3. Saw palmetto one daily 4. Cardura 2 mg daily at HS 5. ASA 325 mg daily. This is on hold. 6. Celebrex 200 mg b.i.d. prn. prescribed on _%#MMDD2002#%_. FAMILY HISTORY: Mother had degenerative arthritis. Father is deceased at 75 from a stroke.
ASA|American Society of Anesthesiologists|ASA|177|179|PLAN|3. Adult-onset diabetes, good control. 4. Depression, stable. 5. Ongoing tobacco abuse. PLAN: The patient is cleared for surgery from Dr. _%#NAME#%_ and myself. She is category ASA 1-2 for general anesthesia. Smoking cessation is always encouraged. The patient will be several days in the hospital after her procedure.
ASA|American Society of Anesthesiologists|ASA|101|103|PLAN|ASSESSMENT: 1. Ganglion cyst. 2. Hyperlipidemia. 3. Borderline hypertension. PLAN: The patient is an ASA II. I see no contraindications to the proposed surgical procedure. The patient needs to return to the clinic for a fasting lipid profile.
ASA|acetylsalicylic acid|ASA|139|141|DISCHARGE MEDICATIONS|Patient continued to do well and was discharged to _%#CITY#%_ Care Center on _%#MMDD2002#%_. DISCHARGE MEDICATIONS: 1. Norvasc 5 mg qd. 2. ASA 325 mg po qd. 3. Captopril 25 mg po qd. 4. Furosemide 40 mg po bid. 5. Vicodin 5/500 q4h prn. 6. Nasonex one spray qd.
ASA|acetylsalicylic acid|ASA|137|139|CURRENT MEDICATIONS|SYSTEM REVIEW: The patient denies pulmonary cardiovascular and CNS type symptoms. CURRENT MEDICATIONS: 1. Zoloft 50 mg daily only. 2. No ASA use, occasional Advil use. Warned to discontinue those medications for 1 week prior to surgery. PHYSICAL EXAMINATION: 46Y, 66.5 inches, 119 pounds, 98/60. HEENT, neck, thyroid, carotids negative.
ASA|acetylsalicylic acid|ASA|147|149|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Lovenox 100 mg subcu every 12 hours until his INR is therapeutic. 2. Dilantin 400 mg qd. 3. Doxycycline 100 mg b.i.d. 4. ASA 81 mg qd. 5. Coumadin 5 mg tablets, 10 mg daily until his INR is therapeutic with adjustment as needed then.
ASA|acetylsalicylic acid|ASA|218|220|MEDICATIONS|3. Hypertension. 4. Irritable bowel syndrome status post a gastrograph and enema in _%#MMDD#%_, which was negative. 5. Hypercholesterolemia. MEDICATIONS: Glucophage 850 mg po tid, Amaryl 2 mg qd, Klor- Con 10 mEq bid, ASA 325 mg qd, Zocor 20 mg qd, Zestril that she's a little unsure and we wonder if it's 40 or 20 mg qd, Lasix 40 mg qd, Toprol XL most likely 50 mg qd.
ASA|acetylsalicylic acid|ASA|170|172|PLAN|Activities otherwise unrestricted. She is to be on the following medications: 1. Lipitor, 10 mg daily. 2. Neurontin 300 mg b.i.d. 3. Lozol 1.25 mg two daily as needed 4. ASA 81 mg daily. 5. Premarin 0.625 mg daily. 6. Hydralazine 10 mg t.i.d. which is new. 7. Omeprazole 20 mg over the counter as needed 8. Multi vitamins and calcium 500 mg t.i.d.
ASA|acetylsalicylic acid|ASA|191|193|MEDICATIONS|Hysterectomy and BSO and bladder repair in 1995. Sinus surgery in _%#MM2003#%_. MEDICATIONS: Esterase 2 mg 1 daily, Nadolol 20 mg 1 daily, Cozaar 100 mg 1 daily, Fosamax 35 mg x once a week, ASA 81 mg 1 daily, clonidine 0.1 mg 1 in the a.m and 2 at bedtime, Effexor 37.5 mg 1 daily, hydrochlorothiazide 12.5 mg 1 daily.
ASA|acetylsalicylic acid|ASA.|203|206|ALLERGIES|MEDICATIONS: Glipizide, Toprol, Levaquin, maintenance prednisone, Combivent, lisinopril, paroxetine and Spiriva. ALLERGIES: She has known allergies to Sulfa, to codeine products, to ciprofloxacin and to ASA. She is 84 years of age. I had a long discussion today with her son who is concerned about considering placing her on hospice status and she understands how tenuous her pulmonary function is.
ASA|acetylsalicylic acid|ASA|122|124|MEDICATIONS|ALLERGIES: He has no known drug allergies. He is allergic to adhesive tape. MEDICATIONS: 1. Norvasc 10 mg p.o. q. day. 2. ASA 81 mg p.o. q. day. 3. Lipitor 20 mg p.o. q. day. 4. Clonidine 0.2 mg p.o. b.i.d. 5. Zetia 10 mg p.o. q. day. 6. Allegra 60 mg p.o. q.a.m.
ASA|American Society of Anesthesiologists|ASA|211|213|ASSESSMENT|NEUROLOGIC: Intact exam. ASSESSMENT: 1. Generally healthy, 71-year-old, white male who is remaining quite active and who wishes to continue to do so. 2. No contra-indication for the proposed procedure. 3. He is ASA 1 for general anesthesia. 4. Hypertension, under good control. 5. Mild prostatic hypertrophy which is somewhat symptomatic, but not overly bothersome.
ASA|American Society of Anesthesiologists|ASA|202|204|PLAN|ASSESSMENT: 1. Chronic muscular pain. 2. Adult onset diabetes mellitus, under excellent control. 3. Hyperlipidemia. PLAN: I see no contraindication to the proposed surgical procedure. The patient is an ASA 2. I will check a basic metabolic panel, as well as a hemoglobin A1C and forward them to the hospital when they are available.
ASA|American Society of Anesthesiologists|ASA|217|219|ASSESSMENT|No edema. NEUROLOGIC intact. LABORATORY: A copy of her prenatal labs, history and physical, and prenatal course are sent along with the faxed copy of the preoperative form and all have been normal. ASSESSMENT: She is ASA category 2 because of her pregnancy at 23 to 24 weeks, but no complication. There is no contraindication for the surgery.
ASA|American Society of Anesthesiologists|ASA|157|159|PLAN|If she needs a potassium this would have to be done at the hospital before her surgery. Last potassium was 4.1 on _%#MM#%_ 26 at the hospital. Patient is an ASA II and possibly III because of her past history of TIA and MI but since she cleared the other surgery, I don't think she will have any problems.
ASA|American Society of Anesthesiologists|ASA|130|132|PLAN|11. Resolving right popliteal cellulitis PLAN: The patient will be admitted on _%#MMDD2003#%_ for redo right arthroplasty. She is ASA Class II-III. Both Dr. _%#NAME#%_ and myself have discussed the risks and benefits with the patient. She is a risk, but benefits are seen with this.
ASA|acetylsalicylic acid|ASA|140|142|DISCHARGE MEDICATIONS|4. Colace 100 mg p.o. q. 12 hours. 5. Nortriptyline 150 mg p.o. q.h.s. 6. Lexapro 20 mg p.o. q. 24 hours. 7. Ritalin 15 mg p.o. q. noon. 8. ASA 81 mg p.o. q.a.m. 9. Glyburide 5 mg p.o. q. 24 hours. 10. Cipro 500 mg p.o. q. 12h. x 3 days. DISCHARGE INSTRUCTIONS: 1. Diet: Regular. 2. Activity: As tolerated.
ASA|acetylsalicylic acid|ASA|156|158|DISCHARGE MEDICATIONS|ET nursing was consulted and wound care recommendations were given. DISCHARGE MEDICATIONS: 1. Macrobid SR 100 mg p.o. b.i.d. 2. Toprol 50 mg p.o. q day. 3. ASA 81 mg p.o. q day. 4. Viokase 4-5 tabs p.o. t.i.d. with each meal. 5. Multivitamin, 1 tab p.o. q day. 6. Vitamin C 250 mg p.o. q day.
ASA|acetylsalicylic acid|ASA|144|146|DISCHARGE MEDICATIONS|3. Depression. 4. History of transient ischemic attack. 5. Gout. 6. Hyperlipidemia. DISCHARGE MEDICATIONS: 1. Allopurinol 100 mg p.o. daily. 2. ASA 325 mg p.o. daily. 3. Ciprofloxacin 500 mg p.o. daily x 7 days. 4. Celexa 20 mg p.o. daily. 5. Lisinopril 10 mg p.o. daily.
ASA|American Society of Anesthesiologists|ASA|118|120|PLAN|IMPRESSION: This is a 70-year-old male with cholelithiasis PLAN: Cholecystectomy tomorrow. He is cleared for surgery, ASA class 2 will continue with his current medications. Would recommend cardiology following in the postoperative period. He is anemic at this time and has had a history of chronic anemia.
ASA|acetylsalicylic acid|ASA|144|146|MEDICATIONS|ALLERGIES: None MEDICATIONS: 1. Keflex 2 grams intravenous two times a day 2. Simvastatin 40 mg. daily. 3. Cholestyramine one package daily. 4. ASA 81 mg daily. 5. Lisinopril 10 mg. daily 6. Naprosyn 500 mg. b.i.d. which is on hold 7. Vicodin for pain
ASA|acetylsalicylic acid|ASA,|178|181|MEDICATIONS|6. Left cataract extraction. 7. Left tib-fib fracture with multiple procedures in the last 2-3 years. ALLERGIES: MS causes severe nausea. MEDICATIONS: Synthroid 100 mcg per day, ASA, Keflex, IV vancomycin, Vicodin, calcium, vitamin D, multivitamins, Tagamet. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Past tobacco use; quit about a year and a half to 2 years ago.
ASA|acetylsalicylic acid|ASA|259|261|HOSPITAL COURSE|Patient is now fully anticoagulated and this should be continued for the next few months; after this time, it should be decided if long term coagulation should be pursued. I did discuss this with the patient's daughter and at this time they are favoring just ASA and not continuing with long term anticoagulation later. LDL was checked and was 61 with HDL, however, on 35. The patient is currently chest pain-free and hemodynamically stable. Blood pressures are not optimal at this time, but are better.
ASA|acetylsalicylic acid|ASA|163|165|MEDICATIONS|5. Humalog insulin. 6. Lantus insulin. 7. Iron 325 mg b.i.d. 8. Atenolol 50 mg q. day. 9. Gemfibrozil 600 mg b.i.d. 10. Sublingual nitroglycerin 0.4 mg p.r.n. 11. ASA 81 mg q. day. 12. Plavix 75 mg q. day. FAMILY HISTORY: Negative for allergic reactions to anesthesia or bleeding diathesis.
ASA|American Society of Anesthesiologists|(ASA|150|153|ASSESSMENT|EKG showed normal sinus rhythm, no acute changes. Chest x-ray within normal limits. ASSESSMENT 1. Healthy patient with localized pathological process (ASA I) for general anesthesia or spinal anesthesia for total vaginal hysterectomy, atrial natriuretic peptide (ANP) repair for prolapse and cystocele issues.
ASA|acetylsalicylic acid|ASA|337|339|PROBLEM #3|There was a concern on admission, given the discrepancies in his anti-10a levels, which were varied from his last admission despite him being on the same dosing, he was thus decreased to 15 mg daily of subcu Lovenox. Anti-10a levels were followed and thought to be therapeutic within the prophylactic range at the time of discharge. His ASA was initially held on admission but was resumed once no evidence of bleeding persisted. His hemoglobin at the time of discharge was 8.8. PROBLEM #4: Dermatology.
ASA|acetylsalicylic acid|ASA|124|126|MEDICATIONS ON DISCHARGE|She will continue with her anti-rejection therapy in the outpatient setting as outlined below. MEDICATIONS ON DISCHARGE: 1. ASA 81 mg p.o. q.d. 2. Lipitor 20 mg p.o. q.d. 3. Calcium/vitamin D 500 mg p.o. t.i.d. 4. Cipro 250 mg p.o. q. 12h. Stop on _%#MMDD2003#%_ (for a new UTI).
ASA|acetylsalicylic acid|ASA|205|207|DISCHARGE MEDICATIONS|The final results showed no evidence of rejection. The patient was discharged home with the recommendation to follow up with the transplant coordinator. DISCHARGE MEDICATIONS: 1. Norvasc 5 mg p.o. q.d. 2. ASA 81 mg p.o. q.d. 3. Lipitor 10 mg p.o. q.d. 4. Calcium carbonate/vitamin D 500 mg p.o. b.i.d. 5. Mycelex troche 1 tablet q.i.d. 6. Neoral 150 mg p.o. b.i.d.
ASA|American Society of Anesthesiologists|ASA|167|169|ASSESSMENT|Chest x-ray within normal limits. Labs will be performed at the hospital on _%#MMDD2003#%_ and has been arranged through the orthopedic office apparently. ASSESSMENT: ASA 2 for right total knee arthropathy under spinal anesthesia. Other medical problems include DJD, hypertension, high cholesterol, diet controlled, osteoporosis, and history of spondylolisthesis.
ASA|acetylsalicylic acid|ASA|191|193|DISCHARGE MEDICATIONS|Sensation: intact throughout. At the time of discharge, the patient denied pain in his left upper extremity. DISCHARGE MEDICATIONS: 1. Colace 100 mg p.o. q12h. 2. Zoloft 100 mg p.o. q24h. 3. ASA 81 mg p.o. q24h. 4. Losartan 75 mg p.o. q24h. 5. Valium 5 mg p.o. q4h p.r.n. pain. 6. Darvocet-NN 100 one to two tabs p.o. q6h p.r.n. pain.
ASA|acetylsalicylic acid|ASA|189|191|ADMISSION MEDICATIONS|pylori demonstrated. His hemoglobin was around 13.2 as of discharge and is slightly lower at the present time. ADMISSION MEDICATIONS: 1. The chart indicates that he was told to stop taking ASA 325, but his wife says he is taking it. 2. Nitroglycerin 0.4 mg sublingually p.r.n. for chest discomfort. 3. Glyburide 5 mg orally b.i.d. 4. Humulin 70/30, 40 units daily.
ASA|acetylsalicylic acid|ASA|190|192|DISCHARGE MEDICATIONS|1. ASA 325 mg per day. 2. Feeding via the PEG tube. I have avoided putting him on Coumadin in view of the fact that he had abnormal liver function studies and we will manage him simply with ASA 325 mg per day.
ASA|acetylsalicylic acid|ASA|142|144|MEDICATIONS|MEDICATIONS: 1. Metoprolol 25 mg p.o. b.i.d. 2. Accupril 20 mg p.o. b.i.d. 3. Adalat 60 mg p.o. q. daily. 4. Doxazosin 4 mg p.o. q. daily. 5. ASA 325 mg p.o. q. daily. 6. Celebrex p.r.n. The patient recently discontinued Lipitor on her own.
ASA|acetylsalicylic acid|ASA|115|117|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Avandia 4 mg p.o. daily 2. Metformin 1000 mg p.o. b.i.d. 3. Lipitor 10 mg p.o. q.h.s. 4. ASA 81 mg p.o. daily 5. Keflex 500 mg p.o. q.i.d. x 7 days 6. Abilify 10 mg p.o. q.h.s. ALLERGIES: No known drug allergies.
ASA|acetylsalicylic acid|ASA,|153|156|MEDICATIONS|6. Hospitalized briefly in _%#MM2001#%_ with nausea, vomiting, and hyponatremia. 7. History of osteoporosis. MEDICATIONS: 1. Neurontin, 300 mg t.i.d. 2. ASA, 81 mg q.d. - on hold for surgery. 3. Fosamax, 70 mg q. one week. HABITS: None. ALLERGIES: None. FAMILY HISTORY: No anesthesia reactions noted. SOCIAL HISTORY: The patient is a widower of several years and has family who will be helping him postoperatively.
ASA|acetylsalicylic acid|ASA|188|190|DISCHARGE MEDICATIONS|His Zocor had been stopped given his multiple complaints. If he continues to do well off Provigil, reintroduction of a statin as an outpatient may be beneficial. DISCHARGE MEDICATIONS: 1. ASA 325 mg p.o. daily. 2. Coreg 3.125 mg p.o. b.i.d. (restart). 3. Digoxin 0.125 mg p.o. daily (restart). 4. Lisinopril 10 mg p.o. b.i.d. (higher dose).
ASA|American Society of Anesthesiologists|(ASA)|134|138|PLAN|4. We will repeat his liver enzymes in the morning. 5. If he does go for surgery he would be an American Society of Anesthesiologists (ASA) Category 2 patient secondary to his coronary artery disease and remote history of a myocardial infarction though he did have a stent in _%#MM#%_ 2004.
ASA|acetylsalicylic acid|ASA.|138|141|ADMISSION MEDICATIONS|3. AAA repair in 1997. 4. Hypertension. 5. Parotid tumor, status post left parotidectomy. 6. Basal cell cancer. ADMISSION MEDICATIONS: 1. ASA. 2. Atenolol. 3. Lisinopril. ALLERGIES: No allergies. SOCIAL HISTORY: Does not currently smoke.
ASA|acetylsalicylic acid|ASA|146|148|ALLERGIES|2. Follow up with Dr. _%#NAME#%_ in 4 days, on Tuesday, in the neurosurgery clinic for staple removal. 3. Continue all home medications including ASA 81 mg p.o. q.day. 4. Discharge medications are Vicodin ES and Senna-S. 5. Return if any weakness, numbness, speech problems, mental status changes, or vision problems.
ASA|acetylsalicylic acid|ASA|197|199|PAST MEDICAL HISTORY|He has not had increased chest pain or cough. The family has not noticed any fever or chills. The patient has not complained of headache. Current medications include 1. Norvasc 10 mg every day. 2. ASA 325 mg every day. 3. Isosorbide 10 mg p.o. t.i.d. 4. Lisinopril 5 mg every day. 5. Prilosec 20 mg every day. 6. Temazepam 15 mg one to two at h.s.
ASA|acetylsalicylic acid|ASA|215|217|MEDICATIONS|According to staff Mr. _%#NAME#%_ has not been complaining of pain, had cough, appeared short of breath, had any nausea, vomiting or diarrhea. MEDICATIONS: 1. Potassium, 20 mEq q. day. 2. Omeprazole 20 mg daily. 3. ASA 81 mg q. day. 4. Lasix 20 mg q. day. 5. Namenda 10 mg b.i.d. 5. Aricept 10 mg daily. 6. Lipitor 20 mg daily.
ASA|American Society of Anesthesiologists|ASA|268|270|PLAN|EKG done in _%#MM#%_ of 2001 right before her cataract surgery showed no acute changes and actually was pretty normal, a little bit of widened QRS and probably old Q in III and AVR. ASSESSMENT: Degenerative joint disease left knee PLAN: Proceed as per Dr. _%#NAME#%_. ASA Category I.
ASA|acetylsalicylic acid|ASA|123|125|MEDICATIONS|2. Protonix 40 mg daily. 3. Tricor 145 mg daily. 4. Paxil 20 mg daily. 5. Lasix 20 mg daily. 6. Lisinopril 20 mg daily. 7. ASA 81 mg daily. 8. Zantac 150 mg b.i.d. REVIEW OF SYSTEMS: As above. She does have a chronic cough. She gets occasional heartburn.
ASA|American Society of Anesthesiologists|ASA|203|205|PLAN|3. Hypertension, under excellent control. 4. History of hyperlipidemia. 5. Pulmonary hypertension, oxygen dependent. PLAN: I see no contraindication to the proposed surgical procedure. The patient is an ASA 3. Given that he is unable to ambulate at this time, I will order a wheelchair for the patient. We will check a comprehensive metabolic panel as well as a hemoglobin A1c and forward those labs to the hospital when they are available.
ASA|acetylsalicylic acid|ASA,|188|191|DIAGNOSES|Recent carotid ultrasound showed no change in the stenosis, and there were no further interventions desired by the family or patient. Blood pressure is controlled, and he is on Plavix and ASA, as well as Lipitor for cholesterol management. DISCHARGE MEDICATIONS: 1. Plavix 75 mg q.a.m. 2. Synthroid 0.15 mg q.a.m.
ASA|acetylsalicylic acid|ASA|171|173|DISCHARGE MEDICATIONS|3. Prevacid 30 mg q.a.m. 4. Terazosin 2 mg p.o. at 3:00 p.m. and q.h.s. 5. Zoloft 150 mg q.a.m. 6. Atenolol 25 mg p.o. q.d. 7. Lipitor 20 mg p.o. q.h.s. 8. Enteric coated ASA 325 mg q.d. 9. Neurontin 300 mg b.i.d. 10. Tylenol 500 mg q.i.d. DISCHARGE PLANS: As outlined above, the patient will be discharged today, _%#MMDD2002#%_.
ASA|acetylsalicylic acid|ASA|134|136|DISCHARGE MEDICATIONS ARE AS FOLLOWS|DISCHARGE MEDICATIONS ARE AS FOLLOWS: 1. Oxycodone 5 mg p.o. q.4h. p.r.n. breakthrough pain only. 2. Percocet 2 tablets p.o. q.6h. 3. ASA 325 mg p.o. q.d. 4. Clonidine 0.2 mg transdermal patch q. week. 5. Lasix 40 mg p.o. q.d. 6. NPH 20 units subQ q.a.m. and 15 units subQ q.p.m.
ASA|acetylsalicylic acid|ASA|146|148||His other medications are to continue as before unchanged. They include: 1. Norvasc 10 mg orally daily. 2. Minoxidil 10 mg twice daily. 3. Coated ASA 325 mg orally. 4. Plavix 75 mg orally daily. 5. Lisinopril 40 mg orally daily. 6. Imdur 30 mg orally daily in the morning.
ASA|acetylsalicylic acid|ASA|75|77|HISTORY OF PRESENT ILLNESS|Zoloft 50 mg q. day, and multivitamin q. day. Dilantin 300 mg at h.s., and ASA 1. q. day since she was taken off the Coumadin. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: She does have bowel and bladder incontinence related to her CVA.
ASA|acetylsalicylic acid|ASA.|164|167|MEDICATIONS|He has bed rails, scooter, stair glide, and bath bench and grab bars. MEDICATIONS: 1. Betaseron. 2. Baclofen. 3. Atenolol. 4. Trileptal. 5. Flonase. 6. Allegra. 7. ASA. 8. Valproic. 9. Zantac. REVIEW OF SYSTEMS: The patient denies headaches. No diplopia or dysphagia. No shortness of breath. Complains of minor incisional chest pain.
ASA|American Society of Anesthesiologists|ASA|196|198|ASSESSMENT|MCV was normal. Potassium and PTT are pending, we will get these results and send them to you. ASSESSMENT: This is a 78-year-old gentleman for a preop, though he looks very healthy he would be an ASA II because of his previous history of coronary artery disease and his alcohol intake. We told him that it would be best for him to stop his alcohol.
ASA|American Society of Anesthesiologists|ASA|139|141|ASSESSMENT|EKG showed normal sinus rhythm with some old inferior changes. Chest x-ray within normal limits, perhaps minimal cardiomegaly. ASSESSMENT: ASA 2 for right total hip arthroplasty with the other medical problems as mentioned above. He does still have some dyslipidemia and would benefit from use of niacin in the future because of his low HDL of 32.
ASA|acetylsalicylic acid|ASA|235|237|ALLERGIES|She was subsequently transferred to the Neurosurgery Ward, where she began ambulating independently, tolerating a regular diet, with pain well controlled on oral pain medications. She will be discharged home. DISCHARGE MEDICATIONS: 1. ASA 325 mg p.o. q.d. 2. Lipitor 10 mg p.o. q.d. 3. Colace 100 mg p.o. b.i.d. 4. Prevacid 30 mg p.o. q.d. 5. Nicotine patch 21 mg transdermal q.d.
ASA|American Society of Anesthesiologists|ASA|209|211|PLAN|NEUROLOGIC: Deep tendon reflexes (DTR) appear equal. SKIN: Within normal limits. ASSESSMENT: Nerve entrapment. PLAN: 1. I see no contraindications to the proposed surgical procedure. 2. The patient will be an ASA II. 3. I did talk to the patient about smoking cessation; she will think this over. 4. She will require follow-up in our clinic secondary to her hyperlipidemia.
ASA|acetylsalicylic acid|ASA|152|154|MEDICATIONS|2. Nasonex one puff in each nostril qd. 3. Mucomyst 600 mg PO b.i.d. 4. Singular 10 mg PO q hs. 5. Albuterol inhaler, nebulizer. 6. Combivent p.r.n. 7. ASA 325 mg PO qd. 8. Prednisone 5 mg PO qd. 9. T3 from his son; 10. Two Extra Strength Tylenol in the morning generally. The record also mentions the use of lisinopril 10 mg daily one year ago.
ASA|acetylsalicylic acid|ASA|125|127|MEDICATIONS|1. Hypertension 2. Diabetes mellitus 3. Hypercholesterolemia 4. Hernia repair in 1996 MEDICATIONS: 1. Elavil 20 mg q.h.s. 2. ASA 81 mg daily 3. Decadron 4 mg b.i.d. 4. Methadone 5 mg q8 hours with 5 mg q4 hours p.r.n. breakthrough pain.
ASA|acetylsalicylic acid|ASA|243|245|DISCHARGE MEDICATIONS|It was thought that the patient was alert to a sufficient degree where his fatigue would not affect his activities of daily living to any significant degree. DISCHARGE MEDICATIONS: 1. Clindamycin 450 mg p.o. t.i.d. x 4 days. 2. Enteric-coated ASA 81 mg p.o. daily. 3. Lasix 30 mg p.o. daily. 4. Seroquel 200 mg p.o. q.h.s. 5. Combivent 2 puffs q.i.d. and 4 puffs q.4h. p.r.n. shortness of breath.
ASA|acetylsalicylic acid|ASA|114|116|DISCHARGE MEDICATIONS|2. Right knee contusion, status post fall. SECONDARY DISCHARGE DIAGNOSIS: Hypertension. DISCHARGE MEDICATIONS: 1. ASA 325 mg p.o. daily. 2. Diovan 320 mg p.o. daily. 3. Premarin 0.3 mg p.o. daily. 4. Metoprolol 12.5 mg p.o. b.i.d.
ASA|acetylsalicylic acid|ASA|218|220|IDENTIFICATION|On admission, orders were written to monitor her for alcohol withdrawal with Ativan to cover her withdrawal symptoms. In addition, the following medications were reordered: Celexa 30 mg daily, Neurontin 900 mg t.i.d., ASA 325 mg daily, Protonix 40 mg daily, Colace 100 mg b.i.d., and miconazole cream 2% to feet b.i.d.
ASA|acetylsalicylic acid|ASA|177|179|IDENTIFICATION|Her affect was congruent. Her insight and judgment were intact. Her mood was moderately depressed but improved since admission. DISCHARGE MEDICATIONS: 1. Celexa 40 mg daily. 2. ASA 325 mg daily. 3. Colace 100 mg daily. 4. Antabuse 250 mg daily. 5. Prevacid 303 mg daily. 6. Nicotine patch per tapering orders, see chart.
ASA|acetylsalicylic acid|ASA|149|151|HOSPITAL COURSE|7. Miralax 1 teaspoon in 8 ounces of water daily. 8. Neurontin 300 mg p.o. b.i.d. 9. Pred Forte ophthalmic drops 1% one drop to right eye b.i.d. 10. ASA 81 mg p.o. daily. DISCHARGE INSTRUCTIONS: 1. Follow up with Dr. _%#NAME#%_ in 1 to 2 weeks. 2. Home healthcare to follow.
ASA|acetylsalicylic acid|ASA|186|188|HOSPITAL COURSE|She also received Rocephin 500 mg IV q. 24 hours and was discharged on Keflex 500 mg b.i.d. for seven to ten days. The only other medication that I will continue her on at this point is ASA 81 mg daily. I am holding her furosemide, Aticand, Norvasc, and Celebrex. She had evidence of depression during her hospital stay and was much brighter today.
ASA|acetylsalicylic acid|A.S.A.|250|255|MEDICATIONS|Her husband still drives and appears to be fully able to take care of the home and as long as she is able to get up out of bed, and takes good care of his wife. MEDICATIONS: Paxil 40 mg every morning. Aricept 5 mg every morning. Lipitor 10 mg q.h.s. A.S.A. 81 mg daily. Also was on alprazolam and Zyprexa, question specific doses. ALLERGIES: Penicillin only. HABITS: Tobacco: None. Alcohol: None. REVIEW OF SYSTEMS: Unremarkble aside from occasional urinary incontinence with no other urinary symptoms.
ASA|acetylsalicylic acid|ASA,|170|173|MANAGEMENT|Deep tendon reflexes are symmetrical and slightly hyperactive. IMPRESSION: 1. Impending CVA. 2. Type II diabetes. MANAGEMENT: He is admitted and placed on IV heparin and ASA, his diabetes will be managed with Glyburide and Neurology will see him in the morning.
ASA|acetylsalicylic acid|ASA.|132|135|ADMISSION MEDICATIONS|He quit smoking approximately 42 years ago and drinks occasionally. ADMISSION MEDICATIONS: 1. Piroxicam. 2. Lipitor. 3. Maxzide. 4. ASA. 5. Glucosamine. FAMILY HISTORY: COPD, possible atherosclerotic hip disease. REVIEW OF SYMPTOMS ON ADMISSION: Patient has bilateral hearing aids, no nausea or vomiting, diarrhea resolving, no weight loss, no change in appetite, and chronic knee pain.
ASA|acetylsalicylic acid|ASA|148|150|MEDICATIONS|1. Qbid one to two p.r.n. 2. Lisinopril 5 mg two q.a.m. and one q.p.m. 3. Protonix 40 mg q.d. 4. Diltiazem XR 180 mg q.d. 5. Hydrocel one q.a.m. 6. ASA 81 mg q.d. 7. Correctol q.a.d. 8. Nasonex. FAMILY HISTORY: No history of breast cancer or colon cancer.
ASA|acetylsalicylic acid|ASA|541|543|CURRENT MEDICATIONS|Illnesses: Hypertension, peripheral vascular disease, prostate carcinoma with radiation therapy and radical prostatectomy, lipid disorder, prior history of nicotine abuse, non insulin dependent diabetes mellitus, bilateral renal artery stenoses, remedied by angioplasty, anterior ischemic OD neuropathy, azotemia with a current BUN of 74 and a creatinine of 2.7 as of _%#MMDD2003#%_ with a hemoglobin of 12.6 and a normal basic metabolic panel with the exception of the BUN and creatinine. CURRENT MEDICATIONS: Lipitor 20, Lopid 600 b.i.d., ASA 325, p.r.n. Darvocet, Plavix 75 daily, Benicar 40. ALLERGIES: NONE. REVIEW OF SYSTEMS: The patient denies cardiovascular, pulmonary and central nervous system type symptoms.
ASA|American Society of Anesthesiologists|ASA|179|181|PLAN|ASSESSMENT: Lung nodule in a patient with a previously-diagnosed and removed lung carcinoma. PLAN: I see no contraindication to the proposed surgical procedure. The patient is an ASA II. Will gladly follow should he require hospitalization postoperatively.
ASA|American Society of Anesthesiologists|ASA|193|195|PLAN|II-XII grossly intact. SKIN - within normal limits. ASSESSMENT: C-section, postpartum tubal ligation. PLAN: I see no contraindication to the proposed surgical procedure. The patient will be an ASA 1.
ASA|acetylsalicylic acid|ASA|143|145|CURRENT MEDICATIONS|He lives with his wife and remains very active with home projects. CURRENT MEDICATIONS: Lamictal 200 mg b.i.d. Lisinopril 10 mg every morning. ASA 81 mg every morning. Folic acid 1 mg every morning. Norvasc 5 mg every morning. Lipitor 20 mg q.h.s. ALLERGIES: No known allergies (NKA).
ASA|American Society of Anesthesiologists|ASA|173|175|PLAN|II through XII grossly intact. SKIN: Within normal limits. ASSESSMENT: Meniscal tear. PLAN: I see no contraindications to the proposed surgical procedure. The patient is an ASA I.
ASA|acetylsalicylic acid|ASA.|384|387|DISCHARGE MEDICATIONS|She had significant associated fatigue, which improved steadily and she was able to be discharged home on the fourth hospital day to continue on an oral regimen and to follow up with her personal physician. DISCHARGE DIAGNOSIS: Asthma exacerbation with associated bronchitis. DISCHARGE MEDICATIONS: As outlined on the chart, albuterol MDI, Levaquin, Medrol taper, Lipitor, Diovan and ASA. Condition stable at the time of discharge.
ASA|acetylsalicylic acid|ASA|423|425|DISCHARGE MEDICATIONS|On _%#MM#%_ _%#DD#%_, 2005, and _%#MM#%_ _%#DD#%_, 2005, the patient will start a p.o. prednisone taper starting with 75 mg, this would then be decreased to 50 mg on _%#MM#%_ _%#DD#%_, 2005, and subsequently to 25 mg on _%#MM#%_ _%#DD#%_, 2005, and finally the patient will continue with 5 mg beginning on _%#MM#%_ _%#DD#%_, 2005, and this will be continued and finally tapered off by the Transplant Clinic coordinator. 2. ASA 81 mg p.o. daily. 3. Calcium carbonate 1250 mg p.o. t.i.d. 4. Mycelex troche 1 troche in the mucous membrane q.i.d.
ASA|acetylsalicylic acid|ASA|213|215|PROBLEM #1|We will control blood sugar by insulin sliding scale during this hospital course. We will check the blood culture and urinalysis to further rule out infection His most recent hemoglobin A1C was 10.4. He will need ASA after discharge. PROBLEM #2: Hypertension. Continue Enalapril. PROBLEM #3: Hyperlipidemia. We will start Statins if his repeat lipid profile shows hyperlipidemia..
ASA|acetylsalicylic acid|ASA|135|137|DISCHARGE MEDICATIONS|2. Serevent Diskus 50 mcg 1 puff inhaled q.12 h. 3. Flovent 220 mg 2 puffs inhaled q.12 h. 4. Prednisone 50 mg p.o. q. day x2 days. 5. ASA 81 mg p.o. q. day. 6. Glipizide 5 mg p.o. q.a.m. 7. Singulair 10 mg p.o. q.p.m.
ASA|acetylsalicylic acid|ASA|141|143|MEDICATIONS|2. Hydrochlorothiazide 25 mg p.o. q. day. 3. Metformin 500 mg p.o. q. day. 4. Protonix 40 mg p.o. q. day. 5. Pravachol 40 mg p.o. q. day. 6. ASA 81 mg p.o. q. day. 7. Allopurinol 100 mg p.o. q. day. 8. Travatan eye drops in both eyes q. day. 9. Levoxyl 0.075 mg p.o. q. day. FAMILY HISTORY: Negative for premature heart disease or stroke.
ASA|acetylsalicylic acid|ASA|118|120|MEDICATIONS|6. Lipitor 20 mg q. day. 7. Motrin 800 mg b.i.d. 8. VESIcare 20 mg q. day. 9. Zoloft 50 mg daily. 10. Tylenol PM. 11. ASA 81 mg q. day. 12. Macrobid 25mg po qd. REVIEW OF SYSTEMS: As above. Over the last 2 weeks she has been severely restricting her fluids in order to control her bladder incontinence.
ASA|acetylsalicylic acid|ASA|252|254|MEDS ON DISCHARGE|Also, positive for intermittent shortness of breath on her last admission and significant fatigue and deconditioning. MEDS ON DISCHARGE: Lisinopril 5mg PO QD Alprazolam 0.25 mg PO prn Novalog 4 units SC TID Lantus 48units SC QD Atorvastatin 80mg PO QD ASA 81mg PO QD Albuterol/ ipratropium nebs Metoprolol 200mg PO BID?? Niaspan 1000mg PO QD oxycodone/acetaminophen 5/325 PO QD Protonix 40 mg PO QD PHYSICAL EXAMINATION: VITAL SIGNS: As per my last visit with her while she was still in the hospital.
ASA|acetylsalicylic acid|ASA|122|124|MEDICATIONS|5. Atenolol 50 mg 1 q.a.m., 2 q.h.s. 6. Lisinopril 40 mg q. day 7. Niacin 500 mg q.h.s. 8. Advair 250/50 1 puff b.i.d. 9. ASA 81 mg q day. 10. Vicodin 1 q.6h. p.r.n. pain 11. Lipitor 20 mg q.h.s. 12. KCL 13. Ipratropium 2 sprays both nostrils t.i.d.
ASA|acetylsalicylic acid|ASA|189|191|DISCHARGE MEDICATIONS|4. Protonix 40 mg p.o. b.i.d. 5. Propulsid 200 mg b.i.d. (not FDA approved, but the patient buys it from a different source). 6. Tetracycline 250 mg p.o. b.i.d. q.o.d. and t.i.d. q.o.d. 7. ASA 81 mg p.o. q.d. 8. MVI one tablet p.o. q.d. 9. Dapsone 50 mg q. Monday and Thursday.
ASA|acetylsalicylic acid|ASA|116|118|DISCHARGE MEDICATIONS|His speech was fluent. DISCHARGE DISPOSITION: He will be subsequently discharged to home. DISCHARGE MEDICATIONS: 1. ASA 81 mg p.o. q.d. 2. Lipitor 20 mg p.o. q.d. 3. Zyban 150 mg p.o. b.i.d. 4. Zantac 150 mg p.o. b.i.d.
ASA|acetylsalicylic acid|ASA|215|217|MEDICATIONS|DISCHARGE PLANS: The patient is discharged to Ebenezer for transition care. Activities as tolerated. Low sodium and diabetic diet. MEDICATIONS: Humulin insulin (70/30) 26 units subqu a.m. and 18 units subqu q.p.m., ASA 81 mg p.o. q.d., Flovent 220 two puffs p.o. b.i.d., dipyridamole 75 mg p.o. b.i.d., Singulair 10 mg p.o. q.h.s., trazodone 25 mg p.o. q.h.s., Celexa 20 mg p.o. q.a.m. (pre-existing depression), Avapro 150 mg p.o. b.i.d., Caltrate plus vitamin D one tab p.o. b.i.d., guaifenesin long-acting 600 mg po.o. b.i.d, quinine sulfate 325 mg p.o. q.h.s. (for nocturnal muscle cramps), FES-04 325 mg p.o. q.a.m., and prednisone 20 mg p.o. q.a.m. and suppertime for one week and then discontinue after follow up with me in approximately one week.
ASA|acetylsalicylic acid|ASA|71|73|MEDICATIONS|ALLERGIES: ACE inhibitors. MEDICATIONS: 1. Glucophage 500 mg t.i.d. 2. ASA 1/4 tablet daily. 3. Hytrin 5 mg qd. 4. Multi vitamins. 5. ______. 6. Tylenol. 7. Avapro 160 mg qd. 8. Celebrex 100 mg b.i.d. p.r.n.
ASA|acetylsalicylic acid|ASA|165|167|DISCHARGE MEDICATIONS|2. Chronic renal insufficiency. 3. Hypertension. 4. Coronary artery disease. DISCHARGE MEDICATIONS: 1. Hydralazine 40 mg p.o. t.i.d. 2. Amlodipine 5 mg p.o. q.d. 3. ASA 325 mg p.o. q.d. 4. Imdur 90 mg p.o. q.d. 5. Paxil 20 mg p.o. q.d. 6. Ativan 0.5 mg p.o. q.h.s. p.r.n. sleep.
ASA|acetylsalicylic acid|ASA|183|185|MEDICATIONS|He was in the U.S. Army between 1965 and 1972 and served over a year in Vietnam. MEDICATIONS: Atenolol 25 mg, Allegra 180 mg, Nasonex 2 puffs each nostril, all on a daily basis, plus ASA at least 325 mg daily. ALLERGIES: No known drug allergies. HABITS: No tobacco use and over the last several years no caffeine, which seems to have helped him control his blood pressure.
ASA|acetylsalicylic acid|ASA|196|198|OTHER PAST MEDICAL HISTORY|10. Nasolacrimal duct stenting. He had had significant epistaxis at one point with taking aspirin with Plavix. As of discharge from the hospital in _%#MM#%_ 2003, his medication list included: 1. ASA 81 mg p.o. daily. 2. Metoprolol 12.5 mg orally b.i.d. 3. Protonix 40 mg orally daily. 4. Lipitor 10 mg orally daily.
ASA|acetylsalicylic acid|ASA|140|142|DISCHARGE MEDICATIONS|16. Roxanol solution 20 mg/5 mL dosage 10-15 mg p.o. q.2h. p.r.n. respiratory distress. 17. Ativan 1 mg p.o. q. bedtime p.r.n. anxiety. 18. ASA 325 mg p.o. q. day. 19. Hydrocortisone cream 1% applied to the affected area with itching p.r.n. b.i.d. HISTORY OF PRESENT ILLNESS: He is an 85-year-old male, came in from the nursing home, Good Samaritan Nursing Home, presented to the Urgent Care in respiratory distress.
ASA|acetylsalicylic acid|(ASA)|341|345|IDENTIFICATION|HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted to station 3A adult chemical dependency detox unit to be monitored for withdrawal from opiates. On admission, orders were written for methadone to cover withdrawal symptoms from the opiates; Effexor XR 225 mg daily, Seroquel 100 mg twice daily, atenolol 50 mg twice daily, enteric-coated aspirin (ASA) 81 mg daily, and ibuprofen 200 to 400 mg up to 4 times daily were ordered. A recheck of his liver function tests was ordered on _%#MM#%_ _%#DD#%_, 2005.
ASA|acetylsalicylic acid|ASA|168|170|DISCHARGE MEDICATIONS|1. Calcium carbonate 500 mg p.o. t.i.d. 2. Gemfibrozil 600 mg p.o. daily. 3. Protonix 40 mg p.o. daily. 4. Atenolol 25 mg p.o. daily. 5. Tamoxifen 20 mg p.o. daily. 6. ASA 325 mg p.o. daily. 7. Ferrous gluconate 324 mg p.o. daily. 8. Vicodin 5/500 one p.o. q.4 h. p.r.n. pain. 9. Cipro 250 mg p.o. b.i.d. x10 days.
ASA|acetylsalicylic acid|ASA|107|109|MEDICATIONS|3. Kay-Ciel 20 mEq q day 4. Tranxene 7.5 mg at h.s. p.r.n. 5. Imdur 30 mg q day 6. Allegra 180 mg q day 7. ASA one q day FAMILY HISTORY: Negative for reactions to anesthesia or bleeding diathesis.
ASA|acetylsalicylic acid|ASA|193|195|IDENTIFICATION|He was monitored using the MSSA rating scale with Ativan to cover withdrawal symptoms. On admission, he was seen by the medical staff regarding his increased liver values, which were repeated. ASA 325 mg daily was added, as he had been taking that prior to admission. By _%#MM#%_ _%#DD#%_, 2005, it was determined that he was out of detox and could be discharged home with his wife.
ASA|acetylsalicylic acid|ASA|137|139|DISCHARGE MEDICATIONS|At that time, the patient was determined to be stable and ready for discharge. DISCHARGE MEDICATIONS: 1. Neurontin 300 mg p.o. daily. 2. ASA 81 mg p.o. daily. 3. Benadryl 25 mg p.o. daily p.r.n. 4. Tylenol No. 3 one to two tablets p.o. q.4 h. p.r.n. pain.
ASA|acetylsalicylic acid|ASA|199|201|LABORATORY DATA|We will check a EKG. CT of the abdomen to evaluate for possible obstruction. Dr. _%#NAME#%_ is notified and I did speak with him about the patient's admission. I feel he is still cleared for surgery ASA class 2-3 pending normal electrolytes.
ASA|acetylsalicylic acid|ASA|155|157|DISCHARGE MEDICATIONS|4. Hydrochlorothiazide was discontinued. 5. Vytorin one tablet p.o. daily. 6. Zantac 150 mg p.o. twice a day p.r.n. GERD. 7. Albuterol two puffs p.r.n. 8. ASA 81 mg p.o. every day. 9. Spironolactone 12.5 p.o. every morning. 10. Lipitor 80 mg p.o. every day, do not substitute. 11. Plavix 75 mg p.o. every day. 12. Lotrel dosage 2.5/10 p.o. every day.
ASA|American Society of Anesthesiologists|ASA|208|210|PLAN|She is otherwise doing well. IMPRESSION: This is a 78-year-old female with asymptomatic worsening left carotid artery stenosis. PLAN: Elective carotid endarterectomy on _%#MMDD#%_ with Dr. _%#NAME#%_. She is ASA class 2, cleared for surgery. She otherwise is doing well. Quello rounder will follow in the hospital.
ASA|acetylsalicylic acid|ASA|169|171|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Lipitor 10 mg p.o. daily. 2. Synthroid 0.75 mg p.o. daily. 3. Estrogen patch. 4. Prometrium 100 mg p.o. daily. 5. Lexapro 20 mg p.o. daily. 6. ASA 81 mg daily. 7. Calcium, vitamin D 500 mg p.o. b.i.d. 8. Multivitamin 1 tab p.o. daily. 9. Metamucil 1 teaspoon daily p.r.n. 10. Ibuprofen 800 mg p.o. t.i.d. x14 days.
ASA|acetylsalicylic acid|ASA|111|113|CURRENT MEDICATIONS|2. Atenolol 100 mg daily. 3. Captopril 50 mg t.i.d. 4. Norvasc 5 mg b.i.d. 5. Quinine sulfate 260 mg daily. 6. ASA 81 mg daily. 7. Hydrochlorothiazide 25 mg daily. 8. Multivitamins. 9. Calcium with magnesium. 10. Glucosamine. 11. Fish oil. CHRONIC DISEASES: 1. Nocturnal leg cramps. 2. Hypothyroidism. 3. Dyslipidemia.
ASA|acetylsalicylic acid|ASA|104|106|CURRENT MEDICATIONS|She does not drink alcohol. ALLERGIES: She is allergic to lemon and sulfa. CURRENT MEDICATIONS: Include ASA 325 mg p.o. q.d., atenolol 50 mg p.o. q.d., Lanoxin 0.125 mg p.o. q.d., hydrochlorothiazide 25 mg p.o. q.d., quinine sulfate 325 mg p.o. q.h.s. p.r.n. for leg cramps.
ASA|acetylsalicylic acid|ASA.|160|163|BLEEDING TENDENCIES|ALCOHOL: 1 to 3 glasses of wine per day. CAFFEINE: 2 cups of coffee per day, 2 to 3 sodas per week. BLEEDING TENDENCIES: None. She does note slight bruising on ASA. She has had no blood transfusions. GYN: Status postop vaginal hysterectomy with BSO in 1994.
ASA|American Society of Anesthesiologists|ASA.|212|215|ASSESSMENT|LABORATORY DATA: Hemoglobin 13.6. Recent A1C of 7.6 EKG shows sinus bradycardia. ASSESSMENT: 1. Abnormal angiogram. 2. Type 2 diabetes mellitus. 3. Hypertension. 4. Hypercholesterolemia. 5. Glaucoma. 6. Class P3 ASA. Please tag a Quello Clinic doctor. Today's visit with Dr. _%#NAME#%_ _%#NAME#%_.
ASA|acetylsalicylic acid|ASA|132|134|DISCHARGE MEDICATIONS|1. Type 2 diabetes mellitus, uncontrolled. 2. Hypertension. 3. Osteoarthritis. 4. Depression and anxiety. DISCHARGE MEDICATIONS: 1. ASA 81 mg p.o. q. day. 2. Atenolol 25 mg p.o. q. day. 3. Cozaar 50 mg p.o. q. day. 4. Glipizide ER 10 mg p.o. q. a.m.
ASA|acetylsalicylic acid|ASA|187|189|MEDICATIONS|The family takes good care of him as evidence by lack of skin breakdown, and the rest of the history was obtained from the old charts. ALLERGIES: No known drug allergies. MEDICATIONS: 1. ASA 81 mg daily. 2. Metoprolol 50 mg b.i.d. 3. Lisinopril 40 mg q. day. 4. Simvastatin 40 mg q. day.
ASA|acetylsalicylic acid|ASA|135|137|MEDICATIONS|2. Colace 200 mg p.o. daily. 3. Senna two tablets p.o. daily. 4. Zocor 40 mg p.o. q.p.m. 5. Nitroglycerine 0.4 mg sublingual p.r.n. 6. ASA 325 mg p.o. daily. ALLERGIES: No known drug allergies. IMMUNIZATIONS: Tetanus and Pneumovax updated on _%#MMDD2005#%_. FAMILY HISTORY: Father had respiratory problems.
ASA|American Society of Anesthesiologists|ASA|194|196|PLAN|DIAGNOSTICS: Her ob ultrasound is as listed above. Her blood type is A positive. ASSESSMENT: Blighted ovum. PLAN: I see no contraindication to the proposed surgical procedure. The patient is an ASA 1. I did answer her questions with regard to both the procedure and what happened to her. I did also talk to her about birth control; at this time she would like to think that over.
ASA|acetylsalicylic acid|ASA|207|209|ADMISSION MEDICATIONS|She also had had a couple of episodes of emesis and some mild intermittent diarrhea in the few days prior to admission. ADMISSION MEDICATIONS: 1. Zocor 20 mg p.o. q. day. 2. Lisinopril 20 mg p.o. q. day. 3. ASA 1 p.o. q. day. PHYSICAL EXAMINATION: On initial exam, she was slightly animated but cooperative.
ASA|acetylsalicylic acid|ASA|205|207|CURRENT MEDICATIONS|HABITS: Tobacco: None. No alcohol use. ALLERGIES: Penicillin and acidic foods like tomato cause some stomach upset. CURRENT MEDICATIONS: 1. Catapres patch 300 mcg weekly. 2. Levothyroxine 75 mcg daily. 3. ASA 325 mg daily. 4. Atenolol 50 mg daily. 5. Lisinopril 40 mg daily. 6. Minoxidil 2.5 mg daily. 7. Acetaminophen 1000 mg nightly and up to q.i.d. p.r.n.
ASA|acetylsalicylic acid|ASA|114|116|DISCHARGE MEDICATIONS|12. Prednisone taper 35 for 2 days, 25 for 2 days, 18 for 2 days, 10 for 2 days. 13. Plavix 75 mg oral daily. 14. ASA 81 mg oral daily.
ASA|acetylsalicylic acid|ASA|163|165|DISCHARGE MEDICATIONS|3. Lasix 20 mg p.o. daily. 4. Sublingual nitroglycerin p.r.n. 5. Omeprazole 20 mg p.o. b.i.d. 6. Imdur 120 mg p.o. daily. 7. Cymbalta 60 mg p.o. daily. 8. Aspirin ASA 325 mg p.o. daily. 9. Toprol-XL 200 mg p.o. daily. 10. Plavix 75 mg p.o. daily. 11. Oxazepam p.r.n. sleep. 12. Ranexa 500 mg b.i.d.
ASA|acetylsalicylic acid|ASA|151|153|MEDICATIONS|He will be on a 2-gm sodium, 1600 calorie ADA diet. He will be up ad lib. MEDICATIONS: 1. Amoxicillin 500 mg t.i.d. for a total of 20 more tablets. 2. ASA 81 mg a day. 3. Monopril 10 mg b.i.d. for hypertension and CHF. 4. Lasix 20 mg q.d. 5. Isosorbide mononitrate 60 mg q.a.m.
ASA|American Society of Anesthesiologists|ASA|173|175|INITIAL ASSESSMENT|INITIAL ASSESSMENT: 1) Healthy, gravida 3 para 1-0-1-1 female currently at term with her third pregnancy. 2) No contraindications to the repeat Cesarean delivery. She is an ASA I for general anesthesia. PLAN: The patient will report to Fairview Southdale Hospital Same Day Surgery for a surgical date with Dr. _%#NAME#%_ _%#NAME#%_ in the a.m.
ASA|acetylsalicylic acid|A.S.A.|292|297|DOB|The ventricular aplasia as noted was treated with verapamil. The family history is significant for her father deceased of colon cancer and her mother deceased of a ruptured AAA. Medications include Premarin 0.625 mg orally daily, Lipitor 20 mg orally daily, Verapamil SR 240 mg orally daily, A.S.A. one orally daily, vitamins E and C, multivitamins with iron, garlic tablets, and Os-Cal. She has no known allergies to medications. Socially, she is married and living with her spouse.
ASA|American Society of Anesthesiologists|ASA|145|147|PLAN|A basic metabolic panel is pending. ASSESSMENT: Cataracts. PLAN: I see no contraindication to the proposed surgical procedure. The patient is an ASA 2.
ASA|acetylsalicylic acid|ASA|197|199|PROBLEM #4|PROBLEM #3: Hypertension, fairly well controlled now with metoprolol XL 12.5 mg daily, and Cozaar 25 mg daily. PROBLEM #4: History of coronary artery disease. She is on isosorbide 10 mg t.i.d. and ASA 81 mg daily. PROBLEM #5: Type 2 insulin-dependent diabetes on low dose Glyburide.
ASA|acetylsalicylic acid|ASA|140|142|MEDS ON ADMISSION|5. CHF with ejection fraction 30% on _%#MMDD2006#%_. 6. Chronic renal insufficiency secondary to diabetic neuropathy. MEDS ON ADMISSION: 1. ASA 80 mg p.o. q. day. 2. Glyburide 5 mg p.o. q. day. 3. Lisinopril 5 mg p.o. q. day. 4. Metoprolol 25 mg b.i.d. 5. Simvastatin 40 mg p.o. q. day.
ASA|American Society of Anesthesiologists|ASA|157|159|ASSESSMENT|No changes since his last EKG four years ago. ASSESSMENT: This is a 70-year-old male with planned elective right knee replacement with Dr. _%#NAME#%_. He is ASA Class 1, cleared for surgery. No surgical or contraindications at this time. He is not taking aspirin or steroids. The patient is given a copy of a preoperative form, faxed to _%#CITY#%_ Hospital.
ASA|acetylsalicylic acid|ASA|82|84|MEDICATIONS|4. Status post cystoplasty. 5. Status post ventral hernia repair. MEDICATIONS: 1. ASA 81 mg p.o. daily. 2. Benefiber 1 tsp with 8 ounces of water b.i.d. 3. Levothyroxine 88 mcg p.o. daily. 4. Provera 10 mg p.o. daily on days 1-10 of each month.
ASA|acetylsalicylic acid|ASA|372|374|MEDICATIONS|Also has dementia, chronic obstructive pulmonary disease, had cerebrovascular accident which has left her with some decreased strength on the right side and some dysphagia, osteoarthritis. Apparently distant history of alcoholism, osteoporosis, depression, macular degeneration. MEDICATIONS: Vicodin 500 2 tabs in the morning and the evening and 1 tab at noon and 4 p.m., ASA 81 mg a day, Miacalcin one spray each day, alternate nostrils, Artificial Tears p.r.n., calcium with vitamin D 600/200 p.o. b.i.d., Unifiber 1 tbsp q. a.m., multivitamin daily, quinine sulfate 324 mg p.o. at bedtime, Imodium 2 mg p.o. daily at 6 a.m. and p.r.n.
ASA|American Society of Anesthesiologists|ASA|202|204|PLAN|5. We will check a basic metabolic panel to ensure no electrolyte abnormality. 6. We will place the patient in Buck's traction for pain control. 7. She should be a Physical Status Classification System ASA II.
ASA|American Society of Anesthesiologists|ASA|204|206|PLAN|3. Adult onset diabetes mellitus under excellent control. 4. Hypertension under excellent control. 5. Hyperlipidemia. PLAN: I see no contraindication to the proposed surgical procedure. The patient is an ASA 3. Will gladly follow while she is in the hospital.
ASA|acetylsalicylic acid|ASA|193|195|MEDICATIONS|1. Glaucoma. 2. Hearing loss. 3. Facial actinic keratosis. ALLERGIES: Bacitracin. HEALTH HABITS: Non-smoker. One coffee per day. MEDICATIONS: 1. Femara 2.5 mg q. day. 2. Cosopt. 3. Xalatan one ASA q. day. 4. Piroxicam 20 mg q. day. 5. One MVI q. day. 6. Calcium and vitamin D. 7. Miacalcin nasal spray, one spray alternating nostrils daily.
ASA|American Society of Anesthesiologists|ASA|185|187|PLAN|3. Shingles, but resolving at this time. 4. Hypertension under fairly good control. 5. Hypothyroidism. PLAN: I see no contraindication to proposed surgical procedure. The patient is an ASA II. I will check a comprehensive metabolic panel, fasting lipid, as well as a TSH. We will forward those results to the hospital when they are available.
ASA|American Society of Anesthesiologists|ASA|164|166|PLAN|ASSESSMENT: 1. Meniscal tear. 2. Questionable history of sarcoidosis. 3. Smoker. PLAN: I see no contraindication for proposed surgical procedure. The patient is an ASA 2.
ASA|acetylsalicylic acid|ASA|196|198|MEDICATION AT THE TIME OF ADMISSION|REVIEW OF SYSTEMS: Checked allergy was normal. ENT, respiratory, GI, genitourinary lymphadenopathy, endocrine, and skin which was normal. MEDICATION AT THE TIME OF ADMISSION: 1. Lipitor 40 mg. 2. ASA 325 mg. 3. Metoprolol 50 mg per day. 4. Hydrochlorothiazide 25 mg a day. PHYSICAL EXAMINATION AT THE TIME OF ADMISSION: She is awake, she is bubbly, very hard of hearing.
ASA|acetylsalicylic acid|ASA|78|80|DISCHARGE MEDICATIONS|Pulmonary and cardiac status appeared to be stable. DISCHARGE MEDICATIONS: 1. ASA 81 mg p.o. every day. 2. Lipitor 20 mg p.o. q.p.m. 3. Zithromax 250 mg p.o. every day with three days remaining.
ASA|acetylsalicylic acid|ASA|143|145|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Acetaminophen 500 mg p.o. t.i.d. for pain. 2. Albuterol 90 mcg inhaled 2 puffs q.i.d. p.r.n. shortness of breath. 3. ASA 81 mg p.o. daily. 4. Calcium and vitamin D 500 mg 1 tablet oral daily. 5. Augmentin 500/125 mg p.o. b.i.d. for 14 days. This is a new medication.
ASA|acetylsalicylic acid|ASA|131|133|HOSPITAL COURSE|2. Prinivil 10 mg p.o. q.day. 3. Pravachol 20 mg p.o. q.day. 4. Singulair 10 mg p.o. q.day. 5. Atrovent MDI two puffs a day. 6. EC ASA 325 mg p.o. q.day. 7. Albuterol MDI with spacer two puffs q.4h. p.r.n. for shortness of breath. 8. Nitroglycerin 0.4 mg p.o. p.r.n. for chest pain.
ASA|American Society of Anesthesiologists|ASA.|223|226|ASSESSMENT|ASSESSMENT: Left lower quadrant incisional hernia, status post prostate cancer and prostatectomy. Heart murmur associated with aortic sclerosis, COPD that is mild, secondary to chemical exposure. Essential tremor, class II ASA. PLAN: Okay for surgery. Staff is Dr. _%#NAME#%_.
ASA|acetylsalicylic acid|A.S.A.|357|362|ADMISSION MEDICATIONS|He presented to the Emergency Department with two days of increasing shortness of breath, fevers, chills, and productive cough. He had not had any hemoptysis or rectal bleeding. ADMISSION MEDICATIONS: Clonidine 0.1 mg b.i.d., Avapro 150 mg q.day, Atenolol 50 mg q.day, Prilosec 20 mg q.day, amiodarone 200 mg q.day, Lipitor 20 mg q.day, Lasix 40 mg b.i.d., A.S.A. 81 mg q.day, Remegel 800 mg four tablets with each meal, Nephrocaps q.day. PHYSICAL EXAMINATION: On initial exam the patient appeared relatively comfortable.
ASA|acetylsalicylic acid|ASA|127|129|MEDICATIONS|HABITS: Non-smoker. No regular exercise. MEDICATIONS : 1. Diovan 80 mg QD 2. Glyburide 2.5 mg QD. 3. Atenolol 50 mg QD. 4. One ASA QD 5. Lipitor 20 mg QD. FAMILY HISTORY: Mother deceased 65 of breast carcinoma.
ASA|acetylsalicylic acid|ASA|162|164|MEDICATIONS AT DISCHARGE|MEDICATIONS AT DISCHARGE: 1. Percocet 1-2 p.o. q.4h. p.r.n. pain. 2. Ativan 0.5 mg q.6-8h. p.r.n. anxiety. 3. Synthroid 0.1 mg 1-1/2 tablets or 0.15 mg daily. 4. ASA 81 mg q. day. 5. Amiodarone 200 mg q. day. 6. Prilosec 20 mg daily. 7. Combivent with spacer 2 puffs q.i.d. and at h.s. p.r.n.
ASA|acetylsalicylic acid|ASA|116|118|MEDICATIONS|One wine per day. Regular exercise. MEDICATIONS: 1. Plavix 75 mg daily which will be held 5 days preoperatively. 2. ASA 81 mg daily which will be held 3 days preoperatively. 3. Toprol 50 mg b.i.d. 4. ___________ 50h. mg q. day. 5. Diovan HCT 160/12.5 mg q. day.
ASA|acetylsalicylic acid|ASA|136|138|MEDICATIONS|4. Pyridoxine HCL 50 mg p.o. daily. 5. Lisinopril 10 mg p.o. daily. 6. Flomax 0.4 mg p.o. b.i.d. 7. Metoclopramide 10 mg p.o. t.i.d. 8. ASA 81 mg p.o. daily. 9. Vitamin D3 1000 unit p.o. daily. SIGNIFICANT PAST MEDICAL HISTORY: 1. Dyslipidemia. 2. BPH. 3. CKD.
ASA|acetylsalicylic acid|ASA|123|125|ADMISSION MEDICATIONS|PAST SURGICAL HISTORY: Stent placement in both the legs and stent placement in heart x2 vessels. ADMISSION MEDICATIONS: 1. ASA 325 mg q. day. 2. Lisinopril/hydrochlorothiazide 20/25 mg b.i.d. 3. Cilostazol 100 mg b.i.d. 4. Toprol XL 50 mg daily. 5. Plavix 75 mg daily. 6. Actos 30 mg daily.
ASA|acetylsalicylic acid|ASA|117|119|MEDICATIONS|4. Multivitamin 1 p.o. daily. 5. Spironolactone 25 mg p.o. daily. 6. Vicodin 5/500 mg 1-2 p.o. q.6h. p.r.n. pain. 7. ASA 81 mg p.o. daily. 8. Lotrisone cream to skin folds b.i.d. SOCIAL HISTORY: She has been married for 43 years.
ASA|American Society of Anesthesiologists|ASA|91|93|ASSESSMENT|UA was normal. Basic metabolic panel is pending. Chest x-ray not performed. ASSESSMENT: 1. ASA I for lumbar fusion re-do at L5-S1 after previous failed fusion. 2. History of chemical dependency. 3. Mild depression. 4. Ongoing paresthesias of lower extremities.
ASA|acetylsalicylic acid|ASA|310|312|DISCHARGE MEDICATIONS|We have discussed with him as well that should he notice difficulty breathing or feel as if his airway is obstructing, he should seek medical attention emergently. DISCHARGE MEDICATIONS: Lisinopril 20 mg p.o. b.i.d., Protonix 40 mg p.o. daily, hydrochlorothiazide 50 mg p.o. daily, digoxin 0.25 mg p.o. daily, ASA 81 mg p.o. daily, Coumadin 5 mg p.o. daily, except 7.5 mg p.o. q. Monday and Friday, allopurinol 300 mg p.o. daily, Xalatan one drop each eye daily, Vicodin 1-2 tablets p.o. q. 4-6h. p.r.n.
ASA|acetylsalicylic acid|ASA|139|141|MEDICATIONS|MEDICATIONS: 1. Coreg 25 mg b.i.d. 2. Diovan 80 mg b.i.d. 3. Vytorin 10/40 q. day. 4. Calcium 500 mg b.i.d. 5. Ambien 10 mg at bedtime. 6. ASA 81 mg q. day. 7. Zoloft 50 mg q day. 8. Fosamax 70 mg q. week. FAMILY HISTORY: Notable for her mother who died of a CVA at 76 she also had peripheral vascular disease.
ASA|American Society of Anesthesiologists|ASA|177|179|ASSESSMENT|Her hemoglobin is 13.0. ASSESSMENT: 1. Degenerative joint disease with right knee pain the most prominent feature at this point. 2. No contraindications to proposed procedures. ASA II for general anesthesia. PLAN: Report to Fairview Ridges Hospital for surgical date with Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2002#%_.
ASA|American Society of Anesthesiologists|ASA|165|167|ASSESSMENT|Urinalysis is pending. ASSESSMENT: 68-year-old woman to undergo replacement of joint arthroplasty under the direction of Dr. _%#NAME#%_. I see no contraindications. ASA class 2. RECOMMENDATIONS: On the morning of surgery, the patient should take her Hyzaar and Levoxyl as scheduled.
ASA|American Society of Anesthesiologists|ASA|234|236|PLAN|4. Carpal tunnel syndrome. 5. Hypertension under excellent control. PLAN: I see no contraindication to the proposed surgical procedure. An EKG today revealed sinus rhythm with no ST or T wave changes present. The patient should be an ASA 3 for surgery. Will check a creatinine, potassium, BUN, and forward to the hospital prior to her procedure. Will also check a CBC and forward those results to the hospital.
ASA|American Society of Anesthesiologists|ASA|143|145|ASSESSMENT|Chem-7 and CBC are pending. ASSESSMENT: 59-year-old man to undergo subtalar fusion procedure for Charcot joint. I see no contraindications for ASA Class 2. RECOMMENDATION: On the morning of the surgery the patient should take his Norvasc and Lisinopril with a small sip of water.
ASA|acetylsalicylic acid|ASA|292|294|MEDICATIONS|His blood sugars prior to admission had been under reasonable control. MEDICATIONS: Medications at the time of admission included gemfibrozil 600 mg b.i.d., cimetidine 800 mg t.i.d., Reglan 5 mg q.i.d., Isordil 40 mg t.i.d., Lasix 40 mg b.i.d., Lopressor 75 mg b.i.d., amlodipine 10 mg q.d., ASA one q.d., lisinopril 20 mg q.d., Niaspan 500 mg at bedtime, glyburide 10 mg q.d. and NPH insulin 20 units in the a.m. and 40 units in the p.m. PHYSICAL EXAMINATION: On initial exam, head, ears, eyes, nose and throat was unremarkable.
ASA|acetylsalicylic acid|ASA.|205|208|HISTORY OF PRESENT ILLNESS|Currently he is not on any treatment for polyneuropathy. He had a workup in Mayo Clinic approximately 10 years ago with EMG which was not conclusive. ADMISSION MEDICATIONS: 1. Coumadin. 2. Hydroxyurea. 3. ASA. 4. Folic acid. 5. Lipitor. 6. Diltiazem. 7. Metoprolol, 8. Lisinopril. ALLERGIES: No known drug allergies. FAMILY HISTORY: The patient has an older sister who is 70 and healthy.
ASA|acetylsalicylic acid|ASA|283|285|ALLERGIES|His Coumadin dose was held during his hospitalization. At the day of admission, his INR was at 2.7 and he was restarted on the Coumadin dose 10 mg q.d. DISPOSITION: The patient is discharged to home. DISCHARGE MEDICATIONS: 1. Hydroxyurea 1000 mg q.d. 2. Folic acid 1 mg p.o. q.d. 3. ASA 325 mg p.o. q.d. 4. Lipitor 20 mg p.o. q.d. 5. Metoprolol 25 mg p.o. b.i.d. 6. Lisinopril 10 mg p.o. q.d.
ASA|acetylsalicylic acid|ASA|214|216|MEDICATIONS|At the time of transfer, he remained afebrile. He had some subtle cognitive and memory dysfunction, but essentially was able to perform all self cares. MEDICATIONS: Medications at the time of transfer included: 1. ASA 81 mg q. day. 2. Atenolol 50 mg q. day. 3. Lipitor 20 mg q. day. 4. Chlorthalidone 25 mg q. day. 5. Decadron 4 mg p.o. b.i.d.
ASA|acetylsalicylic acid|ASA.|261|264|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: See Dr. _%#NAME#%_ on Monday, _%#MMDD2006#%_ at Fairview _%#CITY#%_ Clinic to arrange outpatient colonoscopy and further work up of microcytic anemia in the next couple of weeks. Dr. _%#NAME#%_ to determine if the patient can resume her ASA. HOSPITAL COURSE: The patient had presented to the emergency room initially on _%#MMDD2006#%_ with complaints of severe abdominal pain which apparently has been intermittent for the past 6 months.
ASA|American Society of Anesthesiologists|ASA|195|197|PLAN|ASSESSMENT: 1. Left femoral neck fracture. 2. Hypothyroidism on replacement. 3. Hypertension under excellent control. PLAN: I see no contraindication to the proposed procedure. The patient is an ASA II. We will leave her n.p.o. after midnight. We will hydrate her with D5 with 20 mEq potassium at 75 cc/hour. I will use Morphine 2-8 mg IV q2-4h p.r.n. for pain control.
ASA|American Society of Anesthesiologists|ASA|157|159|PLAN|2. Hypertension under fair control. PLAN: We will have the patient return to clinic tomorrow so we can recheck her blood pressure. Otherwise, she will be an ASA 2. I will also check a basic metabolic and iron. Will forward to the hospital when it is available.
ASA|acetylsalicylic acid|ASA,|165|168|FAMILY HISTORY|He has had rather marked hyperlipidemia and he has been on Lipitor and this has dropped his cholesterol levels to normal. The only other medications he is taking is ASA, one daily. He denies any cardiorespiratory symptoms, gastrointestinal symptoms, or GU symptoms other than the scrotal mass. PHYSICAL EXAMINATION: VITAL SIGNS: He is 67 1/4 inches. Weight 158 pounds.
ASA|acetylsalicylic acid|ASA|76|78|DISCHARGE MEDICATIONS|PRIMARY DIAGNOSES: Depression, weakness, fatigue. DISCHARGE MEDICATIONS: 1. ASA 81 mg PO q.d. 2. Zestril 30 mg PO q.d. 3. Lasix 20 mg PO q.d. 4. Colace 100 mg PO q.d. 5. Toprol XL 25 mg PO b.i.d.
ASA|acetylsalicylic acid|A.S.A.|171|176|MEDICATIONS|FAMILY HISTORY: The family history is unavailable tonight. We will review tomorrow with his wife. MEDICATIONS: Levothyroxine 75 mcg, atenolol 25 mg, lisinopril 20 mg, and A.S.A. 81 mg, all every morning, plus Zocor 10 mg and Aricept 10 mg every evening. Also, since _%#MMDD2003#%_ he has had Vicodin tablets to help ease the pain.
ASA|acetylsalicylic acid|ASA|202|204|MEDICATIONS|5. Peripheral vascular disease, status post carotid endarterectomy bilaterally. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Lipitor 80 mg q.d. 2. Lisinopril 10 mg q.d. 3. Atenolol 50 mg q.d. 4. ASA 325 mg q.d. 5. Multivitamin q.d. 6. Vitamin E. 7. Prilosec 20 mg p.o. q.d. 8. Lupron injection intermittently. SOCIAL HISTORY: The patient is retired as an independent insurance salesman.
ASA|American Society of Anesthesiologists|ASA|192|194|PLAN|Soft. Uterus is firm. Her EXTREMITIES revealed no edema. Deep tendon reflexes were equal. ASSESSMENT: Well exam. PLAN: I see no contraindication for the proposed surgical procedure. She is an ASA 1.
ASA|American Society of Anesthesiologists|ASA|210|212|PLAN|PLAN: The patient will be kept off Coumadin and his INR would be expected to be at least below 1.2 by _%#MMDD#%_, which should allow for open reduction internal fixation of his left hip fracture. He will be an ASA 3 risk at minimum. He does desire a do not intubate status, but does desire cardiac resuscitation in the event of a cardiac arrest.
ASA|acetylsalicylic acid|ASA|194|196|ASSESSMENT|This morning, _%#MMDD2003#%_, the repeat salicylate level was 35 at 02:00 hours and this morning at 08:00 the salicylate level was 24. Urine tox screen only positive for alcohol. ASSESSMENT: 1. ASA overdose secondary to suicide attempt. 2. Nausea secondary to overdose, this is improving. 3. Hematemesis probably secondary to Mallory-Weiss tear now resolved.
ASA|acetylsalicylic acid|ASA|140|142|MEDICATIONS|1. Allopurinol 100 mg daily. 2. Lanoxin 0.25 mg tablets. He takes half a tablet daily. 3. Levoxyl 0.1 mg daily. 4. Prinivil 20 mg b.i.d. 5. ASA 81 mg daily. 6. Diovan 160 mg daily. 7. NPH insulin 70/30, 20 units in the a.m. and 10 units at dinner. PHYSICAL EXAMINATION: GENERAL: Pleasant and cooperative 81-year-old. The patient is rather, I would say, confused about time, place, etc.
ASA|acetylsalicylic acid|ASA|146|148|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Folate 2 mg p.o. q.day. 2. Neurontin 900 mg p.o. t.i.d. 3. Colace 100 mg p.o. b.i.d. 4. Metoprolol 25 mg p.o. b.i.d. 5. ASA 81 mg p.o. q.d. 6. Bactrim DS 1 tab p.o. b.i.d. on Mondays and Thursdays. 7. Lasix 40 mg p.o. q.a.m., 20 mg p.o. q.p.m.
ASA|acetylsalicylic acid|ASA|141|143|MEDICATIONS|PAST SURGICAL HISTORY: None. MEDICATIONS: 1. Atenolol 25 mg p.o. daily. 2. Calcitriol 0.25 mg p.o. daily. 3. Furosemide 40 mg p.o. daily. 4. ASA 81 mg p.o. daily. 5. Daily multivitamin. ALLERGIES: None. ADMISSION LABORATORY DATA: White count 6.2, hemoglobin 12.2, platelet count 224,000, hemoglobin A1c 6.2, INR of 1.09, PTT 28.
ASA|American Society of Anesthesiologists|ASA|159|161|ASSESSMENT|SKIN: No abnormalities with regard to his skin, although did not take his brace off of his knee. ASSESSMENT: 1. Right knee adhesions. 2. Tobacco addiction. 3. ASA class 2 secondary to tobacco addiction. PLAN: May proceed with surgical procedure on _%#MMDD2007#%_. We had discussed starting an antidepressant after his medications.
ASA|acetylsalicylic acid|ASA|162|164|ASSESSMENT|7. Anticoagulation. In view of his acute injuries and eye problem, we will hold his Coumadin and let his INR drift down closer to 2. We will continue him on baby ASA for now.
ASA|acetylsalicylic acid|ASA|141|143|CURRENT MEDICATIONS|day. 5. Septra 160 mg q. day. 6. Prednisone 10 mg q. day. 7. Coreg 12.5 mg q day. 8. Plavix 75 mg q. day. 9. Ursodiol 300 mg two q. day. 10. ASA 81 mg q. day. 11. Spiriva one q. day. 12. Calcium 600 mg q. day. HABITS: He quit smoking in 1992. He rarely has an alcohol drink.
ASA|acetylsalicylic acid|ASA|153|155|MEDICATIONS|MEDICATIONS: List includes: 1. Prednisone 5 mg orally daily. 2. Lisinopril. 3. Hydrochlorothiazide 20/25 1 orally daily. 4. Flomax 0.4 mg at bedtime. 5. ASA 81 mg daily. 6. Atenolol 25 mg at bedtime. 7. Doxazosin 2 mg orally daily. 8. Crestor 5 mg orally daily. SOCIAL HISTORY: He is married, living with his wife who has some problems with dementia and memory loss as well.
ASA|American Society of Anesthesiologists|ASA|165|167|PLAN|ASSESSMENT: Well exam with the exception of a nonpalpable right vas deferens. PLAN: I see no contraindications to the proposed surgical procedure. The patient is an ASA 1.
ASA|acetylsalicylic acid|ASA|202|204|CURRENT MEDICATIONS|At the time of my evaluation on Sunday afternoon her enzymes were negative, and she was pain-free. ALLERGIES: None. CURRENT MEDICATIONS: 1. Actos 45 mg daily. 2. Nifedipine, dose unknown, one a day. 3. ASA 81 mg daily. 4. Lipitor 40 mg every day. 5. Tricor 145 mg every day. 6. Zetia 10 mg every day. 7. Lasix, dose unknown, two tablets in the morning.
ASA|American Society of Anesthesiologists|ASA|128|130|ASSESSMENT|Chest x-ray was within normal limits. Hemoglobin was 12.8, white count 6,600, platelets 267,000. BMP is pending. ASSESSMENT: 1. ASA 1 for left hip replacement with history of degenerative arthritis. 2. Hyperlipidemia. 3. Degenerative joint disease. 4. Fungal dermatitis of the toes, very mild.
ASA|acetylsalicylic acid|ASA|154|156|REASON FOR HOSPITALIZATION|She had no palpitations, lightheadedness, shortness breath or symptoms of CHF. Her medications at the time of admission included Toprol-XL 100 mg q. day, ASA 81 mg daily, Benicar 40 mg q. day, Spironolactone 25 mg b.i.d. and Benadryl 10 mg q.p.m. for itching. PHYSICAL EXAMINATION: On initial exam, she was alert and cooperative.
ASA|acetylsalicylic acid|ASA|127|129|CURRENT MEDICATIONS|4. Lipitor 40 mg p.o. each day at bedtime. 5. Atacan 16 mg p.o. b.i.d. 6. Levobunolol 0.5% 1 drop to each eye b.i.d. 7. Coated ASA 325 mg q.a.m. 8. Nitro 2.5 mg each day at bedtime. 9. Glipizide 10 mg b.i.d. SOCIAL HISTORY: He is married, he is retired from the refrigeration business.
ASA|acetylsalicylic acid|ASA.|244|247|PREHOSPITAL MEDICATIONS|He had routine laboratory testing, physical examination. At that time, no contraindications to donation were identified, and arrangements were made for him to proceed. PREHOSPITAL MEDICATIONS: Currently held. 1. Fluoxetine. 2. Multivitamin. 3. ASA. ALLERGIES: No known drug allergies. HOSPITAL COURSE: The patient underwent da Vinci-assisted laparoscopic donor nephrectomy.
ASA|American Society of Anesthesiologists|ASA|175|177|ASSESSMENT/PLAN|The patient's ketones are negative. Therefore, will check other possible causes for an anion gap and metabolic acidosis such as serum lactate, ethylene glycol methionine, and ASA level. 2. His other electrolytes will be checked such as magnesium and phosphorus to determine if they need replacement.
ASA|acetylsalicylic acid|ASA|141|143|CURRENT MEDICATIONS|DRUG SENSITIVITIES: None noted. CURRENT MEDICATIONS: 1. Accupril 20. 2. Lipitor 20. 3. Toprol XL 25. 4. Ambien 5 h.s. p.r.n. 5. Coumadin. 6. ASA 81 mg. FAMILY HISTORY: Sister died 65 MI. Last INR 2.1 on _%#MMDD2002#%_. His Coumadin has since been discontinued.
ASA|American Society of Anesthesiologists|ASA|166|168|PLAN|SKIN is within normal limits. His hemoglobin is 15.6. ASSESSMENT: Morton's neuroma. PLAN: I see no contraindication to proposed surgical procedure. The patient is an ASA 1. For his health maintenance, will check a total cholesterol as well as an HDL today and follow.
ASA|acetylsalicylic acid|ASA,|164|167|MEDICATIONS|PAST MEDICAL HISTORY: Serious illnesses none. PREVIOUS SURGERY: Chip removal from left elbow 1987. ALLERGIES: None. MEDICATIONS: Ortho Tri-Cyclen. No recent use of ASA, NSAID's or steroids. HABITS: Smokes - none. Alcohol - moderate usage. No history of blood transfusions or abnormal bleeding.
ASA|acetylsalicylic acid|ASA|239|241|MEDICATIONS|Patient remained afebrile. Patient will follow up with Dr. _%#NAME#%_ one week from Monday, _%#MM#%_ _%#DD#%_, 2003. MEDICATIONS: Patient is being discharged to home on the following medications: Procardia ER 60 mg q.d. Zestril 10 mg q.d. ASA 325 mg q.d. MVI 1 tab q.d. Metoprolol 25 mg b.i.d. Patient is not taking any pain medications. Is also being discharged home with Boost four times a day.
ASA|acetylsalicylic acid|ASA|193|195|DISCHARGE MEDICATIONS|8. Osteoporosis. DISCHARGE MEDICATIONS: 1. Lidoderm patch to thighs in the morning and in the evening. 2. Zyrtec 10 mg p.o. q.d. 3. Tegretol 200 mg p.o. t.i.d. 4. Detrol XL 4 mg p.o. q.h.s. 5. ASA 81 mg p.o. q.d. 6. Advair 250/50 one puff b.i.d. 7. Mysoline 250 mg p.o. b.i.d. 8. Colace 100 mg p.o. b.i.d. p.r.n. 9. Singulair 10 mg p.o. q.d.
ASA|acetylsalicylic acid|ASA|160|162|FAMILY HISTORY|3. Colace 100 mg p.o. b.i.d. 4. Senna 1 to 2 tablets p.o. b.i.d. to t.i.d. p.r.n. 5. Magnesium oxide 240 mg p.o. q.d. 6. Centrum Silver one tablet p.o. q.d. 7. ASA 81 mg p.o. q.d. FOLLOW UP: 1. The patient will follow up with neurology stroke clinic at the University of Minnesota in 1 month.
ASA|acetylsalicylic acid|ASA|430|432|ADMISSION DIAGNOSES|He was maintained in the hospital on intravenous antibiotics for rehydration after his illness, as well as for normalization of his electrolyte imbalance. His medications include iron replacement, Lantus insulin 75 units at bedtime, Humalog 15 units with each meal, as well as a sliding scale, Lisinopril 20 mg b.i.d, Imdur 60 mg in the morning, Maxzide one daily, Norvasc 10 mg daily, Coreg 3.125 mg b.i.d., Lopid 600 mg b.i.d., ASA 81 mg daily, Zantac 150 mg b.i.d., Septra DS one p.o. b.i.d., and Cipro 500 mg p.o. b.i.d. each for another week after his discharge, Casodex 50 mg b.i.d., Neurontin 300 mg one t.i.d, Catapres-TTS patch 3 mcg weekly, Vicodin one to two p.o. q.4-6h p.r.n. for pain.
ASA|acetylsalicylic acid|ASA|271|273|CURRENT MEDICATIONS|Occasionally uses alcohol. She occasionally uses caffeine. ALLERGIES: HER DRUG SENSITIVITIES ARE TO PENICILLIN. CURRENT MEDICATIONS: Norvasc 10 mg 1 orally daily, Altace 5 mg 1 orally daily, Synthroid 0.075 mg 1 orally daily, Potassium replacement 10 mEq 1 orally daily, ASA 81 mg 1 orally daily, Insulin 70/30 mix 11 units subcu q morning and evening. Multivitamin with iron 1 orally daily, Fibercon 1 orally bid, prn.
ASA|acetylsalicylic acid|ASA|237|239|DISCHARGE MEDICATIONS|His hospital course was relatively uneventful, and he is discharged today ambulating and tolerating p.o. He is discharged in good condition with instructions to follow up with the Cardiothoracic Surgery Center. DISCHARGE MEDICATIONS: 1. ASA 81 mg p.o. daily. 2. Digoxin 0.125 mg p.o. q.a.m. 3. Colace 100 mg p.o. b.i.d. 4. Lasix 40 mg p.o. daily. 5. Isordil 10 mg p.o. b.i.d. 6. Prinivil 5 mg p.o. q.a.m.
ASA|acetylsalicylic acid|ASA,|137|140|ASSESSMENT AND PLAN|He is asymptomatic tonight. Initial EKG and troponin are negative. Will rule him out for MI with serial troponin. I will continue him on ASA, lisinopril and lovastatin. 3. Psychiatry: The patient reports history of insomnia whenever he takes high-dose steroids.
ASA|acetylsalicylic acid|ASA|258|260|CHIEF COMPLAINT|He denied any dizziness or lightheadedness, in fact, he felt well, but he was in contact with Dr. _%#NAME#%_, who performed the procedure, and finally after continuing to pass blood it was decided to have him come to the hospital. The patient took 700 mg of ASA because of a headache on _%#MMDD2007#%_, which is the day before his procedure. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. MEDICATIONS: 1. Lisinopril 20 a day.
ASA|American Society of Anesthesiologists|ASA|189|191|PLAN|4. Chronic obstructive pulmonary disease. This appears stable. 5. Depression. We will continue the Celexa. 6. Preoperative assessment. Patient appears to be OK for anesthesia. She would be ASA Class 2. This is pending the final results on the patient's urinalysis and coagulations. She is normally DNR/DNI but this can be suspended during surgery.
ASA|acetylsalicylic acid|ASA,|261|264|HISTORY OF PRESENT ILLNESS|He has mild mental retardation, and therefore the rest of the history was not clearly obtainable. He reports a long list of allergies, namely to ciprofloxacin, sulfa drugs, penicillin, cephalosporins, Tylenol with codeine, ibuprofen, Septra, Augmentin, Daypro, ASA, oxy__________________, and Tylox, to name a few. MEDICATIONS: His list of home medications is as above, except for the Imdur; instead of Imdur, at home he takes Isordil 30 mg p.o. q.d., and he does not take imipenem.
ASA|acetylsalicylic acid|ASA.|175|178|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. In _%#MM#%_ 2001, left hip replacement after a fracture secondary to a fall. 2. Hypertension. Reports being placed on Coumadin but unsure why. Now on ASA. Patient denied history of afib. 3. 1998 broken pelvis. Fell on the sidewalk. She is status post hysterectomy 20 years ago.
ASA|acetylsalicylic acid|ASA|256|258|DISCHARGE MEDICATIONS|While she was in house she tolerated PT well and she was transferred across to Fairview University transitional services for further management of her hip fractures and tighter control of her blood pressures. DISCHARGE MEDICATIONS: 1. Lanoxin as above. 2. ASA as above. 3. Fosamax 10 mg p.o. q.d. 4. Calcium gluconate plus vitamin D 1250 p.o. b.i.d. 5. Lisinopril 30 q.d. 6. Metoprolol 25 q.d. 7. Tylenol 650 q.i.d.
ASA|acetylsalicylic acid|ASA|144|146|DISCHARGE MEDICATIONS|3. Celebrex 200 mg p.o. b.i.d. 4. Zyprexa 10 mg p.o. q.h.s. 5. Klonopin 0.5 mg p.o. q.a.m. and 1 mg p.o. q.p.m. 6. Remeron 30 mg p.o. q.h.s. 7. ASA 81 mg p.o. q.d. 8. Prevacid 30 mg p.o. b.i.d. 9. Percocet 5-325 mg p.o. one tablet q.6-8h. p.r.n. for pain.
ASA|acetylsalicylic acid|ASA|120|122|PLAN|3. Abdominal aortic aneurysm 4. Hard of hearing. PLAN: EEG done in the office today was normal. I believe he is Class I ASA for general anesthetic. He is okay for spinal as well. I anticipate no problems.
ASA|acetylsalicylic acid|ASA|114|116|DISCHARGE DIAGNOSIS|3. Phenobarbital 50 mg in the morning and 120 mg at hs. 4. Folic acid 1 mg per day. 5. Prevacid 30 mg per day. 6. ASA 325 mg per day. She will be followed as an outpatient.
ASA|acetylsalicylic acid|ASA|149|151|CURRENT MEDICATIONS|The patient is on chronic anticoagulant therapy for atrial fibrillation. CURRENT MEDICATIONS: 1. Percocet 5 times a day. 2. Skelaxin twice a day. 3. ASA 81. 4. Coreg 6.25 b.i.d. 5. Coumadin as per directed. 6. Furosemide 20 b.i.d. 7. Lipitor 20. 8. Lisinopril 20. 9. Miacalcin spray. 10. Synthroid .15. 11. Lidoderm patch h.s. to the back.
ASA|American Society of Anesthesiologists|ASA|217|219|ASSESSMENT|Recent creatinine was normal. EKG showed normal sinus rhythm, really no significant ST-T wave changes. ASSESSMENT: A 54-year-old gentleman here for preoperative exam with total hip replacement planned. He would be an ASA II for surgery. Right now, his diabetes seems to be under decent control with a hemoglobin A1C 8.4 two months ago but better improvement since then.
ASA|acetylsalicylic acid|ASA|271|273|CURRENT MEDICATIONS|CURRENT MEDICATIONS: Include Tricor 160 p.o. q. day, Coreg 25 p.o. b.i.d., Lipitor 10 p.o. q.h.s., Plavix 75 p.o. q. day, amitriptyline 50 mg p.o. q.h.s., Flovent 220 mcg, 2 puffs b.i.d.; Diovan 160 mg p.o. q. day, Celebrex 100 mg p.o. q. day, Folgard 1 tab p.o. q. day, ASA 81 mg p.o. q. day, Viactiv 1 chew p.o. b.i.d., Zetia 10 mg p.o. q. day, Prilosec 40 mg p.o. q. day, Imdur 60 mg p.o. q. day, Colace 1 tab p.o. b.i.d., multivitamin 1 p.o. q. day, Allegra 60 mg p.o. b.i.d.
ASA|acetylsalicylic acid|ASA|309|311|MEDICATIONS|He carries a number of diagnoses, congestive heart failure, benign hypertensive disease, primary cardiomyopathy, history of atrial fibrillation, hyperlipidemia, chronic obstructive asthma, allergic rhinitis, esophageal reflux, angioneurotic edema, and he has had multiple orthopedic problems. MEDICATIONS: 1. ASA 81 mg. 2. Singulair 10 mg per day. 3. Protonix 40 mg. 4. Advair discus 150/50 tabs, one every six hours as needed.
ASA|acetylsalicylic acid|ASA.|293|296|HISTORY OF THE PRESENT ILLNESS|He has had a persistently sore, swollen thigh since that time that continues to drain and is a risk for an infection and is scheduled now for debridement. He is off Coumadin for the past week because of the increased risk of falling (discontinued on _%#MMDD2004#%_) and maintained on 81 mg of ASA. His hospital stay of _%#MMDD2004#%_ was complicated by anemia of 9.2 on discharge which has been stable at 9.3 on follow up in the nursing home and acute renal failure, hyperkalemia which responded to Kayexalate.
ASA|acetylsalicylic acid|ASA|103|105|MEDICATIONS|MEDICATIONS: 1. Lipitor 10 mg p.o. q.p.m. 2. Avandia 2 mg p.o. daily. 3. Detrol LA 4 mg p.o. daily. 4. ASA 325 mg p.o. daily. 5. Benicar 20 mg p.o. daily. 6. Macrobid 100 mg p.o. b.i.d. x 2 weeks. 7. Dulcolax rectal suppository 10 mg pr p.r.n. constipation.
ASA|acetylsalicylic acid|ASA|145|147|DISCHARGE DIAGNOSES|The patient was also instructed to take his vancomycin as he needs this to avoid sepsis from the possible seeded clot. DISCHARGE MEDICATIONS: 1. ASA 81 mg p.o. q. 24 hours. 2. Pantoprazole 40 mg p.o. q. 24 hours. 3. Hydralazine 10 mg p.o. b.i.d. 4. Colace 100 mg p.o. b.i.d. 5. Lipitor 20 mg p.o. q.h.s.
ASA|American Society of Anesthesiologists|ASA|148|150|ASSESSMENT/PLAN|NEUROLOGICALLY, he is intact. ASSESSMENT/PLAN: 1. Fractured left tibia as noted above, comminuted Salter type II. A healthy 14-year-old male who is ASA I for general anesthesia. He will go the operating room with Dr. _%#NAME#%_ today for fixation of his comminuted left tibial fracture.
ASA|acetylsalicylic acid|ASA|182|184|ALLERGIES|DISCHARGE MEDICATIONS: 1. (_______________) 4 mg p.o. q.24h. 2. Atenolol 50 mg p.o. b.i.d. 3. Avapro 150 mg p.o. b.i.d. 4. Potassium 20 mg p.o. b.i.d. 5. Plavix 75 mg p.o. q.24h. 6. ASA 81 mg p.o. q.24h. 7. Neurontin 800 mg p.o. t.i.d. 8. Hydrochlorothiazide 25 mg p.o. q.24h. 9. Neurontin 800 mg p.o. t.i.d. 10. Lipitor 10 mg p.o. q.24h.
ASA|acetylsalicylic acid|ASA,|267|270|MEDICATIONS|He has been treated for benign prostatic hypertrophy. MEDICATIONS: His current medications include Plendil, 10 mg, 2 orally daily; Lopressor, 50 mg, 1 orally b.i.d.; Lasix, 60 mg, 1-1/2 orally daily; Flomax, 0.4 mg, 1 orally daily; lisinopril, 20 mg, 1 orally daily; ASA, 325 mg, 1 orally daily. He was treated with some Zofran for nausea down in the emergency room, given Tylenol 650 mg and one dose of Cipro, 400 mg IV.
ASA|acetylsalicylic acid|ASA|117|119|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Zithromax 250 mg x 2 days. 2. Levaquin 500 mg q d x 10 days. 3. Librium 10 mg p.o. q.d. 4. ASA 80 mg enteric-coated one q.d. HOSPITAL COURSE: The patient was admitted on _%#MMDD2002#%_ with a diagnosis of pneumonia.
ASA|acetylsalicylic acid|ASA|138|140|MEDICATIONS|2. Digoxin 0.125 mg. QD. 3. Zestril 5 mg QD. 4. Paxil 40 mg QD. 5. Coreg 3.125 mg b.i.d. 6. Zaroxolyn 2.5 mg QOD. 7. Demadex 20 mg QD. 8. ASA 325 mg QD. 9. Doxazosin 4 mg QD. 10. Peri-Colace b.i.d. 11. TUMS prn. 12. Nitroglycerin prn.
ASA|acetylsalicylic acid|ASA|126|128|HOSPITAL COURSE|Medications at that time included Flovent 2 puffs b.i.d., albuterol nebulizations p.r.n., Mucomyst inhaler. Lisinopril 20 mg, ASA q. day which the patient is apparently noncompliant with. He complained of coughing and shortness of breath with chest pain related to the coughing.
ASA|acetylsalicylic acid|ASA|135|137|MEDICATIONS|She was hospitalized for transfusion and further workup. MEDICATIONS: Her medications at the time of admission included, Iron tablets, ASA one q. day; clonazepam 1 mg q.i.d.; OxyContin 20 mg q. 12h; Zocor 40 mg at h.s.; Lasix 40 mg q. day; Percocet one to two p.rn.; Aciphex 20 mg b.i.d.; Viscus lidocaine one or two teaspoons p.r.n. for heartburn as well; cholestyramine powder for chronic diarrhea.
ASA|acetylsalicylic acid|ASA|117|119|MEDICATIONS|5. Potassium 20 mg "p.r.n." 6. Nitro patch 0.6 mg q.h.s. 7. Terazosin 5 mg p.o. q.h.s. 8. Nitrostat 0.4 mg p.r.n. 9. ASA a.c. 325 mg at 0400. HABITS: No alcohol. No smoking x years. PSYCHOSOCIAL: The patient is retired from Northwest Bank where he was an administrator.
ASA|acetylsalicylic acid|ASA|223|225|CURRENT MEDICATIONS|System review in other fashions is non- contributory there being no evidence of chest pain, coronary artery disease, or cerebral vascular disease. CURRENT MEDICATIONS: 1. Norvasc 5 mg. 2. Fosamax 70 weekly. 3. Darvocet. 4. ASA which is discontinued prior to surgery and she will begin after surgery next week. 5. Prinivil 10 b.i.d. for the possibility to deal with diastolic dysfunction.
ASA|acetylsalicylic acid|ASA|99|101|DISCHARGE MEDICATIONS|3. Vioxx 25 po qd. 4. Tamoxifen 20 po qd. 5. Colace 100 po bid. 6. Vicodin 1-2 tabs po q6h prn. 7. ASA 81 mg po qd. 8. Cardizem 180 po qd. 9. Lipitor 10 po qhs. 10. Xalatan eye drops. 11. Fosamax 70 on Friday with usual requirements with 8 ounces of water, NPO and upright for 30 minutes after taking.
ASA|acetylsalicylic acid|ASA|155|157|CURRENT MEDICATIONS|9. Two normal pregnancies. ILLNESSES: 1. Hypertension. 2. Degenerative joint disease. 3. Possible lipid disorder. CURRENT MEDICATIONS: 1. Atenolol 100. 2. ASA 325. 3. Multivitamin. 4. Hydrochlorothiazide 25 a.m. ALLERGIES/DRUG SENSITIVITIES: Codeine, GI disturbances.
ASA|acetylsalicylic acid|ASA|125|127|DIAGNOSES|The medications continued during hospitalization and to be used at home will be as follows: 1. Atenolol 50 mg p.o. daily. 2. ASA 81 mg p.o. daily. 3. Fosinopril 10 mg p.o. daily. 4. Metformin 500 mg p.o. b.i.d. 5. Prandin dosed up to 2 mg before meals t.i.d.
ASA|acetylsalicylic acid|ASA|162|164|DISCHARGE MEDICATIONS|2. Ampicillin 500 mg p.o. q6h after a left groin infection stopped _%#MMDD2003#%_. 3. Artificial tears one to two drops OU b.i.d. for dry eyes. 4. Enteric coated ASA 81 mg p.o. daily for anticoagulation for atrial fibrillation and DVT. 5. Baclofen 5 mg p.o. t.i.d. for leg pain (new). 6. Furosemide 40 mg p.o. q.a.m. and 20 mg q.p.m. for lower extremity edema.
ASA|American Society of Anesthesiologists|ASA.|169|172|PLAN|Hemoglobin 13.3, comprehensive profile to be faxed. ASSESSMENT: 1. Left knee degenerative joint disease. 2. Obesity. 3. Type 2 diabetes. 4. Hypertension. PLAN: Class P2 ASA. Staff with Dr. _%#NAME#%_ _%#NAME#%_. Please tag Quello doctor.
ASA|acetylsalicylic acid|ASA|195|197|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Percocet 1 to 2 tablets po q4 to 6h prn for pain. 2. Ferrous sulfate 325 mg po each day for his postoperative anemia. 3. He will resume his postoperative medications of ASA 81 mg po each day, lisinopril/HCTZ 20/12.5 one tablet po each day, Norvasc 5 mg po each day, Toprol XL 50 mg po each day, and Zocor 40 mg po each day.
ASA|American Society of Anesthesiologists|ASA|169|171|ASSESSMENT|LOWER EXTREMITIES showed no edema. SKIN exam was fine. LABORATORY DATA: CBC was fine. ASSESSMENT: This is a 37-year-old in for pre-op. He should do well. He would be an ASA 1. Will follow-up with patient from here.
ASA|acetylsalicylic acid|A.S.A.|187|192|MEDICATIONS|No falls or trauma. MEDICATIONS: Current medications include: Atenolol 25 mg b.i.d. Coumadin 5 mg five days a week and 2.5 mg two days a week. Lipitor 40 mg a day. Maxzide 75/50 one q.d. A.S.A. 81 mg q.d. Sublingual nitroglycerin 0.4 mg p.r.n. Norvasc 5 mg q.d. ALLERGIES: She has no known allergies. She is a nondrinker. She is a nonsmoker. SOCIAL HISTORY: She is widowed and lives independently.
ASA|American Society of Anesthesiologists|ASA|155|157|PLAN|ASSESSMENT: Breast lump in a person with a history of breast cancer. PLAN: I see no contraindication to the proposed surgical procedure. The patient is an ASA 3. We will gladly follow should she require hospitalization.
ASA|acetylsalicylic acid|ASA|110|112|DISCHARGE MEDICATIONS|2. K-Dur 10 mEq po qd. 3. Aciphex 20 mg po qd. 4. Intal meter dose inhaler two puffs bid. 5. Metamucil qd. 6. ASA 325 mg po qd. 7. Metoprolol 25 mg bid. 8. Lipitor 10 mg qhs. 9. Lexapro 10 mg po qd. 10. Ferrous sulfate 325 mg po qd. 11. Darvocet N100 1-2 tabs po q4h.
ASA|acetylsalicylic acid|ASA|136|138|MEDICATIONS|1. Glipizide 2.5 mg p.o. q.a.m. and 5 mg p.o. q 11:30 am. 2. Depakote 250 mg p.o. q.h.s. 3. Lisinopril 5 mg p.o. q.d. 4. Enteric coated ASA 81 mg p.o. q.d. 5. Nizoral 2% shampoo q week. 6. Nolvadex 10 mg p.o. b.i.d. REVIEW OF SYSTEMS: This is difficult to obtain secondary to a lethargic state and dementia of the patient, but is essentially negative except for items mentioned in the History of Present Illness.
ASA|American Society of Anesthesiologists|ASA|184|186|INITIAL ASSESSMENT|No bone, joint, or soft tissue abnormality are noted. NEUROLOGIC: Intact. INITIAL ASSESSMENT: 1) No contraindication to proposed procedure which is a postpartum tubal ligation. She is ASA I for general anesthesia. 2) Status post normal spontaneous vaginal delivery _%#MMDD203#%_ without complications. PLAN: Postpartum tubal ligation with Dr. _%#NAME#%_ _%#NAME#%_. She will be kept NPO until he has a schedule secured.
ASA|American Society of Anesthesiologists|ASA,|129|132|PLAN|Hemoglobin is stable at 16.4. ASSESSMENT: Chronic otitis with conductive hearing loss and myringostapediopexy. PLAN: The plan is ASA, Class 1, okay for general anesthesia for right middle ear reconstruction and tympanoplasty.
ASA|acetylsalicylic acid|ASA|120|122|DISCHARGE MEDICATIONS|DISPOSITION: The patient is discharged home. DISCHARGE MEDICATIONS: 1. Glyburide 5 mg b.i.d. 2. Elavil 25 mg at h.s. 3. ASA 81 mg per day 4. Klonopin 0.5 mg each a.m. 5. Klonopin 1.0 mg at h.s. 6. Digoxin 0.125 per day 7. Synthroid 0.075 mg per day
ASA|acetylsalicylic acid|ASA|126|128|MEDICATION|3. Vicodin 1 p.o. q. 4 to 6 h. p.r.n. 4. Norvasc 10 mg p.o. q. day. 5. HCTZ 25 mg p.o. q. a.m. 6. Folate 1 mg p.o. q. day. 7. ASA 81 mg p.o. q. day. 8. Prilosec 20 mg p.o. q. day. 9. Levoxyl 100 mcg p.o. q. day. 10. Timolol 0.5% ophthalmic drops 1 drop OU b.i.d.
ASA|acetylsalicylic acid|ASA|79|81|DISCHARGE MEDICATIONS|DISPOSITION: Discharged to home in stable condition. DISCHARGE MEDICATIONS: 1. ASA 81 mg p.o. daily. 2. Lipitor 40 mg p.o. daily (higher dose). 3. Clopidogrel 75 mg p.o. daily (new medication). 4. Gemfibrozil 300 mg p.o. b.i.d.
ASA|American Society of Anesthesiologists|ASA|187|189|PLAN|Deep tendon reflexes were equal. His CNS is in his right lower leg is intact. ASSESSMENT: Tib/fib fracture. PLAN: I see no contraindication to the proposed surgical procedure. Patient is ASA 1, will gladly follow while he is in the hospital.
ASA|acetylsalicylic acid|ASA.|160|163|MEDICATIONS|3. Shingles recently noted. 4. CAD status post angioplasty in 1990. 5. HTN. 6. Hyperlipidemia. 7. DM2. 8. Glaucoma. MEDICATIONS: 1. Ranitidine. 2. Claritin. 3. ASA. 4. Lipitor. 5. Cardizem. 6. Cozaar. 7. Xalatan. 8. Vitamin B. ALLERGIES: PCN, sulfa, morphine, Demerol, clindamycin, Percocet, iodine, Allegra, Nasonex, morphine, and tetanus.
ASA|acetylsalicylic acid|ASA|190|192|MEDICATIONS AT THE TIME OF ADMISSION|MEDICATIONS AT THE TIME OF ADMISSION: Clonidine 0.1 mg p.o. b.i.d., Avapro 150 mg 2 in the morning and 1 in the evening, atenolol 50 mg q. day, Lasix 40 mg b.i.d., amiodarone 200 mg q. day, ASA 81 mg q. day, Lipitor 20 mg q. day, Prilosec 20 mg q. day, Nephrocaps 1 daily, Renagel 800 mg 4 three times a day with each meal.
ASA|acetylsalicylic acid|ASA|146|148|DISCHARGE MEDICATIONS|7. Lasix 80 mg p.o. q.a.m., 40 mg p.o. nightly. 8. OxyContin 10 mg p.o. b.i.d. 9. Senokot 2 tablets p.o. b.i.d. 10. Zocor 10 mg p.o. nightly. 11. ASA 81 mg p.o. daily. 12. Warfarin 7.5 mg p.o. daily. DISCHARGE FOLLOWUP: 1. Dr. _%#NAME#%_ of Fairview University in 1 week. 2. _%#NAME#%_, nurse practitioner at Fairview University.
ASA|acetylsalicylic acid|ASA|130|132|OUTPATIENT MEDICATIONS|3. Stenting, left iliac in 1998. 4. Left knee replacement in 2002. ALLERGIES: No known drug allergies. OUTPATIENT MEDICATIONS: 1. ASA 81 mg 1 tablet daily. 2. Lantus insulin. 3. Novolog insulin. 4. Zestril p.o. 10 mg q. day. 5. Glucophage tablet 500 mg b.i.d. 6. Lipitor 20 mg p.o. daily.
ASA|acetylsalicylic acid|ASA|134|136|MEDICATIONS|Lives locally. Has three daughters in the area. MEDICATIONS: 1. Diltiazem 240 mg daily. 2. Lisinopril HCTZ 10/12.5 one daily. 3. Baby ASA per day. 4. Ibuprofen 200 mg b.i.d. 5. Glyburide 10 mg b.i.d. 6. Metformin 500 mg b.i.d. 7. Atenolol 50 mg daily. REVIEW OF SYSTEMS: Dyspepsia, as per history of present illness.
ASA|acetylsalicylic acid|ASA|109|111|DISCHARGE MEDICATIONS|3. Zoloft 50 mg daily. 4. Cardizem LA 300 mg daily. 5. Caltrate 100 mg daily. 6. Lorazepam 0.5 mg at h.s. 7. ASA 325 mg at h.s. 8. Gabapentin 300 mg at h.s. 9. Hydrocodone with acetaminophen, one q. 4-6 h. p.r.n. pain.
ASA|acetylsalicylic acid|ASA|100|102|DISCHARGE MEDICATIONS|SECONDARY DISCHARGE DIAGNOSES: 1. Hypertension. 2. Diastolic dysfunction. DISCHARGE MEDICATIONS: 1. ASA 81 mg p.o. daily. 2. Cardizem CD 240 mg p.o. daily. 3. Hydrochlorothiazide 25 mg p.o. q.a.m. 4. Levaquin 500 mg p.o. daily x10 days.
ASA|acetylsalicylic acid|ASA|339|341|HOSPITAL COURSE|Bactroban dressing b.i.d. to the foot wound. Follow-up as mentioned during the hospital course with the retinal surgeon, the vascular surgeon, and Podiatry over the next two weeks and then with his primary physician in four weeks. To recheck INR in five days. Medications at discharge include Augmentin 875 mg p.o. b.i.d. times six weeks, ASA 81 mg p.o. q day, Lipitor 20 mg p.o. q.h.s., Captopril 25 mg p.o. b.i.d., digoxin 0.125 mg p.o. q day, Synalar cream to rash on arms b.i.d., Lasix 40 mg p.o. b.i.d., glipizide 5 mg p.o. q day, Lantus insulin 70 units sub-Q q.A.M., multivitamin one p.o. q day, potassium chloride 10 meq p.o. q day, rosiglitazone 8 mg p.o. q day, tolterodine 2 mg p.o. b.i.d., lispro sliding scale before meals with less than 100 blood sugar - no insulin, sugars 100-149 - 8 units, 150-199 12 units, 200-249 - 16 units, 250-349 - 20 units, and greater than or equal to 350 - 24 units as well as Coumadin 5 mg p.o. q Monday, Wednesday, and Friday and 2.5 mg all other days.
ASA|acetylsalicylic acid|ASA|127|129|CURRENT MEDICATIONS|6. Hypertension. 7. Generalized anxiety disorder. 8. Depression. CURRENT MEDICATIONS: 1. Lisinopril. 2. Lopressor 50 b.i.d. 3. ASA 325. 4. Tylenol ______ q. day. 5. Diazepam 10 t.i.d. 6. Benicar 40 one-half daily ie. 20 mg. 7. HCTZ 25 mg. 8. Lipitor 40. ALLERGIES: Celebrex.
ASA|acetylsalicylic acid|ASA|164|166|HOSPITAL COURSE|7. Triamterene/hydrochlorothiazide p.o. q.d. crushed. 8. Allegra 180 mg p.o. q.d. crushed. 9. Vioxx 25 mg p.o. q.d. crushed. 10. Actos 30 mg p.o. q.d. crushed. 11. ASA 81 mg p.o. q.d. crushed. 12. Glyburide 2.5 mg q.a.m., 7 mg q.p.m. FOLLOW UP: Ms. _%#NAME#%_ will follow up with Dr. _%#NAME#%_ in surgery clinic in 1 week's time.
ASA|American Society of Anesthesiologists|ASA|181|183|PLAN|I did talk to the patient about his smoking. He is willing to start on Zyban. Will start him on 150 mg p.o. b.i.d. I will gladly follow while he is in the hospital. He should be an ASA II.
ASA|acetylsalicylic acid|ASA|163|165|DISCHARGE INSTRUCTIONS|Tequin 200 mg daily through _%#MMDD2004#%_. h. Sertraline 50 mg daily. i. Trazodone 25 mg q h.s. j. Senna tablets one daily. k. Multivitamin, one tablet daily. l. ASA 81 mg daily. 2. Cathed UA/UC on _%#MMDD2004#%_. 3. Foley catheter to be discontinued following transfer to the nursing home.
ASA|acetylsalicylic acid|ASA|126|128|DISCHARGE MEDICATIONS|A prescription was called into the patient's pharmacy for a 7- day course of metronidazole therapy. DISCHARGE MEDICATIONS: 1. ASA 325 mg p.o. every day. 2. Colace 100 mg p.o. every day. 3. Furosemide 20 mg p.o. every day. 4. Synthroid 100 mcg p.o. every day. 5. Pantoprazole 40 mg p.o. every day.
ASA|acetylsalicylic acid|ASA.|193|196|ADMISSION MEDICATIONS|PAST MEDICAL HISTORY: Also includes amputation of the left arm status post motorcycle accident 1980s, tonsillectomy in childhood, and prostate surgery (details unknown). ADMISSION MEDICATIONS: ASA. ALLERGIES: THE PATIENT HAS NO KNOWN DRUG ALLERGIES.
ASA|American Society of Anesthesiologists|ASA|236|238|ASSESSMENT|Twelve-lead EKG is attached. ASSESSMENT: The patient is a 78-year-old female with multiple stable medical problems: Congestive heart failure, which apparently has much improved on beta blocker. She has an abdominal hernia. She is still ASA 3 because of her history of heart failure, but I believe she will do well with the surgery.
ASA|acetylsalicylic acid|ASA|91|93|DISCHARGE MEDICATIONS|DIET: As tolerated, low salt, low sugar. ACTIVITY: As tolerated. DISCHARGE MEDICATIONS: 1. ASA 81 mg p.o. once a day. 2. Lisinopril 10 mg p.o. once daily. 3. Metoprolol 25 mg p.o. b.i.d. 4. Metformin 500 mg p.o. b.i.d. 5. Tylenol 650 mg p.o. take 1 q.4-6 h. p.r.n. pain.
ASA|acetylsalicylic acid|ASA|186|188|PRIMARY MD|While she was here, the pharmacy did switch her urine prophylactic antibiotic from nitrofurantoin to Cipro due to her renal status. DISCHARGE MEDICATIONS: 1. Norvasc 5 mg p.o. daily. 2. ASA 325 mg p.o. daily. 3. Lipitor 10 mg p.o. q.p.m. 4. Cipro 250 mg p.o. daily instead of nitrofurantoin. 5. Avandia 2 mg p.o. daily. 6. Percocet 1 p.o. q. 4 hours p.r.n. pain.
ASA|acetylsalicylic acid|ASA|109|111|OPERATIONS/PROCEDURES PERFORMED|DISCHARGE MEDICATIONS: 1. Lipitor 20 mg p.o. q.day. 2. Calcium 500 mg p.o. qd 3. Plavix 75 mg p.o. q.day. 4. ASA 81 mg p.o. q. day. 5. Hydralazine 50 mg t.i.d. 6. Isordil 10 mg p.o. t.i.d. 7. Synthroid 100 mcg p.o. q.day. 8. Toprol XL 75 mg p.o. q.day.
ASA|American Society of Anesthesiologists|(ASA)|249|253|ASSESSMENT|Range of motion of the knees and hips are good with the exception of the left hip which shows some slight discomfort with external rotation. ASSESSMENT: 1. 79-year-old white male in generally good health. He is American Society of Anesthesiologists (ASA) Physical Status Classification Class 2 for general anesthesia due to his age and chronic stable disease. 2. Degenerative joint disease in the left hip, ready for replacement.
ASA|acetylsalicylic acid|ASA|171|173|DISCHARGE MEDICATIONS|4. Cymbalta 120 mg daily starting _%#MM#%_ _%#DD#%_, 2005, and thereafter. 5. Seroquel 25 mg daily at bedtime. 6. Lipitor 20 mg daily a.m. 7. Tricor 145 mg once daily. 8. ASA 325 mg daily. 9. Diovan 40 mg daily. 10. Toprol 25 mg every other day. 11. Protonix 40 mg one time daily.
ASA|acetylsalicylic acid|ASA|162|164|DISCHARGE MEDICATIONS|2. Imdur 60 mg twice a day (down from 120 mg b.i.d.). 3. Zocor 80 mg daily. 4. Effexor XR 150 mg daily. 5. Gemfibrozil 600 mg b.i.d. 6. Celebrex 200 mg daily. 7. ASA 81 mg daily. 8. Nitroglycerin sublingual one as needed under the tongue for angina. 9. Protonix 40 mg p.o. daily (new medication possibly to help with GERD).
ASA|acetylsalicylic acid|ASA|131|133|CURRENT MEDICATIONS|No palpitations. He takes 81 mg of aspirin a day for his prosthetic valve only. CURRENT MEDICATIONS: 1. Zocor 20 mg p.o. daily. 2. ASA 81 mg p.o. daily. SOCIAL HISTORY: He has a 40-pack-year-history of smoking, but quit 15 years ago.
ASA|American Society of Anesthesiologists|ASA|167|169|PLAN|PLAN: A CBC and basic metabolic panel is pending at this time. At this time, I see no absolute contraindications to his proposed surgical procedure. The patient is an ASA III. The patient will get a tetanus shot today for routine health maintenance.
ASA|acetylsalicylic acid|ASA|332|334|HOSPITAL COURSE|There was concern that perhaps the patient's epigastric discomfort may have been related to her Pentasa, which she had taken one dose of prior to admission. There was some question during the patient's past episode of pancreatitis that perhaps Asacol had been related to this, so perhaps the patient has some side effects from five ASA compounds? In regards to the patient's mild lipase elevation, this decreased to approximately 250 by the day of discharge.
ASA|acetylsalicylic acid|ASA|183|185|MEDICATIONS|_%#NAME#%_ does not smoke or drink. ALLERGIES: Codeine and Demerol MEDICATIONS: 1. Tylenol P.M. 2. Multi-vitamin 3. Calcium 4. Celebrex 200 mg q.day 5. Diovan 80 mg 1/2 tabs q.day 6. ASA 325 mg q.day 7. Plavix 75 mg q.day 8. Levothyroxine 0.1 mg q.day 9. Prilosec 20 mg q.day 10. Docusate 11. Labetalol 100 mg q.day
ASA|acetylsalicylic acid|ASA|124|126|MEDICATIONS|Chest x-ray is unavailable for interpretation at this time. ALLERGIES: RELAFEN AND IV CONTRAST ENHANCEMENT. MEDICATIONS: 1. ASA 81 mg daily. 2. Lipitor 80 mg daily. 3. Calcitrol 0.25 mg daily. 4. Lasix 80 mg daily. 5. Lopid 600 mg b.i.d. 6. Imdur 120 mg daily.
ASA|acetylsalicylic acid|ASA|241|243|MEDICATIONS|She just had a complete physical in _%#MM2005#%_, everything was fine and she passed a treadmill test in the Fall of 2003 everything was fine. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Altace 5 mg daily. 2. Lipitor 40 mg daily. 3. ASA 325 mg daily. 4. Sublingual Nitroglycerin p.r.n. PAST SURGICAL HISTORY: 1. Childbirth x2. 2. In 1994 she had a surgical repair of a urethral diverticulum.
ASA|acetylsalicylic acid|ASA|251|253|CURRENT MEDICATIONS|HABITS: She is a nonsmoker, nondrinker. ALLERGIES: She has multiple allergies including penicillin, nitrofurantoin, cyclobenzaprine, erythromycin, carbamazepine, amitriptyline, sulfa and valproic acid. CURRENT MEDICATIONS: 1. Norvasc 7.5 mg daily. 2. ASA 325 mg daily. 3. Tenormin 50 mg p.o. daily. 4. Lipitor 10 mg p.o. daily. 5. Aricept 10 mg p.o. daily. 6. Neurontin 300 mg t.i.d.
ASA|acetylsalicylic acid|ASA|128|130|DISCHARGE INSTRUCTIONS|7. Keppra. She will taper this off with 500 mg p.o. b.i.d. for 5 days and then 500 mg p.o. q.a.m. for 7 days, and then stop. 8. ASA 325 mg p.o. q. day. She should restart this on _%#MM#%_ _%#DD#%_, 2006. FOLLOW UP: She is to follow up with Dr. _%#NAME#%_ in his neurosurgery clinic in 4 weeks' time with a head CT without contrast.
ASA|American Society of Anesthesiologists|ASA|200|202|PHYSICAL EXAMINATION|Physical examination reveals LUNGS: Clear to auscultation CARDIAC: Regular rate and rhythm. No murmur or gallops The remainder of the physical examination is deferred. The patient would be considered ASA category I. MAXILLOFACIAL EXAMINATION: Reveals bilateral mandibular angle fractures, confirmed both on the panoramic radiograph and the CT scan. Both are minimally displaced and third molars are present on both sides.
ASA|American Society of Anesthesiologists|ASA|120|122|PLAN|3. Parkinson's disease. 4. History of prostate cancer. PLAN: 1. He should be okay to have the hip fixed. He would be an ASA III for general anesthesia. 2. We will follow him along while he is in the hospital.
ASA|acetylsalicylic acid|ASA|172|174|DISCHARGE MEDICATIONS|Her hemoglobin was stable at the time of discharge. DISCHARGE MEDICATIONS: 1. Levofloxacin 750 mg p.o. daily until _%#MM#%_ _%#DD#%_, 2005. 2. Lipitor 40 mg p.o. daily. 3. ASA 81 mg p.o. daily. 4. Lexapro 10 mg p.o. daily. 5. Albuterol 2 puffs inhalers q.6 h. p.r.n. 6. Robitussin DM 10 mL q.6-8 h. p.r.n.
ASA|acetylsalicylic acid|ASA|157|159|DISCHARGE DIAGNOSIS|The patient will be provided with the phone number of the Neurology Clinic. DISCHARGE MEDICATIONS: 1. Atorvastatin 10 mg p.o. q. 24 hours. 2. Enteric-coated ASA 325 mg p.o. q. 24 hours. Diet at the time of discharge is a thick liquid diet.
ASA|American Society of Anesthesiologists|ASA|148|150|PLAN|4. Hypertension, under excellent control. 5. Hyperlipidemia. PLAN: I see no contraindications to the proposed surgical procedure. The patient is an ASA 3. Will gladly follow while she is in the hospital.
ASA|acetylsalicylic acid|ASA|101|103|MEDICATIONS|4. Carotid endarterectomies, right and left. 5. Cataract surgery. ALLERGIES: Biaxin. MEDICATIONS: 1. ASA 81 mg q. day. 2. Percocet q.i.d. 3. Cordarone 200 mg q. day. 4. Digoxin 0.125 mg two days a week. 5. Levothyroxine 0.125 mg q. day. 6. Imdur 60 mg q. day.
ASA|acetylsalicylic acid|ASA|160|162|MEDICATIONS|4. Vicodin 1-2 q.6h. p.r.n. for pain. 5. Protonix 40 mg daily. 6. Vicodin B12 injections monthly. 7. Lisinopril 40 mg daily. 8. Flexeril 10 mg t.i.d. p.r.n. 9. ASA 81 mg daily. 10. Albuterol 2 puffs q.4h. p.r.n. for wheezing. 11. Lomotil 2.5 mg p.r.n. for diarrhea. 12. Calcium with vitamin D 1 tablet daily. 13. The patient does have some Compazine intake p.r.n. for nausea.
ASA|acetylsalicylic acid|ASA|145|147|PRIMARY MD|Isoenzymes were ordered and were still pending at the time of discharge. We will continue to follow this at discharge. DISCHARGE MEDICATIONS: 1. ASA 325 mg p.o. daily. 2. Atenolol 75 mg p.o. daily. 3. Lumigan 0.03% 1 drop both eyes nightly. 4. Cosopt ophthalmic drops, 1 drop left eye q.a.m.
ASA|acetylsalicylic acid|ASA|196|198|HOSPITAL COURSE|Once she got here, she actually complained of dizziness and episode of acute weakness where her legs gave out from under her. Her medications at the time of admission included Celexa 10 mg daily, ASA 81 mg daily, Lipitor 40 mg daily, Ativan 0.5 mg daily, Zantac 150 mg p.o. b.i.d. and Aricept 10 mg p.o. daily. PHYSICAL EXAMINATION: GENERAL: On initial exam, she was pleasant, in no acute distress and oriented x2.
ASA|American Society of Anesthesiologists|ASA|222|224|IMPRESSION|Otherwise musculoskeletal is negative. EXTREMITIES: Otherwise negative. NEUROLOGIC: No focal deficits. Hemoglobin today 14.1. IMPRESSION: This is a 19-year-old female with a right foot fracture. She is cleared for surgery ASA class 1.
ASA|acetylsalicylic acid|ASA|115|117|DISCHARGE MEDICATIONS|5. Levothyroxine 0.175 mg daily. 6. Seroquel 25 mg daily. 7. Fexofenadine 180 mg daily. 8. Norvasc 10 mg daily. 9. ASA 81 mg p.o. daily. 10. Keppra 250 mg p.o. b.i.d. PLAN: The plan was for her to go to the TCU to gain more strength and then likely go back to her original living situation.
ASA|acetylsalicylic acid|A.S.A.|168|173|MEDICATIONS|5. Humalog insulin. 6. Lantus insulin. 7. Iron 325 mg b.i.d. 8. Atenolol 50 mg daily. 9. Gemfibrozil 600 mg b.i.d. 10. Sublingual nitroglycerin 0.4 mg p.r.n. 11. 81 mg A.S.A. q day. 12. Plavix 75 mg q day. FAMILY HISTORY: Negative for allergic reactions to anesthesia or bleeding diathesis.
ASA|acetylsalicylic acid|ASA.|179|182|ADMISSION MEDICATIONS|She also completed a course of Metronidazole and 4 or 5 days after stopping the Metronidazole, she started to have a recurrent episode of colitis. ADMISSION MEDICATIONS: 1. 81 mg ASA. 2. Prednisone 40 mg once daily. 3. Multivitamins. 4. Toprol 50 mg once daily for blood pressure. 5. Asacol 400 mg, 2 pills three times a day.
ASA|acetylsalicylic acid|ASA|290|292|MEDICATIONS|The long weekend then intervened and she finally saw Dr. _%#NAME#%_ today on _%#MMDD2006#%_ who immediately admitted her to the hospital and he is planning on debridement and exploration in the operating room, anesthesia to be discussed. ALLERGIES: No known drug allergies. MEDICATIONS: 1. ASA 325 mg daily. 2. Avandia 8 mg daily. 3. Celebrex 200 mg daily. 4. Glipizide 10 mg b.i.d. 5. Lisinopril 10 mg daily.
ASA|American Society of Anesthesiologists|ASA|123|125|ASSESSMENT|Chest x-ray was within normal limits. Hemoglobin 14.1, white count 7200, urinalysis normal. BMP is pending. ASSESSMENT: 1. ASA I for hysterectomy, anterior and posterior repair. 2. History of hyperlipidemia. 3. Osteoporosis. PLAN: We will have her stop her Evista and hold aspirin.
ASA|acetylsalicylic acid|ASA|154|156|ADMISSION MEDICATIONS|2. Depression. 3. Cytomegalovirus. 4. Biliary stricture. 5. Biliary leak. PAST SURGICAL HISTORY: As above, plus TIPS procedure. ADMISSION MEDICATIONS: 1. ASA 81 mg q.Monday, Wednesday, and Friday. 2. Iron 325 mg q.d. 3. Prozac 20 mg q.d. 4. Magnesium oxide 400 mg t.i.d. 5. Multivitamin 1 q.d.
ASA|acetylsalicylic acid|ASA;|153|156|HOSPITAL  COURSE|It was felt that the patient will likely have a prolonged recovery. Patient will be dicharged home on Avelox. For his CAD, patient will be discharged on ASA; he is already on Zocor and gemfibrozil; I will defer starting a beta-blocker until his pulmonary status improves or per his PCP.
ASA|acetylsalicylic acid|ASA|240|242|MEDICATIONS|Nonsmoker, no history of diabetes. PAST MEDICAL HISTORY: Diagnosis - benign prostatic hypertrophy for which he has received a TURP. History of hypertension and supraventricular tachycardia. ALLERGIES: NKDA. MEDICATIONS: Zestril 5 mg daily, ASA 81 mg q.d., testosterone gel q.d. HABITS: No smoking, occasional wine less than one a day.
ASA|acetylsalicylic acid|ASA|195|197|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Atenolol 75 mg p.o. q.d. to jointly treat her essential tremor and hypertension. 2. Vicodin 1-2 tablets p.o. q.4h. p.r.n. 3. Colace 100 mg p.o. b.i.d. 4. Enteric-coated ASA 325 mg p.o. q.d. 5. Lipitor 20 mg p.o. q.d. 6. Nafcillin 2 gm IV q.4h. by her home infusion set.
ASA|acetylsalicylic acid|ASA|144|146|DISCHARGE MEDICATIONS|She will be discharged home. DISCHARGE MEDICATIONS: 1. Glyburide 10 mg p.o. q.a.m., 5 mg p.o. q.p.m. 2. Actos 45 mg p.o. q.d. 3. Enteric-coated ASA 325 mg p.o. q.d. 4. Lipitor 20 mg p.o. q.p.m. 5. Quinine sulfate 260 mg p.o. q.h.s. 6. Colace 100 mg p.o. b.i.d. 7. Vitamin C 500 mg p.o. q.a.m.
ASA|acetylsalicylic acid|ASA|369|371|MEDICATIONS|The patient has no history of surgery. He did have a "rectal problem" many years ago which he treated with hot packing of the rectal area. ALLERGIES: No known drug allergies. MEDICATIONS: Lopressor 50 mg t.i.d., allopurinol 300 qd, Avandia 4 mg po qd, Captopril 37.5 mg t.i.d., Lasix 40 mg po qd, Klor-Con 20 mEq b.i.d., multi-vitamin, vitamin E, B-complex, C vitamin, ASA and glucosamine chondroitin. PAST MEDICAL HISTORY: Hypertension, gout, hyperlipidemia, benign prostatic hypertrophy, left bundle branch block and adult onset diabetes mellitus.
ASA|acetylsalicylic acid|ASA.|121|124|MEDICATIONS ON ADMISSION|MEDICATIONS ON ADMISSION: 1. Zyprexa. 2. Haldol. 3. Atenolol. 4. Keflex. 5. Insulin lente 35 units q.d. 6. Trazodone. 7. ASA. 8. Nifedipine discontinued _%#MMDD2002#%_. ALLERGIES: No known drug allergies. PAST MEDICAL HISTORY: 1. Hypertension. 2. DM2 times years.
ASA|acetylsalicylic acid|ASA|281|283|DISCHARGE MEDICATIONS|After treatment, his creatinine and nitrogen went down, and he felt better. He had edema less, and he does not have exacerbation of CHF and renal insufficiency DISCHARGE MEDICATIONS: Lasix 40 mg p.o. b.i.d., insulin 75/25 40 units subcutaneously b.i.d., Glucotrol 10 mg p.o. q.d., ASA 325 mg p.o. q.d., Vicodin 1-2 pills q.4-6h., MS Contin 15 mg p.o. q. a.c., Neurontin 300 mg p.o. q. a.c., Vistaril 10 mg p.o. q.d., Panafil Green apply to the wound once a day, Metamucil 1 tablespoon in 8 ounces of water b.i.d., Zaroxolyn 5 mg p.o. b.i.d., atenolol 25 mg p.o. q.d.
ASA|acetylsalicylic acid|ASA|127|129|TRANSFER MEDICATIONS|5. OxyContin 10 mg p.o. q.12.h 6. Vitamin B6 100 mg p.o. t.i.d. 7. Glutamine 1 gm p.o. q.i.d. 8. Trental 400 mg p.o. t.i.d. 9. ASA 325 mg p.o. q.d. 10. Prevacid 30 mg p.o. q.d. 11. Flovent inhaler 2 to 3 puffs b.i.d. The patient may use her own supply.
ASA|acetylsalicylic acid|ASA|650|652|PLAN|She did slowly gradually improve and was judged ready to return to the nursing home to continue her convalescence. PLAN: The patient was returned to the nursing home on Restoril 7.5 mg at hs p.r.n. insomnia, Ultram 50 mg q.i.d. p.r.n. pain, Percocet one every 4 hours p.r.n. pain, Atenolol 50 mg po q.d. for high blood pressure, Fosamax 70 mg po once a week for osteoporosis, calcium 500 mg t.i.d. for osteoporosis, multi-vitamins one a day for general principles, Colace 100 mg b.i.d., Robitussin cough syrup, Vioxx 25 mg po q.d. for pain, Travatan 0.004% eye drops one drop in the left eye daily, house supplement for nutrition 4 ounces t.i.d. and ASA 325 mg po q.d. for heart and stroke. She was also sent on oxygen 1-2 liters per minute 24 hours as day.
ASA|acetylsalicylic acid|ASA|113|115|MEDICATIONS|5. DJD. MEDICATIONS: 1. Carbidopa 25/100 p.o. t.i.d. 2. Zocor 20 mg p.o. q.d. 3. Ibuprofen 400 mg p.o. t.i.d. 4. ASA 325 mg p.o. q.d. 5. Niaspan 500 mg p.o. q.d. 6. Lisinopril 10 mg p.o. q.d. 7. Glucophage 500 mg p.o. b.i.d. ALLERGIES: No known drug allergies.
ASA|acetylsalicylic acid|ASA|166|168|HOSPITAL COURSE|The atrial fibrillation resolved following the administration of an esmolol drip. A Cardiac consult was made for medication management. Recommendations were made for ASA only for anticoagulation. DISCHARGE MEDICATIONS: 1. Colace suspension 100 mg b.i.d. 2. Senna suspension 1-4 tablets b.i.d.
ASA|acetylsalicylic acid|ASA|172|174|DISCHARGE MEDICATIONS|7. Nystatin 10 mls swish and swallow q.i.d. 8. Magic mouthwash. 9. Compazine elixir 10 mg q.6h as needed. 10. Fentanyl patch 500 mcg transdermally to be changed q.72h. 11. ASA 1 tablet (325 mg) q.d. DISCHARGE FOLLOW UP: 1. The patient will follow up with Dr. _%#NAME#%_ in the Hematology Oncology Clinic on _%#MMDD2002#%_ at 9:30 a.m.
ASA|acetylsalicylic acid|ASA|271|273|DISCHARGE MEDICATIONS|5. Anemia: The patient continued on his iron for iron deficiency anemia confirmed by iron studies from his _%#MM#%_ _%#DD#%_, 2002, to _%#MM#%_ _%#DD#%_, 2002, hospital stay. DISCHARGE MEDICATIONS: 1. Iron sulfate 325 mg p.o. t.i.d. 2. Multivitamin 1 tab p.o. q.d. 3. EC ASA 325 mg p.o. q.d. 4. Prozac 40 mg p.o. q.d. 5. Metoprolol 25 mg p.o. b.i.d. 6. Zantac 150 mg p.o. b.i.d. 7. Haldol (new medication) 0.5 mg p.o./IM b.i.d.
ASA|acetylsalicylic acid|ASA|170|172|DISCHARGE MEDICATIONS|DISCHARGE PLAN: The patient is to remain on a soft bland diet, which was reviewed with her and her daughter per phone at the patient's request. DISCHARGE MEDICATIONS: 1. ASA 81 mg p.o. q.d. 2. Protonix 40 mg p.o. q.d. (or Aciphex b.i.d.). 3. Zocor 20 mg p.o. q.d. 4. MVI one p.o. q.d.
ASA|acetylsalicylic acid|ASA|125|127|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: She is discharged on the following medications: 1. Allopurinol 100 mg daily. 2. Norvasc 10 mg q.d. 3. ASA 81 mg q.d. 4. Colchicine 600 mg q.d. 5. Sandimmune 150 mg q.d. 6. Prozac 10 mg q.d. 7. Lasix 40 mg q. noon, Lasix 80 mg q.a.m.
ASA|acetylsalicylic acid|ASA|143|145|MEDICATIONS|2. Hypothyroidism. 3. Status post TAH 1954. 4. Status post tonsillectomy. MEDICATIONS: 1. Synthroid. 2. Premarin. 3. Digoxin. 4. Meclozine. 5. ASA 325 mg per os every day. ALLERGIES: No known drug allergies. FAMILY HISTORY: Father died of colon cancer in his 80's.
ASA|acetylsalicylic acid|ASA|233|235|DISCHARGE MEDICATIONS|The patient was agreeable to this. DISCHARGE MEDICATIONS: The patient will be transferred to the Rehabilitation Center on the following medications: 1. Acyclovir 400 mg b.i.d. 2. Albuterol four puffs q4h. 3. Amlodipine 10 mg q.d. 4. ASA 162 mg q.d. 5. Celexa 20 mg q.h.s. 6. Colace 100 mg b.i.d. 7. Epogen 4000 U subcu q. week. 8. Gabapentin 200 mg p.o. b.i.d.
ASA|acetylsalicylic acid|ASA.|251|254|HOSPITAL COURSE|She was discharged to home on postoperative day #2 with the following medication: Percocet 1-2 tablets p.o. q.4-6h. p.r.n. for pain. She was to continue her preoperative medications of Lantus and Humalog insulin, _____________, Levothroid, Zocor, and ASA. She will follow up in my clinic one month from the time of discharge. She was instructed to avoid lifting, bending, and twisting during that follow- up period.
ASA|American Society of Anesthesiologists|ASA|152|154|PLAN|PLAN: I see no contraindication to the proposed surgical procedure. I presume this is going to be done under a local anesthetic. The patient will be an ASA 3. This patient will need both the flu shot as well as a Pneumovax.
ASA|acetylsalicylic acid|ASA|141|143|MEDICATIONS|Also in the past he did have a lymphoscintigraphy test which was negative for any lymphatic duct blockage. ALLERGIES: Sulfa. MEDICATIONS: 1. ASA 81 mg p.o. q. daily. 2. Coumadin 5 mg p.o. q. daily. 3. Furosemide 60 mg IV b.i.d. 4. Glipizide 5 mg p.o. q. daily. 5. K-Dur 40 mEq p.o. b.i.d.
ASA|acetylsalicylic acid|ASA|228|230|CARDIAC RISK FACTORS|CARDIAC RISK FACTORS: Possible family history, no hypertension, positive for smoking 1-1/2 ppd, no diabetes, cholesterol unknown, sedentary lifestyle. In the Emergency Department the patient received metoprolol 5 mg times 3 and ASA 162 mg. ALLERGIES: No known drug allergies. MEDICATIONS: Naprosyn 500 mg po bid, Neurontin listed at 900 mg tid, ASA 81 mg qd, Metamucil prn.
ASA|acetylsalicylic acid|ASA|194|196|MEDICATIONS|In the Emergency Department the patient received metoprolol 5 mg times 3 and ASA 162 mg. ALLERGIES: No known drug allergies. MEDICATIONS: Naprosyn 500 mg po bid, Neurontin listed at 900 mg tid, ASA 81 mg qd, Metamucil prn. He did have a flu injection this fall. PAST MEDICAL HISTORY: Diagnoses include peripheral neuropathy affecting his feet and hands; history of back injury and chronic back pain that refers to pinched nerve or sciatica; history of hyperplastic colon polyps, last colonoscopy _%#MM2000#%_; early COPD.
ASA|acetylsalicylic acid|ASA|172|174|CURRENT MEDICATIONS|She has had no fever while at home. The rest of the review of systems is negative. CURRENT MEDICATIONS: She is on a long list of p.r.n. medications. In addition, she is on ASA 81 mg q. day, Lantus 12 units q.p.m., Glucotrol XL 10 mg q. day, Demadex 40 mg p.o. q.a.m. and 20 mg p.o. q.p.m., Zaroxolyn 2.5 mg q.o.d., Paxil 20 mg q. day, lisinopril 20 mg q. day, Dilantin 100 mg q. day, Zocor 40 mg q. day, Protonix 40 mg q. day, digoxin 0.125 mg p.o. q. Monday, Wednesday, Friday; Lopressor 100 mg b.i.d., hydralazine 25 mg b.i.d., Norvasc 5 mg p.o. q. day.
ASA|acetylsalicylic acid|ASA|144|146|MEDICATIONS|1. Norvasc 5 mg p.o. q.d. 2. Amiodarone 200 mg p.o. q.d. 3. Lisinopril 20 mg p.o. q.d. 4. Kay-Ciel 10 mEq p.o. q.d. 5. Lasix 30 mg p.o. q.d. 6. ASA 81 mg p.o. q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient has never been married. She lives with her twin sister in an apartment.
ASA|acetylsalicylic acid|ASA,|176|179|CURRENT MEDICATIONS|MEDICATION REACTIONS: Amiodarone. CURRENT MEDICATIONS: 1. Prednisone, 10 mg p.o. q.d. 2. Vioxx, 25 mg p.o. q.d. 3. Prevacid, 15 mg p.o. q.d. 4. Actonel, 35 mg p.o. q. week. 5. ASA, 81 mg p.o. q.d. 6. Norvasc, 5 mg p.o. q.d. 7. Lasix, 20 mg p.o. q.d. 8. Vitamin B12, 1,000 mcg subcu q. month. 9. Flovent, 44 mcg 2 puffs b.i.d.
ASA|acetylsalicylic acid|ASA|123|125|DISCHARGE MEDICATIONS|6. Vitamin K 5 mg p.o. q. daily. 7. Prelone 2 mg p.o. q. daily. 8. Bactrim 16 mg p.o. q. Monday, Wednesday, and Friday. 9. ASA 10 mg p.o. q. Monday, Wednesday, and Friday. 10. Phenobarbital 60 mg p.o. q. daily. FOLLOW-UP APPOINTMENTS: 1. Dr. _%#NAME#%_, as previously scheduled in _%#MM2003#%_.
ASA|acetylsalicylic acid|ASA|109|111|MEDICATIONS|Daily treadmill exercise. MEDICATIONS : 1. Norvasc 10 mg QD. 2. Lipitor 10 mg QD 3. Maxzide 75/50 QD. 4. One ASA QD FAMILY HISTORY: Mother deceased 78, myocardial infarction.
ASA|American Society of Anesthesiologists|(ASA)|171|175|PLAN|2. Hypertension under excellent control. PLAN: I see no contraindications to the proposed surgical procedure. The patient will be an American Society of Anesthesiologists (ASA) II.
ASA|acetylsalicylic acid|ASA|337|339|IDENTIFICATION|On _%#MM#%_ _%#DD#%_, 2004, her medications that she had been taking previously were reordered. The medications include Levoxyl 175 mcg every a.m., Ogen 1.25 mg daily, spironolactone 25 mg two tabs twice daily, Bextra 10 mg two times daily, Klor-Con 10 mEq two tablets 3 times daily, Diflucan 200 mg daily, Maxzide 75/50 mg twice daily, ASA 81 mg daily, and Benadryl 25 to 50 mg at bedtime as needed for sleep. Dr. _%#NAME#%_ saw her on _%#MM#%_ _%#DD#%_, 2004, to start the buprenorphine.
ASA|acetylsalicylic acid|ASA|220|222|CURRENT MEDICATIONS|FAMILY HISTORY: Noncontributory. ALLERGIES: He is not allergic to any medications that he is aware of. CURRENT MEDICATIONS: Include Imdur 160 mg, one orally daily; lisinopril/hydrochlorothiazide 20/25, one orally daily; ASA 81 mg, one orally daily; Timoptic XE 0.5 percent eye drops, one drop in each eye daily; Xalatan 0.005 percent eye drops, one drop to each eye daily; nitroglycerin sublingual 0.4 mg p.r.n. for chest pain, which he has not used.
ASA|American Society of Anesthesiologists|ASA|264|266|PLAN|ASSESSMENT: A 65-year-old male with a history of adult-onset diabetes mellitus only under fair control, hypertension, hyperlipidemia, coronary artery disease, with severe osteoarthritis. PLAN: I see no contraindication to the proposed surgical procedure. He is an ASA 3. Because of his above medical history, we will get the patient scheduled for an adenosine thallium stress test on _%#MMDD2004#%_.
ASA|acetylsalicylic acid|ASA|178|180|DISCHARGE MEDICATIONS|His target was 1300 kcal per day. He was taken off TPN day by day, as ambulation and exercise tolerance has increased. DISCHARGE MEDICATIONS: 1. Amiodarone 400 mg p.o. q.12h. 2. ASA 81 mg p.o. daily. 3. Mycelex Troche 1 tab p.o. q.i.d. 4. Darbepoetin 25 mcg subcutaneous q. week. 5. Myfortic 360 mg p.o. b.i.d. 6. Protonix 40 mg p.o. daily.
ASA|acetylsalicylic acid|ASA|141|143|DISCHARGE PLANS|Subsequently arrangements were made for transfer to the nursing home. DISCHARGE PLANS: The patient was sent to Minnesota Masonic Home on: 1. ASA 81 mg daily. 2. Lasix 40 mg daily. 3. Glucotrol XL 5 mg daily. 4. Cozaar 50 mg daily. 5. Lantus 10 units subq in the evening. 6. Coumadin 2.5 mg daily or as directed.
ASA|acetylsalicylic acid|ASA|230|232|DISCHARGE MEDICATIONS|DOB: _%#MMDD1965#%_ FINAL DISCHARGE DIAGNOSES: 1. Right fourth digit abscess with Staphylococcus aureus resistant to penicillin. 2. Hypertension. 3. Diabetes. 4. Hypercholesterolemia. DISCHARGE MEDICATIONS: Actos 15 mg p.o. q.d., ASA 325 mg p.o. q.d., lisinopril 20 mg p.o. q.d., Prilosec 20 mg p.o. q.d., Lipitor 10 mg p.o. q.d., Vicodin 1-2 tablets p.o. q 4-6 hours p.r.n. pain, Keflex 500 mg p.o. t.i.d. for 10 days, Glucotrol XL 5 mg p.o. q.A.M. CONSULTATIONS: Orthopaedic Surgery.
ASA|American Society of Anesthesiologists|ASA|154|156|PLAN|ASSESSMENT: Nephrolithiasis; hypertension under excellent control. PLAN: I see no contraindications to the proposed surgical procedure. The patient is an ASA 2. Will forward the labs to the hospital when they are available.
ASA|acetylsalicylic acid|ASA|536|538|MEDICATIONS AT PRESENT|Her blood sugars have been somewhat better because of this. MEDICATIONS AT PRESENT: Include Macrobid 100 mg b.i.d., omeprazole 40 mg daily, diflucan 100 mg daily, metformin 500 mg t.i.d. with meals, Ditropan 5 mg t.i.d., clonidine 0.2 mg h.s. for hypertension, Cartia XT 300 mg daily, Advair Diskus 100/50 one puff b.i.d., Lisinopril 20 mg daily, albuterol multidose inhaler two puffs q.4h p.r.n. for wheezing, nitroglycerin 0.4 mg sublingual p.r.n. 5 minutes for chest pain, Lasix 40 mg orally b.i.d., potassium chloride 20 mEq daily, ASA 81 mg daily, Os-Cal 500 mg daily, and insulin Humulin N and R b.i.d. PHYSICAL EXAM: Reveals her to be an alert female sitting in the chair.
ASA|acetylsalicylic acid|ASA|152|154|MEDICATIONS|PAST SURGICAL HISTORY: Eye surgery. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Synthroid 0.075 mg p.o. daily. 2. Atenolol 50 mg p.o. b.i.d. 3. ASA 325 mg p.o. daily. 4. Lisinopril 10 mg p.o. daily. 5. Glucophage 500 mg p.o. daily. 6. Garlic b.i.d. SOCIAL HISTORY: The patient lives in a house alone, does not use tobacco, or alcohol.
ASA|American Society of Anesthesiologists|ASA|164|166|PLAN|3. Hypertension under fair to good control. 4. Hyperlipidemia. 5. Osteopenia. PLAN: I see no contraindication to the proposed surgical procedure. The patient is an ASA II. We will start the patient on Fosamax 70 mg p.o. q. week.
ASA|acetylsalicylic acid|ASA|116|118|DISCHARGE MEDICATIONS|2. Imodium every night at bedtime for symptomatic relief. 3. Omeprazole is continued at 20 mg oral daily dosage. 4. ASA 81 mg oral daily. 5. Hydrochlorothiazide 25 mg given Friday and Tuesdays only. 6. Verapamil SR is continued 180 mg p.o. daily. We will requesting Fairview partners to follow her while in the nursing home and subsequently it is intended she will return to her home with Fairview Home Care following her.
ASA|acetylsalicylic acid|A.S.A.|179|184|MEDICATIONS|ALLERGIES: None. MEDICATIONS 1. Aciphex 20 mg daily. 2. Coreg 6.25 mg b.i.d. 3. Wellbutrin 150 mg b.i.d. 4. Zocor 80 mg daily. 5. Lasix 20 mg daily. 6. Lisinopril 10 mg daily. 7. A.S.A. 81 mg daily. 8. A variety of supplements including but not limited to vitamins C, E, B6, and B12. PAST SURGERY: Angiogram in the '90s. Triple bypass in 1993.
ASA|American Society of Anesthesiologists|ASA|189|191|PLAN|ASSESSMENT: 1. Left hip fracture. 2. Anemia, idiopathic. 3. Hypertension, under fair control. 4. Smoker. PLAN: I see no contraindications for proposed surgical procedure. The patient is an ASA 3. Will check her basic metabolic panel. I suspect she has a component of COPD. Will at this time start her on Duonebs q.i.d. I did talk to her about the nicotine patch; she is not interested at this time.
ASA|acetylsalicylic acid|ASA|175|177|HOSPITAL COURSE|On admission, phenobarbital 60 mg 3 times daily was ordered to cover withdrawal symptoms from the Klonopin. Lisinopril 10 mg daily, atenolol 50 mg daily, Lipitor 40 mg daily, ASA 325 mg daily, and Seroquel 100 mg at bedtime with repeat x1 as needed were ordered. On _%#MM#%_ _%#DD#%_, 2005, Wellbutrin XL 150 mg daily was added to treat symptoms of depression.
ASA|acetylsalicylic acid|ASA|140|142|MEDICATIONS|2. Amaryl 4 mg q. day. 3. Lisinopril 10 mg q. day. 4. Actos 45 mg q. day. 5. Celexa 20 mg q. day. 6. Nexium 40 mg q. day. 7. Enteric-coated ASA 325 mg q. day. 8. Quinine sulfate 325 mg q. day. 9. Foltx 1 mg q. day. 10. Centrum vitamins one a day. 11. Hydrochlorothiazide 25 mg q. day, which is also new.
ASA|American Society of Anesthesiologists|ASA|129|131|PLAN|ASSESSMENT: Nephrolithiasis, hypertension. PLAN: I see no contraindication to the proposed surgical procedure. The patient is an ASA 2. Will forward the labs when then are available.
ASA|acetylsalicylic acid|ASA|418|420|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Levaquin 500 mg every other day for another week (reduced schedule due to renal insufficiency with creatinine clearance estimated at about 30), Lasix 40 mg initially had thought 40 mg but at time of discharge, decreasing to 20 mg q. a.m., prednisone 10 mg q. a.m. for another three days, Lipitor 10 mg at bedtime for hypercholesterolemia, timolol 0.25% 1 drop each eye twice daily for glaucoma, ASA enteric coated 81 mg prophylactically, FESO4 325 mg q. a.m. for history of anemia, Prilosec 20 mg q. a.m. for gastroesophageal reflux disease, Lopid 600 mg b.i.d. for hypertriglyceridemia, Flonase 1 puff each nostril b.i.d. for chronic rhinitis, metoprolol 100 mg q. a.m. and 50 mg p.m.
ASA|acetylsalicylic acid|ASA|136|138|MEDICATIONS|2. Hyperlipidemia. 3. Depression. 4. Dysphagia. ALLERGIES: Phenobarbital, Bellergal, MS. HABITS: Nonsmoker. No alcohol. MEDICATIONS: 1. ASA currently on hold. 2. Lisinopril 10 mg q. day. 3. Prozac 20 mg every other day. 4. Trazodone 50 mg at h.s.
ASA|American Society of Anesthesiologists|ASA|135|137|ASSESSMENT|ASSESSMENT: This is a 60-year-old white female in for pre-op. At the present time, she should do well with surgery. I would put her in ASA 2 but I think surgery is indicated. Will start her on Toprol 25 mg tonight and tomorrow night and then 50 mg for one week prior to surgery.
ASA|American Society of Anesthesiologists|ASA|162|164|PLAN|1. Multiple kidney stones. 2. Diabetes under fair control. 3. Hypertension. PLAN: I see no contraindication to the proposed surgical procedure. The patient is an ASA 3.
ASA|acetylsalicylic acid|ASA,|121|124|MEDICATIONS|9. Detrol LA, 4 at bedtime. 10. Coreg, 12.5 mg b.i.d. 11. Amlodipine, 10 mg/day. 12. Folgard, 2 tabs in the morning. 13. ASA, 81 mg. 14. B12 injections, which had been ordered for weekly x 4 and then monthly. It is not clear to me how many she has received.
ASA|acetylsalicylic acid|ASA|147|149|DISCHARGE MEDICATIONS|12. Acute on chronic renal failure. DISCHARGE MEDICATIONS: 1) Quinine 325 mg p.o. q.d. 2) Lipitor 20 mg p.o. q.d. 3) Fosamax 70 mg p.o. weekly. 4) ASA 80 one p.o. daily. 5) Synthroid 0.1 mg p.o. q.d. 6) Imdur 60 mg p.o. b.i.d. 7) Prilosec 20 mg p.o. q.d. 8) Torsemide 40 mg p.o. q.A.M.; 20 mg p.o. q.P.M. 9) Plavix 75 mg p.o. q.d 10) Cozaar 50 mg p.o. b.i.d. 11) Toprol XL 50 mg p.o. q.d. 12) Chlor-Con 10 meq p.o. q.d. 13) Iron tablets 325 mg p.o. q.d. 14) Hydralazine 12.5 mg p.o. t.i.d. 15) Gabapentin 300 mg p.o. t.i.d. 16) Humalog insulin per sliding scale with meals.
ASA|acetylsalicylic acid|ASA|208|210|REVIEW OF SYSTEMS|SOCIAL HISTORY: He is married and works as an executive director for the American Counsel of Engineering companies. REVIEW OF SYSTEMS: He denies chest pain, shortness of breath, recent infectious disease. No ASA use within the last ten days. PHYSICAL EXAMINATION: VITAL SIGNS: 5 feet 9 1/2 inches, weight 181 pounds, blood pressure 126/84, pulse 73 and regular, temperature 97.1. HEENT: TMs normal.
ASA|American Society of Anesthesiologists|(ASA)|230|234|ASSESSMENT|NEUROLOGIC: Intact. ASSESSMENT: 1. Pregnancy loss with what appears to be blighted ovum per the ultrasound. 2. Otherwise healthy female with no contraindications to the proposed procedure. 3. American Society of Anesthesiologists (ASA) Physical Status Classification 1 for general anesthesia. PLAN: The patient will report to Fairview Southdale Hospital for surgical date with Dr. _%#NAME#%_ _%#NAME#%_ on Saturday, _%#MMDD2005#%_.
ASA|acetylsalicylic acid|ASA|243|245|MEDICATIONS AT THE TIME OF DISCHARGE|At the time of discharge, she was still weak enough that she was unremarkable returning home and so arrangements were made for her to go to a transitional care unit. She was however eating fairly well. MEDICATIONS AT THE TIME OF DISCHARGE: 1. ASA 325 mg p.o. every day. 2. Avandia 2 mg p.o. every day. 3. Glipizide EX 5 mg b.i.d. 4. Lipitor 10 mg p.o. every day.
ASA|American Society of Anesthesiologists|ASA|200|202|PLAN|ASSESSMENT: 1. Well exam. 2. Carpal tunnel syndrome. 3. Hypertension, under excellent control. 4. Hyperlipidemia. PLAN: I see no contraindication to the proposed surgical procedure. The patient is an ASA 2. She will receive the influenza vaccine prior to leaving the clinic. I did talk to her about smoking cessation and she is not interested at this time.
ASA|American Society of Anesthesiologists|ASA|150|152|ASSESSMENT AND PLAN|EKG pending. ASSESSMENT AND PLAN: 1. Appendicitis. Pain okay even without analgesics. ____________ surgery planned for later today. Analgesics p.r.n. ASA Class I, okay for surgery. 2. Elevated glucose likely secondary to stress response and/or eating prior to test. We will recheck in a.m. No prior history of diabetes.
ASA|acetylsalicylic acid|ASA|172|174|DISCHARGE MEDICATIONS|Bactrim single strength 1 tab p.o. q. day. 4. Prednisone 5 mg p.o. q. day. 5. Celexa 20 mg p.o. q. day. 6. Lisinopril 10 gm p.o. q. day. 7. Metoprolol 50 mg p.o. b.i.d. 8. ASA 81 mg p.o. 3 times a week every Monday, Wednesday, and Friday. 9. Percocet 5/325 mg one to two tablets p.o. q.4-6 h. p.r.n. pain.
ASA|American Society of Anesthesiologists|ASA|127|129|ASSESSMENT|ABDOMEN: No evident scars. EXTREMITIES: Showed 1+ edema. Her DTRs were slightly hyperactive with no clonus. ASSESSMENT: She is ASA 1 for postpartum tubal ligation. I anticipate she will do well after her normal vaginal delivery this evening. PLAN: To keep her n.p.o. after midnight. Will keep IV flowing for now and check hemoglobin in the morning.
ASA|American Society of Anesthesiologists|ASA|136|138|IMPRESSION|IMPRESSION: This is a 64-year-old male with degenerative hip disease. Planned ORIF of the right hip with Dr. _%#NAME#%_. The patient is ASA class 2, clear for surgery, pending normal BNP. He is otherwise doing well.
ASA|American Society of Anesthesiologists|ASA|225|227|PLAN|SKIN: Within normal limits. CBC, PT, PTT, platelets and creatinine are being drawn at Fairview Ridges Hospital. ASSESSMENT: Kidney stones. PLAN: I see no contraindication to the proposed surgical procedure. The patient is an ASA I.
ASA|acetylsalicylic acid|ASA|141|143|MEDICATIONS ON DISCHARGE|3. Avandia 4 mg p.o. daily. 4. Lisinopril 20 mg daily. 5. Niacin 2000 mg at bedtime. 6. Aricept 5 mg bedtime. 7. Lovastatin 40 mg bedtime 8. ASA 325 mg bedtime. DISCHARGE PLAN: The patient is discharged _%#CITY#%_ Place. He will follow up with _%#NAME#%_ _%#NAME#%_ in the Dementia Clinic of Neurology at the University.
ASA|American Society of Anesthesiologists|ASA|150|152|PLAN|ASSESSMENT: Adenocarcinoma of the rectum in a 44-year-old male. PLAN: I see no contraindication to the proposed surgical procedure. The patient is an ASA II.
ASA|aminosalicylic acid|ASA|156|158|PAST MEDICAL HISTORY|He used caster oil applications to his abdomen and various dietary supplements. Through the patient's 24 year history of crohn's disease, he has not used 5 ASA products, nor has he used immunosuppression with 6MP or Imuran. Relative to complications of Crohn's disease, the patient is now known to have cholelithiasis.
ASA|acetylsalicylic acid|ASA|268|270|MEDICATIONS|She was admitted for presumed CHF and further management. MEDICATIONS: At the time of admission were Synthroid 0.125 mg q day. Lyrica 12.5 mg b.i.d., menthol patch to the skin 3 times daily, Senokot 1 tab b.i.d., oxycodone 5-10 mg every four hours as needed for pain, ASA 81 mg daily, iron supplement and Levaquin for recent urinary tract infection. GENERAL: On initial exam, she appeared to be comfortable. Blood pressure 134/65, pulse 95 and regular, respirations 18.
ASA|acetylsalicylic acid|ASA|158|160|DISCHARGE MEDICATIONS|3. Accolate 10 mg p.o. b.i.d. 4. Advair Diskus 250/50 mcg 1 puff inhaled b.i.d. 5. Roxicet elixir 5-10 mL q.4-6h. p.r.n. pain. 6. Zoloft 25 mg p.o. daily. 7. ASA 81 mg p.o. daily. 8. Vitamin B12 OTC 500 mg p.o. daily. DISCHARGE INSTRUCTIONS: The patient was discharged to home. She will follow a clear bariatric diet.
ASA|American Society of Anesthesiologists|ASA|202|204|PLAN|ASSESSMENT: 1. Severe osteoarthritis to her right knee. 2. Hypertension under excellent control. 3. Hyperlipidemia. PLAN: I see no contraindication to the proposed surgical procedure. The patient is an ASA 2. Will gladly follow while she is in the hospital.
ASA|acetylsalicylic acid|ASA,|131|134|ALLERGIES|8. Gastric ulcers with partial gastrectomy. MEDICATIONS: Pravachol, Plavix, Tagamet, vitamin C and vitamin E, atenolol. ALLERGIES: ASA, Norvasc, dye from angiogram. FAMILY HISTORY: No cancer. REVIEW OF SYSTEMS: No chest pain. Good energy. No shortness of breath.
ASA|acetylsalicylic acid|ASA|209|211|DISCHARGE DIAGNOSES|DISCHARGE MEDICATIONS: Morphine sulfate 15 mg p.o. b.i.d. Can hold if patient unstable. Neurontin 200 mg p.o. b.i.d. Zantac 150 mg p.o. b.i.d. (_______________) 1 mg p.o. q.8h. p.r.n. Atenolol 25 mg p.o. q.d. ASA 81 mg p.o. q.d. Multiple vitamin 1 p.o. q.d. HISTORY OF PRESENT ILLNESS: This is a 62-year-old gentleman who had a lot of complaints.
ASA|acetylsalicylic acid|ASA|145|147|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Zofran 8 mg q8h as needed. 2. Compazine 10 mg q6h as needed. 3. Atenolol 12.5 mg daily. 4. Glucotrol XL 5 mg daily. 5. ASA 325 mg daily. 6. Synthroid 100 mcg daily. 7. Magnesium oxide two tablets b.i.d. 8. Acifex 20 mg daily. Dr. _%#NAME#%_, the patient's primary physician, will monitor the patient's creatinine and restart her Lasix after recovery of her renal insufficiency.
ASA|acetylsalicylic acid|ASA.|180|183|MEDICATIONS|She sees Dr. _%#NAME#%_, Arthritis and Rheumatology Consultants, but this was done per PMD. MEDICATIONS: We do not have any of the dosages on this. 1. Minipress. 2. Wellbutrin. 3. ASA. 4. Protonix. 5. Prednisone. 6. Quinine sulfate. 7. Lipitor. 8. Cardizem. 9. Trental. 10. Minocycline. 11. Premarin. 12. Vitamin B6. 13. Vitamin D.
ASA|acetylsalicylic acid|ASA|93|95|DISCHARGE MEDICATIONS|7. Status post hysterectomy. 8. Status post small bowel resection. DISCHARGE MEDICATIONS: 1. ASA 81 mg by G-tube q.d. 2. Vioxx 12.5/5 ml suspension 10 ml by G-tube q.d. 3. Darvocet-N 100 1 by G-tube b.i.d. 4. Fosamax 70 mg by G-tube q. Saturday.
ASA|acetylsalicylic acid|ASA|118|120|MEDICATIONS|2. Glipizide 5 mg p.o. b.i.d. 3. Norvasc 5 mg p.o. q.d. 4. Atenolol 50 mg p.o. q.d. 5. Cimetidine 400 mg p.o. q.d. 6. ASA q.d. 7. Lipitor 10 mg p.o. q.d. x3 months. PSYCHOSOCIAL: The patient lives with her son, _%#NAME#%_, who is divorced.
ASA|acetylsalicylic acid|ASA|164|166||She carries the diagnosis of mild dementia, depression, hyperlipidemia, and asthma. Currently she is doing quite well. She is on several medications which include: ASA 325 per day, Remeron 15 mg at hs, Clonazepam 0.2 mg every 12 hours and Aricept 10 mg per day. She also takes Zocor 20 mg today. She has felt quite well.
ASA|American Society of Anesthesiologists|ASA|102|104|PLAN|Chest x-ray was negative. ASSESSMENT: Right hip arthroplasty dislocation PLAN: Clearance for surgery. ASA Class II to III. Will review EKG and other labs prior to surgery.
ASA|American Society of Anesthesiologists|ASA|157|159|PLAN|SKIN: Within normal limits. ASSESSMENT: Chronic patellar subluxation. PLAN: I see no contraindication to proposed surgical procedure. The patient will be in ASA I. We will gladly follow should the patient require additional cares.
ASA|acetylsalicylic acid|ASA|361|363|MEDICATIONS|PAST MEDICAL HISTORY: Significant for hypertension, hypercholesterolemia status post appendectomy, status post right inguinal hernia repair, status post right total knee replacement and a right rotator cuff repair. MEDICATIONS: At time of admission included Augmentin 875 mg bid, Vicodin prn for pain, Lisinopril 10 mg q day, Simvastatin 20 mg every other day, ASA 1 q day. On initial exam he was febrile with a temperature of 101.5, blood pressure 142/74, pulse 110, respirations 22 on 2 liters nasal cannula O2.
ASA|acetylsalicylic acid|ASA|168|170|DISCHARGE MEDICATIONS|Coumadin 5 mg tablets, will start with one and a half daily and have that adjusted depending on his INR. 12. Fioricet one to two q4-6h prn for headache. 13. Will start ASA 81 mg after Lovenox is discontinued.
ASA|acetylsalicylic acid|ASA|120|122|MEDICATIONS|ALLERGIES: Sulfa, reaction unknown. He was told this as a young man. MEDICATIONS: 1. Lipitor 10. 2. Lopid 600 b.i.d. 3. ASA 325 q.d. 4. Amiodarone 200 mg q.d. 5. Folate 1 mg q.d. 6. Lisinopril 20 mg q.d. 7. Norvasc 5 mg q.d., recently changed to Lotrel 5/10, although the patient has not actually made the change.
ASA|acetylsalicylic acid|ASA|170|172|DISCHARGE MEDICATIONS|8. Ferrous sulfate 325 mg p.o. t.i.d. 9. Sodium bicarbonate 350 mg p.o. b.i.d. 10. Protonix 40 mg p.o. q.d. 11. Zoloft 100 mg p.o. q.d. 12. Lisinopril 5 mg p.o. q.d. 13. ASA EC 81 mg p.o. q.d. 14. Insulin Lantus 18 units subcutaneous q.h.s. 15. Lispro insulin sliding scale subcutaneous t.i.d. with meals p.r.n. hyper leukemia less than 150 none, 150 to 200 6 units, 200 to 250 8 units, 250 to 300 10 units, 300 to 350 12 units, 350 to 400 14 units, more than 400 16 units.
ASA|American Society of Anesthesiologists|ASA|126|128|PLAN|She can take her other meds up until the day of surgery, and I anticipate she will do well with surgery. We categorize her as ASA 2 for the total hip replacement. For other tests, she will plan a mammogram at some point in the future, and we will also do an adenosine stress thallium preoperatively to be sure that she will do well, but I anticipate that will be essentially normal.
ASA|acetylsalicylic acid|ASA|195|197|CURRENT MEDICATIONS|He has elevated cholesterol, diabetes, elevated blood pressure, history of coronary artery disease. CURRENT MEDICATIONS: More than 10 mg a day gemfibrozil, 600 mg 2 po bid, Zantac 150 mg po bid, ASA 1 po tid, Slo-Niacin 200 mg po q day, Zoloft 50 mg po q day, multivitamin with iron 1 po q day, Coreg 12.5 mg po bid, Lipitor 80 mg po q day, Fibercon daily, Insulin NPH 25 units q.a.m., 34 units q.p.m., Humalog 20 units q.a.m., 25 units q.p.m. SOCIAL HISTORY: He is widowed.
ASA|acetylsalicylic acid|ASA|152|154|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old male with past medical history including a gastrointestinal bleed three years ago secondary to ASA use. The patient was recently diagnosed with amyotrophic lateral sclerosis. The patient came in after having an episode of dizziness and unresponsiveness while Valsavaing on the toilet.
ASA|acetylsalicylic acid|ASA|479|481|CURRENT MEDICATIONS|CURRENT MEDICATIONS: Many. These include Lasix 40 mg b.i.d. before hospitalization, Neurontin 200 mg b.i.d, albuterol MDI two puffs q.i.d., Cytoxan 50 mg every other day orally, ranitidine 150 mg orally daily, Zocor 40 mg orally daily, Glucotrol XL 10 mg daily orally, Synthroid 0.112 mg orally daily, metoprolol 50 mg orally b.i.d., prednisone 10 mg orally daily, acyclovir 400 mg orally b.i.d., Norvasc 10 mg orally daily, Celexa 20 mg orally daily, Plavix 75 mg orally daily, ASA 81 mg orally daily, ASA with codeine No. 3 one or two every 4-6h. p.r.n. for pain. She also is on Aldactone 25 mg orally daily since her last discharge from the hospital.
ASA|acetylsalicylic acid|ASA|503|505|CURRENT MEDICATIONS|CURRENT MEDICATIONS: Many. These include Lasix 40 mg b.i.d. before hospitalization, Neurontin 200 mg b.i.d, albuterol MDI two puffs q.i.d., Cytoxan 50 mg every other day orally, ranitidine 150 mg orally daily, Zocor 40 mg orally daily, Glucotrol XL 10 mg daily orally, Synthroid 0.112 mg orally daily, metoprolol 50 mg orally b.i.d., prednisone 10 mg orally daily, acyclovir 400 mg orally b.i.d., Norvasc 10 mg orally daily, Celexa 20 mg orally daily, Plavix 75 mg orally daily, ASA 81 mg orally daily, ASA with codeine No. 3 one or two every 4-6h. p.r.n. for pain. She also is on Aldactone 25 mg orally daily since her last discharge from the hospital.
ASA|acetylsalicylic acid|ASA|95|97|DISCHARGE MEDICATIONS|DISCHARGE DIAGNOSES: Asthma exacerbation. DISCHARGE MEDICATIONS: 1. Lipitor 20 mg p.o. q.d. 2. ASA - ECA 1 mg q.d. 3. Serevent two puffs b.i.d. 4. Celexa 20 mg p.o. q.d. 5. Albuterol 2.5 mg nebs q.i.d.
ASA|acetylsalicylic acid|ASA|81|83|DISCHARGE MEDICATIONS|The patient was discharged three days postoperatively. DISCHARGE MEDICATIONS: 1. ASA 81 mg p.o. q.d. 2. Synthroid 0.175 mg p.o. q.d. 3. CellCept 500 mg p.o. b.i.d. 4. Bactrim single-strength 1 tablet p.o. q.d.
ASA|acetylsalicylic acid|ASA|420|422|HOSPITAL COURSE|HOSPITAL COURSE: The patient's cardiac catheterization was performed which demonstrated moderate coronary artery disease, and congestive cardiomyopathy which appeared to be out of proportion to his coronary artery disease. It was recommended he continue medical management of his congestive heart failure and the patient was discharged to home to be followed up in the office on Lanoxin 0.125 mg daily, Mucomyst p.r.n., ASA 81 mg, sulindac 150 mg b.i.d., Cardizem CD 180 one daily, allopurinol 100 mg daily, Protonix 40 mg daily, Nasonex 2 puffs b.i.d.
ASA|acetylsalicylic acid|ASA|163|165|MEDICATIONS|3. Levoxyl 0.075 mg q.d. 4. Prednisone 5 mg q.d. 5. Coumadin 2.5 mg q.o.d. alternate with 5 mg q.o.d. 6. Advair 250/50, one puff b.i.d. 7. Albuterol MDI p.r.n. 8. ASA 81 mg q.d. 9. Multivitamins, calcium and niacin. PAST SURGICAL HISTORY: 1. Right total hip arthroplasty in _%#MM#%_ of this year.
ASA|acetylsalicylic acid|ASA|134|136|MEDICATIONS|3. Neurontin 100 mg p.o. b.i.d. 4. Pravachol 10 mg p.o. q.d 5. Atenolol 50 mg p.o. q.a.m., and 25 mg q.h.s. 6. MVI one p.o. daily. 7. ASA 325 daily. 8. Xanax one p.o. daily. PHYSICAL EXAMINATION ON ADMISSION: LUNGS: Left basilar wheezing, otherwise clear to auscultation bilaterally.
ASA|acetylsalicylic acid|ASA|174|176|HOSPITAL COURSE|2. Lisinopril 20 mg p.o. q.d. 3. Multivitamin. 4. Atenolol 25 mg p.o. q.d. 5. Potassium chloride 20 mEq 1 packet q.d. 6. Zantac 75 mg p.o. b.i.d. 7. Lasix 20 mg p.o. q.d. 8. ASA 81 mg p.o. q.d. 9. Reglan 10 mg p.o. q.d. DISCHARGE INSTRUCTIONS: Mr. _%#NAME#%_ is instructed to perform no heavy lifting greater than 10 pounds for 4-6 weeks.
ASA|acetylsalicylic acid|ASA|422|424|HOSPITAL COURSE|6. Rehabilitation. PT and OT were consulted and thought that she might have some improvement from TCU stay but likely long term nursing home. The patient is being discharged to TCU. She will complete a seven day course of Cipro 500 mg p.o. b.i.d. and continue on her other medications which include Zocor 20 mg p.o. q.h.s., glyburide 2.5 mg p.o. q.A.M., trazodone 100 mg p.o. b.i.d., hydrochlorothiazide 25 mg p.o. q day, ASA 325 mg p.o. q day, Risperdal 0.5 mg p.o. q.A.M. and 1 mg p.o. q.P.M. and 0.5 mg p.o. t.i.d. p.r.n. Will have Haldol 0.5 mg p.o. b.i.d. but hold if sedated.
ASA|acetylsalicylic acid|ASA|139|141|PAST MEDICAL HISTORY|His initial troponin was 0.1 in the emergency room. PAST MEDICAL HISTORY: Significant for chronic atrial fibrillation, anticoagulated with ASA rather than Coumadin due to history of angiodysplasias and GI bleeding. 2. Coronary artery disease. 3. Congestive heart failure with anasarca as well as significant valvular disease.
ASA|American Society of Anesthesiologists|ASA|196|198|ASSESSMENT|1. Right elbow cellulitis, status post intracondylar fracture open reduction and internal fixation. 2. Dementia. 3. Atrial fibrillation. 4. Ischemic cardiomyopathy. 5. Osteoporosis. 6. Anemia. 7. ASA class P-3. PLAN: Staff with Dr. _%#NAME#%_. Okay for surgery. Will also check basic metabolic panel, B-12, folate, ferritin, iron, and retic count.
ASA|acetylsalicylic acid|ASA|185|187|CURRENT MEDICATIONS|ETOH - he does not drink alcohol in recent years. CURRENT MEDICATIONS: Albuterol inhaler two puffs q.i.d. p.r.n. Flovent inhaler 220 mcg two puffs q.d. Serevent Diskus two puffs q.h.s. ASA 325 mg q.d. Vicodin 5/500 as above, one to two up to t.i.d. Naprosyn 500 mg b.i.d. p.r.n. for back pain.
ASA|acetylsalicylic acid|ASA,|186|189|CURRENT MEDICATIONS|She denied any orthopnea or PND. CURRENT MEDICATIONS: Klonopin, 2 mg, 1-2 q. day for anxiety. Levothyroxin, 0.5 mg q. day. Zoloft, 100 mg q. day. Verapamil, 360 mg q. day. Colace p.r.n. ASA, 81 mg q. day. Glucosamine chondroitin sulfate. ALLERGIES: She is allergic to sulfa and amoxicillin.
ASA|American Society of Anesthesiologists|ASA|136|138|PLAN|ASSESSMENT: Chronic nasal congestion, polyp. PLAN: I see no contraindication to the proposed surgical procedure. The patient will be an ASA 1.
ASA|acetylsalicylic acid|ASA|176|178|MEDICATIONS|Code status: DNR/DNI. Daughter has power of attorney. MEDICATIONS: At home 1. Micardis 80 mg daily. 2. Furosemide 60 mg daily 3. Reminyl 4 mg b.i.d. 4. Namenda 10 mg t.i.d. 5. ASA 81 mg daily 6. Klor-Con 20 mEq daily 7. Mobic 15 mg daily. 8. Vitamin E 400 IU daily. 9. Cosopt one drop OU q12 hours. 10. Xalatan 0.005% one drop OU every hs.
ASA|acetylsalicylic acid|ASA|421|423|DISCHARGE MEDICATIONS|6. Type 2 diabetes mellitus, reasonable control on oral agents. 7. Chronic obstructive pulmonary disease DISCHARGE MEDICATIONS: Usual admission medications, including Cipro 500 mg strength b.i.d. times five days, Lasix 40 mg daily, Effexor 25 mg daily, Glyburide 5 mg orally b.i.d., Protonix 40 mg daily, theophylline 600 mg daily, Azmacort 4 puffs b.i.d., Combivent 2 puffs q.i.d., Nasacort 2 sprays each nostril daily, ASA 81 mg daily, Senna 2 tabs orally daily, Metformin 500 mg 1 or 2 orally b.i.d. with meals, multivitamins 1 p.o. daily and follow-up with Dr. _%#NAME#%_ in two to three weeks.
ASA|acetylsalicylic acid|ASA|117|119|PROBLEM #2|Patient was at baseline upon discharge. DISCHARGE MEDICATIONS: 1. Potassium chloride 10 mEq p.o. q. day x2 weeks. 2. ASA 81 mg p.o. q. day. 3. Insulin 70/30, 15 units subcutaneous b.i.d. 4. Procrit 40,000 units subcutaneous q. Thursday. 5. Epogen 20,000 units IV post dialysis. The Procrit and Epogen should be re-evaluated by the dialysis team at the next visit.
ASA|acetylsalicylic acid|ASA.|183|186|HOSPITAL COURSE|Her tongue deviated midline. She had no pronator drift and moved all extremities well. Her incision looked good, and she was ambulating at time of discharge. She was continued on her ASA. DISCHARGE INSTRUCTIONS: 1. Follow up with Dr. _%#NAME#%_ in the Neurosurgery Clinic next Thursday. Call _%#TEL#%_ to schedule. 2. Followup appointment in 4-6 weeks also in Dr. _%#NAME#%_'s clinic.
ASA|American Society of Anesthesiologists|ASA|156|158|ASSESSMENT|Chest x-ray within normal limits with a little bit of cardiomegaly noted. LABS: Include CBC, platelets, comprehensive profile, and INR pending. ASSESSMENT: ASA 2 for cervical fusion, C5-7, history of known coronary artery disease with stenting in 2000. COPD and reactive airways, mild hearing loss, DJD, and BPH.
ASA|acetylsalicylic acid|ASA|110|112|CURRENT MEDICATIONS|4. Metoprolol 50 mg 1/2 b.i.d. 5. Tylenol plain for pain control at 650 mg. She was apparently on 325 mg p.o. ASA daily as anticoagulant since _%#MMDD2005#%_ for four weeks. DIET: Regular. ALLERGIES: Sulfa and penicillin. MEDICAL ILLNESSES: 1. Hypertension.
ASA|acetylsalicylic acid|ASA.|153|156|ALLERGIES|Musculoskeletal - negative. Endocrine - he has no history of diabetes or thyroid problems. ALLERGIES: Allergic to penicillin and sensitive to ibuprofen, ASA. FAMILY AND SOCIAL HISTORY: He is married, he works as a roofing contractor.
ASA|acetylsalicylic acid|ASA|137|139|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prednisone 60 mg p.o. daily. 2. Amikacin 500 mg p.o. inhaled b.i.d. 3. Ethambutol 1000 mg p.o. q. 3 x week. 4. ASA 81 mg daily. 5. Lipitor 20 mg p.o. q.h.s. 6. Diflucan 200 mg p.o. daily. 7. Folate 5 mg p.o. daily. 8. Synthroid 75 mcg p.o. daily.
ASA|acetylsalicylic acid|ASA|133|135|DISCHARGE MEDICATIONS|2. Valcyte 450 mg p.o. daily. 3. Prograf 1 mg p.o. daily. 4. Magnesium oxide 400 mg p.o. b.i.d. 5. Zofran 4 mg p.o. q.6 h. p.r.n. 6. ASA 81 mg p.o. daily. 7. Clotrimazole 10 mg p.o. q.i.d. 8. Lexapro 30 mg p.o. daily. 9. Mesalamine 1200 mg p.o. b.i.d.
ASA|acetylsalicylic acid|ASA|155|157|DISCHARGE MEDICATIONS|3. Bactrim single strength p.o. daily. 4. Valcyte 450 mg p.o. every other day. 5. Mycelex troche 1 p.o. four times daily. 6. Protonix 40 mg p.o. daily. 7. ASA 81 mg p.o. daily. 8. Colace 100 mg p.o. daily. 9. Calcium carbonate with vitamin D 1250 mg p.o. twice a day.
ASA|acetylsalicylic acid|ASA|179|181|MEDICATIONS|2. Actigall 300 mg p.o. t.i.d. 3. Azathioprine 150 mg p.o. daily. 4. Prograf 3 mg p.o. q.a.m. , 4 mg p.o. q.p.m. 5. Septra single strength 1 p.o. q. Monday, Wednesday, Friday. 6. ASA 81 mg p.o. daily. 7. Prednisone 5 mg p.o. daily. PHYSICAL EXAMINATION: The patient is a well-nourished woman who is a good historian.
ASA|acetylsalicylic acid|ASA|126|128|MEDICATION|ALLERGIES: He has no known drug allergies. REVIEW OF SYSTEMS: Otherwise negative. MEDICATION: 1. Norvasc 5 mg p.o. q. day. 2. ASA 81 mg p.o. q. day. 3. Mycelex troche 10 mg p.o. q.i.d. 4. Colace 100 mg p.o. b.i.d. 5. Prevacid 30 mg p.o. q. day. 6. Claritin 10 mg p.o. q. day.
ASA|acetylsalicylic acid|ASA.|148|151|MEDICATIONS|8. Lisinopril. 9. Mag Oxide. 10. Metformin. 11. Metoprolol 12. Kay Ciel. 13. Potassium chloride. 14. Ranitidine. 15. Simvastatin. 16. Docusate. 17. ASA. 18. MVI. SOCIAL HISTORY: The patient denies any alcohol use.
ASA|acetylsalicylic acid|ASA,|217|220|MEDICATIONS|She does have a history of asthma, congestive heart failure, hiatal hernia and eczema. MEDICATIONS: She is on numerous medications, including atenolol, albuterol, Allegra, calcium, Celebrex, Klonopin, Cozaar, Darvon, ASA, Lasix, nitroglycerin p.r.n., Prilosec, thyroid replacement, and numerous other medications. She is on Remeron, and is also on Tramadol 50 mg two times per day.
ASA|acetylsalicylic acid|ASA|141|143|IMPRESSION|She has been transfused and now her hemoglobin is 11.0. IMPRESSION: Anemia, profound, developing over three months or less in the setting of ASA use. The patient does take PPIs so perhaps she is taking other NSAIDs; rule out bleeding, peptic ulcer disease, rule out gastric neoplasm.
ASA|acetylsalicylic acid|ASA|149|151|MEDICATIONS|She apparently has had no known significant past medical history and in fact had not presented to a doctor since approximately 1946. MEDICATIONS: 1. ASA 81 mg PO q day. 2. Lasix 20 mg q AM. 3. Prinivil 2.5 mg PO q HS. 4. Prevacid 30 mg q day.
ASA|acetylsalicylic acid|ASA.|136|139|MEDICATIONS|MEDICATIONS: 1. SSKI. 2. Liquibid. 3. Albuterol. 4. Atrovent. 5. Mucomyst. 6. Theophylline 300 mg b.i.d. 7. Isosorbide. 8. Caltrate. 9. ASA. 10. Prednisone chronically 20 mg per day. 11. 02 at two liters per minute. PHYSICAL EXAMINATION: Temperature is 98.9, pulse 82, respiratory rate 28, blood pressure 123/76.
ASA|acetylsalicylic acid|ASA,|286|289|HOME MEDICATIONS|3. Essential hypertension. 4. Hypercholesterolemia. 5. Previous asbestos exposure with known pleural plaquing, however, the patient is unable to say whether or not he has been told he has frank asbestosis. 6. Known history of paroxysmal atrial fibrillation. HOME MEDICATIONS: Coumadin, ASA, digoxin, furosemide, heparin, lisinopril, pindolol, simvastatin. SOCIAL HISTORY: Lifelong never smoker. No history of alcohol abuse.
ASA|acetylsalicylic acid|ASA|173|175|MEDICATIONS|Denies any use of extracurricular drugs now although has a history of cocaine abuse in the past; treatment 4 years ago with success. MEDICATIONS: 1. Norvasc 20 mg daily. 2. ASA 325 mg daily. 3. Levaquin 750 mg daily. 4. Protonix 40 mg daily. 5. Seroquel 300 mg at bedtime. 6. Zocor 20 mg q.p.m.
ASA|acetylsalicylic acid|A.S.A.|160|165|MEDICATIONS|b. Ischemic cardiomyopathy, EF estimated at 30 percent to 35 percent. 3. Hypertension. 4. Hyperlipidemia. MEDICATIONS: Coumadin. Hydrochlorothiazide. Atenolol. A.S.A. Lipitor. Lotrel. Calcium. Colace. Vitamins. Plavix. Imdur. Nitroglycerin sublingually and now Zosyn. ALLERGIES: SULFA DRUGS. FAMILY HISTORY: Heart disease is significant in multiple relatives.
ASA|acetylsalicylic acid|ASA|122|124|MEDICATIONS|1. Norvasc 10 mg p.o. 2. Metoprolol 50 mg p.o. 3. Lipitor 20 mg p.o. 4. Metformin 1,000 mg p.o. 5. Accupril 20 mg p.o. 6. ASA 7. Calcium PAST MEDICAL HISTORY: 1. Type 2 diabetes mellitus, managed with oral agents. 2. Essential hypertension.
ASA|acetylsalicylic acid|ASA,|206|209|ALLERGIES|Her review of 13 systems is otherwise negative. SOCIAL HISTORY: She lives independently and drives herself. Does her own cooking and housework. ALLERGIES: She is allergic to PCN, Nystatin, MS04, terazosin, ASA, nitrofurantoin, dicyclomine, fentanyl, Macro, crystals, and Cisapride. CURRENT MEDICATIONS: 1. Percocet. 2. Advil. 3. Miacalcin. 4. Colace.
ASA|acetylsalicylic acid|ASA|152|154|ADMISSION  MEDICATIONS|3. Synthroid 150 mcg p.o. q.a.m. 4. Vicodin 5/500 p.o. q.h.s. p.r.n. pain. 5. Multivitamin 1 tab p.o. daily. 6. Calcium carbonate 500 mg p.o. q.a.m. 7. ASA EC 81 mg p.o. q.a.m. 8. Melatonin 5 mg p.o. q.h.s. for sleep. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient denies smoking, illicit drug use, and any past IV drug use.
ASA|acetylsalicylic acid|ASA.|135|138|MEDICATIONS|3. History of chronic obstructive pulmonary disease. 4. History of osteoporosis. ALLERGIES: Amoxicillin. MEDICATIONS: 1. Albuterol. 2. ASA. 3. Plavix. 4. Protonix. 5. Senokot. 6. Lopressor. 7. Lipitor. SOCIAL HISTORY: The patient lives alone in a senior apartment in _%#CITY#%_, Wisconsin.
ASA|acetylsalicylic acid|ASA|125|127|MEDICATIONS|MEDICATIONS: Medications that he is currently on include: 1. PCA IV Dilaudid 0.1-0.2 q.10 minutes PCA only. 2. Vitamin C. 3. ASA 21 mg a day. 4. Avodart 0.5 mg daily. 5. Fish oil 1 gram b.i.d. 6. Zestoretic 1 tablet daily. 7. Multivitamin. ALLERGIES: No known drug allergies.
ASA|acetylsalicylic acid|ASA.|119|122|MEDICATIONS|He does wear a partial plate in the left mandibular region. MEDICATIONS: Include 1. Atenolol 2. Diltiazem 3. Plavix 4. ASA. 5. Lipitor White count was 8.2. He was afebrile. The remainder of the past medical history, social history and family history is as noted in the chart.
ASA|acetylsalicylic acid|ASA.|153|156|MEDICATION LIST|Again, history is really not obtainable. Did call the family. ALLERGIES: None known. MEDICATION LIST: This was reviewed. 1. Verapamil 80 mg p.o. q.d. 2. ASA. 3. Calcium. 4. Tylenol. 5. _______________. PAST SURGICAL HISTORY: As stated, otherwise unknown.
ASA|acetylsalicylic acid|ASA.|161|164|OUTPATIENT MEDICATIONS|OUTPATIENT MEDICATIONS: 1. Protonix 2. Lipitor 3. Atenolol 4. Zoloft 5. 6 mercaptopurine 6. Fosamax 7. Neurontin 8. Vicodin 9. Multivitamin 10. Glucosamine. 11. ASA. ALLERGIES: No known allergies. SOCIAL HISTORY: The patient is widowed.
ASA|acetylsalicylic acid|ASA|155|157|HISTORY|Indicates up to date on D/T. Was noted to have a handful of 30 Celexa pills, which she apparently did not ingest. Clinically stable in the Emergency Room. ASA level less than 1, acetaminophen level less than 10. PAST MEDICAL HISTORY: 1. Presumed major depression disorder. Details per Psychiatry.
ASA|acetylsalicylic acid|ASA|241|243|MEDICATIONS ON ADMISSION|6) History of elevated PSA. 7) C. diff colitis, _%#MM#%_ _%#DD#%_. MEDICATIONS ON ADMISSION: Flagyl 500 mg t.i.d., Lasix 20 mg t.i.d., K-Dur 20 mg t.i.d., iron 325 mg t.i.d., Lipitor 20 mg a day, Prevacid 30 mg a day, Toprol XL 50 mg a day, ASA 81 mg a day, lisinopril 2.5 mg a day, and Lomotil two as needed q.4h. MEDICATIONS STARTED AFTER ADMISSION: Vancomycin and IV fluids.
ASA|acetylsalicylic acid|ASA,|314|317|CURRENT MEDICATIONS|PAST MEDICAL HISTORY includes the above-mentioned squamous cell carcinoma. He does also have organic heart disease with congestive heart failure and atrial fib, benign prostatic hypertrophy, psoriasis, B12 deficiency, he is hard of hearing, malnutrition, status post cholecystectomy. CURRENT MEDICATIONS: He is on ASA, metoprolol, Lasix, Roxicet, Colace, and B12. PHYSICAL EXAMINATION: Elderly gentleman appearing his stated age, sitting in his chair, in no acute distress.
ASA|acetylsalicylic acid|ASA|174|176|CURRENT MEDICATIONS|Has had some Bell's palsy, DJD of the back and some chronic undiagnosed pain, abdominal, back and leg. CURRENT MEDICATIONS: That she is on is: 1. Xanax 0.5 mg p.o. q.h.s. 2. ASA 81 mg b.i.d. 3. Clonidine 100 mcg p.o. daily 4. Fentanyl 75 mcg and she has been on that for approximately 6 months.
ASA|acetylsalicylic acid|ASA|139|141|CURRENT MEDICATIONS|Her father died of old age. Her mother died during an influenza epidemic. CURRENT MEDICATIONS: 1. Tylenol 1000 mg po three times a day. 2. ASA 300 mg pr daily. 3. Atenolol 50 mg daily. 4. ___________ one sublingual three times a day. 5. Digoxin 125 mcg IV daily.
ASA|acetylsalicylic acid|ASA|191|193|MEDICATIONS|He does not have significant lower extremity edema. PAST MEDICAL HISTORY: As noted above. ALLERGIES: None known. MEDICATIONS: 1. Aspirin 2. _______ 3. Insulin 4. Solu-Medrol 5. Ranitidine 6. ASA SOCIAL HISTORY: The patient is married and has 3 children.
ASA|acetylsalicylic acid|ASA|141|143|MEDICATIONS|4. Lexapro 15 mg daily. 5. Plavix 75 mg daily. 6. Tricor, unknown dose daily. 7. Simvastatin, unknown dosage. 8. Fish oil, 2 pills b.i.d. 9. ASA 81 mg daily. 10. MDI 1 daily. 11. Nitroglycerin sublingual p.r.n. FAMILY HISTORY: Father deceased at age 78 of bone cancer.
ASA|acetylsalicylic acid|ASA|212|214|RECOMMENDATIONS|RECOMMENDATIONS: 1. I would get dedicated SI joint films (sometimes referred to as Ferguson views). 2 In addition to the RPR, it would be helpful to get screening cardiolipin antibodies and a lupus anticoagulant ASA to make sure that she does not have antiphospholipid syndrome. 3. Lupus and MCTD have been adequately screened by the current or pending labs.
ASA|acetylsalicylic acid|ASA|129|131|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1. Prozac 20 mg daily. 2. Lipitor 10 mg daily. 3. Lisinopril 2.5 mg per day. 4. Os-Cal two tabs per day. 5. ASA 81 mg per day. 6. Alora one patch twice a week. 7. Plavix 75 mg per day. 8. Verapamil 80 mg t.i.d.
ASA|acetylsalicylic acid|ASA|195|197|MEDICATIONS|3. Chronic stasis dermatitis in his lower extremities. 4. Hypertension. 5. Hyperlipidemia. 6. Glucose intolerance. MEDICATIONS: Atenolol, Lisinopril, Zocor, isosorbide, sublingual nitroglycerin, ASA 81 mg a day. ALLERGIES: None reported. SOCIAL HISTORY: He is retired, previously a teacher, lives independently with his wife.
ASA|acetylsalicylic acid|ASA|89|91|CURRENT MEDICATIONS|4. Bilateral cataract surgery. 5. Hypertension. 6. Osteoporosis. CURRENT MEDICATIONS: 1. ASA 325. 2. MVI. 3. Tums. 4. Fosamax 70 mg q. two weeks. 5. Vitamin D one per daily. 6. Metoprolol 50 mg two times a day.
ASA|acetylsalicylic acid|ASA|163|165|MEDICATIONS|No other family history of cancer. SOCIAL HISTORY: Patient is a teacher in the university area and has been active. MEDICATIONS: 1. Tegretol. 2. Multivitamins. 3. ASA 4. Flonase. 5. Ibuprofen. 6. Prilosec. ALLERGIES: Sulfa. REVIEW OF SYSTEMS: NEUROLOGIC: She has no outstanding symptoms from her meningioma at this point.
ASA|acetylsalicylic acid|ASA.|149|152|CURRENT MEDICATIONS|10. Hypertension. 11. Cholecystectomy. 12. Hyperlipidemia. 13. Cataract surgery. 14. History of chronic anemia. CURRENT MEDICATIONS: 1. Coumadin, 2. ASA. 3. Tylenol. 4. Avapro 75 mg 1 to 1 1/2 tabs PO Q day. 5. Lantus insulin. 6. Imdur. 7. Amaryl. 8. Furosemide.
ASA|acetylsalicylic acid|A.S.A.,|140|146|CONSULTATION AND|There has been no history of cardiopulmonary disease nor liver disease. The patient is allergic to codeine. Her current medications include A.S.A., _____, Evista, Fosamax, vitamin E, vitamins, and folic acid. The patient does not use tobacco products nor alcohol. The patient's exam in the emergency room: Blood pressure 192/117.
ASA|acetylsalicylic acid|ASA,|464|467|PSH|PMH: DM type 2, HTN, metabolic syndrome, lymphedema with chronic bilat cellulitis, OSA, presumed BOOP/COP with chronic steroid use tapered in _%#MM2007#%_ PSH: hemorroidectomy, cholecystecomy, bilat salpingoophrectomy Family hx: father - metastatic penile CA; mother - HTN Social hx: negative tobacco hx, rare ETHOH, no illicit drug use. works at bank, lives alone. Allergies: sulfa (GI upset) Home meds: metoprolol, amlodipine, metformin, lantus 26 U, glipizide, ASA, lisinopril, paxil, singulair, crestor, zetia, fosamax, lasix, triamcinolone ROS: See HPI. Otherwise complete ROS reviewed and negative. Vitals: reviewed and as per FCIS Physical exam: General: morbidly obese, nasal canula in place, in NAD.
ASA|acetylsalicylic acid|ASA|158|160|A/P|No biopsy has been done in the past. We will await CT results for evidence of active BOOP and evaluate then for possible bronchoscopy. Would get INR and stop ASA for potential bronchoscopy. 2. CAP treated with Rocephin and arithromycin. 3. OSA - treated with CPAP 4. Restrictive lung disease secondary to morbid obesity. 5. Oxygen dependence.
ASA|acetylsalicylic acid|ASA.|111|114|MEDICATIONS|Currently on a prednisone taper at 4 mg p.o. daily now. MEDICATIONS: 1. Prednisone as per above. 2. Plavix. 3. ASA. 4. Tobrex. 5. Erythromycin eye drops. 6. Other eye drops (patient unsure of name). 7. Lisinopril. 8. Protonix. SOCIAL HISTORY: Denies smoking, drinking alcohol, or drugs.
ASA|acetylsalicylic acid|ASA|111|113|MEDICATIONS|4. Hypertension 5. History of alcoholism 6. Diverticulosis 7. Chronic anemia 8. Hyperlipidemia MEDICATIONS: 1. ASA 81 mg enteric coated daily. 2. Colchicine 600 mg a day. 3. Digoxin 0.125 mg a day. 4. Cardizem CD 200 mg a day. 5. Ferrous Sulfate 325 mg a day.
ASA|acetylsalicylic acid|ASA|196|198||2. Minimal fluid overload. 3. Acute on chronic renal failure, now improving. 4. Recommendations: - NS 75 cc/h for 6 hours only - Hold lasix today - Discontinue lisinopril - Continue metoprol - EC ASA 81 mg QD
ASA|acetylsalicylic acid|ASA|75|77|MEDICATIONS|No tobacco or alcohol. ALLERGIES: No known drug allergies. MEDICATIONS: 1. ASA 81 mg 2. Atenolol 25 mg 3. Calcium 600 plus D, one tablet p.o. q day 4. Crestor 10 mg p.o. q day 5. Folate one tab p.o. q a.m.
ASA|American Society of Anesthesiologists|ASA|152|154|DOB|Physical examination confirms a normal airway and neck anatomy. Lungs are symmetrically clear, cardiovascular exam identified no abnormal findings. The ASA score is 1. The patient was placed continuous ECG, blood pressure, pulse oximetry, and end-tidal CO2 monitoring.
ASA|acetylsalicylic acid|ASA.|161|164|MEDICATIONS|MEDICATIONS: At the time of her original admission included: 1. Vicodin. 2. Insulin 70/30. 3. Plavix. 4. Renagel. 5. Nephrocaps. 6. Lisinopril. 7. Toprol-XL. 8. ASA. 9. Prevacid. 10. Zocor. 11. Quinine. ALLERGIES: Questionable allergy to Lipitor. FAMILY HISTORY: Noncontributory.
ASA|acetylsalicylic acid|ASA|205|207|MEDICATIONS|10. Shortness of breath with activity attributed to her weight. MEDICATIONS: Gemfibrozil, Lipitor, Atacand, clonidine, Novolin, Humalog, methocarbamol p.r.n., loperamide p.r.n. Migrin A. p.r.n. migraines, ASA be b.i.d. ALLERGIES: THE PATIENT IS ALLERGIC TO PENICILLIN.
ASA|acetylsalicylic acid|ASA|141|143|MEDICATIONS|7. Lisinopril 20 mg tablet one daily. 8. Lipitor 40 mg tablet one daily. 9. Indomethacin 20 mg p.r.n. 10. Plavix 75 mg tablet one daily. 11. ASA 325 mg tablet one daily. ALLERGIES: Beta-blockers exacerbate the patient's asthma.
ASA|acetylsalicylic acid|ASA.|144|147|MEDICATIONS|5. Amiodarone. 6. Lisinopril. 7. Senokot. 8. Iron. 9. Coreg. 10. Lasix. 11. Haldol each day at bedtime. 12. Compazine p.r.n. 13. Oxycodone. 14. ASA. 15. Tylenol p.r.n. 16. Ibuprofen p.r.n. 17. Tylenol No. 3, which he is receiving every 4 hours. 18. Ceftazidime through _%#MMDD2007#%_. 19. Vancomycin. SOCIAL HISTORY: The patient lives alone in a townhouse.
ASA|acetylsalicylic acid|ASA.|206|209|PHYSICAL EXAMINATION|If any question, however, the Asacol could be restarted or continued and I reassured the patient that Asacol is usually well tolerated with pregnancies. There is an issue with cleft palate in patients on 5 ASA. This is ____, of course, but rare. Issues were discussed at length. Mrs. _%#NAME#%_ was reassured. She will be seen again as necessary.
ASA|acetylsalicylic acid|ASA.|125|128|MEDICATIONS|She had a previous colonoscopy three years ago which demonstrated diverticula but nothing else. MEDICATIONS: 1. Atenolol. 2. ASA. 3. She has been on colchicine recently and finished a short course of steroids. 4. She is also antibiotics, as previously noted. ALLERGIES: No known drug allergies.
ASA|acetylsalicylic acid|ASA.|143|146|MEDICATIONS|3) History of psoriasis. 4) ? history of hypertension. MEDICATIONS: 1) DuoNeb. 2) Combivent. 3) Zantac. 4) Lisinopril. 5) Psoriatic lotion. 6) ASA. DRUG ALLERGIES: PENICILLIN. SOCIAL HISTORY: The patient is divorces, lives in an apartment.
ASA|acetylsalicylic acid|ASA|84|86|ALLERGIES|She had 3 cesarean sections. FAMILY HISTORY: Father had prostate cancer. ALLERGIES: ASA and ibuprofen. HABITS/SOCIAL HISTORY: The patient quit smoking 30 years ago.
ASA|acetylsalicylic acid|ASA|159|161|ALLERGIES|She also has Flonase 2 sprays daily. 14. Singulair 10 mg daily. ALLERGIES: She has allergy to penicillin and Compazine. She also has an allergy to nuts and an ASA caution versus allergy related to her Plavix use. SOCIAL HISTORY: She lives in a foster care group home in the _%#CITY#%_ area.
ASA|acetylsalicylic acid|ASA|146|148|PLAN|4. Follow-up imaging studies to assess for development of obstructive changes. 5. Decision on steroids after endoscopy. Steroid enemas as well as ASA enemas have been used in this setting with some success. 6. Lastly, consider new antibiotics with ampicillin and doxycycline have been used in people that are Flagyl resistant.
ASA|acetylsalicylic acid|ASA|121|123|MMC 75|By growing these cells in the laboratory we can obtain the genetic material in order to test this pregnancy for the same ASA causing mutation that was previously identified in _%#NAME#%_'s daughter, _%#NAME#%_. We discussed that the results will take at least 10-14 days and may take up to 3-4 weeks to return.
ASA|acetylsalicylic acid|ASA,|131|134|CURRENT MEDICATIONS|Sick sinus syndrome with pacemaker, inguinal hernia repair, Bell's palsy, TURP, gout, inguinal hernia repair. CURRENT MEDICATIONS: ASA, Lipitor, Coreg, Avodart, Flomax, Lasix, Synthroid, Cozaar, potassium, Senna S and Zoloft ALLERGIES NOTHING HE IS AWARE OF. SOCIAL HISTORY: Smoking none. Alcohol none. Married with his wife.
ASA|acetylsalicylic acid|ASA|117|119|OUTPATIENT MEDICATIONS|OUTPATIENT MEDICATIONS: 1. Macrobid 100 mg p.o. q.h.s. 2. Actose 30 mg p.o. q. day. 3. Lipitor 10 mg p.o. q. day. 4. ASA q. day. ALLERGIES: Codeine. SOCIAL HISTORY: The patient is married and does not smoke or drink alcohol.
ASA|acetylsalicylic acid|ASA,|124|127|MEDICATIONS|PAST MEDICAL HISTORY: 1. Lumbar microdiscectomy in 1999. 2. Hypertension. MEDICATIONS: Atenolol, clonidine, labetalol, T3s, ASA, Colace, Dulcolax, Fleet enema, Zofran. ALLERGIES: Sulfa causes rash. FAMILY HISTORY: Hypertension. SOCIAL HISTORY: The patient is married.
ASA|acetylsalicylic acid|ASA,|128|131|MEDICATIONS|2. Hypertension. 3. History of chronic fatigue syndrome. 4. History of possible TIA. MEDICATIONS: Insulin, hydrochlorothiazide, ASA, Lisinopril, Metformin, cyclobenzaprine, vitamin E. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives independently and is single and disabled.
ASA|acetylsalicylic acid|ASA,|195|198|MEDICATIONS|ALLERGIES: Hydralazine and codeine, reactions unknown. MEDICATIONS: Protonix, Terazosin heparin subcutaneously, Catapres, Xalatan in the left eye, Alphagan in both eyes. morphine x1 for the MRI, ASA, Flagyl and Bactrim. FUNCTIONAL HISTORY: The patient lives with his 86-year-old wife in their own home in _%#CITY#%_ _%#CITY#%_.
ASA|acetylsalicylic acid|ASA.|195|198|MEDICATIONS|3. Hypertension 4. Cholecystectomy 5. Appendectomy 6. Hysterectomy 7. History of a bilateral cataract removal and lens placement. 8. History of ovarian cyst MEDICATIONS: 1. Calcium 2. Dyazide 3. ASA. 4. Duonebs four times daily 5. Oxygen two liters per minute 6. Lisinopril 7. Claritin 8. Fosamax 9. Meclizine. SOCIAL HISTORY: She has 100 to 150 pack year history of smoking.
ASA|acetylsalicylic acid|ASA|112|114|MEDICATIONS|2. Lipitor 20 mg p.o. q. day. 3. Atenolol 25 mg p.o. daily. 4. MVI. 5. Fish oil. 6. Calcium. 7. Glucosamine. 8. ASA 81 mg. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Nonsmoker, nondrinker.
ASA|acetylsalicylic acid|ASA|156|158|HOME MEDICATIONS|HOME MEDICATIONS: 1. Arimidex 1mg daily. 2. Metoprolol 25 mg p.o. b.i.d. 3. Nitroglycerin 0.4 mg sublingually p.r.n. chest pain. 4. Aciphex 20 mg daily. 5. ASA 81 mg daily. 6. Ventolin 2 puffs q.4h. p.r.n. 7. Advair 100/50 1 puff b.i.d. 8. Lasix 40 mg b.i.d. 9. Atorvastatin 40 mg at bed-time. 10. Gabapentin 100 mg p.o. b.i.d.
ASA|acetylsalicylic acid|ASA|108|110|TRANSFER MEDICATIONS|FAMILY HISTORY: Per old chart. ALLERGIES: The patient has no known drug allergies. TRANSFER MEDICATIONS: 1. ASA 81 mg p.o. q.d. 2. Depakote. 3. Lactulose 10 cc p.o. q.a.m. 4. Remeron. 5. Zyprexa. 6. Effexor. 7. Fosamax 70 mg p.o. q. week.
ASA|acetylsalicylic acid|ASA.|150|153|MEDICATIONS|3. History of hypertension. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Sinemet 25/100 t.i.d. 2. Lisinopril/HCTZ 20/12.5. 3. Multivitamin. 4. ASA. 5. Senna. 6. Glipizide. 7. Unifiber. 8. Seroquel. FAMILY HISTORY: Family history is negative for CVA or Parkinson's disease.
ASA|aminosalicylic acid|ASA|192|194|IMPRESSION|His symptoms have now increased in the last six weeks with findings of rectal disease. Biopsies have been done, but I believe this probably represents Crohn's disease. He will be started on 5 ASA suppositories. A short course of prednisone will be given as well as Flagyl initiated. Hopefully with this, he can come under good control. We will get the biopsy reports back but I will hold on giving the prednisone until that point.
ASA|aminosalicylic acid|ASA|164|166|IMPRESSION|I do not think this represents any other secondary process. There is no history of trauma or other findings. We will await the biopsy reports and the response to 5 ASA suppositories and Flagyl. It is noted at that point if he is not better, prednisone will be added.
ASA|acetylsalicylic acid|ASA|140|142|HISTORY OF PRESENT ILLNESS|She was diagnosed after experiencing abdominal pain, diarrhea, and some rectal bleeding. Her disease has been somewhat well controlled with ASA derivatives as well as steroid and Cipro, Flagyl. However, approximately a month ago, she came in to Southdale Hospital complaining of perianal pain.
ASA|acetylsalicylic acid|ASA.|124|127|MEDICATIONS|3. History of diabetes mellitus. 4. History of coronary artery disease. ALLERGIES: No known drug allergies. MEDICATIONS: 1. ASA. 2. Decadron. 3. Enalapril 4. Prozac. 5. Glipizide. 6. NovoLog insulin. 7. Metformin. 8. Metoprolol. 9. Nystatin. 10. Protonix. 11. Zocor.
ASA|acetylsalicylic acid|ASA|194|196|MEDICATIONS|1. Significant for hypothyroidism. 2. Osteoporosis. 3. Hyperlipidemia. 4. Aortic stenosis. 5. Status post cesarean section. MEDICATIONS: 1. Synthroid 0.075 mg daily. 2. Fosamax 70 mg weekly. 3. ASA 325 mg a day. 4. Vitamin E. 5. Calcium supplementation. HEALTH HABITS: She has been a life-long nonsmoker, some alcohol and caffeine use.
ASA|acetylsalicylic acid|ASA,|191|194|SOCIAL HISTORY|SOCIAL HISTORY: _%#NAME#%_ lives alone. She does not smoke. Before her stroke, she was a registered nurse. Now, she is a receptionist at Park Nicollet. MEDICATIONS prior to admission include ASA, Diovan, metoprolol, Norvasc, Zocor, Detrol. A brain CT yesterday showed small vessel ischemia but no acute changes.
ASA|acetylsalicylic acid|ASA|108|110|ADMISSION MEDICATIONS|The patient denies hyperlipidemia, diabetes, stroke. ADMISSION MEDICATIONS: 1. Multivitamin 1 every day. 2. ASA 2 tablets adult p.r.n. for pain. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Remarkable for smoking 1 to 1-1/2 packs per day for 40 years.
ASA|acetylsalicylic acid|ASA|117|119|MEDICATIONS|ALLERGIES: Toprol. MEDICATIONS: 1. Protonix 40 mg daily. 2. L-thyroxine 25 mcg daily. 3. Hydralazine 50 mg t.i.d. 4. ASA 81 mg daily. 5. MiraLax p.r.n. FAMILY HISTORY: Brother deceased cancer. Sister deceased cancer.
ASA|acetylsalicylic acid|ASA.|137|140|MEDICATIONS|Please see Dr. _%#NAME#%_'s consultation dated _%#MMDD2003#%_ (? 2004). ALLERGIES: CARBOPLATIN. MEDICATIONS: 1. Synthroid. 2. ______. 3. ASA. 4. Multiple vitamin. 5. Decadron. PHYSICAL EXAMINATION: The patient is a 72-year-old lady in no acute distress.
ASA|acetylsalicylic acid|ASA|210|212|ALLERGIES|7. Peripheral vascular disease. 8. Status post fem-pop in 2004. 9. History of hypertension. ALLERGIES: Penicillin (swollen left arm 40-50 years ago after a shot, not true anaphylactic, nor any real allergies), ASA and one other she is not certain of at this time, may have been Sulfa. MEDICATIONS: 1. Synthroid 125 mcg p.o. q. day. 2. Metoprolol 50 mg p.o. b.i.d.
ASA|acetylsalicylic acid|ASA,|133|136|MEDICATIONS|This is most likely a laceration rather than an in to out injury. ALLERGIES: Percocet, MS, Lipitor and Quinine. MEDICATIONS: Elavil, ASA, Colace, Plavix, Prevacid, Ativan, Milk of Magnesia. PAST MEDICAL HISTORY: Constitutional, skin, HEENT, lymphatic, GI, GU, neurologic, GYN are all negative.
ASA|acetylsalicylic acid|ASA,|129|132|7. BP|Obtained in setting of volume overload post-tx while still in hospital. - she needs this repeated. In addition, she should be on ASA, B-blockade and ACEi therapy. - would start ASA 81mg po qd, d/c hydralazine and start lisinopril 5mg po qd - If bp tolerates, would then start low dose B-blocker; suggest Metoprolol at 12.5mg po bid - WIth smoking hx and hx of decreased LVEF, would suggest starting low dose statin therapy even though LDL within therapeautic range.
ASA|acetylsalicylic acid|ASA,|150|153|MEDICATIONS|4. Left knee replacement, secondary to osteoarthritis. 5. Status post prostate carcinoma. 6. Pacemaker. MEDICATIONS: Metformin, lovastatin, atenolol, ASA, Lasix and vitamins. FAMILY HISTORY: Is reviewed from the chart and old records.
ASA|acetylsalicylic acid|ASA|282|284|MEDICATIONS|6. Ulnar nerve surgery _%#MM2005#%_. The patient denies any hypertension, hyperlipidemia, diabetes, osteoporosis, osteomyelitis, ___________, or other cardiovascular diseases. MEDICATIONS: 1. Coumadin 4 mg p.o. daily. 2. Synthroid 0.225 mg p.o. q.a.m. 3. Iron 325 mg p.o. b.i.d. 4. ASA 1 mg p.o. q.a.m. 5. Trazodone 150 mg p.o. h.s. 6. Lisinopril 2 to 5 mg p.o. q.a.m. 7. Toprol p.o. 2.5 b.i.d. 8. Claritin unknown dosage daily.
ASA|acetylsalicylic acid|ASA,|204|207|MEDICATIONS|4. Chronic obstructive pulmonary disease. 5. Probable lower extremity peripheral vascular disease, intermittent claudication. ALLERGIES: No known medications are no known allergies. MEDICATIONS: Digoxin, ASA, Diltiazem, Colace, Lasix, lisinopril and metoprolol. FAMILY HISTORY: Positive for congestive cardiac failure. SOCIAL HISTORY: The patient is married but her husband resides in a nursing home after a post-bypass stroke.
ASA|acetylsalicylic acid|ASA,|236|239|CURRENT MEDICATIONS|1. Five coronary stents. 2. Placement of three component penile prosthesis in past. 3. Status post cataracts bilaterally. CURRENT MEDICATIONS: Humalog, clonazepam, atenolol, Altace, mononitrate, gemfibrozil, Nitrostat prn, Isotrate ER, ASA, Wellbutrin, Actos, Glucophage, Lipitor, multivitamins. ALLERGIES: No known drug allergies. FAMILY HISTORY: Father congestive heart, sister same.
ASA|acetylsalicylic acid|ASA,|271|274|PSH|8. Left total knee arthroplasty. 9. Ovarian cyst removal, age 16. 10. s/p CABG _%#MMDD2007#%_ Reviewed in chart: current inpatient med list outpatient med list - Nexium, Vicodin, Sensipar 30mg qday, PhosLo 667mg tid, Renagel 800mg tid, hydroxyzine, Allegra, gemfibrozil, ASA, dialyvite, Lexapro, Seroquel, Flexeril SH - no smoking, EtOH abuse, drugs FH non-contributory PE: vitals reviewed I/O's reviewed - essentially anuric alert, very pleasant, non-toxic, in NAD NCAT, no conj, no icterus OP clear neck supple and NT no cervical LAD RRR left PermCath site C/D/I CTA non-labored abdomens soft, incision site C/D/I has right AV fistula (per patient had an aneurysm resected and repaired intra-operatively) trace edema in LE neuro non-focal today's labs reviewed A/P: 65 year old female who is now POD #1 s/p DDKT with DGFx likely due to ATN from prolonged cold ischemia time.
ASA|acetylsalicylic acid|ASA.|80|83|HOME MEDICATIONS|3. Hypertension. 4. Lower extremity orthopedic procedures. HOME MEDICATIONS: 1. ASA. 2. Lexapro. SOCIAL HISTORY: He works as a PA in _%#CITY#%_ _%#CITY#%_. REVIEW OF SYSTEMS: No chest pain, shortness of breath, urinary difficulties.
ASA|acetylsalicylic acid|ASA.|134|137|MEDICATIONS|1. COPD. 2. CAD. 3. Osteoporosis. 4. Hyperlipidemia. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Solu-Medrol. 2. Levaquin. 3. ASA. 4. Plavix. 5. Albuterol. 6. DuoNeb. 7. Spiriva. 8. Zocor. 9. Protonix. 10. Advair. 11. Flomax. 12. Oxycodone p.r.n. FAMILY HISTORY: History of emphysema with assistance from a sister.
ASA|acetylsalicylic acid|ASA|219|221|DISCHARGE MEDICATIONS|He should continue on Coumadin 3 mg p.o. daily, and follow up with at least once weekly INR at the _%#CITY#%_ Dialysis Unit and have his Coumadin adjusted therein. DISCHARGE MEDICATIONS: 1. Coumadin 3 mg p.o. daily. 2. ASA 81 mg p.o. daily. 3. Pantoprazole 40 mg p.o. daily. 4. Hydralazine 10 mg p.o. b.i.d. 5. Colace 100 mg p.o. b.i.d. 6. Aquaphor lotion to affected areas q.i.d.
ASA|acetylsalicylic acid|ASA|159|161|DISCHARGE MEDICATIONS|6. Neoral 150 mg p.o. q.a.m. and 125 mg p.o. q.p.m. 7. Prednisone 5 mg p.o. q.a.m. 8. Bactrim SS one tablet every other day. 9. Valcyte 900 mg p.o. q.a.m. 10. ASA 81 mg p.o. daily. 11. Nitrosation 40 mg p.o. daily. 12. Folate 1 mg p.o. daily. 13. Epogen 30,000 units subcutaneous q. week. 14. Calcium 500 mg p.o. b.i.d.
ASA|acetylsalicylic acid|ASA|171|173|MEDICATIONS|HOSPITALIZATIONS: Childbirth X 2. MEDICAL ILLNESSES: See history of present illness. MEDICATIONS: Atenolol 50 mg po b.i.d., Detrol 2 mg po b.i.d., Celebrex 200 mg q.a.m., ASA 81 mg qd, multi-vite one qd, vitamin E 400 IU qd (she discontinued Detrol, Celebrex ASA, multi-vites, vitamin E, aspirin on _%#MMDD2003#%_).
ASA|acetylsalicylic acid|ASA|208|210|TRANSFERRING MEDICATIONS|7. Osteoarthritis. 8. Left femur/total hip replacement about two years ago after a fall. 9. Hyperlipidemia. TRANSFERRING MEDICATIONS: 1. Albuterol inhaler two puffs b.i.d. 2. Amiodarone 200 mg p.o. b.i.d. 3. ASA 325 mg p.o. q.d. 4. Digoxin 0.125 mg p.o. q.d. 5. Cardizem 240 mg p.o. q.p.m. 6. Colace 100 mg p.o. b.i.d. 7. Lopressor 50 mg p.o. b.i.d.
ASA|acetylsalicylic acid|ASA|128|130|ADMISSION MEDICATIONS|ADMISSION MEDICATIONS: 1. Acyclovir 800 mg 3 times per week. 2. Albuterol nebulizer q.i.d. 3. Ambien CR each day at bedtime. 4. ASA 81 mg daily. 5. Bactrim DS b.i.d. Monday and Tuesday. 6. Benadryl 25 mg p.r.n. itching. 7. Buspirone 30 mg b.i.d.
ASA|acetylsalicylic acid|ASA|191|193|DISCHARGE MEDICATIONS|His creatinine was improving and was 1.32 close to his baseline at the time of discharge. DISCHARGE MEDICATIONS: 1. Metronidazole 500 mg p.o. t.i.d. until _%#MMDD2004#%_ (new medication.) 2. ASA 81 mg p.o. daily. 3. Digoxin 0.25 mg p.o. daily. 4. Imdur 30 mg p.o. daily. 5. Metoprolol XL 100 mg p.o. daily.
ASA|acetylsalicylic acid|ASA|431|433|MEDICATIONS|2. Zocor 20 mg, one tablet, p.o. q.d. (replaced Lipitor which was used from _%#MMDD1999#%_ to _%#MMDD2003#%_) (discontinued _%#MMDD2003#%_ by _%#CITY#%_ Heart Institute post surgery, will decide whether to restart this or a new medication accompanied by 500 mg q.d. of Niaspan per _%#CITY#%_ Heart Institute). 3. Maxzide 75/50, one tablet, p.o. q.d. 4. Flomax 0.4 mg, one tablet, p.o. q.d. since _%#MMDD2003#%_ surgery. 5. Enteric ASA 325 mg, one tablet, p.o. q.d. (discontinued for surgery on _%#MMDD2003#%_). 6. Folic acid 400 mg, one tablet, p.o. q.d. 7. Multivitamin without iron and with 200 mg of selenium to accompany the vitamin E per _%#CITY#%_ Heart Institute, one tablet, p.o. q.d.
ASA|acetylsalicylic acid|ASA|174|176|ADMISSION HISTORY|The patient was found to have a left frontal lobe hemorrhage on _%#MMDD#%_ and it was thought possibly related to Integrilin for the IR procedure. This has since stabilized. ASA was discontinued. The hospitalization has been complicated by two falls.
ASA|acetylsalicylic acid|ASA|183|185|MEDICATIONS|He is exercising not on a routine basis, but certainly is doing heavy work. MEDICATIONS: Again, stable for some years. Toprol XL 100 mg, spironolactone 6.25 mg, lisinopril 20 mg, and ASA 81 mg, all q.a.m. Lopid 600 mg b.i.d., and Lipitor 60 mg q.h.s. ALLERGIES: No known allergies. GENERAL REVIEW OF SYSTEMS: Really unremarkable. He has been feeling quite well, does have problem controlling his weight.
ASA|acetylsalicylic acid|ASA.|160|163|ADMISSION MEDICATIONS|4. History of hypertension. 5. History of hypercholesterolemia. ADMISSION MEDICATIONS: 1. Avapro. 2. Triamterene/hydrochlorothiazide (Maxzide). 3. Prevacid. 4. ASA. 5. Lipitor. ALLERGIES: Penicillin. FAMILY HISTORY: The patient's mother had a history of thrombotic left hemispheric stroke in the 1980's.
ASA|acetylsalicylic acid|ASA|298|300|PAST MEDICAL HISTORY|Medications include insulin NPH/regular 34/17 units subcu b.i.d., Coumadin 5 mg q. p.m., Lisinopril 40 mg q. a.m., Diltiazem 180 mg tablets 2 p.o. q. a.m., Synthroid 125 mcg q. a.m., Prempro 0.625/2.5 mg q. a.m., Wellbutrin 150 mg SR b.i.d., Zocor 20 mg q. h.s., hydrochlorothiazide 25 mg q. a.m., ASA 81 mg q. a.m., B12 injections monthly, Vancenase AQ nasal spray 2 puffs each nostril q. d. to b.i.d., Albuterol inhaler 2 puffs p.o. q.i.d. p.r.n.,and Flovent 220 2 puffs b.i.d. on a p.r.n. basis only and she has not used this of the Albuterol in some months.
ASA|acetylsalicylic acid|ASA.|162|165|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Had left occipital CVA on _%#MMDD2005#%_ leaving her with homonymous hemianopsia. Since that time, she has been on both Plavix and low-dose ASA. Congestive heart failure for the last several years. Echocardiogram half year or more ago showed an ejection fraction of only 20% accompanied with both aortic and mitral valve insufficiency.
ASA|acetylsalicylic acid|ASA|120|122|MEDICATIONS|She is retired and lives with her husband. MEDICATIONS: 1. Synthroid 25 mcg p.o. daily. 2. Crestor 10 mg p.o. daily. 3. ASA 81 mg p.o. daily. 4. Colace 100 mg p.o. b.i.d. 5. Ibuprofen. 6. Percocet p.r.n. 7. Lovenox 90 mg subcu b.i.d. PHYSICAL EXAMINATION: Physical examination on admit was notable for abdomen that showed decreased bowel sounds, minimally tender and slightly distended.
ASA|acetylsalicylic acid|ASA,|254|257|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: 84-year-old Caucasian male with history of CVA with right-sided hemiplegia and expressive aphasia with history of atrial fibrillation, type 2 diabetes, COPD, has upper GI bleed and hematuria. 1. Upper GI bleed. Could be secondary to ASA, Coumidin, & Prednisone. The patient is on IV fluids. He is getting fresh frozen plasma at this time second bag. We will continue his fluids at half-normal saline with 20 mEq of potassium chloride at 120 cc per hour.
ASA|acetylsalicylic acid|ASA|132|134|MEDICATIONS|The colonoscopy was done because he had some rectal bleeding. ALLERGIES: Poppy seeds. MEDICATIONS: 1. Actigall 30 mg p.o. daily. 2. ASA 81 mg p.o. daily. 3. Aricept 10 mg p.o. at bedtime. 4. Coreg 12.5 mg p.o. b.i.d. 5. Bumex 0.5 mg p.o. b.i.d.
ASA|acetylsalicylic acid|ASA|151|153|DISCHARGE MEDICATIONS|His anemia was treated and his heart failure was treated with diminishing in his symptoms. DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg p.o. q. day. 2. ASA 81 mg p.o. q. day. 3. Hydralazine 75 mg p.o. q.i.d. 4. NovoLog sliding scale insulin. 5. Multivitamin 1 tablet p.o. q. day.
ASA|acetylsalicylic acid|ASA|122|124|MEDICATIONS|4. Mega-Mineral one qd. 5. Co-Enzyme Q10 one qd. 6. Vitamin E 400 U qd. 7. Vitamin C 1000 mg qd. 8. Multi-Vite one qd. 9. ASA 81 mg qd. 10. Aciphex 20 mg q a.m. 11. Lasix 80 mg qd. 12. Celebrex 200 mg q a.m. ALLERGIES: None to medications.
ASA|acetylsalicylic acid|ASA|212|214|ASSESSMENT AND PLAN|Will NPO. Will make IV morphine available but anticipate Tylenol and Percocet should be adequate when he is allowed to take p.o.'s. 4) Coronary artery disease. The patient is asymptomatic. Continue Lipitor. Hold ASA until plans for surgery are determined. 5) Fluid, electrolytes, and nutrition. NPO until surgery plans determined. We will begin maintenance IV fluids and recheck basic metabolic profile in the a.m. Cardiac diet when allowed to take p.o.'s.
ASA|acetylsalicylic acid|ASA|133|135|PRESENT MEDICATIONS|Last Td was 1994. ALLERGIES: No known drug allergies. PRESENT MEDICATIONS: 1. Toprol 50 mg decreased from 100 mg in _%#MM2001#%_. 2. ASA q.d. 325 mg coated. He has no problems with his stomach with this. 3. Vitamin E 400 q.d. 4. Ibuprofen 1 q.h.s. for arthritic symptoms.
ASA|acetylsalicylic acid|ASA|294|296|DISCHARGE PLANS|DISCHARGE PLANS: The patient is discharged home, has help from family. Continued on Cipro 500 mg b.i.d., Zoloft 50 mg q.a.m. for depression, which had only recently been diagnosed; plus herroutine home medications, which were Humulin insulin 16 units NPH b.i.d. and 4 units regular q.a.m. plus ASA 81 mg, folic acid q.a.m., Apresoline 50 mg t.i.d., Cozaar 50 mg q.a.m., metoprolol 25 mg b.i.d., Imdur 60 mg at noon, Lasix 20 mg b.i.d., Ativan 0.25 mg b.i.d., Percocet p.r.n. for leg pains, nitroglycerin p.r.n. for chest pain with follow-up in clinic in the near future.
ASA|acetylsalicylic acid|ASA|189|191|MEDICATIONS|PAST MEDICAL HISTORY: 1. Hypertension. 2. Status post arthroscopic knee surgery on both knees. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Labetalol 5-10 mg p.r.n. hypertension. 2. ASA 325 mg daily. 3. Tylenol p.r.n. 4. Docusate p.r.n. FAMILY HISTORY: He has a brother who had a seizure as a child.
ASA|acetylsalicylic acid|ASA.|185|188|MEDICATIONS|No other social history is known. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Hydrocodone. 2. Dilaudid. 3. Electrolytes replacement. 4. Zofran. 5. Compazine p.r.n. 6. Lasix. 7. ASA. 8. Protonix. 9. Zosyn. 10. Amiodarone. 11. Lidocaine patch. REVIEW OF SYSTEMS: A 10-point review of systems was attempted and answers were limited.
ASA|acetylsalicylic acid|ASA,|289|292|RELEVANT HISTORY AND REASON FOR REFERRAL|A CT scan of the head on _%#MMDD2002#%_ revealed volume loss, a lacunar infarct with cavitation at the anterior putamen, anterior limb of the internal capsule and the caudate nucleus, and old posterior medial parietal lobe focal and encephalomalacia. Current medications include Aggrenox, ASA, and labetalol. Family history is significant for a father who died with an abdominal aneurysm and a sister with MI and CABG.
ASA|acetylsalicylic acid|ASA|477|479|MVI|Chronic malnutrition Anemia of chroic disease h/o VRE infection h/o CMV enteritis HTN NSTEMI in 2007 Chronic diarrhea after sigmoidectomy. On supplemental tube feeds throught PEG tube due to severe malnutrition Meds: Calcitriol 0.25 mcg PO Qday Celexa Darbepoeitin 80 mcg S/Q Qweek Lomotil Neurontin Lactobacillus Losartan 25 Qday Meclizine Mirtazapine MVI Opium for diarrhea Compazine Protonix Simethicone Simvastatin 80 QHS Sirolimus 3 QDAY Ursodiol 300 BID Dialudid Tylenol ASA 81 Ceftriaxone 1gm IV Q 24 hour Cipro 750 Q week TMP/SMX 80 mg for prohylaxis Vancomycin PO QID Calcium Carb+Vit D Allergies: NKDA Soc Hx: Smokes 1.5 PPD x 40 years.
ASA|acetylsalicylic acid|ASA.|208|211|HOME MEDICATIONS|8. Prior history of pulmonary hypertension. 9. Recent hospitalization for acute respiratory failure within the last 2-3 months in Indiana. HOME MEDICATIONS: 1. Cardizem. 2. Combivent metered dose inhaler. 3. ASA. 4. Fosrenol. 5. Lanoxin. 6. Synthroid. 7. Metoprolol. 8. Nephrocaps. 9. Protein supplement. 10. ___________. 11. Protonix. 12. Questran.
ASA|acetylsalicylic acid|ASA|95|97|CURRENT MEDICATIONS|Denies any knee pain. Does have some chronic intermittent low back pains. CURRENT MEDICATIONS: ASA 5 grains daily, Isordil 10 mg tid, atenolol 25 mg q AM, levothyroxine 0.05 mg q AM, Lipitor 10 mg q hs, and Zoloft 50 mg q AM.
ASA|acetylsalicylic acid|ASA|150|152|MEDICATIONS|3. Lipitor 20 mg p.o. daily. 4. Ursodiol 250 mg p.o. q.i.d. with food. 5. Asacol 400 mg 3 tablets twice a day. 5. Omeprazole 20 mg 1 tablet daily. 6. ASA 1 tablet p.o. daily. ALLERGIES: None. REVIEW OF SYSTEMS: CONSTITUTIONAL: Negative except for fatigue, malaise, and chronic depression.
ASA|acetylsalicylic acid|ASA|132|134|ALLERGIES|5. History of cholecystectomy. FAMILY HISTORY: Positive for leukemia, lung cancer, ovarian cancer, but no heart disease. ALLERGIES: ASA - patient gets nosebleeds from this. MEDICATIONS: 1. Colace. 2. Lasix. 3. Insulin. 4. Humalog. 5. Lantus.
ASA|acetylsalicylic acid|ASA|353|355|CURRENT MEDICATIONS|Now is fully retired. She remains active, however. She has not smoked since 1991 and does not drink alcohol. CURRENT MEDICATIONS: Zantac 75 mg q.A.M., Alprazolam 0.75 mg q.h.s. and 0.5 mg b.i.d. on a p.r.n. basis, Lopid 600 mg b.i.d., Zocor 40 mg q.h.s., Bentyl 10 mg q.A.M., Premarin 0.625 mg q.A.M., acetaminophen 1000 mg b.i.d., Plavix 75 mg q.A.M., ASA enteric coated 81 mg q.A.M., Toprol XL 100 mg q.A.M., Vioxx 25 mg q.A.M. on a p.r.n. basis and also has nitroglycerin sublingual but generally does not use this.
ASA|American Society of Anesthesiologists|ASA|149|151|ASSESSMENT|Her NEUROLOGICAL exam is intact. ASSESSMENT: 1. Endometriosis with blocked fallopian tubes. 2. No contraindication to the proposed procedure. She is ASA 1 for general anesthesia. PLAN: She will report to Fairview Ridges Hospital on _%#MMDD2002#%_ for a surgical date with Dr. _%#NAME#%_ _%#NAME#%_.
ASA|American Society of Anesthesiologists|ASA|224|226|ASSESSMENT|EXTREMITIES: Without cyanosis, clubbing or edema. LABORATORY DATA: Hemoglobin was drawn today and is pending. ASSESSMENT: 1. Left lung lesion suspicious for recurrence of fibrosarcoma, scheduled to have lesion resection. 2. ASA class 1 risk. 3. Mildly URI symptoms. There are several days before surgery and thinks URI symptoms are viral and will resolve spontaneously.
ASA|American Society of Anesthesiologists|ASA|134|136|ASSESSMENT/PLAN|Urine was clear. ASSESSMENT/PLAN: 1. Pleasant 52-year-old white female in for preop for left knee replacement. I think she will be an ASA II. 1. She is a diabetic, so will get hemoglobin A1C. Also check potassium. She does have a low grade fever now, probably a virus.
ASA|American Society of Anesthesiologists|ASA|189|191|PLAN|ASSESSMENT: 1. Ureterovaginal prolapse. 2. Asthma under excellent control at this time. 3. Depression. PLAN: I see no contraindication to the proposed surgical procedure. The patient is an ASA 3. Because of her depression, will start her on Wellbutrin XL 150 mg p.o. q.d., she was given a one month's supply, she will follow up at that time for a recheck, otherwise will continue her on present drug regimen.
ASA|acetylsalicylic acid|ASA|151|153|MEDICATIONS|She considers herself perimenopausal and has fairly irregular menses. MEDICATIONS: Prior to hospitalization, recent clindamycin. Also, regular dose of ASA enteric coated 325 mg daily, Lasix 40 mg q.a.m., Elavil 20 mg q.h.s. and Flexeril generally 20 mg b.i.d. ALLERGY: Penicillin only.
ASA|acetylsalicylic acid|ASA|212|214|DISCHARGE INSTRUCTIONS|The urine culture grew out 50-100,000 Staphylococcus aureus. It was felt she was ready for discharge. DISCHARGE INSTRUCTIONS: Discharged back to nursing home, her dementia care unit on Isosorbide SA 30 mg daily, ASA 81 mg daily, Lasix 20 mg daily, atenolol 50 mg b.i.d., Avapro 150 mg each day at bed-time, Catapres patch 0.2 mg every 72 hours, cyanocobalamin 1000 mcg IM q. month, Tylenol 500 mg p.o. q.4h. p.r.n., Seroquel 12.5 mg p.o. b.i.d. and Bactrim DS 1 tablet for 5 days.
ASA|acetylsalicylic acid|ASA|180|182|MEDICATIONS|5. K-Dur tablets 10 mEq t.i.d. 6. Had recently been on nortriptyline 25 mg nightly, but this was discontinued just last week. 7. Coreg 6.25 mg b.i.d. 8. Lisinopril 20 mg q.a.m. 9. ASA enteric coated 81 mg tablet daily. 10. Calcium with vitamin D t.i.d. 11. Glucosamine chondroitin t.i.d. 12. Tylenol No. 3 2 tabs t.i.d. on a p.r.n. basis.
AVR|aortic valve replacement|AVR,|157|160|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Atrial fibrillation/flutter, for which he is on heparin drip. 2. Esophageal cancer with recurrence, this was a local recurrence. 3. AVR, 2000. 4. _____ lymphoma, status post chemotherapy in 1999. PAST SURGICAL HISTORY: 1. Esophagectomy in 2000 and a re-excision in 2007 in _%#MM#%_.
AVR|aortic valve replacement|AVR,|148|151|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. St. Jude aortic valve replacement _%#MMDD2006#%_. 2. Anticoagulation secondary to #1. 3. Severe aortic stenosis leading to AVR, likely bicuspid aortic valve. 4. Tonsillectomy at age 23. 5. Appetite at age 25. 6. Tubal ligation at age 25. She denies hypertension, hypercholesterolemia, diabetes mellitus.
AVR|augmented voltage right arm|AVR|146|148|HISTORY OF PRESENT ILLNESS ILLNESS/HOSPITAL COURSE|On examination, she had normal vital signs, heart exam did not reveal any murmurs or gallops. EKG showed T inversions in all the leads except for AVR and lead V1 which was unusal and concerning. Cardiology consultation was done by Dr. _%#NAME#%_ who had raised the possibility of pericardial effusion or dissection.
AVR|augmented voltage right arm|AVR.|180|183|LAB  AND DIAGNOSTIC DATA|I personally reviewed his EKG which shows wide complex rhythm with right bundle branch block and left posterior fascicular block with rate 57. He has ST elevation in leads III and AVR. He has marked ST depression anterolateral of 4-8 mm. CT scan of the head and neck were reported to be negative.
AVR|augmented voltage right arm|AVR|128|130|LABORATORY DATA|Chest x-ray is unremarkable and electrocardiogram reveals no acute ischemic changes. However, there are flipped Q waves in V-1, AVR and AVL. Troponin is negative. White count is 7. Hemoglobin is 13.4. Platelets are 251. Basic metabolic panel is normal with a creatinine of 0.93, potassium of 4.
AVR|aortic valve replacement|AVR|120|122|PAST MEDICAL HISTORY|See history below for likely etiology of the patient's endocarditis. PAST MEDICAL HISTORY: 1. The patient had a CAB and AVR with St. Jude valve in 1997. The patient subsequently developed third-degree heart block about a year ago and had a pacer placed and had this pacer replaced approximately 4 months ago secondary to one of the leads malfunctioning.
AVR|aortic valve replacement|(AVR)|155|159|DISCHARGE DIAGNOSES|1. Congestive heart failure with decompensated exacerbation secondary to 15-pound weight gain. 2. History of aortic stenosis with aortic valve replacement (AVR) in 1999, and coronary artery bypass graft x3 vessels. 3. History of sinus brady for which she had AV pacer placed, 2001.
AVR|augmented voltage right arm|AVR|180|182|HOSPITAL COURSE|HOSPITAL COURSE: 1. Unstable angina: The patient was seen in the emergency room where initial ECG showed some changes consistent with pericarditis including slight PR elevation in AVR and also some T wave inversion in the lateral leads. He was placed on a chest pain pathway and put on telemetry when initial troponin returned negative.
AVR|aortic valve replacement|AVR|125|127|DISCHARGE DIAGNOSES|Discharge from Fairview University Transition Services Date of Discharge: _%#MMDD2002#%_ DISCHARGE DIAGNOSES: 1. Status post AVR and MVR. 2. Bacterial endocarditis, resolved. 3. Wegener's granulomatosis. 4. Type 2 diabetes mellitus. 5. Renal insufficiency. BRIEF HISTORY: This is a 63-year-old male patient who has had a recent hospitalization at Fairview University Medical Center and a stay on Fairview University Transitional Services for rehabilitation after bacterial endocarditis which led to mitral and aortic valve insufficiency.
AVR|aortic valve replacement|(AVR),|121|126|PAST MEDICAL HISTORY|The rest of the patient's review of systems was negative. PAST MEDICAL HISTORY: Significant for aortic valve replacement (AVR), CHF and an ejection fraction of about 40 percent. ADMISSION MEDICATIONS: 1. Lasix. 2. Norvasc. 3. Colace. 4. Coumadin.
AVR|aortic valve replacement|AVR|207|209|PAST MEDICAL HISTORY|Briefly, 1. She has dilated cardiomyopathy secondary to valvular heart disease. Echo of _%#MMDD2000#%_ revealed an EF of 25% with bilateral atrial enlargement. 2. Rheumatic heart disease, assessed with NVR, AVR in 1986. 3. CHF. 4. Atrial fibrillation with atrial tachycardia, assessed with cardioversion _%#MMDD2001#%_. 5. Status post AICD placement _%#MM1999#%_, with revision _%#MMDD2001#%_.
AVR|aortic valve replacement|AVR|333|335|LABS DONE IN THE HOSPITAL|The echocardiogram results: Left ventricular function is normal with an estimated ejection fraction about 60% with mild left ventricular hypertrophy, borderline bi-atrial enlargement with left atrium being 4.3 cm. Patient is in normal sinus rhythm with no atrial fibrillation. Heart rate is 75. Thickened mitral valve with mild MAC. AVR bovine within normal. Trace AI, trace mitral regurgitation, trace TR, trace to mild PR, mild cordal calcification and questionable small right pleural effusion.
AVR|aortic valve replacement|AVR.|221|224|ASSESSMENT/PLAN|6. Acute on chronic renal failure. The patient will receive aggressive IV fluid hydration and we will recheck renal function in the a.m. 7. Peptic ulcer disease. We will start empiric IV proton pump inhibitor therapy. 8. AVR. We will continue Coumadin therapy. If the patient is able to take p.o., we will place on Lovenox in the interim. 9. History of ventricular tachycardia. We will monitor on telemetry.
AVR|augmented voltage right arm|AVR.|149|152|LABS|NEUROLOGICAL: Nonfocal. LABS: Hemoglobin was done today at 15.6. EKG was done. Patient has a conduction-delayed AVF. He does have a little flip T in AVR. R- wave progression is a little poor. ASSESSMENT: 1. Left hip degeneration. 2. Hypertension stable. PLAN: Patient was cleared for surgery. He is a P2 because of his blood pressure.
AVR|aortic valve replacement|AVR|150|152|HISTORY OF PRESENT ILLNESS|The patient had his anticoagulation reversed in preparation for surgery. He was taken to the operating room on _%#MM#%_ _%#DD#%_, 2005, and underwent AVR with a 25 mm pericardial valve, redo CABG x1 with a saphenous vein graft to distal circumflex, and a Maze procedure.
AVR|augmented voltage right arm|AVR|216|218|HOSPITAL COURSE AND PROBLEMS|Due to his initially abnormal EKG, he is to have a cardiac with some LVH that is potentially causing some strain making the ST changes look more pronounced than they are. He does have changes in V1 and V2 as well as AVR that could indicate some right posterior issues. This is the area of his old infarct, however, he had a recent stress test in the past year that showed that he had no periinfarct ischemia and he did have a troponin done which was negative at this time.
AVR|aortic valve replacement|AVR.|158|161|PAST SURGICAL HISTORY|The patient herself is confused, I believe at baseline and very hard of hearing, making review of systems and investigation difficult. PAST SURGICAL HISTORY: AVR. PAST MEDICAL HISTORY: Hypothyroidism. Elevated cholesterol.
AVR|augmented voltage right arm|AVR|184|186|LABORATORY|LABORATORY: His lab results were essentially unremarkable. He had 1 negative troponin at that time. His hemoglobin was 10.3. His INR was 1.07. His EKG showed some inverted T waves and AVR and AVL in V-2; otherwise, was normal sinus rhythm, and these T waves were old. HOSPITAL COURSE: Problem number 1 is chest pain. This patient was taken to the Cardiac Catheterization Lab because there was concern about his subsequent troponins that were actually positive.
AVR|augmented voltage right arm|AVR|240|242|LABORATORY EVALUATION|His hemoglobin is slightly diminished at 12.5, and significantly his BUN is elevated at 48 and creatinine is elevated at 3.8. He has no previous history of renal disease. The patient's electrocardiogram shows an isolated inverted T-wave in AVR and J-point elevation in lead V2-V4, but no acute changes and his initial cardiac markers were negative. He has not had any chest pain. ASSESSMENT: 1. Increasing left lower extremity weakness, possibly due to CVA extension or more likely to hyperglycemia.
AVR|aortic valve replacement|AVR|266|268|REASON FOR ADMISSION|4. Status post aortic and mitral valve replacement. PROCEDURES PERFORMED: None. REASON FOR ADMISSION: The patient is a 76-year-old Caucasian female with an extensive cardiac history including single-vessel coronary artery disease, diastolic dysfunction, status post AVR and MVR, and status post dual-chambered pacer implantation, who presented to the Emergency Department on the day of admission complaining of pressure in her left shoulder and left neck which seemed to extend to her left chest.
AVR|aortic valve replacement|AVR|141|143|PAST MEDICAL HISTORY|The patient is admitted for further workup. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post MI in 1992, status post bypass and AVR in 1994 with LIMA to LAD graft. 2. History of atrial fibrillation/flutter. 3. History of hypercholesterolemia. 4. History of bilateral hip pain for which he takes Tylenol.
AVR|aortic valve resistance|AVR|143|145|PROCEDURES AND TESTS|Carotid ultrasound without stenosis. 3. Echocardiogram with sclerotic aortic valve with a peak gradient of 44, mean gradient of 26, calculated AVR of 0.9, consistent with moderate stenosis. Mild to moderate pulmonary hypertension. 4. Upper endoscopy by Dr. _%#NAME#%_ showing no ulcer disease, inability to intubate the duodenum, small hiatal hernia, small antral polyp.
AVR|augmented voltage right arm|AVR|202|204|PHYSICAL EXAMINATION|Chest CT demonstrated an infiltrate in the left lower lung, but no evidence of pulmonary embolus. Chest x-ray also showed left lower lobe infiltrate. EKG demonstrates sinus rhythm at 98 with Q waves in AVR and AVS and lead 3, but no acute STT wave changes. Blood and urine cultures are pending. ASSESSMENT/PLAN: 70 yo gentleman with diabetes and heart disease admitted with left lower lobe pneumonia.
AVR|aortic valve replacement|AVR|248|250|PAST  MEDICAL HISTORY|Rest of constitutional, eyes, ears, nose, mouth, throat, respiratory, cardiovascular, GI, GU, musculoskeletal, neurologic, endocrine, hematologic, lymphatic and psychiatric review of systems otherwise negative. PAST MEDICAL HISTORY: 1. Status post AVR 1993. 2. COPD on home O2, 2 liters. 3. CHF. Echo _%#MM2005#%_ showed an EF of 30-35%. 4. Hypertension. 5. Recent right scapular fracture _%#MMDD2005#%_.
AVR|UNSURED SENSE|AVR.|242|245|SECONDARY DIAGNOSIS|DISCHARGE DIAGNOSIS: Hypo-osmolality. SECONDARY DIAGNOSIS: Atrial fibrillation, coronary artery disease, hyperlipidemia, hypertension, nonpsychotic brain syndrome, orthostatic hypotension, chronic anticoagulation, prostate cancer status post AVR. Labs of note, sodium 126, potassium 4.3, chloride 91, CO2 32, anion gap of of 3, glucose 99, BUN 16, creatinine 0.91, magnesium 2.1, TSH 3.7. PSA was undetectable.
AVR|augmented voltage right arm|AVR.|119|122|LABORATORY DATA|He has associated PR depression in Lead I, II, V5 and V6. In addition, he has PR elevation in AVR and ST depression in AVR. The remainder of his laboratory values are unremarkable. As noted above, previous Group A strep positive throat culture. No sensitivities were performed. IMPRESSION/PLAN: 1. Elevated troponin. 2. Probable myopericarditis.
AVR|aortic valve replacement|AVR,|193|196|PAST MEDICAL HISTORY|2. Falls related to deconditioning and poor balance. PAST MEDICAL HISTORY: 1. Obstructive sleep apnea. 2. Small vessel ischemic disease. 3. Mild dementia. 4. Atrial fibrillation. 5. Mechanical AVR, MVR, pacer and ICD. 6. Hypocalcemia. 7. Hyperparathyroidism. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is an 85-year-old man who was a nursing home resident up until a short period before discharge.
AVR|aortic valve replacement|AVR|204|206|BRIEF HISTORY OF PRESENT ILLNESS|4. Hypothyroidism. 5. Esophageal gastric junction varices. BRIEF HISTORY OF PRESENT ILLNESS: The patient is a 71-year- old woman with a history of coronary artery disease and Cowden syndrome, status post AVR St. Jude valve and CABG with a LIMA to LAD in _%#MM2005#%_ who presented to the University of Minnesota Medical Center, Fairview, for monitored anticoagulation bridging with heparin for a screening colonoscopy.
AVR|augmented voltage right arm|AVR|177|179|PHYSICAL EXAMINATION|MUSCULOSKELETAL: Decreased range of motion of the left shoulder, otherwise normal. SKIN: Warm, dry, no suspicious lesions. EKG shows slight bradycardia. He has a deep Q wave in AVR which is chronic, back several years. He does have a history of incomplete right bundle branch block which is not really apparent on today's EKG but has been present in ones from years past.
AVR|aortic valve replacement|AVR.|290|293|PAST MEDICAL HISTORY|Unfortunately these fluid collections in the thorax reaccumulated at a rapid rate and the patient was sent to Fairview University Medical Center for treatment with surgical management. PAST MEDICAL HISTORY: 1. Nonsmall cell lung cancer, right upper lobe. 2. Aortic stenosis, history of any AVR. 3. History of CHF. 4. History of AFib. 5. Skin cancer. 6. Prostate cancer. 7. Status post ventral hernia repair. 8. Anemia of chronic disease.
AVR|aortic valve replacement|AVR.|127|130|SURGICAL HISTORY|11. Renal cell carcinoma. TRANSPLANT HISTORY: Deceased donor kidney transplant in _%#MM#%_ 2003. SURGICAL HISTORY: 1. CABG and AVR. 2. Left nephrectomy. 3. Pacemaker placement. ALLERGIES: PHENERGAN, MORPHINE, AND CODEINE. LABORATORY: On admission, creatinine was 1.21. White blood cells were 6.3. Chest x-ray shows minimal airspace opacities in right lower lobe likely representing pneumonia.
AVR|aortic valve replacement|AVR.|259|262||He has a history of renal insufficiency, type 2 diabetes, COPD, hypertension, hyperlipidemia, chronic anemia, and gout. The patient was readmitted for nausea and vomiting on _%#MMDD2006#%_ after being discharged without complications postoperatively from his AVR. His discharge hemoglobin was 9.1. He now presents with nausea, vomiting and anemia and increased BUN and creatinine. He does have a history of chronic renal insufficiency, but this is a new acute component, probably dry.
AVR|augmented voltage right arm|AVR.|196|199||He again sought medical attention at Lakes emergency room, this time had ST segment elevation, most prominent in lead V2 with lesser elevations in I, L, V4 through V6 and also some depressions in AVR. It was unclear whether this represented an acute myocardial infarction or pericarditis. Of note, there is some PR depression in lead I.
AVR|augmented voltage right arm|AVR,|121|124||Of note, there is some PR depression in lead I. There also appears to be a bit in lead II, there is PR elevation in lead AVR, findings that are consistent with probable pericarditis. However, given patient's multiple risk factors, ST segment elevation, it was decided to initiate the ST segment elevation protocol.
AVR|aortic valve replacement|AVR|157|159|PAST MEDICAL HISTORY|No claudication and history of shortness of breath on exertion. PAST MEDICAL HISTORY: 1. Atrial fibrillation status post pacemaker placement. 2. Status post AVR and MVR, on chronic anticoagulation. 3. History of multiple GI bleeds due to angiodysplasia. 4. Congestive heart failure. 5. Hypothyroidism. 6. Psoriasis with psoriatic arthritis. 7. Status post appendectomy and cholecystectomy.
AVR|augmented voltage right arm|AVR|315|317|LABORATORY DATA|Neurologic shows no focal deficits. LABORATORY DATA: WBC 11.3; hemoglobin 12.3; platelets 334; potassium 4.2; creatinine 0.9; troponins negative X4 draws overnight; EKGs were unchanged overnight. EKG here revealed a normal sinus rhythm, rate of 90, no T wave changes or ST changes except some flat T waves in leads AVR and AVL. HOSPITAL COURSE: The patient was ruled out with serial troponins and EKGs as dictated above.
AVR|augmented voltage right arm|AVR|241|243|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: A 63-year-old pleasant female who presented to the emergency room because of palpitations and pressure sensation substernally with shortness of breath. The EKG done in the ER showed atrial fibrillation with rapid AVR and she was given IV diltiazem bolus and was continued on a diltiazem drip. She responded a few minutes later and was back in normal sinus rhythm.
AVR|augmented voltage right arm|AVR,|146|149|LABS ON ADMISSION|WBC 16.5, hemoglobin 15.7, hematocrit is 44.2. Platelets are 262,000. EKG shows sinus tachycardia with no ST-T-wave changes in lead I, II, III or AVR, AVL or AVS. There is no previous EKG to compare ASSESSMENT AND PLAN: 1. Sinus tachycardia secondary to panic attack more likely versus over-the-counter sinus relief medication and caffeine.
AVR|aortic valve replacement|AVR,|217|220|SUMMARY OF HOSPITAL COURSE|SUMMARY OF HOSPITAL COURSE: The patient was admitted to the University of Minnesota Medical Center, Fairview on _%#MM#%_ _%#DD#%_, 2006. On that day, the patient was taken to the operating room where she underwent an AVR, coronary artery bypass graft - LIMA to LAD, maze procedure. The procedure was without complications, and the patient tolerated the procedure well.
AVR|augmented voltage right arm|AVR,|167|170|PHYSICAL  EXAMINATION|EXTREMITIES: Lower extremities show no cyanosis, clubbing or edema. EKG shows sinus tachycardia. There are some nonspecific ST and T-wave abnormalities in leads 1 and AVR, aVL and V1 and V6. LABORATORY DATA: White blood count is 25,000, hemoglobin 12.9, platelets 514,000, INR 1.15, sodium 145, potassium 4.9, chloride 98, CO2 was 11.
AVR|aortic valve replacement|AVR|113|115|SECONDARY DIAGNOSES|2. Status post three-vessel CABG in 2002, the LIMA to LAD in sequential SVG to OM then to the PDA. 3. Mechanical AVR on Coumadin therapy. 4. Normal LV systolic function with an AF of 50%. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 71-year-old gentleman with prior history of coronary artery disease and AVR who is presenting with worsening typical angina.
AVR|aortic valve replacement|AVR|209|211|HISTORY OF PRESENT ILLNESS|3. Mechanical AVR on Coumadin therapy. 4. Normal LV systolic function with an AF of 50%. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 71-year-old gentleman with prior history of coronary artery disease and AVR who is presenting with worsening typical angina. He also had a gated spect within the last month that did show lateral ischemia.
AVR|aortic valve replacement|AVR,|258|261|HOSPITAL COURSE|BUN is 21, creatinine is 1.16. Plan now is to discharge the patient and have a follow up in the CV surgical clinic on _%#MMDD#%_ at 8:45 to visit with CV surgeon with the patient, the patient's power of attorney to discuss the risks of combined procedure of AVR, CABG and carotid endarterectomy. Given the patient's advanced age, he will be at significantly high risk. Revised per MD: _%#MMDD2007#%_, sp
AVR|aortic valve replacement|AVR|261|263|IMPRESSION|Troponin is negative. IMPRESSION: 1. Probable congestive failure. The findings on the chest x-ray are only slight but he has been given Lasix and has had a diuresis so far. We will just restart his oral Lasix. 2. Status post coronary artery bypass grafting and AVR (aortic valve replacement). Plan is to recheck an echocardiogram. 3. Essential hypertension. 4. Hypothyroidism. 5. Hypercholesterolemia.
AVR|aortic valve replacement|AVR|497|499|HISTORY OF PRESENT ILLNESS|DIAGNOSIS: Angina. PROCEDURES PERFORMED: Transthoracic echocardiogram performed on _%#MMDD#%_, which revealed normal LV size, apical wall motion abnormality, mild MR, mildly dilated LA, prosthetic aortic valve with a mean pressure gradient of 12 mmHg and a velocity of 2.7 m/sec, trace AI and mild TR with an EF estimated at 40%, RVSPS at 27+ RAP. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a _%#1914#%_ male with a history of CAD status post CABG in 1993, as well as a history of a prosthetic AVR and CHF with an EF estimated at 35% who was admitted after experiencing some chest discomfort. In the a.m. the patient had some chest pain, which was substernal that seemed to radiate in all directions, but not especially up to his jaw or over to his left arm.
AVR|aortic valve replacement|AVR|127|129|HOSPITALIZATION COURSE|Given this, he was also planned for a CAB x 3. HOSPITALIZATION COURSE: The patient was admitted on _%#MMDD2007#%_ for elective AVR and CAB x 3. He underwent this procedure on this date without any noted difficulty. For further details of the procedure, please refer to the operative note of that date.
AVR|aortic valve replacement|AVR|137|139|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old female with a history of CHF, status post AVR and MVR, as well as current pleural effusion, who presents now with increasing shortness of breath. The problems began in _%#MM#%_ 2007 as the patient developed a right-sided pleural effusion that was subsequently drained.
AVR|aortic valve replacement|AVR|188|190|PAST MEDICAL HISTORY|No other further bleeding was noted. PAST MEDICAL HISTORY: 1. Congestive heart failure: Last EF of 25%, likely dilated cardiomyopathy secondary to valvular disease. 2. Status post MVR and AVR in 1987. 3. History of childhood rheumatic fever. 4. Atrial fibrillation. 5. COPD. 6. V-tach: Status post ICD placement in 2000.
AVR|augmented voltage right arm|AVR,|167|170|LABORATORY|SKIN: Warm and dry with no suspicious lesions. LABORATORY: Hemoglobin today is 11.5. EKG shows normal sinus rhythm, though she does have Q waves in the lateral leads. AVR, AVL and a very tiny one in 1. Slightly early R wave progression. ASSESSMENT: This is a 51-year-old lady coming in for elective laparoscopic supracervical hysterectomy by Dr. _%#NAME#%_ _%#NAME#%_.
AVR|augmented voltage right arm|AVR.|288|291|PHYSICAL EXAMINATION|Hips seem to be pretty much normal. SKIN: Multiple benign appearing lesions, nothing worrisome for malignancy. EKG done in _%#MM#%_ of 2001 right before her cataract surgery showed no acute changes and actually was pretty normal, a little bit of widened QRS and probably old Q in III and AVR. ASSESSMENT: Degenerative joint disease left knee PLAN: Proceed as per Dr. _%#NAME#%_.
AVR|augmented voltage right arm|AVR,|178|181|PHYSICAL EXAMINATION|There is trace ankle edema. NEURO: Nonfocal. EKG was performed in the office. He has atrial fibrillation. There is some nonspecific T wave changes particularly in leads II, III, AVR, AVF and V1 which are really unchanged from his previous tracings. Chest x-ray will be performed. IMPRESSION: 1. Degenerative joint disease affecting the left knee, considerably limiting his mobility.
AVR|aortic valve replacement|AVR.|362|365|IMPRESSION|REVIEW OF SYSTEMS: As noted above. LABORATORY DATA: Available to me from the outside institution includes chemistries from today of 134, 5.4, 98, 20, 81, creatinine 5.1. Echo demonstrating apparent small left ventricle with normal ejection fraction, mild JVD and a large circumferential pericardial effusion. IMPRESSION: 1. Chronic renal failure. 2. Status post AVR. 3. Acute renal failure of multifactorial etiology to include a. ACE inhibitor. b. Diuretic. c. Motrin. 4. Pericardial effusion with normal left ventricular function and no apparent hemodynamic compromise.
AVR|aortic valve replacement|AVR.|207|210|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Dysrhythmia with right bundle branch block, intermittent atrial fibrillation and intermittent sinus arrest status post permanent pacemaker. 2. Congestive heart failure. 3. History of AVR. 4. GI bleed/anemia. 5. Back pain and degenerative joint disease. 6. Chronic renal insufficiency. 7. Liver lesion. 8. Hypothyroid. 9. Hypertension. 10. Deconditioning.
AVR|aortic valve replacement|AVR.|201|204|HOSPITAL COURSE|The patient from the echocardiogram showed pulmonary hypertension with right ventricle systolic pressure at 75 mm plus RAP. The patient will need outpatient pulmonary follow-up for this. 3. History of AVR. The patient's INR was supratherapeutic at the time of his GI bleed at the outside hospital at a level of 7. His INR was allowed to drift down for his pacemaker procedure and then the patient was started on Warfarin and Heparin.
AVR|aortic valve replacement|AVR|412|414|DIAGNOSTIC SUMMARY|Coronary angiogram was performed on _%#MMDD2007#%_. CATHETERIZATION DIAGNOSES: Aortic valve prosthesis, moderate dysfunction, pulmonary artery hypertension, left main coronary artery disease, 4 coronary artery bypass grafts, normal left ventricular function, and left ventricular diastolic dysfunction. DIAGNOSTIC SUMMARY: Coronary angiogram. This is a 47-year-old man with a history of 4 aortic valve surgeries AVR with Bjork-Shiley valve in 1982, replacement of the wall with Medtronic-Hall composite graft in 1985 for subacute bacterial endocarditis.
AVR|augmented voltage right arm|AVR|222|224|HISTORY OF THE PRESENT ILLNESS|Troponin was negative. ECG was personally reviewed by me and showed intermittent sinus rhythm as well as intermittent axillary junction rhythm at about 75 beats per minute. She did not have any significant PR elevation in AVR or PR depression or ST elevation of other leads. Since she was pain-free her tests were negative. I discussed with her all the test results and the fact that it will be very appropriate for her to go back home with reassurance and peace of mind.
AVR|aortic valve replacement|AVR|157|159|PAST MEDICAL HISTORY|3. History of TIAs. 4. History of diverticulosis and GERD. 5. Erectile dysfunction. 6. High blood pressure. 7. History of bicuspid aortic valve, status post AVR in 1983, last echo on _%#MMDD2007#%_, EF more than 55% and moderate aortic root dilatation. 8. History of coarctation of aorta, status post aortic repair in 1958.
AVR|aortic valve replacement|AVR|233|235|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: Cardiac tamponade status post pericardial window. HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old white male who was admitted secondary to cardiac tamponade. The patient has a history significant for an AVR prior to tamponade. The patient's hospital stay was complicated by new-onset of atrial flutter. Following onset of atrial flutter, cardiology was consulted, and a TEE was obtained.
AVR|aortic valve replacement|AVR|169|171|PAST MEDICAL HISTORY|2. History of paroxysmal tachyarrhythmias with history of treatment on flecainide and amiodarone. 3. History of rheumatic fevers status post mechanical mitral valve. 4. AVR secondary to rheumatic fever with porcine valve in 1975 and a Omnistar valve in 1988 and a St. Jude valve in 1999. 5. History of peptic ulcer disease.
AVR|aortic valve replacement|AVR|77|79|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 59-year-old gentleman who presents for AVR and MVR. PAST MEDICAL HISTORY: 1. AS. 2. AI. 3. Mitral insufficiency and regurgitation.
AVR|aortic valve replacement|AVR|217|219|HOSPITAL COURSE|LUNGS: Clear to auscultation bilaterally. Strength was 5/5 throughout. Sensation was intact grossly. HOSPITAL COURSE: This 59-year-old man with a history of valvular disease secondary to rheumatic fever, presents for AVR and MVR at Fairview-University Medical Center. The patient was taken to the OR on _%#MMDD2003#%_, and the procedures were performed without complication.
AVR|augmented voltage right arm|AVR,|151|154|OBJECTIVE|Sensation and strength is normal in her left hand. Skin is warm and dry. No lower extremity edema. EKG shows normal sinus rhythm with Q waves in 3 and AVR, do not have an old one available to compare. Borderline LVH in V2. Spirometry is improved from prior time, which actually now is within normal limits with 81% FVC and FEV-1 at 85%, FEV-1% is 106.
AVR|aortic valve replacement|AVR|129|131|CONSULTS|Negative blood cultures with questionable septic hip joint. Aortic mass on previous aortic valve repair seen on TEE, status post AVR and MVR on the same hospitalization. Negative TEE status post 6 weeks of antibiotics. INR goal of 2.5 to 3.5. 2. Wegener 1999. Complaining of lower extremity and upper extremity weakness.
AVR|aortic valve replacement|AVR|253|255|HISTORY OF PRESENT ILLNESS|REVISED REPORT: CHIEF COMPLAINT: Severe upper respiratory symptoms for eight days with increasing shortness of breath. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 79-year-old, white male with a history of coronary artery disease, status post AVR for critical aortic stenosis in _%#MM2003#%_, congestive heart failure, atrial fibrillation/flutter in _%#MM2003#%_ prior to his valvular surgery and his bypass surgery, prostate cancer diagnosed in _%#MM2004#%_ and treated with radiation therapy, he is on treatment #35 of RT, elevated cholesterol, macular degeneration, who is being admitted as an unassigned to Fairview Southdale Hospital after presenting with upper respiratory symptoms for eight days and shortness of breath.
AVR|aortic valve replacement|AVR|140|142|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Coronary artery disease, status post three vessel bypass in _%#MM2003#%_. 2. Critical aortic stenosis, status post AVR replacement in _%#MM2003#%_, on Coumadin. 3. Preoperative history of atrial fibrillation/atrial flutter, with brief hospitalization here at Fairview Southdale in _%#MM2003#%_.
AVR|aortic valve replacement|AVR.|143|146|ASSESSMENT/PLAN|PT/OT to evaluate and treat the patient. Pain is well controlled with OxyContin and oxycodone. 2. Marfan's syndrome with sequelae. Status post AVR. The patient also had a history of retinal detachment. We will continue Coumadin and enoxaparin pending therapeutic INR after which enoxaparin will be discontinued.
AVR|augmented voltage right arm|AVR|249|251|LABORATORY|Calcium level minimally reduced at 8.4. Otherwise BMP is normal. Initial troponin less than 0.07. INR 0.9. Subsequent troponins 0.29 and 0.55. ECG from _%#MMDD2005#%_ at 21:22 shows sinus rhythm, minimal criteria for LVH, T wave inversion in V3 and AVR and V1, but no acute ST-T wave changes. Chest x-ray viewed on image test. It is a portable film, not a great quality.
AVR|aortic valve replacement|(AVR,|172|176|PAST MEDICAL HISTORY|3. Diabetic triopathy (retinopathy, neuropathy, and nephropathy) associated with type 1 diabetes. 4. Hypertension. 5. Aortic stenosis, status post aortic valve replacement (AVR, porcine), _%#MM2005#%_. 6. Legally blind. 7. Hyperlipidemia. 8. Graves disease, status post radio-iodine ablation. 9. Recent recurrent pneumonia. 10. Gastroesophageal reflux disease (GERD).
AVR|augmented voltage right arm|AVR.|163|166|LABORATORY DATA|EKG was reviewed by myself, demonstrates atrial fibrillation with multiple premature beats. There are no acute ST-T wave changes. Q waves are noted in leads 3 and AVR. I am unable to find an old EKG for comparison. ASSESSMENT AND PLAN: A 72-year-old gentleman with known coronary artery disease most recent plan for medical management, being admitted with chest pain.
AVR|aortic valve replacement|AVR.|44|47|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: 1. Atrial flutter with AVR. 2. Abdominal pain. OPERATIONS/PROCEDURES PERFORMED: 1. Elective synchronized cardioversion done on _%#MM#%_ _%#DD#%_, 2006.
AVR|aortic valve replacement|AVR|174|176|IMPRESSION|3. History of diabetes. Will continue Accu-Cheks and continue his home medications for now. 4. History of hypertension, recently status post pacemaker placement, status post AVR which seemed to be stable. We will get an EKG and continue his home medications. DISPOSITION: Home and in a day or 2 depending on his comfort level giving himself subq injections.
AVR|aortic valve replacement|AVR|249|251|HISTORY OF PRESENT ILLNESS|The patient's last Coumadin dose was on Thursday _%#MMDD2007#%_. The patient's INR today is 1.44. The patient gives no history of shortness of breath, dyspnea on exertion. The patient has a baseline chest pain 2/10, per the patient it is due to his AVR replacement. The valve is tight and he gets a constant dull pain 2/10 in intensity for which he usually takes Percocet 3 times a day.
AVR|aortic valve replacement|AVR|171|173|PAST MEDICAL HISTORY|2. Hypothyroidism. 3. Dyslipidemia. 4. Chronic back pain. 5. Arthritis of left rib. 6. Status post cirsectomy. 7. Status post tonsillectomy and adenectomy. 8. Status post AVR in 1997. 9. Status post percutaneous gastrostomy _%#MMDD2007#%_. ALLERGIES: Cefadroxil. SOCIAL HISTORY: Quit smoking in 1980, used to take 1 pack a day for 20 years.
AVR|augmented voltage right arm|AVR|254|256|OBJECTIVE EXAMINATION|ABDOMEN - benign. LOWER EXTREMITIES - showed no edema. Hemoglobin was normal at 16.3, white blood count 25.4 with significant left shift. Platelets were fine. EKG - showed a normal sinus rhythm but with ST elevations in III and AVF, ST depressions in I, AVR and V2-V5, possibly even including V6. Chest x-ray - was done and was clear.
AVR|aortic valve replacement|(AVR)|148|152|DISCHARGING DIAGNOSES|2. A left below the knee amputation (BKA) secondary to chronic osteomyelitis which was done _%#MMDD2004#%_. 3. Status post aortic valve replacement (AVR) for which he is on Coumadin and that has been managed by the Coumadin Clinic with a goal INR of 2.5 to 3.5.
AVR|augmented voltage right arm|AVR|210|212|PROCEDURES PERFORMED|HOSPITAL COURSE: 1. Chest pain. The patient was seen in the emergency room where initial ECG showed a normal sinus rhythm with rate of 75. There did appear to be diffuse ST elevation with some PR elevation and AVR consistent with pericarditis. Serial troponins were obtained which were negative. The patient was transferred to the telemetry floor where no arrhythmias were noted.
AVR|aortic valve replacement|AVR|53|55|OPERATIONS/PROCEDURES PERFORMED|OPERATIONS/PROCEDURES PERFORMED: Patient received an AVR on _%#MM#%_ _%#DD#%_, 2005, done by Dr. _%#NAME#%_. HISTORY OF PRESENT ILLNESS: The patient has been known to have AV stenosis, bicuspid aortic valve.
AVR|augmented voltage right arm|AVR.|221|224|PLAN|The patient was instructed to stop taking her aspirin today, continue with her other medications. Her hemoglobin was 14.0, potassium pending. EKG showed a normal sinus rhythm with rapid R-wave progression and a Q-wave in AVR.
AVR|aortic valve replacement|AVR|149|151|PAST MEDICAL HISTORY|He had an ATS artificial valve placed. The patient was admitted for the pacer placement. PAST MEDICAL HISTORY: 1. Significant for the aforementioned AVR plus 1 circumflex bypass. 2. He has hypercholesterolemia. 3. He is hypertensive. 4. He has a history of sleep apnea that is mild and that he feels CPAP did not help him for.
AVR|aortic valve replacement|AVR|162|164|BRIEF HISTORY OF PRESENT ILLNESS|BRIEF HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 50-year-old female with a significant past medical history for rheumatic heart disease, status post MVR and AVR in 1974 with redo in 1995. Also, severe pulmonary artery hypertension secondary to LV diastolic dysfunction (has a wedge of 25, normal EF and an index of 2.3) who was admitted for increasing shortness of breath, as well as increased dependence on home oxygen.
AVR|aortic valve replacement|AVR,|224|227|HISTORY OF PRESENT ILLNESS|CONSULTATIONS OBTAINED: CVTS evaluation with Dr. _%#NAME#%_ _%#NAME#%_ for operational feasibility for the tricuspid regurgitation. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 55-year-old female with a history of AVR, MVR, multiple right heart failure exacerbations, atrial fibrillation, diabetes is admitted with increased lower extremity edema and weight gain. HOSPITAL COURSE: PROBLEM #1: CHF. This was felt secondary to likely a combination of severe tricuspid regurgitation.
AVR|aortic valve replacement|AVR|108|110|PROBLEM #4|PROBLEM #3: Type 2 diabetes. The patient was continued on her Lantus and sliding scale insulin. PROBLEM #4: AVR MVR/paroxysmal atrial fibrillation. The patient is currently anticoagulated and is on Coumadin. Her INR this morning is 2.82. She will follow up for evaluation and see INR at the labs this week.
AVR|aortic valve replacement|AVR|175|177|OPERATIONS/PROCEDURES PERFORMED|OPERATIONS/PROCEDURES PERFORMED: None. HISTORY OF PRESENT ILLNESS: This is a 47-year-old gentleman who has a significant past medical history for Marfan syndrome, status post AVR St. Jude in 1991, pulmonary hypertension with restrictive lung disease, cor pulmonale, atrial fibrillation, and ICD/pacemaker placement 2002 who presented to Fairview University Medical Center with complaints of ongoing shortness of breath, peripheral edema, and increased weight gain.
AVR|aortic valve replacement|AVR|210|212|OPERATIONS/PROCEDURES PERFORMED|PAST MEDICAL HISTORY: 1. Charcot deformity of the left foot which is being followed by Dr. _%#NAME#%_. 2. Pulmonary hypertension with restrictive lung disease. 3. OSA, on BiPAP. 4. Marfan syndrome, status post AVR and St. Jude in 1991. 5. Cor pulmonale/CHF with diastolic dysfunction. 6. Atrial fibrillation, status post pacemaker, ICDM.
AVR|aortic valve replacement|AVR|172|174|HOSPITAL COURSE|An EKG showed no ST or T changes. It showed Q-waves in V1 through V2. The patient was evaluated by Dr. _%#NAME#%_ from the cardiovascular service and was deemed to need an AVR and an ostial patch. Due to the patient's renal function, the patient had to undergo dialysis every other day. To accommodate the patient's frequent dialysis needs, a Tenckhoff catheter was placed on _%#MM#%_ _%#DD#%_, 2004.
AVR|augmented voltage right arm|AVR,|180|183|LABORATORY DATA|MCV of 104. Serum alcohol 0.58. Dilantin level 8.3. Troponin time is x 2 less than 0.07. EKG showed normal sinus rhythm, right axis deviation R-wave propagation, inverted T-waves, AVR, AVL in V1. Prolonged QT was also noted with incomplete right bundle branch block. Chest x-ray: No infiltrate or pulmonary edema. Head CT without contrast negative for acute intracranial pathology.
AVR|aortic valve replacement|AVR|142|144|IMPRESSION|3. His hemoglobin is somewhat stable from the discharge hemoglobin from Mayo therefore we will continue his Coumadin for now given his recent AVR surgery. Monitor his hemoglobin closely. We will hold his aspirin, his sulindac and add Protonix. 4. Acute renal failure secondary to his recent nausea, vomiting and diarrhea.
AVR|aortic valve replacement|AVR.|113|116|TRANSFER ASSESSMENT AND PLANS|TRANSFER ASSESSMENT AND PLANS: 1. CV. CHF resolved. Continue on daily Lasix 10 mg p.o. daily for now. History of AVR. Continue on Plavix, heparin and Coumadin until therapeutic on Coumadin, at which time heparin can be discontinued. Hypertension has been controlled on lisinopril, metoprolol and Lasix. We will continue treatment for hyperlipidemia with simvastatin.
AVR|aortic valve replacement|AVR.|203|206|ASSESSMENT AND PLAN|7. Depression, continue the Celexa. 8. Low back pain. Continue the Duragesic patch and OxyContin. 9. Hypertension, continue the Norvasc and the losartan. 10. Coronary artery disease, status post porcine AVR. 11. Complete heart block status post pacemaker placement. 12. Deconditioning. PT/OT consultation will be obtained. 13. Full code. 14. Over one hour was spent in gathering information, talking to the patient and the patient's daughter about care plans.
AVR|augmented voltage right arm|AVR,|271|274|EKG|HEART: Is regular rate and rhythm without murmur ABDOMEN: Soft, a little tender in the left lower quadrant, positive bowel sounds MUSCULOSKELETAL: Normal SKIN: Is warm and dry, no specific lesions. Spirometry is normal EKG: Is slight bradycardia, has a Q-wave in III and AVR, early R-wave progression. ASSESSMENT: This is a 53-year-old lady coming in for an elective hemorrhoidectomy with a repair of fissure.
AVR|aortic valve replacement|AVR.|163|166|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: 1. Pericardial effusion, status post window. 2. Intermittent postoperative atrial fibrillation, treated with amiodarone. 3. History of recent AVR. PROCEDURES: Pericardial window placed by surgeons. HISTORY AND HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 57-year-old gentleman who had a recent aortic valve with a composite graft.
AVR|aortic valve replacement|AVR|234|236|PAST MEDICAL HISTORY|She developed a post biopsy complication with a large retroperitoneal hematoma leading to a prolonged hospitalization in the SICU. PAST MEDICAL HISTORY: The patient's other pertinent past medical history includes status post CABG and AVR in 1998 and status post right hip replacement. She also has a past medical history which included hypertension, hyperlipidemia, history of seizures in 1993.
AVR|aortic valve replacement|AVR.|140|143|PAST MEDICAL HISTORY|He has SVG going to RCA 25% in-stent restenosis. Finally, he has SVG going to his D1/1,2 branch with 50% proximal occlusion. 2. Status post AVR. He has a mechanical St. Jude plus mitral valve repair with ring, _%#MM#%_ 2003 plus tricuspid valve repair. 3. CHF thought secondary to mitral stenosis. His BNP levels are in the 1000 range.
AVR|aortic valve replacement|AVR|143|145|PAST MEDICAL HISTORY|Severe __________/fibrosis. Mild MR. Moderate-to-severe mitral stenosis. Mean gradient is 14 mmHg. Alpha is 2 cm2. He has a normal function in AVR mean gradient of 9.2 mmHg. 5. Status post renal transplant for chronic renal insufficiency. Baseline creatinine is around 2.5. He had living-related donor in 1993.
AVR|aortic valve replacement|AVR.|150|153|PAST MEDICAL HISTORY|He did not complain of any fevers. PAST MEDICAL HISTORY: 1. Congestive heart failure with an EF of 35%. 2. Hypertension. 3. Chronic a-fib. 4. MVR. 5. AVR. 6. Left bundle branch block. 7. Status post appendectomy. 8. Semi-emergent tracheostomy, _%#MMDD2004#%_, secondary to failed extubation. 9. History of DTs secondary to ethanol abuse.
AVR|aortic valve replacement|AVR,|260|263|HISTORY OF PRESENT ILLNESS|ADMISSION DIAGNOSIS: Tracheal stenosis. DISCHARGE DIAGNOSIS: Tracheal stenosis. PROCEDURES PERFORMED: Rigid bronchoscopy with serial tracheal dilations. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 66-year-old male with congestive heart failure status post AVR, MVR, coronary artery bypass grafting, who has postoperative tracheal stenosis. He undergoes numerous bronchoscopic dilations. He presented to the unit yesterday with unabated coughing which lead to extreme shortness of breath.
AVR|augmented voltage right arm|AVR|122|124|HISTORY OF THE PRESENT ILLNESS|The patient's normal sinus rhythm ECG revealed significant ST depression in initially II, III and AVF and ST elevation in AVR and depression in the anterolateral leads. The patient was initially started on aspirin and heparin and treated with sublingual nitroglycerin which did reduce the chest pain somewhat.
AVR|augmented voltage right arm|AVR|276|278|HISTORY OF THE PRESENT ILLNESS|Upon arrival at Fairview Southdale, the patient was evaluated by me and noted to be in acute pulmonary edema with shortness of breath and initial ECG here showed a normal sinus rhythm with rate in the 60s and incomplete left bundle branch block and acute ST elevations in the AVR and reciprocal change in the inferolateral leads. The patient's initial bedside echocardiogram revealed dyskinetic inferior wall motion and akinetic septal anterior and apical walls and LV and RV systolic pressure approximately 30 mmHg.
AVR|aortic valve replacement|AVR|136|138|PAST MEDICAL HISTORY|3. Status post AV nodal ablation and a DDIR pacemaker placement due to atrial fibrillation. 4. Status post hysterectomy. 5. Status post AVR and MVR. FAMILY HISTORY: Please refer to HPI from _%#MM#%_ _%#DD#%_, 2006.
AVR|augmented voltage right arm|AVR.|160|163|LABORATORY DATA|Hepatic panel is within normal limits. Troponin less than 0.04, lipase 204. EKG shows inverted T waves in V2 and V3 with minimal less than 1 mm ST elevation in AVR. Chest x-ray is unremarkable. ASSESSMENT AND PLAN: Ms. _%#NAME#%_ is a 61-year-old woman who presents with episodes of flushing and dyspnea as well as black stools and hematemesis consistent with GI bleeding.
AVR|aortic valve replacement|AVR|183|185|OPERATIONS/PROCEDURES PERFORMED|3. Complete heart block with biventricular pacemaker. 4. Class III to IV congestive heart failure. 5. Hypertension. 6. Depression. OPERATIONS/PROCEDURES PERFORMED: The patient had an AVR with a 23-mm St.Jude replacement, repaired VSD, and left ventricular epicardial lead placement. This was performed on _%#MM#%_ _%#DD#%_, 2006, by Dr. _%#NAME#%_.
AVR|augmented voltage right arm|AVR,|170|173|PHYSICAL EXAMINATION;|Chest x-ray shows normal sized heart and thoracic aorta, clear lung fields. EKG shows sinus rhythm with nonspecific T-wave flattening in V4, V5 and V6 and somewhat in I, AVR, AVL and low inferior leads which is stable from _%#MMDD2005#%_. Admission labs shows a hemoglobin of 14.5 white count 8,400, platelets 310,000, sodium 135, potassium 3.4, chloride 103, cO2 25, BUN 25, creatinine 1.0, GFR 83, normal calcium at 9.3, glucose 91.
AVR|aortic valve replacement|AVR,|164|167|HOSPITAL COURSE|Her nausea was treated with antiemetics and she was able to tolerate a regular diet on postoperative day #5. Status post coronary artery disease, status post CABG, AVR, MVR:. Again, the patient was restarted on her Coumadin as she tolerated diet. She was given perioperative beta-blockers for cardiac protection with good blood pressure control.
AVR|aortic valve replacement|AVR|217|219|PROBLEM #2|The biopsy results were negative for malignancy. The patient tolerated the procedure well and incision was clean and healing very well without any evidence of infection. PROBLEM #2: Bicuspid aortic valve, status post AVR in 1983 and repeat in 1993 with patient-prosthesis mismatch. In 1994, there was an attempted replacement, but it was impossible secondary to excess fibrosis.
AVR|aortic valve replacement|AVR,|144|147|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Fever with nausea and vomiting. HISTORY OF PRESENT ILLNESS: 84-year-old male with a significant past medical history of a fib, AVR, chronic kidney disease, peptic ulcer disease presented with a complaint of fevers and abdominal pain since this afternoon. The patient states of generally not feeling well. Additionally, he describes approximately 2-week history of reddening of his right third toe.
AVR|aortic valve replacement|AVR|155|157|PAST MEDICAL HISTORY|1. History significant for sick sinus syndrome status post DDR pacemaker placement _%#MMDD2007#%_. 2. Coronary disease with history of CABG. 3. History of AVR in _%#MM2004#%_. 4. History of ascending aortic root aneurysm status post repair with a composite graft. 5. History of chronic kidney disease. 6. History of nephrectomy for renal cancer.
AVR|aortic valve replacement|AVR|207|209|ASSESSMENT AND PLAN|Will continue aspirin and Coumadin. The patient will be evaluated by PT, OT and PM&R physician in the a.m. 2. Cardiovascular: History of congestive heart failure secondary to ischemic cardiomyopathy, recent AVR and CABG x1 vessel. He also has a permanent pacemaker secondary to trifascicular block. Pacemaker is functioning appropriately. Will continue the patient on Lasix, aspirin and Metoprolol.
AVR|aortic valve replacement|AVR|173|175|PAST MEDICAL HISTORY|9. Indeterminate lung nodules. 10. Hyponatremia secondary to hydrochlorothiazide use. 11. Atherosclerotic coronary vascular disease with single vessel bypass at the time of AVR surgery. 12. Glaucoma. 13. Status post bilateral varicose veins with bilateral varicose vein stripping. 14. Small bowel obstruction secondary to adhesions, status post lysis.
AVR|aortic valve replacement|AVR.|156|159|IMPRESSION|Otherwise no ST or T-wave abnormalities are noted. Chest x-ray is without infiltrate. IMPRESSION: 1. Hypertensive urgency. 2. Tooth abscess. 3. Status post AVR. PLAN: 1. Other than receiving labetalol in the emergency room, the patient is not receiving her normal a.m. medications today.
AVR|augmented voltage right arm|AVR.|202|205|PHYSICAL EXAMINATION|ABDOMEN: Positive bowel sounds, soft and nontender. EXTREMITIES: She has trace to 1+ edema to her upper shin bilaterally. EKG shows T-wave inversion in leads 1 and aVL and ST elevation of about 1 mm in AVR. Chest x-ray shows pulmonary edema with fluid in the fissure and cardiomegaly. LABORATORY DATA: Sodium 142, potassium 3.9, chloride 106, bicarb 26, BUN 19, creatinine 0.85, glucose 81, BNP 1360, and troponin 0.67.
AVR|aortic valve replacement|AVR|260|262|DISCHARGE DIAGNOSIS|Results and impression: No obvious source of pain in the coronary arteries or grafts. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is a 51-year-old male with a history of aortic stenosis, coronary artery disease, status post 2 vessel CABG, prosthetic AVR in 2004, with hypercholesterolemia, who came into the ED with right-sided chest pain. The pain was dull ache, right parasternal and pleuritic with no radiation, palpitation, or other associated symptoms.
AVR|augmented voltage right arm|AVR|155|157|PHYSICAL EXAMINATION|His DP pulses are full. Chest x-ray shows normal without infiltrates. His EKG has a sinus rhythm at a rate of 85. He has possibly a 1/2 mm ST elevation in AVR and a half mm of ST depression in V4 but otherwise is normal. LABORATORY DATA: INR 0.91, PTT of 32. D-dimer 0.2, troponin 1.65, white count 12.9, hemoglobin 16.3, platelet count 357.
AVR|aortic valve replacement|AVR|68|70|SECONDARY DIAGNOSES|DISCHARGE DIAGNOSIS: Blood loss anemia. SECONDARY DIAGNOSES: 1. S/p AVR secondary to severe aortic regurgitation, _%#MMDD2006#%_. 2. S/p ascending aortic aneurysm repair with grafts on _%#MMDD2006#%_. 3. S/P left inguinal hernia repair years ago. 4. S/p laparoscopic right inguinal hernia repair, _%#MMDD2006#%_.
AVR|aortic valve replacement|AVR.|188|191|HOSPITAL  COURSE|5. Atrial fibrillation. The patient was started on amiodarone. Cyclosporine levels have not been checked after this adjustment and we will need to do this as an outpatient. 6. Status post AVR. The patient was continued on Coumadin. DISCHARGE INSTRUCTIONS: 1. Renal diabetic diet. 2. Activity as tolerated.
AVR|augmented voltage right arm|A.V.R.|203|208|LABORATORY DATA|Triglycerides were 121, LDL 80, HDL 28. EKG showed a sinus tachycardia with occasional PVCs, LVH, and some ST elevation in leads V1, 2, and 3. Her T-waves were upright and normal in all leads except for A.V.R. which was normal inverted. HOSPITAL COURSE: PROBLEM #1: Chest Pain. Patient was admitted and ruled out with troponins X3.
AVR|aortic valve replacement|AVR.|257|260|PAST MEDICAL HISTORY|He is voiding without any difficulty at all. He feels overall that he is simply exhausted and tired, though he does acknowledge that he understands the need for therapies to push and encourage him in order to progress. PAST MEDICAL HISTORY: 1. CAB x 3 with AVR. 2. Sarcoidosis. 3. Hyperlipidemia. 4. Depression, apparently for several years. MEDICATIONS UPON TRANSFER: 1. Lipitor 10 mg p.o. q.d. 2. Celexa 20 mg p.o. q.d.
AVR|aortic valve replacement|AVR.|169|172|PLAN OF CARE|PLAN OF CARE: 1. Deconditioning. The patient is admitted to Fairview-University Transitional Services for rehab, PT, OT, and reconditioning. 2. Status post redo CAB and AVR. Will continue with Coumadin, checking INRs, with our goal being 2.0 to 2.5. This will continue for six weeks, at which time the patient will be placed on aspirin.
AVR|aortic valve replacement|AVR|71|73|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Aortic stenosis. OPERATIONS/PROCEDURES PERFORMED: AVR plus aortic root repair. HOSPITAL COURSE: The patient was taken to the OR on _%#MM#%_ _%#DD#%_, 2002. The OR course was largely uneventful. The patient was transferred from SICU on postoperative day 2 to a stepdown ward.
AVR|aortic valve replacement|AVR,|154|157|IMPRESSION|EKG showed atrial flutter with a 2:1 block. IMPRESSION: This 79-year-old White male with a history of COPD, coronary artery disease, status post CABG and AVR, diabetes, hypothyroidism who presents with symptoms of shortness of breath. Although, his COPD could be contributing to this. This major factor appears to be congestive heart failure, most likely due to dietary indiscretion.
AVR|aortic valve replacement|AVR|208|210|HOSPITAL COURSE|HOSPITAL COURSE: This is a lovely gentleman who speaks German, Ukrainian and Russian, but very minimal English. He initially had on _%#MMDD2007#%_ with Dr. _%#NAME#%_ a coronary artery bypass graft x1 and an AVR replacement. He was noted to have CHF at that time and a pacemaker was placed for trifascicular block. He was discharged to a nursing home for rehabilitation and admitted on _%#MMDD2007#%_ with 2 episodes of TIAs which were manifested by monocular blindness in the left eye.
AVR|aortic valve replacement|AVR|208|210||He is being readmitted now with endocarditis showing necrosis around the aortic valve, extending up the aortic graft. Dr. _%#NAME#%_ _%#NAME#%_ was consulted for repair or replacement and he underwent a redo AVR with a tissue valve and ascending aortic repair. On _%#MMDD#%_ he underwent a redo sternotomy with excision of his aortic valve and conduit, debridement of the subannular cavity, and reconstruction of aortic annulus using bovine pericardium.
AVR|aortic valve replacement|AVR|265|267|SECONDARY DISCHARGE DIAGNOSES AND PAST MEDICAL HISTORY|SECONDARY DISCHARGE DIAGNOSES AND PAST MEDICAL HISTORY: 1. History of coronary artery disease, status post CABG in 1996 with LIMA to LAD, SVG to D1 and SVG to OM3. History of PCI in 1997 and 2003. PCI in 2003 was stent placement in SVG to OM3 graft. 2. Status post AVR in _%#MM2003#%_ at Mayo Clinic porcine aortic valve replacement. 3. Status post laparoscopic cholecystectomy. 4. History of CVA.
AVR|aortic valve replacement|AVR,|131|134|BRIEF HISTORY OF PRESENT ILLNESS|BRIEF HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is an 83-year-old male with a history of coronary artery disease, CVA and porcine AVR, who presented with abdominal pain radiating to his chest. The patient reported history of irritable bowel syndrome and he gets episodes of abdominal pain approximately 1 to 2 times per year.
AVR|aortic valve replacement|AVR|324|326|HOSPITAL COURSE|The coronary angiogram showed 70% left main disease, 50% diagonal 1-2 disease, totally occluded right coronary artery at its mid-portion that is filled by collaterals from the left anterior descending. CV Surgery was then consulted. It was recommended that the patient would need a 3-vessel coronary artery bypass graft and AVR once stable. The patient underwent coronary artery bypass grafting X4 and aortic valve replacement on _%#MMDD2006#%_.
AVR|aortic valve replacement|AVR,|257|260|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSES: 1. Empyema. 2. Congestive heart failure. 3. Obstructive sleep apnea. 4. Mental status changes. HISTORY OF PRESENT ILLNESS: This is a 75-year-old male with a past medical history of coronary artery disease, hyperlipidemia, hypertension, AVR, OSA, multiple subdural hematomas, and empyema, who presented to Fairview-University Medical Center with a change in mental status. The patient is confused and not oriented to circumstance, place, or time.
AVR|aortic valve resistance|AVR|143|145|PROCEDURES AND TESTS|Carotid ultrasound without stenosis. 3. Echocardiogram with sclerotic aortic valve with a peak gradient of 44, mean gradient of 26, calculated AVR of 0.9, consistent with moderate stenosis. Mild to moderate pulmonary hypertension. 4. Upper endoscopy by Dr. _%#NAME#%_ showing no ulcer disease, inability to intubate the duodenum, small hiatal hernia, small antral polyp.
AVR|augmented voltage right arm|AVR|140|142|LABORATORY ON ADMISSION|Urinalysis was not done in the Emergency Department and is pending. EKG reveals sinus rhythm at 63 beats per minute with Q waves in lead 3, AVR and AVF. There is poor R wave progression across the precordial leads with inverted T waves in the precordial leads, as well as some ST segment elevation.
AVR|aortic valve replacement|AVR|169|171|CHRONIC DISEASE/MAJOR ILLNESS|8. 1978 hysterectomy for abnormal pap 9. Varicose vein stripping in 1969. 10. Gravida 2, para 2 11. Remotely tonsillectomy CHRONIC DISEASE/MAJOR ILLNESS: 1. Status post AVR for aortic stenosis 2. Chronic anticoagulation therapy 3. Chronic pruritis related to chronic urticaria thought to be allergic 4. Migraine headaches REVIEW OF SYSTEMS: Is essentially negative, the patient has been generally feeling well.
AVR|augmented voltage right arm|AVR.|257|260|HOSPITAL COURSE|Bidirectional block was demonstrated. During the typical counterclockwise ablation, the patient did have another atypical atrial flutter seen in the SVC-RA junction. The morphology, however, was different with positive in the inferior leads and negative in AVR. The tachycardia was resistant to burst pacing. Since the flutter was not tachycardic, it was decided that he would be monitored for this pathway for now.
AVR|aortic valve replacement|AVR,|160|163|HISTORY OF PRESENT ILLNESS|Her wound dehiscence was treated with wet-to-dry dressing and was followed by ET nurse. She was restarted on Coumadin for anticoag due to history of mechanical AVR, which is being bridged with Lovenox pending therapeutic INR. She has no complaints during my evaluation.
AVR|aortic valve replacement|AVR,|216|219|ASSESSMENT AND PLAN|We will check iron panel and ferritin levels to assess the need for treatment with supplements. 4. Cardiovascular: History of aortic stenosis resulting in congestive heart failure in the past. Status post mechanical AVR, which was done in 1998. Now with compensated CHF. She is back on Coumadin. She is also on Lovenox pending therapeutic INR.
AVR|aortic valve replacement|AVR|217|219||She did have bilateral cellulitis of her shins which had cleared up with just some small open areas which were dry and clean. Her diabetes was treated aggressively with insulin, Protonix was started. She underwent an AVR with a 21 mm mosaic ultra-porcine valve and coronary artery bypass grafting x1 with a saphenous vein graft to RCA on _%#MMDD2007#%_.
AVR|augmented voltage right arm|AVR.|291|294|PROCEDURES|On the day of hospitalization, _%#MMDD2007#%_, white count 11.6, hemoglobin 10, platelet count is 364,000, BUN 47, creatinine 2.5, sodium 134, potassium 4.3. Liver function tests were unremarkable. EKG showed normal sinus rhythm, no acute changes with T-wave inversion in the aVL as well as AVR. A total of 35 minutes spent on this discharge.
AVR|aortic valve replacement|AVR.|237|240|ADMISSION DIAGNOSIS|ADMITTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD BRIEF HISTORY: The patient is a 57-year-old male who was recently discharged from the University of Minnesota Medical Center, Fairview, status post aortic root replacement and an AVR. The patient returned with a 1-day history of lightheadedness. He denied pain or any shortness of breath at the time of admission.
AVR|aortic valve replacement|AVR|176|178|PAST SURGICAL HISTORY|PAST MEDICAL HISTORY: 1. Hypertension. 2. Obesity. 3. Hypercholesterolemia. 4. Rheumatic heart disease. 5. Impotence. PAST SURGICAL HISTORY: 1. Aortic root replacement with an AVR in _%#MM#%_ 2006. 2. Rectal fissure repair in 1999. SUMMARY OF HOSPITAL COURSE: After evaluation in the emergency department, the patient was admitted to the University of Minnesota Medical Center, Fairview.
AVR|augmented voltage right arm|AVR,|156|159|OBJECTIVE|Her fingernails are thickened and discolored. NEURO: Cranial nerves II-XII are intact. EKG shows a normal sinus rhythm. She has some low voltage, Q wave in AVR, a biphasic QRS in 3. Labs are pending at the time of hospitalization. ASSESSMENT: This is a 62-year-old lady with metastatic breast cancer being controlled on Taxotere.
AVR|aortic valve replacement|AVR|111|113|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Unstable angina. 2. Coronary disease with prior CABG in 1986 and again in 1996 with an AVR at that time. 3. Status post stenting of the anastomosis of the saphenous vein graft to the distal right coronary artery this admission.
AVR|aortic valve replacement|AVR|195|197|PAST MEDICAL HISTORY|4. Osteoarthritis. 5. Osteoporosis. 6. Macular degeneration with retinal hemorrhage in _%#MM2004#%_. 7. Chronic stable anemia. 8. Primary pulmonary hypertension. 9. Cor pulmonale. 10. History of AVR with St. Jude's valve approximately 12 years ago. 11. Previous urinary tract infection. 12. Decreased hearing.
AVR|aortic valve replacement|AVR.|355|358|PAST MEDICAL HISTORY|REVIEW OF SYSTEMS: Constitutional, eyes, ENT, mouth throat, neck, respiratory, cardiovascular, GI, GU, musculoskeletal, neurologic, hematologic, endocrine, psychiatric, neurologic, allergic review of systems negative other than as listed above. PAST MEDICAL HISTORY: 1. History of MI. 2. Hypertension. 3. Status post T&A. 4. Anemia. 5. Tremor. 6. Porcine AVR. 7. CABG. 8. GI bleed secondary to diverticula _%#MM2002#%_. 9. Colonoscopy negative for malignant mass at that time. 10. Cataracts. FAMILY HISTORY: Unknown family history per patient report. SOCIAL HISTORY: The patient lives with her son and daughter-in- law.
AVR|aortic valve replacement|AVR.|118|121|FINAL DIAGNOSIS|2. Digoxin toxicity, status post Digibind therapy. 3. Diabetes mellitus type II. 4. Peptic ulcer disease, chronic. 5. AVR. Porcine valve. 6. Weakness. DISPOSITION: TCU for rehab. CONDITION: Stable. DNR/DNI.
AVR|aortic valve replacement|AVR|250|252|HISTORY OF PRESENT ILLNESS|5. History of mitral valve replacement and aortic valve replacement. 6. Deconditioning. HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old female with a history of gastric AVMs and chronic GI bleed with anemia currently on Coumadin for MVR and AVR secondary to rheumatic heart disease, history of coronary artery disease and hypothyroidism. She presented to the ER secondary to chest pain, shortness of breath, repeated hematemesis six days prior to admission and melena three days prior to admission.
AVR|augmented voltage right arm|AVR,|237|240|PHYSICAL EXAMINATION|ABDOMEN: Soft and nontender, no masses or hepatosplenomegaly. NEUROLOGIC: He is not responsive but he has doll's eyes, corneals, pupillary reflexes. He can move his extremities with painful stimuli. EKG shows artifact in leads I, II and AVR, but I do not see anything acute in the other leads. LABORATORY DATA: White count 11,200, hemoglobin 12.3, platelets 243,000, INR not seen in this lab, but recently it was 2.9, so his Coumadin had been decreased by 2.5 mg a week.
AVR|aortic valve replacement|AVR.|91|94|CHIEF COMPLAINT|CHIEF COMPLAINT: Transferred from Fairview Ridges Hospital for cardiac catheterization and AVR. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 72-year-old white male with past medical history significant for congestive heart failure, ischemic heart disease, paroxysmal atrial fibrillation, CVA and severe peripheral vascular disease, admitted to Fairview Ridges secondary to dyspnea on exertion.
AVR|aortic valve replacement|AVR.|591|594|ASSESSMENT/PLAN|Sodium 143, potassium 4.2, chloride 101, carbon dioxide 29, BUN 39, creatinine 1.9, glucose 113, magnesium 2.3. ASSESSMENT/PLAN: This is a 72-year-old white male with past medical history significant for ischemic heart disease, peripheral vascular disease, paroxysmal atrial fibrillation, CHF, hyperlipidemia, hypertension, and CVA, admitted to Fairview Ridges for CHF exacerbation. The patient's transthoracic echocardiogram showed severe aortic insufficiency/aortic stenosis. Subsequently the patient was transferred to Fairview Southdale Hospital for cardiac catheterization and possible AVR. PLAN: Cardiac catheterization (both right and left heart) today. Pending what the cardiac catheterization shows, the patient will be taken to the OR for aortic valve replacement, plus/minus coronary artery bypass grafting.
AVR|aortic valve replacement|AVR|191|193|HISTORY OF PRESENT ILLNESS|INR was also completed and was 1.9. The patient normally has his blood work completed at Dr. _%#NAME#%_'s office and was 2.7 last month. He has a past medical history of aortic stenosis with AVR and MAZE procedure with Dr. _%#NAME#%_ in _%#MM#%_ 2007 and also a left appendage excision at that time. He had recurrent atrial flutter and underwent a cardioversion and reverted back to atrial flutter following his MAZE procedure.
AVR|aortic valve replacement|AVR,|167|170|HISTORY OF PRESENT ILLNESS|He is here for rehab and ongoing medical care. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 60-year-old white male with history of St. Jude mechanical valve AVR, borderline diabetes, hyperlipidemia and depression. He was initially admitted to Methodist Hospital apparently on _%#MMDD2007#%_ with worsening headache after several falls at home.
AVR|aortic valve replacement|(AVR)|213|217|IMPRESSION|Sodium 135, INR 1.11. IMPRESSION: 1. Status post right-sided temporal craniotomy and excision of tumor. Pathology results showed right temporal lobe glioblastoma multiforme. 2. History of aortic valve replacement (AVR) with St. Jude mechanical valve. 3. Borderline diabetes. 4. Hyperlipidemia. 5. Depression. 6. Insomnia. The patient is hemodynamically stable at this time.
AVR|aortic valve replacement|AVR,|247|250|HOSPITAL COURSE|2. Hemodialysis in house. HOSPITAL COURSE: Please refer to the full-dictated H&P by Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD#%_. Briefly, Mr. _%#NAME#%_ is a 74-year-old male patient with severe cardiomyopathy, EF of 35-40%, chronic afib, status post AVR, end-stage renal disease on hemodialysis who presented with a 4-5 day history of dry cough, feeling ill with dyspnea with rigors and chills.
AVR|aortic valve replacement|AVR|190|192|DISCHARGING DIAGNOSES|2. Systemic hypertension. 3. Lower extremity edema related to congestive heart failure. 4. Severe chronic obstructive pulmonary disease with exacerbation. 5. Type 2 diabetes. 6. Status post AVR in 2006 with a tissue valve for which he is anticoagulated with aspirin. 7. History of cocaine abuse in the past as well as recent ETOH abuse per the H and P.
AVR|aortic valve replacement|AVR|502|504|PAST MEDICAL HISTORY|When the patient presented here on _%#MMDD2007#%_, he was trach doming with an FIO2 of 40% and capping during the day and he also had appointment with physical therapy and occupational therapy where he was walking with assistance and sitting out of bed in a chair b.i.d. The patient was DNR and he came with a right-sided chest tube and a jejunostomy that was placed in _%#MM2007#%_. PAST MEDICAL HISTORY: 1. Atrial fibrillation and flutter on anticoagulation. 2. Esophageal cancer with recurrence. 3. AVR in 2004. 4. Follicular lymphoma status post chemo in 1999. 5. Esophagectomy in 2000 with a repeat esophagogastric resection of squamous cell carcinoma of the esophagus at the anastomosis and gastric pull-up with esophagogastric anastomosis in the neck in _%#MM2007#%_.
AVR|aortic valve replacement|AVR|151|153|HISTORY OF PRESENT ILLNESS|He was last admitted to Fairview Southdale Hospital in _%#MM#%_ of 2007 and was to have an outpatient appointment with CV surgery for consideration of AVR coronary artery bypass grafting and carotid endarterectomy. The patient was then admitted to the VA Hospital three weeks ago with what seems as congestive heart failure, treated, and then released from there in a week and admitted to a nursing home in St. Louis Park.
AVR|aortic valve replacement|AVR|156|158|PROCEDURE PERFORMED|ADMISSION DIAGNOSES: 1. Aortic valve insufficiency with history of endocarditis. 2. Ascending aortic root aneurysm. PROCEDURE PERFORMED: On _%#MMDD2007#%_, AVR and aortic root replacement with composite graft (25 mm St. Jude mechanical valve conduit). CONSULTATIONS OBTAINED: 1. Neurology. 2. Cardiopulmonary rehab.
AVR|aortic valve replacement|AVR|159|161|HOSPITAL COURSE|A followup echocardiogram demonstrated worsening aortic insufficiency and a large vegetation. HOSPITAL COURSE: The patient was taken to the operating room. An AVR and aortic root replacement were performed with a 25-mm St. Jude mechanical aortic valve replacement. The patient was admitted to the Cardiovascular ICU for postoperative care and monitoring.
AVR|aortic valve replacement|AVR,|161|164|PAST SURGICAL HISTORY|ALLERGIES: Floxin and related compounds. MEDICATIONS: None PAST SURGICAL HISTORY: 1. Ulcer surgery times two with complications. 2. Status post MVR, status post AVR, both are tissue valves. PAST MEDICAL HISTORY: Chronic diseases - 1. Endocarditis 2. Peptic ulcer disease
AVR|augmented voltage right arm|AVR|133|135|HISTORY OF PRESENT ILLNESS|On exam, he was noted to be tachycardiac. EKG was obtained which showed sinus tachycardia rate of 110, with ST-T wave changes in the AVR lead. He is admitted at this time to investigate those EKG changes. He was sent by ambulance and Fairview Ridges emergency department was notified.
AVR|aortic valve regurgitation|AVR.|204|207|PHYSICAL EXAMINATION|Alert and oriented, bearded gentleman. No jugular venous distention, normal cranial nerves. Precordium, no heave or thrill. Thoracotomy scar noted, S-1 and S-2 both present. Prominent murmur keeping with AVR. Respirations - bilateral resonance and clear lung sounds. ABDOMEN: Soft and non-tender. Right lower quadrant scar. No peritoneal signs at present.
AVR|aortic valve replacement|AVR.|151|154|IMPRESSION|The patient will remain on beta blockers and will do prn. nitroglycerin drip 4. Congestive heart failure. No evidence at presence of decompensation 5. AVR. Will remain on Warfarin dosing per 6. Gastrointestinal bleeding, history of diverticulosis presently with no evidence of diverticulitis although he has an elevated neutrophil count.
AVR|augmented voltage right arm|AVR|225|227|EXAM|Also +1 edema lower extremities, +2 pulses upper. NEUROLOGICAL: Grossly with normal skin, no significant lesions noted. EKG shows nonspecific T-Wave abnormalities and flattening in the inferior leads. Q's in III, AVF and V1, AVR significant for probable old MI otherwise sinus rhythm. CT of her chest to rule out PE was done and did show enlarged perihilar lymph nodes and some granulomas which will be worked up during this admission.
AVR|aortic valve replacement|AVR|70|72||Mr. _%#NAME#%_ _%#NAME#%_ is a 77-year-old gentleman status post CAB, AVR _%#MMDD2007#%_ at Fairview Southdale Hospital with a complicated postop course with respiratory difficulty. He was sent to a TCU from the hospital and is now being readmitted on _%#MMDD2007#%_ with increased shortness of breath.
AVR|aortic valve replacement|AVR,|116|119|PRINCIPAL DIAGNOSIS|PRINCIPAL DIAGNOSIS: Congestive heart failure. _%#NAME#%_ _%#NAME#%_ 85-year-old white female with history of CABG, AVR, which is bovine, atrial fibrillation with pacer who presented to the Emergency Department with persistent cough for 24 hours. She was hospitalized in _%#MM#%_ with congestive heart failure. Echo at that point showed an ejection fraction of 45-50%.
AVR|aortic valve replacement|AVR.|152|155|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Congestive heart failure. 2. Renal insufficiency. 3. Type II diabetes mellitus. 4. History of endocarditis, status post MVR and AVR. BRIEF HISTORY: This is a 57-year-old male patient who has had an extremely prolonged hospital and rehabilitation stay for a variety of medical conditions.
AVR|aortic valve replacement|AVR|300|302|BRIEF HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSES: 1. End-stage congestive heart failure. 2. Prior mitral valve and aortic valve replacement requiring anticoagulation. 3. Acute renal insufficiency. 4. Anemia. BRIEF HISTORY OF PRESENT ILLNESS: This is a 46-year-old female with history of rheumatic heart disease, status post MVR, AVR and AICD placement, who presented to Cardiology Clinic with severe RV and LV dysfunction. She had noticed that for the previous month that she had had increased fatigue as well as shortness of breath, even at rest.
AVR|aortic valve replacement|AVR|145|147|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Is obtained from her husband, who reports: 1. Aortic valve stenosis and coronary artery disease. The patient is to have an AVR and coronary artery bypass today; however, this has been canceled. 2. Diabetes mellitus. 3. End-stage renal disease. 4. Hypertension. PHYSICAL EXAMINATION: On physical exam, temperature is 96.1, pulse 72, blood pressure 120/65.
AVR|aortic valve replacement|AVR|162|164|PAST MEDICAL HISTORY|His wounds have been healing well and he has not had fevers, chills or syncopal episodes. PAST MEDICAL HISTORY: 1. Aortic valve disease with recent bioprosthetic AVR _%#MMDD2004#%_. 2. Chronic renal insufficiency with acute renal insufficiency at the time of the last episode of pericardial tamponade. 3. History of pericardial tamponade one week ago, successfully drained with improvement of acute renal failure.
AVR|aortic valve replacement|AVR|262|264|HOSPITAL COURSE|He underwent coronary angiography demonstrating three vessel coronary artery disease, not particularly amenable to percutaneous revascularization. Given his moderate aortic stenosis and questionable symptoms from this, we elected to move forward with bypass and AVR rather than suboptimal revascularization by percutaneous mechanisms. The patient was seen by Dr. _%#NAME#%_ _%#NAME#%_ who is scheduling his surgery for Tuesday the _%#DD#%_ of _%#MM#%_.
AVR|aortic valve replacement|AVR|168|170|ASSESSMENT/PLAN|We will consult PT, OT, speech and social work. 2. Severe AS. The patient currently is severely debilitated by her disease and is functionally limited. She is planning AVR in near future. No evidence of pulmonary edema. We will monitor her I's and O's and daily weights and provide O2 p.r.n.
AVR|augmented voltage right arm|AVR.|160|163|PHYSICAL EXAM|There is no peripheral edema. Posterior tibialis pulses 1/2 bilaterally. SKIN - clear. NEURO - nonfocal. EKG - shows ST depression V4-V6, possible ST elevation AVR. CBC - the white count is 7.2 and hemoglobin 15.4, electrolytes are normal.
AVR|aortic valve regurgitation|AVR|214|216|HOSPITAL COURSE|Please refer to the patient's H and P for details on the rest of his history and physical. HOSPITAL COURSE: 1. Ascending aortic aneurysm status post aortic valve repair. On initial presentation the etiology of his AVR was unclear. He has been followed by the West Side Clinic who refilled the Coumadin for the patient. He only presented requesting a medication refill, as he had ran out.
AVR|aortic valve regurgitation|AVR.|377|380|HOSPITAL COURSE|He was quite suspicious and actually states that he did not return to West Side Clinic for medication refills because "my primary doctor hates me." He was begun on a heparin drip, and placed on Coumadin 5 mg p.o. q.d. as the right dosage of his Coumadin was unknown. Medical records were obtained from the West Side Clinic and there was still no clear etiology for his initial AVR. He had been noted to be sub-therapeutic on multiple occasions, when reviewing the medical records, since _%#MM#%_ of 2002. He also had been presenting to the West Side Clinic for similar complaints of running out of medications and needing medication refills.
AVR|aortic valve replacement|AVR|214|216|HOSPITAL COURSE|In fact, he had been requesting a new heart, and that was one of the reasons why he presented. In any event, old records from _%#CITY#%_, New York were obtained, and they demonstrated that the patient underwent an AVR secondary to worsening ascending aortic aneurysm with a worsening aortic insufficiency. The patient had been asymptomatic at the time, but has been documented to have a worsening AI based on the repeat echo and CT scans.
AVR|aortic valve replacement|AVR,|189|192|HOSPITAL COURSE|Nevertheless, the patient continues to accuse the surgeons of using him as a guinea pig, and that the surgery was not necessary. Given his high gradient he would be considered for a repeat AVR, and this was also discussed with Dr. _%#NAME#%_ of CV staff here. At any rate, medical records from the West Side Clinic were obtained, and they did state that the patient had been on Coumadin at 10 mg p.o. q.d. on three days of the week, and 8.5 mg p.o. q.d. on other days.
AVR|aortic valve replacement|AVR|207|209|HOSPITAL COURSE|He will be sent down on Coumadin 8 mg p.o. q.d. to simplify his dosage with titration as an outpatient. His INR prior to discharge was 2.37. He will follow with Dr. _%#NAME#%_ to reassess the possibility of AVR in the near future given the high valve gradient and likely worsening aortic stenosis. The patient is reluctant, and actually opposed to having a repeat surgery regardless of worsening heart failure or death.
AVR|aortic valve replacement|AVR|133|135|PAST MEDICAL HISTORY|Status post chemotherapy and XRT, diagnosed in _%#MM2002#%_, had been considered in remission, but recent CT as above. 3. History of AVR and chronic atrial fibrillation. She has been cardioverted twice without sustained response. Echo done in _%#MM2003#%_ showed an ejection fraction of 50%.
AVR|aortic valve replacement|AVR|199|201|DIAGNOSES|Dr. _%#NAME#%_ _%#NAME#%_ is going to speak with the receiving physician prior to transfer. DIAGNOSES: 1. Relapsing idiopathic chronic pancreatitis. 2. Organic heart disease, with history of CAB and AVR in _%#MM2001#%_. 3. History of acute respiratory failure associated with pneumonia, pleural effusion, and intubation. He also has had chest tubes placed in the past.
AVR|aortic valve replacement|AVR.|162|165|CHRONIC DISEASES|8. Lasix 60 mg daily. CHRONIC DISEASES: 1. Congestive heart failure. 2. Diabetes. 3. Hypertension. 4. Coronary artery disease. 5. Aortic stenosis. 6. Status post AVR. 7. Benign prostatic hypertrophy. 8. Presbycusis. 9. Degenerative joint disease of the spine. 10. Diverticulosis. 11. TIA. OPERATIONS AND HOSPITALIZATIONS: 1. Bypass times five. 2. Aortic valve replacement.
AVR|aortic valve replacement|AVR.|199|202|ASSESSMENT|2. Congestive heart failure. 3. Diabetes. 4. Hypertension. 5. Coronary artery disease. 6. Benign prostatic hypertrophy. 7. Presbycusis. 8. Osteoarthritis. 9. Diverticulosis. 10. TIA. 11. Status post AVR. 12. Status post appendectomy. 13. Cervical fusion. 14. Shoulder surgery. 15. Prosthetic right eye. PLAN: 1. Admit. Address ourselves to the bronchospasm. 2. Check echocardiogram and BNP.
AVR|aortic valve replacement|AVR|276|278|HISTORY|It sounds very much like a cardiac arrest with resuscitation successfully applied by a bystander who happened to be a Medtronic representative, whose name I do not know, nor do Mrs. _%#NAME#%_ and/or her friend. _%#NAME#%_ _%#NAME#%_ is a 70-year-old woman who is status post AVR tissue valve in _%#MM#%_, 2002, at which time single vessel bypass using a mammary artery was performed, I presume to the LAD.
AVR|aortic valve replacement|AVR|145|147|CONCLUSION|She has no bruits over the femorals and has good posterior tibial pulses with 1 to 2+ pedal edema. CONCLUSION: 1. Cardiac arrest in patient with AVR two years old this past _%#NAME#%_, pacemaker in _%#NAME#%_ of 2004, and history of asthma and paroxysmal atrial fibrillation.
AVR|augmented voltage right arm|AVR,|157|160|OBJECTIVE|No lower extremity edema. Neuro: Cranial nerves II-XII intact. Patellar reflexes 3-4, symmetric. Station and gait is grossly normal. EKG shows Q waves in 3, AVR, AVF and complete bundle branch block V1 through V4. Did manage to get a copy of an old EKG from about 10 years ago and at that point it was normal in appearance and potassium is pending.
AVR|aortic valve replacement|AVR.|151|154|ADMISSION DIAGNOSIS|HISTORY OF PRESENT ILLNESS: The patient is a 5-month-old male with Down syndrome. He was 1 day status post endotracheal tube for PE tube placement and AVR. The patient had been discharged that following morning on _%#MM#%_ _%#DD#%_, 2004, following successful PE tube placement and successful AVR; however, he began to have increased stridorous breathing with increased inspiratory sounds and became very upset; subsequently, mother was concerned about some difficulty with feeding and the onset of a paler color; subsequently she brought him to the emergency room.
AVR|aortic valve replacement|AVR;|211|214|ADMISSION DIAGNOSIS|He was 1 day status post endotracheal tube for PE tube placement and AVR. The patient had been discharged that following morning on _%#MM#%_ _%#DD#%_, 2004, following successful PE tube placement and successful AVR; however, he began to have increased stridorous breathing with increased inspiratory sounds and became very upset; subsequently, mother was concerned about some difficulty with feeding and the onset of a paler color; subsequently she brought him to the emergency room.
AVR|augmented voltage right arm|AVR|116|118|LABS ON ADMISSION|Troponin and myoglobin negative. EKG was sinus at 83 with a normal axis and widened QRS's with Q waves in 3 AVF and AVR which are old. QRS is also wide on old EKG from _%#MM#%_ 2004 but is worsened on his current EKG. ASSESSMENT/PLAN: A 66-year-old gentleman with known coronary artery disease, status post bypass, who presents with an episode of SVT resolved in the ER with associated chest pain.
AVR|aortic valve replacement|AVR|143|145|PROBLEM #4|The patient was afebrile 24 hours prior to his discharge. The patient required no antibiotics. PROBLEM #4: INR. The patient is on Coumadin for AVR and MVR replacement, along with atrial fibrillation. We did discuss the patient's anticoagulation situation with Cardiology, and they decided that his INR should be between 2.5 and 3.5, and try to be closer to the 2.5 range due to his history of bleed.
AVR|augmented voltage right arm|AVR.|199|202|ELECTROCARDIOGRAM|SKIN: Warm and dry. NEUROLOGIC: Cranial nerves II through XII intact. LABORATORY DATA: Hemoglobin 13.5, WBC 7900, potassium pending. ELECTROCARDIOGRAM: Revealed normal sinus rhythm with a Q- wave in AVR. ASSESSMENT: The patient is a 60-year-old lady coming in for elective right hip replacement.
AVR|aortic valve replacement|AVR|229|231|HISTORY OF PRESENT ILLNESS|2. Successful angioplasty of the proximal right coronary artery. 3. Successful angioplasty of the left main. HISTORY OF PRESENT ILLNESS: A 71-year-old gentleman with coronary artery disease, status post CABG x5 and bioprosthetic AVR in 2001 and previous PCI of RCA and LAD presenting to the hospital with unstable angina without troponin elevation.
AVR|aortic valve replacement|AVR|74|76|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 27-year-old male status post AVR on _%#MM#%_ _%#DD#%_, 2005, presenting with fever of 101.7 and periodic chest pain with radiation to back and neck. The patient's substernal pain has improved throughout the day. He denies shortness of breath, orthopnea, or cough.
AVR|aortic valve replacement|AVR|170|172|HOSPITAL COURSE|The patient, in regards to her pleural effusion, had a chest CT, and it was felt that the patient was not a great candidate for thoracentesis secondary to her mechanical AVR and allergy to heparin. The patient's diuresis continued during her hospitalization. Patient with slightly cloudy urine today. We will obtain a UA/UC prior to discharge. It is recommended that the patient be discharged home with nocturnal oxygen.
AVR|aortic valve replacement|AVR|228|230|TRANSFERRING DIAGNOSES|2. Complex wound management of the left lower extremity thigh and hip for debulking of tumor masses with a recurrent non-Hodgkin's lymphoma in _%#MM2004#%_. 3. Has recently received CHOP and Rituxan chemotherapy. 4. Status post AVR 1998 with subsequent infection in a replacement valve in 1999 with a porcine valve. AICD was implanted at that time. 5. Chronic renal insufficiency.
AVR|aortic valve replacement|AVR.|144|147|PAST MEDICAL HISTORY|He was seen in the emergency room and transferred here for repeat dilatation. PAST MEDICAL HISTORY: 1. Hypertension. 2. Mitral valve repair. 3. AVR. 4. Congestive heart failure. PHYSICAL EXAMINATION: At rest, his respiratory status is stable.
AVR|augmented voltage right arm|AVR.|238|241|LABORATORY|There was a large right pleural effusion noted and an infiltrate at the right medial lung apex. Chest x-ray also showed large right pleural effusion. EKG showed normal sinus rhythm with a rate of 75, some inverted T waves in V1, AVL, and AVR. HOSPITAL COURSE: The patient was admitted to the floor in stable condition.
AVR|aortic valve replacement|AVR,|96|99|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms _%#NAME#%_ is a 66-year-old female with history of ASCVD, recent AVR, and COPD who was admitted with a 1-week history of productive brown sputum, decrease in appetite, headache, general malaise, as well as fever. On admission, chest x-ray revealed a left-sided pneumonia. She was admitted to the medicine service.
AVR|aortic valve replacement|AVR|215|217|PAST  MEDICAL HISTORY|4. Herniorrhaphy. 5. Bicuspid aortic valve with significant aortic regurgitation, status post Ross procedure in 1994. 6. Ascending thoracic aortic aneurysm. 7. Redo open heart surgery _%#MMDD2006#%_ with mechanical AVR and repair of thoracic aortic aneurysm. 8. Dilated cardiomyopathy secondary to significant aortic insufficiency. 9. HSV. 10. History of hepatitis B exposure. FAMILY HISTORY: Brother with valvular heart disease.
AVR|aortic valve replacement|AVR,|152|155|OPERATIONS PERFORMED|10. Status post appendectomy and umbilical hernia repair. OPERATIONS PERFORMED: On _%#MMDD2006#%_ the patient had the following operations: 1. CAB x 1, AVR, triple A repair, exploration of mitral valve. HISTORY OF PRESENT ILLNESS: This is a 74-year-old female who has multiple cardiac risk factors.
AVR|aortic valve replacement|AVR|202|204|HOSPITAL COURSE|The patient will be discharged to home today per GI consult recommendations. With regard to the other medical issues, the patient has been stable. He is known to have diabetes mellitus, hypothyroidism, AVR and hyperlipoidemia. His anemia was attributed to GI bleed. His hemoglobin remained stable between 9 and 10 during this hospital course.
AVR|aortic valve replacement|AVR.|122|125|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Wound dehiscence after total knee arthroplasty. 2. Complicated by wound infection. 3. Status post AVR. 4. Diabetes mellitus. 5. Hypothyroidism treated with replacement therapy. DISCHARGE MEDICATIONS : Please see transfer form.
AVR|aortic valve replacement|AVR|132|134|REVIEW OF SYSTEMS|She denies any weight loss and actually reports some weight gain. Cardiovascular: Per history of present illness, with a history of AVR and ascending aorta dissection repair. Respiratory: No cough but does report some increasing dyspnea on exertion. GI: Per history of present illness. Genitourinary: No frequency or dysuria.
AVR|aortic valve replacement|AVR|170|172|OPERATIONS/PROCEDURES PERFORMED|He was unable to straighten his knee all the way. He denied any numbness or tingling in his right lower extremity. On admission his INR was 5.0. PAST MEDICAL HISTORY: 1. AVR _%#MM#%_ 2002 secondary to bicuspid aortic valve with severe aortic insufficiency. 2. Multiple hospitalizations secondary to cocaine abuse. 3. Hypertriglyceridemia.
AVR|augmented voltage right arm|AVR.|177|180|PHYSICAL EXAMINATION|NEUROLOGIC: Exam is unremarkable. On EKG there is sinus rhythm with Q-wave noted specifically in III and AVF. He also has inverted T-waves in I and AVL and flattened T-waves in AVR. LABS: Show a TSH Of 1.31, troponin of less than 0.07. Basic metabolic panel is normal with a creatinine of 1.
AVR|augmented voltage right arm|AVR|224|226|LABORATORY AND DIAGNOSTIC STUDIES ON ADMISSION|LABORATORY AND DIAGNOSTIC STUDIES ON ADMISSION: Chest x-ray was reviewed by me and showed normal heart size and no infiltrates. EKG was reviewed by me with atrial fibrillation at a rate of 101 with T-wave inversions in III, AVR and AVF, no Q-waves and no previous EKG available for comparison. CBC, basic metabolic panel, troponin, myoglobin and BNP are all normal, TSH pending.
AVR|augmented voltage right arm|AVR|167|169|ASSESSMENT/PLAN|EKG was just repeated and showed sinus rhythm at 70 beats/minute with first-degree AV block with PR interval of 216. He otherwise does have inverted T in lead III and AVR with some downsloping T-segment in AVF. We will not initiate anticoagulation. The patient did not have a significantly high rate. We will consult Cardiology to discuss whether the patient should be on long-term anticoagulation or anti-arrhythmic medications given this episode and the advisability of driving.
AVR|aortic valve replacement|AVR|151|153|HOSPITAL COURSE|The patient was discharged in stable condition with an INR of 1.98. The plan was to recheck her INR in 2 to 3 days to achieve a goal of 2.5 to 3.5 for AVR anticoagulation. Her hemoglobin was also stable at 9.9 at the time of discharge. DISCHARGE MEDICATIONS: 1. Atorvastatin 80 mg p.o. q. day.
AVR|augmented voltage right arm|AVR,|149|152|ASSESSMENT|Her surgical risk would be much higher for general anesthesia. EKG shows a bradycardic sinus rhythm, no acute changes aside from a Q-wave in III and AVR, I do not have an old one to compare it to. The patient will continue with her usual medications.
AVR|augmented voltage right arm|AVR|153|155|IMPRESSION|The EKG by the way is reviewed from this morning and is actually a normal trace with a minor right-sided conduction delay has expressed by an R prime in AVR in lead 1. The rhythms in the emergency room were sinus and/or sinus tachycardia. The blood pressures in the emergency room were 137/88. The location of the discomfort, that I didn't describe his left chest and about the size of a tennis ball as he describes it.
AVR|augmented voltage right arm|AVR.|198|201|PHYSICAL  EXAMINATION BEFORE DISCHARGE|No parasternal heave. ABDOMEN: Unremarkable. EXTREMITIES: No peripheral edema. Repeat EKG on _%#MMDD#%_ showed ST segment is coming down in most of the lead and with some T-wave inversion in V1 and AVR. QRS morphology is largely normal, but there is some suggestion of left access deviation and left anterior fascicular block and his cardiac enzymes as listed above and are coming down.
AVR|aortic valve replacement|AVR|199|201|CHRONIC DISEASE/MAJOR ILLNESS|HABITS: Non-smoker and non-drinker. ALLERGIES: Proton pump inhibitors. CURRENT MEDICATIONS: As listed in medicine reconciliation lit. CHRONIC DISEASE/MAJOR ILLNESS: 1. Senile dementia. 2. History of AVR 9 years ago related to aortic insufficiency. 3. Chronic anticoagulation with Coumadin due to her prosthetic valve. 4. Hypothyroidism, treated with replacement therapy. 5. DJD, status post total knee arthroplasty.
AVR|aortic valve replacement|AVR|181|183|ASSESSMENT|ASSESSMENT: 1. Recurrent upper GI bleed of uncertain etiology with stable hemoglobin at this time in the 9 range. The patient appears to be asymptomatic at this time. 2. History of AVR with stable cardiac function. 3. History of atrial fibrillation, now normal sinus rhythm by EKG. 4. Senile dementia of moderate severity, most likely Alzheimer's type.
AVR|aortic valve replacement|AVR|255|257|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Shortness of breath and fever. HISTORY OF PRESENT ILLNESS: This is a 63-year-old female well known to our service with a history known for COPD, chronic chest pain, presumably in part due to critical aortic stenosis, status post a bovine AVR on _%#MMDD2005#%_ at the University of Minnesota, who had been doing fairly well and actually had been titrated off oxygen since her AVR up until a few days ago when she developed generalized malaise, subjective fevers, chills and progressive shortness breath. She has noted increasing dyspnea especially with exertion. It has gotten to the point where she is developing progressive yellowish phlegm.
AVR|aortic valve replacement|AVR|392|394|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Shortness of breath and fever. HISTORY OF PRESENT ILLNESS: This is a 63-year-old female well known to our service with a history known for COPD, chronic chest pain, presumably in part due to critical aortic stenosis, status post a bovine AVR on _%#MMDD2005#%_ at the University of Minnesota, who had been doing fairly well and actually had been titrated off oxygen since her AVR up until a few days ago when she developed generalized malaise, subjective fevers, chills and progressive shortness breath. She has noted increasing dyspnea especially with exertion. It has gotten to the point where she is developing progressive yellowish phlegm.
AVR|aortic valve replacement|AVR|128|130|HISTORY OF PRESENT ILLNESS|This headache relieved easily with Tylenol. She was also complaining of ongoing weakness and also fatigue pretty much since her AVR and CABG procedure in _%#MM2006#%_. She also complained of decreased appetite and also early satiety, which has a temporal correlation with the timing of the surgery as well.
AVR|augmented voltage right arm|AVR|213|215|IMPRESSION, REPORT AND PLAN|Prior to cardioversion she has a wide complex tachycardia which is regular and in V1 appears to have a right bundle morphology. Post-cardioversion she has ST depressions laterally, as well as some ST elevation in AVR only and no other leads. She has remained in a normal sinus rhythm. She is chest pain-free. Her ECG findings certainly would be consistent with ventricular tachycardia or with a SVT with aberrancy.
AVR|aortic valve replacement|AVR.|265|268|ASSESSMENT AND PLAN|Also check a peripheral smear. She has already gotten at least one unit of blood at this time and I am unsure if a reticulocyte count would help. Check iron studies in the morning. 2. Anemia. Normocytic indices as above. Assessment and plan as above. 3. History of AVR. Continue Coumadin per Pharm D. goal inr 2.5-3.5. 4. Morbid obesity. 5. Recent right hip fracture, status post ORIF. Resume PT and OT. 6. Diabetes mellitus, type 2. Continue Novolin 70/30 with 45 units in the morning and 30 units in the evening.
AVR|augmented voltage right arm|AVR.|108|111|OBJECTIVE|EKG and rhythm strip shows a bigeminy. I do not have an old EKG to compare it to. She does have a Q wave in AVR. LABORATORY: Not done here. ASSESSMENT: This is a 69-year-old lady with a non healing fracture of the right tibia.
AVR|aortic valve replacement|AVR.|256|259|HOSPITALIZATION COURSE|The patient was monitored and then sent home and returned on this hospitalization for elective repair of his aortic root aneurysm. HOSPITALIZATION COURSE: The patient presented on _%#MMDD2007#%_ for elective repair of his aortic root aneurysm and possible AVR. The patient was consented for this procedure and underwent this procedure on this date without any noted complications. For further details of this procedure, please refer the operative note did on _%#MMDD2007#%_.
AVR|aortic valve replacement|AVR|105|107|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. History of a bicuspid aortic valve with a Mosaic tissue valve replacement and an AVR repair on _%#MMDD2007#%_. 2. Postop atrial fibrillation for which he is on amiodarone. 3. Hypothyroidism, which was thought to be subclinical, but he was placed on thyroid medication during hospitalization, but this has been discontinued and thought to be an euthyroid sickness.
AVR|aortic valve replacement|AVR|232|234|PROBLEM # 9|He was distracted to a total of 23.25 mm. Distraction hardware is to be left on for six weeks total, and he should remain on Keflex while it is place. External hardware was placed on _%#MMDD#%_ with plastic rods. The patient had an AVR in the OR on _%#MMDD2002#%_ that showed a moderate 5 to 60 db hearing loss, which is partially conductive, and he will need to be followed up on that.
AVR|aortic valve replacement|AVR|184|186|PAST MEDICAL HISTORY|1. Dilated cardiomyopathy secondary to valvular disease. Echo of _%#MMDD2000#%_ revealed an EF of 25%, with bilateral atria enlargement. 2. Rheumatic heart disease, assessed with MVR, AVR in 1986. 3. CHF. 4. Atrial fibrillation and atrial tachycardia, assessed with cardioversion _%#MM2001#%_. 5. Status post AICD _%#MM1999#%_, with revision _%#MMDD2001#%_.
AVR|aortic valve replacement|AVR|125|127|PAST MEDICAL HISTORY|He generally feels weak during these episodes. The episodes usually last 25-30 minutes. PAST MEDICAL HISTORY: 1. Status post AVR on _%#MMDD2002#%_. 2. Status post pericardial effusion with pericardial window on _%#MMDD2002#%_. Cultures from this grew out staph for which he is taking nafcillin.
AVR|aortic valve replacement|AVR|211|213|HISTORY OF PRESENT ILLNESS|1. Orthotopic cardiac transplantation with bi-atrial anastomosis. 2. AICD placement. 3. Novardis study ERL080A2401. 4. Oral antibiotic therapy. HISTORY OF PRESENT ILLNESS: This is a 52-year-old male status post AVR and MVR secondary to rheumatic heart disease, who was admitted after a right heart catheterization with a history of CHF and recent placement of biventricular pacer.
AVR|aortic valve replacement|AVR,|119|122|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Rheumatic heart disease. 2. Cardiomyopathy secondary to valvular disease, status post MVR and AVR, and AICD placed in 1995. 3. Status post cardiac catheterization with pacer placed recently. DISCHARGE INSTRUCTIONS: 1. Follow up with the Cardiac Service on Thursday, _%#MMDD2002#%_ for another biopsy, a right internal jugular ultrasound, a cardiac echocardiogram, and for adjustment of any medications.
AVR|aortic valve replacement|AVR.|424|427|HOSPITAL COURSE|HOSPITAL COURSE: On arrival to the emergency department, the patient was still sedated, found to be in sinus rhythm; and the ER neurological consultation concluded agitation with delirium, and that he should monitored in the intensive care unit. Initial laboratory studies revealed a slightly elevated white count, normal hemoglobin, normal electrolytes, and an INR of 2.63. The patient had been on Coumadin for status post AVR. The patient was admitted to the intensive care unit for further monitoring.
AVR|aortic valve replacement|AVR,|224|227|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient originally had his surgery on the _%#MMDD#%_ with a subsequent hematoma and bleeding problems at the surgical site. The patient had been anticoagulated before surgery for his St. Jude AVR, and anticoagulation was stopped prior to surgery. However, anticoagulation was restarted postoperatively. He has required a total of 4 units of packed cells while in the hospital prior to transfer to Rehab with his hemoglobin low, being 7.6. Neurologically, he was intact in the hospital setting, though did complain mostly of some left foot burning and numbness.
AVR|aortic valve replacement|AVR.|135|138|PAST MEDICAL HISTORY|The patient is on chronic anticoagulation with warfarin for this. 3. History of severe CHF and left ventricular dysfunction before his AVR. Apparently, the ejection fractions were in the 10-25% between _%#MMDD#%_ and _%#MMDD#%_. An echocardiogram per the patient, was done earlier this month with a report unavailable.
AVR|aortic valve replacement|AVR|130|132|FAMILY HISTORY|7. History of hemorrhoids which are not currently a problem. ALLERGIES: Zantac. FAMILY HISTORY: The patient's mother underwent an AVR replacement many years ago and, apparently, died of complications of anticoagulation. The patient's father died of leukemia at age 48 years old.
AVR|aortic valve replacement|AVR|175|177|IMPRESSION AND PLAN|2. Anemia secondary to postoperative bleeding and anticoagulation. Hemoglobin is currently 9.7 and we are awaiting today's result. We will closely monitor this. 3. History of AVR _%#MM2001#%_ with St. Jude metallic valve requiring anticoagulation. The patient states his anticoagulation INR goals were 2.5 - 3.5 at home.
AVR|aortic valve replacement|AVR,|156|159|DISCHARGE SUMMARY AND DIAGNOSIS|6. Darvocet N100 1-2 tablets every four hours prn pain. DISCHARGE SUMMARY AND DIAGNOSIS: 1. Aortic stenosis, status post homograft composite replacement of AVR, aortic root, and ascending aorta. 2. Hypertension. 3. Dyslipidemia, volume overload requiring diuresis. 4. Postoperative anemia that did not require a transfusion.
AVR|aortic valve replacement|AVR.|80|83|PRINCIPAL DIAGNOSES|PRINCIPAL DIAGNOSES: 1. Aortic stentless valve stenosis. 2. Status post MVR and AVR. OPERATIONS/PROCEDURES PERFORMED: Re-do aortic valve replacement.
AVR|augmented voltage right arm|AVR.|403|406|HISTORY OF PRESENT ILLNESS|She reports that she has had similar chest pain for the past several years and has been treated presumptively for coronary artery disease with beta blockers and Isordil in the past. In the Emergency Room today her first troponin was 3.13; the second troponin here in the Cardiac Intensive Care Unit was 6.16. EKG shows normal sinus rhythm with some flattening of the ST segment in lateral leads AVL and AVR. PAST MEDICAL HISTORY: 1) Colon carcinoma resected in _%#MM#%_, 1995, no recurrence to date.
AVR|aortic valve replacement|AVR.|226|229|PLAN|Risks, indications, benefits and alternatives were discussed with the patient. PLAN: The plan is to proceed with left heart catheterization with coronary angiography with anticipation of then a surgical consultation regarding AVR. Thank you for allowing me to see this gentleman. Please do not hesitate to call me if you have any questions.
AVR|aortic valve replacement|AVR|186|188|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: His past medical history is significant for nonischemic dilated cardiomyopathy with ejection fraction less than 15% and a normal cath in _%#MM#%_ 2003. Status post AVR with porcine valve on _%#MM#%_ _%#DD#%_, 2003, on Coumadin. Pulmonary hypertension with PA pressures of 89/40 without medications and a wedge of 26.
AVR|aortic valve replacement|AVR|196|198|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease. 2. Osteopenia. 3. Abdominal aortic aneurysm repair. 4. Significant coronary artery disease. 5. Coronary artery bypass grafting with AVR replacement in 1993. 6. Moderate to severe mitral and tricuspid insufficiency. 7. Moderate pulmonary hypertension with questionable secondary causes to his chronic obstructive pulmonary disease.
AVR|aortic valve replacement|AVR|135|137|DIAGNOSES|He has had colonoscopy, esophagoscopy, CT scan without identifying source of blood. 3. He has had bypass grafting in 1995 or so and an AVR placed in 1988. 4. As I review his records, the INR was down to 1.1 on _%#MMDD#%_. 5. As I review his EKG, he has right bundle branch block, intermittent atrial fibrillation and intermittent sinus arrest.
AVR|rapid ventricular response:RVR|AVR.|171|174|LABORATORY|Sodium 137, potassium 4.1,chloride 96, bicarbonate 26, BUN 52, creatinine 1.83, glucose 493. Chest x-rays do not show any infiltrates. EKG showed atrial fibrillation with AVR. UA showed more than 1000 glucose, moderate bilirubin, trace ketones, no blood. Albumin 30. No nitrates or leukocyte esterase. Twelve wbc's, no rbc's, 5 to 10 hyaline casts.
AVR|aortic valve replacement|AVR|131|133|HOSPITAL COURSE|Intraoperatively the decision was made to replace the mitral valve. On the date of surgery, _%#MMDD2004#%_, he underwent CABG x 4, AVR and MVR and came through it without any complications. He was able to be weaned off the sedation and extubated on postoperative day #1, and was transferred up to the floor on postoperative day #3.
AVR|aortic valve replacement|AVR.|129|132|OPERATIONS/PROCEDURES PERFORMED|PAST MEDICAL HISTORY: 1. Congestive heart failure with an EF of 35%. 2. Hypertension. 3. Chronic atrial fibrillation. 4. MVR. 5. AVR. 6. Left bundle branch block. 7. Status post appendectomy. 8. Semi-emergent tracheostomy on _%#MM#%_ _%#DD#%_, 2004, secondary to failed extubation.
AVR|aortic valve replacement|AVR.|159|162|PLAN|I will ask Dr. _%#NAME#%_ to consider a flexible sigmoidoscopy to evaluate the cause of his bleed. Currently, he remains hemodynamically stable. 2. History of AVR. Given his risk for valve thrombosis, I would restart him on Coumadin today. There are no signs of active bleeding. 3. Thrombocytopenia. Somewhat chronic based on SCIS labs.
AVR|aortic valve replacement|AVR|173|175|PLAN|The patient is a 78-year-old female admitted to the rehab unit on _%#MMDD2005#%_, discharged _%#MMDD2005#%_. The patient's chief complaints were deconditioning, status post AVR with a vessel bypass. The patient also had ASCVD and AS. The patient was seen by therapies, did well, independent with dressing, toileting, uses a walker and a cane, now mainly with a cane without difficulty.
AVR|aortic valve replacement|AVR|141|143|PAST SURGICAL HISTORY|5. Hypertension. 6. Polymyalgia rheumatica. 7. Chronic renal insufficiency. 8. Baseline creatinine is 2. PAST SURGICAL HISTORY: CABG x 1 and AVR on _%#MMDD2004#%_. ADMISSION MEDICATIONS: 1. Lasix 80 mg p.o. b.i.d. (held for 2 days prior to admission due to her nausea, vomiting, and lightheadedness).
AVR|augmented voltage right arm|AVR,|927|930|LABORATORY DATA|As stated above, he had undergone successful angioplasty and stenting of the middle left anterior descending artery with a Cypher drug-eluting stent (3.0 X 33 mm), PTCA and stenting of the proximal LAD with a 3.5 X 18 mm Cypher drug-eluting stent, PTCA and stenting with a 2.75 X 18 mm Taxus stent to the OMII, PTCA and cutting balloon angioplasty with a 3.0 X 18 mm Cypher drug-eluting stent to severe osteo/proximal second obtuse marginal artery lesion, and PTCA and stent placement with a 2.5 X 18 mm Cypher drug-eluting stent to the distal circumflex. Mr. _%#NAME#%_ has been pain-free since his intervention. LABORATORY DATA: His discharge lab results show a hematocrit of 38, a platelet count of 446,000, hemoglobin of 13.1, potassium 4.4., BUN of 15, and a creatinine of 1.16 with a small troponin leak of 5.49. An electrocardiogram demonstrates a normal sinus rhythm at a rate of 72 with T-wave inversion in leads III, AVR, and when compared to a previous one, there has been no acute change. DISCHARGE MEDICATIONS: 1. Plavix 75 mg po daily. 2. Aspirin 81 mg po daily.
AVR|aortic valve replacement|AVR.|143|146|ASSESSMENT|ASSESSMENT: 1. Extreme bradycardia representing sick sinus syndrome versus third degree AV block versus too much beta blockade. 2. Status post AVR. 3. Chronic anti-coagulation. 4. Uterine cancer status post hysterectomy. 5. Rectal cancer status post AP resection colostomy. 6. Status post video-assisted thoracoscopy for benign disease.
AVR|augmented voltage right arm|AVR|119|121|LABORATORY DATA|Review of the EKG done in the emergency room reveals sinus tachycardia with a rate of 104. The P-waves are inverted in AVR and V1 though V2. They are biphasic in V3 and V4. This suggests left atrial enlargement and underlying significant lung disease.
AVR|aortic valve replacement|AVR|250|252|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 66-year-old gentleman with a past medical history significant for Wagener granulomatosis who also has end-stage kidney disease and is hemodialysis dependent. Additionally, he had a history of SBE with subsequent AVR and MVR in 2001. When he is symptomatic from his Wegener and having a relapse, he generally has diffuse myalgias and an elevated C-ANCA.
AVR|augmented voltage right arm|AVR.|274|277|HISTORY OF PRESENT ILLNESS|In the Emergency Room at Fairview Ridges Hospital, EKG showed atrial fibrillation with rapid ventricular response. She underwent DC cardioversion and was converted to normal sinus rhythm and follow-up EKG showed ST segment elevation in II, III and AVF, and ST depression in AVR. HOSPITAL COURSE: She was transferred emergently to Fairview Southdale Hospital.
AVR|aortic valve replacement|AVR,|205|208|HISTORY OF PRESENT ILLNESS|Prosthetic valve in aortic position with a mean gradient of 16 mmHg. No pericardial effusion. Moderate mitral regurgitation. HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old male with a history of AVR, atrial fibrillation, nonischemic cardiomyopathy with a known EF of 25% to 30%. He is followed by Dr. _%#NAME#%_ _%#NAME#%_. He came in and was admitted on _%#MM#%_ _%#DD#%_, 2005, with an episode of unresponsiveness, which happened 2 days prior to the admission.
AVR|aortic valve replacement|AVR.|188|191|DISCHARGE INSTRUCTIONS|4. Patient is to follow up regarding the biopsy at 7:30 a.m. on _%#MM#%_ _%#DD#%_, 2005. Patient knows to go to the cath lab for this. PAST MEDICAL HISTORY: 1. Significant for status post AVR. 2. Status post severe MR. 3. History of GI bleed of unclear etiology. 4. Afib/A-flutter. 5. Patient has had biventricular ICD x3 that had to be replaced secondary to infections.
AVR|augmented voltage right arm|AVR|231|233|PHYSICAL EXAMINATION|EXTREMITIES: Warm and well perfused. There are good peripheral pulses with no peripheral edema, cyanosis, clubbing or splinter hemorrhaging. NEUROLOGIC: Grossly intact. EKG demonstrates 1 mm of ST segment elevation in leads II and AVR with no changes in AVF. There are no reciprocal changes. Remainder of the EKG shows some nonspecific abnormalities. IMPRESSION: This patient presents with atypical upper abdominal epigastric discomfort of about 12 hours duration.
AVR|aortic valve replacement|AVR.|169|172|HOSPITAL COURSE|He did not have any signs of withdrawal during this hospitalization. He was counseled to discontinue his habit. 6. Anticoagulation. The patient is on Coumadin following AVR. This was discontinued, and he was placed on heparin during this hospitalization. The heparin was held prior to his EEG and was resumed later.
AVR|augmented voltage right arm|AVR|181|183|IMPRESSION|2. History of coronary artery disease, status post coronary artery bypass graft with cardiac enzymes normal, EKG showing right bundle branch block, and ST elevation in lead III and AVR with no prior EKG to compare with. The patient currently chest pain-free. 3. History of abdominal pain in epigastrium associated with belching, likely secondary to problem #1 and gastritic secondary to nausea and vomiting.
AVR|aortic valve replacement|AVR|24|26|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. AVR for severe AS and bicuspid AV with an ejection fraction of 30 to 35%. He had a St. Jude valve placed _%#MMDD2005#%_. 2. CHF.
AVR|aortic valve replacement|AVR|197|199|CHIEF COMPLAINT/HOSPITAL COURSE|3. History of diarrhea prior to admission. 4. Acute episode of confusion at home prior to hospitalization which did clear. CHIEF COMPLAINT/HOSPITAL COURSE: In short, this gentleman recently had an AVR with a St. Jude Reagent valve on the _%#DD#%_ and was at home doing fine when he apparently came downstairs on Sunday and forgot what he was doing.
AVR|aortic valve replacement|AVR|119|121|PAST SURGICAL HISTORY|6. History of congestive heart failure. 7. History of pneumonia in _%#MM2005#%_. PAST SURGICAL HISTORY: 1. Status post AVR replaced 10 years ago. 2. Bilateral cataract surgery. 3. Gastric surgery secondary to ulceration in 1986. ALLERGIES: None known. MEDICATIONS: He has regular home meds. List was reviewed and he says that he is on Coumadin and lisinopril 10 mg a day.
AVR|aortic valve replacement|AVR|422|424|HISTORY OF PRESENT ILLNESS|Aortic root replacement using the Medtronic Freestyle porcine aortic root with reimplantation of the left coronary ostium, single coronary artery bypass graft, using autogenous saphenous vein from the aorta to the right coronary artery. Pacemaker placement secondary to complete heart block. HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old female with a complicated cardiac history and an original mechanic valve AVR in _%#MM#%_ of 2003, for aortic insufficiency and was complicated by endocarditis with severe AI and annular abscess, status post debridement and bioprosthetic AVR in _%#MM#%_ of 2005.
AVR|aortic valve replacement|AVR|349|351|HISTORY OF PRESENT ILLNESS|Pacemaker placement secondary to complete heart block. HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old female with a complicated cardiac history and an original mechanic valve AVR in _%#MM#%_ of 2003, for aortic insufficiency and was complicated by endocarditis with severe AI and annular abscess, status post debridement and bioprosthetic AVR in _%#MM#%_ of 2005. A follow up TEE showed a small fistula between the right coronary cusp and the left ventricular outflow tract.
AVR|aortic valve replacement|AVR|141|143|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: Congestive heart failure exacerbation. SUMMARY: This is a 72-year-old male with valvular cardiomyopathy, status post an AVR course, recently discharged from the hospital on _%#MM#%_ _%#DD#%_, 2005 after being treated for CHF exacerbation. The patient presented to his primary care clinic today with significant lower extremity edema and weight gain of 10 pounds since he was last discharged.
AVR|aortic valve replacement|AVR|348|350|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSES: 1. Hypoglycemia. 2. Aortic stenosis, status post aortic valve replacement and coronary artery bypass graft x2. 3. Ischemic cardiomyopathy. HISTORY OF PRESENT ILLNESS: Briefly, this is a very pleasant, 73- year-old male with a past medical history significant for severe aortic stenosis and coronary artery disease, status post AVR and CABG x2 on _%#MM#%_ _%#DD#%_, 2006, rheumatoid arthritis, ischemic cardiomyopathy, type 2 diabetes. He presented with a hypoglycemic coma. Patient was recently discharged from Fairview University Medical Center after his AVR and CABG to St. Anthony's Health Center.
AVR|aortic valve replacement|AVR|445|447|HISTORY OF PRESENT ILLNESS|3. Ischemic cardiomyopathy. HISTORY OF PRESENT ILLNESS: Briefly, this is a very pleasant, 73- year-old male with a past medical history significant for severe aortic stenosis and coronary artery disease, status post AVR and CABG x2 on _%#MM#%_ _%#DD#%_, 2006, rheumatoid arthritis, ischemic cardiomyopathy, type 2 diabetes. He presented with a hypoglycemic coma. Patient was recently discharged from Fairview University Medical Center after his AVR and CABG to St. Anthony's Health Center. One night prior to admission, the patient was found to be unresponsive and was found at that time to have a glucose of 7 at approximately 11:30 p.m. Patient was discharged on Lantus 50 mg subcutaneous daily and NovoLog 50 units subcutaneous t.i.d. with meals.
AVR|aortic valve replacement|AVR:|125|128|HOSPITAL COURSE|The patient felt very well at the time of discharge, and had no further complaints. 2. Aortic stenosis, status post CABG and AVR: The patient had no symptomatology of ischemic cardiomyopathy or CHF at the time. Initial BNP in the emergency room revealed it was 389.
AVR|aortic valve replacement|AVR|68|70|BRIEF HISTORY|BRIEF HISTORY: The patient is a 46-year-old woman with a history of AVR and MVR and a history of old CVAs, who presented to the University of Minnesota Medical Center, Fairview, complaining of diplopia and dysarthria. Given her history, there was a concern for recent TIA versus stroke.
AVR|aortic valve replacement|AVR|111|113|DISCHARGE INSTRUCTIONS/FOLLOWUP|2. The patient will follow up with Coumadin clinic within 3 to 5 days for management of her INR. Medication is AVR and MVR. Her goal INR is 2.5 to 3.5. 3. The patient should follow up with her primary care physician for management of her current medical needs such as hypertension and long- term anticoagulation.
AVR|augmented voltage right arm|AVR.|120|123|LABORATORY DATA|EKG shows sinus rhythm. There is noted to be some mild slight PR depression throughout as well as a 0.5 PR elevation in AVR. There is also J point elevation of the ST segment at V1 and V2 and nonspecific STT changes in V4 and V5. There is also voltage criteria for LVH. IMPRESSION/DIAGNOSES 1. Atypical chest pain, possibly consistent with pericarditis but could not rule out obstructive coronary artery disease.
AVR|aortic valve replacement|AVR|130|132|HOSPITAL COURSE|Cross clamp time 2 hours and 26 minutes. Bypass time 2 hours and 55 minutes. HOSPITAL COURSE: A 33-year-old male who underwent an AVR aortoplasty on _%#MMDD2006#%_. This he tolerated well. He was postoperatively transferred to the surgical ICU. He was weaned to extubation and his pressures were weaned to off.
AVR|aortic valve replacement|AVR|294|296|BRIEF HISTORY|4. It was noted the previous study from _%#MM2000#%_ was poor quality, therefore it cannot be compared to the study done on this date and the study was done on _%#MMDD2006#%_. BRIEF HISTORY: Ms. _%#NAME#%_ _%#NAME#%_ is a 56-year-old female with a history of ASCVD status post CABG in 1994 and AVR and PFO repair 1-1/2 years ago who presented with 2-week history of chest pain. She stated that chest pain was associated with exertion, however, it was different than her previous angina prior to her CABG.
AVR|UNSURED SENSE|AVR|147|149|PLAN|He was instructed in his care. He will gradually resume his normal activities. He will follow up in my office in one week. A duplex ultrasound and AVR with exercise will performed in one month. As mentioned, if he should develop recurrent problems in the iliac vessels, he would probably be better suited for an aortobifemoral bypass graft.
AVR|aortic valve replacement|AVR.|189|192|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: 1. Adverse drug reaction to Lexapro, symptoms subsided. 2. Hyponatremia, corrected. 3. History of aortic valve replacement. 4. Anticoagulation with Coumadin because of AVR. 5. History of hypertension. 6. History of post-herpetic neuralgia.
AVR|augmented voltage right arm|AVR|206|208|LABORATORY|Also, depressions noted later in V4 through 6. These reached a maximum of 2.3 mm in lead II, otherwise depression noted between 1 1/2 and 1.8 mm in depression horizontally. He did have some ST elevation in AVR and also flipped T waves in the recovery phase which ultimately normalized to his resting EKG at termination at twelve minutes these normalized by approximately 9 minutes into the test and again the patient's symptoms were totally resolved within three minutes in the recovery phase.
AVR|aortic valve replacement|AVR|217|219|HISTORY OF PRESENT ILLNESS|The ER doctor, Dr. _%#NAME#%_, saw and assessed him. The patient has history of cardioversion in the past. He was tried cardioversion at 50 joules without success, 75 joules without success. Because of his history of AVR repair in 2000, he did not attempt further cardioversion. Cardiology was consulted through the ER and patient was started on diltiazem drip to control his rate, which controlled the rate around 100.
AVR|rapid ventricular response:RVR|AVR.|198|201|IMPRESSION|Electrolytes are normal. INR is currently pending. Magnesium is 0.9. Pending also is a TSH. IMPRESSION: This is a 58-year-old male with recurrent atrial fibrillation, rapid ventricular response and AVR. PLAN: Will admit to the ICU, Cardizem drip to control rate.
AVR|aortic valve replacement|AVR.|127|130|SURGICAL HISTORY|11. Renal cell carcinoma. TRANSPLANT HISTORY: Deceased donor kidney transplant in _%#MM#%_ 2003. SURGICAL HISTORY: 1. CABG and AVR. 2. Left nephrectomy. 3. Pacemaker placement. ALLERGIES: PHENERGAN, MORPHINE, AND CODEINE. LABORATORY: On admission, creatinine was 1.21. White blood cells were 6.3. Chest x-ray shows minimal airspace opacities in right lower lobe likely representing pneumonia.
AVR|aortic valve replacement|AVR|187|189|PAST MEDICAL HISTORY|6. History of TIAs. The patient was last admitted to Mayo _%#MM2006#%_ for a TIA. 7. Coronary artery disease. 8. Chronic anemia. 9. Aortic sclerosis with aortic incompetence, status post AVR in _%#MM2005#%_. The patient has been on anticoagulation for unclear reasons from the ....... He has not been on anticoagulation for unclear reasons. We believe this is probably .......valve, and therefore, he has not been on anticoagulation because of that.
AVR|aortic valve replacement|AVR,|208|211|ASSESSMENT AND PLAN|Cardiology consultation. If he rules out, will await for cardiologist input, may need a stress test versus angiogram. Will await for cardiologist input as far as that goes. 2. Atrial fibrillation status post AVR, coronary artery disease, MI and CABG done in the past. He is not on any Coumadin. Patient states that he cannot tolerate Coumadin.
AVR|aortic valve replacement|AVR|294|296|BRIEF HISTORY OF PRESENT ILLNESS|PROCEDURES PERFORMED: Thoracentesis with right-sided chest tube placement on _%#MMDD2007#%_. BRIEF HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old female with a medical history significant for dilated cardiomyopathy secondary to valvular disease with an EF of 25%, status post porcine AVR and MVR in 1987, history of AFib, history of V-TACH status post ICD placement in 2000, COPD, hyperlipidemia, history of rheumatic fever, anemia who came in for outpatient drainage of a recurrent right-sided pleural effusion.
AVR|aortic valve replacement|AVR|180|182|PAST  MEDICAL HISTORY|She is chronically anticoagulated and Coumadin has been followed at the Coumadin Clinic at Oxboro. PAST MEDICAL HISTORY: 1. Coronary disease, status post bypass graft, status post AVR _%#MM2006#%_. 2. Type 2 diabetes. 3. Osteoarthritis 4. History of hypothyroidism 5. History of gastroesophageal reflux disease 6. History of duodenal ulcer.
AVR|augmented voltage right arm|AVR.|252|255|HISTORY OF PRESENT ILLNESS|He has received IV nitroglycerin as well as heparin. His ECG on admission did show some up-scooping ST elevations of a mm or less in II, III and AVF with more diffuse less than 1 mm ST elevation in I, aVL and V1 through V6. He also has PR elevation in AVR. Because of the ECG findings and his persistent chest pain, rule out MI protocol was initiated.
AVR|augmented voltage right arm|AVR.|120|123|IMPRESSION, REPORT AND PLAN|He also has more diffuse J-point elevation in I, aVL and his lateral leads. Also notable is the PR segment elevation in AVR. These findings might be more suggestive of pericarditis. Nevertheless, I would continue with the acute coronary syndrome protocol.
AVR|aortic valve replacement|AVR|235|237|HOSPITALIZATION COURSE|HOSPITALIZATION COURSE: The patient was admitted on _%#MMDD2007#%_ for critical aortic valve stenosis. The patient had coronary angiogram which showed normal coronary arteries without significant disease. The patient then underwent an AVR on _%#MMDD2007#%_. He had a 23mm St. Jude Regeant mechanical valve placed. The procedure was without complications. For further details of the procedure, please refer to the operative note of that date.
AVR|aortic valve resistance|AVR|293|295|HISTORY  OF PRESENT ILLNESS|For the week leading up to this episode, the patient felt well, two weeks previously he had been stricken with what sounds like a viral gastroenteritis, with symptoms of a watery diarrhea, which has resolved completely. He does have a history of moderate aortic stenosis, with his most recent AVR measurements, three years ago, anywhere from 0.9-1.1 cm2. In the Emergency Department evaluation was remarkable for low-grade fever of 99.5-100, and he was slightly tachycardic.
AVR|aortic valve replacement|AVR|154|156|ASSESSMENT  AND PLAN|Upon discharge he was alert and oriented had no further hallucinations. He was cooperative. He was started on anticoagulation in the hospital for porcine AVR and we have chosen not to continue that upon discharge due to fear of non-compliance. He is being discharged to his home on postop day 8, _%#MMDD2007#%_ with home health care in place.
AVR|augmented voltage right arm|AVR|117|119|HISTORY OF PRESENT ILLNESS|He reported relief with sublingual nitroglycerin. EKG showed ST segment depression in leads V3 through V6 and slight AVR ST elevation and left ventricular hypertrophy. Troponin I initially ..??... was 0.09. Please refer to the dictation H and P for details of the History of Present Illness and Past Medical History.
AVR|aortic valve replacement|AVR|194|196|IMPRESSION|Bicarbonate 25, white count 7.7, hemoglobin 13.9, platelets 166. CT scan of the head without contrast shows no abnormality. IMPRESSION: Mr. _%#NAME#%_ is a 73-year-old gentleman with history of AVR seven years ago who developed recent atrial fibrillation/flutter and underwent ablation yesterday _%#MMDD#%_. A transesophageal echocardiogram was performed prior to that and did not show evidence of clot.
AVR|auditory brainstem response:ABR|AVR|90|92|HOSPITAL COURSE DURING THE HOSPITALIZATION IN THE|Preliminary report is 46 XY, high resolution analysis is still pending. 8) He did have an AVR hearing screening test which he passed. He received no immunizations during hospitalization. The patient was transferred to Fairview Ridges on _%#MMDD2002#%_ at which point he worked on his feedings.
AVR|aortic valve replacement|AVR|278|280|HOSPITAL COURSE|Because of the aortic stenosis and the possibility of surgery, cardiology was consulted for preoperative evaluation. They were recommended to proceed with the nephrectomy of plan but to be careful to avoid perioperative hypotension and the patient should be referred for likely AVR after he recovers from his nephrectomy. DISCHARGE MEDICATIONS: Zantac 150 mg p.o. twice a day.
AVR|augmented voltage right arm|AVR.|119|122|HISTORY OF PRESENT ILLNESS|His D-Dimer and initial troponin were negative. His EKG revealed P-wave inversions and II, III, AVF, V2 through V6 and AVR. The patient was admitted to Fairview University Medical Center for further evaluation. HOSPITAL COURSE: Ventricular tachycardia. The patient developed a nonsustained, but prolonged run of ventricular tachycardia that was associated with lightheadedness on the first day of hospitalization.
AVR|aortic valve replacement|AVR.|263|266|SUMMARY OF HOSPITAL COURSE|Heme/Onc continued to follow postoperatively. Postoperatively, the patient did experience atrial fibrillation, which was controlled with amiodarone. He did convert to a normal sinus rhythm. He did also experience acute renal failure secondary to his dye load and AVR. A renal consult was then obtained where they felt the patient needed diuretics held, ACEs and non-steroidal anti-inflammatory drugs, probably all secondary reasons along with IV contrast.
AVR|aortic valve replacement|AVR|280|282|HISTORY OF PRESENT ILLNESS|In the Emergency Department, she was witnessed to have another maroon-colored stool associated with passage of several clots. Hemoglobin in the Emergency Department was measured at 11.3 and last hemoglobin documented per hospital medical records was 12.3. She did undergo porcine AVR in 2000 and is taking Coumadin, with current INR therapeutic at 2.49. Last Coumadin dose was on _%#MMDD2001#%_. She also takes aspirin for a history of transient ischemic attack and her last dose was on the morning of presentation.
AVR|aortic valve replacement|AVR|138|140|PAST SURGICAL HISTORY|8. See history of present illness. PAST SURGICAL HISTORY: 1. Status post bilateral cataract removal and lens implants in 1998. 2. Porcine AVR for AS in 2000. 3. Right carotid endarterectomy in 2000. ALLERGIES: Intolerance to codeine, Mysoline, and Imdur. MEDICATIONS: 1. Zocor 40 mg by mouth qhs.
AVR|aortic valve replacement|AVR|89|91|PAST MEDICAL HISTORY|A chest x-ray shows a large right pleural effusion. PAST MEDICAL HISTORY: 1. Status post AVR _%#MMDD2002#%_ with postoperative A fib. 2. Status post CABG 1997. 3. Status post hernia repair 1973. ALLERGIES: The patient states that he is allergic to Demerol; to which he gets dizzy and diaphoretic.
AVR|aortic valve replacement|AVR.|223|226|HOSPITAL COURSE|4. Hypertension was stable throughout her stay. Her hydrochlorothiazide was held during treatment for constipation. However, now that she is euvolemic with increased mobility, we will resume HCTZ on an outpatient basis. 5. AVR. The patient continued on Coumadin throughout her stay. At the time of discharge, her INR is 3.1 and she will have a follow-up INR to be performed on _%#MMDD2002#%_.
AVR|aortic valve replacement|AVR.|130|133|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Hypertension. 2. History of myocardial infarction. 3. Status post T&A. 4. Anemia. 5. Tremors. 6. Porcine AVR. 7. Coronary artery bypass graft. 8. History of GI bleed secondary to diverticula in _%#MM2002#%_. 9. Colonoscopy negative in _%#MM2002#%_ for a malignant mass.
AVR|aortic valve replacement|AVR|41|43|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. CABG x 3 with an AVR Porcine valve on _%#MM#%_ _%#DD#%_, 2002. 2. Sarcoidosis. 3. Hyperlipidemia. 4. Depression, apparently for several years. CONSULTATIONS: Dr. _%#NAME#%_ _%#NAME#%_, psychiatrist and Dr. _%#NAME#%_ _%#NAME#%_, cardiac surgeon.
AVR|aortic valve replacement|AVR.|191|194|PAST MEDICAL HISTORY|He has had no visual changes or neurologic changes. PAST MEDICAL HISTORY: 1. Esophageal stricture. 2. Hypertension. 3. Probable glomerulonephritis. 4. History of endocarditis. 5. Status post AVR. 6. Status post MVR. 7. Status post VSD repair. 8. History of repair of coarctation of the aorta at one year of age.
AVR|aortic valve replacement|AVR|211|213|HISTORY OF PRESENT ILLNESS|ADMITTING DIAGNOSIS: Right pleural effusion. OPERATIVE PROCEDURES PERFORMED DURING THIS ADMISSION: Placement of right pigtail catheter. HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old male, status post AVR for aortic stenosis on _%#MMDD2003#%_. Surgery was uneventful. Postop course was unremarkable. The patient presented to _%#CITY#%_ _%#CITY#%_ Emergency Room complaining of one day of chest tube site drainage.
AVR|aortic valve replacement|AVR|187|189|PAST MEDICAL HISTORY|14. Ferrous sulfate IM injections. 15. Erythropoietin q. week. PAST MEDICAL HISTORY: 1. Status post renal transplant in 1985; currently with chronic allograft dysfunction. 3. Status post AVR two years ago. 4. GERD. 5. Hypertension. 6. Anemia. 7. Fibrosis. FAMILY HISTORY: Her mother has coronary artery disease and had had a CABG in 1994.
AVR|augmented voltage right arm|AVR,|187|190|OBJECTIVE|SKIN - without significant lesion. NEURO - nonfocal throughout including cranial nerves, strength, sensation and reflexes. EKG - shows bradycardia, first degree AV block with a T down in AVR, AVL and V1. Electrolytes within normal limits including potassium 4.0, BUN 16, creatinine 0.9, glucose 100, troponin I less than 0.07 times two.
AVR|augmented voltage right arm|AVR.|178|181|PHYSICAL EXAMINATION|No lower extremity edema. No chronic venous stasis changes. SKIN - some mild spider veins. No significant cyanosis. EKG shows normal sinus rhythm with no. Has a small V in 3 and AVR. No acute severe ST-T wave elevation. ASSESSMENT: This is a 70-year-old lady coming in with worsening shortness of breath, dyspnea, and intermittent chest pain.
AVR|aortic valve replacement|AVR.|185|188|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. History of mechanical aortic valve. 2. History of hypertension. 3. History of atrial fibrillation. He is on Coumadin. 4. History of appendectomy. 5. History of AVR. ALLERGIES: Reviewed and documented on the chart. PHYSICAL EXAMINATION: There is cellulitis over the dorsum of the hand, associated with the radial-most pin dorsally.
AVR|aortic valve replacement|AVR.|185|188|HOSPITAL COURSE|5. Left foot shot 1994. HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted in stable condition. He was brought to the operating room on _%#MMDD2004#%_ for coronary artery bypass graft x4 and AVR. He tolerated the procedure well. I refer you to the operative note for the details of surgery. His hospital course was complicated by a postoperative stroke on postoperative day #3 which left him with weakness on the left side, both upper and lower extremities, as well as difficulty in swallowing.
AVR|aortic valve replacement|AVR.|98|101|PHYSICAL EXAMINATION|The patient had an EKG, which has no acute changes. He does have the Q waves in II and III and an AVR. The patient has a bundle branch block seen in his precordial leads. The patient is to return tomorrow for a recheck of his white count.
AVR|aortic valve replacement|AVR|168|170|BRIEF HISTORY|OPERATIONS/PROCEDURES PERFORMED DURING THIS ADMISSION: Sternal debridement and rewiring, hydrocele repair. BRIEF HISTORY: The patient is a 61-year-old male status post AVR in _%#MM2004#%_ who had a sternal dehiscence. The patient had a significant history of cirrhosis of the liver. After evaluation by Dr. _%#NAME#%_ _%#NAME#%_ in _%#MM2004#%_, it was deemed necessary for the patient to undergo the aforementioned procedure.
AVR|aortic valve replacement|AVR.|267|270|ASSESSMENT|INR was 1.65 and on recheck was 1.80. Troponins were 0.13 followed by 0.12. D-dimer was within normal limits at less than 0.2. Electrocardiogram shows normal sinus rhythm with no acute changes by my interpretation. ASSESSMENT: Presyncope in a patient with history of AVR. PLAN: 1. Presyncope. He reports no further symptoms overnight and his telemetry is stable.
AVR|aortic valve replacement|AVR,|149|152|HISTORY OF PRESENT ILLNESS|OPERATIONS/PROCEDURES THIS ADMISSION: None. HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old female who had a mitral valve repair, enforcing AVR, CAB x 2, arch replacement with an elephant trunk in _%#MM2003#%_. The patient presented to the emergency room on _%#MMDD2004#%_ with chest and back pain and elevated systolic blood pressure of 210.
AVR|aortic valve replacement|AVR|201|203|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. AML M4 status post consolidation chemotherapy with Ara-C in 2003. 2. Hypertension. 3. Paroxysmal atrial fibrillation. 4. History of right cerebellar hemorrhage. 5. Status post AVR on anticoagulation. ADMISSION MEDICATIONS: 1. Coumadin 10 mg daily. 2. Lovenox 90 mg q.12 hours. 3. Lisinopril. 4. Toprol XL.
AVR|aortic valve replacement|AVR|179|181|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Hyperlipidemia. 2. Chronic low back pain with right lower extremity radiculopathy. 3. Status post appendectomy. 4. Degenerative joint disease. 5. Porcine AVR in 1988. 6. Hard of hearing. 7. Benign prostate hypertrophy. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Married. Rare alcohol use. No tobacco. Lives at home with wife.
AVR|aortic valve replacement|AVR.|181|184|ASSESSMENT/PLAN|Will place the patient on fall precautions. He received IV fluids in the ER. 3. Chronic back pain. Will continue his pain medications, Aqua K pads, PT and OT evaluation. 4. Porcine AVR. The patient is in sinus rhythm and stable. Will continue daily aspirin. 5. Fluids, electrolytes and nutrition. The patient to receive IV fluid maintenance.
AVR|aortic valve replacement|AVR.|134|137|PAST SURGICAL HISTORY|11. Renal cell carcinoma. PAST TRANSPLANT HISTORY: Deceased donor kidney transplant _%#MM#%_ 2003. PAST SURGICAL HISTORY: 1. CABG and AVR. 2. Left nephrectomy. 3. Pacemaker placement. ALLERGIES: PHENERGAN; MORPHINE; CODEINE. LABORATORY DATA: On admission, creatinine was 1.21, white blood count 6.6. PHYSICAL EXAMINATION: Vital signs on admission: Temperature 102.3, blood pressure 136/70, heart rate 92, respirations 24, O2 saturation 98% on room air.
AVR|aortic valve replacement|(AVR)|124|128|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Graft failure. 2. End-stage renal disease. 3. Cerebrovascular accident. 4. Aortic valve replacement (AVR) x 2. 5. Status post appendectomy. 6. Status post cholecystectomy. 7. Hepatitis B and hepatitis C positive. 8. Hyperparathyroidism. DISCHARGE DIAGNOSES: 1. Graft failure. 2. End-stage renal disease.
AVR|augmented voltage right arm|AVR,|251|254|LABORATORY DATA|CHEST: Clear to auscultation. CARDIAC: There was an S1 and S2 without extra sounds or murmur. Carotid upstrokes were normal bilaterally. LABORATORY DATA: EKG demonstrated normal sinus rhythm with 0.5 mm of diffuse ST-segment depression except in lead AVR, where there was mild elevation. Sodium 139, potassium 3.9, BUN 8, creatinine 1.8. Hemoglobin was 12.6, white blood count 9.9 with 75% neutrophils, 15% lymphocytes, 7% monocytes, 2% eosinophils, 1% basophils.
AVR|aortic valve replacement|AVR,|112|115|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_ is a 77-year-old man who is to have a coronary artery bypass graft, AVR, and ventricular aneurysm repair which we are asked to see in consultation regarding abnormal chest x-ray. His chest x-ray showed increased fibrovascular markings, however, his CT scan shows emphysema.
AVR|aortic valve replacement|AVR|155|157|IMPRESSION/PLAN|I have recommended at this time proceeding with electrophysiologic study combined with a tilt study. Will discuss this with the EP service. 2. Status post AVR with good valve function. 3. Status post CABG and previous myocardial infarctions. No evidence for reversible ischemia at this time.
AVR|aortic valve replacement|(AVR)|309|313|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is an 85-year-old woman admitted with weakness, increasing edema, and shortness of breath and felt to have congestive heart failure. Echocardiogram and angiogram showed severe aortic stenosis. She underwent a bioprosthetic aortic valve replacement (AVR) on _%#MMDD2005#%_. Postoperatively she has not done well. She had severe bradycardia, hypoxia and hypotension and had to undergo CPR. Subsequently she underwent a mediastinal exploration for evacuation of mediastinal hematoma and placement of intraaortic balloon pump.
AVR|aortic valve replacement|AVR,|129|132|REASON FOR CONSULTATION|REFERRING PHYSICIAN: I was asked to see the patient by Dr. _%#NAME#%_. REASON FOR CONSULTATION: Cardiogenic shock, postoperative AVR, MVR and pulmonary hypertension. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is an 87-year-old with a complicated past medical history.
AVR|aortic valve replacement|AVR.|169|172|IMPRESSION/PLAN|Cardiac output 2.9, CI equal to 1.6, SVR equal 992, PCWP equal 39. CVP 22. This is on milrinone 0.75. IMPRESSION/PLAN: 1. Cardiogenic shock. 2. Postoperative mechanical AVR. 3. Postoperative mitral valve porcine valve. 4. Anasarca. 5. Renal insufficiency. The patient represents a very difficult therapeutic challenge.
AVR|aortic valve replacement|AVR|199|201|IMPRESSION|2. Encephalopathy exacerbated by #1. 3. Anemia with hemolysis and thrombocytopenia and bone marrow biopsy consistent with CMML and hemolytic transfusion reaction. 4. Diabetes mellitus. 5. History of AVR and coronary artery disease. 6. With new right IJ clot. PLAN: 1. Continue BiPAP. 2. Check ABG. 3. Continue bronchodilators. 4. Question whether he has a right lower extremity DVT.
AVR|aortic valve replacement|AVR|234|236|PAST MEDICAL HISTORY|The patient has no prior documentation of underlying obstructive lung disease, he has not received any narcotic drugs that might explain this. PAST MEDICAL HISTORY: 1. Coronary artery disease. a. Status post CABG 1994. b. Status post AVR St. Jude mechanical valve. c. LV dysfunction with prior ejection fraction 20%. 2. Aortic stenosis. 3. Non-insulin dependent diabetes mellitus.
AVR|aortic valve replacement|AVR|217|219|HISTORY|PROCEDURE: Right total knee arthroplasty with history of bilateral knee degenerative joint disease. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 62 -year-old female with history of coarctation of the aorta repair, status-post AVR 20 years ago and hypertension and hypercholesterolemia and osteoarthritis, with progressive bilateral knee pain, who is very active, underwent right total knee arthroplasty on _%#MMDD2004#%_.
AVR|aortic valve replacement|AVR.|156|159|DIAGNOSIS|We will re-introduce her other medications as her blood pressure improves. 2. Hypercholesterolemia. The patient will continue on her Lipitor. 3. History of AVR. The patient is currently restarted back on Coumadin I believe. 4. Osteoarthritis. The patient will be controlled with routine oral medications.
AVR|augmented voltage right arm|AVR.|156|159|ELECTROCARDIOGRAM 1/6/05|ELECTROCARDIOGRAM _%#MMDD2005#%_: Sinus bradycardia, rate 57. First degree AV block. Old anteroseptal myocardial infarction with Q-waves in V1, V2, V3, and AVR. A comparison was made to an EKG from about 2 years ago which is unchanged. ASSESSMENT/PLAN: 1. Polysubstance dependence; this is per Dr. _%#NAME#%_.
AVR|augmented voltage right arm|AVR,|197|200|HISTORY OF PRESENT ILLNESS|In 2004, in fact, this patient developed atrial fibrillation with rapid ventricular response with profound ST depression of 3-4 mm in V3-V6 and 1-2 mm ST depression, 1, 2, AVF, and ST elevation in AVR, V1 and V2. At that time a nuclear stress test was performed and showed atrial scarring versus thinning. No further evaluation for cardiac ischemia was made. Because of the patient's pneumonia at that time she was treated for her COPD and pneumonia and no further evaluation or treatment for her paroxysmal atrial fibrillation was made.
AVR|augmented voltage right arm|AVR|124|126|LABORATORY DATA|A troponin was negative. BMP, TSH, and Cbc within normal limits. EKG shows Q waves in V1, 2, and 3, and no changes in leads AVR and AVL. ASSESSMENT/PLAN: 1. Schizoaffective disorder and paranoid psychosis per Dr. _%#NAME#%_.
AVR|aortic valve replacement|AVR|97|99|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 65-year- old man who is status post acute AVR replacement secondary to subacute bacterial endocarditis. He is now on a ventilator postoperatively with acute respiratory failure and pulmonary infiltrates which have improved since the postop situation.
AVR|aortic valve replacement|AVR|154|156|PAST MEDICAL HISTORY|He had a blood culture for strep bacteria. He had splenic infarct and splenomegaly. Echocardiogram showed ASAI and a valvular vegetation. He had emergent AVR secondary to SBE. He had bilateral effusions drained. He had no prior pulmonary history, nonsmoker by the chart. He was transfused with FFP, platelet packs. He has a past medical history of diabetes, rotator cuff surgery x 4, detached retina, kidney stone, hiatal hernia.
AVR|aortic valve replacement|AVR,|196|199|ASSESSMENT/PLAN|Dorsalis pedis, posterior tibial pulses are 2+ symmetric. NEUROLOGIC: Grossly intact. SKIN: Unremarkable. ASSESSMENT/PLAN: Overall patient is a pleasant 55-year-old female status post recent redo AVR, who presents with atrial fibrillation with rapid ventricular response symptoms appropriate with his heart pounding, palpitations, shortness of breath, fatigue.
AVR|aortic valve replacement|AVR|184|186|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Includes peripheral vascular disease, diabetes, ASCVD. She has congestive heart failure. She is status post CABG. She has atrial fibrillation. She is status post AVR and MVR. She has a history of mild dementia, hypothyroidism after thyroidectomy and stroke. She has never had urologic surgery and denies stones or urinary tract infection.
AVR|aortic valve replacement|AVR|241|243|REASON FOR CONSULTATION|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD REASON FOR CONSULTATION: _%#NAME#%_ _%#NAME#%_ is a 69-year-old man who was admitted to the hospital with confusion. He is somebody who has had a significant past medical history of AVR in 1990, seizure disorder, peripheral neuropathy, and also had a coarctation of the aorta. He was felt to have an acute encephalopathy with ataxia and incontinence.
AVR|aortic valve replacement|AVR|196|198|REVIEW OF SYSTEMS|It is clearly not Mobitz I pattern in that there is no PR interval prolongation, but it could be Mobitz I. Because of the syncopal episode, the presence of right bundle and left axis, status post AVR and coronary disease, I suspect that he does suffer from intermittent heart block as the presumptive cause of syncope. Because it is the first event, one might delay, give him an event monitor, and document intermittent heart block, although pacemaker may be most appropriate given this setting.
AVR|aortic valve replacement|AVR|255|257|CONCLUSION|He is warm and dry with decreased hair distribution on both legs and a barely palpable dorsalis pedis bilaterally. He has no edema. CONCLUSION: 1. Vasculopath as noted with cerebrovascular, peripheral vascular, and coronary artery disease. 2. Status post AVR with a moderate gradient across the aortic valve in _%#MM#%_, a mean of 20, peak of 43, not unusual for valves. 3. Hyperlipidemia well controlled with LDL of 44 and HDL of 65 back in _%#MM#%_.
AVR|aortic valve replacement|AVR|171|173|CONCLUSION|3. Hyperlipidemia well controlled with LDL of 44 and HDL of 65 back in _%#MM#%_. 4. Controlled hypertension. 5. Mild dementia. 6. Chronic Coumadin because of the St. Jude AVR and question of TIA in the past. My suggestion is that we simply place a pacemaker and let this gentleman go on about his activities.
AVR|aortic valve replacement|AVR|180|182|HISTORY|He also had a history of long-standing atrial fibrillation and he refused Coumadin. Yesterday the patient underwent surgery with Dr. _%#NAME#%_. This was a #21 stented pericardial AVR replacement, a LIMA graft to the LAD and a vein graft to the OM. This vein graft comes off the LIMA graft, however. He also had a left-sided MAZE procedure.
AVR|aortic valve replacement|AVR|115|117|MEDICATIONS|He has chronic recurring atrial fibrillation for which he is on Coumadin and the Coumadin is also for the St. Jude AVR placed in _%#MM#%_ 1999 at which time he had bypass grafting. His ejection fraction and heart cardiac function was checked as was the valve in _%#MM#%_ 2005 and the EF was 50% at that time.
AVR|aortic valve replacement|AVR|224|226|MEDICATIONS|That was decreased to 12.5 mg daily most recently. This gentleman is post-CVA as I understand, but I am not sure of the details of that. He has prostate cancer, dyslipidemia, hypertension and additionally is post-bypass and AVR as noted above. Acid peptic disease and a bleeding ulcer history is identified as is bilateral carotid artery disease.
AVR|aortic valve replacement|AVR|387|389|PHYSICAL  EXAMINATION|He has no edema. He seems like a reasonable historian, although some of his history seems a little bit less than perfect. Current problems are recurrent atrial fibrillation and he may well need a reinstitution of atenolol at some point, but I think he is most likely better off if we discontinue propafenone at this point in time and observe on Coumadin which he certainly needs for his AVR and his recurring atrial fibrillation. Reviewing his records from our office and those in the in the chart, I think beta blockade and perhaps digitalis makes sense without propafenone at this point in time and we will see how things progress.
AVR|aortic valve replacement|AVR|223|225|IMPRESSION|I do believe this gentleman needs initiation of anti-diabetic therapy and I will ask the endocrine group to see him tomorrow if at all possible. IMPRESSION: 1. Poorly controlled diabetes. 2. Unstable angina. 3. Status post AVR and CAB times two in 1996.
AVR|aortic valve replacement|AVR|136|138|PAST MEDICAL HISTORY|4. PET scan 1 month ago reported to be negative. 5. Left hip arthroplasty _%#MMDD2004#%_. 6. AICD placement in 1998 for dysrhythmia. 7. AVR replacement in 1998 with cadaveric valve staph aureus endocarditis in 1999,. 8. Chronic renal failure. 9. Hypercalcemia. 10. Laparotomy and repair of small bowel perforation secondary to lymphoma and treatment.
AVR|aortic valve replacement|AVR|138|140|IMPRESSION|Blood cultures from 5/30 x2 are no growth today. IMPRESSION: Mr. _%#NAME#%_ is a very pleasant 54-year-old gentleman who is postop day #1 AVR for what appeared to be a torn coronary leaflet and acute 4+ AI. There is no history to suggest infection and the etiology of this is not clear.
AVR|aortic valve replacement|AVR|216|218|ASSESSMENT  AND PLAN|DIAGNOSTIC STUDIES: Chest x-ray this afternoon shows some cardiomegaly, sternal wires but no overt edema or infiltrates. ASSESSMENT AND PLAN: Ms. _%#NAME#%_ is a 70-year-old lady who is status post five vessel CABG, AVR and abdominal aortic aneurysm repair on _%#MM#%_ _%#DD#%_ which has been complicated by a stroke, junctional rhythm and respiratory failure and is now oliguric.
AVR|aortic valve replacement|AVR|123|125|PAST MEDICAL HISTORY|On gait evaluation she was only able to take a few steps. PAST MEDICAL HISTORY: 1. History of aortic stenosis, status post AVR in 1998. 2. Status post CABG x4 vessels on _%#MMDD2006#%_. 3. Status post ICD in 1996. 4. Status post stents x3, as stated above. 5. History of von Willebrand disease.
AVR|augmented voltage right arm|AVR|265|267|LABORATORY|Echo showed LVEF of 35-40%. There is apical thrombus measured 2x3 cm. There is also pericardial fluid collection 0.9 cm. EKG shows sinus rhythm, low voltage and also some sign suggesting right ventricular hypertrophy, such as right access deviation, poor R wave in AVR lead and also poor R-wave progression and the ratio of R over S is less than 1 in V5 and V6. ASSESSMENT AND PLAN: This of this very challenging case. The patient has morbid obesity, history of hypertension and dyslipidemia presented with exertional dyspnea for 6-7 days, ejection fraction is depressed and also with increased BNP and physical examination suggesting CHF.
AVR|aortic valve replacement|AVR|116|118|REQUESTING PHYSICIAN|The patient has a history of having had a major upper GI bleed about nine years ago when he was on Coumadin for the AVR done in 1985 and was given a short course of steroids. EGD and colonoscopy were both done and apparently both were unremarkable.
AVR|aortic valve replacement|AVR|226|228|CLINICAL IMPRESSION|CLINICAL IMPRESSION: 1. Status post mitral valve and tricuspid valve repair with left sided Maze procedure with some hypotension requiring pressor support and AV pacing support. 2. History of severe cardiomyopathy. History of AVR and aortic root and aortic arch replacement in 1993. 3. History of congestive heart failure 4. History of atrial fibrillation
AVR|aortic valve replacement|AVR|257|259|RECOMMENDATIONS|RECOMMENDATIONS: 1. Continue vancomycin. 2. I would not add gentamicin at this point with negative blood cultures, there is no data to support any change in outcome. 3. Recheck T echo. 4. Followup MRI of head. 5. Consider MRI of thoracic spine. 6. Consider AVR later this week. 7. Recheck blood cultures times two today. Thank you for involving us again in his care. Dr. _%#NAME#%_ or Dr. _%#NAME#%_ will follow up tomorrow.
AVR|aortic valve replacement|AVR|185|187|ASSESSMENT|Chest x-ray showed edematous changes, otherwise negative. EKG showed left bundle branch block. ASSESSMENT: 1. The patient is stable status post knee arthroplasty for DJD. 2. History of AVR maintained on chronic aspirin therapy with satisfactory cardiac function by preoperative cardiology evaluation with EF of 45-50%. Clear coronary arteries on her aortic valve replacement preoperative evaluation.
AVR|aortic valve replacement|AVR,|184|187|PAST MEDICAL HISTORY|He has no pain. Past medical history does not include any chronic kidney disease, hypertension, diabetes, kidney stones, urinary tract infection. PAST MEDICAL HISTORY: Includes recent AVR, CABG, anemia, BPH, hypertension, hyperlipidemia. PAST SURGICAL HISTORY: Includes cholecystectomy, hemorrhoidectomy, tonsillectomy and adenoidectomy, colonic polypectomy, mastoidectomy and carotid endarterectomy.
AVR|aortic valve replacement|AVR|243|245|ASSESSMENT  AND PLAN|REQUESTING PHYSICIAN: Dr. _%#NAME#%_. REASON FOR CONSULTATION: ICU management and acute renal failure. ASSESSMENT AND PLAN: _%#NAME#%_ _%#NAME#%_ is a 77-year-old man with multiple medical problems who is now status post three-vessel CABG and AVR and has developed acute on chronic renal failure and respiratory distress requiring transfer to the ICU. The patient is currently comfortable on BiPAP. 1. Acute on chronic renal failure.
AVR|aortic valve replacement|AVR|154|156|ASSESSMENT  AND PLAN|He has been seen by pulmonary and started on BiPAP and levofloxacin. a. Agree with pulmonary's plans. b. Further management per pulmonary. 3. Status post AVR and 3 vessel CABG. He appears stable. 4. Hypertension. His is controlled with metoprolol. His pressure is normally high and here it is on the lower side, so I think he is a little dry.
AVR|aortic valve replacement|AVR|243|245|HISTORY OF PRESENT ILLNESS|He is on sliding scale now. a. Check an A1c. 6. Nutrition. The patient is on clear liquid diet. HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old man with multiple medical problems who was admitted for an elective three-vessel CABG and AVR after experiencing angina as an outpatient. The patient had his surgery on _%#MMDD#%_ and it appeared to go well.
AVR|aortic valve replacement|AVR|139|141|PAST  MEDICAL HISTORY|2. Coronary artery disease, status post LAD stent in 1995 and his current admission for three-vessel CABG. 3. Aortic stenosis, status post AVR this admission. 4. Right carotid endarterectomy in 2007. 5. PVD, status post bilateral iliac angioplasties in the past. Also status post left femoral artery angioplasty in 2003.
AVR|aortic valve replacement|AVR|200|202|PAST MEDICAL HISTORY|2. Aortic valve replacement with a St. Jude for severe aortic stenosis, _%#MMDD2005#%_. 3. Coronary artery disease with one-vessel coronary artery bypass graft, SVG to RCA in _%#MM2005#%_, along with AVR and aortic root replacement. 4. Congestive heart failure. 5. Idiopathic cardiomyopathy with an ejection fraction of 25%. 6. Recurrent ventricular tachycardia with AICD in 2003, revision in 2005, and he has ongoing persistent ventricular tachycardia.
AVR|augmented voltage right arm|AVR.|157|160|HISTORY OF PRESENT ILLNESS|Initial echocardiogram showed sinus rhythm with J-point elevations in V-2, V-3 and V-4, and mild PR depressions seen in II and AVF, and PR elevation in lead AVR. In comparison to an echocardiogram from a year ago, it was not significantly different. However, because she continued to complain of this pain, this was treated as an acute coronary syndrome.
AVR|augmented voltage right arm|AVR.|209|212|LABS|EKG demonstrates atrial fibrillation with rapid ventricular response. Heart rate is 164 beats per minute. She has ST segment depression in the inferior leads and the lateral precordial leads with elevation in AVR. Preoperative ECG shows normal sinus rhythm with borderline left atrial enlargement. There is no left ventricular hypertrophy. Rate is 73 beats per minute.
AVR|aortic valve replacement|AVR|170|172|HISTORY OF PRESENT ILLNESS|He actually presented to the hospital with a syncopal episode, which has been worked up, and he was found to have aortic stenosis and a serial right coronary lesions and AVR cab is planned. He has continued to smoke since the diagnosis of small cell carcinoma was made. He was intubated over the past few days and has now been extubated and is conversant and is somewhat confused at times but overall denies any significant symptoms.
AVR|aortic valve replacement|AVR|174|176|ASSESSMENT/PLAN|ASSESSMENT/PLAN: This is a 76-year-old male with AS and a right coronary lesion status post cardiac arrest who has been successfully resuscitated and worked up and now needs AVR cab. I have been asked to perform bronchoscopy in the OR to see if there are any endobronchial lesions and also for airway maintenance because of the potential for pneumonia.
AVR|aortic valve replacement|AVR|190|192|PAST MEDICAL HISTORY|In 1998, he fell and struck his head, had an intracerebral bleed with frontal and temporal edema and facial lacerations. PAST MEDICAL HISTORY: 1. Coronary artery bypass graft with a MVR and AVR on Coumadin 2. Hypertension 3. Hypercholesterolemia 4. Chemical dependency ALLERGIES: to Penicillin. Blood gases had been 7.48, CO2 of 26, pO2 of 179 on 55% on the vent.
AVR|aortic valve replacement|AVR|171|173|PAST MEDICAL HISTORY|There was also a small left pleural effusion. There was no evidence of pericardial effusion on the CT scan. PAST MEDICAL HISTORY: 1. Bicuspid aortic valve. 2. Status post AVR with a 21 mm St. Jude valve. 3. Status post reconstruction of the ascending aorta with a 28 mm Dacron graft. 4. History of ductal breast cancer status post mastectomy, and also currently on tamoxifen therapy.
AVR|aortic valve replacement|AVR,|178|181|ASSESSMENT|2. Ischemic cardiomyopathy - clinical exam suggests it is uncompensated or at least out of proportion. a. Raises the question could he have a pericardial process. 3. Status post AVR, mitral valve repair, CABG times three, PFO closure and MAZE procedure on _%#MMDD2005#%_. a. Hospitalization prolonged due to large surgical procedure. b. Required two thoracentesis of the left which were bloody.
AVR|aortic valve replacement|AVR,|39|42|REASON FOR CONSULTATION|REASON FOR CONSULTATION: Postoperative AVR, hemodynamically instability. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 58-year-old female. I am seeing the patient as she returns from the operating room, Dr. _%#NAME#%_ has asked me to see her to following along in terms hemodynamic management.
AVR|aortic valve replacement|AVR|232|234|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. CVA in _%#MM#%_ of 2002 with residual right hand weakness and word finding difficulty. 2. Osteoporosis. 3. Chronic obstructive pulmonary disease with current tobacco smoking. 4. Aortic stenosis, status post AVR during this admission. 5. History of cholecystectomy. 6. Rectal fissure repair. 7. Bilateral cataract surgery. MEDICATIONS: Currently she is on 1. Maalox p.r.n. 2. Dulcolax.
AVR|aortic valve replacement|AVR|96|98|ASSESSMENT|REASON FOR CONSULTATION: Ventilator management. ASSESSMENT: 1. Respiratory failure, status post AVR and coronary artery bypass graft (1). a. Hypoxemia appears to be primary disorder. b. Most likely secondary to atelectasis, small apical pneumothorax, and hypotension.
AVR|aortic valve replacement|AVR|149|151|PAST MEDICAL HISTORY|She does acknowledge some abdominal discomfort. PAST MEDICAL HISTORY: 1. History of epistaxis. 2. Coronary artery bypass graft on _%#MMDD2006#%_. 3. AVR _%#MMDD2006#%_. 4. Diabetes mellitus. 5. History of pneumonia. 6. Osteoarthritis. 7. UTI _%#MMDD2006#%_. ALLERGIES: Cortisone and penicillin. SOCIAL HISTORY: Widowed x24 years.
AVR|augmented voltage right arm|AVR.|246|249|LABS|Myoglobin of 51. White blood count is 6.7, RBC's of 4.4, hemoglobin 13.1, hematocrit 36.7, MCV of 82, MCH 29.4, MCHC of 35.8, RDW 12.4 and a platelet count of 194. EKG upon admit shows a sinus bradycardia at a rate of 47 with T-Wave inversion in AVR. Repeat EKG with the chest discomfort shows a very subtle sloping of the ST's in the lateral leads. IMPRESSION: 1. Unstable angina. 2. Diastolic murmur. 3. Diabetes mellitus.
AVR|augmented voltage right arm|AVR|247|249|LABORATORY DATA|LABORATORY DATA: Creatinine 1.0, platelet 117,000. Preoperative platelets done approximately _%#MMDD2003#%_ - 91,000 with a hemoglobin of 14.2. EKG shows normal sinus rhythm with frequent PVCs with a rate of 91. QS-wave seen at 2 and questionable AVR which are old compared with preoperative EKG. Preoperative echocardiogram shows normal global systolic function with mild increase in LV wall thickness and thickened aortic valve without hemodynamically significant functional abnormality and mild left atrial enlargement.
AVR|aortic valve replacement|AVR|151|153|MEDICATIONS|5. Pancrease, 1 tablet 3 times per day. 6. Ativan as needed. I understand that she did not have significant coronary artery disease at the time of her AVR and would think that there is no clear reason why she should have developed significant enough disease to preclude operating on her carotid artery, clearly tight and likely symptomatic.
AVR|aortic valve replacement|AVR.|363|366|CONCLUSION|ABDOMEN: She has no hepatomegaly or abdominal aortic prominence. She has no bruits over the aorta or over the femorals which are easily palpable, but the popliteals and the posterior tibials are difficult to appreciate, although thought to be 1+. She is warm and dry in her legs. CONCLUSION: 1. Tight right internal carotid artery stenosis. 2. Status post tissue AVR. 3. Atrial fibrillation with perhaps a 5% per year risk of stroke suggesting that once she gets through the surgery she could probably simply resume her Coumadin rather than be covered with Lovenox, although Lovenox coverage during hospitalization is reasonable when she is able.
AVR|aortic valve replacement|AVR|96|98||Mr. _%#NAME#%_ is a 65-year-old gentleman who was transferred from Regions Hospital status post AVR and coronary artery bypass 1997 with a diagnosis of infective endocarditis. The patient was seen by me and stable at the time of admission; however, since then the patient has suffered a LV apical infarction and is in heart failure.
AVR|augmented voltage right arm|AVR|165|167|PHYSICAL  EXAMINATION|EXTREMITIES: Pedal pulses are normal. His baseline electrocardiogram post-cardioversion was normal with no evidence of WPW, although he does have a minor R prime in AVR and V1. His EKG during the episode of tachycardia shows rates exceeding 300 beats per minute with the QRS negative in I and AVL with deep S-waves and monophasic R-wave in V1 and 2.
AVR|aortic valve replacement|AVR|162|164|ASSESSMENT|Brachioradialis is also brisk compared to the left. His right hand is significantly edematous compared to the left. ASSESSMENT: 88-year-old gentleman status post AVR MVR and CABG on _%#MMDD#%_ with prolonged hospitalization requiring intubation x3 presenting with right upper extremity weakness. PLAN: Per my exam his proximal muscle weakness appears to be more of an acute presences with an acuteness compared to the peripheral, which appears to be more of chronic nature.
AVR|aortic valve replacement|AVR|129|131|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Include coronary artery disease, diabetes mellitus on oral agents, COPD, and congestive failure. He has an AVR and cardiomyopathy. MEDICATIONS ON ADMISSION: 1. Amiodarone. 2. Avandia. 3. Glyburide. 4. Demadex. 5. Aspirin. The aspirin may be incorrect.
AVR|aortic valve replacement|AVR|203|205|HISTORY OF PRESENT ILLNESS|He has no history of H. pylori diagnosis. He has a known LV dysfunction with an EF in the 45% range with significant diastolic dysfunction. He has coronary arteries looked at two months ago prior to his AVR that were said to be normal. No bypasses were performed at that time. He has chronic renal insufficiency with a baseline creatinine above 2.
AVR|aortic valve replacement|AVR|162|164|ASSESSMENT|Brachioradialis is also brisk compared to the left. His right hand is significantly edematous compared to the left. ASSESSMENT: 88-year-old gentleman status post AVR MVR and CABG on _%#MMDD#%_ with prolonged hospitalization requiring intubation x3 presenting with right upper extremity weakness. PLAN: Per my exam his proximal muscle weakness appears to be more of an acute presences with an acuteness compared to the peripheral, which appears to be more of chronic nature.
AVR|aortic valve replacement|AVR.|234|237|PAST MEDICAL HISTORY|Currently the patient is also currently very unresponsive to commands due to reasons that are not clear to me but is supposedly secondary to metabolic reasons per the primary team. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. AVR. 3. Status post lupus. 4. Endstage renal disease status post renal transplant x2 currently on hemodialysis. For meds, social and family history please see fellow note.
AVR|augmented voltage right arm|AVR,|168|171||He has new onset atrial fibrillation with a 12-lead EKG showing nonspecific inferior and lateral T changes but no Q-waves, interestingly enough, except in lead III and AVR, both of which are intracavitary leads. Heart rate is 83 and atrial fibrillation actually quite well controlled. An echocardiogram read by me shows lateral severe wall motion abnormality.
AVR|aortic valve replacement|AVR|127|129|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 53-year-old male who was admitted to the hospital with chest pain, status post AVR at _%#COUNTY#%_ _%#COUNTY#%_ Medical Center on _%#MMDD2007#%_ for endocarditis. He presents with chest pain. We were asked to see the patient for potential cholecystitis.
AVR|aortic valve replacement|AVR|317|319|PAST MEDICAL HISTORY|The patient is currently being treated with antibiotic therapy for presumed infection associated with biliary system and his right lobe tumor, which may be a gallbladder tumor. PAST MEDICAL HISTORY: Significant for diabetes mellitus and end-stage renal disease on hemodialysis and infectious endocarditis status post AVR in _%#MM2007#%_. The patient also had a pacemaker placement and has hypertension. PAST SURGICAL HISTORY: 1. Aortic valve replacement with a tissue 23 mm bioprosthetic valve.
AVR|aortic valve replacement|AVR|226|228|ASSESSMENT|1. Cough/wheezing/dyspnea. 2. Probably represents bronchitis. However, I cannot rule out this is all attributed to her post pericardiotomy syndrome. 3. Pleural pericardial effusion/post pericardiotomy syndrome. 4. Status post AVR and coronary artery bypass graft (X 2) dated _%#MMDD2003#%_. PLAN: 1. Continue nebs in the short term - I do not suspect she will need these long-term.
AVR|aortic valve replacement|AVR|147|149|PAST MEDICAL HISTORY|Prior to her surgery, she did not have any history of cough, wheezing, orthopnea. PAST MEDICAL HISTORY: 1. Coronary artery bypass graft X 2, LIMA, AVR with bioprosthesis dated _%#MMDD2003#%_. 2. Atrial fibrillation. a. Status post pacemaker placement. b. History of Amiodarone. 3. Hypercholesterolemia. 4. No previous history of pneumonia, asthma, bronchitis or TB.
AVR|aortic valve replacement|AVR|194|196|PAST MEDICAL HISTORY|At the time of her most recent hospitalization, an echocardiogram suggested an ejection fraction of around 40%. PAST MEDICAL HISTORY: 1. Aortic stenosis and coronary artery disease treated with AVR and coronary artery bypass graft on _%#MMDD2003#%_. 2. A history of sick sinus syndrome with pacemaker placement _%#MM#%_ 2002.
AVR|aortic valve replacement|AVR|218|220|ASSESSMENT AND PLAN|Per daughter, patient diagnosed with atrial stenosis one year ago and had stated at that time that she would not have surgery. 6. Discharge Planning. This is pending family conference. If patient does not want to have AVR surgery consider TLC Home Care or Hospice Home Care. I did speak with Dr. _%#NAME#%_ who stated if patient refuses surgery she will be appropriate for Hospice.
AVR|aortic valve replacement|AVR|177|179|HISTORY|The patient is a poor historian and information is obtained from the patient, old chart that is available. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 57-year-old gentleman status post AVR for aortic stenosis at Fairview Southdale Hospital on _%#MMDD2007#%_. Discharged on _%#MMDD2007#%_. Perioperatively he was diagnosed to have atelectasis, pneumonia and was treated with incentive spirometry and Levaquin respectively.
AVR|aortic valve replacement|AVR|135|137|HISTORY OF PRESENT ILLNESS|She went to Cardiac Catheterization on _%#MMDD2005#%_. She had been started on Mucomyst before the procedure. She is now scheduled for AVR and coronary artery bypass grafting. She has no prior history of kidney disease and denies stones or urinary tract infection.
AVR|aortic valve replacement|AVR|235|237|HISTORY OF PRESENT ILLNESS|REASON FOR CONSULTATION: Intensive Care Unit management of hypotension, acute renal failure, and respiratory failure after an aortic valve replacement HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 85-year- old who has had an AVR done due to progressive dyspnea. She has chronic kidney disease and is status post unilateral nephrectomy because of malignancy.
AVR|aortic valve replacement|AVR|128|130|PAST MEDICAL HISTORY|It does not appear she is on any vasodilator therapy. PAST MEDICAL HISTORY: The past medical history is complex. 1. Status post AVR and MVR with Bjork-Shiley valves in 1979. 2. Status post coronary artery bypass graft (CABG) and partial pericardiectomy in 1998.
AVR|aortic valve replacement|AVR,|323|326|HISTORY OF PRESENT ILLNESS|REQUESTING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 82-year-old woman I am asked to see after she presented with increasing shortness of breath. She has a complex cardiac history including congestive heart failure due to severe mitral regurgitation, status post MVR and AVR, severe tricuspid regurgitation with moderately severe pulmonary hypertension. She has been having difficult to control left-sided and right-sided heart failure.
AVR|augmented voltage right arm|AVR.|174|177|EKG|He has trivial lower extremity edema. EKG: Electrocardiogram on admission shows mild J point elevation in leads I, II, III, and V5 and V6. There is mild PR elevation in lead AVR. ECHOCARDIOGRAM: As referenced above. LABORATORY: No evidence for troponin rise. He has a mild leukocytosis and left shift possibly due to steroid use.
AVR|augmented voltage right arm|AVR.|308|311|LABORATORY DATA|Her feet were warm. LABORATORY DATA: Sodium 140, potassium 4.5, chloride 106, total CO2 of 24, BUN of 34, creatinine 1.6, INR 1.0. Hemoglobin 9.9, white count 6.1, platelet count 200,000. Electrocardiogram shows a varying amount of inferior as well as anterolateral ST segment depression and ST elevation in AVR. ASSESSMENT AND RECOMMENDATIONS: The patient is having coronary ischemia with chest pain and EKG changes despite treatment in the emergency room.
AVR|aortic valve replacement|AVR|199|201|REVIEW  OF SYSTEMS|12. Metoprolol 25 mg b.i.d. 13. K-Dur 20 mEq b.i.d. x3 doses 14. Dulcolax suppositories. REVIEW OF SYSTEMS: HEENT denies any headaches CONSTITUTIONAL: Denies any weight changes. CARDIAC: Status post AVR and history of coronary artery disease that are stable. PULMONARY: Denies any cough, sputum production, wheezing. GI: No bowel movement as of yet, but he is passing flatus.
AVR|aortic valve replacement|(AVR)|451|455|REASON FOR CONSULTATION|The patient came to the emergency room after having about a half an hour of upper steady chest discomfort that did not seem to vary with respiration or movement and was identified as grade 2 on a scale of 10 and similar to discomfort he had had when he was in _%#CITY#%_ _%#CITY#%_, Minnesota at his cabin walking on a treadmill and walking outdoors as well, relieved by rest. He has known coronary disease and is status post aortic valve replacement (AVR) with a bioprosthesis placed in 2001 with perhaps bypass surgery done at that time and a previous bypass performed I believe in 1990.
AVR|aortic valve replacement|AVR|193|195|ASSESSMENT/PLAN|ASSESSMENT/PLAN: The patient is a 68-year-old gentleman with history of aortic valve replacement for stenosis and coronary artery bypass grafting x 1 for coronary artery disease related to the AVR procedure in 1996. He developed congestive heart failure symptoms in the last 3-4 years. The symptoms have been progressive in the last 1-1/2 years.
AVR|aortic valve replacement|AVR|155|157|HISTORY OF PRESENT ILLNESS|Unfortunately, Dr. _%#NAME#%_'s initial note is missing and there is not clear documentation of exactly what the surgery consisted of. I believe he had an AVR homograft and single bypass surgery. The patient is wide awake and is lying comfortably in bed. He denies significant chest discomfort although he does feel fatigued.
AVR|aortic valve replacement|AVR|172|174||I saw and evaluated the patient with Dr. _%#NAME#%_. Please refer to his extensive note for further details. Briefly, this is a 76 yo female patient who recently underwent AVR for severe aortic stenosis. In the postoperative course, she developed complete AV block and required the placement of a permanent PMK.
AVR|aortic valve replacement|AVR|111|113|A/P|she was gradually rewarmed. She continues to be sedated, intubated. She is hemodynamically stable. A/P: 1. S/p AVR for severe AS. 2. S/p PMK placement. 3. S/p cardiac arrest. 4. Controlled hypothermia protocol completed. 5. Major issues: - Mental status, which will need to be evaluated as her sedation wears off.
AVR|aortic valve replacement|AVR|119|121||Please refer to his extensive note for further details. Briefly, this is a 76 yo female patient who recently underwent AVR for severe aortic stenosis. In the postoperative course, she developed complete AV block and required the placement of a permanent PMK.
AVR|aortic valve replacement|AVR|70|72|A/P|She is sedated, intubated. She is hemodynamically stable. A/P: 1. S/p AVR for severe AS. 2. S/p PMK placement. 3. S/p cardiac arrest. 4. Controlled hypothermia protocol.
AVR|aortic valve replacement|AVR|119|121|INDICATIONS|Please refer to his extensive note for further details. Briefly, this is a 76 yo female patient who recently underwent AVR for severe aortic stenosis. In the postoperative course, she developed complete AV block and required the placement of a permanent PMK.
AVR|aortic valve replacement|AVR|111|113|A/P|she was gradually rewarmed. She continues to be sedated, intubated. She is hemodynamically stable. A/P: 1. S/p AVR for severe AS. 2. S/p PMK placement. 3. S/p cardiac arrest. 4. Controlled hypothermia protocol completed. 5. Major issues: - Mental status, which will need to be evaluated as her sedation wears off.
AVR|augmented voltage right arm|AVR|278|280|LABORATORY DATA|The patient moved all extremities without difficulty. LABORATORY DATA: Electrocardiogram demonstrated mildly inverted T waves in the inferolateral leads but also in V1 and V2 the T wave is mildly biphasic. The T wave changes appear nearly diffuse, excluding only the leads AVL, AVR and possibly I. Other laboratories indicate a normal troponin and normal myoglobin. ASSESSMENT/PLAN: This is an individual who had a tachycardia for the first time.
AVR|aortic valve replacement|(AVR)|197|201|IMPRESSION|White cell count 9.7, hemoglobin 10.7. Sodium is 141, potassium is 3.6, BUN is 25, creatinine is 0.84. IMPRESSION: 1. Postop atrial fibrillation. 2. Five days status post (aortic valve replacement (AVR) and right coronary artery bypass grafting. 3. Diabetes mellitus. PLAN: 1. We will start the patient on intravenous amiodarone today and then switch him to oral amiodarone tomorrow.
AVR|aortic valve replacement|(AVR)|112|116|REASON FOR CONSULTATION|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, M.D. REASON FOR CONSULTATION: Status post aortic valve replacement (AVR) with hypoxemia. ASSESSMENT: 1. Status post aortic valve replacement (AVR). a. No preoperative pulmonary disease/life-long nonsmoker/has allergies and cough since _%#MM#%_ which could represent possible cough-variant asthma.
AVR|aortic valve replacement|AVR|189|191|IMPRESSION|Discussion was held with the family and again there are variances in the degree of support. However, we are doing near maximal support at this time and he is not responding well. 2. Recent AVR and CABG complicated by several cardiac arrests. 3. Probable pneumonia. This will need treatment and culturing. There was possible aspiration too given his course.
AVR|augmented voltage right arm|AVR.|207|210|LABORATORY|Sodium 139, potassium 4.4, glucose 97, BUN 15, creatinine 0.8, calcium 8.8, PTT 28, chest x-ray reported as clear. EKG changes reported decrease in ST Lead I, II, AVF, V3 through V6 with an increased ST and AVR. She is currently on a Heparin drip and awaiting cardiology consultation. IMPRESSION: 1. Idiopathic anaphylaxis. I don't feel at this point that there is further work up that is required given the extensive work up that she has had in the past.
AVR|aortic valve replacement|AVR,|269|272|ASSESSMENT/PLAN|Rhythm strips demonstrates 100% AV paced. ASSESSMENT/PLAN: Overall patient is a 70-year-old gentleman with multiple medical problems as outlined with significant COPD, sleep apnea, diabetes, renal insufficiency, renal failure who is now immediate postoperative from an AVR, partial MAZE procedure and ligation of his left atrial appendage. The patient is currently hemodynamically stable on a moderate dose phenylephrine.
AVR|aortic valve replacement|AVR|140|142|IMPRESSION/PLAN|The patient did develop the bradycardia following a fosphenytoin injection. She also has her Digoxin on hold, would continue to monitor. 2. AVR with St. Jude's device. Continue Coumadin with a goal INR of 2.0 to 3.0. The echocardiogram shows no evidence of clot formation with expected elevated gradients across the valve for St. Jude device.
AVR|aortic valve replacement|AVR|136|138|PAST MEDICAL HISTORY|No leg edema, no orthopnea, no PND, no focal weakness. No anxiety, no depression. PAST MEDICAL HISTORY: 1. Aortic stenosis, status post AVR with porcine valve on _%#MMDD2003#%_. 2. Atrial fibrillation status post AVR. 3. Coronary artery disease? status post angiogram with multivessel CAD.
AVR|aortic valve replacement|AVR.|158|161|PAST MEDICAL HISTORY|No anxiety, no depression. PAST MEDICAL HISTORY: 1. Aortic stenosis, status post AVR with porcine valve on _%#MMDD2003#%_. 2. Atrial fibrillation status post AVR. 3. Coronary artery disease? status post angiogram with multivessel CAD. Echo EF of 65% 4. Right carotid endarterectomy in 2006
AVR|aortic valve replacement|AVR.|219|222|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Diabetes. 2. Hypertension. 3. Peripheral vascular disease. 4. COPD. 5. Chronic atrial fibrillation. 6. Chronic renal insufficiency. 7. Hyperlipidemia. 8. Coronary artery disease. 9. Status post AVR. 10. Aortic aneurysm status post aneurysm repair. 11. Coronary artery disease status post coronary artery bypass grafting surgery. 12. Congestive heart failure. SOCIAL HISTORY: Significant for previously smoking.
AVR|aortic valve replacement|AVR|150|152|PAST MEDICAL HISTORY|No restless leg symptoms. Not a restless sleeper. No cataplexy or paralysis. Tired and fatigued. PAST MEDICAL HISTORY: 1. Dialysis for five years. 2. AVR five-and-a-half years ago, although, she does not recognize cardiomyopathy, she has had organic heart disease. 3. Her PFTs have showed a significant restrictive deficit in the 40% range.
AVR|aortic valve replacement|AVR.|240|243|PLAN|I would obtain fasting lipid profiles but in the meantime I will add a statin medication because he has had previous bypass surgery. If this patient truly has a mitral valve which I believe he has, his INR goal will be 3-3.5 higher than an AVR. It certainly has been a pleasure to be involved in the care of this very nice patient.
AVR|aortic valve replacement|AVR,|263|266|DOB|The pacemaker which had been on the left side was moved to the right. The actual organism involved is not clear, but he did have a TEE, as I understand it, in association with that admission and with that problem that did not show any problem associated with the AVR, which I believe is mechanical, and a composite graft placed in 1989 for Marfan syndrome and an aortic root enlargement, he states, at 4.5 cm.
AVR|aortic valve replacement|AVR|154|156|PAST MEDICAL HISTORY|History is obtained from the chart and record. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post coronary artery bypass graft (? details). 2. AVR with Bjork-Shiley valve in 1981. 3. History of ischemic cardiomyopathy with an EF of 35-40% prior to this hospitalization. 4. Peripheral vascular disease status post left iliofemoral bypass.
AVR|aortic valve replacement|AVR|191|193|SUGGESTIONS|2. Hypokalemia. This needs to be replaced. 3. History of transient ischemic attack, currently stable. 4. History of hypertension which is stable. SUGGESTIONS: 1. Lasix at current dose. 2. No AVR anticipated. 3. Treat COPD exacerbation as you are. 4. Keep his ventricular rate below 100 as you are with Digoxin. 5. Avoid Zaroxolyn as above. Thank you very much for this interesting consultation.
AVR|augmented voltage right arm|AVR.|198|201|LABORATORIES|There were no masses. There was no ABDOMINAL tenderness. LABORATORIES: The electrocardiogram demonstrated sinus bradycardia with a corrected QT interval at 0.42, T wave flattening in V5, V6, 2, and AVR. Other laboratories include a sodium of 137, potassium 4.5, BUN 23, creatinine 1.8. The troponin level was less than 0.07. The TSH level was 1.7. The hemoglobin was 13.3, white blood cell count was 6.7 with 92% neutrophils, 4% lymphocytes, and 3% monocytes.
AVR|aortic valve replacement|AVR|241|243|IDENTIFICATION|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD - thoracic surgeon IDENTIFICATION: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 70-year-old female with 2 recent admissions, most notably _%#MMDD2006#%_, now 3 days postop from a redo sternotomy with AVR and CABG. REASON FOR CONSULTATION: Evaluation and assessment with respect to elevated BUN and creatinine.
AVR|aortic valve replacement|AVR,|162|165|IMPRESSION|REASON FOR CONSULTATION: Evaluation and assessment with respect to elevated BUN and creatinine. IMPRESSION: 0. Postoperative day #3 0. from a redo sternotomy1. , AVR, CABG x2. 1. P1. ostoperative day #1 2. from mediastinal reexploration, question of tamponade and mediastinal wash out. We note some difficulty with chest tube drainage and requirement for additional chest tube placement.
AVR|aortic valve replacement|AVR|209|211|HISTORY|She had had an intraoperative transesophageal echo which showed mild LV enlargement, mild LV dysfunction with global hypokinesis with ejection fraction of 40-45% with normal RV size and function. Her St. Jude AVR was functioning normally with no AI identified. The mean gradient was 15 with peak of 25. The patient did have a preoperative chest x-ray which I reviewed that showed cardiomegaly and small right pleural effusion and minimal atelectasis and calcification of the ascending aorta.
AVR|aortic valve replacement|AVR|193|195|PAST MEDICAL HISTORY|She seemed to be in pain. Since that time she has had a little bit of a nap and seems much stronger and more alert. PAST MEDICAL HISTORY: Previous acute subacute bacterial endocarditis with an AVR homograft in _%#MM#%_ 1995. Her initial A- V surgery was 1975 at the University of Minnesota. She had a previous ejection fraction of 55%, REVIEW OF SYSTEMS: She had some numbness in her body in _%#MM#%_ and she has been followed by Neurology for that.
AVR|aortic valve replacement|AVR|260|262|HISTORY OF PRESENT ILLNESS|The hospitalist service was asked by Dr. _%#NAME#%_ to see the patient for management of her diabetes mellitus while she is an inpatient on the cardiology service. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 81-year-old white female status post an AVR replacement and CABG x1 by Dr. _%#NAME#%_ on _%#MMDD2006#%_ for critical aortic stenosis, who was recuperating at a nursing home and was admitted by Dr. _%#NAME#%_ _%#NAME#%_ after presenting to Minnesota Heart Clinic today with atrial fibrillation with rapid ventricular rate and a moderate pericardial effusion.
AVR|aortic valve replacement|AVR.|154|157|PAST MEDICAL HISTORY|6. Bilateral sensory neural hearing loss. 7. History of diverticulosis. 8. History of low-grade Guillain-Barre syndrome. 9. Allergic rhinitis. 10. Recent AVR. 11. Recent CABG. 12. Atrial fibrillation during this hospitalization. PAST SURGICAL HISTORY: Extensive and includes: 1. Appendectomy 2. Total abdominal hysterectomy
AVR|aortic valve replacement|AVR|196|198|PAST SURGICAL HISTORY|7. Cystocele and vaginal prolapse repair. 8. Cystoscopy for hematuria. 9. Left breast biopsy. 10. Bilateral cataract removal. 11. Laparoscopic cholecystectomy. 12. Left total hip replacement. 13. AVR and CABG x1 on _%#MMDD2006#%_. ALLERGIES: Include penicillin, sulfa. MEDICATIONS ON ADMISSION 1. Amaryl 1 mg p.o. b.i.d.
AVR|aortic valve replacement|AVR|77|79|CHIEF COMPLAINT|The patient was admitted to Abbott Northwestern Hospital in _%#MM2005#%_ for AVR and right coronary artery bypass grafting done _%#MMDD2005#%_. She returned to the hospital with postoperative complications of chest wall pain and was reexplored with sternotomy incision.
AVR|augmented voltage right arm|AVR.|248|251|LABORATORY DATA|SKIN: Warm and dry to touch. NEUROLOGIC: Grossly nonfocal. LABORATORY DATA: Nuclear exercise stress test; exercise stress test revealed dramatically positive electrocardiogram with 3-4 mm changes inferiorly and anterolaterally with ST elevation in AVR. Images on initial read revealed apical and septal mid and distal ischemia that was moderate in size with an LV ejection fraction of 61% at rest, changing to 46% post stress.
AVR|aortic valve replacement|AVR.|139|142|IMPRESSION|This was brought up during her last admission and Dr. _%#NAME#%_ _%#NAME#%_ had agreed to perform coronary artery bypass grafting, MVR and AVR. The patient herself declined at that time and wanted to give it further thought. I have discussed the ramifications of her potential fall yesterday and have suggested that she should reconsider her decision about not having surgery.
AVR|aortic valve replacement|AVR|139|141|PAST MEDICAL HISTORY|Review of systems again is otherwise negative. No recent medication changes. NO KNOWN DRUG ALLERGIES. PAST MEDICAL HISTORY: 1. Status post AVR homograft 2002 2. Diabetes 3. Coronary disease 4. Hyperlipidemia 5. Status post coronary artery bypass surgery times four 6. Normal left ventricular function. CARDIAC RISK FACTORS: Include a family history and age, diabetes.
AVR|aortic valve replacement|AVR|189|191||He was admitted to Ridges Hospital in congestive failure and was subsequently transferred to Fairview Southdale for surgical treatment for aortic stenosis and for mitral disease. He had an AVR and CAB yesterday and postoperatively he has been on the ventilator. Attempt to wean him earlier today failed. PAST MEDICAL HISTORY: He does not have any long-standing history of underlying pulmonary disease.
AVR|aortic valve replacement|AVR|111|113|HISTORY OF PRESENT ILLNESS|Her coronary artery bypass graft involved a LIMA to the LAD and a vein graft to the right coronary artery. Her AVR is a 21 mm Medtronic Mosaic. On review of the chart, her intraoperative course appears to be uncomplicated.
AVR|aortic valve replacement|AVR.|220|223|IMPRESSION|It looks like there was only one remaining dose and so I would just give that dose and follow on telemetry. 2. History of coronary artery disease, aortic stenosis, status post two vessel coronary artery bypass graft and AVR. She is post-operative day #3. On review of her meds, she is on an aspirin and a beta blocker. Lipitor is listed as an allergy, but per her outpatient note, she was agreeable to try another statin.
AVR|augmented voltage right arm|AVR.|361|364|HISTORY OF PRESENT ILLNESS|Since then she has had a bit of stuttering discomfort and a troponin drawn six hours after the pain began was high-normal at 0.08. With pain, her EKG demonstrates a slight T wave flattening in leads III and AVF but there is no ST segment depression or elevation. Her heart rate is both at 51 and 73 beats per minute on serial ECGs. She has no elevation in lead AVR. Chest x-ray was normal. In addition to the nitroglycerin drip and Dilaudid, she was given Lovenox and transferred to the floor.
AVR|aortic valve replacement|AVR|175|177|IDENTIFICATION|IDENTIFICATION: _%#NAME#%_ _%#NAME#%_ is a 55-year-old female who presents on the Cardiology Service with a history of rheumatic disease, associated valve disease status post AVR (aortic valve repair), MVR (mitral valve repair), now with tricuspid regurgitation and presents with increasing pain following percutaneous G-tube placement. PAST MEDICAL HISTORY: 1. Diabetes. 2. Atrial fibrillation. 3. Congestive heart failure.
AVR|aortic valve resistance|AVR|256|258|PAST MEDICAL HISTORY|She is currently intubated but alert. Nurses note issues of low urine output. PAST MEDICAL HISTORY: Diverticulitis as described above, chronic renal failure with baseline creatinine about 1.3 to 1.4, Alzheimer's dementia, aortic stenosis with an estimated AVR of 0.9 cm, anxiety disorder with depression, irritable bowel syndrome, hypertension, bilateral cataract extractions, bilateral knee replacements, hysterectomy with lysis of adhesions, osteoarthritis.
AVR|augmented voltage right arm|AVR.|163|166|PHYSICAL EXAMINATION|He does have 3 mm of ST segment depression in leads V5 and V6, with less degree of ST-T depression in the inferior leads. The ST segment elevation is seen in lead AVR. His troponin is 10.52. Platelets 3.58, INR 1.18, blood gases prior to intubation showed a pH of 7.18, P02 of 72, PC02 of 51.
AVR|aortic valve replacement|AVR.|269|272|IMPRESSION/PLAN|Her ejection fraction is preserved. There is some mild worsening of her aortic valve area, but we shall simply continue to observe this for the time being. Unless there is substantial recovery from this current episode, she is not likely to be a surgical candidate for AVR. Short runs of PSVT are common in the elderly and do not require treatment.
AVR|aortic valve replacement|AVR|110|112|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD _%#NAME#%_ _%#NAME#%_ is a 57-year-old man who is status post AVR on _%#MMDD2005#%_. He had AVR and now has a permanent pacemaker. Postoperatively, was up 9 kilograms in weight. Most fluid has pulmonary congestion and chest x-ray with infiltrates.
AVR|aortic valve replacement|AVR;|163|166|ASSESSMENT|NEPHROLOGY CONSULTATION: Acute renal failure. REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_. ASSESSMENT: _%#NAME#%_ _%#NAME#%_ is a 57-year-old man four days postop AVR; he has had a slowly rising creatinine. I suspect this is prerenal. He has a lot of third spaced fluid that may not diurese as yet.
AVR|aortic valve replacement|AVR,|133|136|PAST MEDICAL HISTORY|He had been noted to be having diarrhea for several days. PAST MEDICAL HISTORY: Includes COPD, CHF, atrial fibrillation, status post AVR, chronic kidney disease, dementia, status post CVA and BPH. He has had bilateral hernia surgery and cardiovascular surgery. ALLERGIES: IODINE AND CODEINE.
AVR|aortic valve replacement|AVR.|199|202|PHYSICAL EXAM|NECK is supple. LUNGS show diminished breath sounds in the left base otherwise clear cardiac exam today. He has a regular rate and rhythm, no murmur. He has metallic valve sounds consistent with his AVR. ABDOMEN: Normal bowel sounds, soft and nontender. No hepatosplenomegaly. GU EXAM: Shows Foley catheter in place. Normal male pattern. EXTREMITIES: Normal nails and joints. Pulses are full in the upper extremities.
AVR|aortic valve replacement|AVR,|142|145|PAST MEDICAL HISTORY|There has been a question of methicillin-resistant Staphylococcus aureus in the past but none documented here. No asthma or TB. He has had an AVR, bypass, prostate cancer. Patient has nocturnal ventilation with tidal volume of 800, FiO2 37%, respiratory rate 12, PEEP of 5. SOCIAL HISTORY: He has never smoked. He is retired. FAMILY HISTORY: See old charts.
AVR|aortic valve replacement|AVR|185|187|CHIEF COMPLAINT|CHIEF COMPLAINT: _%#NAME#%_ _%#NAME#%_ is an 80-year-old woman exactly one week postop from an aortic valve replacement who now presents with hematemesis and melena. The patient had an AVR for stenosis on _%#MMDD2005#%_ and made a good recovery. Yesterday, she left the hospital, was discharged to home and she vomited in the car on the way home.
AVR|aortic valve replacement|AVR.|134|137|CHIEF COMPLAINT|The patient tells me that she was taking 325 mg of aspirin per day for three years for a transient ischemic attack before she had her AVR. Now she is off this and on Coumadin, although the AVR is said to be a tissue valve. She takes no other nonsteroidal anti-inflammatory drugs except occasional Aleve in the past.
AVR|aortic valve replacement|AVR|189|191|CHIEF COMPLAINT|The patient tells me that she was taking 325 mg of aspirin per day for three years for a transient ischemic attack before she had her AVR. Now she is off this and on Coumadin, although the AVR is said to be a tissue valve. She takes no other nonsteroidal anti-inflammatory drugs except occasional Aleve in the past.
AVR|aortic valve replacement|AVR|232|234|ASSESSMENT|Hemoglobin 12.5 today. CT scan of the abdomen performed on _%#MMDD#%_ indicated that most of the stomach is in the chest. ASSESSMENT: 1. Anemia with heme positive stool. Stools are dark but patient is on iron. 2. Status post recent AVR and coronary artery bypass graft. PLAN: 1. Will discuss with attending the feasibility of pursuing upper endoscopy tomorrow.
AVR|aortic valve replacement|AVR|179|181|IMPRESSION|Other causes might be considered as well. 2. Hyponatremia almost certainly exacerbated by thiazide diuretics, which should be avoided in the future. 3. Status post St. Jude 21 mm AVR in 1990 and with LIMA to the LAD stable and long-lasting. 4. Etc as noted above. My bias is that we should not restrict her salt at the present time, but restrict her fluids to 1000 cc a day and begin Natrecor and twice daily Lasix.
AVR|aortic valve replacement|AVR|302|304|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Chronic kidney disease, baseline creatinine of 1.6. Etiology is probably cardiorenal as his EF previously was in the 30% range versus hypertension though that has not been bad. 2. Controlled hypertension. 3. Coronary artery disease, status post two-vessel CABG. 4. Status post AVR 1993. 5. History of complete heart block, status post pacer in 1993. 6. Dyslipidemia. 7. Ischemic heart disease with the history with depressed EF.
AVR|aortic valve replacement|AVR,|241|244|REVIEW OF SYSTEMS|A cultures was positive for Group D Enterococcus. REVIEW OF SYSTEMS: RESPIRATORY: Significant for recurrent tracheostomy and the need for respiratory ventilator support. CARDIAC: Significant for valvular heart disease. She is status post an AVR, MVR, tricuspid replacement with a pacemaker. She also has a history of congestive heart failure. RENAL: Significant for history of recent acute renal failure.
AVR|aortic valve replacement|AVR|184|186||_%#NAME#%_ _%#NAME#%_ is an 82-year-old gentleman followed by a partner Dr. _%#NAME#%_ _%#NAME#%_ with a past medical history significant for coronary artery bypass grafting x2 and an AVR with a St. Jude valve in 1993. He subsequently developed heart block requiring his first pacemaker replaced in 1993. His most recent pacemaker, that being his third, was placed in _%#MM#%_ of this year.
AVR|aortic valve replacement|AVR|115|117|PAST  MEDICAL HISTORY|He has no symptoms to suggest a TIA or CVA. His underlying rhythm is atrial fibrillation. PAST MEDICAL HISTORY: 1. AVR as outlined above. 2. Coronary artery disease as outlined above. 3. Benign prostatic hypertrophy. 4. Hypertension. 5. Hypercholesterolemia, although he is not on any statin.
AVR|aortic valve replacement|AVR|314|316|RECOMMENDATIONS|RECOMMENDATIONS: I believe that the patient's chief complaint of loss of stamina is multifactorial situation due to his multiple active medical conditions. Although the patient would theoretically benefit from aortic valve replacement to unload his left ventricle and improve his survival chances, I doubt that an AVR and coronary artery bypass grafting with dramatically improve his quality of life because he is so chronically debilitated. I think he would likely require greater than 6 months to recover.
AVR|aortic valve replacement|AVR,|170|173|REASON FOR CONSULTATION|I have reviewed this ECG. This shows a regular monomorphic tachycardia with a negative concordance in V1 through V6, negative in II, III and aVF and markedly positive in AVR, suspicious for ventricular tachycardia. She converted spontaneously from this wide complex rhythm to a normal sinus rhythm that showed an underlying left bundle branch block which in comparison to old ECGs was unchanged.
AVR|augmented voltage right arm|AVR|214|216|IMPRESSION|IMPRESSION: Wide complex tachycardia. Although the ECG is not classic for VT, there are several features that would suggest that this is coming from the ventricle, specifically the markedly positive deflections in AVR would suggest a low ventricular origin for this tachycardia. I do not believe that this is an atrial tachycardia with aberrancy because her baseline left bundle branch block looks quite different, especially in the lateral leads.
AVR|aortic valve replacement|AVR|138|140|PAST MEDICAL HISTORY|Her activity level was to be determined by us to see if activity was safe for her. PAST MEDICAL HISTORY: 1. Hypertension. 2. Dementia. 3. AVR in 1997. 4. GERD with GIB in 2004. 5. Right CEA in 1974. 6. CVA 1974. 7. TIA 2003. 8. Cataract surgery.
AVR|aortic valve replacement|AVR|127|129|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Coronary artery disease, status post bypass surgery in _%#MM#%_ 2001. 2. Aortic stenosis, status post AVR in 1997. 3. Hypertension. 4. Diabetes type 2. 5. Hyperlipidemia. 6. Degenerative joint disease. 7. Status post bilateral knee replacement. 8. Status post right shoulder hemiarthroplasty.
AVR|aortic valve replacement|AVR|192|194|IMPRESSION AND RECOMMENDATIONS|Sensation is symmetrically intact to light touch. Reflexes are 1+. IMPRESSION AND RECOMMENDATIONS: This is an 88-year-old gentleman, Russian-speaking, status post coronary bypass grafting and AVR with multiple medical comorbidities. He is currently functionally impaired in his ADLs and mobility. Prior to this he was independent with his ADLs, requiring no assistive device, although he was mobilizing within short distances.
AVR|aortic valve replacement|AVR,|290|293|REASON FOR CONSULTATION|REASON FOR CONSULTATION: To evaluate for rehabilitation needs. REQUESTING PHYSICIAN: Dr. _%#NAME#%_ HISTORY OF PRESENT ILLNESS: This is a 55-year-old male with a history of restrictive cardiomyopathy secondary to his radiation from a distant history of Hodgkin's lymphoma along with ASCVD, AVR, MVR, ESKD, and aortic regurgitation with recent history of aspiration pneumonia and parapneumonic effusion. He has been hospitalized at University of Minnesota Medical Center since _%#MMDD2007#%_.
AVR|aortic valve replacement|AVR.|142|145|PAST MEDICAL HISTORY|3. Gout. 4. Hypertension. 5. Polymyalgia rheumatica. She has chronically been on steroids currently at 40 mg a day. 6. Obesity. 7. History of AVR. 8. Bilateral total knee arthroplasties. 9. Cholecystectomy. 10. Appendectomy. 11. History of osteoporosis. She had been on Actonel previously.
AVR|aortic valve replacement|AVR.|182|185|PAST MEDICAL HISTORY|He denies any fevers and otherwise feels generally well. PAST MEDICAL HISTORY: 1. Previous aortic valve replacement. 2. Aortic valve endocarditis as described above with replacement AVR. 3. Coronary artery disease with bypass grafting. 4. Hyperlipidemia. 5. Left total hip arthroplasty. ALLERGIES: None known though recent rash.
AVR|aortic valve replacement|AVR,|118|121|PROBLEM #5|The patient will followup with cardiology in 3 to 4 weeks for his restrictive cardiomyopathy. PROBLEM #5: Status post AVR, MVR and paroxysmal AFib. The patient before the hospitalization had a atrial and mitral valve replacement and he also has a history of paroxysmal AFib for which he was kept on Coumadin and the goal INR was between 2 and 3.
AVR|aortic valve replacement|AVR|169|171|DISCHARGE FOLLOWUP|3. Hemodialysis, on Monday, Wednesday and Friday under the care of Dr. _%#NAME#%_ _%#NAME#%_. 4. Followup with cardiology in 3 to 4 weeks for restrictive cardiomyopathy AVR and MVR. 5. Followup with Coumadin Clinic in next 3 days. His goal INR has to be between 2 and 3. 6. The patient's primary care physician should be following up with the INR, PTT, complete blood count with 3 to 4 days at the transitional care unit.
AVR|aortic valve replacement|AVR,|168|171|PROBLEM #7|PROBLEM #6: Hypertension. This is well controlled with a combination of atenolol and lisinopril. PROBLEM #7: Coronary artery disease (coronary artery bypass graft x 4, AVR, pacemaker). Currently stable. Continue beta blockers and ACE inhibitors. PROBLEM #8: Severe depression with severe vegetative symptoms and social withdrawal.
AVR|aortic valve replacement|AVR|128|130|PAST MEDICAL HISTORY|3. History of bowel perforation, status post resection in 1998. 4. Status post ICD placement for V-tach in 1998. 5. Status post AVR Medtronic in 1990. 6. Status post pacemaker placement for bradycardia in 1992. 7. Coronary artery disease status post 5-vessel bypass in 1990.
AVR|augmented voltage right arm|AVR.|159|162|PROBLEM #5|PROBLEM #5: Cardiovascular: The patient was admitted on _%#MMDD2007#%_ and underwent cardiovascular clearance. An EKG at that time showed inverted T-waves and AVR. However cardiology was consulted in regards to his and the patient subsequently was found to have a normal stress echo on _%#MM2007#%_, thus per cardiology, they felt it was okay to proceed to OR as scheduled.
AVR|aortic valve replacement|AVR.|335|338|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: This is an 84-year-old male patient with history of coronary artery disease, status post recent stenting X3, ischemic cardiomyopathy, and aortic valve repair on chronic Coumadin who presents with likely upper GI bleed. 1. GI. This is a difficult situation in view of the patient's need for anticoagulation for his AVR. The patient says he has been on Coumadin for long periods of time starting in 1987. He has not had any GI bleeding from that. The patient notes a history of ulcers.
AVR|aortic valve replacement|AVR.|225|228|ASSESSMENT AND PLAN|If the patient were to bleed more acutely, he can stop heparin immediately and the INR will not be too high. Will start Protonix 40 mg IV b.i.d. Keep the patient NPO. Monitor hemoglobin every 8 hours. 2. Cardiac. Status post AVR. He is on chronic Coumadin. He has a high risk for developing a thromboembolic event if he were to stop anticoagulation altogether.
AVR|aortic valve replacement|AVR|332|334|HISTORY OF THE PRESENT ILLNESS|CHIEF COMPLAINT: Cough, shortness of breath, chest pain. HISTORY OF THE PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a very unfortunate 48-year-old male with past medical history significant for aortic insufficiency secondary to a prior subacute bacterial endocarditis approximately 2-3 years ago who is recently status post homograft AVR and single vessel coronary artery bypass (LIMA to left anterior descending), which was complicated by a subsequently pericarditis and readmission in late _%#MM#%_ for a pericardiocentesis emergently performed secondary to tamponade physiology who returned to Fairview Southdale emergency room with a chief complaint of refractory substernal chest pain associated with cough. The patient's symptoms began approximately three days prior to presentation.
AVR|aortic valve replacement|AVR,|316|319|IMPRESSION|Hemoglobin is 11.8, platelets are 177,000. Myoglobin is 42. Initial troponin is high at 0.5. See history of the present illness for remaining labs, EKG And chest x- ray results. IMPRESSION: An unfortunate 48-year-old male with a complicated recent cardiac history including aortic insufficiency requiring homograft, AVR, coronary artery disease, status post LIMA to single vessel coronary artery bypass graft, pericarditis and pericardial effusion with tamponade who again presented to the emergency room with a cough productive of a mildly discolored sputum, no evidence of pneumonia on either exam or chest x-ray, positional chest discomfort that is reproducible on examination and significant EKG abnormalities of unclear etiology.
AVR|augmented voltage right arm|AVR|253|255|ASSESSMENT|The issue is ischemia causing rapid ventricular rate from atrial fibrillation which further causes ischemia or is this atrial fibrillation which is causing demand ischemia. Review of his electrocardiogram shows atrial fibrillation and some elevation in AVR so of course there is concern that there is left main disease. An urgent echocardiogram was performed by myself and reviewed by Dr. _%#NAME#%_ which showed an ejection fraction of about 50%, some mild hypokinesis of the anterior wall, but no evidence of akinesis.
AVR|aortic valve replacement|AVR|295|297|PAST MEDICAL HISTORY|4. Hypertension. 5. Hyperlipidemia. 6. Depression. 7. Anxiety. 8. Congestive heart failure with ejection fraction of 30% on _%#MMDD2006#%_ secondary to severe aortic stenosis. The patient had coronary angiogram on _%#MMDD2006#%_ which showed no significant coronary artery lesions. He underwent AVR with porcine valve on _%#MMDD2006#%_. ALLERGIES: Adhesive tape and nitroglycerin. MEDICATIONS: 1. Paxil 60 mg p.o. daily. 2. Colace 100 mg p.o. daily.
AVR|aortic valve replacement|AVR|152|154|SOCIAL HISTORY|5. Calcium carbonate 500 mg p.o. daily. 6. Lovenox 100 mg subq q. 12 hours. SOCIAL HISTORY: The patient is married and lived with his wife prior to his AVR but currently resides at a nursing home. No tobacco or alcohol. FAMILY HISTORY: Reviewed and noncontributory to patient's current admission.
AVR|aortic valve replacement|AVR|190|192|ASSESSMENT/PLAN|EKG showed sinus tachycardia with left bundle branch block. Heart rate was 102. No acute change compared to old EKG. ASSESSMENT/PLAN: This is a 63-year-old white male who recently underwent AVR with porcine valve, who is here today with CHF exacerbation and gross hematuria. He is also hypotensive and lethargic possibly secondary to early sepsis syndrome.
AVR|aortic valve replacement|AVR|181|183|PROBLEM LIST|PROBLEM LIST: 1. CARDIOVASCULAR: Patient had an angiogram on _%#MMDD2006#%_ which revealed no significant coronary artery disease. Echo on _%#MMDD2006#%_ showed severe AS requiring AVR with porcine valve. EF prior to the AVR was 30%. Now patient with CHF exacerbation. Lasix on hold since _%#MMDD2007#%_ per nursing home physician. Unable to diurese him tonight secondary to hypotension.
AVR|aortic valve replacement|AVR|221|223|PROBLEM LIST|PROBLEM LIST: 1. CARDIOVASCULAR: Patient had an angiogram on _%#MMDD2006#%_ which revealed no significant coronary artery disease. Echo on _%#MMDD2006#%_ showed severe AS requiring AVR with porcine valve. EF prior to the AVR was 30%. Now patient with CHF exacerbation. Lasix on hold since _%#MMDD2007#%_ per nursing home physician. Unable to diurese him tonight secondary to hypotension.
AVR|aortic valve replacement|AVR.|125|128|PROBLEM LIST|Unable to give fluid at this time because of the concern of CHF decompensation. Paroxysmal atrial fibrillation. This is post AVR. In normal sinus rhythm on amiodarone. Rate is well-controlled with low dose metoprolol. I would hold both of these medications tonight secondary to low blood pressure.
AVR|augmented voltage right arm|AVR|132|134|HISTORY  OF PRESENT ILLNESS|He was not diaphoretic, was not particularly short of breath. His EKG shows sinus bradycardia with a Q wave in V1 and V2 as well as AVR which appeared to be unchanged from _%#MM2007#%_. His initial troponin obtained at 0342 is negative.
AVR|augmented voltage right arm|AVR,|134|137|LABORATORY DATA|LABORATORY DATA: All reviewed by myself. Chest x-ray reveals no acute cardiopulmonary disease. EKG shows Q-waves in V1, V2 as well as AVR, sinus bradycardia. These are chronic changes. Serum labs, troponin at 0342 a.m. less than 0.04, myoglobin 31.
AVR|aortic valve replacement|AVR|156|158|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Congestive heart failure diagnosed in 1986. 2. The patient had an MI in 1995. 3. Type 2 diabetes diagnosed in 1976. 4. Status post AVR plus CABG x 3 in 2001. 5. Kidney transplant, 1996. 6. History of chronic venous stasis ulcers bilaterally. 7. Apnea. 8. Hypertension. 9. Hyperlipidemia. 10. Two dialysis fistulas in left arm, one dialysis fistula in right arm.
AVR|aortic valve replacement|AVR|75|77|PROBLEM #2|Angiogram showed now significant coronary disease. PROBLEM #2: Status post AVR on warfarin anticoagulation. The patient has a prosthetic aortic valve and was on warfarin anticoagulation on admission. We held his warfarin, so that his INR could drop down, so that he could safely receive an angiogram.
AVR|aortic valve replacement|AVR|304|306|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Diastolic dysfunction. His last transthoracic echocardiogram on _%#MMDD2006#%_ showed normal global LV systolic function, moderate increase in LV wall thickness, and RVSP = 44 + RA. The patient's last transesophageal echocardiogram on _%#MMDD2006#%_ shows patient is status post AVR without regurg and aortic valve gradient of 8 mmHg. He has normal LV systolic function and moderate left ventricular hypertrophy.
AVR|aortic valve replacement|AVR|225|227|ASSESSMENT|IMAGING: PA and lateral chest x-ray. There is persistent elevation of the right hemidiaphragm with right pleural effusion. There is mild interstitial edema and cardiomegaly. ASSESSMENT: This is a 59-year-old male status post AVR 4 weeks ago, history of diastolic congestive heart failure, hypertension, obstructive sleep apnea, and pulmonary hypertension who presents with mild volume overload, hypertensive urgency, and ongoing complaints of dyspnea.
AVR|augmented voltage right arm|AVR,|108|111|HISTORY OF PRESENT ILLNESS|Electrocardiogram was obtained at _%#CITY#%_, which did show flipped T waves in V4-V6, as well in 1, 2, and AVR, and ABS. These flipped T waves are new compared to previous electrocardiogram from 1999, and 2003. The patient is also noted to have prolonged QT, which is not new compared to the prior electrocardiograms.
AVR|augmented voltage right arm|AVR.|125|128|LABORATORY DATA|Electrocardiogram: Prolonged QT at 450 seconds. There are Q waves in 2, 3, and AVF. T wave is sloped in V4-V6, and 1, 2, and AVR. The T waves flipping is new compared to old electrocardiograms. Chest x-ray: Good expansion bilaterally without any acute process noted.
AVR|aortic valve replacement|AVR,|163|166|ASSESSMENT/PLAN|ASSESSMENT/PLAN: This is a 63-year-old female with a past medical history significant for type II diabetes, hypothyroidism, status post breast cancer, status post AVR, who presents to the clinic today for evaluation of her dermatomyositis. The patient has been on prednisone since _%#MMDD2004#%_ for her dermatomyositis.
AVR|aortic valve replacement|AVR.|249|252|ASSESSMENT/PLAN|Current plan is for physical and occupational therapy to facilitate her recovery from a physical strengthening and stability perspective. She will have sternal precautions. We will monitor her sternal wounds. 2. Aortic stenosis, status post porcine AVR. Date of procedure: _%#MMDD2005#%_. She will now be warfarin anticoagulated secondary to the nature of her valve. Again, sternal precautions will be undertaken. 3. Hyperglycemia. Blood sugars will be monitored for the next couple of days but if she remains stable, these will be discontinued or put to more less frequent screening.
AVR|aortic valve replacement|AVR,|197|200|REASON FOR ADMISSION|Patient was admitted to the hospitalist service for work-up of fever or unknown origin. 1. Fever and leukocytosis. Obviously, given the patient's history of aortic dissection and repair as well as AVR, there was concern for possible endovascular infection or endocarditis. An Infectious Disease consultation was obtained. On admission, a chest, abdomen and pelvic CT scan was obtained, which did not show any evidence of an abscess or reason for a fever.
AVR|augmented voltage right arm|AVR.|160|163|DISCHARGE DIAGNOSES|2. Right clavicular fracture secondary to fall. 3. Acute congestive heart failure. 4. Coronary artery disease status post stent placement on _%#MMDD2007#%_. 5. AVR. 6. Blood loss anemia. 7. Frequent PVCs. DISCHARGE MEDICATIONS: 1. Allopurinol 100 mg p.o. q. 48h. 2. Allopurinol 50 mg p.o. q. 48h.
AVR|aortic valve replacement|AVR|110|112|HOSPITAL COURSE|In addition, her lisinopril was restarted at the time of her discharge to the FUDS. She also has a history of AVR 7-8 y ears ago and was kept on treatment of Lovenox and as a bridge and is in the process Coumadin treatment with a goal INR of 2-3; she is receiving 2.5 mg daily and her INR at the time of discharge is 1.28. The anticoagulation above was recommended by cardiology.
AVR|aortic valve replacement|AVR|146|148|ATTENDING ADDENDUM|PMH, PSH, HPI, meds, FH, SH, and ROS confirmed; see initialed sections of house staff H&P for full details. Briefly, 71-year-old male status post AVR approximately 1 year ago with normal post procedure TEE (but focused on AV) with an approximately 50-pound weight gain and oliguria despite outpatient diuretics.
AVR|aortic valve replacement|AVR,|197|200|HOSPITAL COURSE|The transesophageal echo revealed no evidence of vegetations. A ventriculoseptal defect was seen with a left-to-right shunt in addition to a right-to-left shunt. As the patient had a history of an AVR, the patient was begun on Coumadin at the appropriate dose to ensure a proper INR. Also, at the time of admission, dermatology was consulted to evaluate the patient's rash on his lower extremities.
AVR|aortic valve replacement|AVR|167|169|PROBLEM #2|It is felt that at this time, replacing the aortic valve with a cholecystostomy drain in place is unsafe due to the high risk of postoperative valvular infection. Her AVR will be scheduled for 6 weeks from now after her cholecystostomy drain is removed. She will follow up with Dr. _%#NAME#%_ in Cardiothoracic Surgery Clinic on _%#MMDD2007#%_ at 01:00 p.m. PROBLEM #3: Macular degeneration: The patient is currently legally blind and as a result requires assistance with cholecystostomy tube cares as well as intravenous antibiotics.
AVR|aortic valve replacement|AVR|139|141|FAMILY HISTORY|He was on dialysis for the last five years of his life. He also had history of emphysema and hypertension. Mother is alive and status post AVR as well as hysterectomy; She has early stages of Alzheimer's dementia. One sister status post AVR at the age of 45; second sister status post TKA and is also on medication for depression.
AVR|aortic valve replacement|AVR|181|183|FAMILY HISTORY|He also had history of emphysema and hypertension. Mother is alive and status post AVR as well as hysterectomy; She has early stages of Alzheimer's dementia. One sister status post AVR at the age of 45; second sister status post TKA and is also on medication for depression. SOCIAL HISTORY: Single. Lives with her mother and is the main caregiver for her mom.
AVR|augmented voltage right arm|AVR|214|216|HISTORY OF THE PRESENT ILLNESS|I have the first EKG which was done upon the patient's arrival and I do not see acute ST elevation or depression. There is T-wave inversion in lead I and AVL, but I am questioning the wrong lead position given the AVR lead evaluation, so the second EKG was done. I don't see acute ST elevation or depression and the rhythm is sinus and there is no T-wave inversion over lead I or AVL.
AVR|augmented voltage right arm|AVR.|203|206|PHYSICAL EXAMINATION|EXTREMITIES: Edema which was pitting type. Electrocardiogram on admission revealed poor R wave progression and normal sinus rhythm. There were non-specific STT changes with attenuation V2 to V6 in I and AVR. Left axis deviation was noted. LABORATORY DATA: Sodium 137, potassium 5.7, chloride 96, CO2 of 28, glucose 162, BUN 32, creatinine 1.6, and peak troponin was 11.
AVR|aortic valve replacement|(AVR)|268|272|HISTORY OF PRESENT ILLNESS|The next day the patient was noted to have acute neurologic change and she was diagnosed with a left posterior branch middle cerebral artery (MCA) occlusion. The patient received systemic tissue plasminogen activator (t-PA). Patient also has a history of aortic valve (AVR) and was on Coumadin which was held 4-5 days preoperatively. In the immediate postoperative period she was restarted on heparin and Coumadin per patient's report.
AVR|augmented voltage right arm|AVR.|159|162|LABORATORY DATA|The cycle length is approximately 260 milliseconds. The tachycardia has left bundle branch block morphology and inferior axis. It is negative in leads aVL and AVR. The QRS duration is approximately 140 milliseconds. The tachycardia terminated spontaneously without change of cycling of more than 40 milliseconds. It is, however, clearly sustained ventricular tachycardia. There were no PVCs of a similar morphology or indeed any PVCs recorded before or after this sustained VT.
AVR|aortic valve replacement|AVR|143|145|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Coronary artery disease, status post coronary artery bypass graft in 2000. 2. History of aortic stenosis, status post AVR with bioprosthetic valve. 3. Diabetes mellitus. 4. Hypertension. 5. Hyperlipidemia. 6. History of esophageal cancer, status post resection approximately five or six years ago.
AVR|aortic valve replacement|AVR|150|152|PAST MEDICAL HISTORY|She denies having any nausea or diaphoresis. She states she feels quite comfortable. She knows where she is. PAST MEDICAL HISTORY: 1. Significant for AVR with a bioprosthesis approximately 3 years ago by Dr. _%#NAME#%_ at Methodist Hospital. 2. Atrial fibrillation dating back 20 years.
AVR|aortic valve replacement|AVR,|200|203|ASSESSMENT AND PLAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD. REASON FOR CONSULTATION: Cardiogenic shock. ASSESSMENT AND PLAN: Mr. _%#NAME#%_ _%#NAME#%_ is a 72-year-old man who recently had a two-vessel CABG and AVR, who developed acute hypotension and abdominal pain last night. He was found to have a pericardial hematoma and tamponade and taken to the OR emergently where he was found to have a bleeding right coronary graft.
AVR|rapid ventricular response:RVR|AVR|420|422|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 86-year-old white female with a history of hypertension, chronic kidney disease, stage III, with a creatinine previously documented of 1.3-1.7 in _%#MM#%_ and _%#MM#%_ 2007 and now more recently documented at 2.32, TMJ, hyperlipidemia, anxiety, atrial fibrillation and remote PE in _%#MM2007#%_, who was admitted _%#MMDD#%_ to the 28 with atrial fibrillation with AVR and seen in consultation by Dr. _%#NAME#%_ _%#NAME#%_ at Minnesota Heart and subsequently readmitted again on _%#MMDD#%_-_%#MMDD#%_ at Fairview Ridges Hospital and seen in consultation by Dr. _%#NAME#%_ _%#NAME#%_.
AVR|aortic valve replacement|AVR.|272|275|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a complex 40-year-old with significant burden of illness and problems related to a diagnosis of idiopathic cardiomyopathy from what I understand. He is status post ICD device placement with a history of VSD repair, as well as AVR. He presented to the emergency room because of 3-day history of headache with concern for possible meningitis. This started on antibiotics and definitive LP diagnosis was not possible since the patient had declined procedure.
AVR|aortic valve replacement|AVR|142|144|PAST MEDICAL HISTORY|He also has significant anxiety, and we were asked also to comment on this. PAST MEDICAL HISTORY: 1. Aortic stenosis with bicuspid valve with AVR and VSD done in 2006. 2. VSD 3. Complete heart block status post PTM placement. 4. Congestive heart failure. 5. Hypertension. 6. History of ETOH abuse.
AVR|augmented voltage right arm|AVR.|125|128|LABORATORY DATA|LABORATORY DATA: EKG demonstrated normal sinus rhythm with inverted T-waves in leads V1 through V3 as well as III in AVF and AVR. Other laboratories include a TSH of 2.66, troponin less than 0.04, BNP is 7670. Sodium 139, potassium 5.0, BUN 24, creatinine 1.3. The hemoglobin was 11.5, platelet count 138,000 and white blood cell 6.
AVR|rapid ventricular response:RVR|AVR,|203|206|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_ The hospitalist service was asked by Dr. _%#NAME#%_ to follow _%#NAME#%_ _%#NAME#%_ for his history of mitral valve prolapse with atrial fibrillation with AVR, hypertension and elevated cholesterol. CHIEF COMPLAINT: Abdominal pain since 5:00 p.m. on _%#MMDD2006#%_. HISTORY OF PRESENT ILLNESS: This is a 68-year-old white male with a history of hypertension and mitral valve prolapse with atrial fibrillation with rapid ventricular rate, elevated cholesterol, sigmoid diverticulitis, seasonal allergies for which he was started on prednisone on Friday _%#MMDD2006#%_ who is followed by a Dr. _%#NAME#%_, colorectal surgery and Dr. _%#NAME#%_.
AVR|aortic valve replacement|AVR,|310|313|ASSESSMENT AND PLAN|I had a long discussion on the patient's condition with the patient's Power of Attorney (her son), _%#NAME#%_ _%#NAME#%_, and also updated the patient's condition with Dr. _%#NAME#%_ _%#NAME#%_. 1. Cardiovascular co-morbity due to multifactorial including: Cardiomyopathy with CHF, CAD s/p CABG x1, S/p Bovine AVR, AAA 6 cm, Paroxymal Atrial fibrillation, Hypertenison and old age predispose a very high-risk for cardiac event in the perioperative period including acute congestive heart failure with pilmonary edema and difiuclty with fluid management, acute myocardial infarction, and cardiac dysrhythmia and valvular heart disease.
AVR|augmented voltage right arm|AVR|148|150|ASSESSMENT AND PLAN|The QRS morphology suggests left lateral accessory pathway with negative QRS pattern in lead 1 positive QRS in 2 3 and AVF and negative QRS in lead AVR and aVL. The precordial leads showed a right bundle branch block morphology. The patient was cardioverted again and this time sinus rhythm was restored with preexcitation of the same type except that now with effusion with the AV nodal conduction, the delta wave appears to be isoelectric in lead 1.
AVR|augmented voltage right arm|AVR.|109|112|PHYSICAL  EXAMINATION|There is mild right-sided conduction delay observed with a very small R prime in V1 and a larger R prime and AVR. There is a negative T-wave in V1, a normal finding in there are Q-waves in 3 and AVF but they are not diagnostic for any prior damage.
AVR|aortic valve regurgitation|AVR|197|199|HOSPITAL COURSE|5. Left second toe amputation. HOSPITAL COURSE: Mr. _%#NAME#%_ is a 50-year-old male with endstage renal disease on hemodialysis status post kidney transplant which failed and also history of MVR, AVR and history of DVT. He was admitted to the hospital 8 days ago because of hypoxia, right lower extremity swelling and for possible left second toe amputation because of gangrene.
AVR|aortic valve regurgitation|AVR|220|222|HISTORY|Thank you for asking me to evaluate _%#NAME#%_ _%#NAME#%_ who is an 81-year-old female with fevers, rigors, leukocytosis, diarrhea following coronary artery bypass grafting. HISTORY: This 81-year-old female had CABG and AVR St. Jude's on _%#MMDD2006#%_. Urine culture from _%#MMDD#%_ grew greater than 100,000 Klebsiella pneumoniae that was sensitive to Septra.
AV|atrioventricular|AV|148|149|PLAN|He was monitored from _%#MMDD#%_ to _%#MMDD2007#%_. During this time he had no dizzy spells. His heart rhythm was primarily sinus with first degree AV block with episodes of second-degree AV block and Mobitz AV conduction. Because of the lack of dizziness and good medical follow-up subsequently I did not recommend that he get a pacemaker at this time.
AV|atrioventricular|AV|252|253|HOSPITAL COURSE|HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 70-year-old gentleman with a history of syncope one year ago who presents with recent progressive and quite limiting exertional fatigue and was found to have persistent 2:1 AV block with periods of up to 4:1 AV block and bradycardia with rates of 40 or less. His history is clearly consistent with both symptomatic bradycardia and he clearly had high grade AV block at times.
AV|atrioventricular|AV|344|345|DISCHARGE DIAGNOSES|1. Coronary artery disease status post percutaneous coronary intervention with Taxus drug-eluting stent 3.5 x 18 mm inflated to 18 atmospheres with pre-PTCA of that same lesion, Voyager 2.5 x 12 mm with a total of 135 cc of Optiray 350. 2. Ischemic cardiomyopathy status post bypass surgery. 3. Chronic angina. 4. Conduction disorder, complete AV block status post pacemaker implantation. 5. Diabetes mellitus, insulin dependent. 6. Hypertension. Please refer to _%#NAME#%_ _%#NAME#%_'s very detailed note from _%#MMDD2007#%_.
AV|arteriovenous|AV|184|185|PAST MEDICAL HISTORY|7. COPD, 8. hyperlipidemia 9. hypertension, 10. status post left popliteal arterial bypass with in situ vein graft, 11. status post cataract removal, 12. status post TURP, status post AV fistula placement, 13. status post laparoscopic cholecystectomy, 14. chronic atrial fibrillation. MEDICATIONS: 1. Coumadin 1 mg alternating with 2 mg every other day
AV|atrioventricular|AV|120|121|LABORATORY DATA|Troponin is less than 0.05. Myoglobin is 108. Chest x-ray is negative. 12 lead EKG shows sinus rhythm with first degree AV block with no evidence of ischemia. Rhythm strip did show a Wenckebach second-degree heart block. ASSESSMENT/PLAN: 1. Syncope/secondary heart block. The patient will be evaluated by Cardiology.
AV|atrioventricular|AV|206|207|PAST MEDICAL HISTORY|2. Paroxysmal atrial fibrillation /flutter 3. Labile hypertension 4. History of transient ischemic attack (_%#MM#%_ 2004, _%#CITY#%_, Minnesota) 5. History of pericarditis (1996) 6. History of first degree AV block 7. Status post cholecystectomy (1949) 8. History of staphylococcal bacteremia (1985, left foot, Dr. _%#NAME#%_ _%#NAME#%_) 9. Presbycusis 10. Status post appendectomy 11. Benign prostatic hypertrophy status post transurethral prostatectomy (1996, Dr. _%#NAME#%_)
AV|arteriovenous|AV|253|254|HISTORY|ADMITTING DIAGNOSIS: Cellulitis. DISCHARGE DIAGNOSIS: Same. HISTORY: This 32-year-old woman presented for admission with exacerbation of her longstanding cellulitis in the right lower extremity. She had a past medical history significant for congential AV malformations of the right leg, including extensive involvement of the proximal thigh and labia majora and hip. She had multiple procedures by surgery and interventional radiology and dermatology for treatment of these malformations and had chronic open wound on the medial aspect of her thigh.
AV|atrioventricular|AV|194|195|HOSPITAL COURSE|HOSPITAL COURSE: The patient was admitted for supraventricular tachycardia ablation. She underwent electrophysiology study by Dr. _%#NAME#%_ _%#NAME#%_. The tachycardia initially appeared to be AV node re- entrant tachycardia. After careful studying and mapping, it appeared atypical. VA was short but it was only induced on isoproterenol infusion.
AV|arteriovenous|AV|348|349|HOSPITAL COURSE|It was thought that the best course of action would be to monitor the patient's hemoglobin as an outpatient and given him oral iron to take on a daily basis. If the patient continues to have decreases in his hemoglobin and requires multiple transfusions, it may be re-evaluated that a scope may be done from below to look for the possibility of an AV malformation that may be laser treated alone or to simply leave the situation alone, respecting patient's wishes for either.
AV|arteriovenous|AV|205|206|DISCHARGE FOLLOW-UP|The patient was admitted on _%#MM#%_ _%#DD#%_ and discharged _%#MM#%_ _%#DD#%_, 2005 for congestive heart failure and chronic obstructive pulmonary disease and Dig. toxicity. He has a history of a gastric AV malformation which was oozing and the bleeding was controlled with a gastric clip in _%#MM#%_ of 2004 and he recently had an outpatient transfusion to treat recurrent anemia.
AV|atrioventricular|AV|451|452|HISTORY OF PRESENT ILLNESS|We then proceeded with the radio frequency ablation of the clockwise atrial flutter, which is described in more detail in the procedure report, but which was successful and resulted in persistent bidirectional block and termination of the atrial flutter. He was also found to have atrial flutter. Today at 4:30 the patient is doing extremely well and his electrocardiogram prior to departure from the hospital shows a sinus rhythm with a first-degree AV block, occasional APC, and nonspecific _______________ changes probably related to his prior tachycardia. My plan will be to admit the patient to Fairview Ridges Hospital tomorrow for initiation of treatment with continuous infusion with unfractionated IV heparin.
AV|atrioventricular|AV|243|244|HISTORY OF PRESENT ILLNESS|She denies any syncopal episodes recently, as well as denying any edema or orthopnea, but she does state that she has had anterior chest pain for several months now. She is followed by Dr. _%#NAME#%_ in cardiology clinic for her second degree AV block. PAST MEDICAL HISTORY: 1. Palpitations. The patient had an EP study in _%#MM#%_ of 2004, with an event monitor, which recorded 7 beat run of wide complex QRS tachycardia at a rate of 150 to 160, which was self-terminated.
AV|atrioventricular|AV|187|188|HISTORY OF PRESENT ILLNESS|She did very well, and was discharged home in the care of her parents on _%#MM#%_ _%#DD#%_, 2005, to follow up with Dr. _%#NAME#%_ _%#NAME#%_ or with myself following that to schedule an AV canal repair once the child is slightly older. DISCHARGE MEDICATIONS: 1. Lasix 5 mg p.o. per G-tube t.i.d.
AV|atrioventricular|AV|373|374|IMPRESSION AND PLAN|IMPRESSION AND PLAN: Mr. _%#NAME#%_ is a 56-year-old male with a history of obesity and asthma and a recent history of what sounds like upper respiratory type infection symptoms who is being admitted with tachycardia and a mildly elevated troponin. 1. Left bundle branch block on EKG. 2. Arrhythmia: I suspect this is likely supraventricular tachycardia and would favor an AV nodal reentrant tachycardia. The rhythm while in tachycardia appears to be regular, so I do not suspect this is atrial fibrillation nor I do suspect a flutter.
AV|atrioventricular|AV|159|160|HISTORY OF PRESENT ILLNESS|He was then found to have another syncopal episode and underwent EP study by Dr. _%#NAME#%_ where he was found to have monomorphic ventricular tachycardia and AV nodal reentrant tachycardia. The patient is planned for an ablation _%#MMDD2006#%_. We should note, at the _%#MMDD#%_ EP study his pacer was changed to an internal defibrillator pacer with the addition of another wire and of course a new pacer defibrillator.
AV|arteriovenous|AV|189|190|PAST SURGICAL HISTORY|11. Atherosclerotic cardiovascular disease with myocardial infarct, _%#MM1999#%_. 12. Hyperlipidemia. PAST SURGICAL HISTORY: 1. Gore-Tex AV graft to left upper extremity, 1999 (failed). 2. AV fistulas, left upper extremity x 3, 1999 (all three failed). 3. PTCA with stent to LAD, 1999. 4. Cholecystectomy, age 20.
AV|atrioventricular|AV|166|167|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Showed lungs to be clear and the heart to be irregular rhythm with a regular rate. EKG on admission was normal sinus rhythm with a first degree AV block and a few PVC. T wave inversion in V1 was unchanged from prior EKG. Hemoglobin was 11. K 4.4. INR 0.94, PTT was 25, platelets 276, creatinine 8.5. HOSPITAL COURSE: The patient was taken to the operating room where a living related kidney transplant was performed and placement in the patient's right groin by Drs. _%#NAME#%_ and _%#NAME#%_.
AV|atrioventricular|AV|198|199|ADMISSION DIAGNOSIS|OPERATIONS/PROCEDURES PERFORMED: Include pacemaker extraction and replacement secondary to a fractured pacemaker lead. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 12-year-old male with a history of AV block. He had a pacemaker placed initially at 6 years of age. He had been doing well with the pacemaker and he was in 1 week before his hospitalization for a yearly cardiac appointment.
AV|atrioventricular|AV|178|179|HOSPITAL COURSE|Chest x-ray showed cardiomegaly, redistribution of the pulmonary vasculature, and mild interstitial infiltrates were present. Electrocardiogram showed sinus rhythm, first-degree AV block, occasional premature ventricular contractions, and a left bundle branch block, with a QRS duration of 1.94. At the time of discharge, the patient is ambulating more than 100 feet without difficulty.
AV|arteriovenous|AV|124|125|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. End stage renal disease. 2. Initiation of maintenance hemodialysis. 3. Status post ligation of left AV fistula secondary to Steal Syndrome. 4. Long-standing hypertension. 5. Diabetes. 6. Ingrown toenail. 7. Left-sided pleural effusion on chest x-ray.
AV|atrioventricular|AV|152|153|PAST  MEDICAL HISTORY|She has had no syncopal episodes. She denies any previous history of coronary artery disease. PAST MEDICAL HISTORY: 1. Atrial fibrillation, status post AV nodal ablation with permanent pacemaker placement about 8 years ago. 2. History of urinary tract infection _%#MM2005#%_. 3. History of SIADH.
AV|atrioventricular|AV|157|158|IMPRESSION|If his AV conduction system dysfunction progresses, he may ultimately need a pacemaker, although currently that does not seem to be an issue. IMPRESSION: 1. AV conduction system dysfunction. 2. Controlled atrial fibrillation. 3. Anticoagulation to follow, with long-term commitment to Coumadin. 4. Post-right thoracentesis. 5. Coronary artery disease with mildly diminished left ventricular function.
AV|atrioventricular|AV|168|169|LABORATORY|It does appear without infiltrate or acute processes. EKG done today shows normal sinus rhythm at 95 beats per minute, normal axis. She does have borderline 1st degree AV block. White count is 8.1, hemoglobin 14.5, platelets 348,000. Basic metabolic panel is all within normal limits. ASSESSMENT: This is an 89-year-old female who presents today for preoperative evaluation in anticipation of cataract excision from the right eye on _%#MMDD2006#%_, at Fairview Ridges Hospital by Dr. _%#NAME#%_ for right cataract.
AV|atrioventricular|AV|164|165|HOSPITAL COURSE|She has a follow-up appointment for INR at Dr. _%#NAME#%_'s clinic on Friday. In addition to using antiarrhythmic agents, I also discussed other options, including AV nodal ablation and pacemaker placement. I explained to her that doing this procedure will not eliminate atrial fibrillation; It will only help in control of ventricular rate, and she will become pacemaker dependent.
AV|arteriovenous|AV|359|360|PAST SURGICAL HISTORY|She was readmitted for treatment of her nausea, vomiting, diarrhea and further evaluation of her leukocytosis. PAST SURGICAL HISTORY: Surgical repair of an upper GI bleed, multiple dialysis catheters, splenectomy, renal transplant x3, appendectomy, thyroid surgery, parathyroid surgery, right and left knee arthroscopies, partial right lobectomy secondary to AV malformation, and questionable hysterectomy. PAST MEDICAL HISTORY: 1. Problems include the glomerulonephritis with secondary renal failure, now on her third renal transplant.
AV|arteriovenous|AV|137|138||The patient had recently been hospitalized for rectal bleeding with negative workup and had past history of rectal bleeding secondary to AV malformations in the colon. Other past history included coronary artery bypass, chronic atrial fibrillation on Coumadin and aortic valve replacement.
AV|arteriovenous|AV|206|207|OPERATIONS/PROCEDURS PERFORMED|Small bowel was decompressed. She had an MRI of the abdomen and kidneys that showed no evidence of a renal artery stenosis and no evidence of an acute abdomen. She had a renal ultrasound that showed a mild AV fistula in the lower pole of the kidney that was not significant and no evidence of renal artery stenosis on velocities.
AV|atrioventricular|AV|131|132||Troponins have been negative times three. EKG showed a right bundle branch block. He has had sinus bradycardia with a first degree AV block also. He has had no pain since admission. He just completed a stress echo, but this has not been read. PAST MEDICAL HISTORY: He has a history of hypertension and chronic obstructive pulmonary disease.
AV|arteriovenous|AV|133|134|HISTORY OF PRESENT ILLNESS|3. Hypertension. 4. Status post pancreas transplant at the same time as her kidney transplant which was cadaveric. 5. Left upper arm AV fistula in _%#MM#%_ 2002. ADMISSION MEDICATIONS: Prevacid 30 mg p.o. q.d., metoprolol 25 mg p.o. b.i.d., Norvasc 5 mg p.o. b.i.d., Prograf 3 mg p.o. b.i.d., CellCept 1 g p.o. b.i.d., calcium with vitamin D 1.25 g p.o. b.i.d. ALLERGIES: NO KNOWN DRUG ALLERGIES.
AV|atrioventricular|AV|480|481|LABORATORY|LABORATORY DATA: Chest x-ray shows an enlarged cardiac silhouette with some increased pulmonary vascularization. Sodium 139, potassium 3.5, chloride 96, bicarb 33, BUN 36, creatinine 1.8, calcium 9.2, albumin 3.8, total bili 0.2, alkaline phosphatase 137, ALT 16, AST 22, INR 0.94, hemoglobin 12, white count 11,900 with no differential yet, platelet count 222,000, MCV 90, troponin less than 0.07, myoglobin 10, TSH 3.73, T3 1.62. EKG shows normal sinus rhythm with first-degree AV block. IMPRESSION: The patient is an elderly female with gait instability over the last week and increasing confusion presumably secondary to subacute bilateral frontal infarcts.
AV|atrioventricular|A.V.|167|170|LABORATORY|Bicarbonate 29. BUN 38. Creatinine 1.4. Glucose 103. Bilirubin 0.3. Albumin 2.7. Protein 5.9. Alkaline phosphatase 5.2. ALT 20. AST 18. Electrocardiogram first degree A.V. block with sinus bradycardia. Unchanged from previous electrocardiograms. HOSPITAL COURSE: The patient was admitted and closely followed hemodynamically.
AV|atrioventricular|AV|188|189|LABORATORY DATA|EKG from admission to this hospital on _%#MMDD2003#%_ at 0939 hours shows atrial flutter with a controlled ventricular response. On follow up telemetry and EKG, he has had a second degree AV block (Mobitz type I) with heart rates in the 30-40 range. There are no acute ST changes. Lipid panel is normal. IMPRESSION: This patient has had multiple falls. He is documented to have intermittent sinus rhythm with first degree heart block, controlled atrial flutter and Mobitz I second degree heart block with low heart rates.
AV|atrioventricular|AV|144|145|CARDIOLOGY IMPRESSION|Pulmonary function studies were also done. TSH was pending. 4. Severely disabled by severe joint disease, elderly, frail body. 5. Emphysema. 6. AV conduction system dysfunction with sinus rhythm, left bundle branch block. 7. Acute subendocardial nonlocalized myocardial infarction but probably infra posterolateral.
AV|atrioventricular|AV|145|146|SUMMARY OF HOSPITAL COURSE|There were only a couple of runs lasting 4-5 beats. Subsequent to this acute intervention, he really had no evidence of complications. He had no AV block, no heart failure, no further rhythm disturbances and no further chest pain or angina. His troponin started at 0.2, peaked at 14 and then followed a decrescendo pattern.
AV|arteriovenous|AV|140|141|PHYSICAL EXAMINATION|There are no masses or tenderness. RECTAL exam was not performed. LOWER EXTREMITIES have no cyanosis, clubbing, or edema. There is a patent AV fistula on the left upper arm with some ecchymosis surrounding it. LABORATORY: Laboratories are pending. IMPRESSION: 1. Nausea and vomiting of uncertain cause, question if related to gastroparesis or peptic ulcer disease.
AV|atrioventricular|AV|280|281|DISCHARGE DIAGNOSIS|5. Placement of dual chamber ICD for treatment of recurrent near syncope in a patient with ischemic cardiomyopathy and ejection fraction of 30% by cardiac catheterization. The patient also had a very wide right bundle branch block, left anterior fascicular block and first degree AV block on EKG, suggesting significant underlying conduction system disease which would have required pacemaker, if not ICD in the setting of recurrent near-syncope.
AV|arteriovenous|AV|315|316|LABORATORY DATA AVAILABLE FOR REVIEW|SKIN - without rash, lesions, or jaundice. LABORATORY DATA AVAILABLE FOR REVIEW: Platelet count 297,000, white count 9.7, hemoglobin 15.4, hematocrit 45.7, sodium 142, potassium 3.9, chloride 107, glucose 79, creatinine 0.8, calcium 8.5. A CT scan was done of the head and was reportedly normal other than possible AV malformation. A urine pregnancy test was also negative. IMPRESSION/PLAN: 1. Narcotic precipitated seizures in a patient with previous history of same.
AV|atrioventricular|AV|154|155|IMPRESSION|Tracings from the Emergency Department revealed episodes of third degree AV block. IMPRESSION: This is a 79-year-old woman with syncope from third degree AV block. This cannot be explained by Atenolol at the current doses alone. I do not suspect an intentional overdose from Atenolol. Rather, she has senile heart disease.
AV|atrioventricular|AV|346|347|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: The past medical history has a notation of dementia, depression, chronic pain and peripherovascular disease, diabetes mellitus and GERD. The cardiac monitor notation on the ER nursing record was that she had atrial fib with PVC's noted on the cardiac monitor, however, the EKG is felt to show sinus rhythm with first degree AV block and left bundle branch blocks and left axis deviation and no PVC's were captured there. In the unit her rhythm is that of a sinus bradycardia.
AV|atrioventricular|AV|257|258|PHYSICAL EXAMINATION|The QRS complex exhibited incomplete right bundle branch block configuration, and while the tachycardia felt to terminate on carotid sinus massage it did terminate easily with 6 mg bolus of IV adenosine. It terminated in the atrium, suggesting block in the AV node as the termination mechanism. The EKG performed in sinus rhythm shows ventricular preexcitation; however, has a relatively-long PR interval of about 120 msec.
AV|atrioventricular|AV|196|197|DIAGNOSTIC IMPRESSION|4. Anemia, combination of iron deficiency and B-12. 5. Chronic obstructive pulmonary disease, moderate. 6. Pulmonary hypertension by previous testing. 7. Chronic atrial fibrillation with previous AV node ablation and currently well functioning pacemaker. 8. Hypothyroidism on replacement therapy. 9. Insomnia. 10. Slightly depressive disorder with occasional panic attacks.
AV|atrioventricular|AV|117|118|LABORATORY & DIAGNOSTIC DATA|Babinski is downgoing in both extremities. Sensation is intact. LABORATORY & DIAGNOSTIC DATA: EKG shows first degree AV block, but no acute ST segment changes. Head CT and carotid ultrasounds are negative. White count elevated at 13.8, hemoglobin 11.3, platelets 255,000, INR 1, absolute neutrophil count is 12.7. Electrolytes are unremarkable, BUN of 27, creatinine 1.11, glucose 116.
AV|atrioventricular|AV|119|120|PAST MEDICAL HISTORY|Stent was placed in _%#MM#%_, 2002. 3. Left carotid endarterectomy. 4. Atrial fibrillation status post ablation of the AV node and permanent pacemaker implantation. 5. Pericardial effusion in 2001 6. Melanoma, right scapula, excised in 1998. No evidence of recurrence. 7. Traumatic spine fracture of lumbar spine.
AV|atrioventricular|AV|155|156|HOSPITAL COURSE|On admission, she was not found to be hypoxic. She had an unremarkable CT scan with no acute changes on admission. Her admission EKG showed a first degree AV block with some degree of sinus bradycardia and some PACs. She had a creatinine on admission of 1.36.
AV|arteriovenous|AV|233|234|HOSPITAL COURSE|Interventional radiology evaluated the patient's catheter and with localized TPA was able to remove the fibrin sheath that had formed around the catheter tip. He was then deemed functioning. During this admission, the patient had an AV fistula placed by transplant surgery, Dr. _%#NAME#%_'s staff. This was without complications. The patient will need several months to allow this to mature and then may begin using her fistula for dialysis.
AV|atrioventricular|AV|72|73|DISCHARGE DIAGNOSES|PLANNED DISCHARGE DATE: _%#MMDD2007#%_ DISCHARGE DIAGNOSES: 1. Complete AV block with pause dependent torsades. The patient underwent permanent pacemaker placement on _%#MMDD2007#%_ and remained stable on telemetry thereafter.
AV|atrioventricular|AV|148|149|DISCHARGE MEDICATIONS|In addition, the patient will follow up in Pacer Clinic in one week's time for staple removal in order to increase his lower rhythm from 60-70. His AV delay will be kept at 300 msec to allow _______ conduction. There is actually significant latency in the atrial lead and the patient's PR interval measured from onset of his atrial electrocardiogram, and his 12-lead is actually much less than 300 msec.
AV|atrioventricular|AV|159|160|PLAN|Her vital signs were stable immediately thereafter. She was seen promptly by paramedics and transferred to the hospital. She was observed to have first-degree AV block but no other cardiac arrhythmia was apparent. The paramedic note indicated that she had two episodes, but there is no current documentation of the second episode's duration, etc.
AV|atrioventricular|AV|190|191|IMPRESSION|EXTREMITIES: Good, strong dorsalis pedis pulses noted; her surgical incision in the left hip is well healed. She has no calf tenderness. IMPRESSION: 1) Syncopal episode, possibly related to AV conduction abnormality. 2) Status post repair of recent left hip fracture. DISPOSITION: As per order sheet.
AV|arteriovenous|AV|188|189|OBJECTIVE|Head, eyes, ears, nose and throat: Normocephalic, atraumatic. Pupils equal, round react to light and accommodation, neck supple. Motion intact. Fundi sharp bilaterally. She does have some AV nicking present. TM's were clear. Nasal mucosa within normal limits. Oral cavity without erythema or exudate. Neck is supple, no adenopathy or thyromegaly is present. Her back without CVA or spinal tenderness.
AV|atrioventricular|AV|155|156|CHIEF COMPLAINT/REASON FOR ADMISSION|CHIEF COMPLAINT/REASON FOR ADMISSION: A 4-1/2-month- old female with Down syndrome presents to the pediatric ICU status post repair of a complete balanced AV canal and resection of subpulmonary muscle bundles and PDA ligation and PFO closure. Bypass time 2 hours 54 minutes. Cross-clamp time 2 hours 28 minutes.
AV|atrioventricular|AV|174|175|PROCEDURE|He underwent coronary angiography revealing an 80% proximal LAD lesion and mild diffuse disease up to 50% in the mid portion and an 80% stenosis in the high diagonal branch. AV groove circumflex had a 99% stenosis and the right coronary artery had a 90% stenosis just prior to the crux, 50 to 60% stenosis prior to the take-off of the PLA.
AV|atrioventricular|AV|73|74|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: 1. Tachybrady syndrome, placement of pacemaker with AV nodal ablation. 2. Coronary artery disease with unstable angina on admission. 3. Chronic anemia. Discharge hemoglobin around 9.5. 4. Chronic hyponatremia. Discharge sodium of 130.
AV|atrioventricular|AV|155|156|HISTORY OF PRESENT ILLNESS|He was found to be in atrial flutter and had EF of 25%. He had no previous known history of heart disease. He was cardioverted and an AICD was placed with AV pacing. The patient apparently had a normal angiogram with no evidence of coronary artery disease. I have a progress note from his cardiologist, who states normal _________ on angio.
AV|arteriovenous|AV|175|176|PAST SURGICAL HISTORY|4. Status post heart transplant and kidney transplant as noted above. 5. Status post 2-4 laminectomy. 6. Status post right carpal tunnel release _%#MM#%_ 2002. 7. Status post AV fistula in the right cephalic vein to brachial artery in _%#MM#%_ 2001. 8. Status post hip replacement in 1990. ALLERGIES: No known drug allergies.
AV|arteriovenous|AV|140|141|HOSPITAL COURSE|Problem #2: Stenotic left side dialysis access shunt. This was causing the patient's significant left upper thigh pain in the region of her AV fistula. Initially there was some concern for infection of the fistula; however, it was determined that she did have a stenotic area of the shunt.
AV|arteriovenous|AV|183|184|PHYSICAL EXAMINATION|ABDOMEN: Abdomen is soft. Bowel sounds are present. No enlargement of liver or spleen. EXTREMITIES: Lower extremities seem to have no edema. Pedal pulses are reduced. Right upper arm AV fistula which appears to be patent based on palpation and auscultation. IMPRESSION: 1. Troubles with dialysis access ? if is in the process of reclotting.
AV|arteriovenous|AV|117|118|PLAN|3. End-stage renal disease. 4. Ischemic heart disease with cardiomyopathy. PLAN: 1. We will try dialysis through his AV fistula with placing needles and if this fails he will have placement of a femoral line for one month. He will then be required to stay overnight after the femoral line is removed for adequate hemostasis.
AV|atrioventricular|AV|122|123|LABORATORY DATA|EXTREMITIES: No clubbing, cyanosis or edema. Normal pulses. NEUROLOGIC: Intact. LABORATORY DATA: EKG showed second-degree AV block with PVCs; his old EKGs do show first degree AV block. ASSESSMENT/PLAN: 1. Probable paroxysmal atrial fibrillation by exam with secondary heart block.
AV|atrioventricular|AV|178|179|BRIEF PATIENT'S HISTORY|She did show multiple pauses, which were over 2 seconds and episodes of conduction delay with intermittent left bundle branch block. Given her symptoms of syncope with sinus and AV blocks, the patient was recommended to undergo dual-chamber pacemaker placement. HOME MEDICATIONS: 1. Aspirin 235 mg daily. 2. Atacand 8 mg daily.
AV|atrioventricular|AV|194|195|PAST  MEDICAL HISTORY|14. _%#MM#%_ 2000 hospitalized with supraventricular tachycardia and left ventricular hypertrophy and atrial fibrillation. On that hospitalization the patient had electrophysiologic testing and AV node radiation therapy ablation. The procedure was unsuccessful. The patient does not have a pacemaker. 15. Severe aortic stenosis with valvular area of 0.7 to 0.8 cm2 and a gradient of 53.
AV|atrioventricular|AV|181|182|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Ischemic cardiomyopathy with ejection fraction of 20-25%. 2. Pulmonary edema secondary to congestive heart failure. 3. Status post generator replacement for AV pacer secondary to underlying sick sinus syndrome. OPERATIONS/PROCEDURES PERFORMED: 1. Echocardiogram showing an ejection fraction as stated above at 25- 30%, large regional akinesis of the anterior apical and septal elements, mild MR, and mildly elevated right ventricular systolic pressures of 45 mmHg.
AV|atrioventricular|AV|259|260|HISTORY OF PRESENT ILLNESS|He is not having any fevers. He has not noticed any melena in his stool, in fact has had very few bowel movements in recent days. A chest x-ray was clear. Electrocardiogram showed a question of very slight ST elevation in V2, V3 of maybe 0.5 mm, first degree AV block, otherwise no acute changes. White count is 18,700 with 86% PMN's. Hemoglobin is only 7.9. Platelets 759.
AV|atrioventricular|AV|189|190|DISCHARGE MEDICATIONS|No activity restrictions were recommended for this patient. He was warned not to take any more flecainide, as he is currently on sotalol. The plan for the patient in the future is possibly AV nodal ablation if sotalol does not control his atrial tachycardia.
AV|arteriovenous|AV|239|240|ADMISSION VITAL SIGNS|Positive bowel sounds and no masses were present. GENITALIA: Normal external genitalia for female of her age. SPINE: No spinal tenderness or spine tenderness. There is no edema and no lymphadenopathy. MUSCULOSKELETAL: Left upper extremity AV fistula with ecchymosis and possible thrombus. There is mild erythema. Distal pulses are intact bilaterally. Pain with palpation to that area.
AV|atrioventricular|AV|133|134|HISTORY OF PRESENT ILLNESS|There was periventricular white matter disease consistent with chronic small vessel disease. The patient's EKG showed a first degree AV block with normal sinus rhythm. The patient was admitted to the Cardiac Special Care Unit to rule out a cardiac cause for her fall.
AV|arteriovenous|AV|279|280|PAST MEDICAL HISTORY|3. Recent shoulder surgery 4. Skin cancer surgery within the past few months 5. He has had multiple angioplasties done in the past PAST MEDICAL HISTORY: Significant iron deficiency anemia in the past that has been evaluated a couple times with the most recent evaluation showing AV malformations with cautery treatment in the spring of 2005. SOCIAL HISTORY: He lives in _%#CITY#%_. He works as an investment advisor.
AV|arteriovenous|AV|194|195|HISTORY OF PRESENT ILLNESS|Recently dialysis quality has been poor and the patient presented with a clotted access today. He has had significant access problems in the past. Dr. _%#NAME#%_ created a left upper arm simple AV fistula proximal to the graft approximately two months ago. This access, while patent, is not yet developed satisfactorily and there have been issues with the graft functioning poorly in the past.
AV|atrioventricular|AV|263|264|PAST MEDICAL HISTORY|Subsequently, he has been seen by Dr. _%#NAME#%_, as well as Dr. _%#NAME#%_ and is on medical therapy, but they have been considering angiogram in the near future when his fistula ripens for dialysis. PAST MEDICAL HISTORY: 1. Coronary disease, as noted above. 2. AV nodal conduction disease with sick sinus syndrome. The patient has had a pacemaker in the past and it was actually just replaced approximately a week ago.
AV|atrioventricular|AV|159|160|PRIMARY DIAGNOSES|DISCHARGE DATE: _%#MMDD2007#%_. PRIMARY CARE PHYSICIAN: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD. PRIMARY DIAGNOSES: 1. Rapid atrial fibrillation, now status post AV nodal ablation 2. Left lower lobe pneumonia, concerning for aspiration. 3. Pelvic and retroperitoneal hematoma. SECONDARY DIAGNOSES: 1. Chronic obstructive pulmonary disease. 2. Pelvic fracture in _%#MM2007#%_ with retroperitoneal bleed in _%#MM2007#%_.
AV|atrioventricular|AV|148|149|DISCHARGE MEDICATIONS|The electrocardiogram is actually within normal limits with some mild ST segment straightening in V-5 and 6, not that significant, and first degree AV block. During this hospitalization, her blood pressure has been in actually pretty good control, usually running anywhere from 99 up to 142.
AV|atrioventricular|AV|151|152|PROBLEM #2|After being given diltiazem in the Emergency Department, he converted back to sinus rhythm, with a rate of 40's-50's. He most likely has an underlying AV node dysfunction with his bradycardia at rest, and his inappropriate response to atrial fibrillation. He will continue to be monitored, and at this time, will be treated solely with aspirin.
AV|atrioventricular|AV|208|209|HOSPITAL COURSE|The patient has required oxygen by nasal cannula due to his chronic obstructive pulmonary disease. The patient was transferred to the Cardiovascular floor on postoperative day #5. He has remained with a 100% AV paced rate. He has required three to four liters of oxygen by nasal cannula to maintain oxygen saturations greater than 90%.
AV|atrioventricular|AV|126|127|LABORATORY DATA|PSYCHOLOGICAL: He was oriented in adequately given situation. LABORATORY DATA: EKG showed sinus rhythm. He has a first degree AV block, otherwise normal. Chest x-ray showed some mild small calcified granulomas in the right hemithorax. No acute respiratory or cardiac changes. CBC showed a white blood cell count of 5.7, hemoglobin 13.0, platelets 247,000.
AV|atrioventricular|AV|206|207|LABORATORY DATA|Upper extremities are unremarkable. NEUROLOGIC: The patient can move all four extremities without difficulty. He is alert and oriented x 3. LABORATORY DATA: EKG reveals sinus bradycardia with first- degree AV block, frequent paroxysmal ventricular contractions, rate of approximately 45. Compared to previous EKG done in 2004, rate at that time was approximately 64 with no first-degree AV block nor paroxysmal ventricular contractions.
AV|arteriovenous|AV|166|167|HOSPITAL COURSE|She had no further headache which was controlled with IV morphine 2 mg and her visual acuity was fully intact with no evidence of papilledema, or AV malformations or AV nicking or silver wiring. The UA was negative for blood as well and creatinine was stable. The patient was admitted on lisinopril 20 a day as well as metoprolol 50 a day for the control of her hypertension.
AV|atrioventricular|AV|195|196|HISTORY OF PRESENT ILLNESS|She used to smoke cigarettes but quit many years ago, about 40 or more years, I do not think she had a prior history of chronic pulmonary or cardiac problems. She was admitted and found to be an AV block. Temporary pacemaker was placed. She had a chest x-ray on admission and the one done today show almost complete opacification of the left hemithorax.
AV|arteriovenous|AV|225|226|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: The patient is an 83-year-old gentleman presenting with lower gastrointestinal bleed while on warfarin. 1. Lower gastrointestinal bleed. At this time I would like to believe this is possibly secondary to AV malformation, diverticular or unclear etiology. Will hold warfarin after we check the INR. If need be will reverse him, but at this time I am disinclined to do that.
AV|atrioventricular|AV|225|226|CURRENT MEDICATIONS|3. Diovan and hydrochlorothiazide, 320/25 mg daily. 4. Fluorometholone, as directed daily. 5. Lipitor, 20 mg daily. 6. Norvasc, 5 mg b.i.d. Mr. _%#NAME#%_ _%#NAME#%_ underwent successful dual-chamber pacemaker for high-grade AV block. He had no complications. His pocket site looks free of hematoma and is clean, dry and intact. It is nontender. His pacemaker was interrogated and is functioning appropriately.
AV|arteriovenous|AV|189|190|PAST SURGICAL HISTORY|She has not had any previous history of MI. She had a previous cardiac work-up quite a few years ago as part of a study. PAST SURGICAL HISTORY: 1. Vascular renal transplant times three. 2. AV malformation. 3. Partial right pneumonectomy. 4. Splenectomy. 5. Appendectomy. MEDICATIONS: 1. CellCept 1000 mg PO b.i.d. 2. Gengraf 75 mg b.i.d.
AV|atrioventricular|AV|154|155|LABS EVALUATED DURING THIS HOSPITALIZATION|In summary, this elderly patient presented with syncope and was thought to have third degree heart block and intermittent bundle branch block. She had an AV sequential pacemaker placed, and she subsequently was found to have evidence of tachycardia as well, supporting two diagnoses; one of brady-tachy syndrome, and the second of complete heart block.
AV|atrioventricular|AV|245|246||Mr. _%#NAME#%_ was referred to me for this procedure in _%#MM#%_ of this year by his primary cardiologist, Dr. _%#NAME#%_ _%#NAME#%_. The procedure was technically failing in the sense that I have been unable to completely______ conductions for AV node during the procedure but functionally it has been a success in the sense that the patient has been essentially fully V paced in the 80-130 in VVIR mode of his pacemaker which I implanted on the same occasion.
AV|atrioventricular|AV|213|214|HOSPITAL COURSE|Recommended to have pacer in the past but had declined. Cardiology was consulted who recommended the procedures as above. On admit, EKG was with a rate of 60 showing left bundle-branch, sinus rhythm, first-degree AV block. Repeat EKG on _%#MM#%_ _%#DD#%_, 2006 showing T-wave inversion in the inferior and anterior leads as well as T-wave inversions in the lateral.
AV|atrioventricular|AV|329|330|IMPRESSION|NEUROLOGIC: Shows no gross motor or sensory deficits. LABORATORY DATA: From today show troponin 0.09. Sodium 138, potassium 3.7, chloride 100, bicarbonate 29, BUN 20, creatinine 0.97, glucose 126, calcium 9.4, glucose 140s today, INR 2.18. White count 8.8, hemoglobin 11.5. IMPRESSION: 1. Possible tachy Brady syndrome requiring AV nodal ablation and primary pacemaker placement per cardiology. 2. pneumonia. Stable on antibiotics. 3. Chronic obstructive pulmonary disease.
AV|arteriovenous|AV|441|442|HISTORY  OF PRESENT ILLNESS|She is on dialysis and had an AV fistula attempted _%#MMDD2006#%_, and then a successful attempt on _%#MMDD2006#%_, and has had had dialysis through her fistula for last 3 weeks. She now presents with an acutely clotted fistula, where she was scheduled to have AV fistula thrombolysis by Interventional Radiology, but had an IV allergy dye, therefore she was admitted to the University of Minnesota Medical Center, Fairview, for premeds and AV graft thrombolysis in the a.m. PAST MEDICAL HISTORY: 1. Diabetes mellitus type 2, insulin-dependent. 2. Proliferative retinopathy. 3. Peripheral neuropathy.
AV|aortic valve|AV|498|499|BRIEF HISTORY OF PRESENT ILLNESS|4. Coronary artery disease. 5. Hematuria with documented caruncle. PROCEDURES: Right heart catheterization with PA pressure of 39/17 with a mean of 27, wedge pressure of 17, cardiac output 3.7, cardiac index 2.1. BRIEF HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 80-year-old female with a history of congestive heart failure with preserved systolic function, status post single-vessel CABG, chronic atrial fibrillation with status post pacemaker placement and status post bioprosthetic AV and MV valve. She presented from her primary cardiologist Dr. _%#NAME#%_'s office with concern for weight gain. The patient was admitted during _%#MM2007#%_ with volume overload and there was concern that this was occurring again.
AV|aortic valve|AV|146|147|HOSPITAL COURSE|Repeat echocardiogram on _%#MMDD2007#%_ showed poor contractility with ejection fraction of 31%, secondary leaflets with systolic doming and mean AV gradient of 31 mmHg (peak 49). Digoxin 20 mcg p.o. q.12h. was initiated. On _%#MMDD2007#%_, chest x-ray showed mild pulmonary edema and Lasix was started.
AV|atrioventricular|AV|164|165|PHYSICAL EXAMINATION|I believe he now has indications for a dual chamber DDDR pacemaker. He has had 2 to 5.3 second pauses. He also has had chronic first degree AV block, second-degree AV block and his QRS is 120 milliseconds. Basic heart rate is 50 beats per minute. IMPRESSION: 1. Amazingly well tolerated high degree AV block with 2-5 second pauses
AV|atrioventricular|AV|181|182|HISTORY OF PRESENT ILLNESS|1. Video swallow study. 2. Upper GI series. 3. Chest x-rays. CONSULTATIONS: Speech therapy. HISTORY OF PRESENT ILLNESS: Briefly, _%#NAME#%_ is a 7-week-old girl with Trisomy 21 and AV canal status post palliative PA banding with a past medical history also of reflux and failure to thrive status post G-tube and Nissen admitted from the ED for poor feeding since hospital discharge on _%#MMDD2007#%_.
AV|arteriovenous|AV|143|144|OBJECTIVE|Pupils are equal, round and reactive to light and accommodation , extraocular motion is intact. His fundi were sharp bilaterally. There was no AV nicking present. His tympanic membranes are clear. Nasal mucosa inflamed, but no discharge is present. Oral cavity is without erythema or exudate. NECK; Is supple.
AV|atrioventricular|AV|95|96|SECONDARY DIAGNOSES|PRINCIPAL DIAGNOSIS: Subendocardial infarction SECONDARY DIAGNOSES: 1. Atrial fibrillation. 2. AV block, second-degree. 3. Hypertension. 4. Tobacco abuse. 5. Hyperlipidemia. PRINCIPAL PROCEDURE: PTCA HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 70-year-old man who was admitted on _%#MMDD2004#%_ with complaints of shortness of breath and chest pain.
AV|atrioventricular|AV|141|142|PAST MEDICAL HISTORY|SOCIAL HISTORY: Unremarkable for tobacco or alcohol use. FAMILY HISTORY: Significant for hypertension. PAST MEDICAL HISTORY: 1. Third degree AV block status post pacemaker placement in 1997. Her pacemaker was interrogated in _%#MM#%_ of 2004 and was essentially normal. 2. Asthma. 3. History of TB status post lobectomy.
AV|atrioventricular|AV|218|219|LABORATORY DATA|I detect no deficits. Her speech is normal. LABORATORY DATA: BUN of 136, creatinine 2.62. Sodium 128, potassium 4.6, chloride 88, bicarbonate 22, glucose 104, AST of 40, ALT is 16. EKG shows sinus rhythm, first degree AV block, left axis deviation, right bundle branch block. Hemoglobin of 11.8, white count 10.9. Urine analysis shows positive nitrites, moderate leukocyte esterase, 5-10 white cells.
AV|arteriovenous|AV|134|135|PAST MEDICAL HISTORY|1. End-stage renal disease related to bilateral renal artery stenosis. He has been dialyzing for a number of years. He has a left arm AV fistula. 2. Coronary artery disease, status post bypass surgery in 1997. 3. Sick sinus syndrome, status post pacemaker placement.
AV|atrioventricular|AV|114|115|LABORATORY DATA|CT scan head shows no hemorrhage or masses. 12-lead EKG shows sinus rhythm with rate in the 60s with first degree AV block and left bundle branch block. This is similar to an EKG from _%#MM2003#%_. ASSESSMENT AND PLAN: 1. This is 80-year-old man with a history of coronary artery disease who presents following what appears to be a syncopal episode.
AV|atrioventricular|AV|178|179|LABORATORY DATA|Wearing Depends. EXTREMITIES: There is 2-3+ pitting edema of his normally thin ankles bilaterally. LABORATORY DATA: EKG reveals a sinus rhythm with first degree AV block. Demand AV pacemaker. Nonspecific ST wave changes. Multi-formed PVCs. Right axis deviation. Chest x-ray negative for congestive heart failure per E-D. CBC unremarkable.
AV|arteriovenous|AV|171|172|PAST MEDICAL HISTORY|Donor is a member of the patient's church. PAST MEDICAL HISTORY: 1. Glomerulonephritis, biopsy-proven in 1970, on dialysis since _%#MM#%_ _%#DD#%_, 2001, via left forearm AV fistula. 2. End stage renal disease secondary to above. 3. Hypertension. 4. Hyperlipidemia. 5. Gout. HOSPITAL COURSE: The patient was admitted through same-day surgery on _%#MM#%_ _%#DD#%_, 2002, and under general endotracheal anesthesia, the patient underwent a right heterotopic living non-related renal transplant.
AV|arteriovenous|AV|209|210|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 15-year-old male with end-stage renal disease secondary to obstructive uropathy and MPGN. He presented to dialysis on the day of admission and was found to have an AV fistula clot. He is admitted for graft declotting. PAST MEDICAL HISTORY: 1. End-stage renal disease. 2. Status post two kidney transplants in 1991 and 1995 which both failed secondary to noncompliance.
AV|atrioventricular|AV|361|362|SUMMARY OF HOSPITALIZATION|She is probably going to go home to her daughter's house now for the next two days and follow up with therapy recommendations, as well as her primary physician. I am giving her aspirin not coumadin as her platelet count is good and she is at high risk of recurrent atrial fibrillation i.e. truly has chronic paroxysmal atrial fibrillation but is in 1 st degree AV block right now. PROCEDURES: Echocardiogram reveals mild to moderate mitral regurgitation with mild concentric left ventricular hypertrophy, normal ejection fraction and mild pulmonary hypertension.
AV|atrioventricular|AV|213|214|IMAGING|MCV 107. Sodium 140, potassium 4.0, chloride 105, bicarb 28; BUN 27, creatinine 5.5, estimated GFR 11. Troponins all negative, less than 0.04. IMAGING: EKG from yesterday revealed a sinus rhythm with first-degree AV block, LAD, Q waves in 3 and AVF suggestive of possible previous inferior infarct, age undetermined. No acute ST or T wave changes to suggest ischemia.
AV|atrioventricular|AV|163|164|LABORATORY  DATA|Peak troponin as mentioned was 7.8 on _%#MMDD#%_. Total cholesterol 151, triglycerides 74, LDL 84, HDL 52. EKG _%#MMDD2007#%_ shows sinus rhythm with first degree AV block, rate of 80 beats per minute. There is a left bundle branch block. DISCHARGE MEDICATIONS: 1. Plavix 75 mg 1 tablet p.o. daily to be continued without interruption for 1 year.
AV|aortic valve|AV|152|153|HISTORY OF PRESENT ILLNESS|Also left ventriculogram was performed which revealed an ejection fraction of 55% with hypokinesis of the mid anterior wall. No mitral regurgitation or AV gradient was noted. The patient underwent a PCI of the proximal LAD that was successful with a bare metal stent which was postdilated in the mid distal stent to 5 mm.
AV|atrioventricular|AV|286|287|DOB|3. History of coronary artery disease, well documented on previous charts with a chronic occlusion of RCA and RCA graft and a patent LIMA graft to the LAD and trivial circumflexed disease. 4. Syncope due to a rather dramatic and documented bradycardia, and this was in the face of some AV blocking medicines as noted below on discharge. 5. Obstructive sleep apnea. The patient will follow up with a sleep study and will be coordinated to have CPAP at home to deal with this clear-cut problem.
AV|atrioventricular|AV|231|232|PAST MEDICAL HISTORY|She recently relapsed on her alcohol use. She has been drinking for two weeks, with her last drink on Friday, three days prior to admission. PAST MEDICAL HISTORY: 1. History of alcoholism. 2. History of atrial flutter, status post AV node ablation in _%#MM2005#%_. 3. History of hypertension. 4. Depression. 5. Asthma. 6. Allergic rhinitis. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION 1. Effexor XR 37.5 mg daily.
AV|atrioventricular|AV|196|197|DISCHARGE DIAGNOSIS|4. Atrial arrhythmia with permanent pacemaker and ICD implantation, for which patient is on chronic Coumadin. 5. Type 2 diabetes, uncontrolled. 6. Hypothyroidism. 7. Atrial fibrillation requiring AV node ablation in _%#MM#%_ of 2000. 8. Chronic renal failure based on a creatinine of 1.7 to 1.9.
AV|atrioventricular|AV|97|98|IMPRESSION|Total cholesterol is 221, triglycerides 291. HDL 31, LDL 132. IMPRESSION: I believe this man has AV conduction system dysfunction, paroxysmal atrial fibrillation and atrial flutter and a fast conducting AV node or an accessory pathway leading to a rapid ventricular response at 300+ beats per minute and syncope.
AV|atrioventricular|AV|202|203|IMPRESSION|EXTREMITIES: Bilateral varicose veins. LABORATORY DATA: Electrocardiogram shows sinus bradycardia with first degree AV block. IMPRESSION: 1. Cataract. 2. Hypothyroidism. 3. Hypertension 4. First degree AV block. Patient is OK for the contemplated procedure.
AV|arteriovenous|AV|175|176|REVIEW  OF SYSTEMS|No vomiting or nauseousness. RENAL: Patient has history of end-stage renal disease requiring dialysis. HEMATOLOGIC: Patient does bruise easily, but no easy bleeding. His left AV fistula is currently clotted. SKIN: He does have some bruising on the skin but no other abnormal lesions or rashes. ENDOCRINE: He does have diet-controlled diabetes. MUSCULOSKELETAL: He has a prosthetic right leg after requiring amputation due to infection.
AV|atrioventricular|AV|214|215|HOSPITAL COURSE|It appears to mirror the episode he had at Southdale when he had some transient a-fib. He is on Plavix and he is on aspirin. A recheck EKG when he was admitted here did show normal sinus rhythm with a first-degree AV block. PERTINENT LABORATORY TESTS: 1. On _%#MMDD2007#%_, phenytoin level total 13.9, phenytoin free 1.7, phenytoin percentage free 12.
AV|arteriovenous|AV|171|172|PAST MEDICAL HISTORY|2. Coronary bypass surgery with prosthetic aortic valve St. Jude valve placed by Dr. _%#NAME#%_ _%#NAME#%_ in about 1998. 3. Amputation of the left arm at age 11 days. 4. AV fistula for dialysis. 5. Renal failure because of diabetes for 3 years. 6. Hypertension of late that has not been treated.
AV|arteriovenous|AV|43|44|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: 1. Clotted left-sided AV fistula. 2. End-stage renal disease. HISTORY OF PRESENT ILLNESS: Please see the admission history and physical in the patient's paper chart for further details.
AV|arteriovenous|AV|188|189|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Please see the admission history and physical in the patient's paper chart for further details. Briefly, this is a 72-year-old male admitted for a clotted left AV fistula. The patient missed dialysis on the Wednesday before admission and the day before admission was unable to dialyze due to his AV fistula being clotted off.
AV|aortic valve|AV|193|194|CHIEF COMPLAINT|Preoperative catheterization on _%#MM#%_ _%#DD#%_, 2006, showed a gradient across her jump graft (status post repair of interrupted aortic arch) of 40 mmHg and a gradient of 70 mmHg across her AV valve (bicuspid). This catheterization also showed a VSD, which was closed and no PA bands. Preoperative echo showed on _%#MM#%_ _%#DD#%_, 2006, left atrial enlargement, LVH (concentric), normal LV contractility, bicuspid aortic valve, trace to mild AI, AV gradient which peaked at 81 mmHg, and 30 mm gradient across the aortic arch with no shunts.
AV|atrioventricular|AV|171|172|IMPRESSIONS  ON DISCHARGE|During her stay, digoxin was discontinued. She may subsequently need it should she have recurrent symptomatic paroxysmal atrial fibrillation. IMPRESSIONS ON DISCHARGE: 1. AV conduction system dysfunction/sick sinus syndrome with tachy/brady variant. a. Paroxysmal atrial fibrillation. b. Paroxysmal atrial flutter. c. Pauses documented with greater than 4 seconds of ventricular asystole.
AV|arteriovenous|AV|219|220|PHYSICAL EXAMINATION|Blood pressure is 118/70. GENERAL: The patient looks her stated age and is alert and oriented times three. She has the left eye bandaged. The right eye does react to light. Funduscopic of the right eye does reveal some AV nicking and narrowing. Tympanic membranes are clear bilaterally. Pharynx and thyroid are normal. LUNGS: Clear to auscultation bilaterally. CARDIAC: PMI is not palpable.
AV|atrioventricular|AV|171|172|HOSPITAL COURSE|HOSPITAL COURSE: The patient was admitted through the Cardiac Catheterization Laboratory where she underwent an EP study and successful radiofrequency ablation of typical AV NRT. She had no complications from the procedure and was observed overnight on the telemetry floor. She had sinus rhythm overnight with no recurrent tachycardia. On the day following the procedure, there was a one finger- breadth hematoma over the right femoral vein area with no hematoma over the left femoral vein.
AV|atrioventricular|AV|196|197|LABORATORY|There is trace bilateral lower extremity edema. NEURO: The patient has normal sensation in the lower extremities bilaterally. LABORATORY: Electrocardiogram revealed sinus rhythm with first degree AV block and prominent U waves. Hemoglobin 11.8, platelet count 264,000, white blood cell count 24,300 with hypersegmented neutrophils, 95% neutrophil count.
AV|atrioventricular|AV|174|175|PHYSICAL EXAMINATION|Posterior tibial pulses were 2+ bilaterally. NEURO: The patient has positive Babinski on his left foot which is a new finding. Previous electrocardiogram showed first degree AV block, left bundle branch block, and left ventricular ____ type of pattern. DIAGNOSTIC IMPRESSION: 1. Change in mental condition. a. Rule out CVA.
AV|atrioventricular|AV|319|320|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a _%#1914#%_ patient with a previous history of coronary artery disease for which he underwent stenting of the distal right coronary artery and distal circumflex in _%#MM#%_ of this year. She also has a history of a high degree AV block for which she had a DDD pacemaker placed in late _%#MM#%_ of this year. Mrs. _%#NAME#%_ is seeing me today in clinic because of shortness of breath and fatigue ability as well as peripheral edema.
AV|atrioventricular|AV|228|229|HOSPITAL COURSE|HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ is a delightful 62-year-old gentleman who has a history of ischemic cardiomyopathy with an EF of 32% who presented with palpitations and fatigue associated with atrial flutter with 2:1 AV conduction. The rate of the atrial flutter with difficult to control. Therefore, the patient was recommended to proceed with EP study and ablation.
AV|atrioventricular|AV|120|121|DISCHARGE DIAGNOSES|PENDING DISCHARGE _%#MMDD2007#%_ DISCHARGE DIAGNOSES: 1. Palpitation, dyspnea on exertion, likely secondary to advanced AV block. 2. Fifteen weeks gravid. 3. History of pulmonic stenosis. DISCHARGE MEDICATIONS: 1. Prenatal vitamin. 2. Colace 100 mg daily DISPOSITION: 1. The patient discharged home.
AV|atrioventricular|AV|156|157|HOSPITAL COURSE|HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ is a delightful 79-year-old gentleman who has been followed by Dr. _%#NAME#%_. He has a history of second-degree AV block and an atrial flutter with a slow ventricular rate. He also has known hypertension which is well controlled on medications.
AV|atrioventricular|AV|539|540|PAST MEDICAL HISTORY|The patient's labs revealed his BNP was 3,830, BUN 53, creatinine 2.4. PAST MEDICAL HISTORY: The patient has a significant past medical history of prostate carcinoma, chronic anemia on Aranesp 40 mcg every few weeks, chronic congestive heart failure, macular degeneration, osteoarthritis, hypertension, TIA, aortic insufficiency, paroxysmal atrial fibrillation, severe mitral regurgitation. SURGICAL: Aortic valve replacement with St. Jude aortic valve in _%#MM2005#%_, abdominal aortic aneurysm repair in 1995, pacemaker for third-degree AV block in 2000, small PFO on transesophageal echocardiogram. The patient was admitted to the CSC unit, started on IV dobutamine, IV Lasix.
AV|atrioventricular|AV|180|181|PHYSICAL EXAMINATION|NEUROLOGIC AND CUTANEOUS: Normal. The patient is 73. He was transferred due to concerns about: 1. New onset worsening angina. 2. AV conduction system dysfunction with first degree AV block, intermittent second degree AV block and left bundle branch block. The first issue was the angina. We are going to do an angiogram.
AV|atrioventricular|AV|217|218|PHYSICAL EXAMINATION|NEUROLOGIC AND CUTANEOUS: Normal. The patient is 73. He was transferred due to concerns about: 1. New onset worsening angina. 2. AV conduction system dysfunction with first degree AV block, intermittent second degree AV block and left bundle branch block. The first issue was the angina. We are going to do an angiogram.
AV|atrioventricular|AV|181|182|PAST  MEDICAL HISTORY|However, he felt sluggish, tired and mildly short of breath. He has no dizziness, chest pain or syncope. PAST MEDICAL HISTORY: Hypertension that was medically treated. First degree AV block, idiopathic dilated cardiomyopathy. FAMILY HISTORY: Positive for dilated cardiomyopathy in his father.
AV|atrioventricular|AV|228|229|HOSPITAL COURSE|He was not symptomatic with the junctional escape. It was decided not to proceed with implantation of a permanent pacemaker right away as there is evidence if wait a week or longer, that AV block may resolve. Unfortunately, the AV block did not resolve after this period of waiting. Therefore, it was decided to implant a dual chamber pacemaker for the patient.
AV|atrioventricular|AV|235|236|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Orthotopic heart transplant _%#MMDD2004#%_ secondary to ischemic cardiomyopathy. 2. Transatrial fibrillation and atrial flutter postoperatively in 2004. 3. Type 2 diabetes. 4. Supraventricular tachycardia with AV nodal re-entry tract. 5. Hyperlipidemia. 6. History of acute renal failure. 7. Iron-deficiency anemia. ALLERGIES: Morphine. CURRENT MEDICATIONS: 1. Aspirin 325 mg p.o. daily.
AV|atrioventricular|AV|204|205|PAST MEDICAL HISTORY|4. Congestive heart failure with low ejection fraction. 5. Severe chronic restrictive lung disease, oxygen-dependent. 6. Coronary artery disease. 7. Peripheral vascular disease. 8. Recurrent syncope with AV block status post pacer placement. 9. Hypertension. 10. Coronary artery disease status post angioplasty. 11. Hyperlipidemia. 12. Benign prostatic hypertrophy. 13. Atrial fibrillation status post ablation.
AV|atrioventricular|AV|256|257|LABORATORY DATA|NEUROLOGIC: No focal deficits. LABORATORY DATA: Troponin less than 0.04, white blood count 6, hemoglobin 14.6, platelets 316, INR is 2.34. Sodium 133, potassium 4.3, chloride 100, bicarbonate 22, BUN 13, creatinine 0.74, glucose 99. EKG shows first degree AV block with a rate of 60. Chest x-ray shows left lower lobe atelectasis or scarring.
AV|atrioventricular|AV|127|128|HISTORY OF THE PRESENT ILLNESS|He had an ECG which was unchanged from last _%#MM#%_, although it did show an old right bundle branch block and a first-degree AV block. He was also bradycardic with a heart rate of 56, but there were no ST segment changes. His workup also revealed a new anemia with a hemoglobin of 8.8 and it was microcytic in nature with an MCV of 68.
AV|atrioventricular|AV|141|142|PHYSICAL EXAMINATION|Right femoral pulse is trace to +1. Pedal pulses are diminished. This 80-year-old gentleman presents with dizzy spells, and I believe he has AV conduction system dysfunction. I cannot totally prove the fact that he does not have ventricular tachycardia, but guilt by association his first degree and second degree AV block with bifascicular block in concert with complete heart block was gentle carotid pressure I believe is more than enough information to demand a dual-chamber DDDR pacemaker.
AV|arteriovenous|A.V.|181|184|PAST MEDICAL HISTORY|3. Carpal tunnel disease. 4. History of deep venous thrombosis in the left calf. 5. Obesity. 6. Congenital heart murmur. 7. Hypertension. 8. Anemia secondary to chronic disease. 9. A.V. fistula in the right forearm. 10. Depression. PAST SURGICAL HISTORY: 1. History of gastric bypass 33 years ago. 2. Right knee arthroscopy.
AV|atrioventricular|AV|166|167|LABORATORY DATA|Accordingly, _%#NAME#%_ was discharged on _%#MMDD2003#%_, according to the plan above. LABORATORY DATA: 1. Electrocardiogram: Normal sinus rhythm with a first-degree AV block. 2. Chemistry screen: Normal. 3. Folic acid and B12: Normal. 4. Urinalysis: Bacteria. 5. Complete blood count: Hemoglobin 12.6, white count 8300, RPR negative.
AV|atrioventricular|AV|291|292|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|However she presented not feeling well with abdominal discomfort, in the ER was found to be markedly hypokalemic with a potassium of 6.9. This was treated immediately with calcium, insulin, Lasix and D5W and it did improve. Additionally, she was seen in consultation by Cardiology who noted AV block. She had one prior history of syncope that was unexplained two months ago. Carotid massage by Dr. _%#NAME#%_ revealed quite high-grade AV block, even with a potassium down in the 5 range.
AV|arteriovenous|AV|225|226|SURGERY|She has been maintained on dialysis since 1993. We have had a great deal of difficulty with vascular access over the years and currently we are unable to use her upper extremities. Most recently she has had a right upper arm AV fistula which has functioned for us for the last couple of years. However, this has failed. She previously has had arterial bypass procedure on the left upper extremity and so we therefore cannot use it for vascular access.
AV|atrioventricular|AV|228|229|PAST MEDICAL HISTORY|1. Hypertension. 2. Congestive heart failure, with a recent echo in _%#MM2004#%_ showing decreased LV function with an EF of 30%. She has known 100% LAD occlusion with collateral flow. There is also a history of a second degree AV block with a DDDR pacemaker in _%#MM2003#%_. 3. Dementia. 4. Hypothyroidism. 5. Asthma. 6. Chronic obstructive pulmonary disease.
AV|atrioventricular|AV|156|157|HOSPITAL COURSE|The electrophysiology study was capable of inducing SVT; it was due to typical AV nodal re-entry. Cryomapping succeeded in finding a location in which slow AV conduction could be blocked without affecting antegrade fast pathway conduction. At this location, three cold applications were applied, freezing to minus 70 degrees for 4 minutes.
AV|atrioventricular|AV|244|245|HOSPITAL COURSE|Her evaluation included both cardiology consultation for mild troponin elevation, thought secondary to acute myocardial infarction due to fixed coronary artery disease and hemodynamic fluctuations. In addition, she was noted to have a complete AV block with junctional escape and heart rate in the range of 40-50. Cardiology was consulted on this basis. After consultation with the family, it was decided not to proceed with permanent pacemaker or any other further evaluation of her atherosclerotic coronary disease.
AV|atrioventricular|AV|157|158|HOSPITAL COURSE|She was transferred to the ICU where she was rehydrated. She also was found to have some pauses in her atrial fibrillation. It was felt that she needed less AV blocking therapy, digoxin and beta-blocker therapy were discontinued. Therefore, she was seen in consultation by Cardiology. Thought pacemaker may be useful, however, over ensuing days with withholding her beta blocker and digoxin therapy her cardiac rhythm stabilized at an acceptable rate without significant pauses.
AV|atrioventricular|AV|171|172|HOSPITAL  COURSE|_%#NAME#%_ _%#NAME#%_ has a history of some atrial fibrillation/atrial flutter in the past. Specifically, after his coronary artery bypass grafting last year he had a 2:1 AV conduction atrial flutter' this has resolved, however. Now over the last couple weeks he has been dizzy, light-headed and felt heart palpitations.
AV|atrioventricular|AV|101|102|IMPRESSION|Thereafter, I will follow her in the device clinic and proceed as needed. IMPRESSION: 1. Symptomatic AV conduction system dysfunction. 2. History sick sinus syndrome, but currently no tachycardic components. 3. First degree and second-degree AV block with a fixed heart rate with exercise, walking around the office vigorously, heart rate of 60 was the maximum heart rate.
AV|atrioventricular|AV|195|196|PHYSICAL EXAMINATION|ABDOMEN: Soft, nontender. No masses or hepatosplenomegaly. LYMPHATICS: __________, inguinal, and axillary are negative. Her electrocardiogram other than the sinus bradycardia with a first degree AV block is normal. She has a normal set of electrolytes, but the potassium is 3.6. BUN is 17 and creatinine 1.1. Glucose is a little bit elevated at 157.
AV|atrioventricular|AV|204|205|HOSPITAL COURSE|HOSPITAL COURSE: The patient was transferred for continuation of IV dobutamine at low dose and diuretic therapy. Because of difficulty in controlling heart rate it was elected to have the patient undergo AV node ablation which was done without complication on the day following admission. Her dobutamine was continued for a total of 48 hours while in the hospital and she was started on low dose Coreg 6.25 mg p.o. b.i.d., lisinopril 12.5 mg daily.
AV|atrioventricular|AV|219|220|PROBLEM #1|HOSPITAL COURSE: PROBLEM #1: Syncope: The patient was admitted to telemetry, ruled out for ischemia with three negative troponins and an EKG which showed no changes. Telemetry showed sinus bradycardia with first-degree AV block, but nothing pathologic. The patient then had an echocardiogram on _%#MMDD2007#%_ which had normal EF and no wall motion abnormalities.
AV|arteriovenous|AV|182|183|HOSPITAL COURSE|Evaluation showed extensive upper arm clot. Surgical debridement and/or declot was required. She did also require subclavian vein dilatation and stent placement and ultrasound a new AV fistula was placed by Dr. _%#NAME#%_ on _%#MMDD2003#%_. This appears to be maturing quite rapidly and should be ready for use in the next couple of weeks.
AV|atrioventricular|AV|128|129|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 4-month-old infant with Down syndrome who was diagnosed shortly after birth with an AV canal defect. She has had multiple echoes which have demonstrated slight elevation of her PA pressures, and so we opted to perform her surgery early.
AV|arteriovenous|AV|211|212|ADMISSION EXAMINATION|FOLLOW UP: Her physician followup included colonoscopy on _%#MM#%_ _%#DD#%_, 2003, at 9:30 a.m. with the following prep orders, including general prep for colonoscopy. She is to have an EGD the same day for her AV malformations and should be n.p.o. after midnight on _%#MM#%_ _%#DD#%_, 2003. She is additionally to stop her warfarin on _%#MM#%_ _%#DD#%_, 2003, and initiate her enoxaparin of 65 mg subcu b.i.d. until her PT and INR are therapeutic after the colonoscopy.
AV|atrioventricular|AV|182|183|SUMMARY OF HOSPITAL COURSE|The patient fibrillated during cooling and we were able to decompress the heart adequately and place additional repair sutures around behind the vena cava and anteriorly towards the AV groove and around posteriorly. Additional pledgets and sutures were placed around the anterior part of the cava when we had additional tearing with retraction of the heart.
AV|atrioventricular|AV|137|138|DISCHARGE DIAGNOSES|The patient underwent cardiac catheterization which revealed no significant coronary artery disease. 2. Recurrent episodes of high-grade AV block with a 7second pause while on atenolol and diltiazem. After discontinuation of these medications, the patient had a five-second episode of third degree AV block and several 2-3 second episodes of high-grade AV block.
AV|arteriovenous|AV|151|152|HISTORY|HISTORY: The patient is a diabetic male who has developed end-stage renal disease secondary to diabetic nephropathy. He presents for a placement of an AV fistula with a Gore-Tex graft. PAST MEDICAL HISTORY: 1. Diabetes mellitus, type 2. 2. Diabetic nephropathy.
AV|atrioventricular|AV|230|231|1. FEN|At the time of discharge he was both breast and bottle feeding but obtaining a significant amount of fluids and calories by gavage feeds. 2. Cardiovascular: _%#NAME#%_ had a cardiac echo which showed a balanced AV canal with mild AV valve regurgitation, a double aortic arch with atresia of the right-sided arch and normal function. He showed no evidence of CHF during his hospitalization.
AV|atrioventricular|AV|183|184|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Status post benign ependymoma resection 20 years ago. 2. History of weakness in bilateral lower extremities secondary to tumor resection. 3. Hypertension. 4. AV pacemaker placed _%#MM1991#%_ for sick sinus syndrome. 5. GERD. 6. VPH. 7. Urinary incontinence. 8. Bilateral glaucoma. 9. Status post bilateral cataract extraction. ALLERGIES: No known drug allergies.
AV|atrioventricular|AV|156|157|ASSESSMENT|1. Sounds like vasovagal syncope without any ongoing problems of arrhythmia. 2. Severe charley horse last night, resolved. 3. Bradycardia with first degree AV block. 4. Diabetes mellitus. 5. Hypertension. 6. History of hyperlipidemia on medication. 7. History of coronary artery disease, asymptomatic and stable. PLAN: So far, the patient has been doing fairly good and has no symptoms, which initially prompted the admission to just observe.
AV|atrioventricular|AV|208|209|DISCHARGE DIAGNOSIS|Additionally, the patient was also given amiodarone loading dose and started on amiodarone drip. The patient was noted to be in normal sinus rhythm later when seen by cardiology noted to be in a first-degree AV block with occasional pauses. Amiodarone was discontinued at that time. The patient remained in normal sinus rhythm throughout the remainder of his hospital stay.
AV|atrioventricular|A.V.|241|244|HOSPITAL COURSE|He successfully sustained a normal sinus rhythm for a period of two to three hours even while he was on amiodarone, and then he was unable to maintain this rhythm. Electrophysiology was therefore consulted and it was decided to proceed with A.V. node ablation and placement of pacemaker. He is now pacemaker dependent. A follow-up echocardiogram after placement of pacemaker revealed a persistently reduced ejection fraction of 30%.
AV|atrioventricular|AV|284|285|LABORATORY DATA|LABORATORY DATA: Chest x-ray is unremarkable. Electrocardiogram shows changes that could be compatible with previous inferior and septal infarction, although she has no history of such, there are certainly no acute changes of myocardial ischemia or infarction. She has a first degree AV block and left axis deviation. Her laboratory is remarkable only for some decrease in renal function, the creatinine for a person her age and size is actually significantly elevated at 1.4, estimated GFR is at 38 and that might even be a little high.
AV|atrioventricular|AV|264|265|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old male with a past medical history of pulmonary embolism diagnosed on _%#MM#%_ _%#DD#%_, 2004 and Barrett's esophagus/esophageal cancer who presents from pre-operative holding area with variable second degree AV block. The patient was recently discharged from the Hematology/Oncology Service with the diagnosis of pulmonary embolism. He was discharged on Lovenox and was told to follow up in Surgery.
AV|atrioventricular|AV|167|168|IMPRESSION|1. Atrial flutter with slow ventricular response. It is not clear that he is on any blocking medications that would slow his ventricular rate, though I suspect he has AV nodal disease. We will check an echocardiogram and stop his Prazosin and try some diuretic to control his blood pressure somewhat better and continue with cardiac monitoring.
AV|atrioventricular|AV|135|136|LABORATORY DATA|NEUROLOGICALLY: She functions well. LABORATORY DATA: Is abnormal with the electrocardiogram showing a sinus rhythm with a first degree AV block. The blood work- up was normal with a cholesterol 241, but an HDL of 101. The basic metabolic panel did not get done. It is going to be done by _%#MMDD2004#%_.
AV|atrioventricular|AV|197|198|HOSPITAL COURSE|Please see the Fairview Ridges Hospital discharge summary for details of his hospital stay there. HOSPITAL COURSE: The patient was admitted to Fairview Southdale Hospital. He continued to have 2:1 AV block with sinus pauses off of beta blocker. He was transferred on a weekend. We continued to hold his beta blocker, and his rhythm gradually improved to the point that he no longer had any AV block whatsoever over the last two days.
AV|atrioventricular|AV|160|161|DISCHARGE DIAGNOSIS|ADMITTING DIAGNOSIS: Loss of consciousness and right hip hematoma. DISCHARGE DIAGNOSIS: Loss of consciousness and right hip hematoma. Intermittent first degree AV block. HOSPITAL COURSE: Ms. _%#NAME#%_ did well during her hospital stay.
AV|arteriovenous|AV|219|220|FINAL DIAGNOSES|The patient was previously on peritoneal dialysis but this was discontinued due to abdominal problems as noted above. 3) Atrial fibrillation. 4) Status post placement of left arm fistula, transposition brachial/basilic AV fistula on _%#MM#%_ _%#DD#%_, 2004 5) Status post placement of tunneled dialysis catheter. 6) Hypertension. HOSPITAL COURSE: The patient was admitted on _%#MM#%_ _%#DD#%_, 2004 with peritonitis.
AV|arteriovenous|AV|198|199|HOSPITAL COURSE|Problem #2: End-stage renal disease on hemodialysis: Ms. _%#NAME#%_ was followed by our renal consult team while here in the hospital and received dialysis 3 times per week through her left forearm AV fistula. We did increase the intensity for her hemodialysis to try and prevent further accumulation of pleural fluid and decreased her dry weight from approximately 49 kg to approximately 44 kg.
AV|atrioventricular|AV|134|135|HOSPITAL COURSE|CHIEF COMPLAINT: Syncope. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was admitted with recurrent syncope. Was noted to be in third degree AV block. He received a dual chamber pacemaker with excellent results ands was paced 100% of the time on dismissal. He also had a history of paroxysmal atrial fibrillation and atrial flutter, but has not tolerated Coumadin in the past secondary to a GI bleed.
AV|arteriovenous|AV|209|210|HISTORY OF PRESENT ILLNESS|He was followed by Dr. _%#NAME#%_ _%#NAME#%_ for his medical problems and also for control of his renal failure and dialysis. On _%#MMDD2005#%_, he was taken to the operating room for a left forearm loop PTFE AV shunt. This was proceeded without difficulty. His surgical bypass and ___ continued to heel nicely.
AV|arteriovenous|AV|204|205|PROBLEMS THAT ARE SOLVED|She will need to return to see Dr. _%#NAME#%_ this week when she is off of her Coumadin completely for enteric cololysis to further look at her small bowel. Even if we do find out the cause, it may be an AV malformation or something that is not really amenable to repair. Given her age and her comorbidities, her family and the patient think this is the best plan.
AV|arteriovenous|AV|402|403|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 52-year-old patient with stage V chronic kidney disease on hemodialysis with a history of diabetes and atherosclerotic vascular disease who presented to Fairview- University Medical Center Surgery Clinic on _%#MMDD2003#%_ with complaints of clotted off dialysis access. The patient arrived at the clinic to be seen by Dr. _%#NAME#%_ for possible declotting of the AV fistula. Dr. _%#NAME#%_ recommended that he be admitted for declotting via Interventional Radiology. He was also admitted due to the fact that he had not had dialysis for approximately a week prior to his admission.
AV|atrioventricular|AV|196|197|HISTORY OF PRESENT ILLNESS|He had a negative CBC and chem-7. His troponin was slightly up at 0.17. He had absolutely no complaint of chest pain. His glucose was 67. EKG was the same as on _%#MMDD2002#%_ with a first-degree AV block, right bundle branch block, left anterior and bifascicular blocks, left ventricular hypertrophy. I spoke with his local physician, Dr. _%#NAME#%_, who saw him on _%#MMDD2003#%_ for a complete physical exam.
AV|atrioventricular|AV|230|231|LABORATORY DATA|Plantar responses are flexure. SKIN: Numerous seborrheic keratosis around the neck, and he has been taking some Fluocinonide E Cream for that. LABORATORY DATA: An ECG was performed. This showed sinus bradycardia with first-degree AV block. There is a Q wave in AVF, which is new since his previous ECG in _%#MM2003#%_. Otherwise, there is no evidence for ongoing ischemia. The mechanical reading on today's ECG indicated consistent with inferior wall MI, age undetermined.
AV|arteriovenous|AV|142|143|IMPRESSION|Digoxin level is slightly elevated. IMPRESSION: 1. Gastrointestinal bleeding with recent history of erosive gastritis and colonic and gastric AV malformations and esophageal Candidiasis . 2. Blood loss anemia 3. Diabetes mellitus type 2 with nephropathy and neuropathy 4. Chronic renal failure 5. Anticoagulation (due to artificial aortic valve)
AV|atrioventricular|AV|228|229|HOSPITAL COURSE|The patient was seen in consultation by Dr. _%#NAME#%_. The patient was given glucose, IV Lasix, insulin, and he had had two preadmission doses of Kayexalate. His potassium level promptly fell into the high-normal range and his AV dissociation cleared. He maintained normal sinus rhythm throughout his hospital course. During the course of his evaluation he was found to have anemia with a low ferritin level and a low iron level.
AV|atrioventricular|AV|268|269|HISTORY OF PRESENT ILLNESS|No guarding, rebound, organomegaly or mass. Bowel sounds normal. Distal lower extremities are well perfused, no cyanosis, clubbing or edema. Neurologic: Nonlateralizing. LABORATORY: On admission included an electrocardiogram demonstrating atrial flutter with variable AV block. A left bundle branch block configuration. Not significantly changed compared with tracing _%#MM#%_ _%#DD#%_, 2004. White count 7700, hemoglobin 13.6 grams percent with MCV of 87, platelet count 344,000.
AV|atrioventricular|A.V.|209|212|LABORATORY|LABORATORY: Comprehensive metabolic profile is essentially normal. Hemoglobin 11.3. INR 1.0. Platelet count normal. Digoxin level is 1.0. Electrocardiogram reveals normal sinus rhythm. There is a first degree A.V. block. There is a left bundle branch block. Electrocardiogram is not changed from past electrocardiograms. A chest x-ray reveals cardiomegaly with no congestive heart failure or acute process.
AV|atrioventricular|AV|204|205|PAST MEDICAL HISTORY|She has chronic headache. She is status post appendectomy, status post total abdominal hysterectomy, status post bilateral blepharoplasty, status post left total knee replacement. She has a history of an AV nodal reentrant tachycardia and underwent ablation in 1998. The patient had surgery on the left thumb in _%#MM#%_, 2004. She recently had cataract surgery. SOCIAL HISTORY: The patient lives in _%#CITY#%_, Minnesota, with her grandson.
AV|arteriovenous|AV|65|66|HOSPITAL COURSE|4. The patient had a right arm pseudoaneurysm at the site of the AV fistula, which is asymptomatic. 5. History of bilateral retroperitoneal hematoma, resolved. 6. History of coronary artery disease. The patient was continued on metoprolol 25 mg b.i.d. and Plavix.
AV|arteriovenous|AV|197|198|PROCEDURES|2. Nephropathy with failure of immunosuppressive medication. 3. Peripheral vascular disease. 4. Hypertension. PROCEDURES: 1. Tunnel catheter placement. 2. Hemodialysis. 3. Basilic-to-radial artery AV fistula placed _%#MMDD2005#%_. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ was admitted to Fairview Southdale Hospital with anasarca and refractory fluid overload for initiation of hemodialysis.
AV|atrioventricular|AV|180|181|LAB  DATA|LAB DATA: Sed rate of 58, AST 207, ALT a222, alkaline phosphatase 529. Bilirubin 1.4, direct bilirubin is mildly elevated at 0.5. EKG shows a normal sinus rhythm with first degree AV block. INR, PTT, lipase, platelets, CBC with differential all within normal limits. GGT is 1965. Basic metabolic panel is within normal limits with the exception of a glucose of 122.
AV|arteriovenous|AV|229|230|HOSPITAL COURSE|The patient was admitted with these problems. Iron studies were obtained which confirmed iron deficiency anemia. The patient was transfused to a hemoglobin of 9.8 and has been stable since. Workup by Gastroenterology revealed an AV malformation in the stomach. This bled fairly profusely as it was probed. It was able to be cauterized with no further bleeding and stable hemoglobin thereafter.
AV|arteriovenous|AV|159|160|PROCEDURES|2. Reflux nephropathy. 3. Gout. 4. Atonic bladder. PROCEDURES: 1. Placement of central venous catheter for hemodialysis. 2. Hemodialysis. 3. Placement of left AV fistula for hemodialysis. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 32-year-old male who was admitted.
AV|atrioventricular|AV|230|231|LABORATORY AND DIAGNOSTIC DATA|Hemoglobin and white blood count were normal. EKG showed atrial fibrillation with rapid ventricular response to start with. After she received the metoprolol she ended up going into sinus bradycardia with a prolonged first degree AV block, otherwise normal EKG. ASSESSMENT: This is a pleasant lady in for atrial fibrillation.
AV|atrioventricular|AV|434|435|PAST SURGICAL HISTORY|She has had peripheral vascular disease, abdominal aortic aneurysm, renal artery stenosis, carotid artery sinus sensitivity, psychiatric history with depression, anxiety and post-traumatic stress disorder, fibromyalgia, peripheral neuropathy, gastroesophageal reflux disease, memory issues, hypertension, history of deep venous thrombosis, osteoporosis, and syncope, neurogenic bladder, pacemaker placement. PAST SURGICAL HISTORY: 1. AV node ablation in _%#MM2002#%_. 2. Right carotid endarterectomy _%#MM2003#%_ 3. Hysterectomy without oophorectomy in 1995. 4. Right knee arthroscopy times two 5. Bilateral carpal tunnel times three
AV|atrioventricular|AV|145|146|NARRATIVE SUMMARY|He has no chest pain as long as it continues to be clear. He has no other difficulties, as far as his cardiac exam, except he has a first degree AV block. Because of that, his atenolol dose will be at only 25 mg. He will continue on the verapamil. DISPOSITION: Home. My office in one week.
AV|atrioventricular|AV|195|196|HOSPITAL COURSE|HOSPITAL COURSE: 1. Atrial fibrillation. The patient was admitted for intravenous heparin bridging prior to AV nodal ablation. His Coumadin was stopped. Once his INR was normal, he was taken for AV nodal ablation by Dr. _%#NAME#%_. A total of 10 applications of radio frequency energy to the AV nodal area was done which resulted in complete heart block with junctional escape rhythm at ___ beats per minute.
AV|atrioventricular|AV|178|179||His troponin levels x 3 are within normal limits. Total cholesterol is 211. LDL and HDL are pending at this time. His CBC was also unremarkable, and his EKG showed left anterior AV block. The only medication he takes is Aricept 5 mg. General physical examination today is unremarkable.
AV|atrioventricular|AV|74|75|HOSPITAL COURSE|With the rate responsiveness on, she did not do well at all. Changing the AV interval also did not seem to make as much difference until the pacemaker was placed in DDD mode, then she felt much better and was quite a dramatic difference when she exercised.
AV|arteriovenous|AV|176|177|DISCHARGE DIAGNOSIS|2. Underlying atrial fibrillation, Coumadin not prescribed because of fall risk. 3. Chronic renal failure. Initiation of dialysis and placement of temporary dialysis catheter. AV fistula formed by Dr. _%#NAME#%_. 4. Symptomatic hypercalcemia, likely from calcium and calcitriol. 5. Clinical pseudogout of the ankles. 6. Iatrogenic diarrhea.
AV|atrioventricular|AV|183|184|HISTORY OF PRESENT ILLNESS|In reviewing the monitor strips from last night it appears that most often her rhythm is in the mid to high 40s with some readings in the 30s. The rhythm appears to be a first-degree AV block with intermittent nonconducted PACs. The patient is asymptomatic. She is not noting when her heart rate goes down into the 30s.
AV|atrioventricular|AV|183|184|SECONDARY  DIAGNOSES|3. History of dementia. 1. History of chronic obstructive pulmonary disease. 4. 5. History of benign prostatic hyperplasia. 6. History of diverticulitis. 7. History of Mobitz type II AV block _%#MM2005#%_. 8. History of acute renal failure. 9. History of hypertension. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 84-year-old man with history of Alzheimer's disease and other medical problems as noted above.
AV|atrioventricular|AV|191|192|LABORATORY DATA|No edema. There are no obvious abnormalities. I do not see any track marks or skin rashes or injection sites. LABORATORY DATA: Chest x-ray to my eyes is unremarkable. EKG showed first-degree AV block but otherwise is unremarkable. His blood gas showed a pH of 7.37, CO2 of 38, O2 of 179 and HCO3 of 21. He was on 50% O2 with that blood gas. His initial drug screen was negative.
AV|atrioventricular|AV|169|170|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: 1. Coronary artery disease. 2. Status post successful Cipher stent to the mid-LAD. 3. History of hyperlipidemia. 4. Atrial fibrillation status post AV node ablation with permanent pacemaker implantation with most recent generator change _%#MMDD2005#%_. 5. Gastric reflux. DISCHARGE MEDICATIONS: 1. Plavix 75 mg one tablet p.o. q day for six months
AV|arteriovenous|AV|272|273|PAST SURGICAL HISTORY|PAST MEDICAL HISTORY: End-stage renal disease, type 2 diabetes, history of CHF, COPD, peripheral vascular disease, chronic anemia due to renal failure, peripheral neuropathy, hypothyroidism and chronic constipation. PAST SURGICAL HISTORY: Surgeries include a left forearm AV fistula placed in _%#MM2005#%_, but has not been used as yet. Catheter ablation for atrial flutter in _%#MM2004#%_. Previous MI in 1995, stroke in 1996 without significant residual.
AV|arteriovenous|AV|174|175|PHYSICAL EXAMINATION|LUNGS: Clear. It is impressive that there is no wheezing. HEART: Normal. ABDOMEN: Soft, obese and nontender. EXTREMITIES: Warm with good pulses, 1-2+ dependent edema. Patent AV fistula in the left arm. NEUROLOGIC: Some myoclonic jerks but no focal deficit. LABORATORY AND DIAGNOSTIC DATA: Chest x-ray here shows some subtle increase in pulmonary vascular markings and a left ventricular predominance to the heart.
AV|atrioventricular|AV|290|291|LABORATORY DATA|He has the fistula in his right forearm. LABORATORY DATA: Sodium 146, potassium 4.4, chloride 100, CO2 35, BUN of 28, creatinine 5.21, calcium 9.5. INR 1.13, white count 8.5, hemoglobin 13.0 and platelets 245, troponin less than 0.04, myoglobin 113. EKG is normal sinus with a first degree AV block. Review of chart reveals that when the patient was seen by cardiology year ago the murmur was noted.
AV|atrioventricular|AV|224|225|HOSPITAL COURSE|_%#NAME#%_ _%#NAME#%_ is an 83-year-old female with a known history of coronary artery disease. She also has a history of paroxysmal atrial fibrillation which is difficult to manage with medications. She, therefore, went on AV nodal ablation with a DDDR pacemaker in 2004 and has been on Coumadin. The patient was awakened with substernal chest pressure that radiated to her throat.
AV|atrioventricular|AV|272|273|PAST MEDICAL HISTORY|Slight aortic and mitral valve insufficiency. 11. Subtotal colectomy with ileosigmoid anastomosis (_%#MM#%_ 2000). 12. Syncopal episodes due to tachycardia /bradycardia syndrome (_%#MM#%_ 2001). Flecainide induced ventricular tachycardia. 13. Cardiac catheterization with AV node ablation and pacemaker on _%#MMDD2005#%_. 14. Gastroscopy which showed superficial gastritis and Helicobacter test was negative (_%#MM#%_ 2001). 15. Ventral hernia repair with placement of Marlex mesh (_%#MM#%_ 2001).
AV|atrioventricular|AV|215|216|HOSPITAL COURSE|Nonetheless, while he was getting his stress test he did have some nonsustained V-tach for which he underwent EP study. This showed no evidence of inducible V-tach. There was an inducible sustained atypical form of AV nodal re-entrant tachycardia which was successfully ablated. It is recommended by cardiology that patient receive an MRI to rule out ARV. In regards to his abnormal chest CT, we did ask pulmonary to come by and they recommended a follow-up CT in one month, given his cardiac issues.
AV|arteriovenous|AV|152|153|CHIEF COMPLAINT|The patient has a diagnosis of end stage kidney disease and is currently undergoing renal dialysis. The patient is to be admitted for relocation of his AV shunt for kidney dialysis. HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old male with a history of end stage kidney and severe cardiomyopathy.
AV|atrioventricular|AV|157|158|PROCEDURES PERFORMED|Left main - LIMA to LAD. LAD subtotally occluded in the mid segment, circumflex had moderate disease. RCA has moderate diffuse disease including a 50 to 60% AV groove segment. The LIMA to LAD is wildly patent. The radial graft to the RPDA is patent with mild distal disease in the RPDA.
AV|arteriovenous|AV|168|169|PROBLEM #5|We have anticipated a need to initiate chronic hemodialysis soon. She has seen Dr. _%#NAME#%_ and has had vein mapping last week in preparation for establishment of an AV fistula. She had an appointment with me on Thursday and Friday last week in the office but because of a misunderstanding, she failed both appointments.
AV|atrioventricular|AV|149|150|DISCUSSION|IV heparin will be continued with the administration of nitrates if symptoms warrant. Beta blocker therapy will be held because of the second degree AV block. Antiplatelet therapy will be continued also. Echocardiogram will be obtained to check left ventricular function and look for regional wall motion abnormality.
AV|arteriovenous|AV|179|180|HISTORY|A decision has been made to admit the patient under observation status to evaluate dialysis access options. The patient has longstanding end-stage renal disease. A left upper arm AV fistula which was created by Dr. _%#NAME#%_ in _%#MM#%_ of 2004 has recently been not a good access due to high pressures and poor flow.
AV|arteriovenous|AV|183|184|HOSPITAL  COURSE|The patient's renal function did not readily improve and he went on to have a tunnel catheter placed and dialysis was initiated on _%#MMDD2007#%_. Patient then went on to have a left AV fistula placed by Dr. _%#NAME#%_. His Coumadin was then slowly reintroduced. At the time of discharge his INR is 1.73. Hemoglobin is 9.8. Platelets are 25,000.
AV|atrioventricular|AV|223|224|LABORATORY & DIAGNOSTIC DATA|NEUROLOGIC: There are no obvious neurologic changes. LABORATORY & DIAGNOSTIC DATA: The patient had routine chemistries performed in the Emergency Room and these are still pending. Her electrocardiogram shows a first-degree AV block, it is otherwise unremarkable. IMPRESSION: 1. Fracture of the right hip. 2. History of degenerative osteoarthritis.
AV|atrioventricular|AV|139|140|HISTORY OF PRESENT ILLNESS|Nursing notes indicate the patient was in normal sinus rhythm with first-degree AV block during the night with short runs of second-degree AV block. The patient was asymptomatic at that time but later became symptomatic when ambulating to the bathroom. I am not sure of the timing of that. The patient was also given his usual dose of Toprol XL 100 mg this morning, which may have also contributed to his syncope.
AV|atrioventricular|AV|233|234|HISTORY OF PRESENT ILLNESS|She has complained more profoundly since her drug has been increased, with more dizzy spells, more weakness and more slow heartbeat/bradycardia. Her 24-hour Holter monitor done between yesterday and today does indeed confirm ongoing AV conduction system dysfunction. She had primarily sinus bradycardia and average heart rate of 50 beats per minute. She has had multiple cardiac pauses, with the longest pause being 3.8 seconds and typically they have ranged between 2.5 and 3.8 seconds.
AV|atrioventricular|AV|220|221|LABORATORY|Because of increased INR, I will try to use vitamin K to reverse that. 2. Regarding atrial fibrillation, she has a regular heart rate and rhythm now, but it looks like the underlying rhythm is sinus rhythm with complete AV block, which is consistent with the patient's history of pacemaker implantation and the indication is probably for atrial fibrillation with a difficult-to-control ventricular rate and rhythm, so get AV node ablation and pacemaker implantation.
AV|atrioventricular|AV|185|186|MEDICATIONS|7. Estrace 1 mg p.o. q. day 8. Toprol XL 100 mg p.o. q. day 9. Nitroglycerin 0.4 mg p.o. p.r.n. sublingual 10. Ativan 0.5 mg p.o. p.r.n. Regarding amiodarone, because of patient's ____ AV node ablation, it does not make too much sense to keep amiodarone on the board. The patient is going to take Coumadin for life anyway.
AV|atrioventricular|AV|227|228|PLANNED DATE OF DISCHARGE|He has a history of documented coronary artery disease and an EKG was of no value since it showed sinus bradycardia with a left bundle branch block. In addition they had noted first degree AV blocks, intermittent second degree AV block, and the left bundle branch block showing significant AV conduction system dysfunction. He was transferred for cardiac catheterization because of the fear that his recurring chest pain was unstable angina, as well as his associated AV conduction system dysfunction, and a diagnostically useless EKG.
AV|atrioventricular|AV|251|252|HOSPITAL COURSE|His most recent ablation was in _%#MM2007#%_ when he had ablation of an atrial tachycardia originating from the posterolateral portion of the right atrium. There was no evidence of an accessory pathway. There is no evidence an AH jump to suggest dual AV nodal pathology. At this time, sotalol was also discontinued. He has been on no cardiac medications since this time. The patient has been doing well since this ablation in _%#MM2007#%_ until the past 1-2 weeks and he has experienced several episodes of intermittent palpitations.
AV|atrioventricular|AV|169|170|IMPRESSION|She will see me in two months. She will follow-up with primary care physician thereafter. IMPRESSION: 1. Symptomatic uncontrolled rapid atrial fibrillation treated with AV node ablation and a VVIR pacemaker. 2. Well-preserved LV function. 3. Pacer site hematoma which had to be evacuated. 4. Non-insulin dependent diabetes mellitus. 5. Hypertension. 6. Hypothyroidism. PLAN: As above.
AV|atrioventricular|AV|128|129|HOSPITAL COURSE|Because of this surgery was canceled on _%#MMDD2002#%_. She was seen by Dr. _%#NAME#%_ who felt this was a Type I second degree AV block and sent her to the Heart Center. Her fasting lipids were normal. Stress echo the next day showed that she could exercise for 7 minutes reaching 100% predicted heart rate with no symptoms, normal EKG, and normal stress echo images.
AV|arteriovenous|AV|115|116|PHYSICAL EXAMINATION|CHEST: Clear. HEART: Rhythm is normal. EXTREMITIES: No effusion in his left knee. Has fair range of motion. Has an AV access fistula on his left forearm and has a good bruit over it. LABORATORY DATA: Hemoglobin and potassium will be drawn and faxed to the hospital.
AV|atrioventricular|AV|204|205|PLAN|The patient went into oliguric renal failure, had no urine output and a creatinine which increased to 3.5. The patient was taken to the electrophysiology laboratory where emergently on Saturday morning a AV node ablation was performed. Because of the patient's oliguric renal failure, I did not want to subject him to the dye load associated with placement of a CF lead at this point and I placed two RV leads, one in the RV apex and the other in the right ventricular outflow tract to provide him with bifocal RV pacing.
AV|atrioventricular|AV|152|153|1. CV|Her free thyroxine was normal. Ongoing problems and suggested management: 1. CV: _%#NAME#%_ will need follow-up in cardiology clinic in 2 weeks for her AV canal. 2. ENDO: _%#NAME#%_ should have follow-up thyroid function studies in the future. Discharge measurements: Weight 2065 gms; length 42.5cm; OFC 31.5cm. Physical exam was normal except for Down syndrome facies, a small amount of yellowish right eye crusting and a right hip click without dislocation.
AV|atrioventricular|AV|183|184|HOSPITAL COURSE|The patient in the emergency room however was noted to have episodes of SVT also. Therefore, at the time of her AICD placement she underwent and EP study complete with ablation of an AV nodal re-entry tachycardia. She did well after this procedure. Chest x-ray showed no pneumothorax.
AV|atrioventricular|AV|199|200|OPERATIONS/PROCEDURES PERFORMED|This is a generally negative scan. The chest x-ray shows left lower lobe atelectasis. There is no pulmonary edema. There is no acute infiltrate. The EKG shows normal sinus rhythm with a first-degree AV block and low voltage throughout, otherwise normal EKG. HISTORY OF PRESENT ILLNESS: In brief, this is a 56-year-old male with a history of LVAD placed who had been transferred from _%#CITY#%_, North Dakota.
AV|atrioventricular|AV|213|214|PAST MEDICAL HISTORY|1. History of dementia. 2. History of depression status post electroconvulsive therapy X3. 3. History of congestive heart failure with a low ejection fraction of 30%. 4. History of atrial fibrillation status post AV ablation status post pacemaker placement. 5. History of patent foramen ovale, currently on Coumadin. 6. History of hypertension. 7. History of atrophic ........... disease.
AV|arteriovenous|AV|147|148|PAST MEDICAL HISTORY|4. Dyslipidemia. 5. Gastroesophageal reflux disease (GERD). 6. Hypertension. 7. Degenerative joint disease. 8. Shoulder impingement. 9. History of AV malformation in the GI tract plus status post surgical repair. 10. Gastritis. She has undergone upper GI endoscopy per Dr. _%#NAME#%_ _%#NAME#%_. The most recent report that I have is from _%#MM1998#%_ showing mild gastritis and some dysphagia, probably secondary to esophageal dysmotility.
AV|atrioventricular|AV|251|252|HOSPITAL COURSE|HOSPITAL COURSE: She arrived to cardiac catheterization and underwent an electrophysiology study of the tachycardia, and it was subsequently concluded that she had slow/fast AV nodal re-entry tachycardia. Therefore, we ablated the slow pathway of the AV node. After the ablation of the slow pathway, we felt that it was successful, and we were not able to demonstrate any conduction through the slow pathway.
AV|arteriovenous|AV|154|155|PHYSICAL EXAMINATION|He is afebrile. HEENT: Head is normocephalic. Fundi are benign, discs are sharp. He has grade I hypertensive retinopathy with arteriolar narrowing but no AV nicking, hemorrhages or exudates. NECK: Supple, carotids are 2+ without bruit. HEART: Regular rhythm without murmurs, rubs or gallops. His blood pressure has vacillated here in the Emergency Room, running in the 130 to 150/60 to 70 range.
AV|atrioventricular|AV|251|252|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished, mildly obese male. VITAL SIGNS: Heart rate if 38, he is in sinus rhythm with first degree AV block. PR interval of 240-300 milliseconds. He has also had documented second and third degree AV block as noted above. Blood pressure 130/50. HEAD: Normal. NECK: Free of neck vein distention, mass, bruit or goiter. HEART: Heart was slow with a 1/6 apical murmur. LUNGS: Clear.
AV|atrioventricular|AV|152|153|PAST MEDICAL HISTORY|He was admitted for treatment of these fractures. PAST MEDICAL HISTORY: Significant for cardiomyopathy. He has a history of atrial fibrillation with an AV node ablation. There is also a history of a permanent pacemaker. He has cope and some asthma component. History of type II diabetes mellitus, congestive heart failure, gastroesophageal reflux disease and elevated lipids.
AV|atrioventricular|AV|128|129|DISCHARGE DIAGNOSES|1. Status post syncope. 2. Status post polymorphic ventricular tachycardia, induced by mild hypokalemia and bradycardia. 3. 2:1 AV block. 4. Severe mitral regurgitation with flail valve. 5. Status post mitral valve repair and tricuspid valve repair on _%#MMDD2003#%_.
AV|arteriovenous|AV|144|145|OTHER PAST MEDICAL HISTORY|1. Essential hypertension 2. Gastrointestinal bleed from non-steroidal medications 3. Asthma 4. Benign positional vertigo 5. History of colonic AV malformations. Medications 1. Synthroid 0.075 mg. daily 2. Amiodarone 200 mg daily 3. Lasix 20 mg daily 4. Atenolol 25 mg daily 5. Celebrex 200 mg daily
AV|atrioventricular|AV|287|288|LABORATORY DATA|NEUROLOGIC: No gross sensory or motor deficits. ORTHOPEDIC: She does have moderate stiffness in her back due to the Harrington rods and cervical fusion; it is difficult for her to get up and down off the table. LABORATORY DATA: Hemoglobin 14.1. EKG shows sinus bradycardia, first-degree AV block, small Q-waves in III and AVF which are unchanged from before. ASSESSMENT: 1) Cholelithiasis and intra-abdominal lipoma. 2) Degenerative disc disease.
AV|atrioventricular|AV|135|136|LABS|Sodium 142, potassium 4.5, chloride 117, CO2 11, BUN 28, creatinine 3.7, glucose 78. EKG shows right bundle branch block, first degree AV block, and Q wave in lead III. No acute changes compared to the previous EKG. ASSESSMENT AND PLAN: 1. Chest pain, rule out MI. Will institute CCU rule out MI protocol, get cardiac enzymes x 3, continue nitro drip.
AV|atrioventricular|AV|157|158|HOSPITAL COURSE|PROCEDURES: Stress Sestamibi. Cardiology consult. ALLERGIES: Talwin provides GI upset intolerance. HOSPITAL COURSE: 1. Presyncope. Patient was noted to have AV block II to I, III to I and IV to I at times with a second degree AV block type II. Patient was asymptomatic through her hospital course despite this rhythm.
AV|arteriovenous|AV|353|354|OPERATIONS/PROCEDURES PERFORMED|2. Transthoracic echo performed on _%#MM#%_ _%#DD#%_, 2004, showed normal global LV systolic function, abnormal LV filling indices suggestive of diastolic dysfunction, moderately increased LV wall thickness and mild to moderate left atrial enlargement. 3. Right lower extremity/pelvic ultrasound performed _%#MM#%_ _%#DD#%_, 2004, showed no evidence of AV fistula or hematoma within the right groin, a mixed echogenic lesion lateral to the right testicle within the scrotum, suspicious for hematoma.
AV|atrioventricular|AV|272|273|ASSESSMENT|Will for the time being treat it symptomatically. The patient could talk to an PRM and R doctor regarding this, possibly an MRI of her neck would help. Will also ask Cardiology to help determine the proper management of the paroxysmal atrial contractions and first-degree AV block.
AV|atrioventricular|AV|142|143|HISTORY|He had a blood alcohol level of .26. He was evaluated there with serial EKG's which were unremarkable except for the presents of first degree AV block. Enzymes were obtained, all of which were negative. He was treated with nitroglycerin without any improvement in the chest pain.
AV|atrioventricular|AV|272|273|HOSPITAL COURSE|This was mapped and ablated using the transseptal approach. An hour after ablation, there was still no evidence of retrograde conduction from ventricle to atrium over his accessory connection. At one point during the catheter study, _%#NAME#%_ also had what appears to be AV nodal re-entry tachycardia. He did not have classic signs of AV nodal physiology, but echo beats were inducible after elimination of the accessory connection.
AV|arteriovenous|AV|151|152|PHYSICAL EXAMINATION|HEENT: Atraumatic. Pupils are equal, round, and reactive to light. He is bilaterally aphakic with intraocular lenses. TMs, nose, pharynx unremarkable. AV ratio is 3:4 in the fundi and there are no exudates or hemorrhages. Mouth is moist. NECK: Supple. Thyroid is not enlarged. BACK/SPINE: Palpably nontender.
AV|arteriovenous|AV|21|22|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: AV malformation. DISCHARGE DIAGNOSIS: The same. HISTORY OF PRESENT ILLNESS: The patient is a 25-year-old female who was admitted to Trinity Hospital in North Dakota on _%#MMDD2004#%_ complaining of severe headache and nausea and vomiting. She reports that the headache started five days prior and had gotten worse over the previous several days.
AV|atrioventricular|AV|199|200|HISTORY|Her LV function was diminished with an approximate ejection fraction of 35 to 40% and was felt that some of this was tachycardia media related. She was transferred to Fairview Southdale Hospital for AV node ablation and placement of a pacemaker. She was relatively asymptomatic despite heart rates of 130 to 140 while at bedrest. She subsequently had radio frequency ablation on _%#MMDD2004#%_ with a Medtronic pacemaker placed in the left subclavian space.
AV|atrioventricular|AV|167|168|PHYSICAL EXAMINATION|The patient also has multiple scars on his abdomen and back from ritual village scarification from Somalia. His electrocardiogram shows sinus rhythm with first degree AV block with T-wave inversion in AVL and flattening in V-6. This is very similar to electrocardiograms from prior admissions in 2002.
AV|arteriovenous|AV|238|239|IMPRESSION|IMPRESSION: Mrs. _%#NAME#%_ is again in end-stage renal disease and has been a very difficult dialysis access patient. At this point her upper extremities are not an option and even though she was initially reluctant to a lower extremity AV graft or fistula, she now agrees that this is essentially her only option. The translumbar catheter will clot or become infected at some point, and she does understand this.
AV|aortic valve|AV|139|140|DISCHARGE DIAGNOSES|During hospitalization, his INR was elevated. He was given vitamin K and it was difficult to get his INR back to therapeutic range for his AV replacement. At the time of discharge, his INR was 2.35. His creatinine was 1.7, BUN was 61 on the day of discharge. Electrolytes were otherwise within normal limits. Dig level was 1.8 at time of discharge.
AV|atrioventricular|AV|240|241|ASSESSMENT|LABORATORY DATA: BNP was 336, sodium 138, potassium 6.2, creatinine 3.12, INR 5.07, glucose 144, white count 8,300, hemoglobin 12.6, platelets 159,000. ASSESSMENT: 1. Extreme bradycardia representing sick sinus syndrome versus third degree AV block versus too much beta blockade. 2. Status post AVR. 3. Chronic anti-coagulation. 4. Uterine cancer status post hysterectomy.
AV|atrioventricular|AV|147|148|HOSPITAL COURSE|Following cardiac consultation, medical management was attempted, but the patient continued to have symptomatic pauses and borderline third degree AV block for which a recommendation of a permanent pacemaker was entertained. The patient was followed by Cardiology and underwent this procedure on _%#MMDD2005#%_ at which time he tolerated it without difficulty.
AV|atrioventricular|AV|199|200|ADDENDUM|On the morning of the patient's scheduled departure, that is on _%#MMDD2005#%_ the patient was found to be what initially appeared to be second-degree AV block type 1 (Wenckebach) plus 30 seconds of AV dissociation while on the commode. The patient denied any symptoms at the time of chest pain or palpitations. A cardiologic consultation was requested. Cardiology saw the patient and analyzed the patient's rhythm strip, as well as her EKG and the electrolytes which were drawn after the episode.
AV|arteriovenous|AV|143|144|HOSPITAL COURSE|The patient had temporary pacer wires in. Electrophysiology service was consulted, evaluated the patient for heart block, and advised to avoid AV nodal blocking agents. She remained in heart block with an underlying bradycardic rate. The patient was maintained on a junctional rhythm when the pacemaker was turned off.
AV|arteriovenous|AV|222|223|PHYSICAL EXAMINATION|Pulse 72 and regular. Temperature 98.4. GENERAL: This is an elderly white female who is alert and oriented x 3 with an obvious left facial droop. HEENT: Left facial droop as noted. Otherwise pupils are equal and reactive. AV nicking is noted. Pharynx is grossly normal. LUNGS: Clear to auscultation bilaterally. HEART: Cardiac exam reveals point of maximum impulse (PMI) is not palpable.
AV|atrioventricular|AV|187|188|HISTORY OF PRESENT ILLNESS|She was subsequently referred for an adenosine nuclear stress test, which was done today. The patient's baseline ECG shows sinus tachycardia at 111 beats per minute. There is accelerated AV conduction and an intraventricular conduction delay. It appears that she does have Q waves in leads V1 through V3. With the adenosine infusion, there were no significant ST-T changes.
AV|atrioventricular|AV|309|310|LABORATORY DATA|LABORATORY DATA: White blood cell count 4.7, hemoglobin 11.4 with an MCV of 96, INR 2.15, sodium 137, potassium 4.9, chloride 102, bicarbonate 26, BUN 45, creatinine 2.2, glucose 99, troponin less than 0.07 and BNP is 74. Chest x-ray shows some hyperinflation. EKG shows normal sinus rhythm with first-degree AV block with a PR interval of 220, evidence for early repolarization in V1 through V3. ASSESSMENT AND PLAN: Mr. _%#NAME#%_ is an 82-year-old man presents with atypical chest pain.
AV|atrioventricular|AV|354|355|LABORATORY DATA|Sodium is 141, potassium is 3.4, chloride is 101, CO2 is 28, BUN is 19, creatinine is 0.9 and glucose is 136. BNP is 186. Enzymes are negative. D-dimer is mildly positive at 0.9. She was then followed by CAT scan of the chest, which was pretty much negative except for the left breast "mass up to 2 cm." EKG shows some sinus bradycardia and first-degree AV block. ASSESSMENT AND PLAN: 1. Chest pain. She thinks that she had an angiogram last year in Florida.
AV|arteriovenous|AV|145|146|HOSPITAL COURSE|HOSPITAL COURSE: He was taken to the operating room on _%#MM#%_ _%#DD#%_, 2005, where he underwent an uneventful left basilic vein transposition AV fistula above the antecubital fossa. Postoperatively, he was kept overnight for observation. He was restarted on all his home medications and advanced to a renal diet as tolerated.
AV|atrioventricular|AV|154|155|LABORATORY STUDIES|Her hemoglobin in _%#MM2006#%_ was 11.5. Her hemoglobin in _%#MM2006#%_ was 10.8. EKG shows sinus rhythm, rate of 71. There is evidence of a first-degree AV block and an isolated PAC. IMPRESSION: An 89-year-old woman who has subjective complaint of shortness of breath.
AV|arteriovenous|AV|170|171|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a very pleasant, 84-year-old, white male, who I have been asked to see and evaluate prior to vein patch to the right AV fistula stenosis to be done _%#MMDD#%_ by Dr. _%#NAME#%_. The patient has had two prior surgeries attempting to get a fistula that is adequate for hemodialysis, but unfortunately these have failed.
AV|atrioventricular|AV|218|219|BRIEF MEDICAL HISTORY|In cardiology clinic, Dr. _%#NAME#%_ had a long discussion with the patient regarding the option of the treatment for her paroxysmal atrial fibrillation. The patient opted to have the permanent pacemaker implant after AV node ablation. The benefit and risk were discussed between Dr. _%#NAME#%_ and the patient herself. The patient understands the risk. Informed the consent was obtained.
AV|atrioventricular|AV|150|151|LABORATORY DATA|X-ray was not reviewed by me, but reportedly she has a right hip neck fracture. Chest x-ray is negative. EKG showed a sinus bradycardia, first-degree AV block and some nonspecific changes, including inferior myocardial infarction; I believe these are old changes. ASSESSMENT AND PLAN: 1. Hip fracture - Plan will be per Orthopedics.
AV|arteriovenous|AV|109|110|PHYSICAL EXAMINATION|Pulses 2+ carotids, 1+ in feet, very difficult to palpate on the right radial and absent on the left. He has AV shunts both in the lower arm and AV shunt in the upper arm with nice hum easily palpated. CHEST: Clear with good breath sounds throughout. HEART: Normal S1, S2, +2/6 holosystolic murmur heard really throughout the chest.
AV|atrioventricular|AV|231|232|HISTORY|She had bilateral renal artery stenosis on MRA in _%#MM2005#%_ which was not felt amenable to angioplasty or stent. She has been treated for hypertension with multiple different medications. She also has been treated recently with AV node ablation and single-chamber pacemaker implantation due to atrial fibrillation with rapid ventricular response. She has a history of chronic renal insufficiency with creatinine of 2.5 to 2.8. She has had difficulty with adequate diuresis for the past six to seven months.
AV|atrioventricular|AV|183|184|HOSPITAL COURSE|She was started on a diltiazem drip. Cardiology was consulted. Cardizem was DC'd, ACE inhibitor was also DC'd and the patient was started on metoprolol 50 mg p.o. b.i.d. She also had AV node ablation after which the heart rate was from 70s-90s and patient was restarted on Coumadin. She also had single chamber ventricular pacemaker. The patient was also put on physical therapy, occupational therapy and cardiac rehab.
AV|arteriovenous|AV|159|160|DISCHARGE INSTRUCTIONS|There is a previous occluded AV graft in more distal left arm. She was most recently seen at this hospital during _%#MM#%_ of this year with occlusion of that AV fistula that was successfully revascularized with angioplasty of the left subclavian vein. The patient has been dialyzing relatively stably since that time.
AV|atrioventricular|AV|312|313|LABORATORY DATA|The hemoglobin is 13.3 and the platelet count 119. Chest x-ray, which I have personally reviewed and interpreted, does demonstrate a retrocardiac infiltrate as well as appearance of some increased density at the right base as well. EKG, which I have personally reviewed and interpreted, does show a first degree AV block but is otherwise in sinus rhythm. Q-waves are seen in leads V1 through V2 suggesting a prior anterior myocardial infarction.
AV|arteriovenous|AV|148|149|FOLLOWUP|3. AV fistula is recommended to be postponed as the patient will be on Plavix therapy. The patient must see Dr. _%#NAME#%_ and discuss placement of AV fistula. 4. Dialysis Tuesday, Thursday and Saturday at Fairview _%#CITY#%_, as previously scheduled. 5. The patient will be brought back for a stage PCI per Cath Lab.
AV|atrioventricular|AV|278|279|HOSPITAL COURSE|The parameters were changed to 5 volts. 2. Cardiomyopathy. Patient had history of idiopathic cardiomyopathy in the past and was following at _%#CITY#%_ Heart Institute. Apparently ejection fraction had improved in the more recent exams. He also has a dual-chamber pacemaker for AV block. His last pacemaker generator was upgraded in 2002. On this admission, the echocardiogram showed that his ejection fraction had again decreased to 35%.
AV|atrioventricular|AV|225|226|LABORATORY|ABDOMEN: Negative. EXTREMITIES: There is crepitus and mild swelling of bilateral knees with decreased range of motion on flexion bilaterally. Distal CMS is normal. LABORATORY: EKG is normal except for borderline first-degree AV block and she will bring a copy of this to surgery. IMPRESSION: As above. PLAN: I see no contraindication to surgery.
AV|aortic valve|AV.|180|182|KEY IMAGING AND STUDIES|Echocardiogram _%#MMDD2007#%_: Interpretation Summary Normal LV systolic Contraction LV EF 50% Biatrial enlargement Moderate mitral regurgitation Normal function of the prosthetic AV. No pericardial effusion. Atrial Fibrillation PatientHeight: 70 in PatientWeight: 167 lbs SystolicPressure: 138 mmHg DiastolicPressure: 92 mmHg HeartRate: 108 bpm BSA 1.9 m^2 CT chest with contrast on _%#MMDD2007#%_: IMPRESSION: 1. Severe upper lobe predominant emphysematous changes.
AV|arteriovenous|AV|96|97|ADDENDUM|ADDENDUM: _%#NAME#%_ _%#NAME#%_'s discharge was delayed one day as she underwent left upper arm AV fistula placement by Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2006#%_. She did well postoperatively and was transferred immediately back to the ward.
AV|arteriovenous|AV|139|140|REVIEW OF SYSTEMS|The patient is paraplegic. He has a chronic sacral ulcer. He has a chronic Foley. He has had the PICC line in place since _%#MM#%_ and has AV fistula on his right forearm. Detailed review of systems is otherwise negative. PHYSICAL EXAMINATION: GENERAL: The patient is a pleasant middle-aged male in no acute distress.
AV|atrioventricular|AV|251|252|LABORATORY DATA|Sodium 129, potassium 4.3, bicarbonate 22, BUN and creatinine 5 and 0.7 respectively. Blood sugar is 111, calcium 8.7. White blood cell count 10.9, platelet count 227, hemoglobin 13.3. EKG reviewed by myself shows normal sinus rhythm and first degree AV block. ASSESSMENT AND PLAN: 1. Diarrhea. This is very likely a relapse in Clostridium difficile colitis.
AV|atrioventricular|AV|118|119|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: 1. Recurrent rapid atrial fibrillation that was difficult to control. The patient is status post AV nodal ablation and placement of a single chamber pacemaker. 2. Atrial fibrillation to be treated with Coumadin therapy with an INR drawn in approximately three days on _%#MMDD2007#%_.
AV|atrioventricular|AV|216|217|HOSPITAL COURSE|His left ventricular function (LVH) was moderately depressed with an ejection fraction of about 40% by nuclear medicine test. He had about an 80% LAD stenosis and an occluded right coronary artery (RCA) and occluded AV circumflex. A large intermediate branch had minimal disease. The PDA and the distal circumflex vessels were small on angiography.
AV|atrioventricular|AV|203|204|HOSPITAL COURSE|He will be dismissed on low-dose Toprol-XL 25 mg daily. If he has further problems with atrial fibrillation with rapid ventricular response, consider an electrophysiology evaluation for consideration of AV node ablation and permanent pacemaker implantation given his difficulty with hypotension and bradycardia. DISCHARGE MEDICATIONS: 1. Warfarin 5 mg p.o. q day
AV|arteriovenous|AV|129|130|DISCHARGE PLAN|In addition, she will follow up with Dr. _%#NAME#%_ who saw her during the hospital stay for establishment of a right arm simple AV fistula.
AV|arteriovenous|AV|127|128|PAST SURGICAL HISTORY|2. Cadaveric kidney transplant, 1995. 3. Renal allograft stent, 1996. 4. PTCA with stents in 2000 and 2002. 5. Upper extremity AV fistula, 1994. 6. Umbilical hernia repair, 1999. ALLERGIES: The patient has no known drug allergies.
AV|atrioventricular|AV|264|265|PROBLEM #3|The urologist agreed to plan a transurethral resection of the prostate or a TURP pending clearance from anesthesiology because of his heart condition and his MI approximately a month prior to admission. PROBLEM #3: EKG showed normal sinus rhythm with first degree AV block, occasional PVC's, and Q-wave inversion in the lateral leads. EKG repeated on _%#MM#%_ _%#DD#%_, remained similar. EKG from _%#MM#%_ from Methodist Hospital was not available.
AV|atrioventricular|AV|153|154|HOSPITAL COURSE|HOSPITAL COURSE: The patient underwent a successful electrophysiology study and ablation of the tachycardia. We identified the tachycardia to be typical AV nodal reentry tachycardia. Radiofrequency ablation was done in the slow pathway area. Subsequent to the ablation we tried to induce the tachycardia; however, we were not able to do so.
AV|arteriovenous|AV|174|175|MAJOR PROCEDURES|So, the official diagnosis for this patient should be changed as regards the previous dictation. MAJOR PROCEDURES: Stab avulsion and ligation of saphenous veins, ligation of AV malformation, and initiation of Enoxaparin therapy. Originally, Ms. _%#NAME#%_ planned to be discharged on _%#MMDD2003#%_ after observation of her leg.
AV|atrioventricular|AV|213|214|DISCHARGE DIAGNOSES|She did receive a dose of Synergyst on the day of discharge, _%#MMDD2003#%_, in order to prevent possible future episodes of RSV. The patient has no history of RSV. DISCHARGE DIAGNOSES: 1. Trisomy 21. 2. Complete AV canal. 3. Congestive heart failure. 4. Right hip dysplasia. DISCHARGE MEDICATIONS: 1. Digoxin suspension 15 mcg p.o. b.i.d.
AV|atrioventricular|AV|177|178|PHYSICAL EXAMINATION|NEUROLOGICAL: Alert and oriented times three. Blood pressure is symmetric in both arms. No focal neurologic deficits are noted on exam. EKG, sinus bradycardia with first degree AV block. Chest x-ray by report is clear. LABORATORY ASSESSMENT: Is remarkable for slight decreased hemoglobin which is chronic.
AV|arteriovenous|AV|102|103|PAST SURGICAL HISTORY|12. Cholelithiasis. MEDICATIONS: See attached list. ALLERGIES: NONE. PAST SURGICAL HISTORY: 1. Recent AV shunt, right arm. 2. Tonsillectomy. 3. Cataract extraction. 4. Parathyroid adenoma removal. HABITS: Chronic tobacco use. The patient states he quit smoking one week ago.
AV|atrioventricular|AV|150|151|PHYSICAL EXAMINATION|On the atrial lead the thresholds were slightly improved at 1.7 volts at 0.50 msec. The patient has been programmed to a DDDR pacing mood with a long AV delay, so as to allow intrinsic conduction through her native conduction system, which has a QRS duration of approximately 110 msec.
AV|arteriovenous|AV|135|136|COMPLICATIONS|Patient was admitted _%#MM#%_ _%#DD#%_, 2004, to interventional radiology for repair of right SVC stenosis prior to surgical repair of AV fistula. PAST MEDICAL HISTORY: 1. End-stage renal disease for 3 years. 2. Hypertensive nephrosclerosis. 3. Cerebral palsy with history of seizures.
AV|arteriovenous|AV|278|279|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ noticed that her peritoneal dialysis catheter malfunctioned on Monday of this week. She called into the clinic and was immediately admitted to the hospital for the dialysis catheter removal and scheduled for the operating room for an AV fistula placement. HOSPITAL COURSE: On _%#MM#%_ _%#DD#%_, 2004, the patient underwent an AV fistula graft of the left upper extremity.
AV|atrioventricular|AV|155|156|HOSPITAL COURSE|7. History of chronic obstructive pulmonary disease. 8. Obstructive sleep apnea. 9. Chronic renal insufficiency. HOSPITAL COURSE: PROBLEM #1: Third Degree AV Block. On admission the patient was found to be in complete heart block with a heart rate of 52 beats per minute originating from the ventricle.
AV|atrioventricular|AV|184|185|LABORATORY DATA|No JVP or edema. Carotids normal, no bruits. ABDOMEN: Soft, nontender, no masses or organomegaly. EXTREMITIES: Legs clear. LABORATORY DATA: EKG shows normal sinus rhythm, first degree AV block, left axis deviation, left anterior hemiblock. One PVC is also present. No acute ischemic changes are noted. Compared with his EKG from _%#MM#%_ 2003, no new changes are seen.
AV|atrioventricular|A.V.|201|204|PROBLEM #3|She is reportedly a candidate for gastric bypass surgery and underwent the sleep study as part of the workup preoperatively. PROBLEM #3: Recent pacemaker placement for chronic atrial fibrillation with A.V. nodal ablation. The patient underwent a transesophageal echo to evaluate the pacer wires for any vegetations and this was negative. The pacemaker pocket does not appear infected. The pacemaker itself is functioning appropriately.
AV|arteriovenous|AV|185|186|PRINCIPAL DIDIAGNOSES|MAJOR PROCEDURES/TREATMENTS: 1. Femoral catheter placement. 2. Right common iliac artery stent placement. 3. Ballooning of left innominate vein. 4. Ballooning of left brachial vein. 5. AV graft, left left upper extremity declotting. 6. Hemodialysis. 7. CT angiogram. HISTORY OF PRESENT ILLNESS: AThe patient is a 49-year-old female with end-stage renal disease secondary to diabetes, diabetes mellitus type 1.
AV|arteriovenous|AV|259|260|PAST SURGICAL HISTORY|1. Living-donor kidney transplant (HLA-identical sibling), 1996. 2. Percutaneous transluminal coronary angiography with placement of drug-eluting stents to the left anterior descending coronary artery, _%#MM#%_ 2005. 3. C-section x2. 4. Right upper extremity AV fistula (thrombosed). 5. Left upper extremity AV fistula (thrombosed). ALLERGIES: No known drug allergies. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was taken to the operating room on _%#MM#%_ _%#DD#%_, 2005, for living-donor pancreas transplantation.
AV|arteriovenous|AV|172|173|PAST SURGICAL HISTORY|5. Left fifth toe amputation on _%#MMDD2005#%_. 6. Open reduction internal fixation of right lower extremity fracture. 7. Retinal photocoagulation. 8. Left upper extremity AV fistula. ALLERGIES: Penicillin. HOSPITAL COURSE: The patient was admitted on _%#MMDD2006#%_ for evaluation of variant abdominal pain with nausea, vomiting and dehydration.
AV|arteriovenous|AV|148|149|PAST SURGICAL HISTORY|2. Simultaneous pancreas kidney transplant in 1998 in _%#CITY#%_. 3. Transplant ureteropyelostomy using left native ureter in 1998. 4. Left forearm AV fistula. ALLERGIES: No known drug allergies. HOSPITAL COURSE: The patient was admitted on _%#MMDD2007#%_ for increased creatinine, a 10-pound weight gain and chronic diarrhea.
AV|atrioventricular|AV|169|170|HOSPITAL COURSE|Chest x-ray, troponins and EKG was done and a cardiology consult was obtained. The EKG showed possible ventricular tachycardia. Cardiology verified that the patient had AV disassociation and ventricular tachycardia. Troponins increased to a maximum of 2.98. Therefore, the patient was taken for catheterization. No need for stent placement. Cardiology also had the patient do a sinus exercise test to determine his maximum sinus rate to see if changes were needed to make changes to ICD and/or medications.
AV|atrioventricular|AV|278|279|SOCIAL HISTORY|SOCIAL HISTORY: The patient occasionally smokes a cigarette and occasionally uses alcohol but does not consider himself to be a regular user of either of these substances. He is retired and lives with his wife. He had three EKGs in the emergency room, which showed first-degree AV block but no acute changes. ALLERGIES: He has a stated allergy to sulfa drugs. REVIEW OF SYSTEMS: Negative for headaches; negative for visual changes or hearing disturbances; negative for nausea or vomiting.
AV|arteriovenous|AV|152|153|HOSPITAL COURSE|The patient had thymoglobulin x5 doses on _%#MMDD#%_, _%#DD#%_, _%#DD#%_, _%#DD#%_ and _%#DD#%_. Plasmapheresis was delayed 1 day due to patient's left AV fistula clotting. The patient had had a non-tunneled dialysis catheter put in place for plasmapheresis. Interventional Radiology then declotted the fistula and ballooned fistula. The patient had good flow through the fistula thereafter.
AV|arteriovenous|AV|241|242|PAST SURGICAL HISTORY|2. Exploratory laparotomy and graft pancreatectomy _%#MMDD2007#%_. 3. Segmental bowel resection x2 _%#MMDD2007#%_. 4. Excision and debridement of abdominal wound _%#MMDD2007#%_. 5. G-tube feeding tube placement 2006. 6. Left upper extremity AV fistula 2005. 7. Hysterectomy 2006. 8. Cholecystectomy 1998. 9. Tonsillectomy 1994. ALLERGIES: Neurontin, Flagyl, lisinopril and Diovan.
AV|atrioventricular|AV|165|166|HOSPITAL COURSE|She tolerated the procedure well, was transferred to the cardiac monitoring unit for postop. On postop day #1 she had no change of cardiac tracing. The questionable AV block seen prior to the surgery was unchanged and no obvious ST changes or chest pain. The patient was transferred to the regular surgical floor for the rest of her recuperation.
AV|arteriovenous|AV|166|167|PAST SURGICAL HISTORY.|2. Deceased donor pancreas transplant with enteric drainage on _%#MMDD2004#%_. 3. Total abdominal hysterectomy with bilateral salpingo-oophorectomy. 4. C-section. 5. AV fistula in the right arm. 6. Appendectomy. 7. Tonsillectomy and adenoidectomy. 8. Exploratory laparotomy with lysis of adhesions. 9. Small bowel resection secondary to large internal hernia, volvulus and ischemic bowel _%#MMDD2004#%_.
AV|atrioventricular|AV|136|137|LABORATORY|Pertinent for negative troponin. His creatinine is elevated at 2.6. I reviewed his EKGs which shows sinus bradycardia with first degree AV block and left bundle branch block. There are changes in the T waves between the two EKGs. QRS morphology also drastically changes between the two electrocardiograms suggestive of different lead positions.
AV|atrioventricular|AV|169|170|PATIENT HISTORY|She did not have any follow up arranged though Dr. _%#NAME#%_ had indicated continuation of Warfarin, use of Diltiazem and Digoxin for rate control and consideration of AV nodal ablation with permanent pacing would be an appropriate plan. The AV nodal ablation would be carried out if rate could not be controlled with Diltiazem and Digoxin.
AV|arteriovenous|AV|420|421|PAST MEDICAL HISTORY|Other diagnoses include hypertension, hyperlipidemia, history of chest pain, chronic back pain, asthma, multiple allergies, personality disorder and hepatitis C. The patient says she was jaundiced as an infant. Past surgical history: Bilateral native nephrectomies, kidney transplant times three, thyroidectomy, splenectomy and appendectomy at the time of the nephrectomies, exploratory laparotomies, lung resection for AV malformation, multiple dialysis access operations. MEDICATIONS: Her medication list is reviewed and is quite long.
AV|arteriovenous|AV|162|163|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Significant for: 1. Partial parathyroidectomy. 2. Right knee arthroscopies. 3. Splenectomy. 4. Appendectomy. 5. Three renal transplants. 6. AV malformation of the lung with partial right lobectomy resection. 7. Upper GI bleed. 8. Multiple dialysis grafts. 9. Cervical cancer.
AV|atrioventricular|AV|159|160|ASSESSMENT/PLAN|If her blood pressure remains high, we can start a low-dose angiotensin receptor blocker such as Diovan at 40 mg daily. 2. Sinus bradycardia with first degree AV block. Patient has mild sinus bradycardia with first degree AV block which is consistent with mild conduction disease. I do not think that this is the cause of her symptoms.
AV|UNSURED SENSE|AV|186|187|PHYSICAL EXAMINATION|Elbows negative. PULSES: Pulses are 4+ and equal and distally negative, no Homans' sign or edema. LYMPHATIC: Negative. NEURO: Motor, sensory, DTRs normal. Cranial nerves intact. No wing AV to scapula. Babinski negative distally. SPINE: Cervical, thoracic nontender. Lumbar mild to moderate tenderness at the L-S junction of the left side more than right.
AV|atrioventricular|AV|149|150|IMPRESSION|He has no chest pain, troponins are negative. The patient has had normal stress test in the past. I did discuss with him pacemaker implantation with AV nodal ablation and EP study. This could be performed tomorrow. The patient agrees and consents to this. I do think he has difficult to control heart rates and particularly combined with his anemia right now has probably lead to the syncope episode.
AV|atrioventricular|AV|234|235|IMPRESSION|From an arrhythmia standpoint, she is amazingly tolerant to this and can feel the palpitations of the tachycardia, but has not had dizziness or syncope. Strictly speaking, I think she would be safer if she had a pacemaker with either AV node ablation or medications to discourage PSVT. At this time, however, she is tolerating it well, and we agreed we would monitor her and see how it goes.
AV|atrioventricular|AV|141|142|LABORATORY DATA|LABORATORY DATA: Chest x-ray reveals no acute infiltrates. Formal reading is pending. An EKG reveals normal sinus rhythm with a first degree AV block. There is left axis deviation. There are equivocal Q waves in inferior leads. I don't have an old EKG for comparison. There are no STT changes.
AV|atrioventricular|AV|182|183|PHYSICAL EXAM|NEUROLOGIC: Alert and oriented x 3. Cranial nerves II through XII grossly intact. Initial EKG demonstrates sinus tachycardia at a rate of 133 beats per minute. There is first degree AV block. PAC's are seen. There are Q- Waves in V1 through V3, 3 and AVF. The 3 and AVF are old from a year ago.
AV|atrioventricular|AV|445|446|SOCIAL  HISTORY|ALLERGIES: Allergy to codeine and morphine of unknown type. She also states she is intolerant of Coumadin due to side effects which make her "a zombie and confused." SOCIAL HISTORY: She is a smoker but quit many years ago in 1960 and has not smoked since that time. She uses only occasional alcohol. She is retired and lives in a condominium but has continued to be quite active and has been very functional without prominent symptoms since her AV node ablation and pacemaker placement. REVIEW OF SYSTEMS: Otherwise, she has been feeling fairly well prior to this event.
AV|atrioventricular|AV|297|298|LABORATORY DATA|Laboratory results reveal hemoglobin 14.2. Troponins are negative. D-dimer is negative. BNP is 112. Creatinine 1.25. BUN 31. INR 1.77. ASSESSMENT/PLAN Overall patient is a pleasant, middle-aged gentleman with history of coronary artery disease, history of chronic atrial fibrillation, status post AV nodal ablation and permanent pacemaker who recently had a generator and device change out due to Guidant recall on _%#MMDD2006#%_ who presents with a 3-day history of dyspnea on exertion, shortness of breath and episode of chest discomfort.
AV|atrioventricular|AV|191|192|IMPRESSION AND RECOMMENDATIONS|It is not uncommon to see post-conversion pauses in a patient like Mrs. _%#NAME#%_ given her long history of hypertension with likely the cause of her tachybrady syndrome, in addition to her AV nodal blocker agent. The patient likely to be at risk for future recurrence of the post-conversion pauses. Unfortunately, she does need her current medication to control the atrial fibrillation with rapid ventricular response.
AV|atrioventricular|AV|159|160|LABORATORY DATA|LABORATORY DATA: Creatinine is normal. Potassium 5.2. Hemoglobin 15.8 preoperatively. INR and PTT are normal. EKG preop shows sinus rhythm with a first-degree AV block, P-R interval 228. There is a questionable Q-wave in lead V1, otherwise no pathologic Q-waves. IMPRESSION AND PLAN: Mr. _%#NAME#%_ is a 73-year-old male with a history of hypertension and right hip osteoarthritis admitted following an elective right total hip arthroplasty.
AV|atrioventricular|AV|192|193|PAST MEDICAL HISTORY|1. Status post Medtronic abdominal aortic aneurysm stent graft placement in the past. 2. Pulmonary fibrosis. 3. Hypertension. 4. Hyperlipidemia. 5. Allergic rhinitis. 6. History of 1st degree AV block on EKG with negative stress test recently. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Gemfibrozil 600 mg p.o. b.i.d.
AV|arteriovenous|AV|164|165|PAST  MEDICAL/SURGICAL HISTORY|8. Hyperlipidemia. 9. Hypertension. 10.Chronic atrial fibrillation on anticoagulation. 11.The patient has a history of left ______ arterial bypass. The patient had AV fistula placed. 12.Multiple toe amputations. 13.Laparoscopic hysterectomy. MEDICATIONS: Medications were reviewed and is as stated in the Dr. _%#NAME#%_'s note.
AV|atrioventricular|AV|157|158|PAST MEDICAL HISTORY|The plan is for the patient to come for elective decompression and fenestration of the cyst. PAST MEDICAL HISTORY: 1. Epilepsy. 2. Remote history of primary AV block. SURGICAL HISTORY: Tonsils and adenoids. ALLERGIES: No known drug allergies.
AV|atrioventricular|AV|182|183|LAB  AND DIAGNOSTIC DATA|There is one EKG from _%#MM#%_ of this year which shows the presence of a right bundle branch block. Her admission EKG was reported as showing sinus tachycardia with a second degree AV block and 2:1 AV conduction. This is clearly not the case. This EKG has already been reviewed by Dr. _%#NAME#%_. I certainly agree with _%#NAME#%_'s interpretation that this EKG shows a sinus rhythm with left anterior hemiblock and occasional PVCs.
AV|atrioventricular|AV|206|207|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a pleasant 71-year-old gentleman who has been seen from our clinic by Dr. _%#NAME#%_ for history of atrial fibrillation. The patient also had some intermittent AV dissociation thought due to medications. He also has a diagnosis of underlying multiple myeloma and is being treated at the Mayo Clinic for this.
AV|atrioventricular|AV|268|269|PAST MEDICAL HISTORY|The patient's chest pain has changed in character after angioplasty, but he gets a dull ache, with radiation to both arms, with any type of mild exertion. PAST MEDICAL HISTORY: 1. Ischemic heart disease. 2. Status post three-vessel bypass grafting surgery in 1984. 3. AV nodal ablation and ventricular pacing. 4. Colonic polyp. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Warfarin. 2. Digoxin.
AV|atrioventricular|AV|196|197|PHYSICAL EXAMINATION|LUNGS: Clear without wheezes, rhonchi or rales. ABDOMEN: Rounded, soft, non-tender without hepatosplenomegaly. EXTREMITIES: Trace edema of the ankles EKG shows sinus bradycardia with first degree AV block. Q-waves in V1 and V2. TSH is elevated at 11.7, INR is 1.03. Sodium is 132, potassium is 4.7. Chloride is 98, bicarb is 27, BUN is 38, creatinine is 1.63, glucose is 108.
AV|atrioventricular|AV|318|319|LABORATORY DATA|There is an undulating baseline noted on multiple ECGs which has been interpreted as atrial flutter, however I believe this is motion artifact that is mimicking atrial flutter and occasionally atrial fibrillation. In comparing present ECGs to ones from last year, one can see that he had a very prolonged first degree AV block previously and one can see evidence for P waves in current ECGs matching the first degree AV block that he had previously.
AV|atrioventricular|AV|150|151|MEDICATIONS|5. Also takes Vytorin nightly. He is not on a beta blocker, Digoxin or other rhythm medicines. He is not on any obvious medications that should block AV conduction significantly. FAMILY HISTORY: Truly noncontributory. ALLERGIES: None known. PHYSICAL EXAMINATION: VITAL SIGNS: In the Emergency Department he had a heart rate of 29 to 30 beats per minute and complete heart block.
AV|atrioventricular|AV|184|185|PAST  MEDICAL HISTORY/SURGICAL HISTORY|The remainder of his review of systems is essentially unremarkable. PAST MEDICAL HISTORY/SURGICAL HISTORY: 1. Status post left total hip arthroplasty On _%#MMDD2006#%_ 2. Third-degree AV block with pacemaker placement on _%#MMDD2006#%_. 3. Hypertension. 4. Dementia. 5. Benign prostatic hypertrophy. 6. Bilateral hernia repairs.
AV|atrioventricular|AV|136|137|IMPRESSION|5. Asthma. On metered dose inhalers. 6. Atrial fibrillation, chronic. She has a paced rhythm. She has a dual chamber pacemaker and also AV nodal ablation in the past. She is on Coumadin, INR of 2 to 2.5. 7. Dyslipidemia, on Advair.
AV|atrioventricular|AV|263|264|EKG|NEUROLOGIC: Grossly intact. EKG: This is 100% ventricular paced, but there appears to be sinus rhythm with appropriate sensing. At other times, reviewing his rhythm strip, he is sinus rhythm with normal AV conduction, and at still other times he is appropriately AV paced. ECHOCARDIOGRAM: The echocardiogram demonstrates left ventricular systolic dysfunction; the ejection fraction is estimated to be 30 to 35% with a sequence abnormality very likely secondary to the pacemaker.
AV|atrioventricular|AV|145|146|PHYSICAL EXAMINATION|Whether she will get one now or in the future is not clear to me, but I believe these episodes manifested in the ER are characteristic of severe AV conduction system dysfunction. Tomorrow I will try carotid massage and will see how bradycardic she gets with that, and I will probably review her with our Electrophysiology Service subsequently.
AV|atrioventricular|AV|147|148|ASSESSMENT/PLAN|Chest x-ray was negative. ASSESSMENT/PLAN: 1. Complete heart block. Patient has underlying atrial bigeminy with complete heart block. He is not on AV nodal blockers. Blood pressure is stable. I would suggest checking a TSH to make sure there is no significant hypothyroidism.
AV|atrioventricular|AV|128|129|ASSESSMENT/PLAN|She has had a history of paroxysmal atrial fibrillation but is currently in sinus rhythm. She is protected with diltiazem as an AV nodal blocking agent. At this point I think she is typical risk for this sort of surgery. I do not think she needs further testing. I would not use a perioperative beta blocker mainly because she is on diltiazem and I would be worried about the additive degree of AV nodal blocking and I do believe she would be at risk for heart block.
AV|atrioventricular|AV|103|104|PHYSICAL EXAMINATION|No clubbing or cyanosis is seen. He does appear alert and oriented. His electrocardiogram now shows an AV sequential pacing. His electrocardiogram earlier this morning did show a sinus rhythm, left ventricular hypertrophy and new anterolateral P-wave inversions.
AV|atrioventricular|AV|227|228|IMPRESSION|This arrhythmia does not tend to be dangerous, life threatening or life altering, and it typically does not require anticoagulation. IMPRESSION: 1. Multiple supraventricular tachycardias associated with COPD. a) Some reentrant AV nodal tachycardia. b) Multifocal atrial tachycardia. 2. Severe COPD with moderate pulmonary hypertension. 3. Normal LV function in the past. It should be noted from a laboratory standpoint that her renal function is normal, creatinine 0.8, BUN 20.
AV|atrioventricular|AV|405|406|REFERRING PHYSICIAN|She had respiratory failure and required intubation. She currently is sedated on the respirator, maintained on dobutamine currently with the need for Neo-Synephrine earlier, and has had only Lanoxin continued previously, previously having been on Coreg 25 b.i.d., Aldactone 12 1/2 mg daily, and Cozaar 50 mg daily, to support her cardiomyopathy. She had presented in 1998 with atrial fibrillation, had an AV nodal ablation and a single lead pacemaker placed and was noted initially to have a 20% EF, which at catheterization turned out not to be related to ischemic heart disease.
AV|atrioventricular|AV|231|232|PERTINENT LABORATORY VALUES|MUSCULOSKELETAL: No joint inflammation in the upper extremities. PERTINENT LABORATORY VALUES: Troponin is negative x3, potassium 4.1, creatinine 2.25. White count 7.1, hemoglobin 11.7. Platelets 251,000. EKG on sinus Brady 55 with AV delay of 200 milliseconds. Otherwise, no ST changes. IMPRESSIONS AND RECOMMENDATIONS: Mrs. _%#NAME#%_ is a delightful _%#1914#%_ female with a history of breast cancer and likely metastasis who presented with "nagging" pain.
AV|atrioventricular|AV|171|172|LABORATORY DATA|LABORATORY DATA: White count 4.8, hemoglobin 8.4, MCV 67, platelets 397,000, normal differential. Chemistries are pending. EKG shows normal sinus rhythm with first degree AV block. Inferior Q-waves. Left axis deviation. LVH. Compared with an EKG from _%#MM#%_ these changes are not new. ASSESSMENT: 1. Colon lesion most certainly a carcinoma. 2. Anemia due to above.
AV|atrioventricular|AV|517|518|HISTORY OF PRESENT ILLNESS|In association with that discomfort, he is now noted to be in atrial fibrillation with a reasonably controlled ventricular response, to be hypotensive and to be relatively dry with a BNP on admission that was quite low at 109 and with a 12,900 white count with some left shift. His blood pressure has ranged from 63-98/39-59 and his heart rate from 103-74, currently about 83, such that his atrial fibrillation is remarkably well controlled in spite of the fact that he is not on any medications that would block the AV node, at least currently. In spite of not being on beta-blockers or cardioprotective drugs at this stage of the game, he has had three negative troponins and his EKG does not suggest acute changes.
AV|atrioventricular|AV|228|229|ECG|Obviously, this will need to be monitored. LABORATORY DATA: Laboratory studies obtained today include a Chem-18 which reveals a creatinine of 1.5, BUN is 22, TSH is 1.64, sed rate is 7. ECG: Normal sinus rhythm and first degree AV block. There are Q- waves in the inferior leads as well as a poor R-wave progression across the precordium. His ECG is not significantly changed from an ECG performed _%#MMDD2001#%_.
AV|atrioventricular|AV|148|149|PAST MEDICAL/SURGICAL HISTORY|Her mother had TB. Remote history of social smoking. No hay fever or sinus disease. Other history includes bilateral mastectomy, T&A, appendectomy, AV ablation, gastroesophageal reflux disease, dementia, osteoporosis, and hypothyroidism. FAMILY HISTORY: Mother died of TB in her 30's. Father died at 65 of an myocardial infarction.
AV|atrioventricular|AV|340|341|HISTORY  OF PRESENT ILLNESS|An EKG showed a narrow-complex tachycardia with a heart rate of 158. Dr. _%#NAME#%_ who was on call and recommended Toprol-XL. The review of that 12-lead EKG shows a narrow complex tachycardia with a heart rate of 158 with a QRS axis of -22 degrees, QRS duration 90 milliseconds, no discernible P-waves and a rhythm most compatible with an AV nodal re-entrant tachycardia. REVIEW OF SYSTEMS: Otherwise negative for fever, chills, cough, melena, bright-red blood per rectum, abdominal pain or discomfort, no recent trauma or surgery, no neurological changes or urological changes.
AV|atrioventricular|AV|478|479|HISTORY|REASON FOR CONSULTATION: I am asked to see _%#NAME#%_ _%#NAME#%_ is cardiology consultation because of presentation to Fairview Southdale Hospital with evidence of complete heart block after a fall on the ice. HISTORY: The patient is an 85-year-old elderly white male who is a very poor historian who apparently fell on the ice earlier today and came to the emergency room after falling on the ice and on the monitor was noted to have advanced AV heart block, third degree with AV dissociation and underlying right bundle branch block pattern and left anterior fascicular block pattern consistent with underlying bifascicular block.
AV|atrioventricular|AV|133|134|LABORATORY ON ADMISSION|Urinalysis unremarkable. Chem 18 is remarkable for a creatinine 1.34, albumin 3.1, EKG reveals normal sinus rhythm with first degree AV block. There are nonspecific ST-T changes. There are no acute appearing changes, however.
AV|arteriovenous|AV|136|137|DISCUSSION|Since admission, the patient has been stable. A second CT scan shows no changes in the hemorrhage. Simultaneous CT angiogram reveals no AV malformation, any aneurysm or any vascular occlusion. There is no evidence to suggest neoplasm. The patient's aspirin has been withheld.
AV|atrioventricular|AV|129|130|IMPRESSION|2. Cardiomyopathy. He currently appears euvolemic and well compensated from a heart failure standpoint. 3. History of high grade AV block, stable after ICD implantation. I reviewed his ICD interrogation and there has been no VT or VF episodes. He does have some nonsustained several seconds of an atrial tachycardia which are probably paroxysmal atrial fibrillation.
AV|atrioventricular|AV|223|224|PHYSICAL EXAMINATION|EXTREMITIES: Without clubbing, cyanosis, or edema. Echocardiogram shows normal left ventricular function, concentric left ventricular hypertrophy, trace MR and AI. Follow-up electrocardiogram reveals sinus bradycardia, 2:1 AV block, left bundle branch block, left anterior fascicular block. ASSESSMENT/PLAN: Overall, the patient is an 80-year-old female with evidence of conduction system disease, heart block, and as well right bundle branch block and fascicular block who had a complete syncopal episode.
AV|atrioventricular|AV|232|233|PLAN|AV node ablation with the pacemaker may be the best consideration of all. We will see how it goes after we assess her cardiac status and make a decision with regards to rhythm treatment with or without pacemaker and with or without AV ablation.
AV|atrioventricular|AV|164|165|LABORATORY DATA|Echocardiogram was done with preliminary report showing normal ejection fraction. Official report is pending. EKG on admission here reveals atrial flutter with 2-1 AV block and a rate of 146 beats per minute with nonspecific ST changes. EKG today shows controlled ventricular rate of 88 beats per minute.
AV|atrioventricular|AV|134|135|LABORATORY|In aVL, there may be flutter waves, and this could represent atrial flutter or fibrillation. She is in sinus rhythm with first degree AV block on another EKG. Telemetry is as above. ASSESSMENT: 1. An 84-year-old white female presents for syncope due to tachy-brady syndrome.
AV|atrioventricular|AV|169|170|IMPRESSION|Firstly the QRS morphology is different from the paced morphology. Secondly, the patient had syncope with one of the episodes. Thirdly, the patient has known high grade AV conduction disease and it would be unusual for the patient to be able to have a ventricular rate in the 150s with high grade conduction disease, AV conduction disease.
AV|atrioventricular|AV|148|149|CHIEF COMPLAINT|She has been monitored overnight and has been hemodynamically stable with a heart rate of 50 to 60 beats per minute, sinus rhythm with first degree AV block and QRS is normal. Troponins have been negative. She has been asymptomatic. PAST MEDICAL HISTORY: 1. Hypertension. 2. Vague history of angina - coronary artery disease.
AV|atrioventricular|AV|132|133|IMPRESSION|Chest x-ray shows very minor vascular congestion. Her ECG as noted above in history of present illness. IMPRESSION: 1. Third degree AV block with probable infranodal escape rhythm, probably due to Digoxin toxicity and high dose of betablocker. This is resolved now with the use of Digibind and cessation of Coreg.
AV|atrioventricular|AV|61|62|REASON FOR CONSULTATION|REASON FOR CONSULTATION: Syncope with documented high degree AV block. We have been asked to be involved in the care of _%#NAME#%_ _%#NAME#%_, an 82-year-old woman who has previously been relatively healthy, who was admitted to the hospital after a syncopal spell last evening.
AV|atrioventricular|AV|238|239|REASON FOR CONSULTATION|Left bundle branch block noted on EKG dated _%#MM#%_ _%#DD#%_, 2006, even though today's EKG shows a narrow QRS. While she was being monitored, she showed a sinus rhythm with a first degree AV block, intermittent periods of second degree AV block with 2:1 AV conduction, periods of stable PR intervals, albeit with first degree AV block culminating in complete heart block.
AV|atrioventricular|AV|136|137|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: He is alert and oriented, blood pressure is 132/85. Pulse is 115 and on the monitor is in atrial flutter with 2:1 AV block. Jugular venous pressure is 12 cm. of water. There is prominent atrial flutter waves seen in the neck. There are no carotid bruits. LUNG: Exam reveals bibasilar crackles.
AV|arteriovenous|AV|154|155|HISTORY OF PRESENT ILLNESS|However, he has chronic GI bleeding. The patient had an extensive evaluation for his GI bleeding and it was felt that the probable source was possibly an AV malformation in the small intestine. The patient was at a funeral and had two salty meals which precipitated his sudden onset of dyspnea.
AV|atrioventricular|AV|103|104|VITAL SIGNS|EXTREMITIES: Pulses are weakened. He has varicose veins over the left leg. EKG shows long first-degree AV block with sinus rhythm. He has frequent paroxysmal ventricular contractions. There is underlying sinus bradycardia. Chest x-ray shows moderate congestion when he was admitted.
AV|arteriovenous|AV|107|108|HISTORY OF PRESENT ILLNESS|She has had episodes of recurrent anemia in the past related to GI blood loss that is thought to be due to AV malformations within the gastrointestinal tract. She has had numerous studies done over the years including numerous EGDs, and colonoscopies for evaluation of the problem.
AV|atrioventricular|AV|221|222|DISCUSSION|If her beta blocker and calcium channel blocker are unsuccessful in controlling her heart rate or if the patient cannot tolerate the medications, consideration should be given, as has already been mentioned, for possible AV node ablation with a permanent pacemaker to be inserted. This was discussed with the patient briefly, who is not excited about the idea of having a pacemaker but wants to feel better and feels that the medications are slowing her down.
AV|atrioventricular|AV|258|259|PAST MEDICAL HISTORY|The patient was here in _%#MM#%_ for closed pelvic fracture, and her hemoglobin at that time was 11.1. She has been treating some back pain with Vioxx. She has also been on one baby aspirin daily. PAST MEDICAL HISTORY: 1. Atrial fibrillation. 2. Status post AV node ablation for tachyarrhythmia. 3. Pacemaker placement. 4. Hypertension. 5. CHF. 6. Hyponatremia. 7. Left pelvic fracture. 8. Chronic back pain due to spinal stenosis with sciatica.
AV|atrioventricular|AV|184|185|IMPRESSION REPORT AND PLAN|Radial pulses equal bilaterally. There are no carotid bruits. SKIN: Grossly normal. IMPRESSION REPORT AND PLAN: 1. Paroxysmal atrial fibrillation. 2. Pacemaker dependent with previous AV node ablation and ventricular escape rate of 38 beats per minute. 3. Ventricular ectopy. 4. Palpitations. 5. Right ventricular failure.
AV|atrioventricular|AV|138|139|INDICATION FOR PROCEDURE|He did receive a dose of Rythmol orally along with metoprolol 50 mg b.i.d. Post-conversion, his EKG showed sinus rhythm with first degree AV block, PR interval of 238 msec. QRS was normal. The morning of the atrial fibrillation he had awakened after a poor night's sleep and was a bit sleep-deprived.
AV|atrioventricular|AV|217|218|INVESTIGATIONS|It appeared that the patient had sensation to light touch in all 4 extremities, but again this is limited due to aphasia. Gait examination was not performed. INVESTIGATIONS: EKG showed sinus rhythm with second-degree AV block. Cholesterol screening. Total cholesterol 126, triglycerides 75, LDL 65, HDL 46. Head CT without contrast performed on _%#MMDD#%_ showed no acute intracranial findings.
AV|atrioventricular|AV|262|263|HISTORY  OF PRESENT ILLNESS|This time it was documented on 12-lead EKG with a narrow complex tachycardia at 157 beats per minute with a short RP tachycardia pattern consistent with AV node reentry tachycardia and rare PVCs. Her baseline ECG shows only normal sinus rhythm with first degree AV block without other abnormalities and no evidence of preexcitation. I reviewed these ECGs and this is my interpretation. Her tachycardia and chest pain resolved spontaneously once again within 30 minutes.
AV|atrioventricular|AV|323|324|DOB|She underwent right hip surgery three days ago. Her postoperative course was uneventful until yesterday, when she had multiple episodes of narrow QRS tachycardia, ranging from 170-200 beats/min. The narrow QRS tachycardia had possible retrograde P waves following immediately after QRS complex, suggesting possible typical AV node oriented tachycardia. It responded to adenosine 6 mg and 12 mg and then DC cardioversion. However, the tachycardia kept coming back. The tachycardia was finally controlled with intravenous digoxin.
AV|atrioventricular|AV|150|151|CHIEF COMPLAINT|She is quietly active but somewhat limited by history of aching muscles and fibromyalgia. On admission, her EKG showed sinus rhythm with first degree AV block and no significant ST-T changes. Subsequent EKG showed trivial nonspecific lateral ST abnormalities. Cardiac enzymes were negative x 3.
AV|arteriovenous|AV|150|151|PHYSICAL EXAMINATION|VITAL SIGNS: Vital signs stable. Blood pressure 136/80, pulse 81, respirations 20; he is afebrile. HEENT: Reveals no evidence of trauma. Negative for AV nicking changes in the funduscopic. NECK: The carotid region does appear to demonstrate a minor bruit on the left. NEUROLOGICAL: Cognition is normal. Cranial nerve function is otherwise normal.
AV|atrioventricular|AV|210|211|PAST MEDICAL HISTORY|3. Amiodarone toxicity in 1996, status-post lung biopsy showing fibrotic changes, and treated with steroids. 4. Morbid obesity. 5. Hypertension. 6. Peripheral neuropathy. 7. Atrial fibrillation. 8. Status-post AV nodal ablation with permanent pacemaker. 9. Cor pulmonale. 10. Chronic edema secondary to this. 11. Diabetes mellitus. 12. Possible transient ischemic attack in the past. 13. Chronic obstructive pulmonary disease - Life-long nonsmoker.
AV|atrioventricular|AV|186|187|PHYSICAL EXAMINATION|Liver edge is not felt. EXTREMITIES reveal bounding distal pulses, but no peripheral edema or cyanosis. EKG shows sinus bradycardia, a borderline left axis deviation, and a first degree AV delay. I reviewed his echocardiogram with him. That was done just two weeks ago. All cardiac markers are negative. Chest x-ray was free of congestion.
AV|atrioventricular|AV|149|150|ANCILLARY DATA|BREASTS: No masses. ANCILLARY DATA: CBC as detailed in the HPI. Creatinine 0.98. Calcium 9.1. Troponin-I <0.07. EKG shows sinus rhythm, first degree AV block. Cultures show no growth so far. Reticulocyte count 1.4. IMPRESSION: 1. Pancytopenia. Etiology unclear. Could be related to infectious; vitamin deficiency; myelophthises due to cancer; other primary bone marrow disorders including myeloproliferative, lymphoproliferative, and myelodysplastic disorders; splenic sequestration, hyposplenism, etc.
AV|atrioventricular|AV|152|153|ASSESSMENT  AND RECOMMENDATIONS|If she does not have AV conduction worsening with dobutamine, she may go home with an event monitor. If she continues to have symptomatic type 1 degree AV block, then I would consider pacemaker, although it is rarely implanted for that indication. In addition, I would also think it is beneficial to have an echocardiogram for evaluation of her cardiac structure and function.
AV|atrioventricular|AV|151|152|HISTORY OF PRESENT ILLNESS|In the emergency room, he was given oxygen and a nitroglycerin drip, and his symptoms gradually resolved. EKG showed sinus rhythm with a second-degree AV block with an interventricular conduction defect. In the emergency room, his troponin was elevated at 11.0, and a clinical impression of a subendocardial myocardial infarction was made.
AV|atrioventricular|AV|204|205|HISTORY OF PRESENT ILLNESS|Ms. _%#NAME#%_ _%#NAME#%_ is an 81-year- old woman with a history of coronary artery disease, including angioplasty and stent of the LAD in 2002. She also has had chronic atrial fibrillation, status post AV node ablation and pacemaker implantation. She has diabetes, hypertension and dyslipidemia as well. Lately, she has been having a variety of different problems, including forgetfulness and periods of disorientation.
AV|atrioventricular|AV|256|257|ASSESSMENT/PLAN|He does have a first degree AV block on his EKG and therefore, we should cautiously use these agents and do followup EKGs to make sure there is no worsening of his AV block. I suspect we may not be able to increase medications doses given his first degree AV block. I would also recommend doing a transthoracic echocardiogram to exclude structural heart disease as well as a nuclear imaging procedure to exclude underlying ischemia in this patient.
AV|atrioventricular|AV|197|198|RECOMMENDATIONS|RECOMMENDATIONS: At this point, I would recommend an electrophysiology study. We would evaluate sinus node function (to the extent possible with EP testing; this is rather limited), reliability of AV conduction and inducibility of ventricular tachyarrhythmias. I discussed this procedure in detail with the patient, including the potential risks and benefits.
AV|atrioventricular|AV|143|144|ASSESSMENT|ASSESSMENT: This is a patient with the following issues 1. Second degree AV block. This is a gentleman with a baseline history of first degree AV block. I think that postoperatively with a small amount of hematoma and compression of the carotid this is causing him to have transient second degree AV block.
AV|atrioventricular|AV|204|205|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: History of Crohn's disease. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 48-year-old white female, admitted to this hospital because of syncope with the finding of third degree AV block and ventricular standstill. She has had a permanent pacemaker implanted and is recuperating from that and is due to be discharged tomorrow.
AV|atrioventricular|AV|222|223|IMPRESSION AND PLAN|Occasionally conducted beats are seen which do not show overt evidence for myocardial ischemia/infarction. There are escaped beats seen also. IMPRESSION AND PLAN: Mr. _%#NAME#%_ is a 53-year-old gentleman with high degree AV block which is symptomatic. He is in need of a dual chamber pacemaker. Somewhat unusual for this to occur is his age.
AV|atrioventricular|AV|199|200|CLINICAL  IMPRESSION|Hemoglobin A1c was 6.3. Electrocardiogram shows second-degree AV block, probably Mobitz type 2 with a left bundle branch block pattern with left axis deviation. CLINICAL IMPRESSION: 1. Second-degree AV block, left bundle branch block pattern. 2. History of coronary artery disease, status post coronary bypass surgery in 2005. 3. History of hypertension. 4. History of non-insulin dependent diabetes mellitus.
AV|arteriovenous|AV|258|259|ASSESSMENT|Gait and balance: I do not sit the patient up secondary to recent severe headache after sitting up and the patient's unwillingness to do so at this time. ASSESSMENT: 37-year-old man with balance deficit and cognitive abnormalities as a result of hemorrhagic AV malformation. This has resulted in dependent mobility and some dependent higher level activities of daily living. RECOMMENDATION: 1. Continue physical and occupational therapy as you are for balance and ADL training.
AV|atrioventricular|AV|138|139|IMPRESSION/PLAN|If with increased activity his heart rate becomes more difficult to control, we can always increase his metoprolol dosage. If that fails, AV nodal ablation with the insertion of a pacemaker is a consideration. With this prosthetic aortic valve I would recommend keeping his INR to between 2.5-3.0. It is my pleasure to be involved in this gentleman's care.
AV|atrioventricular|AV|230|231|IMPRESSION|Postoperatively he has done pretty well, although, he has had a persistent arrhythmia which has been clearly identified here as sinus rhythm with second-degree AV block type I (Wenckebach). There is no evidence here of high-grade AV block or third-degree AV block. He is having some light-headedness with standing which I suspect is probably resulting from a combination of aggressive diuresis for some third space fluid.
AV|atrioventricular|AV|139|140|PHYSICAL EXAMINATION|His edema he says has diminished since being in the hospital. His heart cardiac rhythm has shown sinus rhythm with first and second-degree AV block without sustained bradycardia. During sleep his heart rate in the 30s, but this would be unusual. His QRS is narrow and he has components of pain conduction system dysfunction, but at this juncture I believe there asymptomatic.
AV|atrioventricular|AV|110|111|IMPRESSION|Certainly the risk of postop atrial fibrillation is great. He has a pericardial bioprosthesis. IMPRESSION: 1) AV conduction system dysfunction with marked bradycardia/junctional rhythm postoperatively, DDD pacing temporarily provided. 2) History of well-preserved left ventricular function. 3) Coronary artery disease.
AV|atrioventricular|AV|135|136|REASON FOR CONSULTATION|She also had beta blocker for rate control, but it was not particularly successful. The patient has been referred for consideration of AV node ablation and pacemaker implantation. PAST MEDICAL HISTORY: Hypertension, hyperlipidemia, type 2 diabetes. She has mild coronary artery lesion by cardiac catheterization.
AV|atrioventricular|AV|127|128|ASSESSMENT/PLAN|Control heart rates as need be with intravenous or oral beta blockade if heart rate accelerates. Hold Coumadin until pacer and AV node ablation can be performed. Continue telemetry. Low-dose Lasix for elevated BNP and obtain an echocardiogram if this has not been done in the last year.
AV|atrioventricular|AV|150|151|IMPRESSION|I do note, however, that she has underlying conduction disturbance with right bundle branch block and left anterior hemiblock; will have to watch for AV block on medications or if any procedures are done. At a later date we should probably look for coronary artery disease since her LV systolic function is not normal and questionable wall motion abnormalities are seen there.
AV|atrioventricular|AV|219|220|IMPRESSION AND PLAN|This single episode was related to dialysis. The patient tells me that since fine adjustment was made to his dialysis runs, this problem has not recurred. With his active infection, we would certainly like to delay his AV nodal ablation and possible pacer/AICD insertion until this issue is resolved. We will keep an eye on him on an intermittent basis during this hospital admission.
AV|atrioventricular|AV|175|176||He has been having no angina leading up to this incident. His first set of cardiac enzymes were normal and he his first EKG also is normal appearing apart from a first degree AV block. PAST MEDICAL HISTORY: 1. Acute anterior myocardial infarction treated with lytics.
AV|arteriovenous|AV|191|192|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Status post kidney transplant, _%#MM2003#%_. 2. Type 1 diabetes with end-stage renal disease secondary to diabetic nephropathy. 3. Thrombosis of left upper extremity AV fistula. 4. Status post laparoscopic cholecystectomy, 1999. 5. Bilateral retinal photocoagulation. 6. Hypertension. 7. Diabetic neuropathy. SOCIAL HISTORY: He is married and lives with his wife in North Dakota.
AV|arteriovenous|AV|142|143|HISTORY|That disease has actually been relatively well controlled but is going to require long term treatment. As a result, he has had attempts at an AV fistula in his left arm which has failed previous attempts. Dr. _%#NAME#%_ did a reattempt ten days ago which is not yet functional.
AV|atrioventricular|AV|272|273|HISTORY OF PRESENT ILLNESS|His prolactin level was mildly elevated after he had a seizure at home and he ended up having an unremarkable head CT with contrast one day prior to hospitalization and without contrast on the day of hospitalization. He did have intermittent first degree to second-degree AV block which he has had since his stent to the posterior descending artery without any symptoms. The patient underwent angioplasty on _%#MMDD2007#%_ and held his Coumadin for about four days prior to this.
AV|atrioventricular|AV|177|178|HISTORY OF PRESENTING ILLNESS|EKG upon arrival showed atrial fibrillation with rapid ventricular response. This is a new diagnosis for her. EKG on _%#MMDD2003#%_ showed normal sinus rhythm with first-degree AV block. Currently, the patient feels well and essentially back to her baseline.
AV|atrioventricular|AV|142|143|SOCIAL HISTORY|VITAL SIGNS: Blood pressure is 162/80. Ventricular rate on the monitor is between 70 and 80. He appears to be in atrial flutter with variable AV block. HEENT: Examination is unremarkable. Mucous membranes are normal. Dentition is unremarkable. NECK: Examination shows no JVD, no thyromegaly. EXTREMITIES: No evidence of peripheral or central cyanosis.
AV|atrioventricular|AV|135|136|PHYSICAL EXAMINATION|HEENT: Unremarkable. LUNGS: Some crackles bilaterally one-third. CARDIOVASCULAR: Jugular venous distention at 50 cm of water. There is AV disassociation with cannon A waves. There is S1 which is mechanical which is heard intermittently, and an S2. No murmurs are heard. ABDOMEN: Active bowel sounds, nontender, nondistended.
AV|atrioventricular|AV|185|186|PAST MEDICAL HISTORY|4. Restless leg syndrome. 5. Hyperlipidemia. 6. Sleep apnea. 7. Ventral hernia repair. 8. Tonsillectomy. 9. Sinus surgery. 10. Rotator cuff repair 11. Left total knee arthroplasty. 12. AV node ablation. 13. ORIF left elbow. SOCIAL HISTORY: Married and lives at home in _%#CITY#%_, Minnesota.
AV|atrioventricular|AV|195|196|IMPRESSION|I suspect that this is more related to obesity and mild venous insufficiency. Also, the calcium blocking drug diltiazem can promote lower leg edema. 4. Slow atrial fibrillation, a combination of AV conduction system dysfunction and drug side effects. 5. Remove coronary artery disease, but her thallium study within the past year showed normal LV function, no major scars or ischemia.
AV|atrioventricular|AV|335|336|PLAN|I would also increase the carvedilol medication. 2) She is not on diuretic therapy so I would add in Lasix 40 mg IV now and then 40 mg p.o. q.d. 3) Question the use of Coumadin, are there contraindications to Coumadin in this patient. The atrial fibrillation may have had a role also in her transient ischemic attack back in 2002. The AV node ablation with pacemaker does not prevent thromboembolism, as you probably know the atria are still in atrial fibrillation and can still form thrombus.
AV|atrioventricular|AV|261|262|CLINICAL  IMPRESSION|Electrocardiogram showed evidence of advanced heart block, primarily third degree with AV disassociation, a right bundle branch block pattern and possible old inferior infarct present. Chest x-ray not available for viewing. CLINICAL IMPRESSION: 1. Third degree AV heart block. 2. Dyspnea on exertion, shortness of breath with fatigue, probably related to #1. 3. History of prostate cancer. 4. Osteoarthritis, status post bilateral hip replacements.
AV|atrioventricular|AV|152|153|IMPRESSION|I will leave it to the primary care doctors if a neurology workup is necessary, although I am highly suspicious that the episodes can be explained from AV node conduction disease. I will use p.r.n. clonidine for now to control blood pressure, until after the pacemaker is placed.
AV|atrioventricular|AV|136|137|LABORATORY DATA|I do not see where a urine culture was performed. A chest x-ray was unremarkable. EKG: Revealed normal sinus rhythm with a first degree AV block but no acute-appearing changes.
AV|atrioventricular|AV|216|217|EKG|EXTREMITIES: Warm and well perfused with good peripheral pulses. No edema, cyanosis, clubbing or splinter hemorrhaging. NEUROLOGIC: Grossly intact. EKG: Review the ECG, it shows normal sinus rhythm with first degree AV block and is otherwise within normal limits. ASSESSMENT: This patient presents with an episode of near-syncope. She actually had three sequential episodes within a four hour period yesterday morning.
AV|atrioventricular|AV|178|179|ASSESSMENT|She has been hospitalized since about noon yesterday and has not had further episodes. Her rhythm has been completely normal here. Her EKG is normal except for mild first degree AV block. Her cardiac enzymes are negative and no other laboratory studies show any significant abnormalities except for slightly low potassium, probably secondary to Dyazide.
AV|atrioventricular|AV|287|288|IMPRESSION|I highly doubt the possibility of a tachycardia-mediated problem. There is no other suggestion of risk for tachycardia such as ventricular tachycardia with normal LV function and no history of coronary artery disease. Based on the presence of trifascicular block, including first degree AV block, right bundle branch block, and left anterior fascicular block, he clearly has conduction system disease and is at significant risk for bradyarrhythmia.
AV|atrioventricular|AV|142|143|LABORATORY DATA|This is likely a focal atrial tachycardia and not a reentrant tachycardia. This is supported by the fact that intravenous Adenosine increased AV block but did not terminate the atrial tachycardia. This is likely triggered by her postoperative state including altered eating, sleeping, general anesthesia, pain, pain relievers, etc., etc.
AV|arteriovenous|AV|199|200|PHYSICAL EXAMINATION|NECK: No carotid bruits. Thyroid normal. NEUROLOGICAL: Visual fields are full. Extraocular muscles are intact. Pupillary responses are normal and symmetric. Funduscopic examination reveals some mild AV nicking. Facial motility and sensation, tongue and palate motility, speech, language, hearing and shoulder shrug are normal. She has good strength throughout with normal tone, symmetric reflexes and no Babinski signs.
AV|atrioventricular|AV|228|229|PHYSICAL EXAMINATION|HEENT; Conjunctiva red, sclera white, mucous membranes dry. He had no neck veinous distention, mass, bruit or goiter sitting in the chair. VITAL SIGNS: Blood pressure 130/80, heart rate 80 bpm in atrial flutter with high-degree AV block. HEART: Regular without gallop or murmur. LUNGS: Clear. ABDOMEN: Soft, obese, nontender without organomegaly. EXTREMITIES: Showed +1 lower leg edema with chronic venous stasis changes.
AV|atrioventricular|AV|126|127|HISTORY OF PRESENT ILLNESS|She ruled out for a myocardial infarction with negative troponins. EKG was sinus rhythm with no ST changes and a first degree AV block. She had a CT scan of her chest on an emergent basis which was done with contrast. This was negative for any pulmonary embolism or acute thoracic process.
AV|atrioventricular|AV|273|274|PLAN|He had previously been on multiple medications including: Phoslo, Megace, Coreg, Lasix, nitroglycerin, Nephrocaps, lisinopril, Paxil, hydralazine, Imdur, melatonin and Remeron. He has a history of colon cancer as well as peripheral vascular disease as above. He has had an AV shunt placed in the left arm in _%#MM#%_ of 2005. He has had a splenectomy and cholecystectomy and internal fixation of left ankle fracture.
AV|atrioventricular|AV|245|246|DOB|These palpitations are not associated with his shortness of breath and dizziness symptoms, and they were not yesterday. He subsequently converted to a sinus rhythm with an underlying relative bradycardia on medications as well as a first degree AV block. In between any of these episodes, he continues to be active and notes that he swims a half hour to 45 minutes several times a week, and in fact, has been able to do that without change over the last year.
AV|atrioventricular|AV|149|150|LABORATORY DATA|PULSES: Pedal pulses are intact. LABORATORY DATA: Preoperative labs are noted. Hemoglobin 14.3, potassium 4.2. Preoperative EKG reveals first degree AV block with a PR of 0.40. EKG otherwise is normal. The finding of the first degree AV block apparently is a new finding and the patient reports that his primary doctor plans to further evaluate this, i.e., with an echocardiogram.
AV|atrioventricular|AV|145|146|INDICATION FOR CONSULTATION|INDICATION FOR CONSULTATION: Significant bradycardia noted on monitor post left total knee arthroplasty. Claire Falls is 60. She has had chronic AV conduction dysfunction, sick sinus syndrome and paroxysmal atrial fibrillation that has been recently controlled; it has quieted in the past 1-1/2 years with the antiarrhythmic agent Tikosyn.
AV|arteriovenous|AV|184|185|PAST SURGICAL HISTORY|1. Pancreas and kidney transplant with bladder drainage of pancreatic exocrine secretions in 1997. 2. Laser retinal photocoagulation treatments. 3. Vitrectomy. 4. Left upper extremity AV fistula x2. 5. Status post tubal ligation. DISCHARGE MEDICATIONS: 1. CellCept 1 mg p. b.i.d. 2. Prograf 1.5 mg p.o. b.i.d. 3. Bactrim.
AV|atrioventricular|AV|100|101|PHYSICAL EXAMINATION|NEUROLOGIC: She appears to move all four extremities. EKG shows sinus bradycardia with first degree AV block, rate is 54. She shows a Q in III and poor R-wave progression, her BUN on _%#MMDD#%_ was 63, creatinine 1.65; on _%#MMDD2006#%_ it was 54 and 1.62, today it is 57 and 2.47. Potassium was 5.3, bicarbonate 21, sodium 134, chloride 105.
AV|atrioventricular|AV|111|112|ASSESSMENT/PLAN|He and his wife are going to discuss this further, although I doubt he will change his mind as far as pursuing AV node ablation and pacemaker. We are reversing his anticoagulation at this time anyway because of his need for pleural tap. Thank you for allowing me to participate in his care
AV|atrioventricular|AV|130|131|IMPRESSION|Blood sugars will be monitored by the hospitalists. IMPRESSION: 1. Symptomatic paroxysmal ventricular tachycardia associated with AV conduction system dysfunction/sick sinus syndrome. 2. Tachycardia documented. No bradycardia noted. Treatment however is difficult without concern for promoting bradycardia.
AV|atrioventricular|AV|153|154|PHYSICAL EXAMINATION|The patient is in a sinus rhythm. There are frequent APC's. Some of these APC's are blocked. So far, telemetry has revealed no evidence of second degree AV block or any pauses. LABORATORY: Her CBC and electrolytes are normal. IMPRESSION/PLAN: There is no evidence to suggest any hemodynamically significant arrhythmias.
AV|arteriovenous|AV|204|205|PAST MEDICAL HISTORY|7. Status post ventral abdominal herniorrhaphy. 8. Gastroesophageal reflux disease. 9. History of upper GI bleed due to nonsteroidal anti-inflammatory medications. 10. Previous GI bleeding due to colonic AV malformations. 11. History of asthma. 12. Benign positional vertigo. 13. Status post right cataract extraction with lens implant. No history of hyperthyroidism, hypothyroidism, peptic ulcer disease, cancer or tuberculosis.
AV|atrioventricular|AV|211|212|CHIEF COMPLAINT|This was done from Friday to Saturday _%#MMDD#%_ to _%#MMDD2007#%_. This study was stopped on Saturday, red today. This study revealed now sinus rhythm with first degree with periods of second-degree Wenckebach AV conduction and periods of third degree-complete heart block with sinus rhythm at 75 and no QRS with 5-7.7 second pauses. There were isolated VPCs and junctional beats. The PR interval when in sinus rhythm showed first degree AV block, with episodes of 5-4, 4-3 and 3-2 AV conduction.
AV|atrioventricular|AV|371|372|CHIEF COMPLAINT|This study was stopped on Saturday, red today. This study revealed now sinus rhythm with first degree with periods of second-degree Wenckebach AV conduction and periods of third degree-complete heart block with sinus rhythm at 75 and no QRS with 5-7.7 second pauses. There were isolated VPCs and junctional beats. The PR interval when in sinus rhythm showed first degree AV block, with episodes of 5-4, 4-3 and 3-2 AV conduction. Remarkably, despite these arrhythmias, he did not have symptoms and from Friday to Saturday he does not remember any chest pain, palpitations, dizziness, syncope, shortness of breath, orthopnea or lower leg edema.
AV|atrioventricular|AV|166|167|ASSESSMENT|She was also noted to have a mildly elevated pulmonary artery pressure. Most importantly, Dr. _%#NAME#%_ felt that the mitral valve inflow pattern suggested possible AV dissociation but that this was not definite and may have represented Wenckebach or may have been inaccurate. At the time he noted that heart rate was in the 50's and that there were no visible P waves on the echo monitor.
AV|atrioventricular|AV|203|204|ASSESSMENT|She thinks that she has had a few of these episodes for many years, and she usually had warning symptoms. We do not have any likely explanations for her syncope. The closest with come is the question of AV dissociation seen by echocardiographic criteria. Her monitor has not shown such an abnormality. I do not believe that the echo is particularly reliable predictor, and I would not consider placing a pacemaker based on the strength of that evidence alone, especially in light of not having any demonstrated bradycardia on monitor here in the hospital.
AV|UNSURED SENSE|AV|125|126|IMPRESSION AND PLAN|I did discuss this with the patient in some detail and she seems to lean towards proceeding with that. I believe the typical AV and RT is the most likely underlying diagnosis and I did discuss with her the risk of brain injury, cardiac perforation with resulting tamponade and inadvertent AV node damage necessitating permanent pacemaker placement.
AV|atrioventricular|AV|300|301|HISTORY OF PRESENT ILLNESS|His longest pauses have probably been about two and a half seconds. He is asymptomatic throughout all of these episodes. In an effort to improve his heart rate and decrease the number of pauses, his AV nodal blocking agents have been discontinued, but he has continued to have episodes of high-grade AV block. CURRENT MEDICATIONS: 1. Coumadin which was started a few days ago for the patient's diagnosis of factor V Leiden.
AV|atrioventricular|AV|224|225|REASON FOR CONSULTATION|While in the recovery room she was apparently hemodynamically stable but complaining of lower back pain. She does not remember any of this but while on the monitor she went from sinus rhythm with a normal PR interval to 2:1 AV block and then complete heart block that lasts for approximately 20 seconds. It is difficult to judge the end of the monitor strips because of some chest massage that was delivered, but there are 18-20 seconds of P waves at a sinus rhythm of 50-60 beats per minute with no conduction to the ventricles.
AV|atrioventricular|AV|251|252|HISTORY OF PRESENT ILLNESS|Apparently, his wife could not help him off the floor and they called 911 and he was brought to the Emergency Room. There, he had a slow fixed rate pacing pacemaker performance with a fixed heart rate of around 50 beats per minute with no evidence of AV conduction apparent, there was AV dissociation. Since admission, he has been asymptomatic, but he has been kept in bed supine.
AV|arteriovenous|AV|342|343|PLAN|PLAN: We will proceed directly to cardiac catheterization. The risk of coronary angiography and angioplasty will be fully explained to the patient including the risk of stroke, heart attack, death, blood transfusion, emergency bypass surgery, dye nephropathy, dye allergy, cholesterol embolization, vascular damage, pseudoaneurysm formation, AV malformation, limb loss, hematoma formation, ecchymosis, risk of conscious sedation including intubation and aspiration. Patient fully understands the procedure and wishes to proceed. It has been made clear to him that he will not be able to drive home after the procedure and he also may be staying overnight if angioplasty has been performed.
AV|atrioventricular|AV|204|205|EKG|ABDOMEN: Soft. No hepatic engorgement. She has no peripheral edema. EKG: Sinus mechanism with diffuse nonspecific ST abnormalities and mild intraventricular conduction delay. There is a mild first degree AV delay as well as left axis deviation. Chest x-ray and films cannot be located. LAB DATA: Creatinine of 1.6, BUN of 34.
AV|atrioventricular|AV|163|164|LABORATORY DATA|LABORATORY DATA: Sodium 133, potassium 3.3, creatinine 1.1, albumin 4.1, normal liver function tests, normal INR and PTT. EKG shows sinus rhythm with first degree AV block. Right bundle branch block. Hemoglobin is 13.7, white blood cell count 9.5. There is no left shift. Platelet count 259,000. Urinalysis shows gross hematuria and many bacteria.
AV|atrioventricular|AV|220|221|ASSESSMENT/RECOMMENDATIONS|I agree at this time, the INR should be reversed and permanent pacing and AV nodal ablation undertaken. The patient has agreed to proceed after discussion of risks and benefits. She understands that permanent pacing and AV nodal ablation does not cure atrial fibrillation and she will need to continue to use warfarin. I also recommended additional antihypertensive therapy. I believe she would benefit from a re-evaluation by pulmonary medicine of her CPAP.
AV|atrioventricular|AV|170|171|ASSESSMENT/PLAN|I will schedule patient for tomorrow. The success rate should be greater than 90% and risk of serious complications should be around 1%. This includes cardiac tamponade, AV block requiring permanent pacemaker. The patient understands and agrees to proceed.
AV|atrioventricular|AV|155|156|HISTORY|She has a followup visit at Minnesota Heart Clinic on _%#MMDD#%_. We can check at that time and see if she needs additional medicine. I briefly touched on AV node ablation and a pacemaker, but I would only do that if she fails medical treatment for rate control. I would not recommend a pulmonary vein ablation in an 80-year-old who cannot even feel her atrial fibrillation and I would tend to agree Dr. _%#NAME#%_ at this point that I would not recommend type 1 or type 3 antiarrhythmics.
AV|atrioventricular|AV|202|203|ASSESSMENT/PLAN|Otherwise it is difficult to explain regional wall motion abnormalities in a patient with dilated cardiomyopathy. The patient has been treated with heart failure medications. 2. Atrial flutter with 2:1 AV conduction predominantly. Cannot rule out 1:1 AV conduction. We will proceed with electrophysiology study and atrial flutter ablation.
AV|atrioventricular|AV|284|285|IMPRESSION AND PLAN|There seems to be something particular about these child that predisposes them top complete AV block, as even children without surgery but who have Down syndrome seem to be at increased risk of heart block. At this point, I cannot predict whether _%#NAME#%_ will progress to complete AV block, but he does seem to fit 2 criteria for pacemaker implantation. I would recommend that he have a single chamber epicardial ventricular pacemaker placed, at a time that suits the otolaryngologist, because he will need to be re-intubated.
AV|arteriovenous|AV|187|188|HISTORY OF PRESENT ILLNESS|His creatinine was up from his baseline of 2-4.6 and his creatinine was 41 and his sedimentation rate was 105. He was quite anemic with hemoglobin of 7.3. He is known to have multiple GI AV malformations, but has declined laser treatment. While he was in the hospital being evaluated for these problems, he had a CT scan of the chest, abdomen and pelvis and it made an incidental finding of a 1.2 cm left upper lobe peripheral lung nodule which is indeterminate in nature.
AV|arteriovenous|AV|189|190|PAST MEDICAL HISTORY|He has been placed on trimethoprim sulfa, to which the isolate is sensitive. PAST MEDICAL HISTORY: The patient's past history is significant for the neurologic problems associated with his AV malformation of the spine and also a past history of middle cerebral artery aneurysm which required clipping. He has had problems with decubitus ulcers in the past.
AV|arteriovenous|AV|198|199|IMPRESSION|3. Positive blood cultures with gram-positive cocci in clusters determined to be coagulase negative Staph. 4. Past medical history of ischial tuberosity decubitus ulcers. 5. Paraplegia after spinal AV malformation. 6. History of left middle cerebral artery aneurysm and status post clipping, date uncertain. 7. Neurogenic bladder. He has positive urine culture for Acinetobacter species.
AV|arteriovenous|AV|260|261|REASON FOR CONSULTATION|Reviewing the CT scan performed in the Emergency Room does demonstrate moderate bilateral hydronephrosis, and so some element of obstruction is possible. He dialyzes via a right- sided internal jugular tunnel dialysis catheter. He has had previous attempts at AV fistulas both in the right wrist and the left upper arm. Both of these by today's exam appear to be no longer functioning.
AV|atrioventricular|AV|244|245|PHYSICAL EXAMINATION|I believe this diminished energy is multifactorial including the high dose of diltiazem, her age, obesity, deconditioning, medication side effects and possibly her heart rate being a little too low. She has a left bundle branch and significant AV conduction system dysfunction. I think it is unlikely that we will be able to maintain and keep her in sinus rhythm.
AV|atrioventricular|AV|168|169|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Unable to assess, as the patient is intubated and sedated. PHYSICAL EXAMINATION: VITAL SIGNS: She is afebrile. Blood pressure 120/56, heart rate 100 AV paced. CARDIOVASCULAR: LVAD flow is 5.2 L/minute at a fixed rate of 65, with stroke volumes greater than 80 cc. RVAD flow is 5.1 at a fixed rate of 3,000.
AV|atrioventricular|AV|170|171|PHYSICAL EXAMINATION|MEDICATIONS: 1. Aspirin. 2. Diuril. 3. Aranesp. 4. Colace. 5. Protonix. PHYSICAL EXAMINATION: VITAL SIGNS: She is afebrile. Blood pressure 107/36, mean 60, heart rate 99 AV paced. She was intubated and sedated. CARDIOVASCULAR: LVAD flow is 5.4 liters, with a fixed rate of 65 with stroke volume greater than 80 cc.
AV|atrioventricular|AV|122|123||Her EKG shows what is read out as an old inferior infarct with a rate of 58. There is sinus bradycardia with a 1st degree AV block. This was compared with an EKG from _%#MMDD2006#%_ as well as _%#MMDD2006#%_ and shows no significant morphology changes.
AV|atrioventricular|AV|212|213|PHYSICAL EXAMINATION|He has palpable femoral artery pulses on both sides. EKG from admission shows probable atrial flutter with 2:1 AV block. The atrial flutter is clearly documented on multiple rhythm strips with a higher degree of AV block. There appears to be a counterclockwise atrial flutter. His old 12-lead EKG in sinus rhythm shows left anterior hemiblock and borderline AV conduction, and isolated VPCs.
AV|atrioventricular|AV|237|238|IMPRESSION/PLAN|I do not feel that he requires intravenous IIb/IIIa inhibitors or IV nitroglycerin at this time. I have made some slight medication changes, deferring on the increase in his beta blocker treatment because of his preexisting first-degree AV block, and I would prefer to continue short-acting ACE-inhibitor in case of future hemodynamic instability. I believe that as of tomorrow, he is unlikely to need further furosemide.
AV|atrioventricular|AV|153|154|HISTORY OF PRESENT ILLNESS|Since admission, he has been bradycardic with a heart rate in the 50s. An electrocardiogram was reported as showing sinus bradycardia with second-degree AV block, Mobitz type I. I have the opportunity of reviewing these electrocardiograms myself. I think it shows a complete heart block with AV dissociation and bradycardia.
AV|atrioventricular|AV|150|151|STUDIES|She was originally 100% atrial and ventricular paced. With reprogramming of the AV interval, she then had atrial pacing and intact AV conduction. Her AV interval during atrial pacing was approximately 210 milliseconds. The atrial pacing unit was then turned down to 45. She had an underlying narrow complex rhythm at a rate of 60.
AV|atrioventricular|AV|248|249|STUDIES|These were upright in lead II. The PDA appeared to move in and out of the initial portion of the QRS interval, suggesting the possibility of competing atrial and junctional rhythms. Her blood pressure did not change, going from 108 systolic during AV pacing at a rate of 70-106 systolic while sitting up at her intrinsic rate of 60. IMPRESSION: Postoperative atrial standstill/arrest, with junctional escape rhythm, but poor hemodynamics.
AV|atrioventricular|AV|363|364|PAST MEDICAL HISTORY|She has multiple myeloma and amyloidosis including restricted cardiomyopathy, history of nephrolithiasis and urinary tract infections in the past including the MRSA as above, more recently has had less urine infection problems, has had significant problems of pulmonary hypertension and chronic cardiac-related problems. She has a pacemaker in place with a prior AV node ablation and atrial fibrillation. There have been no problems with that pacemaker although it is apparently on recall and needing to be replaced.
AV|atrioventricular|AV|269|270|LABORATORY DATA|GGT 18; TSH 1.16. Remaining liver function was normal. Sodium 139; potassium 3.9; glucose 113; BUN 17; creatinine 0.8; calcium 8.8. Unremarkable urinalysis. WBC 9,800; hemoglobin 12.2; MCV 84; platelets 137,000. EKG demonstrates a normal sinus rhythm with first degree AV block. Occasional premature ventricular contraction. Left axis deviation. Nonspecific ST/T wave change laterally in addition to voltage criteria for left ventricular hypertrophy.
AV|atrioventricular|AV|196|197|ASSESSMENT|3. Heart murmur as described probably related to mitral insufficiency. Cannot exclude component of aortic valvular disease. Suspect previously evaluated by primary care physician. 4. First degree AV block with occasional premature ventricular contraction and voltage criteria for left ventricular hypertrophy on EKG. 5. Status post radiation therapy (?) for prostate cancer.
AV|atrioventricular|AV|192|193|ASSESSMENT/RECOMMENDATIONS|If the patient has a prolonged pause resulting in symptomatic or concerning hypertension, Intravenous atropine at 1 mg can be administered. If the patient has recurrent episodes of high grade AV block or sinus pauses, temporary pacing could be considered as was discussed with Mrs. _%#NAME#%_'s husband, this is a relatively low risk procedure but does limit movement if placed in the groin which is the safest and does represent a potential risk for pneumothorax in an intubated individual with a larger body habitus for pneumothorax.
AV|arteriovenous|AV|168|169||She did undergo a four-vessel cerebral angiogram, also performed by Dr. _%#NAME#%_, which is normal. She underwent MRI scan of the cervical spine looking for an occult AV malformation, and that study was negative. It was felt by Neurosurgery that this was plausibly a migraine event and consultation was obtained.
AV|atrioventricular|AV|150|151|LABORATORY DATA|Her CBC is within normal limits. PTT, INR, myoglobin, troponin, and platelet count were normal. Her EKG showed normal sinus rhythm, with first-degree AV block, normal axis. CT of the head at 9:37 showed minimal atrophic chronic white matter disease, nothing acute, and no intracranial hemorrhage or mass effect.
AV|arteriovenous|AV|186|187|ASSESSMENT/RECOMMENDATIONS|Given those factors, there is still concern with the potential for a right-to-left shunt. The "rounded" echodensity on the chest x-ray raises the possibility of an undiagnosed pulmonary AV malformation. It was recommended that a chest x-ray be repeated, and I would agree. If that rounded density is again noted, the patient should have further evaluation for possible pulmonary AV malformation.
AV|aortic valve|AV|217|218|PAST MEDICAL HISTORY|The patient was in atrial fibrillation during the exam. The AV mean gradient at that time was 37 mmHg. The estimated valve area was not given. A transthoracic echocardiogram done in _%#MM2007#%_, however, revealed an AV mean gradient of 30 and a valve area of 0.8. 2. Coronary artery disease. The patient had a 3-vessel CABG in 1996.
AV|atrioventricular|AV|278|279|LABORATORY  DATA|Full gait was not assessed. LABORATORY DATA: Sodium 132, potassium 5.9, chloride 107, CO2 19, BUN 87, creatinine 2.05, glucose 130, calcium 9.1. WBC 10.3, hemoglobin 12.2, platelets 153. EKG shows sinus rhythm with sinus arrhythmia, right bundle branch block and a first-degree AV block. Occasional PVCs. T-wave inversions consistent with a right bundle branch block and unchanged from _%#MM#%_. In the emergency room, the patient has been given a dose of Imodium 4 mg p.o. along with Kayexalate 15 grams p.o. and normal saline hydration prior to my arrival per Dr. _%#NAME#%_'s orders.
AV|atrioventricular|AV|227|228|PAST MEDICAL HISTORY|She denies any dietary indiscretion. She has been eating soup, but it is homemade soup, not canned soup, and she has been adding no salt to it. PAST MEDICAL HISTORY: Extensive, and includes: 1. Atrial fibrillation, status post AV nodal ablation with permanent pacemaker approximately nine years ago. 2. History of urinary tract infection in _%#MM2005#%_. 3. History of SIADH.
AV|atrioventricular|AV|157|158|ASSESSMENT AND PLAN|Will continue his Lipitor and will check his fasting lipids in the morning. 6. Sinus bradycardia. At this point, patient is asymptomatic. Will watch for any AV blocks. Will hold his blood pressure medications if his pulse is less than 50. DISPOSITION: Patient's hospital stay will probably be 1-2 days. If his enzymes and his stress are negative, patient can be discharged home on oral proton pump inhibitor and outpatient followup for upper GI scope.
AV|arteriovenous|AV|188|189|HOSPITAL COURSE|He required on a few occasions to have a few more units of PRBC's; but, by the time of discharge, his hemoglobin was stable, and stools were clear. Most likely, this is consistent with an AV malformation in the small bowel in between endoscopy and colonoscopy, and will need to be further followed up if bleeding recurs.
AV|atrioventricular|AV|171|172|LABORATORY  DATA|B-type natriuretic peptide 1100. EKG initially shows wide complex tachycardia with concordance in V1 and V6 consistent with ventricular tachycardia. This then converts to AV paced rhythm at a rate of 94. ASSESSMENT: 1. _%#NAME#%_ _%#NAME#%_ is a de lightful 61-year-old male with very complicated history of idiopathic cardiomyopathy status post single vessel coronary artery bypass surgery and aortic valve and root replacement in 2005.
AV|atrioventricular|AV|186|187|PHYSICAL EXAMINATION|EKGs done at St. Francis suggested a supraventricular rhythm with a left bundle branch block although it is difficult to be sure. A second EKG done here shows sinus rhythm, first degree AV block. There is an intraventricular conduction defect, the QT interval is prolonged with a QT of 504 Msec and a QTC of 551 Msec. The QRS is 130 Msec. PR interval was difficult for the computer, but it looks to be greater than 240 Msec.
AV|atrioventricular|AV|127|128|LABS|She has no calf tenderness. She has no erythema or evidence of cellulitis. LABS: EKG shows sinus rhythm, rate 72, first degree AV block. She has some Qs in II, III and AVF consistent with her old EKG. She has a troponin 0.09, myoglobin of 26, a chest x-ray.
AV|arteriovenous|AV|268|269|COMMENTS|Whether he is a candidate for cardioversion at the present time or not, from his history he probably had a tachycardia for about 3-4 days which has been a mixture of sinus ve rsus atrial fibrillation with rapid ventricular rate. With respect to patient having another AV shunt on the other arm, he is very reluctant to have one done because they have failed repeatedly for the last several years.
AV|arteriovenous|AV|154|155|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. End-stage renal disease secondary to obstructive uropathy and Epogen. 2. Status post two failed kidney transplants. 3. History of AV fistula clot and status post two revisions this admission. 4. Pancreatitis, now resolved. 5. History of stent placement in pancreatic duct from _%#MM#%_ _%#DD#%_, to _%#MM#%_ _%#DD#%_, 2002.
AV|atrioventricular|AV|213|214|HOSPITAL COURSE|In the one week prior to discharge the patient had several beats of PVCs, but did not have any sort of nonsustained runs of VT. Throughout her hospital stay the patient has also been noted to have a second degree AV block with intermittent bradycardia down to the 30's as well as atrial fib and atrial flutter. Flutter with variable blocks of 1 to 4/1 to 6.
AV|atrioventricular|AV|174|175|PAST MEDICAL HISTORY|She had been given ceftriaxone, vancomycin, and a single dose of Solu- Medrol prior to arrival at Fairview University Medical Center. PAST MEDICAL HISTORY: 1. Trisomy 21. 2. AV canal defect status post repair. 3. Mechanical tricuspid valve requiring anticoagulation. 4. History of complete heart block following AV canal repair, currently AV paced.
AV|atrioventricular|AV|205|206|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Trisomy 21. 2. AV canal defect status post repair. 3. Mechanical tricuspid valve requiring anticoagulation. 4. History of complete heart block following AV canal repair, currently AV paced. 5. Hepatic fibrosis with intermittent hyperammonemia. 6. Hypothyroidism, on Synthroid replacement. 7. History of group D enterococcus sepsis. 8. History of congestive heart failure due to her congenital heart disease.
AV|atrioventricular|AV|198|199|LABORATORY DATA|Blood cultures obtained. Urinalysis shows no ketones, there are 8 red blood cells, 2 white blood cells, no nitrates or leukocyte esterase. EKG shows J point elevation in V1 through V4, first degree AV block, normal sinus rhythm. ASSESSMENT/PLAN: 1. Hypoxia appears to be multifactorial secondary to congestive heart failure, large hiatal hernia, she may also have an aspirate pneumonia, possibly aspiration pneumonia.
AV|arteriovenous|AV|173|174|PHYSICAL EXAMINATION|He is not able to elevate or depress the eye or intort or extort it. A fundus exam reveals a clear disk with a normal cup-disk ratio. The vessels appear normal with grade 2 AV nicking. There is no evidence of papilledema. The left eye is completely normal. The left eye has normal range of motion. The visual acuity in the left eye is 20/20. The visual acuity in the right eye is 20/40.
AV|aortic valve|AV|378|379|PRESENTING COMPLAINT|PRIMARY CARE PHYSICIAN: UNKNOWN PRESENTING COMPLAINT: Rigors, chills and light-headedness, probably associated with bacteremia / sepsis syndrome related to left lower extremity cellulitis or possiblly left lower quadrant pain, dysuria or recent lead replacement on a pacer defibrillator performed on _%#MM#%_ _%#DD#%_ by Dr. _%#NAME#%_ from Minnesota Heart. In a patient with a AV valve replacement and an artifical left knee. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 79-year-old who does not have diabetes but does have an aortic valve replacement placed in _%#MM2007#%_ for what appeared to be severe AS.
AV|atrioventricular|AV|292|293|HOSPITAL COURSE|On discharge his pacemaker was interrogated and showed that he had atrial tachycardic episode, other than that he is normal sinus rhythm at 80 beats per minute with occasional premature atrial complexes. HOSPITAL COURSE: 1. AV nodal reentry. The patient was admitted with syncope likely from AV nodal reentrant tachycardia. He was converted in the ER with two doses of adenosine and also had some magnesium supplementation downstairs.
AV|atrioventricular|AV|248|249|HOSPITAL COURSE|He was converted in the ER with two doses of adenosine and also had some magnesium supplementation downstairs. He was in normal sinus rhythm. He had Electrophysiology study with ablation the following day after which there was no further inducible AV nodal reentry, however, while down in the radiology department off monitor for his follow-up chest x-ray, the patient again developed some fluttering feeling palpitations and light headedness which quickly resolved.
AV|atrioventricular|AV|346|347|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old woman with a past medical history of COPD secondary to tobacco abuse, bilateral renal artery stenosis by ultrasound and MRI of the aorta about a month ago. She had a recent admission for paroxysmal atrial fibrillation with rapid ventricular response. She presented as an outpatient for an AV nodal ablation plus pacemaker placement for paroxysmal atrial fibrillation. The patient was found to have significant hypertension following the procedure as well as a rise in creatinine and was placed on a nitroglycerin drip to be titrated to maintain systolic blood pressure between 100 and 150.
AV|atrioventricular|AV|189|190||Ms. _%#NAME#%_ _%#NAME#%_ is a very pleasant 66-year-old lady known to me from her prior hospital stays who was admitted to Fairview Southdale Hospital on _%#MMDD2004#%_ because of planned AV nodal radiofrequency ablation of the AV node. Her major medical problem is end stage chronic obstructive pulmonary disease and paroxysms of atrial fibrillation with rapid ventricular response likely related to this.
AV|atrioventricular|AV|225|226|BMT WORK-UP|C. No pulmonary nodules. 4. Chest x-ray shows sequelae of primary fibrosis and atelectasis in the upper lobes questionably due to previous radiation, no other obvious intrathoracic diagnosis. 5. EKG sinus rhythm with primary AV block left axis deviated. 6. Pulmonary function tests. FEV1 equals 59%, FEV1 over FVC equal 80%. DLCO uncorrected equals 71%, DLCO corrected equals 71%. Impression moderate airflow obstruction, probable restriction, mild diffusion defect.
AV|atrioventricular|AV|166|167|PAST MEDICAL HISTORY|Because of continued worsening respiratory symptoms, Lyndsey was brought to Fairview-University Medical Center for admission. PAST MEDICAL HISTORY: 1. Trisomy 21. 2. AV canal, status post repair. 3. Mechanical tricuspid valve, for which Lyndsey requires anticoagulation. 4. Complete heart block following AV canal repair, currently status post pacemaker placement x 2.
AV|atrioventricular|AV|184|185|LABORATORY STUDIES|Review of the monitoring strips from the paramedics reveals what appears to be ST elevation in leads II, III and AVF but 12 lead EKG obtained here in the ER Dept. shows a first degree AV block, some PVC's, possible intraventricular block but no ST changes. There is also no T wave inversions in lead II, III, or AVF which were the ones that were of some concern on the paramedics print out.
AV|arteriovenous|AV|163|164|PAST SURGICAL HISTORY|9. Hemodialysis since 2005. PAST SURGICAL HISTORY: 1. Back surgery, 1999 for spider bite. 2. Laparoscopic cholecystectomy in _%#MM2006#%_. 3. Left upper extremity AV fistula. ALLERGIES: 1. Aspirin. 2. Codeine. 3. Compazine. HOSPITAL COURSE: The patient was admitted on _%#MMDD2007#%_ for an elective pancreas and kidney transplant.
AV|atrioventricular|AV|343|344|IMPRESSION AND PLAN|I told her about an effected chance of successful completion would be about 30% and that the risk of serious complication would be on the order of 1-2%. We specifically did discuss th e risks of iatrogenic brain injury, cardiac chamber perforation with resulting tamponade and need for pericardiocentesis as well as the risk of an inadvertent AV nodal ablation with the need for permanent pacemaker. They understand and they want to proceed. CONCLUSION: Episodes of palpitations and presyncope probably due to supraventricular tachycardia
AV|atrioventricular|AV|149|150|PAST MEDICAL HISTORY|Also the patient has had decreased appetite for solids and has been much sleepier over the past 2 days. PAST MEDICAL HISTORY: 1. Down's Syndrome. 2. AV canal repair. 3. Mechanical tricuspid valve. 4. Complete heart block with pacemaker placement x2. 5. Hepatic fibrosis secondary to hepatic failure. 6. History of group B enterococcal sepsis.
AV|atrioventricular|AV|144|145|PAST MEDICAL HISTORY|3. Hypertension. 4. Coronary artery disease. 5. History of a myocardial infarction in 1999. 6. History of mitral valve replacement. 7. Complete AV block with pacemaker, which was placed in 1993. Batter was placed in 2003. 8. Heart failure. 9. Recently evaluated _%#MMDD2007#%_ and showing severe ischemic cardiomyopathy with injection fraction of 34%.
AV|arteriovenous|AV|149|150|PAST MEDICAL HISTORY|The patient reports that it has been "quiet" for a few years. 2. Renal insufficiency diagnosed 6 years ago, thought secondary to lupus nephritis. 3. AV fistula in the right forearm was placed in late _%#MM2006#%_. 4. History of thrombocytopenia. 5. History of chronic leg ulcers and cellulitis for 3 years.
AV|arteriovenous|AV|453|454|PROCEDURES PERFORMED DURING HOSPITALIZATION|5. Bilateral upper extremity doppler venous ultrasound and vein-mapping performed _%#MMDD2007#%_, which demonstrated partially occlusive thrombus in the right internal jugular vein and medial right subclavian vein, stenotic right axillary vein, thrombosed hemodialysis fistula in the right forearm, thrombosed entire right cephalic vein and left cephalic vein in the mid arm, and normal arterial flow in both extremities. 6. Placement of left upper arm AV fistula performed _%#MMDD2007#%_. BRIEF HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a very pleasant 60-year-old female with history of end-stage kidney disease on hemodialysis, on chronic anticoagulation for history of thrombosed fistulas, who was admitted to the General Medicine Service on _%#MMDD2006#%_ after presenting with 3-4 days of abdominal pain.
AV|atrioventricular|AV|203|204|PROBLEM #2|He has been evaluated by the Cardiology Service for this issue, and they do not think a pacer is necessary at this time. However, if the patient goes into type II second- degree AV block or third-degree AV block, he would need a pacemaker at that time. PROBLEM #4: Endocrine. The patient was noted to have a right-sided adrenal mass of 5.5 cm on CT scan as an incidental finding.
AV|atrioventricular|AV|190|191|LABORATORY DATA|Initial BMP notable for potassium of 6.8. This improved on followup metabolic panel to 5.4. BUN is 51 and creatinine 1.6. CBC is essentially normal. EKG shows sinus rhythm with first-degree AV block. There are no acute ST changes. T-wave inversion as noted in lead III and aVF. Blood cultures obtained in the ER are pending.
AV|atrioventricular|AV|142|143|HISTORY OF PRESENT ILLNESS|Hemoglobin 11.7. MCV 92. Platelet counts 425000. INR 0.91. PTT 30. Salsalate level less than 1. Electrocardiogram demonstrated a first degree AV block. Follow-up tracing at this facility on _%#MMDD2004#%_ demonstrated baseline artifact, normal sinus rhythm with diffuse nonspecific T wave abnormality.
AV|atrioventricular|AV|231|232|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a very pleasant unfortunate 77-year-old male who I actually met approximately 2 months ago. He has a long-standing history of known paroxysmal atrial fibrillation, atrial flutter and second-degree AV block. He has a dual-chamber pacemaker in place. On his pacer checks, he was noted to be in and out of atrial fib. When he became sick with his lung cancer, he missed multiple appointments.
AV|atrioventricular|AV|297|298|PAST MEDICAL HISTORY|She is lying in bed and appears lethargic. Over the last 3-4 days, she also has noticed swelling and redness in her right thumb and has been recently started on antibiotics for possible cellulitis. PAST MEDICAL HISTORY: 1. Hypertension of long standing. 2. History of bradycardia in the past with AV nodal pacemaker inserted in 2003. 3. Hypothyroidism. 4. Pulmonary hypertension in the past with enlarged right ventricle and right ventricular systolic dysfunction.
AV|atrioventricular|AV|170|171|PAST MEDICAL HISTORY|6. Type 2 diabetes mellitus. 7. Aortic stenosis. 8. Mild asthma. 9. History of atrial fibrillation. 10. History of pneumonectomy in 1999 for tuberculosis. 11. History of AV block. 12. Gastroesophageal reflux. 13. Glaucoma. 14. Hypothyroidism. 15. Osteoarthritis. 16. Osteopenia. 17. Mild pulmonary hypertension. 18. History of squamous-cell carcinoma of the left anterior thigh status post excision in 2006.
AV|atrioventricular|AV|391|392|PHYSICAL EXAMINATION|And she was minimally symptomatic with that. Her device is programmed for free tachycardia zone, namely ventricular fibrillation zone over 220 beats per minute to be treated with 41 joule shocks, final ventricular tachycardia zone between 180 and 220 beats per minute to be treated with ATP by 40 shocks and 150 to 180 monitoring only zone. Her bradycardia pacing is DDD70-130, with dynamic AV delay. Her blood cultures from _%#MM#%_ _%#DD#%_ are negative. Today, her troponin is negative times one, WBC normal at 7.8 with normal hemoglobin and her creatinine is normal at 0.9. Her sodium and potassium, chloride and calcium are likewise normal, her blood sugar is somewhat elevated at 228.
AV|atrioventricular|AV|280|281|IMPRESSION AND PLAN|We specifically discussed the risk of iatrogenic vascular injury, cardiac perforation in the stump and need for pericardiocentesis and for the unlikely event of a left-sided focus and the risk of stroke and complication of transseptal procedure. I also told him about the risk of AV block with need for permanent pacemaker implantation in case of focus located close to the AV node. He would like to discuss this with Dr. _%#NAME#%_, his primary physician, first.
AV|arteriovenous|AV|141|142|PAST MEDICAL HISTORY|1. Status post bilateral knee replacement. 2. Abdominal aortic aneurysm repair in 1992, 3. Status post right carotid endarterectomy in 1998, AV fistula placed for possible hemodialysis in 1998. Family tells me is not currently had any dialysis to date. 4. History of dyslipidemia. 5. History of hypertension. 6. History of gastroesophageal reflux disease and peptic ulcer disease.
AV|atrioventricular|AV|311|312|PHYSICAL EXAMINATION|Neurologic: Alert and oriented times three. Cranial nerves II-XII grossly intact. Affect is normal. The ECG demonstrates a right bundle branch block, possible inferior wall Q waves, nonspecific T waves, T-wave inversion in V1 possibly indicative of left atrial enlargement, and there is borderline first-degree AV block. LABORATORY: The TSH is 1.71. Hemoglobin A1C 7.1. Total cholesterol 153.
AV|atrioventricular|AV|328|329|LABORATORY DATA|LABORATORY DATA: Sodium 145, potassium 4.8, chloride 118, CO2 of 18, anion gap of 10, glucose 98, BN 51, creatinine 2.69, GFR estimated at 25, calcium 9.3. White count 10,300, hemoglobin 11.9 with MCV of 94, platelet count 259,000. INR 1.03 with PTT of 28. EKG demonstrates a sinus bradycardia with occasional PAC. First degree AV block. No ischemic change.
AV|atrioventricular|AV|368|369|HISTORY|An echocardiogram at that same time showed left atrial dilatation, preserved left ventricular function with moderate LVH, and a wall motion abnormality of the anteroseptal apical left ventricle consistent with his previous valve surgery. The aortic valve was functioning normally. His ECG during that hospitalization demonstrated sinus bradycardia with a first-degree AV block and nonspecific ST-T wave changes consistent with LVH. Borderline QT prolongation was seen with a Q-Tc of 0.463. ALLERGIES: None known about.
AV|atrioventricular|AV|188|189|PHYSICAL EXAMINATION|Pulses are 1+ below the femorals, 1-2+ above. NEURO: Appeared to be grossly intact, although, not done in detail. Recent electrocardiography showed a normal sinus rhythm with first degree AV block, nonspecific ST T-wave changes. LABORATORY DATA: Laboratory data showed a hemoglobin of 13.1. Hematocrit 37.5. WBC 7.1. Alkaline phosphatase 100.
AV|atrioventricular|AV|168|169|PHYSICAL EXAMINATION|His bradycardia is relatively new. He had been in the 40s and 50s earlier this week and now is in the 30s and 40s. His current EKG shows what appears to be high degree AV block or at least high degree AV dissociation and he has a junctional rhythm at 36-40 beats per minute. I suspect strongly he will end up getting a pacemaker.
AV|arteriovenous|AV|287|288|IMPRESSION AND PLAN|If she does have recurrence of her episode despite beta blocker treatment, I think it wouldn't be unreasonable to offer her radiofrequency ablation which I did discuss with her briefly. From the perspective of disposal tonight, I think that she could be safely dismissed and undergo her AV fistula creation tomorrow as long as the second troponin is negative and if I would recommend given her slight elevation of myoglobin which I believe is false-positive, given the lack of ischemic changes and symptoms on presentation.
AV|atrioventricular|AV|197|198|ASSESSMENT|She believes that started at 12-18 hours before admission. Multiple treatment options have been Explained to this patient. She is reluctant to consider Dofetilide or amiodarone. She would consider AV nodal ablation with pacemaker but wishes to try medical therapy with rate control and anticoagulation first. This is reasonable. We will adjust her medications accordingly.
AV|atrioventricular|AV|102|103|PHYSICAL EXAMINATION|There is a healed scar in the left wrist area after reported orthopedic surgery. EKG shows sequential AV pacing with occasional ventricular ectopy. LABORATORY DATA: Remarkable for elevated BNP at 3,180.
AV|atrioventricular|AV|237|238|ASSESSMENT|On _%#MM#%_ _%#DD#%_, she had profound junctional bradycardia. Previous angiography four years ago apparently showed no significant coronary artery disease. I would favor use of medication before implanting a pacemaker and performing an AV nodal ablation. Our choices generally would be Sotalol or amiodarone since she apparently has left ventricular dysfunction. I would be unlikely to use a type IA medication with her.
AV|atrioventricular|AV|250|251|ASSESSMENT|With normal left ventricular function and no evidence of previous ischemia, this does not have a bad prognostic sign. I will review her most recent echocardiogram. Certainly should she become tachycardic in the future, I would consider pacemaker and AV nodal ablation again. Thank you very much for allowing me help care for this delightful patient.
AV|atrioventricular|AV|207|208|ASSESSMENT|2. Bivesicular block. Although Mobitz' I heart block is probable, I cannot rule-out Mobitz' II. This patient is at high risk for high degree heart block given he has bivesicular heart block and first degree AV block. This is even more so if he has evidence of ongoing ischemia. We will need to make a decision down the road whether he should receive a permanent pacemaker.
AV|atrioventricular|AV|234|235|PAST  MEDICAL HISTORY|7. History of hypothyroidism on replacement. 8. History of bladder polyps and cancer with excision in the past. 9. Gastroesophageal reflux disease. 10. Status post dual chamber pacemaker implantation in 1997 for SVT and second-degree AV block. 11. Peripheral vascular disease. 12. History of alcohol abuse with the patient denying any alcohol since 1995. 13. Anxiety neuroses. 14. Tonsillectomy and adenoidectomy. SOCIAL HISTORY: The patient states he lives with his daughter in their "broken down trailer".
AV|atrioventricular|AV|177|178|HIS LABORATORY RESULTS|His electrolyte panel is unremarkable including creatinine at 0.92. His CBC is also normal. I understand that his D-dimer is also normal. His electrocardiogram shows sequential AV pacing with a wide QRS paced complex at about 200 Msec. A CT of the head was also unremarkable except for brain atrophy.
AV|arteriovenous|AV|135|136|ASSESSMENT AND PLAN|She had a colonoscopy which revealed small polyps and was negative. She underwent a small bowel follow through today to assess for any AV malformation. It should be kept in mind that patients with aortic valve disease, especially aortic stenosis have associated AV malformations and may be difficult to pick up on regular studies.
AV|atrioventricular|AV|162|163|IMPRESSION|IMPRESSION: 1. Relatively controlled atrial fibrillation, but the patient herself has been very intolerant of it over the last month. 2. Sick sinus syndrome with AV conduction system dysfunction. 3. Digoxin excess, with digoxin level of 2.7. 4. Vague chest tightness. I doubt unstable angina, or angina or cardiac origin.
AV|atrioventricular|AV|280|281|REVIEW OF SYSTEMS|No sustained arrhythmia was induced at that time, and her symptoms were thus reproduced during infusion of isoproterenol when she developed sinus tachycardia in conjunction with axillary to junctional rhythm and IV dissociation. It is conceivable that she has some disease of the AV junction, which accounts for both intermittent AV block (she is only minimally AV paced) and her propensity to axillary to junctional rhythm during isoproterenol infusion.
AV|atrioventricular|AV|330|331|REVIEW OF SYSTEMS|No sustained arrhythmia was induced at that time, and her symptoms were thus reproduced during infusion of isoproterenol when she developed sinus tachycardia in conjunction with axillary to junctional rhythm and IV dissociation. It is conceivable that she has some disease of the AV junction, which accounts for both intermittent AV block (she is only minimally AV paced) and her propensity to axillary to junctional rhythm during isoproterenol infusion.
AV|atrioventricular|AV|200|201|HISTORY OF PRESENT ILLNESS|He was subsequently admitted to the CICU. Here the patient is in atrial flutter with a variable block. At times his ventricular rate gets into the 40s. Subsequently, he has not been given any further AV nodal blocking agents. He states that he has about 3/10 substernal chest pressure. He also feels the palpitations. He denies any shortness of breath or lightheadedness.
AV|atrioventricular|AV|155|156|HISTORY|He had an EP study done on _%#MM#%_ _%#DD#%_. He had recurring episodes of atrial fibrillation, however, therefore he had a radiofrequency ablation of the AV node. He had previously had ablation of his atrial tachycardia or atrial flutter done in _%#MM#%_ of 2005 at the VA Hospital.
AV|atrioventricular|AV|313|314|HISTORY OF PRESENT ILLNESS|She therefore was evaluated in the Emergency Department. During an attempt to self-induce vomiting at 7 p.m., she lost consciousness and ventricular fibrillation was documented on defibrillator patches. She was successfully defibrillated with a single discharge, and after brief episodes of sinus rhythm with 2:1 AV block, sinus tachycardia was documented. The patient was intubated and after one episode of seizure, she recovered completely. The patient did not have any history of cardiac disease, syncope, or palpitations in the past.
AV|atrioventricular|AV|205|206|ELECTROCARDIOGRAM|INR 5.57. Sodium 137, potassium 5.1, chloride 104, CO2 26, glucose 103, BUN 35, creatinine 2.6, calcium 9.2. WBC 6.2, hemoglobin 12.4, hematocrit 38.6. BNP 1720. ELECTROCARDIOGRAM: Electrocardiogram shows AV sequential paced rhythm. CHEST X-RAY: Chest x-ray is not available for viewing.
BAL|blood alcohol level|BAL|212|214|LABORATORY DATA|SKIN: No rashes. NEUROLOGIC: Alert and oriented x3, grossly moving all 4 extremities. EXTREMITIES: No pedal edema. LABORATORY DATA: On admission, white blood cell count 15.0, hemoglobin 13.9, platelet count 186, BAL 0.05, D-dimer 3.7. Basic metabolic panel was within normal limits with the exception of potassium which was 2.7. Chest 1x-ray at the time of admission showed a right lower lobe infiltrate.
BAL|bronchoalveolar lavage|BAL|172|174|MAJOR INVESTIGATIONS AND PROCEDURES DONE DURING THIS HOSPITALIZATION|The vocal cords moved normally. The trachea was of normal caliber. The bronchial mucosa and the anatomy were normal. There were no endobronchial lesions and no secretions. BAL was performed. 3. BAL fluid analysis. The Gram-stain on the BAL grew few gram-positive cocci and clusters, few gram-negative rods and few PMNs.
BAL|bronchoalveolar lavage|BAL|169|171|MAJOR INVESTIGATIONS AND PROCEDURES DONE DURING THIS HOSPITALIZATION|The bronchial mucosa and the anatomy were normal. There were no endobronchial lesions and no secretions. BAL was performed. 3. BAL fluid analysis. The Gram-stain on the BAL grew few gram-positive cocci and clusters, few gram-negative rods and few PMNs. The BAL, bacterial and fungal cultures are negative. The BAL AFB stain is negative.
BAL|bronchoalveolar lavage|BAL,|152|155|MAJOR INVESTIGATIONS AND PROCEDURES DONE DURING THIS HOSPITALIZATION|BAL was performed. 3. BAL fluid analysis. The Gram-stain on the BAL grew few gram-positive cocci and clusters, few gram-negative rods and few PMNs. The BAL, bacterial and fungal cultures are negative. The BAL AFB stain is negative. The BAL AFB culture is pending. The RSV shell-vial result is pending.
BAL|bronchoalveolar lavage|BAL|173|175|HISTORY OF PRESENT ILLNESS|On the day of admission, he was febrile up to 102 degrees Farenheit. The patient underwent a bronchoscopy on _%#MMDD2006#%_. The bronchoscopy revealed a normal anatomy. The BAL fluid so far has been negative for bacteria, viruses or fungi. After the voriconazole has been started, the patient has been afebrile for over 24 hours now.
BAL|bronchoalveolar lavage|BAL.|238|241|PHYSICAL EXAMINATION|The patient underwent a bronchoscopy. The bronchioalveolar lavage had 2200 red blood cells, 590 enucleated cells, 95% neutrophils. Bronchial cultures grew normal respiratory flora. There was a light growth of Aspergillus fumigatus on the BAL. There were no organisms seen on the Gram stain. There was no Nocardia growth. Biopsy from the bronchoscopy was negative for malignancy. Vasculitis was considered in the differential as well.
BAL|bronchoalveolar lavage|BAL:|166|169|LABORATORY|LABORATORY: On discharge, white blood cell 5, hemoglobin 11.5, platelets 158, sodium 137, potassium, 3.9, chloride 109, CO2 24, BUN 22, creatinine 1.22. Results from BAL: RSV negative. Influenza A and B antigen negative. CMV negative. Cultures still pending. Cytopathology is negative for malignancy. Negative for PCP. Negative for fungus.
BAL|bronchoalveolar lavage|BAL|190|192|FOLLOW UP|2. Ampicillin 500 mg p.o. q.8h. x14 days. 3. Pulmozyme. 4. Albuterol nebulizers every day. FOLLOW UP: He will followup in Transplant Clinic in approximately 2 weeks. Bacterial cultures from BAL were pending at the time of discharge.
BAL|bronchoalveolar lavage|BAL|178|180|ASSESSMENT AND PLAN|1. Respiratory failure. This is resolving. a. Will continue the oxygen supplementation. b. Continue pulmonary rehabilitation. c. This patient is status post bronchoscopy and the BAL grew Candida albicans. The patient will complete her Voriconazole course. d. The patient will follow up with Dr. _%#NAME#%_ in 2 weeks from now, and she will have a chest x-ray PA and lateral views 1 day before her appointment.
BAL|bronchoalveolar lavage|BAL|124|126|RSV.|The nasopharyngeal swab on _%#MMDD2005#%_ was negative for RSV. The bronchoscopy results were reviewed from _%#MMDD2005#%_: BAL was negative for CMV. RSV negative. AFB pending. Normal respiratory flora. Moderate growth of yeast. ASSESSMENT AND PLAN: The patient is a 59-year-old lady status post right single lung transplant status post COPD _%#MM2002#%_ was experiencing upper respiratory infection and recent bronchitis in the setting of bronchoscopy.
BAL|bronchoalveolar lavage|BAL|221|223|HOSPITAL COURSE|There were no signs of infection or pneumonia on his most recent radiographs or clinically. Earlier in his hospital stay, he showed some air-space disease and bilateral pleural effusions on chest CT, but bronchoscopy and BAL on _%#MMDD2005#%_ were negative. Problem #3. Fluid, electrolytes, and nutrition: During his hospital stay, the patient had many issues with fluid balance.
BAL|blood alcohol level|BAL|221|223|HISTORY OF PRESENT ILLNESS|She has a previous history of bulimia nervosa. She minimizes her alcohol use, stating that it has been a problem over the past month and a half. She presented to the emergency room and at 2 o'clock in the afternoon had a BAL of 0.47. The patient says she has only been drinking a moderate amount of wine. She now enters for further evaluation and therapy.
BAL|bronchoalveolar lavage|BAL|189|191|PROCEDURES PERFORMED|This appearance is compatible with an abscess. 4. Bronchoscopy on _%#MM#%_ _%#DD#%_, 2005, which showed no endobronchial lesions or foreign bodies. The airways were within normal limits. A BAL was not performed. HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old female who presents with productive cough since _%#MM#%_ of 2004 of green and yellow phlegm with occasional hemoptysis (blood-streaking).
BAL|bronchoalveolar lavage|BAL|180|182|PROCEDURES PERFORMED|They thought the lung and brain abscesses were likely due to oral anaerobes. Immunoglobulin levels were checked and were normal. A bronchoscopy was done revealing normal airway. A BAL was not performed due to the size of her cantary lesion and the thought that this may only fill up with saline without much return.
BAL|bronchoalveolar lavage|BAL|180|182|HOSPITAL COURSE|The bronchoscopy was performed on _%#MM#%_ _%#DD#%_, 2005, with the impression of hemoptysis with abnormal chest x-ray diffusely ectatic airway suggesting a left upper lobe source BAL of RUL in left upper lobe worsened. Recommendations from this procedure were to follow up in the culture results, and she will follow up with interventional radiology who did perform the angiography.
BAL|bronchoalveolar lavage|BAL|163|165|ASSESSMENT/PLAN|It should be administered with his pancreatic enzymes. His CellCept is being held due to leukopenia and prednisone should be continued. Infectious disease. Again, BAL cultures are pending. Sputum cultures are still pending from yesterday which will be available by the end of the day today. He is afebrile and empiric antibiotics are not necessary at this moment.
BAL|bronchoalveolar lavage|BAL.|214|217|PAST MEDICAL HISTORY|2. COPD. 3. History of reperfusion injury after right single lung transplant. 4. History of postoperative ileus. 5. History of hypogammaglobulinemia, receiving monthly immunoglobulin. 6. History of Aspergillus, on BAL. 7. History of sinusitis. 8. Anemia. 9. Back pain x2 months secondary to bulging disk. 10. History of depression. 11. History of steroid-induced diabetes. ALLERGIES: TAPE.
BAL|bronchoalveolar lavage|BAL|170|172|PROBLEMS|Her chest CT done on the day of admission showed patchy airspace opacities in the upper lobes with mild bronchiectasis throughout her lungs. She went to bronchoscopy for BAL and to evaluate her upper lobes on _%#MM#%_ _%#DD#%_, 2005. Her BAL showed normal upper airway, but erythema throughout. No mucous plugs were appreciated and pink fluid was returned on the BAL.
BAL|bronchoalveolar lavage|BAL|159|161|PROBLEMS|Her BAL showed normal upper airway, but erythema throughout. No mucous plugs were appreciated and pink fluid was returned on the BAL. The cell counts from the BAL were 1125 rbc's with 4163 nucleated cells. Gram stain showed a few gram-negative rods and prominent PMNs. However, hyphae were also seen on the smear. She had fever on _%#MM#%_ _%#DD#%_, 2004, and considering her BAL smear and the fever, was changed over to itraconazole for fungal coverage on _%#MM#%_ _%#DD#%_, 2004.
BAL|bronchoalveolar lavage|BAL|227|229|OPERATIONS/PROCEDURES PERFORMED|DISCHARGE DIAGNOSIS: Pericardial tuberculosis. CONSULTS: 1. Infectious disease. 2. Pulmonary. 3. Thoracic surgery. OPERATIONS/PROCEDURES PERFORMED: 1. Pericardial centesis with pericardial drain placement. 2. Bronchoscopy with BAL to obtain AFB cultures. 3. VATS procedure for peritracheal lymph node biopsy. HISTORY OF PRESENT ILLNESS: This 17-year-old African American female with a past medical history significant for two recent episode of uveitis and a recent upper respiratory infection, presented to the emergency department on _%#MM#%_ _%#DD#%_.,2005, with chief complaints of chest pain and lower extremity edema.
BAL|bronchoalveolar lavage|BAL|149|151|OPERATIONS/PROCEDURES PERFORMED|A PPD was placed, which was positive. Induced sputum was attempted, but patient failed. At that point, pulmonary was consulted for bronchoscopy with BAL and AFB, based on bronchial lavage was negative. With mediastinal lymphadenopathy, it was decided to consult thoracic surgery for a mediastinoscopy for lymph node biopsy.
BAL|bronchoalveolar lavage|BAL|151|153|DISCHARGE DIAGNOSES|HOSPITAL COURSE: 1. Influenza A: Because of the patient's infiltrate on his chest x-ray and full clinical recovery, bronchoscopy was performed and the BAL ultimately had a positive test for influenza A. Given the patient's immunosuppression and his transplant status, it was decided to go ahead and treat his influenza with Tamiflu for 5 days even though he had been developed symptoms many days before.
BAL|bronchoalveolar lavage|(BAL)|223|227|HOSPITAL COURSE|A subsequent sputum culture on _%#MMDD2005#%_ grew out methicillin-resistant Staphylococcus aureus (MRSA) for which she was begun on vancomycin on _%#MMDD2005#%_. During her hospitalization she had a bronchoalveolar lavage (BAL) on _%#MMDD2005#%_ which was negative and her pleural fluid from the thoracentesis on _%#MMDD2005#%_ never grew out anything. Her last blood cultures were negative x 2 on _%#MMDD2005#%_.
BAL|bronchoalveolar lavage|BAL|127|129|ADMISSION LAB DATA|LUNGS: There are crackles in the left-lower lobe. His I to E ratio is 1:1. ABDOMEN: Benign. SKIN: Clear. ADMISSION LAB DATA: A BAL culture grew out Staphylococcus aureus, which is MSSA. Acid-fast bacilli were 1+ and moderate growth of Aspergillus fumigatus. Negative for mycoplasma, negative for CMV, influenza and RSV. His CBC and BMP are within normal limits.
BAL|bronchoalveolar lavage|BAL|157|159|HOSPITAL COURSE|At the time of discharge, because of his MSSA, he was sent home on oral clindamycin to finish a 14-day course. At the time of this dictation, results of his BAL cultures are staphylococcus aureus, MSSA, acid-fast bacilli not yet identified and Aspergillus fumigatus. A future question about therapy concerns, treatment of this acid-fast bacilli that could be MAI since he has history of MAI.
BAL|blood alcohol level|BAL|201|203|HISTORY OF PRESENT ILLNESS|She had difficulty staying awake, she was shaking and her mother was wondering if she was having seizures although this turned out not to be the case. 911 was called and she was brought to ER. She had BAL of 0.18, normal lab otherwise and negative drug screen except for alcohol. The patient has history of depression and has been Zoloft.
BAL|bronchoalveolar lavage|BAL|133|135|LABORATORY|Cardiothoracic surgery did this on _%#MM#%_ _%#DD#%_, 2002, and they found the right lower lobe medial basal segment was bleeding. A BAL was sent for routine fungal and AFB, as well as cytology. After discussing with Dr. _%#NAME#%_, interventional radiologist, a plan for bronchial angio-embolization was initiated.
BAL|bronchoalveolar lavage|BAL|147|149|HOSPITAL COURSE|In addition, he was also continued on his Zithromax. A pulmonary consult was placed, and the patient underwent bronchoscopy the following day. The BAL fluid returned later that night preliminary positive for adenocarcinoma. In addition, the patient's bronchial culture grew out heavy growth of pseudomonas and moderate growth of Candida albicans.
BAL|bronchoalveolar lavage|BAL|167|169|PROCEDURES PERFORMED DURING THIS ADMISSION|There was a decrease in bilateral pleural effusions, anasarca and ascites. The remainder of the abdominal and pelvic CT was within normal limits. 3. Bronchoscopy with BAL on _%#MM#%_ _%#DD#%_, 2003. This showed moderate purulent secretions bilaterally. 4. Echocardiogram on _%#MM#%_ _%#DD#%_, 2003. This showed normal left ventricular systolic function and moderately to severely decreased right ventricular function.
BAL|bronchoalveolar lavage|BAL|168|170|PROCEDURES THIS HOSPITALIZATION|5. Bronchoscopy performed _%#MMDD2005#%_ due to bilateral infiltrates of the left and right lower lobes on CT scan revealing normal bronchoscopic exam of the lungs and BAL with no culture growth to date. 6. CT angiogram of the chest performed on _%#MMDD2005#%_ due to acute pleuritic chest pain revealing no pulmonary embolism and right and left lower lobe consolidation.
BAL|bronchoalveolar lavage|BAL|259|261|HOSPITAL COURSE|ALLERGIES: PENICILLIN MEDICATIONS: Cafergot p.r.n., hydrocodone p.r.n. HOSPITAL COURSE: The patient was transferred to University of Minnesota Medical Center, Fairview, for possible bronchoscopy. The patient underwent bronchoscopy on _%#MM#%_ _%#DD#%_, 2006. BAL was performed, and multiple studies were obtained. Eventually, the BAL became positive for influenza A antigen. The patient was started on Tamiflu.
BAL|bronchoalveolar lavage|BAL|330|332|HOSPITAL COURSE|ALLERGIES: PENICILLIN MEDICATIONS: Cafergot p.r.n., hydrocodone p.r.n. HOSPITAL COURSE: The patient was transferred to University of Minnesota Medical Center, Fairview, for possible bronchoscopy. The patient underwent bronchoscopy on _%#MM#%_ _%#DD#%_, 2006. BAL was performed, and multiple studies were obtained. Eventually, the BAL became positive for influenza A antigen. The patient was started on Tamiflu. The patient's symptoms improved as did his x-ray. The patient was also started on Levaquin as well for potential concomitant bacterial infection.
BAL|bronchoalveolar lavage|BAL.|141|144|HOSPITAL COURSE|1. Acute rejection: The patient was admitted to the MICU secondary to hypoxia and placed on BiPAP therapy. She underwent a bronchoscopy with BAL. Given her profound hypoxia, it was felt that biopsy would not be appropriate at this time. Her BAL was negative, and she was treated immediately for acute rejection with high-dose IV steroids.
BAL|bronchoalveolar lavage|BAL|210|212|HOSPITAL COURSE|His chest x-ray showed diffuse opacities. The patient underwent bronchoscopy for diagnosis after elective intubation, as it was felt that the procedure could not be safely done without him being intubated. The BAL culture grew Candida (felt likely to be colonizing, not pathogenic), and all other cultures were negative. He received empiric broad- spectrum antibiotics. He was noted to have an elevated creatinine to 2.1. His fractional excretion of sodium was less than 1.
BAL|bronchoalveolar lavage|BAL|272|274|DISCHARGE DIAGNOSES|This was in such a location that it was not very easily approachable with fine needle aspiration secondary to its location to the diaphragm and the liver. 3. Bronchoscopy dated _%#MM#%_ _%#DD#%_, 2003. There was no gross abnormality found except for large mucus plugging. BAL was performed which was negative for infectious etiology or viral studies. Gram stain was negative for bacterial organisms or fungal. The was no CMV or PCP noted.
BAL|bronchoalveolar lavage|BAL.|185|188|PROBLEMS|It was discussed with pulmonary and radiology about the possibility of getting samples of this lesion. Pulmonary thought that there was a 42% change of getting appropriate samples with BAL. Radiology thought it was a risky procedure to get percutaneous biopsies concerning its location close to the diaphragm and the liver.
BAL|bronchoalveolar lavage|BAL|241|243|ASSESSMENT/PLAN|ASSESSMENT/PLAN: This is aa 61-year-old gentleman status post bilateral single-lung transplant in _%#MM#%_ 2006 with possible right lower lobe pneumonia. 1. For the pneumonia, given the fact that he had a history of pseudomonas on a routine BAL performed on _%#MMDD#%_, the patient was started on dual coverage with Timentin and levofloxacin. I did review his cultures today, and his cultures revealed that his Pseudomonas was sensitive to Levofloxacin, and so we are going to change him to only one agent today.
BAL|bronchoalveolar lavage|BAL|153|155|HOSPITAL COURSE|On infectious disease recommendation, the patient was to complete a 2-week course of antibiotic therapy with minocycline. His Staphylococcus aureus from BAL was found to be susceptible to tetracycline. This also covered pneumococcus.
BAL|bronchoalveolar lavage|BAL|308|310|HISTORY OF PRESENT ILLNESS|He had been receiving enzyme replacement for 12 weeks pretransplant and is getting a sibling bone marrow transplant from a sister _%#NAME#%_. Prior to this time, _%#NAME#%_ underwent a CT angiogram of the aorta, a full body CT, an MRI of the brain and spine, lumbar puncture, central line placement, ABR and BAL as well as echocardiogram, and has been doing well aside from some eczema. PAST MEDICAL HISTORY: _%#NAME#%_ was the product of an uncomplicated pregnancy, labor and delivery and has been growing well with disproportionately large OFCs.
BAL|bronchoalveolar lavage|BAL|145|147|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Chronic lymphocytic leukemia. 2. Febrile neutropenia. 3. Clostridium difficile colitis. 4. Possible pneumonia with final BAL results pending. PROCEDURES DONE WHILE INPATIENT: 1. On _%#MMDD2006#%_, bronchoscopy with bronchioalveolar lavage.
BAL|bronchoalveolar lavage|BAL|240|242|PROCEDURES DONE WHILE INPATIENT|3. Clostridium difficile colitis. 4. Possible pneumonia with final BAL results pending. PROCEDURES DONE WHILE INPATIENT: 1. On _%#MMDD2006#%_, bronchoscopy with bronchioalveolar lavage. Anatomy for this bronchoscopy was essentially normal. BAL results did demonstrate a light growth of non-lactose fermenting Gram-negative rods, of which culture speciation remains pending. Otherwise, the remainder of the results was for the most part unremarkable with only rare Gram-positive cocci and rare polymorphic neutrophils seen on Gram-stain and the cytology negative for malignancy.
BAL|bronchoalveolar lavage|BAL|177|179|HOSPITAL COURSE|We did send Aspergillus galactomannan imaging, which was negative and fungal antibodies, which were also negative for Histoplasma and Coccidioides as well as blastomycosis. The BAL did demonstrate rare Gram-positive cocci and rare PMNs, but the culture only grew out a late growth of Pseudomonas aeruginosa that was fairly susceptible including susceptible to levofloxacin, which was the discharge med of choice for him.
BAL|bronchoalveolar lavage|BAL|269|271|HOSPITAL COURSE|The BAL did demonstrate rare Gram-positive cocci and rare PMNs, but the culture only grew out a late growth of Pseudomonas aeruginosa that was fairly susceptible including susceptible to levofloxacin, which was the discharge med of choice for him. The remainder of the BAL results were unremarkable. Also as noted above, the patient did develop Clostridium difficile noted fairly early on with a positive Clostridium difficile toxin as well as a heavy growth noted on the culture.
BAL|bronchoalveolar lavage|BAL|172|174|HISTORY OF PRESENT ILLNESS|Postoperatively, she developed acute respiratory failure requiring intubation and mechanical ventilation. She was intubated for about 2 weeks. Bronchoscopy showed negative BAL cultures. She was treated empirically with vancomycin, imipenem and ganciclovir. Amylase and lipase levels were found to be increasing. This was thought to be secondary to mild pancreatitis. She underwent induction chemotherapy with Thymoglobulin and prednisone.
BAL|bronchoalveolar lavage|BAL|197|199|HOSPITAL COURSE|At time of admission to the hospital, his oxygen saturations were within normal limits at rest but did drop to as low as 85% with minimal exertion. Given concern for rejection, a bronchoscopy with BAL (but no biopsy) was performed on the day of admission. His lungs appear grossly normal and cultures and cytology were unremarkable.
BAL|bronchoalveolar lavage|BAL,|210|213|HISTORY OF PRESENT ILLNESS|He received a myeloablation allo-sibling peripheral blood stem cell transplant for AML-M7 on _%#MMDD2006#%_. Prior to this admission, he had recently been admitted to the hospital and underwent a bronchoscopy, BAL, and transbronchial lung biopsy secondary to increased opacities and central lobular nodules, which were last seen on a CT scan on _%#MMDD2007#%_. The patient also had recently had a lip biopsy on _%#MMDD2007#%_, which was consistent with chronic graft versus host disease.
BAL|bronchoalveolar lavage|BAL|269|271|HISTORY OF PRESENT ILLNESS|She was seen in clinic on _%#MMDD2007#%_, at which time she was feeling much better but her pulmonary function tests continued to be decreased. Repeat bronchoscopy performed on _%#MMDD#%_ demonstrated a single perivascular lymphocytic infiltrate (ISHLT grade A1 B1). A BAL differential count showed 79% PMNs. Cultures remained negative for significant pathogens. CT scans prior to and subsequent to that bronchoscopy showed increased ground-glass opacity and tree-in-bud abnormalities.
BAL|bronchoalveolar lavage|BAL|190|192|ASSESSMENT/PLAN|Diagnostic possibilities include pneumonia, acute rejection, and rapamycin-induced pulmonary toxicity. She will be started on intravenous antibiotics at this point pending bronchoscopy with BAL and transbronchial biopsies tomorrow morning, which hopefully will yield a more definitive diagnosis. 3. Chronic kidney disease, with improved creatinine clearance changing from tacrolimus to rapamycin.
BAL|bronchoalveolar lavage|BAL|81|83|PROCEDURES PERFORMED|2. Hypertension. 3. Type 2 diabetes. 4. Resolving ARDS. PROCEDURES PERFORMED: 1. BAL showed budding yeast and candida, otherwise negative, done on _%#MM#%_ _%#DD#%_, 2003. 2. Right middle lobe lung biopsy. Tissue culture was negative but showed acute interstitial fibrosis consistent with ARDS and multiple chest x-rays throughout the hospitalization following her pulmonary disease.
BAL|bronchoalveolar lavage|BAL|148|150|PROCEDURE|3. Consultation and bronchoscopy by Dr. _%#NAME#%_ _%#NAME#%_ of pulmonology. Bronchoscopy failed to identify right upper lobe lesion. Washings and BAL were obtained and are pending at the time of this dictation. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 60-year-old woman with severe steroid and oxygen dependent COPD.
BAL|bronchoalveolar lavage|BAL|175|177|HOSPITAL COURSE|A lung mass was identified. Bronchoscopy was attempted as it was a very central lesion. Unfortunately, this could not be identified at the time of bronchoscopy. Brushings and BAL were obtained but are unlikely of diagnostic yield. In discussion with Dr. _%#NAME#%_, we considered the option for observation under the suspicion that this is an atypical pneumonia for which antibiotics would be beneficial.
BAL|bronchoalveolar lavage|BAL|239|241|HISTORY OF PRESENT ILLNESS|His post transplant course was complicated by neutropenic fevers for which broader antifungal coverage of Vfend was begun. Also, a CT of the chest was obtained that was abnormal and a bronchoscopy was performed on _%#MM#%_ _%#DD#%_, 2004. BAL findings included gram stain showing mixed gram positive cocci and gram negative rods with culture growing heavy growth of coagulase negative Staph.
BAL|bronchoalveolar lavage|BAL|150|152|PROBLEM #2|The patient continued to have fever with bilateral infiltrates until _%#MMDD2004#%_. PROBLEM #2: Respiratory failure: He underwent a bronchoscopy and BAL on _%#MMDD2004#%_ to evaluate for the etiology for his respiratory failure. He continued to be covered broadly in terms of his antibiotic coverage for that, and also received renal consultation for continued hemodialysis while he was in the hospital.
BAL|bronchoalveolar lavage|BAL|197|199|PAST MEDICAL HISTORY|The patient was hospitalized for bilateral Pseudomonas pneumonia _%#MM#%_ 2004 treated with Fortaz and Zosyn at that time. Also had candida, slow resolution. 4. Mycobacterium avium-intracellulare, BAL performed at time of pneumonia, _%#MM#%_ 2004, grew out Mycobacterium avium- intracellulare in _%#MM#%_. The patient saw Dr. _%#NAME#%_ in _%#MM#%_.
BAL|bronchoalveolar lavage|BAL|204|206|HISTORY OF PRESENT ILLNESS|The patient has had persistent respiratory symptoms and been treated for same. She generally feels mildly short of breath but has not required any outpatient oxygen. As mentioned above, late culture from BAL done in _%#MM#%_ grew out Mycobacterium avium-intracellulare. Infectious disease specialist has started treatment for same yesterday. The patient describes generally worsening shortness of breath over a period of time but especially the last one to two days.
BAL|bronchoalveolar lavage|BAL|217|219|HISTORY OF PRESENT ILLNESS|Her viral studies-EBV, CMV and HIV-6 remained negative, as well as the blood cultures. On _%#MMDD2007#%_, Abelcet was added to her antimicrobial empiric coverage. She also developed pulmonary infiltrate and underwent BAL on _%#MMDD2007#%_ with negative findings other than the light growth of bacillus. The patient remained pancytopenic. We kept her hemoglobin above 8 gm/dL and platelets above 30 due to recurrent epistaxis.
BAL|bronchoalveolar lavage|BAL|150|152|HOSPITAL COURSE|He was asymptomatic and remained stable during his overnight stay. Repeat chest x-ray on the day of discharge showed improvement in the pneumothorax. BAL results at the time of discharge included negative Gram's stain and cytology as well as negative transbronchial biopsy. This was reported as pulmonary parenchyma with no microscopic abnormalities.
BAL|bronchoalveolar lavage|BAL|201|203|HOSPITAL COURSE|We discussed starting Valtrex 1 g daily as prophylaxis, however, the patient was reluctant to add another medication and would like to discuss this in an outpatient setting. Pending the results of the BAL cultures, further treatment will be determined either for infection or chronic graft-versus-host disease. The patient completed weaning off of Gengraf on _%#MMDD#%_ and will continue on 60 mg prednisone daily for now.
BAL|bronchoalveolar lavage|BAL|117|119|BONE MARROW TRANSPLANT WORKUP|5. Virology, CMV equivocal. HSV, EBV positive. 6. Hepatitis B and C, HIV 1 and 2, HTLV 1 and 2, and RPR negative. 7. BAL revealed gram-positive cocci and clusters. Light growth Candida albicans. Moderate growth MRSA. Negative for fungus, CMV and PCP. 8. MUGA revealed ejection fraction of 59.1% and mild LV enlargement.
BAL|bronchoalveolar lavage|BAL|156|158|HOSPITAL COURSE|She had had no hemoptysis and no fever for 1 week prior to discharge. Her vancomycin was discontinued 3 days prior to discharge as repeat cultures from the BAL specimens did not show Enterococcus. She was thus discharged on 2 IV antibiotics, meropenem and tobramycin as well as rifampin, Bactrim, doxycycline orally in addition to her chronic azithromycin.
BAL|bronchoalveolar lavage|BAL|117|119|BONE MARROW TRANSPLANT WORKUP|5. Virology, CMV equivocal. HSV, EBV positive. 6. Hepatitis B and C, HIV 1 and 2, HTLV 1 and 2, and RPR negative. 7. BAL revealed gram-positive cocci and clusters. Light growth Candida albicans. Moderate growth MRSA. Negative for fungus, CMV and PCP. 8. MUGA revealed ejection fraction of 59.1% and mild LV enlargement.
BAL|bronchoalveolar lavage|BAL|233|235|PROCEDURES AND STUDIES|Physical exam at this time showed right upper lobe crackles and symmetric breath sounds throughout. PROCEDURES AND STUDIES: Bronchoscopy and bronchoalveolar lavage was performed on _%#MMDD2007#%_ by Dr. _%#NAME#%_. Cultures from the BAL grew non lactose fermenting gram-negative rods and Aspergillus fumigatus. HOSPITAL COURSE: A PICC line was placed in the OR at the time of the bronchoscopy and BAL.
BAL|bronchoalveolar lavage|BAL.|182|185|HOSPITAL COURSE|Cultures from the BAL grew non lactose fermenting gram-negative rods and Aspergillus fumigatus. HOSPITAL COURSE: A PICC line was placed in the OR at the time of the bronchoscopy and BAL. The patient was started on ceftazidime 200 mg IV q.8h. and doxycycline 100 mg IV daily. The patient received physiotherapy and regularly scheduled nebulizers q.i.d. Cough has decreased and repeat chest x-ray showed continued air space opacity in the right upper lobe, suggesting secretions potentially from pneumonia or consolidation.
BAL|bronchoalveolar lavage|BAL|219|221|HISTORY OF PRESENT ILLNESS|His hospital course was complicated by acute respiratory failure secondary to aspiration pneumonia and ARDS. He required mechanical ventilatory support from _%#MMDD#%_ to _%#MMDD2007#%_. Bronchoscopy was performed with BAL growing Candida albicans. He was treated with antifungal and antibacterial antibiotics which he has completed. Other significant hospital course included acute renal failure requiring temporary hemodialysis secondary to hypotension and ATN.
BAL|bronchoalveolar lavage|BAL|361|363|HOSPITAL COURSE|Her last temperature was on _%#MM#%_ _%#DD#%_ at approximately 8 p.m. The only cultures that ever grew anything were a nasal wash from the _%#DD#%_, the rapid was negative for influenza, but we were notified approximately one week later of a positive influenza B culture. Her blood cultures were negative to date throughout the entire hospitalization, as was a BAL performed off of a bronchoscopy. Her urinalysis were negative for other than mixed flora. 2. Hem: The patient initially had very low counts on the time of admission.
BAL|bronchoalveolar lavage|BAL|128|130|PROBLEM #3|He has not required sublingual or long-acting nitrates during the remainder of his hospitalization. PROBLEM #3: Positive CMV on BAL shell vial. Because Mr. _%#NAME#%_ was nearing his next chemotherapy cycle and ganciclovir can be quite myelosuppressive, it was decided to delay the beginning of the current chemotherapy cycle until after significant amount of the ganciclovir had been given.
BAL|bronchoalveolar lavage|BAL|336|338|RELEVANT TESTS, PROCEDURES AND CONSULTATIONS DURING THIS HOSPITALIZATION|RELEVANT TESTS, PROCEDURES AND CONSULTATIONS DURING THIS HOSPITALIZATION: 1. Bronchoscopy with BAL on _%#MMDD2007#%_, which was positive for Candida albicans and Gram-positive cocci, AFB stain was negative. There was no evidence of viral or other infectious etiologies. Cytology was negative for malignancy. 2. Repeat bronchoscopy with BAL on _%#MMDD2007#%_, which again showed wide growth of Candida albicans, however this time there was no evidence of other organisms or bacteria, seen on BAL.
BAL|bronchoalveolar lavage|BAL.|221|224|RELEVANT TESTS, PROCEDURES AND CONSULTATIONS DURING THIS HOSPITALIZATION|Cytology was negative for malignancy. 2. Repeat bronchoscopy with BAL on _%#MMDD2007#%_, which again showed wide growth of Candida albicans, however this time there was no evidence of other organisms or bacteria, seen on BAL. No bacteria grew from culture. 3. Chest CT on _%#MMDD2007#%_, which showed interstitial air space opacities within the right lung and basilar consolidations worrisome for acute infectious process.
BAL|bronchoalveolar lavage|BAL|344|346|BRIEF HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|Over the next several days of his hospital course, his dyspnea continued to worsen and he eventually developed hypercapnic respiratory failure on _%#MMDD2007#%_ and was transferred to the medical intensive care unit where he was intubated and placed on mechanical ventilation. On the date of the patient's admission, he had a bronchoscopy with BAL performed, which showed evidence of Candida albicans and Gram-positive cocci in his bronchoscopy. His chest CT and chest imaging showed bilateral opacities consistent with pneumonia versus other infectious etiologies or inflammation.
BAL|bronchoalveolar lavage|BAL.|138|141|PAST MEDICAL HISTORY|She is seen today for elective whole lung lavage. PAST MEDICAL HISTORY: 1. Alveolar proteinosis. 2. Mycobacterium avium intracellulare by BAL. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Rifampin 300 mg p.o. 1 capsule b.i.d.
BAL|bronchoalveolar lavage|BAL|422|424|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 55-year-old male who was initially hospitalized on _%#MMDD#%_ at Regions Hospital for what appeared to be a left lower extremity cellulitis that rapidly progressed to acute hypoxic respiratory failure with bilateral infiltrates and effusions eventually requiring ventilatory support. At Regions Hospital he was seen by both pulmonary and infectious disease and a BAL was done. No organisms were identified. Echocardiogram did not show any acute cardiac dysfunction. He was transferred to the University of Minnesota Medical Center, Fairview, on about _%#MMDD#%_ because of his cardiac transplant history and a repeat infectious workup was done including a 2nd BAL on _%#MMDD#%_, which continued to be negative.
BAL|bronchoalveolar lavage|BAL|194|196|HISTORY OF PRESENT ILLNESS|He was transferred to the University of Minnesota Medical Center, Fairview, on about _%#MMDD#%_ because of his cardiac transplant history and a repeat infectious workup was done including a 2nd BAL on _%#MMDD#%_, which continued to be negative. Cardiology was not finding any evidence for acute rejection and a heart biopsy on _%#MMDD#%_ was negative for any inflammation of evidence of rejection.
BAL|bronchoalveolar lavage|BAL|159|161|HOSPITAL COURSE|A pulmonary consult was obtained and a bronchoscopy was scheduled, which was done on _%#MMDD2007#%_. The impression on bronchoscopy was normal examination and BAL was taken. The patient was started on Bactrim and prednisone for PCP treatment on _%#MMDD2007#%_. The patient was also given albuterol and Atrovent nebulizers q.4-6h. as needed.
BAL|blood alcohol level|BAL|350|352|HISTORY OF PRESENT ILLNESS|ADMISSION MEDICATIONS: She was on Propranolol which was recently prescribed by a doctor for tremor but she was not honest with the doctor about how much she was drinking and thus she may have been having some withdrawal tremor at the time of the visit. PHYSICAL EXAMINATION: On admission, her physical examination was essentially normal. LABORATORY: BAL 0.46 on admission. AST 731, GGT 867 and GGT 166. Bilirubin was normal. HOSPITAL COURSE: During the course of this hospital stay she was given Ativan for withdrawal and did fairly well.
BAL|blood alcohol level|BAL|244|246|HISTORY OF THE PRESENT ILLNESS|She started having epigastric pain with nausea and vomiting, multiple episodes of first light brownish emesis and then just retching. She denies any coffee ground appearance. She does admit to alcohol abuse today having drank four beers with a BAL of 0.25. She came to the emergency department and was found to have a lipase of 44,000. A CT of her abdomen revealed acute pancreatitis. She was given 0.5 mg of Dilaudid in the emergency room for pain control.
BAL|bronchoalveolar lavage|BAL|152|154|PROBLEM #2|He was intubated during this procedure due to copious amounts of bleeding secondary to epistaxis. The intubation was performed to secure an airway. The BAL results are as follows: RSV negative. Influenza A and B negative. Nucleated cells 395 and red blood cells 780. Of note, a chest x-ray done on the day of admission showed patchy parenchymal density in the left lung base and no pneumothorax post BAL.
BAL|bronchoalveolar lavage|BAL.|133|136|PROBLEM #2|Of note, a chest x-ray done on the day of admission showed patchy parenchymal density in the left lung base and no pneumothorax post BAL. CT scan done on the day of admission showed ground-glass and tree and bud opacities with air trapping, consistent with bronchiolitis obliterans.
BAL|bronchoalveolar lavage|BAL|243|245|HOSPITAL COURSE|Infectious control did see the patient while she was here and recommended repeat attempts at sputum culture for acid-fast bacilli. This was unable to be done secondary to lack of sputum production. She does continue to have no growth from her BAL with regards to acid-fast bacilli. She did have fever during her hospital stay here. This was thought to be secondary to prolonged time needed to treat tuberculosis prior to defervescence.
BAL|bronchoalveolar lavage|BAL|190|192|PROBLEMS ADDRESSED DURING TRANSITIONAL CARE STAY|4. Underlying anxiety. He currently seems to be improving in terms of his ability to manage his anxiety, and is no longer on anxiolytic agents. 5. Aspergillus pneumonia. This was based on a BAL finding during hospitalization. He currently is on Voriconazole as well as Valganciclovir. He has been afebrile since readmission to Transitional Services.
BAL|bronchoalveolar lavage|BAL,|178|181|PAST MEDICAL HISTORY|Bone marrow biopsy on day #28 demonstrated remission. 2. Status post appendectomy: The patient had an appendectomy in 1994. 3. History of left upper lobe fungal infection from a BAL, that was identified as Aspergillus fumigatus. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Bactrim Double Strength one tablet p.o. q. Monday, Wednesday, Friday.
BAL|bronchoalveolar lavage|BAL|139|141|PROBLEM #2|PROBLEM #2: Hypoxia: The patient continued to be hypoxic despite being treatment for his E. coli pneumonia. The patient underwent a repeat BAL of native lung, which had sputum cultures and BAL cultures demonstrated aspergillous fumigatus. Additionally, CT of the chest demonstrated 10 x 5 cm fluid level in the right native lung.
BAL|bronchoalveolar lavage|BAL|189|191|PROBLEM #2|PROBLEM #2: Hypoxia: The patient continued to be hypoxic despite being treatment for his E. coli pneumonia. The patient underwent a repeat BAL of native lung, which had sputum cultures and BAL cultures demonstrated aspergillous fumigatus. Additionally, CT of the chest demonstrated 10 x 5 cm fluid level in the right native lung. Given this clinical picture in ID consult, the patient was started on voriconazole on _%#MMDD2007#%_ as patient continued to have low-grade fever.
BAL|bronchoalveolar lavage|BAL|181|183|HISTORY OF PRESENT ILLNESS|Despite this, her pulmonary infiltrates did not improve, neither did her shortness of breath. Hence, a repeat bronchoscopy was undertaken about 2 weeks ago. The plan was to do both BAL and biopsy. Because of significant hypoxia, biopsy was not done at that time. The BAL cultures grew enterococcus and Aspergillus along with Candida.
BAL|bronchoalveolar lavage|BAL|173|175|HISTORY OF PRESENT ILLNESS|Hence, a repeat bronchoscopy was undertaken about 2 weeks ago. The plan was to do both BAL and biopsy. Because of significant hypoxia, biopsy was not done at that time. The BAL cultures grew enterococcus and Aspergillus along with Candida. The cocci was also noted to be intracellular as per the BAL cell count and diff.
BAL|bronchoalveolar lavage|BAL|134|136|HISTORY OF PRESENT ILLNESS|Because of persistent cough and shortness of breath, the tobramycin nebs had been discontinued approximately 2 weeks ago. The goal to BAL bronchoscope was to rule out possibility of infection before giving her a trial of steroid therapy for possible (BOOP/RAPA) toxicity.
BAL|bronchoalveolar lavage|BAL|112|114|DISCHARGE DIAGNOSIS|The patient had normal chemistries. Sputum culture was noted as above. Of note, the patient was noted to have a BAL on _%#MM#%_ _%#DD#%_, 2004, which showed E. coli, Klebsiella, Citrobacter, Klebsiella pneumoniae, and Mycobacterium avium-intracellulare. HOSPITAL COURSE: Pneumonia.
BAL|bronchoalveolar lavage|BAL.|135|138|HOSPITAL COURSE|Problem #5. Likely Aspergillus pneumonia: After the patient was discharged, BAL came back positive for growth of filamentous fungus on BAL. He was sent out on Voriconazole 200 mg b.i.d. for prophylaxis; however, we will have to call him and increase this to 300 mg p.o. b.i.d. for treatment of Aspergillus pneumonia.
BAL|bronchoalveolar lavage|BAL.|149|152|PROBLEM #2|Per his recommendations we added legionella PCR, histoplasma antigen, histoblast antibody titers, routine fungal blood cultures, and silver stain to BAL. He is going home on amphotericin for fungal coverage and ceftriaxone for bacterial. Of course he will return if he has a fever.
BAL|bronchoalveolar lavage|BAL|177|179|HOSPITAL COURSE|The Pulmonary Service kindly did do the bronchoscopy on _%#MMDD2006#%_, which showed normal mucosal anatomy in the right lung with no endobronchial lesions and no secretions. A BAL was done, the returns were clear. No further organisms were cultured from the BAL or from the blood. An Aspergillus galactomannan antigen was negative in the blood. A repeat clostridium difficile toxin and culture done on _%#MMDD2006#%_ were negative.
BAL|bronchoalveolar lavage|BAL|481|483|BRIEF HISTORY OF PRESENT ILLNESS|2. Mycobacterium avium-intracellulare complex pneumonia. 3. Prothrombin gene mutation. MAJOR PROCEDURES AND IMAGING: CT scan of the chest with and without contrast dated _%#MMDD2007#%_ shows multiple nodular interstitial disease, slightly increased since _%#MMDD2007#%_, no change in prominent prevascular lymph nodes. BRIEF HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 71-year-old female with recent diagnosis of Mycobacterium avium-intracellulare complex diagnosed via BAL in _%#MM2007#%_, who presented with complaints of nausea, diarrhea and persistent dyspnea. Symptoms appeared to have begun after she initiated therapy for her MAI, which included clarithromycin, ethambutol, Mycobutin.
BAL|bronchoalveolar lavage|BAL|142|144|ASSESSMENT/PLAN|Blood cultures have been obtained. The patient has yet been able to produce sputum. If she fails to respond to this therapy, bronchoscopy and BAL may be required. 2. Acute and chronic renal failure. This is most likely dehydration. I do feel that Celebrex is contraindicated in individuals with chronic renal failure of any sort.
BAL|bronchoalveolar lavage|BAL|132|134|KEY INTERVENTIONS/STUDIES/PROCEDURES|3. Bronchoscopy dated _%#MMDD2006#%_: All signs of cancer in the right upper lobe. No need for bronchial stenting or laser therapy. BAL for cytology was sent and was positive for malignancy-adenocarcinoma. No organisms were identified on GMS stained cytologic specimen. Negative for CMV.
BAL|bronchoalveolar lavage|BAL|148|150|KEY INTERVENTIONS/STUDIES/PROCEDURES|No organisms were identified on GMS stained cytologic specimen. Negative for CMV. Negative for Pneumocystis. Negative for fungus. Gram stain of the BAL showed gram-positive cocci in pairs and chains. 4. Flexible laryngoscopy dated _%#MMDD2006#%_: Breathing technique has been reviewed, and speech pathology was suggested.
BAL|bronchoalveolar lavage|BAL|319|321|PROBLEM #2|During this admission, he had a CT of his chest, which showed no significant change in the large right apical mass and bilateral interstitial and air-space opacities, but interval enlargement of the pericardial effusion and increased right upper lobe air-space opacities suspicious for pneumonia. The bronchoscopy with BAL cytology was positive for malignant adenocarcinoma. Over the course of this hospital stay, the patient continued his radiation therapy for the right upper lobe tumor.
BAL|bronchoalveolar lavage|BAL,|274|277|HOSPITAL COURSE|HOSPITAL COURSE: The patient was admitted and her antibiotic protocol regimen was changed to vancomycin and ceftazidime along with voriconazole. She had a CT scan, which revealed question of some pulmonary infiltrates in the left base. Pulmonary was consulted and performed BAL, which was nondiagnostic and did not grow any organisms. During her stay, she was intermittently febrile and cultured multiple times, however, no infectious agent was identified.
BAL|bronchoalveolar lavage|BAL|197|199|HOSPITAL COURSE|The patient underwent bronchoscopy on _%#MMDD2007#%_ from which there has been no positive cultures. The bronchoscopy BAL was negative for RSV, influenza, CMV and nocardia. The Gram stain from the BAL showed no organisms with few PMNs. The patient also underwent a sputum culture on _%#MMDD2007#%_ with a Gram stain revealing mixed Gram-positive and Gram-negative bacteria and moderate PMNs.
BAL|bronchoalveolar lavage|BAL|133|135|HOSPITAL COURSE|He will instead be discharged on Levaquin 500 mg daily for 10 days through _%#MMDD2007#%_. Levaquin is being used empirically as the BAL cultures have been negative. The patient also is currently being treated for herpes zoster. At the time of admission, his oral Valtrex was changed to IV acyclovir.
BAL|bronchoalveolar lavage|BAL|270|272|PROBLEM #9|On approximately _%#MMDD2007#%_, the patient developed acute respiratory distress with diffuse pulmonary infiltrates on chest CT, likely thought to be due to ARDS. The patient was electively intubated and ventilated, and a bronchoscopy was performed with all subsequent BAL cultures being negative. The patient remained on the ventilator through _%#MMDD2007#%_ with minor improvement in the ventilator settings and chest x-ray.
BAL|bronchoalveolar lavage|BAL|155|157|HOSPITAL  COURSE|Please see the note by Dr. _%#NAME#%_ on _%#MMDD2007#%_ for complete details. The patient underwent bronchoscopy as described above. Biopsies are pending. BAL is also pending. The patient also had fungal and AFP cultures, which were done and are still pending. Overall, the patient remained stable neurologically. For the cough, she was ordered guaifenesin with codeine, which seemed to help a little bit with her cough.
BAL|bronchoalveolar lavage|BAL.|141|144|HOSPITAL PROCEDURES|2. Aspergillus pneumonia. 3. Pulseless electrical activity cardiac arrest. HOSPITAL PROCEDURES: 1. PICC line placement. 2. Bronchoscopy with BAL. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 33-year-old gentleman status post bilateral lung transplant in _%#MM2006#%_ secondary to DIP.
BAL|bronchoalveolar lavage|BAL|192|194|PROCEDURES DONE DURING THIS HOSPITALIZATION|3. Malnutrition 4. Chronic kidney disease. PROCEDURES DONE DURING THIS HOSPITALIZATION: 1. Chest tube placed by Intervention Radiology on _%#MMDD2007#%_ on the left side. 2. Bronchoscopy with BAL and transbronchial biopsy done on _%#MMDD2007#%_. CONSULTS: No consults were obtained during this hospital stay.
BAL|bronchoalveolar lavage|BAL|337|339|PROBLEM #2|PROBLEM #2: Lung transplant. On the day of admission and also 2 days prior to admission, was found to have a low Prograf levels at 4.4 and at 6.6. With increasing opacities in the CT scan, there was concern for acute rejection, especially in light of her recent episode of acute rejection. Hence, we proceeded with doing a bronchoscopy, BAL and transbronchial biopsy. The transbronchial biopsy was suggestive of resolving infection than acute rejection and her immunosuppressive therapy was continued and adjusted with a goal Prograf level of 10 was achieved prior to discharge.
BAL|blood alcohol level|BAL|178|180|PROBLEM #1|Alcohol level 0.26. Osmolality 306. Fibrinogen activity 244, INR 1.13, PTT 32. HOSPITAL COURSE: PROBLEM #1: The patient was admitted on _%#MMDD2007#%_ with alcohol intoxication, BAL 0.26 with thrombocytopenia at 72, hyponatremia at 120, hypokalemia at 3, and with hypertension, controlled with lisinopril. In the Emergency Department, he received "banana bag" 1000 mL.
BAL|bronchoalveolar lavage|BAL.|136|139|HOSPITAL PROCEDURES|HOSPITAL DIAGNOSES: 1. Pulmonary fibrosis. 2. Hemoptysis. 3. Prosthetic aortic valve leakage. HOSPITAL PROCEDURES: 1. Bronchoscopy with BAL. 2. Transthoracic echo. 3. Transesophageal echo. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 58-year-old male with history of UIP diagnosed early this year who was admitted on _%#MMDD2007#%_ with increasing shortness of breath and hemoptysis.
BAL|blood alcohol level|BAL|199|201|HISTORY OF PRESENT ILLNESS|She is willing to go back into treatment in order to make plans. Laboratory work at Fairview Southdale emergency room showed a low sodium at 131, but otherwise her labs were fairly normal except for BAL of 0.41. PAST MEDICAL HISTORY: 1. Knee surgery. 2. Cyst removal from right wrist. 3. D&C.
BAL|blood alcohol level|BAL|229|231|HISTORY OF PRESENT ILLNESS|The patient is single. He lives with his girlfriend. He works for GE (General Electric). The patient enters Fairview Recovery Services at this time on transfer from Fairview Ridges Hospital where he was brought last night with a BAL of 0.46. The patient has a history of alcohol dependence dating back some years. He still lives with a roommate who works for a liquor distributing company and he had easy access to alcohol.
BAL|blood alcohol level|BAL|180|182|HISTORY OF PRESENT ILLNESS|He says that he started drinking about 72 hours ago. He had an excessive amount of alcohol last night and his girlfriend called 911 and he was brought to the emergency room with a BAL of 0.46. He was placed on a 72-hour hold and is now admitted here. The patient admits to anxiety stress, work stress, relationships stress but minimizes his problem with alcohol.
BAL|blood alcohol level|BAL|190|192|HISTORY OF PRESENT ILLNESS|His wife was recently hospitalized at _%#CITY#%_ Ridgeview Hospital for a total knee arthroplasty and he being alone he has increased his usage of alcohol. He was admitted last night with a BAL of 0.41. He was brought to the hospital by his daughter. He now enters for further evaluation and therapy. He is quite embarrassed about what happened.
BAL|bronchoalveolar lavage|BAL,|212|215|PROCEDURES|3. Hypoalbuminemia related to malnutrition and prolonged hospitalization. 4. Contact lens associated coagulase-negative Staphylococcus keratitis of the right eye. PROCEDURES: 1. Chest x-ray. 2. Bronchoscopy with BAL, _%#MMDD2007#%_. 3. Left open lung biopsy. 4. Bilateral chest tube placement, _%#MMDD2007#%_ and removal _%#MMDD2007#%_. 5. Tracheostomy placement on _%#MMDD2007#%_ and removal _%#MMDD2007#%_. 6. PEG _%#MMDD2007#%_.
BAL|bronchoalveolar lavage|BAL,|223|226|HOSPITAL COURSE|CT scan of the chest revealed bilateral nodular consolidation at both lung bases with the right side being greater than the left side. The patient was started on Abelcet IV which he tolerated. He underwent bronchoscopy and BAL, however, all BAL cultures have remained negative. We therefore discussed with the patient the possibility of doing a thoracoscopic biopsy, however, after consultation with Thoracic Surgery team and some discussions with the patient, his wife, and his primary oncologist, Dr. _%#NAME#%_ _%#NAME#%_, decided that the patient should remain on Abelcet and have a follow-up CT scan of the chest as an outpatient.
BAL|bronchoalveolar lavage|BAL|207|209|PROCEDURES DONE DURING THIS ADMISSION|PROCEDURES DONE DURING THIS ADMISSION: 1. Endotracheal intubation and mechanical ventilation _%#MMDD2007#%_ at St. Joseph's Hospital in _%#CITY#%_, extubated on _%#MMDD2007#%_. 2. Bronchoscopy with negative BAL cultures. 3. CT scan of the sinuses and chest _%#MMDD2007#%_ revealing pansinusitis, extensive air space opacities representing pneumonia, hemorrhage and/or ARDS.
BAL|bronchoalveolar lavage|BAL|186|188|HOSPITAL COURSE|I performed a bronchoscopy on _%#MMDD#%_ and it was negative for purulent secretions. Cytology on the bronchoalveolar lavage fluid was negative for malignant cells and cell count on the BAL had only 80 total nucleated cells per microliter which was 22% neutrophils, 5% lymphocytes and 51% monocytes/microphages. Acid fast bacilli smear was negative on the BAL and culture grew light MRSA.
BAL|bronchoalveolar lavage|BAL|213|215|HISTORY OF PRESENT ILLNESS|5. Central line placement in _%#MM2007#%_, subsequently removed. 6. Intubation in _%#MM2007#%_ secondary to respiratory failure. A bronchoscopy from _%#MMDD2007#%_ was consistent with diffuse alveolar hemorrhage. BAL from _%#MMDD2007#%_ grew E. coli. The patient was subsequently extubated on _%#MMDD2007#%_. 7. E. coli (ESBL pneumonia requiring intubation for _%#MM2007#%_ to _%#MMDD2007#%_.
BAL|bronchoalveolar lavage|BAL|182|184|PROBLEM #2|As noted in the previous discharge summary, the patient had pneumonia, which he was then admitted for last time. The patient underwent bronch during his last hospitalization and his BAL showed some gram positive organisms as mentioned in the previous discharge summary. The patient had acid fast bacillus stains, which were negative on _%#MMDD2005#%_ and _%#MMDD2005#%_.
BAL|bronchoalveolar lavage|(BAL)|223|227|HOSPITAL COURSE|A subsequent sputum culture on _%#MMDD2005#%_ grew out methicillin-resistant Staphylococcus aureus (MRSA) for which she was begun on vancomycin on _%#MMDD2005#%_. During her hospitalization she had a bronchoalveolar lavage (BAL) on _%#MMDD2005#%_ which was negative and her pleural fluid from the thoracentesis on _%#MMDD2005#%_ never grew out anything. Her last blood cultures were negative x 2 on _%#MMDD2005#%_.
BAL|bronchoalveolar lavage|BAL|188|190|HOSPITAL  COURSE|A small nodule in the left lower lobe laterally was also noted. The patient underwent a bronchoscopy. Cytology studies were negative for malignancy, fungus, Pneumocystis or CMV. Bronchial BAL AFB stains were positive for acid bacilli. Bronchial cultures did grow out a moderate amount of Klebsiella pneumoniae along with normal flora.
BAL|bronchoalveolar lavage|BAL|190|192|PROCEDURES PERFORMED DURING THIS ADMISSION|The mass was polypoid. The lesion was not traversed. Extrinsic compression was found in the right upper lobe. The airway lumen was about 25% occluded. The lesion was successfully traversed. BAL was performed in the right lower lobe superior basal segment and sent for cell count, cytology, bacterial culture, viral smears and culture, and fungal and AFB analysis.
BAL|bronchoalveolar lavage|BAL|181|183|HOSPITAL COURSE|The pulmonary physicians will call the patient with the results of his biopsy and the patient will follow up with Pulmonary after these results are known. Of note, on the patient's BAL from the bronchoscopy, on the Gram stain, rare gram-positive cocci and rare PMNs were seen, the fungal culture was negative after one day, and the bronchial culture revealed normal respiratory flora preliminarily.
BAL|bronchoalveolar lavage|BAL|152|154|ALLERGIES|Skin: Hairy nevus of the left shin. Neuro: Alert, speech fluent, NAE, sensation normal. HOSPITAL COURSE: 1. Bilateral alveolar interstitial infiltrate, BAL negative for culture for bacterial agents. Lavage was positive for PCP and the Shell Vial was positive for CMV. Because of a note of allergy, clindamycin 900 mg IV q.8 hour, (_______________) 30 mg p.o. q.d. as well as gatifloxacin.
BAL|bronchoalveolar lavage|BAL.|163|166|LABS|D-dimer 2.4. EKG showed sinus tachycardia at a rate of 123. He was tested for HIV and it was pending. The patient was intubated and he was found to have PCP and a BAL. He responded well to Bactrim and Prednisone and corticosteroids. He was extubated after two days and was seen up on the floor with a CD4 count of 12 and diagnosis of AIDS with PCP pneumonia.
BAL|blood alcohol level|BAL|153|155|HISTORY OF PRESENT ILLNESS|She has no children. She has never been pregnant. She tends to isolate. Patient entered Fairview Evening Outpatient Program in _%#MM#%_ after a DWI. Her BAL was greater than .3. She progressed to the outpatient program and it was somewhat lengthened due to her having to go to school one day a week.
BAL|bronchoalveolar lavage|BAL|174|176|HISTORY OF PRESENT ILLNESS|He was recently last treated on his last pneumonia episode with Timentin. The patient had PFTs on _%#MMDD2002#%_, which showed FVC 3, FEV1 of 1.61, FEV1/FVC of 54%. He had a BAL on _%#MMDD2002#%_, which showed 17,000 nucleated cells. No malignancy noted. PCP negative. CMV shell. PAST MEDICAL HISTORY: 1. Heart and lung transplant in 1989, secondary to Eisenmenger syndrome.
BAL|bronchoalveolar lavage|BAL|139|141|PROBLEM #10|We again repeated the CT on _%#MMDD2007#%_ which showed worsening CT scan with extensive air space opacities in both lungs. We performed a BAL on _%#MMDD2007#%_ which had a light growth of Fusarium. We started caspofungin at this time. Again, this BAL grew out VRE and we started linezolid.
BAL|bronchoalveolar lavage|BAL|248|250|PROBLEM #10|We again repeated the CT on _%#MMDD2007#%_ which showed worsening CT scan with extensive air space opacities in both lungs. We performed a BAL on _%#MMDD2007#%_ which had a light growth of Fusarium. We started caspofungin at this time. Again, this BAL grew out VRE and we started linezolid. We were quite concerned that the Fusarium in the patient's lung grew out while they were on Abelcet, so we tried to add posaconazole and saw an immediate increase in LFTs.
BAL|bronchoalveolar lavage|BAL|195|197|PROBLEM #11|At the same time, the patient was placed on Levophed due to periods of hypotension. The patient was diagnosed with ARDS secondary to Fusarium infection in the lung. The patient again underwent a BAL on _%#MMDD2007#%_ which did not show any freak bleed, but the patient was placed on steroids empirically due to increased blood and the ET tube.
BAL|bronchoalveolar lavage|BAL|169|171|PROBLEM #4|In order to obtain more information about the etiology of his respiratory distress, a bronchoscopy was performed on _%#MMDD2007#%_, which _%#NAME#%_ tolerated well. The BAL fluid was negative for malignancy. Rare Gram-positive cocci were identified on Gram stain. It was negative for CMV, PCP and fungus. The only culture positive was white growth Candida albicans.
BAL|bronchoalveolar lavage|BAL|227|229|ASSESSMENT AND PLAN|5. Abnormal liver function tests. The patient has been taking both Valcyte and voriconazole recently. In that regard, the voriconazole was started during hospitalization in _%#MM2007#%_ during which she grew aspergillus from a BAL specimen. The indications for these medications have been relatively soft, as detailed in multiple recent clinic visits. Therefore, I am continuing both medications today, at least until the problem with her liver is sorted out.
BAL|bronchoalveolar lavage|BAL.|259|262|PROCEDURES|Bronchoscopy on _%#MMDD2007#%_, which showed normal exam. Transbronchial biopsies revealed nonspecific organizing pneumonitis. Cytopathology showed pseudohyphae, but was otherwise negative. Cultures were significant for herpes simplex virus isolated from the BAL. The remainder of the cultures were negative. HISTORY OF PRESENT ILLNESS: The patient is 62-year-old female status post right single lung transplantation in _%#MM#%_ 2005 for COPD transferred from an outside hospital for hypoxia and infiltrate on x-ray.
BAL|bronchoalveolar lavage|BAL.|145|148|ASSESSMENT|Picture is consistent with Pneumocystis pneumonia. Will start him with IV Bactrim and steroids. Will also consult Pulmonary regarding need for a BAL. This patient was discussed with ID and they did not suggest broadening his antibiotic coverage at this point unless he would deteriorate.
BAL|bronchoalveolar lavage|BAL|114|116|TESTS PENDING AT DISCHARGE|2. Dr. _%#NAME#%_, Pulmonologist at University of Minnesota Medical Center as needed. TESTS PENDING AT DISCHARGE: BAL fungal culture, bronchial bacterial culture, AFB culture, respiratory viral culture and serum aldosterone. ADDENDUM: Following the discharge of Mr. _%#NAME#%_, the laboratory reported light growth of filamentous fungus and heavy growth of Pseudomonas aeruginosa from a sputum culture obtained on _%#MMDD2007#%_.
BAL|blood alcohol level|BAL|189|191|HOSPITAL COURSE|Hospital course was prolonged by his alcohol dependence and the concern for alcohol withdrawal. The patient claims that he had been experiencing withdrawal symptoms even upon admission yet BAL was 0.28 at that time. He had been intoxicated 4 times in the past month. He was evaluated by psychiatry on _%#MMDD2007#%_, diagnosed with alcohol dependency and withdrawal and highly recommended to go to inpatient detoxification.
BAL|bronchoalveolar lavage|BAL)|288|291|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old woamn, s/p liver tranplant, who was admitted to the University Campus on _%#MMDD#%_ for nausea and confusion. Her workup revealed: 1. PNEUMONIA of unknown etiology (patchy ground glass opacities in both upper lungs with a negative BAL) empirically treated with Zosyn and switched to Levaquin on _%#MMDD#%_. 2. C. DIFFICILE treated with Flagyl for a 14-day course.
BAL|bronchoalveolar lavage|BAL|161|163||The patient was intubated on _%#MMDD2007#%_ because of respiratory distress. She had a bronchoscopy on _%#MMDD2007#%_ which did not show alveolar hemorrhage but BAL culture did grow coag-negative staphylococcus and influenza A. The patient was intubated and was never successfully extubated and died still intubated.
BAL|bronchoalveolar lavage|BAL|167|169|HOSPITAL COURSE|Nevertheless, he will need to continue this. We did perform a cardiac biopsy to evaluate for possible acute rejection. This, as described above, was negative, and his BAL was unremarkable. The patient also had a CT scan prior to his BAL, which showed there was a left lower lobe pneumonia with an atypical infection such as Aspergillus not being able to be ruled out.
BAL|bronchoalveolar lavage|BAL|162|164|HOSPITAL COURSE|At the time of discharge, the patient was afebrile and has no longer had an O2 requirement, was feeling much better. At the time of this dictation, the patient's BAL cultures were also pending. 2. Lung transplant. As noted above, the patient did not have any evidence on transbronchial biopsy of acute rejection.
BAL|bronchoalveolar lavage|BAL|182|184|CHIEF COMPLAINT|His lab results at the time showed a bronchial Gram's stain that showed rare Gram-positive bacilli resembling diphtheroids as well as rare Gram- positive cocci. The remainder of his BAL was pending at the time of admission. HOSPITAL COURSE: PROBLEM #1: FEN. Throughout the hospital course, the patient was taking a full regular p.o. diet.
BAL|bronchoalveolar lavage|(BAL)|180|184|HISTORY OF PRESENT ILLNESS|She has had several bronchoscopies and similar evaluations and has had chronic infiltrates seen on x-rays over the last year. As part of that workup she had bronchoalveolar lavage (BAL) studies late last year which showed Aspergillus growing and while this is not felt to be the obvious cause of the chronic pulmonary problems it was significant enough that it was elected to do a trial of Sporanox.
BAL|blood alcohol level|BAL|202|204|DISCHARGE DIAGNOSIS|She entered after 2 days of excessive drinking. HOSPITAL COURSE: On admission, the patient's physical examination was essentially normal. Her laboratory work was essentially normal. Her GGT was 48. Her BAL on admission was 0.25. The patient did not require medication for detoxication. Antabuse was discussed with her and she was interested. The Antabuse/alcohol reaction was explained.
BAL|bronchoalveolar lavage|BAL|161|163|PROBLEM #2|Chest CT was consistent with bilateral ground glass opacities and patchy consolidations. Pulmonary was consulted, and a bronchoscopy was done. Cultures from the BAL were negative for bacterial, fungal, viral or AFB. However, the patient was started on antifungals and defervesced. She was continued on antifungals and antibiotics throughout her hospitalization.
BAL|bronchoalveolar lavage|BAL|216|218|HOSPITAL COURSE|Showed resolution of her lymphadenopathy. HOSPITAL COURSE: On admission the patient was placed on a combination of ciprofloxacin, Zithromax, Famvir, dapsone, Decadron, and ibuprofen. Bronchoscopy _%#MMDD2004#%_ with BAL was essentially negative with negative cultures. Hypoxia has gradually improved during hospital stay. O2 saturations on room air on date of discharge _%#MMDD2004#%_ ranged from 92 to 96%.
BAL|blood alcohol level|BAL|202|204|MAJOR TESTS AND PROCEDURES PERFORMED|2. Laryngeal candidiasis. 3. Chronic obstructive pulmonary disease. MAJOR TESTS AND PROCEDURES PERFORMED: 1. Bronchoscopy. The patient underwent bronchoscopy that did not show any growth abnormalities. BAL was obtained. 2. Chest CT. The patient had a chest CT done at an outside hospital that showed bilateral infiltrates and emphysematous changes.
BAL|bronchoalveolar lavage|BAL|200|202|HOSPITAL COURSE|The patient was admitted with hypoxia and had an abnormal chest CT with evidence of bilateral infiltrates. Pulmonary consult was obtained and he underwent bronchoscopy which was grossly negative with BAL obtained that did not reveal the etiology of his infiltrates. During the hospitalization, the patient was continued on vancomycin, tobramycin and clindamycin, and at the time of discharge, he was switched to Levaquin.
BAL|bronchoalveolar lavage|BAL|187|189|HOSPITAL COURSE|This did help to improve _%#NAME#%_'s ventilation towards the lung bases. Bronchoalveolar lavage specimens eventually grew out MRSA. The patient has previously grown MRSA from sputum and BAL fluid. This was reviewed with Dr. _%#NAME#%_. She did not feel that this was indicative of invasive MRSA infection but rather simply MRSA colonization of the airways.
BAL|blood alcohol level|BAL|178|180|HISTORY OF PRESENT ILLNESS|Sodium 138, potassium 3.4, chloride 103. C02 was 28. BUN 13, creatinine 0.7, glucose 177, calcium 8.5. Chest x-ray revealed poor inspiration and was negative. U-tox was pending. BAL less than 0.01. EKG showed normal sinus rhythm at 92 beats per minute with nonspecific ST changes. Troponin less than 0.1 x 3. Total bilirubin 0.3, albumin 3.2, protein 6.8, alkaline-phosphatase 64, ALT 59, AST 54.
BAL|bronchoalveolar lavage|BAL;|207|210|HOSPITAL COURSE|Immunoglobulin levels, IgG 1140 and normal, IgA 442 (normal 70-380), IgM was 274 (normal 60-265), and elevated IgE 1528 (0-114). This last is of unclear significance. There were a few fungal elements in the BAL; however, there were no CT signs of bronchiectasis suggestive of bronchopulmonary aspergillosis. 4. The patient complained of right lower quadrant pain during admission.
BAL|bronchoalveolar lavage|BAL|211|213|OPERATIONS/PROCEDURES THIS ADMISSION|OPERATIONS/PROCEDURES THIS ADMISSION: Bronchoscopy was done on _%#MMDD2003#%_, which showed a normal surgical anastomosis in the right main stem bronchus and evidence of surgery. Otherwise, the exam was normal. BAL was obtained. The complication of this procedure was a small pneumothorax on the right side. HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old female who presented to the hospital for a regular follow-up with Pulmonary.
BAL|bronchoalveolar lavage|BAL|336|338|PROBLEM #2|Sputum cultures on _%#MMDD2004#%_ eventually grew out Aspergillus fumigatus and the patient was started on itraconazole 200 mg IV to complete four doses and then converted over to p.o. 200 mg b.i.d. Repeat CT on _%#MMDD2004#%_ showed worsening of the infiltrates. The patient underwent a bronchoscopy for evaluation of the infiltrates. BAL was significant for Aspergillus fumigatus and recently Neisseria organisms. The patient at that time was started on amphotericin B nebulizations on _%#MMDD2004#%_ without complications.
BAL|bronchoalveolar lavage|BAL|219|221|POST PROCEDURE IMPRESSION|The airway examination suggests that this is not a purulent process, and that bacterial infection is probably not the cause. Viral infection, lymphangitic tumor and other atypical processes have not been ruled out. The BAL specimen was sent for rush processing. Empiric treatment with steroids has been discussed with oncology. The possibility of an adverse reaction to the gemcitabine is considered.
BAL|bronchoalveolar lavage|BAL.|238|241|PROCEDURES AND DIAGNOSTIC STUDIES|1. Chest CT, _%#MMDD2004#%_, demonstrating innumerable soft tissue nodules scattered throughout both lungs, which have decreased in size from previous study on _%#MMDD2004#%_. A small pericardial effusion is present. 2. Bronchoscopy with BAL. Final results pending at the time of discharge, but, per the preliminary results demonstrating small budding yeast in bronchial fluid with no evidence of malignancy, CMV or Pneumocystis on cytopathology.
BAL|blood alcohol level|BAL|158|160|DISCHARGE DIAGNOSES|While in the ED the patient became belligerent to the point of requiring emergency Haldol 5 mg and Ativan 2 mg IM, and was also placed in 5-point restraints. BAL was 0.29 in the ED. The patient was on furlough from a 30-day prison sentence secondary to his wife being due to deliver their child on _%#MM#%_ _%#DD#%_, 2005.
BAL|blood alcohol level|BAL|230|232|HOSPITAL COURSE|The patient had suicidal ideation and plan to jump off University of Minnesota bridge. He threw his bike over the bridge and decided to walk to _%#COUNTY#%_ _%#COUNTY#%_ Medical Center instead where in the emergency room he had a BAL 0.04. During his hospital course at Fairview-University Medical Center, the patient showed a rapid improvement and denied any suicidal ideation, homicidal ideation, or psychosis by day #2 of his stay.
BAL|bronchoalveolar lavage|BAL|211|213|HISTORY OF PRESENT ILLNESS|_%#NAME#%_ subsequently developed increasing respiratory distress with worsening CXR and was oxygen dependent. The CT scan of the chest on _%#MMDD2003#%_ showed multiple nodules in the chest. A bronchoscopy and BAL was performed on _%#MMDD2003#%_, and the infectious screen cytology was negative. Pulse bronchoscopy: She was intubated for three days and was successfully extubated on _%#MMDD2003#%_.
BAL|bronchoalveolar lavage|BAL|146|148|HOSPITAL COURSE|His chest x-ray showed dense bilateral infiltrates consistent with ARDS, and was treated with broad-spectrum antibiotics Flolan and also Panavir. BAL was sent to the Minnesota Department of Health, initial results of which are all negative for virology. The patient was transfused multiple units of platelets and fresh frozen plasma.
BAL|bronchoalveolar lavage|BAL|221|223|PROBLEM #3|She maintains stable white count on her decreased CellCept at 1000 b.i.d. She was continued on her Prograf and prednisone taper. PROBLEM #3: Infectious disease. The patient did again grow outpatient Stenotrophomonas from BAL in addition to Klebsiella. She was begun on Bactrim double-strength b.i.d. In the past she has not been able to tolerate higher doses of Bactrim.
BAL|bronchoalveolar lavage|BAL|224|226|HOSPITAL COURSE|The patient underwent bronchoscopy and BAL. BAL results as follows: Cytology negative for malignant cells, positive for yeast. Fungal culture obtained was negative at the time of this dictation. AFB smears obtained from the BAL were negative. The patient was treated empirically with Rocephin and azithromycin. Multiple sputum cultures grew heavy growth of yeast and fluconazole was started.
BAL|bronchoalveolar lavage|BAL|200|202|STUDIES|6. _%#MMDD2005#%_, ERCP with balloon dilation and stone removal. 7. _%#MMDD2005#%_, bronchoscopy, showing mild erythema of airway of left upper and middle lobes, yellow-tinged fluid bilateral airway, BAL for 60 cm yellow fluid retrieved. 8. _%#MMDD2005#%_, transthoracic echocardiogram, showing borderline left ventricular systolic function, mild tricuspid regurgitation, moderate mitral regurgitation, no aortic insufficiency, right-to-left shunt with positive bubble study, estimated left ventricular ejection fraction 55%, estimated right ventricular systolic pressure 34.
BAL|bronchoalveolar lavage|BAL|258|260|HOSPITAL COURSE|He had a diffusing capacity however of approximately 36%. His FEV1 was 1.74. He was seen by infectious disease and he was treated with empiric antibiotics with Zithromax, Septra DS, and Rocephin. He also was seen by pulmonary and bronchoscopy was performed. BAL of the left upper lobe, brushing right upper lobe, biopsy right upper lobe and washings were performed. Thus far, these results are unrevealing. He did have a chest x-ray on _%#MM#%_ _%#DD#%_ which did reveal bilateral interstitial infiltrates.
BAL|bronchoalveolar lavage|BAL.|149|152|PAST MEDICAL HISTORY|11. Chronic diverticulosis. 12. History of pulmonary embolism with positive lupus inhibitor. 13. Leukocytoclastic vasculitis. 14. History of MRSA in BAL. 15. Possible amiodarone-toxicity. MEDICATIONS: 1. Ferrous sulfate 325 mg p.o. b.i.d.
BAL|bronchoalveolar lavage|BAL|254|256|PROCEDURES AND TESTS|Only findings were bibasilar infiltrates and a 2.0 mm indeterminate calcification right lower abdomen. No liver lesions seen. 5. Consultations with Dr. _%#NAME#%_ _%#NAME#%_, Dr. _%#NAME#%_ _%#NAME#%_, and Dr. _%#NAME#%_ _%#NAME#%_. 6. Bronchoscopy with BAL by Dr. _%#NAME#%_ _%#NAME#%_. Studies positive for Pneumocystis. HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ is a 41-year-old heterosexual male from _%#CITY#%_ who is sometimes a music composer and sometimes construction worker.
BAL|bronchoalveolar lavage|BAL|162|164|HOSPITAL COURSE|He was intubated on _%#MM#%_ _%#DD#%_, 2004 for hypoxia despite high levels of oxygen on CPAP. The patient had a bronchoscopy which revealed alveolar hemorrhage. BAL cultures grew enterococcus, and the patient was on empiric coverage for enterococcus. No fungal etiology was determined. The patient developed a pneumothorax and had a chest tube placement.
BAL|bronchoalveolar lavage|BAL|123|125|HOSPITAL COURSE|Given her lack of pulmonary symptomatology, it was unclear if this was related to post bronchoscopy or clear etiology. Her BAL at the time of discharge did show evidence of light growth; however, there were no other organisms seen. She was begun on levofloxacin at the time of her admission because of this infiltrate, and she is to continue this for a complete duration of 10 days.
BAL|bronchoalveolar lavage|BAL|192|194|DISCHARGE DIAGNOSES|a) The patient ruled out with three negative AFB studies for TB. b) Patient underwent bronchoscopy on _%#MMDD2006#%_, showing no purulent secretions, no endobronchial lesions. The patient had BAL of the left apex and transbronchial biopsy x4 of the left apex by Dr. _%#NAME#%_, results are pending at time of discharge. c) Patient was seen in consultation by Dr. _%#NAME#%_, the patient will continue with four more days of Levaquin to complete an appropriate course of antibiotics.
BAL|bronchoalveolar lavage|BAL|158|160|HISTORY OF PRESENT ILLNESS|Course was complicated by neutropenic fevers and pneumonia. A CT of the chest done on _%#MM#%_ _%#DD#%_, 2005, demonstrated bilateral ground-glass opacities. BAL was done. Cultures were all negative, except for coagulase-negative Staphylococcus. He was empirically placed on broad-spectrum antibiotics and amphotericin-B, developed rigors, and was switched over to voriconazole, where he defervesced and remained afebrile.
BAL|bronchoalveolar lavage|BAL|174|176|HOSPITAL COURSE|We escalated her dose of Seroquel and also Klonopin. Overall, this was much improved and was helping with her tolerance with pressure support trials. 7. Adenovirus positive, BAL x2. Her viral culture from her most recent BAL is still pending. We discussed this at length with infectious disease consultation service, and have elected not to treat it at this time, as she is clinically improving on treatment for her bacterial infection.
BAL|bronchoalveolar lavage|BAL|221|223|HOSPITAL COURSE|We escalated her dose of Seroquel and also Klonopin. Overall, this was much improved and was helping with her tolerance with pressure support trials. 7. Adenovirus positive, BAL x2. Her viral culture from her most recent BAL is still pending. We discussed this at length with infectious disease consultation service, and have elected not to treat it at this time, as she is clinically improving on treatment for her bacterial infection.
BAL|bronchoalveolar lavage|BAL|194|196|HOSPITAL COURSE|The patient was also treated for community-acquired pneumonia with levofloxacin. During the hospitalization, infectious disease was consulted, and they recommended obtaining a bronchoscopy with BAL as the patient was not able to induce sputum. Bronchoscopy and BAL were performed on _%#MM#%_ _%#DD#%_, 2006. Until now, all cultures are negative including RSV, rapid antigen, influenza A/B antigen.
BAL|bronchoalveolar lavage|BAL|180|182|HOSPITAL COURSE|During the hospitalization, infectious disease was consulted, and they recommended obtaining a bronchoscopy with BAL as the patient was not able to induce sputum. Bronchoscopy and BAL were performed on _%#MM#%_ _%#DD#%_, 2006. Until now, all cultures are negative including RSV, rapid antigen, influenza A/B antigen.
BAL|bronchoalveolar lavage|BAL.|219|222|HISTORY OF PRESENT ILLNESS|He also recently underwent a bronchoscopy for this decline in pulmonary function and symptomatology, but was unable to get transbronchial biopsies because of his warfarin therapy. He had no significant results from his BAL. He was also recently started back on his CellCept therapy, and as above, was given IV Solu-Medrol burst for presumed chronic rejection.
BAL|bronchoalveolar lavage|BAL|196|198|HISTORY OF PRESENT ILLNESS|The patient was intubated on _%#MM#%_ _%#DD#%_, 2005, secondary to a respiratory failure. The patient initially received Zosyn, Cipro, and vancomycin for a presumed hospital-acquired pneumonia. A BAL was done to evaluate for infection as well as confirm malignancy. This BAL cultures grew out coag-negative staph sensitive to agents the patient was previously on.
BAL|bronchoalveolar lavage|BAL|181|183|HISTORY OF PRESENT ILLNESS|The patient initially received Zosyn, Cipro, and vancomycin for a presumed hospital-acquired pneumonia. A BAL was done to evaluate for infection as well as confirm malignancy. This BAL cultures grew out coag-negative staph sensitive to agents the patient was previously on. The cytological evaluation of the BAL demonstrated adenocarcinoma but no organisms or other signs of infection.
BAL|bronchoalveolar lavage|BAL|132|134|HISTORY OF PRESENT ILLNESS|This BAL cultures grew out coag-negative staph sensitive to agents the patient was previously on. The cytological evaluation of the BAL demonstrated adenocarcinoma but no organisms or other signs of infection. The patient was supported initially with total parenteral nutrition. She received Xeloda for her adenocarcinoma.
BAL|bronchoalveolar lavage|BAL|213|215|HISTORY OF PRESENT ILLNESS|He was seen in clinic by Dr. _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2005, and she readmitted him. At that time, a chest x-ray also showed new infiltrate in his transplanted lung. Therefore, bronchoscopy with BAL and transbronchial biopsies was performed on day of the admission. The BAL is negative, except for some budding yeast (he has been on amphotericin B nebs for Candida for quite some time).
BAL|bronchoalveolar lavage|BAL|335|337|DISCHARGE MEDICATIONS|He will continue on cholestyramine once daily. The patient was noted to have new findings of interstitial changes on his CT scan from the CT in _%#MM#%_ and was seen in consultation by pulmonary and he was felt to have interstitial lung disease, most likely related to chemotherapy, most likely Cytoxan. He underwent bronchoscopy with BAL specimens and urine for Legionella which was negative. Mycoplasma titers would be negative. Cultures of lung material was unremarkable.
BAL|bronchoalveolar lavage|BAL|219|221|HOSPITAL COURSE|Blood culture was negative. Chest CT scan showed a 1.6 x 2- cm cavitary left lower lobe lung lesion associated adenopathy. HOSPITAL COURSE: 1. Cavitary lung lesion secondary to pulmonary tuberculosis. The patient had a BAL performed by the pulmonary team on _%#MM#%_ _%#DD#%_, 2006. AFB stains from the BAL were positive. Cultures are pending at the time of discharge.
BAL|bronchoalveolar lavage|BAL|180|182|HOSPITAL COURSE|HOSPITAL COURSE: 1. Cavitary lung lesion secondary to pulmonary tuberculosis. The patient had a BAL performed by the pulmonary team on _%#MM#%_ _%#DD#%_, 2006. AFB stains from the BAL were positive. Cultures are pending at the time of discharge. The patient was started on quadruple drug therapy of rifampin, ethambutol, isoniazid and pyrazinamide.
BAL|bronchoalveolar lavage|(BAL)|195|199|PROCEDURES AND TESTS|(See separate bronchoscopy report.) In brief, this showed extrinsic compression, apical segment, left upper lobe, extrinsic compression, superior segment, left lower lobe. Bronchoalveolar lavage (BAL) and needle aspiration biopsies performed. Pathology did not reveal malignancy, but did show evidence for Candida, which was felt pathological as the patient is on chronic steroids.
BAL|bronchoalveolar lavage|BAL|193|195|HISTORY OF PRESENT ILLNESS|2. Bronchoscopy last done _%#MM#%_ _%#DD#%_, 2005, showing friable mucosa consistent or concerning for fungal infection. The patient also had exudative material at the site of the anastomosis. BAL was sent and cytology was sent. 3. Echocardiogram dated _%#MM#%_ _%#DD#%_, 2005, shows normal global systolic function with an EF of 70%, mild to moderate LVH, mild right ventricular dilatation, moderate right ventricular hypertrophy.
BAL|bronchoalveolar lavage|BAL|164|166|PAST MEDICAL HISTORY|White cell count of 36. Hemoglobin was 10.7 and stable. Platelets 493. CMV was negative. Nocardia was negative. Blood cultures were all negative. The patient had a BAL done and preliminary cultures are negative to date without any signs of malignancy. His AFB and viral cultures are pending at the time of this dictation.
BAL|bronchoalveolar lavage|BAL.|177|180|LABS PENDING ON DISCHARGE|The patient will call _%#NAME#%_ _%#NAME#%_ at _%#TEL#%_ to schedule. LABS PENDING ON DISCHARGE: 1. Final sensitivities from the sputum culture from _%#MM#%_ _%#DD#%_, 2005. 2. BAL. Nocardia, fungal and AFB cultures. 3. Stool cultures from _%#MM#%_ _%#DD#%_, 2005, for C. diff and S/S/C/E. FOLLOW UP: 1. Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2005, at 9:15 with PFTs and 9:50 in clinic.
BAL|bronchoalveolar lavage|BAL|163|165|HOSPITAL COURSE|The patient underwent induced sputum to obtain samples. So now, the first AFB culture is negative and he has other specimens which are currently pending. The full BAL results are also pending. However, the BAL Gram stain showed rare gram-positive cocci, rare gram-positive rods, and moderate white blood cells.
BAL|bronchoalveolar lavage|BAL,|146|149|HOSPITAL COURSE|However, her pulmonary infiltrates continued to worsen and her respiratory failure continued to progress. Patient had multiple cultures after the BAL, which, on _%#MM#%_ _%#DD#%_, 2005, grew Aspergillus, Paecilomyces, and Fusarium, which were treated with voriconazole and caspofungin for over 3 weeks.
BAL|bronchoalveolar lavage|BAL|231|233|MICROBIOLOGY|Legionella culture bronchial washings negative, bronchial washings light growth Candida albicans and fungal culture showing moderate Candida albicans. AFB stain from bronchial washings negative. Urine test for legionella negative. BAL smear positive for Pneumocystis. IMAGING STUDIES: Admission chest x-ray shows diffuse bilateral interstitial infiltrates.
BAL|bronchoalveolar lavage|BAL|182|184||She has a history of HIV with EBV-associated lymphoma treated with bone marrow transplant 42 days prior. This lymphoma had recurred despite bone marrow transplant. Bronchoscopy with BAL identified diffuse alveolar hemorrhage and later cultures identified Aspergillus and Candida infections. The patient was intubated secondary to hypoxic respiratory failure. Her clinical picture continued to decline throughout her hospital stay and it was determined by her advanced directive and with consultation with her family and power-of-attorney that she would not want to be kept alive via artificial means as the likelihood of recovery was low.
BAL|bronchoalveolar lavage|BAL|217|219|HOSPITAL COURSE|The sensitivities were pending. The patient was switched from Rocephin to Ceftin oral medication 2 days prior to discharge. In addition to this, he was placed on azithromycin. Of note, the yeast that were seen in the BAL Infectious Disease were ......., and they thought it would be a good idea to start him on fluconazole for a short treatment.
BAL|bronchoalveolar lavage|BAL|284|286|HOSPITAL COURSE|In addition to this, he was placed on azithromycin. Of note, the yeast that were seen in the BAL Infectious Disease were ......., and they thought it would be a good idea to start him on fluconazole for a short treatment. The patient remained afebrile throughout his hospitalization. BAL results for cancer cells was negative. Respiratory viral culture was pending. Influenza was negative. CMV was pending. .....was no growth to date at discharge. ......was pending. No PCP was seen on gram stain.
BAL|bronchoalveolar lavage|BAL|240|242|HOSPITAL COURSE|The patient does have bilateral air space opacity seen on chest x-ray consistent with pulmonary edema versus ARDS and is still requiring hemodialysis. The patient is undergoing daily sedation holidays in attempt to wean off the ventilator. BAL was performed to see if there are any infectious etiologies of the patient's opacity seen on chest x-ray; however, this was negative.
BAL|bronchoalveolar lavage|BAL|124|126|PROCEDURES PERFORMED HERE IN HOSPITAL STAY|DISCHARGE DIAGNOSIS: Pulmonary infection of unclear etiology. PROCEDURES PERFORMED HERE IN HOSPITAL STAY: Bronchoscopy with BAL that showed normal flora to grow, CT scan of the chest showing increase in 3 bad opacities and ground-glass opacities bilaterally. INITIAL PRESENTATION: In brief, this is a 51-year-old male with history of AML M6 diagnosed in _%#MM2005#%_, status post NMA, DCU, CT of _%#MMDD2006#%_ which was complicated by grade II GVHD who had been complaining of shortness of breath and cough during the last 7 days previous to admission.
BAL|bronchoalveolar lavage|BAL|232|234|4)  ESRD|6) CMV viremia Pt was treated with gancyclovir when PCR became positive _%#MMDD#%_, and actually cleared her viremia shortly before her death, therefore treatment was stopped early given her pancytopenia. 7) Polymicrobial pneumonia BAL done _%#MMDD#%_ grew E.coli (ESBL), MRSA, and enterobacter, which was treated. However, in the week prior to her death, her CXR showed new infiltrate.
BAL|bronchoalveolar lavage|BAL|167|169|HOSPITAL COURSE|The patient was treated with ceftriaxone and Zithromax in the usual fashion. The CT scan of the chest was abnormal as described above. She underwent bronchoscopy, and BAL was positive for candida which seemed to be from colonization. Clinically, she was responding to antibiotic therapy, and she was afebrile and maintained good saturations during this hospital course.
BAL|bronchoalveolar lavage|BAL|139|141|HISTORY OF PRESENT ILLNESS|On _%#MMDD2006#%_, the patient required intubation for respiratory failure. A bronchoscopy that was done showed a bloody fluid return. The BAL cultures have been negative. He was started on high-dose methylprednisolone for the treatment of diffuse alveolar hemorrhage. The patient was successfully intubated on _%#MMDD2006#%_. He was doing well and ambulating until _%#MMDD2006#%_ when he began to re-experience respiratory distress.
BAL|bronchoalveolar lavage|BAL|151|153|HISTORY OF PRESENT ILLNESS|He was initially put on BiPAP therapy, which he failed and was intubated on _%#MMDD2006#%_. The patient underwent a repeat bronchoscopy and again, the BAL fluid showed a bloody return. He was diagnosed to have a repeat episode of diffuse alveolar hemorrhage. He was given 1 g of methylprednisolone and then continued on the methylprednisolone taper.
BAL|bronchoalveolar lavage|BAL|175|177|HOSPITAL COURSE|Her respiratory symptoms improved during her hospitalization. It was not clear if her fevers were due to her diarrhea or her pneumonia. Pulmonary considered bronchoscopy with BAL only if her symptoms clinically worsened. This was not the case. Studies were sent including sputum, Gram stain culture, urine for Legionella antigen, urine for HISTO antigen, stool cultures etc.
BAL|bronchoalveolar lavage|BAL|239|241|HOSPITAL COURSE|Pulmonary was consulted given her history of adenocarcinoma and chest CT findings and her progressive mediastinal subcarinal and hilar lymphadenopathy. Ultimately she underwent a bronchoscopy following platelet transfusions. She underwent BAL and FNA of subcarinal node. Findings were reviewed with pathology. Unfortunately, they were nondiagnostic, however, treatment team including oncology and pulmonary felt that findings were both CT and rare atypical cells seemed consistent and quite suspicious for recurrence and spread of her adenocarcinoma of the lung.
BAL|bronchoalveolar lavage|BAL|303|305|BRIEF HISTORY OF PRESENT ILLNESS|He was admitted to the hospital and found to have bilaterally patchy opacities in his lungs and was started on the course of Zithromycin and ceftriaxone, however, the patient's respiratory status did not improve over the next several days. The patient then had a pulmonary consult and bronchoscopy with BAL performed on _%#MMDD2007#%_ which showed no evidence of infection, few GPCs and moderate yeast on Gram stain. Then on _%#MMDD2007#%_, the patient developed sudden onset of shortness of breath and respiratory distress requiring BiPAP and possible ventilation.
BAL|bronchoalveolar lavage|BAL|187|189|HOSPITAL COURSE|There were no lesions identified on bronchoscopy. There is a fair amount of secretions that were noted on bronchoscopy. A BAL was sent off. Much of the test and cultures results from the BAL are currently pending and the patient should see Dr. _%#NAME#%_ to followup with these results. The patient's hemoptysis eventually resolved.
BAL|bronchoalveolar lavage|BAL|200|202|SOCIAL HISTORY|Her O2 need gradually decreased to where she maintained saturations of 96 percent on 2 L that decreased to 89-91 percent on room air, which is her baseline. She underwent a transbronchial biopsy with BAL and bronchoscopy which was nondiagnostic. Overall assessment during this hospitalization was that she likely has, given her recent history of frequent pneumonias and the appearance of her chest CT, an interstitial lung disease that has not been clearly diagnosed yet.
BAL|bronchoalveolar lavage|BAL|141|143|PROBLEM #3|This was felt to be likely secondary to mucus plugging. A BAL was obtained from the right middle lobe during the bronchus. Cultures from the BAL revealed no growth after three days. The patient was started on albuterol for the atelectasis in order to help him open his airways and clear his secretions.
BAL|bronchoalveolar lavage|BAL.|139|142|HOSPITAL COURSE|There was some haziness near the aortic valve and vegetations could not be definitively ruled out. The patient underwent bronchoscopy with BAL. There were copious clear secretions and some blood throughout the bronchi but no endobronchial lesion. Patient was seen in ID consultation. It was suggested treating him with vancomycin, Tequin and Septra and this was done in the hospital.
BAL|bronchoalveolar lavage|BAL.|221|224|HOSPITAL COURSE|The left ventricle was normal size, ejection fraction 60%, marked left atrial enlargement. No other significant abnormalities noted. On _%#MMDD2002#%_, Dr. _%#NAME#%_ _%#NAME#%_ decided to proceed with a bronchoscopy and BAL. He was switched from heparin over to Lovenox. The same antibiotics included Imipenem and Zithromax were continued on. The bronchoscopy revealed a nonpurulent process suspected to be inflammatory initially and later confirmed to have no growth on culture.
BAL|bronchoalveolar lavage|BAL|157|159|HOSPITAL COURSE|The patient also had a post-obstructing pneumonia. The cytology on the pleural fluid was negative. The patient had a bronchoscopy performed. Cytology on the BAL was negative and on the brushings was negative, however, biopsy was positive for squamous cell carcinoma. The Oncology Service evaluated the patient. They felt that the patient should be referred for radiation treatment.
BAL|bronchoalveolar lavage|BAL|141|143|PROBLEM #1|He seemed to improve with this dosage regimen but subsequently had fever spikes. He was eventually bronched on _%#MMDD2002#%_, at which time BAL showed positive for AFB cultures, which were subsequently sent out for DNA probing, essentially negative for tuberculosis but positive for a mycoplasma, which is suspected to be ______________.
BAL|bronchoalveolar lavage|BAL|208|210|PROBLEM #3|This was discontinued upon discharge, and oral lesions were resolved on day of discharge. PROBLEM #3: Infectious disease. The patient was seen by Infectious Disease on development of acid-fast bacilli on the BAL cultures. DNA probes were consistent with mycoplasma but not tuberculosis. Infectious Disease was fairly convinced this was a Mycoplasma ____________ species that would respond to cefotaxime and clarithromycin.
BAL|bronchoalveolar lavage|BAL,|133|136|HOSPITAL COURSE|She was initially on vancomycin, which she received for over a week. She received BAL on _%#MMDD2003#%_. Subsequent follow up with a BAL, cultures, and serologies have been negative. She has done continued improvement since receiving a tracheostomy. She is currently doing trach dome trials for 10 hours and on minimal vent requirements, which are as follows: tidal volume 4A , respirations 20, 40% FiO2, and PEEP of 5.
BAL|bronchoalveolar lavage|BAL|199|201|HOSPITAL COURSE|The patient remained afebrile and vital signs stable, otherwise as noted above. She was stable for discharge on _%#MMDD2003#%_. The patient was started on Unasyn 3 gm q12h. IV on _%#MMDD2003#%_ when BAL grew out .............coccus, as well as Fluconazole 200 mg p.o. q. daily when BAL grew out yeast. The patient was changed to p.o. Augmentin on the following day.
BAL|bronchoalveolar lavage|BAL|202|204|HOSPITAL COURSE|She was stable for discharge on _%#MMDD2003#%_. The patient was started on Unasyn 3 gm q12h. IV on _%#MMDD2003#%_ when BAL grew out .............coccus, as well as Fluconazole 200 mg p.o. q. daily when BAL grew out yeast. The patient was changed to p.o. Augmentin on the following day. She has tolerated p.o. Augmentin well without nausea or vomiting.
BAL|blood alcohol level|BAL|228|230|CURRENT MEDICATIONS|MI was ruled out. His TSH was found to be almost 10, suggesting he was noncompliant with his thyroid medication, but his free thyroxine was 1.8. His INR was therapeutic at 2.88. Urine drug screen was negative, but his admission BAL was 0.10. Chest x-ray showed cardiomegaly, pacemaker, and no active disease. Subsequent chest x-ray showed an incidental small nodule, probably a nipple shadow and moderate cardiomegaly.
BAL|blood alcohol level|BAL|131|133|HISTORY OF PRESENT ILLNESS|His doctor recently stopped it due to increased liver functions. He relapsed a few days prior to admission. He was admitted with a BAL of 0.34. HOSPITAL COURSE: On admission his physical examination revealed him to have a slight tremor.
BAL|bronchoalveolar lavage|BAL|259|261|ALLERGIES|During this time, of course, we still continued the treatment of community-acquired pneumonia, but given the lack of diagnosis, we proceeded with a pulmonary consult for bronchoscopy and bronchoalveolar lavage, which was completed on _%#MM#%_ _%#DD#%_, 2004. BAL was performed on the right middle lobe and sent for a cell count, bacterial culture, and viral smears and culture.
BAL|bronchoalveolar lavage|BAL|162|164|HOSPITAL COURSE|The patient was started on Clindamycin. With the initial report of gram- positive cocci, she did receive 1 dose of vancomycin. However, when the culture from the BAL grew out normal respiratory flora, we felt fairly confident saying this was not a Staph infection, but rather a pneumonia that did progress to a lung abscess, perhaps due to the patient's concomitant mononucleosis with a steroid burst.
BAL|bronchoalveolar lavage|BAL|148|150|LABORATORY|Platelet counts 247000. BUN 22. Creatinine 1.4. Tacrolimus level 14.8. CMV antigenemia with 50 positive cells out of 50000 cells. Gram stain of the BAL fluid obtained on the day of admission showed Gram positive cocci and Gram negative rods. Chest x-ray showed increased opacity in the left lung. HOSPITAL COURSE: PROBLEM #1: Pneumonia.
BAL|bronchoalveolar lavage|BAL|193|195|ASSESSMENT/PLAN|1. Community acquired pneumonia. a. See discussion above. b. Standard cares with oxygen, IV antibiotics, blood cultures. c. If symptoms persist and fail to respond to stand treatment, consider BAL or assessment for pleural effusion by CT scan or ultrasound. 2. Chronic steroid use. She does not appear ill enough to warrant high dose steroids.
BAL|bronchoalveolar lavage|BAL|145|147|FOLLOW UP|FOLLOW UP: The patient should follow up with Dr. _%#NAME#%_, her primary care physician within 1 week. At that point, cultures obtained from her BAL should be followed up and a decision should be made of whether to continue the patient on antibiotics or not. It is my pleasure to be involved in the medical team taking care of Ms. _%#NAME#%_.
BAL|bronchoalveolar lavage|BAL|225|227|HISTORY OF PRESENT ILLNESS|On _%#MM#%_ _%#DD#%_, 2005, the patient had a CT of the sinuses and chest, which showed pansinusitis and left lower lobe atelectasis. Subsequently, the patient had a bronchoscopy on _%#MM#%_ _%#DD#%_, 2005. The cultures from BAL showed Pseudomonas and RSV infection. The patient was contacted by the transplant coordinator, and was advised to come to the Fairview- University Medical Center for treatment.
BAL|bronchoalveolar lavage|BAL|326|328|HISTORY OF PRESENT ILLNESS|Legionella urinary antigen was negative. Aspergillus antigen was negative. Her sputum did grow out a heavy growth of Pseudomonas aeruginosa that was resistant to Bactrim but sensitive to other antibiotics tested and for which she was prescribed ciprofloxacin. At discharge her white count came down to 8.7. 2. Cytology of her BAL was negative for malignancy. No organisms were identified in the BAL fluid. The influenza rapid test was negative. RSV on the BAL was negative.
BAL|bronchoalveolar lavage|BAL|135|137|HISTORY OF PRESENT ILLNESS|At discharge her white count came down to 8.7. 2. Cytology of her BAL was negative for malignancy. No organisms were identified in the BAL fluid. The influenza rapid test was negative. RSV on the BAL was negative. 3. Culture for fungal is negative at this point. Nocardia shows no growth after 1 day.
BAL|bronchoalveolar lavage|BAL,|267|270|HISTORY OF PRESENT ILLNESS|3. Culture for fungal is negative at this point. Nocardia shows no growth after 1 day. Part of her room workup showed a normal compliment level in an antinuclear antibody screen of 1.6. Pending studies include AFB stain and culture respiratory viral culture from the BAL, CMV shell viral culture, neutrophil cytoplasmic antibody IgG screen, acetylcholine binding antibody for mild ptosis seen during her stay, and cardiolipin antibody.
BAL|bronchoalveolar lavage|BAL|207|209|DISCHARGE DIAGNOSIS|She stated that she had a throat culture and a course of antibiotics that failed to resolve the throat discomfort. The patient was seen by Dr. _%#NAME#%_ _%#NAME#%_ at Park Nicolett Hospital and underwent a BAL and a biopsy which showed a laryngeal ulcer that was positive for squamous cell carcinoma. The patient was then referred here to Dr. _%#NAME#%_ at the University of Minnesota, and then referred to Dr. _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ for chemotherapy and radiation.
BAL|bronchoalveolar lavage|BAL.|142|145|ASSESSMENT/PLAN|ASSESSMENT/PLAN: 1. Atypical pneumonia. a) See discussion above. b) Respiratory isolation. c) Sputum for KOH, gram stain, AFB x3. d) May need BAL. e) Treatment for common infections with ceftriaxone and azithromycin. f) Blood cultures, including fungal. g) Check HIV status, reconsider if positive. h) Check urinalysis, liver panel, urine histoplasmosis antigen, serum fungal antibody panel.
BAL|bronchoalveolar lavage|BAL|175|177|HOSPITAL COURSE|5. Cryptococcal antigen test was negative. 6. Aspergillus galactomannan antigen was negative. 7. Toxoplasma, IgM and IgG are negative. 8. CMV antigenemia is negative. CMV and BAL fluid was negative. 9. Parvovirus B19 IgG indicated past infection and IgM was negative. DISCHARGE MEDICATIONS: 1. CamPath 30 mg IV _%#MMDD2005#%_, and _%#MMDD2005#%_.
BAL|bronchoalveolar lavage|BAL|348|350|PHYSICAL EXAMINATION|6. RSV pneumonia requiring 3-week hospitalization and 2-week ventilator dependence (_%#MM#%_ 2005). 7. Gastrostomy with tube feeds. PHYSICAL EXAMINATION: Admission physical significant for temperature of 92 degrees Fahrenheit, pulse 90, blood pressure 91/50, oxygen saturation 96% on room air; mild crackles in the right lower lobe consistent with BAL on lung exam, severe neurological impairment, and increased tone. HOSPITAL COURSE: _%#NAME#%_ was admitted to the pediatric pulmonary service on _%#MM#%_ _%#DD#%_, 2005, following a bronchoscopy that revealed omega-shaped epiglottis, redundant arytenoids, laryngotracheomalacia, erythematous airway mucosa, and cloudy thick secretions that later grew MRSA and pseudomonas.
BAL|bronchoalveolar lavage|BAL|153|155|PROBLEM #1|At this time, her white count began to climb, and she became acidotic. Pulmonology consultation was obtained and the patient underwent bronchoscopy with BAL on _%#MM#%_ _%#DD#%_, 2005. As per her chest x-ray, it had continued to worsen along with her clinical picture. The patient was started on fluconazole IV per pulmonary recommendations on _%#MM#%_ _%#DD#%_, 2005, as her clinical course worsened despite being on broad-spectrum antibiotics, and with her CLL, there was a possibility of a fungal or other opportunistic infection.
BAL|bronchoalveolar lavage|BAL.|293|296|ASSESSMENT AND PLAN|We will send off a throat swab for viral. She has no upper respiratory symptoms to suggest respiratory tract infection such as RSV or parainfluenza, but will culture for this. We will treat her empirically with antibiotics including levofloxacin and Zosyn. If she does not respond, we will do BAL. 2. Transplant. The patient is intolerant to CellCept and Imuran as she develops neutropenia. We will continue on Prograf and check a level in the morning.
BAL|bronchoalveolar lavage|BAL|150|152|PROBLEMS|After she contacted Dr. _%#NAME#%_, she referred her to the Emergency Department. PROBLEMS: Management by Systems; 1. Pulmonary. The results from the BAL culture grew MRSA. Therefore, she was started immediately on intravenous vancomycin with a good response. Within a short time, the patient's condition improved and her lung examination was better.
BAL|bronchoalveolar lavage|BAL|162|164|HOSPITAL COURSE|This is concerning for malignancy. Therefore, Pulmonary was consulted and they did a bronchoscopy. However, no endobronchial lesions could be found. Eventually a BAL was done and showed some Candida, but was negative for AFB and other cultures were negative. Other bacterial cultures have remained negative, and this was thought very unlikely to be a malignant lesion.
BAL|bronchoalveolar lavage|BAL|196|198|OPERATIONS/PROCEDURES PERFORMED|DISCHARGE DIAGNOSES: 1. Enterobacter pneumonia. 2. Stage IV lung cancer. OPERATIONS/PROCEDURES PERFORMED: Bronchoscopy (_%#MM#%_ _%#DD#%_, 2006): Bronchoscopy is performed without complication. A BAL was performed in the right middle lobe. HISTORY OF PRESENT ILLNESS: For full details, please see admission history and physical.
BAL|bronchoalveolar lavage|BAL|165|167|BRIEF HISTORY OF PRESENT ILLNESS|Initially, the patient had bilateral pleural effusions and then had bilateral chest tubes placed for draining of the fluid. The patient also had a bronchoscopy with BAL which grew Pseudomonas and group D enterococcus. The patient was started on the antibiotics levofloxacin, ceftazidime, TOBI nebs, and vancomycin, and reduced but continued to have fevers.
BAL|bronchoalveolar lavage|BAL|127|129|HISTORY OF PRESENT ILLNESS|He otherwise denies any recent medication changes. He had a bronchoscopy on _%#MMDD2006#%_ which had a negative AFB stain. The BAL culture showed no growth. Fungal culture was negative. The patient was seen by Dr. _%#NAME#%_ in Pulmonary Clinic today at which time a chest x-ray was done.
BAL|bronchoalveolar lavage|BAL|309|311|POSTTRANSPLANT COURSE|She engrafted on approximately day #16. Her posttransplant course was complicated by diffuse alveolar hemorrhage, for which she was intubated on _%#MMDD2006#%_. She was treated empirically for infection and also received high-dose methylprednisolone for the DAH. Bronchoscopy revealed bloody return; however, BAL cultures were all negative. The patient received aggressive platelet replacement as well as DDAVP and fresh-frozen plasma. Her respiratory status gradually improved and she was able to be extubated on _%#MMDD2006#%_.
BAL|bronchoalveolar lavage|BAL|215|217|PROCEDURES|4. Minimal fluid around the liver and the pelvis with no evidence for abdominal abscess. 5. Air present in the bladder. 3. Chest x-ray done on _%#MMDD#%_, _%#MMDD#%_, _%#MMDD#%_ and _%#MMDD#%_. 4. Bronchoscopy with BAL dated _%#MMDD2006#%_. The result of the bronchoscopy was bronchial mucosa and anatomy are normal. There are no endobronchial lesions and no secretions. The examination was deemed as normal.
BAL|bronchoalveolar lavage|BAL|147|149|HOSPITAL COURSE|The procedure went uneventful and since then, her kidney function has gradually improved. Problem #2: Pneumonia. The patient had bronchoscopy with BAL which showed moderate growth of MRSA. The patient continued to be on voriconazole and levofloxacin. We also treated her with vancomycin and aztreonam.
BAL|bronchoalveolar lavage|BAL,|166|169|HOSPITAL COURSE|The patient continued to be on voriconazole and levofloxacin. We also treated her with vancomycin and aztreonam. With the sensitivity of the Staph aureus coming from BAL, we discontinued her aztreonam. We are continuing with the voriconazole, levofloxacin and the vancomycin at the time of discharge. The patient initially was having fever spikes almost on daily basis; however with continuation of the antibiotics, the patient became afebrile.
BAL|bronchoalveolar lavage|BAL|189|191|HOSPITAL COURSE|After the pulmonary team evaluated the patient, she was also put on vancomycin IV for possible hospital acquired MRSA. Sputum cultures were uninformative. They considered bronchoscopy with BAL if her clinical course worsened. They felt that the risks of performing this procedure given her altered mental status outweighed the benefit.
BAL|bronchoalveolar lavage|BAL|156|158|HOSPITAL COURSE|Suspect Legionella or anaerobic pneumonia. The pulmonary service was consulted and performed a bronchoscopy on _%#MMDD2007#%_. The initial results from her BAL showed a Gram stain with only few PMNs, no organisms. Initial KOH preps and AFB were negative. Both sputum and fungal cultures were also negative on the day of discharge.
BAL|blood alcohol level|BAL|178|180|LABORATORY DATA|BUN 11. Creatinine 0.08. GFR is over 90. Calcium 8.7. Bilirubin 0.2. Albumin 4.6. Total protein 7.9. Alkaline phosphatase 99. ALT 29. AST 36. Lipase 144. Acetaminophen level 12. BAL is 0.28. Salsalate is less than 1. Magnesium 2.3. ASSESSMENT AND PLAN: 1. Polysubstance abuse.
BAL|bronchoalveolar lavage|BAL|171|173|MAJOR TESTS AND PROCEDURES PERFORMED|2. Chest CT without contrast with findings of left upper lobe ground-glass opacities consistent with pneumonia and small bilateral pleural effusions. 3. Bronchoscopy with BAL culture positive for RSV. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 71-year-old male with a history of diabetes, peripheral vascular disease, hypertension, CHF and vasculitis who presented with a chief complaint of cough, fevers and shortness of breath.
BAL|bronchoalveolar lavage|BAL|179|181|HOSPITAL COURSE|After his bronchoscopy the patient became tachypneic and continued to have fevers up to 103.2. Given his respiratory distress he was transferred to the ICU on _%#MMDD2007#%_. The BAL culture results came back positive for RSV and treatment was initiated with ribavirin. After the bronch results were back vancomycin and voriconazole were stopped and he was continued on Levaquin, Zosyn and ribavirin.
BAL|bronchoalveolar lavage|BAL|151|153|HOSPITAL COURSE|The patient's antibiotics were tapered to intravenous Zosyn and he completed the course in the hospital. There were no positive blood cultures and the BAL did not grow any organism other than Candida albicans. The Candida was not deemed to be a pathogen. He was transferred to his assisted living facility with the arrangement of twice daily with physical therapy to assist in rehabilitation.
BAL|bronchoalveolar lavage|BAL|189|191|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: PROBLEM #1: Dyspnea, hypoxia and infiltrates: concerning for infection. The patient had a bronchoscopy today and cultures are pending. He is more hypoxic following the BAL and he is gong to be admitted to the hospital. Yesterday, he was started on Augmentin and I will broaden this antibacterial coverage.
BAL|bronchoalveolar lavage|BAL|141|143|PROBLEM #1|He continued to have fevers and gradually needed more oxygen requirement. Thus, a pulmonary consult was obtained, and bronchoscopy was done. BAL fluid is negative to date for any fungal, bacterial or cytology. The patient began to improve. On the day of discharge, he remains afebrile greater than 24 hours.
BAL|blood alcohol level|BAL|128|130||He is on disability for a head injury in 1999. He had a history of migraines. He was admitted through the emergency room with a BAL of 0.47. The patient was detoxed with Valium and had moderately severe withdrawal. He had some hallucinations. He required Valium for several days.
BAL|bronchoalveolar lavage|BAL|215|217|MEDICATIONS ON ADMISSION|Otherwise clear to auscultation. No crackles or wheezes. Abdomen: Normal bowel sounds. Obese. Nondistended and nontender. Extremities without cyanosis, clubbing or edema. Labs on admission include RSV isolated from BAL on _%#MM#%_ _%#DD#%_, 2002. Bronchial culture from _%#MM#%_ _%#DD#%_, 2002, included Pseudomonas sensitive to Cipro and tobramycin. HOSPITAL COURSE: PROBLEM NUMBER ONE: RSV and Pseudomonas infection. As stated above, these were isolated from bronchoscopy on _%#MM#%_ _%#DD#%_, 2002.
BAL|bronchoalveolar lavage|BAL.|229|232|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old female with COPD who is status post right single-lung transplant on _%#MM#%_ _%#DD#%_, 2001. The patient was having a routine bronchoscopy with transbronchial biopsies and BAL. The procedure was complicated as noted above with bronchial bleeding. During the procedure, the patient also had a very transient episode of bradycardia to 45.
BAL|bronchoalveolar lavage|BAL|268|270|PROCEDURES PERFORMED|Indication: Evaluation of left lower lobe pneumonia. Results: Left lower lobe pneumonia with left pleural effusion and atelectasis. 2. Bronchoscopy (_%#MMDD2002#%_). Indication: Evaluation of pneumonia in a immunosuppressed patient. Results: No endobronchial lesions. BAL positive for multiple different organisms, including Citrobacter, Klebsiella pneumoniae, Group D enterococcus, beta Streptococcus, and moderate Candida albicans.
BAL|bronchoalveolar lavage|BAL|195|197|HOSPITAL COURSE|Patient was initially on admission on Zestril and Cipro for possible other infections at this time. Patient, overall, did well with minor symptoms of fevers. Patient had a bronchoscopy done with BAL which grew both CMV and Bordetella bronchiseptica. At discharge, patient was feeling better, and his BAL cytology was negative for malignancy, negative for PCP, negative for CMV inclusions.
BAL|bronchoalveolar lavage|BAL|227|229|FOLLOW-UP|7. Imdur 120 q.d. 8. Coumadin 2.5 Monday, Tuesday, Wednesday, Friday, Sunday, 5 Thursday, Saturday. 9. Aspirin 81 q.d. FOLLOW-UP: The patient should follow up in the Pulmonary Clinic in approximately one week to obtain further BAL results and should follow up with her primary physician for follow-up of her congestive heart failure within the next week.
BAL|bronchoalveolar lavage|BAL,|254|257|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ is a 62-year-old male with a history of Eisenmenger's syndrome status post heart and bilateral lung transplant in 1989 with a kidney transplant in 2000. He was recently discharged for a previous pneumonia and underwent bronchoscopy with a BAL, which grew two strains of resistant Stenotrophomonas maltophilia. Synergies were not done. However, they were ordered prior to discharge on prior discharge admit.
BAL|bronchoalveolar lavage|BAL.|70|73|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Probable Amiodarone lung toxicity. 2. MRSA in BAL. Unclear whether colonization or true MRSA pneumonia. 3. Pulmonary edema secondary to diastolic dysfunction. 4. Type II diabetes. 5. Paroxysmal atrial fibrillation currently in normal sinus rhythm.
BAL|bronchoalveolar lavage|BAL.|144|147|HOSPITAL COURSE|Stains and cultures were negative for bacteria and fungus. BAL showed moderate leukocytes and positive shell viral cytomegalovirus antigen from BAL. This was reported to the primary team on _%#MMDD2003#%_ at which time the patient was started on IV IG and IV ganciclovir treatment.
BAL|blood alcohol level|BAL|275|277|ADMISSION LABS|Amylase 64, lipase 243, INR 0.93, PTT 34, AST 167, ALT 106, albumin 4.5, total protein 7.5, alkaline phosphatase 102, total bilirubin 0.3, conjugated bilirubin 0. Electrolytes were within normal limits. Sodium 148, potassium 3.8, BUN and creatinine 10 and 0.79 respectively. BAL was 0.2. HOSPITAL COURSE: PROBLEM #1: Alcohol intoxication/withdrawal. The patient was admitted to the Intensive Care Unit, placed on the MSSA protocol for alcohol withdrawal, given IV thiamine and folate along with IV fluids.
BAL|bronchoalveolar lavage|BAL|171|173|OPERATIONS/PROCEDURES PERFORMED|OPERATIONS/PROCEDURES PERFORMED: 1. Bronchoscopy with transbronchial biopsies: No evidence of malignancy noted on transbronchial biopsies. No evidence of acute rejection. BAL positive for nocardia. 2. Thoracentesis: Lymphocyte predominant pleural effusion that is exudative with cultures negative to date. CONSULTATIONS: 1. Gastroenterology: Evaluated the patient and no procedures were performed.
BAL|bronchoalveolar lavage|BAL|163|165|ASSESSMENT/PLAN|It should be administered with his pancreatic enzymes. His CellCept is being held due to leukopenia and prednisone should be continued. Infectious disease. Again, BAL cultures are pending. Sputum cultures are still pending from yesterday which will be available by the end of the day today. He is afebrile and empiric antibiotics are not necessary at this moment.
BAL|bronchoalveolar lavage|BAL|205|207|HOSPITAL COURSE|Infectious workup was positive for CT scan with minimal ground-glass opacities with ill-defined nodules. Pulmonary consult was then obtained for patient to have a bronchoscopy with bronchoalveolar lavage. BAL cultures grew out moderate growth candida glabrata and light growth aspergillus fumigatus. At the time of discharge, sensitivities for candida glabrata were pending.
BAL|bronchoalveolar lavage|BAL.|68|71|MAJOR PROCEDURES|DIAGNOSIS: Fungal pneumonia. MAJOR PROCEDURES: 1. Bronchoscopy with BAL. 2. IV fluids. 3. IV antiemetics. CONSULTS: 1. Pulmonary. 2. Infectious Disease. HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old female with a history of diabetes and end-stage renal disease, status post simultaneous pancreas/kidney transplant with enteric drainage on _%#MM2004#%_, treated for rejection in _%#MM2005#%_.
BAL|bronchoalveolar lavage|BAL.|223|226|HOSPITAL COURSE|In mid-_%#MM#%_ the patient developed fevers and was treated with broad-spectrum antibiotics which included antifungal medication. His hospital course was complicated by HSV PCR positive urine, and HHV6 positive PCR in his BAL. The patient developed alveolar hemorrhage approximately day #20 post BMT which compromised his respiratory status and the patient was intubated.
BAL|blood alcohol level|BAL|145|147||It is worse with eating at times, she has some associated bloating. She feels her abdomen is more swollen then 6 months ago. She has an elevated BAL on admission, is interested in stopping drinking, although she is equivocal about chem dep treatment. She has a h/o of a right breast mass on mammogram and ultrasound but she denies this.
BAL|bronchoalveolar lavage|BAL|310|312|ASSESSMENT AND PLAN|He is presenting with a significant decline in his pulmonary function tests, a FEV1 from 1.60 to 1.14, FVC from 2.18 to 1.68. He also appears to have an infiltrate in the lingula on the left lung, which is his transplanted lung. He is being admitted to the Pulmonary Service for an immediate bronchoscopy with BAL and transbronchial biopsies as well. The transbronchial biopsies are being done as there is some evidence of involvement of the rest of the lung and because of inadequacy of a number of samples from the last biopsy we want to make sure to rule out rejection in the setting of such a significant decline in his pulmonary functions.
BAL|blood alcohol level|BAL|300|302|HISTORY OF PRESENT ILLNESS|However, he denies having any suicidality or making any such statements and says that his last suicidal ideation was quite some time ago. He was transferred to Fairview-University Medical Center, _%#CITY#%_ campus, Emergency Department because of these statements where he was tested again and had a BAL of 0.044. He was placed on a 72-hour hold and admitted by the emergency department physician. PSYCHIATRIC REVIEW OF SYSTEMS: As above in the "History of Present Illness." He denies any new problems.
BAL|bronchoalveolar lavage|BAL|276|278|HOSPITAL COURSE|The lung volumes were reduced, indicating a restrictive pattern which could be due to the patient's decreased neuromuscular status. The bronchoscopy was performed on _%#MMDD2006#%_, which showed normal-appearing anatomic structures with unresolving bilateral infiltrates. The BAL was done; there were negative cultures at the time of discharge. Biopsies were done which were also negative. There was no suggestion of any infectious process.
BAL|blood alcohol level|BAL|129|131|HISTORY OF PRESENT ILLNESS|He said he was also bored and started drinking again. The incident that led to this admission was a state of intoxication with a BAL of 0.48 when he arrived in the emergency room. He was found laying on the ground outside. He was treated for hypothermia.
BAL|bronchoalveolar lavage|BAL|137|139|HOSPITAL COURSE|Pulmonary Medicine bronched the patient, and it showed again diffuse inflammation and cloudy return of bronchoalveolar lavage fluid. The BAL fluid did grow out Candida. Infectious Disease did recommend that he stay on the Levaquin for two weeks and the Diflucan for at least two weeks.
BAL|bronchoalveolar lavage|BAL|192|194|HOSPITAL COURSE|A CT of the chest was obtained here which showed scattered nodular opacities and ground-glass opacity in both lungs suggestive of infection. A bronchoscopy was performed on _%#MMDD2006#%_ and BAL fluid sent. The culture has been so far negative for fungal, bacteria, no cardia, and RSV or CMV origin. The results are still pending for AFB. Upon initial evaluation the thought from Oncology team was that the patient will most likely need chemotherapy.
BAL|bronchoalveolar lavage|BAL|163|165|HOSPITAL COURSE|Given the patient's history of Aspergillus pneumonia, voriconazole was added to his antibiotic therapy. An Infectious Disease consultation was obtained. Blood and BAL fluid were negative for CMV. It was negative for Aspergillus galactomannan antigen, Nocardia, and Pneumocystis. Initially, there was no evidence of acid-fast bacilli; however, at the time of discharge AFB cultures were pending.
BAL|bronchoalveolar lavage|BAL|179|181|PLANS|We will go back to Levaquin seeing she had some response, as well as continue Rocephin. 3. Await current cultures and induced sputum. 4. Question bronchoscopy. Already did have a BAL in 2005 without evidence of a chronic organism such as AFB or fungi. Patient does not look that ill so how aggressive to be is difficult to tell.
BAL|bronchoalveolar lavage|BAL.|159|162|RECOMMENDATIONS|She has had a cardiac vegetation, this should be followed up. Dr. _%#NAME#%_ is following the patient. Consider for PCP. If needed will do a bronchoscopy with BAL. She would need platelets. We have discussed this with the family and patient. Will do serial chest x-rays.
BAL|bronchoalveolar lavage|BAL,|182|185|HISTORY OF PRESENT ILLNESS|The patient developed a significant progressive cough with fever. It eventually lead up to her being intubated in the Intensive Care Unit with a prolonged course. Numerous cultures, BAL, and other studies were done with no eventual diagnosis being made. The patient in fact was extremely ill during the course of this and it appeared possibly terminal at times.
BAL|bronchoalveolar lavage|BAL|129|131|IMPRESSION|Had no positive cultures. It did partially clear and did not look entirely like the current CT scan and chest x-ray do. He had a BAL at that time that was negative for an obvious infectious etiology. 4. Chronic pancreatitis. 5. An 18+ long fever of unknown origin.
BAL|bronchoalveolar lavage|(BAL)|218|222|RECOMMENDATIONS|1. Numerous cultures pending from bronchoscopy done on _%#MMDD2006#%_, and will followup on results with you. 2. Cytopathology data from bronchoscopy showed positive Cytomegalovirus (CMV) in the bronchoalveolar lavage (BAL) and positive fungi in the BAL and the bronch washings. 3. Significant of enterococcus in his bronch specimen is uncertain.
BAL|bronchoalveolar lavage|BAL.|238|241|PLAN|If there is an acute-appearing infiltrate, and his HIV status is negative, will treat with empiric antibiotics and postpone surgery. If there is an acute-appearing infiltrate and he is HIV positive, then would recommend bronchoscopy with BAL. If this is a chronic-appearing infiltrate, will need an interstitial lung disease evaluation postoperatively. 3. Check pulmonary function tests . 4. Mucomyst nebs postoperatively.
BAL|bronchoalveolar lavage|(BAL)|177|181|RECOMMENDATIONS|RECOMMENDATIONS: 1. She has developed respiratory failure and will need intubation and mechanical ventilation. 2. The patient will need bronchoscopy with bronchoalveolar lavage (BAL) in the morning. 3. I will ask Infectious Disease to see the patient this evening. 4. We will get a glucose. 5. She may need an arterial line as well as continuous infusion for her glucose.
BAL|blood alcohol level|BAL|230|232|HISTORY|Left there yesterday, subsequent to which patient consumed 7-8 cocktails to the point of intoxication. Presented to the emergency department at Fairview-Southdale Hospital with increasing despondency and alleged suicidal threats. BAL of .08. No specific active self harm, since maintained on MSSA withdrawal protocol using Ativan. Thiamine 100 mg q day x 3. No overt stigmata of alcohol withdrawal.
BAL|bronchoalveolar lavage|BAL|383|385|PLAN|d. Differential diagnosis includes pneumonia plus/minus inflammatory process (less likely given no response to previous steroid therapy), bronchoalveolar cell carcinoma/ bronchogenic carcinoma given his weight loss and the above symptoms is more likely. PLAN: 1. Antibiotics for gram positive cocci in pairs. 2. Sputum cytology. 3. Possible/probable intubation with bronchoscopy and BAL to look for a malignancy if sputum cytology is negative. 4. May require VATS biopsy. 5. Will initiate _________ for high flow oxygen.
BAL|blood alcohol level|BAL|266|268|LABORATORY|No rigidity. LABORATORY: Sodium 141, potassium 3.9, chloride 109, CO2 24, anion gap of 8, glucose of 79, BUN of 10, creatinine of 0.81, calcium 9.3, albumin 3.9. Liver profile, normal. TSH 1.92, white count 5,800, hemoglobin 13.3, MCV 90, platelet count of 274,000. BAL of .21. ASSESSMENT: 1. Behavioral disturbance, as above. (Diagnosis deferred to Psychiatry).
BAL|bronchoalveolar lavage|BAL,|132|135|PLAN|4. If she is no better with empiric antibiotics and pulmonary pressures do not preclude this, then we should do a bronchoscopy with BAL, possibly even biopsies might be indicated. 5. Initiate nebulizer therapy for history of asthma. HISTORY OF PRESENT ILLNESS: This patient is a 47-year-old female who was admitted yesterday.
BAL|bronchoalveolar lavage|BAL|183|185|RECOMMENDATIONS|The bronchoscopy on _%#MMDD#%_ only grew yeast, although the extubating culture grew Stenotrophomonas. We would suggest that either the Pulmonary Service or the ICU Service do a mini BAL to determine if removing the endotracheal tube would result in clearing of the organisms in his trachea. We would discontinue tobramycin and ciprofloxacin since he has completed three weeks of antibiotic therapy.
BAL|bronchoalveolar lavage|BAL|177|179|ASSESSMENT|Cannot rule out venous thrombo-embolism given her increased risk with her elevated pulmonary artery pressures. d. She is too tenuous for a safe (nonintubated) bronchoscopy with BAL to look for infection. PLAN: 1. Check Duplex ultrasound 2. Check D-Dimer 3. Check sputum culture for PCP
BAL|bronchoalveolar lavage|BAL|178|180|RECOMMENDATIONS|4. COPD. 5. Postop total knee replacement. 6. Agitation. 7. Coumadin coagulopathy. RECOMMENDATIONS: 1. The patient is agreeable to bronchoscopy to evaluate right hilum and allow BAL of the right base for culture. 2. We will give FFP in the morning in case he needs biopsy in light of anticoagulation.
BAL|bronchoalveolar lavage|BAL|142|144|PLAN|Cannot rule out lymphoma. PLAN: 1) Continue broad spectrum antibiotics. 2) If fevers persist over the weekend, we will need bronchoscopy with BAL to look for untreated organisms. 3) Might need platelet transfusion if platelets less than 50,000. HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old female who was admitted on _%#MMDD2003#%_ with pancytopenia and fevers for several weeks to 103 associated with chills, sweats, and myalgias.
BAL|bronchoalveolar lavage|BAL|142|144|PLAN|Cannot rule out lymphoma. PLAN: 1) Continue broad spectrum antibiotics. 2) If fevers persist over the weekend, we will need bronchoscopy with BAL to look for untreated organisms. 3) Might need platelet transfusion if platelets less than 50,000. HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old female who was admitted on _%#MMDD2003#%_ with pancytopenia and fevers for several weeks to 103 associated with chills, sweats, and myalgias.
BAL|bronchoalveolar lavage|BAL|206|208|ASSESSMENT|b. She does do some composting at home, which does raise the suspicion for Aspergillus and histoplasmosis, but she needs a diagnostic procedure to accurately determine this or hospice. c. Bronchoscopy with BAL would help to rule out infection, possibly bronchoalveolar cell carcinoma, but is somewhat high risk given her hypoxemia; cannot safely do transbronchial biopsies given her hypoxemia leaving a VATS with a wedge biopsy to really get adequate tissue sample for a diagnosis.
BAL|bronchoalveolar lavage|BAL|167|169|ONCOLOGY CONSULTATION.|He was seen and did have bronchoscopy performed. There were bloody secretions noted in the left upper lobe with an edematous mucosa without any endobronchial lesions. BAL and bronchial brushings and endobronchial biopsy were performed. Dr. _%#NAME#%_ felt it was likely a nondiagnostic procedure. I was asked to see him regarding further management of what appears to be a lung cancer.
BAL|bronchoalveolar lavage|BAL,|283|286|SUMMARY|Following the physician's fluid resuscitation she was admitted to the Bone Marrow Transplant Unit for further evaluation and management. She has been on Ganciclovir maintenance in the past. Although a CMV shell vial culture was negative 2 days before we were asked to see her from a BAL, the CMV antigenemia was 1 day prior to our being asked to see her. The question is how to manage this child who has antigenemia but a negative shell vial from the bronchial washings is suggesting that this was not etiologically related to her exacerbation.
BAL|blood alcohol level|BAL|145|147|HISTORY OF PRESENT ILLNESS|The record indicates 1 pint of vodka and 1 pint of rum daily. Allegedly he was picked up by police while driving under the influence of alcohol. BAL of 0.3, the patient's second DWI. He was taken to Fairview Southdale Hospital where the patient allegedly complained of abdominal discomfort.
BAL|blood alcohol level|BAL|150|152|REASON FOR CONSULTATION|In the setting of alcohol excess consisting of 5 beers and 2 Bloody Mary's. 911 was called. The police transport of the patient to the ER (as above). BAL of 0.137. Denies alcohol excess on a regular basis. Typical intake 3-4 beers once monthly. No other drug use. PAST MEDICAL HISTORY: 1. Psychiatric illness (as above). Details per psychiatry.
BAL|bronchoalveolar lavage|BAL|205|207|HISTORY OF PRESENT ILLNESS|He was randomized to standard dose daunorubicin and cytarabine. He was able to achieve a remission. Chemotherapy was complicated with basilar infiltrates and bilateral pleural effusions. Bronchoscopy with BAL was negative. He was treated with broad-spectrum antibiotics and Voriconazole with improvement. In _%#MM2007#%_ Mr. _%#NAME#%_ was referred to the University of Minnesota Medical Center, Fairview.
BAL|bronchoalveolar lavage|BAL.|159|162|HISTORY OF PRESENT ILLNESS|Chemotherapy was complicated with febrile neutropenia, and CT findings of basilar infiltrate, and bilateral pleural effusion. He underwent a bronchoscopy with BAL. Cultures were negative. He was treated with broad-spectrum antibiotics and Voriconazole with improvement. On _%#MMDD2007#%_ Mr. _%#NAME#%_ was referred to the University of Minnesota Medical Center, Fairview.
BAL|bronchoalveolar lavage|BAL|217|219|ASSESSMENT|Continue anticoagulation, I would do this through the weekend and if she has made significant progress as far as the pulmonary infiltrate, she may not need bronchoscopy but otherwise she should have bronchoscopy with BAL Monday or Tuesday. I explained the bronchoscopy to the patient.
BAL|bronchoalveolar lavage|BAL|166|168|ASSESSMENT AND PLAN|That being said, she does not appear to be infectious at this time and therefore, we would not recommend starting empiric antibiotics. We will plan bronchoscopy with BAL in the morning, most likely doing a wash of the left lower lobe. It would be reasonable at this time to start her steroids as soon as possible as it will not affect the bronchoscopy results.
BAL|bronchoalveolar lavage|BAL|300|302|IMPRESSION|2. Pulmonary infiltrates for at least several weeks, no clear response to antibiotics ongoing elevated white count for unclear reasons not having much cough currently and not that much change in the infiltrates, question involved in #1 and of course #3 below of significance 3. Actinomycosis grew in BAL from _%#MMDD#%_, this is a new diagnosis and not seen previously. This could be a simple colonizing organism but our actual clinical course immunocompromised status make this a quite possibly significant pathogen here.
BAL|bronchoalveolar lavage|BAL,|266|269|IMPRESSION|3. History of Mycobacterium avium-intracellulare (MAI), currently on therapy. 4. I spoke with Dr. _%#NAME#%_, who does not think a bronchoscopy is needed at this point, but if his fever and dyspnea persist, and there is no other identifiable source, he would need a BAL, at the very least. PLAN: 1. We will recheck chest x-ray in the morning to look for delayed presentation of infiltrate.
BAL|bronchoalveolar lavage|BAL|122|124|ASSESSMENT|Opportunistic infection would be unlikely without new infiltrates and with a white count still in the normal range, but a BAL would be helpful in ruling this out. Her inspired oxygen needs are far to high at this time for a transbronchial biopsy.
BAL|bronchoalveolar lavage|BAL|186|188|PLAN|PLAN: 1. Check echocardiogram. 2. Check BNPL 3. Intubate - given his metabolic acidosis and his inability to support adequate ventilation and need for bronchoscopy. 4. Bronchoscopy with BAL to rule out opportunistic infection. 5. Follow chest x-ray. 6. Follow ABGs. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 61-year-old male who is admitted on _%#MMDD2002#%_ who through the Emergency Department after he developed a fever to 101.8 at the nursing home.
BAL|bronchoalveolar lavage|BAL|203|205|HISTORY OF PRESENT ILLNESS|She also has become hypotensive. Echocardiogram shows normal left ventricular function with dilated right ventricle and moderate pulmonary hypertension (40 plus right atrial pressure). Bronchoscopy with BAL and free biopsies was done earlier today. She is now intubated with a chest tube and on pressors. Other studies of note include a negative lower extremity ultrasound and a notation on the chest CT scan suggesting low likelihood of pulmonary embolus.
BAL|bronchoalveolar lavage|BAL|238|240|IMPRESSION|Other possibility include drug-induced pneumonitis (this would be surprising after long-term use of methotrexate and Arava without significant side effects), infection and rheumatoid arthritis-related pulmonary disease. Bronchoscopy with BAL and biopsies were done today. I would consider infectious disease consult. I would stop all rheumatoid arthritis-related medications as noted above with the exception of steroids.
BAL|bronchoalveolar lavage|BAL|215|217|ASSESSMENT|Agree with high resolution CT scan; must also consider hypersensitivity reaction from his medications, pulmonary fibrosis, and bronchiolitis obliterans organizing pneumonia (BOOP). He may well need bronchoscopy and BAL and ID input.
BAL|bronchoalveolar lavage|BAL|164|166|PLAN|3. Low TSH. PLAN: 1. Ceftriaxone 1 mg IV q day. 2. Follow-up CT scan in six weeks, if infiltrates persist or she clinically deteriorates would do bronchoscopy with BAL and transbronchial biopsies. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is 36-year-old female who was admitted yesterday through the Emergency Department after several visits there for chest pain that has been radiating to the left hand, now right shoulder.
BAL|bronchoalveolar lavage|BAL|133|135|PLAN|Based on her CT scan, a bronchoscopy should be high yield for obtaining a diagnosis. PLAN: Proceed with bronchoscopy today with plan BAL bronch washing. Endobronchial biopsy, brushings, and Wang needle biopsy, all potential options, depending on intra-procedure findings.
BAL|bronchoalveolar lavage|BAL|216|218|CULTURE DATA|IgG level 494. Sputum from _%#MMDD2004#%_: Heavy growth Pseudomonas aeruginosa sensitive to ciprofloxacin and other antipseudomonals. Sputum from _%#MMDD2003#%_: Pseudomonas. Sputum from _%#MMDD2003#%_: Pseudomonas. BAL from _%#MMDD2003#%_: Pseudomonas, resistant to ciprofloxacin, and one colony of Aspergillus fumigatus. Sputum from _%#MMDD2003#%_: Pseudomonas and Stenotrophomonas. Multiple AFB cultures from _%#MM#%_ of 2003 and _%#MM#%_, 2003, were negative.
BAL|bronchoalveolar lavage|BAL|144|146|ASSESSMENT|However, with the adenopathy, the differential broadens. She could have a fungal process. If she does not improve, may need a bronchoscopy with BAL as well as a mediastinoscopy. At this time I would treat her as an exacerbation and pneumonia.
BAL|bronchoalveolar lavage|BAL|205|207|PLAN|a. Differential diagnosis includes atypical pneumonia/pneumonitis, inflammatory pneumonitis (hypersensitivity pneumonitis, sarcoidosis) vs pulmonary vasculitis. PLAN: 1) Will arrange for bronchoscopy with BAL and transbronchial biopsies. 2) Check ESR, ANA, ANCA, rheumatoid factor, hypersensitivity pneumonitis panel and atypical pneumonia screen. 3) Cover with empiric antibiotics for now. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 40-year-old male who presents to the Emergency Department today with a one-day history of myalgias, malaise and coughing up a small amount of bright red blood; this started early this morning.
BAL|bronchoalveolar lavage|BAL|296|298|PLAN|She had progressive respiratory problems and infiltrates on Tequin, now in imipenem, question opportunistic infection versus leukemia itself versus conventional pneumonia versus noninfectious causes. 2. Diabetes mellitus. 3. Hypertension. PLAN: 1. Agree with imipenem for now and watch. 2. Await BAL specimens and adjust. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 59-year-old female who is seen in consultation from Dr. _%#NAME#%_, et al, due to possible pneumonia.
BAL|bronchoalveolar lavage|BAL|239|241|REFERRING PHYSICIAN|The patient has underlying history of COPD and had a chronic persistent pneumonia for at least 3 1/2 months. This patient states that it never cleared despite course of antibiotics and hospitalization. He evidently had a bronchoscopy with BAL last week with Dr. _%#NAME#%_, which was non- diagnostic. AFB stains are negative. Cultures are pending. Fungal stains were negative. Penicillium species grew. Normal flora grew.
BAL|bronchoalveolar lavage|BAL|238|240|PLAN|PLAN: 1. Check rheumatoid factor. 2. Continue Tequin for ten days total. 3. Followup CT scan in six weeks. If no better consider bronchoscopy with transbronchial biopsies versus VATS depending on how the infiltrates appear, or possibly a BAL if she clinically deteriorates between now and six weeks. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 40-year-old female who was admitted yesterday through the Emergency Department with approximately one week of dyspnea, cough, low-grade fever to 100.5. The patient's dyspnea is worse than her baseline.
BAL|bronchoalveolar lavage|BAL|326|328|ASSESSMENT|ABDOMEN: Negative. EXTREMITIES: Negative. LABORATORY DATA: INR was 1.42 today, white count yesterday was 8.9, hemoglobin 10.5, albumin 2.7. ASSESSMENT: This patient has a multisystem illness and has a right posterior infiltrate with possible cavity. Given the pernicity of this, it is appropriate to do bronchoscopy, consider BAL and biopsies looking for granulomatous processes as well as infectious granulomatous processes, AFB as well as fungi. The patient is agreeable to the bronchoscopy, the risks and manner of the tests were explained to the patient and it was arranged for tomorrow.
BAL|bronchoalveolar lavage|BAL|154|156|PLAN|2. Agree withholding steroids for now until diagnosis is obtained. 3. I will review this with Dr. _%#NAME#%_ for possible intraoperative bronchoscopy and BAL of the right upper lobe. 4. Will check complete pulmonary function tests. She informs me that they were normal in _%#MM#%_ at her allergist's office.
BAL|bronchoalveolar lavage|BAL,|126|129|PLAN|PLAN: 1. Continue current antibiotics. 2. Check sputum culture. 3. Since he is feeling better we should hold on bronchoscopy, BAL, transbronchial biopsies unless fevers persist. 4. Needs follow-up CT scan six to eight weeks (regardless of whether he gets a bronchoscopy this admission), if it is unchanged he will need a bronchoscopy with BAL, transbronchial biopsies vs CT guided fine needle aspiration depending on its appearance.
BAL|bronchoalveolar lavage|BAL|236|238|PLAN/RECOMMENDATIONS|4. Question for afterload reduction might be beneficial. 5. Possible right heart catheterization may be helpful to measure cardiac output, SVR, pulmonary capillary wedge pressure, as well as PVR. 6. Bronchoscopy - to evaluate airway, a BAL of the right to rule out an infection given her interstitial process, transcarinal biopsy of the subcarinal lymph nodes to evaluate the etiology.
BAL|bronchoalveolar lavage|BAL|159|161|HISTORY OF PRESENT ILLNESS|She has developed bilateral pulmonary infiltrates on CT scan, and these have persisted despite antibacterial, antifungal, and antiviral therapy. Bronchoscopy, BAL endobronchial biopsy has not been conclusive in terms of narrowing down the etiology of her infiltrates. PAST MEDICAL HISTORY: 1. Juvenile rheumatoid arthritis. 2. B-cell deficiency.
BAL|bronchoalveolar lavage|BAL|153|155|IMPRESSION|I would defer further workup to the pulmonary hypertension specialist that he is seeing at the University of Minnesota. Consideration of a bronchoscopy, BAL and biopsy could be given to further evaluate his parenchyma process. A right heart cath should be considered to more accurately assess his pulmonary artery pressures and as a prelude to a trial of agents for pulmonary hypertension such as Tracleer, Viagra or Flolan.
BAL|bronchoalveolar lavage|BAL.|276|279|ASSESSMENT|No edema, peripheral pulses intact. ASSESSMENT: This patient is an unfortunate patient with a pulmonary process including possible recurrence of Ewing's sarcoma, pneumonia, acute lung injury with cardiomyopathy, hypoxia and pancytopenia. I am asked in regards to performing a BAL. Patient, in my estimation, is high risk for acute respiratory failure, could not be sedated for this, and also high risk because of the coexistent co-morbidities.
BAL|bronchoalveolar lavage|BAL|223|225|ASSESSMENT|I am asked in regards to performing a BAL. Patient, in my estimation, is high risk for acute respiratory failure, could not be sedated for this, and also high risk because of the coexistent co-morbidities. I would not do a BAL at this point. The patient, however, also likely will need intubation in the next 24-48 hours. If he becomes intubated and placed on a ventilator, I would at that time consider BAL.
BAL|bronchoalveolar lavage|BAL.|198|201|ASSESSMENT|I would not do a BAL at this point. The patient, however, also likely will need intubation in the next 24-48 hours. If he becomes intubated and placed on a ventilator, I would at that time consider BAL. He will need coexistent platelet therapy and it still has some significant risk. I discussed this at length with the family and nurses.
BAL|bronchoalveolar lavage|BAL,|240|243|PLAN|Will add atypical coverage with Zithromax now that Levaquin has been discontinued. Await cultures and adjust. Check fungal serology panel. If no positive cultures and ongoing fever, would have a low threshold here to proceed all the way to BAL, biopsy of the right abdomen skin lesion and even bone marrow early on to look for invasive fungal disease. HISTORY: This 53-year-old male is seen in consultation from the hospitalist service and Dr. _%#NAME#%_ due to new acute afebrile illness.
BAL|bronchoalveolar lavage|BAL,|240|243|PLAN|Will add atypical coverage with Zithromax now that Levaquin has been discontinued. Await cultures and adjust. Check fungal serology panel. If no positive cultures and ongoing fever, would have a low threshold here to proceed all the way to BAL, biopsy of the right abdomen skin lesion and even bone marrow early on to look for invasive fungal disease. HISTORY: This 53-year-old male is seen in consultation from the hospitalist service and Dr. _%#NAME#%_ due to new acute afebrile illness.
BAL|blood alcohol level|BAL|196|198|HISTORY|Longest sobriety 110 days. Relapse on marijuana _%#MM#%_ of 2001; 1-2 bowls every 3 days. Once weekly alcohol as above. Four mixed drinks and 2 beers prior to admission. Alleged suicidal threats. BAL of 0.158. Denies history of alcohol- related liver disease, withdrawal, DT, pancreatitis, or upper GI bleeding. Denies other chemical use. Denies specific act of self-harm. Clinical concern regarding burn to the volar aspect of the right wrist sustained 4-5 days ago when area came in contact with steam from a teakettle.
BAL|bronchoalveolar lavage|BAL;|224|227|PLAN|PLAN: 1) Check sputum for fungus. 2) Broaden coverage with piperacillin and tazobactam to cover for potential Pseudomonas. 3) If no clinical improvement and his platelet count could be improved he might be a candidate for a BAL; however, given his low platelet count this is contraindicated. 4) Continue nebulization therapy. 5) No indication for steroids, and will try to avoid this right now given that I think most of his acute pulmonary disease is more due to his pneumonia rather than chronic obstructive pulmonary disease.
BAL|bronchoalveolar lavage|BAL|238|240|ASSESSMENT|No real crackles or wheezes. ASSESSMENT: This patient has chronic lymphocytic leukemia with chronic fever. We will await chest x-ray which has not been done. We were asked in regards to possibility of bronchoscopy. Bronchoscopy including BAL is problematical with his significant thrombocytopenia. We will review his chest x-ray. He may need a CT if there is any questions prior to making a decision regarding bronchoscopy.
BAL|bronchoalveolar lavage|BAL|226|228|ASSESSMENT|My plan had been to do bronchoscopy after his transfusion, however, his respiratory status does not warrant that. Likely he will need intubation and we will proceed from that point. I am suspecting attempt at bronchoscopy for BAL tomorrow morning.
BAL|bronchoalveolar lavage|BAL|181|183|RECOMMENDATIONS|3. Check fungal serologies. 4. He is currently on a combination of clindamycin plus azithromycin, which should be continued for now. 5. Probably he would benefit from bronchoscopy, BAL and/or biopsy. 6. We could screen for connective tissue diseases or pulmonary renal syndromes, although it will be difficult to interpret his urine sediment since he has a bladder tumor.
BAL|bronchoalveolar lavage|BAL|198|200|REFERRING PHYSICIAN|The patient was found to have a pulmonary hemorrhage on _%#MMDD#%_ via bronchoscopy. The patient was placed on an oscillator the next day secondary to poor oxygenation, and nitrous oxide was added. BAL cultures from _%#MMDD#%_ grew a vancomycin resistant enterococcus faecium and a positive acid fast bacilli bacteria yet not identified. The patient was started on Synercid. Today, the patient has been changed from the oscillator to the conventional ventilator.
BAL|blood alcohol level|BAL.|125|128|LABORATORY DATA|No rigidity. LABORATORY DATA: Available. TSH from this morning of 5.49 with GGT of 105. U tox pending. Cannot find record of BAL. ASSESSMENT: The patient is a 40-year-old male admitted with the following: 1. Behavioral disturbance as described.
BAL|bronchoalveolar lavage|BAL|238|240|IMPRESSION|2. Pulmonary infiltrates, mild chronic/subacute symptoms in retrospect, is a compromised host due to chronic steroids, chest x-ray and CT pattern are consistent with aspergillosis although conceivably other involved organisms as well. On BAL has aspergillosis present. 3. Methicillin resistant Staph aureus colonization is in the sputum but doubt MRSA per se' causing acute pneumonia here.
BAL|blood alcohol level|BAL.|146|149|HISTORY|History of self- injurious behavior as a teenager. Overnight hospitalization at St. Joseph's on _%#MMDD2003#%_ subsequent to alcohol excess, 0.17 BAL. Resumption of self-injurious behavior manifested by self-induced cutting with broken glass to the upper extremities bilaterally. Continued self-cutting to the upper extremities and feet subsequent to discharge.
BAL|bronchoalveolar lavage|BAL|214|216|ASSESSMENT|2. Differential diagnosis includes infectious: fungal, atypical, Actinomyces, nocardia; inflammatory: Wagener's granulomatosis; malignancy. 3. Discussed options with the patient. They include: a. Bronchoscopy with BAL and possible transbronchial biopsies to rule out an infection. Infiltrates are somewhat too focal for getting an exact biopsy sample, although it would be worth an attempt.
BAL|bronchoalveolar lavage|BAL|174|176|IMPRESSION|Follow closely. Continue his anticoagulation, not start Coumadin at this time. Depending on his progress, if he improves, he would not need further therapy but he may need a BAL in 72 hours which would be Monday, or biopsy including VAT biopsy which I outlined to the patient and family. This is a judgment decision at this time and we will be available on the weekend to reconsider the workup.
BAL|bronchoalveolar lavage|BAL|148|150|IMPRESSION|I would also get sputum for PCP, AFB and fungi, and cover him with Septra. If he would deteriorate and require mechanical ventilation, I would do a BAL at that juncture as well. He does have borderline ejection fraction and will be getting ginger fluid replacement but this could be an operative problem as well.
BAL|bronchoalveolar lavage|BAL|119|121|LABORATORY|LABORATORY: There are no pertinent new laboratory findings. In the last 24 hours, the aspergillus fumigatus was from a BAL wash on _%#MM#%_ _%#DD#%_, 2005. The bronchial brushing on the same day has no growth to date. Blood cultures on _%#MM#%_ _%#DD#%_, 2005, have no growth to date.
BAL|bronchoalveolar lavage|BAL|116|118|PLAN|b. Chronic nonproductive cough that has abated with antibiotic therapy. PLAN: 1. We will proceed with bronchoscopy, BAL and transbronchial biopsies to obtain a diagnosis. 2. If no diagnosis is obtained, then we will need to do a CT guided biopsy of the right upper lobe mass.
BAL|bronchoalveolar lavage|BAL|146|148|ASSESSMENT|Past chemotherapy with some cytopenia, pulmonary infiltrates. We will monitor for worsening and if he does not improve may need bronchoscopy with BAL for increased respiratory support. Currently is on low flow oxygen with an SAO2 of 97%. We will follow his chest x- ray and his course.
BAL|blood alcohol level|BAL|232|234|ASSESSMENT|Urine pregnancy test was negative. ASSESSMENT: The patient is a 27-year-old female admitted with the following: 1. Depression/anxiety with record indication of a home suicidal ideation in the setting of alcohol excess/intoxication. BAL of 0.217. Deferred to Psychiatry. 2. Alcohol dependency with unsuccessful sobriety: a. No overt signs of alcohol withdrawal presently. b. Normal liver function.
BAL|bronchoalveolar lavage|BAL|111|113|PLAN|I would recommend full dose treatment with voriconazole for presumed fungal infection. PLAN: Bronchoscopy with BAL today.
BAL|bronchoalveolar lavage|BAL|169|171|A/P|1. Ground glass appearence on CT. Ddx includes infection (viral, atypical bacterial, fungal), BOOP. Doubt CHF since echo shows normal EF. We recommend bronchoscopy with BAL to further evaluate. Patient agrees. Repeat INR stat prior to procedure. If INR >1.5, then transfuse FFP. 2. Productive cough. Likely secondary to #1. 3. Hx of pulmonary HTN secondary to HPS.
BAL|bronchoalveolar lavage|BAL|284|286|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 71-year-old admitted _%#MMDD2004#%_ with fever, cough and a chest x-ray showing bilateral predominantly lower lobe infiltrates. He remains febrile up to 102. He underwent a bronchoscopy on _%#MMDD2004#%_, but hypoxia persists. A BAL was performed. He has been treated with Zithromax and Rocephin. Today he feels okay without chest pain or pleurisy. He is dyspneic both at rest or with exertion.
BAL|bronchoalveolar lavage|BAL|136|138|PLANS|2) Continue the Rocephin for now; has already completed a course of Zithromax, but this does not appear to be the answer to this. Await BAL results. Should either get answer, at least pertinent negative information here. None of the smears, PCP prep, etc. are back, were done late yesterday.
BAL|bronchoalveolar lavage|BAL|112|114|PLANS|Does not appear to be deteriorating, and we should be able to get an answer here. If no answer forthcoming from BAL results, continued fever despite antibiotics, even if empirically changed, probably need to do lung biopsy here. HISTORY: This 71-year-old male is known to me from prior admissions; I am now seeing him in consultation from Drs. _%#NAME#%_, _%#NAME#%_ and _%#NAME#%_ due to pneumonia and continued fever.
BAL|bronchoalveolar lavage|BAL.|295|298|PLANS|4) Prior Port-A-Cath infection with current Port-A-Cath functioning well. PLANS: 1) Continue imipenem; add Biaxin for atypicals (intolerant of both Zithromax and Levaquin previously and recently). 2) Await cultures; check Legionella antigen in the urine. 3) If no response in short order, needs BAL. HISTORY: This 37-year-old female is seen in consultation from Dr. _%#NAME#%_ due to acute pneumonia.
BAL|bronchoalveolar lavage|BAL|185|187|PLAN|Most patient's on Amiodarone do have some lamellar body inclusions related to this drug so there can be some changes that may suggest this is inflammatory disorder related to a drug on BAL alone. I have asked Cardiology to address urgency of her catheterization and the need for her Amiodarone. I would like to see a CT scan of the chest without contrast, given her renal insufficiency.
BAL|bronchoalveolar lavage|BAL,|205|208|PLAN|Left kidney and adrenal consistent with renal cell carcinoma and dated _%#MMDD2005#%_. PLAN: 1. Check ANA. 2. Induce sputum for gram stain and culture, as well as fungus. (Rule out ABPA). 3. Bronchoscopy, BAL, and even transbronchial biopsies. I do not think would provide the adequate information and tissue needed for some of the diagnoses of concern.
BAL|bronchoalveolar lavage|BAL.|236|239|IMPRESSION AND PLAN|At this time, he is currently quite unstable with respiratory failure and intubated and so raising the question of a possible opportunistic infection given his immunocompromised states. He did undergo a bronchoscopy this morning with a BAL. Currently, he is on aggressive treatment for opportunistic infections. I agree with the above and ruling out an acute infection while working up his acute leukemia.
BAL|bronchoalveolar lavage|BAL|280|282|RECOMMENDATIONS|I have discussed this regimen with Infections Disease. We will continue imipenem and initiate isoconazole to cover blastohistoplasmosis (bat droppings) and also doxycycline to cover for atypical organism. I will complete bronchoscopy today to rule out an opportunistic infection. BAL only will be completed. He will be seen by Hematology/Oncology for management of his acute myelogenous leukemia. I will also ask the assistance of the Renal Service for ongoing critical care management and fluid management in the setting of anticipating the patient on chemotherapy.
BAL|bronchoalveolar lavage|BAL|167|169|ASSESSMENT/PLAN|ASSESSMENT/PLAN: This patient appears to possibly have an opportunistic pneumonia or atypical pneumonia. The elevated LDH is suspicious. We will do a bronchoscopy for BAL this afternoon. We discussed the manner of the test and the risks with the procedure. The patient is very anxious, and asked me many questions about pneumonia and dying from pneumonia.
BAL|bronchoalveolar lavage|BAL|188|190|ASSESSMENT|REFERRING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD REASON FOR CONSULTATION: Pneumonia. ASSESSMENT: 1. Pneumonia, recurrent versus steroid-responsive inflammatory process. a. Bronchoscopy with BAL and transbronchial biopsies, performed on _%#MMDD2003#%_, showing no evidence of bacterial, viral, AFB or fungus. Essentially nondiagnostic. b. Question of BOOP or inflammatory process, although ESR previously was 36.
BAL|bronchoalveolar lavage|BAL|178|180|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 77-year-old female who is followed by Dr. _%#NAME#%_ _%#NAME#%_ for recurrent pneumonia. She underwent a bronchoscopy with BAL and transbronchial biopsies on _%#MMDD2003#%_ which only grew out candida. PCP was negative. Aspergillus, fungus and AFB were all negative.
BAL|bronchoalveolar lavage|BAL|327|329|RECOMMENDATIONS|This is most likely an anaerobic infection from his recent dental work and would be inclined if his AFB stains are negative x 3 to merely repeat a CT scan in 6-12 weeks to follow resolution of these lesions and wait for his AFB cultures to return. If infectious disease feels it is necessary to start anti-TB medications but a BAL smear negative AFB stain would deter them from this therapy, we would then do bronchoscopy at that point.
BAL|bronchoalveolar lavage|BAL|149|151|PLAN|4. Prior scalp wound infection who looks okay at present. 5. Diarrhea controlled, previous C-Difficile PLAN: Agree with holding on antibiotics until BAL results back or if the patient becomes ill and spikes, will start Tequin and Septra empirically HISTORY: This 22-year-old male is well known to me, see my note from _%#MM#%_ _%#DD#%_, 2003 for details of his ongoing history.
BAL|blood alcohol level|BAL|111|113|LABORATORY DATA|LABORATORY DATA: GGT was okay at 53. TSH reflux is okay at 3.31. The UA tox was positive for alcohol. He had a BAL of 0.29. Sodium was elevated at 145. RDW was 15.3. The rest of the CBC and CMP was okay. ASSESSMENT/PLAN: 1. Alcohol dependence and anxiety per Dr. _%#NAME#%_.
BAL|bronchoalveolar lavage|BAL|168|170|HISTORY OF PRESENT ILLNESS|He has not needed any pressor support. In fact, he is slightly hypertensive. The patient also has an ongoing treatment course for a past Candida infection found from a BAL culture on _%#MM#%_ _%#DD#%_. He has been on Abelcet from _%#MM#%_ _%#DD#%_. REVIEW OF SYSTEMS: CONSTITUTIONAL: Febrile. RESPIRATORY: Oxygen need. CARDIOVASCULAR: Stable. Blood pressures sometimes hypertensive. GASTROINTESTINAL: He had positive blood and blood clots in his stool on _%#MM#%_ _%#DD#%_ and _%#DD#%_.
BAL|bronchoalveolar lavage|BAL|214|216|RECOMMENDATIONS|2. Ceftriaxone 1 gram q.24h. plus oral azithromycin. Would continue azithromycin for 3 more days 250 mg p.o. q. day, to give her a total course of 5 days. 3. Follow-up cultures, temp and cough. 4. Consider PCP and BAL if she is not improving. Thank you for involving me in her care.
BAL|bronchoalveolar lavage|BAL,|124|127|LABORATORY DATA|She is widowed for 5 years. She is retired and lives in a town home on her own. LABORATORY DATA: White blood count is 10.6. BAL, Candida albicans and MRSA moderate. Blood cultures on 1/18, Staphylococcus warneri and Stenotrophomonas maltophilia. One set from blood culture of _%#MMDD#%_ is negative.
BAL|bronchoalveolar lavage|BAL|198|200|HISTORY|This is unchanged from a chest x-ray on _%#MMDD2007#%_. A follow-up chest x-ray showed left lower lobe atelectasis and she was suspected of having mucous plugging so Dr. _%#NAME#%_ _%#NAME#%_ did a BAL on _%#MMDD2007#%_ with copious thick mucopurulent secretions and extensive mucous plugging in left greater than right with normal underlying bronchial airways and no endobronchial lesions.
BAL|bronchoalveolar lavage|BAL|164|166|LABORATORY DATA|No stigmata of endocarditis. Frail. ABDOMEN: Soft, nontender. EXTREMITIES: Rheumatoid changes in hands. No edema. No rash. LABORATORY DATA: White blood count 17.7. BAL Candida albicans and filamentous fungus. AFB negative. Silver strain compatible with Aspergillus. Liver tests normal. Creatinine 1.3. CT chest: No fibrosis or CHF. A single linear scar in the left lower lobe.
BAL|bronchoalveolar lavage|BAL.|211|214|IMPRESSION|Blood cultures from _%#MMDD2007#%_, 1 of 2 Staph species. Chest x-ray _%#MMDD2007#%_ clear. IMPRESSION: 1. Candida in sputum not compatible with pathogen and more compatible with colonization. 2. Aspergillus in BAL. Her CT scan does not show pneumonia nor does her history suggestive of pneumonia upon admission, though there is some history of recent pneumonia and chronic cough for several years.
BAL|bronchoalveolar lavage|BAL|180|182|IMPRESSION|She has a right-sided infiltrate, on antibiotics and appears to be stable. She has sufficient neutrophils for her infection. We will be available for following her chest x-ray and BAL if she so needs.
BAL|bronchoalveolar lavage|BAL|153|155|PLAN|3. Chronic indolent knee infection. 4. Probable obstructive sleep apnea - snores, fatigued, witnessed apnea. PLAN: 1. Will proceed with bronchoscopy and BAL to rule out endobronchial lesions as well as any underlying infection. 2. He may eventually be a candidate for a formal polysomnogram after his cardiac evaluation.
BAL|bronchoalveolar lavage|BAL|223|225|PLAN|I agree with Cardiology consultation. 2. I agree with diuresis. 3. Follow chest x-ray (if no improvement over next 72 hours she might need more investigation which would include CT scan of chest, possible bronchoscopy with BAL if she is intubated, or even a lung biopsy depending on how she proceeds clinically). 4. BiPAP as is. 5. Follow ABG. If PCO2 rises or we cannot maintain her O2, then she will need intubation.
BAL|bronchoalveolar lavage|BAL|221|223|IMPRESSION|PELVIC AND RECTAL: Not performed. LOWER EXTREMITIES: No clubbing, cyanosis or edema, pedal pulses palpable. IMPRESSION: 1) Respiratory failure with bilateral infiltrates, status post bronchoscopy. We will await return of BAL cultures. 2) Episode of congestive heart failure with demand ischemia and small subendocardial myocardial infarction. She is diuresing well on Lasix. She has an ejection fraction of 40%.
BAL|bronchoalveolar lavage|BAL|259|261|MICROBIOLOGY|LABORATORY DATA: His white blood cell count is 2.8. His hemoglobin is 10.9, his platelets are 259 and his creatinine is 1.2. MICROBIOLOGY: Blood cultures times two drawn today are pending. Sputum culture was collected, but inadequate specimen. On _%#MMDD#%_, BAL of left lower lobe grew moderate actinomyces odontolyticus and moderate Candida albicans. IMPRESSION: Mr. _%#NAME#%_ is a 67-year-old man with a history of chronic lymphocytic leukemia and conversion to B. cell lymphoma, status post chemotherapy last being five weeks ago.
BAL|blood alcohol level|BAL|182|184|AVAILABLE LABORATORY DATA|AVAILABLE LABORATORY DATA: Elevated GGT 95 with TSH 2.60. The remaining labs, including CBC, comprehensive metabolic panel, troponin from the emergency department will be retrieved. BAL of 0.4. ASSESSMENT: This is a 39-year-old Hispanic male admitted with the following: 1. Depression/anxiety with alleged suicidal ideation.
BAL|bronchoalveolar lavage|BAL|345|347|PHYSICAL EXAMINATION|The fact that there is still CMV despite treatment with foscarnet with induction is of concern also. It would be our recommendation at this time that with the consolidated left lower lobe and now with their being an apparent pericardial effusion seen on the CT scan in the proximity of the left lower lobe, that diagnostic steps might include a BAL of the left lower lobe, to see if yeast can be seen. We would very strongly recommend echocardiography at this time. If there is fluid there, since it is in the proximity of the consolidated lobe, one would need to consider whether or not a diagnostic tap would be helpful, because the treatment of pericarditis involves both antimicrobial drugs, as well as drainage.
BAL|bronchoalveolar lavage|BAL|322|324|PHYSICAL EXAMINATION|We would very strongly recommend echocardiography at this time. If there is fluid there, since it is in the proximity of the consolidated lobe, one would need to consider whether or not a diagnostic tap would be helpful, because the treatment of pericarditis involves both antimicrobial drugs, as well as drainage. If the BAL of the left lower lobe is not diagnostic, then careful consideration should be, we think, given to an attempt at direct tissue biopsy of an affected part of the lung.
BAL|bronchoalveolar lavage|BAL|126|128|HOSPITAL COURSE|She was also checked for viruses such as RSV, CMV. She was diagnosed with LLL pneumonia. A bronchoscopy was performed and her BAL grew back Pseudomonas, which was sensitive to imipenem. The patient was extubated on _%#MMDD2007#%_ and was transferred to the floor on the _%#DD#%_.
BAL|bronchoalveolar lavage|BAL|418|420|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 74-year- old male who has been hospitalized here at Fairview Southdale Hospital on multiple occasions including _%#MM#%_ _%#DD#%_, 2004, _%#MM#%_ _%#DD#%_ of 2005, _%#MM#%_ _%#DD#%_ of 2005 and most recently _%#MM#%_ _%#DD#%_, 2005. We initially saw him in consultation on _%#MM#%_ _%#DD#%_, 2005 for his progressive infiltrates. He underwent a bronchoscopy with BAL and transbronchial biopsies, which was done on _%#MM#%_ _%#DD#%_, 2005. The bronchoscopy grew MRSA while the transbronchial biopsies showed some fibrosis with chronic inflammation.
BAL|blood alcohol level|BAL|126|128|HISTORY OF PRESENT ILLNESS|This is an Internal Medicine consultation for Dr. _%#NAME#%_. The patient ran out of alcohol and drank 2 liters of Listerine. BAL in the emergency room was 0.06. The patient's withdrawal symptoms consist of diaphoresis, tachycardia, tremors. Additionally, the patient states he has left lower quadrant pain.
BAL|bronchoalveolar lavage|BAL.|194|197|ASSESSMENT AND PLAN|Complicating her course has been a retroperitoneal hematoma, possibly in association with GJ-tube placement. She has had ascites and MRSA has also grown from that fluid in addition to urine and BAL. Palliative medicine team was asked to participate in the scheduled family care conference this afternoon at which time her status will be presented to the family with the very limited options available.
BAL|bronchoalveolar lavage|BAL.|207|210|PAST MEDICAL HISTORY|He is a somewhat difficult historian. There is a question of head trauma from a motor vehicle accident in the past. PAST MEDICAL HISTORY: 1. Recent history of loculated left lower lobe pneumonia status post BAL. Apparently, he has had problems with aspiration in the past. 2. Status post C-spine surgery. 3. Peripheral vascular disease.
BAL|bronchoalveolar lavage|BAL|222|224|ASSESSMENT|Would do an ANCA, FANA, atypical pneumonia lung screen, hypersensitive pneumonia screen and Ace urine for legionella antigen and PPD. Will follow, ultimately if the patient does not improve, he may need a bronchoscopy for BAL or VATS.
BAL|bronchoalveolar lavage|BAL|171|173|IMPRESSIONS|This may be a significant pathogen or just colonizing, would doubt it as the cause of the ongoing process for several weeks.1. 2. Aspergillus apparent colonization in the BAL specimens. Significance of this is unclear. It does not fit particularly well for the several week long problems either. 2. C3. hronic obstructive lung disease. 3. C4. ongestive heart failure.
BAL|bronchoalveolar lavage|BAL|307|309|PLANS|1. If 2. bronch studies otherwise are nonrevealing and she is improving, would simply treat with a longer course of antibiotics, but Zyvox a reasonable oral option, although vancomycin every three days or so due to her renal failure would also be relatively convenient to treat as an outpatient. Await full BAL information to decide on treatment. For now would not treat the Aspergillus, but will have to reconsider that if the clinical picture suggests this is significant.
BAL|bronchoalveolar lavage|BAL|192|194|HISTORY|At transfer, she was switched from antibiotics to vancomycin, Rocephin and clindamycin and feels somewhat better at present. No obvious exposures. Had negative PPDs in the past. She has had a BAL done now, which preliminary results are showing some type of yeast form consistent with Aspergillus. It also is growing methicillin-resistant Staph aureus. She does have a bird and a cat she has been around, but no other definite animal exposures.
BAL|bronchoalveolar lavage|BAL|247|249|ASSESSMENT AND RECOMMENDATIONS|In essence, he functions as a pneumonectomy on the right and therefore cannot undergo transbronchial biopsy of the left lung, as a pneumothorax on the left could be fatal. The patient is at moderate to high risk for bronchoscopy complication with BAL since he functionally does not have a right lung. This was discussed with the patient and his oncologist, Dr. _%#NAME#%_, and they prefer to be aggressive in diagnosing this.
BAL|bronchoalveolar lavage|BAL|257|259|IMPRESSION|IMPRESSION: 1. The patient is a 74-year-old woman here since _%#MMDD#%_ for management of right rib fracture pain after a fall at home. 2. She has abnormal chest x-ray that antedates this hospitalization, and which showed pulmonary infiltrates and nodules. BAL was done on _%#MMDD2004#%_ and culture now shows Mycobacterium avium intracellulare sensitive to clarithromycin, ??..........butin and ciprofloxacin.
BAL|bronchoalveolar lavage|BAL|252|254|SUMMARY OF CASE|SUMMARY OF CASE: The patient is a 74-year-old woman admitted here with right rib pain after she had fallen at home, and sustained rib fracture. She had been hospitalized here last month with what appeared to be a bilateral pneumonia process, and under BAL which yielded results, as noted above. There was not abnormal cytopathology on that particular study. During this hospitalization it is noted she had hypercalcemia with a level of 12.2. The patient has had some evaluation which included renal function studies which revealed renal insufficiency with BUN 63, creatinine 2.99. Renal function improved to some extent with reduction in her BUN and creatinine to 32 and 1.42 over a period of about 48 hours with rehydration.
BAL|bronchoalveolar lavage|BAL,|197|200|RECOMMENDATIONS|RECOMMENDATIONS: 1. The patient currently is on vancomycin, azithromycin and Zosyn which should be continued for now. 2. Follow up outstanding culture and serologic data. 3. Consider bronchoscopy, BAL, thoracentesis, depending upon her progress. 4. She will need continued ICU support, and we note that there are plans to transfer her to the University of Minnesota campus later today.
BAL|bronchoalveolar lavage|BAL|166|168|ASSESSMENT|We are going to be collecting sputum for atypical infections. She is too hypoxemic for a bronchoscopy to be safe, but if she were intubated, then I would recommend a BAL for diagnostic purposes. Her prognosis is guarded. I am going to ask Oncology to follow with us as they know her well, and I discussed her case with Dr. _%#NAME#%_ this afternoon.
BAL|bronchoalveolar lavage|BAL.|225|228|IMPRESSION|Question whether this all represents inflammatory lung disease or evolving adult respiratory distress syndrome (ARDS) or whether there may be some element of infection involved as well. She did have hyphae seen on smear from BAL. RECOMMENDATIONS: 1) I agree with adding fluconazole to cover the Candida albicans.
BAL|bronchoalveolar lavage|BAL|190|192|PLAN|b. Differential diagnosis includes: Fungal disease. He did grow up in northern Wisconsin. Also sarcoidosis is part of the differential. PLAN: 1. We will proceed with bronchoscopy, bilateral BAL and right transbronchial biopsies. 2. If the findings are consistent with sarcoidosis, given he has no symptoms, we would just observe. 3. If the biopsies are non-diagnostic, the patient thinks he would like to do a follow-up CAT scan in three months.
BAL|bronchoalveolar lavage|BAL|317|319|PHYSICAL EXAMINATION|No _________. EYES: Conjunctiva unremarkable. LABORATORY DATA: CT scan and chest x-ray with interstitial infiltrates. Creatinine 2.2, up from 1.8, CSA level 270. CT scan also bilateral pleural effusions, emphysematous changes, tiny calcified granuloma, mild increase in mediastinal adenopathy, less or equal to 2 cm, BAL RSV negative, influenza A & B negative, ______________ cell count, alkaline phosphatase 164, ALT 25, BNP 1,010. Echo - increased left atrium and right atrium, mild LVE, and increased right ventricle size, function otherwise normal.
BAL|bronchoalveolar lavage|BAL|200|202|IMPRESSION|A steroid trial or VAT biopsy are likely necessary. I did review his medication list and none of them strike me as sources of drug reaction, but this should be re-reviewed by Pulmonary. I suspect his BAL will be negative. RECOMMENDATIONS: 1. Follow-up BAL. 2. Consider steroids and/or VAT biopsy. 3. Re-review medications.
BAL|bronchoalveolar lavage|BAL|158|160|RECOMMENDATIONS|4. Obtain University of Minnesota records from his admission three post- weeks transplant. 5. Reassess need for ceftriaxone or azithromycin. We will wait for BAL culture data first. Thank you for involving me in his care.
BAL|blood alcohol level|BAL|154|156|LABORATORY DATA|Reflexes: 1+ in the upper extremities. Lower extremities deferred. LABORATORY DATA: Glucose 148. A urine tox screen was positive for cocaine and alcohol. BAL 0.29. Otherwise, the CBC and comprehensive metabolic panel were normal. ASSESSMENT: 1. Polysubstance dependence. 2. Emesis. 3. Chest wall pain secondary to trauma, most likely.
BAL|blood alcohol level|BAL|194|196|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: 38-year-old male with history of alcohol dependence admitted to Adult Chemical Dependency Unit from the Intensive Care Unit where he was hospitalized overnight for a BAL of 0.44. We were asked by the admitting psychiatrist, Dr. _%#NAME#%_ _%#NAME#%_, to see the patient for a general medical evaluation.
BAL|blood alcohol level|BAL|131|133|LABORATORY DATA|No lateralizing extremity weakness. Romberg negative. Cerebellar function intact. There is no tremor or rigidity. LABORATORY DATA: BAL 0.44, magnesium 2.1, phosphorous 3.6, normal liver function. Sodium 143, potassium 3.5, chloride 103, CO2 23, BUN 11, creatinine 0.8, glucose 103, white count 6100, hemoglobin 14 grams percent with platelet count of 353,000.
BAL|bronchoalveolar lavage|BAL|304|306|IMPRESSION AND PLAN|IMPRESSION AND PLAN: Pneumothorax, which has increased over the past couple of days with an interstitial abnormality seen on chest CT with differential diagnoses that includes respiratory bronchiolitis versus desquamative interstitial pneumonitis associated with smoking. Will proceed with bronchoscopy, BAL and probable biopsies in the morning, obtain consent with the interpreter present. Will follow up on a chest x-ray after bronchoscopy. If the pneumothorax is stable and not worsening he can probably be discharged after the procedure; if pneumothorax worsens he will need chest tube.
BAL|bronchoalveolar lavage|BAL|230|232|ASSESSMENT|No accessory muscle use. CARDIOVASCULAR: Normal S1 and S2, no murmur, S3 or S4, no clubbing, cyanosis or edema or bruising. ASSESSMENT: I agree with the oncologist and internist that the patient has infiltrates. Bronchoscopy with BAL is the most effective way of dealing with this, since she has thrombocytopenia, 25,000 platelets. We are going to give her platelets prior to the bronchoscopy and do a ginger bronchoalveolar lavage for cultures and no biopsies.
BAL|bronchoalveolar lavage|BAL|182|184|PLAN|Doubt opportunistic infection, possibly leukemia as the entire cause of this. PLAN: 1. Continue the Imipenem that has been started, await cultures and adjust accordingly. Await full BAL results. 2. No other work-up unless further problems. HISTORY: This 71-year-old female is seen in consultation by Dr. _%#NAME#%_ and Dr. _%#NAME#%_ due to fever.
BAL|bronchoalveolar lavage|BAL|187|189|RECOMMENDATIONS|Would continue with atypical coverage with azithromycin and antifungal therapy; fluconazole and TNP sulfa for empiric PCP coverage. I feel that patient is too ill at present to withstand BAL unfortunately but we will perform this on Monday, _%#MMDD2004#%_ to rule out the above. The PCP can still be seen up to 48 hours on empiric therapy.
BAL|bronchoalveolar lavage|BAL,|167|170|PLANS|directly related to this infectious process. 6) CNS changes, question infectious but cerebrospinal fluid process is unimpressive. PLANS: 1) Tequin and Sepra. 2) Needs BAL, Dr. _%#NAME#%_ aware. 3) Check sputum and gastric aspirates for AFB. 4) Isolation. 5) Start tuberculosis medications currently while waiting for studies. HISTORY: This 52-year-old male is seen in consultation from Dr. _%#NAME#%_ due to an acute febrile illness.
BAL|bronchoalveolar lavage|BAL|159|161|PLAN|d. This is consistent with a small vessel vasculitis including Wagener's granulomatosis, microscopic polyangiitis. PLAN: 1. Will proceed with bronchoscopy and BAL to evaluate for hemorrhage and infection. 2. High dose Solu-Medrol 250 mg IV q6h. 3. I will review this with Dr. _%#NAME#%_ and rheumatology (Dr. _%#NAME#%_ _%#NAME#%_). 4. C3, C4 and CH50 complement levels.
BAL|bronchoalveolar lavage|BAL|227|229|HISTORY|He was also found to have low hemoglobin. Based on these progressive pulmonary infiltrates, the patient was admitted to the hospital with a plan for biopsy. He had a nodular atypical infiltrative process seen on prior CT scan. BAL has been done, and is not showing anything to date. The patient has had some degree of fevers, including drenching night sweats, and some chills, but no other overt symptoms.
BAL|bronchoalveolar lavage|BAL|259|261|PLAN|PLAN: 1. Diuresis. 2. Follow chest x-ray. 3. Thoracentesis of right for diagnostic and therapeutic purposes. 4. Check BMP. 5. Continue antibiotics. 6. If no clinical/radiographic improvement, or anemia persists with no improvement, could do bronchoscopy with BAL to rule out infectious versus alveolar hemorrhage syndrome. Will hold on this for now since she appears to be clinically improving.
BAL|bronchoalveolar lavage|BAL|119|121|RECOMMENDATIONS|2. Coronary disease, ruled out for MI. 3. 30+ pack year tobacco smoking history. RECOMMENDATIONS: 1. Bronchoscopy with BAL and transbronchial biopsy tomorrow. 2. Outpatient pulmonary function testing. 3. Follow pleural thickening and PFTs as an outpatient for possible development of asbestosis.
BAL|bronchoalveolar lavage|BAL|268|270|IMPRESSION|It is also unclear to what extent her lymphoma has responded to her most recent chemotherapy and whether or not it is involving endobronchial destruction at this juncture. Given these circumstances, I think it is worth pursuing bronchoscopy with endobronchial washes, BAL if possible, and endobronchial biopsy. The course of the bronchoscopy will in part be dictated by the results of today's pending chest CT scan.
BAL|bronchoalveolar lavage|BAL|210|212|PE|1. Hypoxia - DDx on this patient includes PE, volume overload, infection and DAH. Continue with O2 supplements. Agree with 2D-echo. Will need plateletes > than 30 and INR less than 1.5 for possible bronch with BAL in am. 2. Abnormal CT chest - Will need a bronch tomorrow as above.
BAL|bronchoalveolar lavage|BAL|181|183|ASSESSMENT AND PLAN|To differentiate among these we recommend the following: 1. Pneumonia: We agree with empiric broad-spectrum antibiotic coverage. The patient will undergo bronchoscopy tomorrow. The BAL will be sent for Nocardia, Actinomyces, routine fungal and viral cultures. Additionally a cell count will be sent. Pleurisy that he had prior to evidence of pneumonia could suggest an infarct from a fungus versus Nocardia.
BAL|bronchoalveolar lavage|BAL|211|213|PAST MEDICAL HISTORY|The patient switched to Posoconazole. 11. Bilateral endoscopic sinus surgery in _%#MM2006#%_. 12. Bilateral myringotomy tube secondary to infection in _%#MM2006#%_. 13. Light growth of Aspergillus versicolor in BAL from _%#MMDD2007#%_. 14. Left sinusitis secondary to Strep pneumoniae treated with long course of clindamycin. REVIEW OF SYSTEMS: The patient has had intermittent fevers and night sweats for approximately 1-1/2-2 weeks.
BAL|bronchoalveolar lavage|BAL|132|134|PROBLEM #2|Dr. _%#NAME#%_ recommended continuing Posoconazole for now and awaiting for BAL results. She is happy to consult with us concerning BAL results and any changes that may need to be made in as antifungal therapy. The patient will also remain on IV Rocephin or empiric treatment of neutropenic fevers as well as he was placed on linezolid for moderate gram positive cocci as well as gram positive bacilli resembling diphtheroid.
BAL|bronchoalveolar lavage|BAL|167|169|DISPOSITION|He is scheduled to see Dr. _%#NAME#%_ on _%#MMDD2007#%_ at 09:30 when he will get an infusion of Rocephin as well as 2 units of RBCs. Dr. _%#NAME#%_ will follow up on BAL cultures and adjust his antibiotics according. The patient was discharged on Rocephin, linezolid as well as azithromycin for atypicals. The patient will have another blood culture drawn in the clinic on _%#MMDD2007#%_.
BAL|bronchoalveolar lavage|BAL|162|164|HOSPITAL COURSE|He was managed initially on vancomycin, Zosyn and Vfend. BAL cultures from Regency eventually did grow out Candida glabrata, which was seen on previous admission BAL as well. The patient's vancomycin was discontinued. The patient remained on Zosyn and Vfend for the remainder of the hospital course.
BAL|bronchoalveolar lavage|BAL.|173|176|PROBLEM #5|Additionally, in problems with pulmonary, the patient developed hypoxia on _%#MMDD2007#%_. A bronchoscopy was performed and the patient had increasing bloody returns on the BAL. She was started on high dose steroids on _%#MMDD2007#%_ and the patient's methylpred was decreased to 250 mg IV b.i.d. when she began having episodes of hemoptysis and hypoxia.
BAL|bronchoalveolar lavage|BAL,|133|136|PROBLEM #2|The patient had marked improvement on antibiotic and after being removed from the home. Given the patient's increased lymphocytes on BAL, the most likely working diagnosis is that the patient has hypersensitivity pneumonitis from exposure in the home environment. The patient also had pulmonary function tests done during his hospital stay which showed normal lung volumes and capacity.
BAL|bronchoalveolar lavage|BAL|132|134|OPERATIONS/PROCEDURES PERFORMED|1. The patient underwent a bronchoscopy with biopsy on _%#MM#%_ _%#DD#%_, 2004. The impression was the examination was normal and a BAL was performed and a transbronchial biopsy. The cultures from this demonstrated Staphylococcus noncoagulase and Candida albicans. The pathology report from the transbronchial biopsy showed expansion of the interstitium by inflammation cells, mainly lymphocytes and plasma cells in collagen deposition.
BAL|bronchoalveolar lavage|BAL|186|188|HOSPITAL COURSE|In addition, the patient was to follow up with Dr. _%#NAME#%_ in 2-3 weeks with a repeat CT scan of the chest to look for improvement. Of note, the patient did receive a biopsy with her BAL and there were some pathology findings that were consistent with BOOP. The CT scan will help to look for evidence that the BOOP is either worse, improved, or the same.
BAL|bronchoalveolar lavage|BAL.|126|129|PROCEDURES PERFORMED|6. Renal ultrasound. 7. CT of orbit. 8. CT of head. 9. CT of abdomen. 10. Abdominal ultrasound. 11. EGD. 12. Bronchoscopy and BAL. 13. Arterial line. 14. Bone marrow biopsy. HISTORY OF PRESENT ILLNESS: Briefly, this is a 43-year-old female who was admitted from the Hem-Onc Clinic because of abdominal pain, nausea, and weight loss and macrocytic anemia.
BAL|bronchoalveolar lavage|BAL|133|135|HOSPITAL COURSE|However, he had to be reintubated on _%#MMDD2006#%_. A bronchoscopy the next day did not demonstrate any evidence of mucoid plugs. A BAL was obtained at the same time and he was subsequently treated for pneumonia with Primaxin, Levaquin, and Diflucan. His respiratory function slowly improved over time. He was able to be weaned off oxygen as needed and he was started on bronchodilators which on peak flows pre and post treatment showed improvement.
BAL|bronchoalveolar lavage|BAL|123|125|ALLERGIES|We therefore decided to employ the pulmonary team, and bronchoscopy was done on _%#MM#%_ _%#DD#%_, 2003. The result of the BAL lavage, as well as biopsy, are pending at the time of this dictation. During the hospital stay, the patient remained afebrile, and his respiratory distress resolved mostly after the nebulizer.
BAL|bronchoalveolar lavage|BAL|184|186|PROBLEM #2|Fevers did subside somewhat, approximately day plus 6 and he had some intermittent fevers in between. _%#NAME#%_ did have some infectious issues during his hospitalization including a BAL that was completed _%#MMDD2007#%_ which had coagulation negative staph which was treated with vancomycin and also something that came up later, a moderate growth Paecilomyces lilacinus which sensitivity showed to be only be sensitive to Voriconazole was resistant to Caspofungin and Amphotericin B.
BAL|bronchoalveolar lavage|BAL|168|170|BMP WORKUP|7. Virologies: The patient is CMV positive, EBV positive, HSV positive, hepatitis B and C negative, HIV 1 and 2 negative, HTLV 1 and 2 negative and RPR is negative. 8. BAL culture showed heavy growth of coag. negative staph, otherwise negative. IMAGING: 1. CT chest without contrast on _%#MMDD2007#%_: Showed a slight improvement in patchy air space and ground glass opacities in both lungs consistent with an improving pneumonia; resolved bilateral pleural effusions; small pericardial effusion.
BAL|bronchoalveolar lavage|BAL|190|192|HISTORY OF PRESENT ILLNESS|He had mobilization done with Cytoxan, mitazanthene, and ara-C with GCSF priming, prep Cytoxan TBI, and auto BMT on _%#MMDD2005#%_. The patient was noted to be dyspneic in _%#MM#%_ of 2005. BAL was performed which grew candida on Pseudomonas. The patient was treated with IV ceftazidime and voriconazole with Levaquin. Histopathology showed evidence of BOOP. The patient was treated with steroids and taper was started on _%#MMDD2006#%_.
BAL|bronchoalveolar lavage|BAL|193|195|HOSPITAL COURSE|Because the patient had complained of some mild pleuritic chest pain after the bronchoscopy was performed a CT with contrast throughout pulmonary embolism was also performed. Results as above. BAL results came back negative for any infectious causes. Therefore, triple antibiotic therapy was discontinued. The patient was given a course of ceftriaxone.
BAL|bronchoalveolar lavage|BAL|197|199|HOSPITAL COURSE|This was done on _%#MM#%_ _%#DD#%_, 2002, showing copious mucopurulent secretions in the tracheal bronchial tree and evidence of previous surgery in the right lower lobe. Results of the biopsy and BAL showed no evidence of malignancy and stains were negative for PCP, CMV and positive for budding yeast and pseudohyphae. Final cultures showed moderate growth of candida albicans and AFB staining culture pending at the time of discharge.
BAL|bronchoalveolar lavage|BAL|116|118|PROBLEM #2|Of note, Mr. _%#NAME#%_ was on caspofungin during chemotherapy and then was started on Vfend on day zero due to the BAL on _%#MM#%_ _%#DD#%_, 2004, that had a single colony of fungus. Mr _%#NAME#%_ also had a positive C. diff culture light growth on _%#MM#%_ _%#DD#%_, 2004, and completed a 10 day course of Flagyl.
BAL|bronchoalveolar lavage|BAL|272|274|PTT 56.|Calcium 8.9, magnesium 1.6, phosphorus 2.4, total bilirubin 0.5, albumin 3.5, protein 6.9, alkaline phosphatase 80, ALT 21, AST 15. INR 1.18, PTT 56. Microbiology and virology: Bronchoscopy cultures from _%#MMDD#%_ showed filamentous fungi, non-Aspergillus. Bronchoscopy, BAL on _%#MMDD#%_ with positive CMV shell vial, CMV antigenemia negative. Other studies negative. Laboratory results on discharge on _%#MMDD2005#%_. White count 2.1, hemoglobin 8.9, hematocrit 24.8, platelet count 20.
BAL|bronchoalveolar lavage|BAL,|292|295|PAST MEDICAL HISTORY|2. History of respiratory failure, which includes a month-long admission in _%#MM2005#%_ (including mechanical ventilation and status post non-diagnostic open lung biopsy), plus the hospitalization from late _%#MM2005#%_ through _%#MMDD2005#%_ mentioned above that included bronchoscopy with BAL, which showed presence of aspergillus fumigatus and Corynebacterium. 3. Type 2 diabetes related to chronic steroids. 4. Hypertension. 5. Hypercholesterolemia. 6. Remote history of choroidal melanoma involving right eye.
BAL|bronchoalveolar lavage|BAL|186|188|OPERATIONS/PROCEDURES PERFORMED|4. Abdominal ultrasound performed _%#MM#%_ _%#DD#%_, 2005, which demonstrated a mildly prominent extrahepatic bile duct with no obstructing stoned and hepatomegaly. 5. Bronchoscopy with BAL performed _%#MM#%_ _%#DD#%_, 2005. Gram stain of bronchial washings demonstrated rare gram-positive rods, few gram- positive cocci in pairs, rare budding yeast with pseudohyphae, and few white blood cells.
BAL|bronchoalveolar lavage|BAL|182|184|OPERATIONS/PROCEDURES PERFORMED|An infectious disease consultation was requested. They recommended bronchoscopy to better determine the etiology of the patient's pneumonia. This was performed on _%#MM#%_ _%#DD#%_. BAL Gram stain demonstrated no organisms and only few white blood cells. Cultures have been negative with the exception of Candida. However, in discussing the case with both pulmonary and infectious disease, they felt that given that the patient had been on antibiotics for several days when the bronchoscopy was performed, that PCP could not ruled out.
BAL|bronchoalveolar lavage|BAL.|200|203|PLAN|2. Hilar adenopathy. Outside CT results are obtained. Therefore I do not see a reason to repeat chest CT at this time. We will ask Pulmonology to get involved and potentially perform bronchoscopy for BAL. 3. Diabetes. We did add a hemoglobin A1c to this morning's labs and that result is 6.3. We will continue him on the glyburide dosing per outpatient dose and monitor blood glucoses q.i.d. STAFF ADDENDUM Patient seen and examined by me with the resident above with the aid of a sign language interpreter.
BAL|bronchoalveolar lavage|BAL|260|262|PROBLEM #2|A chest CT was obtained on _%#MM#%_ _%#DD#%_, 2003, in conjunction with a fever workup, that showed a right middle lobe pneumonia and small right pleural effusion. At this time, the patient was using blow-by oxygen to maintain his normal oxygen saturations. A BAL was done on _%#MMDD2002#%_, which showed some budding yeast on KOH prep, but cultures from the BAL were all negative to date.
BAL|bronchoalveolar lavage|BAL|165|167|HOSPITAL COURSE|He has evidence for continued effusion/infiltrate persistent in the left lower lobe from prior pneumonia. The patient underwent bronchoscopy with biopsy, as well as BAL lavage, and a thoracentesis with evaluation of fluid on both the right and left sides. All of the above procedures did not detect infection. Thoracic Surgery was asked to place a second chest tube, as the first chest tube placed was not appropriately draining air or fluid.
BAL|bronchoalveolar lavage|BAL|151|153|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Precursor T-cell lymphoma, status post myeloablative double-cord transplant. 2. Neutropenic fevers. 3. Probable pneumonia with BAL group D enterococcus and coag- negative staph. 4. Bacteremia with Corynebacterium jeikeium. 5. Hemorrhagic cystitis; BK virus positive. 6. Nausea, vomiting, and decreased oral intake requiring TPN.
BAL|bronchoalveolar lavage|BAL|175|177|HISTORY OF PRESENT ILLNESS|CSF has been negative for leukemia. The patient then presented to the BMT Clinic to discuss BMT options. During workup, CT scan of the chest revealed nodules in both lungs. A BAL was counted, with heavy growth of Candida albicans/glabrata and HSV. He was then started on voriconazole and Valtrex. VATS on _%#MMDD2006#%_ grew bacillus sensitive to Levaquin.
BAL|bronchoalveolar lavage|BAL.|167|170|ADMIT PHYSICAL EXAMINATION|LFTs: Alkaline phosphatase 64. ALT 51. AST 18. Total bilirubin 0.9. OTHER STUDIES DURING AND PROCEDURES: On _%#MM#%_ _%#DD#%_, 2002, she underwent a bronchoscopy with BAL. All cultures and viral cultures were negative and remained so at the time of discharge. The only thing that is pending are her AFB cultures.
BAL|bronchoalveolar lavage|BAL.|196|199|DISCHARGE DIAGNOSES|2. Multiple myeloma, lambda light chain restricted. 3. Acute and chronic renal insufficiency. 4. History of right lower extremity deep venous thrombosis. 5. Single colony of filamentous fungus on BAL. HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old male with a history of multiple myeloma, lambda light chain stage IIA, who also has a history of chronic renal insufficiency, gout, anemia, history of a right lower extremity deep venous thrombosis.
BAL|bronchoalveolar lavage|BAL.|125|128|PROCEDURES THIS ADMISSION|The patient had no other complaints at the time of admission. PROCEDURES THIS ADMISSION: 1. Bronchoscopy _%#MMDD2006#%_ with BAL. 2. Chest CT without contrast _%#MMDD2006#%_. Decrease in the previously noted nodule and ground-glass opacities except for a tiny amount of ground- glass opacity remaining distally.
BAL|bronchoalveolar lavage|BAL|131|133|HOSPITAL COURSE|Further evaluation with MRA would help better delineate the area. HOSPITAL COURSE: PROBLEM #1. RSV pneumonitis: The results of the BAL did not show evidence of RSV. However, the patient did complete a 5-day course of the ribavirin aerosolized therapy which he tolerated fairly well.
BAL|bronchoalveolar lavage|BAL|339|341|HOSPITAL COURSE|But because the patient had received treatment for greater than 3 months and did not have evidence of a pulmonary embolism and just a DVT, it was felt safe to stop all anticoagulation, especially in lieu of his renal functi on. PROBLEM #6. Single filamentous fungus colony on BAL: Before admission the patient did have a bronchoscopy with BAL which did grow back a single filamentous fungus colony which was speciated as being a penicillium species. The patient had been on Fluconazole prophylaxis dosing as an outpatient; however, because of this finding, the patient was switched to Voriconazole 300 mg p.o. b.i.d. and will be continued indefinitely at this point.
BAL|bronchoalveolar lavage|BAL|183|185|BMT WORK UP|8. A bone marrow biopsy revealed hypocellular marrow (30% cellular) with no evidence of lymphoma. 9. An S-Pap revealed hypogammaglobulinemia with no monoclonal protein. 10. Bronchial BAL from _%#MM#%_ 2003 confirmed the diagnosis of Aspergillus and a BAL from _%#MM#%_ 2004 confirmed mycobacterium fortuitum. REVIEW OF SYSTEMS: Mr. _%#NAME#%_ was tired, and reported that he had persistent dyspnea on exertion that actually had improved in the past 2 weeks.
BAL|bronchoalveolar lavage|BAL|153|155|BMT WORK UP|9. An S-Pap revealed hypogammaglobulinemia with no monoclonal protein. 10. Bronchial BAL from _%#MM#%_ 2003 confirmed the diagnosis of Aspergillus and a BAL from _%#MM#%_ 2004 confirmed mycobacterium fortuitum. REVIEW OF SYSTEMS: Mr. _%#NAME#%_ was tired, and reported that he had persistent dyspnea on exertion that actually had improved in the past 2 weeks.
BAL|bronchoalveolar lavage|BAL|233|235|HOSPITAL COURSE|CT of chest on _%#MMDD2006#%_ showed patchy left lower lobe ground glass opacities with denser consolidation, few smaller scattered areas of left upper lobe ground glass opacities and a small area of right middle lobe consolidation. BAL grew VRE; previous BAL was already growing nocardia (see below). He was successfully extubated on _%#MMDD2006#%_, remained on room air for the remainder of the hospitalization and was treated with linezolid on _%#MMDD2006#%_ to _%#MMDD2006#%_.
BAL|bronchoalveolar lavage|BAL|256|258|HOSPITAL COURSE|CT of chest on _%#MMDD2006#%_ showed patchy left lower lobe ground glass opacities with denser consolidation, few smaller scattered areas of left upper lobe ground glass opacities and a small area of right middle lobe consolidation. BAL grew VRE; previous BAL was already growing nocardia (see below). He was successfully extubated on _%#MMDD2006#%_, remained on room air for the remainder of the hospitalization and was treated with linezolid on _%#MMDD2006#%_ to _%#MMDD2006#%_.
BAL|bronchoalveolar lavage|BAL|273|275|DISCHARGE MEDICATIONS|A bronchoalveolar lavage on _%#MM#%_ _%#DD#%_, 2005, which Dr. _%#NAME#%_ stated was actually more of a mucus culture showed 7 red blood cells and 865 nucleated cells with a differential of 6 neutrophils, 2 lymphocytes, 3 monocytes, 4 basophils, and 85 eosinophils. On the BAL specimen, the CMV rapid shell was negative. Mycoplasma PCR was negative. AFB stain was negative. The culture showed heavy growth of MRSA and a fungal culture showed heavy growth of Aspergillus fumigatus.
BAL|bronchoalveolar lavage|BAL.|165|168|HOSPITAL COURSE|With her fungal culture positive for heavy growth of Aspergillus, Dr. _%#NAME#%_ emphasized that this was just a mucous sample from her bronchoscopy, and not a true BAL. She felt the fungus was just trapped in her mucous and not an active infection in her lung. Her chest x-ray findings were not consistent with an Aspergillus fungal infection of the lung.
BAL|bronchoalveolar lavage|BAL.|380|383|LABORATORY STUDIES|His extremities are warm and well perfused. LABORATORY STUDIES: Sodium 141, potassium 5.3, chloride 109, carbon dioxide 25, glucose 99, BUN 34, creatinine 1.72, estimated GFR is 44, calcium is 9.5, magnesium 1.6, phosphorus 4.2, TSH 0.78. CMV DNA quantitation is pending as is respiratory viral culture, AFB culture, AFB stain, bronchial culture, fungal culture and Gram stain of BAL. Tacrolimus level of 10.0 and an INR of 0.96. PULMONARY FUNCTION TESTS (from yesterday 10/01): Show FEV1 of 1.29 liters, which is 33% of predicted, an FVC of 2.15 liters, which is 42% of predicted and an FEV1/FVC of 78% of predicted.
BAL|bronchoalveolar lavage|BAL|255|257|ASSESSMENT AND PLAN|Currently he is afebrile and does not look septic. We will continue his prophylactic dose of penicillin VK secondary to his low IgG. 3. Pulmonary. The patient was noted to have polymicrobial pneumonia per bronchoscopy that was done on _%#MMDD2007#%_. His BAL grew Candida glabrata, coagulase-negative staph and enterococcus. He was treated with vancomycin and voriconazole. The vancomycin was discontinued prior to his transfer. He is still on voriconazole at this time.
BAL|bronchoalveolar lavage|BAL|196|198|PROBLEM #5|A chest CT obtained on _%#MMDD2006#%_ revealed patchy confluent ground glass opacities in the left upper lobe and increased bilateral pleural effusions and basilar atelectasis or consolidation. A BAL was not obtained at that time secondary to concern for her ability to tolerate the procedure without requiring intubation.
BAL|bronchoalveolar lavage|BAL|250|252|HOSPITAL COURSE|On _%#MMDD2003#%_ he was pan-scanned for persistent fevers and was found to have pansinusitis, which was treated with 10-days Zithromax after his vancomycin was discontinued. In _%#MM2003#%_ _%#NAME#%_ grew VRE which was sensitive to Synercid on his BAL culture. Repeat sputum culture on _%#MMDD2003#%_ revealed light growth of VRE. He was treated with a 2-week course of Synercid. He continued to have persistent low-grade temperature with occasional spikes but no positive blood or urine cultures after that point.
BAL|blood alcohol level|BAL|130|132|ADMISSION LABORATORY DATA|Normal total bilirubin, protein, and albumin. A UA reveals greater than 1000 glucose, no ketones. U-tox was positive for ETOH and BAL was 0.33. A head CT revealed no acute pathology with minimal frontal fluid collection, likely representing an arachnoid cyst.
BAL|bronchoalveolar lavage|BAL|191|193|LABORATORY DATA|Bronchoscopy results from _%#MMDD2006#%_ include a negative Nocardia culture to date. Fungal culture is growing a moderate amount of yeast. He is growing normal flora. AFB stain is negative. BAL fluid had 3500 red cells and only 207 white cells. Respiratory viral culture from _%#MMDD2006#%_ is negative to date. RSV rapid antigen was negative.
BAL|bronchoalveolar lavage|BAL|259|261|HOSPITAL COURSE|The surgeon was Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_. A VATS biopsy was performed of the right middle lobe. Microbiology from this would eventually grow no specific organisms. However, after surgical biopsy, bronchoscopy results from _%#MM#%_ _%#DD#%_, 2005, BAL did return. This was remarkable for a Mycobacterium chelonae/abscessus complex was identified. It was sensitive to amikacin, clarithromycin, tobramycin, and linezolid; it was resistant to cefoxitin, ciprofloxacin, trimethoprim sulfa, and minocycline.
BAL|bronchoalveolar lavage|BAL|231|233|PROBLEM #6|PROBLEM #6: Disseminated candidiasis. On admission, Ms. _%#NAME#%_ was noted to have multiple problems with cutaneous candidiasis, most notably in her groin area. She was started on miconazole powder with good result. Of note, her BAL did grow out Candida albicans, though it was felt this was not clinically significant and so initially was not treated.
BAL|bronchoalveolar lavage|BAL|172|174|DIAGNOSTIC TESTS AND PROCEDURES|5. Possible GI bleed. 6. Acute myocardial infarction. 7. Possible amyloidosis. 8. Decubitus ulcers. 9. Pelvic abscess. DIAGNOSTIC TESTS AND PROCEDURES: 1. Bronchoscopy and BAL on _%#MMDD2005#%_. Per notes, bronchoscopy revealed blood coming from the left upper lobe; however, no active bleeding at the trach site was noted.
BAL|bronchoalveolar lavage|BAL|172|174|DIAGNOSTIC TESTS AND PROCEDURES|1. Bronchoscopy and BAL on _%#MMDD2005#%_. Per notes, bronchoscopy revealed blood coming from the left upper lobe; however, no active bleeding at the trach site was noted. BAL fluid was consistent with no organisms seen and no growth. Cultures were negative in terms of fungal and anaerobic, as well as the regular fluid cultures.
BAL|bronchoalveolar lavage|BAL|241|243|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1: Respiratory. Given the patient's bilateral pleural effusions and increased left-sided infiltrate, he was treated for hospital- acquired pneumonia empirically with Zosyn, levofloxacin, and initially vancomycin. A BAL was performed on _%#MMDD2005#%_; cultures from this BAL did not show any growth. Vancomycin was discontinued and the patient was continued to be treated for presumed hospital-acquired pneumonia.
BAL|bronchoalveolar lavage|BAL|239|241|PROBLEM #3|Mr. _%#NAME#%_ defervesced on _%#MMDD2005#%_, approximately five days after his last IL2 injection. In light of persistent neutropenia, however, we are continuing broad-spectrum coverage with vancomycin, ceftriaxone, and voriconazole. The BAL results warrant follow up, and a repeat CT should be obtained next week. PROBLEM #4: GI. Mr. _%#NAME#%_ had alternating constipation and diarrhea.
BAL|bronchoalveolar lavage|BAL|175|177|HISTORY OF PRESENT ILLNESS|He was subsequently seen by Nephrology Consult Team which adjusted his diuretic medications. He was also noted to have hemoptysis and subsequently underwent bronchoscopy with BAL culture growing CMV and pseudomonas species after which he was placed on appropriate antibiotics. Other significant issue during this hospital course was that he had melena, for which an EGD was obtained on _%#MMDD2007#%_.
BAL|bronchoalveolar lavage|BAL|155|157|ADMISSION LABORATORY DATA|Bronchial cultures showed light growth of coag-negative Staphylococcus. Fungus culture showed no growth. Gram's stain showed no organisms. Analysis of the BAL fluid showed 1383 red cells, 1025 nucleated cells, 7% eosinophils, 55% neutrophils, 24% lymphocytes. HOSPITAL COURSE: PROBLEM #1: Acute interstitial pneumonitis, etiology of which is unclear at this time.
BAL|bronchoalveolar lavage|BAL|136|138|HOSPITAL COURSE|The pulmonary team is consulted and he underwent a bronchoscopy with bronchoalveolar lavage for cultures. All of these studies from the BAL were negative. Eventually as it became more clear that his fevers were secondary to hemolytic uremic syndrome and the right upper lobe findings were atelectasis, his antibiotics were discontinued.
BAL|bronchoalveolar lavage|BAL,|112|115|PROCEDURES|Findings include mixed pulmonary opacification of the right greater than left lung fields. 5. Bronchoscopy with BAL, _%#MMDD2007#%_. 6. Transthoracic echocardiogram, _%#MMDD2007#%_. Findings include a normal left ventricular systolic function with estimated ejection fraction of greater than 55%.
BAL|bronchoalveolar lavage|BAL|211|213|HOSPITAL COURSE|Problem #2. Infectious disease: At the time of admission the patient had sputum culture sent and grew out moderate growth of Pseudomonas fluorescens putida group which was resistant to ciprofloxacin. Subsequent BAL grew out two strains of Pseudomonas as well as moderate growth of Candida albicans. His AFB and CMV remained negative as well as his respiratory viral culture.
BAL|bronchoalveolar lavage|BAL|120|122|MAJOR PROCEDURES AND DIAGNOSTIC TESTS|The AFB stain was negative. The BAL-fluid culture has so far not grown any bacteria or fungus. The viral studies on the BAL fluid are pending. IMPORTANT INVESTIGATIONS DONE: Early in his hospital stay: The patient has had 2 bone marrow biopsies.
BAL|bronchoalveolar lavage|BAL|239|241|CMV.|He received a 21-day course of ganciclovir. Subsequent PCRs done on _%#MMDD2006#%_ and _%#MMDD2006#%_ have been negative, with no detection of CMV. On _%#MMDD2006#%_ the patient underwent a bronchoscopy with a bronchioalveolar lavage. The BAL fluid has had a negative Gram stain, AFB stain. The cultures have been negative. The virals studies are pending. Over the last few days, we have had problems with the fluid status of Mr. _%#NAME#%_.
BAL|bronchoalveolar lavage|BAL|173|175|IMAGING AND PROCEDURES DONE DURING HOSPITALIZATION|Cytology was negative for malignancy. No organisms identified. Negative for CMV, pneumocystis, and fungus with a comment that this was an adequate specimen. Microbiology on BAL from _%#MMDD2006#%_ showed moderate group D enterococcus susceptible to ampicillin with intermediate susceptibility to penicillin. The fungal cultures have grown light growth penicillium species as well as a light growth of aspergillus fumigatus single colony.
BAL|bronchoalveolar lavage|BAL|169|171|HOSPITAL COURSE|The patient received 5 days of ribavirin inhalation. The patient also has a positive sputum culture from _%#MMDD2006#%_ as well as a single colony of aspergillus on the BAL so the patient was placed on .......and fluconazole was discontinued. The patient also had a BAL with moderate growth group D enterococcus not VRE.
BAL|bronchoalveolar lavage|BAL|344|346|PAST MEDICAL HISTORY|3. Gout, no recent flare. 4. Hyperlipidemia, treatment on hold for peripheral blood stem cell transplant. 5. Inguinal hernia repair. 6. Myeloablative allogeneic sibling peripheral blood stem cell transplant on _%#MMDD2005#%_ for T-cell PLL, with complications of grade 3 mucositis, Staph epidermidis bacteremia, persistent fevers with negative BAL with resolution with Vfend, acute renal failure, reactivation of herpes zoster of right C5 dermatome, hemorrhagic cystitis with positive BK virus, Klebsiella and Stenotrophomonas bacteremia on _%#MMDD2005#%_ with subsequent _________ removal and treated for 14 days with Cipro and Bactrim ending on _%#MMDD2005#%_.
BAL|bronchoalveolar lavage|BAL|260|262|KEY PROCEDURES/STUDIES PERFORMED|Focal findings suggestive of intravascular organizing thrombi. D. GMS stain for fungi, stain for acid-fast bacilli, and gram stain for bacteria are negative. There were no virocyte or pathic changes identified. 3. The patient had a bronchoscopy performed. The BAL was negative for malignancy. No organisms were identified. GMS stains had no pathologic assessments. This was also negative for CMV, negative for PCP, and negative for fungus.
BAL|bronchoalveolar lavage|BAL|278|280|PROBLEM #5|Pulmonary continued to consult on Mr. _%#NAME#%_ _%#NAME#%_'s case and they felt that his respiratory status would not improve unless there was significant reduction in tumor burden. We did complete another bronchoscopy on _%#MMDD#%_ looking again for infection and had another BAL on _%#MMDD#%_ looking for infection and that did not reveal any infection. Approximately over the last week prior to Mr. _%#NAME#%_ _%#NAME#%_'s death, he had increasing oxygen requirements.
BAL|bronchoalveolar lavage|BAL.|149|152|PROCEDURES|CONSULTING SERVICES: 1. Pediatric Infectious Disease. 2. Genetics. 3. Pediatric Immunology. 4. Pediatric Pulmonary. PROCEDURES: 1. Bronchoscopy with BAL. 2. CT scan of chest, abdomen and pelvis. 3. PICC placement. 4. Chest x-ray. 5. IVIG. DISCHARGE CONDITION: Fair. DISPOSITION: Discharge to the Days Inn Hotel in _%#NAME#%_. The patient's mother was instructed to not return home to _%#CITY#%_, Minnesota, at this time.
BAL|bronchoalveolar lavage|BAL|301|303|PROBLEM #6|Stool for wbc's was negative. At the recommendations of the Infectious Disease Service, the patient's stool was recent for a viral culture as well as stool exam for the specific parasite Cryptosporidium and Microsporidian. The patient is to remain in drop precautions until his viral studies from his BAL and stool return negative for adenovirus. He is to remain on contact precauti ons until cultures reveal that is clear of MRSA.
BAL|bronchoalveolar lavage|BAL,|202|205|HOSPITAL COURSE|Herpes simplex virus was also cultured from bronchial BAL, for which she was started on acyclovir, and she should continue up until surgery. Methicillin-sensitive Staph aureus also grown from bronchial BAL, same species that was found in the blood. She is on treatment for this as outlined above, Aspergillus fumigatus also on bronch.
BAL|bronchoalveolar lavage|BAL|201|203|HOSPITAL COURSE|She had originally been on ketoconazole for her Cushing syndrome; however, she was switched to voriconazole, and she should continue this for approximately 2 more weeks up until surgery. Her bronchial BAL also grew Branhamella catarrhalis, for which she was started on clindamycin, as well as prevotella, for which she received doxycycline.
BAL|bronchoalveolar lavage|BAL|189|191|HOSPITAL COURSE|Into the hospital course the patient had further respiratory compromise and was seen to have consolidations. The patient had a bronchoscopy with bronchioalveolar lavage. Cultures from this BAL grew out pseudomonas and citrobacter. The patient was treated for this and currently still on Primaxin and Levaquin for treatment of this infection.
BAL|bronchoalveolar lavage|BAL.|134|137|ASSESSMENT AND PLAN|We will proceed with a bronchoscopy to assess for any evidence of acute hemorrhage, and send for appropriate studies as well as get a BAL. At this point we will: A. Start on Linezolid, tobramycin and imipenem (please see allergies). B. Send blood cultures, BAL, as well as CMV, HSV, influenza A, RSV.
BAL|bronchoalveolar lavage|BAL,|257|260|ASSESSMENT AND PLAN|We will proceed with a bronchoscopy to assess for any evidence of acute hemorrhage, and send for appropriate studies as well as get a BAL. At this point we will: A. Start on Linezolid, tobramycin and imipenem (please see allergies). B. Send blood cultures, BAL, as well as CMV, HSV, influenza A, RSV. C. Continue with p.o. prednisone at 40 mg for immunosuppression as well as consult Rheumatology Department in the morning for any other recommendations on immunosuppression for vasculitis, although those options seem to be limited at this point.
BAL|bronchoalveolar lavage|BAL|160|162|ADMISSION LABS|Drug screen positive for opiates, diphenhydramine. Blood cultures negative. TSH 0.98. Legionella antigen negative. Sputum culture moderate coag-negative staph. BAL fluid negative for malignancy, PCP and fungus. BAL cultures, coag-negative staph. Fungal cultures, Candida. Gram's stain positive for gram-positive cocci in pairs and chains.
BAL|bronchoalveolar lavage|BAL|211|213|ADMISSION LABS|Drug screen positive for opiates, diphenhydramine. Blood cultures negative. TSH 0.98. Legionella antigen negative. Sputum culture moderate coag-negative staph. BAL fluid negative for malignancy, PCP and fungus. BAL cultures, coag-negative staph. Fungal cultures, Candida. Gram's stain positive for gram-positive cocci in pairs and chains. Retic count 1.8, iron level 29, transferrin 155, TIBC 231, iron saturation 13, ferritin 228, folate 611, B12 609.
BAL|bronchoalveolar lavage|BAL|145|147|HISTORY OF PRESENT ILLNESS|She was given induction chemotherapy which was complicated by febrile neutropenia. She reportedly had a positive Aspergillus galactomannan but a BAL and a biopsy of lung mass were both negative for aspergillus. She was treated with VFEND and showed dramatic improvement on her chest CT.
BAL|bronchoalveolar lavage|BAL|213|215|HOSPITAL COURSE|She developed febrile neutropenia for which she was treated with IV antibiotics including Ceftazidime, vancomycin and tobramycin. Chest x-rays revealed bilateral pneumonia with infiltrates and a bronchoscopy with BAL was done on _%#MMDD2006#%_. The BAL grew out light growth Staph for which she was treated with a course of vancomycin.
BAL|bronchoalveolar lavage|BAL|197|199|HOSPITAL COURSE|An AFB stain was negative. Cytology was also negative for malignancy or fungus on GMS stain. Bacterial and fungal cultures were still pending at the time of discharge. Of note, the cytology of the BAL fluid was also negative. Cardiology was consulted due to concerns about pericarditis and the presence of her pericardial effusion.
BAL|bronchoalveolar lavage|BAL|184|186|HOSPITAL COURSE|A chest x-ray on _%#MMDD2007#%_, revealed increased pleural effusions and right upper lobe atelectasis and/or consolidation. The patient underwent bronchoscopy on _%#MMDD2007#%_ and a BAL revealed infections with Candida glabrata, coag negative Staph and Enterococcus. The infections were treated with vancomycin and voriconazole, as the Enterococcus and Staph were susceptible to vancomycin and the Candida was susceptible to voriconazole.
BAL|bronchoalveolar lavage|BAL|255|257|ASSESSMENT AND  PLAN.|If that opacity was persistent at that time no further investigation needed, but if not, we will obtain CT scan of the chest to rule out any mass lesions on that side and if that is positive then we will obtain pulmonary consultation for bronchoscopy and BAL biopsy and we will follow up closely. 7. History of osteoarthritis of bilateral knees, right more than left. Stable, we will just treat with Tylenol at this time and we will follow up closely.
BAL|bronchoalveolar lavage|BAL.|142|145|DISCHARGE DIAGNOSES|He was discharged with a prescription for fluconazole as well as ciprofloxacin to cover the Staphylococcus epidermitis that grew light on the BAL. 4. Anemia. Patient does have a history of chronic anemia which was currently thought to be due to Hydrea, however, now it appears this could very well be due to bone marrow malignancy.
BAL|bronchoalveolar lavage|BAL|218|220|HOSPITAL COURSE|Patient was switched from ceftazidime which he had a penicillin allergy, the patient did have some hives with ceftazidime so he was switched to imipenem. Blood cultures taken on the patient have been negative to date. BAL was performed on the patient on _%#MMDD2005#%_. Cultures from the BAL have grown a single colony of filamentous fungus identified as penicillium.
BAL|bronchoalveolar lavage|BAL|222|224|HOSPITAL COURSE|BAL was performed on the patient on _%#MMDD2005#%_. Cultures from the BAL have grown a single colony of filamentous fungus identified as penicillium. Bacterial cultures remain negative to date. Bacterial cultures from the BAL grew normal respiratory flora. Dr _%#NAME#%_ was consulted concerning the penicillium colony. She felt that one colony of penicillium should not be double covered and would be adequately covered with either Voriconazole or caspofungin.
BAL|bronchoalveolar lavage|BAL|213|215|HOSPITAL COURSE|The patient went on to develop increase shortness of breath and tachypneic requiring supplemental oxygenation, alternating between BiPAP and face mask oxymizer. A bronchoscopy was performed on _%#MMDD#%_ with the BAL being negative to date. The patient's respiratory status has overall improved with aggressive diuresis, however he continues to require supplemental oxygenation in order to maintain his saturations over 90.
BAL|bronchoalveolar lavage|BAL|140|142|PROBLEM #1|The patient's inhaled steroids were stopped secondary to the patient growing what seems to be Candida albicans and fungal elements out of a BAL from approximately one week ago. I think it is appropriate at this time to continue to hold his inhaled steroids, however we will need to get the pulmonary service involved as this patient is quite complex.
BAL|bronchoalveolar lavage|BAL,|241|244|LABORATORY|The pulmonary team was involved in the care of this patient, and we did perform a CT of the chest, with the results reported above, as well as a bronchoscopy with bronchoalveolar lavage, as well as a pleural tap. Culture from blood from the BAL, as well as from the pleural tap were sent, as well as gram stain and AFB stain, and all of them did not grow any specific pathogen.
BAL|bronchoalveolar lavage|BAL|200|202|HOSPITAL COURSE|The patient was also immediately placed on BIPAP as he seemed to do better with the BIPAP in place. The patient had bronchoscopy performed on _%#MM#%_ _%#DD#%_, 2002, which had the above description. BAL was obtained, and cultures were obtained which showed a negative CMV shell viral culture, negative AFB stain, and AFB culture is still pending.
BAL|bronchoalveolar lavage|(BAL)|162|166|PROCEDURES/TREATMENT PERFORMED|4. Chest x-ray, PA and lateral views, _%#MMDD2005#%_: Revealed multiple tiny pulmonary nodules. 5. HIV test, _%#MMDD2005#%_: Negative. 6. Bronchioalveolar lavage (BAL) with culture, _%#MMDD2005#%_: None were positive at time of dictation. 7. CT scan of chest without contrast, _%#MMDD2005#%_: No change.
BAL|bronchoalveolar lavage|BAL|160|162|PROCEDURES|No evidence of air fluid level or bony erosion is noted. 4. Bronchoscopy and bronchoalveolar lavage. No biopsy was performed, but right upper lobe geri-segment BAL was performed. This has been growing a light growth of group D enterococcus, heavy growth of alpha hemolytic streptococcus, and moderate growth of beaded- branching diphtheroids, which is a possible Nocardia species.
BAL|bronchoalveolar lavage|BAL|158|160|DISCHARGE DIAGNOSES|7. Bronchoscopy with bronchoalveolar lavage performed on _%#MMDD2004#%_. This was performed in response to the ground-glass opacity seen on the chest CT. The BAL washing did grow group D Enterococcus which was sensitive to ampicillin. Studies for CMV, PCP, and fungus were all negative. For the patient's initial presentation, past medical history, social history please see the interim summary dictated by Dr. _%#NAME#%_ _%#NAME#%_.
BAL|bronchoalveolar lavage|BAL|220|222|ASSESSMENT|The risk is upper airway bleeding. I recommend platelet transfusion today with a one hour post-transfusion platelet count. If we can get his platelets to over 50,000 even, I would be willing to consider bronchoscopy for BAL tomorrow afternoon with a repeat platelet transfusion. Sputum can be induced for various studies. Please see the orders. Empiric coverage should be broad and should include PCP particularly.
BAL|blood alcohol level|BAL|187|189|HOSPITAL COURSE|He did use hash and benzodiazepines in the 1970s. He denies intravenous drug use. HOSPITAL COURSE: He was hospitalized on _%#MMDD2004#%_ to the Medical Unit at Fairview University with a BAL of 0.3. He was treated with MSSA withdrawal protocol using Ativan. Mild tachycardia, on metoprolol, 6 mg of Ativan over the last two days, secondary to apparent anxiety.
BAL|bronchoalveolar lavage|BAL|175|177|HISTORY OF PRESENT ILLNESS|The next day he was dyspneic and a chest x-ray showed bilateral lower lobe consolidated infiltrates with effusions. His condition deteriorated and he became hypoxic. He had a BAL and was transferred to the MICU and subsequently intubated on _%#MMDD2007#%_ because of worsening hypoxia. He became oliguric with an increasing creatinine. His care was transferred to University of Minnesota Medical Center, Fairview, because of his cardiac and transplant history.
BAL|bronchoalveolar lavage|BAL|222|224|HISTORY OF PRESENT ILLNESS|On _%#MMDD2005#%_, because of prolonged decreased level of consciousness, he underwent and EEG. This was negative for current seizure activity. He was febrile. He had increased secretions. He underwent a bronchoscopy with BAL on _%#MMDD2005#%_. The cultures were positive for Strep pneumo, and he was continued on antibiotics. He has also has transient hyperglycemia, which has been treated supportively.
BAL|bronchoalveolar lavage|BAL|205|207|RECOMMENDATIONS|One may want to consider checking a urine for Legionella to rule out this pathogen as an etiology for the new nodule. 3. If he has clinical deterioration, one may need to consider another bronchoscopy and BAL and/or biopsy of that new right upper lobe nodule, as he is early in the post transplant course and the infectious differential remains quite wide.
BAL|bronchoalveolar lavage|BAL|174|176|HISTORY OF PRESENT ILLNESS|The chest x-ray at that time showed a right lower lobe infiltrate, following which a CAT scan showed a right lower lobe mass in the hilar mass with mediastinal adenopathy. A BAL was consistent with adenocarcinoma of the lung. At that time, the patient was not felt to be a surgical candidate. A PET scan on _%#MMDD#%_ was consistent with multiple uptake in the mid mediastinum, right hilar region and within the lung, as well as left axillary lymph node, inguinal and pelvic lymph nodes, multiple lesions in the thoracic and lumbar spine, as well as the bony pelvis and the right paraspinal area.
BAL|bronchoalveolar lavage|BAL|203|205|PERTINENT INVESTIGATIONS|A. Bilateral pneumothoraces, there is an increased area of bleb pneumothorax on the right side of the chest, persist pneumothorax on the left apex. 4. Bronchoscopy with BL on _%#MM#%_ _%#DD#%_, 2006: A. BAL growing a few positive cocci in clusters, which were thought to be coag-negative staphylococcus. BRIEF HISTORY OF PRESENTING ILLNESS: Mr. _%#NAME#%_ is a 33-year-old Hispanic male who presented from jail in respiratory distress.
BAL|bronchoalveolar lavage|BAL.|127|130|HOSPITAL COURSE|PROBLEM #6. Candida glabrata: The patient has colonized with Candida glabrata and to date has been grown in stool, throat, and BAL. It is unclear whether the glabrata in the BAL is problematic, but in any case is being treated with the patient's current antimicrobials.
BAL|bronchoalveolar lavage|BAL|147|149|PROBLEM #2.  ARDS|Otherwise, he is hemodynamically stable. His lung transplan t did not look like acute rejection and he was not treated for an acute rejection. The BAL and biopsies did not show any acute rejection. Again, he was on reduced immune suppressants secondary to his PTLD.
BAL|bronchoalveolar lavage|BAL|193|195|RECOMMENDATIONS|Ideally an abdominal and pelvic CT scan would also be useful secondary to this patient's fevers and abdominal pain. If this patient's respiratory status worsens she may need a bronchoscopy and BAL for diagnostic reasons. 5. Consider an ophthalmology examination if the conjunctivitis does not improve. Thank you for this interesting consult. We will follow with you.
BAL|bronchoalveolar lavage|BAL|233|235|HISTORY OF PRESENT ILLNESS|She denied any vomiting, blood in her stool, chest pain, shortness of breath, rash, or changes in her usual headaches at that time. She was found to have bilateral infiltrates and admitted for antibiotic therapy. She has undergone a BAL on _%#MMDD2006#%_ with findings of interstitial pneumonitis, but culture negative at that time. During her hospitalization on _%#MMDD2006#%_ she has finished her 30 day commitment for chemical dependency.
BAL|bronchoalveolar lavage|BAL|229|231|HISTORY OF PRESENT ILLNESS|She has continued to be febrile and continues to have abdominal pain, diarrhea, and no clear source of the infection has been identified as of yet and processed. There was some concern for lymphoma or reoccurrence of a past MAI. BAL biopsy, flow cytometry, BAL cytopathology, and peripheral blood smear have all been taken. There have been no clear leads at this point. She has received treatment with imipenem, Mycobutin, dapsone, and fluconazole, azithromycin, and levofloxacin, as well as her regular HIV medications for treatment of the infectious disease processes.
BAL|bronchoalveolar lavage|BAL|257|259|HISTORY OF PRESENT ILLNESS|She has continued to be febrile and continues to have abdominal pain, diarrhea, and no clear source of the infection has been identified as of yet and processed. There was some concern for lymphoma or reoccurrence of a past MAI. BAL biopsy, flow cytometry, BAL cytopathology, and peripheral blood smear have all been taken. There have been no clear leads at this point. She has received treatment with imipenem, Mycobutin, dapsone, and fluconazole, azithromycin, and levofloxacin, as well as her regular HIV medications for treatment of the infectious disease processes.
BAL|bronchoalveolar lavage|BAL|365|367|LABORATORY DATA|diff. Peripheral blood smear done on _%#MMDD2006#%_ showed normocytic normochromic anemia with anisonpoililosytosis, occasional spherocytes, prekeratocytes, occasional desmocytes, occasional elliptocytes, rare dacryocyte, and polychromasia. On _%#MMDD2006#%_ she had a BAL biopsy which just showed interstitial pneumonitis. On _%#MMDD2006#%_ the cytopathology from BAL demonstrated positive fungus, positive pseudohyphae, positive budding yeast. On _%#MMDD2006#%_ peripheral blood smear showed moderate normochromic, normocytic anemia with occasional bite and blister cells.
BAL|bronchoalveolar lavage|BAL|145|147|ASSESSMENT AND PLAN|We discussed it with infectious disease Dr. _%#NAME#%_ and she had a thought about the possibility of the lung being the sources, especially her BAL before showed that Klebsiella and E. coli and she had Klebsiella bacteremia in _%#MM#%_ and now she has E. coli bacteremia. Infectious disease thought that this can be something related to her stent.
BAL|bronchoalveolar lavage|BAL|205|207|PAST MEDICAL HISTORY|4) Probable previous myocarditis with ongoing cardiomyopathy. 5) Previous tobacco smoker of many years with COPD. 6) History of hypertension. 7) Iatrogenic pneumothorax, _%#MM#%_ of 2003. Bronchoscopy and BAL grew out Candida, and he was treated with oral Diflucan. 8) Pulmonary embolus, _%#MM#%_ of 2003, as above. 9) In _%#MM#%_ of 2003, right forearm AV fistula placed.
BAL|blood alcohol level|BAL|134|136|LABORATORY|No lateralizing extremity weakness. Romberg is negative. Cerebellar function is intact. There is no tremor or rigidity. LABORATORY: A BAL of 0.045 on presentation. Complete metabolic profile on _%#MMDD2003#%_ was normal with a potassium of 4.0, sodium 139, BUN 15, creatinine 1.0, normal liver function.
BAL|bronchoalveolar lavage|BAL|138|140|DISCHARGE DIAGNOSES|2. Pneumonia: The patient was started at presentation on intravenous ciprofloxacin and Zosyn. He did respond well to the antibiotics. His BAL culture at this time is not growing any bacteria. However, because of his high risk given his immunosuppression and the presence of influenza, we felt that continuing his antibiotics through his followup visit with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2005, would be appropriate.
BAL|bronchoalveolar lavage|BAL|161|163|PROCEDURES|Cultures were negative for bacteria. Fungal culture shows heavy growth Candida albicans. AFB stain negative. AFB culture is in progress. There is a bronchoscopy BAL culture from _%#MMDD2005#%_ that does show light growth Candida, light growth Aspergillus, and light growth Alternaria species. See history and physical dictated _%#MMDD2005#%_ for full details of past medical history and presenting symptoms.
BAL|blood alcohol level|BAL|148|150||While at Crossroads Halfway House she relapsed. She was a victim of an assault 9 days prior to admission. She was seen in the emergency room with a BAL of 0.36 and admitted. The patient was detoxed with Valium and did well. She required little medication and was medically stable by _%#MMDD2004#%_.
BAL|bronchoalveolar lavage|BAL|178|180|PROCEDURES PERFORMED|ADMISSION DIAGNOSIS: Viral pneumonia. DISCHARGE DIAGNOSES: 1. Enterococcus pneumonia. 2. Candida pneumonia. 3. Hypertension. 4. Diabetes. PROCEDURES PERFORMED: Bronchoscopy with BAL on _%#MMDD2003#%_. HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old Caucasian female with end-stage renal failure secondary to diabetes mellitus, type 1.
BAL|bronchoalveolar lavage|BAL|166|168|HOSPITAL COURSE|The patient had a chest tube placed on _%#MMDD2007#%_ to help remove this fluid for both therapeutic and diagnostic purposes. The patient also had a bronchoscopy and BAL on _%#MMDD2007#%_. The results of the patient's paracentesis and bronchial culture showed evidence of gram-positive cocci on Gram stain and his bronchial culture showed evidence of moderate growth of Staphylococcus lugdunensis which was pansensitive.
BK|BK (virus)|BK|140|141|PAST MEDICAL HISTORY|5. Hypertension. 6. Cataracts. He is blind in left eye. 7. Peripheral neuropathy. 8. Gastroparesis. 9. Kidney graft failure #1 secondary to BK polyoma. 10. BK polyoma nephropathy. 11. Pancreas graft failure secondary to chronic rejection of pancreas graft #1. 12. Positive B-cell crossmatch with DSA. Subsequent humoral rejection treated with IVIG & plasmapheresis with one rituximab dose.
BK|BK (virus)|BK|156|157|PAST MEDICAL HISTORY|5. Hypertension. 6. Cataracts. He is blind in left eye. 7. Peripheral neuropathy. 8. Gastroparesis. 9. Kidney graft failure #1 secondary to BK polyoma. 10. BK polyoma nephropathy. 11. Pancreas graft failure secondary to chronic rejection of pancreas graft #1. 12. Positive B-cell crossmatch DSA class II humoral rejection, acute treated with IVIG plasmapheresis x 13 rituximab doses.
BK|BK (virus)|BK|206|207|DISPOSITION AT DISCHARGE|The patient's hematology/gastrointestinal, cardiovascular, endocrine, fluid, electrolytes, nutrition issues have remained unchanged since the previous note. Regarding the patient's hemorrhagic cystitis and BK viruria, she is now status post 4 doses of intravesicular cidofovir. We have noticed some slight improvement in the hematuria over the past few days.
BK|BK (virus)|BK|306|307|BRIEF MEDICAL HISTORY|PROCEDURES PERFORMED: Transplant nephrectomy. BRIEF MEDICAL HISTORY: This is a 29-year-old African-American man with a history of end-stage renal disease secondary to focal segmental glomerulonephritis, status post deceased donor kidney transplant in _%#MM2006#%_. The transplant course was complicated by BK viremia requiring stopping all immunosuppression. The patient lost graft function and was back on hemodialysis since _%#MM2007#%_ three times a week.
BK|below knee|BK|214|215||She was taken to surgery the day following admission for extensive debridement of the three areas involved and placement of the wound VAC over the coccygeal ulcer. She was also treated with prisma dressings to the BK stump wound, as well as the left heel wound. She stabilized following admission. Transfer was arranged to a Transitional Care Unit for further treatment and wound VAC care of her coccygeal wound.
BK|below knee|BK|24|25|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. BK amputation left lower extremity for osteomyelitis of the left foot. 2. Diabetes mellitus. 3. Congestive heart failure (_______________). 4. Coronary artery disease symptomatic.
BK|below knee|BK|212|213|HISTORY OF PRESENT ILLNESS|Dr. (_______________), after admission, recommended amputation to the patient who was otherwise medically stable. Please see HPI and initial examination for details. HOSPITAL COURSE: The patient underwent a left BK amputation. He tolerated this well. The chronic drainage from the foot which was initially treated with IV vancomycin and Zosyn was continued postoperatively per recommendation of Dr. _%#NAME#%_ who followed the patient for ID purposes.
BK|below knee|BK|164|165|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Type 1 diabetes, fair to poor control. 2. Hypertension. 3. Diabetic complications including retinopathy, peripheral vascular disease, left BK amputation. 4. History of asthma on intermittent steroid use. 5. Severe osteoarthritis. 6. Status post total abdominal hysterectomy. 7. Status post appendectomy.
BK|BK (virus)|BK|242|243|DISCHARGE DIAGNOSES|Patient with a hemophagocytic syndrome which is characterized by neutrophils with nuclear hypersegmentation toxic granulation. 4. Molecular RFLP analysis reveals 100% donor engraftment on _%#MMDD2004#%_. 5. Hemorrhagic cystitis with positive BK virus treated with cidofovir. 6. History of low level CMV antigenemia positivity as of the beginning of _%#MM2004#%_ with no positive tests after that date.
BK|BK (virus)|BK|207|208|PROBLEM #2|EBV virus DNA was sent on _%#MMDD2004#%_ and no active EBV infection was identified at that time. PROBLEM #2: Hemorrhagic Cystitis. Although this was not documented in the FCIS chart, the patient was weakly BK virus positive. Due to this as well as her CMV antigenemia that had been a problem for her in _%#MM#%_, it was felt that she should be treated with cidofovir and later ganciclovir.
BK|BK (virus)|BK|131|132|PROBLEM #6|He was again started on vancomycin and amphotericin B. The vancomycin was changed to clindamycin before discharge. He had positive BK virus of his urine while having hemorrhagic cystitis. He had a positive HSV culture of his inflamed lip and was treated with topical acyclovir.
BK|BK (virus)|BK|152|153|PROBLEM #8|At this point, a slow steroid wean was begun. PROBLEM #8: Urinary: _%#NAME#%_ had hemorrhagic cystitis develop in mid _%#MM2005#%_. He was positive for BK virus on _%#MMDD2005#%_. He continued to have moderate bloody urine at the time of discharge. DISCHARGE MEDICATIONS: 1. Bactrim single strength one tablet b.i.d. Monday and Tuesday.
BK|below knee|BK|280|281|HISTORY|CHIEF COMPLAINT: Decubitus ulcer of the coccyx, gangrenous changes with drainage of the right stump and dry gangrene of the left heel HISTORY: _%#NAME#%_ _%#NAME#%_ is an 87-year old white female who was recently a patient of Fairview Southdale Hospital and had undergone a right BK amputation because of a non-healing right tib-fib fracture secondary to severe atherosclerotic disease. She has been a patient at the _%#CITY#%_ Care Center and came into the Fairview Southdale Wound Healing Institute Clinic for evaluation today and she was found to have three areas that needed extensive debridement and also a Wound Vac placement and because of this, she is going to be admitted to Fairview Southdale for surgical debridement tomorrow morning.
BK|below knee|BK|173|174|PLAN|8. Glucose intolerance. PLAN: Will be to have surgery review him. Will follow his sugars to see if he really does have high glucose. Treat the legs conservatively with TEDS BK elevation. Follow lytes and elevated BBC and rehydrate.
BK|BK (virus)|BK|188|189|PROBLEM #3|_%#NAME#%_ did receive 2 doses of IVIG during this hospitalization and tolerated them well. A CRP obtained on _%#MMDD2005#%_ was 155. A CRP at the time of discharge was 43.7. Of note, her BK virus test from the day of admission was positive, thus supporting the decision to decrease her immunosuppression. At the time of discharge, _%#NAME#%_ was discharged to home on voriconazole and caspofungin for the Candida parapsilosis UTI, vancomycin for the coag-negative staph bacteremia, ganciclovir for the EBV and CMV positive PCRs, and Bactrim prophylaxis.
BK|below knee|BK|184|185|HISTORY OF PRESENT ILLNESS|He has no pain up in the jaw, through the back and no diaphoresis. No nausea, no shortness of breath. The patient has known atherosclerotic vascular disease. He is status post a right BK amputation and left AK amputation. He has diabetes mellitus of 30 years' duration and he remains a regular cigarette smoker.
BK|below knee|BK|255|256|ASSESSMENT|1. Acute non-Q wave myocardial infarction. 2. Diabetes mellitus of 30 years' duration with complications of peripheral vascular disease, retinal vascular disease, chronic kidney disease and peripheral neuropathy. 3. Cigarette smoker. 4. Status post right BK amputation and left AK amputation. PLAN: Will admit to CICU. Will begin with heparin, aspirin, beta blockers, nitroglycerin will be as needed.
BK|below knee|BK|185|186|PHYSICAL EXAMINATION|Jugular veins are moderately distended. As mentioned, the patient has labored breathing. ABDOMEN: Non-tender, no masses, pelvic or rectal exam deferred. EXTREMITIES: There is bilateral BK amputees DIAGNOSTIC IMPRESSION: 1. Pneumonia 2. Respiratory failure 3. Critical aortic stenosis 4. Extensive pulmonary granulomatosis and fibrosis.
BK|below knee|BK|192|193|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: See recent record from _%#MM#%_. Significant problems include: 1. Diabetes mellitus, insulin dependent, since age 13. 2. PAD. Five procedures on the right leg prior to a BK amputation. She has had several procedures on the left leg. The last one was a femoral- femoral bypass graft in _%#MM#%_.
BK|below knee|BK|181|182|PHYSICAL EXAMINATION|Thyroid is negative. Carotids are equal. CHEST: Clear to A&P. HEART: Regular rhythm. No murmur or rub. ABDOMEN: Soft and nontender. No masses. BACK: No CVA tenderness. EXTREMITIES: BK amputation on the right. On the left, sutures remain in place on the stump of the left great toe. Exposed bone in the central area of the neck. No drainage.
BK|below knee|BK|196|197||His course of illness has been complicated by recent deep venous thrombosis of his lower extremity and then a subsequent embolic phenomenon that compromised his lower extremity and he underwent a BK amputation here a little over a month ago. He has had problems since that time with being able to fully extend his knee.
BK|below knee|BK|141|142|PHYSICAL EXAMINATION|ABDOMEN: Reveals somewhat obese abdomen with a well healed midline scar. There is no tenderness or organomegaly. EXTREMITIES: He has a right BK amputation in his right lower extremity with prosthesis on. His left leg has evidence of ischemic disease in the left lower lobe up to essential hypertension mid-calf level with blistering and erythema and some edema.
BK|BK (virus)|BK|103|104|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Allograft rejection of kidney transplant. 2. Hyperkalemia. 3. Hypertension. 4. BK virus positive. SECONDARY DIAGNOSES: 1. Focal segmental glomerulosclerosis. 2. Recurrent sinusitis. 3. Cytomegalovirus positive.
BK|BK (virus)|BK|257|258|HISTORY OF PRESENT ILLNESS|2. Hemodialysis. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 18-year-old girl with a past medical history for recurrent focal segmental glomerulosclerosis. She is status post renal transplant x3 with allograft rejection. She is EBV positive and BK virus positive who presents to the University of Minnesota Medical Center with hypertension. Her pressure is 160/100, however, she was asymptomatic on admission.
BK|below knee|BK|327|328|PROBLEM #6|PROBLEM #6: Physical deconditioning. The patient had a prolonged hospitalization and was still recovering from the neurological symptoms from her CNS lymphoma at the time of discharge; her situation was exacerbated by the fact that her "good" leg (from the perspective of recent neurologic events) is functionally limited by a BK amputation. The patient is being discharged to Fairview Transitional Services Unit for acute rehab. The patient has fair short-term rehab potential.
BK|BK (virus)|BK|174|175|ALLERGIES|He received vigorous replacement of IV fluids during the hospitalization. In addition, Pyridium was continued through the hospitalization. Cultures were sent for adenovirus, BK virus, urine cultures, and cytology, which subsequently showed no positive findings. The hemorrhagic cystitis subsequently did resolve approximately 4 or 5 days after admission.
BK|BK (virus)|BK|193|194|DISCHARGE DIAGNOSES|2. Red blood cells and platelet transfusion dependent. 3. Right elbow nodule of uncertain etiology. 4. Hemorrhagic cystitis. 5. Gram-positive cocci bacteremia. 6. Candida glabrata in feces. 7. BK virus in urine. IMAGING DONE DURING HOSPITALIZATION: CT of the chest without contrast done _%#MMDD2004#%_.
BK|BK (virus)|BK|194|195|HOSPITAL COURSE|This was treated with vancomycin for two weeks. The patient also grew out Candida glabrata from his feces and has been on nystatin for the past 10 days. As mentioned above, the patient also has BK virus in his urine. 6. Depression: The patient has significant depression. He has been on Effexor and Zyprexa during the hospitalization.
BK|below knee|BK|138|139|HOSPITAL COURSE|Patient did not have any episodes of bloody vomiting or any blood in the stools, and his stool guaiac was negative. 10. Patient had right BK amputation from his peripheral vascular disease. Patient had a wound care followup done for wound dressing. Patient has history of heart failure in the past, but his ventricular function was normal with medication therapy.
BK|BK (virus)|BK|144|145|HISTORY OF PRESENT ILLNESS|A biopsy was obtained, which indicated mild acute vascular rejection and moderate acute cellular rejection with negative C4D count and negative BK stain. He arrived to the University Hospital for further treatment of his rejection. Creatinine at the time of admission was 2.31. HOSPITAL COURSE: The patient was admitted for treatment of his acute cellular and (2:40) vascular rejection with OKT3.
BK|below knee|BK|213|214|HISTORY OF PRESENT ILLNESS|Dr. _%#NAME#%_ felt he wanted to give her a chance at a more limited amputation, but this has not gone well. The wound is not healing and she has severe pain. Therefore, she is being brought in at this time for a BK amputation of the affected leg. There have been no other medical problems with the exception of some diarrhea that was recently documented to be C.
BK|BK (virus)|BK|156|157|HOSPITAL COURSE|A screening transthoracic cardiac echocardiogram was performed which showed mild aortic regurgitation and no pericardial effusion. Troponins were negative. BK virus and CMV antigenemia were both negative. White blood cell count was within normal limits as well. The patient was set to be discharged on _%#MMDD2004#%_. Her diarrhea was ruled out; we had ruled out infections causes.
BK|BK (virus)|BK|221|222|PAST MEDICAL HISTORY|12. Migraine headaches. 13. Hypertension. 14. Hyperlipidemia. 15. Gastroesophageal reflux disease. 16. History of alcoholism and alcoholic cirrhosis. 17. Splenic infarct by CT _%#MM2006#%_ secondary to hypersplenism. 18. BK virus with left serum viral load greater than 1,122,007. 19. Pneumonia in _%#MM2006#%_ was group D and Klebsiella pneumonia. 20. Back surgery, L4-L5, in 2002. 21. Appendectomy. 22. Total knee replacement, 2000.
BK|BK (virus)|BK|120|121|PROBLEM #3|She was maintained on prophylactic fluconazole, acyclovir and Bactrim. PROBLEM #3: Hemorrhagic cystitis. Evaluation for BK virus is pending at the time of this dictation. Ms. _%#NAME#%_ continued to have intermittent hematuria and dysuria which did clear somewhat with IV hydration.
BK|below knee|BK|195|196|DISCHARGE STATUS|There is 3+ edema of the left leg. Pulses are 0 DP, 0 PT, 2 popliteal, 4 femoral. The wound was dressed during his hospital stay and on _%#MMDD2002#%_ he was taken to surgery where he had a left BK popliteal to ankle level posterior tibial bypass using in situ left greater saphenous vein and thrombectomy to the left popliteal to posterior tibial in situ bypass graft by Dr. _%#NAME#%_.
BK|below knee|BK|169|170|ASSESSMENT|2. Diabetes mellitus of 40 years duration. 3. Status post renal transplantation in 1982. 4. Immunosuppressed. 5. Retinal vascular disease with blindness. 6. Status post BK amputation, right side, for Charcot joint. PLAN: Cultures have been obtained and the patient was started on Rocephin and Zithromax.
BK|BK (virus)|BK|194|195|DISCHARGE INSTRUCTIONS|11. Aspirin 81 mg p.o. daily. 12. Cellcept 500 mg p.o. q.i.d. DISCHARGE INSTRUCTIONS: 1. The patient will also need to submit a urine specimen in the morning to the Transplant Center to run for BK virus. 2. Diet is regular. 3. Activities as tolerated.
BK|BK (virus)|BK|117|118|DIAGNOSIS|DIAGNOSIS: Rule out rejection of pancreas allograft, status post pancreas and kidney transplants (latter failed from BK virus). PROCEDURES PERFORMED: CT-guided biopsy of transplant pancreas on _%#MMDD2005#%_ showed no rejection.
BK|BK (virus)|BK|221|222|HISTORY OF PRESENT ILLNESS|His post transplant course was complicated by one episode of acute rejection of the pancreas allograft in _%#MM#%_ 2004. The patient also developed kidney graft dysfunction in _%#MM#%_ 2004. Biopsy of the kidney revealed BK polyoma virus, and the patient was treated with antivirals with reduction in immunosuppression, but ultimately requiring return to dialysis on _%#MMDD2005#%_.
BK|BK (virus)|BK|149|150|PAST MEDICAL HISTORY|7. History of anastomotic urine leak at the pancreatico- duodenocystostomy in _%#MM#%_ 2003. 8. Partial small bowel obstruction in _%#MM#%_ 2003. 9. BK polyoma virus of kidney allograft in _%#MM#%_ 2004. 10. Chronic renal insufficiency secondary to polyoma virus. The patient has recently been restarted on dialysis in _%#MM#%_ 2005 with current creatinine in the range of 7.
BK|below knee|BK|182|183|SUMMARY OF CASE|The patient's past history is well chronicled in other examiners' notes, but she does have a history of several vascular bypass procedures to her right lower extremity and her right BK amputation in 2002. Past surgical history also included a cholecystectomy and hernia repair. She has been diabetic for several years. The patient has no specific medication allergies.
BK|below knee|BK|154|155|SUMMARY OF CASE|She had normal vital signs, with BP approximately 140 systolic/80-86 diastolic. Resting pulse was normal. Skin examination showed good integrity over the BK amputation site on her right lower extremity, although the stump was somewhat cool. She had her left leg in a splint and brace-type of dressing, but had no particular symptoms after her BKA.
BK|BK (virus)|BK|200|201|HOSPITAL COURSE|The patient was okay with this plan and he was to continue on his steroid taper for his GVHD. We did start him on Ditropan 5 mg t.i.d. for the spasms, which he is to continue as an outpatient. He was BK virus positive from his urine. There is no necessary reason to treat this at this time because he is not extreme hemorrhagic cystitis.
BK|BK (virus)|BK|138|139|PAST MEDICAL HISTORY|2. Hypertension, fair to poorly controlled. 3. Diabetic complications - Retinopathy with blindness, neuropathy in her legs, she has had a BK on the left. 4. Asthma, treated with chronic oral steroids, as well as with inhaled steroids. 5. Osteoarthritis, which is severe and requires chronic narcotics.
BK|below knee|BK|344|345|HISTORY|CHIEF COMPLAINT: Heel ulcer. HISTORY: _%#NAME#%_ _%#NAME#%_ is an 83-year-old gentleman who is brought her from North Ridge Care Center where he had been admitted on _%#MMDD2006#%_ following a cerebrovascular accident and being hospitalized at North Memorial on _%#MMDD2006#%_. The patient has generalized weakness. He has had a previous right BK amputation and he now presents with ischemic pressure ulcer on the left heel, which has been deteriorating over the past several weeks and becoming more and more ischemic and necrotic.
BK|BK (virus)|BK|340|341|HISTORY OF PRESENT ILLNESS|He underwent HLA-matched allogenic sibling peripheral blood stem cell transplant on _%#MMDD2005#%_. He received all four doses of methotrexate. His posttransplant course was complicated by multiple problems, including Staph epi bacteremia, mucositis, renal insufficiency, herpes zoster, grade II skin GVH, hemorrhagic cystitis secondary to BK virus, CMV reactivation, and left pulmonary nodule that was treated empirically with voriconazole. He also had a line- associated DVT that was six months after transplant.
BK|below knee|BK|130|131|LABORATORY TESTS|HOSPITAL COURSE. The patient initially required control of her congestive heart failure in preparation for general anesthetic and BK amputation of the left leg. Once she was ready for this, the patient underwent the procedure without major complications.
BK|BK (virus)|BK|188|189|HISTORY OF PRESENT ILLNESS|His post-transplant course was complicated by one episode of acute rejection of the pancreas allograft in 2004 and kidney graft dysfunction in _%#MM#%_ 2004. Biopsy of the kidney revealed BK polyomavirus, and the patient was treated with antivirals with reduction in immunosuppression, but he ultimately required hemodialysis, starting _%#MMDD2005#%_.
BK|BK (virus)|BK|201|202|PAST MEDICAL HISTORY|3. Peripheral neuropathy. 4. Diabetic gastroparesis. 5. Hypertension. 6. Diabetic nephropathy and end-stage renal disease. 7. History of partial small bowel obstruction in _%#MM#%_ 2003. 8. History of BK polyomavirus. 9. Chronic hemodialysis. PAST TRANSPLANT HISTORY: 1. Simultaneous pancreas and kidney transplantation with bladder drainage of pancreatic exocrine function in _%#MM#%_ 2003.
BK|BK (virus)|BK|211|212|PAST TRANSPLANT HISTORY|1. Simultaneous pancreas and kidney transplantation with bladder drainage of pancreatic exocrine function in _%#MM#%_ 2003. 2. Enteric conversion in _%#MM#%_ 2003. 3. Transplant nephrectomy in _%#MM#%_ 2005. 4. BK polyomavirus with kidney graft failure. 5. Acute pancreas allograft rejection in _%#MM#%_ 2004. 6. Acute pancreas allograft rejection _%#MMDD2005#%_.
BK|BK (virus)|BK|341|342|PRIOR HOSPITALIZATIONS AND SURGERIES|3. Eczema. 4. Diagnosed with aplastic anemia on _%#MMDD2005#%_, failed immunosuppressive therapy. 5. Unrelated donor bone marrow transplant on _%#MMDD2006#%_, course complicated by: pancreatitis, pan colitis treated with Clindamycin and Flagyl, CMV viremia, EBV viremia (received Rituximab on _%#MMDD2006#%_), hemorrhagic cystitis (positive BK virus), left-sided hydronephrosis and proximal ureteropelvic junction obstruction with sloughing pocula (most recent ultrasound showed resolution of hydronephrosis on _%#MMDD2006#%_).
BK|BK (virus)|BK|190|191|HISTORY OF PRESENT ILLNESS AND COURSE IN HOSPITAL|He has chronic kidney disease and has been followed by Dr. _%#NAME#%_ _%#NAME#%_ from nephrology department. He had a kidney transplant in 2005 that failed this summer, lightly secondary to BK virus infection. Arrangement was made to have him started on hemodialysis. Of note, the patient has been having a decline in kidney function for the past 7 years.
BK|BK (virus)|BK|195|196|DIAGNOSES|2. Graft-versus-host disease of the skin and gut. 3. Pulmonary aspergillosis. 4. Diffuse alveolar hemorrhage. 5. Acute renal failure. 6. Atrial fibrillation with RVR. 7. Hemorrhagic cystitis. 8. BK viremia. 9. Epstein-Barr virus viremia. 10. Hypogammaglobulinemia. 11. Unstable angina. 12. Hypercarbic respiratory failure. SUMMARY OF EVENTS LEADING TO DEATH: In the final days of _%#NAME#%_'s life he had multiorgan failure with complications involving particularly his pulmonary and renal systems.
BK|BK (virus)|BK|224|225|PROBLEM #2|As the sirolimus level was slightly detectable, we will check 1 final sirolimus level this coming Thursday as an outpatient. PROBLEM #2: Chronic kidney disease: The patient did undergo a renal consultation. There is a serum BK virus DNA quantification that is pending. Should that be positive, it was the feeling of the renal consultation team that the patient should undergo a kidney biopsy.
BK|below knee|BK|297|298||_%#NAME#%_ _%#NAME#%_ is a 52-year-old woman who has had diabetes mellitus of long duration that was insulin dependent was admitted with swelling, pain and discharge from the stump of her left great toe. She has a history of peripheral arterial disease and has had previous bypass grafts. She has BK amputation of the right leg. She had an amputation of the left great toe in _%#MM#%_ 2002. Consultation was asked by Surgery and Infectious Disease. LABORATORY DATA: Electrolytes normal.
BK|BK (virus)|BK|199|200|HOSPITAL COURSE|The patient was given a dose of Zenapax on his first hospital day for suspected acute rejection. Upon review of the labs, the patient was noted to have drawn a PCR of his urine which showed positive BK virus. Another differential included possible viral associated cause for his kidney failure. The following morning the patient underwent a kidney biopsy, and the results of which showed no evidence for acute rejection and no evidence for any viral associated infection.
BK|BK (virus)|BK|236|237|HOSPITAL COURSE|Thus, the renal dysfunction could be a cyclosporine mediated effects for his creatinine increase; although, the patient had previously been on cyclosporine for an extended period of time without any issues. The patient also had a serum BK virus PCR sent which was negative. The patient remained afebrile while he was in the hospital. Since the etiology of his creatinine elevation could not be determined while the patient was in the hospital, further workup will be in an outpatient setting.
BK|BK (virus)|BK|228|229|DATE/TIME OF DEATH|She did well until approximately 30 days post transplant, at which time she developed acute renal failure of unclear etiology requiring a dialysis. In addition she developed hemorrhagic cystitis with urine cultures positive for BK virus. She required continuous bladder irrigation and had persistent hematuria. She then developed progressive respiratory distress and a bronchoscopy-isolated group D enterococcus, C and V shell vial-positive, and adenovirus.
BK|BK (virus)|BK|133|134|PROBLEM #5|His creatinine and electrolytes are stable at the time of discharge. PROBLEM #5: Genitourinary. History of hemorrhagic cystitis with BK positive, but he had no hematuria during this hospitalization. PROBLEM #6: Cardiovascular. He was admitted with nausea and vomiting after some shoveling and was ruled out for MI.
BK|BK (virus)|BK|252|253|HISTORY OF PRESENT ILLNESS|Unfortunately, post-transplant course was complicated by acute allograft rejection and he gradually lost his kidney function due to this. It was believed that his allograft rejection was the result of calcineurin inhibitor toxicity as well as possibly BK virus infection, as recently diagnosed. Postoperative course was also complicated by urethral stricture, resulting in percutaneous nephrostomy tube placement.
BK|BK (virus)|BK|207|208|HOSPITAL COURSE|Again on _%#DD#%_, _%#NAME#%_ had a positive blood culture from his blue port that grew out coag-negative staph with the same sensitivity pattern. In addition, because of his dysuria, we did check urine for BK virus and _%#NAME#%_ had 5,350,900 copies of BK virus in his urine. Since all of his organisms from his line were sensitive to vancomycin, he was discharged to home to complete a course of IV vancomycin.
BK|BK (virus)|BK|255|256|HOSPITAL COURSE|Again on _%#DD#%_, _%#NAME#%_ had a positive blood culture from his blue port that grew out coag-negative staph with the same sensitivity pattern. In addition, because of his dysuria, we did check urine for BK virus and _%#NAME#%_ had 5,350,900 copies of BK virus in his urine. Since all of his organisms from his line were sensitive to vancomycin, he was discharged to home to complete a course of IV vancomycin.
BK|BK (virus)|BK|239|240|3.  INFECTIOUS DISEASE|Virology studies collected during the course of the patient's stay showed an EBV IgG level of 6.43, EBV IgM level of 3.15, and no detectable EBV nuclear antibody. His CMV IgM was negative as was his rotavirus antigen. Quantitative PCR for BK virus and CMV were negative. His quantitative EBV DNA was 26,000 and his herpes-6 antibody was at a level that may indicate current or past infection.
BK|BK (virus)|BK|223|224|ADMITTING DIAGNOSES|ADMITTING DIAGNOSES: 1. End-stage renal disease. 2. Type 1 diabetes mellitus with triopathy. 3. History of hemolytic anemia. 4. History of a living-donor kidney transplant in 1986 with subsequent transplant nephrectomy for BK virus. 4. Status post deceased donor pancreas transplant in 2004. DISCHARGE DIAGNOSES: 1. End-stage renal disease. 2. Type 1 diabetes mellitus with triopathy.
BK|BK (virus)|BK|305|306|LABORATORY DATA ON ADMISSION|LABORATORY DATA ON ADMISSION: White blood cell count 7.4, hemoglobin 8.9, hematocrit 25.9, sodium 138, potassium 4.2, chloride 114, bicarb 13, BUN 30, creatinine 2.05, glucose 90, calcium 9. INR is 1.14, PTT 32, mycophenolic acid level was 5.76, MPA glucuronide is 101.7, also at the time of admission, a BK virus and CMV, DNA were sent and these were later found to be negative. HOSPITAL COURSE: Following his biopsy _%#NAME#%_ was restarted on his home medications except for his fluconazole secondary to concerns that this may be interfering with his metabolism of tacrolimus.
BK|BK (virus)|BK|141|142|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: End-stage kidney disease from unknown etiology, status post living donor kidney transplant in 2005, which failed due to BK nephropathy. SERVICE: Kidney transplant. ATTENDING: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD. FELLOW: Dr. _%#NAME#%_.
BK|BK (virus)|BK|193|194|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ _%#NAME#%_ is a 65-year-old gentleman with end-stage kidney disease from unknown etiology. He was status post living donor kidney transplant in _%#MM2005#%_, which failed due to BK nephropathy. He was started on hemodialysis on _%#MM2006#%_. The patient was admitteed for a living donor kidney retransplant. Because he has a donor specific antibody, he has been receiving IVIG and plasmaphoresis for antibody reduction to his current living donor.
BK|BK (virus)|BK|180|181|HOSPITAL COURSE|He was tolerating a regular diet without any nausea or vomiting prior to discharge. An ID consult was obtained due to the patient's history of the failed renal transplant due to a BK virus. They recommend checking it weekly BK PCR for 4 weeks and then to check it monthly. They also recommended that due to the patient's foster daughter's history of MRSA in the urine that the daughter avoids changing the patient's diapers and wear gloves if necessary.
BK|BK (virus)|BK|140|141|HOSPITAL COURSE|An ID consult was obtained due to the patient's history of the failed renal transplant due to a BK virus. They recommend checking it weekly BK PCR for 4 weeks and then to check it monthly. They also recommended that due to the patient's foster daughter's history of MRSA in the urine that the daughter avoids changing the patient's diapers and wear gloves if necessary.
BK|BK (virus)|BK|188|189|LABORATORY WORK|LABORATORY WORK: Shows hemoglobin 11.4, white count 3600, platelet count 61,000. Electrolytes are normal range. Echocardiogram from _%#MMDD2007#%_ no vegetation. Ejection fraction 50-55%. BK virus from urine positive. ASSESSMENT: 1. This is a patient with recent coag-negative Staphylococcus bacteremia, I would note that she has had previous bacteremias in the past, which are presumably no longer a factor.
BK|BK (virus)|BK|166|167|ASSESSMENT|When her antibiotics are stopped she should have surveillance blood culture on day 2 and again on day 6 or with any recurrent fever. 2. Urine with blood and positive BK virus. No treatment for this at present. Problem seems to be improving. 3. Graft-versus-host disease with associated immune disturbance.
BK|BK (virus)|BK|118|119||She has a Charcot foot and has been nonweight-bearing for many months. The plan is to stop her Pletal and then have a BK amputation in the next two weeks. Hospital stay was uncomplicated. She had some hypotension, so lisinopril was held. DISCHARGE DIAGNOSES: 1. Type 1 diabetes. 2. Gastroesophageal reflux disease.
BK|BK (virus)|BK|146|147|PAST MEDICAL HISTORY|8. Pneumonia diagnosed in _%#MM2006#%_. 9. Gastrointestinal GVHD and chronic diarrhea. 10. GVHD of the skin. 11. Hemorrhagic cystitis with a high BK virus load. ALLERGIES: No known drug allergies. HOSPITAL COURSE: PROBLEM #1: Infectious disease: _%#NAME#%_ was found to be febrile on admission with a temperature of 100.2. His temperature remained mildly elevated with max ranging from 100.3 to 101.5 over the next 3 days.
BK|BK (virus)|BK|298|299|HISTORY OF CURRENT ILLNESS|She was electively intubated and placed on the ventilator. Bronchoscopy was performed and BAL grew adenovirus which was not treated due to the nephrotoxicity of the therapy. In addition to the neural toxicity and mental status deterioration, _%#NAME#%_ developed hemorrhagic cystitis with positive BK virus in her urine. She received 3 cidofovir bladder infusions and was on continuous bladder irrigation for over 1 month with no evidence of clinical improvement.
BK|below knee|BK|123|124|HISTORY OF PRESENT ILLNESS|This was followed a year later with an attempt to right femoral to distal popliteal which failed and ended up with a right BK amputation. He had a coronary bypass surgery in 1987 and repeat in 1993. He had a fissurectomy and anal fissurectomy in 1999. As noted last year, he had the left femoral popliteal bypass.
BK|below knee|BK|131|132|DISCHARGE DIAGNOSIS|PLAN: Basic metabolic panel in one week and Accu-Cheks on a regular basis. DISCHARGE DIAGNOSIS: 1. Skin infection of the foot with BK amputation. 2. Insulin-dependent diabetes mellitus 3. Congestive heart failure with cardiomyopathy. 4. Depression.
BK|BK (virus)|BK|218|219|BRIEF HOSPITAL COURSE|The patient eventually required dialysis. Cardiology consult service was consulted for atrial fibrillation with RVR which was very difficult to control. The patient developed hemorrhagic cystitis which was found to be BK virus positive. After a brief period of stability, the patient had a second episode of increasing respiratory requirement.
BK|BK (virus)|BK|172|173|PAST MEDICAL HISTORY|4. Gastroesophageal reflux disease. 5. Hypertension. 6. Dyslipidemia. 7. Benign prostatic hypertrophy. 8. Erectile dysfunction. 9. History of hiatal hernia. 10. History of BK nephropathy status post transplant nephrectomy in _%#MM2007#%_. 11. History of Mycobacterium infection pneumonia in right lower lobe in 2006. 12. History of squamous cell carcinoma. 13. Charcot joint left foot.
BK|BK (virus)|BK|174|175|PROBLEM#1|The patient also had a renal workup for an elevated creatinine and previous history of chronic renal insufficiency. The workup included metabolic renal panel, urine test for BK virus, hemoglobin A1c and glucose. The renal team suggested starting the patient on enalapril prior to discharge for elevated blood pressures and protein found in his urine as well as have the patient follow up with an adult nephrologist upon discharge.
BK|BK (virus)|BK|166|167|PROBLEM #4|Urinalysis/urine culture on admission was negative. His symptoms were actually suspected to be secondary to the cyclophosphamide and improve with adequate IV fluids. BK virus was checked _%#MMDD2005#%_ and came back positive (greater than 1:1000). However, it was opted not to treat because of subjective improvement.
BK|BK (virus)|BK|265|266|DISCHARGE INSTRUCTIONS|9. Dextromethorphan 30 mg p.o. q.6h p.r.n. cough. DISCHARGE INSTRUCTIONS: The patient was discharged to the Argyle House and will return to BMT Clinic starting _%#MMDD2005#%_. He should have daily CBCs, chem 10s three times a week, and weekly liver function tests. BK virus should be rechecked, particularly if the patient becomes symptomatic again. He should have full restaging studies on day 28 (_%#MMDD2005#%_) at which time his previous chest CT findings can be followed.
BK|BK (virus)|BK|181|182|BRIEF HOSPITAL COURSE BY SYSTEM|A urine culture was obtained on admission along with urine microscopic analysis. Urine culture later returned no growth final. As part of transplant protocol, the patient underwent BK virus qualitative PCR as well as urine for BK virus. The results of these studies are pending at this time. 3. Fluids, electrolytes, and nutrition: The patient consumed a regular diet during his hospitalization.
BK|BK (virus)|BK|146|147|BRIEF HOSPITAL COURSE BY SYSTEM|Urine culture later returned no growth final. As part of transplant protocol, the patient underwent BK virus qualitative PCR as well as urine for BK virus. The results of these studies are pending at this time. 3. Fluids, electrolytes, and nutrition: The patient consumed a regular diet during his hospitalization.
BK|below knee|BK|455|456|HISTORY|CHIEF COMPLAINT: Bleeding from right leg ulcer. HISTORY: _%#NAME#%_ _%#NAME#%_ is an 80-year-old gentleman who has had significant problems with a chronic wound of his right lower leg and foot area was brought in by ambulance today when he had the sudden onset of bleeding at the time of dressing change to his right lower leg. The patient has a history of having had significant problems with arteriosclerotic vascular disease and already has had a left BK amputation and had developed an anterior tibial ulceration from which he has had intermittent significant bleeding, and this has caused at least two prior hospitalizations within the last six months from significant bleeding from this hypergranulation tissue of the anterior tibial wound.
BK|BK (virus)|BK|277|278|PAST MEDICAL HISTORY|Of note, she has had an extensive history of anxiety/panic attacks, but feels that she has had better control over the past few weeks. PAST MEDICAL HISTORY: 1. Fanconi anemia status post transplant on _%#MMDD2006#%_ that was CMV negative, HSV positive. Complications including BK virus, hemorrhagic cystitis, pulmonary edema requiring intubation. 2. CSA toxicity and PRES (posterior reversible leukoencephalopathy syndrome) with seizure and she was on Keppra through _%#MM2007#%_.
BK|BK (virus)|BK|204|205|HISTORY OF PRESENT ILLNESS AND HOSPITALIZATION COURSE|PROCEDURES DONE DURING HOSPITALIZATION: Transplant nephrectomy. HISTORY OF PRESENT ILLNESS AND HOSPITALIZATION COURSE: Mr. _%#NAME#%_ is status post deceased donor kidney transplant and being treated for BK virus infection for about 2 months before this admission. After the second dose of cidofovir a few days ago, he developed generalized weakness, headache, nausea and vomiting.
BK|BK (virus)|BK|147|148|HISTORY OF PRESENT ILLNESS AND HOSPITALIZATION COURSE|The patient also developed fevers up to 102.2. With that, his serum creatinine increased to 6.2 mg/dL the morning of this admission. The patient's BK virus blood levels were very high and considering the fact that he was having renal dysfunction, it was decided that he undergo renal biopsy.
BK|BK (virus)|BK|190|191|HISTORY OF PRESENT ILLNESS AND HOSPITALIZATION COURSE|The kidney biopsy showed acute graft rejection that necessitated kidney removal. Transplant nephrectomy was done on _%#MMDD2007#%_ both for the treatment of acute cellular rejection and the BK nephropathy. The patient's postoperative course was mainly uncomplicated; however, on postoperative day #2, the patient developed some shortness of breath and his O2 saturation was only in the high 80s.
BK|below knee|BK|154|155|HISTORY OF PRESENT ILLNESS|She also had evidence of a small non-Q wave MI during that time. She underwent an amputation of the left great toe during that stay. She previously had a BK amputation on the right that was a few years ago for vascular problems. Prior to that she had had multiple revascularization procedures on the right leg.
BK|below knee|BK|143|144|PHYSICAL EXAMINATION|CHEST: Clear to percussion and auscultation. HEART: Regular rhythm, no murmur or rub. ABDOMEN: Soft and nontender with no masses. EXTREMITIES: BK amputation on the right. Stump is clean and healed with no lesions. Left leg has slight swelling over the dorsum of foot, extending to over 1st and 2nd metatarsals.
BK|BK (virus)|BK|238|239|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Significant for positive EBV diagnosis and C. diff toxin that was positive on _%#MMDD2007#%_, finished 14-day course of Flagyl. _%#NAME#%_ also had a history of suspected hemorrhagic cystitis with urine positive for BK virus on _%#MMDD2007#%_. PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: Weight 119.9 kilograms, pulse 122, blood pressure 104/66, respirations 32, oxygen saturations 97% on room air and temperature 36.5 degree celsius.
BK|BK (virus)|BK|265|266|CLINICAL HISTORY|Her baseline creatinine is 1.4. However, on outpatient labs she was noted to have a creatinine of 3.9. She has had 1 previous episode of rejection which was treated with Solu-Medrol in _%#MM#%_ 2005. She also has a history of positive C4D staining and positive for BK virus in the past. She also reports 3- to 4-day history of diarrhea with abdominal pain and decreased p.o. intake.
BK|BK (virus)|BK|149|150|PAST MEDICAL HISTORY|She was admitted for possible kidney biopsy due to her elevated creatinine. PAST MEDICAL HISTORY: 1. RPGN and associated end-stage renal disease. 2. BK viremia in the past. 3. Hypertension. 4. Hypothyroidism. 5. History of rejection. 6. Hypercholesterolemia. 7. Living related kidney transplant on _%#MM#%_ _%#DD#%_, 2002.
BK|BK (virus)|BK|203|204|PAST MEDICAL HISTORY|10. GVHD of the skin treated successfully with triamcinolone. He has also been treated with a short course of methylprednisolone during his last hospitalization. 11. Hemorrhagic cystitis related to high BK virus load. Resolved by discharge of last hospitalization. MEDICATIONS: 1. Florinef 0.1 mg p.o. q. day. 2. Protonix 20 mg p.o. q. day.
BK|BK (virus)|BK|386|387|PAST MEDICAL HISTORY|1. Aplastic anemia diagnosed on _%#MM#%_ _%#DD#%_, 2005. She failed immunosuppressive therapy; an unrelated donor bone marrow transplant was performed on _%#MM#%_ _%#DD#%_, 2006. Her course has been complicated by pancreatitis, pancolitis treated with clindamycin and Flagyl, CMV viremia, EBV viremia, which she received rituximab in _%#MM#%_ 2006, hemorrhagic cystitis with a positive BK virus, left-sided hydronephrosis, and proximal ureteropelvic junction obstruction with flossing pocula that has since resolved on an ultrasound done on _%#MM#%_ _%#DD#%_, 2006.
BK|below knee|BK|250|251|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 54-year-old man with severe diabetes and renal failure was admitted back to the hospital with an avascular infected right foot. He is prepared for surgery and taken to the operating room where a BK amputation was done with immediate postoperative plaster dressing. Postoperatively she has done very well. He has remained afebrile, showed no signs of infection.
BK|below knee|BK|216|217|SURGICAL PROCEDURE|He will be discharged to home or the nursing home and will be followed up in our office in two weeks for a cast change. FINAL DIAGNOSIS: Avascular right foot secondary to diabetes mellitus. SURGICAL PROCEDURE: Right BK amputation with immediate fit prosthesis.
BK|BK (virus)|BK|152|153|TPN.|Symptoms can be followed up as an outpatient and he will be on a steroid taper. 4. Hemorrhagic cystitis. Initially felt to be from Cytoxan but he had a BK virus that showed up in his urine that also is known to cause the hemorrhagic cystitis. There is no treatment for this. This resolved on its own.
BK|below knee|BK|147|148|EXAMINATION|HEART: Unremarkable except the usual soft ejection type systolic murmur at the base. ABDOMEN: Negative. EXTREMITIES: Reveal no edema. Healed right BK amputation and reduced pulses. NEUROLOGIC: Demonstrates the usual findings of peripheral neuropathy. LABORATORY STUDIES: Since admission are noteworthy for troponin-I, which is gradually lower from 2 to 1.8 to 1.6. The patient's blood glucose is about 200 after Solu-Medrol therapy.
BK|below knee|BK|142|143|ASSESSMENT|Her left foot again has this ischemic looking area but it has healed adequately. ASSESSMENT: She is a _%#1914#%_ demented patient who needs a BK amputation on the right. Will have Ortho see her for this. The patient is DNR/DNI as per son and other family's request.
BK|BK (virus)|BK|223|224|PAST SURGICAL HISTORY|5. IVC Greenfield filter placed on _%#MMDD2007#%_. 6. Cystoscopy and removal of penile prosthesis on _%#MMDD2007#%_. 7. Nissen fundoplication. 8. Right lower lobe lung biopsy in 2007. 9. Transplant nephrectomy secondary to BK nephropathy in _%#MM2007#%_. 10. Splenectomy secondary to hemolytic autoimmune anemia and incidental appendectomy in _%#MM2007#%_. 11. Retinal photocoagulation. 12. Thrombectomy and thrombolytics for bilateral femoral vein to IVC filter thrombosis in _%#MM2007#%_.
BK|BK (virus)|BK|266|267|INDICATIONS FOR ADMISSION|The patient began to feel concerned because he took additional doses to make up for the dose he vomited and was worried that his levels were excessive causing shakiness. Of note, the patient had a living donor kidney transplant in 2005, but this failed secondary to BK nephropathy. He reports no sore throat, congestion, shortness of breath, cough, chest pain, dysuria or rashes, but does report nausea, vomiting, decreased appetite, vertigo, headache, fever and shakiness.
BK|BK (virus)|BK|367|368|HOSPITAL COURSE|HOSPITAL COURSE: The patient was admitted to the Transplant Service on _%#MMDD2007#%_ for further workup of possible rejection. A renal ultrasound was performed and was normal and on admission the patient was pancytopenic with a white blood cell count of 2.3, hemoglobin of 9.2, platelet count of 44 and CMV DNA quantitation was elevated with a log of 6.5 as well as BK virus PCR quantitative was elevated to log 5.9. The patient was transfused with multiple packs of platelets and an renal biopsy was performed.
BK|BK (virus)|BK|53|54|ADMITTING DIAGNOSES|ADMITTING DIAGNOSES: Anemia, here for kidney biopsy, BK nephropathy, iatrogenic coagulopathy. DISCHARGE DIAGNOSES: 1. BK viremia. 2. Acute transplant rejection 1A.
BK|BK (virus)|BK|134|135|INDICATIONS FOR ADMISSION|He has had continued poor graft function. He was seen in renal transplant clinic on _%#MMDD2007#%_ and it was discovered that a prior BK virus level had returned high. The patient is admitted for transplant renal biopsy and monitoring due to recent Coumadin use.
BK|BK (virus)|BK|173|174|HOSPITAL COURSE|A lumbar puncture was performed with an opening pressure of 24 cm of water. She tolerated the procedure well. Initial studies and CSF were normal. Further studies including BK and JC virus PCR and CSF oligoclonal bands as well as other PCR studies are pending. Neurosurgery was consulted for possible brain biopsy. This, however, was put on hold as review of her outpatient MRI studies from _%#MMDD2006#%_ was suspicious for PML, progressive multifocal leukoencephalopathy.
BK|BK (virus)|BK|493|494|LABORATORY STUDIES|Urine culture is pending. Magnesium 1.4, ferritin 322, lipase 717, amylase 179, total bilirubin less than 0.1, albumin 3.2, alkaline phosphatase 116, ALT 24, AST 18 and phosphorous 4.4. INR 1.15, PTT 29. CSF studies, white blood cell count of CSF 1, red blood cell count of CSF 1, CSF glucose 52, CSF protein 55, CSF cryptococcal antigen negative, CSF routine bacteria culture negative, CSF fungal culture negative, CSF Gram stain negative, CSF India ink preparation negative, CSF PCR for JC, BK and other viruses are pending. DISCHARGE MEDICATIONS: 1. Valcyte 450 mg p.o. b.i.d. 2. Advair Diskus 500/50 mcg 1 puff p.o. b.i.d.
BK|BK (virus)|B.K.|159|162|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1 History of AML type M2 and has received blood transplant as described above in the HPI. 2 History of hemorrhagic cystitis secondary to B.K. virus. 3 History of staph epidermidis bacteremia. 4 History of streptococcus bacteremia. 5 History of GVH (off prednisone since _%#MMDD#%_). 6 CMV positive. HOSPITAL COURSE: PROBLEM #1. Possible hand, foot and mouth disease: The patient's symptoms and exam was highly suggestive of hand, foot and mouth disease.
BK|BK (virus)|BK|222|223|PAST MEDICAL HISTORY|Cytogenetics showed trisomy 21. The patient received induction chemotherapy with idarubicin and cytarabine 3 plus 7. 2. Myeloablative double cord blood transplant for AML-M2 on _%#MMDD2006#%_. 3. Hemorrhagic cystitis with BK viruria. 4. Grade 3 acute GVH of the skin and gut. The patient started prednisone on _%#MMDD2006#%_, with taper held due to continued GI symptoms.
BK|BK (virus)|BK|156|157|IMPRESSION|He was subsequently started on ganciclovir for treatment of the reactivated CMV. During this hospitalization, it was also noted that _%#NAME#%_'s urine was BK virus positive, which was sent during his previous hospitalization and was felt to account for his hemorrhagic cystitis. During the workup of _%#NAME#%_'s CVM reactivation, he was seen by Ophthalmology who noted a conjunctival nevus in his right eye.
BK|BK (virus)|BK|233|234|MICRO|RADIOLOGY: Chest x-ray from outside hospital reveals right-sided pneumonia. CT chest from outside hospital not yet available. MICRO: Urinalysis: Large blood. No fecal leukocytes. Negative Legionella pneumophila antigen. EBV pending. BK pending. CMV pending. Blood cultures, including fungal cultures x 2 sites pending. LABS: Sodium 131, potassium 518, chloride 107. C02 16, BUN 90, creatinine 5.4, glucose 109, calcium 8.6, magnesium 1.5, phosphorus 4.7. White count 8.9, 90% neutrophils, 3% lymphocytes, 7% monocytes.
BK|BK (virus)|BK|168|169|PROCEDURES|PROCEDURES: During the admission included the pancreas biopsy, which was negative for rejection or infection. She also had histoplasmosis testing which was negative, a BK virus, which was negative. Renal ultrasound showed no hydronephrosis. She had numerous chest x-rays with a left lobe pneumonia being identified.
BK|BK (virus)|BK|199|200|DISPOSITION|DISPOSITION: At discharge labs on her final day of her admission included a creatinine a 1.7, hemoglobin 10.6, white blood count 3.4, amylase 137, lipase 306. Urine and blood cultures were negative. BK virus negative, histoplasmosis negative. The patient was instructed to continue her Levaquin for 5 more doses. She will followup with Dr. _%#NAME#%_ of infectious disease in 2 weeks.
BK|BK (virus)|BK|220|221|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Diabetes mellitus type 1 complicated by proliferative retinopathy, peripheral neuropathy, gastroparesis and diabetic nephropathy. 2. End-stage renal disease secondary to diabetic nephropathy and BK virus. 3. Hypertension. 4. History of small-bowel obstruction _%#MM2003#%_. 5. Subarachnoid hemorrhage in _%#MM2004#%_. 6. History of kidney graft failure secondary to BK polyoma virus in _%#MM2004#%_.
BK|BK (virus)|BK|200|201|PROBLEM #7|He continues to have hyperbilirubinemia, which is currently being treated with ursodiol. PROBLEM #7: Genitourinary: As mentioned previously, he had difficult to manage hemorrhagic cystitis, which was BK virus positive. He required aggressive hydration during this time, but as mentioned previously this was now resolved. PROBLEM #8: graft versus host disease: He continues on CSA IV and mycophenolate for prophylaxis of GVHD.
BK|BK (virus)|BK,|153|155|HOSPITAL COURSE|The next day second stool specimen was sent for C. diff toxins, which were negative. Stools cultures have also been negative. Virology studies including BK, CMV, DNA quants and adenovirus and rotavirus, stool antigen were negative. The patient subsequently had a colonoscopy, which revealed normal colon.
BK|BK (virus)|BK|222|223|PAST MEDICAL HISTORY|13. Hypothyroid. 14. Secondary adrenal insufficiency. 15. Urinary incontinence with cystoscopy in _%#MM2007#%_ showing nonspecific bladder thickening without any changes on VCUG indicating reflux. He was also at that time BK virus positive. PHYSICAL EXAM ON ADMISSION: VITAL SIGNS: Temperature 36.3, pulse 124, blood pressure 100/62, respirations 20, O2 saturations are 100% on room air, weight 35 kilograms, height 142 cm.
BK|below knee|BK|184|185|HISTORY OF PRESENT ILLNESS|He has a history of significant arteriosclerotic peripheral vascular disease which was repaired with a bypass on _%#MMDD2001#%_ of the left common femoral to the right profundus right BK popliteal revascularization. This has failed and amputation is now planned. Surgery is scheduled with Drs. _%#NAME#%_ and _%#NAME#%_ on _%#MM#%_ _%#DD#%_. The patient states his understanding and is looking forward to "no more pain" after the operation.
BK|below knee|BK|151|152|PHYSICAL EXAMINATION|ABDOMEN: Is obese, but no LKKS, mass, tenderness. Liver is 10 cm height by percussion. LEGS: Reveal brown moderately stiff scaly, dermatitis from just BK to the ankles. She has superficial varicosities very small. Her dorsalis pedis, posterior tibials, and popliteal pulses are almost unobtainable, maybe 1/4+.
BK|below knee|BK|81|82||_%#NAME#%_ _%#NAME#%_ is a 79-year-old female who recently underwent surgery for BK amputations for peripheral vascular disease and then developed a perforated sigmoid colon resulting in colostomy surgery. She was transferred back from _%#CITY#%_ Care Center because of decreased level of alertness and not eating well the last few days.
BK|below knee|BK|131|132|ASSESSMENT|EXTREMITIES: She has amputations of both lower legs. SKIN: A little erythema below the breasts. ASSESSMENT: 1. Infection of recent BK amputation, left leg. 2. Incisional drainage from her abdominal surgery for perforated bowel. 3. Diabetes. 4. Cervical cancer. 5. Radiation proctitis/cystitis. 6. Hypertonic bladder.
BK|BK (virus)|BK|255|256|PROBLEM #9|The TLC Program has also been involved with _%#NAME#%_'s care over the past several weeks. PROBLEM #9: Genitourinary. Early after transplant _%#NAME#%_ had severe hemorrhagic cystitis, which required continuous bladder irrigation, and she was noted to be BK virus positive. PROBLEM #10: Hematology. _%#NAME#%_'s hemoglobin transfusion parameter is 8 and her platelet transfusion parameter is 50, however, she has not recently needed platelets of those transfusion parameter level.
BK|below knee|BK|222|223|PHYSICAL EXAMINATION|He is in no acute distress. His head and neck exam is normal other than many missing teeth. CHEST: Clear. HEART: Regular rhythm. No murmurs heard. ABDOMEN: Nontender. EXTREMITIES: Damaged distal right lower extremity with BK amputation. The left side is difficult to palpate pulses. RECTAL: Not done at this time. NEURO: Diminished sensation to the feet.
BK|BK (virus)|BK|189|190|PROBLEM #6|She did have intermittent febrile episodes during her hospitalization and was treated with broad spectrum antibiotics. All blood cultures remain negative. A urine specimen was positive for BK virus with greater than 10 million copies noted on _%#MMDD2007#%_. A repeat urine specimen for BK virus remains pending at this time.
BK|BK (virus)|BK|168|169|PROBLEM #6|All blood cultures remain negative. A urine specimen was positive for BK virus with greater than 10 million copies noted on _%#MMDD2007#%_. A repeat urine specimen for BK virus remains pending at this time. In addition an EBV, PCR level also remains pending from _%#MMDD2007#%_. These results should be followed up in the bone marrow transplant clinic.
BK|BK (virus)|BK|175|176|DISCHARGE DIAGNOSES|2. Chemotherapy induced transverse myelitis with urinary retention and paraplegia. 3. Hypertension. 4. CMV pneumonitis. 5. CMV retinitis. 6. Hemorrhagic cystitis secondary to BK virus. 7. VRE urinary tract infection. CONSULTATION DURING THIS ADMISSION: 1. On _%#MMDD2007#%_ pulmonology with bronchoscopy and bronchoalveolar lavage. 2. On _%#MMDD2007#%_ neurology consult.
BK|BK (virus)|BK|246|247|HOSPITAL COURSE|3. CMV retinitis found on _%#MMDD2007#%_. She has received 2 intraocular injections of foscarnet and ganciclovir. For her CMV infection she received foscarnet and ganciclovir intravenously. 4. Hemorrhagic cystitis detected on _%#MMDD2007#%_ with BK virus detected in the urine. 5. Hypertension controlled with as needed hydralazine currently. 6. Nausea and vomiting during conditioning chemotherapy controlled with Zofran drip and currently with Zofran as needed.
BK|BK (virus)|BK|199|200|PROBLEM #3|He was treated with Ditropan and intermittent Pyridium. He continued to have significant symptomatic hemorrhagic cystitis requiring multiple Foley placements and continuous bladder irrigation. He is BK virus positive. His GBI was stopped on _%#MMDD2008#%_ and his Foley was removed. At the time of discharge, he is still having cherry red urine.
BK|BK (virus)|BK|241|242|HISTORY OF PRESENT ILLNESS|The patient's post transplant course was been complicated by the following: Staph infection, Enterobacter cloacae, mycobacterium, AVM bacteremia, VRE, MAI pneumonia requiring intubation x2, CMV reactivation, EBV reactivation, cholecystitis, BK viruria, GBHD. More recently the patient was admitted on _%#MMDD2007#%_ for CMV reactivation. The patient presents today because of fevers of 103 at home.
BK|below knee|BK|141|142|HISTORY OF PRESENT ILLNESS|He has had a sore throat, a little bit of headache, aching, and some nausea. He has a long history of diabetes mellitus. He is status post a BK amputation on the right side and spends all his time in a wheelchair, although he can make transfers. As noted above, he has been progressively weaker with a cough, some chills, sore throat, just not feeling well and then the episode of syncope or near-syncope this afternoon.
BK|below knee|BK|204|205|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Ulcer, left heel. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 55-year-old male with diabetes and renal failure who has been followed for a long time by my office. He has had a BK amputation on the right, which has now been fitted with a prosthesis. He is actually doing quite well. He has had multiple finger amputations.
BK|below knee|BK|288|289||Her INR on that day was 1.81. Before her surgery for five days, she had had Lovenox subq q.12h. and then, of course, all was withheld, even her usual routine Coumadin, and she had a 1.08 INR on _%#MMDD2003#%_ and a 1.81 on _%#MMDD2003#%_. She states herself she has continued to wear her BK support hose at all times as she knows it is very important. She has a past medical history of recurrent DVTs over the last several years, almost having an umbrella placed on an admission about a year ago.
BK|below knee|BK|232|233|REVIEW OF SYSTEMS|He has some radicular pain down his left leg. He says he has been documented to have a herniated disk problem in his low back. As far as neuro goes, he says that he does have good sensation in his left foot. Has an amputation stump BK on the right side due to trauma. PAST SURGICAL HISTORY: _______________. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure on repeated in the 140s/70s.
BK|below knee|BK|149|150|PHYSICAL EXAMINATION|There is a healed sternal scar. HEART: Regular rhythm. No ectopy observed. ABDOMEN: Soft. No masses. No tenderness. Healed scars. EXTREMITIES: Right BK stump. Left leg - decreased pulses in left foot. No edema. He says sensation is intact. LABORATORY DATA: Normal electrolyte and renal function.
BK|below knee|BK|134|135|IMPRESSION|History of hypertension. History of hyperlipidemia, he does not take any statins now. History of reaction to Niacin. History of right BK amputation due to trauma. History of appendectomy. History of cholecystectomy.
BK|BK (virus)|BK|236|237|HISTORY OF PRESENT ILLNESS|He underwent non-myeloablative umbilical cord stem cell transplant _%#MMDD2005#%_, complicated by neutropenic fevers and pansensitive Pseudomonas pneumonia, treated with Ciprofloxacin. Also had history of hemorrhagic cystitis which was BK positive and resolved with antiviral treatment. The patient was discharged in _%#MM2005#%_ and then was readmitted on _%#MMDD2005#%_ for this hospitalization, due to increased shortness of breath, orthopnea, and wheezing with a dry cough.
BK|BK (virus)|BK|369|370|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Unchanged from previous H&P. Crohn's disease, status post total proctocolectomy with ileostomy and short bowel syndrome with chronic diarrhea, type 2 diabetes mellitus, renal transplant 6 years ago secondary to ATN and dehydration, anxiety and depression, left rotator cuff injury, GERD, fibromyalgia, osteoarthritis, history of CMV ........ with BK virus on 2004 and 2005, and history of MRSA recent hospitalization for right upper lobe pneumonia and cellulitis. REVIEW OF SYSTEMS: Malaise, weakness, fatigue, fibromyalgia, osteoarthritis, decreased urine output, recently resolving oral thrush, and dyspnea on exertion, cough, heavy feeling.
BK|BK (virus)|BK|280|281|HISTORY OF PRESENT ILLNESS|The patient is being treated with Thymoglobulin and has had a recent decrease of creatinine from 5 to 3.5. Her baseline creatinine was 1.3. The patient had a biopsy performed in transplantation clinic on _%#MM#%_ _%#DD#%_, 2003, which revealed acute rejection and some concern of BK virus. She is admitted today for OKT3 therapy. PAST MEDICAL HISTORY: 1. End-stage liver disease secondary to hepatitis C which she contracted at age 25.
BK|BK (virus)|BK|185|186|PROBLEM #4|He was recently switched from Gengraf to Neoral to see if that was the cause of the eosinophilia. PROBLEM #4: Genitourinary: _%#NAME#%_ developed severe hemorrhagic cystitis related to BK virus. His continuous bladder irrigation was stopped on _%#MM#%_ _%#DD#%_, 2004, and his Foley was removed on _%#MM#%_ _%#DD#%_, 2004. He continues to have bloody urine with occasional clots and shreds, but no dysuria.
BK|BK (virus)|BK|161|162|PROBLEM #6|He did have frequency and urgency and was started on scheduled Ditropan and p.r.n peridium. His fluids were also increased to 120 milliliters/hour. Notably, the BK virus was positive in his urine. PROBLEM #7. Neurology. _%#NAME#%_ was on Trileptal at home for seizure prophylaxis.
BK|below knee|BK|161|162|OPERATIONS/PROCEDURES PERFORMED|11. History of splenic infarct. 12. Penile implant. 13. Status post bowel resection in _%#MM#%_ 2002 at St. Francis hospital for ischemic colitis. 14. Bilateral BK amputation at (_______________) hospital in 2000 and 2001. 15. Anemia of chronic disease. 16. Coronary artery disease. Last angiogram in _%#MM#%_ 2004 showed diffuse coronary artery disease and was without any focal lesions, amenable to treatment.
BK|BK (virus)|BK|201|202|HOSPITAL COURSE|3. Infectious Disease: He was started on ceftriaxone and vancomycin upon admission. A urinalysis, urine culture and blood cultures were obtained. These were all negative. Today at discharge, EBV, CMV, BK virus, parvovirus, adeno virus, enterovirus, and West Nile virus were all tested for. At discharge, EBV and CMV were negative. The other viral exams were negative except for parvovirus.
BK|BK (virus)|BK|124|125|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Graft-versus-host disease. 2. C. difficile colitis. 3. Dehydration. 4. Urinary tract infection with BK virus. 5. Status post non-myeloablative allogeneic sibling transplantation for mantle cell lymphoma. HOSPITAL PROCEDURES: 1. Chest x-ray on _%#MMDD2006#%_, which was clear.
BK|BK (virus)|BK|88|89|PROBLEM #4|He was started on IV fluids, and this improved after his diarrhea resolved. PROBLEM #4: BK virus urinary tract infection. The patient had BK virus present in his urine in the BMT Clinic. He was maintained on Pyridium on initiation of his hospitalization.
BK|below knee|BK|162|163|FOLLOW-UP INSTRUCTIONS|He stabilized and was anxious to go home. At the time of discharge, he was up and able to get around as usual in his wheelchair. The patient is status post right BK amputation for peripheral vascular disease. DISCHARGE MEDICATIONS: Include: 1. Ventolin inhaler 2 puffs p.o. q. 4 hours p.r.n.
BK|below knee|BK|172|173|DISCHARGE DIAGNOSES|4. Renal failure due to diabetes-on dialysis. 5. COPD. 6. Coronary disease. 7. Obesity. 8. Peripheral vascular disease. 9. Chronic venostasis disease. 10.Status post right BK amputation due to peripheral vascular disease-gangrene of the right foot.
BK|BK (virus)|BK|188|189|HOSPITAL COURSE|Biopsy results revealed mild acute tubulointerstitial rejection and immunofluorescence was positive for polyoma virus. Given these biopsy results showing ongoing rejection and concern for BK virus contributing to it, the patient was given a 3-day course of methylprednisolone 500 mg each day and was given a 1 time dose of IVIG.
BK|BK (virus)|BK|120|121|PROBLEM #2|The patient was continued on renal diet during her hospitalization and had no difficulty tolerating it. PROBLEM #2: ID: BK virus positive in urine and blood with PCRs as stated above in FEN/GI/Renal. PROBLEM #3: CV/Heme: The patient had CBC checked on _%#MMDD2007#%_ revealed an white blood cell count of 7.7, hemoglobin 10.9 and platelets 171,000.
BK|BK (virus)|BK|176|177|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. End-stage renal disease (ESRD) status post renal transplant in _%#MM2007#%_. 2. Mild acute tubulointerstitial rejection on status post renal biopsy. 3. BK virus positive. DISCHARGE MEDICATIONS: 1. Ferrous sulfate 160 mg p.o. daily.
BK|BK (virus)|BK|217|218|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Diabetes mellitus type 1. 2. Proliferative retinopathy. 3. Peripheral neuropathy. 4. Diabetes mellitus gastroparesis. 5. End-stage renal disease secondary to diabetes mellitus nephropathy and BK virus. 6. History of small bowel obstruction in _%#MM2003#%_. 7. Hypertension. 8. Subarachnoid hemorrhage in _%#MM2003#%_. PAST TRANSPLANT HISTORY: 1. Deceased donor simultaneous pancreas-kidney transplant with bladder drainage of pancreatic exocrine secretions in _%#MM2003#%_.
BK|BK (virus)|BK|136|137|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: Moderate tubulointerstitial acute renal allograft rejection episode with some mild vascular changes and history of BK virus infection. CLINICAL HISTORY: The patient is a 16-year-old girl with end-stage renal disease secondary to MPGN, status post living-related kidney transplant in _%#MM#%_ 2002 who was recently admitted with increased creatinine.
BK|BK (virus)|BK|211|212|DISCHARGE INSTRUCTIONS|4. Followup with Dr. _%#NAME#%_ of pediatric nephrology in 1 week to assess her rejection treatment. 5. She will also follow up with Dr. _%#NAME#%_ _%#NAME#%_ of Infectious Disease for monthly followup with her BK virus status. On discussion with Dr. _%#NAME#%_ _%#NAME#%_, she will not be continued on outpatient ganciclovir or valacyclovir for CMV prophylaxis since her CMV level was normal.
BK|BK (virus)|BK|138|139|IMPORTANT INVESTIGATIONS AVAILABLE DURING THIS HOSPITALIZATION|4. Methotrexate-induced mucositis, which is resolving. IMPORTANT INVESTIGATIONS AVAILABLE DURING THIS HOSPITALIZATION: INVESTIGATIONS: 1. BK virus PCR. 61,100 copies/mL, 4.8 log copies detected in the urine. The patient is asymptomatic for a urinary tract infection or cystitis and was hence not treated.
BK|BK (virus)|BK|197|198|HOSPITAL COURSE|He was placed on Synthroid and his dose was last adjusted on _%#MMDD2006#%_. He got monthly TSH and free T4 checks. 7. Urology. _%#NAME#%_ had hemorrhagic cystitis following his lung biopsy, and a BK virus PCR showed greater than 1 million copies. _%#NAME#%_ was placed on Ditropan and Pyridium, and given increased fluids.
BK|BK (virus)|BK|389|390|HOSPITAL COURSE|Of note, _%#NAME#%_'s CRP became markedly elevated on the second day of her stay at the hospital, the initial value was 19.9 on admission, but elevated on _%#MMDD2006#%_ to 257 and slowly came down over the next week from that point to a discharge value of 26.5. Due to the high creatinine and the continued fevers, ID was consulted on _%#MMDD2006#%_. Viral cultures were obtained for the BK virus, EBV and CMV. Those cultures showed _%#NAME#%_ was BK virus positive, EBV negative and CMV negative. Upon administration of the ceftriaxone, _%#NAME#%_'s fevers dropped and she became afebrile, as of _%#MMDD2006#%_.
BK|BK (virus)|BK|132|133|HISTORY OF PRESENT ILLNESS|In addition, he had a PEG tube placed on that day for tube feedings. The other longterm complication Mr. _%#NAME#%_ experienced was BK viruria. He developed severe hemorrhagic cystitis associated with the BK virus early in his hospital course and his hematuria, dysuria, and bladder spasms persisted nearly continuously for the next three months.
BK|BK (virus)|BK|205|206|HISTORY OF PRESENT ILLNESS|In addition, he had a PEG tube placed on that day for tube feedings. The other longterm complication Mr. _%#NAME#%_ experienced was BK viruria. He developed severe hemorrhagic cystitis associated with the BK virus early in his hospital course and his hematuria, dysuria, and bladder spasms persisted nearly continuously for the next three months.
BK|BK (virus)|BK|261|262|SECONDARY DIAGNOSIS|5. Coagulase-negative Staphylococcal bacteremia. 6. Hyperbilirubinemia. 7. Malnutrition. 8. Diabetes secondary to steroids versus cyclosporin. 9. Cyclosporin-induced hypertension. 10. Vaginal bleeding. 11. Mucositis. 12. Urinary frequency and incontinence. 13. BK virus in the urine. HISTORY OF PRESENT ILLNESS: The patient is a 38-year-old woman who was diagnosed with pH positive precursor B-ALL.
BK|BK (virus)|BK|213|214|PROBLEM #10|PROBLEM #10: Urinary frequency: The patient did develop some urinary frequency and incontinence. She was started on Ditropan, which did help her symptoms improve. On _%#MMDD2007#%_, she developed hematuria, and a BK virus level was checked. It came back as positive for greater than 1,000,000; however, since her symptoms were improving, we decided not to treat her.
BK|BK (virus)|BK|162|163|FOLLOWUP LABS|5. Toprol-XL 50 mg q. day. 6. NovoLog, as directed before. 7. Cipro 250 mg p.o. b.i.d. for next 7 days. FOLLOWUP LABS: Please follow adenovirus, cytomegalovirus, BK virus study, and CD4 count. It was a pleasure to be involved in Ms. _%#NAME#%_'s care.
BK|BK (virus)|(BK|267|269|DEATH DIAGNOSES|DEATH DIAGNOSES: 1. Acute myeloid leukemia (AML - M7), status post myeloablative triple umbilical cord transplant with natural killer cell therapy. 2. Diffuse alveolar hemorrhage. 3. Cardiorespiratory failure from diffuse alveolar hemorrhage. 4. Hemorrhagic cystitis (BK virus infection). 5. Cytomegalovirus viremia. 6. Probable fungal pneumonia. MAJOR PROCEDURES DONE DURING THIS ADMISSION: 1. On _%#MMDD2006#%_, the patient had a bone marrow biopsy, which was hypocellular with no evidence of leukemia.
BK|BK (virus)|BK|176|177|FAMILY HISTORY|He is to have labs drawn q. Monday, Wednesday and Friday. He is to return to the Transplant Center on _%#MM#%_ _%#DD#%_, 2002, for labs as well as _%#MM#%_ _%#DD#%_, 2002, for BK virus PCR testing. His home care agency will be Fairview Home Care. DISCHARGE MEDICATIONS: His discharge medications will be the following: 1. Norvasc 5 mg p.o. q.a.m.
BK|BK (virus)|BK|171|172|DISCHARGE DIAGNOSES|DISCHARGE DATE: _%#MMDD2007#%_. DISCHARGE DIAGNOSES: 1. Hypertensive emergency. 2. Hypertensive encephalopathy. 3. Genital herpes. 4. Recent MCV activation. 5. History of BK virus. IMAGING AND PROCEDURES: 1. Head CT _%#MMDD2007#%_ showing no acute intracranial pathology.
BK|BK (virus)|BK|278|279|BRIEF HISTORY OF PRESENT ILLNESS|REVISED _%#MMDD2007#%_/JJ DISCHARGE DIAGNOSES: Accelerated hypertensive. BRIEF HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old female with a medical history significant for type 1 diabetes status post pancreas transplant and status post failed kidney transplant due to BK virus who is scheduled for a living donor renal transplant on _%#MMDD2007#%_ who presented with her second episode of hypertensive emergency in approximately 2 weeks. Please refer to my dictated admission history and physical for full details.
BK|BK (virus)|B.K.|217|220|HOSPITAL COURSE|4. Recent CMV activation. This was evaluated during this hospitalization by an infectious disease team and since her most recent CMV PCR was negative her Valtrex was changed to maintenance dose Valcyte. 5. History of B.K. virus. This was investigated also by the infectious disease team and it was felt that since her B.K. virus had been inactive that her leflunomide as well as her ciprofloxacin could be discontinued.
BK|BK (virus)|B.K.|318|321|HOSPITAL COURSE|4. Recent CMV activation. This was evaluated during this hospitalization by an infectious disease team and since her most recent CMV PCR was negative her Valtrex was changed to maintenance dose Valcyte. 5. History of B.K. virus. This was investigated also by the infectious disease team and it was felt that since her B.K. virus had been inactive that her leflunomide as well as her ciprofloxacin could be discontinued. DISCHARGE INSTRUCTIONS: The patient is to check her blood pressure four times daily following taking her regular blood pressure medication throughout the day.
BK|below knee|BK|214|215|PHYSICAL EXAMINATION|EXTREMIITIES: Reveal left knee to be in immobilizer. He does have pain with palpation of left knee. There is no edema of left foot and ankle. He is status post partial left foot amputation. He is status post right BK amputation on the right. Only sensation to light touch in left ankle and foot. I do not appreciate a pedal pulse on his left.
BK|BK (virus)|BK|243|244|HOSPITAL COURSE|Due to the unknown reason for the leukopenia, the patient's Bactrim and Valcyte were discontinued per recommendations of nephrology. Further workup to evaluate the neutropenia was performed by measuring parvovirus B19 antibodies, IgG, IgM and BK virus PCR quantification. These were pending at the time of discharge. The patient received a transplant ultrasound which showed ureteropelvic junction thickening, no sign of abscess or fluid collection or hydronephrosis.
BK|below knee|BK|243|244|SUMMARY|She has had chronic back pain since a motor vehicle accident in 1994, underwent back surgery including fusion L5-S1 in _%#MM#%_ of 2000, at Fairview University Hospital. She has had residual back pain ever since, pleuritic type pain and right BK amputation, pain management has been incomplete. PAST MEDICAL HISTORY: Childhood illnesses: None serious. Adult illnesses: Serious motor vehicle accident in 1994 with numerous surgeries, resulting in BK amputation of right leg.
BK|below knee|BK|151|152|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Childhood illnesses: None serious. Adult illnesses: Serious motor vehicle accident in 1994 with numerous surgeries, resulting in BK amputation of right leg. History of asthma. Has albuterol inhaler at home, but uses rarely. Essential hypertension. Remote history of depression. Remote history of gastroesophageal reflux disease.
BK|below knee|BK|187|188|PHYSICAL EXAMINATION|No wheeze, rhonchi. Heart tones are regular rhythm. No gallop or murmur. Abdomen is soft without palpable mass. Bowel sounds are normal. Genitourinary: Pelvic exam deferred. Extremities: BK amputation right leg. No areas of skin breakdown. Left leg: Pulse is present in the groin, knee, and ankle. Reflex is 1+ out of 4+. Neurological exam: Cranial nerves intact____________________ diminished overall.
BK|below knee|BK|195|196|IMPRESSION|Reflex is 1+ out of 4+. Neurological exam: Cranial nerves intact____________________ diminished overall. Toe signs down- going. IMPRESSION: 1. Chronic low back pain. 2. Neuralgia right leg, post BK amputation. 3. Hypertension. 4. Asthma. 5. Obesity. PLAN: Admission to Dr. _%#NAME#%_'s service for temporary placement of a dorsal column stimulator.
BK|below knee|BK|213|214|PHYSICAL EXAMINATION|No evidence of major hernia. Bowel sounds were present. She complained of discomfort with light palpation in all four quadrants. Pelvic examination was not done. The lower extremities showed no significant edema. BK amputation site not inflamed. Neurologically, she seemed to be interactive through the interpreter and was able to provide a medical history accurately per interpreter.
BK|below knee|BK|166|167|IMPRESSION|IMPRESSION: 1. This is an adult woman here with signs and symptoms of bowel obstruction. 2. Past history of appendectomy and right hemicolectomy. 3. Status post left BK amputation. 4. Status post left hip arthroplasty and left knee surgery. PLAN: 1. The patient will be kept in the Intensive Care Unit for close observation and monitoring.
BK|BK (virus)|BK|207|208|PROBLEM #9|He does have a history of reflux and treatment with Prevacid has continued. PROBLEM #9: Genitourinary. _%#NAME#%_ developed hemorrhagic cystitis on _%#MMDD#%_ about three weeks after bone marrow transplant. BK virus was positive. Hemorrhagic cystitis did continue throughout his admission up until the day of discharge. PROBLEM #10: Neurologic. _%#NAME#%_ developed pain secondary to GCSF and a Fentanyl PCA was started to help control this pain.
BK|BK (virus)|BK|202|203|PROBLEM #3|His CSF from _%#MMDD2002#%_ is positive for echovirus 13 enterovirus. _%#NAME#%_ was also known to have rotavirus in his stool on _%#MMDD2002#%_ and _%#MMDD2002#%_, which cleared by _%#MMDD2002#%_, and BK virus in his urine. PROBLEM #4: Pulmonary. CT scans of _%#MMDD2002#%_ and _%#MMDD2002#%_ revealed persisting calcification of the anterior mediastinum and large bilateral effusions with associated dependent atelectasis.
BK|below knee|BK|208|209|SURGICAL HISTORY|5. Kidney-pancreas transplant _%#MM#%_ _%#DD#%_, 1999. Currently the pancreas is drained into the bladder. 6. Patient is also status post tubal ligation. 7. Numerous eye surgeries. 8. Left toe amputation. 9. BK amputation on the right. PAST MEDICAL HISTORY: 1. Diabetes type I. 2. Visual impairments due to cataracts (she has a shell on the right eye) which was treated with an alcohol block for glaucoma.
BK|BK (virus)|BK|181|182|PROBLEM #8|PROBLEM #8: Urology. The patient developed hematuria approximately three days ago on _%#MMDD2003#%_. Urine was pink with some clots; no pain. He has been treated with hydration and BK virus cultures are pending. DISCHARGE MEDICATIONS: 1. Vitamin K 5 mg p.o. once a day for two weeks, then discontinue.
BK|below knee|BK|157|158|FOLLOW UP|She had resection of the area early with replacement of bone and then with a lymph salvage in _%#MM#%_ of 2001. She had recurrent ankle osteo and then had a BK amputation. She was given two different types of chemotherapy. Her last was with ifosfamide of VP-16. She was off chemo in _%#MM#%_ of 2001. Her initial chemo was Adriamycin, cisplatin, and methotrexate.
BK|below knee|BK|143|144|REASON FOR ADMISSION|REASON FOR ADMISSION: Dysvascular lower extremity, right leg. _%#NAME#%_ _%#NAME#%_ has failed transmetatarsal amputation and brought in for a BK amputation. Dr. _%#NAME#%_ _%#NAME#%_ performed the surgery. She has multiple medical problems evaluated and stabilized. She was transferred to a rehab center with good careful family attention.
BK|below knee|BK|173|174|PHYSICAL EXAMINATION|Thyroid negative. Carotids are equal. CHEST: Clear to percussion and auscultation HEART: Regular rhythm, no murmur or rub. ABDOMEN: Soft, nontender. No masses. EXTREMITIES: BK amputation on the right leg. The left foot has an open ulcer at the base of the stump of the left great toe. No inflammation or drainage. Trace of pedal edema on the left.
BK|below knee|BK|141|142|DIAGNOSIS|DIAGNOSIS : 1. Osteomyelitis persistent in the surgical stump left great toe. 2. Severe peripheral vascular disease to the left leg. 3. Post BK amputation on the right 4. Diabetes mellitus, insulin dependent, age 13. 5. Coronary artery disease, recent angiography. 6. Previous cerebrovascular accident with minimal residual left sided weakness
BK|below knee|BK|220|221|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Right frontal parietal stroke near the vertex and the precentral gyrus. In addition, new tiny lacunar infarct in the right periventricular matter as well. 2. Peripheral vascular disease with left BK and right heel ulcer with recent femoral popliteal bypass and local wound care treatment for his ulcer. 3. Atherosclerotic coronary disease. 4. History of chronic obstructive pulmonary disease.
BK|below knee|BK|115|116|DISCHARGE MEDICATIONS|The patient did have paresis of the left arm. He was alert and oriented. He seems to have control of the course of BK amputation there though and there were no facial signs. The patient was admitted. MRI revealed the acute stroke in the right frontal parietal cortex near the vertex and the tiny lacunar infarct in the right periventricular white matter.
BK|BK (virus)|BK|146|147|HOSPITAL COURSE|She should also continue her estrogen patch for an approximate two-week period, and then, this can be discontinued if her bleeding has stopped. A BK virus urine sample was sent just prior to discharge, so this result is pending at this time. PROBLEM #2: Heme. She had a bone marrow biopsy on _%#MMDD2003#%_ which revealed 100% donor engraftment and no evidence of lymphoma.
BK|BK (virus)|BK|188|189|PROBLEM #7|On the day of discharge, her creatinine was 0.67. She also developed mild urinary frequency and hematuria on _%#MMDD2004#%_. Urine was sent for culture, which was negative, as well as for BK virus, which was still pending at the time of discharge. Her urine is mostly yellow, with occasional bloody shreds. She was not treated with aggressive IV hydration, as her oral intake of fluids was quite good.
BK|BK (virus)|BK|232|233|HOSPITAL COURSE|By hospital day #2 _%#NAME#%_ was very active on the floor, was eating well, and was urinating on a regular basis. He denied any pain, and his urinalysis and urine cultures were negative for yeast and bacteria. A urine PCR test for BK virus is pending, and results will be discussed on an outpatient basis. PROBLEM #2: Poor social care. The patient has an unfortunate history of being placed in foster care a number of times, and being abused by his biological mother.
BK|BK (virus)|BK|187|188|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 54-year-old woman with a history of a living unrelated kidney transplant in _%#MM1999#%_. She experienced loss of this kidney secondary to BK virus and some reflux nephropathy. Hemodialysis was re-initiated in _%#MM2001#%_. She has been a three times weekly dialysis dependent since _%#MM2001#%_.
BK|BK (virus)|BK|179|180|CONDITION ON DISCHARGE|The patient was comfortable and stable for discharge to home at this time. She was requiring no oxygen and had excellent O2 saturations on room air. Urine and serum screening for BK virus was drawn on the day of discharge, to screen for further presence of BK virus in this patient. She will need close surveillance for BK, given that she had previous allograft loss secondary to this etiology.
BK|BK (virus)|BK|182|183|CONDITION ON DISCHARGE|She was requiring no oxygen and had excellent O2 saturations on room air. Urine and serum screening for BK virus was drawn on the day of discharge, to screen for further presence of BK virus in this patient. She will need close surveillance for BK, given that she had previous allograft loss secondary to this etiology.
BK|BK (virus)|BK|77|78|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Right hemiparesis. 2. Shingles, left upper chest. 3. BK virus of transplanted kidney with renal insufficiency. 4. Status post pancreas and kidney transplants. PROCEDURES PERFORMED: 1. CT scan of head x 2.
BK|BK (virus)|BK|234|235|ADMISSION HISTORY|ADMISSION HISTORY: _%#NAME#%_ _%#NAME#%_ is a 40-year-old female status post kidney and pancreas re-transplant in 2000 to treat type 1 diabetes and triopathy. Her course has been complicated by infection of the transplant kidney with BK virus resulting in renal insufficiency. She presents now with severe bilateral weakness that is most striking in the right lower extremity and right upper extremity.
BK|BK (virus)|BK|130|131|PAST MEDICAL HISTORY|HIV, HGLV, hepatitis C and B negative. 2. Patient also had IDDM since 1991. 3. Hypertension. 4. Hemorrhagic cystitis secondary to BK virus and possibly Cytoxan. 5. Autoimmune graft-versus-host disease. 6. Renal insufficiency secondary to CSA and BK virus. 7. CMV antigenemia. PHYSICAL EXAMINATION: Final temperature was 99.1, pulse 92, blood pressure 144/80, respiration 20, saturating 95% on room air.
BK|BK (virus)|BK|170|171|PAST MEDICAL HISTORY|3. Hypertension. 4. Hemorrhagic cystitis secondary to BK virus and possibly Cytoxan. 5. Autoimmune graft-versus-host disease. 6. Renal insufficiency secondary to CSA and BK virus. 7. CMV antigenemia. PHYSICAL EXAMINATION: Final temperature was 99.1, pulse 92, blood pressure 144/80, respiration 20, saturating 95% on room air.
BK|BK (virus)|BK|219|220|BRIEF HISTORY OF PRESENT ILLNESS|Helpful in his workup was a consultation by Dr. _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2004, which revealed a main differential diagnosis of the hemorrhagic cystitis greater than 100 days after transplant would be BK versus adenovirus versus CMV. The patient does have recent CMV reactivations as described above that had been not responsive to ganciclovir induction therapies x 2, and therefore, he was initiated on foscarnet this hospitalization on _%#MM#%_ _%#DD#%_, 2004.
BK|BK (virus)|BK|242|243|BRIEF HISTORY OF PRESENT ILLNESS|He will follow up with Dr. _%#NAME#%_ _%#NAME#%_ in clinic tomorrow on _%#MM#%_ _%#DD#%_, 2004 to help address continuing tapering of his steroids for graft-versus-host disease. Again pending at the time of discharge are the viral studies of BK virus adenovirus of the urine that had been sent and they are pending as well as serum BK virus PCR that was sent and is not yet back.
BK|BK (virus)|BK|154|155|BRIEF HISTORY OF PRESENT ILLNESS|Again pending at the time of discharge are the viral studies of BK virus adenovirus of the urine that had been sent and they are pending as well as serum BK virus PCR that was sent and is not yet back. Should the patient develop more problems with hematuria, it would be recommend education to consider discussing bladder biopsy again with the patient at that time.
BK|BK (virus)|BK|180|181|PROBLEM #3|PROBLEM #3: Hemorrhagic cystitis: The patient developed hematuria and urinary retention. A Foley catheter was inserted, and this did result in resolution of the urinary retention. BK virus was sent and positive. However, the patient was not treated due to his renal insufficiency. Hematuria resolved after a period of approximately five days. A Foley catheter was removed three days prior to discharge, and the patient has been urinating without difficulty.
BK|below knee|BK|200|201|OBJECTIVE|GENITALIA: External normal. Foley present. Hernia not checked. EXTREMITIES: No cervical, axillary or femoral nodes. Femoral pulses present. DP, PT on left normal. Warm, pink and dry on left. He has a BK on the right, still in dressing. EKG rhythm shows rate in 120s to 130s. Electrolytes normal.
BK|below knee|BK|190|191|HISTORY OF PRESENT ILLNESS|He had been hospitalized earlier for deep venous thrombosis of his left leg. This was complicated by a subsequent arterial thrombosis that compromised his lower extremity and he underwent a BK amputation of that leg a couple of months ago. He has been rehabbing this at present and developed once again a pain in the thigh.
BK|BK (virus)|BK|180|181|PROBLEM #6|She is being discharged on prophylactic antifungal and PCP regimen of Fluconazole and Bactrim. She is also being discharged on Levaquin for encapsulated organisms. Of note, she is BK virus positive but this has not clinically manifested itself recently. PROBLEM #7: GU: Early in _%#MM#%_, _%#NAME#%_ did show signs of hemorrhagic cystitis with a few clots.
BK|below knee|BK|246|247|HOSPITAL COURSE|REFERRING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_. HOSPITAL COURSE: On _%#MMDD2005#%_, _%#NAME#%_ _%#NAME#%_, a 67-year-old man, was admitted to Fairview Southdale Hospital and prepared for surgery. The patient underwent surgery for a right fem-pop BK bypass in situ and debridement of second right toe. The patient had excellent Doppler pulses status post surgery. He did have a second right toe that was debrided during his first surgical procedure, but continued to show infection and poor wound healing status post bypass.
BK|BK (virus)|BK|219|220|HISTORY OF PRESENT ILLNESS|She was admitted with the assumed diagnosis of rejection for biopsy and treatment. PAST MEDICAL HISTORY: FSGS. Recurrent sinusitis. C-diff. CMV. Recurrent FSGS. Recurrent rejections. EBB positive. Renal osteodystrophy. BK virus positive. HOSPITAL COURSE: Ms. _%#NAME#%_ was admitted on _%#NAME#%_ _%#DD#%_, 2006, with the previous mentioned diagnosis, increased creatinine.
BK|BK (virus)|BK|271|272|HISTORY OF PRESENT ILLNESS|Infectious disease consult was obtained. We were concerned about a vital infection because she is immunocompromised due to end-stage renal disease and diabetes. Multiple studies were ordered: Cytomegalovirus, adenovirus urine culture, stool study for adenovirus antigen, BK virus urine, and plasma PCR, and urine cytology for Kaposi sarcoma. We also obtained CD4 count. If CD4 was less than 50, we would consider microbacterial blood culture.
BK|BK (virus)|BK|162|163|FOLLOWUP LABS|5. Toprol-XL 50 mg q. day. 6. NovoLog, as directed before. 7. Cipro 250 mg p.o. b.i.d. for next 7 days. FOLLOWUP LABS: Please follow adenovirus, cytomegalovirus, BK virus study, and CD4 count. It was a pleasure to be involved in Ms. _%#NAME#%_'s care.
BK|BK (virus)|BK|130|131|HOSPITAL COURSE|In reviewing his abdominal CTs from back in _%#MM#%_, this change was there at that time. In terms of his hematuria, an assay for BK virus came back positive, which was a likely cause of his hematuria. To treat his BK virus, he was started on oral ciprofloxacin.
BK|BK (virus)|BK|21|22|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: BK virus elective transplant nephrectomy. DISCHARGE DIAGNOSIS: Status post transplant nephrectomy and COPD. HISTORY OF PRESENT ILLNESS: The patient is a 42-year-old male with diabetes type 1 nephropathy who received a transplant kidney in 1991 from his mother.
BK|BK (virus)|BK|188|189|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 42-year-old male with diabetes type 1 nephropathy who received a transplant kidney in 1991 from his mother. The patient was now diagnosed with BK virus and requested transplant nephrectomy prior to re-transplantation. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Renagel. 2. Phoslo.
BK|BK (virus)|BK|200|201|BRIEF HOSPITAL COURSE|9. Cardiac stent x 5, most recently one month ago. Has been off of Plavix for one week. BRIEF HOSPITAL COURSE: The patient was admitted on _%#MMDD2006#%_ for an elective transplant nephrectomy due to BK viremia. On admission, the patient was healthy and in no apparent distress. The patient tolerated the procedure well. Postoperatively, the patient did have an episode of hypotension.
BK|BK (virus)|BK|223|224|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Hypertension. HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old female with a history of type 1 diabetes, status post pancreas transplant, status post kidney transplant in 1995 which was lost due to BK virus infection in 2006, and status post nephrectomy in _%#MM#%_ 2007. The patient is currently on hemodialysis. She was recently discharged from University of Minnesota Medical Center, Fairview, on _%#MMDD2007#%_ following an episode of hypertensive urgency.
BK|BK (virus)|BK|167|168|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: This is a 51-year-old female with a history of type 1 diabetes, status post pancreas transplant and status post renal transplant rejection due to BK virus and subsequent nephrectomy, presenting with hypertensive urgency. 1. Hypertensive emergency with encephalopathy. The patient was given a total of 0.7 mg of clonidine today and labetolol 20 mg IV.
BK|BK (virus)|BK,|240|242|HOSPITAL COURSE|His creatinine was slightly elevated at 0.7. HOSPITAL COURSE: _%#NAME#%_ was admitted for evaluation and treatment of his fever with leukopenia. While in the hospital, he received a variety of laboratory tests including renal battery, UAC, BK, EBV and CMV virus testing. He also was given CRP and blood culture. He was not initially started on antibiotics.
BK|BK (virus)|BK|188|189|HOSPITAL COURSE|Over the next day, his test results returned. He continued to have a slightly elevated creatinine at approximately 0.7. He was negative for Epstein-Barr virus and for Cytomegalovirus. His BK virus testing did not return during the course of his stay. His blood culture and urine cultures were negative. His chest x-ray showed mildly prominent vascular markings and possible diffuse infiltrate which was consistent with community-acquired mycoplasma pneumonia.
BK|BK (virus)|BK|286|287|PAST MEDICAL HISTORY|She was also seen in clinic for her history of fever and then, subsequently, admitted to the Pediatric Bone Marrow Transplant Service. PAST MEDICAL HISTORY: 1. bone marrow transplant, unrelated donor, transplanted _%#MMDD2006#%_. Course complicated by hemorrhagic cystitis secondary to BK virus, pulmonary edema and volume overload requiring intubation in _%#MM2006#%_. 2. Coag-negative Staph line infection in _%#MM2006#%_, treated with vancomycin with cultures negative at follow-up.
BK|BK (virus)|BK|161|162|FOLLOW-UP|His post transplant course was also complicated by CMV viremia, which was treated with ganciclovir. During ganciclovir therapy, Mr. _%#NAME#%_ was found to have BK virus in his urine. Ganciclovir was discontinued and Mr. _%#NAME#%_ received a single dose of cidofovir to treat his BK as well as his CMV.
BK|BK (virus)|BK|181|182|FOLLOW-UP|During ganciclovir therapy, Mr. _%#NAME#%_ was found to have BK virus in his urine. Ganciclovir was discontinued and Mr. _%#NAME#%_ received a single dose of cidofovir to treat his BK as well as his CMV. In the final days of his hospitalization, Mr. _%#NAME#%_ developed respiratory distress requiring intubation.
BK|below knee|BK|144|145|PHYSICAL EXAMINATION|LUNGS: Are clear to auscultation and percussion. Respiratory rate 12 per minute and in no distress. Normal bilateral femoral pulsations. He had BK thick, brown support socks on legs. Dorsalis pedis pulses are okay, 4/4+. RECTAL: Deferred. IMPRESSION: 1. Febrile episode for two days. 2. Severe headache for two days
BK|below knee|BK|142|143|HISTORY OF PRESENT ILLNESS|She is coming in because of an infection in her incision on her left BKA which has been draining and has abscess formation. She already has a BK on the right side as well, has severe vasculitis in addition to her diabetes contributing to her peripheral vascular disease.
BK|below knee|BK|224|225|HISTORY OF PRESENT ILLNESS|He was started empirically on Augmentin and Vicodin. He presented to the office and felt to have probable vascular compromise on his right leg . His left leg had had a similar problem a year ago and ultimately ended up in a BK amputation. He does have severe atherosclerotic vascular disease. He has had previous myocardial infarctions. He also has scleroderma. He did have attempted revascularization of his left leg, but ultimately had amputation of that.
BK|below knee|BK|40|41|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Failure of left BK amputation to heal with left BK revision by Dr. _%#NAME#%_. 2. Right renal abscess. 3. Urinary tract infection with Pseudomonas aeruginosa.
BK|below knee|BK|72|73|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Failure of left BK amputation to heal with left BK revision by Dr. _%#NAME#%_. 2. Right renal abscess. 3. Urinary tract infection with Pseudomonas aeruginosa. 4. Severe peripheral vascular disease, status post femoral popliteal bypass on the right and failed bypass on the left with need for amputation in _%#CITY#%_ _%#CITY#%_.
BK|below knee|BK|150|151|DISCHARGE MEDICATIONS|8. Plavix 75 a day. 9. Flomax 0.5 per day. Mr. _%#NAME#%_ _%#NAME#%_ was admitted by Dr. _%#NAME#%_ and seen by Dr. _%#NAME#%_ for revision of a left BK amputation which had failed to heal. He was taken to surgery and this was performed without complication. During the course of his preoperative evaluation, it was noted that he had pyuria and a urinary culture grew out Pseudomonas aeruginosa.
BK|below knee|BK.|171|173|OBJECTIVE|Liver is 10 cm. height by percussion. HEART: Percusses to normal size. LEGS: Reveal really dryness, lack of skin growth, no definite stasis dermatitis, has Jobst on up to BK. No pretib pitting. JV negative. IMPRESSION: 1. Recurrent dizziness severe times two weeks with 2. Syncope with a fall _%#MMDD2003#%_ with a head contusion.
BK|BK (virus)|BK|196|197|HISTORY OF PRESENT ILLNESS|The patient developed pink- tinged urine with urinalysis on _%#MM#%_ _%#DD#%_, 2004, showing over 4000 red cells. This is likely a side effect of the Cytoxan, although we have sent serologies for BK virus which are pending at the time of this dictation. We have continued to aggressively hydrate the patient to keep urine output at a high level and prevent formation of clots.
BK|BK (virus)|BK|319|320|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 40-year-old male with longstanding diabetes mellitus, onset age 14, with end-stage renal disease, status post kidney after pancreas transplantation in 1998 and 2002 respectively with biopsy-proven moderate acute rejection of his pancreas on _%#MMDD2005#%_. He has had a history of BK polyoma virus since 2004 of his pancreas. This was treated with a decrease in his immunosuppression and initiation of Arava.
BK|BK (virus)|BK|181|182|DIAGNOSIS|DISCHARGE DATE: _%#MMDD2007#%_. DIAGNOSIS: 1. Type 1 diabetes mellitus. 2. End-stage renal disease secondary to diabetic nephropathy. 3. Failure of kidney allograft #1 secondary to BK polyoma nephropathy. 4. Failure of pancreas allograft #1 secondary to chronic rejection. PROCEDURES/TREATMENTS: Left transplant nephrectomy followed by simultaneous pancreas and kidney retransplantation with enteric drainage of pancreatic exocrine secretions, _%#MMDD2006#%_.
BK|BK (virus)|BK|207|208|PAST MEDICAL HISTORY|9. Metabolic complications of bladder-drained pancreas graft, 2001. 10. Pseudomembranous colitis, 2001. 11. Pancreas graft failure secondary to chronic rejection, 2005. 12. Kidney graft failure secondary to BK nephropathy. PAST SURGICAL HISTORY: 1. Deceased donor pancreas transplant with bladder drainage, _%#MM1998#%_. 2. Conversion of pancreas graft from bladder drainage to enteric drainage, _%#MM2001#%_.
BK|BK (virus)|BK|184|185|HOSPITAL COURSE|He initially required an insulin drip and was subsequently converted to low dose Lantus insulin to maintain tight glycemic control. Because of his history of kidney graft failure from BK nephropathy, he only received 3 doses of Thymoglobulin induction immunosuppression. He was discharged on a 2-drug immunosuppression protocol with tacrolimus and mycophenolate.
BK|BK (virus)|BK|260|261|HOSPITAL COURSE|His workup included a consultation by Renal and Pulmonary. His chest CT was negative for any evidence of mass or lung pathology that could lead to his hemoptysis. The rest of his workup included a CMV and EPV and urine BK PCRs. His CMV was positive and so was BK urine. For this the patient was started on IV ganciclovir at 300 mg IV once a day. The etiology of his symptoms is most likely CMV and the patient will continue to remain of IV ganciclovir for the next 2 weeks.
BK|below knee|BK|98|99|POSTOP DIAGNOSIS|I discussed the importance of elevation and staying off of it as much as he can, but he has got a BK on the other side and he must work. He is aware of the risks of too much dependency and bumping it, falling down, etc.
BK|BK (virus)|BK|191|192|PROBLEM #5|PROBLEM #5: Hematology. Her current hemoglobin transfusion parameter is 8 and platelet transfusion parameter is 40,000, due to hemorrhagic cystitis, which developed on _%#MMDD2005#%_. She is BK virus positive. She does not require blood product premeds. She requires daily platelet transfusions and tested platelet antibody negative.
BK|BK (virus)|BK|195|196|DISCHARGE DISPOSITION|Results should be reported to the Transplant Office for monitoring and immunosuppression dosing. He will follow up with Dr. _%#NAME#%_ of the Nephrology service as scheduled for treatment of his BK polyoma virus. He was told to contact the Transplant service for a fever of 101 degrees Fahrenheit or greater or return of his abdominal pain.
BK|BK (virus)|BK,|197|199|HOSPITAL COURSE|HOSPITAL COURSE: The patient was admitted to 6B for infectious disease workup. The patient was empirically treated with Zosyn, Diflucan and vancomycin. The patient had several labs drawn including BK, CMV, EBV, Rapid Strep and culture. All lab work was positive for BK in the urine of greater than 10 million. Serum BK PCR was ordered. The patient had a computed tomography scan with sinus studies due to complaints of likely sinusitis.
BK|BK (virus)|BK|187|188|HOSPITAL COURSE|The patient was empirically treated with Zosyn, Diflucan and vancomycin. The patient had several labs drawn including BK, CMV, EBV, Rapid Strep and culture. All lab work was positive for BK in the urine of greater than 10 million. Serum BK PCR was ordered. The patient had a computed tomography scan with sinus studies due to complaints of likely sinusitis.
BK|BK (virus)|BK|164|165|HOSPITAL COURSE|The patient had several labs drawn including BK, CMV, EBV, Rapid Strep and culture. All lab work was positive for BK in the urine of greater than 10 million. Serum BK PCR was ordered. The patient had a computed tomography scan with sinus studies due to complaints of likely sinusitis. The results of the computed tomography scan showed pansinusitis. Ears, nose and throat consult was obtained.
BK|BK (virus)|BK|192|193|HOSPITAL COURSE|On the day of discharge, the patient was afebrile. He had a serum creatinine of 2.53 mg/dL. Blood sugars in the 24 hours prior to discharge were 99-167. On the day of discharge, the patient's BK virus PCR was pending, as well as nasopharyngeal culture of the left middle and right middle meatus. DISCHARGE MEDICATIONS: 1. CellCept 500 mg p.o. b.i.d. 2. Prograf 1 mg p.o. b.i.d.
BK|BK (virus)|BK|141|142|HOSPITAL COURSE|Biopsies of the kidney and pancreas allografts were obtained. The kidney biopsy for the first time showed cytopathic changes consistent with BK polyoma virus. The pancreas graft showed moderate chronic pancreatitis with minimal acute rejection. The patient was started on a course of weekly intravenous cidofovir and the leflunomide dose was doubled.
BK|BK (virus)|BK|275|276|DISCHARGE DISPOSITION|Transplant laboratory studies should be obtained twice weekly as the patient continues on the cidofovir protocol. He should follow up with Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ from the Infectious Disease service regarding the cidofovir treatment and monitoring of BK polyoma virus load. The patient was told to contact the Transplant service for any increase in drainage, pain, redness, or swelling of the percutaneous biopsy sites.
BK|BK (virus)|BK|238|239|PAST MEDICAL HISTORY|11. Recent urinary tract infections with sepsis _%#MM2007#%_ with VRE Klebsiella oxytocia. 12. History of c. difficile colitis _%#MM2006#%_. 13. History of leukopenia secondary to medications. 14. Recent decubitus ulcer _%#MM2006#%_. 15. BK virus with last serum viral load greater than 1 million _%#MMDD2007#%_. 16. Pneumonia in _%#MM2006#%_ with group D and klebsiella pneumonia.
BK|BK (virus)|BK|228|229|HOSPITAL COURSE|During the operative procedure the patient had a kidney graft biopsy which results were positive for mild acute tubulointerstitial rejection. Patient was treated for rejection with steroids. At the time of discharge testing for BK virus was still pending. Patient was admitted on a 2-drug regimen of her immunosuppression with myfortic and Prograf.
BK|BK (virus)|BK|176|177|DISPOSITION AT DISCHARGE|Patient to follow up with her primary care provider Dr. _%#NAME#%_ to follow up on blood pressure management and medications. Patient's results of kidney biopsy evaluating for BK virus pending at the time of discharge. Staff to follow up. Patient is to have regular diet with supplements.
BK|BK (virus)|BK|180|181|HOSPITAL COURSE|Biopsy revealed chronic allograft nephropathy with no evidence of acute rejection or ischemic injury. During this hospitalization, it was noted that on his previous admission, the BK virus PCR from urine on _%#MMDD2004#%_ came back positive. A repeat BK PCR was sent on _%#MMDD2004#%_ and results are pending at this time.
BK|BK (virus)|BK|149|150|HOSPITAL COURSE|During this hospitalization, it was noted that on his previous admission, the BK virus PCR from urine on _%#MMDD2004#%_ came back positive. A repeat BK PCR was sent on _%#MMDD2004#%_ and results are pending at this time. Mr. _%#NAME#%_ tolerated the biopsy procedure well. On the day of discharge, creatinine was 3.21 and CMV antigenemia was quantitated at 50.
BK|BK (virus)|BK|202|203|DISCHARGE INSTRUCTIONS|3. He is to contact the transplant coordinator to arrange followup appointments. 4. Home care has been set up so Mr. _%#NAME#%_ will receive IV ganciclovir at his home. 5. Follow up in clinic regarding BK virus and possible reduction in immunosuppression including Neoral to improve kidney function. 6. Initiate workup to re-list for kidney re-transplantation.
BK|BK (virus)|BK|149|150|HOSPITAL COURSE|During this hospitalization, it was noted that on his previous admission, the BK virus PCR from urine on _%#MMDD2004#%_ came back positive. A repeat BK PCR was sent on _%#MMDD2004#%_ and results are pending at this time. Mr. _%#NAME#%_ tolerated the biopsy procedure well. On the day of discharge, creatinine was 3.21 and CMV antigenemia was quantitated at 50.
BK|BK (virus)|BK|156|157|HISTORY OF PRESENT ILLNESS|He is status post kidney transplant in 2001 as well as status post deceased donor pancreas transplant in 2003. He had subsequent transplant nephrectomy for BK polymerous infection in 2004. He had a Tenckhoff catheter placed on _%#MMDD2005#%_ for initiation of peritoneal dialysis. He was noted to have increased serum amylase and lipase levels and had undergone a pancreas biopsy on _%#MMDD2005#%_ which showed mild acute rejection of pancreas allograft, grade 1/3 of the pancreas allograft.
BK|BK (virus)|BK|200|201|PAST TRANSPLANT HISTORY|5. Hypothyroidism. PAST TRANSPLANT HISTORY: 1. Living related kidney transplantation in 2001. 2. Deceased donor pancreas transplantation 2003. 3. Transplant nephrectomy on _%#MMDD2005#%_ secondary to BK polyoma viral infection. 4. On chronic hemodialysis since nephrectomy on Monday, Wednesday, and Friday for which he did not tolerate. 5. Now undergoing peritoneal dialysis. PAST SURGICAL HISTORY: Peritoneal dialysis catheter placement on _%#MMDD2005#%_.
BK|BK (virus)|BK|159|160|HISTORY OF PRESENT ILLNESS|He is status post kidney transplant in 2001, as well as status post deceased donor pancreas transplant in 2003. He had a subsequent transplant nephrectomy for BK polyoma virus infection. He had a Tenckhoff catheter placed on _%#MMDD2005#%_. He presented to clinic with weakness, fatigue and tachycardia, as well as increased amylase and lipase.
BK|BK (virus)|BK|188|189|PAST TRANSPLANT HISTORY|5. Hypothyroidism. PAST TRANSPLANT HISTORY: 1. Living-related kidney transplant, 2001. 2. Deceased donor pancreas transplant 2003. 3. Transplant nephrectomy on _%#MMDD2005#%_ secondary to BK polyoma viral infection. 4. On hemodialysis since nephrectomy on Monday, Wednesday and Friday, which he did not tolerate. 5. Now undergoing peritoneal dialysis. PAST SURGICAL HISTORY: Peritoneal dialysis catheter placement on _%#MMDD2005#%_.
BK|BK (virus)|BK|203|204|HOSPITAL COURSE|Mr. _%#NAME#%_ had continuing fevers even though he was on what appeared to be appropriate antimicrobial coverage. The Infectious Disease service, who had been following the patient daily, felt that his BK virus infection was likely a contributing factor. As such, they recommended transplant nephrectomy. Mr. _%#NAME#%_ then underwent his transplant nephrectomy on _%#MMDD2005#%_.
BK|BK (virus)|BK|336|337|HISTORY OF PRESENT ILLNESS|1. IV antibiotics. 2. Antibiotics and peritoneal dialysis. HISTORY OF PRESENT ILLNESS: This is a 42-year-old gentleman with longstanding type 1 diabetes mellitus and endstage renal disease who is status post kidney transplant in 2001 as well as a deceased donor pancreas transplant in 2003. He had subsequent transplant nephrectomy for BK polyoma viral infection in 2004. He had a Tenckhoff catheter placed on _%#MMDD2005#%_ for initiation of peritoneal dialysis after not tolerating hemodialysis.
BK|BK (virus)|BK|206|207|PAST TRANSPLANT HISTORY|5. Hypothyroidism. PAST TRANSPLANT HISTORY: 1. Living related kidney transplant patient in 2001. 2. Deceased donor pancreas transplant patient in 2003. 3. Transplant nephrectomy _%#MMDD2005#%_ secondary to BK polyoma viral infection. 4. On chronic hemodialysis nephrectomy Monday, Wednesday, Friday for which he did not tolerate. 5. Peritoneal dialysis. 6. Pancreas allograft rejection on _%#MMDD2005#%_ requiring thyroglobulin as well as OKT3.
BK|BK (virus)|BK|162|163|HISTORY  OF PRESENT ILLNESS|He received a living related-donor kidney transplant from his brother in 1991, which subsequently failed secondary to chronic rejection. He also has a history of BK nephropathy. Therefore, he subsequently had a transplant nephrectomy in _%#MM#%_ 2006. He then was placed on dialysis from _%#MM2004#%_ through _%#MM2007#%_.
BK|BK (virus)|BK|186|187|PAST MEDICAL HISTORY|5. Hypertension. 6. Cataracts. 7. Blindness in left eye secondary to diabetic retinopathy. 8. Peripheral neuropathy. 9. Diabetic gastroparesis. 10. Kidney graft failure #1, secondary to BK polyoma virus. 11. BK polyoma nephropathy. 12. Pancreas graft failure secondary to chronic rejection of pancreas allograft #1. 13. Positive B cell crossmatch DSA class II acute humoral rejection treated with IV Ig and plasmapheresis x13 doses and 1 dose of rituximab.
BK|BK (virus)|BK|208|209|PAST MEDICAL HISTORY|5. Hypertension. 6. Cataracts. 7. Blindness in left eye secondary to diabetic retinopathy. 8. Peripheral neuropathy. 9. Diabetic gastroparesis. 10. Kidney graft failure #1, secondary to BK polyoma virus. 11. BK polyoma nephropathy. 12. Pancreas graft failure secondary to chronic rejection of pancreas allograft #1. 13. Positive B cell crossmatch DSA class II acute humoral rejection treated with IV Ig and plasmapheresis x13 doses and 1 dose of rituximab.
BK|BK (virus)|BK|140|141|PAST MEDICAL HISTORY|5. Hypertension. 6. Cataracts. He is blind in left eye. 7. Peripheral neuropathy. 8. Gastroparesis. 9. Kidney graft failure #1 secondary to BK polyoma. 10. BK polyoma nephropathy. 11. Pancreas graft failure secondary to chronic rejection of pancreas graft #1. 12. Positive B-cell crossmatch with DSA. Subsequent humoral rejection treated with IVIG & plasmapheresis with one rituximab dose.
BK|BK (virus)|BK|156|157|PAST MEDICAL HISTORY|5. Hypertension. 6. Cataracts. He is blind in left eye. 7. Peripheral neuropathy. 8. Gastroparesis. 9. Kidney graft failure #1 secondary to BK polyoma. 10. BK polyoma nephropathy. 11. Pancreas graft failure secondary to chronic rejection of pancreas graft #1. 12. Positive B-cell crossmatch DSA class II humoral rejection, acute treated with IVIG plasmapheresis x 13 rituximab doses.
BK|BK (virus)|BK|159|160|DISCHARGE FOLLOW-UP|2. She also should check her labs t.i.d. for complete blood count, BMP-10, Rapamune, and CellCept levels. 3. In particular attention in further care should be BK virus and EBV since patient is on immunosuppression.
BK|BK (virus)|BK|148|149|DISPOSITION ON DISCHARGE|The patient is to continue his transplant labs as previously scheduled. The patient is also to continue to follow up with infectious disease on his BK viral load and his CMV viral load. The patient is also to report signs and symptoms of increased drainage, increased pain, or increased swelling at biopsy site or an elevated temperature of 101 degrees Fahrenheit or higher.
BK|BK (virus)|BK|211|212|HISTORY OF PRESENT ILLNESS|He is status post living donor kidney transplant from _%#MMDD1986#%_ and a pancreas after kidney transplant in _%#MM2004#%_. He had been treated in the past with Campath for his transplant. He now has developed BK virus nephropathy leading to the graft loss and requiring returned to hemodialysis. He was also found to have a warm hemolytic anemia, which has not responded well to steroid therapy.
BK|BK (virus)|BK|172|173|HISTORY OF PRESENT ILLNESS|Therefore, he now presents for an elective splenectomy, as well as transplant nephrectomy. The plan was to proceed with the nephrectomy so that we can adequately treat his BK virus so that he can undergo a living donor kidney transplant in the near future. PAST MEDICAL HISTORY: 1. Type 1 diabetes mellitus. 2. Proliferative retinopathy.
BK|BK (virus)|BK|213|214|DISCHARGE INSTRUCTIONS|He should not drive for 1 week. He will follow up with his personal physician on return home and in Transplant Clinic in two weeks. He will continue his previous routine labs. He should have close followup of his BK viral load. He should continue his and q. Monday, Wednesday, Friday routine dialysis.
BK|BK (virus)|BK|347|348|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 64-year-old male with a history of end-stage renal disease secondary to diabetic nephropathy and a history of type 1 diabetes who underwent a living donor kidney transplant in 1986 and a deceased donor pancreas transplant in 2004. The patient had a transplant nephrectomy in _%#MM2007#%_ for BK virus nephropathy. The patient had is status post living donor kidney transplant on _%#MMDD2007#%_. The patient was positive B-cell crossmatch and received plasmapheresis and IVIG pre- and postoperatively.
BK|BK (virus)|BK|149|150|PAST MEDICAL HISTORY|4. Diabetic gastroparesis. 5. Gastroesophageal reflux disease. 6. Hypertension. 7. Dyslipidemia. 8. BPH. 9. History of hiatal hernia. 10. History of BK nephropathy. 11. History of Mycobacterium infection, pneumonia. 12. History of squamous cell carcinoma. 13. Charcot joint of the left foot. 14. Group D enterococcus urinary tract infection in _%#MM2007#%_
BK|BK (virus)|BK|149|150|PAST SURGICAL HISTORY|5. Nissen fundoplication. 6. Right lower lobe low right lower lung biopsy. 7. Placement of penile prosthesis. 8. Transplant nephrectomy secondary to BK nephropathy in _%#MM2007#%_. 9. Splenectomy secondary to hemolytic autoimmune anemia and appendectomy _%#MM2007#%_. 10. Retinal photocoagulation. ALLERGIES: Allergies penicillin. HOSPITAL COURSE: The patient was admitted to 6B and started on continuous bladder irrigation.
BK|BK (virus)|BK|116|117|HOSPITAL COURSE|It refers to hypertension. The patient's beta-blocker was also increased during this hospitalization. The patient's BK virus PCR was greater than 10 million copies. The patient's BK virus PCR in the serum was negative. Recommendations by infectious disease were to monitor the patient's BK virus PCR in the urine.
BK|BK (virus)|BK|185|186|HOSPITAL COURSE|The patient's BK virus PCR was greater than 10 million copies. The patient's BK virus PCR in the serum was negative. Recommendations by infectious disease were to monitor the patient's BK virus PCR in the urine. Due to patient's extended postoperative course physical therapy and occupational therapy felt that he would be a candidate for acute rehab.
BK|BK (virus)|BK|167|168|HOSPITAL COURSE|Creatinine remained elevated at the time of discharge at 1.94 mg/dL. Etiology of increased creatinine remains unknown at this time although virology studies including BK (polyoma virus) will be followed after the time of discharge by Pediatric Nephrology Service as well as transplant coordinator.
BK|BK (virus)|BK|168|169|HISTORY OF PRESENT ILLNESS|He has a prolonged past medical history complicated by prolonged hospitalizations with CMV and renal failure. He subsequently lost his kidney function secondary to the BK polyoma of RSPRA. He presented to Radiology for a scheduled biopsy of a liver mass. At that time he was found to be orthostatic and anemic with a hemoglobin of 6.1. He was sent to the emergency department for further evaluation.
BK|BK (virus)|BK|161|162|PAST TRANSPLANT HISTORY|2. Enteric conversion, _%#MM2003#%_. 3. Recent history of post biopsy pancreatitis, _%#MM2005#%_. 4. Living-donor kidney transplant, _%#MM2000#%_. 5. History of BK polyoma virus of kidney. 6. Chronic rejection and reinstitution of hemodialysis, _%#MM2005#%_. 7. Status post coronary artery disease stenting. 8. Status post appendectomy. HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted on the _%#MMDD2005#%_ and was afebrile on admission.
BK|BK (virus)|BK|131|132|HISTORY OF PRESENT ILLNESS|She received deceased donor kidney transplant in 1994 and a living non-related kidney transplant in _%#MM2004#%_ which was lost to BK virus. She is now on hemodialysis. She also received a deceased donor pancreas transplant with enteric drainage on _%#MM2005#%_ and it has been euglycemic and independent of exogenous insulin.
BK|BK (virus)|BK|83|84|DIAGNOSES|DISCHARGE DATE: _%#MMDD2006#%_ DIAGNOSES: 1. Renal transplant failure secondary to BK virus and transplant ureterostenosis. 2. Anemia-multifactorial, most likely secondary to medications. 3. Hypertension.
BK|BK (virus)|BK|135|136|HISTORY OF PRESENT ILLNESS|She has had issues with ureterostenosis of her second kidney transplant causing allograft dysfunction. She also has been found to have BK virus with the last viral load greater than one million. She has been seen by Dr. _%#NAME#%_ as an outpatient. Her creatinine has increased over the last 2 months from 1.8 to 4.3 on this admission.
BK|BK (virus)|BK|205|206|HOSPITAL COURSE|2. Vancomycin. 3. Codeine. 4. Morphine. 5. Thorazine. HOSPITAL COURSE: The patient was admitted on _%#MMDD2006#%_ for placement of hemodialysis catheter secondary to kidney transplant failure secondary to BK virus in transplant, ureterostenosis and anemia. The patient was found to be hypertensive, and her antihypertensive meds were managed.
BK|BK (virus)|BK|149|150|FOLLOW-UP|FOLLOW-UP: 1. The patient was set up with outpatient dialysis at Divida in _%#CITY#%_. 2. The patient is to follow up with Infectious Disease on her BK virus load and treatment as scheduled. 3. The patient is to follow up with Dr. _%#NAME#%_ as necessary. 4. The patient is to have transplant labs 3 x week for 2 weeks with Prograf levels, and then per Transplant Center.
BK|BK (virus)|BK|172|173|HOSPITAL COURSE|No signs of acute rejection. Kidney biopsy was suspicious for polyoma virus cytopathic changes, and biopsy slides were sent to Mayo for further staining. The patient had a BK PCR quantitative drawn, but was pending at the time of discharge. The patient has a history of aplastic anemia and hemolytic autoimmune anemia.
BK|BK (virus)|BK|176|177|HOSPITAL COURSE|Dr. _%#NAME#%_ _%#NAME#%_ was consulted regarding monitoring for opportunistic infections given the patient's history of immunosuppression. Recommendations to monitor for EBV, BK and CMV weekly. For induction the patient received 3 doses of Thymoglobulin with a steroid taper.
BK|BK (virus)|BK|231|232|DISPOSITION AT DISCHARGE|2. Followup with Dr. _%#NAME#%_ for a kidney transplant 3 month appointment on _%#MMDD2007#%_ at 2:10 p.m. The patient to have transplant labs 3 times a week for 2 weeks per lab letter and then per protocol. The patient is to have BK PCR quantitative, CMV PCR quantitative and EBV PCR quantitative q. week. 3. Patient to followup with her primary, Dr. _%#NAME#%_ _%#NAME#%_ as needed.
BK|BK (virus)|BK|166|167|DISPOSITION|Laboratory results should be reported to the Transplant office for monitoring of graft function and dosing of immunosuppression. In _%#MM#%_ 2005, a urine sample for BK virus DNA by PCR was positive for 7000 copies. During this hospitalization, a blood sample was obtained for BK virus which should be followed up as an outpatient.
BK|BK (virus)|BK|148|149|DISPOSITION|In _%#MM#%_ 2005, a urine sample for BK virus DNA by PCR was positive for 7000 copies. During this hospitalization, a blood sample was obtained for BK virus which should be followed up as an outpatient. The patient was told to contact the Transplant Service for an increased drainage, pain, redness, or swelling from his biopsy or IV sites and to call for a fever of 101 degrees or higher, increased headaches with neck pain and stiffness, or increased muscle pain with joint stiffness.
BK|below knee|BK|199|200|SUBJECTIVE|While there he was continued on treatment for severe cellulitis and sepsis related to a draining open wound on the left lateral thigh and reactivation of chronic osteomyelitis of the femur. He has a BK amputation on that side. The patient has continued to recuperate and is close to baseline according to his daughter. He has packing the wound and changing the dressing on a daily basis and remains on intravenous antibiotics.
BK|below knee|BK|317|318|IMPRESSION|REASON FOR CONSULTATION: Evaluation of antibiotic management. IMPRESSION: 1. This is a 72-year-old gentleman here to continue management after surviving an episode of sepsis syndrome related to a flare-up of osteomyelitis of the left femur. 2. He has a history of peripheral vascular disease and left lower extremity BK amputation ten to twelve years ago. 3. He has chronic osteomyelitis with an open wound involving the left lateral thigh. 4. History of Crohn's disease and status post colectomy, ileostomy.
BK|below knee|BK|189|190|PHYSICAL EXAMINATION|LUNGS: On exam he had clear lung fields. HEART: Rate was slow and irregular. ABDOMEN: Soft; nontender. EXTREMITIES: Right lower extremity was deeply pigmented, and his left lower extremity BK amputation. Review of pertinent laboratory studies, his INR was elevated 3.49, having being 1.78 four days earlier.
BK|below knee|BK|183|184|PAST MEDICAL HISTORY|She has had pneumonia, diabetic foot ulcers, diabetic neuropathy, nephritis, nephropathy, retinopathy, hypertension, hyperlipidemia, anemia of chronic disease, and Candida. She had a BK amputation done in _%#MM#%_, 2002. SOCIAL HISTORY: She lives in a community apartment with her husband.
BK|below knee|BK|138|139|PHYSICAL EXAMINATION|HEART: I do not hear a murmur. LUNGS are clear. ABDOMEN: There is an umbilical hernia and a large diastasis recti. EXTREMITIES: She has a BK amputation and some mild edema. NEURO: Decreased sensation in the left extremity. RECTAL EXAM reveals decreased tone and soft stool.
BK|below knee|BK|197|198|IMPRESSION|2. The patient has long term diabetes mellitus with sequelae including peripheral neuropathy, peripheral vascular disease, and retinopathy. She is legally blind. 3. The patient is status post left BK amputation. 4. Status post revascularization surgery to both legs in 1994. 5. Hypertension. 6. Hypothyroidism. 7. Eczematoid rash, left forearm.
BK|below knee|BK|204|205|PHYSICAL EXAMINATION|I could not hear any murmurs or gallops. ABDOMEN: Stoma present for her ileostomy, colostomy, and there is obvious ventral hernia present as well. Detailed examination not possible in a sitting position. BK stumps sites non- inflamed. NEUROLOGIC: Alert, interactive, with articulate speech and no focal, cranial, or peripheral nerve signs on screening examination conducted at the bedside.
BK|below knee|BK|171|172|HISTORY OF PRESENT ILLNESS|The patient has had longstanding problems with his left foot related osteomyelitis. He is seeing Dr. _%#NAME#%_ for this and is due to have a partial foot amputation or a BK amputation related to chronic ostia, which has not been resolved with chronic antibiotic therapy and multiple surgical procedures.
BK|below knee|BK|185|186|PHYSICAL EXAMINATION|I do not see any evidence for spider nevi. HEART: Regular rhythm. LUNGS: Lungs are clear. ABDOMEN: Shows an open granulating wound. She has decubitus on her lower back and the previous BK amputation as noted. There is no stigmata of liver disease. LABORATORY DATA: Hemoglobin initially 13. The patient was likely dehydrated. Hemoglobin yesterday 10.3, MCV 91, platelet count is normal.
BK|below knee|BK|165|166|RECOMMENDATIONS|We recommend that the patient undergo further toe amputation versus a transmetatarsal amputation. The transmetatarsal amputation is not as good biomechanically as a BK or a digit amputation. The patient will have much better biomechanic function with the toe amputation, and prosthetically, it is much easier to accommodate.
BK|below knee|BK|117|118|HISTORY|This pleasant 81-year-old female is a resident of _%#NAME#%_. She has an interesting past history of polio and had a BK amputation on the right leg at age 6 and then she subsequently had a fractured femur at age 12. She currently is relatively independent. She does wear a BK prosthesis on the right leg.
BK|below knee|BK|111|112|DISCUSSION|IMPRESSION: Cervical trochanteric right hip fracture. DISCUSSION: We discussed the options. Obviously with her BK she would benefit from a prosthesis versus open reduction and internal fixation, but will discuss those options and review x-rays.
BK|below knee|BK|190|191|PHYSICAL  EXAMINATION|Motor examination revealed only a very mild right arm drift and hand grip was slightly reduced on the right but not bad. Finger tapping was mildly slowed on the right. He has a recent right BK amputation. He was able to move his left leg fairly well and lift it from the bed slightly and wiggle his toes.
BK|below knee|BK|233|234|HISTORY OF PRESENT ILLNESS|The patient was hospitalized in _%#CITY#%_ with painful right lower foot and evidence of blocking of femoral arteries. The patient has known atherosclerotic vascular disease. She is status post actually of an amputation I believe of BK on the left knee for peripheral vascular disease in the past. She also underwent a left endarterectomy several years ago. The patient's risk factors for atherosclerotic vascular disease are diabetes mellitus of about 20 years duration from hypertension and hyperlipidemia on therapy.
BK|BK (virus)|BK|186|187|SUBJECTIVE|_%#NAME#%_ is CMV negative and HSV positive. _%#NAME#%_ has experienced difficulties with hypertension secondary to cyclosporine therapy. In _%#MM2006#%_ _%#NAME#%_ was hospitalized for BK hemorrhagic cystitis and severe volume overload. During this admission _%#NAME#%_ required intubation for 9 days due to pneumonia and respiratory failure.
BK|below knee|BK|131|132|IMPRESSION|REASON FOR CONSULTATION: Evaluation of perioperative antibiotic management. IMPRESSION: 1. This is a 24-year-old man here for left BK amputation on _%#MM#%_ _%#DD#%_, 2002, because of MRSA osteomyelitis which is refractory and recurrent. His last positive culture was on _%#MM#%_ _%#DD#%_, 2002. The organism tested sensitive to tetracycline, gentamicin, sulfa drugs and to Vancomycin.
BK|below knee|BK|143|144|PHYSICAL EXAMINATION|He had a grandfather who had prostate cancer. PHYSICAL EXAMINATION: On exam, he is an alert, pale-complected individual who is now status post BK amputation on the left. The wound area is encased in a large bulky postoperative dressing. The right lower extremity showed no circulatory abnormalities or signs of phlebitis.
BK|below knee|BK|206|207|PHYSICAL EXAMINATION|Thyroid not enlarged. No neck masses are noted. LUNGS: Clear with good air movement. CARDIAC: Exam reveals regular rhythm without murmurs or gallops. ABDOMEN: Benign. EXTREMITIES: No edema. There is a left BK amputation stump, well healed. Multiple digits are missing from prior amputation. NEUROLOGIC: Cranial nerves are grossly intact. Motor exam shows symmetric strength. LABORATORY DATA: Chemistry panel is normal.
BK|BK (virus)|BK|221|222|HOSPITAL COURSE|The molecular diagnostic lab is having a difficult time interpreting these due to the number of donors _%#NAME#%_ has had. Thus far we have no results. 4. Genitourinary. _%#NAME#%_ has ongoing hemorrhagic cystitis and is BK virus positive. He at one time did require continuous bladder irrigation, however, this has been off for an extended period of time at this point.
BK|BK (virus)|BK|309|310|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 16-year-old boy with a history of pre-B cell leukemia who is status-post multiple procedures and bone marrow transplants including multiple exposures to Cytoxan. He is currently admitted with renal failure, veno-occlusive disorder and several infections including BK virus in his urine. Urology was consulted after attempts to irrigate a previously placed 3-way Foley catheter were unsuccessful.
BK|below knee|BK|210|211|HISTORY|She has a 21 year history of type 1 diabetes, complicated by advanced proliferative diabetic retinopathy, peripheral vascular disease and end stage renal disease. It has been determined that she will require a BK amputation on the left side. She has been anticoagulated with Coumadin and low dose aspirin due to chronic atrial fibrillation.
BK|below knee|BK|182|183|IMPRESSION|2. She has a long history of diabetes mellitus type 1 with multiple sequelae, including retinopathy, neuropathy and nephropathy. 3. Peripheral vascular disease and status post right BK amputation. 4. Organic heart disease and known coronary artery disease. 5. Hypertension. 6. Dyslipidemia. RECOMMENDATIONS: 1. The wound cares are actually going quite well.
BK|below knee|BK|178|179|PHYSICAL EXAMINATION|NECK: Lymph node examination of the neck was negative. LUNGS: Clear. CARDIAC: Tones distant; rhythm was regular. No murmurs were heard. EXTREMITIES: Her lower extremity showed a BK amputation on the right; no signs of phlebitis. NEUROLOGIC: Check showed her mentation to be clear, her speech articulate. Oriented to person, place and time. No focal signs on screening examination conducted at the bedside.
BK|below knee|BK|143|144|PHYSICAL EXAMINATION|CARDIAC: Exam reveals a loud S-4. There is no murmurs. Carotid pulses are 2+, femoral pulses are only 1+. There are no bruits. She has a right BK and her left leg is somewhat wrapped. I did not check her pulse. Neck veins are relatively flat. ABDOMEN: Exam is benign. There is no organomegaly. The abdominal aorta is not palpably enlarged.
BK|below knee|BK|158|159|PHYSICAL EXAMINATION|No major lymphangitis. Some possible lymphadenopathy in the left arm area. Ulcerations under good control. No major lower extremity infections. Currently his BK site is OK. LAB AND DIAGNOSTIC DATA: All pending. Thank you much for the consultation.
BK|below knee|BK|128|129|PHYSICAL EXAMINATION|He is warmed to about 2 inches above the calcaneous and has fairly good anterior skin. It appears that we can get a 4 to 5 inch BK amputation safely on him. IMPRESSION: Avascular gangrenous left foot secondary to diabetes mellitus. We will plan to proceed with surgery, hopefully on Thursday, as he will be dialyzed on Wednesday and that would be a perfect time to do the surgery.
BK|BK (virus)|BK|182|183|PAST MEDICAL HISTORY|She was found to have a donor specific antibody and returned for phoresis in _%#MM2005#%_, but has been fine since that time. 2. Status post living donor transplant in 2003, lost to BK virus. 3. Hypertension. 4. History of hypothyroidism, on thyroid replacement since age 9. 5. History of anemia with the most recent procrit shot on _%#MMDD2007#%_ (she has neglected to return to clinic for this).
BK|BK (virus)|BK|272|273|LABORATORY DATA|When the albumin was 4.6, the calcium was 7.1. Additional laboratory tests done in _%#MM2007#%_ as further evaluation of her diarrhea included stool for white cells was negative. EBPcr was negative. Prograf level was 3.5. CMV negative. Blood and fungal cultures negative. BK virus was negative in the urine. Adenovirus was negative. Her white count in _%#MM2007#%_ was also as low as 1.6 and a hemoglobin was 6.9.
BK|BK (virus)|BK|151|152|ASSESSMENT|Even though the EBV virus is negative, it is of concern that she could have ...??.... particularly since she has had 2 transplants and she did develop BK with the first one. Her white count is low, so it could also be consistent with a virus. 2. Low white count: This could have multiple etiologies. She is on a standard MMF dose which should probably be titrated back.
BK|BK (virus)|BK|151|152|ASSESSMENT|The anion gap has dropped from 21 to 14, likely reflecting the D5 IV so that now the anion gap is just secondary to renal insufficiency. 7. History of BK virus: Recurrence needs to be ruled out. RECOMMENDATIONS: 1. Decrease MMF to 500 t.i.d. 2. Aranesp 60 mcg subcu today and q. week.
BK|BK (virus)|BK|118|119|IMPRESSION|She does have a baseline creatinine in the 2's, so she does not have perfect function in this kidney. We are awaiting BK virus testing to determine whether this might be contributing. At this point, she needs her blood pressure increased. 2. Hypotension: The patient has a fever and hypotension and is quite anemic.
BK|below knee|BK|224|225|PHYSICAL EXAMINATION|His abdomen is soft. The femorals are palpable. I don't hear bruits over the femorals, but he has a fair amount of folds and I didn't listen as carefully as I might. I can't feel popliteals. He has no edema in his legs with BK amputations bilaterally. The left one has been having some trouble healing he says. He hasn't yet been fit for a prosthesis on that side although he has one for the right side.
BK|BK (virus)|BK|149|150|PAST MEDICAL HISTORY|She has a history of bilateral avascular necrosis of her hips secondary to prolonged steroid treatment, history of hemorrhagic cystitis secondary to BK virus. History of fungal retinitis and esophageal stricture status post delactation. She has a history of herpes zoster. SOCIAL HISTORY: She lives with her biological mother.
BK|BK (virus)|BK|223|224|HISTORY OF PRESENT ILLNESS|The patient has a history of pulmonary fibrosis secondary to radiation and she also had pericardial effusions. She has bilateral knee avascular necrosis secondary to steroids. She has a history of hemorrhagic cystitis with BK virus. She has history of GERD and fungal retinitis. Most recently she had a relapse in _%#MM2005#%_. She had chemotherapy and completed this in _%#MM2006#%_. The patient was then admitted with complaints of fever and confusion.
BK|below knee|BK|244|245|IMPRESSION|She had an appendectomy and a right hemicolectomy with findings of ruptured appendix and ischemic cecal area at the time of surgery. 2. She has history of peripheral vascular disease or trauma to the left lower extremity which resulted in left BK amputation. 3. Status post hysterectomy. RECOMMENDATIONS: 1. We reviewed her culture data which showed E. coli in her urine and a combination of E. coli, pseudomonas, and group D enterococcus from the appendix area.
BK|BK (virus)|BK|412|413|INFORMANTS|Family was advised that without bone marrow transplant, his lymphoma, which was not in remission, would likely be lethal, and that they risked the possibility of enterovirus encephalitis during the transplant course. His subsequent transplant course has been complicated with good early engraftment, inability to tolerate oral cares, with candidal oral pharyngitis, rotavirus diarrhea, hemorrhagic cystitis from BK virus which has not resolved, CMV antigenemia which has resolved, and being persistently febrile. Pulmonary status in the past has been complicated by a right pleural effusion which resolved after bronchoscopy, and most recently he is shown to have enterovirus growing from the bronchoscopy.
BK|below knee|BK|174|175|DISCUSSION|DISCUSSION: Ms. _%#NAME#%_'s history is already well described in previous notes. The patient has well established diffuse atherosclerotic disease. She is status post recent BK amputation on the right because of ischemia in the right foot. A previous attempt at transmetatarsal amputation for healing was not successful.
BK|below knee|BK|162|163|PAST MEDICAL HISTORY|9. Congestive heart failure. 10. Valvular heart disease. 11. Decubitus ulcers. 12. Obesity. 13. Remote cholecystectomy. 14. Peripheral vascular disease with left BK amputation. HER CURRENT IN-HOSPITAL MEDICATIONS: Insulin, enteric-coated aspirin 81 mg, aztreonam, Coreg, darbepoetin, Lasix, glucagon, Ativan, Risperdal and vancomycin.
BK|BK (virus)|BK|146|147|PLAN|She is being treated with two times fluid maintenance and keeping her platelet count high. Her coagulation parameters are intact. We are awaiting BK virus studies of her urine. She was scheduled for bladder ultrasound tomorrow. She has a white count of 2200 with an ANC of 1400.
BK|below knee|BK|166|167|SUMMARY  OF CASE|4. Add ciprofloxacin 500 mg by mouth twice daily and plan 3-4 weeks as he convalesces. SUMMARY OF CASE: This is a 69-year-old gentleman who came in earlier today for BK amputation of his right lower extremity. He has had a complex orthopedic history with multiple procedures involving the right lower extremity and ankle and unfortunately the evolution of chronic infection and osteomyelitis.
BK|below knee|BK|372|373|PREOPERATIVE LABORATORY DATA|Finally, the patient has been found to have a mass in the right fourth rib that is pretty suspicious for a metastatic lesion; a needle biopsy was not successful (it yielded nondiagnostic tissue), and an open biopsy had been planned when the patient's current acute illness developed. The physical examination is remarkable for a lot of diabetic complications, including a BK amputation on one side; the arm with the thrombosis shows resolving edema; there were no prominent collateral veins in the skin, and there were no palpable cords at other sites.
BK|below knee|BK|372|373|PREOPERATIVE LABORATORY DATA|Finally, the patient has been found to have a mass in the right fourth rib that is pretty suspicious for a metastatic lesion; a needle biopsy was not successful (it yielded nondiagnostic tissue), and an open biopsy had been planned when the patient's current acute illness developed. The physical examination is remarkable for a lot of diabetic complications, including a BK amputation on one side; the arm with the thrombosis shows resolving edema; there were no prominent collateral veins in the skin, and there were no palpable cords at other sites.
BK|BK (virus)|BK|292|293|PAST MEDICAL HISTORY|This is determined from problems walking, incontinence, and problems with school performance. 2. Unrelated cord blood transplant _%#MM#%_ _%#DD#%_, 2004, complicated by hemorrhagic cystitis, hypertension, diabetes, CMV antigenemia, seizures, and focal left hemispheric status epilepticus and BK virus positive. ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: Numerous, please see admit orders.
BK|BK (virus)|BK|360|361|HISTORY OF PRESENT ILLNESS|His bone marrow transplant was on _%#MMDD2005#%_. The patient was recently readmitted on _%#MMDD2005#%_ with complaint of fevers. His current hospital course has been complicated by viral and fungal pneumonia, acute respiratory distress syndrome, and hemorrhagic cystitis thought likely due to chemotherapy induction with cyclophosphamide, and it is felt that BK virus is also contributing to his hemorrhagic cystitis, likely. PAST MEDICAL, SOCIAL HISTORY, REVIEW OF SYSTEMS: Please see Admission History and Physical, on _%#MMDD2005#%_, by Dr. _%#NAME#%_.
BK|BK (virus)|BK|268|269|ASSESSMENT|Urine ran clear to very faint pink on brisk CBI after hand-irrigation and catheter exchange. The patient tolerated the procedure well. ASSESSMENT: Hemorrhagic cystitis in a bone marrow transplant patient, likely due to Cytoxan treatment in the recent past, as well as BK virus involving the bladder. PLAN: Plan at this point to continue continuous bladder irrigation and wean to clear as able.
BK|below knee|BK|190|191|IMPRESSION|Consult requested by Dr. _%#NAME#%_ and Dr. _%#NAME#%_. REASON FOR CONSULT: Evaluation and perioperative antibiotic management. IMPRESSION: 1. This is an 81-year-old gentleman here for left BK amputation on _%#MMDD#%_. 2. He has cellulitis and osteomyelitis of the left lower extremity and associated with this a nonhealing foot wound.
BK|below knee|BK|111|112|REASON FOR CONSULTATION|The patient also has absolutely serious vascular disease. She has had a four-vessel CAB and she has had a left BK amputation. Her skin is as thin as skin can get. There are multiple injuries to the skin. There is, what I consider, almost an ischemic look to the skin in areas and certainly there are multiple areas of cellulitis.
BK|BK (virus)|BK|231|232|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 24-year-old gentleman with end stage kidney disease secondary to rapidly progressive glomerulonephritis, who received a kidney transplant in 2001. This graft was subsequently lost to BK virus, and he underwent a transplant nephrectomy in 2002. Subsequently, he has received a deceased donor kidney on _%#MM#%_ _%#DD#%_, 2006, and this was complicated by a positive B cell crossmatch.
BK|below knee|BK|147|148|REASON FOR CONSULTATION|Today he says that his arm is stronger but still not normal. He has had no headache. He denies any change in his vision or language. He has a left BK amputation. He has not been up and so he does not know about his leg, but he does not note any difference in how it feels at this point, in as far as his strength.
BK|below knee|BK|120|121|PHYSICAL EXAMINATION|Muscle tone is natural bilaterally. In the legs, both hip flexors are quite strong equally, and of course he has a left BK amputation. I cannot fully test the right leg either because of his dressings and splint. Sensory testing is unremarkable to touch and temperature bilaterally in the upper extremities and in the face.
BK|below knee|BK|187|188|PHYSICAL EXAMINATION|HEENT: Negative. NECK: Normal. LUNGS: Clear. CARDIAC: Regular rate and rhythm. No murmurs or gallops appreciated. ABDOMEN: Obese, otherwise benign. EXTREMITIES: No edema. There is a left BK amputation. Stump is clean and well-healed. Peripheral pulses are normal. NEUROLOGIC: Cranial nerves are intact. Motor exam shows symmetric strength.
BK|below knee|BK|224|225|REASON FOR CONSULTATION|Blood cultures were drawn and the patient was admitted to the ICU for treatment of his septic condition. I was asked to evaluate this. I have operated on the patient in the past for breakdown of his soft tissue on his right BK stump on two different occasions. PAST MEDICAL HISTORY: 1. Insulin-dependent diabetes since 1990. 2. Diabetic peripheral neuropathy.
BK|below knee|BK|149|150|SUMMARY OF CASE|3. He needs periodic follow-up per his primary care physician after he leaves this facility. SUMMARY OF CASE: This is an 88-year-old man who has had BK amputation on the right on the above-stated date after a long battle with an infected nonunion of the right tibia. The surgery went reasonably well, although he is considered high risk for recurrence of infection because of the prior history of major infection, nonunion and Paget's disease as well as other factors in his case that would affect his host immunity status.
BK|below knee|BK|206|207|PHYSICAL EXAMINATION|ABDOMEN: Abdomen is benign. EXTREMITIES: There are amputations of digits 3 and 5 on the right hand and left 4th digit. There are bilateral lower extremity amputations with an AK amputation on the right and BK amputation on the left. NEUROLOGIC: Somnolence and left upper extremity paresis. LABORATORY DATA: Electrolyte panel done yesterday was normal.
BK|below knee|BK|186|187||Angiography and a Rotablator procedure were done yesterday. This was through a right femoral approach. He had pain in the medial right thigh last night. He has had previous recent right BK and left AK amputations. These were presumably for peripheral arterial disease although he is not quite sure. Evaluation for his pain has included an ultrasound of the right groin that showed no evidence of a pseudoaneurysm or hematoma and a normal femoral artery.
BK|below knee|BK|194|195|PHYSICAL EXAMINATION|He has been placed on wound care measures including Silvadene to his right lower extremity. PHYSICAL EXAMINATION: VITAL SIGNS: He is afebrile, vital signs stable as noted in the chart. His left BK stump looks good though he has a slight flexion contraction indicative of chronic none use of that lower extremity and being bedridden.
BK|below knee|BK.|221|223|HISTORY OF PRESENT ILLNESS|He brought the patient to the operating room last night for an I and D of the foot, found complete necrosis of the plantar fascial aspect in the forefoot. I was consulted for definitive procedure which I recommended as a BK. I met the family and met the patient today. We discussed the options with the loss of blood supply to the foot.
BK|below knee|BK.|186|188|HISTORY OF PRESENT ILLNESS|I met the family and met the patient today. We discussed the options with the loss of blood supply to the foot. A Syme's amputation would not be functional and therefore I recommended a BK. The patient does not have current ulcerations on the contralateral foot. PAST MEDICAL HISTORY: 1. Diabetes mellitus type 2. 2. History of appendectomy.
BK|below knee|BK|131|132|IMPRESSION AND PLAN|IMPRESSION AND PLAN: The patient will need a BK. I had a long discussion with the family and we are going to go ahead today with a BK on this side. Risks and benefits of this are discussed with the family and they want to proceed.
BK|below knee|BK|244|245|PAST MEDICAL/SURIGICAL HISTORY|He has not had any angina or equivalent of angina, no shortness of breath and his bowel and bladder seem to be working at the present time. The patient voices to feel well at this time. PAST MEDICAL/SURIGICAL HISTORY: 1. The patient required a BK amputation of his left leg on _%#MMDD1945#%_ after he sustained a WWII injury to his left leg. 2. Laminectomy at L4-5 in 1998 for treatment of spinal canal stenosis with partial, but significant improvement in back pain.
BK|below knee|BK|166|167|PHYSICAL EXAMINATION|LUNGS: Clear. HEART: Sounds are regular and normal. ABDOMEN: Moderately obese. RECTAL: Deferred at this time. GENITALIA: Deferred at this time. EXTREMITIES: He has a BK amputation on his left leg. There are drains from his right hip for his total right hip replacement. DIAGNOSTIC IMPRESSION: 1. Postop right-sided total hip replacement, doing very well.
BK|below knee|BK|187|188|HISTORY|The patient is still smoking heavily. He is limited in his ability to comply with instructions to keep his leg elevated but is making an attempt to do so. He has had no problems with his BK amputation site on the left lower extremity. His diabetic control has been reasonably good. His renal function has been stable.
BK|below knee|BK|46|47||Mr. _%#NAME#%_ came in today after he had his BK amputation accomplished at F-UMC recently. He is still being treated for cellulitis, dermatitis, venostasis, and a burn to the right foot over the medial aspect of his great toe.
BK|below knee|BK|201|202|LOCATION|Mr. _%#NAME#%_ came in for followup of his leg infections. In the interval since last being seen he continues to do reasonably well. He managed to lose some weight. He is recovering properly after his BK amputation. The right foot had shown improvement in terms of swelling, erythema, and some healing of the burn over the right great toe and on the dorsum of the foot.
BK|below knee|BK|117|118|IMPRESSION|REASON FOR CONSULTATION: Perioperative medical management. IMPRESSION: 1. This is a 56-year-old woman here for right BK amputation done earlier today for chronically infected right Charcot foot. 2. She has diabetes mellitus, which is uncontrolled. 3. Organic heart disease with history of Adriamycin, cardiotoxicity and congestive heart failure.
BK|below knee|BK|203|204|RECOMMENDATIONS|4. History of breast cancer. She is status post surgery, chemotherapy and radiation treatment in 2004. 5. Hypertension. RECOMMENDATIONS: 1. We will follow the postoperative orthopedic protocol after her BK amputation. 2. She will be maintained an excellent diabetic control. She is currently on a combination of Lantus plus Regular insulin using carbohydrates counting 1:1 with meals.
BK|BK (virus)|BK|206|207|HISTORY OF PRESENT ILLNESS|However, Dr. _%#NAME#%_ felt that he was likely to have continued presence of the autoantibody clones which might recur in the setting of increased immunosuppression. The last transplant was complicated by BK nephropathy with a PCR that seemed to increase when the immunosuppression was increased for the autoimmune hemolytic anemia. Prior to this transplant BK PCR was negative (since _%#MM#%_ 2007).
BK|BK (virus)|BK|131|132|HISTORY OF PRESENT ILLNESS|Prior to this transplant BK PCR was negative (since _%#MM#%_ 2007). A transplant nephrectomy was done in an attempt to prevent the BK virus from recurring. The patient underwent a second kidney transplant on _%#MMDD2007#%_ with a niece as a donor.
BK|BK (virus)|BK|128|129|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Living related donor kidney transplant in 1986. 2. Pancreas transplant in _%#MM#%_ 2004. 3. History of BK virus nephropathy with graft failure in 2007 with graft nephrectomy in _%#MM#%_ 2007. 4. History of autoimmune hemolytic anemia, treated with prednisone until _%#MM#%_ 2007.
BK|BK (virus)|BK|146|147|PLAN|1. IV fluids. 2. Recheck urine culture. 3. Recheck amylase and lipase. 4. Fluid collection management per surgery. 5. Lower extremity Doppler. 6. BK virus PCR in urine and serum. 7. Low threshold for biopsy if creatinine continues to increase. 8. Attempt to increase Prograf level to at least 8.
BK|BK (virus)|BK|220|221|PAST MEDICAL HISTORY|13. Mycobacterial infection pneumonia. 14. Status post living donor kidney transplant in 1986. 15. Status post deceased donor kidney transplant in 2004. 16. Status post enteric conversion of his pancreas transplant. 17. BK nephropathy of transplanted kidney. PAST SURGICAL HISTORY: Includes: 1. Living donor kidney transplant in 1986, deceased donor pancreas after kidney in 2004 with bladder drainage.
BK|BK (virus)|BK|175|176|PAST MEDICAL HISTORY|The patient has had some decreased hemoptysis requiring some transfusions since being in the hospital. PAST MEDICAL HISTORY: 1. First kidney transplant in 1986, rejected with BK virus. 2. Pancreas transplant in _%#MM2004#%_. Had Campath after that. 3. Autoimmune hemolytic anemia thought secondary to Campath diagnosed _%#MM2006#%_ subsequently treated with steroids and splenectomy.
BK|BK (virus)|BK|172|173|IMPRESSION|3. He has long-standing diabetes mellitus with multiple sequelae. 4. Prior renal transplantation in 1986 and subsequent post-transplant nephrectomy in _%#MM2007#%_ after a BK virus nephropathy was recognized. 5. History of pancreas transplant in 2004 with subsequent enteric conversion. 6. Gastrointestinal bleed _%#MM2007#%_, resolved. 7. History of deep venous thrombosis including into his transplanted renal vein in _%#MM2007#%_.
BK|below knee|BK|246|247|SUMMARY OF CASE|SUMMARY OF CASE: _%#NAME#%_ _%#NAME#%_ is a 28-year-old gentleman who was admitted because of stump cellulitis of the right lower extremity. He has an interesting past history of a congenital defect of his right lower extremity, which required a BK amputation early in life. He has adapted well and unfortunately has had 2 or 3 episodes of a soft tissue infection and cellulitis involving his stump site in the past three years.
BK|below knee|BK|255|256|HISTORY|The patient has history of prior claudication and underwent revascularization procedure first off in _%#MM#%_ with a left femoral to above knee popliteal artery bypass grafting. The patient subsequently in _%#MM#%_ had right superficial femoral artery to BK popliteal bypass performed without immediate complications or problems. The patient did well in the postop state without obvious difficulties until presenting again in _%#MM#%_ with occluded right femoral popliteal bypass grafting.
BK|below knee|BK|214|215|IMPRESSION|I believe that considering her noncompliance issues, her diabetes and her vascular disease that the most effective way to treat this would be to proceed with a below-knee amputation. Dr. _%#NAME#%_ believes that a BK level will heal up. I do not believe that it is likely that attempts to revascularize the foot will prove fruitful; he agrees.
BK|below knee|BK|185|186|SUMMARY  OF CASE|She has a history of diabetes with associated peripheral neuropathy and Charcot foot. A couple of years ago she had an infection in the right lower extremity, which ultimately led to a BK amputation on that side. The foot drainage at the heel has been cultured at Unity Hospital the report indicates the presence of MRSA.
BK|below knee|BK|194|195|SUMMARY OF CASE|He is on an insulin schedule as well. He has stated allergies to lithium and to Septra. The patient is not able to provide a meaningful medical history to me at this time. He is now status post BK amputation and is convalescing reasonably well. He had been receiving perioperative antibiotics in the form of vancomycin and imipenem as noted above.
BK|below knee|BK|191|192|SUMMARY OF CASE|The patient is examined at the bedside. He is a fair complected adult gentleman with coarse features. He is repetitive in answering some questions and becomes agitated quite easily. He has a BK amputation on the left leg which appears to be non- inflamed. His right lower extremity has a small pressurized ulcer over the heel.
BK|below knee|BK|114|115|PAST MEDICAL HISTORY|He has a past history of trauma and subsequent C-spine surgery in the late 1980s and again in 2000. He also had a BK amputation on the right for osteomyelitis. He has maintained sobriety for at least the past three years. He does, however, have a history of depression. ALLERGIES: The patient has stated allergies to codeine, Darvocet, penicillin, and sulfa drugs.
BK|below knee|BK|168|169|ASSESSMENT|As he had swelling of the right residual limb and could not don his prosthesis, further PT evaluation was not completed. ASSESSMENT: 48-year-old male status post right BK amputation and left total hip revision. RECOMMENDATIONS: Agree with plan to provide home physical therapy. Would recommend the patient be screened by occupational therapy before discharge home.
BK|below knee|BK|161|162|PHYSICAL EXAMINATION|My presumption is that he will need a transmitted ....sal amputation with less than a 50% chance of healing it. If he fails to heal this site, he would go on to BK amputation. ADMITTING IMPRESSION: 1. Multiple ongoing medical problems: urinary tract, pulmonary, and extremity.
BK|below knee|BK|252|253|ADMITTING IMPRESSION|2. Gangrene right great toe. 3. Status post distal bypass to right foot approximately one year ago. 4. As mentioned above, not a good chance that he will be able to heal any kind of amputation site in his foot and is most likely going to end up with a BK amputation. PLAN: Continue to treat him medically. His INR is being adjusted.
BK|below knee|BK|139|140|REASON FOR CONSULTATION|This is a 76-year-old male who has diabetes mellitus 30 years duration. He has severe peripheral vascular disease. He is status post right BK amputation. The patient has had a slow healing ulcer on his left foot, he is actually planned for skin grafting of that this Saturday.
BK|below knee|BK|144|145|PAST  MEDICAL HISTORY|The patient is undergoing evaluation by Dr. _%#NAME#%_ and by vascular. PAST MEDICAL HISTORY: 1. Peripheral vascular disease, status post right BK amputation. 2. Atherosclerotic coronary disease, he is status post a coronary artery bypass grafting approximately 10 years previously, he has had no anginal symptoms or heart failure in the last year.
BK|BK (virus)|BK|471|472|IMAGING|A urine culture from this specimen is pending. Her most recent creatinine from a Chem-7 panel on _%#MMDD2007#%_ is reviewed and is significant for a potassium of 5.1, a blood urea nitrogen of 33, creatinine of 1.44. Her INR is 1.01. A hemogram from _%#MMDD2007#%_ is reviewed with white count of 8.0, hemoglobin of 7.3, hematocrit of 21.5, platelets of 162. IMAGING: A renal ultrasound is completed on _%#MMDD2007#%_ and is reviewed which appears normal. There is also a BK virus PCR pending on the urine specimen. IMPRESSION: This is a 36-year-old woman status post dual umbilical cord transplant for ALL, day 93, who presents with another episode of recurrent hemorrhagic cystitis, most likely secondary to her 2 courses of chemotherapy.
BK|below knee|BK|214|215|REASON FOR CONSULTATION|She is known to have extensive cerebrovascular and vascular risk factors of atherosclerotic heart disease, chronic atrial fibrillation, peripheral vascular disease, status post fem-pop bypass and ultimately a left BK amputation. She is a smoker. She has a history of hypertension but no diabetes nor hypercholesterolemia. PAST MEDICAL HISTORY: Remarkable for diagnoses listed above including vulvar cancer surgery in 1958, depression, Giardia, C. dif and chronic renal impairment.
BK|below knee|BK|191|192|PHYSICAL EXAMINATION|She does answer yes/no questions, although not always appropriately. She does follow simple commands. She has good strength and tone in both arms and her right leg. She is status post a left BK amputation. She has preserved sensation bilaterally. Facial symmetry, palate and tongue function are noted. She has symmetrical reflexes in the upper extremities and a questionable upgoing toe on the right.
BK|BK (virus)|BK|214|215|PAST MEDICAL HISTORY|5. History of subarachnoid hemorrhage; no current intervention. 6. Question of graft versus host disease. 7. ID: Positive yeast bacteremia likely Candida with recent Candida krusei on culture, positive HHV6, urine BK virus, positive C. diff. _%#MMDD2007#%_, positive staph aureus on BAL. 8. Diffuse alveolar hemorrhage continues currently. 9. ARDS. 10. Hypertension. 11. History of pericarditis. 12. History of pancreatitis.
BK|below knee|BK|185|186|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: Likely osteomyelitis with chronic drainage of right third toe. She has a difficult situation in that she has a chronic heal ulcer as well as a toe ulcer. She has a BK amputation on her other side and has been ambulatory up until recently. She wished to remain ambulatory, and I believe, based upon this, it would be most reasonable to consider amputation of the third toe as I do not believe this is likely to heal even with the extended use of antibiotics.
BK|below knee|BK|135|136|PHYSICAL  EXAMINATION|EARS, NOSE AND THROAT: Is unremarkable. CHEST: Clear HEART: Has regular rate and rhythm. ABDOMEN: Soft. EXTREMITIES: The right leg has BK amputation. The left, there is some edema of the left foot with decreased peripheral pulses. NEUROLOGIC: The patient is alert and oriented. Cranial nerves II-XII are intact.
BK|below knee|BK|160|161|PRIOR HOSPITALIZATIONS|MEDICATIONS: Vistaril p.r.n. PRIOR HOSPITALIZATIONS: Multiple hospitalizations for depression and chemical dependency. He has also been hospitalized for a left BK amputation for traumatic injury. CHRONIC DISEASE/MAJOR ILLNESS: 1. Chronic anxiety and depression. 2. Chronic alcoholism.
BK|below knee|BK|136|137|REQUESTING PHYSICIAN|He was in diabetic ketoacidosis and after he was stabilized for 24-48 hours, he was taken to surgery by Dr. _%#NAME#%_ _%#NAME#%_ and a BK amputation was done of his left foot and lower leg. He also has been seen by Dr. _%#NAME#%_ from Vascular Surgery and the patient has a strong biphasic dorsalis pedis and posterior tibial pulse at the right ankle level.
BK|below knee|BK|215|216|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD Mr. _%#NAME#%_ _%#NAME#%_ is a 47-year-old gentleman seen today at the request of Dr. _%#NAME#%_ for initial orthopedic consultation with regard to painful, red, left BK stump. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ states that he is a diabetic individual who has had bilateral BK amputations in the past at Regions Hospital.
BK|below knee|BK|150|151|PAST SURGICAL HISTORY|There is no family history of colorectal carcinoma. PAST SURGICAL HISTORY: Includes placement of plate and pins in his right wrist. He has had a left BK amputation, approximately four years ago. This was performed in _%#CITY#%_ for foot ulcer. The patient states that he has not used tobacco products, but he does smoke approximately 15 pipe full of tobacco a day.
BK|below knee|BK|200|201|PHYSICAL EXAMINATION|ABDOMEN: Markedly obese. There is no evidence for hepatosplenomegaly, no bruits noted. There is no apparent ascites. There are no ecchymotic areas appreciated. RECTAL: Deferred. EXTREMITIES: The left BK amputation. There is 1-2+ peripheral edema involving the right leg and changes of chronic stasis dermatitis. NEURO: Appears to be essentially intact. LAB DATA: Liver function tests yesterday were within normal limits.
BK|BK (virus)|BK|153|154|PAST MEDICAL HISTORY|3. Type 2 diabetes. 4. Anxiety and depression. 5. Left rotator cuff problems. 6. GERD. 7. Fibromyalgia and osteoarthritis. 8. History of CMV in 2002 and BK in _%#MM2004#%_ and _%#MM2005#%_. 9. Past history of MRSA. MEDICATIONS: 1. Claritin 10 mg p.o. q.a.m. 2. Vitamin C 500 mg a day. 3. Glipizide ER 2.5 mg p.o. daily.
BK|BK (virus)|BK|726|727|A/P|PMH: DM1 s/p pancreas and LDKT transplants - pancreas in 2001 - kidney in 2000 (brother) without rejection HTN GERD CAD history sz depression HUS/TTP from Prograf Allergies: sulfa, Cipro Meds: MMF 1gm bid dapsone Keppra Reglan carafate Prevacid Effexor metoprolol amlodipine 10 qday SH: lives at nursing home FH: non contributory PE: vitals reviewed alert, pleasant, in NAD NCAT no conj, no icteurs OP clear neck supple and without LAD RRR CTAB abdomen soft and NT no edema no obvious joint swelllings neuro exam grossly non-foca imaging and labs reviewed A/P: 49 year old female admitted for kidney biospy for elevated creatinine. Doubt rejection, suspect mostly ATN, possible AIN. - check renal ultrasound - check CMV, EBV, BK - check urine protein/creatinine - check urine eosinophils - will biopsy later today Addenum: consent for kidney biopsy obtained, signed, and placed in chart patient in supine position inferior pole of transplant kidney noted in LLQ local analgesia obtained with 1% lidocaine 3 passes made, all with successful retrieval of renal tissues hemostatsis achieved with pressure no obvious complications I participated in this evaluation and kidney allograft biopsy and agree with the fellow's note above.--_%#NAME#%_
BK|BK (virus)|BK|176|177|HISTORY OF PRESENT ILLNESS|Ms. _%#NAME#%_ has an extensive history of renal disease. She has had 2 renal transplants. The second was performed as part of the pancreas kidney transplant. Unfortunately, a BK nephropathy developed resulting in failure of the renal graft, though not of the pancreas. Since that infection, she has been dialysis dependent. With dialysis dependence, has come difficult to control hypertension.
BK|BK (virus)|BK|154|155|ASSESSMENT|Results reviewed. ECG: None available for review. ASSESSMENT: 1. Diabetes mellitus, complicated by renal failure, currently hemodialysis dependent due to BK nephropathy. 2. Refractory hypertension related to renal failure, cyclosporin and erythropoietin; though, it is possible that secondary hypertension related either to renal artery stenosis of the native kidneys, cushing syndrome or hyperadrenalism is present.
BK|below knee|(BK|270|272|IMPRESSION|Alkaline phosphatase was elevated. IMPRESSION: 1. Rectal carcinoma, recurrent, status post chemotherapy and radiation therapy. 2. History of IgA myeloma, status post chemotherapy. 3. Diabetes mellitus with associated vasculopathy manifest by peripheral vascular disease (BK amputation). 4. Renal failure requiring hemodialysis. 5. Evidence of coronary artery disease. 6. History of possible asbestosis. 7. Recurrent decubitus ulcers with osteomyelitis.
BK|below knee|BK|160|161|PAST MEDICAL HISTORY|He has diabetic nephropathy and peripheral neuropathy. He has diabetic retinopathy with complete blindness. He also has peripheral vascular disease for a right BK amputation in 2003. He has hypertension and had an ileal resection due to ischemia and ileostomy and subsequent takedown.
BK|BK (virus)|BK|198|199|IMPRESSION|4. Diabetes mellitus. 5. Anxiety and depression. 6. Past medical history of serious staphylococcal infections x 3 or 4 including sepsis syndrome and MRSA. 7. Past medical history of CMV in 2002. 8. BK virus infection in 2005. RECOMMENDATIONS: 1. Check MRSA surveillance cultures. 2. Add vancomycin at 800 mg IV every 24 hours for additional staph coverage and monitor drug levels and renal function closely.
BK|below knee|BK.|221|223|PAST MEDICAL HISTORY|She underwent a CAT scan last night that showed a significant amount of subcutaneous air both on the chest and the left side of the neck. PAST MEDICAL HISTORY: 1. Ischemic cardiomyopathy, status post heart transplant. 2. BK. 3. Diabetes mellitus. 4. Kidney transplant. MEDICATIONS: Lipitor, hydrochlorothiazide, Maalox, Prograf, minocycline, Nephrocaps, and daptomycin.
BK|below knee|BK|131|132|IMPRESSION|REASON FOR CONSULTATION: Evaluation of antibiotic management. IMPRESSION: 1. This is a 63-year-old gentleman here with an infected BK amputation site. He is status post debridement on the _%#DD#%_ of _%#MM#%_. Wound cultures show group D enterococcus and a variety of gram negative rods including Enterobacter and Pseudomonas.
BK|below knee|BK|170|171|REASON FOR CONSULTATION|The patient apparently underwent revascularization of the left lower extremity last year in _%#CITY#%_ _%#CITY#%_. There was failed revascularization. He ended up with a BK amputation. The patient now has exposed femur has been admitted by Dr. _%#NAME#%_ to have revision of his BK amputation. The patient has apparently quite severe peripheral vascular disease.
BK|below knee|BK|164|165|REASON FOR CONSULTATION|There was failed revascularization. He ended up with a BK amputation. The patient now has exposed femur has been admitted by Dr. _%#NAME#%_ to have revision of his BK amputation. The patient has apparently quite severe peripheral vascular disease.
BK|below knee|BK|282|283|REASON FOR CONSULTATION|The actual details of the previous surgeries are unavailable to myself, but he clearly has undergone a right femoral popliteal bypass which has done well and he has had bypass on the left which did not succeed and he ended up with a BK amputation. He simply has failure of the left BK to heal with exposed bone. No real pain or other symptoms associated with that at this time. The patient has known coronary disease. He underwent stenting of the coronary artery in _%#MM#%_ of 2001 that seemed to function well and he has had no anginal symptoms or heart failure by history since that time.
BK|below knee|BK|193|194|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Diabetes. 2. Past CVA in 1994 with left-sided weakness. 3. Hypertension. 4. Status post coronary artery bypass graft x 3. 5. Status post pacemaker. 6. Status post left BK amputation. 7. Hypothyroidism. 8. Hypercholesterolemia. 9. Short-term memory problems. 10. Gout. ADMISSION MEDICATIONS: 1. Allopurinol 100 mg b.i.d. 2. Atenolol 25 mg po 1 qam.
BK|below knee|BK|119|120|REQUESTING PHYSICIAN|She also had recent vascular surgery on the left complicated by healing problems. In terms of examination of her right BK stump, the posterior flap of the proximal 5 cm is cold. The anterior aspect is erythematous anteromedially. There is two areas of greater than 1 cm skin breakdown with purulence in the incisional area itself.
BK|below knee|BK|293|294|REQUESTING PHYSICIAN|The skin itself is viable with the exception of the tip of the fourth toe and the plantar lateral surface of the 5th ray where it also seems to be in early stage of necrosis. I discussed this with this woman to do a revision below knee amputation would result in an unlikely healing/two short BK stump to effectively wear a prosthesis. Therefore, she is looking at an above knee amputation and that brings with it its attendant problems with prosthetic wear and energy cost of ambulating with that type of prosthesis.
BK|below knee|BK|167|168|SUBJECTIVE|The patient has a history of a gastric banding operation in the year 2000. He is 61 years old. He has a long history of diabetes. He was admitted this time for a left BK amputation, which apparently was done on Sunday. The patient complains of a years' worth of abdominal discomfort, occasional nausea and vomiting.
BK|BK (virus)|BK|156|157|PAST MEDICAL HISTORY|The bladder was also irrigated until clear at that time. PAST MEDICAL HISTORY: 1. Biphenotypic leukemia. 2. History of DVTs in _%#MM#%_ 2006. 3. History of BK virus cystitis. 4. History of recent hemorrhagic cystitis. 5. History of subconjunctival hemorrhage. PAST SURGICAL HISTORY: 1. Right shoulder surgery for torn ligament.
BK|BK (virus)|BK.|116|118|PLANS|7. Bipolar disorder. PLANS: Vancomycin for now alone. Does not need prolonged antibiotics here as soon we can go to BK. Will simply cover around the procedure. Does not look toxic or ill, so I do not think we need to broaden the antibiotics at this point.
BK|below knee|BK|283|284|PAST MEDICAL HISTORY|Vancomycin was discontinued; he was switched to clindamycin and Levaquin and has remained afebrile since that time. PAST MEDICAL HISTORY: Remarkable for hereditary spherocytosis, splenectomy. He has had cholecystectomy in the past also related to spherocytosis, and he had the right BK osteotomy as above. ALLERGIES: No known drug allergies, but we will now list him with probable vancomycin allergy.
BK|BK (virus)|BK|137|138|IMPRESSION|4. History of MAI pulmonary infection. 5. History of CMV infection reactivation. 6. History of EBV infection reactivation. 7. History of BK viurea (?). 8. JP drain, right groin in a lymphocele area after she had previous pseudoaneurysm repair. 9. Graft versus host disease. 10. Leukocytosis with significance uncertain, but probably multifactorial etiology.
BK|below knee|BK|177|178|PAST MEDICAL HISTORY|It was also hoped that with thyroid hormone replacement that her hypothermia would also be corrected and that there be a general metabolic improvement. PAST MEDICAL HISTORY: 1. BK amputation for gangrene, _%#MM2007#%_. 2. C. difficile colitis. 3. Urinary tract infection. 4. Acute renal failure. 5. History of recurrent gastrointestinal bleed presumed secondary to arteriovenous malformations with red blood cell transfusion dependence.
BK|BK (virus)|BK|180|181|PAST MEDICAL HISTORY|7. Claudication. 8. Depression. 9. Right BKA. 10. Failed kidney transplant secondary to chronic rejection. 11. Coronary artery disease. 12. History of hemodialysis. 13. History of BK nephropathy. PAST SURGICAL HISTORY: 1. Kidney and pancreas transplant as noted above.
BK|BK (virus)|BK|191|192|PAST MEDICAL HISTORY|Once again the patient denies any pain. There are no paresthesias. PAST MEDICAL HISTORY: 1. Acute myelogenous leukemia. 2. Cytomegalovirus. 3. Recurrent vancomycin-resistant enterococcus. 4. BK viremia history. 5. Graft-versus-host disease. 6. Mycobacterium intracellularly pulmonary infection. 7. Cholelithiasis. 8. Mastoidectomy. CURRENT MEDICATIONS: 1. Fluconazole p.o. 2. Erythromycin. 3. Zosyn IV. 4. Foscarnet.
BK|below knee|BK|201|202||Ms. _%#NAME#%_ was hospitalized in _%#CITY#%_ after being found on the floor of her home. The presentation was attributed to sepsis due to gangrene of the right foot. The patient underwent an emergent BK amputation. This sequence of events occurred in late _%#MM#%_ and the patient was recuperating from the septic event and surgery when on _%#MMDD2007#%_ she sustained a major myocardial infarct with hypotension.
BK|BK (virus)|BK|198|199|PAST MEDICAL HISTORY|3. Diabetic gastroparesis. 4. Gastroesophageal reflux disease. 5. Hypertension. 6. Dyslipidemia. 7. Benign prostate hypertrophy. 8. Erectile dysfunction. 9. History of hiatal hernia. 10. History of BK nephropathy, status post transplant nephrectomy. 11. History of mycobacterium infection pneumonia, right lower lobe, 2006. 12. History of squamous cell carcinoma.
BK|BK (virus)|BK|146|147|PAST SURGICAL HISTORY|7. Nissen fundoplication. 8. Right lower lobe lung biopsy, 2006. 8. 8. 9. Placement of penile prosthesis. 10. Transplant nephrectomy secondary to BK nephropathy, _%#MM2007#%_. 11. Splenectomy secondary to hemolytic autoimmune anemia and incidental appendectomy, _%#MM2007#%_. 12. Retinal photocoagulation. ALLERGIES: Penicillin. HOSPITAL COURSE: The patient was admitted to 6B at the University of Minnesota Medical Center, Fairview, for a 10-day history of shortness of breath.
BK|BK (virus)|BK|258|259|PROBLEM #8|In a prior hospitalization, _%#NAME#%_ had lesions that were discovered which were consistent with possible post- transplant lympho_________ disease or infection. The etiology of these lesions remains unknown. During this hospitalization, urine was sent for BK virus which was negative. Subsequently, urine was sent for JC virus, and the results of that test have not yet re turned. PROBLEM #9: Hypertension. _%#NAME#%_ was continued on her Atenolol, Norvasc, and Lisinopril during this hospitalization and her blood pressures remained within normal range.
BK|BK (virus)|BK|139|140|ADMISSION DIAGNOSES|2. Fevers. 3. Mucositis. 4. Graft-versus-host disease of the skin involving almost 40% of body surface area. 5. Hematuria, with a positive BK virus in the urine. 6. Hepatitis B. 7. Positive PPD. DISCHARGE DIAGNOSES: 1. Anaplastic large T-cell lymphoma, status post allogeneic sibling bone marrow transplant with 6/6 match.
BK|BK (virus)|BK|126|127|HOSPITAL COURSE|Although she continued to have good urinary output, we did not elect to do any sort of CBI at that time. We did check her for BK virus, which was positive. She continued to do the same with her complaints until _%#MMDD2003#%_, which made her 12 days out from her transplant, when she developed some slight fevers.
BK|BK (virus)|BK|228|229|DISCHARGE DIAGNOSES|ADMISSION DIAGNOSES: 1. Fever. 2. Elevated creatinine. 3. Fanconi's anemia, status post cord blood transplant in _%#MM2005#%_. DISCHARGE DIAGNOSES: 1. Adenovirus nephritis. 2. Hemorrhagic cystitis secondary to adenovirus and/or BK virus infection. 4. Methylbacterium bacterium. 5. Fanconi's anemia, status post cord blood transplant in _%#MM2005#%_. PROCEDURES/CONSULTATIONS: 1. Renal consult. 2. Infectious Disease consult. 3. Gastrointestinal consult.
BK|BK (virus)|BK|153|154|LABORATORY DATA|IgG CSF to serum ratio increased. Albumin CSF to serum ratio increased. CMV DNA quantification negative. HSV PCR negative. EBV quantitative is negative. BK virus in CSF negative. Tota l protein increased to 110. CSF glucose increased to 103. Gram stain shows no organisms.
BK|BK (virus)|BK|255|256|PROBLEM #2|This should be followed weekly in outpatient setting. The patient was found to have BK positive viruria on _%#MMDD2007#%_ with greater than 10 million copies. He, subsequently, received 2 doses of IV cydotovir on _%#MMDD2007#%_ and _%#MMDD2007#%_. Repeat BK virus PCR from _%#MMDD2007#%_ is pending at the time of this dictation. The patient was also started on Nystatin q.i.d. for moderate growth of Candida albicans in the throat on _%#MMDD2007#%_.
BK|BK (virus)|BK|255|256|PROBLEM #9|He did require Foley catheter placement; however, this was for approximately 4-5 days, and this was discontinued on _%#MMDD2007#%_. He is status post 2 doses of IV Cidofovir on _%#MMDD2007#%_ and _%#MMDD2007#%_. He remains on Ditropan. A repeat urine for BK virus on _%#MMDD2007#%_ is pending at the time of this dictation. PROBLEM #10: Analgesia. The patient was on a Fentanyl PCA during hospitalization, which was tapered off the day prior to the patient's discharge.
BK|BK (virus)|BK|325|326|HOSPITAL COURSE|She converted to negative antigenemia on _%#MMDD2003#%_, and has been negative for CMV antigen since that time. In addition, she was having problems with hemorrhagic cystitis. Her urine was assayed for BK virus, and was strongly positive; most recent study done on _%#MMDD2003#%_ was greater or equal to 1 to 1000 titers for BK virus, which is very high; repeat urine assays from _%#MMDD2003#%_ and _%#MMDD2003#%_ are pending at this time. The patient has received five doses of cidofovir for treatment of hemorrhage cystitis and BK virus, the most recent on _%#MMDD2003#%_, which was a renally-adjusted dose.
BK|BK (virus)|BK|418|419|HOSPITAL COURSE|In addition, she was having problems with hemorrhagic cystitis. Her urine was assayed for BK virus, and was strongly positive; most recent study done on _%#MMDD2003#%_ was greater or equal to 1 to 1000 titers for BK virus, which is very high; repeat urine assays from _%#MMDD2003#%_ and _%#MMDD2003#%_ are pending at this time. The patient has received five doses of cidofovir for treatment of hemorrhage cystitis and BK virus, the most recent on _%#MMDD2003#%_, which was a renally-adjusted dose. The sixth and final dosage of Cidofovir is due on _%#MMDD2003#%_.
BK|BK (virus)|BK|220|221|HOSPITAL COURSE|The patient had been treated with Ditropan for bladder spasms, but has not needed this for the entire past week. Etiology of hemorrhagic is somewhat unclear; it could be secondary to side effects of chemotherapy, versus BK viral infection. The patient has received five doses of cidofovir and will receive her last on _%#MMDD2003#%_, as described earlier.
BK|BK (virus)|B.K.|218|221|HOSPITAL COURSE|However, _%#NAME#%_ was started on Ditropan and pyridium for bladder spasm associated with suspected hemorrhagic cystitis. Urinalysis was positive for blood and urine culture was negative for bacteria but positive for B.K. virus on _%#MMDD#%_. With continued intermittent blood tinged urine a repeat bladder ultrasound was done on _%#MMDD#%_ but showed no hydronephrosis or clots.
BK|BK (virus)|BK|305|306|HISTORY OF PRESENT ILLNESS/SUMMARY OF TRANSITIONAL CARE STAY|She was admitted to the University of Minnesota Hospitals on frequent occasions for nausea and vomiting related to graft versus host disease and initiation of TPN support for nutrition. Her GI symptoms have waxed and waned and she presents this time with hemorrhagic cystitis thought to be related to the BK virus. She also was found to have positive PCR tests for CMV and EBV viruses. She presented to the Transitional Care Unit for further medical management, ongoing surveillance and platelet infusion and further nutritional support with TPN.
BK|BK (virus)|BK|95|96|ASSESSMENT AND PLAN|There is a question of whether to start Sirolimus in the near future to treat this further. 4. BK virus. Her counts remained up and she remains with hematuria. Further treatment pending at the discretion of bone marrow transplant.
BK|BK (virus)|BK|158|159|HOSPITAL COURSE|Problem #8. Genitourinary: The patient had hemorrhagic cystitis secondary to Cytoxan in his conditioning therapy for peripheral blood stem cell transplant. A BK virus was sent off on his urine which came back as positive. The patient was hydrated during cystitis and supported with increased platelet transfusions.
BK|BK (virus)|BK|159|160|PROBLEM #5|PROBLEM #5: Hemorrhagic cystitis. The patient was noted to have developed hematuria during the course of this hospitalization. Urine cytology was positive for BK virus. Parameters were placed greater than 50,000, and he required continuous bladder irrigation for approximately one week. At the time of discharge, there was no further bleeding or further evidence of cystitis.
BK|BK (virus)|BK|146|147|DISCHARGE DIAGNOSES|2. Graft-versus-host disease of the stomach and probable skin involvement which was not biopsy proven. 3. Mild hemorrhagic cystitis with positive BK virus. 4. Cytomegalovirus reactivation disease with positive antigenemia. PROCEDURES PERFORMED: 1. Double umbilical cord blood CD34 transplant, _%#MMDD2004#%_.
BK|BK (virus)|BK|219|220|ASSESSMENT AND PLAN|PROBLEM #2. Chronic kidney disease. The patient has a long history of chronic kidney disease, and I am unsure if she has undergone renal consultation in the past. She does have urine PCR studies, which are positive for BK virus. I am unclear if this has been thoroughly evaluated and what recommendations have been made. In light of this, we will consult the renal team today.
BK|BK (virus)|BK|235|236|PROBLEM #1|Overall the patient's hospital course was complicated by neutropenic fevers with bacteremia and probable pneumonia, as will be described below. In addition, the patient suffered from hemorrhagic cystitis during his stay, likely due to BK virus. The patient also required TPN due to severe nausea and later decreased appetite. Overall the patient has remained afebrile since day +25 (_%#MMDD2005#%_).
BK|BK (virus)|BK|172|173|PROBLEM #3|PROBLEM #3: Hemorrhagic cystitis. The patient suffered from hemorrhagic cystitis and large amounts of hematuria. He required a Foley catheter. The patient was positive for BK virus. He had a Foley in for 3 weeks, which was removed on _%#MMDD2005#%_. Currently the patient is voiding well and his platelets are being kept at greater than 50,000.
BK|BK (virus)|BK|168|169|HOSPITAL COURSE|UA was also negative, Epstein-Barr virus DNA quantitative showed less than a 1000 and there is no EBV DNA detected, so results were negative. CMV DNA was also negative BK virus PCR was also negative. The patient remained afebrile throughout her hospital stay. 4. Cardiovascular/respiratory: The patient's cardiovascular and respiratory status remained stable throughout her hospital stay.
BK|BK (virus)|BK|155|156|PROBLEM #7|PROBLEM #7: GU. On _%#MMDD2006#%_ a 3-way Foley urinary catheter was placed due to hematuria and inability to void. This did resolve as of _%#MMDD2006#%_. BK virus was negative. The catheter was removed on _%#MMDD2006#%_ and _%#NAME#%_ has not had any difficulty with hematuria or voiding since that time.
BK|BK (virus)|BK|323|324|PROBLEM #3|In addition, he has known bilateral small kidneys. The renal team was consulted on _%#MMDD2007#%_ for continued workup of increased BUN and their conclusions were elevated BUN was secondary to tacrolimus. In addition, a renal ultrasound was performed which did show enlargement of both kidneys from previous ultrasounds. A BK virus of this urine was sent which was negative and a cystatin C level was elevated at 1.87 which was noted by the primary team and will be followed as an outpatient.
BK|BK (virus)|BK|195|196|HOSPITAL COURSE|The patient also developed hematuria early on in her course and urine was submitted, which revealed positive BK virus. The patient received multiple bladder irrigations of cidofovir to treat the BK virus. The last BK virus that was checked continued to be positive. She did not receive IV cidofovir due to her renal status.
BK|BK (virus)|BK|152|153|HOSPITAL COURSE|Post surgery he had a lot of bladder spasms and was begun on Amicar drip prior to surgery which was continued for 5 days, through _%#MMDD2003#%_. Urine BK virus was initially negative but recheck was positive from beginning of _%#MM2003#%_. When his cystitis worsened he was treated with IVIG for 3 doses, followed by an additional 6-week course of IVIG.
BK|BK (virus)|BK|118|119|HOSPITAL COURSE|When his cystitis worsened he was treated with IVIG for 3 doses, followed by an additional 6-week course of IVIG. The BK viral load was subsequently noted to be decreasing. During the first week of _%#MM2003#%_, _%#NAME#%_ had bilateral nephrostomy tubes placed, and have occasionally needed replacement or repositioning by Interventional Radiology.
BK|BK (virus)|BK|129|130|HOSPITAL COURSE|Repeat CT scan on _%#MMDD2003#%_ showed persistent pansinusitis, unchanged from the study of _%#MMDD2003#%_. As mentioned above, BK virus from urine was positive on _%#MMDD2003#%_ and again positive on _%#MMDD2003#%_. Initially this was not treated but as the cystitis worsened on about _%#MMDD2003#%_, he was then treated with IVIG, completing a 6-week course, begun on _%#MMDD2003#%_.
BK|BK (virus)|BK|190|191|PROBLEM #4|We will have to follow her creatinine levels closely, especially with increasing Prograf dose. The renal team was consulted for this during the last hospitalization. As per their recs Serum BK virus was done and turned out to be negative. (Review previous d/c summary). PROBLEM #5: Hypertension. She is hypertensive at this clinic visit.
BK|BK (virus)|BK|139|140|PROBLEM 5|It was suggested of a mild early hemorrhagic cystitis. Therefore, the patient was placed on Pyridium, and his urine was sent for a PCR for BK virus. This is pending at the time of discharge. As mentioned above, the patient was to continue on a prednisone taper on discharge to treat his presumed gut graft versus host disease.
BK|BK (virus)|BK|153|154|IMPRESSION|If there is progression in her renal insufficiency further evaluation will be pursued. With the renal insufficiency and fever, we will also evaluate for BK virus. I have discussed the patient at length with Dr. _%#NAME#%_ who will assume care for this patient in the morning.
BK|BK (virus)|BK|182|183|IMPRESSION|The patient's post transplant course was complicated by hemorrhagic cystitis which required the patient to be readmitted in late _%#MM#%_/early _%#MM#%_. The patient was found to be BK positive from his urine, and this was believed to be the source of his hemorrhagic cystitis. It was felt that the patient was a good candidate for conservative therapy, as his hemorrhagic cystitis resolved with bladder irrigation, and was not deemed severe.
BK|BK (virus)|BK|150|151|HOSPITAL COURSE|1. Sedimentation rate of 58 mm per hour. 2. C-reactive protein of 47.2 mg/dL. The following were tests that were pending at the time of discharge. 1. BK virus quantification. 2. Herpes simplex virus measuring by PCR. 3. IgG and IgM levels to bartonella.
BK|BK (virus)|BK|187|188|PROBLEM #3|A PPD and controller placed which showed anergic response both control and in tuberculin antigen. Further blood work up was negative included EBV, adenovirus, parvovirus, enterovirus and BK virus. CMV PCR was mildly positive on _%#MMDD2007#%_. During his last admission with 200 copies, however two subsequent tests were negative.
BK|BK (virus)|BK|119|120|PROBLEM #4|Urine studies have included schistosomiasis, and cultures of adenovirus, CMV and BK virus. PROBLEM #4: Urinary issues. BK virus of the urine was positive. Of note is last UA on _%#MMDD2007#%_ was mildly positive for blood, but no signs of infection were seen.
BK|BK (virus)|BK|140|141|PROBLEM #4|Biopsy showed focal nonreaction hyperplasia, hemosiderin and no evidence of cystitis. Bacterium fungal cultures of the tissues are pending. BK virus PCR was positive on _%#MMDD2007#%_, was positive with 765,000 copies. However, this is not correlated with sickle exam or blood findings as PCR blood for BK was negative.
BK|BK (virus)|BK|217|218|PROBLEM #4|Bacterium fungal cultures of the tissues are pending. BK virus PCR was positive on _%#MMDD2007#%_, was positive with 765,000 copies. However, this is not correlated with sickle exam or blood findings as PCR blood for BK was negative. Ureaplasma and mycoplasma of the blood are pending as well as the final cultures and fungal cultures on bladder tissue biopsy.
BK|BK (virus)|BK|304|305|HOSPITAL COURSE|He also received one dose of total body radiation. Transplantation was performed on _%#MM#%_ _%#DD#%_, 2005 with HLA matched allogeneic sibling donor which was actually the cousins with a 6/6 match. His transplant course has been complicated by significant petechiae and hematuria which was tested to be BK virus positive on _%#MM#%_ _%#DD#%_, 2005. He did not receive any viral medications for that, he did receive IV fluid flushes and lasix to continually irrigate his bladder.
BK|BK (virus)|BK|171|172|HOSPITAL COURSE|He has not had any complications of significant hemorrhage. A repeat urinalysis is pending at this time. His platelet parameters were increased based on his petechiae and BK virus positivity was some red cells in his UA to 30,000 or greater. Since that time, his petechiae have improved. He also experienced a slight SIADH with nadir of serum sodium at 131 which resolved with 3% normal saline.
BK|BK (virus)|BK|141|142|HOSPITAL COURSE|2. Infectious disease: He has no signs or symptoms of infection at this time. He is on prophylactic antibiotics as noted below. Again, he is BK virus positive from the urine. He is also CMV, HSV, EBV positive prior to transplant. He did spike his temperature on _%#MM#%_ _%#DD#%_, 2005, for which a vancomycin and stress test was started; however, with negative cultures those were discontinued, and his temperature was correlated to IgG administration.
BK|BK (virus)|BK|126|127|DISCHARGE MEDICATIONS|Request for platelet antibodies were sent and is pending. DISCHARGE MEDICATIONS: 1. Vitamin C 1 g daily; to certify urine for BK virus. 2. Lasix 20 mg daily. 3. Gabapentin 300 mg at p.m./ a.m. 4. Metoprolol 25 mg daily. 5. Fluconazole 200 mg daily through day 100.
BK|BK (virus)|BK|198|199|PROBLEM #12|He also had occupational therapy and speech therapy during his hospital stay and these services should continue while _%#NAME#%_ is an outpatient. PROBLEM #12: GU. _%#NAME#%_ had been noted to have BK virus in his urine on _%#MM#%_ _%#DD#%_, 2005, and at this time he was also noted to have blood clots in his urine.
BK|BK (virus)|BK|485|486|PAST MEDICAL HISTORY|3. Gout, no recent flare. 4. Hyperlipidemia, treatment on hold for peripheral blood stem cell transplant. 5. Inguinal hernia repair. 6. Myeloablative allogeneic sibling peripheral blood stem cell transplant on _%#MMDD2005#%_ for T-cell PLL, with complications of grade 3 mucositis, Staph epidermidis bacteremia, persistent fevers with negative BAL with resolution with Vfend, acute renal failure, reactivation of herpes zoster of right C5 dermatome, hemorrhagic cystitis with positive BK virus, Klebsiella and Stenotrophomonas bacteremia on _%#MMDD2005#%_ with subsequent _________ removal and treated for 14 days with Cipro and Bactrim ending on _%#MMDD2005#%_.
BK|BK (virus)|BK|136|137|PROBLEM #2|He was continued on his nystatin suspension swish and spit. We also checked his CMV antigenemia, which was negative, and he had a urine BK virus PCR checked which was positive and adenovirus urine culture checked, which was pending at the time of discharge. PROBLEM #3: Immunology. Due to patient's liver biopsy results with the mild graft-versus-host disease his prednisone was increased to 40 mg b.i.d. and he was continued on his home doses of CellCept and Gengraf for immunosuppression.
BK|BK (virus)|BK|343|344|HISTORY OF PRESENT ILLNESS|She, however, had difficulty being able to keep up with all of the therapy there and it was felt that she was more appropriate for Subacute Rehab, which is why we are transferring her to this service today. Her other major medical problems during the course of hospitalization have involved hemorrhagic cystitis that was felt to be related to BK virus, and lichenoid changes of buccal mucosa that was suggestive but nondiagnostic for chronic graft versus host disease. She has also had a Schirmer's test that was apparently negative for chronic graft versus host disease.
BK|BK (virus)|BK|283|284|PROBLEM #6|On the 2 days prior to Mr. _%#NAME#%_ _%#NAME#%_'s death, his creatinine increased to 1.98 and then to 2.98. His urine production fell from around 2 liters to approximately 800 mL and on the 24 hours prior to his death, 300. The patient did have a history of hematuria with positive BK virus, but this seemed to resolve probably a week into his hospitalization. We did consult renal and did not proceed with dialysis.
BK|BK (virus)|BK|163|164|PROBLEM #3.    ENT|This is her goal rate for caloric needs per the dietitian. _%#NAME#%_ has been tolerating her feeds well. PROBLEM #5. Genitourinary: She has a history of positive BK virus from _%#MMDD2005#%_ due to her hemorrhagic cystitis. She will be discharged on D5-1/2 normal saline plus 20 mEq of KCl at 150 mL/hr which is 2 times maintenance.
BK|BK (virus)|BK|213|214|HOSPITAL COURSE|There was the thought that the patient may have been pancytopenic due to his multiple viral infections. The patient had multiple virology studies during his hospitalization including PCR for EBV, CMV, adenovirus, BK virus and human metapneumovirus. Of note, the patient had a positive EBV PCR which then cleared on subsequent checks. The patient had a positive adenovirus PCR on BAL and a positive PCR for HHV6.
BK|BK (virus)|BK|127|128|PROBLEM #5|This was treated and his diarrhea resolved. PROBLEM #5: Genitourinary: _%#NAME#%_ developed hemorrhagic cystitis with positive BK virus PCR. He received cidofovir for this in addition to continuous bladder irrigation. His hematuria resolved and he since had good urine output.
BK|BK (virus)|BK|268|269|HOSPITAL COURSE|There was concern that these cyclic fevers were secondary to CMV, and CMV antigen and PCR were sent and both returned negative. ID was consulted as well and _%#NAME#%_ had a long list of viral microbial studies performed consisting of the following: HSV PCR, EBV PCR, BK virus PCR, Bartonella henselae antibody, Coxsackie A and B antibody, adenovirus culture, Parvovirus PCR, cryptococcal antigen, Aspergillus antigen, mycoplasma PCR, influenza A and B antigen, blood cultures, urine cultures, AFB culture as well as enteroviral PCR, BCG, IgG, diphtheria and tetanus antibodies.
BK|BK (virus)|BK|236|237|PROBLEM #7|He is on Actigall. His bilirubin on discharge had improved and was 8.3 total with direct of 3.3. PROBLEM #7: Genitourinary. At admission, he had new extensive hemorrhagic cystitis documented on CT scan. Urine cultures were positive for BK virus. He was treated symptomatically and this issue has nearly resolved. Upon discharge, he was no longer having clots in his urine and was having no dysuria.
BK|BK (virus)|BK|208|209|PAST MEDICAL HISTORY|The patient goes to _%#CITY#%_ _%#CITY#%_ Dialysis Monday, Wednesday, and Friday. Living non-related donor transplant from wife at _%#COUNTY#%_ _%#COUNTY#%_ Medical Center in 2001. Transplant nephrectomy for BK polyomavirus in _%#MM2005#%_. The patient is currently on the kidney transplantation list. The patient reports a potential donor is being worked up at this time.
BK|BK (virus)|BK|268|269|HOSPITAL  COURSE|The patient's creatinine decreased to 1.35 mg/dL with IV fluids but did not reach her baseline of 1.1 mg/dL, therefore, a renal consult was obtained. A biopsy of the patient's kidney transplant on _%#MMDD2007#%_ was negative for cellular and humoral rejection and for BK virus. The patient's creatinine then increased to 1.45 mg/dL. It was felt that the patient's increased creatinine may be due to ATN, but the etiology was unclear at this time.
BK|BK (virus)|BK|171|172|HOSPITAL COURSE|Repeat urine culture on _%#MMDD2007#%_, showed no growth. Adenovirus, urine culture PCR was done on _%#MMDD2007#%_ and _%#MMDD2007#%_, both showed no adenovirus detected. BK virus was suggested on _%#MMDD2007#%_ and _%#MMDD2007#%_, which showed less than 1000 (negative). UA was done on _%#MMDD2007#%_, showing white blood cells greater than 182.
BK|BK (virus)|BK|248|249|PROBLEM #11|Subsequent BK-virus levels on _%#MMDD2006#%_ revealed 86,800 copies, with a repeat level on _%#MMDD2006#%_ revealing greater than 10,000,000 copies. His hemorrhagic cystitis resolved, and his fluids were discontinued despite being positive for the BK virus. He has experienced no further evidence of hemorrhagic cystitis. A repeat BK- urine level from _%#MMDD2006#%_ remains pending at the time of discharge.
BK|BK (virus)|BK|318|319|HISTORY OF PRESENT ILLNESS|He is status post living donor kidney transplant on _%#MMDD2007#%_, and he has a history of deceased donor pancreas transplant on _%#MM2004#%_, with bladder drainage followed shortly by enteric conversion. He had a prior living donor transplant and underwent a transplant nephrectomy earlier in 2007, secondary to the BK nephropathy. The patient was admitted at the University of Minnesota Medical Center, Fairview in _%#MM2007#%_, for GI bleed and anemia secondary to GI bleed, atrial fibrillation, hyperkalemia and deconditioning.
BK|BK (virus)|BK|137|138|PAST MEDICAL HISTORY|6. Hypertension. 7. Dyslipidemia. 8. Benign prostatic hypertrophy. 9. Erectile dysfunction. 10. History of hiatal hernia. 11. History of BK nephropathy status post truncal nephropathy, _%#MM2007#%_. 12. History of Mycobacterium infection pneumonia in the right lobe, 2006. 13. History of squamous cell carcinoma. 14. Charcot joint, left foot.
BK|BK (virus)|BK|218|219|PAST MEDICAL HISTORY|Blast peripheral blood RFLPs on _%#MMDD2006#%_ showed that he is 100% donor in both the M and N fraction. His post- transplant course has been complicated with acute and chronic graft versus host disease, CMV viremia, BK virus with hematuria and fungal pneumonia with both penicillium nocardia and now aspergillus fumigatus 2. Graft versus host disease. He has a history of acute graft versus host disease of the skin, esophagus and stomach, progressing to chronic graft versus host disease of the skin, oral mucosa, gastrointestinal tract and lungs.
BK|BK (virus)|BK|273|274|HISTORY OF PRESENT ILLNESS|During the course of that admission, he had several weeks of fever spikes for which an extensive workup was done and no specific etiology was found. He has had new-onset urinary incontinence which was worked up extensively by Urology; bladder thickening on CT and positive BK virus in one urine sample with no corresponding blood component were found. At discharge, his fevers had subsided and his urinary symptoms had improved considerably.
BK|BK (virus)|BK|237|238|PAST MEDICAL HISTORY|13. Secondary adrenal insufficiency, on cortef and occasionally requires stress dosing. 14. Sequestration, _%#MM2007#%_ for history of caries and gingivitis. 15. Urinary incontinence. Cystoscopy and biopsy done in _%#MM2007#%_; positive BK virus in the urine only; nonspecific bladder thickening on CT; VCUG showed no reflux; stable left hydronephrosis and bilateral ureteral ectasis.
BK|BK (virus)|BK|153|154|FELLOW|1. Multiple myeloma. 2. Status post nonmyeloablative allogeneic cousin bone marrow transplant done on _%#MM#%_ _%#DD#%_, 2005. 3. Hematuria secondary to BK virus. 4. Orthostasis. 5. Atrial fibrillation with rapid ventricular response. 6. Coronary artery disease. 7. Group D Enterococcus from bronchial washings.
BK|BK (virus)|BK|210|211|FELLOW|He was matched for 6/6 HLA markers. Again, this transplantation was from his cousin, though it is listed as an allo-sib. Transplant was complicated by hematuria. It was then discovered that he was positive for BK virus. This resolved with continuous bladder irrigation and acidification of the urine. Counts remained stable during this time. Again, hematuria has subsequently resolved.
BK|BK (virus)|BK|209|210|PROBLEM #3|A repeat lumbar puncture on _%#MMDD2007#%_, did not demonstrate any infection and HHV-6 was less than 200 copies. The patient developed hematuria approximately 40 + days after transplant and was found to have BK viruria. Her BK virus PCR was greater than 10 million on _%#MMDD2007#%_. She was not initially treated for this specifically other than providing platelet support.
BK|BK (virus)|BK|217|218|PROBLEM #7|There was mild hydronephrosis of the right kidney. A small amount of ascites in Morrison's pouch and a small left pleural effusion, also noted was hepatomegaly. PROBLEM #7: Genitourinary. It was noted the patient has BK viruria with hematuria. She is currently receiving intravesicular cidofovir and platelets for hemorrhagic cystitis. We obtained a bladder ultrasound that did not demonstrate a definite clot.
BK|BK (virus)|BK|330|331|PROBLEM #5|PROBLEM #5: Heme: _%#NAME#%_ remained pancytopenic, etiology unclear, could be multifactorial, likely due to ganciclovir. RFLPs from _%#MMDD2007#%_ and _%#MMDD2007#%_ remained pending. We will continue to monitor _%#NAME#%_'s counts as an outpatient and transfused to keep her platelet count greater than 20,000 due to history of BK viruria and hemoglobin greater than 9 due to low ejection fraction, _%#NAME#%_ did not require any transfusions during this hospitalization.
BK|BK (virus)|BK|207|208|DIAGNOSES|DIAGNOSES: 1. Day plus 26 status post Haplo-NK infusion for refractory AML with 30% blast based on most recent bone marrow biopsy from _%#MMDD2007#%_. 2. Hypertension. 3. Vancomycin-resistant bacteremia. 4. BK viruria. 5. Shortness of breath thought to be secondary to pulmonary edema. 6. Diabetes mellitus. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 49-year-old male who was diagnosed with MDS in _%#MM2006#%_.
BK|BK (virus)|BK|141|142|HOSPITAL COURSE|3. The patient also developed hematuria and subsequent urine cultures were positive for BK viruria. He was not aggressively treated for this BK viruria, however he was started on empiric Levaquin. The patient was started on caspofungin at admission for antifungal prophylaxis.
BK|BK (virus)|BK|262|263|PAST MEDICAL HISTORY|11. Bacteremia with group D beta-hemolytic strep on _%#MMDD2007#%_, coag-negative staph, sensitive to vanco only, _%#MMDD2007#%_, group D enterococcus sensitive to vanco, _%#MMDD2007#%_, coag-negative staph, sensitive to vanco and linezolid, _%#MMDD2007#%_. 12. BK virus in the urine, _%#MMDD2007#%_. 13. VRE in the urine, _%#MMDD2007#%_ and _%#MMDD2007#%_. PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: Weight 85.4 kg, temperature 98.6, blood pressure 130/84, pulse 86, respirations 20, oxygen saturation 100% on room air.
BK|BK (virus)|BK|282|283|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Fanconi anemia status post unrelated bone marrow transplant, _%#MMDD2006#%_, discharged day+19, CMV negative, HSV positive, course complicated by steroid-induced hyperglycemia and hypertension secondary to cyclosporine. 2. Hemorrhagic cystitis secondary to BK virus in _%#MM2006#%_. 3. Pulmonary edema/volume overload, _%#MM2006#%_ (intubated x9 days). 4. Coag, negative Staph, line infection, _%#MMDD2006#%_, currently being treated with vancomycin.
BK|BK (virus)|BK|148|149|ASSESSMENT AND PLAN|He also has had status post pancreas transplantation in _%#MM2004#%_ with bladder drainage converted to enteric drainage at that time. He developed BK virus nephropathy in his transplant kidney, necessitating transplant nephrectomy in _%#MM2007#%_ leading to the most recent transplant experience. 2. Hemolytic anemia secondary to autoimmune process. He is post-splenectomy in _%#MM2007#%_ and incidental appendectomy in _%#MM2007#%_.
BK|BK (virus)|BK|309|310|PAST MEDICAL HISTORY|1. AML-M2 diagnosed in _%#MM2006#%_ with elevated white count and thrombocytopenia, cytogenetics at that time showed trisomy 21, received induction chemotherapy with idarubicin and cytarabine 3+7. 2. Myeloablative double umbilical cord blood transplant for AML on _%#MMDD2006#%_. 3. Hemorrhagic cystitis with BK viruria. 4. Grade 3 acute GVH of the skin and gut, started prednisone on _%#MMDD2006#%_ with taper held several times due to continued GI symptoms, patient finally completed taper on _%#MMDD2007#%_.
BK|BK (virus)|BK|162|163|HISTORY OF TRANSITIONAL CARE STAY|This was his second renal transplant as his first transplant dating back to 1986, unfortunately undewent post-transplant nephrectomy in _%#MM2007#%_ secondary to BK viral nephropathy. He underwent living donor renal transplant on _%#MMDD2007#%_. His postoperative course was quite complicated including the development of a cryptogenic pneumonia.
BK|BK (virus)|BK|205|206|PROBLEM #3|His Aspergillus galactomannan levels have remained negative. In addition, viral studies sent on _%#MMDD2005#%_ revealed an EBV PCR level of less than 1000 copies, parvovirus level that was negative, and a BK virus level per urine specimen which again was positive. His most recent IgG level was 754 on _%#MMDD2005#%_. All other surveillance blood and stool cultures remained negative.
BK|BK (virus)|BK|238|239|PROBLEM #4|He remains afebrile at this time and should continue on his prophylactic coverage of Bactrim, fluconazole, Acyclovir, and Levaquin. PROBLEM #4: Genitourinary. _%#NAME#%_ continues with hemorrhagic cystitis, presumably due to the positive BK virus. He had been passing multiple quarter to silver dollar-sized clots daily without difficulty or dysuria. He underwent a renal/bladder ultrasound on _%#MMDD2005#%_, which was normal and without intraluminal clots noted within the bladder.
BK|BK (virus)|BK|229|230|HOSPITAL COURSE|Of note, a repeat chest CT from _%#MMDD2006#%_ showed only minimal improvement in the consolidation in his left upper lobe and superior left lower lobe. Other significant infectious disease issues during hospitalization included BK viruria resulting in hemorrhagic cystitis. Of note, his BK virus PCR from the urine on _%#MMDD2006#%_ was greater than 100,00,000 copies, and he was subsequently treated with 2 courses of intravesicular cidofovir on _%#MMDD2006#%_ and _%#MMDD2006#%_.
BK|BK (virus)|BK|288|289|HOSPITAL COURSE|Of note, a repeat chest CT from _%#MMDD2006#%_ showed only minimal improvement in the consolidation in his left upper lobe and superior left lower lobe. Other significant infectious disease issues during hospitalization included BK viruria resulting in hemorrhagic cystitis. Of note, his BK virus PCR from the urine on _%#MMDD2006#%_ was greater than 100,00,000 copies, and he was subsequently treated with 2 courses of intravesicular cidofovir on _%#MMDD2006#%_ and _%#MMDD2006#%_.
BK|BK (virus)|BK|141|142|HOSPITAL COURSE|In addition, he received IV cidofovir x2 doses on _%#MMDD2006#%_ and _%#MMDD2006#%_. Unfortunately, this did not result in a decrease in the BK virus of his urin e, as a repeat on _%#MMDD2006#%_ BK virus PCR demonstrated greater than 100,00,000 copies.
BK|BK (virus)|BK|110|111|HOSPITAL COURSE|Unfortunately, this did not result in a decrease in the BK virus of his urin e, as a repeat on _%#MMDD2006#%_ BK virus PCR demonstrated greater than 100,00,000 copies. We discussed with Infectious Disease as far as repeating cidofovir treatment; however, they did not recommend this given the lack of response with the first 2 doses.
BK|BK (virus)|BK|139|140|HOSPITAL COURSE|EBV (Epstein-Barr Virus) studies were sent both on _%#MMDD2006#%_ and on this admission. They are pending at the time of this dictation. A BK virus, qualitative urine PCR was obtained. This was sent on both the urine and the serum. A urine viral culture for CMV was also requested. Infectious Disease consultation did not recommend any further work-up for these intermittent fevers, and high-normal temperatures at this point, and the results can be followed by the patient's primary nephrologist, Dr. _%#NAME#%_ _%#NAME#%_ with assistance from Infectious Disease if necessary.
BK|BK (virus)|BK|248|249|BRIEF HISTORY|The Transplant Surgery service was also consulted and saw the patient on a regular basis, intervening with the immunosuppression medication and following issues with his transplanted kidney. At the time of discharge, Infectious Disease had ordered BK virus, testing of the urine, and other selected viral tests for the urinary tract system. This testing will need to be followed up in the Transplant Surgery Clinic, specifically, the Kidney Clinic.
BK|BK (virus)|BK|189|190|RECOMMENDATIONS|On _%#MMDD2005#%_, _%#NAME#%_ underwent an allogeneic cord blood transplantation, with continued active aspergillus wound infection. _%#NAME#%_ has a history of hemorrhagic cystitis due to BK virus and renal insufficiency due to CSA, as well as hypertension for the same reason. _%#NAME#%_ has experienced pancreatitis. Prior to her illness in _%#MM#%_, _%#NAME#%_ had been in a good general state of health.
BK|BK (virus)|BK|117|118|6.   GI|Currently the patient returned adenovirus negative from his stool early last week. The patient was also positive for BK virus in his stool and blood and unfortunately three are no treatments for that at this present time. An addition note: He was treated with 3 doses of nitazoxanide for his adenovirus.
BK|BK (virus)|BK|92|93|ACTIVE DIAGNOSES|2. Alveolar hemorrhage. 3. Respiratory failure. 4. Hemorrhagic cystitis. 5. CMV viremia. 6. BK virus in urine. 7. Vancomycin-resistant enterococcus (VRE) of gastrointestinal tract. 8. Fungal pneumonia. 9. Anxiety disorder. 10. Positive human herpesvirus 6 (HHV6) PCR.
BK|BK (virus)|BK|209|210|POSITIVE CULTURES SINCE ADMISSION|2. _%#MMDD2006#%_: C. difficile positive in stool. 3. _%#MMDD2006#%_: VRE in stool. 4. _%#MMDD2006#%_: Coag negative staph in the blood. 5. _%#MMDD2006#%_: Coag negative staph in the blood. 6. _%#MMDD2006#%_: BK virus in the urine. 7. _%#MMDD2006#%_: HHV6 virus in the blood. 8. _%#MMDD2006#%_: Vancomycin-resistant enterococcus. 9. _%#MMDD2006#%_: Yeast culture of throat showing light growth of yeast.
BK|BK (virus)|BK|148|149|POSITIVE CULTURES SINCE ADMISSION|8. _%#MMDD2006#%_: Vancomycin-resistant enterococcus. 9. _%#MMDD2006#%_: Yeast culture of throat showing light growth of yeast. 10. _%#MMDD2006#%_: BK virus PCR positive, greater than 1 million copies. 11. _%#MMDD2006#%_: Yeast culture of feces shows moderate growth Candida fumata. 12. _%#MMDD2006#%_: Fungal culture of bronchial fluid shows moderate growth of Candida fumata.
BK|BK (virus)|BK|294|295|POSITIVE CULTURES SINCE ADMISSION|16. _%#MMDD2006#%_: Vancomycin-resistant enterococcus of feces-moderate growth. 17. _%#MMDD2006#%_: Vancomycin-resistant enterococcus of tongue showing heavy growth 18. _%#MMDD2006#%_: Vancomycin-resistant enterococcus of tongue showing moderate growth of strain 2 group D. 19. _%#MMDD2006#%_: BK virus PCR quant greater than 1 million copies. 20. _%#MMDD2006#%_: Yeast culture of feces showed moderate growth of Candida fumata.
BK|BK (virus)|BK|193|194|HOSPITAL COURSE|PROBLEM #4. Genitourinary: Please see the interim summary dated _%#MMDD#%_ for previous details. Please see the above paragraph, infectious disease, for details on his hemorrhagic cystitis and BK virus in the urine. The morning of this interim summary the patient's creatinine rose from 1.28 to 1.78. He has also had renal insufficiency several times during this admission.
BK|BK (virus)|BK|151|152|HISTORY OF PRESENT ILLNESS|He underwent several days of continuous bladder irrigation and aggressive platelet replacement. As noted in the positive cultures above, he tested for BK virus on _%#MM#%_ _%#DD#%_, 2006. Infectious disease was consulted at this time who recommended a 14-day course of ciprofloxacin.
BK|BK (virus)|BK|157|158|PAST MEDICAL HISTORY|Prednisone was started for this. He is on a taper currently. 7. Hemorrhagic cystitis noted since _%#MM#%_ _%#DD#%_, 2004. It is not clear if this was due to BK virus or not. No results are in the computer. 8. Frequent platelet transfusions. 9. Hypertension secondary to steroid use. 10. Increasing creatinine recently, presumed secondary to amphotericin.
BK|below knee|BK|234|235|HPI|The skin around the squamous cell cancer area is somewhat compromised with some maceration around the heel and also callus formation on the right heel, which measures about 3-4 cm. The patient was seen by a surgeon, who recommended a BK amputation. The patient is sent to us to seek options of treatment. In clinic we had a Plastic Surgery and Anesthesiology consultation because of the situation that she may have to have general anesthesia for each radiation treatment if she does receive radiation.
BK|BK (virus)|BK|186|187|DIAGNOSES|Currently day +57 from transplant. 2. Left upper lobe fungal pneumonia with parapneumonic effusion. Fungal etiology being Malassezia furfur. 3. Severe hemorrhagic cystitis probably from BK virus. 4. Coagulase negative Staphylococcus bacteremia currently on treatment. 5. Vancomycin-resistant enterococci (VRE) infection in the urine. 6. Acute graft versus host disease (GVHD).
BK|BK (virus)|BK|195|196|IMPORTANT INVESTIGATIONS|The patient is on linezolid. 2. Urine culture from _%#MMDD2006#%_: Grew VRE 50-100,000 colonies/mL. This was speciated as Enterococcus faecium, which is susceptible to linezolid and Synercid. 3. BK virus PCR from _%#MMDD2006#%_: Showed more than 7.0 log copies of BK virus. 4. CMV, DNA and PCR from _%#MMDD#%_, _%#MMDD#%_ and _%#MMDD2006#%_: Negative.
BK|BK (virus)|BK|164|165|IMPORTANT INVESTIGATIONS|This was speciated as Enterococcus faecium, which is susceptible to linezolid and Synercid. 3. BK virus PCR from _%#MMDD2006#%_: Showed more than 7.0 log copies of BK virus. 4. CMV, DNA and PCR from _%#MMDD#%_, _%#MMDD#%_ and _%#MMDD2006#%_: Negative. 5. Fungal culture from bronchoscopy done from _%#MM2006#%_: Suggestive of Malassezia furfur infection.
BK|BK (virus)|BK|183|184|ACTIVE DIAGNOSES|9. Torsemide 20 mg IV x1 today. ACTIVE DIAGNOSES: 1. Anaplastic large T-cell lymphoma status post non-myeloablative double umbilical-cord transplant day 42. 2. Hematuria secondary to BK virus infection. 3. Ascites. 4. Elevated liver function tests, etiology unclear. 5. Renal insufficiency. 6. Resolved fever of unknown origin. IMAGING STUDIES: 1. Chest x-ray PA and lateral, _%#MMDD2006#%_: Impression (1) Clear lungs.
BK|BK (virus)|BK|145|146|POSITIVE VIROLOGY STUDIES|No further testing was done. 4. _%#MMDD#%_: Culture of feces showing moderate growth of Candida glabrata. POSITIVE VIROLOGY STUDIES: _%#MMDD#%_: BK virus PCR quantitative of urine showing greater than 1 million copies per milliliter. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 39-year-old woman with ALK- negative anaplastic large T-cell lymphoma.
BK|BK (virus)|BK|179|180|HOSPITAL COURSE|The patient has also had decreased urine output over the past 24 hours. As noted above, we are going to try some diuresis with torsemide this afternoon. Another issue is positive BK virus and hematuria. The patient had hematuria for approximately 2-3 weeks, which resolved over the past 2-3 days. She has been treated with levofloxacin for BK virus. Followup BK virus PCR should be done over the next week or so.
BK|BK (virus)|BK|187|188|HOSPITAL COURSE|Another issue is positive BK virus and hematuria. The patient had hematuria for approximately 2-3 weeks, which resolved over the past 2-3 days. She has been treated with levofloxacin for BK virus. Followup BK virus PCR should be done over the next week or so. PROBLEM #5. Neurological: The patient has had some problem with confusion, particularly in the morning.
BK|BK (virus)|BK|145|146|PROBLEM #1.   BMT|The patient's most recent problem is a reactivation of CMV with 500 copies on _%#MMDD2006#%_. The patient has undergone cidofovir for persistent BK viremia in the urine, and Infectious Disease has been consulted as to whether to start ganciclovir or whether cidofovir will cover CMV.
BK|BK (virus)|BK|175|176|PROBLEM #1.   BMT|We did perform a bladder ultrasound which did not show any appearance of large clot, but found many small clots. The patient has been placed on ciprofloxacin for the positive BK virus, as per literature search. The patient was on that for approximately 7 days, and has been maintained on Levaquin post-Cipro.
BK|BK (virus)|BK|124|125|PROBLEM #1.   BMT|The patient has received 2 doses of IV cidofovir, and his BK virus continues to be greater than 10 to the 7th. We do have a BK virus pending from last Monday. We finally did remove the patient's Foley catheter on _%#MMDD2006#%_. Bladder spasms and suprapubic pain have not gotten any worse.
BMP|beta-natriuretic peptide:BNP|BMP|399|401|LABORATORY DATA|NEUROLOGIC: Cranial nerves II-XII were intact. LABORATORY DATA: EKG rate 70, normal sinus rhythm, normal axis, normal intervals, nonspecific T-wave flattening. White blood cell count 7.6, hemoglobin 17.3, hematocrit 48.8, platelets of 125, sodium 143, potassium 4.1, chloride 104, CO2 24, BUN 13, creatinine 0.80, glucose of 321, albumin 4.9, total protein 9.2, lipase 207, troponin less than 0.04, BMP of 66. PROBLEM #1: Cardiovascular. The patient has coronary artery disease. He is status post a coronary artery bypass grafting with stenting x4.
BMP|basic metabolic profile|BMP|171|173|FOLLOW-UP APPOINTMENTS|12. Vitamin B12 supplements. FOLLOW-UP APPOINTMENTS: 1. With Dr. _%#NAME#%_ _%#NAME#%_ at Quello Clinic in 5-7 days with further anemia workup per Dr. _%#NAME#%_. CBC and BMP checked in 5-7 days with results to Dr. _%#NAME#%_. 2. Endocrinology, next available appointment within 7-10 days to assess adrenal mass and possible Cushing's disease with abnormal dexamethasone suppression test.
BMP|basic metabolic profile|BMP|221|223|ADMISSION LABS|ADMISSION LABS: Significant for white blood cell count of 30.6, 45% neutrophils, 10% monocytes, 45% lymphocytes. Hemoglobin was 12.3 and platelets were 367,000. Accu-Chek on admission to the Emergency Department was 112. BMP was obtained and unremarkable. Chest x-ray was obtained revealing heavy airspace opacity in the upper lobes that was consistent with pneumonia versus atelectasis.
BMP|basic metabolic profile|BMP|164|166|HOSPITAL COURSE|She was treated with IVF and cr came down to 2.2 on the day of this discharge. She will follow-up with her primary care physician in clinic for further monitoring. BMP results on the day of discharge are pending. DISPOSITION: She will be discharged to home on Prednisone 20 mg p.o. daily times two days and Vistaril 50 mg p.o. q12h p.r.n. times two days.
BMP|basic metabolic profile|BMP|188|190|ADMISSION LABS|ADMISSION LABS: His white cell count was 8.0 with a differential of 78% neutrophils, 14% lymphocytes, 6% monocytes, 2% eosinophils. His hemoglobin was 14.7, platelets 339,000. His initial BMP had a sodium of 138, potassium 3.8, glucose 374, his BUN 20, creatinine 0.58. Amylase and lipase were checked and both normal.
BMP|basic metabolic profile|BMP:|267|270|LABORATORY DATA|ABDOMEN: Soft, nontender and nondistended, obese and operative incision well healed. EXTREMITIES: Trace edema bilaterally. LABORATORY DATA: On day of admission, CBC revealed WBC 5.8, hemoglobin 9.1 and platelets 262, INR was 1.02, ionized calcium 4.6, magnesium 2.0. BMP: Sodium 140, potassium 3.4, chloride 105, CO2 26, BUN 8 and creatinine 0.51. The patient did have elevated blood sugars from 123 to 252.
BMP|beta-natriuretic peptide:BNP|BMP|174|176|HOSPITAL COURSE|He has moderate-to-severe tricuspid regurgitation and RV systolic pressure was 61 plus RA. He has been gently diuresed and at the time of discharge is clinically better. His BMP was 745. There are no previous BMPs that I can locate in the old records. Apparently, he was previously on an ACE inhibitor, which appears to have been stopped with his hospitalization in _%#NAME#%_ for acute renal failure.
BMP|basic metabolic profile|BMP,|210|213|IMPRESSION|Plan to place a Foley in the patient and note the amount of urine outflow, get a urinalysis and urine culture and check a fractional excretion of sodium. We will obtain a renal ultrasound, we will check a CBC, BMP, magnesium, phosphorus, liver panel. We will hold the patient's the Avandia, his Imdur and hydralazine, Lipitor, secondary to his low blood pressure, we will check a TSH and continue his Synthroid.
BMP|basic metabolic profile|BMP|180|182|LABORATORY DATA|Troponin is less than 0.04. EKG shows left axis deviation, nonspecific T-wave abnormality, sinus bradycardia with first degree AV block and APR of 276 milliseconds. CBC is normal. BMP is normal. Troponin is less than 0.04. IMPRESSION AND PLAN: This is a 73-year-old man with a chest pain at high risk for cardiac pain.
BMP|basic metabolic profile|BMP,|136|139|FOLLOW-UP|FOLLOW-UP: 1. His follow-up should be on Thursday, _%#MMDD2004#%_ in the Oncology Clinic at 8 a.m. with a CBC, differential, platelets, BMP, and a vancomycin level. 2. He should also follow up in the Oncology Clinic on _%#MMDD2004#%_ with CBC, differential, platelets, BMP, and possible chemotherapy.
BMP|basic metabolic profile|BMP.|136|139|ASSESSMENT AND PLAN|He has received Zosyn. Will initiate vancomycin. We will initiate a scheduled 25% albumin along with IV fluids. Will obtain serial CBC, BMP. Will obtain a lactate level, monitor his urine output. He will need a central line, arterial line. I have already discussed with Anesthesiology.
BMP|basic metabolic profile|BMP,|164|167|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|The patient's vital signs were stable, except for mildly elevated temperature of 100.0 degrees. Her initial laboratory data showed CBC within normal limits, normal BMP, but elevated alkaline phosphatase of 224, ALT of 53 and AST of 47. Her INR was 4.28. The patient was initially admitted to treat her elevated INR and treat her ongoing fever.
BMP|beta-natriuretic peptide:BNP|BMP|241|243|COURSE IN HOSPITAL|She did have a slight amount of fluid overload and received IV Lasix which resolved quickly and then she did not need Lasix after 2 days. She slowly improved with antibiotics and prednisone for her chronic obstructive pulmonary disease. Her BMP did drop from a high of 1200 to 425 and now on day of discharge is feeling her breathing is quite close to normal.
BMP|basic metabolic profile|BMP|294|296|PERTINENT LABORATORY DATA|5. Activity should be as tolerates. 6. I did also discuss with _%#NAME#%_ _%#NAME#%_, who will notify _%#NAME#%_ _%#NAME#%_, who is the patient's pre transplant coordinator of the patient's discharge. PERTINENT LABORATORY DATA: 1. _%#MM#%_ _%#DD#%_, 2005, INR 3.15. 2. _%#MM#%_ _%#DD#%_, 2005, BMP normal except BUN slightly elevated at 30 as is glucose at 111. 3. _%#MM#%_ _%#DD#%_, 2005, PTT 94 (she was on heparin drip which was discontinued this morning).
BMP|basic metabolic profile|BMP|248|250|ADMISSION LABORATORY DATA|Of note, there was significant pain and tenderness within any sudden type of motion, especially moving in or out of bed, requiring pain medications to get the pain under control. ADMISSION LABORATORY DATA: His admitting labs were significant for a BMP well within the normal limits exhibiting a sodium of 134, potassium 4.1, chloride 96, bicarb 29, BUN of 10, creatinine 0.88, and glucose of 104.
BMP|basic metabolic profile|BMP|181|183|DISCHARGE MEDICATIONS|6. Zoloft 50mg once daily. 7. Percocet one to two tabs q 4-6h as needed. 8. Flagyl 500 mg t.i.d. for ten more days. Followup care with Dr. _%#NAME#%_ in two to three weeks, CBC and BMP in one week.
BMP|basic metabolic profile|BMP,|253|256|ADMISSION DIAGNOSIS|Derm's recommendations were for a Vanicream with 2.5% hydrocortisone, and I recommended initiating a UDV treatment when the patient returned to _%#CITY#%_. We also recommended to consider repeat pruritus workup. We will obtain CBC with differential and BMP, and their last recommendation was Nizoral shampoo lathered to the scalp, leave on 5 minutes before rinsing. On _%#MM#%_ _%#DD#%_, 2005, the patient's vital signs were stable and the patient was afebrile, tolerating a p.o. diet, ambulating without difficulty, and having bowel movement.
BMP|basic metabolic profile|BMP|172|174|HISTORY OF PRESENT ILLNESS|CT of her C-spine showed no evidence of C-spine fracture. EKG showed normal sinus rhythm with sinus tachycardia. U-tox was negative. Urine pregnancy test negative. CBC and BMP were essentially normal. Salicylate, Tylenol level were negative and alcohol level showed 0.2. She was given Ativan for rather significant agitation.
BMP|basic metabolic profile|BMP|173|175|FAMILY HISTORY|Strength was intact in his lower extremities and was at his baseline. ADMISSION LABORATORIES: White count 5.7, hemoglobin 14.2, platelet count 219,000, 67% neutrophils. His BMP had a sodium of 141, potassium of 3.5, chloride 108, CO2 24, BUN 13, creatinine 0.9, glucose 120, calcium 8.4, magnesium 2.4, and phosphorus 2.2. Urinalysis showed amber, cloudy urine with a negative glucose and a small amount of bilirubin, negative ketones, specific gravity of 1.026, a small amount of blood, pH 5, trace protein, urobilinogen 1, positive nitrites, large leukocyte esterase, 3 white blood cells, and 9 red blood cells.
BMP|basic metabolic profile|BMP|157|159|DISCHARGE MEDICATIONS|5. Cozaar 50 b.i.d. 6. Lipitor 40 a day. 7. Metoprolol 12.5 a day. 8. Aldactone 12.5 a day. Patient is to see me in 1-2 weeks with a TSH in four weeks and a BMP next week.
BMP|basic metabolic profile|BMP|184|186|ASSESSMENT/PLAN|ASSESSMENT/PLAN: There is no contraindication to this procedure assuming a venous doppler of the left leg which I have ordered for today reveals no sign of DVT. Also, assuming CBC and BMP drawn today are acceptable. I have also drawn a lipid panel to follow-up with is hypercholesterolemia, but this should not reflect on his appropriateness for further.
BMP|basic metabolic profile|BMP|176|178|LABORATORY|3. _%#MM#%_ _%#DD#%_, 2003, hemogram. White count 10.7, hemoglobin 11.5, platelet count 721,000. 4. _%#MM#%_ _%#DD#%_, 2003, TSH 6.01, albumin 3.5. 5. _%#MM#%_ _%#DD#%_, 2003, BMP within normal limits with creatinine noted to be 0.8. 6. _%#MM#%_ _%#DD#%_, 2003, as well as _%#MM#%_ _%#DD#%_, 2003, troponins x3 which were negative.
BMP|basic metabolic profile|BMP|147|149|LABORATORY|ALLERGIES: The patient has no drug allergies. LABORATORY: 1. _%#MM#%_ _%#DD#%_, 2003, white count 5.1, hemoglobin 8.8. 2. _%#MM#%_ _%#DD#%_, 2003, BMP was within normal limits except for BUN was 35, although this was done yesterday when it was 51. Creatinine is 1.2 (It was 1.3 yesterday). Please refer to FCIS for trend of renal function.
BMP|basic metabolic profile|BMP.|187|190|HOSPITAL COURSE|He had no edema on presentation. With IV fluids therapy, his edema did not recur. We are holding his Lasix. We will continue to hold his Lasix until followup with primary MD and followup BMP. 5. Hepatitis, mild asymptomatic. Normal abdominal exam, no right upper quadrant tenderness. The patient had mild elevation of his transaminases. No obstructive pattern likely related to his ongoing alcohol use, he drinks a 12-pack a day.
BMP|basic metabolic profile|BMP,|130|133|PLAN|4. Orthopedic follow-up. 5. Weight-bearing as tolerated with a walker and bunion boot. 6. Resume outpatient meds. 7. Recheck CBC, BMP, and sed rate. 8. Clinical observation with parameters for which nursing staff should call.
BMP|basic metabolic profile|BMP|136|138|LABORATORY|Bowel sounds are normally active. EXTREMITIES: Unremarkable. NEUROLOGIC: Grossly intact. LABORATORY: On admission CBC was unremarkable. BMP was unremarkable. ASSESSMENT: 1. History of gastroparesis with need for feeding tube 2. Sphincter of Oddi dysfunction.
BMP|basic metabolic profile|BMP|168|170|LABORATORY DATA|EXTREMITIES: Otherwise noncontributory. NEUROLOGICAL EXAM: Nonfocal. The patient is lethargic. LABORATORY DATA: Normal hemoglobin, WBC elevated at 18.5 with 83% PMN's. BMP is normal aside from BUN of 29. Lipase normal. Liver function tests normal. IMPRESSION: 1. Subacute to more chronic persistent nausea and vomiting and abdominal pain for several weeks.
BMP|basic metabolic profile|BMP:|231|234|LABORATORY DATA|He is deemed safe to be discharged. He will go home at this time to his mother's house as apparently his house needs some attention in regards to being cleaned up. LABORATORY DATA: 1. _%#MMDD2003#%_: PSA 65.9, ionized calcium 4.2. BMP: sodium 132, creatinine 0.8, and the rest is within normal limits. 2. _%#MMDD2003#%_: Hemogram: white count 11.6, hemoglobin 15.5, platelet count 104,000.
BMP|basic metabolic profile|BMP|159|161|LABORATORY DATA|PSYCHIATRIC: The patient is awake. She is not oriented or alert. LABORATORY DATA: CBC shows a white count elevated at 12.7, hemoglobin 11.3, normal platelets, BMP within normal limits, blood cultures pending. CT scan of the neck shows skin thickening over the left cheek, induration of subcutaneous fat, area of soft-tissue density lateral to body of mandible approximately 4.0 cm x 1.5 cm, possible phlegmon vs neoplastic process.
BMP|basic metabolic profile|BMP|139|141|NOTE|7. Imdur 60 mg q.d. 8. Aspirin enteric-coated 81 mg q.d. 9. Prozac 10 mg q.d. 10. Calcium Carbonate + Vitamin D 500 mg p.o. t.i.d. NOTE: A BMP will be done on Monday.
BMP|basic metabolic profile|BMP|155|157|ASSESSMENT|ASSESSMENT: 1. Left knee osteoarthritis, severe and no longer responding to conservative treatment. Plan is surgery as scheduled. 2. Hypertension. Plan is BMP done today. Continue sodium avoidance. Continue current medications. Electrocardiogram done today and sent along for this preop. It shows left bundle branch block with no significant change since _%#MM#%_ of 2000.
BMP|basic metabolic profile|BMP,|232|235|PLAN|PLAN: Blood cultures times 2 have already been performed. Will treat the patient with Ancef 1 gram IV q.6h. Will check a sed rate. Will hydrate her with D5 electrolyte #75 at 75 cc per hour. Will check a right hip x-ray. Will check BMP, CBC in the morning.
BMP|basic metabolic profile|BMP|160|162|ASSESSMENT/PLAN|Will check culture. 3. Fluid and electrolytes, hyponatremia, hypovolemic, secondary to diarrhea and dehydration. Will use normal saline in the ER. Will recheck BMP this morning. 4. Questionable new cardiomegaly. Will obtain an echo this morning. Cardiology to see. 5. Hypertension. Will continue to need outpatient medication and titrate up Catapres.
BMP|beta-natriuretic peptide:BNP|BMP|206|208|HOSPITAL COURSE|His appetite continued to improve. He was very excited to be able to go home, and felt that he was capable back to his baseline to be back at home. Of note, this patient was enrolled in the BMP trial and a BMP level was drawn on the day of discharge. PROBLEM #2: Anticoagulation. He has been on Coumadin for atrial fibrillation, and his INR was very elevated when he came in.
BMP|basic metabolic profile|BMP|117|119|PLAN|We will monitor her closely over the next 48 hours. I am going to start her on Lasix 40 mg IV b.i.d. We will check a BMP on _%#MMDD2003#%_ in the morning. Leave her on her same other meds. We will check a digoxin level. We will try to get her up and moving as tolerated.
BMP|beta-natriuretic peptide:BNP|BMP|140|142|LABORATORY|LABORATORY: WBC 7.4, hemoglobin 13.3, platelets 409, troponins negative x 3. Electrolytes were normal. LFTs were normal. Magnesium was 2.2, BMP 589. UA was normal and TSH was normal. The patient will be sent home with 1. Metoprolol 50 mg p.o. b.i.d. 2. Aspirin 81 mg p.o. daily.
BMP|basic metabolic profile|BMP|209|211|DISCHARGE LABORATORY|ABDOMEN: Benign. DISCHARGE LABORATORY: Hemoglobin 9.1 (9.9?) and stable for at least two days prior to discharge. He will need outpatient further evaluation and workup. He is otherwise hemodynamically stable. BMP dated _%#MMDD2004#%_ shows a sodium 129, potassium 3.8, chloride 95, bicarb 25, BUN 28, creatinine 0.97. DISPOSITION: 1. The patient will be discharged to _%#COUNTY#%_ for ongoing aggressive rehab, physical therapy, occupational therapy, and speech therapy.
BMP|basic metabolic profile|BMP:|102|105|ADMISSION LABORATORY DATA|Skin was pink and warm. NEUROMUSCULAR: Moving all extremities. Non- focal. ADMISSION LABORATORY DATA: BMP: Sodium 138, potassium 3.8, chloride 104, CO2 26, glucose 99, BUN 21, creatinine 0.54. Calcium 9.5. White count on admission was 7.0. Hemoglobin was 13.2. Normal differential on the white count.
BMP|basic metabolic profile|BMP|206|208|LAB  DATA|EXTREMITIES: Are otherwise unremarkable. NEURO: Noncontributory. LAB DATA: Hemoglobin 12.5, WBC 10.3, normal INR. Troponin and myoglobin both slightly elevated. Digoxin level low, chemistries showed normal BMP aside from glucose of 143. Protein is slightly elevated at 9.0. IMPRESSION: 1. Acute pulmonary edema with rise in cardiac enzymes.
BMP|basic metabolic profile|BMP|313|315|PROBLEM #1|SKIN: Unremarkable with no rashes noted. ASSESSMENT: _%#NAME#%_ is a 12-year-old boy with gamma-delta T-cell non-Hodgkin's lymphoma status post BMT now with recurrence, here for donor lymphocyte infusion. PROBLEM #1: Fluids, electrolytes, and nutrition. _%#NAME#%_ can continue on a regular diet. We will check a BMP every day along with calcium, mag, phos, and uric acid, and correct any major abnormalities. PROBLEM #2: Bone marrow transplant. _%#NAME#%_ will undergo donor lymphocyte infusion on _%#MMDD2006#%_ using MT2003-15.
BMP|basic metabolic profile|BMP|257|259|LABORATORY EVALUATION|Sodium 142, potassium 4.4, BUN and creatinine 19 and 1.0, calcium 8.7, total bilirubin 0.7, albumin 3.7, total protein 8.4, alkaline phosphatase 116, ALT 83, AST 68, C-reactive protein normal at 6.6. Erythrocyte sedimentation rate elevated at 66. Follow-up BMP was normal. B-type natriuretic peptide 25. Pending test results include the complement C3-C4, neutrophil cytoplasmic antibody, IgG screen, cryoglobulin, parasite stain, parvovirus, B19 antibodies, antinuclear antibody screen, rheumatoid factor, Lyme screen.
BMP|basic metabolic profile|BMP,|200|203|LABORATORY DATA|The patient has had an indwelling Foley which apparently is chronic. EXTREMITIES: No edema. LABORATORY DATA: Electrocardiogram shows nonspecific ST-T changes and a slow rate atrial fibrillation. CBC, BMP, basic metabolic panel and troponin x1 and TSH are normal. IMPRESSION: 1. Chest pain. I doubt this was a significant.
BMP|basic metabolic profile|BMP|138|140|HOSPITAL COURSE|She appears to be dry on exam at this point. We will hold her Lasix for the next day and a half and restart that at 40 b.i.d. She needs a BMP with her primary on Monday to check her electrolytes and titrate her Lasix as needed. We will hold her Diovan today and restart that tomorrow.
BMP|basic metabolic profile|BMP,|120|123|FOLLOW UP|2. Follow up with Dr _%#NAME#%_ her surgeon in 1-1 1/2 weeks. 3. Follow up with Dr _%#NAME#%_ p.r.n. 4. She will have a BMP, calcium and magnesium done in one week. DISCHARGE MEDICATIONS: 1. Atenolol 100 mg p.o. daily. 2. Hydrochlorothiazide 25 mg daily.
BMP|basic metabolic profile|BMP|148|150|DISCHARGE MEDICATIONS|A digoxin level will be ordered next week and follow up with primary care. The patient needs to follow up with her primary care in a week with CBC, BMP and a digoxin level. The patient needs to follow up with Dr. _%#NAME#%_ in 3-4 weeks.
BMP|basic metabolic profile|BMP|146|148|FOLLOWUP CARE|FOLLOWUP CARE: 1. The patient needs to follow up with her primary care provider in 1 week for her post-hospitalization visit. She needs to have a BMP drawn on _%#MMDD2006#%_. 2. The patient will see Dr. _%#NAME#%_ in clinic 1 week prior to her scheduled surgery (as yet to be determined) in _%#MM#%_ or _%#MM#%_.
BMP|basic metabolic profile|BMP|163|165|PHYSICIAN FOLLOW-UP|PHYSICIAN FOLLOW-UP: Follow up with nephrology in one week as a new patient. Issues to address: The patient is status post kidney transplant. Patient is to have a BMP prior to visit. Studies pending at the time of discharge: None. Follow-up with internal medicine in 2 weeks as a new patient.
BMP|basic metabolic profile|BMP|133|135|DISCHARGE MEDICATIONS|12. Oxycodone 5-10 mg p.o. q 4 hours p.r.n. for pain 13. Lasix 20 mg p.o. daily 14. Kay Ciel 20 mEq p.o. daily. 15. She is to have a BMP done when she goes to see her primary physician in one week and we are sending her home with duonebs 2.5-0.5 mg in 3 liters nebulization solution inhaled q.4h.
BMP|basic metabolic profile|BMP|204|206|LABORATORY/X-RAY DATA|LABORATORY/X-RAY DATA: I reviewed all of her lab work. Her chest x-ray was reviewed by me and it does not show any acute chest disease. EKG shows atrial paced rhythm but no significant Q's or ST changes. BMP looks fine with a normal creatinine. INR is normal, CBC is normal. Troponin is less than 0.04, myoglobin is 52.
BMP|basic metabolic profile|BMP|123|125|HOSPITAL COURSE|The patient was also started on iron tablets while in the hospital. The patient's repeat labs showed hemoglobin of 8.6 and BMP normal, but the patient is still receiving 1 more unit of blood. The patient will be discharged to home.
BMP|basic metabolic profile|BMP,|138|141|DISCHARGE FOLLOW-UP|14. Status post tonsillectomy. CODE STATUS: DNR/DNI. DISCHARGE FOLLOW-UP: 1. Follow-up is to be with Dr. _%#NAME#%_ in 7-10 days. 2. INR, BMP, CBC on _%#MMDD2007#%_ with results to Dr. _%#NAME#%_. 3. The patient will need a repeat urinalysis/urine culture in 7-10 days.
BMP|basic metabolic profile|BMP|135|137|PHYSICIAN FOLLOW-UP|Patient needs TCU and needs to be seen by OT and PT. PHYSICIAN FOLLOW-UP: Follow up with nursing home physician in one week to recheck BMP as the patient on Demadex for peripheral edema. PROCEDURES OR OPERATIONS: None. IMPORTANT LABORATORY AND X-RAYS: Patient had CT scan of the chest on _%#MMDD2007#%_ that showed pulmonary embolism.
BMP|basic metabolic profile|BMP|317|319|DISCHARGE INSTRUCTIONS|She is to follow up with Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD#%_ at 10:00 and she is to follow up with Dr. _%#NAME#%_, her primary care physician on _%#MMDD#%_ and she is having an INR checked tomorrow, _%#MMDD#%_, at Fairview Cedar Ridge Clinic. She is to see Dr. _%#NAME#%_ _%#NAME#%_ in 3 months. She is to have a BMP done at Cedar Ridge Clinic on _%#MMDD#%_ with Dr. _%#NAME#%_. DISCHARGE MEDICATIONS: 1. Lasix 40 mg p.o. daily.
BMP|basic metabolic profile|BMP,|210|213|IMPRESSION|Will continue patient on his baby aspirin considering his coronary history and start Coumadin on _%#MMDD2003#%_. The patient is currently hemodynamically stable. Will check screening lab studies including CBC, BMP, platelets, INR, PT-T as well as liver test. Will hold off on hypercoagulable workup for now considering the history of knee brace which is likely to have caused his deep vein thrombosis.
BMP|basic metabolic profile|BMP|195|197|ASSESSMENT/PLAN|2. Chronic renal failure. Baseline creatinine is approximately 2. Now mild increase secondary to dehydration. Will treat the patient's nausea with p.r.n. Zofran, encourage PO fluids and re-check BMP in am. 3. Left bundle branch block, chronic. The patient is asymptomatic. 4. Anemia. The patient with chronic pernicious anemia and has stable hemoglobin.
BMP|basic metabolic profile|BMP|154|156|LABORATORY DATA|Normal bowel sounds. No masses. Slight tenderness on the left side of abdomen as I get closer to the hip. EXTREMITIES: No edema. LABORATORY DATA: CBC and BMP are normal. Electrocardiogram shows nonspecific ST-T changes. IMPRESSION: 1. Left hip dislocation.
BMP|basic metabolic profile|BMP|57|59|LABS AT THE TIME OF ADMISSION|LABS AT THE TIME OF ADMISSION: CBC within normal limits. BMP within normal limits. Amylase, lipase, and troponin within normal limits. Valproic acid level is 46. Chest x- ray also done which is normal.
BMP|basic metabolic profile|BMP,|147|150|DISCHARGE FOLLOWUP|9. Leucovorin 1 at 2230 on _%#MMDD2005#%_, next dose at 5 a.m. on _%#MMDD2005#%_. DISCHARGE FOLLOWUP: 1. Home health to check CBC, platelet count, BMP, AST, ALT, total and direct bilirubin, mag and phos on _%#MMDD2005#%_ via Children's Home Care. 2. Return to hospital or call clinic for temperature over 100.5 degrees Fahrenheit.
BMP|basic metabolic profile|BMP|171|173|FOLLOWUP|8. Zofran 4 mg p.o. q.6 h. p.r.n. nausea. 9. MiraLax 17 grams p.o. daily p.r.n. constipation. FOLLOWUP: _%#NAME#%_ will follow up in Oncology Clinic for CBC with diff and BMP on _%#MMDD2007#%_, _%#MMDD2007#%_ and _%#MMDD2007#%_. He will have an admission check-in appointment with Dr. _%#NAME#%_ on _%#MMDD2007#%_. _%#NAME#%_ was discharged with his mother and siblings to the Ronald McDonald House where they plan to stay until his admission next week.
BMP|bone morphogenetic protein|BMP.|147|150|OPERATIVE PROCEDURES PERFORMED|1. Removal of failed internal fixation, left proximal femur. 2. Repair of nonunion with use of iliac crest autograft, local autograft, and infused BMP. 3. Revision internal fixation, left proximal femur with a 95 degree angled blade plate and broad large fragment locking plate.
BMP|basic metabolic profile|BMP|125|127|DISCHARGE INSTRUCTIONS|10. Hypokalemia. 11. Bronchitis. 12. Osteoporosis prophylaxis. DISCHARGE INSTRUCTIONS: The patient is to have hemoglobin and BMP checked in three days at Fairview Oxboro Clinic. She should have 24-hour urine in two weeks for protein, creatinine clearance, and glucose.
BMP|basic metabolic profile|BMP|179|181|LABORATORY DATA|Neurologic exam: cranial nerves II through XII grossly intact; sensation intact to light touch; gait deferred; strength 5/5 bilaterally; reflexes 1+ bilaterally. LABORATORY DATA: BMP remarkable for a glucose of 120, hemoglobin done yesterday was 7.1 with white count of 8.5, platelet count 250,000, INR 0.94, PTT 29, valproic acid level 44, previously 58; Dilantin level 10.
BMP|basic metabolic profile|BMP|192|194|HOSPITAL COURSE|4. Hypertension. The patient's blood pressure was mildly elevated throughout the stay at 160s/80s. Her Maxzide dose was increased to a full tablet of 37.5/25 one tablet p.o. q. day. Follow-up BMP was within normal limits. 5. Anemia. When the patient was admitted her hemoglobin was 11.3, but decreased to 10.7 at discharge.
BMP|basic metabolic profile|BMP,|222|225|HISTORY OF PRESENT ILLNESS|FOLLOW UP: The patient is to see her primary care provider in 1-2 weeks for recheck blood pressure and hemoglobin. Follow up with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2004. Outpatient lab on IV antibiotics to include CBC, BMP, sed rate weekly, with results faxed to Dr. _%#NAME#%_. Antibiotics to be administered intravenously at Fairview Southdale IV Therapy.
BMP|basic metabolic profile|BMP|157|159|PERTINENT LABORATORY TESTS|PERTINENT LABORATORY TESTS: 1. _%#MMDD2004#%_: WBC 11.3, which is slightly elevated. 2. Urine culture and urinalysis as previously noted. 3. _%#MMDD2004#%_: BMP within normal limits with bicarbonate slightly elevated, at 35. 4. _%#MMDD2004#%_: WBC 11.8, hemoglobin 12.1, and platelet count 177,000.
BMP|basic metabolic profile|BMP|134|136|PHYSICAL EXAMINATION|Because she has history of coronary artery disease, and she was thinly-built female, we started her on low fluid rate. We checked her BMP the next day and sodium had gone to 129, but she was discharged to short-term rehabilitation where they can take care of her sodium as it was not abnormally low.
BMP|basic metabolic profile|BMP|141|143|PLAN|PLAN: 1) Will obtain echocardiography to assess heart function. 2) The patient will be diuresed with IV Lasix. 3) Will follow his uric acid, BMP and BNP as well as liver function tests. 4) Cardiology consultation will be obtained per patient request. He is well known to Minnesota Heart Clinic.
BMP|basic metabolic profile|BMP.|159|162|PHYSICAL EXAMINATION|ABDOMEN: Soft, it is nondistended, bowel sounds are present. EXTREMITIES: There is no peripheral edema. Pedal pulses are palpated. Blood work reviewed. Normal BMP. Normal hemogram, INR, troponin and myoglobin. UA is negative. Serum HCG is negative. Chest x-ray unremarkable. CT chest for PE is unremarkable. Echogram is pending. EKG reviewed shows inferolateral ST segment changes, which are non-classifiable at this point in time.
BMP|basic metabolic profile|BMP|189|191|LABORATORY DATA|Distal lower extremity pulses are 2+. NEUROLOGIC: Nonfocal. He is oriented to time, place and person. LABORATORY DATA: Chest x-ray and EKG are pending at the time of this dictation. He had BMP in our office on _%#MMDD2007#%_ with a creatinine of 1.7, BUN of 39 which is his baseline, K was 4.1.
BMP|basic metabolic profile|BMP|135|137|ADMISSION LABORATORY DATA|He moves all extremities. ADMISSION LABORATORY DATA: WBC 3.8, hemoglobin 10.7, platelets 291. Differential 48 N, 32 L, 18 M, 1 E, 1 B. BMP normal. LFTs normal aside from mildly elevated ALT at 71. HOSPITAL COURSE: PROBLEM #1. FEN/GI: _%#NAME#%_ was maintained on IV fluids during chemo and placed on Zofran drip and dexamethasone to control nausea and vomiting during chemo.
BMP|basic metabolic profile|BMP|205|207|IMPRESSION AND PLAN|5. Polysubstance abuse history. In addition to psychiatry seeing the patient, we will have chemical dependency also see the patient. We will place the patient on thiamine, folate, multivitamin, and obtain BMP and CBC labs in the morning for completeness. Will also apply bacitracin to the patient's superficial forearm wounds.
BMP|basic metabolic profile|BMP|187|189|ADMITTING LABS|Normal motor and sensory. ADMITTING LABS: UA was negative. Abdominal and pelvic CT was negative. Lipase and amylase within normal limits. CBC within normal limits. Beta HCG was negative. BMP within normal limits. LFTs within normal limits. HOSPITAL COURSE: 1. Fluid, electrolytes, and nutrition. The patient received IV fluids through her hospital stay.
BMP|basic metabolic profile|BMP|201|203|FAMILY HISTORY|ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: Without edema. NEUROLOGIC: No focal abnormalities. LABORATORY STUDIES ON ADMISSION : CBC was significant for a WBC of 1.6 and a hemoglobin of 11.0. BMP was within normal limits. INR was elevated at 2.68. PTT was 42. D-dimer quantitative was 3.1. CT scan of the chest could not be done secondary to patient report of difficulty breathing with contrast previously.
BMP|basic metabolic profile|BMP|185|187|LABORATORY|Vent is set at SMIV 850/8/5/5 40% FiO2. LABORATORY: Significant for a hemoglobin of 9.4, previously 11.2. An INR of 2.18. BMP had a BUN of 77 and a creatinine of 1.46. Remainder of the BMP was normal. AVG was 7.25/38/26/16. HOSPITAL COURSE: PROBLEM #1: Urology. The patient came in with gross hematuria that was controlled after cystoscopy was cauterized.
BMP|basic metabolic profile|BMP|169|171|LABORATORY DATA|No bruits, jugular venous distention or edema appreciated. ABDOMEN: Soft and nontender without hepatosplenomegaly or masses. EXTREMITIES: Unremarkable. LABORATORY DATA: BMP and CBC normal. There is moderate elevation of AST and ALT. Cardiac enzymes are negative so far. Electrocardiogram shows lateral T-wave inversion and modest J-point depression only.
BMP|beta-natriuretic peptide:BNP|BMP|194|196|ASSESSMENT|ASSESSMENT: This is a 66-year-old lady admitted with worsening shortness of breath, mildly febrile, with an elevated white count. The chest x-ray reveals congestive heart failure (CHF), but the BMP is not severely elevated. Also now with a rising troponin without any chest pain. PLAN: 1. Congestive heart failure. Her echo is pending. We will gently diurese her.
BMP|basic metabolic profile|BMP,|215|218|FOLLOW UP|3. Loratadine 10 mg p.o. q. day x5 days. FOLLOW UP: The patient will be seen by Dr. _%#NAME#%_ on Thursday, _%#MM#%_ _%#DD#%_, 2005, at 3 p.m. Followup evaluation will include a CBC with differential and platelets, BMP, and LFTs. The patient was advised to call the Masonic Cancer Clinic or afterhours care team if she develops any signs or symptoms of fever, increased pain, increased cough, or shortness of breath.
BMP|basic metabolic profile|BMP|201|203|DISCHARGE INSTRUCTIONS|Follow-up with Dr. _%#NAME#%_ _%#NAME#%_, Fairview Southdale Hospital, in 1 week or sooner if worse. Follow with Neurology Clinic in _%#CITY#%_ Clinic in 1 or 2 weeks. Outpatient labs: Dilantin panel, BMP _%#MM#%_ _%#DD#%_, 2005, and results to be sent to Dr. _%#NAME#%_ and _%#CITY#%_ Neurology Clinic. Home health nurse for left ankle wound care and medical management.
BMP|basic metabolic profile|BMP|194|196|HOSPITAL COURSE|She had 2+ femoral pulses bilaterally. Her skin exam showed multiple scars over her chest. HOSPITAL COURSE: 1. SENGI: Evelyn remained n.p.o. on admission overnight with maintenance IV fluids. A BMP was checked, which was normal. She was evaluated by the stoma nurse from the GI team, _%#NAME#%_ _%#NAME#%_, on the morning after admission.
BMP|basic metabolic profile|BMP|154|156|LABORATORY VALUES|Bowel sounds are present. EXTREMITIES: Show no edema. SCREENING NEUROLOGIC: Nonfocal. LABORATORY VALUES: Include urine that showed positive for bacteria. BMP that showed a sodium of 125, BUN of 37, creatinine of 2.36. White count was 9,300 with 90 PMNs, hemoglobin was 12.4. Abdominal CT per ER was negative.
BMP|basic metabolic profile|BMP|157|159|HISTORY OF PRESENT ILLNESS|LABORATORY: Laboratory results on admission: Karlye had a CBC with a white count of 2.6, hemoglobin of 9.6, and platelets of 409. Her ANC was 1.5. She had a BMP which was completely within normal limits including a BUN of 10 and a creatinine of 0.22. She also had liver function studies that were within normal limits.
BMP|basic metabolic profile|BMP|139|141|LABORATORY STUDIES|ABDOMEN: Soft without tenderness, mass or organomegaly. There is no flank tenderness to palpation. LABORATORY STUDIES: Notable for CBC and BMP that are unremarkable. UA has 7 WBCs. Abdominal and chest CT are negative except for a 2 cm left adrenal nodule. ASSESSMENT: 1. Chest pain with associated nausea, vomiting and shortness of breath.
BMP|beta-natriuretic peptide:BNP|BMP|181|183|PROBLEM #1|No intracardiac vegetations and a small pericardial effusion not hemodynamically significant. Despite continuation of antibiotics, the patient became hypoxic requiring more oxygen. BMP obtained shows 29300, markedly elevated. The patient was started on BiPAP 12/6 with 50% oxygen but the patient's family stated the patient was unable to tolerate BiPAP.
BMP|basic metabolic profile|BMP|144|146|LABORATORY DATA|NEUROLOGICAL: Grossly intact. Cerebellar function normal. LABORATORY DATA: CBC, white count 4.6, hemoglobin 9.8, platelet 565,000. On admission BMP within normal limits with a creatinine of 0.92. HOSPITAL COURSE: PROBLEM#1: Heme/Onc: The patient receives cytarabine and etoposide during this chemotherapy.
BMP|basic metabolic profile|BMP|232|234|LABORATORY RESULTS|LABORATORY RESULTS: At the time of admission, the patient had a white blood cell count of 6.6, hemoglobin of 8.4, platelets of 277. The patient had an MCV of 16 and RDW of 18.1. The patient's hepatic panel was normal. The patient's BMP revealed sodium of 143, potassium of 3.8, chloride of 106, CO2 of 22, BUN of 7, creatinine of 0.78 with a glucose of 106, and anion gap 15.
BMP|basic metabolic profile|BMP|297|299|IMPRESSION AND PLAN|Based on the fact that the patient has had a recent stress test done by a cardiologist at The Marsh, and that he has no angina or any angina equivalents, I would place him at a low risk for cardiopulmonary complications. I will fax a copy of his CBC and EKG to the preop area, and once his UA and BMP are complete, I will fax those as well. He was told to hold his aspirin and any nonsteroidals prior to surgery.
BMP|beta-natriuretic peptide:BNP|BMP|367|369|LABORATORY DATA|Cardiovascular: Regular rate and rhythm. S1 and S2. Positive systolic ejection murmur. Musculoskeletal: Positive pedal edema. Neurologic: No focal deficits. LABORATORY DATA: Sodium 140, potassium 4.0, chloride 101, C02 23, BUN 24, creatinine 0.7, glucose 102, calcium 9.8, total bilirubin 0.7, total protein 8.7, alkaline phosphatase 90, albumin 4.5, ALT 54, AST 46, BMP ______ 1300, white count 9.9, hemoglobin 13.4, platelets 333, INR 1.26. C. diff negative. HOSPITAL COURSE: PROBLEM #1: GI. The patient presented with nausea, vomiting, and diarrhea.
BMP|basic metabolic profile|BMP|135|137|HOSPITAL COURSE|Her UA was negative. Her myoglobin and troponin were negative. Her CBC was within normal limits with white count 5.5, hemoglobin 13.6. BMP within normal limits. PAST MEDICAL HISTORY: 1. Hypertension. 2. GERD with hiatus hernia.
BMP|basic metabolic profile|BMP|187|189|PERTINENT LABORATORY STUDIES|The BNP was 21. Troponins negative times three. ALT 18 and AST 20. Total cholesterol 296, triglycerides 481, HDL 35, LDL unable to calculate. Homocysteine level normal at 7.5. Subsequent BMP and CBC normal. HOSPITAL COURSE 1. Unstable angina. The patient is a 46-year-old gentleman with a known history of coronary artery disease status post inferior MI with stent placement at Abbott Northwestern Hospital _%#MM2004#%_.
BMP|beta-natriuretic peptide:BNP|BMP|163|165|OPERATIONS/PROCEDURES PERFORMED|Of note, in her last hospital stay, she was found to be in pulmonary edema. After that admission, she was started on Lasix at 40 mg orally b.i.d. On admission her BMP was elevated to 802. For this reason, she was given IV Lasix for diuresis. Additionally, she was febrile, with a temperature of 101.1. She had a chest x-ray which showed bibasilar subsegmental atelectasis and/or consolidation.
BMP|basic metabolic profile|BMP|142|144|LABORATORY|Romberg is negative. HEAD CT: Unremarkable. LABORATORY: Urinalysis shows small leukocyte esterase, white blood cells 0-2. Troponins negative. BMP is normal. CBC is normal. Chest x-ray is unremarkable. EKG reveals sinus rhythm without any ischemic changes. ASSESSMENT AND PLAN: Accelerated hypertension and dizziness.
BMP|basic metabolic profile|BMP,|177|180|HISTORY OF PRESENT ILLNESS|She was not eating, not sleeping. Her mood is extremely low and there were concerned about her health and they brought her to the emergency room for evaluation. In the ER, CBC, BMP, urinalysis, tox screen were all normal. She was admitted to the Psychiatric ward for ongoing evaluation and treatment of her depression.
BMP|basic metabolic profile|BMP.|134|137|ASSESSMENT AND PLAN|Further antibiotics per ENT. The patient has no clear contraindications to proceeding with surgery if needed. We will check a CBC and BMP. The Emergency Department physician will suture his right facial lacerations.
BMP|basic metabolic profile|BMP|140|142|LABORATORY DATA|There is mild to moderate left lower abdominal pain without rebound or guarding. EXTREMITIES: No edema. LABORATORY DATA: As outlined above. BMP is remarkable for a creatinine slightly elevated at 1.4. LFTs are normal. Troponin is negative. CBC reveals white count 22,500, hemoglobin 12.
BMP|basic metabolic profile|BMP|105|107|LABORATORY DATA|EXTREMITIES: Without any clubbing, cyanosis or unequal edema. LABORATORY DATA: 1. Include normal CBC and BMP preoperatively and normal CEA and PSA levels. Imaging the CT scan of the abdomen and pelvis on _%#MMDD2007#%_ revealed 3 cm of focal wall thickening the cecum (this is not resected).
BMP|basic metabolic profile|BMP|122|124|DISCHARGE INSTRUCTIONS AND FOLLOW-UP|Suggested follow up with a primary MD that she might identify on her own at Fairview Ridges Clinic in about 2 weeks, with BMP and CBC with diff and platelets at that time. Also, suggest follow up in 4-6 weeks with nephrology, Dr. _%#NAME#%_ of Intermed, and follow up in 4-6 weeks with gastroenterology, Dr. _%#NAME#%_ _%#NAME#%_.
BMP|basic metabolic profile|BMP|137|139|LABORATORY DATA|She has a somewhat depressed-appearing affect. LABORATORY DATA: EKG was normal. CBC: White count 8900, hemoglobin 12.3, hematocrit 38.1. BMP is normal. Liver functions are normal. Urinalysis was not sent. Serum for ketones was 2.9. Ammonia level was 17. ASSESSMENT/PLAN: 1. Nausea, vomiting and weakness. The patient's hepatic panel was done but an amylase and lipase were not sent.
BMP|basic metabolic profile|BMP|177|179|LABORATORY|All other exam is within normal limits. LABORATORY: White blood cell count is 13.9 with a left shift of 77% neutrophils. Hemoglobin is 13.2, hematocrit 37.7, and platelets 254. BMP is without abnormality. Total bilirubin is 1.2. Albumin is 4.0. Total protein is 7.8. Alkaline phosphatase is 63. AST is 17. ALT is 15, amylase 66, and lipase 36.
BMP|basic metabolic profile|BMP|144|146|LABORATORY DATA ON ADMISSION|Deep tendon reflexes were 2+ bilaterally in the upper and lower extremities. LABORATORY DATA ON ADMISSION: The patient's INR was 2.6. A CBC and BMP were ordered for the following morning. HOSPITAL COURSE: The patient was started on Ancef 1 gm IV q.8h. During the course of her stay, the cellulitis began to resolve.
BMP|basic metabolic profile|BMP|165|167|HISTORY OF THE PRESENT ILLNESS|In the emergency department, repeat CT scan shows diverticulitis with a small perforation but no abscess formation. The white count is 12,500 with a left shift. The BMP is normal. The urinalysis and lipase are normal. The patient does have positive rebound and significant tenderness in the right lower quadrant and the low midline abdomen.
BMP|basic metabolic profile|BMP|217|219|LABORATORY DATA/IMAGING|Cystocele present with straining. Uterus approximately 6 to 8 week size and mobile. LABORATORY DATA/IMAGING: The patient had a chest x-ray, EKG, TSH, complete blood count with differential and platelets, as well as a BMP prior to surgery. HOSPITAL COURSE: PROBLEM #1: Disease. The patient went to the operating room for her planned procedure for grade 1 endometrial adenocarcinoma.
BMP|basic metabolic profile|BMP|231|233|PLAN|3. Congestive heart failure management has to be optimized with continuation of Coreg 25 mg twice a day, Apresoline 25 mg daily and Altace 10 mg twice a day. Potassium was 3.5 at the time of discharge, it is imperative that repeat BMP be checked in three to five days to make sure that potassium does not continue to go up as the ACE inhibitor dose has been increased.
BMP|basic metabolic profile|BMP|214|216|DISCHARGE MEDICATIONS|Chest x-ray would show a right upper lobe infiltrate compatible with his previous known lung cancer. CT scan of the head showed no acute intercranial pathology. A MRI of the brain showed no metastatic disease. The BMP was elevated at 555. The patient was admitted and his medications were adjusted. We needed to hold most of his cardiac medicines due to profound hypotension.
BMP|basic metabolic profile|BMP|219|221|ASSESSMENT AND PLAN|We will hold her hydrochlorothiazide, check all electrolytes and we will place her on a perioperative beta-blocker and hold for bradycardia or hypertension. The patient has no history of asthma. We will check a CBC and BMP to rule out electrolyte abnormalities. 3. Fall. It appears to be simply from tripping on the sidewalk. It is possible that she may have an underlying dehydration related to her hydrochlorothiazide.
BMP|basic metabolic profile|BMP|133|135|PLAN|2. Tylenol p.r.n. IV normal saline bolus of 1 L and then half-normal saline with 20 mEq potassium at 150 cc/hour. 3. We will check a BMP on admission and then CBC in the morning. 4. If she remains afebrile for 24-48 hours, then we may be able to discharge on p.o. medications.
BMP|basic metabolic profile|BMP|159|161|DISCHARGE DIAGNOSIS|It was very hard for her to move it and move the leg. LABORATORY ON ADMISSION: ESR 49. CRP 5.1. Blood culture negative. Urine and urine culture were negative. BMP in normal limits. HOSPITAL COURSE: 1. Pre-cellulitis versus cellulitis: She did not have an increase in swelling or redness over her left leg but had increased ESR and CRP which are the markers which we usually follow for the course of the problem during the hospital admissions.
BMP|basic metabolic profile|BMP|138|140|PROBLEM #4|He continued to receive IV fluids through _%#MMDD2006#%_. With a GFR of over 90 on _%#MMDD2006#%_, he was able to discontinue the fluids. BMP was within normal limits on discharge. No need for further BMPs. Tolerating normal diet, eating very well. Normal ins and outs.
BMP|basic metabolic profile|BMP.|164|167|ASSESSMENT AND PLAN|Titrate insulin drip to keep her between 100 to 150. Serial BMPs q 4 hours for the next 12 hours and replace her potassium, which I suspect will be low on her next BMP. When she corrects her acidosis, will wean her off the insulin drip and restart Lantus. Strongly counseled and educated her on diabetic compliance and potential long term ramifications of uncontrolled diabetes.
BMP|basic metabolic profile|BMP.|253|256|HISTORY OF PRESENT ILLNESS|She has otherwise been doing well lately. She was recently evaluated by her primary nurse practitioner which she had a normal TSH, normal EKG, but was noted to have slightly high cholesterol. In the emergency room she was noted to have a normal CBC and BMP. CT of the abdomen noncontrast showed 9 mm right proximal ureter stone with obstruction and second right intrarenal stone.
BMP|basic metabolic profile|BMP|123|125|HOSPITAL COURSE ILLNESS|I have reviewed that with Dr. _%#NAME#%_ and he has cleared her for restarting ACE inhibitors. The patient will need early BMP checked next week to make sure there is no evidence of dye-induced nephropathy. I also increased her Imdur to 90 mg per day for better antianginal management.
BMP|basic metabolic profile|BMP|138|140|ASSESSMENT/PLAN|Meanwhile, the patient will be n.p.o. with IV fluids and morphine PCA for pain. Would like to recheck his fasting lipids, CBC, platelets, BMP and lipase in the morning. In addition, still await the results of the ultrasound and will also await the results of the CT of abdomen and pelvis to evaluate his left lower quadrant abdominal pain and also his pancreas.
BMP|beta-natriuretic peptide:BNP|BMP|134|136|PROBLEM #2|PROBLEM #2: Right ventricular failure: This was discussed with pulmonary and it was felt that it was due to his pulmonary embolism. A BMP was checked and only found to be slightly elevated. He does not have significant lower extremity edema or JVD. This can be followed up as an outpatient and should likely improve with time.
BMP|basic metabolic profile|BMP|168|170|REHABILITATION COURSE|A followup orthopedic appointment with Dr. _%#NAME#%_ on _%#MMDD2007#%_. Primary MD followup within the next 1-2 weeks. Home health care with RN visits to monitor INR, BMP and hemoglobin. Outpatient physical therapy. DISCHARGE MEDICATIONS: 1. Os-Cal with vitamin D 1250 mg b.i.d.
BMP|beta-natriuretic peptide:BNP|BMP|204|206|LABORATORY DATA|NEUROLOGIC: The patient appears grossly intact and nonfocal. SKIN: No rashes. LABORATORY DATA: D-dimer 0.6. Chest CT scan negative for PE, peliminary read. Troponin less than 0.04, myoglobin is negative. BMP is essentially normal. White cell count of 11.2. EKG shows sinus rhythm with a heart rate of 83. No acute ST changes. QT interval is 420. Blood cultures were obtained in the ER and are pending.
BMP|basic metabolic profile|BMP|96|98|LABORATORY|Memory is intact. His insight into his illness as well as his judgment is fair. LABORATORY: His BMP was within normal limits except for a mildly low creatinine of 0.65. His calcium was within normal limits. HOSPITAL COURSE: The patient is a 44-year-old male who had recently been discharged from inpatient FUMC on Friday, _%#MM#%_ _%#DD#%_, 2005, and was readmitted to the hospital on _%#MM#%_ _%#DD#%_, 2005, to the ICU after drinking heavily and feeling somewhat obtunded.
BMP|basic metabolic profile|BMP|194|196|LAB  AND DIAGNOSTIC DATA|SKIN: No rashes. LAB AND DIAGNOSTIC DATA: The patient had EKG done from _%#MMDD#%_ and today. These are completely normal. She had a head CT done on _%#MMDD#%_ which was normal. She had CBC and BMP done again on _%#MMDD#%_ and today . All of these are normal. IMPRESSION: 1. Chest and back pain, completely relieved by nitroglycerin.
BMP|basic metabolic profile|BMP,|187|190|PAST MEDICAL HISTORY|On _%#MM#%_ _%#DD#%_, 2005, he had further evaluation including a rectal biopsy by Dr. _%#NAME#%_. Additional studies at that time included normal thyroid studies, ESR of 9, and a normal BMP, CBC, and hepatic panels. He also had an upper endoscopy which was normal. His short stature is followed by Dr. _%#NAME#%_ from endocrine. He has been found to have a normal bone age study with borderline normal IGF findings, which will be rechecked in approximately 3 months.
BMP|basic metabolic profile|BMP|142|144|ASSESSMENT AND PLAN|a Foley will be placed. b. He will be watched carefully for postobstructive diuresis. c. A renal ultrasound will also be obtained. d. Recheck BMP in the morning 3. Hyperkalemia improved to normal with the use of Kayexalate. Suspect this is due to the acute renal failure referenced above: Plan: a. Telemetry monitoring b. Check potassium
BMP|basic metabolic profile|BMP|197|199|DISCHARGE INSTRUCTIONS|8. On her right posterior thigh wound, she should have extensive clinical care spray by 3-M foam dressing with transparent ......... use skin prep for no sting under ......... 9. She should have a BMP and BNP on _%#MMDD2006#%_. 10. She also can have oxygen 1 to 2 liters continuous.
BMP|basic metabolic profile|BMP|129|131|HOSPITAL COURSE|There was no indications for dialysis. Potassium was normal. She was not acidotic. Her phosphorus was 5.1. She needs a follow-up BMP on Monday with results faxed to Dr. _%#NAME#%_. Smoking cessation counseling was done during the hospitalization and the patient was discussed further with her primary, Dr. _%#NAME#%_.
BMP|basic metabolic profile|BMP|174|176|PLAN|We will initiate IV metoprolol for postop beta blockage. Sinus tachycardia could be secondary to pain as well. We will hold his hyperlipidemia medications currently. CBC and BMP in the a.m. and repeat chest x-ray in a couple of days. He also has hypokalemia. He is on replacement per protocol.
BMP|basic metabolic profile|BMP|189|191|DISCHARGE INSTRUCTIONS|13. The patient to take potassium supplement, K-Dur 20 mEq p.o. q. day for three days, as she was hypokalemic in the hospital. DISCHARGE INSTRUCTIONS: The patient to have follow-up CBC and BMP on _%#MMDD2006#%_ and call results to Dr. _%#NAME#%_ _%#NAME#%_, who is the primary care physician for the patient. The patient is to have follow-up with Dr. _%#NAME#%_ in one to two weeks.
BMP|basic metabolic profile|BMP,|280|283|HOSPITAL COURSE|On _%#MMDD2006#%_, her weight was 39.68 kg and on _%#MMDD2006#%_ it was 40.68 kg and that will need to be monitored on a weekly basis by the homecare team. The game plan was for her to have labs rechecked 1 week before her GI appointment at the _%#CITY#%_ Hospital and will check BMP, magnesium, calcium, PTH level, hemoglobin, vitamin D, vitamin E, vitamin B6, carotene, albumin, prealbumin and transferrin levels and Dr. _%#NAME#%_ can assess whether she is improving her nutrition and vitamin stores with enteral support alone and more active treatment of malabsorption.
BMP|basic metabolic profile|BMP.|109|112|DISCHARGE MEDICATIONS|Upright for 1-2 hours after meals. Pureed diet. TSH, T4 in 5-6 weeks. Follow with primary MD 5-7 days with a BMP.
BMP|basic metabolic profile|BMP|155|157|DISCHARGE MEDICATIONS|The patient is to follow up with outpatient psychiatry as above. Dr. _%#NAME#%_ from urology in two weeks. Office follow up with myself on _%#MMDD2007#%_. BMP and hemoglobin on _%#MMDD2007#%_ and _%#MMDD2007#%_. CONDITION ON DISCHARGE: Stable.
BMP|basic metabolic profile|BMP|237|239|HOSPITAL COURSE|To remain off of aspirin and Coumadin. Continue Levaquin an additional week for a question of infiltrate left lung base on chest x-ray, picked up on _%#MMDD2007#%_ subsequent to development of mild degree of dyspnea. Recheck hemoglobin, BMP by RN on _%#MMDD2007#%_ with results called to myself. DISCHARGE MEDICATIONS: 1. Combivent 2 puffs q.i.d. 2. Pulmicort Respules inhaled b.i.d.
BMP|basic metabolic profile|BMP|367|369|PROBLEM #2|PROBLEM #2: Elevated creatinine. The patient's creatinine is elevated to 1.6 from 1.1 I _%#MM#%_ 2007, the etiology of this could be dehydration, however, the patient's BUN to creatinine ratio is not 20:1, another etiology of this increased creatinine could be cocaine use, which can be nephrotoxic. We will continue to monitor the patient's creatinine by ordering a BMP in the morning. PROBLEM #3: Thyroid. The patient's TSH is low at 0.12. The patient has no known history of thyroid disorder and the patient has no symptoms of hyperthyroidism on review of systems.
BMP|basic metabolic profile|BMP|139|141|PHYSICAL EXAMINATION|Pelvic exam revealed a mobile 8 cm uterus without palpable mass on bimanual rectovaginal exam. Review of pathology was as described above. BMP was normal with the exception of glucose of 114, creatinine was 0.5, potassium 3.7. GFR 132. Hemoglobin 14, hematocrit 42, white count 13, platelets 43,000.
BMP|basic metabolic profile|BMP|162|164|LABORATORY STUDIES|AST is a little elevated at 46, but ALT is normal. Her reticulocyte count was elevated at 3.8. Again, chest x-ray was normal. Lipase and amylase were normal. Her BMP was normal. ASSESSMENT AND PLAN: 1. Fever and chill: Both fever and chills disappeared. ID recommended no oral antibiotics to go home with.
BMP|basic metabolic profile|BMP:|155|158|LABORATORIES ON ADMISSION|LABORATORIES ON ADMISSION: Her white blood cell count is 5.6. Hemoglobin 13.3. Platelets 327. Her differential is 61 neutrophils, 24 lymphs, 15 monocytes. BMP: Sodium 140. Potassium 4.8. Chloride 104. Bicarb 13. BUN 22. Creatinine 0.5. Glucose 42. Calcium 10.5. Albumin 4.9. Protein 8.1. Normal LFTs. ASSESSMENT AND PLAN: _%#NAME#%_ is a 4-year-old Somalia female with chronic vomiting here with an acute vomiting illness with dehydration and significant metabolic acidosis needing inpatient stay for IV fluid rehydration and re-establishment of oral intake.
BMP|basic metabolic profile|BMP|163|165|HOSPITAL DISCHARGE AND FOLLOWUP|3. The patient does not have a primary care physician. Upon transfer from acute rehab, he will need to have that established. 4. The patient will need to have his BMP checked in 1 week. DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg p.o. daily 2. Dulcolax 10 mg p.r. p.r.n. constipation.
BMP|basic metabolic profile|BMP|264|266|LABORATORY DATA|Forehead movement is symmetric. Smile were symmetric. Examination of his vision reveals right visual field cut in each eye consistent with a right homonomous hemianopsia. LABORATORY DATA: EKG shows normal sinus rhythm with heart rate of 73. Labs including CBC and BMP as well as coagulation studies appear normal. Head CT shows no evidence of bleed. Brain MRI scan shows a recent area of infarction left posterior medial temporal and adjacent left anterior medial occipital lobe.
BMP|basic metabolic profile|BMP|138|140|LABS|Power 5x5. Deep tendon reflexes intact. Coordination and gait were normal. LABS: His troponin was less than 0.07. Amylase 67, lipase 210. BMP shows sodium of 141, potassium 3.8, chloride 106, bicarb 27, BUN 13, creatinine 0.9, and glucose 101. EKG shows sinus brady at about 59 with a right bundle branch block.
BMP|basic metabolic profile|BMP|175|177|LABORATORY|Regular rate and rhythm without murmurs. ABDOMEN: Soft, nontender, and nondistended with positive bowel sounds. SPINE: Straight without any lesions. LABORATORY: On admission, BMP shows BUN of 9 and creatinine 0.65. CBC shows white count of 5.1, hemoglobin 9.8, platelets 441, and an ANC of 3.0. HOSPITAL COURSE: ONC: She received her fifth round of preoperative chemotherapy with methotrexate.
BMP|basic metabolic profile|BMP|122|124|HOSPITAL COURSE|This was done on a twice per day basis. Her legs were elevated. I also added Aldactone 25 mg daily. After several days, a BMP was ordered which indicated a normal potassium. The lower extremity edema improved markedly. At the time of her discharge, the redness had improved dramatically.
BMP|basic metabolic profile|BMP|195|197|ADMISSION LABORATORY DATA|NEUROLOGIC: Exam remarkable for mildly decreased tone. ADMISSION LABORATORY DATA: An essentially normal CBC with white count 8.1 (88% neutrophils), hemoglobin elevated at 16.3 and platelets 259. BMP remarkable only for slightly elevated sodium 145; potassium 4.1, chloride 106, bicarbonate 22, BUN 14, creatinine 0.59, glucose 91 and calcium 9.4. Essentially normal LFTs with an elevated alkaline phosphatase of 654, ALT 45, AST 41, albumin 4.7, total protein 7.8, bilirubin less than 21.
BMP|basic metabolic profile|BMP|159|161|ADMITTING LABORATORY DATA|SPINE: No defects. LYMPHATICS: No edema. MUSCULOSKELETAL: Moves all extremities, warm and well perfused. SKIN: Slight jaundice. ADMITTING LABORATORY DATA: His BMP showed a sodium of 131, potassium of 5, chloride 105, bicarbonate 21, BUN 21, creatinine 1.1, glucose 68 and calcium of 3.4. He has a total bilirubin of 4.6 and direct bilirubin of 0.2. His CBC showed a white blood cell count of 16.6, hemoglobin 15.6, platelets 260,000 and ANC of 8.817. His VBG pH of 7.34, pCO2 of 28, pO2 of 48 and bicarbonate of 20 and saturating 90%.
BMP|basic metabolic profile|BMP|126|128|PHYSICIAN FOLLOW-UP|The patient did have an INR prior to visit. The patient should have an INR drawn on _%#MMDD2007#%_. The patient should have a BMP prior to visit. SPECIAL INSTRUCTIONS: 1. If the patient's weight increases by 5 pounds, he should notify his MD.
BMP|basic metabolic profile|BMP|129|131|IMPRESSION AND PLAN|5. Hypophosphatemia: We will check this in the morning. The patient has needed replacement while at F-UMC. Also, we will check a BMP and hemoglobin. DISPOSITION: The patient will be discharged to home in the near future.
BMP|basic metabolic profile|BMP|135|137|PLAN|I will slowly advance the Coumadin as it caused a GI bleed during her previous hospitalization. I will monitor her INR, hemoglobin and BMP very closely. The patient has been consistently hypertensive since admission to Transitional Service. I will consider increasing antihypertensive medication if her blood pressure is still consistently elevated.
BMP|basic metabolic profile|BMP|152|154|LABS ON ADMISSION|No hepatosplenomegaly could be appreciated. Her neuro status was intact. LABS ON ADMISSION: Her white count was 4.0, hemoglobin 8.9, platelets 146. Her BMP was within normal limits except for a glucose of 268. HOSPITAL COURSE: The patient was admitted to the Hematology/Oncology service for management of her recurrent epistaxis.
BMP|basic metabolic profile|BMP|138|140|PHYSICIAN FOLLOWUP|PHYSICIAN FOLLOWUP: 1. _%#NAME#%_ _%#NAME#%_ should follow up with a new primary physician to assume care of her diabetes and to repeat a BMP as the patient had hypokalemia in the hospital. The patient informs me that she is no longer able to follow with a physician at Crosstown Clinic because of her noncompliance issues.
BMP|basic metabolic profile|BMP,|309|312|LABORATORY DATA|It is well perfused throughout. MUSCULOSKELETAL: Full range of motion in all extremities. NEUROLOGIC: Patellar DTRs are 2+ bilaterally. LABORATORY DATA: From clinic on _%#MMDD2007#%_, CBC revealed a white count of 3.6, hemoglobin 13.4, platelets 287,000, hematocrit 37.9 and absolute neutrophil count of 1.2. BMP, sodium 144, potassium 3.8, chloride 106, CO2 26, BUN 9, creatinine 0.82, glucose 93 and calcium 8.7. Bilirubin total 0.2, albumin 4.1, total protein 7.0, alkaline phosphatase 120, ALT 51 and AST 44.
BMP|basic metabolic profile|BMP,|114|117|LABORATORY DATA|There is no peripheral edema. NEUROLOGIC: Grossly normal. SKIN: Warm and dry. LABORATORY DATA: Show a normal CBC, BMP, amylase and lipase. INR is 2.24. Abdominal CT showed a mechanical small-bowel obstruction along with sigmoid diverticulitis. ASSESSMENT: 1. Small-bowel obstruction. Will keep n.p.o., give IV fluids and as her vomiting is resolved at this point, will not put an NG in unless it returns.
BMP|basic metabolic profile|BMP|74|76|LABORATORY|LABORATORY: White count 10.2, hemoglobin of 15.6, platelet count 301,000. BMP and blood culture and wound culture are pending. ASSESSMENT AND PLAN: 1. Cat bite, right thumb, with extension concerning for propagation. He will get a wound culture obtained by Dr. _%#NAME#%_ from the Emergency Room.
BMP|basic metabolic profile|BMP|131|133|LABORATORY DATA|4. Albuterol inhaler on a p.r.n. basis. LABORATORY DATA: At the time of admission CBC, WBC 7.6, hemoglobin 11.4, platelet 250,000. BMP showed sodium 140, potassium 4.1, chloride 110, CO2 is 25, glucose 74, creatinine 0.9, calcium 8.7, magnesium 2.6. LFTs done were normal and UPT was negative.
BMP|basic metabolic profile|BMP|154|156|ASSESSMENT AND PLAN|4. Diabetes mellitus. The patient will be continued on Glucophage 500 mg p.o. b.i.d. 5. Preop EKG will be obtained and preop labs which include a CBC and BMP will also be obtained. The patient's aspirin will be kept on hold in case she goes for an abdominal surgery in the near future.
BMP|basic metabolic profile|BMP|105|107|LABORATORY|Strength is equal. Finger-to-nose is normal. There is some truncal ataxia with walking. LABORATORY: CBC, BMP are normal. MRA shows mild to moderate stenosis in internal carotids and vertebrals. CT scan of the head showed acute infarct in the posterior inferior aspects of both cerebellar hemispheres.
BMP|basic metabolic profile|BMP|252|254|LABS ON ADMISSION|She has been asymptomatic and had no heartburn. LABS ON ADMISSION: White count was 5.2, hemoglobin was 13.6, hematocrit 40.5. The patient's blood type was drawn. She is O positive, antibody negative. Abdominal x-ray was performed which was negative. A BMP was performed. Electrolytes were all within normal limits. Lipase was normal at 97. Lactate was drawn, which was normal level at 1.9.
BMP|basic metabolic profile|BMP|187|189|LABORATORY|Neurologically, he moved all extremities equally, and cranial nerves 2 through 12 intact. LABORATORY: At the time of admission, white count of 11.9, hemoglobin of 12.0, platelets of 437. BMP was normal. He had an LP done, and the cerebrospinal fluid revealed 2 white blood cells, 5 red blood cells, clear colorless fluid, glucose 49, protein 30.
BMP|basic metabolic profile|BMP|145|147|LABORATORY|No ST-T changes. Portable chest x-ray showed no acute pulmonary disease. CBC showed a white count of 6.4, with hemoglobin of 7.7 done in the ER. BMP was within normal. Troponin less than 0.04 and myoglobin was 43. BNP was 123. Chest CT with contrast showed no evidence of pulmonary embolism.
BMP|basic metabolic profile|BMP,|165|168|LABORATORY DATA|Chest x-ray shows a normal sized heart and clear lungs. Serum labs, platelet count 117,000 which is slightly low. Initial troponin is 0.08. CBC, Chem-7 as well as a BMP, all unremarkable otherwise. All labs reviewed by myself. The computer system is shutdown at the moment.
BMP|basic metabolic profile|BMP|278|280|HOSPITAL COURSE|Cultures are negative at 24 hours. The patient had significant relief with the thoracentesis to the point where he is able to breathe comfortably and maintain adequate oxygenation off supplemental oxygen and feels that he is ready for discharge. His laboratory studies included BMP and CBC are pending from this morning. There is concern about anemia. His hemoglobin on the 12th was 9.2 and MCV of 94.
BMP|basic metabolic profile|BMP,|184|187|DISCHARGE PLAN|DISCHARGE PLAN: 1. She should see her primary care physician in 1 to 2 weeks at Fairview _%#STREET#%_ (Dr. _%#NAME#%_). At that time if her primary care physician would please check a BMP, as well as a hemoglobin. 2. Home RN will be visiting the patient, and please have her check blood pressures and bring a record to the primary care physician visit; in order to assist her primary care physician in possibly titrating antihypertensive medications.
BMP|basic metabolic profile|BMP.|145|148|DISCHARGE FOLLOW-UP|DISCHARGE FOLLOW-UP: She will follow-up with Dr. _%#NAME#%_ in the next 7-10 days. Wound care will seen. She will follow-up of her INR, Digoxin, BMP.
BMP|basic metabolic profile|BMP,|354|357|FOLLOW-UP|These have all been arranged. He is also to have a follow-up appointment with Dr. _%#NAME#%_ in the Ophthalmology Clinic on _%#MMDD2003#%_ at 3:15 p.m. His next scheduled follow-up appointment in the Pediatric Hematology/Oncology Clinic will be _%#MMDD2003#%_, at which time he will have laboratories, including CBC with differential and platelet, LFTs, BMP, magnesium, phosphate, ESR, and ferritin checked, after which he will be admitted for continuation of his chemotherapy. It has been a pleasure taking care of _%#NAME#%_ during this admission, and I look forward to taking care of him again in the future.
BMP|basic metabolic profile|BMP|160|162|LABORATORY DATA|Her stool specimen showed only E. coli 0:157 and no Salmonella species was isolated. Her complete hemogram with differential count was within normal limits and BMP showed sodium 139, potassium 4.2, chloride 110, CO2 21, glucose 66, blood urea nitrogen 5 and creatinine of 1. Her ESR was 10 and CRP was 4.8. In short, all the labs were within normal limits.
BMP|basic metabolic profile|BMP.|201|204|PLAN|Discussion with ortho indicates that the procedure is to be very superficial, not going into the joint space, in which case reversal of anticoagulation may not be necessary. PLAN: 1. Follow up INR and BMP. 2. Surgical procedure as above. If reversal of anticoagulation not required we will continue with Coumadin for DVT prophylaxis. 3. Probable follow-up venous Doppler ultrasounds both legs to assess status with regard to prior DVT.
BMP|basic metabolic profile|BMP|138|140|LABORATORY DATA|EXTREMITIES: Without edema. LABORATORY DATA: CBC demonstrates a white count of 8.1, hemoglobin 15.3, neutrophils are elevated at 77%. Her BMP demonstrates a creatinine of 0.70. Electrolytes otherwise unremarkable. Chest x-ray, hyperinflated lungs with no evidence of obvious infiltrate.
BMP|basic metabolic profile|BMP|280|282|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: Low fat diet, diabetic diet. Followup precautions, in chair q.i.d., ambulate q.i.d. Physical therapy, occupational therapy consult. Turn q. 2 hours. Followup with Urologic Consultants _%#CITY#%_ office, Dr. _%#NAME#%_ or colleague for prostatism symptoms. BMP in 4 days, then q week times x4. Call MD if creatinine greater than 2. Blood pressure and pulse b.i.d. Call MD if systolic blood pressure greater than 150 x2 or systolic less than 100 x 1 or call for a pulse greater than 110 or pulse less than 60, q.i.d. Accu-Cheks, call MD if blood sugar greater than 300 or less than 70, followup with Dr. _%#NAME#%_ Cross Fairview Ridges Internal Medicine clinic 1 week following discharge.
BMP|basic metabolic profile|BMP|160|162|1. ID|We will guaiac her stools times three while here. We will recheck a hemoglobin tonight at 1800, and if it continues to drop consider transfusion. Check another BMP in the morning. She also has a history ITP which has a unknown cause normal the past. We will follower her platelet levels also as certain infections can cause decrease platelets overall.
BMP|basic metabolic profile|BMP|240|242|PHYSICAL EXAMINATION|Screening CBC and BMP are sent and pending. She had normal studies with her physical as well in _%#MM#%_ with the exception at that time of CBC showing a hemoglobin of 14.9, white count 9.6 and platelets were 457,000 slightly elevated. The BMP was totally normal. Potassium at that time was 3.7 and will recheck those studies today. ASSESSMENT: The patient has no known contraindications to proceeding with planned surgery.
BMP|basic metabolic profile|BMP|189|191|PHYSICAL EXAMINATION    VITAL SIGNS|Strength 5/5 in all extremities. Cranial nerves 2 through 12 grossly intact. LABORATORY DATA: White count was 7.6, hemoglobin 12.2, and platelets 417,000, 50% neutrophils, 36% lymphocytes. BMP was within normal limits. A chest x-ray was within normal limits. HOSPITAL COURSE: PROBLEM #1: Sickle cell crisis. He was treated with aggressive IV fluids, oxygen, and IV Demerol for pain control.
BMP|basic metabolic profile|BMP:|91|94|LABORATORY DATA|The left side was full at 5/5. Babinski's on the right foot was positive. LABORATORY DATA: BMP: Normal except for a blood glucose of 210. Liver function tests were within normal limits. WBC and differential were normal.
BMP|basic metabolic profile|BMP:|163|166|LAB  DATA|No femoral bruits noted on examination today. He did not have any cyanosis, clubbing or edema of his extremities. He was alert and oriented times three. LAB DATA: BMP: Sodium d134, potassium 5.2, chloride 101, C02 22, BUN 19, creatinine 1.5, BUN/creatinine ratio 13. Calcium 9.3, fasting blood sugar 97. IMPRESSION/PLAN: 1. Coronary artery disease.
BMP|basic metabolic profile|BMP.|104|107|DIAGNOSTIC TESTS|3. The patient will stop Plavix three days prior to surgery. DIAGNOSTIC TESTS: Hemoglobin, protime, and BMP. EKG will also be done today. Results will be faxed to the Same Day Surgery Center at Fairview Southdale Hospital.
BMP|beta-natriuretic peptide:BNP|BMP|157|159|LABORATORY DATA|Sodium 145, potassium 3.0, chloride 101, bicarb 28, BUN 32, creatinine 1.6, glucose 108, calcium 8.8. Negative for influenza A and B. INR 5.12 on admission. BMP was 72, troponin negative. IMAGING: Chest x-ray and chest CT as above. HOSPITAL COURSE: PROBLEM #1: Anemia. The patient reports chronic anemia, and she has received transfusions in the past.
BMP|basic metabolic profile|BMP|124|126|FOLLOW UP|He will be seen by Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2004, at 10:30 a.m. The patient was also advised to have a CBC with BMP Monday a.m. at Emanuel St. Joe's clinic every Monday, Wednesday, and Friday to start on _%#MM#%_ _%#DD#%_, 2004. He will have primary care followup with Dr. _%#NAME#%_ _%#NAME#%_.
BMP|basic metabolic profile|BMP|180|182|PERTINENT LABORATORY TESTS|Any other labs would be per the transplant team, and I will leave a message with them in regards to this. PERTINENT LABORATORY TESTS: 1. _%#MMDD2004#%_: Amylase 48, magnesium 1.4, BMP within normal limits, except chloride slightly elevated, at 111, creatinine 1.62, calcium 8.0, phosphorus 4.2. 2. _%#MMDD2004#%_: WBC 5.7, hemoglobin 10.4, platelet count 339,000. 3. _%#MMDD2004#%_: Lipase 67.
BMP|basic metabolic profile|BMP|238|240|PERTINENT LABORATORY TESTS|I did spend time chatting with her niece, _%#NAME#%_, today, in regards to discharge plans and follow-up cares. PERTINENT LABORATORY TESTS: 1. _%#MMDD2004#%_: Hemogram: WBC 7.4, hemoglobin 10.4, platelet count 344,000. 2. _%#MMDD2004#%_: BMP within normal limits, with chloride noted to be 110. BUN is 27, and creatinine is 1.04. 3. _%#MMDD2004#%_: INR 1.47. 4. _%#MMDD2004#%_: INR 1.60. 5. _%#MMDD2004#%_: INR pending. Will be drawn tomorrow morning.
BMP|basic metabolic profile|BMP|100|102|LABORATORY DATA|EXTREMITIES: No edema. SKIN: Unremarkable. NEUROLOGIC EXAM: Nonfocal. LABORATORY DATA: Lipase 1251. BMP is normal. CBC is normal, with a white count of 6.2, platelets of 223. Right upper quadrant ultrasound reveals a normal gallbladder, with fatty liver.
BMP|basic metabolic profile|BMP|158|160|DISCHARGE PLANS|The patient was transferred to the floor, also during the course of her hospital stay where she remained stable. DISCHARGE PLANS: 1. The patient is to have a BMP drawn on _%#MMDD2004#%_ at Smiley's Clinic. 2. The patient is then to follow up with me on _%#MMDD2004#%_ to ensure electrolytes are stable.
BMP|basic metabolic profile|BMP.|187|190|ASSESSMENT AND PLAN|At this time will check a hemoglobin A1c. He states that he has not had any sugar intake since midnight, which is approximately 6 hours now. We will revaluate what his glucoses is on his BMP. Will suspect some steroid-induced hyperglycemia. Follow Accu-Cheks 4 times daily. Clinically, he denies any history of polydipsia, polyphagia, or weight changes.
BMP|basic metabolic profile|BMP.|273|276|ASSESSMENT AND PLAN|I doubt MRSA. Failure with ceftriaxone probably was related to his being ambulatory at the time and also with weak staph or strep coverage with ceftriaxone. We will elevate the leg, gently hydrate the patient, obtain blood cultures, obtain admission labs including CBC and BMP. We will mark off the area of erythema with a black marker and follow closely. 2. Type 2 diabetes: We will hold his metformin and place him on insulin sliding scale with diabetic diet.
BMP|basic metabolic profile|BMP|158|160|LABORATORY DATA|ABDOMEN: Obese, soft, nontender with large ventral hernia. No lymphadenopathy palpated. LABORATORY DATA: White blood count 10, hemoglobin 12.6, platelets 83, BMP normal. Creatinine 0.77. EKG from outside facility shows normal sinus rhythm with rate of 81. Chest x-ray from outside facility showed clear chest. HOSPITAL COURSE: The patient was admitted on _%#MMDD2007#%_ at which point she underwent exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, open cholecystectomy and ventral hernia repair with porcine mesh.
BMP|basic metabolic profile|BMP|169|171|LABORATORY|Strength is equal in all extremities. No obvious swelling. LABORATORY: Blood work reviewed. White count of 15.4, hemoglobin 14.1. D-dimer is 0.3, platelets are 246,000. BMP is unremarkable. Troponin is 0.08.. EKG shows no acute changes. Chest x-ray shows compression fracture at T11 and no acute infiltrate.
BMP|basic metabolic profile|BMP|152|154|LABORATORY DATA|LYMPHORETICULAR: Negative for anterior/posterior cervical adenopathy. Negative for trochlear adenopathy. NECK: No JVP, no bruits. LABORATORY DATA: CBC, BMP and a CT scan: Official reports are pending. ASSESSMENT/PLAN: Probable partial small-bowel obstruction versus ileus versus ulcer. Will have to obtain the official report as well as the CT scan from Suburban Radiology.
BMP|basic metabolic profile|BMP,|247|250|PLAN|2. We will recheck right femur films as well as obtain a chest x-ray and a CT of the chest, abdomen and pelvis with and without contrast. 3. We will order appropriate labs for metastatic workup as well as preop clearance including a CBC, PT, INR, BMP, magnesium, phosphorus, CRP, ESR, serum protein electrophoresis and alkaline phosphatase. 4. We will keep the patient under adequate pain control with Buck's traction applied to the right lower extremity.
BMP|basic metabolic profile|BMP|218|220|PERTINENT LABS ON ADMISSION|Gait not observed. PERTINENT LABS ON ADMISSION: The patient's white count is 2.0 with an ANC of 700, hemoglobin 10, and platelets 15. The patient's ALT was elevated at 200, AST elevated at 240, otherwise the remaining BMP and pancreatic enzymes were unremarkable. HOSPITAL COURSE: 1. GI: The patient was started on IV fluids on admission.
BMP|basic metabolic profile|BMP|159|161|HOSPITAL COURSE|HOSPITAL COURSE: 1. FEN. The patient admitted and placed on IV fluids per chemo protocol. Received regular pediatric diet and strict Is and Os. Received daily BMP which was normal with consistent mild hypokalemia. 2. Renal. The patient remained on her daily dose of Lasix 20 mg daily. 3. Oncology. The patient was treated with chemotherapy per protocol CCG _%#PROTOCOL#%_, which included vincristine, methotrexate, cyclophosphamide, doxorubicin, methotrexate levels were measured daily until day of discharge.
BMP|basic metabolic profile|BMP,|113|116|ASSESSMENT/PLAN|This could possibly be due to ulcer disease. I will get a GI consult in the morning. The patient will have LFTs, BMP, and lipase checked. Further testing as follows based on the results of those tests. The patient will be placed on antiemetics as needed for her nausea.
BMP|basic metabolic profile|BMP|282|284|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: 56-year-old with diverticulitis evaluated by Dr. _%#NAME#%_ already who does not want to operate but wants to give him antibiotics and follow. Dr. _%#NAME#%_ thinks he probably perforated but might have already resealed. Will get blood cultures times two, CBC, BMP and INR and also start ampicillin, Cipro and Flagyl and do a serial abdominal exam and surgery will follow along.
BMP|bone morphogenetic protein|BMP|238|240|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|She has developed increasing back and buttock pain on the left, and a CT scan had noted an L5-S1 pseudoarthrosis. Because of the pain, the options were discussed, and she would like to go undergo an anterior spinal fusion with the use of BMP graft. HOSPITAL COURSE: Ms. _%#NAME#%_ was transferred to the general floor for her postoperative cares.
BMP|basic metabolic profile|BMP|263|265|PERTINENT LABORATORY TESTS|He does assures me he will make an appointment with Dr. _%#NAME#%_ within one week for follow-up, and that he will go to Dr. _%#NAME#%_'s office on Monday for a INR draw, so Dr. _%#NAME#%_ may regulate his Coumadin. PERTINENT LABORATORY TESTS: 1. _%#MMDD2003#%_, BMP within normal limits, of note though BUN is 47, creatinine is 1.7. 2. _%#MMDD2003#%_, INR 2.21, INR on _%#MMDD2003#%_ was 2.26. 3. _%#MMDD2003#%_, WBC 8.7, hemoglobin 10.4 (stable), platelet count 312,000.
BMP|bone morphogenetic protein|BMP.|165|168|HOSPITAL PROCEDURES|9. Status post amputation of toes on the left foot. 10. History of esophagitis. HOSPITAL PROCEDURES: _%#MMDD2003#%_, L4-S1 PLIF with instrumentation, bone graft and BMP. HOSPITAL COURSE: The patient was taken to the operating room on _%#MMDD2003#%_ for L4 to S1 posterior lumbar interbody fusion with bone graft, BMP, and instrumentation.
BMP|beta-natriuretic peptide:BNP|BMP|194|196|OBJECTIVE|SKIN without significant lesion. The chest x-ray shows some cephalization and some mild CHF changes. Electrolytes all within normal limits except for the BUN slightly up at 36, calcium 8.5. The BMP is up at 443. LFTs normal except for albumin low at 2.6. The CBC shows the white count slightly up at 12.2. Hemoglobin 12.1. Normal platelets.
BMP|basic metabolic profile|BMP|178|180|DISCHARGE FOLLOW-UP|DISCHARGE FOLLOW-UP: 1. The patient will follow-up with her primary care physician, Dr. _%#NAME#%_ _%#NAME#%_ at Fairview Oxboro Clinic in one to two weeks. Will check follow-up BMP and hemoglobin one week after discharge with results to Dr. _%#NAME#%_ for follow-up. 2. The patient will follow-up with Cardiology, Minnesota Heart Clinic, to be arranged by floor nurses at the time of discharge.
BMP|basic metabolic profile|BMP,|227|230|HISTORY OF PRESENT ILLNESS|She also noted her to be bleeding from her gums, and decided therefore to bring her to the Emergency Department. In the emergency room, her CBC was normal other than a hemoglobin of 10.0, which is stable from _%#MM#%_ of 2004, BMP, troponin were benign. The patient was unable to stand without assistance in the Emergency Department, and therefore is admitted for ongoing evaluation, treatment, and possible change in disposition ultimately.
BMP|basic metabolic profile|BMP|223|225|HISTORY OF PRESENT ILLNESS|Abdomen was soft, nontender, nondistended, positive bowel sounds. Neuro exam was within normal limits. No edema was noted. LABORATORY: Initial laboratory assessment included a CBC of 4.9, hemoglobin 15.9, platelets of 222. BMP with a sodium of 142, potassium 3.6, chloride 102, bicarbonate 25, BUN 14, creatinine 0.78. AST, ALT were within normal limits.
BMP|bone morphogenetic protein|BMP|222|224|SURGEON|This was treated in Texas with intramedullary nail fixation. She went on to develop an obvious nonunion at this site. After discussion with Dr. _%#NAME#%_ in his clinic, she decided to undergo repeat internal fixation and BMP application to her nonunion of the left humerus. HOSPITAL COURSE: The patient was admitted and taken to the operating room on _%#MM#%_ _%#DD#%_, 2004.
BMP|basic metabolic profile|BMP|197|199|LABORATORY & DIAGNOSTIC DATA|EXTREMITIES: No edema. LABORATORY & DIAGNOSTIC DATA: Electrocardiogram was read by the Emergency Room physician as showing sinus rhythm, I do not have a copy at the time of this dictation. CBC and BMP are normal. X-ray did show a fracture of the left lateral condyle. IMPRESSION: 1. Syncope. Certainly this is a dramatic syncope suggesting cardiogenic allergen.
BMP|basic metabolic profile|BMP|224|226|PLAN|ASSESSMENT: This is a 9-1/2-year-old male status post cardiac surgery on bypass with post pericardectomy syndrome. PLAN: 1. Fluids, electrolytes, and nutrition. The child will be allowed to p.o. a regular diet as tolerated. BMP was obtained and has been found to be normal. Further electrolytes will be checked as needed through this hospital stay with correction of any electrolyte abnormalities occurring as needed to maintain normal sinus rhythm.
BMP|basic metabolic profile|BMP|125|127|HISTORY OF PRESENT ILLNESS|The chest x-ray was positive for bilateral infiltrates. The creatinine was noted to be 1.6 and the BUN was normal at 17. The BMP is otherwise normal. The white count is elevated at 14,900 with 79% PMNs. The hemoglobin is 10.7 with a normal MCV of 84.
BMP|beta-natriuretic peptide:BNP|BMP|162|164|LABORATORY|He was not in any distress. He had decreased breath sounds diffusely, but no crackles or consolidation. LABORATORY: His laboratory results were normal save for a BMP of 806 and a hemoglobin reduced at 11.7. Troponins were negative. He was admitted for further workup and treatment.
BMP|basic metabolic profile|BMP|223|225|LABS|GENITAL AND RECTAL: Not done. EXTREMITIES: Some decreased skin turgor; non-tender calves; diminished pulses; degenerative joint changes; no edema. LABS: White count of 14,800, with a left shift. Hemoglobin 11.1. MCV is 93. BMP shows sodium of 129. The rest of her chemistry panel is actually normal. Chest x-ray shows infiltrates in all areas of the lung which are fairly faint.
BMP|basic metabolic profile|BMP,|132|135|PLAN|Protonix 40 mg once a day for stomach. Restoril for sleep. Check his potassium this evening and then begin tomorrow, check CBC, UA, BMP, amylase, and lipase and decide what medications will need him on.
BMP|basic metabolic profile|BMP,|248|251|DISCHARGE PLANS|2. The patient is also to follow-up with Dr. _%#NAME#%_ regarding her transplant on _%#MMDD2004#%_ at 9:30 a.m. 3. Fairview Home Health Care will come to the patient's home every Tuesday and Thursday at 8 a.m. for lab draws, which should include a BMP, phosphorus, magnesium, hepatic panel, and drug levels, which will be sent to the Transplant Center. 4. Further follow-up regarding her transplant will be coordinated by _%#NAME#%_ _%#NAME#%_ at the Transplant Center, at phone #_%#TEL#%_.
BMP|basic metabolic profile|BMP|166|168|DISCHARGE INSTRUCTIONS|9. INR therapeutic at discharge. 10. Hypertension. DISCHARGE INSTRUCTIONS: 1. Follow-up with Dr. _%#NAME#%_ in two weeks. The patient to come in fasting. Should have BMP checked at that time. 2. Follow-up with Dr. _%#NAME#%_ as per his office. 3. INR advised to be checked on _%#MMDD#%_ or _%#MMDD#%_ at _%#CITY#%_ Clinic.
BMP|beta-natriuretic peptide:BNP|BMP|184|186|ADMISSION LABORATORY DATA|Calcium 9.1. Creatinine 0.25. Magnesium 1.7. Phosphorus 2.6. VBG from peripheral site revealed 7.21 pH, pCO2 85, pO2 43, and oxygen saturation of 78%, and bicarbonate 33. CO2 noted on BMP was 36. RSV nasal washing and viral culture were negative. Urinalysis was remarkable for a ketones of greater than 80. Specific gravity 1.028. Protein 30. White blood count 4, red blood cells 4, nitrate and leukocyte esterase negative.
BMP|basic metabolic profile|BMP,|134|137|LABORATORY DATA|Peripheral nervous system was otherwise normal. LABORATORY DATA: White cell count was 11.1 with normal differential white cell count. BMP, sodium 140, potassium 3.9, chloride 108, CO2 23, BUN 18, creatinine 0.86. IMPRESSION: 1. Parasomnias. This patient has symptoms in keeping with parasomnia, possibly made worse recently with recent viral upper respiratory infection.
BMP|basic metabolic profile|BMP|217|219|LABORATORY DATA|EXTREMITIES: Normal other than some mild calf tenderness, which the patient notes as well trying to walk. EKG shows sinus rhythm. LABORATORY DATA: Chest x-ray was normal. CT scan of the head was within normal limits. BMP and CBC were normal. Myoglobin 2,000. Troponin less than 0.07. IMPRESSION: New onset of apparent seizure disorder, etiology unclear.
BMP|basic metabolic profile|BMP|193|195|PERTINENT LABORATORY TESTS|It is thought that this is possibly referred pain from the several surgeries and manipulations in her right neck, having to do with her VA shunt. PERTINENT LABORATORY TESTS: 1. _%#MMDD2004#%_: BMP within normal limits. 2. _%#MMDD2004#%_: Hemogram is within normal limits, though hemoglobin a little low, at 10.7. 3. MRI: Unremarkable. 4. Right shoulder x-ray: Normal.
BMP|basic metabolic profile|BMP:|135|138|HISTORY OF PRESENT ILLNESS|NEUROLOGIC: Within normal limits. LABORATORY: Initial labs demonstrated a WBC of 11.3, hemoglobin of 13.3, platelets of 225. INR 1.07. BMP: Sodium 137, potassium 3.8, chloride 109, bicarbonate 22, BUN 23, creatinine 1.23, glucose 92. EKG demonstrated right bundle branch block. HOSPITAL COURSE: 1. Three-vessel coronary artery disease without left main lesion: An echocardiogram was performed and demonstrated normal global LV systolic function with no regional wall motion abnormalities, but a technically difficult examination.
BMP|bone morphogenetic protein|BMP.|162|165|OPERATIONS/PROCEDURES PERFORMED|1. Removal of the plate and broken screws from right distal femur. 2. Open reduction, internal fixation of the right distal femur with a custom locking plate and BMP. HOSPITAL COURSE: The patient was admitted to a ward afterwards.
BMP|basic metabolic profile|BMP|227|229|PROBLEM #5|PROBLEM #4: History of diabetes mellitus type 2: We increased her dose of Actos with improvement in her blood sugars. We will continue to monitor. PROBLEM #5: Hypertension: We increased her dose of Captopril and will recheck a BMP in a week. PROBLEM #6: Recent cataract surgery. We will continue the eyedrops and discuss a follow-up plan with the surgeon.
BMP|basic metabolic profile|BMP|163|165|PERTINENT LABORATORY TESTS|PERTINENT LABORATORY TESTS: 1. _%#MMDD2005#%_, WBC 17.9, hemoglobin 10.1, platelet count 366,000. 2. _%#MMDD2005#%_, WBC 17.0, hemoglobin 10.3. 3. _%#MMDD2005#%_, BMP is normal, as is magnesium and phosphorus. IMPRESSION AND PLAN: 1. Status post Roux-en-Y gastric bypass reversal surgery _%#MMDD2005#%_.
BMP|basic metabolic profile|BMP|179|181|LABORATORY DATA|LABORATORY DATA: Sputum (_%#MMDD2005#%_) was negative. Troponin I (_%#MMDD2005#%_) was negative. On _%#MMDD2005#%_ ABGs were normal. WBC 7.8, hemoglobin 11.6, platelet count 106. BMP was normal. Magnesium and phosphorus were normal. CHEST X-RAY, _%#MMDD2005#%_: Revealed clear lungs with feeding tube in place.
BMP|basic metabolic profile|BMP,|248|251|REASON FOR HOSPITALIZATION|5. Sarcoidosis. 6. Hypertension. REASON FOR HOSPITALIZATION: Ms. _%#NAME#%_ is an 81-year-old woman with moderate dementia who was brought in by her husband for two days of weakness, fever and possibly dry cough. Workup in ER showed normal CBC and BMP, but chest x-ray showed possible lower lobe infiltrate. She also had a fever over 102 in the ER. She was admitted for management of pneumonia. She was started on ceftriaxone, quickly defervesced and fever did not return and her weakness significantly improved within 48 hours as well.
BMP|basic metabolic profile|BMP|204|206|DISCHARGE LABORATORY & DIAGNOSTIC DATA|EXTREMITIES: Resolving right leg cellulitis and right lower lobe organized hematoma. DISCHARGE LABORATORY & DIAGNOSTIC DATA: WBC count of 11.7 on _%#MMDD2006#%_, hemoglobin 13.1 and platelets of 187,000. BMP on _%#MMDD2006#%_ showed a sodium of 138, potassium 4.8, BUN 47, creatinine 2.17 and glucose of 67. The patient's BUN and serum creatinine and renal insufficiency were discussed with the patient.
BMP|beta-natriuretic peptide:BNP|BMP|189|191|LABORATORY DATA|INR 0.94. PTT 29. D-dimer 0.8. Sodium 142. Potassium 3.7. Chloride 104. CO2 27. Glucose 97. BUN 11. Creatinine 1.32. Calcium 9.8. T- bilirubin 0.5. AST 29. ALT 24. Alkaline phosphatase 59. BMP 10. Troponin less than 0.07. Total protein 9.1. Albumin 4.7. Electrocardiogram shows no change compared to _%#MMDD2006#%_. Normal sinus rhythm. Chest x-ray reveals no infiltrates, normal mediastinum.
BMP|basic metabolic profile|BMP|220|222|ASSESSMENT/PLAN|Will check sputum gram stain culture, blood cultures are pending, with possible allergic reaction IV levofloxacin. Will prescribe Benadryl p.r.n. and change to IV Zosyn therapy. Will provide supportive cares. Will check BMP for further antibiotic dosing to ensure creatinine is within normal limits. Will place on aspiration precautions, obtain speech and video swallowing for further evaluation for aspiration given her history of CVI.
BMP|basic metabolic profile|BMP|149|151|LABORATORY DATA|EXTREMITIES: No edema. Pulses present. LABORATORY DATA: Lactic acid 1.3. CBC shows hemoglobin 11.7, hematocrit 36.1, white count 7.4, platelets 268. BMP shows sodium 140, potassium 3.7, chloride 105, bicarb 27, BUN 10, creatinine 0.8, glucose 118. EKG result is pending. ASSESSMENT AND PLAN: Patient is to have surgery for incarcerated ventral hernia.
BMP|basic metabolic profile|BMP|173|175|DISCHARGE INSTRUCTIONS|4. Tequin 200 mg p.o. daily 5. Imdur 60 mg p.o. daily DISCHARGE INSTRUCTIONS: 1. Physical therapy and occupational therapy at rehabilitation to evaluate and treat. 2. Check BMP on Tuesday, _%#MMDD2004#%_. 3. Code status is DNR/DNI. PROCEDURES PERFORMED: Echocardiogram on _%#MMDD2004#%_ which showed an ejection fraction of 45%.
BMP|basic metabolic profile|BMP.|210|213|PHYSICAL EXAMINATION|EXTREMITIES: No edema present. Laboratory tests were done. EKG showed normal sinus rhythm. Chest x-ray showed borderline cardiomegaly. Otherwise, both lungs were clear. Preoperative labs done revealed a normal BMP. She did have an elevated BUN and creatinine, at 27 and 1.31, respectively. Her white blood cell count was 13.4. Her hemoglobin was 13.3. Her platelet count was 315.
BMP|basic metabolic profile|BMP,|222|225|FOLLOW UP|2. Patient has follow up with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2004, at 10:00 a.m. 3. Patient has follow up with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2004, at 10:30 a.m. Patient will also have a CBC with differential, BMP, liver function tests to be drawn on _%#MM#%_ _%#DD#%_, 2004, before his appointment with Dr. _%#NAME#%_. The patient will be taught how to use his 5-FU pump and will be managed by Fairview Home Infusions.
BMP|basic metabolic profile|BMP|153|155|FOLLOW-UP INSTRUCTIONS|5. K-Dur 8 mEq p.o. q.d. (new). FOLLOW-UP INSTRUCTIONS: 1. The patient should follow up with his primary physician, Dr. _%#NAME#%_, next week to check a BMP to assess his potassium, BUN, and creatinine. 2. Follow-up with Dr. _%#NAME#%_ to be arranged. 3. Follow up with me in one month.
BMP|basic metabolic profile|BMP,|243|246|PROBLEMS|3. Follow up in Oncology Clinic on _%#MM#%_ _%#DD#%_, 2005, at 2 p.m., for Avastin treatment, and also on _%#MM#%_ _%#DD#%_, 2005, with Dr. _%#NAME#%_. The patient will also have home health care to administer IV ciprofloxacin and draw a CBC, BMP, LFTs, and get a UA on _%#MM#%_ _%#DD#%_, 2005, for Oncology Clinic. DISCHARGE MEDICATIONS: 1. Bactrim 40 mg p.o. b.i.d. on Mondays and Tuesdays.
BMP|basic metabolic profile|BMP,|200|203|DISCHARGE INSTRUCTIONS|5. Home occupational therapy and physical therapy will be ordered as the patient remains weak. 6. The patient is to have labs done at Fairview Oxboro Clinic on _%#MMDD2005#%_ in the morning including BMP, magnesium and Dilantin levels. DISCHARGE MEDICATIONS: 1. Vicodin p.r.n. 2. Dilantin 300 mg b.i.d.
BMP|basic metabolic profile|BMP|190|192|IMPRESSION AND PLAN|IMPRESSION AND PLAN: A _%#1914#%_ man with the following: Hyponatremia, likely secondary to use of diuretics and recent UTI. We will rule out SIADH versus renal sodium loss. We will check a BMP now after the one done in the emergency room. Patient had been on 150 of normal saline from the emergency room. We will check a urine sodium and urine creatinine and urine osmolality, in addition to a serum osmolality.
BMP|basic metabolic profile|BMP|149|151|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1: Fluid, electrolytes, and nutrition: Initially, _%#NAME#%_ received a fluid flush and maintenance IV fluids. He also had BMP to monitor any changes. He was stable and gradually as his pain control was better he did take more orally prior to discharge.
BMP|beta-natriuretic peptide:BNP|BMP|183|185|STUDIES|QTc was somewhat prolonged at 0.495. Ischemic appearing changes. Blood alcohol level was 0.09. Chest x-ray was negative. Troponin was less than 0.07. Lipase was 56. LFTs were normal. BMP was 9. Electrolytes were normal. CBC was unremarkable. ASSESSMENT: 1. Atypical chest pain likely secondary to anxiety or possibly GERD.
BMP|basic metabolic profile|BMP|224|226|HOSPITAL COURSE|Alcohol intake: He states that he drinks socially and has never had a problem with alcohol or alcohol withdrawal. HOSPITAL COURSE: Patient was admitted to Telemetry and cardiac enzymes ruled out any cardiac injury. He had a BMP done which was normal. He had a cardiac echo performed on _%#MMDD#%_ which showed diastolic dysfunction and some mild aortic root enlargement.
BMP|bone marrow transplant:BMT|BMP|131|133|HOSPITAL COURSE|On the day of discharge, his white count was 3.9 and his hemoglobin 9.6 and platelet count 26 and he was instructed to followup in BMP clinic the following day for a possible platelet transfusion. 3. EPI and GI. _%#NAME#%_ maintained an adequate appetite during this hospitalization and was on a regular diet.
BMP|basic metabolic profile|BMP|254|256|PHYSICAL EXAMINATION  VITAL SIGNS|PHYSICAL EXAMINATION VITAL SIGNS: She was afebrile. Heart rate is in the 60s, blood pressure 118/57, respiratory rate 18 which is 100% on 2 liters. Her physical exam was otherwise unremarkable. Her white count is normal. She had a hemoglobin of 7.1. Her BMP showed a sodium of 129. Lactic acid is normal. Her BNP and troponin are normal. She was admitted to the floor with concerns of ischemic colitis.
BMP|basic metabolic profile|BMP|144|146|PLAN|PLAN: The patient will followup in CORE Clinic with Minnesota Heart in two weeks and see me in approximately 1 month. The patient should have a BMP checked at either clinic in one week. She will attempt to improve her low salt diet as mentioned above. DISCHARGE MEDICATIONS: 1. Calcium with vitamin D 600 mg b.i.d.
BMP|basic metabolic profile|BMP|122|124|LABORATORY|Lab tests show a troponin of 0.04. Blood cultures are pending. UA shows moderate LE, 3 WBCs. BNP is 186. Myoglobin is 45. BMP shows sodium 143, potassium 4.1, chloride 107, bicarb 26, BUN 48, creatinine 1.2, calcium level 8.2. CBC shows hemoglobin 11.6, hematocrit 35.8, white count 17.2, platelets 219.
BMP|basic metabolic profile|BMP|184|186|DISCHARGE PLAN|2. She should follow a low salt diet. 3. Daily weight measurement will be useful and if weight increases by more than three pounds, consideration of Lasix could be given. 4. Follow-up BMP in one week. Patient needs to follow up with her primary care physician in two to four weeks.
BMP|basic metabolic profile|BMP|276|278|LABORATORY RESULTS ON ADMISSION|EXTREMITIES: Without cyanosis or edema. NEUROLOGIC: Significant for decreased tone throughout, plus 1 to 2 beats of clonus bilaterally. LABORATORY RESULTS ON ADMISSION: White count 11.9, 65% neutrophils, 12% monocytes, 22% lymphocytes. Hemoglobin was 10.7, platelets 554,000. BMP was unremarkable. Rapid Influenza A and B, and RSV were obtained, which were negative. CRP was 5.8 mg/L. LFTS were obtained, which also demonstrated no abnormalities.
BMP|basic metabolic profile|BMP|89|91|LABORATORY|Pulse is present. His x-ray is reviewed. I do not see a definite infiltrate. LABORATORY: BMP shows sodium 134, potassium 4.2, chloride 103, bicarb 22, BUN 25, creatinine 0.7, glucose 98. CBC shows hemoglobin 8.6, hematocrit 26.9, white count 3.6, platelet 123, neutrophil is 67%.
BMP|basic metabolic profile|BMP|243|245|HOSPITAL COURSE|No murmur or gallop. Abdomen: Soft with no organomegaly and normal bowel sounds. Extremities: There was no pedal edema. On the day of admission on _%#MM#%_ _%#DD#%_, 2006, her white blood count was 3.4, hemoglobin 11.3, platelets 359, and her BMP was within normal limits with a creatinine of 0.48, BUN 4, potassium 3.5, and magnesium 1.7. So, she was given cisplatin with good hydration.
BMP|basic metabolic profile|BMP|171|173|HOSPITAL COURSE|EKG showed right bundle branch block with occasional atrial pacing and old inferior infarct. Troponins were negative x3. Chest x-ray was essentially unremarkable. CBC and BMP were unremarkable. His INR was 1.64. He was admitted to the telemetry unit. Serial troponins were unremarkable. Telemetry noted asymptomatic 6-beat run of ventricular tachycardia.
BMP|basic metabolic profile|BMP|344|346|SUMMARY OF HOSPITAL COURSE|The patient's initial dose of Lasix was 40 mg p.o. b.i.d., however, I noticed during the hospitalization his dose was decreased to 20 mg p.o. b.i.d. I agree with that because on labs today the patient's sodium is 147, which would indicate the patient is mildly volume depleted intravascularly. We will send him with a dose of 20 mg p.o. b.i.d. BMP should be checked by primary care physician in the next couple of days to follow the sodium. Once again, it is very important that the primary care physician follows the basic metabolic panel to recheck his sodium in the next couple of days and we will arrange for that.
BMP|basic metabolic profile|BMP|168|170|ADMISSION LABORATORY|ADMISSION LABORATORY: White cell was 8.6, hemoglobin 11.4 and platelets 237,000. Differential showed 85% neutrophils, 11% lymphocytes, 3% monocytes and 1% eosinophils. BMP was normal. CRP 25.3 mg per liter. Blood culture showed no growth after 2 days. HOSPITAL COURSE: 1. FEN: The patient was too nauseated to take p.o. intake at the time of admission.
BMP|basic metabolic profile|BMP|172|174|LABS|3. Atenolol. 4. Simvastatin. 5. Triamterene and hydrochlorothiazide. 6. Felodipine. 7. Calcium. 8. Vicodin. ALLERGIES: None. LABS: On day prior to discharge, the patient's BMP was as follows: Sodium 137, potassium 4.2, chloride 109, CO2 of 25, glucose 97, creatinine 1.56 and calcium 8.4. Her postoperative hemoglobin was 9.9.
BMP|basic metabolic profile|BMP:|197|200|LABS ON ADMISSION|Her cranial nerves were intact. She had diffuse decrease in tone and was able to move all extremities. LABS ON ADMISSION: White count 7.3, hemoglobin 18.5 and platelets 101,000. VBG 7.45-34-33-23. BMP: Sodium 141, potassium 4.5, chloride 108, bicarbonate 25, BUN 20, creatinine 0.44 and glucose 98. HOSPITAL COURSE: 1. Fluid, electrolytes and nutrition. _%#NAME#%_ only had a short history of loose stools and no history of emesis or feeding intolerance.
BMP|basic metabolic profile|BMP|221|223|IMPRESSION|Will get a sed trait and start him on Zosyn for now to cover both abdominal, respiratory or urinary etiology. Will get a UA and get blood cultures times two. 3. Ischemic cardiac myopathy with diastolic dysfunction. Get a BMP and do I's and O's and do daily weights. 4. Hypertension. Blood pressure okay. Continue the same medications for now.
BMP|basic metabolic profile|BMP|140|142|ADMISSION PHYSICAL EXAM|His initial laboratory data included a white count 19.4, 29% neutrophils, 54% lymphocytes, 17% monos. Hemoglobin 11, platelets 480,000. His BMP was normal with a bicarb of 23, glucose 105, blood culture was done. He was given I.V. fluids by bolus and admitted upstairs with I.V. fluids, albuterol nebs as needed, and slow p.o. intake as tolerated.
BMP|basic metabolic profile|BMP,|184|187|HISTORY OF PRESENT ILLNESS|He was given Zofran and Tylenol/ibuprofen for the temperature and a normal saline (02:02) 20 mL/kg flush. A full septic workup was initiated there which included a blood culture, CBC, BMP, UA, UC of catheter specimen as well as CSF analysis. As stated above, he was transferred to the University of Minnesota Children's Hospital for further evaluation and management.
BMP|basic metabolic profile|BMP|188|190|LABORATORY|PHYSICAL EXAMINATION: On admission, his vital signs were pulse of 63, temperature afebrile, blood pressure 126/72, respirations 18, and saturating 97% on room air. LABORATORY: His CBC and BMP were normal, and his troponins were negative x3. The patient was noticed to have some J-point elevations and diffuse ST segment elevations on his EKG, and therefore, the patient was taken to the catheterization lab straight from the ER.
BMP|basic metabolic profile|BMP,|214|217|HOSPITAL COURSE|The patient is to monitor his blood pressures regularly on an outpatient basis. He is to follow-up with his new primary MD at Park Nicollet _%#CITY#%_ Clinic next week to follow-up his blood pressures, to obtain a BMP, follow-up EKG and possibly an echocardiogram to evaluate for his cardiomegaly and LVH and rule out hypertensive cardiomyopathy. At this time, his blood pressure is adequately controlled. As to the etiology of his hypertension, this is likely essential hypertension, doubt secondary causes given his normal electrolytes, normal TSH, he had no abdominal bruits, however, secondary causes can be ruled out through his new primary MD if deemed necessary.
BMP|basic metabolic profile|BMP|234|236|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|With that her symptoms have improved roughly about 75%. Also I had long talks with the patient regarding her social stress. In my opinion, the patient suffers from a lot of social stress. She agrees to work on it. Her other lab work, BMP and CBC had been within normal limits relatively. Her UPEP was negative for monoclonal gammopathy. 2D echocardiogram did not show any major abnormality.
BMP|basic metabolic profile|BMP|172|174|ADMISSION LABS|He is missing his thumbs on each side. He has a papular rash on his forearm, and cranial nerves were intact. ADMISSION LABS: White count 6.7, hemoglobin 9.5, platelets 86. BMP was significant for a creatinine of 1.56. Amylase and lipase were normal. A UA had 30 protein, negative nitrites and leukocyte esterase, 4 white blood cells, positive hyaline casts present, mucus.
BMP|basic metabolic profile|BMP|245|247|HOSPITAL COURSE|Enalapril and Lasix were held during her hospitalization and she was gently hydrated and her creatinine improved from 1.7-1.2. Sher had good urine output. She will restart her Lasix and an ACE inhibitor in one day following discharge. Follow-up BMP with primary MD at time in 1 week. DISCHARGE MEDICATIONS: 1. Prednisone 50 mg daily. 2. Toprol-XL 50 mg at bedtime.
BMP|basic metabolic profile|BMP.|160|163|PLAN|We will rehydrate with IVs, hold his tube feeding. Culture stool, especially for C. diff. Continue his present medications except for glipizide. Follow WBC and BMP. Add Lasix for modestly elevated BNP. At this point will use azithromycin and Zosyn for possible aspiration pneumonia but will try to discontinue that as soon as possible.
BMP|basic metabolic profile|BMP|192|194|PROCEDURES|2. Klippel-Trenaunay-Weber syndrome. 3. Asthma. 4. Lymphangioma. 5. Herpes simplex infection. DISCHARGE DIAGNOSIS: Cellulitis on the left leg. CONSULTS: None. PROCEDURES: The patient had CBC, BMP and histopathology, ESR, CRP during this admission. HISTORY OF PRESENT ILLNESS: The patient is 27-year-old female with a history of Klippel-Trenaunay-Weber syndrome and history of multiple leg cellulitis in the past.
BMP|basic metabolic profile|BMP|150|152|LABS ON ADMISSION|From _%#MM#%_ _%#DD#%_, 2002, the patient's white count is 2.0. Hemoglobin 9.2. platelets 468. ANC of 1480. On clinic day of admission, the patient's BMP reveals the sodium is 139. Potassium 4.0. Chloride 107. Bicarb is 23. BUN is 10. Creatinine is 0.3. Glucose is 92. ALT is 44. AST is 47.
BMP|basic metabolic profile|BMP|119|121|DISCHARGE FOLLOW-UP|She will need staple removal at that time. 4. Follow up with Dr. _%#NAME#%_ in 7-14 days. 5. CBC with diff, platelets, BMP on _%#MMDD2007#%_ with results to Dr. _%#NAME#%_. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 72-year-old female who presented to the Fairview Southdale Emergency Department with complaints of left lower extremity pain and swelling on _%#MMDD2007#%_.
BMP|basic metabolic profile|BMP.|161|164|LABORATORY STUDIES|He also had virtually no sense of balance or sense of placement of his legs. LABORATORY STUDIES: Notable for a white count of 10,000, hemoglobin of 14.1, normal BMP. HOSPITAL COURSE: He was admitted for what appeared to be acute onset neuropathy.
BMP|bone morphogenetic protein|BMP|189|191|PROCEDURES|3. Status post previous L4-5 and L5-S1 total laminectomy with ongoing right leg radiculopathy. PROCEDURES: 1. Anterior spinal effusion L3-L4, L4-L5, L5-S1 with ALIF Synthes bone grafts and BMP with complete diskectomy at L3-L4, L4-L5, L5-S1. 2. Posterior spinal fusion L3 to the sacrum with TSRH 3D instrumentation, revision decompression right L4-L5, and right iliac crest bone graft.
BMP|basic metabolic profile|BMP|211|213|DISCHARGE INFO|3. Followup appointment with Dr. _%#NAME#%_ with Infectious Diseases on _%#MMDD2007#%_ at 10 o'clock am. 4. Appointment with Dr. _%#NAME#%_, the patient's primary MD on the week after discharge. At that time, a BMP and a CBC should be checked. 5. A followup appointment with Dr. _%#NAME#%_ in Orthopedics in _%#MM#%_. 6. An MRI of the spine with and without contrast should be completed at the University of Minnesota on _%#MMDD2007#%_ at 1 o'clock pm.
BMP|basic metabolic profile|BMP|120|122|DISCHARGE DISPOSITION|2. The patient will follow up with the CORE clinic sometime in the next 2 weeks. 3. We will be on a low salt diet. 4. A BMP should be performed in the next 2 weeks. 5. A fasting lipid profile should be performed in the next 4-6 weeks as well.
BMP|basic metabolic profile|BMP|198|200|LABORATORY DATA|Soft, nontender, and nondistended. NEUROLOGIC: Alert and oriented. Nonfocal. SKIN: No rash. LABORATORY DATA: On admission, white blood count 6.7, hemoglobin 12.1, and platelets 387,000. ANC is 3.3. BMP is within normal limits. UA is without protein and glucose, negative nitrite and leukocyte esterase, four white cells, three red cells, few calcium oxalate crystals.
BMP|basic metabolic profile|BMP|251|253|ASSESSMENT AND PLAN|SKIN: Showed some psoriatic lesions. ASSESSMENT AND PLAN: On admission, a 59-year-old female with a left inguinal hernia without signs of incarceration/strangulation was admitted to the General Vascular Service under Dr. _%#NAME#%_ and underwent CBC, BMP and UA. HOSPITAL COURSE: The patient was noted to have a UTI and started on Levaquin, dose 250 mg p.o. daily.
BMP|basic metabolic profile|BMP|183|185|IMPRESSION AND PLAN|We will start the patient on broad antibiotics including Zosyn and vancomycin. We will consult infection disease. We will order Gram stain and culture. We will check a CBC as well as BMP and Sed rate. We will keep patient n.p.o. after midnight for anticipated surgery in the morning. I did discuss this with Dr. _%#NAME#%_.
BMP|basic metabolic profile|BMP|163|165|HOSPITAL COURSE|He did have one episode of nocturnal anuresis. To avoid this, due to his high volume of intravenous fluids, he was woken up every 2 hours at night to urinate. His BMP including creatinine remained normal. 2. Ewing sarcoma: _%#NAME#%_ received chemotherapy with etoposide and ifosfamide and mesna. His CBC was checked prior to discharge with white count of 2.3, ANC of 1.8, hemoglobin of 9.8 and platelets of 172.
BMP|basic metabolic profile|BMP|210|212|DISCHARGE FOLLOWUP|11. Oxycodone 5-10 mg p.o. q.4 hours p.r.n. pain. 12. Zofran 8 mg p.o. q.6-8 hours p.r.n. DISCHARGE FOLLOWUP: 1. The patient has an appointment in the Oncology Clinic on _%#MMDD2007#%_ for CBC diff, platelets, BMP and that day he will receive vincristine at 11 a.m. 2. The patient should continue to receive assessments Mondays and Thursdays.
BMP|basic metabolic profile|BMP|123|125|PLAN|FENa is pending and UA is pending. This does appear to be a new issue because he had a creatinine of 1.03 in _%#MM#%_. The BMP overnight was stable. We recommend on rechecking this in 1 to 2 days and will follow up with the FENa and the urinalysis.
BMP|basic metabolic profile|BMP,|126|129|DISCHARGE INSTRUCTIONS|5. He should return to Oncology Clinic on _%#MMDD2002#%_ to see Dr. _%#NAME#%_. He should have a CBC with diff and platelets, BMP, magnesium, phosphorus, UA and LFTs done at this time. 6. He is tentatively scheduled for readmission on _%#MMDD2002#%_ for chemotherapy per protocol CCG _%#PROTOCOL#%_, cycle 4.
BMP|basic metabolic profile|BMP,|284|287|DISCHARGE PLANS|2 Diabetes mellitus type 2: Hemoglobin A1C was 8.4. She is currently taking Glucotrol. Control her diabetes can be assessed as an outpatient. 3 Hypothyroidism - last TSH was 0.25, we decreased her Synthroid from 200 micrograms p.o. q.d. to 150 mcg p.o. q.d. - recommend checking TSH, BMP, and CBC in four weeks. The patient was seen and examined and discussed with Dr. _%#NAME#%_.
BMP|basic metabolic profile|BMP.|118|121|ASSESSMENT/PLAN|We will treat her with ampicillin sulbactam 3 g IV q.6h. and monitor. We will check a CBC in the morning as well as a BMP. If this continues to improve, we will consider treatment with antibiotics only. If it worsens or is slightly improved, we will consider orthopedic surgery consult.
BMP|basic metabolic profile|BMP:|153|156|HOME MEDICATIONS|Neurologic Exam: Normal. LABORATORY: CBC: WBC 14.9, H and H 10.6 and 32.8, platelets 287,000. Neutrophils 42%, lymphocytes 36, and monocytes 15. MCV 71. BMP: Sodium and potassium 139/5.9, chloride and bicarb 107/27. BUN and creatinine 5/0.6. Glucose 78. AST 13, ALT 51, and albumin 3.8. Total protein and bilirubin were normal.
BMP|basic metabolic profile|BMP|207|209|DISCHARGE MEDICATIONS|17. Robitussin AS one teaspoon p.o. b.i.d. prn. 18. Regular insulin sliding scale. The patient will have a follow-up appointment with Dr. _%#NAME#%_ _%#NAME#%_ her primary MD on _%#MMDD2002#%_ at 11:30 a.m. BMP will be obtained in seven days on this patient with results faxed to Dr. _%#NAME#%_ at _%#TEL#%_. Greater than 30 minutes were spent coordinating patient's discharge on today's date.
BMP|basic metabolic profile|BMP,|158|161|PLAN|PLAN: 1. Admit to medical ward. 2. Increase oral Lasix diuresis. Lower extremity elevation. Thigh high Ted hose. 3. Consider Jobst compression. 4. Check CBC, BMP, and INR. 5. Close monitoring of electrolytes, BUN, and creatinine on increased Lasix. 6. Continue other medications as at home. 7. Review disposition options with Dr. _%#NAME#%_.
BMP|basic metabolic profile|BMP|263|265|PHYSICAL EXAMINATION|NEURO: Non-focal. The patient is frankly tremulous however. Electrocardiogram reveals a sinus tachycardia with no acute STT wave changes, ventricular rate of 115 beats per minute. CT of the abdomen is currently pending. Blood alcohol level is 0.24, lipase is 59, BMP reveals a sodium of 138, potassium of 3.3, glucose of 95, chloride of 95, bicarb of 22, BUN of 7, creatinine of 1.0, anion gap of 22, albumin is 4.6, alkaline phosphatase 140, AST 87, ALT 48, INR is 1.1, PTT is 26, hemoglobin is 15, hematocrit 44.8, white blood cell count is 6.3, platelet count is 145, 81% neutrophils.
BMP|beta-natriuretic peptide:BNP|BMP|153|155|LABORATORY DATA|INR 3.11. Troponin less than 0.07. Sodium is mildly decreased, at 132; potassium is normal, at 4.2; BUN is elevated, at 46; elevated creatinine, at 1.8. BMP elevated at 451. LFTs within normal limits. Magnesium and calcium are both normal, at 2.2 and 9.5, respectively. EKG shows a paced rhythm. Chest x-ray is remarkable for cardiomegaly, but otherwise there are no acute processes.
BMP|basic metabolic profile|BMP|171|173|ASSESSMENT|1. Hypercalcemia with normal albumin and abnormal protein electrophoresis. Suspicious for malignancy like melanoma. Will recheck calcium as well as ionized calcium. Check BMP for renal function. Recheck serum and urine protein electrophoresis; if normal, recommend bone marrow biopsy. Check an EKG. Check lumbar spine and chest x-ray. Hydrate patient with normal saline.
BMP|basic metabolic profile|BMP:|156|159|RECENT LABORATORY TESTS|CONSULTANTS: 1. Dr. _%#NAME#%_, Therapeutic Radiology.. 2. Dr. _%#NAME#%_, ENT. 3. Dr. _%#NAME#%_, Dermatology. RECENT LABORATORY TESTS: 1. _%#MMDD2002#%_, BMP: within normal limits. However, BUN has been climbing and was 69, creatinine 1.3, magnesium 2.2, phosphorus 3.4, albumin 2.8.
BMP|basic metabolic profile|BMP|111|113|ADMISSION LABORATORY DATA|Neuro was grossly intact with no focal abnormalities. ADMISSION LABORATORY DATA: CBC was within normal limits. BMP was significant for hypokalemia at 2.7 and slightly high glucose at 136. C. diff culture, toxin, and stool culture were pending at the time of admission.
BMP|beta-natriuretic peptide:BNP|BMP|183|185|OBJECTIVE|However, she does respond to simple commands. Sodium 144, potassium 3.5, chloride 102, bicarb 27, BUN 19, creatinine 1.1, glucose 158, white count 17.6, hemoglobin 14.2, glucose 403, BMP 99, D-dimer negative (from outside hospital). Troponin negative. ABG shows a pH of 7.43, pO2 of 91, and a pCO2 of 40. HOSPITAL COURSE: The patient was admitted to the MICU intubated and on dopamine.
BMP|basic metabolic profile|BMP|210|212|DISCHARGE FOLLOW-UP/INSTRUCTIONS|1. She will be followed up at Minnesota Heart Clinic, also when her INR is 2 needs her catheter removed at Interventional Radiology. 2. She will have daily INRs called to her primary care physician, and a CBC, BMP within a week. ADDENDUM: The patient has been able to obtain a bed at St. Gertrude's in _%#CITY#%_.
BMP|basic metabolic profile|BMP|167|169|PLAN|8. DuoNebs on a p.r.n. basis. PLAN: She will have following of her INR in the nursing. We will check hemoccults x3 which were not obtained during her hospitalization. BMP and hemoglobin in three days time. Chest x-ray in two weeks for follow-up of her CHF and pneumonia.
BMP|beta-natriuretic peptide:BNP|BMP|164|166|LABORATORY DATA|His lungs are clear. He does have 2+ lower extremity edema bilaterally. LABORATORY DATA: His hemoglobin is 8.8. His troponin is 0.25, and is trending downward. His BMP is 1610. His EKG shows many PVC's, and inferior wall, II, III, and AVF T-wave changes. HOSPITAL COURSE: Cardiac. The patient was admitted to telemetry. He essentially had a positive troponin, with a peak at 0.25, which was trending downward.
BMP|basic metabolic profile|BMP|69|71|HOSPITAL COURSE|A urinalysis was sent prior to his discharge. On _%#MMDD2004#%_, his BMP had a potassium of 5.4, chloride 110, bicarbonate 16, BUN 44, creatinine 2.11. On _%#MMDD2004#%_, his sodium was 134, potassium 5.9. ADDENDUM: The patient was started on sodium bicarbonate secondary to him being somewhat metabolically acidotic, as well as with the high potassium.
BMP|beta-natriuretic peptide:BNP|BMP|164|166|LABORATORY DATA|No organomegaly. LABORATORY DATA: Chest x-ray was reviewed by myself showing interstitial prominence but no other abnormality that I can detect. CBC and BMP noted. BMP normal at 45. Electrocardiogram shows sinus tachycardia with J-point elevation that compared with 92 does not appear to be new.
BMP|basic metabolic profile|BMP,|141|144|LABORATORY|LABORATORY: Laboratory data from _%#MMDD2004#%_ at an outside hospital shows white blood cell count of 13.3, hemoglobin 11.3, platelets 355. BMP, sodium 136, potassium 3.9, chloride 104, bicarbonate of 29, BUN 14, creatinine 0.9, with a glucose of 93. ASSESSMENT/PLAN: This is a 24-year-old man, status post gunshot wound to the left chest.
BMP|beta-natriuretic peptide:BNP|BMP|248|250|LABORATORY DATA|His postoperative course was complicated by intermittent fevers and some mild wound dehiscence and inflammation and was treated with opening it up and packing and antibiotics. LABORATORY DATA: Potassium dropped to 3.2. Glucose ranged from 130-198. BMP elevated at 645. Chest x-ray showed small effusions bilaterally, otherwise normal. White count 15,600. Hemoglobin 9.4. OPERATIVE REPORT: He had segmental resection of the ascending colon.
BMP|basic metabolic profile|BMP:|151|154|PERTINENT LABORATORY TESTS|PERTINENT LABORATORY TESTS: 1. _%#MMDD2004#%_, ESR 11(was 26). 2. _%#MMDD2004#%_, WBC 9.2, hemoglobin 11.6, platelet count 311,000. 3. _%#MMDD2004#%_, BMP: Sodium 138, potassium 3.2 (she is having this replaced), chloride 92, CO2 32, BUN 20, creatinine 1.25 and glucose 88.
BMP|basic metabolic profile|BMP|84|86|HOSPITAL COURSE|12) DuoNebs t.i.d. 13) Toprol XL 75 mg daily. 14) Coumadin 1 mg daily. He will have BMP and INR checked on _%#MMDD2005#%_.
BMP|basic metabolic profile|BMP|161|163|HISTORY OF PRESENT ILLNESS|She never had any pain like this in the past. In the ER, the white count was 13,500. The PMNs were 73 percent. The hemoglobin was just slightly low at 11.2. The BMP was normal. The lipase, however, was noted to be 2336. Liver function tests were normal, however. CT of the abdomen shows diffuse colitis. Some stranding in the pancreas.
BMP|basic metabolic profile|BMP|197|199|PLAN|PLAN: Pre-op for upcoming angiogram: I have told her to hold her aspirin and nonsteroidal anti-inflammatory and I will fax over a copy of the EKG and the CBC, along with her recent cholesterol and BMP to the pre-op area prior to her angiogram. I did draw an INR and a PTT today, and I will fax those over to the Fairview Southdale Hospital pre-op area prior to her surgery as well.
BMP|basic metabolic profile|BMP|149|151|LABORATORY AND DIAGNOSTICS|EXTREMITIES normal. SKIN warm and dry, no rash. LABORATORY AND DIAGNOSTICS: CBC was ordered and was within normal limits with a normal differential. BMP was also within normal limits. The D-dimer was than 0.2. Urinalysis was negative. A pelvic ultrasound with transvaginal probe was obtained. There was a 3.5 cm complex cyst in the left ovary, likely a hemorrhagic cyst with a small amount of free fluid in the pelvis.
BMP|basic metabolic profile|BMP|260|262|PERTINENT LABORATORY TESTS|PERTINENT LABORATORY TESTS: 1. _%#MMDD2005#%_, potassium 3.8. 2. _%#MMDD2005#%_, WBC 3.4, hemoglobin 11.1, platelet count 47,000. 3. _%#MMDD2005#%_, total bilirubin 2.4, alkaline phosphatase 132, ALT 15, AST 31. 4. _%#MMDD2005#%_, INR 1.72. 5. _%#MMDD2005#%_, BMP was normal, except chloride slightly elevated at 112, creatinine 0.81. 6. _%#MMDD2005#%_, hemoglobin 7.5 for which she received her most recent transfusion of blood.
BMP|beta-natriuretic peptide:BNP|BMP|187|189|HISTORY|Albumin normal at 3.9. Review of the old chart reveals normal liver function tests in _%#MM#%_ of 2004. Lipase normal at 78, troponin I undetectable. Myoglobin modestly increased at 465. BMP elevated at 1500. INR elevated at 4.72. EKG shows atrial fibrillation with no acute findings prior to the arrest. Subsequent EKG is pending. PAST MEDICAL HISTORY: Also pertinent for chronic atrial fibrillation mentioned above.
BMP|basic metabolic profile|BMP|202|204|PLAN|Relatively well compensated. DISCUSSION: The patient has no complaints or findings on exam to contraindicate proceeding with surgery as planned. PLAN: 1. Surgery as scheduled. 2. Recheck hemoglobin and BMP (Crohn's disease and diarrhea). 3. UA/UC. 4. The patient will attempt to move up the appointment with GI regarding Crohn's disease.
BMP|basic metabolic profile|BMP|249|251|HISTORY OF PRESENT ILLNESS|She remained anemic with a hemoglobin of 8.8. On the day of discharge, her BUN was 121, creatinine 4.2. The patient would hoped to be transferred to Martin Luther Manor on _%#MMDD2005#%_ or _%#MMDD2005#%_. We will want to check her electrolytes and BMP in three days post discharge. She should probably follow-up with her nephrologist again in a couple of weeks. She also apparently has an arranged appointment with a vascular surgeon for assessing vascular access for her dialysis which her nephrologist will be needed in the near future.
BMP|basic metabolic profile|BMP|137|139|LABORATORY DATA|EXTREMITIES: Good peripheral pulses. No edema. NEUROLOGIC: Grossly intact. LABORATORY DATA: INR 1.22. Hemoglobin 13.4, white count 10.5. BMP is normal. Platelet 287,000. ASSESSMENT AND PLAN: 1. Increasing low back pain related to her chronic degenerative disk disease for which she is scheduled for an epidural tomorrow by Dr. _%#NAME#%_.
BMP|basic metabolic profile|BMP,|130|133|FOLLOW UP|10. Coreg 50 mg p.o. b.i.d. 11. Lasix 40 mg daily. FOLLOW UP: Follow up with Dr. _%#NAME#%_, primary, with an INR check, BNP, and BMP, Dr. _%#NAME#%_, and Dr. (_______________). As mentioned above, home care has been arranged.
BMP|basic metabolic profile|BMP:|225|228|DISCHARGE LABS|A UA did show hematuria. His fever did subside and he is to continue the Levaquin to complete a course of five days. DISCHARGE LABS: INR 1.2. CBC shows hemoglobin of 13.9, hematocrit 43.1, white count 7.4, platelets 151,000. BMP: Sodium 139, potassium 4.3, chloride 99, bicarb 30, BUN 15, creatinine 1.4, glucose 142. DISCHARGE MEDICATIONS: 1. Lovenox 95 mg subcu q 12 hours.
BMP|basic metabolic profile|BMP|155|157|DISCHARGE PLAN|Again, his INR on discharge was 2.28. The plan was to continue Coumadin therapy for one more month. 3. Hypertension. As noted above, lisinopril was added. BMP was within normal limits when discharged. He will followup on his hypertension with his primary, accordingly. 4. Diabetes. Presently diet controlled, with hemoglobin A1c in the goal.
BMP|basic metabolic profile|BMP,|128|131|DISCHARGE MEDICATIONS|5. Pregabalin 50 mg p.o. b.i.d. for neuropathy. Follow up with Dr. _%#NAME#%_, Park Nicollet _%#CITY#%_ Clinic next week with a BMP, CBC and liver panel. Follow up with Fairview _%#CITY#%_ Pain Clinic at next available appointment. Follow up with Dr. _%#NAME#%_ _%#NAME#%_ in Orthopedic Consultants in approximately 10 days.
BMP|basic metabolic profile|BMP|198|200|LABORATORY DATA|NEUROLOGIC: Examination is not performed in any detail in view of the patient's sedation and recent agitation. LABORATORY DATA: Hemoglobin 12.8, white count 9500, BMP on admission was unremarkable, BMP upon repeat this morning was again unremarkable with a creatinine of 0.7, potassium was 3.5. An EKG was not attempted. ASSESSMENT: 1. Traumatic hematuria in a patient with bladder atony who has a chronic indwelling Foley cathter.
BMP|basic metabolic profile|BMP|139|141|DISCHARGE PLAN|Imaging done in the hospital included an abdominal x-ray which was negative. DISCHARGE PLAN: Follow up in the clinic in two days to have a BMP done. DISCHARGE MEDICATIONS: 1. KCL 20 mEq p.o. daily. 2. Colchicine 0.6 mg p.o. b.i.d.
BMP|basic metabolic profile|BMP|109|111|HISTORY OF PRESENT ILLNESS|He was brought to the health nurse and was referred to the emergency room. His workup there included CBC and BMP that were within normal limits. The thyroid was normal.. The D-dimer was slightly elevated. CT of his lungs was negative for pulmonary emboli.
BMP|basic metabolic profile|BMP|126|128|DISCHARGE MEDICATIONS|6. Amiodarone 400 mg b.i.d. through _%#MMDD2005#%_ and then 200 mg b.i.d. thereafter. He will have INR checks in a week, CBC, BMP and PT OT and speech therapies.
BMP|basic metabolic profile|BMP|153|155|LABORATORY|No egophony or whispered pectoriloquy. No dullness to percussion. LABORATORY: Her initial white cells 13.6 with 73% neutrophils and 22% lymphocytes. Her BMP was normal. Her chest x-ray as above showed improvement on ground-glass hazy opacities. She was admitted again under the Medicine Service with Pulmonary followup.
BMP|basic metabolic profile|BMP|261|263|DISCHARGE INSTRUCTIONS|The patient did have some blood loss anemia, with a hemoglobin of 9.6 on the day of discharge, which will be followed at FUTS. DISCHARGE INSTRUCTIONS: The patient will be transferred to Fairview-University Transitional Services and have followup hemoglobin and BMP in 2 days. The patient will follow up with Dr. _%#NAME#%_ as suggested by Orthopedics.
BMP|basic metabolic profile|BMP|158|160|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: 1. Bacitracin and gauze to paracentesis sites. 2. Accu-Cheks q.i.d. with sliding scale coverage t.i.d. before meals. 3. Check CBC and BMP on Monday, _%#MM#%_ _%#DD#%_, 2006. 4. PT and OT to evaluate and treat per rehab protocol. DIET: Moderate consistent carbohydrate diet in 6 small meals. CODE STATUS: DNR and DNI.
BMP|basic metabolic profile|BMP|172|174|LABORATORY DATA|LABORATORY DATA: CBC in 2 days. B12 and folate level in 2 days. INR in 2 days, then daily thereafter. We will call results to MD. Oxygen 2 liters nasal cannula continuous. BMP in 2 days, then every week, call to MD DIET: Low fat, dysphagia level II, nectar-thick liquids.
BMP|basic metabolic profile|BMP|294|296|LABORATORY DATA|EXTREMITIES: 1 plus edema with palpable pulses. NEUROLOGIC: Nonfocal. LABORATORY DATA: UA 5 ketones, moderate blood, large LE, 100 protein, greater than 182 white blood cells, 160 red cells, positive transitional cells, and renal tubular cells. CBC white count 8.2, hemoglobin 10.4, MCV of 88, BMP notable for a BUN of 24, creatinine 1.35. LFTs including albumin are normal. Chest x-ray showed bilateral effusions per the emergency room. BNP is stable at 162.
BMP|basic metabolic profile|BMP|196|198|LABORATORY DATA|LUNGS: Good air entry, clear to auscultation. ABDOMEN: Soft, nontender, no organomegaly, bowel sounds present. EXTREMITIES: No edema, pulses present. LABORATORY DATA: Amylase is 67, lipase is 44. BMP is normal apart from creatinine of 1.6. His CBC is normal. ASSESSMENT AND PLAN: 1. Partial small bowel obstruction. Keep him n.p.o., IV hydration.
BMP|basic metabolic profile|BMP.|187|190|PLAN|She does not have all classic findings of an appendicitis, but I think that is probably what this is unless this is a kidney stone, will get a urine and check. PLAN: Admitted, will get a BMP. Start IV fluids, n.p.o., ask the surgeons to see her. We will use some MS for pain.
BMP|basic metabolic profile|BMP|145|147|HISTORY OF PRESENT ILLNESS|Her last IV IG treatment was _%#MM2006#%_. The patient was admitted for further evaluation and management. CBC: WBC showed 6.2, hemoglobin 10.9, BMP was normal. Chest x-ray showed a small retrocardiac infiltrate. The patient said that she has recently been treated for pneumonia with Augmentin by Dr. _%#NAME#%_ and still had some amount of cough.
BMP|basic metabolic profile|BMP|191|193|HOSPITAL COURSE|The creatinine has risen slightly from the _%#DD#%_ of _%#MM#%_, but still is within the normal range. As I said, his due to have a BMP checked tomorrow by the primary care physician. If the BMP is normal, or around that level, then the Glucovance can be restarted at the previous dose.
BMP|basic metabolic profile|BMP|139|141|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: 1. Home care does see for nursing, speech evaluation, physical, and occupational therapy. 2. Home care will draw a BMP this week. 3. Follow up with Dr. _%#NAME#%_ in 2 weeks soon if there any other problems. DISCHARGE MEDICATIONS: 1. Acyclovir 800 mg p.o. 5 times a day, x7 days.
BMP|basic metabolic profile|BMP,|98|101|HEALTH LABS|She was continued on a magnesium sulphate at 2 g an hour. HEALTH LABS: Including a CBC, LFTs, and BMP, were repeated and within normal limits. PLAN: The patient's plan was for induction of labor after 24 hours after second dose of betamethasone.
BMP|basic metabolic profile|BMP,|205|208|LABORATORY|Romberg testing was negative. CEREBELLAR TESTING: Finger-to-nose and heel-to-shin were unremarkable. Gait appeared to be normal. LABORATORY: Laboratory studies on the day of admission showed a normal CBC, BMP, TSH, and UA and LFTs. Head CT was consistent with right putaminal hypodensity. HOSPITAL COURSE: The patient was admitted to the telemetry service with no complications.
BMP|basic metabolic profile|BMP|193|195|LABORATORY DATA|LABORATORY DATA: EKG demonstrates normal sinus rhythm without ischemic changes. D-dimer is low at 0.2. Chest x-ray is pending at this time. Troponin. #1 is less than 0.04, troponin #2 is 0.04. BMP is normal. Hemoglobin is somewhat depressed at 11.3 though with a normal MCV, white blood cell count is 5.9.
BMP|basic metabolic profile|BMP|212|214|LABORATORY DATA|LABORATORY DATA: Serum ketones are positive. Urinalysis, specific gravity 1.016, glucose greater than 1000, positive ketones, negative nitrites and leukocyte esterase with 2 WBC and 1 RBC per high-powered field. BMP significant for a sodium of 139, potassium 4.7, chloride 95, bicarbonate 24, creatinine 1.36 with BUN 24, glucose elevated at 371.
BMP|basic metabolic profile|BMP|212|214|INPATIENT ATTENDING|Lungs clear. Abdomen soft nontender, nondistended, normal bowel sounds. No organomegaly. Skin without lesions. Lymphatics unremarkable. ADMISSION LABS: White count 7.5, hemoglobin 13.4, platelets 287, and normal BMP with BUN 8 and creatinine 0.47. There was normal calcium, phosphorus, and albumin. INR 1.09, PTT 32. HOSPITAL COURSE: She underwent sedated renal biopsy overseen by the Pediatric ICU faculty.
BMP|basic metabolic profile|BMP|177|179|LABORATORY RESULTS|NEUROLOGIC: Cranial nerves II through XII were grossly intact. No focal deficits. LABORATORY RESULTS: The patient had an ethanol level of 0.17. His lipase was normal at 64. His BMP was normal with a sodium of 140, potassium of 3.5 chloride of 97, carbon dioxide of 26, BUN 13, and creatinine 0.8. His white blood count was 5.8, hemoglobin was 13.9, and platelets were 222.
BMP|basic metabolic profile|BMP.|260|263|DISCHARGE INSTRUCTIONS|13. Seroquel 25 daily. 14. Aspirin 81 mg daily. 15. Ferrous sulfate 325 mg 3x a day. 16. Oxycodone 5 mg q.4 hours p.r.n. pain. DISCHARGE INSTRUCTIONS: The patient is going to follow up with her primary physician within one week with repeat labs including CBC, BMP.
BMP|basic metabolic profile|BMP|213|215|PLAN|PLAN: 1. Get calorie counts and observation of amount and nature of the intake and we will also get nutrition to help us with this. 2. We will increase his rate of continuous feeds to 30 mL hour. 3. We will get a BMP to monitor his calcium levels. 4. We will get an upper GI and swallow study to assess for reflux and aspiration.
BMP|basic metabolic profile|BMP|149|151|IMPRESSION AND PLAN|We will be a bit careful about his potassium replacement given his renal failure and avoid potassium replacement protocol for now. We will recheck a BMP in the morning. 8. Urinalysis: Notable for white cells and white blood cell clumps. Doubt urinary tract infection but we will send urine culture for completeness.
BMP|basic metabolic profile|BMP|343|345|CARDIAC DISCHARGE SUMMARY|His INR on discharge was 2.39. He will be followed by Dr. _%#NAME#%_ who has seen him in the past. His blood pressures in the hospital have ranged from 91 at a low to a high of 146, but his pre-discharge blood pressure are 111/63 and heart rate 81 allowing us to increase his lisinopril from 2.5 b.i.d. to 5.0 b.i.d. and we will plan to get a BMP on Monday, a few days from now, to be sure that his potassium does not rise abruptly, although, I doubt that it will as his renal function is normal.
BMP|basic metabolic profile|BMP|260|262|HOSPITAL COURSE|The patient is asymptomatic from this. 3. Hypertension. The patient does have a history of hypertension and her systolic pressures range between 130 and 160. She has been treated with Lasix for her hypertension. We added lisinopril 5 mg a day. She will need a BMP checked in the future and also her blood pressure rechecked to assess the need for changes in medication. DISCHARGE MEDICATIONS: 1. Prednisone 30 mg a day. 2. Theophylline 200 mg a day.
BMP|basic metabolic profile|BMP|252|254|HOSPITAL COURSE|NEUROLOGIC: Unremarkable. LYMPHATIC: Unremarkable. HOSPITAL COURSE: 1. FEN. The patient maintained normal p.o. throughout the course of her admission on a regular diet and her weight was stable. She did have her screening labs checked which included a BMP that was all normal including magnesium and phosphorous. Her vitamin E level was increased at 11, so her dose was halved to 200 mg daily.
BMP|basic metabolic profile|BMP|118|120|DISCHARGE INSTRUCTIONS|10. Nexium 40 mg p.o. daily. 11. Mirapex as previously dosed. 12. Vitamin B2 100 mg daily. DISCHARGE INSTRUCTIONS: 1. BMP in 1 week. 2. Discontinue ibuprofen. 3. Low sodium diet. He met with nutrition. 4. BiPAP 12/6 with 2 liters oxygen at night and with naps.
BMP|basic metabolic profile|BMP|143|145|ASSESSMENT/PLAN|Additionally, I will make IV Dilaudid available. I will also start him on the Pharmacy's constipation prevention protocol. I will get a CBC, a BMP and TSH. 2. Urinary retention, this is likely related to his BPH. I do not think he had cauda equina syndrome without any significant numbness or radicular pain.
BMP|basic metabolic profile|BMP|181|183|IMPRESSION|The BUN is not markedly elevated which may suggest that he had some preexisting disease. We will admit him for observation status and hydrate him with normal saline and recheck the BMP in the morning. 2. Diabetes mellitus. Because of his poor oral status, I will check Accu-Cheks and respond with sliding scale insulin overnight.
BMP|basic metabolic profile|BMP|124|126|FOLLOW UP APPOINTMENTS|FOLLOW UP APPOINTMENTS: 1. With Dr. _%#NAME#%_ in 4-5 days. 2. At Minnesota Lung in 3-4 weeks to consider sleep study. 3. A BMP in 4 days with results to Dr. _%#NAME#%_. 4. A CBC in 1 month. 5. Further treatment for gallstone disease, hernia and right lung mass will be deferred to Dr. _%#NAME#%_ as considered per his discretion.
BMP|basic metabolic profile|BMP|141|143|FOLLOWUP|The patient should be on 1.5 liter fluid restriction. FOLLOWUP: The patient is to follow up with TCU physician on _%#MMDD2007#%_ with repeat BMP to evaluate for sodium and potassium. The patient should have a BMP done on _%#MMDD2007#%_ to evaluate sodium and potassium.
BMP|basic metabolic profile|BMP|210|212|HOSPITAL COURSE|4. Stage III chronic kidney disease. The patient's creatinine is elevated and at her age she has evidence of stage III chronic kidney disease. Her Avapro use should be monitored closely. She will have a repeat BMP in one week. 5. Hyperlipidemia. The patient will continue on her cholesterol medications.
BMP|basic metabolic profile|BMP,|105|108|LABORATORY DATA ON ADMISSION|The patient is responding to tactile stimuli by screaming. LABORATORY DATA ON ADMISSION: CBC was normal. BMP, potassium of 3.3 and was otherwise normal. LFTs were significant for a slightly elevated AST at 93, Tylenol and salicylate levels were normal, lactate and VVT were normal, CK was elevated at 2674.
BMP|basic metabolic profile|BMP|146|148|LABS ON ADMISSION|Inguinal exam was refused. LABS ON ADMISSION: White count was 6.3. Hemoglobin 8.8. Platelets 231. Neutrophils 87. ANC of 5.6. INR of 1.27. Panel, BMP is sodium 141, potassium 3.9, chloride 107, bicarb is 24, BUN 12, creatinine 0.6, glucose 106, ALT of 21, AST of 28, bili total 0.3, direct less than 1.
BMP|basic metabolic profile|BMP|282|284|DISCHARGE FOLLOW-UP|10. Enteric-coated aspirin 81 mg po qday. 11. Coumadin 7.5 mg po tonight, 5 mg tomorrow night, and 7.5 mg Tuesday night, and then as directed. DISCHARGE FOLLOW-UP: The patient will follow-up with _%#NAME#%_ _%#NAME#%_ in 3 days to reassess his fluid status, adjust his Coumadin and BMP will be obtained at that point as well to make sure that he is not hypokalemic or developing any renal failure.
BMP|basic metabolic profile|BMP|130|132|DISCHARGE FOLLOW-UP|He will follow-up again with _%#NAME#%_ _%#NAME#%_ for ____ and AV optimization and initiation of Coreg. He will have a follow-up BMP in 10 days and 3 weeks at Minnesota Heart Clinic. He will follow-up with myself in 6 weeks.
BMP|basic metabolic profile|BMP,|164|167|1. FEN|While on IV fluids his glucose levels were stable. On his first trial off IV fluids his pre-feeding glucose dropped to 31. A hypoglycemic workup was done including BMP, Insulin, Growth Hormone Binding Protein, TSH, Serum and Urine ketones, and Lactic Acid. On _%#MMDD#%_ his IV fluids were stopped and a pre-feeding glucose was checked.
BMP|basic metabolic profile|BMP|158|160|FOLLOW-UP|6. Zofran 8 mg p.o. q4-6h prn nausea. 7. Emla cream. FOLLOW-UP: 1. Dr. _%#NAME#%_ in Oncology Clinic in _%#MMDD2002#%_. He will also receive a CBC with diff, BMP and liver function tests and urinalysis at that time. 2. Outpatient laboratory will include a CBC with diff qMonday and Thursday with results faxed to _%#NAME#%_ _%#NAME#%_ at _%#TEL#%_.
BMP|basic metabolic profile|BMP.|342|345|ASSESSMENT|Patient is a 58-year-old woman with a history of postoperative atrial fibrillation with rapid ventricular response and a history suggestive of recurrent episodic tachyarrhythmia over the past two years admitted for observation, currently hemodynamically stable. ASSESSMENT: 1. Arrhythmia. Continue telemetry monitoring. Check troponin, check BMP. Cardiology consult: given the patient's history of recurrent symptomatology over two years she may benefit from an EP study (prior negative holter monitor).
BMP|basic metabolic profile|BMP|176|178|LABORATORY|MUSCULOSKELETAL: Negative. Antigravity strength in his right upper extremity. LABORATORY: White count of 2.7 with an ANC of 1.7, hemoglobin of 11.4, platelet count 145. He had BMP which was normal except for a potassium which was a little low at 3.2 and normal on recheck. His BUN was 4. His creatinine was 0.6. His protein was 7.6, albumin 4.8, alk.
BMP|beta-natriuretic peptide:BNP|BMP|189|191|LABS|Lungs are clear to auscultation bilaterally. Abdomen is soft, somewhat distended, with normal bowel sounds, and non-tender. Extremities are warm and well-perfused. There is no edema. LABS: BMP 34, troponin less than 0.3, D-dimer 322 (which is normal), white count 4.7, hemoglobin 14.2, platelets 216, potassium 4.4, BUN 21, creatinine 0.9. HOSPITAL COURSE: Shortness of breath.
BMP|basic metabolic profile|BMP|119|121|PHYSICAL EXAMINATION|Posterior tibialis pulses are intact bilaterally at 2+. NEUROLOGIC EXAM is intact. Troponin is less than 0.07. CBC and BMP are normal otherwise. EKG reveals a flattening of the T wave in lead III, otherwise no significant ST segment changes noted.
BMP|basic metabolic profile|BMP|188|190|ASSESSMENT AND PLAN|The patient will continue in BiPAP today and be re-evaluated later in the day to see if we could decrease this. 2. Hyponatremia. This is chronic, probably secondary to COPD. We will check BMP in the morning and IV fluids will be D5 normal saline with 20 mEq of potassium at 100 cc/hour. 3. Hypertension. We will continue his home medications. 4. Hyperlipidemia.
BMP|basic metabolic profile|BMP,|208|211|FOLLOW-UP|2. On _%#MMDD2003#%_ at the Mesonic Day Hospital at 9:30 for labs, including CBC, differential, platelets, BMP, and a possible transfusion. 3. Oncology Clinic _%#MMDD2003#%_ for CBC, differential, platelets, BMP, and EBV quantitative PCR. 4. GFR at 7:30 on _%#MMDD2004#%_ in Nuclear Medicine. 5. Next admission _%#MMDD2004#%_ for chemotherapy round three protocol _%#PROTOCOL#%_.
BMP|basic metabolic profile|BMP|206|208|LABORATORY|CHEST: Clear to auscultation bilaterally. ABDOMEN: Bowel sounds are positive, soft, non-tender, non- distended, no masses. EXTREMITIES: No edema. NEUROLOGIC: Normal. Mucous membranes are moist. LABORATORY: BMP was normal with a BUN of 17, creatinine 0.45, LFTs were normal, CBC was notable for a white count of 19.3 with 89 neutrophils.
BMP|basic metabolic profile|BMP|124|126|LABORATORY|INITIAL PHYSICAL EXAMINATION: By Dr. _%#NAME#%_ revealed grade 2/6 systolic murmur and dependent basilar rales. LABORATORY: BMP was normal with exception of BUN of 46, creatinine of 2.7. Hemoglobin 10.2, which dropped to a low of 7.7, white count is 8200, INR of 2.57. HOSPITAL COURSE: The patient was seen in consultation by Cardiology who felt that this was unlikely to be angina.
BMP|basic metabolic profile|BMP|193|195|PHYSICAL EXAMINATION|NEUROMUSCULAR: Unremarkable. Carotid, radial, pedal, and femoral pulses are intact. Resting electrocardiogram dated _%#MMDD2004#%_ is normal. Chest x-ray is unremarkable, unchanged since 2001. BMP was been ordered and will be faxed. Hemoglobin is 12.9%.
BMP|basic metabolic profile|BMP,|131|134|LABORATORY DATA|Consequently, the patient will go home with this drain in place after Dr. _%#NAME#%_ did review today. LABORATORY DATA: There is a BMP, hemoglobin, and zinc level pending from this morning on _%#MMDD2004#%_. On _%#MMDD2004#%_ hemoglobin A1c 5.7. Phosphorus 4.2. Magnesium 2.1. BMP within normal limits at that point with a glucose noted to 158, and calcium 7.5. On _%#MMDD2004#%_ hemoglobin 9.9. On _%#MMDD2004#%_ transferrin 145 and albumin 2.5.
BMP|basic metabolic profile|BMP|175|177|ASSESSMENT/PLAN|The patient will be placed on a clear liquid diet. 2. Acute renal failure secondary to severe dehydration. We will aggressively hydrate patient with normal saline and recheck BMP in the a.m. 3. Hypertension. We will continue her chronic meds with p.r.n. holding parameters. We will continue to monitor her blood pressures and adjust as needed.
BMP|basic metabolic profile|BMP,|137|140|ADMISSION LABORATORY DATA|NEUROLOGIC: Alert, oriented x 3, and there is no focal deficit appreciated. ADMISSION LABORATORY DATA: CBC with differential cell count, BMP, INR, sedimentation rate, and CPK total within normal limits. ASSESSMENT AND PLAN: The patient is a 21-year-old male otherwise healthy who presents with one week history of right arm pain, swelling, and erythema with limited range of motion started after trial of plasma donation through IV right antecubital area.
BMP|basic metabolic profile|BMP|156|158|PLAN|8. Other procedures as above. DISCUSSION: No complaints or findings to contraindicate proceeding with surgery as planned. PLAN: 1. Surgery as scheduled. 2. BMP (hypertension) and hemoglobin (GERD) preop. 3. I will be available the day of surgery and will follow the patient perioperatively if she requires overnight hospitalization.
BMP|beta-natriuretic peptide:BNP|BMP|227|229|LABORATORY DATA|The laboratory reported marked target cells of poikilocytosis, ovalocytosis, and isocytosis, and rare red cell fragments. Her INR was elevated at 2, PTT was 30 seconds. Her calcium was elevated on admission at 10.7 mg percent. BMP was greater than 5000. Chest x-ray performed on admission showed a left lower lobe opacification unchanged from _%#MM#%_, cardiomegaly, and fracture of the left proximal humerus unchanged.
BMP|basic metabolic profile|BMP|96|98|LABS|Reflexes are normal. Mental status exam is per Dr. _%#NAME#%_. LABS: Prior to admission, normal BMP and CBC, negative urine pregnancy screen.
BMP|basic metabolic profile|BMP|72|74|LABS|Sensation intact to light touch. Reflexes are symmetrical 1+. LABS: Her BMP from today is normal. Her platelets 402,000. WBC count is 11.2. VITAL SIGNS: Today show her blood pressure to be 141/82, heart rate 92, respirations 18, temperature 98.7 IMPRESSION/RECOMMENDATION: This 62-year-old female with a history of CLL and ITP with recent splenectomy and occipital craniotomy with resection of cerebellar hematoma status post VP shunt placement.
BMP|basic metabolic profile|BMP|260|262|LABORATORY|She has a mild anemia. Urinalysis is unremarkable. Drug screen is positive for barbiturates and tricyclics which would not be unusual given her Flexeril and Fioricet that she takes at home. She does not have an opiates in her urine or any other illicit drugs. BMP was reviewed and was fine. INR is normal. Ethanol was negative. Tylenol was in the appropriate range for someone who is taking the medication she takes.
BMP|basic metabolic profile|BMP.|153|156|LABORATORY DATA|Treatment to be continued and followed by Dr. _%#NAME#%_'s team. The patient is medically stable. Will get routine labs in a.m. including hemoglobin and BMP. 2. Urethral stricture. Will consult Dr. _%#NAME#%_ of Urology for management of when and how to remove urinary Foley catheter. 3. Mild intermittent asthma. Currently stable, will continue with albuterol inhaler as prescribed above.
BMP|basic metabolic profile|BMP,|377|380|LABORATORY EVALUATION|LABORTORY EVAUATION: Pre-op labs reveal pre-op hemoglobin of 16, platelets 216, WBC 8.3, sodium 141, potassium 4.5, chloride 107, CO2 28, BUN 18, creatinine 0.9. EKG revealed normal sinus rhythm without signs of previous ischemic events. A chest x-ray was unremarkable. LABORATORY EVALUATION: Presently includes postoperative hemoglobin on _%#MMDD#%_ of 14.5. I have ordered a BMP, which is at this point pending. ASSESSMENT AND PLAN: 1. Status post lumbar laminectomy. The patient's radicular pain appears to have been resolved.
BMP|basic metabolic profile|BMP.|203|206|MEDICATIONS|Attempts to manage medically have included antibiotic therapy for his pneumonia, vigorous diuresis, and heart failure therapy. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Insulin. 2. Aspirin. 3. BMP. 4. Lasix. 5. Glipizide. 6. Heparin. 7. Hydralazine 8. Imdur. 9. Lansoprazole. 10. Lisinopril. 11. Solu-Medrol. 12. Metolazone.
BMP|basic metabolic profile|BMP|143|145|ASSESSMENT|3. Recent history of acute renal failure, which appears to be resolving gradually. We should carefully follow her I's and O's, and recheck her BMP in the morning. 4. History of colon cancer. The colostomy appears to be working appropriately. She should follow up with her primary MD and surgeons regarding this issue once the psychiatric issues are more stable.
BMP|basic metabolic profile|BMP,|180|183|ASSESSMENT AND PLAN|3. Asthma, controlled with meds. Will change Advair to scheduled 1 puff b.i.d. and order albuterol p.r.n. 4. Anemia, mild, probably secondary to surgical blood loss. 5. Will check BMP, cortisol, TSH tomorrow to evaluate for evaluate for possible Cushing's and depression.
BMP|basic metabolic profile|BMP|164|166|ASSESSMENT AND PLAN|The patient is medically stable. Pain management per Dr. _%#NAME#%_. 2. A-fib. Continue with recommended Coumadin dose 5 mg per day. Recheck INR on _%#MMDD2005#%_. BMP and hemoglobin. 3. Hypotensive state, probably secondary to BP medications and pain narcotics. 250 mg bolus h.s. over 1 hour, hold if systolic blood pressure is less than 110.
BMP|basic metabolic profile|BMP|111|113|ASSESSMENT AND PLAN|We will instruct the nurses to place Teds and Pneuma boots on the patient. 7. Labs in the a.m. will be CBC and BMP to monitor metabolic status.
BMP|bone morphogenetic protein|BMP|114|116|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 26-year-old white female who underwent a disk space injection L3-L4, BMP and type for degenerative disk disease and chronic pain with Dr. _%#NAME#%_ 4 days ago. She has had persistent similar to what she had preoperatively in her mid back region; this has continued postoperatively and is nonradicular.
BMP|basic metabolic profile|BMP|158|160|PLAN|PLAN: We will check a urinalysis/urine culture. We will hold the patient's hypertensive medications until her blood pressure increases. I will check baseline BMP and hemoglobin following the surgery.
BMP|basic metabolic profile|BMP|186|188|IMPRESSION, REPORT AND PLAN|However, I will evaluate for thyroid dysfunction and hemachromatosis with an iron and TIBC. Would continue to titrate up his medications for afterload reduction. Will check an a.m. CBC, BMP and a BNP. I will check a renal ultrasound in the morning to evaluate his creatinine of 1.6, especially since he will need high doses of Ace inhibitors.
BMP|basic metabolic profile|BMP|178|180|ASSESSMENT AND PLAN|The patient is loaded with fosphenytoin to prevent seizure. Neurosurgery has been consulted. The patient will likely have an MRI. 2) Fluid, electrolytes, nutrition; will check a BMP in the morning, continue normal saline at present, but if the patient continues to be NPO change IV fluid to D5 half-normal saline with 20 mEq of potassium per liter.
BMP|basic metabolic profile|BMP|126|128|NEUROLOGIC|Postoperative labs included a hemoglobin of 10.3. Preoperative labs included a hemoglobin of 12.5 and MCV of 74. Preoperative BMP was normal. Preoperative chest x-ray was normal. Preoperative pulmonary function tests included an FEV1 of 3.5. EKG obtained secondary to tachycardia revealed sinus tachycardia at the rate of 125.
BMP|basic metabolic profile|BMP|130|132|LABORATORY DATA PRIOR TO SURGERY|Pedal pulses are intact. Sensation is grossly intact in the lower extremities. LABORATORY DATA PRIOR TO SURGERY: Hemoglobin 11.7. BMP normal. EKG was essentially normal.
BMP|basic metabolic profile|BMP|190|192|LABORATORY  DATA|Urine culture is pending. Urine tox screen is negative. EKG reveals equivocal Q-waves in the inferior leads. Magnesium is 1.0, phosphorus 2.7. Tacrolimus level is 12.7. CBC is unremarkable. BMP is remarkable for a creatinine of 1.35. Liver function tests were normal on the _%#DD#%_ of this month.
BMP|basic metabolic profile|BMP|211|213|PLAN|13. Parameters for a lisinopril and metoprolol. 14. Review antihypertensive regimen prior to discharge based on clinical status at that time. Ultimate followup with primary care provider. Recheck hemoglobin and BMP on _%#MMDD2006#%_. 15. Parameters for which nursing staff should call. Thank you for the consultation. We will follow along with you.
BMP|basic metabolic profile|BMP|116|118|LABORATORY  DATA|LABORATORY DATA: Creatinine on _%#MMDD2007#%_, 1.83. GFR 39, potassium 5.1, sodium 142, bicarbonate 29, rest of the BMP was normal. Blood alcohol level and salicylate levels within normal limits. Urine tox screen negative. INR 1.84. ASSESSMENT AND PLAN: 1. Depression. 2. History of cerebrovascular accident and deep vein thrombosis.
BMP|basic metabolic profile|BMP|224|226|ASSESSMENT AND PLAN|6. Wrist laceration and cellulitis. Continue with Keflex, however, change to 500 mg daily x five additional days. Do not use occlusive bandages for dressings. 7. Electrolyte imbalance. Electrocardiogram ordered. Repeat stat BMP and hemoglobin. Dr. _%#NAME#%_ will be called with the results. 8. Lesion on the alar area of the nose. Nicely healed. Discontinue using tetracycline. Thank you for this consultation.
BMP|basic metabolic profile|BMP|141|143|LABORATORY DATA|On _%#MMDD2007#%_ the comprehensive metabolic panel was normal. BMP drawn on _%#MMDD2007#%_ was significant for glucose 199. The rest of the BMP was within normal limits. Anion gap 3.9, calcium 7.2. INR 1.28. Hemoglobin 9.1. Crystal analysis of right elbow aspirate showed no crystals.
BMP|basic metabolic profile|BMP|133|135|PLAN|Patient reports he has not been using his CPAP at home due to difficulty with usage. 5. Blood work for morning including hemoglobin, BMP and electrolyte panel.
BMP|basic metabolic profile|BMP|125|127|LABORATORY DATA|EXTREMITIES: Intact pedal pulses, no clubbing or cyanosis. LABORATORY DATA: Preoperative labs are reviewed. Hemoglobin 13.2. BMP is normal. Preoperative EKG is normal.
BMP|basic metabolic profile|BMP|179|181|LABORATORY|ABDOMEN: Soft; non-tender; non- distended. There is no hepatosplenomegaly. EXTREMITIES: No signs of trauma. NEUROLOGIC: He is alert, he is pleasant. LABORATORY: Included a normal BMP and CBC.
BMP|basic metabolic profile|BMP|140|142|LABORATORY DATA|LABORATORY DATA: WBC 3.8, absolute neutrophils 0.9, percent of neutrophils 24, percent of lymphocytes 69. Rest of CBC within normal limits. BMP within normal limits. TSH normal, GGT normal. Drug urine screen negative. ASSESSMENT AND PLAN: 1. Depression per Dr. _%#NAME#%_. 2. Leukopenia most likely secondary to allopurinol use.
BMP|basic metabolic profile|BMP.|165|168|ADMISSION LABORATORY DATA|PAST MEDICAL HISTORY: Noted for a urinary tract infection. ADMISSION LABORATORY DATA: Her admission laboratories were really fairly unremarkable in terms of CBC and BMP. The rib films did reveal the fracture. She has been initially seen by physical therapy briefly. MEDICATIONS: Her medications at the time of her arrival here had included: 1. Atenolol 25 per day.
BMP|basic metabolic profile|BMP|149|151|PLAN|PLAN: No medical change is recommended at this time. I will be happy to see her during her stay for any intercurrent medical issues. We will recheck BMP due to her history of bulimia in several days.
BMP|basic metabolic profile|BMP|223|225|ASSESSMENT/PLAN|ASSESSMENT/PLAN: 1. Schizoaffective disorder. Treatment per Dr. _%#NAME#%_. 2. History of acute renal failure with hemodialysis secondary to antifreeze ingestion. Presumed return to normal renal function. We will check the BMP tomorrow. 3. Electroconvulsive therapy clearance. Will get electrocardiogram. 4. Constipation. Colace as needed. 5. Abrasion to the left palmar aspect of fourth and fifth digit.
BMP|basic metabolic profile|BMP|170|172|ADDENDUM|7. Bowel regimen. Thank you for the consultation. We will follow the patient on Medicine and on Rehab Unit subsequent to transfer. ADDENDUM: Preoperative labs included a BMP with sodium 139, potassium 4.8, chloride 102, CO2 32, anion gap 5, glucose 98, BUN 27, creatinine 1.13, hemoglobin 14.5 gm%.
BMP|basic metabolic profile|BMP|212|214|LABORATORY DATA|Strength is 5/5 bilaterally. Gait is within normal limits. Reflexes are 1+ bilaterally. LABORATORY DATA: (_%#MMDD2002#%_) TSH is 4.86. Urine tox screen is still pending. Depakote is 63. WBC 8.5. Hemoglobin 13.8. BMP and rest of CMP is within normal limits with the exception of calcium being slightly elevated at 10.6.
BMP|basic metabolic profile|BMP|216|218|LABORATORY|No sign of acute infection, as well, further scratching is noted over the right anterior thigh. No sign of infection. Gait was not assessed. LABORATORY: Laboratory evaluation reveals a hemogram within normal limits. BMP and liver function tests, all within normal limits. TSH slightly elevated at 6.01. ASSESSMENT/PLAN: 1. Depression. This will be followed by Dr. _%#NAME#%_. 2. Self-induced lacerations to the arms and thigh.
BMP|basic metabolic profile|BMP|175|177|ASSESSMENT/PLAN|3. Hypertension, blood pressure currently stable, will continue patient's chronic antihypertensives. Will monitor blood pressures and adjust medications as needed. Will check BMP for baseline. 4. Obstructive sleep apnea, will continue CPAP while inpatient. 5. Status post gastric bypass. Will continue patient's multivitamins and B12 supplements.
BMP|basic metabolic profile|BMP.|101|104|LABS ON ADMISSION|Last use of opiates was 1997. Last use of cocaine was in _%#MM#%_ of 2001. LABS ON ADMISSION: Normal BMP. A valproic acid level is less than 1.
BMP|basic metabolic profile|BMP|204|206|IMPRESSION|Would continue his medications for hypertension with parameters. Would continue him on Protonix for GERD, would continue his Advair and albuterol inhalers as previously done, would follow up with CBC and BMP in the morning. Would check a urinalysis and urine culture one of my partners will follow along. Will resume his home medication regimen as he tolerates this and as his appetite improves.
BMP|basic metabolic profile|BMP|139|141|LABORATORY DATA|MENTAL STATUS EXAMINATION: Per Dr. _%#NAME#%_. LABORATORY DATA: Remarkable for Tegretol level of 4.3. Serum pregnancy screen was negative. BMP was remarkable for an anion gap of 21 with CO2 19. Urinalysis was positive for ketones. Follow-up BMP obtained prior to this admission was normal.
BMP|basic metabolic profile|BMP,|116|119|IMPRESSION|We will check uric acid, CK and myoglobin to make sure he does not have rhabdomyolysis. In the morning will check a BMP, magnesium and phosphorus. We will send the urine for sodium and fractional excretion of sodium.
BMP|basic metabolic profile|BMP|175|177|ASSESSMENT AND PLAN|He did have an apneic episode for about 30 seconds when a CPAP trial was tried earlier today. He is not on any sedation or pain medications. a) Will check an ABG and a repeat BMP for possible hypercapnia and other metabolic derangements. His panel yesterday was okay. b) Continue ventilator with weaning trials as able.
BMP|basic metabolic profile|BMP|159|161|ASSESSMENT/PLAN|4. Hyperlipidemia by history. We will continue with the Lipitor. 5. Hypothyroidism, stable. We will continue with the Synthroid as dosed above. We will draw a BMP and hemoglobin along with a reflux TSH in the a.m. on _%#MMDD2004#%_.
BMP|basic metabolic profile|BMP|180|182|ASSESSMENT AND PLAN|3. Hypertension. Her blood pressure is at goal. I would suggest adding potassium supplementation with her Hyzaar/hydrochlorothiazide, which can potentially lower potassium. Repeat BMP and magnesium level should be done in a week after discharge. 4. Finally, we should check a TSH level as she is on Synthroid supplements and this will be to make sure that she is not overtreated for her hypothyroidism.
BMP|basic metabolic profile|BMP|118|120|LABORATORY EVALUATION|Pulses intact bilaterally. Her gait was quite steady and normal. LABORATORY EVALUATION: Is reviewed reveals a CBC and BMP without abnormality. INR today is 2.32. Over the last several days it has been elevated on _________. ASSESSMENT AND PLAN: 1. Anxiety disorder. This will be followed by Dr. _%#NAME#%_.
BMP|beta-natriuretic peptide:BNP|BMP|218|220|LABORATORY DATA|Chest x-ray is not available for viewing. Known bilateral pulmonary infiltrates were described by report from the emergency room. LABORATORY DATA: Sodium 138, potassium 3.9, chloride 98, C02 27, BUN 9, creatinine 0.8. BMP was 817, myoglobin 35, troponin less than 0.7. Hemoglobin 14.0, hematocrit 40.9, WBC was 21.8 with a left shift with 83% polys, calcium 8.8, INR was 1.29.
BMP|basic metabolic profile|BMP,|132|135|IMPRESSION|IMPRESSION: Right hip fracture per orthopedics. The patient is not cleared medically pending evaluation with chest x-ray, EKG, CBC, BMP, liver panel, TSH, urinalysis, urine culture, and echocardiogram to evaluate murmur. We ill hold the aspirin, hold nifedipine and one of my partners will reevaluate the patient in the morning when this data is available for medical clearance.
BMP|basic metabolic profile|BMP,|169|172|PLAN|11. Degenerative joint disease, stable. 12. Umbilical hernia, recurred 2 years ago, status post surgery in 1982. PLAN: We are ordering routine labs on the patient: CBC, BMP, UA, GGT, etc. Give patient a copy of labs on discharge. Call MD with abnormal labs.
BMP|basic metabolic profile|BMP|176|178|PHYSICAL EXAMINATION|Cranial nerves II - XII were grossly intact. Sensation is intact to light touch. Strength is 5 out of 5 bilaterally. Gait is within normal limits. Reflexes are 1+ bilaterally. BMP showed sodium at 136 with Potassium of 3.6, BUN of 17, creatinine of 1.0, the rest of BMP is within normal limits. CBC shows a wbc of 5.5 with a hemoglobin of 13.5. On _%#MMDD#%_ a TSH of 2.71, uric acid of 5.2, INR of 0.94 and Sed Rate of 11, all within normal limits.
BMP|basic metabolic profile|BMP|187|189|ASSESSMENT AND PLAN|4. Patient is started on Lithium therapy. Knowing that this interacts with Ibuprofen as well as the Lasix and HZTZ, we have prescribed these medications but cautiously. We will recheck a BMP times two. 5. Xerosis. Patient's skin appears to be more dry than fungal in nature. The Triamcinolone is of no benefit for either of these conditions and, therefore, we d/c'd it.
BMP|basic metabolic profile|BMP.|316|319|IMPRESSION|I agree with the current strategy to use prednisone medication with stable daily dose following her hospitalization, though would return to the 7.5 mg daily dose when she is ready to leave the hospital and also able to eat regular meals with her pharyngitis. Other lab tests were requested for TSH, free T4, ALT and BMP. I would continue the current levothyroxine thyroid hormone, though switch to intravenous dosing if she is unable to swallow the thyroid pill this admission.
BMP|beta-natriuretic peptide:BNP|BMP|183|185|LABORATORY DATA|PSYCHIATRIC: Mood and affect is appropriate. LABORATORY DATA: White count is 4.2, hemoglobin 15.6, hematocrit 46.5, platelets are 95,000. Myoglobin 27, troponin I was less than 0.07. BMP is up slightly at 606, this is likely secondary to his pulmonary hypertension. The patient appears euvolemic on examination. Sodium is 139, potassium 4.1, chloride 107, bicarbonate 23, anion gap of 90, BUN 17, creatinine 1.0, glucose is elevated at 141, calcium 9.3. D-dimer was 0.5.
BMP|basic metabolic profile|BMP.|220|223|LABORATORY DATA|Liver function tests are normal. A BMP obtained prior to admission at HCMC is remarkable for a sodium of 147, potassium 4.7, bicarb 110, creatinine 2.4, BUN 26. Labs will be repeated this p.m., including a CPK level and BMP.
BMP|beta-natriuretic peptide:BNP|BMP|251|253|LABORATORY|EXTREMITIES: Without edema, +2 dorsalis pedis pulses bilaterally. LABORATORY: EKG shows left bundle branch block with normal sinus rhythm. No acute ST, T-wave changes. It is unclear if this is a new finding. There are no previous EKGs for comparison. BMP 126, sodium 143, potassium 3.5, BUN 14, creatinine 0.9, INR 0.92, PTT 30, hemoglobin 13.7, platelets 200, white count 7.3, myoglobin mildly elevated at 149, troponin also mildly elevated at 0.19. Echocardiogram was completed showing severely depressed LV function with an EF estimated at 10% and severe global hypokinesis.
BMP|basic metabolic profile|BMP|174|176|PLAN|4. Soap and water cleanse beneath the breasts b.i.d. with thorough drying. Cornstarch in the morning. Nystatin powder at h.s. 1% hydrocortisone cream p.r.n. pruritus. 5. Add BMP and CBC to labs. 6. Clinical observation. Thanks for the consultation. Will follow along as clinically indicated.
BMP|beta-natriuretic peptide:BNP|BMP|203|205|LABORATORIES|Moves all four extremities well. LABORATORIES: The creatinine has gone from 3.9 to 3.5 and her BUN 90 to 81. Her sodium is 125, potassium 5.1, chloride 94, and bicarbonate 24. Her hemoglobin is 9.6. Her BMP is elevated. A UA is unremarkable. On _%#MMDD2005#%_ her BUN is 47 and creatinine 1.9. IMPRESSION: Acute renal failure, most likely prerenal due to congestive heart failure, diuretics, and poor p.o. intake.
BMP|basic metabolic profile|BMP.|218|221|LABORATORY|Review of blood chemistries over the last several weeks indicate a baseline creatinine of approximately 1.0 as well as unremarkable thyroid function tests. Labs will be obtained in the morning including a follow up of BMP.
BMP|basic metabolic profile|BMP|167|169|ASSESSMENT AND PLAN|He does have minor hypokalemia, which I presume is related to his diuretic. I will replace this with 20 mEq of Potassium Chloride x 1 today and will plan to recheck a BMP in the morning. 3. History of brain aneurysm. The patient will be seen by See of neurology for further evaluation of this issue.
BMP|basic metabolic profile|BMP|149|151|LABORATORY  DATA|No drainage is noted. No break in the skin is noted. NEUROLOGIC: Deferred to Dr. _%#NAME#%_. LABORATORY DATA: Most recently included hemoglobin 9.5. BMP is normal. A chest x-ray obtained postoperatively reveals opacification left lung base, obliterating the left hemidiaphragm, compatible with atelectasis or infiltrate.
BMP|basic metabolic profile|BMP:|76|79|LABORATORY DATA|Sensation intact to light touch. Strength 5/5 bilaterally. LABORATORY DATA: BMP: Elevated sodium at 147, otherwise within normal limits. CBC: Within normal limits. Serum ethanol 0.1. Aspirin level under 1. Tylenol level under 10. Urine drug screen positive for cannabinoids.
BMP|basic metabolic profile|BMP|201|203|PLAN|5. Status post right hand surgery. 6. Daily alcohol intake as above, without history of alcohol withdrawal. PLAN: 1. Mobilize per Orthopedics. 2. Intravenous fluid support. 3. Followup labs to include BMP and hemoglobin. 4. Incentive spirometry. 5. Continuous oximetry while on PCA. Adjust dose as narcotic naive. 6. Parameters for which the nursing staff should call. Check blood pressure with upright posture to ensure not significantly orthostatic.
BMP|basic metabolic profile|BMP|194|196|LABORATORY DATA|CMP on _%#MM#%_ _%#DD#%_ revealed a high glucose of 135 and high albumin of 4.8, otherwise within normal limits. CK on _%#MM#%_ _%#DD#%_ was normal. Ethanol level on _%#MM#%_ _%#DD#%_ was 0.01. BMP on _%#MM#%_ _%#DD#%_ revealed low anion gap of 2.6 and a low calcium of 8.3, otherwise within normal limits. CBC on _%#MM#%_ _%#DD#%_ revealed high white blood cell count of 13.8, low red blood cell count of 3.93, low hemoglobin 12.7, and low hematocrit of 36.9, in addition to low platelet count of 147 and high absolute neutrophil of 9.5, otherwise within normal limits.
BMP|basic metabolic profile|BMP|211|213|LABORATORY DATA|Strength is 5/5 bilaterally in both the upper and lower extremities. LABORATORY DATA: Labs from _%#MMDD2007#%_: CBC with differential showed RBCs of 3.48, hemoglobin 11.1, hematocrit 33.1, with 16% lymphocytes. BMP showed potassium of 3.2, glucose 113, and an estimated GFR at 43. Creatinine was 1.30. TSH was 0.54. Lab testing from _%#MMDD2007#%_: Urinalysis with micro showed trace leukocyte esterase and WBCs of 4.
BMP|basic metabolic profile|BMP|200|202|LABORATORY DATA|ABDOMEN: Soft, nontender, nondistended; suprapubic catheter is in place. EXTREMITIES: Lower extremities reveals no edema. Pedal pulses are intact. LABORATORY DATA: Hemoglobin 11.1 today. INR is 2.16. BMP is unremarkable.
BMP|basic metabolic profile|BMP|158|160|PLAN|13. Hysteroscopy and laparoscopy in 1990s. PLAN: 1. Admit ICU. 2. Morphine sulfate PCA as ordered. 3. Incentive spirometry. 4. IV Zofran for nausea. 5. Check BMP and hemoglobin this evening. 6. Recheck a.m. labs. 7. IV fluid support as ordered.
BMP|basic metabolic profile|BMP|231|233|ASSESSMENT/PLAN|Will monitor his O2 sats and provide O2 p.r.n. write for DuoNeb p.r.n. and start incentive spirometry use. 5. Gout, currently stable, will continue allopurinol. 6. Fluids, electrolytes, nutrition. Currently stable, will check a.m. BMP and follow-up will monitor I's, O's and daily weights. Thank you for this consultation.
BMP|basic metabolic profile|BMP|146|148|ASSESSMENT/PLAN|Hypertension was stable. GERD, the patient takes Zantac and it is controlled. Coronary artery disease, angiogram history. We are going to check a BMP on Monday in the morning and order capsaicin for her nerve pain applying to shoulder and leg p.r.n. Discontinue her fluid restriction.
BMP|basic metabolic profile|BMP.|171|174|RECOMMENDATION|RECOMMENDATION: The patient has been receiving Lasix but she generally just takes this on a p.r.n. basis, for edema. We will check a postoperative hemoglobin as well as a BMP. I will be able to see _%#NAME#%_ during the hospitalization for these and any other medical concerns and follow her after anticipated transfer to the Transitional Unit.
BMP|basic metabolic profile|BMP|196|198|PROBLEM|Nontender and nondistended. Extremity showed left ankle brace was in place. LABORATORY: Laboratory data: White blood cell count was 15.1, hemoglobin 12.3, hematocrit 36.8, platelet count 230,000. BMP showed sodium 139, potassium 3.6, chloride 106, CO2 22, BUN of 8, creatinine 0.66, glucose 90, and calcium 9.3. Chest x-ray showed right lower lobe infiltrate with a left mid lung 6 mm nodule.
BMP|basic metabolic profile|BMP|213|215|PLAN|Consultation by Dr. _%#NAME#%_ of vascular surgery and we will continue D5 lactated Ringer's while n.p.o. ,IV metoprolol for right now, will treat other blood pressure higher than 160 on an as-needed basis. Check BMP in a.m. Zofran as needed for nausea.
BMP|basic metabolic profile|BMP.|182|185|ASSESSMENT AND PLAN|16. History of acute renal failure. It does not appear that patient required dialysis. Current kidney function appears good. We will monitor. 17. Elevated liver tests. We will order BMP. 18. Persisting nausea. We will order Zofran and monitor. Thank you for this consultation. We will follow the patient medically.
BMP|basic metabolic profile|BMP|202|204|PHYSICAL EXAMINATION|Gait appears normal. Laboratory evaluation as of _%#MMDD2004#%_ reveals a TSH of 1.74. Platelets normal. Hemogram with a white count slightly low at 3.2. Normal differential. Hemoglobin normal at 13.1. BMP was normal. ASSESSMENT/PLAN: 1. Behavioral concerns. This will be followed by Dr. _%#NAME#%_. 2. Asthma, mild, intermittent, which appears to be well controlled presently.
BMP|basic metabolic profile|BMP|138|140|LABORATORY DATA|She moves all extremities. There is no rigidity. She is not tremulous. LABORATORY DATA: Labs on admission included an unremarkable CBC. A BMP was remarkable for potassium of 3.3. A nonfasting glucose was 120. BUN was 10 and creatinine 0.7. Urine tox screen was negative.
BMP|basic metabolic profile|BMP,|159|162|PLAN|We will check q.i.d. Accu-Cheks and monitor along with her. 4. Hypertension, stable. 5. Hypothyroidism. PLAN: The plan will be to check routine labs including BMP, hemoglobin. Blood glucose be monitored as noted above. No changes will be made to insulin regimen at least for the time being.
BMP|basic metabolic profile|BMP|252|254|PLAN|There are no complaints or findings to contraindicate. 11. Recurrent sprain of left ankle, with residual sense of instability. Will request orthopedic consultation. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. ECT if planned. Will check BMP prior to proceeding. 3. Doxycycline 100 mg b.i.d. for 7 days. 4. Albuterol metered-dose inhaler p.r.n. as ordered.
BMP|basic metabolic profile|BMP|194|196|LABORATORY DATA|LUNGS: Clear. CARDIAC: Regular rate and rhythm without murmurs. ABDOMEN: Soft, nontender, no masses. EXTREMITIES: Intact pedal pulses. No edema. LABORATORY DATA: Preoperative labs are reviewed. BMP is normal. Hemoglobin 14.9. EKG revealed normal sinus rhythm. There are questionable Q-waves in lead 3 and aVF. This was noted to be unchanged from past EKGs by the patient's primary physician, Dr. _%#NAME#%_.
BMP|basic metabolic profile|BMP,|210|213|LABORATORY DATA|There is no free fluid. LABORATORY DATA: Admission laboratory reveals lipase 6018, amylase 538, alkaline phosphatase 438, ALT 453, AST 934. Total bilirubin 0.7. Hemoglobin 10.1 with a white blood count 11,200. BMP, myoglobin, troponins are negative, as is urinalysis. INR slightly elevated at 1.27. IMPRESSION: 1. The patient has evidence of cholelithiasis with cholecystitis. He likely has a gallstone pancreatitis.
BMP|beta-natriuretic peptide:BNP|BMP|137|139|RECOMMENDATIONS|RECOMMENDATIONS: 1. I will check a bioimpedance to compare to his previous test in _%#MM#%_ when he was thought to be fairly optimal. 2. BMP levels will also be drawn to see whether that can be a useful marker to follow whether he is having COPD exacerbations or heart failure exacerbations.
BMP|basic metabolic profile|BMP|174|176|LABORATORY  DATA|EXTREMITIES: Intact pedal pulses. There is no edema. SPINE AND NEUROLOGIC: Examinations are as per Dr. _%#NAME#%_. LABORATORY DATA: Thus far: Blood glucoses in the mid 200s. BMP reveals a creatinine of 1.4. INR, as above, is 1.45. Platelet count has not been obtained but will be obtained.
BMP|basic metabolic profile|BMP|223|225|ASSESSMENT AND PLAN|2. Left renal mass of unclear etiology. University of Minnesota Urology has been consulted regarding further evaluation of this issue. 3. Nausea and vomiting. Electrolytes are normal, however, I will recommend a recheck of BMP in the morning. Continue to monitor vital signs and offer IV rehydration. Thanks for the consult.
BMP|basic metabolic profile|BMP,|258|261|RECOMMENDATIONS|The patient relates having a past negative stress test. RECOMMENDATIONS: The patient's respiratory status will be monitored closely postoperatively. Albuterol inhalers and nebs will be made available for p.r.n. use. Followup labs, including a hemoglobin and BMP, will be obtained. P.r.n. proton pump inhibitor therapy will be started. I will be able to follow Mr. _%#NAME#%_ during his hospitalization for concurrent medical issues. DISCUSSION: _%#NAME#%_ _%#NAME#%_ is a 55-year-old man who underwent the above-mentioned surgery by Dr. _%#NAME#%_.
BMP|basic metabolic profile|BMP|286|288|PLAN|6. Nausea, most likely secondary to anesthesia. 7. No known coronary artery disease with history of essentially unremarkable stress echocardiogram in summer of 2007. PLAN: 1. Will restart Norvasc 10 mg p.o. daily. 2. Omeprazole 20 mg p.o. daily. 3. Routine labs tomorrow a.m. including BMP and hemoglobin. 4. DVT prophylaxis per Dr. _%#NAME#%_'s team. 5. Zofran as needed for nausea. 6. We will follow closely with you for any intercurrent medical issues.
BMP|basic metabolic profile|BMP|233|235|LAB EVALUATION|No masses are palpable. The abdomen is nondistended. Patient locates the pain (when it was present) at the right iliac crest involving the right flank and back. LAB EVALUATION: Shows a hemoglobin 13.6, white count 10.6 with 85 PMNs. BMP is normal. Hepatic panel is normal except for an AST of 56, INR 1.9. IMAGING STUDIES: Include a gallbladder ultrasound with multiple nodal stones and no wall thickening or ductal dilation.
BMP|beta-natriuretic peptide:BNP|BMP|159|161|LABORATORY AND DIAGNOSTIC DATA|Hemoglobin 12.8. Hematocrit 37.9. Platelet count 233,000. Arterial blood gas on above ventilator settings, pH 7.22, pC02 47, p02 142, INR 3.15 from admission. BMP is 202. Serum sodium is 141. Potassium 3.8. Chloride 105. C02 content 25. BUN 25. Creatinine 1.89. Glucose 108. Chest x-ray was reviewed from around midnight pre-intubation.
BMP|basic metabolic profile|BMP,|166|169|LABORATORY DATA|NEUROLOGIC: He is alert, fully oriented. He is not tremulous. Motor, sensory, and coordination are intact. LABORATORY DATA: Ordered and pending include a hemoglobin, BMP, thyroid function tests, and EKG.
BMP|basic metabolic profile|BMP|154|156|LABORATORY DATA|Gait appeared stable with the patient slightly favoring her left hip. LABORATORY DATA: WBC 13.5, otherwise the CBC was normal. Glucose 299, otherwise the BMP was normal. Urine tox screen positive for cannabinoids. Blood glucose this morning 220. ASSESSMENT/PLAN: 0. De0. pression and other psychiatric issues.
BMP|basic metabolic profile|BMP|105|107|LABORATORY & DIAGNOSTIC DATA|NEUROLOGIC: Mental status as above. The patient is moving all extremities. LABORATORY & DIAGNOSTIC DATA: BMP from today shows sodium 133, potassium 4, chloride 100, CO2 28, BUN 21, creatinine 1.05, glucose 123, calcium 8. Labs from _%#MMDD#%_ showed a white count of 8.3 with a hemoglobin of 11.3 and platelets of 157,000.
BMP|basic metabolic profile|BMP|80|82|LABORATORY DATA|Reflexes 2+ bilaterally. Sensation intact to light touch. LABORATORY DATA: CBC, BMP and TSH are normal. It should be noted that the TSH was checked during the patient's admission in _%#MM#%_ and was within normal limits.
BMP|basic metabolic profile|BMP|125|127|ASSESSMENT AND PLAN|At present the patient is normotensive with only atenolol. I will elect to hold the Accupril at present. I will also check a BMP in the morning as baseline renal function is not available to me. I will closely follow his blood pressures and fluid status.
BMP|basic metabolic profile|BMP,|96|99|PLAN|3. Coronary artery disease, stable. 4. Gastric ulcer, stable. PLAN: Will check a digoxin level, BMP, and CBC in the morning. Will discontinue the Colace and start the patient on Senokot S two tablets p.o. q.h.s. Will change the IV to D5 normal saline at 75 cc an hour.
BMP|basic metabolic profile|BMP,|208|211|PLAN|2. U of M Endocrine consultation to help adjust Humalog insulin based on carbohydrate load. Situation was discussed with Dr. _%#NAME#%_, the patient's endocrinologist, who agreed with this approach. 3. Check BMP, U/A, UC. 4. Clinical observation. Orders for D-50-W and glucagon on record p.r.n. severe hypoglycemia/altered mental status.
BMP|basic metabolic profile|BMP.|179|182|ASSESSMENT AND PLAN|9. History of migraine headaches. Will have available Imitrex 50 mg p.o. x1 p.r.n. 10. Hypokalemia. We will start KCL or potassium chloride 40 mEq x1 and reassess with tomorrow's BMP. 11. Leukopenia. Most likely secondary to medications, however, will get white blood cell count with differential tomorrow a.m. We very much appreciate the consultation and we will certainly follow this patient regarding her upcoming labs and any new issues should they arise.
BMP|basic metabolic profile|BMP,|194|197|LAB DATA|No lateralizing extremity weakness. Romberg negative. Cerebellar function intact. There is mild tremor of the distal upper extremities. No rigidity. LAB DATA: From _%#MMDD#%_, includes a normal BMP, with glucose 118. CO2 mildly reduced at 19, normal Cbc with hemoglobin 16.5. MCV of 98. Platelet count 229,000. BUN 10. Creatinine of 1.2. Normal liver profile.
BMP|basic metabolic profile|BMP|182|184|ASSESSMENT/PLAN|2. Postoperative agitation and dizziness possibly secondary to anesthesia. Vistaril has seemed to help significantly. 3. Chronic kidney disease, stable clinically. We will recheck a BMP tomorrow in the a.m. 4. Hypertension, controlled. We will continue with current medication.
BMP|basic metabolic profile|BMP.|156|159|ASSESSMENT|3. Hyponatremia, probably from administration of hypotonic fluids. We will change IV fluid to normal saline 125 mL per hour and we will continue to monitor BMP. 4. History of depression on Celexa. 5. Insomnia, currently on Ativan p.r.n., but if the patient is still having difficulty sleeping, we should resume Ambien, which he was taking from home.
BMP|basic metabolic profile|BMP|186|188|LABORATORY DATA|Strength 5/5 bilaterally. Deep tendon reflexes of the patella was within normal limits and equal bilaterally. Grip strength was strong bilaterally. LABORATORY DATA: From _%#MMDD2004#%_: BMP within normal limits except for glucose of 115 and calcium 7.3. CBC is significant for low hemoglobin at 12.4 and low hematocrit at 36.6. The patient's WBC is 4.1, platelets 189.
BMP|basic metabolic profile|BMP,|146|149|PLAN|5. IV fluids until adequate p.o. Increase rate to 125 cc/hour. 6. Parameters for which nursing staff should call. 7. Recheck a.m. labs, including BMP, magnesium, and hemoglobin. Thank you for the consultation. Will follow along with you.
BMP|basic metabolic profile|BMP|325|327|LABORATORY DATA|INR 4.82, PTT 41. Potassium 3.2, calcium 7.8, amylase 143, phosphorus 1.2, magnesium 1.9. Potassium 2.8, calcium 8.2, phosphorus 0.7. ALT 2994, AST 1273, conjugated bilirubin 3.1, bilirubin delta 1, total bilirubin 6.7, albumin 2.4, protein 4.6. INR 2.87. Magnesium 2.3. _%#MMDD2006#%_: Potassium 3.1, calcium 8.2, remaining BMP within normal limits. Phosphorus 1.3, magnesium 2.0. Conjugated bilirubin 4.1, bilirubin delta 1.4, total bilirubin 8.1, albumin 2.2, protein 4.6, ALT 2168, AST 278.
BMP|basic metabolic profile|BMP|183|185|LABORATORY DATA|Left leg reveals contractures at the knees. Left foot is warm to the touch. LABORATORY DATA: Postoperative labs included a hemoglobin of 8.5 down from his preoperative level of 10.1. BMP is normal. I would add that his preoperative labs were remarkable for hemoglobin A1C of 5.5, hemoglobin 10.1 with a MCV of 88.
BMP|basic metabolic profile|BMP|269|271|LABORATORY|Normoactive bowel sounds. EXTREMITIES: Unremarkable. NEUROLOGIC: Grossly intact. LABORATORY: The patient is now status post 3 units of packed RBCs with repeat hemoglobin pending. Hemoglobin following 2 units was 7.8. Iron level 21, iron saturation 5, ferritin level 4, BMP with unremarkable labs. Admission hemoglobin 5.7, platelet count 363,000, white count 4900. ASSESSMENT: 1. Microcytic anemia, consistent with iron deficiency. 2. Prior history of anemia in 2002.
BMP|basic metabolic profile|BMP|156|158|LABORATORY DATA|ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: No pedal edema. Pulses are intact. LABORATORY DATA: Preoperative labs were reviewed. An EKG is normal. BMP is normal. Hemoglobin is 15.0.
BMP|basic metabolic profile|BMP|214|216|ASSESSMENT/PLAN|PSYCHIATRIC: Mood is stable, affect is appropriate. LABORATORY: Pending. ASSESSMENT/PLAN: 1. Orthostatic hypotension; encourage fluids, continue to monitor, continue hydrochlorothiazide with parameters. Will get a BMP in the a.m. If patient continues to have tachycardia will check an EKG, encourage patient to move from sitting to standing very slowly.
BMP|basic metabolic profile|BMP.|90|93|LABORATORY|Cranial nerves II-XII appear intact. Her gait is quite steady. LABORATORY: Normal CBC and BMP. Her urinalysis revealed positive hematuria, otherwise unremarkable. ASSESSMENT/PLAN: 1. Depression. She is followed by Dr. _%#NAME#%_.
BMP|basic metabolic profile|BMP|266|268|PHYSICAL EXAMINATION|There are nonspecific repolarization changes diffusely. His chest x-ray shows diffuse reticular interstitial infiltrates, most pronounced in the left base. His CT of the abdomen showed mild degree of subcutaneous edema but no definite intra-abdominal pathology. His BMP is notable for slight elevated blood sugar at 130, creatinine of 1.5 and is otherwise normal. His TSH and troponin are normal with mildly elevated BNP at 472.
BMP|basic metabolic profile|BMP|157|159|LABORATORY & DIAGNOSTIC DATA|SKIN: Without rashes or ulcerations. PSYCHIATRIC: No anxiety or depression. LABORATORY & DIAGNOSTIC DATA: She had a hemoglobin this morning that was 15. Her BMP was reviewed, it was normal and her creatinine was normal. ASSESSMENT/PLAN: 1. Hypertension. I would recommend continuing her Norvasc and Maxzide.
BMP|basic metabolic profile|BMP|156|158|RECOMMENDATIONS|4. Ulcerative colitis. 5. GERD. RECOMMENDATIONS: The patient's blood pressure will be monitored. Hydrochlorothiazide will be held for the first day or 2. A BMP will be obtained in the morning. He will be maintained on his usual GI medications. Thank you for having me see this patient. DISCUSSION: _%#NAME#%_ _%#NAME#%_ is a 68-year-old man who underwent cervical spine decompression with C5-6 foraminotomy by Dr. _%#NAME#%_.
BMP|basic metabolic profile|BMP|84|86|LABORATORY DATA|Sensation is intact to light touch. Strength is 5/5 bilaterally. LABORATORY DATA: A BMP was normal. Sodium 136, potassium 3.8, calcium level was slightly decreased at 8.1. Troponin was normal at 0.04. EKG showed sinus rhythm with a first-degree the atrioventricular block with a rate of 67.
BMP|basic metabolic profile|BMP|96|98|LABORATORY DATA|No mass. Extremities reveal normal muscular bulk. Her gait her appears normal. LABORATORY DATA: BMP is within normal limits other than a glucose slightly elevated at 136. Liver function tests normal. TSH is normal at 1.38. CBC is unremarkable.
BMP|basic metabolic profile|BMP|238|240|IMPRESSION AND PLAN|If quinolones are necessary could retry it under close observation. 4. Chronic fatigue, most likely multifactorial, secondary to her history of microcytic, hypochromic anemia and a recent history of hypokalemia; would recheck her CBC and BMP today.
BMP|basic metabolic profile|BMP|140|142|LABORATORY EXAM|VITAL SIGNS: The patient is currently afebrile with stable vital signs. LABORATORY EXAM: White count 6.6, hemoglobin 9, platelet count 251, BMP is within normal limits, magnesium of 2, CRP 35.8, ESR 133. ASSESSMENT: The patient is a 53-year-old male with a past medical history of T10 paraplegia with a complex sacral decubitus ulcer in extensive cavity likely pelvic osteomyelitis with no evidence of systemic infection or sepsis at this time.
BMP|basic metabolic profile|BMP.|182|185|LABORATORY DATA|The ventricular rate was relatively fast during the VT and the longest run was about 15 cycles. LABORATORY DATA: His current labs showed elevated troponin but normal white count and BMP. ASSESSMENT AND RECOMMENDATIONS: This is a relatively young man who had acute inferior myocardial infarct.
BMP|basic metabolic profile|BMP|139|141|LABORATORY DATA|EKG revealed normal sinus rhythm with questionable Q-waves in the inferior leads. No wall motion abnormality is noted on his echo. CBC and BMP were normal.
BMP|basic metabolic profile|BMP.|168|171|LABORATORY|She is currently receiving TPN through a peripherally inserted central catheter (PICC). LABORATORY: Include recent hemoglobin of 10.5 on _%#MMDD#%_ and a fairly normal BMP. Her preoperative CEA level was 3.8 (normal 0-3). ASSESSMENT: Stage III (T3 N1 MX) colon cancer- _%#NAME#%_ seems to be nearly recovered from her recent hemicolectomy surgery.
BMP|basic metabolic profile|BMP|179|181|RECOMMENDATIONS|2. Mild hypernatremia, dehydration secondary to ethanol use. The patient's oral intake has been adequate since admission. RECOMMENDATIONS: The patient's intake will be monitored. BMP will be repeated. To be monitored for alcohol withdrawal. I will be able to see him during his hospitalization for concurrent medical issues.
BMP|basic metabolic profile|BMP|163|165|LABORATORY  DATA|ABDOMEN: Positive bowel sounds, soft and nontender. EXTREMITIES: No edema. LABORATORY DATA: Hemoglobin 13.9, potassium 3.6. Her EKG shows normal sinus rhythm. Her BMP from _%#MMDD2007#%_, sodium 137, potassium 3.3, chloride 99, bicarbonate 29, BUN 12, creatinine 0.83, calcium 9.2. Glucose was 103. ASSESSMENT/PLAN: 1. Hypertension, well controlled on her current medications. Will continue her current medications and follow.
BMP|basic metabolic profile|BMP,|222|225|ASSESSMENT/PLAN|LABS: Creatinine this morning is 5.31. UA is negative. There is a culture that showed E-Coli, there is a repeat culture that is pending. ASSESSMENT/PLAN 1. Tachycardia with possible sepsis. Will DC Levaquin. Will repeat a BMP, will place the patient on renal dose Zosyn. Will check an EKG to insure it is sinus tachycardia, will change her fluids to normal saline without potassium.
BMP|basic metabolic profile|BMP|130|132|LABORATORY|LABORATORY: CBC shows mildly elevated white count probably due to stress at 14, good hemoglobin, normal platelets, INR is normal. BMP within normal limits and ethanol level was 0.07. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 37.2, pulse 64, blood pressure 131/76, respirations 18, satting 95% on room air.
BMP|basic metabolic profile|BMP|294|296|HOSPITAL COURSE|4. Chronic renal failure. The 24-hour urine creatinine clearance was 15; she will not need scheduled dialysis but will rather be continued to be dialyzed for symptoms and/or for electrolytes abnormalities. She is to follow up with Dr. _%#NAME#%_ in the renal clinic within the next week with a BMP at that visit. We are unable to schedule this over the weekend, and the patient was instructed to call on Monday morning and set up an appointment for as soon as possible within the next week.
BMP|basic metabolic profile|BMP|172|174|ASSESSMENT AND PLAN|10. Will check his CT scan of his abdomen and pelvis to rule out any METS. He might also need PET scan. Will also get his ABGs and followup chest x-ray and a.m. labs, CBC, BMP and daily INR. Will get today, echocardiogram, bilateral lower extremity Doppler and if possible CT scan of his abdomen and pelvis. Will put in Pulmonary, Oncology and Respiratory consults for BiPAP settings.
BMP|basic metabolic profile|BMP|160|162|FOLLOWUP LAB TESTS|3. Followup with GI Clinic with Dr. _%#NAME#%_ as needed for teaching or problems with her GJ tube. FOLLOWUP LAB TESTS: CBC with differential and platelets and BMP every Monday and Thursday via home care. DISCHARGE MEDICATIONS: 1. Zoloft 25 mg p.o. daily. 2. Peridex 15 mL p.o. 2 times a day.
BMP|basic metabolic profile|BMP,|123|126|HOSPITAL COURSE|No report was available for this CT. The head CT report from _%#MM#%_ _%#DD#%_, 2006, reported a normal brain scan. A CBC, BMP, INR, PTT, and lipid panel were all unremarkable. Cholesterol was 145 with LDL cholesterol being 78 and HDL 43. Urinalysis was performed and was unremarkable. The patient presented was informed of his MRI/MRA results on _%#MM#%_ _%#DD#%_, 2006, and a long discussion did take place regarding our concerns and plan.
BMP|basic metabolic profile|BMP,|117|120|INSTRUCTIONS|8. Hydralazine 25 mg p.o. q 6 hours, recently increased from 10 mg a day on _%#MMDD2006#%_. INSTRUCTIONS: Daily INR, BMP, CBC with platelets q 4-8 hours. Call MD if heart rate greater than 100 and less than 50, systolic blood pressure greater than 165, less than 100, respiratory rate greater than 25, less than 10.
BMP|basic metabolic profile|BMP|188|190|LABORATORY DATA|MUSCULOSKELETAL: Equally strong hand grips; leg strength is moderate to strong. LABORATORY DATA: 1. _%#MMDD2005#%_: WBC 4.6, hemoglobin 9.3, and platelet count 292,000. 2. _%#MMDD2005#%_: BMP was normal with the following exceptions: CO2 34, glucose 202, BUN 31, creatinine is normal at 1.45. Magnesium 1.2 and phosphorus 3.0.
BMP|basic metabolic profile|BMP|325|327|HOSPITAL COURSE|There is a question if this was true hyperkalemia or a lab error, however, given the potential grave consequences we will at this time recommend not restarting spironolactone in combination with the lisinopril. We feel this is too high a risk to have a repeat episode of hyperkalemia. 2. CHF. The patient was admitted with a BMP of 2200 and fairly mild symptoms, and no evidence on chest x-ray of worsening failure. The patient was diuresed gently and at her baseline. A BMP was checked which was 1100 which we feel for her represents her equilbrated state in CHF.
BMP|basic metabolic profile|BMP|144|146|PHYSICAL EXAMINATION|NEUROLOGIC: She has cerebral palsy. She is able to say one or two words, but seemed very distressed at times during examination. She had normal BMP on admission. HOSPITAL COURSE: PROBLEM #1: Fluids, electrolytes and nutrition: The patient was given her usual regimen with her PEG tube feedings which amounts to four feedings per day.
BMP|basic metabolic profile|BMP|181|183|LABORATORY DATA|She had moderate aniso, slight poikilocytosis, positive hypochromasia. Sodium 136, potassium 5.1, chloride 100, bicarb 25, BUN 63, creatinine 1.8, glucose 129, calcium 8.4, PTT 34, BMP greater than 1300. INR 3.76 on _%#MM#%_ _%#DD#%_, 2002. ASSESSMENT AND PLAN: 1) Congestive heart failure exacerbation in a patient with known coronary artery disease.
BMP|basic metabolic profile|BMP|166|168|ADMITTING LABS|MUSCULOSKELETAL: Exam was normal. SKIN: Revealed mild erythema near his catheter site in his abdomen region. NEUROLOGICAL: Grossly normal. ADMITTING LABS: A complete BMP was done and normal, sodium 139, potassium 3.8, chloride 105, bicarb 27, BUN 17, creatinine 0.96, glucose 81, magnesium 1.8, phosphorous 4.7, ALT 48, AST 33, bili total 0.2, Alka phos 101 and INR 1.16. HOSPITAL COURSE: PROBLEM #1 FEN: _%#NAME#%_ received IV fluids per the chemo protocol.
BMP|basic metabolic profile|BMP|180|182|LABORATORY|The rash is blotchy and pink. It is nonscaling in appearance. Neurological examination is grossly within normal limits. LABORATORY: Laboratories at the time of admission include a BMP which is normal with a sodium 135, potassium 3.8, BUN 15, and creatinine of 0.43, calcium is 7.2, ionized calcium 4.4, magnesium 1.7, phosphorous 6.1. CBC has a white count of 7.1 with a normal differential and a hemoglobin of 7.6. Platelets are 319.
BMP|basic metabolic profile|BMP|149|151|PERTINENT LABORATORY EXAMS|5. On _%#MMDD2002#%_, vancomycin level was 9.3. 6. On _%#MMDD2002#%_, a white count was 6.6, hemoglobin 9.4., platelets 259,000, MCV 77, and RDW 19. BMP is as follows: Within normal limits with creatinine noted to be 0.6, phosphorus 3.6, calcium 9.2, and magnesium 1.5. DIAGNOSTIC STUDIES: EKG on _%#MMDD2002#%_: Sinus rhythm with a first degree AV block, otherwise within normal limits.
BMP|basic metabolic profile|BMP,|174|177|FOLLOW UP|2. With Dr. _%#NAME#%_ _%#NAME#%_ in pulmonology in _%#NAME#%_-_%#NAME#%_ building _%#MM#%_ _%#DD#%_ at 2 p.m. 3. Prior to his appointment with Dr. _%#NAME#%_, he is to have BMP, magnesium, phosphorus, CBC with differential and platelets in the first- floor lab on _%#MM#%_ _%#DD#%_ at 11 a.m.
BMP|basic metabolic profile|BMP|240|242|ADMISSION DIAGNOSIS|It is clean and dry. On his skin exam, he does have 3 areas of skin breakdown with healing blisters and abrasions on his left ankle. There is no tenderness with these areas and no drainage. LABORATORY: On admission, _%#NAME#%_ has a normal BMP and normal hepatic panel on admission. His albumin level is 513. He had a negative UA. His white count was 6.4, with an ANC of 2.6. His hemoglobin was 12.0 and a platelet count of 250.
BMP|basic metabolic profile|BMP,|276|279|FOLLOW UP|FOLLOW UP: To have a CBC with differential and platelets drawn twice weekly at West House with results faxed to _%#NAME#%_ _%#NAME#%_ at _%#TEL#%_. He was to follow up with the hematology/oncology clinic on _%#MM#%_ _%#DD#%_, 2003, with a CBC with differential and platelets, BMP, magnesium phosphatase, LFTs, and a UA with his next admission for chemotherapy which would be methotrexate. He is on a regular diet. His activity was as tolerated with crutches.
BMP|basic metabolic profile|BMP|190|192|ADMISSION LABORATORY DATA|ADMISSION LABORATORY DATA: Stool Rotavirus, salmonella, shigella, campylobacter, E. coli culture and Clostridium difficile culture and antigen are all pending at the time of this dictation. BMP was drawn in the emergency department and shows a sodium of 139, potassium level of 6.4, chloride level of 110, bicarbonate level of 20, BUN of 10 and creatinine of 0.37. Glucose level 85.
BMP|basic metabolic profile|BMP|171|173|DISCHARGE INSTRUCTIONS|10. Erythromycin 85 mg p.o. or G-tube q.i.d. 11. Tobramycin 45 mg p.o. or G-tube q.8h. x 2 weeks. DISCHARGE INSTRUCTIONS: 1. Follow up with Dr. _%#NAME#%_ in one week. 2. BMP with magnesium and phosphorus on Monday, _%#MM#%_ _%#DD#%_, 2002, to follow up on total parenteral nutrition administration. 3. Diet as follows: 750 cc of Tolerex plus 30 cc of Microlipid.
BMP|beta-natriuretic peptide:BNP|BMP|139|141|LABORATORY|Her sodium was 135, potassium 4.9, chloride 104, bicarb 17, BUN 61, creatinine 2.7, glucose 142, calcium 8.1, magnesium 2.2, and phos 4.4. BMP was noted to be elevated at 1742. Alk phos 195, total bili 2.3, ____ 1.4, CRP 24.2, albumin 2.3. HOSPITAL COURSE: PROBLEM #1: Abdominal pain and liver abscess.
BMP|basic metabolic profile|BMP|119|121|PERTINENT LABORATORY TESTS|It was 8.9, and he did receive two units of packed cells at that time. PERTINENT LABORATORY TESTS: 1. _%#MMDD2003#%_ - BMP within normal limits and with a creatinine noted to be 0.8 and calcium 8.3. 2. _%#MMDD2003#%_ - Hemoglobin 10.1. 3. _%#MMDD2003#%_ - C-reactive protein 2.59 and ESR 49 (these are goin g down).
BMP|basic metabolic profile|BMP|234|236|LABORATORY DATA|Elevated RDW at 15.1, WBC 7100, hemoglobin 15.3, platelet count 208,000, with mild elevation of neutrophils at 71% and mild decrease in lymphocytes at 21%. _%#MMDD2006#%_: decreased anion gap 5.3, decreased calcium 8.6, otherwise all BMP values within normal limits. CK was normal at 121. Admission EKG showed sinus rhythm with sinus arrhythmia, ventricular rate 78, and QTC length 419.
BMP|basic metabolic profile|BMP|115|117|LABORATORY DATA|PSYCHIATRIC: Alert and oriented, appropriate with responses, direct eye contact. LABORATORY DATA: _%#MMDD2003#%_ - BMP was within normal limits except potassium is borderline at 3.6. Creatinine is 1.1. Phosphorus and magnesium were within normal limits.
BMP|basic metabolic profile|BMP|145|147|LABORATORY|LABORATORY: Preoperative labs included a white count of 3.7, hemoglobin 11.6, and platelets 128. INR was 1.04 and PTT 24. Magnesium level was 2. BMP was remarkable for a creatinine of 1.33, BUN 34, albumin 4.0, and total protein 8.3. All other values were within normal limits.
BMP|basic metabolic profile|BMP,|188|191|PHYSICAL EXAMINATION|Pulmonary artery pressure 49/19. Mixed venous oxygenation was 37%. Pulmonary artery regimen was 30. Cardiac output vesiculation was 1.1 and DEXA 0.6. The patient was started on Milrinone, BMP, and Lasix in the Medical ICU. The patient was unable to converted out of his rhythm of atrial fibrillation. Patient underwent a transesophageal echogram on the _%#DD#%_ of _%#MM#%_, which showed an injection fraction of about 10%.
BMP|basic metabolic profile|BMP|137|139|ASSESSMENT|We will check urine studies at this time to further evaluate the hyponatremia. We will rehydrate her with IV normal saline and recheck a BMP in the morning. 5. Ascites and cirrhosis: The patient does have a chronic hepatic issue which will only be resolved with liver transplantation.
BMP|basic metabolic profile|BMP,|226|229|LABORATORY|His speech is clear. Psychiatric: Alert and oriented x 4 with appropriate responses as well as direct eye contact. LABORATORY: 1. On _%#MMDD2004#%_, C. Difficile, negative. 2. On _%#MMDD2004#%_, magnesium 1.8, phosphorus 3.4. BMP, within normal limits except the following: chloride 110, BUN 29. Creatinine is normal at 0.81. Calcium is 7.0. 3. On _%#MMDD2004#%_, WBC 6.9, hemoglobin 10.1, platelet count 52,000.
BMP|basic metabolic profile|BMP|152|154|ACTIVITY|We are recommending that at the first clinic visit, the patient does have a CBC with platelets and differential. We are also recommending that he get a BMP at his first meeting. Additionally, we have recommended that he gets a cyclosporine level at his first clinic. The family will be instructed to not give the oral dose of cyclosporine on the morning of his clinic date.
BMP|basic metabolic profile|BMP|211|213|ADMISSION LABS|HEART: Regular rate and rhythm. No murmurs. Good pulses. ABDOMEN: Soft, nontender, slightly distended, normal bowel sounds. SKIN: Without rashes. NEUROLOGIC: Unremarkable with her being alert. ADMISSION LABS: A BMP remarkable for a low potassium of 2.9 and also had sodium 137, chloride 107, bicarb 23, BUN 4, creatinine 0.49, glucose 82 and calcium 8.6. Her CBC had a normal white count of 10.5, a decreased hemoglobin of 9.6 with an MCV of 78 and a platelet count of 185,000.
BMP|beta-natriuretic peptide:BNP|BMP|187|189|PROBLEM #4|Differential diagnoses include congestive heart failure with infection. The patient did not have any fevers, cough, but the patient did have a history of congestive heart failure and his BMP was elevated at 758. The patient was subsequently switched to IV Lasix 60 mg b.i.d. with good urine output. The patient's oxygen saturations initially improved, but at the time of this dictation, the patient again is requiring oxygen despite having good diuresis.
BMP|basic metabolic profile|BMP|158|160|ASSESSMENT AND PLAN|It is unclear whether she has baseline renal dysfunction or whether this is related to mild sepsis. We will provided IV fluids at 100 cc/hr and follow up her BMP this evening and tomorrow morning. We will be holding her antihypertensives, including her Lasix.
BMP|basic metabolic profile|BMP,|163|166|FOLLOW-UP|DISCHARGE MEDICATIONS: 1. Lexapro 10 mg p.o. q.a.m. 2. Concerta 45 mg p.o. q.a.m. FOLLOW-UP: 1. Dr. _%#NAME#%_ on _%#NAME#%_ to _%#NAME#%_ for a follow-up weight, BMP, and consideration of a Holter monitor for sinus bradycardia. 2. Follow-up in the F-UMC Pediatric Renal Clinic on Tuesday, _%#MMDD2003#%_, appointment to be arranged with _%#NAME#%_ at _%#TEL#%_.
BMP|beta-natriuretic peptide:BNP|BMP|226|228|PHYSICAL EXAMINATION|The EKG shows a right bundle branch block with perhaps nonspecific ST and T changes which does not seem distinctly changed from previous EKG. The lab work shows normal troponin and myoglobin. She does have a slightly elevated BMP at 114, suggesting fluid overload. She has a slightly low potassium of 3.2. Her renal function is normal and her hemoglobin is 12.1, white count 6,900 with a normal differential.
BMP|beta-natriuretic peptide:BNP|BMP|355|357|LABORATORY|JVD was positive at 11 cm. Cardiovascular: Regular rate and rhythm, S1, S2, 3/6 harsh systolic murmur heard over the second intercostal space. Lungs: Clear to auscultation bilaterally. Neurologic: Expressive aphasia. LABORATORY: WBC 15.4, hemoglobin 10.5, platelets 131,000, INR 1.2, sodium 130, potassium 4.2, chloride 97, CO2 32, BUN 13, creatinine .9, BMP 400, calcium 8.5. Chest x-ray on admission showed bi-basilar infiltrates with progression of mixed interstitial and alveolar infiltrate changes in the upper lungs with stable bi-basilar pulmonary infiltrate and pleural fluid.
BMP|basic metabolic profile|BMP|195|197|ASSESSMENT AND PLAN|I do not believe her elevated BUN and creatinine are related to decreased cardiac output though possible. 11. Anion gap metabolic acidosis. Possibly related to decreased perfusion. We will check BMP following fluid resuscitation at this time. If persistently elevated, will check CK and salicylate, will also check a lactate level.
BMP|basic metabolic profile|BMP|290|292|LABORATORY DATA|She does withdraw to pain. SKIN: Negative. LABORATORY DATA: ABG obtained in the ER prior to intubation notable for pH of 7.3, pCO2 87, pO2 63, and bicarbonate of 41. Saturation is 86% on 10 liter facemask. Brain-natriuretic peptide is 1230, troponin is 0.14. Myoglobin is negative. Initial BMP notable for potassium of 6.8. This improved on followup metabolic panel to 5.4. BUN is 51 and creatinine 1.6. CBC is essentially normal.
BMP|basic metabolic profile|BMP|157|159|LABORATORY DATA|SKIN AND NEUROLOGIC: Examinations are grossly intact. LABORATORY DATA: Initial troponin was mildly elevated to 1.36, second troponin is elevated to 3.4. The BMP is essentially normal except for mildly elevated glucose at 136. Myoglobin was mildly elevated as well to 186. The EKG on admission was reviewed and is essentially normal with sinus bradycardia.
BMP|basic metabolic profile|BMP.|216|219|RECOMMENDATIONS|Fluid restriction should be continued. 6. I also suggesting having Physical Therapy evaluate her prior to discharge. RECOMMENDATIONS: 1. Change Toprol-XL to Coreg. 2. Change Aldactone to 12.5 mg daily with follow-up BMP. 3. We will change the lisinopril to 10 mg twice a day. 4. We will repeat a chest x-ray in the morning, and if she still has moderate effusion, can consider pleural tap under ultrasound guidance.
BMP|basic metabolic profile|BMP|249|251|ASSESSMENT/PLAN|At this time, presence of right ventricular dysfunction will make therapy with diuresis somewhat challenging. Excessive diuresis could lead to enteral left-sided intravascular volume depletion and progressive renal insufficiency. I would follow the BMP closely. If she agrees to coronary angiogram, I would certainly perform right heart catheterization with an intention to assess the wedge pressure.
BMP|basic metabolic profile|BMP,|154|157|RECOMMENDATIONS|Thus our recommendations are as follows. RECOMMENDATIONS: 1. Incentive spirometry 10 times per hour while awake. 2. Consider cardiac evaluation including BMP, ECG, and echocardiogram with bubble study to rule out intracardiac shunt. 3. Continue to obtain spot pulse oximetry measurements on the patient and titrate supplemental oxygen as needed to keep the saturation above 90%.
BMP|basic metabolic profile|BMP|142|144|PLAN|2. Morphine sulfate PCA, zero continuous for now. 3. Vancomycin IV per spine. 4. Intravenous fluid support. 5. Serial followup labs including BMP and hemoglobin. Transfuse p.r.n. hemoglobin less than 10 with prior question of coronary artery disease. 6. Zofran p.r.n. for nausea. 7. Patient supine for 72 hours due to dural tear (as above).
BMP|beta-natriuretic peptide:BNP|BMP|151|153|ASSESSMENT/PLAN|His respiratory distress is most likely multifactorial in etiology. His clinical presentation, the initial chest x-ray, and the traumatically elevated BMP are all consistent with acute superimposed on chronic heart failure. He has had a good diuresis with greater than a nine pound weight loss over the course of the past five days, and his creatinine has remained relatively stable.
BMP|basic metabolic profile|BMP.|140|143|PLAN|Certainly may have blood pressure lowering effect from narcotic analgesia, bed rest, etc. 5. Follow up labs including serial hemoglobin and BMP. 6. Encourage incentive spirometry. 7. Resume other home medications including Lipitor and Timolol. Enteric-coated aspirin if okay with Dr. _%#NAME#%_. 8. Apnea monitor on morphine sulfate PCA.
BMP|basic metabolic profile|BMP,|66|69|PLAN|Will need Foley catheter placement perioperatively. PLAN: 1. CBC, BMP, magnesium. 2. Accu-Chek with sliding scale regular insulin coverage. 3. Attempt to obtain copy of old EKG from Fairview Lakes. 4. Foley catheter placement. 5. Anticipate surgery to be performed under spinal anesthesia.
BMP|basic metabolic profile|BMP|170|172|ASSESSMENT AND PLAN|We are going to check apical heart rates q. shift and call if his heart rate is greater than 140 or less than 160. In addition, we are also going to do a magnesium and a BMP in the morning, right now we are going hold digitalis to see how he does on this medication. Thank you for the consultation we will continue to follow this patient.
BMP|basic metabolic profile|BMP|194|196|LABORATORY DATA (1/18/02)|Sensation is intact to light touch. Strength is 5/5 bilaterally. Gait is within normal limits. Reflexes are 1+ bilaterally. LABORATORY DATA (_%#MMDD2002#%_): White blood cell count was 9.6. His BMP was within normal limits with the exception of an elevated blood glucose at 143. His eye culture shows light growth of coagulase negative staph that is highly-susceptible to ciprofloxacin.
BMP|basic metabolic profile|BMP.|174|177|PLAN|8. Bilateral carpal tunnel release. PLAN: 1. We will be happy to follow the patient on FUTS when transferred later today. 2. Follow up labs to include recheck hemoglobin and BMP. 3. Start iron therapy. 4. Encourage incentive spirometry. 5. Psychiatry consultation regarding depression.
BMP|basic metabolic profile|BMP|180|182|LABS UPON ADMISSION|SKIN: No rashes. NEUROLOGIC: Normal strength, 2+ patellar reflexes. LABS UPON ADMISSION: Negative tox screen, AST 20 , ALT 25, acetaminophen 97, urine pregnancy test was negative. BMP was normal. CBC showed a white blood cell count of 8.8. Hemoglobin was 15. Platelets 342. HOSPITAL COURSE: PROBLEM #1: GI. _%#NAME#%_ was initially placed on a clear diet, but then advanced to a regular diet.
BM|bowel movement|BM|397|398|HISTORY OF PRESENT ILLNESS|ADMITTING DIAGNOSIS: Fibrous tumors. DISCHARGE DIAGNOSIS: Recurrent sarcoma. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 62-year-old female with a several hour history of "bad cramps quote" prior to admission and was postop week 2 from resection of fibrous tumors who was passing flatus prior to previous discharge after surgery and who was tolerating a regular diet and who also had a BM 2 days after discharge. However, since the prior discharge 2 weeks ago, the patient started developing 8/10 intermittent colicky abdominal pain with tenesmus on the day prior to admission and emesis x3.
BM|bowel movement|BM.|212|214|HOSPITAL COURSE|The patient did not have any nausea or vomiting and on postoperative day #2 Foley was removed and the NG tube was also removed because of decreased output. On postoperative day #3, the patient had flatus, but no BM. She was tolerating clears without any nausea or vomiting and on night of postoperative day #3, the patient was tolerating a regular diet and had bowel movements.
BM|bowel movement|BM"|227|229|BRIEF  HISTORY AND HOSPITAL COURSE|It is also possible that he may have had a vagal syncope from urinary retention or probably could have fallen in an attempt to use the restroom. During my visit here, he had gotten up quite quickly because he "needed to have a BM" and required 2-3 nursing staff just for redirection. I wonder if he may have tripped accidentally. He was seen by PT here and they did recommended that he would benefit from further PT.
BM|bowel movement|BM|254|255|PHYSICAL EXAMINATION|Vital signs stable. PHYSICAL EXAMINATION: Initial and first day of hospitalization includes lungs with decreased breath sounds at bases. Abdomen distended, tender in the epigastric and lower pelvic area, decreased bowel sounds. She had a small amount of BM on _%#MMDD2006#%_. Soap suds enema were to be continued. She is tolerating magnesium citrate oral p.o. well. CAT scan of the abdomen and pelvis is scheduled on _%#MMDD2006#%_.
BM|bowel movement|BM,|113|115|HOSPITAL COURSE|Her creatinine improved to 1.2. Her calcium dropped to 11.2. Her iron studies were mixed. GI saw her due to dark BM, but there was no blood and it was recommended that she continue intravenous proton pump inhibitor which could be switched to oral and it was decided not to do a CT scan due to her poor renal function.
BM|bowel movement|BM|261|262|HOSPITAL COURSE|3. Fluids, electrolytes, and nutrition/gastrointestinal. The patient did experience some significant abdominal pain on _%#MM#%_ _%#DD#%_, 2004, and was noted to have not had a bowel movement for 5 days. He was treated with 17 g Miralax which produced one large BM 10 hours later and resolved the pain. DISCHARGE MEDICATIONS: 1. Bactrim DS 1 tablet PO b.i.d. Monday and Tuesday.
BM|bowel movement|BM|134|135|REVIEW OF SYSTEMS|CARDIOVASCULAR: Hypertension noted, no chest discomfort again. GI: No symptoms. There was a bit of abdominal cramming with her bloody BM this evening. GU: She has nocturia normally, two or three times per night. MUSCULOSKELETAL: There has been no arthritic pain, certainly not any usage of non-steroidal medication.
BM|bowel movement|BM|241|242|REVIEW OF SYSTEMS|SOCIAL HISTORY: Single, she lives with her granddaughter. She has been in the United States for the past four years, has four children, does not smoke and drinks no alcohol. REVIEW OF SYSTEMS: Positive for constipation, per patient her last BM was 15 days ago. In addition, she states she did have an MRI done of the LS spine sometime in _%#MM2005#%_. However, she could not disclose the location of the exam, who ordered it, who her primary physician is, or the exact findings on MRI results.
BM|bowel movement|BM.|168|170|HOSPITAL COURSE|The patient is a 41-year- old woman with a history of umbilical hernia diagnosed approximately six months ago. She has had occasional abdominal pain. She had decreased BM. She presented with nonreducible, severe, abdominal pain to the ER. Please see initial H&P by Dr. _%#NAME#%_ for details. The patient had a cold pack applied to her abdomen in the ER and umbilical hernia was reduced with resolution of her pain.
BM|bowel movement|BM.|155|157|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Benefiber 1 packet p.o. t.i.d. for diarrhea in 60 mL of beverage of choice. 2. Immodium 2 mg p.o. q.i.d. and as needed for loose BM. Up to 16 mg/24 hours. 3. Zinc sulfate 220 mg p.o. daily. 4. Multivitamin with minerals, 1 daily. 5. Topamax 100 mg p.o. b.i.d. for seizures.
BM|bowel movement|BM|143|144||My key findings: CC: abdominal pain, vomitting HPI: 22 yo woman with DM1 s/p failed kidney transplant with abd. pain, N/V for 2-3 days. Pt had BM last night at 7, nl, no blood. She also c/o sore throat and right ear pain. Exam: VSS as per EMR Gen:NAD, pleasant Pulm:CTABL CV:nl s1s2 no m/r/g Abd:soft ND, mild diffuse tenderness Labs, radiology studies, and medications reviewed.
BM|bowel movement|BM|164|165|HISTORY OF PRESENT ILLNESS|The wound culture was positive for MRSA. Upon her arrival to Fairview Transitional Service, the patient complained of a mild tenderness in her right calf. Her last BM was a couple of days ago. PAST MEDICAL HISTORY: 1. Glaucoma. 2. Hyperlipidemia. 3. History of congestive heart failure.
BM|bowel movement|BM|192|193|DISCHARGE MEDICATIONS|7. Benefiber 2 scoops in water, flushes b.i.d. 8. Colace liquid 100 mg b.i.d., hold if loose stools. 9. Tylenol 650 mg q.4-6 hours p.r.n. for pain. 10. Dulcolax suppository 1 per rectum if no BM x 3 days. TOPICAL PREPARATIONS: 1. Miconazole 2% powder b.i.d. to the groin and scrotum for redness.
BM|bowel movement|BM|237|238|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: The patient is a _%#1914#%_ female with a 2-week history of abdominal pain, constipation, and gas pains. It has been worse the last week, and more severe today. She has had no BM in 2 weeks. She has been trying to take milk of magnesia for the last 1 week, after visiting with her primary physician, and she has had no relief.
BM|bowel movement|BM|131|132|HISTORY OF PRESENT ILLNESS|No change in bowel habits. The patient reportedly was drinking baking soda mixed with water which seems to help her pain. Her last BM was the day prior to this admission. She also reports a decreased appetite because of pain.
BM|bowel movement|BM.|134|136|HISTORY OF PRESENT ILLNESS|She had no shortness of breath. Her last bowel movement had been the day before, and then after admission last night did have a large BM. Her blood sugars typically will in the 200 range. She had not noticed any recent change in the last couple of days.
BM|bowel movement|BM.|136|138|HISTORY OF PRESENT ILLNESS|She has more recently been unable to keep food and fluids down. She states she has mild diffuse abdominal pain which is relieved with a BM. She denied any fevers, chills, or sweats. Up until recently she had been able to eat rice without problems. She states that she had had no chicken intake recently and no sick contacts.
BM|bowel movement|BM|227|228|PAST MEDICAL HISTORY|2. History of coag-negative bacteremia. 3. Mucositis last admission, _%#MM2002#%_. 4. Pyloric stenosis, surgically corrected as a child. 5. Normocytic-normochromic anemia, biopsy _%#MM2002#%_. 6. History of thrombocytopenia on BM biopsy, _%#MM2001#%_. PERTINENT PHYSICAL FINDINGS: Chest x-ray _%#MMDD2003#%_ showed slightly increased air space opacity in the right middle lobe, which may represent early pneumonia, with no significant changes.
BM|bowel movement|BM|186|187|LABORATORY ON ADMISSION|Strength, reflexes symmetrically within normal limits. LABORATORY ON ADMISSION: 1. Hemoglobin 10.4, white count 9.5 with 80% neutrophils and 9% lymphocytes; platelets 480. U/A negative. BM was unremarkable with a creatinine of 0.9. Calcium was 8.9, INR 1.97, PTT 28. Dig level 1.2. 2. CT scan of the head was negative.
BM|bowel movement|BM|166|167|2. FEN|He has been noted to have intermittent retractions, but he has had no recorded apneic spells. 2. FEN: _%#NAME#%_ was started on TPN at time of admission and feeds of BM or SCF 20kcal/oz was started on _%#MMDD2006#%_. Feeds will be advanced today as tolerated to give him a total fluid goal of 130-140ml/kg/day.
BM|bowel movement|BM|169|170|REVIEW OF SYSTEMS|She denies any respiratory complaints, dyspnea, chest pain or cough. At this time, she denies any abdominal pain or bloating. Again, her bowels are working and her last BM was this morning. It was formed and brown in color. She is voiding without any difficulty. She denies any burning or urgency with urination. The remainder of her review of systems is negative.
BM|bowel movement|BM.|176|178|HISTORY|As of _%#MM#%_ _%#DD#%_, 2006, the patient was doing well clinically. No problems with postural dizziness. No chest discomfort, dyspnea, or nausea. Improved appetite. Positive BM. Adequate pain control. Blood pressure in the 120s/70s, heart rate 70s and regular, O2 saturation 95% on room air. Accu-Cheks in the low 100s. Unremarkable cardiopulmonary exam. Felt stable for discharge.
BM|bowel movement|BM,|131|133|HOSPITAL COURSE|Some aphagia, some difficulty swallowing. Cardiopulmonary exam was normal. The patient had normal bowel and bladder function. Last BM, _%#MM#%_ _%#DD#%_, 2006. She is minimum assist with bed mobility, toilet transfers with moderate assist, 40 feet with maximum assist hand held on ambulation.
BM|bowel movement|BM|227|228|* FEN|_%#NAME#%_'s other medical problems that were not an issue during this hospitalization included mild BPD, a VSD and ROP previously requiring laser. Ongoing problems and suggested management: * FEN: _%#NAME#%_ was discharged on BM plus Enfacare to 24 kcal/oz on an ad lib on demand schedule. * GI: _%#NAME#%_ will follow-up with surgery * Cardiac: Tiny VSD that will require cardiology follow-up if the murmur persists.
BM|bowel movement|BM|229|230|* FEN|* _%#NAME#%_'s other medical problems that were not an issue during this hospitalization included mild BPD, a VSD and ROP previously requiring laser. Ongoing problems and suggested management: * FEN: _%#NAME#%_ was discharged on BM plus Enfacare to 24 Kcal/oz on an ad lib on demand schedule. * GI: _%#NAME#%_ will follow-up with surgery * Cardiac: Tiny VSD that will require cardiology follow-up if the murmur persists.
BM|bowel movement|BM.|226|228|ASSESSMENT AND PLAN|Given his low-grade fever, empirically give him 1 dose of Rocephin to cover SBP, at least until we have some fluid analysis. 2. Probable melena. He did report some dark-appearing stools earlier in the day. He reports a couple BM. Currently his hemoglobin is 15.3, although this might be hemoconcentrated from his dehydrated state. He is otherwise hemodynamically stable. Check guaiac stools and consider EGD if there is any evidence of ongoing loss or bleeding.
BM|bowel movement|BM|222|223|HOSPITAL COURSE|On postoperative day, the day of discharge, _%#MMDD2002#%_, the patient had some nausea in the a.m., however was able to tolerate full breakfast and full lunch. The patient is ambulating, demonstrating bowel function with BM and flatus. The pain is well controlled. The patient is being discharged home in good condition without signs of infection at wound site.
BM|bowel movement|BM|151|152|ALLERGIES|On postoperative day five patient began having bowel function demonstrated by flatus. On postoperative day six patient continued with flatus and had a BM Decision was made at this time to discontinue NG tube. Patient tolerated DC of NG tube well. Patient was begun on clears. Patient initially did not tolerate clears well. Patient was made nothing by mouth on postoperative eight.
BM|bowel movement|BM|150|151|ALLERGIES|The patient was advanced to full diet on postoperative day number nine. Patient continued to tolerate p.o. Continued to demonstrate bowel function by BM and flatus. The patient was ambulating and pain was well controlled on postoperative day number nine. Postoperative day ten JP was discontinued. Discharge planning was begun.
BM|bowel movement|BM|159|160|HISTORY OF PRESENT ILLNESS|On the day of admission she reported the abdominal pain persisted until arrival to the emergency department after administration of pain medications. Her last BM was three days prior to admission, which was normal. She reports only minimal flatus since then. She denies any melena or hematochezia.
BM|bowel movement|BM|263|264|HOSPITAL COURSE|MUSCULOSKELETAL: Right knee pain with extension, tender under kneecap. LABORATORY: On admission, white count 5.2, hemoglobin 13.7, hematocrit 40.1, platelets 249. HOSPITAL COURSE: 1. Abdominal Pain: Pain felt unlikely to be secondary to obstruction due to recent BM and flatus, also with an abdominal x-ray negative for obstruction. Patient started on IV Dilaudid for pain control and kept n.p.o. General Surgery was consulted, and CT of the abdomen was obtained.
BM|bowel movement|BM|184|185|HISTORY OF PRESENT ILLNESS|Her diet was clear liquids because of nausea and advanced to full liquids and hot cereal, peanut butter, and toast. She said she has been able to eat very little but she has not had a BM yet. She says Colace usually helps. She was discharged in satisfactory condition with satisfactory prognosis. DISCHARGE INSTRUCTIONS: 1. Diet qualitative diabetic. 2. Appointments 1-2 weeks with Dr. _%#NAME#%_, 1 month with Dr. _%#NAME#%_.
BM|bowel movement|BM|164|165|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: Cardiovascular - see above. Respiratory - see above. No known history of COPD or emphysema in the past. Gastrointestinal - mild nausea today, no BM times two days. Urinary stress and urge urinary incontinence on Detrol LA. Bleeding tendencies, integumentary, endocrine reviews are all negative.
BM|bowel movement|BM|185|186|ASSESSSMENT|ASSESSSMENT: 20-year-old white female with no significant prior medical history admitted for hyperemesis. She is beta HCG negative. I think causes are UTI versus constipation. Her last BM was one week ago and x-ray shows lots of stools. PLAN: IV hydration, the patient received 2 liters of normal saline in the ER with good response.
BM|bowel movement|BM|273|274|HOSPITAL COURSE|Fluids were cut back on the second day and due to the profuse itching, she was switched over to an oral pain medication and did extremely well on Darvocet alone. By the third day, she was improved. She still had no flatus but on the fourth postoperative day, she developed BM and passed flatus and her diet was advanced from clear liquids to a soft diet. IV was discontinued and subsequently she made rapid progress and by the third postoperative day, she was eating a regular diet, totally ambulatory, had no evidence of wound complications or infection and was discharged home with a prescription for Darvocet and she will resume her Cozaar.
BM|bowel movement|BM.|150|152|TRANSFER MEDICATIONS|11. Chronic anemia. TRANSFER MEDICATIONS: 1. Lotrisone CR cream topical to each axilla and under breast b.i.d. 2. Therevac enema rectally daily if no BM. 3. Lexapro 10 mg p.o. daily. 4. Folic acid 1 mg daily. 5. Neurontin 100 mg p.o. daily at 9 a.m. and 2 p.m. as well as 200 mg at bedtime for neuropathic pain.
BM|bowel movement|BM|312|313|HISTORY AND HOSPITAL COURSE|2. Foley. 3. Peripheral IV. HISTORY AND HOSPITAL COURSE: The patient is a 16-year-old male who had presented with complaints of 7 hours of increasing abdominal pain that was localized to the left lower quadrant. He did not have any nausea or vomiting. He also did not have any flatus, but he did have a positive BM that evening of presentation. The patient has a history small-bowel obstruction. Past medical history is significant for Burkitt lymphoma, status post bone marrow transplant 3 years previous, also has gastroesophageal reflux disease.
BM|bowel movement|BM.|134|136|HISTORY AND HOSPITAL COURSE|His pain is controlled. He has not required any pain medicines for the past few days. He had no nausea or vomiting. He has a positive BM. On postoperative day #4, in the evening, the patient would like to return home, and at this time, he is stable for discharge per BMT.
BM|bowel movement|BM.|105|107|DISCHARGE MEDICATIONS|11. Omnicef 600 mg p.o. daily x7 days. 12. Milk of magnesia 30 mL p.o. daily as needed on days 1-2 of no BM. 13. Zofran 4 mg p.o. q.6h. as needed for nausea. The patient may resume bowel programs in the group home which is already established, may substitute home medicines for the above.
BM|bowel movement|BM.|222|224|DISCHARGING MEDICATIONS|DISCHARGING MEDICATIONS: 1. Compazine 5 mg p.o. q. 6 hours p.r.n., she has not needed much of this lately, but I will send her home with it. 2. Megace 400 mg p.o. daily. 3. Senokot-S 1-2 tablets p.o. daily, hold for loose BM. 4. Dilantin 100 mg p.o. daily at noon. 5. Dilantin 300 mg p.o. q.a.m. 6. Dilantin 200 mg p.o. q.p.m. 7. Protonix 20 mg p.o. daily.
BM|bowel movement|BM.|150|152|HISTORY OF PRESENT ILLNESS|The pain started 3-4 days prior to this admission. She denies fever, chills, nauseaor vomiting. She was constipated recentlt and was straining during BM. Abdominal pain became worse today and subsequently came to the emergency room for evaluation. CT scan of the abdomen and pelvis was done at the ED, which showed ruptured appendicitis but no free intraperitoneal air.
BM|bowel movement|BM|151|152|REVIEW OF SYSTEMS|She has 2 grown daughters and two additional foster kids who no longer live with her. She is on medical disability. REVIEW OF SYSTEMS: Constipated- no BM for the past two weeks. Other than HPI, 10-point review of systems is negative. PHYSICAL EXAMINATION: GENERAL: She is alert and oriented x3.
BM|bowel movement|BM|154|155|HISTORY OF PRESENT ILLNESS|She had an ultrasound which was normal, then a CT scan, and she had liver function tests that were normal. The CT scan did show some increased amounts of BM in the colon and slight distension. Small bowel loops were at the upper limits of normal, but there were no inflammatory changes or signs of any acute process apparently.
BM|bowel movement|BM|236|237|HISTORY OF PRESENT ILLNESS|He does know and has been counseled before on avoiding such foods as nuts and grains as well as popcorn but took his chances. His pain is quite similar to his previous diverticular flare before. He denies any fevers or chills. His last BM was yesterday p.m. and denies any blood. He reports that there were only small amounts and was very painful. PAST HISTORY: Diverticulitis, GERD, and DJD. ALLERGIES: PENICILLIN, which causes an anaphylactic reaction.
BM|bowel movement|BM|300|301|OPERATIONS/PROCEDURES PERFORMED|3. Lower extremity edema. OPERATIONS/PROCEDURES PERFORMED: Flat and upright plate of the abdomen showing a large amount of air and stool in the colon, nonobstructive bowel gas pattern. HISTORY OF PRESENT ILLNESS: An 85-year-old woman who presents with the complaint of constipation, stating her last BM was 5 days prior to admission. Also has chronic back pain, takes 100 mcg fentanyl patch as well as OxyContin 20 mg daily, also takes short-acting oxycodone, has chronic constipation and has had previous troubles with this.
BM|bowel movement|BM|175|176|DISCHARGE DIAGNOSES|Subsequent to surgery has done well and has had a low grade temperature of 100.5 in the healing phases. Normal O2 sats. Normal vital signs. Tolerated liquids well. Has had no BM and had moderately increased amount of stool noted on admission flat and upright of the abdomen. The patient will thus be discharged on the regular blood pressure medications.
BM|bowel movement|BM|146|147|DISCHARGE MEDICATIONS|The patient will follow up in the office in approximately 10 days. DISCHARGE MEDICATIONS: 1. Milk of Magnesia daily as needed. 2. Dulcolax for no BM x48 hours. 3. She will continue her carbidopa/levodopa 25/100 two tablets three times a day one half hour before meals. 4. Mirapex 1 mg 3 times a day. 5. She will continue her levothyroxine 0.088 mg daily.
BM|bowel movement|BM.|181|183||The patient's postoperative course was unremarkable. Her hemoglobin was stable at 8.9. She was discharged on the fourth postoperative day. She was passing flatus, but had not had a BM. This was then treated with suppository. She had normal bladder function at this time. She has prescriptions for Percocet and ibuprofen and will return to the office in 2 weeks.
BM|bowel movement|BM|112|113|DISCHARGING MEDICATIONS|11. Milk of magnesia 30 mL p.o. each day at bedtime p.r.n. 12. Fleet enema 133 mL per rectum daily p.r.n. if no BM every 1-2 days. 13. Neurontin 300 mg p.o. t.i.d. for neuropathic pain. 14. Morphine sulfate 2-4 mg oral solution p.o. q.2h. p.r.n. breakthrough pain and this is the solution 2 mg per mL.
BM|bowel movement|BM.|241|243|REVIEW OF SYSTEMS|PULMONARY: The patient denies significant cough. Did note some discomfort with breathing deeply when she had the episode of getting hot and sweaty and subsequently vomiting in church. GASTROINTESTINAL: The patient reports she has had normal BM. GENITOURINARY: Denies vaginal discharge and urinary change. EXTREMITIES: No pain or edema. NEUROLOGIC: At baseline the patient ambulates with a cane.
BM|bowel movement|BM.|156|158|TRANSFERRING MEDICATIONS|12. Sensorineural hearing loss. 13. Constipation: Intermittent. TRANSFERRING MEDICATIONS: 1. Dulcolax suppository 10 mg per rectum every two days p.r.n. no BM. 2. Fleets enema 133 mL per rectum every 44 hours p.r.n. constipation. 3. Prinivil 15 mg p.o. daily. 4. Neurontin 200 mg p.o. every day at 1300 hours.
BM|bowel movement|BM|167|168|ASSESSMENT AND PLAN|At this point in time I am inclined to add Reglan 5 mg t.i.d. with meals to this patient. 2. Constipation. This is a definite change in bowel pattern. She usually has BM twice a day and she has not had one for about 2 to 2-1/2 days. Will use fleets enema as needed. 3. Back pain. Will continue with the tramadol as well s Flexeril.
BM|bowel movement|BM|163|164|REVIEW OF SYSTEMS|He has some cognitive deficits with poor insight and judgment. REVIEW OF SYSTEMS: No headache, nausea, or vomiting. No shortness of breath or abdominal pain. Last BM was today. He has some back pain secondary to being in bed. He has decreased vision in his right eye and cannot see out of that eye.
BM|bowel movement|BM,|138|140|HISTORY OF PRESENT ILLNESS|The patient had severe intermittent abdominal cramps in the right side during his iron infusion in the Masonic Center. The patient had no BM, but still passing gas and no nausea and vomiting. The patient was admitted to the hospital with the diagnosis of partial small bowel obstruction.
BM|bowel movement|BM|208|209|PLAN|The admission physical examination was within normal limits. Problems during the hospitalization included the following: 1. F/E/N- _%#NAME#%_ was started on TPN at 60 cc/kg/day followed by gavage feedings of BM from the aunt (whom it was decided could use her breast milk in bottles to feed _%#NAME#%_). Her parenteral nutrition was discontinued on _%#MMDD#%_ and gavage feedings were increased to full feeds.
BM|bowel movement|BM|162|163|HISTORY OF PRESENT ILLNESS|Apparently, on the day of this admission (_%#MMDD2007#%_), the patient was constipated and has taken some stool softener. She then went to the bathroom and had a BM which she described as hard bowel movements. Soon after that, she had syncopal episode which was witnessed by her guardian and a 24-hour nurse aide.
BM|bowel movement|BM|361|362|HISTORY|She was seen in clinic with generalized weakness over a period of days to weeks; she had been recently treated for presumptive urinary tract infection with an antibiotic that neither she nor her son can remember, and still was not feeling well also so she presented back to the clinic today and x-rays taken showed reportedly increased loops of bowel. Her last BM was approximately 2-3 days ago. She also has had much worsening of her weakness and then was sent to the emergency room for further evaluation.
BM|bowel movement|BM|199|200|HISTORY OF PRESENT ILLNESS|She tried to take some liquids and just developed increasing discomfort that progressed for the next couple hours leading to a phone call and she was directed to the emergency room. She had a normal BM yesterday and had no prior warning symptoms of any bowel problems. She does have a history of recurrent small-bowel obstruction with multiple bowel surgeries including hernia repair, appendectomy, hysterectomy and left partial colectomy for diverticulitis and an oophorectomy in the past.
BM|bowel movement|BM.|153|155|DISCHARGE MEDICATIONS|Last dose will be tomorrow morning _%#MMDD#%_. 9. Cardizem CD 120 mg p.o. q day. 10. Dulcolax suppositories. 1 p.o. q 3rd day with dig stimulation if no BM. 11. Haldol 3 mg p.o./IM/IV q.h.s. p.r.n. sundowning. 12. Natural tears 1 to 2 drops both eyes q.i.d. p.r.n. and at the bedside for dry eyes.
BM|bowel movement|BM.|114|116|TRANSFER MEDICATION|(The patient usually takes 3 or 4 doses of this a day). 8. Dulcolax suppository per rectum p.r.n. q. 3 days if no BM. The patient usually uses visual stimulation for his morning bowel programs. HOSPITAL COURSE: The patient was admitted originally to FUMC for ischial ulcers, and a surgical consultation from _%#CITY#%_ Hospital where he had presented with a temperature of 101.5. He was found to have E. Coli in a urinary tract infection and was treated for this as well.
BM|bowel movement|BM.|134|136|PHYSICAL EXAMINATION ON DISCHARGE|PHYSICAL EXAMINATION ON DISCHARGE: Vitals were: Respiratory 18/20, O2 sats 98% on room air. I's and O's 2270 in, 1700 out. Five times BM. Pulse 60 - 65. VPA 131/50. General: The patient was lying in bed. HEAD: Normocephalic, atraumatic. NECK: LUNGS: Clear, but difficult to examine due to poor inspiration.
BM|bowel movement|BM|219|220|HISTORY OF PRESENT ILLNESS|She went to the ER and the Dilaudid medication she received there helped and moving was making it worse. She has had several episodes of emesis, she denies chest pain, shortness of breath, she had a good appetite. Last BM was _%#MMDD2004#%_. No vaginal bleeding, no pain with urination, no urgency but she does have frequency as she is early pregnant.
BM|bowel movement|BM|225|226|HISTORY OF PRESENT ILLNESS|Over the last two days the patient has been increasingly confused, has had decreased p.o. intake and has increased twitching. She has had no history of fevers, chills, nausea, vomiting, diarrhea, dysuria, frequency. Her last BM was two days ago. She has had no falls, no trauma. She denies any headache. She may not be taking her lactulose as recommended per her physician.
BM|bowel movement|BM|110|111|REVIEW OF SYSTEMS|6. Fluoxetine 20 mg p.o. q. day, started yesterday. REVIEW OF SYSTEMS: The patient notes that he had a normal BM yesterday. He denies any pain of any sort. He denies shortness of breath. He admits to anorexia. Also, nausea and vomiting postprandially several times.
BM|bowel movement|BM|131|132|DISCHARGE MEDICATIONS|8. Zofran 4 mg dissolvable tablet every 4 hours as needed for nausea and vomiting. 9. Fleet's enema as needed every 8 hours for no BM x24 hours. 10. Senokot two tablets p.o. twice daily for constipation. 11. Percocet 5/325 mg 1-2 tablets every three hours as needed for pain.
BM|bowel movement|BM|143|144|PROBLEM #5|PROBLEM #5: GI: She was noted on hospital day #2, to have a slightly distended abdomen with diffuse abdominal tenderness. She also reported no BM for 2 days. On hospital day #3, an NG tube was placed and there was copious output of over 3000 cc. Unfortunately, at this time, she did vomit around her chest tube with significant output.
BM|bowel movement|BM|230|231|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient states for the last 3 days he has had right-sided chest pain that has been pleuritic; he has been feeling more and more weak, eating less and less. Last night he went to the bathroom, had a BM all over the floor and fell and could not get up through the night. He finally got up this morning and was taken to the Emergency Room.
BM|bowel movement|BM|158|159|HISTORY OF PRESENT ILLNESS|She did report worsening nausea and vomiting and has not had anything to eat since then. She tried some water this morning, however threw it all up. Her last BM was yesterday and describes it was being normal without melena or hematochezia. She denies any diarrhea or recent travel. Her pain is exacerbated by any movement whatsoever.
BM|bowel movement|BM|280|281|DOB|However, in the postoperative course the patient did develop increasing anemia and ecchymosis over her abdomen extending down to her thighs and hemoglobin was dropped to about 7.9 where it stabilized. The patient had a fair amount of pain but this was relenting and patient had a BM and had normal flatus, however, stools were somewhat loose. The patient was discharged home with a hemoglobin of 7.9 on the 5th day following surgery to be followed closely at the Oxboro Clinic.
BM|bowel movement|BM.|123|125|1. FEN|Today the patient is feeling well and doing well being able to eat regular diet and tolerating food very well. She has had BM. It is still loose, but with no cramps or problem. She is well hydrated and vital signs are stable on exam.
BM|bowel movement|BM|259|260|ASSESSMENT AND PLAN|I think I will have Cardiology see her and provide their opinion regarding better control of her atrial fibrillation rate and any further management that may be needed from Cardiology standpoint. 3. Constipation. Currently resolving itself. The patient had a BM at the time of this dictation. 4. COPD. Stable. 5. Renal insufficiency. The patient's creatinine has risen from 1.4 to 3.6 in the last few days.
BM|bowel movement|BM.|170|172|HOSPITAL COURSE|Her abdominal xray on the day of discharge, however, was soft with very good bowel sounds. She had been eating very little and it may be a day or two yet before her next BM. She is advised that her Oxycontin can be very constipating and that she needs to be on a regular bowel regimen for this.
BM|bowel movement|BM|249|250|DISPOSITION|_%#NAME#%_ had the following lines placed: peripheral IV. _%#NAME#%_ was initially maintained on a parenteral glucose infusion. Feedings were started on _%#MMDD2005#%_ shortly after admission and she tolerated the increase in volume and strength of BM oral feeds and NG gavage Enfamil well. At the time of discharge, she was breastfeeding and bottling all of her feedings of 22 kcal BM and formula.
BM|bowel movement|BM|255|256|DISPOSITION|Feedings were started on _%#MMDD2005#%_ shortly after admission and she tolerated the increase in volume and strength of BM oral feeds and NG gavage Enfamil well. At the time of discharge, she was breastfeeding and bottling all of her feedings of 22 kcal BM and formula. Her weight at the time of discharge was 2318 gm with a head circumference of 35.5 cm and length of 45.5 Problem # 2: Jaundice _%#NAME#%_ had mild physiologic jaundice with a peak bilirubin of 7.6. She did not require any specific therapy.
BM|bowel movement|BM|154|155|DISCHARGE DIAGNOSIS|On the day prior to discharge, her diet was advanced from clears to a regular diet. She continued to tolerate her diet without any nausea or vomiting and BM and continued to pass normal stool and gas without any pain. DISCHARGE MEDICATIONS: 1. Lisinopril 20 mg p.o. daily. 2. Zoloft 50 mg p.o. daily.
BM|bowel movement|BM.|188|190|DISCHARGE MEDICATIONS|7. Tylenol 650 mg p.o. q.i.d. 8. Calcium with vitamin D 500 mg p.o. b.i.d. 9. MiraLax 17 grams p.o. q. day, to be held for loose stools. 10. _________ per rectum p.r.n. every other day no BM. 11. Oxycodone 5 mg p.o. t.i.d. p.r.n. for back up pain. Patient will follow up with his primary care physician within one week of discharge from TCU.
BM|bowel movement|BM.|150|152|HISTORY OF PRESENT ILLNESS|The patient has took these medications for the past two days without a relief. Actually, she stated her pain is worse today. She also reports pain w/ BM. She reports nonproductive cough and sore throat as well. She reports having cold-like symptoms for the past few days. She stated her nephew at home had similar URI symptoms.
BM|bowel movement|BM|190|191|HISTORY OF PRESENT ILLNESS|He reports a history of shortness of breath for the past few days, but denies chest pain, palpitations, blurred vision or headache. He normally has a bowel movement every 2-3 days. His last BM was 2 days prior to this admission. In the emergency room the patient has received some Ativan and a dose of pain medication.
BM|bowel movement|BM|145|146|HISTORY OF PRESENT ILLNESS|Her left upper quadrant abdominal pain which is crampy and has awoken her from sleep. She has positive nausea. No vomiting or diarrhea. Positive BM and passing gas. Pain is not relieved with Roxicet. PAST MEDICAL HISTORY: 1. Obesity. She has lost approximately 40 pounds since her 2002 Roux-en-Y gastric bypass at HCMC.
BM|bowel movement|BM|394|395|HISTORY OF PRESENT ILLNESS|ADMISSION MEDICATIONS: Synthroid 125 mcg p.o. daily. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 48-year-old male with a past history is significant for colon cancer, status post left hemicolectomy in 1992 who presented in the Emergency Room with abdominal pain, which started that morning and had nausea, vomiting, hematemesis, hematochezia or bright red blood per rectum. He had 1 BM the morning of admission, which was soft. He had no other complaints of dysuria or fevers. In the Emergency Room as part of his initial evaluation, he was found CT of the abdomen to have mild to moderately distant loops of small bowel consistent with a partial small bowel obstruction without significant edema.
BM|breast milk|BM|141|142|ID|Jaundice should improve as baby tolerates full feeds and begins stooling. Discharge medications, treatments and special equipment: 1. Gavage BM feeds at 45mL every three hours until breast feeds are adequate. Discharge measurements: Weight 2770 gms; length 47 cm; OFC 33 cm.
BM|bowel movement|BM|278|279|HISTORY OF PRESENT ILLNESS|She was discharged to home after 2 days, but continued to have abdominal pain and returned with complaints of cramping and nausea and some vomiting of a nonbilious, nonbloody emesis. On the day of admission, she was unable to keep any of her medicine down. She reports her last BM was the day prior to her admission and that it was hard and painful, but nonbloody. She also complained of some mild dysuria. She denied fevers and also reports decreased p.o. intake in the last 24-48 hours.
BM|bowel movement|BM|123|124|DISCHARGE MEDICATIONS|C. 301-350 = 8 units subcu D. 351-400 =10 units subcu E. ( 400 = Call MD or NP 20. Dulcolax suppository PR 1 tonight if no BM today for mild constipation. 21. Gatifloxacin 200 mg p.o. every day for 8 additional days, for total of 10 days coverage for a ( 100,000 E. coli UTI.
BM|bowel movement|BM|159|160|HOSPITAL COURSE|HOSPITAL COURSE: The patient's hospital course was reasonably uncomplicated. He did have a relatively prolonged postoperative ileus. He persisted in having no BM or flatus for sometime. Eventually he did start to have bowel function and tolerated a diet without significant difficulties.
BM|bowel movement|BM|142|143|HOSPITAL COURSE|He was out of bed and feeling much better. The patient was voiding well on his own within 2 days postoperatively, and began to pass gas and a BM indicating that we could advance his diet. He started with a clear liquid diet, and by the time of discharge he was tolerating a full liquid diet without incident.
BM|bowel movement|(BM)|306|309|HISTORY OF PRESENT ILLNESS|However, only superficial biopsies were obtained. The patient presented to the Women's Clinic this afternoon for followup and stated she had other black bowel movement since discharge. However, she denies ongoing weakness or lethargy since the time of discharge. The patient states her last bowel movement (BM) was the morning before admission and said it was formed, not black, and last BM was a couple of days prior at which time the patient states the BM was becoming more formed The patient denies nausea, vomiting, hematemesis, coffee-ground emesis, denies bright red blood per rectum, denies ongoing abdominal pain.
BM|bowel movement|BM|270|271|HISTORY OF PRESENT ILLNESS|However, she denies ongoing weakness or lethargy since the time of discharge. The patient states her last bowel movement (BM) was the morning before admission and said it was formed, not black, and last BM was a couple of days prior at which time the patient states the BM was becoming more formed The patient denies nausea, vomiting, hematemesis, coffee-ground emesis, denies bright red blood per rectum, denies ongoing abdominal pain.
BM|bowel movement|BM|163|164|ASSESSMENT AND PLAN|There was no evidence of bleeding on upper endoscopy. Hemoglobin was 10.8. Blood pressure and heart rate normal. No BM since day prior to admission, at which time BM was formed and, "Not black as it had been in the past." The patient denied nausea, vomiting, or other sign of active GI bleed.: At this time will monitor the patient on the floor for sign of acute GI bleed.
BM|bowel movement|BM.|337|339|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Bright red blood per rectum. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 82-year-old female who has had loose stools this week, but only one BM per day, with sudden onset of bright red blood per rectum on _%#MMDD2006#%_ at 1500. She has had a total of four stools, with diminished bright red blood with each BM. She has had associated bilateral lower quadrant crampy abdominal pain and tenesmus. The patient states that there was no relation to p.o. intake, no previous episodes of similar symptoms.
BM|bowel movement|BM|136|137|HOSPITAL COURSE|Patient is to continue on hip precautions. PROBLEM #2. Constipation. On admission here, it was found out that the patient had not had a BM since before the surgery. She was placed on bowel program and was maintained on this. She did not have any further complaints of constipation.
BM|bowel movement|BM|637|638|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Abdominal pain, nausea. HISTORY OF PRESENT ILLNESS: This is a 74-year-old female with a history of partial small bowel obstruction back in _%#MM#%_ of 2006 requiring some exploratory laparotomy and what appears to be lysis of adhesions (patient describes it as bowel release in the lower abdomen) as well as a recurrent operation for a hiatal hernia repair in _%#MM#%_ of 2006, complicated with some postop atyp at the time who now presents here with recurrent diffuse abdominal pain described as sharp all across her abdomen. This appears similar to her prior abdominal pain. She reports 2 episodes of emesis. Her last BM was yesterday morning and since then has not been able to pass any flatus. The pain is described as 10/10. Currently pain is under better control after the NG tube is placed.
BM|bowel movement|BM|217|218|* FEN|She remains on caffeine with a caffeine level pending from _%#MMDD2007#%_ at the time of transfer. Discharge medications, treatments and special equipment: * Caffeine 6 mg po daily * Glycerin 0.25 supp pr qday PRN no BM x 24 hrs. Discharge measurements and exam: Weight 1680 gm, length 40 cm, OFC 30 cm.
BM|bowel movement|BM|166|167||Initially there was a stool ordered for cultures and C. diff but as patient has not had any bowel movements since admission these have not obtained and definition no BM in 24 hours now is consistent with resolution of her diarrhea.
BM|bowel movement|BM|401|402|HISTORY OF PRESENT ILLNESS|2. Hypothyroidism. 3. Constipations. 4. CHF due to volume oeverload. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 61-year-old with history of ischemic dilated cardiomyopathy, chronic renal failure, diabetes and hypothyroidism presents with shortness of breath and constipation. The patient initially came because of the constipations. He felt some abdominal discomfort since Saturday and no BM for the last 4 days. He went to a local hospital where he received stool softener, did not get better, did not have BMs, so he decided to come to the ED here.
BM|bowel movement|BM|147|148|HOSPITAL COURSE|The abdominal x-ray revealed some dilated loops of bowel but no free air. There is no evidence of small bowel obstructions. The patient did have a BM prior to discharge and he felt better. His abdominal discomfort resolved. The patient will be sent home with docusate 100 mg every night and he was told to take it every night and hold it when he has diarrhea.
BM|bowel movement|BM.|154|156|PLAN|Aggressive work on range of motion to be assisted with CPM machine. 2. Rehab nursing to address bowel program just recently results after several days no BM. Will check a few postvoid residuals Ultrasound to verify urine emptying given her opioid use. 3. Pain management: Presently with OxyContin 10 mg twice daily, as well as Percocet 1-2 tablets every 4 hours as needed.
BM|bowel movement|BM.|199|201|HISTORY|As of _%#MMDD2007#%_, she continued to do well clinically. Ambulatory. Tolerating stairs. Successfully completed physical therapy. Again, adequate pain control. No cardiopulmonary symptoms. Positive BM. Voiding well. Stable blood pressure 120/64, heart rate 80s, temperature 98.9 and O2 sat 98% room air. Urine culture, multiple species consistent with contamination. Follow-up hemoglobin as above.
BM|bowel movement|BM|212|213|HOSPITAL COURSE|There were no other polyps. She had bleeding internal hemorrhoids, which were the cause of her bleed. The patient was constipated and Peri-Colace was added to her regimen to avoid excessive strain while having a BM and to reduce the risk of bleeding. The patient was also advised to follow up. The patient will also follow up with the Colorectal Surgery for possible intervention or banding of her hemorrhoids.
BM|bowel movement|BM.|252|254|POSTOPERATIVE COURSE|Please see their notes for further specifics. The patient did have an NG in place after surgery during expected postoperative ileus. She slowly had return of bowel sounds by _%#MMDD2007#%_ and by _%#MMDD2007#%_ finally had return of flatus and a small BM. Therefore, she was cleared to start diet intake. Note: NG had inadvertently been pulled during the night on _%#MMDD2007#%_. She also on _%#MMDD#%_ was able to discontinue use of PCA for pain management and start oral medication for pain control.
BM|bone marrow|BM|176|177|PROCEDURES|INTERIM DIAGNOSES: 1. Pre B-cell ALL. 2. Hypofibrinogenemia. 3. Insomnia. 4. Hyponatremia. 5. Pulmonary nodule. PROCEDURES: 1. Diagnostic bone marrow biopsy on _%#MMDD2007#%_. BM revealed 100% cellularity with 96% blasts. The peripheral smear showed 94% blasts at this time. Flow cytometric analysis characterized this as a pre B-cell ALL.
BM|bowel movement|BM|163|164|HISTORY OF PRESENT ILLNESS|He has had persistent periumbilical pain 6 out of 10 which he rated as sharp. He described it as non-radiating. The patient had not produced over those 2 days any BM or any flatus suggesting an obstructive picture. However, with Gastrografin enema he did produce stool and his constipation symptoms were relieved.
BM|bowel movement|BM|132|133|HISTORY OF PRESENT ILLNESS|He has no fever. His pain is actually improved now with some Zofran and morphine in the ED. He is actually passing flatus. His last BM was this morning and described as normal. PAST HISTORY: Significant for Crohn's. PAST SURGICAL HISTORY: Status post small bowel resection and appendectomy.
BM|bowel movement|BM.|136|138|HOSPITAL COURSE|When he was transferred to the floor, the patient did get some MiraLax as well as glycerin suppositories and he did have 1 other larger BM. The patient did much better and became much more responsive once he had his Foley catheter placed. The patient was continued on his bowel regimen of Senokot 2 tables twice a day.
BM|bowel movement|BM,|113|115|HOSPITAL COURSE|Her creatinine improved to 1.2. Her calcium dropped to 11.2. Her iron studies were mixed. GI saw her due to dark BM, but there was no blood and it was recommended that she continue intravenous proton pump inhibitor which could be switched to oral and it was decided not to do a CT scan due to her poor renal function.
BM|bowel movement|BM|174|175|BRIEF HISTORY OF PRESENT ILLNESS|The patient states the pain is sharp and constant, located in the epigastric region and nonradiating. She is having difficulty eating. She is having lots of nausea. Her last BM was the morning of admission, it was normal. She continues to pass small amounts of gas at the time of admission. She follows a low-residue diet at home. The patient states she was hospitalized in _%#CITY#%_.
BM|bowel movement|BM|128|129||This awoke her from her sleep and has been recurrent today without nausea or vomiting, without change in bowel habit besides no BM in the last two days. She denies any fever or chills. She denies any weight loss. She does have a significant history of similar symptoms, approximately 11 months ago when a diagnosis of ischemic colitis was made on flexible sigmoidoscopy.
BM|bowel movement|BM|165|166|PROCEDURES|The patient denied any history of fevers, chills, hematochezia or melena. She is currently on a puree diet and has been tolerating it, aside from the pain. The last BM was the morning of presentation. Past medical history is significant for status post gastric bypass revision with ventral herniorrhapy in _%#MM#%_ of 2002, status post right inguinal hernia repair, status post cholecystectomy, status post appendectomy.
BM|bowel movement|BM.|207|209|HOSPITAL COURSE|1. GI. Ammonia level was within normal limits. The patient's CT at North Memorial Medical Center had shown subdural hematoma. The patient's lactulose was increased from 30 cc q.i.d. 45 cc q.i.d. without any BM. The patient's mental status has not changed. The patient did not have any sign of spontaneous bacterial peritonitis and he is empirically treated with levothyroxine 500 mg p.o. q.d. at the nursing home.
BM|bowel movement|BM|163|164|PROBLEM #2|The patient normally gets dialyzed on Monday, Wednesday, and Friday. PROBLEM #2: Diarrhea. The patient was admitted with chocolate- color, watery stools, up to 10 BM a day for about 1 week. She was hydrated with fluid during this hospital course. The patient's stool was sent to the laboratory for bacterial workup.
BM|bowel movement|BM|108|109|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient appears in a lot of pain. She is vomiting and she went to have a BM during the interview. NECK: She does not have any lymphadenopathy. No evidence of JVD. CARDIOVASCULAR: She has tachycardia. Does not have any murmurs, gallops or rubs.
BM|bowel movement|BM|193|194|HOSPITAL COURSE|PROBLEM #7. Gastrointestinal: From a gastrointestinal standpoint, the patient did go 3 days without a bowel movement. Dulcolax was added to help with this constipation, and resulted in 1 large BM prior to discharge. The patient was encouraged to take her MiraLax scheduled at home for her history of having severe constipation.
BM|bowel movement|BM.|174|176|DISCHARGING MEDICATIONS|6. Topical lidocaine 4% 40-60 mL every wound VAC change on Monday, Wednesday and Friday. 7. Ferrous gluconate 324 mg p.o. daily. 8. Milk of magnesia 30 mL every 2 days if no BM. 9. Oxycodone 5-10 mg p.o. every 4 hours p.r.n. pain. 10. Celebrex 200 mg p.o. daily. 11. Lidoderm patch 5% 2 patches each side of the incision, on 12 hours, off 12 hours.
BM|bowel movement|BM|132|133|PLAN|Also independence with transfers if at all possible. 3. Rehab nursing to work with bowel and bladder program. He is constipated, no BM for 4 days, so will increase bowel meds from current Colace and to add Senokot 2 twice a day. Can add Milk of Magnesia and suppository/enemas as needed per nursing bowel protocol.
BM|bowel movement|BM|143|144|POSTOPERATIVE COURSE|He also received TPN until he was able to tolerate p.o. intake. He was able to have the NG removed on _%#MMDD2007#%_ and had not had flatus or BM Intal that time. After it was removed and the TPN was weaned off and he was slowly advanced on clear liquid diet.
BM|bowel movement|BM.|113|115|DISCHARGE MEDICATIONS|2. Oxycodone 5 mg p.o. 4 times daily x4 p.r.n. pain. 3. Colace 100 mg p.o. twice daily, take until he had a good BM. 4. MiraLax 17 g p.o. twice daily. 5. Fluconazole 100 mg p.o. daily. 6. Bactrim Double Strength 1 tab p.o. twice daily on Mondays and Tuesdays.
BM|bowel movement|BM|139|140|HISTORY OF PRESENT ILLNESS|He went to the toilet and he noticed that he was only having bright red bleeding. He had similar four more episodes with an urge to have a BM but resulted in a small to moderate amount of bright red bleeding. He mentioned this to his son who was visiting with him and at that point in time he was brought to the emergency room.
BM|bowel movement|BM|150|151|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: No URI symptoms. No chest pain, shortness of breath, dyspnea on exertion, abdominal pain, urine or bowel difficulty. He has had no BM for the last 3 days. No other bone or joint pain. His IV infiltrated, though, in the emergency room, and he has some right arm stiffness from that.
BM|bowel movement|BM.|120|122|HISTORY|The patient had not had a BM in greater than 4 days. The patient states that her stool was likely melanotic on her last BM. The patient's hemoglobin however is stable and remained stable during her hospitalization, which is around the 12 range. Thus, after her physical exam, history and imaging, it was determined that the patient likely had a partial small bowel obstruction, the etiology was not quite clear.
BM|bowel movement|BM|227|228|HISTORY OF PRESENT ILLNESS|She has been doing well until approximately 48 hours ago when she developed abdominal pain and discomfort associated with vomiting when she ate. She denies hematemesis, melena, hematochezia or bright red blood per rectum. Last BM was yesterday and normal. She denies fevers or sick contacts. HOSPITAL COURSE: On _%#MMDD2007#%_, Ms. _%#NAME#%_ was admitted to the MIS service.
BM|bowel movement|BM|156|157|HISTORY OF PRESENT ILLNESS|She has had no similar complaints in the past. She does admit that she has chronic constipation, approximately one bowel movement every other day. Her last BM was two days ago. She denies any recent change in her food habits, medications or activity. PAST MEDICAL HISTORY: 1. Sleep apnea. 2. Hypertension, diet-controlled.
BM|bowel movement|BM.|170|172|CURRENT MEDICATIONS|Past surgical history: None obtainable. CURRENT MEDICATIONS: Patient group home list. Please see for full details but they include bisacodyl 10 mg suppository p.r.n., no BM. Depakote 125 mg p.o. q.d. Diazepam 2 mg p.o. b.i.d. Constulose 10 mg/15 cc, 30 cc p.o. b.i.d. Depakote 250 mg t.i.d. Carnitor 330 mg two tabs p.o. t.i.d. Baclofen 20 mg one p.o. q.i.d. Lamictal 25 mg tabs two p.o. q.i.d. Dantrium 25 mg b.i.d. Certagen one p.o. q.d. Calcium carbonate 1250 mg, 5 cc q.a.m. ALLERGIES: ASPIRIN AND TEGRETOL.
BM|breast milk|BM|104|105|ASSESSMENT|He passed the ABR hearing screening test. Immunizations: none given _%#NAME#%_ was discharged on 24Kcal BM fortified with Enfacare on an ALD schedule. The parents were asked to make an appointment for their child to see you within one week.
BM|bowel movement|BM.|213|215|DISCHARGE MEDICATION|Apparently, there are many family issues in regard to her children with whom she has joint custody and apparently her brother did sexually abuse one of her children. 9. Milk of Magnesia 30 cc p.o. q. 3 days if no BM. 10. Dilaudid 2 mg p.o. q. 4 to 6 h. p.r.n. for breakthrough pain. 11. Tylenol 1 to 2 tablets (325 to 650 mg) q. 3 to 4 h. p.r.n. fever or mild pain.
BM|bowel movement|BM|174|175|HISTORY OF PRESENT ILLNESS|She reports that _%#NAME#%_ is latching well and does swallow and suck. Mom also reports that her milk "came in" on the evening prior to admission. Mom noted one wet and one BM on the day of admission. _%#NAME#%_ had one wet and two stools on the day prior to admission. Her birth weight was 8 lb, 1 oz. Mom's blood type was A negative.
BM|bowel movement|BM|469|470|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 71-year-old white female with a history of multiple sclerosis since her teens, transitional cell bladder cancer, invasive, requiring cystectomy and total abdominal hysterectomy with ileal conduit, basal cell carcinoma of the skin, trigeminal neuralgia, recurrent small bowel obstructions x2, who is followed by Dr. _%#NAME#%_ _%#NAME#%_ at _%#CITY#%_ Clinic. The patient was in her usual state of health and had a BM this morning. Tonight at around 9:30 p.m., she began noting bloating and discomfort in the center of her abdomen. This was associated with some nausea, but she had no vomiting.
BM|bowel movement|BM|159|160|REGULAR HOMEGOING MEDICATIONS|7. Tylenol 1000 mg p.r.n. b.i.d. for pain or fever 8. Milk of Mag suspension q.48h. p.r.n. constipation along with: 9. Dulcolax suppository q.48h p.r.n. if no BM
BM|bowel movement|BM.|157|159|HISTORY OF PRESENT ILLNESS|He was instructed to avoid maneuvers that would cause syncope such as bending over. He was also cautioned about bearing down too aggressively while having a BM. Reassurance was provided to the patient and wife, although they still feel that they would like to be seen in followup by cardiology.
BM|bowel movement|BM|243|244|HOSPITAL COURSE|He was treated conservatively without any surgical intervention. On the day of discharge, the patient was able to tolerate clear liquid diet. He had good bowel sounds. His abdominal pain has completely resolved. He has not passed gas or had a BM yet, but otherwise feels back to his baseline. The patient will be discharged to home today with follow-up with his primary care physician in one week.
BM|bowel movement|BM|160|161|REVIEW OF SYSTEMS|She is retired. REVIEW OF SYSTEMS: No chest pain. She has shortness of breath. No runny nose. Cough. No abdominal pain.. No urinary difficulties. She has had a BM every other day or so. No other pain. No swelling or rash. Remainder of the review of systems is negative. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 154/89, pulse 70, respiratory rate 24, temperature 95.9. GENERAL: She is in bed.
BM|bowel movement|BM|421|422|HISTORY OF PRESENT ILLNESS|When he continued to bleed, Colon and Rectal Surgery was consulted and he underwent flex sig on _%#MMDD2006#%_. The bleeding ulcer was ligated with hemostasis. He was discharged to a nursing home on _%#MMDD2006#%_ with hemoglobin at 9.2. He has not had any bleeding until this morning at approximately 10 a.m. For the past 3 days, he has not had a bowel movement and was given Milk of Mag last night, which resulted in a BM this morning and shortly after that, his rectal bleeding started and would not stop. Therefore, he was sent into the Emergency Room for further evaluation.
BM|bowel movement|BM.|192|194|HISTORY OF PRESENT ILLNESS|6. Status post bilateral hernia repairs. HISTORY OF PRESENT ILLNESS: _%#MM#%_ _%#DD#%_ _%#NAME#%_ was noted to have a couple episodes of emesis in the last couple of days and he had not had a BM. He was given milk of magnesia that day and had a medium to small size bowel movement. The next day he also got 2 doses of milk of magnesia but no bowel movement.
BM|bowel movement|BM|183|184|HISTORY OF PRESENT ILLNESS|No dysuria. The patient is tolerating her pureed diet. The patient did vomit once, small amount after eating rice an noodles. No nausea currently. Complains of constipation with last BM about a week ago. HOSPITAL COURSE: On admission, the patient's wound seroma was drained at the bedside with a Q-tip.
BM|breast milk|BM|285|286|1. FEN|Physical exam was normal. PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent on _%#MMDD#%_ and the results are pending at discharge. He passed the ABR hearing screening test. Immunizations: none given _%#NAME#%_ was discharged on gavage feedings of BM or Enfamil with iron at 39 cc Q3hours. Thank you again for allowing us to share in the care of your patient.
BM|bowel movement|BM.|120|122|DISCHARGE MEDICATIONS|3. Calcitonin 200 IU q.d. nasally, alternating nostrils. 4. Senokot S one to two tablets p.o. b.i.d. and hold for loose BM. 5. Tums 500 mg chew t.i.d. 6. Lipitor 10 mg p.o. q.h.s. 7. Metoprolol 50 mg p.o. b.i.d. and hold if systolic blood pressure less than or equal to 90 or heart rate less or equal to 60.
BM|bowel movement|BM|152|153|REVIEW OF SYSTEMS|3. Lipitor, they think it is 20 mg. She gave a kidney to a son who had renal failure. REVIEW OF SYSTEMS: GI: Denies abdominal pain, ulcer, GERD, normal BM every day. GU: Denies any dysuria, hematuria, or acute change. CARDIORESPIRATORY: Denies chest pain. Denies chronic coryza in the a.m., but I doubt this is true.
BM|bowel movement|BM|212|213|HISTORY OF PRESENT ILLNESS|The patient was hemodynamically stable, with no change in her hemoglobin since her last recorded hemoglobin of 13.8 on _%#MMDD2003#%_. The patient denied bright red blood per rectum, tarry black stools. Her last BM was the night before admission at 7:00 p.m., which was well- formed, brown stools. The patient also denied bright red emesis. She had no pain, fevers, chills, abdominal pain, chest pain, shortness of breath, bowel or bladder problems.
BM|bowel movement|BM|173|174|BRIEF HISTORY|The pain has been waxing and waning since then and described as a "knotlike" sensation since. He reports having regular bowel movements up until the last two days. His last BM was approximately two days ago, which is unusual. There is no nausea, vomiting, diarrhea, or fever. He denies any recent travel or unusual ingestions.
BM|bowel movement|BM|188|189|REVIEW OF SYSTEMS|He has not had a bowel movement but does not feel constipated at this time. He has had no bowel movement since his surgery. His p.o. intake is improving but, as he says, "How can I have a BM when I have not had anything to eat?" He had some difficulty with urination in the hospital that seemed related to his poor p.o., and it responded well to fluid flush.
BM|bowel movement|BM|200|201|HISTORY OF PRESENT ILLNESS|Despite taking Percocet one tablet q.4-6h for the first couple days and then change to Darvocet one every four to six hours, she did not have significant relief of pain. Secondary to constipation (no BM for the past four days), she stopped taking her narcotics and switched to Tylenol yesterday noon. Her last dose of Tylenol was last night. This morning she woke up with increased pain and secondary to not having a bowel movement, she presented herself to the emergency room for further evaluation.
BM|bowel movement|BM|169|170|HISTORY OF PRESENT ILLNESS|The Cipro had been started on _%#MMDD2007#%_ after a urine culture was positive for pseudomonas. Appetite has been good. She has been having normal BMs. She had a large BM here upon arrival. No blood in her stools. No hematemesis. The patient states her vomiting and nausea has resolved. The patient denied any chest pain during her episodes. She does have a history of an MI about 20 years ago.
BM|bowel movement|BM.|139|141|DISCHARGING MEDICATIONS|7. Ambien 5 mg every night p.r.n. insomnia. 8. Mylanta 30 mL every 4 hours p.r.n. 9. Milk of magnesia 30 mL by mouth every other day if no BM. 10. Fleet enema 133 mL every day p.r.n. constipation. 11. Oxycodone 5-7.5 mg every 4 hours p.r.n. pain. 12. Lidoderm patches 5% 1-2 patches apply to the skin on in the morning and off in the p.m. near the surgical site.
BM|bowel movement|BM|201|202|PROBLEM #5|PROBLEM #5: Constipation. The patient had significant constipation symptoms on admission. He was treated with an aggressive bowel regimen, including Colace, Senokot, MiraLax and lactulose. He had good BM results and was converted over to an outpatient regimen of Colace, senna and MiraLax. He understands that he should have a stool at least every other day as an outpatient.
BM|bowel movement|BM.|125|127|HISTORY OF HOSPITALIZATION|She was able to ambulate and her incisions were healing nicely. She was discharged home in a stable condition after having a BM. DISCHARGE PROBLEMS: Morbid obesity with multiple comorbidities status post laparoscopic Roux-en-Y gastric bypass
BM|bone marrow|BM|261|262|HOSPITAL COURSE|She will also be stet up with the bone marrow transplant clinic in order to go through further evaluation for future bone marrow transplant. During her hospital course her case was discussed in Hematology conference. The general feeling was that she would need BM transplant in view of her age and severity of her illness. Before discharge her white count's and her hemoglobin were stable and she also had a good neutrophil count.
BM|bowel movement|BM|141|142|FOLLOWUP APPOINTMENT|1. Lexapro 10 mg p.o. daily. 2. Cyclobenzaprine 10 mg p.o. t.i.d. 3. Senna plus docusate sodium 1 tablet p.o. b.i.d. for constipation. If no BM in 24 hours, then increase it to 2 tablets p.o. b.i.d. 4. Lyrica 50 mg p.o. t.i.d. 5. Amitriptyline 25 mg p.o. each day at bedtime.
BM|bowel movement|BM.|144|146|HOSPITAL COURSE|On postoperative day #4, the patient was breathing easier, and her nasogastric tube was discontinued. The patient was not yet passing flatus or BM. On postoperative days #5 and #6, the patient complained of some crampy abdominal pain, and tube feedings were begun.
BM|bowel movement|BM|204|205|HISTORY OF PRESENT ILLNESS|3. Dehydration, mild. HISTORY OF PRESENT ILLNESS: A 2-year 10-month-old boy brought over from Smiley's Clinic by his mother who noted that he had diarrhea on Saturday, _%#MM#%_ _%#DD#%_, 2004, and had no BM since. He then had some cold symptoms and rhinorrhea with increased work of breathing. He was brought in to the clinic that a.m. and sent over with a chest film due to his tachypnea and subcostal retractions.
BM|bowel movement|BM|158|159|HISTORY OF PRESENT ILLNESS|There, he was found to have a perirectal abscess. It was identified and drained and produced 10 cc of purulent material and some clot. The patient did have a BM on arrival to the ED. He was admitted overnight for IV antibiotics. PAST MEDICAL HISTORY: Obstructive sleep apnea, CHF, history of right elbow effusion.
BM|bowel movement|BM|157|158|REVIEW OF SYSTEMS|He denies any cough, orthopnea, PND. His chronic ankle edemais worse postoperatively, but slowly improving. Mild constipation the last few days, with a hard BM this morning. Preexisting right shoulder pain from playing baseball with his grandson was acutely worse postoperatively. The occupational therapist has been working with him so he has recovered some range of motion, but it still not back to his best baseline.
BM|bowel movement|BM.|221|223|HOSPITAL  COURSE|Telemetry monitoring during the course of the hospitalization consistently demonstrated sinus rhythm with no ectopy or fibrillation. It was postulated that this was likely a vasovagal event, in association with her large BM. The patient underwent physical and occupational evaluation and was found to be somewhat weak and frail.
BM|bowel movement|BM|162|163|HISTORY OF PRESENT ILLNESS|Around 9:00, he became diaphoretic and had mid abdominal pain that radiated out from below the umbilicus above the bladder to both sides. He states that his last BM was normal yesterday. While he was at the airport he had recurrent waves of this discomfort associated with diaphoresis that improved with passing gas per rectum.
BM|breast milk|BM|251|252|1) FEN|Gavage feeds were started on day 3. _%#NAME#%_ did not do well breast feeding, possibly due to decreased maternal milk supply, secondary to maternal hypertension, and was switched to bottle feeds on day 9. At discharge, she is taking 170 cc/kg/day of BM and formula. Her electrolytes remained within normal limits. 2) Pulmonary: _%#NAME#%_ arrived at the NICU intubated due to respiratory distress.
BM|bowel movement|BM.|190|192|DISCHARGE MEDICATIONS|9. OxyContin 10 mg p.o. b.i.d. for pain. 10. Colace 100 mg p.o. b.i.d. p.r.n.; this has not been needed here, but it may well be at home. 11. Milk of Magnesia 30 cc p.o. q. 3 days p.r.n. no BM. 12. Flagyl 250 mg p.o. q.i.d. for 2 weeks. This was started on _%#MMDD2003#%_. 13. Percocet one to two tablets p.o. q4-6h p.r.n. for breakthrough pain.
BM|bowel movement|BM|134|135|HISTORY OF THE PRESENT ILLNESS|In talking with the patient, he states that his last bowel movement that contained any blood was approximately one week ago. His last BM was approximately two to three days ago and was nonbloody at that time. He denies any abdominal pain. His weight loss is estimated at approximately 10 to 20 pounds over the past two months.
BM|bowel movement|BM.|196|198|PHYSICAL EXAMINATION|Cardiovascular shows regular rate and rhythm. Abdominal exam shows a urostomy in the right upper quadrant with clear urine, a colostomy in the left upper quadrant, no stool, no new gas since last BM. The patient is obese, soft abdomen, positive bowel sounds. A healed midline and left lower quadrant incision. Visible fist- sized bulge in the left lower quadrant, reducible with rim of fascia.
BM|breast milk|BM|223|224|1. FEN|She was switched back to breast milk on _%#MMDD2004#%_, fortified to 26kcal/oz with Neosure and HMF. On _%#MMDD2004#%_, pro-mod was added to her diet in order to increase protein intake to 4mg/kg/day. Feeds were changed to BM + HMF and protein supplement to 24 kcal/oz on _%#MMDD2004#%_. _%#NAME#%_ began cue-based feeds on _%#MMDD2004#%_. Due to increased nutritional need due to growth, her minimum was increased to 150cc per 12 hours.
BM|bowel movement|BM.|151|153|HISTORY OF PRESENT ILLNESS|They are often hard and painful. He also passes liquid stool in his diaper. His first few months of life, he required rectal stimulation to reduce his BM. This continued to 18 months of age. Symptoms significantly decreased from 18 months to 2 years of age, but has continuously been issues since then.
BM|bowel movement|BM,|246|248|REVIEW OF SYSTEMS|He denies dental difficulties or problems. He denies dyspepsia. He denies chest pain, shortness of breath, coughing, or current palpitations, though did have the atrial fib in the hospital. No history of DVTs or PEs. He is currently having loose BM, which is being helped by the Imodium, secondary to the tube feedings. No difficulty with urination. He does feel he empties his bladder.
BM|bowel movement|BM|158|159|DISCHARGE MEDICATIONS|8. For gastroesophageal reflux disease Ranitidine 150 mg q.h.s. 9. For constipation Milk of Magnesia 30 cc p.o. q. day, and Dulcolax one tablet at h.s. if no BM in 48 hours. 10. For low back pain control Vicodin one to two tablets every six hours as needed for pain. 11. Celebrex 200 mg one tablet a day for 14 days.
BM|bowel movement|BM|165|166|IMPRESSION AND PLAN|5. Gastroesophageal reflux disease prophylaxis. She has Zantac. 6. Bowel cares: Constipation prevention senna therapy and will add p.r.n. Dulcolax suppository of no BM after 3 days. 7. Depression: She is on Prozac which was started during recent hospitalization. 8. DVT prophylaxis: She is not a candidate for anticoagulation therapy secondary to her aneurysm.
BM|bowel movement|BM.|241|243|PROBLEM #3|He is on Coumadin. PROBLEM #3: Gastrointestinal. Abdominal flat plate and CT of the abdomen not terribly revealing for a source of his pain. Stool throughout the colon may be contributory, so we will put him on stool softeners and promote a BM. PROBLEM #4: Genitourinary. Possible urinary tract infection. We await cultures.
BM|bone marrow|BM|152|153|PAST MEDICAL HISTORY|Induction therapy, included intrathecal RSE, intrathecal methotrexate, vincristine, dexamethasone, daunorubicin, and PEG asparaginase. He had an LP and BM bone marrow on _%#MMDD2004#%_ that was negative for malignancy, and he has been unable to proceed with consolidation secondary to aspergillus and low blood counts.
BM|breast milk|BM|131|132|* FEN|A referral for future dosing has been sent to MVNA. Ongoing problems and suggested management: * FEN: _%#NAME#%_ was discharged on BM fortified with Enfacare to 22 cal/oz on an ad lib on demand schedule. For preterm infants with suboptimal post-natal growth or ongoing osteopenia, we suggest a fortified post-discharge formula.
BM|bowel movement|BM.|131|133|HISTORY OF PRESENT ILLNESS|In the evening she started having some blood with her diarrhea and passing both maroon-colored clot and bright red blood with each BM. After the second BM like this, she came to the emergency room for evaluation. She has not had any recent fevers, night sweats, weight loss.
BM|bowel movement|BM,|308|310|HOSPITAL COURSE|We tried again to remove the Foley on the sixth postoperative day and subsequently he was able to void, although with some residual and I placed him on Flomax and with that, he continued to void in satisfactory amounts and made progress. His diet was advanced on the sixth postoperative day after flatus and BM, and consultation was obtained again with Dr. _%#NAME#%_ regarding the patient's clinically positive margin. Pathologically, the information came back that it was negative but I still thought it probably a good idea to give him a boost to this local area since we had marked it.
BM|bowel movement|BM|157|158|HISTORY OF PRESENT ILLNESS|The patient's appetite has been normal with good p.o. intake; no vomiting; some nausea; bowel movements have been normal; no diarrhea; no constipation. Last BM was last night. No dysuria. She has a positive vaginal discharge, white, thick, and foul-smelling, for the last three to four days with no vaginal itching.
BM|bowel movement|BM.|181|183|PHYSICAL EXAMINATION|The LUNGS are clear to auscultation. The HEART has a regular rate and rhythm without any murmurs noted. The ABDOMEN is benign. Left lateral tenderness is noted but desires need for BM. No localizing signs or symptoms or evidence of any surgical pathology appreciated. PELVIC, BREASTS, GENITOURINARY, and RECTAL deferred. EXTREMITIES without any significant edema noted.
BM|bowel movement|BM|121|122|HISTORY OF PRESENT ILLNESS|She does report eating some sunflower seeds earlier that evening. Her bowel habits are described as normal with a normal BM yesterday evening. There is no melena or hematochezia. She was nauseous and had one episode of emesis this morning which was nonbloody.
BM|bowel movement|BM|133|134|HISTORY OF PRESENT ILLNESS|The patient stated that he had increased weakness and lethargy. The patient denied any tremor or confusion. The patient had his last BM recently and had a runny nose, but otherwise no shortness of breath or chest pain. No sore throat. No change in his urination or pain with urination.
BM|bowel movement|BM|126|127|HOSPITAL COURSE|Currently she is able to ambulate without difficulty. She has had no nausea or vomiting. She is passing flatus but has had no BM as of yet. DISCHARGE MEDICATIONS: 1. Celexa 40 mg PO q. day.
BM|bowel movement|BM,|136|138|SYSTEM REVIEW|Says that she has colitis. Indicates that she has not had a colonoscopy. Had about three movements of her bowels today after one normal BM, and some days totally normal with the BM. GENITOURINARY: Indicates that there is frequent urination. Stress incontinence occurs.
BM|bowel movement|BM|142|143|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: The patient was sent home on the following medications: 1. Protonix 40 mg p.o. q. day. 2. Imodium 2-4 mg p.o. q. loose BM with a max of 8 mg per day. 3. Lidocaine gel 2% every 2 hours as needed. 4. Colace 100 mg p.o. b.i.d. p.r.n. constipation.
BM|breast milk|BM|247|248|FOLLOW UP|Problems during the hospitalization included the following: 1. F/E/N - Trophic feeds were started on _%#MMDD2003#%_ (we waited to feed until his stool became heme negative.) He was slowly increased to a goal of 160 ml/kg/day and then to fortified BM once he tolerated the volume goal. He was advanced on his feedings slowly secondary to reflux. He was supplemented with TPN until he was able to tolerate full feeds.
BM|bowel movement|BM,|165|167|HISTORY OF PRESENT ILLNESS|She has insomnia and took Ambien last evening, which helped. Bowel movements were previously quite loose and frequent, but stated this morning she had a large, soft BM, but is significantly improving. She denied dizziness, headaches, or chills though feels weak. Please refer to review of systems for further data.
BM|bowel movement|BM|168|169|PROBLEM LIST|Her diarrhea was most likely secondary to Senokot, which she was taking when she was put on iron supplement. Her bowel habits are now back to her baseline. She had one BM this morning. 2. Cardiovascular: History of congestive heart failure secondary to diastolic dysfunction. The patient is clinically compensated. She was getting Lasix 100 mg p.o. daily on admission.
BM|bowel movement|BM|158|159|HISTORY OF PRESENT ILLNESS|The vomit was initially clear and then became bilious but nonbloody. Eventually she developed dry heaves. The patient's bowel movements were normal. Her last BM was in the morning and was soft but formed. She denied any fevers, sweats, or chills. At the time of admission, she denied any abdominal pain.
BM|bone marrow|BM|175|176|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: _%#NAME#%_ is scheduled to follow up with Dr. _%#NAME#%_ _%#NAME#%_ at BMT clinic on Wednesday, _%#MM#%_ _%#DD#%_, 2006. He will also have labs at the BM clinic on Monday, _%#MM#%_ _%#DD#%_, 2006. It has been a pleasure to be involved in _%#NAME#%_'s medical care. Please do not hesitate to contact me with any further questions or concerns.
BM|breast milk|BM|199|200|ASSESSMENT AND PLAN|By DOL 25 (_%#MMDD2004#%_) he was able to take full-volume gavage feeds, and tolerated full-caloric feeds as of _%#MMDD2004#%_ at which time TPN was discontinued. He has been tolerating full feds of BM fortified to 26kcal. He is on Diuril and Aldactone to help his respiratory status. He is on NaCl supplementation. 6. Gastrointestinal: Lincoln exhibited reflux symptoms on DOL 6 (_%#MMDD2004#%_) with a gastric pH in the 3s, so he was placed in reverse Trendelenberg and started on ranitidine.
BM|bowel movement|BM|215|216|DISCHARGE INSTRUCTIONS|_%#NAME#%_ will be in touch with the patient regarding this appointment and also regarding the date and time for her surgery. DISCHARGE INSTRUCTIONS: She is asked to call for a temperature greater than 100.4, if no BM x3 days, or for nausea and vomiting or increased pain not controlled by her medications.
BM|bowel movement|BM|180|181|PHYSICAL EXAMINATION|Head, ears. eyes, nose, and throat are clear. Eating breakfast. No difficulties with swallowing. Chest is clear. Heart: Regular rate and rhythm. GU: Without a Foley catheter. Last BM was on _%#MM#%_ _%#DD#%_, 2005. She uses a walker with therapist. She continues to work on upper and lower extremity strength and function.
BM|bowel movement|BM|131|132|BRIEF HISTORY AND PHYSICAL EXAM|The pain was localized to his epigastric area with radiation to the back. He denied any vomiting, but did have some nausea. Normal BM a night before, no blood in his stool and no vomiting. On admission his blood pressure was 117/75, heart rate 92, respirations of 18, temperature of 98.8, 02 sat 90% on room air.
BM|bowel movement|BM|125|126|ADMISSION DIAGNOSIS|Patient reports chest pain that feels like gas pain for the last 2 days. He denies nausea, vomiting, fever, chills. His last BM was on _%#MM#%_ _%#DD#%_, 2005, 1 day prior to admission, but he has not had any gas since. Patient denies any melena or hematochezia. In the emergency room, patient had an abdominal film taken, and that showed severe colonic obstruction.
BM|bowel movement|BM.|149|151|HOSPITAL COURSE|Aggressive pulmonary toilet was initiated with deep breathing and coughing on a regular basis. Postoperative day 2, the patient had had no flatus or BM. She was alert and her lungs were still sounding coarse, was decreased in the bases. She was started on a bowel regime of Reglan and Dulcolax suppositories until she had a BM.
BM|bowel movement|BM.|171|173|HOSPITAL COURSE|She was alert and her lungs were still sounding coarse, was decreased in the bases. She was started on a bowel regime of Reglan and Dulcolax suppositories until she had a BM. She was to continue aggressive incentive spirometry. Postoperative day 3, the patient was noted again to have a temperature of 100.2; however, her respiratory status continued to improve and she had had a bowel movement x2, on the night of _%#MM#%_ _%#DD#%_, 2005, so on _%#MM#%_ _%#DD#%_, 2005 she was started on clears and p.o. pain medicine.
BM|breast milk|BM|206|207|FOLLOW UP|He was maintained on TPN in addition to gavage feeds until _%#MMDD2005#%_ when he was tolerating enough feedings via the enteral route. At the time of discharge, he was receiving his feedings per gavage of BM fortified to 24kcal/oz with Enfamil human breastmilk fortifier, 36 mL every 3 hours. He was also starting to breastfeed ad lib about 2 times per day when his mother was available.
BM|bowel movement|BM|220|221|HISTORY OF PRESENT ILLNESS|She is incontinent of both feces and urine. She does still have occasional urine output. However, this is chronic. She has no increased abdominal distention and is currently still passing flatus and did have some formed BM times two yesterday. REVIEW OF SYSTEMS: No cough, no shortness of breath, no focal pain.
BM|bowel movement|BM|201|202|HOSPITAL COURSE|On the morning of admission postoperative day #4, the patient was doing very well, with minimal pain. He did complain of mild-to-moderate genital edema, and had only passed small amounts of flatus and BM at the time of discharge. He did feel a pressure, like he needed to have some bowel movement. This feeling was helped yesterday with a gentle suppository. The patient is otherwise afebrile and hemodynamically stable, he has excellent clear yellow urine output, and JP creatinine is serum.
BM|bowel movement|BM|269|270|BRIEF HISTORY AND HOSPITAL COURSE|3. History of multiple sclerosis. BRIEF HISTORY AND HOSPITAL COURSE: A 41-year-old gentleman with history of MS, nonambulatory at baseline, who presents here with significant constipation. His last bowel movement was on _%#MMDD2006#%_. His usual bowel habits include a BM every other day. He does report some problems with constipation in the past. He had been using a suppository at home, more often lately but without any improvement in results.
BM|bowel movement|BM.|132|134|BRIEF HISTORY AND HOSPITAL COURSE|He had subsequently refused further enemas since then. He continued to improve and states that he felt a lot better after his large BM. He will be placed on scheduled MiraLax 17 grams daily for the next 5 days to ensure adequate clearance of his significant stool impaction.
BM|breast milk|BM|151|152|DISPOSITION|She passed the ABR hearing screen test on _%#MMDD2005#%_. Immunizations: Hepatitis B vaccine was given on _%#MMDD2005#%_. _%#NAME#%_ was discharged on BM or Enfamil 20 with Fe taking 15-60 ml every 2-3 hours and/or attempting breast-feeding every 2-3 hours ALD with minimal volumes.
BM|bowel movement|BM|309|310|HISTORY OF PRESENT ILLNESS|DOB: _%#MMDD1934#%_ CHIEF COMPLAINT: Fever, hypoxia. HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old gentleman with history of recurrent aspiration pneumonia, history of CVA's with associated contractures and dementia secondary to alcohol abuse, who presents with fever and hypoxia following a large BM and emesis. Unclear whether the patient had ongoing fever prior to his emesis. He presents from the _%#CITY#%_ _%#CITY#%_ Medical Center nursing facility.
BM|breast milk|BM|160|161|SUMMARY OF HOSPITAL STAY|Feedings were started on _%#MMDD2006#%_, and she tolerated the increase in volume and strength of. At the time of discharge, she was tolerating her feedings of BM to 24 kcal/oz with Similac HMF via NG tube, 17 mL every 2 hours. Her weight at the time of discharge was 1216 gm with a head circumference of 25.5 cm and length of 39 cm.
BM|bowel movement|BM.|225|227|HOSPITAL COURSE|The patient's Levaquin was thus continued for her UTI. The patient continued to improve throughout the remainder of her hospital stay. She was able to advance to a pureed diet without any noted nausea or vomiting following a BM. The patient had adequate pain control with p.o. pain medications prior to discharge. The patient was able to up and ambulate without any difficulty.
BM|bowel movement|BM|340|341|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Abdominal pain and low back pain. HISTORY OF PRESENT ILLNESS: This patient is a 76-year-old who has complained of some low abdominal pain and low back pain since the last couple of days, fairly steady, no injury that he knows of , like to his back or anything like that. He has had decreased appetite the last few days. No BM for about 4 days. No diarrhea. No fevers. Also states he usually makes a little bit of urine despite his renal failure, but has not for the last few days as well, which is unusual for him.
BM|bowel movement|BM|166|167|HISTORY OF PRESENT ILLNESS|She states she has been unable to take any oral food or fluids without having emesis to follow. She denies any abdominal pain. Please note she did have a large, soft BM this morning. She is passing flatus. She did have difficulties with nausea and vomiting following her first cycle of therapy.
BM|breast milk|BM|269|270|SPECIFIC DISCHARGE INSTRUCTIONS|We were able to start parenteral nutrition on _%#MMDD2007#%_. He was maintained on this until _%#MMDD2007#%_, when he was tolerating enough feedings via the enteral route. Feedings were started on _%#MMDD2007#%_, and he tolerated the increase in volume and strength of BM and Enfamil 20 kcal/oz. At the time of transfer, he was bottling most of his feedings of Enfamil 20 kcal/oz with gavage supplementation, 37 mL every 3 hours as well as breastfeeding ad lib.
BM|breast milk|BM|132|133|* FEN|At the time of discharge, he was breastfeeding most of his feedings on cue-based schedule, as well as taking two bottles per day of BM fortified to 24 kcal. His weight at the time of discharge was 1958 gm with a head circumference of 31.5 cm and length of 43.5 cm.
BM|bowel movement|BM.|248|250|HOSPITAL COURSE|The patient was started on Ativan for muscle relaxants. On _%#MMDD2007#%_ there was a question of an anastomotic leak because of the increased tenderness in the patient's abdominal exam and the fact that he had still not passed any flatus or had a BM. The patient was without nausea or vomiting. The CT scan was done, which showed no leak. A PICC line was placed and the patient was started on TPN.
BM|breast milk|BM|206|207|* FEN|She was treated with 48 hours of ampicillin and gentamicin while her blood cultures were pending. This problem has resolved. Ongoing problems and suggested management: * FEN: _%#NAME#%_ is currently taking BM fortified with Enfacare to 24 kcal/oz. She is on an adlib schedule and is tolerating this very well. She also receives tri-vi-sol with iron. * CV/RESP: _%#NAME#%_ has been stable on room air for quite some time.
BM|bowel movement|BM.|161|163|HISTORY OF PRESENT ILLNESS|He says that he had not had a bowel movement since last week. He was successful in having a bowel movement. He did note some blood on his toilet paper after the BM. He says that afterwards he had significant pain in the left side of his chest wall, worse with breathing. He says that this was after straining after sitting on the toilet.
BM|bowel movement|BM|157|158|HISTORY OF PRESENT ILLNESS|She was told to report to the emergency room should her symptoms worsen, given her complicated past history. Prior to presentation today, the patient's last BM was 2 days prior to this admission; however, during the course of this admission, the patient had a loose bowel movement.
BM|bowel movement|BM|216|217|REVIEW OF SYSTEMS|2. Hypertension. 3. Overweight. FAMILY HISTORY: Positive for diabetes. SOCIAL HISTORY: Patient lives at home with her granddaughter and her mother. REVIEW OF SYSTEMS: Boyfriend has strep throat. Patient hasn't had a BM for several days. She had been recently treated for a bladder infection. PHYSICAL EXAMINATION: Patient is overweight. She is in moderate distress secondary to abdominal pain. Vital signs: Afebrile, blood pressure 154/92, weight 238.6, pulse 91, 97% sats, BG is 214 and was higher overnight.
BM|bowel movement|BM|162|163|MEDICATIONS|2. Zoloft 150 mg p.o. q day. 3. Benadryl 25 mg p.o. q8 hours prn for pain. 4. Decadron 4 mg p.o. b.i.d. 5. Vitamin B6 100 mg p.o. t.i.d. 6. Senokot S regimen for BM q three days. 7. Vitamin A 800 mg p.o. q a.m. 8. Glutamine 1 gram p.o. q.i.d. 9. Leucovorin 25 mg p.o. t.i.d.
BM|bone marrow|BM|183|184|STAFF ADMIT NOTE|Plan Broad infectious screen, focused screen for rheumatologic and malignancy. CT scan of abdomen to evaluate for abdominal abscess, especially around kidney. Differ other radiology, BM biopsy, other lab tests based on above results. Discontinue antibiotics. Monitor temp and vitals closely.
BM|bowel movement|BM|123|124|REVIEW OF SYSTEMS|Denies chest pain, shortness of breath, orthopnea, PND, or pedal edema. No cough, fevers or chills. She has not had a good BM for 2 weeks, but she has had a very poor intake. Reports falling because of weakness with the poor intake, bruising her nose and arms.
BM|bowel movement|BM|153|154|HOSPITAL COURSE|The patient was placed on multiple medications for multiple stool softeners. During the last 3 days his bowel became more regular, but he did not have a BM yesterday. He is requesting fleets enema prior to discharge. It is recommended the patient should continue the stool softeners and try to have regular bowel movement and just holding those medications when he has diarrhea just to avoid severe straining.
BM|bowel movement|BM|134|135|HISTORY OF PRESENT ILLNESS|Did take an Imodium and that helped but then it actually kind of stopped him up a little bit but that seems better now. He did have a BM yesterday which was again watering. Now he has been having some slowly building right lower quadrant pain since the surgery and also on the right side just underneath his right ribs, though he says he has had problems with a lot of pain there prior that they thought was probably from the adhesions, maybe a little right CVA tenderness as well, though he says he has had pain back there before as well.
BM|bowel movement|BM|160|161|HISTORY OF PRESENT ILLNESS|She had associated nausea. Pain has been intermittent over the last several months. Pain today was more severe than it has ever been. No fevers or emesis. Last BM was today at 1:30 and was normal. Appetite has been good. No weight loss. Has been taking Zofran at home, which has helped with the nausea.
BM|breast milk|BM.|270|272|TPN|PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are pending at discharge. She passed the ABR hearing screening test. Immunizations: none Brianna was discharged on TPN and beginning feeds of 5cc q 3 hours gavaged of BM. Thank you again for allowing us to share in the care of your patient.
BM|bowel movement|BM.|170|172|PROCEDURES PERFORMED DURING THIS HOSPITALIZATION|The patient was then transferred and admitted to 6B for further monitoring and care. On postop day number one the patient was tolerating diet, ambulating, had flatus and BM. However, immediately prior to discharge the patient developed nausea without vomiting, and decision was made to allow the patient stay overnight.
BM|bowel movement|BM|158|159|PHYSICAL EXAMINATION|The patient had an NG tube remain in place secondary to lack of flatus and/or BM. On hospital day 4, the patient had return of bowel function demonstrated by BM and flatus. The patient's NG output was only 350 cc over a 24-hour period prior to discharge. The patient was not complaining of abdominal pain. The patient's physical examination at the time of discharge: The patient was alert and oriented x3.
BM|bowel movement|BM|164|165|HISTORY OF PRESENT ILLNESS|Presents on _%#MMDD2002#%_ with eight hours of epigastric and low back pain, colicky but never 0 and 0, no lower abdominal pain, three emesis this AM, no PO, loose BM this AM, no blood, no hematemesis. Pain radiates through to the back. Otherwise well. REVIEW OF SYSTEMS: Times ten negative.
BM|bowel movement|BM|196|197|DOB|This started Monday evening with a twinge which has progressed to the point that last night she was unable to sleep with bad lower abdominal pain in the right lower quadrant. She reports a normal BM this morning. No nausea or vomiting. No change in appetite. In fact, she ate this morning a piece of peanut butter toast with milk.
BM|bowel movement|BM.|174|176|DISCHARGE DIAGNOSIS|On post-op day three the patient was having flatus. The patient had not had a bowel movement; however, the patient was agreeable to having his suppository which results in a BM. The patient was tolerating p.o., ambulating, and pain was well controlled. The patient's creatinine on post-op day two was 1.7. DISCHARGE PHYSICAL EXAMINATION: APPEARANCE: Alert and oriented x 3.
BM|bowel movement|BM|190|191|HISTORY OF PRESENT ILLNESS|She is a rather anxious person and admittedly so. She has tried previous SSRIs and anxiolytics without much relief. She was at the super market yesterday a.m and had a sudden urge to have a BM and noted that she had explosive diarrhea. She only reports diffuse abdominal cramping, but no fevers, chills. She describes her stool as loose, watery, but no obvious blood.
BM|bowel movement|BM|190|191|ASSESSMENT|She denies any unusual ingestion over the past 1 week, but did report drinking some well water a few weeks ago up north. She, however, has not had any problems with the well water. Her last BM was this morning. She developed some nausea and emesis, but that has resolved with some IV fluids. Noted in her history is that she did take some hydrochlorothiazide approximately 1 month ago, as well as Paxil earlier this week.
BM|bowel movement|BM|126|127|PLAN|2. Gastroenteritis. The patient reports that this may just be an exacerbation of her irritable bowel syndrome. She only had 1 BM this morning. I will check at cecal white cells to differentiate between inflammatory and noninflammatory causes. Given her history of drinking well water, I will also add an O&P, as well as stool culture to her labs.
BM|bowel movement|BM|144|145|DISCHARGE MEDICATIONS|2. Lexapro 10 mg p.o. q.d. 3. Clonazepam 4 mg p.o. q.d. 4. Protonix 40 mg p.o. q.d. 5. Magnesium citrate one-half bottle p.o. q. week p.r.n. no BM or constipation. 6. Tylenol 650 mg p.o./PR q6h p.r.n. 7. Zomig 5 mg p.o. p.r.n., may repeat x 2 in two hours with 10 mg per day max.
BM|breast milk|BM|249|250|1. FEN|The admission physical examination was positive for prematurity. Problems during the hospitalization included the following: 1. FEN: _%#NAME#%_ was on TPN from DOL #2 to DOL #13, after that he gradually started taking enteral feeds. He worked up to BM fortified to 26Kcal with good Wt gain. He was changed to breast milk fortified to 22Kcal in preparation for discharge.
BM|bowel movement|BM|284|285|HOSPITAL COURSE|PAST MEDICAL HISTORY: Hypertension, on Toprol. Otherwise no other significant past history. No history of abdominal pain, no history of hematochezia. HOSPITAL COURSE: NG tube is placed and within 24 hours he is feeling quite a bit better with normal white count down to 5,000, normal BM on the morning of the _%#DD#%_ and exam was soft belly. Review of CT scan with Dr. _%#NAME#%_ _%#NAME#%_ showed no significant mass, was appearance of a chronic small bowel obstruction on the right side and the small bowel and flat and upright of the abdomen both today and yesterday showed only mild findings of small bowel obstruction.
BM|breast milk|BM|183|184|1. FEN/GI|Both of these studies were normal with no evidence of intracranial hemorrhage. Ongoing problems and suggested management: 1. FEN/GI: _%#NAME#%_ is tolerating gavage feeds of 45 cc of BM 24 q3 hours. He is also taking breastfeeds of 15-25 ml q 8 hours. 2. RESP: _%#NAME#%_ continues on caffeine citrate 10 mg PO/NGT qd.
BM|bowel movement|BM|141|142|HOSPITAL COURSE|With supportive care and IV hydration his abdominal pain was improved. He had a benign abdominal exam and actually had one normal non-bloody BM on the day prior to discharge. 2. Bilateral pleural effusion. The patient had some left pleural effusion on the PA and lateral chest x-ray.
BM|bowel movement|BM|143|144|TRANSFERRING MEDICATIONS|11. Percocet one tablet per G-tube q.6 h p.r.n. (with limit of Tylenol to be 4 g in a 24 hour period). 12. Imodium 2 mg per G-tube after loose BM p.r.n. (limit 60 mg internal jugular a 24 hour period). 13. Nasal spray (saline) at bedside to be used p.r.n. by patient.
BM|bowel movement|BM.|140|142|DIAGNOSTIC IMPRESSION|He has no difficulty in speech nor any mental confusion. Able to eat. DIAGNOSTIC IMPRESSION: 1. Acute able pain now suddenly resolved after BM. One suspects constipation. Air in biliary tree found on CT, possibly secondary to prior procedure on bile duct. Possibility of cholangitis is entertained. Sudden improvement and lack of leukocytosis suggests that was not present.
BM|bowel movement|BM|211|212|HISTORY OF PRESENT ILLNESS|She states she has a mild headache 3/10 in the frontal region but no radiation. This began about 2 days ago. The patient denies weakness or asymmetry. No symptoms of urinary irrigation. The patient reports last BM was 5 days ago with normal brown stool. Denies any peripheral distal edema. The patient provided a history of a fall and displayed minimal confusion.
BM|bowel movement|BM.|115|117|DISCHARGING AND TRANSFER MEDICATIONS|12. Glucotrol 10 mg p.o. q.a.m. and Glucotrol 5 mg p.o. q.p.m. 13. Dulcolax suppository one PR q. 3 days p.r.n. no BM. 14. Milk of magnesia 15 to 30 mL p.o. q. 3 days no BM. 15. Fleets enema one per rectum q. day p.r.n. 16. Guaifenesin with dextromethorphan 5 mL p.o. q.4 h. p.r.n.
BM|breast milk|BM|238|239|PERTINENT LABORATORY TESTS|The mild jaundice resolved with increased fluid intake, there was no need for phototherapy. This was most likely mild physiologic jaundice. Ongoing problems and suggested management: F/E/N - continue to work on feedings, supplement Mom's BM with similac plus iron. Discharge medications, treatments and special equipment: Tri-vi-sol .5 ml po daily Discharge measurements: Weight 3770 gms; length 52 cm; OFC 36 cm.
BM|bowel movement|BM|158|159|PHYSICAL EXAMINATION|GENERAL: She is alert, cooperative, no acute distress. HEENT: Clear. CHEST: Clear. HEART: Regular rate and rhythm. ABDOMEN: Soft; positive bowel sounds; last BM _%#MMDD2005#%_. GU: The patient was continent of urine. NEURO: She continues to have some short-term memory difficulties. ASSESSMENT: As above. PLAN: 1. Discharge her to home with home health, THM, and PT/OT.
BM|bowel movement|BM|139|140|DOB|She has had no previous onset of this kind of pain before. The pain also radiates through to her back. Denies dysuria, denies fever, had a BM this morning. SOCIAL HISTORY: She is an insurance rep. She had no children and lives with her husband.
BM|bowel movement|BM.|316|318|HISTORY OF PRESENT ILLNESS|However, in the past several months she has had increased frequency and episodes of bright red blood per rectum, and in the past two to three months has been experiencing four to eight loose wet stools with blood associated with each bowel movement. She states there is an eighth to a quarter cup of blood with each BM. No associated weight loss. She does complain of occasional "tarry stools with otherwise cherry-red blood" in stools. No associated nausea/vomiting currently. No abdominal pain. It is not worsened or associated with food ingestion.
BM|bone marrow|BM|169|170|PROBLEM #4|Hematology recommended a peripheral blood smear, which showed marked normochromic normocytic anemia, moderate leukopenia, reactive lymphocyte morphology with occasional BM immunoblasts and pre-B cells. Given that _%#NAME#%_ is immunosuppressed decision was made to do a bone marrow biopsy, which did show HSV6. At the time of discharge _%#NAME#%_'s WBC was 2.3, hemoglobin 7.9 with an absolute neutrophil count of 0.1. PROBLEM #5: Dermatology: A Dermatology consultation was obtained and the rash was biopsied and found to be most likely a viral exanthem.
BM|bowel movement|BM.|122|124|HISTORY|She reports stools that have become small and caliber and has been having to strain more frequently when she was having a BM. She was referred by her primary doctor as having a positive rectal examination. She then underwent a colonoscopy that showed an obstructing lesions in the distal colon.
BM|bowel movement|BM|214|215|REVIEW OF SYSTEMS|The patient's previous lipase prior to discharge was in the 200s at last admission, currently elevated at 5400. He denies any fevers or chills. REVIEW OF SYSTEMS: The patient complains of constipation, no adequate BM since his prostate surgery per patient report. In addition, he is complaining of increased urinary frequency, urinary hesitancy, burning with urination and decreased urine output.
BM|bowel movement|BM|366|367|DISCHARGE MEDICATIONS|No evidence for metastatic diseases. Sinuses are clear. DISCHARGE MEDICATIONS: We will restart him on his Lexapro 5 mg p.o. daily. Lasix 10 mg p.o. daily, Glucotrol XL 5 mg p.o. q.i.d., Synthroid 150 mcg p.o. daily, Ativan 0.5 to 1 mg p.o. q.4h. p.r.n., Restoril 7.5 mg p.o. at bedtime p.r.n., OxyContin 20 mg p.o. q.12h., MiraLax 17 g p.o. daily, Fleet Enema if no BM x3 days, Prilosec 20 mg p.o. daily, diltiazem ER 180 mg p.o. daily, nitrofurantoin 100 mg p.o. b.i.d. x4 days, and Florinef 100 mcg p.o. daily, he needs to be monitored for any dyspnea or CHF with this medication.
BM|bowel movement|BM|261|262|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 3-year-old girl with cystic fibrosis who was admitted with a 3-day history of constipation and a 1-day history of pain and vomiting. Emesis was described as nonbloody and nonbilious. Her father reported that her last BM was on the Sunday prior to admission. It was described as loose and watery. Since that time, she had not had any stools.
BM|bowel movement|BM.|186|188|HISTORY  OF PRESENT ILLNESS|She has been exposed to multiple ill contacts at her school within the past several weeks. Today while in the bathroom she had three separate syncopal events. Each episode occurred with BM. The patient had one episode where she had mild trauma to her right forehead with small laceration. However, she denies headache, no blurred vision, no focal weakness and her nausea and vomiting are significantly improved with p.r.n. Zofran.
BM|breast milk|BM|218|219|1. FEN|3. Ophthalmology: Follow-up with Dr. _%#NAME#%_ in 6 weeks. Discharge medications, treatments and special equipment: 1. Polytrim eye drops 2-3 drops in each eye QID. 2. TriViSol solution with iron 1 ml P.O q Daily. 3. BM fortified with Neosure to 22 Kcal/ oz ad lib on demand. . _%#NAME#%_ meets the AAP criteria for receiving Synagis. He received his first dose on _%#MMDD2006#%_ and will need monthly shots until the RSV season has ended.
BM|bowel movement|BM|126|127|HISTORY OF PRESENT ILLNESS|The patient was in her usual state of health until this a.m. She awoke feeling normally and ate a normal breakfast; she had a BM thereafter which she normally does. After her first bowel movement she subsequently had the urge to have three to four subsequent bowel movements.
BM|bowel movement|BM|180|181|HISTORY OF PRESENT ILLNESS|He states developed fairly sudden of nausea and vomiting last night, some abdominal pain around the belly button area. Denied any diarrhea, constipation, blood in his stools. Last BM was _%#MMDD2006#%_. Came to the Emergency Room. PAST MEDICAL HISTORY: krohn's disease. PAST SURGICAL HISTORY: Status post partial small bowel resection. CURRENT MEDICATIONS: None.
BM|bowel movement|BM|149|150|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: Denies any chest pain, breathing difficulty or shortness of breath. She reports vomiting. No change in her bowel movement. Normal BM yesterday. No fever, no chills. She has chronic incontinence when laughing or coughing consistent with bladder prolapse. For a full review of systems please refer to the nursing admission database dated _%#MMDD2006#%_ at 17:45 that was reviewed by me.
BM|bowel movement|BM.|340|342|DISCHARGE MEDICATIONS|8. The patient is stable for discharge to home on _%#MM#%_ _%#DD#%_, 2006, with home physical therapy; followup at home dialysis unit on Monday, Wednesday, and Friday; and scheduled appointments with primary care, orthopedics, ophthalmology, and sleep study. DISCHARGE MEDICATIONS: 1. Senokot-S 1 tablet twice daily, 2 tablets b.i.d. if no BM. 2. Ofloxacin 0.3% 1 drop right eye, q.i.d. 3. Lipitor 10 mg at bedtime. 4. Norvasc 10 mg daily. 5. Nephrocaps 1 capsule daily.
BM|bowel movement|BM.|129|131|DISCHARGE MEDICATIONS|She was recently D/Ced from Region's Hospital with a partial SBO. She's been eating and passing flatus. Now about 10 d without a BM. No fevers, chills, sweats, chest pain, lightheadedness, weakness. Mild SOB at baseline. ROS o/w negative. PAST MEDICAL HISTORY: 1. Pentalogy of Cantrell.
BM|bowel movement|BM|236|237|HISTORY  OF PRESENT ILLNESS|He does report some associated nausea. Pain is described as mainly epigastric but somewhat diffuse cramping in nature and radiating to his back. His bowel habits have been otherwise unremarkable with no melena or hematochezia. His last BM was just early this morning. He denies any fevers or chills. PAST MEDICAL HISTORY: He was admitted here earlier in _%#MM2006#%_ with symptoms of an intractable vomiting.
BM|bowel movement|BM.|163|165|HOSPITAL COURSE|Cytology had not come back yet on the thoracentesis. On the morning of _%#MMDD2006#%_, he had gotten up to go to the bathroom with nursing assistance with a small BM. When he got back to the bed, he started foaming at the mouth, had a glazy stare. Code blue was called. Family decided against aggressive measures. Eventually his pulse became more and more bradycardic, and eventually stopped, and he was declared dead at around 10:20 in the morning on _%#MMDD2006#%_, presumably from abrupt decrease in blood pressure and cardiac output secondary to his trivalvular heart disease.
BM|bowel movement|BM|152|153|POSTOPERATIVE COURSE|She was slowly able to advance to a regular diet by _%#MMDD2006#%_ after some issues with nausea afterwards and did have increase of bowel activity and BM by _%#MMDD2006#%_. During that time had she advanced her activity level as well and was having good urinary function. The patient was therefore okayed for discharge on _%#MMDD2006#%_ by Surgery and Internal Medicine.
BM|bowel movement|BM|170|171|CURRENT MEDICATIONS|9. Fosamax 70 mg weekly. 10. Tylenol extra strength one at bedtime 11. Metamucil one packet daily 12. Singular 10 mg daily 13. Milk of Magnesia two tablets p.r.n. for no BM x48 hours 14. Triamterene/hydrochlorothiazide 37.5/25 mg 1/2 tablet daily. FAMILY HISTORY: Significant for father dying in his mid 90s and mother dying at age 69 of leukemia.
BM|bowel movement|BM|263|264|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is an 88-year-old male who presented with an inguinal left-sided lump that appeared on the day of admission around noon. The patient has nausea and some abdominal discomfort. No vomiting prior to admission. The patient is passing BM on the day of admission. No blood per rectum. No chest pain or shortness of breath. The patient states that he does not have generalized abdominal pain.
BM|bowel movement|BM|145|146|HISTORY OF PRESENT ILLNESS|This is her third hospitalization since _%#MM#%_ 2006. She is here today complaining of right-sided abdominal pain. She stated she had not had a BM since last Wednesday. She denies nausea or vomiting. CT of the abdomen and pelvis in the emergency room revealed diffuse stool in large colon.
BM|bowel movement|BM|250|251|HISTORY OF PRESENT ILLNESS|She has a history of perforated diverticulitis, for which she received a sigmoidectomy and colostomy with subsequent colostomy takedown. The patient states that her abdominal pain is located around her stomal takedown site. Positive flatus. Positive BM the night prior to admission. Positive nausea and emesis x 2. The patient denied any dysuria, hematuria, or increased urinary frequency.
BM|bowel movement|BM|219|220|REVIEW  OF SYSTEMS|Chest x-ray is negative for any infiltrate. REVIEW OF SYSTEMS: No headache, no dizziness, no chest pain, no shortness of breath, positive for abdominal pain, nausea and 1 vomiting, no diarrhea. The patient had her last BM yesterday. No focal weakness, no hematochezia. PAST MEDICAL HISTORY: 1. CAD, CABG, triple vessel six years ago
BM|bowel movement|BM|167|168|REVIEW OF SYSTEMS|No problems of urinating or burning, occasionally incontinent. This occurred before her stroke. No history of back pains or joint pains. Occasional constipation, last BM today. PHYSICAL EXAMINATION: Vitals stable. The patient was alert, oriented x 3, with pleasant affect.
BM|bowel movement|BM|155|156|COURSE IN THE HOSPITAL|Lungs are clear. Heart is regular. Her abdomen is soft and nontender. Her incision is dry and intact. She has bowel sounds and is passing flatus and had a BM last night. She is presenting tolerating pureed diet and is well enough to go home. She will be sent home with pain medications, which consist of Roxicet elixir.
BM|bowel movement|BM|265|266|HOSPITAL COURSE|Postoperatively she developed temp on the 2nd postoperative day without obvious cause and this eventually resolved and gradually she made output by the 5th postoperative day and subsequently her diet was slowly advanced and by the 7th postoperative day she had had BM and flatus. She finally was hungry. Her nausea had cleared up and then her diet was advanced and finally on the 21st postoperative day she was eating a soft diet without evidence of nausea or cramps.
BM|bowel movement|BM|221|222|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 17-year-old man with a history of CF diagnosed in the neonatal period with CF associated insulin-dependent diabetes mellitus, admitted with an ileus. Patient had been without a BM since 2 days prior to admission and has had noticed increased abdominal distention and increased abdominal pain rated 8 to 10 out 10 and described as sharp and diffuse in character.
BM|bowel movement|BM.|126|128|ADMISSION DIAGNOSIS|The patient was then started on clear liquids and advanced to larger volumes as tolerated. On postop day 1, the patient had a BM. Postop morning of day 2, the patient states she was feeling fine, ambulating and was ready for discharge. The patient's physical exam at the time of the discharge, the patient is alert and oriented x 3, regular rate and rhythm, no rubs, gallops, or murmurs.
BM|bowel movement|BM|164|165|HISTORY OF PRESENT ILLNESS|Today the patient has no complaints of headaches, dizziness, chest pain, shortness of breath, nausea and vomiting. She does complain of constipation and has had no BM x 4 days, has had occasional acid reflux at night and occasional urine incontinence if her leg spasms are "very bad".
BM|bowel movement|BM|260|261|DISCHARGE MEDICATIONS|16. Dulcolax suppository per rectum q. 3 days p.r.n. no BM or constipation. 17. Nicotine gum p.r.n. at the bedside per his home routine, which, he says, helps his breathing as he feels short of breath. 18. Milk of Magnesia 30 cc p.o. p.r.n. constipation or no BM x 3 days. 19. Oxygen 2-3 liters as per the patient's home routine. ALLERGIES: The patient does not have any drug allergies.
BM|bowel movement|BM|248|249|HISTORY OF PRESENT ILLNESS|PROCEDURES: _%#MMDD2003#%_ - Placement of G-tube for chronic decompression. HISTORY OF PRESENT ILLNESS: This 54-year-old man with peritoneal carcinomatosis presents with postprandial fullness, nausea and vomiting after meals. He has also not had a BM for five days. The patient was diagnosed with peritoneal carcinomatosis in _%#MM2001#%_ and progressed on Capecitabine. He had surgical debulking and intraperitoneal hyperthermic mitomycin in _%#MM2002#%_.
BM|bowel movement|BM,|173|175|HISTORY OF PRESENT ILLNESS|He denies any chills, fevers, or sweats. He denies any chest pain, shortness of breath, or coughing. He denies any nausea or vomiting. He states he now is having some loose BM, but normally does struggle with constipation at times. Please refer to review of systems for further information.
BM|bowel movement|BM|190|191|IMPRESSION/PLAN|Again I am awaiting a call from the patient's care physician so I may place this information on our records. 5. Constipation: This is resolved at this time. He actually is having some loose BM from probably the vancomycin. I will order p.r.n. Senokot and he would like prunes on his tray each morning. 6. Probable head rash on his back: We will monitor closely secondary to him being on vancomycin.
BM|bowel movement|BM|142|143|HISTORY OF PRESENT ILLNESS|This episode has been more prolonged and severe than other episodes, and she feels like there is a large amount of gas in her belly. Her last BM was the day before admission, and she had multiple loose stools. She had been taking some Milk of Magnesia. She does have some mild nausea, vomiting that is yellow, but no blood.
BM|breast milk|(BM|243|245|2. IPV   2/16/03; 4/17/03|4. Prevnar _%#MMDD2003#%_; _%#MMDD2003#%_ 5. Hepatitis B _%#MMDD2003#%_ (Recombivax); 6. _%#MMDD2003#%_ (Comvax) _%#NAME#%_ will be a candidate for Synagis for the upcoming fall RSV season. _%#NAME#%_ was discharged on Breast milk 28 kcals/oz (BM + Enfacare 4kcal/oz plus microlipid 4 kcal/oz plus protein powder to total 4 g. protein/kg/day) taking 55 ml every 3 hours from 0800-2000 hours and drip feedings of 22 cc/hour by pump to his GT from 2000-0800 hours.
BM|breast milk|BM|195|196|2. IPV   2/16/03; 4/17/03|Blood cultures obtained upon admission were negative. 3. _%#NAME#%_ was given TPN. Enteral feedings were initiated and advanced without difficulty. She is currently on full enteral feedings with BM fortified to 24 kcal/oz at 24 cc every 3 hours. Feedings were fortified on _%#MMDD2003#%_. 4. Neuro: _%#NAME#%_ received a head ultrasound on _%#MMDD2003#%_ at one week of age to rule out IVH.
BM|breast milk|BM|156|157|2. IPV   2/16/03; 4/17/03|1. Continued growth and development: We recommend the breast milk feedings be fortified to 24 kcal/oz with human milk fortifier. She is currently receiving BM 24 kcal/oz, 24 cc every 3 hours. _%#NAME#%_ is a good candidate to receive Synagis during the upcoming RSV season.
BM|bowel movement|BM|164|165|HISTORY OF PRESENT ILLNESS|She reports doing quite well and tolerating physical therapy, and had actually sat down to have a BM after walking the halls with PT. She does recall finishing her BM and was unassisted. She felt lightheaded, woozy and when they checked her blood pressure it was noted to have a blood pressure in the 90s/50s.
BM|bowel movement|BM|144|145|HISTORY OF PRESENT ILLNESS|The patient's postpartum course has been unremarkable. She has remained afebrile. Her pain has been well controlled. She has had flatus, but no BM with continually decreasing lochia. Her fundus remained firm and below the umbilicus. Her postpartum hemoglobin was 13.2. The patient was discharged home on postpartum day #2, given Rhogam prior to discharge.
BM|bowel movement|BM,|166|168|DISCHARGE MEDICATIONS|9. Latanoprost 0.005%, one drop to right eye daily at 9 pm for glaucoma. 10. Simvastatin 40 mg at 9 pm for hypercholesterolemia. 11. Imodium one tablet after a loose BM, then 2 mg p.o. p.r.n. loose stools; maximum of 8 mg every day. 12. Magic Mouthwash q.i.d. p.r.n. mucositis. LABORATORY TESTS: 1. _%#MMDD2003#%_ - WBC 3.0, hemoglobin 10.9, platelet count 77,000.
BM|bowel movement|BM|261|262|ADDENDUM|3. Fluids, electrolytes, and nutrition/gastrointestinal. The patient did experience some significant abdominal pain on _%#MM#%_ _%#DD#%_, 2004, and was noted to have not had a bowel movement for 5 days. He was treated with 17 g Miralax which produced one large BM 10 hours later and resolved the pain. DISCHARGE MEDICATIONS: 1. Bactrim DS 1 tablet PO b.i.d. Monday and Tuesday.
BM|bowel movement|BM|169|170|HISTORY OF PRESENT ILLNESS|The patient was recently discharged on _%#MMDD2004#%_ after a brief admission for dehydration and ileus. The patient on presentation on _%#MMDD2004#%_ presented with no BM since discharge. The patient was seen by Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2004#%_ and was given oral stool softeners. The patient was noted to have emesis x3 between her clinic visit and presentation to the hospital.
BM|bowel movement|BM|247|248|HISTORY OF PRESENT ILLNESS|1. TPN. 2. Pressors. HISTORY OF PRESENT ILLNESS: This is a 69-year-old male admitted from an outside hospital on _%#MM#%_ _%#DD#%_, 2005, where he presented with abdominal pain for approximately 12 hours. The pain was moderate to severe. His last BM was the morning prior to admission. He denied nausea and vomiting. He did have a fever of 101 at the outside ED and a white blood count of 11.2. He was admitted to the outside hospital, but subsequently his pressures dropped into the 60s systolic.
BM|bowel movement|BM|202|203|HISTORY OF PRESENT ILLNESS|He presented with recurrent bright red blood per rectum. He had about three episodes at home, which were described as somewhat huge and massive. He has had about two more since admission, with his last BM approximately one hour ago with about 800 ml of bright red blood. He does report some slight dizziness if he gets up.
BM|bowel movement|BM.|136|138|HISTORY OF PRESENT ILLNESS|Per the patient's wife, the patient's shortness of breath is no worse. He just got anxious and short of breath when he could not have a BM. He has a history of chronic constipation and usually goes every 3-5 days, but frequently requires over-the-counter medications and/or enemas to have a stool.
BM|bowel movement|BM.|101|103|IMPRESSION|Will place him on Sorbitol or Lactulose and a bowel regimen to see if we can get him to have a daily BM. Will check a TSH to make sure that he does not have hypothyroidism contributing to his chronic constipation and will get the abdominal x-rays to look for fecal impaction.
BM|bowel movement|BM|134|135|REVIEW OF SYSTEMS|He does admit to an intermittently productive cough which he feels is secondary to his COPD. He also admits to constipation; his last BM had been two to three days ago. He also admits to a dry mouth which he feels is secondary to the oxygen that he is presently on.
BM|bowel movement|BM|170|171|HISTORY  OF PRESENT ILLNESS|The patient is positive for sweats and frequent nausea. The patient had an emesis a couple weeks ago. The patient reports frequent flatus and frequent loose stools, last BM was yesterday. The patient's glucose is poorly controlled. She has poor appetite. Noted to have gross hematuria. The patient reports mild dysuria, positive for history of urinary tract infections.
BM|bowel movement|BM|142|143|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: She is DNR/DNI status at the assisted living. There is a history of constipation, but apparently she had a rather large BM earlier this week. She does have the history of presenile dementia rapidly progressive of the frontal lobe type. No additional data is available. No records of her original neurologic work up are available at this time.
BM|bowel movement|BM|174|175|PLAN|Unable to maintain oral intake. Streaks of blood noted in most recent emesis. Also with abdominal pain, epigastric, burning that radiates into chest. No fevers or chills. No BM for the past 4 days. VS, medications, and labs reviewed in FCIS. Alert, cooperative, mild distress due to discomfort Sclera clear, oralphayrnx clear Neck supple, no LAD Lungs clear, no crackles or wheezes.
BM|bowel movement|BM|136|137|PHYSICAL EXAMINATION|No family present. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.7, respiratory rate 17, blood pressure 110/52, heart rate 72. Last BM _%#MMDD#%_. GENERAL: Sedated, on ventilator. CARDIOVASCULAR: Regular rate and rhythm. RESPIRATORY: Decreased _________. ABDOMEN: Soft, bowel sounds present. EXTREMITIES: No edema.
BM|bowel movement|BM|139|140|HISTORY OF PRESENT ILLNESS|Chest pain on right is mild and chronic at 2 to 3 over 10. The patient has left chest pain now, 8/10, medications are helping. Had a large BM last evening. Bladder control is good. Gets short of breath easily. No rashes, no joint pain. Some numbness in his left chest and his right first, second, and third fingers.
BM|bowel movement|BM|142|143|REVIEW OF SYSTEMS|Prior to this he was independent with ADLs and was responsible for some household tasks. REVIEW OF SYSTEMS: The patient reports having had no BM since _%#MMDD#%_ He also has right-sided weakness. Vision is improved. He is eating small bites okay. The rest of the systems were negative for the 10 point review of systems.
BM|bowel movement|BM|153|154|REVIEW OF SYSTEMS|Mother also has heart disease. Her father's side has diabetes. REVIEW OF SYSTEMS: The patient is having some chills and is not passing gas yet. Her last BM was yesterday, prior to surgery. She denies any fevers, constipation, diarrhea, nausea, vomiting, headache, chest pain, cough, shortness of breath.
BM|bowel movement|BM|319|320|REVIEW OF SYSTEMS|He is a retired salesman. REVIEW OF SYSTEMS: Remarkable for 5 pound weight loss over past couple of months; he describes occasional nausea and headache, and as above, he is quite preoccupied with his bowel function and demanding an enema. However, he has had frequent loose stools since the cholecystectomy, and had no BM for last 3 days, which has him quite concerned. He describes chronic slowness of urination with hesitancy. PHYSICAL EXAMINATION: GENERAL: The patient is well- appearing male in no acute distress.
BM|bowel movement|BM|215|216|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: Denies headache. Has some baseline visual changes but nothing acute. Mild hearing decrease but stable. No signs for aspiration. Occasional cough, no shortness of breath. Bowels are variable, last BM yesterday. More regular consistency though had been constipated. Continent of urine. Sensation is decreased in the right leg but reportedly okay in the hands.
BM|bone marrow|BM|154|155|ADDENDUM|Prior to transplant Mrs. _%#NAME#%_ will be followed by Dr. _%#NAME#%_ _%#NAME#%_ and, after transplant by the BMT clinic. ADDENDUM: Since our consult, a BM biopsy was performed and revealed residual disease. Mrs. _%#NAME#%_ will require additional chemotherapy before transplant.
BM|bowel movement|BM.|169|171|REVIEW OF SYSTEMS|Power of attorney is niece, _%#NAME#%_. Unknown of other family in the area. REVIEW OF SYSTEMS: Positive abdominal pain, "no and yes" to question if she needs to have a BM. No family present. Old charts reviewed, unreliable historian. PHYSICAL EXAMINATION: GENERAL: In bed, crying "_%#NAME#%_," legs pulled to her chest.
BM|bowel movement|BM.|245|247|REVIEW OF SYSTEMS|The patient denies any elicit or IV drug use. FAMILY HISTORY: The patient's mother had diabetes type 2, and her father passed away from lung cancer. REVIEW OF SYSTEMS: Positive for constipation. The patient cannot remember when she had her last BM. When the patient was interviewed later on in the day she reported that she had had a bowel movement today. The patient also reports that she gets diarrhea occasionally after eating greasy foods.
BM|bowel movement|BM|180|181|PHYSICAL EXAMINATION|CARDIOVASCULAR: S1, S2, no murmur, no rubs. ABDOMEN: Bowel sounds are hypoactive in her abdomen. She is nontender. She does complain that she has had diarrhea bouts yesterday with BM x4 loose. She has not had any diarrhea since last evening. Denies tenderness or pain in the abdomen. MUSCULOSKELETAL: Lower extremities are equal strength on flexion and extension.
BM|bowel movement|BM|135|136|REVIEW OF SYSTEMS|CARDIOVASCULAR: The patient is unable to tell me if he has any chest pain. GASTROINTESTINAL: The patient is incontinent of stool, last BM is _%#MMDD2005#%_. GENITOURINARY: The patient is incontinent of urine most of the time. He now has a Foley in, but wears depends per wife.
BM|bowel movement|BM|162|163|PHYSICAL EXAMINATION|Unable to arouse at this time. PHYSICAL EXAMINATION: VITAL SIGNS: 96.8, heart rate 74, respiratory rate 18, blood pressure 179/80, pulse ox 99% on room air. Last BM is _%#MMDD2005#%_. GENERAL: Unable to arouse at this time. HEENT: Dry mouth. No secretions. RESPIRATORY: Decreased breath sounds. CARDIOVASCULAR: Regular rate and rhythm.
BM|bowel movement|BM|182|183|REVIEW OF SYSTEMS|The daughter states the patient has not been coughing and does not have excess secretions. He has been NPO today. Per nursing the patient has positive rectal check and no documented BM since _%#MMDD2005#%_. Per daughter and staff, the patient has been restless and agitated and has some generalized jerking motions.
BM|bowel movement|BM|245|246|HISTORY OF PRESENT ILLNESS|He has a history of DVT X2 in the past after lower extremity orthopedic surgery most recently in _%#MM#%_ 2001 complicated by pulmonary embolus. The patient denies any chest pain. His appetite has been diminished after surgery; he has not had a BM since surgery. HABITS: The patient is a former smoker but has been smoking on and off for many years.
BM|bowel movement|BM|177|178|HISTORY OF PRESENT ILLNESS|She was having DMs and eventually tolerated a diet and was sent home. She was readmitted almost immediately with an increased pressure discomfort in her abdomen. She has had no BM or flatus since last evening. She has no appetite. Her normal bowel movements are loose and without blood. She did have a normal colonoscopy a year ago and currently has mild crampy pain.
BM|bowel movement|BM|190|191|PAST MEDICAL HISTORY|His stooling is described as reasonably within normal limits aside from the fact that his stools are described as being very large. There is no history of encopresis, and he typically has a BM everyday or two. Lastly, his stream occasionally is regarded as spraying. He has never had a urinary tract infection. PHYSICAL EXAMINATION: GENERAL: Currently, he is resting comfortably and in no acute distress.
BM|bowel movement|BM|78|79|HISTORY OF PRESENT ILLNESS|The patient has no complaints at this time. She stated that she has not had a BM since last night. PAST MEDICAL HISTORY: 1. Asthma. 2. Allergic rhinitis. 3. Depression.
BM|bowel movement|BM|352|353|ASSESSMENT AND PLAN|3. Dyspnea: He has mild dyspnea on exertion only. Will continue to monitor, considering his lung metastases, which will probably increase, he will most likely continue to develop worsening dyspnea which may, at some point, require home oxygen. 4. Constipation: He said intermittently he goes a couple of days with no bowel movement, but normally has 1 BM at least every-other-day, and he does not feel that constipation is a problem at this time. He has stool softeners and laxatives at home which he can use p.r.n. Will continue to monitor.
BM|UNSURED SENSE|BM|144|145|HISTORY OF PRESENT ILLNESS|The density is rather homogenous, which is also consistent with melanoma. The patient was referred to Dr. _%#NAME#%_ _%#NAME#%_, who reported a BM of 8.0, an MT of 1.5, a BD of 9.9, and DT of 2.71, with a maximum height of 4.56, and a base diameter of 9.9. She is now referring the patient to the Radiation Oncology Department for possible I-125 eye plaque therapy.
BM|bowel movement|BM|144|145|HISTORY OF PRESENT ILLNESS|I was asked to see this patient by Dr. _%#NAME#%_ for internal medicine consultation. The patient's only complaint is of constipation. Her last BM was about three to four days ago. PAST MEDICAL HISTORY: 1. Major depressive disorder. 2. Emphysema, diagnosis 2-1/2 years ago.
BM|bowel movement|BM|192|193|REVIEW OF SYSTEMS|FAMILY HISTORY: Per old chart. REVIEW OF SYSTEMS: Negative for fever, chills, diarrhea, nausea, vomiting, headache, chest pain, cough, or dyspnea. She does admit to constipation with her last BM three to four days ago. She also admits to being more tired, but is unsure how long that has been going on. She also admits to occasional hot flashes and her last menstrual was about one year ago.
BM|bowel movement|BM|318|319|REVIEW OF SYSTEMS|She rarely drinks alcohol. FAMILY HISTORY: Not obtained. REVIEW OF SYSTEMS: Negative headaches, fevers, chills, lightheadedness, chest pain, palpitations, shortness of breath, abdominal pain, nausea, vomiting. She states she periodically has difficulties with constipation. She has passed a small amount of flatus, no BM since surgery. She has a catheter in her bladder. PHYSICAL EXAMINATION: GENERAL: The patient appears to be a moderately obese 59-year-old woman found lying in bed who seems sleepy, but is in no acute distress.
BM|bowel movement|BM|206|207|REVIEW OF SYSTEMS|No shortness of breath, chest pains, or abdominal pains. No joint swelling. Has decreased active range of motion of his left shoulder secondary to arthritis. Occasional rash with itching. Bowels okay. Last BM _%#MMDD2006#%_. Had some urgency with urination. No urinary tract infection. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.
BM|bowel movement|BM|179|180|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.1; pulse 82; respiratory rate 16; blood pressure 118/72; oxygen saturations at 96% on room air. SKIN: Clear, no edema. She had a BM on _%#MMDD2005#%_. Urine on antibiotics for UTI. MUSCULOSKELETAL: Orthopaedics to evaluate today for a second opinion concerning her left shoulder pain and rotator cuff injury.
BM|bowel movement|BM.|207|209|PLAN|Her last bowel movement was on Thursday, _%#MMDD2006#%_. Will place on bowel program, including Senokot-S 2 tablets once a day and Colace 100 mg p.o. b.i.d, and give her a suppository tonight if there is no BM. 10. Bladder. Will check PVRs x 2. If PVRs are more than 250 cc, we will straight cath. Check a U/A if needed. EXPECTED LENGTH OF STAY: About 12 to 14 days.
BM|bowel movement|BM|200|201|PLAN|2. We will await the patient's progress in the next 24 hours to see if current adjustment of oxycodone controls her pain. 3. We will add scheduled Tylenol to her regimen plus p.r.n. Tylenol. 4. If no BM by tomorrow we will increase her bowel program.
BM|bowel movement|BM|211|212|SPIRITUAL SOURCES OF HELP|She denies dysphagia, denies excess secretions. CARDIOVASCULAR: She denies angina or palpitations. RESPIRATORY: She denies dyspnea or cough. GI: She denies nausea, vomiting, diarrhea, or constipation. She had a BM this morning. GU: She denies incontinence. MUSCULOSKELETAL: She reports weakness and fatigue. SKIN: She denies rash. PSYCHIATRIC: She had difficulty sleeping last night, but typically does not report insomnia.
BM|bowel movement|BM|295|296|REVIEW OF SYSTEMS|Throat, he denies hoarseness, swelling or stiffness. RESPIRATORY: He does have a history of emphysema with slight COPD but denies any shortness of breath at this time. CARDIOVASCULAR: He denies edema, palpitations, DVTs and chest pain. GASTROINTESTINAL: He reports occasional constipation. Last BM was yesterday. MUSCULOSKELETAL: He has a little bit of arthritis in his hands but denies any other stiffness or joint swelling in his back or legs.
BM|bowel movement|BM|145|146|ASSESSMENT AND PLAN|He has been seen by Psychiatry, on Celexa and Klonopin, has Ativan p.r.n. available, also on trazodone each day at bed time. 4. Constipation. No BM since admission, recommend Senokot-S two tabs p.o. each day at bed time. 5. Goals of care. Met with patient's entire family and patient separately.
BM|bowel movement|BM|190|191|PHYSICAL EXAMINATION|GENERAL: Alert, cooperative, oriented to time and place. MUSCULOSKELETAL: No significant changes in strength sensation on the left. GENITOURINARY: Continent of urine. GASTROINTESTINAL: Last BM _%#MMDD2005#%_. CHEST: Clear. HEART: Regular rate and rhythm. When the patient was seen the patient had a decreased blood pressure, was tired, and had some blurred vision in therapy.
BM|bowel movement|BM|131|132|PHYSICAL EXAMINATION|GENERAL: Alert, cooperative, in no acute distress. HEENT: Clear. CHEST: Clear. HEART: Regular rate and rhythm. ABDOMEN: Soft. Last BM _%#MMDD2005#%_. GENITOURINARY: She is continent of urine. MUSCULOSKELETAL: Good strength in the hand on the left, uses her right to assist her arm over head on the left.
BM|bowel movement|BM|155|156|HISTORY OF PRESENT ILLNESS|Positive mild left knee pain without shortness of breath and chest pain. No nausea or vomiting. Bowel and bladder control is good. Mild constipation, last BM yesterday. No numbness or tingling. Decreased sensation. PHYSICAL EXAMINATION VITAL SIGNS: Stable. Temperature 99.3, heart rate 108, respirations 20, and blood pressure 120/72.
BM|bowel movement|BM|218|219|ASSESSMENT AND PLAN|2. Dyspnea. Complained of mild dyspnea, increased dyspnea with activity. Recommend morphine 1-2 mg IV q.1 hour p.r.n. Recommend DC with Roxanol 5-10 mg p.o. q.2 hours p.r.n. 3. CODE STATUS DNR/DNI. 4. Constipation, no BM documented. Recommend Senokot S2 tabs p.o. q.h.s. 5. Depression complained of feeling depressed. Zoloft was increased to 100 mg q. day, today. 6. Goals of care. Met with patient. He is confused and unable to assess his understanding of his illness.
BM|bowel movement|BM|146|147|REVIEW OF SYSTEMS|RESPIRATORY: Denies dyspnea. Reports progressive cough with yellow sputum. GI: Denies any abdominal pain. Denies nausea. Denies vomiting. Reports BM today. GU: Reports having a long-term catheter. MUSCULOSKELETAL: Reports increased weakness and fatigue over the last week or so. SKIN: Denies any rash or open areas. PSYCHIATRIC: The patient does have history of depression.
BM|bowel movement|BM|144|145|PHYSICAL EXAMINATION|No borders of masses noted or palpable masses noted. He has a Foley catheter indwelling which is patent and has adequate urine output. His last BM was _%#MMDD2007#%_ which was black formed stool so is struggling with some constipation, but denies feeling discomfort at this time.
BM|bowel movement|BM|159|160|REVIEW OF SYSTEMS|MOUTH/THROAT: Negative. LUNGS: Negative. HEART: Negative. GI: Negative, except the patient complains of having constipation on and off. She describes having a BM every 1 to 2 days, or every 3 days. GU: The patient states that she has symptoms of urgency, frequency, and incontinence over the past 2 months.
BM|bowel movement|BM|183|184|PHYSICAL EXAMINATION|GENERAL: Alert, cooperative, in no acute distress. HEAD, EYES, EARS, NOSE, AND THROAT: Clear. CHEST: Clear. HEART: Regular rate and rhythm. ABDOMEN: Soft. GU: Continent of urine. GI: BM _%#MMDD2005#%_. SKIN: Few draining areas on the abdomen. Wound sites look okay. MUSCULOSKELETAL: Decreased balance still. Has good strength and increased endurance, decreased coordination.
BM|bowel movement|BM|139|140|ASSESSMENT  AND PLAN|2. Constipation. The patient is certainly at risk for constipation given the morphine PCA. She does have some gaseous distention and if no BM would recommend either an enema or suppository 3. Seizure disorder. Her medications will be held until speech path evaluation. She will have some p.r.n. Ativan however.
BM|bowel movement|BM|164|165|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.4, pulse 69, respirations 18, blood pressure 174/93, O2 saturations 97%. He is 5 feet, 6 inches, 152 pounds. Last BM was _%#MMDD#%_. He is on O2 continuous nasal cannula at 3 liters. GENERAL: He is alert, he has expressive aphasia and feels like he is slow to find words.
BM|bowel movement|BM|160|161|REVIEW OF SYSTEMS|CARDIOVASCULAR: She denies edema, palpitations, DVTs and chest pain. GASTROINTESTINAL: She denies constipation, diarrhea, heartburn or abdominal pain. Her last BM was Monday, presurgically. MUSCULOSKELETAL: She has minimal complaints of stiffness, swelling but no joint pain in hands or legs. NEUROLOGIC: She denies balance, speech, dizziness issues. GENITOURINARY: She denies dysuria, frequency or burning.
BM|bowel movement|BM|215|216|REVIEW OF SYSTEMS|CARDIOVASCULAR: Denies edema, palpitations. She did have 1 positive DVT in 2001, in the lower right extremity. She denies chest pain. GASTROINTESTINAL: She denies constipation, abdominal pain or heartburn. Her last BM was yesterday. MUSCULOSKELETAL: She denies stiffness, swelling of joints, back, legs, hands. NEUROLOGIC: She denies balance, speech, dizziness issues or memory loss.
BM|bowel movement|BM|143|144|PHYSICAL EXAMINATION|GENERAL: Alert, cooperative, no acute distress. HEENT: Clear. CHEST: Clear. TLSO in place. HEART: Regular rate and rhythm. ABDOMEN: Soft. Last BM unsure, thinks it was yesterday. Nursing will follow up with this. GU: Without Foley. NEUROLOGIC: The patient is oriented to time and place.
BM|bowel movement|BM|214|215|PHYSICAL EXAMINATION|HEART: Regular rate and rhythm. EXTREMITIES: Right leg without heat, swelling, redness, mild pain to palpation, good range of motion. GU: Question retention. Urologic consultation asked by Dr. _%#NAME#%_. GI: Last BM was _%#MMDD2005#%_. ASSESSMENT: As above. PLAN: 1. Continue treatment. 2. Await discharge when bed available.
BM|bowel movement|BM|152|153|SUMMARY OF CASE|She has no specific history of TB exposure, no cardiac disease or diagnoses. Her GI review is positive for poor appetite, slight nausea. She has had no BM activity since her surgery. She has no history of diabetes, hypertension, or blood dyscrasia. She has no prior history of neuropathy. The patient describes a long history of left flank and back pain, both during and before her pregnancy, and was using ibuprofen and prescribed pain medications on a fairly regular basis.
BM|bowel movement|BM|217|218|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 96.7; pulse 79; respiratory rate 18; blood pressure 141/75; oxygen saturations at 94% on room air. GENERAL: Alert, cooperative, in no acute distress. BOWEL/BLADDER: Last BM on _%#MMDD2005#%_. The patient is continent of urine. MUSCULOSKELETAL: Good upper extremity strength and lower extremity strength. SKIN: Left wound on his neck appears well-healed. No discharge.
BM|bowel movement|BM|150|151||Continue to work on speech and swallowing and cognition. He is stand- by assist with grooming. Mild complaint of left neck pain and mouth sores. Last BM was _%#MMDD2005#%_. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 96.6, pulse 77, respiratory rate 18, blood pressure 124/72, oxygen saturation 96% on room air.
BM|bowel movement|BM|106|107||Status post left endarterectomy with postoperative CVA. The patient seen on rounds, no new problems. Last BM 1105. Incontinent of urine. Notes fatigue when up with walker, but improving. Speech improving. PHYSICAL EXAMINATION: Temperature 98.4, pulse 80, respirations 18, blood pressure 117/71, oxygen sats 97% on room air.
BM|bowel movement|BM|156|157|REVIEW OF SYSTEMS|CARDIOVASCULAR: She does have periodic lower edema. No palpitations, DVTs or chest pain. GASTROINTESTINAL: She denies abdominal pain or heartburn. Her last BM was 11/28. MUSCULOSKELETAL: She has arthritic changes in hands, wrists, as well as knees and ankles. NEUROLOGIC: CVA in 2003, she has periodic TIAs. Her right lower extremity is weaker.
BM|bowel movement|BM|172|173|REVIEW OF SYSTEMS|There was some report of her having CHF, but a relatively normal EF was on the last echo. GASTROINTESTINAL: She does not report constipation. She denies diarrhea. Her last BM was _%#MMDD#%_. MUSCULOSKELETAL: She just reports normal joint swelling and that sort of thing with age-related arthritis. NEUROLOGIC: She denies balance, dizziness, and speech issues. URINARY: She at this time has a Foley catheter indwelling and has decreased levels of urine output.
BM|bowel movement|BM|342|343|HISTORY OF PRESENT ILLNESS|REFERRING PHYSICIAN: Dr. _%#NAME#%_. CHIEF COMPLAINT: Seizures. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 16-year-old male with frontal cerebral adrenal leukodystrophy, well known to me, presented to the emergency department earlier today with 4 episodes of coffee ground emesis, no stools for 2 days and a slight fever and cough. His last BM was _%#MMDD#%_. Upon arrival to the floor, he was noted to have a focal seizure in the face and right arm, without generalization.
BM|bowel movement|BM|160|161|PHYSICAL EXAMINATION|HEAD, EARS, EYES, NOSE, THROAT: Clear. CHEST: Clear. HEART: Regular rate and rhythm. GU: Without catheterization, voiding on his own. Small residuals. GI: Last BM _%#MMDD2005#%_. SKIN: Clear. MUSCULOSKELETAL: No significant change in strength or sensation from yesterday. He continues to work on ADLs. He is wearing his TLSO, making gains with therapy.
BM|bowel movement|BM|193|194|PHYSICAL EXAMINATION|GENERAL: Alert, cooperative, in no acute distress. HEENT: Clear. CHEST: Clear. HEART: Regular rate and rhythm. GENITOURINARY: Without Foley, voids on own, low residuals. GASTROINTESTINAL: Last BM _%#MMDD2005#%_. SKIN: Clear. A few bruises on his thighs where he gets his Lovenox injections. MUSCULOSKELETAL: Sensory line approximately his thighs. No movement at his toes or ankles.
BM|bowel movement|BM|197|198|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Asked to see this 52-year-old female who was admitted with sudden onset of crampy abdominal pain at 2 a.m. associated with nausea and vomiting. She has had no flatus or BM for approximately 2 days. She still is uncomfortable, especially when her NG tube was disconnected for a trip to the restroom.
BM|bowel movement|BM|772|773|REVIEW OF SYSTEMS|ALLERGIES: NKDA MEDICATIONS: aspart medium dose correction scale aspart 2 units /meal Lantus as per the HPI L-T4 200 mcg/day Lipitor 80 mg/day, Benadryl 25 mg q HS, Compazine 5-10 mg q 6 hours prn, sevelamer 800 mg po q day SOCIAL HISTORY: lives in Florida; nonsmoker FAMILY HISTORY: father MI; + DM; + HTN REVIEW OF SYSTEMS: eating more since admission compared to what she was seating before 10 system ROS as per the HPI or negative ALLERGIES: NKDA REVIEW OF SYSTEMS: Recent 20# gain of water weight which has now also been dialyzed off, otherwise weight is stable Chronic cold intolerance Legally blind; can read with lighted magnifier Lifelong constipation followed by a period of diarrhea a few months ago (had to take Lomotil then). Now more recently she as regular BM – at least once/day “not myself” Difficulty walking, not stable on feet - requires stabilitizing assistance to walk; + weakness Has been on HD Mon, Wed, Fri in Boca Raton Florida 10 system ROS as per the HPI or negative EXAMINATION: VITALS Tmax this hospitalization 37.6, HR 65, BP 162/67 GENERAL: very thin middle aged woman lying flat in bed ; she is in NAD SKIN: normal color, temperature, texture without hirsutism, alopecia or purple striae HEENT: EOMI, no scleral icterus, eyelid retraction, stare, lid lag, proptosis or conjunctival injection.
BM|bowel movement|BM|190|191|LABORATORY DATA|Hemoglobin 9.5. ESR 103. She had an MRI which showed severe arteriosclerotic disease, bilateral iliac system and generalized arteriosclerosis throughout the body on a CT scan. She has had a BM today which was loose. IMPRESSION: The patient has advanced renal artery stenosis and depleted physical condition based on lack of nutritional support.
BM|bowel movement|BM.|109|111|HISTORY OF PRESENT ILLNESS|He reports that it is uncomfortable and cramp-like. He says this occurs after he has tried to void or have a BM. The patient's says that one month ago he was voiding and had regular bowel movements, but since that time he has had constipation and incontinence.
BM|bowel movement|BM|159|160|REVIEW OF SYSTEMS|GASTROINTESTINAL: Reports decreased appetite, negative for constipation. Does have some abdominal pain with recurrence of pancreatitis. Denies heartburn, last BM was earlier today. MUSCULOSKELETAL: He has left-sided weakness both upper extremity and lower extremity which is new. NEUROLOGIC: Reporting the same balance and dizziness issues related to the left field deficits on upper and lower extremities.
BM|bowel movement|BM|114|115|HISTORY OF PRESENT ILLNESS|He has had no nausea or vomiting, fevers or chills and has had no change in bowel habits, though he has not had a BM in about three days. This is normal for him. He said that he has not had much of an appetite because of the pain.
BM|bowel movement|BM|127|128|REVIEW OF SYSTEMS|Denies sensory changes or any swallowing difficulties. No shortness of breath or pains in her chest. Foley removed last night. BM in hospital prior to admission. Some weakness on her left side and left face. PHYSICAL EXAMINATION: VITAL SIGNS: 97.1, 68, pulse 127/75, blood pressure 20, respirations 97% saturations on room.
BM|bowel movement|BM|134|135|REVIEW OF SYSTEMS|FAMILY HISTORY: Remarkable for CA of the stomach with her mother. SOCIAL HISTORY: She lives with her husband. REVIEW OF SYSTEMS: Last BM was _%#MMDD#%_ and urination is fine. She denies any chest pain or shortness of breath. Denies any depression, denies any pain in the right arm.
BM|bowel movement|BM|181|182|ASSESSMENT AND PLAN|1. Pain; denies pain. Monitor, recommend discharge with Roxanol 5-10 mg sublingual q2h p.r.n. 2. Dyspnea; Denies. Monitor, recommend Roxanol as above at discharge. 3. Constipation; BM today, monitor. 4. Spiritual support; the patient is Catholic, also met TLC chaplain _%#NAME#%_ _%#NAME#%_. 5. Psychosocial, spiritual support and goals of care. Met with patient's daughter _%#NAME#%_.
BM|bowel movement|BM|137|138|PHYSICAL EXAMINATION|RESPIRATORY: Decreased breath sounds. CV: Regular rate and rhythm. No murmur. ABDOMEN: Bowel sounds are present. Soft. Unknown when last BM was, but hospice nurse reports regular bowel movements. EXTREMITIES: No edema. SKIN: Intact. MUSCULOSKELETAL: Unable to assess. NEUROLOGIC: Difficult to arouse, had morphine.
BM|bowel movement|BM|215|216|REVIEW OF SYSTEMS|MEDICATIONS: MiraLax, Singulair, Milk of Magnesia. ALLERGIES: To penicillin. SOCIAL HISTORY: The child is a 6th grader and denies use of chemicals of abuse. FAMILY HISTORY: Not obtained. REVIEW OF SYSTEMS: Her last BM occurred today. She denies other physical complaints presently. PHYSICAL EXAMINATION: Healthy-appearing 12-year-old in no acute distress.
BM|bowel movement|BM|119|120|PHYSICAL EXAMINATION|CARDIOVASCULAR: S1, S2, no murmur, no rubs. ABDOMEN: Bowel sounds are positive in all 4 quadrants. He did have a small BM yesterday. His regular pattern is a bowel movement every other day. GENITOURINARY: No frequency or burning. Peripheral vasculature no edema in the left foot.
BM|bowel movement|BM|228|229|BRIEF HISTORY|There is no evidence of free air or perforation. The patient's lab demonstrate good kidney function with creatinine 0.8, and there is no evidence of infection with a white count 6.2. The patient does relate that his last normal BM was eight days ago. He had a small BM yesterday. EXAMINATION: He is in no acute distress. He is afebrile. Vital signs are stable. The abdomen is soft and nondistended.
BM|bowel movement|BM|266|267|BRIEF HISTORY|There is no evidence of free air or perforation. The patient's lab demonstrate good kidney function with creatinine 0.8, and there is no evidence of infection with a white count 6.2. The patient does relate that his last normal BM was eight days ago. He had a small BM yesterday. EXAMINATION: He is in no acute distress. He is afebrile. Vital signs are stable. The abdomen is soft and nondistended.
BM|bowel movement|BM|146|147|ASSESSMENT/PLAN|2. Dyspnea. Appears comfortable, monitor. 3. Anxiety; appears relaxed straight now; on BuSpar daily; has Haldol available p.r.n. 4. Constipation; BM on _%#MMDD#%_. Monitor. 5. Code status: The patient is DNR/DNI per family request. 6. Goals of care and support; the patient is confused, unable to have a reasonable conversation.
BM|bowel movement|BM|135|136|PHYSICAL EXAMINATION|CARDIOVASCULAR: Slightly irregular. No murmur, no rub. ABDOMEN: Bowel sounds are positive in all 4 quadrants. No tenderness. She had a BM yesterday and has had small amounts of BM today, which seemed slightly constipation. GENITOURINARY: She has a Foley catheter in, which has clear yellow urine coming from it.
BM|bowel movement|BM|177|178|PHYSICAL EXAMINATION|CARDIOVASCULAR: Slightly irregular. No murmur, no rub. ABDOMEN: Bowel sounds are positive in all 4 quadrants. No tenderness. She had a BM yesterday and has had small amounts of BM today, which seemed slightly constipation. GENITOURINARY: She has a Foley catheter in, which has clear yellow urine coming from it. PERIPHERAL VASCULATURE: No edema bilaterally lower extremities, no ulcerations. Pedal pulses are intact.
BM|bowel movement|BM|171|172|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Heart rate 92, respiratory rate 20, blood pressure 107/63, temperature 97.1, oxygen sats are 99% on four liters per nasal cannula. Last BM is unknown. GENERAL: The patient is alert and cooperative. HEENT: No excess secretions. CHEST: Lung sounds clear. Respiratory rate without effort.
BM|bowel movement|BM.|191|193|ASSESSMENT AND PLAN|Continue to assess for efficacy. 2. Dyspnea. The patient denies this at this time. Continue oxygen per nasal cannula for comfort. Continue to assess respiratory status. 3. GI. Unsure of last BM. Rectal check with Dulcolax suppository if positive. Continue to monitor bowel status, especially with narcotic orders. 4. Multiple decubiti. ET NR unsure of ability to save left hand with current measures, continue antibiotics and dressing changes.
BM|bowel movement|BM,|221|223|ASSESSMENT|Nonsteroidals could also contribute to loose bowel movement. Other drug side-effect is a potential factor. Cannot exclude emotional component (i.e., related to anxiety). Irritable colon may account for constipation/loose BM, as above. If patient has frank watery diarrhea, we will check a stool study, looking for ova and parasite, white cells, and bacterial culture.
BM|bowel movement|BM,|157|159|HISTORY OF PRESENT ILLNESS|He has no numbness, tingling or paresthesias, which are persistent in his legs. He has been able to urinate since his time in the hospital. He has not had a BM, but has passed gas. Over the course of his hospital stay, his pain has improved slightly, but not significantly.
BM|bowel movement|BM|174|175|ADDENDUM|Prior to transplant Mr. _%#NAME#%_ will be followed by Dr. _%#NAME#%_ _%#NAME#%_, and after transplant by the BMT clinic. ADDENDUM: Patient seen here prior to _%#MMDD2003#%_ BM biopsy which revealed blast crisis. Mr. _%#NAME#%_ will return home for additional chemotherapy at this time.
BM|UNSURED SENSE|(BM)|124|127|HPI|My key findings: CC: Ewing sarcoma, stage IV, undergoing treatment. HPI: At diagnosis large right pelvic mass and lung mets (BM) chemotherapy resulted in PR by week 12, got IMRT (3600 cGy) at Memorial _%#NAME#%_ _%#NAME#%_; resection one month later had "focally" positive margin with minimal tumor necrosis.
BM|bowel movement|BM|134|135|REVIEW OF SYSTEMS|She has had some abdominal pain, she reports and denies heartburn. Has had some difficulty with bowel movements. She did have a small BM this morning. MUSCULOSKELETAL: Negative for contribution. NEUROLOGICAL: She has had some bouts of dizziness, especially when she would stand in a hot shower, possibly orthostatic blood pressures.
BM|bone marrow|BM|145|146|ASSESSMENT AND PLAN|HISTORY OF CHEMOTHERAPY: None. KPS score: Approximately 90. ASSESSMENT AND PLAN: Mr. _%#NAME#%_ is a 67-year-old Caucasian male with stage T1 N2 BM 9 (IVA) moderately differentiated squamous cell carcinoma of the base of tongue. He has minimal medical comorbidities and his performance status is excellent.
BM|bowel movement|BM|229|230|PHYSICAL EXAMINATION|ENDOCRINE: Denies anorexia. HEME/LYMPH: Denies fever or chills. NEUROLOGIC: Complained of low back pain 6 out of 10 at present. Increased to 9 out of 10 at times. PHYSICAL EXAMINATION: 98.8, 92, 20, 165/77, 96% on room air. Last BM was _%#MMDD2005#%_. GENERAL: Alert, up in chair. HEENT: Hard of hearing. Glasses. No secretions. RESPIRATORY: Decreased breath sounds. CARDIOVASCULAR: Tachy. ABDOMEN: Bowel sounds present.
BM|bone marrow|BM|278|279|A/P|2. AMS - workup in progress 3. CMV viremia - treatment with Valcyte started 4. anemia/thrombocytopenia - high LDH and low haptoglobin suggests intravascular hemolysis (ie TTP-HUS) although no evidence on smear, pancytopenia could certainly be explained by active CMV viremia -> BM suppression, follow now but would treat if high clinical suspicion I was present and participated in this evaluation and agree with the fellow's note above.
BM|bowel movement|BM|339|340|ASSESSMENT AND PLAN|The pain increases to 8-10 with any movement currently on OxyContin 30 mg p.o. q.a.m. and OxyContin 20 mg p.o. q.h.s. Has oxycodone 5 mg p.o. q 4 hours p.r.n. Recommend methadone 7.5 mg p.o. q.8h., also change to morphine, 5 mg p.o. q.2 hours p.r.n. Attempted a call to Dr. _%#NAME#%_, orders written. 2. Constipation. The patient reports BM yesterday. Recommend change Senokot S to 2 tabs p.o. q.h.s. TLC will continue to follow patient while here in the hospital.
BM|bowel movement|BM|308|309|HISTORY OF PRESENT ILLNESS|She is denying any dysphagia, odynophagia or diarrhea. She usually has one to two bowel movements every day that are formed and brown, however, she does have on occasion a sensation of incomplete evacuation. Since admission, her nausea, vomiting and diarrhea have stopped as of 9:00 a.m. yesterday, her last BM was yesterday which was semi-formed. She is denying any black or bloody stools, no hematemesis, denies any chronic NSAID use.
BM|bowel movement|BM|142|143|ASSESSMENT AND PLAN|1. Pain. Complained of pain to low back and abdomen. ___________ following for pain. 2. Dyspnea. Denies dyspnea. Monitor. 3. Constipation. No BM documented. Recommend Dulcolax suppository today and Senokot S two tablets q.h.s. 4. Depression and anxiety. The patient feels depressed and anxious off and on.
BM|bowel movement|(BM)|214|217|REVIEW OF SYSTEMS|She has pain and is on PCA with Dilaudid. Her pain level is currently under good control except with movement. She has a Foley catheter in place. Prior to this hospitalization she was having normal bowel movements (BM) and has not had a BM today. PHYSICAL EXAMINATION: VITAL SIGNS: Vital signs were stable. GENERAL: The patient is in no acute distress and appears to be resting comfortably lying at a 30 degree inclination.
BM|bowel movement|BM|144|145|ASSESSMENT/PLAN|2. Dyspnea. Denies dyspnea, has O2 per nasal cannula. Recommend Roxanol 5-10 mg p.o. sublingual q.2 hours p.r.n. at discharge. 3. Constipation. BM yesterday, will monitor. 4. Anxiety. Appears relaxed at this time. Recommend Ativan solution 0.5-1.0 mg p.o./sublingual q.4 hours p.r.n. at discharge.
BM|bowel movement|BM|205|206|REVIEW OF SYSTEMS|CARDIOVASCULAR: Denies edema, palpitations, DVTs or chest pain. Does have a significant history for hypertension. GASTROINTESTINAL: Denies constipation, abdominal pain or change in stooling patterns. Last BM was the day before admission which would have been _%#MMDD#%_. She does have GERD. NEUROLOGICAL: Negative for balance, speech, dizziness issues.
BM|bowel movement|BM|510|511|REVIEW OF SYSTEMS|_%#MMDD2007#%_ TSH < 0.01, free T4 1.42, TSI < 1 There was a fetal US this AM ? it appears to report no IUGR. PAST MEDICAL HISTORY: Graves? hyperthyroidism MEDICATIONS: Betametathasone given PTU 50 mg tid MVI ALLERGIES: NKDA SOCIAL HISTORY: moved from Taiwan one year ago; grad student at U of MN; husband is chemist FAMILY HISTORY: one sister with goiter and one with thyroid cancer, parents without thyroid disease; HTN father REVIEW OF SYSTEMS: No eye symptoms Negative cardiac, denies palpitations 2 loose BM yesterday had blood per vagina on _%#MMDD#%_ no tremor worried that continuity with Dr _%#NAME#%_ will be lost 10 system ROS otherwise as per the HPI or negative EXAMINATION: GENERAL young woman in no apparent distress.
BM|bowel movement|BM|289|290|HISTORY OF PRESENT ILLNESS|She believes she might have had a cortrosyn stim test at that time, doesn't recall being told of the results. occasionally dizzy and lightheaded x 1-2 weeks prior to fall _%#MMDD#%_ 95/60 with drop to 75/50 with standing gmcsf started _%#MMDD#%_ x 5 days with plan to admit _%#MMDD#%_ for BM harvest; Her last dose of GMcsf was _%#MMDD#%_; the dose is being held today _%#MMDD#%_ BP 83/63 with HR 90's, fell at home _%#MMDD2007#%_ 68/40 with HR 106 in clinic, dizziness with standing; no improvement wiht 1 liter NS; admit - got more saline and iv saline _%#NAME#%_ states she last had decadron in _%#MM2007#%_.
BM|bowel movement|BM|1701|1702|REVIEW OF SYSTEMS|She believes she might have had a cortrosyn stim test at that time, doesn't recall being told of the results. occasionally dizzy and lightheaded x 1-2 weeks prior to fall _%#MMDD#%_ 95/60 with drop to 75/50 with standing gmcsf started _%#MMDD#%_ x 5 days with plan to admit _%#MMDD#%_ for BM harvest; Her last dose of GMcsf was _%#MMDD#%_; the dose is being held today _%#MMDD#%_ BP 83/63 with HR 90's, fell at home _%#MMDD2007#%_ 68/40 with HR 106 in clinic, dizziness with standing; no improvement wiht 1 liter NS; admit - got more saline and iv saline _%#NAME#%_ states she last had decadron in _%#MM2007#%_. She lasthad c diff in _%#MM2007#%_ Recent relevant labs are as noted: _%#MMDD2007#%_: TSH 1.19, free T4 1.06 today: Na 137, K 4.1, Cl 104, Co2 24, BUn 32, creatinine 2.87, glucose 94 _%#MM2007#%_ CT abdomen: no focal lesions of adrenals PAST MEDICAL HISTORY: nonhodgkins lymphoma -diagnosis 10 yrs ago 9 courses of CHOP, ending 1998 _%#MM2007#%_ recurrence presenting as retroperitoneal mass, hydronephrosis, involvement of right kidney _%#MM2007#%_ R-ice chemotherapy DHAP _%#MM2007#%_-_%#MM2007#%_ -- ? does P stand for predisone nonfunctioning right kidney, atrophic ckd cholecystectomy 1998 PE right lung _%#MMDD2007#%_ c difficile MEDICATIONS acyclovir, claritin, compazine, florinef 0.2 mg/day; fluconazole 100 mg/day, levaquin, lexapro, K , Oxycodone ALLERGIES: penicilling, flu shots SOCIAL HISTORY: married, 3 children FAMILY HISTORY: dm father; no thyroid, no adrenal; no addisons REVIEW OF SYSTEMS: not eating well, nothing tastes good no change in skin color dizzy with standing, but improved; today the main problem with walking is back pain has 't had a BM toady, hardly had BM yesterday; normally has 3-4 BM/day - notes she has seen pill fragments in her stool efore back aching neuorpathy in feet since CHOP trouble with balance LMP at the time of her first rounds of chemo in the early 1990's 10 system ROS as per the HPI or negative EXAMINATION: vitals: 77/46 with HR 56 standing, supine 71/59 with HR 56 GENERAL: middley aged woman lying flat in bed in NAD SKIN: normal color without hyperpigmentation + alopecia; normal temperature, texture without hirsutism, or purple striae HEENT: PER, EOMI, no scleral icterus, eyelid retraction, stare, lid lag, proptosis or conjunctival injection.
BM|bone marrow|BM|143|144|PATHOLOGY|Creatinine 0.76, total bilirubin 0.6. TSH 0.57. ALD 803. PATHOLOGY: UHH06-561 (_%#MMDD2006#%_) No evidence lymphoma. UHR06-84 (_%#MMDD2001#%_) BM involved by B-cell lymphoma. IMPRESSION: Mantle cell lymphoma with recurrence after autologous transplant.
BM|bowel movement|BM|208|209|PHYSICAL EXAMINATION|RESPIRATORY: Lungs sounds are clear bilaterally to auscultation, easily to clear congestion with cough. CARDIOVASCULAR/HEART: S1, S2, no murmur, no rub. ABDOMEN: Bowel sounds are present. No tenderness. Last BM was yesterday. GENITOURINARY: No burning, frequency or odor issues. PERIPHERAL VASCULATURE: No edema bilaterally to the lower extremities. No ulcerations.
BM|bowel movement|BM|154|155|SUBJECTIVE|SUBJECTIVE: The patient is status post right hip disarticulation, decreased ADLs, constipation. The patient was seen on rounds. No new problems. He had a BM this morning. Feels better. Now eating. No bladder problems. Pain control okay when he takes his meds. Wounds to be checked by Surgery today. Nursing reports no problems with his wounds.
BM|bowel movement|BM|209|210|ASSESSMENT AND PLAN|1. Pain. The patient denies pain at this time complained of pain with dressing changes. He has extra strength Tylenol and p.r.n. Dilaudid available. Will monitor. 2. Dyspnea, denies. Monitor. 3. Constipation. BM yesterday. 4. Advanced directive. Discussed the importance advanced directives with patient. He understands. At this time, he prefers to remain full code but would never want long-term life support
BM|bowel movement|BM|125|126|REVIEW OF SYSTEMS|3. Norvasc 5 mg daily. 4. Avandia 2 mg daily. 5. Percocet p.r.n. 6. Ditropan 4 mg daily. REVIEW OF SYSTEMS: Constipation, no BM for 3 days. No blurred vision or double vision. No runny nose. She has dyspnea on exertion. Paroxysmal nocturnal dyspnea, lie flat. No nausea, vomiting, diarrhea, edema, leg pain, or rash.
BM|bowel movement|BM|188|189|REVIEW OF SYSTEMS|Independent with ADLs prior to admission. REVIEW OF SYSTEMS: Denied change in vision. Hearing, speech. No headache, dizziness. Without shortness of breath, chest or abdominal pain, recent BM and now feels less abdominal distention and feels crampy has improved. Foley catheter is in now, notes urology suggested leaving it in until ambulatory more.
BM|bowel movement|BM|313|314|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ is a 32-year- old who had a sudden onset of periumbilical abdominal pain last night which has been steady since onset, and increased in severity over the past few hours. She had no nausea or vomiting associated, her bowels have worked normally, including today, with a BM at about 1 p.m. She has past history of Crohn disease and underwent bowel resection in _%#MM2001#%_ at Fairview Southdale Hospital.
BM|bowel movement|BM|189|190|HISTORY OF PRESENT ILLNESS|She has severe COPD and a chronic cough and says that over the last 48 hours she felt that she noted the hernia protruding more than normal. She also has been constipated and has not had a BM in several days and thought her stomach was more distended because of this. She presented to the emergency room today because of the protuberance of the hernia and her constipation.
BM|bowel movement|BM|147|148|HISTORY OF PRESENT ILLNESS|She states she develops significant discomfort in the hernia when this was palpated in the emergency room. This was relieved after she had a large BM following an enema in the emergency room. PAST MEDICAL HISTORY: Significant for severe chronic obstructive pulmonary disease for which she is oxygen dependent.
BM|bowel movement|BM|219|220|REVIEW OF SYSTEMS|DEPRESSION: The patient does not complain of depression. ANXIETY: The patient complains of occasional anxiety. INSOMNIA: No complaints of insomnia. BOWEL FUNCTION: The patient states he has regular bowel function; Last BM on _%#MMDD#%_. FATIGUE: The patient has some mild to moderate fatigue especially when undergoing infections. MEDICATION ALLERGIES AND DRUG SENSITIVITIES: Morphine. CURRENT MEDICATIONS: Iron sulfate, magnesium oxide, Protonix, folic acid, metoprolol, Ursodiol, CellCept, simethicone, Bactrim, hydrochlorothiazide, Lasix, Cozaar, Levofloxacin, prednisone.
BM|bowel movement|BM|170|171|REVIEW OF SYSTEMS|Denies chest pain, denies palpitations. GASTROINTESTINAL: She has a good appetite, she does not report any constipation, she denies abdominal pain or heartburn, her last BM was yesterday. MUSCULOSKELETAL: She has swollen warm knees bilaterally. These joints have been bothering her for years. They were going to do a knee replacement but her peripheral circulation was not adequate for to be able to undergo that surgery.
BM|bowel movement|BM|178|179||She is making gains with therapy. The patient tires easily with steps. She is independent with her ADLs, walking without standby assistance for short distances now. Bowels: Last BM was _%#MMDD2005#%_. She is continent of urine. No new problems are noted. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.4, pulse 108, respiratory rate 18, blood pressure 105/68, oxygen saturation 96% on room air.
BM|bowel movement|BM|188|189|PHYSICAL EXAMINATION|She is 99% oxygenation on room air. GENERAL: She is alert, cooperative, in no acute distress. HEAD, EARS, EYES, NOSE, THROAT: Clear. CHEST: clear. HEART: Regular rate and rhythm. GI: Last BM on _%#MMDD2005#%_. GU: Continent of urine. MUSCULOSKELETAL: She has wounds in her knees that appear okay. Increased range of motion to approximately 90 degrees flexion. ASSESSMENT: As above.
BM|bowel movement|BM.|162|164|5. CODE STATUS|3. Congestion: He is very congested and recommend glycopyrrolate 0.2 mg 3 to 4x per day, and will not affect his mental status. 4. Constipation: Unsure when last BM. Abdomen is distended. Recommend Dulcolax suppository and Senokot each day through NG tube. 5. CODE STATUS: DNR/DNI. 6. Communication: I met with family and firm team for 30 minutes.
BM|bowel movement|BM|209|210|PHYSICAL EXAMINATION|LUNGS: Sounds are crackles and expiratory wheezes on the right side, left side is diminished. HEART: Sounds S1, S2, no murmur. ABDOMEN: Decreased bowel sounds, rotund abdomen, nontender to palpation. He had a BM was earlier today. Peripheral vasculature no edema, no ulcerations. MUSCULOSKELETAL: He does hold his legs in contracted fashion, up towards his body as well as his upper extremities.
BM|bowel movement|BM|154|155|REVIEW OF SYSTEMS|Denies chills. Reports right shoulder pain, received Tylenol with some relief. Reports nausea, poor appetite, no energy to eat. Denies constipation, last BM this a.m. States that he may have some depression, feels like he cannot keep going like this. Denies anxiety, denies insomnia, denies edema to extremities, complaints of pruritus all over.
BM|bowel movement|BM|204|205|REVIEW OF SYSTEMS|FAMILY HISTORY: Positive for thoracic aneurysm in multiple family members. REVIEW OF SYSTEMS: All 10-point review of systems was done and is positive as above, otherwise negative except for having had no BM for the last two days. FUNCTIONAL STATUS: The patient has again been evaluated by PT and OT and has been noted to be standby assist for short distance ambulation.
BM|bowel movement|BM|275|276|PLAN|Patient making gains with therapy, uses walker with minimal assist, approximately 40 to 50 feet, decreased balance, decreased sensation in upper extremity and decreased strength in upper extremity. Bladder scans from 487 to 739 cc with catheter volumes of 600 to 700 cc. Had BM yesterday. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: He is alert and cooperative, in no acute distress.
BM|bowel movement|BM|271|272|ASSESSMENT/PLAN|1. Pain. The patient complained of pain this morning, all over body, rating 6-7/10, has taken Percocet and has had some relief and now rating pain as 3/10. We will continue to monitor. 2. Dyspnea. Patient denies dyspnea. We will monitor. 3. Constipation. The patient had BM yesterday. We will monitor. 4. Code status. Did discuss code status with patient and given his situation, he would like to be DNR/DNI.
BM|bowel movement|BM|169|170|ASSESSMENT AND PLAN|1. Pain. The patient appears comfortable, has Dilaudid available p.r.n. He is sedated on propofol. 2. Dyspnea. Appears comfortable, sedated on vent. 3. Constipation. No BM since admission yesterday, will monitor. 4. Anxiety, agitation. Appears comfortable, sedated on propofol. 5. Code status. The patient is full code. 6. Family support, patient is married (separated to _%#NAME#%_ _%#NAME#%_).
BM|bowel movement|BM|222|223|PLAN|ASSESSMENT: As noted. PLAN: We will try to examine rectal tone and anal length to determine if decreased bladder function is secondary to over stretch or nerve injury or both. The patient would like to wait until he has a BM to have this checked. Worried about accidents with stimulation. We will check with primary-care doctor about the use of Lovenox for patient, as he is not ambulating.
BM|bowel movement|BM|194|195|ASSESSMENT/PLAN|Maximum is 400 mg a day. May slow down the need for paracentesis. Recommend consult to Interventional Radiology for paracentesis catheter. 3. Dyspnea. Appears comfortable. 4. Constipation. Last BM _%#MMDD2005#%_. Increase Senokot to twice a day instead of every day. Also give Bisacodyl suppository x1 today. 5. Psychosocial/spiritual. Unable to assess spiritual background.
BM|bone marrow|BM)|119|121|HPI|My key findings: CC: ALL. HPI: Tibial pain led to MRI and biopsy confirming ALL in tibia. Rest of w/u for ALL (CNS and BM) Exam: Leg casted, no adenopathy or hepatosplenomegaly.
BM|bowel movement|BM|156|157|PHYSICAL EXAMINATION|Depth and quality is based on whether he is having pain at this time. HEART: Regular, with no murmur or rub. ABDOMEN: Soft. Bowel sounds positive. He had a BM yesterday. No scars. No tenderness. Peripheral vasculature is intact. NEUROLOGIC: Difficult to assess neurological due to muscle spasming and no involuntary movements.
BM|bowel movement|BM|170|171|REVIEW OF SYSTEMS|His father died of an MI at age 72. REVIEW OF SYSTEMS: Patient reports an occasional cough which is nonproductive. He also reports difficulty with constipation. His last BM was five days ago. He reports that this is not unusual for him. He treats this by increasing fiber in his diet and states that this works well.
BM|bowel movement|BM|182|183|SUBJECTIVE|She needs minimum assist with gait and sit-to-stand. Therapist and nursing note indicated improved cognition with current pain medications. She is continent of urine and bowel. Last BM was _%#MMDD2005#%_. Skin is okay, and incision site looks well per nursing. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 99.3, heart rate 83, blood pressure 134/72, 95% on room air.
BM|bowel movement|BM,|147|149|ASSESSMENT AND PLAN|Recommend Lexapro 10 mg p.o. q. day. I wonder if we should also consider Ritalin for a short-term 2.5 mg p.o. q.8h. a.m. and noon. 4. Bowels. Last BM, _%#MMDD#%_, monitor. 5. Goals of care. Will attempt to call the family tomorrow a.m. and will set up a family meeting. I spoke to the patient. She is tired of all the medical problems but unsure of what she wants to do, seems withdrawn Thank you for the opportunity to assist in the care of this patient.
BM|bowel movement|BM|217|218|ASSESSMENT AND PLAN|1. Pain. The patient denies pain. Does report feeling uncomfortable in bed and needs to be repositioned frequently. 2. Dyspnea. The patient denies monitor. 3. Constipation. The patient reports feeling constipated. No BM documented since admission. Recommend bisacodyl suppository 10 mg per rectum x1. 4. Depression and anxiety patient. Reports feeling depressed and anxious.
BM|bowel movement|BM|141|142|REVIEW OF SYSTEMS|GASTROINTESTINAL: She has abdominal pain with eating as I have previously stated. It has been worse the last 3 or 4 months. She had her last BM on _%#MMDD#%_. GENITOURINARY: She has acute renal failure, but is having no problems with voiding. She reports right-sided kidney stones. MUSCULOSKELETAL: She has chronic pain syndrome, neuropathy in her lower extremities and in her hands.
BM|bowel movement|BM|186|187|ASSESSMENT/PLAN|Recommend Dilaudid 0.1-0.2 mg IV q.30 minutes p.r.n. 2. Dyspnea; complains of mild dyspnea, feels she has some nasal congestion; will monitor. 3. Constipation; denies constipation, last BM was yesterday. 4. Code status: The patient was very clear TLC RN yesterday and Dr. _%#NAME#%_ yesterday that she wants to be DNR/DNI. Dr. _%#NAME#%_ also spoke to the patient's health care agent today; healthcare agent had left the room by the time writer entered..
BM|bowel movement|BM|114|115|PHYSICAL EXAMINATION|CARDIOVASCULAR: S1, S2, no murmur, no rubs. ABDOMEN: Bowel sounds are positive in all 4 quadrants. She did have a BM today that was after 8 days of constipation and the only intervention that worked was GoLYTELY colonoscopy prep. Patient has not had a history of major constipation issues.
BM|bowel movement|BM|152|153|ASSESSMENT/PLAN|Consider Dilaudid 0.1 mg IV q.2h. p.r.n. 2. Dyspnea. The patient _________________. Recommend Dilaudid as above p.r.n. for dyspnea. 3. Constipation. No BM since admit. Recommend Bisacodyl suppository 10 mg per rectum x1 today. Recommend Senokot q.h.s. 4. Family communication. TLC chaplain, _%#NAME#%_, called patient's son, _%#NAME#%_. Please see his note.
BM|bowel movement|BM.|293|295|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old woman who was seen three days postoperatively after having lumbar spinal fusion for degenerative disk disease of the lumbar spine. The patient denies any other acute medical problems. She has been constipation since surgery, has had no BM. Otherwise, she is getting along fairly well. The pain is under satisfactory control. PAST MEDICAL HISTORY: 1. Habits. She is a nonsmoker, has one drink a day.
BM|bowel movement|BM.|162|164|HISTORY OF PRESENT ILLNESS|Her only complaints are right sided chest tightness that feels like her asthma. Her pain is well controlled on Vicodin and the morphine PCA. She denies flatus or BM. PAST MEDICAL HISTORY: 1. Degenerative joint disease in both knees.
BM|bowel movement|BM|193|194|HISTORY OF PRESENT ILLNESS|Post-procedure she has unfortunately been experiencing some nausea and vomiting and had a difficult time eating because of this. She otherwise denies abdominal pain or cramping. She did have a BM yesterday with the help of an enema and has had denied any diarrhea today. However, she feels that the enema was very helpful yesterday.
BM|bowel movement|BM|257|258|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.8, pulse 89, blood pressure 117/81, respirations 16, 96% sats on room air. GENERAL: Alert, cooperative, no acute distress. HEENT: Clear. HEART: Regular rate and rhythm. ABDOMEN: Soft. Positive bowel sounds. BM yesterday. GU: 120 to 731 cc with catheter at 0 to 750 cc q.4h. MUSCULOSKELETAL: As above. Strength increasing in lower extremities. PSYCHOLOGICAL: Oriented to time and place.
BM|bowel movement|BM|140|141|ASSESSMENT AND PLAN|Therefore, we have recommend Citrucel one tablespoon p.o. q. day and we did discontinue the Colace. Given the length of time since his last BM we did also recommend Dulcolax 10 mg per rectum q12h p.r.n. constipation with the first dose being today if does not have a bowel movement before 6 p.m. We will also try Senokot S one tablet p.o. b.i.d. p.r.n.
BM|bowel movement|BM|158|159|SUBJECTIVE|I appreciate Medicine's help with neurologic changes and renal decrease. SUBJECTIVE: The patient is without complaints this a.m. Bowel and bladder okay. Last BM _%#MMDD2005#%_. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 96.1, pulse 65, respirations 18, blood pressure 130/86, 95% sats on room air.
BM|bowel movement|BM|157|158|PHYSICAL EXAMINATION|Oxygen saturation 94% on room air. GENERAL: Alert, cooperative, no acute distress. SKIN: Clear. Bladder/bowel UA/UC sent last night as a follow-up. Her last BM was _%#MMDD2005#%_. Discussed this with nursing. We will treat her as appropriate for constipation. ASSESSMENT: As above. PLAN: Continue therapy. Pass on this weekend and possible discharge early next week.
BM|bowel movement|BM|185|186|REQUESTING PHYSICIAN|He has had well documented amylase and lipase elevations associated with his pancreatitis and his current visit is associated with a lipase of 3900. He presented at this time with last BM 36 hours prior to admission and was very typical of his recurrent pancreatitis. Because the pain persisted, he presented to the Emergency Room and was subsequently admitted to the hospital.
BM|bowel movement|BM|179|180|REVIEW OF SYSTEMS|FAMILY HISTORY: Negative for any history of CNS tumor, otherwise limited information available at present. REVIEW OF SYSTEMS: Positive for headache, 8/10, dry mouth and had loose BM yesterday. Has a Foley in place, otherwise the review of system is as above in the history. A 10-point review of systems was otherwise negative. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed male sitting in a chair in no acute distress, alert, oriented x3, does complain of some difficulty in comprehension, although following commands simply.
BM|bowel movement|BM|179|180|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: Negative. She does not complain of any chest pain, shortness of breath, fever, chills, nausea, headache, vomiting, cough, or dyspnea. No constipation. Her last BM was Sunday night and her appetite is okay. PAST MEDICAL HISTORY: She has a metal rod on her right shin 7 years ago, she has a metal plate in her right arm 3 years ago, and a rod from her shoulder to her elbow in the right arm, plate in the left ankle, and she has a colonoscopy in _%#MM#%_, which was okay.
BM|bowel movement|BM|160|161|PLAN|After that she should go on more aggressive stool softeners to maintain a daily bowel movement. We can discontinue the Foley catheter once she has had a decent BM and assess her at that time. I have asked the nursing staff to call me if her postvoid bladder scans still show residual urines at or above 300 mL.
BM|bowel movement|BM|154|155|ASSESSMENT/PLAN|If she was less short of breath and comfortable she may be able to increase her activity and PT. 3. Constipation. Recommend Senokot S 2 tabs q. h.s. Last BM _%#MMDD2005#%_ but she feels like her abdomen is full. 4. Disposition: The patient wants to go home after her antibiotics are finished.
BM|bowel movement|BM|140|141|HISTORY|He apparently did tolerate some p.o. intake. He has had no noted emesis. He has had some relief following a bowel movement, indicating last BM was earlier this morning. He denied constipation or diarrhea. He has had no signs of GI blood loss; no dysuria or hematuria.
BM|bowel movement|BM|171|172|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 96.8 degrees Fahrenheit, heart rate 70, blood pressure 121/74, respiratory rate 20. Oxygen saturation 99% on room air. Last BM was at 5:24. GENERAL: The patient is alert. HEENT: No secretions noted, wearing glasses. RESPIRATORY: Lungs clear to auscultation. CARDIOVASCULAR: Regular rate and rhythm, no murmur.
BM|bowel movement|BM|152|153|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.5, heart rate 107, blood pressure 131/86, respiratory rate 22, pulse oximetry 93% on Venti mask. Last BM on _%#MMDD2005#%_. GENERAL: Alert, sitting up in chair. HEENT: Venti mask, no secretions. RESPIRATORY: Wheezes throughout. CARDIOVASCULAR: Tachycardic.
BM|bowel movement|BM|165|166|ASSESSMENT/PLAN|4. Anxiety. According to notes the patient gets anxious. Will need to assess in future visits. The patient was lethargic today on p.r.n. Ativan. 5. Constipation. No BM documented. On Senokot every day. Recommend increase of Senokot to twice a day. 6. Goals of care. We will need to discuss goals of care with the patient when she is less lethargic.
BM|bowel movement|BM|165|166|REVIEW OF SYSTEMS|The patient reports a cough and dry throat probably secondary to intubation for surgery. The patient denies leg pain, tingling, or numbness. The patient also denies BM or flatus. PHYSICAL EXAMINATION: GENERAL: In no acute distress. VITAL SIGNS: Taken at 0800 revealed temperature 98.3 degrees, pulse 104 beats per minute, blood pressure 142/68, respirations 20, and oxygen saturations 95%.
BM|bowel movement|BM|207|208|REVIEW OF SYSTEMS|She denies any DVTs and denies chest pain again. GASTROINTESTINAL: She states she has a good appetite and that she is not plagued with constipation. She denies abdominal pain. She denies heartburn. Her last BM was on Monday. MUSCULOSKELETAL: She denies stiffness or swelling to joints. NEUROLOGICAL: She denies any balance problems, any speech problems, any dizziness or any memory loss.
BM|bowel movement|BM|162|163|HISTORY OF PRESENT ILLNESS|At this time his primary complaint is constipation. He has been taking Senokot and Colace but they have not worked very well. The patient reported having a small BM a few days ago, and he uses a suppository every few days. because of constipation he has been eating less and has not had a normal bowel movement for 1 month, since starting his medications.
BM|bowel movement|BM|153|154|PHYSICAL EXAMINATION|GENERAL: Alert, cooperative, in no acute distress. HEENT: Clear. Speech was improving. CHEST: Clear. HEART: Regular rate and rhythm. ABDOMEN: Soft. Last BM on _%#MMDD2005#%_. GENITOURINARY: Without Foley. SKIN: Clear. Scalp wounds look good. MUSCULOSKELETAL: Strength 0/5 in the wrist, 3+ to 4/5 in the grip on the right.
BM|bowel movement|BM|178|179|ASSESSMENT/PLAN|Recommend morphine as above for dyspnea. The patient's son is also concerned that the patient's O2 falls off overnight, asked RN to tape O2 to patient's cheeks. 3. Constipation. BM _%#MMDD#%_, monitor. 4. Anxiety. Patient anxious at times, has Ativan p.r.n. available, continue p.r.n. Ativan. 5. Nausea, complaint of emesis this morning after breakfast, on Reglan 10 mg IV q.i.d. scheduled a.m. p.r.n. Has Zofran available p.r.n. Continue current medications.
BM|bowel movement|BM|2032|2033|REVIEW OF SYSTEMS|Biopsy of liver mets _%#MMDD2007#%_ showed well differentiated adenoca consistent with pancratic primary. Tumor was positive for synaptophysin and negative for chromagranin, and hence it was called neuroendocrine tumor _%#MMDD2005#%_ liver biopsy showed metastatic well differentiated neuroendocrine cancer _%#MMDD#%_ at 3 PM glucose 140 _%#MMDD#%_ glucose 148 at noon _%#MMDD2006#%_ 0940 glucose 115 _%#MMDD2006#%_ at 0650 glucose 116 _%#MMDD2006#%_ at 0300 glucose 187 _%#MMDD2006#%_ at 3PM glucose 82 _%#MMDD2006#%_ glucose 147 _%#MMDD2007#%_ at 0747 glucose 395 _%#MMDD2007#%_ at noon glucose 229 on decadron _%#MMDD2007#%_ at 0700 glucose 107 _%#MMDD2007#%_ at 0600 glucose 315, 300 at 850, 294 at noon (1.5 units of novolog) _%#MMDD2007#%_ 280 _%#MMDD2007#%_ at 0742: Na 132, K 4.1, Cl 99, Co2 28, BUN 10, creatinine 0.7, glucose 280, Mg 1.5, phos 3, Ca 8.9, total bili 0.2, alk phos 86, ALT 24, AST 27, albumin 3.4 PAST MEDICAL HISTORY: pancreatic islet cell tumor -metastatic to liver, ovaries _%#MM2006#%_ chemoembolization of liver mets _%#MM2006#%_ detoxification precedex? in ICU _%#MMDD2007#%_ celiac plexus block - decadron x 2 weeks chronic back and shoulder pain mva migraines kidney stones bladder diverticulum GERD bilateral SPO _%#MM2006#%_ MEDICATIONS decadron 10 mg iv q 24 hours-- started _%#MMDD#%_ at 1600 clorthalidone, atenolol 100 mg, elavil 50-75 mg q HS, tylenol, lexapro 20 mg bid, neurontin 200 mg bid, hydromorphone prn, Very low dose Novolog insulin correction scale: glucose 150-199 give 0.5 units, glucose 200-249 give 1 unit, glucose 250-299 give 1.5 units, glucose 300-349 give 2 units, glucose > 350 give 2.5 units methadone po, nictine patch, pantoprazole, PCA, miralax senna, sucralfate, restoril ALLERGIES: NKDA SOCIAL HISTORY: lives alone; smokes; 4 kids FAMILY HISTORY: lung cancer father; non hodgkins lymphoma mother; hypothyroid daughter; No kidney stones; no known pituitary disease REVIEW OF SYSTEMS: low energy weight stable notes her vision changed with last steroid treatment last BM today has been getting out of bed nocturia 1-2 times/night drinks alot of water due to thirst LMP 2 yrs ago 10 system ROS otherwise as per the HPI or negative EXAMINATION: VITALS: temp 36.5, HR 76/minute, Bp 126/78, RR 18/minute GENERAL: centrally obese middle aged woman in no apparent distress SKIN: pink cheeks, otherwise normal color, temperature, texture without hirsutism, alopecia or purple striae HEENT: PER, EOMI, no scleral icterus, eyelid retraction, stare, lid lag, proptosis or conjunctival injection.
BM|bowel movement|BM|180|181|HISTORY OF PRESENT ILLNESS|Pain comes and goes, is localized in the back. She also reports her numbness appears to be improving in the legs. In addition, she feels she is significantly constipated. Her last BM was 2 days prior to the surgery. PAST MEDICAL HISTORY: 1. Lumbar laminectomy. 2. CSF leak status post laminectomy.
BM|bowel movement|BM|151|152|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: GENERAL: As above. Otherwise, she denies any numbness, tingling, any nausea, or any bladder or bowel incontinence. She had her last BM yesterday and was feeling a little bit constipated. PHYSICAL EXAMINATION: GENERAL: Pleasant lethargic female lying in bed, easily awakened, appropriate, oriented to place, person, and time.
BM|bowel movement|BM|231|232|REVIEW OF SYSTEMS|FAMILY HISTORY: Reviewed and noncontributory. REVIEW OF SYSTEMS: 10-organ systems were checked and were all negative other than left lower extremity weakness and pain as well as pain at surgical site. She also reports not having a BM recently. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 99.1, blood pressure 122/59, heart rate 57, respiration 20, 97% saturation on room air.
BM|bowel movement|BM|147|148|CC|CC: We were asked to see this patient by Dr. _%#NAME#%_ for evaluation of an abnormal CT chest and worsening hypoxia in this patient who underwent BM Tx 12 days ago HPI: This 55 yo lady who was admitted to undergo autologous BM transplant for multiple myeloma.
BM|bowel movement|BM|163|164|REVIEW OF SYSTEMS|RESPIRATORY: No cough, dyspnea or hemoptysis. CARDIOVASCULAR: No chest pain or palpitations. GASTROINTESTINAL: No nausea, vomiting, constipation or diarrhea. Last BM was yesterday and described as brown and well formed without blood mixed with stool in toilet bowl or on toilet paper. The patient reports constipation when not using Benefiber. GENITOURINARY: No dysuria or hematuria.
BM|bowel movement|BM|176|177|REVIEW OF SYSTEMS|He reports shortness of breath upon exertion and an occasional wet cough with white sputum for about the past month. He also complains of intermittent diarrhea now with a soft BM and no nausea or vomiting. His appetite has improved over the past 2 days. He has a history of intermittent back pain and bilateral foot pain.
BM|bowel movement|BM.|133|135|DISCHARGE MEDICATIONS|3. Iron sulfate 325 mg by mouth twice daily. 4. Lisinopril 40 mg by mouth daily. 5. Senokot S 1-2 tablets by mouth twice daily if no BM. 6. Vitamin B12 1000 mcg by mouth daily. 7. Sorbitol 30 mL by mouth twice daily. 8. MiraLax 17 g by mouth daily mixed with water.
BM|bowel movement|BM|151|152|REVIEW OF SYSTEMS|He does occasionally have some nasal congestion. He does have intermittent chronic constipation though currently feels that is not an issues after his BM this morning. He does become tired when he is walking but denies any dizziness, headache or chills. He does have dentures. He does not have any current teeth problems though does have multiple missing teeth.
BM|bowel movement|BM|216|217|SYMPTOM REVIEW|Occasional mild lightheadedness. No headache or visual change. Cardiopulmonary symptoms as above. Denies nausea or vomiting. Occasional crampy abdominal discomfort. Regular bowel movements with tendency toward loose BM up to twice daily. No signs of GI blood loss. No voiding complaints. Has had arthralgias of the digits of the hands.
BM|bowel movement|BM|135|136|REVIEW OF SYSTEMS|He states he has no difficulty urinating and that is PSA is also normal. He states he had diarrhea about three days ago and has had no BM since then; however, he states his appetite has not yet returned to normal. He did say he had gout several years ago in his left great toe, and though he does have arthritis in many joints, he had it significantly in his left knee a few years ago.
BM|bone marrow|BM|492|493|DISCHARGE DIAGNOSES|LABORATORY: At the time of admission, white count was 3, hemoglobin was 9.1, platelet was 166, and ANC was 2.7. Electrolytes as follows, sodium was 139, potassium was 3.9, chloride 107, bicarbonate 23, BUN 6, creatinine 0.6, glucose 121, calcium 8.5, magnesium 2.1, and phosphorus of 2.9. CSA level that was drawn on _%#MM#%_ _%#DD#%_, 2005, came back elevated at 403, and the patient had a history of positive CMV antigen of 1388. HOSPITAL COURSE: Problem #1: Fanconi's anemia, 39 days post BM bone marrow transplant. At the time of admission, the patient had previously been doing well status post transplant. CSA level was noted to be elevated at the time of admission to 403.
BM|bowel movement|BM.|177|179|REVIEW OF SYSTEMS|GASTROINTESTINAL: Denies abdominal pain, nausea or vomiting. Moves bowels regularly unless she were to get constipated with codeine. She then eats a lot of prunes to facilitate BM. Denies history of PUD or gastritis. Experiences heartburn if she eats spicy foods. GENITOURINARY: Endorses a stress incontinence-hyperactive bladder. NEUROLOGIC: As above. Experiences blurred vision and a dizziness and lightheadedness with a spinning sensation as stuttering symptoms of TIAs.
BM|bowel movement|BM|199|200|HISTORY OF PRESENT ILLNESS|She denies any chills, fevers, blurred vision, or dizziness when she is partaking in therapy. She denies nausea, vomiting, or diarrhea, and does complain of being mildly constipated, though her last BM was two days ago. She feels her appetite is good and that she is sleeping good. She does complain of some pain in her feet, though not a significant amount, which is relieved by Vicodin.
BM|bowel movement|BM,|266|268|HISTORY OF PRESENT ILLNESS|He denies any further chest pain. Aside from this, he does describe a very sore mouth that has been bothersome over the last three to four days. He also notes ongoing constipation. He did take Milk of Magnesium Citrate approximately three days ago with a very large BM, however he denies any further bowel movement since that time. REVIEW OF SYSTEMS: Constitutional - he describes ongoing anorexia, as well as mild weight loss.
BM|bowel movement|BM|214|215|REVIEW OF SYSTEMS|Cardiac -negative for any recent palpitations, PND or orthopnea. Again, he denies any recurrent angina or chest discomfort. Gastrointestinal - notable for ongoing constipation over the last three days. Again, last BM was on Sunday and was successful only after the use of magnesium citrate. He does describe continuous nausea that has been present over the last week, since receiving his chemotherapy.
BM|bowel movement|BM.|125|127|ADMISSION DIAGNOSIS|She lives in _%#NAME#%_ _%#NAME#%_. REVIEW OF SYSTEMS: Significant for a 30-pound weight loss in the last 2 months without a BM. She has pain in the abdomen which she treats with Percocet. Her vital signs were stable. Her abdomen was soft, slightly tender in the mid lower quadrant.
BM|bowel movement|BM.|184|186|REVIEW OF SYSTEMS|She denies abdominal pain. Her last bowel movement was prior to surgery which was on _%#MMDD2006#%_. She does state she had a small bowel movement mostly composed of hard, marble-like BM. She denies any nausea or vomiting. She denies any urgency, frequency or dysuria, however does say that her urine smells terrible.
BM|bowel movement|BM|297|298|HISTORY OF PRESENT ILLNESS|The patient is noted to be a poor historian. The patient states that after his last discharge he was sent home without his seizure medications, had a seizure, was admitted to _%#COUNTY#%_ _%#COUNTY#%_ Medical Center, and was discharged about 3 weeks ago. The patient reports that he has not had a BM x1 week, and usually has very regular BMs. His last BM was unremarkable. PAST MEDICAL HISTORY: 1. Recent admission to Fairview _%#CITY#%_ for work up of an abdominal mass.
BM|bowel movement|BM|145|146|REVIEW OF SYSTEMS|Denies any blood clots in lungs or legs. Does occasionally get dyspepsia after eating. Denies dysphagia. Does complain of constipation with last BM on Monday or Tuesday as previously noted. Denies incontinence, dysuria, or frequency of urination. Denies gout or arthritis. She denies a history of tremors or seizures. Occasionally, does have insomnia when in hospital.
BM|bowel movement|BM|397|398|DISCHARGE MEDICATIONS|EXTREMITIES: Lower extremities, skin is warm, dry and intact. She has a pain flaky rash throughout her upper extremities around, her eyes and lower extremities, worse on lower extremities. This appears to be stable through her hospital stay. DISCHARGE MEDICATIONS: Levaquin 250 mg daily x4 more days, then discontinue, iron gluconate 325 mg p.o. b.i.d. Fleet enema day p.r.n., may repeat x1 if no BM by _%#MMDD2006#%_, Dulcolax 5-10 mg p.o. daily p.r.n. if no BM x48 hours, Colace 100 mg p.o. b.i.d. Senokot 1 p.o. daily, hold if loose stools, doxepin chloride 10 mg at bedtime, tricor 160 mg daily., triamcinolone 0.05% ointment applied t.i.d. to trunk and extremities, hydrocortisone 0.25% cream apply to the neck and face t.i.d., pancreatin 50 mg p.o. t.i.d., Compazine 10 mg q.8h. p.r.n. nausea, Percocet 5/325 1-2 tabs p.o. q.6h. p.r.n. pain.
BM|breast milk|(BM|135|137|* FEN|Ongoing problems and suggested management: * FEN: _%#NAME#%_ was discharged on breast milk plus Neosure powder plus Beneprotein powder (BM 26 kilocalories/oz + Beneprotein), on an ad-lib on demand schedule. We recommend continuing this regimen for the next 2 months or until she documents adequate weight gain.
BM|bowel movement|BM|212|213|HISTORY OF PRESENT ILLNESS|The patient developed fevers to 102 the night of admission but reports having some low-grade temperatures during the night over the last few nights. The patient also had some abdominal pain. She denied flatus or BM in weeks. No cough, shortness of breath, chest pain, sore throat, diarrhea, or headache. The patient last received topotecan last week. It was due for administration on _%#MM#%_ _%#DD#%_, 2006, but was cancelled secondary to low blood counts.
BM|bowel movement|BM.|155|157|CURRENT MEDICATION LIST|4. Darbepoetin 40 mcg injections, 1 injection subcutaneously weekly for anemia of chronic disease. 5. Theravac 283 mg enema rectally every other day if no BM. 6. Colace 200 mg tablets b.i.d. 7. Fondaparinux 2.5 mg injections subcutaneously daily for DVT prophylaxis. 8. Lasix 40 mg 1 tablet daily. 9. Apresoline 100 mg tablets 1 tablet q.i.d. for blood pressure, hold if systolic pressure is less than or equal to 90.
BM|bowel movement|BM|179|180|HISTORY OF PRESENT ILLNESS|He does complain of dyspnea on exertion, anxiety, and tremor for about 2 years. He denied any palpitations between the episode 2 years ago, and the current episode. He reported 1 BM daily normally. Also complained of increased perspiration on the hands and soles for the last couple of years, and reported intermittent cough productive of yellow sputum for the last several years.
BM|bowel movement|BM|153|154|HISTORY OF PRESENT ILLNESS|She has complained of nausea off and on for about two days, with a little vomitus, she said last evening. Denies constipation or diarrhea, with her last BM being today. She feels her pain is controlled fairly well in regards to a trigeminal neuralgia. Please refer to review of systems for further data in this area.
BM|bowel movement|BM|169|170|REVIEW OF SYSTEMS ON ADMISSION|These were subjective fevers, however. She has a history of hypertension and heart murmur. She has a history of a CABG. She had some nausea and abdominal pain. Her last BM was the morning of admission. She also has a history of hematuria. She has an indwelling Foley catheter secondary to urinary retention.
BM|bowel movement|BM|276|277|LLNESS|The patient was reported to be very compliant with her medications at home.On review of systems, the patient reported pleuritic chest pain, but denies orthopnea, she reported shortness of breath and chest pain with deep inspiration. No change in bowel habits where she gets a BM ever 2-3 days. She has an ophthalmology appointment on _%#MM#%_ _%#DD#%_, 2002. Otherwise, she denies any blurry vision or eye pain.
BM|bowel movement|BM|138|139|REVIEW OF SYSTEMS|12. Erythropoietin REVIEW OF SYSTEMS: Cardiovascular - no angina. Respiratory - see HPI. Gastrointestinal -slight nausea this morning, no BM for the last several days. No vomiting, diarrhea, abdominal pain. Renal - some increased urinary frequency with Lasix but no hematuria, dysuria.
BM|bowel movement|BM.|232|234|PROBLEM #1|The patient went several days without bowel movement with intervention hindered by postop n.p.o. status immobility and Dilaudid PCA use. Dulcolax suppository was given x1 on _%#MMDD2007#%_ with resulting flatus and small streaks of BM. He had return of BMs with Senokot use after resuming p.o. diet. The patient did have some difficulty with nausea postop and was well controlled with Zofran.
BM|bowel movement|BM|135|136|* FEN|After no further episodes, feeds were started again on _%#MMDD#%_ with breastmilk or Enfamil Premature 20kcal/oz and later advanced to BM fortified to 24kcal/oz. At the time of discharge, he was breast feeding or bottling all of his feedings of Breastmilk with Enfacare fortified to 24kcal, and feeding on a cue based schedule.
BM|bowel movement|BM.|163|165|PAST MEDICAL HISTORY|No history of conjunctivitis. HEENT: He did have a sore throat for 1 day 2 days prior to admission but this resolved. GI: No diarrhea. Could not remember his last BM. GU: The patient had been grabbing at his groin more often per the parents but denied any pain or dysuria. No incontinence during the daytime though he does have this occasionally at night.
BM|breast milk|BM|131|132|* FEN|You will need to arrange for her to receive Synagis this coming RSV season. Ongoing problems: * FEN: _%#NAME#%_ was transferred on BM or Enfacare, both have added Beneprotein and are fortified to 28Kcal using Enfacare. She is taking 50ml every 3 hours. She is receiving all feeds via gavage.
BM|bowel movement|BM|125|126|HOSPITAL COURSE|He also tried to get out of bed as per the nursing note. He was given Haldol on this day. He was noted to have a soft, brown BM and urine in the bed. On _%#MMDD2007#%_ at 8 a.m. the patient was oriented x2 and he stated that he was painful, he was also noted not to be eating well.
BM|bowel movement|BM,|464|466|PRN MEDICATION|PRN MEDICATION: In addition, she is receiving p.r.n. medication, Tylenol 325 mg/NJ q. 4 hours p.r.n pain, Dulcolax suppository p.r.n. for constipation, hydralazine 10 mg IV q. 2 hours p.r.n. systolic blood pressure greater than 150, hydromorphone Dilaudid 0.5 mg IV q. 2 h. p.r.n. pain, lorazepam 0.5 mg IV q. 4 hours p.r.n. anxiety, magnesium citrate 1 bottle daily for constipation/NJ, magnesium sulfate electrolyte replacement, Fleets enema rectal daily p.r.n. BM, potassium chloride electrolyte replacement, and phosphorus K-phos electrolyte replacement. DISCHARGE PLANNING: Per patient's daughter's recommendation, they would like to transfer her to the Mayo Clinic and have her resume care with her primary doctor, who is Dr. _%#NAME#%_.
BM|bowel movement|BM|322|323|REVIEW OF SYSTEMS|CARDIOVASCULAR: Denies edema, palpitations, DVTs and chest pain. GASTROINTESTINAL: She reports that she has had a decrease in appetite, has had an increase in difficulty stooling as in constipation. Denies abdominal pain, heartburn. She does have a history of GI bleed with her last admission in _%#MM#%_ and had her last BM 3 days ago. REVIEW OF SYSTEMS: GASTROINTESTINAL: She reports a decreased appetite and increase in problems with her bowel movements as under constipation.
BM|bowel movement|BM|144|145|REVIEW OF SYSTEMS|GASTROINTESTINAL: She says her appetite is decreased recently and she has no complaint of constipation or abdominal pain or heartburn. Her last BM was 2 days ago, that would be _%#MMDD#%_. MUSCULOSKELETAL: She denies stiffness or joint swelling. She uses a walker. She has no back pain, leg pain or upper extremity pain.
BM|bowel movement|BM|124|125|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: A 10-point review of systems was done and is positive as above, otherwise unremarkable. He has not had a BM for the last 8 days and has a Foley catheter in addition to his G-tube. MEDICATIONS: Please refer to the medication chart.
BM|bowel movement|BM|128|129|IMPRESSION AND PLAN|He also continues on his Spiriva and Advair inhalers as well as Theophylline. Would obtain a Theophylline level. 5. Alternating BM pattern - Apparently a chronic problem and patient is involuntary of stool. He is on Benefiber and Metamucil and lactobacillus as well as Lomotil for this problem.
BM|bowel movement|BM|153|154|REVIEW OF SYSTEMS|She discusses having a decreased ability to take air in. GASTROINTESTINAL: She reports decreased appetite because of pain. Denies constipation, her last BM was on Saturday. MUSCULOSKELETAL: She talks about stiffness in the spinal areas, cervical and lumbar. She reports swelling in her hands and knees bilaterally and the hips have constant pain in them as she is walking.
BM|bowel movement|BM|231|232|REVIEW OF SYSTEMS|No visual change. Denies chest discomfort or dyspnea. Had occasional cough, no sputum. Denied nausea, vomiting, dyspepsia. Occasional vague mid to upper abdominal discomfort (question tightness). Tendency toward constipation, last BM on _%#MMDD2004#%_. No sign of recent GI blood, no voiding complaints. History of incontinence, as above. Chronic lumbar pain with intermittent lower extremity radicular component.
BM|bowel movement|BM|226|227|PHYSICAL EXAMINATION|FAMILY HISTORY: Non-contributory. REVIEW OF SYSTEMS: Unable to obtain. PHYSICAL EXAMINATION: VITAL SIGNS: T-max 99.8, pulse 70 to 80s, blood pressure 130s to 140s/60s to 70s, and oxygen saturation 98% on trach dome mask. Last BM was _%#MMDD2004#%_. GENERAL: His eyes are open but he is not responsive to commands. He does move and responds to uncomfortable stimuli in both his musculatures in his face and his eyes.
BM|bowel movement|BM.|200|202|HISTORY OF PRESENT ILLNESS|The patient states that she is very tired and very achy and a bit confused, but says the procedure went quite well. She states that she has been eating and she has been drinking fluids. She has had a BM. PAST MEDICAL HISTORY: 1. Glaucoma. 2. GERD. 3. Hypertension. 4. Hyperthyroidism. 5. Osteoarthritis. 6. Anxiety. 7. Depression. 8. Infiltrating ductal carcinoma grade 1 of the right breast.
BM|bone marrow|BM|195|196|ASSESSMENT/RECOMMENDATIONS|ASSESSMENT/RECOMMENDATIONS: Ms. _%#NAME#%_ is a young 22-year-old with severe progressive scleroderma who was admitted yesterday for coordination of her medical care. She is being considered for BM or stem cell transplant to combat this disease. She has severe restrictive lung disease with a normal CT exam of her lung parenchyma, suggesting that the lung disease is secondary to muscle weakness.
BM|bowel movement|BM|169|170|PHYSICAL EXAMINATION|His sounds are tympanic to percussion and very solid in the lower her half of his abdomen. Bowel sounds are not audible to auscultation. He did have a report of a large BM yesterday and has had loose stools since stool softeners had been applied to him. CARDIOVASCULAR: His heart rate is as somewhat boggy with slight mitral regurgitation.
BM|bowel movement|BM|124|125|REVIEW OF SYSTEMS|Denies respiratory difficulties, no chest pain. Currently no abdominal pain, no nausea. She has constipation but had a good BM today after some Milk of Magnesia. As noted above, she has hesitancy of urination. She has a couple of new bumps that showed up on her skin in the recent past.
BM|bowel movement|BM|211|212|PHYSICAL EXAMINATION|She is currently on room air. LUNGS: Clear throughout. CARDIOVASCULAR: Heart rate is regular. Heart sounds are normal S1, S2. ABDOMEN/GASTROINTESTINAL: Abdomen is soft, nontender. Bowel sounds are present. Last BM was on _%#MMDD2007#%_. She was given a Dulcolax suppository today. EXTREMITIES: The patient is able to walk but with standby assist. .........is moving all extremities. SKIN: Intact. NEUROLOGIC: The patient is confused and oriented to person only.
BM|bowel movement|BM|153|154|REVIEW OF SYSTEMS|She discusses having a decreased ability to take air in. GASTROINTESTINAL: She reports decreased appetite because of pain. Denies constipation, her last BM was on Saturday. MUSCULOSKELETAL: She talks about stiffness in the spinal areas, cervical and lumbar. She reports swelling in her hands and knees bilaterally and the hips have constant pain in them as she is walking.
BM|bowel movement|BM|136|137|HISTORY OF PRESENT ILLNESS|Chest: Some mild bilateral rhonchi. Heart: Regular rate and rhythm. Abdomen soft. Wound is okay. GU: He is continent of urine. GI: Last BM _%#MM#%_ _%#DD#%_, 2005. Musculoskeletal: Patient is about without assistance. Still some tremor. Psychologically, decreased memory, shaky speech as before.
BM|bowel movement|BM|195|196|PHYSICAL EXAMINATION|GENERAL: She was alert, cooperative, no acute distress. HEENT: Clear. CHEST: Clear to auscultation. HEART: Regular rate and rhythm. ABDOMEN: Soft. Positive bowel sounds. Continent of urine. Last BM _%#MMDD2006#%_. NEUROLOGICAL: Increasing strength with therapy. She is oriented. LABORATORY: Hemoglobin 12.3. Urine culture has been negative.
BM|bowel movement|BM,|80|82|CHIEF COMPLAINT|PRIMARY MD: _%#NAME#%_ _%#NAME#%_, MD CHIEF COMPLAINT: Presyncopal episode post BM, chest pressure with this. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 82-year-old white female with cardiac risk factors of her age/sex combination and hyperlipidemia and hypertension.
BM|bowel movement|BM|147|148|PHYSICAL EXAMINATION|GENERAL: Alert, cooperative, no acute distress. HEAD, EARS, EYES, NOSE, THROAT: Clear. CHEST: Clear. HEART: Regular rate and rhythm. ABDOMEN: Last BM _%#MMDD#%_, eating well. MUSCULOSKELETAL: Decreased proprioception and strength at the ankles and toes. GU: Voiding on own. Will check residuals. Patient agrees. ASSESSMENT: As above.
BM|bowel movement|BM|175|176|REVIEW OF SYSTEMS|RESPIRATORY: She does have a history of asthma and does get occasional bronchitis, usually in the winter. CARDIOVASCULAR: Negative. GASTROINTESTINAL: Negative. She did have a BM today. MUSCULOSKELETAL: The left knee as her only musculoskeletal stiffness or joint problems. NEUROLOGICAL: Negative. URINARY: Negative for dysuria, frequency or burning. ENDOCRINE: Negative for diabetes or thyroid.
BM|bowel movement|BM|146|147|PHYSICAL EXAMINATION|Scan for 116 to 387 cc yesterday. Had incontinent episode, continue ICP and teaching. May want a condom catheter at night. GASTROINTESTINAL: Last BM was on _%#MMDD2005#%_. SKIN: Clear. PSYCHOLOGIC: He answers short questions, is sleepy. NEUROLOGIC: Increased tone, 3-/4, on an Ashworth scale.
BM|bowel movement|BM|302|303|REVIEW OF SYSTEMS|RESPIRATORY: She denies cough, shortness of breath, chest pain. CARDIOVASCULAR: She had right CVA as mentioned before with residual left upper and lower extremity weakness, though she is able to walk around. She denies any edema, palpations, DVTs or chest pain. GASTROINTESTINAL: No contribution. Last BM was yesterday. MUSCULOSKELETAL: She denies stiffness, swelling joints in hands and legs. NEUROLOGICAL: Denies any contributing factors to her stay. URINARY: She denies dysuria, frequency, burning.
BM|bowel movement|BM|145|146|HOSPITAL COURSE|The patient has made gains with his therapies and felt to be stable by Orthopedics. The patient is making progress with therapies as noted. Last BM _%#MMDD2007#%_. Continent of urine. Moderate assist for bed mobility, minimal assist to sit to stand, transfers with wheeled walker, contact guard assist.
BM|bowel movement|BM|186|187|PHYSICAL EXAMINATION|She reads okay with her glasses. Speech and swallowing appear to be okay. Chest was clear. HEART: Regular rate and rhythm. GENITOURINARY: Continent without Foley. GASTROINTESTINAL: Last BM _%#MMDD2005#%_. SKIN: Clear. NEUROLOGIC: Decreased sensation in the left upper and lower extremity. Decreased strength on the left side 4/5, strength on the right is 4+/5 generally.
BM|bowel movement|BM|144|145|PHYSICAL EXAMINATION|Blood pressure 154/84. 95% saturations on room air. GENERAL: She is alert, cooperative and in no acute distress. Bowel and bladder are ok. Last BM this morning. Skin is clear. MUSCULOSKELETAL: Good upper extremity range of motion with minimal pain. She continues to work on lower extremity range of motion secondary to her right TKA.
BM|bone marrow|BM|144|145|HPI|Assessment and Plan: Patient is scheduled to have stent placement. Palliative radiation is pending due to low count. She was also found to have BM packed with lymphoma.
BM|bowel movement|BM|112|113|1. FEN|6. Coumadin 5 mg a day with 1 1/2 tablets or 7.5 mg on Saturday. 7. Milk of Magnesia 30 cc 1-2x daily to have a BM every day. His diet otherwise will be no added salt diet and follow up in the next 3- 4 days with Dr. _%#NAME#%_.
BM|bowel movement|BM|213|214|PHYSICAL EXAMINATION|PSYCHIATRIC: Denies insomnia. ENDOCRINE: Denies weight loss or anorexia. HEME/LYMPH: She has had fevers. PHYSICAL EXAMINATION: Heart rate 60, blood pressure 165/74, respirations 22, O2 97%, temperature 99.4. Last BM was _%#MMDD2006#%_. GENERAL: Elderly female lying in bed, appears very tired but is able to stay awake during our conversation. She also is mildly dyspneic. HEENT: Pupils are round and equal.
BM|bowel movement|BM|189|190|PHYSICAL EXAMINATION|LUNGS: Clear bilaterally. HEART: S1, S2 are present. No murmurs or irregularity. ABDOMEN: Soft, nontender. No hepatosplenomegaly. Bowel sounds are present in all 4 quadrants. Last recorded BM was Saturday, _%#MMDD#%_. GENITOURINARY: He does have a Foley catheter. Negative UA. UC, straw colored, denies pain. SKIN: Poor turgor, dry.
BM|bowel movement|BM|173|174|REVIEW OF SYSTEMS|CARDIOVASCULAR: No edema, palpitations, DVTs or chest pain. GASTROINTESTINAL: No appetite changes. She does have chronic constipation. No abdominal pain, no heartburn. Last BM was on Sunday. MUSCULOSKELETAL: No stiffness in the joints of her upper or lower extremities. She does have severe back pain in the mid thoracic region.
BM|bowel movement|BM|212|213|FINDINGS|However, this was discontinued on postoperative day #1 since which the patient has been tolerating p.o. Percocet with good control of her pain symptoms. The patient has resumed normal bowel function having had a BM but will be sent home with Colace on a p.r.n. basis. The patient is breast-feeding, states this is going well. DISPOSITION: A 25-year-old para 1-0-0-1, postoperative day #4, status post primary low transverse C-section secondary to induction of labor for superimposed preeclampsia, requesting discharge home today.
BM|bowel movement|BM|249|250|ADMISSION DIAGNOSIS|DOB: _%#1914#%_ ADMISSION DIAGNOSIS: Small-bowel obstruction. The patient is a _%#1914#%_ white female who was admitted overnight with a history of abdominal pain, nausea, and vomiting since late last week - Thursday, Friday, or Saturday. She had a BM on Sunday which she felt was normal. No diarrhea. Episodes of nausea and vomiting since late last week, however. No prior history of small-bowel obstruction. She does have a history of colon resection for colon cancer in 1992 with no known recurrence.
BM|bowel movement|BM|187|188|REVIEW OF SYSTEMS|No alcohol. No IV drug use. REVIEW OF SYSTEMS: 10 organ systems were checked and were all negative other than what was stated in the history of present illness. The patient has not had a BM since admission. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 102.7, blood pressure 139/80, heart rate 148, respirations 22 on 98% saturation on 2 liters of nasal cannula.
BM|bowel movement|BM.|188|190|ADMISSION DIAGNOSIS|On postoperative day 1, the patient underwent upper GI barium study which demonstrated no abnormalities. The patient was then started on dulcolax suppositories. The patient had a positive BM. On postoperative day 2, the patient was then started on clears that the patient tolerated well. Later on postoperative day 2, the patient stated that she was ready for discharge.
BM|bowel movement|BM|179|180|REVIEW OF SYSTEMS|Cardiac: Negative for any recent chest pain, palpitations, PND, or orthopnea. Gastrointestinal: Notable for ongoing constipation which is likely due to his narcotic use. His last BM was approximately three days ago and was large and formed. He denies any problems with nausea or vomiting. Again, he does describe anorexia.
BM|bowel movement|BM|165|166|HISTORY OF PRESENT ILLNESS|I think he only had a spinal for anesthesia. He is tolerating a diabetic diet without nausea or vomiting. The patient's other complaint is of constipation. His last BM was two nights ago. PAST MEDICAL HISTORY: 1. Type II diabetes, with bilateral lower extremity neuropathy and recurrent non-healing wounds, diagnosed twelve years ago.
BM|bowel movement|BM.|154|156|HISTORY OF PRESENT ILLNESS|He has had nausea, vomiting, chills. He did have breakfast this morning. He had a normal bowel movement at midnight and since then describes no flatus or BM. He describes the pain as a 10 out of 10, although he does not look to be in that much discomfort and moves well in bed.
BM|bowel movement|BM|207|208|PHYSICAL EXAMINATION|GENERAL: Ill-appearing, on vent, sedated. NEUROLOGIC: Sedated. CARDIOVASCULAR: Regular rate and rhythm, no murmur. RESPIRATORY: Coarse lung sounds. GI: Gastric tube for tube feed. Bowel sounds present, last BM _%#MMDD#%_. GU: Foley. SKIN: Many ecchymotic areas. EXTREMITIES: No edema. LABORATORY & DIAGNOSTIC DATA: _%#MMDD#%_ WBC 15.4, hemoglobin 11.5, sodium 154, potassium 3.5, chloride 127, BUN 96, creatinine 2.87. Chest x-ray from _%#MMDD#%_ shows extensive infiltration throughout right lung, increased density left lung.
BM|bowel movement|BM|187|188|REVIEW OF SYSTEMS|She denies any palpitations, PND, or orthopnea. Gastrointestinal is notable for some waves of nausea. She did have one emesis this morning. She states her bowels are moving with her last BM on _%#MMDD2005#%_. She states they are brown in color and formed. Family are here and they concur with this. She denies any difficulty with urination. She has been without any burning or urgency.
BM|breast milk|BM|121|122|1. FEN|She remained on TPN until day of life 11. Enteral feeds were initiated on day of life #3 and at discharge she was taking BM ALD successfully. She also received intermittent diuretics for fluid overload. _%#NAME#%_ was started on iron supplements on day of life 18. 2. RESP: _%#NAME#%_ was initially intubated and received surfactant replacement therapy for respiratory distress prior to transport to FUMC.
BM|bowel movement|BM|203|204|TPN|6. Peds Surgery - Pediatric surgery would like to see _%#NAME#%_ in two weeks to follow up GT placement. Discharge medications, treatments and special equipment: 1. Ranitidine 7 mg NG BID 2. GT feeds of BM 85 mL every three hours _%#NAME#%_ is a good candidate to receive Synagis during the upcoming RSV season.
BM|bowel movement|BM|247|248|PRIMARY PHYSICIAN|HOSPITAL COURSE: The patient was admitted for abdominal pain. He came with films from Abbot Northwestern that were negative for free air and/or significant air-fluid levels. The patient was hit aggressively with multiple laxatives and had a large BM overnight the day of admission. The a.m. exam revealed no abdominal tenderness and the patient felt much more comfortable. There was no change in his medication regimen with the exception of the addition of laxatives.
BM|bowel movement|BM|283|284|HOSPITAL COURSE|I discussed with Dr. _%#NAME#%_, who in light of no temp, redness or other symptoms, agrees with dc home and he will see the patient in his clinic in the am and no antibiotics to be ordered at this time. The rest of exam: Pain control fine, no other c/o's, eating better and no N/V. BM normal, formed. Voids w/o probs. Lungs CTA, S1S2 w/o m/g/r, ABD: as described and right abd drsg d&i. Pink area near mid lower and mid left has nearly resolved.
BM|bowel movement|BM|146|147|ASSESSMENT/PLAN|Wound care per Plastics recommendation. We will continue the patient on 0.25% acetic acid dressing change q. shift with perineal irrigation after BM p.r.n. RN and ET nurse to teach the patient on how to perform her own dressing change prior to discharge to home.
BM|bowel movement|BM|159|160|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: Negative for recent upper respiratory infection, chest pain or shortness of breath. No nausea or vomiting. Patient is passing flatus but no BM yet postoperatively. The rest of the 10-point review of systems is negative. PHYSICAL. VITAL SIGNS: Blood pressure 115/55-60, heart rate 80-90, temperature 100.5 max, respiratory rate 20, oxygen saturation 94% on room air.
BM|bowel movement|BM|203|204|OBJECTIVE|The patient is Catholic. Parish priest is involved. Wife requesting family meeting to discuss the above. Code is DNI. ALLERGIES: To scallops. OBJECTIVE: From the chart temp 101 axillary, 82, 32, 126/60. BM last _%#MMDD2003#%_. The patient is alert, non-verbal. Tremors come and go. SKIN: Mild diaphoresis. CHEST: Respiratory rate 40 a minute with rhonchi and expiratory wheeze, left base greater than right.
BM|bowel movement|BM,|109|111|HISTORY OF PRESENT ILLNESS|He reports having about 10 watery diarrhea the day prior to this admission. On the day of admission he had 6 BM, which he described as watery. No blood or mucus mixed with this stool. He also denies abdominal pain, fever, nausea or vomiting.
BM|bowel movement|BM|119|120|MEDICATIONS|2. Lasix 80 mg p.o. daily. 3. Folic acid 1 mg p.o. b.i.d. 4. Lactulose 60 mL p.o. q.4 h., may titrate up or down for 5 BM per day. 5. Magnesium oxide 400 mg p.o. q.i.d. 6. Multivitamin with minerals 1 tablet p.o. daily. 7. Protonix 40 mg p.o. daily. 8. Vitamin K 10 mg p.o. daily.
BM|bowel movement|BM|173|174|VITAL SIGNS|NEUROLOGIC: I am unable to assess. She currently is receiving thickened liquids due to a video swallow that was done by physical therapy and has a Foley catheter. She had a BM today which was loose. Her INR is 3.6 and that is down from 4.0 of yesterday. White blood cell count is elevated at 12.5. Hemoglobin is 10.7. Creatinine is elevated at 1.4. Chest x-ray shows lower left lobe atelectasis and new lower right lobe infiltrate.
C&S|culture and sensitivity|C&S|206|208|LABORATORY|EXTREMITIES: Grossly unremarkable. NEUROLOGIC: Alert, short-term memory decreased, no gross cranial nerve deficits. LABORATORY: Hemoglobin 11.8, C diff toxin eight, negative times two, heme positive stool, C&S negative for bacteria. BMP - creatinine 1, BUN 32. ESR 111. ASSESSMENT: 1. Diarrhea, apparently resolving. 2. Heme positive stool of unclear etiology.
C&S|culture and sensitivity|C&S|201|203|ASSESSMENT|She may have other causes for pain, including GYN, rule out abscess or other possibility. There is no current evidence of toxic megacolon on physical examination. Will check for C. Difficile and stool C&S for infectious ______________. CT scan of the abdomen will be obtained. PLAN: 1) CT scan of the abdomen and pelvis to be obtained.
C&S|conjunctivae and sclerae|C&S|213|215|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted. Otherwise negative per 10-system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-tanned-appearing, white male, with intermittent chest pain. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. CARDIAC: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|467|469|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: As above, otherwise negative. Negative for constitutional, negative for pulmonary, negative for cardiac, positive for gastrointestinal, negative for genitourinary, positive for hematologic, negative for immunologic, negative for endocrine, negative for musculoskeletal, negative for neuro/psych. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished-appearing white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|219|221|PHYSICAL EXAMINATION|Positive for musculoskeletal with osteoporosis. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, demented white female in no acute distress with tremor of lower lip. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|209|211|PHYSICAL  EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise negative per ten system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished-appearing white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|carcinosarcoma:CaS|C&S,|206|209|PAST MEDICAL HISTORY|CHIEF COMPLAINT: A _%#1914#%_ woman comes to the ER complaining of increasing shortness of breath, fatigue and lower extremity weakness. PAST MEDICAL HISTORY: Significant for: 1. Recently diagnosed ovarian C&S, please see HPI. She underwent a debulking procedure in _%#MM#%_. 2. History of stomach cancer status post gastrectomy and partial colectomy in 1967.
C&S|protein C and protein S|C&S,|163|166|PLAN|3. I would check a hypercoagulable workup, including factor V genetic mutation and factor 20210A genetic mutation and also check an antithrombin activity, protein C&S, cardiolipin antibody and homocysteine level. 4. I would manage his pain with Percocet and if he needs IV medication, I would use morphine 2-4 mg IV q.3h. as needed for pain.
C&S|culture and sensitivity|(C&S).|228|233|PLAN|2. Check an echocardiogram. 3. Treat patient with Levaquin 500 mg daily which would cover urinary tract infection and cover any bacterial etiology of the patient's pulmonary crackles. 4. Check sputum for culture and sensitivity (C&S). 5. Do daily weights. 6. Ultimately the patient will require some social services as due to the acute illness as she is too weak to return back home at this time.
C&S|culture and sensitivity|C&S|63|65|PLAN|Sputum Gram stain and culture has been sent as well as UA with C&S and micro, Tessalon Perles and guaifenesin with codeine p.r.n. for pain. As for her folliculitis the Zosyn will cover that as well, especially for staph infection, and Triamcinolone cream to be applied to affected area t.i.d. Overall the patient appears to be clinically stable at this time.
C&S|protein C and protein S|C&S,|297|300|IMPRESSION|IMPRESSION: 1. Acute right lower extremity DVT with prior history of DVT in a gentleman who has had multiple hospitalization and recent surgeries. Whether this patient has a hypercoagulable state is unclear, but would agree to admit the patient for observation, check his factor V Leiden, protein C&S, antithrombin activity and start him on Lovenox subq b.i.d. in addition to Coumadin. Will administer education for Lovenox therapy to be continued as an outpatient.
C&S|culture and sensitivity|C&S.|147|150|PLAN|ASSESSMENT: Elderly white male with fever and lethargy, etiology uncertain at this time. PLAN: Pan culture. Also, was sent for a UA with micro and C&S. I will consider the Vancomycin 1 gram IV q12h that will be followed pharmacy and continue Rocephin 1 gram IV q12h.
C&S|culture and sensitivity|C&S|122|124|PLAN|CT scan of the abdomen will be obtained. PLAN: 1) CT scan of the abdomen and pelvis to be obtained. 2) Stool cultures for C&S and C. Difficile toxin titer to be obtained. 3) Full panel of labs will be checked and old records obtained from _%#CITY#%_ Hospital.
C&S|conjunctivae and sclerae|C&S|190|192|PHYSICAL  EXAMINATION|He does develop acne with steroids. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing African-American male in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy, acne scars on face. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|central nervous system:CNS|C&S|270|272|HOSPITAL COURSE|For details of the history of present illness, review of systems and physical exam at the time of admission, please see the admission H&P from _%#MMDD2007#%_. HOSPITAL COURSE: 1. Fever. The patient was admitted to general medicine floor. The concern initially was for a C&S infection since the patient recently had a ventriculostomy hardware removal. His physical examination and laboratory workup did not confirm this suspicion.
C&S|conjunctivae and sclerae|C&S|192|194|PHYSICAL EXAMINATION|Otherwise, negative and noncontributory per 10 system review. PHYSICAL EXAMINATION: GENERAL: Well-developed thin, ruddy complected white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|203|205|PHYSICAL EXAMINATION|Otherwise, remaining system review is negative. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished-appearing white female currently in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion HEART: Regular rate and rhythm, no murmurs, rubs or gallops.
C&S|culture and sensitivity|C&S|282|284|PHYSICAL EXAMINATION|Presently receiving Vancomycin and Levofloxacin for urinary tract infection and Methicillin resistant staphylococcus aureus in the blood _%#MMDD2002#%_ (subsequent cultures negative). She has a history of multiply resistant organisms in the urine. We will recheck a urinalysis with C&S obtain blood cultures times two, continue her present antibiotics for now and hold her in Methicillin resistant staphylococcus aureus isolation.
C&S|conjunctivae and sclerae|C&S|156|158|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white male in no acute distress, mildly pale. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear with mildly pale conjunctivae, no icterus. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|culture and sensitivity|(C&S)|303|307|HISTORY|(For complete details, see Admission History and Physical without changes or amendments.) Physical examination per Admission History and Physical without additions or deletions. Laboratory Data: Normal electrolytes, normal liver tests, normal lipase. CBC was unremarkable. Stool culture and sensitivity (C&S) was negative. CT scan of the abdomen demonstrated an apparent inflammation of the distal terminal ileum.
C&S|culture and sensitivity|C&S|242|244|PLAN|Will follow with serial troponins. An echocardiogram will be ordered accordingly and also receive Tylenol p.r.n. As for his gastroesophageal reflux disease, he will receive Zantac 75 mg p.o. daily. Fasting lipids as well as UA with micro and C&S has been ordered as well. Also, I will obtain a CMP, TSH, magnesium and phosphorous level. If the patient remains stable clinically, he can be discharged home and an outpatient stress test will continue ordered for him accordingly.
C&S|protein C and protein S|C&S.|137|140|FOLLOW-UP INSTRUCTIONS|She will also need to establish herself with a primary care doctor within the next week to follow up on the pending lab results, protein C&S. She will need consultation with GYN. The patient will make that with Dr. _%#NAME#%_ _%#NAME#%_, is advised for tomorrow. She will need consultation with hematology.
C&S|protein C and protein S|C&S|185|187|HISTORY OF PRESENT ILLNESS|The patient has no personal history of a blood clot, but was on NuvaRing and had just completed a 20-hour car ride shortly before admission. She does have a family history of a protein C&S deficiency in a cousin who had a stroke at age 35. For full details of the history of present illness, past medical history and physical examination, please refer to the H&P from the date of admission.
C&S|culture and sensitivity|(C&S).|217|222|PLAN|EKG: EKG shows normal sinus rhythm. No ischemic changes. IMPRESSION: Right lower lobe pneumonia with chronic obstructive pulmonary disease (COPD) exacerbation. PLAN: 1. Sputum will be sent for culture and sensitivity (C&S). 2. Tequin 400 mg IV q.24h. will be given. 3. We will follow up the CBC and comprehensive panel. 4. We will continue with Xopenex inhalers. 5. The patient will use his own CPAP machine.
C&S|protein C and protein S|C&S,|176|179|PROBLEM #1|Estimated blood loss less than 20 cc. The patient is strongly advised and encouraged to quit smoking to prevent recurrent thrombosis. The hypercoagulability workup for protein C&S, homocysteine and factor V Leyden are pending at the time of dictation. Fasting lipid panel showed total cholesterol of 201, HDL 25, LDL 83 and triglycerides 467.
C&S|culture and sensitivity|(C&S).|160|165|PLAN|PLAN: 1. Will check a CT scan to rule out a stone. If a large stone is present we will get Urology involved. 2. Check a urinalysis with culture and sensitivity (C&S). 3. She is afebrile now and there is no gross infection by the _%#MMDD2002#%_ urinalysis so we will hold her antibiotics.
C&S|culture and sensitivity|C&S.|228|231|PHYSICAL EXAMINATION|His MRI is negative. I suspect that he has had an acute worsening due to some sort of metabolic derangement or infection causing the recent worsening. We will start him on Reminyl. We will check a chemistry profile, urinalysis, C&S. Dr. _%#NAME#%_ will see him for a general physical. We have occupational therapy, physical therapy see him. Social service will get involved. He will obviously need some sort of placement.
C&S|culture and sensitivity|C&S|122|124|PLAN|CT scan of the abdomen will be obtained. PLAN: 1) CT scan of the abdomen and pelvis to be obtained. 2) Stool cultures for C&S and C. Difficile toxin titer to be obtained. 3) Full panel of labs will be checked and old records obtained from _%#CITY#%_ Hospital.
C&S|conjunctivae and sclerae|C&S|264|266|PHYSICAL EXAMINATION|Negative for pulmonary or cardiac problems. Negative for GU, hematologic, immunologic, endocrine, neuropsych or musculoskeletal. PHYSICAL EXAMINATION: Well-developed, well-nourished- appearing African-American male in no acute distress. Vital signs stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular with no murmurs, rubs or gallops.
C&S|culture and sensitivity|(C&S).|156|161|PLAN|3. He will also be under the community-acquired pneumonia pathway on the Levaquin arm. 4. Sputum will be sent to the Laboratory for culture and sensitivity (C&S). 5. 1800-calorie American Diabetic Association (ADA) diet. 6. Insulin sliding scale q.i.d. will be used. 7. We will hold off on any kind of stress test at this time given the patient's acute febrile illness.
C&S|conjunctivae and sclerae|C&S|210|212|PHYSICAL EXAMINATION|Otherwise negative per 10-system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished-appearing, overweight, white female, currently in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. CARDIAC: Regular rhythm. No murmurs, rubs or gallops.
C&S|protein C and protein S|C&S|212|214|PAST MEDICAL HISTORY|5. Cerebrovascular accident with left hemiplegia and dysphagia. She has a feeding tube. 6. History of atrial fibrillation and deep venous thrombosis on Coumadin therapy for a hypercoagulable state with a protein C&S deficiency per her old record. 7. Thalamic hemorrhage stroke. She was seen in Mayo Clinic at that time at St. Mary's Hospital. 8. History of peptic ulcer bleeding. 9. Diabetes mellitus.
C&S|conjunctivae and sclerae|C&S|223|225|PHYSICAL EXAMINATION|Her periods tend to be quite scant. Remaining 10-system review is negative. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished-appearing, white female, in no acute distress. VITAL SIGNS: Stable. Afebrile. HEENT: C&S clear. PERRLA. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. CARDIAC: Regular rhythm. No murmurs, rubs or gallops. ABDOMEN: Soft and scaphoid, nontender, without any organomegaly or masses.
C&S|culture and sensitivity|C&S|221|223|PLAN|2. Continue IV hydration with normal saline at 150 cc an hour, will bolus again if systolic blood pressure falls below 80. 3. Potassium protocol. 4. Ambien at bedtime. 5. Stools have been sent for white blood cell count, C&S and C. diff testing. 6. Zofran p.r.n. for nausea. 7. I would prefer to hold off on Lomotil at this time until stool white blood cell count has been completed.
C&S|protein C and protein S|C&S|267|269|ASSESSMENT  AND PLAN|1. Pulmonary embolism. Will admit and start anticoagulation; prior to this initiation will obtain usual hypercoagulable workup including factor V Leiden, prothrombin gene mutation, antiphospholipid antibody, homocystine level, antithrombin III deficiency and protein C&S levels. Continue to avoid tobacco and will discontinue her NuvaRing. 2. Pulmonary sarcoidosis; the patient is at the end of a prednisone taper; will continue at last dose for the next two days.
C&S|protein C and protein S|C&S|193|195|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Patient noted to have frequent PVCs in the PACU following surgery. HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old gentleman with history of pulmonary emboli, protein C&S deficiency, thoracic aneurysm and hypertension who presents for an outpatient repair by Dr. _%#NAME#%_ for a ruptured right quadriceps tendon. Intraoperatively, he was doing well.
C&S|conjunctivae and sclerae|C&S|150|152|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished-appearing, alert, oriented white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|protein C and protein S|C&S|198|200|OTHER DIAGNOSES|DISCHARGE DIAGNOSES: 1. Frequent premature ventricular contractions. 2. Status post quadriceps tendon repair. OTHER DIAGNOSES: 1. History of pulmonary emboli. 2. Glaucoma 3. Hypertension 4. Protein C&S deficiency 5. Tobacco abuse 6. Possible underlying chronic obstructive pulmonary disease. CONSULTS: None. IMAGING STUDIES: 1. Echocardiogram study shows no significant valve disease.
C&S|culture and sensitivity|C&S.|171|174|IMPRESSION AND PLAN|She WOULD BE WILLING TO HAVE ELECTROCARDIOVERSION, HOWEVER IF NECESSARY. 3. Urinary tract infection by history. We will continue her Macrobid, recheck her urinalysis with C&S. 4. ?mediastinal widening on chest x-ray, more likely just rotation. No chest pain or back pain at present, will review with radiology
C&S|conjunctivae and sclerae|C&S|184|186|EXAMINATION|He is married. REVIEW OF SYSTEMS: The patient could not provide any history. GI as noted. EXAMINATION: Thin, pale-appearing white male in no acute distress. Vital signs stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P, no wheezes heard. ABDOMEN: Soft and scaphoid, nontender without any organomegaly or masses.
C&S|conjunctivae and sclerae|C&S|153|155|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed overweight, pleasant white female lying in bed in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|310|312|PHYSICAL EXAMINATION|FAMILY HISTORY: Negative for GI problems. ALLERGIES: None known. REVIEW OF SYSTEMS: GI as noted, otherwise negative per 10 point system review as it pertains to this admission. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|135|137|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is an elderly, obese white male in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx with a left facial droop. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops. Healed sternotomy.
C&S|conjunctivae and sclerae|C&S|180|182|PHYSICAL EXAMINATION|She complains of shortness of breath with exertion. She is constantly swallowing air and burping. She is complaining of abdominal discomfort. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. Neck without mass or adenopathy. CARDIAC: Regular rhythm, no murmurs, rubs or gallops. LUNGS: Decreased breath excursion anteriorly.
C&S|conjunctivae and sclerae|C&S|192|194|PHYSICAL EXAMINATION|Positive for gastrointestinal as noted. PHYSICAL EXAMINATION: GENERAL; The patient is a well-developed, well-nourished-appearing white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|culture and sensitivity|C&S|164|166|RECOMMENDATIONS|No specific change in management, however, would occur if this diagnosis were made at this point in time. RECOMMENDATIONS: 1. Continue advancing her diet. 2. Stool C&S mainly to check for enteropathogenic E. coli. 3. Colonoscopy in four weeks, will schedule this. 4. Oral antibiotics and at this point would consider her for Augmentin or Keflex.
C&S|conjunctivae and sclerae|C&S|163|165|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Well-developed, elderly, pleasant white female in no acute distress. Denies any symptoms at this time. VITAL SIGNS: Stable. Afebrile. HEENT: C&S clear. Oropharynx is benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs, or gallops.
C&S|conjunctivae and sclerae|C&S|201|203|PHYSICAL  EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise negative per twelve point system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, Asian male in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear with scleral icterus. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|147|149|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Elderly white male appearing younger than stated age, sounds very intellectually sharp. Vital signs stable. Afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Exertional wheezing noted. Clear to A&P. CARDIAC: Regular rhythm. Normal _________________. ABDOMEN: Soft but distended with increased tympany. No palpable organomegaly.
C&S|conjunctivae and sclerae|C&S|141|143|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished white male with poor memory, in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|190|192|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: Thin white male appearing somewhat disheveled and in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Conjunctivae mildly pale. Oropharynx: Poor dentition. NECK: Without masses. LUNGS: Clear to auscultation and percussion. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|175|177|PHYSICAL EXAMINATION|Negative for musculoskeletal or neuropsych. PHYSICAL EXAMINATION: GENERAL: The patient is an elderly, ruddy-faced white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS; Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|193|195|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white female, initially tearful, but towards the end of the visit was much calmer. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to AP. CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|182|184|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, uncomfortable-appearing white female wearing a wig and unable to speak English. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|201|203|PHYSICAL EXAMINATION|Additional information unable to be obtained because of patient's confusion. PHYSICAL EXAMINATION: Cachectic-appearing white male, appearing older than stated age. Vital signs stable. Afebrile. HEENT: C&S clear with conjunctival sclerae icteric. Oropharynx is benign. Poor dentition. NECK: Without masses. CHEST: Lungs are clear to auscultation and percussion.
C&S|conjunctivae and sclerae|C&S|204|206|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: Elderly obese white female currently complaining of pain in her "tailbone." VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|170|172|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: The patient is a well-developed- appearing white female, intubated, sedated. Vital signs: Blood pressure 120/60, pulse 60, temperature 99.6. HEENT: C&S clear. Nares: Dried blood. Oropharynx with orogastric tube and intubated. Cardiac: Regular rhythm, no murmurs, rubs or gallops. Abdomen soft, scaphoid, no bowel sounds heard, no tenderness elicited, no organomegaly or masses ascertained.
C&S|conjunctivae and sclerae|(C&S):|238|243|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI: As noted. Otherwise noncontributory. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: Well-developed, elderly, clinically ill-appearing female with shortness of breath wearing O2. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: Without masses or adenopathy. LUNGS: Decreased breath sounds on the left side, right clear. HEART: Regular rhythm. No murmurs, rubs or gallops. BREASTS: Left mastectomy site.
C&S|culture and sensitivity|(C&S).|292|297|PLAN|LABORATORY DATA: Creatinine 1.31, INR 1.21. ASSESSMENT: Chronic diarrhea for the past one month, rule out Clostridium difficile related, infectious, related to tumor or medications. PLAN: 1. Await CT scan of the abdomen. 2. Await Clostridium difficile toxin titer, cultures and sensitivities (C&S). 3. Agree with empiric trial starting with Flagyl. 4. Further plans to follow the above results.
C&S|conjunctivae and sclerae|(C&S):|183|188|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, overweight, pale white female who is mildly diaphoretic. VITAL SIGNS: Vital signs are stable. Afebrile. HEENT: Conjunctivae and Sclerae (C&S): Clear with conjunctivae pale. Oropharynx: Benign. NECK: No masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops. ABDOMEN: Soft, obese and nontender without any organomegaly or masses.
C&S|conjunctivae and sclerae|C&S|166|168|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well nourished appearing white male in no acute distress. VITAL SIGNS: Stable. His color now is excellent. HEENT: Exam C&S clear. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|226|228|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished-appearing white female in no acute distress, anxious. VITAL SIGNS: Stable. Blood pressure and pulse unremarkable, temperature 101.3 orally. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|143|145|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: A well-developed, hyper-anxious appearing, white female in no acute distress. VITAL SIGNS: Stable. Afebrile. HEENT EXAM: C&S clear. No icterus. Pharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs, or gallops. ABDOMEN: Soft but mildly distended with mild tympany.
C&S|culture and sensitivity|C&S|162|164|HISTORY OF PRESENT ILLNESS|She has not seen any red blood. She has had urgency and lower abdominal cramping. She has had some nausea without vomiting. Stool cultures have been negative for C&S and one negative for C. diff toxin titer. The patient has also been started on some other new medications as an outpatient for her heart, none of which have been thought to contribute to her current problem.
C&S|conjunctivae and sclerae|C&S|174|176|PHYSICAL EXAMINATION|Positive for endocrine, with diabetes. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, elderly white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear, oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|186|188|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory per 10 system review. PHYSICAL EXAMINATION: GENERAL: Thin, elderly white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion HEART: Irregular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|231|233|PHYSICAL EXAMINATION|NEUROPSYCH: Negative. IMMUNOLOGIC/HEMATOLOGIC/ENDOCRINE: Negative. PHYSICAL EXAMINATION: Well-developed, elderly white male lying in ICU in no acute distress. VITAL SIGNS: BP systolic approximately 102 on low dose dopamine. HEENT: C&S clear. No icterus. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|133|135|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Alert, oriented white female with poor recall of recent events. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|213|215|PHYSICAL  EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory per 10 system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished-appearing white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|234|236|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Gastrointestinal as above, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: The patient is an obese, plethoric-appearing elderly white male with some audible wheezing. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear, oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Diffuse wheezing with decreased inspirations. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|158|160|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished-appearing elderly white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear, oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|126|128|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Elderly white female lying in bed wearing O2. Comfortable at rest. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion HEART: Regular rhythm with grade 2/6 systolic murmur heard throughout precordium.
C&S|conjunctivae and sclerae|C&S|307|309|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white male appearing younger than stated age in no acute distress. He is complaining of intermittent right upper quadrant abdominal pain. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|182|184|PHYSICAL EXAMINATION|Negative for neuropsych. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished, very pleasant white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|198|200|PHYSICAL EXAMINATION|5. Benicar. 6. Zocor. 7. Trazodone. 8. Xanax. PHYSICAL EXAMINATION: Well-developed, somewhat lethargic white female due to pain meds, holding the upper abdomen. Vital signs stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Difficult to take deep inspirations. Clear to A&P. CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|161|163|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished white female in no acute distress. She is a vague historian. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm. No murmurs, rubs or gallops. ABDOMEN: Soft and scaphoid, nontender without any organomegaly or masses.
C&S|conjunctivae and sclerae|C&S|195|197|PHYSICAL EXAMINATION|Negative for immunologic, musculoskeletal, GU, eyes or ears. PHYSICAL EXAMINATION: Well-developed, well-nourished- appearing elderly white female in no acute distress. Vital signs stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm with rate 2/6 systolic murmur at the apex.
C&S|conjunctivae and sclerae|C&S|158|160|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished-appearing elderly white male appearing younger than his stated age. VITAL SIGNS: Stable. HEENT; C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Healed sternotomy, irregular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|(C&S):|194|199|PHYSICAL EXAMINATION|Negative for dermatologic problems. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: Well-developed, well-nourished appearing white male in no acute distress. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: With healing right neck scar. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|(C&S):|166|171|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Stable. Temperature 102.2 degrees today. GENERAL: Frail elderly white female in no acute distress. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|205|207|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished-appearing white male in no acute distress. He feels now that the meat bolus has passed. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|163|165|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: The patient is a cachectic, elderly, chronically-ill and very frail-appearing white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm with a systolic murmur heard, although difficulty to hear heart sounds.
C&S|conjunctivae and sclerae|(C&S):|141|146|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: Well-developed, elderly white male in no acute distress. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|221|223|PHYSICAL EXAMINATION|Negative neuropsych. Positive hematologic. Negative for endocrine. Negative for immunologic. PHYSICAL EXAMINATION: Thin, elderly white female applying her makeup in no acute distress. Vital signs stable. Afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm with grade 2/6 systolic murmur and apex going into the axilla.
C&S|conjunctivae and sclerae|C&S|160|162|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted. Otherwise noncontributory. PHYSICAL EXAMINATION: Pleasant, obese white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. CARDIAC: Regular rhythm. No murmurs, rubs or gallops. ABDOMEN: Obese, soft, tender quite diffusely, more so over left rib cage area, as well as left lower quadrant area.
C&S|conjunctivae and sclerae|C&S|248|250|PHYSICAL EXAMINATION|Positive for genitourinary problems. Negative for neurological, psychiatric problems. PHYSICAL EXAMINATION: The patient is a well-developed, well- nourished-appearing, overweight pleasant white male in no acute distress. Vital signs stable. HEENT: C&S clear, oropharynx benign. Neck: No masses or adenopathy. Lungs clear to percussion and auscultation. Cardiac rhythm regular, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|(C&S):|150|155|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Vital signs are stable. GENERAL: Morbidly obese white female in no acute distress. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: No masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|186|188|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory. PHYSICAL EXAMINATION: Well-developed, well-nourished appearing white male in no acute distress. Vital signs are stable. HEENT: C&S clear. Oropharynx is benign. NECK: Without masses or adenopathy. CHEST: Lungs are clear to auscultation and percussion. HEART: Regular rhythm, no murmurs, rubs or gallops. ABDOMEN: Soft, scaphoid, nontender without any organomegaly or masses.
C&S|conjunctivae and sclerae|C&S|203|205|PHYSICAL EXAMINATION|FAMILY HISTORY: Negative for GI problems. PHYSICAL EXAMINATION: GENERAL: Thin, elderly, white male, appearing younger than stated age, in no acute distress. NG tube in place. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. CARDIAC: Regular rate and rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|146|148|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: A thin, elderly white female with a bandage across the forehead, in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|152|154|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Lethargic, demented white female in no acute distress. Vital signs stable, afebrile. 02 on 3 liters of nasal prong 02 94%. HEENT: C&S clear. Oropharynx benign. NECK: Without masses. LUNGS: Clear to A&P. CARDIAC: Regular rate and rhythm with grade 2/6 systolic murmur heard throughout the precordium.
C&S|conjunctivae and sclerae|C&S|200|202|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise negative per 10 system review. PHYSICAL EXAMINATION: GENERAL: Well-developed elderly white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear with pale conjunctivae. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|228|230|PHYSICAL EXAMINATION|SOCIAL HISTORY: Otherwise, noncontributory. REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: Well-developed, obese, elderly white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|212|214|PHYSICAL  EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: A well-developed elderly white female appearing younger than stated age in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. She is status post right thoracentesis today.
C&S|conjunctivae and sclerae|C&S|145|147|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Obese white female in no acute distress. She is sitting comfortably in bed. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|354|356|PHYSICAL EXAMINATION|Positive for pulmonary, negative for cardiac problems, positive for gastrointestinal as noted, positive for genitourinary, positive for endocrine, negative for hematologic, immunologic, neuro, psych or musculoskeletal. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, elderly white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Rales at base. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|(C&S):|244|249|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI: As noted; otherwise noncontributory. PHYSICAL EXAMINATION: VITAL SIGNS: Vital signs are stable. GENERAL: Well-developed, well-nourished appearing elderly white female in no acute distress. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: No masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|217|219|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory. PHYSICAL EXAMINATION: A well-developed, well-nourished, appearing thin, white female with poor memory and no acute distress. VITAL SIGNS: Stable. HEENT EXAM: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs, or gallops.
C&S|conjunctivae and sclerae|C&S|163|165|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Thin white male, lying supine in the ICU. VITAL SIGNS: Stable. He is intubated. Vital signs stable on dopamine and levophed. HEENT: C&S clear with conjunctival pallor. Oropharynx, patient is intubated. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|183|185|PHYSICAL EXAMINATION|Attentive family. REVIEW OF SYSTEMS: GI as noted. Otherwise noncontributory. PHYSICAL EXAMINATION: Well-developed, elderly white male in no acute distress. Vital signs stable. HEENT: C&S clear. Pharynx benign. Mild slurring of speech. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs or gallops. ABDOMEN: Soft, scaphoid, nontender without any organomegaly or masses.
C&S|conjunctivae and sclerae|C&S|158|160|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory. PHYSICAL EXAMINATION: Overweight white female in no acute distress. Vital signs are stable. HEENT: C&S clear. Oropharynx is benign. NECK: Without masses or adenopathy CHEST: Lungs are clear to auscultation and percussion. HEART: Regular rhythm, no murmurs, rubs or gallops ABDOMEN: Obese, protuberant, mild skin changes consistent with resolving cellulitis with induration and erythema.
C&S|conjunctivae and sclerae|(C&S)|158|162|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white male in no acute distress. VITAL SIGNS: Stable. HEENT: Conjunctivae and sclerae (C&S) are clear. Oropharynx benign. NECK: No masses or adenopathy. LUNGS: Clear to auscultation and percussion HEART: Cardiac Exam: Regular rhythm.
C&S|conjunctivae and sclerae|C&S|133|135|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Well-developed, well-nourished appearing, pale white male in no acute distress. Vital signs are stable. HEENT: C&S clear. Oropharynx is benign. NECK: No masses or adenopathy. CHEST: Lungs are clear to auscultation and percussion. HEART: Regular rhythm, no murmurs, rubs or gallops. ABDOMEN: Soft, scaphoid, nontender without any organomegaly or masses.
C&S|conjunctivae and sclerae|C&S|134|136|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Well-developed, well-nourished- appearing white male in no acute distress. Vital signs stable. Afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular with no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|(C&S):|199|204|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted; otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: Well-developed elderly Asian male in no acute distress. VITAL SIGNS: Stable. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx benign. NECK: No masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Cardiac Exam: Regular rate and rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|171|173|PHYSICAL EXAMINATION|Otherwise, 12-point system review negative. PHYSICAL EXAMINATION: GENERAL: Well-developed, obese, elderly, white female, in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, with no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|163|165|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, elderly, pale, white male in no acute distress, lying comfortably in ICU bed. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear with pale conjunctivae. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm.
C&S|conjunctivae and sclerae|C&S|164|166|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Well-developed, thin white male in no acute distress. Vital signs stable. NG tube in place. Mild abdominal distention noted, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to AP. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|158|160|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, very pleasant white female appearing younger than stated age in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|246|248|PHYSICAL EXAMINATION|The patient unable to give history. PHYSICAL EXAMINATION: GENERAL: Elderly white female lying somewhat uncomfortably on the cart with clear significant abdominal distention. VITAL SIGNS: Stable, afebrile. O2 saturations off oxygen of 92%. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|235|237|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Gastrointestinal as noted, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL; The patient is a cachectic elderly white male in no acute distress with some apparent confusion, alert. VITAL SIGNS: Sable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Decreased breath sounds. CARDIAC: Distant heart sounds, regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|(C&S):|158|163|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed elderly white male in no acute distress. NG tube in place. VITAL SIGNS: Stable. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: No masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|158|160|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: A well-developed, elderly, white male in no acute distress. Receiving blood transfusion now. VITAL SIGNS: Stable. Afebrile. HEENT EXAM: C&S clear. Oropharynx benign. Poor dentition. NECK: Without masses. LUNGS: Clear to A&P. Barrel chested. CARDIAC: Regular rhythm. No murmurs, rubs, or gallops.
C&S|conjunctivae and sclerae|(C&S):|176|181|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: Well-developed, well-nourished, well-developed appearing white female in no acute distress. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Pierced tongue. NECK: Without masses. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|153|155|PHYSICAL EXAMINATION|Otherwise noncontributory. PHYSICAL EXAMINATION: Well-developed, well-nourished- appearing white female in no acute distress. Vital signs stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs, or gallops.
C&S|conjunctivae and sclerae|C&S|177|179|PHYSICAL EXAMINATION|VITAL SIGNS; Stable with a blood pressure systolic of 90s to low 100s, pulse is stable in the 80s. HEENT: Carotid enlargement noted, multiple small telangiectasias on the face. C&S clear with muddy sclerae, not overtly icteric. Oropharynx benign. Neck without masses. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|171|173|PHYSICAL  EXAMINATION|Please back up under HPI. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|139|141|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Elderly white male with flat affect lying in bed in no acute distress. VITAL SIGNS: Stable, afebrile HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|culture and sensitivity|C&S,|128|131|PLAN|2. History of multiple sclerosis. 3. Depressed gammaglobulins. PLAN: 1. Colonoscopy in a.m. 2. Prep this evening. 3. Stools for C&S, O&P in view of her IgG decrease.
C&S|conjunctivae and sclerae|C&S|242|244|PHYSICAL EXAMINATION|IMMUNOLOGIC: Negative. HEMATOLOGIC: Negative. ENDOCRINE: Negative. MUSCULOSKELETAL: Negative. NEUROPSYCH: Positive. PHYSICAL EXAMINATION: Well-developed, well-nourished- appearing white female in no acute distress. Vital signs stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|155|157|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed elderly white female in no acute distress. Being transfused currently. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion HEART: Irregular rhythm. No murmurs, rubs, gallops. ABDOMEN: Soft and scaphoid, nontender without any organomegaly or masses detected.
C&S|conjunctivae and sclerae|C&S|209|211|PHYSICAL  EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise negative per twelve point system review. PHYSICAL EXAMINATION: GENERAL: Thin elderly and pale appearing white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|147|149|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished-appearing, very fidgety white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|188|190|PHYSICAL EXAMINATION|Otherwise, noncontributory per 10 system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished-appearing female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to AP. CARDIAC: Regular rhythm with grade III/VI systolic murmur heard into the left axilla, beginning in the apex.
C&S|conjunctivae and sclerae|C&S|189|191|PHYSICAL EXAMINATION|SOCIAL HISTORY: The patient lives in assisted living and is a retired actuary. PHYSICAL EXAMINATION: GENERAL: An elderly, thin, white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm. No murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|243|245|PHYSICAL  EXAMINATION|FAMILY HISTORY: Negative for GI problems. REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory per remaining 10 point system review. PHYSICAL EXAMINATION: GENERAL: Elderly thin white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|173|175|PHYSICAL EXAMINATION|Negative for all other systems. PHYSICAL EXAMINATION: GENERAL; The patient is elderly and alert, thin while male in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Icteric sclerae. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops. ABDOMEN: Slightly distended, possible fluid shift, no ballottable liver or spleen, small midline hernia below xiphoid process, reducible.
C&S|conjunctivae and sclerae|C&S|219|221|PHYSICAL  EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise unremarkable per 12 point review of systems. PHYSICAL EXAMINATION: GENERAL: Well-developed, overweight African-American female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|159|161|PHYSICAL EXAMINATION|Negative for neuropsych. PHYSICAL EXAMINATION: GENERAL; The patient is a thin elderly white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without complaint masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops, defibrillator in place.
C&S|conjunctivae and sclerae|C&S|221|223|PHYSICAL  EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise negative for contributory ten-point system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, obese, moon-faced white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|187|189|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed but sedated white female, arouseable and able to answer questions. She is somewhat shaky when aroused. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion HEART: Regular rhythm, grade 2/6 systolic murmur along the sternal border.
C&S|conjunctivae and sclerae|(C&S):|161|166|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Thin, chronically ill-appearing, elderly white male who is wearing O2. He is comfortable at rest. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: Without masses or adenopathy. LUNGS: Distant breath sounds. HEART: Regular rhythm. No murmurs, rubs or gallops. ABDOMEN: Soft and scaphoid, nontender, without any organomegaly or masses.
C&S|conjunctivae and sclerae|(C&S):|203|208|PHYSICAL EXAMINATION|Musculoskeletal: Negative. Neurologic: Negative. Psychiatric: Negative. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: Elderly, thin white male in no acute distress. HEENT: Conjunctivae and Sclerae (C&S): Clear. Pale conjunctivae. Oropharynx: Benign. NECK: No masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm with crisp prosthetic valve sound. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|187|189|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished-appearing, white male, lying comfortably in ICU. VITAL SIGNS: Stable, with blood pressure 106/62, pulse 71, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|245|247|PHYSICAL EXAMINATION|Positive for hematologic. Negative for immunologic. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed white male with multiple tattoos in no acute distress, NG tube in place, distended abdomen. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear, oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|158|160|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished-appearing elderly white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Conjunctivae pale. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Decreased breath sounds but clear bilaterally. CARDIAC: Regular rhythm, no murmurs, rubs or gallops. ABDOMEN: Soft, scaphoid with mild tenderness in the right lower quadrant area without mass, no rebound or guarding, no organomegaly, normoactive bowel sounds.
C&S|conjunctivae and sclerae|C&S|232|234|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise negative per contributory ten system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished-appearing white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|202|204|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise negative for remaining review of systems. PHYSICAL EXAMINATION: Well developed, thin, elderly white female in no acute distress. Vital signs are stable. HEENT: C&S clear. Oropharynx is benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. Healing left thoracotomy scar. ABDOMEN: Soft, scaphoid, nontender without any organomegaly or masses.
C&S|culture and sensitivity|(C&S).|259|264|PLAN|ASSESSMENT: Acute bloody diarrhea. Abnormal CT scan demonstrating probable colitis; rule out ischemic colitis which is likely a possibility versus infectious versus other such as inflammatory bowel disease. PLAN: 1. Will check stool culture and sensitivities (C&S). 2. IV antibiotics will be started in the setting of probable ischemic colitis. 3. Clear liquids to be started. 4. Flexible sigmoidoscopy to be checked tomorrow.
C&S|conjunctivae and sclerae|C&S|201|203|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, chronically ill-appearing white female with obvious choreiform movements. She appears to be somewhat uncomfortable. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx dry. NECK: No adenopathy or masses but rigid. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmur, rub or gallops.
C&S|conjunctivae and sclerae|C&S|133|135|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, sallow appearing elderly white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Decreased breath sounds bilaterally, coughing. No wheezes or rhonchi heard.
C&S|conjunctivae and sclerae|C&S|229|231|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Well-developed, well-nourished appearing white male, initially writhing in pain. Following some morphine, the patient is feeling better, but still having discomfort. Vital signs are stable. Afebrile. HEENT: C&S clear. Oropharynx is benign. NECK: Without masses or adenopathy. CHEST: Lungs are clear to auscultation and percussion. HEART: Regular rate and rhythm, no murmurs, rubs or gallops ABDOMEN: Soft, scaphoid.
C&S|conjunctivae and sclerae|C&S|147|149|PHYSICAL EXAMINATION|ENDOCRINE: Negative. PHYSICAL EXAMINATION: Well-developed, well-nourished- appearing white female in no acute distress. Vital signs stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. HEART: Regular rate and rhythm. No murmurs, rubs, or gallops.
C&S|conjunctivae and sclerae|C&S|212|214|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished-appearing pregnant white female in no acute distress. VITAL SIGNS: Stable; temperature max last p.m. was 100.3, now afebrile. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|152|154|PHYSICAL EXAMINATION|Otherwise noncontributory. PHYSICAL EXAMINATION: Well-developed, well-nourished- appearing white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|(C&S):|242|247|PHYSICAL EXAMINATION|Immunologic: Negative. Hematologic: Negative. Musculoskeletal: Positive. Neuropsychiatric: Negative. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: Obese, well-developed white female in no acute distress. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: No masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops. ABDOMEN: Obese, soft and nontender without any organomegaly or masses.
C&S|conjunctivae and sclerae|(C&S):|160|165|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: Well-developed, well-nourished appearing white female in no acute distress. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|(C&S):|204|209|PHYSICAL EXAMINATION|Positive for neurologic and psychiatric. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: Pale white female lying in the Intensive Care Unit (ICU) in no acute distress. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops.
C&S|protein C and protein S|C&S,|212|215|PERTINENT LABORATORY STUDIES|She has had a fibrinogen level of 395. Her liver panel is normal. Beta hCG is negative. Other lab tests that have been ordered by the hospitalist staff include factor V Leiden, prothrombin gene mutation, protein C&S, lupus anticoagulant, antithrombin III and anticardiolipin IgG and IgM. PHYSICAL EXAMINATION: GENERAL: She is a pleasant, somewhat apprehensive female, does not appear to be in any distress.
C&S|conjunctivae and sclerae|C&S|246|248|PHYSICAL EXAMINATION|Negative for genitourinary. Negative for endocrine, hematologic, immunologic, musculoskeletal and neuropsych. PHYSICAL EXAMINATION: GENERAL; Well-developed, well-nourished-appearing white female in no acute distress . VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx with coated white tongue consistent with thrush. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation.
C&S|conjunctivae and sclerae|C&S|187|189|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well developed, thin white female in distress because of abdominal pain. She points to the right lower quadrant area. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to AP. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|culture and sensitivity|C&S|204|206|PLAN|Alternatively, this could be another infectious agent versus acute appendicitis versus less likely IBD. PLAN: 1. A consultation with surgery to follow with us. 2. Continue supportive care. 3. Await stool C&S results.
C&S|conjunctivae and sclerae|C&S|156|158|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL; The patient is a well-developed, overweight elderly white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|146|148|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, obese white female, anxious and in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. The left eye unable to be examined because of eyelid problems. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation.
C&S|conjunctivae and sclerae|C&S|149|151|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, thin, elderly white female with obvious dyspnea at rest. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Poor air excursion, decreased breath sounds. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|138|140|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed elderly white female with low husky voice in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Decreased breath sounds in left lower lung field secondary to elevated hemidiaphragm.
C&S|conjunctivae and sclerae|C&S|245|247|PHYSICAL EXAMINATION|She has one daughter who is by the bedside. REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory per 10 system review. PHYSICAL EXAMINATION: GENERAL: Well-developed moon-facies white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Mild scleral icterus. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|257|259|PHYSICAL  EXAMINATION|HEALTH HABITS: Non-smoker, rare alcohol. REVIEW OF SYSTEMS: GI as noted, otherwise negative per contributory ten organ system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, thin white male in no acute distress. VITAL SIGNS: Stable. Afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|(C&S):|169|174|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: Well-developed, well-nourished appearing pleasant white female in no acute distress. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: No masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|145|147|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Elderly white male with fine ecchymoses located over her arms, upper chest. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear, no icterus. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Some crackles heard throughout. HEART: Irregular rhythm, no murmurs, rubs, gallops. Spider angiomata noted on anterior chest well.
C&S|conjunctivae and sclerae|C&S|141|143|PHYSICAL EXAMINATION|Otherwise noncontributory. PHYSICAL EXAMINATION: Elderly, thin white male in no acute distress. Vital signs stable. NG tube in place. HEENT: C&S clear. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular with no murmurs, rubs, or gallops. ABDOMEN: Mildly distended, soft with bowel sounds present. No tenderness.
C&S|conjunctivae and sclerae|(C&S):|205|210|PHYSICAL EXAMINATION|Positive for musculoskeletal with arthritis. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: Well-developed, well-nourished appearing white female in no acute distress. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|273|275|PHYSICAL  EXAMINATION|FAMILY HISTORY: Noncontributory. Sister does have gallstones. REVIEW OF SYSTEMS: GI as noted, and otherwise negative per 10-system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished, elderly white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear with mild scleral icterus. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Healing right th2oracotomy scar. Otherwise, clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|192|194|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished-appearing white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|178|180|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted with all other systems n eg. PHYSICAL EXAMINATION: Thin elderly white female in no acute distress. Vital signs are stable. She is afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs or gallops. ABDOMEN: Soft but tender diffusely without rebound or guarding.
C&S|conjunctivae and sclerae|C&S|179|181|PHYSICAL EXAMINATION|The patient is unable to provide all answers. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed but thin white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear with right eye deviated to the right, oropharynx benign with poor dentition. Neck without any masses. LUNGS: Clear to percussion and auscultation.
C&S|conjunctivae and sclerae|C&S|160|162|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory PHYSICAL EXAMINATION: Obese white male in no acute distress. Vital signs are stable. Afebrile. HEENT: C&S clear. Oropharynx is benign. NECK: Without masses or adenopathy. CHEST: Lungs are clear to auscultation and percussion. HEART: Regular rhythm, no murmurs, rubs or gallops. ABDOMEN: Obese, soft, nontender without any organomegaly or masses.
C&S|conjunctivae and sclerae|C&S|155|157|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white female currently in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear with question of mild scleral icterus. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|150|152|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL; The patient is a well-developed, obese white male in no acute distress, anxious. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear, oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|259|261|PHYSICAL EXAMINATION|Negative for genitourinary. Negative for hematologic, endocrine, immunologic, musculoskeletal or neuropsych. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished-appearing white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|224|226|PHYSICAL EXAMINATION|His wife attends the patient today. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished-appearing white male in no acute distress, intermittently spitting into a basin. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|144|146|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, overweight white female, very pleasant. No acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|152|154|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, elderly white female appearing younger than stated age in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Conjunctiva pale. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|188|190|PHYSICAL EXAMINATION|Negative for genitourinary. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished-appearing elderly white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|164|166|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a thin, elderly white female appearing younger than her stated age, in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Irregular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|243|245|PHYSICAL  EXAMINATION|Has children. HABITS: Nonsmoker, no alcohol. REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory per 10 system review. PHYSICAL EXAMINATION: GENERAL: Very obese, pleasant Hispanic female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|226|228|PHYSICAL  EXAMINATION|REVIEW OF SYSTEMS: GI as noted; otherwise negative per ten point system review with regard to this presentation. PHYSICAL EXAMINATION: GENERAL: Morbidly obese female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|175|177|PHYSICAL EXAMINATION|Negative for neuropsych. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, thin elderly white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|culture and sensitivity|C&S|154|156|PLAN|4. Pelvic ultrasound with verbal report indicating left ovarian cyst versus ectopic pregnancy. PLAN: 1. GYN evaluation to be obtained. 2. Check for stool C&S and C. difficile toxin titer. 3. Hydration. 4. Further plans can then be made.
C&S|conjunctivae and sclerae|(C&S):|215|220|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Stable. Afebrile. GENERAL: Well-developed, moon facies, white male with truncal obesity and muscle wasting of the extremities in no acute distress. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: No masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|143|145|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: A well-developed, well-nourished appearing white female in no acute distress. VITAL SIGNS: Stable. Afebrile. HEENT EXAM: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs, or gallops. ABDOMEN: Soft and scaphoid. Mild tenderness in left lower quadrant without rebound or guarding.
C&S|culture and sensitivity|C&S,|147|150|LABS|LABS: Yesterday, white count was 14,900 with hemoglobin at 14, oral platelet count, other labs unremarkable. Flex sig: Please see report. Stool of C&S, O&P positive for Gram stains, negative for O&P. C&S pending. ASSESSMENT: 1. Hematochezia. 2. Flexible sigmoidoscopy indicating ulcer and patchy inflammation in the sigmoid area.
C&S|culture and sensitivity|C&S.|137|140|PLAN|3. Occasional diverticula seen. Suspect this is ischemic colitis, rule out Crohn's colitis, infectious colitis. PLAN: 1. Await stool for C&S. 2. Continue IV Cipro and Flagyl. 3. IV fluids and supportive care. 4. Check CT scan of abdomen and pelvis next.
C&S|conjunctivae and sclerae|C&S|217|219|PHYSICAL EXAMINATION|Positive for neuropsych. Positive for musculoskeletal. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished-appearing white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear, oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|139|141|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: A well-developed and well-nourished appearing white male, in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIOVASCULAR: Regular rate and rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|(C&S):|146|151|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, overweight white female in no acute distress. VITAL SIGNS: Stable. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Cardia Exam: Regular rhythm. No murmurs, rubs, gallops. ABDOMEN: Obese and soft with mild tenderness in the upper abdominal area without rebound or guarding.
C&S|conjunctivae and sclerae|C&S|233|235|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: General: A well developed, well nourished-appearing white female walking initially slowly because of discomfort. When seen in bed, she was comfortable and had no complaints. Vital signs stable. Afebrile. HEENT: C&S clear. Oropharynx benign. Neck: Without masses or adenopathy. Lungs: Clear to A&P. Cardiac: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|(C&S):|229|234|PHYSICAL EXAMINATION|Negative for hematologic, immunologic, musculoskeletal, neurologic, psychiatric. PHYSICAL EXAMINATION: VITAL SIGNS: Vital signs are stable. GENERAL: Obese, elderly white male in no acute distress. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops. ABDOMEN: Very obese (difficult to examine because of the obesity).
C&S|conjunctivae and sclerae|C&S|171|173|PHYSICAL  EXAMINATION|Otherwise noncontributory per 10 system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, obese, elderly white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. No icterus. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Diffuse crackles, no wheezing. HEART: Regular rhythm with soft systolic murmur near the mid sternal border.
C&S|conjunctivae and sclerae|C&S|141|143|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL; The patient is a well-developed, obese elderly white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|212|214|PHYSICAL EXAMINATION|He is married. REVIEW OF SYSTEMS: GI as noted, otherwise negative per 10 system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, obese white male in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|174|176|PHYSICAL EXAMINATION|No alcohol. REVIEW OF SYSTEMS: GI as noted, otherwise negative. PHYSICAL EXAMINATION: Elderly, obese white female in no acute distress. VITAL SIGNS: Stable. Afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular. No murmurs, rubs, or gallops. ABDOMEN: Protuberant, firm, nontender without any organomegaly or masses. Normoactive bowel sounds.
C&S|conjunctivae and sclerae|C&S|190|192|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white male, appearing very comfortable, not appearing acutely ill at this time. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|143|145|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, elderly white male in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear, no icterus. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops. ABDOMEN: Obese, soft and nontender, without any organomegaly or masses, bowel sounds normally active.
C&S|conjunctivae and sclerae|(C&S):|199|204|PHYSICAL EXAMINATION|Neuropsychiatric: Negative. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. Afebrile. GENERAL: Well-developed, elderly white female who is wearing O2 with noted tachypnea. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: Without masses or adenopathy. LUNGS: Decreased breath sounds bilaterally. No rales or wheezes. HEART: Regular rhythm.
C&S|conjunctivae and sclerae|C&S|216|218|PHYSICAL EXAMINATION|Positive for endocrine. Neuropsychiatric positive as noted. Musculoskeletal as noted. PHYSICAL EXAMINATION: GENERAL: The patient is a thin female with constant movement of legs. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|167|169|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished-appearing Spanish-speaking white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|(C&S):|205|210|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Vital signs are stable. Afebrile. GENERAL: Elderly white female appearing younger than stated age with mild tachypnea. She is wearing O2. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: Without masses or adenopathy. LUNGS: Crackles at right base. HEART: Regular rhythm. No murmurs, rubs or gallops. ABDOMEN: Soft and scaphoid, nontender, with no organomegaly or masses.
C&S|culture and sensitivity|(C&S),|150|155|RECOMMENDATIONS|Note excessive alcohol use, but lipase is normal and no pancreatitis reported on the CT scan. RECOMMENDATIONS: 1. Stool for culture and sensitivities (C&S), ova and parasites (O&P), Clostridium difficile toxin, Escherichia coli and Yersinia. 2. Empiric antibiotics with ciprofloxacin and Flagyl to treat Campylobacter, etc.
C&S|conjunctivae and sclerae|C&S|206|208|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Cachectic appearing white male with temporal wasting, tachypneic, lying at rest. VITAL SIGNS: Stable. With increased respiratory rate to approximately 18-20, afebrile. HEENT: C&S clear with conjunctival pallor, no icterus. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|culture and sensitivity|C&S.|223|226|ASSESSMENT|This is not consistent with Giardiasis acutely or chronically, and affects the small bowel and not the colon. We will need to look for other causes for colitis. Stools are negative for Clostridium difficile toxin titer ana C&S. 3. Elevated liver tests. These appear to be improving, and will need to continue to follow. PLAN: We will need to speak with the wife tomorrow in order to obtain informed consent to perform a paracentesis and flexible sigmoidoscopy to further await the above findings.
C&S|conjunctivae and sclerae|C&S|252|254|PHYSICAL EXAMINATION|HABITS: Nonsmoker, no alcohol FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory per 10 system review. PHYSICAL EXAMINATION: GENERAL: Elderly, obese white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|133|135|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Well developed, very uncomfortable white male in some distress because of pain. Vital signs are stable. HEENT: C&S clear. Oropharynx is benign. NECK: Without masses or adenopathy LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops ABDOMEN: Soft, with very mild tenderness in the mid epigastric area with no elicitation of discomfort with palpation of the chest or upper abdomen.
C&S|conjunctivae and sclerae|C&S|145|147|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, pale-appearing, white male, in no acute distress. VITAL SIGNS: Stable. Currently afebrile. HEENT: C&S clear with pale conjunctivae. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm.
C&S|culture and sensitivity|C&S,|198|201|LABORATORY|Total bilirubin is 1.5. This has been fractionated previously, consistent with Gilbert's syndrome. Electrolytes, with sodium 125, potassium 3.6. Stool cultures from last admission negative for O&P, C&S, and Clostridium difficile toxin titer. ASSESSMENT: 1. HIV/AIDS. 2. Chronic diarrhea. Now vastly improved after starting empiric Flagyl and Cipro.
C&S|conjunctivae and sclerae|C&S|184|186|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, overweight female, unable to speak English. Communicated through son. She is in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|210|212|PHYSICAL EXAMINATION|Negative for genitourinary, immunologic, hematologic, endocrine, musculoskeletal, neuropsych. PHYSICAL EXAMINATION: GENERAL: The patient is an obese white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|160|162|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished-appearing elderly white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|194|196|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted; otherwise, all other systems negative. PHYSICAL EXAMINATION: A well-developed, very obese female in no acute distress. VITAL SIGNS: Stable. Afebrile. HEENT EXAM: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs, or gallops. ABDOMEN: Obese, soft, nontender, without any organomegaly or masses.
C&S|conjunctivae and sclerae|C&S|166|168|PHYSICAL EXAMINATION|Positive for musculoskeletal. Negative for neuropsych. PHYSICAL EXAMINATION: Well developed, pleasant white male in no acute distress. Vital signs are stable. HEENT: C&S clear. Oropharynx is benign. NECK: Without masses or adenopathy. CHEST: Lungs are clear to auscultation and percussion. HEART: Regular rhythm, no murmurs, rubs or gallops. ABDOMEN: Soft, scaphoid.
C&S|conjunctivae and sclerae|C&S|215|217|PHYSICAL EXAMINATION|Negative endocrine. Negative immunologic. Musculoskeletal - Osteoporosis. Negative for neuropsych. PHYSICAL EXAMINATION: Cachectic, elderly white female, very spry and no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. The patient is hoarse. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs or gallops. ABDOMEN: Soft, scaphoid, nontender without any organomegaly or masses. Normoactive bowel sounds.
C&S|conjunctivae and sclerae|C&S|142|144|PHYSICAL EXAMINATION|Otherwise noncontributory. PHYSICAL EXAMINATION: Well-developed, thin, elderly white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. No crepitus of thorax or neck area. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs or gallops. ABDOMEN: Soft, scaphoid, nontender without any organomegaly or masses.
C&S|conjunctivae and sclerae|C&S|187|189|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished-appearing, African-American female, appearing in no acute distress at the present time. VITAL SIGNS: She is afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. CARDIAC: Regular rhythm. No murmurs, rubs or gallops. ABDOMEN: Soft, scaphoid.
C&S|conjunctivae and sclerae|C&S|217|219|PHYSICAL EXAMINATION|Negative for musculoskeletal. Negative for neuropsych. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, thin white female in no acute distress, NG tube in place. VITAL SIGNS: Vital signs stable. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops. ABDOMEN: Soft, nondistended, mildly tender in the lower abdominal area without rebound or guarding, no organomegaly or masses, bowel sounds are active.
C&S|conjunctivae and sclerae|C&S|213|215|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise negative for a ten organ system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, overweight white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. No icterus. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|(C&S):|202|207|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Stable. Afebrile. GENERAL: Well-developed, well-beingnourished, well-tanned white male complaining of some upper abdominal discomfort. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: No masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|154|156|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, chronically ill-appearing elderly white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. No icterus. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|160|162|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed white female complaining of pain out of proportion to how she is appearing. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|culture and sensitivity|(C&S).|176|181|LABORATORY DATA|BUN and creatinine 52 and 1.74, respectively, which is elevated. In _%#MM#%_ 2005 she had a negative Clostridium difficile toxin as well as stool for culture and sensitivities (C&S). CT SCAN: CT scan of the abdomen in _%#MMDD2005#%_ as well as _%#MM#%_ 2005 show mild nonspecific thickening of the descending sigmoid colon.
C&S|culture and sensitivity|(C&S),|203|208|RECOMMENDATIONS|1. Diabetes mellitus. 2. Recent non-Q-wave myocardial infarction (MI). 3. Diffuse peripheral vascular disease. RECOMMENDATIONS: 1. Repeat stool for Clostridium difficile toxin, culture and sensitivities (C&S), and ova and parasites (O&P). 2. I believe an MR angiogram is advisable in view of the significant calcifications seen in the superior mesenteric and celiac arteries.
C&S|conjunctivae and sclerae|C&S|182|184|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise negative for complete system review. PHYSICAL EXAMINATION: GENERAL: Obese white female in no acute distress. Vital signs are stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation . HEART: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|173|175|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white male, appearing much younger than stated age in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|256|258|PHYSICAL EXAMINATION|FAMILY HISTORY: Otherwise noncontributory. REVIEW OF SYSTEMS: GI as noted, otherwise negative per ten organ system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|214|216|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted. Otherwise noncontributory. PHYSICAL EXAMINATION: Thin, very small, obviously mentally challenged white male with flexure contractures of arms and wrists. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx - There appears to be upper palate deformity, possibly high arch with a large tongue. NECK: Without masses. LUNGS: Clear to A&P. CARDIAC: Regular rhythm.
C&S|conjunctivae and sclerae|C&S|228|230|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white female lying comfortably in bed. Last pain medication was more than 6 hours ago. She currently denies any pain. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to AP. CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|(C&S):|208|213|PHYSICAL EXAMINATION|Endocrine: Negative. Musculoskeletal: Negative. Neuropsychiatric: Positive. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: Well-developed, thin male in no acute distress. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: No masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops. ABDOMEN: Soft, scaphoid and nontender without any organomegaly or masses.
C&S|conjunctivae and sclerae|C&S|154|156|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed elderly white female lying in bed on the orthopedic floor in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|culture and sensitivity|C&S|336|338|LABORATORY|ABDOMEN: Slightly distended and tympanitic with palpable bowel loops and hyperactive bowel sounds, mild tenderness in the lower abdominal area without rebound or guarding, no organomegaly or masses. EXTREMITIES: 1+ peripheral edema. LABORATORY: Hemoglobin 10.2. Electrolytes unremarkable. Stool cultures negative for C. diff yesterday, C&S pending. ASSESSMENT: 1. Diarrhea in the context of longstanding as well as acute use of antibiotics.
C&S|conjunctivae and sclerae|C&S|194|196|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|culture and sensitivity|C&S|209|211|LABORATORY|Normoactive bowel sounds. Well-healed surgical scars. Bowel sounds normoactive. EXTREMITIES: Unremarkable. NEUROLOGIC: Grossly intact. LABORATORY: WBC 5100, hemoglobin of 12.4. Stool cultures for Giardia, O&P C&S and C. diff toxin titer and culture are negative. Fecal leukocytes none seen. CMP not noteworthy. It should be noted that the MCV is 82.
C&S|conjunctivae and sclerae|C&S|207|209|PHYSICAL  EXAMINATION|He uses a walker. REVIEW OF SYSTEMS: GI as noted, otherwise negative for ten system review. PHYSICAL EXAMINATION: GENERAL: Well-developed elderly white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|178|180|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory per 10 system review. PHYSICAL EXAMINATION: GENERAL: Obese white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|142|144|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Well-developed, well-nourished- appearing, dark-skinned male in no acute distress. Vital signs stable. Afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular with no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|147|149|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, overweight elderly white female in no acute distress. A halo is placed. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Not able to be easily examined because of the halo. LUNGS: Clear to A&P, although most of lungs covered with halo.
C&S|conjunctivae and sclerae|C&S|269|271|PHYSICAL EXAMINATION|Negative for genitourinary. Positive for neuropsych with depression. Negative for hematologic, immunologic, endocrine. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished-appearing white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. Neck without masses. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|174|176|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished-appearing white female in no acute distress. VITAL SIGNS: Stable. Temperature elevated. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops. ABDOMEN: Soft, scaphoid, with diffuse abdominal tenderness which the patient attributes to her lupus, no localized tenderness, no rebound or guarding, no organomegaly or masses, normoactive bowel sounds.
C&S|conjunctivae and sclerae|C&S|232|234|PHYSICAL EXAMINATION|Negative family history for GI problems. REVIEW OF SYSTEMS: GI as noted, otherwise negative per 10-system review. PHYSICAL EXAMINATION: GENERAL: Alert, thin and elderly white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear with pale conjunctivae. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. CARDIAC: Regular rhythm, no murmurs, rubs or gallops. ABDOMEN: Soft and scaphoid, nontender without any organomegaly or masses.
C&S|conjunctivae and sclerae|C&S|183|185|PHYSICAL  EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: Well-developed large African-American male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. NECK: Without masses. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops. ABDOMEN: Soft, mildly protuberant, nontender without any organomegaly or masses noted.
C&S|conjunctivae and sclerae|C&S|236|238|PHYSICAL EXAMINATION|FAMILY AND SOCIAL HISTORY: Noncontributory. REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|253|255|PHYSICAL EXAMINATION|SOCIAL HISTORY: The patient is retired. Grown children. REVIEW OF SYSTEMS: GI as noted, otherwise negative per 10 system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, thin, elderly white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|(C&S):|205|210|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white male in no acute distress with intermittent abdominal cramping. VITAL SIGNS: Stable. Afebrile. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: No masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm. No murmurs, rubs, gallops. ABDOMEN: Soft and scaphoid. Mild tenderness to the right of midline without rebound or guarding.
C&S|conjunctivae and sclerae|C&S|246|248|PHYSICAL  EXAMINATION|Father had peptic ulcer disease. HABITS: Nonsmoker, no alcohol. REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory per 10 system review. PHYSICAL EXAMINATION: GENERAL: Elderly white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear with conjunctivae mildly pale. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. CARDIAC: Regular rhythm, no murmurs, rubs or gallops. ABDOMEN: Obese, soft, with healed surgical scars, mildly tender right midabdomen in a small area without rebound or guarding, no organomegaly or masses and normoactive bowel sounds.
C&S|conjunctivae and sclerae|(C&S):|156|161|PHYSICAL EXAMINATION|Some of the questions answered appear to be appropriate, but then the patient will drift off and not complete her thoughts. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: No masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|202|204|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished-appearing elderly white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|culture and sensitivity|C&S.|159|162|PLAN|Alkaline phosphatase 64, ALT 54, AST 59. INR 1.07. Troponin < 0.07. IMPRESSION: One day of bloody diarrhea and cramps, likely ischemic colitis. PLAN: 1. Stool C&S. Rule out enterotoxigenic E. coli. 2. Limited colonoscopy in a.m. to further evaluate.
C&S|conjunctivae and sclerae|C&S|149|151|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed elderly white male in no acute distress, confused. Lying in ICU. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm. No murmurs, rubs or gallops. ABDOMEN: Soft and scaphoid, nontender without any organomegaly or masses.
C&S|conjunctivae and sclerae|C&S|184|186|PHYSICAL  EXAMINATION|She is retired. REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: Obese, elderly white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx unremarkable. NECK: Without masses or adenopathy. LUNGS: Clear to A and P. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|244|246|PHYSICAL  EXAMINATION|She is single. No children. REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory per ten point system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|139|141|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Well developed, anxious white male in no acute distress. Vital signs are stable. Head, ears, eyes, nose and throat : C&S clear. Oropharynx is benign. NECK: Without masses, adenopathy. CHEST: Lungs are clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops. ABDOMEN: Soft and scaphoid, nontender, without any organomegaly or masses.
C&S|conjunctivae and sclerae|C&S|234|236|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, lethargic but arousable white female. She has recently had Ativan. She has no acute distress. She is going to the bathroom following Gastrografin enema today. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|238|240|PHYSICAL  EXAMINATION|SOCIAL HISTORY: Single. Retired. REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory per 10 system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, obese, elderly white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion HEART: Regular rhythm. No murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|145|147|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, pleasant, elderly, obese white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. Anicteric. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. CARDIAC: Regular rhythm. No murmurs, rubs or gallops. ABDOMEN: Obese with dressing over a cholecystectomy site.
C&S|conjunctivae and sclerae|C&S|155|157|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished-appearing thin white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation/ CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|133|135|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: Frail appearing elderly white female, soft spoken, in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|(C&S):|174|179|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Vital signs are stable. GENERAL: Pleasant, elderly white male in no acute distress. He has total alopecia. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops. ABDOMEN: Soft and nontender.
C&S|conjunctivae and sclerae|C&S|298|300|PHYSICAL EXAMINATION|Lives with her husband. REVIEW OF SYSTEMS: GI as noted, otherwise negative including eyes, ears, lungs, heart, GU, immunologic, endocrine, neuropsych, and musculoskeletal. Hematologic notable. PHYSICAL EXAMINATION: Overweight, pleasant white female in no acute distress. Vital signs stable. HEENT: C&S clear. Oropharynx benign. NECK: Without obvious masses. LUNGS: Clear to A&P. CARDIAC: Regular with no murmurs, rubs, or gallops. ABDOMEN: Rotund, soft. Tender in the lower abdominal pain without rebound or guarding.
C&S|conjunctivae and sclerae|C&S|187|189|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: Elderly. GENERAL: Well-developed white male in no acute distress. Difficulty with maintaining open eyes due to his myasthenia. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|(C&S):|213|218|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, pale appearing white male in no acute distress lying in the Intensive Care Unit (ICU). VITAL SIGNS: Vital signs are stable. Afebrile. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion HEART: Regular rhythm with a faint systolic murmur along the lower sternal border.
C&S|conjunctivae and sclerae|C&S|224|226|PHYSICAL EXAMINATION|She denies any other issues on review of systems. PHYSICAL EXAMINATION: The patient is a well-developed, well- nourished-appearing, overweight, elderly white female in no acute distress. Vital signs stable, afebrile. HEENT: C&S clear, oropharynx benign. Neck without masses or adenopathy. Lungs clear to percussion and auscultation. Cardiac: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|(C&S):|172|177|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Elderly, thin white female in no acute distress. VITAL SIGNS: Vital signs are stable. HEENT: Right corneal opacity. Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: No masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops.
C&S|culture and sensitivity|(C&S)|192|196|LABORATORY DATA|LABORATORY DATA: Laboratory tests today include sodium 131, BUN 122, creatinine 5.82. WBC 5600, hemoglobin 11.0, MCV 95, platelet count 259. High protein in the urine. Culture and sensitivity (C&S) of stool is pending. Clostridium difficile negative. Ova and parasites (O&P) negative. No polymorphonuclear neutrophils (PMN) seen in stool.
C&S|conjunctivae and sclerae|(C&S):|219|224|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Middle-aged white male who can be arouseable but was lethargic with obvious abdominal distention. He has been intermittently seizing. VITAL SIGNS: Stable. Afebrile. HEENT: Conjunctivae and Sclerae (C&S): Clear. NECK: No masses or adenopathy. LUNGS: Clear anteriorly. HEART: Cardiac Exam: Regular rhythm. No murmurs, rubs or gallops. ABDOMEN: Distended, firm and tympanitic with tenderness diffusely.
C&S|conjunctivae and sclerae|C&S|144|146|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Elderly white male appearing younger than stated age in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion HEART: Regular rhythm with grade 2-3/6 systolic heard in the apex.
C&S|conjunctivae and sclerae|(C&S):|201|206|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Vital signs are stable. GENERAL: Well-developed, well-nourished appearing white male in the Intensive Care Unit in no acute distress. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: No masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|186|188|PHYSICAL EXAMINATION|Negative for immunologic. Negative for neuro/psych. PHYSICAL EXAMINATION: GENERAL: The patient is a thin, elderly white female in no acute distress. VITAL SIGNS: Stable, icteric. HEENT: C&S clear with icteric sclerae. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops. ABDOMEN: Soft, scaphoid, nontender without any organomegaly or masses, normoactive bowel sounds.
C&S|conjunctivae and sclerae|C&S|165|167|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a thin, elderly male appearing chronically ill, mildly jaundiced and in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Scleral icterus. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Decreased breath sounds bilaterally. CARDIAC: Regular rhythm, no murmurs, rubs or gallops. ABDOMEN: Distended with fluid present, midline healed abdominal scar, no mass detected, no organomegaly, soft and nontender.
C&S|conjunctivae and sclerae|C&S|138|140|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL; The patient is an obese, pleasant white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Healed sternotomy, regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|217|219|PHYSICAL EXAMINATION|Remaining system review is negative/noncontributory. PHYSICAL EXAMINATION: GENERAL: Well-developed, emotionally labile, white female in no acute distress. She is awake and alert. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|261|263|PHYSICAL EXAMINATION|Negative for prior hematologic problems. Negative for immunologic. Negative for neuropsych or musculoskeletal. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished-appearing black male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|203|205|PHYSICAL EXAMINATION|Psychiatric, with depression. Neuro, otherwise negative. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished-appearing, icteric, white female, in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. CARDIAC: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|153|155|PHYSICAL EXAMINATION|No regular alcohol. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, elderly white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|174|176|PHYSICAL EXAMINATION|Positive for neuropsych with depression. PHYSICAL EXAMINATION: Well-developed, well-nourished- appearing gravid white female in no acute distress. Vital signs stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|161|163|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, pleasant elderly white female appearing younger than her stated age. VITAL SIGNS: Stable. HEENT: C&S clear, oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|169|171|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, overweight white male in no acute distress. VITAL SIGNS: Weight 323 pounds, height 6 feet 1 inch. HEENT: C&S clear. Oropharynx fine. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|195|197|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished-appearing Tibetan woman in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|207|209|PHYSICAL EXAMINATION|Negative for immunologic, hematologic, endocrine, musculoskeletal, neuro, psych. PHYSICAL EXAMINATION: GENERAL: The patient is an elderly, thin white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear, oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|culture and sensitivity|C&S,|135|138|PHYSICAL EXAMINATION|RECTAL: Deferred; apparently was heme positive in the Emergency Room, with stool cultures performed previously which were negative for C&S, O&P. EXTREMITIES: Unremarkable. NEUROLOGIC: Grossly intact. LABORATORY DATA: Normal CBC and urinalysis from the Emergency Room.
C&S|conjunctivae and sclerae|C&S|193|195|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed elderly white female currently lying in ICU, crying out "ow" every few minutes. She denies she has any pain. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|171|173|PHYSICAL EXAMINATION|Positive for endocrine with diabetes. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, elderly white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|219|221|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, overweight white male lying in ICU bed with trach on respirator, unable to arouse at this time. VITAL SIGNS: BP systolic in the 80 range, pulse 130 range, afebrile. HEENT: C&S clear. Oropharynx with ET tube. LUNGS: Clear to auscultation and percussion HEART: Rapid rhythm, with no murmurs, rubs or gallops. ABDOMEN: Obese, soft, without elicitable tenderness, no organomegaly or masses and bowel sounds present.
C&S|conjunctivae and sclerae|C&S|333|335|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted. Negative for constitutional, negative for eye or ear, negative for pulmonary or cardiac, negative for hematologic, immunologic, endocrine, GU, positive for musculoskeletal, negative for neuropsych. PHYSICAL EXAMINATION: Well-developed, thin white male in no acute distress. Vital signs stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs or gallops. ABDOMEN: Soft, slightly distended, not particularly tympanitic, soft, no tenderness elicited, no organomegaly or masses detected.
C&S|conjunctivae and sclerae|C&S|141|143|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing elderly white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|177|179|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as above. Otherwise noncontributory. PHYSICAL EXAMINATION: Well-developed, well-nourished- appearing male in no acute distress. Vital signs stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs, or gallops.
C&S|conjunctivae and sclerae|C&S|143|145|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Well developed, pale, white female wearing oxygen. Mild tachypnea noted. Vital signs are stable. Afebrile. HEENT: Eyes - C&S clear with pale conjunctivae. Oropharynx is benign. NECK: Without masses. CHEST: Lungs - some coarse breath sounds, right side, no wheezes.
C&S|conjunctivae and sclerae|C&S|164|166|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished, overweight white female in no acute distress. Denies pain now. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|138|140|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, pale elderly white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Crisp valve sounds, healing sternotomy, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|216|218|PHYSICAL EXAMINATION|Positive for neuropsych with seizure disorder. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, very uncomfortable- appearing white female. She is also lethargic. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx with thrush. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops. ABDOMEN: Loose skin folds related to weight loss from gastric bypass surgery, healed surgical scars.
C&S|conjunctivae and sclerae|C&S|224|226|PHYSICAL EXAMINATION|Positive for gastrointestinal as noted. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished-appearing white male in no acute distress. VITAL SIGNS: Stable. Temperature 100.2 max last night. HEENT: C&S clear, oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops. ABDOMEN: Mildly distended, soft with voluntary guarding left side, no organomegaly or masses detected.
C&S|conjunctivae and sclerae|C&S|181|183|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a morbidly-obese white female lying in the Intensive Care Unit with tracheostomy, on respirator. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear with pale conjunctivae. Neck without mass or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops. ABDOMEN: Very obese, soft, no elicitable tenderness, no organomegaly or masses detected.
C&S|culture and sensitivity|C&S.|275|278|ASSESSMENT|Also, the patient's other medications that can cause mental status change including the Ambien, which is taken at bedtime p.r.n. In the interim, his prior medications will be renewed. A chest x-ray has been ordered to rule out any infiltrates, as well as a UA with micro and C&S. Nursing staff has been ordered to do blood cultures x2 if he has temperature greater than 100.4. The patient is clinically stable at this time and symptoms have resolved.
C&S|conjunctivae and sclerae|C&S|195|197|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise negative. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white male in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|193|195|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory. PHYSICAL EXAMINATION: A well-developed, elderly, pleasant, white male in no acute distress. Vital signs stable. Afebrile. HEENT EXAM: C&S clear. Oropharynx benign. NECK: Without masses, adenopathy, or crepitus. CHEST: Clear. LUNGS: Clear to A&P. No anterior chest wall crepitus. CARDIAC: Regular rhythm. No murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|221|223|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Otherwise noncontributory except as noted above. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, pale white male in no acute distress. VITAL SIGNS: Stable. Pulse in the 90 range. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops. ABDOMEN: Soft and scaphoid, nontender, without any organomegaly or masses, normoactive bowel sounds.
C&S|conjunctivae and sclerae|C&S|199|201|PHYSICAL  EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise negative per 10 system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, obese white female currently in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|123|125|PHYSICAL  EXAMINATION|GENERAL: Pale, elderly white male with bandage on top of skull in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|193|195|PHYSICAL EXAMINATION|VITAL SIGNS: Indicate in the endoscopy lab that his heart rate is regular and tachycardic up to a rate of 180. He is asymptomatic from this. He denies any prior history of palpitations. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm but tachycardic, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|(C&S):|140|145|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: Well-developed, pale white female in no acute distress. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|170|172|PHYSICAL  EXAMINATION|MEDICATIONS: Zoloft 50 mg daily and multivitamin. PHYSICAL EXAMINATION: GENERAL: Obese, pleasant white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. No icterus. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|142|144|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished but pale appearing white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|169|171|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted. Otherwise noncontributory. PHYSICAL EXAMINATION: Well-developed, overweight white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular with no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|253|255|PHYSICAL EXAMINATION|SOCIAL HISTORY: The patient lives with her daughter. REVIEW OF SYSTEMS: GI as noted, and otherwise negative per complete system review. PHYSICAL EXAMINATION: GENERAL: Well-developed elderly white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|213|215|PHYSICAL  EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise negative for complete review of systems. PHYSICAL EXAMINATION: GENERAL: Well-developed, overweight, elderly white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|182|184|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory per 10-system review. PHYSICAL EXAMINATION: GENERAL: Elderly white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. Healed scar on left. LUNGS: Clear to A&P with decreased breath sounds.
C&S|conjunctivae and sclerae|C&S|175|177|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing but thin white female in no acute distress. VITAL SIGNS: Stable. Temperature 100 degrees orally HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|256|258|PHYSICAL EXAMINATION|HABITS: Nonsmoker, no alcohol. REVIEW OF SYSTEMS: GI as noted, otherwise negative per remaining complete review of systems. PHYSICAL EXAMINATION: GENERAL: Well-developed, depressed-appearing, white female, in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm. No murmurs, rubs or gallops.
C&S|culture and sensitivity|(C&S).|190|195|LABORATORY DATA|Normal white count. Normal hemoglobin. Unremarkable liver profile. Negative Clostridium difficile toxin and titer. Negative ova and parasites (O&P). Negative stool culture and sensitivities (C&S). ULTRASOUND: Ultrasound shows distended gallbladder and mildly dilated common duct system (nonspecific).
C&S|conjunctivae and sclerae|C&S|219|221|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed elderly white female appearing younger than stated age in no acute distress. VITAL SIGNS: Stable. Currently afebrile. Temperature earlier this a.m. was 100.1 orally. HEENT: C&S clear. No icterus. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|215|217|PHYSICAL  EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory per 10 system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|139|141|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, icteric white male lying in bed in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear with scleral icterus. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|231|233|PHYSICAL  EXAMINATION|ALLERGIES: TO MORPHINE AND SHELLFISH. REVIEW OF SYSTEMS: GI as noted, otherwise negative per ten point system review. PHYSICAL EXAMINATION: GENERAL: Well developed, thin white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|139|141|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, very alert elderly white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|147|149|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Elderly, cachectic and very mentally alert white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear with conjunctival pallor. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm.
C&S|conjunctivae and sclerae|C&S|148|150|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished-appearing white female lying in bed in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear with conjunctival pallor. Oropharynx benign. Significant adenopathy right submandibular . LUNGS: Clear to auscultation and percussion HEART: Regular rhythm.
C&S|conjunctivae and sclerae|C&S|191|193|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, and otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: Elderly, pale-appearing white female in no acute distress. VITAL SIGNS: Stable. Afebrile. HEENT: C&S clear. Conjunctivae pale. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|(C&S):|183|188|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed obese white male smelling of cigarette smoke. He is in no acute distress. VITAL SIGNS: Stable. Afebrile. HEENT: Conjunctivae and Sclerae (C&S): Clear with possible faint scleral icterus. Oropharynx: Benign. NECK: No masses or adenopathy, adenopathy. LUNGS: Clear to auscultation and percussion.
C&S|conjunctivae and sclerae|C&S|151|153|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Thin, elderly white female, alert, highly anxious, repetitively asking questions. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|180|182|PHYSICAL  EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: A thin, elderly white female, very hard of hearing. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|233|235|PHYSICAL EXAMINATION|Negative for hematologic, immunologic and endocrine problems. Negative for musculoskeletal and neuropsych. PHYSICAL EXAMINATION: GENERAL: Well-developed, elderly white male in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear, oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|200|202|PHYSICAL EXAMINATION|She is denying abdominal pain at this time, but she is an unreliable historian. Vital signs stable. The patient has been febrile, although the temperatures are not yet documented in the chart. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Rhonchi on left side. CARDIAC: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|183|185|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted. Otherwise noncontributory. PHYSICAL EXAMINATION: Well-developed, well-nourished- appearing white male in no acute distress. Vital signs stable. HEENT: C&S clear. Oropharynx - Cannot open mouth very wide due to prior surgery and radiation. No obvious oral lesions seen. No thrush noted. NECK: Without masses or adenopathy.
C&S|conjunctivae and sclerae|C&S|271|273|PHYSICAL EXAMINATION|ALLERGIES: None known to medications. Probably latex allergy. REVIEW OF SYSTEMS: GI as noted, otherwise negative per 10 system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white female, in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to AP. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|243|245|PHYSICAL EXAMINATION|HABITS: Nonsmoker, no alcohol. REVIEW OF SYSTEMS: GI as noted, otherwise negative per complete system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished-appearing white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. No icterus. Oropharynx clear. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|159|161|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted. Otherwise noncontributory. PHYSICAL EXAMINATION: A thin elderly white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. Healed surgical scars. LUNGS: Clear to A&P. CARDIAC: Regular with no murmurs, rubs, or gallops.
C&S|conjunctivae and sclerae|C&S|156|158|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing African-American female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|202|204|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, thin white male with full beard, appearing older than stated age, lying quietly in bed, curled up in fetal position. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx with ulcer along the right buccal mucosa. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation.
C&S|conjunctivae and sclerae|C&S|244|246|PHYSICAL  EXAMINATION|FAMILY HISTORY: History of alcoholism in the family. REVIEW OF SYSTEMS: GI as noted, otherwise negative per 10 system review. PHYSICAL EXAMINATION: GENERAL: Obese tearful white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. No icterus. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|137|139|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is an elderly white female, well nourished, in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|223|225|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished-appearing, white female, intermittently spitting up her saliva. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses, adenopathy or crepitus in the neck or chest area. LUNGS: Clear to auscultation and percussion. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|159|161|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: A well-developed, white male, postoperative, lying in bed with complaints of abdominal pain. VITAL SIGNS: Stables. Afebrile. HEENT EXAM: C&S clear. Oropharynx benign. NECK: No masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs, or gallops. ABDOMEN: Soft, scaphoid, tender. Incisions with some localized drainage on the dressing.
C&S|conjunctivae and sclerae|C&S|165|167|PHYSICAL EXAMINATION|Gastrointestinal as noted. PHYSICAL EXAMINATION: GENERAL: The patient is a demented, pleasant elderly white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx with poor dentition. NECK: Without masses. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|159|161|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: A well-developed, white male, postoperative, lying in bed with complaints of abdominal pain. VITAL SIGNS: Stables. Afebrile. HEENT EXAM: C&S clear. Oropharynx benign. NECK: No masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs, or gallops. ABDOMEN: Soft, scaphoid, tender. Incisions with some localized drainage on the dressing.
C&S|conjunctivae and sclerae|(C&S):|206|211|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: Well-developed, well-nourished appearing elderly white female appearing younger than her stated age in no acute distress. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: No masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|139|141|PHYSICAL EXAMINATION|Otherwise noncontributory. PHYSICAL EXAMINATION: Well-developed, thin, elderly white male in no acute distress. Vital signs stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|237|239|PHYSICAL EXAMINATION|Negative for genitourinary, hematologic, immunologic, endocrine, musculoskeletal, neuro, psych. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, obese, pleasant white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear superiorly but with rales half way up bilaterally from the bases.
C&S|conjunctivae and sclerae|C&S|236|238|PHYSICAL  EXAMINATION|FAMILY HISTORY: Negative for are GI related problems. REVIEW OF SYSTEMS: GI as noted, otherwise negative per ten system review. PHYSICAL EXAMINATION: GENERAL: Morbidly obese white female in no acute distress VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|144|146|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Thin, elderly white female with memory difficulties, in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Neck without masses or adenopathy. LUNGS: Clear to auscultation and percussion HEART: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|(C&S):|145|150|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing elderly white male in no acute distress. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. He does have removable partial dentures. NECK: No masses or adenopathy. LUNGS: Clear to auscultation and percussion.
C&S|conjunctivae and sclerae|C&S|187|189|PHYSICAL  EXAMINATION|Her husband lives in assisted living in the same facility. PHYSICAL EXAMINATION: GENERAL: Well-developed, pleasant, elderly white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Conjunctivae pale. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|(C&S):|177|182|PHYSICAL EXAMINATION|Negative for GU problems. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: Well-developed, elderly white female in no acute distress at rest. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|270|272|PHYSICAL  EXAMINATION|SOCIAL HISTORY: The patient lives with her husband. PHYSICAL EXAMINATION: GENERAL: Alert and awake white female lying in the emergency room, appearing weak and fatigued. VITAL SIGNS: Blood pressure 114/65, pulse 120, temperature 101.2. O2 saturation 86% on room. HEENT: C&S clear with PERRLA, oropharynx benign. Dry mucous membranes. NECK: Without masses or adenopathy. HEART: Regular rhythm with grade III/VI systolic murmur heard at the apex, radiating up to the neck bilaterally with diastolic murmur radiating into the axilla.
C&S|conjunctivae and sclerae|C&S|291|293|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: Well-developed elderly white male appearing younger than stated age in no acute distress. Short-term memory loss, but able to appropriately answer most questions. VITAL SIGNS: Stable. Afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|163|165|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: A well-developed, fairly sallow- appearing, white male in no acute distress. Comfortable at rest. VITAL SIGNS: Stable. Afebrile. HEENT EXAM: C&S clear. Oropharynx benign. NECK: Without masses. LUNGS: Clear to A&P. CARDIAC: Regular rhythm without murmurs or rubs. S2 gallop. ABDOMEN: Distended with fluid. Soft, nontender, without any organomegaly or masses.
C&S|conjunctivae and sclerae|C&S|175|177|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well developed elderly white female appearing appropriately depressed, in no acute distress, . VITAL SIGNS: Stable. Currently, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|212|214|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing, alert and awake, white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|190|192|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white male without any tremors. He is alert and oriented. In no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|194|196|PHYSICAL  EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise negative per 10 system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, overweight white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|254|256|PHYSICAL EXAMINATION|FAMILY HISTORY: Negative for GI related problems. REVIEW OF SYSTEMS: GI as noted, otherwise negative per 10 system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, overweight white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|159|161|PHYSICAL EXAMINATION|Positive for neuropsych. PHYSICAL EXAMINATION: Well-developed, obese Hispanic woman in no acute distress, seated in an easy chair. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|207|209|PHYSICAL  EXAMINATION|REVIEW OF SYSTEMS: GI as noted, and otherwise non-contributory per 10 system review. PHYSICAL EXAMINATION: GENERAL: Sallow-complected white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|141|143|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: A well-developed, well-nourished appearing white male in no acute distress. VITAL SIGNS: Stable. Afebrile. HEENT EXAM: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs, or gallops. ABDOMEN: Soft and scaphoid with mild tenderness without rebound or guarding in the right lower quadrant area in a small area.
C&S|conjunctivae and sclerae|C&S|193|195|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory per 10 system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, thin white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear with conjunctiva pallor. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion HEART: Irregular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|163|165|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing, almost cachectic appearing white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. No icterus. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|culture and sensitivity|C&S|197|199|LABORATORY DATA|ABDOMEN: This is mildly distended but soft and completely nontender. Liver does not appear enlarged. LABORATORY DATA: Hemoglobin 11, white count 11.2. Other labs are relatively unremarkable. Stool C&S O&P and C. diff have all been obtained and are all pending. IMPRESSION: This patient clearly has had a pancolitis. Biopsies are consistent with ulcerative colitis.
C&S|conjunctivae and sclerae|C&S|173|175|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing elderly white female, alert and oriented in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|(C&S):|198|203|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Stable. Afebrile. GENERAL: Well-developed, well-nourished, well-developed, mildly obese white female in no acute distress at rest. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|132|134|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Pale, elderly white female in no acute distress in intensive care unit. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|189|191|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: The patient is a thin, well-developed white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|413|415|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Negative for constitutional, negative for eye or ear problems, positive for lung problems, negative for cardiac, positive for GI, negative for GU, negative for hematologic, immunologic, positive for endocrine, negative for musculoskeletal, and negative for neuropsych. PHYSICAL EXAMINATION: Well-developed, morbidly obese white female in no acute distress. Vital signs stable. Afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs, or gallops.
C&S|conjunctivae and sclerae|C&S|176|178|PHYSICAL EXAMINATION|Negative for neuropsych. PHYSICAL EXAMINATION: Well-developed, well-nourished- appearing elderly and very vibrant white female in no acute distress. Vital signs stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|178|180|PHYSICAL EXAMINATION|Otherwise, negative for remaining review of systems. PHYSICAL EXAMINATION: GENERAL: A pale, obese white female lying in the ICU in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear with pale conjunctivae. Oropharynx is benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs or gallops. ABDOMEN: Obese, soft and nontender without any organomegaly or masses and normoactive bowel sounds.
C&S|conjunctivae and sclerae|C&S|133|135|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed elderly white female, very pleasant, in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Conjunctiva mildly pale. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|138|140|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Alert, thin, white male, appearing older than stated age in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. Status post craniotomy on the right. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|160|162|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, overweight white female currently in no acute distress, sitting up in bed. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. No icterus. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|224|226|PHYSICAL EXAMINATION|She is married. REVIEW OF SYSTEMS: GI as noted, otherwise negative per 10 system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. No icterus. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|(C&S):|169|174|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing African-American male in no acute distress. VITAL SIGNS: Stable. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx benign. NECK: No masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|241|243|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Unable to obtain. PHYSICAL EXAMINATION: The patient is a well-developed, well- nourished-appearing elderly white female in no acute distress. VITAL SIGNS: Stable. She is awake but uncooperative. She does not speak. HEENT: C&S clear, oropharynx benign. NECK: No mass or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|172|174|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white female appearing younger than stated age in no acute distress. Vital signs are stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|culture and sensitivity|C&S|155|157|PLAN|Repeat liver tests to be checked. 2. Ultrasound of the abdomen will be obtained. Depending on those results, an MRCP may be ordered. 3. Stool cultures for C&S and C. difficile toxin titer will be checked. Further plans will then follow.
C&S|conjunctivae and sclerae|(C&S):|223|228|PHYSICAL EXAMINATION|Otherwise noncontributory. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. Afebrile. GENERAL: Well-developed, well-nourished, well-developed appearing white male in no acute distress. Ruddy face. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops. Healed sternotomy.
C&S|conjunctivae and sclerae|C&S|264|266|PHYSICAL EXAMINATION|FAMILY/SOCIAL HISTORY: The patient lives with her husband. REVIEW OF SYSTEMS: Gastrointestinal as above, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, thin white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear, no icterus appreciated. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops, Medi-Port in place.
C&S|conjunctivae and sclerae|C&S|206|208|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory per 10 system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, obese, pleasant white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|145|147|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|225|227|PHYSICAL EXAMINATION|Positive for musculoskeletal and positive for neuropsych, with depression. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished-appearing white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|174|176|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is an elderly white male in no acute distress at this time. NG tube is clamped and in place. VITAL SIGNS: Stable, afebrile. HEENT; C&S clear, oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|138|140|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, elderly, very mentally sharp, white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|192|194|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as above. Otherwise the patient unable to provide information. PHYSICAL EXAMINATION: Well-developed, elderly white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs, or gallops.
C&S|conjunctivae and sclerae|C&S|143|145|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, pleasant white male with bilateral hearing aids. No acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|166|168|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Cachectic-appearing elderly white male with short-term memory difficulties in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion HEART: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|250|252|PHYSICAL EXAMINATION|Negative for GU. Positive for neuropsych with depression. Negative for musculoskeletal in the past, hematologic, immunologic, or endocrine. PHYSICAL EXAMINATION: Well-developed, overweight white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. No icterus. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs, or gallops. ABDOMEN: Distended, firm, tympanitic, no admissible tenderness, but patient appears uncomfortable in palpating the upper abdomen.
C&S|conjunctivae and sclerae|C&S|130|132|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Not able to obtain from patient. PHYSICAL EXAMINATION: Pale, thin female, intubated and sedated in ICU. HEENT: C&S clear. Oropharynx with ET tube in place. LUNGS: Clear bilaterally. CARDIAC: Irregular rhythm. ABDOMEN: Soft, scaphoid, no inducible tenderness. No masses.
C&S|conjunctivae and sclerae|C&S|158|160|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished elderly white male in no acute distress lying in the ICU. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear with conjunctiva pale. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|294|296|PHYSICAL EXAMINATION|He lives with his wife. They have four children. REVIEW OF SYSTEMS: GI as noted, otherwise negative per ten-point system review as it relates to this admission. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|151|153|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing, thin white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|205|207|PHYSICAL EXAMINATION|Otherwise noncontributory. HABITS: Nonsmoker. No alcohol. PHYSICAL EXAMINATION: Well-developed, thin, elderly white female depressed, and in no acute distress. NG tube in place. Vital signs stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs, or gallops. ABDOMEN: Soft, scaphoid, no specific areas of tenderness, no organomegaly or masses.
C&S|conjunctivae and sclerae|C&S|249|251|PHYSICAL EXAMINATION|HABITS: Nonsmoker, no alcohol. REVIEW OF SYSTEMS: GI as noted, otherwise negative 10-point review for this particular admission. PHYSICAL EXAMINATION: GENERAL: A thin, elderly white female currently in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|culture and sensitivity|C&S.|166|169|HISTORY OF PRESENT ILLNESS|He denies any fever or chills. The diarrhea has decreased in quantity, although he had four loose stools today, two during the night. Stool cultures are negative for C&S. He has not been on antibiotics. He had some foreign travel to Mexico a few months ago, not more recently. The patient denies any nausea or vomiting. Of note is that the patient did have several weeks of diarrhea in the _%#MM#%_ to _%#MM#%_ time frame.
C&S|conjunctivae and sclerae|C&S|161|163|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished-appearing overweight white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|135|137|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed elderly white female, hard of hearing, in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|223|225|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Gastrointestinal as noted, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished-appearing white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear, oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Irregular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|148|150|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, confused white female with clots of blood around her buttocks. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|(C&S):|236|241|PHYSICAL EXAMINATION|Positive for neuropsychiatric. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. Afebrile. GENERAL: Cachetic-appearing white male in no acute distress. He has dysarthria from his cerebrovascular accident (CVA). HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. Temporal wasting. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops. ABDOMEN: Evidence of weight loss.
C&S|conjunctivae and sclerae|C&S|239|241|PHYSICAL EXAMINATION|History of recent chills. All other review of systems otherwise noncontributory with regards to current illness. PHYSICAL EXAMINATION: Well-developed, well-nourished- appearing white female in no acute distress. Vital signs stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|210|212|PHYSICAL EXAMINATION|Negative for immunologic, endocrine, hematologic, musculoskeletal or neuropsych. PHYSICAL EXAMINATION: Well-developed, well-nourished appearing white female in no acute distress. Vital signs are stable. HEENT: C&S clear. Oropharynx is benign. NECK: Without masses or adenopathy. CHEST: Lungs are clear to auscultation and percussion. HEART: Regular rhythm with grade 2/6 systolic murmur, radiating to lower left sternal border and to the axilla.
C&S|conjunctivae and sclerae|C&S|204|206|PHYSICAL  EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise negative per 10 point system review. PHYSICAL EXAMINATION: GENERAL: Well developed, thin white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|204|206|PHYSICAL  EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise negative per 10 point system review. PHYSICAL EXAMINATION: GENERAL: Well developed, thin white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|132|134|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: A thin, pale appearing elderly white female in no acute distress in ICU. VITAL SIGNS: Stable. HEENT: C&S clear with pale conjunctivae. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm with grade 2/6 systolic murmur in the aortic area and grade 2/6 systolic murmur heard into the axilla.
C&S|conjunctivae and sclerae|C&S|187|189|PHYSICAL  EXAMINATION|FAMILY HISTORY: Negative for colon CA or polyps. PHYSICAL EXAMINATION: GENERAL: Well-developed Somali female with a somewhat flat affect in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|253|255|PHYSICAL EXAMINATION|Negative for immunologic, negative for endocrine, negative for neuropsych, positive for musculoskeletal as noted above. PHYSICAL EXAMINATION: GENERAL: The patient is an overweight, pleasant black female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|251|253|PHYSICAL EXAMINATION|FAMILY HISTORY: Otherwise negative. REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory per 10 system review. PHYSICAL EXAMINATION: GENERAL: A well-developed, well-nourished appearing white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to AP. CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|155|157|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Obese African-American male in no acute distress. Vital signs stable. Unable to give reliable history. VITAL SIGNS: afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|204|206|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Gastrointestinal as noted, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, obese white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear, oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|176|178|PHYSICAL EXAMINATION|Positive for musculoskeletal. PHYSICAL EXAMINATION: GENERAL; The patient is a well-developed, pleasant white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|194|196|PHYSICAL EXAMINATION|Negative for neuropsych. PHYSICAL EXAMINATION: GENERAL: The patient is a very pale, very short white female in no acute distress with obvious exophthalmos. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|central nervous system:CNS|C&S|203|205|SUMMARY|EEG will be obtained looking for any evidence of underlying seizure activity. If these measures are not revealing and he does not improve, then a spinal tap would be indicated to evaluate possibility of C&S infection. Thank you very much for allowing us to participate in the care and evaluation of this very interesting gentleman.
C&S|conjunctivae and sclerae|C&S|250|252|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Gastrointestinal as noted, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished-appearing, very animated white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|(C&S):|168|173|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, anxious and tearful white female in no acute distress. She is thin. VITAL SIGNS: Stable. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm. No murmurs, rubs or gallops. ABDOMEN: Soft and scaphoid, mildly tender in midepigastric area without rebound or guarding.
C&S|conjunctivae and sclerae|C&S|143|145|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, overweight white female in no acute distress in the CICU. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|228|230|PHYSICAL EXAMINATION|Positive for endocrine. Negative for immunologic. Negative for musculoskeletal. Positive for neuropsych. PHYSICAL EXAMINATION: GENERAL: Well-developed, elderly white male in no acute distress, obese. VITAL SIGNS: Stable. HEENT; C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|155|157|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, elderly, white female, appearing younger than stated age, in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|175|177|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Elderly, lethargic, but easily rousable white female in no acute distress. She is wearing O2 at 2 liters. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|151|153|PHYSICAL EXAMINATION|Positive for neuropsych. PHYSICAL EXAMINATION: Well-developed, well-nourished- appearing white female in no acute distress. Vital signs stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|167|169|PHYSICAL EXAMINATION|She wears glasses. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, overweight white female, pale and in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear, oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|226|228|PHYSICAL EXAMINATION|Otherwise unable to obtain. PHYSICAL EXAMINATION: Well-developed, overweight, elderly white female lying in bed in no acute distress on BiPAP machine. NG tube in place with clear material within it. Vital signs stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear. No wheezes or rhonchi. CARDIAC: Regular rhythm. No murmurs, rubs, or gallops.
C&S|conjunctivae and sclerae|C&S|215|217|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory per 10 system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|201|203|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, elderly white male appearing younger than stated age in no acute distress. VITAL SIGNS: Stable. Currently his temperature is in the high 99 range. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|248|250|PHYSICAL EXAMINATION|Genitourinary: Occasional urinary incontinence. Positive for musculoskeletal with recent healing left shoulder fracture. Negative for neuropsych. PHYSICAL EXAMINATION: GENERAL; Depressed, tearful white female. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|146|148|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, pregnant white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|175|177|PHYSICAL EXAMINATION|Negative for neuropsych. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished-appearing white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|172|174|PHYSICAL EXAMINATION|Positive for GI as noted. Negative for GU. PHYSICAL EXAMINATION: Well-developed, well-nourished appearing white female in no acute distress. Vital signs are stable. HEENT: C&S clear. Oropharynx is benign. NECK: Without masses or adenopathy. CHEST: Lungs are clear to auscultation and percussion. HEART: Regular rhythm, no murmurs, rubs or gallops. ABDOMEN: Soft but tender in the periumbilical area as well as right lower quadrant area without rebound or guarding, no organomegaly or masses.
C&S|conjunctivae and sclerae|C&S|212|214|PHYSICAL EXAMINATION|We lack any other details. REVIEW OF SYSTEMS: Unable to obtain from patient. PHYSICAL EXAMINATION: Obese white male, intubated and unresponsive. Blood pressure 130/50, pulse 51, temperature 35.4 rectally. HEENT: C&S clear. Oropharynx is benign. NECK: Without masses or adenopathy. CHEST: Lungs are clear to auscultation and percussion. HEART: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|140|142|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Pale appearing elderly white female in no acute distress, vital signs stable. T-max axillary 100.2 last night. HEENT: C&S clear with conjunctiva pale. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|378|380|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Negative for constitutional, negative for eye or ear, negative for pulmonary, cardiac, positive for gastrointestinal, negative for hematologic, immunologic, endocrine, positive for musculoskeletal, negative for neuropsych. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, overweight white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|180|182|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Thin white male lying in Intensive Care Unit intubated and sedated. VITALS: Blood pressure systolic is in the 90s range. Pulse is in the 80s. HEENT: C&S clear. Oropharynx unremarkable. NECK: Without masses or adenopathy. LUNGS: Bilateral rhonchi. HEART: Regular rhythm, no murmurs, rubs, gallops. ABDOMEN: Soft, no tenderness elicited, no masses, no organomegaly. Bowel sounds are normally active.
C&S|conjunctivae and sclerae|(C&S):|187|192|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Vital signs are stable. GENERAL: Well-developed, well-nourished appearing overweight white female in no acute distress. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|156|158|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is an elderly white male in the Intensive Care Unit with protuberant abdomen, on O2. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|171|173|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, very elderly, cachectic-appearing and pale white female in no acute distress. VITAL SIGNS: Stable. HEENT: Alopecia totalis. C&S clear with pale conjunctivae. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm with soft systolic murmur in midsternal area.
C&S|conjunctivae and sclerae|C&S|153|155|PHYSICAL EXAMINATION|Positive for endocrine. PHYSICAL EXAMINATION: Well-developed, well-nourished appearing white female in no acute distress. Vital signs are stable. HEENT: C&S clear. Pharynx benign. NECK: Without masses or adenopathy. CHEST: Lungs are clear to auscultation and percussion. HEART: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|178|180|PHYSICAL EXAMINATION|FAMILY HISTORY: Otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing African male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|154|156|PHYSICAL EXAMINATION|Otherwise noncontributory. PHYSICAL EXAMINATION: Well-developed, well-nourished appearing white male in no acute distress. Vital signs are stable. HEENT: C&S clear. Oropharynx is benign. NECK: No adenopathy CHEST: Lungs are clear to auscultation and percussion. HEART: Regular rhythm, no murmurs, rubs or gallops ABDOMEN: Soft, scaphoid, nontender.
C&S|conjunctivae and sclerae|C&S|246|248|PHYSICAL EXAMINATION|FAMILY HISTORY: Negative for GI related problems. REVIEW OF SYSTEMS: GASTROINTESTINAL: As noted, otherwise negative per 10 system review. PHYSICAL EXAMINATION: GENERAL: Thin, elderly white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Conjunctivae pale. Oropharynx benign with poor dentition. NECK: Without masses. LUNGS: Clear to auscultation and percussion HEART: Regular rhythm with grade 2/6 systolic murmur radiating into the axilla and up into the bases.
C&S|conjunctivae and sclerae|C&S|191|193|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well developed, thin, pale-appearing, elderly white female in no acute distress. She is wearing nasal prong O2. VITAL SIGNS: Stable. Currently afebrile. HEENT: C&S clear with pale conjunctivae. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|204|206|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Gastrointestinal as noted otherwise noncontributory PHYSICAL EXAMINATION: Well developed elderly white male in no acute distress. Vital signs stable. HEAD, EYES, EARS, NOSE AND THROAT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops ABDOMEN: Soft and scaphoid, non-tender without any organomegaly or masses, normal active bowel sounds LABS: Basic metabolic panel unremarkable.
C&S|conjunctivae and sclerae|C&S|146|148|PHYSICAL EXAMINATION|Otherwise negative. PHYSICAL EXAMINATION: Well-developed, well-nourished- appearing white female in no acute distress. Vital signs stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Occasional crackle, otherwise clear. CARDIAC: Prosthetic metallic valve sound without murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|(C&S):|165|170|PHYSICAL EXAMINATION|Otherwise noncontributory. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: Elderly white female wearing O2 in no acute distress. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: No masses or adenopathy. LUNGS: Clear bilaterally. HEART: Regular rhythm. No murmurs, rubs or gallops. ABDOMEN: Soft, protuberant abdomen, not distended with any fluid or masses.
C&S|conjunctivae and sclerae|C&S|147|149|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, obese white female wearing nasal prong O2. She is in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without any masses or adenopathy. LUNGS: Decreased breath sounds at bases, no rales heard. CARDIAC: Regular rhythm, no murmurs, rubs or gallops. ABDOMEN: Obese, soft, nontender without any organomegaly or masses.
C&S|conjunctivae and sclerae|C&S|129|131|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Well-developed, well-nourished appearing white female in no acute distress. Vital signs are stable. HEENT: C&S clear on right side, artificial eye on left. Oropharynx is benign. NECK: Without masses or adenopathy. CHEST: Lungs are clear to auscultation and percussion.
C&S|conjunctivae and sclerae|C&S|131|133|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: An elderly, well-developed, thin white male with basin, spitting up saliva. VITAL SIGNS: Stable. HEENT EXAM: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs, or gallops.
C&S|conjunctivae and sclerae|C&S|200|202|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise negative per 10 system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|(C&S):|173|178|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Vital signs are stable. GENERAL: Well-developed, pale and thin elderly white female in no acute distress. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: No masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|210|212|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed elderly white female with halting speech, which I suspect is related to her prior stroke. She is thin, and no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Pharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm. No murmurs, rubs, gallops appreciated.
C&S|conjunctivae and sclerae|C&S|254|256|PHYSICAL EXAMINATION|FAMILY HISTORY: Negative for GI problems. REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory per ten systems reviewed. PHYSICAL EXAMINATION: GENERAL: Well-developed, elderly, pleasant white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|273|275|PHYSICAL EXAMINATION|HABITS: Quit smoking seven years ago, negative for alcohol. REVIEW OF SYSTEMS: GI as noted, otherwise negative for remaining contributory review of systems. PHYSICAL EXAMINATION: Pale, elderly, obese white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Lesion right cheek. NECK: Without masses. LUNGS: Decreased breath sounds bilaterally but clear. CARDIAC: Regular rhythm, no murmurs, rubs, gallops. ABDOMEN: Soft, obese, mild tenderness diffusely without rebound or guarding, no organomegaly or masses noted.
C&S|conjunctivae and sclerae|C&S|165|167|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing overweight pleasant white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|146|148|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: A thin, elderly white female with a bandage across the forehead, in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|(C&S):|235|240|PHYSICAL EXAMINATION|Otherwise negative per ten-system review. PHYSICAL EXAMINATION: GENERAL: Well-developed thin white female in some acute distress because of abdominal pain. VITAL SIGNS: Vital signs are stable. Afebrile. HEENT: Conjunctivae and Sclerae (C&S): Clear. No icterus. Oropharynx: Benign. NECK: No masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Cardiac Exam: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|187|189|PHYSICAL EXAMINATION|Positive for neuropsych. PHYSICAL EXAMINATION: GENERAL; The patient is a well-developed, well-nourished-appearing white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|157|159|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, obese, plethoric-appearing white male in no acute distress, wearing O2. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|160|162|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Well-developed, elderly white female with distended abdomen and no acute distress. NG tube in place. Vital signs stable. Afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear anteriorly. CARDIAC: Regular rhythm. No murmurs, rubs, or gallops. ABDOMEN: Very distended, tympanitic with high-pitched bowel sounds.
C&S|conjunctivae and sclerae|C&S|196|198|PHYSICAL EXAMINATION|He does not need to take medication for this. PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished-appearing white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|179|181|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, overweight white female in no acute distress, appearing comfortable at rest. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC; Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|141|143|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a thin, elderly white male, alert and awake, in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear, oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|139|141|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, delightful elderly white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|(C&S):|186|191|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: Well-developed, overweight, alert white male in no acute distress. Nasogastric (NG) tube is in place. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops. ABDOMEN: Tenderness everywhere in the abdomen which he states is chronic.
C&S|conjunctivae and sclerae|C&S|207|209|PHYSICAL EXAMINATION|Negative for endocrine, hematologic, immunologic, neuro and psych. PHYSICAL EXAMINATION: GENERAL; The patient is an obese white female, uncomfortable because of abdominal pain. VITAL SIGNS: Afebrile. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|238|240|PHYSICAL EXAMINATION|Cardiac as noted with chest pain. GI as noted. Negative for GU, endocrine, dermatologic, neuromuscular and psych. PHYSICAL EXAMINATION: Elderly white female lying in bed comfortably without any acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular rhythm. No murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|176|178|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, elderly white female, appearing younger than stated age. She is in no acute distress. Very pleasant. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion HEART: Regular rhythm, with grade 3/6 systolic murmur consistent with mitral regurgitation heard in the left axillary area.
C&S|conjunctivae and sclerae|C&S|215|217|PHYSICAL  EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise negative per ten point system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished-appearing white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|(C&S):|154|159|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, pleasant, elderly white female in no acute distress. Rambling historian. . HEENT: Conjunctivae and Sclerae (C&S): Clear. No icterus. Oropharynx: Benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion. HEART: Regular rhythm. No murmurs, rubs or gallops. ABDOMEN: Soft and scaphoid .
C&S|conjunctivae and sclerae|C&S|159|161|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is well-developed, well-nourished-appearing pleasant white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. No icterus. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops. ABDOMEN; Soft, scaphoid, nontender without any organomegaly or masses, normoactive bowel sounds, healed surgical incisions.
C&S|conjunctivae and sclerae|C&S|200|202|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing elderly white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|232|234|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white female wearing a wig, appearing younger than stated age. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|281|283|PHYSICAL EXAMINATION|SOCIAL HISTORY: The patient is retired. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory per 10 system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, overweight, elderly white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Conjunctiva mildly pale. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|178|180|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, overweight, elderly and chronically ill-appearing white female wearing knitted cap overhead. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: No masses or adenopathy. LUNGS: Clear to auscultation and percussion. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|152|154|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, uncomfortable-appearing white male lying in the ICU on a PCA pump. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|167|169|PHYSICAL EXAMINATION|She is widowed and lives by herself. PHYSICAL EXAMINATION: GENERAL: The patient is an elderly white female in no acute distress. VITAL SIGNS; Stable, afebrile. HEENT: C&S clear, oropharynx benign. NECK; Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|148|150|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, obese white female in very good spirits, in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|culture and sensitivity|C&S|188|190|LABORATORIES|No organomegaly or masses. Normoactive bowel sounds. Extremities unremarkable. Neurologic exam grossly intact. LABORATORIES: Normal white count and hemoglobin. Normal liver profile. Stool C&S pending. CT scan demonstrating thickened right- sided colon from cecum to hepatic flexure with some fat stranding and a few diverticula seen in the area.
C&S|conjunctivae and sclerae|C&S|223|225|PHYSICAL  EXAMINATION|Works at the VA Hospital. REVIEW OF SYSTEMS: GI as noted, otherwise negative/noncontributory. PHYSICAL EXAMINATION: GENERAL: Well-developed, overweight, pleasant white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm. No murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|222|224|PHYSICAL EXAMINATION|HABITS: Quit smoking years ago. Minimal alcohol. REVIEW OF SYSTEMS: GI as noted, otherwise negative per 10 system review. PHYSICAL EXAMINATION: Thin, pleasant white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|368|370|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted. Otherwise negative for constitution, negative for eyes except wearing contacts, negative for ear problems, negative for pulmonary, cardiac, hematologic, immunologic, endocrine, musculoskeletal, and neuropsych. Negative for GU. PHYSICAL EXAMINATION: Well-developed, overweight white male in no acute distress. Vital signs stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIAC: Regular with no murmurs, rubs, or gallops.
C&S|conjunctivae and sclerae|(C&S):|232|237|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: As noted; otherwise noncontributory. PHYSICAL EXAMINATION: VITAL SIGNS: Vital signs are stable. GENERAL: Well-developed, well-nourished appearing white female in no acute distress. HEENT: Conjunctivae and Sclerae (C&S): Clear. Oropharynx: Benign. NECK: No masses or adenopathy. LUNGS: Inspiratory wheezes heard diffusely without any rhonchi. HEART: Regular rhythm.
C&S|conjunctivae and sclerae|C&S|205|207|PHYSICAL EXAMINATION|Otherwise, noncontributory. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white male with some lower chest discomfort related to food bolus. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. No crepitus in chest or neck area. LUNGS: Clear to auscultation and percussion.
C&S|conjunctivae and sclerae|C&S|246|248|PHYSICAL EXAMINATION|FAMILY HISTORY: Negative for GI problems. REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory per 10 system review. PHYSICAL EXAMINATION: GENERAL: Well-developed elderly pleasant white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|194|196|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Unable to obtain from the patient this time. PHYSICAL EXAMINATION: Chronically ill-appearing white male on respirator with tracheostomy. VITAL SIGNS: Stable. Afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses. LUNGS: Clear anteriorly. CARDIAC: Regular rhythm. No murmurs, rubs, or gallops. ABDOMEN: Soft, mildly distended, and tympanitic. Nontender. No organomegaly or masses.
C&S|conjunctivae and sclerae|C&S|209|211|PHYSICAL EXAMINATION|Otherwise negative per remaining review of systems. PHYSICAL EXAMINATION: GENERAL: A well-developed, well-nourished appearing white female with dry heaves, uncomfortable. VITAL SIGNS: Stable. Afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to A&P. CARDIOVASCULAR: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|171|173|PHYSICAL EXAMINATION|Gastrointestinal as above. PHYSICAL EXAMINATION: GENERAL: The patient is an elderly white female in no acute distress, lying in bed. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|162|164|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished-appearing white female in no acute distress. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. Neck without masses or adenopathy. LUNGS: Clear to percussion and auscultation. CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|228|230|PHYSICAL EXAMINATION|SOCIAL HISTORY: The patient is retired. REVIEW OF SYSTEMS: GI as noted, otherwise negative per 10 system review. PHYSICAL EXAMINATION: GENERAL: Well-developed elderly white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|263|265|PHYSICAL  EXAMINATION|SOCIAL HISTORY: Retired, otherwise noncontributory. REVIEW OF SYSTEMS: GI as noted, otherwise negative per ten-point system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, overweight, pleasant white female in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|209|211|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, thin elderly white female, appearing to be lethargic but arouseable, not answering questions with minimal numbers of words. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion HEART: Irregular rhythm, no murmurs, rubs or gallops, well-healing sternotomy.
C&S|conjunctivae and sclerae|C&S|219|221|PHYSICAL  EXAMINATION|He has grown children. REVIEW OF SYSTEMS: GI as noted, and otherwise negative per 10 system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, overweight white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|134|136|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed elderly white female in no acute distress. VITAL SIGNS: Stable. She is afebrile. HEENT: C&S clear. No scleral icterus. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs or gallops.
C&S|conjunctivae and sclerae|C&S|146|148|PHYSICAL EXAMINATION|Vital signs are stable with BP systolic at approximately 118 range, mildly tachycardic in the 110 range. Temperature 100.6 degrees orally. HEENT: C&S clear with scleral icterus. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion HEART: Regular rhythm, tachycardic with no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|202|204|PHYSICAL EXAMINATION|FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Noncontributory. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|culture and sensitivity|C&S|177|179|LABORATORY  DATA|White count of 23,400, hemoglobin 8.7 and platelet count 474,000. Blood sugar is 85. Chest x-ray with stable moderate CF changes, with right upper lobe nodular opacities. Urine C&S is so far negative. Recent arterial blood gases with pH 7.47, pCO2 46, pO2 78, bicarbonate 33 on 3 liters of O2 with a 95% saturation.
C&S|conjunctivae and sclerae|C&S|184|186|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished-appearing, elderly white female, appearing younger than her stated age, in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm. No murmurs, rubs or gallops.
C&S|protein C and protein S|C&S|228|230|HOSPITAL COURSE|Due to the patient's underlying Goodpasture's syndrome/vasculitis, Dr. _%#NAME#%_ thought to be appropriate to initiate a hypercoagulable workup. Labs including antithrombin III, prothrombin G, mutation factor V Leiden, protein C&S and a antiphospholipid antibody syndrome. Labs were sent and pending at the time of discharge. The patient will follow up with Dr. _%#NAME#%_ _%#NAME#%_, her primary care physician for further evaluation.
C&S|conjunctivae and sclerae|(C&S))|158|163|ASSESSMENT AND PLAN|Urinary tract infection. a. We will continue the Bactrim that was started in the emergency room, confirm cultures and sensitivities (Conjunctivae and sclerae (C&S)) and adjust the antibiotic therapy if indicated. 4. Chronic valvular cardiomyopathy/heart failure. The patient appears to be intravascularly depleted.
C&S|protein C and protein S|C&S|140|142|RENAL SYSTEM|Anticardiolipin, IgG and IgM were negative. Antithrombin-3 was normal at 83. The ANA was negative. Antiphospholipid antibiotics and protein C&S were also checked; however, I do not have those results available to me at this time. These results will definitely need to be reviewed before the patient would ever attempt pregnancy in the future.
C&S|culture and sensitivity|(C&S)|210|214|HOSPITAL COURSE|On _%#MMDD2003#%_ an ultrasound-guided thoracentesis was done on the right side because of ongoing fluid problems. He was started on Tequin 400 mg daily. Pleural fluid was checked for culture and sensitivities (C&S) and Gram's stain. He was changed from oral Tequin to IV Tequin. Blood cultures were obtained on _%#MMDD2003#%_ given the fact that he had a Foley catheter.
C&S|culture and sensitivity|C&S|133|135|LABORATORY  DATA|CBC normal. Dilantin level is subtherapeutic at less than 3. Liver function test normal. Albumin 4.2. Calcium level is normal. Urine C&S is negative. Chest x-ray with cardiomegaly and hilar adenopathy, no focal lesions. CT of the head with encephalomalacia present in areas of previous metastases, post radiation.
C&S|culture and sensitivity|C&S|127|129|LABORATORY DATA|Lipase normal at 95. Blood cultures negative. Urinalysis unremarkable. Stool for C. diff toxin was negative. Stool for O&P and C&S both negative. Hemoglobin 10.5, platelets 212,000, white count 8.7. Her white count was 9.7 on admission and hemoglobin 12.3 at that time.
C&S|culture and sensitivity|C&S,|160|163|LABORATORY DATA|Calcium is 8.6. Liver function tests are normal except for an albumin of 3.2. Lipase is 21. At the doctor's office, Southdale Pediatrics, he has had stools for C&S, Clostridium difficile, and ova and parasites. The urinalysis is negative. IMPRESSION: This patient presents with an acute to subacute colitis with significant blood loss, rule out inflammatory bowel disease, especially ulcerative colitis.
C&S|protein C and protein S|C&S.|221|224|PAST  MEDICAL HISTORY|a. Hypercoagulable workup at that time was negative. This included normal antithrombin III, negative factor V Leiden, negative prothrombin mutation negative lupus inhibitor. Normal homocystine. Normal ANA. Normal protein C&S. studies. b. MRI/MRA of the brain showed proximal stenosis of the vertebral arteries bilaterally as well as distally at both vertebral arteries and the basilar artery secondary to her atherosclerosis versus fibromuscular dysplasia or vasculitis unchanged compared with _%#MMDD1999#%_ and acute infarct in the left lateral and posterior temporal lobe, left lateral occipital lobe, probably in the distribution of the left posterior cerebral artery and posterior temporal branch.
C&S|protein C and protein S|C&S|230|232|BRIEF HISTORY AND HOSPITAL COURSE|Interestingly, her baseline APTT is normal. She was started on 75 mg of Lovenox subq q.12h and was started on Coumadin per protocol. A homocysteine level, anticardiolipin, Factor V Leiden and lupus inhibitor was obtained. Protein C&S was not able because she was already given a dose of Lovenox. She remained otherwise hemodynamically stable and on the day prior to discharge was ambulatory in the hallways with little dyspnea or chest pain.
C&S|protein C and protein S|C&S,|146|149|ALLERGIES|A hypercoagulable panel was drawn to evaluate for any hypercoagulable disease state. These included factor V Leiden, activated protein C, protein C&S, homocysteine, antithrombin III, G20210A mutation, lupus inhibitor, and anticardiolipin antibody. These are unlikely to reveal any positive findings, but should be followed up as an outpatient.
C&S|protein C and protein S|C&S|134|136|ASSESSMENT AND RECOMMENDATIONS|I would check a factor V Leiden, a factor 2 mutation, and lupus anticoagulant when she is off anticoagulation. A factor C and protein C&S can be checked. I would recommend Lovenox 1 mg/kg b.i.d. for 6 weeks. The duration of anticoagulation can be prolonged. If any of the above factors are positive or she can be on a prophylactic dose of Lovenox after the six weeks if the above factors are positive.
C&S|culture and sensitivity|C&S|191|193|LABORATORY DATA|WBC count is 8.6, hemoglobin 10.6 with normochromic, normocytic indices, normal platelet count and blood sugar is 107, INR 1.28. Liver function tests normal except for reduced albumin. Urine C&S with mixed colonies, low count and sputum so far negative to date. There are no organisms on sputum Gram stain and few polys are present.
C&S|conjunctivae and sclerae|C&S|206|208|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: GI as noted, otherwise negative per 10 system review. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white male in no acute distress. VITAL SIGNS: Stable. HEENT: C&S clear. No icterus. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C&S|conjunctivae and sclerae|C&S|161|163|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white male in no acute distress, lying in the ICU. VITAL SIGNS: Stable, afebrile. HEENT: C&S clear. Mild conjunctiva pallor. Oropharynx benign. NECK: Without masses or adenopathy. LUNGS: Clear to auscultation and percussion CARDIAC: Regular rhythm, no murmurs, rubs, gallops.
C3|cervical (level) 3|C3|71|72|HISTORY OF PRESENT ILLNESS|He also underwent at the same time decompression and lysis of scars at C3 through C7, a decompression of the spinal cord injury and nerve roots with posterior fixation with lateral mass screws from C2-C7.
C3|(complement) component 3|C3|137|138|HOSPITAL COURSE|Dr. _%#NAME#%_ requested further lab testing including serum protein electrophoresis and CRP which ultimately were normal. As noted, the C3 was 73 (below a lower threshold of 90), C4 was 11 which is below the lower threshold of 15 and the CH50 is 52 which is less than the lower threshold of normal at 60.
C3|cervical (level) 3|C3|138|139||On the day of admission, she underwent an uncomplicated canal expanding cervical laminoplasty from C3 through C7. A posterior fusion from C3 through C5 was carried out as well. Marked degenerative changes and obvious shingling were found at the C3-4 and C4-5 levels.
C3|(complement) component 3|C3|185|186|HOSPITAL COURSE|Sed rate was slightly elevated at 67. Iron studies were obtained. An ASO titer was 39. His DNA double-stranded was negative. Basement membrane antibody was negative. ANCA was negative. C3 was slightly low at 79 and C4 was normal. Cryoglobulins were sent, but the test was canceled, this will need to be resent again as an outpatient.
C3|(complement) component 3|C3|172|173|HOSPITAL COURSE|Urinalysis continued to show many red blood cells and many white blood cells. For the sterile pyuria, she received chlamydia and gonorrhea PCR both of which were negative. C3 level was decreased, C4 level was normal. RF was negative. ASO and DNase-B levels results were pending at the time of discharge.
C3|(complement) component 3|C3,|193|195|HOSPITAL COURSE|Within 2 days of starting the ganciclovir, her temperatures were gone, and her nausea and vomiting improved. It was not felt that her lupus was active this hospitalization, secondary to normal C3, C4 levels, and a normal double-stranded DNA level. Thus, it was also not felt necessary to proceed with further doses of Cytoxan, as had been placed for her as an outpatient.
C3|cervical (level) 3|C3|157|158|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Cervical stenosis. DISCHARGE DIAGNOSIS: Cervical stenosis OPERATIONS/PROCEDURES PERFORMED: 1. C3 to C6 and partial C7 laminectomies. 2. C3 to C6 lateral mass fixation and fusion. HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old right- handed man who presented to clinic complaining of low back as well as neck pain and diffuse weakness in his upper extremities.
C3|cervical (level) 3|C3|174|175|HISTORY OF PRESENT ILLNESS|A brain and spine MRI was done within a few hours after her presentation and was consistent with extensive increased T2 signal within the cervical spinal cord extending from C3 to T1 levels. Her brain MRI was normal. HOSPITAL COURSE: _%#NAME#%_ was initially admitted to the Intensive Care Unit for close monitoring.
C3|(complement) component 3|C3|144|145|IMAGING STUDIES|Lupus inhibitor battery is negative. IGG was normal. SSB LA antibody, IGG normal. DNA double stranded negative at 4 international units per ml, C3 and C4 levels 136 and 15 respectively and both normal. TNA single stranded antibody IGG was 51, elevated. Immunofixation IGG, IGM, IGA shows no monoclonal proteins.
C3|(complement) component 3|C3|166|167|PLAN|The RA factor was less than 20. Hepatitis C antibody was negative. Hepatitis B surface antigen was in the normal range. The ANA was less than 1, also normal, and the C3 and C4 were also in the normal range. The neutrophil cytoplasmic antibody was less than 120 and CH50 complement was 146 with reference range 60-144, with that done on _%#MMDD#%_.
C3|(complement) component 3|C3|201|202|HISTORY OF PRESENT ILLNESS|Her urine has been dark brown to grossly bloody. She has also had increasing fatigue. She has had extensive workup in the past including IVP, pelvic CT, urine protein and creatinine, ANCA, complements C3 and C4, basic metabolic panel, ANA, complete blood count, and anti-DNase B. All of these labs or imaging studies were negative. A 24-hour urine included a total urine protein of 0.46. Urinalysis showed large blood, specific gravity of 1.014, red blood cells of 839, negative white blood cells with many bacteria.
C3|cervical (level) 3|C3|267|268|HOSPITAL COURSE|EXTREMITIES: Without edema. SKIN: No rash. HOSPITAL COURSE: The patient is a 55-year-old white male with past medical history significant for cervical stenosis, admitted electively to University of Minnesota Medical Center, University Campus neurosurgery service for C3 to C8 laminectomy with segmental arthrodesis. He tolerated the procedure well with no postoperative complications. He was then transferred to the acute rehabilitation center on _%#MMDD2005#%_.
C3|(complement) component 3|C3|245|246|HOSPITAL COURSE|As the patient's chest pain and shortness of breath were believed not to be cardiac in origin, the patient underwent further work up for possible lupus flare-up. Sedimentation rate was normal at 14. Antinuclear antibody was negative. Compliment C3 was normal at 160, compliment C4 was normal at 27. CRP was normal at 0.57. The patient was seen by Rheumatology who believed that the patient's lupus was in remission and recommended adjustment of thyroid medication.
C3|cervical (level) 3|C3|224|225|DIAGNOSIS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 56-year-old male who has been followed by Dr. _%#NAME#%_ in his clinic for worsening spinal canal stenosis from C2-C7. The patient has had prior anterior cervical fusions from C3 through C6. Of concern was some signal change in the spinal cord, especially on the right side, that also corresponded to some right-sided deficits in his hand.
C3|(complement) component 3|C3|148|149|RELEVANT LABORATORY DATA ON ADMISSION|Chemistries on admission revealed a sodium of 144, potassium 6, BUN 105, and creatinine 10.6. Her chloride was 116 and bicarbonate was 14. Her last C3 level was 48 and C4 level was 6. She was negative for lupus anticoagulant. Her LFTs were unremarkable. ASSESSMENT/PLAN: The patient is a 21-year-old female with a history of lupus nephritis.
C3|cervical (level) 3|C3|246|247|HISTORY OF PRESENT ILLNESS|The patient was evaluated in the neurosurgery clinic by Dr. _%#NAME#%_ _%#NAME#%_, and after a long discussion regarding the different options, a decision was made to proceed with a decompressive laminectomy and fusion of the cervical spine from C3 to C7. HOSPITAL COURSE: Ms. _%#NAME#%_ was admitted to the University of Minnesota Medical Center on _%#MM#%_ _%#DD#%_, 2005.
C3|cervical (level) 3|C3|207|208|IMPRESSION|Patient's neurosurgeon, Dr. _%#NAME#%_, requested this consult. IMPRESSION: 1. This is a 75-year-old woman here after a complex cervical spine surgical procedure on the _%#DD#%_ of _%#MM#%_ which included a C3 to 6 laminectomy with bilateral foraminotomies and fusion. 2. Patient has a history of cervical stenosis and spondylolysis with myoneuropathy.
C3|(complement) component 3|C3|179|180|FOLLOW UP|She may call her transplant coordinator with any questions or concerns that she has about her monthly IV IgG dose as well as the next appointment. She also should be followed for C3 levels at least once a month if not every other week to monitor recurrence of her disease. The patient has no activity restrictions and can be on a regular diet.
C3|cervical (level) 3|C3,|376|378|PAST MEDICAL HISTORY|ASSESSMENT/CHIEF COMPLAINT: _%#NAME#%_ _%#NAME#%_ is a 64-year- old white male who apparently was found to have a colovesical fistula and presents today for a preoperative assessment for surgical repair of this under general anesthesia guidance by Dr. _%#NAME#%_. PAST MEDICAL HISTORY: Notable for: 1. Carcinoma of the prostate. 2. Diverticulitis. 3. Peptic ulcer disease. 4. C3, C4 cervical radiculopathy. 5. Mild left shoulder impingement, status post medical treatment. PAST SURGICAL HISTORY: 1. Cholecystectomy in 1988. 2. Carpal tunnel repair in 1986.
C3|(complement) component 3|C3|221|222|HISTORY OF PRESENT ILLNESS|UA completed _%#NAME#%_ _%#DD#%_, 2002, demonstrated large blood, 100 protein, trace leukocytes, and 3+ SSA. Also demonstrated positive casts with 3 to 5 white blood cells. CRP completed _%#MM#%_ _%#DD#%_, 2002, was 1.5. C3 equals 131. C4 equals 15.5. C-ANCA and T-ANCA completed on _%#MM#%_ _%#DD#%_, 2002, were negative. HOSPITAL COURSE: The patient was admitted and did well overnight.
C3|cervical (level) 3|C3,|197|199|HISTORY OF PRESENT ILLNESS|12. History of diverticulitis status post sigmoid resection in 1997. 13. History of headache secondary to cervicalgia status post radiofrequency neural ablation of cervical medial branch nerves of C3, C4. 14. History of Clostridium difficile. 15. Status post T&A. 16. Status post total abdominal hysterectomy in 1980. 17. Status post D&C.
C3|cervical (level) 3|C3|241|242|TESTS|Small osteophytes noted as well. 2. MRI of the brain with and without contrast showed chronic white matter disease, small old cerebellar infarction, nothing acute. 3. CT of the cervical spine showed multilevel degenerative disk disease from C3 through C7 level with small central disk protrusion C3-C4. Degenerative changes at the atlanto-axial joint and some mild degenerative changes at the posterior facet joints.
C3|cervical (level) 3|C3|280|281|HOSPITAL COURSE|HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was admitted to the hospital on _%#MM#%_ _%#DD#%_, 2006, for operative treatment of a congenital acquired cervical stenosis picture. On the day of admission, he underwent an uncomplicated extensive canal-expanding cervical laminoplasty from C3 through C7. A cervical nonunion was repaired at C5-C6. He underwent foraminotomies for nerve root compression syndrome. The procedure was uncomplicated. The blood loss was 400 cc.
C3|(complement) component 3|C3|161|162|HOSPITAL COURSE|It was felt that an LP as well as a muscle biopsy was not indicated at this time. The labs that were back at the time of discharge were the complement levels of C3 and C4, and these were found to be in the normal ranges. His C-reactive protein on _%#MMDD2006#%_ was 71.6 and it had come down from _%#MMDD#%_ when it was 80.7. Antibody levels were also found to be normal.
C3|(complement) component 3|C3|151|152|HOSPITAL COURSE|The renal biopsy did show a 4.7 x 0.6 x 1.8 cm extracapsular collection on her left kidney consistent with an extracapsular hematoma. She had a repeat C3 level which was 84 and a repeat C4 which was 16. She had a negative ANA. The results of an anti-double-stranded DNA sustained were pending at discharge.
C3|cervical (level) 3|C3|251|252|HISTORY OF PRESENT ILLNESS|ADMISSION AND DISCHARGE DIAGNOSIS: C3 lytic bony tumor. OPERATION AND PERFORMED DURING THIS HOSPITAL ADMISSION: Removal of C3 tumor with fusion and corpectomy. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 34-year-old woman who was diagnosed with a C3 bony lytic lesion originally presenting to the emergency room with ongoing worsening pain, tremor and discomfort. She underwent an embolization of the arteries to the tumor on _%#MMDD2006#%_.
C3|(complement) component 3|C3|267|268|PROBLEM #6|This is consistent with chronic disease. PROBLEM #6: Rheumatology/Lupus. Prior to admission on _%#MM#%_ _%#DD#%_ patient had an ANA which was 8.6, a double-stranded DNA was 233, complement C4 was 13, and complement C3 was 86. On _%#MMDD#%_ an ANA was 7.1, complement C3 82, and complement C4 was 13. Cardiolipin antibody IgG was 6.2 and IgM was 7.8. PROBLEM #7: Endocrine. Patient's PTH was slightly elevated at 234. Again, the concern is probably partial noncompliance with his medications causing it.
C3|cervical (level) 3|C3|130|131|OPERATIONS PERFORMED|PRIMARY DIAGNOSIS: Spondylosis at C3-C4 level, C4 left radiculopathy and left C4 neural foraminal stenosis. OPERATIONS PERFORMED: C3 to C4 ACDF with plate. Please see the operative note for details. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 27-year-old male with previous diagnosis of tubular aggregate myopathy who had symptoms of neck pain and numbness and pain in both arms going down to both thumbs and index fingers.
C3|(complement) component 3|C3,|219|221|LABS DURING THIS ADMISSION|SKIN: There is no rash or other lesions. MUSCULOSKELETAL: There is no apparent joint pain on palpation. LABS DURING THIS ADMISSION: Hemoglobin 11.6, platelets 353, WBC 6.8. AST 107, ALT 82, GGT 31. Alpha-1 antitrypsin, C3, and C4 levels were all within normal limits. Total and direct bilirubin were within normal limits. INR was 1.2. PTT was 30.
C3|cervical (level) 3|C3|165|166|PAST SURGICAL PROCEDURES|3. Headaches. 4. Headache and vertigo. PAST SURGICAL PROCEDURES: 1. Transfacial resection of the dens, C1 arch, and clivus _%#MMDD2003#%_. 2. Posterior occipital to C3 fusion _%#MMDD2003#%_. 3. Tracheostomy. 4. Lumbar drainage postoperatively. ALLERGIES: Dilantin, Neurontin, Compazine, and Reglan. HOSPITAL COURSE: Uneventful for neurological, hematological, or infectious complications.
C3|(complement) component 3|C3|183|184|HOSPITAL COURSE|The possibility of adding a steroid inhaler will be addressed on an outpatient basis. PROBLEM #3: History of neuropathy that is unexplained at this time. Cryoglobulins and complement C3 and 4 levels were sent. It is anticipated that neurological referral can be undertaken to further evaluate this on an outpatient basis.
C3|cervical (level) 3|C3|160|161|HISTORY OF PRESENT ILLNESS|She was evaluated first in the emergency room and treated for her contusions and her abrasions. A C-spine film was done and a head CT was done and a CT scan of C3 through C7. The CT of the spine showed multilevel changes consistent with disk disease. They did not see any acute fractures. She was transferred to the floor essentially due to intoxication and chest wall pain.
C3|(complement) component 3|C3|168|169|LABORATORY DATA PENDING|1. Benadryl 25 mg p.o. q.4h p.r.n. 2. Claritin 10 mg p.o. q day 3. Prednisone 60 mg q day for four more days LABORATORY DATA PENDING: C1-esterase inhibitor; complement C3 level; complement C4 and complement CH50 levels.
C3|cervical (level) 3|C3|264|265|OPERATIONS/PROCEDURES|OPERATIONS/PROCEDURES: 1. MRI cervical spine with and without contrast: Impression: New myelopathic signal within the spinal cord at C3-C4 due to severe degenerative disease with superimposed congenital narrowing of the canal. Dorsal epidural space enhancement at C3 through C7 due to either venous congestion or infection/inflammation. Enhancement in C4-C5 vertebral bodies likely due to severe discogenic changes unchanged from outside MRI.
C3|(complement) component 3|C3|171|172|HOSPITAL COURSE|We also checked the ASO titer and DNase B antibody to evaluate for exposure to strep. The FANA, ANCA, ASO titer, and C4 levels were all within normal limits. Of note, his C3 level was low at 17 on admission and rose over the course of his stay to a high of 73 on discharge. This is still low for C3 level. DNase B antibody was only mildly elevated at 170 on admission and doubled by _%#MMDD#%_ at 340.
C3|(complement) component 3|C3|138|139|HOSPITAL COURSE|Of note, his C3 level was low at 17 on admission and rose over the course of his stay to a high of 73 on discharge. This is still low for C3 level. DNase B antibody was only mildly elevated at 170 on admission and doubled by _%#MMDD#%_ at 340. This indicated that the patient had been exposed to strep.
C3|cervical (level) 3|C3|227|228|HISTORY OF PRESENT ILLNESS|MRI at that time showed a cervical spinal cord mass extending through the cervical and upper thoracic spinal cord. The mass was subsequently identified as an astrocytoma on biopsy. _%#NAME#%_ is now status post laminoplasty of C3 through C6 on _%#MMDD2003#%_, and status post Hickman placement on _%#MMDD2003#%_. _%#NAME#%_'s neurologic deficits have been limited to hemiparesis of the left upper extremity without changes in bowel or bladder function, bilateral lower extremity or right upper extremity movements.
C3|(complement) component 3|C3|242|243|HOSPITAL COURSE|For inflammatory diseases such as vasculitis including HST, Kawasaki, and Wegener's, they were checked previously with a skin biopsy and cardiac echocardiogram. For autoimmune diseases such as JRA and lupus, we checked acute phase reactants, C3 normal at 175, C4 normal at 19, CH50 is still pending. Rheumatoid factor is normal at less than 20. An ANA antinuclear antibody screen is negative at less than 1.0. For connective tissue diseases such as scleroderma or dermatomyositis, we checked a CK which is low at 30 and an aldolase which is still pending.
C3|cervical (level) 3|C3,|259|261|PHYSICAL EXAMINATION|Laboratories are pertinent for an initial troponin-I that was borderline at 0.36 at 0750 while the myoglobin was 32, but followup troponin-I at 1203 clearly in the elevated range at 1.30. A chest x-ray was normal. Cervical spine films showed narrowing at the C3, C4, and C5 interspaces likely with degenerative changes and mild hypertrophic changes. ASSESSMENT: Atypical left upper chest, axillary, forearm, and neck discomfort, mostly last night, with vague persistence into the day and now associated with mild troponin-I elevation.
C3|cervical (level) 3|C3|191|192|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Posttraumatic cervical stenosis and syrinx. DISCHARGE DIAGNOSIS: Posttraumatic cervical stenosis and syrinx. OPERATIONS/PROCEDURES PERFORMED: On _%#MM#%_ _%#DD#%_, 2004, C3 laminectomy with syringostomy. HISTORY OF PRESENT ILLNESS: This is a 47-year-old white male who is status post cervical spine trauma in 1974, suffered a cervical fracture and underwent anterior cervical fusion and sustained a C6 quadriplegia.
C3|cervical (level) 3|C3|160|161|ADMISSION DIAGNOSIS|He presents with several-month history of decline in his muscular function of his biceps and deltoid which he is reliant on. His MRI reveals both a stenosis at C3 and a syrinx above C3 and partially below C3 also. The patient presents for elective decompression. PAST MEDICAL HISTORY: Includes only minor musculature contractures and constipation and neurogenic bladder requiring Foley catheter.
C3|cervical (level) 3|C3,|254|256|HISTORY OF PRESENT ILLNESS|He denied any weakness. He also had some pain in his neck that did not radiate into his arm. He denied any other pain or sensory symptoms. CT done in the emergency department was initially read as possible multilevel cervical vertebral body fractures at C3, C4, C5, and C6, with a possible fracture of the lateral mass at C5. Patient was admitted to the neurosurgery service for observation and workup.
C3|cervical (level) 3|C3.|201|203|MEDICAL ILLNESSES|The patient, however, was hospitalized in _%#MM#%_ of this year after a severe fall in which he sustained multiple lacerations to her face, and nasal fracture. She also had suffered a chip fracture of C3. She has recovered quite well. ALLERGIES: Penicillin MEDICATIONS: 1. Vioxx, she stopped preoperative 2. Darvocet N100
C3|(complement) component 3|C3,|210|212|ADMISSION PLAN|Blood pressure on admission was 123/78, pulse 96. ADMISSION PLAN: Repeat the electrolytes with a full metabolic panel with protein, albumin, magnesium phosphorous, calcium, and anti- DNAse B, ASO titer, CH-50, C3, C4, and a FANA. Her blood pressures will be monitored every 2 hours, her electrolytes, as I said, will be reassessed and she will continue on a normal saline flush of 20/kg, so a total of 800 cc.
C3|cervical (level) 3|C3|176|177|PROCEDURE THIS ADMISSION|DIAGNOSIS: Degenerative disc disease, spinal stenosis and cervical myelopathy. PROCEDURE THIS ADMISSION: C4 and corpectomy and bilateral decompression of the C4 and C5 nerves, C3 through 5 anterior spinal fusion with instrumentation, local autograft and fibular allograft. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is a 64-year-old man who has a long history of progressive weakness and incoordination in his upper and lower extremities.
C3|(complement) component 3|C3,|229|231|DISCHARGE DIAGNOSES|The mitral, tricuspid, and aortic valves are normal. There is no evidence of pericardial effusion. 4. Special tests done for evaluation of secondary hypertension. ANA negative. Antiglomerular basement membrane antibody negative. C3, C4 and CH50 levels normal. TSH normal. Rheumatoid factor negative. Urine toxicology screen for cocaine and amphetamines negative. Renin activity 1.5 ng/L/hour (normal range). Serum metanephrine level normal.
C3|cervical (level) 3|C3|188|189|HISTORY OF PRESENT ILLNESS|6. Hypertension. 7. Hyperglycemia. 8. Urinary stasis. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 69-year-old gentleman with a history of spinal stenosis who underwent C6 laminectomy, C3 through C5 and C7 laminoplasty, bilateral foraminectomies at C6 and C7 with foraminotomies on the right C5 and C4 levels by Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2007#%_.
C3|cervical (level) 3|C3|315|316|PERTINENT RADIOLOGICAL EXAMS|No evidence of acute bleed. Mass effect had resolved, with no changes posteriorly. On _%#MMDD2003#%_, did show advanced spondylosis and disk disease, affecting predominantly C4-C7, with some in the atlantoaxial articulation, as well as in addition to a reverse curvature and a grade 1 anterior spondylolisthesis of C3 on C4. On _%#MMDD2003#%_, multi-level degenerative findings with approximately 3 mm anterior subluxation of C3 on C4, likely degenerative based, with reversal of the normal cervical lordosis from C3 to C7.
C3|cervical (level) 3|C3|343|344|PERTINENT RADIOLOGICAL EXAMS|On _%#MMDD2003#%_, did show advanced spondylosis and disk disease, affecting predominantly C4-C7, with some in the atlantoaxial articulation, as well as in addition to a reverse curvature and a grade 1 anterior spondylolisthesis of C3 on C4. On _%#MMDD2003#%_, multi-level degenerative findings with approximately 3 mm anterior subluxation of C3 on C4, likely degenerative based, with reversal of the normal cervical lordosis from C3 to C7.
C3|cervical (level) 3|C3|135|136|PROCEDURE PERFORMED|ADMITTING DIAGNOSIS: Post-traumatic degenerative disk disease from C3 to C6. DISCHARGE DIAGNOSIS: Same. PROCEDURE PERFORMED: ACDF from C3 to C6. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 21-year-old female with a long history of neck pain and degenerative disk disease from C3 to C6.
C3|(complement) component 3|C3|155|156|LABS AT TIME OF DISCHARGE|The patient also had a CK level of 95. An SPEP was negative for any monoclonal spike. Hepatitis B negative, hepatitis C negative. HIV negative. Complement C3 and C4 were within normal limits. An ANA was negative. Micro-albumin urine ratio was elevated at 175.5. FANA is 2.2 suggesting renal involvement.
C3|(complement) component 3|C3|140|141|DISCHARGE DIAGNOSIS|It was thought that the family may have an MSG allergy which is contained in food products. The patient did have complement levels drawn. A C3 was 127, a C4 was 19, both of which were normal. He also had a ELP done which showed a minimal increase spike in the IgG and a low IgM.
C3|cervical (level) 3|C3|204|205|HISTORY OF PRESENT ILLNESS|Apparently a baclofen pump is being considered. The patient has a history of dystonia since 1980. He has been diagnosed as having truncal dystonia and Stiffman's syndrome. He also has had a trauma to his C3 nerve root. He has had a closed head injury. He has been in a motor vehicle accident. The patient has pain and spasms in his truncal region and lower and upper extremities.
C3|(complement) component 3|C3|219|220|HOSPITAL COURSE|Pain control was achieved through IV and oral pain medications and she seemed comfortable with the regimen noted on the chart. Lupus: The laboratory evaluation does support the potential of lupus flare with a decreased C3 and C4. However, at this time, this is by no means the most significant issue. Depression and anxiety: The patient is somewhat anxious and has had the previous diagnosis of anxiety and depression.
C3|(complement) component 3|C3|209|210|LABORATORY|ANC 12.8. Sodium 138, potassium 2.7, and bicarbonate 28. BUN 19, creatinine 2.24. LFT is normal. INR 1.07. Blood cultures negative. Cryoglobulins level was less than 18. ANCA negative. Amylase 40, lipase 262. C3 level 120, C4 level 27, hepatitis C antibody negative, HIV negative. Urine eosinophil is negative. Urine protein- creatinine ratio 1.89. Drug screen positive for cannabinoids and opiates.
C3|(complement) component 3|C3,|105|107|ASSESSMENT/PLAN|They have asked that we order a sedimentation rate and ANA, rheumatoid factor, APLA, ANCA, cryoglobulin, C3, C4, and urinalysis for sediment for now. I discussed this with Dr. _%#NAME#%_. He said that we could choose heparinization.
C3|(complement) component 3|C3|134|135|HOSPITAL COURSE|However, the patient declined collection of urine and stool. At this time, the results for FANA, serum tryptase are pending. Both the C3 and C4 were normal. FOLLOWUP: The patient has a scheduled appointment with her primary care physician on _%#MM#%_ _%#DD#%_, 2005.
C3|cervical (level) 3|C3.|262|264|ADMISSION DIAGNOSIS|She had not done well with conservative care of Darvocet, physical therapy, heat and ice, and thus was admitted for pain control and further evaluation. Prior to admission she had undergone cervical spine films which demonstrated minimal compression fracture of C3. There was poor visualization of C7 to T1 secondary to thoracic kyphosis. Chest x-ray demonstrated hyperinflated lungs. A nuclear medicine bone scan, full body, demonstrated increased uptake over the left calvarium which was new in comparison to previous studies.
C3|cervical (level) 3|C3|148|149|HOSPITAL COURSE|There was no definite compression of the spinal cord or cervical nerve roots. He did have active inflammatory changes and edema on the facet joints C3 and C4 bilaterally and on the left side at C4 and C5. The radiologist did recommend an injection of cortisone and lidocaine on this basis for diagnostic and therapeutic purpose.
C3|cervical (level) 3|C3|197|198|PROCEDURE|PROCEDURE: Imaging: CT of the neck without contrast done on _%#MMDD2007#%_, results still pending at the time of discharge. X-ray of her cervical spine, 2-3 views showing 4 mm spondylolisthesis of C3 on C4 in flexion; this does reduce on extension. There is also spondylolisthesis at the T5-T6 level approximately 3 mm which does not reduce on extension.
C3|(complement) component 3|C3|149|150|ADMISSION MEDICATIONS|Additionally, multiple labs were obtained upon admission, including an ASO titer which was negative. Complement levels were obtained revealing a low C3 and a normal C4. CRP was obtained and was elevated at 1.04. FANA was negative. Antiglomerular basement membrane antibody was negative. P-ANCA and C-ANCA and anti-DNA antibody were all negative at the time of discharge.
C3|cervical (level) 3|C3|189|190|PROCEDURES PERFROMED WHILE IN THE HOSPITAL|2. Migraine headaches. PROCEDURES PERFROMED WHILE IN THE HOSPITAL: 1. Anterior spinal fusions C7 to T1 with anterior cage. 2. Posterior spinal fusion revision with lateral mass plates from C3 to T1 and inner spinous process cables C7 to T1 and C6-7. 3. Left posterior iliac crest bone graft.
C3|(complement) component 3|C3,|165|167|PLAN|PLAN: 1. Patient return to the clinic in approximately two weeks. 2. Await completion of the following studies: Cryoglobulin, FANA, ANCA, CRP, cardiolipin antibody, C3, C4, serum protein electrophoresis, and rheumatoid factor. Once these studies have been completed, would then consider referring patient to a geneticist at the University of Minnesota for further evaluation.
C3|cervical (level) 3|C3.|202|204|DIAGNOSIS|This was thought to be secondary to indigestion, and this was resolved with antacids. On _%#NAME#%_ _%#DD#%_, 2004, the patient was taken back to the operating room for a posterior fusion of C1 through C3. He tolerated that procedure well and was sent back to the orthopedic ward for postoperative management. A Miami J collar was fit. The patient was receiving IV pain control with a blotted PCA.
C3|(complement) component 3|C3|161|162|LABORATORY DATA|Initial sodium 128, potassium 5.5, chloride 98, bicarbonate 16. BUN 67; creatinine 3.01; glucose 60. C-reactive protein 11.5. ASO 447 (normal 0-240). Complement C3 47 mg/dL (normal 90- 160). C4 24. ANA screen negative. Anti-DNA B antibody 170. Initial urinalysis revealed a specific gravity of 1.019 with 15 mg/dL ketones, large blood, greater than 300 mg/dL protein, large leukocyte esterase and negative nitrite.
C3|cervical (level) 3|C3|268|269|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. von Hippel-Lindau disease, with: Cerebellar hemangioblastomas, status post gamma knife surgery in _%#MM#%_ 2004. Right adrenal pheochromocytoma, resected in 1997. Hemangioblastoma of C5 through T1, previously resected. Cervical laminectomy of C3 through C4 for syrinx. Obstructive hydrocephalus, status post VP shunt in _%#MM#%_ 2004. Tracheostomy placed in _%#MM#%_ 2004. 2. Insulin-dependent diabetes mellitus secondary to steroids.
C3|(complement) component 3|C3|148|149|ALLERGIES|Greater than 300 protein. Electrolytes revealed sodium 140, potassium 4.2, BUN 16, creatinine 0.6, albumin 3.1, total protein was 6.5, normal LFTs, C3 10 (low), C4 34 (normal). Chest x-ray did show an obscure right heart border consistent with atelectasis or possible infiltrate.
C3|cervical (level) 3|C3|329|330|HOSPITAL COURSE|He was evaluated by Neurology once admitted and was determined to have some developmental delays and multiple cognitive deficits, but did receive a MRI of his cervical cord, which demonstrated cervical compression thought possibly to be partially correctable with surgery, and therefore Neurosurgery became involved and did do a C3 through C5 laminectomy. The patient tolerated this well and was discharged on postoperative day #2. Cardiology did evaluate him to help clear him for surgery and thought he was low risk obviously and okay to proceed.
C3|(complement) component 3|C3,|395|397|DISCHARGE MEDICATIONS|Without any extra treatment and just with bedrest over the admission, patient had dramatic improvement in her hip pain and was ambulating relatively pain-free without antalgia but at the time of discharge, she had some discomfort with hip abduction. Otherwise, was doing well. She remained afebrile during hospitalization. Rheumatology did order some labs including an ANA, double stranded DNA, C3, C4, rheumatoid factor, which were drawn but are pending at the time of discharge. Patient is to follow-up at the HealthPartners _%#CITY#%_ _%#CITY#%_ Clinic if she is having increased symptoms or to follow-up with Dr. _%#NAME#%_, her usual rheumatologist with HealthPartners.
C3|(complement) component 3|C3,|137|139|DISCHARGE DIAGNOSES|Specifically, there were no areas of abnormal enhancement, other work-up was unremarkable including sed rate of 17. b. Component studies C3, C4 and neutrophil cytoplasmic antibodies as well as double stranded DNA and ANA screen were sent but will need follow up at the time of discharge.
C3|(complement) component 3|C3|104|105|ADMISSION LABORATORY DATA|No scrotal edema and 2+ pitting edema on the lower extremities. ADMISSION LABORATORY DATA: _%#NAME#%_'s C3 level was 19.6, C4 level 23.2, creatinine 9.78. His antiDNase B was grossly elevated at 4850, and remained grossly elevated throughout his hospitalization.
C3|(complement) component 3|C3|230|231|PROBLEM #3.  GI|PROBLEM #5. Hematology: _%#NAME#%_ demonstrated the presence of hemolytic anemia with elevated LDH and decreased haptoglobin, and the peripheral smear was not consistent. However, Coombs test was performed and was negative, but a C3 Coombs was positive. Hematology was consulted and recommended that, because of this complement-mediated process, no steroid treatment was necessary, and none was initiated.
C3|(complement) component 3|C3|391|392|PROBLEM #2|_%#NAME#%_ tolerated the procedure very well and after being watched in the PICU overnight was easily transitioned back to the floor without episodes of respiratory distress. She had no additional respiratory problems during this admission. PROBLEM #2: Rheumatology: _%#NAME#%_ had had an extensive workup at the outside hospital that included negative C-ANCA, P-ANCA, RPR, mycoplasma, IgM, C3 and C4 levels, C1 esterase levels, total compliment and IgA, IgG and IgM levels. She had a moderately raised ESR and CRP. ANCA's were repeated and additional rheumatologic tests were done during this admission in attempts to further define a possible inflammatory or autoimmune process without significant findings.
C3|(complement) component 3|C3,|138|140|PROBLEM #2|They also recommended Benadryl and ranitidine and asked us to obtain 24-hour urine histamine, serum IgE, serum tryptase level, complement C3, complement C4 levels as well. These levels were drawn and the patient was discharged to home after the lab draw. The patient will follow up in the allergy clinic in 1 week's time and they will follow up on the lab result at that time.
C3|cervical (level) 3|C3|223|224|HISTORY OF PRESENT ILLNESS|There was also a small amount of pericardial effusion. Total body bone scan on _%#MMDD2003#%_ revealed no evidence of bony metastases. MRI of the soft tissues done on _%#MMDD2003#%_ revealed an enhancing abnormality in the C3 vertebral body and left transverse process with encasement of the left vertebral artery at the level of the transverse foramen compatible with metastatic disease.
C3|cervical (level) 3|C3|165|166|DISCHARGE DIAGNOSES|DOB: _%#MMDD2003#%_ DISCHARGE DIAGNOSES: 1. Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia with sepsis. 2. Phlegmon involving the epidural space from C3 to C5 anteriorly. 3. Possible small abscess at the level of C5-C6 anteriorly in the epidural space. 4. Poor p.o. intake, not agreeable to PEG tube placement.
C3|(complement) component 3|C3|321|322|LABORATORY DATA|The patient did not appear to be talking to anyone in the room other than the physicians and did not appear to exhibit any auditory hallucinations. LABORATORY DATA: White count 4.8, hemoglobin 11, platelets 225, creatinine 0.9, BUN 12, ANA greater than 10, cardiolipin IgG antibody 2.3, IgM antibody 7.6, SSB antibody 7, C3 67, SSA antibody 5, TSH 1.04, lupus inhibitor negative, complement C4 6. CSF culture negative. Grams stain-no organisms, glucose 57, protein 45, white cells none.
C3|cervical (level) 3|C3|230|231|DISPOSITION|Mr. _%#NAME#%_ is a 53-year-old gentleman, who had a rather complex cervical spine history, did have a prior spinal cord injuries, and had these changes consistent with ongoing cord compression basically from the inferior part of C3 and through upper C7. On the day of admission, _%#MM#%_ _%#DD#%_, 2005, he underwent an uncomplicated canal-expanding cervical laminoplasty from C3 through C7 and the laminar foraminotomy on the open side at C4-C5.
C3|(complement) component 3|C3|172|173|HPI AND BRIEF HOSPITAL COURSE|On further labs her sodium was 137, potassium 3.7, chloride 106, bicarbonate 25, BUN 18, creatinine 0.9, and calcium 9. LFTs were normal. Bilirubin was 0.1, lipase 59, and C3 108. CMV DNA was negative. ESR 35. Urine pregnancy test was negative. UA was normal. She underwent CT scans as described above.
C3|cervical (level) 3|C3|110|111|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Cervical myelopathy secondary to spinal stenosis, status post C4 and C5 corpectomies, C3 through C7 anterior spinal fusion with instrumentation, fibular allograft and local autograft. 2. Dysphagia. 3. Oral thrush. 4. Cognitive abnormalities of unclear etiology.
C3|cervical (level) 3|C3|120|121|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Neck pain following a fall at home, rule out cervical spine trauma in a postoperative patient with C3 through C7 laminectomy. DISCHARGE DIAGNOSIS: Neck pain following a fall at home, rule out cervical spine trauma in a postoperative patient with C3 through C7 laminectomy.
C3|cervical (level) 3|C3|159|160|HOSPITAL COURSE|There was a small defect in the splenium of the corpus callosum from axonal degeneration related to right occipital lobe hematoma, congenital fusion of C2 and C3 vertebrae. The patient also had an MRA of his head which was normal and an MRI/MRA of his neck which again was normal.
C3|cervical (level) 3|C3|173|174|ADMISSION DIAGNOSIS|He underwent a diskogram at the C7-T1 and C3-C4 levels, which did not appear to be contributing to his pain, and so the decision was made to perform a posterior fusion from C3 to C7 after consultation with the patient and his wife. PAST MEDICAL HISTORY: Significant for anterior cervical diskectomy and fusion at C5 to C6 2001 and then posterior left-sided C5- C6 foraminotomy in 2002, and then anterior cervical diskectomy and fusion C4-C5 in 2002.
C3|cervical (level) 3|C3|136|137|CHIEF COMPLAINT|EMG at that time was not consistent with that diagnosis. An MRI of the cervical spine in _%#MM#%_ 2005 showed congenital narrowing from C3 to C7 but said to have no evidence of myelopathy. She was given a course of plasmapheresis at that time and showed no improvement in hospital; however, when she went back to her group home, her caregivers said it was easier to separate her legs and put her diaper on and that she seemed to have more movement in her arms.
C3|cervical (level) 3|C3|179|180|HOSPITAL COURSE|He was assessed by the anesthesia service. Then after informed consent, he was taken to the operating room where he went an uneventful and uncomplicated cervical laminectomy from C3 to C7 in a lateral mass screw fusion. Postoperatively, he was transferred to the ICU where he remained neurologically stable, and was monitored there for approximately 24 hours, at which point he was transferred to the general neurosurgery floor where he showed signs of slightly-improved motor function.
C3|(stage) C3|(C3|231|233|IMPRESSION|RECTAL: No rectal masses noted. Prostate gland biopsy changes noted on right side of prostate gland from near base to apex. IMPRESSION: 1. Palpable bilateral abnormalities involving rectal wall. The patient is evidence for stage C (C3 A) disease. 2. Prostate nodule. 3. Rising PSA. 4. History of radiation therapy. RECOMMENDATIONS: Again I had a long talk with patient regarding the options for therapy, including rationale, risks, goals, side affects, and alternatives.
C3|cervical (level) 3|C3|134|135|MAJOR PROCEDURES|DATE OF DISCHARGE: _%#MMDD2006#%_. DISCHARGE DIAGNOSIS: Cervical stenosis. MAJOR PROCEDURES: 1. C4 and C5 corpectomy with fusion from C3 to C6 performed on _%#MM#%_ _%#DD#%_, 2006. 2. C3-C7 decompressive laminectomies bilateral foraminotomies at all levels, and lateral mass fixation performed on _%#MM#%_ _%#DD#%_, 2006.
C3|cervical (level) 3|C3|250|251|HOSPITAL COURSE|She was kept in a cervical collar postoperatively. On _%#MM#%_ _%#DD#%_, the patient was taken back to the operating room for a decompressive cervical laminectomy at C3 to C7 with bilateral foraminotomies at all levels and lateral mass fixation from C3 to C7. Once again, the patient was transferred to the Intensive Care Unit and left intubated overnight. She was extubated on postoperative day #1. She developed atrial fibrillation with rapid ventricular response and was placed on diltiazem drip.
C3|(complement) component 3|C3,|179|181|HOSPITAL COURSE|A CK with 156, creatinine clearance at 4.12. Twenty-four hour urine protein 1.9 g, (_______________) at 1.6. Twenty-four hour urine creatinine at 1.57. On discharge, C-ANCA, ASO, C3, C4, microalbumin, urine, aldosterone, and renin all pending. There was perhaps some prerenal component to this renal failure. Creatinine did go to 3.97 but on discharge, BUN 42 and creatinine 3.89 and GFR of 22.
C3|cervical (level) 3|C3.|246|248|DISCHARGE MEDICATIONS|The pin sites appeared stable. She had on radiographic evaluation, markedly displaced C2 hangman fracture with comminution of the posterior elements. On the day after admission, she underwent an uncomplicated posterior cervical fusion from C1 to C3. The bone was noted to be osteoporotic given her pre-hospitalization difficulties with osteoporosis and incremental difficulties with bone healing, bone morphogenic protein was utilized to augment the fusion construct.
C3|(complement) component 3|C3|175|176|SIGNIFICANT STUDIES AND PROCEDURES|3. Hepatitis serologies, positive hepatitis C antibody, positive hepatitis B core antibody; otherwise negative. 4. Elevated rheumatoid factor of 108. 5. Low complement levels C3 if 74, C4 is 3. CH50 is 3. 6. Hypogammaglobulinemia on protein electrophoresis.
C3|(complement) component 3|C3|254|255|HOSPITAL COURSE|Associated workup included urinalysis which was essentially benign demonstrating a concentrated urine with only modest protein. Protein to creatinine ratio was noted to be 6 gm. Urine sodium was not markedly depressed. Serologies were normal. Complement C3 and C4 were normal. ANA titer was negative. ANCA was also noted to be negative. Hepatitis B and C were normal. His creatinine gradually improved over the course of his hospitalization to a discharge value of 6.5. He was anemic related certainly to his renal insufficiency and his epistaxis and he did require a transfusion.
C3|(complement) component 3|C3|240|241|HOSPITAL COURSE|On arrival to the pediatric floor, the Cytoxan therapy protocol was instituted, and a chest x-ray on admission shows decreased right effusion with clear lungs. Electrolytes on admission were within normal range with albumin 2.1, complement C3 of 59, complement C4 of 15, and hemoglobin of 11.3 with total white count 7.9, and platelets 371. Urinalysis on admission shows leukocyte esterase with negative nitrite, WBC 14 with hyaline casts and mucus and a few bacteria.
C3|cervical (level) 3|C3|81|82|PROCEDURE PERFORMED|DISCHARGE DIAGNOSIS: Cervical myelopathy and radiculopathy. PROCEDURE PERFORMED: C3 to C7 laminectomy, foraminotomy, lateral mass instrumentation, fixation, and fusion. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 53-year-old, right-handed male, who was injured while working in a nursing home in _%#MMDD#%_.
C3|cervical (level) 3|C3|195|196|HISTORY OF PRESENT ILLNESS|He complains of significant axial neck pain, also pain going down his right arm with numbness and tingling, and subjective weakness. He had a past MRI that showed severe cervical stenosis in the C3 to C7 levels and the patient is here for posterior cervical laminectomy with decompression of the cervical spinal cord. PAST MEDICAL HISTORY: 1. Hypertension. 2. GERD. 3. Umbilical hernia repair.
C3|cervical (level) 3|C3|167|168|PAST SURGICAL HISTORY|1. Nissen fundoplication in _%#MM2004#%_. 2. History of gastric bypass surgery for obesity. 3. Lumbar fusion surgery in L2 and L5. 4. History of cervical spine fusion C3 to C7. 5. Left heart catheterization in _%#MM2003#%_. FAMILY HISTORY: She has brothers and sisters with asthma and morbid obesity.
C3|cervical (level) 3|C3|231|232|ADMISSION DIAGNOSIS|OPERATIONS/PROCEDURES PERFORMED: Removal of a posterior cervical fusion hardware. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 51-year-old female who underwent laminectomies from C3 to C6 with posterior lateral mass fixation at C3 to C7 on _%#MM#%_ _%#DD#%_, 2004. She returned to the clinic reporting left arm pain at C7 distribution. A CT of her cervical and high thoracic spine showed a movement of the thoracic pedicle screws into the neural foramen.
C3|cervical (level) 3|C3|219|220|HISTORY OF PRESENT ILLNESS|These had revealed some nonspecific areas of the brain, which are likely secondary to small vessel ischemic disease, but without any evidence of metastasis. She also has some areas of abutment of the spinal cord in the C3 through C6 levels, but without cord compression. There is also a noted disk bulging at the C6-C7 level. It is unclear if these are new or old findings.
C3|cervical (level) 3|C3|154|155|HISTORY OF PRESENT ILLNESS|REASON FOR ADMISSION: For rehab care. HISTORY OF PRESENT ILLNESS: This is a 65-year-old white man with multiple medical problems who recently underwent a C3 through C5 cervical laminectomy for cervical stenosis with myelopathy on _%#MMDD2006#%_. The patient was in acute rehab when he began having mental status changes and was transferred to the general medical floor at University of Minnesota Medical Center, Fairview, for hypotension.
C3|cervical (level) 3|C3|189|190|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: This is a 65-year-old man status post C3 through C5 laminectomy. 1. Neurologic: His mental status changes resolved with Narcan for opiate overdose. He does have recent C3 through C5 laminectomy and he will follow up with CT scan on _%#MMDD2006#%_, then in clinic again with Dr. _%#NAME#%_ on _%#MMDD2006#%_. 2. Transplant: He was to continue immunosuppression for heart and kidney transplant.
C3|cervical (level) 3|C3|140|141|PAST MEDICAL HISTORY|16. Ibuprofen 200 mg q.6 hours. 17. Tacrolimus 3 mg b.i.d. PAST MEDICAL HISTORY: 1. History of cervical stenosis and myelopathy status post C3 to C5 laminectomy and decompression _%#MMDD2006#%_. This has been complicated with apparent fluid collections around the surgical site, compressing the spinal cord, requiring drainage on two separate occasions.
C3|cervical (level) 3|C3|102|103|ADMISSION/DISCHARGE DIAGNOSES|ADMISSION/DISCHARGE DIAGNOSES: Bilateral pedicle fractures of C2 without displacement and fracture of C3 left facet joint without significant displacement. OPERATIONS/PROCEDURES PERFORMED DURING THIS HOSPITAL ADMISSION: MRI and CT angiogram.
C3|cervical (level) 3|C3,|187|189|HOSPITAL COURSE|When her position was satisfactory, she was moved from halo traction into a halo vest. On _%#MMDD2006#%_ she was taken to the operating room for a posterior decompression and occiput C2, C3, and C4 fusion. Postoperatively, she had a slow increase to baseline. She was ambulating and tolerating a regular diet. Her pain was controlled with p.o. medicines, and at the time of discharge she had cranial nerves II-XII intact, her right deltoid was a 4/5, her left deltoid was a 5/5, her bilateral biceps, triceps, wrist flexion, wrist extension, and intrinsic muscles of the hand, as well as hip flexion, knee extension, knee flexion, ankle dorsiflexion, ankle plantar flexion were all 5/5.
C3|(complement) component 3|C3,|192|194|HOSPITAL COURSE|_%#NAME#%_'s laboratory results for examination of his nephrotic syndrome showed initially a urine to protein creatinine ratio of 9.06. His UA was within normal limits except for protein. His C3, C4 were within normal limits. ANCA was within normal limits. Poststrep labs from the outside hospital were within normal limits.
C3|cervical (level) 3|C3|134|135|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 47-year-old man who is being admitted from Abbott Northwestern Hospital. He was found to have a C3 through C6 spinal cord lesion in _%#MM#%_ of this year following complaints of neck and shoulder pain. On _%#MM#%_ _%#DD#%_, 2002, he underwent resection of the tumor with C2 through C6 laminectomy.
C3|(complement) component 3|C3|186|187|HISTORY OF PRESENT ILLNESS|Briefly, her past medical history is significant for several episodes of strep pharyngitis, presenting initially with tea-colored urine in _%#MM#%_ of 2001. At that time her ASO titers, C3 and C4 were all normal. She was then followed through the Nephrology Clinic and showed improvement of her microscopic hematuria but persistent mild proteinuria.
C3|cervical (level) 3|C3|164|165|PROCEDURE THIS ADMISSION|DIAGNOSIS: Congenital fusion at C2-3 with cervical spinal stenosis and foraminal stenosis on the left side with a C5 and C6 radiculopathy PROCEDURE THIS ADMISSION: C3 laminectomy, C4-C6 laminoplasty with instrumentation HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is a 50- year-old man who was injured while performing his work as a crane operator.
C3|cervical (level) 3|C3|90|91|PROCEDURE THIS ADMISSION|DIAGNOSIS: Spinal stenosis and multilevel cervical radiculitis. PROCEDURE THIS ADMISSION: C3 through C7 laminoplasty with instrumentation and foraminotomies on the left side at C4, C5, C6 and C7. HISTORY OF PRESENT ILLNESS Mr. _%#NAME#%_ _%#NAME#%_ is a 59-year-old man who has a four month history of left arm numbness and tingling.
C3|cervical (level) 3|C3|147|148|HISTORY OF PRESENT ILLNESS|On the date of admission, she underwent a posterior cervical fusion, C1-C4 using internal fixation at C1-C4 including C1 and C2 pedicle screws and C3 and C4 lateral mass screws. She had a right iliac bone graft harvested as well. Neuromonitoring was utilized during the case. Postoperatively, she was stable.
C3|cervical (level) 3|C3|233|234|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 52-year-old African American gentleman with past medical history significant for questionable myasthenia gravis who had a posterior fusion at C2 to C6 level with laminectomy from C2 to C3 in _%#MM2007#%_. The patient was admitted to the Neurologic Service _%#MMDD2007#%_ with numbness and tingling of the left thigh and increased spasticity of lower extremities.
C3|(complement) component 3|C3|154|155|HOSPITAL COURSE|5. Lupus and rheumatoid arthritis. The patient was complaining of general aches and pains and sleeping so much, like when she has a lupus flare; however, C3 and C4 levels were normal. Double-stranded DNA was ordered. Rheumatology felt she was not having a lupus flare at this time. They made no specific recommendations other than an MRI for her lower extremity weakness.
C3|(complement) component 3|C3|126|127|HISTORY OF PRESENT ILLNESS|The patient had labs obtained which included IgF 146, IgG of 753, IgM of 130, Ig of 574. WBC was 12.8. Eosinophilia was 5%. A C3 was 126, a C% 45, and a CH50 was 111. The patient was told to increase her Advair to 2 puffs b.i.d. but she did also recently have approximately 2 weeks prior to admission sinus surgery.
C3|cervical (level) 3|C3|230|231|PAST MEDICAL HISTORY|She required a course of steroid therapy. Then the diagnosis of pernicious anemia was also added, and this has been treated with B12. 13. On _%#MMDD1997#%_, the patient underwent multiple level posterior cervical laminectomy from C3 to C7 with good results. She had multiple herniated cervical discs with compression of the spinal cord. 14. Cholecystitis and cholelithiasis, requiring laparoscopic cholecystectomy in _%#MM1999#%_.
C3|cervical (level) 3|C3|126|127|HISTORY OF PRESENT ILLNESS|After full evaluation by Dr. _%#NAME#%_, he recommended that the patient undergo anterior cervical diskectomy and fusion from C3 to C6. The risks, benefits, and alternatives to this were explained to the patient, and consent was obtained. PAST MEDICAL HISTORY: 1. Open prostatectomy. 2. Bilateral knee replacements.
C3|(complement) component 3|C3|198|199|LAB DATA|Urine drug screen was negative. Uric acid was 6.8 with panel showing cholesterol of 612, triglyceride 358, LDL 490, HDL 50. LDH was slightly elevated at 9.08 with normal range between 325, and 750. C3 was 207, which was above the higher limits of normal of 200. C4 was normal at 37 within normal range of 15 to 50.
C3|cervical (level) 3|C3,|230|232||_%#NAME#%_ _%#NAME#%_ was admitted for operative treatment of a severe cervical kyphosis associated with marked stenosis. This was a long standing problem. On the day of admission, she underwent an anterior cervical corpectomy at C3, 4, and 5 in an allograft strut and local bone graft type fusion from C2 to C6 with application of a halo. The procedure itself was otherwise uncomplicated save for the fact that she lost substantial amounts of blood with marked bleeding from numerous points including the bone, the epidural space, the veins, and the surrounding soft tissues.
C3|(complement) component 3|C3|141|142|LABORATORY DATA|Creatinine in _%#MM#%_ was 0.88 ,in _%#MM#%_ 1.09, on admission here initially 1.59 and then subsequently 1.25. Albumin is 2.4. LDH is 1322. C3 is low at 38. T4 was low normal at 20. Her urinalysis has consistently shown 100-300 protein since _%#MM#%_ as well as small to moderate blood.
C3|cervical (level) 3|C3|167|168|PROCEDURE THIS ADMISSION|DISCHARGE DATE: _%#MMDD2006#%_ DIAGNOSIS: Cervical and lumbar spinal stenosis, early cervical myelopathy, and degenerative lumbar scoliosis. PROCEDURE THIS ADMISSION: C3 through C-7 laminoplasty with posterior spinal fusion at C5-6 and L2, L3, L4 and L5 laminectomies with T11-S1 posterior spinal fusion with segmental instrumentation, local autograft and Infuse bone morphogenic protein.
C3|(complement) component 3|C3|169|170|HOSPITAL COURSE|Antineutrophil cytoplasmic antibody IgG was positive at 1:256. C- ANCA was abnormally high at 58.3 with the normal range being less than 5. Lyme antibodies were normal. C3 and C4 were within the normal range. The patient was discharged to home with Naproxen for pain control, Tylenol No. 3 for pain control, and follow up with Dr. _%#NAME#%_ with the potential for a sinus mucosal biopsy to be completed as an outpatient.
C3|cervical (level) 3|C3|134|135|OPERATIONS / PROCEDURES PERFORMED|ADMISSION / DISCHARGE DIAGNOSIS: Cervical stenotic myelopathy. OPERATIONS / PROCEDURES PERFORMED: During this hospitalization include C3 through C5 laminectomy. HOSPITAL COURSE: Mr. _%#NAME#%_ is a 65-year-old man with a past medical history significant for a heart transplant, a kidney transplant, as well as hyperlipidemia, peripheral vascular disease, status post left iliac stent, arterial embolus of the left leg with resultant left leg weakness and numbness, diabetes, kidney transplant, atrial fibrillation, necrosis of the left sternal head, history of chronic diverticulitis, gastroesophageal reflux syndrome, a history of basal and squamous cell carcinoma of the face, and spinal stenosis who presented with complaints of neck pain shooting into both arms, tingling and numbness of upper and lower extremities, and progressive weakness.
C3|cervical (level) 3|C3|187|188|HOSPITAL COURSE|His weakness had progressed to the point where he was forced to use a walker. He steadfastly denies any bowel or bladder problems. He presented for surgery and underwent an uncomplicated C3 through C5 laminectomy. Postoperatively, he was returned to the floor where he was monitored closely. He continued to have problems with pain management throughout his hospital stay.
C3|(complement) component 3|C3|258|259|HOSPITAL COURSE|Rheumatology was consulted for possible connective tissue disorder, presenting with pulmonary symptoms and systemic symptoms. He had an extensive work-up including hepatitis serology, HIV antibody testing, ......rheumatoid factor, ferritin level, compliment C3 and C4, and an angiotensin converting enzyme, ANCA antibody, which were all negative and within normal limits. His subjective symptoms of muscle pain and rash were resolved partially at the time of discharge.
C3|cervical (level) 3|C3|164|165|PAST MEDICAL HISTORY|4. Abdominal aortic aneurysm. An ultrasound done on _%#MMDD2002#%_ showed a diameter of 3 cm. 5. Gastroesophageal reflux disease. 6. Osteoarthritis. 7. Status post C3 to C4 cervical fusion. 8. Mitral valve prolapse. SOCIAL HISTORY: The patient has a 30-pack-year history of smoking cigarettes, but she quit in 1997.
C3|cervical (level) 3|C3.|227|229|EXAMINATION|He had a CT of the head that showed no acute changes or bleeding but just chronic small-vessel ischemic change. C-spine films showed degenerative changes with possibly degenerative fusion and slight anterior listhesis of C2 on C3. CT was also carried out and showed bilateral neural foraminal stenosis and again the mild listhesis of L3-L4 also noted. X-rays of the humerus and right hip showed no fracture.
C3|(complement) component 3|C3|266|267|LABORATORY VALUES|Hemoglobin stable at 11.6. Urinalysis shows no albumin, but is leukocyte esterase positive and showing a little yeast, but only 2-4 white cells, 0-2 rbc's. Total protein is 7.6, albumin 3.2, ALT 113, GGT 912, alk phos 597, bili normal, AST normal. INR 1.14, PTT 35. C3 and C4 are within normal limits. CRP is quite high at 11.1. ASSESSMENT AND PLAN: Ongoing migratory polyarthritis in a 72- year-old man who had a recent significant insect bite.
C3|cervical (level) 3|C3|383|384|HOSPITAL COURSE|The patient was initially maintained on his carbamazepine; however, for the benefit of obtaining evidence of electrographic seizures, the patient's carbamazepine was held during his hospitalization while he was undergoing video EEG monitoring. The patient did have multiple seizures while on video EEG monitoring, which seemed to originate in the left posterior quadrant, maximal at C3 and P4, suggestive of a central parietal focus for epilepsy on the left side of the brain with secondary generalization.
C3|cervical (level) 3|C3,|174|176|PROCEDURES|1. Anterior cervical plating across the fracture site with plate extending from C4-6 and compression fracture. 2. Posterior cervical exposure from C2-T1 with laminotomies at C3, 4, 6 and 7 along with pedicle screw fixation. HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old gentleman who had a fall approximately 2 months prior to presentation which since then has had sharp pain in his neck which has continued.
C3|cervical (level) 3|C3|276|277|HISTORY OF PRESENT ILLNESS|He was admitted to the University of Minnesota medical center, and on _%#MMDD2007#%_ underwent an anterior corpectomy with a C4-C5 graft and Harm cage and methylmethacrylate from C3-C5 and an anterior plate. At that time, he also underwent decompression and lysis of scars at C3 through C7, a decompression on the spinal cord and nerve root with posterior fixation with lateral mass screws from C7-C2.
C3|cervical (level) 3|C3|31|32|ADMISSION/DISCHARGE DIAGNOSIS|ADMISSION/DISCHARGE DIAGNOSIS: C3 lytic bony tumor. OPERATION/PROCEDURES PERFORMED DURING THIS HOSPITAL ADMISSION: Embolization of arteries around C3 tumor and assessment of flow of left vertebral artery. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 34-year-old woman with a history of neck pain.
C3|cervical (level) 3|C3|142|143|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 34-year-old woman with a history of neck pain. She was diagnosed with tumor of the C3 vertebral body after an MRI. She presented to the hospital for presurgical embolization of her spinal bony tumor. HOSPITAL COURSE: Ms. _%#NAME#%_ tolerated this procedure well and was soon returned to the intensive care unit where she did quite well.
C3|cervical (level) 3|C3,|207|209|PAST MEDICAL HISTORY|Yesterday he felt okay. He has had no diarrhea. His last bowel movement was yesterday. PAST MEDICAL HISTORY: Motor vehicle crash _%#MMDD2006#%_ with a left broken clavicle, cervical spine fracture, possibly C3, eight broken ribs on the left, bleeding into the left inner ear. He is currently being followed by neurosurgery as well as orthopedic surgery.
C3|cervical (level) 3|C3|159|160|HOSPITAL COURSE|ADMITTING DIAGNOSIS: Cervical spondylosis. HOSPITAL COURSE: Ms. _%#NAME#%_ was admitted on _%#MMDD2006#%_ after uncomplicated C4 corpectomy, as well as fusion C3 through C6. Estimated blood loss 20 cc. No intraoperative complications. On postoperative day 1, she was complaining of swallowing difficulty.
C3|cervical (level) 3|C3|149|150|HISTORY|A radiolucent interbody cage was performed elsewhere. On the day of admission, he underwent uncomplicated canal expanding cervical laminoplasty from C3 through C6. Inspection of the fusion site demonstrated clear mobility at the C6-C7 level, and therefore, underwent a concomitant posterior cervical fusion C6-C7 segmental fixation.
C3|(complement) component 3|C3|221|222|LABORATORY VALUES|LABORATORY VALUES: White count 18.6, hemoglobin 14.7, platelets 243, sodium 140, potassium 3.7, chloride 110, bicarbonate 28, BUN 14, creatinine 1.0, glucose 82, INR 0.88, PTT 23. As an outpatient on _%#MMDD#%_, he had a C3 level of 183, a C4 level of 31, total complement 133, ESR 81. HIV, hepatitis B and C were negative. His UA revealed greater than 300 mg/dL protein, 2 white cells, 2 red cells.
C3|(complement) component 3|C3|429|430|PROCEDURES PERFORMED|BRIEF HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is an 18-year-old girl diagnosed with lupus nephritis in _%#NAME#%_ of 1999 who was in her stable state of health until about 1 month ago when things began to "flare up." At that time, she had just come back from a trip to Europe with "flu-like symptoms" which included nausea, fever, chills, diarrhea, and vomiting. She subsequently developed edema, increased proteinuria, decreased C3 and C4, hypertension. She notes she did take her medications in Europe and was exposed to "flu and cold." She was subsequently admitted 2 days after returning home on _%#MM#%_ _%#DD#%_, 2002, for blood pressure and edema control.
C3|(complement) component 3|C3|168|169|PROCEDURES PERFORMED|Potassium was increased at 5.8. BUN was elevated at 134. Creatinine was elevated at 3.4. Phosphorous was elevated at 6.7. C3 was slightly decreased at 84. Her previous C3 on _%#MM#%_ _%#DD#%_, 2002, was 55. C4 at the time of admission was 13. Previously on _%#MM#%_ _%#DD#%_, 2002, it was 5. A CBC revealed a hemoglobin of 11.1 with an MCV of 84 and an RDW of 16.3. White blood cell count was slightly elevated at 13 with a corresponding neutrophilia and leukopenia.
C3|(complement) component 3|C3,|204|206|FOLLOW UP|6. Calcium carbonate 600 mg p.o. t.i.d. 7. Furosemide 20 mg p.o. b.i.d. 8. Prinivil 10 mg p.o. b.i.d. FOLLOW UP: _%#NAME#%_ is to have the following blood tests on Friday, _%#MM#%_ _%#DD#%_, 2002: A BMP, C3, C4, albumin, and CBC. Her father is to contact Dr. _%#NAME#%_ following receipt of the laboratory results.
C3|(complement) component 3|C3|201|202|SIGNIFICANT LAB DATA|SIGNIFICANT LAB DATA: ANCA dated _%#MMDD2002#%_ 1:512, nonspecific pattern. ANCA dated _%#MMDD2002#%_ is 1:2048 in P-ANCA pattern. Anti-GBM dated _%#MMDD2002#%_ is 5 - within normal limits. Complement C3 74, complement C4 18. Rheumatoid cryoglobulin less than 18. Haptoglobin 56, ANA negative. ESR dated _%#MMDD2002#%_ is 71, ESR dated _%#MMDD2002#%_ 21.
C3|(complement) component 3|C3|215|216|LABORATORY|3. Transient hypertension. 4. Depression/anxiety. OPERATIONS/PROCEDURES PERFORMED: None. CONSULTS: De. _%#NAME#%_. LABORATORY: On admission, CBC within normal limits, other than hemoglobin at 10.3. ANA less than 1. C3 109, C4 20, CH-50 was 157. HOSPITAL COURSE: 1. Migraine. The treatment was following consultation and per Dr. _%#NAME#%_.
C3|cervical (level) 3|C3|137|138||She did have some mobility at the C3-C4 area and marked degenerative changes at the C4-C5 level. Therefore, the fusion was extended from C3 through C5. She was solidly fused anteriorly at C5-C6. She tolerated that procedure well. She awoke, was neurologically intact.
C3|(complement) component 3|C3|145|146|HISTORY OF PRESENT ILLNESS|She has a normal TSH and CK level and normal folic acid level. She was found to have a persistently prolonged INR of 1.35 and a mildly decreased C3 and C4 level. Double strand DNA was negative. She had a weak lupus anticoagulant, but it was interpreted as possible false/positive and recommended to repeat with normal INR> Her carbamazepine level was checked, it was 3.1, and her total phenytoin was checked which was 18.1. Vitamin B12 level is 758 which is in the high upper normal range.
C3|cervical (level) 3|C3|276|277|PAST MEDICAL HISTORY|At that time the patient required a course of steroid therapy and in addition to this, the diagnosis of pernicious anemia was made and she was started on treatment with good B12. 15. _%#MMDD1997#%_, the patient underwent multiple levels of posterior cervical laminectomy from C3 to C7 with good results. The procedure was indicated for herniated cervical disc at multiple levels with compression of the spinal cord.
C3|cervical (level) 3|C3|198|199|DISCHARGE DIAGNOSIS|The MRI of the neck on _%#MM#%_ _%#DD#%_, 2004, showed a large mass in the left upper neck measuring approximately 5 cm in transverse diameter and 2.5 cm in AP diameter. It was extending from C1 to C3 and was going to the epidural space in the spinal canal, but it was not encroaching on the spinal cord. Apart from pain that he was complaining of, the patient had no weakness in the upper or lower extremities.
C3|cervical (level) 3|C3,|257|259|HISTORY OF THE PRESENT ILLNESS AND HOSPITAL COURSE|We also checked an MRI at the C-spine to rule out any stenosis or impingement as a cause for his left upper extremity and lower extremity weakness. He did, in fact, have a multilevel degenerative disk disease with mild to moderate central canal stenosis at C3, C4, and C5 to C6, but there was no recorded deformity and no ____ impingement. It was thought by me and neurology that this could perhaps explain some of his symptoms, but given the other MRI findings, Dr. _%#NAME#%_ _%#NAME#%_ of neurology was concerned that he may have a PML.
C3|cervical (level) 3|C3|139|140|PHYSICAL EXAMINATION|The only difference noted on the exam of the left arm is slight numbness to light touch in the left thumb. There is some tenderness around C3 through C5 palpation of the spine and left paraspinous musculature. Additionally, there is some tenderness in the left trapezius and left deltoid.
C3|cervical (level) 3|C3|236|237|PROCEDURES PERFORMED DURING THE HOSPITALIZATION|2. Urinary tract infection. 3. Coronary artery disease as well as atrial arrhythmias and secondary long-term anticoagulation. PROCEDURES PERFORMED DURING THE HOSPITALIZATION: 1. Radiation therapy. 2. Cervical biopsy of the tumor at the C3 level by Dr. _%#MM#%_ on _%#MMDD2004#%_. HOSPITAL COURSE: Ms. _%#NAME#%_ _%#NAME#%_ is an 82-year-old woman who was admitted to Fairview Southdale Hospital with progressive difficulty with swallowing as well as weakness in her hands and legs.
C3|cervical (level) 3|C3|172|173|HOSPITAL COURSE|After admission to the hospital, she had imaging studies including an MRI scan of the cervical spine showing a mass in the upper precervical region with destruction of the C3 vertebral body and some evidence of spinal cord compression. She underwent a biopsy by Dr. _%#NAME#%_ with findings of a chordoma.
C3|(complement) component 3|C3|351|352|HISTORY OF PRESENT ILLNESS|C-reactive protein 1.53. HOSPITAL COURSE: The patient was initially evaluated in the emergency department by the rheumatology service who recommended admission due to concerns for lupus flare, flare of hepatitis B, Fitz- Hugh-Curtis syndrome, abdominal abscess or, most likely, a lupus flare with serositis. Subsequent studies showed a low complement C3 at 40, low complement C4 of 9; the patient's hepatitis B status was confirmed. She underwent CT of the abdomen that showed a small amount of abdominal ascites and moderate pelvic ascites, questionable edema of the gastric wall, a stable hyperdensity in the right kidney, sclerosis of the femoral heads consistent with avascular necrosis which was stable, and cardiomegaly with mild pulmonary edema.
C3|cervical (level) 3|C3.|160|162|REASON FOR ADMISSION|We have just received copies of those which show nothing significant in the thoracic or the lumbar area, but she has an enhancing intramedullary cord lesion at C3. Consultation was obtained with Neurology and they were concerned at that level over the possibility of respiratory compromise. We will be admitting her for further evaluation on this lesion.
C3|cervical (level) 3|C3|245|246|HISTORY OF PRESENT ILLNESS|The patient's neurologic symptoms, physical examination, and imaging studies revealed that she was a surgical candidate. She was given the diagnosis of multilevel spondylosis with ventral cord compression. She also had degenerative listhesis of C3 on C4 with kyphosis from C3-C5. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was taken to the operating room on _%#MM#%_ _%#DD#%_, 2005, for ACDF C3-C4.
C3|(complement) component 3|C3|190|191|ADMISSION LABORATORY DATA|Chemistry panel was unremarkable. His UA was negative. His INR was 2.58. ALT was 72. AST was 61. Alkaline phosphatase 189, protein was 8.3 and albumin was 3.8. Other labs: The patient had a C3 and C4 level added on after he was discharged. C3 was 187, C4 was 38. On _%#MM#%_ _%#DD#%_, his INR was 3.05. His Alkaline phosphatase was 204, total protein 8.3. ALT was 64, and AST was 52.
C3|(complement) component 3|C3,|167|169|HOSPITAL COURSE|He had taken three doses of Warfarin at the time that he developed this rash. Allergy was consulted and they did come to see the patient, they did recommended a serum C3, C4, CH50, C1Q, C1 esterase inhibitor functionality, and they also requested checking an alpha and beta tryptase, as well as a 24-hour urine PGD2 histamine.
C3|cervical (level) 3|C3,|146|148|HOSPITAL COURSE|He had an uneventful in-hospital course, and upon discussion with Mr. _%#NAME#%_ review of his MRI imaging, a multilevel cervical laminoplasty at C3, 4, 5, 6, and C7 was elected. He will be discharged to home and will return upon scheduling of this surgery.
C3|cervical (level) 3|C3,|270|272|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 55-year-old woman who was brought to the emergency room by her husband on _%#MMDD2003#%_ with complaints of a nonhealing ulcer on the back of her right thigh. She is a paraplegic, having suffered a neck fracture of C3, 4 and 5, in a motor vehicle accident in 1969. She has had difficulty with slow-healing ulcers on both legs in the past.
C3|(complement) component 3|C3|186|187|HISTORY OF PRESENT ILLNESS|Given his presentation with atypical hemolytic uremic syndrome, C3 and C4 complement levels were drawn on both _%#NAME#%_ and his parents. Factor H levels were also drawn on _%#NAME#%_. C3 levels were essentially normal for both parents and the factor H in _%#NAME#%_ was originally normal to slightly below normal.
C3|cervical (level) 3|C3|225|226|HOSPITAL COURSE|HOSPITAL COURSE: The patient was admitted to the hospital and after being assessed by the Anesthesia service, she was taken to the operating room where she underwent an uneventful anterior cervical diskectomy and fusion from C3 to C7 with plating. Postoperatively she was put in a collar and was transferred to the regular neurosurgery floor, where her main postoperative issue was pain and recovery of movement.
C3|cervical (level) 3|C3|264|265|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ was admitted on _%#MM#%_ _%#DD#%_, 2004, with the diagnosis of congenital-acquired cervical stenosis. HOSPITAL COURSE: On the day of admission he underwent an uncomplicated canal expanding cervical laminoplasty from inferior C3 through upper T1 and a segmental plate fixation at each level. He also underwent a foraminotomy at the left C6-C7 for decompression of the C7 nerve root.
C3|(complement) component 3|C3|324|325|ADDENDUM|Specifically, kidney biopsy result with comments from Children's Hospital at _%#CITY#%_ Pathology Department dated _%#MMDD2002#%_ that showed diffuse proliferative glomerulonephritis with 65% crescents. The comment said the patient has strong serologic evidence of SLE with high titer double strand DNA bodies; however, her C3 and C4 levels were normal and she exhibits a P ANKA and MPO antibodies. Her laboratories included an ENA panel was negative, her anti RULE OUT antibody was positive at 102.4. Her anti LA antibody was positive at 151.02. Her anti SCL-70 antibody was negative, anti JO-1 antibody was negative.
C3|(complement) component 3|C3|169|170|ADMISSION LABORATORIES|The remainder of her physical examination is unremarkable. ADMISSION LABORATORIES: WBC 7.7, hemoglobin 11.4, platelets 255. Normal differential. ESR 63, ALT 15, AST 21, C3 99, C4 less than 2, TSH 1.70, valproic acid 142, electrolytes normal with a creatinine of 1.0, blood cultures were negative to date.
C3|cervical (level) 3|C3|174|175|BRIEF REASON FOR ADMISSION|3. Chest x-ray demonstrated complete opacification of the right mid and lower lung fields. BRIEF REASON FOR ADMISSION: Mr. _%#NAME#%_ is a 27-year-old male with a history of C3 quadriplegia secondary to a motor vehicle accident, status post tracheostomy, who presented with decreased oxygenation at home. He had had a trach removed on _%#MMDD2005#%_. Since then, he has had increased coughing spells with desaturations of 92% at home.
C3|propionylcarnitine|C3|148|149|HISTORY OF PRESENT ILLNESS|She was a term newborn of an uncomplicated pregnancy with a birth weight of 6 pounds 5 ounces. The expanded newborn screen revealed an elevation of C3 (propionyl carnitine). At age 9 days reason, she was brought to her primary care physician who drew electrolytes, which were normal.
C3|cervical (level) 3|C3|86|87|REASON FOR ADMISSION|REASON FOR ADMISSION: The patient is scheduled for posterior cervical laminoplasty at C3 through 7 with instrumentation by Dr. _%#NAME#%_. CHIEF COMPLAINT: Neck and right arm pain. HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old male who first presented to my office a couple of months ago with increasing neck and right arm pain and some right arm weakness.
C3|cervical (level) 3|C3|160|161|IMPRESSION|Urinalysis was clear. EKG showed no acute changes. IMPRESSION: A 48-year-old male with cervical spinal stenosis, scheduled for posterior cervical laminoplasty, C3 through 7 with instrumentation with Dr. _%#NAME#%_. I see no contraindication to proceeding. The patient will continue to follow here for routine health care maintenance.
C3|(complement) component 3|C3|254|255|LABORATORY DATA|Urinalysis was normal. C-reactive protein was 0.51. Protein electrophoresis, however, was abnormal, increased gamma fraction and there was a large monoclonal protein seen in the gamma fraction. The neutrophil cytoplasmic antibody was normal. Complements C3 and C4 were normal. Lupus inhibitor was normal. INR was normal. Cardiolipin antibodies IgM and IgG were normal. Thrombin time was normal. Calcium was 9.6. Thoracic spine was normal.
C3|cervical (level) 3|C3|121|122|PROCEDURES PERFORMED|DISCHARGE DIAGNOSES: 1. Cervical spondylosis. 2. Cervical degenerative disk disease. dd OPERATIONS/PROCEDURES PERFORMED: C3 to C6 laminoplasty. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 45-year-old gentleman with a long history of neck pain with multiple level degenerative disk disease.
C3|cervical (level) 3|C3,|227|229|PROCEDURES PERFORMED|PROCEDURES PERFORMED: MRI of the spine without contrast. This showed the cervical vertebrae appeared normally aligned. There was no evidence of a fracture of the cervical spine. There was large anterior osteophyte formation at C3, C4 and C5. There was narrowing of the disk height of C4 to C5, C5 to C6, and C6 to C7, and C7 to T1 is demonstrated.
C3|cervical (level) 3|C3,|262|264|PAST SURGICAL HISTORY|13. Nystatin mouthwash. ALLERGIES: The patient denied any allergies but review of records shows she is allergic to penicillin that causes rashes. PAST SURGICAL HISTORY: 1. Status post wedge resection of the left lung cancer by Dr. _%#NAME#%_ in _%#MM2004#%_. 2. C3, C2 occiput fusion in the past. 3. Abdominal aneurysm surgery in _%#MM2005#%_. 4. Removal of odontoid. SOCIAL HISTORY: The patient lives with son in the same house.
C3|(complement) component 3|C3|143|144|HOSPITAL COURSE|He also had immunoglobulin assays performed including IgG with subclasses, IgA, IgM, and IgE; all of those were read as normal. His complement C3 was normal. At the time of discharge, he has a complement CH50 centile which is pending. Bordetella pertussis, parapertussis, DNA, and PCR are pending, and a Chlamydia trachomatis DFA is pending.
C3|cervical (level) 3|C3,|136|138|HOSPITAL COURSE|The indications for a fusion of that length were that he was in essence spontaneously fused between the occiput and ring of C1, and C2, C3, and C4 were spontaneously fused. Therefore, wall motion was concentrated at C1-2 joint. Internal fixation and autogenous crest graft were utilized.
C3|(complement) component 3|C3,|212|214|HOSPITAL COURSE|In the 12 hours prior to discharge, his blood pressures were between 103 to 113 over 60 to 81. He, otherwise, remained stable from respiratory and cardiovascular standpoint. Again his lab data and his diminished C3, normal C4, and elevated antistreptolysin-O titer obtained in _%#CITY#%_ _%#CITY#%_ suggest the diagnosis of postinfectious glomerulonephritis. As above the antistreptolysin-O antibody and anti-Dnase B obtained here are still pending at the time of this dictation.
C3|(complement) component 3|C3|127|128|HOSPITAL COURSE|Also, further testing included complement and immunoglobulin levels. Her C3 was borderline low at 76; normal is 90 to 200. Low C3 is associated with recurrent pyogenic infections. The patient was counseled at length on contact precautions and frequent hand washing as well as optimization of maintenance of skin barrier contact.
C3|cervical (level) 3|C3,|188|190|PAST MEDICAL HISTORY|The patient did have Helicobacter pylori testing at that time, but unfortunately, the results are not available and the patient states that they have not been informed of the results. 10. C3, C4, small paracentral disc protrusion. PAST SURGICAL HISTORY: 1. Roux-en-Y bypass surgery in _%#MM#%_ of 2004. 2. Open cholecystectomy in _%#MM#%_ of 2004
C3|(complement) component 3|C3,|207|209|ASSESSMENT|I suspect he has underlying renal artery stenosis, but I would not expect it to progress this fast. He also has no flank pain or other complaints for infarction. The plan will be to check ASO, anti-DNase B, C3, C4, FANA, ANCA, and anti-GBM antibody. We will consult Renal for further evaluation and possible kidney biopsy. 2. Hypertension: We have obviously held his lisinopril. Currently, he has been started on clonidine and should probably add in calcium channel blockers, such as amlodipine to that and discontinue his atenolol, as he has developed first-degree AV block and some bradycardia with the very high dose of atenolol for his renal insufficiency.
C3|cervical (level) 3|C3|171|172|PAST MEDICAL AND SURGICAL HISTORY|The patient has been on Plaquenil and prednisone for that. 2. Chronic vomiting which is being treated with Zofran. 3. Benign heart murmur. 4. Status post neck surgery for C3 to C8 herniation - about 2 years ago. 5. Status post open reduction and internal fixation of left shoulder.
C3|cervical (level) 3|C3|149|150|PAST MEDICAL HISTORY|Most of the time she smokes less than once per week. She has a history of hyperlipidemia, osteopenia with Fosamax treatment, hypertension. She had a C3 fusion, she had a left lung wedge resection of a primary lung cancer in _%#MM#%_ 2004 by Dr. _%#NAME#%_. She fell off a horse last year and may have fractured a rib and her coccyx.
C3|(complement) component 3|C3|282|283|OPERATIONS/PROCEDURES PERFORMED|She did have lupus anticoagulant test which was weakly positive, and it was recommended that she have repeat testing in 6 weeks since a transient presence of the lupus anticoagulant does not necessarily confer an increased thrombotic risk. Sedimentation rate was 36. Her compliment C3 level was decreased at 65. C4 normal. Her immunoglobulins were normal with the exception of a slightly lower IgM level. She did have some sicca symptoms on admission including dry eyes and dry mouth, and antibodies for Sjogren syndrome are pending at this time.
C3|cervical (level) 3|C3|130|131|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 51-year-old male who is well known to the neurosurgery service. He is status post C3 through C7 revision and laminectomies with lateral mass fixation done on _%#MM#%_ _%#DD#%_, 2005. The patient has developed a pseudomeningocele postoperatively. However, there was no drainage on his admission from the incision.
C3|cervical (level) 3|C3|138|139|DISCHARGE DIAGNOSES|3. C3 to C7 kyphosis. DISCHARGE DIAGNOSES: 1. Cervical spondylosis with stenosis. 2. Chronic herniated nucleus pulposus C4 through C7. 3. C3 to C7 kyphosis. 4. Posterior spinal fusion of C3 through C7 with segmental fixation and anterior cervical diskectomy and fusion of C3 through C7 with subtotal corpectomy C4 through C6.
C3|cervical (level) 3|C3|399|400|OPERATIVE PROCEDURE|Surgical management was discussed with her and risks, benefits, and alternatives to the anterior posterior decompression were discussed, and she chose to have the surgery. OPERATIVE PROCEDURE: On _%#MM#%_ _%#DD#%_, 2006, the patient was brought to the operating room and an anterior cervical decompression and fusion of C3 through C7 with subtotal corpectomy of C4, C5, and C6, anterior graft strut C3 through C7 with fibular strut was placed along with anterior plate fixation of the same levels. The patient tolerated the procedure well. There was a small CSF leak, but that was managed with Putter gelfoam and gelfoam square and prior to closure there did not appear to be a CSF leak.
C3|cervical (level) 3|C3.|330|332|OPERATIONS/PROCEDURES PERFORMED|OPERATIONS/PROCEDURES PERFORMED: 1. Chest x-ray on _%#MM#%_ _%#DD#%_, 2005, revealed cardiomegaly, nonspecific interstitial lung disease, bilateral pleural thickening, and calcified abdominal aortic aneurysm. 2. Soft tissue x-ray on _%#MM#%_ _%#DD#%_, 2005, showed anterolisthesis of C5 and C6 and DJD at the inferior endplate of C3. 3. Abdominal ultrasound, which revealed aneurysm 3.7 cm and very slight increase since last image of _%#MM#%_ 2001. CT angiogram of the chest dated _%#MM#%_ _%#DD#%_, 2005, revealed no PE, ground-glass opacities within the lung parenchyma likely secondary to expiratory technique, small pleural effusion, mass in the middle mediastinum partially surrounds the esophagus.
C3|(complement) component 3|C3|299|300|HOSPITAL COURSE|Dr. _%#NAME#%_ stopped the hydrochlorothiazide, lisinopril, the Glucophage was stopped on admission and I also stopped the statin because of the possibility of rhabdomyolysis, but there was no indication of any rhabdomyolysis. She had a creatinine clearance with an initial standard clearance of 9, C3 was normal at 177, C4 was slightly elevated at 53. Hepatitis B surface antigen proved that she was negative, but antibody proved that she had immunity, and hepatitis C antibody was negative.
C3|(complement) component 3|C3|228|229|LABORATORY|Nontender. His peripheral pulses were of 2+. Skin: Warm and well perfused with capillary refill less than 2 seconds and no peripheral edema. LABORATORY: His labs previous to admission showed an UA with 300 of protein. No blood. C3 of 68, C4 of 11, and ANA of less than 1. Prior to this admission, _%#NAME#%_ was not experiencing any symptoms.
C3|cervical (level) 3|C3|265|266|DISCHARGE MEDICATIONS|The patient also had excruciating neck pain which was making it difficult to sleep, and so with the headaches and neck pain an MRI of the head as well as the neck was done. The brain MRI was normal. The cervical spine MRI revealed mild degenerative disk bulging at C3 through C6 with mild spinal canal stenosis between C4 and C6. At C5 and C6 there was a small left posterior disk herniation with normal neuroforaminal regions.
C3|(complement) component 3|C3|204|205|PROBLEM #2|During the cross matching in the blood bank it was found that _%#NAME#%_ had an unidentified antibody. _%#NAME#%_ was found to be A positive, DAT positive plus 1, DAT anti-C positive plus 1, IgG invalid, C3 positive. The blood bank continued to monitor for developments in identifying the antibody. _%#NAME#%_ received her packed red blood cells on the second day of admission.
C3|(complement) component 3|C3|340|341|PRINCIPAL DIAGNOSIS|Creatinine had increased from 2.81 to 3.71 on the day of admission. Her urine toxicology screen was negative. (_______________) Other labs that were drawn either at the time of admission or during the hospital stay included an HIV antibody which was negative, neutrophil cytoplasmic antibody which was negative, and ANA which was negative, C3 which was normal at 92, C4 normal at 27, CH50 normal, anti-GBM was negative, hepatitis B surface antibody negative, hepatitis B surface antigen was negative, hepatitis C antibody was negative.
C3|(complement) component 3|C3|162|163|LABORATORY|His abdomen exam is normal. His spine is straight. He is circumcised, and his testes are descended. He has no cervical lymphadenopathy. LABORATORY: On admission, C3 and C4 were with normal values as well as his CH50 being normal. His iron level was normal as well as vitamin A, E, and D.
C3|cervical (level) 3|C3|124|125|DISCHARGE DIAGNOSIS|ADMITTING DIAGNOSIS: Mass on posterior elements of C3 on the right side. DISCHARGE DIAGNOSIS: Mass on posterior elements of C3 on the right side. PROCEDURES: C3 laminectomy with tumor resection and C2-4 fusion. HISTORY AND PHYSICAL: Several-week history of neck stiffness that has been unaccompanied by other neurologic changes.
C3|cervical (level) 3|C3|85|86|PROCEDURES|DISCHARGE DIAGNOSIS: Mass on posterior elements of C3 on the right side. PROCEDURES: C3 laminectomy with tumor resection and C2-4 fusion. HISTORY AND PHYSICAL: Several-week history of neck stiffness that has been unaccompanied by other neurologic changes.
C3|cervical (level) 3|C3|175|176|HISTORY OF PRESENT ILLNESS|A CT is consistent with subarachnoid and intraventricular hemorrhage. She also has nondisplaced fracture of the odontoid vertebral body. She also has possible fracture of the C3 spinous process. She had fallen at the time of initial presentation. CBC shows white cell count of 16.6, hemoglobin 12.4, platelet count 295,000 and coags with INR 1.03, PTT 26.
C3|cervical (level) 3|C3|80|81|OPERATIONS AND PROCEDURES PERFORMED|ADMISSION DIAGNOSIS: Cervical spondylosis. OPERATIONS AND PROCEDURES PERFORMED: C3 through C5 posterior cervical fusion with instrumentation. Mountaineer instrumentation. HISTORY OF PRESENT ILLNESS AND PAST MEDICAL HISTORY: Please see the admission H&P for details.
C3|(complement) component 3|C3|262|263|LAB DATA ON ADMISSION|EKG showed a rate of 107, normal sinus rhythm, no peak T-waves. White count was 8.1, hemoglobin 11.1, and platelets 249. On admission here, the patient had sodium of 134, potassium 5.7, chloride 101, bicarb 23, glucose 92, BUN 165, creatinine 1.36, calcium 8.9, C3 of 30, C4 25, C-reactive protein 13.7, ANA of less than 1. Neutrophil cytoplasmic antibody of less than 1:20, ASO of 324, UA with large blood, greater than 300 mg/dL of protein, 104 white cells, and 44 red cells.
C3|(complement) component 3|C3|240|241|HOSPITAL COURSE|PROBLEM #3. Renal. The patient has acute glomerulonephritis with laboratory studies consistent with post-infectious glomerulonephritis with a positive ASO titer. Anti-DNase B was pending at discharge. The patient was also noted to have low C3 and normal C4, which are consistent with post-infectious glomerulonephritis. The patient had significantly elevated BUN and creatinine on admission.
C3|(complement) component 3|C3,|129|131|FOLLOWUP PLANNING|The patient should have her stool re-guaiac'd at this time. She should have followup laboratory studies at 6 weeks with a repeat C3, basic metabolic panel and hemoglobin, and urinalysis. If the urinalysis continues to have hematuria, she should have a repeat urinalysis every 1-2 months until the hematuria has resolved.
C3|(complement) component 3|C3|333|334|MAJOR PROCEDURES|DISCHARGE DIAGNOSES: 1. Influenza A. 2. Pneumonia. MAJOR PROCEDURES: Workup for immunological deficiency including the following, slide coag test was 4, which is in the negative range, diphtheria IgG titer 494, which is also in the normal range of 330-1194, diphtheria IgM was 101, normal range is 40-165, HIV 1 and 2 were negative, C3 is mildly elevated at 192 with the normal range of 85-180, C4 was normal at 24 with a range of 15-50, CH-50 is pending at the time of discharge. The patient had IgG subtypes, total was 484, which is within the normal range of 330-1165, CRP was 176 on _%#MMDD2007#%_ and had come down to 61 on _%#MMDD2007#%_.
C3|(complement) component 3|C3|270|271|HOSPITAL COURSE|Several severe bilateral neuroforaminal narrowing at C6-C7 and C7-T1, multilevel broad-based disk bulges in the thoracic spine without spinal cord narrowing. An antibody panel was obtained for evaluation of Devic vasculitis and Lyme disease, the results are as follows: C3 155, C4 23, SSB 2, SSA 6, Lyme disease negative, ESR 13, ANC negative, anti-Smith antibodies negative. Pending are anti-NMO antibody for Devic disease. In addition, the patient was evaluated by Pain Service for his intractable lower extremities.
C3|(complement) component 3|C3|240|241|HOSPITAL COURSE|Upon follow up, the patient's creatinine also improved to a value of 2.27. He also received an additional fluid bolus prior to discharge. His CK level was drawn which was slightly elevated at 534, myoglobin was checked and found to be 110, C3 and C4 levels were normal. Renal ultrasound was performed which was unremarkable. 3. Hypertension. The patient's hypertensive medications of atenolol and lisinopril were held with his hospitalization due to renal effects.
C3|cervical (level) 3|C3|191|192|HISTORY OF PRESENT ILLNESS AND PAST MEDICAL HISTORY|OPERATIONS/PROCEDURES PERFORMED: None. HISTORY OF PRESENT ILLNESS AND PAST MEDICAL HISTORY: In brief, Ms. _%#NAME#%_ is a 43-year-old woman who is approximately 2 weeks post discharge from a C3 through C7 laminectomy, foraminotomy at C5-C6 and C6-C7, and posterior fusion at C3 through C7. The patient had a somewhat complicated postoperative course from the pain perspective because in the past she had been a chronic narcotic abuser and was in drug rehabilitation and was rather habituated to most of the medications that we had tried.
C3|cervical (level) 3|C3|136|137|PAST SURGICAL HISTORY|HOSPITALIZATIONS: Secondary to her severe COPD. PAST SURGICAL HISTORY: 1. She is status post a cervical fusion from her ____________ to C3 secondary to a motor vehicle accident. 2. Left upper lobe partial lobectomy, secondary to cancer in 2004. 3. Abdominal aneurysm repair. FAMILY HISTORY: Is unremarkable. SOCIAL HISTORY: The patient is divorced.
C3|cervical (level) 3|C3,|229|231|LABORATORY|INR 1.14. Magnesium is slightly elevated at 2.4. Urinalysis shows ketones, protein, nitrites, leukocyte esterase, many bacteria, and 5-10 WBC in clumps. Urine culture is pending. CT scan of the C-spine shows severe DJD of C2 and C3, and a 4-5 mm anterior spondylolisthesis as well as some central canal stenosis at the C2-C3 junction. There is also C3-C4 anterior degenerative fusion noted. There is C4-C5, C5-C6 and C6-C7 severe degenerative disk disease with loss of height and near-obliteration of the disk.
C3|(complement) component 3|C3|145|146|HISTORY OF PRESENT ILLNESS|At that time, he was noted to have gross hematuria. He was noted to have a normal renal ultrasound at that time. He also had negative ANA, ANCA, C3 and C4. A 24-hour urine collection done through catheterization showed a total protein of 118 mg. His creatinine was elevated during the admission to 1 from a baseline of 0.4 to 0.5. Further workup also showed that ASO was negative, anti-DNAase B was negative, hepatitis B was nonreactive, rheumatoid factor was negative and a urine culture was negative.
C3|(complement) component 3|C3|247|248|LABORATORY DATA|6. Left knee fluid was also sent to Pathology and this showed hemorrhagic fluid with numerous white blood cells without evidence of crystals. LABORATORY DATA: The patient also had the following labs done: E&A was 1.9 which is weakly positive. The C3 was 166, C4 25. Rheumatoid factor 81. Lyme serology negative. Cholesterol was 175. Triglyceride 93. HDL 48. LDL 108. Immunoelectrophoresis showed IgG of 979.
C3|(complement) component 3|C3,|121|123|LABORATORY DATA|On _%#MMDD2007#%_, her urine was negative for protein at that time. She has had a C4, which was 14 on _%#MMDD2007#%_ and C3, which was 93. Both were low normal. She had a normal renal ultrasound on _%#MMDD2007#%_. HOSPITAL COURSE: FEN/ Reno: _%#NAME#%_ was n.p.o. initially prior to her renal biopsy.
C3|(complement) component 3|C3,|121|123|RECOMMENDATIONS|3. Recent pneumonia. 4. History of miliary tuberculosis (Tbc). RECOMMENDATIONS: 1. I would recommend obtaining ESR, CRP, C3, DNA antibodies, anticardiolipin antibodies and lupus anticoagulant. 2. We will await the results of the MRI. 3. I would strongly consider lumbar puncture (LP) given the presentation, her history of tuberculosis (TB), and the immunosuppression and the risk of further atypical infection.
C3|cervical (level) 3|C3|296|297|HOSPITAL PROCEDURES|3. Chronic kidney disease. 4. Diabetes. HOSPITAL PROCEDURES: Chest x-ray on _%#MMDD2006#%_ is clear lung fields with a 6 mm offset between T8 and T9 vertebral bodies representing wedging and right hilar nodular calcifications. Cervical spine film on _%#MMDD#%_ showed degenerative changes at C2, C3 and C4 with the presence of an ICD. BRIEF HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is an 83-year-old gentleman with a history of underlying diabetes, coronary artery disease, mitral valve replacement and atrial fibrillation who presents through the emergency department with increased cough and hyperglycemia.
C3|cervical (level) 3|C3|222|223|OPERATIONS AND PROCEDURES PERFORMED|ADMISSION DIAGNOSIS: Cervical stenosis. SECONDARY DIAGNOSES: Parkinson's disease, lumbar stenosis and spondylolisthesis. OPERATIONS AND PROCEDURES PERFORMED: Cervical laminectomy C3 through C6, repeat C3-C6, once again at C3 through C6, with pedicle screw and lateral mass screw fixation posteriorly. HISTORY OF PRESENT ILLNESS AND PAST MEDICAL HISTORY: Mr. _%#NAME#%_ is a 70-year-old male with severe cervical stenosis, who had intermittent bilateral radicular symptoms related to his stenosis.
C3|cervical (level) 3|C3|132|133|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 69-year-old gentleman with history of spinal stenosis who underwent C6 laminectomy, C3 through C5, and C7 laminoplasty, bilateral foraminectomy at C6 and C7 with foraminotomies on the right C4 and C5 levels as well by Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2007#%_. His symptoms leading to the procedure he describes as bilateral 1st through 3rd digit numbness, bilateral forearm pain, upper extremity weakness noted most with elbow flexion and chronic neck pain.
C3|(complement) component 3|C3|278|279|LABORATORY TESTS|The patient had glucose monitoring, the highest was 336. The glucose dropped to 141 as soon as the TPN was discontinued, although she is still on prednisone 40 mg twice a day. On _%#MMDD#%_ EKG was normal. BMP showed a glucose of 156, ANA was weakly positive at 2.7. Complement C3 was down to 42, C4 was slightly low at 11. Total complement was low at 29. Double stranded DNA was negative. On _%#MMDD#%_ blood type was O positive. Followup chest x-ray was normal.
C3|cervical (level) 3|C3,|167|169|HOSPITAL COURSE|A CT scan of the brain revealed possible agenesis of the corpus callosum, but no acute changes. The CT scan of the cervical spine showed a congenital fusion of C2 and C3, but no acute changes. Her basic metabolic panel was unremarkable. She had mild anemia. A serum pregnancy test was negative, magnesium level was normal and a TSH was normal as well.
C3|cervical (level) 3|C3|212|213|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 62-year-old woman with history of chronic neck pain. She was seen by Dr. _%#NAME#%_ in his clinic, found to have significant cervical spondylolisthesis from C3 to C7. Her symptoms consisted of severe chronic pain with headaches and neck pain. She was being treated with large doses of home narcotics.
C3|cervical (level) 3|C3|115|116|PRINCIPAL DIAGNOSIS|PRINCIPAL DIAGNOSIS: Cervical spondylosis with cervical stenosis. MAJOR PROCEDURE DURING THIS ADMISSION: Posterior C3 to C7 expansile laminoplasty with mini-plates and segmental fixation at C3 to C7. HISTORY OF PRESENT ILLNESS: This is a 45-year-old female with a complex history of spine pathology.
C3|cervical (level) 3|C3|190|191|PRINCIPAL DIAGNOSIS|PRINCIPAL DIAGNOSIS: Cervical spondylosis with cervical stenosis. MAJOR PROCEDURE DURING THIS ADMISSION: Posterior C3 to C7 expansile laminoplasty with mini-plates and segmental fixation at C3 to C7. HISTORY OF PRESENT ILLNESS: This is a 45-year-old female with a complex history of spine pathology. She has unsteadiness of her gait, complaints of urinary incontinence, and weakness and paresthesias throughout half of her body.
C3|(complement) component 3|C3|181|182|HOSPITAL COURSE|The patient had a broad battery of coagulation studies obtained as well as serologies for a more generalized connective tissue disorder. She had an undetectable ANA. She had normal C3 and C4 complement components. She had normal level of cardiolipin antibodies. She had a normal homocysteine level. Factor V and Factor II studies are pending yet. Protein-C studies were borderline low.
C3|cervical (level) 3|C3|161|162|OPERATIONS/PROCEDURES PERFORMED|ADMISSION DIAGNOSIS: Multilevel cervical stenosis with myelopathy. OPERATIONS/PROCEDURES PERFORMED: On _%#MM#%_ _%#DD#%_, 2002. 1. Left partial C2 and full left C3 and C4 hemilaminectomies. 2. Right C3 and C4 hemilaminectomies. 3. Left C5-C6 hemilaminectomy. 4. Left C6 foraminotomy. All performed with minimally invasive METRx system.
C3|(complement) component 3|C3,|221|223|HOSPITAL COURSE|Dr. _%#NAME#%_ _%#NAME#%_ came in to consult and felt that there was a pyoderma syndrome with either eczema herpeticum or herpes simplex. Therefore, Valtrex was added to his medications. Other labs included Lyme's titer, C3, C4, ANA testing. Finally, he underwent evaluation by Neurology, and it was felt that he would benefit from antidepressants also.
C3|(complement) component 3|C3,|186|188|PAST MEDICAL HISTORY|Patient notes that with his urinary tract infections he acquires bladder pain and fevers. 3. Nephrotic range proteinuria. Renal workup which began in _%#MM#%_ 2001 showed negative FANA, C3, C4, total complements, anti-GBM, as well as urine protein electrophoresis. On _%#MM#%_ _%#DD#%_ cholesterol was 189, LDL was unable to be estimated secondary to an elevated triglyceride level at 481.
C3|(complement) component 3|C3|150|151|HOSPITAL COURSE|Negative antinuclear antibodies, rheumatoid factor of less than 20, negative anti-double strength DNA antibodies. A C reactive protein of 0.1. Normal C3 and C4 levels of 106 and 19 respectively. An a.m. Cortisol level was checked and found to be 9.1. Lumbar puncture was performed on _%#MMDD2003#%_ without complications and showed 2 white blood cells, 48 red blood cells with a glucose of 71 and a protein of 69.
C3|cervical (level) 3|C3|219|220|HISTORY OF PRESENT ILLNESS|An MRI revealed a high-grade cervical stenosis, with some events of cervical spinal cord compression and signal change from a herniated nucleus pulposus. In 2000, he underwent a decompressive cervical laminectomy, from C3 through C7. His neck pain was relieved from that time, until _%#MM2001#%_, when he slipped on the floor and underwent subsequent knee surgery, and then redeveloped pain in the neck and head, mid-back, and weakness of the right arm, and difficulty with turning his head.
C3|cervical (level) 3|C3|169|170|PAST SURGICAL HISTORY|8. Ventricular hypertrophy. 9. GERD, status post gastric ulcer and GI bleed in _%#MM2001#%_. PAST SURGICAL HISTORY: 1. The above-mentioned cervical laminectomy in 2000, C3 through C7. 2. Tonsillectomy. 3. Nissen fundoplication, 1994. 4. Cholecystectomy. 5. Negative left testicular biopsy. 6. Cardiac angiogram, _%#MMDD2003#%_, with normal coronary arteries, normal LV function, and no valvular heart disease.
C3|cervical (level) 3|C3|253|254|PAST MEDICAL HISTORY|She denies any fevers, changes in appetite, changes in urination or bowel movements, upper respiratory infection symptoms, breathing difficulties, nausea, vomiting, or rash. PAST MEDICAL HISTORY: 1. Spinal cord astrocytoma diagnosed in _%#MM2003#%_. 2. C3 to C6 laminoplasty and biopsy of the spinal cord with intraoperative evoked potential monitoring on _%#MMDD2003#%_. ALLERGIES: No known drug allergies. FAMILY HISTORY: History of lung cancer in great grandparents who were heavy smokers, and a history of some kind of blood cancer in a great grandparent.
C3|(complement) component 3|C3,|343|345|PROBLEM #5|_%#NAME#%_ did have a spike in her CRP halfway through her hospitalization but then continued to decrease in her CRP down to the 20s at the time of discharge. Infectious disease consultation recommended several investigations including rheumatologic workup. Results of this workup included a low IgG at 318, a low IgM at 28, normal complement C3, slightly elevated complement C4 at 52 (normal 15-50), negative CMV DNA PCR. Negative DNA double stranded PCR. Negative Epstein-Barr virus DNA PCR.
C3|cervical (level) 3|C3|175|176||He was admitted to _%#CITY#%_ Hospital by Dr. _%#NAME#%_ and was transferred here on Dr. _%#NAME#%_'s service on _%#MMDD2002#%_. On _%#MMDD2002#%_, the patient underwent type C3 open grade 2 pilon fracture, I and D, wound revision, application of circular external fixator and ORIF to the left tibial pilon fracture.
C3|(stage) C3|C3|88|89|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 45-year-old white female with a history of C3 ovarian cancer, who presents with complaints of shortness of breath. Her history is as follows: In 1998, the patient had a TH-BSO end staging, with 6 courses of Taxol and cisplatin, and was diagnosed with C3 ovarian cancer.
C3|(complement) component 3|C3|358|359|PROBLEM #2|She had multiple laboratory studies done including a sed rate which was 37, influenza A and B tests which were both negative, creatinine clearance that showed a standard clearance of 131, 24-hour urine protein that was 0.17. BUN and creatinine remained normal during this hospital stay. ANA screen was positive at 1.6. Double-stranded DNA had a value of 24. C3 level was 49. C4 level was 5. TSH was 1.24. C-reactive protein was less than 0.2. Lupus anticoagulant test was normal.
C3|cervical (level) 3|C3|183|184|HOSPITAL COURSE|HOSPITAL COURSE: 1. Neurological: After thorough evaluation, the diagnosis of Guillain- Barre syndrome was discarded and instead, through MRI and physical examination, a diagnosis of C3 through C6 incomplete tetraplegia was determined. Neurosurgery took the patient to the OR and did a C3 through C6 cervical laminectomy. The paraspinal abscess was positive for staph aureus. On presentation he had significant forelimb paraplegia and sensory abnormalities with decreased pin prick below T4 on the right and below C7 on the left.
C3|cervical (level) 3|C3|286|287|HOSPITAL COURSE|HOSPITAL COURSE: 1. Neurological: After thorough evaluation, the diagnosis of Guillain- Barre syndrome was discarded and instead, through MRI and physical examination, a diagnosis of C3 through C6 incomplete tetraplegia was determined. Neurosurgery took the patient to the OR and did a C3 through C6 cervical laminectomy. The paraspinal abscess was positive for staph aureus. On presentation he had significant forelimb paraplegia and sensory abnormalities with decreased pin prick below T4 on the right and below C7 on the left.
C3|(complement) component 3|C3|265|266|HISTORY OF PRESENT ILLNESS|She has lupus nephritis. She was previously treated with Imuran and prednisone, Cytoxan and prednisone and high-dose Imuran and prednisone. Previous treatments have all been ineffective. She started CellCept _%#MM#%_ _%#DD#%_, 2002, and has had some improvement in C3 and C4 since. She was well until approximately 5 days prior to admit. At that time, she was in Europe at the end of a 2-week choir trip and she began to have emesis x3.
C3|cervical (level) 3|C3|252|253|PAST MEDICAL HISTORY|2. Gastroesophageal reflux disease. 3. Abdominal aortic aneurysm approximately 3 cm by ultrasound in _%#MM2002#%_. 4. Hyperlipidemia diagnosed in 1993. 5. Subarachnoid hemorrhage secondary to aneurysm in _%#MM2001#%_. 6. Osteoarthritis. 7. Incision of C3 and C4. 8. Mitral valve prolapse. 9. Status post tubal ligation. 10. History of fibroids. PROCEDURES WHILE IN HOUSE: None.
C3|cervical (level) 3|C3|289|290|HISTORY OF PRESENT ILLNESS|PROCEDURES PERFORMED: C3,4,5,6,7 cervical laminoplasty performed on _%#MMDD2003#%_. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 45-year-old male who was previously admitted to the Neurosurgery Service for evaluation of his cervical spondylolysis and cervical radiculopathies. A C3 through 7 cervical laminoplasty was elected and he presents for this procedure. Preoperatively his motor strength is full; sensation is intact on exam.
C3|cervical (level) 3|C3,|256|258|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. COPD. The patient has been a smoker for about 40 years and does smoke approximately five cigarettes a day. 2. Mechanical small bowel obstruction in _%#MM2003#%_. 3. Cervical arthritis with spinal stenosis by MRI, showing fusion of C3, C4 vertebral bodies. 4. History of intentional overdose with aspirin and oral contraceptives in 1973. PAST SURGICAL HISTORY: 1. Tubal ligation. 2. Right oophorectomy.
C3|cervical (level) 3|C3|162|163|PAST SURGICAL HISTORY|PAST SURGICAL HISTORY: 1. Tubal ligation. 2. Right oophorectomy. 3. Appendectomy. 4. Left ulnar nerve transposition. 5. Left breast biopsy. 6. Cervical fusion of C3 and C4. 7. Repair of mechanical small bowel obstruction in _%#MM2003#%_. FAMILY HISTORY: Her father disappeared after suspicious circumstances 32 years ago and has never been found.
C3|(complement) component 3|C3|311|312|ADMISSION LABORATORY DATA|Cerebellar and reflex exams were normal. ADMISSION LABORATORY DATA: Sodium 123, potassium 3.4, chloride 90, CO2 31, BUN 30, creatinine 0.4, glucose 127 and calcium 7.1, magnesium 2.5, phosphorus 5.2, ionized calcium 4.0, albumin 2.0. White blood cell count 19.8, hemoglobin 12.3, platelet count 652. Complement C3 93 (lower limit of normal 90). Complement C4 20 (lower limit of normal 15), total complement CH 50 was 50 (lower limit of normal 60).
C3|(complement) component 3|C3|203|204|LAB RESULTS ON ADMISSION|Of note, hepatitis B surface antigen was positive. Hepatitis C antibody was negative. _____ hydrogenase was normal at 554. A complement was drawn. The complement C3 was 113, which was normal. Complement C3 was 113, which was normal. Complement C4 was 35 which was normal. C-reactive protein was elevated at 1.90. Other specimens sent were ANA, ____ .
C3|cervical (level) 3|C3|176|177|PROCEDURES PERFORMED|PREOPERATIVE DIAGNOSES: Cervical myelopathy and radiculopathy. POSTOPERATIVE DIAGNOSES: Cervical myelopathy and radiculopathy. PROCEDURES PERFORMED: Anterior C4-C5 and partial C3 and C6 carpectomies, allograft and Zephyr plating for anterior cervical fusion. HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old right- handed white male who was transferred from the VA Medical Center for workup of cervical myelopathy and radiculopathy.
C3|cervical (level) 3|C3|146|147|HOSPITAL COURSE|As her headache did not improve significantly, anesthesiology was consulted, and the patient was given a cervical spine facet injection at C2 and C3 bilaterally. This also did not improve her headache much. The patient will follow up with neurology as an outpatient regarding her chronic headaches.
C3|cervical (level) 3|C3.|306|308|RADIOLOGY|Toes are upgoing bilaterally. RADIOLOGY: The patient had a CT of the cervical spine which revealed moderate spinal canal stenosis, posterior osteophyte at C6-7, mild to moderate canal stenosis at C4-5 and C5-6, bilateral neuroforaminal narrowing at multiple levels, and 2.6 mm of anterolisthesis at C2 and C3. The patient also had flexion and extension films prior to discharge which did not show any instability. HOSPITAL COURSE: She was placed in a hard collar for support and continued on Decadron 10 mg q. 6h.
C3|(complement) component 3|C3|174|175|PROBLEM #2|Her steroids were gradually tapered and she was weaned to a maintenance schedule for discharge. Cardiolipin antibody, IgG 2.2, IgM 1.9. Complement CH50 total 104. Complement C3 95, complement C4 17. Antinuclear antibody screen negative. PROBLEM #3: Infectious Disease. We did consider that the patient's head and abdominal pain might be related to infection.
C3|cervical (level) 3|C3|127|128|DISCHARGE MEDICATIONS|He was evaluated in the Emergency Department. CT scanning of the brain was negative. CT scanning of the cervical spine down to C3 was negative for fracture or dislocation. He was however somewhat confused, disoriented, lethargic, and substantially uncomfortable and was admitted for inpatient review.
C3|(complement) component 3|C3|231|232|HOSPITAL COURSE|Urinalysis was essentially normal. Her admission white blood cell count was 10,000 with a 90 percent lymphocyte count. It was also noted that two weeks prior to admission, the had a multitude of labs showing liver function, normal C3 and C4 complement levels, the absence of any lupus inhibitor or cardiolipin IgG or IgM as well as the absence of ___________ antibody in the testing.
C3|cervical (level) 3|C3|191|192|HOSPITAL COURSE|She had no further questions, and consent was obtained. For full details of this discussion, please see the clinic notes. HOSPITAL COURSE: On _%#MM#%_ _%#DD#%_, 2004, the patient underwent a C3 to C5 anterior cervical diskectomy and fusion with removal of C5-6 plate for solid fusion at C5-6. The patient tolerated the procedure well, was extubated in the operating room, and was transferred to the PACU in stable condition.
C3|(complement) component 3|C3|142|143|PROBLEM #2|Her labs remained stable while she was here. PROBLEM #2: Rheumatology: A Rheumatology consultation was placed for possible flare up of lupus. C3 and C4 levels were within normal limits. Her CRP was only 1.35 and ESR was 20. She is to follow up with Rheumatology in one week.
C3|cervical (level) 3|C3|161|162|HISTORY OF PRESENT ILLNESS|As the symptoms progressed he did present to Dr. _%#NAME#%_ and was scheduled for surgery on the _%#DD#%_ of _%#MM#%_. On the _%#DD#%_ of _%#MM#%_ he did have a C3 through C7 foraminotomy with a laminectomy and lateral screw placement (lateral mass instrumentation and fixation). He, at this time, still does have a cast on his right arm from the scaphoid fracture.
C3|(complement) component 3|C3|187|188|HISTORY OF PRESENT ILLNESS|He had a total protein of 3.2, albumin 2.0, and globulin level decreased at 1.2, and decreased total bilirubin of less than 0.1. He had negative urine culture and he had basically normal C3 level of 87, and normal C4 level of 20. Finally, he had negative ASO screen. ALLERGIES: None. MEDICATIONS: None except occasional Tylenol for relief of teething pain.
C3|cervical (level) 3|C3|191|192|PAST MEDICAL HISTORY|There are some records from Abbott- Northwestern Hospital, which describe his complex past medical history, which will be described below. PAST MEDICAL HISTORY: 1. Quadriplegia since 1998 at C3 secondary to spinal surgery. 2. Diabetes mellitus. 3. Paroxysmal atrial fibrillation. 4. Hypercholesterolemia. 5. Multiple urinary tract infections as follows: In _%#MM2004#%_, MRSA; _%#MM2003#%_, Enterobacter aerogenes; _%#MM2003#%_, Citrobacter and MRSA; _%#MM2002#%_, MRSA; _%#MM2002#%_, MRSA; _%#MM2002#%_, Enterobacter aerogenes.
C3|(complement) component 3|C3|195|196|HOSPITAL COURSE|Initial arterial blood gas showed pH of 7.49, PCO2 of 35, PO2 of 60, on room air. ACE level positive at 97. Urinalysis with trace nitrites, negative for protein. C- reactive protein 1.91. Normal C3 and C4 levels. Lupus inhibitor was not present. This patient subsequently underwent mediastinoscopy by Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2002#%_, at which time nonnecrotizing granuloma of the right paratracheal lymph nodes was noted.
C3|(complement) component 3|C3|189|190|LABORATORY|CBC on _%#MM#%_ _%#DD#%_, 2006, had a WBC count of 2.1, hemoglobin 10.3, and platelets 249,000. On _%#MM#%_ _%#DD#%_, 2005, the patient had a complement C4, which was within normal limits, C3 level within normal limits. HOSPITAL COURSE: The patient is a 21-year-old Hmong lady with demyelinating venous disease since the age of 16, who was admitted to the University of Minnesota Medical Center, Fairview center on _%#MM#%_ _%#DD#%_, 2005, for progressive lower extremity weakness and with loss of urinary control.
C3|(complement) component 3|C3,|174|176|PROCEDURES AND LABORATORY STUDIES|Abdomen and pelvis were unremarkable. 3. Iron panel shows: iron 11, TIBC 600, iron saturation 2, ferritin 34, which are consistent with iron-deficiency anemia. 4. Complement C3, C4, CH50, cardiolipin antibody IgG, IgM, Lupus inhibitor, inhibitor, homocystine level were normal. Protein-S level is slightly high at 132%; normal range is 65%-125%.
C3|cervical (level) 3|C3|209|210|HISTORY OF PRESENT ILLNESS|He denies any cough or dizziness. No history of trauma. He saw his primary care provider and on _%#MMDD2005#%_ had an MRI of his cervical spine without contrast which showed minimal central disk protrusion at C3 and C4 as well as C4 and C5 but was otherwise normal. The patient states that since his MRI, that is, in the last few days, his neck discomfort has worsened.
C3|(complement) component 3|C3|293|294|HOSPITAL COURSE|1. SLE. The initial screening test demonstrated possible kidney involvement with large blood and a normal protein and creatinine ratio of 0.12. Direct antiglobulin test was normal. ANA was positive at greater than 10. ENA antibodies were all normal. Double-stranded DNA was positive at 40,40. C3 and C4 were low with C3 being 43 and C4 being 5. Rheumatoid factor was less than 20. Neuronal nuclear antibody panel was less than 10.
C3|cervical (level) 3|C3|155|156|MAJOR PROCEDURES AND TREATMENTS|ADMISSION DIAGNOSIS: C3 through C7 stenosis and nerve root compression. MAJOR PROCEDURES AND TREATMENTS: On _%#MM#%_ _%#DD#%_, 2006, the patient underwent C3 through C7 laminectomy and fixation with lateral mass screws. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ has been followed in our clinic for sometime.
C3|cervical (level) 3|C3|156|157|HISTORY OF PRESENT ILLNESS|She was electively scheduled for surgical revision of her left clavicle fracture prior to our surgery. Once this was accomplished, she was then planned for C3 through C7 laminectomies with fixation as described above. HOSPITAL COURSE: The patient tolerated the procedure quite well, was extubated in the operating room, and was transferred to the surgical intensive care unit at _%#CITY#%_ Hospital for a longstanding evaluation.
C3|(complement) component 3|C3|164|165|HOSPITAL COURSE|He was then evaluated by the Allergy service who felt he was safe for discharge to home. Several labs were drawn including the following: IgM 61, IgA 113, IgG 889, C3 of 106 and C4 of 15. 2. Status post AV nodal ablation. The patient was monitored on telemetry during this hospitalization which showed that he was 100% paced.
C3|(complement) component 3|C3|138|139|PROCEDURE AND OTHER TESTS DONE|Hepatitis B surface antibody is negative. Parvovirus showed no evidence of active parvovirus. Double-stranded DNA was for low complement. C3 and CK were all normal. Direct antiglobulin test negative. Rheumatoid negative. ANKA negative. 3. Hematocrit pathology showed no evidence of any malignancy.
C3|(complement) component 3|C3|155|156|LABORATORY AND TEST RESULTS|CBC with white count 2200, hemoglobin 12.7, platelet count 407. Double- stranded DNA was 2 (negative). ANA screen was negative. ANCA was 1:512 (positive). C3 was normal, C4 was normal at 27, rheumatoid factor was negative and she had Sm antibody IgG which was negative and SSA Rho antibody that was negative and SSB or La antibody that was negative and scleroderma antibody was negative.
C3|cervical (level) 3|C3|145|146|IMAGING|Hypertrophic change around the humeral head. 8. X-ray of cervical spine showed moderate severe degenerative changes noted 3 mm retrolisthesis of C3 on C4. No evidence of acute fracture. 9. CT of head showed no acute findings. The patient did also have a UTI initially, so she was put on Cipro 250 mg p.o. twice a day.
C3|(complement) component 3|C3|432|433|LABORATORY DATA ON ADMISSION|CBC was normal, white count 8,600 with a normal differential, hemoglobin 14.1, Keppra level 10.7. MRI scanning of the brain was done showing no evidence for any acute change on diffusion-weighted imaging, a 2 cm area of encephalomalacia and gliosis in the left mid frontal parasagittal region was noted similar to previous descriptions. Her sed rate was borderline elevated at 25. C-reactive protein was negative at 4.2. Complement C3 was 110, C4 was low at 14, routine urinalysis was negative. Chest x-ray was negative as well. Lumbar puncture was performed showing no white cells, no red cells, glucose 51, protein 48, no growth on the culture, negative Gram stain.
C3|cervical (level) 3|C3|211|212|HISTORY OF PRESENT ILLNESS|MRI revealed spinal cord edema from C1 to the midthoracic area and gadolinium enhancement from C6 to T4. She had multiple level of degenerative disks and ossification of the posterior longitudinal ligament from C3 to C7. Spinal tap was also performed. The results of the workup found a diagnosis of transverse myelitis. As she became neurologically stable, she was not able to manage her bowel and bladder and was not to manage her paraparesis from mobility and ADL standpoint and recommended for admission to the inpatient rehab unit.
C3|cervical (level) 3|C3,|62|64|PROCEDURES THIS ADMISSION|DIAGNOSIS: Cervical myelopathy. PROCEDURES THIS ADMISSION: 1. C3, C4, C5 and C6 laminoplasty with instrumentation. 2. Left C4-5 and C7 foraminotomies. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 46-year-old woman who has an 18-month history of progressive neck pain and headache and left arm tingling.
C3|cervical (level) 3|C3|120|121|HOSPITAL COURSE|ADMITTING DIAGNOSIS: Cervical spondylitic myelopathy. HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ underwent laminoplasty C3 through C7 on _%#MMDD2006#%_. There was a difficult intubation. Medicine consult was obtained. In addition intraoperative ENT consult.
C3|(complement) component 3|C3|206|207|PERTINENT  LABORATORY TESTS|6. _%#MMDD2007#%_. Ultrasound of the right lower leg was negative for DVT. 7. _%#MMDD2007#%_ INR was 1.04. 8. _%#MMDD2007#%_, WBC 5.1, hemoglobin 11.1, platelet count 138,000. 9. _%#MMDD2007#%_, complement C3 was 106, complement C4 was 10. 12. _%#MMDD2007#%_, HCV RNA quantitative was 1,810,000 with a log of HCV RNA quantitative was 6.3.
C3|cervical (level) 3|C3,|209|211|HOSPITAL COURSE|Therefore, initially he was at Ridges and transferred here for further evaluation and stabilization on _%#MM#%_ _%#DD#%_. He underwent again a C2 through C4 decompression laminectomy with decompression of the C3, C4, and C5 nerve roots to the posterolateral approach. Also C3-C4 anterior cervical diskectomy and fusion with plates.
C3|cervical (level) 3|C3|201|202|PROCEDURE THIS ADMISSION|DIAGNOSIS: Spinal stenosis and cervical myelopathy and central disk herniation at the C3-4 level. PROCEDURE THIS ADMISSION: C3-C4 anterior cervical discectomy and fusion with BAK-C instrumentation and C3 through C6 laminoplasty with foraminotomies on the left side at C4-5 and C6. C3-C6 was done with instrumentation with foraminotomies at C4-5 and C6.
C3|(complement) component 3|C3|171|172||Initial evaluation revealed a fairly unremarkable physical exam. White count was 3.5, hemoglobin 11.4 and platelet 284,000. BMP unremarkable with a creatinine of 0.6, Low C3 (63) & C4 (6) and slightly elevated sedimentation rate 30. HOSPITAL COURSE: Problem #1: The patient was treated with IV Solu-Medrol x2 with significant improvement in her symptoms.
C3|(complement) component 3|C3|238|239|HISTORY OF PRESENT ILLNESS|4. Infectious disease: Sean received IM Bicillin in his left thigh for treatment of his streptococcus. 5. Renal: _%#NAME#%_ was diagnosed with post-streptococcal glomerulonephritis. Labs to support this diagnosis included an ASO of 1950, C3 low at 12, C4 normal at 21. An anti-DNase B is pending at the time of this dictation. His creatinine, as stated above, on discharge was 0.9 and subsequently improving.
C3|(complement) component 3|C3|302|303|HISTORY OF PRESENT ILLNESS|FOLLOW UP: The patient is to follow up with Dr. _%#NAME#%_, his primary care physician, in 1 week, and should obtain the following labs 1 week after discharge: a set of electrolytes including a BUN and creatinine; 2-3 weeks after discharge, a set of electrolytes including a BUN and a creatinine and a C3 level; and then after 3 weeks afterwards until the labs normalize, a C3 level and a creatinine. These labs are expected to be normal approximately 3 months after discharge.
C3|cervical (level) 3|C3|188|189|REASON FOR HOSPITALIZATION|Cervical spine films were performed but showed advance and generally with hypertrophic changes in the mid and lower cervical spine with narrowing at C5 and minimal anterior subluxation of C3 on C4. Chest x- ray showed some chronic interstitial changes. X-ray of the thumb showed no fracture. The patient had symptoms of weakness in the left upper extremity.
C3|(complement) component 3|C3|130|131|HISTORY OF PRESENT ILLNESS|The serum sodium was 133, potassium 4, chloride 103, bicarbonate 25, BUN 12, creatinine 0.6, and glucose 89. The CRP was 1.5. The C3 was 131, and the C4 was 13.5. HOSPITAL COURSE: A renal biopsy was performed on _%#MM#%_ _%#DD#%_, 2002, without complications.
C3|cervical (level) 3|C3|191|192|LABORATORY|LABORATORY: Initial CBC was normal. Chemistries showed sodium 142, potassium 3.9, chloride 107, CO2 28, BUN 14, creatinine 1.3 and glucose 93. ESR was 49. X-rays of the cervical spine showed C3 through C7 end plate spurring with area of the greatest spurring in the C3 to C5 area. C3 and C4 showed central canal impingement and some moderate central stenosis.
C3|(complement) component 3|C3,|171|173|LABORATORY DATA|Rheumatology was involved to determine whether there was any systemic vasculitis. However, the laboratory studies were unremarkable. Sedimentation rate was 37. Complement C3, C4 were negative. Cryoglobulin was normal. CRP was elevated at 6.87. His ANA, BNC, and IgG were all normal. We did check an echocardiogram on _%#MMDD#%_ which showed a sinus rhythm with PAC's.
C3|cervical (level) 3|C3|205|206|RADIOLOGY|Light touch is intact bilaterally. Pinprick is intact bilaterally. RADIOLOGY: On review of the spine films that the patient brought with her she does appear to have posterior pedicle screws extending from C3 to C7. She has an anterior plate that extends from C4 to C7. These pedicle screws, rods, and the plate all appear to be in good alignment.
C3|(complement) component 3|C3|210|211|PERTINENT LABORATORY DATA|Her potassium was low here in the rehab setting, as low as 2.6, and this was vigorously replenished. PERTINENT LABORATORY DATA: 1. _%#MMDD2003#%_: Potassium 4.1. 2. _%#MMDD2003#%_: ESR 35, CRP 0.81. Complement C3 57, complement C4 9, albumin 2.4. 3. _%#MMDD2003#%_: BMP within normal limits except for the following; C02 33, anion gap 3, BUN 26, creatinine 1.1, calcium 8.2.
C3|(complement) component 3|C3|200|201|HISTORY OF PRESENT ILLNESS|The patient is here for a kidney biopsy, for further workup of her persistent microscopic hematuria. The patient has had some workup in the past as an outpatient, including a negative FANA and normal C3 and C4 levels. The patient has had a urine calcium-to-creatinine ratio of 0.06, which is normal. She also has had a normal audiogram. She has had a negative cystoscopy and a renal ultrasound in 1995 that was normal.
C3|(complement) component 3|C3|264|265|HISTORY OF PRESENT ILLNESS|She is scheduled for native kidney biopsy. She was recently admitted to Fairview _%#CITY#%_ from _%#MMDD2003#%_ through _%#MMDD2003#%_ for first-trimester hyperemesis and dehydration. The patient was found to be hypoalbuminemic, to have hypocomplementemia (with a C3 of 75 and a C4 of 12) and nephrotic-range proteinuria, documented with a 24-hour urine obtained on _%#MMDD2003#%_; at that time, there was 12.76 gm of protein.
C3|(complement) component 3|C3|139|140|PHYSICAL EXAMINATION|The one repeat on _%#MM#%_ _%#DD#%_ was indeterminate in nature. We also note from _%#MM#%_ _%#DD#%_ the C2 complement was at 2.8, normal. C3 was 123 and normal. C4 was 18 and normal. CH50 was 209, which is in the high range. ASSESSMENT: This is a patient with vasculitis with clinical features of sinusitis, nephritis, and p-ANCA positive, along with a purpuric rash.
C3|cervical (level) 3|C3|153|154||He has a substantial scalp laceration. He was evaluated with CT scan of the brain which was negative. CT scan of the cervical spine down to the level of C3 which was negative for fracture or dislocation and plain x-rays which were also negative. He has aroused. He was however, somewhat impaired in terms of his level and content of consciousness and was felt to be incapable of taking care of himself and it was recommended to inpatient review.
C3|(complement) component 3|C3|222|223|HOSPITAL COURSE|Curiously the reticulocyte count was never elevated. 4. Routine urinalysis on admission showed some protein but only 0-2 RBC, a few granular casts were present. 5. ANA was negative and anti-GBM antibody was also negative. C3 and C4 complements were normal at 96 and 21 mg/dL, respectively. Haptoglobin was very low at less than 6 mg/dL. 6. Liver function studies revealed normal bilirubin, total and direct, as well as normal alkaline phosphatase and ALT.
C3|(complement) component 3|C3|149|150|HOSPITAL COURSE|Her sed rate had been checked on _%#MMDD#%_ and was 140. Her neutrophilic cytoplasmic antibody was repeated and it was 1:64. Her complement showed a C3 of 142, a C4 of 35. Her CH50 was 145, C-reactive protein was quite elevated at 18.6 with normal being 0- 0.8. Her S-Pap showed marked hypoalbuminemia with increased Alpha 1 and Alpha 2 globulins.
C3|cervical (level) 3|C3|73|74|OPERATIONS/PROCEDURES PERFORMED|ADMISSION DIAGNOSIS: Cervical stenosis. OPERATIONS/PROCEDURES PERFORMED: C3 laminectomy, _%#MM#%_ _%#DD#%_, 2004. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 52-year-old male seen in neurosurgery clinic by Dr. _%#NAME#%_ for a persistent shooting pain down his left arm, bilateral shoulder pain, and some paresthesias in both arms.
C3|cervical (level) 3|C3|108|109|HISTORY OF PRESENT ILLNESS|The patient does have a history of previous cervical surgery by Dr. _%#NAME#%_ which involved a fusion from C3 to C7. On examination in clinic, the patient was found to have full strength with normal sensation in both upper and lower extremities and on review of the MRI, he was found to have a significant stenosis at the C2-C3 level with some T2 signal change in the spinal cord at that level.
C3|cervical (level) 3|C3,|146|148|HOSPITAL COURSE|CT of the spine showed no acute fractures or spinal findings; however, it did show spondylosis of the entire cervical spine and compromise of the C3, 4, and 6 nerve foramen. EKG showed ventricular pacing. LABORATORIES: His troponin was less than 0.07. Of note, on his BMP, his creatinine and BUN were elevated with a creatinine level of 2 and BUN level of 58, this was consistent with a prerenal state, and he was hydrated with 500 cc of half-normal saline, and his Lasix was decreased to 20 mg per day instead of twice a day.
C3|cervical (level) 3|C3|219|220|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old right- handed white male transferred from the VA Medical Center for the second part of a 2-part staged surgery. He previously underwent anterior C4-5 and partial C3 and C6 corpectomies, allograft, and Zephyr plating for anterior cervical fusion on _%#MMDD2004#%_. During that previous hospitalization, he was found to have suspected osteomyelitis and cellulitis in his right lower extremity, and the posterior part of his fusion was delayed.
C3|cervical (level) 3|C3|77|78|PROCEDURES PERFORMED|DISCHARGE DIAGNOSES: Cervical myelopathy. PROCEDURES PERFORMED: 1. Posterior C3 to C7 cervical laminectomies, foraminotomies and fusion with Axon screws and rods. 2. C5 corpectomy, partial C4 and C6 corpectomies, C4 to C6 intracervical fusion with fibular strut allograft.
C3|cervical (level) 3|C3|198|199|HISTORY OF PRESENT ILLNESS|He also does have occasional bowel incontinence and urinary incontinence. The patient had an MRI scan that shows marked stenosis with cord compression and abnormal signal in the cord extending from C3 to C7 with subluxation at C4 with a combination of discs, osteophyte and with significant cord compression. He also at the thoracic spine has a compression fracture at T12 with disc material below with osteophyte.
C3|cervical (level) 3|C3|216|217|PAST SURGICAL HISTORY|PAST SURGICAL HISTORY: 1. Deceased donor pancreas transplant alone with bladder drainage of pancreatic exocrine secretions _%#MMDD2007#%_. 2. Tubal ligation. 2. Hysterectomy. 3. Shoulder surgery. 4. Knee surgery. 5. C3 through C5 laminectomy. 6. Oophorectomy. ALLERGIES: Levaquin, Lexapro, penicillin. HOSPITAL COURSE: The patient had an ultrasound of the pancreas on admission, which showed mild edematous pancreas transplant.
C3|cervical (level) 3|C3|198|199|PAST SURGICAL HISTORY|PAST SURGICAL HISTORY: 1. Deceased donor pancreas transplant with bladder drainage of pancreatic exocrine secretions, _%#MMDD2007#%_. 2. Hysterectomy. 3. Short shoulder surgery. 4. Knee surgery. 5. C3 through C5 laminectomy. 6. Oophorectomy. 7. Tubal ligation. ALLERGIES: Lexapro, Levaquin, penicillin. HOSPITAL COURSE: The patient was admitted to 6B and was treated with IV Fluids, electrolytes and IV antiemetics.
C3|cervical (level) 3|C3|174|175|PHYSICAL EXAMINATION|Her grip strength has minor deficits. REFLEXES: Symmetrical in upper and lower. There is no clonus. Hoffmann's is negative. SENSORY EXAM: Reveals intact sensation throughout C3 to T1 in the right upper extremity. Left upper extremity reveals diminished sensation along the ulnar border of her forearm and also the last 2 digits of her left hand.
C3|cervical (level) 3|C3|189|190|REASON FOR CONSULTATION|REASON FOR CONSULTATION: I am asked by Dr. _%#NAME#%_ to see Ms. _%#NAME#%_ _%#NAME#%_ for a medical oncology consultation regarding recent findings of a pathologic compression fracture at C3 as well as soft tissue mass involving the abdomen with hydronephrosis and for discussion regarding further diagnostic steps.
C3|(complement) component 3|C3,|225|227|PAST MEDICAL HISTORY|3. Lymphopenia during hospitalizations. Extensive work-up done in the past hospitalization with discharge on _%#MMDD2003#%_. Immune studies including T and B cell subsets, quantitative immunoglobulins with IgG subsets, CH50, C3, C4, antibody production to past vaccines, lymphocyte proliferation to mitogens and antigens, and HIV were all within normal limits. PHYSICAL EXAMINATION: Temperature max 103.4. General exam: Alert, social, in no acute distress, looks well-nourished.
C3|(complement) component 3|C3|106|107|HISTORY OF PRESENT ILLNESS|She is eating. Her bowels are working normally. She does have peripheral edema as well. The patient had a C3 of 56 and a C4 of 14 on _%#MMDD2006#%_. Her double-stranded DNA antibodies were greater than 200 on that day. These were repeated on _%#MMDD2006#%_. Her C3 at that point was 51 and her double-stranded DNA was down to 118.
C3|(complement) component 3|C3,|142|144|ASSESSMENT AND PLAN|In any case if administration of antibiotics which have been associated with a former reaction must be used then would check a baseline CH50, C3, C4, C3A and serum tryptase and follow closely. If she develops urticaria or a similar cutaneous reaction then we will repeat these labs, and discontinue the antibiotics only if she develops systemic symptoms.
C3|cervical (level) 3|C3|125|126|IMPRESSION|2. He has degenerative arthritis of the cervical spine with dense sclerotic changes on his CT scan at the inferior aspect of C3 and C4 vertebral bodies. 3. Hypertension. 4. History of bladder cancer. He has had a history of BCG installation. 5. History of seizure disorder. The patient is on phenytoin.
C3|(complement) component 3|C3|244|245|RECOMMENDATIONS|9. Multiple drug allergies. RECOMMENDATIONS: 1. Will proceed with CT of the abdomen (contrast okay with normal creatinine). 2. Evaluate residual kidney for possible mass. 3. Quanitate urine protein and creatinine clearance. 4. Will check FANA, C3 and C4 complements. 5. Avoid NSAIDs. 6. Checking UC. 7. ACE inhibitors and diuretics are okay for now - any way to taper her diuretic dosing ?.
C3|cervical (level) 3|C3|298|299|IMAGING|He has no significant tenderness to palpation of his right calf, and he has no significant atrophy in upper or lower extremities including his hands and feet. IMAGING: On review of his MRI scan, the patient has significant cervical spine disease involving ligamentous hypertrophy that extends from C3 down to approximately C6. The posterior longitudinal ligament is remarkably thickened and may be calcified though this is difficult to fully assess from the MRI.
C3|cervical (level) 3|C3|192|193|IMAGING|The thickness does seem to be worse at the disk space levels where there are probably disk bulges that may be calcified, too. This does result in significant spinal stenosis that extends from C3 to C6 and a neural foraminal narrowing that appears to be significant at C4-5 and C5-6. On the sagittal T2, there is a hint of some T2 signal change within the spinal cord but this is not marked though on the axial view the spinal cord shape is clearly distorted.
C3|cervical (level) 3|C3|205|206|PLAN|We have discussed with the patient the potential for cervical decompressive procedure, and because of the curvature of his cervical spine and the multilevel nature of his pathology, he likely would need a C3 to C6 decompressive laminectomy with lateral mass screw fixation and fusion. We discussed this procedure and the risks and benefits associated with it, and at the end of the consultation the patient and his wife were going to talk about things amongst themselves and then plan on contacting the Spine Neurosurgery Clinic to arrange a follow up and further evaluation as needed.
C3|cervical (level) 3|C3|173|174|PAST MEDICAL HISTORY|3. Laryngeal carcinoma. 4. Esophageal carcinoma. 5. Hypertension. 6. GERD. 7. Hypothyroidism. 8. Rheumatoid arthritis. 9. Osteoporosis. 10. History of epidural abscess from C3 to C6 with evidence of osteomyelitis and diskitis. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Parenteral Dilaudid 4 mg per hour with PCA demand boluses of 2 mg q. 15 minutes.
C3|(complement) component 3|C3|171|172|RECOMMENDATIONS|RECOMMENDATIONS: 1. Continue with trial of IV hydration with diuretic p.r.n. low urine output. 2. Repeat urinalysis with microscopic exam. 3. Check complements, including C3 and C4. 4. Renal ultrasound. 5. Trial of Reglan 10 mg IV times one as recent attempt to place feeding tube resulted in the tip only in the gastric antrum.
C3|(complement) component 3|C3|208|209|LABORATORY DATA|He seemed to have intact sensation throughout. LABORATORY DATA: Persistent leukopenia, thrombocytopenia, and anemia over this last year. He also has had low complements on numerous occasions and has both low C3 and C4 on this admission. His anti-DNA antibody was positive approximately one month ago. MRI done on admission here shows no lesions compatible with inflammatory changes and no evidence for a new infarct.
C3|cervical (level) 3|C3|153|154|LABORATORY|CK is not done. Creatinine is 1.1. Urine has 2+ protein. Neck film shows calcified carotids bilaterally. Extensive degenerative changes are present from C3 to C7. Brain MRI shows no ischemia on diffusion-weighted images. Bright T2 signals are parent scattered throughout the gray-white junction bilaterally, more prominent in the posterior regions.
C3|cervical (level) 3|C3|214|215|PAST  MEDICAL HISTORY|PAST MEDICAL HISTORY: Remarkable for end-stage COPD, oxygen dependent. She has a history of Addison's disease. She has a history of atrial fibrillation. She is status post rectal fistula repair. She is status post C3 laminectomy. She is status post total abdominal hysterectomy for cervical cancer in 1971. She is also status post appendectomy. HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old female with severe COPD who was admitted for weakness and chest pain from the emergency room.
C3|(complement) component 3|C3|199|200|DISCUSSION|She has been subsequently seen not only by her primary care physician, Dr. _%#NAME#%_, but also by rheumatologist, Dr. _%#NAME#%_. Additional lab studies include negative ASO titer, normal levels of C3 and C4, normal serum protein electrophoresis, a second sedimentation rate obtained four days ago elevated to 38, a simultaneous C-reactive protein elevated to 5.28. We note that the patient has a detectable IGG antibodies to parvovirus but no IGM antibodies.
C3|(complement) component 3|C3,|194|196|LABORATORY DATA|Electrolytes showed: Sodium 139. Potassium 6.8. Chloride 108. Bicarbonate 20. BUN 132. Creatinine 14.9. Labs that were drawn at _%#CITY#%_ _%#CITY#%_ Children's that are pending include a FANA, C3, C4, ASO, anti-GBM, and ANCA. RADIOLOGY: Chest x-rays are as described above. ASSESSMENT: 1. Acute renal failure.
C3|cervical (level) 3|C3,|208|210|RECOMMENDATIONS|1. Have a goal of halting the progression of his disease as well as to insure an optimal outcome. I delineated the form of plan of a C3-C4 posterior decompression with placement of lateral mass screws in C2, C3, C4 and C5 followed by temporary closure. We would then reposition the patient and perform a C3-C4 anterior cervical diskectomy and fusion with plate using a corner stone PSR lordotic graft with bone morphogenic protein followed by primary closure, and then repositioning the patient in the prone position and reopening his previous wound and implanting the rods and cross ties and performing a C2 through C5 posterior lateral arthrodesis.
C3|(complement) component 3|C3|255|256|HISTORY OF PRESENT ILLNESS|She was also seen in consultation by Dr. _%#NAME#%_ from rheumatology, who found no signs or symptoms or history suggestive of vasculitis on initial questioning and evaluation. Her workup so far has included: Negative rheumatoid factor, bland urinalysis. C3 and C4 were both within normal limits, chest x-ray negative and serum protein immunoelectrophoresis was likewise unremarkable.
C3|cervical (level) 3|C3.|88|90|HISTORY OF PRESENT ILLNESS|They feel it was apparently a modified mantle field with the superior border roughly at C3. He states that his pain improved after that but started to worsen again 4 days ago, at which time he rated his pain as 10/10.
C3|(complement) component 3|C3,|121|123|ASSESSMENT|ASSESSMENT: 1. Certainly await follow-up laboratory reports as well as EMG. 2. I would like to go ahead and add an ANCA, C3, and DNA antibodies. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 41-year-old white male attorney who was admitted yesterday with the relatively recent onset of problems.
C3|cervical (level) 3|C3,|239|241|LABS|2. Nondisplaced fracture of the left C7 facet. 3. Chip fracture off the superior aspect of the C1 arch versus bone fragment adjacent to the area of osteoarthritis in the atlantoaxial joint. 4. Compression fracture of the superior plane of C3, with retropulsed fracture causing mild spinal canal stenosis. ASSESSMENT/PLAN: The patient is a 57-year-old white female who has been very healthy.
C3|(complement) component 3|C3,|197|199|RECOMMENDATIONS|RECOMMENDATIONS: 1. I would continue IV steroids. I see no need to advance the Cytoxan at the present time. 2. We will check his ANCA subtypes, c-NCA and p-ANCA. We also will obtain cryos, ______, C3, C4 levels. These have been ordered. 3. Either myself or Rheumatology on call this weekend, Dr. _%#NAME#%_, will follow up with you on this patient.
C3|cervical (level) 3|C3|115|116|ASSESSMENT|REQUESTED BY: _%#NAME#%_ _%#NAME#%_, MD ASSESSMENT: 1. Status post posterior spinal fusion C2-C3 with foraminotomy C3 - C7 for treatment of cervical stenosis. 2. Suboptimal pain control postoperatively. 3. Hypertension, stable. 4. History of Sjogren syndrome.
C3|cervical (level) 3|C3|165|166|REQUESTING PHYSICIAN|She was diagnosed with meningitis and staph aureus bacteremia. A work up eventually lead to an MRI scan which identified a cervical epidural abscess, extending from C3 to C6. Evaluation by Dr. _%#NAME#%_ on _%#MMDD#%_ reveals weakness of the right deltoid biceps and mild weakness of the distal right upper extremity.
C3|cervical (level) 3|C3|196|197|PHYSICAL EXAMINATION|Mild pedal edema. Distal pulses are otherwise intact. MRI scan of the cervical and thoracic spine plus lumbar spines are reviewed. Of note, the pre-operative MRI revealed an epidural abscess from C3 to C7 with mild effacement of adjacent spinal cord. There is dural enhancement at L4-5, possibly reflective of meningitis.
C3|(complement) component 3|C3|443|444|HISTORY OF PRESENT ILLNESS|Evaluation thus far here includes WBC 8400 with 4600 neutrophils and 2700 lymphocytes, hemoglobin 13.8, platelet count 293,000, normal chemistry panel, BUN 19, creatinine 0.83, bilirubin 0.2, albumin 4.3, total protein 7.2, ALT 15, AST 15, negative mononucleosis screen, CRP 4.9, ESR 9, negative rapid strep, negative blood culture, normal urinalysis except for small leukocyte esterase, normal chest x-ray, negative rheumatoid factor, normal C3 at 126, normal C4 at 26. Pending are an RPR, wound culture, gram stain on the wound, hepatitis A, B and C, total hemolytic complement, ANCA and ANA.
C3|cervical (level) 3|C3.|174|176|RADIOGRAPHIC STUDIES|There is increase in size of the irregular fluid collection lateral component, which is superficial and just a few millimeters below the skull surface at the level of C2 and C3. Right mastitis is worse. There is no definite dural enhancement, however. Some abnormal low signal intensity is noted in C5 and C6 vertebrae.
C3|cervical (level) 3|C3,|134|136|DOB|She also had an MRI of the cervical spine, which was done in 2002, which showed a small area of abnormal signal in the spinal cord at C3, suggestive of chronic demyelination. MRI of the brain was also obtained on _%#MMDD#%_ and was normal. There was no evidence of intracranial demyelination. The thoracic spine showed no further demyelinating problems.
C3|cervical (level) 3|C3|315|316|RADIOGRAPHIC STUDIES|LABORATORY DATA: White blood cell count 8.3, hemoglobin 12.4, platelet count 149,000, hematocrit 39.4. Sodium 145, potassium 3.7, chloride 108, bicarbonate 29, BUN 47, creatinine 1.1 with glucose of 117. RADIOGRAPHIC STUDIES: Cervical spine from _%#MMDD2003#%_ revealed some residual posterior 4 mm displacement of C3 on C4. ASSESSMENT AND PLAN: Mr. _%#NAME#%_ is a 62-year-old white male with parotitis of the right parotid gland which has been unresponsive to antibiotics.
C3|cervical (level) 3|C3|142|143|PROBLEM|Review of her recent MRI scan demonstrates multilevel cervical stenosis. She does have a congenital and acquired stenosis, it is present from C3 through C7. There are no acute changes. She has mild at worst stenosis. There are no intramedullary signal changes.
C3|cervical (level) 3|C3|194|195|SOCIAL HISTORY|Given the fact that he is kyphotic, I believe that he would be best served by an anterior decompression. This would remove the ventral aspect of the bony compression. I would recommend at least C3 to C6. The issue is whether or not he needs a simultaneous posterior stabilization. Given the fact that we are dealing primarily with a myelopathy, I would recommend focusing on the decompression from C3 to C6 with subtotal corpectomy of C4 and C5, anterior strut graft from C3 to C6 with anterior plate fixation.
C3|cervical (level) 3|C3|303|304|HISTORY OF PRESENT ILLNESS|The patient underwent a couple of neurosurgical procedures. In reviewing his extensive neurosurgical history, it looks like the patient underwent at least 2 different procedures. One on _%#MM#%_ _%#DD#%_, he underwent C3, C4 anterior cervical diskectomy and fusion, C5-6 corpectomy with strut graft and C3 to C7 anterior cervical instrumentation. The second procedure was done on _%#MM#%_ _%#DD#%_, which involved cervical C2 through T3 arthrodesis and C2 through T3 instrumentation.
C3|cervical (level) 3|C3,|141|143|HISTORY OF PRESENT ILLNESS|Additionally he had an MRI scan of the spine revealing multiple areas of abnormal marrow signal involving multiple vertebral bodies from C2, C3, C7, T1, T2 and T3. The spinous process of C2 was also involved. He is referred now for consideration of lumbosacral palliative irradiation.
C3|(complement) component 3|C3|227|228|LABORATORY DATA|Platelets are 215. Some previous labs from her prior hospitalization include on _%#MMDD2002#%_, Strongyloides antibodies negative; on _%#MMDD2006#%_, a fungal serology antibody panel was negative; on _%#MMDD2002#%_, complement C3 and C4 were both low. C3 was 34, and C4 was 4. ANCA was negative. On _%#MMDD2002#%_, ANA was negative. RADIOLOGY: Chest x-ray done on _%#MMDD2002#%_ showed left basilar infiltrate, faint appearance.
C3|(complement) component 3|C3|252|253|LABORATORY DATA|Platelets are 215. Some previous labs from her prior hospitalization include on _%#MMDD2002#%_, Strongyloides antibodies negative; on _%#MMDD2006#%_, a fungal serology antibody panel was negative; on _%#MMDD2002#%_, complement C3 and C4 were both low. C3 was 34, and C4 was 4. ANCA was negative. On _%#MMDD2002#%_, ANA was negative. RADIOLOGY: Chest x-ray done on _%#MMDD2002#%_ showed left basilar infiltrate, faint appearance.
C3|(complement) component 3|C3,|146|148|IMPRESSION|We will evaluate him with a urinalysis, urine for sodium and FEna, urine for eosinophils. We will do glomerulonephritis workup with an ANCA, ANA, C3, C4, CH50, hepatitis C antibody, hepatitis B surface antigen and antibody and a C reactive protein. Will recheck his laboratories in the morning. Given his abdominal discomfort will get a flat and upright x-ray to make sure there is no free air.
C3|cervical (level) 3|C3|131|132|HISTORY OF PRESENT ILLNESS|We were asked to see the patient postoperatively for general medical care. Significant history of posterior cervical spine fusion, C3 through C7, _%#MMDD2006#%_. Chronic pain with bilateral upper extremity radicular component. Hand paresthesias. Subjective weakness. Narcotic requirement over the last 6 years, taking anywhere from 2-4 Percocet daily.
C3|cervical (level) 3|C3|151|152|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old gentleman who is now approximately a month and a half out from a cervical decompression from C3 to C5. He did very following his surgery, but over the last week or so he has developed increased pain in his neck and his right shoulder.
C3|(complement) component 3|C3,|157|159|HISTORY OF THE PRESENT ILLNESS|Work-up revealed no positive cultures and he has subsequently defeveresced. The patient had laboratory studies on _%#MMDD2006#%_ which included an ANA, ANCA C3, C4, hepatitis B. screening and hepatitis C screening. These were all normal with the exception of the ANA which was weakly positive at 1.7. The patient is not able to give a good history right now.
C3|cervical (level) 3|C3|159|160|PAST MEDICAL HISTORY|2. History of left hip surgery. 3. History of right hip surgery in 2005. 4. Left upper rib removal in 1989. 5. L4 resection in 1991. 6. Bone spur resection at C3 in 1992. 7. Right inguinal herniorrhaphy in 1994. 8. Chronic pain syndrome treated with narcotics. 9. Hypertension. 10. Polysubstance abuse as documented on records from Fairview Ridges. ALLERGIES: Codeine causes rash and hydrocodone "shallow breathing." FAMILY/SOCIAL HISTORY: Per documentation on chart.
C3|cervical (level) 3|C3|162|163|IMPRESSION|This has been a progressive problem for him for the past few years. He also has chronic atrial fibrillation and is status post cardioversion. He has a history of C3 fracture in 1998. He has had problems with malnutrition, gastroesophageal reflux disease, and weight loss, and has had a PEG tube placement since _%#MM2004#%_.
C3|(complement) component 3|C3,|115|117|RECOMMENDATIONS|Her ANCA is negative, but other autoimmune labs are pending. RECOMMENDATIONS: 1. I would obtain parvovirus titers, C3, DNA antibodies and repeat urinalysis. 2. I think it would be an interesting idea to stop antibiotics. 3. I would like to start her on prednisone at a small dosage of 15 mg daily.
C3|(complement) component 3|C3|270|271|IMPRESSION|This represents a slightly under-collected specimen for a male and, as such, may actually under estimate the degree or proteinuria that is present in this setting. His work up to date, including serum protein and urine electrophoresis is negative. He has had complement C3 and C4 which have also been negative. If this were glomerular nephritis secondary to infection, one would expect to see low complements.
C3|cervical (level) 3|C3|215|216|HISTORY OF PRESENT ILLNESS|He denied bowel or bladder incontinence. He was referred to Dr. _%#NAME#%_ in _%#MM2004#%_. Dr. _%#NAME#%_ felt he was an appropriate candidate for cervical surgery. He was admitted on _%#MMDD2005#%_, and underwent C3 through C7 laminectomy, foraminectomy, lateral mass fixation and fusion. There were no complications. Postoperatively, he has been immobilized in a cervical collar.
C3|cervical (level) 3|C3|72|73|REASON FOR CONSULTATION|He carries a diagnosis of cervical myelopathy and stenosis, status post C3 though C7 foraminotomy with laminectomy and screw placement by Dr. _%#NAME#%_ on _%#MMDD2005#%_. HISTORY OF PRESENT ILLNESS: Onset of the patient's symptoms seemed to be related to a fall he sustained at work.
C3|cervical (level) 3|C3|132|133|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old gentleman admitted to station 10A following a posterior cervical fusion of C3 and 4, as well as instrumentation and iliac crest bone graft. Since surgery, the patient has experienced a significant nausea. He had two episodes of vomiting last evening and received Zofran with no further episodes of vomiting but continued nausea.
C3|cervical (level) 3|C3|234|235|HISTORY OF PRESENT ILLNESS|She was sober, and then in _%#MM#%_ 2005, the patient had a stroke while she was driving and was in a head- on motor vehicle accident. She sustained an injury to her left leg which required a left above-the-knee amputation. She had a C3 neck fracture and right arm fracture. She has residual side effects from her stroke, including left peripheral vision loss.
C3|cervical (level) 3|C3|224|225|STUDIES|Dense bilateral lower lobe atelectasis. Extensive nodular and ground glass opacities in the upper lobes suspicious for infection. CT of the cervical spine on _%#MMDD2005#%_ shows extensive postop changes, partial _______ of C3 through C5, erosive lytic changes of lateral masses of C3 and 4. CT of the abdomen and pelvis show renal mass involving inferior pole of left kidney, no lymphadenopathy, bibasilar atelectasis, and diffuse hepatic infiltration.
C3|(complement) component 3|C3,|304|306|ASSESSMENT AND RECOMMENDATIONS|However, if tuberculosis wasn't ruled out previously, we will consider ruling this out as a potential contributor to the fever, by perhaps checking a PDD. We would recommend ruling out an additional immunodeficiency. Would suggest checking complement levels to rule out complement deficiency by checking C3, C4, CH50, and to rule out additional immunoglobulin deficiency by checking IgG, IgA, IgM, and IgE. Would check a C-reactive protein level to rule out any potential autoimmune disease.
C3|(complement) component 3|C3|258|259|RECOMMENDATIONS|1. I would proceed with some invasive hemodynamic monitoring with art line which will also allow blood gas monitoring as well as a Swan- Ganz catheter to assess his hemodynamics and gauge fluid therapy. 2. Check cryoglobulins. 3. Check complements including C3 and C4. 4. Stress ulcer prophylaxis in the form of Protonix and DVT prophylaxis in the form of Pneumo-Boots and TED stockings.
C3|cervical (level) 3|C3|145|146|PAST MEDICAL HISTORY|2. Type II diabetes mellitus 3. History of hypertension 4. History of spontaneous cervical hematoma approximately one year ago. 5. This was from C3 to C6. She was seen by Dr. _%#NAME#%_ and this resolved spontaneously. 6. History of osteoporosis
C3|(complement) component 3|C3,|215|217|RECOMMENDATIONS|2. Low level rheumatoid factor, consistent with chronic inflammation. RECOMMENDATIONS: 1. Check MRI of the hips for inflammatory changes. 2. Workup for vasculitis needs to be completed. We will order cryoglobulins, C3, C4 levels, as well as an ANCA that has already been ordered. 3. Check anti-CCP, which is a more sensitive and specific measure for rheumatoid arthritis.
C3|(complement) component 3|C3,|250|252|RECOMMENDATIONS|5) A diffuse vasculitis such as PAN could also provoke pulmonary symptoms such as these. RECOMMENDATIONS: I, at this time, would recommend a serologic work-up which would include an A&E with a demonstration of pattern and titer, double stranded DNA, C3, C4, SSA, SSB, Smith, RNP, sedimentation rate, CRP, both C&P ANKA. I will continue to follow with you. Thank you for this interesting consult.
C3|(complement) component 3|C3|127|128|LABORATORY DATA|He had a sister who had breast cancer and lung cancer. LABORATORY DATA: Anti-GBM is negative. Compliment normal. C4 is normal. C3 is normal. ANA is negative. Chest x-ray shows reticular infiltrates bilaterally at the lung bases which is unchanged from _%#MMDD2002#%_.
C3|cervical (level) 3|C3|398|399|HISTORY OF PRESENT ILLNESS|She denies change in bowel or bladder. She does have occasional headaches, and some shortness of breath. An MRI of the spine was done on _%#MMDD2005#%_ which showed extensive metastatic disease in the cervical and upper thoracic spine with multiple pathologic compression fractures causing severe spinal cord stenosis at C4 and mild spinal canal stenosis at T1 with bilateral foraminal stenosis at C3 to C4. Her pain has improved since admission. She was seen by neurosurgery and they have decided not to do surgery.
C3|(complement) component 3|C3|192|193|PERTINENT LABS|Liver function tests are minimally elevated except for the LDH which is quite a bit elevated. The haptoglobin is low. Reticulocyte count could not be done because of "interfering substances." C3 and C4 are normal. Screening chemistries are normal, although initially a potassium was slightly low. Thank you very much for the chance to see this pleasant woman.
C3|cervical (level) 3|C3|288|289|HISTORY OF PRESENT ILLNESS|Ms. _%#NAME#%_ is a 65-year-old gentleman with cervical radiculopathy, myelopathy, and kyphosis who is status post an anterior cervical procedure for decompression instability in _%#MM#%_ of 2005 who was admitted for an elective part 2 posterior revision with lateral mass screw fixation C3 through C7. Postoperatively he demonstrated significant troubles with pain control requiring a pain consult. A Miami J was used additionally for stability. He was seen by the physical therapist, occupational therapist, and physiatrist.
C3|cervical (level) 3|C3|241|242|PHYSICAL EXAMINATION|Her knees are not acutely inflamed. The ankles show chronic swelling edema and significant joint line tenderness. MTPs have mild inflammation present. NECK: Her neck has reduced range of motion with some tenderness induced with palpation at C3 and C4. ASSESSMENT: 1. Chronic rheumatoid arthritis. Unfortunately, it is endstage result of this devastating chronic disease.
C3|cervical (level) 3|C3|322|323|PAST MEDICAL HISTORY|Primary changes included altered sensory band around her left abdomen, sensation of a blood pressure cuff around her entire right arm, and sensation that her right leg feels like wood. PAST MEDICAL HISTORY: 1. Multiple sclerosis (secondary progressive). 2. Hypothyroidism. 3. Herpes zoster, without complication in a left C3 distribution which began one month ago and has largely resolved. 4. Pneumonia with septic shock and coma x 2 weeks occurring one year ago.
C3|(complement) component 3|C3,|182|184|ASSESSMENT/PLAN|Continue the patient on vent for now. 2. Angioedema of the lips. Differential diagnosis includes systemic massive cytosis and hereditary acquired ___________ deficiency. Check serum C3, C4, CH50, C1Q, C1 esterase inhibitor function study. Check a ganceritriptase level alpha beta, 24 hour urine histamine, 24 hour urine PGD2.
C3|(complement) component 3|C3,|185|187|ASSESSMENT|Various possible diagnoses were explored including exposure to Lyme disease, lupus, or some systemic inflammatory disease. That physician ordered additional lab studies including FANA, C3, C4 and Lyme disease antibody test, results of which were all normal. These records also indicated that a HLA-B27 test was done, with positive results, which raised the possibility that inflammation and oral ulcers are connected.
C3|(complement) component 3|C3,|187|189|RECOMMENDATIONS|RECOMMENDATIONS: 1. I think we obviously will await the other laboratory tests. 2. Await the bone marrow results that was obtained today. 3. I will add some laboratory studies, including C3, DNA antibodies, CK and parvovirus titers. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 42-year-old white female who was admitted yesterday with the recent onset of a febrile illness and other issues.
C3|(complement) component 3|C3,|239|241|RECOMMENDATIONS|RECOMMENDATIONS: 1. I have written for a one week course of prednisone starting at moderately high dose (20 mg b.i.d.) with rapid taper off. 2. Additional laboratory workup as ordered. This will include urinalysis, cardiolipin antibodies, C3, C4 and C reactive protein. 3. It is likely that she will be able to be discharged soon when her chest pain has improved a bit more.
C3|propionylcarnitine|C3|199|200|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a now 9-day- old who is confirmed to have methylmalonic acidemia. Her diagnosis was initially made by an abnormal newborn screen with an elevated C3 with also elevated methylmalonic acid in the newborn bloodspot. Confirmatory tests sent by her primary care physician at Health Partners, Dr. _%#NAME#%_ _%#NAME#%_, revealed that her urine organic acids had a methylmalonic acid of 3000, low serum carnitine, and low plasma carnitine.
C3|cervical (level) 3|C3|115|116|PAST SURGICAL HISTORY|He did smoke cigarettes remotely, but I am not quite sure how much. PAST SURGICAL HISTORY: 1. Fusion of C1 through C3 relating to his fall last summer. 2. He has had a total knee arthroplasty and states that it no longer causes pain.
C3|cervical (level) 3|C3|245|246|HISTORY OF PRESENT ILLNESS|In _%#MM2006#%_ a CT scan revealed increased disease in the vertebrae with the lung and liver stable. In _%#MM2006#%_ he had pain in his right neck and hip and received palliative radiation with the C-spine receiving 4000 cGy in 20 fractions to C3 through C5 and the left hip receiving 4000 cGy, both done in 200 cGy fractions. In _%#MM2007#%_ CT scan of the chest, abdomen and pelvis showed no change in disease.
C3|(complement) component 3|C3,|165|167|PLAN|Her oral infection is being treated with Clindamycin. At this time, I recommend monitoring for resolution of her symptoms off of the propylthiouracil. An ANKA, ANA, C3, C4, and antihistone antibody is pending. Even if these labs do appear positive, I would be hesitant to aggressively treat the associated conditions if there was evidence of resolution off of the propylthiouracil.
C3|(complement) component 3|C3|130|131|LABORATORY DATA|Subsequently had 2 units of RBCs and has been at 9.3. INR 1.18 on _%#MMDD#%_, PTT 33. He has a history of antibodies with IgG and C3 on direct Coombs. LDH 1141 on _%#MMDD#%_, retic count 0.9, haptoglobin 13. Anemia. The patient may possibly have multifactorial anemia with regard to fluid shifts and hematuria.
C3|cervical (level) 3|C3|128|129|HISTORY OF PRESENT ILLNESS|The patient continues to have a frontal headache. An MRI of his cervical spine was performed and shows stenosis stretching from C3 to C6. Neurosurgery was consulted for this finding. The patient denies pain in his upper extremities, numbness in his upper extremities, as well as denying pain and numbness in his lower extremities.
C3|cervical (level) 3|C3|178|179|PAST SURGICAL HISTORY|PAST SURGICAL HISTORY: 1. Left knee replacement. 2. Left knee fusion. 3. Appendectomy. 4. Cholecystectomy. 5. Lumbar decompression. MRI shows stenosis of the cervical spine from C3 to C6. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.4. Blood pressure 115/76. Pulse 98.
C3|cervical (level) 3|C3,|136|138|PHYSICAL EXAMINATION|X-rays: I reviewed the report of his CT scan. I do not have the actual scan. He has severe spinal stenosis at multiple levels including C3, 4-5, 5-6 and 6-7. There is some cord deformity associated with this. ASSESSMENT: Cervical spondylosis. Possible cord compression with signs of upper motor neuron disorder, but not necessarily myelopathic or with evidence of myelomalacia.
C3|cervical (level) 3|C3|144|145|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old male who presents for medical consultation following a posterior cervical lymphoplasty C3 through C7 with instrumentation foraminotomies at C4-5, C5-6, and C6-7. The patient had the surgery today without apparent complications. He has a history of anxiety in is feeling slightly anxious regarding the situation.
C3|(complement) component 3|C3|158|159|IMPRESSION|Will get a FENa to evaluate whether he is prerenal or renal toxicity. Would evaluate his history of a lupus-like syndrome by checking a FANA, CH50, sed rate, C3 and C4. Would also check a liver panel and a lipase with his history of abdominal pain. I have asked Dr. _%#NAME#%_ to send both rapid urine tox screen and a complete drug screen.
C3|(complement) component 3|C3|131|132|LABS|ANA was less than 1.0 or negative. Myoglobin was 27, rheumatoid factor was less than 20, troponin less than 0.07, complement level C3 normal. Magnesium on admission was low normal at 1.6. White count on admission was elevated at 14.8, and his glucose was higher on admission at 182.
C3|(complement) component 3|C3|178|179|DISCUSSION AND RECOMMENDATIONS|DISCUSSION AND RECOMMENDATIONS: I agree with discontinuation of Bactrim. Currently, the patient is not on medication.agree with blood transfusion support. I will obtain DAT with C3 and IgG, Cold agglutinins. will check for G6PD deficiency and repeat a.m. labs with LDH and haptoglobin for followup on hemolysis.
C3|(complement) component 3|C3|252|253|LABORATORY  DATA|UA subsequently specific: specific gravity still concentrated at 1.025, trace ketone, trace blood with 2-5 red cells, positive nitrites, negative leukocyte esterase, 2-5 white cells, hyaline casts and a few granular casts. 5. ANA and ANCA negative. 6. C3 is low at 58. 7. Urine sodium was less than 5. 8. Blood cultures and urine cultures negative growth today.
C3|(complement) component 3|C3,|180|182|RECOMMENDATIONS|His temporal arteries are easily palpable, full, and nontender. He does seem fairly stable since started on Lovenox. RECOMMENDATIONS: 1. He should have a further workup to include C3, C4, anti-DNA antibodies, protein electrophoresis, anti-SSA, anti-SSB, cardiolipin antibodies. We will await his ANCA. 2. I would probably hold steroids for now given his age and other issues and the lack of other clinical features.
C3|(complement) component 3|C3,|167|169|IMPRESSION/RECOMMENDATION|An abdominal/chest/pelvic CT is planned. Probable biopsy of the mass is also planned. Oncology will be following the patient as well. I will order an aldolase, ANCAs, C3, C4, ANA, rheumatoid factor and angiotensin converting enzyme level as well. Thank you for this interesting consult. I will continue to follow.
C3|cervical (level) 3|C3.|166|168|IMPRESSION|It was noted that when looking at the scans from early _%#MM#%_ to the present, there does appear to be incremental increase in the amount of slippage between C2 and C3. The anterior aspect of the ring at C1 appears to be slightly more anterior than clivus and is normal. Of critical note is when working at the base of her skull, there appears to be a fracture through the base of the clivus.
C3|cervical (level) 3|C3|27|28|ASSESSMENT|ASSESSMENT: 1. Status post C3 through C7 posterior decompression and fusion. The patient appears to be doing quite well postoperatively. 2. History of hypertension. Patient's blood pressure has been generally controlled postoperatively.
C3|cervical (level) 3|C3|155|156|DIAGNOSIS|She noted an upper back lesion. She underwent surgery. This was found to be a Clarks level of 4 with some residual tumor. She was treated. She developed a C3 epidural tumor. This was also treated with radiation. On _%#MMDD2005#%_ she underwent gamma knife radiosurgery for 4 tumors. Three of the 4 tumors have disappeared. The fourth shows evidence of central necrosis.
C3|cervical (level) 3|C3|232|233|HISTORY OF PRESENT ILLNESS|She had intact sensation in the lower extremities. She had positive Babinski signs bilaterally. She wasn't able to walk. She also had mild pronator drift bilaterally. Her cranial nerves were intact. She underwent decompression from C3 to C6. There were no intraoperative complications. As she is below her functional baseline, a Physical Medicine and Rehabilitation consult was requested.
C3|propionylcarnitine|C3|122|123|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is an 11-day-old infant who was identified by the State Newborn Screen to have an elevated C3 acylcarnitine. Reflex testing showed elevated methylmalonic acid with absence homocysteine. Follow-up testing sent by the pediatrician showed elevated methylmalonic of over 500 mg creatinine in the urine organic acid study.
C3|cervical (level) 3|C3|229|230|REASON FOR CONSULT|Respiratory easy. Cognitive assessment is unable. Skin at his heels and elbows are within normal limits. ASSESSMENT: A 62-year-old gentleman with cervical stenosis with myelopathy, status post decompression and screw fixation of C3 through C7 on _%#MM#%_ _%#DD#%_, 2005. I am unclear of his current disability in that he is still quite lethargic from surgery and has not yet been evaluated by OT or PT.
C3|(complement) component 3|C3|128|129|ASSESSMENT/PLAN|She previously underwent workup and was found to have a negative ANA, normal total compliment level, and a normal C4 level. Her C3 level was decreased on two occasions to 77 mg/dL and 76 mg/dL in _%#MM2003#%_ and _%#MM2003#%_ respectively. This suggests a defect in the patient's immune system. Given that the patient is doing well clinically on Singulair and Zyrtec, with no episodes of angioedema since her last visit at this clinic, we will not pursue evaluation of the patient's alternatives at this point.
C3|(complement) component 3|C3,|215|217|RECOMMENDATIONS|However, I would recommend a CT of the abdomen to evaluate for possible intra-abdominal process. I would further work up her autoimmune possibilities with a serum protein electrophoresis, C- reactive protein (CRP), C3, C4, hepatitis panel, cryoglobulins, SSA, SSB, anti-native DNA, anti-Scl-70, antimitochondrial, anti-smooth muscle, and antithyroid antibodies. Also, I would continue antibiotic coverage for now.
C3|cervical (level) 3|C3|219|220|PHYSICAL EXAMINATION|The skin is generally intact with rather tight turgor. Circulatory status is intact with exception of small amount of numbness over the dorsum of the foot. AP lateral and oblique views of the foot and ankle reveal type C3 highly comminuted intraarticular distal tibial fibular fracture with severe collapse of the articular surface and at least 15-20 small fragments in the articular surface.
C3|(complement) component 3|C3,|135|137|CURRENT LABORATORY VALUES|He has chronic nystagmus with the last ophthalmologic visit in _%#MM#%_ with no change. CURRENT LABORATORY VALUES: Normal lactate 1.5, C3, C4, sedimentation rate of 9, CRP less than 0.2, ANA 1.3, normal INR, PTT, d-dimer. Multiple laboratory studies are pending, including echocardiogram. He had a renal ultrasound earlier today.
C3|(complement) component 3|C3|215|216|HISTORY|This has not occurred to date. The patient has carried a diagnosis of a "lupus-like" syndrome in the past. She has seen one of my partners. She has been known to have mild elevation of FANA and slight depression of C3 complement. She has had mild elevations of cardiolipin antibodies on at least one occasion. Her creatinine had been stable in the past. She has had arthralgias and low-grade arthritis and was treated with Plaquenil up until about a year ago.
C3|cervical (level) 3|C3|184|185|ASSESSMENT|PTT 28, INR 1.0. Sodium is 142, potassium 4.0, chloride 104, CO2 27, anion gap 11, glucose 136, BUN 17, creatinine 1.09. ASSESSMENT: A 66-year-old male admitted with the following: 1. C3 through C7 laminoplasty for cervical spondylitis/myelopathy. Adequate pain control. Stable neurologic status. 2. Difficult intubation, evaluated with flexible laryngoscopy.
C3|cervical (level) 3|C3|241|242|IMAGING STUDIES|Sensation is intact to light touch and pain in the feet. The toes are upgoing. Reflexes are hyperactive throughout. IMAGING STUDIES: MRI of the neck demonstrates a 6 cm mass involving the retropharynx extending back to encompass the body of C3 and traversing the spinal canal on the left side with compression of the spinal cord and rotation of the cord off to the right.
C3|cervical (level) 3|C3|198|199|LABORATORY DATA|The complete blood count is within normal limits. A head CT performed in the ER is negative. A CT of the cervical spine showed no fracture or subluxations, but there was foraminal stenosis noted in C3 and C4. ASSESSMENT/PLAN: 1. Depression. 2. Suicidal ideation.
C3|cervical (level) 3|C3|230|231|HISTORY OF THE PRESENT ILLNESS|4. No indication for steroids at this time. 5. Will check pulmonary function tests after his surgery heals. HISTORY OF THE PRESENT ILLNESS: The patient is a 59-year-old male with achondrodysplasia/ dwarfism. The patient underwent C3 through C7 decompression with spinal stenosis due to his achondrodysplasia on _%#MMDD2002#%_ The patient was noted to have some wheezing intraoperatively as well as some increase in his airway pressures.
C3|cervical (level) 3|C3|168|169|RADIOLOGIC DATA|There also appears to be a T2 through T3 disc herniation causing mild compression on the thecal sac. CT scan of the cervical spine reveals degenerative disc disease at C3 through 4 and C5 through 6 with ossification of the posterior longitudinal ligament from C3 through C7. Severe spinal canal stenosis is noted at C3 through 4 and C5 through 6 secondary to osteophytes.
C3|cervical (level) 3|C3|215|216|RADIOLOGIC DATA|CT scan of the cervical spine reveals degenerative disc disease at C3 through 4 and C5 through 6 with ossification of the posterior longitudinal ligament from C3 through C7. Severe spinal canal stenosis is noted at C3 through 4 and C5 through 6 secondary to osteophytes. No fractures are noted on the CT scan. Cervical myelogram was also obtained.
C3|(complement) component 3|C3,|190|192|RECOMMENDATIONS|1. Angiogram is pending. 2. Laboratories as ordered that will include ANA, double stranded DNA, FM antibody, antihistone antibody, sedimentation rate, C reactive protein, repeat urinalysis, C3, C4, CH50, ANCA, serum electrophoresis. 3. I have ordered a high resolution chest CT scan for further evaluation of the pulmonary hypertension and other pulmonary findings.
C3|(complement) component 3|C3|280|281|IMPRESSION|Given the negative BAL studies for infection thus far, I agree that obtaining lung tissue will be critical to rule out an opportunistic infection. 2. Acute renal failure of unclear etiology. The patient's doubled-stranded DNA was negative previously. However, she does have a low C3 and a history of proteinuria, as well as lymphopenia, which is suggestive of active lupus. Renal sediment can be relatively benign with DPGN. However, given the multiple possible causes of renal failure in this patient, obtaining renal tissue to guide therapy, would be extremely helpful.
C3|cervical (level) 3|C3|158|159|RECOMMENDATIONS|RECOMMENDATIONS: I believe that she should undergo urgent compression of her cervical spinal through a cervical laminectomy which I will try to restrict from C3 to C5. I should be able to compress the collection if it is liquid through this relatively small opening and to the intraspinal canal.
C3|cervical (level) 3|C3|196|197|HISTORY OF PRESENT ILLNESS|At this point, conservative treatment was recommended. The patient, however, has had some bilateral upper extremity pain, left greater than right. She has had this pain ever since she underwent a C3 through C7 spinal fusion surgery per Dr. _%#NAME#%_ at Abbott Northwestern Hospital in _%#MM#%_ of 2006. This pain persisted but improved with physical therapy.
C3|(complement) component 3|C3|186|187|PLAN|PLAN: 1. Labs ordered today include a FANA, anti-DNA, anti-ENA, anti-SSA, anti-SSB, ANCA, C-reactive protein, sedimentation rate, rheumatoid factor, serum protein electrophoresis (SPE), C3 and C4 levels. 2. Will follow along this patient while she is in the hospital and check to see if any of these labs come back positive.
C3|(complement) component 3|C3|240|241|HISTORY OF PRESENT ILLNESS|White blood cells were 12.8, neutrophils 77%, eosinophils 5%. RAST testing was negative for timothy, grass, ragweed, herbarium, aspergillus fumigatus A alternata. Also negative RAST test for silver birch, oak, and D pteronyssinus, farinae. C3 was 126, C4 was 34, CH50 111. At the end of the visit at the allergy clinic, the patient was asked to increase her Advair to 2 puffs of 500/50 b.i.d., but on questioning today the patient states she was actually still only taking 1 puff b.i.d. The patient had also been told she could continue her Allegra, but she had stopped it recently, thinking that she may have required skin tests on the upcoming allergy clinic visit.
C3|(complement) component 3|C3|122|123|ASSESSMENT|ASSESSMENT: The patient is a 34-year-old woman who is status post C1 and partial C2 resection, as well as occiput through C3 fusion. Although she demonstrates no new neurologic deficits, she does have significantly compromised balance secondary to halo vest and deconditioning due to the last two weeks of bedrest.
C3|cervical (level) 3|C3|311|312|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 57-year-old female who presented on _%#MM#%_ _%#DD#%_, 2002 with decreased mentation and neck pain, noted to have an epidural abscess which was drained at Fairview Southdale Hospital by Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_. She underwent a laminectomy from C3 through T2. The patient is intubated and unresponsive and on IV antibiotics. She has cultured positive for Strep. On CT scan of the neck performed yesterday, _%#MM#%_ _%#DD#%_, she was noted to have a 2 cm right posterolateral paraspinal abscess and also a phlegmon and abscesses in the prevertebral space at the level of the thyrohyoid membrane.
C3|(complement) component 3|C3|245|246|RECOMMENDATIONS|Rather, I would favor some primary pulmonary process, particularly atypical infection, lymphoproliferative malignancy or even amyloid. It appears that tissue may be necessary. RECOMMENDATIONS: 1. Would check a CK, protein electrophoresis, ANCA, C3 and repeat liver functions to completely work up. 2. Consider lymph node (lung) biopsy. 3. Consider bone marrow. SUBJECTIVE: _%#NAME#%_ _%#NAME#%_ is a 77-year-old white female admitted several days ago.
C3|(complement) component 3|C3|130|131|MEDICATIONS|Noteworthy serologic studies done during the last hospitalization include a negative ANA, a negative ANCA, but low levels of both C3 and C4 components of complement. The patient had an elevation of his platelet function clotting test in spite of a normal platelet count during the last hospitalization.
C3|cervical (level) 3|C3|171|172|HISTORY|HISTORY: The patient is being admitted to 10A. The patient is a 53- year-old female who underwent posterior cervical osteotomy with dural patch and anterior decompression C3 through C7 by Dr. _%#NAME#%_ _%#NAME#%_ from Spine Surgery earlier today. We were asked to see the patient postoperatively for general medical care with particular regard to known history of diabetes and hypertension.
C3|cervical (level) 3|C3|229|230|ASSESSMENT|Minor nonspecific T-wave abnormality inferiorly and across the anterolateral precordium. ASSESSMENT: The patient is a 53-year-old female with the following: 1. Posterior cervical osteotomy/dural patch with anterior decompression C3 through C7 (as above). Prolonged anesthesia. Stable hemodynamics. Adequate pain control. Residual somnolence secondary to protracted effects from anesthesia, which has gradually diminished in the PACU.
C3|cervical (level) 3|C3|158|159|HISTORY OF PRESENT ILLNESS|The patient is status post cervical spine surgery. HISTORY OF PRESENT ILLNESS: This is a 53-year-old female who is status post posterior cervical fixation at C3 through C7. She was taken back for durotomy exploration, repair, and lumbar drain placement. She is now in the ICU with a questioning of worsening cerebrospinal fluid collection, as seen on MRI.
C3|cervical (level) 3|C3|184|185|HISTORY OF PRESENT ILLNESS|A chest x-ray showed a new upper lobe pulmonary mass of unclear etiology. CT PET scan done earlier this week showed diffuse hypermetabolic lesions in her left trochanter, mid-sternum, C3 and L2 vertebrae, as well as the right hilar node. Ms. _%#NAME#%_ has been feeling better in general since her admission.
C3|cervical (level) 3|C3,|184|186|IMAGES REVIEWED|IMAGES REVIEWED: Lumbar spine x-ray from _%#MMDD2007#%_ demonstrate no fractures. Lumbar spine CT from _%#MMDD2007#%_ demonstrated no fractures and evidence of previous laminectomy at C3, C4, and C5 and lumbar spine MRI obtained on _%#MMDD2007#%_ demonstrated no evidence of cord compression. LABORATORY DATA: Sodium 139, creatinine 1.0, hemoglobin 11.5, white count 7.4, platelets 218.
C3|cervical (level) 3|C3|207|208|SUBJECTIVE|The patient's low back and neck pain began due to an injury in 1993 when he worked as a firefighter and carried an 11-year-old child down multiple flights of stairs. In 1993 he had surgery to replace C2 and C3 at Mercy Hospital. Approximately 5 weeks ago the patient had back surgery to fuse L4 and L5. Other than his low back and neck pain the patient has no other complaints today.
C3|(complement) component 3|C3|179|180|RECOMMENDATIONS|RECOMMENDATIONS: 1. Continue IV fluids with normal saline. 2. Repeat routine urinalysis; urine culture and blood cultures are pending. 3. Check fractional excretion of sodium. 4. C3 C4, FANA, ANCA all pending. 4. Further workup pending course. At this point it would seem that renal biopsy is not indicated.
C3|cervical (level) 3|C3|218|219|ASSESSMENT AND PLAN|Most recent CT scan from _%#MMDD2007#%_ shows fusion C3 to C6 anterior posterior. ASSESSMENT AND PLAN: 17-year-old young man with esophageal perforation status post cervical fracture and fusion anterior/posterior from C3 to C6. 1. We will discuss timing of the surgery with Dr. _%#NAME#%_ and Dr. _%#NAME#%_.
C3|cervical (level) 3|C3|325|326|IMAGING|IMAGING: An MRI of her cervical spine done on _%#MMDD2007#%_ which is without contrast, which is of good quality at an outside institution, which is in our PAC system shows 1 cervical 2-3 intervertebral T2 hyperintensity extending posteriorly, which also extends superiorly and inferiorly into the vertebral bodies of C2 and C3 without any cord compression. This is likely diskitis, osteomyelitis and/or abscess. LABORATORY EXAMINATION: Sodium 141, potassium 3.7, chloride of 101, BUN 10 and creatinine 0.5 with a white count of 8.8, hemoglobin of 12.8 and platelets of 207.
C3|cervical (level) 3|C3|174|175|PAST  MEDICAL HISTORY|6. Hypertension 7. Hyperlipidemia 8. BPH. 9. History of rheumatoid arthritis. 10. History of nephrolithiasis, specific details not known. 11. History of cervical laminectomy C3 through C7. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 77-year-old man who was hospitalized _%#MMDD#%_-_%#MMDD2007#%_ when he was hospitalized for coronary artery bypass grafting and aortic valve replacement.
C3|(complement) component 3|C3|241|242|HISTORY OF PRESENT ILLNESS|She has been in and out of the hospital and during the course of her hospitalizations she was seen by Dr. _%#NAME#%_. Laboratory studies showed a significant positive FANA with a positive anti-SM, positive RNP, positive SSA, low complements C3 and C4, and a positive double stranded DNA antibody. A diagnosis of systemic lupus erythematosus was made. At that point, she had also developed a rash on her malar region as well as the palms of her hands and on her feet.
C3|(complement) component 3|C3|143|144|HOSPITAL COURSE|Cardiolipin antibodies were essentially unremarkable. Rheumatoid factor was elevated at 1000. Antinuclear antibody screen was weakly positive. C3 was 99 with a C4 of 11. Total complement was low normal. The patient was given high dose oral steroids with some improvement in his symptoms.
C3|cervical (level) 3|C3|217|218|STUDIES/IMAGING|3. C-spine films, swimmer's view, on _%#MMDD2004#%_ revealed degenerative changes, C-spine with loss of disc space height at C2 to C6. No fracture or subluxations. 4. CT study of C-spine on _%#MMDD2004#%_ revealed at C3 cannot exclude compression fracture, but no definite posterior displacement of bone into central canal. Significant motion artifact. 5. CT of head without contrast on _%#MMDD2004#%_ revealed no significant changes with age-related volume loss and large lateral and 3rd ventricle.
C3|(complement) component 3|C3|240|241|SUMMARY OF HOSPITAL COURSE|Again, the chest CT scan showed indeterminate mediastinal and hilar lymphadenopathy, increased patchy bibasilar infiltrate changes, Aldolase level was 9.7, upper limit of normal is 8.1. CK level was normal. Myoglobin was normal. Compliment C3 and C4 were within normal limits. C-reactive for K 7.24. IGE level was very high at 2608. Hemoglobin A1C was 5.9. ANA was negative. C-ANKA was negative.
C3|(complement) component 3|C3,|236|238|FAMILY HISTORY|At the time of discharge, rheumatology had recommended repeat lab studies to confirm the diagnosis, and these lab studies are still pending or will be drawn as an outpatient at the time of dictation, and they include factor X activity, C3, C4, double-stranded DNA, lupus anticoagulant, anticardiolipin antibodies, and ENA panel. Rheumatology did recommend that for the patient's anticoagulation to follow factor X activity and the goal of factor X activity is between 20% to 25%.
C3|(complement) component 3|C3,|305|307|POSTOPERATIVE COURSE|One further Prograf level was also checked on _%#MMDD2003#%_ and was found to be 8.5. Per the transplant team, their goal postoperatively was to keep her between 5 and 8, and the did not do any dose adjustments at that time as they were happy with that level. Nephrology team also requested an ANA level, C3, and C4 levels to be drawn prior to discharge and those are pending at the time of this dictation. The patient had fasting cholesterol checked prior to discharge and it returned within normal limits (cholesterol 199 with triglycerides 126, LDL cholesterol 124, and HDL 49).
C3|propionylcarnitine|C3|294|295|FURTHER DISCHARGE INSTRUCTIONS|In addition, she is to follow up with the primary physicians, if she has any concerns regarding the patient's development, growth, and management. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 6-day-old term new born female who was discovered on the Minnesota new born screen to have an elevated C3 acylcarnitine level of 10.85 with a normal level being less than 5.25. Further, second tier testing revealed methylmalonic acid level of 160 with a normal range being less than 15.
C3|(complement) component 3|C3|126|127|DISCHARGE MEDICATIONS|On _%#MM#%_ _%#DD#%_, 2002, to evaluate for vasculitity secondary to his elevated ESR and CRP. ANCA was less than 1:16 ratio. C3 was 126, C4 was 27. During the course of the hospital stay, the etiology for his weight loss was continued to be undetermined.
C3|propionylcarnitine|C3|93|94|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Possible cobalamin deficiency (newborn metabolic screen positive for C3 acetylcarnitine, homocystine and methylmalonic acid. Urine organic acids with mildly elevated methylmalonic). 2. Unconjugated hyperbilirubinemia status post phototherapy, likely physiologic.
C3|propionylcarnitine|C3|150|151|HOSPITAL COURSE|The patient continued to breast feed well throughout hospitalization. 2. Metabolic. Given the newborn metabolic screen pattern of modest elevation of C3 acetylcarnitine at 6.94 micromoles per liter (abnormal greater than 5.25), with mild elevation of homocystine at 20 micromoles per liter (abnormal greater than 15) and methionine of 11.5 micromoles per liter (abnormal greater than 5).
C3|(complement) component 3|C3|222|223|LABORATORY DATA|4. Liver function tests were all normal. Her albumin was at 2.2 with total protein of 6.5. 5. INR 1.46. 6. HIV negative. 7. CMV antigenemia negative. 8. _%#MMDD2003#%_. Cryoglobulin negative. 9. _%#MMDD2003#%_. Complement C3 at 35 and C4 at 11. For C3, normal is 90-100 and C4 normal is 15-50. 10. Rheumatoid factor _%#MMDD2003#%_, 354, normal 0-20. 11. _%#MMDD2003#%_. Iron studies: Iron level 89, normal 35-180, transferrin 75, normal 210-360, total iron binding capacity 112, normal 315-540, iron saturations 79%, ferritin 386, normal 10-300.
C3|(complement) component 3|C3|201|202|PROBLEM #2|The creatinine to 1.6 relatively stable a high of 1.7. A large batter of labs were ordered during the course of hospitalization to determine the cause of the renal failure. These included a complement C3 and C4, ASO and anti-DNase B titers, FANA, ANCA, sedimentation rate, CRP, and a glomerular basement membrane. All labs were within normal limits with the exception of ASO titer which was elevated at 2,100.
C3|(complement) component 3|C3,|287|289|PLAN|Outside records have been obtained at the time of this dictation and there is no significant laboratory results regarding a rheumatologic workup. We will ask for a Rheumatology consult and send of multiple rheumatologic studies including ANCA, antinuclear antibody, double stranded DNA, C3, C4 and total compliment levels, rhe umatoid factor and vitamin D levels. Preliminary consultation with Rheumatology has requested angiotensin-converting enzyme, hepatitis serologies, EBV and CMV, antiglomerular basement membrane, and parvovirus serologies.
C3|(complement) component 3|C3|250|251|HOSPITAL COURSE BY SYSTEMS|On admission, the patient's protein-to-creatinine ratio was 0.95. It peaked at 2.5 and then by the time of discharge it was back down to 0.74. With respect to her compliment levels she was admitted with a C3 of 67 and a C4 of 17 and on discharge her C3 was 88 and her C4 was 19. Antidouble stranded DNA was 125 on admission and 77 on discharge. At the time of discharge it was thought that her Zoster as well as her periorbital cellulitis had become close enough to resolution that it would be safe to restart her CellCept at her previous dose and continue her prednisone at the dose that was maintained during her hospitalization.
C3|(complement) component 3|C3|143|144|ASSESSMENT AND PLAN|Will check IgG, IgM, IgA titers and IgG subclasses. Will check an HIV test as discussed with the patient, and he does consent. Will also check C3 and C4 complement levels. Consult with Dr. _%#NAME#%_, his hematologist, who is familiar with him to further follow and to make other suggestions as needed.
C3|(complement) component 3|C3|192|193|HOSPITAL COURSE|During this hospitalization, we repeated complements as well as double stranded DNAs and CRPs and sedimentation rate. The CRP was approximately 1.89 on admission, sedimentation rate being 18, C3 170, C4 was 26, and a homocystine level was 25.2. RNP antibody IgG was 7, Smith antibody was 13, and a UA was obtained which did reveal some hyaline casts.
C3|cervical (level) 3|C3|182|183|INTERIM DIAGNOSES|Mild aortic root dilatation. There was moderate concentric left ventricular hypertrophy. 6. C3-C4 anterior cervical decompression, evacuation of abscess, diskitis and osteomyelitis. C3 -C4 arthrodesis with PEEK grafting BNP. C3-C4 instrumentation with 32.5 mm vision plate and four fixed 13 mm screws. 7. MRI of the C-spine with and without contrast performed on _%#MMDD2007#%_.
C3|cervical (level) 3|C3|233|234|HISTORY OF PRESENT ILLNESS|She is familiar with some of her care as well as the Neurology Service there. On their review in the emergency department at Mayo, they decided after looking at AP and lateral x-rays of the cervical spine, that the existing hardware C3 through C6 anterior and posterior fusion with C4-5 corpectomies and fibular strut graft was all intact. They sent her to her primary care physician for further observation, work-up and question of outpatient scheduled MRI.
C3|cervical (level) 3|C3|147|148|PAST MEDICAL HISTORY|3. Cervical cancer, status post hysterectomy. 4. History of motor vehicle accident resulting cervical strain and chronic neck pain. 5. Status post C3 through C6 anterior and posterior fusion with C4-5 and C5 corpectomies. The operative indication for this was cervical myelopathy and central canal "narrowing."
C3|cervical (level) 3|C3|175|176|IMAGING|IMAGING: 1. C-spine x-ray was performed, AP and lateral: The hardware seen appe ars to be intact and correctly placed Thre is what appears to be a laminar wire located at the C3 level, although this is oddly placed. There are lateral mass screws at C3, 4, 5 and 6. Anteriorly there is a fibular strut graft at levels 4 and 5 where corpectomies were done.
C3|(complement) component 3|C3|195|196|ASSESSMENT|However, this concern appears to have been dispelled with improved counts without any major treatment. There does not appear to be any other obvious cause for the serositis aside from her lupus. C3 levels are normal which is also a little bit atypical. In general, I would have thought this would have been a lower low normal in the presence of active inflammatory disease.
C3|(complement) component 3|C3|188|189|HOSPITAL COURSE|The patient was started on prednisone 60 mg po qd and rapidly tapered to 40 mg po qd. Close follow up will be done as an outpatient with Dr. _%#NAME#%_. ANA titers less than 1, complement C3 184 normal, complement C4 43 normal. Angiotensin converting enzymes increased 149 (normal 9-67). 3. Renal failure of chronic renal failure: The patient had a bland urinalysis.
C3|(complement) component 3|C3|141|142|PROBLEM #3|The thought of a rheumatologic based autoimmune process is raised although she has a negative ANA. Compliment levels were sent and her total C3 is decreased at 77. The CH50 is pending at the time of this dictation, but the results should be followed up as an outpatient.
C3|(complement) component 3|C3.|247|249|DISCHARGE DIAGNOSIS|He was transfused with packed red blood cells 3 times in _%#CITY#%_ with the highest hemoglobin level of 8.3. In _%#CITY#%_ other notable laboratory tests included a total bilirubin of 6.2, a direct antiglobulin test positive for Coombs with anti C3. The blood bank then showed cold antibodies. A review of the peripheral blood smear also showed marked agglutination. A manual reticulocyte count was done and was 9.8. The testing for RSV, influenza AB, parainfluenza, and adenovirus were negative.
C3|(complement) component 3|C3|299|300|LABORATORY|A CBC revealed a white count of 7.7, hemoglobin of 8, platelets of 189. echogenicity of 134, potassium of 5.0, chloride of 111, CO2 of 15, glucose of 136, BUN 50, creatinine 5.0, and a calcium of 6.8. Her albumin was 2.6, ionized calcium was 3.8, phosphorus was 8.2, magnesium 1.2, uric acid 6.6. A C3 was 85, a C4 was 15. Double- stranded DNA was weakly positive at 58. Cardiolipin antibody IgG was absent, but IgM was positive at 16.5. An INR was 0.94, PTT 28, thrombin time 19, antinuclear antibody positive at 4.1. Renal ultrasound on admission revealed kidneys with increased echogenicity in the cortices bilaterally.
C3|(complement) component 3|C3|180|181|PROBLEM #2|Doctors _%#NAME#%_ and _%#NAME#%_ were extensively involved in _%#NAME#%_'s hospital stay. Labs on admission included a double stranded DNA level of 2090. ANA was greater than 10. C3 initially was 19 which improved to 55 by discharge. C4 was initially 3 and improved to 6 by discharge. ESR was 126 and improved to 104 at discharge though it fluctuated quite a bit throughout the hospital stay.
C3|(complement) component 3|(C3|204|206|PAST MEDICAL HISTORY|His appetite he reports is normal. PAST MEDICAL HISTORY: 1. SLE. A. Diagnosed at age 14 (_%#MM#%_ 1999) with fatigue, N/V, low-grade fever, rash, weight loss of 25 pounds, hepatitis, with low complements (C3 was 76, C4 11), positive FANA, leukopenia, positive anti-Smith, positive ds anti-DNA. The patient was treated with prednisone. B. Flare of SLE in _%#MM#%_ 2000, the patient was treated with prednisone and Imuran, methotrexate.
C3|(complement) component 3|C3|143|144|PAST MEDICAL HISTORY|We also checked both C3 and C4 to follow the status of her transplant kidney. On admission the C3 was 22 and a C4 was 14, and on discharge the C3 was 38 and the C4 was 22. We also did a 24-hour urine collection which showed an elevated protein to creatinine ratio of 1.76. DISCHARGE INFORMATION: The discharge diagnosis was a central line catheter infection which was removed and then replaced during this hospitalization.
C3|(complement) component 3|C3,|264|266|MAJOR INVESTIGATIONS AND PROCEDURES DONE DURING THIS HOSPITALIZATION|The stool bacterial culture for SSCE was negative. A special stool culture for vibrio non-cholera as well as cholera species were carried out and was found to be negative. 5. IBD serology screen. The patient's ANCA was strongly positive with a titer of 1:160. Her C3, C4, CH50 50 levels were normal. Rheumatoid factor was negative. Her HIV was negative. Her CRP on admission was 130. 6. CT-guided biopsy of necrobiotic pulmonary nodules. This was done on _%#MMDD2007#%_.
C3|(complement) component 3|C3|119|120|DISCHARGE MEDICATIONS|Specifically, the ENA panel is pending. rheumatology have requested C3 and C4, both of which are within normal limits. C3 is 138 with a range between 90 and 200. C4 is 22 with a range between 15 and 50. Serum IgG, IgA, IgM were all repeated per rheumatology's recommendation, and they are all within normal limits.
C3|cervical (level) 3|C3|318|319|HOSPITAL COURSE|There are active areas of demyelination. On the cervical spine MRI, this was a limited exam secondary to patient motion, but there is probable abnormal T2 signal hyperintensity within the cervical spinal cord, likely related to the multiple sclerosis. The T2 signal hyperintensity is present in multiple areas between C3 and C6 levels. There is no abnormal contrast enhancement within the cervical spinal cord. The patient was continued on her Betaseron and Fampridine at the beginning of the admission.
C3|(complement) component 3|C3|132|133|PROCEDURES PERFORMED|All of these studies were normal except for a slightly elevated IgE level at 315. The CH50 was normal along with the C4 levels. The C3 level was slightly low at 84. The patient's rheumatoid factor level was slightl y elevated at 36 with a normal ranging between 0-20.
C3|(complement) component 3|C3|213|214|LABORATORY DATA|LDH 11,200. Iron 80, iron saturation 36%, transferrin 149, transferrin binding 222. Urinalysis: pH 5.5, protein 10, mucus positive, creatinine 201, total protein 0.14, protein to creatinine ratio 0.07. Complement C3 160, C4 16, CK less than 20. C-reactive protein 117. Flow cytometry shows precursor B lymphoblastic leukemia. HOSPITAL COURSE: Problem #1. Oncology: Peripheral blood was drawn with smears done.
C3|(complement) component 3|C3|136|137|LABORATORY VALUES|Hemoglobin remained normal. Molecular diagnostics demonstrated a normal factor V Leiden. Normal rheumatoid factor was found. Complement C3 and 4 were normal. The anti-rho and anti-LA antibodies were also quite normal, as were C-reactive protein and ESR. Smith antibody was done. DNA double-stranded angiotensin and .............enzyme were also done and quite normal.
C3|cervical (level) 3|C3|314|315|HISTORY OF PRESENT ILLNESS|Bilateral hip x-ray done on _%#MMDD2002#%_ that reveals multiple lytic lesions involving both iliac bones, sacrum, femoral neck on the right. HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old man with multiple myeloma diagnosed in _%#MM#%_ of 2001 when he presented with T1 compression fracture with C7 and C3 lytic lesions visualized on x-ray with normal SPEP and positive UPEP with light chains 2.23 grams in 24 hours. Bone marrow biopsy revealed 50% of plasma cells. At the time of presentation, the patient presented with normal hemoglobin, normal creatinine, and hypercalcemia with calcium of greater than 10.
C3|(complement) component 3|C3|200|201|HOSPITAL COURSE|Her rheumatologist, Dr. _%#NAME#%_, was consulted to obtain a better history and assessment of patient's lupus. In addition, to help determine if patient's clinical picture was due to active lupus, a C3 and C4 were obtained. C3 was 86. C4 was 14. CRP was 288. ESR was 94. The CRP and ESR were felt to be unreliable due to patient's postoperative state and anemia.
C3|cervical (level) 3|C3|388|389|PAST MEDICAL HISTORY|A CT scan was performed on _%#MMDD2007#%_ of the abdomen and pelvis, because of patient having fevers, and abdominal pain, and there was some concern that he might have an abscess in his VP shunt system; however, that was felt to be negative per the radiologist's report. PAST MEDICAL HISTORY: 1. History glioblastoma multiforme. Please see my extensive history in the HPI. 2. History of C3 and C4, as well as C4-C5 effusions following traumatic spinal surgery. 3. History of previous knee surgery. 4. Gastroesophageal reflux disease.
C3|(complement) component 3|C3|166|167|HOSPITAL COURSE|Normal range was 0 to 240 international units per milliliter and thus is unremarkable. She concurrently had a DNAPB test sent which was also unremarkable. Complement C3 and C4 were evaluated and both were reasonable with C3 at 117 and C4 at 16. ANA was negative at less than 1.0. Hepatitis serologies were unremarkable.
C3|(complement) component 3|C3|174|175|PROBLEM #8|An ANA was found to be less than 1, and ANCA less than 1:116. A double-stranded DNA was less than 2. RNP's, Smith, SSA, SSB and scleroderma were also thought to be negative. C3 and C4 levels were also in the normal range. An ESR on admission was 52, along with a CRP of 13 at the time of discharge.
C3|(complement) component 3|C3,|216|218|IMPORTANT LABORATORY DATA|CONSULTS: 1. Rheumatology. 2. Transfusion medicine. 3. Physical therapy. 4. Occupational therapy. 5. PMNR. 6. Nutrition. IMPORTANT LABORATORY DATA: The following labs were negative including blood cultures, CRP, C4, C3, IgA, IgG, IgM, lupus anticoagulant, cardiolipin IgG and IgM, compliment CH50, hepatitis B and C, stool VRE negative x2. . Positive labs include ESR of 135, positive NMO antibody, urine culture growing E. coli.
C3|(complement) component 3|C3|178|179|LABORATORY DATA|A chest x-ray was ordered when she entered the hospital. It was described as having patchy perihilar densities due to poor inspiration with an otherwise normal x-ray. Complement C3 was 146, complement C4 was 22. She had an antinuclear antibody screen that was less than 1.0. She had a neutrophil cytoplasmic antibody IgG screen that was interpreted as negative.
C3|(complement) component 3|C3|113|114|HOSPITAL COURSE|Ultimately lab values came back showing a positive ASO titer, a negative FANA, a negative ANCA, as well as a low C3 and a low C4 level. Anti-DNase B was still pending upon discharge. Urinalysis showed blood as well as protein but was not significant for a urinary tract infection on urine culture.
C3|cervical (level) 3|C3,|259|261|PHYSICAL EXAMINATION IN THE EMERGENCY DEPARTMENT GENERAL|Cranial Nerves 3, 4, and 6: Forward gaze is conjugate, extraocular movements are intact, there is no nystagmus, pupils are equally round and reactive to light and accommodation bilaterally. Cranial Nerve 5: Facial sensations of light touch intact, C1 through C3, corneal reflex intact bilaterally. Cranial Nerve 7: Facial strength is symmetric. There is no facial asymmetry noted. Cranial Nerve 8: Hearing intact bilaterally. Cranial Nerve 9 through 12: The uvula elevates midline, the tongue protrudes midline.
C3|(complement) component 3|C3|136|137|HISTORY OF PRESENT ILLNESS|He has been an otherwise healthy child. Workup done during his _%#MMDD#%_ admission revealed negative P and C ANCA, negative ASO titer, C3 was 95 (normal), C4 was 29 (normal), FANA was negative. He was noted to have an elevated total cholesterol at 272, with an elevated LDL fraction at 175, and an elevated triglyceride fraction at 281.
C3|(complement) component 3|C3|176|177|HOSPITAL COURSE|Infectious cause was also another possibility; however, her CRP remained low throughout her hospital stay. In addition, her FANA, ANCA and complement were normal. Of note, her C3 was low-normal at 77; her C4 was 17. In treatment for acute renal failure which developed the night of _%#MMDD2004#%_ with a creatinine rise to 3.43 and a BUN of 61, she was begun on hemodialysis.
C3|(complement) component 3|C3|268|269|HISTORY OF PRESENT ILLNESS|A head MRI was ordered and performed on the morning of admission; this was normal. Labs drawn in clinic on the day of admission following his MRI revealed a creatinine of 4.5, BUN of 54, urinalysis was greater than 300 protein and positive for red blood cells, normal C3 and C4 levels, and an ASO titer only slightly above the normal range, at 141. His blood pressure at that time, on the day of admission, was 170/120.
C3|(complement) component 3|C3|181|182|LABS UPON ADMISSION|Rapid influenza A and B was found which was negative along with the rapid strep which was negative. Laboratories 2 weeks prior to admission had demonstrated normal complement level C3 being 94 and C4 is 16 respectively, and CRP of 0.40. _%#NAME#%_'s CRP upon admission was 145 mg/L. HOSPITAL COURSE: 1. Fluid, electrolytes, and nutrition: _%#NAME#%_ came into the hospital on a 1 liter fluid restriction.
C3|(complement) component 3|C3|212|213|LABORATORY DATA|Her urinalysis showed small bilirubin, moderate blood, 2 RBCs, 2 WBCs, negative nitrites and negative leukocyte esterase, many bacteria. Chest x-ray and abdominal x-rays were done and described above. Her C4 and C3 were both very low at 3 and 58, respectively. Her LD was elevated at 2760. Her reticulocyte count was extremely elevated at 61.4%. Her haptoglobin was less than 6.
C3|(complement) component 3|C3|194|195|HISTORY OF PRESENT ILLNESS|Her urine showed significant amount of blood and her creatinine did not correct with hydration and so further work-up of glomerulonephritis was undertaken. The patient had low compliment levels C3 was 16 and C4 was 2. Hepatitis B surface antigen negative. Final hepatitis C evaluation was negative. ANA was strongly positive. ANCA was negative. The patient had iron studies suggestive of chronic inflammatory anemia.
C3|(complement) component 3|C3|222|223|HOSPITAL COURSE|On _%#MMDD2004#%_, an influenza antibody rapid antigen and an RSV antigen and culture were sent and were negative. Compliment CH50 total was sent and was normal, as well as C3 and C4, which were decreased, with compliment C3 55 and compliment C4 7. After the patient completed treatment with Cytoxan plasmapheresis was switched to high-dose prednisone 80 mg followed by 60 mg p.o. q.i.d. and had rare episodes of hemoptysis.
C3|(complement) component 3|C3|293|294|LABORATORY DATA|LABORATORY DATA: At the time of admission, laboratory results were significant for sodium 139, potassium 4.7, chloride 109, bicarb 20, BUN 15, creatinine 0.75. Glucose 112. Calcium 9.4. Albumin 4.2. White blood cell count 3.8. Hemoglobin 13.8. Platelets 303. INR 1.02, PTT 27, fibrinogen 292, C3 73, C4 11, double-stranded DNA at 182, ANA 5, and rheumatoid factor less than 20. HOSPITAL COURSE: PROBLEM #1: Fluids, Electrolytes, Nutrition. _%#NAME#%_ was maintained on a regular diet during the hospitalization.
C3|(complement) component 3|C3|221|222|PROBLEM #9|His total immunoglobulin IgG level was 2360, which was elevated, and his IgG subclasses were all mildly elevated or within normal limits. HIV I and II antibody were negative. Complement levels were also obtained, and his C3 was 156 and C4 was 29, both within normal limits. PROBLEM #10: Psychosocial. The patient was seen by both Social Work and Pediatric Psychology during his hospitalization, given his prolonged hospital course at Regions, _%#CITY#%_ _%#CITY#%_ Children's, and here.
C3|(complement) component 3|C3,|328|330|HISTORY OF THE PRESENT ILLNESS|On _%#MMDD#%_, when he presented with concerns that this may be a rheumatological presentation, an ANA and rheumatoid factor as well as sed rate were obtained as well as GC and Chlamydia thinking this may be a sexually transmitted disease having infiltrated into his joint space. All these studies were negative. Also a CMV and C3, C4 were also obtained which were also negative. The patient left the clinic on _%#MMDD2005#%_, he returned with continued symptoms and now development of right upper quadrant pain with lower back pain, non-radiating.
C3|(complement) component 3|C3|404|405|PLAN|She clearly does not have any other symptoms or findings that would support this diagnosis, but since a thorough evaluation has not yielded any etiology of the organic brain syndrome, it is certainly reasonable to look a bit more with some blood tests. PLAN: 1. Further laboratory studies to include repeat FANA, SSA and SSB antibodies, extractable nuclear antigens, anti-double-stranded DNA antibodies, C3 and C4 levels. We will also check serum protein electrophoresis with immunoelectrophoresis. 2. Await CT scan, lumbar puncture and blood results. 3. No treatment is recommended at this time.
C3|(complement) component 3|C3,|134|136|ASSESSMENT|She apparently has had a positive FANA in the distant past, but several years ago in testing up here, she had a negative FANA, normal C3, normal DNA antibodies, normal CBC and negative anti-SSA and SSB. Except for her findings secondary to CVA, things seem negative.
C3|(complement) component 3|C3,|262|264|RECOMMENDATIONS|At this point she certainly deserves further workup, but I would not start prednisone or IV steroids unless we have very definite evidence of lupus or something inflammatory. RECOMMENDATIONS: 1. I certainly agree with the angiogram scheduled. 2. Labs to include C3, anti-DNA antibodies, and ANCA. Anticardiolipin antibodies have been ordered by Dr. _%#NAME#%_. SUBJECTIVE: _%#NAME#%_ _%#NAME#%_ is a 63-year-old white female who has previously been admitted to Fairview Southdale Hospital.
C3|(complement) component 3|C3,|138|140|ASSESSMENT AND PLAN|In any event, we will look a bit harder by doing some further laboratory studies such as an ANCA, SSA, SSB, double-stranded DNA antibody, C3, C4, angiotensin-converting enzyme level, and hepatitis screen. We will get a chest x-ray to screen for sarcoidosis or asymptomatic lesions of Wegener's granulomatosis.
C3|(complement) component 3|C3,|238|240|HISTORY OF PRESENT ILLNESS|In addition, she has thrombocytopenia with platelets of 79,000. Laboratory evaluation includes the following: as stated above, _%#MM2003#%_ she had an erythrocyte sedimentation rate that was normal, a double-stranded DNA that was normal, C3, C4, and CT were all normal. Smooth muscle antibody was normal. RNP antibody was normal. SSA and SSB, the Ro and La antibodies, were both normal.
C3|(complement) component 3|C3|368|369|PREVIOUS EVALUATIONS|Creatinine 0.93, BUN 10, and normal electrolytes. His CRP was 91.3. Laboratory studies from today include creatinine 1.07, BUN11, WBC 18,600, hemoglobin 12.4, platelet count 298,000, differential 16,400 neutrophils and 800 lymphocytes, albumin 3.3, and magnesium 1.8, phosphorus 2.5. Troponin negative. Negative ANA, negative rheumatoid factor, LD 382, uric acid 3.5, C3 120, C4 30. Pending results include total complement, antihistone antibody, and anti-ENA panel and anti-dsDNA antibody.
C3|(complement) component 3|C3|254|255|REASON FOR CONSULTATION|The evaluation from _%#MM#%_ _%#DD#%_ through the _%#DD#%_ included a kidney biopsy which showed an interstitial nephritis. She had a connective tissue work-up including a negative ANA, ANCA, and anti-_____ antibodies. Anti-GBM antibodies were negative. C3 complement was normal at 92. C4 complement was depressed at 12. Her white count during the hospitalization was as high as 25,800 with 39% eosinophils.
C3|(complement) component 3|C3,|211|213|PLAN|13. Bipolar disorder. 14. History of abnormal PFT in 1999, with flattening of the inspiratory loop and the possibility of extrathoracic obstruction. DLCO corrected was reduced. PLAN: 1. Recommend checking serum C3, CH50, and C1Q. Await the results of C1 esterase functional inhibitor and C2. 2. Recommend checking serum TSH, antithyroglobulin antibody, and antithyroid peroxidase.
C3|(complement) component 3|C3|183|184|PLAN|PLAN: Laboratory studies to include ANKA, hepatitis B and C serology, Sjogren's antibodies, West Nile serology. If her ANA is positive, I will add double-stranded DNA antibody levels C3 and C4. I think further test to consider would be a bone marrow biopsy, a bone scan, a tagged white blood cell study, and possibly a transesophageal echocardiogram.
C3|(complement) component 3|(C3,|114|117|RECOMMENDATIONS|At that time one of the concerns might be a serum sickness type reaction evolving. At that time compliment levels (C3, C4, CH50) liver transaminases, urinalysis looking for nephritis, physical examination, etc., could be performed. One might even consider a skin biopsy to determine if there is an eosinophilic infiltrate, compliment deposition, etc.
C3|(complement) component 3|C3|143|144|HISTORY OF PRESENT ILLNESS|In addition, her extractable nuclear antigen for anti-Smith and anti-RNP were also negative. She did not have any anti-native DNA nor abnormal C3 complement levels. Her lupus anticoagulant, as measured by the viper test, was negative. ANA antibodies were negative. ANCA antibodies were negative. A peripheral smear was obtained on two separate occasions that showed spherocytes and schizocytes not to be identified on extensive scanning of her peripheral smear.
C3|(complement) component 3|C3,|124|126|RECOMMENDATIONS|RECOMMENDATIONS: 1. Repeat CT scan of the abdomen with contrast to evaluate the pancreas and liver. 2. Sed rate, CRP, FANA, C3, C4, and CH50. 3. Rheumatoid factor. 4.ANCA. 5. Cryoglobulin, serum protein electrophoresis. 6. Coombs' direct. 7. Hepatitis B and C serologies. 8. Urinalysis and if that normal, we should obtain a 24 hour urine for protein and creatinine clearance.
C3|cervical (level) 3|C3,|380|382|HISTORY OF PRESENT ILLNESS|REQUESTING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_. REASON FOR CONSULTATION: Evaluate for rehabilitation needs. HISTORY OF PRESENT ILLNESS: This is a 52-year-old gentleman with a history of questionable/possible myasthenia gravis and he has cervical spine stenosis at C3-C4 with cervical spondylosis, status post decompressive laminectomy at C2-C3 with pedicle screw fixation of C2, C3, C4, C5 and C6 bilaterally and arthrodesis of the joints at C2-C3, C3-C4, C4-C5 and C5-C6 using autologous bone graft and DBX matrix done by Dr. _%#NAME#%_ on _%#MMDD2007#%_.
C3|(complement) component 3|C3|237|238|HISTORY OF PRESENTING ILLNESS|She currently denies joint pain of any sort. Recent relevant labs include an ANA of 3.5 which is weakly positive and antidouble-stranded DNA which is negative and anti-Smith antibody which is negative. The patient's total complement and C3 were within normal limits. Her C4 is at the lower limit of normal. RPR was negative, urinalysis was negative, creatinine was 0.7 and sedimentation rate was 58.
C3|cervical (level) 3|C3|470|471|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 58-year-old female with a known history of COPD, alcoholic polyneuropathy, and a known history of type 2 diabetes and hypertension who was admitted to the acute rehab unit following a complex neck surgery that she had for a severe central canal stenosis at the level of C4-5 that was performed on _%#MMDD2006#%_. The surgery included C4-5 carpectomies with a decompression of the spinal cord and bilateral C4, C5, and C6 nerves and C3 to C7 anterior spinal fusion and instrumentation and fibular allograft and local allograft procedure. For further details regarding that procedure, please refer to the discharge summary and operative note by Dr. _%#NAME#%_ _%#NAME#%_.
C3|cervical (level) 3|C3,|211|213|PAST MEDICAL HISTORY|At that time she had a CT of her chest, abdomen and pelvis which showed some lesions in her liver and kidney. She also had an MRI of her cervical and thoracic spine, which showed some increased hypointensity in C3, C7, and T5. Per Hematology- Oncology Service, these CT and MRI findings are consistent with recent chemotherapy treatment.
C3|(complement) component 3|C3,|122|124|RECOMMENDATIONS|RECOMMENDATIONS: 1. We need to follow up on the FANA and get the previously recommended anti-DNA, anti- sniff antibodies, C3, C4, and I would also add a CH50. 2. Urinalysis with a urine protein to creatinine ratio. 3. Total IgG looking for hypergammaglobulinemia. 4. Serum ferritin for the possibility of systemic onset JRA.
C3|(complement) component 3|C3|175|176|LABORATORY DATA|Rapid Strep and mono strain are negative. Blood culture, urine culture, and CMV screening are pending. For reference, laboratory studies from _%#MMDD2003#%_ included a normal C3 at 179, CK of 1264 with a cutoff of 170 (AST of 61 with a cutoff of 40. Creatinine is 0.7, BUN 12, hemoglobin 9, platelet count 132,000, WBC 2200 with 1400 lymphocytes and 700 neutrophils.
C3|(complement) component 3|C3,|176|178|RECOMMENDATIONS|One should also consider cryoglobulinemic vasculitis. RECOMMENDATIONS: 1. Sedimentation rate and CRP. 2. FANA, rheumatoid factor and serum protein electrophoresis. 3. ANCA. 4. C3, C4 and CH50 complements. 5. Cryoglobulin. 6. Liver panel. 7. Repeat u rinalysis. 8. Chest x-ray. 9. I would consider CT angiogram of his mesenteric arteries, particularly if he redevelops severe abdominal pain.
C3|(complement) component 3|C3|252|253|RECOMMENDATIONS|6. Recent MSSA (methicillin-susceptible Staphylococcus aureus) staph right arm infection, treated with Vancomycin as an outpatient. Most recent level noted to be 50. RECOMMENDATIONS: 1. Await serologies and blood cultures including as noted complement C3 C4, cryoglobulins, hepatitis C. 2. Await renal ultrasound to rule out obstruction. Evaluate size and asymmetry which should be unremarkable in this setting.
C3|cervical (level) 3|C3|246|247|HISTORY OF PRESENT ILLNESS|MRI of the spine revealed extensive spinal cord edema from C1 through the mid thoracic area with diffuse gadolinium enhancement from C6 to T4. She has multiple level degenerative disks and ossification of the posterior longitudinal ligament from C3 to C7. She has moderate to severe stenosis of the canal, approximately 4 mm. Her working diagnosis is transverse myelitis versus spinal stenosis. Workup is underway.
C3|cervical (level) 3|C3|238|239|REASON FOR VISIT|Over the next couple of months following that accident, she improved to the point where she was able to ambulate but with significant weakness and spasticity. In 1995, she underwent an anterior cervical fusion with an anterior plate from C3 to C6. Then, in 1998, she was treated for a syrinx with shunting and revision of her hardware following several years of increasing left leg weakness and decreasing function in her arms.
C3|(complement) component 3|C3,|343|345|DISCUSSION|She was given Kayexalate. Her potassium rose during the night as high as 7.1 but subsequently has fallen to 6 and later 5.4. BUN and creatinine have not significantly change, most recently 54 and 5.7. Phosphorous is elevated at 8 on two consecutive readings. Pending at this time are antinuclear antibody, antineutrophil cytoplasmic antibody, C3, C4, and CH50 complement components. Sedimentation rate is a bit higher yet at 65. INR is minimally elevated at 1.22 while PTT is normal at 35.
C3|(complement) component 3|C3|265|266|HISTORY OF PRESENT ILLNESS|Her poor current physical status may also be implicated in this pregnancy loss. Workup for lupus disease and pregnancy loss included negative gonorrhea and chlamydia cultures, negative anticardiolipin antibodies, negative double stranded DNA, normal compliments of C3 and C4, HIV negative, hepatitis B surface antigen negative, antibody screen negative, normal platelet count, normal creatinine, and normal sensitive TSH.
C3|(complement) component 3|C3|299|300|HISTORY OF PRESENT ILLNESS|A biopsy that was done originally in North Dakota at his first hospitalization has been reviewed and shows immune-mediated glomerulonephritis with mesangial expansions, scattered partial crescents, well preserved interstitium and subepithelial, subendothelial and mesangial-immune deposits. IgA and C3 staining were positive. These findings were felt to be consistent with severe IgA nephropathy or possibly SLE. His evaluation to date for autoimmune conditions has shown a negative ANCA, negative FANA, negative anti-ENA, negative antidouble stranded DNA.
C3|(complement) component 3|C3|141|142|HISTORY OF PRESENT ILLNESS|Her last platelet count was 169,000. Her hemoglobin was 9.6. Her last BUN was 62, and her creatinine was 5.36. Her most recent albumin is 3. C3 and C4 were measured on _%#MMDD2004#%_ at 76 and 13. Electrolytes show increased phosphorus, normal magnesium, normal calcium and otherwise are as expected.
C3|cervical (level) 3|C3.|128|130|HISTORY OF PRESENT ILLNESS|The mass invaded the floor of mouth and obliterated the mylohyoid. The mass indented the right internal jugular at the level of C3. There was no evidence of bony erosion of the mandible or hyoid. There were a number of zone 1 borderline enlarged lymph nodes.
C3|(complement) component 3|C3|337|338|LABORATORY DATA|CHEM 7: Sodium 137, compensation potassium 3.8, chloride 100, bicarbonate 26, BUN 10, creatinine 0.8, glucose 114. LFTs: AST 34, ALT 39, alkaline phosphatase 107, total bilirubin 0.3, INR 1.06. Serology was obtained at the previous admission: ANA is mildly positive at 30.8, rheumatoid factor negative, antismooth muscle antibodies 222, C3 89, C4 mildly low at 12, anti-cardiolipin antibody negative, S-pep without any evidence of a monoclonal spike. West Nile antibodies negative, HIV negative, Klebsiella serologies negative.
C3|(complement) component 3|C3|150|151|HISTORY OF PRESENT ILLNESS|According to notes I have from a phone call with Dr. _%#NAME#%_ today, there was a significantly elevated double-stranded DNA antibody measurement, A C3 of only 57, and C4 of approximately 4. She also developed trouble today with nausea and vomiting. She had some abdominal pain before but had not been vomiting.
C3|(complement) component 3|C3,|161|163|RECOMMENDATIONS|7. Agitation, restlessness, possibly due to anxiety, cerebral metastases, although CT of the head was negative; drug withdrawal. RECOMMENDATIONS: 1. Check serum C3, C4, CH-50, C1Q, C1-esterase inhibitor functional study. We will add them to the _%#MMDD2003#%_ 2250 labs. This was p honed into the laboratory, and I spoke with _%#NAME#%_ _%#NAME#%_ in the laboratory.
C3|(complement) component 3|C3|217|218|HISTORY OF PRESENT ILLNESS|I cannot tell from the records that I have whether her pericardial effusion completely resolved in between her admissions. The patient had a FANA and INCA done on that hospitalization, which were normal. She also had C3 and C4 levels drawn, both of which were quite low at 34 and 4 respectively. Parvovirus B19 was negative for acute infection. HIV testing was negative.
C3|(complement) component 3|C3|169|170|BRIEF HISTORY OF PRESENT ILLNESS|_%#NAME#%_ has been worked up in pediatric nephrology and has had 24-hour urine that had a significant amount of protein (720 mg in a 24-hour period). He has had normal C3 C4, negative FENa. Creatinines have been stable when checked. PAST MEDICAL HISTORY: 1. History of asthma, only requiring Singulair once a day for control.
C3|(complement) component 3|C3|136|137|HOSPITAL COURSE|ANA was positive at greater than 10. ENA antibodies were all normal. Double-stranded DNA was positive at 40,40. C3 and C4 were low with C3 being 43 and C4 being 5. Rheumatoid factor was less than 20. Neuronal nuclear antibody panel was less than 10.
C3|cervical (level) 3|C3|230|231|PAST MEDICAL HISTORY|The only relieving medication she has been able to receive is 2 mg of morphine IV q.4h. A medicine such as Mylanta or Maalox or Zantac provide no relief. PAST MEDICAL HISTORY: 1. Significant for chronic neck pain. She underwent a C3 through C7 laminectomy in _%#MM2006#%_. She continues to have intermittent radicular symptoms involving the right upper extremity. She is currently on pregabalin for management of those symptoms.
C3|(complement) component 3|C3|182|183|LABORATORY DATA|No evidence of malignancy noted. Electrocardiogram done on _%#MMDD2005#%_ revealed a right bundle branch block with possible premature atrial complexes with aberrancy. CRP was 1.91. C3 and C4 were evaluated and were within normal limits. ACE level was 94. Parathormone level was decreased at 4. Vitamin D level was normal. Troponin-I was less than 0.07 X 2.
C3|cervical (level) 3|C3|175|176|ADMISSION IMPRESSION|ADMISSION IMPRESSION: 1. The patient is a 48-year-old gentleman here after a complex neurosurgical procedure on _%#MMDD2005#%_ for cervical spinal stenosis. This consisted of C3 through C7 level laminectomies, foraminotomies, fixation, and fusion using autologous bone. He has myelopathic and radicular symptoms in the upper and lower extremities.
C3|cervical (level) 3|C3|138|139|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: She has a long history of chronic pain problems from multiple lumbar and cervical surgeries. She had a fourth C3 fusion in _%#MM#%_. Apparently this one is successful so far. While in the hospital, she developed atrial fibrillation and was transferred to the Intensive Care Unit.
C3|cervical (level) 3|C3|43|44|PRIMARY DIAGNOSIS|PRIMARY DIAGNOSIS: Intramedullary tumor at C3 through T3. TREATMENTS AND PROCEDURES PERFORMED DURING THIS HOSPITALIZATION: Cervical laminectomy C3 through T2 and intradural and intramedullary debulking of intramedullary tumor on _%#MMDD2007#%_. BRIEF HISTORY AND PERTINENT OBJECTIVE FINDINGS: Mr. _%#NAME#%_ is a 48-year-old male with a long history of low back pain.
C3|cervical (level) 3|C3,|152|154|HISTORY OF PRESENT ILLNESS|Treatment history includes Arava, Plaquenil, Vioxx, prednisone, and methotrexate. 2. Status post bilateral total hip arthroplasties. 3. Status post C2, C3, C4, C5 spinal fusion. 4. Borderline hypertension. 5. Chronic leg edema. 6. Skin vasculitis.
C3|(complement) component 3|C3|180|181|RECOMMENDATIONS|RECOMMENDATIONS: 1) I would pursue further workup of the elevated sedimentation rate with CRP, serum protein electrophoresis, and cryoglobulin. 2) Lupus anticoagulant, VDRL, ANCA, C3 and C4. 3) Consider lumbar puncture. 4) We will discuss the case in more detail with Drs. _%#NAME#%_ and _%#NAME#%_, in neurology. If the workup continues unfruitful, one could give consideration to a central nervous system angiogram.
C3|cervical (level) 3|C3|398|399|SUMMARY OF EVENTS LEADING TO DEATH|SUMMARY OF EVENTS LEADING TO DEATH: Mr. _%#NAME#%_ was a 78-year-old man, who was admitted to the hospital on _%#MM#%_ _%#DD#%_, 2005, and underwent a C3-C6 fusion and C4-C5 corpectomy for degeneration at C4-C5 with retroportion of C5 with respect to C4 and compression into the C4 vertebral body. Postoperatively, the patient was found to have hematoma in the surgical site for which he underwent C3 corpectomy, C2-C6 fusion with fibular allograft on _%#MM#%_ _%#DD#%_, 2005. Postoperatively, the patient was delirious and psychotic for several days and had respiratory problems believed to be secondary to aspiration as he had an abnormal swallow study.
C3|cervical (level) 3|C3|53|54|DIAGNOSIS|The patient of Dr. _%#NAME#%_ _%#NAME#%_. DIAGNOSIS: C3 through C4 and C5 through C6 level stenosis in the cervical spine. MAJOR PROCEDURES AND TREATMENTS: 1. Anterior cervical diskectomy and fusion of C3-C4 and C5-C6 done on _%#MM#%_ _%#DD#%_, 2006.
C3|(complement) component 3|C3,|277|279|PENDING LABORATORY TESTS|WOUND CARE: The patient should leave the Steri-Strips over his mediastinoscopy site until they fall off. PENDING LABORATORY TESTS: Currently, there are pending fungal, mycobacterial, and standard bacterial cultures on the patient's lymph node, as well as Chlamydia antibodies; C3, C4 levels; alpha- fetoprotein, and cryoglobulins.
C3|(complement) component 3|C3,|189|191|PROBLEM #1|We will workup this acute and chronic renal failure with fractional increase in sodium and renal ultrasound. We will also obtain urinalysis. The patient will also get IgG, IgA, IgM levels, C3, C4 level, urine and protein electrophoresis for further workup of intrinsic renal disease. The patient will be evaluated by the renal team and they do not think the patient needs dialysis at this point in time.
C3|cervical (level) 3|C3.|195|197|HISTORY|Dr. _%#NAME#%_ placed a stent through the occluded portion which was demonstrated to be due to a high-grade stenosis due to dissection of the internal carotid artery at the skull base from C1 to C3. There was minimal flow distally. Intracranial thrombolysis was attempted as a result of the lack of intracranial flow. An 8 x 40 mm stent was placed across the dissection area.
C3|(complement) component 3|C3,|251|253|HOSPITAL COURSE|Hematology consultation was obtained during his stay. It was recommended that he stay on Coumadin and low dose aspirin indefinitely. A Rheumatology consultation was obtained to assess for possibility of vasculitis. A workup was done including an ANA, C3, C4, ANCA, cryoglobulin, SPEP, and C-reactive protein. These were pending at the time of discharge. 2. Right leg wound. The patient's bypass incision was healing well with some good wound formation.
C3|(complement) component 3|C3,|191|193|FAMILY HISTORY|The patient has been found to have a mild anemia which may be anemia of chronic disease. His ESR was 94. Though the SSA was positive, he has had a normal Lyme titer, rheumatoid factor, FANA, C3, C4 and anti-SSB. There has been significant elevation of the ferritin level. His white blood count has been either normal or elevated, again which would be somewhat against Sjogren's where they tend to have lower white counts.
C4|cervical (level) 4|C4|184|185|HISTORY OF PRESENT ILLNESS|Therefore, an MRI was obtained that showed no acute intracranial pathology, normal MRA of the circle of Willis. Normal MRA of the major artery of the neck, degenerative changes at the C4 and C5 level. No evidence of dissection of the vertebral or carotid artery on the neck. Erythrocyte sedimentation rate was 43 and CRP was 10.0. In addition, a pain consult was obtained that recommended lidocaine patch for pain control.
C4|cervical (level) 4|C4|221|222|HOSPITAL COURSE|Preoperative CT scan did not reveal the fusion to be entirely solid, three months after that index operation and therefore the fusion was extended to encompass those levels. The intervening segments between the C1-C2 and C4 through C7 area was noted at that time of surgery to be markedly degenerated with cavernous facet joint changes.
C4|(complement) component 4|C4|149|150|HOSPITAL COURSE|An ASO titer was 39. His DNA double-stranded was negative. Basement membrane antibody was negative. ANCA was negative. C3 was slightly low at 79 and C4 was normal. Cryoglobulins were sent, but the test was canceled, this will need to be resent again as an outpatient. He had no urine eosinophils. Cryoglobulins were resent this hospitalization.
C4|(complement) component 4|C4|166|167|PROBLEM # 1|Also MPGN. Less likely would be an autoimmune syndrome due to the patient's paucity of other findings. PROBLEM # 1: Renal. We will check the patient's complement C3, C4 levels, a FANA, and ANCA, rheumatoid factor to evaluate for autoimmune causes. Additionally an ASO titer and DNase-B antibody to evaluate for exposure to strep.
C4|(complement) component 4|C4|276|277|HOSPITAL COURSE|5. Rheumatology. In consultation with _%#NAME#%_'s primary rheumatologist, her lupus was managed initially with a burst of Solu-Medrol followed by prednisone. She had a double-stranded DNA level of 3110. She also had complement levels drawn demonstrating C3 level of 35 and a C4 level of 11. These were consistent with her outpatient laboratory results. Additionally, her ALT and AST were followed for liver involvement.
C4|cervical (level) 4|C4,|152|154|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: 61-year-old white female with history of C5 intramedullary mass. She underwent bilateral laminectomies at C5, C6 and caudal C4, biopsy and subtotal tumor resection on _%#MMDD2006#%_. Biopsy results revealed astrocytoma consistent with pilocystic variant, Malignant feature cannot be ruled out.
C4|cervical (level) 4|C4|139|140|HOSPITAL COURSE|HOSPITAL COURSE: Mrs. _%#NAME#%_ was admitted for intravenous pain medication, and was brought within 24 hours to the operating room for a C4 through C6 anterior cervical discectomy and fusion. She tolerated the procedure well and had near complete resolution of her pain postoperatively.
C4|cervical (level) 4|C4|272|273|HOSPITAL COURSE|He underwent lumbar spine films which showed minimal degenerative disk disease and facet disease in the lower spine with no evidence of acute fracture. Cervical spine films showed moderate, multi-level degenerative disk and facet disease with minimal spondylolisthesis of C4 and C5, likely related to degenerative disease. Chest x-ray was unremarkable and MRI of C-spine showed multi-level disease diffusely, as well as some foraminal and central stenosis.
C4|cervical (level) 4|C4,|148|150|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. C5-C6 and C6-C7 cord and nerve root compression from herniated disks. 2. Ossification of posterior longitudinal ligament at C4, C5, C6 OPERATIONS/PROCEDURES PERFORMED: 1. C5-C6, C6-C7 anterior cervical diskectomy and fusion. 2. Partial C6 corpectomy.
C4|(complement) component 4|C4|104|105|LABORATORY DATA|INR 0.89, PTT 24 sec, C-reactive protein of 0.03 and IgA 23 and LD 671 and ESR 1, compliment C3 113 and C4 22. A UA was negative for ketones, negative bilirubin, pH of 7.5 and a urine total protein was 0.12 with a total protein to creatinine ratio of 1.09. Giardia negative.
C4|(complement) component 4|C4,|201|203|ASSESSMENT AND PLAN|Epinephrine 0.3 mg times one additional dose now. Consult Allergy specialist. I spoke with Dr. _%#NAME#%_, on call for Dr. _%#NAME#%_ and Dr. _%#NAME#%_. She recommended checking serum tryptase level, C4, C3, C1 esterase inhibitor total and functional levels, serum IgE levels, TSH, and complete metabolic panel. We will await labs, but do suspect highly the ACE inhibitor as the culprit for her tongue swelling.
C4|cervical (level) 4|C4|231|232|SUMMARY OF CASE|Postoperative hemoglobin is unknown. She has several pre-existing medical conditions in addition to her severe degenerative arthritis. These include hypertension, hyperlipidemia, hypothyroidism, past history of migraines, and left C4 radiculitis. She also has a past surgical history of left total hip arthroplasty in _%#MM2001#%_. The patient had been a smoker, but quit many years ago.
C4|cervical (level) 4|C4|160|161|LABORATORY DATA|CT scan of his spine without contrast on _%#MMDD#%_, postoperatively, showed postoperative changes partial corpectomy of C5 body with fusion cage from inferior C4 to superior C6 and anterior spinal fusion C4 to C6. Posterior spinal fusion was seen from C3 through C7 with pedicle screws identified in lateral masses of C3, 5, 6, 7, and on the left side on C4.
C4|cervical (level) 4|C4.|141|143|LABORATORY DATA|Posterior spinal fusion was seen from C3 through C7 with pedicle screws identified in lateral masses of C3, 5, 6, 7, and on the left side on C4. The heads of these screws were interconnected with a metallic rod bilaterally. No evidence of impingement. There is also evidence of wide midline hemilaminectomies from C3 through C7, and residual subchondral and sclerotic changes in vertebral bodies C7 through T1.
C4|(complement) component 4|C4|116|117|ADMISSION LABORATORY|Her INR was 1.03 and PTT 21. Basic metabolic panel was unremarkable. Her BUN was 34 and creatinine 0.72. Her C3 and C4 complement levels were low at 45 and 5 respectively. HOSPITAL COURSE: _%#NAME#%_ underwent her renal biopsy on the day of admission without complications.
C4|cervical (level) 4|C4|249|250|HISTORY OF PRESENT ILLNESS/CURRENT PROBLEM LIST|This responded to plasmapheresis. On _%#MMDD2005#%_, the patient had a fall with what was thought to be an associated seizure. Following his fall, he was noted to have a right greater tubercle fracture of the right humerus. A CT scan demonstrated a C4 fracture as well. This was reviewed by Neurosurgery and thought to have no surgical intervention needed. He was placed in a cervical collar and expected to wear that at all times except for when sleeping.
C4|(complement) component 4|C4|151|152|IMAGING STUDIES|Lupus inhibitor battery is negative. IGG was normal. SSB LA antibody, IGG normal. DNA double stranded negative at 4 international units per ml, C3 and C4 levels 136 and 15 respectively and both normal. TNA single stranded antibody IGG was 51, elevated. Immunofixation IGG, IGM, IGA shows no monoclonal proteins.
C4|(complement) component 4|C4|193|194|LABORATORY DATA|LABORATORY DATA: Hemoglobin of 11.4 on discharge. Creatinine of 0.8. White cell count 12.9. She had a urinalysis and urine culture that were negative for any growth. She has complement C3 112, C4 16, CH 50 is 92. She had a cyclic citrullinated peptide antibody IGG that was noted to be 104 which is elevated. She had an RNP of 4, Smith antibody of 6, all within normal range.
C4|cervical (level) 4|C4|162|163|PAST MEDICAL HISTORY|10. Depression. 11. History of a CVA that left her blind in her left eye. 12. History of a subdural hematoma after a fall just in _%#MM#%_ of 2005. 13. Bilateral C4 fractures, also secondary to the above. 14. Chronic back pain. She states this is in her low back and radiates into her buttocks.
C4|cervical (level) 4|C4|156|157|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Disk herniation with stenosis C4-C5 and C5-C6. Procedure dated _%#MM#%_ _%#DD#%_, 2005, anterior cervical diskectomy and decompression C4 through C6 with plating. HOSPITAL COURSE: Ms. _%#NAME#%_ _%#NAME#%_ is a 47-year-old female who underwent uncomplicated decompression and fusion of C4 through C6 on _%#MM#%_ _%#DD#%_, 2005.
C4|cervical (level) 4|C4|131|132|HISTORY OF PRESENT ILLNESS|She presented to the United Hospital emergency department last week and CT scan was done. Evidently, it was nondiagnostic, but the C4 and C5 levels apparently are not well seen and she was advised to have an MRI scan done. She presented to her primary care clinic with this request and the MRI was ordered and carried out last evening.
C4|cervical (level) 4|C4.|209|211|HISTORY OF PRESENT ILLNESS|A plain lateral C- spine film was obtained. This was initially cleared by the ED staff, but he continued to complain of neck pain. CT was done, which showed a C4 fracture involving the body and left lamina of C4. The patient is otherwise neurologically intact and only complains of neck pain. He denies any headache, nausea, vomiting, motor, or sensory changes.
C4|(complement) component 4|C4|278|279|HOSPITAL COURSE|As the patient's chest pain and shortness of breath were believed not to be cardiac in origin, the patient underwent further work up for possible lupus flare-up. Sedimentation rate was normal at 14. Antinuclear antibody was negative. Compliment C3 was normal at 160, compliment C4 was normal at 27. CRP was normal at 0.57. The patient was seen by Rheumatology who believed that the patient's lupus was in remission and recommended adjustment of thyroid medication.
C4|(complement) component 4|C4|196|197|PROBLEMS|The combination of his thrombocytopenia and hemolysis is likely to be Evans syndrome. An autoimmune workup was initiated to look for a possible cause for Evans syndrome. His IgG, IgA, IgM, C3 and C4 were all within normal limits. IgE, ANA, and viral studies were pending at the time of discharge. 3. Congenital heart disease. _%#NAME#%_ had a repair of a double outlet right ventricle as a baby.
C4|(complement) component 4|C4|303|304|HOSPITAL COURSE|CA-125 at that time was 264. Hepatitis screening antibodies and serologies revealed negative findings except for hepatitis A antibody. Hepatitis A IgM antibody was negative however. Subsequent serologies ordered and result received during the hospitalization included an ANA of 1.3, C3 decreased at 78, C4 decreased at 11 and an alphafetoprotein normal at 4.2. Others serologies were ordered, but currently pending at the time of discharge.
C4|cervical (level) 4|C4,|204|206|HISTORY OF PRESENT ILLNESS|MR of the neck unable due to size of patient being unable to get further into an MRI machine. She was transferred at room 335 for further evaluation. Review of the workup from prior admission noted a C3, C4, C5 discopathy with compression of the cervical spine, some degenerative disc disease noticed in the lower lumbar spine. She had sedimentation rate of 126. Electrocardiogram of her heart was noted to be normal.
C4|cervical (level) 4|C4|268|269|HISTORY OF PRESENT ILLNESS|There has been evidently two different radiation oncologists, one treating him at the Humphrey Cancer Center here in _%#CITY#%_ _%#CITY#%_ and one at Mayo, and they have somewhat disagreed about further treatment. It looks like he maybe has additional growth into the C4 C spine and then recent MRI showed that the tumor is growing into the base of the brain. One of his oncologists said he did not consider treating, but that the oncologist at Mayo thought that they should continue to treat.
C4|cervical (level) 4|C4|49|50|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Recurrent UTIs. 2. C3 to C4 quadriplegia with neurogenic bladder. HISTORY OF PRESENT ILLNESS: Please see prior discharge summary for complete details of her past medical history.
C4|cervical (level) 4|C4|200|201|CT SCAN OF CERVICAL SPINE|There is also some abnormal enhancement anterior to C4. There is evidence of neck adenopathy bilaterally. There is no spinal canal compromise. CT SCAN OF CERVICAL SPINE: CT shows lytic destruction of C4 with a wedge compression deformity. This also shows bilateral adenopathy. BONE SCAN: Scan is negative with no abnormality seen anywhere, including in the C4 region.
C4|cervical (level) 4|C4|380|381|PAST MEDICAL HISTORY|ASSESSMENT/CHIEF COMPLAINT: _%#NAME#%_ _%#NAME#%_ is a 64-year- old white male who apparently was found to have a colovesical fistula and presents today for a preoperative assessment for surgical repair of this under general anesthesia guidance by Dr. _%#NAME#%_. PAST MEDICAL HISTORY: Notable for: 1. Carcinoma of the prostate. 2. Diverticulitis. 3. Peptic ulcer disease. 4. C3, C4 cervical radiculopathy. 5. Mild left shoulder impingement, status post medical treatment. PAST SURGICAL HISTORY: 1. Cholecystectomy in 1988. 2. Carpal tunnel repair in 1986.
C4|(complement) component 4|C4|131|132|HOSPITAL COURSE|In discussion with the Pediatric Nephrology team, several diagnoses were entertained. A FANA was obtained to rule out lupus, a C3, C4 was obtained to rule out lupus post-streptococcal glomerulonephritis and membranoproliferative glomerulonephritis. ANCA was drawn to rule out vasculitis. ASO titers were also drawn to rule out post-streptococcal glomerulonephritis and an anti-DNA titer was also drawn.
C4|(complement) component 4|C4,|239|241|HOSPITAL COURSE|The patient's urine was checked for calcium and creatinine ratio, for possible nephrocalcinosis, and a urine myoglobin was also checked. CT scan results ruled out polycystic kidney disease and stones, and the other tests such as FANA, C3, C4, ANCA, ASO titer and anti-DNA titer should be followed up by the patient's pediatrician in Virginia. DISCHARGE INSTRUCTIONS: 1. The patient is being discharged to home in good condition with no medications.
C4|cervical (level) 4|C4|123|124||_%#NAME#%_ _%#NAME#%_ is a 58-year-old woman who on the day of admission underwent an uncomplicated cervical laminoplasty. C4 through C7 were decompressed. Foraminotomies were carried out on the right side. The procedure itself was uncomplicated. Fixation was good. Blood loss was minimal.
C4|(complement) component 4|C4|127|128|HISTORY OF PRESENT ILLNESS|Also demonstrated positive casts with 3 to 5 white blood cells. CRP completed _%#MM#%_ _%#DD#%_, 2002, was 1.5. C3 equals 131. C4 equals 15.5. C-ANCA and T-ANCA completed on _%#MM#%_ _%#DD#%_, 2002, were negative. HOSPITAL COURSE: The patient was admitted and did well overnight.
C4|cervical (level) 4|C4|152|153|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 49-year-old man without had previously undergone an anterior cervical diskectomy and fusion from C4 to C7. He presented to Dr. _%#NAME#%_'s clinic with recurrent mechanical neck pain symptoms. Workup was done, and this was felt to be consistent with adjacent segment degeneration proximal and distal to his fusion.
C4|(complement) component 4|C4|131|132|LABORATORY DATA AT F-UMC|Antistreptolysin O was mildly elevated at 597. DNase B antibody was elevated at dilution of 1:1360. Complement levels, both C3 and C4 levels, were decreased. Chest x-ray showed mild interstitial with small bilateral pleural effusions but no focal consolidations. Renal ultrasound showed both kidneys normal in size for age, no evidence of hydronephrosis or shadowing renal calcification.
C4|(complement) component 4|C4|276|277|PROBLEM #2|PROBLEM #2: Renal. The clinical course and laboratory data are most suggestive of post-streptococcal glomerulonephritis with elevated anti- strep antibodies and low C3 complement level, without any other autoimmune markers. The only concerning fact was low C4, although a low C4 can be seen in a small number of cases of post-streptococcal glomerulonephritis. At this time we elected not to do a biopsy, and to follow _%#NAME#%_ to see if he has full resolution of his symptoms.
C4|cervical (level) 4|C4.|201|203|HISTORY OF PRESENT ILLNESS|12. History of diverticulitis status post sigmoid resection in 1997. 13. History of headache secondary to cervicalgia status post radiofrequency neural ablation of cervical medial branch nerves of C3, C4. 14. History of Clostridium difficile. 15. Status post T&A. 16. Status post total abdominal hysterectomy in 1980. 17. Status post D&C.
C4|cervical (level) 4|C4|323|324|DISCHARGE DIAGNOSIS|RADIOLOGY: The patient had a CT scan. It showed no acute intracranial pathology, an old lacunar infarct, and small-vessel ischemic disease which was unchanged from previous. Patient also had a CT of the C spine without contrast which noted severe degenerative changes throughout the cervical spine, anterior subluxation of C4 on C5 which may be related to severe degenerative change, and anterior subluxation of C3 on C4 and C7 on T1. No evidence of vertebral body fracture. HOSPITAL COURSE: The patient was stable.
C4|cervical (level) 4|C4|346|347|IMAGING STUDIES|Degenerative changes mentioned above resulted in mild right C3-C4 neuroforaminal narrowing, moderate bilateral C4-5 neuroforaminal narrowing, moderate to severe bilateral C5-C6 neuroforaminal narrowing, severe right C6-C7 neuroforaminal narrowing and mild to moderate left C6-C7 neuroforaminal narrowing. There is mild spinal canal stenosis from C4 through C6. 3. Chest x-ray on admission negative. PERTINENT LABORATORY STUDIES: Ethanol level was negative, white blood cell count 9.8, hemoglobin 14.3 and platelet count 188.
C4|(complement) component 4|C4|410|411|LABORATORY|LABORATORY: Pertinent labs on admission included sodium 140, potassium elevated at 5.9, chloride 118, bicarbonate 12, BUN 122, creatinine 16.84, glucose 93, and a total calcium low at 4.9. CBC showed white blood cell count of 8.9, hemoglobin 7.9, hematocrit 23.1, and platelets 123,000. INR was 1.24. PTT 36. Phosphorus was elevated at 7.8. C3 complement was borderline low at 82 (normal 92 to 100 mg/dL), and C4 was normal at 35 (normal at 15 to 50 mg/dL). Chest x-ray on admission showed normal heart size and pulmonary vasculature with lungs clear.
C4|(complement) component 4|C4|254|255|LABORATORY|Sodium 138, potassium 4.4, chloride 111, bicarbonate 21, BUN 14, creatinine 1.01, glucose 82, and calcium 9.0. Albumin was 3.1, total protein 7.6. AST, ALT, and alkaline phosphatase were all within normal limits. Complement levels include a C3 of 19 and C4 of 25. White count was 16.2 with 69% neutrophils and 19% lymphocytes. Hemoglobin 10.8 and platelets 363. HOSPITAL COURSE: _%#NAME#%_ was admitted for evaluation of whether or not this hematuria and proteinuria were due to a postinfectious glomerulonephritis or was indeed a flare of her membranoproliferative glomerulonephritis which had been in remission.
C4|cervical (level) 4|C4|173|174|HISTORY OF PRESENT ILLNESS|She was given IV methylprednisolone with some improvement however decision was made to perform a biopsy and decompression laminectomy. She has now undergone C5-6 and caudal C4 bilateral laminectomies and biopsy and subtotal resection of C5 on _%#MMDD2006#%_. As she became stable, she was dependent with ADLs and mobility, tolerating the rehab process, experiencing a significant amount of pain, and was recommended for admission to the inpatient rehab unit.
C4|(complement) component 4|C4|189|190|PROBLEM #6|This is consistent with chronic disease. PROBLEM #6: Rheumatology/Lupus. Prior to admission on _%#MM#%_ _%#DD#%_ patient had an ANA which was 8.6, a double-stranded DNA was 233, complement C4 was 13, and complement C3 was 86. On _%#MMDD#%_ an ANA was 7.1, complement C3 82, and complement C4 was 13. Cardiolipin antibody IgG was 6.2 and IgM was 7.8. PROBLEM #7: Endocrine.
C4|(complement) component 4|C4|289|290|PROBLEM #6|This is consistent with chronic disease. PROBLEM #6: Rheumatology/Lupus. Prior to admission on _%#MM#%_ _%#DD#%_ patient had an ANA which was 8.6, a double-stranded DNA was 233, complement C4 was 13, and complement C3 was 86. On _%#MMDD#%_ an ANA was 7.1, complement C3 82, and complement C4 was 13. Cardiolipin antibody IgG was 6.2 and IgM was 7.8. PROBLEM #7: Endocrine. Patient's PTH was slightly elevated at 234. Again, the concern is probably partial noncompliance with his medications causing it.
C4|cervical (level) 4|C4|184|185|HOSPITAL COURSE|She was seen by the Pain Service. She failed a test dose of intrathecal analgesia, presumably, in retrospect, due to the fact that she has nearly complete block of the spinal canal at C4 through approximately T1 or T2. This was demonstrated on MRI of the chest on _%#MMDD2003#%_. The patient was subsequently transferred to the Medical Intensive Care Unit, where she was started on a ketamine drip.
C4|(complement) component 4|C4|315|316|PROBLEM #2|He will continue on prednisone 40 mg for a total of 5 days and Benadryl p.r.n. He will follow up with his primary care provider in one week; sooner if he develops more swelling or more shortness of breath. Of note, another consideration for his uvular edema is hereditary angioedema. C1 esterase inhibitor CH50 and C4 were sent. The results of C4 were within normal limits at 25.
C4|(complement) component 4|C4|138|139|PROBLEM #2|Of note, another consideration for his uvular edema is hereditary angioedema. C1 esterase inhibitor CH50 and C4 were sent. The results of C4 were within normal limits at 25. The other studies are pending and should be followed up by his primary care provider.
C4|cervical (level) 4|C4|136|137|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: Cervical myelopathy with cervical spondylosis procedure, anterior cervical discectomy and decompression and fusion C4 to C6. HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a gentleman who has had marked paresthesias in both hands as well as his feet.
C4|(complement) component 4|C4;|209|211|HOSPITAL COURSE|The patient remained asymptomatic the next day. A number of laboratory tests were ordered to evaluate for hereditary angioedema; these were pending and include C1-esterase inhibitor; complement C3; complement C4; and complement CH50 levels. An antinuclear antibody screen was performed that was negative at less than 1. Since the patient was stable, he was discharged to home with follow up with his primary care physician, Dr. _%#NAME#%_ _%#NAME#%_ at the _%#CITY#%_ Group in one to two weeks.
C4|(complement) component 4|C4|172|173|DISCHARGE DIAGNOSIS|He continued to diurese well with furosemide. On his third hospital day, certain studies obtained on admission returned. Of note, complement C3 was 8 mg/dcL, markedly low. C4 was also low at 10 mg/dcL. An ASO titer was elevated at 1440. The low complement and elevated ASO were sufficient to confirm the suspected diagnosis of post-streptococcal glomerulonephritis.
C4|(complement) component 4|C4|255|256|HOSPITAL COURSE|NO focal neurologic deficits. The patient is alert. LABORATORY DATA: On admission: Sodium 132, chloride 102, bicarbonate 817, creatinine 1.2, BUN 50, glucose 79, calcium 8.5. HOSPITAL COURSE: Problem #1. Renal: We checked the patient's complement C3, and C4 levels, FANA, ANCA, and rheumatoid factor to evaluate for autoimmune causes of his hematuria. We also checked the ASO titer and DNase B antibody to evaluate for exposure to strep.
C4|(complement) component 4|C4|160|161|DISCUSSION|It seems that most likely diagnosis is hereditary angioedema. If this workup has not yet been completed, one might consider blood tests to check C1 INH levels, C4 and C2, as well as C1q. Consideration could be given to danazol treatment, though it should be pointed out the patient has done very well for 40 years with no attacks that could not be managed in a conservative way.
C4|(complement) component 4|C4|175|176|PHYSICAL EXAMINATION|Thyroglobulin antibody elevated at 473, thyroid thyroxidase antibody elevated 355. Anti-ribosomal P antibody is pending. CRP undetectable. Erythrocyte sedimentation rate 126, C4 complement 11, C3 compliment 60. Smith antibody negative. Urine HCG negative. SSA/Ro antibody elevated at 320, SSB/La antibody elevated at 162, antinuclear antibody screen positive TSH 15.9 elevated.
C4|cervical (level) 4|C4|222|223|IMAGING|2. Hypoxic respiratory failure. 3. Oral candidiasis. 4. History of left lung transplant for chronic obstructive pulmonary disease. IMAGING: 1. Cervical spine MRI dated _%#MMDD2007#%_ showed enhancing lesion of the dent in C4 vertebral body as well as a right-sided disc herniation causing right neuroforaminal stenosis. 2. Cervical spine x-ray dated _%#MMDD2007#%_ revealed no instability on flexion and extension views.
C4|(complement) component 4|C4|149|150|HOSPITAL COURSE|Electrolytes, liver profile, renal function, LD were all within normal limits. ASO titer was 29, which was normal. Complement tests including C3 and C4 were normal. The patient's rash coalesced nto larger lesions by the day of discharge.
C4|(complement) component 4|C4.|103|105|HOSPITAL COURSE|In addition, her C3 and C4 were checked during this hospital stay, but were low at 41 for C3 and 6 for C4. The patient is scheduled for a PET scan next week per Rheumatology's recommendations. DISCHARGE PLANS AND FOLLOW-UP: The patient is being discharged to Station 12 on the _%#CITY#%_ Psychiatry Unit, as she is currently committed.
C4|(complement) component 4|C4|150|151|HISTORY OF PRESENT ILLNESS|ANCA was negative. Hepatitis B surface antigen was negative. Anti-hepatitis B core antibody was negative. HIV was negative. A C3 was found to be 116, C4 23. INR was 1.13, platelets normal. Anti-double stranded DNA was negative. On admission, _%#NAME#%_ had no complaints of illness. He said his activity and appetite were doing well.
C4|cervical (level) 4|C4|212|213|PROCEDURE PERFORMED|DIAGNOSIS: Right-sided C4-5 and C5-6 arachnoid cyst. DISCHARGE DIAGNOSIS: Same. PROCEDURE PERFORMED: On _%#MMDD2004#%_ was a right C5-6 hemilaminectomy and foraminotomy and drainage and obliteration of the right C4 through C6 arachnoid cyst. HISTORY OF PRESENT ILLNESS: 32-year-old white female who presents with chronic neck and right upper extremity pain after an assault occurred in _%#MM2003#%_.
C4|(complement) component 4|C4,|214|216|ADMISSION PLAN|Blood pressure on admission was 123/78, pulse 96. ADMISSION PLAN: Repeat the electrolytes with a full metabolic panel with protein, albumin, magnesium phosphorous, calcium, and anti- DNAse B, ASO titer, CH-50, C3, C4, and a FANA. Her blood pressures will be monitored every 2 hours, her electrolytes, as I said, will be reassessed and she will continue on a normal saline flush of 20/kg, so a total of 800 cc.
C4|cervical (level) 4|C4|132|133|LABORATORY TESTS|Potassium was 4.4. CT scan of the spine: Revealed no acute fracture. Cervical spine: There is multiple level degenerative change of C4 and C5 and C6-C7. Electrolytes were normal. Glucose was 131, creatinine 1.02 and calcium 8.3. Hemoglobin was 12.9, MCV 95, platelet count 141.
C4|cervical (level) 4|C4|211|212|PROCEDURES|DISCHARGE DIAGNOSES: 1. Cervical spondylitic myelopathy. 2. Coronary artery disease. 3. Urinary tract infection. 4. Hyponatremia. PROCEDURES: 1. Adenosine stress test. 2. Decompressive cervical laminectomy from C4 to C6 and bilateral foraminotomies at C4-C5 and right C5-C6 foraminotomy. PRIMARY PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_ ATTENDING: Dr. _%#NAME#%_ _%#NAME#%_
C4|cervical (level) 4|C4|205|206|HOSPITAL COURSE|An EMG was done which showed a pattern more consistent with a neuropathy rather than a myopathy. This prompted evaluation of his cervical spine and a CT myelogram and MRI demonstrated spinal stenosis from C4 to C6 and foraminal stenosis at C4-C5, C5-6. Neurosurgery was consulted and the patient was indeed myelopathic. He was taken to the Operating Room on _%#MMDD2002#%_ for the above stated procedure.
C4|(complement) component 4|C4|167|168|PAST MEDICAL HISTORY|4. Bilateral hearing loss secondary to war trauma. 5. Hepatitis B surface antigen positive. 6. Glomerulonephritis diagnosed in 1997. 7. ANCA, ANA, hepatitis C, C3 and C4 were negative. 8. Progressive chronic renal insufficiency with baseline creatinine 2.1. FAMILY HISTORY: Sister with diabetes. Multiple siblings with hypertension. Son with "kidney problems". Daughter with renal failure status post renal biopsy.
C4|(complement) component 4|C4|150|151|HISTORY OF PRESENT ILLNESS & SUMMARY OF HOSPITAL|Folate 10.6. Vitamin B-12 greater than 1500. C- reactive protein was high at 15.5. Cryoglobulin was high at 24. Rheumatoid factor high at 184. C3 and C4 were slightly depressed. Sodium on admission was 118. This was corrected. BUN on admission was 94 reflecting dehydration. This did get better during her hospital stay. Similarly, the creatinine was high on admission at 2.7. This normalized during her hospital stay.
C4|cervical (level) 4|C4|11|12|DIAGNOSIS|DIAGNOSIS: C4 to C7 anterior cervical decompression and fusion. HOSPITAL COURSE: This patient was admitted and underwent an elective anterior cervical decompression and fusion from C4 to C7 by staff physician, Dr. _%#NAME#%_ _%#NAME#%_.
C4|(complement) component 4|C4|296|297|DISCHARGE PLAN|DISCHARGE PLAN: Follow-up with Dr. _%#NAME#%_ in approximately a week-and-a-half. The following laboratory results are pending: Western blot for Lyme's test, parvovirus B19 antibodies, ASO titer, ANCA, serum protein electrophoresis, double-stranded anti-DNA antibodies, ENA antibodies and C3 and C4 levels.
C4|cervical (level) 4|C4|177|178|LABORATORY DATA|LABORATORY DATA: CBC normal. INR and PTT normal. Basic metabolic panel normal. Troponin normal. CT of the head revealed no bleed. C spine showed 3 mm anterior spondylolisthesis C4 and C5. Otherwise, no other abnormalities. There is some motion artifact. MRI of the neck has official results pending; however, per the emergency room staff, there was no obvious abnormality.
C4|(complement) component 4|C4.|226|228|HOSPITAL COURSE|Pain control was achieved through IV and oral pain medications and she seemed comfortable with the regimen noted on the chart. Lupus: The laboratory evaluation does support the potential of lupus flare with a decreased C3 and C4. However, at this time, this is by no means the most significant issue. Depression and anxiety: The patient is somewhat anxious and has had the previous diagnosis of anxiety and depression.
C4|(complement) component 4|C4|126|127|LABORATORY|INR 1.07. Blood cultures negative. Cryoglobulins level was less than 18. ANCA negative. Amylase 40, lipase 262. C3 level 120, C4 level 27, hepatitis C antibody negative, HIV negative. Urine eosinophil is negative. Urine protein- creatinine ratio 1.89. Drug screen positive for cannabinoids and opiates.
C4|cervical (level) 4|C4|172|173|PHYSICAL EXAMINATION|HEAD, EYES, EARS, NOSE AND THROAT: Eyes pupils equal, round, and reactive to light. No scleral injection. OROPHARYNX: Mucosa is pink and moist. NECK: Kyphosis secondary to C4 fracture. CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs or gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
C4|(complement) component 4|C4|141|142|HOSPITAL COURSE|However, the patient declined collection of urine and stool. At this time, the results for FANA, serum tryptase are pending. Both the C3 and C4 were normal. FOLLOWUP: The patient has a scheduled appointment with her primary care physician on _%#MM#%_ _%#DD#%_, 2005.
C4|(complement) component 4|C4|230|231|LABORATORY AND DIAGNOSTIC STUDIES ON DISCHARGE|Liver function tests have been slightly elevated, and the day of discharge her AST is 83 and her ALT is 39, alkaline phosphatase 106. Parasite stain was negative for ehrlichia species, complement C3 is decreased to 44, complement C4 decreased to 6, complement C2 and C5 still pending. Antinuclear antibody was greater than 10 which is positive. Rheumatoid factor was elevated at 25.
C4|cervical (level) 4|C4|116|117|HOSPITAL COURSE|He did have active inflammatory changes and edema on the facet joints C3 and C4 bilaterally and on the left side at C4 and C5. The radiologist did recommend an injection of cortisone and lidocaine on this basis for diagnostic and therapeutic purpose.
C4|cervical (level) 4|C4|83|84|DISCHARGE DIAGNOSES|PATIENT: _%#NAME#%_, _%#NAME#%_. DISCHARGE DIAGNOSES: 1. Sacral decubital ulcer 2. C4 quadriplegia. 3. Diabetes mellitus type 2. 4. Hypertension. DISCHARGE MEDICATIONS: 1. Vitamin C 500 mg b.i.d. 2. Baclofen 10 mg three times a day.
C4|cervical (level) 4|C4|203|204|PROCEDURE|PROCEDURE: Imaging: CT of the neck without contrast done on _%#MMDD2007#%_, results still pending at the time of discharge. X-ray of her cervical spine, 2-3 views showing 4 mm spondylolisthesis of C3 on C4 in flexion; this does reduce on extension. There is also spondylolisthesis at the T5-T6 level approximately 3 mm which does not reduce on extension.
C4|cervical (level) 4|C4|441|442|HOSPITAL COURSE|His treatment here initially included carbohydrate counting with meals with appropriate insulin coverage, but given his limited understanding of how to do this, at the time of discharge we are switching him to the high intensity regimen and the TCU staff can work with him, educating him more about how to go about managing his diabetes more appropriately. 3. Hypertension. The patient's blood pressure was quite labile, probably related to C4 quadriplegia and he is also on Florinef for orthostasis, so I did increase his Catapres to a TTS 3 patch at the day of discharge and that will have to be monitored as an outpatient.
C4|(complement) component 4|C4,|166|168|HISTORY OF PRESENT ILLNESS|Because of his repeated pulmonary infections, an extensive workup for immunodeficiency was undertaken. His immunoglobulins were noted to be normal as well as his C3, C4, CH50, factor B, and T cell markers. He was noted to have a low IgA and a low IgE; however, these would be expected to be low in a patient of his age.
C4|cervical (level) 4|C4|297|298|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Combined liver and kidney transplant, _%#MM2002#%_, for end-stage liver disease (ESLD) secondary to ethanol associated cirrhosis and hypertensive nephropathy. 2. Cervical myelopathy, status post laminectomy of C3-C7 in _%#MM2002#%_. The patient also underwent an anterior C4 corpectomy and strut graft reconstruction on _%#MMDD2002#%_. At this time, bone fragment material was submitted for culture; candida albicans and a multi-drug resistant strain of coag negative staph were identified.
C4|cervical (level) 4|C4|181|182|RADIOLOGY|Urinalysis was negative. RADIOLOGY: CT of the cervical spine done in the emergency department reveals severe degenerative changes in the cervical spine and retrolisthesis of C3 and C4 with involvement of the cervical cold. Head CT is negative for any subdural or other bleed. It shows a moderate amount of atrophy. PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile.
C4|cervical (level) 4|C4|175|176|PAST MEDICAL HISTORY|Recent A1C is 7.8 and has diabetic education scheduled later this week. Patient has sleep apnea and is on nasal CPAP. He has a history of cervical spinal stenosis status post C4 decompression. Patient has chronic neuropathy of his feet since surgery for a T5 meningioma. He has benign prostatic hypertrophy which presented with urinary retention postoperatively.
C4|cervical (level) 4|C4.|146|148|HOSPITAL COURSE|She later complained of neck pain but does have chronic neck pain. C spine of her neck was done which showed a 30% anterior displacement of C3 on C4. She also advanced degenerative disease of C4-5, C5-6 and C6-7 with disk space narrowing. There was no however, acute findings. The patient also had a CT of her head which showed no evidence for hemorrhage but did have large ventricles but no skull fracture, other than atrophy it was otherwise negative.
C4|(complement) component 4|C4|191|192|LABORATORY DATA|Initial sodium 128, potassium 5.5, chloride 98, bicarbonate 16. BUN 67; creatinine 3.01; glucose 60. C-reactive protein 11.5. ASO 447 (normal 0-240). Complement C3 47 mg/dL (normal 90- 160). C4 24. ANA screen negative. Anti-DNA B antibody 170. Initial urinalysis revealed a specific gravity of 1.019 with 15 mg/dL ketones, large blood, greater than 300 mg/dL protein, large leukocyte esterase and negative nitrite.
C4|cervical (level) 4|C4|301|302|LABORATORY DATA|AST 220, ALT 105, ALP 150 and total bilirubin is 1. CT of the C-spine shows degenerative changes with mild C3-C4 foraminal narrowing, moderate bilateral C4-C5 foraminal narrowing, moderate-to-severe bilateral C5-C6 and severe right C6-C7 foraminal narrowing as well as mild spinal canal stenosis from C4 through C6 levels. ASSESSMENT AND PLAN: Mr. _%#NAME#%_ is a 54-year-old man who presents with alcohol withdrawal and likely alcohol related seizure.
C4|(complement) component 4|C4|183|184|HOSPITAL COURSE|Her CD3 which was 96, CD4 16, CD8 79, C- reactive protein 2.7, and ESR 120. Neutrophil and cytoplasmic IgG were normal. Antinuclear antibody screening was weakly positive. Complement C4 11, complement C3 44, rheumatoid factor 97, hepatitis A negative, hepatitis B negative, hepatitis C negative, LDH 667, CMV IgG antibody was positive, and influenza was negative.
C4|cervical (level) 4|C4|211|212|ADMISSION LABORATORY|CT of the face reveals the minimally displaced right superior orbital rim fracture, as well as the previously noted right temporal bone fracture. CT of the cervical spine reveals surgical changes from the prior C4 through C6 anterior fusion. There is significant degenerative changes, but no acute fractures or dislocations. CT of the thoracic and lumbar spine shows no acute fractures or dislocations.
C4|(complement) component 4|C4|360|361|ADMISSION LABORATORY DATA|ADMISSION LABORATORY DATA: Included a basic metabolic panel within normal limits and a hemogram revealing a white blood cell count of 12.2, hemoglobin of 9.6, platelets of 256, CRP was 23.1. Additional antibody labs were drawn revealing an IgG of 1670 and IgA of 419, IgM of 339. Additionally, rheumatoid factor less than 20 was noted, a C3 level of 144 and a C4 level of 16. At the time of this dictation, an antinuclear antibody result is pending. Blood cultures were drawn on the day of admission. HOSPITAL COURSE: After being admitted to the hospital, the patient was begun on intravenous antibiotics including tobramycin and imipenem and rapidly defervesced.
C4|(complement) component 4|C4,|317|319|PLAN|PLAN: 1. Get a surgical consult from Dr. _%#NAME#%_ to evaluate the patient for adhesions in view of that she has had a total abdominal hysterectomy, bilateral salpingo-oophorectomy, appendectomy and cholecystectomy. 2. Will check serology for lupus, including ANA and anti-double- stranded DNA antibody, a CH50, C3, C4, CRP. Will check an MRI of her thoracic and lumbar spine to rule out nerve impingement causing radicular pain on the right side.
C4|cervical (level) 4|C4|135|136||C6 and C7 were normal. C7 and T1 was normal. There was no evidence for fracture. There was Grade 1-2 degenerative spondylolisthesis of C4 and C5 secondary to marked central and moderate severe left-sided foraminal stenosis. Marked degenerative joint disease of C3 and C4, mild to moderate right central canal stenoses with a slight cord deformity at C5- 6 secondary to degenerative joint disease disk disease.
C4|cervical (level) 4|C4,|223|225||There was no evidence for fracture. There was Grade 1-2 degenerative spondylolisthesis of C4 and C5 secondary to marked central and moderate severe left-sided foraminal stenosis. Marked degenerative joint disease of C3 and C4, mild to moderate right central canal stenoses with a slight cord deformity at C5- 6 secondary to degenerative joint disease disk disease.
C4|(complement) component 4|C4|210|211|HOSPITAL COURSE|Her lisinopril for hypertension and her Tricor for hyperlipidemia were also withheld. Antinuclear antibody was not present. Antineutrophil cytoplasmic antibody was also not present. Complement component C3 and C4 were in the normal range. Serum immunoglobulins revealed a low IgG of 615, low IgM of 30, and normal IgA of 190. Urine immunofixation ELP revealed no monoclonal protein. A bone marrow biopsy was obtained, which showed no plasma cell dyscrasia, slightly low iron stores, slight hypocellularity, and no evidence of malignancy.
C4|cervical (level) 4|C4|226|227|HISTORY OF PRESENT ILLNESS|PRIMARY CARE PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_ CHIEF COMPLAINT: Lethargy, fever HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 64-year-old male who was brought in by his son for lethargy and fever. The patient is a C4 quadriplegic since 1995 after having fallen down the stairs at home. The patient has had frequent urinary tract infections and a urinary tract infection with septicemia in the past.
C4|cervical (level) 4|C4|282|283||Ms. _%#NAME#%_ _%#NAME#%_ is a 59-year-old woman who was admitted for operative treatment of cervical stenosis secondary to degenerative cervical spondylolisthesis. On the day of admission, _%#MMDD2006#%_, she underwent uncomplicated anterior cervical decompression and fusion from C4 through C7. Instrumentation was utilized in addition to bone graft. She tolerated the procedure well, awoke neurologically intact and had numerous medical comorbidities.
C4|(complement) component 4|C4|187|188|LABORATORY|Erythrocyte sedimentation rate 92, C-reactive protein 19.3. Basic metabolic panel: Sodium 140, potassium 4.0, BUN 12, creatinine 0.81, IgA 137, IgG 742, DNA screen less than 1.0, C3 184, C4 14 with normal range 15-50. Hepatic panel: AST 22, ALT 42, alkaline phosphatase 125, albumin 3.9, total bilirubin 0.7. Lyme screen negative.
C4|(complement) component 4|C4,|226|228|HOSPITAL COURSE|On discharge his temperature 98.4 and he was discontinued off of antibiotics due to no source of infection. His fevers may be related to his tumor or an autoimmune/rheumatologic disorder. He had blood work, including ANA, C3, C4, and CH50 drawn to further evaluate for a rheumatologic cause. On admission a sedimentation rate and CRP were significantly elevated and this could be due to a number of causes as listed above.
C4|(complement) component 4|C4,|251|253|DISCHARGE INSTRUCTIONS|He has appointment scheduled with Dr. _%#NAME#%_, his primary oncologist on _%#MMDD2004#%_ at 10:30 for follow-up of hospitalization, and for chemotherapy. Laboratory results currently pending, which need to be followed up in clinic, include ANA, C3, C4, CH50, coagulation studies, erythropoietin level, a urine panel, hemolysis panel, direct Coombs, and reticulocyte count. The patient's wife has noted that his mental status has been slightly off for the past several months, and may be considered in clinic to obtain a head CT or MRI to further evaluate this.
C4|cervical (level) 4|C4|193|194|HISTORY|She also had a C-spine done at that time which showed some disc space narrowing in the C5 through C7 area consistent with degenerative changes with a small posterior osteophytic spur along the C4 through C7 area. The patient also underwent a chest CT scan on that day which showed no evidence of aortic dissection and only mild cardiomegaly.
C4|cervical (level) 4|C4,|227|229|HISTORY OF THE PRESENT ILLNESS|He had flaccid paralysis of the extremity which included absence of deltoid, biceps, triceps, wrist extension as well as very mild intrinsic finger flexion, which I would grade at 3-. Sensation was diffusely lost involving the C4, 5, 6 and portions of the 7 dermatome. There were no localized symptoms to the left side. He did have some ptosis and possibly changes in reactivity of the right pupil which would be consistent with a Horner's syndrome with no other sequelae of that.
C4|(complement) component 4|C4|233|234|HOSPITAL COURSE|An autoimmune workup was undertaken which was remarkable for CRP of 61.5, negative rheumatoid factor, negative ANA. 2. Assess the IgG3. 3. Assess A-IgG. 4. Scleroderma antibody IgG. 5. JO-1 antibody IgG3, complement levels of C3 and C4 were within normal limits. On _%#MM#%_ _%#DD#%_, 2005, a thoracoscopy and wedge resection of the right upper and right lower lobe was undertaken.
C4|(complement) component 4|C4|233|234|LABORATORY EVALUATION|Ionized calcium was 4.8, INR and PTT were normal. HISTORICAL LABORATORY EVALUATION: Previous workup showed hypoalbuminemia. Previous albumin 2.4. He has also had an ASO screen which was negative on _%#MMDD2005#%_ and a C3 of 147 and C4 of 33. His total cholesterol was elevated at 249. At 24-hour urine collection on _%#MMDD2005#%_ showed a volume of 650, total protein of 720 (normal would be 150 mg).
C4|cervical (level) 4|C4|79|80|DIAGNOSES|The patient of Dr. _%#NAME#%_ _%#NAME#%_. DIAGNOSES: 1. History of cytosis. 2. C4 tumor/histiocytic tumor. MAJOR PROCEDURES AND TREATMENTS: C4 corpectomy and fusion done on _%#MM#%_ _%#DD#%_, 2006.
C4|cervical (level) 4|C4|145|146|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient was recently a consult of ours as an inpatient at the University Hospital. On recent scan for neck pain, C4 tumor was found, and the patient was therefore electively planned for biopsy/removal and hardware fixation. HOSPITAL COURSE: The patient was readmitted per the above description.
C4|(complement) component 4|C4|185|186|SIGNIFICANT STUDIES AND PROCEDURES|3. Hepatitis serologies, positive hepatitis C antibody, positive hepatitis B core antibody; otherwise negative. 4. Elevated rheumatoid factor of 108. 5. Low complement levels C3 if 74, C4 is 3. CH50 is 3. 6. Hypogammaglobulinemia on protein electrophoresis. HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ _%#NAME#%_ is a 49-year-old lady with a history of lower extremity vasculitis by skin biopsy, as well as known history of hepatitis C.
C4|(complement) component 4|C4|150|151|HOSPITAL COURSE|So, we ordered a hepatitis screen. We ordered VDRL and Lyme antibody. We placed PPD and that will be checked in 72 hours from now. We also sent a C3, C4 and ACE level. ANCA was sent also. Her RF and ANA were normal. We obtained above diagnostic workup to rule out any other vascular abnormalities which were normal.
C4|(complement) component 4|C4|261|262|HOSPITAL COURSE|On arrival to the pediatric floor, the Cytoxan therapy protocol was instituted, and a chest x-ray on admission shows decreased right effusion with clear lungs. Electrolytes on admission were within normal range with albumin 2.1, complement C3 of 59, complement C4 of 15, and hemoglobin of 11.3 with total white count 7.9, and platelets 371. Urinalysis on admission shows leukocyte esterase with negative nitrite, WBC 14 with hyaline casts and mucus and a few bacteria.
C4|cervical (level) 4|C4|217|218|SYNOPSIS OF HISTORY AND PHYSICAL|The patient also has had MRA of the neck and circle of Willis which was essentially normal. Neurology consultation was obtained and Dr. _%#NAME#%_ ordered an MRI of the cervical spine which showed a solid fusion from C4 through C7 and mild degenerative retrolisthesis of C3-C4 and anterior subluxation C7 and T1. During the hospital course, the patient started feeling much better.
C4|cervical (level) 4|C4|127|128|PROCEDURES|PROCEDURES: 1. Tracheostomy by general CJ surgery. 2. EEG showing L5 alfa and data data variable activity with three C3-P3 and C4 -P4 for bisynchronous bitespikes. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ ?? is a 69-year-old female with ALS who was previously living at home and had a PEG placed in _%#MM2007#%_ for dysphagia and malnutrition secondary to ALS, who was found unresponsive by her husband on the day of admission.
C4|(complement) component 4|C4|331|332|ADDENDUM|Specifically, kidney biopsy result with comments from Children's Hospital at _%#CITY#%_ Pathology Department dated _%#MMDD2002#%_ that showed diffuse proliferative glomerulonephritis with 65% crescents. The comment said the patient has strong serologic evidence of SLE with high titer double strand DNA bodies; however, her C3 and C4 levels were normal and she exhibits a P ANKA and MPO antibodies. Her laboratories included an ENA panel was negative, her anti RULE OUT antibody was positive at 102.4. Her anti LA antibody was positive at 151.02. Her anti SCL-70 antibody was negative, anti JO-1 antibody was negative.
C4|(complement) component 4|C4|194|195|HISTORY OF PRESENT ILLNESS|The patient was seen by Dr. _%#NAME#%_ at the University of Minnesota and was referred for biopsy after a number of negative labs including a T4 of 0.69, TSH of 1.73, albumin of 4.6, C3 of 155, C4 of 21, negative ANCA and ANA. She had an anti-double-stranded DNA antibody of 2, which was negative; factor XI 88%, and total compliment of 104.
C4|cervical (level) 4|C4|118|119|PROCEDURES THIS ADMISSION|DIAGNOSIS: Cervical spinal stenosis, degenerative disc disease and cervical myelopathy. PROCEDURES THIS ADMISSION: 1. C4 and C5 corpectomy. 2. C3-C7 anterior spinal fusion with instrumentation, fibular allograft and local autograft. 3. Her surgery was complicated by a spinal fluid leak and on postoperative day #3 she had a lumbar CSF drain placed.
C4|cervical (level) 4|C4,|303|305|HISTORY OF PRESENT ILLNESS|Workup was consistent with severe central canal stenosis at level C4-C5, C5-C6 with severe degenerative changes consistent with cervical myopathy. She underwent surgery on _%#MMDD2006#%_ with Dr. _%#NAME#%_ _%#NAME#%_. Surgery included C4-C5 carpectomies with decompression of spinal cord and bilateral C4, C5, C6 nerves, C3 to C7 anterior spinal fusion and instrumentation, fibular allograft and local autograft. Intraoperatively of note, the posterior longitudinal ligament and dura were noted to be densely adherent and during attempts at decompression the dural space was violated.
C4|(complement) component 4|C4,|178|180|HOSPITAL COURSE|Her lip swelling has decreased. The Allergy Service was consulted, and their opinion is that the patient had a local anaphylactoid reaction. They sent out tryptase levels, CH50, C4, and 24-hour urine for histamine levels. The results are pending at the time of discharge. Vioxx was discontinued. The patient was started on Allegra 60 mg p.o. b.i.d. The patient will follow-up with Dr. _%#NAME#%_ in two weeks after discharge.
C4|(complement) component 4|C4,|181|183|PROBLEM #1|It is also possible they felt this could represent an latex allergy, a possible autoimmune disorder, or mastocytosis. Several lab studies were recommended including a tryptase, C3, C4, CH50, ESR, FANA, and 24 hour urine for histamine. She was continued on Benadryl and doxepin was added for her itching.
C4|cervical (level) 4|C4|263|264|PAST MEDICAL HISTORY|He underwent a left percutaneous nephrolithotomy on _%#MMDD2002#%_. He urgently presented to the operating room on _%#MMDD2002#%_ for a second-look nephrostomy on the left side and a proposed percutaneous stone removal on the right side. PAST MEDICAL HISTORY: 1. C4 quadriplegia in 1987. 2. Hypertension, which is very labile and responsive to sympathetic reactions, consistent with autonomic dysreflexia.
C4|(complement) component 4|C4|148|149|LABORATORY DATA|CENTRAL NERVOUS SYSTEM: Grossly intact. SKIN: No suspicious rash noted. PSYCHIATRIC: Mentation and affect normal. LABORATORY DATA: C1 esterase, C3, C4 all pending at this time. ASSESSMENT AND PLAN: Angioedema of the face. Patient received an epinephrine intramuscularly, Decadron intravenous and Benadryl intravenous and also Zantac.
C4|cervical (level) 4|C4,|177|179|PROCEDURE THIS ADMISSION|DIAGNOSIS: Spinal stenosis and multilevel cervical radiculitis. PROCEDURE THIS ADMISSION: C3 through C7 laminoplasty with instrumentation and foraminotomies on the left side at C4, C5, C6 and C7. HISTORY OF PRESENT ILLNESS Mr. _%#NAME#%_ _%#NAME#%_ is a 59-year-old man who has a four month history of left arm numbness and tingling.
C4|cervical (level) 4|C4.|196|198|INR 0.95.|CT of the head: Old lacunar infarct in the right corona radiata, with no acute infarct, mild atrophy. CT of the C-spine: Normal above C3-C4. Beam hardening artifact obscures the exam below C3 and C4. EKG: Normal sinus rhythm. No ST or T-wave changes to suggest ischemia.
C4|cervical (level) 4|C4|325|326|PROCEDURES PERFORMED|PROCEDURES PERFORMED: 1. On _%#MMDD2007#%_, the patient was placed in halo traction. 2. On _%#MMDD2007#%_, the patient had a decompressive posterior cervical laminectomy with revision decompression including removal of old fusion bones and posterior spinal cord and nerve root decompression with segmental instrumentation of C4 and T1 with pedicle screws, rods and cross connectors and anterior cervical C6 corpectomy. At the same time, he also had an anterior cervical spinal cord decompression and nerve root decompression at C5-C6 and C6-C7 bilaterally decompressing the nerve roots with structural allograft for anterior cervical arthrodesis from C5-C7 and anterior cervical plating from C5-C7.
C4|(complement) component 4|C4|178|179|HOSPITAL COURSE|There was also noted possibly some small kidney stones in the right kidney. Nephrology was consulted and began a workup of nephritis. A C3 panel was 121, normal being 90 to 200. C4 panel was 23, normal being 15 to 50. Her neutrophil cytoplasmic antibody IgG screen was less than 1:16, and this is normal.
C4|cervical (level) 4|C4|370|371|SUMMARY|Sodium 141, potassium 4, chloride 109, CO2 24, BUN 30, creatinine 2.15, glucose 117, calcium 8.2, magnesium 1.9, phosphorus 4.3. Dilantin level 2.8 (up from 1 3 days ago, at which time dose adjusted from 100 to 200 mg at h.s.). SUMMARY: The patient is a 49-year-old male admitted to the rehab service following hospitalization for exacerbation of multiple myeloma and a C4 fracture either associated with fall, pathology, or seizure. Neurosurgery felt he could be managed conservatively. He has also had significant right shoulder pain with underlying multiple myeloma lesions.
C4|(complement) component 4|C4|132|133|LABORATORY DATA|Sodium 135, potassium 3.3, chloride 93, CO2 27, anion gap 15, BUN 80, creatinine 3.68, calcium 9.0, glucose 104. Complement C3 131, C4 27. Erythrocyte sedimentation rate 11. Calculated FeNa 1.7%, urine creatinine 97, urine sodium 79. Urine osmolality 434. Urine potassium 10. Urine chloride 70. CT of chest from _%#MMDD2005#%_ was reviewed and was found to negative for pulmonary embolism.
C4|(complement) component 4|C4|116|117|PAST MEDICAL HISTORY|He does not know of any other medical problems within his family. PAST MEDICAL HISTORY: 1. HIV and AIDS. His recent C4 count on _%#MMDD2005#%_ was 1. His ANC was 400 at that time as well. 2. Necrotizing ulcerative gingivitis. When he presented with this problem in early to mid _%#MM2005#%_, he required his wisdom teeth extracted.
C4|cervical (level) 4|C4|269|270|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: A 62-year-old female with past medical history of severe cervical and lumbar spinal surgeries had recurrent spinal stenosis cervically and underwent an anterior C4-5 corpectomy, infusion and a secondary surgical procedure with the posterior C4 through C7 fusion on _%#MMDD2007#%_. Symptoms leading to surgery included bilateral tingling of all her fingers in both hands as well as pian and tingling in the upper lateral arm in a symmetrical pattern.
C4|cervical (level) 4|C4|118|119|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Cervical spondylolytic disease with progressive kyphosis and quadriplegia progressing from C6 to C4 level. DISCHARGE DIAGNOSIS: Cervical spondylolytic disease with progressive kyphosis and quadriplegia progressing from C6 to C4 level.
C4|(complement) component 4|C4|220|221|DISCHARGE DIAGNOSES|LABORATORY: The patient's electrolytes were sodium 122, potassium 4.9, chloride 94, bicarbonate 18, BUN 72, creatinine 10.4, glucose 103. TSH was 53.6. White count of 14.5, hemoglobin 11.9. CRP of 1.73, SR 61. Patient's C4 was 22. C3 of 132. Phenol was 8.4. ANA was negative. Protein electrophoresis or SPEP was negative. The patient was admitted for the management of her renal failure.
C4|cervical (level) 4|C4|117|118||DISCHARGING DIAGNOSES: 1. Incomplete spinal cord injury C5 from a fall back in _%#MM#%_ while living in Texas with a C4 through C6 decompression fusion including an anterior cervical diskectomy and corpectomy from C4-C6 on _%#MMDD2007#%_. She also had a mesh cage and anterior plate with bone graft done at that time.
C4|cervical (level) 4|C4|173|174|PAST MEDICAL HISTORY|3. Chronic pain syndrome. 4. Recurrent UTIs with pseudomonas, neurogenic bladder and suprapubic catheter. 5. Status post spinal cord decompression and graft arthrodesis. 6. C4 through C6 autologous iliac crest graft with cervical plate. 7. History of substance abuse. HOSPITAL COURSE: The patient was admitted to the hospital in stable condition with the above-listed diagnoses.
C4|cervical (level) 4|C4|134|135|LABORATORY  DATA|CT scan of the head shows no evidence for acute bleed or other abnormality. CT scan of the C-spine shows some degenerative changes at C4 through C6 but no acute fracture or other pathology. Left wrist film shows a distal radial fracture. CT scan of the maxillofacial area shows some subcutaneous bruising but no evidence for fracture.
C4|cervical (level) 4|C4|154|155|PROCEDURES|CONSULTATIONS: 1. Intensivist. 2. Physical Therapy. 3. Occupational Therapy. 4. Physical Medicine/Rehabilitation. PROCEDURES: 1. _%#MMDD2006#%_. Anterior C4 and C5 corpectomy, partial C3 and C6 corpectomy, C3-4, C4-5, and C5-6 diskectomy. C3-C6 fibular allograft/DBX structural interbody fusion. C3-C6 vector plate fixation microscopic visualization and fluoroscopic interpretation.
C4|(complement) component 4|C4|156|157|DISCHARGE DIAGNOSES|Hepatitis A serologies are still pending. ANA was weakly positive. ANCA was negative and ASO titer was negative. Complements are slightly low, C3 of 76 and C4 of 12. Ultimately Mr. _%#NAME#%_ underwent percutaneous biopsy of the left kidney demonstrating, at least on a preliminary basis, acute tubular necrosis with no significant histologic glomerular abnormalities identified.
C4|cervical (level) 4|C4.|202|204|PAST MEDICAL HISTORY|Left subclavian artery stenosis with stent placement _%#MM#%_ 2002. Hyperlipidemia, hypertension, degenerative joint disease of the right knee, and cervical myelopathy with decompression and fusion C3- C4. While in the medical unit, the patient was evaluated by Dr. _%#NAME#%_ from orthopedics. MRI of the right knee was obtained demonstrating no meniscus tear, no ligament tear.
C4|(complement) component 4|C4|326|327|ASSESSMENT/PLAN|3. Hypertension, uncontrolled. 4. Impaired fasting glucose. SECONDARY DIAGNOSES: Secondary diagnoses as mentioned above in the in past medical history. ASSESSMENT/PLAN: The patient is admitted for observation. I will perform some additional blood work essentially including the serum tryptase and the complement levels C2 and C4 complements, C1Q, and also C1 inhibitor levels to see if patient had a truly anaphylactic reaction. It has been reported with angiotensin receptor blockers as well and so at this point I will completely stop the Cozaar and replace it by other antihypertensive.
C4|(complement) component 4|C4|444|445|LABORATORY DATA ON ADMISSION|CBC was normal, white count 8,600 with a normal differential, hemoglobin 14.1, Keppra level 10.7. MRI scanning of the brain was done showing no evidence for any acute change on diffusion-weighted imaging, a 2 cm area of encephalomalacia and gliosis in the left mid frontal parasagittal region was noted similar to previous descriptions. Her sed rate was borderline elevated at 25. C-reactive protein was negative at 4.2. Complement C3 was 110, C4 was low at 14, routine urinalysis was negative. Chest x-ray was negative as well. Lumbar puncture was performed showing no white cells, no red cells, glucose 51, protein 48, no growth on the culture, negative Gram stain.
C4|(complement) component 4|C4,|147|149|HOSPITAL COURSE|She was also on Ranitidine and Atarax. This was changed to Zyrtec. Laboratory studies obtained in the hospital included C1 esterase inhibitor, C3, C4, and ANA, all of which are pending at the time of this dictation. She is asymptomatic with no urticaria found on physical exam at the time of discharge.
C4|cervical (level) 4|C4|170|171|PAST MEDICAL HISTORY|4. Abdominal aortic aneurysm. An ultrasound done on _%#MMDD2002#%_ showed a diameter of 3 cm. 5. Gastroesophageal reflux disease. 6. Osteoarthritis. 7. Status post C3 to C4 cervical fusion. 8. Mitral valve prolapse. SOCIAL HISTORY: The patient has a 30-pack-year history of smoking cigarettes, but she quit in 1997.
C4|fourth heart sound:S4|C4;|185|187|PHYSICAL EXAMINATION|Neck supple; no jugular venous distention; no thyromegaly. Lungs: Bilateral rales and rhonchi heard diffusely heard over both lungs fields. Heart: Both heart sounds are audible; no S2, C4; no murmurs or gallops. Abdomen: Slightly distended; no rebound tenderness; no guarding; no rigidity. Scars of old surgery are benign. Extremities: The patient has bilateral lower extremity edema left greater than right.
C4|cervical (level) 4|C4|160|161|HOSPITAL COURSE|She had an emergent x-ray performed, and was taken emergently to the operating room again, where her neck was opened and re-explored. There was seen around her C4 to C6 region an arterial bleeder causing an epidural hematoma. This was evacuated, along with fresh blood and some blood clot.
C4|(complement) component 4|C4|223|224|PENDING TEST RESULTS|No pulmonary emboli. Mildly prominent bilateral axillary lymph nodes. Unable to tap loculated effusion. MICROBIOLOGY: Urine culture: No growth to date. PENDING TEST RESULTS: DNA double-stranded antinuclear antibody screen, C4 and C3, 24-hour urine collection for creatinine clearance and total protein. HOSPITAL COURSE: 1. Pneumonia with pleurisy. _%#NAME#%_ _%#NAME#%_ is a 26-year-old woman with a history of Sjogren's and lupus and prior history of recurrent calcium renal stones, who presents with pleuritic chest pain for approximately 3 weeks in induration, with some associated dry cough.
C4|cervical (level) 4|C4|142|143|PROCEDURES|5. Video swallow which showed a thin liquid aspiration. 6. MRI of the C-spine and T-spine which showed long segment of spinal cord edema from C4 through T3 and multiple levels of spinal canal stenosis caused by congenital stenosis, multiple disk herniations. 7. Ultrasound of the aorta which was unremarkable. Repeat video swallow showed silent aspiration with nectar consistency liquids.
C4|cervical (level) 4|C4|126|127|HOSPITAL COURSE|ADMITTING DIAGNOSIS: Cervical spondylosis. HOSPITAL COURSE: Ms. _%#NAME#%_ was admitted on _%#MMDD2006#%_ after uncomplicated C4 corpectomy, as well as fusion C3 through C6. Estimated blood loss 20 cc. No intraoperative complications. On postoperative day 1, she was complaining of swallowing difficulty.
C4|cervical (level) 4|C4|192|193|DESCRIPTION OF PROCEDURE|ATTENDING SURGEON: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD. DESCRIPTION OF PROCEDURE: On the day of admission, Ms. _%#NAME#%_ _%#NAME#%_ underwent an uncomplicated posterior cervical fusion from C4 through C7. The preoperative indications were that of a prior multiply operated cervical spine consisting of a remote anterior decompression with residual stenosis, posterior laminoforaminotomy with persistent symptoms and subsequent anterior corpectomy from C4 through C7.
C4|cervical (level) 4|C4|156|157|DISCHARGE PHYSICAL EXAM|Her hand grip is 5/5 bilaterally as well as her biceps and triceps strength. She has full range of motion of her upper extremities. Her sensation is intact C4 through T2 distribution bilaterally and she has strong radial pulses bilaterally. She has a negative Homans. PENDING TEST RESULTS: None. DISCHARGE MEDICATIONS: The patient will continue her preoperative medications which included 1.
C4|(complement) component 4|C4|234|235|LABORATORY VALUES|LABORATORY VALUES: White count 18.6, hemoglobin 14.7, platelets 243, sodium 140, potassium 3.7, chloride 110, bicarbonate 28, BUN 14, creatinine 1.0, glucose 82, INR 0.88, PTT 23. As an outpatient on 5/31, he had a C3 level of 183, a C4 level of 31, total complement 133, ESR 81. HIV, hepatitis B and C were negative. His UA revealed greater than 300 mg/dL protein, 2 white cells, 2 red cells.
C4|(complement) component 4|C4,|434|436|PROCEDURES PERFORMED|BRIEF HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is an 18-year-old girl diagnosed with lupus nephritis in _%#MM#%_ of 1999 who was in her stable state of health until about 1 month ago when things began to "flare up." At that time, she had just come back from a trip to Europe with "flu-like symptoms" which included nausea, fever, chills, diarrhea, and vomiting. She subsequently developed edema, increased proteinuria, decreased C3 and C4, hypertension. She notes she did take her medications in Europe and was exposed to "flu and cold." She was subsequently admitted 2 days after returning home on _%#MM#%_ _%#DD#%_, 2002, for blood pressure and edema control.
C4|(complement) component 4|C4,|99|101|FOLLOW UP|FOLLOW UP: Ana is to have the following blood tests on Friday, _%#MM#%_ _%#DD#%_, 2002: A BMP, C3, C4, albumin, and CBC. Her father is to contact Dr. _%#NAME#%_ following receipt of the laboratory results.
C4|(complement) component 4|C4,|373|375|HISTORY|I elected to update some of her laboratories and the results are as follows: serum sodium 123 (which was down from 137); creatinine 2.4 (which was up from 1.7); in addition, she was noted to be hypercalcemic with a calcium of 10.5 which corrected to 11.5. Her hematocrit was noted to be 27.3. She was markedly iron deficient. With respect to her glomerular disease her C3, C4, and ASO titers were essentially unremarkable. As such, I called the patient yesterday, _%#MMDD2002#%_, and told her that she needed to come in immediately to have her labs redrawn; she said she could not do that but she would come in today, _%#MMDD2002#%_.
C4|cervical (level) 4|C4|167|168|REVIEW OF SYSTEMS|No lumps or bumps or pigmented lesions. MUSCULOSKELETAL: As most of her problems relating to neck, recent cervical spine x-rays, pain shows some anterior listhesis of C4 and C5, numerous osteophytes and disk space narrowing. HEENT: Denies unusual headaches or dizziness. Vision: Usually has her eyes checked regularly, Dr. _%#NAME#%_ recently did an eye exam, no signs of retinopathy and referral was made for oculoplasty.
C4|cervical (level) 4|C4.|130|132|DIAGNOSTIC IMPRESSION|2. Previous right hip fracture with _%#NAME#%_'s screw in place. 3. Posterior element fracture of C1. Laminar fractures of C3 and C4. 4. Head concussion without loss of consciousness. 5. Intermittent hypertension 6. Heart murmur, rule out significant aortic valvular disease 7. Probable previous small stroke by history.
C4|cervical (level) 4|C4|125|126|PROCEDURES AT THE TIME OF HOSPITALIZATION|4. MRI of the C-spine on _%#MMDD2007#%_: There are degenerative disc changes as seen on the CT scan, but now also the C3 and C4 level. There were no fractures noted. 5. Shoulder x-ray on _%#MMDD2007#%_: There were degenerative changes in the shoulder without evidence of fracture or dislocation.
C4|cervical (level) 4|C4|141|142|PROCEDURE PERFORMED|ADMISSION DIAGNOSIS: Extradural and intraspinal mass C4. DISCHARGE DIAGNOSIS: Extradural and intraspinal mass C4. PROCEDURE PERFORMED: Right C4 hemilaminectomy with exploration of extradural mass. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 44-year-old gentleman who presented to the Emergency Room with radicular pain in the shoulders.
C4|(complement) component 4|C4|134|135|LABORATORY FINDINGS DURING THIS ADMISSION|MCV was 74. A basic metabolic battery within normal limits. The exception is a glucose of 122 and calcium of 8.3. A C3 component 116, C4 19, iron level 43, transferrin 151, transferring binding capacity 225, iron saturation is 19. Reticulocytes 1.8%. Ferritin of 139. A chest x-ray showed no acute infiltrates.
C4|(complement) component 4|C4|193|194|HOSPITAL  COURSE|She was seen by Rheumatology and Dermatology and amongst us she had blood cultures, which were negative, ANA which was negative, ANCA which was negative. Rheumatoid factor was negative. C3 and C4 with were within normal limits. Her ESR was 19, her CRP was 87.5. HIV was negative. Chest x-ray showed no lesions. Cryoglobulins were pending. Skin cultures including fungal were pending.
C4|(complement) component 4|C4|152|153|HISTORY OF PRESENT ILLNESS|She has a normal TSH and CK level and normal folic acid level. She was found to have a persistently prolonged INR of 1.35 and a mildly decreased C3 and C4 level. Double strand DNA was negative. She had a weak lupus anticoagulant, but it was interpreted as possible false/positive and recommended to repeat with normal INR> Her carbamazepine level was checked, it was 3.1, and her total phenytoin was checked which was 18.1. Vitamin B12 level is 758 which is in the high upper normal range.
C4|(complement) component 4|C4|196|197|HOSPITAL COURSE|Doppler studies of the legs were also negative for any deep venous thromboses. Troponin quickly normalized to 0.2. TSH was 2.4. Complement C3 was decreased at 82 (normal range 90-200). Complement C4 was also decreased at 14 (normal range 15-50). C-reactive protein was 0.21. Rheumatoid factor was less than 20. D-dimer was less than 0.2. INR was 1.0. Hemoglobin was 11.8. Sed rate was 7.
C4|cervical (level) 4|C4|175|176|HISTORY OF PRESENT ILLNESS|OPERATIONS/PROCEDURES PERFORMED: Redo C5 to C6 anterior cervical disk fusion with plating. HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old woman who previously had a C4 to C5, C5 to C6, and C6 to C7 ACDF in _%#MM#%_ 2003 for left arm pain. The patient returns complaining of persistent neck pain without radicular pain in the arms.
C4|(complement) component 4|C4,|136|138|HOSPITAL COURSE|They did recommend a short temporary course of steroids and did additional laboratory work-up. They did add a cardiolipin antibody, C3, C4, CRP which are pending at the time of this dictation. She had a very uneventful hospital course and was improving.
C4|cervical (level) 4|C4|202|203|DISCHARGE  DIAGNOSES|3. History of mitral valve repair, 2002. 4. Frequent premature ventricular contractions. 5. History of hypertension. 6. Degenerative joint disease and prior laminectomy. 7. History of C5 carpectomy and C4 through C6 anterior spinal fusion. 8. Parkinson's disease, history of deep brain stimulator placement. 9. History of essential tremor. 10. History of transient ischemic attack.
C4|(complement) component 4|C4|159|160|LAB  DATA|Routine parasites, rare PMN's no parasites seen. Surface antibody negative. CMV IGN pending. CMV IGG 59.0 (positive for previous exposure). Compliment C3 200, C4 43. Angiotensin converting enzyme 38, (normal). EBV serology pending. Total IGE, IGM, IGG, IGA levels normal. Lyme disease IGG Elisa pending. Alikia antibodies IGG, IGM pending.
C4|cervical (level) 4|C4,|261|263|HISTORY OF THE PRESENT ILLNESS AND HOSPITAL COURSE|We also checked an MRI at the C-spine to rule out any stenosis or impingement as a cause for his left upper extremity and lower extremity weakness. He did, in fact, have a multilevel degenerative disk disease with mild to moderate central canal stenosis at C3, C4, and C5 to C6, but there was no recorded deformity and no ____ impingement. It was thought by me and neurology that this could perhaps explain some of his symptoms, but given the other MRI findings, Dr. _%#NAME#%_ _%#NAME#%_ of neurology was concerned that he may have a PML.
C4|(complement) component 4|C4,|147|149|PROBLEM #2|PROBLEM #2: Renal. As stated above, he was dialyzed 3/4 days during admission. His Prednisone was continued on the current dose. He did have a C3, C4, ANA, double-stranded DNA and CRP levels drawn all of which were pending at the time of this dictation. PROBLEM #3: Endocrine. He had an endocrine consult to help with his elevated blood sugars while on the steroids.
C4|cervical (level) 4|C4|104|105|PAST MEDICAL HISTORY|The patient was advised to come to the emergency room. PAST MEDICAL HISTORY: 1. C-spine fracture at the C4 level leading to quadriplegia, tracheostomy, and on ventilation since 1994. 2. Diabetes type II. 3. Prostate cancer. 4. History of MRSA infection.
C4|(complement) component 4|C4|154|155|HOSPITAL COURSE|By the time of discharge the patient had minimal facial edema and no lower extremity edema bilaterally. The patient had decreased levels with a C3 of 17, C4 of 13, secondary to his presentation, and these levels, and positive ASO, it is most likely that the patient had Poststreptococcal glomerulonephritis.
C4|(complement) component 4|C4|376|377|HISTORY OF PRESENT ILLNESS|C-reactive protein 1.53. HOSPITAL COURSE: The patient was initially evaluated in the emergency department by the rheumatology service who recommended admission due to concerns for lupus flare, flare of hepatitis B, Fitz- Hugh-Curtis syndrome, abdominal abscess or, most likely, a lupus flare with serositis. Subsequent studies showed a low complement C3 at 40, low complement C4 of 9; the patient's hepatitis B status was confirmed. She underwent CT of the abdomen that showed a small amount of abdominal ascites and moderate pelvic ascites, questionable edema of the gastric wall, a stable hyperdensity in the right kidney, sclerosis of the femoral heads consistent with avascular necrosis which was stable, and cardiomegaly with mild pulmonary edema.
C4|cervical (level) 4|C4|136|137|ADMISSION DIAGNOSIS|HISTORY OF PRESENT ILLNESS: This is a 41-year-old male who was seen in clinic noted with multiple level degenerations and stenosis from C4 to C7. However, most notably the patient had mechanical instability at the C3-4 level with 35-degree motion from flexion to extension.
C4|cervical (level) 4|C4|459|460|PERTINENT TESTING|MRI of the brain done _%#MMDD2005#%_, no evidence of an acute infarct or intracranial mass, nonspecific supratentorial white matter changes, most likely due to chronic small vessel ischemic changes, several hypointense lesions on the gradient echo sequence in the cerebral hemisphere and right anterior medulla. An MRI of the cervical spine done _%#MMDD2005#%_ demonstrates some mild multi-level degenerative disc disease with mild central spinal stenosis of C4 through C7. HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ is a 78-year-old male with history of stroke, seizure disorder and congestive heart failure and presents with lower extremity weakness.
C4|(complement) component 4|C4,|203|205|HOSPITAL COURSE|They also recommend a FENA and orthostatics, which were obtained. In addition, for further workup of her underlying renal disease, they recommended a battery of immunologic tests including ......C3, and C4, hep B and C serologies, ANA, NCA, anti......antibodies, a urine protein creatinine ratio, and a fasting lipid profile. IV fluids were continued. The patient's creatinine the second day of hospitalization was essentially stable, .....0.69, and remained stable until _%#MMDD2005#%_ at which time she had a decrease in her creatinine to 5.0. The patient's creatinine then continued to improve and at discharge was 3.83. Again, this was thought to be secondary to a prerenal etiology, although the patient will require close follow-up with Dr. _%#NAME#%_ secondary to her underlying membranous nephropathy.
C4|cervical (level) 4|C4|236|237|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 43-year-old male with diagnosis of neurofibromatosis type 1 with multiple neurofibromas identified. He presented to the neurosurgery clinic for evaluation of a large nerve root lesion at the C4 level with spinal cord compression., He was evaluated by Dr. _%#NAME#%_, and presents for cervical laminectomy and resection of tumor.
C4|(complement) component 4|C4|148|149|HOSPITAL COURSE|They recommended for her to continue as a regular outpatient follow-up including continuing the medications as stated above. They did also obtain a C4 level, which was 3. No comment was made about this level or its significance. Patient was watched for the remainder of the day of admission, and when she was noted to have no further compromise she was discharged from the hospital into the care of her parents.
C4|(complement) component 4|C4|167|168|ADMISSION LABORATORY DATA|AST was 61. Alkaline phosphatase 189, protein was 8.3 and albumin was 3.8. Other labs: The patient had a C3 and C4 level added on after he was discharged. C3 was 187, C4 was 38. On _%#MM#%_ _%#DD#%_, his INR was 3.05. His Alkaline phosphatase was 204, total protein 8.3. ALT was 64, and AST was 52.
C4|(complement) component 4|C4,|171|173|HOSPITAL COURSE|He had taken three doses of Warfarin at the time that he developed this rash. Allergy was consulted and they did come to see the patient, they did recommended a serum C3, C4, CH50, C1Q, C1 esterase inhibitor functionality, and they also requested checking an alpha and beta tryptase, as well as a 24-hour urine PGD2 histamine.
C4|(complement) component 4|C4|212|213|HISTORY OF PRESENT ILLNESS|He then went on to become oliguric, and this prompted a peritoneal dialysis catheter placement to occur with subsequent peritoneal dialysis. Given his presentation with atypical hemolytic uremic syndrome, C3 and C4 complement levels were drawn on both _%#NAME#%_ and his parents. Factor H levels were also drawn on _%#NAME#%_. C3 levels were essentially normal for both parents and the factor H in _%#NAME#%_ was originally normal to slightly below normal.
C4|cervical (level) 4|C4|184|185|HISTORY|The patient was ultimately seen in consultation by Dr. _%#NAME#%_ of neurosurgery and flexion extension views of the spine were done which showed 3 mm of anterior subluxation of C3 on C4 on flexion when compared with extension views. Degenerative changes were noted. Because of this, a cervical spine CT was ordered and done on _%#MM#%_ _%#DD#%_.
C4|(complement) component 4|C4|182|183|HISTORY OF PRESENT ILLNESS|She was treated with vancomycin to cover the possibility of cellulitic component and had the rash biopsied and it was a leukocytoclastic vasculitis. Cryoglobulins were present and a C4 was low. She was switched to an oral antibiotic and discharged. A CT scan done before discharge showed some lung nodules and recurrence of gastric wall thickening.
C4|cervical (level) 4|C4|212|213|PROCEDURE THIS ADMISSION|DATE OF ADMISSION: _%#MMDD2005#%_ DATE OF DISCHARGE: _%#MMDD2005#%_ DIAGNOSIS: C4-5 and C5-6 degenerative disc disease, with foraminal stenosis on the right side at C5-6. PROCEDURE THIS ADMISSION: C5 corpectomy, C4 discectomy, anterior spinal fusion, with a fibular allograft, local autograft, and instrumentation. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 55-year- old woman who has a three-year history of neck, right shoulder and arm pain.
C4|(complement) component 4|C4|176|177|ADMISSION LABORATORIES|The remainder of her physical examination is unremarkable. ADMISSION LABORATORIES: WBC 7.7, hemoglobin 11.4, platelets 255. Normal differential. ESR 63, ALT 15, AST 21, C3 99, C4 less than 2, TSH 1.70, valproic acid 142, electrolytes normal with a creatinine of 1.0, blood cultures were negative to date.
C4|cervical (level) 4|C4,|295|297||There, he was prescribed Percocet and a Medrol Dosepak, and x-rays were performed. I find cervical spine films that were performed on _%#MMDD2005#%_ and reports as follows: Bony neural foramina widely patent mild degenerative changes seen with anterior osteophytic spurs; inferior end plates of C4, C5, and C6 without disk space narrowing; and some degenerative changes of the facet joints. He states that his leg pain has been slowly improving and now he has been able to walk.
C4|(complement) component 4|C4|198|199|ADDITIONAL MEASURES|Plan for the patient to have Accucheks q.i.d., covered by Regular standard insulin sliding scale. ADDITIONAL MEASURES: We will send the following add-ons to the patient's admission laboratories - a C4 level, a C1q level and a TSH. We will also hold any further antibiotics at this time.
C4|(complement) component 4|C4|220|221|HOSPITAL COURSE|Her sed rate was elevated at 65, but the patient has had recent clavicle fracture and also has a large ecchymosis on her anterior chest wall that I feel could be causing her elevated ESR. Her C3 was normal at 98 and her C4 was normal at 28. At this point the patient still has a pending compliment CH50 and ANA and a neutrophil cytoplasmic antibody pending.
C4|(complement) component 4|C4|265|266|ADMISSION LABORATORY DATA|On admission, his vital signs were within normal limits. His physical examination was also within normal limits with the exception of a small patch of dermatitis on his left anterior shin. ADMISSION LABORATORY DATA: CBC was normal. Normal IgE level. Normal C3, and C4 levels. HOSPITAL COURSE: PROBLEM #1: Provocative food challenge. The patient completed a MSG provocative food challenge, including placebo doses, per allergy protocol.
C4|cervical (level) 4|C4|228|229|HISTORY OF PRESENT ILLNESS|He had no radicular component to this. Because of his history of neurofibromatosis a MRI scan was done revealing substantial neurofibroma in the mid cervical area. There were numerous neurofibromas with the largest one being at C4 level resulting in a significant mass effect and distortion of the cervical cord. For that reason the patient was referred to Dr. _%#NAME#%_ who is recommending cervical laminectomy for removal of this tumor.
C4|cervical (level) 4|C4|231|232|PROCEDURES PERFORMED|PROCEDURES PERFORMED: MRI of the spine without contrast. This showed the cervical vertebrae appeared normally aligned. There was no evidence of a fracture of the cervical spine. There was large anterior osteophyte formation at C3, C4 and C5. There was narrowing of the disk height of C4 to C5, C5 to C6, and C6 to C7, and C7 to T1 is demonstrated.
C4|cervical (level) 4|C4|251|252|SUMMARY OF EVENTS LEADING TO DEATH|SUMMARY OF EVENTS LEADING TO DEATH: Mr. _%#NAME#%_ was a 78-year-old man, who was admitted to the hospital on _%#MM#%_ _%#DD#%_, 2005, and underwent a C3-C6 fusion and C4-C5 corpectomy for degeneration at C4-C5 with retroportion of C5 with respect to C4 and compression into the C4 vertebral body. Postoperatively, the patient was found to have hematoma in the surgical site for which he underwent C3 corpectomy, C2-C6 fusion with fibular allograft on _%#MM#%_ _%#DD#%_, 2005.
C4|cervical (level) 4|C4|279|280|SUMMARY OF EVENTS LEADING TO DEATH|SUMMARY OF EVENTS LEADING TO DEATH: Mr. _%#NAME#%_ was a 78-year-old man, who was admitted to the hospital on _%#MM#%_ _%#DD#%_, 2005, and underwent a C3-C6 fusion and C4-C5 corpectomy for degeneration at C4-C5 with retroportion of C5 with respect to C4 and compression into the C4 vertebral body. Postoperatively, the patient was found to have hematoma in the surgical site for which he underwent C3 corpectomy, C2-C6 fusion with fibular allograft on _%#MM#%_ _%#DD#%_, 2005.
C4|cervical (level) 4|C4|206|207|LABORATORY AND DIAGNOSTIC STUDIES|CT of the cervical spine without contrast was performed showing no fractures identified, though the patient has prominent degenerative disk disease throughout the cervical spine with a spondylolisthesis of C4 on C5 and C5 on C6 on a degenerative basis. Hip x-ray shows a right total hip arthroplasty that is well positioned.
C4|cervical (level) 4|C4|160|161|HOSPITAL COURSE|He appears to have had a remote C1-2 level injury with marked degenerative arthritis and pain. On the day of admission, he underwent an uncomplicated occipital C4 fusion. The indications for a fusion of that length were that he was in essence spontaneously fused between the occiput and ring of C1, and C2, C3, and C4 were spontaneously fused.
C4|cervical (level) 4|C4|144|145|HOSPITAL COURSE|The indications for a fusion of that length were that he was in essence spontaneously fused between the occiput and ring of C1, and C2, C3, and C4 were spontaneously fused. Therefore, wall motion was concentrated at C1-2 joint. Internal fixation and autogenous crest graft were utilized.
C4|(complement) component 4|C4,|211|213|ASSESSMENT|I suspect he has underlying renal artery stenosis, but I would not expect it to progress this fast. He also has no flank pain or other complaints for infarction. The plan will be to check ASO, anti-DNase B, C3, C4, FANA, ANCA, and anti-GBM antibody. We will consult Renal for further evaluation and possible kidney biopsy. 2. Hypertension: We have obviously held his lisinopril. Currently, he has been started on clonidine and should probably add in calcium channel blockers, such as amlodipine to that and discontinue his atenolol, as he has developed first-degree AV block and some bradycardia with the very high dose of atenolol for his renal insufficiency.
C4|(complement) component 4|C4,|174|176|IMPRESSION|Our diagnostic workup will include a renal ultrasound and a chest x-ray. We will get urine for sodium, FENa and eosinophils. We will get serologies, including ANA, ANCA, C3, C4, CH50 and hepatitis serologies. We will also check a CK and myoglobin. We will check his iron, B12 and folate levels. In terms of treatment, I will continue his Toprol XL, we will put him on a renal diet, we will put him on D5 half normal saline with 50 of bicarbonate at 100 cc/hour.
C4|cervical (level) 4|C4,|362|364|OPERATIVE PROCEDURE|Surgical management was discussed with her and risks, benefits, and alternatives to the anterior posterior decompression were discussed, and she chose to have the surgery. OPERATIVE PROCEDURE: On _%#MM#%_ _%#DD#%_, 2006, the patient was brought to the operating room and an anterior cervical decompression and fusion of C3 through C7 with subtotal corpectomy of C4, C5, and C6, anterior graft strut C3 through C7 with fibular strut was placed along with anterior plate fixation of the same levels.
C4|(complement) component 4|C4|206|207|HOSPITAL COURSE|Electron microscopy is pending. Further studies demonstrated significant deposition of type III collagen in glomeruli suggestive of type III glomerulopathy. Lab studies also demonstrated low C3 with normal C4 complement level Because of known association of factor H deficiency and type III collagen glomerulopathy, factor H studies were sent, the result of which is still pending.
C4|cervical (level) 4|C4|131|132|HISTORY OF PRESENT ILLNESS|The falls have been increasing over the course of the last year. In _%#MM#%_ 2004 the patient underwent an L4-L5 laminectomy and a C4 through C5 fusion for cord compression with myelopathy at both levels. Since that time, the patient has been unable to work because his falls have increased in frequency.
C4|(complement) component 4|C4|278|279|HOSPITAL COURSE|As the patient's chest pain and shortness of breath were believed not to be cardiac in origin, the patient underwent further work up for possible lupus flare-up. Sedimentation rate was normal at 14. Antinuclear antibody was negative. Compliment C3 was normal at 160, compliment C4 was normal at 27. CRP was normal at 0.57. The patient was seen by Rheumatology who believed that the patient's lupus was in remission and recommended adjustment of thyroid medication.
C4|cervical (level) 4|C4.|135|137|MEDICATIONS|An EEG was obtained, which showed posterior right slowing, one generalized discharge during the recording and very infrequent spike at C4. He was stable during the entire hospitalization and had no complications or difficulty. Spinal fluid from _%#CITY#%_ _%#CITY#%_ ER was present and was sent for culture.
C4|cervical (level) 4|C4|121|122|PAST MEDICAL HISTORY|She was therefore admitted to the hospital for workup. PAST MEDICAL HISTORY: Three neck surgeries. She is fused from the C4 to the C7 level. Her neck problems are work related. CURRENT MEDICATIONS: 1. Estratest one tab p.o. each day.
C4|cervical (level) 4|C4|164|165|HISTORY OF PRESENT ILLNESS|PAST MEDICAL HISTORY: 1. Cobalamin C deficiency and homocystinuria. 2. Multiple hospitalizations for vomiting and dehydration. 3. History of acute otitis media. 4. C4 vertebral anomaly. Diet is Propel Mix 1/3rd cup mixed with 8 ounces of water ad lib, plus normal diet excluding meat.
C4|cervical (level) 4|C4|167|168|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: On the day of admission, Mr. _%#NAME#%_ _%#NAME#%_ underwent an uncomplicated canal-expanding laminaplasty with instrumented segments from C4 through C7 and partial undercutting of C3 lamina. He also underwent a foraminotomy at the C4-C5 and C5-C6 disk spaces on the left.
C4|cervical (level) 4|C4|288|289|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Syncope and aphasia. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 58-year-old male with recent extensive C-spine surgery on _%#MMDD2005#%_, including C4, C5, C6 and C7 expansile laminoplasty with wide foraminotomy right C4-5 and C5-6, and segmental fixation of C4 through C7 for underlying cervical spondylosis with multilevel stenosis by Dr. _%#NAME#%_ _%#NAME#%_ at University of Minnesota Medical Center on _%#MMDD2005#%_.
C4|cervical (level) 4|C4|147|148|HISTORY OF PRESENT ILLNESS|She had recently undergone a C5 through C7 revision of her fusion and anterior cervical diskectomy, decompression, and fusion of cervical vertebra C4 and C5. Per the patient her chronic back and neck pain and multiple subsequent surgeries are related to a traumatic head injury in 1998 from a falling brick.
C4|cervical (level) 4|C4|33|34|PRIMARY DIAGNOSES|PRIMARY DIAGNOSES: 1. C3 through C4 spondylosis as seen on MRI. 2. Parkinson's disease. PRINCIPAL PROCEDURES/TREATMENTS: On this visit a C3-4 anterior cervical diskectomy and fusion were done.
C4|cervical (level) 4|C4|21|22|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: C4 compression fracture. OPERATIONS/PROCEDURES PERFORMED: Surgical planning. HISTORY AND PHYSICAL: The patient is 17-year-old right-handed gentleman who developed neck pain following a fall on _%#MM#%_ _%#DD#%_, 2005.
C4|cervical (level) 4|C4.|65|67|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Fracture dislocation, unilateral facet, C3- C4. HOSPITAL COURSE: Ms. _%#NAME#%_ _%#NAME#%_ underwent uncomplicated anterior cervical diskectomy with decompression and fusion with open reduction C3-C4 on _%#MM#%_ _%#DD#%_, 2006.
C4|cervical (level) 4|C4|146|147|DISCHARGE MEDICATIONS|The brain MRI was normal. The cervical spine MRI revealed mild degenerative disk bulging at C3 through C6 with mild spinal canal stenosis between C4 and C6. At C5 and C6 there was a small left posterior disk herniation with normal neuroforaminal regions.
C4|cervical (level) 4|C4|417|418|ASSESSMENT|Total bilirubin 0.45, total protein 7.5, albumin is 4.3, globulin 3.2, TSH is normal at 1.67. ASSESSMENT: This is a 39-year-old male with past medical history including C2 to C4 level cervical fusion, who is scheduled for vasectomy under general anesthesia on _%#MMDD2005#%_ at Fairview Ridges Hospital under Dr. _%#NAME#%_. 1. Preop evaluation. 2. Sinus bradycardia. 3. Immunization up to date. 4. Status post C2 to C4 cervical level fusion. 5. Tobacco dependence. 6. Family history of coronary artery disease. 7. Status post lateral internal sphincterotomy. 8. Obesity. PLAN: I see no contraindications to surgery at this time.
C4|(complement) component 4|C4|367|368|PRINCIPAL DIAGNOSIS|Creatinine had increased from 2.81 to 3.71 on the day of admission. Her urine toxicology screen was negative. (_______________) Other labs that were drawn either at the time of admission or during the hospital stay included an HIV antibody which was negative, neutrophil cytoplasmic antibody which was negative, and ANA which was negative, C3 which was normal at 92, C4 normal at 27, CH50 normal, anti-GBM was negative, hepatitis B surface antibody negative, hepatitis B surface antigen was negative, hepatitis C antibody was negative.
C4|cervical (level) 4|C4|169|170|LABORATORY|His abdomen exam is normal. His spine is straight. He is circumcised, and his testes are descended. He has no cervical lymphadenopathy. LABORATORY: On admission, C3 and C4 were with normal values as well as his CH50 being normal. His iron level was normal as well as vitamin A, E, and D.
C4|(complement) component 4|C4|410|411|LABORATORY DATA|Additional labs obtained, initially not available at the time of discharge, are as follows: Cardiolipin antibody IgG is 3.6 (Interpretation: Absent or none detected), cardiolipin antibody IgM 2.2 (Interpretation: Absent or none detected), lupus inhibitor battery was negative with mixing study not indicated as aPTT was normal at both reagents. dRVVT screen was normal. Complement C3 was 147 mg/dL, complement C4 was 19 mg/dL, complement total (CH50) 110, CAE unit double-stranded DNA 61 international units per milliliter (Interpretation: Weakly positive), urine creatinine was 110 mg/dL.
C4|cervical (level) 4|C4|221|222|HISTORY OF PRESENT ILLNESS|The other party had run a stop sign and it was a near head-on collision, at that time her airbag had deployed. She did not suffer lost consciousness but was disoriented and had a stiff neck. The patient was found to have C4 lateral mass and a nondisplaced laminar fracture. She was placed in a Philadelphia collar for vive months. The patient reports that she underwent a lot of physical therapy which felt like forever.
C4|(complement) component 4|C4,|254|256|HOSPITAL COURSE|PROBLEM #3. Renal. The patient has acute glomerulonephritis with laboratory studies consistent with post-infectious glomerulonephritis with a positive ASO titer. Anti-DNase B was pending at discharge. The patient was also noted to have low C3 and normal C4, which are consistent with post-infectious glomerulonephritis. The patient had significantly elevated BUN and creatinine on admission. Over several days these values both trended down. Her BUN was 35 at discharge and her creatinine 0.79. _%#NAME#%_ had a renal ultrasound during her hospitalization that showed enlarged kidneys with increased echogenicity that was consistent with medical renal disease and her history of glomerulonephritis.
C4|(complement) component 4|C4|278|279|HOSPITAL COURSE|Several severe bilateral neuroforaminal narrowing at C6-C7 and C7-T1, multilevel broad-based disk bulges in the thoracic spine without spinal cord narrowing. An antibody panel was obtained for evaluation of Devic vasculitis and Lyme disease, the results are as follows: C3 155, C4 23, SSB 2, SSA 6, Lyme disease negative, ESR 13, ANC negative, anti-Smith antibodies negative. Pending are anti-NMO antibody for Devic disease. In addition, the patient was evaluated by Pain Service for his intractable lower extremities.
C4|cervical (level) 4|C4|178|179|HOSPITAL COURSE|HOSPITAL COURSE: This gentleman was actually admitted for neuropathic symptoms and weakness in his upper extremities and had a C3-C4 laminectomy on the _%#MMDD#%_ for C3 through C4 cervical stenosis. His function has improved, though there is a slight weakness in his left arm at times still. His numbness has improved. He has met the goals of PT and OT.
C4|cervical (level) 4|C4|267|268|MAJOR PROCEDURES AND DIAGNOSTIC TESTS|MAJOR PROCEDURES AND DIAGNOSTIC TESTS: MRI spine _%#MMDD2007#%_ showing evidence of further extension of tumor involving C2 with impingement and displacement of the subarachnoid space and spinal cord posteriorly. There is no evidence yet for spinal cord compression. C4 lesion unchanged. CT head without contrast _%#MMDD2007#%_ normal. Bone scan (whole body) _%#MMDD2007#%_ showing increased uptake in the cervical spine, left humeral head, left femoral neck.
C4|(complement) component 4|C4.|152|154|HISTORY OF PRESENT ILLNESS|At that time, he was noted to have gross hematuria. He was noted to have a normal renal ultrasound at that time. He also had negative ANA, ANCA, C3 and C4. A 24-hour urine collection done through catheterization showed a total protein of 118 mg. His creatinine was elevated during the admission to 1 from a baseline of 0.4 to 0.5. Further workup also showed that ASO was negative, anti-DNAase B was negative, hepatitis B was nonreactive, rheumatoid factor was negative and a urine culture was negative.
C4|cervical (level) 4|C4|197|198|PAST MEDICAL HISTORY|He elected to proceed with the bilateral percutaneous nephrolithotomy. We had planned to undertake the first stage of this on the left side during this hospital admission. PAST MEDICAL HISTORY: 1. C4 quadriplegia. 2. Bilateral kidney stones. ADMISSION MEDICATIONS: 1. Amitriptyline 100 mg p.o. q.h.s. 2. Percocet 1-2 p.o. q.4h. p.r.n.
C4|(complement) component 4|C4,|370|372|LABORATORY DATA|Negative cardiolipin, negative ultrasound for renal artery stenosis, a.m. protein is 2.53 and 24 hours 1.09. She had a urine protein:creatinine ratio of 1.47, normal would be expected to be less than 0.2. she had a urinalysis that showed 100 mg of protein in her urine on _%#MMDD2007#%_. On _%#MMDD2007#%_, her urine was negative for protein at that time. She has had a C4, which was 14 on _%#MMDD2007#%_ and C3, which was 93. Both were low normal. She had a normal renal ultrasound on _%#MMDD2007#%_.
C4|(complement) component 4|C4|161|162|DISCUSSION|The laboratory tests obtained when Dr. _%#NAME#%_ _%#NAME#%_ saw her two weeks ago along with his note will be included as part of the record. At that point her C4 was minimally diminished, there was modest diminution of C3, and DNA antibodies were elevated greater than 200. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 35-year-old woman who was admitted today with a seizure.
C4|(complement) component 4|C4|144|145|HOSPITAL COURSE|Rheumatoid factor was negative. Her IgG was elevated at 2130. Parvovirus B 19 IgG was positive, but IgM was negative. Her C3 was low at 49, her C4 was low normal at 10, and CH 50 was low at 6. Thyroid studies were normal. Still pending are the following labs: Antidouble stranded DNA antibody, anti-smith antibody, anticardiolipin antibody, anti-RNP antibody and anti-Ro antibody.
C4|(complement) component 4|C4|165|166|PAST MEDICAL HISTORY|4. Chronic renal insufficiency. Baseline creatinine 2.4 to 3.6. On _%#MM#%_ _%#DD#%_, 2002, A1c less than 1 to 16, ANA negative, HCV negative, HBV negative, C3 141, C4 33. 5. Chron disease diagnosed in 1985 in Florida. 6. Hypercholesterolemia. 7. Oligospermia secondary to cyclophosphamide. ALLERGIES: No known drug allergies.
C4|cervical (level) 4|C4|167|168|PROCEDURES PERFORMED DURING THIS ADMISSION|DISCHARGE DIAGNOSIS: Same. PROCEDURES PERFORMED DURING THIS ADMISSION: 1. Occipitocervical fusion with Medtronic plates and C2 pedicle screws, C3 lateral mass screws, C4 right lateral mass screws, autograft and allograft used, _%#MMDD2002#%_. 2. Left posterior iliac crest harvesting with mesh-crest plasty and allograft.
C4|cervical (level) 4|C4|127|128|PROCEDURES PERFORMED THIS ADMISSION|PRIMARY DIAGNOSES: 1. Cervical spondylolisthesis C3 to C7. 2. Chronic pain syndrome. PROCEDURES PERFORMED THIS ADMISSION: ACDF C4 to C7. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 62-year-old woman with history of chronic neck pain.
C4|(complement) component 4|C4|163|164|HOSPITAL COURSE|The patient had an elevated phosphorus of 8.7 and elevated parathyroid hormone 217. A battery of serologic studies were performed. ANA was weakly positive at 2.0, C4 complement was normal, C3 complement mildly depressed at 77, neutrophil cytoplasmic antibody was highly elevated in a pANCA distribution at 1-160.
C4|(complement) component 4|C4.|191|193|HOSPITAL COURSE|Her serologic studies from the outpatient arena in Dr. _%#NAME#%_'s office included no evidence of a lupus anticoagulant, no evidence of anticardiolipin antibody, normal C3, undetectably low C4. We understand as well that antiDNA antibodies were not observed. The patient had a diuresis of approximately 8 kilos during the hospitalization from 83-75 kilograms.
C4|cervical (level) 4|C4|168|169|OPERATIONS/PROCEDURES PERFORMED|ADMISSION DIAGNOSIS: Multilevel cervical stenosis with myelopathy. OPERATIONS/PROCEDURES PERFORMED: On _%#MM#%_ _%#DD#%_, 2002. 1. Left partial C2 and full left C3 and C4 hemilaminectomies. 2. Right C3 and C4 hemilaminectomies. 3. Left C5-C6 hemilaminectomy. 4. Left C6 foraminotomy. All performed with minimally invasive METRx system.
C4|(complement) component 4|C4,|225|227|HOSPITAL COURSE|Dr. _%#NAME#%_ _%#NAME#%_ came in to consult and felt that there was a pyoderma syndrome with either eczema herpeticum or herpes simplex. Therefore, Valtrex was added to his medications. Other labs included Lyme's titer, C3, C4, ANA testing. Finally, he underwent evaluation by Neurology, and it was felt that he would benefit from antidepressants also. He did undergo an EEG which was normal, and the rest of his labs did come back normal.
C4|(complement) component 4|C4|144|145|HISTORY OF PRESENT ILLNESS|These treatments have been ineffective. She started on MMF in _%#MM2001#%_ along with her prednisone and has had some improvement in her C3 and C4 since. She was well until approximately four days prior to admit. At that time, she was at the end of a two-week trip in the Europe.
C4|(complement) component 4|C4|191|192|PROBLEM #5|_%#NAME#%_'s hemoglobin was 9.4, down from her baseline of approximately 11, and her erythropoietin was increased to 8000 units subcu two times per week. PROBLEM #5: On admission, her C3 and C4 were obtained. They were 37 and 4, respectively. Her anti-DNA was elevated at 167. It was felt that her lupus was more active, and it is unclear whether she had been complying with her immunosuppression recently.
C4|(complement) component 4|C4|157|158|HOSPITAL COURSE|Negative antinuclear antibodies, rheumatoid factor of less than 20, negative anti-double strength DNA antibodies. A C reactive protein of 0.1. Normal C3 and C4 levels of 106 and 19 respectively. An a.m. Cortisol level was checked and found to be 9.1. Lumbar puncture was performed on _%#MMDD2003#%_without complications and showed 2 white blood cells, 48 red blood cells with a glucose of 71 and a protein of 69.
C4|cervical (level) 4|C4|170|171|DISCHARGE DIAGNOSES|6. C-4 necrosis with abscess in 2003. 7. Right oral cutaneous fistula with exposure of vertebral body plate fixed with right pectoralis major muscle flap. 8. Status post C4 and C5 anterior vertebrectomy. 9. Left anterior iliac crest graft harvesting. 10. Arthrodesis of C3-C4, C4-C5, C5-C6. 11. Hypertension. 12. Hypothyroidism.
C4|(complement) component 4|C4|206|207|HISTORY OF PRESENT ILLNESS|Urinalysis included a specific gravity of 1.013, large blood, greater than 300 protein, 31 WBCs, 150 RBCs. Lactate dehydrogenase was 1496, reticulocyte count was 3.3. A C3 complement was done which was 47. C4 complement was 19. Peripheral smear was per his fragment and RBCs with anemia and thrombocytopenia. HOSPITAL COURSE: 1. FEN. The patient's electrolytes remained stable. Of note, his BUN and creatinine had a transient increase throughout his hospitalization with his baseline creatinine being 0.5, creatinine increasing as high as 0.8 during this admission and was 0.6 on day of discharge.
C4|(complement) component 4|C4|177|178|IMPRESSION/PLAN|Should he continue to do well, he will be discharged to home with a prescription for prednisone 30 mg q.d. x 2d. While in the hospital, he is having a C1 esterase inhibitor and C4 complement study drawn to help rule out angioedema, although there is no family history of this. I contacted Dr. _%#NAME#%_ _%#NAME#%_ of the Southdale Pediatrics Allergy Department, who feels that the patient's reaction most likely represents a sensitivity to nonsteroidal anti-inflammatory products, and indicated that there is no formal allergy test that he would advise performing for this, and that the best course of management would be to advise the patient to avoid nonsteroidal anti-inflammatories in the future, which was done.
C4|cervical (level) 4|C4|260|261|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. COPD. The patient has been a smoker for about 40 years and does smoke approximately five cigarettes a day. 2. Mechanical small bowel obstruction in _%#MM2003#%_. 3. Cervical arthritis with spinal stenosis by MRI, showing fusion of C3, C4 vertebral bodies. 4. History of intentional overdose with aspirin and oral contraceptives in 1973. PAST SURGICAL HISTORY: 1. Tubal ligation. 2. Right oophorectomy.
C4|(complement) component 4|C4|176|177|PROBLEM #2|Because of the concern for post streptococcal glomerulonephritis, a Renal consult was obtained. He had a BUN and creatinine, which were within normal limits. Complement C3 and C4 were drawn and were normal. His total complement result is still pending at the time of this dictation, as well are his ASO titer and DNAase B antibody.
C4|(PO Box) C4|_%#ADDRESS#%_|201|213|ALLERGIES|In conclusion, the patient is a 60-year-old gentleman who has symptomatic diskogenic disease, who will be a surgical candidate under the care of Dr. _%#NAME#%_. _%#NAME#%_ _%#NAME#%_, MD _%#ADDRESS#%_ _%#ADDRESS#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_, MN _%#55400#%_
C4|cervical (level) 4|C4|185|186|HOSPITAL COURSE|HOSPITAL COURSE: The patient was assessed by the anesthesia service and taken to the operating room _%#MM#%_ _%#DD#%_, 2004, where he underwent an uneventful cervical foraminotomy from C4 to C7 on the right side. This was done in the sitting position. Postoperatively, the patient was transferred to the regular floor of the hospital where he remained stable and had significant decrease in his right arm pain.
C4|cervical (level) 4|C4|198|199||His pain was well controlled and he was able to be discharged to home shortly thereafter with oral narcotics and a followup in the clinic. It was noted that his MRI scan showed malacia changes from C4 to C6 consistent with prior cervical stenosis.
C4|(complement) component 4|C4|192|193|PROBLEM #2|Her steroids were gradually tapered and she was weaned to a maintenance schedule for discharge. Cardiolipin antibody, IgG 2.2, IgM 1.9. Complement CH50 total 104. Complement C3 95, complement C4 17. Antinuclear antibody screen negative. PROBLEM #3: Infectious Disease. We did consider that the patient's head and abdominal pain might be related to infection.
C4|(complement) component 4|C4|238|239|HOSPITAL COURSE|Urinalysis was essentially normal. Her admission white blood cell count was 10,000 with a 90 percent lymphocyte count. It was also noted that two weeks prior to admission, the had a multitude of labs showing liver function, normal C3 and C4 complement levels, the absence of any lupus inhibitor or cardiolipin IgG or IgM as well as the absence of ___________ antibody in the testing.
C4|cervical (level) 4|C4|138|139|DISCHARGE DIAGNOSIS|She also noticed some mild weakness of her upper extremities. She had an MRI that showed a significant amount of degenerative disk at the C4 to C5 level with disk herniation as well as spinal cord compression. She demonstrates 4/5 deltoid strength. On examination she does demonstrate full strength in all 4 extremities, but she does have sustained clonus, and she presents for C4 to C5 ACDF.
C4|cervical (level) 4|C4.|306|308|IMAGING|No numbness and tingling in any extremity. No cough, weight loss, shortness of breath, constipation, or diarrhea. IMAGING: MRI shows infiltration of multiple cervical spine levels with tumor and vertebral body collapse, greatest at C3-4-5, with retropulsion of bony fragments, and spinal canal stenosis at C4. LABORATORY DATA: White count 6.8, hemoglobin 11.3, platelets 248. Sodium 140, potassium 3.6, chloride 106, CO2 25, BUN 9, creatinine 0.56, glucose 106, alkaline phosphatase 104, ALT 35, AST 26.
C4|(complement) component 4|C4|328|329|HOSPITAL COURSE|However, _%#NAME#%_ was noted to have some features, which could be consistent with Marfan syndrome. Please see Dr. _%#NAME#%_'s dictation from _%#MM#%_ _%#DD#%_, 2005. The part of the workup are as follows: Labs, which have returned: Urinalysis showing small blood with 1 rbc, but otherwise negative, ESR of 6, C3 level of 87, C4 level of 13, ANA less than 1, anti-double-stranded DNA of less than 2. Lupus anticoagulant study that is negative. Rheumatologic studies, which are pending: Antineutrophil cytoplasmic antibody, anti-Smith antibody, anticardiolipin antibody, HLA-B27, official read on spine films looking for possible spondyloarthropathy.
C4|cervical (level) 4|C4,|136|138|PROCEDURE THIS ADMISSION|PREOPERATIVE DIAGNOSES: 1. Cervical spinal stenosis. 2. Multi-level cervical foraminal stenosis on the right. PROCEDURE THIS ADMISSION: C4, C5, C6, and C7 laminoplasty with instrumentation with foraminotomies on the right side at C4, C5, C6, and C7. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 51-year-old woman who has a two-and-a-half-month history of right neck and arm pain.
C4|(complement) component 4|C4|177|178|HOSPITAL COURSE|C-spine sample taken and test did not show any specific finding. There was no sign of malignancy in CSF. VDRL was negative also. C-reactive protein was elevated at 26.4, C3 and C4 normal. Platelet count was also normal. They decided to treat patient with physical therapy and occupational therapy and send him from hospital to rehab, and follow him up as an outpatient, with no clear conclusion for cause of his weakness and fall at this point.
C4|(complement) component 4|C4,|153|155|LABORATORY|CBC on _%#MM#%_ _%#DD#%_, 2006, had a WBC count of 2.1, hemoglobin 10.3, and platelets 249,000. On _%#MM#%_ _%#DD#%_, 2005, the patient had a complement C4, which was within normal limits, C3 level within normal limits. HOSPITAL COURSE: The patient is a 21-year-old Hmong lady with demyelinating venous disease since the age of 16, who was admitted to the University of Minnesota Medical Center, Fairview center on _%#MM#%_ _%#DD#%_, 2005, for progressive lower extremity weakness and with loss of urinary control.
C4|(complement) component 4|C4|115|116|PENDING STUDIES|STUDIES COMPLETED: Completed studies at the time of hospital discharge include an ESR of 16, CRP of 6.1, C3 of 87, C4 of 11, ANA was negative. Double stranded DNA was negative. Ferritin was 1200.
C4|(complement) component 4|C4|142|143|HISTORY OF PRESENT ILLNESS|Previous UA in _%#MM#%_ 2005 revealed 20 to 29 red blood cells, 100 mg/dL of protein with a negative urine culture. At that time, C3 was 141, C4 was 27, creatinine 0.8. _%#MM#%_ 2005, UA showed over 300 mL/dL protein over 50 rbc's. In _%#MM#%_ of 2006, the patient had over 300 mL of protein, 94 red blood cells, urine protein to creatinine ratio was 3.35, ASO was normal at 231, DNase was 680, C3 and C4 were normal, and CRP was 0.7. ALLERGIES: NO KNOWN DRUG ALLERGIES.
C4|(complement) component 4|C4|116|117|HOSPITAL COURSE|She did receive IV fluids on the way down from _%#CITY#%_ to the University of Minnesota. C3 was found to low at 8. C4 was 16 which was low normal, and albumin was 2.6. Protein to creatinine ratio was 0.17 which was normal. ANA was negative. DNase B was 480. ASO was pending at the time of discharge.
C4|cervical (level) 4|C4|246|247|SUMMARY|On a recent MRI scan, there was an evidence of C2-C3 and C3-C4 stenosis of the cervical spine. Flexion/extension x-rays revealed instability between C2 and C3. Therefore, on the same day he was admitted to the hospital and C3 laminectomy, C2 and C4 laminotomy, and posterolateral fusion of C2 through C4 with autografted that was obtained from the left iliac crest posteriorly were performed.
C4|cervical (level) 4|C4|160|161|HISTORY OF PRESENT ILLNESS|He saw his primary care provider and on _%#MMDD2005#%_ had an MRI of his cervical spine without contrast which showed minimal central disk protrusion at C3 and C4 as well as C4 and C5 but was otherwise normal. The patient states that since his MRI, that is, in the last few days, his neck discomfort has worsened.
C4|cervical (level) 4|C4|187|188|OPERATIONS/PROCEDURES PERFORMED|DISCHARGE DIAGNOSIS: Metastatic breast carcinoma with impending pathologic fracture of cervical spine. OPERATIONS/PROCEDURES PERFORMED: Posterior stabilization and fusion from C2 through C4 with segmental fixation on the left side. On the right, Dewar technique with cortical allograft bone plate C2 through T4 with segmental fixation and percutaneous threaded Steinmann pins at each level.
C4|cervical (level) 4|C4|135|136|HOSPITAL COURSE|After discissions of the risks and benefits of the procedure, the patient requested to proceed. HOSPITAL COURSE: The patient underwent C4 and C6 corpectomies with anterior plating and fusion from C3-C7 and lateral mass fixation also from C3-C7 on _%#MM#%_ _%#DD#%_, 2005, without complications.
C4|cervical (level) 4|C4,|163|165|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Juvenile rheumatoid arthritis for which she takes methotrexate. A. Left knee replacement. B. Lumbar fusions. C. Cervical fusions of C2 to C4, _%#MM2005#%_. 2. Gastroesophageal reflux disease (GERD). 3. Depression. 4. Migraine headaches. 5. Bilateral hip replacements. 6. Obstructive sleep apnea, uses BiPAP machine at home.
C4|cervical (level) 4|C4|325|326|PHYSICAL EXAMINATION|EXTREMITIES: The lower extremities were free of significant edema. MUSCULOSKELETAL: On exam she had diffuse tenderness to palpation of her muscles throughout both upper and lower extremities, including her trapezius muscles most prominently. She had some mild tenderness to palpation of the C7 process, as well as the C3 and C4 processes. Joint exam of the upper extremities revealed significant ulnar deviation and other joint deformities of her metacarpophalangeal (MCP) and proximal interphalangeal joint (PIP) consistent with juvenile rheumatoid arthritis.
C4|(complement) component 4|C4,|202|204|PLAN|Solu-Medrol 40 mg intravenously every six hours, Benadryl 50 mg orally every six hours. Will go ahead and check hepatic panel and INR, peripheral smear from morphology and a TSH, along with C1q levels, C4, C2 and C1 inhibitor functional assay.
C4|cervical (level) 4|C4|156|157|HISTORY OF PRESENT ILLNESS|She had an unremarkable chest x-ray and an MRI of the C-spine. The MRI showed mild congenital stenosis of the cervical spinal canal. At the level of C3 and C4 there was moderate to severe degenerative disk disease with loss of disk height and a circumferential disk bulging with osteophytes from the vertebral endplates.
C4|(complement) component 4|C4|151|152|HISTORY OF PRESENT ILLNESS|Urine culture has shown no growth. Additional labs that were done; INR was 1.04, PTT 31, fibrinogen found was 29, complement C3 was 94, and complement C4 was 23. ANA was less than 1, therefore negative. CRP was 13.9. LDH was 739. Uric acid 1.7. Protein total urine to creatinine ratio was 1.13, and creatinine in urine was 48.
C4|(complement) component 4|C4|276|277|HISTORY|HISTORY: The patient was transferred after a short stay at the _%#CITY#%_ campus, unit _%#ADDRESS#%_, for continued rehabilitation and treatment of her acute problem, which is a recurrent urinary tract infection with pyelonephritis symptoms. Rehabilitation continues from her C4 quadriplegia after an injury suffered in _%#MM2005#%_. The patient has had significant difficulty over the past several months with recurrent infections.
C4|cervical (level) 4|C4|65|66|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Anterior cervical decompression and fusion, C4 to C7. DATE OF DISCHARGE: _%#MMDD2006#%_. DISCHARGE DIAGNOSES: 1. Anterior cervical decompression and fusion, C4 to C7.
C4|(complement) component 4|C4|158|159|DISCHARGE DIAGNOSIS|INR was 0.99. PTT was 32, and fibrinogen activity was 744. Her ANA was less than 1, therefore negative. Streptolysin O antibody was less than 25. C3 was 134, C4 was 24. Neutrophil cytoplasmic antibody was less than 1 to 116 ratio. Ionized calcium was 4.7. Phosphorus was 4.8, and magnesium was 1.8. Anti-DNase B titer was less than 60.
C4|cluster of differentiation 4:CD4|C4|130|131|ASSESSMENT AND PLAN|We will likely have ID consulted and may need EGD by Gastrointestinal for further assessment. 2. HIV AIDS. Unclear of her current C4 and viral load. She states it has not been checked in some time, I believe during her last hospital admission.
C4|cervical (level) 4|C4|136|137|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Diabetes mellitus type 2. 2. Hypertension. 3. C-spine disease with history of surgery done on his C-spine from C4 to C7. I do not know exactly what the operation was, however the patient denies any neurologic deficits after the surgery.
C4|cervical (level) 4|C4|136|137|DISCHARGE PHYSICAL EXAM|LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender and nondistended. EXTREMITIES: Sensation is intact to light touch of C4 through T2. Her strength is 5/5 in all muscle groups including biceps, triceps and wrist extension and wrist flexion, finger abduction and adduction.
C4|cervical (level) 4|C4|154|155|HOSPITAL COURSE|Therefore, initially he was at Ridges and transferred here for further evaluation and stabilization on _%#MM#%_ _%#DD#%_. He underwent again a C2 through C4 decompression laminectomy with decompression of the C3, C4, and C5 nerve roots to the posterolateral approach. Also C3-C4 anterior cervical diskectomy and fusion with plates.
C4|(complement) component 4|C4|175|176|HOSPITAL COURSE|He will have close followup with Dr. _%#NAME#%_, Minnesota Allergy & Asthma next week to followup on his lab tests. He had a compliment CH 50 total, C1 esterase inhibitor and C4 level pending at time of discharge. The patient will be discharged with prednisone taper, p.r.n. Benadryl and scheduled Zantac.
C4|(complement) component 4|C4,|183|185|RECOMMENDATIONS|RECOMMENDATIONS: 1. Consider Solu-Medrol bolus of approximately 125 mg times 1-2 doses while continuing the Plaquenil. I have arranged to obtain the patient's sedimentation rate, C3, C4, double stranded DNA, FANA, RNP, SM, SSA, and SSB. 2. I will ask one of my partners to follow up with your patient during the remainder of her hospital stay.
C4|cervical (level) 4|C4|216|217|HISTORY OF PRESENT ILLNESS/SUMMARY OF TRANSITIONAL CARE STAY|Ms. _%#NAME#%_ is an 83-year-old woman, who was transferred from the acute rehab unit to transitional care secondary to a plateau in her progress in terms of functional therapy. The patient has undergone an anterior C4 through C6 cervical decompression and fusion at the University of Minnesota Hospitals for chronic cervical radiculopathy. Her postop course included some difficulty with swallowing, which persisted.
C4|(complement) component 4|C4|181|182||Initial evaluation revealed a fairly unremarkable physical exam. White count was 3.5, hemoglobin 11.4 and platelet 284,000. BMP unremarkable with a creatinine of 0.6, Low C3 (63) & C4 (6) and slightly elevated sedimentation rate 30. HOSPITAL COURSE: Problem #1: The patient was treated with IV Solu-Medrol x2 with significant improvement in her symptoms.
C4|cervical (level) 4|C4|246|247|DISCHARGE DIAGNOSIS|ADMISSION DIAGNOSIS: Cervical spondylolytic disease with progressive kyphosis and quadriplegia progressing from C6 to C4 level. DISCHARGE DIAGNOSIS: Cervical spondylolytic disease with progressive kyphosis and quadriplegia progressing from C6 to C4 level.
C4|cervical (level) 4|C4|165|166|PROCEDURES|4. Anterior cervical kyphosis reduction. 5. C6 corpectomy. 6. Anterior cervical fusion from C5 to C7 with fibular strut graft. 7. Anterior cervical arthrodesis from C4 to C7 with plating. PRIMARY PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_ of _%#CITY#%_ _%#CITY#%_ Medical Center.
C4|(complement) component 4|C4,|428|430|HOSPITAL COURSE|2. Allergy reaction with most antibiotics. Allergy was consulted as above and thinking the patient has multiple allergy reaction with most antibiotic including sulfa, cephalosporin, piperacillin, ticarcillin and aminoglycoside, however, imipenem didn't cause any allergic reaction to the patient so imipenem was removed from his allergy list. Allergy also recommended monitor allergy symptoms with rash, fever and with left C3, C4, CH50 and urinalysis. 3. Diarrhea. Thinking that the patient's diarrhea is secondary to malabsorption the patient was continued with pancreatic enzymes and the patient also was checked for C-difficile toxin and culture.
C4|cervical (level) 4|C4|90|91|PROCEDURE|ADMITTING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_ PROCEDURE: Posterior cervical laminoplasty C4 through C7. _%#NAME#%_ _%#NAME#%_ is a 59-year-old white male who has had a several year history of increasing gait instability with bilateral hip pain with ambulation which has become worsened over time.
C4|cervical (level) 4|C4.|194|196|REASON FOR HOSPITALIZATION|Cervical spine films were performed but showed advance and generally with hypertrophic changes in the mid and lower cervical spine with narrowing at C5 and minimal anterior subluxation of C3 on C4. Chest x- ray showed some chronic interstitial changes. X-ray of the thumb showed no fracture. The patient had symptoms of weakness in the left upper extremity.
C4|(complement) component 4|C4|150|151|HISTORY OF PRESENT ILLNESS|The serum sodium was 133, potassium 4, chloride 103, bicarbonate 25, BUN 12, creatinine 0.6, and glucose 89. The CRP was 1.5. The C3 was 131, and the C4 was 13.5. HOSPITAL COURSE: A renal biopsy was performed on _%#MM#%_ _%#DD#%_, 2002, without complications. He remained hospitalized overnight and did not have any tenderness at the site of the biopsy of any urinary bleeding.
C4|cervical (level) 4|C4,|144|146|ADMISSION DIAGNOSIS|The patient was then admitted to 6B for further observation and care. PAST MEDICAL HISTORY: The patient has a history of herniated neck disk at C4, breast lumpectomy, hysterectomy, and cesarean section x 2. ADMISSION MEDICATIONS: Zoloft and Pepcid which she uses occasionally. ALLERGIES: No known drug allergies.
C4|cervical (level) 4|C4|142|143|HOSPITAL COURSE|MRI scan of the cervical spine was repeated on _%#MMDD2003#%_. This study was felt to be entirely normal. The questionable abnormality at the C4 level which was seen previously was not present on this study. Because of the continued plegia despite five runs of plasmapheresis and the atypical findings on MRI scan, the patient underwent a spinal angiogram that was carried out by Dr. _%#NAME#%_ on _%#MM2003#%_.
C4|(complement) component 4|C4|175|176|LABORATORY DATA|Rheumatology was involved to determine whether there was any systemic vasculitis. However, the laboratory studies were unremarkable. Sedimentation rate was 37. Complement C3, C4 were negative. Cryoglobulin was normal. CRP was elevated at 6.87. His ANA, BNC, and IgG were all normal. We did check an echocardiogram on _%#MMDD#%_ which showed a sinus rhythm with PAC's.
C4|cervical (level) 4|C4|259|260|RADIOLOGY|Light touch is intact bilaterally. Pinprick is intact bilaterally. RADIOLOGY: On review of the spine films that the patient brought with her she does appear to have posterior pedicle screws extending from C3 to C7. She has an anterior plate that extends from C4 to C7. These pedicle screws, rods, and the plate all appear to be in good alignment. There is no evidence of a fracture on the films.
C4|(complement) component 4|C4|207|208|HISTORY OF PRESENT ILLNESS|The patient is here for a kidney biopsy, for further workup of her persistent microscopic hematuria. The patient has had some workup in the past as an outpatient, including a negative FANA and normal C3 and C4 levels. The patient has had a urine calcium-to-creatinine ratio of 0.06, which is normal. She also has had a normal audiogram. She has had a negative cystoscopy and a renal ultrasound in 1995 that was normal.
C4|(complement) component 4|C4,|148|150|PAST MEDICAL HISTORY|Urine protein-creatinine ratio was 6.4. Workup included a negative ANA, a negative ANCA, a negative anti-GBM antibody, and normal complement C3 and C4, per report. Cholesterol was 299, and LDL was 220. The patient was supposed to have her kidney biopsy one week after her visit; however, she never appeared for follow-up.
C4|(complement) component 4|C4|184|185|LABORATORY DATA|She appears cachectic. LABORATORY DATA: Her serum electrolytes were normal. BUN 17. Creatinine 0.8. Troponin-I level on the previous admission was less than 0.7. His compliment C3 and C4 on _%#MMDD2003#%_ was 94 and 16. New compliment levels still pending, but those are normal. ANA less than 1.0. Her UA was essentially normal.
C4|(complement) component 4|C4|226|227|LABORATORY DATA|Electrolytes were normal including potassium 3.8, sugar 101, hemoglobin 13.1, white count 10,500, sedimentation rate was 56 which is consistent with her connective tissue problems. ANA was 2.0 which is weakly positive. C3 and C4 were normal. CT of the chest, pelvis, and abdomen was normal except for mammary implant on the left. HOSPITAL COURSE: It was felt that her symptoms were chronic pain issues.
C4|cervical (level) 4|C4|219|220|DISCHARGE DIAGNOSIS|She remained neurologically intact. Spinal cord monitoring was unchanged. She was mobilized in a rigid orthosis. After discussion, with particular concerns for late graft complications, a posterior cervical fusion from C4 to C7 was carried out. Solid fixation was achieved with standard lateral mass and trans-spinous process cabling, occasional lateral mass plating and trans-spinous process cable fixation.
C4|cervical (level) 4|C4|202|203|DISCHARGE DIAGNOSIS|Skin did not show any rashes. Neurologically, he had a known history of quadriplegia, but did not appear significantly changed from outpatient exam. PAST MEDICAL HISTORY: 1. Quadriplegia at C1, C2, C3, C4 with no documentation of the cause of this. 2. Recurrent UTIs with history of MRSA urine infections. Patient does have a neurogenic bladder for which she is permanently catheterized.
C4|cervical (level) 4|C4|180|181|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 50-year-old who was evaluated in neurosurgery clinic by Dr. _%#NAME#%_. The patient has had previous anterior cervical fusions from C4 to C7. After these procedures, the patient had recovered well. She was involved in an accident at work where she was hit in the side of the neck and after that event had pain radiating down her left arm, including the shoulder and elbow.
C4|cervical (level) 4|C4.|284|286|HEAD, EYES, EARS, NOSE AND THROAT|He has a scalp laceration over the right temple. He has multiple bruises and ecchymosis over the face and upper cervical spine, particularly about the left orbit. His mid cervical spine is very soft in the axillary line. There was no radiation to the extremities. It is approximately C4. He has no radicular symptoms with movement of the head upon the neck, but his motion causes substantial neck discomfort.
C4|(complement) component 4|C4|183|184|FAMILY HISTORY|3. Status post partial thyroidectomy in 1999. ADMISSION MEDICATIONS: Medications include prenatal vitamins. ALLERGIES: SHE HAS NO DRUG ALLERGIES. FAMILY HISTORY: Her son also has low C4 level. Her mother has essential thrombocytosis. SOCIAL HISTORY: She lives in _%#CITY#%_, Wisconsin with her husband and son and she works here at Fairview-University Medical Center in the Anatomy Department and Cadaver Procurement.
C4|cluster of differentiation 4:CD4|C4|130|131|HOSPITAL COURSE|The results of the transplant renal biopsy was negative for any evidence of acute or chronic rejection, was mildly positive for a C4 positive, otherwise unremarkable. On postop day 14, patient's creatinine continued to actually improve below 2.5. In subsequent hospital days, his creatinine trended down to at the best postop level of 2.18 with good urine output.
C4|(complement) component 4|C4|197|198|HISTORY OF PRESENT ILLNESS, HOSPITAL COURSE|With regards to her rash, she had rheumatologic workup, as well as infectious workup. This workup included a sed. rate that was normal at 30, as mentioned above. Total complement as well as C3 and C4 levels were obtained and all were within normal limits. Urinalysis was unremarkable. A Lyme screen was obtained and was unremarkable. FANA was obtained and is elevated at 8.9, but it is difficult to assess this in the setting of rheumatoid arthritis.
C4|cervical (level) 4|C4|143|144|DISCHARGE DIAGNOSIS|10. Benign prostatic hypertrophy. 11. Right shoulder rotator cuff syndrome. 12. Status-post prior surgeries from the meningiomas at the T3 and C4 level (uncertain if this includes the previously noted meningioma at T5). DISCHARGE MEDICATIONS: 1. Ultram 50 mg p.o. p.r.n. 2. Flomax 0.4 mg p.o. nightly
C4|(complement) component 4|C4|131|132|HISTORY OF PRESENT ILLNESS|On _%#MMDD2004#%_ _%#NAME#%_ was seen by Dr. _%#NAME#%_ _%#NAME#%_ at that time and complemental levels were still low. C3 80, and C4 10, and throat swab was six positive for heavy growth of beta- hemolytic streptococcus Group A. He also had a very elevated anti- DNAase B titer of greater than 1360.
C4|cervical (level) 4|C4|153|154|HISTORY OF PRESENT ILLNESS|The patient had an MRI scan that shows marked stenosis with cord compression and abnormal signal in the cord extending from C3 to C7 with subluxation at C4 with a combination of discs, osteophyte and with significant cord compression. He also at the thoracic spine has a compression fracture at T12 with disc material below with osteophyte.
C4|(complement) component 4|C4|231|232|HOSPITAL COURSE|BUN and creatinine were elevated slightly. CRP was elevated at 11.9. Uric acid level was elevated at 10.7. Double-stranded DNA antibodies were negative. Hepatitis serology was negative. Complement levels revealed normal C3 at 165, C4 was slightly elevated at 14. X-rays were done of the affected joints, all of which were essentially normal. She was given 80 mg of Solu-Medrol in the ER.
C4|cluster of differentiation 4:CD4|C4|21|22|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: C4 D-positive transplant biopsy. DISCHARGE DIAGNOSES: C4 D-positive transplant biopsy. MAJOR PROCEDURES OR TREATMENTS: IVIG with plasmapheresis. HISTORY OF PRESENT ILLNESS: This woman is a 27-year-old female with endstage renal disease secondary to output syndrome who is status post living related kidney transplant on _%#MM#%_ _%#DD#%_, 2004.
C4|cluster of differentiation 4:CD4|C4|75|76|DISCHARGE DIAGNOSES|ADMISSION DIAGNOSES: C4 D-positive transplant biopsy. DISCHARGE DIAGNOSES: C4 D-positive transplant biopsy. MAJOR PROCEDURES OR TREATMENTS: IVIG with plasmapheresis. HISTORY OF PRESENT ILLNESS: This woman is a 27-year-old female with endstage renal disease secondary to output syndrome who is status post living related kidney transplant on _%#MM#%_ _%#DD#%_, 2004.
C4|cervical (level) 4|C4,|335|337|ADMISSION LABORATORY DATA|CAT scan of the head was done in the emergency room, which revealed a small subarachnoid hemorrhage in the left temporal region, an old left parietal infarct, and cerebral atrophy. The patient also had a cervical spine CT done, which showed a fracture at the level of C6, degenerative disk disease, and spinal stenosis at the level of C4, C5, and C6. HOSPITAL COURSE: PROBLEM #1: Subarachnoid bleed. The patient was admitted with possible history of fall and she also had laceration on her forehead.
C4|cervical (level) 4|C4|181|182|HISTORY OF PRESENT ILLNESS|During his stay, he had a fall on _%#MMDD2005#%_ resulting in a C4 fracture, as well as a slightly displaced pathologic fracture in his right proximal humerus. On CT and x-ray, his C4 fracture does not appear to be pathologic. His head CT has been negative. The etiology of his fall was uncertain, but was associated with a seizure.
C4|cervical (level) 4|C4|325|326|HISTORY OF PRESENT ILLNESS|Ms. _%#NAME#%_ is a 54-year-old woman with a complex medical history who underwent a radical anterior cervical colpectomy at C5 and C6 with discectomy at C4-5 and C6-7, debulking of a retropharyngeal mass, excision of an epidural inflammatory mass, and a strut graft placement using pyriform mesh and methylmethacrylate from C4 through C7 with anterior cervical plating. She underwent this surgery on _%#MMDD2006#%_ by Dr. _%#NAME#%_. She has been doing well since her discharge from the hospital.
C4|cervical (level) 4|C4.|187|189|HISTORY OF PRESENT ILLNESS|A previous CT of the cervical spine showed diffuse degenerative changes, most prominent at C3-C4 and C4-5, then the MRI of her cervical spine showed signal change in the cord at level of C4. She had worse and chronic changes present at C3-C4 and C4-C5. She had severe canal stenosis at C3-C4 and C4-C5. There was a tiny central disk protrusion in addition to extensive ventral ridging at C3-C4.
C4|(complement) component 4|C4|270|271|ASSESSMENT|One might also consider the patient's symptoms as a manifestation of possible neoplastic disease such as metastatic disease from his colon cancer. Other inflammatory processes as well might need to be considered as we note previous serologic studies have included a low C4 but normal C3, negative ANA and negative ANCA. Recommendations at this point would include continued inpatient evaluation, continued antibiotics for at least another day.
C4|(complement) component 4|C4|121|122|HISTORY OF PRESENT ILLNESS|She is eating. Her bowels are working normally. She does have peripheral edema as well. The patient had a C3 of 56 and a C4 of 14 on _%#MMDD2006#%_. Her double-stranded DNA antibodies were greater than 200 on that day. These were repeated on _%#MMDD2006#%_. Her C3 at that point was 51 and her double-stranded DNA was down to 118.
C4|(complement) component 4|C4,|146|148|ASSESSMENT AND PLAN|In any case if administration of antibiotics which have been associated with a former reaction must be used then would check a baseline CH50, C3, C4, C3A and serum tryptase and follow closely. If she develops urticaria or a similar cutaneous reaction then we will repeat these labs, and discontinue the antibiotics only if she develops systemic symptoms.
C4|(complement) component 4|C4|138|139|ASSESSMENT|I presume that her right upper quadrant abdominal pain is related to a serositis from the lupus. We will also suggest checking her C3 and C4 as well as her DS/DNA antibody since these were both abnormal prior to treatment. I would like to see her back in follow up in the clinic in one week.
C4|cervical (level) 4|C4|175|176|PAST MEDICAL HISTORY|He however has shown remarkable recovery. PAST MEDICAL HISTORY: 1. Cervical myelopathy secondary to C4-5, C5-6 spondylosis status post anterior cervical diskectomy and fusion C4 to C7 on _%#MMDD2006#%_. 2. History of polyarthritis. 3. History of rheumatoid arthritis. He is on chronic immunosuppressive medications that are Arava and Prednisone.
C4|cervical (level) 4|C4|170|171|HISTORY OF PRESENT ILLNESS|REFERRING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_. HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old female who presents status post anterior cervical disk fusion of C4 through C7 with instrumentation placement. I was asked to see the patient at the request of Dr. _%#NAME#%_ _%#NAME#%_ for internal medicine consult to manage postoperative atenolol and other medical problems.
C4|cervical (level) 4|C4|170|171|HISTORY OF PRESENT ILLNESS|REFERRING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_. HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old female who presents status post anterior cervical disk fusion of C4 through C7 with instrumentation placement. I was asked to see the patient at the request of Dr. _%#NAME#%_ _%#NAME#%_ for internal medicine consult to manage postoperative atenolol and other medical problems.
C4|cervical (level) 4|C4|229|230|HISTORY OF PRESENT ILLNESS|REFERRED BY: _%#NAME#%_ _%#NAME#%_, MD CONSULTANT: _%#NAME#%_ _%#NAME#%_, MD HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old Caucasian female admitted to 10A after having an anterior cervical decompression and fusion of C4 through C7. She is having a posterior cervical decompression fusion surgery on _%#MMDD2006#%_. The estimated blood loss from her surgery was approximately less than 150 cc.
C4|(complement) component 4|C4|127|128|PLAN|5. Diabetes type 2. This is clinically controlled. PLAN: The patient will have Solu-Medrol IV and Benadryl IV. We will check a C4 level. We will also check for a C1 esterase inhibitor. We will also check a baseline EKG and continue telemetry.
C4|cervical (level) 4|C4|110|111|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old, Caucasian male who is admitted to Rehab following a C4 to C6 decompression laminectomy and foraminotomy. I was asked by Dr. _%#NAME#%_ to see the patient for an Internal Medicine consultation, and the patient was examined on _%#MMDD2002#%_.
C4|cervical (level) 4|C4|283|284|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 77-year-old Caucasian male who has been having a complicated recent history with aching in his neck, back, shoulders, and legs. He was evaluated at University Hospital and finally diagnosed with a cervical spondylolytic myopathy and underwent a C4 through C6 decompression laminectomy on _%#MMDD#%_, and subsequently admitted to the rehab floor on _%#MMDD2002#%_. He has been here during the last three weeks. During that time he has had some fluctuations in his bowel movements alternating between constipation and diarrhea, with some degree of concern from the nurses that he is having stool impaction unless he gets laxatives.
C4|(complement) component 4|C4|262|263|HISTORY OF PRESENT ILLNESS|She was also seen in consultation by Dr. _%#NAME#%_ from rheumatology, who found no signs or symptoms or history suggestive of vasculitis on initial questioning and evaluation. Her workup so far has included: Negative rheumatoid factor, bland urinalysis. C3 and C4 were both within normal limits, chest x-ray negative and serum protein immunoelectrophoresis was likewise unremarkable. Pending: ANCA, SSA, SSB, double stranded DNA titer, Ace level, hepatitis screens; PAST MEDICAL HISTORY: 1. Lifelong history of migraines, -Describes it as a posterior occipital pain without any other neurologic symptoms.
C4|(complement) component 4|C4|210|211|PHYSICAL EXAMINATION|Her most recent labs from _%#MM#%_ _%#DD#%_, 2003, indicate a white count of 6.6, platelet count 191,000, hemoglobin 13.2. DNA antibodies are greater than 130 with a decreased level of C4, normal C3s. Her last C4 count was 7 mg/dl. Her serum creatinine was 0.9. Her LFTs were within normal limits and her erythrocyte sedimentation rate was 32, although she was pregnant at this time.
C4|cervical (level) 4|C4|87|88||I was asked by Dr. _%#NAME#%_ in the Emergency Room to see _%#NAME#%_ _%#NAME#%_ for a C4 fracture. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a _%#1914#%_ white female who fell yesterday evening and was found down by her daughter.
C4|(complement) component 4|C4|201|202|RECOMMENDATIONS|RECOMMENDATIONS: 1. I would continue IV steroids. I see no need to advance the Cytoxan at the present time. 2. We will check his ANCA subtypes, c-NCA and p-ANCA. We also will obtain cryos, ______, C3, C4 levels. These have been ordered. 3. Either myself or Rheumatology on call this weekend, Dr. _%#NAME#%_, will follow up with you on this patient.
C4|cervical (level) 4|C4|186|187|HISTORY OF PRESENT ILLNESS|MRI on _%#MMDD2005#%_ showed a left anterolateral cervical paraspinal mass increased in size versus previous exam _%#MMDD2005#%_. There was extension into the cervical epidural space at C4 and C5, as well as tumor in the left C6 and C7 neural foramina in the region of the left C7 and C8 nerve roots.
C4|cervical (level) 4|C4.|185|187|CC|__x___ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Metastatic breast cancer, now with intramedullary lesion at C4. HPI: Radiation treatment to 4000 cGy to cervical/thoracic spine. Assessment and Plan: We have offered low-dose re-treatment to her lesion.
C4|(complement) component 4|C4,|237|239|PLAN|I think it will be important to start intravenous steroids tonight to see if we can turn the patient's status to a more stable situation and not see further deterioration. PLAN: 1. Further laboratory evaluation to include ANCA, ANA, C3, C4, C-reactive protein, CPK, cryoglobulins, hepatitis B and C screening, AST, ALT, lipid panel, cardiolipin antibodies, Lyme titer, and Ehrlichiosis screen.
C4|(complement) component 4|C4|186|187|HISTORY|Urinalysis showed the absence of significant proteinuria or hematuria. Urine sodium was noted to be 10, urine creatinine of 65. Calculated FENa by my calculation was about 0.19%, C3 and C4 levels were normal. I changed his IV fluid from hypotonic isotonic solution and his creatinine today has improved to 1.7 mg/deciliter, decreased from 2.0, he has significant urine output.
C4|(complement) component 4|C4|132|133|LABORATORY DATA|Her C-reactive protein was 24.8 at that time and the double-stranded DNA was present at 193. Her C3 was in the normal range but the C4 was slightly low at 13 (15-50 mg/dl). PHYSICAL EXAMINATION: GENERAL: The patient is lying comfortably in bed although having some difficulty retrieving information that she would like to communicate with me.
C4|cervical (level) 4|C4|88|89|PAST MEDICAL HISTORY|There were no seizures at the scene and no rhinorrhea on arrival. PAST MEDICAL HISTORY: C4 to C6 anterior cervical fusion by Dr. _%#NAME#%_, hysterectomy, sinus surgery, depression, asthma. MEDICATIONS: Advair, Spiriva, Zoloft. ALLERGIES: Penicillin and codeine. SOCIAL HISTORY: She is a married manicurist who has no children of her own, although her husband has two from a previous marriage.
C4|cervical (level) 4|C4|226|227|EXAMINATION|Reviewing his current MRI we see a patchy and I would feel nonspecific white matter abnormalities in the periventricular regions bilaterally. Importantly on the cervical MRI we do see a small area of probable demyelination at C4 level in the left lateral cord and some modest cord atrophy at that level as well. IMPRESSION: Likely chronic multiple sclerosis. Will allow the patient appropriate convalescence from his current surgery.
C4|cervical (level) 4|C4.|321|323|RADIOGRAPHIC STUDIES|LABORATORY DATA: White blood cell count 8.3, hemoglobin 12.4, platelet count 149,000, hematocrit 39.4. Sodium 145, potassium 3.7, chloride 108, bicarbonate 29, BUN 47, creatinine 1.1 with glucose of 117. RADIOGRAPHIC STUDIES: Cervical spine from _%#MMDD2003#%_ revealed some residual posterior 4 mm displacement of C3 on C4. ASSESSMENT AND PLAN: Mr. _%#NAME#%_ is a 62-year-old white male with parotitis of the right parotid gland which has been unresponsive to antibiotics.
C4|cervical (level) 4|C4.|210|212|RADIOGRAPHIC STUDIES|We reviewed all old records including his most recent CT of the neck. Findings noted in HPI. RADIOGRAPHIC STUDIES: Cervical spine from _%#MMDD2003#%_ revealed some residual posterior 4 mm displacement of C3 on C4. ASSESSMENT AND PLAN: Mr. _%#NAME#%_ is a 62-year-old white male with parotitis of the right parotid gland which has been unresponsive to antibiotics.
C4|cervical (level) 4|C4|268|269|SOCIAL HISTORY|I would recommend at least C3 to C6. The issue is whether or not he needs a simultaneous posterior stabilization. Given the fact that we are dealing primarily with a myelopathy, I would recommend focusing on the decompression from C3 to C6 with subtotal corpectomy of C4 and C5, anterior strut graft from C3 to C6 with anterior plate fixation. I told him that he would then be in a collar for 6 to 12 weeks.
C4|cervical (level) 4|C4|88|89|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old male who underwent revision of C4 through C7 decompression and fusion with instrumentation by Dr. _%#NAME#%_ _%#NAME#%_ from Spine Surgery. We were asked to see the patient postoperatively for general medical care with particular regard to known history of sleep apnea, hypertension, and diabetes.
C4|cervical (level) 4|C4|222|223|HISTORY OF PRESENT ILLNESS|The patient underwent a couple of neurosurgical procedures. In reviewing his extensive neurosurgical history, it looks like the patient underwent at least 2 different procedures. One on _%#MM#%_ _%#DD#%_, he underwent C3, C4 anterior cervical diskectomy and fusion, C5-6 corpectomy with strut graft and C3 to C7 anterior cervical instrumentation. The second procedure was done on _%#MM#%_ _%#DD#%_, which involved cervical C2 through T3 arthrodesis and C2 through T3 instrumentation.
C4|(complement) component 4|C4.|269|271|PAST MEDICAL HISTORY|Her review of systems is otherwise negative. PAST MEDICAL HISTORY: Significant mostly for the _%#MM#%_ admission with extensive workup during that admission for the etiology, which was unrevealing. Some abnormalities were noted, including low complement values, C3 and C4. 2. Addison's disease diagnosed on last admission, being treated by Endocrine. 3. Hypothyroidism. 4. Gastritis. SOCIAL HISTORY: She does not use tobacco, does not drink.
C4|cervical (level) 4|C4,|196|198|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Recurrence cysts and other skin lesions for years now. He currently has a cyst on his left buttocks. 2. History of motor vehicle accidents, one in which he injured C3 and C4, another one 3 years when he was run over by a car and had fracture of his left leg. 3. Bipolar. SURGERIES: Mid shaft fracture of his tibia and fibula on his left side.
C4|(complement) component 4|C4,|161|163|HISTORY OF THE PRESENT ILLNESS|Work-up revealed no positive cultures and he has subsequently defeveresced. The patient had laboratory studies on _%#MMDD2006#%_ which included an ANA, ANCA C3, C4, hepatitis B. screening and hepatitis C screening. These were all normal with the exception of the ANA which was weakly positive at 1.7. The patient is not able to give a good history right now.
C4|cervical (level) 4|C4.|238|240|HISTORY OF PRESENT ILLNESS|A CT scan and MRI demonstrated a huge mass in the left parapharyngeal area displacing the mandibular ramus, extending to the parotid superiorly and into the orbit, as well as inferiorly down to the parapharyngeal area to a level of about C4. He needed emergency tracheostomy and was started on COG Protocol D _%#PROTOCOL#%_. He has had an excellent response and at week 12, in lieu of going on to local control measures, it was elected to continue chemotherapy because of his excellent response and in hopes of diminishing the volume which would need to be treated with radiation.
C4|cervical (level) 4|C4|242|243|HISTORY|In addition, given the problems that are occurring, I suppose reconsideration of the mass itself could be undertaken. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 64-year-old male who has a very complicated medical history primarily related to a 1995 C4 quadriplegia from an accident. As part of this syndrome, he has had several infection complications over the years, including septicemia, multiple urinary tract infections and aspiration pneumonia event last year with intubation and major problems.
C4|cervical (level) 4|C4|154|155|PHYSICAL EXAMINATION|Does feel the fever that has been occurring currently. PHYSICAL EXAMINATION: GENERAL: 64-year-old male, appears his stated age. He has obvious changes in C4 quadriplegia. His mental status seems relatively normal, although there is a definite language barrier issue, son is here to help interpret.
C4|cervical (level) 4|C4|175|176|LABORATORY DATA|_%#NAME#%_ _%#NAME#%_ is a 61-year-old man who we are asked to see in consultation regarding acute respiratory failure, most probably secondary to pneumonia. The patient is a C4 quadriplegic since 1995 after a motor vehicle accident. He was admitted with abdominal pain and found to have a pelvic mass, small bowel obstruction secondary to a schwannoma.
C4|cervical (level) 4|C4|343|344|PAST MEDICAL HISTORY|No known drug allergies. He had no history of pneumonia, asthma, bronchitis, however, when he would have colds since his quadriplegia he would have difficulty breathing and the family would assist with diaphragmatic breathing to help patient clear secretions. The patient has no history of tuberculosis. PAST MEDICAL HISTORY: 1. Pertinent for C4 cord injury. 2. He had surgical stabilization of bladder rupture 1994. 3. Suprapubic catheter. 4. GERD. MEDICATIONS: Prior to admission he was on Baclofen, Prozac, Zantac and Ambien.
C4|(complement) component 4|C4|145|146|LABORATORY DATA|ABDOMEN: Non- distended. Soft and non-tender. EXTREMITIES: Negative edema of upper or lower extremities. Negative for cyanosis. LABORATORY DATA: C4 level of 3. Sodium 143, potassium 3.5, chloride 108, bicarbonate 28, BUN 6, creatinine 0.6, glucose 89. WBCs 8.1, hemoglobin 11.4, hematocrit 33.8. INR 0.94. PTT 28.
C4|(complement) component 4|C4|143|144|HISTORY|Other serologies done have been normal including a negative ANCA. His complements are all within normal limits including C2 of 2.8, C3 of 123, C4 of 18 and CH-50 of 209, all done in early _%#MM#%_. He is hepatitis B and C antigen/antibodies are negative. PAST MEDICAL HISTORY: Fairly benign except for the current problem.
C4|cervical (level) 4|C4|254|255|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is an 83-year-old right-handed woman who is postoperative day #2 for a 2-level ACDF cervical surgery secondary to severe cervical stenosis. She had decompression and fusion of the cervical spine from C4 through C5 and C5 through C6. She had worsening hyporeflexia and gait instability for the last month. She came in for this elective surgery, which was performed under general anesthesia.
C4|(complement) component 4|C4|202|203|IMPRESSIONS|He has not developed any rash. Further serologies for the evaluation of vasculitis to date have been unremarkable including a sed rate which was normal and compliments were also were normal, C3 of 139, C4 of 19. Other serologies are pending at this time and should be followed up upon. HSP (Henoch- Schonlein purpura) can present with a combination of hematuria and abdominal pain in young males, typically at a younger age than this.
C4|cervical (level) 4|C4|214|215|HISTORY OF PRESENT ILLNESS|He was well until recently when he began to complain of neck pain and progressive weakness. He was evaluated in his community, _%#CITY#%_, North Dakota, where a scan revealed a large spinal cord tumor invading the C4 vertebral body and compressing the spinal cord. He became hypotensive and quadriplegic. He was admitted to University of Minnesota Medical Center, Fairview, on _%#MMDD2005#%_.
C4|cervical (level) 4|C4|216|217|HISTORY OF PRESENT ILLNESS|He became hypotensive and quadriplegic. He was admitted to University of Minnesota Medical Center, Fairview, on _%#MMDD2005#%_. He was taken to surgery and underwent anterior cervical corpectomy and decompression at C4 and C5. He was immobilized with internal fixation as well as a halo vest immobilization. He was extubated on _%#MMDD2005#%_, but has required BiPAP. Abdominal and pelvic CT revealed a renal mass and atelectasis.
C4|cervical (level) 4|C4|178|179|PHYSICAL EXAMINATION|ABDOMEN: Sounds are positive in all four quadrants, no tenderness. PERIPHERAL VASCULATURE: No lower extremity edema, pedal pulses present. MUSCULOSKELETAL: Cervical - C2 through C4 reveals spinous process hyperalgesia, as well as painful paraspinal muscles in the cervical area. This pain is reported to radiate up to the occipital region, as well as up to the top of her head.
C4|cervical (level) 4|C4.|239|241|IMPRESSION|Laboratory data shows all normal laboratory systems. IMPRESSION: My impression of this gentleman is that he is having some myofascial pain with trigger points at the right trapezius superior border as well as in his paraspinous muscles at C4. He also has some evidence of occipital neuralgia on the right greater than the left, moves up into the supraorbital region and behind the right eye.
C4|cervical (level) 4|C4|61|62|ASSESSMENT|ASSESSMENT: 1. Status post spinal fusion from the occiput to C4 for the treatment of nonunion of a previous fusion. The patient is hemodynamically stable perioperatively. 2. History of obstructive sleep apnea.
C4|cervical (level) 4|C4|138|139|PHYSICAL EXAMINATION|When asked she does indicated that she felt somewhat light-headed. MRI of the cervical spine does show at C4-5 an anterior subluxation of C4 on 5 about 2 mm with a prominent annular bulge and some component of central broad based disk protrusion which leads to moderate central spinal stenosis.
C4|cervical (level) 4|C4|205|206|PHYSICAL EXAM|STATION AND GAIT - the patient is lying in bed and can move both legs, but I did not have him stand up. SKULL AND SPINE - the head is atraumatic. C-spine is tender over the dorsal spinous process at about C4 and C5. There is also paraspinal muscle tenderness on the right at that level. CRANIAL NERVES - visual fields are full. Extraocular movements are impaired.
C4|(complement) component 4|C4.|196|198|ASSESSMENT AND PLAN|This could also be atypical Wegener's granulomatosis. I have requested various rheumatologic serologies, including an ANA, rheumatoid factor, complement levels, which would include a C50, C3, and C4. I have also requested double-stranded DNA and Sjogren antibodies along with repeat sedimentation rate and C-reactive protein. I agree with Dr. _%#NAME#%_' plan of continuing antibiotics for a 2-3 day period and then discontinuing the antibiotics and see how the patient does.
C4|cervical (level) 4|C4|174|175|RADIOLOGIC DATA|CT scan of the cervical spine without contrast showed grade 1-2 spondylolisthesis of C4 on C5 without significant canal or nerve root compromise. There is what appears to be C4 perched on top of C5 facet on the left. On the right side there is a fracture through the posterior C4 facet.
C4|cervical (level) 4|C4.|193|195|IMPRESSION|IMAGING: We have reviewed her MRI of the spine from _%#MMDD2005#%_. IMPRESSION: Ms. _%#NAME#%_ is a 36-year-old female with metastatic breast cancer from C2 through T2 with cord compression at C4. PLAN: We have recommended external beam radiation therapy for her spinal cord compression.
C4|cervical (level) 4|C4|338|339|HPI|The patient was offered to have a biopsy which she declined and finally came to the emergency room because of worsening of pain. On MRI, she was found to have extensive metastases of the cervical and upper thoracic spine with multiple pathology compression of the spine causing severe spinal cord stenosis and impingement at the level of C4 and T1, as well as between C3 and C4. The patient was seen for possible palliative radiation treatments. Exam: Well-developed, moderately nourished Ethiopian female patient who is in no acute distress.
C4|cervical (level) 4|C4.|375|377|HPI|The patient was offered to have a biopsy which she declined and finally came to the emergency room because of worsening of pain. On MRI, she was found to have extensive metastases of the cervical and upper thoracic spine with multiple pathology compression of the spine causing severe spinal cord stenosis and impingement at the level of C4 and T1, as well as between C3 and C4. The patient was seen for possible palliative radiation treatments. Exam: Well-developed, moderately nourished Ethiopian female patient who is in no acute distress.
C4|cervical (level) 4|C4|180|181|NECK|NEUROLOGIC: There is a slight weakness of the right upper extremity, otherwise, unremarkable. Assessment and Plan: Metastatic spinal lesion with spinal compression at the level of C4 and T1-2 area likely due to metastatic lesion from her breast cancer until otherwise proven. The patient was seen by neurosurgery who felt that surgery was not indicated and palliative radiation therapy will be given.
C4|(complement) component 4|C4|199|200|PERTINENT LABS|Liver function tests are minimally elevated except for the LDH which is quite a bit elevated. The haptoglobin is low. Reticulocyte count could not be done because of "interfering substances." C3 and C4 are normal. Screening chemistries are normal, although initially a potassium was slightly low. Thank you very much for the chance to see this pleasant woman.
C4|cervical (level) 4|C4,|137|139|HISTORY OF PRESENT ILLNESS|1. The presence of a small avulsion fracture at the inferior body of C7. 2. A question of a linear fracture involving the facet joint at C4, and very possibly C5. This is again a questionable issue. There is no indication for instability. There is no disc herniation. The spinal cord is normal.
C4|(complement) component 4|C4,|260|262|RECOMMENDATIONS|RECOMMENDATIONS: 1. Continue IV fluids with normal saline. 2. Check spot urine for fractional excretion of sodium (urine sodium, urine creatinine). 3. Renal ultrasound to look at kidney size and echogenicity. 4. Follow-up urinalysis. 5. Will check a FANA, C3, C4, hepatitis B and C studies, further serologies, etc. pending course. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 56-year- old Indonesian ENT physician who was visiting her family in _%#CITY#%_, Oklahoma when she became ill with vomiting and nausea two or three days prior to admission.
C4|cervical (level) 4|C4|181|182|PAST MEDICAL HISTORY|She did have brain resection in 1999 and since then has been seizure-free. 4. Degenerative joint disease of the spine, diagnosed in _%#MM2000#%_ with stenosis and bone spurs around C4 and C5. 5. Carpal tunnel syndrome bilaterally diagnosed four months ago, presently seeing a neurosurgeon. 6. Hepatitis, most likely A. The patient explains that there was acute inflammation of her liver when she was 11 years old and it has since resolved.
C4|(complement) component 4|C4|243|244|RECOMMENDATIONS|RECOMMENDATIONS: 1. I have written for a one week course of prednisone starting at moderately high dose (20 mg b.i.d.) with rapid taper off. 2. Additional laboratory workup as ordered. This will include urinalysis, cardiolipin antibodies, C3, C4 and C reactive protein. 3. It is likely that she will be able to be discharged soon when her chest pain has improved a bit more.
C4|(complement) component 4|C4,|156|158|HISTORY OF PRESENT ILLNESS|In Med Center One on _%#MMDD2007#%_ the patient was further evaluated by obtaining a urinalysis showing 40-50 red blood cells per high power field, his C3, C4, ANA, rapid Strep, ESR and CRP were within normal limits. The patient was started on Rocephin which was subsequently stopped after 48 hours when results from urine culture came back as negative.
C4|cervical (level) 4|C4|195|196|ASSESSMENT|Hemoglobin 9.6. White count 12,000. ASSESSMENT: 1. Diabetes mellitus not adequately controlled with current regime, running persistent hyperglycemia, averaging around 300. 2. Quadriplegia due to C4 spinal injury. 3. History of prostate cancer. 4. Hypertension under satisfactory control at this time. PLAN: We will initially increase Lantus insulin up to 26 units daily at h.s. We will increase sliding scale insulin coverage.
C4|cervical (level) 4|C4|105|106|ASSESSMENT|There is no basic metabolic panel noted on the chart. ASSESSMENT: 1. Status post posterior spinal fusion C4 C5 with mammoplasty C2 C4. 2. Gastric reflux. This is currently controlled. PLAN: We will continue the IV Dilaudid during the night and Dr. _%#NAME#%_'s team will reevaluate pain management in the morning as far as switching the patient to oral medications.
C4|cervical (level) 4|C4.|131|133|ASSESSMENT|There is no basic metabolic panel noted on the chart. ASSESSMENT: 1. Status post posterior spinal fusion C4 C5 with mammoplasty C2 C4. 2. Gastric reflux. This is currently controlled. PLAN: We will continue the IV Dilaudid during the night and Dr. _%#NAME#%_'s team will reevaluate pain management in the morning as far as switching the patient to oral medications.
C4|cervical (level) 4|C4|213|214|HISTORY OF THE PRESENT ILLNESS|The patient has undergone both cervical CT imaging with fine cuts and reconstructions as well as a cervical CT MR. Of note: On her cervical CT imaging, there appears to be mass behind more prominently the body of C4 through the superior portion of the body of T1. In order to clarify this, emergent MRI scanning was done, there is certainly a mass from C4 through the superior portion of T1 that has a consistency of that of acute blood by MRI imaging.
C4|cervical (level) 4|C4|136|137|HISTORY|She was brought by EMS to the Fairview Southdale where she underwent a CT scan and MRI scan which revealed a cervical epidural hematoma C4 through T1 at its most maximal diameter. There does appear to be some blood layering out in the thoracic spine below that.
C4|cervical (level) 4|C4|129|130|PHYSICAL EXAMINATION|The patient is reportedly continent. CT scan of his cervical spine shows a transverse, non-displaced fracture of the C2 body. At C4 and C5 on the right side, there are fractures of the facet joints as well. More severe at C5 than on C6, but these fractures are likewise non-displaced.
C4|(complement) component 4|C4,|225|227|PAST MEDICAL HISTORY|4. Nephrotic range proteinuria. Following by Nephrology at Fairview- University Medical Center. Hospitalization _%#MM2002#%_ for renal biopsy demonstrating minimal change nephropathy. Prior workup included negative FANA, C3, C4, total complement, antiglomerular basement membrane as well as urine protein electrophoresis. Prior lipids, total cholesterol 189, LDL unable to estimate due to elevated triglycerides at 481, HDL of 26.
C4|cervical (level) 4|C4|275|276|CHRONIC DISEASE/MAJOR ILLNESS|CHRONIC DISEASE/MAJOR ILLNESS: 1. Depression. 2. Multiple eye problems, including macular degeneration with detached retina and cataract surgery in the past leading to blindness in the left eye. 3. She also suffers from carpal tunnel syndrome and fibromyalgia. 4. History of C4 radiculopathy. REVIEW OF SYSTEMS: She has chronic migraine headaches that are actually improved in recent years.
C4|(complement) component 4|C4,|152|154|ASSESSMENT|There is no evidence for underlying lupus or a vasculitic disorder, but this needs to be worked up somewhat further. I agree with the ordering of a C3, C4, and ANA. I would add to that an ANCA, cryoglobulins, serum protein electrophoresis, C-reactive protein as well as a urinalysis.
C4|(complement) component 4|C4.|165|167|IMPRESSION|Will get a FENa to evaluate whether he is prerenal or renal toxicity. Would evaluate his history of a lupus-like syndrome by checking a FANA, CH50, sed rate, C3 and C4. Would also check a liver panel and a lipase with his history of abdominal pain. I have asked Dr. _%#NAME#%_ to send both rapid urine tox screen and a complete drug screen.
C4|(complement) component 4|C4|144|145|LABORATORY DATA|Potassium 3.2. Direct antiglobulin test is negative. Serum protein electrophoresis is normal with no monoclonal protein. C3 level is low at 87. C4 level is normal at 18. C-reactive protein is less than 0.02 mg/dL. Differential performed on blood on _%#MM#%_ _%#DD#%_, 2005 showed once again 79% lymphocytes and 13% neutrophils.
C4|cervical (level) 4|C4|84|85|PAST MEDICAL HISTORY|3. Scheduled to start IL2 therapy as well this week. PAST MEDICAL HISTORY: 1. Prior C4 level ACDF (anterior cervical discectomy fusion). This was done approximately 5 years ago. 2. In 1969 the patient had a hunting accident where a bullet fragment skipped off the water and penetrated his right eye.
C4|cervical (level) 4|C4,|203|205|HISTORY OF PRESENT ILLNESS|She was rushed to the hospital, where she was noted to have fracture of her right humerus with possible radial nerve palsy. She also underwent CT C-spine films, which showed degenerative disk disease at C4, 5 and 6 levels, but no fractures. She denies loss of consciousness, dizziness or any other injuries. She also denies having any falls in the recent past.
C4|cervical (level) 4|C4|264|265|ASSESSMENT|ASSESSMENT: My conclusions are that this patient is suffering from neuropathic pain radiating from the left hip area all the way down to the left leg as well as inflammation of the spine in the lumbar 1, 2, and 3. She also has some neuropathic pain radiating from C4 to the left shoulder and down to the left arm. There is also some obvious evidence of somatosensory pain in the left trapezius and shoulder area as well as the neck, the cervical spine area.
C4|cluster of differentiation 4:CD4|C4|148|149|PLAN|He had some lab studies done recently, but they are not available for review at this time. Last labs I see are from _%#MM2003#%_, at which time his C4 count was 139 and his viral load was 20,273. The patient's medications include Bactrim, trazodone, Trizivir, Lexapro, Kaletra, Protonix, and Mucinex.
C4|cervical (level) 4|C4|129|130|IMAGING|IMAGING: I did review his most recent MRI scan that was completed and as noted above, it appears to me that he has a fusion from C4 to C7 at this point. There is some bone spurring from the fusion which does appear to contact the spinal cord at about the C6-7 level on both the left and right sides.
C4|(complement) component 4|C4|196|197|LABORATORY DATA|Reflex is symmetric. Plantar reflexes downgoing. Sensation intact to light touch and pinprick. Coordination is good. LABORATORY DATA: Complements are normal. Double-stranded DNA negative. C3 117, C4 36, phenytoin 3.4 on admission. INR 1.23. Anticardiolipin 1020 negative. Double-stranded DNA 1004 negative. Renin activity negative. IMPRESSION: Despite adequate control of systemic lupus erythematosus, the patient is dialysis-dependent with severe end-stage ischemic kidneys.
C4|cervical (level) 4|C4|191|192|IMPRESSION|IMPRESSION: 1. This is a 63-year-old gentleman here to continue treatment, after complex C-spine surgeries on _%#MM#%_ _%#DD#%_. This included a C4 through 7 discectomy, C5 and 6 corpectomy, C4 through 7 bilateral foraminotomy, and C4 through 7 fusion, plus strut allografting and plating. 2. He has a history of C-spine epidural abscess, with vertebral osteomyelitis, associated with methicillin sensitive Staph Aureus.
C4|(complement) component 4|C4.|183|185|REASON FOR CONSULTATION|She was noted to be hypertensive and was evaluated by Dr. _%#NAME#%_. Workup included serologies for glomerulonephritis, all of which were negative, including ANCA, ANA, anti-GBM and C4. The 24-hour urine collection was done which showed normal VMA and metanephrine but a creatinine clearance was markedly reduced at 42 mL per minute.
C4|cervical (level) 4|C4|177|178|HISTORY OF PRESENT ILLNESS|A MRI of the cervical spine completed at Suburban Imaging-_%#CITY#%_ _%#CITY#%_ on _%#MMDD2007#%_ reveals a metastasis to C5 with some epidural tumor extension proximally up to C4 and then also at the C5 level. There appears to be some compression of the right C5 nerve root. A MRI of the right shoulder completed on the same date reveals marked tendinopathy involving the supraspinatus with some partial thickness tearing.
C4|(complement) component 4|C4,|219|221|RECOMMENDATIONS|However, I would recommend a CT of the abdomen to evaluate for possible intra-abdominal process. I would further work up her autoimmune possibilities with a serum protein electrophoresis, C- reactive protein (CRP), C3, C4, hepatitis panel, cryoglobulins, SSA, SSB, anti-native DNA, anti-Scl-70, antimitochondrial, anti-smooth muscle, and antithyroid antibodies. Also, I would continue antibiotic coverage for now. Finally, I will review the patient's chart at our office with Dr. _%#NAME#%_ to see if there is any evidence of a more systemic autoimmune disease.
C4|cervical (level) 4|C4|149|150|PHYSICAL EXAMINATION|She has been using a walker for approximately four years. __________angle is 15 degrees. She has well-healed surgical scars anteriorly overlying the C4 vertebral body and posteriorly from her occiput down to the C7 region. She has minimal range of motion and it appears that her entire occiput to C7 region is stiff.
C4|(complement) component 4|C4,|141|143|CURRENT LABORATORY VALUES|He has chronic nystagmus with the last ophthalmologic visit in _%#CITY#%_ with no change. CURRENT LABORATORY VALUES: Normal lactate 1.5, C3, C4, sedimentation rate of 9, CRP less than 0.2, ANA 1.3, normal INR, PTT, d-dimer. Multiple laboratory studies are pending, including echocardiogram. He had a renal ultrasound earlier today.
C4|cervical (level) 4|C4|136|137|IMAGING|He does have mild right-sided headache. See History of Present Illness for remainder of review of systems. IMAGING: Partial collapse of C4 with collapse of C5. Partial collapse of C6 vertebral bodies. Cervical stenosis. PHYSICAL EXAMINATION: He is awake, alert and oriented.
C4|cervical (level) 4|C4|337|338|PAST MEDICAL HISTORY|ALLERGIES: None. MEDICATIONS: Birth control pills, Vicodin, Ibuprofen. At the onset of her pain she did take the over-the-counter medication for fibromyalgia which is primarily vitamin supplements given to her by her mother. PAST MEDICAL HISTORY: In 1997 she had right knee arthroscopy. In 1999 and 2000 she underwent cervical fusion of C4 to T1 with hardware ___. She does have chronic pain associated with that and has been taking the Vicodin and Ibuprofen for that.
C4|cervical (level) 4|C4|215|216|IMAGING|She has 5/5 strength throughout. IMAGING: A cervical spine MRI is reviewed, which does reveal a somewhat stenotic cervical spine, as well as a likely autofusion of C3 and 4. She does also have disk herniations from C4 through C7. Plain films of her cervical spine do reveal a likely autofusion of C3/4. No acute fracture or dislocation. ASSESSMENT: Likely, left carpal tunnel syndrome and right long digit trigger finger.
C4|(complement) component 4|C4|252|253|HISTORY OF PRESENT ILLNESS|White blood cells were 12.8, neutrophils 77%, eosinophils 5%. RAST testing was negative for timothy, grass, ragweed, herbarium, aspergillus fumigatus A alternata. Also negative RAST test for silver birch, oak, and D pteronyssinus, farinae. C3 was 126, C4 was 34, CH50 111. At the end of the visit at the allergy clinic, the patient was asked to increase her Advair to 2 puffs of 500/50 b.i.d., but on questioning today the patient states she was actually still only taking 1 puff b.i.d. The patient had also been told she could continue her Allegra, but she had stopped it recently, thinking that she may have required skin tests on the upcoming allergy clinic visit.
C4|cervical (level) 4|C4|227|228|REASON FOR CONSULTATION|HISTORY OF PRESENT ILLNESS: The patient is a 17-year-old white female with history of C1 on C2 subluxation. She was admitted on _%#MM#%_ _%#DD#%_, 2006, for 4 days of cervical halo traction and then underwent occipital through C4 fusion yesterday. The patient has had symptoms of upper extremity weakness and paralysis since 2000. In 2000, she sustained a fall out of bed and subsequent to that, could not move her arms and legs for approximately 20 minutes.
C4|cervical (level) 4|C4|167|168|CHRONIC DISEASE/MAJOR ILLNESSES|The patient denies any other acute medical problems. ALLERGIES: IODINE; CODEINE; MORPHINE. MEDICATIONS: Listed in the current MAR. CHRONIC DISEASE/MAJOR ILLNESSES: 1. C4 spinal cord transection. 2. Schizophrenia. 3. Diabetes mellitus. 4. Recurrent stasis ulcers. 5. Asthma. 6. Past history of pneumonia. REVIEW OF SYSTEMS: Essentially negative at this time. He is also being evaluated during his stay by the ER nursing service for a stasis ulcer.
C4|cervical (level) 4|C4|93|94|HISTORY|DOB: _%#MMDD1959#%_ INDICATION: Melena and diarrhea. HISTORY: This is a 44-year-old who is a C4 quadriplegic who had an ileal diversion either revised or made in _%#MM#%_. When he was in the hospital, he said he was taking some aspirin but since leaving, so probably the last month, he has not had any aspirin.
C4|cervical (level) 4|C4,|139|141|HISTORY OF PRESENT ILLNESS|The patient has a history of a spinal cord injury in 1983 when he fell from a tree while trimming branches. The patient states he suffered C4, 5, and 6 fractures and underwent anterior surgical stabilization of his spine. He was, unfortunately, left with a Brown-Sequard syndrome with profound right upper extremity weakness, moderate right lower extremity weakness, and paresthesias and patchy numbness over his entire body from the mid-chest distally.
C4|cluster of differentiation 4:CD4|C4|292|293||Some labs done recently included a complete metabolic profile that showed no significant abnormalities, although his BUN was slightly elevated at 28 and creatinine was 1.09. Amylase 85, lipase 197, hemoglobin 14.6, white cell count 6.2, platelet count 183,000, HIV viral load non-detectable, C4 count 625. This compares favorably to previous laboratory studies. On exam, he is an alert, attentive individual who seems not distressed.
C4|(complement) component 4|C4|137|138|MEDICATIONS|Noteworthy serologic studies done during the last hospitalization include a negative ANA, a negative ANCA, but low levels of both C3 and C4 components of complement. The patient had an elevation of his platelet function clotting test in spite of a normal platelet count during the last hospitalization.
C4|cervical (level) 4|C4.|217|219|PHYSICAL EXAMINATION|We did recommend that she have an MRI of her spine, which was done at Fairview-University Medical Center on _%#MMDD2005#%_. The cervical spine films did not show any evidence of metastatic disease, only some spurs at C4. However, the thoracic spine did show a 70% decrease in height at T7 with some anterior wedging and abnormal signal, highly suspicious for metastatic cancer.
C4|cervical (level) 4|C4|244|245|HISTORY OF PRESENT ILLNESS|She ultimately went back to her primary physician and, on _%#MMDD2005#%_, MRI scan of the cervical spine revealed a metastatic deposit in the C7 area with a compression fracture and mild central canal stenosis. There were also lesions noted at C4 and C5. Subsequent bone scan confirmed a C7 lesion, with an additional left skull metastases and two left rib spots. Further workup was suggested by me, including an MRI scan of the T- spine, and there were scattered lesions throughout the thoracic vertebrae, the largest being at T7 and T11, but there was no extraosseous extension, and no compression deformities.
C4|cervical (level) 4|C4,|188|190|IMAGES REVIEWED|IMAGES REVIEWED: Lumbar spine x-ray from _%#MMDD2007#%_ demonstrate no fractures. Lumbar spine CT from _%#MMDD2007#%_ demonstrated no fractures and evidence of previous laminectomy at C3, C4, and C5 and lumbar spine MRI obtained on _%#MMDD2007#%_ demonstrated no evidence of cord compression. LABORATORY DATA: Sodium 139, creatinine 1.0, hemoglobin 11.5, white count 7.4, platelets 218.
C4|cervical (level) 4|C4,|139|141|HISTORY OF PRESENT ILLNESS|The plate extends from C4-C6 over the compression fracture site. He is now in a cervical collar. He had placement of pedicle screws at C3, C4, C6, C7. The patient was below baseline for ADLs and mobility. He lives alone and needs to be fully independent and functional before discharging from the hospital.
C4|cervical (level) 4|C4|172|173|IMPRESSION|He has a known L1 compression fracture with some retropulsion but no overt conus compression. IMPRESSION: Left C5 radiculopathy due to multiple myelomatous invasion of the C4 vertebral body. It does not require operative stabilization of this lesion. I would recommend beginning immediate radial therapy and continuing his Decadron.
C4|cervical (level) 4|C4|166|167|PHYSICAL EXAMINATION|There are metastatic lesions of myeloma in the skull and at the tip of the clivus. He has lung lesions as well. The C4 lesion extends into the epidural space in left C4 foramen with impingement of the C5 nerve root. IMPRESSION: Multiple myeloma with C5 radiculopathy accounting for his arm weakness.
C4|cervical (level) 4|C4|138|139|HISTORY OF PRESENT ILLNESS|Final pathology results are pending, however, it is presumed to be an posterior element bone cyst. She had posterior instrumentation from C4 through T1. She is now in a neck brace. Neurologically the strength in her arms have improved since her surgery 5 days ago.
C4|cervical (level) 4|C4|326|327|ASSESSMENT/RECOMMENDATIONS|ASSESSMENT/RECOMMENDATIONS: _%#NAME#%_ is a right-handed individual young girl who is 5 days post-op for surgical excision of a C6 neck mass presumed to be a bone cyst that caused compression of the spinal cord. She has quadriplegia worse on the left than on the right but is improving. She has posterior cervical fusion from C4 through T1. Neurologically she has intact bowel and bladder and an overall improving neurologic picture. Functional abilities are also improving. Recommendations are that the patient should go to an acute rehab facility for ongoing PT and OT as she is below the baseline for ADLs and mobility.
C4|cervical (level) 4|C4,|170|172|HISTORY OF PRESENT ILLNESS|The plate extends from C4-C6 and compression of the fracture. He also had posterior cervical exposure from C2 through T1. He is status post bilateral laminotomies at C3, C4, C6 and C7 for exposure and guidance of a pedicle screw fixation. He has placement of pedicle screws at C3,C4, C6 and C7.
C4|cervical (level) 4|C4.|183|185|IMAGING|He has equivocal Babinskis bilaterally. Cerebellar could not be tested. IMAGING: 1. Cervical CT done today, _%#MMDD2007#%_, shows a right vertebral brief fenestration at the level of C4. 2. Cervical MRI done today, _%#MMDD2007#%_, shows: A. No syrinx. B. No hematoma. C. At the C6-C7 level ventrally the subarachnoid spaces prominent, but there is no distortion of the spinal cord.
C4|(complement) component 4|C4|253|254|HOSPITAL COURSE|At this time, the plan was for cervical ripening and induction with platelets over 100,000. Results of further labs revealed anticardiolipin antibody, IgG positive, IgM negative, haptoglobin 95 (reference range 15 to 200), complement C3 124, complement C4 11, and reticulocyte percentage 2.8. Plan to continue with second dose of IV IG as previously written. On _%#MM#%_ _%#DD#%_, 2005, hospital day #3, she is 39 plus 1 weeks; she continues to deny vision changes or right upper quadrant pain.
C4|(complement) component 4|C4|268|269|HOSPITAL COURSE|The patient underwent extensive laboratory workup the night of admission. The workup included a sed rate that was elevated at 70, CRP elevated at 32.3, and an ANA that was elevated at 4.7. The patient also had a complement C3 that was within normal limits, complement C4 within normal limits, a rheumatoid factor that was negative, a c-ANCA that was negative, a Lyme test that was negative, hepatitis C virus panel that was negative, _____ antibody negative, HIV negative and protein electrophoresis without monoclonal protein spike.
C4|(complement) component 4|C4|160|161|HOSPITAL COURSE|Cardiolipin antibodies were essentially unremarkable. Rheumatoid factor was elevated at 1000. Antinuclear antibody screen was weakly positive. C3 was 99 with a C4 of 11. Total complement was low normal. The patient was given high dose oral steroids with some improvement in his symptoms.
C4|(complement) component 4|C4|247|248|SUMMARY OF HOSPITAL COURSE|Again, the chest CT scan showed indeterminate mediastinal and hilar lymphadenopathy, increased patchy bibasilar infiltrate changes, Aldolase level was 9.7, upper limit of normal is 8.1. CK level was normal. Myoglobin was normal. Compliment C3 and C4 were within normal limits. C-reactive for K 7.24. IGE level was very high at 2608. Hemoglobin A1C was 5.9. ANA was negative. C-ANKA was negative.
C4|(complement) component 4|C4|158|159|LABORATORY TESTS|LABORATORY TESTS: WBC 12.1 with left shift. Hemoglobin 11.8. MCV 89. Platelet count 255. Electrolytes within normal limits. Glucose 113. Calcium 8.9. T3 105. C4 20. Sedimentation rate 59. Prior DNA double-stranded was negative. The ______________________ was pending. Urine cultures and blood cultures were negative.
C4|(complement) component 4|C4|313|314|POSTOPERATIVE COURSE|One further Prograf level was also checked on _%#MMDD2003#%_ and was found to be 8.5. Per the transplant team, their goal postoperatively was to keep her between 5 and 8, and the did not do any dose adjustments at that time as they were happy with that level. Nephrology team also requested an ANA level, C3, and C4 levels to be drawn prior to discharge and those are pending at the time of this dictation. The patient had fasting cholesterol checked prior to discharge and it returned within normal limits (cholesterol 199 with triglycerides 126, LDL cholesterol 124, and HDL 49).
C4|(complement) component 4|C4|208|209|PHYSICAL EXAMINATION|LABORATORY: CBC: White count 5.1, hemoglobin 7.2, hematocrit 20.4, platelets 59. Differential revealed a low absolute lymphocyte count at 1.3, otherwise differential was unremarkable. C3 was depressed at 45, C4 normal but on the low side at 21. LD was elevated at 1563. Factor H level drawn the subsequent morning revealed a level of 323 with the lower limit of normal being 422.
C4|(complement) component 4|C4|139|140|PERTINENT LABORATORY STUDIES|Albumin 3.1. Peak creatinine 2.3. Phenyl less than 1%. TSH is 1.79. Peak white blood cell count 20. Angiotensive converting enzyme 14. C3, C4 compliment levels normal at 181 and 43, respectively. Blood gas: pH 7.24, PCO2 63, PO2 60. Hemoglobin A1C 9%. Last arterial blood gas: pH 7.4, PCO2 59, bicarbonate 36.
C4|(complement) component 4|C4|170|171|HOSPITAL COURSE|Her creatinine improved. The ultrasound showed the above findings, consistent with chronic kidney disease; however, there was some concern for sarcoid Ace levels and C3, C4 compliment level were negative. Patient's creatinines returned to about 1.0. She was then actively diuresed for clear fluid retention secondary to obstructive sleep apnea.
C4|cervical (level) 4|C4|102|103|HOSPITAL COURSE|The patient was admitted to the Neurology Service. HOSPITAL COURSE: PROBLEM #1: Signal abnormality in C4 to T4 areas of the cord. The patient's MRI of cervical, thoracic, and lumbar spine were repeated after admission, and it was determined to have signal abnormality of the C4 to the T4 cord levels.
C4|(complement) component 4|C4|191|192|PROBLEM #8|PROBLEM #8: Rheumatologic. As part of the work up for _%#NAME#%_'s autoimmune thrombocytopenia, we obtained an ANA and complement levels. The ANA was slightly positive at 3.1, and the C3 and C4 were slightly decreased. A Rheumatology consultation was obtained. Per the Rheumatology consult team, _%#NAME#%_ does not currently meet the criteria for systemic lupus erythematosus, but she will follow up in their clinic as necessary following discharge.
C4|cervical (level) 4|C4|196|197|PAST MEDICAL HISTORY|In _%#MM#%_ of 2003, she underwent total diskectomy of C4-C5 and C6-C7 with an extensive decompression. Hardware was removed at the level of C5-C6 and then a fusion was completed all the way from C4 to C7. The patient also has a significant lumbar disease she tells me and no surgery is planning on her lumbar spine due to the fact that she has got severe chronic obstructive pulmonary disease.
C4|cervical (level) 4|C4|244|245|IMPRESSION|Glucose is 183, BUN is 56, creatinine is 2.1, calcium is 7.9. IMPRESSION: This is a 62-year-old lady who is diabetic, with chronic obstructive pulmonary disease, continues to smoke. She has significant C-spine disease, what appears to have had C4 to C7 fusion and she actually had paresthesias in her upper extremities prior to her C-spine surgeries. She, at present, appears to have had a local infection of her left forearm which was lanced and she was placed on antibiotics.
C4|cervical (level) 4|C4,|187|189|HISTORY OF PRESENT ILLNESS|MRI of the entire spine was performed. It was also said that imaging of the brain was done but this was not clearly documented. Imaging of the cervical spine showed a small lesion around C4, but this had been present in a much earlier study a few years back. Being that the spinal MRI was not helpful in explaining the patient's worsening symptoms, the patient was transferred to Fairview University Hospital on _%#MMDD#%_.
C4|(complement) component 4|C4,|208|210|PROBLEM #2|The creatinine to 1.6 relatively stable a high of 1.7. A large batter of labs were ordered during the course of hospitalization to determine the cause of the renal failure. These included a complement C3 and C4, ASO and anti-DNase B titers, FANA, ANCA, sedimentation rate, CRP, and a glomerular basement membrane. All labs were within normal limits with the exception of ASO titer which was elevated at 2,100.
C4|(complement) component 4|C4|291|292|PLAN|Outside records have been obtained at the time of this dictation and there is no significant laboratory results regarding a rheumatologic workup. We will ask for a Rheumatology consult and send of multiple rheumatologic studies including ANCA, antinuclear antibody, double stranded DNA, C3, C4 and total compliment levels, rhe umatoid factor and vitamin D levels. Preliminary consultation with Rheumatology has requested angiotensin-converting enzyme, hepatitis serologies, EBV and CMV, antiglomerular basement membrane, and parvovirus serologies.
C4|(complement) component 4|C4|200|201|HOSPITAL COURSE|During this hospitalization, we repeated complements as well as double stranded DNAs and CRPs and sedimentation rate. The CRP was approximately 1.89 on admission, sedimentation rate being 18, C3 170, C4 was 26, and a homocystine level was 25.2. RNP antibody IgG was 7, Smith antibody was 13, and a UA was obtained which did reveal some hyaline casts.
C4|(complement) component 4|C4|147|148|HISTORY OF PRESENT ILLNESS|INR 1.1. D-dimer greater than 4. Sedimentation rate of 10. Unremarkable basic metabolic profile. Normal liver function. C3 compliment was 128 with C4 compliment of 31. ANA screen was negative. IMAGING: Imaging of the right shoulder was pursued with MRI dated _%#MMDD2006#%_.
C4|(complement) component 4|C4|146|147|DISCHARGE DIAGNOSES|Smith antibody IgG was elevated at 257, RNP antibody IgG was elevated at 155. Scleroderma antibody was negative or normal at 3. Complement C3 and C4 levels were low at 68 and 13, respectively. Anticardiolipin antibody was not detected. ANCA was less than 1:16, which is within the reference range.
C4|cervical (level) 4|C4|190|191|BRIEF HISTORY OF PRESENT ILLNESS|5. NG tube feedings while intubated. 6. CT head on _%#MM#%_ _%#DD#%_, 2005: No acute bleed. 7. CT spine on _%#MM#%_ _%#DD#%_, 2005: Findings: A. Fracture of the anteroinferior aspect of the C4 vertebral body with slight anterior excursion of the fracture fragment. This is age indeterminate. Otherwise, there are mild degenerative changes throughout the cervical spine.
C4|cervical (level) 4|C4|256|257|PROBLEMS IN HOSPITAL COURSE TO-DATE|Prior to this hospitalization, it was thought that he should have a renal biopsy to further evaluate other possibilities of renal failure such as amyloid, and this will deferred to the patient's primary oncologist to be followed up on as an outpatient. 3. C4 fracture. The patient has multiple lytic lesions in the spine, and the fracture was likely as a result of his fall on _%#MM#%_ _%#DD#%_, 2005.
C4|(complement) component 4|C4|703|704|HOSPITAL COURSE|Her calcium reached a low of 5.7 with a low of her ionized calcium at 3.4. Her calcium carbonate dose was increased to 600 mg p.o. q.i.d. while in the hospital with a resulting calcium on discharge of 6.9 and ionized calcium of 3.4. She was started on Calcitrol 0.5 mcg p.o. q.d. and brought down to a level of Calcitrol 0.25 mcg q.d. The patient was also placed on PhosLo for an increased phosphorus with a maximum level of 11.6. She was instructed to take the PhosLo with each meal and had a resulting discharge phosphorus of 7.3. While in the hospital a consult was made to a nutritionist who discussed a low sodium, low phosphorus diet with _%#NAME#%_ and her family. Initially, _%#NAME#%_'s C3 and C4 were within normal limits with a C3 of 95 and a C4 of 15, however, just prior to discharge she had these complement levels drawn again after her discharge and they were found to be a value of 60 for C3 and 6 for her C4.
C4|(complement) component 4|C4|754|755|HOSPITAL COURSE|Her calcium reached a low of 5.7 with a low of her ionized calcium at 3.4. Her calcium carbonate dose was increased to 600 mg p.o. q.i.d. while in the hospital with a resulting calcium on discharge of 6.9 and ionized calcium of 3.4. She was started on Calcitrol 0.5 mcg p.o. q.d. and brought down to a level of Calcitrol 0.25 mcg q.d. The patient was also placed on PhosLo for an increased phosphorus with a maximum level of 11.6. She was instructed to take the PhosLo with each meal and had a resulting discharge phosphorus of 7.3. While in the hospital a consult was made to a nutritionist who discussed a low sodium, low phosphorus diet with _%#NAME#%_ and her family. Initially, _%#NAME#%_'s C3 and C4 were within normal limits with a C3 of 95 and a C4 of 15, however, just prior to discharge she had these complement levels drawn again after her discharge and they were found to be a value of 60 for C3 and 6 for her C4.
C4|cervical (level) 4|C4.|282|284|PAST SURGICAL HISTORY|Endocarditis prophylaxis was recommended. An adenosine thallium scan on _%#MMDD2006#%_ showed no myocardial perfusion, however they cannot exclude balance ischemia. There was normal left ventricular function. PAST SURGICAL HISTORY: 1. Anterior cervical fusion for herniated disk in C4. 2. Right total knee replacement on _%#MM2005#%_. 3. Peritoneal catheter placement on _%#MM2006#%_. 4. Failed AV Fistula placement on _%#MM2006#%_.
C4|cervical (level) 4|C4|160|161|PROBLEM #1|_%#NAME#%_ also underwent MRI of her surgical spine, which showed posterior surgical changes at C1, C2 and C6. Heterogeneous area of T2 hyperdensity noted from C4 to C7 at which point normal spinal cord tissue was not visualized. PROBLEM #2: Respiratory: _%#NAME#%_ was intubated immediately upon arrival to the North Memorial and remained intubated until a tracheostomy could be placed by ENT on _%#MMDD2007#%_.
C4|cervical (level) 4|C4|191|192|FOLLOW UP|There was possible gallbladder sludge without any evidence of acute cholecystitis and the common bile duct was normal at 5 mm. The MRI of his cervical spine showed a benign hemangioma in the C4 body and no significant cord abnormalities were noted. On the addendum from the _%#CITY#%_ MRI of _%#MM#%_ of 2003, they did note scattered abnormal signal within the cervical cord, consistent with demyelination at that time, but there was too much artifact on the admission MRI to show significant changes.
C4|(complement) component 4|C4|241|242|6. GI|7. Rheumatology/lupus: Prior to admission, the patient had not been seen for followup for 9 months and had been off his medicines for a couple of months. Labs were checked and the patient was found to have low complement, C3 was 69 and then C4 was 6. A double-stranded DNase was 154. The patient was started on prednisone 25 mg p.o. t.i.d. and CellCept 250 mg p.o. b.i.d.
C4|cervical (level) 4|C4.|127|129|CONTINUATION ASSESSMENT AND PLAN|He does have some decreased grip strength on the left. I doubt this is related to his neck pain as his pain appears to be over C4. We will continue to follow, provide a topical lidoderm patch to the site and Aqua-K pad. 7. Pain control. We will provide p.r.n. oxycodone and a bowel regimen to prevent constipation.
C4|(complement) component 4|C4|111|112|PAST MEDICAL HISTORY|We also checked both C3 and C4 to follow the status of her transplant kidney. On admission the C3 was 22 and a C4 was 14, and on discharge the C3 was 38 and the C4 was 22. We also did a 24-hour urine collection which showed an elevated protein to creatinine ratio of 1.76. DISCHARGE INFORMATION: The discharge diagnosis was a central line catheter infection which was removed and then replaced during this hospitalization.
C4|(complement) component 4|C4|117|118|PROCEDURES PERFORMED|All of these studies were normal except for a slightly elevated IgE level at 315. The CH50 was normal along with the C4 levels. The C3 level was slightly low at 84. The patient's rheumatoid factor level was slightl y elevated at 36 with a normal ranging between 0-20.
C4|cervical (level) 4|C4|200|201|PROCEDURES|There are mild degenerative changes noted in C4 to C6 with moderate to severe right neuroforaminal narrowing noted in C5 to C6, and right neuroforaminal narrowing of mild to moderate disease noted in C4 to C5. There is no evidence of spinal stenosis. 3. Sniff test, _%#MMDD2005#%_, demonstrates left hemidiaphragmatic paralysis.
C4|(complement) component 4|C4|218|219|PROBLEMS|His 24-hour protein to creatinine ratio in his urine was 3.82 on _%#MM#%_ _%#DD#%_, 2002, and had down-trended to 1.6 on _%#MM#%_ _%#DD#%_, 2002. Renal service did follow the patient during his hospitalization. C3 and C4 levels were normal. An ANA was negative. The patient does only have 1 kidney status post left nephrectomy for multicystic dysplastic kidney in _%#MM#%_ of 2000.
C4|(complement) component 4|C4|146|147|PROBLEM #4|Studies which are pending at the time of discharge include a neutrophil function test, including NBT and chemotaxis function. In addition, C3 and C4 levels for complement were drawn and an HIV I/II antibody test was drawn. She also had immunophenotyping done to evaluate her T and B cell lines.
C4|(complement) component 4|C4|292|293|LABORATORY FINDINGS AND INVESTIGATIONS|LABORATORY FINDINGS AND INVESTIGATIONS: From _%#MMDD2007#%_, sodium was 143, potassium 4.3, chloride 111, CO2 24, BUN 29, creatinine 0.98, glucose 116, bilirubin 0.2, calcium 9.5, albumin 3.7. Total protein was 7.3, alkaline phosphatase 157, ALT 27, AST 37, complement C3 was 106, compliment C4 was 10; that is slightly low on the complement C10. Hepatitis B surface antigen was negative. HIV 1 and 2 antibodies negative.
C4|cervical (level) 4|C4.|161|163|IMAGING STUDIES|MRI of the C-spine without contrast shows multiple lesions in the cerebellar hemispheres of indeterminant etiology. Multiple lesions in the bone marrow, C1, C2, C4. These were discussed with radiology and not thought to be metastatic, and in fact, there was no clear lesions noted. The study was of very poor quality. Multilevel degenerative disk disease and degenerative facet arthropathy causing severe spinal canal stenosis at C4-5 and moderate spinal canal stenosis at C3-4 and C5-6.
C4|(complement) component 4|C4|124|125|HOSPITAL COURSE|In addition, to help determine if patient's clinical picture was due to active lupus, a C3 and C4 were obtained. C3 was 86. C4 was 14. CRP was 288. ESR was 94. The CRP and ESR were felt to be unreliable due to patient's postoperative state and anemia.
C4|(complement) component 4|C4,|97|99|C.|Urine protein to creatinine ratio is pending at the time of this dictation. 8. Rheumatology: C3, C4, and RF were all negative. Proteinase III antibody was strongly positive supporting the diagnosis of Wagner's. We are awaiting repeat P- ANCA and C-ANCA at the time of this dictation.
C4|cervical (level) 4|C4,|57|59|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Cord compression at the level of C4, C7, and T2 secondary to metastatic lesions in these vertebral bodies with fractures. 2. Metastatic breast cancer status post mastectomy, chemotherapy, and radiation.
C4|(complement) component 4|C4|166|167|ADDENDUM|Antinuclear antibody screen was negative. A peripheral blood smear showed a reactive thrombocytosis, no evidence for myeloproliferation. Complement C4 and complement C4 levels were within normal limits although complement CH50 total value was slightly elevated. An ESR done while in the hospital was 18 and subsequent lipase levels were within normal limits.
C4|cervical (level) 4|C4,|148|150|PROCEDURES PERFORMED DURING THIS HOSPITALIZATION|9. MRI of the C-spine performed on _%#MMDD2007#%_ shows no abnormal spinal cord signal, mild degenerative disc disease in the cervical spine at C3, C4, C5 and C6. 10. Peripheral blood smear performed on _%#MMDD2007#%_ shows normochromic normocytic anemia with leukocytosis secondary to toxic neutrophilia and slight eosinophilia.
C4|cervical (level) 4|C4|238|239|OPERATIONS/PROCEDURES PERFORMED|OPERATIONS/PROCEDURES PERFORMED: 1. L4-L5 osteotomy with L2 through S1 re-instrumentation on _%#MM#%_ _%#DD#%_, 2006. 2. Ureteral stent placement. 3. Revision of spine fusion anterior and posterior approach on _%#MM#%_ _%#DD#%_, 2006. 4. C4 through C6 anterior cervical diskectomy and fusion on _%#MM#%_ _%#DD#%_, 2006. HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old female with a long history of spine issues including 17 prior spine surgeries to the cervical, thoracic, and lumbar spine, last procedure in 2004, who presents with coronal imbalance complaints.
C4|cervical (level) 4|C4|145|146|HOSPITAL COURSE|An MRI was obtained which demonstrated herniated disks at the C4-C5 and C5-C6 levels. Neurology was consulted and a decision to proceed with the C4 through C6 ACDF was made. The patient underwent this procedure in an emergent fashion on the night of _%#MM#%_ _%#DD#%_, 2006, into the morning of _%#MM#%_ _%#DD#%_, 2006.
C4|(complement) component 4|C4|148|149|HOSPITAL COURSE|She concurrently had a DNAPB test sent which was also unremarkable. Complement C3 and C4 were evaluated and both were reasonable with C3 at 117 and C4 at 16. ANA was negative at less than 1.0. Hepatitis serologies were unremarkable. Given all of these findings, per Nephrologies recommendations the patient was started on steroids and improved quite dramatically on this course of steroids, although it was unclear if she might have improved without the trial of steroids as the initiation of this occurred somewhere around the nadi r of her creatinine course.
C4|(complement) component 4|C4|144|145|LABORATORY DATA|It was described as having patchy perihilar densities due to poor inspiration with an otherwise normal x-ray. Complement C3 was 146, complement C4 was 22. She had an antinuclear antibody screen that was less than 1.0. She had a neutrophil cytoplasmic antibody IgG screen that was interpreted as negative.
C4|(complement) component 4|C4|126|127|HOSPITAL COURSE|Ultimately lab values came back showing a positive ASO titer, a negative FANA, a negative ANCA, as well as a low C3 and a low C4 level. Anti-DNase B was still pending upon discharge. Urinalysis showed blood as well as protein but was not significant for a urinary tract infection on urine culture.
C4|(complement) component 4|C4|144|145|HISTORY OF PRESENT ILLNESS|His fluorescent antinuclear antibody came back positive with a speckled pattern and a very high double-stranded DNA antibody titers. His C3 and C4 and total complement levels were low. He had a renal biopsy performed on hospital day number 4 at _%#CITY#%_ _%#CITY#%_ Childrens which showed diffuse proliferative glomerulonephritis with 30% crescents, most consistent with lupus nephritis.
C4|(complement) component 4|C4|175|176|HOSPITAL COURSE|His urine protein to creatine ratio remained elevated. It was 23.98 at the time of discharge. His complement levels increased. His C3 was 27 at admission and 50 at discharge. C4 was 5 at admission and 11 at discharge, and his anti-double-stranded deoxyribonucleic acid decreased from greater than 500 at _%#CITY#%_ _%#CITY#%_ Childrens to 29 several days prior to discharge. There was a double- stranded deoxyribonucleic acid test pending.
C4|(complement) component 4|C4|117|118|PROBLEM #2|Negative workup during this time included an ANCA, FANA, ESR, and CRP. His C3 level was slightly low, at 85, and his C4 was normal, when checked during this hospitalization. A cardiolipin antibody was pending at the time of discharge. His protein to creatinine ratio improved from 5 on admission to 1.4 at the time of discharge.
C4|cervical (level) 4|C4,|216|218|HOSPITAL COURSE|MRI of the brain on _%#MMDD2006#%_ show small hyperintense lesion with central hypointensity in several sites also suspicious for metastatic disease. His MRI of the cervical pine showed osteopenic vertebral body C3, C4, and C5. Borderline small spinal canal without evidence of spinal cord compression. Mild degenerative changes in the cervical spine. MRI of the thoracic spine obtained on _%#MMDD2006#%_ showed multiple metastatic spinal cord lesions, right lung and left pleural base lesions.
C4|(complement) component 4|C4|226|227|HOSPITAL COURSE|3. Renal: _%#NAME#%_'s lupus and membranous nephropathy upon admission was under well control with her CellCept and prednisone. She was taking prednisone 20 mg t.i.d. Her complement levels upon presentation were C3 at 148 and C4 at 39, both was in normal limits. It was felt by the nephrology staff involved that _%#NAME#%_'s lupus was essentially turned off with her high dose steroids and CellCept given her initial diagnostic presentation of lupus.
C4|(complement) component 4|C4|192|193|HOSPITAL COURSE|2. Systemic lupus. The patient given past history and concern of possibility of infiltrate being results of lupus. A consult was obtained from Rheumatology, and at their recommendations C3 an C4 were sent which demonstrated a C3 of 156 and a C4 of 36, both of which were not lowered. Clinically she was felt to not be having a lupus flare at this time.
C4|(complement) component 4|C4|283|284|PHYSICAL EXAMINATION|Beta 2 glycoprotein antibody was negative. RNP antibody negative. With this information, rheumatology consult stated that in spite of her specific imaging, this was most consistent with lupus cerebritis. The patient was treated with high-dose steroids as well as Cytoxan. Her repeat C4 level was less than 2.0 on _%#MMDD2002#%_ and C5 was also unmeasurable. On the day prior to discharge, a repeat C3, C4 and double-strength DNA antibody was also sent, which is pending at the time of this dictation.
C4|(complement) component 4|C4|205|206|LABORATORY DATA|Her urinalysis showed small bilirubin, moderate blood, 2 RBCs, 2 WBCs, negative nitrites and negative leukocyte esterase, many bacteria. Chest x-ray and abdominal x-rays were done and described above. Her C4 and C3 were both very low at 3 and 58, respectively. Her LD was elevated at 2760. Her reticulocyte count was extremely elevated at 61.4%. Her haptoglobin was less than 6.
C4|(complement) component 4|C4|193|194|HOSPITAL COURSE|At the time of discharge the patient's energy level had returned to her baseline, and she was feeling much better. PROBLEM #2. Systemic lupus erythematosus. Given the patient's very low C3 and C4 levels, she likely had also an active flare of her lupus. We did check an anti-double-stranded DNA antibody that came back at 9 and was negative.
C4|(complement) component 4|C4,|187|189|DISCHARGE INSTRUCTIONS|He was instructed that in the presence of acute hives or breathing problems, that he should seek care immediately. I asked the patient to have them perform the following tests: Serum C3, C4, C850, C1 esterase inhibitor .............., C1Q, Triptene, 24 hour urine histamine, PGD2, CBC with differential and LFTs.
C4|(complement) component 4|C4|260|261|HOSPITAL COURSE|Phosphorus was 5.9 and decreased to 5.7 by discharge. Other electrolytes were within normal limits. CRP on admission was 2.97 and 0.99 by discharge. Urine DNA amplification for GC and Chlamydia was negative, RPR negative, FANA negative, ANCA negative, C3 121, C4 130, rheumatoid factor less than 20, antiglomerular membrane antibody pending at discharge. LDH 625, uric acid 8.5. Overall the patient's renal status improved throughout the admission with IV fluid support alone.
C4|cervical (level) 4|C4|220|221|PAST MEDICAL HISTORY|She has had a left heart cath back in 2001 and an angio and angiography at that time and at that time, medical management was recommended. 6. History of cervical spinal stenosis with myelopathy in 2003 for which she had C4 through C7 anterior spinal fusion with instrumentation, allograft and autograft done. 7. 2003, she also had C-Difficile colitis. 8. Chronic obstructive pulmonary disease exacerbation 9.
C4|(complement) component 4|C4|318|319|HOSPITAL COURSE|The following tests were established through rheumatology to include: RNP 81, Smith antibody 135, SSA (Ro) 199, SSB (La) 4, double-stranded DNA 13, ANA 6.8, cardiolipin antibody 5.1, cardiolipin was negative, cryoglobulin was negative. Protein C activity was elevated at 197, protein S was decreased at 50, C3 was 65, C4 16. Based on the clinical findings and lab tests, Rheumatology concluded that the patient does have lupus, SLE. With this recent diagnosis, lupus was considered to contribute to her pathology of her pontine lesion.
C4|(complement) component 4|C4,|143|145|PROBLEM # 1|We will obtain multiple lab tests and further workup of her pancytopenia including parvovirus DNA by PCR, CK, LDH, uric acid, Coombs test, C3, C4, and CH50. We will consider in the morning getting double stranded antibodies for lupus If malignancy seems likely we will consider CT scan of her chest, abdomen and pelvis to further evaluate any tumors such as lymphoma.
C4|(complement) component 4|C4,|161|163|ASSESSMENT AND PLAN|He has had steadily dropping hemoglobin with jaundice. Interestingly, his RDW is not elevated. We will check a complete anemia workup including haptoglobin, C3, C4, Coombs' test, cold agglutinins, a Hematology/Oncology consult, will check ANA and rheumatoid factor. We will also be checking other routine laboratory studies along with LDH.
C4|(complement) component 4|C4|332|333|HISTORY OF THE PRESENT ILLNESS|On _%#MMDD#%_, when he presented with concerns that this may be a rheumatological presentation, an ANA and rheumatoid factor as well as sed rate were obtained as well as GC and Chlamydia thinking this may be a sexually transmitted disease having infiltrated into his joint space. All these studies were negative. Also a CMV and C3, C4 were also obtained which were also negative. The patient left the clinic on _%#MMDD2005#%_, he returned with continued symptoms and now development of right upper quadrant pain with lower back pain, non-radiating.
C4|(complement) component 4|C4|289|290|PROBLEM #1|This is pending at the time of discharge. The patient's presentation would be an atypical presentation for Reiter's or other connective tissue disease. These things were deemed less likely with regard to the lack of arthralgias or arthritis-like symptoms. However, anticomplement, C3, and C4 were sent prior to discharge to look for evidence of vasculitis or immune complex disease. ANA was also sent, though SLE is also a less likely diagnosis.
C4|(complement) component 4|C4|158|159|PLAN|PLAN: 1. Further laboratory studies to include repeat FANA, SSA and SSB antibodies, extractable nuclear antigens, anti-double-stranded DNA antibodies, C3 and C4 levels. We will also check serum protein electrophoresis with immunoelectrophoresis. 2. Await CT scan, lumbar puncture and blood results. 3. No treatment is recommended at this time.
C4|(complement) component 4|C4|376|377|PREVIOUS EVALUATIONS|Creatinine 0.93, BUN 10, and normal electrolytes. His CRP was 91.3. Laboratory studies from today include creatinine 1.07, BUN11, WBC 18,600, hemoglobin 12.4, platelet count 298,000, differential 16,400 neutrophils and 800 lymphocytes, albumin 3.3, and magnesium 1.8, phosphorus 2.5. Troponin negative. Negative ANA, negative rheumatoid factor, LD 382, uric acid 3.5, C3 120, C4 30. Pending results include total complement, antihistone antibody, and anti-ENA panel and anti-dsDNA antibody.
C4|(complement) component 4|C4|162|163|REASON FOR CONSULTATION|She had a connective tissue work-up including a negative ANA, ANCA, and anti-_____ antibodies. Anti-GBM antibodies were negative. C3 complement was normal at 92. C4 complement was depressed at 12. Her white count during the hospitalization was as high as 25,800 with 39% eosinophils. She was noted to have very mild renal function abnormalities.
C4|(complement) component 4|C4|152|153|HISTORY OF PRESENT ILLNESS|Other studies recommended and ordered by Rheumatology included functional C1 esterase inhibitor, the results of which are still pending. C2 is pending. C4 is within normal limits at 25. Rheumatology was also concerned about the possibility of angioedema, and recommended either an Allergy or Dermatology consultation.
C4|(complement) component 4|C4,|176|178|RECOMMENDATIONS|2. I did not aspirate the right knee but that also would be a possibility for diagnosis of CPPD. 3. Additional laboratories including calcium, phosphorus, magnesium, ANCA, C3, C4, CH50, cardiolipin antibodies, and serum electrophoresis. 4. Consider other workup for malignancy, including possible abdominal CT scan and/or bone marrow biopsy.
C4|cervical (level) 4|C4|178|179|PAST SURGICAL HISTORY|Extremities: No cyanosis, clubbing, or edema. Skin: No rashes, lesions, or ulcers. Musculoskeletal: Gait appears normal. Cervical spine is tender to palpation from approximately C4 to T2. Neck range of motion is limited in all directions. Lumbar spine is tender to palpation from L2 and below. Neurologic: The patient is alert and oriented. Cranial nerves 2 through 12 are grossly intact.
C4|(complement) component 4|C4.|187|189|RECOMMENDATIONS|RECOMMENDATIONS: 1) I would pursue further workup of the elevated sedimentation rate with CRP, serum protein electrophoresis, and cryoglobulin. 2) Lupus anticoagulant, VDRL, ANCA, C3 and C4. 3) Consider lumbar puncture. 4) We will discuss the case in more detail with Drs. _%#NAME#%_ and _%#NAME#%_, in neurology. If the workup continues unfruitful, one could give consideration to a central nervous system angiogram.
C4|(complement) component 4|C4|189|190|LABORATORY DATA|No evidence of malignancy noted. Electrocardiogram done on _%#MMDD2005#%_ revealed a right bundle branch block with possible premature atrial complexes with aberrancy. CRP was 1.91. C3 and C4 were evaluated and were within normal limits. ACE level was 94. Parathormone level was decreased at 4. Vitamin D level was normal. Troponin-I was less than 0.07 X 2.
C4|cervical (level) 4|C4,|384|386|HISTORY OF PRESENT ILLNESS|REQUESTING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_. REASON FOR CONSULTATION: Evaluate for rehabilitation needs. HISTORY OF PRESENT ILLNESS: This is a 52-year-old gentleman with a history of questionable/possible myasthenia gravis and he has cervical spine stenosis at C3-C4 with cervical spondylosis, status post decompressive laminectomy at C2-C3 with pedicle screw fixation of C2, C3, C4, C5 and C6 bilaterally and arthrodesis of the joints at C2-C3, C3-C4, C4-C5 and C5-C6 using autologous bone graft and DBX matrix done by Dr. _%#NAME#%_ on _%#MMDD2007#%_.
C4|(complement) component 4|C4|271|272|HISTORY OF PRESENTING ILLNESS|She currently denies joint pain of any sort. Recent relevant labs include an ANA of 3.5 which is weakly positive and antidouble-stranded DNA which is negative and anti-Smith antibody which is negative. The patient's total complement and C3 were within normal limits. Her C4 is at the lower limit of normal. RPR was negative, urinalysis was negative, creatinine was 0.7 and sedimentation rate was 58.
C4|cervical (level) 4|C4,|444|446|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 58-year-old female with a known history of COPD, alcoholic polyneuropathy, and a known history of type 2 diabetes and hypertension who was admitted to the acute rehab unit following a complex neck surgery that she had for a severe central canal stenosis at the level of C4-5 that was performed on _%#MMDD2006#%_. The surgery included C4-5 carpectomies with a decompression of the spinal cord and bilateral C4, C5, and C6 nerves and C3 to C7 anterior spinal fusion and instrumentation and fibular allograft and local allograft procedure.
C4|cervical (level) 4|C4,|214|216|ASSESSMENT|ASSESSMENT: 1. Chronic obstructive pulmonary disease. 2. Alcohol-induced polyneuropathy. 3. History of severe central canal stenosis status post C4-5 carpectomy with decompression of the spinal cord with bilateral C4, C5, and C6 nerves of C3 to C7 anterior spinal fusion, fibular allograft, and local allograft procedures. 4. Nausea. 5. Dysphagia. 6. Gastroesophageal reflux disease. 7. Type 2 diabetes.
C4|cervical (level) 4|C4|176|177|ASSESSMENT|Left axis deviation. Normal QRS and QT intervals. No ischemic change. ASSESSMENT: There is a 59-year-old female with the following: 1. Anterior cervical decompression/effusion C4 through C7 with __________/allograft. Stable hemodynamics. Adequate pain control. 2. Chronic rhinitis (question allergic versus vasomotor) with component of rhinitis medicamentosa due to recurrent use of over-the-counter decongestant.
C4|(complement) component 4|C4|214|215|HISTORY OF PRESENT ILLNESS|Other features that were noted at that time subsequently were difficulty with cold fingers and toes (Raynaud's phenomenon), rash on her forehead (discoid lupus), and leukopenia. Her mother believes that the C3 and C4 have been doing relatively well as well as the anti-double strand DNA level. Her treatment over the years has included prednisone, Plaquenil, Imuran, Celebrex, and possibly other medications.
C4|(complement) component 4|C4,|127|129|LABORATORY DATA|The ALT is also mildly elevated at 49 with a cutoff of 35. INR is normal at 1.1 and PTT is normal at 33. Bilirubin is 0.3. C3, C4, and anti-double strand DNA are pending. Rapid Strep and mono strain are negative. Blood culture, urine culture, and CMV screening are pending.
C4|(complement) component 4|C4,|255|257|RECOMMENDATIONS|6. Recent MSSA (methicillin-susceptible Staphylococcus aureus) staph right arm infection, treated with Vancomycin as an outpatient. Most recent level noted to be 50. RECOMMENDATIONS: 1. Await serologies and blood cultures including as noted complement C3 C4, cryoglobulins, hepatitis C. 2. Await renal ultrasound to rule out obstruction. Evaluate size and asymmetry which should be unremarkable in this setting.
C4|cervical (level) 4|C4|163|164|CLINICAL IMPRESSION|2. Question history of fast heart rate in the past, no documented cardiac disease. 3. Respiratory failure/pneumonia. 4. ?History of hypertension. 5. Quadriplegia, C4 accident in 1994. 6. Pelvic Schwannoma. 7. Hypoalbuminemia. 8. History of gastroesophageal reflux disease. 9. History of depression. DISCUSSION: The patient's two monitor strips that appear to show a flutter-like rhythm, show a very rapid flutter rhythm at a rate of 400-500, which is much faster than expected atrial flutter.
C4|(complement) component 4|C4|235|236|LABORATORY|LABORATORY: Laboratory data of interest from _%#CITY#%_ _%#CITY#%_ shows a positive FANA in a 1:1280 titer in a nucleolar pattern. Antinative DNA antibodies were negative as was the rheumatoid factor. Sedimentation rate was 10. C3 and C4 complements were normal. Hepatitis A, B and C were negative. The lumbar puncture showed 4 red cells, 1 white cell, protein of 48 and a glucose of 52.
C4|cervical (level) 4|C4|190|191|HPI|She had oophorectomy and has been on Tamoxifen since 2000. Presented with neck pain and right arm weakness after a carnival ride and found to have mets to cervical spine, epidural mass, and C4 fracture. Exam: Neck with stabilizing collar. Right arm weakness, especially upper arm.
C4|cervical (level) 4|C4,|144|146|HISTORY OF PRESENT ILLNESS|Dr. _%#NAME#%_'s work up revealed significant cervical cord compression related to degeneration of C4-5 with retropulsion of C5 with respect to C4, and compression into the C4 vertebral body. Dr. _%#NAME#%_ elected to undergo surgery. He was admitted to Fairview-University Medical Center on _%#MMDD2005#%_.
C4|cervical (level) 4|C4|173|174|HISTORY OF PRESENT ILLNESS|Dr. _%#NAME#%_'s work up revealed significant cervical cord compression related to degeneration of C4-5 with retropulsion of C5 with respect to C4, and compression into the C4 vertebral body. Dr. _%#NAME#%_ elected to undergo surgery. He was admitted to Fairview-University Medical Center on _%#MMDD2005#%_. He underwent C4-5 corpectomy and C3-6 fusion. Postoperatively, he was stable.
C4|cervical (level) 4|C4|251|252|RECOMMENDATIONS|Conditioning for this protocol includes chemotherapy and total body irradiation given in 8 fractions over 4 days, for a total dose of 1200 cGy. Upon reviewing previous radiation records, we were concerned that the dose per fraction was 350 cGy to the C4 to T3 spine. On further review of additional radiation records from _%#CITY#%_, we feel that the 1200Y cGy total body irradiation should be tolerable in combination with the previous radiation, taking into account the fraction size.
C4|cervical (level) 4|C4,|328|330|LABORATORY DATA|WBC is 4.4 with 9.0 hemoglobin, 116,000 platelets and 84% polys, albumin 3, alkaline phosphatase is elevated at 536 and AST is elevated at 125 with other liver function tests normal. A right lower extremity x-ray is unremarkable. An MRI scan of the thoracic and lumbar spines last month showed significant loss of height in the C4, C5 and C7 regions due to tumor with insignificant spinal canal stenosis and no cord compression with lesions in T4 and T9, again with no cord compres sion seen.
C4|(complement) component 4|C4|197|198|HISTORY OF PRESENT ILLNESS|His evaluation to date for autoimmune conditions has shown a negative ANCA, negative FANA, negative anti-ENA, negative antidouble stranded DNA. His initial C3 at Children's was in the 60s, but his C4 was normal. His total IgG initially was 204 and has not been repeated. He has a preexisting history of frequent infections when younger, but it is now known whether he has had a low IgG previously.
C4|(complement) component 4|C4|294|295|RECOMMENDATIONS|Typically in SLE, this number will come up over time with adequate immunosuppression, but sometimes we have had to temporarily give them intravenous IG because they are so profoundly hypogammaglobulinemic and they are having infectious problems. 5. I would continue to periodically recheck C3, C4 and his ENA screen and recheck his ferritin (although systemic onset JRA seems unlikely). 6. Further evaluation of his heart (if not already done) including echocardiogram, looking for valvular lesions typical of lupus may be helpful.
C4|(complement) component 4|C4.|429|431|HISTORY OF PRESENT ILLNESS|While on steroids she developed pneumonia leading to diagnosis of pleural and parenchymal lung disease, and has subsequently manifested focal segmental glomerulonephritis (and hematuria first noted in _%#MM2006#%_, biopsy completed this week), inflammatory eye disease (followed by Dr. _%#NAME#%_ _%#NAME#%_) and has been found to have a lupus inhibitor, high titer ANA, high titer double strand DNA antibody, and low C3 and low C4. There have been some problems with followup and therefore, her final workup seems to be coming together, mainly on this admission.
C4|(complement) component 4|C4|125|126|LABORATORY TESTS|Glucose 113, BUN 18, and creatinine of 1.01 with a calcium of 8.9. CRP 67.2 and ESR 59. Compliment C3 was 105 and compliment C4 was 20. The patient had a double stranded DNA done on _%#MMDD2006#%_, which was negative. The patient also ANA on _%#MMDD2006#%_, which was weakly positive with a value of 1.7 and 1.4.
C4|cervical (level) 4|C4,|174|176|HISTORY OF PRESENT ILLNESS|Further studies included an MRI of the cervical spine on _%#MMDD2005#%_ that showed a C7 compression fracture with mild central stenosis. Other lesions were also seen in her C4, C5, and T1 vertebrae. A bone scan on _%#MMDD2005#%_ again showed the C7 lesion, as well as increased uptake in the left skull and 2 left ribs.
C4|cervical (level) 4|C4|225|226|HISTORY OF PRESENT ILLNESS|REASON FOR CONSULTATION: I was consulted by Dr. _%#NAME#%_ of Orthopedic Surgery to manage the patient's chronic medical conditions. HISTORY OF PRESENT ILLNESS: This 20-year-old male with past medical history significant for C4 to C5 quadriplegia secondary to injury related to work in 2003. His past medical history is also significant for recurrent bilateral lower extremity deep venous thrombosis, recurrent urinary tract infection, and recent spinal cord surgery.
C4|cervical (level) 4|C4|211|212|HISTORY OF PRESENT ILLNESS|He has had problems with his neck and has what he calls a degenerative condition involving his cervical spine and disks. Initially this involved his C6-7 interspace, but more recently has become multilevel from C4 through 7. He has seen various physicians, including a neurologist for this condition, has received two epidural steroid injections, and received physical therapy.
C4|cervical (level) 4|C4|154|155|PHYSICAL EXAMINATION|SPINE/SKULL: Head is atraumatic. The patient has longstanding low back pain, but on palpation of the C-spine she has localized tenderness over the C5 and C4 dorsal spinous processes. The C7 nerve root exit on the left is relatively benign, but C6 and C5 are quite tender.
C4|(complement) component 4|C4|169|170|HISTORY OF PRESENT ILLNESS|According to notes I have from a phone call with Dr. _%#NAME#%_ today, there was a significantly elevated double-stranded DNA antibody measurement, A C3 of only 57, and C4 of approximately 4. She also developed trouble today with nausea and vomiting. She had some abdominal pain before but had not been vomiting.
C4|cervical (level) 4|C4|56|57|OPERATION|DISCHARGE DIAGNOSIS: Cervical radiculopathy. OPERATION: C4 through C6 anterior cervical discectomy and fusion. Followup will be in six weeks' time with AP and lateral cervical spine x- rays.
C4|cervical (level) 4|C4|130|131|PROCEDURES AND TESTS|Many of these are related to her two prior surgeries. For details she attached reports. There is a subtle cord abnormality at the C4 level of undetermined etiology. Differential is broad but could represent reaction to prior cervical stenosis. 3. Lumbar epidural steroid injection with good result. Chest x-ray with changes consistent with COPD but no pneumonia.
C4|cervical (level) 4|C4|45|46|PRINCIPAL DIAGNOSIS|PRINCIPAL DIAGNOSIS: Cervical radiculopathy, C4 through C6. SECONDARY DIAGNOSES: 1. A 4 cm left thyroid mass. 2. Resolved cardiac palpitations. 3. Nicotine addiction. 4. History of anemia. CONSULTANTS: Neurosurgery. ALLERGIES: Epidural pain injection (labor).
C4|cervical (level) 4|C4|78|79|PRE-OPERATIVE DIAGNOSIS|PRE-OPERATIVE DIAGNOSIS: Osteoarthritis and degenerative spondylolisthesis of C4 and C5. PROCEDURE: Anterior cervical discectomy and fusion C4-5, C5-6 and C6-7 with dry cortical allograft bone and Synthes plate.
C4|(complement) component 4|C4|231|232|PLAN|PLAN: 1. Fluids, electrolytes and nutrition: We will put him on a strict no-salt diet and limit his fluids to three-quarter maintenance. We will draw a BMP now and tomorrow morning to evaluate kidney function. We will obtain a C3, C4 and FANA to evaluate kidney disease classification. We will obtain a urine protein to creatinine ratio. Since he is rather edematous, we will give him a dose of Lasix 0.5 mg/kg tonight and tomorrow morning.
C4|cervical (level) 4|C4|136|137|ASSESSMENT AND PLAN|EXTREMITIES: Upper extremity strength and mobility seem relatively preserved and symmetric. Gait is not tested. ASSESSMENT AND PLAN: 1. C4 fracture. Now admitted with new fourth cervical vertebra fracture without displacement. Awaiting the neurosurgery consultation and make decisions accordingly. Certainly, at this point she represents an adequate surgical risk although at her advanced age there is some risk just for age alone.
C4|cervical (level) 4|C4|87|88|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 45-year-old white woman who presents status post C4 through C7 decompression and fusion. She has 2 medical issues, #1 is asthma which has been under good control. She reports that she is aware of her triggers and avoids them regularly.
C4|(complement) component 4|C4|185|186|LABORATORY DATA ON ADMISSION|Differential was 59% neutrophils, 24% lymphocytes, 17% monos, and 0% eosinophils. An antinuclear antibody drawn on the day prior to transfer was mildly elevated at 1.3. C3 was 146, and C4 was 30. Liver function tests were unremarkable. IMAGING: The ultrasound from Ridges Hospital showed kidneys above the normal limits of size for this age.
C4|cervical (level) 4|C4,|135|137|PHYSICAL  EXAMINATION|Station and gait: The patient felt very insecure standing up. SKULL AND SPINE: The C-spine was remarkably tender to palpation over the C4, C5, C6 and C7 dorsal spinous processes, as well as the left-sided nerve root exits/facet joints. When he flexed his neck to touch the chin to the chest, he did so without difficulty but noted a tingling sensation down the back.
CA|cancer|CA|93|94|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 72-year-old man with metastatic colon CA who is being admitted for weakness and cough. Apparently, two or three weeks ago he developed a cough and was seen twice by Dr. _%#NAME#%_, his primary care physician.
CA|cancer|CA.|179|181||The patient returns today with improved cognition. The episode may have been related to UTI or seizure disorder. The patient with anaplastic anemia, chronic ITP, and right breast CA. Had fall with left occipital subdural hematoma _%#MMDD2006#%_ subsequent transfer to acute rehab before recent cognitive changes noted above.
CA|cancer|CA.|161|163|PLAN|For the time being will treat her medically with Heparin, Nitroglycerin, beta blockers, and aspirin and monitor her troponins. 3. History of non-small cell lung CA. At this time, no obvious future chemo is planned. Her prognosis is guarded. Dr. _%#NAME#%_ or Dr. _%#NAME#%_ has been asked to see the patient while she is here.
CA|carbohydrate antigen|CA|160|161|LABS|ADL STATUS: Energy is down, but she is sleeping well, eating well, maintaining weight. LABS: Labs, bone scan and CT all show her disease to be stable, with her CA 27-29 continuing to fall to 135. CHEMO HISTORY: The patient had her last chemo in about 2001.
CA|carbohydrate antigen|CA|187|188|HISTORY|Rectovaginal shows 5 x 5-cm posterior mass of the uterus, which is smooth. Uterus is mobile. Stool: Guaiac negative. Extremities: Without clubbing, cyanosis, or edema. PREOPERATIVE LABS: CA 125 is equal to 142, drawn on _%#MM#%_ _%#DD#%_, 2005, potassium 4.0, creatinine of 0.8. Preoperative hemoglobin is 13.3. HOSPITAL COURSE: PROBLEM #1: Disease. The patient tolerated her procedure very well.
CA|cancer|CA|155|156|HISTORY OF PRESENT ILLNESS|DOB: CHIEF COMPLAINT: Dysphagia and gagging. HISTORY OF PRESENT ILLNESS: A 65-year-old unfortunate female with a history of metastatic non-small cell lung CA who presents here with an episode of gagging and dysphagia. She was recently hospitalized at Fairview Southdale for pneumomediastinum as the result of an endoscopy with esophageal balloon dilation for esophageal strictures secondary to previous radiation therapy.
CA|cancer|CA.|193|195|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Hypertension. 2. Diabetes. 3. Removal of laryngeal mass and tonsillectomy _%#MM#%_ of 2004. This was benign. 4. Prostatectomy in _%#MM#%_ of 2003 secondary to prostate CA. 5. Carpal tunnel surgery in 1982. DISCHARGE MEDICATIONS: 1. Prilosec 20 mg p.o. every day.
CA|cancer|CA.|33|35|PREADMISSION DIAGNOSIS|PREADMISSION DIAGNOSIS: Prostate CA. DISCHARGE DIAGNOSIS: Same. CHIEF COMPLAINT: Prostate cancer. HISTORY OF PRESENT ILLNESS: This is a 62 year old relatively healthy gentleman who is evaluated in clinic for prostate cancer.
CA|cancer|CA.|206|208|FAMILY HISTORY|FAMILY HISTORY: Both parents deceased. Father died at 95. Mother died at the age of 71 with heart trouble. One brother obese with heart trouble. No sisters. Two sons alive and well. Wife died of pancreatic CA. OBJECTIVE: GENERAL: Very mesomorphic pleasant male, flat on his back on the ER gurney.
CA|carbohydrate antigen|CA|200|201|LABS|PAIN: Right port site is tender. LABS: Calcium is down to 7.7, and we have talked to her about that. CT scan, bone scan. Her markers have dropped quite dramatically with three cycles of Taxotere. Her CA 27-29 went from 442 down to 249. Her CEA went from 274 down to 78.6. Thus, these drugs seem to be working.
CA|cancer|CA.|146|148|FAMILY HISTORY|3. Hydrochlorothiazide 25 mg q. day. 4. Actonel 35 mg q. week. FAMILY HISTORY: Mother deceased at 94 of "old age." Father deceased at 85 of colon CA. Five sisters, one brother alive and well. Two children with diabetes and hyperlipidemia in both. No family history of allergic reaction to anesthesia or bleeding diathesis.
CA|cancer|CA,|156|158|FAMILY HISTORY|MEDICATIONS: 1. Lipitor 10 mg q. day. 2. Hydrochlorothiazide 50 mg q. day. 3. Aspirin 81 mg q. day. FAMILY HISTORY: Father deceased 86, arthritis, prostate CA, TIA. Mother deceased 43, aneurysm. Brother 59 and 64, alive and well. Sister 67, heart disease. Children, _%#NAME#%_ 39, _%#NAME#%_ 36, alive and well.
CA|cancer|CA|131|132|PAST MEDICAL HISTORY|2. Pneumonia on the left in 2001 complicated by possible empyema. He is status post thoracotomy secondary to this. 3. Left glottic CA diagnosed in _%#MM#%_ 2005 and treated in the above fashion. 4. No history of cardiac disease or diabetes.
CA|cancer|CA|276|277|HISTORY OF PRESENT ILLNESS|The patient is scheduled for direct laryngoscopy and biopsy by Dr. _%#NAME#%_ at University of Minnesota Medical Center, Fairview, on _%#MMDD2006#%_. HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old white male with a past medical history significant for squamous cell CA of the buccal mucosa, status post radiation treatment, who recently had a CAT scan and reportedly was noted to have a lesion on the vocal cord.
CA|cancer|CA|126|127|PAST MEDICAL HISTORY|SOCIAL HISTORY: She lives at home with her husband, her three children are in town. PAST MEDICAL HISTORY: Significant for: 1. CA colon, with liver mets noted in 2000, but they are now better, on a revisit, and see the dictation on Abaton dated _%#MM#%_ of this year.
CA|cancer|CA.|168|170|FAMILY HISTORY|30-pack year history of smoking and was smoking up until admission to _%#CITY#%_ on _%#MMDD2002#%_. Denies ETOH usage. FAMILY HISTORY: Positive for diabetes and breast CA. REVIEW OF SYSTEMS: As per history of present illness and as follows: General: negative with appetite increased.
CA|carbohydrate antigen|CA|128|129|DIAGNOSTIC IMPRESSION|On review there was not definite invasion. Staging tumor markers demonstrated a normal CA 125, CA 19-9 minimally elevated and a CA 27.29 elevated at 400. The patient ultimately underwent a laparoscopic biopsy of a peritoneal nodule which demonstrated metastatic mucinous adenocarcinoma.
CA|cancer|CA,|247|249|HISTORY OF PRESENT ILLNESS|He contacted his primary physician, _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD. The patient was a little bit confused when we saw him but this could have been secondary to dilaudid that was given in the ER. PAST MEDICAL HISTORY: Significant for bladder CA, chronic renal insufficiency, SLE diagnosed in 1962, ANA titer 1:640. He used to have nephrolithiasis with removal of stones. Hypertension.
CA|cancer|CA.|153|155|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1) Right mastectomy in 1995. 2) Dilation and curettage in 1999 for postmenopausal bleeding on tamoxifen. SERIOUS ILLNESSES: Breast CA. ALLERGIES: IODINE, SULFA, IBUPROFEN. HABITS: Nonsmoker, no alcohol.
CA|cancer|CA.|193|195|FAMILY HISTORY|The patient quit more than five years ago but is exposed to a significant amount of passive tobacco as her husband is a smoker. No alcohol history. FAMILY HISTORY: Mother deceased from stomach CA. MEDICATIONS: The patient's home medications are the same as those on discharge.
CA|cancer|CA|163|164|FAMILY HISTORY|PAST MEDICAL HISTORY: Gestational diabetes; blood sugar was checked at the office visit on _%#MMDD2006#%_ and was 80. FAMILY HISTORY: Her oldest sister has breast CA and had surgery eight years ago. Dad had prostate cancer and kidney cancer. SOCIAL HISTORY: She works full time for Encompass Medical Transcription and also at the Legion Hall.
CA|cancer|CA.|200|202|HOSPITAL COURSE|Bone marrow biopsy was performed for AFB and fungal as well as urine fungal antibodies, these tests are still pending at this time. Of note, the patient's history is significant for metastatic breast CA. The patient recently under treatment, though somewhat immunosuppressed. Throughout the hospitalization, the patient continued to have fevers to 102, though 36 prior hours prior to discharge the fevers disappeared and patient felt well.
CA|cancer|CA,|138|140|ASSESSMENT|Will instigate previous recommendations: DC atenolol and digoxin and begin Rythmol 150 mg p.o. t.i.d. as previously suggested. 2) Ovarian CA, status post surgery and chemotherapy. 3) Nausea and vomiting, Zofran 4 mg p.o. or IV q2h as needed.
CA|cancer|CA|135|136|HOSPITAL COURSE|At that time, he had a MRI of the thoracic spine and CAT scan of he chest, abdomen, and pelvis, and was diagnosed with metastatic bone CA from his prostate. He was seen by Radiation Oncology, Hematology-Oncology, Urology, and Physical Therapy in the hospital as well. He was started on a hormonal treatment for his metastatic cancer and pain medications.
CA|cancer|CA.|145|147|PAST MEDICAL HISTORY|I am not aware of a history of DVT or PE in the past. PAST MEDICAL HISTORY: Mr. _%#NAME#%_'s past medical history is remarkable for: 1. Prostate CA. He is status post prostatectomy several years ago. He recently was noted to have a slight elevate of PSA, which did prompt his radiation therapy.
CA|cancer|CA|120|121|PAST MEDICAL HISTORY|5. Hypothyroidism. 6. History of SVT. 7. History of right breast CA. 8. History of right upper lobectomy for small cell CA in 1996. She is disease-free. 9. History of polio involving her left leg. 10. Obesity. 11. History of multiple cerebral meningiomas, which are stable, and for which the patient is asymptomatic.
CA|cancer|CA|141|142|IMPRESSION|12) 31 pack-year history of nicotine addiction. 13) Emphysema with history of recurrent pneumonia. 14) Spinal stenosis in 1995. 15) Prostate CA post radiation therapy in 1995. 16) Hyperlipidemia with personal and positive family history of ASHD. 17) Renal insufficiency since 2000. 18) PAD. 19) Hypertension. 20) Depression, under treatment.
CA|cancer|CA.|178|180|PAST MEDICAL HISTORY|3. Left DVT after TKA. 4. Chronic urinary incontinence. 5. Osteoporosis. 6. Chronic neck and low back pain. 7. Anterior cervical discectomy, 1/05. 8. Right mastectomy, 1994, for CA. ALLERGIES: 1. Penicillin. 2. Iodine. 3. Sulfa. 4. Lactulose. The patient had zoster in _%#MM#%_ 2005.
CA|cancer|CA|109|110|HOSPITAL COURSE|The patient is to follow up with Dr. _%#NAME#%_ from oncology in 3 weeks. HOSPITAL COURSE: 1. Adenocarcinoma CA of the colon. The patient presented with anemia, fatigue and weight loss. He had an initial hemoglobin of 7.1. The patient's hemoglobin was 14.6 in _%#MM#%_ 2006.
CA|cancer|CA.|148|150|DATE OF DISCHARGE|The patient also had difficulties voiding during hospital stay and had to be intermittently catheterized. The patient does have history of prostate CA. The patient was discharged on postop day #4 to subacute rehab. MEDICATIONS: Flomax 0.4 mg p.o. once daily. FOLLOWUP: In addition to seeing his PCP for suture removal in 7 to 10 days, he is also to see his PCP for his symptoms of urinary retention.
CA|cancer|CA|110|111||He has had a persistent cough with some phlegm. He was diagnosed with pneumonia. He has had a history of lung CA with a lobectomy and radiation, COPD, GERD. He has not used tobacco for 12 years. He is on Advair and albuterol at home so he was worked up for pneumonia being treated with IV Levaquin.
CA|carbohydrate antigen|CA|148|149|HISTORY OF PRESENT ILLNESS|The suboptimal cytoreduction was secondary to a mesenteric lymph node as well as left groin node of approximately 2 cm. At that time, the patient's CA 125 was 2070. The patient underwent 6 courses of Taxol and carboplatin with a decrease in her CA 125 to 30. In _%#MM#%_ 2002, the patient was begun on consolidation therapy with weekly Taxol with a plan for 12.
CA|cancer|CA|288|289|PAST MEDICAL HISTORY|No bloody or black stools. PAST MEDICAL HISTORY: 1. ASCVD with dilated cardiomyopathy and EF of 25% in the past, although better as noted on recent echo and critical aortic stenosis. Prior angiogram was done in 1997. 2. Hiatal hernia. 3. Colonic polyps, but last scope as noted above. 4. CA of the breast with mastectomy in 1960. 5. Bilateral oophorectomy and appendectomy in the 1960s. 6. T&A in 1999. MEDICATIONS: 1. Coreg 12.5 b.i.d. 2. Imdur 30 a day.
CA|cancer|CA|190|191|FAMILY HISTORY|No medical allergies. 2. EGD and colonoscopy in _%#MM2003#%_. Negative except for Barrett's esophagus. FAMILY HISTORY: Mother had a myocardial infarction in her 70's. Sibling with laryngeal CA at age 48. Father died of cancer of the jaw and alcoholism. SOCIAL HISTORY: He is married. He is a retired insulator.
CA|cancer|CA,|172|174|HOSPITAL COURSE|HOSPITAL COURSE: The patient was admitted for right pleural effusion and increasing shortness of breath. Dr. _%#NAME#%_ was consulted due to history of non small-cell lung CA, with poor prognosis. The patient improved with administration of oxygen, Lasix to decrease pleural effusions, and nebulizer treatments p.r.n. for shortness of breath.
CA|cancer|CA|188|189|HISTORY OF PRESENT ILLNESS|DOB: _%#MMDD1919#%_ CHIEF COMPLAINT: Nausea, vomiting, anemia. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 85-year-old female with history of chronic anemia as well as bladder CA diagnosed in 1992. She presents here with nausea and vomiting. She was seen by her primary MD, Dr. _%#NAME#%_ this past Wednesday and was noted to be anemic with hemoglobins in the 7s.
CA|carbohydrate antigen|CA|300|301|HOSPITAL COURSE|6. Call if increased pain or fever over 101. HOSPITAL COURSE: PROBLEM #1: The patient was admitted with abdominal pain, and was found to have a 14 cm right liver mass on CT of the abdomen. CT- guided liver biopsy was performed and showed pathology consistent with her prior history of breast cancer. CA 27.29 was elevated at 73. AFP was normal at 4.2. Additionally, she had a CT of the chest, which showed either motion defect or possible filling defects in some pulmonary arteries, but lower extremity Dopplers were negative, so this was felt to be artifact.
CA|cancer|CA.|333|335||Mr. _%#NAME#%_ _%#NAME#%_ is a 69-year-old gentleman who was admitted to Fairview Southdale Hospital on _%#MMDD2007#%_ with atrial fibrillation and rapid ventricular response, congestive heart failure, and severe aortic stenosis with aortic insufficiency, history of high blood pressure, hypercholesterolemia and history of prostate CA. Cardiology treated patient for his atrial fib controlling his rate down into the 80s and diuresed him significantly. Dr. _%#NAME#%_ _%#NAME#%_ was then consulted for aortic valve replacement.
CA|cancer|CA|123|124|FAMILY HISTORY|10. Coreg 6.25 mg b.i.d. 11. Iron sulfate 27 mg twice a day. ALLERGIES: No known drug allergies. FAMILY HISTORY: Laryngeal CA and rheumatoid arthritis. SOCIAL HISTORY: No tobacco. No alcohol. No drug use. She is a retired worker from Dayton's.
CA|cancer|CA|174|175|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: The past medical history includes a 1984 transverse colectomy for colon cancer with a colostomy which was later taken down. She is also post basal cell CA resections of face, leg, and back. She is hypothyroid and has had a seizure disorder since 65 years old. PHYSICAL EXAMINATION: Temperature 101 degrees, but she pulled it out quickly.
CA|cancer|CA,|128|130|PAST MEDICAL HISTORY|However, this episode is more severe. PAST MEDICAL HISTORY: 1. COPD with FEV-1 of 43% in 2001. 2. Stage 1A, non-small cell lung CA, status post radiation therapy, status post chemotherapy with Taxotere time three cycles. 3. Essential hypertension. 4. Adult onset diabetes . SOCIAL HISTORY: The patient has been smoking for at least fifty years.
CA|cancer|CA,|160|162|HOSPITAL COURSE|_%#NAME#%_ _%#NAME#%_ is a 75-year-old male with known history of severe emphysematous COPD as well as status post treatment for left upper lobe non-small cell CA, status post radiation therapy and chemotherapy. This past Saturday the patient developed upper respiratory tract infectious symptoms with stuffy nose, relatively clear drainage and increased shortness of breath.
CA|cancer|CA|184|185|HISTORY OF PRESENT ILLNESS|She underwent colonoscopy by Dr. _%#NAME#%_, who was unable to complete the procedure because of inability to pass the colonoscope to through the lumen due to extrinsic compression. A CA 125 was also elevated. A fine-needle aspiration of the omentum performed on _%#MMDD2004#%_ was consistent with adenocarcinoma. The patient presented to Parker- Hughes Cancer Center on _%#MMDD2004#%_.
CA|cancer|CA,|216|218|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ was admitted to the hospital for the management of subacute upper back and chest pain felt secondary to recent compression fracture. Because of her history of metastatic breast CA, a bone scan was obtained. This revealed uptake primarily in the upper thoracic area, most consistent with a nonmetastatic process.
CA|cancer|CA|137|138|DISCHARGE DIAGNOSIS|3. Status post aortic valve replacement. 4. Right bundle branch block. 5. Hypothyroidism. 6. History of CA of the bladder. 7. History of CA of the prostate.
CA|cancer|CA.|137|139|FAMILY HISTORY|Father deceased, 82. Brother deceased, 72, heart disease, diabetes, ETOH, renal failure. Sister, 76, alive and well. Sister, 65, thyroid CA. Daughters 48, 47, 42, all alive and well. SOCIAL HISTORY: Grew up in _%#CITY#%_ _%#CITY#%_, husband is a retired NWA pilot.
CA|California|CA|161|162|SOCIAL HISTORY|Maternal grandmother also had a contrast allergy manifest as laryngeal edema. SOCIAL HISTORY: Patient is an only child and lives with her parents in _%#CITY#%_, CA (near _%#CITY#%_). Dad's name is _%#NAME#%_, and he works as a help desk manager/IT governance. Her mother, _%#NAME#%_, is currently a stay-at-home mom; she previously worked in graphic design.
CA|cancer|CA|378|379|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 52-year-old pleasant Caucasian lady who was in a good state of health until _%#MM#%_ of 1999 when she presented with symptoms of dysuria and later on with shortness of breath with exertion. Evaluation at that point was of large pleural effusion on chest x-ray. Pleurocentesis was completed, and cytology showed metastatic ovarian CA as per patient's description. In _%#MM#%_ of 1999, she completed total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and appendix removal.
CA|cancer|CA.|189|191|HOSPITAL COURSE|The patient is incontinent from his previous surgery. The patient is taking up to 12 pills of Lomotil every day, and is still having diarrhea. HOSPITAL COURSE: PROBLEM #1: Metastatic colon CA. The patient is taking Avastin. The patient has been told that hospice may be viable option. The patient currently refuses hospice, and wishes to remain at home.
CA|carbohydrate antigen|CA|152|153|SUMMARY|He was found to have an abnormal CAT scan with liver masses. His workup included colonoscopy, which showed an abnormal mass consistent with malignancy. CA and PSA levels were pending. He had CT scan of the abdomen and pelvis, and those are pending as well. He was seen by a general surgeon and planned to have exploration and surgery next week.
CA|cancer|CA.|182|184|ADMITTING HISTORY AND PHYSICAL|ADMITTING HISTORY AND PHYSICAL: Please see course to date dictation dated _%#MM#%_ _%#DD#%_, 2004. Interval: Patient is a 31 year old with stage IVB, grade 3, metastatic endometrial CA. She is currently on a phase 1 study with a continuous infusion of Taxotere. Patient was seen by Dr. _%#NAME#%_ _%#MM#%_ _%#DD#%_, 2004. At that time, patient had shortness of breath and increasing pain.
CA|cancer|CA.|138|140|PROBLEM #1|Remainder of hospital course will be discussed in a systems-based manner. PROBLEM #1: Disease. Stage IVB, metastatic, grade 3 endometrial CA. This is progressive. Patient is currently on a phase 1 study for salvage therapy on continuous infusion of Taxotere.
CA|cancer|CA|279|280|HOSPITAL COURSE|HOSPITAL COURSE: 1. Acute hypoxia and respiratory failure. He presents here with progressive weakness, shortness of breath and productive phlegm as well as hemoptysis. He denies any sick contacts or travel. He has a history significant for stage 4 metastatic non small cell lung CA and underwent the first dose of his second cycle of chemo just one week prior to this presentation. His breathing had gotten progressively worse over the day and came in for evaluation.
CA|cancer|CA|215|216|FAMILY HISTORY|9. Calcium. 10. Vitamin D. 11. Humalog insulin and Humulin N insulin regimen per Dr. _%#NAME#%_. FAMILY HISTORY: Negative for allergic reaction to anesthesia or bleeding diathesis. Father deceased at 75 of prostate CA and parkinsonism. Mother, 88, hip osteoarthritis. Sister, 63, breast CA. Sister, 65, alive and well. Sister, 67, alive and well. Brother, 56, alive and well. Son, _%#NAME#%_ (31), with diabetes.
CA|cancer|CA.|142|144|PAST MEDICAL HISTORY|3. Thyroidectomy for previous thyroid CA. 4. Tubal sterilization. 5. Nasal surgery. 6. T&A. 7. Wisdom teeth. PAST MEDICAL HISTORY: 1. Thyroid CA. 2. One abnormal Pap smear and the repeat was normal. No atypia since that time. 3. Mammogram and colon cancer screening are up-to-date.
CA|cancer|CA,|187|189|FAMILY HISTORY|FAMILY HISTORY: Negative for allergic reactions to anesthesia or bleeding diathesis. Mother deceased 81 of hypertension, post-hip fracture complications. Father deceased 72 of pancreatic CA, MI at 55. Brother age 62, alive and well. Brother 55, brain aneurysm, doing well. Brother age 52, alive and well. Sister 45 alive and well.
CA|cancer|CA|207|208|HOSPITAL COURSE|_%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 60-year-old woman admitted _%#MMDD2007#%_ by Dr. _%#NAME#%_ _%#NAME#%_ with shortness of breath and cough. She was diagnosed in early _%#MM#%_ 2007 with small cell lung CA and has extensive bilateral disease and mediastinal adenopathy and has been enrolled in a clinical trial for chemotherapy. She was admitted due to progressive dyspnea, fatigue and cough of 2-3 days' duration, with very poor appetite.
CA|carbohydrate antigen|CA|121|122|LABORATORY|PSYCHIATRIC: Good memory, orientation and affect. LABORATORY: Hemoglobin 10.2, white count 5200, platelet count 114,000. CA 125 level is 389, down from last month. PLAN: The patient will be admitted to the hospital for chemotherapy, returning to my office in approximately three weeks.
CA|cancer|CA.|53|55|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Stage IIIC, grade 3 endometrial CA. DISCHARGE DIAGNOSIS: Stage IIIC, grade 3 endometrial CA. HISTORY OF PRESENT ILLNESS: This is a 49-year-old female who was diagnosed in _%#MM#%_ of 2003 with a lower extremity DVT.
CA|cancer|CA,|215|217|CHIEF COMPLAINT|DOB: _%#MMDD1960#%_ She is scheduled for laparoscopic assisted vaginal hysterectomy and bilateral salpingo-oophorectomy at Fairview Ridges Hospital on _%#MMDD2005#%_ at 10:15 a.m. CHIEF COMPLAINT: History of breast CA, strong family history of breast and ovarian CA, genetics testing positive. The patient requests to proceed with prophylactic bilateral salpingo-oophorectomy and hysterectomy.
CA|cancer|CA|119|120|ADMISSION DIAGNOSIS|REVISION DATE: R/_%#MMDD2006#%_ ADMISSION DIAGNOSIS: This is a 59-year-old women with a history of diabetes and breast CA with concurrent chemotherapy, who presented with typical chest pain with pressure radiating to the left shoulder and arm. The EKG was nondiagnostic, and had some Q-wave blunting on the precordial leads.
CA|carbohydrate antigen|CA|155|156|MAJOR PROCEDURES|2. CT scan of abdomen on _%#MMDD#%_: Moderately enhancing lesions, largest 12.3 x 7.9 cm in the inferior aspect of the liver. Tumor markers are following: CA 19-9 161,000, CEA 432, CA-125 8600 and alfa-fetoprotein 2.4. Echocardiogram on _%#MMDD#%_ showed normal left ventricle in size and/or thickness and ejection fraction was estimated at 55%.
CA|cancer|CA,|170|172|PAST MEDICAL HISTORY|3. Peptic ulcer disease 1970, details unknown. 4. Hyperlipidemia. 5. Repeated pneumonias 1997, 1999, 2005 and 2006. 6. Hypertension. 7. Osteopenia. 8. Nonsmall cell lung CA, stage I. 2 cm. lymph node resected at that time was negative. The patient entered a CCOP 9. COPD 2.5 liters nasal cannula O2 use chronically.
CA|cancer|CA.|113|115|PAST MEDICAL HISTORY|2. Tonsillectomy. 3. Bilateral cataract surgeries. Medical illnesses: 1. Hypothyroidism, treated. 2. Left breast CA. 3. Past history of pneumonias. ALLERGIES: She has allergies to codeine and Demerol.
CA|cancer|CA,|141|143|FAMILY HISTORY|3. Nexium 40 mg p.o. q. day. 4. Baby aspirin per day. ALLERGIES: MORPHINE GIVES HIM DELUSIONS. FAMILY HISTORY: Significant for CAD, prostate CA, and gallbladder disease. SOCIAL HISTORY: The patient denies any tobacco abuse, he drinks 3- 4 glasses of wine per week.
CA|carbohydrate antigen|CA|240|241|HOSPITAL COURSE|Gynecologic exam shows normal-appearing external genitalia and atrophic vagina. Bimanual exam shows no masses but diffuse fullness. Rectal exam shows no masses. HOSPITAL COURSE: 1. Disease: Based on the results of the CT scan and patient's CA 125 which is elevated, we are suspicious of a malignancy. However, given her acute superior mesenteric and portal vein thromboses requiring anticoagulation, the patient is not safe to undergo surgery at this time.
CA|carbohydrate antigen|CA|194|195|HISTORY OF PRESENT ILLNESS|She was having some weight loss and anorexia. She had evidence of progression of her disease. She was found to be HER- 2/neu negative and was placed on Navelbine starting in _%#MM#%_ of 2003. A CA 27-29 seemed to decrease suggesting an improvement and she then went down to Arizona and was on a drug holiday. By _%#MM#%_ of 2003 her marker level had increased and nodules had been noted covering her torso anteriorly, particularly in the chest wall area.
CA|cancer|CA.|220|222|HOSPITAL COURSE|On _%#MM#%_ _%#DD#%_, 2004, extensive family meeting was held by myself with the patient and the patient's whole family. Close evaluation was noted towards the medical aspects at this present time: 1. Metastatic gastric CA. 2. Right lower lobe pneumonia. 3. Poor nutrition. In the setting of metastatic disease the patient and the patient's family understood that only palliative treatment can prolong life for a minimal amount of time.
CA|cancer|CA.|220|222|HOSPITAL COURSE|After the intracranial procedure, her nausea improved considerably, however, the patient continued to use scheduled Zofran. She had 30% to 40% oral intake and continued on TPN throughout the hospital stay. 4. Metastatic CA. The patient has a breast CA with metastatic disease intraabdominally and intracranially. She is on Doxil monthly chemotherapy. She is going to go on with the plan as per Dr. _%#NAME#%_.
CA|carbohydrate antigen|CA|117|118|HISTORY OF PRESENT ILLNESS|The patient did have a weight gain over the last year and did complain of bloating and early satiety. She did have a CA 125 drawn at an outside institution. The patient presents to the operating room on the morning of _%#MM#%_ _%#DD#%_, 2006, for evaluation and removal of this pelvic mass.
CA|cancer|CA|88|89||Patient admitted to acute rehab _%#MDMD2006#%_. An 81-year-old woman with squamous call CA of the right lung, receiving chemotherapy and radiation, complaining of right shoulder pain. An MRI performed: Found to have an apical tumor of the chest with impingement of the vertebral column, collapse of T2 vertebral body, some moderate involvement of T5, slight collapse of discs and subluxation.
CA|carbohydrate antigen|CA|215|216|HISTORY OF PRESENT ILLNESS|Ultrasound done in the emergency room felt that there was significant intrahepatic as well as extrahepatic biliary ductal dilatation from a pancreatic mass. When he was admitted, the tumor marker was looked and the CA 19-9 level was within normal limits. It was decided to do a MRI with MRCP which showed a massively enlarged gallbladder, multiple gallstones, intra and extrahepatic biliary dilatation with probable obstruction at the level of the common bile duct.
CA|cancer|CA,|112|114|PLAN|At this point Vivian is not capable of adding to the discussion. Other medical problems include: 1. Endometrial CA, which is stable. 2. Hypertension. Her blood pressure is elevated, likely secondary to pain. Her blood pressure will be monitored postoperatively.
CA|cancer|CA,|470|472|PAST MEDICAL HISTORY|HOME MEDICATIONS: Include Advair 100/50 one puff twice daily, Atrovent 2 puffs twice daily, diltiazem extended release 240 mg p.o. once daily, calcium 1000 mg p.o. once daily, multivitamin, garlic and Vicodin p.r.n. as needed. PAST MEDICAL HISTORY: Paroxysmal atrial fibrillation, COPD with cor pulmonale, had home O2, which she used at night time, osteoporosis with left spine fractures, history of breast CA, stage I, status post right lumpectomy in 2002, had XRT for CA, denied hormonal therapy. REVIEW OF SYSTEMS: Positive for shortness of breath on exertion and productive cough.
CA|cancer|CA.|108|110|FAMILY HISTORY|Her mother had breast cancer diagnosed about 30 years ago; she is alive at age 74. She also has had bladder CA. PAST MEDICAL HISTORY: 1. Rectosigmoid colon cancer diagnosed this summer, status post resection of the primary sigmoid lesion in _%#MM2004#%_ and subsequent partial hepatectomy in _%#MM2004#%_ with hepatic artery pump placement.
CA|cancer|CA|175|176|PAST MEDICAL HISTORY|2. Increased blood pressure. 3. Peripheral vascular disease, status post correction of his aortic aneurysm. 4. Diabetes mellitus. 5. Radiation proctitis. 6. GERD symptoms. 7. CA or prostate with radiation therapy. 8. Chronic renal failure. 9. History of appendectomy, cholecystectomy, AAA repaired. 10. History of DVT and TIA.
CA|carbohydrate antigen|CA|140|141|LABS|PSYCHIATRIC: Negative. PAIN: She has some achiness with Neupogen. PAIN MANAGEMENT: Ibuprofen does not work real well. LABS: Her CEA and her CA 27-29 have increased fairly dramatically, basically doubling. The CEA was 106, and now is 203. CA 27-29 was 250, and now is 347. SOCIAL/FAMILY HISTORY: No change. CHEMO & RADIATION THERAPY HISTORY: She has been on Gemzar.
CA|cancer|CA.|231|233|IMPRESSION|Ethanol level is less than 0.01. Urine is unremarkable. Her specific gravity was greater than 1.030. IMPRESSION: 1. Hyponatremia, most likely is secondary to likely her hydrochlorothiazide, triamterene and possibly SIADH, rule out CA. We will get a urine and serum osmolality, urine sodium. Try and restrict fluids and since her sodium did not change significantly with normal saline infusion, we will go ahead and change it to 3% saline and monitor her sodium very closely.
CA|cancer|CA|186|187|HISTORY OF PRESENT ILLNESS|She reports multiple family members have had similar symptoms in the last few weeks, including her husband and daughter. She has had a complicated recent history with nonsmall cell lung CA diagnosed in _%#MM2006#%_, post-chemo x2, discontinued due to intolerance and completed radiation therapy. She moved here from _%#CITY#%_, Florida in the last 2 months and has been followed with Dr. _%#NAME#%_.
CA|cancer|CA|177|178|ASSESSMENT AND PLAN|There is no peripheral edema. Pulses are intact. There is no open areas on his extremities. His grip strength is symmetrically weak. ASSESSMENT AND PLAN: 1. Large nonsmall cell CA of the lung with a mass measuring approximately 10 cm on last imaging study in the right lung fields. He currently is receiving daily radiation treatment. He has followup scheduled with Dr. _%#NAME#%_ and will continue with radiation to Fairview Southdale after transfer.
CA|carbohydrate antigen|CA|220|221|SUBJECTIVE|The patient indicates in the last 4-5 days he has had slight discomfort in the right upper abdomen. He has had no change in bowel habits. No dark stool, blood, evidence of anemia, abnormal liver function tests, etc. His CA antigen is pending at the time of this dictation. The patient was seen for routine physical examination on _%#MMDD2007#%_ at which time I requested that he have follow up colonostomy, apparently he had a colon polyp removed _%#MM2003#%_ and was to have return for follow up to Dr. _%#NAME#%_ _%#NAME#%_, this was a tubulovillous adenoma.
CA|cancer|CA|171|172|ASSESSMENT AND PLAN|There is no peripheral edema. Pulses are intact. There is no open areas on his extremities. His grip strength is symmetrically weak. ASSESSMENT AND PLAN: 1. Nonsmall cell CA of the lung with a mass measuring approximately 10 cm on last imaging study in the right lung fields. He currently is receiving daily radiation treatment. He has followup scheduled with Dr. _%#NAME#%_ and will continue with radiation to Fairview Southdale after transfer.
CA|UNSURED SENSE|CA|152|153|HISTORY OF PRESENT ILLNESS|He had 1 previous treatment for cocaine dependence as a few years ago at the Beacon Program associated with the Salvation Army. He was active in NA and CA subsequently and has stayed off cocaine since. He has never had an alcohol problem. His last use was greater than 24 hours ago, and he is having moderate withdrawal symptoms of stomach cramps, leg cramps, aches, chills and coryza.
CA|carbohydrate antigen|CA|189|190|HISTORY OF PRESENT ILLNESS|She has had a very good clinical response to treatment. HOSPITAL COURSE: 1. Metastatic breast cancer. The patient was maintained on Arimidex throughout the hospitalization. Her most recent CA 27.29 level was 256. This is down from her pretreatment level of 1386. 2. Dilated cardiomyopathy with congestive heart failure. 3. Atypical noncardiac chest pain.
CA|carbohydrate antigen|CA|78|79|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: 1. History of breast cancer. 2. Pelvic mass. 3. Elevated CA 125. 4. Also, past medical history significant for hypertension and osteopenia. DISCHARGE DIAGNOSIS: 1. History of breast cancer. 2. Pelvic mass.
CA|cancer|CA|184|185|PAST MEDICAL HISTORY|7. Retinal stroke in 2002. 8. Entropion repair. 9. Cataract repair. 10. Peripheral vascular disease. 11. Negative stress test 2001. 12. Ischemic colitis in 1996. 13. Hypertension. 14. CA of prostate with prior radiation. 15. GI bleed due to aspirin in 1992. 16. Laminectomy 1995. 17. Carotid endarterectomy. MEDICATIONS: 1. Singulair 10 mg a day.
CA|cancer|CA|217|218|HOSPITAL COURSE|She will follow up with her primary care physician, Dr. _%#NAME#%_, on _%#MM#%_ _%#DD#%_, 2006, Dr. _%#NAME#%_ of Cardiology on _%#MM#%_ _%#DD#%_, 2006, Dr. _%#NAME#%_ at the Women's Health Center for her endometrial CA on _%#MM#%_ _%#DD#%_, 2006. The patient also will follow up in the Stroke Clinic in 1 month. She was given the Stroke Clinic phone number to call and arrange her own appointment.
CA|carbohydrate antigen|CA|176|177|HOSPITAL COURSE|A retroperitoneal mass and multiple liver densities were found as described above. GI consults recommended multiple labs and biopsy. The alphafetoprotein was elevated at 15.5, CA 19-9 elevated at 866 and CEA normal 1.1. LFTs remained elevated throughout his admission. His INR was found to be elevated at 2.54 several days into admission.
CA|cancer|CA|169|170|IMPRESSION|2. Chronic left pneumonitis secondary to underlying lung CA. The patient's chest x-ray shows continued extensive infiltrates. Whether this is due to his underlying lung CA versus an active infiltrate is unknown. He has relatively few symptoms of pneumonia, but given his recent chemo, his dyspnea and his elevated white count, I think it is prudent to treat him empirically with Zosyn and azithromycin.
CA|cancer|CA|246|247|PAST MEDICAL HISTORY|No real association with food and he denies any significant change in his bowel habits. He denies chronic constipation. PAST MEDICAL HISTORY: Includes coronary disease with CABG in 2001, hypertension, hypercholesterolemia and metastatic prostate CA presumed to be in remission in summer of last year. PAST SURGICAL HISTORY: Status post chole and CABG.
CA|carbohydrate antigen|CA|155|156|HISTORY OF PRESENT ILLNESS AND BRIEF HOSPITAL COURSE|She was recently discharged from Medicine Service after she was initiated on hemodialysis. She was getting CT for followup of endometrial cancer since her CA level was high in the clinic. She went for the CT scan on _%#MMDD2006#%_ and started having chills while getting a CT abdomen.
CA|carbohydrate antigen|CA|109|110|IMPRESSION AND PLAN|5. I would get an anemia panel including a haptoglobin, LDH and iron level. 6. I would check a CA, CA 27-29, CA 19-9 and consider an abdominal and pelvic CT scan for workup for weight loss. 7. I would check a troponin and echocardiogram to evaluate for any previous MI or congestive heart failure.
CA|cancer|CA|350|351|ILLNESSES|PAST MEDICAL HISTORY/HOSPITALIZATIONS/OPERATIONS: Bilateral total knee arthroplasty, right total hip arthroplasty, hysterectomy, appendectomy, cholecystectomy, colon resection for rectal fistula and diverticulitis, nephrectomy secondary to kidney cancer, sinus surgery, ear surgery. ILLNESSES: 1. Hypertension 2. Anxiety and panic disorder. 3. Renal CA 4. Renal insufficiency, post-nephrectomy 5. Chemical dependency treatment 30 years ago 6. Macular degeneration 7. Urinary stress incontinence 8. Hyperlipidemia.
CA|carbohydrate antigen|CA|353|354|IMPRESSION  AND PLAN|We will start with thrombolysing one extremity and putting the Greenfield filter in place after which we will reevaluate for thrombolytics thrombolyzing the other extremity. Furthermore, during his hospitalization, the patient will be set up to have a CT scan of the chest, abdomen and pelvis to evaluate for possible underlying malignancy as well as a CA 99 and a CEA level. Mr. _%#NAME#%_'s daughter was called and I reviewed the situation with her.
CA|carbohydrate antigen|CA|127|128|HOSPITAL COURSE|The patient had a bone marrow test performed, and this again was not conclusive. In the mean time, we had obtained an elevated CA 125 tumor marker, which we could not readily explain. Finally, the patient seemed to be somewhat more stable. An exploratory laparoscopy was performed.
CA|cancer|CA|179|180|PAST MEDICAL HISTORY|3. Diabetes mellitus type II on glyburide. 4. Hypertension on Inderal. 5. Peptic ulcer disease noted at hospitalization at Abbott in _%#MM#%_ of this year. 6. Status post uterine CA (hysterectomy). PAST SURGICAL HISTORY: Includes the hysterectomy, appendectomy, and the multiple eye surgeries as noted.
CA|cancer|CA|153|154|HISTORY OF PRESENT ILLNESS|Respiratory symptoms were increasing as well. He came in for the CT and for evaluation in the ER. CT of the chest apparently showed extensive metastatic CA as well as pneumonia. Patient was admitted for treatment of the pneumonia as well as for further work-up of the CA. PAST MEDICAL HISTORY: 1. Coronary artery bypass surgery in 1997.
CA|cancer|CA|302|303|FAMILY HISTORY|4. History of chronic headaches evaluated by neurologist, Dr. _%#NAME#%_, and is currently on medications for that - Neurontin 300 mg b.i.d. and amitriptyline 50 mg, one or two at bedtime. FAMILY HISTORY: Carriers of known oncogene. Patient states seven brothers and sisters as well as father all with CA including CA of the lung, stomach, liver and throat. Sisters with breast and uterine CA. Father with pancreatic CA. REVIEW OF SYSTEMS: Cardiac: As above. GI: History of reflux for which he takes Prevacid and constipation with a bowel movement every 2-3 days which has been a problem over the last several months.
CA|cancer|CA.|201|203|FAMILY HISTORY|FAMILY HISTORY: Carriers of known oncogene. Patient states seven brothers and sisters as well as father all with CA including CA of the lung, stomach, liver and throat. Sisters with breast and uterine CA. Father with pancreatic CA. REVIEW OF SYSTEMS: Cardiac: As above. GI: History of reflux for which he takes Prevacid and constipation with a bowel movement every 2-3 days which has been a problem over the last several months.
CA|carbohydrate antigen|CA|179|180|PAST MEDICAL HISTORY|She is currently getting chemotherapy consisting of Gemzar every two weeks in _%#CITY#%_, Minnesota. Her last dose was _%#MM#%_ _%#DD#%_, 2002. They are following serial CEAs and CA 19-9's; they are also following serial platelet counts, which have been about 140,000. She also gets occasional Procrit, and her last Procrit was in _%#MM#%_, 2002.
CA|cancer|CA|96|97|PATHOLOGY|5. Removal of left third rib. 6. Esophagogastroscopy. PATHOLOGY: . Left lung positive for adeno CA with angiolymphatic invasion as well as vascular involvement and a bronchial marginal of 0.1 cm with positive visceropleural involvement.
CA|cancer|CA,|303|305|PAST MEDICAL HISTORY|CT scan was negative. There was no loss of consciousness, developed UTI in the hospital, history of osteoporosis and admitted to rehabilitation because of max assist with ADLs, pain and limited standing. PAST MEDICAL HISTORY: Diabetes mellitus type 2, osteoporosis, ?CVA, osteoarthritis left knee, skin CA, multiple excisions, history of fall and a pelvic fracture 2 years ago, hypertension, hyperlipidemia. SOCIAL HISTORY: The patient lives alone, widow, lives in an apartment, gets intermittent help from a friend who is an RN.
CA|cancer|CA|195|196|PAST  MEDICAL HISTORY|CHIEF COMPLAINT: Mrs. _%#NAME#%_ is a 60-year-old woman with small cell lung CA, admitted with bilateral pneumonia, anemia, hypokalemia and hyponatremia. PAST MEDICAL HISTORY: 1. Small cell lung CA diagnosed in _%#MM#%_ of this year. She has been undergoing chemotherapy. Her last treatment was approximately one week ago. 2. Diabetes mellitus. 3. Recurrent hyponatremia thought to be SIADH related to problem #1.
CA|cancer|CA|170|171|ASSESSMENT|Creatinine 0.4, BUN 16, hemoglobin 7, white count 12,000. Chest x-ray shows bilateral infiltrates. ASSESSMENT: 1. Pneumonia, will treat with Levaquin. 2. Small cell lung CA with anemia. We will transfuse with 2 units packed red blood cells and have Hematology/Oncology see while she is here in the hospital.
CA|cancer|CA|207|208|PAST SURGICAL HISTORY|Atenolol 50 mg daily. ALLERGIES: No known drug allergies. PAST SURGICAL HISTORY: Vaginal hysterectomy, D&C, bilateral mastectomy, implant placement, left implant revision, liposuction, history of basal cell CA of the back. Transfusions positive in 1983. HEALTH HABITS: Smoking none. Alcohol occasional. SOCIAL HISTORY: The patient is married and works for Wooddale church.
CA|cancer|CA.|173|175|PAST MEDICAL HISTORY|The patient has extensive bronchoalveolar lung CA throughout the left lung field, and has been following at Mayo Clinic for this. PAST MEDICAL HISTORY: Bronchoalveolar lung CA. An adenocarcinoma of the lung was resected in _%#MM#%_ of 2003 for what was felt to be possible cure at time. He redeveloped an extensive left lung field infiltrative mass which has proven to be bronchoalveolar lung CA.
CA|cancer|CA.|263|265|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Bronchoalveolar lung CA. An adenocarcinoma of the lung was resected in _%#MM#%_ of 2003 for what was felt to be possible cure at time. He redeveloped an extensive left lung field infiltrative mass which has proven to be bronchoalveolar lung CA. History of prostate cancer in of 1997, following with Dr. _%#NAME#%_. Basal cell carcinomas was removed from the scalp. Hypertension.
CA|cancer|CA.|194|196|PAST MEDICAL HISTORY|3. History of third heart block, pacemaker dependent. He underwent lead changes in _%#MM#%_ 2005. See the dictation by Dr._%#NAME#%_. 4. Remote history of shingles. 5. Radical prostatectomy for CA. 6. History of glaucoma surgery. 7. History of vein stripping. 8. History of left carotid endarterectomy 1999. MEDICATIONS: 1. Toprol-XL 150 mg daily. 2. Lipitor 80 mg daily.
CA|cancer|CA.|48|50|DIAGNOSIS THIS HOSPITALIZATION|DIAGNOSIS THIS HOSPITALIZATION: Small cell lung CA. PAST MEDICAL HISTORY: 1. Remote history of smoking. 2. Parkinson's disease, currently followed by Dr. _%#NAME#%_ _%#NAME#%_ of _%#CITY#%_ Clinic of Neurology.
CA|cancer|CA|71|72|PAST MEDICAL HISTORY|There has been no evidence to date of cirrhosis. PAST MEDICAL HISTORY: CA of the tonsil with subsequent surgical excision, radiation therapy and chemotherapy, chronic alcoholism, alcoholic liver disease, hypertension, fracture of left lower extremity, hyperlipidemia, reflux esophagitis, erosive gastropathy, intermittent asthma, gastroesophageal reflux disease, depression, pneumonia, tabagism.
CA|cancer|CA|151|152|PAST MEDICAL HISTORY|3. Hypertension. 4. History of intermittent fibrillation. 5. Hyperlipidemia. 6. Borderline diabetes mellitus. 7. History of left lumpectomy for breast CA followed by radiation therapy 2004. 8. The patient's coronary artery status is not clear. She did actually start to have a coronary artery evaluation last year.
CA|cancer|CA|125|126|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: 1. Diverticular bleed. 2. Coronary artery disease. 3. Hypertension. 4. Depression 5. Hyperlipidemia. 6. CA of the prostate. _%#NAME#%_ _%#NAME#%_ is an 86-year-old white male who presented with bright red blood per rectum with excessive frequent stooling and large volumes of blood.
CA|cancer|CA.|131|133|ASSESSMENT/PLAN|He does not presently appear to be having an episode of congestive heart failure. 4. Anemia. This is likely secondary to his colon CA. We will monitor his hemoglobin and transfuse him should his hemoglobin drop below 9. 5. Ultimate disposition after meeting with oncology, a discussion will need to occur as to whether or not palliative chemotherapy should be considered and/or whether or not the patient should stop other medications with the understanding that put him at a greater risk of vascular disease.
CA|cancer|CA,|147|149|PAST MEDICAL HISTORY|She does try to approach her pain in a positive way. She is on narcotics but her dose has been stable now for a couple years. 3) History of breast CA, status post left mastectomy. 4) History of depression with suicide attempts in the past. 5) Status post cholecystectomy. At the time she did have a common duct stone with ERCP and sphincterotomy done.
CA|cancer|CA,|249|251|HOSPITAL COURSE|I would add that there were mediastinal and bilateral hilar adenopathy noted as well with the largest being 1.2 cm. A Pulmonary consultation was requested. It was suspected the patient's hypoxia was a function of underlying COPD exacerbated by lung CA, though some concern that the relatively rapid onset of marked hypoxia was a bit unusual simply from the lung masses that were noted on the CT scan.
CA|cancer|CA.|152|154|FAMILY HISTORY|3. Atenolol 50 mg qd. 4. Levaquin day 5 of 10 for asymptomatic UTI. FAMILY HISTORY: Mother deceased at 92 of "old age". Father deceased at 52, probable CA. Sister deceased at 78 of CVA. Sons 52, 49 and 34 all alive and well. SOCIAL HISTORY: She grew up in _%#CITY#%_ _%#CITY#%_, MN. She is married.
CA|carbohydrate antigen|CA|166|167|ADMISSION DIAGNOSIS|In _%#MM#%_ 2001, the patient received Doxil times 5 until _%#MM#%_ 2002. At that time, she was stopped secondary to a normal CA 125. In _%#MM#%_ 2002, a rise in the CA 125 occurred to 47. In _%#MM#%_ 2002, the patient underwent Gemzar with rise in her CA 125 to 80. In _%#MM#%_ 2002, the patient underwent weekly Taxol times 10 with the CA 125 decreased to 29.
CA|cancer|CA,|172|174|PAST MEDICAL HISTORY|She is admitted at this time for suprapubic catheter insertion. PAST MEDICAL HISTORY: Hospitalizations & operations - _%#MMDD2003#%_ excision of right lower lid basal cell CA, _%#MM2003#%_ lower extremity Staph aureus cellulitis, _%#MM2003#%_ cellulitis and MRSA urine infection, _%#MM2002#%_ left leg fracture, _%#MM2002#%_ right hip fracture and repair with chronic lymphedema subsequently, 1991 left foot neuroma excision, 1984 cholecystectomy, 1981 total hysterectomy, 1945 tonsillectomy.
CA|cancer|CA,|150|152|HISTORY OF PRESENT ILLNESS|Ms. _%#NAME#%_ is a 52-year-old female with a past medical history significant for COPD, diabetes mellitus, chronic low back pain, history of ovarian CA, and hyperlipidemia who presents with fevers, chills, and increasing nonproductive cough. The patient stated that the fever started on the evening prior to admission with a peak temperature of 102.8. The patient also complained of chills, muscle aches, and a worsening cough over the past 3 days prior to admission.
CA|cancer|CA|205|206|HOSPITAL COURSE|If pain persists notify 911. 9. ______________45 mg IM every 6 months. 10. Zoloft 100 mg one p.o. daily. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 78-year-old male with known hyperlipidemia and prostate CA who has been experiencing a 3-month history of exertional angina. He underwent a nuclear stress test which showed anterior apical ischemia with wall motion abnormalities and a decreased blood pressure in Bruce protocol stage 3.
CA|carbohydrate antigen|CA|172|173|HOSPITAL COURSE|His response to his chemo will need to be assessed prior to the third round of therapy. Also significant is the patient had hepatitis serologies, which were negative and a CA antigen elevated to 410.8. The GI Service was involved in this patient's care. Mr. _%#NAME#%_ also had significant lower extremity edema, which was thought secondary to his metastatic disease.
CA|cancer|CA|200|201|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ is a 46-year-old female with a history of stage IV colon cancer, who is currently on palliative management. The patient originally was diagnosed with colon CA in 2002. She underwent a partial colectomy as well as chemotherapy for her cancer. She then underwent palliative radiation later on complicated by a colovaginal fistula.
CA|cancer|CA|102|103|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Severe COPD for which she is on chronic O2. 2. History of nonsmall cell lung CA that was resected in 1985. 3. ASCVD, status post MI after an angioplasty in 1994. 4. Hypertension. 5. Hypothyroidism. 6. History of TIA/CVA in the past.
CA|carbohydrate antigen|CA|211|212|HOSPITAL COURSE|Esophagogastroduodenoscopy showed an inflammatory mass involving the pylorus, and biopsy was taken which showed invasive carcinoma. Dr. _%#NAME#%_ from Oncology was then consulted and recommended checking a CA, CA 19-9, along with a PET scan. CA 19-9 was elevated at 84 with the normal range being 0-37. The patient's CEA was also elevated at 4.4 with the normal range being 0 to 2.5.
CA|cancer|CA|178|179|IMPRESSION|She responded to intravenous fluids and Diltiazem. She is now back to baseline, vital signs and mental status with no obvious distress. 2. She has a history of metastatic breast CA to the central nervous system with right temporal and left frontal brain lesions, and is status post chemotherapy and full brain radiation treatment.
CA|cancer|CA|293|294|REASON FOR HOSPITALIZATION|DOB: _%#MMDD1922#%_ REASON FOR HOSPITALIZATION: A 79-year-old gentleman who was brought to the ER from TCU by his family because of increasing weakness and fatigue and because the family in general was just not happy with the care at the TCU. He recently was found to have metastatic prostate CA involving multiple areas of the skeleton, as well as large areas of liver metastases. During his recent hospitalization he did grow methicillin-resistant staph from his urine and was discharged on oral Septra.
CA|carbohydrate antigen|CA|200|201|HOSPITAL COURSE|This will be done as an outpatient. The most likely possibility is that the patient has metastatic cholangiocarcinoma. A second less likely possibility would be a recurrence of her breast cancer. Her CA 2729 was slightly elevated at 44; this is a breast cancer tumor marker. Dr. _%#NAME#%_ did not feel that chemotherapy was indicated at this time.
CA|carbohydrate antigen|CA|168|169|HISTORY & HOSPITAL COURSE|She had abdominal distention and lower abdominal pain. X-ray was significant for a small bowel obstruction. When she was admitted one week prior, one of her lab tests, CA 125, was noted to be elevated. This was rechecked and still was elevated. CT scan was obtained. The small bowel showed possible recurrence of the peritoneal carcinomatosis, and also metastatic disease to the left lobe of the liver, a 2 cm hypodense mass.
CA|carbohydrate antigen|CA|50|51|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Pelvic mass with elevated CA 125. 2. Diabetes. 3. History of myocardial infarction x 3. 4. History of coronary artery bypass graft (CABG) and stent placement.
CA|cancer|CA,|280|282|PAST MEDICAL HISTORY|She also has history of admission last _%#MM#%_ 2002 for anemia secondary to Mallory-Weiss tear requiring endoscopy and clip repair of the Mallory-Weiss tear to stop bleeding. She has history of aortic valvular stenosis, moderate significant. She also has history of right breast CA, status post mastectomy 15 years ago done at the University of Minnesota without evidence of any recurrence. CURRENT MEDICATIONS: 1. Lisinopril 10 mg daily. 2. Lexapro 10 mg daily.
CA|cancer|CA|130|131|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Acute pancreatitis. 2. Cholelithiasis. 3. Hypertension. 4. Hyperlipidemia. 5. Gastroesophageal reflux. 6. CA of the breast. 7. Adynamic ileus. _%#NAME#%_ _%#NAME#%_ is a 77-year-old white female who was admitted with acute abdominal pain lasting for approximately 24 hours associated with nausea, one episode of vomitus and excessive belching.
CA|cancer|CA,|272|274|HISTORY  OF PRESENT ILLNESS|IDENTIFICATION: _%#NAME#%_ _%#NAME#%_ sees Dr. _%#NAME#%_ _%#NAME#%_ at the Fairview Oxboro Clinic. CHIEF COMPLAINT: Back pain. HISTORY OF PRESENT ILLNESS: The patient is a pleasant 86-year-old female with multiple underlying medical problems including nonsmall cell lung CA, a probable bladder tumor as well as a recent ER visit 2 days ago for vaginal bleeding and an ultrasound which revealed a 2 cm mass within the uterine fundus.
CA|cancer|CA|155|156|BRIEF HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Abdominal pain and chest pain. BRIEF HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 46-year-old with history of metastatic breast CA to bone, lungs and liver. Status post Port-A-Cath removal on _%#MMDD2007#%_. Presented with acute onset of left-sided chest pain and left lower quadrant abdominal pain waking the patient up at around 3 a.m. The patient explains that she woke up in the middle of the night because of chest pain which was 6/10 in intensity, located in the left chest wall and left hemithorax aggravated by coughing and taking a deep breath.
CA|cancer|CA.|251|253|ASSESSMENT|This probably represents either mild underlying diverticulitis or a small bowel obstruction which is spontaneously resolving. 2. COPD appears to be well compensated at this time. 3. History of schizophrenia. 4. CAD, asymptomatic. 5. History of breast CA. PLAN: 1. Agree with Dr. _%#NAME#%_'s orders. Will advance diet and decrease IV fluids.
CA|cancer|CA|143|144|PROCDURES|3. Status post chemo-embolization of hepatic lesions. CONSULTS: Interventional Radiology. PROCDURES: Chemo-embolization of non-small-cell lung CA to hepatic lesions. BRIEF MEDICAL HISTORY: This is a 59-year-old gentleman with non-small-cell cancer with metastases to the liver, presenting for chemo- embolization of the hepatic lesions.
CA|cancer|CA,|177|179|FAMILY HISTORY|MEDICATIONS: 1) Zestril 40 mg q.d. 2) Atenolol 50 mg q.d. 3) Vitamin C. 4) Calcium. 5) Magnesium. 6) Multivites. FAMILY HISTORY: Positive for diabetes in her mother and bladder CA, positive for hypertension and CVA in her father, positive for heart disease in her brother. No family history of allergic reactions to anesthesia or bleeding diathesis.
CA|cancer|CA|131|132|PAST MEDICAL HISTORY|The pain is worse with movement. PAST MEDICAL HISTORY: Significant for tonsillectomy as a child. He also has a history of prostate CA and has radium seeds implanted in the prostate. He has a history of kidney stones. No known allergies. MEDICATIONS: Include Protonix, Citrucel, aspirin, vitamins, fluoxetine, and Flomax. REVIEW OF SYSTEMS: Negative with the exception of the HPI.
CA|cancer|CA|150|151|FAMILY HISTORY|5. Vitamin B-12, B-6, folate, calcium, vitamin D and magnesium. 6. Nitroglycerin p.r.n. (no recent use). FAMILY HISTORY: Mother deceased, 83, bladder CA and CHF. Father deceased at 41 (CVA) at 32, possibly trauma-related. Sister, 70, CABG, hyperlipidemia. Sister, 65, CABG, hyperlipidemia. Brother, 65, hypertension and pulmonary fibrosis.
CA|cancer|CA,|132|134|HISTORY OF PRESENT ILLNESS|DOB: _%#MMDD1959#%_ CHIEF COMPLAINT: GI bleed. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 44-year- old male with rectal CA, who was admitted for rectal bleed. He was seen in the emergency room with bright red blood per rectum. Of significance is, obviously, his rectal CA which he has follow up set for consultation with heme/onc.
CA|cancer|CA.|144|146|CHIEF COMPLAINT|DOB: _%#MMDD1951#%_ CHIEF COMPLAINT: History of endometrial thickening, endometrial polyp in a patient on Tamoxifen therapy for previous breast CA. HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old white female Para 2-0-0-2, husband post vasectomy, LMP of _%#MM2000#%_, status post left lumpectomy and radiation for breast malignancy who has been on Tamoxifen since that time who had had some vaginal bleeding and underwent an examination under anesthesia.
CA|cancer|CA.|39|41|ADMITTING DIAGNOSIS|ADMITTING DIAGNOSIS: Papillary thyroid CA. DISCHARGE DIAGNOSIS: Same. PROCEDURES PERFORMED DURING THIS ADMISSION: Total thyroidectomy. The patient is a 26-year-old female who presented with papillar CA by needle biopsy and was scheduled for a total thyroidectomy by Dr. _%#NAME#%_.
CA|cancer|CA,|256|258|HISTORY OF PRESENT ILLNESS|PROCEDURE: Replacement of 10-French retrograde Simploc catheters with 10-French sumps per CV Radiology on _%#MMDD2002#%_. HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old female with an extensive gynecological history, with endometrial and vaginal CA, status post pelvic exenteration in _%#MM2001#%_. She was initially admitted to the Plastic Surgery and Gynecologic Services for local excision and flap closure of a grade 4 decubitus ulcer.
CA|cancer|CA|214|215|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: He denies any abdomen pain or change in stool habits at this point or ongoing problems with GERD. GU - Denies any problems with his urination. Of course, he has been impotent since 1998 prostate CA treatment with Radon. Neuromuscular - He denies any seizure, tremor, loss of vision, motion, and sensation. Stable on his Dilantin. Cardiorespiratory - Denies any recent acute chest pain or shortness of breath.
CA|cancer|CA:|240|242|DISCHARGE DIAGNOSES|4. Status post small bowel obstruction: Neurogenic ileus. 5. Nicotine withdrawal: She has been on the nicotine patch since early _%#MM#%_, which has been decreased to 7 mg a day during her stay here. 6. Pain control secondary to metastatic CA: TLC in pain management team had been consulted. CONSULTATIONS: 1. Hematology-Oncology with Dr. _%#NAME#%_. 2. Dr. _%#NAME#%_ _%#NAME#%_, who did an excision of her metastatic CA of the right proximal tibia and a prophylactic internal fixation on _%#MMDD2002#%_.
CA|cancer|CA;|113|115|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. History of hypertension for which he is on atenolol 25 mg daily. 2. History of prostate CA; underwent radical prostatectomy several years ago without evidence of recurrence at this point. 3. Approximately one year ago patient had chest pain symptoms and was evaluated and ruled out for any coronary artery disease without evidence of disease.
CA|cancer|CA,|198|200|ASSESSMENT|On recent CT in _%#MM#%_ she had left suprahilar mass and continuous left hilar adenopathy, pulmonary nodules and liver metastases. ASSESSMENT: The patient is a 38-year-old with metastatic cervical CA, history of rectal CA. PLAN: The patient is admitted per Oncology, pain control per them.
CA|cancer|CA.|199|201|PLAN|PLAN: 1. Left hip pain. No evidence of fracture. We may need to repeat the MRI in 6 weeks to follow up on the acetabular lesion. We consider bone scan. We will start PT and OT for now. 2. Pancreatic CA. We will have Dr. _%#NAME#%_ see the patient while he is here in the hospital. 3. Disposition. I am wondering if the patient needs long-term care.
CA|carbohydrate antigen|CA|121|122|LABS|LABS: TSH is slightly above normal, but T4 is normal, and I would not change her Synthroid. Her CEA has gone up to 61.3. CA 27-29 has gone up to 152. CHEMOTHERAPY TREATMENT: She has been on Xeloda. She has previously had Navelbine x 10 cycles.
CA|cancer|CA.|138|140|DISCHARGE DIAGNOSES|I did speak with Dr. _%#NAME#%_ _%#NAME#%_ from Neurology, who said no further plasmapheresis is needed. 2. History of COPD and pulmonary CA. This is stable, and the patient does p.r.n. nebulizers in his room with set up. 3. History of inferior MI, stable. 4. Hypothyroidism. The patient is on Synthroid.
CA|cancer|CA,|149|151|HOSPITAL COURSE|Normal omentum, appendix, ovaries, and tubes. No evidence of disease, except for the left node. HOSPITAL COURSE: 1. Disease: She has stage 4 ovarian CA, status post Taxol and carboplatin x 3 for neoadjuvant chemotherapy. 2. Fluids, electrolytes, and nutrition: The patient had IV fluids on the first day postoperative.
CA|cancer|CA|118|119|IMPRESSION AND PLAN|2. _%#MMDD2004#%_ - potassium 4.0. 3. _%#MMDD2004#%_ - creatinine 0.38, BUN 9. IMPRESSION AND PLAN: 1. Non-small cell CA stage 4 of the left lung with metastasis to the L3 lumbar spine. She did have her first round of chemotherapy recently and radiation therapy, which was done _%#MMDD2004#%_.
CA|carbohydrate antigen|CA|134|135|PLAN|The patient also understands that there is a very small risk that this could represent an ovarian cancer, even though the CT scan and CA 125 levels are reassuring. Postoperative recovery was reviewed as well as six weeks of lifting restrictions, postoperatively. In addition to this, we discussed that at the time of the surgery, a tubal dye study could be done which would alleviate the need to have an outpatient hysterosalpingogram which is a somewhat painful procedure.
CA|cancer|CA,|215|217|DISCHARGE DIAGNOSES|The patient will get 2 g of calcium gluconate again this morning for the calcium of 7.3, and then we will discharge the patient with p.o. replacement to be seen in the clinic on Monday for the lab draws. For breast CA, the patient tolerated the Cytoxan given during the hospitalization very well. She did complain of some nausea and vomiting, which was taken care of with the help of Zofran.
CA|cancer|CA|242|243|PAST MEDICAL HISTORY|8. Depression. 9. Cataracts. 10. Appendectomy. 11. Tonsillectomy. 12. Fractured left humerus in the 1970s. 13. Macular degeneration. 14. Esophageal varices with hemorrhage in 1997. 15. Chronic obstructive pulmonary disease. 16. Squamous cell CA of the hand and neck in 2002. 17. Thrombocytopenia. CURRENT MEDICATIONS: 1. Spironolactone 25 mg t.i.d.
CA|carbohydrate antigen|CA|271|272|COMPLICATIONS|COMPLICATIONS: None. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 49-year-old who was diagnosed with stage IIIC papillary serous ovarian carcinoma in 2002. She has had 8 cycles of Taxol, carboplatin, and topotecan and is in the GOG 182 study. With that treatment, her CA 125 went down from 57 to 7. Approximately, 1-1/2 years later, the patient had a recurrence. Since the recurrence, she has had 8 more cycles of chemotherapy with carboplatin and Gemzar which was completed in _%#MM#%_ 2005.
CA|cancer|CA.|95|97|IMPRESSION|The patient was subsequently transferred to nursing home. IMPRESSION: 1. Metastatic esophageal CA. 2. E. coli and Enterococcus faecalis urinary tract infection. 3. Right upper lobe pneumonia. 4. Type 2 diabetes. 5. Anemia. 6. History of osteoporosis. 7. Neurogenic bladder. 8. Hyperlipidemia.
CA|cancer|CA.|162|164|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: A 75-year-old female who was admitted on _%#MMDD2005#%_ in the setting of neutropenic fever status post previous chemo for esophageal CA. HOSPITAL COURSE: Patient was admitted to Med Surge, was seen that same day by ID, started on imipenem and Vanco.
CA|cancer|CA,|190|192|PAST MEDICAL HISTORY|It was decided to admit her tele. to monitor her and obtain consultation with cardiology. PAST MEDICAL HISTORY: Significant for her cardiovascular disease, history of left metastatic breast CA, mild to moderate renal insufficiency. She is being anticoagulated because of atrial fibrillation. EXAM: Today showed that her vital signs were stable.
CA|cancer|CA.|305|307|HOSPITAL COURSE|HOSPITAL COURSE: The patient remained stable throughout hospitalization. Abdominal ultrasound revealed significant ascites and so ultrasound-guided paracentesis was performed. Cytology is still pending. However, fluid was suspicious for malignancy and CA99 was modestly elevated consistent with a gastric CA. Chest CT was done which revealed multiple bilateral pulmonary nodules with adenopathy consistent with metastatic disease as well as peritoneal free fluid with nodularity consistent with a peritoneal CA.
CA|cancer|CA|112|113|FAMILY HISTORY|He is a retired police officer. FAMILY HISTORY: Mother died at 87, father died at 93 of old age. A brother with CA of the head and neck, a sister with cancer, not sure of the type. REVIEW OF SYSTEMS: Otherwise negative. He has felt quite well.
CA|cancer|CA,|223|225|HISTORY OF PRESENT ILLNESS|ADMITTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, M.D. REASON FOR ADMISSION: Resection of bladder tumor. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is a 71-year- old male who had been undergoing evaluation of prostate CA, who on cystoscopy for persistent hematuria was discovered to have a bladder tumor. He is admitted at this time for tumor resection.
CA|cancer|CA,|29|31|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Breast CA, bilateral mastectomies with reconstruction. CURRENT MEDICATIONS: None. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 43-year-old woman, now scheduled for left breast reconstruction.
CA|cancer|CA|271|272|PAST MEDICAL HISTORY|18. Skin biopsy on forehead in early 2004. 19. On _%#MMDD2004#%_ the patient underwent left breast skin biopsy because of nipple retraction on the left side. She also had a palpable mass above the areola measuring 2.7 x 1.5 x 1.3 cm on mammogram, this was suspicious for CA and on biopsy the diagnosis was confirm of adenocarcinoma of the breast. The patient was seen by Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ and the patient had a grade 2 infiltrating lobular carcinoma involving the left breast region.
CA|cancer|CA.|185|187|PAST MEDICAL HISTORY|Augustana also reports that she has not been taking p.o. PAST MEDICAL HISTORY: 1. Recurrent falls. 2. Atrial fibrillation. 3. Colon cancer in 1995. 4. Status post mastectomy for breast CA. 5. Hypertension. 6. Cataracts. 7. Glaucoma. 8. CHF. CURRENT MEDICATIONS: 1. BuSpar 7.5 mg p.o. daily.
CA|cancer|CA.|157|159|REVIEW OF SYSTEMS|He denies any significant tobacco abuse. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Constitutional: Weakness. Hematologic/Oncology: Metastatic lung CA. Pulmonary: Per HPI. Cardiovascular: Denies any history of coronary disease or congestive heart failure. He does report some history of palpitations and "abnormal heart rhythm." Hematologic: History of left lower extremity DVT.
CA|cancer|CA.|202|204|REVIEW OF SYSTEMS|He does report some hemoptysis, which started today. Musculoskeletal: Chronic low back pain which is now controlled with pain medications. Neurologic: No focal deficits, but history of metastatic brain CA. Endocrine: No history of diabetic or thyroid disorder. Integumentary: He reports a petechial rash on his chest which is apparently new over the last day or two.
CA|cancer|CA|260|261|HOSPITAL COURSE|4. Pain control. PROCEDURES PERFORMED DURING THIS ADMISSION: Bilateral lower extremity DVT shows extensive DVTs from knee to groin and clot includes inferior vena cava. HOSPITAL COURSE: 1. _%#NAME#%_ _%#NAME#%_ is a 60-year-old male with metastatic pancreatic CA and a history of still smoking one pack per day who was admitted with lower extremity pain and edema, left greater than right.
CA|cancer|CA|136|137|ASSESSMENT/PLAN|EXTREMITIES: Lower extremities show a trace of edema. SKIN: Clear. ASSESSMENT/PLAN: A 73-year-old male with a history of hepatocellular CA now presenting with greater than 30 pound weight loss in the last 6 months. 1. Weight loss with a history of hepatocellular CA. This is suspicious for recurrence.
CA|carbohydrate antigen|CA|191|192|PLAN|4. The patient and her mother were consulted to call with severe abdominal pain or fever and they were given the phone number for 7C. 5. Tumor markers were drawn including alpha-fetoprotein, CA 125, hCG, LD, and inhibin. 6. This plan was discussed with Dr. _%#NAME#%_ _%#NAME#%_.
CA|cancer|CA|150|151|HISTORY OF PRESENT ILLNESS|DOB: _%#MMDD1943#%_ CHIEF COMPLAINT: Fever. HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old Caucasian male who was diagnosed with pancreatic CA about two months ago. He started chemotherapy on Monday. Since then, they have been adjusting his pain medication and he was recently started a few days ago on a 75-mcg fentanyl patch.
CA|carbohydrate antigen|CA|220|221|HOSPITAL COURSE|The patient had control of pain with medications. Her liver enzymes were unremarkable and including amylase and lipase also normal. Her tumor markers were significant for elevated CEA 9.8, normal CA19-9 (14), and normal CA 27/29 (30). The patient was given p.o. intake and tolerated that fairly well. Her diet was advanced, and at the time of discharge the patient is able to take regular food with no nausea, vomiting or increase in abdominal pain.
CA|cancer|CA.|194|196|PAST SURGICAL HISTORY|3. Atrial fibrillation. He was on Coumadin in the past, but due to bleeding he was taken off of it. He is being followed at the VA. 4. Bladder CA. PAST SURGICAL HISTORY: Surgery for the bladder CA. ALLERGIES: None. SOCIAL HISTORY: He quit smoking about 40 years ago. He does not drink alcohol.
CA|cancer|CA|223|224|FAMILY HISTORY|ALLERGIES: The patient does not have any drug allergies. FAMILY HISTORY: As far as family history, there is a history of carcinoma of the breast in patient's mother, but at an older age. Also, a couple of first cousins had CA of the breast at a younger age. There is a family history of depression in patient's father. No diabetes or no other malignancies. Her father died at age 83 of heart disease and complications of depression.
CA|cancer|CA,|183|185|PAST MEDICAL HISTORY|At the present time she is drinking oral contrast and await the CT of her abdomen. PAST MEDICAL HISTORY: 1. History of Parkinson's disease, currently on Sinemet. 2. History of rectal CA, followed by Dr. _%#NAME#%_, has a colostomy. 3. History of osteoporosis. 4. History of senile cataracts, her eye doctor is Dr. _%#NAME#%_ _%#NAME#%_, apparently she has refused cataract surgery in the past.
CA|carbohydrate antigen|CA|230|231|FINAL DIAGNOSES|Apparently, he did have what sounds like an ERCP with brushings and tumor marker analysis performed at Abbott Northwestern Hospital. These records are not available for my interpretation, but _%#NAME#%_'s daughter states that the CA 19-9 level (pancreatic cancer tumor marker) was markedly elevated - approximately 1200. I am now asked to address his current imaging findings, laboratory studies, and for my oncologic management recommendations.
CA|carbohydrate antigen|CA|222|223|PAST MEDICAL HISTORY|He has a recurrence of the biliary cirrhosis diagnosed by biopsy on _%#MM2006#%_ and placed back on the list. Percutaneous transhepatic cholangiogram on _%#MM2006#%_ showed a sclerosing cholangitis and had a CEA level and CA 19-9 from 9000 down to 3700. His virology studies were negative as also a history of thyroid nodule that was removed and excised on 2002.
CA|cancer|CA.|205|207|HOSPITAL COURSE|PROBLEM #2: Umbilical nodule. Surgery was consulted as there was a concern that this patient had a newer onset of umbilical nodule noted especially with history of DVTs now and history of pancreatic adeno CA. Surgery felt that the umbilical mass was likely some hernia with omental fat but there was no gas and nothing noted on CAT scan.
CA|carbohydrate antigen|CA|221|222|HOSPITAL COURSE|She initially had a CT scan, which showed duodenal obstruction with biliary dilatation in her liver and pancreas. Therefore, it was highly suspicious for pancreatic cancer. Therefore several labs were ordered including a CA 19-9, which came back greater than 600. She also was noted to have some pulmonary nodules on CT scan. These were followed up with a secondary CT scan, which showed them to be enlarged, however, they were highly suspicious for metastasis.
CA|cancer|CA|158|159|PAST MEDICAL HISTORY|The pain was relieved with rest and sublingual nitroglycerin. PAST MEDICAL HISTORY: 1. Colon cancer, status post resection, now has an ileostomy. 2. Prostate CA treated with radiation. 3. Atrial fibrillation, rate controlled and anticoagulated. 4. Non Hodg lymphoma. 5. Benign prostatic hypertrophy. PHYSICAL EXAMINATION: On admission, the vital signs were stable.
CA|cancer|CA|186|187|ASSESSMENT|I doubt PE as the cause, as she is on Coumadin and recent CT is without PE. Possible IPF as a cause or other pulmonary process will need further evaluation. She has a distant history of CA of the breast, but I doubt this is the cause. 2) Known depressed ejection fraction, on an ACE inhibitor. Her blood pressure has not allowed a higher dose and I have stopped her beta blocker recently due to low blood pressure.
CA|cancer|CA|232|233|PAST MEDICAL HISTORY|9. Delayed gastric emptying. 10. Anxiety. 11. Left rotator cuff tear 2003, patient was told to have surgery to repair this but delayed having this operated upon when it was discovered that she had a left parotid gland squamous cell CA which took precedent over treatment of the rotator cuff. This got better spontaneously only to recently get worse. 12. Rosacea. 13. Hypertension. 14. Cervical spondylosis. 15. Adrenal adenoma.
CA|cancer|CA.|180|182|DISCHARGE DIAGNOSIS|PLANNED DATE OF DISCHARGE: _%#MMDD2007#%_ PRIMARY MD: _%#NAME#%_ _%#NAME#%_, MD of Oxboro Clinic Internal Medicine. DISCHARGE DIAGNOSIS: 1. Endstage metastatic non-small-cell lung CA. 2. Patient and family wishes to be discharged to home hospice for comfort care. 3. Pericardial effusion without tamponade. COURSE OF HOSPITALIZATION: Please refer to my admission history and physical as well as the heme/onc consultation of Dr. _%#NAME#%_ _%#NAME#%_ and cardiology consultation of Dr. _%#NAME#%_ _%#NAME#%_.
CA|cancer|CA,|143|145|PAST MEDICAL HISTORY|CHIEF COMPLAINT: A 52-year-old woman presents to the ER with abdominal pain and nausea. PAST MEDICAL HISTORY: Significant for metastatic colon CA, originally diagnosed in 2003 and at that time she had a ruptured cecum. She had a couple of surgeries that year, which included an appendectomy, cholecystectomy, hysterectomy, distal small bowel resection and partial chole resection.
CA|cancer|CA.|86|88|SECONDARY DIAGNOSIS|DOB: _%#MMDD1935#%_ PRINCIPAL DIAGNOSIS: 1. Neutropenia. SECONDARY DIAGNOSIS: 1. Lung CA. PRINCIPAL PROCEDURES: Isolation, protected by isolation, administration of pain medication and consultation with Heme/Onc, Dr. _%#NAME#%_.
CA|cancer|CA,|244|246|CLINICAL IMPRESSION|Patient's GNEC shows BUN of 86, creatinine of 6.1, glucose of 51 with potassium of 5.5, chloride 111. CLINICAL IMPRESSION: 1. Generalized progressive edema, multifactorial induration. 2. Worsening renal failure. 3. Progressive metastatic colon CA, chemotherapy on hold. 4. Cardiomyopathy with systolic dysfunction. 5. Infected laceration, left shin. PLAN: The patient was admitted to Fairview _%#CITY#%_ and the patient was started on IV antibiotics, Bumex 1 mg IV, push twice a day to optimize pain control.
CA|cancer|CA|113|114|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: This is a _%#1914#%_ gentleman with history of CA of the prostate on Lupron for the last 10 years, history of occasional bronchitis and past angiogram for dyspnea on exertion. He comes in now with acute worsening of that where he cannot make it from the bedroom to the bathroom without being severely short of breath.
CA|carbohydrate antigen|CA|160|161|LABORATORY DATA|Hemoglobin is ......6 with a white count of 17.8. Her electrolytes are normal. ......... GC, gonorrhea and Chlamydia tests are pending, and tumor markers, CEA, CA 125/AFB are all pending. Blood culture and urine cultures are pending. ........ moderate ....... PHYSICAL EXAMINATION: Her examination was significant with abdomen slightly distended with fluid wave positive.
CA|cancer|CA|141|142|SUMMARY|REASON FOR ADMISSION: Fatigue, weakness, and poor appetite. SUMMARY: Mr. _%#NAME#%_ _%#NAME#%_ has a known case of Duke's C metastatic colon CA status post hemicolectomy undergoing chemotherapy at the Parker Hughes Cancer Center. Last course of chemotherapy about 3 weeks back. Admitted for above chief complaint with admitting considerations of: 1. Weakness and fatigue secondary to dehydration, poor appetite, and metastatic cancer.
CA|cancer|CA|111|112|DOB|DOB: _%#MMDD1917#%_ The patient is an 86-year-old white female with a history of recently diagnosed pancreatic CA with obstructing jaundice. She had a stent placed in _%#MM#%_. She had two rounds of chemo, one round of radiation. She presented to the ER with weakness and vomiting for about a day prior to admission.
CA|cancer|CA.|169|171|HISTORY OF PRESENT ILLNESS|She had initially presented with a swelling and pain in her right tibia, and following a work-up a tumor was found at that site and subsequently the non-small cell lung CA. Patient did have a plating of that right tibia. With this most recent admission, she did have a small bowel obstruction, which was thought to be of neutropenic of CA neutropenic ileus and this did resolve.
CA|cancer|CA.|178|180|FAMILY HISTORY|FAMILY HISTORY: Mother deceased at 91 of CVA. Father deceased in his 60's, heart disease and chronic obstructive pulmonary disease. A sister, 62, valvular heart disease, ovarian CA. A brother is 68, scoliosis. A brother is 58, alive and well. Children: 39, seizure disorder, 36 and 35 alive and well.
CA|carbohydrate antigen|CA|176|177|HISTORY|Her history is also remarkable for a mucinous cystadenoma which was a borderline tumor. She has been followed by the oncologist at the University of Minnesota and had a recent CA 125 which was 1 when they had previously been 4. She is worried that this is a recurrence of tumor. She presents for removal of the nodule and possible excision of the top of the vaginal cuff, as well as evaluation of the pelvis for possible recurrent tumor and/or adhesions and endometriosis.
CA|cancer|CA.|173|175|FINAL DIAGNOSIS|2. Rehydration. 3. Renal insufficiency. 4. Metastatic colon CA. FINAL DIAGNOSIS: 1. Renal insufficiency improved. 2. Dehydration improved. 3. Arthritis. 4. Metastatic colon CA. The patient is a 75-year-old female with a history of advanced colon CA, status post colostomy.
CA|cancer|CA.|192|194|HISTORY OF PRESENT ILLNESS|ADMISSION DIAGNOEIS: Nausea, vomiting, and mild dehydration and laryngeal cancer. HISTORY OF PRESENT ILLNESS: This is a 59-year-old female who did have concurrent chemoradiation for laryngeal CA. She did have a first cycle of Cisplatin on _%#MMDD2003#%_, and at the same time she was started on daily radiation to her leg.
CA|cancer|CA|228|229|BRIEF HISTORY AND HOSPITAL COURSE|2. Lower extremity pain bilaterally. 3. History of metastatic prostate cancer. 4. Bilateral pleural effusion. 5. Constipation. BRIEF HISTORY AND HOSPITAL COURSE: The patient is a 61- year-old male with known metastatic prostate CA who was followed at Iowa who presented with a one day history of epigastric pain, somewhat now diffuse without radiation.
CA|cancer|CA|177|178|CHIEF COMPLAINT|CHIEF COMPLAINT: The patient transferred to the ER from the nursing home with concerns about mental status. The patient is an 83- year-old male with a history of non-small cell CA of the lung. History of external beam radiation therapy. The patient with recent thoracic compression fractures thought to be unrelated to metastatic disease.
CA|cancer|CA|190|191|HISTORY OF THE PRESENT ILLNESS|DOB: _%#MMDD1925#%_ CHIEF COMPLAINT: Dyspnea postop. HISTORY OF THE PRESENT ILLNESS: The patient is a 78-year-old male with a known significant history of tobacco abuse as well as laryngeal CA who presents to my service post laryngeal biopsy with worsening dyspnea. According to the patient, he reports his usual state of health and had undergone a preop exam by Dr. _%#NAME#%_ _%#NAME#%_ on the day prior to his laryngoscopy and laryngeal biopsy today.
CA|cancer|CA.|212|214|SOCIAL HISTORY|His oral intake has been adequate. There really have been no acute medical issues over the last several months. The patient did initially have significant pain in the pelvis area secondary to metastatic prostate CA. This has improved with treatment of his prostate CA and with the above analgesic medication regimen. PHYSICAL EXAMINATION: Mr. _%#NAME#%_ is a withdrawn, though very pleasant male, who is in no distress.
CA|cancer|CA|150|151|FAMILY HISTORY|ALLERGIES: She has no drug allergies, but she is SENSITIVE TO PAIN MEDICATIONS. FAMILY HISTORY: Father with ASCVD and aneurysm. Mother with polio and CA of the breast and brain. Brother questionable stroke. Sister with Alzheimer's. She is widowed lives independently at this point in an apartment.
CA|cancer|CA|200|201|HISTORY OF PRESENT ILLNESS|Enlarged retrocrural lymph node unchanged. Cholelithiasis. Splenomegaly with the placement of the left kidney anteriorly. HISTORY OF PRESENT ILLNESS: A 52-year-old male with history of hepatocellular CA secondary hepatitis C. Patient had presented to his primary care provider with increasing abdominal pain. A CT was done which showed increase in the tumor size, it was then planned for patient to have chemoembolization.
CA|cancer|CA.|141|143|HOSPITAL COURSE|The determination as to whether or not to proceed in this regard would be dependent upon his prognosis from his metastatic transitional cell CA. The patient will have follow-up with myself in ten days, with Dr. _%#NAME#%_ in approximately two and a half weeks after his transesophageal echocardiogram and in a similar time frame for Hematology/Oncology follow-up.
CA|carbohydrate antigen|CA|118|119|HISTORY OF PRESENT ILLNESS|There were a few, less than 1 cm lymph nodes in the right pericecal region, and the remainder of the CT was normal. A CA 125 was also obtained on _%#MMDD2004#%_ and this was 141.7. REVIEW OF SYSTEMS: The patient denies any constipation or diarrhea although has had some urinary frequency for several weeks, and was recently treated with Cipro for a urinary tract infection.
CA|carbohydrate antigen|CA|273|274|PROCEDURES PERFORMED|On _%#MMDD2004#%_ the patient underwent her initial staging surgery which was an exploratory laparotomy, bilateral salpingo-oophorectomy, CUSA, rectal sigmoid resection, descending colostomy. Hartman's pouch, and omentectomy. She was suboptimally cytoreduced at that time. CA 125 was 4500 and this fell to 1005 postoperatively. The patient had had a previous abdominal hysterectomy for benign indications.
CA|cancer|CA|200|201|HOSPITAL COURSE|With his SVT his heart rate was controlled with diltiazem drip and eventually transitioned over to oral diltiazem. He was at _%#CITY#%_ Rehab for palliative therapy for his bony mets for his prostate CA and, during his hospitalization there, he developed acute delirium. He was transferred to the MICU at Fairview-University Medical Center where it was determined that he had developed MRSA bacteremia and MRSA urine infection.
CA|carbohydrate antigen|CA|122|123|COMPLICATIONS|Taxol/Carbo x6. In _%#MM#%_ 2002, CA 125 was up to 225. No chemo was done secondary to trip to Alaska. • In _%#MM#%_ 2002 CA 125 down to 132, Carbo was given and then during cycle #2, she had a reaction. In _%#MM#%_ 2002, trip to Hawaii. _%#MM#%_ 2002 Doxil x6 done through _%#MM#%_ 2003.
CA|carbohydrate antigen|CA|151|152|COMPLICATIONS|In _%#MM#%_ 2002, trip to Hawaii. _%#MM#%_ 2002 Doxil x6 done through _%#MM#%_ 2003. In _%#MM#%_ 2003, Gemzar. _%#MM#%_ 2003, weekly Taxol with rising CA 125. In _%#MM#%_ 2004, Hexalen, then Carbo x2. INTERVAL: The patient is here today for Carbo desensitization #3.
CA|carbohydrate antigen|CA|201|202|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: 1. Ascites of unclear etiology. 2. Abdominal pain, presumably secondary to ascites, but improved. 3. Mild anemia most consistent with anemia of chronic disease. 4. Mildly elevated CA 125.to be followed in gynecology. HISTORY OF PRESENT ILLNESS: Please see admission history and physical.
CA|cancer|CA|61|62|HOSPITAL COURSE|DOB: HOSPITAL COURSE: This 55-year-old female has pancreatic CA and non-healing wound/recurrent abscess at the site of her previous JP drain. This has been not amenable to local management and she presents today for
CA|cancer|CA|247|248|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Shortness of breath, increasing for the last two days. PRIMARY CARE PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 88-year-old white female with a known history of non-small-cell lung CA which was diagnosed by a CT-guided biopsy of the left lung _%#MM2003#%_ and path showed non-small-cell carcinoma. She also had a CT at that time that showed pleural based and parasternal region anterior mass on the left and also some mass on the right costophrenic angle.
CA|cancer|CA|127|128|FAMILY HISTORY|One coffee per day. Four ETOH per week. MEDICATIONS: ASA. FAMILY HISTORY: Mother deceased at 89. Father deceased of pancreatic CA and ETOH abuse, age 69. One brother and one sister alive and well. One child alive and well. No family history of allergic reactions to anesthesia or bleeding diathesis.
CA|cancer|CA,|177|179|CONSULTATION OBTAINED DURING HOSPITALIZATION|PAST MEDICAL HISTORY: 1. Coronary artery disease status post CABG x2 in 2001 and 2002, recent stress test 3 days ago was negative for any acute ischemia. 2. History of prostate CA, status post radiation therapy, followed by brachytherapy. 3. Diabetes mellitus type 2, diet controlled. 4. Hypertension. REVIEW OF SYSTEMS: Otherwise, negative.
CA|cancer|CA.|375|377|PAST MEDICAL HISTORY|As delineated above, he was noted to be in new onset atrial fibrillation and is getting his echocardiogram today, and due to his mild to moderate dyspnea on exertion, in combination with his purulent sputum and his new onset atrial fibrillation, he is being admitted to the hospital for further evaluation and management. PAST MEDICAL HISTORY: 1. Hyperlipidemia. 2. Prostate CA. 3. Mitral regurgitation, discovered in 2004. PAST SURGICAL HISTORY: 1. Prostatectomy. 2. Hydrocele repair. MEDICATIONS: None.
CA|cancer|CA|185|186|PAST MEDICAL HISTORY|4. Retinal CVA in 2002. 5. Entropion repair. 6. Cataract extraction. 7. Peripheral vascular disease. 8. Negative stress test in 2001. 9. Ischemic colitis in 1996. 10. Hypertension. 11. CA of the prostate with radiation therapy. 12. Gastrointestinal bleed due to aspirin in 1992. 13. Laminectomy in 1995. 14. Carotid endarterectomy in 1989. MEDICATIONS: 1. Singulair 10 mg daily.
CA|cancer|CA|265|266|PAST MEDICAL HISTORY|She has had no oral intake for weeks now. Her pain has been relatively well controlled with an increased dose of fentanyl patch and OxyFast p.r.n. PAST MEDICAL HISTORY: She has a history of COPD, osteoarthritis, depression, restless leg syndrome, the squamous cell CA of the esophagus and hypopharynx, is first diagnosed in _%#MM2004#%_. She has had cisplatin and radiation. As recently as a month ago, she had a laser treatment to see if it could reduce some of the recurrent tumor in her throat to allow for swallowing.
CA|cancer|CA.|201|203|PHYSICAL EXAMINATION|Also patient takes Valium for anxiety. The patient will be discharged today back to Fairview Southdale. Follow up by hospitalist and consultation with Oncology for evaluation and treatment of her lung CA. Also follow up on her right hip fracture for culture and sensitivity with Ortho. Medications per hospital chart. Pending workup ultrasound of her carotids per hospital system.
CA|cancer|CA|236|237|ASSESSMENT|ASSESSMENT: 1. Dehydration secondary to dysphagia. The dysphagia is apparently related to traumatic intubation at the time of his recent lung surgeries. It seems less likely that his weight loss is directly related to his squamous cell CA or what is felt to be low-grade lymphoma. It is possible, though less likely as well, that his poor intake is related to some other GI process, i.e. esophageal obstruction, peptic ulcer disease, etc.
CA|cancer|CA.|170|172|PAST MEDICAL HISTORY|Currently the pain is an 8/10 with increased nausea and vomiting. PAST MEDICAL HISTORY: 1. Bilateral hernia repairs times three. 2. History of prostatectomy for prostate CA. 3. An incarcerated right inguinal hernia causing a small-bowel obstruction requiring surgical reduction and repair in 2003. MEDICATIONS: None. The patient does generally take an aspirin every day but stopped the aspirin as of Monday.
CA|carbohydrate antigen|CA|265|266|ASSESSMENT|EXTREMITIES: Without clubbing, cyanosis or edema. DERMATOLOGIC: Clear. ASSESSMENT: Healthy adult female for total abdominal hysterectomy, bilateral salpingo-oophorectomy given her longstanding history of pelvic pain, uterine fibroids and endometriosis and elevated CA 125. Further because of the patient's history of the hypermobile urethra, small cystourethrocele on examination and demonstration of loss of urine, it is recommended that she undergo a Burch urethropexy with placement of a Bonanno suprapubic catheter.
CA|carbohydrate antigen|CA|209|210|HISTORY OF PRESENT ILLNESS|These included alpha-fetoprotein, which was elevated to 653; lactate dehydrogenase of 757; uric acid of 3.3; ESR of 9; and HPA of 17.8; AZMA of 12.6; VIP 8; INR 0.86; PTT 3; ferritin 15; beta hCG less than 3; CA 1.6, and CA125 of 25. These studies were all essentially normal, with the exception of alpha-fetoprotein. Hematology/Oncology also recommended a CT study, which showed an 8-cm hepatic mass.
CA|cancer|CA.|86|88|REASON FOR ADMISSION|REASON FOR ADMISSION: Wire localization lumpectomy and sentinel node biopsy of breast CA. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 64-year-old female who had findings of an abnormal mammogram recently, which led to further evaluation with a spiculated right breast mass.
CA|cancer|CA|215|216|HISTORY OF PRESENT ILLNESS|2. Remote past history of smoking. 3. Worked as an industrial painter, exposed to numerous chemicals. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 87-year-old man with recent diagnosis of small cell lung CA with multiple falls. Seen first in the clinic at that time and evaluated for falls with an MR head showing no evidence for metastatic disease to the brain, however, there has been metastatic disease found in the liver on previous evaluation prior to hospitalization.
CA|cancer|CA|380|381|PAST MEDICAL HISTORY|He denies history of rheumatic fever, tuberculosis or pneumonia. He has had a previous history of 3 vessel coronary bypass graft surgery in 2003, hypertension, atrial fibrillation and flutter and radiofrequency ablation procedure in 2000 for flutter. PAST MEDICAL HISTORY: See above. Past history also includes nephrolithiasis, ankylosing spondylitis, degenerative joint disease, CA of the prostate, iron deficiency anemia, anemia of chronic disease, glaucoma, cervical vertebra fracture, gout, hyperlipidemia, post-herpetic neuralgia, diverticulitis, irritable bowel syndrome, lower GI bleed from rectal AVMs and rectal ulcers, previous surgery in the right hip the cervical spine, right knee, left inguinal herniorrhaphy hydrocele repair Morton's neuroma surgery, bilateral hip arthroplasty procedures, right knee replacement, left ankle fusion, IOL each eye, and radiation seed implants.
CA|cancer|CA|168|169|IMPRESSION/REPORT/PLAN|It does appear that she has some diverticula in her sigmoid and this may explain her anemia, however I would like to make sure that she does not have significant colon CA or other causes. I note that the barium enema was suboptimal due to difficult retention and fecal material. At this point in time we will also hold her Coumadin secondary to the anemia.
CA|cancer|CA|157|158|ASSESSMENT|ASSESSMENT: Several day history of weakness, dyspnea, nausea occurring in the setting of recent chemotherapy in a patient with a history of known metastatic CA to the liver as well as congestive heart failure. There is somewhat uncertainty at the time of admission as to the cause for the patient's symptoms.
CA|carbohydrate antigen|CA|299|300|HOSPITAL COURSE|The pain was eventually controlled with oral medication. We were not sure whether this is perhaps a hypercoagulable state caused by perhaps a pancreatic cancer or if this was another perhaps inherited thrombophilia that just had not been discovered at this point. People felt that with the negative CA 19-9, it seemed less likely to be pancreatic cancer but again we will get that PET scan as an outpatient and hopefully a biopsy done later.
CA|cancer|CA|74|75|PAST MEDICAL HISTORY|REASON FOR ADMISSION: Acute GI bleed. PAST MEDICAL HISTORY: 1. Pancreatic CA in 2000, status post Whipple. 2. Cardiovascular disease with acute inferior wall MI, _%#MMDD2002#%_, treated with successful PTCA of a 100% mid-circ lesion as well as PTCA of a 95% OM-1 lesion with Dr. _%#NAME#%_ on _%#MMDD2002#%_.
CA|cancer|CA.|65|67|ADMISSION PROBLEMS|TRANSITIONAL SERVICES ADMISSION PROBLEMS: 1. Non-small cell lung CA. 2. Status post right upper lobectomy and chest wall excision, secondarily to lung CA. HISTORY OF PRESENT ILLNESS: This is a 62-year-old female patient with the above mentioned procedure on _%#MMDD2002#%_.
CA|cancer|CA.|161|163|HOSPITAL COURSE|CT scan also showed multiple metastases to pleura and liver. Initially patient was started on Cipro for treatment of pneumonia with diagnosis of metastatic lung CA. Consult was obtained with Hematology/Oncology and proposal for pursuing tissue biopsy and other work-up. Patient strongly emphasized that she did not want to have any testing that would cause pain, did not want to have biopsy done.
CA|cancer|CA|334|335|PAST MEDICAL HISTORY|2. Hypercoagulable state, status post deep venous thrombosis X2, last _%#MM#%_ 2002 with a pulmonary embolus by the patient's report related to inadequate anticoagulation when the patient stopped taking his Coumadin. 3. Status post thyroidectomy, on Synthroid replacement with dosage adjustment as noted above. 4. History of prostate CA with subsequent radiation to the bowel and episodic low-grade GI bleeding. 5. Chronic renal insufficiency. 6. Chronic iron-deficiency anemia. 7. Coronary artery disease, status post proximal LAD stent _%#MM2002#%_.
CA|carbohydrate antigen|CA|198|199|ADMISSION DIAGNOSIS|On _%#MM#%_ _%#DD#%_, 2002, CT of the abdomen and pelvis showed a soft tissue mass, 4.2 x 2.5 cm in the right femoral region, and a mass/nodular tissue, 1.7 cm in size, in the right iliac region. A CA 125 level, at their highest were 52, the most recent, on _%#MM#%_ _%#DD#%_, 2002, was 6. PAST MEDICAL HISTORY: The patient's past medical history, she is a para 5-0-0-5, history of right breast cancer, progesterone-receptive positive and history of ovarian cancer as detailed in the HPI.
CA|cancer|CA.|191|193|FAMILY HISTORY|6. Niacin leading to hot flashes. FAMILY HISTORY: Mother died of a CVA at age 79. Father of leukemia at age 63. Brother died at 72 of colon cancer. Another brother with bladder CA and throat CA. All her siblings were heavy smokers. SOCIAL HISTORY: The patient denies any tobacco use and occasional alcohol use.
CA|cancer|CA.|371|373|FAMILY HISTORY|She worked previously as a medical secretary. FAMILY HISTORY: Her parents died both at the age of 69; her mother from inoperable cancer involving the retroperitoneum of uncertain etiology and her father died of a stroke and had coronary artery disease. She describes all of her siblings having had coronary artery disease and one brother having passed away from prostate CA. REVIEW OF SYSTEMS: See HPI. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 151/99, pulse 96, respiratory rate 16, pulse ox 96%.
CA|cancer|CA|209|210|SUMMARY|5. Degenerative arthritis. SUMMARY: This is an 84-year-old woman, admitted here on the above date to continue treatment and rehabilitation for the above-noted medical problems. She had recurrent squamous cell CA of the vulva and had a couple of surgical treatments and has also received chemo and radiation treatment. She came to us in a somewhat deconditioned state for the purpose of strengthening dietary assessment, physical and occupational therapy, and continued medical management.
CA|cancer|CA,|174|176|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: EYES: Diplopia, double vision. EARS: No tinnitus. CARDIOVASCULAR: Hypertension present. No chest pain, no palpitation. RESPIRATORY: Has nonsmall cell lung CA, no shortness of breath, no cough. GI: Negative. GU: No dysuria. HEMATOLOGIC: No anemia. ENDOCRINE: Negative. CONSTITUTIONAL: No fever. CNS: No dizziness. Has right leg weakness.
CA|cancer|CA|171|172|HOSPITAL COURSE|He had O2 sats that were greater than 90. He had a BUN that was elevated and albumin that was low, creatinine of 1.4. He was admitted with a diagnosis of pneumonia, colon CA and peripheral edema. He was also noted to be hypertensive. We started him on IV antibiotics, O2. We checked his labs and offered him control for his blood pressure as well as his pain control.
CA|cancer|CA.|242|244|PAST MEDICAL HISTORY|The patient had a CEA of 0.9 on _%#MMDD2002#%_ and a chest x-ray on _%#MMDD2002#%_ consistent with possible COPD and fibrosis. PAST MEDICAL HISTORY: 1. Right lower lobectomy because of cancer found in the lung, possibly from metastatic colon CA. 2. Hemilobectomy in 1991 because of colon cancer. 3. IOL OU. 4. Left breast biopsy, benign. 5. Left shoulder surgery.
CA|carbohydrate antigen|CA|67|68|ADMITTING DIAGNOSIS|DOB: _%#MMDD1952#%_ ADMITTING DIAGNOSIS: Pelvic mass with a normal CA 125. DISCHARGE DIAGNOSIS: Benign papillary serous cystadenofibroma of the ovary. PROCEDURE: Examination under anesthesia, exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic washings.
CA|cancer|CA|164|165|FAMILY HISTORY|She is a non-smoker. Social alcohol. No formal exercise. Fairly active. FAMILY HISTORY: Her mother had Parkinson disease, lived to age 85. Her father had laryngeal CA and died at age 65. Her brother died from trauma. A second brother just died from lung cancer. REVIEW OF SYSTEMS: She has anxiousness about the upcoming surgery; otherwise, no acute complaints.
CA|cancer|CA|232|233|HISTORY OF PRESENT ILLNESS|REASON FOR ADMISSION: Increasing cough, progressive shortness of breath and fever of 1-week duration. HISTORY OF PRESENT ILLNESS: A 58-year-old Caucasian male admitted with a known case of metastatic progressive non-small cell lung CA admitted for above-chief complaint with admitting consideration of right upper lobe pneumonia and #2 consideration was metastatic progressive non-small cell lung CA.
CA|cancer|CA,|174|176|FAMILY HISTORY|She has had multiple problems with her knees, at 7 years old a torn ligament, and at 14 years old subpatellar cartilage was found. FAMILY HISTORY: Negative for colon, breast CA, arteriosclerotic heart disease, suicide. There is depression in her mother, diabetes in her paternal GF. Depression in maternal aunts and cousins, one is bipolar. Paternal uncle with a CVA at 33 years old.
CA|carbohydrate antigen|CA|175|176|HISTORY OF PRESENT ILLNESS|The patient was optimally cytoreduced in _%#MM#%_ 1999. She subsequently underwent 6 cycles of Taxol and carboplatin. She was found to be BSE 1 mutation positive. Her initial CA 125 was 98 and then it went to the teens following therapy. She was without evidence of recurrent disease for 16 months.
CA|cancer|CA;|242|244|ASSESSMENT|1. Weakness. Differential includes TIA versus recurrence of his carcinoma, versus metabolic abnormality, versus rheumatologic abnormality, versus infectious diseases. We will check alpha fetoprotein to assess the status of his hepatocellular CA; although, given the negative CT last month, this is unlikely. Check bilateral carotid ultrasounds. Vitamin B12 and folate are pending.
CA|cancer|CA.|191|193|SUBJECTIVE|SUBJECTIVE: This 70-year-old male is going for an extensive resection of multiple basal cell carcinomas of the face. He has recently undergone an excision of a left medial canthal basal cell CA. PAST MEDICAL HISTORY: 1. Hypertension. 2. History of coronary artery disease, status post CABG x3 in 1993.
CA|California|CA|360|361|DSA|16. Zofran 48 mg p.o. q.6 h. p.r.n. nausea. cc: _%#NAME#%_ _%#NAME#%_, M.D. _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_ _%#CITY#%_, CA _%#94300#%_ _%#NAME#%_ _%#NAME#%_, RN Translplant Center MMC 482 DSA MMC 195 Ms. _%#NAME#%_ _%#NAME#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_ _%#CITY#%_, CA _%#95100#%_
CA|cancer|CA|161|162|PAST MEDICAL HISTORY|Cardiac consult noted. Aortic valve strands questionable on TEE. The patient complained of right hip pain, possible bursitis. PAST MEDICAL HISTORY: 1. Left lung CA resection approximately 3-4 years ago. 2. Macular degeneration. 3. Hypertension. 4. Increased cholesterol. 5. History of a. fib. CURRENT MEDICATIONS: See hospital chart. ALLERGIES: No known drug allergies.
CA|cancer|CA,|200|202|PAST MEDICAL HISTORY|She has never had detox with buprenorphine before. She needs detox and reestablishment of her recovery program. PAST MEDICAL HISTORY: 1. Hepatitis C, treated unsuccessfully with interferon. 2. Breast CA, treated with a bilateral mastectomy and reconstructive surgery. 3. Hypertension, for which she has been on Diovan and lisinopril. 4. Barrett's esophagus, for which she recently had an ablation.
CA|carbohydrate antigen|CA|256|257|RECOMMENDATIONS AND DISCUSSION|Her elevated creatinine may interfere with choice of chemotherapy, since cisplatinum is part of most active regimens in esophageal carcinoma. I will recheck her creatinine post admission and hydration, which could hopefully improve. I will check a CEA and CA 2729 for tumor markers, which could be followed up during chemotherapy. Radiation therapy could be considered for local symptomatic relief. These findings and recommendations were discussed with her daughter, who was present at the bedside.
CA|carbohydrate antigen|CA|147|148|HISTORY OF PRESENT ILLNESS|In _%#MM2005#%_ the patient was on Alkeran with a mild response, but this was stopped with concern for secondary malignancies. In _%#MM2005#%_ her CA 125 rose again to 94, and she was begun on Cytoxan and Avastin. Her CA decreased to 24. In _%#MM2005#%_ the patient CA 125 was 18, and she was continued on her Cytoxan and Avastin.
CA|carbohydrate antigen|CA|139|140|HISTORY OF PRESENT ILLNESS|In _%#MM2005#%_ her CA 125 rose again to 94, and she was begun on Cytoxan and Avastin. Her CA decreased to 24. In _%#MM2005#%_ the patient CA 125 was 18, and she was continued on her Cytoxan and Avastin. She was seen in the gynecology/oncology clinic on _%#MMDD2005#%_, where they performed a physical examination.
CA|cancer|CA.|211|213|FAMILY HISTORY|Dyslipidemia, hypertension, obstructive sleep apnea on CPAP, adrenal mass followed by primary physician. Coronary artery disease, status post MI, _%#MM2005#%_. FAMILY HISTORY: She has a family history of breast CA. ALLERGIES: To penicillin. MEDICATIONS: Include insulin, Lantus and Novolin. Clindamycin recently for a dental procedure.
CA|cancer|CA.|201|203|HPI|It was worse after eating. He denies previous history of indigestion, fatty food intolerance. He denies back pain, jaundice or pancreatitis. He is 12 days status post chemotherapy for metastatic colon CA. The patient is reasonably comfortable at this time following morphine injection. PAST MEDICAL HISTORY: Significant for status post AP resection in _%#MM#%_ for rectal CA.
CA|carbohydrate antigen|CA|156|157|RECOMMENDATIONS|4. Start broad-spectrum antibiotic as preparation for ERCP. 5. Check INR in the morning, correct as needed, needs to be <1.3 at time of procedure. 6. Check CA 19-9, CEA. 7. Follow LFTs and for sign/symptoms of sepsis 8. Start the basic workup for elevated liver enzyme and get hepatitis serologies iron panel.
CA|cancer|CA|172|173|DISCUSSION|She currently denies currently having headache, abdominal pain or chest pain. _%#NAME#%_'s main complaint is that of chronic nausea, which predated the diagnosis of breast CA approximately 3 months ago. She has gone to 3 chemotherapy courses, which have also left her with nausea. She did undergo lumpectomy prior to chemotherapy and will require radiation therapy, which was completed with chemotherapy.
CA|carbohydrate antigen|CA|183|184|LABORATORY DATA|Calcium is normal at 9.2. TSH is normal at 1.79 with a normal phosphorus level. Liver function studies are all normal. Tumor marker studies obtained on _%#MM#%_ _%#DD#%_, 2007 show a CA 27.29 at 39, CA 19-9 at 97 (normal range 0-37), a CEA level 4.1. Serum iron level showed normal serum and normal iron saturation index.
CA|cancer|CA.|276|278|PERTINENT PAST MEDICAL HISTORY|The patient is status post ERCP performed by my colleague, Dr. _%#NAME#%_ at Fairview Southdale Hospital approximately one month ago with metal wall stent for biliary obstruction. He had a large ampullary mass noted was biopsied and consistent with metastatic small cell lung CA. Other past medical history is significant for hypertension. HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old gentleman with above past medical history who presented through the Emergency Room at Fairview Ridges with fever and altered mental status as above.
CA|cancer|CA.|241|243|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 53-year-old gentleman I am asked to see in consultation for TLC palliative care from Dr. _%#NAME#%_ _%#NAME#%_. He was admitted for fever and confusion and has a diagnosis of metastatic small cell CA. He has metastases to the liver, brain and mets to the right hip, radiation therapy to the right hip. He also has a duodenal mass, and I understand he needs further evaluation of the gallbladder as well.
CA|cancer|CA.|133|135|HISTORY OF PRESENT ILLNESS|She also has been refusing her physical therapy because of pain and fatigue. Oncology/Hematology has been following her for her lung CA. She has had chemotherapy in the recent past. CT scan one week ago showed a worsening of the tumor. CODE STATUS: FULL CODE. PAST MEDICAL HISTORY: 1) MS. 2) Lung cancer.
CA|cancer|CA|192|193|ASSESSMENT AND PLAN|MUSCULOSKELETAL; Right arm brace. LABORATORY DATA: From _%#MM#%_ 7: Sodium 139, BUN 14, creatinine 0.64, calcium 6.8. ASSESSMENT AND PLAN: The patient is a 65-year-old female with MS and lung CA with mets, status post open reduction and internal fixation. 1) Pain; the patient is in severe pain. Will start methadone 2.5 mg sublingual q8h and morphine p.r.n. 2) Insomnia may improve with improved pain control.
CA|cancer|CA|163|164|PAST MEDICAL HISTORY|2. He drinks a moderate amount of alcohol, Windsor and water as I understand it a couple of quarts a week. PAST MEDICAL HISTORY: His past medical history includes CA of the colon about 5 years ago with a recent colon evaluation, suggesting no recurrence. Last year he had bilateral cataract surgery. REVIEW OF SYSTEMS: Review of systems is remarkably negative and done quite completely.
CA|carbohydrate antigen|CA|212|213|HISTORY|She had fairly recent evaluation with CT of the abdomen as well as MRCP, both done in _%#MM#%_ of this year with no obvious treatable stenosis in her biliary tree, and no other significant lesion identified. Her CA 99's have fluctuated, 283 in _%#MM#%_ and 154 in _%#MM#%_. The patient is currently too confused to provide any meaningful history.
CA|cancer|CA|190|191|PAST MEDICAL HISTORY|The patient was hospitalized here for similar concerns last summer. _%#NAME#%_ denies acute physical concerns. PAST MEDICAL HISTORY: 1. Chronic psychiatric illness. 2. History of testicular CA status post surgery x2. This included a retroperitoneal dissection I believe 2 or 3 years ago. He is followed at the Mayo Clinic for this.
CA|cancer|CA|172|173|PAST MEDICAL HISTORY|1. Current problems with the skin lesions. 2. Atrial fibrillation. 3. Hypertension. 4. Iron deficiency anemia. 5. Depression. 6. Possible urethral stricture. 7. Basal cell CA of the left lower lid, left side of the neck, dorsal side of the both hands previously. REVIEW OF SYSTEMS: He is increasingly fatigued for about 1 month.
CA|carbohydrate antigen|CA|155|156|IMPRESSION|2. PET scan as an outpatient at Life Scan in _%#CITY#%_ to rule out distant metastasis and/or rule in a primary site of disease. 3. Tumor markers for CEA, CA 19-9, CA- 125. 4. Routine postoperative care. 5. Follow-up in my clinic (MOHPA-_%#NAME#%_) after discharge for a further discussion of the final pathology, PET scan and bone scan results.
CA|carbohydrate antigen|CA|368|369|DOB|3. Small right-sided pleural effusion. Given that these findings were worrisome for peritoneal carcinomatosis, I was asked to address these CT findings and for further recommendations regarding diagnostic strategies. I spoke initially with Dr. _%#NAME#%_ on the morning of _%#MMDD2004#%_, and recommended diagnostic/therapeutic paracentesis and tumor markers (CA-125, CA 19-9, and CEA). I am now seeing _%#NAME#%_ in full consultation after these tests were performed. REVIEW OF SYSTEMS: Essentially positive for some residual abdominal swelling, fullness and pain.
CA|cancer|CA,|159|161|ASSESSMENT|2. History of pulmonary embolism on _%#MMDD#%_. INR is slightly subtherapeutic, probably secondary to the fact she missed a recent dose. 3. Status post breast CA, status post mastectomy followed by radiation therapy. 4. Right ankle pain, status post crush injury, _%#MM2005#%_. RECOMMENDATIONS: The patient's Coumadin dose will be increased in the next couple of days to 5 mg each day.
CA|carbohydrate antigen|CA|141|142|HISTORY OF PRESENT ILLNESS|She has undergone an extensive workup. A CT done in _%#MM#%_ demonstrated ascites with mild ductal dilatation. There is no obvious mass. Her CA level was 7.9. CA 2729 was 65. She has had normal liver function test. She had an ultrasound of the gallbladder, which revealed stones in the gallbladder.
CA|carbohydrate antigen|CA|159|160|HISTORY OF PRESENT ILLNESS|She has undergone an extensive workup. A CT done in _%#MM#%_ demonstrated ascites with mild ductal dilatation. There is no obvious mass. Her CA level was 7.9. CA 2729 was 65. She has had normal liver function test. She had an ultrasound of the gallbladder, which revealed stones in the gallbladder.
CA|cancer|CA|162|163|REASON FOR PROCDURE|She does not take any aspirin or NSAID's. She does not have any known allergies. Her general health is otherwise stable. She had surgery a year ago for a grade 1 CA of the ovary. She had a hysterectomy and otherwise has had a tonsillectomy. She knows about congenital aortic stenosis but otherwise has been in good health.
CA|cancer|CA.|98|100|PAST SURGERIES INCLUDE|2. Hypertension. 3. Diabetes mellitus. 4. Hypertension. PAST SURGERIES INCLUDE: Prostatectomy for CA. Right knee arthroscopy. Right femur fracture repair in 1960. Cataract repair. Cholecystectomy. MEDICATIONS: Capoten 50 mg three times a day. Lopressor 25 mg twice a day.
CA|cancer|CA,|131|133|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Breast CA, P/S chemotherapy. HPI: 28-year-old young patient with stage III breast cancer, primarily on left side, was 6.5 cm.
CA|cancer|CA|132|133|FAMILY HISTORY|SOCIAL HISTORY: Lives independently and is a retired former alcohol abuser, but not recently. FAMILY HISTORY: Mother had pancreatic CA from previous consultant's notes. PHYSICAL EXAMINATION: GENERAL: A 72-year-old man who is alert and oriented in no obvious distress.
CA|cancer|CA,|146|148|PAST MEDICAL HISTORY|No abdominal pain, kidney or liver disease. No history of emphysema. PAST MEDICAL HISTORY: 1. Hypertension. 2. Atrial fibrillation. 3. Basal cell CA, removed. MEDICATIONS: 1. Diovan 40 mg daily. 2. Doxazosin. ALLERGIES: No known drug allergies.
CA|cancer|CA|129|130|ASSESSMENT|In addition, she has pulmonary nodules which are increasing in size. ASSESSMENT: A 56-year-old female with metastatic pancreatic CA and nonsmall cell lung CA. Her pancreatitis is secondary to the pancreatic mass and pancreatic ductal obstruction. The biliary stent can also contribute to the obstruction. Would recommend that the symptoms be treated medically with pain management as you are.
CA|cancer|CA.|121|123|IMPRESSION|I explained to the patient that I suspect that her prognosis is quite poor, given her CLL and her widely metastatic lung CA. The patient hopes to have a discussion about prognosis and possible treatment options with the oncologist and appreciates a frank discussion.
CA|cancer|CA,|117|119|PAST MEDICAL HISTORY|He has been eating poorly and was sleeping when I came to see him. PAST MEDICAL HISTORY: As indicated hepatocellular CA, status post embolectomy, status post intrathecal pump placement on _%#MMDD2003#%_. ALLERGIES: I do not see any listed.
CA|cancer|CA|180|181|LABORATOR AND DIAGNOSTIC STUDIES|CT showed a mass on the left chest wall which is where his pain is. He also had a histology report from a biopsy showing poorly differentiated neuroendocrine carcinoma, small cell CA and thought to be metastasized to the left chest wall. The patient is very open to me discussing end of life and discussing his tumor, his cancer and wanting to just be very sure that he is kept comfortable and that he wants to go home.
CA|cancer|CA.|203|205|REVIEW OF SYSTEMS|He was a trucker. HEALTH HABITS: Nonsmoker, no alcohol. REVIEW OF SYSTEMS: GI as noted, otherwise negative for constitutional, negative for pulmonary, negative for cardiac. Positive for GU with prostate CA. Positive musculoskeletal with rotator cuff repair. Negative for neuropsych, hematologic, immunologic and endocrine. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished appearing white male in no acute distress.
CA|cancer|CA,|152|154|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Newly diagnosed left breast CA, T1 N0 M0 HPI: Patient underwent lumpectomy and sentinel lymph node examination, primary 1.1 cm, without axillary disease.
CA|cancer|CA|149|150|ASSESSSMENT|Very likely she will come to surgery. I do not think there was any hernias contributing to her obstruction. Additional possibilities include ovarian CA as presenting with bowel obstruction. If gastrograph and colon is negative, may need to send CA-125 and she likely will come to surgery.
CA|cancer|CA|296|297|PAST MEDICAL HISTORY|He has a history of Paget's disease and on x-ray shows a generalized bone demineralization. PAST MEDICAL HISTORY: Remarkable for Paget's, Crohn's disease, acute and chronic renal insufficiency with creatinine ranging between 2 and 3, pernicious anemia, hypertension, right ankle fracture, remote CA of the prostate with 25 radiation therapies and allergic rhinitis. FAMILY HISTORY: Both parents died at 87 years old. Unknown causes.
CA|cancer|CA|289|290|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old woman who presented with a fever of 103 and a recent diagnosis of urinary tract infection and there was concern about possible sepsis. She has a history of short gut syndrome secondary to radiation colitis, history of squamous cell CA of the cervix, status post radiation and hysterectomy in 2002, nonischemic cardiomyopathy with ejection fraction of 30% among other medical problems.
CA|cancer|CA|120|121|FAMILY HISTORY|He has a history of obstructive sleep apnea. He has a history of depression. Positive for cancer in his brother who has CA of a testicle. PAST SURGICAL HISTORY: 1. Appendectomy 1973. 2. Surgery on his palate some years ago.
CA|cancer|CA|169|170|CONSULTING ATTENDANT PHYSICIAN|She was admitted for ERCP and possible stent placement, and also she was put on prophylactic antibiotics for possible infection. PAST MEDICAL HISTORY: Recurrent ovarian CA diagnosed in 2003. It became stage IIIC ovarian cancer, which was treated with chemotherapy, but is refractive to therapy at this time.
CA|cancer|CA|131|132|FAMILY HISTORY|Occasional alcohol intake every other week, 1-3 glasses at a time. FAMILY HISTORY: ASVD significant of father with cardiomyopathy. CA in mother, died of uterine cancer. Diabetes in father, paternal grandfather and uncle. Hypertension in father. REVIEW OF SYSTEMS: RESPIRATORY: Positive for asthma in childhood. SKIN: Positive, rash for eczema.
CA|cancer|CA.|211|213|PAST MEDICAL HISTORY|2. Coronary artery disease. He had a coronary angiogram in _%#MM2005#%_, which revealed mild disease. I am not aware of any recent cardiac evaluations. 3. Hypertension. 4. Hyperlipidemia. 5. History of prostate CA. 6. History of chronic kidney disease with a creatinine most recently of 1.4. MEDICATIONS: 1. Metoprolol. 2. Zetia. 3. Lipitor. 4. Aspirin. The doses of which are being clarified.
CA|carbohydrate antigen|CA|132|133|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: 59-year-old female with a 14 cm solid and cystic right ovarian mass noted on CT scan at 1003. She had a CA of 125 at that time and it was recommended that she undergo total abdominal hysterectomy, bilateral salpingo-oophorectomy and a staging procedure, however, she opted not to do that.
CA|cancer|CA|114|115|ASSESSMENT AND PLAN|Sodium level is 136, potassium level is 4.2, creatinine 0.8. ASSESSMENT AND PLAN: 59-year-old female with ovarian CA and significant ascites: 1. When we discussed her care options, in care planning, she would like to consider chemotherapy, although she has been ambivalent about that with the medical staff.
CA|cancer|CA|191|192|FAMILY HISTORY/SOCIAL HISTORY|FAMILY HISTORY/SOCIAL HISTORY: The patient is disabled due to back pain. She is married, lives with husband, no children. Disabled due to chronic back pain. Positive family history for colon CA in father, who died from this in his 50s. REVIEW OF SYSTEMS: GI as noted. Negative for constitutional changes, negative for eye or ear problems.
CA|cancer|CA|82|83|PAST MEDICAL HISTORY|His only other medication preop was aspirin 81 mg daily. PAST MEDICAL HISTORY: 1) CA of the prostate with radical prostatectomy eight years ago. 2) Previous abdominal aneurysm surgery. 3) Previous gallbladder surgery. 4) No known coronary heart disease, diabetes or chronic pulmonary disease.
CA|cancer|CA,|146|148|FAMILY HISTORY|11. Albuterol inhaler p.r.n. 12. Lorazepam p.r.n. 13. Morphine p.r.n. SOCIAL HISTORY: He is a nonsmoker, nondrinker. FAMILY HISTORY: Negative for CA, negative for ASCVD, negative for diabetes, negative for hypertension. REVIEW OF SYSTEMS: He has difficulty to complying with this secondary to his dementia.
CA|cancer|CA|174|175|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is an 84-year-old gentleman I am asked to see in consultation for pain evaluation by Dr. _%#NAME#%_. He has a history of nonsmall cell CA of the lung and is complaining of pain all over. When I asked him specifically where his pain is, he states and he points actually to the lower abdominal area.
CA|cancer|CA|268|269|ASSESSMENT|ASSESSMENT: 1. Pain that he has described as all over historically, however, more specifically, he is stating currently that it is in focused on the pelvic area, with hot poker sensation going down the right thigh anteriorly and laterally. 2. History of nonsmall cell CA of the lung. Further diagnostics are being done with bone scan to rule out bone metastases. 3. Status post back surgery with hardware. In terms of the differential for pain, because I have no other information, I am currently going to assume that some of the pain, especially the hot poker type pain, could be related to the hardware in his back as at his age, there could be some degeneration of his vertebral bodies that have loosened some of the hardware and created that right-sided hot poker type pain in his right thigh.
CA|cancer|CA,|234|236|REASON FOR CONSULTATION|I was asked to see this patient by Dr. _%#NAME#%_ _%#NAME#%_ of Cardiology after he completed the cardiac catheterization emergently. HISTORY OF PRESENT ILLNESS: This is a 75-year-old gentleman with a history of diabetes and prostate CA, which is under good control, who presented with a sudden onset of worsening shortness of breath that awoke him from his sleep.
CA|cancer|CA|135|136|FAMILY HISTORY|Alcohol use is occasional. Recreational drugs, none. FAMILY HISTORY: Mother and aunt both have spine curvatures. Maternal aunt has had CA of the breast. Maternal grandmother has CA of the breast. Her father died at age 62 on _%#MM2004#%_ due to emphysema. He has no children herself. PHYSICAL EXAMINATION: VITAL SIGNS: Heart rate 62, respirations 16, blood pressure 99/65 and 102/65, O2 sats within normal limits on room air.
CA|cancer|CA|167|168|PAST MEDICAL HISTORY/PAST SURGICAL HISTORY|PAST MEDICAL HISTORY/PAST SURGICAL HISTORY: 1. Usher's syndrome with congenital deafness and progressive retinitis pigmentosa, now legally blind. 2. Transitional cell CA as above. 3. UTI. FAMILY HISTORY: Negative for any malignancies. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 110/80, heart rate 70, temperature 98.6. GENERAL: She is a very pleasant middle-aged woman accompanied by her family.
CA|cancer|CA.|168|170|PAST MEDICAL HISTORY|No previous episodes of GI bleeding. GU: She is urinating normally. All other systems were negative. PAST MEDICAL HISTORY: Significant for TAH/BSO secondary to uterine CA. She also had hip replacement, fracture of her right ankle, fracture of her collar bone, right knee replacement, an appendectomy.
CA|cancer|CA|159|160|PAST  MEDICAL HISTORY|His course was uncomplicated. 2. History of left upper lobectomy for lung cancer in 1995. 3. Chronic chest wall pain secondary to above. 4. History of bladder CA in 1980. 5. Unknown coronary artery status. The patient denies knowledge of a history of coronary disease but denies knowledge of a formal coronary artery assessment.
CA|cancer|CA.|246|248|HISTORY OF PRESENT ILLNESS|He states that even with the least amount of water, such as with brushing his teeth, he will immediately start to choke and have difficulty breathing and be unable to swallow the water. He has a chronic cough following his treatment for the lung CA. He denies that he is having any respiratory distress. PAST MEDICAL HISTORY: 1. COPD. 2. Status post tonsillectomy. MEDICATIONS: ________ and Azmacort. ALLERGIES: None.
CA|carbohydrate antigen|CA|233|234|ASSESSMENT|It was at that point that we felt that we were not obtaining adequate response, and beginning in the middle of _%#MM#%_ of 2005 I started her on oral Xeloda. This has resulted in a very nice clinical response such that the patient's CA 27.29 marker has dropped and currently is measuring in the upper 40's. In addition, we have been monitoring the patient's liver metastases and possible splenic metastasis.
CA|cancer|CA,|129|131|ASSESSMENT AND PLAN|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: Prostate CA, T2a, N0, M0; PSA 15, Gleason 4+3. Dr. _%#NAME#%_ was here to discuss his therapeutic options. I spent over 60 minutes explaining the options and am in complete agreement to give EBT with a brachytherapy boost.
CA|cancer|CA|233|234|FAMILY HISTORY|6. Sleep apnea. 7. Renal calculi, last time was one year ago needed extraction and usually needs extraction she has not had lithotripsy. FAMILY HISTORY: Positive for father with MI in his 50s, diabetes, hyperlipidemia, hypertension. CA of the breast, osteoporosis. SOCIAL HISTORY: She works full-time. She is married and her husband live in _%#CITY#%_ _%#CITY#%_, Minnesota.
CA|cancer|CA|138|139|PAST MEDICAL HISTORY|He recently self- discontinued Amantadine, stating it was not helpful. His Sinemet dose has not recently been changed. 2. History of lung CA 6 years ago, apparently melanoma. The patient has been stable and is followed by Oncology for this. 3. History of bilateral quadriceps tear this past summer.
CA|cancer|CA|199|200|HISTORY OF PRESENT ILLNESS|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD CHIEF COMPLAINT: Increasing abdominal pain. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 57-year-old white male with a history of colorectal CA in 1997 with metastatic disease to the lung. He has received chemotherapy with 5-FU, Leucovorin, and CTP 11 with considerable mild toxicity and recurrent fever.
CA|cancer|CA.|229|231|IMPRESSION|d. There could be an element of SIADH. 2. Admission for abdominal pain and probable dehydration. 3. Past history of congestive heart failure (CHF) and possible pulmonary hypertension. 4. Previous resection of scalp squamous cell CA. 5. History of hypertension. 6. Pernicious anemia. RECOMMENDATIONS 1. Continue hydration with normal saline.
CA|carbohydrate antigen|CA|111|112|LOCATION|He has had a negative colonoscopy and a negative CT scan of the chest. His lab values reveal a CEA of 68.3 and CA 99 of less than 3. He had an elevated lipase on admission. His BUN and creatinine have been in the 50s and around 3 respectively.
CA|cancer|CA|205|206|ASSESSMENT|_%#NAME#%_ has a history of transient postoperative nausea presumably related to anesthesia. It appears that she has tolerated morphine otherwise. Her abdominal examination is benign. 3. History of breast CA status post bilateral mastectomy. 4. History of tachycardia treated with atenolol. 5. Chronic benzodiazepine use. 6. History of lung lesion currently being followed by primary physician.
CA|cancer|CA.|182|184|HISTORY OF PRESENT ILLNESS|However, elevated liver tests were found as well as a lipase of greater than 40,000. The patient denies any new meds. She is treated for hypertension, depression, and has had breast CA. She denies any alcohol intake. In addition, the patient was told she is anemia on this admission.
CA|cancer|CA.|152|154|PAST MEDICAL HISTORY|She does recall being told she was anemic after some knee surgery approximately a year ago. PAST MEDICAL HISTORY: 1. Hypertension. 2. History of breast CA. 3. Depression. 4. Gout. 5. Elevated lipids. 6. Glaucoma. PAST SURGICAL HISTORY: History of left shoulder replacement, knee replacements, foot surgery.
CA|cancer|CA|152|153|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Recurrent metastatic breast CA of right breast, axillary swelling of right arm. HPI: Had left breast cancer in _%#MM1996#%_ and had mastectomy and recurred.
CA|cancer|CA|88|89|PAST MEDICAL HISTORY|The patient has decreased balance, decreased endurance. PAST MEDICAL HISTORY: 1. Breast CA with mastectomy. 2. Hysterectomy. 3. Hypertension. 4. Arthritis. MEDICATIONS: See hospital chart. ALLERGIES: No known drug allergies. SOCIAL HISTORY: She lives with 2 children in a house, one level; independent with self-cares; 7 to 8 steps to enter.
CA|cancer|CA,|194|196|ASSESSMENT AND PLAN|CT of the abdomen, as noted above, showed hydronephrosis, bilateral pleural effusions, and suspicion of hepatic and adrenal metastases. ASSESSMENT AND PLAN: 1. 77-year-old woman with esophageal CA, status post surgical procedure, now with multiple co-morbidities, who has not improved significantly in spite of aggressive and valiant efforts, now with biopsy of her new neck lesion pending and also evaluation of new potential lesions in liver and adrenal gland.
CA|cancer|CA;|311|313|PSH|She also has OSA, that is treated with CPAP set at 13. PMH: DM type 2, HTN, metabolic syndrome, lymphedema with chronic bilat cellulitis, OSA, presumed BOOP/COP with chronic steroid use tapered in _%#MM2007#%_ PSH: hemorroidectomy, cholecystecomy, bilat salpingoophrectomy Family hx: father - metastatic penile CA; mother - HTN Social hx: negative tobacco hx, rare ETHOH, no illicit drug use.
CA|cancer|CA.|142|144|REASON FOR CONSULTATION/HISTORY OF PRESENT ILLNESS|Further scans upon her admission have revealed right iliac bone lesion, lung lesions as well as liver lesions, all consistent with metastatic CA. She does have a past medical history of breast CA approximately 10-12 years ago, so etiology and origin of this new level of cancer is be still being investigated.
CA|carbohydrate antigen|CA|134|135|IMPRESSION  AND PLAN|I will also recommend proceeding with completing his staging workup by obtaining a CT of his chest. I will also recommend obtaining a CA 99 and CEA level. I reviewed the above probable diagnosis with the patient at length.
CA|cancer|CA|193|194|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Metastatic cancer of neck. Postop. HPI: Had history of squamous cell CA of mucosal surface of nasal ala, in _%#MM2001#%_, treated with Mohs surgery. In _%#MM2002#%_, developed multiple enlarging lymph nodes on right neck.
CA|cancer|CA.|158|160|PAST MEDICAL HISTORY|9. Iliac artery aneurysm repair. 10. Obstructive sleep apnea requiring BiPAP. 11. Type 2 diabetes, details are not clear. 12. Allergic rhinitis. 13. Prostate CA. 14. Lung nodule, history not clear. 15. History of nephrolithiasis. 16. History of left inguinal hernia repair. 17. TURP. 18. Open reduction and internal fixation, right ankle.
CA|cancer|CA|290|291|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: COPD, hypertension, PVD, carotid stenosis, urinary incontinence, hard of hearing, GERD, anxiety, depression and renal insufficiency status post thyroidectomy in 1946. Bilateral breast augmentation in 1977. Left carotid endarterectomy in 1996. Left thigh squamous cell CA carcinoma in 1997. Multiple hospitalizations with COPD, some hospitalizations also with very mild CHF and elevated BNP. SOCIAL HISTORY: She is widowed. Her husband was under hospice care of end-stage COPD and was in the hospital at Regions then went home for awhile and then in the hospital again and then is in home again with one daughter before coming into the hospital.
CA|cancer|CA,|162|164|PAST MEDICAL/SURGICAL HISTORY|2. Hypertension. 3. Negative stress test last year. 4. History of Wolff-Parkinson-White syndrome, status post ablation. 5. History of right mastectomy for breast CA, 1996, without recurrence. 6. Hysterectomy with BSO. 7. Cholecystectomy. MEDICATIONS: 1. Neurontin 300 mg at h.s. 2. Amitriptyline 25 mg at h.s., which she ran out of a few days ago.
CA|cancer|CA|119|120|HISTORY OF PRESENT ILLNESS|She was given dextrose and brought into the emergency room and sent to 6A and treated. She has a history of metastatic CA with increasing generalized weakness which has been getting progressively worse. She was recently in the hospital several weeks ago for that.
CA|cancer|CA|168|169|HISTORY OF PRESENT ILLNESS|The patient denies any nausea or vomiting. She denies any bowel changes. The patient did have a colonoscopy in _%#MM#%_ with Dr. _%#NAME#%_ for family history of colon CA in father. This demonstrated a slightly redundant colon, but otherwise a negative exam. PAST MEDICAL HISTORY: 1. Hypertension. 2. Exercise-induced asthma. 3. Osteoporosis.
CA|carbohydrate antigen|CA|126|127|HISTORY OF PRESENT ILLNESS|She had evaluation consisting of CT scan and endoscopy which localized a mass near the head of the pancreas, with an elevated CA 19-9. She then underwent ultrasound and a biopsy. The aspiration showed adenocarcinoma and on _%#MMDD2002#%_ she went for surgery with Dr. _%#NAME#%_ at the Mayo Clinic for a Whipple procedure. Pathology revealed grade 2/4 adenocarcinoma, tumor size of 3.0 x 2.7 x 1.2 cm.
CA|cancer|CA.|147|149|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: 1B Grade 3 endometrial CA. HPI: S/P TAH/BSO/nodes. Exam: Scar healing well. No adenopathy. Assessment and Plan: Discussed treatment options at length.
CA|cancer|CA|138|139|FAMILY HISTORY/SOCIAL HISTORY|HABITS: Nonsmoker. No alcohol. FAMILY HISTORY/SOCIAL HISTORY: The patient lives with his wife. He is retired. No family history for colon CA or polyps. REVIEW OF SYSTEMS: CONSTITUTIONAL: Negative. PULMONARY: Negative. CARDIAC: Negative. GI: As above.
CA|cancer|CA|200|201|PAST MEDICAL HISTORY|She states she is feeling wonderful. PAST MEDICAL HISTORY: 1. Bipolar affective disorder. 2. Hypertension. 3. COPD. 4. Non-insulin-dependent diabetes mellitus. 5. Hyperlipidemia. 6. History of breast CA without known recurrence. 7. History of hysterectomy. PRESENT MEDICATIONS: 1. Zyprexa. 2. Trazodone. 3. Lisinopril 20 mg q.d. 4. Calcium 1000 mg p.o. q.d.
CA|carbohydrate antigen|CA|261|262|IMPRESSION|If this potentially could represent a breast primary, the patient might be responsive to hormonal therapy; this would be our best bet as this would be the least toxic option for control of her cancer, with the best chance of response. Therefore, I will check a CA 27-29 tumor marker level and ask Pathology to check estrogen-receptor (ER) and progesterone- receptor (PR) on the tumor. If this is not a breast primary we might need to think about an ovarian primary given the elevated CA-125 level.
CA|cancer|CA,|144|146|PAST MEDICAL HISTORY|He does have atrial fibrillation for which he is chronically anticoagulated. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hyperlipidemia. 3. Colon CA, status post surgery. 4. Diabetes mellitus. HOME MEDICATIONS: 1. Coumadin 5 mg p.o. q. day. 2. Aspirin 325 mg p.o. q. day. 3. Cartia 240 mg p.o. q. day.
CA|cancer|CA.|195|197|ASSESSMENT|_%#NAME#%_ is currently requiring oxygen. She does not appear to be acutely ill from a pulmonary standpoint. 4. Chronic atrial fibrillation. 5. Mildly elevated calcium possibly secondary to lung CA. I doubt that this is contributing significantly to her mental status concerns. 6. Recent UTI. _%#NAME#%_ is currently asymptomatic in this regard.
CA|cancer|CA|213|214|HISTORY OF PRESENT ILLNESS|The patient had 10 cc of blood loss. He is extremely comfortable other than having some gas pains. In surgery he was noted to have right hydronephrosis. The patient is 2 years status post cystectomy for a bladder CA with neobladder construction. He has had several follow up cystoscopies. He had BCG treatment x2 most recently in 2004. PAST MEDICAL HISTORY: He is a nonsmoker, moderate drinker, 1 drink per day.
CA|cancer|CA,|133|135|ASSESSMENT|ASSESSMENT: 1) Anemia with normal MCV. 2) Heme-positive stool, rule out upper vs lower gastrointestinal source. 3) History of throat CA, status post radiation and chemotherapy. 4) Prior EGD with esophageal ulcer, treated with Prevacid preceding her throat CA. 5) Dysphagia following radiation with abnormal esophogram with cervical web and prominent cricopharyngeal muscle.
CA|carbohydrate antigen|CA|186|187|INDICATIONS|Subsequent to that he had a CT scan at Suburban Imaging which showed extensive omental caking suspicious for peritoneal carcinomatosis and ascites with a large cake. A CEA was negative; CA 19.9 which suggests pancreas was elevated. The patient had a paracentesis on _%#MMDD2006#%_ which showed an exudate based on the protein.
CA|cancer|CA|144|145|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Remarkable for hypertension, partial colectomy secondary to CA of the colon. Multiple small vessel CVA on chronic Plavix. CA of the rectum, depression, history degenerative joint disease, status post total abdominal hysterectomy and bilateral salpingooophorectomy, cholecystectomy and left cataract surgery.
CA|cancer|CA|120|121|PAST SURGICAL HISTORY|1. Hypertension. 2. COPD on oxygen therapy. 3. Dementia. PAST SURGICAL HISTORY: 1. Appendectomy. 2. Left mastectomy for CA of the breast in 1994. 3. Oophorectomy. 4. Tonsillectomy and adenoidectomy. SOCIAL HISTORY: She did smoke until 1995. She is a nursing home resident and widowed. She does not use alcohol.
CA|carbohydrate antigen|CA|225|226|RADIOGRAPHIC STUDIES|ALLERGIES: Seafood and pork. MEDICATIONS: Femara 2.5 mg at bedtime. RADIOGRAPHIC STUDIES: Bone scan indicated cervical, thoracic and lumbar spine metastases and left scapular, right and left ribs she has breast tumor markers CA 27.2, 482. REVIEW OF SYSTEMS: CONSTITUTIONAL: No weight loss. She states though that this pancreatitis pain has created some difficulty with eating because some of the foods exacerbate the pancreatitis pain.
CA|cancer|CA.|123|125|HISTORY OF PRESENT ILLNESS|She had thoracentesis done that drained 700 cc of blood-tinge fluid from her pleural space and she has a metastatic breast CA. I was told prior to going in to see her that she does not want any discussion or any talk around hospice at this point.
CA|carbohydrate antigen|CA|227|228|PLAN|5. No history of cardiopulmonary disease. 6. Mild chronic renal insufficiency with most recent creatinine of 1.6, about 2 months. Ago. PLAN: 1. Patient to have stat Labs including chemistry panel, LFT, amylase, lipase, CBC and CA 125. 2. Flat plate and upright of abdomen to evaluate for bowel obstruction and distention, which may be followed with CT of the abdomen, if suspicious findings for obstruction, and to evaluate for possible recurrent ovarian cancer 3.
CA|cancer|CA.|176|178|PROBLEM #1|We will closely monitor patient for fluid overload. PROBLEM #1: Gastrointestinal. The patient just had right anterior resection, proctoscopy, and ileostomy secondary to rectal CA. His pain is well controlled. The abdominal wound dressing is clean, dry, and intact. The patient is being followed by Colorectal Surgery. Continue Protonix 40 mg IV daily for GI prophylaxis.
CA|cancer|CA,|167|169|PAST MEDICAL HISTORY|She does describe a mild nonproductive cough, which she states may be related to allergies. PAST MEDICAL HISTORY: 1. Bipolar affective disorder. 2. History of uterine CA, status post hysterectomy here in 2004. 3. Borderline diabetes mellitus per patient account, it is not clear how this is followed. 4. No known coronary artery disease per patient account. It is not clear if she has ever had a formal coronary artery assessment.
CA|cancer|CA|100|101|PAST MEDICAL HISTORY|She was not aware of the fact that she was in atrial fibrillation. PAST MEDICAL HISTORY: 1. Uterine CA as outlined above. 2. Renovascular hypertension, status post bilateral renal angioplasties. 3. Status post hysterectomy for menorrhagia. 4. Diabetes. 5. Previous history of smoking, quit two months ago.
CA|cancer|CA,|134|136|PAST  MEDICAL HISTORY|The patient denies any nausea, vomiting, fevers or chills. She denies seeing any bleeding. PAST MEDICAL HISTORY: 1. History of breast CA, status post previous right mastectomy. 2. End-stage renal failure on chronic hemodialysis. 3. COPD. 4. History of aortic abdominal aneurysm in an inoperable candidate.
CA|cancer|CA|179|180|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1) Status post bilateral hip arthroplasties. 2) History of back surgery. 3) History of colostomy following radiation damage to rectum, with history of colon CA apparently. 4) Chronic renal insufficiency with baseline creatinine of 3.5. 5) Elevated cholesterol. 6) Coronary artery disease. 7) Diabetes mellitus. MEDICATIONS: 1) Insulin.
CA|cancer|CA,|89|91|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is an 88-year-old female with a history of colon CA, hepatic mets, and dementia. She fell and was found with swollen elbow by nursing home staff. She was brought to the ER. X-RAYS: X-rays confirmed olecranon fracture, age indeterminate.
CA|cancer|CA|192|193|HISTORY OF PRESENT ILLNESS|However, he has developed several problems since then, including recently in _%#MM#%_ of this year being admitted for left lower lobe pneumonia. He also has RAEB, as well as transitional cell CA of the bladder. The patient came into clinic and was admitted for new infiltrates. He was treated with antibiotics as well as transfusion for a hemoglobin of 8.
CA|cancer|CA|142|143|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Cirrhosis of liver. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 56-year-old white female with a history of breast CA metastatic to bone, status post modified radical mastectomy in 1996 who was referred initially to Dr. _%#NAME#%_ a year and a half ago for elevated liver tests, and found to have cirrhosis.
CA|carbohydrate antigen|CA|296|297|PLAN|ALLERGIES: Antibiotics, latex, Prozac, iodine, adrenaline, bee stings, shellfish. PHYSICAL EXAMINATION: There was no physical exam, but her vital signs show her height to be 64 inches, blood pressure 110/78, pulse 64, respirations 18, temperature 96.6, weight 190. PLAN: The patient will get her CA 27-29 checked every four months for this year. If they remain normal, I will see her in one year.
CA|cancer|CA|332|333|FAMILY HISTORY|_%#NAME#%_ from social service did call her and we have set up a family conference for 11:30 tomorrow to discuss the summary of the patient's health status and summary of the recent events with embolic episodes and care that the patient seems to be wanting at this point. She is wheelchair-bound and she is widowed. FAMILY HISTORY: CA of the breast and coronary artery disease. HEALTH HABITS: She quit smoking in 1990 and no alcohol.
CA|carbohydrate antigen|CA|145|146|IMPRESSION  AND PLAN|Both he and his sister asked many intelligent questions and I answered them to their satisfaction. At this time, I recommend obtaining a CEA and CA 19.9 levels. Prior to starting chemotherapy he will need a complete staging workup with a CT scan of the chest, abdomen and pelvis as a new baseline.
CA|carbohydrate antigen|CA|119|120|DISCUSSION|I agree with CT scan of the abdomen; may consider pelvic and chest CT to look for metastatic breast cancer. I will add CA 2729 tumor marker for her breast cancer. Elevated LDH could be associated with hemolytic process, therefore I will obtain a retic count and haptoglobin.
CA|cancer|CA.|161|163|REVIEW OF SYSTEMS|HEENT: Unremarkable. Respiratory system is unremarkable. Cardiovascular system is significant for hypertension. Genitourinary system is significant for prostate CA. Gastrointestinal system is unremarkable. Endocrinology system is significant for diabetes. Musculoskeletal system is significant for gout. Neurological system is unremarkable. PHYSICAL EXAMINATION: He is alert and oriented x3.
CA|cancer|CA.|133|135|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Prostate CA. HPI: PSA 12. T1C. Gleason 6. Exam: Small nonenlarged, nonnodular prostate. No masses. Assessment and Plan: Radiation options discussed at length.
CA|cancer|CA.|131|133|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Breast CA. Inflammatory breast CA, chest wall, recurrence HPI: She had T4 N2 M0 left breast CA, infiltrating ductal CA originally, had bilateral mastectomy and chemotherapy _%#MM#%_, 2001.
CA|cancer|CA.|202|204|DIAGNOSTIC  IMPRESSION|5. Hypothyroidism. 6. Hypertension. 7. Easy bruising most of her life. 8. Past history of Crohn's disease, currently on remission. 9. Post-multiple cancer surgery in the past, partial thyroidectomy for CA. Radical modified left mastectomy for CA at age 40. Hysterectomy for CA at age 40 so far no obvious recurrence at this point.
CA|carbohydrate antigen|CA|223|224|LOCATION|He is now status post 5 cycles of Gemzar on an every-other-week schedule and seems to be tolerating this regimen quite well. We are gratified to see that he is gaining weight. He is no longer having abdominal pain, and his CA 199, which was up to 162,000 at initiation, after the 6th cycle had dropped to 55,000. I view this as a very dramatic response, although it is still obviously very elevated.
CA|cancer|CA|136|137|PAST  MEDICAL HISTORY|2. Exudative pleural effusions. 3. Longstanding orthostatics dizziness. 4. Anemia. 5. BPH. 6. Depression. 7. Remote history of squamous CA of the tongue with neck dissection. PAST SURGICAL HISTORY: 1. Partial tongue resection as noted.
CA|cancer|CA.|149|151|FAMILY HISTORY|Father had a CVA and mother had TIAs. A sister also has hypertension and hyperlipidemia. There is no history of coronary artery disease, diabetes or CA. SOCIAL HISTORY: He is married. He has one daughter. He is a retired cost analyst for the Air Force Reserve.
CA|cancer|CA|149|150|HISTORY OF PRESENT ILLNESS|He had mentioned today and rounds that she will be going to hospice of the Lakes. She is postoperative for colostomy and has a history of metastatic CA of the breast status post radiation, which I believe she is still receiving that and did have chemotherapy. She has cerebellar mass and mediastinal adenopathy and then now has a colostomy.
CA|cancer|CA.|174|176|FAMILY HISTORY|Appendectomy in the distant past, angioplasty left leg in 1994, angioedema secondary to ACE inhibitor on _%#MM2005#%_. FAMILY HISTORY: Remarkable for her sister with stomach CA. Father with some type of CA unknown. ALLERGIES: Penicillin, sulfa, erythromycin, lisinopril, losartan. Losartan causes elevated creatinine.
CA|cancer|CA|203|204|FAMILY HISTORY|Appendectomy in the distant past, angioplasty left leg in 1994, angioedema secondary to ACE inhibitor on _%#MM2005#%_. FAMILY HISTORY: Remarkable for her sister with stomach CA. Father with some type of CA unknown. ALLERGIES: Penicillin, sulfa, erythromycin, lisinopril, losartan. Losartan causes elevated creatinine.
CA|cancer|CA.|164|166|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: 75-year-old male with stage IV NSC lung CA. HPI: S/P 375OCGY of whole brain RT, now symptomatic left cerebral peduncle lesion.
CA|cancer|CA|196|197|FAMILY HISTORY|Family is very supportive and has been here much of the time in the Intensive Care Unit. FAMILY HISTORY: She has a family history of sister dying at 49 years old of colon cancer. Mother with lung CA who is still alive at 79 years old. Father died of an MI. ALLERGIES: Iodine and Neurontin. Neurontin created dizziness when she took it systemically.
CA|cancer|CA|160|161|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Odor to biliary drainage, feeling poorly. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 57-year-old white male diagnosed with gastric CA in _%#MM#%_, 2003. This was poorly differentiated. He underwent a partial gastrectomy with Billroth-II anastomosis and postop chemotherapy.
CA|cancer|CA|194|195|HISTORY OF PRESENT ILLNESS|DATE OF CONSULTATION: _%#MMDD2007#%_ HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 63-year-old woman I am asked to see in consultation for palliative care by Dr. _%#NAME#%_ and she has metastatic CA of the breast with bone metastases and was admitted with acute left proximal femur fracture and had an open reduction and internal fixation on the left femur as well as a left bipolar hemiarthroplasty on _%#MMDD2007#%_.
CA|cancer|CA,|198|200|HISTORY|We will be available to assist as needed in this setting. HISTORY: Limited history available on Mr. _%#NAME#%_. He is a known patient at the VA and has recently been treated there for synovial cell CA, which is thought as a result of exposure to Agent Orange inference. Apparently has no significant other past medical history from what I could tell from the limited records we have available.
CA|cancer|CA|166|167|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Dementia. 2. Hearing loss. 3. Macular degeneration. 4. Coronary artery disease. 5. Hypertension. 6. Prostate CA. 7. Dyslipidemia. 8. TIA. 9. CA of colon. 10. Rhinitis. MEDICATIONS: Prior to admission are chlorpheniramine, temazepam, lisinopril, Lipitor, Namenda, Exelon, multivitamins, aspirin daily, acetaminophen, oxybutynin and Vicodin.
CA|cancer|CA,|131|133|PAST MEDICAL HISTORY|3. Chronic anemia. 4. Hypertension. 5. Peripheral vascular disease with history of left carotid endarterectomy. 6. History of lung CA, status post partial lung resection. 7. History of gout. 8. History of trigeminal neuralgia. REVIEW OF SYSTEMS: Is also positive for leg fatigue and legs giving out with walking.
CA|cancer|CA.|118|120|PAST  MEDICAL HISTORY|She denies nausea, vomiting, abdominal pain, diarrhea. PAST MEDICAL HISTORY: 1. Bipolar disorder. 2. History of colon CA. She is status post resection of colon cancer at the hepatic flexure. She apparently has not required chemotherapy and has had no complications.
CA|cancer|CA.|180|182|IMPRESSION|2. Past medical history of atrial fibrillation, but not on Coumadin the last year. Also, cancer of left ear with a resection and it is unclear if it is squamous cell or basal cell CA. 3. Code is DNR/DNI and staff is reporting family want comfort care. 4. Allergies - none known. 5. Review of systems - nonverbal and nonresponsive.
CA|cancer|CA.|211|213|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1) Sinusitis, started on amoxicillin a few days before admission. 2) Diabetes mellitus. 3) Status post subtotal colectomy for multiple polyps. 4) Status post cholecystectomy. 5) Pancreatic CA. 6) Hypertension. 7) Elevated lipids. MEDICATIONS AT HOME: 1) Amoxicillin. 2) Vicodin. 3) Lorazepam. 4) Zocor.
CA|carbohydrate antigen|CA|165|166|RECOMMENDATIONS|3. Anemia associated with malignancy and chemotherapy. 4. Left breast nodule, etiology unclear, primary versus metastatic deposit. RECOMMENDATIONS: 1. I will obtain CA 125 tumor marker for her primary peritoneal carcinomatosis, which if it is elevated would confirm progressive disease. 2. I will also obtain CA 27.29 for primary breast cancer and evaluate her breast nodule by mammogram.
CA|cancer|CA.|153|155|FAMILY HISTORY|PAST MEDICAL HISTORY: Remarkable for TIA, depression, tubal ligation and degenerative joint disease. FAMILY HISTORY: Remarkable for a mother with breast CA. Father with prostate CA with metastases. They are both alive. Paternal grandfather with metastatic prostate CA. Maternal aunts with CA of the breast. SOCIAL HISTORY: She lives with her husband.
CA|carbohydrate antigen|CA|211|212|SUMMARY CASE|This was ER positive and weekly progesterone receptor positive, was negative for HER2 by FISH analysis. The patient had some laboratory studies on _%#MMDD2007#%_ with a CBC, which was unremarkable; however, her CA 2729 tumor marker came back markedly elevated at 654. I believe this was an unanticipated finding. On _%#MMDD2007#%_, probably as a result of bilateral breast cancer and the markedly elevated CA 2729, Dr. _%#NAME#%_ ordered a PET CT scan.
CA|cancer|CA|178|179|PAST  MEDICAL HISTORY|A repeat set of blood gasses is being checked. Initially there was evidence of metabolic acidosis and hypoxia. PAST MEDICAL HISTORY: See also the H&P. The problems have included CA of the stomach with a Whipple procedure involving a pancreatectomy ten years ago, coronary heart disease9(not known prior to this admission) diabetes mellitus, post-pancreatectomy, nephrolithiasis, none recently FAMILY HISTORY: Negative for diabetes, coronary heart disease, renal disease.
CA|cancer|CA|134|135|PAST  MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Hemophilia A 2. Status post right hip replacement. 3. Glaucoma. 4. Bilateral cataract surgery. 5. Basal cell CA on top of the head. 6. Dementia. MEDICATIONS: Aricept, Xalatan and Trusopt. No aspirin or nonsteroidal use.
CA|cancer|CA|163|164|PAST MEDICAL HISTORY|Again, the study was unremarkable for any evidence of intracranial pathology. She does not describe any headache at this time. PAST MEDICAL HISTORY: Includes lung CA as noted above which was diagnosed _%#MM#%_ 2003. Past history also includes hypertension, anxiety/depression, hypothyroidism, hyperuricemia, chronic renal insufficiency and a diagnosis of conversion disorder.
CA|cancer|CA|118|119|CHIEF COMPLAINT|CHIEF COMPLAINT: 73-year-old Somali male presented with weakness and dehydration and was found to have possible liver CA with mets via the CT scan. Transition and Life Choices consulted to discuss goals of care and advanced care planning with the patient and family.
CA|cancer|CA.|174|176|PAST MEDICAL HISTORY|3. Peripheral neuropathy secondary to diabetes. 4. History of cerebrovascular disease. The patient is status post left carotid endarterectomy in 1997. 5. History of prostate CA. 6. Hypertension. 7. Hyperlipidemia. 8. History of right hemispheric CVA, occurring in the setting of coronary artery surgery in _%#MM1998#%_. MEDICATION: 1. Humulin 70/30, 17 units before breakfast and 22 units before evening meal.
CA|cancer|CA.|213|215|FAMILY HISTORY|SOCIAL HISTORY: She is a receptionist, married. Husband is ill with end-stage renal failure, on dialysis, and lives in _%#CITY#%_. No family members in the immediate community. FAMILY HISTORY: Positive for breast CA. PHYSICAL EXAMINATION: She is lying in bed, unable to respond to commands.
CA|carbohydrate antigen|CA|227|228|IMPRESSION|The patient has become jaundiced from obstruction at the level of the common bile duct, and GI has been asked to see for possible ERCP and placement of a biliary stent. His liver function will be followed, a serum tumor marker CA 19-9 will be obtained to evaluate for the possibility of a primary pancreatic carcinoma, although this would seem quite unlikely given the rapidity of growth of these lesions.
CA|cancer|CA|120|121|PAST MEDICAL HISTORY|He has no history of cardiovascular disease. His blood pressure is controlled, as noted today. PAST MEDICAL HISTORY: 1) CA of the prostate with orchiectomy and radiation, followed at Mayo Clinic without recurrence. 2) Bronchiectasis, followed by Pulmonary at Mayo. 3) Hypoxemia and pneumonia for which he was hospitalized in 2002 at Fairview Southdale Hospital.
CA|cancer|CA.|179|181|HISTORY|8. We will follow with you as deemed necessary during the course of her hospitalization. HISTORY: This is a 50-year-old female with a known diagnosis of metastatic non small cell CA. She has known METS to both brain and to her retroperitoneal and mesenteric lymph nodes. She has been receiving chemotherapy under the direction of the Oncology service as an outpatient.
CA|cancer|CA|244|245|HISTORY OF PRESENT ILLNESS|On further examination, upon doing a biopsy, status post doing stent placements to the larynx and esophagus, they found that there is carcinoma. The patient also has a history of lung carcinoma and they are questioning whether this is the lung CA metastasized, or whether this is a new primary site. The patient has been seen by Thoracic Surgery and by Radiation Oncology who both feel that he is not amenable to treatment at this time.
CA|cancer|CA|193|194|REASON FOR CONSULTATION|She has been seeing Dr. _%#NAME#%_ and has had several attempts of chemotherapy, the latest of which has been more aggressive and causing more side effects for her. She currently has a primary CA of breast with liver metastasis and bony metastasis as well. She has been struggling with increased ascites, abdominal distention and discomfort as well as constant fatigue and anorexia.
CA|cancer|CA|204|205|PAST  MEDICAL HISTORY|1. Coronary artery disease. 2. Atrial fibrillation. 3. Chronic Coumadin use. 4. Type 2 diabetes mellitus. 5. Hypertension. 6. Elevated lipids. 7. Seizure disorder. 8. Prostate CA in remission. 9. Bladder CA in remission. SURGICAL 1. Coronary artery bypass grafting 2. ICD/pacemaker 3. Cataract surgery 4. Tonsillectomy 5. Cholecystectomy. ALLERGIES: None known. HOME MEDICATIONS: Albuterol, Dilantin, metformin, glipizide, aspirin, Coumadin, lisinopril, Toprol, Lipitor, digoxin, allopurinol.
CA|cancer|CA.|163|165|PAST  MEDICAL HISTORY|4. Atrial fibrillation. He claims his last episode of a fib was 12-13 years ago but is on chronic Coumadin. 5. History of seizure disorder. 6. History of prostate CA. 7. History of small CVA four years ago. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Lisinopril 20 mg q. day 2. Lipitor 40 q.h.s., 3. Glipizide 10 mg q. day 3. Aspirin. 4. Dilantin.
CA|cancer|CA.|212|214|ASSESSMENT/PLAN|ASSESSMENT/PLAN: 1. Overall, the patient is an unfortunate, 60-year-old gentleman with multiple problems, including vascular, cardiovascular, ischemic cardiomyopathy and more importantly metastatic Merkel's cell CA. Etiology of the chest pain is clearly secondary to musculoskeletal, probably secondary to metastases. It is difficult to say whether or not the patient has had any angina of late, but given the brief duration of the chest pain, certainly there has been no significant progression of his anginal symptoms.
CA|cancer|CA|192|193|HISTORY OF PRESENT ILLNESS|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD CHIEF COMPLAINT: Dysphagia, odynophagia. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 71-year-old white male with history of squamous CA of the lung, receiving radiation therapy and chemotherapy. He has received ongoing radiation treatments until one week ago. He then had the onset of significant problems with swallowing and pain with swallowing.
CA|cancer|CA|207|208|PAST MEDICAL HISTORY|He is finding that he has some increased saliva now with his problems with dysphagia and odynophagia. The patient is receiving TPN. PAST MEDICAL HISTORY: 1. In 1998, dysphagia with soft palate squamous cell CA treated with surgery and radiation therapy. This was complicated by actinomycosis of the jaw with replacement with bone grafting. 2. In _%#MM2003#%_, non-small cell CA of the lung resected, apparently a squamous cell CA stage IB.
CA|cancer|CA|240|241|PAST SURGICAL HISTORY|PAST MEDICAL HISTORY: 1. Hepatitis C with cirrhosis and varices. 2. Depression. 3. Thrombocytopenia. PAST SURGICAL HISTORY: Left tibia and fibula fracture with open reduction and internal fixation, cholecystectomy, appendectomy, basal cell CA of the nose. MEDICATIONS: Lexapro, Abilify, Nexium, spironolactone 50 mg b.i.d. ALLERGIES: Vicodin causes tremors.
CA|cancer|CA,|166|168|CHRONIC DISEASE/MAJOR ILLNESS|2. History of congestive heart failure. 3. Paroxysmal atrial fibrillation. 4. Hypertension. 5. Chronic renal insufficiency. 6. Chronic anemia. 7. History of prostate CA, status post prostatectomy with sphincter implant. 8. Abdominal aortic aneurysm. 9. DVT and PE in the past. 10. Chronic venous stasis disease. 11. Chronic back pain related to spinal stenosis and degenerative changes with pain dating back many years.
CA|cancer|CA|163|164|ASSESSMENT|2. Chronic renal insufficiency. 3. Hypertension. Appears to be under good control. 4. History of benign prostatic hypertrophy and prostate CA. Apparently prostate CA is being monitored without intervention. PLAN: No medical changes recommended at this time. His current antihypertensive program appears to be adequate.
CA|cancer|CA|181|182||He had a volume study of his prostate on _%#MM#%_ _%#DD#%_, 2002; the size of the gland is now 32.5 gm. We plan to do brachytherapy on _%#MM#%_ _%#DD#%_, 2002 for his grade III/III CA of the prostate in both lobes.
CA|cancer|CA.|155|157|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Metastatic non-small cell lung CA. HPI: Status post stereotactic with single met on _%#MMDD2002#%_, now presents with 2nd small isolated brain met.
CA|cancer|CA.|214|216|PHYSICAL EXAMINATION|I do not have any plans for orthopedic interventions at this time. She does not have any mechanically unstable lesions. We will need to consult oncology for their recommendations for treatment of metastatic breast CA.
CA|carbohydrate antigen|CA|200|201|FURTHER LAB STUDIES|FURTHER LAB STUDIES: Alpha fetoprotein is 15.4, positive hep C serology, creatinine 0.78, BUN of 6, white count 5, hemoglobin 13.4, hematocrit 37.9 with an MCV of 92, platelet count 99,000, INR 1.26. CA 125-41. C. difficile toxin negative. Hep B and Hep A antibody was negative. Ferritin is 169, LDH is a 547. IMPRESSION AND PLAN: The patient is a very pleasant 53-year-old female who presents with increased abdominal girth of 3 months' duration.
CA|cancer|CA|183|184|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Bipolar affective disorder. 2. Hypertension. 3. History of pneumonia requiring hospitalization a couple of years ago. 4. History of a hemicolectomy for colon CA in 1997. The patient's coronary artery status is not known. ALLERGIES: None.
CA|cancer|CA|121|122|PAST  MEDICAL HISTORY|He denies any other numbness, tingling, weakness, bowel or bladder complaints. PAST MEDICAL HISTORY: History of prostate CA and lung CA with chronic obstructive pulmonary disease, long smoking history, chronic anemia, hypertension. He had a left lower lobe lung resection two years ago and has a hilar mass which has been stable in size with repeat imaging.
CA|cancer|CA,|149|151|PAST MEDICAL HISTORY|He is referred to us for consideration of possible palliative radiation treatments to the cervical spine lesion. PAST MEDICAL HISTORY: 1. Esophageal CA, status post resection. 2. Septorhinoplasty. MEDICATIONS: Toprol, allopurinol, Nexium, Darvocet, gabapentin. ALLERGIES: Penicillin. FAMILY HISTORY: No family history of cancer.
CA|cancer|CA.|218|220|IMPRESSION/RECOMMENDATIONS|If the liver biopsies show recurrent disease, one could consider palliative radiation treatment to the C-spine lesion. However, it is unusual to see a paraspinal mass presenting as a metastatic disease with esophageal CA. If the liver biopsy is negative, one would definitely consider biopsying the C-spine lesion before considering radiation treatments.
CA|cancer|CA|38|39|PROBLEM|PROBLEM: T1, N2B Mo basaloid squamous CA of left base of tongue. Mr. _%#NAME#%_ was seen in the Therapeutic Radiation Department on _%#MM#%_ _%#DD#%_, 2002 for consultation by Drs. _%#NAME#%_ _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_, at the request of Dr. _%#NAME#%_.
CA|cancer|CA.|124|126|FAMILY HISTORY|Two children. Multilevel house. No smoking. Occasional alcohol use. FAMILY HISTORY: Father with a stroke. Mother pancreatic CA. ALLERGIES: None. MEDICATIONS: Please see hospital chart.
CA|cancer|CA.|173|175|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old man who we were asked to see because of headaches and imbalance. The patient has a history of metastatic renal cell CA. He was recently treated with Adriamycin and his last dose was given on _%#MMDD2007#%_. He developed secondary to this nausea and emesis. He was significantly dehydrated.
CA|carbohydrate antigen|CA|258|259|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: I first met the patient a couple of weeks ago. At that time, she presented with increasing abdominal bloating and abdominal distention, and evaluation revealed evidence of ascites with an omental cake on CT scanning, and elevated CA 125 level in the 425 range, and a paracentesis revealed evidence of carcinoma. I suggested referral to Dr. _%#NAME#%_ _%#NAME#%_ for laparotomy and debulking, and on _%#MMDD2004#%_ the patient was admitted to Abbott Northwestern Hospital, and did undergo that surgical procedure.
CA|cancer|CA.|140|142|PAST  MEDICAL HISTORY|2. Hypertension. 3. Hyperlipidemia. 4. Hypothyroidism. 5. Peripheral neuropathy with left foot Charcot joint. 6. GERD. 7. History of breast CA. 8. History of heart murmur for which the patient states she has been evaluated. She has had an unremarkable echocardiogram. She is not aware of known coronary artery disease.
CA|cancer|CA|174|175|ASSESSMENT|He has a Foley catheter in. He is not able to move the right side at all upper or lower extremities. . ASSESSMENT: Palliative care patient, 70 years old with metastatic lung CA with mets to the brain with the following issues. Urinary tract infection being treated with Levaquin and dehydration receiving fluids.
CA|carbohydrate antigen|CA|202|203|DOB|She began Navelbine systemic chemotherapy at that time. Her disease involves the pleura, liver and skeletal system. More recently she has been treated with weekly Taxotere with decent response (falling CA 27-28 over the past month). Her last dose of chemotherapy occurred on _%#MMDD2004#%_. _%#NAME#%_ was admitted to Fairview Ridges Hospital with an episode of syncope today.
CA|cancer|CA|219|220|PAST MEDICAL HISTORY|She had a metabolic acidosis REVIEW OF SYSTEMS: Unobtainable. FAMILY HISTORY: Negative but unobtainable. SOCIAL HISTORY: Lives with husband, otherwise unobtainable. PAST MEDICAL HISTORY: Pertinent for stage II cervical CA and prediabetes. PHYSICAL EXAMINATION . GENERAL: The patient is intubated. VITAL SIGNS: SaO2 is 100%, pulse is 79.
CA|cancer|CA|305|306|HISTORY OF PRESENT ILLNESS|It was determined that approximately a year ago he was determined to have had an abdominal mass and chose not to have any treatment. He does have a history of congestive heart failure, atrial fibrillation, and after evaluation in the ER last night, was found to have, what is believed to be, an abdominal CA with brain mets and possible lung mets. Prior to coming to the hospital he had been on Lasix, Lanoxin, Lisinopril, Toprol, and Warfarin.
CA|carbohydrate antigen|CA|120|121|PAST MEDICAL HISTORY|5. GERD. 6. Hypertension. 7. History of esophageal ulcers in past as noted above due to Fosamax. 8. History of elevated CA in 1999 with negative ERCP. 9. Small bowel obstruction with surgery in 1995. 10. History of left-sided ischemic colitis.
CA|cancer|CA|136|137|HISTORY OF PRESENT ILLNESS|An IVP is being scheduled for tomorrow. The patient denies any jaundice, change in color of urine or stool. She has the same pancreatic CA pain, unchanged from previously. There are otherwise no new symptoms. PAST MEDICAL HISTORY: 1) Metastatic pancreatic CA.
CA|cancer|CA,|170|172|HISTORY OF PRESENT ILLNESS|She denies any nausea or vomiting. The patient had a negative screening colonoscopy except for a few diverticula found 11 years ago. There is no family history for colon CA, polyps or IBD. The patient does have significant cramping with the bowel habits.
CA|carbohydrate antigen|CA|195|196|ASSESSMENT, EVALUATION, AND RECOMMENDATION|We would recommend palliative care, pain management, and consideration of hospice care at some point. We would also recommend continuing to include family in the process. We will plan to check a CA 199 and a CA. 2. Syndrome of inappropriate secretion of antidiuretic hormone. She does have some discrepancy between her urine and serum osmolality.
CA|carbohydrate antigen|CA|263|264|LABORATORY DATA|EXTREMITIES: No edema, cyanosis or clubbing. NEURO: Non-focal. LABORATORY DATA: A CBC was obtained on admission and was within normal limits with a hemoglobin of 15.6, platelets of 276. Chemistry profile was within normal limits with normal liver function tests. CA on _%#MMDD#%_ was slightly elevated at 2.9. CT scan of the abdomen and pelvis on _%#MMDD#%_ showed small bowel obstruction with soft tissue density throughout the pelvis with suggestion of carcinomatosis.
CA|cancer|CA|203|204|IMPRESSION|IMPRESSION: 1) Oliguria following acute hypotensive episode during heart cath. 2) Possible ATN developing, though urine output now picking up. 3) Possible element of obstructive uropathy in patient with CA of bladder and right ureteral stent; the appearance of increasing urine volume tends to rule against this. 4) Cardiomyopathy, possible infiltrative, amyloidosis, etc; status post cardiac biopsy today.
CA|cancer|CA|242|243|PAST MEDICAL HISTORY|These lesions are located in the left upper back and shoulder area and looks like it is actually originating from behind his ear on down to the upper arm. PAST MEDICAL HISTORY: Coronary artery disease, status post CABG, hypertension, bladder CA status post cystoscopy, history of CVI with right-sided weakness that is mild, chronic renal disease with creatinine of 3.2, elevated cholesterol, aneurysm status post diastolic dysfunction with CHF, tobacco history, chronic lower extremity edema.
CA|cancer|CA|198|199|DOB|Following an evaluation by Dr. _%#NAME#%_, it was determined that he had pain actually on a lot of other areas besides his chest wall. This is a gentleman who has been diagnosed with non-small cell CA of the lung and he has been on Oxycontin 120 mg t.i.d. and oxycodone 5 mg 25 tablets a day, and actually a couple of days ago his wife stated that she was concerned because he had over- medicated in an attempt to get his pain under control, and so they would like a revised pain management treatment plan.
CA|cancer|CA|155|156|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Blood in NG tube. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 65-year- old, white female with a history of metastatic squamous CA to brain, mixed neuroendocrine neoplasm. This is felt to be secondary to a probable lung CA. This has been complicated by a CVA. The patient has had a postoperative ileus, has an NG tube in place.
CA|cancer|CA|100|101|PAST MEDICAL HISTORY|She is receiving IV fluids. She has some urine output noted. PAST MEDICAL HISTORY: 1. Nonsmall cell CA with details as noted above. 2. Hypercoagulable state, presumed secondary to above with both arterial and venous involvement in the past 3.
CA|cancer|CA.|166|168|PAST MEDICAL HISTORY|3. Chronic renal insufficiency. 4. Coronary artery disease. 5. Left nephrectomy. 6. Pacemaker for bradycardia. 7. Partial amputation of 3 and 4 digits. 8. Basal cell CA. 9. Hypertension. 10. Increased cholesterol. 11. Gastric reflux. ALLERGIES: Sulfa, Accupril, hydrochlorothiazide, ibuprofen. MEDICATIONS: See hospital chart.
CA|cancer|CA,|68|70|CHIEF COMPLAINT|CHIEF COMPLAINT: Rectal bleeding, positive family history for colon CA, need for inpatient colonoscopy prepping. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 48-year-old, single, white female with a chronic history of constipation, moving her bowels every two or three days.
CA|cancer|CA.|133|135|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Prostate CA. T1C, Gleason 2+2 = 4 with PSAS of 5.4. HPI: Obstructive symptoms prompted TURP and unexpected finding of cancer.
CA|cancer|CA.|154|156|HISTORY|He has a complex urologic history which is described in the chart. He is status post left nephrectomy for renal carcinoma. He is also status post bladder CA. He has undergone cobalt treatment, which left him with recurrent ureteral obstruction. This necessitated the placement of an ileal conduit which itself had been intermittently obstructing in the past causing systematic UTIs.
CA|cancer|CA|272|273|PLAN|Prior medical history is significant for fibromyalgia, depression, tobacco abuse in the past, osteoporosis, Raynaud's phenomenon, vaginal cancer status post radical vulvectomy, cervical cancer as well, left breast cancer status post lumpectomy and radiation, right breast CA as well. History of multiple actinic keratosis and squamous cell carcinomas, benign essential hypertension and hypercholesterolemia, bilateral shoulder spur removal.
CA|cancer|CA|306|307|FAMILY HISTORY|PAST MEDICAL HISTORY: Remarkable for rheumatoid nodules, rectal bleeding, vocal cord surgery, fibromyalgia syndrome, whiplash injury on _%#MMDD2004#%_, asthma, two C-sections, three jaw surgeries and esophageal strictures. SOCIAL HISTORY: She does work part-time. FAMILY HISTORY: Father died of esophageal CA in his 50s, and there is also coronary artery disease in her family. ALLERGIES: Zantac with a rash and lactose and now she tells me that she did have a rash from the Lidoderm that I gave her for the abdominal pain that she was having in the emergency room and so I added that to the allergy list.
CA|cancer|CA|139|140|PAST SURGICAL HISTORY|PAST MEDICAL HISTORY: 1. Hypertension. 2. Angina. PAST SURGICAL HISTORY: 1. Hysterectomy and oophorectomy 18 months back with diagnosis of CA endometrium. 2. Cholecystectomy. 3. Lumpectomy of the right breast with a diagnosis of carcinoma of the breast. 4. Appendectomy. PAST CHEMOTHERAPY/RADIATION: The patient had radiation treatments to the breast.
CA|carbohydrate antigen|CA|214|215|IMPRESSION/PLAN|Once he is stable he will need further workup for staging as well as workup performed to look for his primary. I will recommend obtaining a tumor marker level to rule out possible pancreatic versus colon cancer. A CA 99 and CA level will be obtained today. I would recommend obtaining a full CT scan of the chest, abdomen and pelvis for full staging workup as well as to evaluate for possible small bowel obstruction versus ileus.
CA|cancer|CA|181|182|DISCUSSION|Please see Dr. _%#NAME#%_'s notes and the notes of the Smiley's residents for details regarding the events leading up to surgery. Briefly, the patient has known metastatic prostate CA and is admitted because of progressive lower extremity weakness secondary to cord compression from tumor. This necessitated the above surgery. The patient has received radiation therapy for his prostate CA and was more recently started on corticosteroids when a cord compression was suspected.
CA|cancer|CA|177|178|PAST SURGICAL HISTORY|CURRENT MEDICATIONS: Listed in the reconciliation list. PAST SURGICAL HISTORY: 1. 2005, breast implant replacement. 2. 2005, T4 biopsy. 3. 1985, bilateral mastectomy for breast CA 4. 1974, cholecystectomy. CHRONIC DISEASE/MAJOR ILLNESSES: 1. Hypertension. 2. DJD.
CA|cancer|CA|246|247|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old gentleman I am asked to see in consultation for palliative care by Dr. _%#NAME#%_. He was admitted for weakness, acute renal failure with chronic renal failure diagnosed with squamous cell CA of the lung, status post wedge resection that was done recently and then 2 episodes of coffee ground emesis. Currently he is having quite a bit of pain in his right foot better that occurs with dressing changes as well as any movement.
CA|cancer|CA,|315|317|PAST MEDICAL HISTORY|Since hospitalization patient she has been receiving pulmonary treatment and actually has been coughing productively a lot more now and is actually clearing her airway some so she does feel better today from the standpoint of her breathing. PAST MEDICAL HISTORY: COPD, oxygen dependent, cardiac dysrhythmia, breast CA, vulva neoplasia and osteoporosis with vertebral body compression fracture. She is status post mastectomy on the left in 1994, TAH, cholecystectomy and appendectomy.
CA|cancer|CA|164|165|NEUROLOGY CONSULTATION|End-stage renal disease; on dialysis three days a week. Hyperlipidemia. He is status post laparotomy for adhesions or bowel obstructions, appendectomy, and bladder CA excision. Medications include digoxin, Lasix, Norvasc, Lipitor, Coumadin, and Centrum Silver.
CA|cancer|CA|191|192|HISTORY OF PRESENT ILLNESS|Transitions and Life Choices is consulted secondary to her deteriorating status after starting palliative radiation. HISTORY OF PRESENT ILLNESS: A 68-year-old woman with a history of ovarian CA originally treated in 2005, stage III, and had newly diagnosed left parietal lobe CVA on _%#MMDD2006#%_, as well as a small, early subacute infarct in the right medulla area in_%#MM2006#%_ after she came in complaining of weakness.
CA|cancer|CA,|186|188|PAST MEDICAL HISTORY|2. Rheumatoid arthritis. 3. Chronic obstructive pulmonary disease. 4. Borderline diabetes mellitus as noted above. 5. Gastroesophageal reflux disease. 6. History of endometrial/cervical CA, status post hysterectomy with bilateral salpingo-oophorectomy, 1975. MEDICATIONS: 1. Advair 500/50 one puff twice a day.
CA|cancer|CA|274|275|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Cirrhosis with hepatitis C secondary to a tattoo that is in her right shoulder in 1996 that she stated was done in her living room. 2. Ascites. 3. Coagulopathy in _%#MM2006#%_. 4. ETOH. Heavy in the past. 5. Nephrolithiasis. 6. Benign tremor breast CA with bony mets and mets to the spine in 1997; however, she states now Dr. _%#NAME#%_ is telling her that she cannot find any cancer.
CA|cancer|CA.|115|117|PAST MEDICAL HISTORY|No chest pain. No urinary symptoms. No upper respiratory infection symptoms. PAST MEDICAL HISTORY: History of lung CA. The patient had left upper lobe of the lung removed in _%#MM2005#%_. He has also history of anxiety, history of arthritis. PAST SURGICAL HISTORY: As mentioned above, left upper lung lobe surgery.
CA|cancer|CA.|138|140|PAST MEDICAL HISTORY|It appears that his last stress test was in _%#MM#%_ 2002. At that time, he had intact LV systolic function. 2. Hypertension. 3. Prostate CA. 4. History of multiple orthopedic procedures. The patient denies knowledge of complications from these surgeries.
CA|cancer|CA.|109|111|FAMILY HISTORY|Former alcohol user retired music teacher who lives with his wife. FAMILY HISTORY: Father died of pancreatic CA. Mother died of stroke. REVIEW OF SYSTEMS: Denies any decreased vision, hearing, speech or swallowing.
CA|carbohydrate antigen|CA|126|127|DISCUSSION/RECOMMENDATIONS|Will await final pathology on her biopsy. I will obtain CT scan of the chest for complete staging preoperatively and will add CA 19-9 as a baseline. Will follow up after pathology report and further recommendation will depend on the stage of her cancer and resectability status.
CA|cancer|CA|243|244|FAMILY HISTORY|PAST SURGICAL HISTORY: Hysterectomy, bladder repair, fibroid excision on the breast, right knee surgery, left hip surgery, IVC placed. FAMILY HISTORY: Father with colon cancer, mother with CAD, hypertension with her siblings and a sister with CA of the breast. SOCIAL HISTORY: She is widowed. She has a daughter who is present today.
CA|cancer|CA|184|185|PAST MEDICAL HISTORY|There is a lot of pain, there was a greater amount of pain when she first came in as compared to now and deep breathing increased that pain. PAST MEDICAL HISTORY: Remarkable for COPD, CA of the lung, status post right upper lobectomy, type 2 diabetes, atrial fibrillation, right subclavian stenosis, macular degeneration, retinal vascular occlusion, chronic UTIs, status post right lung lobectomy.
CA|cancer|CA|257|258|HISTORY OF PRESENT ILLNESS|DATE OF CONSULTATION: _%#MMDD2007#%_ HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 51-year-old gentleman whom I am asked to see in consultation for palliative care by Dr. _%#NAME#%_. He has a diagnosis of CA of the colon with liver metastasis. The CA of the colon was diagnosed in 2005. He has had 6 rounds of chemotherapy. He was given a poor prognosis, and that was actually something that I read in the report of Dr. _%#NAME#%_, his psychiatrist report.
CA|cancer|CA.|168|170|PAST SURGICAL HISTORY|PAST MEDICAL HISTORY: COPD, chronic sinusitis, anxiety, history of hypertension and history of hyponatremia. PAST SURGICAL HISTORY: Includes left mastectomy for breast CA. ALLERGIES: Levaquin, penicillin and sulfa. MEDICATIONS: Current drugs include Advair, Lasix and Nasacort. See Preop H&P for full list.
CA|cancer|CA|161|162|PAST MEDICAL HISTORY|He is anorectic. The decision today by the patient and wife has been to proceed to hospice care. PAST MEDICAL HISTORY: Atrial fibrillation, status post MI, lung CA followed by radiation chemotherapy, mets to bone and brain, radiation for brain mets, peripheral vascular disease, hypothyroidism, hypertension, pneumonia.
CA|cancer|CA|203|204|PAST HISTORY|He has no cardiac history. He has had diabetes since the 1980s, and he does have retinopathy. PAST HISTORY: 1. Diabetes as noted since the 1980s. 2. Hypertension since the 1980s. 3. High cholesterol. 4. CA of the prostate with surgery in 1977, and he has been stable since then. 5. Cataract surgery. 6. Normal colonoscopy last year.
CA|cancer|CA|172|173|PAST MEDICAL HISTORY|He has been hemodynamically stable. At the current time the patient describes fair pain control. Denies chest pain or shortness of breath. PAST MEDICAL HISTORY: 1. Bladder CA diagnosed in 2002. He has undergone intra bladder chemotherapy. Installation was over a month ago. 2. Diabetes mellitus currently diet controlled.
CA|cancer|CA.|297|299|IMPRESSION|B12 and folate are normal. Troponins are normal. INR is somewhat elevated at 1.43. IMPRESSION: This patient presents with iron deficiency anemia in the setting of anticoagulants, namely Coumadin. There is a history of colon polyps not checked for 16 years, rule out colon cancer, rule out gastric CA. RECOMMENDATIONS: Proceed to EGD and colonoscopy tomorrow after prep today.
CA|cancer|CA|275|276|HISTORY OF PRESENT ILLNESS|REQUESTING PHYSICIAN: Dr. _%#NAME#%_ HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 46-year-old gentleman I am asked to see in consultation for palliative care by Dr. _%#NAME#%_ who did a right thoracotomy yesterday. He has 2 chest tubes in and was diagnosed with nonsmall cell CA of the right upper lobe and is just in recovery phase from his surgery. Currently, _%#NAME#%_ states that he has been doing very well.
CA|cancer|CA.|160|162|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Brain metastases, Stage IV NSC lung CA. HPI: S/P whole brain radiation therapy, now with new mass in brain stem.
CA|cancer|CA|190|191|PAST MEDICAL HISTORY|There is a maternal history of early cardiovascular disease. His mother, however, died in her 90s. PAST MEDICAL HISTORY: Notable for tonsillectomy, vasectomy, prostatic biopsy and prostatic CA with seed implants in 2004. Allergic rhinitis, occasional heartburn, and a traumatic neuroma excision in the feet. The patient denies any history of stomach ulcers. He denies any history of GI pain.
CA|cancer|CA.|184|186||He also has a known ischemic cardiomyopathy and apparently became volume overloaded recently. He was seen in consultation and diuresis was recommended with good response. A/P: 1. Lung CA. 2. Ischemic cardiomyopathy with volume overload. 3. Continue with diuresis.
CA|cancer|CA|139|140||Information on the medications and vitals are listed in the EMR. Briefly, this is a 59 yo male patient with a history significant for lung CA undergoing treatment. He also has a known ischemic cardiomyopathy and apparently became volume overloaded recently following administration of chemotherapy.
CA|cancer|CA.|108|110|FAMILY  HISTORY|The patient had not had a previous history of urinary tract infections. FAMILY HISTORY: Father has prostate CA. Maternal grandfather died in his 80s with a malignancy. Her mother and 2 siblings are in good health. There are no children.
CA|carbohydrate antigen|CA|187|188|ALLERGIES|LABORATORY: Hemoglobin was 10.9, white count 6.1, platelets 253. BMP showed a sodium of 129, potassium 3.8, chloride 107, bicarbonate 25. BUN less than 2, creatinine 0.65, glucose of 68. CA 125 was 462 on _%#MM#%_ _%#DD#%_, 2006. It was previously 262 on _%#MM#%_ _%#DD#%_, 2006. A CT of the abdomen and pelvis showed 1. Left pleural effusion associated with left lower lobe compressive atelectasis.
CA|cancer|CA.|205|207|HOSPITAL COURSE|Plan was IV fluids, Benadryl, Ativan, Zofran, BDR suppositories, CT scan, and daily electrolytes. HOSPITAL COURSE: 1. Disease. As previously stated, the patient has known stage IV papillary serous ovarian CA. She underwent 3 cycles of neoadjuvant carboplatin and Taxol and then her debulking procedure and round 4 of carboplatin and Taxol before she was admitted on _%#MM#%_ _%#DD#%_, 2005, for persistent nausea and vomiting 2 days after her last chemotherapy.
CA|cancer|CA|194|195|PROBLEM #3|There were rare three-dimensional groups of atypical cells with prominent nucleoli and suspicious for a prostatic adenocarcinoma. This is likely consistent with his previous history of prostate CA and the possibility of recurrence. This will be addressed on an outpatient basis by urology. For the time being he will remain on Decadron with consideration for hormonal therapy.
CA|carbohydrate antigen|CA|158|159|HISTORY OF PRESENT ILLNESS|Ms. _%#NAME#%_ returned to the operating room for takedown of this ileostomy. I will briefly summarize the remainder of her course to date. At diagnosis, her CA 125 was 413. She was put on GOG 182 and randomized for the Gemzar/carbo arm. She began Gemzar on _%#MM#%_ _%#DD#%_, 2001, and completed 8 courses of Gemzar/carbo on _%#MM#%_ _%#DD#%_, 2002, at which time her CA 125 was 8.
CA|cancer|CA|238|239|ASSESSMENT|She also is status post left breast surgery with what she reports is lumpectomy, but appears to be somewhat more extensive and then with reconstructive surgery as well as breast reduction on the right side. She has a past history of skin CA on the tip of the nose which is now well healed, showing no sign of recurrence. Status post cholecystectomy, appendectomy, hysterectomy - all well healed. Probably the abdominal complaints are due to a viral gastroenteritis.
CA|cancer|CA|206|207|HISTORY OF PRESENT ILLNESS|1. Chest CT and VQ scan, which are both positive for PE. 2. Port-A-Cath placement on _%#MM#%_ _%#DD#%_, 2003. HISTORY OF PRESENT ILLNESS: This is a 53-year-old female who has a history of metastatic breast CA to bone, who presented with sudden onset of right-sided chest pain which is localized in right upper chest wall and radiates to back.
CA|carbohydrate antigen|CA|211|212|HOSPITAL COURSE|15. Social/prognosis. Ms. _%#NAME#%_'s overall status progressively deteriorated throughout her hospitalization. Her original problem of bowel obstruction was thought to be related to her ovarian cancer and her CA 125 was noted to be elevated on admission. Initiation of chemotherapy was discussed as an option when the patient became clinically stable; however, as her clinical condition deteriorated secondary to other medical issues, her prognosis appeared grim and her options for chemotherapy appeared futile.
CA|cancer|CA|269|270|FAMILY HISTORY|Tonsillitis years ago. Also has developed hypertension but only on higher doses of prednisone, has been on atenolol for this since earlier this year. FAMILY HISTORY: Father with peptic ulcer disease but also was taking large doses of NSAIDS. Father also with prostatic CA and developed hypertension and ASCVD in his mid to late 60s resulting in CABG. He is now 74 and doing well. His mother died of breast cancer.
CA|cancer|CA|211|212|PROBLEM #1|The patient was admitted to 7C. She had an ultrasound of her bilateral upper extremities which revealed an occlusive thrombus in her left innominate vein. PROBLEM #1: Disease. Patient has recurrent IIIC ovarian CA and also was planning to have chemotherapy for this. Plan was to begin the chemotherapy after the MRSA was clear. Patient is followed by Dr. _%#NAME#%_. PROBLEM #2: Heme. Patient's hemoglobin on admission was noted to be 8.9. On _%#MM#%_ _%#DD#%_, 2005, it was noted to be 7.3. The patient did receive 2 units of packed red blood cells and was started on ferrous sulfate for her decreased hemoglobin.
CA|carbohydrate antigen|CA|196|197|CONSULTS|In _%#MM#%_ 2004, the patient received Doxil x1 and she also had a CT scan done on _%#MM#%_ 2004. The patient had paracentesis done on _%#MM#%_ _%#DD#%_, 2004, and on _%#MM#%_ _%#DD#%_, 2004. The CA 125 on _%#MM#%_ _%#DD#%_, 2003, when she was (_______________) again was 131. The patient went to Arizona after that during Thanksgiving and the patient will follow up for chemotherapy there.
CA|cancer|CA|172|173|HOSPITAL COURSE|Nevertheless multiple samples of pleural fluid sent for cytology were negative for malignancy and at this point, Mr. _%#NAME#%_ has no definitive proof that his esophageal CA has recurred. Plan is for followup PET CT scan as previously scheduled for and _%#MMDD2007#%_. Mr. _%#NAME#%_ was seen by Dr. _%#NAME#%_ who performed his original esophageal stent placement during this admission for radiologically demonstrated intraperitoneal and retroperitoneal free air as described above.
CA|cancer|CA.|157|159|SOCIAL HISTORY|He has no immediate family members nor is he in a long- term partnership. His father died at age 49 of an MI. His mother died at age 48 of metastatic breast CA. His nearest relative is an uncle whom he is close to. The uncle's name is _%#NAME#%_ _%#NAME#%_. Mr. _%#NAME#%_ states that his uncle would be able to make medical decisions for him in the event that he cannot communicate.
CA|carbohydrate antigen|CA|166|167|ALLERGIES|Hematology was consulted. Due to concern that her small bowel infarction was due to recurrent breast cancer, her serum was assayed for the breast cancer tumor marker CA 27.29, which was within normal limits. There were no evidence of metastatic lesions on a chest x-ray or on the outside CT scan of the abdomen and pelvis.
CA|carbohydrate antigen|CA|261|262|FOLLOW UP INSTRUCTIONS|Her next appointment is _%#MMDD2007#%_ at 12:45 p.m. 2. She is scheduled for the second phase of her nuclear medicine scan on _%#MMDD2007#%_ at 1 p.m. 3. She has an appointment scheduled with Dr. _%#NAME#%_ on _%#MMDD2007#%_ at 11:30 a.m. CBC, chem 10, LDH and CA 27 29 will be checked prior to this appointment. 4. Home IV antibiotics will be provided through Fairview Homecare Infusion.
CA|carbohydrate antigen|CA|211|212|PROBLEM #2|Treatment was halted due to evidence of cardiomyopathy. She is being followed currently by Dr. _%#NAME#%_ as an outpatient. The breast cancer was thought to be well controlled given the patient's low and stable CA 27-29 breast tumor marker and stability of metastatic lesions on recent CT scans. During this hospitalization, MRI of the brain was obtained to assess for metastatic lesions.
CA|carbohydrate antigen|CA|169|170|HISTORY OF PRESENT ILLNESS|The mass at that time measured 3.1 x 2.1, and in the past it measured 5 x 2.7cm. The patient's CA 125 at that time was also 16, which is much improved from the previous CA 125 of 31 in _%#MM#%_ and 101 in _%#MM#%_ of 2005. She has recently just completed this course of chemotherapy. She had recently just completed this course of chemotherapy.
CA|carbohydrate antigen|CA|210|211|HISTORY OF PRESENT ILLNESS|In the upper left quadrant multiple mesenteric and omental nodules were seen ranging in size from 9mm to 3.8 cm. There was a soft tissue density identified at the right hepatic lobe measuring 1.5 x 3.6 cm. Her CA 125 at that time was 577 on _%#MM#%_ _%#DD#%_, 2006. Due to her diagnosis of adenocarcinoma, medical oncology was consulted, and the patient was seen at the Coborn Cancer Center.
CA|cancer|CA|188|189|ACTIVE PROBLEM LIST|She has not had fevers during her readmission to Transitional Care. 4. Status post liver/kidney transplant, date of procedure _%#MMDD2005#%_, for underlying hepatitis C and hepatocellular CA as well as associated hepatorenal syndrome. 5. Malnutrition. The patient has had persistent difficulty with ongoing intractable nausea and vomiting.
CA|cancer|CA|206|207|IMPRESSION|Chronic anemia secondary to multiple factors above. 12. Nicotine abuse, 80+ year pack history, on two packs per day since 16 years old. She states she is down to one pack per day now. 13. History of breast CA 1988, post radiation and chemo (Dr. Bender). 14. Malnutrition, severe cachexia. 15. Anorexia chronic. 16. Glucose intolerance requiring insulin sliding scale on past hospitalizations.
CA|carbohydrate antigen|CA|359|360|LABORATORY DATA|LABORATORY DATA: On the day prior to discharge lab results were hemoglobin 7.1, corrected hemoglobin 10, white blood count 7.1, platelet count 111, sodium 136, potassium 4.6, chloride 107, bicarbonate 20, BUN 17, creatinine 1.35, glucose 118, calcium 7.4, magnesium 1.8, phosphorus 3.2. Paracentesis fluid sent on _%#MMDD2004#%_ contained 54 nucleated cells. CA 19-9 was normal as was alpha fetoprotein. The last liver function tests were obtained _%#MMDD2004#%_. Bilirubin was 0.8, ALT 19, alkaline phosphatase 1060 down from a peak of 1627.
CA|cancer|CA.|147|149|HISTORY OF PRESENT ILLNESS|COMPLICATIONS: None. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 59-year-old female with stage IV grade II papillary serous endometrial CA. The patient presented to the emergency room complaining of a significant amount of nausea, vomiting, and elevated temperature status post her first chemotherapy treatment at the end of _%#MM#%_.
CA|UNSURED SENSE|CA.|145|147|PROCEDURE/OPERATIONS|2. Aortic valve replacement St. Jude. 3. Aortic root replacement. 4. Aortic arch replacement. 5. Coronary artery bypass graft x one. RSVG 2 hour CA. 6. Reimplantation of great vessels. 7. Reduced sternotomy. 8. Mediastinal exploration with repeat single coronary artery bypass graft. 9. Mediastinal exploration emergent. 10. Minilaparotomy x two. 11. BIVAD placement.
CA|carbohydrate antigen|CA|229|230|HISTORY OF PRESENT ILLNESS|In _%#MM2002#%_ she had Doxil x 2 cycles. Her CA 125 continued to rise to 75, and she had severe side effects from the Doxil. In _%#MM2002#%_, she had Gemzar that resulted in severe neutropenia, and again a continued rise of her CA 125 to 62. In _%#MM2002#%_ she had Hexalen, which caused severe abdominal pain and a rise in her CA 125. In _%#MM2002#%_ she also had Navelbine. Her CA 125 decreased from 63 to 22.
CA|carbohydrate antigen|CA|136|137|HISTORY OF PRESENT ILLNESS|In _%#MM2002#%_ she also had Navelbine. Her CA 125 decreased from 63 to 22. She received a total of 13 weeks of Navelbine, and then her CA 125 started to rise to 26. In _%#MM2003#%_, she began Tamoxifen 20 mg b.i.d. In _%#MM2003#%_, her CA 125 rose to 66, and she chose to continue Tamoxifen.
CA|carbohydrate antigen|CA|161|162|HISTORY OF PRESENT ILLNESS|She received a total of 13 weeks of Navelbine, and then her CA 125 started to rise to 26. In _%#MM2003#%_, she began Tamoxifen 20 mg b.i.d. In _%#MM2003#%_, her CA 125 rose to 66, and she chose to continue Tamoxifen. In _%#MM2003#%_, she was admitted for viral meningitis. She had a CT scan of her head that was negative.
CA|carbohydrate antigen|CA|257|258|DISCHARGE DIAGNOSES|No evidence of active colitis. She does have a history of colonoscopy in the distant past and has been getting occasional loose stools. There also was a somewhat complex 1 cm intra-cortical cyst in the right kidney which probably should be evaluated again. CA 19-9 pending by the time of this dictation. 6. Right kidney complex cyst. Will require outpatient evaluation with an ultrasound scan and follow-up.
CA|carbohydrate antigen|CA|208|209|ESR 16.|ESR 16. Urinalysis showed no evidence of gross protein. Hemoglobin 14.9. White count 14. Platelet count 370,000. Sodium 139. Potassium 3.7. BUN 15. Creatinine 0.6. Calcium 9.4. Magnesium 2.0. Phosphorus 3.5. CA 19.9, tumor marker is still pending by the time of this dictation. MRI of lumbar spine is recommended as an outpatient. Ultrasound scan of the patient's right kidney is recommended as an outpatient.
CA|cancer|CA.|154|156|ASSESSMENT AND PLAN|Unclear the clinical significance of her dilated pelvic veins. There is the possibility of a pelvic vein thrombosis should she have an underlying ovarian CA. She has essentially a soft abdomen with some mild guarding in the right upper quadrant. I cannot entirely explain the radiation of her pain to her chest.
CA|carbohydrate antigen|CA|100|101|ADMISSION DIAGNOSES|REFERING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_. ADMISSION DIAGNOSES: 1. Pelvic mass with an elevated CA 125, 2. Probable stage 3C papillary serous ovarian cancer, based on paracentesis, pathology result prior to _%#MM2006#%_. 3. Hypertension, treated. 4. History of breast cancer in 2002 status post lumpectomy and radiation.
CA|carbohydrate antigen|CA|192|193|ASSESSMENT|A rectovaginal exam was not done during this visit. ASSESSMENT: 57-year-old Somali female with intermittent spotting per vagina. Simple hyperplasia without atypia. Complex right ovarian mass. CA 125 - 39 and repeated at 37. PLAN: With an interpreter present, I had a lengthy discussion with the patient as well as the patient's daughter.
CA|cancer|CA|172|173|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Painful mass of right lower abdominal wall from CA of CX. HPI: This area has been previously treated, and mass is getting larger and deeper in abdominal wall.
CA|cancer|CA|182|183|PAST  MEDICAL HISTORY|2. Ischemic cardiomyopathy. 3. CAD on the basis of nuclear stress test and a previous non Q wave MI earlier this month. 4. Hypothyroidism. 5. Diabetes for many years. 6. Endometrial CA with hysterectomy. 7. Dyslipidemia. 8. Status post previous kidney surgery, one for trauma and one for cyst. 9. History of hemorrhoids with need for transfusion few weeks ago.
CA|carbohydrate antigen|CA|167|168|HISTORY OF PRESENT ILLNESS|It however has markedly increased in size to more than doubled, appears to be a complex cyst on evaluation with scanning techniques and is associated with an elevated CA 125 initially of 42 and now increased to 213. There is concern for an associated malignant process. An additional complication has been an acute occipital infarct on the right by recen t CT scan that may be associated with left visual loss per family report.
CA|carbohydrate antigen|CA|124|125|REFERRING PHYSICIAN|The ERCP revealed a large, ampullary mass, pathology of which came back as a villus adenoma and a biliary drain was placed. CA antigen 19-9 which is associated with pancreatic GI cancers was sent and has returned as 15,982 which is consistent with a malignant process.
CA|cancer|CA.|159|161|HPI|My key findings: CC: Left breast CA, liver cirrhosis with ascites/ HPI: Chronically ill due to alcoholic liver cirrhosis. Now she also has stage I left breast CA. Exam: Ill-defined induration of left upper-outer-quadrant with tenderness.
CA|cancer|CA|382|383|FAMILY HISTORY|PAST MEDICAL HISTORY: Remarkable for non-Hodgkin's lymphoma, as above. Hypertension, GERD, carotid stenosis, hyperlipidemia, positive PPD without receiving INH; impaired fasting glucose, DJD and spondylosis, status post lumbar fusion, 1959 and 1996; laminectomy in the lumbar area, 2004; colonoscopy in _%#MM2002#%_ with tubular adenoma. FAMILY HISTORY: Remarkable for brother with CA of the colon. Father with CA of the lung. SOCIAL HISTORY: He lives with his wife, _%#NAME#%_. He is retired and he has his daughter, _%#NAME#%_, here today.
CA|cancer|CA|142|143|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Remarkable for rheumatoid arthritis. 2. Positive chronic lower extremity paresthesia and pain. 3. Stage D metastatic CA of the colon with palliative chemotherapy. 4. Partial colectomy, ileostomy and status post splenectomy, omentectomy, resection in the peritoneal metastases.
CA|cancer|CA|233|234|DOB|No pneumonia is present, no viral upper respiratory infections have occurred but he states whenever he takes a deep breath it does hurt, and any thoracic movement at all does increase the pain. 2. Patient has a paralyzed tongue. Had CA of the tongue and the buccal region four to five years ago, 6 rounds of chemotherapy, 38 rounds of radiation therapy.
CA|cancer|CA|182|183|PAST  MEDICAL HISTORY|2. Ischemic cardiomyopathy. 3. CAD on the basis of nuclear stress test and a previous non Q wave MI earlier this month. 4. Hypothyroidism. 5. Diabetes for many years. 6. Endometrial CA with hysterectomy. 7. Dyslipidemia. 8. Status post previous kidney surgery, one for trauma and one for cyst. 9. History of hemorrhoids with need for transfusion few weeks ago.
CA|cancer|CA,|136|138|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Left breast CA, status post mastectomy and axillary lymph node sampling. HPI: The patient was found to have two separate lesions.
CA|cancer|CA|152|153|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Patient with base of tongue CA with bilateral neck me tastasis. HPI: He has been diagnosed since _%#MM2001#%_ and had received alternative medical care, non-standard.
CA|cancer|CA.|208|210|HPI|My key findings: CC: Left side blindness and headaches. HPI: Was found to have a lesion in the ethmoid-sphenoid sinus extending to left eye and toward cavernous sinus. Lesion showed undifferentiated squamous CA. He was also found to have multiple lung lesions and biopsy showed undifferentiated adenocarcinoma at the referring hospital.
CA|carbohydrate antigen|CA|93|94|RECOMMENDATIONS|Treatment goals would be palliative rather than curative, however. RECOMMENDATIONS: 1. Check CA 27.29 to help further confirm the presence of metastatic breast cancer. 2. Try to obtain previous records from _%#COUNTY#%_ _%#COUNTY#%_ Medical Center.
CA|cancer|CA|142|143|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Metastatic breast CA to cervical spine with epidural compression, multiple spinal mets, and fracture of C4. HPI: Had Stage II left breast CA in _%#MM1999#%_. Had left mastectomy, axillary dissection, and chemo and hormonal treatment.
CA|cancer|CA|159|160|HPI|My key findings: CC: Metastatic breast CA to cervical spine with epidural compression, multiple spinal mets, and fracture of C4. HPI: Had Stage II left breast CA in _%#MM1999#%_. Had left mastectomy, axillary dissection, and chemo and hormonal treatment. She had oophorectomy and has been on Tamoxifen since 2000.
CA|cancer|CA,|141|143|PAST MEDICAL HISTORY|7. Interstitial lung disease. 8. Chronic obstructive pulmonary disease. 9. Myocardial infarction. 10. PTCA. 11. History of recurrent bladder CA, status post surgery, as well as cholecystectomy and appendectomy. 12. History of chronic anemia.
CA|carbohydrate antigen|CA|249|250|LABORATORY STUDIES|Liver function tests: Slightly low albumin at 3.2, normal uric acid, LDH slightly elevated at 777, anemia hemoglobin 10.3, white count and platelets are normal. Tumor markers were done, which showed normal alpha-fetoprotein, normal beta hCG, normal CA 125 and normal CA 19-9. IMAGING STUDIES: The patient underwent a PET CT scan, CT of the thorax, MRI of the brain.
CA|cancer|CA,|193|195|FAMILY HISTORY|HEALTH HABITS: She smokes 4-6 cigarettes a day. No alcohol. ALLERGIES: Droperidol and codeine, Tylenol, Compazine, Vicodin and Pen-VK. FAMILY HISTORY: Remarkable for her grandmother with colon CA, mother with skin CA. SOCIAL HISTORY: She lives alone. She does work and I believe she works for the County.
CA|cancer|CA|132|133|SOCIAL HISTORY|Alcohol occasional. SOCIAL HISTORY: The patient is married, has two kids and lives with her husband. FAMILY HISTORY: Father died of CA of the lung. Mother died of heart disease, brother has a defibrillator. REVIEW OF SYSTEMS: HEENT: Negative. CARDIOVASCULAR: As above, otherwise negative.
CA|cancer|CA|222|223|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Inability to swallow. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 66- year-old white male, status post treatment with radiation therapy and chemotherapy for locally advanced non-small-cell lung CA diagnosed in _%#MM2000#%_. He was able to provide some history, and this was helped by his daughter who was in attendance.
CDI|center for diagnostic imaging|CDI|174|176|SOCIAL HISTORY|She has two sisters in good health. One son and one daughter, both in good health. Grandfather possibly with Crohn's disease. SOCIAL HISTORY: _%#NAME#%_ _%#NAME#%_ works for CDI as a front office supervisor. She is married and lives with her husband and two children, ages 5 and 7. She drinks 2-3 cups of coffee a day and one can of caffeinated soda every 2-3 days.
CDI|center for diagnostic imaging|CDI.|239|242|HISTORY OF PRESENT ILLNESS|The patient denies any cough, denies any fevers, denies any pleuritic chest pain and denies any gastroesophageal reflux disease. The patient did have a stress test, specifically adenosine thallium in _%#MM#%_ or _%#MM#%_ of this year from CDI. That apparently was normal. This was performed because of the significant cardiac risk factors, however, at that point he was not having any chest pain.
CDI|center for diagnostic imaging|CDI|160|162|DISCHARGE PLAN|8. DISCHARGE PLAN: The patient is to follow up with Dr. _%#NAME#%_ in 1-2 weeks. He is to take no aspirin or NSAID products. He is to set up an appointment for CDI for trigger point injection at T2 and L4.
CDI|UNSURED SENSE|CDI.|280|283|PAST MEDICAL HISTORY|She has a history of breast cancer, history of small TIAs in the past, a history of severe kyphosis, tonsillectomy, D&C, lumpectomy and eyelid surgery. She has recently had fairly significant back pain secondary to spinal stenosis, but has done well with 2 epidural injections of CDI. MEDICATIONS: Include: 1. Atenolol 50 mg. 2. Prinivil 10 mg.
CDI|center for diagnostic imaging|(CDI),|240|245|HISTORY OF PRESENT ILLNESS|Arrangements were made and she was seen by Dr. _%#NAME#%_ for an opinion and was advised to consider three- level spinal decompression and fusion. Arrangements were made to try an epidural steroid injection at Center for Diagnostic Imaging (CDI), but the patient developed dribbling of urine and epidural steroid injection was not performed for that reason. Yesterday she was advised to come to the emergency room because of progressive pain and increasing numbness in the legs and could not do so because she was caring for her granddaughter in her daughter's absence.
CDI|center for diagnostic imaging|(CDI)|167|171|HISTORY OF PRESENT ILLNESS|She has also been seen by Dr. _%#NAME#%_, had an MRI scan (described below) and was scheduled for outpatient caudal epidural steroids at Center for Diagnostic Imaging (CDI) for next week. Because of ongoing severe pain, she came to the emergency room today. PAST MEDICAL HISTORY: Hypertension. PAST SURGICAL HISTORY: Bilateral cataract extractions.
CDI|center for diagnostic imaging|CDI|166|168|HISTORY OF PRESENT ILLNESS|She has lost four more pounds since last week. She has had persistent diarrhea. We were, however, prepared to manage that as an outpatient until the radiologist from CDI called me to report that he had seen a left pulmonary embolism on the CT scan in addition to the above findings.
CDI|center for diagnostic imaging|CDI|116|118|HISTORY OF PRESENT ILLNESS|Her right shoulder symptoms recurred over the last few months. 2. In _%#MM2006#%_ she had an MRI of the shoulder at CDI showing moderate sized 50-80% partial thickness articular surface tear of the distal supraspinatus tendon without muscular atrophy. Also, moderate infraspinatus and subscapularis tendinosis with distal articular surface degeneration and fraying but no discrete tear.
CDI|center for diagnostic imaging|CDI|190|192|FOLLOW-UP|4. We attempted to obtain an ultrasound of his right shoulder to rule out a rotator cuff injury. However, Radiology felt an MRI would be more appropriate. We will schedule him for an MRI at CDI in _%#CITY#%_ after his discharge, to be followed up with his primary care physician. The patient was discharged in good stead with medications at home.
CDI|center for diagnostic imaging|CDI|204|206|HOSPITAL COURSE|He has done well in the hospital, his labs have been mentioned, chest x-ray did not show any acute problems. MRI done before he came in indicated the tumor as mentioned. This was done as an outpatient at CDI and a large soft tissue mass was noted, not particularly differentiated. Electrocardiogram was normal, possibly an old septal infarct, otherwise a normal/abnormal electrocardiogram.
CDI|center for diagnostic imaging|CDI.|317|320|HISTORY|Her cough has persisted, and in spite of treatment with antibiotics this mass has also persisted. The patient had previous CT scans of the chest; one of them was done last year in _%#MM#%_ and she also had another scan in Arizona in _%#MM#%_ 2007 and more recently she had a CT scan of her chest on _%#MMDD2007#%_ at CDI. In view of the fact that this mass is causing bronchial obstruction with chronic intractable cough and the fact that it is not clearcut what the nature of the mass is a transthoracic needle biopsy of this mass was recommended prior to referred to Dr. _%#NAME#%_ for thoracotomy and excision of this mass.
CDI|center for diagnostic imaging|CDI.|164|167|ASSESSMENT|6. Hyperlipidemia on Lipitor. We will follow the patient from here once the adenosine thallium results are available which has been scheduled for _%#MMDD2004#%_ at CDI. Hopefully we can clear the patient for surgery.
CDI|center for diagnostic imaging|CDI|171|173|HOSPITAL COURSE|1. Disease. Examination did confirm the presence of a rectovaginal fistula; however, the patient did not tolerate the exam well. She had a CT scan in an outside facility, CDI in _%#CITY#%_; however, the results have not become available as of her discharge. As the patient is stable and afebrile, the plan is to discharge her to home on _%#MM#%_ _%#DD#%_, 2004, knowing that Dr. _%#NAME#%_ will be calling the patient to come up with a plan of treatment for her fistula.
CDI|center for diagnostic imaging|CDI.|226|229|MRI|Pulses are intact. X-RAYS: AP and lateral x-rays of his knee show some mild global changes bilaterally of the medial compartment, some mild patellofemoral arthrosis. MRI: On _%#MMDD#%_, he underwent an MRI scan, left knee, at CDI. The scan is compatible with a horizontal tear of the posterior horn of the medial meniscus. There is also some moderate chondromalacia in the midline of the trochlear groove.
CDI|center for diagnostic imaging|(CDI)|710|714|CT SCAN|CLINIC LABORATORY DATA: She was evaluated on _%#MMDD2002#%_ at the clinic and had blood tests done at that time which include the following: white count 11.7, hemoglobin 12.1, platelets 267; urinalysis unremarkable except for trace protein and small bilirubin; glucose 122, BUN 21.7, creatinine 0.95, sodium 132, potassium 5.04, chloride 96.9, total protein 6.16, albumin 2.59, ALT 151, total bilirubin 2.15, carbon dioxide 22.9, AST 1260, alkaline phosphatase 186, calcium 10.46, TSH 0.59. At this time the patient denied any icterus, generalized pruritus or scleral icterus, however, she did complain of generalized weakness. CT SCAN: A CT scan of the abdomen was obtained from Center for Diagnostic Imaging (CDI) on _%#MMDD2002#%_ with findings as follows. There was a generalized enlargement of both lobe of the liver with between 50- 100 heterogenous, round, solid masses throughout the liver averaging 1.7- to 3.5-cm in diameter.
CDI|center for diagnostic imaging|CDI|162|164|PHYSICAL EXAMINATION|She does have a negative Homans, but diffuse edema distally. The neurovascular status is intact. Her hip has good range of motion. Duplex ultrasound performed at CDI was called in with the report of proximal right lower extremity deep venous thrombosis. The iliac vessels in the pelvis were assessed which appeared clear but deep venous thrombosis extending to the proximal thigh.
CDI|center for diagnostic imaging|CDI|174|176|HISTORY|The patient denies any specific bowel or bladder complaints. He has had an MRI scan of his back. I do not have the films for review. However, I do have a report performed at CDI on _%#MMDD2002#%_. This showed mild thoracolumbar Scheuermann's. There was a posterior annular tear and small subligamentous disc protrusion at L4-5 level.
CDI|center for diagnostic imaging|CDI|323|325|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a _%#1914#%_ patient of Dr. _%#NAME#%_ _%#NAME#%_. He resides independently in _%#CITY#%_, Minnesota. He has been followed for several years for aortic valve stenosis and his most recent echocardiogram performed as an outpatient at CDI showed that he had a trileaflet aortic valve which was thickened and calcified. His calculated valve area was 0.62 cm squared with a mean transvalvular gradient of 56 mm of mercury.
CDI|center for diagnostic imaging|CDI|135|137|REVIEW OF SYSTEMS|Mother died at age 80, uncertain cause. REVIEW OF SYSTEMS: Cardiovascular - Recent nuclear cardiac stress test done in _%#MM2003#%_ at CDI in _%#CITY#%_ _%#CITY#%_ _%#CITY#%_. The patient reports this was normal. This was done as a preoperative evaluation for melanoma surgery.
CDI|center for diagnostic imaging|CDI.|128|131|HISTORY OF PRESENT ILLNESS|She in fact had what sounds like an adenosine nuclear stress test performed just on the day prior to admission on _%#MMDD#%_ at CDI. Those results are pending. She has, however, not had any of this chest aching sensation that brought her to the ER.
CDI|center for diagnostic imaging|CDI|182|184|DISCHARGE PLAN|He agreed that the patient should follow up within the next few weeks. The patient will also follow up with Dr. _%#NAME#%_ in the Spine Clinic in approximately 2 weeks at which time CDI procedure will be performed. The patient was counseled extensively about any new symptoms, specifically any bowel or bladder incontinence, any new numbness, tingling, or weakness in his lower extremities should prompt immediate presentation to the emergency room.
CDI|center for diagnostic imaging|CDI.|215|218|HISTORY OF PRESENT ILLNESS|In the last 2 weeks she has had an MRI at Suburban Imaging which showed central stenosis and degenerative disk disease but no real neural foraminal stenosis. She had a steroid injection at the L5 root 1 week ago at CDI. Unfortunately, this has not relieved her pain. She also seen Dr. _%#NAME#%_ in Orthopedic Surgery. She is unable to get pain relief.
CDI|center for diagnostic imaging|CDI.|151|154|PLAN|We will have physical therapy see the patient for ambulation. Will have Dr. _%#NAME#%_ see her tomorrow. Will obtain records from Suburban Imaging and CDI. Will check postvoid residual and place a Foley if needed. We will start some Senokot and Colace. Ultimately the plan will be to get her symptoms controlled and have her continue this evaluation and treatment as an outpatient.
CDI|center for diagnostic imaging|CDI|201|203|DOB|She was having persistent pain and difficulty with ambulation, was referred to Orthopedics and saw Dr. _%#NAME#%_ on _%#MMDD2002#%_, was sent for MRI of the pelvic bones on _%#MMDD2002#%_ performed at CDI and this did show a superior ramus fracture on the left of the symphysis pubis and probably an associated left sacral fracture possibly accounting for her left buttock pain.
CDI|center for diagnostic imaging|CDI,|205|208|LABORATORY DATA|LABORATORY DATA: MRIs show herniated and ruptured disc in her neck and low back. These reports are not currently available in my current charting for specific commenting on them, but are available through CDI, where she has had these studies. Venipuncture was taken for hemoglobin, CBC, platelet count, urinalysis with microcoagulation and electrolytes.
CDI|center for diagnostic imaging|CDI|175|177|HISTORY OF PRESENT ILLNESS|She has taken hydrocodone for pain and has also been taking some Bextra, has been on Neurontin 600 mg q.h.s. She had previous corticosteroid injections to her lumbar spine at CDI in _%#CITY#%_ _%#CITY#%_, with temporary relief of the spinal-stenosis symptoms. The patient has been followed by Dr. _%#NAME#%_ for several years for her back pain and at this point, pain has become too severe to be managed by medical therapy alone.
CDI|center for diagnostic imaging|(CDI)|340|344|HISTORY OF PRESENT ILLNESS|An MR scan at this point showed a thecal hemorrhage at the area of L4-5 which appeared to be on supine films at meniscus level consistent with blood and a semi-emergent brain MR, including an MRA and thoracic and lumbar repeat MR scans were obtained and per Dr. _%#NAME#%_ _%#NAME#%_ in Neuroradiology through Center for Diagnostic Imaging (CDI) were felt to be within normal limits. The source of the bleed at this point is not determined and because of the acute nature of his symptoms he was admitted for pain management issues, physical therapy and occupational therapy of both the lumbar spine as well as the upper right extremity and a repeat neurological evaluation per Dr. _%#NAME#%_ and a neurosurgical consultation through Dr. _%#NAME#%_ _%#NAME#%_.
CDI|center for diagnostic imaging|CDI|314|316|HISTORY|3. Plantar fasciitis. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 55-year-old female who is seen in presurgical consultation after she suffered a right anterior cruciate ligament tear while skiing on _%#MMDD2005#%_. She drove back from Colorado and subsequently saw Dr. _%#NAME#%_. MRI scan of the right knee performed at CDI on _%#MMDD2005#%_ showed marked sprain and complete tear of the mid to proximal aspect of the anterior cruciate ligament, as well as a short segment of longitudinal peripheral tear of the posterior horn of the lateral meniscus.
CDI|center for diagnostic imaging|CDI|198|200|PERTINENT HISTORY|She was mildly nauseated but has not vomited. She has had normal bowel and bladder habits. She has felt slightly feverish but has not taken her own temperature. The CT scan done as an outpatient at CDI _%#CITY#%_ _%#CITY#%_ facility is consistent with acute appendicitis. She has subsequently been sent here to Fairview Southdale Hospital for operative care.
CDI|center for diagnostic imaging|CDI.|209|212|HISTORY|The patient describes the pain as right below the right pectoralis major muscle, going into his shoulder. The patient also incidentally had a cortisone shot about one to two weeks ago of his right shoulder at CDI. The patient states since his injection that his range of motion has improved and he was able to move his arm much better.
CDI|center for diagnostic imaging|CDI,|139|142|DOB|He subsequently returned to the _%#CITY#%_ _%#CITY#%_. He has been seen for this by Dr. _%#NAME#%_. He has undergone an MRI of his knee at CDI, which apparently showed signs of cartilage derangement. Because of this, he is now scheduled to undergo arthroscopy to his left knee at Fairview Ridges Hospital on _%#MM#%_ _%#DD#%_.
CDI|center for diagnostic imaging|CDI|123|125|IMPRESSION|Unfortunately, a repeat CT scan of the chest, abdomen, and pelvis was performed and when compared to her outside film from CDI done a few weeks previously there was evidence of progression. Specifically, the liver lesions were reportedly more numerous and slightly increased in size.
CDI|center for diagnostic imaging|CDI|113|115|LABS|No JVP, or edema, but legs are large. ABDOMEN: Soft. Nontender. No masses. LABS: Have been ordered. As above the CDI CT angiogram showed the clots and rib fractures. ASSESSMENT: 1. Pulmonary emboli. I should also mention that when I talked to the radiologist, and he noted that these clots do not appear new, but they have probably been there several weeks.
CDI|center for diagnostic imaging|CDI|142|144|LABORATORY AND DIAGNOSTIC DATA|TSH was 0.029. Creatinine was 1.7. Glucose 73. Remainder of the comprehensive metabolic panel was normal. She had a stress dobutamine echo at CDI on _%#MMDD2005#%_ which was negative for inducible ischemia and considered to be demonstrative of good overall cardiac function. The final report is pending, but I spoke to the physician who read this.
CDI|center for diagnostic imaging|CDI.|134|137|ASSESSMENT|Her husband points out that she has had several episodes of hallucination after operations and most recently after the stress test at CDI. She was subsequently seen and had a CT scan and lab testing at Southdale Emergency Room. I think all of this underscores the fact that this procedure is high risk.
CDI|center for diagnostic imaging|CDI|163|165|HOSPITAL COURSE|He tried lifting her and hurt his own back and therefore was unable to continue to care for her at home. The patient did have a CT done at an outside institution, CDI in _%#CITY#%_ _%#CITY#%_ _%#CITY#%_. This was done on _%#MMDD2006#%_. This showed the following: 1. Grade I degenerative anterior spondylolisthesis at L5-S1 with gaseous degeneration and mild to moderate up/down foraminal stenosis without ganglionic impingement.
CDI|center for diagnostic imaging|CDI|222|224|IMPRESSION|No rebound. Bowel sounds are normal. LABORATORY DATA: At today's visit, I did send her to the hospital for a CBC, a PT, INR, liver function studies, and a CANCER19-9 tumor marker. IMPRESSION: Films were available from the CDI Radiology Clinic. I did show them to Dr. _%#NAME#%_ _%#NAME#%_, our radiologist, and he felt that this patient was a candidate for a needle biopsy of either the pancreatic mass or one of the liver lesions.
CDI|center for diagnostic imaging|CDI|350|352|HISTORY OF PRESENT ILLNESS|Pap smear was normal, stool guaiac was negative, there were no ovarian masses, urinalysis revealed no hematuria on two occasions, and her hemoglobin was normal at 13.1. She has had no loss of weight or unusual cough or any hemoptysis or hoarseness. On _%#MMDD2004#%_, Dr. _%#NAME#%_ suggested that she have a PET scan of the chest, which was done at CDI on _%#MMDD2004#%_, and revealed hypermetabolic foci in the right hilum, suspicious for malignancy, and an indeterminate SUV measurement in the upper aspect of the right lower lung.
CDI|center for diagnostic imaging|CDI|113|115|PHYSICAL EXAMINATION|Plans will depend on the results of the MRI scan. Of note, she did undergo an epidural steroid injection through CDI and this was associated with marked exacerbation of her pain. It was this exacerbation where she subsequently underwent the IM injection of the Demerol.
CDI|center for diagnostic imaging|CDI|179|181|ASSESSMENT AND PLAN|During this hospitalization, I plan to workup these conditions by performing the follow: 1. CT scan of the chest, abdomen, and pelvis (with comparison to his outside CT scan from CDI on _%#MMDD2004#%_). 2. Diuresis with IV Lasix. 3. Close monitoring of his electrolyte levels given the planned diuresis. 4. Possible MRI of brain to compare to previous outside scan.
CDI|center for diagnostic imaging|CDI|190|192|OPERATIONS/PROCEDURES PERFORMED|3. MRI of right knee and right proximal tibia. Impression: Interval decrease in size of enhancing interosseous lesion in the proximal lateral tibial metaphysis in comparison to the MRI from CDI dated _%#MM#%_ _%#DD#%_, 2006. Scattered areas of decreased T1 signal and increased T2 signal on fat saturation sequences in the femoral metadiaphyseal and diaphyseal regions.
CDI|center for diagnostic imaging|CDI.|214|217|ADDENDUM|Going through her past history at St. Vincent's Hospital in Alabama in _%#MM1999#%_, she also had had a microcytic anemia. I have also obtained now a copy of her MRI of the cervical spine dated _%#MMDD2005#%_ from CDI. This showed there to be a midline and right paramidline, small extruded C6-7 disk herniation which indents the thecal sac without cord compression or deformity.
CDI|center for diagnostic imaging|CDI|214|216||Patient denies any nausea, vomiting, diarrhea. The patient has good appetite, nothing really bothers him unless somebody is touching it. Patient ate well, good bowel movements, no change of appetite. I sent him to CDI CT scan and they found appendicitis, they said acute appendicitis, and I called Dr. _%#NAME#%_, surgeon, about this result and I asked the radiologist, Dr. _%#NAME#%_ in CDI, to talk to Dr. _%#NAME#%_ directly.
CDI|center for diagnostic imaging|CDI|253|255||On examination, she was noted to walk with an antalgic gait favoring the left leg and she was noted to use a cane in the right hand for subjective instability. She exhibited medial joint line tenderness. An MRI examination of the left knee performed at CDI on _%#MMDD#%_ demonstrates a tear involving the middle third of the medial meniscus. Some degree of chondromalacia the patella was also noted. She is now admitted for an arthroscopy of the left knee.
CDI|center for diagnostic imaging|CDI.|156|159|HISTORY|The patient has been followed by physicians since last year. She already had three CT scans of the chest. The most recent one was done on _%#MMDD2007#%_ at CDI. This shows no interval change in the size of the mass. She has had a 3.4 cm by 2.1 cm smooth, lobulated nodule or mass in the posteromedial superior segment of the left lower lobe.
CDI|clean, dry, intact|CDI.|359|362|DISCHARGE INSTRUCTIONS|15. NovoLog sliding scale for use during day time; if glucose 120-149 take 1 Unit; glucose 150-199 take 2 Units; glucose 200-249 take 3 Units; glucose 250-299 take 5 Units; glucose 300-349 take 7 Units; glucose greater than 350 take 8 Units. DISCHARGE INSTRUCTIONS: 1. The patient to be on a moderate ADA diet. 2. She will have right upper extremity dressing CDI. 3. Sponge bath. 4. DuoDERM dressings to the inguinal area bilaterally q.48 hours. 5. Sling to right upper extremity. 6. She will also follow up with Dr. _%#NAME#%_ in 10-14 days.
CDI|center for diagnostic imaging|CDI.|213|216|HISTORY  OF PRESENT ILLNESS|Given the fact that these had appeared to be healing quite well, obtained a plain x-ray of the foot which was negative for any abnormalities and given the continued discomfort, MRI which was recently performed at CDI. This did not show any evidence of osteomyelitis, it did show some soft tissue edema and swelling according to the patient.
CDI|center for diagnostic imaging|CDI.|176|179||An MRI examination was performed demonstrating a shallow disc protrusion and an anular tear at the L5-S1 level. She was treated with an epidural steroid injection performed by CDI. She was treated with physical therapy. She had some modest improvement until late _%#MM#%_ when she was run into by one of her two 60-pound bulldogs.
CDI|center for diagnostic imaging|CDI|108|110|LABS STUDIES|LABS STUDIES: I do not have blood work here, but I do have a copy of his CT scan of _%#MMDD2002#%_ from the CDI in _%#CITY#%_ _%#CITY#%_. This shows bilateral spondylolysis of L5 with some underlying juvenile diskogenic disease. There is also broad-based and lateral bulging of the disk annulus with a possible disk herniation into the foramen of the exiting L5 left nerve root.
CDI|clean, dry, intact|CDI.|185|188|ADMITTING AND DISCHARGE DIAGNOSIS|PHYSICAL EXAMINATION ON DISCHARGE: She is alert and oriented, in no apparent distress, non ill-appearing. Cranial nerves 2-12 are grossly intact. Her incisions, as mentioned above, are CDI. She is not complaining of any pain or other symptoms of discomfort, nausea, vomiting, dyspnea. DISCHARGE PLANNING: She is to follow with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2005, for nasal packing removal.
CDI|center for diagnostic imaging|CDI|198|200|PHYSICAL EXAMINATION|She has no motor weakness. She has only very mildly positive straight leg raising on the left leg at the time of her most recent examination. An MRI examination of the lumbar spine was performed by CDI on _%#MMDD2006#%_. This has been interpreted showing an extruded posterolateral disk herniation at the L5-S1 level on the left side, compressing the left S1 nerve root.
CDI|center for diagnostic imaging|CDI|115|117|PAST MEDICAL HISTORY|He had been titrated up to the Coreg dose, fairly high of 50 mg twice a day. He did have an echocardiogram done at CDI showing an ejection fraction of 55% on _%#MMDD2002#%_, as well as an adenosine thallium test showing an ejection fraction of 58%.
CDI|center for diagnostic imaging|CDI|156|158|HISTORY|She had no coughs or colds and no sinus symptoms. No urine symptoms or other localizing symptoms. Of significance is the fact the patient was just in for a CDI and during that stay she had flu-like symptoms prior to discharge with some neck and head pain. She really did not feel great after discharge. During her prior stay, the MRI did confirm the presence of a stroke.
CDI|center for diagnostic imaging|CDI,|153|156|HISTORY OF PRESENT ILLNESS|She gets her usual primary care done at the _%#CITY#%_ _%#CITY#%_ Clinic, but has not been there recently. Because her daughter is a transcriptionist at CDI, she took advantage of a calcium score test and was told that there was a substantial amount of calcium discovered.
CDI|center for diagnostic imaging|(CDI)|129|133|HISTORY OF PRESENT ILLNESS|In view of the above, the patient had MRI scans of cervical and thoracic spines which were done at Center for Diagnostic Imaging (CDI) this afternoon. The results were discussed over the phone with the radiologist. The patient has a paraspinal mass at the T-4 level and also moderate acute compression fracture of T-4 which is all most consistent with the localization of the pain.
CDI|center for diagnostic imaging|CDI|207|209|PAST MEDICAL HISTORY|She was scheduled for an outpatient EEG which was done three days later and read by Dr. _%#NAME#%_ as essentially negative for any epileptiform or focal abnormalities. MRI scan of the brain was scheduled at CDI where she works. The study was done on _%#MMDD2006#%_ and showed a tiny white matter abnormality in the middle of the pons and a single nonspecific left external capsular focus of T2 abnormality as well.
CDI|center for diagnostic imaging|CDI|168|170|PAST MEDICAL HISTORY|Neoplasm infarct, demyelinating issues were raised in the differential diagnosis. Because of the intrapontine abnormality, MR angiography was subsequently performed at CDI as well. We have not seen this study, by report the radiologist states that there is some narrowing of the vertebrobasilar arteries possibly relating to ectasia or dissection.
CDI|center for diagnostic imaging|CDI|258|260|IMAGING|Of note, her CBC in the Emergency Room today revealed a white blood cell count of 8900, hemoglobin of 10.9, MCV of 90 and platelet count of 893,000. Her sodium level was 127. IMAGING: 1. A recent CT scan of the chest, abdomen and pelvis on _%#MMDD2006#%_ at CDI (comparison _%#MMDD2006#%_ from Mayo Clinic) revealed 2 of the representative lower lobe nodules have increased in size consistent with metastasis in that there are approximately 17 right lung and 10 left lung nodules.
CDI|center for diagnostic imaging|CDI|257|259|HISTORY|Other changes noted consisted of significant lumbar scoliosis with degenerative spondylosis at multiple levels and facet degeneration with other areas of nerve root impingement. She subsequently was further evaluated with a left S1 nerve root block done at CDI on _%#MMDD2002#%_; this gave her complete relief of her radicular left lower extremity pain. The symptoms then recurred and after a thorough discussion of the potential causes and potential treatment with surgery including procedure alternatives, complications, risks and benefits, she agreed to proceed and has been scheduled for lumbar laminectomy at L5-S1 on the left with diskectomy and left S1 nerve root decompression.
CDI|center for diagnostic imaging|CDI,|200|203|HISTORY OF PRESENT ILLNESS|There was question of whether she had a stroke in the past, but CT and MRI's have not shown any clearcut damage. In 2004 she had a Cardiolite stress test as well as a recent dobutamine stress test at CDI, both of which suggested anterior wall ischemia, but in _%#MM#%_ of this year, she had a Cardiolite stress test that showed that she had a mild fixed anterior count depression with an EF of 66% which was improved from her studies in 2004.
CDI|center for diagnostic imaging|CDI|142|144|HISTORY OF PRESENT ILLNESS|Her aortic stenosis has been followed for some time originally by Dr. _%#NAME#%_ at _%#CITY#%_ Lake Clinic. She had an echocardiogram done at CDI on _%#MMDD2002#%_ showing an aortic valve area of 0.7 cmm. Prior echocardiogram done showed a valve area of 1.1 cmm in 1996. The patient had been noticing some progressive shortness of breath with exertion only over the last several months.
CDI|center for diagnostic imaging|CDI.|167|170|HISTORY  OF PRESENT ILLNESS|He was recently seen by Dr. _%#NAME#%_ for the first time and reported these symptoms. He is referred for a stress echocardiogram study performed on _%#MMDD2007#%_ at CDI. He was able to exercise for 6 minutes on the Bruce protocol, achieving only 70% of maximum predicted heart rate.
CDI|center for diagnostic imaging|CDI|101|103|IMPRESSION|I saw Dr. _%#NAME#%_ to provide cardiology consultation after the stress echocardiogram performed at CDI indicated ischemia within the mid-LAD distribution. I discussed these findings with the patient in detail and suggested that we pursue this further with an invasive coronary angiogram and possible angioplasty and stent.
CDI|center for diagnostic imaging|CDI|237|239|HISTORY OF PRESENT ILLNESS|DIAGNOSIS: Painful retained hardware left sacroiliac joint. HISTORY OF PRESENT ILLNESS: The patient has had painful left buttocks since left SI joint fusion several years ago. The patient had repeated injections done on this SI joint at CDI but did not have pain relief with this procedure. He had an increase of pain and tenderness in the posterior buttock.
CDI|center for diagnostic imaging|CDI.|150|153|SOCIAL HISTORY|PAST MEDICAL HISTORY: As above. FAMILY HISTORY: Both parents are in good health. Grandfather possibly with Crohn's disease. SOCIAL HISTORY: Works for CDI. Married. Two children. Occasional caffeine. Minimal alcohol. No smoking. REVIEW OF SYSTEMS: As above and otherwise negative.
CDI|center for diagnostic imaging|CDI|188|190|HISTORY OF PRESENT ILLNESS|He came into the emergency room Sunday, was given more pain meds, Percocet, which helped, but he was still sore. He called his primary care physician just recently, and an MRI was done at CDI yesterday. However, since then, he has continued to have increasing pain and now feels that his legs are weak, he could not support himself.
CDI|center for diagnostic imaging|CDI|89|91|LABORATORY DATA|The EXTREMITIES are free of edema. He has good pedal pulses. LABORATORY DATA: CT done at CDI is as noted; a copy will be included in his chart. His initial WBC was 13,400 on the _%#DD#%_; it dropped to 8,600 on the _%#DD#%_.
CDI|center for diagnostic imaging|CDI|156|158|HISTORY|She was seen by her primary care physician at HealthPartners and referred to Ophthalmology. Apparently, MRI scanning of the brain was done, she believes at CDI in _%#CITY#%_ _%#CITY#%_ _%#CITY#%_, and upon this being found to be negative, no follow-up or management was rendered to her. She reports that since that time, she has been somewhat fatigued but has had no other symptoms until today while sorting laundry on the floor of her basement had difficulty getting up, but she was able to navigate to the bathroom, but noted clumsiness of her hands, particularly the left one in undoing her jeans.
CDI|center for diagnostic imaging|CDI.|166|169|IMPRESSION|We will arrange for MRI scanning of the brain, MR angiography, carotid ultrasonography and echocardiography. We will be obtaining her records from HealthPartners and CDI. Further recommendations will be dependent upon preliminary studies.
CDI|center for diagnostic imaging|CDI|204|206|HISTORY|She still has had persistent and significant left buttock and lateral thigh pain on the left only. This extends down somewhat into the left lower leg and calf. Previous MRI scan done on _%#MMDD2004#%_ at CDI shows an extruded left-sided L5-S1 disc herniation. Due to the patient's increasing discomfort and inability to care for herself at home, she was therefore admitted for pain control.
CDI|center for diagnostic imaging|CDI,|302|305|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Significant for Hashimoto thyroiditis diagnosed in 1997, pernicious anemia diagnosed in 1998, reduction mammoplasty in 2001, tummy tuck in 2001, neck injury 8 years ago, status post multiple rhizotomies and cervical blocks, as well as facet nerve blocks done by Dr. _%#NAME#%_ in CDI, status post appendectomy in 1971, status post lumpectomy of the left breast, status post cone biopsy of the cervix, status post fistulotomy.
CDI|center for diagnostic imaging|CDI|206|208|PHYSICAL EXAMINATION|No ascites. No rebound. Positive bowel sounds. At today's visit I did send her to the hospital for a CBC, PT, INR, liver function tests, and CA19-9 tumor marker. The patient's films were available from the CDI Radiology Clinic. I did show them to Dr. _%#NAME#%_ _%#NAME#%_, our radiologist, and he felt that this patient was a candidate for a needle biopsy of either the pancreatic mass or one of the liver lesions; hopefully, preferably the liver lesion would be amenable.
CDI|center for diagnostic imaging|CDI|282|284|SOCIAL HISTORY|PAST MEDICAL HISTORY: Negative. REVIEW OF SYSTEMS: Head, eyes, ears, nose, throat, heart, lung, abdomen, neuro, musculoskeletal, integumentary, extremities otherwise negative. FAMILY HISTORY: Maternal grandfather with colon cancer. SOCIAL HISTORY: She works full time as a tech for CDI and also starting x-ray school on _%#MMDD2004#%_. PHYSICAL EXAMINATION: GENERAL: A pleasant female in no acute distress.
CDI|center for diagnostic imaging|CDI|135|137|HISTORY OF THE PRESENT ILLNESS|The patient has chronic pain syndrome and gets trigger point injections. He had a cervical epidural steroid injection yesterday at the CDI Clinic or Central Diagnostic Imaging. He says that they did a MRI of his neck before hand that used contrast. When th contrast was used, he felt a pressure in his neck and chest.
CDI|center for diagnostic imaging|CDI|163|165|HISTORY OF THE PRESENT ILLNESS|When th contrast was used, he felt a pressure in his neck and chest. Today, he woke up and had a headache and also felt nauseated and has been vomiting. He called CDI this morning and they recommended that he go see his primary care doctor. He saw Dr. _%#NAME#%_ at _%#CITY#%_ Center Clinic as his regular doctor, Dr. _%#NAME#%_ _%#NAME#%_ was off today.
CDI|center for diagnostic imaging|CDI|137|139|ASSESSMENT|The patient is scheduled for synovial cyst decompression by Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2007#%_. The most recent MRI obtained at CDI on _%#MMDD2007#%_ does show mild central and moderate to marked right subarticular stenosis of L4-5 with degenerative spondylolisthesis of 10% caused by widened, fluid-filled and degenerated facet joints predisposing the segment instability.
CDI|center for diagnostic imaging|CDI|189|191|DOB|There is some diffuse edema of entire lower extremity. There is a mild effusion, and there is medial joint line tenderness. She has had an MRI examination of the left knee performed at the CDI on _%#MMDD2003#%_. This demonstrates a tear of the tibial attachment of the posterior horn of the medial meniscus. In addition, chondromalacia of the medial femoral condyle and of the patellofemoral joint is also noted.
CDI|center for diagnostic imaging|CDI|183|185|HOSPITAL COURSE|He reports progressive onset of acute back pain that was unresponsive to p.o. narcotics. He was started on morphine PCA overnight and was tapered in the morning. His MRI records from CDI were unavailable, as they were closed over the weekend. He was admitted on an early Saturday morning. He was placed on bed rest for day one and then his activities were increased ad lib.
CDI|center for diagnostic imaging|CDI.|205|208|IMAGING DATA|Gait was steady. With tandem walking, the patient's balance was less good than expected, particularly with backward tandem. Romberg was absent. IMAGING DATA: The patient's father brought her MRI scan from CDI. We reviewed it as well as the scans of her mother which were brought from home. The patient's scan shows multiple hyperintense lesions in the subcortical and periventricular white matter.
CDI|center for diagnostic imaging|CDI|225|227|HISTORY|Then she went to urgent care in _%#CITY#%_ _%#CITY#%_ and Dr. _%#NAME#%_ ordered an MRI (but she has severe claustrophobia so this did not get done). She did, however, have one epidural steroid injection on _%#MMDD2005#%_ at CDI in _%#CITY#%_ _%#CITY#%_ _%#CITY#%_. She felt fine for about four days, and felt that she was getting better management of her pain and better walking and better quality of life.
CDI|center for diagnostic imaging|CDI|277|279|PLAN|She went off the prednisone. The pain has intensified and become very severe, and she is unable to obtain rest with her current narcotic pain medication. She had a consultation with Dr. _%#NAME#%_ _%#NAME#%_ and he ordered an MRI scan. The MRI was recently accomplished at the CDI _%#CITY#%_ _%#CITY#%_ site and the report has a summary of single level disk dissection and degeneration at L5-S1. There is stenosis on the left subarticular recess. There is bilateral facet degenerative change, left greater than right.
CDI|center for diagnostic imaging|CDI|149|151|PHYSICAL EXAMINATION|NEUROLOGIC: She has an absent left ankle reflex. She has positive straight leg raising on the left side. She has had an MRI examination performed in CDI on _%#MM#%_ _%#DD#%_, 2006. This demonstrates a herniated disc at the L5-S1 level on the left side, producing a moderately compressed left S1 nerve root.
CDI|center for diagnostic imaging|CDI|198|200|PHYSICAL EXAMINATION|She has no motor weakness. She has only very mildly positive straight leg raising on the left leg at the time of her most recent examination. An MRI examination of the lumbar spine was performed by CDI on _%#MMDD2006#%_. This has been interpreted showing an extruded posterolateral disk herniation at the L5-S1 level on the left side, compressing the left S1 nerve root.
CDI|center for diagnostic imaging|CDI|173|175|ASSESSMENT AND PLAN|We will consult Dr. _%#NAME#%_, who knows her well, and has arranged for epidural steroids in the past. We will also try a Medrol Dosepak, and try to get the CT report from CDI Imaging in _%#CITY#%_ _%#CITY#%_ _%#CITY#%_. 2. Urinary tract infection. The patient received Levaquin already. We will get blood cultures x2, and await urine culture.
CDI|center for diagnostic imaging|CDI.|182|185|CHIEF COMPLAINT|Evaluation of her spine shows she has a well-healed midline incision. Radiographic Evaluation: Radiographic exam reviewed today includes her previous plain films as well as MRI from CDI. This shows minimal scarring at the site of her laminotomy from her previous diskectomy. This is on the right side at L5-S1. The disk height is a little bit lost there; otherwise, the remainder of the MRI of her lumbar spine is unremarkable.
CDI|center for diagnostic imaging|CDI|194|196|LABORATORY DATA|Urine osmolality 901, serum osmolality 276. Chest x-ray right middle lobe cavitary lesion with air fluid level, new since chest x-ray done 1 year ago. CT of the chest on _%#MMDD2006#%_, done at CDI cavitary mass at the right middle lobe measuring 8.0 x 10.6 cm. There is soft tissue nodularity present with air fluid levels.
CDI|center for diagnostic imaging|CDI|234|236|PAST MEDICAL HISTORY|Several films had been taken subsequently and the pain had seemed to have persisted too long so she was referred to Dr. _%#NAME#%_ _%#NAME#%_ of an orthopedics group who asked her to get an MRI of the pelvis and this was performed at CDI in _%#CITY#%_ _%#CITY#%_ _%#CITY#%_ on Wednesday, _%#MM#%_ _%#DD#%_, 2002. I was able to listen to the dictated report on the CDI dictation line and this indicated that there was an abnormal geographic lesion around the symphysis pubis and that there was a "pathologic fracture" of the left pubis ramus with perhaps an associated fracture in the sacrum posteriorly.
CDI|center for diagnostic imaging|CDI|364|366|PAST MEDICAL HISTORY|Several films had been taken subsequently and the pain had seemed to have persisted too long so she was referred to Dr. _%#NAME#%_ _%#NAME#%_ of an orthopedics group who asked her to get an MRI of the pelvis and this was performed at CDI in _%#CITY#%_ _%#CITY#%_ _%#CITY#%_ on Wednesday, _%#MM#%_ _%#DD#%_, 2002. I was able to listen to the dictated report on the CDI dictation line and this indicated that there was an abnormal geographic lesion around the symphysis pubis and that there was a "pathologic fracture" of the left pubis ramus with perhaps an associated fracture in the sacrum posteriorly.
CDI|center for diagnostic imaging|CDI|154|156|COURSE WHILE AT TRANSITION SERVICES|We did have the Pain Service evaluate him. We felt it was best that he sticks with his current pain management system, including seeing Dr. _%#NAME#%_ at CDI for his epidural steroid injections. He was given oral pain management, and was able to progress in his mobility. His renal insufficiency was evaluated during his stay. His creatinine stabilized at approximately 2-2.5. His electrolytes remained stable during his admission.
CDI|center for diagnostic imaging|CDI|120|122||He came into the office today and was found to have an elevated white count of 16,800 with a left shift. He was sent to CDI for a CAT scan which was read as left portal vein thrombosis with a mass in the hepatic lobe of the liver: Abscess versus malignancy - metastases.
CDI|center for diagnostic imaging|(CDI)|366|370|BRIEF HISTORY|The reason this was done in _%#MM#%_ and she had seen Dr. _%#NAME#%_ _%#NAME#%_ who had suggested that with all her risk factors (i.e., strong family history of heart disease, sister having several heart attacks, and she had non-insulin- dependent diabetes as well as hypertension) that she should have something done. This was done at Center for Diagnostic Imaging (CDI) and we do not have the report. Nevertheless she was scheduled to see a cardiologist _%#MMDD2003#%_. Approximately three weeks ago she began to noticed increasing dyspnea, chest pain, pain in the neck, and shoulder pressure relieved with rest so she was brought in for evaluation as the pain seemed to be increasing in intensity.
CDI|center for diagnostic imaging|CDI,|215|218|HISTORY OF PRESENT ILLNESS|For the first two weeks of _%#MM2004#%_, she was seeing intermittent flashing lights in her peripheral vision. Dr. _%#NAME#%_, her ophthalmologist, ordered an MRI/MRA of the head and neck on _%#MMDD2004#%_, done at CDI, _%#CITY#%_ _%#CITY#%_ _%#CITY#%_, which revealed poor flow in the distal-most cervical and intracranial part of the non-dominant left vertebral artery, as well as small-vessel ischemic disease; however, there was no acute infarct at that time.
CDI|center for diagnostic imaging|CDI,|176|179|DISCHARGE DIAGNOSES|DOB: _%#MMDD1918#%_ ADMITTING DIAGNOSES: Rule out myocardial infarction, transient ischemic attack, weakness and confusion. DISCHARGE DIAGNOSES: Suspect mild pericarditis, new CDI, dementia, atrial fibrillation, left rib pain, hypertension, hyponatremia. COURSE IN HOSPITAL: The patient was admitted to the emergency department with chest pain.
CDI|center for diagnostic imaging|CDI|145|147|SUBJECTIVE|This interferes with his playing of handball, etc. He has seen multiple orthopedists and pediatrists, I believe, but recently had an MRI scan at CDI in _%#CITY#%_ _%#CITY#%_ _%#CITY#%_, which showed moderate tendinosis with moderate intrasubstance bleeding of the Achilles tendon distally at the calcaneal insertion with calcaneal spurring in this region as well as fluid within the flexor hallucis longus tendon sheath.
CDI|center for diagnostic imaging|CDI|141|143|HISTORY|She was able to walk with a hemiparetic gait but did require a cane held in the left hand. An MRI scan had been done of the left shoulder at CDI on _%#MMDD2004#%_ which was noted to show a full thickness tear of the supraspinatus portion of the rotator cuff with retraction and mild atrophy.
CDI|center for diagnostic imaging|CDI|151|153|HISTORY|She states she has had backaches in the past but nothing that approximated the type of pain that she has had this time. She did undergo an MRI scan at CDI and I have the report of that. PAST MEDICAL HISTORY: Significant for previous surgery of hysterectomy with associated bladder suspension.
CDI|center for diagnostic imaging|CDI|109|111|HISTORY OF PRESENT ILLNESS|Starting about two weeks ago, she developed back and left leg pain. As an outpatient, she had an MRI scan at CDI which reportedly showed moderate spondylolytic changes, worse at L4-L5 and L5-S1, with small disk bulge to the left causing neuroforaminal stenosis at both of these levels.
CDI|center for diagnostic imaging|CDI|246|248|HISTORY OF PRESENT ILLNESS|As an outpatient, she had an MRI scan at CDI which reportedly showed moderate spondylolytic changes, worse at L4-L5 and L5-S1, with small disk bulge to the left causing neuroforaminal stenosis at both of these levels. She had a procedure done at CDI which appears to have been an attempted sciatic nerve block. The Band-Aid is about 8 cm from the midline in the left buttock area.
CDI|center for diagnostic imaging|CDI|226|228|IMPRESSION|IMPRESSION: Severely symptomatic left L5 radiculopathy failing conservative management. I do not see value in repeating her MRI. She is unlikely receiving adequate tissue level from the oral Decadron. The procedure she had at CDI was certainly not a lumbar epidural, and I feel that is the next reasonable step. Another option would be surgery, from which I understand the patient is not excited, nor is Dr. _%#NAME#%_.
CDI|center for diagnostic imaging|CDI|173|175|CHIEF COMPLAINT|X-rays of the back, hip and knee were all performed and these were normal. At Fairview Ridges blood was drawn for cultures. Cultures were negative. The patient also went to CDI on Friday for a bone scan which is also negative. The patient reports that most of the pain is stemming from the right knee and travels up and down the leg.
CDI|center for diagnostic imaging|CDI|203|205|HISTORY|Lifting things with her arms is painful. Crossing her right arm across her anterior chest also causes pain. In view of the amount of pain that she experienced, MRI scan of the right shoulder was done at CDI on _%#MMDD2005#%_. The scan shows broad base, full thickness tearing of the supraspinatus tendon. There is mild tearing and fraying of the anterior fibers of the infraspinatus tendon.
CDI|center for diagnostic imaging|CDI.|240|243|PATIENT IDENTIFICATION|The sonohistogram showed again a posterior fundal filling defect consistent with a large polyp measuring 3.4 x 1.6 x 2.1 cm. Incidentally, there was also noted to be a left ovarian cyst which had previously been seen on the ultrasound from CDI. The cyst was again seen and visualized in the ultrasound of _%#MMDD2006#%_. A CA-125 was drawn and was normal. The patient was evaluated and scheduled for surgery, which was to include examination under anesthesia, diagnostic hysteroscopy, D&C, excision of an endometrial polyp, followed by a diagnostic laparoscopy and possible left ovarian cystectomy.
CDI|center for diagnostic imaging|CDI|330|332|HISTORY OF PRESENT ILLNESS|She recently moved to the _%#CITY#%_ _%#CITY#%_ area from Maryland and over the last several months she has developed classic heart failure symptoms including orthopnea and PND as well as lower extremity edema. She has been followed at the _%#CITY#%_ Lake clinic. Echo was done there today with preliminary results I believe from CDI suggesting an EF of 23%, global hypokinesis, moderate mitral regurgitation and moderate tricuspid regurgitation with elevated pulmonary pressures.
CDI|center for diagnostic imaging|CDI|137|139|HISTORY OF PRESENT ILLNESS|Patient was sent for orthopedic consultation who thought that the patient may have a stress fracture. The patient was sent for an MRI at CDI in _%#CITY#%_, Minnesota. Evaluation of the MRI by the radiologist at CDI revealed that the patient had a DVT in the left common iliac.
CDI|center for diagnostic imaging|CDI|211|213|HISTORY OF PRESENT ILLNESS|Patient was sent for orthopedic consultation who thought that the patient may have a stress fracture. The patient was sent for an MRI at CDI in _%#CITY#%_, Minnesota. Evaluation of the MRI by the radiologist at CDI revealed that the patient had a DVT in the left common iliac. Patient was sent to the hospital for further evaluation and treatment.
CDI|center for diagnostic imaging|CDI.|263|266|HOSPITAL COURSE|Patient was started on Lovenox. HOSPITAL COURSE: 1. DVT. As previously stated, an ultrasound of the pelvis did not reveal that there was a DVT in the common iliac. The MRI report was reviewed by the emergency room physician but the actual MRI never did come from CDI. It is assumed that the patient did have a DVT and will be treated as such. She was started on Lovenox b.i.d. dosing and eventually started on Coumadin to get to a therapeutic level between 2 and 3.
CDI|center for diagnostic imaging|CDI|159|161|HOSPITAL COURSE|She elects, however, not to undergo blood patch here and will be discharged to home. If her symptoms persist she will get an outpatient blood patch perhaps at CDI or perhaps here. The patient is discharged on _%#MMDD2006#%_. Diagnosed listed above.
CDI|center for diagnostic imaging|CDI|145|147|HISTORY OF PRESENT ILLNESS|She has markedly positive straight leg raising on the left side. She has had a repeat MRI examination of the lumbar spine. This was performed at CDI and demonstrates an extruded disk herniation at the L5-S1 level on the left side, producing impingement of the left S1 nerve root.
CDI|center for diagnostic imaging|CDI|116|118|PLAN|3. History of a prostate cancer with radiation. 4. High blood pressure. 5. History of hiatal hernia. PLAN: Refer to CDI for an MRI scan of the right hip. Based on the x-rays and history, schedule for admission to Fairview Southdale Hospital on _%#MMDD2007#%_with a cannulated screw fixation of his right hip at 8 a.m. on _%#MMDD2007#%_ at Fairview Southdale Hospital.
CDI|center for diagnostic imaging|CDI|138|140|GENERAL PHYSICAL EXAMINATION|Popliteal space is negative. Distally, no other problems, pulses intact and equal. X-rays are negative. MRI reviewed and done _%#MMDD#%_, CDI _%#CITY#%_ _%#CITY#%_: Findings, small but a complex meniscus tear, posterior horn, possibly at the peripheral edge, but does have a vertical component.
CDI|center for diagnostic imaging|(CDI)|221|225|HISTORY OF PRESENT ILLNESS|She saw Dr. _%#NAME#%_ in _%#MM#%_ and he recommended that she have surgery with Dr. _%#NAME#%_ and she has seen him in consultation and understands the nature of the surgery. An MRI done at Center for Diagnostic Imaging (CDI) on _%#MMDD2002#%_ revealed the herniated disk. She has failed with conservative treatment. PAST MEDICAL HISTORY: 1. Peptic acid disease with two bleeding ulcers in the past.
CDI|center for diagnostic imaging|CDI.|116|119|PAST MEDICAL HISTORY|3) No known coronary artery disease, although she had a stress test yesterday of which we are awaiting results from CDI. 4) Degenerative joint disease; the patient had MRI of the left knee several days ago; we are awaiting the results of this.
CDI|UNSURED SENSE|CDI.|84|87|DISCHARGE DIAGNOSES|2. Mitral valvular disease with intermittent atrial fibrillation as likely cause of CDI. 3. Hypertension 4. Diabetes mellitus, poor control. 5. Hypernatremia. 6. Congestive heart failure 7. Placement of feeding tube. 8. CODE STATUS IS DNR, DNI PROCEDURES AND TESTS: Admission chemistries with normal electrolytes, glucose 155, BUN 24, creatinine 0.9. CBC with hemoglobin of 13, white count 9.8, platelet count 270.
CDI|center for diagnostic imaging|CDI.|189|192|HISTORY OF PRESENT ILLNESS|Again, the patient is pain-free at this time. The patient is a 78-year-old female with no previous history of ischemic disease. She did undergo a stress echocardiogram on _%#MMDD2003#%_ at CDI. There she had a reasonable exercise capacity, she achieved 100% of predicted maximum, and had a normal echocardiogram with stress and with rest.
CDI|center for diagnostic imaging|CDI|173|175|ASSESSMENT|2. Moderate risk factors given age, hypertension, hyperlipidemia. 3. Systolic murmur seems most compatible with aortic valve disease. Interestingly on the echo performed by CDI back in _%#MM2003#%_ they do not mention anything about the aortic valve. PLAN: 1. We will admit the patient. 2. Check serial troponins.
CDI|center for diagnostic imaging|CDI|208|210||He was subsequently seen at Queen of Peace. X-ray at that time showed no acute fracture. However, because of the amount of pain that he had he subsequently underwent an MR arthrogram of his right shoulder at CDI in _%#CITY#%_. His MR arthrogram showed a large tear of the entire posterior as well as superior, and much of the adjacent inferior labrum associated with posterior capsular stripping with this injury.
CDI|center for diagnostic imaging|CDI|197|199|HISTORY OF PRESENT ILLNESS|Office evaluation demonstrated tenderness in the right lower quadrant with associated rebound. CBC, CMP were obtained (pending). Patient referred for CT scan of the abdomen and pelvis performed at CDI in _%#CITY#%_ _%#CITY#%_ later this afternoon; demonstrated the appendix to be dilated to 9 mm with little contrast enhancement. This was reviewed with the radiologist. He indicated appendix was 3 mm dilated over normal size, contrast enhancement consistent with mild inflammatory change felt to be coalescent for appendicitis.
CDI|center for diagnostic imaging|CDI|214|216|HOSPITAL COURSE|He tolerated a regular diet. At the time of discharge the patient was afebrile and his vital signs were within normal limits including his blood sugars. The patient has an incredibly supportive home environment at CDI Home who have come to visit him regularly during this hospitalization and are eager to have him return to their care upon discharge.
CDI|center for diagnostic imaging|CDI,|154|157|DISCHARGE INSTRUCTIONS|16. Prograf 1.5 mg p.o. b.i.d. 17. Torsemide 15 mg p.o. b.i.d. (hold Lasix while on torsemide) DISCHARGE INSTRUCTIONS: The patient is being discharged to CDI, his group home, with supervision. He is to return to his previous diet and his previous activity level. He is to contact the clinic, inpatient care unit, or transplant coordinator with elevated temperature, increasing pain, increasing swelling, or other concerns.
CDI|Children's Depression Inventory|CDI|295|297|TEST RESULTS|She was oriented to person, place and time. TEST ADMINISTERED AND TASK COMPLETED: Diagnostic interview, children's depression inventory, sentence completion test, review of previous psychological evaluation on _%#MMDD2005#%_. TEST RESULTS: TVI resulted in clinically significant level for total CDI score; negative mood, anhedonia, negative self esteem. Items of interest include; "I think about killing myself but I would not do it, I am not sure things will work out for me, I am sure that terrible things will happen to me, things bother me many time." Items of interest on the sentence completion test include; "I cannot understand why I am so F--- 'd up, I wish people would not hurt me, I often worry about everything." Summary of psychological evaluation can be reviewed in Medical Records as mentioned above.
CDI|center for diagnostic imaging|CDI,|140|143|IMAGING STUDIES|He has a normal white count and hemoglobin of likewise normal at 15. Platelets are 283. IMAGING STUDIES: In addition to the imaging done at CDI, we performed a MRI of the cervical spine with contrast and also a noncontrast cervical CT. CT appears negative for any bony infiltration or abnormalities. The MRI, however, does reveal some enhancing material which appears extradural and in dense the thecal sac and causes moderate cord compression.
CDI|center for diagnostic imaging|CDI|180|182|PAST MEDICAL HISTORY|No right leg radicular component. Typically has had left buttock and left thigh radicular pain in the past, which is presently quiescent. Nerve root injection on _%#MMDD2004#%_ at CDI in _%#CITY#%_. Chiropractic intervention to the cervical spine, which has not been significantly bothersome. 3. Obesity, presumably exogenous. 4. History of "blood clot" left upper extremity subsequent to IV placement in the emergency room at Fairview _%#CITY#%_ over one year ago.
CDI|center for diagnostic imaging|CDI|293|295|RECOMMENDATIONS|Recent CT _%#MMDD2004#%_ showed clear tumor progression. The patient is symptomatic with chest pain and shortness of breath, although has found relief with Vioxx and prednisone. RECOMMENDATIONS: We will give our final treatment recommendations following receipt of the patient's CT films from CDI imaging dated _%#MMDD2004#%_ and discussion with Dr. _%#NAME#%_. _%#NAME#%_ _%#NAME#%_, MD Resident Physician _____ Patient seen and examined by me and resident.
CDI|center for diagnostic imaging|CDI;|148|151|RADIOGRAPHS|Reflexes are symmetrically reactive at the knees and ankles; she has no ankle clonus. RADIOGRAPHS: An MRI of the lumbar spine was done yesterday at CDI; it was compared with a previous scan from early _%#MM#%_. Yesterday's scan showed marked progression of the discitis/osteomyelitis at the L1-2 level with near total involvement of the L1 and L2 vertebra.
CDI|center for diagnostic imaging|CDI|139|141|HISTORY|She was admitted through the Emergency Room this early afternoon of _%#MMDD2003#%_ because of stress study. She had seen Dr. _%#NAME#%_ at CDI who had been evaluating her for vascular disease. I do not have the results of all these tests but for all that she attempted a stress nuclear study this morning.
CDI|Children's Depression Inventory|(CDI),|358|363|TESTS ADMINISTERED AND TESTS COMPLETED|There is no evidence of hallucinations, delusions, paranoid ideation, grossly inappropriate affect, or other frank manifestation of psychotic disorder. He was oriented to person, place, and time. TESTS ADMINISTERED AND TESTS COMPLETED: Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A), Rorschach Ink Blot Test, Children's Depression Inventory (CDI), Sentence Completion Test. TEST RESULTS: As of this evaluation session the MMPI-A was not yet completed.
CDI|Children's Depression Inventory|(CDI)|138|142|TEST RESULTS|As a result these individuals may be seen as having poor judgment and poor problem solving abilities. The Children's Depression Inventory (CDI) was administered on _%#MMDD2005#%_. He did not rate himself at a clinically significant level for negative mood, interpersonal problems, ineffectiveness, anhedonia, or negative self-esteem.
CDI|center for diagnostic imaging|CDI,|174|177|TREATMENT RECOMMENDATIONS|Mr. _%#NAME#%_ is morbidly afraid of MRI studies, and declined additional investigation, and went home. I spoke with him this morning. He agreed to undergo CT angiography at CDI, which I arranged for him with Dr. _%#NAME#%_ _%#NAME#%_. I have not had further discussion with Mr. _%#NAME#%_. However, CDI informs me that he has declined his investigation at this point, and plans to schedule this on Monday morning.
CDI|center for diagnostic imaging|CDI|196|198|TREATMENT RECOMMENDATIONS|I spoke with him this morning. He agreed to undergo CT angiography at CDI, which I arranged for him with Dr. _%#NAME#%_ _%#NAME#%_. I have not had further discussion with Mr. _%#NAME#%_. However, CDI informs me that he has declined his investigation at this point, and plans to schedule this on Monday morning. I did leave a message with Mr. _%#NAME#%_ at his home, that this would be inadvisable, and he should come in today to have a CT angiogram done to rule out stroke.
CDI|center for diagnostic imaging|CDI|163|165|REASON FOR CONSULTATION|He is a patient who I saw back in mid _%#MM#%_ when he was seen for a positive stress echocardiogram. The stress echocardiogram was performed by Dr. _%#NAME#%_ at CDI and Dr. _%#NAME#%_ _%#NAME#%_ sent the patient in for cardiac consultation. The stress echocardiogram suggested anterior ischemia.
CDI|center for diagnostic imaging|CDI|151|153|HISTORY|He states that an echocardiogram did indicate mitral regurgitation of at least a moderate nature. He previously had a Adenosine nuclear stress test at CDI which the patient notes was normal. CARDIAC RISK FACTORS: Include morbid obesity, adult onset diabetes mellitus for the last two years, hypertension for the last one year.
CDI|center for diagnostic imaging|CDI|113|115|PHYSICAL EXAMINATION|ABDOMEN: Obese. EXTREMITIES: Show 2+ mostly nonpitting edema at the ankles. I refer the interested reader to the CDI _%#CITY#%_ chest CT scan on _%#MMDD2007#%_ which I reviewed today, both films and report, and to the Fairview Ridges echocardiogram of _%#MMDD2007#%_ which I reviewed and discussed with Dr. _%#NAME#%_ of Cardiology.
CDI|center for diagnostic imaging|CDI.|132|135|HISTORY|He has not seen a cardiologist since that time. He is followed by his family doctor. He had a nuclear stress test done last year at CDI. It showed no ischemia, but because of very frequent premature ventricular contractions, the ejection fraction and wall motion could not be analyzed.
CDI|center for diagnostic imaging|CDI|243|245|HISTORY OF PRESENT ILLNESS|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, M.D. HISTORY OF PRESENT ILLNESS: I was asked to visit _%#NAME#%_ _%#NAME#%_, an 89-year-old who had been admitted on _%#MMDD2004#%_ for chest discomfort. She has known heart disease, having been at CDI last fall and a test showed coronary artery disease, as I understand it, although the actual test is not available. She had a CVA on _%#MMDD2003#%_ with weakness in the right hand and right leg that have improved toward normal.
CDI|center for diagnostic imaging|CDI.|195|198|HISTORY OF PRESENT ILLNESS|When the diagnosis of sarcoma was made, the patient was referred to Dr. _%#NAME#%_ _%#NAME#%_ at the Fairview-University Medical Center. A CT scan of the chest was performed on _%#MMDD2002#%_ at CDI. Reportedly, this was negative. An open- sided MRI scan was performed on _%#MMDD2002#%_. We have reviewed these films ourselves, and they reveal only minimal evidence of residual tumor, which is quite difficult to appreciate.
CDI|center for diagnostic imaging|(CDI)|277|281|HISTORY|She was started on Flomax and an antihistamine and this at most showed some very slight initial benefit, but more recently her symptoms have progressively worsened despite pulmonary therapy. When she did not improve Dr. _%#NAME#%_ referred her to Center for Diagnostic Imaging (CDI) for a stress echo evaluation. I do not have this study to review at this time but the patient claims that this stress echo was abnormal showing ischemia in a left anterior descending (LAD) distribution.
CDI|center for diagnostic imaging|CDI|269|271|REQUESTING PHYSICIAN|This revealed a probably metastatic disease T2 to T3 with an epidural component. The patient has since had additional imaging studies. I do not have these reports, although apparently he had additional MRI scanning as well as a CT scan of the chest and abdomen done at CDI in _%#CITY#%_ _%#CITY#%_. After discussion with Dr. _%#NAME#%_, these tests were reportedly negative.
CDI|Children's Depression Inventory|(CDI),|357|362|TESTS ADMINISTERED AND TASKS COMPLETED|There was no evidence of hallucinations, delusions, paranoid ideation, grossly inappropriate affect, or other frank manifestation of psychotic disorder. She was oriented to person, place, and time. TESTS ADMINISTERED AND TASKS COMPLETED: Diagnostic interview, Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A), Children's Depression Inventory (CDI), Revised Children Manifest Anxiety Scale (RCMAS). TEST RESULTS: The MMPI-A was responded to an open and honest manner, and the profile is valid and interpretable.
CDI|center for diagnostic imaging|CDI|235|237|HISTORY|She underwent echocardiography during _%#MM#%_, 2003, which was remarkable only for the presence of a dynamic left ventricular outflow gradient which increased from 19 to 111 mmHg with Valsalva. She underwent a stress nuclear study at CDI which was "normal" during _%#MM#%_ 2003. PAST MEDICAL HISTORY: 1. Myopathy, undetermined etiology. 2. Recent tapering of steroids, subsequent failure to thrive.
CDI|center for diagnostic imaging|CDI|127|129|HISTORY OF PRESENT ILLNESS|This was initially worked up and thought to be myositis ossificans. On _%#MMDD2004#%_ the patient had an MRI on the outside at CDI in _%#CITY#%_ _%#CITY#%_, Minnesota. We do not have these films, but apparently they show a mass. On _%#MMDD2004#%_, the patient had a plain film here at Fairview-University Medical Center which showed a soft tissue calcification adjacent to the lateral epicondyle.
CDI|center for diagnostic imaging|CDI|154|156|HISTORY OF PRESENT ILLNESS|A biopsy was performed at United Hospital, but is not available for review, but per records, it revealed high-grade sarcoma. An MRI scan was performed at CDI Imaging on _%#MMDD2003#%_ which revealed a mass in the left thigh which measured 12.5 x 9.7 cm. The patient was then referred to Dr. _%#NAME#%_ _%#NAME#%_ for surgical resection.
CDI|center for diagnostic imaging|CDI|177|179|HISTORY OF PRESENT ILLNESS|I am not sure how this was described to him as he denied having coronary artery disease in the past until about a year ago when he had a stress echocardiogram. This was done in CDI imaging service at _%#CITY#%_ _%#CITY#%_ _%#CITY#%_ and was reportedly suggestive of mild inferior ischemia. The patient did not go to the cardiologist as he was stubborn.
CDI|center for diagnostic imaging|CDI|130|132|LABORATORY  DATA|At Dr. _%#NAME#%_'s office, included a normal white blood cell count and was otherwise unremarkable. The patient had a CT scan at CDI that is not available, but by report shows evidence of acute appendicitis. Discussed in detail with the patient. I think she is a suitable candidate for laparoscopic appendectomy.
CDI|center for diagnostic imaging|CDI|229|231||He also was retaining fluids which was felt to be partially due to Actos which was decreased with improvement in his peripheral edema. He still has some peripheral edema. Apparently an echocardiogram was done last Friday through CDI and there was some valvular pathology. He was supposed to be seen at Minnesota Heart Clinic this week, however, he came in with some GI problems and missed his appointment with us.
CDI|center for diagnostic imaging|CDI.|162|165|HISTORY OF PRESENT ILLNESS|About a month ago she developed abdominal pain and was seen at the Fairview _%#CITY#%_ _%#CITY#%_ clinic. A CT of the abdomen and pelvis was done at that time at CDI. She states that she was told she had "colitis" and was treated with a course of antibiotics. She was actually scheduled for a colonoscopy at our _%#CITY#%_ center tomorrow to further investigate this.
CDI|center for diagnostic imaging|CDI|209|211|IMPRESSION|Also consider infectious etiology versus medication induced, which seems unlikely. We will check her stools for infectious etiology and leukocytes. Will also check hepatitis serologies. Will request a CT from CDI in _%#CITY#%_ _%#CITY#%_ to obtain any details regarding her recent "colitis." Will also review her recent CT done yesterday to see if the small bowel wall thickening can be reached with an endoscope.
CDI|center for diagnostic imaging|CDI|202|204|HISTORY OF PRESENT ILLNESS|Over the past 6 months the patient has developed progressive pain in the preauricular area, especially when chewing or descending from an airplane flight. The brain MRI was repeated on _%#MMDD2005#%_ a CDI in _%#CITY#%_ _%#CITY#%_. That scan confirmed a complex signal mass with slight enhancement involving the geniculate ganglion, labyrinthine portion of cranial nerve VII, and proximal internal auditory canal, as well as the medial aspect of the middle ear.
CDI|center for diagnostic imaging|CDI|179|181|IMAGING|There is some degenerative disk disease throughout the lumbar spine. At L5-S1 there is a moderate paracentral disk herniation without obvious neural compression. An MRI scan from CDI dated _%#MM2005#%_ is also available and reviewed today. Again noted is an L5-S1 right paracentral disk herniation. There appears to be no significant change between the two exams.
CDI|center for diagnostic imaging|CDI|393|395|HISTORY OF PRESENT ILLNESS|He is penicillin allergic and cannot take penicillin derivatives. He has observed over the last six months or so that Bactrim has been more effective than other antibiotics and that the sputum production will often resolve while on Bactrim, but will return within a few days of going off. He wintered out of state and presented to my office again recently. A CT scan at the end of _%#MM#%_ at CDI in _%#CITY#%_ demonstrated patchy peripheral faint infiltrates too small to show up on fluoroscopy, but suggestive of ongoing infection in the setting of a man with a cough productive of purulent sputum.
CDI|center for diagnostic imaging|CDI|110|112|HISTORY OF PRESENT ILLNESS|He has been fairly active recently and did not have chest pain with exertion. A stress echocardiogram done at CDI through Quello Clinic was performed on _%#MMDD2003#%_. The patient exercised for 3 minutes and 33 seconds on a Bruce protocol and the stress test was terminated due to severe ST segment depression.
CDI|center for diagnostic imaging|CDI,|167|170|REASON FOR CONSULTATION|It only lasts for a few minutes. Otherwise, she has no chest pain on exertion. I believe that is the start of her chest pains. She underwent a stress nuclear study at CDI, I do not have the results at present. She was told that her heart tracing showed atrial fibrillation but nevertheless she was able to complete the stress test.
CDI|center for diagnostic imaging|CDI,|129|132|PAST MEDICAL HISTORY|7. History of work-related injury; the patient apparently fell down stairs. He states he has had imaging of his back and neck at CDI, an imaging center. He also states that he has been to several of these imaging centers; he could not give me a definite location.
CDI|center for diagnostic imaging|CDI|109|111|NEUROLOGIC EXAMINATION|Achilles and patellar deep tendon reflexes are within normal limits. I have reviewed her head CT obtained at CDI and there is bifrontal subdural hematomas within the frontopolar region without significant mass effect. LABORATORY: White blood cell count 6.9, hemoglobin 12.9, hematocrit 38.1, platelets 329,000.
CDI|center for diagnostic imaging|CDI|288|290|HISTORY|She has had some increased activities recently, what with her job which entailed a fair bit of travel in addition to assisting her daughter who had a recent total knee arthroplasty and also has a one-year-old. Two years ago she did undergo a lumbar epidural steroid injection through the CDI and had had excellent relief for her symptoms at that time. PHYSICAL EXAMINATION: She was lying on her right side and seemed fairly comfortable.
CDI|center for diagnostic imaging|CDI|211|213|HISTORY|It has progressively gotten worse over the last week. She apparently saw her primary care clinic at HealthPartners. An MRI was obtained. There is a copy of the MRI report within the chart. This was performed at CDI on _%#MMDD2007#%_. It showed an extruded left L4-5 disc herniation extending cranially. This compressed the left L5 nerve root. There was severe disc degeneration L3-4.
CDI|center for diagnostic imaging|CDI.|247|250||She is followed by Dr. _%#NAME#%_ _%#NAME#%_ for a prior history of a left shoulder fracture and also a recent L2 compression fracture. Mrs. _%#NAME#%_ had seen Dr. _%#NAME#%_ yesterday and he set her up for an epidural steroid injection today at CDI. She was walking to CDI when she fell and landed on her bottom, and was unable to continue with walking due to the pain.
CDI|center for diagnostic imaging|CDI|135|137||Mrs. _%#NAME#%_ had seen Dr. _%#NAME#%_ yesterday and he set her up for an epidural steroid injection today at CDI. She was walking to CDI when she fell and landed on her bottom, and was unable to continue with walking due to the pain. She was brought to the Emergency Room via ambulance complaining of back pain.
CDI|center for diagnostic imaging|CDI,|188|191|HISTORY OF PRESENT ILLNESS|She has had pain radiating into her right lower extremity, and her symptoms transiently improved with a Medrol Dosepak. The patient underwent an MRI scan of the lumbar spine last month at CDI, and this apparently revealed a pathologic fracture in the L5 vertebra. She has been seen by Dr. _%#NAME#%_ for consideration of mediastinoscopy and also by Dr. _%#NAME#%_ for a possible L5 biopsy, and she is tentatively scheduled for a biopsy procedure on _%#MMDD2007#%_.
CDI|center for diagnostic imaging|CDI|135|137|RECOMMENDATIONS|Over the next couple of days the pain persisted and he developed fevers as high as 104 degrees. He was seen in Urgent Care and sent to CDI for an abdominal CT scan, which was consistent with pancreatitis. He was then admitted to Fairview Ridges Hospital. Initial pancreatic enzymes were normal and they have stayed that way.
CDI|center for diagnostic imaging|CDI|253|255|HISTORY OF PRESENT ILLNESS|She has back pain that started about a week ago during _%#MMDD#%_ holiday and has a history of chronic low back pain but ended up having pain that was so severe that she sought help from her chiropractor last week. The MRI results have been obtained by CDI and indicate multi-level lower thoracic and lumbar disk degeneration, 3 mm broad based central and right posterior lateral disk herniation at L3-4 with moderate disk degeneration but there was no neural impingement.
CDI|center for diagnostic imaging|CDI|229|231|HISTORY OF PRESENT ILLNESS|Per mom, the patient had become somewhat stable. Therefore, they did not feel it was worthwhile to go to the emergency room on Sunday evening. Therefore, they called the nurse's line on Monday morning and had the MRI obtained at CDI in _%#CITY#%_ _%#CITY#%_ today for assessment of her pain. Today, _%#NAME#%_ states that her pain is improving greatly from where she was on Sunday night.
CDI|Children's Depression Inventory|CDI|90|92|TEST RESULTS|Overall, there is little to no concern about underlying psychopathology or psychosis. The CDI did not result in any clinically significant level for depressive symptoms. The RCMAS did not result in any clinically significant level for anxiety symptoms.
CDI|Children's Depression Inventory|CDI|89|91|TEST RESULTS|Most of the time, these individuals tend to accurately interpret their environments. The CDI resulted in a mildly clinically significant level for feelings of ineffectiveness. Items of interest include "I want to kill myself...I am bad many times...I do not do what I'm told most times...I have to push myself all the time to do my school work." SUMMARY OF CURRENT FINDINGS: This is a 14-year-old Caucasian male who was admitted to the subacute diagnostic unit at University of Minnesota Medical Center, Fairview, due to threatening suicide and experiencing ongoing suicidal ideation and depressive symptoms.
CDI|center for diagnostic imaging|CDI|209|211|RECOMMENDATIONS|She does have decreased range of motion of there and these symptoms may be explained by right hip arthritis. Additionally, we will get lumbar spine films AP and lateral views. We will try to obtain the recent CDI lumbar spine MRI for evaluation. We will make further recommendations based on these tests. The case will be discussed with Dr. _%#NAME#%_.
CDI|center for diagnostic imaging|CDI|304|306|HISTORY OF PRESENT ILLNESS|He had been seen by Dr. _%#NAME#%_. They scheduled replacement of his Harrington rods on _%#MMDD2006#%_, and so he has been trying various things for pain management in order to survive his pain until the Harrington rods are replaced, in which he anticipates a reduction of his pain. He has been seen at CDI in _%#CITY#%_ for in injections under fluoroscopy of local anesthetics around the Harrington rods. I asked him if they were trigger points, and he says that he thinks that those were deeper than trigger points, so I will be calling CDI in _%#CITY#%_ to see what that procedure was.
CDI|center for diagnostic imaging|CDI|125|127|ASSESSMENT|He has increased his analgesic medicines, the ibuprofen and aspirin, because of the increased pain. He has also been sent to CDI from Dr. _%#NAME#%_ for injections around the Harrington rods, and I will see what that injection was tomorrow because we may be able to replicate that here for better pain control.
CDI|center for diagnostic imaging|CDI|155|157|HISTORY  OF PRESENT ILLNESS|On _%#MMDD#%_, she had a CT scan that showed a decrease in fluid in the cavity compared to an earlier CT scan of _%#MMDD2006#%_. The _%#MMDD#%_ CT scan at CDI showed a thick walled irregular mass like structure in the right hilum as well as mass like consolidation in the right middle lobe.
CDI|center for diagnostic imaging|CDI|278|280|ASSESSMENT AND PLAN|She now has brain metastases and probable pulmonary and rib cage metastases as well as a large complicated local reoccurrence in the right middle lobe which has cavitated and apparently become infected. I would like to review the CT scan from the last 2 weeks which was done at CDI in _%#CITY#%_ to see whether the mass could be radiated centrally to decrease obstruction, but it appears to me that the right middle lobe has simply been replaced by tumor which has now cavitated and that the infection cannot be drained nonsurgically because of the high probability of contaminating the pleural space.
CDI|center for diagnostic imaging|CDI|341|343|ASSESSMENT|It looks a little more prominent to me. When I view his _%#MMDD2005#%_ I think there is a very faint density in the same area, however, this is impossible to be certain of since the available computer viewing screen has poor resolution for this purpose. I recommend a CT scan of the chest. We will get my office records and the records from CDI in _%#CITY#%_ where I think his most recent chest x-ray was done. I discussed the plan of care with the patient and his significant other at the bedside.
CDI|center for diagnostic imaging|CDI|241|243|HISTORY OF PRESENT ILLNESS|She has been essentially asymptomatic. However, at her daughter's urging, she underwent a heart scan at CDI in _%#CITY#%_ _%#CITY#%_ _%#CITY#%_. She had a high calcification score and subsequently underwent a nuclear medicine stress test at CDI as well. This was strongly positive. Because of this, the patient was referred to Dr. _%#NAME#%_. He recommend coronary angiography which was performed on _%#MMDD2006#%_.
CDI|center for diagnostic imaging|CDI|166|168|HISTORY OF PRESENT ILLNESS|The weakness was so severe that he was unable to stand up alone. Since his hospitalization, he has had a workup. Prior to hospitalization, he had an MRI scan done at CDI an subsequent to hospitalization, he had a repeat MRI scan with contrast. There is concern regarding epidural abscess. ALLERGIES: The patient denies any allergies to medications.
CDI|center for diagnostic imaging|CDI|116|118|PAST MEDICAL HISTORY|She has had chest discomfort in the past which occurs at rest. By all accounts, she had a nuclear scan performed at CDI in _%#MM#%_ of this year and according to the report was negative for ischemia. She is getting no exertional chest discomfort at present. No orthopnea, PND, or ankle edema.
CDI|center for diagnostic imaging|CDI|172|174|ASSESSMENT|ASSESSMENT: 1. Metastatic non small cell lung cancer. Increasing mets to liver with increasing to lung despite chemotherapy. Increased infiltrates on CT scan, performed at CDI (unavailable at this time). 2. Progressive dyspnea with cough, chest tightness, wheezing (all of which are new). She is mildly better. Differential diagnoses include lymphangitis spread, drug related pneumonitis (would need bronchoscopy and transbronchial biopsies with BAL), infectious (community acquired pneumonia, opportunistic infections are not out of the realm of possibilities) and this would require bronchoscopy with BAL, could be airway disease with bronchitis.
CDI|center for diagnostic imaging|CDI|172|174|PLAN|We will await the brain MRI. If the brain MRI is negative, we can do a bronchoscopy with BAL and transbronchial biopsies after I have reviewed the films. I have called the CDI in _%#CITY#%_ _%#TEL#%_. Films are to be sent here to the floor. I will review his films after they arrive. HISTORY OF PRESENT ILLNESS: Patient is a 53-year-old female followed by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_.
CDI|center for diagnostic imaging|CDI|224|226|HISTORY OF PRESENT ILLNESS|These findings were discussed with Dr. _%#NAME#%_ at that time and we decided to proceed with an MR spectroscopy to help distinguish between recurrent tumor versus radiation necrosis. This was performed on _%#MMDD2002#%_ at CDI and that showed that the left occipital lesion was primarily necrosis. The left putamen/frontal lesion had central necrosis with peripheral tumor so both tumor and necrosis, and the right medial frontal/corpus callosum lesion showed increased choline consistent with residual tumor and a small amount of necrosis.
CDI|center for diagnostic imaging|CDI|167|169|RADIOGRAPHIC EVALUATION|There are no palpable masses in this region, however. She has no pain with internal and external rotation of the hip itself. RADIOGRAPHIC EVALUATION: Her CT scan from CDI is not yet available. This is negative by her family's report and included the pelvis. MRI scan of the lumbar spine demonstrates severe stenosis at L4-5.
CDI|center for diagnostic imaging|CDI|259|261|RECOMMENDATIONS|RECOMMENDATIONS: She has already gotten physical therapy and medications. For this reason, I recommend epidural steroid injection. We also discussed the possible need for surgical intervention should conservative measures fail. I will review the CT scan from CDI when it is made available to me to ensure that this is, in fact, negative. There is no evidence of hip pathology by exam, although she could have a sacral insufficiency fracture, which would have been ruled out by her pelvic CT scan.
CDI|center for diagnostic imaging|CDI.|128|131|DOB|By history she was admitted to the hospital with increasing back pain. She has previously, however, had a CAT scan performed at CDI. This had shown a questionable polyp and to this end we are seeing her. She states that she has a longstanding history of irritable bowel.
CDI|center for diagnostic imaging|CDI|103|105|PHYSICAL EXAMINATION|The electrolytes are normal as well. The sed rate is only 15. I did review the patient's CAT scan from CDI and the findings are only as described. There is a question of an 8-mm pedunculated filling defect; however, they are quite indeterminate about this.
CDI|center for diagnostic imaging|CDI|175|177|RADIOLOGIC DATA|LABORATORY DATA: INR 0.95, PTT 29. Sed rate is 5. White count 6.5, platelets 232,000. RADIOLOGIC DATA: No MRI is available to view at this time, though there is a report from CDI _%#CITY#%_ _%#CITY#%_ Flagship that reports a broad-based central disk bulge at L5-S1, producing moderate impingement of the left S1 nerve root, and mild impingement of the right S1 nerve root.
CDI|Children's Depression Inventory|(CDI),|342|347|TESTS ADMINISTERED AND TASKS COMPLETED|There is no evidence of hallucinations, delusions, paranoid ideation, grossly inappropriate affect, or other frank kind for frustration of psychotic disorder. She was oriented to person, place, and time. TESTS ADMINISTERED AND TASKS COMPLETED: Minnesota Multi-Phasic Personality Inventory-Adolescent (MMPI-A), Children's Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS). TEST RESULTS: The MMPI-A was responded to in an open and honest manner, and the profile is valid and interpretable.
CDI|center for diagnostic imaging|CDI|133|135|TEST RESULTS|There is also less likelihood for depressive and anxiety-related symptoms. In addition, all the scales are within normal limits. The CDI did not result in any clinically significant level for depressive symptoms; although she had a mild elevation, negative mood, and ineffectiveness.
CDI|center for diagnostic imaging|CDI.|288|291|HISTORY OF PRESENT ILLNESS|REQUESTING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_ IMPRESSION: Liver mass HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 68-year-old man who has had a week of fever, chills, lower abdominal pain, anorexia, and vomiting. He came to his physician yesterday and was sent for CT scan at CDI. Reportedly this showed a mass in the liver and left portal vein thrombosis. He was admitted. PAST MEDICAL HISTORY: Significant for no abdominal operations.
CDI|center for diagnostic imaging|CDI|267|269|LABORATORY|Although it is extremely unlikely that any tumor is recurring in the brain stem, post radiation necrosis happening 20 or 30 years after radiation is not unreasonable. I would recommend an MRI of the brain with emphasis on the brain stem to compare against his MRI at CDI a year ago to ensure that no clear changes are occurring. Continuing the patient on the Seroquel 100 mg a day is reasonable for the present.
CDI|center for diagnostic imaging|CDI|250|252|PAST MEDICAL HISTORY|Headache with Feldene. He does obtain some benefit with Naprosyn 500 mg b.i.d. Imaging studies have demonstrated degenerative disc disease with herniated disc at L2-3 and L4-5 with possible disc herniated at L5-S1. Plan to undergo facet injection at CDI on _%#MMDD2005#%_. 3. Obstructive sleep apnea, on CPAP. 4. History of recurrent "kidney infection." PAST SURGICAL HISTORY: 1. Four surgeries, left hand. 2. Left shoulder surgery. 3. Lumbar decompression x 1.
CDI|Children's Depression Inventory|(CDI),|443|448|TESTS ADMINISTERED AND TASKS COMPLETED|He has had fleeting suicidal ideation. There is no evidence of hallucinations, delusions, paranoid ideation, grossly inappropriate affect, or other frank manifestation of psychotic disorder. He is oriented to person, place, and time. TESTS ADMINISTERED AND TASKS COMPLETED: Diagnostic interview, review of medical record, Minnesota Multiphasic Personality Inventory - Adolescent (MMPI-A), Rorschach Inkblot Test, Children Depression Inventory (CDI), Revised Children Manifest Anxiety Scale (RCMAS). TEST RESULTS: The MMPI-A was responded to in an open and honest manner and the profile is valid and interpretable.
CDI|Children's Depression Inventory|CDI|156|158|TEST RESULTS|Conversely, this patient, in fact, does believe that he is having command hallucinations. This was discrepant with Dr. _%#NAME#%_'s interview with him. The CDI did result in a clinically significant level for a negative mood, although was subclinical for interpersonal problems, ineffectiveness, anhedonia and negative self-esteem.
CDI|Children's Depression Inventory|(CDI)|171|175|TEST RESULTS|Individuals such as these also tend to have difficulty being forthcoming and may not want to tap into underlying distressful symptoms. The Children's Depression Inventory (CDI) was administered on _%#MMDD2005#%_. He rated himself at a clinically significant level for negative mood and anhedonia. Items of interest include "I am sad all the time. I feel like crying everyday. I have trouble sleeping every night. I do not have any friends."
CDI|center for diagnostic imaging|(CDI)|214|218|HISTORY OF PRESENT ILLNESS|She has had no previous history of myocardial infarction, congestive heart failure (CHF), or cardiac arrhythmias. She did have what sounds like an adenosine thallium test performed by Center for Diagnostic Imaging (CDI) approximately three weeks ago which per verbal report showed an area of anterior ischemia with normal left ventricular systolic function.
CDI|center for diagnostic imaging|CDI|211|213|SOCIAL  HISTORY|3. Prenatal multivitamin daily. 4. Tylenol p.r.n. ALLERGIES: CECLOR, ERYTHROMYCIN, GENTAMICIN, KEFLEX, LEVAQUIN, ATIVAN, WELLBUTRIN, CLINDAMYCIN, IVP CONTRAST AND MORPHINE. SOCIAL HISTORY: The patient works for CDI radiology. She is a scheduler. She quit smoking two years ago. She denies any alcohol use. She is married, she has a pet dog and cat.
CDI|center for diagnostic imaging|CDI.|173|176|HISTORY OF PRESENT ILLNESS|Apparently she has been having some vague headaches for some time, especially in the frontal part of her head, and was seen by her physician. She had an MRI of the brain at CDI. The MRI of the brain showed a small extra- axial enhancing mass deep to the right pterion, most likely a meningioma.
CDI|center for diagnostic imaging|CDI|160|162|HISTORY OF PRESENT ILLNESS|He described it as a band-like chest discomfort across his chest. It was stuttering in nature. It would come and go. He had had a stress echocardiogram done at CDI approximately one month ago and was told he had no evidence of ischemia. Because of his normal stress test one month ago, he did not think that his chest pain could be secondary to his heart.
CDI|center for diagnostic imaging|CDI.|201|204|HISTORY OF PRESENT ILLNESS|He had some chest pain with his exercise but he did not have any ischemic changes on EKG or echocardiogram. His echocardiogram showed normal LV function at that time. The patient had further workup at CDI. He recalls being told that his other studies were also normal. I do not have those results available. He has continued to have dyspnea but it has not changed over these couple of years.
CDI|center for diagnostic imaging|CDI.|188|191|HISTORY OF PRESENT ILLNESS|The pain was then gone when she woke up although she continued to have some perceived weakness in her left arm. She has had some evaluation of her heart recently through Quello Clinic and CDI. This included an echocardiogram performed on _%#MMDD2004#%_ showing normal left ventricular size and function and mild concentric left ventricular hypertrophy.
CDI|Children's Depression Inventory|CDI|171|173|TEST RESULTS|Most of the time these individuals tend to accurately perceive their environment and there is no significant evidence of underlying psychosis or psychopathology. Both the CDI and the RCMAS were not clinically significant for depressive or anxiety symptoms. SUMMARY OF CURRENT FINDINGS: This is a 14-year-old African American female who was admitted to the subacute diagnostic unit at the University of Minnesota Medical Center, Fairview due to conflicts with her mother and threatening suicide.
CDI|center for diagnostic imaging|CDI.|134|137|HISTORY|She apparently had another fall. She has had back pain and at my request on _%#MMDD2006#%_ she had an MRI scan of the lumbar spine at CDI. The report is on the chart. That scan showed a new compression fracture at L4; compared to a scan in 1997 it was felt to be at least moderately acute secondary to either trauma or osteoporosis.
CDI|center for diagnostic imaging|CDI|117|119|HISTORY OF PRESENT ILLNESS|In the emergency room he was placed on BiPAP and he vomited and aspirated. He was thought at that time to have had a CDI with aspiration. It was also felt he was having an myocardial infarction. At this time it is unknown if the patient had a stroke.
CDI|center for diagnostic imaging|CDI.|218|221|HISTORY OF PRESENT ILLNESS|He tells me that he was on Vicodin at home and other nonsteroidal anti-inflammatories that he just felt did not agree with him. He has had an MRI of his lumbar spine done with a report in the chart _%#MMDD2006#%_ from CDI. Moderate to advanced lumbar degenerative disk disease is noted. There is moderate facet hypertrophy in the upper lumbar segments and central restenosis bilaterally at L3-4 of a mild degree, mild to moderate at L2-L3.
CDI|center for diagnostic imaging|CDI|147|149|REQUESTING PHYSICIAN|He did x-rays in his office and did a CT scan of her back which did not reveal any abnormalities. She had a bone scan done on _%#MM#%_ _%#DD#%_ at CDI and he then ordered a CT myelogram on the _%#DD#%_. The patient had not received any information and the patient became worse with increased nausea, vomiting, and came to the Emergency Room for admission.
CDI|center for diagnostic imaging|CDI|219|221|RECOMMENDATIONS|2. Clear clinical symptoms of neurogenic claudication with fairly wide- based gait and poor ability to ambulate any distance. 3. Anxiety. RECOMMENDATIONS: 1. Conservative management. 2. Recommend epidural injections at CDI and a referral has been made for L4-5 and L5-S1 levels. 3. Continue with physical therapy and ibuprofen as per her normal routine.
CDI|center for diagnostic imaging|CDI|224|226|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ is a new patient of Dr. _%#NAME#%_ _%#NAME#%_, who was seen in Dr. _%#NAME#%_ _%#NAME#%_'s clinic this last week for back pain. In a visit with Dr. _%#NAME#%_ it was determined that Mr. _%#NAME#%_ would go to CDI for a epidural injection as he was suffering from a disk herniation at the L5-S1 level. Mr. _%#NAME#%_ had this epidural steroid injection done yesterday, on _%#MMDD2006#%_, and has not received any relief from this steroid injection.
CDI|center for diagnostic imaging|CDI,|166|169|HISTORY OF PRESENT ILLNESS|He states that in an office visit this last week Dr. _%#NAME#%_ noted that he had some lower extremity weakness and after his epidural steroid injection yesterday at CDI, he states that his weakness increased some. ASSESSMENT AND PLAN: In a discussion with Mr. _%#NAME#%_, the following treatment options were provided: He was told that if his pain was so severe or if he started to notice any bowel or bladder symptoms such as urinary or fecal incontinence or urinary or fecal retention, that he should present immediately to the University of Minnesota Medical Center, Fairview, _%#CITY#%_ ER where I personally will come in and examine him and discuss him with the chief of Orthopedic Surgery on call this weekend, Dr. _%#NAME#%_ _%#NAME#%_.
CDI|center for diagnostic imaging|CDI|97|99|PHYSICAL EXAMINATION|Her motor exam was 5/5 except for grade IV strength of her left EHL. Review of her MRI both from CDI as well as her most recent scan are quite similar. This demonstrates multilevel disk dehydration with a previous left-sided decompression at L3-4 and 4-5.
CDI|center for diagnostic imaging|CDI|173|175|REVIEW OF SYSTEMS|He does have blindness in the right eye secondary to a viral insult in the distant past, and carries a diagnosis of sleep apnea as well. A stress echocardiogram was done at CDI in _%#MM#%_, the report of which I have to look at. It was done on beta blockers and lipid-lowering drugs. The Bruce protocol was used, and he went 9 minutes, completed the exercise, and noted some chest tightness during the final stage, with a negative electrocardiogram for ischemia.
CDI|center for diagnostic imaging|CDI.|227|230|HISTORY OF PRESENT ILLNESS|He is not experiencing recent persistent cough or shortness of breath, or experienced any episodes of hemoptysis. The patient is scheduled to undergo a CT of the body and MRI of the hand on Thursday, _%#MM#%_ _%#DD#%_, 2003 at CDI. PAST MEDICAL HISTORY: Other than his newly diagnosed sarcoma and eight year history of right hand discomfort, the patient has had no ongoing medical conditions.
CDI|center for diagnostic imaging|CDI|199|201|PLAN|The patient indicated an understanding of these potential risks and a willingness to proceed with treatment. Written signed consent was obtained. 3. The patient will be undergoing imaging studies at CDI on Thursday. We have obtained release of information signed by the patient so as to allow us access to the results. We appreciate the opportunity to participate in the evaluation and care of this most interesting young man.
CDI|center for diagnostic imaging|(CDI)|218|222|HISTORY OF PRESENT ILLNESS|She denies chest pain, tightness, or pressure. She has not had any left arm, neck, jaw, shoulder, or back discomfort with this. In fact, she had a recent stress echocardiogram performed a Center for Diagnostic Imaging (CDI) which showed no evidence of myocardial ischemia. She reports that she has not had an echocardiogram. As she was being transferred up to the Cardiac Special Care Unit this converted spontaneously to sinus rhythm.
CDI|Children's Depression Inventory|(CDI),|399|404|TESTS ADMINISTERED AND TASKS COMPLETED|She did have fleeting suicidal ideation without a plan. There was no evidence of hallucinations, delusions, paranoid ideation, grossly inappropriate affect, or other frank manifestation or psychotic disorder. She was oriented to person, place, and time. TESTS ADMINISTERED AND TASKS COMPLETED: Diagnostic interview, review of medical records, Rorschach Inkblot test, Children's Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS). TEST RESULTS: The Rorschach Inkblot test resulted in 15 responses which is a valid and interpretable protocol.
CDI|center for diagnostic imaging|CDI|136|138|PHYSICAL EXAMINATION|We will start him on intravenous steroids tomorrow, we will have a neurosurgeon see him tomorrow. We will attempt to get his films from CDI courier to the hospital.
CDI|center for diagnostic imaging|CDI|158|160|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is an 84-year-old female. She has a history of degenerative disc disease and spinal arthritis. She was referred to CDI for an epidural steroid injection. She had a right L2- 3 translaminar epidural on _%#MMDD2006#%_. She had complete relief of pain with no complications documented.
CDI|center for diagnostic imaging|CDI|158|160|HISTORY OF PRESENT ILLNESS|This demonstrated a calcium score of 527 in the LAD distribution. The remainder was nearly completely normal. An adenosine nuclear scan was performed through CDI on _%#MMDD2002#%_. The patient had a very small reversible apical defect consistent with LAD ischemia. Patient has never had coronary angiography performed.
CDI|center for diagnostic imaging|CDI|141|143|HISTORY|He has been seen by a neurologist for evaluation of his stroke. The MRI scan also shows a left C4-5 disc osteophyte formation, but this is a CDI outside scan and is not available at this point. ALLERGIES: None. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Status post MI with stents.
CDI|center for diagnostic imaging|CDI|207|209|ASSESSMENT/PLAN|History of a recent stroke and also anticoagulation would prevent any sort of surgical intervention at this time. Mr. _%#NAME#%_ should be followed in our office on an outpatient basis, however. The outside CDI MRI scan was requested and will be reviewed when available.
CDI|center for diagnostic imaging|CDI.|255|258|IMPRESSION|He was brought back to the Cath Lab two days later where he underwent successful rotostenting of his right coronary artery. The patient states he did quite well. He had a routine follow-up stress nuclear scan performed last week through Quello Clinic and CDI. This did demonstrate an area of inferior ischemia consistent with restenosis of his right coronary artery. The patient notes that at peak exercise, he did develop some burning in his throat and upper chest.
CDI|center for diagnostic imaging|CDI|146|148|PHYSICAL EXAM|General chemistries revealed normal electrolytes with a BUN of 21 and a creatinine of 1.1. Troponin and myoglobin are negative. A CT scan done at CDI just yesterday shows increase of her mediastinal lymphadenopathy suggestion of progressive malignancy. There is a large right-sided pleural effusion and some atelectasis or possible infiltrate in the right lung.
CDI|center for diagnostic imaging|CDI|159|161|HISTORY OF PRESENT ILLNESS|He was seen by Dr. _%#NAME#%_ approximately 6 weeks ago, who evaluated him and recommended a followup if his symptoms progressed. His original MRI was done at CDI at the end of _%#MM2007#%_, it showed a number of abnormal findings, including diffuse intracranial dural enhancement as well as abnormal intramedullary spinal cord signal in the cervical region.
CDI|center for diagnostic imaging|CDI|151|153|LABORATORY AND OTHER DATA|LABORATORY AND OTHER DATA: An MRI scan of the cervical spine was reviewed from this evening compared with the previous study from CDI. On the previous CDI study, they reported an annular tear at C4-C5 without herniation with mild facet hypertrophy and mild left-sided foraminal stenosis.
CDI|center for diagnostic imaging|CDI|168|170|HISTORY OF PRESENT ILLNESS|At that time he was seen by a chiropractor in his hometown where he was treated for 2 weeks without improvement. He was then referred for an MRI of the lumbar spine at CDI where this was performed and he received an epidural steroid injection that same day. He had improvement in his symptoms for one-week time. Upon return of his pain he was referred to the pain management clinic in _%#CITY#%_.
CDI|center for diagnostic imaging|CDI|157|159|HISTORY OF PRESENT ILLNESS|We did not have access to her surgical operative pathology report. Therefore, the status of her margins were unclear. Her CT from the outside institution at CDI was reviewed and appeared to have left maxillary invasion as well as the left ethmoid sinus being completely filled with polypoid mucosa thickening.
CDI|center for diagnostic imaging|CDI|201|203|IMAGING|EXTREMITIES: No edema in the lower extremities. NEUROLOGIC: Cranial nerves II-XII are intact, 5/5 strength in the upper and lower extremities. Normal gait. IMAGING: CT from outside institution done at CDI was reviewed, showing polypoid mucosal thickening filling left maxillary sinus, frontal sinus, ethmoid sinuses and nasal cavity which projects into the left nasopharynx.
CDI|center for diagnostic imaging|CDI.|199|202|RADIOLOGY|MUSCULOSKELETAL: Status post right elbow surgery with dressing intact, no drainage visible. Distal extremity warm, sensate to light touch. RADIOLOGY: MRI right elbow _%#MMDD2007#%_: MRI performed at CDI. Abnormal MRI of the right elbow with specific findings of marked osteoarthritis of the radio-capitalar joint and mild osteoarthritis of the ulnohumeral joint.
CDI|center for diagnostic imaging|CDI|181|183|PAST MEDICAL HISTORY|4. Hyperlipidemia. 5. Depression. a. Symptoms developing in 2005 with occasional angry behavior, impulsive behavior and possible early dementia. b. CT scanning on _%#MMDD2005#%_ at CDI is normal except for prominent lateral ventricles raising the possibility of very early NPH. c. Normal TSH, B12, CK and other lab studies this year.
CDI|center for diagnostic imaging|CDI|215|217|HISTORY OF PRESENT ILLNESS|The latter part of _%#MM#%_ and early _%#MM#%_ of this year, placed by primary care provider on antibiotics for suspicion of acute diverticulitis. Discontinued after 2-3 days subsequent to return of abdominal CT at CDI demonstrating no intra-abdominal pathology. Subsequent demonstration of a prominent right thigh mass for which patient underwent open biopsy of Dr. _%#NAME#%_ _%#NAME#%_ from Orthopedic Surgery on _%#MMDD2007#%_. Seen by myself postoperatively for recurrent problems with nausea, vomiting and diffuse lower abdominal discomfort and diarrhea.
CDI|center for diagnostic imaging|CDI|153|155|HISTORY OF PRESENT ILLNESS|She states that the pain is not like that which she had previously with pancreatitis. The patient also states that she had an adenosine thallium done at CDI Center for diagnostic imaging on _%#STREET#%_ _%#STREET#%_ in _%#CITY#%_ _%#CITY#%_ _%#CITY#%_. CDI was contacted and the patient did have an adenosine thallium that was performed on _%#MMDD2005#%_ and it was a negative study.
CDI|center for diagnostic imaging|CDI|167|169|HISTORY OF PRESENT ILLNESS|The patient also states that she had an adenosine thallium done at CDI Center for diagnostic imaging on _%#STREET#%_ _%#STREET#%_ in _%#CITY#%_ _%#CITY#%_ _%#CITY#%_. CDI was contacted and the patient did have an adenosine thallium that was performed on _%#MMDD2005#%_ and it was a negative study.
CDI|center for diagnostic imaging|CDI|136|138|PLAN|We might need to talk to IR tomortow to see if they recommend drainage once our CT here is obtained. IR is unable to review the scan ay CDI _%#CITY#%_ _%#CITY#%_. I suspect this fluid explains her bloating. 2. For gentle bloating and distention, we will check a Clostridium difficile and stool studies.
CDI|Children's Depression Inventory|CDI,|95|98|TEST RESULTS|At this time, _%#NAME#%_ exhibited symptoms of anxiety as well. TEST RESULTS: Results from the CDI, which is a self report measure designed to assess for symptoms of depression in children and adolescence, reflects an overall score within the lower average range, indicating that _%#NAME#%_ perceives himself as experiencing less symptoms of depression than the majority of other males his age.
CDI|Children's Depression Inventory|CDI|362|364|TEST RESULTS|TEST RESULTS: Results from the CDI, which is a self report measure designed to assess for symptoms of depression in children and adolescence, reflects an overall score within the lower average range, indicating that _%#NAME#%_ perceives himself as experiencing less symptoms of depression than the majority of other males his age. All subcutaneous-scales of the CDI were within the normal range. _%#NAME#%_ did endorse items indicating that he worries about aches and pains many times, and is tired many days.
CDI|center for diagnostic imaging|CDI|140|142|RADIOGRAPHIC STUDIES|The patient has normal gait and balance. Cranial nerves II through XII are intact without focal deficit. RADIOGRAPHIC STUDIES: CT scan from CDI (_%#MMDD2002#%_) is reviewed and discussed above in History of Present Illness. The most recent MRI scan from _%#MMDD2002#%_ is reviewed on our in-house computer system.
CDI|Children's Depression Inventory|CDI|121|123|TEST RESULTS|TEST RESULTS: _%#NAME#%_ completed several self-report measures to assess for symptoms of depression and anxiety. On the CDI Chyanna obtained an overall score within the below average range, indicating that _%#NAME#%_ is experiencing less symptoms of depression than other females approximately her age.
CDI|Children's Depression Inventory|CDI|252|254|TEST RESULTS|On the CDI _%#NAME#%_ obtained an overall score within the below average range, indicating that _%#NAME#%_ is experiencing less symptoms of depression than other females approximately her age. _%#NAME#%_'s scores on the different sub scales within the CDI were also within the average to below-average range. _%#NAME#%_'s overall score on the RCMAS was within the average range, indicating that she is not experiencing clinically significant symptoms of anxiety for age and gender.
CDI|Children's Depression Inventory|(CDI),|223|228|PSYCHOLOGICAL FUNCTIONING|PSYCHOLOGICAL FUNCTIONING: _%#NAME#%_'s psychological functioning was assessed using self-rating scale, a sentence completion test, a projective measure and a clinical interview. Results from the Child Depression Inventory (CDI), which is a self-rating scale designed to assess depressive symptoms in children in adolescence reflected an overall score within the average range.
CDI|Children's Depression Inventory|(CDI),|406|411|TESTS ADMINISTHERED AND TASKS COMPLETED|There is no evidence of hallucinations, delusions, paranoid ideation, grossly inappropriate affect, or other frank manifestation of psychotic disorder. He was oriented to person, place, and time. TESTS ADMINISTHERED AND TASKS COMPLETED: Diagnostic interview, review of medical record, Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A), Rorschach Inkblot Test, Children's Depression Inventory (CDI), Sentence Completion Test. TEST RESULTS: The MMPI-A was administered on _%#MMDD2005#%_. He responded to the items in an open and honest manner and the profile is valid and interpretable.
CDI|Children's Depression Inventory|(CDI),|304|309|TESTS ADMINISTERED AND TASKS COMPLETED|Thus, psychotic disorder cannot yet be ruled out. She was oriented to person, place, and time. TESTS ADMINISTERED AND TASKS COMPLETED: Diagnostic interview, review of medical record, Minnesota Multiphasic Personality Inventory - Adolescent (MMPI-A), Rorschach Inkblot Test, Children Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS). TEST RESULTS: The MMPI-A was responded to in an open and honest manner and the profile was valid and interpretable.
CDI|Children's Depression Inventory|(CDI)|184|188|ACADEMIC ACHIEVEMENT SKILLS|PSYCHOLOGICAL FUNCTIONING: _%#NAME#%_'s psychological functioning was assessed using several self-report measures and a clinical interview. Results from the Child Depression Inventory (CDI) reflected an overall score within the average range, suggesting that _%#NAME#%_ did not endorse a higher than typical number of depressive symptoms than other males his age.
CDI|Children's Depression Inventory|(CDI)|263|267|FINE MOTOR SPEED AND DEXTERITY|EMOTIONAL, SOCIAL, AND BEHAVIORAL FUNCTIONING: _%#NAME#%_'s functioning in these areas was assessed using several different measures including self-report measures, a sentence completion test, and a clinical interview. Results from the Child Depression Inventory (CDI) reflected an overall score within the clinically significant range (T equals 84), which indicates that _%#NAME#%_ views herself as having a significantly higher number of depressive symptoms than other females approximately her age.
CDI|Children's Depression Inventory|CDI|353|355|FINE MOTOR SPEED AND DEXTERITY|Results from the Child Depression Inventory (CDI) reflected an overall score within the clinically significant range (T equals 84), which indicates that _%#NAME#%_ views herself as having a significantly higher number of depressive symptoms than other females approximately her age. She also obtained clinically significant scores on subscales from the CDI measuring negative mood, interpersonal problems, and anhedonia (difficulty experiencing pleasure). _%#NAME#%_ obtained scores within the borderline range on subscales measuring feelings of ineffectiveness and negative self-esteem.
CDI|center for diagnostic imaging|CDI|176|178|LABORATORY  DATA|Judgment and insight also appear normal. LABORATORY DATA: Endoscopy report from _%#MMDD2007#%_ was reviewed with the patient and his wife. A CT scan obtained yesterday through CDI is not yet available for review. As stated, the pathology report is also not yet available. Per recent discussion, however, with the pathologist, the biopsy does apparently show non-Hodgkin's lymphoma, possibly diffuse large cell B cell histology.
CDI|center for diagnostic imaging|CDI|168|170|PAST MEDICAL HISTORY|C. Presently indicates right lumbar and buttock pain as well as left lumbar and left leg radicular pain. Left foot paresthesias. Nerve root injection _%#MMDD2004#%_ at CDI in _%#CITY#%_. Chiropractic intervention to the cervical spine which has been beneficial. 3. Exogenous obesity. 4. "Blood clot" left upper extremity subsequent to IV placement in the emergency room at Fairview _%#CITY#%_, over one year ago.
CDI|Children's Depression Inventory|(CDI,|308|312|SOCIAL, EMOTIONAL AND BEHAVIORAL FUNCTIONING|_%#NAME#%_ demonstrated some impulsive tendencies on this task, demonstrating poor planning before each design. SOCIAL, EMOTIONAL AND BEHAVIORAL FUNCTIONING: _%#NAME#%_'s functioning across these areas was assessed using a personality Inventory (MMPI-A), a sentence completion test (SCT), self rating scales (CDI, RCMAS) and a clinical interview. Results from the MMPI-A indicate that _%#NAME#%_ approached this measure in a relatively open manner and that results are valid.
CDI|Children's Depression Inventory|(CDI),|493|498|TESTS ADMINISTERED|In addition to ADHD, _%#NAME#%_ also has a history of nocturnal enuresis and oppositional defiant disorder (ODD) that was diagnosed at Washburn Child Guidance Center in _%#MM2007#%_. TESTS ADMINISTERED: Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV), Wechsler Individual Achievement Test - Second Edition (WIAT-II), Selected subtests, the Trail-Making Test, Verbal Fluency Test, Conners Continuous Performance Test - Second Edition (CPT (CPT-II), Child Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS), Roberts Apperception Test for Children (RATC) and clinical interview. BEHAVIORAL OBSERVATIONS: _%#NAME#%_ presented to the evaluation appearing neatly and casually dressed at approximately his age.
CDI|Children's Depression Inventory|CDI,|222|225|TEST RESULTS|Psychological Functioning: _%#NAME#%_'s Psychological functioning was assessed using a self-rating scale, a projective measure (RATC), and a clinical interview. He obtained an overall score within the average range on the CDI, which is a self-rating scale designed to assess for symptoms of depression in younger people. As such, results indicate that _%#NAME#%_ did not endorse a higher than typical number of items associated with depression for age and gender.
CDI|center for diagnostic imaging|CDI,|185|188|ASSESSMENT|B. Tenderness over the right sacroiliac joint and sciatic notch region. May have radicular nerve root impingement/irritation. C. Status post lumbar and cervical rhizotomy procedures at CDI, as above. D. Neurologically appears to be intact. 3. Probable tension/muscle contraction headache. 4. Issue of dyspnea both at rest and with exertion, likely multifactorial.
CDI|center for diagnostic imaging|CDI,|199|202|PLAN|8. Right medial thigh pain/induration. Rule out phlebitis involving the greater saphenous vein. PLAN: 1. Implement recommendations as per pain program. 2. Request office records from Dr. _%#NAME#%_, CDI, and spine imaging from North Memorial Me dical Center. 3. Prevacid 30 mg q.day. 4. Venous Doppler ultrasound right lower extremity.
CDI|Children's Depression Inventory|(CDI),|632|637|TESTS ADMINISTERED|Results reflected a full-scale IQ within the lower average range (FS IQ = 90) and 25th percentile. TESTS ADMINISTERED: Wechsler Intelligence Scale for Children-IV Edition (WISC-IV), Wechsler Individual Achievement Test, Second Edition (WIAT-II), the Trail Making Test, Verbal Fluency Test, Connors Continuous Performance Test, Second Edition (CPT-II, Wide Range Assessment of Memory and Learning, Second Edition (WRAML-II), Selected Subtests, the Lafayette Grooved Pegboard Test, the Beery Buktenica Developmental Test of Visuomotor Integration (Beery VMI, Fifth Edition), Sentence Completion Test (SCT), Child Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS), Robert's Apperception Test for Children (RATC) and clinical interview. BEHAVIORAL OBSERVATIONS: _%#NAME#%_ presented to the evaluation appearing somewhat shorter in stature for his age.
CDI|Children's Depression Inventory|(CDI),|129|134|TESTS ADMINISTERED|For the current psychological consultation the following tests were administered. TESTS ADMINISTERED: Child Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS), Sentence Completion Test (SCT), Robert's Apperception Test for Children (RATC), and clinical interview.
CDI|Children's Depression Inventory|CDI|259|261|TEST RESULTS|He obtained a total score on this measure within the average range, indicating that _%#NAME#%_ did not endorse a higher than typical number of items, in general, associated with depression. However, he did obtain a borderline elevation on a subscale from the CDI indexing anhedonia or difficulty experiencing pleasure. As such, results indicate that _%#NAME#%_ is experiencing less pleasure in his life than would be expected for his age.
CDI|Children's Depression Inventory|CDI|164|166|SUMMARY AND CLINICAL IMPRESSIONS|Regarding mood, _%#NAME#%_ did appear mildly depressed and became tearful at many points during the assessment. He also endorsed a borderline level of items on the CDI associated with anhedonia or difficulty experiencing pleasure. Overall, a diagnosis of a depressive disorder, not otherwise specified is being given to describe his sadness, irritability, and mood instability.
CDI|Children's Depression Inventory|CDI|146|148|TEST RESULTS|These individuals also tend to revert to fantasy quite easily and likely use defense mechanisms such rationalization and intellectualization. The CDI resulted in a mildly clinically significant level for ineffectiveness and negative self-esteem. Items of interest include, "I think about killing myself but I would not do it." "I do not like myself." "I do very badly in subjects I used to be good in." "I'm not sure if anybody loves me." The RCMAS resulted in mildly clinically significant levels for social concerns.
CDI|Children's Depression Inventory|(CDI)|508|512|TESTS ADMINISTERED|_%#NAME#%_ has 2 half-brothers and 2 half-sisters. The family history is reportedly significant for ADHD and panic disorder on the paternal side and some mental illness on the maternal side. TESTS ADMINISTERED: Wechsler Individual Achievement Test - Second Addition (WIAT-II), selected subtests Trail Making Test, Parts A and B Verbal Fluency Test Beery-Buktinica Developmental Test of Visual-Motor Integration Sentence Completion Test Robert Apperception Test for Children (RATC) Child Depression Inventory (CDI) Revised Children's Manifest Anxiety Scale (RCMAS) Clinical Interview BEHAVIORAL OBSERVATIONS: _%#NAME#%_ presented to a the evaluation as a well-groomed child who appeared approximately his age.
CDI|Children's Depression Inventory|CDI|218|220|TEST RESULTS|Emotional, Social and Behavioral Functioning: _%#NAME#%_'s emotional, social, and behavioral functioning was assessed using several self-report measures, projective measures, and a clinical interview. Results from the CDI reflected an overall score within the "at-risk" range (T = 64). These results suggest that _%#NAME#%_ endorsed a higher number of items associated with depression than the majority of boys his age.
CDI|Children's Depression Inventory|(CDI),|376|381|TESTS ADMINISTERED|The family is apparently receiving some Respbid support services to help them manage _%#NAME#%_ occasionally on the weekends. TESTS ADMINISTERED: Wechsler Intelligent Scale for Children - 4th Edition (WISC IV), Wechsler Individual Achievement Test - 2nd Edition (WIAT - II, selected subtests), Rey Complex Figure Test (RCFT), Grooved Pegboard Test, Child Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS), clinical interview, phone consultation with _%#NAME#%_'s school case manager and English teacher, review of records.
CDI|Children's Depression Inventory|CDI|86|88|TEST RESULTS|They also likely have difficulty responding appropriately to certain social cues. The CDI resulted in clinically significant level for negative mood. She also scored at a clinically significant level for ineffectiveness, anhedonia, and negative self esteem.
CDI|Children's Depression Inventory|CDI,|249|252|TEST RESULTS|He also performed within the below average range on Trail-Making tests parts A and B, reflecting weaknesses in the areas of visuomotor speed, working memory, and mental flexibility. 4. Social, Emotional, and Behavioral Functioning: Results from the CDI, which is a self-report rating scale for children measuring symptoms of depression, reflected an overall score within the average range.
CDI|Children's Depression Inventory|CDI|298|300|TEST RESULTS|4. Social, Emotional, and Behavioral Functioning: Results from the CDI, which is a self-report rating scale for children measuring symptoms of depression, reflected an overall score within the average range. _%#NAME#%_ obtained a borderline score, reflecting at-risk concern on a subscale from the CDI measuring symptoms of feelings of ineffectiveness. The RCMAS, which is a self-rating scale for symptoms of anxiety in children, indicated that _%#NAME#%_ attained an overall score within the average range.
CDI|Children's Depression Inventory|(CDI),|462|467|TESTS ADMINISTERED|He reported he has no contact with his biological father and never has known him. TESTS ADMINISTERED: Wechsler Intelligence Scale for Children-IV Edition (WISC-IV), Wechsler Individual Achievement Test - Second Edition (WIAT-II), selected subtests, Trail Making Test, Parts A and B, Verbal Fluency Test, The Lafayette Groved Pegboard Test, Bury Burke Technical Developmental Test of Visual-Motor Integration (Bury VMI), Fifth Edition, Child Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS) and Clinical Interview. BEHAVIORAL OBSERVATIONS: _%#NAME#%_ presented to the evaluation appearing neatly and casually dressed and approximately his age.
CDI|Children's Depression Inventory|CDI,|167|170|ACADEMIC ACHIEVEMENT|Social, emotional, and behavioral functioning. _%#NAME#%_'s functioning in these areas was assessed using self-rating scales on a clinical interview. He was given the CDI, which is a self-rating scale designed to assessed a child's level of depression. _%#NAME#%_ obtained an overall score within the borderline "at risk" range (T equals 63).
CDI|Children's Depression Inventory|CDI|194|196|TEST RESULTS|Overall, these individuals tend to have a strong desire to relate to others, but may have difficulty developing secure relationships. At times, these individuals may be in some distress. 3. The CDI did not result in any clinically significant scales, including negative mood, interpersonal problems, ineffectiveness, anhedonia, and negative self-esteem.
CDI|Children's Depression Inventory|(CDI),|482|487|TESTS ADMINISTERED AND TASKS COMPLETED|No evidence of obsession/compulsion, suicidal ideation or homicidal ideation. There is no evidence of hallucination, delusion, paranoid ideation, grossly inappropriate affect or other frank manifestation of psychotic disorder. He was oriented to person, place, and time. TESTS ADMINISTERED AND TASKS COMPLETED: Diagnostic interview, review of medical records, Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A), Rorschach Ink Blot test, Children's Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS). TEST RESULTS: 1. The MMPI-A was responded to in an open and honest manner in the profile, valid and interpreter mode.
CDI|Children's Depression Inventory|CDI|162|164|TEST RESULTS|There is little to no indication of significant impulsivity but these individuals do tend to have some difficulty developing secure relationships with others. 3. CDI did not have any clinically significant scales, negative mood, interpersonal problems, ineffectiveness, anhedonia, or negative self esteem. Items of interest include, "I am sure that terrible things will happen to me," "many things are my fault," and "there are some bad things about my looks."
CDI|Children's Depression Inventory|(CDI)|258|262|RESULTS|No significant problems with impulsivity were observed. Due to _%#NAME#%_'s cooperating throughout testing, it is felt the results are an accurate reflection of his psychological functioning at this time. RESULTS: Results from the child depression inventory (CDI) and revised children's manifest anxiety scale (RCMAS) which are self-report measures designed to assess for symptoms of depression and anxiety respectively, reflected borderline elevations on sub scales from the CDI associated with negative mood and feelings of ineffectiveness.
CDI|Children's Depression Inventory|CDI|271|273|RESULTS|RESULTS: Results from the child depression inventory (CDI) and revised children's manifest anxiety scale (RCMAS) which are self-report measures designed to assess for symptoms of depression and anxiety respectively, reflected borderline elevations on sub scales from the CDI associated with negative mood and feelings of ineffectiveness. More specifically, _%#NAME#%_ endorsed items indicating that he is sad many times, is not sure if things will work out for him, is bad all the time, does not like himself, and thinks about harming himself, but would not do so.
CDI|Children's Depression Inventory|(CDI).|217|222|TESTS ADMINISTERTED|_%#NAME#%_ described his relationship with his siblings as "kind of close." _%#NAME#%_' mother reportedly works full time at Medical Art Press in _%#CITY#%_ _%#CITY#%_. TESTS ADMINISTERTED: Child Depression Inventory (CDI). Revised Children's Manifest Anxiety Scale (RCMAS). Minnesota Multiphasic Personality Inventory-Adolescent version (MMPI-A). Thematic Apperception Test (TAT). Sentence Completion Test (SCT). Clinical interview. BEHAVIORAL OBSERVATIONS: _%#NAME#%_ presented to the evaluation as a thin adolescent male who appeared approximately his age.
CDI|Children's Depression Inventory|CDI|284|286|TEST RESULTS|There is a somewhat psychotic quality to some of these responses, although it should be noted that this individual may still be experiencing a psychotic response to drug abuse. The CDI was administered on _%#MMDD2005#%_. He rated himself at a clinically significant level for a total CDI score, negative mood, ineffectiveness, and negative self-esteem. Items of interest include "I am sad all the time, "I think about killing myself, but I would not do it," " I do not like myself," " I do not have any friends," "I feel like crying every day." The Sentence Completion Test seemed to be somewhat disorganized and scattered.
CDI|Children's Depression Inventory|(CDI),|807|812|TESTS ADMINISTERED|_%#NAME#%_ was started on Paxil medication (20 mg q.h.s.) when admitted to the hospital to address her anxiety and irritability and has reported positive effects from the medication. She has no known drug allergies. TESTS ADMINISTERED: Wechsler Intelligence Scale for Children - 4th Edition (WISC-IV), Wechsler Individual Achievement Test - 2nd Edition (WIAT-II), (selected subtests), Connors Continuous Performance Test - 2nd Edition (CPT-II), The Trail Making Tests, parts A and B, Verbal Fluency Test, Rey Complex Figure Test (RCFT), Wide Range Assessment of Memory and Learning - 2nd Edition (WRAML-II), selected subtests, The Buktenica Developmental Test of Visual Motor Integration (Beery VMI - 5th Edition), Lafayette Grooved Pegboard Test, Sentence Completion Test (SCT), Child Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS), Minnesota Multiphasic Personality Inventory - Adolescent Version (MMPI-A) and Clinical Interview. BEHAVIORAL OBSERVATIONS: _%#NAME#%_ was evaluated over two separate testing sessions at the adolescent day treatment unit at University of Minnesota Medical Center, Fairview.
CDI|Children's Depression Inventory|CDI,|156|159|TEST RESULTS|Results also reflect anxiety about her relationship with her boyfriend and an underlying fear of relapsing with drugs and alcohol. _%#NAME#%_ completed the CDI, which is a self-rating scale designed to assess her symptoms of depression in children and adolescents. She obtained an overall score within the borderline range, indicating that _%#NAME#%_ endorses somewhat higher than typical number of items associated with depression for her age and gender.
CDI|Children's Depression Inventory|(CDI)|102|106|TEST RESULTS|It is also unclear how secure their relationships are with others. The Childhood Depression Inventory (CDI) was administered on _%#MMDD2005#%_. She rated herself at a clinically significant level for a total CDI score negative mood and negative self-esteem.
CDI|center for diagnostic imaging|CDI|198|200|PAST MEDICAL HISTORY|1. Status post cholecystectomy. 2. Status post right inguinal herniorrhaphy. 3. Atherosclerotic heart disease as mentioned above with previous myocardial infarction. An echocardiogram _%#MMDD#%_ at CDI demonstrated an ejection fraction of 55-60% with septal wall motion abnormality. 4. Asbestosis with pleural plaques noted on previous chest x-rays.
CDI|Children's Depression Inventory|(CDI),|227|232|TESTS ADMINISTERED AND TASKS COMPLETED|She is oriented to person, place, and time and there is no evidence of any problems with impulse control. TESTS ADMINISTERED AND TASKS COMPLETED: Diagnostic interview, review of medical records, Children's Depression Inventory (CDI), Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A), Rorschach Inkblot Test, Sentence Completion Test. TEST RESULTS: The patient was administered the CDI on _%#MMDD2005#%_.
CDI|Children's Depression Inventory|CDI|204|206|EMOTIONAL, SOCIAL, AND BEHAVIORAL FUNCTIONING|EMOTIONAL, SOCIAL, AND BEHAVIORAL FUNCTIONING: _%#NAME#%_ was given self-rating skills, a Sentence Completion Test, and a clinical interview to assess his functioning across these areas. Results from the CDI reflect an overall score within the average range, indicating that _%#NAME#%_ did not endorse a higher than typical number of items associated with depression for his age.
CDI|Children's Depression Inventory|CDI|268|270|EMOTIONAL, SOCIAL, AND BEHAVIORAL FUNCTIONING|Results from the CDI reflect an overall score within the average range, indicating that _%#NAME#%_ did not endorse a higher than typical number of items associated with depression for his age. However, he obtained a clinically significant score on a subscale from the CDI indexing feelings of ineffectiveness. _%#NAME#%_ endorsed items indicating that he can never be as good as other children, feels his school work is not as good as before, has some friends but wished he had more, feels alone many times, and has fun at school only once in a while.
CDI|Children's Depression Inventory|CDI|161|163|TEST RESULTS|They also likely have superficial relationships with others. There is a tendency for these individuals to fantasize especially under a great deal of stress. The CDI did not result in any clinically level for depressive symptoms and the RCMAS did not result in any clinically significant level for anxiety symptoms.
CDI|Children's Depression Inventory|CDI|108|110|TASKS ADMINISTERED AND TASKS COMPLETED|They also tend to take an ideational approach to coping and may spend a great deal of time fantasizing. The CDI resulted in a mildly clinically significant level for negative self esteem although there was no clinically significant level for negative mood, interpersonal problems, ineffectiveness, or anhedonia.
CDI|Children's Depression Inventory|(CDI)|196|200|TEST RESULTS|_%#NAME#%_ refused to complete either of the rating scales fully and therefore total scores could not be obtained. However, she did complete significant portions of the Child Depression Inventory (CDI) and Revised Children's Manifest Anxiety Scale (RCMAS). Therefore, some perceptions regarding her levels of depression and anxiety were gathered. On the CDI, _%#NAME#%_ was quite cooperative initially and then refused to complete the 2nd page.
CDI|Children's Depression Inventory|CDI,|239|242|TEST RESULTS|However, she did complete significant portions of the Child Depression Inventory (CDI) and Revised Children's Manifest Anxiety Scale (RCMAS). Therefore, some perceptions regarding her levels of depression and anxiety were gathered. On the CDI, _%#NAME#%_ was quite cooperative initially and then refused to complete the 2nd page. It appeared as though she became overwhelmed. _%#NAME#%_ endorsed items on the CDI indicating that she feels sad many times, feels nothing "at home" is fun at all, worries that bad things will happen to her, hates herself and thinks about killing herself but would not do it.
CDI|Children's Depression Inventory|CDI|177|179|TEST RESULTS|On the CDI, _%#NAME#%_ was quite cooperative initially and then refused to complete the 2nd page. It appeared as though she became overwhelmed. _%#NAME#%_ endorsed items on the CDI indicating that she feels sad many times, feels nothing "at home" is fun at all, worries that bad things will happen to her, hates herself and thinks about killing herself but would not do it.
CDI|Children's Depression Inventory|(CDI)|284|288|SUMMARY OF CLINICAL IMPRESSIONS|_%#NAME#%_'s responses on projective measures tended to be brief and extremely immature in content, especially in comparison to her average responses on a measure of her abstract verbal reasoning abilities. _%#NAME#%_ also endorsed a number of items on the Child Depression Inventory (CDI) indicating that she is experiencing a number of depressive symptoms, such as self-hatred and sleep difficulties. She also endorsed items on the Revised Children's Manifest Anxiety Scale (RCMAS) reflecting a number of worries and fears.
CDI|Children's Depression Inventory|(CDI),|341|346|TESTS ADMINISTERED AND TASKS COMPLETED|There is no evidence of hallucinations, delusions, paranoid ideation, grossly inappropriate affect, or other frank manifestation of psychotic disorder. She was oriented to person, place, and time. TESTS ADMINISTERED AND TASKS COMPLETED: Diagnostic interview, review of medical record, Rorschach Inkblot Test, Children's Depression Inventory (CDI), Sentence Completion Test. TESTS RESULTS: The Rorschach Inkblot Test was administered on _%#MMDD2005#%_.
CDI|Children's Depression Inventory|CDI|222|224|TESTS RESULTS|In addition, during times of stress or ambiguity, these individuals tend to regress to more childlike behavior. The CDI was administered on _%#MMDD2005#%_. She rated herself at a clinically significant level for the total CDI score, interpersonal problems, ineffectiveness, and negative self-esteem. Items of significance include "I feel like crying many days." Many days I do not feel like eating." "I get into fights many times, and I never do what I am told." She is also uncertain if "anybody loves her." The Sentence Completion Test was administered on _%#MMDD2005#%_.
CDI|Children's Depression Inventory|(CDI,|210|214|PSYCHOLOGICAL FUNCTIONING|_%#NAME#%_'s working memory and processing speed skills are also within the borderline range for his age. PSYCHOLOGICAL FUNCTIONING: _%#NAME#%_'s psychological functioning was assessed using self-rating scales (CDI, RCMAS), the Sentence Completion Test (SCT), a projective measure (RATC) and a Clinical Interview. Results of the CDI, which is a self-rating scale designed to assess symptoms of depression, reflected an overall score within the average range.
CDI|Children's Depression Inventory|CDI|220|222|PSYCHOLOGICAL FUNCTIONING|PSYCHOLOGICAL FUNCTIONING: _%#NAME#%_'s psychological functioning was assessed using self-rating scales, the Sentence Completion Test, a projective measure, and a clinical interview. She obtained an overall score on the CDI within the average range. As such, results indicate that _%#NAME#%_ did not endorse a higher than typical number of items associated with depression for her age and gender.
CDI|Children's Depression Inventory|(CDI),|232|237|TESTS ADMINISTERED|_%#NAME#%_ has participated in some individual and family therapy since the summer of 2004. TESTS ADMINISTERED: Wechsler Intelligence Scale for Children - Fourth Edition (WISC-IV), Kinetic Family Drawing, Child Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS), Sematic Apperception Test (TAT), Sentence Completion Test, and Clinical Interview. BEHAVIORAL OBSERVATIONS: _%#NAME#%_ was tested over one testing session at Fairview-University Medical Center Adolescent Mental Health Day Treatment Program.
CDI|Children's Depression Inventory|CDI|73|75|TEST RESULTS|At times these individuals also tend to have poor coping mechanisms. The CDI results in clinically significant levels for negative mood, ineffectiveness, anhedonia, and negative self-esteem. Items of interest include: "I want to kill myself." "I do not like myself." "I am sad all the time." "I do not want to be with people at all." The RCMAS resulted in clinically significant levels for physiological anxiety and mildly clinically significant levels for worry/oversensitivity and social concern/concentration.
CDI|Children's Depression Inventory|CDI|68|70|TEST RESULTS|Otherwise, they tend to accurately interpret their environment. The CDI only resulted in mildly clinically significant levels for interpersonal problems. Items of interest include "I am fat many times. I do not do what I'm told most times, and I am tired many days." The RCMAS did not result in any clinically significant levels for anxiety- related symptoms.
CDI|Children's Depression Inventory|CDI|203|205|BEHAVIORAL OBSERVATIONS|The evaluator told _%#NAME#%_ that she would need to discontinue testing if he remained violent. _%#NAME#%_ stopped his negative physical behaviors for several minutes, while I verbally administered the CDI and RCMAS to him. _%#NAME#%_ had refused to write responses. He began hitting the chair cushions with his fists and testing was then discontinued.
CDI|Children's Depression Inventory|CDI|98|100|TEST RESULTS|Staff also stated that _%#NAME#%_ had slept well the night before. TEST RESULTS: Results from the CDI reflected an overall score within the solidly average range for age and gender. _%#NAME#%_ obtained a borderline score, reflecting a higher than typical elevation on a sub-scale measuring interpersonal problems.
CDI|Children's Depression Inventory|CDI,|242|245|TEST RESULTS|_%#NAME#%_ obtained clinically significant elevations on scales 1 (hypochondriasis) and 4 (psychopathic deviate). Results indicate that _%#NAME#%_ tends to focus excessively on somatic complaints, which is consistent with his response on the CDI, in which _%#NAME#%_ indicated that he is worried about aches and pains all the time. Individuals with this profile on the MMPI-A also tend to be extremely self-focused, negativistic in thinking, and to blame others for their own misdoings.
CDI|Children's Depression Inventory|(CDI)|359|363|ATTENTIONAL AND PSYCHOLOGICAL FUNCTIONG|_%#NAME#%_'s other difficulties with anxiety, depression, and symptoms of Obsessive-Compulsive Disorder also make a diagnosis of ADHD difficult at this time, as these disorders often tend to interfere with concentration skills and motivation in particular areas. _%#NAME#%_ also completed several self-report measures, entitled the Child Depression Inventory (CDI) and Revised Children's Manifest Anxiety Scale (RSMAS). Results from the CDI reflected a significant elevation on a subscale indexing symptoms of negative self-esteem (T=70).
CDI|Children's Depression Inventory|CDI|174|176|ATTENTIONAL AND PSYCHOLOGICAL FUNCTIONG|_%#NAME#%_ also completed several self-report measures, entitled the Child Depression Inventory (CDI) and Revised Children's Manifest Anxiety Scale (RSMAS). Results from the CDI reflected a significant elevation on a subscale indexing symptoms of negative self-esteem (T=70). Borderline elevations are also evident on a subscale indexing symptoms related to feelings of ineffectiveness.
CDI|Children's Depression Inventory|CDI|243|245|TEST RESULTS|In addition, he endorsed items indicating that he worries about aches and pains all the time, feels alone all the time, never has fun at school, does not have any friends, and does very badly in subjects he use to be good in. Results from the CDI reflected clinically significant subscales related to ineffectiveness (T-score=80), anhedonia (T-score=90), and negative self-esteem (T-score=88). On the RCMAS, which is a self-report measure of anxiety, _%#NAME#%_'s total anxiety score was in the 88th percentile in comparison to his age mates, indicating that he is experiencing higher levels of anxiety than 88% of other boys his age.
CDI|Children's Depression Inventory|CDI,|226|229|TEST RESULTS|Throughout testing, _%#NAME#%_'s frustration level increased significantly on tasks that were more difficult for him, such as this one. Results from the clinical interview with _%#NAME#%_ were consistent with results from the CDI, RCMAS, and projective measures. During the interview _%#NAME#%_ described feeling sad about not having friends.
CDI|Children's Depression Inventory|(CDI,|457|461|SOCIAL, EMOTIONAL AND BEHAVIORAL FUNCTIONING|_%#NAME#%_ obtained a high average score on this task. Overall, results from an assessment of _%#NAME#%_'s memory functioning reflects average to above-average verbal and visual memory skills for age. SOCIAL, EMOTIONAL AND BEHAVIORAL FUNCTIONING: _%#NAME#%_'s social, emotional and behavioral functioning was assessed using an interview with his maternal aunt, consultation with hospital staff, the Test of Problem-Solving - 3rd edition, self-rating skills (CDI, RCMAS), a sentence completion test (SCT) and a clinical interview. The evaluator conducted a phone interview with _%#NAME#%_'s aunt, Ms. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2007#%_ to help with diagnostic clarification and treatment recommendations.
CDI|Children's Depression Inventory|CDI,|167|170|SOCIAL, EMOTIONAL AND BEHAVIORAL FUNCTIONING|Responses also indicate that _%#NAME#%_ is focused on rules, tend to think in a concrete manner and enjoys reading and learning about nature. _%#NAME#%_ completed the CDI, which is a self-rating scale designed to assess for symptoms of depression in younger people. He obtained an overall score within the average range, indicating that _%#NAME#%_ did not endorse a higher than typical number of items associated with depression for his age or gender.
CDI|Children's Depression Inventory|(CDI)|401|405|TESTS ADMINISTERED AND TASKS COMPLETED|There is no evidence of hallucinations, delusions, paranoid ideation, gross inappropriate affect or other frank manifestation of psychotic disorder. She was oriented to person, place and time. TESTS ADMINISTERED AND TASKS COMPLETED: Diagnostic interview Review of medical record Minnesota Multiphasic Personality Inventory - Adolescent (MMPI-A) Rorschach Ink Blot test Children's Depression Inventory (CDI) Revised Children's Manifest Anxiety Scale (RCMAS) TEST RESULTS: 1. The MMPI-A was responded to in a cautious manner, although the profile is valid and interpretable.
CDI|Children's Depression Inventory|(CDI),|490|495|TESTS ADMINISTERED AND TASKS COMPLETED|There is no evidence of compulsion or homicidal ideation. There is no evidence of hallucinations, delusion, paranoid ideation, grossly inappropriate affect, or other frank manifestation of psychotic disorder. She was oriented to person, place, and time. TESTS ADMINISTERED AND TASKS COMPLETED: Diagnostic interview, review of medical record, consultation with staff, Minnesota Multiphasic Personality Inventory - Adolescent (MMPI-A), Rorschach inkblot test, Children's Depression Inventory (CDI), Revised Children Manifest Anxiety Scale (RCMAS). TEST RESULTS: The MMPI-A was responded to in an open and honest manner and the profile is valid and interpretable.
CDI|Children's Depression Inventory|(CDI),|232|237|TEST RESULTS|His performance is mildly delayef for his age and consistent with that of a 6-year, 3-month-old child. Social, Emotional and Behavioral Functioning: _%#NAME#%_'s functioning across these areas was assessed using a self-rating scale (CDI), a projective measure (RATC) and a clinical interview. _%#NAME#%_ obtained an overall score on the CDI, which is a self-rating scale designed to assess for symptoms of depression in children, within the average range.
CDI|Children's Depression Inventory|CDI,|234|237|TEST RESULTS|Social, Emotional and Behavioral Functioning: _%#NAME#%_'s functioning across these areas was assessed using a self-rating scale (CDI), a projective measure (RATC) and a clinical interview. _%#NAME#%_ obtained an overall score on the CDI, which is a self-rating scale designed to assess for symptoms of depression in children, within the average range. However, he did endorse items indicating frequent worries about aches and pains, as well as difficulty sleeping.
CDI|Children's Depression Inventory|CDI|239|241|SOCIAL, EMOTIONAL, AND BEHAVIORAL FUNCTIONING|SOCIAL, EMOTIONAL, AND BEHAVIORAL FUNCTIONING: _%#NAME#%_'s social, emotional, and behavioral functioning were assessed using self-rating scales, a projective measure, a Sentence Completion Test, and a clinical interview. Results from the CDI reflect an overall score within the average range. As such, results indicate that _%#NAME#%_ did not endorse a higher than typical number of items associated with depression for his age and gender.
CDI|Children's Depression Inventory|CDI|178|180|SOCIAL, EMOTIONAL, AND BEHAVIORAL FUNCTIONING|As such, results indicate that _%#NAME#%_ did not endorse a higher than typical number of items associated with depression for his age and gender. None of the subscales from the CDI were within the borderline or clinically significant range either. _%#NAME#%_ also completed the RCMAS, which is a self-rating scale designed to assess symptoms of anxiety in children and adolescents.
CDI|Children's Depression Inventory|(CDI),|256|261|DEMOGRAPHICS AND BACKGROUND INFORMATION|She is oriented to person, place, and time. TESTS ADMINISTRATION AND TASK COMPLETED: Diagnostic interview, review of medical record, Minnesota Multiphasic Personality Inventory - Adolescent (MMPI-A), Rorschach inkblot test, Children's Depression Inventory (CDI), Revised Children ManifestAnxiety Scale (RCMAS). TEST RESULTS: The MMPI-A was responded to in a cautious manner, although the profile was valid and interpretable.
CDI|Children's Depression Inventory|CDI|176|178|DEMOGRAPHICS AND BACKGROUND INFORMATION|These individuals also may not have a good grasp of their underlying emotional content. It seems they also have a somewhat unusual perspective about the world around them. The CDI did not result in any clinically significant levels of depressive symptoms. The RCMAS did not result in any clinically significant level for anxiety symptoms.
CDI|Children's Depression Inventory|CDI|89|91|TEST RESULTS|Thus these individuals need to be closely monitored for potential suicidal gestures. The CDI was administered on _%#MMDD2005#%_. She had a highly clinically significant levels for total CDI score, negative mood, anhedonia, and negative self-esteem.
CDI|Children's Depression Inventory|CDI|186|188|TEST RESULTS|Thus these individuals need to be closely monitored for potential suicidal gestures. The CDI was administered on _%#MMDD2005#%_. She had a highly clinically significant levels for total CDI score, negative mood, anhedonia, and negative self-esteem. She had clinically significant level for ineffectiveness. Items of interest include "I have myself," "I think about killing myself, but I would not do it," "I'm sad all the time," "I do everything wrong," and "I feel alone all the time." The Sentence Completion Test was administered on _%#MMDD2005#%_.
CDI|Children's Depression Inventory|(CDI),|694|699|TESTS ADMINISTERED|His medication at the time of admission to day treatment included Adderall XR (40 mg in the morning), clonidine (0.1 mg x3 daily), Prozac (20 mg in the morning), Advair, albuterol inhaler, Singulair (5 mg daily), melatonin (3 mg at night, as needed) and claritin in the evening. TESTS ADMINISTERED: Wechsler Intelligence Scale for Children-4th Addition (WISC-IV), Wechsler Individual Achievement Test-2nd Addition (WIAT-II, selected subtests), The Trailmaking Tests, parts A and B, Verbal Fluency Test, the Lafayette Grooved Pegboard Test, the Beery-Buktinica Developmental Test of Visual Motor Integration (Beeery, VMI-5th addition), Sentence Completion Test (SCT), Child Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS) and Clinical Interview. BEHAVIORAL OBSERVATIONS: _%#NAME#%_ was evaluated at Fairview's Day Treatment Center over 2 separate testing sessions.
CDI|Children's Depression Inventory|CDI,|122|125|EMOTIONAL, SOCIAL AND BEHAVIORAL FUNCTIONING|He also completed sentences suggesting that he is particularly interested in history and sports. _%#NAME#%_ completed the CDI, which is a self-rating scale designed to assess for symptoms of depression. Results were within the average range, indicating that _%#NAME#%_ did not endorse a higher than typical number of items associated with depression for his age and gender.
CDI|Children's Depression Inventory|(CDI),|513|518|TEST ADMININSTERED AND PROCEDURES|TEST ADMININSTERED AND PROCEDURES: Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV). Wechsler Individual Achievement Test-Second Edition (WIAT-II, Selected subtests, the Trail Making Test, Verbal Fluency Test, Connor's Continuous Performance Test-Second Edition (CPT-II), Berry-Buktinica Developmental Test of Visuomotor Integration (Berry BMI), Lafayette Grooved Pegboard Test, Wide Range Assessment of Memory and Learning-Second Edition (WRAML-II), Selected subtest, Child Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS), Sentence Completion Test (SCT), Roberts Apperception Test for Children (RATC), parent interview and review of records.
CDI|Children's Depression Inventory|CDI,|205|208|PSYCHOLOGICAL FUNCTIONING|PSYCHOLOGICAL FUNCTIONING: _%#NAME#%_'s psychological functioning was assessed using self-rating scales, a sentence completion test, a projective measure and a clinical interview. _%#NAME#%_ was given the CDI, which is a self-rating scale designed to assess depression in young people. He obtained an overall score within the average range, indicating that _%#NAME#%_ did not endorse a higher than typical number of items associated with depression for age and gender.
CDI|Children's Depression Inventory|CDI|172|174|TEST RESULTS|TEST RESULTS: Psychological functioning: _%#NAME#%_'s psychological functioning was assessed using the CDI, RCMAS, SCT, RATC, and a diagnostic assessment. Results from the CDI reflect an overall score within the average range, indicating that _%#NAME#%_ did not endorse a higher than typical number of depressive symptoms for age and gender.
CDI|Children's Depression Inventory|CDI|191|193|SUMMARY OF CURRENT FINDINGS|They also seem to have immature relationships with others. Conversely, they usually do accurately perceive the actions of others and tend to understand the consequences of their own actions. CDI resulted in no clinically significant level for any of the depressive scales. Items of interest include "I think about killing myself but I would not do it." The RCMAS also did not result in any clinically significant level for anxiety symptoms.
CDI|Children's Depression Inventory|(CDI),|330|335|TESTS ADMINISTERED AND TESTS COMPLETED|She was oriented to person, place, and time. Her affect was somewhat sad and her mood was consistent with her affect. TESTS ADMINISTERED AND TESTS COMPLETED: Diagnostic interview, review of medical record, Minnesota Multiphasic Personality Inventory - Adolescent (MMPI-A), Rorschach Ink Blot Test, Children's Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS). TESTS RESULTS: The MMPI-A was responded to in an open and honest manner and the profile is valid and interpretable.
CDI|Children's Depression Inventory|CDI,|168|171|PSYCHOLOGICAL FUNCTIONING|PSYCHOLOGICAL FUNCTIONING _%#NAME#%_'s psychological functioning was assessed using self-rating scales, a projective measure and a clinical interview. He was given the CDI, which is a self-rating scale designed to assess his overall level of depressive symptoms. Results reflected an overall score within the broadly average range.
CDI|Children's Depression Inventory|CDI|219|221|PSYCHOLOGICAL FUNCTIONING|As such, results indicate that in general, _%#NAME#%_ did not endorse a higher than typical number of items associated with depression for his age and gender. He did obtain a borderline elevation on a subscale from the CDI indexing negative self-esteem. _%#NAME#%_'s anxiety level was assessed using the RCMAS, which is a self-rating scale.
CDI|Children's Depression Inventory|CDI|77|79|TESTS RESULTS|These individuals also have a strong need for relationships with others. The CDI resulted in a mildly clinically significant level for negative moods. Items of interest include "I do not like myself, many bad things are my fault, I feel like crying many days, and I have trouble sleeping many nights." The RCMAS did not result in any clinically significant level for anxiety symptoms.
CDI|Children's Depression Inventory|CDI|246|248|HISTORY OF PRESENT ILLNESS|The latter part of _%#MM2006#%_/early _%#MM2007#%_ for which patient was placed by his primary care provider on antibiotics for suspicion of acute diverticulitis. Discontinued after 2-3 days subsequent to return of abdominal CT scan performed at CDI which apparently demonstrated no intra-abdominal pathology. Presence of a right thigh mass, prompting surgical intervention as above. Report of liposarcoma on biopsy. Procedure tolerated well. No problems with general anesthesia.
CDI|Children's Depression Inventory|(CDI)|133|137|TESTS ADMINISTERED|She denies being on any other medications. She also denied any other health concerns. TESTS ADMINISTERED: Child Depression Inventory (CDI) Reviewed Children's Manifest Anxiety Scale (RCMAS) Minnesota Multiphasic Personality Inventory - Adolescent Version (MMPI-A) Roberts Apperception Test for Children (RATC) Clinical interview.
CDI|Children's Depression Inventory|(CDI)|262|266|TEST RESULTS|Overall, it is felt that the current test results are an accurate and valid estimation of _%#NAME#%_'s level of functioning, as she was cooperative and appeared to try her best throughout the assessment. TEST RESULTS: Results from the Child Depression Inventory (CDI) reflected a total score within the clinically significant range, indicating that _%#NAME#%_ endorsed a higher level of depressive symptoms on this measure than other females her age.
CDI|Children's Depression Inventory|(CDI),|474|479|TESTS ADMININSTERED|Her primary care physician is Dr. _%#NAME#%_ at Allina _%#CITY#%_ Clinic. TESTS ADMININSTERED: Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV), Wechsler Individual Achievement Test-Second Edition (WIAT-II), selected subtests, the Trail Making Test, Verbal Fluency Test, Wisconsin Card Sorting Test (WCST), Wide Range Assessment of Memory and Learning-Second Edition (WRAML-II), selected subtests, Ray Complex Figure Test (RCFT), Child Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS), Sentence Completion Test (SCT), Roberts Apperception Test for Children (RATC), and clinical interview.
CDI|Children's Depression Inventory|(CDI)|247|251|PSYCHOLOGICAL FUNCTIONING|PSYCHOLOGICAL FUNCTIONING: _%#NAME#%_'s psychological functioning was assessed primarily to evaluate symptoms of depression, anxiety and to help clarify her general diagnosis. _%#NAME#%_ obtained an overall score on the Child Depression Inventory (CDI) within the borderline range, reflecting at risk level of symptoms of depression for her age and gender. She also obtained borderline elevations on subscales indexing feelings of ineffectiveness, anhedonia (difficulty experiencing pleasure) and negative self-esteem.
CDI|Children's Depression Inventory|(CDI),|275|280|TESTS ADMINISTERED|Concerns regarding akithisia were noted and therefore _%#NAME#%_'s doctors were considering a trial of Klonopin to address her psychotic symptoms. TESTS ADMINISTERED: Wechsler Adult Intelligence Scale - Third Edition (WAIS-III), Selected Subtests, Child Depression Inventory (CDI), Thematic Apperception Test (TAT) clinical interview, and review of previous evaluations and hospital records. BEHAVIORAL OBSERVATIONS: _%#NAME#%_ was alert and somewhat oriented during the evaluation.
CDI|Children's Depression Inventory|CDI.|417|420|SUMMARY AND CLINICAL IMPRESSION|A review of test results in conjunction with _%#NAME#%_'s previous history, indicate that he in fact still exhibits a number of attention-deficit hyperactivity disorder characteristics, symptoms of depression and anxiety, and symptoms which are consistent with auditory and visual hallucinations. _%#NAME#%_ endorsed many symptoms of anxiety on the RCMAS and many symptoms of depression (especially anhedonia) on the CDI. His affect was also extremely restricted in range throughout the evaluation. _%#NAME#%_ described poor peer relationships despite a desire to make more friends and a significant amount of loss and grief associated with separating from his mother.
CDI|Children's Depression Inventory|(CDI)|177|181|CURRENT TESTS ADMINISTERED|A: Trail Making Tests Part A and B. B: Verbal Fluency Test. 2. The Wide Range Assessment of Memory and Learning-II (WRAML- II, Selected subtests). 3. Child Depression Inventory (CDI) 4. Revised Children's Manifest Anxiety Scale (RCMAS). 5. Sentence Completion Tests. 6. Clinical Interview. BEHAVIORAL OBSERVATIONS: _%#NAME#%_ had some mild difficulty transitioning from the playroom at the hospital to the testing room, yet was able to do so with encouragement about receiving a reward if he participated nicely.
CDI|Children's Depression Inventory|CDI,|213|216|BEHAVIORAL/PSYCHOLOGICAL FUNCTIONING|BEHAVIORAL/PSYCHOLOGICAL FUNCTIONING: _%#NAME#%_'s psychological functioning was assessed using the CDI, RCMAS, Sentence Completion Test, and Clinical Interview. The examiner assisted _%#NAME#%_ in completing the CDI, which was a difficult process, as _%#NAME#%_ required the responses read to him for each multiple choice questions numerous times.
CDI|Children's Depression Inventory|CDI|211|213|BEHAVIORAL/PSYCHOLOGICAL FUNCTIONING|Overall, results reflected a total CDI score within the borderline range (T=67) reflecting a number of concerns and symptoms related to depression. _%#NAME#%_ obtained borderline scores across sub-scales of the CDI (negative mood, interpersonal problems, ineffectiveness, anhedonia, and negative self-esteem), reflecting concerns in all areas.
CDI|Children's Depression Inventory|CDI|213|215|BEHAVIORAL/PSYCHOLOGICAL FUNCTIONING|This was _%#NAME#%_'s general style during the assessment when the examiner asked him questions regarding his parents and events leading up to the hospitalization. In fact, when _%#NAME#%_ endorsed an item on the CDI indicating that he felt he was unsure if someone loved him, the examiner attempted to follow up with him regarding his response.
CDI|Children's Depression Inventory|CDI.|163|166|SUMMARY/CLINICAL IMPRESSION|Concerns regarding symptoms of depression also appeared evident in this assessment due to _%#NAME#%_'s restricted affect, and responses to particular items on the CDI. _%#NAME#%_ also appeared extremely uncomfortable discussing personal and/or family struggles. _%#NAME#%_'s recent increase in behavioral difficulties is also likely related to depression.
CDI|center for diagnostic imaging|CDI|254|256|HISTORY OF PRESENT ILLNESS|She does relate that she is not sure what makes it worse or what makes it better other than the narcotics making it better. She denies any weakness to her right leg. Past treatments have been chiropractic physical therapy, epidural steroid injections at CDI in _%#CITY#%_, stretches, Icy-Hot patches and Biofreeze. She states that she has tried the regimen of exercise and stretching, and it does not get any better.
CDI|Children's Depression Inventory|(CDI)|513|517|PSYCHOLOGICAL ASSESSMENT|For example, when he was shown a neutral picture of a man and woman in a room together, _%#NAME#%_ stated, "They are having an argument." When asked what had happened, _%#NAME#%_ stated, "They got angry." When _%#NAME#%_ was asked to describe how the story ended, he stated, "They get divorced." In another picture in which a child is sitting by their parent in a neutral fashion, _%#NAME#%_ reported that the story ended by the child getting either kidnapped or hurt. Results from the Child Depression Inventory (CDI) completed by _%#NAME#%_ reflected scores well below the average range, indicating that he had not been experiencing significant symptoms of depression within the last 2 weeks.
CDI|center for diagnostic imaging|CDI|181|183|REASON FOR CONSULTATION|She saw Dr. _%#NAME#%_ and had, I believe, an epidural steroid around that time. No relief occurred but Dr. _%#NAME#%_ said that she was not a surgical candidate, so he sent her to CDI for injection for the evaluation for radiofrequency ablation. The first procedure that they did at CDI was rupturing a cyst in the lumbar area and while that was successful, it did not help the pain.
CDI|center for diagnostic imaging|CDI|203|205|REASON FOR CONSULTATION|No relief occurred but Dr. _%#NAME#%_ said that she was not a surgical candidate, so he sent her to CDI for injection for the evaluation for radiofrequency ablation. The first procedure that they did at CDI was rupturing a cyst in the lumbar area and while that was successful, it did not help the pain. The second procedure they did was numbing up the nerves exiting out of the facet joint and that was actually a sympathetic block, which numbed up one side but as soon as the medication wore off, she had the pain right back again but it was a positive sign indicating that they should move forward for a rhizotomy.
CDI|Children's Depression Inventory|CDI|141|143|TEST RESULTS|During times of stress and ambiguity, it is likely that these individuals tend to present with a more severe psychopathological picture. The CDI was administered on _%#MMDD2005#%_. She had clinically significant level for total depression index, negative mood, ineffectiveness, anhedonia, and negative self-esteem.
CDI|Children's Depression Inventory|(CDI),|256|261|HISTORY OF PRESENT ILLNESS|He was oriented to person, place, and time. TESTS ADMINISTERED AND TASKS COMPLETED: Diagnostic interview, review of medical records, Minnesota Multiphasic Personality Inventory - Adolescent (MMPI-A), Rorschach ink blot test, Childrens Depression Inventory (CDI), Revised Childrens Manifest Anxiety Scale (RCMAS). TEST RESULTS: The MMPI-A was responded to in a highly defensive manner to the point where there was questionable validity.
CDI|Children's Depression Inventory|CDI|250|252|HISTORY OF PRESENT ILLNESS|Their relationships tend to be superficial, and they may even believe that their relationships are more secure than they truly are. These individuals tend to be immature from an emotional standpoint when compared to their chronological age. Both the CDI and the RCMAS did not result in any clinically significant levels for either depression or anxiety respectively. This is consistent with his defensiveness and, due to the high face validity, these measures are likely not useful for this individual.
CDI|center for diagnostic imaging|CDI|186|188|IMAGING|Significantly decreased mobility in the lower extremities consistent with tightened muscles. PSYCHIATRIC: Mood and affect euthymic. IMAGING: 1. MRI of the lumbosacral spine performed at CDI on _%#MMDD2005#%_ showed a 12 mm intradural nodular mass within the posterior thecal sac at L1 with displacement or mass effect on the tip of the conus medullaris.
CDI|center for diagnostic imaging|CDI|174|176|IMAGING|There is chronic multilevel foraminal stenosis, moderate bilaterally at L4-L5 and mild at the remaining levels of L5 through S1. 2. MRI of the lumbosacral spine performed at CDI on _%#MMDD2005#%_. This is re- imaging with intravenous gadolinium, and shows heterogeneous enhancement of the 13 mm extramedullary intradural nodule at L1 and shows enhancement of an additional smaller 3-4 mm intradural nodule in the more distal thecal sac.
CDI|Children's Depression Inventory|CDI,|224|227|PSYCHOLOGICAL, SOCIAL, AND BEHAVIORAL FUNCTIONING|PSYCHOLOGICAL, SOCIAL, AND BEHAVIORAL FUNCTIONING: _%#NAME#%_'s functioning in these areas was assessed using a self-rating scale, a sentence completion test, a projective measure, and a clinical interview. Results from the CDI, which is the self-rating scale designed to assess for symptoms of depression in children, reflected an overall score within the average range.
CDI|Children's Depression Inventory|(CDI),|464|469|TESTS ADMINISTERED AND TASKS COMPLETED|There is no evidence of hallucinations, delusions, paranoid ideation, grossly inappropriate affect or other frank manifestations of psychotic disorder. He was oriented to person, place and time. TESTS ADMINISTERED AND TASKS COMPLETED: Diagnostic interview, review of medical records, Bender Gestalt test, Wechsler Adult Intelligence Scale-Third Edition (WAIS-III), Minnesota Multiphasic Personality Inventory - Adolescent (MMPI-A), Children's Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS). TEST RESULTS: The Bender Gestalt test did not result in any clinically significant rotations or distortions.
CDI|Children's Depression Inventory|CDI|82|84|TEST RESULTS|They may not be forthcoming and also tend to have immature coping mechanisms. The CDI did not result in any clinically significant levels for depressive symptoms. There was a mildly clinically level for negative self-esteem. Items of interest include: "I do not like myself." "I am bad many times." "I think about killing myself but I would not do it." The RCMAS resulted in a clinically significant level for worry/oversensitivity.
CDI|Children's Depression Inventory|(CDI),|393|398|TESTS ADMINISTERED AND TASKS COMPLETED|No evidence of hallucination, delusion, paranoid ideation, grossly inappropriate affect, or other frank manifestation of psychotic disorder. He was oriented to person, place, and time. TESTS ADMINISTERED AND TASKS COMPLETED: Diagnostic interview, review of medical record, Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A), Rorschach ink blot test, Children Depression Inventory (CDI), Sentence Completion Test. TEST RESULTS: The MMPI-A was administered on _%#MMDD2005#%_. He responded to the items in an open and honest manner, and the profile was valid and interpretable.
CDI|Children's Depression Inventory|CDI|212|214|TEST RESULTS|Although this protocol does not quite reach the level of psychotic, it is quite evident that they function in an extremely low level of performance when under a great deal of stress or coping with ambiguity. The CDI resulted in a mildly clinically significant level for interpersonal problems. Otherwise, he did not rate himself at a clinically significant level for total depression index score, negative mood, ineffectiveness, anhedonia, or negative self esteem.
CDI|Children's Depression Inventory|(CDI),|312|317|TESTS ADMINISTERED AND TASKS COMPLETED|There was no evidence of hallucinations, delusions, paranoid ideation, grossly inappropriate affect, or other frank manifestation of psychotic disorder. He was oriented to person, place, and time. TESTS ADMINISTERED AND TASKS COMPLETED: Diagnostic interview, review of medical record, Child Depression Inventory (CDI), Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A), Rorschach Inkblot Test, Sentence Completion. TEST RESULTS: This patient was administered the CDI. He did not score at a clinically significant level for negative mood, interpersonal problems, anhedonia, or negative self-esteem.
CDI|Children's Depression Inventory|CDI,|231|234|TEST RESULTS|Social, emotional, and behavioral functioning: _%#NAME#%_'s social, emotional and behavioral functioning were assessed using self-rating scales, a projective measure, and a non-standardized child-based assessment. Results from the CDI, which is a self-rating scale designed to assess for symptoms of depression in children, reflect a clinically significant level of depression in comparison to other boys _%#NAME#%_'s age.
CDI|Children's Depression Inventory|(CDI),|548|553|TESTS ADMINISTERED|_%#NAME#%_ reported that his biological father was in prison at this time. TESTS ADMINISTERED: Wechsler Intelligence Scale for Children-IV Edition (WISC-IV), Wechsler Individual Achievement Test-Second Edition (WIAT-II) (Selected Subtests), the Trail Making Test, Parts A and B, Verbal Fluency Test, Wide Range Assessment of Memory and Learning, Second Edition (WRAML-II), Selected Subtest, The Lafayette Grooved Pegboard Test, the Beery Buktenica Developmental Test of Visuomotor Integration (Beery VMI, Fifth Edition), Child Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS), Sentence Completion Test (SCT) and clinical interview. BEHAVIORAL OBSERVATIONS: _%#NAME#%_ was evaluated over two separate testing sessions, as he could not attend or remain seated long enough, even with breaks, to complete the evaluation in one afternoon or morning.
CDI|Children's Depression Inventory|CDI|182|184|HISTORY OF PRESENT ILLNESS|These individuals also tend to have a negative perception of body image. Overall though, especially under a great deal of stress, they tend to show deterioration of functioning. The CDI resulted in a clinically significant level for negative mood and a mildly clinically significant level for negative self-esteem.
CDI|Children's Depression Inventory|(CDI)|386|390|TESTS ADMINSISTERED|A relative on the paternal side of the family also has a history of schizoaffective disorder. The patient has no reported contact with biological father. TESTS ADMINSISTERED: Wechsler Intelligence Scale for Children, 4th Edition (WISC-IV) Trail Making Test, Parts A and B Verbal Fluency Test Rey Complex Figure Test NEPSY, Tower Subtest Grooved Pegboard Test Child Depression Inventory (CDI) Revised Children Manifest Anxiety Scale (RCMAS) Minnesota Multiphasic Personality Inventory- Adolescent Version (MMPI-A) Clinical Interview BEHAVIORAL OBSERVATIONS: _%#NAME#%_ was cooperative with the evaluator upon initially meeting at the hospital and throughout the evaluation.
CDI|Children's Depression Inventory|(CDI),|350|355|TESTS ADMINISTERED AND TASKS COMPLETED|In fact, the "voice" that she hears may not be good evidence of true auditory hallucinations. She was oriented to person, place, and time. TESTS ADMINISTERED AND TASKS COMPLETED: Diagnostic interview, review of medical record, Wechsler Intelligence Scale for Children-Third Edition (WISC-III), Rorschach Inkblot test, Children's Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS). TEST RESULTS: The WISC-III is a measure to determine overall verbal and nonverbal intellectual functioning levels.
CDI|Children's Depression Inventory|CDI|304|306|PERFORMANCE SUBTEST|Their relationships with others also tend to be superficial. They have the ability to accurately interpret the environment around them although under a great deal of stress seem to regress and respond impulsively and sometimes with poor accuracy. They can easily become tangential and lacking focus. The CDI and the RCMAS were not clinically significant for depressive or anxiety symptoms. There was some evidence of mild clinically significant level for interpersonal problems on the CDI.
CDI|Children's Depression Inventory|CDI.|238|241|PERFORMANCE SUBTEST|They can easily become tangential and lacking focus. The CDI and the RCMAS were not clinically significant for depressive or anxiety symptoms. There was some evidence of mild clinically significant level for interpersonal problems on the CDI. Items of interest include "I do not like myself," "I think about killing myself but I would not do it," and "I feel like crying everyday." SUMMARY OF CURRENT FINDINGS: This is a 12-year-old female who is admitted to the Subacute Diagnostic Unit at the University of Minnesota Medical Center, Fairview due to impulsivity, hyperactivity, and suicidal ideation.
CDI|Children's Depression Inventory|(CDI),|543|548|TEST ADMINISTERED|_%#NAME#%_ also has a reported history of some self-injurious behaviors and biting nails and cuticles excessively. TEST ADMINISTERED: Wechsler Intelligence Scale for Children (WAISC-IV), Wechsler Individual Achievement Test-II (WIAT-II), Selected Subtests, the Trail Making Tests, Parts A and B, Verbal Fluency Test, Wide Range Assessment of Memory and Learning-II (WRML-II), Selected subtests, Lafayette Grooved Pegboard Test, the Berry-Buktinica Developmental Test of Visuomotor Integration (Berry VIM-V Edition), Child Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS), Roberts Apperception Test for Children (RATC), and Clinical Interview. BEHAVIORAL OBSERVATIONS: _%#NAME#%_ was evaluated at Fairview over two separate days.
CDI|Children's Depression Inventory|CDI,|191|194|SOCIAL, EMOTIONAL AND BEHAVIORAL FUNCTIONING|SOCIAL, EMOTIONAL AND BEHAVIORAL FUNCTIONING: _%#NAME#%_'s functioning across these areas was assessed using self-rating scales, a projective measure and clinical interview. Results from the CDI, which is a self-rating scale designed to assess a child's level of depressive symptoms reflected an overall score within the average range.
CDI|Children's Depression Inventory|CDI,|227|230|EMOTIONAL/SOCIAL/BEHAVIORAL FUNCTIONING|EMOTIONAL/SOCIAL/BEHAVIORAL FUNCTIONING: _%#NAME#%_'s emotionally, social and behavioral functioning was assessed using several self-report measures (CDI and RCMAS), the MMPI-A, and a brief clinical interview. Results from the CDI, which is a self-report measure designed to assess for symptoms of depression in children in adolescence, reflected an overall score within the clinically significant range for age.
CDI|Children's Depression Inventory|CDI|260|262|EMOTIONAL/SOCIAL/BEHAVIORAL FUNCTIONING|_%#NAME#%_ also obtained scores within the clinically significant range on sub-scales from the CDI measuring negative mood, and her personal problems, feelings of ineffectiveness, and negative self- esteem. A review of _%#NAME#%_'s individual responses on the CDI indicate that she endorse the following items: "I am sad all the time, I am not sure if things will work out for me, I do many things wrong, I am bad many times, I am sure that terrible things will happen to me, I do not like myself, many bad things are my fault, and I want to kill myself." _%#NAME#%_ also endorsed the following items: "I feel like crying every day, things bother me all the time, I like being with people, it is hard to make up my mind about things, I look okay, I have to push myself all the time to do my school work, I sleep pretty well, I am tired many days, many days I do not feel like eating, and I do not worry about aches and pains." Finally, she endorsed the following items: "I feel alone many times, I have fun at school once in awhile, I have plenty of friends, my school work is not as good as before, I can be just as good as other kids if I want to, I am not sure if anybody loves me, I do not do what I am told most times, and I get into fights many times." Results from the RCMAS, which is a self-report measure designed to assess for symptoms of anxiety in children and adolescence, reflected a total anxiety score within the borderline range and 83% for age.
CDI|Children's Depression Inventory|CDI|155|157|DEMOGRAPHICS AND BACKGROUND INFORMATION|They may also manifest depressive-related symptoms. Overall though, there is little-to-no evidence of any psychotic processing based on this protocol. The CDI resulted in a highly clinically significant level for negative mood, interpersonal problems, ineffectiveness, anhedonia, and negative self-esteem.
CDI|Children's Depression Inventory|CDI|198|200|TEST RESULTS|Their relationships with others usually are superficial and they tend to revert to fantasy when under a great deal of stress. Overall, these individuals tend to have immature coping mechanisms. The CDI resulted in a highly clinically significant level for negative mood, interpersonal problems, ineffectiveness, and anhedonia. She has scored at a clinically significant level for negative self-esteem.
CDI|Children's Depression Inventory|CDI|148|150|TEST RESULTS|Their relationships also tend to be somewhat superficial with others. These individuals often tend to revert to a fantasy life quite easily. 3. The CDI resulted in clinically significant levels for negative mood and anhedonia. Items of interest include "I think about killing myself, but I would not do it," "I do not like myself," and "I am tired all the time."
CDI|Children's Depression Inventory|(CDI),|316|321|DEMOGRAPHIC AND BACKGROUND INFORMATION|She was oriented to person, placed and time. TESTS ADMINISTERED AND TASKS COMPLETED: Diagnostic interview, review of medical record, Wechsler Adult Intelligence Scale - 3rd Addition (WAIS-3), Minnesota Multiphasic Personality Inventory - Adolescent (MMPI-A), Rorschach ink blot test, Children's Depression Inventory (CDI), Revised Children Manifest Anxiety Scale (RCMAS). TEST RESULTS: The WAIS-3 was administered to estimate verbal and nonverbal intellectual functioning levels.
CDI|Children's Depression Inventory|CDI|165|167|PERFORMANCE SUB-TEST|These individuals also tend to have superficial relationships with others, although they may feel that their relationships are more secure than they really are. The CDI resulted in clinically significant level for ineffectiveness. Items of interest include "I think about killing myself but I would not do it," "I am tired many days" and "I feel alone at many times.
CDI|Children's Depression Inventory|CDI|160|162|TEST RESULTS|These individuals also likely have difficulty coping with the various stressors in their lives and may manifest depressive and/or anxiety related symptoms. The CDI was administered on _%#MMDD2005#%_. He did not rate himself at a clinically significant level for interpersonal problems, ineffectiveness, anhedonia, or negative self-esteem.
CDI|Children's Depression Inventory|CDI|136|138|TEST RESULTS|Their defense mechanisms also tend to be somewhat immature and as a result their coping style may be somewhat hampered at times. 3. The CDI resulted in clinically significant level for interpersonal problems and ineffectiveness. Items of interest include, "I do not like myself," "I think about killing myself, but I would not do it," and "I feel alone many times."
CDI|Children's Depression Inventory|CDI,|158|161|RESULTS|These results suggest that _%#NAME#%_ views herself as experiencing significantly lower levels of depression and anxiety than her age mates. In regard to the CDI, _%#NAME#%_ endorsed items indicating that she does not think about killing herself, likes herself, has fun in many things, feels she looks okay, and does not view schoolwork as a problem.
CDI|Children's Depression Inventory|CDI|160|162|TEST RESULTS|These individuals also tend to have superficial relationships with others and tend to believe that their relationships are more secure than they truly are. The CDI and the RCMAS did not result in clinically significant levels for depressive and anxiety symptoms respectively. Once again, due to the high face validity of these measures it is likely that this individual was easily able to maintain his defensiveness in his responses to these items.
CDI|Children's Depression Inventory|CDI|98|100|TEST RESULTS|Otherwise they appear to be coping relatively well with the various stressors in their lives. The CDI resulted in a highly clinically significant level for negative mood, interpersonal problems, ineffectiveness, anhedonia, and negative self-esteem.
CDI|Children's Depression Inventory|(CDI),|390|395|MENTAL STATUS EXAMINATION|He was oriented to person, place, and time. There was some question about his level of impulsivity, and based on verbal ability, his intellectual functioning appeared to be within the average range. .......has completed diagnostic interview, review of medical records, Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A), Rorschach Inkblot Test, Children's Depression Inventory (CDI), Brown ADD Scales-Adolescent, _%#NAME#%_'s Continuous Performance Test (CPI). TEST RESULTS: The MMPI-A was responded to in an open and honest manner, and the profile is valid and interpretable.
CDI|Children's Depression Inventory|CDI|165|167|TEST RESULTS|Others will describe these individuals and immature, and they appear to be utilizing defense mechanisms and also are immature when compared to their peer group. The CDI resulted in mildly significant clinically levels for negative mood, ineffectiveness, and anhedonia. Items of interest include "I am bad many times," "Many bad things are my fault," "I have some friends, but I wish I had more," I do very badly in subjects I used to be good in." The Brown ADD Scales-Adolescent resulted in highly clinically significant levels for all the ADHD scales including activation, attention, effort, affective instability, and memory problems.
CDI|Children's Depression Inventory|CDI),|148|152|TEST RESULTS|E. Behavioral and Psychological Functioning _%#NAME#%_'s behavior and emotional functioning was assessed using self- report rating forms (RCMAS and CDI), a projective measure (RATC) and a clinical interview. Results from the RCMAS, which is an anxiety measure for children, reflected a borderline elevation (T=61) on the Total Anxiety Scale, indicating that _%#NAME#%_ is experiencing as much as or more anxiety than approximately 87% of other Caucasian boys his age in the normative group on this test.
CDI|Children's Depression Inventory|(CDI),|333|338|BACKGROUND AND REFERRAL INFORMATION|TESTS ADMINISTERED: Wechsler Individual Achievement Test- Second Edition (WIAT - II), selected subtests: Wide Range Assessment of Memory and Learning-Second Edition (WRAML-II), selected subtest. Rey Complex Figure Test (RCFT). The Beery Buktenica Visual Motor Integration Test ( Beery VMI), fifth edition, Child Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS), Sentence Completion Test (SCT), Robert Apperception Test for Children (RATC), and then clinical interview.
CDI|Children's Depression Inventory|(CDI)|273|277|MEMORY AND LEARNING SKILLS|EMOTIONAL, SOCIAL, AND BEHAVIORAL FUNCTIONING: _%#NAME#%_'s emotional, social, and behavioral functioning was assessed using several Self-Rating Scales, a projective measure, a sentence completion test, and a clinical interview. Results from the Child Depression Inventory (CDI) reflected an overall score within the borderline "at risk" range. _%#NAME#%_ also obtained a borderline score on the subscale from the CDI indexing symptoms or feelings of ineffectiveness.
CDI|Children's Depression Inventory|CDI|238|240|DIAGNOSTIC IMPRESSION|Finally, in regard to mood and behavior, results from an assessment of _%#NAME#%_'s functioning in these areas are consistent with diagnoses of depressive disorder, not otherwise specified, as _%#NAME#%_ endorsed a number of items on the CDI consistent with childhood depression. It was also documented in his file at the hospital that he is exhibiting a number of characteristics and symptoms of depression.
CDI|Children's Depression Inventory|CDI|307|309|EMOTIONAL, SOCIAL, AND BEHAVIORAL FUNCTIONING|_%#NAME#%_'s mother was also interviewed to assist with this. Results from the Child Depression Inventory, reflected a total CDI score within the average range in comparison to other boys his age. _%#NAME#%_ obtained a borderline score on a subscale relating to interpersonal problems. Although his overall CDI score was not clinically significant, he endorsed several items reflecting symptoms of depression (e.g., I am sad all the time, I do many things wrong, I think about killing myself but would not do it).
CDI|Children's Depression Inventory|(CDI),|406|411|TESTS ADMINISTERED AND TASKS COMPLETED|There is no evidence of hallucination, delusion, paranoid ideation, grossly inappropriate affect, or other frank manifestation of psychotic disorder. She was oriented to person, place, and time. TESTS ADMINISTERED AND TASKS COMPLETED: Diagnostic interview, review of medical records, Minnesota Multiphasic Personality Inventory-Adolescent ((MMPI-A), Rorschach Inkblot test, Children's Depression Inventory (CDI), and Sentence Completion test. TEST RESULTS: The MMPI-A was administered on _%#MMDD2005#%_. She responded to the items in an open and honest manner, and the profile is valid and interpretable.
CDI|Children's Depression Inventory|(CDI).|252|257|TESTS ADMINISTERED AND TASKS COMPLETED|He is oriented to person, place, and time. TESTS ADMINISTERED AND TASKS COMPLETED: Diagnostic interview. Review of medical record. Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A). Rorschach Inkblot Test. Children's Depression Inventory (CDI). Revised Children's Manifest Anxiety Scale (RCMAS). TEST RESULTS: The MMPI-A was responded to in an open and honest manner and the profile is valid and interpretable.
CDI|Children's Depression Inventory|(CDI),|298|303|TESTS ADMINISTERED AND TASK COMPLETED|As a result there may be evidence of psychotic disorder. He was oriented to person, place and time. TESTS ADMINISTERED AND TASK COMPLETED: Diagnostic interview, review of medical records Minnesota Multiphasic Inventory (adolescent, MMPI-A), Rorschach ink blot test, Children's Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS). TEST RESULTS: The MMPI-A was responded to in an open and honest manner and the profile was valid and interpretable.
CDI|Children's Depression Inventory|CDI|128|130|TEST RESULTS|In addition their coping mechanisms are somewhat immature. Based on this protocol, a psychotic process cannot be ruled out. The CDI resulted in a clinically significant level for interpersonal problems, ineffectiveness, anhedonia, and negative self-esteem. Items of interest include "I think about killing myself, but I would not do it." "I hate myself." "I am bad many times." "I feel lonely at times." He also noted, "I look ugly," and "I am tired all the time." The RCM resulted in highly clinically significant levels for physiological anxiety, worry/over- sensitivity, and s ocial concerns/concentration.
CDI|Children's Depression Inventory|CDI|101|103|TEST RESULTS|These individuals tend to have some underlying anger and tend to develop poor coping mechanisms. The CDI was administered on _%#MMDD2005#%_. She had highly clinically significant levels for total CDI score, negative mood, and negative self- esteem.
CDI|Children's Depression Inventory|CDI|196|198|TEST RESULTS|These individuals tend to have some underlying anger and tend to develop poor coping mechanisms. The CDI was administered on _%#MMDD2005#%_. She had highly clinically significant levels for total CDI score, negative mood, and negative self- esteem. She had clinically significant levels for interpersonal problems, ineffectiveness, and anhedonia.
CDI|Children's Depression Inventory|(CDI)|430|434|TESTS ADMINISTERED|His last outpatient psychiatrist was apparently _%#NAME#%_ _%#NAME#%_ (_%#TEL#%_). The family also apparently is working with a social worker (_%#TEL#%_), Ms. _%#NAME#%_ _%#NAME#%_. TESTS ADMINISTERED: Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV) Wechsler Individual Achievement Test - Second Edition (WIAT-II) Selected subtests Trail-Making Test, Parts A and B Verbal Fluency Test Child Depression Inventory (CDI) Revised Children's Manifest Anxiety Scale (RCMAS) Clinical interview. BEHAVIORAL OBSERVATIONS: _%#NAME#%_ presented to the evaluation appearing casually and neatly dressed, and moderately overweight for his age.
CDI|Children's Depression Inventory|CDI,|183|186|SOCIAL, EMOTIONAL AND BEHAVIORAL FUNCTIONING|TEST RESULTS: _%#NAME#%_ psychological functioning was assessed using self-rating scales, a Sentence Completion Test, a projective measure, and a clinical interview. Results from the CDI, which is a self-rating scale designed to assess symptoms of depression in children, reflected an overall score within the broadly average range.
CDI|Children's Depression Inventory|(CDI),|445|450|TESTS ADMINISTERED AND TASKS COMPLETED|There was no evidence of hallucinations, delusions, paranoid ideation, grossly inappropriate affect or other frank manifestation of psychotic disorder. He was oriented to person, place, and time. TESTS ADMINISTERED AND TASKS COMPLETED: Diagnostic interview, review of medical record, Wechsler Intelligence Scale for Children-3rd edition (WISC-III), Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A), Childhood Depression Inventory (CDI), Rorschach Ink Blot Test, and Sentence Completion Test. TEST RESULTS: Cognitive functioning: The WISC-III was administered to evaluate verbal and nonverbal intellectual functioning levels.
CDI|Children's Depression Inventory|CDI|206|208|PERSONALITY FUNCTIONING|These individuals also tend to have difficulty in school, possibly due to conflict or emoti onal constraints. The CDI is a self-rating measure for various aspects of depressive- related symptoms. His total CDI score, as well as negative mood and ineffectiveness, were at a clinically significant level. The Rorschach Ink Blot Test was administered on _%#MMDD2005#%_. He had 14 responses, which resulted in a valid and interpretable protocol.
CDI|Children's Depression Inventory|(CDI),|423|428|TESTS ADMINISTERED AND TASKS COMPLETED|There is no evidence of hallucination, delusion, paranoid ideation, grossly inappropriate affect, or the frank manifestation of psychotic disorder. He was oriented to person, place, and time. TESTS ADMINISTERED AND TASKS COMPLETED: Diagnostic interview, review of medical record, Minnesota Multi-Phasic Personality Inventory-Adolescent (MMPI-A), Millon Adolescent Clinical Inventory (MACI), Children's Depression Inventory (CDI), Beck Anxiety Inventory (BAI). TEST RESULTS: The MMPI-A was responded to in a significantly cautious manner to the point where the profile has questionable validity.
CDI|Children's Depression Inventory|CDI,|250|253|PSYCHOLOGICAL AND BEHAVIORAL FUNCTIONING|PSYCHOLOGICAL AND BEHAVIORAL FUNCTIONING: _%#NAME#%_'s psychological and behavioral functioning was assessed using self-rating scales, projective measures, and a clinical interview. _%#NAME#%_ obtained solidly average scores across all scales of the CDI, indicating that he is not experiencing a clinically significant level of depression in comparison to other adolescent boys approximately his age.
CDI|Children's Depression Inventory|CDI,|219|222|SOCIAL, EMOTIONAL, AND BEHAVIORAL FUNCTIONING|SOCIAL, EMOTIONAL, AND BEHAVIORAL FUNCTIONING: Finally, _%#NAME#%_'s functioning in these areas was evaluated using self-rating scales, a Sentence Completion Test, a projective measure, and a clinical interview. On the CDI, which is a self-rating scale designed to assess for symptoms of depression in children, _%#NAME#%_ obtained an overall score within the borderline "at risk" range.
CDI|center for diagnostic imaging|CDI|138|140|HISTORY OF PRESENT ILLNESS|At that time, _%#NAME#%_ had had 2 prior EEG studies, the most recent a year and a half earlier. _%#NAME#%_ had a cranial MRI obtained at CDI on _%#MMDD2003#%_. This demonstrated findings consistent with mesial temporal sclerosis affecting the left medial temporal lobe. An EEG at the time of Dr. _%#NAME#%_'s initial evaluation of _%#NAME#%_ showed no abnormalities.
CDI|Children's Depression Inventory|CDI|108|110|TEST RESULTS|These individuals tend to be highly impulsive and may not understand the consequences of their actions. The CDI was administered on _%#MMDD2005#%_. She rated herself at a clinically significant level for total CDI score, negative mood, and anhedonia.
CDI|Children's Depression Inventory|CDI|210|212|TEST RESULTS|These individuals tend to be highly impulsive and may not understand the consequences of their actions. The CDI was administered on _%#MMDD2005#%_. She rated herself at a clinically significant level for total CDI score, negative mood, and anhedonia. She also rated herself at a mildly clinically significant level for ineffectiveness.
CDI|Children's Depression Inventory|CDI|119|121|TEST RESULTS|These individuals also tend to have somewhat superficial relationships with others and immature coping mechanisms. The CDI did not result in a clinically significant level for depressive symptoms and the RCMAS did not result in clinically significant levels for anxiety symptoms.
CDI|Children's Depression Inventory|CDI|103|105|PERSONALITY AND BEHAVIORAL FUNCTIONING|_%#NAME#%_ describes his idea of having a good time as "hanging out with my friends." Results from the CDI reflected an overall score within the average range for age. Results from the RCMAS reflected an overall score within the average range as well.
CDI|Children's Depression Inventory|(CDI)|226|230|SOCIAL, EMOTIONAL, AND BEHAVIORAL FUNCTIONING|SOCIAL, EMOTIONAL, AND BEHAVIORAL FUNCTIONING: _%#NAME#%_'s psychosocial and behavioral functioning were assessed using several self report measures as well as a clinical interview. Results from the Child Depression Inventory (CDI) reflected an overall CDI score within the normative range. However, _%#NAME#%_ obtained borderline elevation on subscales measuring interpersonal problems and a sense of ineffectiveness.
CDI|Children's Depression Inventory|(CDI|167|170|TEST RESULTS|Results are consistent with an age equivalent of 7 years, 6 months. _%#NAME#%_'s emotional, social, and behavioral functioning were assessed with self-report measures (CDI and RCMAS), Projective Measures (RATC) and sentence completion and a clinical interview. Results of interviews with _%#NAME#%_'s father and EBD teacher were also helpful in this process.
CDI|Children's Depression Inventory|CDI|308|310|TEST RESULTS|_%#NAME#%_'s emotional, social, and behavioral functioning were assessed with self-report measures (CDI and RCMAS), Projective Measures (RATC) and sentence completion and a clinical interview. Results of interviews with _%#NAME#%_'s father and EBD teacher were also helpful in this process. Results from the CDI reflected a number of symptoms of depression, with _%#NAME#%_'s total score within the borderline range (T=68). _%#NAME#%_ also obtained significant elevations on subscales indexing negative mood (T=70), and anhedonia (T=75).
CDI|Children's Depression Inventory|(CDI),|187|192|PREVIOUS EVALUATION|He was also administered a variety of checklists and self-report instruments pertaining to internalizing and externalizing behavior and depression. On the Children's Depression Inventory (CDI), he produced scores that were all very low; the Total CDI score fell within the average or normal range. Similarly, on the Revised Children's Manifest Anxiety Scale (RCMAS), he again scored well below the range of clinical significance overall and on individual measures of different kinds of anxiety, except with regard to physiological anxiety.
CDI|Children's Depression Inventory|CDI|86|88|TEST RESULTS|Based on this protocol, there is little to no indication of psychotic processing. The CDI resulted in no scales that were a clinically significant level for depressive-type symptoms. Items of interest do include, "I want to kill myself," "I am sure that terrible things will happen to me," and "I feel alone many times." Sentence Com pletion Test was administered on _%#MMDD2005#%_.
CDI|Children's Depression Inventory|(CDI),|694|699|TESTS ADMINISTERED|Ms. _%#NAME#%_ stated that she has also had some concerns that _%#NAME#%_ may be struggling with bipolar affective disorder after reading about the symptoms associated with this diagnosis. TESTS ADMINISTERED: Wechsler Intelligence Scale for Children - IV Edition (WISC-IV), Wechsler Individual Achievement Test - II Edition (WIAT-II), selected subtests, the Trail-Making Test, Verbal Fluency, Wisconsin Card-Sorting Test (WCST), Connors Continuous Performance Test - II Edition (CPT-II), Lafayette Grooved Pegboard Test, the Beery Buktenica Developmental Test of Visual Motor Integration (Beery VMI 5th Edition), Revised Children's Manifest Anxiety Scale (RCMAS), Children Depression Inventory (CDI), Sentence Completion Test (SCT), Robert's Apperception Test for Children (RATC), and clinical interview. BEHAVIORAL OBSERVATIONS: _%#NAME#%_ was evaluated at the University of Minnesota Medical Center, Fairview in the day treatment program over 2 separate testing sessions.
CDI|Children's Depression Inventory|(CDI,|392|396|TEST RESULTS|_%#NAME#%_ obtained well below-average scores on the short and longer delayed recall trials, likely associated with poor planning and organization on the copy portion, as opposed to true visual memory weaknesses. Social, Emotional and Behavioral Functioning: _%#NAME#%_'s functioning across these areas was assessed using a measure to evaluate social reasoning (TOPS-III), self-rating scales (CDI, RCMS), a sentence compl etion test (SCT), a projective measure (RATC), and a clinical interview.
CDI|Children's Depression Inventory|CDI|143|145|TEST RESULTS|Assessment of mood and anxiety level with self-rating scales indicate that _%#NAME#%_ endorsed a clinically significant number of items on the CDI and RCMAS. As such, findings suggest that _%#NAME#%_ is experiencing a higher than typical level of depression and anxiety in comparison to other boys approximately his age.
CDI|Children's Depression Inventory|(CDI)|275|279|TEST RESULTS|Overall, it is felt that the results of the evaluation are an accurate reflection of Herman's functioning at this time, as he was generally cooperative, particularly when given space and time to respond to questions. TEST RESULTS: Results from the Child Depression Inventory (CDI) and Revised Children's Manifest Anxiety Scale (RCMAS) reflect scores within the average range for age. Those measures are self report and scales. However, it is important to note that _%#NAME#%_ appeared to minimize negative feelings and changed his answers on several occasions as well.
CDI|Children's Depression Inventory|CDI|202|204|TEST RESULTS|Other than _%#NAME#%_'s depressed affect and lower concentration level, he did not demonstrate any other extremely atypical mannerisms or behaviors during the evaluation. TEST RESULTS: Results from the CDI reflect an overalls score within the average range for age and gender. However, _%#NAME#%_ obtained a borderline "at risk" score on a subscale from the CDI assessing feelings of ineffectiveness.
CDI|Children's Depression Inventory|CDI|187|189|TEST RESULTS|TEST RESULTS: Results from the CDI reflect an overalls score within the average range for age and gender. However, _%#NAME#%_ obtained a borderline "at risk" score on a subscale from the CDI assessing feelings of ineffectiveness. _%#NAME#%_ endorsed items indicating that he is sad many times, feels nothing will work out for him, does many things wrong, does not like himself, feels many bad things are his fault, and thinks about killing himself, but would not do it.
CDI|Children's Depression Inventory|(CDI).|250|255|TESTS ADMINISTERED/TASKS COMPLETED|She was oriented to person, place, and time. TESTS ADMINISTERED/TASKS COMPLETED: Diagnostic interview. Review of medical record. Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A). Rorschach Inkblot Test. Children's Depression Inventory (CDI). Revised Children's Manifest Anxiety Scale (RCMAS). TEST RESULTS: The MMPI-A was responded to in an open and honest manner and the profile is valid and interpretable.
CDI|Children's Depression Inventory|CDI,|170|173|PSYCHOLOGICAL FUNCTIONING|PSYCHOLOGICAL FUNCTIONING: _%#NAME#%_'s psychological functioning was assessed using self-rating scales, the SC T, the MMPI-A, and a clinical interview. Results from the CDI, which is a self-rating scale designed to assess for symptoms of depression in children in adolescence, reflected a solidly average score.
CDI|Children's Depression Inventory|CDI|185|187|TEST RESULTS|Results indicate that, in general, _%#NAME#%_ views himself as experiencing less symptoms of depression than the majority of other males approximately his age. Other subscales from the CDI were also within the solidly average range. _%#NAME#%_ endorsed items indicating that it is difficult for him to make up his mind and that he has to push himself many times to do his school work.
CDI|Children's Depression Inventory|(CDI),|408|413|TESTS ADMINISTERED AND TASKS COMPLETED|There is no evidence of hallucinations, delusions, paranoid ideation, grossly inappropriate affect, or other frank manifestation of psychotic disorder. He was oriented to person, place, and time. TESTS ADMINISTERED AND TASKS COMPLETED: Diagnostic interview, review of medical records, Minnesota Multiphasic Personality Inventory - Adolescent (MMPI-A), Rorschach inkblot test, Children's Depression Inventory (CDI), and Revised Children's Manifest Anxiety Scale (RCMAS). TEST RESULTS: The MMPI-A was responded to in a highly defensive manner, to the point where the profile is neither valid nor interpretable.
CDI|Children's Depression Inventory|CDI|173|175|TEST RESULTS|They are likely immature individuals who have a difficult time coping with the various stressors in their lives. As a result they may be easily influenced by others. 3. The CDI results did not result in any clinically significant level of depressive symptoms. 4. The RCMAS also did not result in any clinically significant level for anxiety symptoms.
CDI|Children's Depression Inventory|CDI|157|159|TEST RESULTS|They also have significant difficulty developing secure relationships with others. At times, they may be seen as somewhat impulsive emotionally as well. The CDI resulted in clinically significant levels for ineffectiveness and negative self-esteem. There was also a mildly clinically significant level for negative mood.
CDI|Children's Depression Inventory|CDI|189|191|PSYCHOLOGICAL/PERSONALITY FUNCTIONING|PSYCHOLOGICAL/PERSONALITY FUNCTIONING: _%#NAME#%_ completed several self report measures to assess for symptoms of depression, anxiety, as well as personality development. Results from the CDI reflected a force within the average to below average range for age. These results suggest that _%#NAME#%_ views herself as experiencing less symptoms of depression than other adolescent girls approximately her age.
CDI|Children's Depression Inventory|CDI|263|265|PSYCHOLOGICAL/PERSONALITY FUNCTIONING|These results suggest that _%#NAME#%_ views herself as experiencing less symptoms of depression than other adolescent girls approximately her age. However, it is important to note that _%#NAME#%_'s affect and behavior were not congruent with her responses on the CDI and it is likely that she minimize her symptoms of depression. _%#NAME#%_ did endorse items indicating that she did not like herself, had fun in school only once in awhile, and had some friends, but wished she had more.
CDI|Children's Depression Inventory|CDI|187|189|SUMMARY/CLINICAL IMPRESSION|Results from other testing reflected a tendency for _%#NAME#%_ to deny and/or minimize negative feelings, as evidenced by invalid results from the MMPI-A, and extremely low scores on the CDI and RCMAS. It is possible as well that _%#NAME#%_'s borderline intellectual functioning contributes to her tendency to minimize negative feelings due to lower insight about her feelings.
CDI|Children's Depression Inventory|(CDI),|315|320|EMOTIONAL, SOCIAL, AND BEHAVIORAL FUNCTIONING|EMOTIONAL, SOCIAL, AND BEHAVIORAL FUNCTIONING: _%#NAME#%_'s functioning in these areas was assessed using several self-report measures, a projective measure entitled the Roberts Apperception Test for Children (RATC), a sentence completion task, and a clinical interview. Results from the Child Depression Inventory (CDI), which is a self-report measure designed to assess for symptoms of depression in children and adolescents, reflected an overall score within the borderline range.
CDI|Children's Depression Inventory|(CDI),|485|490|TESTS ADMINISTERED|_%#NAME#%_ reported that his mother was a t eenager when he was born. TESTS ADMINISTERED: Wechsler Intelligence Scale for Children - Fourth Edition (WISC-IV), Wechsler Individual Achievement Test - Second Edition (WAIT-II)selected subtests, The Trail Making Test, parts A and B, Controlled Word Association Test (CWAT), The Connor's Continuous Performance Test - Second Edition (CPT II), , Wisconsin Card Sorting Test (WCST), Rey Complex Figure Test (RCFT), Child Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS), Sentence Completion Test (SCT), clinical interview, parent interview and review of previous hospital records.
CDI|Children's Depression Inventory|CDI,|182|185|PSYCHOLOGICAL FUNCTIONING|PSYCHOLOGICAL FUNCTIONING: _%#NAME#%_'s psychological functioning was assessed using self-rating scales, a sentence completion test (SCT), and a clinical interview. Results from the CDI, which is a rating scale designed to assess for symptoms of depression in younger people, reflect an overall score within the clinically significant range.
CDI|Children's Depression Inventory|(CDI),|452|457|TESTS ADMINISTERED AND TASK COMPLETED|He still has some fleeting suicidal ideation. There is no evidence of hallucinations, delusions, paranoid ideation, grossly inappropriate affect or other frank manifestation of psychotic disorder. He was oriented to person, place, and time. TESTS ADMINISTERED AND TASK COMPLETED: Diagnostic interview, review of medical record, consultation with staff, Minnesota Multiphasic Inventory (MMPI-A), Rorschach Ink Blot Test, Children's Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS). TEST RESULTS: The MMPI-A was responded to in an open and honest manner and the profile is valid and interpretable.
CDI|Children's Depression Inventory|CDI|124|126|TEST RESULTS|Their relationships with others, at times, may be somewhat superficial and less secure, than they truly think they are. The CDI resulted in clinically significant levels for negative mood and negative self-esteem. Items of interest include, "I want to kill myself...All bad things are my fault...I do not like myself...I feel alone many times." The RCMAS resulted in clinically significant level for worry/over-sensitivity and social concerns/concentration.
CDI|Children's Depression Inventory|CDI|234|236|TEST RESULTS|Individuals with protocol similar to hers tend to not be forthcoming about the various stressors in their lives and may be concerned about being evaluated. As a result, no further interpretation will be completed at this time. 3. The CDI resulted in clinically significant level for ineffectiveness. Items of interest include "many things are my fault," "I do many things wrong," "I feel alone at many times," and "I do very badly in subjects I used to be good in."
CDI|Children's Depression Inventory|CDI|80|82|TEST RESULTS|In addition, these individuals may have immature relationships with others. The CDI was suggestive of an individual who scored at a clinically significant level for interpersonal problems, ineffectiveness, and negative self-esteem.
CDI|Children's Depression Inventory|CDI|207|209|SOCIAL/EMOTIONAL AND BEHAVIORAL FUNCTIONING|SOCIAL/EMOTIONAL AND BEHAVIORAL FUNCTIONING: _%#NAME#%_'s social, emotional and behavioral functioning were assessed using self-rating scales, a projective measure and a clinical interview. Results from the CDI reflected overall score within the average range, indicating that _%#NAME#%_ did not endorse a higher than typical number of items associated with depression for age and gender.
CDI|Children's Depression Inventory|CDI|184|186|TEST RESULTS|Items of interest include, "I don't have enough energy to do anything," "I have trouble making any decisions," "I feel like crying, but I can't," "I would like to kill myself." 4. The CDI was administered 5 days later, which resulted in clinically significant level for ineffectiveness and negative mood. Items of interest include, "I have trouble sleeping many nights," "I am tired many days," "I feel like crying many days." At this point, she stated, "I think about killing myself, but I would not do it."
CDI|Children's Depression Inventory|CDI|131|133|TEST RESULTS|At times, they may be emotionally expressive. Based on this profile, there is little to no concern about psychotic processing. The CDI resulted in a significant level for interpersonal problems. He scored at a clinically significant level for ineffectiveness and anhedonia.
CDI|Children's Depression Inventory|(CDI),|501|506|TESTS ADMINISTERED|In consulting with hospital staff who have communicated with the family, the family has also expressed concern about _%#NAME#%_'s heightened activity level and difficulty focusing for quite some time. TESTS ADMINISTERED: Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV), The Trail-Making Test Part A and B, Verbal Fluency Test, The Lafayette Grooved Pegboard Test, the Berry Buktenica Developmental Test of Visual Motor Integration (Berry VMI)-5th Edition, Child Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS), Sentence Completion Tests (SCT), Robert's Apperception Test for Children (RATC), and clinical interview.
CDI|Children's Depression Inventory|CDI,|269|272|SOCIAL, EMOTIONAL AND BEHAVIORAL FUNCTIONING|SOCIAL, EMOTIONAL AND BEHAVIORAL FUNCTIONING: _%#NAME#%_'s functioning in these areas was assessed using several self-rating scales (in which the evaluator helped him), a sentence completion test, a projective measure and a clinical interview. _%#NAME#%_ was given the CDI, which is a self-rating scale designed to assess symptoms of depression in children and adolescents. He obtained an overall score within the clinically significant range.
CDI|Children's Depression Inventory|(CDI)|483|487|TESTS ADMINISTERED|TESTS ADMINISTERED: Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV) Wechsler Individual Achievement Test - Second Edition (WIAT-II) Selective subtests, Wide Range Assessment of Memory and Learning - Second Edition (WRAML-II). Selective subtests, Rey Complex Figure Test (RCFT) Trail-Making Tests, parts A and B Verbal fluency test, Sentence Completion tests (SCT) Minnesota Multiphasic Personality Inventory - Adolescent Version (MMPI-A) Child Depression Inventory (CDI) Revised Children's Manifest Anxiety Scale (RCMAS) Clinical interview BEHAVIORAL OBSERVATIONS: _%#NAME#%_ presented to the assessment appearing casually and appropriately dressed.
CDI|Children's Depression Inventory|(CDI,|178|182|PSYCHOLOGICAL FUNCTIONING|PSYCHOLOGICAL FUNCTIONING: _%#NAME#%_'s psychological functioning was assessed using a Sentence C ompletion test, the MMPI-A, a clinical interview and several self-rating scales (CDI, RCMAS). Results from the SCT indicate that _%#NAME#%_ places a significant amount of importance on her performance in swimming, yet feels overwhelmed and pressured by the competitive aspects of this sport.
CDI|Children's Depression Inventory|CDI|154|156|PSYCHOLOGICAL FUNCTIONING|As such, results indicate that _%#NAME#%_ is endorsing items indicating that her energy level is higher than typical for age and gender. Results from the CDI reflect clinically significant elevations on subscales measuring overall symptoms of depression, as well as negative mood, feelings of ineffectiveness, anhedonia, and negative self-esteem.
CDI|Children's Depression Inventory|(CDI)|500|504|TESTS ADMINISTERED AND TASKS COMPLETED|No evidence of hallucinations, delusions, (although more information is necessary concerning the contact that he may or may not have had with his biological mother), paranoid ideation, grossly inappropriate affect, or other frank manifestation of psychotic disorder. He is oriented to person, place, and time. TESTS ADMINISTERED AND TASKS COMPLETED: Diagnostic interview, review of medical records, Millon Adolescent Clinical Inventory (MACI), Rorschach Inkblot Test, Children's Depression Inventory (CDI) Revised Children Manifest Anxiety Scale (RCMAS). TEST RESULTS: The MACI was responded to in an open and honest manner and the profile was valid and interpretable.
CDI|Children's Depression Inventory|CDI|228|230|TEST RESULTS|These individuals also tend to be somewhat emotionally impulsive. Overall though these individuals do desire close relationships with others. There may be a tendency for these individuals to have immature coping mechanisms. The CDI resulted in mildly clinically significant level for negative mood. Items of interest include "I think about killing myself, but I would not do it," "I am sad many times," "I am not sure if anybody loves me." The RCMAS resulted in mildly clinically significant level for worry/oversensitivity.
CDI|Children's Depression Inventory|CDI.|212|215|PAST MEDICAL HISTORY|Outpatient evaluation pending the evening of _%#MMDD2006#%_. Clinical correlation with nocturnal snoring. 4. Chronic lumbar pain with apparent documented disk hernia and bone spurs on lumbar MRI performed at the CDI. Pain into the right buttock. Aggravated by a period of decreased activity, i.e. sleeping. No lower extremity weakness or paresthesias. PRN sulindac for discomfort.
CDI|Children's Depression Inventory|CDI|99|101|TEST RESULTS|These individuals tend to have difficulty developing secure relationships with others as well. The CDI suggested a clinically significant level for ineffectiveness and negative self esteem. Items of interest include, "I want to kill myself," although he did note that he was wavering between the items "I think about killing myself but I would not do it" and "I want to kill myself." Although he has had recent suicidal ideation, as stated earlier, he does not have any plan to do so.
CDI|Children's Depression Inventory|(CDI)|294|298|CURRENT TESTS ADMINISTERED|Recommendations for individual and family therapy were also made. CURRENT TESTS ADMINISTERED: Wechsler Intelligence Scale for Children-IV edition (WISC-IV) Rey-Osterrieth Complex Figure Test Trails A and B Controlled Oral Word Association Test (verbal fluency test). Child Depression Inventory (CDI) Revised Children's Manifest Anxiety Scale (RCMAS) Incomplete Sentences Clinical Interview. BEHAVIORAL OBSERVATIONS: Initially upon greeting the examiner, _%#NAME#%_ engaged in very minimal eye contact and spoke in a slow, relatively monotone, soft voice.
CDI|Children's Depression Inventory|(CDI),|149|154|TESTING RESULTS|_%#NAME#%_'s emotional, social, and behavioral functioning were also assessed as part of the evaluation. Results from the Child Depression Inventory (CDI), a self-report measure designed to assess symptoms of depression in children in adolescents reflected significantly elevated scores on all subscales.
CDI|Children's Depression Inventory|(CDI),|506|511|TESTS ADMINISTERED|TESTS ADMINISTERED: Wechsler Individual Achievement Test-Second Edition (WIAT-II), Selected subtests Controlled Oral Word Association Test (COWAT), Connors Continuous Performance Test-Second Edition (CPT-II), the Trail Making Test, Wide Range Assessment of Memory and Learning-Second Edition (WRAML-II), selected subtests Vineland Adaptive Behavior Scales (VABS)-interview edition, Parent Interview, Roberts Apperception Test for Children (RATC). Sentence Completion Test (SCT), Child Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS), Clinical Interview. BEHAVIORAL OBSERVATIONS: _%#NAME#%_ was evaluated over 2 separate testing sessions at Fairview's Partial Plus Outpatient Unit.
CDI|Children's Depression Inventory|(CDI,|638|642|PSYCHOLOGICAL FUNCTIONING|Standard scores between 90-109 are considered average. His performance is as follows: Domain Standard Score % Age equivalent Communication 47 less 1% 6 years, 6 months Daily living skills 51 less 1% 7 years, 2 months Socialization 49 less 1% 4 years, 11 months Adaptive behavior composite 46 less 1% 6 years, 2 months Overall, results reflect well below average adaptive functioning skills across all tested domains, suggesting that in general, _%#NAME#%_ is functioning in his day-to-day life similarly to an early 6-year-old child. PSYCHOLOGICAL FUNCTIONING: _%#NAME#%_'s psychological functioning was assessed using self-report scales (CDI, RCMAS), a sentence completion test (SCT) and a projective measure (RATC). _%#NAME#%_ completed the CDI, which is a self-rating scale designed to assess for symptoms of depression in young people.
CDI|Children's Depression Inventory|CDI,|209|212|PSYCHOLOGICAL FUNCTIONING|PSYCHOLOGICAL FUNCTIONING: _%#NAME#%_'s psychological functioning was assessed using self-report scales (CDI, RCMAS), a sentence completion test (SCT) and a projective measure (RATC). _%#NAME#%_ completed the CDI, which is a self-rating scale designed to assess for symptoms of depression in young people. He obtained an overall score within the average range, suggesting that _%#NAME#%_ did not endorse a higher than typical number of items associated with depression for his age.
CDI|Children's Depression Inventory|CDI|161|163|TEST RESULTS|These individuals also likely have superficial relationships with others and may have a difficult time maintaining relationships over a long period of time. The CDI was administered on _%#MMDD2005#%_. He did not rate himself at a clinically significant level for negative mood, interpersonal problems, ineffectiveness, anhedonia, and negative self-esteem.
CDI|Children's Depression Inventory|(CDI),|401|406|TESTS ADMINISTERED/TASKS COMPLETED|There is no evidence of hallucinations, delusions, paranoid ideation, grossly inappropriate affect, or other frank manifestation of psychotic disorder. He was oriented to person, place, and time. TESTS ADMINISTERED/TASKS COMPLETED: Diagnostic interview, review of medical record, Minnesota Multiphasic Personality Inventory - Adolescent (MMPI-A), Rorschach Inkblot Test, Children Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS). TEST RESULTS: The MMPI-A was responded to in an open and honest manner and the profile is valid and interpretable.
CDI|Children's Depression Inventory|CDI|114|116|TEST RESULTS|Based on this profile though, there is little to no indication of significant anxiety or depressive symptoms. The CDI resulted in mildly clinically significant levels for negative mood and anhedonia. Items of interest include "I think about killing myself, but I would not do it, I am sad many times, I do not like myself, and "there is some bad things about my looks." The RCMAS did not result in a clinically significant level for anxiety-related symptoms.
CDI|Children's Depression Inventory|(CDI),|431|436|TEST ADMINISTERED AND TEST COMPLETED|There is no evidence of hallucinations, delusions, paranoid ideation, grossly inappropriate affect, or other frank manifestation of psychotic disorder. She was oriented to person, place, and time. TEST ADMINISTERED AND TEST COMPLETED: Diagnostic interview, Minnesota Multiphasic Personality Inventory - Adolescent (MMPI-A), Rorschach Inkblot Test, Revised Children's Manifest Anxiety Scale (RCMAS), Children's Depression Inventory (CDI), review of medical record, and consultation with staff. TEST RESULTS: After consultation with Dr. _%#NAME#%_ and _%#NAME#%_, the therapist on 3C, it was apparent that this patient's behavior was likely significantly different from when she was admitted to the adolescent mental health unit both times in _%#MM#%_ of this year.
CDI|Children's Depression Inventory|CDI|328|330|TEST RESULTS|In fact, she scored a clinically significant level for total anxiety, worry, oversensitivity, and social concerns. Items of interest include "I get nervous when things do not go the right way for me, I worry about what is going to happen, my feelings get hurt easily when I am fussed at, I wake up scared some of the time." The CDI resulted in clinically significant level for ineffectiveness as well as mildly clinically significant levels for interpersonal problems and anhedonia.
CDI|Children's Depression Inventory|CDI|134|136|TEST RESULTS|The relationships also tend to be superficial, although they may feel that the relationships are more secure than they truly are. The CDI resulted in mildly clinically significant level for anhedonia. Items of interest include, "I think about killing myself but I would not do it," "I don't like myself" and "I'm not sure if anybody loves me." The RCMAS resulted in clinically significant levels for total anxiety, physiological anxiety, worry/oversensitivity, and social concerns.
CDI|Children's Depression Inventory|(CDI),|245|250|BEHAVIORAL OBSERVATIONS|EMOTIONAL, SOCIAL, AND BEHAVIORAL FUNCTIONING: _%#NAME#%_'s emotional, social and behavioral functioning was assessed using several self-report measures, a projected measure, and a clinical interview. Results from the Child Depression Inventory (CDI), which is a self-report measure designed to assess for symptoms of depression in children, reflected an overall score within the clinically significant range.
CDI|Children's Depression Inventory|CDI|221|223|BEHAVIORAL OBSERVATIONS|These results indicate that _%#NAME#%_ endorsed a higher than typical number of items associated with depression and growth approximately her age. She also obtained clinically significant elevations on subskills from the CDI indexing negative mood, interpersonal problems, feelings of ineffectiveness, and negative self-esteem. Results from the Revised Children's Manifest Anxiety Scale (RCMAS), which is a self-report measure designed to assess for symptoms of anxiety in children, reflected an overall score within the borderline "at risk" range.
CDI|Children's Depression Inventory|CDI,|257|260|BACKGROUND AND REFERRAL INFORMATION|Overall, due to _%#NAME#%_'s cooperative nature throughout testing, it is felt that the current results are generally accurate reflection of her functioning at this time. TEST RESULTS: _%#NAME#%_ obtained an overall score within the borderline range on the CDI, reflecting "at risk" level of depressive symptoms and comparison to other females approximately her age. Results suggest that _%#NAME#%_ endorsed a higher than typical level of symptoms of depression in comparison to other females her age.
CDI|Children's Depression Inventory|CDI|152|154|BACKGROUND AND REFERRAL INFORMATION|Results suggest that _%#NAME#%_ endorsed a higher than typical level of symptoms of depression in comparison to other females her age. Results from the CDI also reflected a clinically significant elevation on subscale indexing interpersonal problems and negative self-esteem. Result from the (RCMAS), which is the self-report measure designed to assess for symptoms of anxiety in children, also reflected in overall score within the borderline "at risk" range.
CDI|Children's Depression Inventory|(CDI),|411|416|TESTS ADMINISTERED|Please review hospital records for more specific information regarding his background history. TESTS ADMINISTERED: Wechsler Intelligence Scale for Children - Fourth Edition (WISC-IV), Wechsler Individual Achievement Test - Second Edition (selected subtests), Beery Visual Motor Integration Test (Beery, VMI), Rey Complex Figure Test (RCFT), Rey Auditory Verbal Learning Test (RAFLT), Child Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS), Roberts Apperception Test for Children (RATC), Minnesota Multiphasic Personality Inventory - Adolescent Version (MMPI-A), Sentence Completion Test (SCT), and clinical interview.
CDI|Children's Depression Inventory|CDI|231|233|RESULTS|Psychological Functioning - _%#NAME#%_'s psychological functioning was assessed using self-report rating skills, a personality inventory, a sentence completion test, a projective measure, and a clinical interview. Results from the CDI reflected an overall score within the clinically significant range. Clinically significant elevations were also evident on subscales from the CDI indexing negative mood, interpersonal problems, anhedonia, and negative self-esteem.
CDI|Children's Depression Inventory|(CDI),|588|593|TESTS ADMINISTERED|Medications as of _%#MMDD#%_ included Risperdal and Zoloft. He had been followed outpatient by psychiatrist, Dr. _%#NAME#%_ _%#NAME#%_. TESTS ADMINISTERED: Wechsler Intelligent Scale for Children - fourth edition (WISC-IV), Connors Computerized Performance Test - second edition (CPT-II), attempted, yet patient would not complete the Trail Making Test, Verbal Fluency, Wisconsin Card Sorting Test (WCST), Rey Complex Figure Test (RCFT), Lafette Grooved Pegboard Test, Berry Bukpenika Developmental Test of Visual-Motor Integration (Berry VMI - fifth edition), Child Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS), Sentence Completion Test (SCT) and clinical interview. BEHAVIORAL OBSERVATIONS: _%#NAME#%_ was evaluated 1 day at the Adolescent Day Treatment Unit at Fairview.
CDI|Children's Depression Inventory|CDI,|202|205|PSYCHOLOGICAL FUNCTIONING|PSYCHOLOGICAL FUNCTIONING: _%#NAME#%_'s psychological functioning was assessed using self-rating scale, a sentence completion test (SCT), a projective measure and a clinical interview. He completed the CDI, which is a self-rating scale designed to assess a young person's level of depression. _%#NAME#%_ obtained an overall score within the average range, indicating that he did not endorse a higher than typical number of items associated with depression for his age and gender.
CDI|Children's Depression Inventory|(CDI),|296|301|TESTS ADMINISTERED|More information regarding _%#NAME#%_'s history was not available at the time of this assessment, as his psychiatrist's dictation was not yet available in his file. TESTS ADMINISTERED: Wechsler Intelligent Scale for Children - 4th Edition (WISC-IV), selected subtests, Child Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS), Roberts Apperception Test for Children (RATC), Sentence Completion Test, and clinical interview.
CDI|Children's Depression Inventory|CDI,|278|281|TEST RESULTS|Notable items endorsed by _%#NAME#%_ include: I have trouble sleeping every night, I am tired all the time, I never have fun at school, things bother me all the time, I feel alone all the time, and aches and pains bother me all the time. Overall, in reviewing results from this CDI, _%#NAME#%_'s scores indicate that he is experiencing a significantly higher level of depressive symptoms than the majority of other boys his age.
CDI|Children's Depression Inventory|CDI.|417|420|SUMMARY AND CLINICAL IMPRESSION|A review of test results in conjunction with _%#NAME#%_'s previous history, indicate that he in fact still exhibits a number of attention-deficit hyperactivity disorder characteristics, symptoms of depression and anxiety, and symptoms which are consistent with auditory and visual hallucinations. _%#NAME#%_ endorsed many symptoms of anxiety on the RCMAS and many symptoms of depression (especially anhedonia) on the CDI. His affect was also extremely restricted in range throughout the evaluation. _%#NAME#%_ described poor peer relationships despite a desire to make more friends and a significant amount of loss and grief associated with separating from his mother.
CDI|Children's Depression Inventory|(CDI),|415|420|TESTS ADMINISTERED AND TASKS COMPLETED|There is no evidence of current hallucinations, delusions, paranoid ideation, grossly in appropriate affect, or other frank manifestation of psychotic disorder. He is oriented to person, place, and time. TESTS ADMINISTERED AND TASKS COMPLETED: Diagnostic interview, review of medical record, Minnesota Multiphasic Personality Inventory - Adolescent (MMPI-A), Rorschach Inkblot Test, Children's Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS). TEST RESULTS: The MMPI-A was responded to in a cautious manner.
CDI|Children's Depression Inventory|CDI|77|79|TEST RESULTS|Overall though there is little to no indication of psychotic processing. The CDI resulted in a mildly clinically significantly level for ineffectiveness. Items of interest include "I think about killing myself, but I would not do it." "I do not like myself." "I am sad many times." "I do many things wrong." The RCMAS did not result in any clinically significant level for anxiety symptoms.
CDI|Children's Depression Inventory|CDI|105|107|TEST RESULTS|Sometimes, these individuals may not have a good understanding of the consequences of their actions. Her CDI resulted in clinically significant levels for negative mood, interpersonal problems, ineffectiveness, and negative self-esteem. Items of interest include, "I think about killing myself, but I would not do it." "I am sad all the time." "Most days, I do not feel like eating." "I look ugly." The Sentence Complete Test items of interest include, "I hope I'll never die alone." "People think I am crazy and hyper." "I can't understand why I can't be happy.
CDI|Children's Depression Inventory|CDI|198|200|EMOTIONAL, SOCIAL AND BEHAVIORAL FUNCTIONING|Results indicate that _%#NAME#%_ is not endorsing a clinically significant number of depressive symptoms in comparison to other adolescent boys approximately his age. None of the subscales from the CDI were elevated either. Results from the RCMAS also reflected an overall score within the average range, indicating that _%#NAME#%_ did not endorse a clinically significant number of symptoms of anxiety in comparison to other adolescent boys approximately his age.
CDI|Children's Depression Inventory|CDI,|237|240|TEST RESULTS|SOCIAL, EMOTIONAL, AND BEHAVIORAL FUNCTIONING: _%#NAME#%_'s social, emotional, and behavioral functioning was assessed using self-rating scales, a Sentence Completion Test, a projective measure and a clinical interview. Results from the CDI, which is a self-rating scale designed to assess symptoms of depression in children and adolescents, reflected an overall score within the solidly average range.
CDI|Children's Depression Inventory|CDI|182|184|TEST RESULTS|Results indicated that _%#NAME#%_ does not view herself as having a higher level of depressive symptoms than the majority of other adolescents her age. Results for sub-scales of the CDI were also within the average range. _%#NAME#%_ did endorse items indicating that she thinks about killing herself, but would not do it, feels many bad things are her fault, and worries bad things will happen to her.
CDI|Children's Depression Inventory|CDI,|240|243|PSYCHOLOGICAL FUNCTIONING|PSYCHOLOGICAL FUNCTIONING: _%#NAME#%_'s psychological functioning was assessed using self-rating scale, a sentence completion test (SCT), a projective measure (RATC) and a clinical interview. Results from a self-report measure entitled the CDI, reflected an overall score within the average range. As such, results indicate that _%#NAME#%_ did not endorse a higher than typical number of items associated with depression for an individual his age and gender.
CDI|Children's Depression Inventory|(CDI)|214|218|TEST RESULTS|_%#NAME#%_ had less difficulty completing questionnaires in which the examiner helped him by reading the different types of responses he could choose. He obtained an overall score on the Child Depression Inventory (CDI) within the highly significant range (T = 84), reflecting a number of symptoms of depression in comparison to other boys his age.
CDI|Children's Depression Inventory|CDI|62|64|TEST RESULTS|There is no evidence of psychosis based on this protocol. The CDI was suggestive of clinically significant level for negative mood, interpersonal problems and effectiveness and negative self esteem. Items of interest include "I think about killing myself but I would not do it," "I do not like myself and I feel alone many times." The RCMAS resulted in highly clinically significant levels for worry/over sensitivity, social concerns and total anxiety.
CDI|Children's Depression Inventory|(CDI)|163|167|TESTS ADMINISTERED THIS EVALUATION|4. Wide Range Assessment of Memory and Learning (WRAML), selected subtests a. Revised Children's Manifest Anxiety Scale (RCMAS) b. Children's Depression Inventory (CDI) c. Robert Apperception Test (RAT) d. Incomplete Sentences e. Clinical Interview BEHAVIORAL OBSERVATIONS: _%#NAME#%_ was brought to the examiner's testing room on the day treatment floor and was compliant and cooperative throughout the assessment.
CDI|Children's Depression Inventory|CDI|435|437|TEST RESULTS|Results from the Grooved Peg Test, in which _%#NAME#%_'s fine motor abilities with her dominant and nondominant hands, were assessed and were within the solidly average range. In order to assess _%#NAME#%_'s social, emotional, and behavioral functioning, she was administered several projective measures (the Robert Apperception Test and Incomplete Sentences), several self-report tests (the RCMAS which is an anxiety measure, and the CDI which is a measure of depressive symptoms in children), and a clinical interview. The results from the Robert Apperception Test reflected stories with a detached quality, in which _%#NAME#%_ often referred to parental figures, especially father figures, in a detached tone, using words such as "the guy in the story," as opposed to talking about him as a fatherly figure.
CDI|Children's Depression Inventory|CDI,|178|181|SELF-RATING SCALES|Due to _%#NAME#%_'s cooperative nature during testing, results appear to be an accurate reflection of his current psychological functioning. SELF-RATING SCALES: Results from the CDI, which is a self-rating measure designed to assess symptoms of depression in children and adolescents, reflected an overall score within the upper average range, indicating that _%#NAME#%_ is experiencing more symptoms of depression than his peers, yet that his symptoms are not considered within the clinically significant range.
CDI|Children's Depression Inventory|(CDI),|535|540|TESTS ADMINISTERED|_%#NAME#%_ has had an atypical response to traditional ADHD medications such as Adderall. TESTS ADMINISTERED: Wechsler Intelligence Scale For Children-IV Edition (WISC-IV), Wechsler Individual Achievement Test-II Edition (WIAT-II), selected subtests, Trail Making Test Part A and B, Verbal Fluency Test, Wide Range Assessment of Memory and Learning-II Edition (WRAML-II), selected subtests, Lafayette Grooved Pegboard Test, Beery-Buktinica Developmental Test of Visuomotor Integration (Berry VMI-V Edition), Child Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS), and clinical interview. BEHAVIORAL OBSERVATIONS: _%#NAME#%_ presented to each day of the evaluation appearing casually and neatly dressed and well groomed.
CDI|Children's Depression Inventory|CDI,|231|234|PSYCHOLOGICAL FUNCTIONING|Social, emotional, and behavioral functioning: _%#NAME#%_'s social, emotional and behavioral functioning were assessed using self-rating scales, a projective measure, and a non-standardized child-based assessment. Results from the CDI, which is a self-rating scale designed to assess for symptoms of depression in children, reflect a clinically significant level of depression in comparison to other boys _%#NAME#%_'s age.
CDI|Children's Depression Inventory|CDI|217|219|TEST RESULTS|In addition, they tend to have superficial relationships with others even though they may feel that their relationships are more secure than they truly are. They tend to be self-consumed and emotionally immature. The CDI resulted in mildly clinically significant levels for negative mood and negative self-esteem. Items of interest include "I think about killing myself, but I would not do it," "I do not like myself," "There are some bad things about my looks.
CDI|Children's Depression Inventory|CDI,|140|143|TEST RESULTS|Overall, results are felt to be an accurate estimate of _%#NAME#%_'s psychological functioning at this time. TEST RESULTS: Results from the CDI, which is a self-report measure designed for children and adolescents ages 7 to 11, reflected an overall score within the average range.
CDI|Children's Depression Inventory|(CDI,|292|296|TEST RESULTS|He earned a below average score on the recall trial of the Rey Complex Figure Test after a 30 minute delay, which was likely associated with organizational weaknesses, as opposed to a true visual memory weakness. _%#NAME#%_'s psychological functioning was assessed using self-report measures (CDI, RCMAS), a personality inventory (MMPI-A), a projective measure (TAT), and a clinical interview. Results from the CDI indicate that _%#NAME#%_ did not endorse a clinically significant level of depressive symptoms in comparison to other boys his age.
CDI|Children's Depression Inventory|CDI|89|91|TEST RESULTS|The immature responses may also be evident of lower verbal intellectual functioning. The CDI and the RCMAS did not result in clinically significant levels for depressive or anxiety symptoms, respectively. Due to the high phase validity of these inventories, though, this should not completely rule out depressive or anxiety disorder.
CDI|Children's Depression Inventory|(CDI),|386|391|MENTAL STATUS EXAMINATION|There is no evidence of hallucinations, delusions, paranoid ideation, grossly inappropriate affect or other frank manifestation of psychotic disorder. He was oriented to person, place and time. Tests administered, tasks completed, diagnostic interview and review of medical record, Minnesota Multiphasic Personality Inventory-A, Rorschach Ink Blot Test, Children's Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS). TEST RESULTS: The MMPI-A was responded to in an open and honest matter, and the profile was valid and interpretable.
CDI|Children's Depression Inventory|CDI|125|127|TEST RESULTS|Their defenses appear to be somewhat immature, and they may have difficulty developing severe relationships with others. The CDI resulted in _________________ significant levels for __________________. Items of interest include "I think about killing myself, but I would not do it," "I look ugly," "I never have fun at school." The RCMAS resulted in clinically significant levels for total anxiety, worry/oversensitivity and social concerns/concentration.
CDI|Children's Depression Inventory|CDI|61|63|TEST RESULTS|He also has difficulty responding to school-based items. His CDI resulted in clinically significant levels for interpersonal problems. Items of interest, include "many bad things are my fault." "I get into fights many times." "I do not do what I am told most times." SUMMARY OF CURRENT FINDINGS: This is a 17-year-old Caucasian male who was admitted to the Subacute Diagnostic unit at the University of Minnesota Medical Center - Fairview under the care of _%#NAME#%_ _%#NAME#%_, MD, due to angry outbursts and anger management problems.
CDI|Children's Depression Inventory|(CDI),|255|260|DEMOGRAPHIC AND BACKGROUND INFORMATION|He was oriented to person, place, and time. TESTS ADMINISTERED AND TASKS COMPLETED: Diagnostic interview, review of medical record, Minnesota Multiphasic Personality Inventory - Adolescent (MMPI-A), Rorschach ink blot test, Childrens Depression Inventory (CDI), Revised Children Manifest Anxiety Scale (RCMAS). TEST RESULTS: MMPI-A was responded to in an open and honest manner, and the profile was valid and interpretable.
CDI|Children's Depression Inventory|CDI|157|159|DEMOGRAPHIC AND BACKGROUND INFORMATION|They may feel as if they are being criticized and, as a result, this protocol is likely not representative of his overall personality functioning level. His CDI resulted in an (_______________) significant level for negative mood, as well as anhedonia and negative self-esteem. Items of interest include "being sad all the time," "I hate myself," and "I never have fun at school." He also noted, "I feel (_______________) many times." The RCMAS resulted in clinic with significant level for worry/ultrasensitivity and social concerns.
CDI|Children's Depression Inventory|(CDI),|632|637|TESTS ADMINISTERED|_%#NAME#%_ has apparently engaged in some sexual behaviors, such as taking off clothing and touching her genital area to her younger brother, yet more specific information about these behaviors is unknown to the evaluator. TESTS ADMINISTERED: Wechsler Intelligence Scale for Children-4th addition (WISC-IV), Wechsler Individual Achievement Test-2nd addition (WIAT-II), Selected Sub Test, The Trail Making Tests, parts A and B, Verbal Fluency Test, Wide Range Assessment of Memory and Learning-2nd addition (WRAML-2), Selected Sub Test, The Beery-Buktinica Motor Integration Test (Beery BMI),5th addition, Child Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMS), Robert's Apperception Test for Children (RATC) and Clinical Interview. BEHAVIOR OBSERVATIONS: _%#NAME#%_ presented to the evaluation on each occasion appearing neatly and casually dressed.
CDI|Children's Depression Inventory|CDI,|215|218|SOCIAL, EMOTIONAL AND BEHAVIORAL FUNCTIONING|SOCIAL, EMOTIONAL AND BEHAVIORAL FUNCTIONING: _%#NAME#%_'s social, emotional and behavioral functioning were assessed using self rating scales, a projective measure in a clinical interview. _%#NAME#%_ completed the CDI, which is a self rating scale designed to assess a child's level of depression in comparison to peers. Results reflected an average score, indicating that she did not endorse a higher than typical level of depressive symptoms for her age and gender.
CDI|Children's Depression Inventory|CDI|210|212|EMOTIONAL, SOCIAL, AND BEHAVIORAL FUNCTIONING|EMOTIONAL, SOCIAL, AND BEHAVIORAL FUNCTIONING: _%#NAME#%_'s emotional, social, and behavioral functioning was assessed using self-report measures, a projective measure on a clinical interview. Results from the CDI reflected an overall score within the average range. Results indicate that Vincent did not endorse a higher than typical number of items associated with depression for age and gender.
CDI|Children's Depression Inventory|(CDI),|679|684|TESTS ADMINISTERED|In fact, his play was described by his mother as quite imaginative and wide in range in terms of interests. TESTS ADMINISTERED: Wechsler Intelligence Scale for Children- Fourth Edition (WISC-IV), Wechsler Individual Achievement Test- Second Edition (WIAT-II), Selected Subtests, Wide Range Assessment of Memory and Learning-2 (WRAML-2), Selected Subtests, Rey Complex Figure Test (RCFT), Beery Butenica Developmental Test of Visuomotor Integration (Berry VMI, Fifth Edition, the Lafayette Grooved Pegboard Test, Trail Making Tests, Parts A and B, Verbal Fluency Test, The Robert's Apperception Test for Children (RATC), Sentence Completion Task (SCT), Child Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS), Clinical interview, parent interview and review of hospital and other medical records. BEHAVIORAL OBSERVATIONS: _%#NAME#%_ presented to the evaluation as a mildly overweight male who appeared casually dressed, neatly groomed and approximately his age.
CDI|Children's Depression Inventory|(CDI,|277|281|SOCIAL, EMOTIONAL AND BEHAVIORAL FUNCTIONING|It is important to note that _%#NAME#%_ rushed through this task, which could have negatively impacted his performance. SOCIAL, EMOTIONAL AND BEHAVIORAL FUNCTIONING: _%#NAME#%_'s functioning across these areas was assessed using a projective measure (RATC), self-rating scales (CDI, RCMAS), a Sentence Completion Test (SCT) and a clinical interview. Results from the RATC indicated that _%#NAME#%_ does struggle to pick up on some social and interpersonal cues more than typical for age.
CDI|Children's Depression Inventory|CDI|305|307|SOCIAL, EMOTIONAL AND BEHAVIORAL FUNCTIONING|For example, _%#NAME#%_ completed the sentence beginning with, I wish my father, by stating "died." He completed another sentence beginning with, to me homework, by stating "sucks." Irritability regarding poor grades in school and family stress were also evident themes in his responses. Results from the CDI were consistent with a clinically significant elevation for his overall score. As such, results indicate that _%#NAME#%_ endorsed a higher than typical number of items associated with depression compared to other males his age.
CDI|clean, dry, intact|CDI,|229|232|PHYSICAL EXAMINATION|99% on room air. HEENT: The patient wears glasses. HEENT within normal limits. LUNGS: Clear. CARDIAC: Regular rate and rhythm. ABDOMEN: Obese, positive bowel sounds, soft, nontender, non-distended EXTREMITIES: right hip incision CDI, no drainage on the bandage. NEUROLOGIC: The patient neurologically appears to be stable. SKIN: Without any suspicious lesions. The hip wound appears to be healing well. Head CT negative, right lower extremity Doppler negative for DVT.
CDI|Children's Depression Inventory|CDI|72|74|TEST RESULTS|In addition, they appear to have a somewhat depressed personality. This CDI resulted in clinically significant levels for total CDI score, ineffectiveness, and anhedonia. Negative mood was at a borderline clinically significant level. Items of interest include "I do many things wrong, I do not like myself, I feel alone many times, and I have to push myself all the time to do my schoolwork." The RCMAS resulted in highly clinically significant levels for total anxiety, physiological anxiety, and social concerns, as well as concentration difficulties.
CDI|Children's Depression Inventory|CDI|128|130|TEST RESULTS|In addition, they appear to have a somewhat depressed personality. This CDI resulted in clinically significant levels for total CDI score, ineffectiveness, and anhedonia. Negative mood was at a borderline clinically significant level. Items of interest include "I do many things wrong, I do not like myself, I feel alone many times, and I have to push myself all the time to do my schoolwork." The RCMAS resulted in highly clinically significant levels for total anxiety, physiological anxiety, and social concerns, as well as concentration difficulties.
CDI|Children's Depression Inventory|CDI,|206|209|PSYCHOLOGICAL AND BEHAVIORAL FUNCTIONING|PSYCHOLOGICAL AND BEHAVIORAL FUNCTIONING: _%#NAME#%_'s psychological and behavioral functioning was assessed using several self-report measures, projective tests, and a clinical interview. Results from the CDI, w hich is a self-report measure designed to assess for symptoms of depression in children, reflected an overall score within the solidly average range for age.
CDI|Children's Depression Inventory|(CDI)|407|411|TEST ADMINISTERED AND TASKS COMPLETED|There is no evidence of hallucinations, delusions, paranoid ideation, grossly inappropriate affect, or other frank manifestation or psychotic disorder. She was oriented to person, place, and time. TEST ADMINISTERED AND TASKS COMPLETED: Diagnostic interview, review of medical records, Minnesota Multiphasic Personality Inventory - Adolescent (MMPI-A) Rorschach Inkblot Test, Children's Depression Inventory (CDI) Revised Children's Manifest Anxiety Scale (RCMAS). TEST RESULTS: The MMPI-A was responded to in an open and honest manner and the profile is valid and interpretable.
CDI|Children's Depression Inventory|CDI|119|121|TEST RESULTS|They also have a strong need to connect with other people. There is little to no evidence of psychotic processing. The CDI resulted in a highly clinically significant level for negative mood, interpersonal problems, and ineffectiveness. Items of interest include "I think about killing myself, but I would not do it", "I do not like myself", and "I am bad all the time".
CDI|Children's Depression Inventory|CDI|111|113|TEST RESULTS|Their relationships also tend to be somewhat superficial and they tend to have immature coping mechanisms. The CDI resulted in a clinically significant level for ineffectiveness and negative self-esteem. Items of interest include "I think about killing myself, but I would not do it, I do many things wrong, I feel alone many times, and I am not sure if anybody loves me." The RCMAS resulted in clinically significant levels for worry, oversensitivity, and social concerns/concentration.
CDI|Children's Depression Inventory|CDI,|262|265|EMOTIONAL, SOCIAL AND BEHAVIORAL FUNCTIONING|EMOTIONAL, SOCIAL AND BEHAVIORAL FUNCTIONING: _%#NAME#%_'s emotional, social and behavioral functioning was assessed using several self-report rating scales, a Sentence Completion Task, a Personality Inventory (MMPI-A) and a clinical interview. Results from the CDI, which is a self-report measure designed to assess for symptoms of depression in children and adolescents, reflected an overall score within the solidly average range.
CDI|Children's Depression Inventory|(CDI)|235|239|BACKGROUND AND REFERRAL INFORMATION|Overall, due to _%#NAME#%_'s level of cooperation and motivation during testing, it was felt that the results were an accurate reflection of her level functioning at this time. TEST RESULTS: Results from the Child Depression Inventory (CDI) reflected an overall score within the average range. These results suggest that _%#NAME#%_ did not endorse a clinically significant level of depressive symptoms in comparison to other females approximately her age.
CDI|Children's Depression Inventory|CDI|141|143|TEST RESULTS|They tend to have superficial relationships with others although may feel as if their relationships are more secure than they truly are. The CDI resulted in clinically significant level for negative self-esteem, anhedonia, and negative mood. Items of interest include "I think about killing myself, but I would not do it, I hate myself, I look ugly, I feel alone many times." The RCAMS resulted in clinically significant level for worry/over sensitivity, and social concerns/concentration.
CDI|Children's Depression Inventory|CDI|117|119|TESTS RESULTS|Conversely these individuals tend to not be psychologically minded and usually have immature defense mechanisms. The CDI resulted in clinically significant levels for negative mood, interpersonal problems, ineffectiveness, anhedonia, and negative self- esteem. Items of interest include "I want to kill myself," "I am bad many times," "I do not like myself," and "I feel alone many times." The RCMAS resulted in mildly clinically significant level for total anxiety as well as clinically significant level for social concerns.
CDI|Children's Depression Inventory|(CDI)|214|218|TESTS ADMINISTERED, TASKS COMPLETED|She was oriented to person, place and time. TESTS ADMINISTERED, TASKS COMPLETED: Diagnostic interview. Minnesota Multiphasic Personality Inventory - (MMPI-A) Rorschach Ink Blot Test Children's Depression Inventory (CDI) Revised Children's Manifest Anxiety Scale (RCMAS) TEST RESULTS: 1. The MMPI-A was responded to an open and honest manner, and the profile valid and interpretable.
CDI|Children's Depression Inventory|CDI,|118|121|TEST RESULTS|It is felt that it is an accurate reflection of his current psychological functioning. TEST RESULTS: Results from the CDI, which is a self-report measure designed to assess symptoms of depression in children and adolescents, reflect an overall score within the slightly below average range.
CDI|Children's Depression Inventory|(CDI)|254|258|TESTS ADMINISTERED AND TASKS COMPLETED|He was oriented to person, place and time. TESTS ADMINISTERED AND TASKS COMPLETED: Diagnostic interview. Review of medical record. Minnesota Multiphasic Personality Inventory - Adolescent (MMPI-A) Rorschach Ink Blot Test. Children's Depression Inventory (CDI) Revised Children's Manifest Anxiety Scale (RCMAS). TEST RESULTS: 1. The MMPI-A was responded to in a highly cautious manner, although the profile is still valid and interpretable.
CDI|Children's Depression Inventory|CDI|170|172|TEST RESULTS|It should be noted, too, that these individuals tend to be at a higher risk for addictive type behaviors, although she denied any current substance or alcohol abuse. The CDI was suggestive of an individual who scored at a highly clinically significant level for negative self-esteem, total CDI score negative mood, and ineffectiveness.
CDI|Children's Depression Inventory|CDI|72|74|TEST RESULTS|Overall, these individuals tend to have immature coping mechanisms. The CDI resulted in clinically significant levels for negative mood, ineffectiveness, and anhedonia. Items of interest include "I do not like myself," "Many things are my fault," "I feel alone many times," and "I am tired all the time." SUMMARY OF CURRENT FINDINGS: This is a 15-year-old Caucasian female who was admitted to the Subacute Diagnostic Unit at the University of Minnesota Medical Center Fairview due to ongoing depressive and anxiety symptoms.
CDI|Children's Depression Inventory|(CDI),|161|166|TEST RESULTS|Lower scores on this subtest are often associated with a weakness in sustained attention. Psychological functioning. Results from the Child Depression Inventory (CDI), which is a self-rating scale designed to assess for symptoms of depression in children, reflected an overall score within the borderline range (T=67).
CDI|Children's Depression Inventory|CDI,|189|192|TEST RESULTS|_%#NAME#%_ appeared to want to make a nice impression, and overall results are felt to be an accurate estimate of her psychological functioning at this time. TEST RESULTS: Results from the CDI, which is a self-report measure designed to assess symptoms of depression in children and adolescents, reflected an overall score within the solidly average range for age and gender.
CDI|Children's Depression Inventory|CDI|154|156|TEST RESULTS|As stated earlier, the Rorschach Inkblot Test was attempted to be administered, although she was not receptive. As a result, no responses were given. The CDI resulted in clinically significant level for negative self-esteem, and mildly clinically significant levels for ineffectiveness and anhedonia. Items of interest include, "I do not like myself," "I do everything wrong," "I think about killing myself, but I would not do it," "I'm not sure if anybody loves me." The RCMAS resulted in a mildly clinically significant level for social concerns and concentration.
CDI|center for diagnostic imaging|CDI|196|198|PAST MEDICAL HISTORY|There is also mild central canal stenosis at L3-4 and L2-3 with moderate to advanced disc degeneration and bilateral facet arthropathy at each of these two levels. This is an MRI that was done at CDI dated _%#MMDD2002#%_. The patient has also had a trial of physical therapy that was to no avail. THERE ARE NO KNOWN ALLERGIES. The patient is a non-smoker.
CDI|center for diagnostic imaging|CDI|137|139|ASSESSMENT|The patient is scheduled for synovial cyst decompression by Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2007#%_. The most recent MRI obtained at CDI on _%#MMDD2007#%_ does show mild central and moderate to marked right subarticular stenosis of L4-5 with degenerative spondylolisthesis of 10% caused by widened, fluid-filled and degenerated facet joints predisposing the segment instability.
CDI|Children's Depression Inventory|(CDI)|249|253|TEST RESULTS|_%#NAME#%_ also endorsed items indicating that it is difficult for him to keep his mind on his schoolwork, he wiggles a lot in his seat, feels nervous, and often worries about bad things happening to him. Results from the Child Depression Inventory (CDI) reflected an overall score within the non-clinically significant range (T=49). _%#NAME#%_'s subscale scores were also average for his age, indicating that _%#NAME#%_ is not experiencing a clinically significant level of depressive symptoms in comparison to other boys his age.
CDI|Children's Depression Inventory|(CDI,|262|266|PSYCHOLOGICAL FUNCTIONING|He obtained an overall score within the low average, mildly delayed range (SS=85, 16th percentile), consistent with an age equivalent of a 9-year-old child. PSYCHOLOGICAL FUNCTIONING: _%#NAME#%_'s psychological functioning was evaluated using self-rating scales (CDI, RCMAS) and a clinical interview. Results from the CDI, which is a self-rating scale designed to assess for symptoms of depression in children, reflected an overall score within the average range.
CDI|center for diagnostic imaging|CDI|140|142|LABORATORY AND DIAGNOSTICS|INTEGUMENT: Skin is warm and dry with no rashes, petechia, purpura. The patient is mildly jaundiced. LABORATORY AND DIAGNOSTICS: CT done at CDI in _%#CITY#%_ _%#CITY#%_ on _%#MMDD#%_ shows moderate to severe intra and extrahepatic biliary dilatation as well as gallbladder dilatation suggesting the stent may be obstructed.
CEA|carcinoembryonic antigen|CEA|200|202|IMPRESSION|I reviewed the pathology, and both of these were noncancerous and at that point in time it was felt that a repeat colonoscopy in two years would be the preferred management. Interestingly enough, his CEA at that point in time was normal. He also has a history of prostate cancer, but as noted above his recent PSA in the last month or two in our clinic was approximately 0.2 which is stable.
CEA|carcinoembryonic antigen|CEA|126|128|HISTORY OF PRESENT ILLNESS|It was distended and hard. Bowel sounds were present. PREOPERATIVE LABORATORY STUDIES: The patient had a CA- 125 of 307 and a CEA of less than 0.5. Basic metabolic panel was within normal limits. Calcium 8.4, hemoglobin 12.4, white blood cell count 11.6, platelets 325.
CEA|carcinoembryonic antigen|CEA|120|122|LABORATORY DATA|LABORATORY DATA: Her markers have increased quite dramatically. She has gone from a CA19-9 of 383,263, to 423, 316. Her CEA has gone from 385 to 595. FAMILY HISTORY/SOCIAL HISTORY: No change ALLERGIES: No known allergies PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 110/74, pulse 78, respirations 20, temperature 98, and weight 116.
CEA|carcinoembryonic antigen|CEA|185|187|LABORATORY DATA|Does not have pain currently. ADL STATUS: Energy is down. Eating: Well. Sleeping: Well. Maintaining weight: Yes. LABORATORY DATA: The patient was started on Faslodex last month and her CEA went from 10.7 down to 9.1. Her CA27.29 went from 883 down to 518. She is tolerating it well. ALLERGIES: Penicillin PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 120/80, pulse 88, respirations 22, temperature 97.5, and weight 158.
CEA|carcinoembryonic antigen|CEA|164|166|LABORATORY DATA|PSYCH: Negative. PAIN: Pain is 9 out of 10 and she takes MS with good relief. ADL STATUS: Appetite is good. Energy is down. LABORATORY DATA: Labs show her elevated CEA and CA27.29. CEA is 16.8. CA27.29 is up to 185. FAMILY HISTORY/SOCIAL HISTORY: No change. CHEMOTHERAPY/RADIATION TREATMENT: Current chemotherapy has been Gemzar and taxotere, but she has been off out in Arizona and has returned.
CEA|carcinoembryonic antigen|CEA,|212|215|LABS|LABS: Labs, chest x-ray, bone scan, and CT scan, all show the abnormalities on the CT scan to be stable, thus probably not secondary to any cancer. The patient does have emphysema. She has a perpetually elevated CEA, of which the highest has been 15.9, the lowest has been 7.4, and it is 9.9 at the present time. CHEMO & RADIATION THERAPY HISTORY: She had no chemotherapy. She has been on tamoxifen and Arimidex for five years, and thus is off of those.
CEA|carcinoembryonic antigen|CEA|171|173|HOSPITAL COURSE|Amylase was normal as well. The patient was admitted and seen in consultation by the Gastroenterology service as well as Colon and Rectal Surgery service. TSH was normal. CEA was also normal. Abdominal flat and upright exams were done which showed a moderate amount of area in the stomach with a few air-fluid levels in the mid abdomen which was consistent with possible small bowel obstruction.
CEA|carcinoembryonic antigen|CEA|125|127|LABORATORY DATA|Her differential was slightly left shifted. Liver function tests were within normal limits, as was her creatinine at 0.l8. A CEA level is pending. Imaging includes the aforementioned CT scan on admission of the abdomen and pelvis revealing the splenic flexure lesion measuring approximately 1 cm in size (ultimately proven to be 6 x 3 cm).
CEA|carcinoembryonic antigen|CEA|220|222|ASSESSMENT/PLAN|Therefore, I discussed at length today with _%#NAME#%_, the high likelihood that she will ultimately be provided 5FU based systemic chemotherapy once she recovers from her surgery. I will simply await the results of the CEA level and likely obtain a new CT scan of the chest and/or PET scan as an outpatient prior to further discussion regarding treatment.
CEA|carcinoembryonic antigen|CEA|197|199|HISTORY OF PRESENT ILLNESS|Subsequent studies per Dr. _%#NAME#%_ _%#NAME#%_ et al. determined on the PET scan and CT scan that there was a prominent mass or node in the retroperitoneal area. Chemotherapy was started and the CEA value fell. Imaging studies of this retroperitoneal mass or lymph node showed decreased size. Her last round of chemotherapy was approximately six weeks ago.
CEA|carcinoembryonic antigen|CEA|274|276|ASSESSMENT/PLAN|It is unclear as to whether or not this is secondary to an adrenalin stress response in addition to his bowel obstruction or if this is due to the fact that he had coffee and cookies previously. We will check hemoglobin A1C on the patient. 4. History of gastric cancer. His CEA was mildly elevated approximately one year ago. CEA will be obtained presently in this patient, as to whether or not there has been a dramatic increase from his previous mild elevation.
CEA|carcinoembryonic antigen|CEA|191|193|BRIEF HISTORY|Initial diagnosis _%#MM2005#%_ and is status post pancreatectomy in _%#MM2005#%_. He did have complications postop with an abscess. Several months afterwards, he had another elevation in his CEA levels, and recurrence of the pancreatic cancer in retroperitoneal lymph nodes. The patient has been in study protocol since _%#MM2005#%_. Prior to admission, the patient states he has developed worsening fatigue and need to sleep 14-16 hours a night, plus taking naps during the day.
CEA|carcinoembryonic antigen|CEA|229|231|HISTORY OF PRESENT ILLNESS|On CT scan, the other organs were normal, such as liver, spleen, pancreas, adrenal, kidneys, gallbladder, bowel, appendix are normal. There is no ascites, no retroperitoneal lymphadenopathy. CA-125 was negative, less than 6, and CEA was negative, less than 0.4, and liver profile was normal. Because of the large cystic mass, she is undergoing laparotomy, left ovarian cystectomy, possible left salpingo- oophorectomy.
CEA|carcinoembryonic antigen|CEA|140|142|HOSPITAL COURSE|There was also increased mediastinal and right axillary lymphadenopathy as well. She had cancer markers sent that were mildly elevated on a CEA of 4.6 as well. She underwent a CT PET scan which showed a marked increased activity in her liver, several lymph nodes in the mediastinum, as well as axillary lymph node which was consistent with metastatic spread of disease.
CEA|carcinoembryonic antigen|CEA|203|205|HOSPITAL COURSE|GYN was consulted in regards to this pelvic mass and felt that this was probably ovarian in nature. She underwent a pelvic ultrasound, which demonstrated some extension of an ovarian mass. A CEA-125 and CEA level were obtained and came back high, suggestive of ovarian cancer. Dr. _%#NAME#%_ from Gynecology Oncology was consulted and felt that the patient will need a staging and a debulking procedure at Fairview Southdale after transfer from Fairview _%#CITY#%_.
CEA|carcinoembryonic antigen|CEA|265|267|HOSPITAL COURSE|2. Subcarinal lymphadenopathy. CT of the chest was not done in the outside facility, as the primary focus was on the pancreatic mass. However, since the EUS did see this subcarinal lymphadenopathy, pulmonary was consulted at that time. They did recommend getting a CEA and CA 19-9, both of which were negative. HIV was also negative. Angiotensin-converting enzyme looking for a sulci was negative.
CEA|carcinoembryonic antigen|CEA|152|154|HOSPITAL COURSE|Following paracentesis, a mass effect was noted in the upper abdomen. Abdominal ultrasound demonstrated enlarged cirrhotic liver with nodular margin. A CEA elevated at 27.3 (smoker). EGD pursued on _%#MM#%_ _%#DD#%_, 2005, demonstrating a varices/portal gastropathy. Exam was suspicious for linitis plastica consistent with diffuse inflammatory adenocarcinoma.
CEA|carcinoembryonic antigen|CEA|232|234|LABORATORY DATA|ABDOMEN: Soft and fairly nontender. His laparoscopic incisions are healing well and covered with Steri-strips. EXTREMITIES: Without clubbing, cyanosis, or unequal edema. LABORATORY DATA: Includes both a pre and postoperative normal CEA level (postoperatively the level was less than 0.5). His hemoglobin on _%#MMDD#%_ was 11.6. His admit CBC revealed a white blood cell count of 6300, hemoglobin of 11.8, platelet count of 244,000.
CEA|carcinoembryonic antigen|CEA|203|205|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Significant for: 1. CA colon, with liver mets noted in 2000, but they are now better, on a revisit, and see the dictation on Abaton dated _%#MM#%_ of this year. 2. Hypertension. 3. CEA was 1.8 at normal on _%#MMDD2001#%_. CURRENT MEDICATIONS: Triamterene/hydrochlorothiazide, and Coumadin. She does have a Port-A-Cath in place as well.
CEA|carcinoembryonic antigen|CEA|237|239|HISTORY OF PRESENT ILLNESS|Pelvic ultrasound showed a normal endometrial cavity, two or three small fibroids present, what appears to be atrophic left ovary and may be a slightly enlarged right ovary with no cystic structures. The patient also has had an elevated CEA and CA125. Both the CAT scan and the pelvic ultrasound disclosed a small amount of ascites present. The patient is being admitted for diagnostic laparoscopy to look for peritoneal involvement, ovarian cancer, abdominal cancer, etc.
CEA|carcinoembryonic antigen|CEA|127|129|HOSPITAL COURSE|Dr. _%#NAME#%_ consulted Dr. _%#NAME#%_, and also ordered a CT scan of the abdomen and pelvis for the next day. In addition, a CEA was done, which is pending at the time of this dictation. The CT scan of the abdomen and pelvis showed: 1) Multiple hepatic metastases, more likely colon than thyroid cancer.
CEA|carcinoembryonic antigen|CEA|194|196|PLAN|PLAN: He will undergo an outpatient bowel prep and then have surgery on _%#MM#%_ _%#DD#%_ at approximately 5 p.m. Preoperative orders have been called in to the Care Suites including drawing of CEA lab test. The CT scan results from last week are not available at the time of dictation.
CEA|carcinoembryonic antigen|CEA|180|182|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: On _%#MMDD2002#%_, the patient had abnormal bleeding x 2-3 months, with a 30-pound weight loss, fatigue, and increasing abdominal pain. CA-125 was 221. CEA was 1.6. On _%#MMDD2002#%_, CT of the abdomen and pelvis revealed a large pelvic mass, free peritoneal fluid, and liver lesions.
CEA|carcinoembryonic antigen|CEA|319|321|ADMISSION LABORATORY DATA|Neuro exam was nonfocal. ADMISSION LABORATORY DATA: Hemoglobin 11.3, hematocrit 34.0, white blood cell count 6.8. Electrolytes of note: potassium was low at 3.2, glucose was high at 185; INR is elevated at 1.11; PTT was normal at 27. Liver function tests were mildly elevated; alkaline phosphatase 166, AST 51, ALT 52. CEA levels were elevated at 106.5. CA-125 level is elevated at 197. UA was negative on admission. HOSPITAL COURSE: The patient was admitted and worked up for her diffuse abdominal pain.
CEA|carcinoembryonic antigen|CEA|149|151|PAST MEDICAL HISTORY|He has had nothing productive when he coughs and he has not had any chest pain. PAST MEDICAL HISTORY: He has had a right carotid stent in 1998, left CEA in _%#MM2005#%_, pacemaker in _%#MM2005#%_, cholecystectomy, benign bladder tumor repair and coronary bypass and mitral valve replacement with a St. Jude valve and aortic graft in 2001. ALLERGIES: He has no known drug allergies, but Gemfibrozil causes him to be nauseated and gives him diarrhea.
CEA|carcinoembryonic antigen|CEA,|149|152|PLAN|6. Family history of brain tumor in her brother. PLAN: Will admit for pain control and further evaluation. Will check tumor markers including CA125, CEA, CA19-9, alphafetoprotein, LDH, will obtain blood cultures and UA/UC and check temperatures q. 4h for the first 24 hours and if she shows fever, would institute some wide-spectrum antibiotics to include coverage for anaerobes.
CEA|carcinoembryonic antigen|CEA|155|157|IMPRESSION AND PLAN|My first diagnosis on the differential would be ovarian cancer in the ovary that was left at the time of the surgery in 2003. I would check a CA-125 and a CEA tumor marker. Will be requested from intervention to do a CT-guided biopsy and send the tissue for pathology for evaluation.
CEA|carotid endarterectomy|CEA|157|159|PAST MEDICAL HISTORY|5. Peripheral vascular disease. 6. Multinodular goiter. 7. Restless leg syndrome. 8. Meningioma removal x 2 in 2001 and 2002. 9. The patient did have a left CEA (left carotid endarterectomy) _%#MM2005#%_. TRANSFERRING MEDICATIONS: 1. Verapamil 240 mg daily in the a.m.
CEA|carcinoembryonic antigen|CEA|180|182|IMPRESSION|I also discussed the patient's problem with Dr. _%#NAME#%_ _%#NAME#%_ and he will see her in consultation for consideration of treatment of the ovarian cancer. Of note is that the CEA and CA-125 drawn at Methodist Hospital are pending.
CEA|carcinoembryonic antigen|CEA|170|172|HISTORY OF PRESENT ILLNESS|The patient was seen in consultation with Dr. _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2002, and at that time was evaluated for her pelvis mass, ascites, and elevated CEA 125. She was admitted. On exam, a mass was felt extending above the umbilicus. HOSPITAL COURSE: The patient was admitted on _%#MM#%_ _%#DD#%_, 2003, and was admitted for a pelvic mass and increased CEA 125.
CEA|carcinoembryonic antigen|CEA|193|195|HISTORY OF PRESENT ILLNESS|She was admitted. On exam, a mass was felt extending above the umbilicus. HOSPITAL COURSE: The patient was admitted on _%#MM#%_ _%#DD#%_, 2003, and was admitted for a pelvic mass and increased CEA 125. On _%#MM#%_ _%#DD#%_, 2003, she underwent an exploratory laparotomy, total abdominal hysterectomy and bilateral salpingo-oophorectomy, appendectomy, omental biopsy, exam under anesthesia, extensive enterolysis, repair of enterotomies, peritoneal washings, and pelvic biopsies.
CEA|carcinoembryonic antigen|CEA|170|172|PLAN|PLAN: 1. Physical therapy and occupational therapy to continue, to place patient in rehab. 2. Dr. _%#NAME#%_, her oncologist, would like to see her in about six weeks. A CEA should probably be accomplished in about a month so that result will be available.
CEA|carcinoembryonic antigen|CEA|137|139|HOSPITAL COURSE|Pelvic ultrasound confirmed this finding. She was seen in consultation by the gynecologist. She had a CA-125 tumor marker negative. AFP, CEA and LDH are pending at time of time of this dictation. She is not a surgical candidate currently, given her recent cardiac and pulmonary issues, even if it was recommended.
CEA|carcinoembryonic antigen|CEA|276|278|REASON FOR ADMISSION & HOSPITAL COURSE|The patient requested that we try to do surgery as soon as possible, and we were able to do the colon resection on the same day as his colonoscopy. The pathology report revealed a T1N0M0, stage I, moderately- differentiated adenocarcinoma of the right colon. His preoperative CEA level was 0.9. His hospital course was uneventful after the right hemicolectomy.
CEA|carcinoembryonic antigen|CEA.|140|143|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 70-year-old gentleman who has history of colorectal cancer in the past. Recently he had arising CEA. A PET scan demonstrated a high intake in the liver. The patient was seen by Dr. _%#NAME#%_ in the clinic in relation to the management options of persistent lesion in segment 6A/4A at the right lobe of liver.
CEA|carcinoembryonic antigen|CEA,|190|193|HOSPITAL COURSE|This would reveal multiple lesions in the liver that would be most compatible with carcinoma, although, a definitive diagnosis could not be made especially without intravenous contrast. The CEA, though, would be elevated at 6702. The patient progressed poorly with progressive liver failure.
CEA|carotid endarterectomy|CEA|151|153|HOSPITAL COURSE|3. Distant tobacco use. 4. Past alcohol use (approximately 12 years ago). 5. Degenerative joint disease. HOSPITAL COURSE: The patient underwent a left CEA on _%#MM#%_ _%#DD#%_, 2003. There were no operative complications. The patient was transferred to the SICU for brief hemodynamic monitoring.
CEA|carcinoembryonic antigen|CEA|122|124|LABORATORY RESULTS|LABORATORY RESULTS: Show a hemoglobin of 9, creatinine of 0.9 and BUN of 17. Her CA125 is slightly elevated at 51 and her CEA is less than 0.5. ASSESSMENT: This is a 40-year-old woman with a 27 cm.
CEA|carcinoembryonic antigen|CEA|107|109|ASSESSMENT|Her CA 27-29, which has always been elevated in the mid-40s to mid-50s, went up to 64, and down to 62. Her CEA is normal. PLAN: I will see her again in four months, and repeat her labs and x- rays.
CEA|carcinoembryonic antigen|CEA|188|190|HISTORY OF PRESENT ILLNESS|The patient was transferred to Fairview-University Medical Center secondary to concern for ovarian versus primary peritoneal tumor. The patient was found to have a CA-125 of 376, a normal CEA at 0.2. Chest x-ray was consistent with a right pleural effusion. CT scan of the abdomen and pelvis showed a large amount of ascites.
CEA|carcinoembryonic antigen|CEA.|152|155|HOSPITAL COURSE|1. Disease: The patient with malignant ascites. Cytology from a paracentesis consistent with adenocarcinoma. The patient had an elevated CA-125, normal CEA. The patient will have a colonoscopy following her discharge from the hospital to evaluate for any possible colon cancer as primary.
CEA|carcinoembryonic antigen|CEA|192|194|ADMISSION LABORATORY DATA|ABDOMEN: Flat, nondistended, nontender, and positive bowel sounds. NEUROLOGIC: The patient was intact. ADMISSION LABORATORY DATA: Elevated creatinine at 2.09, baseline is 1.5, and an elevated CEA that was 201.3. Albumin 3.7. HOSPITAL COURSE: The patient was admitted to the hospital for chest tube placement and management of subcutaneous emphysema with air leak.
CEA|carcinoembryonic antigen|CEA|209|211|HOSPITAL COURSE|She was seen in consultation by GI who agreed with conservative treatment with subsequent endoscopic ultrasound after discharge. Her hemoglobin A1c was checked and was 5.9. Her cancer antigen 19-9 was 23. Her CEA level was 3.3. The patient's lipase increased on the second day of admission on the _%#DD#%_ up to 3,534. However, on the eleventh that had dropped to 552. On the day of discharge it was 173.
CEA|carcinoembryonic antigen|CEA,|375|378|BRIEF HISTORY OF PRESENT ILLNESS|On her initial workup, her white count was 10.6, hemoglobin 7.7, platelets 146, MCV 92, RDW 26.1, chemistry panel was remarkable for potassium of 3 and creatinine 1.22. On LFTs, her AST was 136, ALT 39, alkaline phosphatase 268, total bilirubin 18.8. Her hepatitis panels were negative for hepatitis B surface antigen, hepatitis C antibodies and hepatitis A antibodies. ANA, CEA, were also negative. Ferritin level was 33, folic acid 6.4. ISSUES: 1. Alcoholic hepatitis as described above. Due to her history, AST> ALT ratio, and other negative workup her hepatitis was thought to be secondary to alcohol abuse.
CEA|carcinoembryonic antigen|CEA|201|203|HISTORY OF PRESENT ILLNESS|CT scan of the abdomen was unremarkable. The patient had a colonoscopy in the last six months as she has a history of gastrointestinal bleeding, as well as colon cancer in the past. C-A 99, as well as CEA tumor markers came back negative. The liver was unremarkable and adrenal examination revealed simple adenomas only.
CEA|carcinoembryonic antigen|CEA|199|201|HISTORY OF PRESENT ILLNESS|The patient has refused further treatment with chemotherapy. His liver functions have been increasing and his previous alkaline phosphatase done in _%#MM#%_ of 2002 was 430, AST of 67. The patient's CEA has also been increasing and the level on _%#MM#%_ of 2002 was 133.3. The patient and his wife says they have been using some herbal supplements like liver sensor, but he does not want to go through chemotherapy.
CEA|carcinoembryonic antigen|CEA.|174|177|LABORATORY DATA|Pelvic and rectal exams declined today. EXTREMITIES: Unremarkable NEUROLOGIC: Nonfocal. SKIN: Clear at this time. LABORATORY DATA: EKG looks fine. Pending are hemoglobin and CEA. IMPRESSION: 1. Colon cancer. 2. History of melanoma. 3. Otherwise healthy. PLAN: Class I for general anesthetic.
CEA|carcinoembryonic antigen|CEA|173|175|PLAN|Pending are hemoglobin and CEA. IMPRESSION: 1. Colon cancer. 2. History of melanoma. 3. Otherwise healthy. PLAN: Class I for general anesthetic. Will fax the hemoglobin and CEA to surgery, anticipate no major problems.
CEA|carcinoembryonic antigen|CEA|286|288|HISTORY OF PRESENT ILLNESS|She has completed cycle #2 day 15, and most recent CT scan obtained approximately four weeks ago revealed a dramatic improvement in her liver metastasis with a decrease in the overall size of her liver. Her retroperitoneal and pelvic adenopathy had largely resolved. Unfortunately, her CEA level, as well as her CA-99 have remained elevated, however, clinically she has continued to improve. She comes into the office today for continuation of her chemotherapy and a preoperative visit.
CEA|cerebrovascular accident:CVA|CEA|137|139|LABORATORY|BUN is 23, creatinine 0.88, and glucose 88. CT of her head on admission to the emergency department showed old changes with possible old CEA of the left frontal lobe, no acute changes. Ultrasound of lower extremity showed right posterior tibial vein thrombus and right Baker's cyst.
CEA|carotid endarterectomy|CEA|232|234|HISTORY OF PRESENT ILLNESS|As you recall, this patient has been a diabetic for the past ten years, and also has a cardiovascular risk factor positive for a postmenopausal female, obesity, tobacco abuse and diabetes mellitus. She also has a history of a right CEA in 1999, a right fem-pop in 2001, and a left fem-pop in 2003. She works as an LPN at a nursing home, working the nigh shift.
CEA|carcinoembryonic antigen|CEA|504|506|HISTORY OF PRESENT ILLNESS|During this hospitalization, a CT scan of the abdomen and pelvis revealed a large 2.5 x 8.8 splenic hematoma infiltrations draining nodularity of the omentum as well as ascites and free fluid in the pelvis, additionally 3 liver lesions approximately 1 x 1 cm each, were suspicious for metastatic process and a soft tissue mass at the level of the iliac vessels was found to be causing hydronephrosis of the left side of the patient's known horseshoe kidney. Laboratory studies revealed CA-125 of 539 and CEA of 35.5. Thus, she was referred to the University of Minnesota Women's Cancer Center for further consultation. She was then hospitalized from _%#MMDD2007#%_ to _%#MMDD2007#%_ for increasing abdominal pain and at that time underwent a Lasix renogram and renal ultrasound, which revealed normal urinary function.
CEA|carcinoembryonic antigen|CEA|179|181|DISCHARGE DIAGNOSIS|The tumor markers were also done due to the lung mass and the CA-125 was elevated to 33 and the breast tumor markers CA 27.29 was elevated at 110. The CA 19-9 was normal at 8 and CEA was minimally elevated at 3.1. CT-guided biopsy of the lung, mediastinum was done on _%#MM#%_ _%#DD#%_ and follow-up x-rays did reveal bibasilar pulmonary infiltrates or atelectasis.
CEA|carcinoembryonic antigen|CEA|208|210|LABORATORY DATA|LABORATORY DATA: Laboratory evaluation in Florida was otherwise unrevealing. The patient had normal renal functions with BUN of 11, creatinine of 1.0 and potassium 4.1. Ferritin was slightly elevated at 595. CEA was 2.4. Iron, however, was low at 36. Hemoglobin 12.1 on _%#MMDD2003#%_. Chest x-ray showed no active disease. The remainder of the CT scan was unrevealing.
CEA|carcinoembryonic antigen|CEA|176|178|ASSESSMENT AND PLAN|There is no lymphedema. NEUROLOGIC: Cranial nerves II-XII are intact. ASSESSMENT AND PLAN: The patient has no evidence on CT scan or physical exam of recurrent disease but his CEA is gradually climbing. I have told both him and his wife that the smoking, even though he has cut back quite dramatically to about 1/2 pack a day, may still be affecting this, and I have written him a prescription for Nicoderm patch, and for Mycostatin powder.
CEA|carotid endarterectomy|CEA.|120|123|PAST MEDICAL HISTORY|She is uncertain of the etiology. 2. Hypertension. 3. Her only surgery is vascular access surgery and status post right CEA. 4. She has no history of diabetes, MI, stroke, bypass surgery or peptic ulcer disease. ALLERGIES: She has no allergies. HOME MEDICATIONS: Norvasc, clonidine, metoprolol, Nephrocaps, Lipitor and aspirin.
CEA|carotid endarterectomy|CEA.|118|121|FAMILY HISTORY|She does not smoke or drink. FAMILY HISTORY: Mother died of "flu". Father had ASCVD and CEA, died of a stroke after a CEA. She has a brother and sister who are healthy. PHYSICAL EXAMINATION: GENERAL: She is alert and oriented.
CEA|carcinoembryonic antigen|CEA|145|147|ADMISSION LABS|No small-bowel obstruction was noted. On hospital day#3, the patient's CA-125 had returned to 14. In addition, her TSH had returned at 1 and her CEA returned at 1.1. All of these values were normal.
CEA|carcinoembryonic antigen|CEA|223|225|PROBLEM #2|This is deferred to Infectious Disease for further evaluation and treatment. Tumor markers were obtained on admission: CA-125 was 24 (normal), alpha-fetoprotein was 2.5 (normal), beta hCG was negative, LD was 371 (normal), CEA was 1.3 (normal). PROBLEM #3: Hematology: The patient had complaints of ongoing vaginal bleeding.
CEA|carcinoembryonic antigen|CEA,|176|179|BRIEF HISTORY OF PRESENT ILLNESS|There was also a questionable mass in the liver which was felt to be most consistent with hemangioma but further workup was recommended. Labs pending at the time of discharge; CEA, AFP, and CA 19-9. DISCHARGE PLAN: The patient will be discharged home today with plan to see me in the clinic on Friday, _%#MM#%_ _%#DD#%_, 2006.
CEA|carcinoembryonic antigen|CEA|160|162|HISTORY OF PRESENT ILLNESS|No acute intervention was recommended but right upper quadrant ultrasound was recommended as an outpatient. Tumor markers were drawn during the admission and a CEA level was slightly elevated. Gastroenterology recommended an outpatient colonoscopy.
CEA|carcinoembryonic antigen|CEA|138|140|ADMISSION LABORATORY DATA|Coagulation studies: INR 1.04, PT 56.3, fibrinogen 309. Tumor staging studies: Beta HCG was 17; this was increased. Alpha-fetoprotein and CEA were pending. HOSPITAL COURSE: PROBLEM #1: Fluid, electrolytes, and nutrition.
CEA|carcinoembryonic antigen|CEA|228|230|HOSPITAL COURSE|His ALT was 109. His AST was 104. The patient had a hemoglobin A1C of 7.1. Lipase of 170. Total protein of 6.9. TSH of 1.87. The patient had mitochondrial antibodies that returned as 0.1. He had a Digoxin level of 1.2. He had a CEA antigen that returned as 30.4. The patient's hemoglobin was 11.3. MCV was 94. The patient's hemoglobin was 9.7 and his platelet count was 120,000.
CEA|carcinoembryonic antigen|CEA.|113|116|HISTORY OF PRESENT ILLNESS|She was admitted to the hospital on _%#MMDD#%_, where she was noted to be hypercalcemic and also had an elevated CEA. She had received chemotherapy a few days earlier with carboplatin/VP-16. She was noted to have abnormal liver functions with an elevated alkaline phosphatase at 755, AST 76, albumin 3, calcium 11.7. She had a CAT scan of her abdomen on _%#MMDD#%_ which revealed multiple liver metastases, gallstones, atrophic left kidney and a small left pleural effusion.
CEA|carcinoembryonic antigen|CEA,|188|191|RECOMMENDATION|EXTREMITIES are unremarkable. ASSESSMENT: Colon cancer, transverse colon. Patient has not been operated. RECOMMENDATION: Proceed to surgery as scheduled. Will check a CBC, platelet count, CEA, liver enzymes, lytes, chest x-ray and EKG.
CEA|carcinoembryonic antigen|CEA|195|197|PROBLEM #3|The adrenal nodules should also be worked up for functionality including 24-hour urine collection for metanephrine and other possible workup through Endocrine if appropriate. Also we recommend a CEA and an AFP to further clarify the possible malignant potential of this bowel loop abscess, given the patient's previous history of high-grade dysplasia in 2002 and colon polyps, as well as a family history of colon cancer in his mother.
CEA|carcinoembryonic antigen|CEA|144|146|DISCHARGE MEDS|She did meet with Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2005#%_. He is going to set up a PET scan for her and he has already ordered CA-125 and a CEA level. She also needs a port-A-Cath to be placed by Dr. _%#NAME#%_ as an outpatient in the next week or two prior to initiating chemotherapy.
CEA|cancer:CA|CEA|184|186|PAST MEDICAL HISTORY|No speech difficulties or understanding others as well. No increased weakness of the lower extremity. No disturbance of vision. No headaches. PAST MEDICAL HISTORY: 1) Hypertension. 2) CEA diagnosed on MRI a number of years ago. 3) Bilateral total knee arthroplasty. 4) Status post right hip ORIF. 5) Rheumatoid arthritis. ALLERGIES: None. MEDICATIONS: 1) Prednisone 5 mg q.d. 2) Lasix 20 mg q.d. 3) Metoprolol 12.5 mg b.i.d. 4) Lisinopril 2.5 mg q.d. 5) Folic acid 1 mg q.d. 6) Citalopram 10 mg q.d. 7) Ciprofloxacin 500 mg b.i.d. recently for a UTI.
CEA|carotid endarterectomy|CEA|173|175|PAST SURGICAL HISTORY|6. Hydrochlorothiazide Dr. _%#NAME#%_ held. 7. Aspirin 81 mg. 8. Protonix 40 mg q. day. 9. Simvastatin 20 mg a day. PAST SURGICAL HISTORY: Right carotid stent in 1998, left CEA in _%#MM2005#%_, pacemaker in _%#MM2005#%_, cholecystectomy, benign bladder tumor repair and coronary bypass surgery and mitral valve replacement and aortic graft in 2001.
CEA|carcinoembryonic antigen|CEA|310|312|PLAN|I discussed the risk and benefits of carboplatin and Taxol chemotherapy at reasonable doses, considering her medical circumstance. I have ordered a number of tests, including pulmonary function tests, an arterial blood gas, and repeat her CBC, her INR, her complete metabolic profile, a CA-125, CA 19-9, and a CEA level. Finally, I did renew all of her previous medications with the exception of her aspirin, and ordered her some morphine sulfate 1-2 mg p.r.n.
CEA|carcinoembryonic antigen|CEA|248|250||_%#NAME#%_ _%#NAME#%_ is admitted through the Emergency Department for complications of treatment for his metastatic colon cancer with liver metastases. He had been treated with FOLFOX and seemingly tolerated it well. He was treated 2 weeks ago. A CEA has gone down, suggesting the possibility of response. In the last couple days he has had problems with ongoing nausea and vomiting, diarrhea, weakness and fatigue, poor oral intake and was seen in the Emergency Department and subsequently admitted to the hospital.
CEA|carcinoembryonic antigen|CEA|146|148|ASSESSMENT AND PLAN|As an outpatient, _%#NAME#%_ should have a PET/CT scan to ensure no distant metastatic sites (although I doubt this given his normal preoperative CEA level). He should also consider port a catheter placement prior to follow up in my clinic to assist with later chemotherapy delivery.
CEA|carcinoembryonic antigen|CEA.|115|118|3.  THE PATIENT WILL BE A FULL CODE.|PLAN: 1. For pancreatic abnormality. Hospitalize the patient and obtain MRI of the pancreas. Check a CA 19-9 and a CEA. Check PSA. 2. For elevated INR. Cut down the patient's Coumadin. In fact hold it for now and may be restarted later. We may need to reverse this if we consider biopsy.
CEA|carcinoembryonic antigen|CEA|246|248|SUMMARY OF HOSPITAL COURSE|The patient had a CT scan in the emergency room which suggested possible pancreatic malignancy in the head of the pancreas and, therefore, he was admitted. MRI was obtained which confirmed the suspicion of pancreatic malignancy. CA99, as well as CEA tumor marker was still pending. The patient's liver function tests were unremarkable during this hospitalization, but his INR was supratherapeutic on a low dose of Coumadin.
CEA|carcinoembryonic antigen|CEA.|136|139|PROBLEM #2|The lymph nodes were negative for the estrogen receptors and progesterone receptors. They were positive on immune staining for S100 and CEA. She has been followed at _%#COUNTY#%_ _%#COUNTY#%_ Medical Center initially and then transferred care to the Abbott Northwestern Medical Center.
CEA|carcinoembryonic antigen|CEA|252|254|HISTORY OF PRESENT ILLNESS|She underwent diversion colostomy following chemotherapy, following low anterior resection with Hartmann pouch surgery. She was followed by Dr. _%#NAME#%_ at oncology clinic. According to his note, she is in remission from colon cancer and most recent CEA was 2.1. However, she was concerned about her chronic iron deficiency anemia. At initial laboratory at emergency room, hemoglobin was found to be 7.7, which was 8.8 yesterday.
CEA|carcinoembryonic antigen|CEA|257|259|HISTORY OF PRESENT ILLNESS|A CT scan was subsequently obtained and showed multiple splenic calcified granulomas, with a left pelvic mass measuring 7 cm; a right pelvic mass measuring 4 cm; and no evidence of pelvic lymphadenopathy, omental caking, and/or ascites. CA-125 was 15.2 and CEA was 1.1, both within normal limits. She was subsequently sent to the University of Minnesota Women's Cancer Center for consultation.
CEA|carotid endarterectomy|CEA|126|128|PHYSICAL EXAMINATION|Pupils are equal, round, reactive to light. MOUTH: Shows good dentition. Posterior pharynx is clear. NECK: Supple. There is a CEA scar on the right. LUNGS: Show clear breath sounds on the right, some basilar rales on the left. CARDIAC: Regular rate and rhythm, normal S1, S2. 2/6 systolic ejection murmur.
CEA|carcinoembryonic antigen|CEA|174|176|HOSPITAL COURSE|She will follow up with Dr. _%#NAME#%_ to discuss adjuvant chemotherapy. She had previously been followed at Abbott-Northwestern Hospital for her polycythemia vera. Baseline CEA level was obtained, which was within normal limits.
CEA|carcinoembryonic antigen|CEA|140|142|LABORATORY AND DIAGNOSTIC STUDIES|His platelet count was also normal at 281,000, but his white blood cell count was elevated at 17.2 with a left shift of 98% neutrophils. No CEA level has yet been drawn. ASSESSMENT/PLAN: Likely colorectal carcinoma. At present it is impossible to establish exact TNM staging given that _%#NAME#%_ has not yet had his definitive surgical procedure.
CEA|carcinoembryonic antigen|CEA|286|288|ASSESSMENT/PLAN|I plan on seeing him in the next few days once his path is available to establish his staging and discuss potential adjuvant treatment options, i.e., 5-FU-based chemotherapy if he has either high stage 2 or stage 3 disease. I have also recommended the following: 1. Check perioperative CEA level. 2. Consider CT/PET scan as an outpatient. 3. Follow up in my clinic after recovery from surgery (approximately 2-3 weeks) to discuss all surgical pathology and the possibility of adjuvant treatment.
CEA|carcinoembryonic antigen|CEA|218|220|FOLLOW-UP|FOLLOW-UP: She is to follow up in the next 2 weeks with her own primary care physician as well as to follow with Dr. _%#NAME#%_ _%#NAME#%_ of the Hem-Onc Service within the next 2 weeks to also follow up on her recent CEA level that was drawn during this admission.
CEA|carcinoembryonic antigen|CEA|132|134|LABORATORY|LABORATORY: Included a slightly low hemoglobin of 12.8 on _%#MMDD#%_. His electrolyte panel was normal with a creatinine of 0.94. A CEA level is pending from tonight. ASSESSMENT AND PLAN: Likely stage III (T1 N2 MX) rectal cancer.
CEA|carcinoembryonic antigen|CEA|295|297|ASSESSMENT  AND PLAN|In particular, the lymph node spread and his young age are high risk factors which portend a poor outcome if nothing beyond surgery were to be offered (40-50% chance of disease recurrence). I have recommended the following things to _%#NAME#%_ today: 1. Routine postoperative recovery. 2. Check CEA level to ensure no postop elevation. 3. General surgical consultation for Port-A-Cath placement to assist with chemotherapy administration.
CEA|carcinoembryonic antigen|CEA|310|312|HISTORY OF PRESENT ILLNESS|There was no etiology found for her pancreatitis. There was a CAT scan that she had in the past that had showed calcifications in the pancreas consistent with chronic pancreatitis, otherwise ultrasounds have not revealed any stones or cholecystitis. Gastroenterology has evaluated her in the past, had ordered CEA and CA 19-9 levels and those were normal last time in addition. Yesterday evening she awoke with severe abdominal pain and it has been persistent.
CEA|carcinoembryonic antigen|CEA,|197|200|HOSPITAL COURSE|The pelvic peritoneal and cul-de-sac biopsies were positive for metastatic carcinoid tumor as was the right ovary. This is consistent with a T2, N0, M1 carcinoid. Further testing revealed negative CEA, alpha-fetoprotein, and urine 5HIAA. This was indicative that there has been no liver spread of the carcinoid tumor. The patient was seen by oncology who will follow her as an outpatient but unlikely any specific treatment would be performed.
CEA|carcinoembryonic antigen|CEA|153|155|HOSPITAL COURSE|Occasionally people need frequent therapeutic taps. Spironolactone was initiated at 25 mg twice daily to see if this could help the abdominal ascites. A CEA level was drawn and was 1.5. Her case was discussed with Dr. _%#NAME#%_ over the phone as Dr. _%#NAME#%_ was out of town.
CEA|carcinoembryonic antigen|CEA|209|211|LABS|PSYCHIATRIC: Negative. PAIN: She has some achiness with Neupogen. PAIN MANAGEMENT: Ibuprofen does not work real well. LABS: Her CEA and her CA 27-29 have increased fairly dramatically, basically doubling. The CEA was 106, and now is 203. CA 27-29 was 250, and now is 347. SOCIAL/FAMILY HISTORY: No change. CHEMO & RADIATION THERAPY HISTORY: She has been on Gemzar.
CEA|carcinoembryonic antigen|CEA|139|141|STUDIES|STUDIES: Chest x-ray within normal limits. Abdominal x-ray with multiple air fluid levels consistent with partial small bowel obstruction. CEA 1.1 with within normal limits. ASSESSMENT/PLAN: A 57-year-old female with recurrent nonsurgical colon cancer recently receiving chemo who suffers recurrent episode of partial small bowel obstruction possibly secondary to constipation.
CEA|carcinoembryonic antigen|CEA|159|161|FOLLOW UP|He is to follow up in oncology clinic on _%#MM#%_ _%#DD#%_, 2006, with Dr. _%#NAME#%_ with CBC, platelets, complete metabolic panel, magnesium phosphorus, and CEA level drawn. His next hospital admission date is scheduled for _%#MM#%_ _%#DD#%_, 2006, with round 7 of his chemotherapy with Avastin, 5-FU, oxaliplatin, and leucovorin.
CEA|carcinoembryonic antigen|CEA|257|259|ASSESSMENT AND PLAN|I suspect a lot of her mucositis and mouth sores are all secondary to the fact that her white blood cell count is so low at this time. Ultimately, _%#NAME#%_ may need to consider significant dose reduction in her FOLFIRI plus Avastin versus a reimaging and CEA tumor marker analysis, which if indicative of progressive disease, would make me consider palliative care alone.
CEA|carcinoembryonic antigen|CEA|228|230|FOLLOWUP INSTRUCTIONS|Today, he presents to the clinic but was unable to climb the sitars (and the clinic elevators were out of commission) which led us to admit him for the following reasons: 1. Intravenous rehydration. 2. Laboratory evaluation. 3. CEA analysis. 4. Re-imaging (a CT scan of the chest, abdomen and pelvis was scheduled previously as an outpatient for _%#MMDD2006#%_).
CEA|carcinoembryonic antigen|CEA|172|174|HISTORY OF PRESENT ILLNESS|A repeat colonoscopy a year later showed no recurrence of the tumor. In _%#MM2005#%_, the patient visited his primary-care physician, who noticed thyroid nodules. A repeat CEA demonstrated a level of 27,000. It was at this point of time that he was found to have metastatic disease, and on _%#MMDD2005#%_ he started receiving multiple cycles of chemotherapy.
CEA|carotid endarterectomy|CEA.|206|209|PLAN|7. Incentive spirometer at bedside. 8. Discussed CT scan findings and need for follow up in the next 8-12 weeks. 9. Continue medications for hypertension. 10. Continue dipyridamole and aspirin given recent CEA. That is healing well with no concern. 11. For ichthyosis, Eucerin cream to the legs twice a day. 12. May use also doxepin 10 mg p.o. at bedtime.
CEA|carcinoembryonic antigen|CEA|152|154|HOSPITAL COURSE/PLAN|Dr. _%#NAME#%_' oncology was consulted for recommendations on ongoing palliative chemotherapy. Per oncology recommendations, a PET scan was ordered and CEA level was checked. His CEA level was normal, which was 0.8. PET scan was done on _%#MMDD2006#%_. Since the PET scan showed localized distal esophageal cancer without metastasis, Dr. _%#NAME#%_' had a discussion with the patient and the relatives about a possible surgical consult in the future as an outpatient.
CEA|carcinoembryonic antigen|CEA|143|145|PLAN|4. Nutritious pudding between meals. The patient has an ongoing workup for his cachexia. Data thus far includes minimally elevated PSA at 4.5. CEA is normal at 1.1. CA27 and 29 are pending. His last two tests were done to look for recurrent breast cancer.
CEA|carotid endarterectomy|CEA.|163|166|PAST MEDICAL HISTORY|She is now developing constant pain with pale flesh at the very tip of her left great toe. PAST MEDICAL HISTORY: 1. Peripheral vascular disease, status post right CEA. 2. Status post left SFA stenting. 3. Coronary artery disease with history of angina. 4. SVT. 5. Hyperlipidemia. 6. COPD. 7. Glaucoma/cataract. 8. CRF with baseline creatinine 1.5.
CEA|carcinoembryonic antigen|CEA|260|262|PAST MEDICAL HISTORY|10. Status post colectomy and, as mentioned in the history of present illness, colorectal cancer with metastases to the liver, status post resection, adjuvant radiation and chemotherapy. She follows up with Dr. _%#NAME#%_ every 6 months. On _%#MMDD2007#%_ her CEA was less than 5. CT and PET scans were negative for any recurrence. 11. Hypertension. ALLERGIES: Iodine. Penicillin. Seafood. MEDICATIONS: 1. NovoLog 1 unit per 2 carbohydrate units.
CEA|carotid endarterectomy|CEA|179|181|PAST SURGICAL HISTORY|7. Omeprazole 20 mg q. day. When she takes it her heartburn is pretty good and she has been taking it regularly. 8. Premphase that she stopped. PAST SURGICAL HISTORY: She had the CEA surgery on the left side in _%#MM2007#%_ after an episode of amaurosis fugax. She is gravida 4, para 4, all vaginal deliveries. Angioplasty with stent in _%#MM2007#%_.
CEA|carcinoembryonic antigen|CEA|263|265|ASSESSMENT AND PLAN|Hopefully, during this hospital stay, she can be optimized from both a pain control and nutritional standpoint and also undergo a repeat oncologic evaluation to gauge the efficacy of the recent 6 cycles of FOLFIRI plus Avastin therapy. If she has a fairly decent CEA level and imaging findings, I will likely recommend cautious observation off therapy for the next 4-6 weeks. During this hospital stay, I have asked the pharmacist to prepare short-term total parenteral nutrition (TPN) to be provided to _%#NAME#%_ through her central venous catheter (Port-A-Cath).
CEA|carcinoembryonic antigen|CEA|162|164|LABORATORY DATA|Her baseline creatinine was 1.5 but this has improved to 0.95. A BNP was markedly elevated on _%#MMDD#%_ at 4270 indicating possible CHF. No LFs or perioperative CEA level were obtained. Her most recent hemoglobin after 2 units of PRBC transfusion was 9.6 on _%#MMDD#%_. ASSESSMENT AND PLAN: Stage II (T2 N0 MX) adenocarcinoma of the colon- given _%#NAME#%_'s age, past medical history (dementia and coronary artery disease in particular), and stage II diagnosis with possible favorable histologic features including MSI, I would recommend cautious oncologic observation after recovery from surgery.
CEA|carcinoembryonic antigen|CEA|241|243|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|The liver surface was irregular suggesting cirrhosis. There was also a small, presumed loculated fluid collection anterior to the liver adjacent to the mass that did not enhance, felt to be most likely hematoma. A small amount of ascites. A CEA was sent and was normal at 1.0. Alphafetoprotein, however, was markedly elevated at 2,332.7. He was found to have renal insufficiency with admission creatinine of 2.67. He was modestly hydrated and this has improved upon discharge to creatinine of 1.69 today.
CEA|carcinoembryonic antigen|CEA,|297|300|PAST MEDICAL HISTORY|2. History of a.fib. with CHF. Echocardiogram _%#MM2001#%_, revealed 2+ mitral insufficiency, 1-2+ tricuspid insufficiency, EF of 60- 70% with no wall motion abnormality, positive diastolic dysfunction. 3. History of malnutrition and hypoalbuminemia with workup _%#MM2001#%_, revealed an elevated CEA, negative paraneoplastic workup. 4. History of gastrectomy age 36, with a repeat Roux-en-Y Billroth II, upper endoscopy _%#MM2001#%_, secondary to anemia which was normal.
CEA|carotid endarterectomy|CEA.|234|237|HISTORY OF PRESENT ILLNESS|3. Type 2 diabetes. 4. Hypertension. 5. Mental status changes. HISTORY OF PRESENT ILLNESS: This is a 68-year-old male with a history of Type 2 diabetes, peripheral vascular disease, hypertension, hyperlipidemia, and status post right CEA. The patient presented on _%#MMDD2003#%_ with mental status changes, per his wife. The patient claims that he has not been feeling well.
CEA|carotid endarterectomy|CEA|106|108|PAST MEDICAL HISTORY|The patient was a smoker. He quit approximately two years ago. PAST MEDICAL HISTORY: 1. Status post right CEA approximately two months ago. 2. Hypertension x 30 years. 3. Hypercholesterolemia x 2 1/2 years. 4. Type 2 diabetes, with peripheral neuropathy and chronic renal insufficiency.
CEA|carcinoembryonic antigen|CEA|166|168|HOSPITAL COURSE|Oncology was consulted and they elected to see her 2 months after the above surgery. They would like to follow up on her complete blood count, basic metabolic panel, CEA level and iron panels prior to her office visit. Also after surgery the patient developed some atelectasis and possible aspiration pneumonia.
CEA|carcinoembryonic antigen|CEA|105|107|HOSPITAL COURSE|The workup further included CT scan of his chest, abdomen and pelvis as well as an MRI of the rectum and CEA antigen. It appears that the tumor is stage S2NO meaning that the tumor invades into the muscularis propria but does not extend into the mesorectal fat and that no lymph nodes were seen on the MRI.
CEA|carcinoembryonic antigen|CEA|205|207|HISTORY OF PRESENT ILLNESS|He is status post subtotal colectomy with ileocecal anastomosis in _%#MM#%_ 2005. _%#NAME#%_ had been treated in clinic with leucovorin and 5- FU x4. However, due to progression of his disease: Increasing CEA level of 11 and new subcutaneous mass and a 4- to 5cm lesion at the dentate line. He was started on inpatient chemotherapy. His first round of chemotherapy began on _%#MM#%_ _%#DD#%_, 2006.
CEA|carcinoembryonic antigen|CEA.|224|227|PAST  MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Coronary artery disease with history of small RCA infarct and RCA stenting as above. 2. Peripheral vascular disease with calf claudication. 3. Bilateral carotid artery stenosis status post bilateral CEA. 4. CVA with minimal residual. 5. Dyslipidemia. 6. Hypertension. 7. Status post appendectomy. 8. Status post AAA repair. MEDICATIONS: At arrival were 1. Prinivil 10 mg daily. 2. Norvasc 5 mg daily.
CEA|carotid endarterectomy|CEA|224|226|PHYSICAL  EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 120/70, pulse 60 and regular, respirations 16 and unlabored. GENERAL: Alert, oriented, in no distress. HEENT: Reveals supple neck with normal carotid upstrokes and bilateral CEA scars. There is a left carotid bruit. Throat is clear with an edentulous upper. No cyanosis or pallor. Pupils are equal. LUNGS: Reveal somewhat decreased air movement with some coarse crackles at the bases but no wheeze or rhonchi.
CEA|carcinoembryonic antigen|CEA|144|146|ASSESSMENT  AND PLAN|3. Consider outpatient PET/CT scan to improve on available staging imaging. 4. Optimal pain control and nutritional supplementation. 5. Check a CEA level, CA 19 level and PSA tonight to improve on a primary tumor elucidation. 6. Follow up in my office within the next 1-2 weeks to discuss the available pathology, upcoming imaging (including a likely CT/MRI of the brain to rule out CNS metastasis) and available treatment options.
CEA|carcinoembryonic antigen|CEA|173|175|PROCEDURES|This is a 47-year-old gentleman with a history of stage 3 colon cancer, status post a left hemicolectomy in _%#MM#%_ 2000. Also status post 5-FU, who had an increase in his CEA and PET scan revealing a liver mass which returned adenocarcinoma on biopsy. Chest CT and CAT revealed no other mets. He presents to Fairview-University Medical Center for elective left hepatectomy on _%#MM#%_ _%#DD#%_, 2002.
CEA|carcinoembryonic antigen|CEA|194|196|LABORATORY FINDINGS AND RESULTS|Strength in the right and left is 5/5 in the upper extremities and 4/5 in the lower extremities bilaterally. LABORATORY FINDINGS AND RESULTS: WBC 5.4. Hemoglobin 10.9 with a hematocrit of 32.3. CEA on _%#MM#%_ _%#DD#%_, 2002 was 1.9. The urinalysis showed a few bacteria but negative nitrites and negative leukocytes. Sodium 138. Potassium 3.5. Chloride 106. Bicarb 25. BUN 12.
CEA|carcinoembryonic antigen|CEA|131|133|HOSPITAL COURSE|Bone scan showed that bony metastases were unlikely. Findings were more likely due to prior history of some rib trauma. PSA was 2. CEA was 303. AST was elevated, and alkaline phosphatase liver fraction was elevated. Additionally, on chest x-ray, a 2 cm left pulmonary nodule was noted.
CEA|carcinoembryonic antigen|CEA|344|346|LABORATORY AND IMAGING DATA|His wife was supportive of this plan as well. By _%#MMDD2003#%_, he was ready for discharge to a skilled nursing home with recommendations that he not drive a motor vehicle until he had completed a driver's road test evaluation or the equivalent. LABORATORY AND IMAGING DATA: 1. Chemistry screen: Glucose 129, calcium 8.1; otherwise, normal. A CEA was 3.5. This was followed up by Dr. _%#NAME#%_. Urinalysis revealed some mucus. Complete blood count: Hemoglobin ranged from a low of 10.2 to a high of 11.0 with a normal differential.
CEA|carotid endarterectomy|CEA,|263|266|PAST MEDICAL HISTORY|A nitroglycerin drip has not resulted in any relief of the patient's symptoms at this time. PAST MEDICAL HISTORY: Hyperlipidemia, peripheral vascular disease, prostatitis, right bundle branch block, glaucoma, Bell's palsy, pericarditis in 1992, status post right CEA, status post cholecystectomy and status post inguinal hernia repair. MEDICATIONS: 1. Zocor 20 mg po q.d. 2. Folic acid 1 mg po q.d.
CEA|carcinoembryonic antigen|CEA|162|164|HISTORY OF PRESENT ILLNESS|A CT scan that was performed revealed a large amount of ascites and a 14 x 14 cm mass, suspicious for a malignancy. Her CA-125 on _%#MMDD2003#%_ was 619, and her CEA was 2.8. She was referred to Dr. _%#NAME#%_ _%#NAME#%_ at the Woman's Health Center where she decided to undergo surgical management.
CEA|carcinoembryonic antigen|CEA|255|257|HISTORY OF PRESENT ILLNESS|Regardless, she received chemotherapy with 5-FU and leucovorin for five days, repeated every four weeks, which continued through _%#MM#%_ of 2003. At that time, her CEA was less than 10 according to her daughter, and chemotherapy was held for the summer. CEA was repeated in _%#MM#%_ 2003, and apparently was over 100 nanograms per milliliter at the time. The patient has five children who live in the _%#CITY#%_/_%#CITY#%_.
CEA|carcinoembryonic antigen|CEA|216|218|HISTORY OF PRESENT ILLNESS|He was found to be well in clinic and therefore was asked to undergo a 12th and potentially final cycle FOLFIRI systemic chemotherapy with Avastin today. Of note, recent PET/CT scans and laboratory studies including CEA levels have suggested that his disease is responding and therefore, a potential break from chemotherapy was appropriate, with plans for close oncologic observation off therapy over the holidays.
CEA|carcinoembryonic antigen|CEA|302|304|HISTORY OF PRESENT ILLNESS|The obstipation was thought related perhaps to high-dose diltiazem for her congestive heart failure, but because of a 70-pound weight loss they are planning to continue their workup for malignancy. Other part of her workup while was she in included laboratory studies that did show a slightly elevated CEA level of 7.2 and slightly elevated CA125 of 59. Please refer to the discharge summary when it is available for full details.
CEA|carcinoembryonic antigen|CEA|152|154|PAST MEDICAL HISTORY|Status post multiple PCIs, details are unknown. 2. Diabetes type 2 for 12 years. 3. History of stroke. 4. History of carotid stenosis, status post left CEA of 1994. Carotid ultrasound in _%#MM#%_ 2006 showed a widely patent left carotid, and 16-49% stenosis of the right carotid.
CEA|carcinoembryonic antigen|CEA|320|322|ASSESSMENT AND PLAN|1. Await CT scans of the chest, abdomen and pelvis (so in that if a new abnormality is identified in a potentially more easily accessible site for biopsy this should be biopsied as opposed to bone). (2. Await SPEP results and add quantitative immunoglobulins plus/minus fixation if monoclonal protein is found. 3. Check CEA and CA 19 9 levels such to rule out colon cancer and pancreatic biliary carcinoma. In summary, I will follow up on _%#NAME#%_'s case once his CT scans, tumor markers and other information becomes available.
CEA|carcinoembryonic antigen|CEA|171|173|HOSPITAL COURSE|The pathology report from this specimen revealed a T2N0M0, stage 1, moderately differentiated adenocarcinoma. The radial margins of the rectum revealed no residual tumor. CEA level was 1.3. DISCHARGE FOLLOW-UP: He will follow up in our office to discuss ileostomy takedown in about three weeks.
CEA|carcinoembryonic antigen|CEA|224|226|DISPOSITION|He is admitted for further treatment and evaluation. He has had workup as an outpatient of various labs including serum protein electrophoresis, FANA, _______, rheumatoid factors all of which were normal. He had, however, a CEA of 3.9 with normals being to 3.0, a C-reactive protein of 45.6, PSA of 10.0 which has been noted before, sed rate 85 and hemoglobin 10.6 which has been also noted in the past.
CEA|carcinoembryonic antigen|CEA|187|189|PHYSICAL EXAMINATION|She is in no acute distress. VITAL SIGNS: Blood pressure 110/60, weight 125 pounds. LABORATORY DATA; CBC reveals a hemoglobin of 13.8, platelets 247. Complete metabolic panel was normal. CEA 125 was less than 0.4. CA-125 was 3. She had a normal Pap smear in _%#MM2007#%_. CT scan done on _%#MMDD2007#%_ reveals a large cystic mass in the midline anterior to the bladder measuring 8 x 11 x 7 cm, unclear etiology.
CEA|carcinoembryonic antigen|CEA|137|139|DISCHARGE DIAGNOSES|It appears that the largest node was approximately 3.4 by 2 cm, which had enlarged from 1.7 x 1.5 cm in late _%#MM#%_ of 2007. 5. Normal CEA and CA99 tumor markers obtained during this hospitalization. 6. Recent pulmonary embolus in the right lower extremity deep venous thrombosis noted on _%#MM#%_ _%#DD#%_, 2007 at St. Francis hospital with resolution of lower extremity clot on ultrasound scan as well as upper and lower pulmonary embolus on CT scan performed during this hospitalization on _%#MM#%_ _%#DD#%_.
CEA|carcinoembryonic antigen|CEA|186|188|HOSPITAL COURSE|The pattern was suspicious for a mass. She also had some cholelithiasis noted. The patient also had a GI consult. She had an upper GI with small bowel follow through which was normal. A CEA was done which was 4.0. Because of scheduling the patient will go home and be readmitted next week for elective surgery.
CEA|carcinoembryonic antigen|CEA|222|224|HOSPITAL COURSE|She had a pelvic ultrasound that confirmed a solid mass in her ovary. Tumor markers were checked with a negative CA125 but a positive CEA at 4.9. The upper limit of normal is 2.5. It is possible that smoking can raise the CEA level but not likely. 5. Disposition. The patient was seen by physical therapy and occupational therapy who felt that the patient was extremely weak and deconditioned and would be in need of further therapy.
CEA|carcinoembryonic antigen|CEA|154|156|HOSPITAL COURSE|The patient also had lipids done during this hospitalization with a cholesterol of 189, triglycerides of 75, LDL of 120, and HDL of 54. The patient had a CEA done, which is pending at the time of this dictation. She also had hepatitis antibodies done, which are also pending at the time of this dictation.
CEA|carotid endarterectomy|CEA|315|317|PHYSICAL EXAMINATION|No other review of systems is available. PHYSICAL EXAMINATION: VITALS: Blood pressure upon initially being seen was 140/80, pulse 107 and regular, respiratory rate 14 per ventilator. He was sedated, intubated and unresponsive. Carotid upstrokes were grossly normal. No bruits were appreciated. There were bilateral CEA scars. He was intubated and without pallor. LUNGS: Crackles in the dependent region posteriorly, greater on the right than the left.
CEA|carotid endarterectomy|CEA.|172|175|ASSESSMENT|ASSESSMENT: 1. Pneumonia with chest pain. 2. Arteriosclerotic heart disease with status post coronary artery bypass graft. 3. Peripheral vascular disease, status post left CEA. 4. Hyperlipidemia on treatment. 5. Type II diabetes mellitus. 6. Ischemic cardiomyopathy. PLAN: 1. Will admit the patient and place her on Tequin. We will resume her home medications all except her Coumadin and her Glucophage.
CEA|carcinoembryonic antigen|CEA|176|178|PAST MEDICAL HISTORY|The patient had seen Dr. _%#NAME#%_ in the recent past with no events on the Holter monitor for 1 week. * Colon cancer, status post resection greater than 10 years ago. Recent CEA within normal limits per patient. * Status post hysterectomy. * Vertigo, maintained on meclozine for several years. SOCIAL HISTORY: The patient recently moved here from Illinois to live with her daughter.
CEA|carotid endarterectomy|CEA|170|172|OPERATIONS/PROCEDURES PERFORMED|PAST MEDICAL HISTORY: Includes angioplasty in 1984, and in 2003. In 1998 he had a CABG. He has had 17 stents placed. Hypertension 20 years ago. Left carotid 95% blocked. CEA placed on 3 times. He has peripheral vascular disease, as well. ADMISSION MEDICATIONS: Include TriCor 160 mg p.o. every day, aspirin 81 mg every day, lisinopril 20 every day, Nitrol patch, atenolol 100 mg at nighttime, Plavix 75 mg every day, Lipitor 80 mg every day, nortriptyline 25 mg every day, Zetia 10 mg every day, diltiazem 120 mg every day.
CEA|carcinoembryonic antigen|CEA|188|190|HISTORY OF PRESENT ILLNESS|She also was found to have an enlarged right pelvic lymph node, as well as lymph node versus peritoneal implant in the deep left pelvis. CA-125 was drawn on _%#MMDD2004#%_, which was 561. CEA on _%#MMDD2004#%_ was 1.1. The remainder of her lab values at that time were within normal limits. The patient did come in to see Dr. _%#NAME#%_ on _%#MMDD2004#%_ for consultation, at which time the risks, benefits, and alternatives of proceeding with surgery were explained.
CEA|carcinoembryonic antigen|CEA|163|165|ASSESSMENT & PLAN|NEUROLOGIC: Cranial nerves II-XII are intact. ASSESSMENT & PLAN: The patient has no physical evidence of progression of disease. It is somewhat worrisome that her CEA is up, but will be keep watching that to see if it is just within a normal swing for her. She will continue on her Herceptin and her Arimidex. If her markers keep going up, we will have to consider returning to chemotherapy.
CEA|carcinoembryonic antigen|CEA|210|212|ASSESSMENT|The patient was continued on his 5FU and then referred back to us for consideration of treatment of his recurrent or persistent cancer identified by Dr. _%#NAME#%_ on exam. It should be noted that both PSA and CEA levels are normal. The patient was seen in consultation by Dr. _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2002, in the radiation therapy department.
CEA|carcinoembryonic antigen|CEA|269|271|COMPLICATIONS|There was no definite lymphadenopathy or fluid seen. However, she was also noted to have multiple hyperdense lesions within the liver, the largest measuring 3.3 centimeters, and she also had a focal 2.5 centimeter mass on her spleen. A preoperative CA125 was 67, and a CEA was normal at 1.2. PAST MEDICAL HISTORY: Is as follows: 1. Gravida 1 para 1-0-0-1. 2. Carpal tunnel. 3. Psoriasis.
CEA|carcinoembryonic antigen|CEA|301|303|PLAN|2. We will obtain labs tonight including a CBC with differential, platelets, prothrombin time, partial thromboplastin time (PTT), basic metabolic panel, AST, ALT, alkaline phosphatase, total protein, lipase, albumin, calcium, phosphorus, BUN, creatinine, electrolytes, urinalysis, sedimentation rate, CEA level, CA 19-9. 3. I will order an EKG and a chest x-ray, PA and lateral, in the morning. 4. I will also place the patient on IV heparin per the protocol by the pharmacist.
CEA|carcinoembryonic antigen|CEA,|152|155|IMPRESSION|She does not have any symptoms of carcinoid syndrome. She will have follow-up endocrine evaluations along the way, with her 5-hydroxyindoleacetic acid, CEA, and CA-125. She will be seen in clinic in nine days for a wound check. She had no complications.
CEA|carcinoembryonic antigen|CEA|276|278|HOSPITAL COURSE|A CT of the abdomen and pelvis indicated a large, multiloculated cystic mass on the right adnexa consisting of 2 larger cystic components with measurements of 20 x 28 x 26 cm and 15 x 10 x 11 cm with no ascites or adenopathy noted. A CA125 was elevated at 895.2 with a normal CEA of 2.4 and AFP of 0.9. For definitive diagnosis and removal of the mass, the patient was consented for exploratory laparotomy with removal of a mass.
CEA|carcinoembryonic antigen|CEA|154|156|HISTORY OF PRESENT ILLNESS|It was 9 x 12 x 8 cm invading the rectosigmoid colon, irregular left anterior pubis, question invasion. Her preoperative CA-125 was 537; her preoperative CEA was less than 0.5. PAST MEDICAL HISTORY: 1. Hyperlipidemia. 2. P0. PAST SURGICAL HISTORY: Total abdominal hysterectomy and bilateral salpingo-oophorectomy in 1969 for unknown gynecologic cancer.
CEA|carcinoembryonic antigen|CEA|159|161|OPERATIONS/PROCEDURES PERFORMED|There were 2 tiny cholesterol polyps in the gallbladder, hepatomegaly with other signs suggesting cirrhosis, and splenomegaly. Also of note, the patient had a CEA level drawn which was elevated at 64. DISCHARGE MEDICATIONS: 1. Ursodiol 600 mg p.o. b.i.d. 2. Rifampin 300 mg p.o. q.day.
CEA|carcinoembryonic antigen|CEA|179|181|LABS|ADL STATUS: Energy is good. She is sleeping well, eating well, maintaining weight. LABS: TSH is slightly above normal, but T4 is normal, and I would not change her Synthroid. Her CEA has gone up to 61.3. CA 27-29 has gone up to 152. CHEMOTHERAPY TREATMENT: She has been on Xeloda. She has previously had Navelbine x 10 cycles.
CEA|carotid endarterectomy|CEA.|181|184|PAST MEDICAL HISTORY|She has not had any other particular neurologic symptoms such as vision change, but her speech has been somewhat hesitant. PAST MEDICAL HISTORY: Pertinent as above for the previous CEA. She also had repair of an infrarenal abdominal aortic aneurysm in 1997, a previous cholecystectomy, previous open heart surgery with bypass in 1987 following a myocardial infarction, and has a history of hypercholesterolemia and hypertension, as well as hypothyroidism.
CEA|carcinoembryonic antigen|CEA|137|139|HISTORY OF PRESENT ILLNESS|He underwent radiation therapy and chemotherapy, following polypectomy, and had been doing very well. However, in _%#MM2002#%_, he had a CEA level of 130 and a PET scan showed lesions on both sides of his liver. Random liver biopsy was negative, and plan had been made for open biopsy.
CEA|carcinoembryonic antigen|CEA|192|194|HISTORY OF PRESENT ILLNESS|A CT scan of his abdomen showed a small amount of ascites and heterogenous-looking omentum and mesentery. Tumor markers were sent off at this time with a suspicion of malignancy, an dhe had a CEA of 69. The patient was then sent to gastroenterology for a colonoscopy which was normal and upper endoscopy which was normal as well as endoscopic ultrasound which was normal.
CEA|carcinoembryonic antigen|CEA|149|151|LABORATORY DATA|ADL STATUS: Energy - she has a little more energy. Eating: Better. Sleeping: Well. Maintaining weight: Yes. LABORATORY DATA: Markers are up with her CEA being up to 385, CA19-9 will not be back until next week. FAMILY HISTORY/SOCIAL HISTORY: No change since _%#MM2004#%_. ALLERGIES: No known allergies PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 108/64, pulse 68, respirations 16, temperature 98, and weight 115, height 5'4".
CEA|carcinoembryonic antigen|CEA|238|240|HISTORY OF PRESENT ILLNESS|The patient has been having weekly paracentesis. She did have 5-FU 500 mg infused into her abdomen last week and has maybe slightly less recurrent ascites today. Her markers have been relatively stable. CA27.29 has gone up to 155 and her CEA is up slightly. The patient has is due for her third cycle of carboplatin and taxotere today. REVIEW OF SYSTEMS: GENERAL: Weight is down 5 pounds. Fatigue is getting worse.
CEA|carcinoembryonic antigen|CEA|151|153|PLAN|3. Chest and abdominal CT scan with p.o. and IV contrast to evaluate for possible primary malignancy. 4. We will check a prostate specific antigen and CEA level to evaluate for prostate and colon malignancy. 5. We will continue the patient on phenytoin at 200 mg p.o. b.i.d. He was started on fosphenytoin in the Emergency Department.
CEA|carcinoembryonic antigen|CEA|136|138|LABORATORY DATA|PAIN: Negative. ADL STATUS: Energy is down, but he is sleeping well, eating well and maintaining weight. LABORATORY DATA: Labs show his CEA to be up slightly at 21. It has been 19, 18, 21. CT scan in particular shows axillary adenopathy is improved, but the area of the lung is fairly stable.
CEA|carcinoembryonic antigen|CEA|186|188|LABORATORY DATA|PAIN: Negative. ADL STATUS: Energy is down, but she is sleeping well with the Elavil, eating well and maintaining weight. LABORATORY DATA: Labs show her markers have gone down with both CEA and CA27.29 decreasing. CHEMOTHERAPY/RADIATION TREATMENT: She is currently on Herceptin, carboplatin and Gemzar, and last treatment was _%#MMDD2004#%_.
CEA|carcinoembryonic antigen|CEA|221|223|PROBLEM #2|Hemoglobin posttransfusion was 13.4. PROBLEM #2: Gastric carcinoma metastatic to the liver. Heme- Oncology was consulted, and they will be following her postdischarge from the hospital. She is currently asymptomatic. Her CEA during this hospital stay is 492.4. White blood cell count is 46.9. Platelet count 293. Hemoglobin, as mentioned previously, is 13.4. It was 8.8 on admission.
CEA|carcinoembryonic antigen|CEA|144|146|HOSPITAL COURSE|The pathology report from the specimen revealed a moderately differentiated adenocarcinoma within the polyp. There was a T1 N0M0 carcinoma. The CEA level at the time of admission was 1.5. This corresponds to a Stage I cancer. No adjuvant therapy was offered to patient.
CEA|carcinoembryonic antigen|CEA|173|175|LABORATORY DATA|PAIN: Negative. ADL STATUS: Energy: Low. Eating: She is eating well. Sleeping: She is sleeping well. Maintaining weight: Yes. LABORATORY DATA: Normal except for an elevated CEA at 6.1 but as the patient has been cutting back her smoking it has gone from 6.9 to 6.1. CHEMOTHERAPY/RADIATION THERAPY HISTORY: The patient has had no chemotherapy or hormone therapy.
CEA|carcinoembryonic antigen|CEA|356|358|HOSPITAL COURSE|There is a focal low attenuation area with internal calcification to the right lateral aspect of the fluid collection and combination with aortocaval and retrocrural adenopathy and nodules in the peritoneum highly suspicious for metastatic ovarian cancer. Hypodense lesions in the liver and spleen were too small to adequately characterize. CA-125 was 20. CEA was 1.6. The patient underwent Pap smear that was without evidence of alignancy. She also had colonoscopy with biopsies that were negative without other findings.
CEA|carotid endarterectomy|CEA.|225|228|PAST MEDICAL/SURGICAL HISTORY|PAST MEDICAL/SURGICAL HISTORY: 1. Coronary artery disease, status post two-vessel CABG in 1981 (incomplete revascularization). 2. Peripheral artery disease, status post abdominal aortic aneurysm repair, status post bilateral CEA. 3. Ischemic cardiomyopathy with an ejection fraction of 30% in _%#MM2005#%_. 4. Lung cancer, status post resection. 5. Colon cancer. ALLERGIES: No known allergies.
CEA|carcinoembryonic antigen|CEA|226|228|LABORATORY  DATA|Alkaline phosphatase is 375. INR 1.57. PTT is normal. CBC shows white cell count 19.7. Hemoglobin is 14, which is up from 12.9 one week ago. Platelets are normal. Other recent labs include a CA 19/9 level which was 109, and a CEA level which was 13.9. These were approximately 1 week ago. IMPRESSION AND PLAN: Mr. _%#NAME#%_ is a 67-year-old male with a new diagnosis of hepatomegaly with hepatic metastases 1 week ago.
CEA|carcinoembryonic antigen|CEA|187|189|HISTORY OF PRESENT ILLNESS|He is status post subtotal colectomy with ileocecal anastomosis in _%#MM#%_ 2005. Initially, _%#NAME#%_ had been managed as an outpatient with 5-FU therapy but was found to have climbing CEA levels and a new mass at the dentate line. He had this mass removed in _%#MM#%_ 2006 and was then started on regimen similar to the FOLFOX/7 regimen.
CEA|carcinoembryonic antigen|CEA|197|199|HISTORY|He indicates he had a colonoscopy in the last "couple of years" and the exam was unremarkable. He had a right hemicolectomy related to his colon surgery. Apparently, he has had a slightly elevated CEA antigen, and for this reason, a CT scan of the abdomen was done. There was a vague 3 cm ill-defined density in the region of the ileocecal anastomosis.
CEA|carotid endarterectomy|CEA|292|294|PROCEDURES|PROCEDURES: 1. Right CEA. 2. Four vessel CABG. This is a 47-year-old gentleman with known coronary artery disease and carotid stenosis (right greater than left) who was recently admitted on _%#MMDD#%_ for evaluation for possible CABG and CEA. The patient was readmitted on _%#MMDD2004#%_ for CEA and planned CABG on _%#MMDD2004#%_. The patient has been having worsening symptoms of angina over the past several months. The patient was noted to only walk a half block without pain.
CEA|carotid endarterectomy|CEA|183|185|HOSPITAL COURSE|SOCIAL HISTORY: Positive for tobacco use, one pack per day use times many years. HOSPITAL COURSE: PROBLEM #1: CEA: The patient was admitted on _%#MMDD2004#%_ for evaluation and right CEA by Neurosurgery. Given patient's coronary artery disease, the patient was evaluated preoperatively by cardiology. The patient underwent a right CEA on _%#MMDD2004#%_. There were no other complications.
CEA|carotid endarterectomy|CEA|250|252|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1: CEA: The patient was admitted on _%#MMDD2004#%_ for evaluation and right CEA by Neurosurgery. Given patient's coronary artery disease, the patient was evaluated preoperatively by cardiology. The patient underwent a right CEA on _%#MMDD2004#%_. There were no other complications. The patient tolerated the procedure well. For further details of the operation please refer to the operative note dated _%#MMDD2004#%_.
CEA|carcinoembryonic antigen|CEA|140|142|HOSPITAL COURSE|Prior to that, he would like to repeat a CT scan of the chest, abdomen and pelvis in the next few weeks. Pertinent laboratory tests: 12/21, CEA 1.8, WBC 4.5, hemoglobin 10.8, platelets 382,000. 12/20: BMT within normal limits except chloride 114, bicarbonate 19.
CEA|carcinoembryonic antigen|CEA|185|187|IMPRESSION|Additional studies with respect to this evaluation have included a normal CBC, normal liver panel, normal Helicobacter pylori antibody test, and normal TTG antibody. AFB was normal and CEA mildly elevated at 2.7. Stool cultures also have been negative. The patient subsequently has seen Dr. _%#NAME#%_ several times for this and ultimately underwent endoscopic ultrasound on _%#MMDD2005#%_.
CEA|carcinoembryonic antigen|CEA|164|166|LABORATORY DATA|She saw Dr. _%#NAME#%_. He wants another CT in 3 months. Her tumor markers which had been going down when she was on treatment have now gone in the last month from CEA of 21.6 to 33.2, and a CA27.29 from 120 to 176. CHEMO/RADIATION TREATMENT HISTORY: Drugs are on hold. She was on Taxotere in the past, Navelbine and then Xeloda, Arimidex.
CEA|carotid endarterectomy|CEA.|197|200|PAST SURGICAL HISTORY|Cardiomyopathy, presumed ischemia. Ejection fraction of 35 to 40% with global hyperkinesis in _%#MM#%_ 2005. Hypothyroidism. History of cerebrovascular accident. PAST SURGICAL HISTORY: Status post CEA. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Socially, he lives with son and daughter-in-law.
CEA|carcinoembryonic antigen|CEA|214|216|HOSPITAL COURSE|ADMISSION MEDICATIONS: Include atenolol, Lipitor, Synthroid, Lotrel, glipizide, amitriptyline, Tylenol, and Percocet. HOSPITAL COURSE: 1. Disease. Pelvic masses obvious on exam and CT scan. CA-125 is normal at 20, CEA was less than 0.5. The patient's pain was well controlled during this admission, therefore she did not need urgent surgery.
CEA|carcinoembryonic antigen|CEA.|179|182|SUBJECTIVE DATA|She does have a persistent weakness of her right lower and upper extremity, however, she is ambulating on her own accord. Most recently _%#NAME#%_ has been found to have a rising CEA. Because of this, imaging studies were obtained including a PET CT scan, as well as a MRI of the liver. PET scan revealed uptake within the mediastinal and bilateral hilar lymph nodes.
CEA|carcinoembryonic antigen|CEA|159|161|PLAN|Amylase and lipase level at this time do not indicate an acute pancreatitis. We will keep the patient NPO after midnight. We will send off a CA99 as well as a CEA tonight. U. tox. is also pending at this time. We will control abdominal pain with p.r.n. Dilaudid. We will await GI recommendations for further management. 2. Psychiatric issues.
CEA|carcinoembryonic antigen|CEA|282|284|HISTORY OF PRESENT ILLNESS|Speech and language consult was placed. He was found to demonstrate pooling without penetration or aspiration and it is recommended he continues on a regular diet with thin liquids and use of a chin tuck. The patient has a history of adenocarcinoma of the prostate. He has elevated CEA and was seen by Urology and while an inpatient did receive Zoladex for this condition. He has a history of arthrosclerotic cardiovascular disease with inferior wall ischemia and chronic atrial fibrillation.
CEA|carcinoembryonic antigen|CEA|123|125|FOLLOW-UP APPOINTMENTS|3. In 2 weeks time when she follows up with Dr. _%#NAME#%_ she should have a CBC with differential, chemistry panel, and a CEA level drawn. 4. The patient has a follow-up appointment with the Pain Clinic for establishing an accurate pain control regimen.
CEA|carcinoembryonic antigen|CEA|140|142|CONDITION AT TRANSFER|He has been on a number of different treatments including FOLFOX, Erbitux and Xeloda. Most recently he was noted to have slightly elevating CEA and was having some vague abdominal complaints. We elected to perform CT scans of his chest, abdomen and pelvis, performed on _%#MMDD#%_.
CEA|carcinoembryonic antigen|CEA|208|210|PAST MEDICAL HISTORY|He has a recurrence of the biliary cirrhosis diagnosed by biopsy on _%#MM2006#%_ and placed back on the list. Percutaneous transhepatic cholangiogram on _%#MM2006#%_ showed a sclerosing cholangitis and had a CEA level and CA 19-9 from 9000 down to 3700. His virology studies were negative as also a history of thyroid nodule that was removed and excised on 2002.
CEA|carcinoembryonic antigen|CEA.|172|175|PLAN|Monitor lipase. I am not sure an ERCP for stent can help in this situation but it may help with diagnosis. 2. For large pancreatic head tumor. Check tumor markers CA 19-9, CEA. Obtain surgical consult. Obtain an ultrasound scan of the liver for tiny anomaly which I think not a met. We will not be able to obtain an MRI, as she still has a bullet in her left lower extremity.
CEA|carcinoembryonic antigen|CEA|165|167|LABORATORY STUDIES|NEUROLOGIC: The patient's right upper and lower extremities are noticeably weaker than the left, although she is able to ambulate. LABORATORY STUDIES: CA-125 189.5, CEA 2.0, CA-125 at our institution is 230, preoperative hemoglobin 12.4, platelets 218, basic metabolic panel entirely within normal limits.
CEA|carcinoembryonic antigen|CEA.|140|143|LABORATORY|Good DP pulses. SKIN - generally normal. NEUROLOGIC - grossly normal. LABORATORY: Hemoglobin 11.8. Labs pending include A1C, TSH, ALT, AST, CEA. Chest x-ray was within normal limits. ASSESSMENT: 1. ASA I for ileostomy take-down. 2. History of rectal cancer, currently on chemotherapy. No signs of recurrence.
CEA|carcinoembryonic antigen|CEA|137|139|PLAN|The patient has stated that she and her husband have completed their childbearing. 2. We will check LVH, alpha fetoprotein, inhibin, and CEA today. Urine pregnancy test has been negative x 2, but we also check at the morning of surgery, given that this is a woman of reproductive age.
CEA|carcinoembryonic antigen|CEA|186|188|HOSPITAL COURSE|Cortisol and thyroid function was also checked. TSH was found to be low with normal free T-4 possibly related to sick euthyroid status. Outpatient follow up I believe is time warranted. CEA was checked and found to be 1.9. FINAL DIAGNOSES: 1. Severe hyponatremia due to water intoxication. 2. Severe weakness secondary to hyponatremia.
CEA|carcinoembryonic antigen|CEA|152|154|ASSESSMENT AND PLAN|We will ask oncology to see the patient tomorrow. We will guaiac stools times three to assess again for any evidence of blood in the stools and check a CEA level to assess for any colon primary source. Again, the patient is status post negative mammogram and breast exam within the last five month's time and so this was deferred.
CEA|carcinoembryonic antigen|CEA|205|207|HISTORY OF PRESENT ILLNESS|The patient had an a.m. cortisol drawn that next day with thyroid functions which were normal. Urine studies were not consistent with SIADH and the low sodium was presumed secondary to water intoxication. CEA level was normal at 1.9. The patient's sodium level quickly responded and increased to 136. She then contacted me about a week and a half later stating that she felt her appetite was changing some and also felt mildly depressed.
CEA|carcinoembryonic antigen|CEA|148|150|HISTORY OF PRESENT ILLNESS|This picture was consistent with disease progression, and he was started back on Xeloda, with marked improvement in pain as well as decrease in the CEA level from over 1000 to approximately 400. He has since returned to Minnesota and has resumed his Xeloda. Laboratory studies obtained in our office earlier this week showed an elevated creatinine of 2.0, compared with his baseline studies.
CEA|carcinoembryonic antigen|CEA|212|214|HOSPITAL COURSE|On hospital day six, the patient was noted to have an increase in bilirubin up to 21.2. Pediatric Gastroenterology was asked to see the patient once again as they know her quite well. They recommended checking a CEA and AFP, and to have weekly liver function tests and close follow-up with Dr. _%#NAME#%_ Sharp. 7. Infectious disease. The patient had intermittent fevers throughout her hospitalization, and a chest x-ray was obtained, and showed a right middle lobe pneumonia.
CEA|carcinoembryonic antigen|CEA|117|119|SIGNIFICANT LABORATORY DATA|Hopefully chemotherapy would be somewhat beneficial. SIGNIFICANT LABORATORY DATA: Revealed a C-A-125 elevated at 76. CEA elevated at 2.9. Normal liver function tests. Hemoglobin of 12.9. The patient was ready for discharge to home doing quite well on the eighth postoperative day.
CEA|carcinoembryonic antigen|CEA|196|198|HOSPITAL COURSE|No further investigation to look for the possibility of underlying malignancy was undertaken during this hospitalization. Laboratory studies did show normal liver function studies. Values such as CEA or CT scan of the abdomen looking for intra-abdominal pathology were not undertaken but certainly can be considered in the clinic and felt warranted.
CEA|carcinoembryonic antigen|CEA|141|143|PHYSICAL EXAMINATION|White count at that time was 4500 with a hemoglobin of 13.9. Other labs on _%#MMDD2002#%_ was a normal comprehensive panel, a CA-125 of 5.4, CEA of 1.4, amylase 65, lipase 38, H. pylori was negative. ASSESSMENT/PLAN: With her in the American Society of Anesthesiology Category of P-2 with her history of hypertension well controlled and diabetes well controlled, recent UTI, however with recent culture negative and currently asymptomatic, would request that cath specimen be done at the time she enters the hospital for clean catch UA to make sure that is clear.
CEA|carcinoembryonic antigen|CEA|263|265|HOSPITAL COURSE|The patient was subsequently evaluated with laboratory testing including a TSH which returned at 48.82. He had an albumin of 2.5 during his hospitalization. He had an anemia work-up including a folic acid which was 24, a red blood cell folic acid which was 1047. CEA was .9, PSA was 1.2. The patient was noted to have a low platelet count throughout his hospitalization from 106 to 110,000.
CEA|carotid endarterectomy|CEA.|171|174|PAST MEDICAL HISTORY|6. Status post appendectomy. 7. Status post tonsillectomy. 8. Hypercholesterolemia. 9. Status post lumbar spine surgery. 10. GERD. 11. Hiatal hernia. 12. Status post left CEA. PHYSICAL EXAMINATION ON ADMISSION: VITALS: Blood pressure is 159/78, pulse 129, respiratory rate was 28, satting 94% on 3- 1/2 L, temperature was 100.7. LUNGS: The exam was significant for decreased breath sounds bilaterally with crackles at the base.
CEA|carcinoembryonic antigen|CEA|278|280|HOSPITAL COURSE|His postoperative course was uneventful. He was advanced up to a regular diet without difficulty and with the exception of some confusion at night, tolerated the surgery and the recovery fairly well. The pathology report revealed a T3N2M0 adenocarcinoma of the splenic flexure. CEA level was 5.5. This was a moderately differentiated adenocarcinoma. He was discharged to a nursing home on _%#MMDD2003#%_. DISCHARGE FOLLOW-UP: He will follow up in our office in about three weeks.
CEA|carcinoembryonic antigen|CEA|251|253|HOSPITAL COURSE|Additional studies that were sent included a TSH, which was normal, 2.81; HIV was negative; sed rate 52, C-reactive protein 3.69, which is elevated. LDH 496. Quantitative immunoglobulins were normal with the exception of a mildly elevated IgA of 398. CEA level was normal at 1.2. Alpha-fetoprotein was normal at 2.6. Beta hCG tumor marker was normal at less than 3. DISCHARGE MEDICATIONS: The patient was given Tylenol No. 3 to aid for any pain from his biopsy site.
CEA|carcinoembryonic antigen|CEA|146|148|PLAN|He will have telemetry. Will treat the UTI with some low-dose Tequin, which I think he will tolerate well. GI will see him for ERCP. Will check a CEA antigen, and I think he should have a baseline PSA at some point. With his elevated MCV, he may benefit from a B-12 level.
CEA|carcinoembryonic antigen|CEA|91|93|LABORATORY DATA|Sleeping well, eating is so-so and weight is down 4 pounds. LABORATORY DATA: Labs show his CEA has gone down slightly to 12.5. Otherwise relatively stable. FAMILY HISTORY/SOCIAL HISTORY: No change. ALLERGIES: To penicillin. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 98/62, pulse 80, respirations 18, temperature 97 and weight 153.
CEA|carcinoembryonic antigen|CEA|222|224|LABS|ADL STATUS: The patient's energy is down. She is sleeping well, eating well, maintaining weight. LABS: Labs, chest x-ray and bone x-ray show really no evidence of recurrent disease, but her CA 27-29 went up to 46, and her CEA went up to 3.7. CHEMOTHERAPY: She has never had chemotherapy because she had DCIS.
CEA|carcinoembryonic antigen|CEA|155|157|HISTORY OF PRESENT ILLNESS|He was treated with six months of FU and Leucovorin. He then had his colostomy taken down. He did well, however, this summer he noted to have elevation of CEA level. CT scan done and appeared to having isolated mesenteric metastasis near the superior mesenteric artery and superior mesenteric vein.
CEA|carcinoembryonic antigen|CEA|219|221|HOSPITAL COURSE|This most likely represents anemia of chronic disease. She did have stool guaiac times 2, and those were negative. 3. Pancreatic lesion. This was found on her abdominal CT and prompted a GI consult with Dr. _%#NAME#%_. CEA was within normal limits, and CA19-9 is still pending at the time of discharge. The patient underwent an endoscopic ultrasound on _%#MM#%_ _%#DD#%_, 2004.
CEA|carcinoembryonic antigen|CEA|120|122|HOSPITAL COURSE|Hemogram was significant for a white blood count of 2.4, a hemoglobin of 11, and a platelet count of 299. Postoperative CEA level was 8.7. Postoperatively on _%#MM#%_ _%#DD#%_, 2004, the patient was noted to have a deficit in urine output. This was treated with a bolus of intravenous fluid and the patient responded well.
CEA|carcinoembryonic antigen|CEA|113|115|HISTORY OF PRESENT ILLNESS|The patient's markers have been going up. Her CA27.29 has gone up since she started on Xeloda from 47 to 79. Her CEA has gone from 5 to 7.6. She has been having some increasing symptoms with the Xeloda. REVIEW OF SYSTEMS: GENERAL: She has sweats, drenching at times.
CEA|carcinoembryonic antigen|CEA|206|208|LABS|ADL STATUS: Energy is good. She is not sleeping well because of face pain. She is eating well, maintaining weight. LABS: Marked decrease in her markers, with CA 27-29 going from almost 900 down to 300, and CEA going from 10.5 to 3.5. SOCIAL/FAMILY HISTORY: No change. TREATMENT: Currently on Faslodex. ALLERGIES: Penicillin. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 124/70, pulse 92, respirations 24, temperature 98.0, weight 158.
CEA|carcinoembryonic antigen|CEA|225|227|DISCUSSION|Whether or not it is arising from that or not is unclear. This raises the possibility that his biopsy will turn up a rather strange malignancy, but certainly high on the list would be an occult colon carcinoma; I did order a CEA as well. I have discussed my consultation also with _%#NAME#%_ _%#NAME#%_, Nurse Practitioner at Fairview _%#TOWN#%_ _%#TOWN#%_.
CEA|carcinoembryonic antigen|CEA|144|146|HOSPITAL COURSE|He recommended close observation. At that time he recommended a CEA level and a repeat CT scan of her abdomen in two to three months. She had a CEA level done that showed a CEA level of 0.8. I thought likely that her hemoglobin with a normal MCV was likely secondary to chronic disease.
CEA|carcinoembryonic antigen|CEA|163|165|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: 1. She will follow-up with Dr. _%#NAME#%_ _%#NAME#%_ in one week. 2. Follow-up with Dr. _%#NAME#%_ in two weeks. 3. Also she should have a CEA level done in two to three months. 4. She also needs to have a CT scan of the abdomen done in two to three months.
CEA|carcinoembryonic antigen|CEA|165|167|DISCHARGE INSTRUCTIONS|5. She will need to have also an oncologist to follow her up as an outpatient. That will be the choice of Dr. _%#NAME#%_ for the follow-up CT scan and the follow-up CEA in two to three months. 6. Dr. _%#NAME#%_ _%#NAME#%_ did see the patient while she was in the hospital, but Dr. _%#NAME#%_ may have his own preference for oncologist to work with.
CEA|carcinoembryonic antigen|CEA,|255|258|HISTORY OF PRESENT ILLNESS|He was hospitalized in _%#MM#%_ 2005, and an abdominal ultrasound showed 2 new hypoechoic liver lesions, although there was poor visualization secondary to position and no sedation, but these lesions were concerning for hepatocellular carcinoma. However, CEA, alpha-fetoprotein, and beta HCG levels were not consistent with malignant process. Repeat ultrasound showed a 1.5 x 1.1 x 1.3 cm lateral left lobe lesion, and a 2.0 x 3.1 x 1.5 lesion in the right peripheral lobe.
CEA|carcinoembryonic antigen|CEA|153|155|DISCHARGE DIAGNOSIS|HISTORY OF PRESENT ILLNESS: This patient is a 57-year-old referred to Dr. _%#NAME#%_ for bilateral new pulmonary nodules in the setting of an increasing CEA level. The patient is status post resection of a primary colon adenocarcinoma and was found on follow up to have developed a nodule in the right lower lobe and another one in the left lower lobe.
CEA|carcinoembryonic antigen|CEA|261|263|PLAN|She has already taken clear liquids for the past three to four days and will be placed at n.p.o. after midnight in anticipation of likely undergoing surgery on Tuesday. An abdominal CT scan will be ordered to rule out metastatic disease along with CMP, CBC and CEA tests.
CEA|carcinoembryonic antigen|CEA,|190|193|LABS|ENDOCRINE: Hypothyroid. NEURO: Negative. No dizziness, headache or weakness. IMMUNE: Spring allergies. PSYCHIATRIC: Negative. PAIN: Negative. LABS: Labs show increased markers, CA 27-29 and CEA, but she was off chemo for three weeks with her son's wedding. SOCIAL/FAMILY HISTORY: Her son got married. CHEMO & RADIATION THERAPY HISTORY: She is on Taxotere every week with Herceptin.
CEA|carcinoembryonic antigen|CEA|172|174|FAMILY HISTORY|He underwent surgery with the finding of a stage IIIB colon cancer. I saw him in my office for the first time in _%#MM#%_ and did obtain a baseline CEA. Unfortunately, the CEA climbed and the PET scan revealed evidence of probable metastases in the liver and hilar and perihilar regions of the lung.
CEA|carcinoembryonic antigen|CEA|145|147|PLAN|She underwent colonoscopy which demonstrated a mass in the cecum which was biopsied and demonstrated a poorly-differentiated adenocarcinoma. Her CEA was normal. Her CA-99 was elevated at 64. It was felt that she had a poorly-differentiated adenocarcinoma of the colon and she was started on chemotherapy using Folfox plus Avastin.
CEA|carcinoembryonic antigen|CEA|218|220|PAST MEDICAL HISTORY|Also had 1 episode of seizure after surgery for colon cancer, due to hypertensive encephalopathy. Diagnosed 1 month ago with adenocarcinoma of the colon with treatment of colectomy. No metastases were discovered. Last CEA level was 1.5 in _%#MM#%_. Followed regularly by Dr. _%#NAME#%_. Dr. _%#NAME#%_ prescribed him Zeloda ALLERGIES: NO KNOWN DRUG ALLERGIES.
CEA|carcinoembryonic antigen|CEA|178|180|FINAL DIAGNOSIS|FINAL DIAGNOSIS: 1. Partial small bowel obstruction with ongoing symptoms. 2. Malnutrition due to poor intake. 3. History of colon cancer with recent negative colonscopy, normal CEA and CA 19-9 without evidence for spread. 4. Recent recurrent breast cancer, status post mastectomy with no evidence for further spread.
CEA|carcinoembryonic antigen|CEA|193|195|HISTORY OF PRESENT ILLNESS|She had a PET scan, which showed a moderate focal hypermetabolism associated with a left lower lobe pulmonary nodule, but no other areas of hypermetabolism were seen. The patient's most recent CEA was 0.9. She continues to be asymptomatic; however, she continues to smoke. A CT-guided biopsy was positive for malignant cells, consistent with a colorectal carcinoma in this past.
CEA|carcinoembryonic antigen|CEA|224|226|LABORATORY|His deep tendon reflexes are brisk and symmetric. He had a normal gait and sensation was intact throughout. LABORATORY: Labs on admission: A complete metabolic panel, magnesium, and phosphorus were obtained and were normal. CEA was 3.4. White blood count was 5.1 with a differential of 54% neutrophils, 28% lymphocytes, 13% monocytes, 4% eosinophils, 1% basophils, and an ANC of 2.8, hemoglobin was 10.9, and platelets 306.
CEA|carcinoembryonic antigen|CEA|183|185|ADMITTING LABS|Most recent CBC was 3 days prior to admission. White blood cell count mildly reduced at 3.4. Hemoglobin 10.3, which is stable from previous value. Platelet count was normal at 233. A CEA level was drawn 2 days prior to admission, mildly elevated at 2.7. Previous level was 2.5, which was drawn on _%#MM#%_ _%#DD#%_, 2006.
CEA|carcinoembryonic antigen|CEA|137|139|REASON FOR ADMISSION AND HOSPITAL COURSE|The only abnormality found was a minimally elevated CEA of 3 and that needs a follow up with his primary care. I would recommend another CEA level in 3-6 months. 3. Sideroblastic macrocytic anemia. The patient had anemia on admission. Apparently he had a bone marrow last year at the VA, showing ringer sideroblast.
CEA|carcinoembryonic antigen|CEA|303|305|FOLLOW UP|The patient is to follow up in the oncology clinic on _%#MM#%_ _%#DD#%_, 2006, where he will have labs drawn including CBC, platelets, and a complete metabolic panel, as well as be admitted for round #6 of his chemotherapy with Avastin, 5-FU, and oxaliplatin. We will also recommend possibly checking a CEA level at this time to assess the status of his adenocarcinoma. The patient has no special diet or activity restrictions, though we are encouraging Boost nutrition supplementation.
CEA|carcinoembryonic antigen|CEA|165|167|ASSESSMENT AND PLAN|It is my understanding that he will be sent to a rehabilitation facility to get stronger and undergo physical therapy. I highly doubt colon cancer, given his normal CEA marker, but his recent CT scan of the abdomen did reveal some retroperitoneal lymphadenopathy and possible lymphadenopathy in the right inguinal region as well.
CEA|carcinoembryonic antigen|CEA|156|158|LABORATORY|INR is 1. PTT is 32. BUN and creatinine 25 and 1.2. Potassium 4.3, albumin 4.5, bilirubin 0.5, alkaline phosphatase 133, AST and ALT are both less than 30. CEA is normal at 1.5. Tumor marker AFP is normal at 2. IMPRESSION: The patient with a very unusual, large liver mass with some calcifications and necrotic areas with no GI symptoms at all, completely asymptomatic.
CEA|carcinoembryonic antigen|CEA|142|144|LABORATORY DATA|EXTREMITIES: The extremities were without clubbing, cyanosis or edema. He is in Ted hose. LABORATORY DATA: His laboratories include a pending CEA level. Electrolyte panel revealing slightly low sodium of 127, but normal creatinine of 0.9. His CBC on _%#MMDD#%_, revealed a white blood cell count of 7.2, hemoglobin of 12.6 (likely postoperative), MCV of 88 and platelet count of 260,000, a normal differential.
CEA|carcinoembryonic antigen|CEA.|225|228|IMPRESSION|We will discuss with Anesthesiology the possibility of using an LMA time of intubation versus endotracheal tube because of her vocal cord problems. Laboratory tests will be done today, including the liver function test and a CEA. As mentioned, the CT scan revealed no evidence of metastatic disease. Risks and benefits of surgery have been discussed at length with the patient and she is willing to proceed.
CEA|carcinoembryonic antigen|CEA|199|201|LABORATORY|LABORATORY: CBC with a white blood cell count 7.4, hemoglobin of 10.8, MCV of 93, platelet count of 360,000. Her LFTs when checked a few days ago were within normal limits. Her creatinine was 0.6. A CEA level and iron studies (ordered today) are pending. ASSESSMENT AND PLAN: Stage II (T3N0Mx) colon cancer- _%#NAME#%_ is doing well at postoperative day 3 and has no signs of postoperative complication.
CEA|carcinoembryonic antigen|CEA,|83|86|TSH 1.48.|Cytology from the fluid reveals tumor cells; still waiting for the staining. Serum CEA, PSA pending.
CEA|carcinoembryonic antigen|CEA|220|222|SUMMARY|She feels better and she lives with her granddaughter and is very comfortable about going home today and would like to do the rest of the tests as an outpatient. I will schedule a biopsy of a liver lesion on Monday. Her CEA level was minimally elevated at 7. However, CA 19-9 was significantly increased at 5126 which again raises suspicion for primary pancreatic cancer.
CEA|carcinoembryonic antigen|CEA,|146|149|ASSESSMENT/PLAN|1. GI. Patient will be made NPO overnight with bowel rest, IV fluids, given antiemetics, pain medications as needed. Will check tumor markers for CEA, CA19-9 as well as amylase. It is unclear whether Dr. _%#NAME#%_ has been notified by Dr. _%#NAME#%_. Will clarify that tomorrow. 2. Hypertension. Prinivil 5 mg q day.
CEA|carcinoembryonic antigen|CEA|176|178|HISTORY OF PRESENT ILLNESS|She has developed some discomfort in the left flank as well as fatigue and weight loss. She was found on evaluation by Dr. _%#NAME#%_ to be anemic with a hemoglobin of 10. Her CEA level is 1.5. Dr. _%#NAME#%_ obtained a CT scan which shows 20-30 liver nodules consistent with metastases and mass in the region of the descending colon.
CEA|carcinoembryonic antigen|CEA.|137|140|IMPRESSION|2. Known coronary artery disease with abnormal electrocardiogram, but no symptoms of angina. 3. Past history of colon cancer with normal CEA. 4. Hypertension. 5. History of nephrolithiasis. PLAN: 1. Proceed as per Dr. _%#NAME#%_ _%#NAME#%_. 2. Consideration for a paraoperative monitoring should be given considering the electrocardiographic abnormality, and for cardiology consultation should he complain of any chest symptoms.
CEA|carcinoembryonic antigen|CEA|215|217|FOLLOW-UP|On _%#MM#%_ _%#DD#%_, she underwent a needle biopsy and was found to have a poorly differentiated adenocarcinoma. It was felt that this could possibly represent a primary lung cancer. The tumor stained positive for CEA and CA-125, making a GYN primary site also plausible. Additional staging studies demonstrated an unremarkable abdomen with the exception of a small amount of ascites in the pelvis.
CEA|carcinoembryonic antigen|CEA|230|232|PLAN|Patient was feeling stronger. She was eating better. In the meantime we repeated her liver function tests which were persistently abnormal. Alkaline phosphatase was 440, ALT 175, AST 441, bilirubin was normal at .4. We obtained a CEA antigen which was 7.1. We obtained a CT scan of the abdomen and liver and there were three small liver lesions which were too small to really characterize.
CEA|carcinoembryonic antigen|CEA|154|156|LABORATORY DATA|His glucose is 95. BUN 12. Creatinine 1.4. His albumin was 2.8. His calcium was normal at 9.1. Total protein 6.0. His liver function tests were normal. A CEA was drawn but is pending. Platelet count reveals 1,026,000. His urinalysis was normal. ASSESSMENT: 1. Familial adenomatous polyposis, probably a new mutation by history, although other family members have not yet been screened.
CEA|carcinoembryonic antigen|CEA,|235|238|HOSPITAL COURSE|Otherwise, the patient remained hemodynamically stable. 3. Respiratory. The patient remained on room air throughout the course of her stay, without complications. 4. Oncology. On admission, the patient had a normal HVA, VMA, beta HCG, CEA, and AST. As noted in the laboratory section above, the patient had a biopsy showing rhabdomyosarcoma. Her metastatic workup consisting of a bone scan, chest x-ray, and chest CT were all negative.
CEA|carcinoembryonic antigen|CEA|165|167||She is right-handed. The patient is not a reliable historian. She denies previous history of strokes, seizures, paresis, paresthesias, or vertigo. The patient had a CEA of 0.9 on _%#MMDD2002#%_ and a chest x-ray on _%#MMDD2002#%_ consistent with possible COPD and fibrosis. PAST MEDICAL HISTORY: 1. Right lower lobectomy because of cancer found in the lung, possibly from metastatic colon CA.
CEA|carcinoembryonic antigen|CEA|168|170|DISCHARGE FOLLOW-UP|Prior to that appointment, she will have her CT scan of the chest, abdomen, and pelvis for baseline. She will also have basic labs, as well as liver function tests and CEA drawn.
CEA|carcinoembryonic antigen|CEA|185|187|HISTORY OF PRESENT ILLNESS|A CT was performed and revealed. a large amount of ascites and a 14 x 14 cm mass, suspicious for ovarian cancer. Preoperative evaluation included a CA125 of 619 on _%#MMDD2003#%_ and a CEA of 2.8. After findings of this pelvic mass, she was referred to Dr. _%#NAME#%_ _%#NAME#%_ at the Women's Health Center.
CEA|carcinoembryonic antigen|CEA|163|165|PAST MEDICAL HISTORY|1. History of hypertension x 15 years. 2. History of hyperlipidemia x 15 years. 3. History of angina, Class 2, x 10 years. 4. History of renal stones, status post CEA of the right side on _%#MMDD#%_. 5. Status post TURP for bladder tumor. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Atenolol 50 mg p.o. q. day.
CEA|carcinoembryonic antigen|CEA|216|218|HOSPITAL COURSE|She was discharged on the _%#DD#%_ which was postoperative day number five, in good condition. The pathology report revealed a T2N0M0 (stage 1) moderately differentiated adenocarcinoma of the rectosigmoid colon. Her CEA level at time of discharge was less than 0.5. She will follow up in our office in three to four weeks or sooner should problems develop.
CEA|carcinoembryonic antigen|CEA|155|157|LABORATORY DATA|SKIN: Warm and dry without any lesions. LABORATORY DATA: CBC obtained today within normal limits. __________ obtained a week ago was within normal limits. CEA 2729 is stable at 76. IMPRESSION AND PLAN: 1) Mrs. _%#NAME#%_ is an elderly woman with a history of metastatic breast cancer to the esophagus causing dysphagia from which she is having poor oral intake and has become dehydrated and ________ with anorexia and weight loss.
CEA|carcinoembryonic antigen|CEA|153|155|ASSESSMENT AND PLAN|NEUROLOGIC: Cranial nerves II-XII are intact. ASSESSMENT AND PLAN: No evidence of recurrent disease . I will see her again in three months with lab. Her CEA which had been 8.9 is down to 8.1 so it is at her normal range again.
CEA|carcinoembryonic antigen|CEA|202|204|LABS|PSYCHIATRIC: A little depressed and anxious. SLEEP: She is sleeping better. PAIN: MS Contin 15 mg b.i.d. with good control. LABS: Labs on _%#MMDD2005#%_ showed that her CA 27-29 went up to 182, but her CEA went down to 4.6. CHEMO & RADIATION THERAPY HISTORY: She has had four cycles of AC, four cycles of Taxol, and currently is on Herceptin.
CEA|carcinoembryonic antigen|CEA|141|143|LABORATORY DATA|LABORATORY DATA: Urinalysis is negative. Blood sugar is 125. Total protein 8.4. Differential was ok except for the RDW is slightly elevated. CEA is 319.5. ASSESSMENT/PLAN: 1. History of colon cancer with brain metastasis.
CEA|carcinoembryonic antigen|CEA|221|223|LABORATORY  DATA|EXTREMITIES: No edema, cyanosis or clubbing. NEUROLOGIC: Alert and oriented x 3, there is no motor or sensory, cerebellar deficit. LYMPHATIC: There is no cervical, supraclavicular or axillary adenopathy. LABORATORY DATA: CEA level was 2.1 prior to her surgery, hemoglobin is 9.1 prior to her surgery and currently it is 9.8. IMPRESSION AND PLAN: Mrs. _%#NAME#%_ is a 64-year-old woman with multiple comorbidities and a recent diagnosis of stage II T3 N 0M 0 adenocarcinoma of the colon without any high risk features.
CEA|carcinoembryonic antigen|CEA|148|150|LABORATORY DATA|Rapid alternating movements with minimal difficulty. Finger-nose-finger with minimal difficulty. Heel-to-shin normal. No clonus. LABORATORY DATA: A CEA on _%#MMDD2006#%_ measured 2083. ASSESSMENT: A 72-year-old male with known metastatic colon cancer, now with metastasis to his brain causing loss of balance.
CEA|carcinoembryonic antigen|CEA;|235|238|DISCUSSION/RECOMMENDATION|Other etiologies are metastatic disease from unknown primary; the most common include gastrointestinal, although he has no symptoms and no evidence of masses outside the liver based on CT scan. I will start workup by obtaining PSA and CEA; this can give some direction, although biopsy of the liver lesion is ultimately necessary. This will be challenging since he is on heparin for bilateral PEs.
CEA|carcinoembryonic antigen|CEA|149|151|DISCUSSION/RECOMMENDATION|His hospital course consisted of anticoagulation. A biopsy of the liver was consistent with adenocarcinoma. The primary site of this is unknown. His CEA level was elevated at 23. Special stains of the biopsy were performed which revealed mostly a GI primary and chemotherapy was discussed with him.
CEA|carcinoembryonic antigen|CEA.|185|188|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Chronic kidney disease of unclear etiology with a creatinine of 2.8. She has left kidney atrophy. 2. Chronic abdominal pain. 3. History of positive CA 19-9 and CEA. 4. Sjogren syndrome. 5. History of hypokalemia for over 20 years, initially in part due to laxative abuse. 6. Nephrolithiasis with surgery in 1990 7. Hypertension. 8. Abnormal LFTs.
CEA|carcinoembryonic antigen|CEA|254|256|ASSESSMENT AND PLAN|Her last CT scan and visit with me was in _%#MM2006#%_, which showed further progression of the retroperitoneal adenopathy, however, the patient was clinically stable and doing well. Labs at that time showed a hemoglobin of 11.1 with normal indices. Her CEA was 0.6. Her LDH was normal at 500. She did have an elevated sed rate of 92 and the beta 2 microglobulin was up to 6.3. This was interpreted by myself as showing slowly progressing non-Hodgkin's lymphoma, but we felt we could still continue to follow her especially since she wanted to remain living independently.
CEA|carcinoembryonic antigen|CEA|203|205|HISTORY OF PRESENT ILLNESS|On _%#MMDD2007#%_ the patient was seen by Dr. _%#NAME#%_ and neoadjuvant chemoradiation was recommended prior to definitive resection. The patient was seen by Dr. _%#NAME#%_ on _%#MMDD#%_, at which time CEA was checked and found to be 0.5 mcg (within normal limits). LFTs were also within normal limits. Chemotherapeutic options were discussed including Xeloda and intravenous 5-FU.
CEA|carcinoembryonic antigen|CEA,|146|149|IMPRESSION AND PLAN|I would also include a chest CT, as well as an MRI of the brain given the extent of her disease. In addition I would obtain tumor markers such as CEA, C8, and 729 and CA125, as well as a mammogram. If these do not reveal the primary site of the cancer, then I would proceed with biopsy of one of the spinal lesions.
CEA|carcinoembryonic antigen|CEA|162|164|LABORATORY DATA|This is at least partially mobile. I cannot appreciate any endoluminal lesions. LABORATORY DATA: CT scan, as above. INR 4.34, now corrected to 2.35. Albumin 3.9, CEA 2.8. IMPRESSION: Abdominal, pelvic, and omental masses concerning for carcinoma of the ovary.
CEA|carcinoembryonic antigen|CEA|113|115|LABS|SLEEP: It is hard to sleep at times with her back. PAIN: 2-3. LABS: Labs show her markers to have increased. Her CEA is 6.1, and CA 27-29 is 194. SOCIAL/FAMILY HISTORY: No change. CHEMO & RADIATION THERAPY HISTORY: She has had Xeloda, Zometa and Taxotere for eight doses.
CEA|carotid endarterectomy|CEA.|162|165|PAST SURGICAL HISTORY|2. Status post CVA. 3. Diabetes x10-15 years on oral hypoglycemic agents. 3. Hypertension x at least 10 years. 4. PAST SURGICAL HISTORY: 1. Status post bilateral CEA. 2. Status post cholecystectomy. 3. Status post right THA. 4. Status post T&A. 5. Status post breast lumpectomy. ALLERGIES: None.
CEA|carcinoembryonic antigen|CEA|161|163|IMPRESSION/RECOMMENDATIONS|Plans therefore will be addressed regarding both the rectal cancer and the prostate cancer. We will be obtaining a bone scan prior to his discharge and a repeat CEA to see if it is coming down in his new baseline. I will be planning on seeing him in my office following his outpatient visit at the University of Minnesota Radiation Therapy Department to facilitate the oral Xeloda portion of his radiation treatment schedule.
CEA|carcinoembryonic antigen|CEA|331|333|DISCUSSION|I would anticipate that he has approximately a 10% chance of dying of his cancer within the next 10 years and that his absolute benefit of taking some form of systemic chemotherapy would be quite low at approximately 1-2%. I would therefore not recommend chemotherapy. He does need follow-up by his primary physician with periodic CEA determinations every 4 months for the first couple of years and a colonoscopy at one year is advised as well. It is noted that a CEA was not performed during his present hospital stay and I did recommend that that be performed.
CEA|carcinoembryonic antigen|CEA|223|225|REFERRING PHYSICIAN|She was offered chemotherapy and received Xeloda between _%#MM#%_ 2002 and _%#MM#%_ 2003, with gratifying response. She had near normalization of her CEA and shrinkage of tumors. More recently, however, this past fall, the CEA began to climb and treatment was switched to etoposide, leucovorin, and 5-FU, due to these parameters. She received her first cycle of treatment approximately two weeks ago, tolerating it well without any nausea or vomiting.
CEA|carcinoembryonic antigen|CEA,|172|175|PHYSICAL EXAMINATION|This note will also suffice for the preoperative history and physical, as well as his consultation. We are sending him to the hospital for some laboratory work including a CEA, CA 99 and a PSA. I am also scheduling Mr. _%#NAME#%_ for a PET CT scan for further staging purposes as well.
CEA|carcinoembryonic antigen|CEA|80|82|LABS|No palpable masses. No tenderness, no guarding, no rebound. LABS: Show elevated CEA and 141.5. Her hemoglobin is 11, white count is not back. Electrolytes show abnormal sodium at 125. Her potassium is 2.6. BUN is elevated at 37.
CEA|carcinoembryonic antigen|CEA|118|120|IMPRESSION|I have yet to see a final report on that, however. We did receive some lab results from you back in _%#MM#%_ when his CEA was determined to be 0.9. At today's visit Mr. _%#NAME#%_ looked well. His weight was 218 pounds. Blood pressure was 120/70, pulse was 80, respirations were 20, temperature was 99.
CEA|carcinoembryonic antigen|CEA|240|242|PHYSICAL EXAMINATION|There is no clear mass lesion within the liver, although this scan does not include an arterial phase. I do not see clear evidence of extrahepatic disease. His laboratory tests are most notable for a CA19-9 that is greater than 3000, and a CEA that is greater than 60. ASSESSMENT: Possible cholangiocarcinoma. Neither the CA19-9 or CEA are diagnostic of a specific etiology, but it is extremely likely that he has malignant disease, probably cholangiocarcinoma just on basis of these lab tests and the clinical scenario.
CEA|carcinoembryonic antigen|CEA|229|231|ASSESSMENT|I do not see clear evidence of extrahepatic disease. His laboratory tests are most notable for a CA19-9 that is greater than 3000, and a CEA that is greater than 60. ASSESSMENT: Possible cholangiocarcinoma. Neither the CA19-9 or CEA are diagnostic of a specific etiology, but it is extremely likely that he has malignant disease, probably cholangiocarcinoma just on basis of these lab tests and the clinical scenario.
CEA|carcinoembryonic antigen|CEA|234|236|LABS|HEART revealed no murmurs. ABDOMEN was not examined thoroughly due to her recent surgery and her abdominal binder in place. LOWER EXTREMITIES revealed trace edema bilaterally. LABS: Laboratory studies obtained on admission included a CEA level of less than 0.5. Her hemoglobin was 13.8, white blood count 10,600, platelet count 300,000. Serum chemistries included normal liver enzymes and a normal serum creatinine.
CEA|carcinoembryonic antigen|CEA|146|148|HISTORY OF PRESENT ILLNESS|Further workup including a CT of the chest, abdomen and pelvis revealed a 4.6 cm mass at the distal rectum as well as a 2.8 cm mass in the liver. CEA was obtained and was found to be elevated at 4.3. The patient underwent an MRI with endorectal colon on _%#MMDD2007#%_ which revealed a 2.5 x 2.9 x 2 cm mass in the rectum with extension into the Denonvilliers' fascia and as well as involvement of the internal anal sphincter.
CEA|carcinoembryonic antigen|CEA|143|145|PLAN|Hemoglobin should be monitored regularly to monitor for any drop in her hemoglobin and stool will be obtained for Hemoccult test. I will check CEA level to evaluate for possible colon malignancy based on her history of polyps and suspected gastrointestinal bleed. Colonoscopy could be considered if the bleeding continues. IVC filter placement would be considered if she continues to have gastrointestinal bleed and planned interruption of anticoagulation with presence of deep venous thrombosis in the lower extremities.
CEA|carcinoembryonic antigen|CEA|124|126|DISCUSSION/RECOMMENDATIONS|In the meantime, will await the results of the barium enema to see if there is any specific abnormality. I will obtain PSA, CEA and fractionated alkaline phosphatase in view of significant elevation without much changes of AST, ALT, and bilirubin. If he has significant elevation of bony fraction, may pursue with bone scan.
CEA|carcinoembryonic antigen|CEA|362|364|DISCUSSION/RECOMMENDATIONS|B-12 level was within normal range. However, that could fluctuate based on daily intake, and I would evaluate fasting homocysteine and methylmalonic acid to rule out undetected B-12 deficiency, which may benefit parenteral B-12 supplementation. Chronic illness anemia, ie associated with malignancy could attribute to drop in hemoglobin. Therefore, I will check CEA level to rule out evidence of recurrence of his cancer, and if it is elevated, will be evaluated by CT scans. Lower back pain could be seen with plasma cell disorders.
CEA|carcinoembryonic antigen|CEA|147|149|IMPRESSION|This may be related to, of course, ileus compounded by carcinomatosis, as the patient appears to have had progressive deterioration. The patient's CEA level is elevated at 66. The alpha fetoprotein level was normal at 3.9. The patient's liver biopsy is interpreted as revealing poorly differentiated adenocarcinoma.
CEA|carotid endarterectomy|CEA|178|180|IMPRESSION/RECOMMENDATIONS|This is all per CT, surgery, pulmonary, and cardiology consultants. 2. Confusion, mild, likely multifactorial due to meds, resolving infection, situational, elevated BUN, ? post CEA changes all in the setting of a man who seemed to have some pre-existing mild dementia. I would discontinue his Ativan and Ambien as this likely is exacerbating the problem.
CEA|carcinoembryonic antigen|CEA|148|150|PHYSICAL EXAMINATION|Complete blood count today showed a hemoglobin of 12.4, WBC 7900, platelets 159,000. CEA and basic metabolic panel have been drawn. The most recent CEA was on _%#MMDD2004#%_ and it was normal at 1.7. At this juncture we are planning on repeating a CT of his chest, abdomen, and pelvis, if it is negative then I believe it will be appropriate to have his Port-A-Cath removed.
CEA|carcinoembryonic antigen|CEA|237|239|IMPRESSION|She is certainly a candidate for postoperative chemotherapy using 5 Fluorouracil and Leucovorin, and I would also consider adding Oxaliplatin in a Folfox 4 regimen if she is confirmed to have evidence for distant metastatic disease. Her CEA level will be followed and her abdominal CT scan and/or MRI scan of the liver will be monitored to help assess her response to therapy over the next several months.
CEA|carcinoembryonic antigen|CEA|209|211|STUDIES|An echocardiogram has confirmed a decreased left ventricular performance with an ejection fraction of 30-35%. The patient's chemistries have included a hemoglobin of 11.7 and a white count of 10,000. He had a CEA antigen slightly elevated at 4.1, but I really do not know if this is clinically significant. His kidney function includes a creatinine of 2.1 and a BUN of 70.
CEA|carcinoembryonic antigen|CEA|201|203|IMPRESSION|He and his family have requested that I be the primary hospice provider, and I hope that is okay with you. The patient did have a CEA drawn on _%#MM#%_ _%#DD#%_, and it was already up to 256. A repeat CEA was drawn today, and results are pending. I will plan on seeing Mr. _%#NAME#%_ back in four weeks.
CEA|carcinoembryonic antigen|CEA|188|190|LABORATORY STUDIES|RECTAL: His previous rectal examination on _%#MMDD2002#%_ was positive for stool. His prostate is moderately enlarged. LABORATORY STUDIES: On review of ancillary testing, his preoperative CEA was 6. Hemoglobin at the present time is 9.0, MCV 71, white count 11,000, platelets 354,000. Liver function tests are normal. Creatinine 1.2, calcium 8.7. CT scan of the abdomen is significant for multiple hepatic metastases in both lobes of the liver, the largest of which is 7 cm in the right lobe, and the smallest is 2.5 cm.
CEA|carcinoembryonic antigen|CEA|144|146|LABORATORY DATA|RECTAL: Digital rectal exam reveals hemoccult positive stool. EXTREMITIES: Within normal limits. LABORATORY DATA: Very low iron saturation. His CEA is pending. Hemoglobin at time of admission was 5, after transfusion it came up to 9.5. His mean cell volume was 70. His albumin is within normal limits. His liver function tests are grossly normal.
CEA|carcinoembryonic antigen|CEA|158|160|DISCUSSION/RECOMMENDATIONS|She will need cancer surveillance followup, and I will arrange to see her after she completes rehabilitation in the next four weeks. I will obtain a baseline CEA level for future reference. I appreciate the opportunity to participate in the care of _%#NAME#%_ _%#NAME#%_.
CEA|carotid endarterectomy|CEA.|109|112|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient suffers from encephalopathy, new seizure, and confusion, status post CEA. The patient was seen on rounds. No new problems. Confusion continues. He is making gains with therapy. He walks with a walker from room to rehab with therapist near.
CEA|carcinoembryonic antigen|CEA|172|174|IMPRESSION  AND PLAN|Once he is discharged I would recommend that he follow up with me in 2-3 weeks. Prior to his discharge I would recommend obtaining liver function tests as well as baseline CEA level. Thank you for allowing me to participate in the care of Mr. _%#NAME#%_.
CEA|carcinoembryonic antigen|CEA|307|309|IMPRESSION|He appears to have T3 N0 M0 disease, but I would recommend completion of his staging with an abdominal and pelvic CT scan once he recovers further from his surgery. If this is negative, I would favor observation off therapy, with monitoring of his laboratory studies, including liver function studies and a CEA level every four months over the next couple of years, then every six months for an additional few years. A repeat colonoscopy should be obtained in one year, then every 2 to 3 years thereafter.
CEA|carcinoembryonic antigen|CEA|146|148|LABORATORIES|Complete mass could not be identified. LABORATORIES: Blood tests from _%#MMDD2006#%_: Hemoglobin 10.0. White count 7400. Platelet counts 538,000. CEA from _%#MMDD2006#%_ was 11, elevated, normal being 0-2.5. Previous CEA from 2004, was 1.8 within normal limits. ASSESSMENT AND PLAN: The patient has very extensive rectal cancer with possible fistulous tract to the perineal skin.
CEA|carcinoembryonic antigen|CEA|153|155|PERTINENT LABORATORY DATA|Comprehensive metabolic battery was fairly normal with slightly elevated creatinine of 1.45. Amylase and lipase levels were normal as was INR and PTT. A CEA was elevated at 7.4. Iron was 22, TIBC 380 with 6% saturation. Serum ferritin was 8 and reticulocyte count on _%#MMDD2006#%_ was 2.1% with an absolute reticulocyte count of 57.6. CT SCAN OF ABDOMEN AND PELVIS: The liver appeared to be normal with no evidence of metastatic disease.
CEA|carcinoembryonic antigen|CEA|352|354|DISCUSSION/RECOMMENDATIONS|DISCUSSION/RECOMMENDATIONS: I will obtain CT scan of the chest to evaluate the lung lesion which may help differentiate between primary lung malignancy with metastasis versus lung metastasis if he has multiple lung lesions. Colonoscopy is scheduled for today and biopsy will be done if he was found to have any lesions confirm diagnosis, I will obtain CEA level as a baseline and will decide upon further workup depending on the colonoscopy findings, if his colonoscopy showed colon cancer, he will be advised to have palliative resection and biopsy of the liver at the same time.
CEA|carcinoembryonic antigen|CEA.|199|202|LABORATORY DATA|ABDOMEN; The abdomen has a well-healed incision with staples in place, but is otherwise soft and nontender without obvious organomegaly. EXTREMITIES: There is no pedal edema. LABORATORY DATA: Normal CEA. Review of the pathology shows a moderately-differentiated adenocarcinoma arising from a tubular villous adenoma with invasion into the submucosa with margins negative but with metastases to three out of four regional lymph nodes.
CEA|carcinoembryonic antigen|CEA|258|260|LABORATORY AND DIAGNOSTIC STUDIES|LABORATORY AND DIAGNOSTIC STUDIES: CBC shows white blood cell count of 7,900, hemoglobin 9.2 with MCV of 85, platelet count of 211,000. Her liver function tests reveal mild transaminase elevation (ALT 61, AST 93), alkaline phosphatase 212, creatinine 1.2. A CEA level was not found. ASSESSMENT: 1. Metastatic (stage 4) colon cancer with known/biopsy-proven liver metastases.
CEA|carcinoembryonic antigen|CEA|155|157|LABORATORY AND DIAGNOSTIC STUDIES|LABORATORY AND DIAGNOSTIC STUDIES: Abdominal film today does show continued dilated loops of small bowel which are concerning for small bowel obstruction. CEA is minimally elevated at 3.7. White blood cell count is 11,100, and hemoglobin is 13.0. ASSESSMENT AND PLAN: This is a patient with a small bowel obstruction after a large abdominal surgery years ago.
CEA|carcinoembryonic antigen|CEA|145|147|ASSESSMENT AND PLAN|If indeed she has resolution of her symptoms, then I think she would be able to avoid surgery. There is some concern with her minimally elevated CEA level, and that will need to be taken into consideration as we move along. She should be at fairly low risk for recurrence of her previous colon cancer, though certainly there is some possibility of having a new colon cancer in her remaining colon; and colonoscopy might be considered.
CEA|carcinoembryonic antigen|CEA|216|218|HISTORY OF PRESENT ILLNESS|This resulted in a colonoscopy and biopsy _%#MMDD2005#%_ showing a hemi-circumferential mass 12 cm from the anal verge in the lower sigmoid colon. Pathology showed a grade 2 moderately differentiated adenocarcinoma. CEA at that time measured 25.6. CT scan showed an apple core lesion 4 to 5 cm in length in the rectosigmoid colon. Low anterior resection was performed _%#MMDD2005#%_by Dr. _%#NAME#%_. Pathology from the procedure showed that the tumor was located above the peritoneal reflection and penetrated into, but not through the muscularis propria.
CEA|carcinoembryonic antigen|CEA|236|238|ASSESSMENT|ASSESSMENT: The patient is a 47-year-old male with Stage T2 N0 M0 adenocarcinoma of the colon status post low anterior resection _%#MMDD2005#%_. The entire tumor appeared to be located above the peritoneal reflection. His postoperative CEA measures 7.3, which is significantly decreased from his preoperative value. RECOMMENDATIONS: Approximately 45 minutes were spent with the patient and his wife discussing he role of radiation therapy for his cancer.
CEA|carcinoembryonic antigen|CEA|288|290|ASSESSMENT AND PLAN|Prior to any systemic chemotherapy I have asked _%#NAME#%_ to simply recover from her surgery and consider outpatient PET/CT scanning to ensure no residual/metastatic disease. We will check serum ferritin and iron studies given her anemic state to ensure no underlying iron deficiency. A CEA level will also be checked during this admission. In summary, I plan to see _%#NAME#%_ in the outpatient setting approximately 3 weeks' time to discuss further 5-FU-based chemotherapy (either intravenously or orally with a 5-FU prodrug/Xeloda/capecitabine.
CEA|carcinoembryonic antigen|CEA|129|131|HISTORY OF PRESENT ILLNESS|He then has been followed by his primary physician in California, and has been doing well until recently when he had an elevated CEA level. This led to a workup, including a PET scan and CT scan, which showed possible adrenal metastasis, with a 3-cm lesion, and a possible mesenteric nodule suspicious for cancer, according to their radiologist.
CEA|carcinoembryonic antigen|CEA|128|130|PHYSICAL EXAMINATION|VITAL SIGNS: His vital signs are normal. He is an afebrile, blood pressure 133/72. A PSA was drawn and is normal at 0.55, and a CEA was also 1.0. I met with the patient and his family and we discussed his disease status.
CEA|carcinoembryonic antigen|CEA|227|229|HISTORY OF PRESENT ILLNESS|His post treatment PET CT scan remained stable until _%#MMDD2007#%_ when PET CT scan showed a slight increase in the size of nodule (from 1.6 x 1 to 2 x 1.5 cm). There was also slight increase in PET activity. His most current CEA level is increased at 5.9. Because Mr. _%#NAME#%_ has already received radiation to the para-aortic region, he is not considered a candidate for retreatment using conventional radiation therapy.
CEA|carcinoembryonic antigen|CEA,|230|233|REFERRING PHYSICIAN|Subsequently, she did undergo a liver biopsy on _%#MM#%_ _%#DD#%_, which revealed a poorly differentiated nonsmall cell carcinoma. The suggested primary sites were broad but by immunohistochemical testing it was negative for AFP, CEA, CA19-9, thyroglobulin. It was positive for cytokeratin 7 and 20, which is commonly seen in upper digestive tract malignancy and possibly bladder cancer.
CEA|carcinoembryonic antigen|CEA|206|208|LABORATORY|Her differential is slightly left shifted. Of note, the hemoglobin dropped with rehydration which likely indicates anemia of chronic disease. There has been no active GI bleeding No liver function tests or CEA level were drawn during the admission. Her electrolyte panel when last checked was fairly stable on _%#MMDD2007#%_ with only a mildly low sodium of 132.
CEA|carcinoembryonic antigen|CEA|262|264|PHYSICAL EXAMINATION|This was done at the Minnesota Heart Clinic. White count 7.5, hemoglobin 14,000, platelets 239,000. Basic metabolic panel has been sent. I should also mention the patient recently as well had a CT done of his chest, abdomen and pelvis due to a slightly elevated CEA level of 3.1. This CT was just done at Suburban on _%#MM#%_ _%#DD#%_ showing no evidence of recurrent or metastatic disease, with solitary borderline enlarged retroperitoneal lymph node, and tiny ill-defined nodule in the right upper lobe that is probably not significant.
CEA|carcinoembryonic antigen|CEA|197|199|LABORATORY DATA|There was no evidence of ascites. EXTREMITIES: Lower extremities revealed no edema. NEUROLOGIC: Nonfocal. LABORATORY DATA: Laboratory studies on admission included normal liver function studies. A CEA level was markedly elevated at 146. Her CBC was entirely normal. IMPRESSION: 84-year-old female with probable pancreatic carcinoma with liver metastases.
CEA|carcinoembryonic antigen|CEA|128|130||He started having significant abdominal pain in _%#MM#%_ and finally came in for evaluation this fall. Dr. _%#NAME#%_ found his CEA level was elevated and he was seen by Dr. _%#NAME#%_. Subsequent workup has shown that he has an elevated CEA antigen level.
CEA|carcinoembryonic antigen|CEA|135|137||Dr. _%#NAME#%_ found his CEA level was elevated and he was seen by Dr. _%#NAME#%_. Subsequent workup has shown that he has an elevated CEA antigen level. CT scans of his abdomen showed dilated stomach with no obvious evidence of metastatic disease. Within the past week he was taken down to surgery and a portion of a nodule on his abdominal wall was removed without any definitive diagnosis.
CEA|carcinoembryonic antigen|CEA|113|115|LABORATORY DATA|ALT is 171. AST 255. Troponins are less than 0.07. Her pO2 is 81 mm/Hg; FiO2 at 2.0 liters; pCO2 is 55. Her last CEA was 494 on _%#MMDD2003#%_. PHYSICAL EXAMINATION: General: She is an ill-appearing female. HEENT: Her neck was supple. There was no tracheal deviation.
CEA|carotid endarterectomy|CEA|142|144|PHYSICAL EXAMINATION|Extraocular muscles are intact. Disks are sharp. Tympanic membranes are normal. Mouth is unremarkable. NECK: Bandaged on the left side at her CEA site. LUNGS: Clear to auscultation and percussion. CARDIOVASCULAR: Irregularly, irregular rhythm with a normal S1, S2. There is a 2/6 systolic murmur along the left sternal border.
CEA|carcinoembryonic antigen|CEA|180|182|ADDITIONAL LABORATORY STUDIES OF NOTE|Bowel sounds were normal. EXTREMITIES: Distal extremities were unremarkable. ADDITIONAL LABORATORY STUDIES OF NOTE: The patient's INR is 1.13, and his PTT is 26. Also pending is a CEA and a CA 19-9 tumor marker. IMPRESSION/PLAN: My impression initially is that this gentleman does have a metastatic malignancy, most likely is pancreatic, but other gastrointestinal site is still possible.
CEA|carcinoembryonic antigen|CEA|351|353|IMPRESSION  AND PLAN|Her laboratory studies at today's visit showed a hemoglobin of 12.1, a white count of 7900 with 71% PMNs, 12% lymphocytes and platelets 289,000. Her liver function tests were all normal. (The CT scan of her lungs did include her upper abdomen, and there was no evidence of metastasis in the liver, and the adrenal glands were normal bilaterally.} Her CEA at today's visit was 1.9 which is certainly not elevated and, thus, it appears that her primary tumor is probably not producing this substance, so we cannot use it as a marker.
CEA|carcinoembryonic antigen|CEA|281|283|LABORATORIES|SKIN: Without rashes, petechiae, or areas of cellulitis. LABORATORIES: CBC with a white blood cell count of 8600, hemoglobin of 8.3, MCV of 90, platelet count of 252,000. Her liver function tests were normal on _%#MM#%_ _%#DD#%_ and her stool occult blood studies were negative. A CEA level was not drawn but a CA-125 level was pending. ASSESSMENT AND PLAN: 1) A 53-year-old white female with presumed stage III (T3 N1 NX) adenocarcinoma of the colon versus metastatic lesion to the colon from as yet undiagnosed primary gynecologic malignancy -- the clear cell adenocarcinoma histology of Mrs. _%#NAME#%_'s tumor is somewhat less common and does suggest a possible underlying gynecologist malignancy.
CEA|carcinoembryonic antigen|CEA|177|179|LABORATORY|The lower extremities reveal no edema. LABORATORY: Laboratory studies on admission include an alkaline phosphatase of 100, ALT 25, AST 21, total bilirubin 1.1, and albumin 3.6. CEA level less than 0.5. Hemoglobin 13.1 (MCV 91). White blood count 8000. Platelet count 459,000. IMPRESSION: A 61-year-old female with Duke's C2 colon carcinoma, status post left hemicolectomy.
CEA|carotid endarterectomy|CEA.|168|171|PAST MEDICAL HISTORY|1. CVA 1 1/2 years ago, as a result has decreased vision with decreased reading and some decreased fine motor skills. As a result of the CVA he did receive a bilateral CEA. 2. Depression secondary to the CVA. 3. Hypertension. 4. Glucose intolerant of which he states he was diagnosed three to four weeks ago and he is being controlled with diet.
CEA|carcinoembryonic antigen|CEA|191|193|RECOMMENDATIONS|4. History of coronary artery disease for which he is essentially asymptomatic at present. RECOMMENDATIONS: 1. Continue postoperative care. 2. Begin iron supplements when tolerated. 3. Check CEA level if not previously done but start with a baseline value. 4. Review the pathology report when it becomes available. I will be happy to follow him with you during hospitalization.
CEA|carcinoembryonic antigen|CEA|202|204|IMPRESSION|Whether or not further tissue might be appropriate such as via mediastinoscopy will be at the discretion of her future physicians. I did today order a few lab tests including a CA-27-29 tumor marker, a CEA and a protein electrophoresis. Hopefully, by the time of discharge the path report will be available and I will provide this to her at discharge so she can take to her future physician visits.
CEA|carcinoembryonic antigen|CEA|162|164|LABORATORIES|Platelet count 119,000. After transfusion, his hemoglobin was 8.2 on _%#MMDD2005#%_, 8.0 on _%#MMDD2005#%_, and 8.9 yesterday, _%#MMDD2005#%_. No preop or postop CEA level was drawn. ASSESSMENT AND PLAN: A 57-year-old white male with likely stage 2 (T3N0Mx) adenocarcinoma of the colon (with some high-risk features).
CEA|carotid endarterectomy|CEA.|178|181|IMPRESSION|The patient agrees after this discussion. 2. Hypertension treated 3. Dyslipidemia on Crestor per patient 4. Peripheral vascular disease status post abdominal aortic aneurysm and CEA. PLAN: We Will proceed with emergent catheterization with further recommendations following the results of the study.
CEA|carotid endarterectomy|CEA|126|128|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: The patient is alert and oriented. I do not hear any cervical bruits. He has a barely perceptible right CEA scar. He has normal cervical and upper extremity pulses. Chest is clear. He has a loud murmur of aortic stenosis. His heart is regular. He is neurologically intact. I discussed with the patient during this setting would not favor intervention or further evaluation at this time for his right carotid disease.
CEA|carcinoembryonic antigen|CEA|156|158|ASSESSMENT|I also had discussion regarding the potential for an attempt at laparoscopic RFA in the future, if this lesion appears to be growing. I have also ordered a CEA level just as a baseline at this time. Once the patient is stable enough for discharge from the hospital, he can be scheduled to see me in the office in approximately 3 months with a repeat 3-phase liver protocol CT scan for further evaluation of this lesion, as well as a repeat CEA level.
CEA|carcinoembryonic antigen|CEA,|290|293|RECOMMENDATIONS|RECOMMENDATIONS: The patient's CT scan will be reviewed. Once we have preliminary information regarding the CT and stool culture studies, the patient would likely be a candidate for colonoscopy. This could be performed on Friday by Dr. _%#NAME#%_ _%#NAME#%_. We will send thyroid function, CEA, and alpha-fetoprotein levels, and review the CT scan. Thank you for the opportunity to assist with Ms. _%#NAME#%_'s care.
CEA|carcinoembryonic antigen|CEA|330|332|LABORATORY STUDIES|Lower extremities revealed no significant edema. NEUROLOGIC EXAMINATION: Nonfocal. LABORATORY STUDIES: On admission included a hemoglobin of 9.1 (MCV 62), white blood count 9,800, BUN 11, creatinine 0.8, platelet count 709,000, albumin 3.1, alkaline phosphatase 167, ALT 14, AST 33, total bilirubin 0.6, electrolytes were normal. CEA level pending. IMPRESSION: 1. 17-year-old female with widely metastatic colon carcinoma with apparent slow progression of her metastatic disease over the past several months.
CEA|carcinoembryonic antigen|CEA.|168|171|LAB  AND DIAGNOSTIC DATA|There is no lymphadenopathy. The PMI is nondisplaced. ABDOMEN: Soft and nontender. There is no pedal edema. LAB AND DIAGNOSTIC DATA: Were all normal including a normal CEA. IMPRESSION: _%#NAME#%_ _%#NAME#%_ is a very pleasant 34-year-old man with a newly diagnosed T3 N2 M0 or stage III adenocarcinoma of the colon.
CEA|carcinoembryonic antigen|CEA|150|152|LABORATORY DATA|LABORATORY DATA: On admission, hemoglobin was 8.2, with an MCV of 73, white count 4900, platelets 458,000. Basic metabolic panel was normal. He had a CEA of 1597. Alkaline phosphatase was 95, AST 38, total bilirubin less than 0.1. Chest x-ray on _%#MMDD2003#%_ showed bilateral pleural effusions with bibasilar atelectasis.
CEA|carcinoembryonic antigen|CEA,|215|218|LOCATION|He was in favor of this, so we will change him from an intermittent Xeloda to a more continuous dose, using 1500 mg in the morning and 1000 in the p.m. on an ongoing basis. We will obviously keep a close eye on his CEA, and if this is not effective, then we have no choice but to try a different anti- colon cancer drug, such as oxaliplatin.
CEA|carcinoembryonic antigen|CEA,|231|234|LOCATION|His CEA at that point was over 1500. We started him on a combination of chemotherapy on _%#MM#%_ _%#DD#%_ with CPT-11, 5FU, and leucovorin. Mr. _%#NAME#%_ received a total of five such cycles, and we are gratified to note that his CEA, when last checked on _%#MMDD2003#%_, was down to 21. He did have some difficulty with the chemotherapy in terms of diarrhea and mild anemia, but he has done quite well of late and he is now gaining weight.
CEA|carcinoembryonic antigen|CEA|129|131|HISTORY OF PRESENT ILLNESS|There was some questionable intermediate size of small lesion in the liver which was concluded as a benign lesion by ultrasound. CEA at that time was elevated to 45.6. Patient was again offered a neoadjuvant chemoradiation followed by surgical resection.
CEA|carcinoembryonic antigen|CEA|311|313|LABORATORY DATA|LABORATORY DATA: CBC from _%#MM#%_ _%#DD#%_: Hemoglobin 13, hematocrit 38, white count 8500, platelet count 393,000, serum albumin 3.3, alkaline phosphatase 99, ALT 25, AST 21, total bilirubin 0.2, calcium 8.4 which is low normal. Electrolytes: Sodium 141, potassium 3.9, chloride 102, BUN 18, creatinine 0.74, CEA 92.3 normal being up to 2.5. Pathology is pending. ASSESSMENT/PLAN: This is a 65-year-old Hmong patient with locally advanced rectal cancer most likely T3 N1 M0.
CEA|carotid endarterectomy|CEA,|345|348|HISTORY OF PRESENT ILLNESS|The requesting cardiologist is Dr. _%#NAME#%_ _%#NAME#%_. HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old gentleman who has a history of hypertension, hyperlipidemia, previous history of coronary artery disease, myocardial infarction, and PCI. The patient has been asymptomatic from a cardiac prospective. He was recently evaluated for CEA, and he was sent for an adenosine stress test. The adenosine stress test showed LV dilatation, reversible defect of anteroapical and inferoseptal region.
CEA|carcinoembryonic antigen|CEA|104|106|DOB|There was a small amount of fluid in the cul-de-sac region, but no other definite disk disease. A preop CEA was normal, and the patient was therefore taken to the operating room just yesterday by Dr. _%#NAME#%_. I have reviewed the operative findings with Dr. _%#NAME#%_ in person.
CEA|carcinoembryonic antigen|CEA|218|220|IMPRESSION|Brief consultation with the on-call pathologist, Dr. _%#NAME#%_, indicates that this process is malignant, although special stains are pending at this time. I would therefore recommend the following: 1. Add CA19-9 and CEA tumor level markers to the next blood draw to assist in diagnosis. 2. Repeat CBC, CMP, lipase, and amylase levels. 3. OxyContin for improved long-acting pain relief in addition to short- acting IV morphine.
CEA|carotid endarterectomy|CEA.|266|269|PAST SURGICAL HISTORY|PAST SURGICAL HISTORY: She is status post ORIF of the hip on the left that was complicated by DVT and she is status post mesenteric bypass secondary to ischemia. Status post hysterectomy, she is status post right total hip arthroplasty. She is status post bilateral CEA. ALLERGIES: Zantac, Bactrim, morphine and codeine.
CEA|carotid endarterectomy|CEA|156|158|PAST  MEDICAL HISTORY|3. Peripheral vascular disease, status post bilateral femoral popliteal bypass surgeries on _%#MM#%_ _%#DD#%_, 2007. 4. Right CEA in _%#MM#%_ 2007. 5. Left CEA in _%#MM#%_ 2007. 6. Echocardiogram in _%#MM#%_ 2007 showed an EF of 50% with inferior hypokinesis and LVH. 7. Documented history of atrial flutter. I do not have full details available to me at this time.
CEA|carcinoembryonic antigen|CEA|239|241|DISCUSSION/RECOMMENDATIONS|We also discussed the lack of any proof of benefit of adjuvant therapy and there was no clinical trials for stage I disease. Therefore, the recommendation is watchful waiting and recommended monitoring through Cancer Surveillance Program. CEA was mildly elevated. This will be repeated during his follow-up. I also discussed with the pathologist who reviewed his specimens there was no microscopic indications of microsatellite instability, but with his age under 50 the test for hereditary non-polyposis colon cancer could be done.
CEA|carcinoembryonic antigen|CEA|145|147|RECOMMENDATIONS|Abdomen was benign. At today's visit, a CBC was obtained along with liver function studies. If there are any problems, I will call you. Her last CEA was on _%#MM#%_ _%#DD#%_, 2001, and was normal at 1.8. We will see this patient back periodically in the future.
CEA|carcinoembryonic antigen|CEA|137|139|IMPRESSION  AND PLAN|Both he and his sister asked many intelligent questions and I answered them to their satisfaction. At this time, I recommend obtaining a CEA and CA 19.9 levels. Prior to starting chemotherapy he will need a complete staging workup with a CT scan of the chest, abdomen and pelvis as a new baseline.
CEA|carcinoembryonic antigen|CEA|250|252|IMPRESSION|At that point, if we do opt for treatment, we will plan six months of adjuvant 5-FU and leucovorin. If the patient opts against chemotherapy, which would be my bias and the standard recommendation, then we will set up a follow up regimen with serial CEA monitoring and periodic colonoscopies, the first at his one year date. Thank you for allowing me to participate in _%#NAME#%_ _%#NAME#%_'s care.
CEA|carotid endarterectomy|CEA|189|191|PHYSICAL  EXAMINATION|VITAL SIGNS: Stable with a pulse of 61. She is afebrile with normal oxygen saturations on room air. HEENT: Reveals supple neck with normal carotid upstrokes without bruits. There is a left CEA scar. Pupils are equal. There is no cyanosis or pallor. She has edentulous upper and mostly edentulous lower jaw with clear throat.
CEA|carcinoembryonic antigen|CEA,|300|303|LABORATORY STUDIES|She was placed on Zosyn for her infiltrates. LABORATORY STUDIES: Arterial blood gases showed a pH of 729, pCO2 38, pO2 64, sodium 138, K of 4-1/2, creatinine 2.12, BUN 20, normal protein earlier in her hospital course and normal albumin. She had elevated alkaline phosphatase. Elevated GGT, elevated CEA, elevated CA-125 and an elevated alpha-fetoprotein. She has also had weight loss and nonproductive cough prior to admission. Other review of systems is pertinent for snoring, dry mouth in the morning, daytime hypersomnolence.
CEA|carcinoembryonic antigen|CEA|188|190|HISTORY OF PRESENT ILLNESS|The patient subsequently received 6 months of FOLFOX and tolerated fairly well with some mild peripheral neuropathy. Unfortunately, in _%#MM2006#%_, the patient was found to have a rising CEA 3 months after his chemotherapy. Imaging studies revealed an enlarged mesenteric lymph node which was small. PET CT also confirmed the disease progression. The patient at that time was seen by Dr. _%#NAME#%_ _%#NAME#%_.
CEA|carotid endarterectomy|CEA|208|210|PHYSICAL EXAMINATION|VITAL SIGNS: She is afebrile with blood pressure 117/56, pulse in the 60s and oxygen saturation is 92% on supplemental oxygen. HEENT/NECK: With a supple neck with grossly normal carotid upstrokes and a right CEA scar. There is soft right carotid bruit. She has a slightly disconjugate gaze with equal pupils. There is no cyanosis or pallor. CHEST: Reveals increased AP diameter with diffuse rather severely decreased air exchange.
CEA|carcinoembryonic antigen|CEA|200|202|LABORATORY DATA|Serum electrolytes studies have been normal. Creatinine measured on _%#MMDD2007#%_ is 0.63 and a CBC measured today shows a white count of 11,200, hemoglobin 11.4, platelet count 227,000. There is no CEA determination available. IMPRESSION: Apparently isolated cerebral metastasis now status post resection with histology consistent with a colon primary.
CEA|carcinoembryonic antigen|CEA|180|182|IMPRESSION|This is consistent with tumor recurrence. She had an enteroclysis study which finished yesterday. This revealed a delayed transit time but with no single point of obstruction. Her CEA level is normal, but her CEA level has always been normal. On physical examination, she actually appears non-toxic. She has a nasogastric tube in place.
CEA|carcinoembryonic antigen|CEA|198|200|HISTORY OF PRESENT ILLNESS|I do not have any baseline lab tests other than a hemoglobin of 14.4 with a white count of 5900. She had a chest x-ray that was clear. Electrocardiogram was normal. I do not have liver functions or CEA present. Mrs. _%#NAME#%_ has a Duke's C colon cancer. This is an exceedingly unusual presentation for a small tumor within the villous adenoma that is well differentiated.
CEA|carcinoembryonic antigen|CEA|203|205|LABORATORY DATA|EXTREMITIES: No edema. NEUROLOGIC: Nonfocal. SKIN: I do not see any spiders. LABORATORY DATA: Electrolytes were abnormal and now have normalized. Alkaline phosphatase is 231. Bilirubin 2.6. Albumin 3.8. CEA is 30, normal up to 3.5. Hemoglobin is 12. White count is 4.1. CT SCAN: CT scan shows surgical clips in the left aspect of the pelvis, sigmoid diverticulosis and thickening suggesting early diverticulitis, prominence of the intrahepatic bile duct in the left lobe of the liver, status post cholecystectomy, aneurysmal dilatation of the abdominal aorta, and degenerative changes of the spine.
CEA|carcinoembryonic antigen|CEA|236|238|LABORATORY DATA|His incision site looks clean. EXTREMITIES: No edema, warm, well perfused. NEUROLOGIC: Intact. No focal findings. LABORATORY DATA: Potassium today is 4.6 with a hemoglobin of 13.1. His preop potassium was 3.5 with a hemoglobin of 15.5. CEA on _%#MMDD#%_ was just 1.0. ASSESSEMENT/PLAN: Patient is postoperative colon resection for sigmoid adenocarcinoma.
CEA|carcinoembryonic antigen|CEA,|248|251|PLAN/RECOMMENDATIONS|We will discontinue the prednisone and in place substitute Decadron 10 mg t.i.d. to help with potential edema in the area of the tumor. Various laboratory studies have been ordered including a comprehensive metabolic battery, beta 2 microglobulin, CEA, PSA and I believe it would be appropriate to obtain a chest CT to rule out possible lung primary. We also had a protein electrophoresis ordered. I would consider a neurosurgical opinion for possible surgical intervention and diagnostic biopsy.
CEA|carcinoembryonic antigen|CEA|95|97|LABORATORY DATA|IMMUNE: Negative. PSYCH: Negative. SLEEP: OK with Ambien. PAIN: Negative. LABORATORY DATA: Her CEA has come down since surgery. She is due for an MRI the end of _%#MM#%_. FAMILY HISTORY/SOCIAL HISTORY: Her 35-year-old son may have Crohn's. He is being worked up for it, or colitis.
CEA|carcinoembryonic antigen|CEA|135|137|LABORATORY DATA|PSYCH: Depression is under good control with her Effexor. SLEEP: Ambien and trazodone help her sleep. PAIN: Negative. LABORATORY DATA: CEA is going down. MRI looks as though she has some changes secondary to the surgery but we need to do close follow-up.
CEA|carcinoembryonic antigen|CEA|117|119|IMPRESSION AND PLAN|If that were cancer, I would get a CT scan of the abdomen and pelvis to rule out metastatic disease. We will check a CEA level today as well. I would ask the primary team to evaluate the need for Coumadin long term as she does have multiple polyps.
CEA|carotid endarterectomy|CEA|187|189|PHYSICAL EXAMINATION|LUNGS: Clear to auscultation in all fields with good respiratory effort. NECK; Normal carotid upstrokes; there is a left carotid bruits but no right carotid bruit. There is a well-healed CEA scar on the right. Thyroid is normal to palpation. HEENT: No xanthelasma or cyanosis. CARDIAC: Regular rate and rhythm, normal S1 and S2.
CEA|carcinoembryonic antigen|CEA|259|261|DISCUSSION/RECOMMENDATIONS|I will obtain the CT scan report of the abdomen and pelvis from earlier this month to look for particular abnormalities which may direct the diagnosis toward primary malignancy. I will obtain a CA-125 for possible ovarian or primary peritoneal carcinoma, and CEA which could be elevated with primary gastrointestinal malignancy. I also discussed with her that exploratory laparotomy and debulking surgery may be considered as an up front option.
CEA|carotid endarterectomy|CEA|206|208|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a pleasant 76-year-old female with history of coronary artery disease, status post CABG in 1996 with a LIMA to LAD, SVG to PDA, SVG to OM, bilateral CEA one year later, hypertension, diabetes, obesity, recent tobacco cessation, multiple abdominal masses of ill-defined nature, who presents with increasing shortness of breath for the past two weeks, and possible plus or minus 5 pound weight gain. She presented to the ER with essentially class IV dyspnea.
CEA|carcinoembryonic antigen|CEA|299|301|IMPRESSION|She has a modest risk of disease recurrence, in the range of 25-30% following surgery alone, but there is no clear benefit to adjuvant chemotherapy in this setting, especially in view of her multiple underlying medical problems. I would recommend periodic follow-up with liver enzymes and perhaps a CEA level to watch for signs of disease recurrence in the future. Otherwise, no specific follow-up or treatment if necessary. The situation was reviewed with the patient and her family, including her overall prognosis and follow-up needs.
CEA|carcinoembryonic antigen|CEA|225|227|LABORATORY  DATA|LABORATORY DATA: Laboratory studies obtained on admission included a white blood count of 8400, hemoglobin 9.4, platelet count 306,000. Liver function studies were normal, and her serum creatinine was 1.1. Calcium was 8.3. A CEA level was not performed. An abdominal and pelvic CT scan on _%#MMDD2007#%_ revealed diffuse fatty infiltration of liver with no significant adenopathy in the abdomen or pelvis.
CEA|carcinoembryonic antigen|CEA|215|217|RECOMMENDATIONS|We could plan on starting treatment in approximately three to four weeks from now to allow adequate recovery from this hospitalization. I think she should continue on iron as you are presently doing. I have drawn a CEA level today. Thank you very much for asking me to see this pleasant patient.
CEA|carcinoembryonic antigen|CEA|195|197|PLAN|PLAN: I have made the following recommendations to _%#NAME#%_ today: 1. Routine postoperative recovery per her primary surgeon/physicians. 2. A recheck CBC/CEA (to insure no anemia or persistent CEA elevation respectively). 3. Outpatient PET/CT scan in 2-3 weeks to complete TNM staging. 4. Follow up with me (MOHPA, _%#CITY#%_) in approximately 3-4 weeks' time to discuss the diagnosis, prognosis, staging and treatment options.
CEA|carcinoembryonic antigen|CEA|331|333|PLAN|I am pleased to report that _%#NAME#%_ has been a model patient and he has tolerated all of his treatment quite well since _%#MMDD#%_, and he will be completing his adjuvant treatment as of _%#MMDD2004#%_. Throughout this time frame his labs have remained stable. His most recent liver functions were entirely normal, and his last CEA determination on _%#MMDD#%_ was normal at 0.8, we have repeated it today. CURRENT MEDICATIONS: (Unchanged). 1. Lipitor. 2. Coreg. 3. Cozaar.
CEA|carcinoembryonic antigen|CEA|183|185||All of these show only the scar in the ablated areas of her liver. They are unchanged and there is no evidence of recurrent malignancy. In addition, her serum tumor markers CA125 and CEA levels have remained normal. _%#NAME#%_ currently is being maintained on alternating sequence of tamoxifen 20 mg b.i.d. for three weeks, alternating with Megace 80 mg b.i.d. for three weeks.
CEA|carcinoembryonic antigen|CEA|237|239|SOCIAL HISTORY|Other pertinent laboratory studies that have been obtained on _%#MMDD2003#%_: Hemoglobin was 13.8. Hematocrit was 42. White count 7100 with 58% neutrophils, 29% lymphocytes and 9% monocytes. Her platelet count was 337,000. INR was 0.95. CEA was 1.0. Alpha fetoprotein was 3.6. A comprehensive metabolic panel was entirely normal, including normal liver functions, BUN of 12 and creatinine of 0.7. Albumen was 7.2. Her CA-125 was elevated modestly at 158.
CEA|carcinoembryonic antigen|CEA|52|54|STUDIES|STUDIES: The pathology report is as already stated. CEA level from _%#MMDD2004#%_ was 0.7. Serum electrolytes were normal on _%#MMDD2004#%_. CBC on this date was normal as well, with a hemoglobin of 13.5 gm/dl.
CEA|carotid endarterectomy|CEA.|138|141|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Cerebrovascular disease with bilateral carotid bruits and stenosis noted on last hospitalization, status post right CEA. Status post cataract surgery. Status post left total knee arthroplasty. Status post shoulder surgery _%#MMDD2003#%_. Status post right hip fracture with total hip arthroplasty _%#MM2003#%_.
CEA|carcinoembryonic antigen|CEA|158|160|LABORATORY DATA|NEUROLOGIC: He has no asterixis. LABORATORY DATA: His white count 9.4, hemoglobin 13.3, hematocrit 30.6, MCV is 94, platelet count 188,000. INR 0.99. Antigen CEA with 2.2. B-core antibody is positive. Hepatitis B surface antibody was positive. Hepatitis B surface antigen was negative. Hepatitis C antibody was checked and was found to be positive.
CEA|carcinoembryonic antigen|CEA|168|170|IMPRESSION|She will be scheduled to undergo a staging PET scan in 2 or 3 weeks and she may also benefit from a bone scan or a needle biopsy of the left adrenal lesion. A baseline CEA level will be obtained today. Her previous records from Abbott Northwestern Hospital will be obtained regarding her history of polycythemia, especially given her family history of polycythemia in several family members.
CEA|carcinoembryonic antigen|CEA|159|161|PHYSICAL EXAMINATION|There is no evidence of disk disease on either the CT scan of the chest or the previous CT scan of the abdomen. The remainder of his labs are stable. I note a CEA in the 4.5 range. IMPRESSION: _%#NAME#%_ _%#NAME#%_ is an otherwise healthy 55-year-old man, who has developed an adenocarcinoma of the duodenum that is stage 3 with metastatic spread to four regional lymph nodes.
CEA|carcinoembryonic antigen|CEA|135|137|PROBLEM #5|We did not pursue a PET scan during this admission as there is still too much inflammation in the belly to provide an accurate read. A CEA level was redrawn and was only 13. However, if the soft tissue density remains or is larger at the patient's next CAT scan a PET scan should be done to further evaluate for recurrence of malignancy.
CEA|carcinoembryonic antigen|CEA|218|220|HISTORY OF PRESENT ILLNESS|The patient had been on adjuvant chemotherapy with oxaliplatin and Xeloda, but recently oxaliplatin was discontinued due to some side effects. The patient has been followed by Dr. _%#NAME#%_ continuously. Recently her CEA increased during treatment without any positive PET scan findings. In mid-to-late _%#MM#%_ she started having problems with unstable gait and dizziness.
CEA|carcinoembryonic antigen|CEA|177|179|LABORATORY DATA (8/23/05)|She seems to have no motor weakness, however, her balance is very disturbed and she refuses to stand up. SKIN: Very thin with much ecchymosis. LABORATORY DATA (_%#MMDD2005#%_): CEA 3.5, white count 7700, hemoglobin 14.1, platelet count 140,000. Creatinine 0.6, LDH 265, total bilirubin 0.9, potassium 7.8, alkaline phosphatase 96.
CEA|carcinoembryonic antigen|CEA|209|211|PHYSICAL EXAMINATION|LUNGS: Lungs are clear. HEART: Regular. ABDOMEN: Abdomen is soft and nontender, nondistended with normal, active bowel sounds. She has no masses. The results of her colonoscopy were reviewed. She had a normal CEA level. She did have colonic biopsies which came back as showing adenocarcinoma, moderate to poorly differentiated. ASSESSMENT: This 84-year-old female has a near-obstructing adenocarcinoma of the colon.
CEA|carcinoembryonic antigen|CEA|174|176|IMPRESSION|I therefore have ordered a barium enema. That will be performed tomorrow. This will be followed up by a CT scan to check for metastatic disease as well as a hepatic panel, a CEA and chest x-ray. The patient has been tentatively scheduled for a sigmoid colectomy on _%#MMDD#%_. She understands the surgery, the prep, risks and potential complications and consents.
CEA|carcinoembryonic antigen|CEA|341|343|LABORATORY AND DIAGNOSTICS|EXTREMITIES: 1+ posterior tibial pulses bilaterally. No edema. INTEGUMENT: Skin is warm and dry with no rashes, petechiae or purpura. LABORATORY AND DIAGNOSTICS: Sodium 134, potassium 4.2, BUN 26, creatinine 1.07, white count 15, hemoglobin 13, MCV 93, platelets 248,000, lipase 1,449, bilirubin 0.8, alkaline phosphatase 85, ALT 7, AST 20, CEA 2.0 and INR 3.22. CT of the abdomen and pelvis shows a large hiatal hernia containing most of the stomach.
CEA|carcinoembryonic antigen|CEA|118|120|LABORATORY DATA|IMMUNE: Negative. PSYCH: Negative. SLEEP: Negative PAIN: Negative. LABORATORY DATA: Lab and CT were normal except his CEA is slightly elevated. His last colonoscopy was _%#MMDD2002#%_ and he is supposed to have one about every three years. FAMILY HISTORY/SOCIAL HISTORY: No change ALLERGIES: No known allergies PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 134/80, pulse 68, respirations 20, temperature 98.2, and weight 190.
CEA|carcinoembryonic antigen|CEA|182|184|DISCUSSION/RECOMMENDATIONS|However, if the colonoscopy is negative, I will arrange for a CT-guided biopsy of the liver. The complications and procedure were discussed in detail with the patient. I will obtain CEA and PSA to look for tumor markers. The patient inquired about prognosis. I deferred details about prognosis until tissue diagnosis and stage of the malignancy is known.
CEA|carcinoembryonic antigen|CEA|137|139|RECOMMENDATIONS|RECOMMENDATIONS: Recommend resection. Will plan for operative intervention tomorrow. Will arrange for preoperative CT of the abdomen and CEA level. In addition, would like to transfuse one additional unit of blood in preparation for surgery.
CEA|carcinoembryonic antigen|CEA|139|141|HISTORY OF PRESENT ILLNESS|Her lymph nodes revealed 9 of 19 total positive for localized metastatic spread. No other staging imaging studies were performed nor was a CEA level. _%#NAME#%_ is now at postoperative day #5 from her definitive surgery and is doing quite well.
CEA|carcinoembryonic antigen|CEA|167|169|LABORATORY DATA|LABORATORY DATA: Include a presurgical CBC with a white blood cell count of 6000, hemoglobin of 13.7, MCV of 88, platelet count of 282,000 with normal differential. A CEA level and hepatic panel are pending (ordered today). ASSESSMENT AND PLAN: Stage III (T3 N2 MX) rectal carcinoma -- it appears _%#NAME#%_ has had a curative surgery based on her clear resection margins on the surgical pathology report.
CEA|carcinoembryonic antigen|CEA|179|181|ASSESSMENT|Her weight was 129 pounds and blood pressure 106/70. Patient will return to see me in three months. We will be monitoring her tumor markers and other tests as indicated. Her last CEA was 3.1 on _%#MM#%_ _%#DD#%_. I did advise the patient that she should get her yearly flu vaccine through your office.
CEA|carcinoembryonic antigen|CEA|229|231|RECENT LABORATORIES|RECENT LABORATORIES: Include hemoglobin from _%#MMDD2004#%_ of 8.5. Her white blood cell count was 10,300 with a platelet count of 341,000. Her MCV was low at 68. Liver function tests were within normal limits on _%#MMDD2004#%_. CEA level was elevated at 23 mcg/l on _%#MMDD2004#%_ (one day prior to the operation). ASSESSMENT AND PLAN: A 77-year-old white female with Stage II colon cancer with high risk features (large primary tumor size, poorly differentiated/high grade histology) - based on my review of _%#NAME#%_'s pathology, I am concerned about her risk of recurrence over the next five to ten years.
CEA|carcinoembryonic antigen|CEA|221|223|PLAN|At this point she is in remission after dissection, and her risk of recurrence is really exceedingly low. PLAN: We could consider a baseline CT scan postoperatively, and then I would consider monitoring her with periodic CEA laboratory evaluation. The most important part of her follow-up, however, will be with serial colonoscopies. My suggestion is that she have a repeat colonoscopy obtained roughly one year from now.
CEA|carcinoembryonic antigen|CEA|214|216|PLAN|There is no pancreatic mass. There was no apparent retroperitoneal lymphadenopathy. On _%#MMDD2005#%_ an abdominal tap was performed and the peritoneal fluid was positive for malignant adenocarcinoma, positive for CEA CK 7, and CK 20. Negative for CDX with differential including gastric or pancreatic primary. His alpha-fetoprotein was 5.7. The CEA level was elevated at 27.3. Please see Dr. _%#NAME#%_'s admission note for details.
CEA|carcinoembryonic antigen|CEA|143|145|HISTORY OF PRESENT ILLNESS|The surgery was followed by chemotherapy. The patient was followed by clinical examination and CEA. On _%#MMDD2002#%_ there was an increase in CEA from 2.3 to 5.7. The patient had colonoscopy on _%#MMDD2002#%_ which demonstrated a 4 cm infiltrating mass in the rectum. Biopsy was suspicious for cancer but was not diagnostic. On _%#MMDD2002#%_ another biopsy was attempted, and it did not reveal any malignancy.
CEA|carcinoembryonic antigen|CEA|196|198|IMPRESSION|LABORATORY DATA: PSA was 0.4 (_%#MMDD2003#%_). IMPRESSION: Mr. _%#NAME#%_ is a 77-year-old gentleman with recurrent adenocarcinoma of the colon. We believes this is recurrent colon cancer, as his CEA has risen, and doubt this to be recurrent prostate cancer was only 0.4. PLAN: Dr. _%#NAME#%_, Dr. _%#NAME#%_ and myself met with the patient and discussed potential laparotomy with colostomy followed by radiation therapy.
CEA|carcinoembryonic antigen|CEA|192|194|IMPRESSION/PLAN|There are no apparent masses. At today's visit, her hemoglobin was 11.3, white count 4000, platelets were 136,000. On _%#MMDD2006#%_ at your office, she had an ALT of 28 and an AST of 32. The CEA was drawn today and is pending. In considering at this point her various options following surgical resection of an isolated metastasis, there is a paucity of data regarding what to do with patients at this point in time.
CEA|carcinoembryonic antigen|CEA|151|153|IMPRESSION/PLAN|We subsequently did do an MRI of her abdomen on _%#MMDD2006#%_, which showed a partial right hepatectomy but no evidence of disease recurrence. Serial CEA markers have been stable with the most recent one in the end of _%#MM2007#%_ being normal at 1.1. Her liver functions studies are normal.
CEA|carcinoembryonic antigen|CEA|226|228|IMPRESSION|Her legs are warm. According to the patient, she had a CT scan on her last admission and underwent colonoscopy with Dr. _%#NAME#%_ prior to his leaving _%#CITY#%_. In terms of her cancer follow-up, I suggested that she have a CEA drawn. Otherwise, she appears to be up to date. I will review her CT scan that was performed on her last admission.
CEA|carcinoembryonic antigen|CEA|262|264|LABORATORIES|LABORATORIES: CBC from _%#MM#%_ _%#DD#%_, 2003: White blood cell count 8.4, hemoglobin 11.0 with an MCV of 85, platelet count of 251,000. His hemoglobin A1c was 8.8. Electrolytes were within normal limits except for a slightly low calcium at 7.6. A preoperative CEA level was normal at 1.7. Histopathology from right hemicolectomy indicates the following: 1) Moderate to poorly differentiated infiltrating adenocarcinoma with ulceration and extension through the muscularis to the approximate outer serosal surface.
CEA|carcinoembryonic antigen|CEA|183|185|LABORATORY STUDIES AT THE TIME OF ADMISSION|EXTREMITIES revealed no edema. LABORATORY STUDIES AT THE TIME OF ADMISSION: Included normal liver function studies including an alkaline phosphatase, ALT, AST, and total bilirubin. A CEA level was minimally elevated at 3.6 preoperatively. His CBC revealed a hemoglobin of 11.3 (MCV 65). White blood count 14,300, platelet count 401,000. IMPRESSION: A 65-year-old male with a Duke's C2 colon carcinoma (T4N2M0), with growth extension of his tumor to the parietal peritoneum.
CEA|carcinoembryonic antigen|CEA.|125|128|RECOMMENDATIONS|RECOMMENDATIONS: 1. Await thoracentesis fluid. 2. Hepatitis C antibody. 3. Hepatitis B surface antigen and core antibody. 4. CEA. 5. Alpha-fetoprotein. 6. Ultrasound-guided liver biopsy if no diagnosis was made post thoracentesis.
CEA|carcinoembryonic antigen|CEA.|116|119|ONCOLOGY CONSULTATION|There was focal extranodal extension identified as well. I do not believe that she has had CT scans or preoperative CEA. Dr. _%#NAME#%_ at the time of surgery notes no liver metastases. We were asked to see her regarding further management of this particular problem.
CEA|carotid endarterectomy|CEA|172|174|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Coronary artery disease, status post drug-eluting stent to the LAD. 2. Gastroesophageal reflux disease. 3. Carotid artery disease status post left CEA in _%#MM2007#%_. 4. Cancer of the larynx treated with surgery and radiation many years ago. SOCIAL HISTORY: She lives with her husband. She still works.
CEA|carotid endarterectomy|CEA|231|233|CURRENT PHYSICAL EXAMINATION|The patient says it was increased slightly when she was informed that she would have to stay another day in the hospital. Respiratory rate is 20, sating 99% on room air. JVP is flat. Carotids are 2+ without bruits. There is a left CEA scar. CARDIAC: Regular rate and rhythm. There is a physiologic split S2; P2 was not increased. The LV apical impulse is nonsustained. It is not displaced; it is at the midclavicular line.
CEA|carcinoembryonic antigen|CEA|153|155|LABORATORIES|LABORATORIES: Laboratories include a CBC on _%#MMDD2003#%_ with a hemoglobin of 9.3. The MCV was 96. White count 6300. Platelets 142,000. A preoperative CEA level was normal at less than 0.5. The electrolytes were within normal limits. RADIOLOGY: CT of the abdomen and pelvis revealed: 1. Extensive renal cysts, greater on the left than right.
CEA|carcinoembryonic antigen|CEA.|140|143|RECOMMENDATIONS|We will also set her up for a CT scan of the chest to rule out pulmonary disease, and I will check a tumor marker, including a CA-125 and a CEA. We will wait for this above workup. If the CA-125 is elevated and/or if the cytology is suspicious for ovarian cancer, my bias would be to proceed with a laparotomy for debulking surgery, and if that proves to be a peritoneal or ovarian primary, to then proceed with chemotherapy after debulking laparotomy.
CEA|carcinoembryonic antigen|CEA|231|233|RECOMMENDATIONS|The patient has associated hypogammaglobulinemia. To determine the precise nature of this imaging finding, I would consider the following laboratory and imaging studies. RECOMMENDATIONS: 1. Check serum amylase and lipase. 2. Check CEA and CA 19-9. 3. Endoscopic ultrasound at F-UMC to clearly determine nature of lesion in head of pancreas, and if suspicious in appearance, a fine-needle aspiration biopsy can be obtained.
CEA|carcinoembryonic antigen|CEA|221|223|DISCUSSION/RECOMMENDATIONS|I have asked him to meet with me in the office and he requested that his daughter to be with him and I will accompany the idea to have family members with him to address concerns and questions about cancer. I will obtain CEA level as a baseline and liver function tests also as a baseline prior to any systemic therapy. There are clinical studies available for his particular stage, however, I having active prostate cancer diagnosed just recently will preclude him from entering these clinical trials.
CEA|carotid endarterectomy|CEA|197|199|PHYSICAL  EXAMINATION|Potassium was 4.5, creatinine 1.08, hemoglobin 15.9 grams. Platelets were normal. White count, normal. PHYSICAL EXAMINATION: HEAD: Showed vital signs as above. Head was normal NECK: Showed a right CEA scar, without bruits. No neck vein distention noted at 30 degrees. HEART: Mildly irregular 50-60 beats per minute with no gallop or murmur.
CEA|carcinoembryonic antigen|(CEA)|148|152|LABORATORY DATA (5/14/02)|There are no areas of decreased sensation or weakness. His gait is within normal limits. LABORATORY DATA (_%#MMDD2002#%_): Carcinoembryonic antigen (CEA) at 1.6. Electrolytes are all within normal limits with the exception of chloride which is 110. Albumin 4.1, alkaline phosphatase 99, ALT 14, AST 16, bilirubin and lactic dehydrogenase (LDH) within normal limits at 0.3 and 401 respectively.
CEA|carotid endarterectomy|CEA|223|225|PAST MEDICAL HISTORY|2. AVR with Bjork-Shiley valve in 1981. 3. History of ischemic cardiomyopathy with an EF of 35-40% prior to this hospitalization. 4. Peripheral vascular disease status post left iliofemoral bypass. 5. Status post bilateral CEA in 1996 with recurrent 90% stenosis on left. 6. Status post CVA with resultant photosensitivity. 7. Hypertension.
CEA|carotid endarterectomy|CEA.|175|178|PAST SURGICAL HISTORY|Atrial fibrillation. Abdominal hernia. Clostridium difficile. Recent myocardial infarction. PAST SURGICAL HISTORY: Self-inflicted gunshot wound to the abdomen. Tonsillectomy. CEA. Left hip replacement. Left cataract surgery. REVIEW OF SYSTEMS: Review of systems not available as the patient at this time is mute.
CEA|carcinoembryonic antigen|CEA|193|195|LABORATORY DATA|Trace lower extremity edema. LABORATORY DATA: CBC with a white blood cell count 7600, hemoglobin 9.5, MCV 93, platelet count 217,000. Creatinine normal at 1.2, as were the liver function tests CEA level was not drawn. X-RAYS: Upper GI study revealed a hiatal hernia.
CEA|carcinoembryonic antigen|CEA|185|187|ASSESSMENT/PLAN|Therefore, given the patient's age, I have recommended to her simply close observation alone. I have recommended that she follow up in our clinic in approximately 2-3 months with a new CEA level and CT scan of the abdomen and pelvis. 2. Hematology. a. _%#NAME#%_ is quite anemic (hemoglobin 9.5 with a normal MCV).
CEA|carotid endarterectomy|CEA.|246|249|IMPRESSION|He has no carotid hypersensitivity on exam today. 2. Coronary artery disease with multiple revascularizations. Stable angina pectoris. Normal ejection fraction. 3. Peripheral vascular disease with bilateral claudication and status post bilateral CEA. 4. Diabetes mellitus. RECOMMENDATION: 1. I would change his Norvasc to hs dosing.
CEA|carcinoembryonic antigen|CEA|121|123|LABORATORY DATA|SLEEP: Negative PAIN: He is on Vicodin and Flexeril for his back pain, some oxycodone . LABORATORY DATA: Increase in his CEA but he continues to smoke. CHEMO/RADIATION TREATMENT HISTORY: Last drugs were 5- FU and Leucovorin.
CEA|carcinoembryonic antigen|CEA|140|142|LABORATORY DATA|LABORATORY DATA: Markers around the time of initiation of therapy were quite elevated with a CA27.29 at 1340, rechecked it and it was 1438. CEA had gone up to 37.6, on recheck it was 42.8. FAMILY HISTORY/SOCIAL HISTORY: No change CHEMO/RADIATION TREATMENT HISTORY: She continues on Zometa and started her University of Minnesota protocol first dose.
CEA|carcinoembryonic antigen|CEA|197|199|LABORATORY DATA|The patient has no hepatosplenomegaly. RECTAL: Not performed. Distal extremities are unremarkable. LABORATORY DATA: Hemoglobin 11.8. White count 5200 with a normal differential. Platelets 262,000. CEA 1.1. CA27-29 13. Comprehensive metabolic panel was normal with the exception her alkaline phosphatase was slightly elevated at 151, normal up to 150.
CEA|carcinoembryonic antigen|CEA|169|171|LABORATORIES|Her electrolyte panel is normal except for an elevated glucose of 213. Her creatinine is normal at 0.8. Liver function tests were not performed during this admission. A CEA level has not been drawn. PATHOLOGY: 1. Right hemicolectomy: a) Adenocarcinoma, intestinal type, moderately differentiated, 4 cm in the maximum diameter, invading through the muscular propria into the pericolonic adipose tissue.
CEA|carotid endarterectomy|CEA|154|156|PHYSICAL EXAMINATION|GENERAL: He is alert and oriented, in no distress. HEENT: Reveals supple neck. Carotid upstrokes are diminished, more so on the left. There are bilateral CEA scars. There are bilateral soft carotid bruits. There is no cyanosis or pallor. Throat is clear. LUNGS: Clear, without increased effort. CARDIOVASCULAR: S1, S2 without murmur, gallop, heave or JVD.
CEA|UNSURED SENSE|CEA|207|209|PAST MEDICAL HISTORY|There was no dizziness or syncopal episodes. She thinks she may be mildly short of breath. PAST MEDICAL HISTORY: 1. History of thromboembolic disease, probable pulmonary embolism when her primary peritoneal CEA was diagnosed. 2. Hypothyroidism. FAMILY HISTORY: There is no family history of premature atherosclerotic disease.
CEA|carcinoembryonic antigen|CEA|235|237|ASSESSMENT/PLAN|Therefore, I recommend the following: 1. Routine postoperative recovery over the next one to two weeks, as the patient should be free of infection and/or any abscess prior to proceeding with systemic chemotherapy (see below). 2. Check CEA level now, as an elevated marker would suggest utility of this marker in the future to diagnose early recurrence. 3. PET scan as an outpatient, to complete staging and rule out distant metastasis.
CEA|carcinoembryonic antigen|CEA|190|192|PLAN|PLAN: 1. Old history. 2. MRCP may not be possible in this gentleman due to some type of prior ear surgery with implant. 3. Observe a little longer on a trial of Actigall. 4. Check CA199 and CEA tumor markers.
CEA|carcinoembryonic antigen|CEA|171|173|PHYSICAL EXAMINATION|She is not icteric, face is symmetric. She has a slightly protuberant mass in the left lateral chest wall which is palpable and quite tender to palpation. As noted above, CEA was elevated. Alpha fetoprotein was normal. ASSESSMENT AND PLAN: Ms. _%#NAME#%_ is a 62-year-old female with metastatic adeno-carcinoma of unknown primary, possibly lung versus pancreatic.
CEA|carcinoembryonic antigen|CEA,|219|222|LABORATORY DATA|ABODMEN: Soft; non- distended. Bowel sounds were normal. LABORATORY DATA: Hemoglobin 15.3, WBC 12,900, platelets 311,000. Liver function studies were normal. We will initiate cycle #2 at this point. I am monitoring her CEA, a level was also drawn. I will see her back in 3 weeks.
CEA|carcinoembryonic antigen|CEA|229|231|DISCHARGE MEDICATIONS|He was admitted for further evaluation of this condition. Since admission, _%#NAME#%_ has had tumor marker analysis and a CT-guided biopsy of a dominant liver lesion performed. The pathology at this time is pending, but both his CEA level and alpha fetoprotein (AFP) level was mildly elevated. He also had mild lipase elevation but normal LFTs and CBC. REVIEW OF SYSTEMS: Is notable for some residual right upper quadrant/flank pain, but this is improved with recent use of fentanyl patch.
CEA|carotid endarterectomy|CEA.|242|245|PHYSICAL EXAMINATION|Other systems negative. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 36.8, heart rate 61, blood pressure 133/74, respiratory rate 18 and he is in no acute distress. NECK: Supple. No JVD, no carotid bruits. There is a postop scar from right CEA. LUNGS: Clear to auscultation. ABDOMEN: Nontender and nondistended. HEART: Regular rate and rhythm. There is a mechanical click from his mechanical valve heard.
CEA|carcinoembryonic antigen|CEA|180|182|ANCILLARY DATA|White count 8.1. She did receive transfusion perioperatively. Chest x-ray from the _%#DD#%_ negative. Hemoglobin dropped to 9.8 on the _%#DD#%_. EKG: Left ventricular hypertrophy. CEA level is 0.8 from the 24th. IMPRESSION: 1. Stage 2 T4N0M0 right colon cancer, moderately differentiated, with lymphatic/vascular invasion, status post right hemicolectomy.
CEA|carcinoembryonic antigen|CEA|157|159|PERTINENT LABORATORY STUDIES|ALT 19. AST is elevated at 94. His total bilirubin is slightly elevated at 1.6, conjugated 0.4. Calcium was 8.6. He did have a PSA of 2.0. His INR, PTT, and CEA requests are pending. A urine culture did show greater than 100,000 colonies of group D Enterococcus. He had a blood culture which is negative thus far after 2 days.
CEA|carcinoembryonic antigen|CEA|211|213|PLAN|Her family was present for the discussion and many of them had questions, all of which were answered. I asked that she have a transvaginal ultrasound to further delineate the lesion. In addition, a CA-125 and a CEA will be ordered. She was also noted to have an infiltrate on her chest x-ray as well as significant pyuria.
CEA|carcinoembryonic antigen|CEA|175|177|OTHER PERTINENT STUDIES|Breasts are soft, no masses. ABDOMEN: Soft, small midline incision scar from laparoscope noted. No masses are palpable. OTHER PERTINENT STUDIES: A recent INR 0.98, PTT of 26, CEA of 1.0. DISCUSSION: This is a 77-year-old female former smoker now diagnosed with squamous cell carcinoma from the left lung.
CEA|carcinoembryonic antigen|CEA|162|164|IMPRESSION|At this time there is no proven benefit from improved survival or recurrence with adjuvant chemotherapy. I therefore suggest observation. I will check a baseline CEA and ask him to see me in a month or so for a quick postop check. If doing well at that point we will switch to evaluations every three months with CEA monitoring with plans to get a colonoscopy at one year.
CEA|carcinoembryonic antigen|CEA.|173|176|HISTORY OF PRESENT ILLNESS|It is now much better and has resolved. During this hospitalization, he did have a repeat alpha fetoprotein level drawn. The most recent one was 2401. He does have a normal CEA. His other laboratory parameters show a normal coagulation profile. His hepatic panel is negative with a total protein of 7.8, albumin of 3.7, ALT of 57, AST of 68.
CEA|carcinoembryonic antigen|CEA|241|243|PTT.|Pertinent recent laboratory studies on _%#MMDD2006#%_: Hemoglobin 10.9, white 5,100, platelets 206,000, liver function studies were normal, with the exception of a alkaline phosphatase that was slightly elevated at 154. Sed rate was 50. His CEA was 3.1. We will be drawing a PT and a PTT. On physical examination, he is a pleasant gentleman appropriate in his responses.
CEA|carcinoembryonic antigen|CEA|180|182|HEENT|His daughter was in favor of this and we left it that they would see me back in the clinic in approximately three weeks. We will recheck his blood counts at that time along with a CEA tumor marker.
CEA|carcinoembryonic antigen|CEA.|119|122|PLAN|Where in a case like this is always the development of pancreatic cancer. PLAN: 1. N.p.o. 2. IV fluids. 3. CA 19.9 and CEA. 4. Eventual endoscopic ultrasound looking for any worrisome changes.
CEA|carcinoembryonic antigen|CEA|166|168|IMPRESSION|I suggested to the patient that at this point we get her home to recover from her surgery. I would like to suggest a baseline CT scan of the abdomen and pelvis and a CEA in a couple weeks when she has recovered further from surgery. Unless there is surprise and evidence of distant disease, my suggestion is the patient proceed with adjuvant chemotherapy.
CEA|carcinoembryonic antigen|CEA,|178|181|PLAN|Would plan on leaving rectum for now as, if he is disease free after chemo and possible right liver resection, he could have ileoanal pouch procedure done at a later date. PLAN: CEA, mark for stoma colon resection, ileostomy, possible liver biopsy tonight or tomorrow. Patient's family requests second opinion from Colorectal surgeon. Dr. _%#NAME#%_ _%#NAME#%_ contacted, will defer to her and please call again if needed.
CEA|carcinoembryonic antigen|CEA|154|156|HISTORY OF PRESENT ILLNESS|She has metastatic colon cancer from _%#MM1999#%_ with a grade 3, stage 3 adenocarcinoma, status post right hemi. She received adjuvant chemotherapy. Her CEA rose. She had omental mets. Port-A-Cath was placed. CAVO chemotherapy was started. CEA began to fall and then started rising again in _%#MM2003#%_.
CEA|carcinoembryonic antigen|CEA|241|243|HISTORY OF PRESENT ILLNESS|She has metastatic colon cancer from _%#MM1999#%_ with a grade 3, stage 3 adenocarcinoma, status post right hemi. She received adjuvant chemotherapy. Her CEA rose. She had omental mets. Port-A-Cath was placed. CAVO chemotherapy was started. CEA began to fall and then started rising again in _%#MM2003#%_. The patient had a reaction to chemotherapy on her last admission.
CEA|carcinoembryonic antigen|(CEA,|136|140|ASSESSMENT AND PLAN|Therefore, I have recommended the following: 1) Routine serum markers to assist in the diagnosis in search for an unknown primary tumor (CEA, CA19-9, CA125, and alpha fetoprotein). 2) CT guided biopsy of the most accessible liver lesion (as this will likely be well tolerated and avoid the risk of pneumothorax if lung biopsy were attempted).
CEA|carcinoembryonic antigen|CEA|184|186|ASSESSMENT AND PLAN|When his CEA started to rise in _%#MM#%_, we have now subsequently switched him to Xeloda as a single agent two weeks out of every three orally. He has been once again responding. His CEA at the initiation on _%#MMDD2003#%_ was 234. It has now once again dropped to 68, and _%#NAME#%_ continues to do quite well now.
CEA|carcinoembryonic antigen|CEA|481|483|IMPRESSION, REPORT AND PLAN|I have discussed the case with one of our gastrointestinal colleagues, Dr. _%#NAME#%_, who will be contacting one of his partners as I would like them to proceed with at least a partial colonoscopy with attempt to biopsy and placement of a long rectal tube versus stent of this obstructing area for bowel preparation, decompression of the colon in preparation for surgical intervention. She will receive Fleet enemas in anticipation of the above-mentioned studies. We will check a CEA level for baseline purposes. This was discussed with the patient. She understands and is agreeable with this plan. Thank you for the interesting consult.
CEA|carcinoembryonic antigen|CEA|176|178|HISTORY OF PRESENT ILLNESS|At that time, the patient was offered adjuvant chemotherapy, which she received between _%#MM#%_ 2000 and _%#MM#%_ of 2000. At that point, she was followed. Unfortunately, her CEA began to rise, and in _%#MM#%_ 2001 it was determined that she had recurrent disease with omental metastases. She had a Port-A-Cath catheter placed, and beginning in _%#MM#%_ 2001 she was placed on combination chemotherapy.
CEA|carcinoembryonic antigen|CEA|188|190|HISTORY OF PRESENT ILLNESS|Her CEA, however, began to rise, and we initiated therapy with Xeloda single agent in the spring of 2002. She received a total of 11 such cycles through the summer of 2002, when again her CEA began to rise, and a CT scan in _%#MM#%_ 2002 showed progression in the omental and peritoneal areas. Last fall, we therefore switched her to CPT-11 on an every-other-week basis.
CEA|carcinoembryonic antigen|CEA|198|200|PLAN|We will try a Dulcolax suppository. I am going to place a Duragesic patch 25 mcg to help alleviate this patient's abdominal cramps and pain. We will follow her with appropriate x-rays, etc. Also, a CEA is being drawn. Thank you, very much, for asking me to see this nice lady.
CEA|carcinoembryonic antigen|CEA|173|175|PLAN|The patient was treated with adjuvant 5-FU and leucovorin beginning in _%#MM#%_ 2000 to _%#MM#%_ 2000. She tolerated treatment well. Unfortunately, in _%#MM#%_ of 2001, her CEA began to rise and a CT scan in _%#MM#%_ of 2001, showed an omental mass. A Port-A-Cath catheter was inserted and the patient was started on combination chemotherapy.
CEA|carcinoembryonic antigen|CEA|143|145|PLAN|Beginning last _%#MM#%_, she was placed on Xeloda and this resulted in a fairly prolonged period of stabilization, but no actual change in her CEA levels. By _%#MM#%_ of this year, there was some progression in the omentum with peritoneal metastases. Her CEA, at that time, was over 200. We started her on a new regimen in _%#MM#%_, using CPT-11, and she has been on an every- other-week regimen since that time.
CEA|carcinoembryonic antigen|CEA|185|187|HISTORY OF PRESENT ILLNESS|Her postoperative level was 3.6. She is now admitted to the hospital with progressive abdominal pain that she has had for two months. She also notes rectal bleeding for two months. Her CEA level is now 23. She had a CT scan, which is not available to me today, which revealed two large pelvic masses.
CEA|carcinoembryonic antigen|CEA|212|214|IMPRESSION  AND PLAN|Also, her risk of recurrence is in the 10-15% range and clinical studies has not proven any advantage with adjuvant chemotherapy. Hence, I would recommend close follow-up alone with every 4-monthly exam, CBC and CEA levels with a 1-year followup colonoscopy. After 2 years we will then go to 6-monthly follow-up and after 5 years on a yearly basis.
CEA|carcinoembryonic antigen|CEA|234|236|DISCUSSION AND RECOMMENDATIONS|Therefore, I will hold off the procedure and consider doing it with contrast if his creatinine improved significantly. Otherwise, noncontrast CT or a PET scan will be done depending on the finding with tissue diagnosis. I will obtain CEA and PSA which may help in differentiating his suspected malignancy and a bone scan will be considered based on his pain although has been chronic and no recent increase in the chest or lower lower back.
CEA|carotid endarterectomy|CEA,|260|263|PAST SURGICAL HISTORY|She has cerebral vascular disease, status post CEA on the right. She has diabetes and hypertension. PAST SURGICAL HISTORY: Carpal tunnel release bilaterally, cataract bilaterally, appendectomy, status post CABG, status post lower extremity bypass, status post CEA, status post right oophorectomy. MEDICATIONS: On admission, glipizide, omeprazole, metoprolol, lisinopril, HCTZ, Norvasc, Zetia and aspirin.
CEA|carcinoembryonic antigen|CEA|240|242|LABORATORY DATA|Normal motor and sensory examination (5/5 in the upper and lower extremities) and a cerebellar examination was nonfocal and intact. LABORATORY DATA: Hemoglobin 11, white blood cell count 19,500, platelet count 641,000, CA-125 261 units/ml, CEA 1.8, INR 1.65. CT scan reveals a 10.3 x 9.2 x 7.5 mass which is probably bilateral in the left pelvis.
CEA|carotid endarterectomy|CEA|160|162|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Diabetes mellitus, diet controlled. 2. Rheumatoid arthritis. 3. Hypertension. 4. Peripheral vascular disease, status post left carotid CEA after multiple TIAs, without recurrence since CEA. 5. Vasodepressor syncope, as above. 6. She describes some chronic renal failure history.
CEA|carcinoembryonic antigen|CEA,|209|212|IMPRESSION/PLAN|In addition, we will need a tissue diagnosis and I recommend proceeding with CT-guided biopsy of the lung and the liver lesions. I would also obtain tumor markers to rule out possible primaries. These include CEA, CEA-Tc 99m, and CA 27.29. Once his staging and diagnostic work-up has been completed and if he is clinically stable, I would recommend discharge to home and follow-up with me in the office next week to discuss his staging and diagnostic work-up.
CEA|carcinoembryonic antigen|CEA|284|286|RECOMMENDATIONS|I discussed these possible diagnoses with Ms. _%#NAME#%_ and recommended to her that she have additional studies to help further clarify where the tumor in may be arising. RECOMMENDATIONS: 1. Send blood for tumor marker studies including a CA-19.9, CA-125 and also a CA27.29 and also CEA level. 2. Screening mammogram 3. GYN oncology evaluation. 4. Vicodin for help with pain control. I discussed these recommendations with Ms. _%#NAME#%_ and she indicates understanding of the plan.
CEA|carcinoembryonic antigen|CEA|138|140|LABORATORY WORK|His platelet count is 260,000. His white count is 11,000. His alkaline phosphatase is elevated, otherwise his liver functions are normal. CEA is not drawn. He did have a CT scan of the abdomen and pelvis with the above noted findings.
CEA|carcinoembryonic antigen|CEA|161|163|SUBJECTIVE|This revealed hepatocellular carcinoma with extensive necrosis. The tumor cells were positive for many markers consistent with liver cancer. It was negative for CEA monoclonal and polyclonal AFP, EMA. This was signed out as hepatocellular carcinoma. Other laboratory studies of significance show this gentleman to be hepatitis B surface antibody positive.
CEA|carcinoembryonic antigen|CEA|163|165|ASSESSMENT AND PLAN|CBC showed hemoglobin of 14.8, hematocrit 45, white count 6200 with a normal differential. Platelets were 237,000. Her liver function studies were unremarkable. A CEA has been drawn, the most recent one in _%#MM#%_ was normal at 1.1. At this point, I would am recommending that the patient may have her Port-A-Cath catheter removed.
CEA|carcinoembryonic antigen|CEA|153|155|HISTORY OF PRESENT ILLNESS|The later part of _%#MM#%_ or _%#DD#%_ 2002 the patient was found to have pelvic mass when she was evaluated for the problems of stoma. At that time her CEA was also elevated to 5.3. FNA showed recurrent cancer. The patient underwent chemoradiation treatment which created numerous side effects and complication including renal failure.
CEA|carcinoembryonic antigen|CEA|164|166|HISTORY OF PRESENT ILLNESS|Since then she has been doing reasonably well and hasn't had any evidence of gross disease and CEA was also within normal limits. Unfortunately in _%#MM2006#%_ her CEA started to elevate at 4.4, however, there wasn't any radiographic evidence of recurrence. On follow-up in _%#MM2006#%_ the patient started having vague urinary symptoms and had a CT of the pelvis which showed right-sided hydronephrosis with recurrent presacral mass which measured about 5 x 3 cm in size causing right ureter obstruction.
CEA|carcinoembryonic antigen|CEA|158|160|LABORATORY DATA|VITAL SIGNS: Afebrile. Stable vitals. The remainder of the exam is deferred. LABORATORY DATA: WBC 9.4, hemoglobin 14.1, creatinine 1.49, urinalysis negative. CEA is markedly elevated at 37. CT does reveal the aforementioned pathology. In addition, there is delay in excretion into the dilated right upper tract down to the true pelvis.
CEA|carcinoembryonic antigen|CEA|200|202|LABORATORY DATA|ABDOMEN: Soft, nontender. GU: Examination not done. LABORATORY DATA: Reveals a creatinine of 0.7. CBC revealed hemoglobin of 12.6, platelets of 218. The patient has elevated serum markers of CA 19-9, CEA and alphafetoprotein. His PSA is 0.25. Urinalysis showed 2 red blood cells. No history of urine cytology. IMPRESSION: This is a 52-year-old gentleman with metastatic adenocarcinoma of unknown primary for further evaluation.
CEA|carcinoembryonic antigen|CEA|210|212|ASSESSMENT|However, she does remain at high risk of early disease recurrence given the possible serosal involvement of her tumor and localized lymph node metastasis. Therefore, it is now prudent to repeat a postoperative CEA level and consider an outpatient PET/CT scan to ensure no distant metastatic disease. I have recommended to her and her daughter that she follow up in my clinic in approximately 2-3 weeks' time after being cleared by her surgeon to discuss possible adjuvant chemotherapy.
CEA|carotid endarterectomy|CEA|136|138|PHYSICAL EXAMINATION|She is quite clear and her speech and language seem intact. Her neck is supple. There are no carotid bruits and there is a healed right CEA scar. Her fundi are benign and visual fields appear to be intact to confrontation. Her eye movements are full. She has no nystagmus. Her face appears fairly symmetrical with equal motion and equal sensation bilaterally.
CEA|carcinoembryonic antigen|CEA|245|247|LABORATORY  DATA|EXTREMITIES: Show edema. NEUROLOGIC: Appears to be nonfocal. Decision-making capacity has previously been intact but currently is not clear due to altered mental status. LABORATORY DATA: As noted in HPI. Additionally, CA19-9 is elevated at 168, CEA is elevated at 749. Alpha-fetoprotein is 2.1. Hepatitis studies have been negative. Liver function tests show a normal bilirubin and alkaline phosphatase of 161, an ALT of 65 and AST of 110.
CEA|carcinoembryonic antigen|CEA|177|179|LABORATORY DATA 11/19/06|Glucose 105. BUN 24. Creatinine 0.6. Magnesium 2.0. Phosphorus 3.8. Histopathology report from T12 vertebral body showed metastatic adenocarcinoma consistent with lung primary. CEA on _%#MMDD2006#%_ was 5.3, with a normal range of 0 to 2.5. PSA was 2.08. RADIOLOGY: CT of the chest, abdomen and pelvis done on _%#MMDD2006#%_ showed a 1.6 cm spiculated pleural-based nodule in the right upper lobe, which was increased from 1.1 cm in _%#MM2004#%_.
CEA|carcinoembryonic antigen|CEA|130|132|LABORATORY DATA|2. Chest x-ray showing interstitial changes in the lower lungs which were likely chronic and no acute findings. 3. CA-125 is 165, CEA was 1.2. Basic metabolic panel shows glucose of 112 and creatinine of 0.98. Hemoglobin was 13.2 with a platelet count of 381,000.
CEA|carcinoembryonic antigen|CEA|180|182|LABORATORY/IMAGINGS|LABORATORY/IMAGINGS: EKG on _%#MM#%_ _%#DD#%_, 2006, was normal. Electrolytes within normal limits. INR was 1.05, hemoglobin 14.7, WBC of 6.5, and platelets of 369. CA125 was 180. CEA was 2 which is within normal limits. A mammogram done on _%#MM#%_ _%#DD#%_, 2006, was negative. MRI of the brain to rule out a positive metastasis on _%#MM#%_ _%#DD#%_, 2006, showed no definitive intracranial metastasis.
CEA|carcinoembryonic antigen|CEA|117|119|PROBLEM #3|However, this was limited by lack of contrast. The patient is to follow up with Dr. _%#NAME#%_ as an outpatient. The CEA performed during this hospitalization was essentially 0.5. PROBLEM #4: Rheumatology. The patient has a history of gout. He has been continued on allopurinol throughout the hospitalization.
CEA|carcinoembryonic antigen|CEA|156|158|HISTORY|3. Gastrointestinal. Colonoscopy on _%#MMDD2004#%_ was normal with the exception of a 4-5 mm sessile polyp. EGD on _%#MMDD2004#%_ was within normal limits. CEA was 1.3 on the same day 4. GYN. Pap smear on _%#MMDD2004#%_ was within normal limits. Ultrasound of the pelvis on _%#MMDD2004#%_ revealed an 18 mm endometrial stripe and fluid in the pelvis.
CEA|carcinoembryonic antigen|CEA|147|149|HISTORY OF PRESENTING ILLNESS|On _%#MMDD2006#%_, an alpha fetoprotein tumor marker and chorionic gonadotropin were drawn, which were both normal. CA 125 at that time was 16 and CEA was 11.9. Testosterone was 0.56 and estradiol was 28. When the patient was seen by Dr. _%#NAME#%_ on _%#MMDD2006#%_ she was not complaining of any symptoms.
CEA|carcinoembryonic antigen|CEA|168|170|HISTORY OF PRESENT ILLNESS|The ovaries appeared to be normal. Paracentesis was then performed and was positive for adenocarcinoma. The cells were CK-20 negative and estrogen receptor positive. A CEA was negative. This supported a GYN primary for her adenocarcinoma. Discussion was undertaken with the patient including the risks, benefits, and alternatives to proceeding with surgical diagnosis and staging, and the patient gave informed consent to go ahead with the above-named procedure.
CEA|carcinoembryonic antigen|CEA|176|178|HISTORY OF PRESENT ILLNESS|The biopsy of the liver mass gross appearance resembled an adenocarcinoma, and this was sent for further differentiation. The patient also had CEA, alpha-fetoprotein and CA99. CEA came back less than 0.5, alpha-fetoprotein came back 2.4, and CA99 came back significantly elevated at 1369. Following the placement of the percutaneous transhepatic biliary drainage, the patient's bilirubin which had initially rose to 11.9 dropped to 6.2 the day of discharge with also a decrease in her transaminases and alkaline phosphatase.
CEA|carcinoembryonic antigen|CEA|199|201|HISTORY OF PRESENT ILLNESS|Chest x-ray was also performed which revealed a worsening right large pleural effusion. A thoracentesis was again performed on _%#MM#%_ _%#DD#%_, 2006. The pleural fluid was positive for malignancy, CEA was within normal limits. CA-125 was 1320. Risks, benefits and alternatives were discussed with the patient of proceeding with exploratory laparectomy, total abdominal hysterectomy, bilateral salpingooophorectomy, omentectomy, and stated procedures including the risk of infection, bleeding, and damage to surrounding organs.
CEA|carcinoembryonic antigen|CEA.|325|328|HISTORY OF PRESENT ILLNESS|The pathology was re-examined by our pathologist, Dr. _%#NAME#%_ _%#NAME#%_, at the Women's Health Laboratory, who diagnosed the patient with adenocarcinoma of the cervix, grade 2/3, endocervical and papillary type with angio and lymphatic invasion. Immunoperoxidase stain was performed. It was positive for P53, CA-125, and CEA. It was negative for vimentin and estrogen receptor. The patient was seen and examined in the Women's Health Center Clinic on _%#MM#%_ _%#DD#%_, 2004.
CEA|carcinoembryonic antigen|CEA,|221|224|PROBLEM #4|The comment stated that the tumor was mostly adenocarcinoma with focal areas of squamous differentiation and showed extensive necrosis. The tumor cells were positive for CAM 5.2 and focally for vimentin, and negative for CEA, consistent with an endometrial rather than a cervical primary. PRINCIPAL DIAGNOSIS: Adenosquamous carcinoma of the uterus, stage 3C.
CEA|carcinoembryonic antigen|CEA|213|215|HISTORY OF PRESENT ILLNESS|The patient had preop visit with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2006, and was consented for laparotomy and removal of the ovarian mass and if needed a staging procedure and also for a D and C. The patient's CEA 125 levels on _%#MM#%_ _%#DD#%_, 2006, is at 24 which is within normal limits, so the patient was admitted to University of Minnesota Medical Center, Fairview, on _%#MM#%_ _%#DD#%_, 2006, for her surgery.
CEA|carcinoembryonic antigen|CEA|264|266|HISTORY OF PRESENT ILLNESS|This difference was likely felt due to measuring technique. The patient has had previous kidney and heart transplant as well as gastric bypass and he it is seen in consultation at the request of Dr. _%#NAME#%_ for consideration of surgical resection. Preoperative CEA is 5.7. PAST MEDICAL HISTORY: Ischemic cardiomyopathy, chronic renal failure, obesity, malignant neoplasm of skin, bilateral arms, head, chest, basal squamous cell and melanomas.
CEA|carcinoembryonic antigen|CEA|222|224|PROBLEM #3|There was initially a report of a mass in the liver which resulted in the patient getting a MRI scan of her liver. That scan showed evidence of nodular sclerosis in 2 places which appeared to be dysplastic. Due to her low CEA levels and alpha fetoprotein levels this was not felt to represent cancer. These nodules were too small for a biopsy. Based on this GI recommended follow up in 3 months with another MRI.
CEA|carcinoembryonic antigen|CEA|210|212|SOCIAL HISTORY|She was given 4 units of packed cells at the outside institution and a number of laboratory tests were drawn; specifically, 2 tumor markers eventually revealed positive values, specifically CA 19-9 was 115 and CEA was 369. Upon arrival to our institution, she was no longer bleeding from her gastric varices significantly. Following an interventional radiology procedure to coil these varices, the patient experienced no further bleeding from the gastric varices.
CEA|carcinoembryonic antigen|CEA|256|258|ADMITTING HISTORY AND PHYSICAL|She underwent bronchoscopy on _%#MMDD2003#%_ at Abbott Northwestern Hospital. Pathology was consistent with a non-small-cell lung cancer that was a moderately differentiated adenocarcinoma with mucin production. CA125 on _%#MMDD2003#%_ was 260.6 units/mL. CEA was 14.3 ng/mL. CT of the head from _%#MMDD2003#%_ showed no evidence of metastases. The patient was initiated on single agent Taxotere for her non-small-cell lung cancer on _%#MMDD2003#%_ and rituxan for her non-Hodgkin's lymphoma.
CEA|carcinoembryonic antigen|CEA|131|133|SUMMARY OF HOSPITALIZATION|Weight loss: The other facility obtained tumor markers which we did get the results of and they were unremarkable. CA 19-9 was 26. CEA was 2.1 both of which are normal. On the day of discharge she has a stable III/VI sys murmur and limited range of motion of upper extremity joint with puffiness but no pain the right ankle is tender with palpation both bilateral malleoli.
CEA|carcinoembryonic antigen|CEA|268|270|PAST  MEDICAL HISTORY|Imaging of the abdomen including a CT and MRI scan at that time where generally unremarkable with the exception of an area of abnormal colonic wall thickening. Given the coexisting weight loss, Dr. _%#NAME#%_ had done some screening studies for malignancy including a CEA and CA19-9. Both were found to be elevated at that time. There was a suspicion of pancreatic cancer, however, the patient refused further evaluation, stating that she would not be interested in treatment.
CEA|carcinoembryonic antigen|CEA|180|182|HISTORY OF PRESENT ILLNESS|Neoadjuvant chemotherapy was recommended and the patient underwent 3 cycles of carboplatin with an AUC of 6 and Taxol 175 mg/sq m. This resulted in a reduction in her CA125 to 58. CEA increased to 18.8. The CA99 and CA27-29 were not rechecked. The patient presented for followup where options were presented. The patient elected to proceed with interval debulking with subsequent treatment to be determined after final pathology.
CEA|carcinoembryonic antigen|CEA|280|282|HISTORY OF PRESENT ILLNESS|Upon discussion with her obstetrician-gynecologist, Dr. _%#NAME#%_, it was felt that due to risk of ovarian malignancy, she would be referred to the University of Minnesota for further evaluation. A CA-125 was 43.8. An alpha-fetoprotein was also performed with a value of 3 and a CEA was performed at that time with a value of 0.9. Due to the fact that there was the presence of a 9-cm mass with an elevated CA-125, it was recommended at the time of consultation that she undergo an exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy and possible staging.
CEA|carcinoembryonic antigen|CEA|144|146|LABORATORY|There are 2 small lesions at approximately 1 o'clock in the vagina. Redundant tissue that are palpable and nodular. LABORATORY: CA-125 was 9.8, CEA 1.2. Preop hemoglobin on _%#MM#%_ _%#DD#%_, 2004, was 13.6. HOSPITAL COURSE: The patient was admitted and underwent an uncomplicated exploratory laparotomy, bilateral salpingooophorectomy with extensive lysis of adhesions, retroperitoneal exploration, washings and cystoscopy.
CEA|carcinoembryonic antigen|CEA|211|213|HOSPITAL COURSE|Her hepatitis C antibody and hepatitis B surface antigen were studied as part of the evaluation and were found to be negative. Her liver function tests were found to be within normal limits: alkphos 77, ALT 10. CEA and CA19-9 were performed and her CEA was 21 and CA19-9 was 65, which was elevated. A GI consult was obtained to assist in evaluating her liver cysts and ascites.
CEA|carcinoembryonic antigen|CEA|84|86|ADMITTING DIAGNOSES|ADMITTING DIAGNOSES: 1. Large abdominal pelvic mass, complex in nature. 2. Elevated CEA and CA-125. 3. History of bilateral pulmonary emboli. 4. Elevated homocystinuria. 5. Hypothyroidism. 6. Hypertension. 7. Right-sided heart failure.
CEA|carcinoembryonic antigen|CEA|142|144|LABORATORY DATA|Pelvic/rectal deferred. NEUROLOGIC: Grossly nonlateralizing. Gait tested. LABORATORY DATA: Laboratory data in addition to the above includes: CEA 0.7 on _%#MMDD2004#%_. This morning: Sodium 137. Potassium 5.1. Chloride 105. CO2 21. Anion gap 10. Glucose 112. BUN 22. Creatinine 1.18. GFR 46.
CEA|carcinoembryonic antigen|CEA|415|417|LABORATORY|It is soft and ballotable. EXTREMITIES: Trace edema bilaterally. LABORATORY: On _%#MM#%_ _%#DD#%_, 2006, CA-125 was 29. On _%#MM#%_ _%#DD#%_, 2006, hemoglobin 12.8, hematocrit 40.9, platelets 361, white blood cells 7.5; sodium 138, potassium 4.7, chloride 102, CO2 of 29, glucose 98, BUN 25, creatinine 1.7, calcium 9.8; AST 23, albumin 3.8, alkaline phosphatase 68, ALT 13, total bilirubin 0.7, total protein 6.6; CEA was 0.8, another CA-125 of 37, CA-27-29 of 44.6. A chest x-ray was done which had an impression of mild cardiomegaly, hiatal hernia, and previous left mastectomy.
CEA|carcinoembryonic antigen|CEA.|197|200|FOLLOW UP STUDIES|8. Nexium 40 mg p.o. every day. 9. Ambien 5 mg p.o. q.h.s. p.r.n. FOLLOW UP STUDIES: 1. The patient has to have cancer screening performed due to first time pulmonary embolism as well as increased CEA. We recommend doing a colonoscopy as well as a mammogram to look for occult malignancy. We should also obtained a ____ smear to look for hematologic malignancies.
CEA|carcinoembryonic antigen|CEA|151|153|ASSESSMENT  AND PLAN|The patient will be given some clear liquid for tonight and n.p.o. after midnight. The patient will be rehydrated with pain medication as necessary. A CEA level will be obtained. Once surgery has been performed, oncology consultation will be undertaken in addition. Please see note below with disposition. 2. Hypertension, stable. Continue Cardia and will hold hydrochlorothiazide during hydration.
CEA|carcinoembryonic antigen|CEA|154|156|HOSPITAL COURSE|Her PAP came back essentially normal; however, she did have endometrial cells present. The patient was also assessed with colonoscopy given her increased CEA at 25.9 and colonoscopy was essentially normal. The patient was taken to the operating room on _%#MMDD2007#%_ for an exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy and staging procedure.
CEA|carotid endarterectomy|CEA|180|182|IMPRESSION AND PLAN|13. Anemia. This appears to be an anemia of chronic disease, and hemoglobin is stable. 14. History of permanent pacemaker for complete heart block in _%#MM#%_ 2003. 15. History of CEA bilateral, this past summer, _%#MM#%_ and _%#MM#%_ of 2003. 16. Bilateral heel ulcers. We will use Allevyn and get the ET wound nurse to see the patient.
CEA|carcinoembryonic antigen|CEA|143|145|CHIEF COMPLAINT|LABORATORY: Please note the pelvic ultrasound and transvaginal ultrasound findings described in the history of present illness. CA-125 was 12, CEA was normal at 1.5. HOSPITAL COURSE: Patient had an uncomplicated hospital course. She was transferred from the Post-Anesthesia Unit in stable condition.
CEA|carotid endarterectomy|CEA|185|187|PHYSICAL EXAMINATION|Oropharynx is clear without tonsillar enlargement or exudate. Neck exam is significant for a JVP of 10 to 12 cm of water. There is no cervical lymphadenopathy. Old scars from her right CEA as well as her thyroidectomy are appreciated. Both are well healed without induration. Cardiovascular exam demonstrates normal S1, S2.
CEA|carcinoembryonic antigen|CEA|177|179|HISTORY OF PRESENT ILLNESS|She also was found to have a 1.7 x 2.0 cm round nodule from the left adrenal. The urine culture came back showing greater than 100,000 E. coli. She was switched to Bactrim. Her CEA is 1.4. On _%#MM#%_ _%#DD#%_, 2004, the patient was transferred to 7C from HCMC. She states that she first noted the pelvic pain on _%#MM#%_ _%#DD#%_, 2004.
CEA|carcinoembryonic antigen|CEA|189|191|DISCHARGE MEDICATIONS|Of note, the patient did receive Ativan in the hospital and he became very agitated and restless following administration of this. Dr. _%#NAME#%_, Minnesota Oncology, will follow patient's CEA level. DIET: Recommend clear to soft diet as tolerated, given his partial colonic obstruction.
CEA|carcinoembryonic antigen|CEA|117|119|LABORATORY DATA|Magnesium level 1.7. Total protein 6.1. Triglyceride level of 75. CA125 was done on _%#MMDD2002#%_. There was also a CEA done which was normal at 1.4. The prealbumin level was mildly low at 14 on _%#MMDD2002#%_, and this is normal at 19 on _%#MMDD2002#%_, probably indicated that her caloric intake is adequate for the nutritional improvement.
CEA|carcinoembryonic antigen|CEA,|154|157|PROBLEM #2|Early in the hospitalization, when it was unclear that his mental status change was related to his narcotic use, we did send off tumor markers, including CEA, that did come back marginally elevated at 3. However, in light of his chronic end-stage liver disease and pancreatitis, it is unclear of the relevance of this finding.
CEA|carcinoembryonic antigen|CEA,|47|50|DIAGNOSES ON ADMISSION|DIAGNOSES ON ADMISSION: 1. Elevated CA-125 and CEA, evidence of carcinomatosis and pelvis mass on CT scan. 2. Increasing abdominal pain. 3. Left renal hydronephrosis. 4. Peripheral vascular disease.
CEA|carcinoembryonic antigen|CEA|170|172|LABORATORY DATA|MCV of 70 consistent with iron deficiency. Serum iron low at 14 with low normal ferritin of 22. A known history of prostate cancer with PSA of 6.24 and colon cancer with CEA of 0.8. PHYSICAL EXAMINATION: GENERAL: Admission exam demonstrated a fatigued appearing elderly male in no acute distress.
CEA|carcinoembryonic antigen|CEA|293|295|PHYSICAL EXAMINATION|LABORATORY EVALUATION (please note this is a review of laboratory evaluation obtained at the outside hospital): The patient's white cell count today is 8.4, hemoglobin 8.3, platelet count 100, total bilirubin is 5.4, AST 100, ALT 46, albumin 2.9, total protein 6.0, creatinine of 0.6, AFP 13, CEA pending, CA 125 pending. The patient is negative for serologies of hepatitis B, C and A. The patient's antismooth muscle body is positive however the patient's antimitochondrial is negative.
CEA|carcinoembryonic antigen|CEA|168|170|HISTORY OF PRESENT ILLNESS|Ms. _%#NAME#%_ was referred to the University of Minnesota Women's Cancer Center for consultation. CA125 obtained during her previous hospitalization came back as 719. CEA was less than 4. On presentation for further evaluation of the mass, she was without complaints. She had no complaints of abdominal distension or early satiety.
CEA|carcinoembryonic antigen|CEA|163|165|PROBLEM #8|He received ultrasound that revealed no evidence of acute cholecystitis, however, there was a potential adherent stone versus polyp on the ultrasound. He also had CEA and CA19 9 levels drawn, which were mildly elevated compared to the normal range. However, his ducts were completely within normal limits in the liver, common bile duct, and pancreatic duct on both CT and ultrasound imaging studies this admission.
CEA|carcinoembryonic antigen|CEA,|206|209|OUTPATIENT FOLLOW-UP|4. The patient should see Dr. _%#NAME#%_ in follow-up on _%#MMDD2005#%_ on a Tuesday at 09:50. The patient is scheduled for pulmonary function tests at 08:30 that same morning. 5. The patient should have a CEA, CA19 9 right upper quadrant scheduled in approximately three months in _%#MM2005#%_ to follow-up on the above changes. 6. The patient's weight should be monitored as an outpatient to evaluate the adequacy of his oral diet off the tube feeds.
CEA|carcinoembryonic antigen|CEA.|125|128|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Left pleural effusion. 2. Ascites. 3. History of breast and colorectal cancer. 4. Elevated CA125 and CEA. 5. Hypertension. 6. Congestive heart failure. 7. Chronic anemia of unknown etiology. 8. Diabetes mellitus type 2. 9. Hypercholesterolemia. 10. Gastritis.
CEA|carcinoembryonic antigen|CEA|151|153|HISTORY OF PRESENT ILLNESS|There seems to be a thickening of the omentum that could represent metastatic disease. She had tumor markers performed at that point, with an elevated CEA at 5.7 and an elevated CA125 of 446. She had a paracentesis done of the ascites, but upon checking with the hospital, as well as the Pathology Lab, no evidence of cytology from the paracenteses were done.
CEA|carcinoembryonic antigen|CEA|174|176|ADMISSION PHYSICAL EXAMINATION|Mammogram BIRADS II negative. CBC revealed hemoglobin of 11.9, platelets of 78, white count of 7.5. Basic metabolic panel was within normal limits with a creatinine of 0.69. CEA of 5.3. CA 125 of 22. Gonorrhea and Chlamydia both negative. ALT 97, AST 83. HOSPITAL COURSE: 1. Disease: After the extensive preoperative evaluation described in the previous paragraph, the patient was taken to the operating room for exploratory laparotomy, bilateral salpingo-oophorectomy and washings.
CEA|carcinoembryonic antigen|CEA|142|144|5.  GI|This imaging study also showed splenomegaly. The patient's ALT and AST were 97 and 83, total bilirubin was 0.9, alkaline phosphatase was 7.8, CEA was 5.3. Intraoperatively, her liver did appear markedly cirrhotic. The patient will need follow up for her untreated hepatitis C. She was given an appointment to follow up with GI in one week.
CEA|carcinoembryonic antigen|CEA,|143|146|HOSPITAL COURSE|Her preoperative workup included a chest x-ray, EKG, CA-125, liver function tests, basic metabolic panel, CBC with differential and platelets, CEA, and a UPTP the morning of surgery. She was also to have a bowel prep and Hibiclens scrub. PROBLEM #1: Disease. On _%#MMDD2003#%_, the patient underwent an exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic washings, omentectomy, mobilization of the splenic flexure, appendectomy, and CUSA x 45 minutes.
CEA|carcinoembryonic antigen|CEA|168|170|LABORATORY DATA|LABORATORY DATA: Her labs from _%#MMDD2007#%_ show a white count of 5.3, hemoglobin 8.3, platelet count of 307. Her basic metabolic panel was within normal limits. Her CEA from _%#MMDD2007#%_ was mildly elevated at 4.4. Her liver function tests from _%#MMDD2007#%_ were normal except for a low albumin of 1.9 and total protein decreased to 4.6.
CEA|carcinoembryonic antigen|CEA|307|309|SUBJECTIVE|In addition, a rectal ultrasound showed that the outer serosal layer of the rectal sigmoid area was breached and that there were several enlarged lymph nodes in the area and it does appear that he is a clinical stage T3 N1 cancer. A biopsy was not apparently performed and will need to do so. The patient's CEA level was slightly elevated at 4.0. The patient is here to see me to discuss the next approaches regarding management and therapy.
CEA|carcinoembryonic antigen|CEA|331|333|HISTORY OF PRESENT ILLNESS|The lower uterine segment had 100% invasion with extension to the surface as was the myometrium with 94% invasion. There was no definite evidence of vascular invasion. Because of the above findings and final pathology, the tumor cells were stain which revealed diffusely positive for CAM 5.2 and focally for vimentin, negative for CEA which was almost consistent with endometrial rather than cervical primary, per pathology report. Because of the above, it was recommended the patient be placed on Protocol #GOG _%#PROTOCOL#%_ with pelvic plus or minor paraaortic radiation followed by cisplatin doxorubicin, or cisplatin, doxorubicin and Taxol secondary to the advanced stage of the carcinoma of the endometrium.
CEA|carcinoembryonic antigen|CEA|349|351|PAST MEDICAL AND SURGICAL HISTORY|PAST MEDICAL AND SURGICAL HISTORY: Otherwise remarkable for morbid obesity more than 400 pounds, type 2 diabetes, sleep apnea, previous appendectomy, previous herniorrhaphy and recent gynecologic surgery on the _%#DD#%_ for removal of a left mucinous neoplasm with a total abdominal hysterectomy, adhesion lysis and bilateral salpingo-oophorectomy. CEA and CA-125 were reported to be normal. The patient has had no other recent hospitalizations. Functional Status prior to admission was normal. Currently it is 10% Palliative Perfomance Score and the patient is moribund.
CEA|carcinoembryonic antigen|CEA|215|217|RECOMMENDATIONS|He needs to recovery from his surgery, and I will see him back in the clinic in about a week from discharge to discuss in more details about the possible treatment options with various chemotherapy. Please obtain a CEA level with his next blood draw. 2. Would defer placing a port till afebrile and cleared of infection.
CEA|carcinoembryonic antigen|CEA.|213|216|PAST  MEDICAL HISTORY|He is status post CABG in 1995. 2. Chronic intermittent stable chest pain, possible angina. 3. Ischemic cardiomyopathy, ejection fraction 30-35% on previous echo. 4. Peripheral vascular disease, status post right CEA. 5. History of CVA in 1994 and TIA in 2004. 6. Chronic renal insufficiency with creatinines running around 3.0.
CEA|carcinoembryonic antigen|CEA|291|293|HISTORY OF PRESENT ILLNESS|However, there was no evidence of multiple myeloma. He does have an elevated IgA at 1030, consistent with a benign monoclonal gammopathy. His IgG is normal at 900. IgM was 92. Of note is the fact that the patient's alpha-fetoprotein was only very minimally elevated at 13.6. He had a normal CEA at 3.4, and his PSA was 0.2. Serum immunofixation did show a monoclonal IgA. Specific description of the bone fragments showed this to be a metastatic, well-differentiated hepatocellular carcinoma.
CEA|carcinoembryonic antigen|CEA|223|225|HISTORY OF PRESENT ILLNESS|The patient reports that with the elevated CEA and these findings on his scans it was felt that the lesion had recurred, and chemotherapy was started. The patient began 5-FU on _%#MMDD2002#%_. In _%#MM2002#%_ the patient's CEA was reportedly 4.3. On _%#MMDD2002#%_ the patient had a CT scan of his chest, abdomen, and pelvis. There was moderate interval progression of the retroperitoneal lymph node enlargement.
CEA|carcinoembryonic antigen|CEA|177|179|PLAN|3. Check arterial blood gas on room air. 4. Change Rocephin and azithromycin to levofloxacin and plan to complete a 10 day course. 5. Overnight oximetry on room air. 6. Check a CEA level. 7. The patient awaiting outpatient colonoscopy as noted above. 8. Outpatient follow up with Dr. _%#NAME#%_ for the right middle lobe lung nodule.
CEA|carcinoembryonic antigen|CEA.|178|181|IMPRESSION|We will also order some other laboratory tests including lupus anticoagulant, beta 2 microglobulin, free serum kappa and lambda light chains, angiotensin converting enzyme and a CEA. I will initiate Naprosyn at 500 mg twice a day in hopes that this might alleviate some of his night sweats.
CEA|carcinoembryonic antigen|CEA|136|138|HISTORY OF PRESENT ILLNESS|This was performed at Methodist Hospital. After completing radiation therapy he went on to receive 52 weeks of 5-FU and levamisole. His CEA levels evidently remained stable. Then in late 1998 he developed a recurrence manifested as an obstruction. He underwent resection of a 3.7 cm mass which was found to be grade 2 adenocarcinoma.
CEA|carcinoembryonic antigen|CEA|155|157|HISTORY OF PRESENT ILLNESS|After a permanent colostomy was performed in _%#MM1999#%_ he underwent 26 more weeks of chemotherapy with 5- FU as well as leucovorin. In _%#MM2001#%_ his CEA level was found to be elevated at 7.7. CT scan of the chest, abdomen and pelvis in _%#MM2001#%_ demonstrated a presacral mass.
CEA|carcinoembryonic antigen|CEA|134|136|LABORATORY STUDIES FROM ADMISSION|LABORATORY STUDIES FROM ADMISSION: Showed normal serum electrolytes, BUN is 12, creatinine is 0.7. Liver function studies are normal. CEA on _%#MMDD2002#%_ is 1.2. CBC from _%#MMDD2002#%_ shows a white count of 6900, hemoglobin 12.7, platelet count of 278,000 with a normal differential.
CEA|carcinoembryonic antigen|CEA|224|226|HISTORY OF PRESENT ILLNESS|For two years and ten months Mrs. _%#NAME#%_ was in remission until _%#MM2001#%_, when she had recurrence on the peritoneum. At that time she underwent another 5 or 6 cycles of carboplatin and Taxol and by _%#MM2001#%_, the CEA 125 was elevated. Mrs. _%#NAME#%_ sought a second opinion at the Mayo Clinic. There she was offered adjuvant chemotherapy. By _%#MM2002#%_ she had undergone a metastatic workup and CT can of the chest with contrast revealed an enlarged lymph node along the right side of the retrosternal area measuring 4.5 x 3.5 cm, located anterior to the superior vena cava and the aortic arch.
CEA|carotid endarterectomy|CEA|147|149|DISCHARGE DIAGNOSES|Taxus stent to his proximal saphenous vein graft to his diagonal. This was performed on _%#MMDD2007#%_. 2. Peripheral vascular disease status post CEA in 2005 3. Hyperlipidemia 4. Tobacco abuse. DISCHARGE MEDICATIONS: 1. Plavix 75 mg p.o. q. daily 2. Aspirin 81 mg p.o. q. daily 3. Lisinopril 2.5 mg p.o. b.i.d.
CEA|carcinoembryonic antigen|CEA|196|198|REVIEW OF SYSTEMS|She has also been found to have leukocytosis with a white count of 20,800, hemoglobin 9.9, platelet count 498,000. General chemistries are unremarkable; creatinine and calcium are unremarkable. A CEA is less than 0.5. ESR 68, TSH is normal, hepatitis screens are negative. Liver function tests show an albumin of 3.1, alkaline phosphatase 464, ALT and AST both up at 162 and 233 respectively.
CR|controlled release|CR|138|139|MEDICATIONS|4. Ativan 0.5 mg as needed for anxiety every 6 hours. 5. Celexa 20 mg orally once daily. 6. Synthroid 25 mcg orally once daily. 7. Ambien CR 6.25 mg orally as needed every night for sleep. PAST MEDICAL HISTORY: Signififcant for hypothyroidism, anxiety, insomnia, GERD and hypertension.
CR|controlled release|CR|167|168|DISCHARGE MEDICATIONS|10. Amitriptyline. 11. Norvasc. 12. Lipitor. 13. Oxycodone 5 mg 1-2 pills p.o. q. 6h. p.r.n. for pain, of which 30 pills were dispensed without any refills; oxycodone CR extended release 20 mg p.o. q. 12h., of which 30 pills were dispensed. SPECIFIC DISCHARGE INSTRUCTIONS: The patient is to be on a low-fiber diet.
CR|controlled release|CR|173|174|MEDICATIONS|Attempts to taper apparently have worked poorly and she has not tolerated other similar medicines. 3. Ambien she said 5 mg initially, but it turns out it is actually Ambien CR 12.5 mg p.o. nightly. 4. Metamucil p.r.n. 5. Multivitamin p.r.n. PREVIOUS SURGERIES: Include a cholecystectomy, hysterectomy and bilateral oophorectomy.
CR|controlled release|CR|160|161|DISCHARGE MEDICATIONS|5. Amlodipine 10 mg p.o. q day. 6. Calcium carbonate with vitamin D 500 mg p.o. t.i.d. 7. Colace 100 mg p.o. b.i.d. 8. Synthroid 0.1 mg p.o. q day. 9. Eskalith CR 450 mg p.o. q day. 10. Lopressor 75 mg p.o. b.i.d. 11. Protonix 40 mg p.o. q day. 12. FiberCon two tablets p.o. q day.
CR|controlled release|CR|178|179|MEDICATIONS AT HOME|5. Neurontin 300 mg p.o. 6 times a day. 6. Diovan 160 mg p.o. q.day. 7. Naprosyn 500 mg p.o. b.i.d. 8. Miacalcin 200 International Units per mL once a day. 9. Carbidopa/levodopa CR 50/200 p.o. q.h.s. 10. Trazodone 100 mg p.o. q.day. 11. Effexor 150 mg p.o. q.day. 12. Flexeril 10 mg p.o. b.i.d.
CR|controlled release|CR|133|134|MEDICATIONS|10. History of appendectomy. 11. History of vaginal biopsy. 12. History of depression. MEDICATIONS: 1. Aspirin 81 mg daily. 2. Paxil CR 25 mg daily. 3. Plavix 75 mg p.o. daily. 4. Toprol 50 mg daily. 5. Lisinopril 20 mg daily. 6. Spironolactone 25 mg daily. 7. Lasix 20 mg daily.
CR|controlled release|CR|140|141|DISCHARGE MEDICATIONS|Insight and judgment intact. Mood stable. DISCHARGE MEDICATIONS: 1. See medications ordered on admission; he is to continue those. 2. Paxil CR 12.5 mg on _%#MMDD2004#%_. 3. Paxil CR 25 mg daily starting _%#MMDD2004#%_ and thereafter. 4. Seroquel 25 mg up to 3 times daily as needed for anxiety.
CR|controlled release|CR|168|169|MEDICATIONS|MRI was done and this did show a small right parietal infarct consistent with his abnormalities. MEDICATIONS: Patient's medications include atenolol 50 mg daily, Paxil CR 12.5 mg daily. He is supposed to take Allopurinol, which he has not been taking and an aspirin, which he has not been taking.
CR|controlled release|CR|146|147|DISCHARGE MEDICATIONS|12. K-Dur 40 mEq oral b.i.d. 13. Metformin 1000 mg p.o. b.i.d. 14. Actos 30 mg p.o. daily. 15. Hydrochlorothiazide 12.5 mg p.o. daily. 16. Ambien CR 12.5 mg p.o. at bedtime p.r.n. 17. Iron 1 tablet p.o. daily. 18. Folic acid 400 mcg p.o. daily. 19. Fish oil 1000 mg p.o. daily. 20. Centrum silver 1 tablet p.o. daily.
CR|controlled release|CR|157|158|MEDICATIONS BEFORE ADMISSION|She has an alcoholic beverage about three times a week. She no longer smokes. MEDICATIONS BEFORE ADMISSION: Monopril 40 mg a day, Aricept 10 mg a day, Paxil CR 12.5 mg daily, folic acid 1 mg daily, Buspar 10 mg p.o. t.i.d., potassium 10 mEq b.i.d., hydrochlorothiazide 12.5 mg daily, Risperdal 0.25 mg daily at bedtime, Zantac 150 mg daily, calcium 500 mg 2 tablets daily, Trazodone 50 mg 1.5 tablets at bedtime, Atrovent and albuterol nebulization therapy q. 4 hours p.r.n., albuterol q. 4 hours p.r.n.
CR|controlled release|CR|112|113|PLAN|11. History of herniorrhaphy. 12. Hyperlipidemia. PLAN: 1. No-added-salt, fat-controlled diet. 2. Nitroglycerin CR 6.5 mg p.o. b.i.d. 3. Coreg 3.125 mg p.o. b.i.d. 4. Lisinopril 20 mg p.o. q. day 5. Plavix 75 mg p.o. q. day 6. Aspirin 325 mg p.o. q. day with food
CR|controlled release|CR|126|127|CURRENT MEDICATIONS|6. She is gravida 3, para 3. 7. Cholecystectomy. 8. Breast lumpectomy. CURRENT MEDICATIONS: 1. Zoloft 50 mg daily. 2. Sinemet CR 25/100 1/2 pill p.o. 3. Vitamin E 400 units daily. 4. Synthroid 0.025 mg daily. 5. Neurontin 100 mg b.i.d. 6. Glucosamine 500 mg t.i.d. 7. Calcium and magnesium daily.
CR|controlled release|CR|144|145|HISTORY OF PRESENTATION|His medications will consist of: 1) Aspirin enteric coated 81 mg p.o. q day. 2) Os-cal 500 mg. 3) Oyster shell two tablets p.o. q.d. 4) Sinemet CR one tablet p.o. q.i.d. 5) Ferrous sulfate 325 mg p.o. b.i.d. 6) Lasix 80 mg p.o. b.i.d. 7) Glyburide 25 mg p.o. b.i.d. 8) Lisinopril 10 mg p.o. q.d. 9) Imdur 60 mg SR p.o. q.d. 10) Protonix 40 mg p.o. q.d. 11) Prednisone 50 mg p.o. q.d. 12) Metoprolol 25 mg p.o. b.i.d. 13) Senna p.r.n. 14) Zoloft 50 mg p.o. q.d. The patient needs to follow-up with his primary care physician on Monday with a repeat basic metabolic panel including creatinine and potassium.
CR|controlled release|CR|135|136|DISCHARGE MEDICATIONS|3. Spironolactone 25 mg daily. 4. Vitamin K 5 mg daily. 5. Rifampin 400 mg three times daily. 6. Zinc 220 mg twice daily. 7. Oxycodone CR 10 mg twice daily. 8. Protonix 40 mg twice daily. 9. Lactulose 30 cc five times daily. 10. Ibuprofen 400 mg q. 4 hours p.r.n. 11. Hydroxyzine 50 mg q. 4 hours p.r.n. HOSPITAL COURSE: 54-year-old male with above past medical history presented to the emergency room at University of Minnesota Medical Center at the request of his family for acute onset of confusion.
CR|controlled release|CR|219|220|MEDICATIONS|Her most recent dose of Depakote mentioned in her medical record is Depakote extended release 1,000 mg at bedtime daily. She was discharged from Fairview Ridges hospital approximately a week ago on this dose. 3. Ambien CR 12.5 mg at bedtime on a p.r.n. basis. 4. Xalatan eyedrops for glaucoma. ALLERGIES: She lists a host of medications that she is allergic to including PENICILLIN, sulfa, codeine, Valium, Librium, quinolones and some pain medications such as Vicodin.
CR|controlled release|CR|145|146|PAST MEDICAL HISTORY|Has not noticed any edema. PAST MEDICAL HISTORY: Limited information available. Chronic atrial fibrillation for which she takes diltiazem 180 mg CR qd. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives alone, is not a smoker and denies alcohol use.
CR|controlled release|CR|153|154|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Norvasc 5 mg a day for hypertension. 2. Sinemet 25/100, one-half at 2:30, 25/100, a full tablet at 8 a.m. and 12 noon, Sinemet CR 25/100, one four times a day for Parkinson's. 3. Hydrochloric acid, five drops with meals. 4. Synthroid .1 daily. 5. Multivitamin daily. 6. Tylenol Extra Strength. 7. Darvocet as needed for pain.
CR|controlled release|CR|222|223|DISCHARGE MEDICATIONS|Also recommended a follow-up appointment with Dr. _%#NAME#%_ next week for follow-up of her cellulitis. She will have a home care nurse assessment done. DISCHARGE MEDICATIONS: 1. Keflex 500 p.o. q.i.d. x 10 days. 2. Paxil CR 37.5 mg p.o. q.d. 3. Ividol cream applied to legs b.i.d. 4. Norvasc 5 mg p.o. q.d. 5. Hydrochlorothiazide 25 mg p.o. q.d. 6. Calcium with vitamin D 600 mg p.o. q.d.
CR|controlled release|CR|533|534|DISCHARGE MEDICATIONS|His hemoglobin dropped from 11.8 to 8.6 at which time he received two units of packed cells with good results. Currently his hemoglobin is 10.5. DISCHARGE MEDICATIONS: Enteric-coated aspirin 81 mg p.o. q.d. Darvocet one to two tablets p.o. q.4-6.h. p.r.n. Acetaminophen 650 mg p.o. q.6.h. p.r.n. Dulcolax suppositories p.r. p.r.n. Restoril 7.5 mg p.o. h.s. p.r.n. Lopressor 25 mg p.o. b.i.d. Calcitonin nasal spray one spray in alternate nostrils q.d. Lipitor 20 mg p.o. h.s. Prevacid 30 mg p.o. q.d. Calcium 1250 mg p.o. q.d. Paxil CR 25 mg p.o. q.d. Coumadin 2.5 mg p.o. q.d. Keep INR at 1.5. The patient will follow-up with Dr. _%#NAME#%_ while in the nursing home.
CR|controlled release|CR|127|128|ALLERGIES|DISCHARGE MEDICATIONS: The patient is being discharged on the following medications: 1. Zoloft 50 mg p.o. q.d. 2. Indomethacin CR 75 mg capsule p.o. q.d. 3. Ultram 50 mg q.d. 4. Aleve 220 mg p.o. q.6-8h. p.r.n. 5. Actigall 300 mg p.o. b.i.d. 6. Roxicet elixir 5 to 10 cc p.o. q.4h. p.r.n. for pain.
CR|controlled release|CR|137|138|DISCHARGE MEDICATIONS|2. Ferrous sulfate 324 mg one p.o. t.i.d. 3. Hydrochlorothiazide 12.5 mg one p.o. daily 4. Lisinopril 10 mg one p.o. daily. 5. Oxycodone CR 10 mg one p.o. q.12h. p.r.n. 6. Senokot S two tabs p.o. daily p.r.n. 7. Zocor 20 mg one p.o. daily. The patient has a TCU bed available at _%#CITY#%_ Care Center.
CR|cardiorespiratory|CR:|124|126|REVIEW OF SYSTEMS|She has daily bowel movements. GU: No dysuria, hematuria, or frequency. She has nocturia x 2. She does have monthly menses. CR: No chest pain, but is short of breath with more activity due to her obesity. She denies edema. The patient denies significant current cough and denies earache, plugged ears or nasal congestion to any degree.
CR|controlled release|CR|170|171|DISCHARGE MEDICATIONS|7. Protonix 40 mg p.o. 2 times a day. 8. Zoloft 200 mg p.o. q.day. 9. Restoril 15 mg p.o. every-other-day. 10. Reglan 10 mg p.o. 30 minutes before meals. 11. Propranolol CR 120 mg p.o. q.day. FOLLOW UP: The patient to follow up with primary care physician within 1 month for evaluation of his cholesterol as well as liver enzymes, and also for further management of his hypertension.
CR|controlled release|CR|130|131|DISCHARGE MEDICATIONS|4. Inderal LA 80 mg p.o. b.i.d. 5. Niaspan 500 mg half tablet p.o. t.i.d. 6. CoQ10 1 tablet p.o. b.i.d. 7. Carbidopa and levodopa CR 50/200 mg 1 tablet p.o. b.i.d. 8. Niacin 500 mg p.o. q. day. 9. ReQuip 4 mg p.o. t.i.d. DISCHARGE INSTRUCTIONS: The patient was instructed not to lift more than 10 to 15 pounds for the next 6 weeks.
CR|controlled release|CR|146|147|DISCHARGE MEDICATIONS|3. Estradiol 2 mg daily. 4. Protonix 40 mg daily. 5. PhosLo tabs t.i.d. with meals. 6. Rocaltrol 0.25 mcg p.o. Monday-Wednesday-Friday. 7. Ambien CR 12.5 mg p.o. nightly. 8. Procrit 10,000 units once a week on Thursday. 9. Phenergan 12.5 to 25 mg p.o. as needed for nausea.
CR|controlled release|CR|140|141|DISCHARGE MEDICATIONS|7. Synthroid 175 mcg p.o. daily. 8. Lisinopril 20 mg p.o. daily. 9. Nasonex 2 sprays per nostril daily. 10. MVI 1 p.o. daily. 11. Oxycodone CR 10 mg p.o. b.i.d. 12. Allegra D 1 p.o. b.i.d. p.r.n. 13. Oxycodone 5-10 mg p.o. q.4h. p.r.n. pain. HOSPITAL COURSE: Rehab course was unremarkable.
CR|controlled release|CR|144|145|MEDICATIONS PRIOR TO ADMISSION|7. Albuterol inhaler 90 mcg inhaler 2 puffs q.4h. p.r.n. shortness of breath. 8. Alprazolam (Xanax) 0.5 mg p.o. q.8h. p.r.n. anxiety. 9. Ambien CR 5 mg p.o. at bedtime/p.r.n. 10. Levothyroxine 100 mcg p.o. daily. 11. Nexium 40 mg p.o. daily. 12. Paroxetine 30 mg p.o. daily.
CR|controlled release|CR|143|144|MEDICATIONS|ALLERGIES: No known drug allergies. MEDICATIONS: 1. Albuterol MDI 2 puffs q. 4-6h p.r.n. 2. Carbidopa/levodopa 25/100 2 p.o. q.i.d. 3. Sinemet CR 50-200 (?) 1 p.o. q.h.s. 4. Mirapex 0.125 p.o. t.i.d. and 0.25 mg p.o. t.i.d. 5. Triamterene 1 p.o. q.d. 6. Aspirin 325 mg p.o. q.d.
CR|controlled release|CR|139|140|CURRENT MEDICATIONS|5. Lisinopril hydrochlorothiazide 20/25 one q.d. 6. Trazodone 50 mg two tabs q. hour of sleep. 7. Lipitor 20 mg q. hour of sleep. 8. Paxil CR 25 mg two tablets q.a.m. 9. Protonix 40 mg q.d. 10. Celebrex 200 mg q.d. 11. Tylenol 650 mg p.r.n. ALLERGIES: The patient currently has an allergy to ginseng.
CR|controlled release|CR|139|140|CURRENT MEDICATIONS|2. Cholecystectomy. 3. Appendectomy. 4. Lung biopsy in the past. 5. Right shoulder surgery for rotator cuff. CURRENT MEDICATIONS: 1. Paxil CR 12.5 mg daily. 2. Zofran 4 mg p.o. q.8h. p.r.n. 3. Remeron 15 mg at h.s. 4. Premarin 0.625 mg per day. 5. Oral vancomycin. ALLERGIES: History of penicillin and sulfa allergies.
CR|controlled release|CR|118|119|MEDICATIONS|2. Zetia 10 mg daily. 3. Metamucil. 4. Lasix 20 mg daily. 5. Norvasc 5 mg daily. 6. Lisinopril 40 mg daily. 7. Ambien CR 12.5 mg daily. 8. Lescol 40. 9. Flonase two puffs in each nostril twice daily. 10. Effexor 37.5 mg daily. 11. Multivitamin. During the patient's last hospitalization, his colonoscopy demonstrated sigmoid diverticulosis with bleeding in the general area.
CR|controlled release|CR|168|169|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Zofran 8 mg orally every 8 hours. 2. Senna 1 to 2 tablets orally two times a day. 3. Gabapentin 600 mg orally three times a day. 4. Oxycodone CR 20 mg orally twice daily. 5. Prednisone 100 mg orally once daily to be taken for _%#MM#%_ _%#DD#%_, 2006, only. FOLLOWUP APPOINTMENT: He will come in to the Cancer Center on _%#MM#%_ _%#DD#%_, 2006, to receive his dose of Neulasta and Aranesp subcutaneously.
CR|controlled release|CR|218|219|CURRENT MEDICATIONS|Recent D and C in _%#MM#%_ she was pretty much knocked out and does not remember much but she does remember feeling the instruments although no significant pain when the D and C was done. CURRENT MEDICATIONS: 1. Paxil CR 25 mg a day. 2. Kay Ciel 10 mEq 2 tablets a day. 3. Ascorbic acid. 4. Multivitamin. 5. Calcium with vitamin D. 6. Digestive enzyme.
CR|controlled release|CR|242|243|MEDICATIONS|ALLERGIES: None. MEDICATIONS: Vicodin p.r.n., Nitro sublingually p.r.n. which she has not had to use for a good long time. The patient is on Warfarin but has stopped it for the operation. She takes Alprazolam 0.5 mg p.r.n. anxiety and Ambien CR dose unknown, at bedtime for sleep. PAST SURGERY: Catheter ablation of excess retractions in the heart times two.
CR|controlled release|CR|172|173|DISCHARGE MEDICATIONS|2. Zocor 20 mg p.o. daily. 3. Caltrate 600 mg p.o. b.i.d. 4. Cozaar 25 mg p.o. daily. 5. Folic acid 1 mg p.o. daily. 6. Hydrochlorothiazide 25 mg p.o. daily. 7. Isosorbide CR 60 mg p.o. q.i.d. 8. Metoprolol 12.5 mg p.o. b.i.d. 9. Sublingual nitroglycerin 0.4 mg sublingual q.5 minutes x3 p.r.n. for chest pain.
CR|controlled release|CR|95|96|ADMISSION MEDICATIONS|2. Perirectal abdominal surgery. 3. Tonsillectomy. ADMISSION MEDICATIONS: 1. Sinemet 50/200 mg CR p.o. q.4h. 2. Comtan 200 mg p.o. t.i.d. 3. Parlodel 5 mg p.o. 2 tablets three times daily. 4. Requip 4 mg p.o. three times daily. 5. Vitamin E 1000 units daily.
CR|controlled release|CR|137|138|DISCHARGE MEDICATIONS|7. Zocor 20 mg p.o. daily. 8. Protonix 20 mg p.o. daily. 9. Paxil 30 mg p.o. daily. 10. Robaxin 1500 mg p.o. t.i.d. p.r.n. 11. OxyContin CR 20 mg p.o. b.i.d. 12. Multivitamins Ocuvite 1 p.o. daily. 13. Senokot-S 1 to 2 tablets p.o. b.i.d. p.r.n. 14. Oxycodone 5 mg 1 to 2 tablets p.o. q.i.d. p.r.n. breakthrough pain.
CR|controlled release|CR|158|159|DISCHARGE MEDICATIONS|10. Multivitamin with minerals one tab p.o. daily. 11. Nexium 20 mg p.o. daily. 12. Ativan 0.5 mg p.o. h.s. p.r.n. 13. Detrol-LA 4 mg p.o. h.s. 14. Oxycodone CR 20 mg p.o. b.i.d. for pain 15. Oxycodone 5 mg p.o. q.4-6h. p.r.n. for pain. 16. Aspirin 81 mg p.o. daily. 17. Macrobid 100 mg p.o. h.s.
CR|controlled release|CR|161|162|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. daily. 2. Magnesium oxide 800 mg p.o. b.i.d. 3. Reglan 10 mg p.o. t.i.d. 4. Multivitamin 1 p.o. daily. 5. Oxycodone CR 40 mg p.o. t.i.d. 6. Nexium 40 mg p.o. daily. 7. Senokot S 1 p.o. b.i.d. 8. Prograf 3 mg p.o. q.a.m. 9. Prograf 2 mg p.o. q.p.m. 10. Ditropan XL 10 mg p.o. daily.
CR|controlled release|CR|176|177|DISCHARGE MEDICATIONS|220. Nasonex one spray each nostril daily. 221. Nystatin the statin. Five 5 mL swish and swallow q.i.d. x 2 weeks. 22. MetroGel 0.75% topically daily next . 32. Hydrocortisone CR 2.5% topically t.i.d. 33. Nizoral shampoo 2% which daily next . 34. Lidoderm patch, 1 patch topically q.12h., 35. fFentanyl 25 mcg patch q.72h., next. 36. Albuterol 2 puffs inhaler q.4h. Pp.r.n. shortness of breath.
CR|controlled release|CR|161|162|MEDICATIONS|6. Carbidopa/levodopa 25/100 one tab q.a.m., one tablet at 4:00 p.m. two tabs at h.s. 7. Lanoxin 0.125 mg a day. 8. Chlorthalidone 50 mg a day. 9. Pentoxicelene CR 400 mg t.i.d. 10. Diltiazem CR 240 mg daily. 11. Effexor XR 37.5 mg daily. ALLERGIES: Codeine and sulfa. SOCIAL HISTORY: She is married, husband's name is _%#NAME#%_ and they currently live alone in assisted living, no tobacco use.
CR|controlled release|CR|155|156|MEDICATIONS|17. Fentanyl patch 25 mcg which started when he hit the hospital. 18. Sorbitol 30 p.o. q. day. 19. Milk of Magnesia 15 to 30 p.o. q. day p.r.n. 20. Ambien CR 12.5 p.o. each day at bed-time p.r.n. 21. Roxicodone 5-10 q.4 hours p.r.n. 22. Vicodin 1-2 p.o. q. 6 hours p.r.n. PHYSICAL EXAMINATION: GENERAL: The patient is resting on his left side in no apparent distress.
CR|controlled release|CR|208|209|HOME MEDICATIONS|13. Fosamax 70 mg p.o. q. Saturday. 14. Sinemet 25/100 2 tablets p.o. q.8 a.m., 25/100 1-1/2 tablets p.o. q. noon, 25/100 1-1/2 tablets p.o. q.4 p.m., 25/100 1 tablet p.o. q.4 a.m. p.r.n. tremor. 15. Sinemet CR 25/100 1 tablet p.o. at bedtime. ALLERGIES: Penicillin (rash), Ambien (hallucinations).
CR|controlled release|CR|143|144|MEDICATIONS|15. Neurontin 200 mg p.o. t.i.d. 16. Ondansetron hydrochloride 4 mg p.o. q.6 hours p.r.n., nausea. 17. Os-Cal 500 mg p.o. b.i.d. 18. Oxycodone CR 10 mg p.o. b.i.d. 19. Pred-Forte ophthalmic solution 1% one drop each eye every Tuesday and Friday. 20. Protonix 20 mg p.o. q.a.m. 21. Simvastatin 20 mg each day at bedtime.
CR|controlled release|CR|146|147|CURRENT MEDICATIONS|10. Protonix 40 mg p.o. twice daily. 11. Rapamycin 6 mg p.o. daily. 12. Stadol 2 sprays in each nostril every 4 hours p.r.n. for pain. 13. Ambien CR 12.5 mg p.o. at h.s. PHYSICAL EXAMINATION: Today the patient appeared tired.
CR|controlled release|CR|122|123|DISCHARGE MEDICATIONS|5. Hypothyroidism. DISCHARGE MEDICATIONS: 1. Depakote 125 mg p.o. q.a.m. and q.h.s. 2. Haldol 0.5 mg p.o. q.h.s. 3. Paxil CR 12.5 mg p.o. q.h.s. 4. Aspirin 81 mg p.o. q. day. 5. Levoxyl 75 mcg p.o. q. day. 6. Zosyn 3.375 gm IV q.8 hours x11 days, to complete a 14-day course.
CR|controlled release|CR|156|157|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Imdur 30 mg per day. 2. Toprol 50 mg b.i.d. 3. Lasix 20 mg per day. 4. Lopid 600 mg per day. 5. Aspirin 81 mg per day. 6. Sinemet CR 50/200 1 p.o. b.i.d. 7. Cosopt eye drops one drop OS b.i.d. 8. Iron sulfate 324 mg per day. 9. Claritin 10 mg per day. 10. Pentasa 250 mg eight tablets b.i.d.
CR|controlled release|CR.|138|140|DISCHARGE DIAGNOSES|7. Poor nutrition: The patient is eating well. 8. Deconditioning: She has met the goals of PT and OT. 9. Anxiety. We did resume her Paxil CR. We also do have her on trazodone at bedtime as well as p.r.n. Xanax, low dose at bed time, which has helped her insomnia.
CR|controlled release|CR|203|204|DISCHARGE MEDICATIONS|3. Probable Alzheimer's disease. 4. Alcoholic spinal cord disease. 5. Diabetes, adult onset. 6. Normochromic anemia, longstanding. 7. Homocystinemia. DISCHARGE MEDICATIONS: Lisinopril 10 mg daily, Paxil CR 25 mg daily, Folgard 2 tablets daily, multiple vitamin 1 tablet daily, Lantus insulin 35 units subcutaneously daily, Humalog insulin with a sliding scale, Diltiazem 180 mg daily, Detrol LA 2 mg h.s., Namenda 5 mg daily, Reminyl 4 mg b.i.d.. PLANS FOR DISCHARGE: Patient is going to be discharged to a skilled rehabilitation unit/Augustana Homes.
CR|controlled release|CR|162|163|MEDICATIONS|His risk factors include the increased cholesterol, hypertension, cigarette smoking, family medical history, but are negative for diabetes. MEDICATIONS: 1. Paxil CR 25 mg po q day. 2. Lipitor 40 mg po q day. 3. Imdur 30 mg po q day. 4. Norvasc 10 mg po q day. SOCIAL HISTORY: He lives with his ex-wife.
CR|controlled release|CR|154|155|HOSPITAL COURSE|She has an O2 sat of 94% on room air. The patient's back pain has been better controlled by taking her off her Percocet and she has been put on OxyContin CR 10 mg p.o. b.i.d. with Oxycodone 5 to 10 mg p.o. q.4h. p.r.n. break through pain. The patient has also been put on a bowel prep Senna docusate.
CR|controlled release|CR|200|201|DISCHARGE MEDICATIONS|1. Aspirin 2600 mg t.i.d. 2. Amiodarone 200 mg p.o. b.i.d. through _%#MMDD#%_ and then daily for one month 3. Toprol-XL 25 mg p.o. daily 4. Oxycodone one to two tabs every 4 hours p.r.n. 5. OxyContin CR 10 mg q.12h x5 days; then OxyContin CR 10 mg each day at bed-time x5 days, then stop 6. Prilosec 20 mg p.o. b.i.d. 7. Imuran 175 mg p.o. daily
CR|controlled release|CR|208|209|MEDICATIONS|The patient is on steroids for rheumatoid arthritis, that is a Crest Syndrome, and also on Plaquenil. MEDICATIONS: List includes: 1. Prednisone 5 p.o. b.i.d. 2. Ambien 5 at bedtime for insomnia. 3. Oxycodone CR 30 mg in the morning for pain, and 20 extended release q.p.m. for pain 4. Aspirin 81 mg b.i.d. 5. Plaquenil 200 p.o. b.i.d.
CR|controlled release|CR|133|134|DISCHARGE  MEDICATIONS|1. Vitamin B12 1,000 mcg q day. 2. Dalmane 30 mg q.h.s. p.r.n. 3. Lasix 40 mg p.o. q. day. 5. Potassium 10 mEq p.o. q day. 6. Niacin CR 1,000 mg p.o. q. day. The patient should follow up with Dr. _%#NAME#%_ in 1 week for reassessment of symptoms and recheck of his blood pressure.
CR|controlled release|CR|152|153|CURRENT MEDICATIONS|3. Diltiazem ER 180 mg p.o. q.d. 4. Depakote 250 mg p.o. b.i.d. 5. Triamcinolone 0.1% cream applied to scaly lesions daily. 6. Dovonex CR/triamcinolone CR applied to affected area and rub in b.i.d. 7. Tegrin ointment applied to scalp daily. FAMILY HISTORY: Cannot obtain family history.
CR|controlled release|CR|157|158|DISCHARGE MEDICATIONS|5. Prednisone 5 mg p.o. every day; Dr. _%#NAME#%_ to reassess the dose, the frequency, and the duration. 6. Colace 100 mg p.o. every day p.r.n. 7. Oxycodone CR 1 p.o. b.i.d. p.r.n. 8. Coumadin 2 mg p.o. every day. 9. Augmentin 875 mg p.o. b.i.d. for 10 days; start date is _%#MM#%_ _%#DD#%_, 2004.
CR|controlled release|CR|173|174|DISCHARGE MEDICATIONS|2) Albuterol inhaler. 3) Baclofen 50 mg q.i.d. 4) Wellbutrin SR 150 mg b.i.d. 5) Clonazepam as previously prescribed - I believe she is taking 1.5 mg p.o. q.i.d. 6) Sinemet CR 50/200 one tablet five times a day. 7) Celexa 80 mg q day. 8) Zocor 20 mg at bedtime. 9) Baby aspirin one q day. 10) Seroquel 25 mg at bedtime.
CR|controlled release|CR|144|145|DISCHARGE  MEDICATIONS|8. Zoloft 50 mg p.o. q. day. 9. Detrol-LA 4 mg p.o. q. day. 10. Vitamin D 400 units by mouth twice a day. This is a new medicine. 11. OxyContin CR 10 mg p.o. b.i.d. for pain. This is a new medicine and intended to be needed for approximately 3-4 weeks.
CR|controlled release|CR|125|126|DISCHARGE MEDICATIONS|4. Niaspan 1 gram p.o. daily at bedtime. 5. Protonix 40 mg p.o. twice daily. 6. Zocor 20 mg p.o. daily at bedtime. 7. Ambien CR 25 mg p.o. daily at bedtime. 8. Calcium with vitamin D 600/200 mg, one tablet p.o. twice daily. 9. Tylenol Arthritis 2 tablets p.o. three times daily as needed.
CR|controlled release|CR|186|187|DISCHARGE FOLLOW-UP|Because of apnea and bradycardia episodes, Wayne was treated with caffeine citrate. The last episode occurred on _%#MMDD2007#%_, and the medication was discontinued on _%#MMDD2007#%_. A CR scan was obtained on the night of _%#MMDD2007#%_ and the results were as follows: immature respiratory pattern with a significant amount of periodic breathing, and multiple prolonged mixed central/obstructive spells.
CR|controlled release|CR|147|148|MEDICATIONS|4. Milk of Magnesia 5. Benadryl p.r.n. 6. Dulcolax p.r.n. 7. Lidoderm patch that was recently discontinued 8. Fosamax 70 mg per week. 9. Oxycodone CR 10 mg 3 times a day 10. multivitamin daily. 11. Norvasc 10 mg daily. 12. Omeprazole 20 mg daily. 13. Vitamin D 400 international units daily. 14. Levoxyl 0.2 mg daily.
CR|controlled release|CR|140|141|ALLERGIES|3. Permax 1.5 g p.o. q.a.m. and 4 g p.o. q.p.m. 4. Sinemet 25/100 one tab p.o. 7 times a day. The patient may taper to symptoms. 5. Sinemet CR 50/200 1 tab p.o. 7 times a day. DISCHARGE INSTRUCTIONS: 1. Diet is regular. 2. Activity is as tolerated.
CR|cardiorespiratory|CR|237|238|2. PPROM|He then progressed to nasal cannula oxygen. He has been off supplemental oxygen since _%#MMDD2002#%_. A CR scan on _%#MMDD2002#%_ was normal on diuretics. His diuretics and sodium supplement were discontinued on _%#MMDD2002#%_. A repeat CR scan on _%#MMDD2002#%_ showed an obstructive episode and desaturation with and without feedings . _%#NAME#%_ was started on Zantac and a repeat CR scan on _%#MMDD2002#%_ was normal.
CR|controlled release|CR|190|191|DISCHARGE MEDICATIONS|1. Gentamicin 400 mg IV q.a.m. x 2 weeks. 2. Vancomycin 1.2 gm IV q12h x 4 weeks. 3. Atenolol 25 mg p.o. q.d. 4. Amantadine 100 mg p.o. q.a.m. 5. Sinemet 25/100 one p.o. x 5 q.d. 6. Sinemet CR 25/200 one p.o. x 7 q.d. 7. Requip 2 mg p.o. q.i.d. 8. Citrucel 17 gm p.o. q.d. 9. Multivitamin one p.o. q.d. 10. Senna S two p.o. q.d.
CR|controlled release|CR|113|114|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: GENERAL: Sweats. She has hot flashes since going on Effexor. She had better relief with Paxil CR 25 mg. EYES: She had LASIK surgery done. EARS: Negative. NOSE: Negative. THROAT: Negative. No sore throat or hoarseness. CARDIOVASCULAR: Negative for cardiac pain or irregular heartbeat. RESPIRATORY: Negative.
CR|controlled release|CR|200|201|MEDICATIONS|The patient has an older brother who was recently diagnosed with diabetes mellitus. MEDICATIONS: 1. Liquibid two tablets b.i.d. 2. Potassium supplements 20 mEq daily. 3. Lipitor 10 mg daily. 4. Paxil CR 25 mg daily. 5. _____ 1 mg at bedtime. 6. Lasix 40 mg b.i.d. 7. Augmentin, dose unknown. 8. Spironolactone 25 mg daily. 9. Advair discus one puff b.i.d. REVIEW OF SYSTEMS: The patient denies any chest pain.
CR|controlled release|CR|118|119|DISCHARGE MEDICATIONS|3. Coumadin 5 mg q.d. 4. Ibuprofen 400 mg q.d. 5. Imodium 2 mg p.o. each week p.r.n. 6. Lisinopril 5 mg q.d. 7. Paxil CR 25 mg q.d. 8. Prednisone 10 mg b.i.d. 9. Triamterene/hydrochlorothiazide 1 p.o. q.d. 10. Zocor 40 mg p.o. q.d. 11. Atenolol 50 mg q.d. 12. Multivitamin 1 p.o. q.d.
CR|controlled release|CR|238|239|HOSPITAL COURSE|I did ask psychiatry to see him during this admission and Dr. _%#NAME#%_ was in agreement that no benzodiazepine should be used for his anxiety. He appears extremely anxious. She recommended starting Zyprexa 10 mg p.o. at bedtime., Paxil CR 12.5 mg p.o. at bedtime, and trazodone 50 mg p.o. t.i.d. and 150 mg p.o. at bedtime to assist with insomnia. She did recommend an inpatient psychiatric transfer to titrate meds and to offer psychotherapy for his depression, anxiety, history of psychosis, and history of benzodiazepine abuse.
CR|controlled release|CR|180|181|DISPOSITION|He was looking into getting into Hazelden, but there was a delay. He was now planning on going to the Retreat. He was discharged on _%#MMDD2004#%_. He was to continue taking Paxil CR 25 mg daily. DISCHARGE DIAGNOSES: Alcohol dependence. He was discharged to the Retreat on _%#MMDD2004#%_.
CR|controlled release|CR|371|372|HOSPITAL COURSE|Given his gastritis and his proven propensity to bleed, it was decided that he should not continue on long-term Coumadin therapy, and given his acute-appearing gastritis, that for the immediate post-hospitalization period he should also not continue on aspirin therapy. He tolerated his proton pump inhibitor well. 2. Parkinson's disease. The patient had been on Sinemet CR b.i.d., and continued to have cognitive difficulties, namely, following commands, with fairly severe clinical bradykinesia. Neurology service was consulted, and given his symptomatology, he was switched from Sinemet CR to regular Sinemet to be dosed more frequently.
CR|controlled release|CR|155|156|CURRENT MEDICATIONS|FAMILY HISTORY: Father had hypertension. Mother had cerebrovascular accident (CVA) in her sixties. CURRENT MEDICATIONS: 1. Cartia 240 mg daily. 2. Sinemet CR 50/200 q.h.s. 3. Dyazide one daily. 4. Aspirin 81 mg daily. 5. Plavix 75 mg daily. 6. Lisinopril 20 mg daily. 7. Zoloft 100 mg daily.
CR|controlled release|CR|136|137|DISCHARGE MEDICATIONS|4. Bisacodyl suppositories 10 mg PR q. day p.r.n. for constipation. 5. Sorbitol 30 mL p.o. q. day p.r.n. for constipation. 6. Oxycodone CR 10 mg p.o. b.i.d. for pain. 7. Oxycodone 5 mg p.o. q.4 h. p.r.n. for pain. 8. Zocor 20 mg p.o. q.o.d. 9. Glyburide 5 mg p.o. 1 to 4 tablets p.o. q. day depending on the patient's blood sugar, this is according to his previous outpatient regimen.
CR|controlled release|CR|174|175|IDENTIFICATION|She was advised not to take Darvocet any longer. She stated that she will follow up with Dr. _%#NAME#%_ in the office. DISCHARGE MEDICATIONS: 1. Geodon 40 mg b.i.d. 2. Paxil CR 25 mg daily. 3. Seroquel 100 mg b.i.d. 4. Effexor XR 150 mg daily. 5. Depakote ER 1500 mg daily at bedtime.
CR|controlled release|CR|196|197|DISCHARGE MEDICATIONS|In addition, he was instructed to follow up to have an adenosine thallium stress test done at the earliest opening to evaluate him for coronary artery disease. DISCHARGE MEDICATIONS: 1. Diltiazem CR 240 mg p.o. q. day, this is a new medication. 2. Aspirin 325 mg p.o. q. day. 3. Atenolol 25 mg p.o. q. day. 4. Lisinopril 20 mg p.o. q. day. 5. Aciphex 20 mg p.o. b.i.d.
CR|controlled release|CR|170|171|MEDICATIONS|5. Valcyte 450 mg daily. 6. Ursodiol 300 mg b.i.d. 7. hydrocodone 600 mg 6 hours as needed 8. sulfide/Bactrim DS 1 tablet p.o. every Monday, Wednesday, Friday. 9. Ambien CR 6.25 mg at the bed time as needed. PAST MEDICAL HISTORY: 1. Cadaveric liver transplant in _%#MM2005#%_.
CR|controlled release|CR|323|324||This 44-year-old patient with complicated past medical history, treated by Dr. _%#NAME#%_ in the Clinic of Neurology for trigeminal neuralgia, currently have her on methadone 5 mg, she states the dose is t.i.d. although I do not have any prescription as actual bottle showing that. She is also on Prevacid for GERD, Ambien CR at bedtime for sleep, Klonopin 1 tablet t.i.d. for pain, uses albuterol inhaler 2 puffs q.i.d. p.r.n. shortness of breath.
CR|cardiorespiratory|CR|249|250|HOSPITAL COURSE|We did discuss with the parents whether or not we wanted to pursue lumbar puncture to look for meningitis and the decision was made to not do this given the low likelihood of having it be a bacterial meningitis. _%#NAME#%_ was also monitored with a CR monitor given his history of turning blue and no significant events were noted. At the time of discharge, it was thought that his illness was most consistent with a viral etiology, and while the exact etiology of _%#NAME#%_'s blue spell is unknown, it was thought to be most consistent with vasovagal or breath holding spell.
CR|controlled release|CR|164|165|HISTORY OF PRESENT ILLNESS|The patient did have stenting done at that time and was discharged with an ejection fraction of approximately 30%. He is discharged on Plavix, Lipitor, Coreg 20 mg CR daily as well as lisinopril 5 mg b.i.d., Plavix 75 mg daily, aspirin 81 mg daily, nitroglycerin 0.4 mg q5 minutes p.r.n., metformin ER 750 mg daily and Lantus 20 units subq daily as well as Folic acid 1 mg daily and multivitamins and minerals 1 orally daily.
CR|controlled release|CR|153|154|MEDICATIONS|6. Fosamax 70 mg on Sunday. 7. Atropine drops one drop b.i.d. (I believe this is for secretions.) 8. Sinemet 25/100 1-1/2 tablets p.o. t.i.d. 9. Sinemet CR 50/200 one p.o. daily. 10. Vasotec 10 mg p.o. b.i.d. 11. Metoprolol 50 mg b.i.d. 12. Aspirin 81 mg daily. 13. Calcium 600 mg daily. ALLERGIES: None.
CR|cardiorespiratory|CR|206|207|HOSPITAL COURSE|On DOL 37 he had a cardiorespiratory study (CR) which suggested an immature infant with numerous episodes of periodic breathing, periods of apnea and desaturation. He was restarted on caffeine and a repeat CR on DOL 38 revealed periods of apnea and heart rate drops with feeding, but also during sleep. He was reloaded a half dose of caffeine and maintenance increased.
CR|cardiorespiratory|CR|281|282|IMPRESSION|_%#NAME#%_ received her 2 month immunizations on _%#MMDD2003#%_. 3. Respiratory - _%#NAME#%_ was intubated and ventilated during week 3 of life secondary due to the pseudomonas pneumonia and she was extubated on DOL#30. Keyana was treated with caffeine for apnea of prematurity. A CR scan on _%#MMDD#%_ showed a premature pattern of breathing, with a repeat CR scan on _%#MMDD#%_ showing normal pattern. Caffeine was discontinued and she has been stable until discharge.
CR|controlled release|CR|190|191|DISCHARGE MEDICATIONS|During his hospitalization, he continued to improve with daily PT/OT and PM&R evaluations. He is currently in stable condition. DISCHARGE MEDICATIONS: 1. Clonazepam 1 mg nightly. 2. Sinemet CR 50/200 mg at 8 a.m., 4 p.m., and 10 p.m. 3. Selegiline 5 mg b.i.d. 4. Amantadine 100 mg b.i.d. 5. Proscar 5 mg q.a.m. 6. Vitamin E 400 units q.a.m.
CR|controlled release|CR|197|198|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Oxygen p.r.n. low saturations. 2. Augmentin 875 mg p.o. b.i.d. for seven days. 3. Lisinopril 20 mg a day; hold for systolic less than 110. 4. Ogen 0.625 a day. 5. Sinemet CR 25/100, one at h.s. 6. Mirapex 0.25 b.i.d. 7. Calcium 600 b.i.d. DISCHARGE FOLLOW-UP: Dr. _%#NAME#%_ in 1-2 weeks. HISTORY: _%#NAME#%_ _%#NAME#%_ is a very pleasant 79-year-old female admitted to the hospital for possible urinary tract infection in a setting of some increased confusion.
CR|controlled release|CR|201|202|MEDICATIONS|2. Klonopin 0.5 mg 2 at bedtime. 3. Keppra 500 mg orally b.i.d. for control of seizures. 4. Oxycodone 5 mg 1-2 p.o. q.4h p.r.n. pain. 5. Fioricet with codeine 30 mg p.r.n. q.4h for headache. 6. Ambien CR 6.25 mg orally h.s. for sleep 7. Calcium 600 mg with D t.i.d. 8. Potassium chloride 10 mEq t.i.d. 9. She also takes Shaklee vitamins and a medication called Pain-etrate which apparently is an over-the-counter analgesic.
CR|controlled release|CR|135|136|DISCHARGE  MEDICATIONS|6. Lipitor 20 mg daily. 7. Aspirin 81 mg daily. 8. Multivitamin 1 tablet daily. 9. Nebulizer solution daily as needed. 10. Guaifenesin CR 600 mg p.o. b.i.d. HOSPITAL COURSE: Mr. _%#NAME#%_ is a pleasant 70-year-old male with COPD, O2 dependent, who had 7 days of cough, fever, productive sputum and feeling poorly.
CR|controlled release|CR|141|142|CURRENT MEDICATIONS|2. Valium 5 mg daily. 3. OxyContin 10 mg t.i.d. 4. Requip 0.5 mg t.i.d. 5. Gabapentin, the dose of which is not clear at this time. 6. Paxil CR 37.5 mg daily. 7. Hydroxyzine 100 mg t.i.d. SOCIAL HISTORY: The patient is unemployed secondary to his back pain.
CR|controlled release|CR|110|111|DISCHARGE MEDICATIONS|10. Neurontin 600 mg p.o. b.i.d. 11. Neurontin 900 mg p.o. q.h.s. 12. Norvasc 10 mg p.o. q. day 13. OxyContin CR 10 mg p.o. b.i.d. 14. Senna 2 tablets p.o. q.h.s. p.r.n. 15. Vicodin 1-2 tablets p.o. q.6h. p.r.n. 16. Zantac 150 mg p.o. b.i.d. 17. Aspirin 325 mg p.o. q. day
CR|controlled release|CR|182|183|DISCHARGE MEDICATIONS|It also seems that steroids and epinephrine are not helpful in this condition and these were not continued in the hospital. DISCHARGE MEDICATIONS: 1. Cymbalta 50 mg a day. 2. Ambien CR 12.5 mg q.h.s. p.r.n. DISCHARGE INSTRUCTIONS: She should seek medical attention with increasing swelling or any signs of breathing difficulties.
CR|cardiorespiratory|(CR)|152|155|FOLLOW-UP APPOINTMENTS|Results were normal. Cardiology was consulted and recommended CR scan and cranial ultrasound. Problem # 4: Respiratory. Leah had two cardio-respiratory (CR) scans while in the NICU because of frequent desaturations. The first CR scan was performed on _%#MM#%_ _%#DD#%_, 2006 and revealed an immature breathing pattern with approximately 50% periodic breathing, over 250 short desaturations episodes and a baseline saturation of 91%.
CR|controlled release|CR|136|137|MEDICATIONS|2. Ciprofloxacin 250 mg b.i.d. 3. Zyprexa 5 mg at bedtime. 4. Citalopram 60 mg daily. 5. Clonazepam 2 mg 1-2 tabs at bedtime. 6. Ambien CR 12.5 mg at bedtime. 7. Oxycodone p.r.n. 8. Premarin 0.625 mg daily. 9. Actos 45 mg daily. 10. Pyridium 200 mg b.i.d. 11. Gabapentin 600 mg t.i.d.
CR|controlled release|CR|142|143|MEDICATIONS|8. DVTs. MEDICATIONS: 1. Effexor XR 150 mg daily. 2. Klonopin 0.5 mg q.12 h. 3. Remeron 60 mg nightly. 4. Trazodone 50 mg nightly. 5. Lithium CR 900 mg nightly. 6. Coumadin 13 mg nightly. 7. Ultram 50 mg q.6 h. 8. Omeprazole 20 mg daily. 9. Neurontin 800 mg t.i.d. ALLERGIES: Seroquel, Paxil and Celexa.
CR|controlled release|CR|165|166|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. daily. 2. Glyburide 5 mg p.o. b.i.d. 3. Lisinopril 13 mg p.o. daily. 4. Multivitamin 1 tablet p.o. daily. 5. Oxycodone CR 40 mg p.o. b.i.d. 6. Pantoprazole 40 mg p.o. daily. 7. Rosiglitazone 4 mg p.o. daily. 8. Simvastatin 20 mg p.o. daily.
CR|controlled release|CR|179|180|DISCHARGE MEDICATIONS|4. Hypertension. 5. Myalgia. DISCHARGE MEDICATIONS: 1. Atenolol 100 q.day. 2. Aspirin 81 q.day. 3. Glucotrol XL 10 q.day. 4. Lisinopril 20 q.day. 5. Avandia 4 q.day. 6. Oxycodone CR 40 q8 hours. 7. Senokot two tabs at hs. 8. Lipitor 20 q.day.
CR|controlled release|CR|130|131|IDENTIFICATION|On admission, the following medications were reordered: Synthroid 0.137 mcg daily, Avian birth control pill once daily, and Paxil CR 12.5 mg daily. She was initially kept on close observations. On _%#MM#%_ _%#DD#%_, 2004, Ativan 0.5 mg one to two tabs up to 2 times daily was ordered for anxiety.
CR|controlled release|CR|189|190|MEDICATIONS|MEDICATIONS: The patient states he takes 1. Metformin 850 mg p.o. b.i.d. 2. Protonix. 40 mg p.o. daily. 3. Doxazosin 2 mg p.o. daily. 4. Hydrochlorothiazide 25 mg p.o. daily. 5. Nifedipine CR 60 mg p.o. daily. 6. Albuterol two puffs four times a day, as needed. 7. Advair 250/50 mg one puff b.i.d. 8. Lisinopril 10 mg p.o. daily.
CR|controlled release|CR|101|102|CURRENT MEDICATIONS|FAMILY HISTORY: Multiple family members with coronary artery disease. CURRENT MEDICATIONS: 1. Ambien CR 6.25 mg p.o. q.h.s. p.r.n. 2. Amiodarone 100 mg p.o. q.a.m. 3. Aspirin 81 mg p.o. q.a.m. 4. Digoxin 0.125 mg p.o. q.h.s.
CR|controlled release|CR|189|190|MEDICATIONS|MEDICATIONS: 1. Enteric-coated aspirin p.o. b.i.d. 2. Colace 100 mg p.o. b.i.d. 3. Lyrica, 25 mg p.o. b.i.d. 4. Metoprolol 12.5 mg p.o. b.i.d. 5. Omeprazole 20 mg p.o. q. day. 6. OxyContin CR 20 mg p.o. b.i.d. 7. Calcium with vitamin D one tab p.o. b.i.d. 8. Senokot-S p.r.n. constipation. ALLERGIES: She has no known drug allergies. SOCIAL HISTORY: She resides at Mount Olivet.
CR|controlled release|CR|184|185|DISCHARGE MEDICATIONS|She is also to contact physician for any signs of increased drainage, pain, swelling or temperature of 101.5 degrees Fahrenheit or higher. DISCHARGE MEDICATIONS: Include, 1. Metformin CR 500 mg p.o. daily. 2. Valium 5 mg p.o. q.6h. p.r.n. muscle spasm, #30. 3. Vicodin 5/500 mg one to two tablets p.o. q.6h. p.r.n. pain #35.
CR|controlled release|CR|126|127|DISCHARGE MEDICATIONS|10. Seroquel 100 mg p.o. at bedtime. 11. Zoloft 100 mg p.o. at bedtime. 12. Trazodone 50-100 mg p.o. q.h.s. p.r.n. 13. Ambien CR 5 mg p.o. q.h.s. p.r.n. 14. Lasix 40 mg p.o. daily. 15. Coumadin. She was to get her vancomycin q.24h. per ID.
CR|controlled release|CR|131|132|DISCHARGE MEDICATIONS ARE AS FOLLOWS|11. CellCept 1000 mg oral twice a day. 12. Tacrolimus 5 mg oral twice a day. 13. Prednisone 2.5 mg oral twice a day. 14. Diltiazem CR 240 mg oral daily. 15. Furosemide 20 mg oral daily. 16. Toprol-XL 50 mg oral daily. 17. Pancrease MT 10 five capsules oral with meals and snacks.
CR|controlled release|CR|130|131|DISCHARGE MEDICATIONS|5. Cozaar 25 mg, 1 tab p.o. daily. 6. Cortef 7.5 mg, 1 tab p.o. t.i.d. 7. Oxycodone 5 mg, 1 tab p.o. q.4-6 h. p.r.n. 8. Oxycodone CR 10 mg, 1 tab p.o. q.p.m. 9. Oxycodone CR 20 mg, 1 p.o. q.a.m. 10. Ambien 5 mg, 1 tab p.o. daily at bedtime.
CR|controlled release|CR|163|164|DISCHARGE MEDICATIONS|2. Chest x-ray PA and lateral done prior to clinic appointment. DISCHARGE MEDICATIONS: 1. Lyrica 150 mg p.o. t.i.d. 2. Lasix 20 mg p.o. daily. 3. Morphine sulfate CR 30 mg p.o. b.i.d. 4. Flonase daily. 5. Lorazepam 1 mg p.o. t.i.d. p.r.n. 6. Senokot 2 tablets b.i.d. while taking narcotics.
CR|controlled release|CR|146|147|DISCHARGE MEDICATIONS|7. Multivitamin one tablet daily. 8. Accupril 20 mg daily. 9. Senokot 2 tablets each day at bedtime p.r.n. 10. Zocor 20 mg p.o. daily. 11. Ambien CR 6.25 mg p.o. each day at bedtime. 12. Dilaudid 2-4 mg q.3h. p.r.n. 13. Aspirin 325 mg p.o. daily. 14. Calcium with vitamin D 1500 mg p.o. daily as a supplement.
CR|controlled release|CR|514|515|MEDICATIONS|Denies illicit drug use. Apparently lives alone. PERTINENT DRUG ALLERGIES: NUMEROUS AND INCLUDE ALENDRONATE, TRAMADOL, FLUOXETINE, NORTRIPTYLINE, FELODIPINE, PROPOXYPHENE, AMITRIPTYLINE, DYPHYLLINE, VIOXX, ZOLPIDEM, ASPIRIN AND TRAZODONE, PIROXICAM, PRAZOSIN, CELEBREX, GABAPENTIN, CARBAMAZEPINE, OXAPROZIN, SERTRALINE A PNEUMOCOCCAL POLYSACCHARIDE VACCINATION, BACLOFEN, CYCLOBENZAPRINE, MAPROTILINE, IBUPROFEN. MEDICATIONS: Per patient include. 1. Aciphex 20 mg daily. 2. Enteric-coated aspirin p.r.n. 3. Ambien CR 12.5 mg daily. 4. methocarbamol 750 mg p.o. q.i.d. Of note, there are other medicines listed in the chart but the patient states that she is not taking these.
CR|controlled release|CR|211|212|DISCHARGE MEDICATIONS|3. Activities as tolerated. FOLLOW-UP INSTRUCTIONS: Follow up in Stroke Clinic in 4-6 weeks. DISCHARGE MEDICATIONS: 1. Aggrenox 1 tablet p.o. b.i.d. for stroke prevention. 2. Lisinopril 40 mg daily. 3. Morphine CR 15 mg b.i.d. as needed for pain. 4. Albuterol 1 puff q. 4-6h. as needed for asthma. 5. Hydrochlorothiazide 25 mg daily. 6. Lipitor 40 mg daily.
CR|controlled release|CR.|131|133|PLAN|9. Benign prostatic hypertrophy. Continue Uroxatral at this point in time. PLAN: Will hold oxycodone, use Dilaudid IV. Hold Ambien CR. Hold aspirin. Will await Renal consultation and discuss case with Dr. _%#NAME#%_. Will see orders for details. Will work on IV fluids, D5 normal saline at 200 cc an hour.
CR|controlled release|CR|203|204|MEDICATIONS|1, Hypertension. 2. Overweight. 3. Obstructive sleep apnea. MEDICATIONS: 1. Multivitamin daily. 2. Vitamin D with calcium 1,200 mg daily. 3. Triamterene/hydrochlorothiazide 75/50 one daily. 4. Verapamil CR 240 mg daily. 5. CPAP for sleep apnea at night with no oxygen. ALLERGIES: Erythromycin with GI side effects and CT scan dye.
CR|controlled release|CR|148|149|DISCHARGE INSTRUCTIONS|5. Protonix 80 mg p.o. b.i.d. 6. OxyContin 40 mg p.o. b.i.d. 7. Calcium 1000 mg p.o. daily. 8. Centrum Women's Multivitamin 1 p.o. daily. 9. Ambien CR 12.5 mg p.o. each day at bedtime p.r.n. 10. Phenergan 12.5 mg 1-2 tablets p.o. q. 4h. p.r.n. nausea.
CR|controlled release|CR|170|171|MEDICATIONS|1. ERCP-induced pancreatitis. 2. Gastroesophageal reflux. 3. Essential hypertension. MEDICATIONS: 1. Atenolol 100 mg daily. 2. Hydrochlorothiazide 25 mg daily. 3. Ambien CR 12.5 mg daily at bedtime. Of note, the patient was tried on Zoloft, and could not take this after a couple of doses.
CR|controlled release|CR|138|139|DISCHARGE MEDICATIONS|11. ..............1 sublingually of the 25/100 at 1300 hours. 12. Prilosec 20 mg p.o. daily. 13. Senna 1 p.r.n. constipation. 14. Sinemet CR 50/100 1 p.o. t.i.d. and 1/2 q.h.s. 15. Tobradex eye drops 1 drop left eye t.i.d. 16. Voltaren eye drops 1 drop left eye q.i.d.
CR|cardiorespiratory|CR|228|229|DISCHARGE FOLLOWUP|He required headbox oxygen for a short time, was quickly weaned to room air, and transferred to the nursery. _%#NAME#%_ was then transferred back to the NICU for dusky spells. One apneic spell was witnessed on _%#MMDD2005#%_. A CR scan later that same evening was normal. _%#NAME#%_ had a repeat CR scan performed on _%#MMDD2005#%_ revealed moderate amounts of periodic breathing, with an occasional desaturation to 60-70%, self resolving.
CR|controlled release|CR|176|177|MEDICATIONS ON DISCHARGE|ALLERGIES: SULFA AND CODEINE. MEDICATIONS ON DISCHARGE: Fosamax 70 mg p.o. q. Monday; bacitracin to left arm as above; calcium carbonate plus vitamin B12, 50 mg daily. Sinemet CR 50/200 one p.o. at bedtime; 25/100 three q. 6 a.m., 11 a.m., and 4 p.m. Plavix 75 mg p.o. daily, Lexapro 20 mg p.o. q.a.m., ferrous sulfate 325 mg p.o. daily, Flonase 2 sprays per naris, lidocaine patch 5% one to two to skin every 24 hours and remove after 12 hours, Claritin 10 mg p.o. daily, Ativan 1 mg p.o. at bedtime, MVI with minerals 1 p.o. daily, OxyContin 10 mg p.o. b.i.d., Percocet 5/325 1 to 2 p.o. q.4-6 h. p.r.n pain, Protonix 40 p.o. daily, Requip 250 mcg p.o. bi.d., Senokot-S 1 to 2 p.o. daily p.r.n.
CR|controlled release|CR|239|240|MEDICATIONS|The patient describes having had a recent possible mild URI symptoms with a runny nose but no other acute infectious or other complaints. MEDICATIONS: 1. Dilantin 400 mg daily. 2. metformin 500 mg b.i.d. 3. Glyburide 5 mg b.i.d. 4. Ambien CR 6.25 mg q.h.s. p.r.n. 5. Prevacid 30 mg daily. 6. Plavix 75 mg daily. 7. hydrochlorothiazide 25 mg daily. 8. lisinopril 40 mg daily.
CR|controlled release|CR|138|139|DISCHARGE MEDICATIONS|The patient had a biopsy of the nodule on her right hand prior to discharge. DISCHARGE MEDICATIONS: 1. Murelax one scoop daily. 2. Ambien CR 12.5 daily at bed. 3. OxyContin 20 mg two pills every 12 hours. 4. Oxycodone 5 mg, 1 to 2 every two hours.
CR|controlled release|CR|140|141|MEDICATIONS|10. Potassium chloride 20 mEq b.i.d. 11. Os-Cal with D 500 mg daily. 12. Centrum Silver one daily. 13. Celebrex 200 mg daily. 14. Carbidopa CR tablets 1 each day at bed time for restless legs. 15. Prednisone 10 mg daily. 16. Lorazepam 0.5 mg q. 4h. p.r.n. anxiety. 17. Xopenex inhaler 2 puffs every 4 hours as well as a nebulizer q. 4h. p.r.n.
CR|controlled release|CR|132|133|MEDICATIONS|5. Spironolactone 50 mg p.o. daily. 6. Protonix 40 mg p.o. daily. 7. Nadolol 40 mg p.o. daily. Started on _%#MMDD2006#%_. 8. Ambien CR 6.25 mg p.o. q.h.s. Started _%#MMDD2006#%_. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature is 95.8, pulse 53, respiratory rate 18, blood pressure 146/95.
CR|controlled release|CR|179|180|DISCHARGE MEDICATIONS|Clinically, _%#NAME#%_ was much more comfortable and had higher baseline oxygen saturations when positioned prone and in her danny sling than when supine. _%#NAME#%_ had a normal CR scan on _%#MMDD2002#%_ with her positioned prone and elevated in her danny sling. Considering the contrasting CR scans with different positioning and her evident clinical difference when she is prone versus supine, the decision was made to recommend Kiara continue to remain prone and elevated in her danny sling for sleeping and on her CR monitor at home.
CR|controlled release|CR|138|139|DISCHARGE MEDICATIONS|11. Zolpidem 5 mg p.o. each day at bedtime p.r.n. insomnia. 12. Oxycodone 10-15 mg tablets p.o. q. 3h. p.r.n. for pain #50. 13. Oxycodone CR 40 mg p.o. q. 8h. for pain, scheduled. 14. Calcium 1250 mg p.o. daily. 15. Bisacodyl suppository 1 PR daily until bowel movement.
CR|controlled release|CR|100|101|MEDICATIONS|8. Status post lysis of adhesions in 2002. 9. H. pylori. MEDICATIONS: 1. Xanax 0.5 daily. 2. Ambien CR 12.5 h.s. 3. Lipitor - dose unclear. 4. Zoloft - dose unclear. 5. Acyclovir once a day - dose unclear. 6. Hydroxyzine daily - dose unclear.
CR|controlled release|CR|193|194|PROBLEMS|She does have a history of Prsby esophagus. She was continued on Protonix 40 mg daily. Carafate was added q.i.d. Due to persistent issues with nausea, her Paxil was discontinued and this Paxil CR was substituted for this. The patient had improvement in her nausea and reflux symptoms prior to discharge. Did review reflux precautions as well as dietary measures with regard to reflux.
CR|controlled release|CR|89|90|MEDICATIONS ON ADMISSION|5. Obesity. 6. Hypercholesterolemia. 7 Tobacco abuse. MEDICATIONS ON ADMISSION: 1. Paxil CR 25 mg p.o. q. day. 2. Premarin 0.3 mg p.o. q. day. 3. Coreg 6.25 mg p.o. b.i.d. 4. Zestril 5 mg p.o. q. day.
CR|controlled release|CR|90|91|CURRENT MEDICATIONS|4. High cholesterol. 5. Diabetes. 6. Parkinson's disease. CURRENT MEDICATIONS: 1. Sinemet CR 25/100 2 times p.o. daily. 2. Sinemet CR 25/100 1 tab at h.s. 3. Catapres 0.2 mg b.i.d. 4. Hydrochlorothiazide 25 mg p.o. daily.
CR|controlled release|CR|131|132|CURRENT MEDICATIONS|4. High cholesterol. 5. Diabetes. 6. Parkinson's disease. CURRENT MEDICATIONS: 1. Sinemet CR 25/100 2 times p.o. daily. 2. Sinemet CR 25/100 1 tab at h.s. 3. Catapres 0.2 mg b.i.d. 4. Hydrochlorothiazide 25 mg p.o. daily. 5. ______________ 25 mg p.o. b.i.d. 6. Neurontin 100 mg p.o. t.i.d.
CR|controlled release|CR|183|184|DISCHARGE MEDICATIONS|5. Lorazepam 1 mg p.o. q.6 h. as needed. 6. Oxycodone acetaminophen 5/325 mg 1-2 tablets q.4-6 h. p.r.n. for pain. 7. Oxycodone 15 mg p.o. q.4 h. p.r.n. for pain. 8. Morphine sulfate CR 60 mg p.o. q.8 h. p.r.n. for pain. 9. Morphine sulfate 30 mg p.o. q.8 h. p.r.n. for pain. 10. Certagen 1 tablet p.o. daily.
CR|controlled release|CR|149|150|DISCHARGE MEDICATIONS|Mupirocin 2% ointment to buttock wound site p.r.n. 6. Neurontin 300 mg p.o. each day at bedtime x 2 days then increase to b.i.d. x 1 week. 7. Ambien CR 12.5 mg p.o. each day at bedtime insomnia. 8. Oxycodone 5 mg p.o. q. 4 h p.r.n. pain. 9. Pyridoxine 300 mg p.o. daily x 5 more days.
CR|controlled release|CR|232|233|ADMISSION MEDICATIONS|ALLERGIES: Penicillin causes rash, fluoxetine causes emesis, phenytoin and carbamazepine cause wheezing and shortness of breath. ADMISSION MEDICATIONS: 1. __________ 1 g p.o. b.i.d. 2. Centrum multivitamin p.o. daily. 3. Paroxetine CR 12.5 mg p.o. each day at bedtime. 4. Clonazepam 1 mg p.o. each day at bedtime. 5. Trazodone 100 mg p.o. each day at bedtime. 6. Androderm patch 10 mg daily.
CR|controlled release|CR|147|148|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Lovenox 40 mg subcu q. daily x1 month. 2. Percocet 5/325 1 to 2 tabs q.4-6h p.r.n. for pain dispensed #100. 3. OxyContin CR 20 mg p.o. q.12h dispensed #60. 4. Colace 100 mg p.o. b.i.d. 5. Milk of Magnesia 30 mL p.o. b.i.d. p.r.n. for constipation.
CR|controlled release|CR|221|222|DISCHARGE MEDICATIONS|He is already on allopurinol 300 mg daily with a normal uric acid level of 4.6 on _%#MMDD2007#%_, and he was given allopurinol p.r.n. at the time of discharge. DISCHARGE MEDICATIONS: 1. Allopurinol 300 mg daily. 2. Paxil CR with increase to 37.5 mg p.o. daily during his stay here upon the recommendation of the psychiatrist. 3. Protonix 40 mg daily. 4. He has Tylenol p.r.n. available.
CR|controlled release|CR|136|137|MEDICATIONS|For this reason, the patient is being admitted to the Intensive Care Unit for further evaluation and management. MEDICATIONS: 1. Ambien CR 6.25 mg p.o. daily at bedtime. 2. Lexapro 10 mg p.o. daily. 3. Ventolin two puffs q.i.d. p.r.n. 2. Toprol-XL 50 mg p.o. daily. 3. Premarin 0.625 mg p.o. daily.
CR|controlled release|CR|261|262|CURRENT MEDICATIONS|MEDICATIONS: Vytorin 10/20 one tablet every day, Mirapex one tablet t.i.d., fluoxetine 20 mg one p.o. q. day, trazodone 50 mg 1-2 p.o. each day at bedtime, Vicodin 1-2 p.o. q4-6 hours p.r.n., Prilosec 20 mg p.o. q. day, Wellbutrin XL 300 mg p.o. q. day, Ambien CR 12.5 mg p.o. q. day, Amerge 2.5 mg as needed. ALLERGIES: She is allergic to sulfa, belladonna and codeine.
CR|controlled release|CR|202|203|DISCHARGE MEDICINES|Prednisone 40 mg daily for three days, then 20 mg daily for five days, then 10 mg daily for five days, then 5 mg daily for five days. Librium 10 mg in the morning, 5 mg at 3:00 p.m. and 8:30 p.m. Paxil CR 25 mg a day. Ativan 1 mg p.o. t.i.d. Digoxin 0.125 a day. Cozaar 50 mg a day. Cardizem CD 180 mg a day. Diet is no added salt, and she should be getting Boost, one can twice a day.
CR|controlled release|CR|314|315|MEDICATIONS|PAST SURGICAL HISTORY: Multiple previous surgeries including previous shoulder surgery, previous right elbow surgery, previous back surgery, bladder surgeries, bilateral breast implants, previous cataracts. MEDICATIONS: 1. Singulair 10 mg a day. 2. Zyrtec 10 mg a day. 3. Nasonex spray, one spray b.i.d. 4. Ambien CR 12.5 mg at bedtime. 5. Indocin 75 mg p.r.n. ALLERGIES: Penicillin (hives and nausea). HABITS: She continues to smoke one pack per day. She has wine 2-3 times a week.
CR|controlled release|CR|176|177|DISCHARGE MEDICATIONS|7. Lopressor 50 mg p.o. b.i.d. 8. Vitamins B and C, folic acid and zinc. 9. Lyrica 150 mg p.o. b.i.d. 10. Zocor 40 mg p.o. q day. 11. Zanaflex 4 mg p.o. at night. 12. Zolpidem CR 10 mg p.o. q h.s. 13. Vicodin 1 q.i.d. for pain p.r.n. 14. Valtrex 1,000 mg b.i.d. until _%#MMDD2007#%_. 15. Albuterol inhaler one q4h p.r.n. shortness of breath
CR|controlled release|CR|136|137|MEDICATIONS|The rest of 10-point review of systems is negative. MEDICATIONS: 1. Aricept 10 mg p.o. q.a.m. 2. Sinemet 25/25 up to 7 a day 3. Sinemet CR 25/200 one at bedtime. 4. Namenda 10 mg q.a.m. 5. Zonisamide 100 mg p.o. daily was started the night prior to admission
CR|controlled release|CR|154|155|MEDICATIONS|ALLERGIES: No known drug allergies. MEDICATIONS: 1. Levoxyl 100 mcg once a day. 2. Gemfibrozil 600 mg p.o. b.i.d. 3. Aspirin 81 mg daily 4. Verapamil 240 CR q.day . LABORATORY AND DIAGNOSTIC DATA: His EKG is in normal sinus rhythm with no ischemic changes.
CR|controlled release|CR|95|96|CURRENT MEDICATIONS|2. Potassium chloride 20 mEq daily. 3. Lisinopril 5 mg daily. He is not currently taking Coreg CR 10 mg daily. REVIEW OF SYSTEMS: GENERAL: No fevers or chills. CARDIOVASCULAR: Syncopal spell as above, with diaphoresis and substernal chest pain.
CR|controlled release|CR|176|177|DISCHARGE MEDICATIONS|7. OxyContin 30 mg every evening for pain. 8. Percocet 1-2 tabs every 8 hours p.r.n. for breakthrough pain. 9. Oxycodone CR 20 mg by mouth every morning for pain 10. Oxycodone CR 20 mg by mouth for pain at noon. 11. NPH 30 units every morning and 20 units every night 12. Insulin aspart 10 mg subcu at breakfast, lunch 10 units and supper dose also 10 units; also medium insulin sliding scale with aspart Novolog.
CR|controlled release|CR|125|126|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Reglan 10 mg p.o. t.i.d. with meals and each day at bedtime. 2. Aspirin 81 mg p.o. daily. 3. Coreg CR 80 mg p.o. daily. 4. Effexor XR 150 mg p.o daily. 5. NPH insulin 21 units q.a.m. and 21 units q.p.m.
CR|controlled release|CR|211|212|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prednisone taper 40 mg p.o. daily for 3 days, 30 mg p.o. daily for 3 days, 20 mg p.o. daily for 3 days, 10 mg p.o. daily for 3 days, then stop. 2. Vitamin C 500 mg p.o. daily. 3. Coreg CR 10 mg p.o. daily. 4. Prozac 20 mg p.o. daily in the morning. 5. Robitussin-AC as directed. 6. Cozaar 100 mg p.o. daily.
CR|cardiorespiratory|CR|214|215|DISCHARGE FOLLOW-UP|Problem #2: Apnea. _%#NAME#%_ had several apneic and bradycardic episodes during his first several days of life. The last episode occurred on _%#MMDD2007#%_. He was evaluated with several studies. Head CT, EEG and CR scans were all normal. The last episode occurred on _%#MMDD2007#%_. Problem #3: Sepsis. _%#NAME#%_'s mother was GBS negative. Rupture of membranes occurred <1 hours prior to delivery.
CR|controlled release|CR|131|132|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Seroquel 25 mg p.o. b.i.d. with possible q.h.s. dosing as needed. 2. Lexapro 5 mg p.o. daily. 3. Sinemet CR 500/200 - 1 p.o. t.i.d. 4. Megace 800 mg p.o. daily. 5. MiraLax 17 gm p.o. daily p.r.n. constipation. 6. Hydrochlorothiazide 25 mg p.o. daily. 7. Aspirin 81 mg p.o. daily.
CR|controlled release|CR|167|168|ASSESSMENT AND PLAN|5. Hypertension: Currently stable and well controlled. Continue metoprolol 25 mg b.i.d. and lisinopril 20 mg b.i.d. 6. Insomnia: The patient alternates between Ambien CR 12.5 at bedtime and Lunesta 3 mg at bedtime. If needed, he will try the Ambien while in the hospital. 7. Seizure disorder: The patient's hypoglycemic seizure is currently being managed with a Dilantin taper.
CR|controlled release|CR|155|156|DISCHARGE MEDICATIONS|2. Oxycodone 5 mg p.o. q.6 hours p.r.n. breakthrough pain, 30 tablets were given. 3. Omeprazole 20 mg p.o. b.i.d. 4. Zoloft 25 mg p.o. daily. 5. Diltiazem CR 180 mg p.o. daily. 6. Nephrocaps 1 cap p.o. daily. 7. Bactrim Single Strength 1 tablet p.o. b.i.d. 8. Flagyl 500 mg p.o. t.i.d.
CR|controlled release|CR,|164|166|HOSPITAL COURSE|1. Hydrochlorothiazide 25 mg a day. 2. Her eyedrops of an unknown type that she puts in her right eye twice a day for glaucoma 3. Librium 10 mg at night. 4. Ambien CR, I believe, 6.25 mg at night. 5. Aspirin 81 mg daily. 6. She can continue taking her vitamin E which I believe was recommended by her eye doctor.
CR|controlled release|CR|176|177|HISTORY OF PRESENT ILLNESS|DISCHARGE MEDICATIONS: 1. Aspirin 81 mg daily. 2. Plavix 75 mg daily. 3. Prednisone 5 mg daily. 4. Prograf 2 mg b.i.d. 5. Os-Cal b.i.d. 6. CellCept 250 mg b.i.d. 7. Nifedipine CR 60 mg b.i.d. 8. Lipitor 40 mg daily at night. 9. Hydralazine 75 mg t.i.d. 10. Furosemide 40 mg b.i.d. 11. Metoprolol 12.5 mg b.i.d.
CR|controlled release|CR|166|167|OUTPATIENT MEDICATIONS|8. Lasix 40 mg p.o. q.a.m. 9. Potassium chloride 20 mEq p.o. b.i.d. 10. Calcium with vitamin D 600 mg p.o. b.i.d. 11. Multivitamin one tablet p.o. q.d. 12. Verapamil CR 120 mg p.o. q.a.m. 13. Lutein 20 mg p.o. q.d. ALLERGIES: 1. Sulfa. 2. Morphine. 3. Depo-Medrol. The patient does not have a true allergy to contrast, but should avoid it secondary to a history of renal insufficiency and exacerbation of her renal insufficiency in the past when she did receive that.
CR|controlled release|CR|253|254|DISCHARGE PLANS|Otherwise, he has been doing well following his intervention. He is being discharged from the hospital in stable condition with stable vital signs. DISCHARGE PLANS: The patient has been advised to continue with his home medications, consisting of Paxil CR 25 mg q.d., and Vicodin 5/500, 1 tablet q.4-6h. p.r.n. pain. He has been advised to go to Dr. _%#NAME#%_ _%#NAME#%_'s office this morning to have evaluation of his toothache.
CR|controlled release|CR|106|107|DISCHARGE MEDICATIONS|She is okay to take thin liquids as long as she uses chin tuck maneuver. DISCHARGE MEDICATIONS: 1. Ambien CR 12.5 mg p.o. q. day. 2. Gabapentin 100 mg p.o. q. day. 3. Glipizide 5 mg p.o. q. day. 4. Lasix 40 mg p.o. q. day 5. Lisinopril 10 mg p.o. b.i.d. (decreased dose).
CR|controlled release|CR|114|115|MEDICATIONS|6. Cerebrovascular infarction. MEDICATIONS: 1. Sinemet 25/100, 1-2 tabs q. 4 hours (7-12 times a day). 2. Sinemet CR 500/200, 1 tablet p.o. daily at bedtime. 3. Aricept 10 mg p.o. q.a.m. 4. Ativan 0.5 mg daily p.r.n. 5. Namenda 10 mg p.o. q.a.m. 6. Zoloft 100 mg p.o. daily.
CR|controlled release|CR|147|148|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg p.o. b.i.d. 2. Colace 100 mg p.o. daily for constipation. 3. Metoprolol 25 mg p.o. b.i.d. 4. Oxycodone CR 10 mg q.12h. 5. Percocet 1-2 tabs by mouth every 4 hours p.r.n. for pain. 6. Aspirin 81 mg p.o. daily. 7. Albuterol inhaler 1 puff inhaled every q.4-6h. p.r.n.
CR|controlled release|CR|217|218|MEDICATIONS|5. PVD, stenting in bilateral legs. MEDICATIONS: 1. Oxycodone 5 mg, had most recently been on 3 tabs daily. 2. Gabapentin 300 mg t.i.d. 3. UroXatral 10 mg. 4. Omeprazole 20 mg b.i.d. 5. Norvasc 10 mg daily. 6. Ambien CR 12.5 mg at bedtime. 7. Lipitor 20 mg daily. 8. Seroquel 300 mg at bedtime. 9. Aspirin 325 mg daily. ALLERGIES: No known drug allergies. FAMILY HISTORY: Sister died of breast cancer.
CR|controlled release|CR|168|169|DISCHARGE MEDICATIONS|90% in-stent restenosis of distal LAD, narrowly, but not outside the stent. DISCHARGE MEDICATIONS: 1. Sinemet 25/100 1 tablet by mouth 4 times a day. 2. Sinemet 50/200 CR 2 tablets by mouth at bedtime. 3. Plavix 75 mg by mouth daily. 4. Lisinopril 10 mg by mouth daily. 5. Lopressor 12.5 mg twice a day. 6. Zocor 20 mg by mouth every evening.
CR|controlled release|CR|280|281|DISCHARGE MEDICATIONS|2. History of rickets. 3. Non-verbal intelligence testing showing visual spatial difficulties, unclear if opportunity related, secondary to visual disturbance or primarily cognition. 4. Hyperopia, in need of glasses DISCHARGE MEDICATIONS: 1. Trileptal 600 mg b.i.d. 2. Calcitriol CR 0.5 mcg b.i.d. 3. Calcium supplements 500 mg 4 times a day. HOSPITAL COURSE: 1. Neurology: 4 days of video EEG documented no clinical episodes and normal EEG.
CR|controlled release|CR|153|154|DISCHARGE MEDICATIONS|2. Bactrim 1-1/2 tablets q. Monday and Tuesday. 3. Carnitor 330 mg p.o. twice daily. 4. Prevacid 30 mg p.o. b.i.d. 5. Celluvisc 4 times daily. 6. Ambien CR 12.5 mg p.o. at bedtime. 7. Melatonin 3 mg p.o. each day at bedtime. 8. Remeron 30 mg p.o. each day at bedtime.
CR|controlled release|CR|164|165|CURRENT MEDICATIONS|13. Lipitor 10 mg down NG tube daily. 14. Reglan 5 mg down NG tube daily. 15. Nexium 40 mg down NG tube daily. 16. Seroquel 25 mg down NG tube daily. 17. Oxycodone CR 20 mg rectally at bedtime. ALLERGIES: 1. Cymbalta (fatigue). 2. Feldene (edema). 3. Zyprexa (CNS changes and confusion).
CR|cardiorespiratory|CR|241|242|1. FEN|2. Resp: _%#NAME#%_ maintained adequate saturations without supplemental O2. She had some apneic spells that were treated with Theophylline briefly. She never required intubation. She demonstrated numerous episodes of obstructive apnea on a CR scan on DOL # 32 but repeat CR scan one week later was normal. 3. CV: On day 2 of life a loud murmur was appreciated.
CR|controlled release|CR|178|179|MEDICATIONS|6. Albuterol nebulizer treatment q.i.d. 7. Atrovent nebulizer treatment q.i.d. 8. Pulmicort inhaler q.i.d. (this is not listed on the _%#MMDD2002#%_ discharge summary). 9. Paxil CR 25 mg p.o. q.d. 10. Ativan 1 mg p.o. t.i.d. SOCIAL HISTORY: The patient continues to try to live independently at the _%#CITY#%_ _%#CITY#%_ Villa.
CR|controlled release|CR|158|159|DISCHARGE MEDICATIONS|2. Hernia repair on the left in 1998. ALLERGY: NKDA. DISCHARGE MEDICATIONS: 1. Sinemet 25/100 1.25 tablets p.o. 5 times a day. 2. Sinemet 50/200 which is the CR 1 tablet p.o. q. h.s. 3. Mirapex 1.25 mg p.o. t.i.d. 4. Flumadine 100 mg p.o. b.i.d. 5. Selegiline hydrochloride 5 mg p.o. q. day. 6. Famotidine 20 mg p.o. b.i.d.
CR|controlled release|CR|132|133|MEDICATIONS|FAMILY HISTORY: Really noncontributory to this illness. MEDICATIONS: 1. Comtan 200 mg, 1-1/2 tablets five times per day. 2. Sinemet CR 50/200, five times per day. 3. Aminodyne 100 mg b.i.d. 4. Mirapex 1 mg tablets, 1-1/2 q.i.d. 5. Phenobarb 97.2, two tablets in the morning and then 64.8 mg a day also.
CR|controlled release|CR|191|192|HOSPITAL COURSE|An elective MRI for Parkinson's disease protocol was also to be performed. HOSPITAL COURSE: The patient was on a number of medications for her Parkinson's disease. Upon admission her Sinemet CR was decreased, two out of four doses were discontinued. Her Sinemet 25/100 was increased. Mirapex was kept as it was. Throughout her hospitalization this medication regimen was changed in lieu of increased side effects of dyskinesia associated with Sinemet dosing.
CR|controlled release|CR|227|228|SUMMARY OF HOSPITAL COURSE|SUMMARY OF HOSPITAL COURSE: The patient admitted _%#MMDD2003#%_ through the emergency department with a 2- to 3-day history of progressive dyspnea at rest, anorexia, and poor oral intake accompanied by worsening anxiety. Paxil CR had been started on _%#MMDD2003#%_ with the hopes that this would improve anxiety; however, this had been discontinued days ago due to abdominal pain and anorexia.
CR|cardiorespiratory|CR|167|168|PLAN|3) Cough. 4) Heart murmur, scheduled to see cardiologist next week. PLAN: _%#NAME#%_ will be kept on ampicillin and cefotaxime. He will be monitored with oximetry and CR monitor. He will be allowed to eat his normal diet.
CR|controlled release|CR|159|160|CURRENT MEDICATIONS|7. Gout in 2001. CURRENT MEDICATIONS: 1. Lipitor 40 mg a day. 2. Lisinopril 5 mg a day. 3. Aspirin 1 a day which he will stop. 4. Folic acid and B12. 5. Paxil CR 25 mg a day. 6. Trazodone p.r.n. sleep. ALLERGIES: No known drug allergies. SOCIAL HISTORY: No smoking, alcohol is rare.
CR|complete remission|CR|153|154|RECOMMENDATIONS|3. Insulin-dependent diabetes mellitus. Worsening blood sugars on high dose prednisone. RECOMMENDATIONS: 1. In view of the fact that she is not quite in CR after cycle 6 and with the high risk IPI feature score and high risk for recurrence, I have recommended a total of 8 cycles of chemotherapy with the same regimen.
CR|complete remission|CR|122|123|DISCHARGE MEDICATIONS|PET scan (positron emission tomography) after sixth cycle is not quite in CR. There is much improvement, but not quite in CR and due to high risk features decided to do a total of 8 cycles. BRIEF HOSPITAL COURSE: 1. Lymphoma. The patient successfully received chemotherapy as documented above for her seventh cycle with no issues.
CR|controlled release|CR|111|112|MEDICATIONS|MEDICATIONS: The patient's medications are: 1. Cymbalta 90 mg a day. 2. Femara 2.5 mg a day. 3. Ambien 12.5 mg CR each day at bed-time. ALLERGIES: The patient has history of IVP dye, penicillin, erythromycin, velosef.
CR|controlled release|CR|142|143|DISCHARGE MEDICATIONS|2. Norvasc 5 mg p.o. daily. 3. Hydralazine 50 mg p.o. b.i.d. 4. Synthroid 37.5 mcg p.o. daily. 5. Multivitamin 1 tab p.o. daily. 6. OxyContin CR 10 mg p.o. q.12h. 7. Percocet 1-2 tabs p.o. q.4-6h. p.r.n. 8. Senna 1-2 tabs p.o. daily p.r.n. DISPOSITION: Discharge to home in a stable condition.
CR|controlled release|CR|151|152|DISCHARGE MEDICATIONS|She was discharged to home and will need followup with Endocrine Clinic for further management of her blood glucoses. DISCHARGE MEDICATIONS: 1. Ambien CR 12.5 mg oral each day at bedtime. 2. Enteric-coated aspirin 81 mg p.o. daily. 3. Atenolol 50 mg p.o. daily. 4. Benadryl 50 mg p.o. each day at bedtime.
CR|controlled release|CR|153|154|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Celexa 20 mg p.o. daily. 2. Synthroid 75 mcg p.o. daily. 3. Lisinopril 20 mg p.o. daily. 4. Zocor 40 mg p.o. daily. 5. Sinemet CR 50-100 two tablets p.o. q.i.d. 6. Tylenol No. 3 one-two tablets p.o. q.6h. p.r.n. extreme pain #30. 7. Keflex 500 mg p.o. q.12h. x7 days.
CR|controlled release|CR|125|126|MEDICATIONS|Longstanding functional bowel syndromes for which she was told years ago as she had "abdominal epilepsy". MEDICATIONS: Paxil CR 25 mg daily and Trazodone 50 mg po daily. ALLERGIES: ADVERSE REACTION TO IMITREX SUBCUTANEOUS, NOT TO ORAL IMITREX.
CR|controlled release|CR|202|203|HOSPITAL COURSE|He was encouraged to maintain sobriety. The ALT and AST were mildly abnormal on admission; there was slight improvement but they were still mildly abnormal at the time of discharge. He was taking Paxil CR for an anxiety disorder and this was continued. PLAN: The patient was discharged on _%#MM#%_ _%#DD#%_, 2003, and encouraged to participate in some sort of outpatient chemical dependency program as above.
CR|controlled release|CR|232|233|DISCHARGE MEDICATIONS|PLAN: The patient was discharged on _%#MM#%_ _%#DD#%_, 2003, and encouraged to participate in some sort of outpatient chemical dependency program as above. Also encouraged to joint Alcoholics Anonymous. DISCHARGE MEDICATIONS: Paxil CR 25 mg daily and Tegretol 200 mg three times daily. Office follow-up will be with me in approximately 10 days and with Neurology consultant, Dr. _%#NAME#%_, in one month.
CR|controlled release|CR|189|190|MEDICATIONS ON ADMISSION|PAST MEDICAL HISTORY: 1. Parkinson's disease. 2. Hypertension. 3. Status post CVA, with right-sided weakness. 4. Congestive heart failure. 5. Glaucoma. MEDICATIONS ON ADMISSION: 1. Sinemet CR 50-100 1 b.i.d. 2. _____ pres 100 b.i.d. 3. Cipro 500 mg b.i.d. 4. Colchicine 0.6 mg q.d. 5. Com________ 200 mg b.i.d. 6. Lisinopril 2.5 mg q.d.
CR|controlled release|CR|159|160|MEDICATIONS|MEDICATIONS: 1. Aspirin 81 mg a day. 2. Lisinopril 20 mg a day. 3. Toprol XL 15 mg a day. 4. Spironolactone 25 mg a day. 5. Atorvastatin 40 mg a day. 6. Paxil CR 20 mg per day. 7. Pantoprazole 40 mg a day. 8. Ativan as needed. PHYSICAL EXAMINATION: At the time of admission: VITAL SIGNS: Blood pressure 113/42 with a heart rate of 63 and regular.
CR|controlled release|CR|464|465|DISPOSITION|She will follow-up with Dr. _%#NAME#%_ _%#NAME#%_ in the next seven days or so at which time I would like her to have a repeat of her basic metabolic panel. She will, in the meantime, remain off of diuretic. Medications include Advair Discus 250/50 one inhalation b.i.d., amitriptyline 25 mg at bedtime, Tiazac 240 mg daily, Flexeril 10 mg p.o. q.h.s., MiraLax one capful in 8 ounces of water q day, lisinopril/hydrochlorothiazide 10/12.5 mg daily, Pentoxifylline CR 400 mg one p.o. t.i.d., Senna tablets one p.o. q.h.s. p.r.n., Neurontin 100 mg p.o. b.i.d., clonidine 0.3 mg p.o. b.i.d., Pravachol 40 mg p.o. q day, albuterol nebulizer treatments b.i.d., Colace 100 mg daily, aspirin 81 mg daily, Tylenol with codeine one p.o. b.i.d. p.r.n. Also note that I added in prednisone 10 mg p.o. q day for three days and the patient will continue on Glucotrol XL 20 mg p.o. q day for the three days that she is on the prednisone and then she will drop back again to Glucotrol XL 10 mg daily.
CR|controlled release|CR|207|208|DISCHARGE MEDICATIONS|While an inpatient, it was noted that her blood pressure was in the normal range after being restarted on Univasc, so she was told to stop Norvasc at the time of discharge. DISCHARGE MEDICATIONS: 1. Sinemet CR 50/200 1-1/2 tablets t.i.d. 2. Carbidopa 25 mg p.o. b.i.d. 3. Plavix 75 mg p.o. q. day. 4. Aspirin 325 mg p.o. q. day 5. Celexa 40 mg p.o. q. day.
CR|controlled release|CR|182|183|DISCHARGE DIAGNOSIS|He has had no previous treatment. He was detoxed with buprenorphine and did well. He was stable medically and transferred to Lodging Plus on _%#MMDD2007#%_. He was to maintain Paxil CR 25 mg daily. He was also to take Suboxone on a tapering schedule taking 2 mg t.i.d. for 3 days, then 2 mg b.i.d. for 3 days, then 2 mg daily for 3 days, then 1 mg daily for 4 days.
CR|controlled release|CR|129|130|MEDICATIONS|It is to be done by Dr. Dr. _%#NAME#%_ _%#NAME#%_, scheduled for 1:00 on the _%#DD#%_. MEDICATIONS: 1. ASA daily. 2. Propranolol CR 120 mg daily. 3. Lisinopril 40 mg daily. 4. Allopurinol 300 mg daily. 5. Fosamax 70 mg q. week. HABITS: She is a nondrinker, nonsmoker, caffeine intake is 1 servings or less per day.
CR|controlled release|CR|195|196|DISCHARGE DIAGNOSIS|2. Allegra 180 mg p.o. q.a.m. 3. Probax 5.5 mg p.o. a day in divided doses of 1.5 mg p.o. q.a.m. and 1 mg p.o. 4 times a day. 4. Sinemet 25/100 times a day per the patient's schedule. 5. Sinemet CR 50/200 7 times a day per the patient's schedule. 6. Augmentin 875 mg p.o. twice a day for 3 days. 7. Vicodin 1 to 2 tablets p.o. q.6h. p.r.n. FOLLOW UP: He is to followup with his primary care physician over at the neurosurgery clinic in 14 days for suture removal and he will followup with neurology per the Parkinson's program nurse, _%#NAME#%_, at _%#TEL#%_.
CR|cardiorespiratory|CR|140|141|PLAN|Upon arrival to the NICU he was quickly weaned off oxygen and has been stable on room air. _%#NAME#%_ has had self-limiting apnea spells. A CR scan showed an immature breathing pattern and central apnea. Owen was loaded with caffeine and started on caffeine 5m/kg/day. Owen was discharged home on a CR monitor. Parents did receive monitor teaching.
CR|cardiorespiratory|CR|214|215|PLAN|_%#NAME#%_ has had self-limiting apnea spells. A CR scan showed an immature breathing pattern and central apnea. _%#NAME#%_ was loaded with caffeine and started on caffeine 5m/kg/day. Owen was discharged home on a CR monitor. Parents did receive monitor teaching. 3. Infectious Disease- Because of the increasing oxygen need and the respiratory distress, Owen underwent a septic workup.
CR|cardiorespiratory|CR|210|211|PLAN|1. Central Apnea- _%#NAME#%_ will be followed by the apnea program at _%#CITY#%_ _%#CITY#%_ Children's. _%#NAME#%_ will have a CR monitor at home and daily caffeine doses. Parents have received training on the CR monitor. Discharge medications, treatments and special equipment: 1. CR monitor 2. Tri Vi Sol 0.5 ml oral daily
CR|controlled release|CR|119|120|MEDICATIONS|6. Fatty tumor with surgery in the '90s. 7. Ovarian cyst with surgery in her 30s. MEDICATIONS: Avapro 150 a day. Paxil CR 12.5 a day. ALLERGIES: None. SMOKE: Ten cigarettes a day. ALCOHOL: Minimal. SOCIAL HISTORY: She is married.
CR|controlled release|CR.|183|185|PAST MEDICAL HISTORY|He has a history of back pain from a motor vehicle accident. He has a history of temporomandibular joint dysfunction. The patient has a history of anxiety for which he has used Paxil CR. REVIEW OF SYSTEMS: Occasional wheezing. Occasional diarrhea. He has occasional pain in his joints and generalized arthralgia.
CR|controlled release|CR|154|155|MEDICATIONS|5. Coronary artery bypass grafting x5 in 1992. MEDICATIONS: 1. Albuterol MDI two puffs b.i.d. as directed. 2. Singulair 10 mg p.o. q. day. 3. Guaifenesin CR 1200 mg p.o. b.i.d. p.r.n. 4. Prednisone 10 mg p.o. q. day. 5. Atrovent MDI six puffs q.i.d. 6. Theophylline CR 300 mg p.o. b.i.d. 7. Lipitor 20 mg p.o. q. day.
CR|controlled release|CR|165|166|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Tequin 200 mg p.o. daily. x 7 days. 2. Fosamax 17 mg p.o. q. week. 3. Lexapro 20 mg p.o. daily. 4. Estradiol 2 mg p.o. daily. 5. Oxycodone CR 10 mg p.o. q.12h. 6. Percocet 1-2 p.o. q.4h. p.r.n. 7. Protonix 40 mg p.o. b.i.d. 8. Klor-Con 20 mEq 2 p.o. b.i.d. 9. Inderal LA 60 mg p.o. daily.
CR|controlled release|CR,|122|124|ALLERGIES|ALLERGIES: To latex. CURRENT MEDICATIONS include: 1. Duragesic patch, 25 mcg q. 3 days. 2. Toprol XL, 50 q. day. 3. Paxil CR, 12.5 mg at lunch, 35.5 in the evening. 4. Potassium over the counter, which she uses daily. 5. Tizanidine, 4 mg at h.s. for leg cramps. 6. Neurontin, 300 q.i.d.
CR|controlled release|CR|125|126|DISCHARGE MEDICATIONS|Her affect was congruent, her insight and judgment intact, and her mood improved and stable. DISCHARGE MEDICATIONS: 1. Paxil CR 25 mg daily. 2. Flonase nasal spray, 2 sniffs each nostril daily. 3. Premphase 1 tablet daily. DISCHARGE PLAN: 1. She is to continue the prescribed medication.
CR|controlled release|CR|130|131|DISCHARGE MEDICATIONS|1. Probable viral gastritis. 2. Dehydration, resolved. DISCHARGE MEDICATIONS: 1. Meclizine 12.5-25 mg p.o. b.i.d. p.r.n. 2. Paxil CR (controlled release) 25 mg p.o. daily. DISCHARGE FOLLOW-UP: The patient is to follow up with Dr. _%#NAME#%_ next week .
CR|controlled release|CR|113|114|MEDICATIONS|ALLERGIES: Iodine. She had an IVP once and had a rash from the dye. MEDICATIONS: 1. Plavix 75 mg daily. 2. Paxil CR 25 mg daily. 3. Toprol XL 50 mg daily. 4. Lasix 30 mg daily. 5. Lisinopril 30 mg p.o. b.i.d. 6. ASA 81 mg daily.
CR|controlled release|CR|141|142|DISCHARGE MEDICATIONS|11. Protonix 40 mg p.o. daily. 12. Zocor 40 mg p.o. daily. 13. Vitamin B1 100 mg p.o. daily. 14. Effexor XR 225 mg p.o. daily. 15. OxyContin CR 10 mg p.o. q.a.m. 16. Percocet 1 tablet p.o. q. 6h. p.r.n. pain. 17. OxyContin 10 mg p.o. q.p.m. 18. Lidoderm patch 1 patch daily. 19. Potassium chloride 20 mEq daily.
CR|controlled release|CR|253|254|MEDICATIONS|ALLERGIES: Penicillin (rash). Sulfa (rash). Codeine (nausea). Eldepryl (nausea). Mycin antibiotics (nausea). No trouble with cephalosporins or fluoroquinolones. MEDICATIONS: 1. Sinemet. She is not sure of the dosage. In the past she has been on Sinemet CR 50/200 three times a day plus regular Sinemet 25/100 1 1/2 tablets four times a day, plus one at bed time. 2. She takes Lexapro 10 mg daily. 3. She is on Requip.
CR|controlled release|CR|179|180|MEDICATIONS|MEDICATIONS: The patient monitors her own medications, and her daughter is uncertain as to whether or not she adheres to the schedule. She is on Sinemet 25/100 t.i.d. and Sinemet CR 50/200 for her restless legs. She is on Mirapex 0.125 mg p.o. 7 times daily. She is on Accupril and Lasix for hypertension, Glucophage for diabetes, isosorbide, Lipitor, Os-Cal, Slow-Mag, Zaroxolyn, Zoloft, and the previously mentioned Percocet and Vicodin.
CR|controlled release|CR|141|142|DISCHARGE MEDICATIONS|3. Aspirin 81 mg p.o. q.d. 4. Lipitor 20 mg p.o. q.d. 5. Miacalcin nasal spray in alternating naris q.d. 6. Tums 500 mg p.o. q.d. 7. Sinemet CR 50/200, 1 p.o. b.i.d. 8. Coreg 25 mg p.o. q.d. 9. Plavix 75 mg p.o. q.d. x 28 doses. 10. Lasix 20 mg p.o. b.i.d.
CR|controlled release|CR|157|158|CURRENT MEDICATIONS|PAST SURGICAL HISTORY: 1. T & A. 2. Tubal ligation. 3. D & C. ALLERGIES: None known. CURRENT MEDICATIONS: 1. Advair 250/50 b.i.d. 2. FemHRT 1/5 qd. 3. Paxil CR 25, one PO qd. 4. Desyrel 50 mg 1/2 pill to 2 PO q hs p.r.n. 5. Caltrate qd. 6. Advil p.r.n. REVIEW OF SYSTEMS: HEENT: Has had some headaches associated with cough recently.
CR|controlled release|CR|170|171|PAST HISTORY|PAST HISTORY: Reveals that she has had a right rotator cuff repair. She has had the TIAs as mentioned and also history of breast biopsy. She has also been taking Sinemet CR 25/100 one or two h.s. for restless legs. She is on Coumadin 3-4 mg daily and Metamucil daily. The patient has been living at home alone, I believe she is widowed.
CR|controlled release|CR|279|280|DISCHARGE MEDICATIONS|ABDOMEN: Benign. LAB AND DIAGNOSTIC DATA: BNP _%#MMDD2004#%_ shows sodium 139, potassium 4.2, BUN 14, creatinine 0.93. White count normal at 8.1, hemoglobin stable at 9.9, platelets stable at 130. C-difficile toxin culture pending as per above. DISCHARGE MEDICATIONS: 1. Sinemet CR 50/200 one tablet PO 5 times a day. 2. Sinemet 20/100, half tablet PO 5 times a day. 3. Comtan 300 mg PO qd. 4. Mirapex 1 mg PO q.i.d.
CR|cardiorespiratory|CR|217|218|DOL #5.|The head CT was normal. In addition, serum electrolytes (including calcium, magnesium, and phosphorus) were normal. The spells have not occurred since DOL #6 (_%#MMDD2004#%_). He passed a car seat trial. An overnight CR scan was done on _%#MMDD2004#%_, and was abnormal, with 3 alarm episodes (two heart rate drops and one desaturation), episodes of central apnea, and a breathing pattern consistent with immaturity.
CR|cardiorespiratory|CR|221|222|DISCHARGE MEDICATIONS|The most likely etiology for the hyperbilirubinemia was physiologic. This problem has resolved. Problem #4: Apnea of Prematurity. _%#NAME#%_ had a possible apneic episode vs. ALTE on the morning of admission. Therefore a CR scan was obtained which _%#NAME#%_ passed. This scan indicated ... Problem #5: Gastrointestinal. _%#NAME#%_ could possible have some degree of gastroesophageal reflux disease with a history of frequent spitting up per _%#NAME#%_'s mother.
CR|controlled release|CR|183|184|DISCHARGE MEDICATIONS|4. Advair 100/50 one puff b.i.d. 5. Amaryl 2 mg p.o. daily. 6. Lisinopril/hydrochlorothiazide 20/12.5 mg p.o. daily. 7. Nasonex 2 sprays daily p.r.n. bilateral nostrils. 8. Oxycontin CR 20 mg p.o. b.i.d. 9. Zantac 150 mg p.o. b.i.d.. 10. Bactrim DS one p.o. b.i.d. x7 days. 11. Ocean spray nasal saline to nostrils p.r.n. FOLLOW UP: Follow up with Dr. _%#NAME#%_ within one week.
CR|controlled release|CR|212|213|IDENTIFICATION|HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted to station 3A adult chemical dependency detoxification unit to be monitored for withdrawal from opioids. On admission, the following medications were reordered, Paxil CR 50 mg daily, Prinivil 40 mg daily, Cardizem 180 mg daily, Allegra 180 mg daily, albuterol inhaler p.r.n, Naprosyn 500 mg as needed, Advair inhaler every day, trazodone 100 mg at bedtime, and Prilosec 20 mg daily.
CR|controlled release|CR|151|152|DISCHARGE MEDICATIONS|1. Celexa 20 mg p.o. q. day. 2. Artificial Tears 1 drop both eyes q.2h. p.r.n. 3. Colace 100 mg p.o. b.i.d. 4. Senokot 1 tablet p.o. b.i.d. 5. Sinemet CR 50/200, 1 tablet p.o. t.i.d. 6. Levaquin 250 mg p.o. q. day x 3 days. DISCHARGE FOLLOW UP: The patient will follow up with her primary care provider in 7-10 days.
CR|controlled release|CR|161|162|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Klonopin 0.5 mg to 1 mg in the a.m. and at 3 p.m. and at 0.5 mg at noon and q h.s. 2. Levothroid 50 mg down the G-tube q h.s. 3. Paxil CR 25 mg down the G-tube q a.m. 4. Remeron 30 mg down the G-tube q h.s. 5. Tylenol 650 mg down the G-tube t.i.d. p.r.n.
CR|controlled release|CR|145|146|DISCHARGE MEDICATIONS|8. Lisinopril 5 mg p.o. daily. 9. Metoprolol 25 mg p.o. b.i.d. 10. Multivitamin one p.o. daily. 11. Oxycodone CR 10 mg p.o. q.a.m. 12. Oxycodone CR 20 mg p.o. q.p.m. 13. MiraLax two packets p.o. b.i.d. 14. K-Dur 20 mEq p.o. daily. 15. Requip 150 mcg p.o. b.i.d.
CR|controlled release|CR|269|270|MEDICATIONS|The patient has been apprised of the risks of anesthesia, the risks and benefits of surgery and some of the possible complications thereof and requests we proceed. ALLERGIES: Compazine, Darvocet and Percocet. MEDICATIONS: 1. Xopenex MDI 2 puffs q.i.d. p.r.n. 2. Ambien CR 5 mg at bedtime p.r.n. 3. Requip 1 mg at bedtime. 4. Neurontin 600 mg t.i.d. 5. Celexa, dose unknown one a day
CR|controlled release|CR|183|184|DISCHARGE MEDICATIONS UPON DISCHARGE|18. Tolterodine 4 mg p.o. daily. 19. Vitamin D 50,000 units p.o. q. week. 20. Zolpidem 10 mg p.o. daily p.r.n. insomnia. 21. Hydromorphone 8 mg p.o. q.i.d. p.r.n. pain. 22. Oxycodone CR 20 mg extended release p.o. t.i.d. 23. Tylenol 650 mg p.o. q. 4-6h. p.r.n. pain or fever. 24. Lidoderm patch 5% q. 24h. 25. Calcium carbonate 500 mg p.o. b.i.d.
CR|cardiorespiratory|CR|212|213|RECOMMENDATION|Ongoing problems and suggested management: 1. Periventricular Nodular Heterotopia - F/U with Dr. _%#NAME#%_ (neurology) in 2 months, F/U with Dr. _%#NAME#%_ (neurosurgery) in 2 months. Patient being sent home on CR monitor. 2. Feeds - Continue to thicken PO feeds with rice cereal. Continue to give Enfamil 20 with iron at 75cc every 3 hours, first offered PO, remainder given thru PEG tube.
CR|controlled release|CR|201|202|MEDICATIONS AT THE TIME OF DISCHARGE|MEDICATIONS AT THE TIME OF DISCHARGE: Atenolol 50 mg q.a.m., B12 15 mcg IM monthly, Humalog 75/25 insulin mix, taking 26 units in the morning and 10 units in the evening. Lisinopril 10 mg daily. Paxil CR 12.5 mg daily in hopes of stimulating her appetite and lessening any component of depression. Reglan 10 mg t.i.d., taken one- half hour before meals.
CR|controlled release|CR|142|143|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Azithromycin 250 mg daily through _%#MMDD2005#%_. 2. Ceftin 500 b.i.d. x 10 days. 3. BuSpar 10 mg b.i.d. 4. Sinemet CR 25/100 1 b.i.d. 5. Clozapine 50 mg every morning and 250 mg at 5 p.m. 6. Namenda 10 mg b.i.d. 7. Aricept 10 mg q.h.s.
CR|controlled release|CR|145|146|MEDICATIONS|16. Cataract surgery in 2002. 17. Tonsillectomy as a child. MEDICATIONS: 1. Klonopin 0.5 mg q.h.s. 2. Sinemet 25/250 five times daily 3. Sinemet CR 50/200 one to two q.h.s. 4. Mirapex 1 mg t.i.d. 5. Calcium with vitamin D 6. MiraLax 1 scoop per day
CR|controlled release|CR|175|176|ADMISSION MEDICATIONS|She is to restart her Paxil. She was kept overnight on the night of _%#MM#%_ _%#DD#%_, 2005, because of the snowstorm, but discharged the following day. MEDICATIONS: 1. Paxil CR 25 mg p.o. every day. 2. Lactulose 30 mL p.o. q.8h. p.r.n. to titrate to 5 loose stools per day. 3. Ambien 5 mg p.o. at bedtime as needed for insomnia.
CR|controlled release|CR|122|123|MEDICATIONS|4. Tobacco use. 5. Status post tonsillectomy. ALLERGIES: Penicillin. MEDICATIONS: 1. Protonix 40 mg p.o. q. day. 2. Paxil CR 12.5 mg p.o. q. day. FAMILY HISTORY: Negative for inflammatory bowel disease. SOCIAL HISTORY: Single.
CR|controlled release|CR|210|211|HOSPITAL COURSE|She was monitored using the MSSA rating scale. Ativan was not initially ordered for withdrawal symptoms. On admission, medications were ordered: Lipitor 10 mg at bedtime, verapamil ER 120 mg q. a.m., verapamil CR 250 mg at bedtime, Levsin 0.125 mg SL every 4 hours as needed for diarrhea, Imodium 2 mg as needed for diarrhea, Trazodone 100 mg at bedtime, and phenobarbital 30 mg three times daily.
CR|controlled release|CR|134|135|DISCHARGE MEDICATIONS|2. Seroquel 50 mg 8 a.m. and 4 p.m. and 100 mg at bedtime. 3. Lipitor 10 mg at bedtime. 4. Verapamil ER 120 mg at 8 a.m. 5. Verapamil CR 240 mg at bedtime. 6. Phenobarbital taper (see chart). DISCHARGE PLAN: 1. She is to continue the prescribed medications.
CR|controlled release|CR|159|160|CURRENT MEDICATIONS|2. Laparoscopy and ovarian cystectomy x 2. ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: Albuterol, Intal inhaler, Azmacort inhaler, Nasonex, Paxil CR 20 mg, Allegra-D, Singulair 10 mg daily, Tagamet, Reglan, Zantac and Prilosec. SOCIAL HISTORY: The patient is married to _%#NAME#%_ and she does not smoke.
CR|controlled release|CR|150|151|MEDICATIONS ON TRANSFER|4. Methadone 120 mg p.o. daily. 5. Morphine sulfate 1-2 mg IV q. 1 hour p.r.n. for pain. 6. Zofran 4 mg IV q. 6 hours p.r.n. for nausea. 7. Oxycodone CR 20 mg p.o. b.i.d. for pain. 8. Percocet 1-2 tablets p.o. q. 4 hours p.r.n. 9. Seroquel 25 mg p.o. t.i.d. and 600 mg p.o. q. h.s.
CR|controlled release|CR|148|149|HISTORY OF PRESENT ILLNESS|The patient has no known drug allergies. ADMISSION MEDICATIONS: 1. Peridex 10 mL swish-and-spit b.i.d. 2. Fluconazole 100 mg PO daily. 3. OxyContin CR 10 mg PO b.i.d. 4. Miralax 17 g PO b.i.d. SOCIAL HISTORY: The patient lives in _%#CITY#%_ _%#CITY#%_ with his father and relatives.
CR|controlled release|CR|136|137|DISCHARGE MEDICATIONS|2. Toprol XL 25 mg b.i.d. which is a new dose. 3. Aspirin 81 mg daily. 4. Flomax 0.4 mg daily. 5. Lisinopril 20 mg daily. 6. Nifedipine CR 60 mg daily. 7. Plavix 75 mg daily for a minimum of a year if not lifelong. 8. Proscar 5 mg daily. 9. Protonix 40 mg daily.
CR|controlled release|CR|214|215|CURRENT MEDICATIONS|The patient is being followed closely by Dr. _%#NAME#%_ of Neurology Service at the University of Minnesota Medical Center, Fairview. ALLERGIES: Penicillin, Aerocaine, and Cogentin. CURRENT MEDICATIONS: 1. Sinemet CR 50/200 mg, 2 tablets p.o. q.8 h. 2. Sinemet 25/100 mg 2 tablets p.o. at 6 a.m., noon, 6 p.m., and midnight.
CR|controlled release|CR|100|101|DISCHARGE MEDICATIONS|He was prepared for discharge to Lakeridge Rehabilitation Center. DISCHARGE MEDICATIONS: 1. Sinemet CR 50/200 1 tab p.o. q.i.d. 2. Prilosec 20 mg p.o. b.i.d. 3. Micardis 40 mg p.o. daily. 4. NPH insulin 25 units subcutaneously q.a.m.
CR|controlled release|CR|172|173|MEDICATIONS|Primary medical provider is Dr. _%#NAME#%_ at the _%#CITY#%_ HealthPartners Clinic and psychiatrist is Dr. _%#NAME#%_ with HealthPartners Psychiatry. MEDICATIONS: 1. Paxil CR 12.5 mg daily. 2. Ativan 1 mg at bedtime. 3. Enteric-coated aspirin 81 mg daily. 4. Icaps daily. FAMILY HISTORY: She has a sister with a history of breast cancer.
CR|controlled release|CR|175|176|DISCHARGE  MEDICATIONS|3. Mild reflux esophagitis. PLAN: The patient is transferred to the care of Dr. _%#NAME#%_ in the mental health unit. DISCHARGE MEDICATIONS: 1. Protonix 40 mg Q day. 2. Paxil CR 25 daily and as per Dr. _%#NAME#%_. HISTORY: _%#NAME#%_ _%#NAME#%_ presented with prolonged nausea and vomiting of undetermined etiology.
CR|controlled release|CR|131|132|ADMISSION MEDICATIONS|3. Spironolactone 25 mg p.o. q.day. 4. Vitamin K 5 mg q.day. 5. Rifampin 400 mg p.o. t.i.d. 6. Zinc 20 mg p.o. b.i.d. 7. Oxycodone CR 10 mg p.o. b.i.d. 8. Protonix 40 mg p.o. q.day. 9. Lactulose 30 mL 5 times per day to be titrated for loose stools.
CR|controlled release|CR|167|168|MEDICATIONS|She is now scheduled to undergo arthroscopy to both further define as well as to treat this condition. ALLERGIES: Sulfa. MEDICATIONS: 1. Avapro 150 mg a day. 2. Paxil CR 12.5 mg a day. MAJOR DIAGNOSIS: 1. Hypertension. 2. Depression. 3. Hyperlipidemia. HOSPITALIZATIONS: Childbirth. SURGERIES: Urethral dilatation. Tubal ligation.
CR|controlled release|CR|158|159|MEDICATIONS|MEDICATIONS: 1. Lasix 40 mg p.o. b.i.d. 2. Cozaar 50 mg p.o. b.i.d. 3. Pravachol 20 mg p.o. each day at bedtime 4. Tylenol 2 tablets p.o. p.r.n. 5. Verapamil CR 180 p.o. b.i.d. 6. Aspirin 81 mg p.o. daily. 7. Cardura 4 mg 2 tablets each day at bedtime. 8. PhosLo 667 mg p.o. q.i.d. 9. Folic acid 1 mg p.o. q.a.m. 10.Neupogen injections 3 times a week.
CR|controlled release|CR|130|131|MEDICATIONS|He is on clonazepam on one list that says 2 mg at night. He is on another one that says lorazepam 3-4 mg at night. He is on Paxil CR 12.5 mg daily, Metamucil, Colace and cholestyramine - he says he uses that p.r.n. He also is apparently on a half a Vicodin p.r.n., sometimes an Oxytrol patch as well.
CR|controlled release|CR,|299|301|MEDICATIONS|She has had 3 right ear surgeries with tympanoplasties, tonsillectomy in childhood, 2 vaginal deliveries and she reports TIA although I did not see this mentioned specifically in her medical records. MEDICATIONS: Include inderal, vitamin C, multivitamin, vitamin E, Neurontin, Prozac, Imdur, Ambien CR, Lasix, Nasonex, clonazepam, lisinopril, Fosamax, Selsun, Zocor, Prilosec and nitroglycerine. SOCIAL HISTORY: The patient is not a smoker. Denies any alcohol.
CR|controlled release|CR|182|183|CONDITION ON DISCHARGE|2. Lipitor 10 mg p.o. once a day. 3. Prednisone 5 mg p.o. once a day. 4. Calcitriol 0.25 mcg p.o. once a day. 5. Ferrous sulfate 325 mg p.o. 3 times a day. 6. Isosorbide mononitrate CR 90 mg p.o. twice a day. 7. Torsemide 50 mg p.o. twice a day. 8. Toprol XL 50 mg p.o. once a day. 9. Coumadin 3 mg p.o. once a day. 10. Diltiazem 240 mg p.o. once a day.
CR|controlled release|CR|193|194|MEDICATIONS|MEDICATIONS: Home medications most recently have included Stalevo 150 mg along with 1/2 of a 25/100 mg Sinemet about every 3-1/2 hours or so. She also has been using about three of the Sinemet CR (controlled-release) over the course of the day. She is also on a multivitamin, vitamin C, Lipitor, Zoloft (presumably 50 mg).
CR|controlled release|CR|150|151|IDENTIFICATION|Mr. _%#NAME#%_ was admitted to station 3A Adult Chemical Dependency Detox Unit to be monitored for withdrawal from opioids. He was restarted on Paxil CR 25 mg daily that he had been taking prior to admission. He was seen by Dr. _%#NAME#%_ and started on a dose of buprenorphine to cover withdrawal symptoms from opioids.
CR|controlled release|CR|126|127|DISCHARGE MEDICATIONS|3. Vitamin C 500 mg daily. 4. Carbidopa/levodopa 25/100 by mouth 4x a day one hour before meals. 5. Carbidopa/levodopa 25/100 CR p.o. each day at bed time. 6. Multivitamin once daily. 7. Seroquel 25 mg p.o. each day at bed time. 8. Zoloft 75 mg p.o. daily. DISCHARGE INSTRUCTIONS: The patient is to follow up with Dr. _%#NAME#%_ in two to four weeks with regard to her Parkinson's disease management.
CR|controlled release|CR|120|121|DISCHARGE MEDICATIONS|11. Metamucil 1 packet p.o. daily. 12. Milk of Magnesia 30 mL p.o. daily. 13. Senokot-S 1 tab p.o. b.i.d. 14. Oxycodone CR 10 mg p.o. q.12h. 15. Percocet 1-2 p.o. q.6h. p.r.n. pain. 16. Albuterol inhaler 1-2 puffs q.4h. p.r.n. 17. Flovent 220-mcg inhaler 2 puffs inhaled b.i.d. ADMISSION MEDICATIONS: Same as discharge medications except for Lovastatin 40 mg q.h.s. instead of Zocor.
CR|controlled release|CR|162|163|MEDICATIONS|However, she reports being prone to falling, especially during the last year or two. MEDICATIONS: Currently, _%#NAME#%_ takes 1. Celexa 20 mg daily. 2. verapamil CR 180 mg daily. 3. Coumadin protocol 4. propafenone 150 mg twice daily. 5. Lipitor 10 mg once daily. 6. Fosamax 70 mg weekly
CR|controlled release|CR|242|243|DISCHARGE MEDICATIONS|However, upon further discussion with the family, this order has been resented and in discussing with the patient, she actually does wish at the current time to be full code status. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg a day. 2. Cardizem CR 480 mg daily. 3. Lasix 40 mg daily. 4. Lisinopril 10 mg daily. 5. Singulair 10 mg p.m. 6. Atrovent MDI q.i.d.
CR|controlled release|CR.|128|130|MUSCULOSKELETAL|Therefore, we scheduled with her medications to be given prior to moving her. She will be discharged on oxycodone and oxycodone CR. Multiple family meetings were held to discuss her prognosis.
CR|controlled release|CR|226|227|DISCHARGE MEDICATIONS|2. Tobacco abuse. 3. Hyperlipidemia. DISCHARGE MEDICATIONS: 1. Plavix 75 mg p.o. daily x at least one year. 2. Lopressor 25 mg p.o. b.i.d. 3. Nitroglycerine 0.4 mg sublingual p.r.n. 4. Omeprazole 20 mg p.o. daily. 5. Zolpidem CR 12.5 mg q h.s. p.r.n. insomnia. 6. Aspirin 325 mg p.o. daily. 7. Simvastatin 40 mg p.o. q h.s. HISTORY: _%#NAME#%_ _%#NAME#%_ is a very delightful 58-year-old female who was having atypical chest discomfort and was admitted to the hospital.
CR|controlled release|CR|120|121|MEDICATIONS|7. K-Tabs 10 q. day 8. Lisinopril 2.5 mg q. day 9. Mirapex 0.25 mg q. day 10. Prilosec 20 p.o. q. day 11. Phenobarbital CR 15 p.o. b.i.d. 12. Phenytoin extended release 100 p.o. b.i.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He is DNR/DNI and lives in a nursing home.
CR|controlled release|CR|144|145|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Her usual medications include Zoloft 50 mg daily. Advair 250/50, 1 puff b.i.d., tramadol 50 mg q.4h. p.r.n. pain, Ambien CR 12.5 mg at bedtime for sleep, Fosamax 70 mg weekly for osteoporosis, vitamin B12 injections 1000 mcg subq monthly for B12 deficiency, pernicious anemia and pancreatic enzymes, Ultrase 1 tab t.i.d. with meals.
CR|controlled release|CR|137|138|DISCHARGE MEDICATIONS|4. Protonix 40 mg p.o. daily. 5. Rifaximin 400 mg p.o. t.i.d. 6. Calcitriol 0.25 mcg p.o. daily. 7. Lactulose 30 cc p.o. q.i.d. 8. Paxil CR 25 mg p.o. q.p.m. 9. Allegra 180 mg p.o. daily. 10. Spironolactone 12.5 mg p.o. daily. 11. Torsemide 10 mg p.o. daily.
CR|controlled release|CR|137|138|DISCHARGE PLAN|4. For pain control, she was discharged on Percocet 5/325, 1-2 tablets p.o. q. 3-4 hours p.r.n. pain. 5. She was discharged on oxycodone CR 30 mg extended release p.o. q. 12 hours for pain. Ms. _%#NAME#%_ and her family were in agreement with this plan at this time, and had no further questions.
CR|controlled release|CR|146|147|DISCHARGE MEDICATIONS|10. Quinine sulfate 520 mg tablets p.o. 1 per day before dialysis on Monday, Wednesday and Friday. 11. Vitamin E 400 units p.o. daily. 12. Ambien CR 6.25 mg p.o. each day at bedtime p.r.n. 13. Aspirin 81 mg p.o. daily. 14. Zithromax 250 mg p.o. daily for 2 more days and then DC.
CR|controlled release|CR|196|197|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: All to be reevaluated by Dr. _%#NAME#%_ within three to six months for continuation 1. Lactobacillus powder p.o. for diarrhea p.r.n. 2. Claritin 10 mg p.o. daily. 3. Ambien CR 12.5 mg p.o. q.h.s. p.r.n. for insomnia 4. Vicodin 1-2 tablets q.4h. p.r.n. for pain 5. Lorazepam 0.5 mg p.o. 30 minutes prior to sleep p.r.n. She is to use either lorazepam or Ambien but not both 6.
CR|controlled release|CR|120|121|MEDICATIONS|ALLERGIES: Valium which causes confusion, penicillin and NSAIDs. MEDICATIONS: 1. Colace 100 mg p.o. b.i.d. 2. OxyContin CR 10 mg p.o. b.i.d. 3. Pepcid 20 mg q h.s. 4. Senna 2 tabs q h.s. 5. Aspirin 325 mg p.o. daily. 6. Prednisone 5 mg p.o. daily.
CR|controlled release|CR|104|105|DISCHARGE MEDICATIONS|2. Atenolol had been held at the time of admission, but was restarted. DISCHARGE MEDICATIONS: 1. Ambien CR 6.25 mg p.o. q.h.s. 2. Os-Cal plus D one tab p.o. q. day. 3. Clotrimazole 1 inch to mouth five times daily.
CR|cardiorespiratory|CR|228|229|PROCEDURE LIST|Problem # 6: Failed Car Seat Trial. _%#NAME#%_ did not pass his car seat trial on _%#MMDD2006#%_ so a CR scan was done that evening and showed some periodic breathing and no apnea. He did have periods of desaturation during his CR scan and was given supplemental oxygen and flow by nasal cannula thus confounding the CR scan results. The car seat trail was repeated on _%#MMDD#%_ and he passed and so was discharged.
CR|controlled release|CR|207|208|MEDICATIONS|19. Triamcinolone cream to rash twice a day. 20. Coumadin 5 mg every Tuesday, Wednesday, Thursday, Friday, Saturday and Sunday and 7.5 mg every Monday. 21. Albuterol inhaler 2 puffs q.i.d. p.r.n. 22. Ambien CR 12.5 mg q.h.s. 23. Diazepam 2 mg daily p.r.n. 24. Benadryl 25-50 mg 3 times a day p.r.n. itching. 25. Midrin 1-2 capsules every 2 hours as needed for headache.
CR|controlled release|CR|332|333|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Synthroid 75 mcg p.o. daily. 2. Aricept 10 mg p.o. each day at bedtime. 3. Amantadine 100 mg p.o. q.a.m. 4. Pergolide 1 mg p.o. t.i.d. The patient's family namely his wife requested that the patient stay on his previous Sinemet regimen; however, recommendations from Neurology consultation are for Sinemet CR 50 and 200 mg at 8 a.m. and 8 p.m. and regular Sinemet 25 and 100 at 11 a.m., 2 p.m. and 5 p.m. FOLLOWUP INSTRUCTIONS: The patient is to follow up in the Neurology clinic with Dr. _%#NAME#%_ on _%#MMDD#%_ at 11:30 a.m.
CR|controlled release|CR|133|134|DISCHARGE MEDICATIONS|2. Clarinex 5 mg q. day. 3. Zetia 10 mg q. day. 4. Flonase as directed. 5. Imdur 60 mg q. day. 6. Metoprolol 150 mg b.i.d. 7. Ambien CR p.r.n. 8. Nitrostat p.r.n. 9. Protonix 40 mg q. day. 10. MiraLax q. day. 11. Crestor 10 mg q. day. 12. Flomax 400 mcg a day.
CR|controlled release|CR|187|188|DISCHARGE MEDICATIONS|7. Hypothyroidism. Stable on replacement therapy. 8. Hyperlipidemia. The patient was maintained on her our usual medication. DISCHARGE MEDICATIONS: At the time of discharge, 1. Oxycodone CR 60 mg p.o. q. 12h. 2. Dilaudid 6 mg p.o. q. 4h., up to 2 doses a day. , She has been given 60 doses of that .
CR|controlled release|CR|131|132|MEDICATIONS|17. Metoprolol 200 mg p.o. b.i.d. 18. Lasix 20 mg p.o. daily p.r.n. edema. 19. Compazine p.r.n. 20. TMC cream b.i.d. 21. Oxycodone CR 20 mg p.o. q.12h. 22. Levaquin 250 mg p.o. daily x14 days beginning on 7/15. 23. Zyvox 600 mg p.o. q.12h., beginning on _%#MMDD#%_. REVIEW OF SYSTEMS: GENERAL: The patient states she had a low-grade fever of 100.4 this morning, denies any chills, rigors, does claim a 5 pound weight loss over the last 2 weeks.
CR|controlled release|CR.|160|162|DISCHARGE MEDICATIONS|The patient should stop taking Neurontin per _%#NAME#%_ _%#NAME#%_'s recommendations. The patient should stop taking trazodone, as she is already taking Ambien CR. FOLLOWUP APPOINTMENTS: 1. The patient has an appointment with _%#NAME#%_ _%#NAME#%_ of MAPS - Midway, on _%#MMDD2007#%_ as previously scheduled.
CR|controlled release|CR|200|201|DISCHARGE MEDICATIONS|6. Lasix 60 mg p.o. b.i.d. for edema. 7. Neurontin 300 mg p.o. t.i.d. for neuropathic diabetic pain. 8. Metformin 500 mg p.o. daily for diabetes mellitus. 9. Nexium 40 mg p.o. twice daily. 10. Ambien CR 12.5 mg p.o. each day at bedtime. 11. Insomnia p.r.n. 12. Aspirin 81 mg p.o. daily. 13. Atenolol 50 mg p.o. daily. 14. Cozaar 100 mg p.o. daily.
CR|cardiorespiratory|CR|236|237|1. FEN|CR scan done _%#MMDD#%_-_%#MMDD2012#%_ while lying flat showed acid reflux into the esophagus, 17.4% periodic breathing and numerous central apneic events. The patient was started on Zantac and placed in reflux precautions based on the CR scan results. CR scan was repeated _%#MMDD#%_-_%#MMDD2012#%_ with reflux precautions while on Zantac. Numerous short, central apneic events were observed and possibly mixed apneic events with desaturation, indicating an immature respiratory pattern possibly complicated by GER.
CR|cardiorespiratory|CR|180|181|IMPRESSION|_%#NAME#%_ was started empirically on Zantac as refulx was another possible etiology of the apnea. Ongoing problems and suggested management: Resp- _%#NAME#%_ had a total of three CR scans during his hospitalization. The first scan was normal while he remained on oxygen and lasix. A second scan had significant findings for 62 episodes of desaturations, and approximately 4 % of the time his saturations were at 85%.
CR|controlled release|CR|138|139|DISCHARGE MEDICATIONS|9. Aricept 5 mg p.o. q.d. 10. Folic acid 1 mg p.o. q.d. 11. Risperdal 0.5 mg p.o. q.d. 12. Zoloft 100 mg p.o. q.d. 13. Carbidopa/Levodopa CR 25/100 p.o. b.i.d. 14. Lasix 80 mg p.o. q.d. 15. Spironolactone 25 mg p.o. b.i.d. 16. Enalapril 2.5 mg p.o. q.a.m., 5 mg p.o. q.p.m.
CR|controlled release|CR|125|126|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Sinemet LE 25/100 1/4 tablet at 0700 and 1100. 2. Sinemet LE 25/100 1/2 tablet at 1900. 3. Sinemet CR 50/200 1/2 tablet at 0700, 1100, 1900, and 2300. 4. Sinemet CR 50/200 1/4 tablet at 1500. 5. Mirapex 0.5 mg p.o. at 0700 and 1100.
CR|controlled release|CR|729|730|DISCHARGE MEDICATIONS|6. Allergic rhinitis. 7. Mild initial hyponatremia, responding to fluids. Probably due to mild dehydration. DISCHARGE MEDICATIONS: Prednisone 30 mg p.o. daily x 7 days, then 25 mg p.o. daily x 7 days, then 20 mg p.o. daily x 7 days, then 15 mg p.o. daily; Augmentin 875 mg p.o. b.i.d. with food x 7 days, Flagyl 500 mg p.o. t.i.d. x 10 days, Questran Light 1 packet in fluid at h.s. for diarrhea; Imodium AD, one after each loose bowel movement to a maximum of 6 in 24 hours, use p.r.n.; Humulin N to be increased to 40 units subcu b.i.d. while on higher dose prednisone with 30 units subcu b.i.d., Humulin R as per previous protocol with the addition of sliding scale that he has used previously, Nexium 40 mg p.o. daily, Paxil CR 37.5 mg p.o. daily, Rhinocort 1 puff each nostril daily, and Astelin nasal spray 2 puffs each nostril b.i.d. DISCHARGE INSTRUCTIONS AND FOLLOW UP: The patient is encouraged to follow up with Dr. _%#NAME#%_ within 1-2 weeks with particular attention to his diarrhea and glycemic control and with Dr. _%#NAME#%_ with respect to pneumonia and sarcoidosis within 2-3 weeks.
CR|controlled release|CR|116|117|DISCHARGE MEDICATIONS|11. Remeron 30 mg at h.s. 12. Sinemet 25/100 mg one tablet daily at 4:30 a.m. and 9:00 a.m. (Continued) 13. Sinemet CR 50/200 mg 1-1/2 tablets daily at 7:00 a.m., 1/2 tablet daily at 11:00 a.m., 1 tablet twice daily at 5:00 p.m. and 9:00 p.m.
CR|C-reactive|CR|229|230|PAST MEDICAL HISTORY|For remainder, see impressions listed in end of dictation. She last received lab work in the clinic on _%#MMDD2002#%_ showing the positive H. pylori, normal lytes except for slightly low sodium of 131.1 and low chloride of 96.1. CR protein is normal at 7.91, and normal CBC with hemoglobin of 14. She did on _%#MMDD#%_ have a higher glucose of 111, BUN and creatinine okay, and liver function was normal as was calcium.
CR|cardiorespiratory|CR|162|163|PROBLEM #2|Bronchoscopy showed patient with right vocal cord paresis and no other etiology for the stridor. He was observed in the Pediatric Intensive Care Unit with O2 and CR monitoring. He remained stable on room air without any need for Nebs or other intervention. Swallow study showed the patient with four episodes of airway penetration taking normal consistency formula.
CR|controlled release|CR|183|184|ADDENDUM|The patient did not feel as though she could return to her home and was quite depressed. We had psychiatry come by and assess the patient. They recommended that we increase her Paxil CR to 25 mg q.a.m., continue with Xanax 0.25 p.o. b.i.d., DC her Ambien and start using trazodone 50 mg p.o. q.h.s. It was recommended that she follow up with psychiatry, with Dr. _%#NAME#%_ or _%#NAME#%_, _%#TEL#%_ _%#TEL#%_.
CR|controlled release|CR|134|135|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Meclizine 25 mg p.o. q.i.d. x 4d. 2. Atenolol 100 mg p.o. q.d. 3. Avalide 300/12.5 mg p.o. q.d. 4. Dynacirc CR 5 mg p.o. q.d. 5. Hydralazine 50 mg p.o. t.i.d. DISPOSITION: The patient is discharged to home. She is to follow up with her primary care physician as needed.
CR|controlled release|CR|144|145|DISCHARGE MEDICATIONS|Anxiety and depression. Mild TSH elevation. Possible early hypothyroidism. Dyspepsia. DISCHARGE MEDICATIONS: Synthroid 25 mcg p.o. daily. Paxil CR 12.5 mg p.o. daily. Protonix 40 mg p.o. daily. Lorazepam 0.5 mg to 1 mg p.o. q.6 h. p.r.n. Norvasc 5 mg p.o. daily. DISCHARGE INSTRUCTIONS AND FOLLOWUP: The patient is to follow up with Dr. _%#NAME#%_ within about a week in the clinic, sooner p.r.n.
CR|controlled release|CR|185|186|CURRENT MEDICATIONS|6. _%#NAME#%_'s cyst surgery. 7. Angioplasty. ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: Medications currently are as follows: 1. Amantadine 100 mg p.o. b.i.d. 2. Sinemet CR 25/100 1 p.o. b.i.d. 3. Klonopin 1 mg q.h.s. and 0.5 mg p.o. q.a.m. 4. Zantac. 5. Toprol XL 100 mg p.o. q.d. 6. Aspirin 81 mg p.o. q.d.
CR|controlled release|CR|188|189|MEDICATIONS|Toprol- XL 100 mg two tablets a day. Lasix 80 mg one in the morning and half in the evening. Serevent Diskus two puffs b.i.d. Actonel 35 mg p.o. each week. Actos 45 mg p.o. q.d. Diltiazem CR 360 mg p.o. q.d. Novolin insulin 70/30, 79 units subcu every morning, 77 units subcu every evening. Paxil 40 mg p.o. q.d. Tri-Chlor 160 mg p.o. q.d. B12 1000 mcg subcu every month.
CR|controlled release|CR|203|204|PERTINENT LAB TESTS|The patient may be a candidate for AA at some time. At this point, the primary treatment will be deferred. He will take Seroquel 25 to 50 mg t.i.d. p.r.n., and Seroquel 100 mg at h.s. He will take Paxil CR 12.5 mg daily. DISCHARGE DIAGNOSES: 1. Anxiety disorder with panic. 2. Alcohol abuse.
CR|controlled release|CR|141|142|HOSPITAL COURSE|The patient has begun to ambulate in the halls on a several times a day basis and really seems to be improving her strength. She is on Paxil CR 12.5 mg daily and it would seem that her depression seems to be improving as well. The patient does have gastroparesis and neuropathy from her diabetes and is maintained on Reglan.
CR|controlled release|CR|136|137|DISCHARGE MEDICATIONS|She also had a history of some progressive Parkinson's disease. DISCHARGE MEDICATIONS: She was discharged to home on: 1. Sinemet 50/200 CR b.i.d. 2. Atenolol 50 q day 3. Nexium 40 q day 4. Xanax p.r.n. DISCHARGE DIAGNOSIS: 1. Parkinson's disease. 2. Depression.
CR|controlled release|CR|179|180|DISCHARGE MEDICATIONS|2. Zyrtec 10 mg p.o. daily. 3. Effexor XR 300 mg p.o. q.a.m. 4. Zyprexa 2.5 mg p.o. daily. 5. Benztropine 0.5 mg p.o. b.i.d. 6. Hydrochlorothiazide 25 mg p.o. daily. 7. Diltiazem CR 180 mg p.o. b.i.d. 8. Xanax 1 mg p.o. b.i.d. 9. Trazodone 150 mg p.o. q.h.s. 10. Os-Cal with vitamin D 1 tablet p.o. b.i.d. 11. Nicotine patch 20 mg; change daily.
CR|controlled release|CR|146|147|PAST MEDICAL HISTORY/MEDICATIONS/ALLERGIES|She has gastroesophageal reflux disease, for which she takes Protonix. She has hypothyroidism, treated with Synthroid. She is on Evista and Paxil CR 25 mg for depression. She takes no other medications and has no additional medication allergies, aside from her difficulties with the statins.
CR|controlled release|CR|246|247|MEDICATIONS|She does suffer from some memory loss issues. She does not smoke and does not drink. MEDICATIONS: Include Indocin 50 mg b.i.d., Elavil 10 mg q.h.s., atenolol 75 mg q.d., Lasix 20 mg q.d., gemfibrozil 600 mg b.i.d., multivitamin, vitamin E, Paxil CR 25 mg p.o. q.d., Coumadin 1 mg on Monday, Wednesday, Friday, and 2 mg all other days is the dose that she is supposed to be taking.
CR|controlled release|CR|220|221|HOSPITAL COURSE|The remainder of his electrolytes were still normal. By the time of discharge, he was breast feeding very well. He, however, was not taking his usual solid intake. 2) Respiratory/cardiovascular: _%#NAME#%_ was kept on a CR monitor while hospitalized. His sats remained normal on room air throughout. He did not develop any respiratory difficulty following his initial emesis with difficulty breathing in the immediate time period.
CR|controlled release|CR|183|184|DISCHARGE MEDICATIONS|Her discharge diet was regular. Physical therapy was ordered as per Dr. _%#NAME#%_. DISCHARGE MEDICATIONS: 1. Lipitor 10 mg p.o. q.h.s. 2. Benicar 40 mg 1/2 tablet p.o. q.d. 3. Paxil CR 25 mg p.o. q.d. 4. Plavix 75 mg p.o. q.d. 5. Fosamax 70 mg p.o. every Tuesday. 6. Aspirin 81 mg p.o. q.d.
CR|controlled release|CR|180|181|HOSPITAL COURSE|The patient was subsequently discharged home on the following medications: 1. Celebrex 400 mg p.o. q.d. 2. Neurontin 800 mg p.o. q.i.d. 3. Lopressor 25 mg p.o. b.i.d. 4. OxyContin CR 60 mg at eight o'clock in the morning, 40 mg at two o'clock in the afternoon and 40 mg at 2000 hours.
CR|cardiorespiratory|CR|134|135|HOSPITAL COURSE|There were no cardiac murmurs. Normal S1 and S2. No gallops. Due to this concern regarding low resting heart rate, he was placed on a CR monitor. Generally his heart rates were in the 90's to 100's with brief dips to the 80's. No spells with color change. A 12 lead EKG was obtained and faxed to Children's Heart Clinic.
CR|controlled release|CR|131|132|MEDICATIONS|He takes a multivitamin with zinc. He takes Colace 1 p.o. b.i.d., Effexor SR 75 mg a day. He also takes Lasix 20 mg daily, Sinemet CR 250/50 2 p.o. q. a.m., 1 p.o. at noon at 1 at 5 p.m. He also takes Glucotrol XL 2.5 mg daily, takes a salt tab daily, Lopressor 500 mg b.i.d. He has been on a tapering dose of Dilantin.
CR|controlled release|CR|117|118|DISCHARGE MEDICATIONS|2. Fluconazole 100 mg p.o. daily for 14 days. 3. Dilaudid 4 to 6 mg p.o. q.3 to 4h. as needed for pain. 4. OxyContin CR 10 mg p.o. b.i.d. 5. Trazodone 150 mg p.o. at bedtime. 6. Yasmine 0.03/3 mg, one tablet p.o. daily. 7. Ibuprofen 400 mg p.o. q.i.d.
CR|controlled release|CR|273|274|HISTORY OF THE PRESENT ILLNESS|As far as potential allergens that may have caused this anaphylactic reaction and angioedema, the patient states that on _%#MM#%_ _%#DD#%_ at 2005, she reports using Zyban which she takes 150 mg b.i.d. The last dose was at 1500 hours on _%#MMDD2005#%_, she also took Paxil CR of 25 mg on _%#MMDD2005#%_. She also states that on _%#MMDD2005#%_, at approximately 2000 hours, she had a muffin that contained bananas and nuts.
CR|controlled release|CR|144|145|DISCHARGE MEDICATIONS|She was continued on her Advair and albuterol on a p.r.n. basis. DISCHARGE MEDICATIONS: 1. Enteric-coated aspirin 81 mg p.o. q. day. 2. Sinemet CR 25/200, one and a half tablets q.i.d. and one tablet q.h.s. 3. Colace 100 mg q. day. 4. Clonazepam 0.5 mg p.o. q.h.s.
CR|controlled release|CR|217|218|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Insulin 70/30, 40 units in the morning, after breakfast, 10 units before dinner. 2. Toprol 25 mg p.o. b.i.d. 3. Lisinopril 20 mg p.o. q. day. 4. Ferrous gluconate 324 mg p.o. b.i.d. 5. Paxil CR 25 mg p.o. q. day. 6. Synthroid 88 mcg p.o. q. day. 7. Neurontin 100 mg p.o. at bedtime, 100 mg at dinner, 200 mg at noon.
CR|controlled release|CR|192|193|DIAGNOSIS|DISCHARGE MEDICATIONS: Her discharge medications included her home medications including Imitrex 50 mg p.r.n., Bextra 20 mg q. day, Inderal LA 160 mg q. day, trazodone 50 mg q.h.s., and Paxil CR 25 mg, 2 p.o. q. day. She was also given Percocet 1-2 tablets p.o. q.4-6 hours p.r.n. for pain as well as Keflex 500 mg p.o. t.i.d. to be taken while the JPs are in place.
CR|controlled release|CR|150|151|HISTORY OF PRESENT ILLNESS/ HOSPITAL COURSE|His vital signs became stable. Psychiatrist, Dr. _%#NAME#%_ was consulted for his alcoholism, depression and anxiety. He started the patient on Paxil CR 50 mg PO daily and Seroquel 100 mg PO b.i.d. and 25 to 50 mg PO b.i.d. p.r.n. CD evaluation was also obtained, but the patient did show any interest in CD treatment.
CR|controlled release|CR|96|97|MEDICATIONS|3. Eczema. ALLERGIES: Penicillin (she gets hives). MEDICATIONS: 1. Claritin as needed. 2. Paxil CR 25 mg daily. PHYSICAL EXAMINATION: Her uterus is normal size, but ultrasound shows there is a small myoma on the uterus measuring about 3.4 x 3.9 cm.
CR|controlled release|CR|132|133|HOSPITAL COURSE|1. Her usual Loestrin, 2. Fluoxetine, 20 mg a day. 3. Protonix 40 mg b.i.d. 4. Senokot as needed. 5. Zelnorm 60 mg b.i.d. 6. Ambien CR 12.5 mg q at bed-time. She will call with any questions or problems. She will be followed aggressively as an outpatient.
CR|controlled release|CR|180|181|DISCHARGE DIAGNOSIS|She had no motor weakness. She was discharged to Country Manor Rehabilitation in stable condition. All her incisions were clean, dry, and intact. DISCHARGE MEDICATIONS: 1. Sinemet CR 50/200 mg p.o. t.i.d. 2. Rimantadine 100 mg p.o. b.i.d. 3. Vitamin C 1 p.o. q. day. 4. Folic acid 1 p.o. q. day. 5. Calcium and vitamin D 1 p.o. q. day.
CR|controlled release|CR|160|161|MEDICATIONS|MEDICATIONS: From a list that we have include 1. Vasotec 40 mg p.o. daily. 2. lorazepam 0.5 mg p.o. q.6h. p.r.n. 3. Cardizem 360 mg p.o. q.2h. daily. 4. Ambien CR 12.5 mg p.o. q.h.s. 5. Xopenex nebs q.8h. p.r.n. 6. Digoxin 125 mcg p.o. daily. 7. Xalatan 0.005% eyedrops one drop both eyes Daily.
CR|controlled release|CR|190|191|MEDICATIONS|5. Blindness. 6. Hypertension. 7. Osteoporosis with prior compression fractures. 8. Glaucoma. MEDICATIONS: Medications according to the daughter include: 1. Seroquel 25 mg t.i.d. 2. Sinemet CR 50/200 mg t.i.d. 3. Sinemet 25/100 mg t.i.d. 4. Diltiazem XR 240 mg a day. 5. Lumigan eye drops. 6. Cosopt. ALLERGIES: Penicillin and aspirin. HABITS: Smoking: None. Alcohol: None.
CR|controlled release|CR|246|247|DISCHARGE MEDICATIONS|I am recommending that she follow up with Dr. _%#NAME#%_ in clinic next week to make further plans regarding whether or not to proceed with gynecologic surgery. DISCHARGE MEDICATIONS: 1. Soma 350 mg 1/2 to 1 tab by mouth 3 times daily. 2. Ambien CR 12.5 mg by mouth at night as needed. 3. Albuterol inhaler 1-2 puffs every 6 hours as needed. 4. Advair 250/50 1 puff twice daily. 5. Lipitor 10 mg by mouth daily.
CR|controlled release|CR|117|118|CURRENT MEDICATIONS|3. Ativan 0.5 mg p.o. t.i.d. p.r.n. 4. Tylenol #3 one to two p.o. q4-6h p.r.n. 5. Norvasc 10 mg p.o. q day. 6. Paxil CR 12.5 mg p.o. q day. 7. Multivitamin one q day. 8. Ferrous sulfate 325 mg p.o. q day. HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old white female who over the last ten days has had increasing difficulty with pain and discomfort of the left internal orbital ridge.
CR|controlled release|CR|155|156|MEDICATIONS|3. Lisinopril 40 mg b.i.d. 4. Albuterol nebs p.r.n. 5. Cholestyramine one scoop b.i.d. 6. Actonel 35 mg weekly. 7. Advair 250/50 one puff b.i.d. 8. Ambien CR 10 mg q.h.s. 9. Aricept 10 mg q.h.s. 10. Asacol 400 mg daily. 11. Calcium with vitamin D one b.i.d. 12. Clonidine 0.1 mg b.i.d. 13. Cymbalta 60 mg daily.
CR|controlled release|CR|106|107|DISCHARGE MEDICATIONS|7. Colace 100 mg p.o. b.i.d. 8. Percocet 5/325 1-2 tabs p.o. q. 6 hours p.r.n. pain, No. 20. 9. OxyContin CR 20 mg p.o. b.i.d. wean to 1 tab in 2 weeks after seeing primary care MD, #40 given.
CR|controlled release|CR|285|286|ADMISSION MEDICATIONS|She feels quite fatigued and lethargic. After the patient was seen in the clinic, the patient was admitted for mental status changes as well as hyponatremia found on labs today. ALLERGIES: Tegaderm transparent dressing. ADMISSION MEDICATIONS: 1. Acyclovir 800 mg p.o. daily. 2. Ambien CR 12.5 mg at bedtime as needed for sleep. 3. Ativan 1 mg as needed. 4. Bactrim DS 800-160 mg tablet, one tablet b.i.d. on Mondays and Tuesdays.
CR|controlled release|CR|152|153|DISCHARGE MEDICATIONS|11. Lasix 40 mg p.o. daily. 12. Cozaar 50 mg p.o. b.i.d. 13. Ferrous sulfate 325 mg p.o. three times a day. 14. Methylin 10 mg p.o. daily. 15. Methylin CR 20 mg b.i.d. 16. Quinine sulfate 260 mg p.o. twice daily. 17. Renagel 3200 mg p.o. t.i.d. 18. Sodium bicarbonate 2600 mg p.o. q.i.d. 19. Bactrim 1 tab p.o. daily.
CR|controlled release|CR|258|259|DISCHARGE MEDICATIONS|There was also noted to be biatrial enlargement. She was felt ready for discharge home on _%#MMDD2006#%_, with monitoring of INR levels through Dr. _%#NAME#%_'s office. DISCHARGE MEDICATIONS: 1. Nexivar 200 mg twice daily. 2. Actonel 35 mg weekly. 3. Ambien CR 12.5 mg each day at bedtime. 4. Celexa 20 mg daily. 5. Cozaar 50 mg daily. 6. Multivitamin, one pill taken daily. 7. Oxycodone 5-10 mg every 4 hours p.r.n. pain.
CR|controlled release|CR.|167|169|HISTORY OF PRESENT ILLNESS/PHYSICAL EXAM|At 10:00 p.m. he took 2-1/2 tablets of the 50/200 Sinemet CR. At 10:00 a.m. he took 1 tablet of Sinemet CR 50/200. At 6:00 p.m. he took 1 tablet of the 50/200 Sinemet CR. He was also given a prescription for Sinemet 25/100 1 tablet t.i.d. as needed for stiffness or slow movements. The patient's wife states that he has not received that p.r.n. dosing in quite some time as the last time he received it, he experienced a visual hallucination.
CR|controlled release|CR|117|118|DISCHARGE MEDICATIONS|9. Cipro 500 mg p.o. b.i.d. x5 days, then stop. 10. Flomax 0.4 mg p.o. daily until seen by the urologist. 11. Ambien CR 12.5 mg p.o. at bedtime. 12. Neurontin 900 p.o. b.i.d. 13. Zoloft 150 mg p.o. daily. 14. Chlorzoxazone 500 mg p.o. b.i.d.
CR|controlled release|CR|144|145|DISCHARGE MEDICATIONS|PT, OT were ordered. A CBC with basic metabolic panel was ordered in five days' time. Regular diet is ordered. DISCHARGE MEDICATIONS: 1. Ambien CR 5 mg p.o. each day at bed-time p.r.n. 2. Potassium 20 mEq p.o. q. day. 3. Lasix 20 mg p.o. q. day. 4. Zoloft 50 mg p.o. daily 5. Nexium 40 mg p.o. q. day.
CR|controlled release|CR|143|144|MEDICATIONS|MEDICATIONS: 1. Vicodin 1-2 p.r.n. 2. Mobic 15 mg once a day. 3. Zyrtec 10 mg a day. 4. Ambien 5 mg at bedtime, apparently she had some Ambien CR as well. It is unclear whether she ever takes both of them. 5. Synthroid 0.1 mg or 100 mcg once a day.
CR|controlled release|CR|140|141|DISCHARGE MEDICATIONS|DISCHARGED INSTRUCTIONS: The client was discharged home. DISCHARGE MEDICATIONS: Vistaril 25 to 50 mg p.o. q.4-6 h. p.r.n for anxiety, Paxil CR 25 mg p.o. daily, and Lexapro 20 mg x1 day, then 10 mg x3 days. FOLLOW UP: Follow up with outpatient, appointment with Dr. _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2006, and Dr. _%#NAME#%_ to discuss therapy options with the patient at that time.
CR|controlled release|CR|153|154|MEDICATIONS|ALLERGIES: No known drug allergies. MEDICATIONS: 1. Lisinopril 10 mg p.o. daily. 2. Toprol-XL 75 mg p.o. daily. 3. temazepam 30 mg p.o. q.h.s. 4. Ambien CR 12.5 mg p.o. q.h.s. 5. Tylenol #3 1 p.o. p.r.n. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature is afebrile, BP pressure 160/88, heart rate 64, respirations are normal.
CR|controlled release|CR|131|132|DISCHARGE  INSTRUCTIONS|6. Lipitor 10 mg q. day. 7. Tricor 145 mg q.h.s. 8. Multi-vitamin 1 q day. 9. Neurontin 300 mg each day at bedtime. 10. Nifedipine CR 90 mg q. day. 11. Benicar 40 mg q. day. 12. Omeprazole 20 mg each day at bedtime. 13. Oxycodone CR 20 mg 1-2 tabs q.12h 14. Paxil 20 mg q. day.
CR|controlled release|CR|185|186|MEDICATIONS|5. Vicodin p.r.n. for foot pain. 6. Lantus 64 units subq at night and 15 units subq in the a.m. 7. NovoLog 5 units subq breakfast, 12 units subq at lunch, 25 units q. dinner. 8. Ambien CR 12.5 mg p.o. q.h.s. p.r.n. insomnia. PREVIOUS SURGERIES: Include multiple foot surgeries bilaterally, they figure about 4 on each foot.
CR|cardiorespiratory|CR|233|234|PLAN|DISCHARGE MEDICATIONS: 1. Prilosec 3 mg b.i.d. 2. Iron 3 mg b.i.d. Auditory screening was done and he passed that. Metabolic screening was sent on _%#MMDD2006#%_. PLAN: _%#NAME#%_ will be discharged home today pending results of the CR study once these are available. He will follow up with Dr. _%#NAME#%_ _%#NAME#%_ of _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ Clinic _%#CITY#%_ on Friday of this week.
CR|controlled release|CR|98|99|DISCHARGE MEDICATIONS|3. No follow up with Dr. _%#NAME#%_ is required. DISCHARGE MEDICATIONS: 1. Percocet. 2. OxyContin CR 10 mg p.o. b.i.d. 3. Wellbutrin. 4. Premarin.
CR|controlled release|CR|134|135|DISCHARGE MEDICATIONS|3. Lipitor 80 mg p.o. daily 4. Nexium 40 mg p.o. b.i.d. 5. Norvasc 5 mg p.o. daily 6. Hydrochlorothiazide 25 mg p.o. daily 7. Ambient CR 12.5 mg p.o. each day at bed-time 8. Levaquin 500 mg p.o. daily x3 days 9. Vicodin 1 p.o. q 6 hours p.r.n.
CR|controlled release|CR|205|206|DISCHARGE MEDICATIONS|9. Neurontin 100 mg t.i.d. 10. Prednisone at 40 mg daily, on a slow tapering dose over the course of two weeks. 11. Zoloft 50 mg q. day. 12. Triamcinolone acetate 0.1% topical ointment b.i.d. 13. Zolpidem CR 12.5 mg each day at bedtime. 14. Percocet one to two tablets p.o. q.6 hours p.r.n. 15. Enteric-coated aspirin 81 mg p.o. q. day. DISCHARGE INSTRUCTIONS: The patient is discharged home and is to follow with his primary physician in one week.
CR|controlled release|CR|105|106|CURRENT MEDICATIONS|GENITOURINARY: Unable to elicit history. ALLERGIES: Reported to Aricept. CURRENT MEDICATIONS: 1. Sinemet CR 25/100 1 p.o. t.i.d. 2. Glucerna shake oral liquid 120 cc t.i.d. 3. Metformin 1000 mg p.o. b.i.d. 4. Sinemet 10/100 1/2 tablet in the morning.
CR|controlled release|CR|183|184|HOSPITAL COURSE|Currently the patient's stools are well formed and no longer complaining of abdominal pain. 5. Pain control. The patient is currently comfortable on a regimen consisting of oxycodone CR 20 mg p.o. b.i.d. along with oxycodone 5 mg 1-2 tabs q.4-6 hours p.r.n. pain. She also takes Actiq p.r.n. This can be obtained from her primary physician in _%#CITY#%_, Dr. _%#NAME#%_.
CR|controlled release|CR|158|159|HISTORY OF PRESENT ILLNESS|She has little insight into these issues. However, her urinary tox screen came up positive only for benzodiazepines and trycyclics, and she is on both Ambien CR and Elavil. She has had significant issues with narcotics in the past. However, her narcotics were negative in the urine and she had little response to Narcan in the ER.
CR|controlled release|CR|258|259|2.  FEN|2. FEN: _%#NAME#%_ received IV fluids per protocol. He ate well throughout his hospital stay and his electrolytes remained within normal limits. 3. Insomnia: _%#NAME#%_ noted that he continued to have some difficulty sleeping upon admission. He tried Ambien CR for this at home with little relief. We tried Lunesta during his hospital stay and he has agreed to continue with a trial of this at home.
CR|controlled release|CR|110|111|DISCHARGE MEDICATIONS|4. Imdur 60 mg p.o. q. day. 5. Synthroid 100 mg p.o. q. day. 6. Ferrous sulfate 325 mg p.o. q. day. 7. Ambien CR 6.25 mg each day at bedtime. 8. Omeprazole 20 mg p.o. q. day. 9. Penicillin VK 250 mg p.o. q. day.
CR|controlled release|CR|159|160|MEDICATIONS AT THE TIME OF ADMISSION|2. Benadryl 25-50 mg each day at bedtime p.r.n. 3. Colace 100 mg twice daily. 4. Flovent 2 puffs twice daily. 5. Morphine CR 200 mg 3 times daily. 6. Morphine CR 60 mg 3 times daily. 7. Multivitamin 1 tablet daily. 8. Nicotine patch 21 mg. 9. Oxycodone 10 mg each day at bedtime p.r.n. SOCIAL HISTORY: Lives with 3 children in duplex with roommate.
CR|controlled release|CR|162|163|DISCHARGE MEDICATIONS|PROBLEM #3: Parkinson's; he was maintained on his usual regimen of Parkinson's medicines without changing. DISCHARGE MEDICATIONS: Unchanged including: 1. Sinemet CR 50/100 one tab p.o. q.i.d. at 0730 hours, 1100 hours, 1500 hours, and 1900 hours. 2. Sinemet regular 25/100 1-1/4 tablets p.o. t.i.d. at 0730 hours, 1100 hours, and 1900 hours.
CR|controlled release|CR,|149|151|MEDICATIONS ON DISCHARGE|9. Morphine sulfate 5-10 mg oral solution p.o. q. 2h. p.r.n. for pain. 10. Patanol 1-2 drops, solution ophthalmic for both eyes daily. 11. Oxycodone CR, also known as OxyContin 20 mg extended release per rectum q. 12h. for pain. 12. Risperdal 0.5 mg p.o. tablet at bedtime as needed for agitation.
CR|controlled release|CR|250|251|PROBLEM #4|PROBLEM #4: Cardiology. Given the patient's history of palpitations and his parents being able to visually see his heart beat rapidly within his chest, which occur for several minutes 1-2 times per month, cardiology was consulted. He was placed on a CR monitor for close monitoring and had two episodes of pulse into the 150s. An EKG with one episode revealed only sinus tachycardia. His mother noted that these episodes did not correspond to the symptoms that he complained of previously.
CR|controlled release|CR|122|123|DISCHARGE MEDICATIONS|4. Recurrent urinary tract infection (UTI). 5. History of diabetes. DISCHARGE MEDICATIONS: 1. Oxyfast p.r.n. 2. OxyContin CR 10 mg per rectum b.i.d. 3. Duragesic patch 25 mcg every 3 days. 4. Ativan 0.52 mg liquid every 2 hours p.r.n. DISPOSITION: To Elim Home extended-care facility in _%#CITY#%_, Minnesota for comfort care.
CR|controlled release|CR|131|132|DISCHARGE MEDICATIONS|14. Paxil 20 mg p.o. q day 15. Synergen 1 tab p.o. q.a.m. 3-4 tabs p.o. q.p.m. 16. Milk of Magnesia 30 cc p.o. q day 17. Silvadene CR q day under right breast 18. Multivitamin 1 tab p.o. q day 19. Compazine 1 tab pr q day 20. Prevacid 30 mg p.o. q day X6 weeks 21. Enteric-coated aspirin 81 mg p.o. q day Ranitidine was stopped and Fosamax was held.
CR|controlled release|CR|182|183|MEDICATIONS|She has never had any adverse reaction to anesthesia. MEDICATIONS: One aspirin per day. Celebrex 200 mg daily for arthritis. Lisinopril 10 mg daily. Premarin 0.625 mg daily. Sinemet CR 25/100 one pill at bedtime for restless legs. ALLERGIES: None known. Note that the patient has never had any adverse reaction to anesthesia.
CR|controlled release|CR|257|258|CURRENT MEDICINES|Chest x-ray appeared unchanged from previous. There was right lower lobe infiltrate noted. CURRENT MEDICINES: Tequin 400 mg one p.o. q.d., Fibercon one p.o. q.d., quinine sulfate 260 mg p.o. q.h.s, Colace 100 mg p.o. t.i.d., Aricept 5 mg p.o. q.d., Sinemet CR 50/200 two tablets p.o. q.a.m., one p.o. q.h.s., enteric-coated aspirin 325 mg p.o. q.d. ALLERGIES: Patient has adverse reaction to amantadine - rash.
CR|controlled release|CR.|170|172|DISCHARGE MEDICATIONS|Her symptoms of a Gardnerella infection have not recurred; she may need to follow up with her regular doctor about that if it does. She will go home on her regular Paxil CR. We will hold the Naprosyn and the Flexeril as well. She takes ____________nasal inhaler which she will continue. She has been on Zyrtec 10-mg per day which she will continue.
CR|controlled release|CR|193|194|DISCHARGE MEDICATIONS|Rehab was unremarkable for difficulties, and he progressed well through postoperative day #3, where he was ready for transfer to a rehabilitation facility. DISCHARGE MEDICATIONS: 1. Felodipine CR 5 mg p.o. q.d. 2. OxyContin 20 mg p.o. b.i.d. p.r.n. pain. 3. Tylenol #3 one p.o. q.4-6h p.r.n. pain. 4. Coumadin to be adjusted per INR and nomogram schedule.
CR|controlled release|CR|120|121|DISCHARGE MEDICATIONS|2. Os-Cal with vitamin D, 1 tablet b.i.d. 3. Combivent MDI 2 puffs q.i.d. p.r.n. 4. Lopressor 50 mg b.i.d. 5. OxyContin CR 10 mg b.i.d. 6. Senokot 2 tablets q.d. DISCHARGE FOLLOW UP PLAN: The patient needs follow up with Dr. _%#NAME#%_ within one week, with CBC, basic metabolic panel, and lipase.
CR|controlled release|CR|192|193|DISCHARGE MEDICATIONS|His platelet count was 108,000. His hemoglobin was normal at 13.6. PLAN: The patient was transferred to the Residential Lodging Plus Program on _%#MMDD2003#%_. DISCHARGE MEDICATIONS: 1. Paxil CR 25 mg q.d. 2. BuSpar 10 mg b.i.d. 3. Atenolol 50 mg q.d. 4. KCl 20 mEq q.d. 5. Multivitamin q.d. 6. Folic acid q.d. DISCHARGE DIAGNOSES: 1. Alcohol dependence.
CR|controlled release|CR|181|182|PROBLEM #5|PROBLEM #4: Congestive Heart Failure. Stable. The patient was continued with digoxin, lisinopril, aspirin, and Lasix. PROBLEM #5: Parkinsonism. The patient was continued on Sinemet CR 25/100 mg t.i.d. She was seen by neurologist, Dr. _%#NAME#%_ _%#NAME#%_. She was recommended to continue Sinemet CR at 25/100 mg q.h.s. instead of t.i.d. PROBLEM #6: Hypertension.
CR|controlled release|CR|334|335|HOSPITAL COURSE|She is planning on going back to Arizona within the next 10 days, and I asked her to follow-up with Dr. _%#NAME#%_ whom she knows in three or four days to be sure that she is stable. Her discharge medications will be all her same home medications which include Lasix 20 mg a day, MiraLax 17 grams a day, Protonix 40 mg a day, Norpace CR 100 mg b.i.d., Colace 100 mg a day, Flovent 220 mcg inhaler two puffs b.i.d., Diltiazem CD 240 mg a day, Liquibid 600 mg b.i.d., digoxin 0.125 mg a day, Advair 500/50 one puff p.o. b.i.d., Combivent inhaler as needed.
CR|controlled release|CR|213|214|DISCHARGE MEDICATIONS|3. Synthroid 0.05 mg p.o. every day. 4. Levsin 0.125 mg p.o. 1 to 2 q.4h. as needed for Bell's spasm. Alternate with Librax if taking. 5. Percocet 1 to 2 tablets p.o. q.6h. as needed for severe pain. 6. OxyContin CR 10 mg p.o. b.i.d. p.r.n. severe pain for longer-acting relief.
CR|controlled release|CR|164|165|PLAN|11. Lisinopril 10 mg PO qd. 12. Centrum Silver one PO qd. 13. Bactroban ointment apply to right lower leg wound area qd. 14. Zyprexa 2.5 mg PO t.i.d. 15. OxyContin CR 10 mg PO b.i.d. 16. Protonix 40 mg PO qd. 17. Bextra 20 mg PO qd. 18. Aldactone 25 mg PO qd. 19. Effexor XR 37.5 mg PO qd.
CR|controlled release|CR|432|433|DISCHARGE MEDICATIONS|She was eating a diabetic diet just prior to discharge back home. DISCHARGE MEDICATIONS: Isosorbide mononitrate 60 mg p.o. q.A.M., ranitidine 150 mg p.o. b.i.d., furosemide 80 mg p.o. q.A.M., Senna two tablets p.o. b.i.d., clonidine patch 0.2 mg change weekly, Zyprexa 5 mg p.o. q.h.s., insulin NPH 20 units sub-Q in the morning, 12 units sub-Q in the evening, Levothyroxine 0.175 mg p.o. q day, metoprolol 25 mg p.o. b.i.d., Paxil CR 25 mg p.o. q day, Plavix 75 mg p.o. q day. DISPOSITION: The patient is returning to the _%#CITY#%_ _%#CITY#%_ Health Care Center.
CR|controlled release|CR|134|135|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Vancomycin one gram IV q 24 hours to be followed by Dr. _%#NAME#%_, 2. Amantadine 100 mg b.i.d., 3. Sinemet CR 25/100, one PO b.i.d., 4. Benadryl 25 mg at h.s. 5. Klonopin 1 mg hs. 6. Plavix 75 mg per day. 7. Toprol XL 25 mg per day.
CR|controlled release|CR|491|492|HOSPITAL COURSE|He is now being transferred to Ebenezer Ridges Care Center for long term care since his wife is unable to care for him at home. His medications include Plavix 75 mg a day for stroke prevention, Wellbutrin XL 300 mg daily for depression, Aricept 10 mg daily for memory disturbance, Lipitor 40 mg daily for hyperlipidemia, and Norvasc 10 mg daily for hypertension, Maxzide 25/37.5 daily for hypertension, levothyroxine 50 mcg daily for hypothyroidism, Sinemet 25/100 orally q.i.d. and Sinemet CR 50/200 one-half tablet h.s., Seroquel 100 mg h.s. for agitation, Flomax 0.4 mg daily for BPH and Percocet one to two orally q.4.h. p.r.n. for pain, as well as Ambien 5 mg h.s. p.r.n. sleep and Ecotrin 325 mg daily.
CR|controlled release|CR|183|184|PLAN|Furosemide 60 mg daily except Tuesdays and Thursdays; on Tuesdays and Thursdays she takes 80 mg daily. Meclizine 25 mg three times daily p.r.n. dizziness. Fosamax 70 mg weekly. K-Dur CR 20 mEq daily. Vicodin 5/500 one pill every 4 hours p.r.n. pain. Zantac 75 mg at bedtime p.r.n. She has been instructed to get an appointment with our offices, anticoagulation clinic, in 4-5 days, and to see her primary physician, Dr. _%#NAME#%_ _%#NAME#%_, in approximately two weeks.
CR|controlled release|CR|194|195|MEDICATIONS|All her surgeries were at a young age. She has not been in the hospital for more than 50 years, according to her son. MEDICATIONS: Xalatan ophthalmic solution 0.005% to the right eye; Diltiazem CR 180 mg qd; enteric coated aspirin 81 mg qd. ALLERGIES: Thiazides and nicardipine. SOCIAL HISTORY: She's a nonsmoker, no alcohol use.
CR|controlled release|CR|173|174|DISCHARGE MEDICATIONS|3. Hypothyroidism. The patient was found to have a significantly elevated TSH of 10.3, so she was started on Synthroid, which she tolerated. DISCHARGE MEDICATIONS: 1. Nitro CR 2.5 mg p.o. b.i.d. UTI. 2. Cipro 250 b.i.d. x 4 days. 3. For a hypothyroid, Synthroid 50 mcg p.o. q.d.
CR|controlled release|CR|204|205|DISCHARGE MEDICATIONS|1. Azithromycin 250 mg for one additional day (to complete a five day course). 2. Ceftin 500 mg p.o. b.i.d. for six days (to complete a ten day course). 3. Robitussin, over-the-counter, p.r.n. 4. Sinemet CR 50/200, one p.o. t.i.d. 5. Klonopin 0.5 mg b.i.d. 6. Aricept 10 mg at h.s. 7. Prozac 40 mg a day. 8. Xalatan 0.005%, one drop both eyes, h.s.
CR|controlled release|CR|158|159|MEDICATIONS|2. Vitamin E 400 IU 3. Lasix 40 mg daily 4. Levoxyl 150 micrograms 5. Nitro-Dur patch on in the morning, off at bedtime. 6. Nitroglycerin sublingual 7. Paxil CR 12.5 mg daily 8. KCl 10 mEq daily 9. Premarin 0.3 mg daily 10. Tenormin 50 mg daily 11. Tylenol 1000 mg b.i.d. p.r.n. ALLERGIES: Not allergic to any known medications.
CR|controlled release|CR|109|110|DISCHARGE MEDICATIONS|DISCHARGE DIAGNOSES: 1. Alcohol dependence. 2. Depression. 3. Hypertension. DISCHARGE MEDICATIONS : 1. Paxil CR 25 mg daily. 2. Lisinopril 10 mg daily. 3. Hydrochlorothiazide 25 mg daily. DISCHARGE FOLLOWUP : She was to followup with her own doctor.
CR|cardiorespiratory|CR|182|183|ASSESSMENT AND PLAN|He had no further apnea episodes and the Aminophylline was stopped on _%#MMDD2005#%_. He was having self-resolving heart rate drops and desaturation episodes prior to discharge so a CR scan was done on _%#MMDD2005#%_. The results were abnormal with many desaturations and one apneic episode. He was loaded with caffeine citrate 20 mg/kg and started on a daily maintenance dose of 5 mg/kg.
CR|controlled release|CR|191|192|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Neoral 250 mg p.o. q.a.m. and 225 mg p.o. q.p.m. 2. Norvasc 10 mg p.o. daily. 3. Aspirin 325 mg p.o. daily. 4. Calcium with vitamin D 1250 mg p.o. b.i.d. 5. Sinemet CR 25/100 2 tabs p.o. each day at bedtime. 6. Chlorthalidone 25 mg p.o. daily. 7. Mycelex troche 10 mg p.o. t.i.d.
CR|controlled release|CR|141|142|DISCHARGE MEDICATIONS|21. Detrol 2 mg b.i.d. 22. Valcyte 450 mg daily. 23. Dilaudid 1-2 tablets q. 4-6h. p.r.n. as needed. 24. Hydralazine 25 mg daily. 25. Ambien CR 12.5 mg in the evening as needed. 26. NovoLog insulin sliding scale. The patient has a followup appointment on _%#MMDD2006#%_, renal nurse on _%#MMDD2007#%_.
CR|controlled release|CR|184|185|DISCHARGE MEDICATIONS|10. Aspirin 81 mg p.o. daily. 11. Protonix 40 mg p.o. daily. 12. Colace 100 mg p.o. b.i.d. p.r.n. for constipation. 13. Senokot 1-2 tabs p.o. b.i.d. p.r.n. for constipation. 14. Paxil CR 50 mg p.o. daily. 15. Imodium 2 mg p.o. with each diarrhea stool, maximum of 6 mg in 24 hours. 16. Lantus 5 units subcutaneous q. h.s. 17. NovoLog sliding scale subcutaneous t.i.d. before meals p.r.n. for hyperglycemia.
CR|controlled release|CR|133|134|HISTORY OF PRESENT ILLNESS|She denies any previous chemical dependency history, and she denies any use of chemicals at this time. She currently is taking Paxil CR 25 mg daily, Risperdal 0.5 mg daily and Remeron at bedtime. She states that these medications have been effective in treating her depression.
CR|controlled release|CR|415|416|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_'s family has kept a detailed journal and log of his behaviors and symptoms, essentially showing a gentleman who is intermittently confused with hallucinations and delusions, who is difficult to verbally redirect, and who is not getting much current benefit from psychoactive medications prescribed. Whether his hallucinations and delusions are acutely worsened by his complicated schedule or Sinemet CR or not, plus Selegiline is also not clear at present. CHEMICAL DEPENDENCY HISTORY: None known. PAST PSYCHIATRIC HISTORY: No additional data.
CR|controlled release|CR.|183|185|NONPSYCHIATRIC MEDICATIONS ON ADMISSION|3. Osteoarthritis with recent right knee replacement. Apparently he had a respiratory arrest during that surgery. 4. Incontinence. NONPSYCHIATRIC MEDICATIONS ON ADMISSION: 1. Sinemet CR. 2. Neurontin. 3. Selegiline. 4. Folic acid. 5. Cosopt. 6. Senna. PSYCHIATRIC MEDICATIONS: 1. Seroquel 100 mg at 1:00 a.m.
CR|controlled release|CR|172|173|CURRENT MEDICATIONS|1. Omeprazole 20 mg p.o. b.i.d. 2. Vicodin 5/500 mg not to exceed 8 tablets a day. 3. Paxil CR 37.5 mg p.o. daily. 4. Lorazepam 1 mg p.r.n. 5. Pyridium p.r.n. 6. Verapamil CR 240 mg p.o. daily. 7. Ambien 10 mg p.o. q.h.s. 8. Soma 350 mg p.o. b.i.d. 9. Cephalexin 250 mg p.o. daily. 10. Patanol 0.1% one drop to both eyes b.i.d.
CR|controlled release|CR|179|180|CURRENT MEDICATIONS|FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She quit smoking in 1967. ALLERGIES: LYRICA, ACETAMINOPHEN AND NORVASC. CURRENT MEDICATIONS: 1. Cozaar 100 mg daily 2. Nifedipine CR 30 mg daily. 3. OxyContin 40 mg 1 tablet q.12h. 4, Lasix 40 mg daily. 5. Klor-Con 10 mEq two tablets daily. 6. Neurontin 100 mg daily
CR|controlled release|CR|142|143|DISCHARGE MEDICATIONS|ALLERGIES: No known drug allergies. DISCHARGE MEDICATIONS: (_%#MMDD2003#%_) 1. Depakote 1500 mg q.h.s. 2. Levoxyl 0.175 mg daily. 3. Eskalith CR 450 mg t.i.d. 4. Lexapro 30 mg daily. PRESENT MEDICATIONS: 1. Depakote 1500 mg q.h.s.
CR|controlled release|CR|131|132|ASSESSMENT AND PLAN|PT as per her primary team and for DVT prophylaxis the patient was ordered Coumadin. Pain management was ordered to have oxycodone CR 10 mg p.o. b.i.d. and Percocet 1-2 tablets p.o. q. 4 h. For GI prophylaxis we will add Protonix 40 mg daily.
CR|controlled release|CR|124|125|MEDICATIONS|PAST MEDICAL HISTORY: 1. Depression. 2. Asthma. She has not used an inhaler for approximately 1 year. MEDICATIONS: 1. Paxil CR 25 mg once a day. As described above, she has been taking this only once or twice a month. 2. She uses Ortho Evra patch. She has been off the past week and is supposed to resume this on _%#MMDD2004#%_.
CR|controlled release|CR|132|133|PAST MEDICAL HISTORY|The workup for the pulmonary embolism has been negative so far. 4. Chronic migraines. This has been treated in the past with Prozac CR and prednisone. However, the patient stated that the Prozac CR was associated with side effects which included sexual dysfunction.
CR|controlled release|CR|108|109|MEDICATIONS PRIOR TO ADMISSION|5. Left orbital blowout fracture repair and eyelid surgery today. MEDICATIONS PRIOR TO ADMISSION: 1. Ambien CR 12.5 mg p.o. each day at bedtime. 2. Aspirin 81 mg p.o. daily. 3. Elavil 100 mg each day at bedtime. 4. Tylenol with codeine. 5. Ativan 1 mg. 6. Imitrex 100 mg.
CR|controlled release|CR|102|103|HOME MEDICATIONS|11. Recent left orbital blowout fracture status post surgical correction. HOME MEDICATIONS: 1. Ambien CR 12.5 mg daily at bedtime, 2. Aspirin 81 mg once daily. 3. Elavil 100 mg daily at bedtime, 4. Tylenol with codeine used as needed for cough. 5. Ativan 1 mg used as needed.
CR|controlled release|CR|267|268|CURRENT MEDICATIONS|2. Hypertension. 3. Chronic constipation. 4. Gastroesophageal reflux disease. 5. Hypothyroidism. 6. Macular degeneration. CURRENT MEDICATIONS: Advair inhaler, amiloride 5 mg q.d., hydrochlorothiazide 50 mg q.d., Prevacid 30 mg q.d., Synthroid 100 mcg q.d., oxycodone CR 10 mg p.r.n. (administered since admission), Toradol (since admission), atropine and prednisolone eye drops. Today she received an epidural steroid injection. In the emergency department on _%#MMDD2002#%_, she received 8 mg of morphine sulfate IM and 25 mg of Vistaril IM.
CR|controlled release|CR|161|162|CURRENT MEDICATIONS|6. Lantus 100 units subcu every day. 7. Lisinopril 40 mg p.o. once a day. 8. Metoprolol 100 mg p.o. twice a day. 9. Topamax 40 mg p.o. once a day. 10. Diltiazem CR 180 mg p.o. once a day. 11. Glucophage 850 mg p.o. 3 times a day. 12. Lovenox 95 mg subcu twice a day.
CR|creatinine|CR|174|175|STAFF|STAFF: Patient seen and examined by me. Recent cultures (_%#MMDD#%_) have been negative with the exception of mixed flora contamination _%#MMDD#%_. Afebrile with normal WBC. CR slow rise to 1.7. Lasix renal scan with catheter in the bladder will help define if ureteral stenting is required.
CR|complete remission|CR|121|122|HPI|My key findings: CC: Recurrent NHL, positive CSF. Waldeyer's ring. HPI: HIV patient who had stage IV NHL with _________. CR with chemotherapy. Now presented with positive CSF and recurrence in the Waldeyer ring area and paracarvenous sinus area. Exam: Lethargic, palpable neck node on right diplopia. Assessment and Plan: Patient will start IT chemotherapy.
CR|controlled release|CR|163|164|ASSESSMENT AND PLAN|3. Acid reflux, intermittent. Usually occurs in evening. The patient may use Zantac 150 mg p.o. q.p.m. 4. Hypertension, controlled. Will hold Avapro and verapamil CR for systolic blood pressure less than 100 mmHg. 5. Seasonal allergies. Patient may use Benadryl p.r.n. Thank you for this consultation.
CR|controlled release|CR.|188|190|HISTORY OF PRESENT ILLNESS|This chemotherapy was chosen instead of routine ABVD because of his significant history of coronary artery disease and cardiac problem. The patient responded to chemotherapy and reached a CR. The patient then was followed closely and did not proceed with consolidation radiation treatment. On CT scan from _%#MM2005#%_ he had some questionable progression of the lymphadenopathy compared to the prior CT scan.
CR|controlled release|CR|201|202|MEDICATIONS|3. Benign familial tremor. The patient reports that this is currently under good control, but it will vary from day to day and throughout the day as to how bad the tremor is. MEDICATIONS: 1. Verapamil CR 240 mg q.d. 2. Atenolol 100 mg q.d. 3. Celexa. 4. Indocin 50 mg q6h p.r.n. 5. Allopurinol. ALLERGIES: No known drug allergies.
CR|controlled release|CR.|228|230|MEDICATIONS|DERMATOLOGIC: No skin cancer or lesions. INFECTIOUS DISEASE: Denied. GENERAL: The patient denies any lumps, bumps, headaches, fevers, chills, night sweats, weight loss, or other tumor-like complaints. MEDICATIONS: 1. Nifedipine CR. 2. Atenolol/chlorthalidone. 3. Potassium chloride. 4. Flomax. 5. Aspirin. 6. Multivitamins (therapeutic M) 7. Vitamin C 8. Calcium. 9. Glucosamine. 10. Omega 3. 11. Kai-Kit Wan Chinese herbs.
CR|controlled release|CR|324|325|MEDICATIONS|3. No surgeries. The patient denies knowledge of heart disease, diabetes, asthma, hypertension, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, thyroid disease, seizure, tuberculosis, or anemia. ALLERGIES: No medication allergies recorded. MEDICATIONS: Medications prior to admission included: 1. Paxil CR 12.5 mg every day for four days, then discontinue. 2. Neurontin. 3. Lipitor 10 mg daily. 4. Zantac 150 mg daily. 5. Chewable vitamin daily. 6. Trileptal 75 mg b.i.d.
CR|controlled release|CR|162|163|ADMISSION MEDICATIONS|2. Anxiety disorder, paranoia, and urinary dysfunction. 3. Appendectomy in the past. ALLERGIES: Penicillin. ADMISSION MEDICATIONS: 1. Sinemet 50/200 mg at 8 p.m. CR formulation. 2. Sinemet 25/100 two tablets t.i.d. at 6 a.m., 10 a.m., and 6:30 p.m. 3. Zoloft 50 mg q. day. 4. Lasix 40 mg q. day.
CR|controlled release|CR|173|174|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Sinemet 25/100 two tablets at 6: a.m., 10:30 a.m., and 3:30 p.m. 2. Ropironole 8 mg p.o. t.i.d. at 6:30 a.m., 10:30 a.m., and 3:30 p.m. 3. Sinemet CR 50/200 at 8 p.m. 4. Zoloft 50 mg q. day. 5. Lasix 40 mg q. day. 6. Ditropan XL 15 mg q. day. 7. Seroquel 50 mg q.h.s. DISCHARGE INSTRUCTIONS: 1. After his evaluation, it was decided the patient would not to be a good candidate for deep vein stimulation.
CR|controlled release|CR,|237|239|MEDICATIONS|5. Tremors. 6. Question of developmental delay. 7. Berger's disease. 8. Hypothyroidism. 9. Status post appendectomy. ALLERGIES: Ibuprofen. MEDICATIONS: Please see FCIS for detailed list of medications that include dexamethasone, Sinemet CR, Dilantin, nifedipine, nicotine patch, levothyroxine and trazodone. FAMILY HISTORY: Positive for Parkinson's in the mother and carpal tunnel in a brother.
CR|controlled release|CR|166|167|ADMISSION MEDICATIONS|16. Protonix 40 mg p.o. b.i.d. 17. Seroquel 75 mg p.o. each day at bedtime. 18. Seroquel 75 mg p.o. q.6 h. p.r.n. 19. Imitrex 6 mg injection q.4 h. p.r.n. 20. Ambien CR 6.25 mg p.o. each day at bedtime p.r.n. ALLERGIES: Compazine (anaphylaxis) Zoloft and Celexa.
CR|controlled release|CR|130|131|OUTPATIENT MEDICATIONS|3. Insulin 60 units in the a.m. and 30 units in the p.m. 4. Metformin 500 mg p.o. b.i.d. 5. Iron with multivitamin. 6. Nifedipine CR 90 mg p.o. daily. 7. Colace 100 mg p.o. b.i.d. 8. The patient stopped the aspirin prior to surgery. ALLERGIES: Morphine produces itching.
CR|controlled release|CR.|205|207|ADMISSION MEDICATIONS|ADMISSION MEDICATIONS: 1. Soma. This medication was discontinued upon admission to the hospital. 2. Inderal LA 160 mg p.o. daily. 3. Maxzide 75/50 p.o. daily. 4. Amitriptyline 100 mg p.o. daily. 5. Ambien CR. This medication was also discontinued while patient was in the hospital. ALLERGIES: No known drug allergies SOCIAL HISTORY: Patient does not smoke.
CR|controlled release|CR.|91|93|ADMISSION MEDICATIONS|9. Frequent bronchitis, greater than one time per year. ADMISSION MEDICATIONS: 1. Eskalith CR. 2. Lamictal. 3. Seroquel. 4. Lexapro 10 mg p.o. daily. 5. Colace 100 mg b.i.d. 6. Protonix. 7. Ambien. 8. Albuterol inhaler one to two puffs p.o. q.4-6 h. p.r.n.
CR|controlled release|CR|152|153|MEDICATIONS ON ADMISSION|PAST SURGICAL HISTORY: 1. Hysterectomy secondary to uterine cancer. 2. Hand surgery. MEDICATIONS ON ADMISSION: 1 Celexa 20 mg p.o. q. day. 2. Verapamil CR 180 mg p.o. q. day. 3. Coumadin propafenone 150 mg p.o. b.i.d. 4. Lipitor 10 mg p.o. q. day. 5. Fosamax 70 mg p.o. weekly. 6. Viactiv two to three tablets per day.
CR|controlled release|CR|101|102|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1. Lamictal 100 mg twice a day. 2. Xanax XR 2 mg morning, 1 mg at h.s. 3. Paxil CR 50 mg a day. 4. BuSpar 30 mg in the morning and 15 mg at h.s. 5. Urecholine 25 mg 1 to 2 times per day.
CR|controlled release|CR|156|157|MEDICATIONS|3. COPD. a. No previous documentation. 4. Status post lumpectomy. 5. Cholecystectomy. MEDICATIONS: At last admit was 1. Zoloft 50 mg p.o. q day. 2. Sinemet CR 25/100 one-half pill p.o. q day. 3. Vitamin E 400 units q day. 4. Synthroid 0.025 mg per day. 5. Neurontin 100 mg p.o. b.i.d. 6. Glucosamine 500 mg p.o. t.i.d.
CR|controlled release|CR|154|155|ADMISSION MEDICATIONS|6. Dicyclamine 20 mg p.o. q.i.d. p.r.n. diarrhea. 7. Lomotil 2.5 mg p.o. b.i.d. p.r.n. diarrhea. 8. Lorazepam 1 mg p.o. q.h.s. p.r.n. insomnia. 9. Ambien CR 12.5 mg p.o. q.h.s. 10. Nasacort AQ 1 spray each nostril b.i.d. p.r.n. 11. Omeprazole 20 mg p.o. b.i.d. 12. Oxycodone 10 mg p.o. t.i.d. p.r.n. headaches. 13. Prednisone 10 mg p.o. q.a.m.
CR|controlled release|CR|217|218|RECOMMENDATIONS|She is substantially improved over 24 hours ago and I would anticipate that she might go home as soon as Monday or Tuesday if she continues to improve at this rate. I suggest we switch her Ambien to 12.5 mg of Ambien CR at bedtime and resume the other medications as at home, but I would discontinue the Accolate since she is already on Singulair.
CR|controlled release|CR|146|147|MEDICATIONS|9. Calcium. 10. DuoNeb nebulizer p.r.n. 11. Coumadin 5 mg q. day. 12. Aspirin 81 mg daily 13. Zestril 10 mg q. day. 14. Multi-vitamin. 15. Ambien CR 12.5 mg q.h.s. p.r.n. 16. Metoprolol 25 mg p.o. b.i.d. 17. Nitroglycerin p.r.n. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post CABG in 1992. 2. Status post pacemaker placement.
CR|controlled release|CR|107|108|MEDICATIONS|MEDICATIONS: Medications currently include: 1. Clozaril 50 mg p.o. q. a.m., 75 mg p.o. q. p.m. 2. ________ CR 450 mg q. a.m., 675 mg p.o. q. p.m. 3. Zyprexa 20 mg p.o. q. h.s. 4. Gabapentin 400 mg p.o. t.i.d. 5. Topamax 100 mg b.i.d.
CR|controlled release|CR|127|128|PRESENT MEDICATIONS|ALLERGIES: No known drug allergies. PRESENT MEDICATIONS: 1. Zofran 4 mg q.6h. p.r.n. nausea. 2. Protonix 40 mg q.a.m. 3. Paxil CR 12.5 mg q.a.m., increasing to 25 mg CR q.a.m. on _%#MMDD#%_. 4. Trazodone 50-100 mg q.h.s. 5. Effexor XR 75 mg q.d.
CR|controlled release|CR|213|214|MEDICATIONS|The patient was sent to Dr. _%#NAME#%_ for further recommendations and Dr. _%#NAME#%_ thought she would be a suboptimal candidate for atrial fibrillation ablation. MEDICATIONS: 1. Warfarin as prescribed. 2. Coreg CR 40 mg daily. 3. Aspirin 81 mg daily. 4. Cardizem 180 mg daily. 5. Vitamin E, dose uncertain. 6. Simvastatin 20 mg p.o. nightly.
CR|complete remission|CR|242|243|HPI|The patient was seen about 2-1/2 months ago. She has been started on Taxol and carboplatin following ECOG protocol _%#PROTOCOL#%_, although she is not on protocol. The patient had good response from chemotherapy, although she has not reached CR on repeat CT scan. Her mass has reduced more than 30%, which is good enough to follow with further treatment with weekly Taxol and radiation treatment.
CR|controlled release|CR|149|150|OUTPATIENT MEDICATIONS|However, she was unable to afford the medication and did not take it. She states that this has resolved on its own. OUTPATIENT MEDICATIONS: 1. Paxil CR 50 mg p.o. q.h.s. 2. Trazodone 50-150 mg p.o. q.h.s. 3. Vistaril 25 mg p.o. p.r.n. q.i.d. ALLERGIES: The patient reports an allergy to droperidol, Compazine, and Haldol.
CR|controlled release|CR|242|243|MEDICATIONS|3. Chemical dependency. CHEMOTHERAPY HISTORY: Mr. _%#NAME#%_ received 4 cycles of doxorubicin and ifosfamide prior to his surgical resection. RADIATION HISTORY: None. MEDICATIONS: 1. Depakote. 2. Percocet. 3. Mirtazapine. 4. Morphine sulfate CR 30 mg tablets 2 tablets b.i.d. 5. Oxycodone 10 mg p.o. q.4 h. p.r.n. 6. Sonata 10 mg p.o. each day at bedtime.
CR|controlled release|CR|149|150|OUTPATIENT MEDICATIONS|10. OxyContin 2 mg p.o. q.12 hours. 11. Zantac 150 mg p.o. b.i.d. 12. Paxil CR 50 mg p.o. q. day. 13. Ativan 0.5 to 1 mg q.4 hours p.r.n. 14. Ambien CR 12 mg p.o. q. h.s. 15. Hydrocodone 10/650 p.r.n. 16. Tylenol Extra Strength p.r.n. 17. NPH insulin 34 units subcu q a.m. and 15 units subcu q p.m.
CR|controlled release|CR|191|192|OUTPATIENT MEDICATIONS|OUTPATIENT MEDICATIONS: 1. Allegra 180 mg p.o. daily. 2. Singulair 10 mg p.o. daily. 3. Advair Diskus 250/50 1 puff b.i.d. 4. Lipitor 10 mg p.o. daily. 5. Tricor 145 mg p.o. q.p.m. 6. Niacin CR 250 mg 3 tablets b.i.d. 7. Xenical 120 mg p.o. t.i.d. 8. Flonase 2 puffs each nostril daily. 9. Albuterol 1-2 puffs p.r.n. 10. Multivitamin 1 tablet p.o. daily.
CR|controlled release|CR|162|163|MEDICATION|4. Hypertension, which per the chart has been labile, related to anxiety. 5. GERD. 6. Irritable bowel syndrome. MEDICATION: 1. Toprol XL 100 mg b.i.d. 2. Sinemet CR 50/200 one q.i.d. 3. Tums 5 to 8 mg t.i.d. 4. Sinemet 10/100 one t.i.d. 5. Seroquel 12.5 mg t.i.d. 6. Ativan 0.5 mg at hs 7. Comtan 200 mg b.i.d.
CR|controlled release|CR|134|135|MEDICATIONS|9. Xalatan eye drops 0.005% 1 drop each eye every evening. 10. Caltrate 350 mg 1 twice daily. 11. Multivitamin once daily. 12. Ambien CR 6.25 mg q.h.s. p.r.n. 13. Tylenol #3 1-2 q.4-6h. p.r.n. pain. 14. Meclizine 25 mg 4 times daily p.r.n. dizziness.
CR|controlled release|CR|176|177|MEDICATIONS|MEDICATIONS: Medications prior to admission include: 1. Gabapentin 300 mg p.o. each day at bedtime 2. Vicodin p.r.n. 3. Xalatan 0.005% eye drops daily to left eye. 4. Morphine CR 15 mg p.o. b.i.d. p.r.n. pain. 5. Timolol one drop to right eye b.i.d. 6. Tizanidine 4 mg p.o. daily. 7. Coumadin 7.5 mg p.o. daily to keep INR 2.0-3.0.
CR|controlled release|CR|195|196|CURRENT MEDICATIONS|She has not been very happy living in the nursing home over the last week or so. CURRENT MEDICATIONS: 1. Imodium. 2. Ativan. 3. Albuterol nebulizer. 4. Seroquel for anxiety. 5. Lasix. 6. Sinemet CR 50/200 at h.s. and 50/200 at 8:00 a.m. and 1600 hours; Sinemet CR 50/200 one-half tablet at 0400 hours and 1200 hours.
CR|controlled release|CR|240|241|MEDICATIONS|PAST MEDICAL HISTORY: CABG. Aortic aneurysm repair. History of aortic stenosis. Chronic renal failure. Hypertension. MEDICATIONS: Ranitidine, aspirin 81 daily, Toprol XL 100 bid, Allegra 30 daily, Lipitor 20 daily, Zetia 10 daily, DynaCirc CR 10 daily, Catapres .3 mg daily. Blood pressure has been quite variable and sometimes difficult to manage.
CR|controlled release|CR|228|229|MEDICATIONS|Her mother had a stroke. SOCIAL HISTORY: The patient is a retired RN She does not smoke, does not have any excessive amounts of alcohol. MEDICATIONS: 1. Sinemet 25 100 One tablet q.h.s. 2. Lovastatin 20 mg daily p.o., 3. Ambien CR 6.25 mg 1 p.o. q.h.s. 4. Actos 30 mg 1 daily p.o. 5. Metformin hydrochloride ,1000 mg 1 tablet twice a day with food, 6. Lisinopril 5 mg 1 p.o. daily.
CR|controlled release|CR|237|238|HISTORY|I had recommended we proceed with ah MRI of his neck, as well as physical therapy, but _%#NAME#%_ canceled all of those visits. _%#NAME#%_ is on Carbidopa/levodopa 25/100, one pill about 7 times a day. He takes this along with a Sinemet CR 50/1200 and along with a Requip 3 mg all at the same time. I had recently prescribed Clonazepam at bed time for him.
CR|controlled release|CR|125|126|MEDICATIONS|12. Tonsillectomy. 13. Cholecystectomy. 14. Back surgery. 15. Total knee arthroplasty. MEDICATIONS: On admission: 1. Sinemet CR 25/100 PO b.i.d. 2. Clonazepam 2 mg q hs. 3. Amantadine 100 mg PO q hs. 4. Plavix 75 mg PO qd. 5. Zantac 150 mg PO qd.
CR|controlled release|CR|121|122|MEDICATIONS|1. Metoprolol 50 mg 1/2 tablet b.i.d. 2. Lipitor 10 mg per day. 3. Zantac 150 mg b.i.d. 4. Isordil 10 mg b.i.d. 5. Paxil CR 25 mg per day. 6. Multi-vitamin. In hospital, these have been continued, with the addition of Ancef 1 gram q8 hours, and Docusate.
CR|controlled release|CR|174|175|MEDICATIONS|2. Aggrenox b.i.d. 3. Razadyne 8 mg b.i.d. 4. Foltex q. day. 5. Altace 5 mg. 6. Lovastatin 40 mg a day. 7. Carbidopa/levodopa 25/100 q. 4 hours. 8. Levodopa/carbidopa 50/200 CR q. evening. 9. Amantadine 100 mg a day. 10. Keppra 500 mg at bedtime. 11. Depakote (discontinued). PAST MEDICAL HISTORY: 1. Diagnosis of parkinsonian syndrome.
CR|controlled release|CR|170|171|CURRENT MEDICATIONS|ALLERGIES: Percocet intolerance (nightmares). CURRENT MEDICATIONS: 1. Trazodone 150 mg at bedtime. 2. Tylenol p.r.n. 3. Maalox p.r.n. 4. Milk of Magnesia p.r.n. 5. Paxil CR 25 mg two q.a.m. FAMILY HISTORY: No known serious illness. HABITS: He smokes one pack per day. Polysubstance abuse as described above.
CR|controlled release|CR|216|217|HISTORY|Details regarding psychiatric illness and circumstance leading up to present hospitalization as per Dr. _%#NAME#%_. The patient relates a history of anxiety disorder with panic attacks for which he had been on Paxil CR 37.5 mg (?) for approximately one year. Incomplete symptomatic relief. Significant weight gain over the last six months. He is followed at Park Nicollet Clinic with recent change in provider.
CR|complete remission|CR.|162|164|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: ALL with high initial WBC HPI: In 1st CR. CNS negative at dx. Exam: No adenopathy Assessment and Plan: Because of age and high WBC prophylactic whole brain XRT recommended.
CR|controlled release|CR|115|116|MEDICATIONS|3. Trazodone 200 mg at h.s. 4. Restoril 50 mg at h.s. on a p.r.n. basis. 5. Lansoprazole 15 mg per day. 6. Allegra CR twice a day on a p.r.n. basis. 7. Metronidazole 250 mg t.i.d. which he is supposed to be taking for Blastocystis hominis infection but he has not yet started.
CR|controlled release|CR|187|188|ASSESSMENT AND PLAN|She is doing well postoperatively, although her blood pressures have been normal. She seems to be doing well in terms of pain control on PCA. They have also started her on some oxycodone CR at 10 mg p.o. q.12h. She is also on a Dilaudid PCA. She seems to be doing well at this point. She is getting fluids at 80 cc per hour and they are going to change that soon as she seems to be taking p.o. at this point.
CR|controlled release|CR|130|131|MEDICATIONS ON ADMISSION|MEDICATIONS ON ADMISSION: 1. EES 333 mg t.i.d. 2. Aspirin 325 mg daily. 3. Diltiazem 60 mg t.i.d. 4. Plavix 75 mg daily. 5. Paxil CR 12.5 mg daily, which was started two days ago. 6. Ativan 0.5 mg one to two times a day p.r.n. anxiety. ALLERGIES: None. SOCIAL HISTORY: The patient's husband died earlier this year.
CR|controlled release|CR|157|158|MEDICATIONS|6. Simethicone 80 mg on a p.r.n. basis with meals. 7. Metformin 500 mg at noon and 1000 mg in the morning and p.m. 8. Zyprexa 20 mg twice a day 9. Verapamil CR 240 mg twice a day. 10. Zocor 20 mg a day. 11. Glyburide 5 mg twice a day. 12. Hydrochlorothiazide 25 mg every morning. 13. Lisinopril 40 mg every morning.
CR|complete remission|CR|208|209|HISTORY OF PRESENT ILLNESS|CT showed extensive adenopathy. Bone marrow biopsy showed extensive bone marrow involvement. The patient was treated with CHOP and Rituxan of eight cycles, which ended in _%#MM2004#%_. The patient had a near CR in _%#MM2004#%_. The patient developed hip and back pain again and returned. A PET scan was positive for paraspinal mass and pulmonary lesions.
CR|controlled release|CR|198|199|MEDICATIONS|He recently had some chest discomfort which is what led to his hospitalization. MEDICATIONS: 1. His regimen at home for his Parkinson's disease includes: Mirapex 0.5 mg three times a day 2. Sinemet CR 50/200, one tablet at 6:30, one tablet at 11:00 a.m., one tablet at 5 p.m. 3. Sinemet immediate release 25/100, one tablets at 6:30, one tablet at 11:00, one-half tablet at 3 p.m. and one-half tablet of the controlled release version taken at 10 p.m.
CR|controlled release|CR|113|114|MEDICATIONS|11. Synthroid 25 mcg p.o. daily. 12. Mirapex 0.75 mg p.o. at bedtime. 13. Zoloft 200 mg p.o. daily. 14. Zolpidem CR or Ambien CR 12.5 mg at bedtime. 15. Aciphex 20 mg p.o. daily. 16. Rhinocort 2 sprays everyday in nostril.
CR|controlled release|CR|117|118|MEDICATIONS|3. She denies any history of hypertension, diabetes, or asthma. MEDICATIONS: 1. Depakote 500 mg p.o. q.a.m. 2. Paxil CR 20 mg p.o. q.a.m. 3. Seroquel 25 mg two tablets p.o. q.h.s. 4. Seroquel 25 mg p.o. p.r.n. 5. Neurontin 600 mg p.o. q.h.s. ALLERGIES: The patient is allergic to penicillin which causes a rash.
CR|controlled release|CR|125|126|MEDICATIONS|MEDICATIONS: On admission: 1. MiraLax powder daily p.r.n. 2. Restoril 7.5 mg at bedtime, alternating with #3. 3. Ambien 6.25 CR p.r.n. insomnia. 4. Flomax 0.4 mg daily. 5. Clarinex 5 mg daily. 6. Flonase nasal spray 2 inhalations each nostril daily.
CR|controlled release|CR|174|175|ADMISSION MEDICATIONS|2. Essential hypertension. ADMISSION MEDICATIONS: 1. Lamictal which was started at 15 mg p.o. q.h.s. x1 week and is being titrated up. 2. Lithium CR 240 mg q.a.m. 3. Lithium CR 450 mg to receive 1-1/2 tab which is 675 mg q.h.s. 4. Lorazepam 1 mg orally 2 times a day. 5. Atenolol 50 mg orally every morning.
CR|controlled release|CR|147|148|MEDICATIONS|Enteric coated aspirin 80 mg once a day. Prevacid 30 mg a day. Remeron 45 mg at bedtime. Zyprexa 5 mg in the morning and 15 mg at bedtime. Sinemet CR 50/200 at bedtime. Celexa 20 mg a day. Empiric Colace two a day. MEDICATION ALLERGIES: Sulfa. FAMILY AND SOCIAL HISTORY: Are as per the chart.
CR|controlled release|CR|156|157|MEDICATIONS|4. Lisinopril 2.5 mg p.o. daily p.r.n. 5. Synthroid 50 mcg p.o. daily p.r.n. 6. Lipitor 10 mg p.o. daily p.r.n. 7. Metformin ER 500 mg p.o. t.i.d. 8. Sular CR 10 mg p.o. daily. 9. Fosamax 70 mg p.o. q. week. SOCIAL HISTORY: The patient is a Japanese American who was born in _%#CITY#%_, Washington and grew up in California but she was forced into an interment camp in the 1940s during the second world war, given American paranoia about people of Japanese descent.
CR|controlled release|CR|465|466|PREOP MEDICATIONS|MEDICATION ALLERGIES: No known drug allergies. PREOP MEDICATIONS: Reviewed including glucosamine sulfate, multivitamins, citalopram 40 mg 1-1/2 tablets daily, Diovan 160 mg daily, Lipitor 10 mg daily, Lorazepam 1 mg 1-2 tablets each day at bedtime p.r.n., tramadol with acetaminophen 1-2 tablets up to t.i.d. p.r.n., albuterol 2 puffs q.i.d. p.r.n., baclofen 10 mg 2 tablets each day at bedtime, trazodone 1 each day at bedtime (question dose) and morphine sulfate CR 15 mg q.12 h. p.r.n. indicating that taking only 2 tablets over the last month. Also on fish oil 3 capsules daily, Coenzyme Q daily.
CR|controlled release|CR|149|150|MEDICATIONS|1. Lipitor 10 mg q. day. 2. Lasix 20 mg everyday. 3. Levaquin 500 mg IV q. day. 4. Synthroid 50 mcg q. day. 5. Metoprolol 25 mg q. day. 6. Oxycodone CR 10 mg q. 8 hours. 7. Protonix 40 mg q. day. 8. Potassium 20 mEq q. day. 9. Senokot 1 q. day. 10. Tylenol p.r.n. for pain.
CR|controlled release|CR.|150|152|ADMISSION MEDICATIONS|7. Vocal cord polyps, removed in 1978 and 1979. 8. Cesarean sections x 2. 9. Hepatitis C. ADMISSION MEDICATIONS: 1. Glucophage 2. Neurontin. 3. Paxil CR. 4. Geodon. 5. Insulin Humulin NPH 17 units q.a.m. 10 units q.h.s. 6. Insulin Humalog 6 units q.a.m. 4 units at 17:00.
CR|complete remission|CR|287|288|HISTORY OF PRESENT ILLNESS|_%#NAME#%_ did well until _%#MM2003#%_ when she developed an isolated bone marrow relapse at 22 months of therapy. She received four-drug reinduction and consolidation x 2 with FLAG with a good response at day 14 with the bone marrow at that point showing only 5% blasts, and she was in CR by day 33. A bone marrow transplant was considered in first complete remission, but there were no matched sibling donors.
CR|controlled release|CR.|193|195|OUTPATIENT MEDICATIONS|3. History of herniated L4-5 with subsequent low back pain secondary to a motor-vehicle accident in _%#MM#%_ of 2002. 4. History of fibromyalgia. OUTPATIENT MEDICATIONS: 1. Trazodone. 2. Paxil CR. 3. Xanax. 4. Methadone 110 mg p.o. q.d. which the patient has tapered from. She states that this was through a methadone clinic. ALLERGIES: Penicillin produces urticaria.
CR|controlled release|CR|213|214|CURRENT MEDICATIONS|ALLERGIES: None. Nausea and vomiting with Vicodin. He has tolerated Percocet in the past. CURRENT MEDICATIONS: Coumadin for deep venous thrombosis prophylaxis. Morphine sulfate PCA, as described above. Nifedipine CR 30 mg daily. Lisinopril 10 mg daily. Bupropion hydrochloride 150 mg daily. Glyburide 5 mg b.i.d. Metformin 1000 mg b.i.d. Famotidine 40 mg b.i.d. Tacrolimus 5 mg b.i.d. Azathioprine 125 mg daily.
CR|controlled release|CR|124|125|ADMISSION MEDICATIONS|3. Geodon 20 mg b.i.d. 4. Temazepam 7.5 mg at bedtime. 5. Prilosec 20 mg b.i.d. 6. Florinef Acetate 0.1 mg daily. 7. Ambien CR 6.25 mg at bedtime. 8. Aspirin 325 mg daily. 9. Vitamin B12 1000 mcg daily. 10. Citracal plus vitamin D one tab p.o. b.i.d.
CR|controlled release|CR|253|254|MEDICATIONS|PAST MEDICAL HISTORY: She has a history of cardiomyopathy, chest pain, irritable colon, depression, osteoarthritis, obesity, low back pain, hyperlipidemia, and syncopal episodes in the past. MEDICATIONS: She is on Ativan 1 mg q.h.s., meclizine, Sinemet CR 50/200 two tablets p.o. q.h.s., Lipitor 20 mg half tablet q.d., Zestril 10 mg q.d., and Lexapro 10 mg q.d. ALLERGIES: SHE IS ALLERGIC TO CODEINE, ASPIRIN, FLOXACIN, NSAIDS, SALSALATE.
CR|controlled release|CR|148|149|MEDICATIONS|MEDICATIONS: Currently, 1. Atenolol 25 mg PO QHS 2. Calcium with vitamin D. 500 mg PO daily 3. Ancef 4. Multivitamins one tab PO Q day 5. OxyContin CR prn. 6. Senna 1-2 tabs PO b.i.d. 7. Coumadin SOCIAL HISTORY: She is a non-smoker. Lives independently. She denies any significant alcohol use.
CR|controlled release|CR|129|130|ADMISSION MEDICATIONS|2. Hypercholesterolemia. PAST SURGICAL HISTORY: Left shoulder surgery x 3 between 2001 and 2002. ADMISSION MEDICATIONS: 1. Paxil CR 70 mg p.o. q.a.m. He has been off this medication for one week. 2. Lipitor 20 mg p.o. q.a.m. ALLERGIES: Penicillin, iodine, and shellfish.
CR|complete remission|CR.|132|134|PROBLEM|PE: No neurologic symptoms noted. PLAN: Because CT scan appears to show residual disease in hilum area, the patient is not a proven CR. There is no data to show any survival improvement in this class of patients. Should she receive a CR in the future we can consider PCI at that time.
CR|controlled release|CR|230|231|PAST MEDICAL HISTORY|PAST SURGERIES: Tubal ligation 1980, right inguinal hernia 1983, diskectomy L5 in 1999, left knee replacement in _%#MM#%_ 2006 and 1996, partial hysterectomy. MEDICATIONS: Include 1. Geodon 60 mg. 2. Effexor XR 75 mg. 3. Lithobid CR 300 mg. 4. Protonix 40 mg. 5. Alavert 10 mg. 6. Nortriptyline 10 mg. 7. Fentanyl patch 25 mcg. ALLERGIES: ALLERGIES INCLUDE AMOXICILLIN, RASH AND SWELLING IN BOTH EYES, BLOOD PRESSURE GOES DOWN.
CR|controlled release|CR|134|135|MEDICATIONS|2. Rocephin 1 gram IV x1. 3. Levaquin 500 mg IV every 24 hours. 4. Flagyl 500 mg IV q8h. 5. Home medications are Trazodone and Ambien CR and CR was recently started. 6. Xanax 0.25 mg 1-2 t.i.d. p.r.n. 7. Methadone in his home medication as well 5 mg.
CR|controlled release|CR.|167|169|PAST MEDICINES|He would like to continue this in the hospital, he would also like to have oral swabs ordered to help keep his mouth moist. At night the patient uses Ambien, which is CR. LABORATORY on _%#MMDD2007#%_, serum creatinine is 1.06.
CR|controlled release|CR|162|163|MEDICATIONS PRIOR TO SURGERY|The patient denies anesthetic complications from these procedures. He denies a history of DVT/PE. MEDICATIONS PRIOR TO SURGERY: 1. Lipitor 40 mg a day. 2. Ambien CR 12.5 mg daily at bedtime. 3. Vicodin on a p.r.n. basis, generally twice a day. ALLERGIES: None. HABITS: The patient denies cigarette use. His alcohol use is as described above.
CR|controlled release|CR|185|186|MEDICATIONS|ALLERGIES: CODEINE causes stomach upset, CELEBREX, with diarrhea, ACTONEL, GI upset, MIRTAZAPINE, weakness and disorientation. MEDICATIONS: On admission, Coumadin 5 mg daily, Diltiazem CR 300 mg daily, Toprol XL 100 mg daily, Darvocet N 100 every 6 hours p.r.n., Trazodone 50 mg 1 to 2 tablets p.o. at bedtime p.r.n..
CR|controlled release|CR|173|174|MEDICATIONS|Please see review of systems below for further details. MEDICATIONS: Currently 1. Depakote ER 1000 mg each day at bedtime. 2. Seroquel 400 mg each day at bedtime. 3. Ambien CR 6.25 mg q.h.s. p.r.n. 4. Ibuprofen 600 mg t.i.d. p.r.n. pain. 5. Seroquel 25-50 mg q.6h. p.r.n. agitation. ALLERGIES: THE PATIENT HAS ALLERGY TO LATEX, VICODIN, BRAZILIAN NUTS, PENICILLIN, SULFA, CODEINE, LIBRIUM, VALIUM, DUST AND CATS.
CR|controlled release|CR|184|185|RECOMMENDATIONS|2. CT scan of the cervical spine without contrast. 3. Right shoulder and humerus x-ray: The patient had significant tenderness in the right shoulder on examination. 4. Restart Sinemet CR 25/100 one tablet twice a day to begin with food. Premedicate 30 minutes earlier with 25 mg of Lodosyn. 5. I agree with physical therapy and Social Service evaluation.
CR|controlled release|CR|166|167|CURRENT MEDICATIONS|6. History of orbital cellulitis as a youngster without sequelae. CURRENT MEDICATIONS: 1. Zantac 150 mg p.o. b.i.d. 2. Benzoyl peroxide topical lotion. 3. Wellbutrin CR 150 mg p.o. b.i.d. 4. Erythromycin topical. 5. Minocycline 100 mg p.o. b.i.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The child is living in the care of his parents and attends the 10th grade.
CR|controlled release|CR|135|136|HISTORY OF PRESENT ILLNESS|The patient has been seeing a therapist and also has been evaluated by Dr. _%#NAME#%_ _%#NAME#%_ (Psychiatry). The patient is on Paxil CR 12.5-mg tablets daily and this has just been recently increased to 25-mg tablets. She has been on medication for nine or ten days at this time.
CR|controlled release|CR.|148|150|MEDICATIONS|1. Triglidie. 2. Lipitor. 3. Potassium. 4. Lasix 80 mg p.o. daily. 5. Protonix. 6. Lamictal. 7. Bacitracin ointment 8. Vitamin C. 9. Sinemet 25/100 CR. 10. Seroquel. 11. Vicodin. 12. Chromogen. 13. Iron sulfate. 14. Multivitamin. 15. Vitamin C. ALLERGIES: He has no known drug allergies.
CR|controlled release|CR|172|173|CURRENT MEDICATIONS|4. Nystatin swish and swallow. 5. Zosyn 4.5 grams IV q.8 h. 6. Tobramycin 150 mg IV daily. 7. Valgan cyclovir 450 mg daily. 8. Voriconazole 200 mg p.o. b.i.d. 9. Oxycodone CR 10 mg q.12 h. for pain. 10. Calcium carbonate with vitamin D 1250 mg a day. 11. Magnesium oxide 800 mg p.o. b.i.d. 12. Pancrease 1-5 tablets p.o. with meals 3 times a day.
CR|controlled release|CR|147|148|ADMISSION MEDICATIONS|ADMISSION MEDICATIONS: None. Presently maintained on trazodone 50 to 100 mg q.h.s. p.r.n. sleep; Seroquel 25 mg q. six hours p.r.n. anxiety; Paxil CR 12.5 mg q. day; p.r.n. Tylenol, Maalox, and milk of magnesia. FAMILY HISTORY: Father died from myocardial infarction; mother died from complications of diabetes and renal disease.
CR|controlled release|CR|187|188|MEDICATIONS|2. Dilaudid 4 mg p.o. q3-4h p.r.n. break-through pain. 3. Neurontin 1200 mg q.a.m., 600 mg noon, suppertime and q.h.s., with a total of 3000 mg daily. 4. Trazodone 100 mg q.h.s. 5. Paxil CR 62.5 mg daily. 6. Rabeprazole 20 mg daily. 7. Lovastatin 40 mg daily. 8. Lisinopril 20 mg daily. 9. Nitroglycerin 0.4 mg sublingual p.r.n. chest pain.
CR|closed reduction|CR|141|142|ASSESSMENT AND PLAN|No AV block appreciated. ASSESSMENT AND PLAN: 1. Status post ORIF of the mandibular parasymphysis fracture, right condylar neck fracture and CR of left intracapsular fracture. Management per Orthopedic Surgery. 2. Syncope. I suspect this is secondary to orthostatic hypotension. I doubt this represents a primary cardiac etiology or a primary neurologic disorder.
CR|controlled release|CR|104|105|MEDICATIONS ON ADMISSION|9. Prior tobacco use, quit in 1995 and currently does not smoke. MEDICATIONS ON ADMISSION: 1. Diltiazem CR 240 mg daily. 2. Metoprolol XL 100 mg daily. 3. Warfarin adjusted to the INR. 4. Simvastatin 40 mg daily. 5. Hydrochlorothiazide 25 mg daily.
CR|controlled release|CR|180|181|MEDICATIONS|4. Levothyroxine 100 mcg per day. 5. Fosamax 70 mg weekly. 6. Rocaltrol 0.25 mcg daily. 7. Calcium twice daily. 8. Lisinopril/hydrochlorothiazide 20/12.5 twice daily. 9. Diltiazem CR 180 mg twice daily. 10. Clonidine 0.1 mg twice daily. 11. Asacol 800 mg 3 times daily. 12. Aspirin 325 mg once daily. 13. Imuran 100 mg daily.
CR|controlled release|CR|151|152|MEDICATIONS|2. ASD repair. 3. Inguinal hernia repair. 4. Gingival surgery. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Aspirin 325 mg daily. 2. Divalproex CR 1250 mg at bedtime. 3. Colace 100 mg b.i.d. 4. Haldol 5 mg IM x1. 5. Lamictal 150 mg a.m. 6. Ativan 2 mg IM x1. 7. Seroquel 150 mg each day at bedtime with routine p.r.n. meds.
CR|controlled release|CR|140|141|MEDICATIONS|1. Ocuvite 2 tablets b.i.d. 2. Advair Diskus 100/50 mcg 1 puff b.i.d. 3. Cetaphil cream p.r.n. 4. Hydrocortisone 2.5% cream p.r.n. 5. Paxil CR 25 mg daily. 6. Dipyridamole 25 mg daily. 7. Lipitor 10 mg daily. 8. Detrol LA 2 mg p.o. daily. 9. Neurontin 600 mg p.o. t.i.d.
CR|controlled release|CR.|101|103|MEDICATIONS|MEDICATIONS: 1. Lipitor 40 mg PO nightly 2. Lopid 600 mg PO b.i.d. 3. Bextra 20 mg PO daily 4. Paxil CR. 25 mg PO daily 5. Toprol XL 100 mg PO daily 6. Aspirin 325 PO daily 7. Nexium 40 mg PO daily 8. Atacand 32 mg PO daily
CR|controlled release|CR|360|361|MEDICATIONS|Other known serious illness: None. He denies heart disease, hypertension, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, thyroid disease, tuberculosis, or anemia. ALLERGIES: None known. MEDICATIONS: Present medications include Nicotine inhaler p.r.n.; Geodon 80 mg q.a.m. and q.h.s.; Glucophage 500 mg b.i.d.; Lexapro 20 mg q.a.m.; Paxil CR 25 mg q.h.s.; with p.r.n. Tylenol, Maalox, and milk of magnesia. FAMILY HISTORY: His mother has diabetes. HABITS: He has three to four cigarettes daily.
CR|controlled release|CR|117|118|HISTORY|Patient indicates postpartum depression after the birth of her daughter in 1995, treated as an outpatient with Paxil CR and trazodone. Never hospitalized. PAST MEDICAL HISTORY: 1. Alcohol dependence as above.
CR|controlled release|CR|159|160|PLANS|3. Bowel management with a routine bowel program. 4. Bladder: The patient is voiding and has normal bladder control. 5. Pain: I plan to start her on OxyContin CR on a scheduled basis to achieve better pain control. Estimated length of stay in rehab is 1-1/2 weeks, with discharge expected to home with some assistance from family and friends.
CR|controlled release|CR,|113|115|MEDICATIONS|9. Prilosec 20 mg a day. 10. Lisinopril 5 mg a day. 11. Actos 15 mg daily. 12. Tamoxifen 10 mg b.i.d. 13. Ambien CR, the dose of which is not clear. There is concern that she has been abusing this as well. ALLERGIES: No known drug allergies. SOCIAL HISTORY: _%#NAME#%_ is retired.
CR|controlled release|CR|145|146|DISCHARGE MEDICATIONS|12. Simvastatin 80 mg every evening. 13. Desyrel 25 mg p.r.n. at bedtime for insomnia. 14. Ambien 5 mg at bedtime p.r.n. insomnia. 15. OxyContin CR 10 mg q.12h. for pain; that is a scheduled med. 16. Oxycodone/acetaminophen combination 1-2 tablets q.4h. p.r.n. pain. 17. P.r.n. Tylenol 650 mg q.6h.
CR|controlled release|CR.|279|281|ADMISSION MEDICATIONS|PAST MEDICAL HISTORY: 1. Depression. 2. Denies history of chronic medical illnesses, including cardiopulmonary disease, diabetes, hypertension, and infectious disease. PAST SURGICAL HISTORY: Left arm fracture repair. ADMISSION MEDICATIONS: 1. Lexapro 10 mg p.o. daily. 2. Ambien CR. ALLERGIES: No known drug allergies. SOCIAL HISTORY/HABITS: The patient is single. No children. States he is a full-time student in a master's program.
CR|cardiorespiratory|CR|210|211|PROBLEM #4.  CV|PROBLEM #6. Ophthalmology: The patient's ophthalmologic exam showed no signs of vasculitis, uveitis, or optic nerve damage. However they did recommend that within the next month the patient should return for a CR exam. PROBLEM #7. Heme/Onc: Heme/Onc was consulted due to the patient's history of a microangiopathic process in the kidneys and history of hemolytic anemia.
CR|controlled release|CR|250|251|MEDICATIONS|MEDICATIONS: Include Zoloft 50 mg p.o. q. day, Neurontin 300 mg, 1-2 tablets every night as needed for restless legs; prednisone 10 mg p.o. q. day for shortness of breath, isosorbide mononitrate 30 mg tablets, one- half tablet p.o. q. day; diltiazem CR 120 mg p.o. q. day, Xalatan 0.005 percent, 1 drop right eye, q.h.s., Alphagan 0.15 percent, one drop both eyes b.i.d., Azopt 1 percent, 1 drop both eyes b.i.d. SOCIAL HISTORY: Negative tobacco, alcohol, or drug use.
CR|controlled release|CR|235|236|DISCHARGE MEDICATIONS|_%#MMDD#%_: Normal chemistry, sodium, with creatinine of 0.67, with BUN 10, creatinine 0.67, sodium 140, potassium 3.1. DISCHARGE MEDICATIONS: 1. Clozaril 12.5 mg p.o. q.a.m., 62.5 mg p.o. q.h.s. 2. Aspirin 325 mg each day. 3. Sinemet CR 50/200 2 tabs p.o. t.i.d., 1.5 tabs in afternoon, 0.5 tablet q.h.s. 5. Requip 1 mg p.o. t.i.d. 6. Gatifloxacin 400 mg p.o. each day for 10 days, until _%#MMDD2004#%_.
CR|controlled release|CR|125|126|MEDICATIONS|6. Morphine sulfate 10 mg/5 cc, one teaspoon p.o. q.4h. p.r.n. 7. OxyContin 20 mg CR one p.o. t.i.d. 8. OxyContin 10 mg p.o. CR one p.o. t.i.d. 9. Diovan 160 mg p.o. daily. 10. Lasix 40 mg two p.o. each morning, 1-1/2 tablets p.o. each noon.
CR|controlled release|CR|124|125|ADMISSION MEDICATIONS|ADMISSION MEDICATIONS: 1. OxyContin 80 mg a.m. and 20 mg p.m. 2. Vicodin 10/325. 3. Xanax 1 mg, I believe, daily. 4. Ambien CR 12.5 mg q.h.s. 5. Lunesta 3 mg q.h.s. 6. Lamictal 100 mg daily. 7. Mirtazepine 30 mg daily. 8. Fluoxetine 20 mg daily. 9. Seroquel 50 mg daily.
CR|controlled release|CR|145|146|CURRENT MEDICATIONS|6. Lasix 20 mg p.o. q. day. 7. Metoprolol 50 mg p.o. q. day. 8. Potassium tablet 40 mEq p.o. q. day. 9. Lexapro 20 mg p.o. q. day. 10. OxyContin CR 10 mg b.i.d. 11. Seroquel 25 mg q.h.s. 12. Warfarin (on hold) 2 mg q. Monday, Wednesday and Friday; 1.5 mg Tuesday, Thursday, Saturday, Sunday.
CR|controlled release|CR|173|174|ADMISSION MEDICATIONS|5. Lipitor 40 mg p.o. daily. 6. MS Contin 30 mg p.o. t.i.d. 7. Valium 20 mg p.o. t.i.d. 8. Colace 100 mg p.o. x six daily. 9. Multivitamins one tablet p.o. daily. 10. Paxil CR 75 mg p.o. daily. SOCIAL HISTORY: The patient has a 26 year pack history and still continues to smoke.
CR|controlled release|CR|223|224|MEDICATIONS UPON ADMISSION|No history of drug abuse and she exercises once in a while. MEDICATIONS UPON ADMISSION: Included atenolol and chlorthalidone 100/25 mg p.o. daily, amitriptyline 25 mg 2-3 at bedtime, Lexapro 20 mg 2 daily, morphine sulfate CR 100 mg 1 tab t.i.d., hydromorphone 4 mg 1-2 tablets q.3-4h. as needed and Prevacid over-the-counter. ALLERGIES: NKDA. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 140/90, current weight 227 pounds and height 69 inches.
CR|controlled release|CR|166|167|DISCHARGE INSTRUCTIONS|3. Lifting restrictions were not given; however, the patient was instructed not to drive while on narcotic pain medication. 4. Discharge medications include morphine CR 100 mg t.i.d., hydrocodone 4 mg 1-2 tabs by mouth every 3 hours as needed for pain, atenolol and chlorthalidone 100/25 mg, amitriptyline 25 mg 3 tabs at bedtime, Prevacid 25 mg p.o. b.i.d., Senokot-S 2 tabs p.o. 1-2 times daily as needed for constipation, ibuprofen 600 mg p.o. q.6h. as needed for pain and Compazine 5 mg 1-2 tabs by mouth q.6-8h. p.r.n. nausea.
CR|controlled release|CR|139|140|PAST MEDICAL HISTORY|She has had periodic steroid injections in both of her knees. 2. Morbid obesity. She has a BMI of 55. 3. Hypertension. She is on verapamil CR 240 mg daily, chlorthalidone 50 mg daily, and lisinopril 40 mg daily. 4. Diabetes mellitus type 2. She manages this with metformin.
CR|controlled release|CR|138|139|CURRENT MEDICATIONS|The patient's Coumadin has been on hold for the last five days in preparation for possible back injections. CURRENT MEDICATIONS: 1. Coreg CR 20 mg daily for the past 2 weeks, though this was increased yesterday by Minnesota Heart Clinic to 40 mg daily.
CR|controlled release|CR|184|185|MEDICATIONS BEFORE ADMISSION|4. History of fibromyalgia. Of note, within the last year, she has had upper endoscopy and colonoscopy, which were negative, per her primary MD. MEDICATIONS BEFORE ADMISSION: 1. Paxil CR 25 mg p.o. q.d. 2. Prevacid 30 mg p.o. q.d. 3. Imitrex p.r.n. TRANSFER MEDICATIONS: Spironolactone 25 mg p.o. b.i.d. ALLERGIES: She is allergic to penicillin.
CR|controlled release|CR|306|307|MEDICATIONS|Hypertension, gastroparesis, irritable bowel syndrome, hard of hearing. FAMILY HISTORY: Not obtained. MEDICATIONS: Ambien 10 mg po q hs, ibuprofen sporadically during the day, Trazodone 100 mg po q hs, __________ 20 mg po qid, Levothyroxine 50 micrograms po q day, Seroquel 100 mg 4 tablets po q hs, Paxil CR 25 mg 2 tablets po q.a.m., Flomax 0.4 mg tid, Prevacid 30 mg 1-3 tablets a day, Depakote ER 500 mg po q hs 2 tablets, Lisinopril 10 mg po q day, Vicodin 5/500 1 po q 4-6 hours prn, ___________ 25 mg 1 po q day.
CR|cardiorespiratory|CR|205|206|GI|Because of apneic and bradycardic episodes, _%#NAME#%_ was treated with theophylline / caffeine. Caffeine was stopped on _%#MMDD2007#%_; however _%#NAME#%_'s last episode occurred on _%#MMDD2007#%_. (If a CR scan or MMU was obtained, please include the results at this point.) Problem # 7: Cardiovascular. _%#NAME#%_ had an echocardiogram at birth due to murmur, which revealed a small PDA.
CR|controlled release|CR|188|189|MEDICATIONS|1. Depakote ER 1500 mg b.i.d. 2. Neurontin 300 mg in the a.m. and midday and 600 mg each day at bedtime. 3. Inderal 20 mg t.i.d. 4. Seroquel 300 mg 1-2 p.o. each day at bedtime. 5. Ambien CR 12.5 mg each day at bedtime. 6. Klonopin 2 mg each day at bedtime and 1 mg p.r.n. b.i.d. for anxiety. 7. Vistaril 50 mg each day at bedtime. 8. Ativan 0.5 mg b.i.d.
CR|complete remission|CR|142|143|HISTORY OF PRESENT ILLNESS|She had no B symptoms, but heterogenous breast activity of unclear significance. She was treated with 6 cycles of ABVD in _%#MM2006#%_ with a CR confirmed by PET CT in _%#MM2006#%_. This was followed by palliative radiation therapy to the right femur for leg pain. In _%#MM2006#%_, the PET CT revealed increased activity in the superior mediastinum, anterior to the trachea, right paratracheal region and bibasilar tonsillar pillar.
CR|controlled release|CR|144|145|DISCHARGE MEDICATIONS|11. Coumadin 3 mg p.o. daily. 12. Benadryl 50 mg p.o. twice daily p.r.n. itching. 13. Zyrtec 5 mg p.o. twice daily p.r.n. allergies. 14. Ambien CR 6.25 mg p.o. everyday at bedtime. 15. Dilantin ER 300 mg p.o. q.a.m. 16. Dilantin ER 400 mg p.o. everyday at bedtime. 17. Aspirin 81 mg p.o. daily.
CR|controlled release|CR|119|120|MEDICATIONS|3. CellCept 750 mg b.i.d. 4. Phos-Lo 667 mg t.i.d. 5. Reglan 5 mg q.a.m. and at bedtime. 6. Colace 100 b.i.d. 7. Paxil CR 25 mg daily. 8. Norvasc 10 mg daily. 9. Metoprolol 50 mg b.i.d. 10. Ambien 5 mg daily. 11. Calcium with vitamin D 500 mg b.i.d.
CR|controlled release|CR|401|402|DISCHARGE MEDICATIONS|She is to call with increased drainage, increased pain, increased swelling or temperature greater than 100.4, inability to pass flatus or have a bowel movement or any other questions or concerns. DISCHARGE MEDICATIONS: Dilaudid 8-12 mg every 3 hours as needed for pain, Celebrex 100 mg twice daily as needed for pain, Ativan 1 mg every 6 hours as needed for anxiety with only 10 tablets given, Ambien CR 6.25 mg, she can take 1-2 tablets at night as needed for sleep and only 15 tablets were given of this, Senokot 1-2 tablets p.o. twice daily to prevent constipation, Neurontin 300 mg t.i.d. and Flexeril 10 mg up to 3 times a day as needed for muscle spasm.
CR|controlled release|CR|307|308|CURRENT MEDICATIONS|She has had treatment in the past for uterine or cervical cancer with radiation treatment and with hysterectomy approximately 15 years ago. She had tonsillectomy as a child. CURRENT MEDICATIONS: Include labetalol at 100 mg twice daily, Lisinopril 20 mg daily, Lipitor 40 mg daily, Plavix 75 mg daily, Paxil CR 25 mg daily, tamoxifen 10 mg daily, Fosamax 70 mg weekly, Viactiv once daily, Vioxx once daily, and one-half of a double strength Septra tablet daily for history of recurrent urinary tract infections.
CR|controlled release|CR|135|136|DISCHARGE MEDICATIONS|The patient should continue taking his magnesium oxide as outpatient. DISCHARGE MEDICATIONS: 1. Allopurinol 100 mg daily. 2. Diltiazem CR 180 mg p.o. twice daily. 3. Fosamax 70 mg p.o. weekly. 4. Lasix 20 mg p.o. q.a.m. 5. Lisinopril 5 mg p.o. daily. 6. Senna 8.5 mg p.o. b.i.d. as needed for constipation.
CR|cardiorespiratory|CR|190|191|* UTI|Caffeine therapy was begun on _%#MMDD2007#%_, and discontinued on _%#MMDD2007#%_. She also received 5 days of aminophylline therapy following further apneic spells, ending _%#MMDD2007#%_. A CR scan was performed on _%#MMDD2007#%_, which showed continued apneic spells and desaturations. A second CR scan was performed _%#MMDD2007#%_, and was normal.
CR|cardiorespiratory|CR|243|244|* GU|_%#NAME#%_ will also be followed by the infant apnea program at Children's Hospital Clinics of _%#CITY#%_ _%#CITY#%_ and will be eventually weaned to a prone position after feedings. Discharge medications, treatments and special equipment: 1. CR monitor 2. Reglan 0.15 mg q6 hr 3. Zantac 3.5 mg q12 hr 4. FeSO4 5mg po q24 hr 5. Caffeine 5mg po q24 hr _%#NAME#%_ is a good candidate to receive Synagis during the upcoming RSV season.
CR|controlled release|CR|138|139|MEDICATIONS|9. Metoprolol 25 mg p.o. b.i.d. 10. Amlodipine 10 mg p.o. daily. 11. Tylenol Extra Strength 500 mg p.o. p.r.n. 12. Isosorbide mononitrate CR 50 mg p.o. daily. 13. Nexium 40 mg p.o. p.r.n. 14. Bactrim DS 1 tab p.o. b.i.d. x 7 days. Five doses remaining. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient previously lived alone in a townhouse, but recently moved in with her daughter.
CR|controlled release|CR|181|182|DISCHARGE MEDICATIONS|7. Multivitamin 1 p.o. each day. 8. Pancreacarb MS-8 40-88-45-MU 8 to 10 tablets with meals each day. 9. Prevacid 15 mg p.o. each day. 10. Reglan 1 tablet p.o. t.i.d. 11. Vitamin C CR 500 mg 1 tablet p.o. b.i.d. 12. Vitamin E 400 International Units 1 tablet p.o. each day. 13. Vitamin E 5 mg 1 tablet p.o. once per week.
CR|controlled release|CR|144|145|ADMISSION MEDICATIONS|6. Lorazepam 0.5 mg. Take 1-3 daily/p.r.n. 7. Mucinex 600 mg. Take 1 tab daily. 8. Paxil 10 mg daily. 9. Spiriva 1 puff daily. 10. Theophylline CR 300 mg daily. 11. Trazodone 150 mg q. h.s. ALLERGIES: PENCILLIN; BIAXIN; MORPHINE; MRI BYE. SOCIAL HISTORY: Patient was living at home alone in a rental apartment.
CR|controlled release|CR|200|201|DOB|The patient has not been on chronic prednisone recently. The patient does have a history of hypertension. Her medications at present include: 1. monopril 40 mg daily, 2. Aricept 10 mg daily, 3. Paxil CR 12.5 mg daily, 4. folic acid 1 mg daily, 5. BuSpar 10 mg t.i.d., 6. potassium chloride 10 mEq b.i.d., 7. hydrochlorothiazide 12.5 mg daily, 8. Risperdal 0.25 mg daily h.s., 9. ranitidine 150 mg daily, 10. calcium 500 mg two tablets daily, 11. trazodone 50-mg strength 1-1/2 pills h.s., and 12. a question of whether she has been on some oral steroids.
CR|controlled release|CR|158|159|MEDICATIONS|3. Combivent 2 puffs q.i.d. 4. Ferrous gluconate 300 mg q. day. 5. Fish oil 1000 mg 3 times a day. 6. Furosemide 40 mg twice daily. 7. Isosorbide mononitrate CR 30 mg q. day. 8. Multivitamin with iron 1 tablet q. day. 9. Os-Cal D 1 tablet q. day. 10. Omeprazole 20 mg q. day.
CR|controlled release|CR|152|153|MEDICATIONS|4. Amitriptyline each day at bedtime, dose not determined as yet. 5. Neurontin 200 mg p.o. each day at bedtime. 6. Lisinopril 5 mg p.o. daily. 7. Paxil CR 25 mg p.o. daily. 8. Actos 30 mg p.o. daily. 9. Propranolol 20 mg p.o. daily. 10. Neurontin 100 mg p.o. each a.m. 11. Keflex 500 mg p.o. q.i.d. which has been scheduled for an additional 2 days.
CR|cardiorespiratory|CR|142|143|PAST MEDICAL HISTORY|The patient was discharged home on a cardiorespiratory monitor for 7 weeks and had only a single desaturation episode during the 7 weeks. The CR monitor was discontinued after that and he has had no subsequent problems. He was initially treated with Prilosec and Reglan for the reflux as well as reflux precautions, including a _%#NAME#%_ _%#NAME#%_.
CR|controlled release|CR|122|123|ADMISSION MEDICATIONS|29. Chronic pain. She has been visiting the pain clinic since 1997 for neuropathic pain. ADMISSION MEDICATIONS: 1. Ambien CR 10 mg p.o. daily at bedtime. 2. Ativan one tablet p.o. t.i.d. p.r.n. 3. Claritin 5 mg one tablet p.o. daily. 4. Coumadin. This was stopped on Friday. This has been taken as directed by her primary-care physician.
CR|complete remission|CR|310|311|IMPRESSION|IMPRESSION: 22-year-old male with history of stage IVB nodular sclerosing Hodgkin's lymphoma, status post one cycle of ABVD and five cycles of chemotherapy per protocol AHOD _%#PROTOCOL#%_, which consisted of ABVE, prednisone, and Cytoxan. The patient completed chemotherapy 2-1/2 weeks ago and has achieved a CR via PET scan, but remains with some residual on CT scan. The patient presents today for the possibility of radiation therapy.
CR|controlled release|CR|119|120|HOME MEDICATIONS|HOME MEDICATIONS: 1. Clonopin 0.5 mg p.o. t.i.d. 2. Prozac 60 mg p.o. q. a.m. 3. Seroquel 25 mg p.o. q. h.s. 4. Ambien CR 12.5 mg p.o. q. h.s. 5. Dilaudid 4 mg p.o. q. 6 hours. HOSPITAL MEDICATIONS: 1. Initiation on _%#MMDD2006#%_, Fentanyl patch 25 mcg q. 72 hours topically.
CR|controlled release|CR|262|263|PRESENT MEDICATIONS;|4. Marshall-Marchetti procedure. 5. Cholecystectomy. Without known heart disease, diabetes, asthma, hypertension, renal disease, documented peptic ulcer disease, hepatitis, seizure or tuberculosis. MEDICATION ALLERGIES: None known. PRESENT MEDICATIONS; 1. Paxil CR 75 mg q.h.s. 2. Nicoderm 21-mg patch. 3. Neurontin 800 mg q.i.d. 4. Lidoderm patch 5%, maximum of 3 patches, 12 hours on, 12 hours off.
CR|controlled release|CR|146|147|PRESENT MEDICATIONS|7. Tetracycline 500 mg b.i.d. 8. Levothroid 75 micrograms q. day. 9. Xanax 2 mg q.i.d. 10. Maxzide one daily. 11. Prevacid 30 mg b.i.d. 12. Paxil CR 37.5 mg two at h.s. 13. Clonidine 0.1 mg 1/2 at h.s. for vasomotor instability. 14. Ambien 5 mg two at h.s. 15. Seroquel 100 mg three at h.s.
CR|controlled release|CR|213|214|CURRENT MEDICATIONS|1. Sulfa. 2. Thorazine. 3. Erythromycin. CURRENT MEDICATIONS: 1. Extra Strength Tylenol q.6h p.r.n. 2. Lidoderm patch to her ankles p.r.n. ankle pain. 3. Metoprolol extended release25 mg p.o. q. day. 4. Oxycodone CR 10 mg p.o. q.12h. 5. Protonix 20 mg p.o. b.i.d. 6. Miralax p.r.n. 7. Compazine 10 mg IV q.6h p.r.n. 8. Maxalt 5 mg p.o. for migraine headache q.2h. p.r.n.
CR|controlled release|CR|148|149|MEDICATIONS ON TRANSFER|This was held starting _%#MMDD#%_. 13. Prilosec 40 mg p.o. daily. 14. Actos 15 mg p.o. daily. 15. Duonebs q.i.d. 16. Celexa 30 mg daily. 17. Niacin CR 500 mg p.o. daily. 18. Atenolol 100 mg p.o. daily. 19. Lipitor 80 mg p.o. daily. 20. Multivitamins 1 p.o. q. day. 21. Gemfibrozil 600 mg p.o. b.i.d.
CR|controlled release|CR|279|280|1. HISTORY|She has a history of hypercholesterolemia, hypothyroidism, lymphedema of the left upper right arm, pseudomonas pneumonia in 2002, pleurodesis was attempted on the right MEDICATIONS AT The TIME OF ADMISSION INCLUDE: 1. Protonix 40 mg per day 2. Synthroid 0.88 mg per day 3. Paxil CR 12.5 mg per day 4. Crestor 20 mg per day 5. Lasix 20 mg per day 6. Temazepam 15 mg at h.s. 7. Neurontin 300 mg p.o. t.i.d. for neuropathy 8. Potassium chloride 10 mEq. p.o. b.i.d.
CR|controlled release|CR|146|147|PRESENT MEDICATIONS|PRESENT MEDICATIONS: 1. Prevacid 30 mg daily. 2. Multivitamin daily. 3. Vistaril 150 mg q.h.s. 4. Valium 20 mg q.h.s., with 10 mg q.a.m. 5. Paxil CR 25 mg b.i.d. 6. Ativan 1 to 2 mg p.o. q.1-2 h. p.r.n. acute anxiety/agitation. FAMILY HISTORY: Remarkable for heart disease and diabetes.
CR|complete remission|CR|208|209|HPI|Additionally, a PET scan showed uptake in multiple lymph nodes in the bilateral lower neck, supraclavicular area, and posterior mediastinum. He underwent four cycles of chemotherapy responding quickly with a CR after two cycles. He is PET-negative now. He is referred for discussion regarding adjuvant radiotherapy. He was initially on COG protocol AHOD _%#PROTOCOL#%_, and is eligible to be randomized either to involved-field radiotherapy or not, but because of the family preferences he has decided not to be randomized and instead is going ahead with the involved-field radiation.
CR|controlled release|CR|148|149|MEDICATIONS|2. Requip 1 mg t.i.d. 3. Premarin 0.625 mg daily. 4. Prevacid 30 mg daily. 5. Hydrochlorothiazide 12.5 mg daily. 6. Aspirin 325 mg daily. 7. Ambien CR 12.5 mg at bedtime. 8. Omeprazole 20 mg b.i.d. (?) 9. Flexeril 10 mg t.i.d. 10. Ciprodex ear solution 3 drops left ear daily. 11. Cymbalta 60 mg daily.
CR|controlled release|CR|243|244|MEDICATIONS ON ADMISSION|The patient denies PND, orthopnea, or peripheral edema. ALLERGIES: None known. MEDICATIONS ON ADMISSION: Prempro 0.625/2.5 mg q.d., Celexa 40 mg q.d., Toprol XL 100 mg q.d., Prevacid 30 mg q.d., aspirin 81 mg q.d., Lipitor 40 mg q.h.s., Paxil CR 12.5 mg q.d., Levoxyl 125 mcg p.o. q.d., Plavix 75 mg q.d., oxaprozin 600 mg, 2 tablets after breakfast; Imdur 60 mg q.d., and 75/25 Humulin 30 units b.i.d. with sliding scale insulin as well.
CR|controlled release|CR.|167|169|STATUS AT DISCHARGE|She will continue to take Coumadin tablets for another 3 weeks. The patient was also put on the following pain medications for pain control: 1. Vistaril. 2. Oxycodone CR. PLAN: We plan to see this patient at 4 weeks from now in the ortho clinic.
CR|controlled release|CR|162|163|MEDICATIONS|She has never been pregnant. Works as a computer software support engineer. Does not smoke, drinks very little alcohol. MEDICATIONS: Cymbalta 60 mg daily, Ambien CR 12.5 mg nightly, over-the-counter analgesics. REVIEW OF SYSTEMS: Remarkable primarily for the abdominal problems, intermittent swelling in hands and feet with minimal trauma.
CR|controlled release|CR.|199|201|MEDICATIONS|PAST MEDICAL HISTORY: Anxiety. PAST SURGICAL HISTORY: Cesarean section. PRENATAL COURSE: Complicated by placenta previa, severe constipation, insomnia and anxiety. MEDICATIONS: 1. Zelnorm. 2. Ambien CR. ALLERGIES: Codeine leads to nausea. HOSPITAL COURSE: On _%#MMDD#%_, the patient presented for amniocentesis. A nonstress test was reactive.
CR|controlled release|CR|168|169|TRANSFER MEDICATIONS|2. Azmacort 3 puffs p.o. t.i.d. 3. Multivitamin liquid 1 p.o. q.d. 4. Estratest (1.25/2.5) 1 tablet p.o. q.d. for hormone replacement. 5. Sinemet CR 25/100 and Sinemet CR 50/200, 1 of these tablets p.o. t.i.d. 6. Trazodone 150 mg p.o. q.h.s. 7. BuSpar 50 mg p.o. q.a.m. 8. Neurontin 300 mg q.h.s. 9. Colace liquid 100 mg p.o. b.i.d.
CR|controlled release|CR.|168|170|IMPRESSION|1. UHH05-1067 (_%#MMDD2005#%_): 1% blasts with foci of hemophagocytosis. 2. UC05-974 (_%#MMDD2005#%_): CSF - negative for malignancy. IMPRESSION: ALL with HLH in first CR. RECOMMENDATIONS: _%#NAME#%_ _%#NAME#%_ is a good candidate for consideration of double cord transplantation.
CR|controlled release|CR|177|178|HPI|__x___ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Limited small-cell lung cancer. HPI: S/P CT/RT with CR Exam: Lungs clear, SC nodes negative, CN II-XII intact Assessment and Plan: We have offered prophylactic cranial irradiation.
CR|complete remission|CR|184|185|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Extensive small-cell lung cancer HPI: Status post CT now in CR Exam: Lungs clear, no neurologic deficits. Assessment and Plan: We have offered PCI, but have explained that this is to decrease the likelihood of further brain failure, not to influence survival.
CR|complete remission|CR|140|141|HPI|Assessment and Plan: Limited stage SCLC. I recommend radiotherapy to decrease recurrence and extend survival. I would also consider PCDI if CR after combined modality therapy.
CR|complete remission|CR.|193|195|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Limited stage small-cell lung cancer. HPI: Status post chemo/RT with CR. Exam: Lungs clear. No SC node palpated. Assessment and Plan: We have offered the patient PCI.
CR|controlled release|CR|167|168|MEDICATIONS|2. Fatty tumor removed with surgery in 90s. 3. Right knee arthroscopy in 1997 and 1998. 4. Hypertension, on treatment since 2002. MEDICATIONS: Avapro 150 a day, Paxil CR 12.5 a day. HEALTH HABITS: Smokes six cigarettes a day, alcohol minimal. SOCIAL HISTORY: She is married.
CR|complete remission|CR.|199|201|IMPRESSION|LABORATORY DATA: Hemoglobin 10.7, white count 5.8, platelets 120,000. Creatinine 1.32. PATHOLOGY: UHR05-269 (_%#MMDD2005#%_): AML. (_%#MMDD2005#%_): No evidence of leukemia. IMPRESSION: AML in first CR. RECOMMENDATIONS: I would agree that _%#NAME#%_ _%#NAME#%_ is a good candidate for consideration of non-myeloablative mini prep transplant as per our protocol _%#PROTOCOL#%_.
CR|controlled release|CR|228|229|MEDICATIONS ON ADMISSION|Also, Dr. _%#NAME#%_, a gynecologic oncologist was consulted to examine the vulva under anesthesia and performed an excision as necessary. Prior to admission, the patient was reasonably healthy. MEDICATIONS ON ADMISSION: Ambien CR 12.5 mg p.o. each day at bedtime. ALLERGIES: Codeine. On admission her CBC and potassium were obtained.
CR|controlled release|CR|107|108|MEDICATIONS|DISCHARGE DIAGNOSIS: Acute alcoholic intoxication with alcohol withdrawal. DISCHARGE MEDICATIONS: 1. Paxil CR 25 mg p.o. q.d. 2. Singulair 10 mg p.o. q.d. 3. Advair 500/50, one puff b.i.d. 4. Albuterol MDI two puffs q. 4-6h. p.r.n.
CR|complete remission|CR.|249|251|HISTORY OF PRESENT ILLNESS|She was found to have standard risk ALL and was treated per CCG protocol and achieved a complete remission. In _%#MM1999#%_, she relapsed in the bone marrow 2-1/2 years after transplant and was treated per the New York protocol and again achieved a CR. In 2002, she relapsed again 1-1/2 years after her last relapse and was re- induced achieving a third CR.
CR|controlled release|CR|308|309|DISCHARGE INSTRUCTIONS|She was afebrile. Blood pressure 102/59. The patient was then discharged on _%#MMDD2004#%_. DISCHARGE INSTRUCTIONS: Activity as tolerated. Medications - prednisone 20 mg one tablet daily for three days and then 10 mg one tablet daily for three days and then stop, Seroquel 50 mg one tablet at bedtime, Paxil CR 25 mg one tablet daily, Zyprexa 5 mg one tablet in the A.M. and 5 mg one tablet at 6:00 P.M. and 5 mg two tablets at bedtime, lorazepam 0.5 mg one to two tablets four times as needed for anxiety.
CR|controlled release|CR|155|156|MEDICATIONS|8. Paxil 20 mg in the morning 9. Prevacid 30 mg in the morning 10. Vitamin E 11. B12 shot every four weeks 12. Meclizine as needed for vertigo 13. Sinemet CR 25/100 at bedtime ALLERGIES: No medication allergies. SOCIAL HISTORY: The patient is a retired policeman and lives at home with his wife.
CTA|computed tomographic angiography|CTA.|149|152|FINAL DIAGNOSES|6. Folic acid 1 tab daily. 7. Imodium p.r.n. 8. Multivitamin 1 daily. 9. Percocet p.r.n. FINAL DIAGNOSES: 1. Infrarenal aortic plaque dissection. a. CTA. b. Aortobiiliac bypass graft. 2. Calcified splenic artery aneurysm. a. Excision with primary end-to-end anastomosis. 3. History of paroxysmal atrial fibrillation with chronic Coumadin anticoagulation and pacemaker.
CTA|computed tomographic angiography|CTA|92|94|IMAGES|He has a very slow unsteady finger-to-nose test and poor trunk stability. IMAGES: Reviewed. CTA from the outside hospital demonstrates a 1.3 cm aneurysm at the bifurcation of the left internal carotid artery as well as bilateral hygroma extending from the frontal to the occipital lobe.
CTA|clear to auscultation|CTA.|139|142|PHYSICAL EXAMINATION|SKIN: Dry and warm. HEENT: Head without trauma. Pupils round, react to light Mouth appears normal. NECK: A neck collar is in place. LUNGS: CTA. HEENT: regular rate and rhythm, no murmurs. ABDOMEN: Soft, bowel sounds positive, nontender. EXTREMITIES: No edema. Moving all extremities.
CTA|clear to auscultation|CTA,|260|263|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Weight 45.7 kg, temperature 99.3, pulse 109 to 120, respiratory rate 20, blood pressure 113 to 120/57 to 83. CARDIOVASCULAR: Heart sounds were regular with a loud split S2 and tachycardia; no murmurs were appreciated. LUNGS: CTA, normal I:E ratio. EXTREMITIES: Revealed mild sclerodactyly. LABORATORY DATA: The patient has on _%#MMDD2004#%_ a hemoglobin of 11.7, hematocrit 34.5, white blood cell count 6.2, platelets 255, INR 1.12, AST 428, ALT 152, alkaline phosphatase 82.
CTA|clear to auscultation|CTA|191|193|HOSPITAL COURSE|Postoperatively, patient was managed on unit 6C. She remained n.p.o. on postoperative day 1. On postoperative day 2, it was noted that patient had a temperature of 101.2 and was tachycardic. CTA of the chest revealed a large clot in the IVC. Due to patient's fever and tachycardia, she was transferred to the surgical intensive care unit.
CTA|clear to auscultation|CTA.|211|214|FAMILY HISTORY|FAMILY HISTORY: Noncontributory. A well-nourished Caucasian female looking younger that her age in no acute distress. HEENT: Sclerae nonicteric. Oral mucosa moist. Neck is supple. Respirations unlabored. Lungs: CTA. CV: RRR, S1, S2, no murmur. Abdomen: Positive bowel sounds, soft and nontender to palpation. Extremities: The right knee incision shows some yellowing ecchymosis, with area lateral to the knee decreasing in ecchymotic size, incision clean, dry, and intact.
CTA|computed tomographic angiography|CTA|273|275|BRIEF HISTORY|REASON FOR ADMISSION: Laparoscopic left donor nephrectomy. BRIEF HISTORY: The patient is a 50-year-old male who wishes to donate his kidney to his sister-in-law. He denies any medical contraindications to transplantation. He had a normal exercise cardiac stress test and a CTA of the kidneys demonstrated single arteries, veins, and ureters on both right and left kidneys. We, therefore, elected proceed with a left hand-assisted donor nephrectomy.
CTA|clear to auscultation|CTA|143|145|OBJECTIVE|Posterior pharynx is pink and moist without lesions or exudate. Neck Exam: Supple. Full range of motion. No adenopathy, no thyromegaly. Lungs: CTA bilaterally. CV: RRR without murmur, gallop or rub. Abdomen: Positive bowel sounds, soft, nontender, nondistended, no hepatosplenomegaly. Extremities: Warm with good perfusion.
CTA|clear to auscultation|CTA.|197|200|PHYSICAL EXAMINATION|HEAD, EYES, EARS, NOSE AND THROAT: Shows his head to be normocephalic, atraumatic. Ears are clear. Nasal passages are patent. Oropharynx - no lesions. NECK: No nodes, thyromegaly or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs, gallops or clicks. ABDOMEN: Is soft, non-tender without masses or organomegaly GENITOURINARY: Exam was deferred.
CTA|clear to auscultation|CTA|189|191|PHYSICAL EXAMINATION|On exam, afebrile, 68 pulse, 16 respirations, blood pressure 92/54, T-max 100 degrees Fahrenheit, 94% O2 SAT on room air. Alert, oriented. Skin: Normal temperature. HEENT: Dry lips. Chest: CTA bilaterally. CVS: No murmurs. Abdomen: Soft, nontender, bowel sounds were heard. Extremities: Pedal edema was noted. LABS: That were significant were occult blood was positive x 2.
CTA|clear to auscultation|CTA|162|164|OBJECTIVE|Funduscopic exam with sharp disks, normal vasculature. Posterior oropharynx __________. Neck: Supple, full range of motion, no adenopathy, no thyromegaly. Lungs: CTA bilaterally. Cardiovascular: Regular rate and rhythm without murmur, rub or gallop Abdomen: Positive bowel sounds, soft, non-tender, non- distended.
CTA|clear to auscultation|CTA|261|263|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 122/74, pulse 97, respiratory rate 12, O2 sat 96%, temp 99.4. GENERAL: The patient is a pleasant male in no acute distress. HEENT: PERRL, conjunctivae clear. OP with moist mucous membranes. NECK: Supple. LUNGS: CTA bilaterally. HEART: Regular rate and rhythm; no murmur. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: Left lower extremity with no edema and intact pedal pulses.
CTA|clear to auscultation|CTA|210|212|PHYSICAL EXAMINATION|GENERAL: When I saw the patient on the floor she was lying in her hospital bed. She would open her eyes, but did not respond verbally otherwise. HEENT: PERRL. OP very dry mucous membranes. NECK: Supple. LUNGS: CTA bilaterally. HEART: RRR, no murmur. ABDOMEN: Soft and seemed to be tender to palpation as she did groan a bit with abdominal examination.
CTA|clear to auscultation|CTA|206|208|PHYSICAL EXAMINATION|VITAL SIGNS: Weight 211 pounds, temperature 97.3; blood pressure 134/80; pulse 78; respiratory rate 16. HEENT: Head was normocephalic, otherwise unremarkable. NECK: No adenopathy or masses detected. LUNGS: CTA bilaterally. HEART: Regular rate and rhythm; no rubs or murmurs; normal S1, S2, no s3. GENITAL/RECTAL: Deferred. EXTREMITIES: Unremarkable. ASSESSMENT: 1. History of true vocal cords squamous cell carcinoma.
CTA|clear to auscultation|CTA.|196|199|EXAM ON ADMISSION   GENERAL|NECK: No lymphadenopathy or thyromegaly. SKIN : Skin and cheeks were flushed, no rashes. Warm and dry. CARDIOVASCULAR: RRR, no murmurs. Mild tenderness to palpation at mid to last sternum. LUNGS: CTA. ABDOMEN: Positive bowel sounds, WNL, soft, central epigastric tenderness to palpation. No CVA tenderness. NEUROLOGIC: Alert and oriented x3. No focal deficits.
CTA|computed tomographic angiography|CTA|237|239|OPERATIONS/PROCEDURES PERFORMED|OPERATIONS/PROCEDURES PERFORMED: 1. MRI/MRA of the brain was performed which showed evidence of a cerebrovascular infarction in the PICA distribution involving the right cerebellum. 2. MRA which did not show evidence of dissection. 3. A CTA to rule out vertebral artery dissection. There was no evidence vertebral artery dissection on CTA. 4. Transesophageal echocardiogram which revealed a patent foramen ovale.
CTA|computed tomographic angiography|CTA.|153|156|OPERATIONS/PROCEDURES PERFORMED|2. MRA which did not show evidence of dissection. 3. A CTA to rule out vertebral artery dissection. There was no evidence vertebral artery dissection on CTA. 4. Transesophageal echocardiogram which revealed a patent foramen ovale. 5. Bilateral lower extremity Dopplers which did not show any evidence of deep venous thrombosis.
CTA|computed tomographic angiography|CTA|206|208|HOSPITAL COURSE|Hypercoagulability labs were drawn on this patient. Given the patient's age and location of infarction, a basilar artery dissection was very concerning. His initial MRI did not contain an MRA. Therefore, a CTA was obtained which raised the question of whether or not there may be dissection within the right vertebral artery causing the infarction.
CTA|clear to auscultation|CTA|234|236|PHYSICAL EXAMINATION|EARS: TMs are obscured with cerumen. THROAT: Oropharynx is clean without exudate, some erythema. Mucous membranes are dry. NECK: No lymphadenopathy or thyromegaly. CARDIO-VASCULAR: 2/6 systolic murmur, regular rate and rhythm. LUNGS: CTA bilaterally, no crackle, wheeze or rhonchi. Slight decreased sounds in the right lower field, but slight decreased air movement over the right lower lobe field.
CTA|clear to auscultation|CTA|297|299|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: On admission, temperature 97.5, pulse 104, blood pressure 149/93, respirations 16, O2 sat 97%. GENERAL: He is awake, confused, NC/AT. Eyes: conjunctival injection with crusting. Oropharynx with older/eroded dentition. CARDIOVASCULAR: Irregular irregular. LUNGS: CTA anteriorly. NECK: Without JVD. ABDOMEN: Soft; non-tender; non- distended. Bowel sounds were present. LYMPHATICS: Without peripheral edema. NEURO: Grossly intact. LABORATORY ON ADMISSION: White count 1.2, hemoglobin 11.7, absolute neutrophils 0.6, absolute lymphocytes 0.4. Complete metabolic panel, sodium 135, potassium 3.5, chloride 106, CO-2 26.
CTA|computed tomographic angiography|CTA|154|156|HOSPITAL COURSE|He underwent MRI with MRA which did not reveal any aneurysms or structural abnormalities that could account for his headache. The patient then also had a CTA which do not reveal any structural or aneurysmal problems. The patient was treated with IV methylprednisolone x1 which again did not resolve the patient's headache.
CTA|clear to auscultation|CTA.|167|170|PHYSICAL EXAMINATION|The patient is afebrile. EARS: Are grossly normal. EYES: EOMI, PERRLA. Nasal passages are clear. Oropharynx is negative. NECK: No nodes, thyromegaly or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs, gallops or clicks. ABDOMEN: Is soft, non-tender without masses. GENITOURINARY: Exam was deferred.
CTA|clear to auscultation|CTA|224|226|EXAMINATION|Throat does show poor dentition. Receding gums. Mouth and throat otherwise okay. No obvious back or flank tenderness. No cervical, supraclavicular, axillary, or inguinal adenopathy. Carotids equal. No obvious bruits. LUNGS: CTA throughout at this time. HEART: RRR. No click, murmur, or extra sounds noted. ABDOMEN: Soft, nontender. No masses. Normal bowel sounds. No hepatosplenomegaly. EXTREMITIES: Reflexes - Biceps and patella were 2+ and equal with good strength, flexion and extension feet, legs, and hands.
CTA|clear to auscultation|CTA.|146|149|PHYSICAL EXAM|Respirations 20, pulse 80. No acute distress. HEENT: NCAT. Ears are normal. Oropharynx is negative. NECK: No nodes, thyromegaly or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs, gallops, or clicks. ABDOMEN: Soft with some mild mid epigastric discomfort. No rebound, guarding, masses, or HSM was noted. GU exam was deferred.
CTA|clear to auscultation|CTA.|134|137|PHYSICAL EXAM ON ADMISSION|TMs, EACs are clear. EOMI. PERRLA. Nasal passages are clear. Oropharynx is negative. NECK: No nodes, no thyromegaly or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs, gallops, or clicks. ABDOMEN: Morbidly obese without what I could were any masses or organomegaly, although his exam is extremely difficult secondary to his weight.
CTA|clear to auscultation|CTA.|154|157|PHYSICAL EXAMINATION ON ADMISSION|HEAD is normocephalic, atraumatic. Ears are normal. EOMI, PERRLA. Nasal passages are clear. Oropharynx is negative. NECK: No nodes or thyromegaly. CHEST: CTA. CORONARY: Regular rate with a grade I/VI low- pitched systolic murmur heard beast at the lower left sternal border. A little bit of radiation up the left sternal border and maybe a little bit towards the mid clavicular line.
CTA|clear to auscultation|CTA.|132|135|PHYSICAL EXAMINATION|EARS: Grossly normal. EOMI, PERRLA. Nasal passages are clear. Oropharynx is negative. NECK: No nodes, thyromegaly or bruits. CHEST: CTA. CORONARY: Regular rate, occasional irregular beat. He is still up and around 150 with his heart rate. ABDOMEN: Is soft, non-tender without masses or organomegaly. GENITOURINARY: Exam was deferred.
CTA|clear to auscultation|CTA.|192|195|INITIAL EXAMINATION|Her nasal passages are clear. Oropharynx shows no teeth on the lower and her own teeth upper. She has tried dentures in the past without success. NECK: No nodes, thyromegaly or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs, gallops or clicks. ABDOMEN: Is soft, non-tender except in the right lower quadrant where she has mild tenderness.
CTA|clear to auscultation|CTA|222|224|ALLERGIES|ALLERGIES: None. PHYSICAL EXAMINATION: Reveals an alert and oriented female in no acute distress. The head exam is normocephalic. ENT-the mouth is moist, large tonsils. The neck is no adenopathy, euthyroid. Respiratory is CTA bilaterally. Cardiovascular is regular rate and rhythm, no murmurs, rubs, or gallops. The abdomen is soft, nontender, and nondistended, positive bowel sounds, no masses.
CTA|clear to auscultation|CTA|145|147|ALLERGIES|PHYSICAL EXAMINATION: Temperature 97.6, BP 146/82, pulse 100 and regular. Skin: Normal. HEENT: Normal. Neck: Normal. Heart: RRR. Distant. Lungs: CTA bilaterally. Abdomen: Soft, obese, nontender. No palpable masses. Extremities: Massive edema. Neuro: Grossly intact. STUDIES: EKG: Sinus rhythm with nonspecific intraventricular conduction delay.
CTA|clear to auscultation|CTA|210|212|ALLERGIES|ADMISSION MEDICATIONS: 1. Lorazepam. 2. Lipitor. 3. Hydroxyzine. 4. Paxil. ALLERGIES: NKDA. REVIEW OF SYMPTOMS: Was negative. PHYSICAL EXAMINATION: Temperature 98.7, BP 142/102, pulse 94, respirations 20. RRR. CTA bilaterally. LABORATORY: Hemoglobin 13.8. Potassium 4.9. Platelets 282,000. EKG was normal. ASSESSMENT: A 53-year-old, morbidly obese female presenting for VBG surgery.
CTA|clear to auscultation|CTA|212|214|PHYSICAL EXAMINATION|ALLERGIES: Codeine and penicillin. PHYSICAL EXAMINATION: Blood pressure 125/68, pulse 83, respirations 16, temperature 98. HEENT: PERRLA. Thyroid nonpalpable. Cardiovascular: RRR, S1 and S2. No MRG. Lungs: Clear CTA bilaterally. Abdomen: Nontender, nondistended. Extremities: 1+ edema in the lower legs bilaterally. Positive distal pulses. No rashes. LABS ON ADMISSION: Sodium 139, potassium 3.5, chloride 107, bicarb 20, BUN 19, creatinine 0.6, glucose 177, white count 11.4, hemoglobin 11.5, crit 33.5, platelet count 44,000.
CTA|clear to auscultation|CTA|210|212|HISTORY OF PRESENT ILLNESS|General: Pleasant woman, NAD, comfortable. HEENT: Eyes injected sclerae, PERRL. Oropharynx moist. One small benign appearing submandibular lymph node. Neck: Supple. Cardiovascular: RRR, split S2 normal. Lungs: CTA bilaterally. Abdomen: Soft, active, high pitched bowel sounds. Minimal tenderness to palpation. The patient has a subcutaneous calcified mass not fixed to deeper plains.
CTA|clear to auscultation|CTA|178|180|PHYSICAL EXAMINATION|GENERAL: In no acute distress, comfortable in bed. HEENT: Normocephalic, atraumatic. NECK: Supple. No lymphadenopathy. CARDIOVASCULAR: Regular rate and rhythm, S1 and S2. LUNGS: CTA bilaterally. No wheezing, no crackles. ABDOMEN: Soft, nontender, and nondistended. Mild diffuse tenderness with negative bowel sounds. Negative CVA tenderness.
CTA|clear to auscultation|CTA.|233|236|PHYSICAL EXAMINATION|HEAD, EYES, EARS, NOSE AND THROAT: NC/AT. Tympanic membranes are occluded on the right with cerumen and clear on the left. EOMI, PERRLA. Nasal passages are clear. Oropharynx is negative. NECK: No nodes, thyromegaly or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs. Paced rhythm. ABDOMEN: Is soft, non-tender without masses or organomegaly. GENITOURINARY: Exam shows normal female. EXTREMITIES: With some swelling in both the ankles.
CTA|clear to auscultation|CTA|141|143|PHYSICAL EXAMINATION|He smells of urine. . HEENT: The patient's halo apparatus is intact, PERRL, OP with dry mucous membranes. NECK: Stabilized with halo. LUNGS: CTA bilaterally. HEART: RRR no murmur. ABDOMEN: Soft; nontender; non-distended. EXTREMITIES: Bilateral lower extremities without edema. NEURO: Grossly non-focal. SKIN: The patient's back and buttocks with extensive Stage I pressure ulcers and papulopustular changes.
CTA|clear to auscultation|CTA|127|129|PHYSICAL EXAMINATION|HEENT: PERRLA, EOMI. No JVD. Oral mucosa is normal. HEART: S1, S2 normal. Systolic murmur, 3/6, regular rate and rhythm. LUNG: CTA no wheezing, no rales. ABDOMEN: Right tenderness in right upper quadrant. No rebound tenderness. Bowel sounds are present. GENITOURINARY: No CVA tenderness. NEUROLOGIC: Cranial nerves II through XII are grossly intact.
CTA|clear to auscultation|CTA|154|156|VITAL SIGNS|HEENT: Head is atraumatic. Oropharynx: Mucous membranes are moist, no erythema. NECK: Supple without lymphadenopathy. CARDIOVASCULAR: RRR. No MRG. LUNGS: CTA bilaterally. ABDOMEN: Bowel sounds present. Soft, moderate tenderness in right lower quadrant. No guarding. No rebound. No Murphy. SPINE: Without CVA tenderness.
CTA|clear to auscultation|CTA|176|178|PHYSICAL EXAMINATION|EOM intact. Mucous membranes moist with good dentition. No oropharyngeal erythema. LYMPHATICS: No supraclavicular, cervical, axillary or inguinal lymphadenopathy. RESPIRATORY: CTA bilaterally. BREASTS: No masses. Nontender. No nipple discharge. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Soft, nontender and slightly obese. Active bowel sounds. Well healed cholecystectomy incision.
CTA|computed tomographic angiography|CTA|269|271|HISTORY OF PRESENT ILLNESS|She was seen on _%#MMDD2006#%_ by Rheumatology who recommended a temporary biopsy, which was never done, but the primary team did notice some right pupil myosis and possible right ptosis as well, which was concerning for Horner syndrome in their estimation. An MRI and CTA were ordered and neurology was involved at that point. The result of these studies was that a right carotid artery stenosis versus dissection at the petrous portion of the right internal carotid artery was thought to present.
CTA|UNSURED SENSE|CTA.|81|84|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Pneumonia. 2. Dehydration. 3. Status fall with increased CTA. 4. Hypertension. 5. Degenerative joint disease. 6. Reactive airway disease. HISTORY OF PRESENT ILLNESS: An 84-year-old male who has fallen at home, general weakness, dehydration.
CTA|clear to auscultation|CTA.|153|156|PHYSICAL EXAMINATION|HEENT: NCAT. Tympanic membranes are clear. Nasal passages are clear. EOMI. PERRLA. Oropharynx is negative. Neck: No nodes, thyromegaly or bruits. CHEST: CTA. COR: Regular rate without murmurs. The patient is bradycardic. ABDOMEN: Soft and nontender without masses or organomegaly. GU: Deferred.
CTA|clear to auscultation|CTA|144|146|PHYSICAL EXAMINATION|Head normocephalic, atraumatic. His neck was supple. No JVD, no carotid bruits. CARDIOVASCULAR: Regular rhythm. A II/VI systolic murmur. LUNGS: CTA bilaterally. No wheezing, no crackles. ABDOMEN: Positive bowel sounds, soft. Tender over the left lower quadrant extending to the left flank.
CTA|clear to auscultation|CTA|202|204|PHYSICAL EXAMINATION|GENERAL: The patient is a pleasant male who is in obvious distress with any type of motion. HEENT: PERRL, conjunctivae clear, OP dry mucous membranes and dentures both up and down. NECK: Supple. LUNGS: CTA bilaterally. HEART: Regular rate and rhythm with occasional premature beat and 2/6 systolic ejection murmur. ABDOMEN: Obese, soft, currently non-tender. Normoactive bowel sounds. EXTREMITIES: Bilateral lower extremities with 2+ pitting edema.
CTA|clear to auscultation|CTA|145|147|HOSPITAL COURSE|GI cocktail was given to the patient with some relief of symptomatology, and he will be discharged on Protonix to be followed up as noted below. CTA of the chest performed as base of D-dimer on admission was 0.9 and is as noted above. 2. Diabetes mellitus type 2: On discharge, the patient will continue his outpatient regimen and followup as noted below.
CTA|clear to auscultation|CTA|180|182|PHYSICAL EXAMINATION|EXTREMITIES: Lower extremities 5/5, no edema. Dorsal pedal pulses 2+. SKIN: Warm and dry. NECK: Supple, no lymphadenopathy. CARDIOVASCULAR: Regular rate and rhythm, S1, S2. LUNGS: CTA bilateral. MINI-MENTAL STATUS: The patient was oriented x3. LABORATORIES: Showed calcium was 8.2, albumin 3.8, alkaline phosphatase 95, amylase 64, lipase 140, INR 1.11, troponin less than 0.04. Hepatic panel was within normal limits as well as influenza A antigen was negative and influenza B antigen was negative.
CTA|computed tomographic angiography|CTA|227|229|PHYSICAL EXAMINATION|There are no obvious reflexes present. She is status post below-the-knee amputation on the right. Head CT in the Fairview Lakes ER showed a subarachnoid hemorrhage categorized as a Fisher grade 3 with moderate hydrocephalus. A CTA is suggestive of a right vertebral artery aneurysm at the level of the clevis. If confirmed this appears to be a fusiform aneurysm that measures perhaps 5.5 mm in its maximal diameter.
CTA|clear to auscultation|CTA|140|142|PHYSICAL EXAMINATION|His responses were immediate. His ability to follow instructions were good. NEUROLOGIC: Cranial nerves II through XII appear intact. CHEST: CTA through bowel. CARDIOVASCULAR: Regular rate and rhythm without murmur. Perfusion was good. ABDOMEN: Extremely obese. Mr. _%#NAME#%_ weighed in at 340 pounds on admission.
CTA|clear to auscultation|CTA,|203|206|PHYSICAL EXAMINATION|HEENT: Head is nontraumatic. Ears, no abnormality detected. Mouth and throat, no abnormality detected. Eyes, PERRLA, EOMI extraocular muscle intact. NECK: Supple. CARDIOVASCULAR: RRR. No murmurs. LUNGS: CTA, no additional sounds. ABDOMEN: Soft and lax. No organomegaly. SKIN: Pink and dry. NEUROLOGIC: Cranial II through cranial XII is intact.
CTA|clear to auscultation|CTA.|177|180|PHYSICAL EXAMINATION|HEAD, EYES, EARS, NOSE AND THROAT: NC/AT. Ears are grossly normal. EOMI, PERRLA. Nasal passages are clear. Oropharynx is negative. NECK: No nodes, thyromegaly or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs, gallops or clicks. ABDOMEN: Is soft, non-tender without masses. GENITOURINARY: Exam was deferred.
CTA|clear to auscultation|CTA|193|195|ADMISSION PHYSICAL EXAMINATION|EOMI; PERRLA; non-icteric. MMM; no thrush. NECK: JVD: 0; LAD: 0; _____: 0; carotid rate: 0. Neck supple. CARDIOVASCULAR: RRR; S1, S2 normal. S3: 0; S4: 0. Systolic 2/6 murmur, left LSB. LUNGS: CTA bilaterally. ABDOMEN: supple, obese, hyperactive BS. G: 0; R: 0. Mild tenderness to palpation in the right upper quadrant (RUQ). SPINE: some right paraspinal tenderness. SKIN: warm, dry.
CTA|clear to auscultation|CTA|152|154|PHYSICAL EXAMINATION (HLI)|HEENT: PERRLA, conjunctivae are clear, sclera are non-icteric. OP with moist mucous membranes. NECK: Supple, no lymphadenopathy, no thyromegaly. LUNGS: CTA bilaterally, no respiratory distress. HEART: RRR, no murmur. ABDOMEN: Soft, with tenderness to palpation in the epigastric region. No rebound, no guarding, normoactive bowel sounds, no mass, no hepatosplenomegaly.
CTA|clear to auscultation|CTA.|162|165|PHYSICAL EXAMINATION|EARS: Grossly normal. EOMI, PERRLA. Nasal passages are clear. Oropharynx shows dentures, otherwise is unremarkable. NECK: No nodes, thyromegaly or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs ABDOMEN: Is soft, with moderate mid epigastric discomfort to palpation. No masses or organomegaly are noted. GENITOURINARY: Exam shows normal female EXTREMITIES: Symmetric pulses, some mild degenerative joint disease changes.
CTA|clear to auscultation|CTA.|161|164|PHYSICAL EXAMINATION|Nasal passages are clear. Eyes show scarring of the left eye and she is blind in that eye. Oropharynx is negative. Neck: No nodes, thyromegaly or bruits. CHEST: CTA. COR: Regular rate without murmurs. BREASTS: Without masses. ABDOMEN: Soft with no tenderness. No masses or organomegaly. GU: Normal female. EXTREMITIES: Symmetric pulses and no swelling.
CTA|clear to auscultation|CTA|133|135|OPERATIONS/PROCEDURES PERFORMED|Nose: No rhinorrhea. Mouth with approximately 1-cm lesion on the right lower lip, throat is clear. Neck is supple, no LAD. Lungs are CTA bilaterally. Cardiovascular regular rate and rhythm, no murmur appreciated. Abdomen: Soft, tender to palpation in the hypogastric area. There is no rebound or guarding.
CTA|clear to auscultation|CTA|168|170|PHYSICAL EXAMINATION|HEENT: Normocephalic and atraumatic. PERRL. Conjunctivae are clear. OP with moist mucous membranes. Face without evidence of trauma. NECK: Supple and nontender. LUNGS: CTA anteriorly. HEART: RRR, no murmur. ABDOMEN: Obese, soft, nontender. EXTREMITIES: Right upper extremity is in a sling and this was not removed for further examination.
CTA|clear to auscultation|CTA|154|156|PHYSICAL EXAMINATION|HEENT: Mild strabismus noted, PERRL, conjunctivae clear. Oropharynx with moist mucous membranes. NECK: Supple, no lymphadenopathy, no thyromegaly. LUNGS: CTA bilaterally. HEART: Regular rate and rhythm; no murmur. ABDOMEN: Multiple surgical scars. She has a ventral nonreducible hernia that is tender to palpation; no rebound or guarding.
CTA|clear to auscultation|CTA|187|189|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Weight 73 kilos, blood pressure 130/70, pulse 88. GENERAL: Alert and oriented in no acute distress. HEENT: NECK: Supple without LAD. RESPIRATORY/LUNGS: CTA bilaterally, both anteriorly and posteriorly. CARDIOVASCULAR: Regular rate and rhythm without S3 or S4. ABDOMEN: Soft; mildly tender. No rebound, guarding, or masses are noted.
CTA|computed tomographic angiography|CTA|149|151|HOSPITAL COURSE|The patient noted swelling and discomfort in both of her legs on _%#MMDD2007#%_. HOSPITAL COURSE: The patient was admitted on _%#MMDD2007#%_ after a CTA revealed thrombus extending from the superficial femoral veins and occluding the veins all the way up to the level of the renal arteries.
CTA|computed tomographic angiography|CTA|141|143|OPERATIONS/PROCEDURES PERFORMED THIS ADMISSION|2. Hyperlipidemia. 3. Small PFO with minimal shunt. 4. Same as admission diagnoses above. OPERATIONS/PROCEDURES PERFORMED THIS ADMISSION: 1. CTA head and neck and CTP remarkable for left frontal craniotomy associated with postop changes, diffuse low attenuation in the periventricular and supraventricular white matter most likely secondary to radiation, limited CT perfusion study, CTA showing minimal atherosclerotic changes in the bilateral carotid arteries.
CTA|clear to auscultation|CTA,|224|227|PHYSICAL EXAMINATION|Nares were congested. Oropharynx was minimally erythematous. Eyes were unable to be examined due to lack of cooperation. Neck was noted for bilateral posterior cervical lymphadenopathy, left greater than right. Respiratory, CTA, no increased work at breathing, no wheezes, rales, or rhonchi. Cardiac, RRR, without M. 2+ pulses, good perfusion. Abdominal exam, normal active bowel sounds, soft, nontender, no masses, no HSM.
CTA|clear to auscultation|CTA.|157|160|PHYSICAL EXAMINATION|HEAD: Normocephalic, atraumatic. EARS: Normal. EOMI. PERRLA. Nasal passages are clear. Oropharynx is negative. NECK: No nodes, thyromegaly or bruits. CHEST: CTA. CORONARY: Regular rate Right breast is absent and the scar is clear. ABDOMEN: Is soft, non-tender without masses or organomegaly. GENITOURINARY: Exam was deferred.
CTA|clear to auscultation|CTA|135|137|PHYSICAL EXAMINATION ON ADMISSION|Head: ATNC. Icterus: 0. EOMI, PERRL. HEENT: Oral mucosa moist and pink. Neck: Thyromegaly 0. LAD 0. Carotid bruit x 2: 0. Respiratory: CTA bilaterally. CV: RRR, S1, S2 normal. MRG: 0. Abdomen: Bowel sounds plus. Nontender. Bulging flanks. Extremities: No edema.
CTA|clear to auscultation|CTA|186|188|PHYSICAL EXAM ON ADMISSION|The patient appeared to be in no acute distress. Her TMs, EACs were clear. EOMI, PERRLA. Nasal passages are clear. Oropharynx is negative. NECK: No nodes, thyromegaly, or bruits. CHEST: CTA with decreased breath sounds at the bases. Chest wall was tender to palpation over the mid sternum on both left and right sides.
CTA|clear to auscultation|CTA|169|171|PHYSICAL EXAMINATION ON ADMISSION|PHYSICAL EXAMINATION ON ADMISSION: Appearance: No acute distress. Comfortable. Head: NCAT. Eyes: PERRL, EOMI. Tongue dry. Neck: Supple. No lymphadenopathy. Respiratory: CTA bilaterally. Cardiovascular: RRR, S1, S2 normal, MGR 0. Abdomen: Soft with minimal tenderness in the right lower quadrant. Distended with normal bowel sounds. Extremities: No edema. He has 2+ distal pulses.
CTA|computed tomographic angiography|CTA|220|222|PERTINENT WORKUP|There has been change in the overall mass effect although more prominent T1 signal is identified in the left frontal lobe consistent with evolution of the hemorrhage. Conventional cerebral angiogram were read as normal. CTA done pending official result. MEDICATION ON DISCHARGE: 1. Meclizine 25 mg every eight hours p.r.n.
CTA|clear to auscultation|CTA.|143|146|PHYSICAL EXAMINATION|HEAD, EYES, EARS, NOSE AND THROAT: NC/AT. Ears are normal. EOMI, PERRLA. Oropharynx is negative. NECK: No nodes, thyromegaly or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs, gallops or clicks. ABDOMEN: Is soft, non-tender except in the right upper quadrant to mid epigastric area.
CTA|clear to auscultation|CTA|190|192|PHYSICAL EXAMINATION|HEENT: PERRL, conjunctivae clear. External ears intact. OP with moist mucous membranes. Neck: Supple, no lymphadenopathy, no thyromegaly. Carotids strong and symmetric with no bruit. Lungs: CTA bilaterally, no respiratory distress, good air flow. Heart: RRR, no murmur. Abdomen: Soft with tenderness in the left lower quadrant. No rebound or guarding.
CTA|clear to auscultation|CTA|227|229|PHYSICAL EXAMINATION|GENERAL: WN/WD, NAD. HEAD: NC/AT, soft anterior fontanel. EYES: Small conjunctival hemorrhage in both eyes. EARS: Patent, clear TMs bilaterally. NOSE: Patent. MOUTH/THROAT: OP is clear. NECK: Supple. No lymphadenopathy. LUNGS: CTA bilaterally. BREASTS: Tanner stage I. CARDIOVASCULAR: RRR; no murmurs, rubs, or gallops; regular S1 and S2. ABDOMINAL: Soft, nontender, nondistended, normoactive bowel sounds. GENITALIA: Tanner stage I, bilateral descended testes.
CTA|clear to auscultation|CTA|175|177|PHYSICAL EXAMINATION|She is afebrile. GENERAL: She is frail appearing, weak appearing, and confused. HEENT: Left pupil is non-reactive. OP is dry. NECK: Supple. No lymphadenopathy. No JVD. LUNGS: CTA anteriorly. HEART: Irregularly irregular and tachycardic. ABDOMEN: Diffuse tenderness most notably in the epigastric region. No rebound. No guarding. Bilateral lower extremities without edema. SKIN: Warm and dry.
CTA|clear to auscultation|CTA|186|188|PHYSICAL EXAMINATION|He is complaining of right lower extremity cramping sensation. HEENT: PEERL. Conjunctivae clear. OP clear with intact dentition. NECK: Supple, no lymphadenopathy, no thyromegaly. LUNGS: CTA bilaterally. HEART: Regular rate and rhythm, no murmur. ABDOMEN: Obese, soft, nontender. Periumbilical surgical scar noted. EXTREMITIES: Left lower extremity with 1+ pitting ankle edema and intact pedal pulse.
CTA|clear to auscultation|CTA|114|116|DISCHARGE CONDITION|DISCHARGE CONDITION: Stable. Exam T 98.2 P77 BP 143/69 20 93% on RA. No complaints. HEENT WNL Cor RRR s MRG Chest CTA bilaterally. Abdomen soft, NTND +BS. Ext No Clubbing, cyanosis or edema. DISCHARGE DISPOSITION: The patient will be discharged home to assisted living facility with nurse visits for assessment and to follow as needed.
CTA|clear to auscultation|CTA|159|161|DISCHARGE CONDITION|DISCHARGE CONDITION: Stable. T94.5 P55 BP120/65 R16 Sat 95% on RA. In no acute distress. HEENT sclera nonicteric neck no lymphadenopathy. COR Reg s MRG. Chest CTA bilaterally. Abd soft NTND no hepatosplenomegaly. Ext no edema, no tremors. DISCHARGE DISPOSITION: She will be discharged to Mental Illness/Chemical Dependency treatment.
CTA|computed tomographic angiography|CTA.|287|290|MAJOR PROCEDURE AND TREATMENTS|2. Fusiform dilatation of the posterior circulation with general dysplasia of the cerebral vessels including full anterior circulation supply from dilated vertebral system and dropout of carotid artery supply bilaterally. MAJOR PROCEDURE AND TREATMENTS: 1. Angiogram. 2. MRI and MRA. 3. CTA. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is a 45-year-old gentleman who has been otherwise healthy veteran at the North Dakota VA Home.
CTA|computed tomographic angiography|CTA|168|170|HOSPITAL COURSE AND PROBLEM LIST|HOSPITAL COURSE AND PROBLEM LIST: PROBLEM #1: Non-convulsive status. The patient had what appeared to be focal seizures on admission. CT was obtained, which did show a CTA hyperintense lesion involving the left posteroparietal occipital lobe of undetermined etiology. An MRI was obtained, which showed minimal leptomeningeal and gyral enhancement around that area.
CTA|clear to auscultation|CTA.|247|250|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: On admission, in no acute distress. HEENT: Normocephalic, atraumatic, tympanic membranes and EACs normal, EOMI, PERRLA. Nasal passages are clear. Oropharynx is negative. Neck: No nodes, thyromegaly or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs. ABDOMEN: Soft and nontender, normal bowel sounds; I do not appreciate any masses. BREAST: Not done. GENITOURINARY: Not done. EXTREMITIES: Without swelling, normal symmetric pulses.
CTA|clear to auscultation|CTA|265|267|PHYSICAL EXAMINATION|ALLERGIES: Codeine. MEDICATIONS: Iron 1 p.o. t.i.d. for at least 6-7 months in order to build up her hemoglobin in order to be scheduled for surgery. PHYSICAL EXAMINATION: General appearance: Awake, in no acute distress. Head and neck: Within normal limits. Lungs: CTA bilaterally. Cardiovascular: RRR. Abdomen: Soft, nondistended, and nontender with ___________________ due to the previous C-sections she had. Genitourinary: No CVA tenderness. Bimanual: Uterus enlarged, mildly tender. The size was approximately 18 weeks.
CTA|computed tomographic angiography|CTA|313|315|HISTORY OF PRESENT ILLNESS|ADMISSION DIAGNOSES: Subarachnoid hemorrhage and hydrocephalus. OPERATIONS/PROCEDURES PERFORMED: Placement of left-sided external ventricular drainage catheter. HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ is a 57-year-old female transferred from _%#CITY#%_ _%#CITY#%_, South Dakota, with subarachnoid hemorrhage. CTA reveals right MCA aneurysm as well as hydrocephalus. HOSPITAL COURSE: Patient was admitted _%#MM#%_ _%#DD#%_, 2004.
CTA|clear to auscultation|CTA.|163|166|PHYSICAL EXAMINATION  VITAL SIGNS|HEAD: Normocephalic, atraumatic. EYES: EOMI. Pupils equal, round, and reactive. EARS: TMs are clear. NECK: No LAD. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: CTA. ABDOMEN: Mild left lower quadrant tenderness. SKIN: Healing sores, bilateral antecubital area. NEUROLOGIC: Alert and oriented. PSYCHIATRIC: Extremely talkative. Insight is fair to poor.
CTA|computed tomographic angiography|CTA|282|284|HISTORY OF PRESENT ILLNESS|He was brought to the Fairview University Medical Center Emergency Department at around 6 p.m. and shortly thereafter, the patient noted resumed slurred speech (but worse), right facial droop, and right-sided weakness. The Neurology team evaluated at 6:15 p.m. A CT of the head and CTA were performed, which were negative for acute bleed/or stroke signs. The patient was given TPA in the emergency department and transferred to Medical Intensive Care Unit.
CTA|computed tomographic angiography|CTA|133|135|PLAN|He will follow up in my office in one week. Due to the fixation problems in the proximal graft this will be watched very closely and CTA will be performed in 1 month and per routine following this
CTA|clear to auscultation|CTA|139|141|PHYSICAL EXAMINATION|Cognitively she appears intact. She follows directions well. Conversational flow in his normal. Mood and affect appear appropriate. CHEST: CTA throughout. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Soft, flat, nontender, bowel sounds present. EXTREMITIES: Lower extremities mild +1 edema noted.
CTA|clear to auscultation|CTA|279|281|PHYSICAL EXAMINATION|General: The patient is a pleasant female who currently is in no distress, having received parenteral pain medication by the time I am seeing her. HEENT: PERRL. Conjunctiva have a clear opiate with moist mucous membranes. Neck: Supple, no lymphadenopathy, no thyromegaly. Lungs: CTA bilaterally. No respiratory distress. Heart: RRR, no murmur. Abdomen: Soft, with mild diffuse right greater than left tenderness. No focal tenderness to palpation, no mass, no organomegaly, normoactive bowel sounds.
CTA|clear to auscultation|CTA.|143|146|PHYSICAL EXAMINATION|HEAD: Normocephalic, atraumatic. EOMI, PERRLA. Nasal passages are clear. Oropharynx is negative. NECK: No nodes, thyromegaly or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs, gallops or clicks, occasional irregular beat was noted and on her EKG she was noted to have occasional premature ventricular contractions.
CTA|clear to auscultation|CTA|154|156|PHYSICAL EXAMINATION|SKIN: Normal temperature. Normal color. No signs of dehydration are noted. HEENT: NAD except maybe dry tongue. NECK: Supple. Good range of motion. CHEST: CTA bilateral. CVS: RRR, no murmurs. ABDOMEN: Soft, non-tender. No organomegaly. Bowel sounds are heard. EXTREMITIES: No peripheral edema is noted.
CTA|clear to auscultation|CTA.|237|240|DISCHARGE EXAM|Pulse was 60 and regular. Respirations 20 and regular. O2 saturation on room air was 88, on two liters of oxygen was 95. General exam shows him in no acute distress. Oropharynx is negative. Neck, no nodes, thyromegaly, or bruits. Chest, CTA. Coronary showed a grade 1/6 systolic murmur in lower left sternal border. This is old and unchanged. Abdomen is benign. Extremities are without swelling.
CTA|clear to auscultation|CTA|180|182|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: On exam, he appeared to have stable vital signs, and he was alert and oriented and pleasant as always. Skin: Normal color and temperature. HEENT: NAD. Chest: CTA bilateral. CVS: Regular rate and rhythm. Abdomen: Soft and nontender. Extremities: Trace peripheral edema noted. DISCHARGE MEDICATIONS: Discharge medications are as follows, aspirin 325 mg p.o. daily, may adjust as PMD sees appropriate in the future.
CTA|clear to auscultation|CTA|249|251|PHYSICAL EXAMINATION|These vitals were obtained on the Medical floor. GENERAL: The patient is a pleasant female who is lying still in a dark room with a cool washcloth on her forehead. HEENT: PERRL, conjunctivae clear. OP with dry mucous membranes. NECK: Supple. LUNGS: CTA bilaterally. HEART: Regular rate and rhythm, no murmur. ABDOMEN: Soft, nontender. BILATERAL LOWER EXTREMITIES: No edema. BACK: Lumbar puncture site is covered with a bandage, and there is no sign of bleeding.
CTA|clear to auscultation|CTA|166|168|PROCEDURES|5. Anemia. 6. Pneumonia. 7. Adrenal insufficiency. 8. Deep vein thrombosis and history of heparin-induced thrombocytopenia. 9. Comfort cares and DNR/DNI. PROCEDURES: CTA chest, abdomen and pelvis, _%#MMDD2006#%_: Large left pleural effusion, porcelain gallbladder unchanged, tip shunt unchanged, and multiple compression fractures.
CTA|computed tomographic angiography|CTA|183|185|HISTORY OF PRESENT ILLNESS|She was started on IV narcotics for this headache but it did not relieve the pain at all and it was still rated as 9/10. During this hospitalization she had workup with MRI, MRA, and CTA which showed a left MCA aneurysm and a subarachnoid hemorrhage as well as vasospasm in the M1 and A1 segments, by report.
CTA|computed tomographic angiography|CTA|100|102|RADIOLOGY|Her right toe is upgoing. Her left toe is downgoing. RADIOLOGY: We reviewed an MRI/MRA as well as a CTA from the outside hospital that do in fact suggest an aneurysm at the bifurcation of the left MCA. These are also suggestive of vasospasm at the M1 and A1 segments on the left.
CTA|clear to auscultation|CTA|298|300|PHYSICAL EXAMINATION VITAL SIGNS|PHYSICAL EXAMINATION VITAL SIGNS: On discharge, temperature is 97.9, heart rate 90, blood pressure 106/80, respiratory rate 16-20, and O2 saturation 93% at room air. GENERAL: The patient is awake, oriented x3. No acute distress. CARDIOVASCULAR: Regular rate and rhythm. S1 and S2 heard. PULMONARY: CTA bilaterally. ABDOMEN: Nontender, soft, and mildly distended with umbilical hernia with everted umbilicus. EXTREMITIES: Left lower extremity has erythema with the dry skin overlying.
CTA|clear to auscultation|CTA.|151|154|PHYSICAL EXAMINATION|No lymphadenopathy. Pupils are equal, round, and reactive to light. Oropharynx is clear. NECK: Supple. CARDIOVASCULAR EXAM: Distant heart sound. LUNG: CTA. ABDOMEN: Obese. EXTREMITIES : Significant pitting edema noted. (_______________) was noted. LABORATORY: On admission, sodium 139, potassium 2.8, BUN 89, and creatinine 1.39. LFTs were within normal limits.
CTA|clear to auscultation|CTA|203|205|PHYSICAL EXAMINATION  VITAL SIGNS|Throat: Mucous membranes are moist. Much repaired dentition. Posterior pharyngeal wall generally hyperemic/erythematous. NECK: Supple without lymphadenopathy. CARDIOVASCULAR: RRR. No MRG. No JVD. LUNGS: CTA with good air movement. ABDOMEN: Soft and nontender. No masses. No HSM. BREASTS: Normal without axillary lymphadenopathy. LYMPHATIC: No supraclavicular lymphadenopathy.
CTA|clear to auscultation|CTA.|187|190|PHYSICAL EXAMINATION  VITAL SIGNS|OROPHARYNX : Without erythema. Mucous membranes were moist. EARS: Normal TMs on exam. NECK: Without JVD, supple without TM. CARDIOVASCULAR: Tachy and no murmurs, rubs, or gallops. LUNGS: CTA. ABDOMEN: Soft, nontender with no murmurs. No HSM, no bruits. EXTREMITIES: Equal pedal pulses 2+. No CVA tenderness. SKIN: No rash, warm and dry.
CTA|computed tomographic angiography|CTA|174|176|PROCEDURES|In brief, there is left temporal theta and delta slowing, sharply contoured transience in the left temporal region, but they are not distinctively epileptiform in nature. 2. CTA had a neck showing mild-to-moderate narrowing at the left ICA cavernous segment, supraclinoid segment to atherosclerotic calcifications, moderate cerebral and cerebellar volume loss, patchy low attenuation areas in the cerebellum, left greater than right.
CTA|computed tomographic angiography|CTA|225|227|PLAN|Strength is preserved 5/5 in all major muscle groups. PLAN: This is a gentleman with a C2 hangman's fracture who will be placed in a halo later this afternoon when equipment is brought in at the correct size. He will undergo CTA for evaluation of any hemorrhage or hematoma secondary to fracture of the C2 vertebral body. We will get PT and OT involved with him to evaluate for stability.
CTA|computed tomographic angiography|CTA|218|220|HOSPITAL COURSE|Later that night she underwent a run of SVT and was started on amiodarone and followed by cardiology until she was weaned off the amiodarone in a few days without any further event. On _%#MMDD2007#%_ she did undergo a CTA for verapamil administration into the left vertebral artery for minimal spasming of the basilar left M1 segment. On _%#MM#%_ _%#DD#%_, she actually started waking up and becoming less lethargic.
CTA|clear to auscultation|CTA|280|282|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.8, heart rate 110, blood pressure 118/84, respiratory rate 32, O2 is 100% on room air. GENERAL: The patient is awake, alert and oriented x3. HEENT: Atraumatic, normocephalic. NECK: Supple, thyroid enlarged without nodules. LUNGS: CTA anteriorly. CV: Tachy irregularly irregular. No rub or gallop noted. ABDOMEN: Soft, nontender, positive bowel sounds. EXTREMITIES: Positive pulse, negative edema. SKIN: No rash. NEUROLOGIC: Nonfocal.
CTA|clear to auscultation|CTA|150|152|PHYSICAL EXAMINATION ON ADMISSION|HEAD: NC/AT. EYES: PERRLA. EARS: WNL. MOUTH: Bite mark on the right side of the tongue. NECK: Supple. CARDIOVASCULAR: Positive S1 and S2, RRR. LUNGS: CTA B/L. SKIN: Warm. LYMPHATICS: No edema. NEURO: Cranial nerves II through XII grossly intact. The patient is not oriented to self, person or place.
CTA|clear to auscultation|CTA,|222|225|PHYSICAL EXAMINATION|GENERAL: Patient is sedated on vent. HEENT: Normocephalic, atraumatic. Pupils are sluggish but reactive and equal bilaterally. NECK: Supple. No lymphadenopathy. No JVD. CARDIAC: Regular rate and rhythm. No murmurs. LUNGS: CTA, intubated. ABDOMEN: Obese, nontender, positive bowel sounds. EXTREMITIES: Positive pulses, positive edema. SKIN: Chronic changes pretibial area bilaterally.
CTA|clear to auscultation|CTA|153|155|PHYSICAL EXAMINATION|GENERAL: Patient eating, no acute distress. Alert and oriented x3. HEENT: Atraumatic and normocephalic. NECK: Supple, no JVD. No lymphadenopathy. LUNGS: CTA anteriorly. No wheezes or crackles. CV: Irregular rate and rhythm without murmur. ABDOMEN: Soft, nontender, positive bowel sounds. EXTREMITIES: Positive pulses, positive for edema.
CTA|computed tomographic angiography|CTA|169|171|HOSPITAL COURSE|She was seen in consultation by Dr. _%#NAME#%_ of neurosurgery service. They felt the patient was neurologically intact and they recommended a repeat CT scan as well as CTA to evaluate for another cause of her bleed. Her INR was normalized with the use of blood products and vitamin K given the bleed as it was initially 2.17. From a neurological standpoint, the patient remained asymptomatic during her hospital stay complaining only of a headache which continually improved and resolved.
CTA|clear to auscultation|CTA,|121|124|HOSPITAL COURSE|The rest of exam: Pain control fine, no other c/o's, eating better and no N/V. BM normal, formed. Voids w/o probs. Lungs CTA, S1S2 w/o m/g/r, ABD: as described and right abd drsg d&i. Pink area near mid lower and mid left has nearly resolved.
CTA|computed tomographic angiography|CTA|402|404|PROCEDURES PERFORMED|Impression: Interval extension of abnormal signal intensity that was confined to the left cerebral hemisphere on the previous study and now extends in to the pons and right cerebral hemisphere are concerning for progression of the patient's underlying astrocytoma, small vessel ischemic disease, and old cortical infarcts. No change questionable distal left internal carotid aneurysm. Recommend MRA or CTA for further evaluation. 3. _%#MMDD2005#%_ feeding tube placement Radiology. New NJ tube with its tip in the fourth portion of the duodenum.
CTA|computed tomographic angiography|CTA|176|178|3. ASSESSMENT AND PLAN|She is to be admitted to the Neurosurgical Service with Dr _%#NAME#%_ as the attending and to have an MRI of the c-spine to further investigate neurologic damage, as well as a CTA looking particularly at the bilateral vertebral arteries and we will re-evaluate. The possibilities of traction, versus collar, versus surgery after the results of the above are obtained.
CTA|clear to auscultation|CTA.|187|190|OBJECTIVE|OBJECTIVE: VITAL SIGNS: Afebrile; heart rate is in the 70s; blood pressure 98/61; respiratory rate 16; oxygen saturations at 99% on room air. GENERAL: Alert, weak, elderly female. HEENT: CTA. TMs are clear. PERRLA, EOMI. OP is clear. NECK: Supple without adenopathy, thyromegaly, or carotid bruits. CARDIOVASCULAR: Paced. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Bowel sounds are positive, soft, nontender, nondistended.
CTA|clear to auscultation|CTA|147|149|PHYSICAL EXAMINATION|GENERAL: The patient is a thin-appearing male in no acute distress. HEENT: PERRL, conjunctivae clear. OP with poor dentition. NECK: Supple. LUNGS: CTA bilaterally. HEART: RRR. No murmur. ABDOMEN: Soft; nontender. GU: Scrotum and testes and penis within normal limits. EXTREMITIES: Bilateral lower extremities without edema.
CTA|computed tomographic angiography|CTA|187|189|PRESENTATION|PRESENTATION: _%#NAME#%_ _%#NAME#%_ is a 54-year-old male with history of known occluded right carotid and history of left carotid endarterectomy in 2000. Recent follow-up ultrasound and CTA suggested a possible re-narrowing of the left carotid artery. The patient was seen by Dr. _%#NAME#%_ and has elected to proceed with angiogram with possible stenting.
CTA|clear to auscultation|CTA|140|142|PHYSICAL EXAMINATION|OP with slightly dry mucous membranes. No dentures. She does have intact dentition. NECK: Supple, no lymphadenopathy or thyromegaly. LUNGS: CTA bilaterally. HEART: RRR, no murmurs. ABDOMEN: Soft, non-tender. EXTREMITIES: Bilateral lower extremities with trace pitting edema in the feet. SKIN: Stasis changes in ankles and a few scattered ecchymoses.
CTA|clear to auscultation|CTA,|147|150|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient was alert and oriented x3, was little sleepy in between because of the Ativan. CVS: RRR, no murmur. RS: CTA, BS positive bilaterally. PA: Soft, nontender, no mass. NEUROLOGICAL: CN nerve II to XII intact. EXTREMITIES: No edema, no calf tenderness.
CTA|clear to auscultation|CTA|157|159|PHYSICAL EXAMINATION|No epistaxis. Neck: Supple. Lymphadenopathy 0. Thyromegaly: 0. No DJD. CV: Regular rate and rhythm. S1, S2 normal. MRJ 0. Peripheral pulses times 4+. Chest: CTA bilaterally. Abdomen: Soft, NTND, bowel sound positive, ______0. Heme negative stools. Extremities: Lower extremities LEE, fair. Skin: Multiple healing scratch wounds on the lower extremities.
CTA|clear to auscultation|CTA|259|261|REVIEW OF SYSTEMS ON ADMISSION|Mild nausea. Otherwise negative. PHYSICAL EXAMINATION ON ADMISSION: Appearance: Comfortable, no acute distress, slightly anxious. Head: NCAT. HEENT: PERRL. EOMI. Anicteric. Oropharynx clear and moist. Neck supple without lymphadenopathy. No JVD. Respiratory: CTA bilaterally. Cardiovascular: Tachycardic, irregular, S1, S2 normal with loud P2. Abdomen: Soft, NTND. No organomegaly. Normoactive bowel sounds. Extremities: No lower extremity edema.
CTA|clear to auscultation|CTA|164|166|EXAMINATION ON ADMISSION|GENERAL APPEARANCE: Alert and oriented x3, NAD. HEAD: Atraumatic. EYES: PERRLA, EOMI x2. NECK: Supple. CARDIOVASCULAR: Distant heart sounds. Regular rhythm. LUNGS: CTA bilaterally, no crackles, no wheezes. ABDOMEN: Soft, nontender and nondistended. Positive bowel sounds, no organomegaly. SKIN: No rashes. NEUROLOGIC: Cranial nerves II through XII are grossly intact.
CTA|computed tomographic angiography|CTA|386|388|IMAGING REVIEWED|A right occipital ventriculostomy is in place. Per the outside nurse it was draining 13-18 mL per hour on the patient's way to University of Minnesota Medical Center, Fairview. The patient's ICPs were between 3 and 5. IMAGING REVIEWED: Head CT done at 5:15 in the morning demonstrates diffuse subarachnoid hemorrhage filling the basal cisterns with increased lateral ventricle size and CTA demonstrates a 6 mm intracranial aneurysm. PERTINENT LABS: Sodium 141, potassium 3.6, creatinine 1.3, glucose 212, white count 15.8, hemoglobin 15.8, platelets 270, INR 1.0, troponin 0.22. ASSESSMENT: This is a 75-year-old woman with grade 5 subarachnoid hemorrhage.
CTA|computed tomographic angiography|CTA|129|131|FOLLOW-UP|3. He will see Dr. _%#NAME#%_ in 2 months. 4. He may or may not need a nuclear stress test in 6 months. He may or may not need a CTA of his OM grafts in the future to see if these are patent. This needs to be reviewed with Dr. _%#NAME#%_ _%#NAME#%_, his cardiologist.
CTA|clear to auscultation|CTA.|145|148|PHYSICAL EXAMINATION|Pupils are equal, round and reactive to light. NECK: C-spine was cleared. Patient has full range of motion without pain and no JVD noted. LUNGS: CTA. CARDIOVASCULAR: Regular rate and rhythm. No murmurs, rubs or gallop. ABDOMEN: Soft, nontender. Positive bowel sounds. No guarding or rebound noted.
CTA|computed tomographic angiography|CTA,|190|193|ASSESSMENT AND PLAN|Nonetheless, I do not have a firm alternative diagnosis and be ruled out for myocardial infarction. He will have serial troponins. Given the fact that he has had multiple stress tests and a CTA, I will hold off on getting another stress test. Instead I will get an opinion from the Cardiology Department to find out what they would recommend as far as repeating another stress test versus going to angiogram versus not doing any further cardiac testing.
CTA|clear to auscultation|CTA|254|256|PHYSICAL EXAMINATION|As described above, she does open her eyes briefly and responds to most yes/no questions, but is, otherwise, quite sedated. HEENT: PERRL, conjunctivae clear. OP with somewhat dry mucous membranes. NECK: Supple, no lymphadenopathy, no thyromegaly. LUNGS: CTA bilaterally. HEART: Regular rate and rhythm, no murmur. ABDOMEN: Soft with mild diffuse tenderness to palpation, no rebound or guarding.
CTA|computed tomographic angiography|CTA|132|134|DISCHARGE DIAGNOSES|5. Fusiform aneurysmal dilation of the cavernous right internal carotid artery seen on CT of the neck. The patient will need MRA or CTA for further evaluation. IMAGING: 1. _%#MMDD2005#%_: Abdominal x-ray findings: Nonobstructive bowel gas pattern, no free air.
CTA|computed tomographic angiography|CTA|183|185|IMAGING|No evidence of discreet retropharyngeal abscess. Level II A lymphadenopathy bilaterally. Fusiform aneurysmal dilation of the cavernous right internal carotid artery. Recommend MRA or CTA for further evaluation. 8. _%#MMDD2005#%_: Chest Pax and lateral x-ray findings: Resolution of the right middle lobe pneumonia, mild cardiomegaly, mural calcification consistent with arthrosclerotic vascular disease, and diffuse hyperlucent vertebral bodies consistent with osteoporosis.
CTA|clear to auscultation|CTA.|125|128|PAST MEDICAL HISTORY|Neck was supple. No JVD, but difficult to visualize due to thickness of neck. Cardiovascular: RR, no M or R. Distant. Lungs: CTA. Abdomen: Central obesity, bowel sounds positive. No organomegaly. Obesity/gynecomastia. (_______________). No CVA tenderness. Does have prominence of thoracic curvature soft tissue.
CTA|clear to auscultation|CTA|132|134|PE|He is to follow up with his primary care provider within 2 days. PE: baby appears alert, active, AFOF cardio: RRR, no murmur lungs: CTA b/l abd: soft, NT/ND, BS EXT: no hip clicks, negative ortolani/barlow skin: normal back: no sinuses/dimples neuro: grossly intact A/P: term infant with initial hypoglycemia and hypothermia all issues resolved.
CTA|computed tomographic angiography|CTA|123|125|RECOMMENDATIONS|Labs are pending. ASSESSMENT: This is a 14-year-old boy with a sudden right upper extremity monoplegia. RECOMMENDATIONS: A CTA to rule out dissection of the vertebral artery or the carotid artery. We will obtain an MRI tomorrow and obtain a Neurology consult tomorrow.
CTA|computed tomographic angiography|CTA.|306|309|HOSPITAL COURSE|He had been weaned off his Neosynephrine. As our original plan, he was seen by neurology to help determine whether chronic Coumadin anticoagulation is indicated with this questionable change in his MRI preoperatively. They noticed a questionable right facial weakness. Because of this, we performed a head CTA. This revealed no evidence of acute infarct but it appeared that the left internal carotid artery may be occluded. In retrospect, this may have happened in the recovery room with the weakness in his arm.
CTA|computed tomographic angiography|CTA|155|157|HISTORY OF PRESENT ILLNESS|He has been having hard time catching up with other athletes that he has been running with for years. He has stress test that was negative and then he had CTA that showed heavy calcification of LAD and diagonal with inconclusive lumen diameters. He was sent for an elective angiogram. Angiogram showed a left dominant system with very small RCA and has had a 40% lesion in the mid vessel.
CTA|clear to auscultation|CTA|172|174|SURGICAL HISTORY|Lymph node exam reveals multiple lymph nodes in the left axilla. Otherwise unremarkable physical exam with regular rate and rhythm. No murmurs, rubs, or gallops. Lungs are CTA bilaterally. Abdomen is soft, nontender, and nondistended. Positive bowel sounds. HOSPITAL COURSE: The patient did well after her left modified radical breast mastectomy and was transferred to the floor in stable condition.
CTA|clear to auscultation|CTA|121|123|ALLERGIES|HEENT: AT/NC, PERL, EOMI. Oropharynx clear. Neck: Supple. LAD: 0. Thyromegaly: 0. CV: RRR, S1, S2 normal. MRG: 0. Chest: CTA bilaterally. Abdomen: Soft, NT/ND, LN: 0. GU: Per patient genital herpes. Skin: Hairy nevus of the left shin. Neuro: Alert, speech fluent, NAE, sensation normal.
CTA|clear to auscultation|CTA|215|217|HISTORY OF PRESENT ILLNESS|No alcohol. No drug user. PAST SURGICAL HISTORY: The patient had a cesarean section back in her country of origin. PHYSICAL EXAMINATION: General exam: Not in acute distress. HEENT: Pupils PERRLA. Neck supple. Lungs CTA bilaterally. Cardiovascular: RRR. Abdomen gravid with Pfannenstiel skin incision. Genitourinary: Noncontributory. Pelvic exam deferred. Legs: No calf tenderness. Edema +1.
CTA|clear to auscultation|CTA.|186|189|DISCHARGE EXAM|DISCHARGE EXAM: Vital signs are stable. Weight is 80.3 kilograms. He is afebrile. He is in no acute distress. His oropharynx is negative. Neck, no nodes or thyromegaly or bruits. Chest, CTA. Coronary, regular rate with occasional irregular beat. He does have paroxysmal atrial fibrillation. Abdomen was soft, nontender without masses or organomegaly.
CTA|clear to auscultation|CTA|164|166|PHYSICAL EXAMINATION|He is lying in a darkened, quiet room. HEENT: PERRL. EOMI. Conjunctiva: Clear. OP with moist, mucous membranes. Neck: Mildly stiff, but no extreme rigidity. Lungs: CTA bilaterally. Heart: RRR, no murmur. Abdomen: Soft, non-tender. Bilateral lower extremities without edema. Skin: Normal turgor. Neurological: Cranial nerves II through XII were intact.
CTA|computed tomographic angiography|CTA|169|171|HOSPITAL COURSE|The patient is being followed by General Surgery and will be transferred to their service for a complete resection of his liver mass. Please note that the patient had a CTA performed on _%#MMDD2007#%_, which was reported as no definite aneurysm or stenosis of the major intracranial arteries and showed right occipital and parietal hypodensities that were suspicious for subacute infarctions.
CTA|clear to auscultation|CTA|173|175|PHYSICAL EXAMINATION|Answering questions appropriately, alert and oriented. HEENT: Atraumatic, normocephalic. Speech clear. No dysphagia apparent CARDIOVASCULAR: Regular rate and rhythm. LUNGS: CTA bilaterally. ABDOMEN: Flat, nontender, nondistended, positive bowel sounds. SKIN: Upper extremities clear. Lower extremities diffuse stasis changes to the epidermis of her right foreleg, chronically present.
CTA|clear to auscultation|CTA.|188|191|PHYSICAL EXAMINATION|GENERAL: No acute distress. Alert and oriented x3. HEENT: Atraumatic, normocephalic. PERRLA. EOMs intact bilaterally. NECK: Supple. No JVD. LUNGS: Rhonchi on the upper left lobe otherwise CTA. CARDIOVASCULAR: Regular, rate and rhythm. No murmurs, rubs or gallop. ABDOMEN: Distended to hyperactive bowel sounds, nontender. EXTREMITIES: Positive pulses, 2+ edema, warm, well perfused.
CTA|clear to auscultation|Lungs:CTA,|140|149|REVIEW OF SYSTEMS|DERMATOLOGIC: Negative for rash PE:BP 190'97, P72, T97.8, rr 16. A & o x 3. HEENT:Negative Neck: Supple without bruits, jvp or thyromegaly, Lungs:CTA, CVS:RRR with normal S1, S2, no murmur, rub or click. Abd:Distended, no rebound, bs diminished. Ext:venous stasis disease. Neuro:Compatible with longstanding Ms.Skin:no rash.
CTA|computed tomographic angiography|CTA|220|222|RECOMMENDATIONS|Given the location and the extent of the AVM in the brainstem, it will not be a candidate for neurosurgical excision and the size of the AVM will make it difficult for radiosurgery. RECOMMENDATIONS: 1. Obtain an MRI and CTA in the a.m. 2. Likely endovascular embolization on Thursday or Friday, plus or minus Gamma Knife depending the results of the outside studies.
CTA|clear to auscultation|CTA.|155|158|PHYSICAL EXAMINATION|EYES: Could not be examined as the patient was too sleepy. EARS: Were grossly normal. OROPHARYNX: Showed some dry mucous membranes. NECK: No nodes. CHEST: CTA. CORONARY: Showed a Grade I-II/VI systolic murmur heard best at the lower left sternal border but with radiation to the right sternal border and up along the right and left upper sternal border.
CTA|clear to auscultation|CTA.|188|191|PHYSICAL EXAMINATION|Vital signs are stable. Patient is afebrile. HEENT: NCAT. EOMI. PERRLA. Ears are grossly normal. Oropharynx shows some dry mucous membranes. NECK: No nodes, thyromegaly, or bruits. CHEST: CTA. Coronary regular rate without murmurs, gallops, or clicks. ABDOMEN: Soft, nontender, without masses or organomegaly. She does have an ileostomy on the right side of the abdomen.
CTA|clear to auscultation|CTA|161|163|PHYSICAL EXAMINATION ON ADMISSION|Appearance: A young woman in NAD. Head: NC/AT. Eyes: Left conjunctival injection. HEENT: White pharyngeal lesions. Neck: Supple, no thyromegaly: 0. Respiratory: CTA AUSCULTATION bilaterally. CV: Tachycardic, RRR, S1, S2 normal, MRG: 0. Abdomen: Soft, slightly tender to palpation in all 4 quadrants. GU: ND. Skin: Right triple-lumen catheter. LABS ON ADMISSION: Chem 10: Sodium 134, potassium 2.8, chloride 79, bicarb 25, BUN 76, creatinine 2.5, glucose 673.
CTA|clear to auscultation|CTA|215|217|PHYSICAL EXAMINATION|Overnight heart rates were 46 to 59. General: Patient is a pleasant, anxious-appearing male in no acute distress. HEENT: PERRL, conjunctivae clear. Oropharynx clear with moist mucous membranes. Neck: Supple. Lungs: CTA bilaterally. No respiratory distress. Heart: RRR, no murmur. Abdomen: Soft with mild left lower quadrant tenderness to palpation. No rebound or guarding. No mass. No hepatosplenomegaly, normoactive bowel sounds.
CTA|clear to auscultation|CTA|203|205|PHYSICAL EXAMINATION|HEENT: PERRL. Conjunctivae clear. TMs clear with normal landmarks bilaterally. Oropharynx clear with mucous membranes. The patient wears dentures. Neck supple, no lymphadenopathy, no thyromegaly. Lungs: CTA bilaterally, no respiratory distress. Heart: Regular rate and rhythm, no murmur. Abdomen: Soft with mild tenderness in the left lower quadrant.
CTA|clear to auscultation|CTA.|177|180|PHYSICAL EXAMINATION|She is in no acute distress lying in bed. NOSE AND THROAT: Exam is negative. EARS: Are grossly normal. OROPHARYNX: Is negative. NECK: No thyromegaly or bruits. No nodes. CHEST: CTA. CORONARY: Regular rate without murmurs ABDOMEN: Is soft, normal bowel sounds are present. No masses or organomegaly noted. GENITOURINARY: Exam was deferred. EXTREMITIES: Showed symmetric pulses, no swelling.
CTA|clear to auscultation|CTA|280|282|PHYSICAL EXAMINATION|He was then transferred back to Fairview Southdale Hospital. PHYSICAL EXAMINATION: HEENT: Upon discharge, head was normocephalic and atraumatic with anterior fontanelle open, sutures overlapping slightly. Eyes: Red reflex bilaterally. Tympanic membranes clear bilaterally. LUNGS: CTA bilaterally. HEART: Regular rate and rhythm. No murmurs. Pulses equal. ABDOMEN: No hepatosplenomegaly. NTND. GENITALIA: Testes descended bilaterally status post circumcision. EXTREMITIES: No hip clicks.
CTA|clear to auscultation|CTA|193|195|EXAMINATION|Mouth and throat unremarkable. Eyes - PERRL. EOMI. There is no obvious cervical, supraclavicular, axillary, or inguinal adenopathy. HEART: RRR. No click, murmurs, or extra sounds noted. LUNGS: CTA throughout. ABDOMEN: Soft. No palpable masses. Normal bowel sounds. There is mild to moderate diffuse tenderness most prominent left lower quadrant.
CTA|clear to auscultation|CTA.|162|165|PHYSICAL EXAMINATION|EOMI, PERRLA. Nasal passages are clear. Oropharynx shows dentures upper and lower. Moderately dry mucous membranes. NECK: No nodes, thyromegaly or bruits. CHEST: CTA. Except for rales at the bases, right greater than left. CORONARY: Regular rate without murmurs, gallops or clicks. ABDOMEN: Is soft, non-tender without masses or organomegaly.
CTA|clear to auscultation|CTA.|148|151|PHYSICAL EXAMINATION|EOMI, PERRLA. Nasal passages are clear. Oropharynx shows dentures, upper and lower. No other lesions. NECK: No nodes, thyromegaly or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs, gallops or clicks. ABDOMEN: Is soft, non-tender without masses or organomegaly. GENITOURINARY: Exam showed a normal male. I did not repeat his prostate exam.
CTA|clear to auscultation|CTA.|205|208|PHYSICAL EXAMINATION|He is in no acute distress. He is obese. HEAD, EYES, EARS, NOSE AND THROAT: NC/AT. Ears are grossly normal. EOMI, PERRLA. Nasal passages are clear. Oropharynx is negative. NECK: No nodes or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs, gallops or clicks. ABDOMEN: Is obese, non-tender without masses or organomegaly. GENITOURINARY: Shows normal male. EXTREMITIES: There was swelling in the right lower extremity.
CTA|clear to auscultation|CTA,|242|245|PHYSICAL EXAMINATION|We discontinued the patient's Norvasc today and her follow up Dialysis Center is going to _%#CITY#%_ _%#CITY#%_ Dialysis Center, as opposed to _%#CITY#%_ _%#CITY#%_ as was previously dictated. PHYSICAL EXAMINATION: Unchanged today with lungs CTA, no JVD, pleasant affect and improved BP. LEE is still present and ABdominal exam reveals no HSM and bs are present.
CTA|clear to auscultation|CTA.|71|74|CURRENT MEDICATIONS|CVS - s1, s2 heard; loud SM heard through out, lungs - good air entry; CTA. Abdomen - soft, nontender, no organomegaly, Bowel sounds normal. Extremities - right shin abraded but not actively bleeding currently, pulses well felt, no edema.
CTA|computed tomographic angiography|CTA|332|334|PROCEDURES|2. MRI/MRA head and neck stroke protocol showing early subacute infarct in the medial right occipital and temporal lobe in the distribution of the right PCA, multiple old lacunar infarct in the left cerebellar hemisphere, mild white matter changes in the bilateral cerebral hemispheres, occluded right posterior cerebral artery. 3. CTA head and neck showing hypodensity in the medial right occipital lobe and posterior right temporal lobe, complete occlusion of the P1 segment of the right posteriorly cerebral artery, plaque with 78% stenosis at the origin of the right vertebral artery, and minimal plaques with less than 20% stenosis of the proximal left internal carotid artery distal to the bulb.
CTA|computed tomographic angiography|CTA|146|148|HOSPITAL COURSE|He also had a transesophageal echocardiogram. There was no evidence of cardioembolic source and with the findings of the MRA and subsequently the CTA of likely atherothrombotic/embolic etiology. Also, identified stroke risk factors and management during hospitalization. A lipid panel was checked showing a total cholesterol of 222 with LDL of 157.
CTA|clear to auscultation|CTA.|168|171|EXAMINATION|Eyes could not be examined due to the fact she could not open them up due to her somnolence. Her oropharynx is negative. NECK: No nodes, thyromegaly, or bruits. CHEST: CTA. Did not get a real good exam of that because she could not take a real deep breath due to her somnolence.
CTA|clear to auscultation|CTA.|135|138|PHYSICAL EXAMINATION|Ears are grossly normal. EOMI, PERRLA. Nasal passages are clear. Oropharynx is negative. NECK: No nodes, thyromegaly or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs ABDOMEN: Is soft, non-tender without masses or organomegaly GENITOURINARY: Exam was deferred. Right groin does show evidence from her previous catheter. CMS is intact to the feet.
CTA|clear to auscultation|CTA|220|222|HOSPITAL COURSE|His pulse was 78, his respirations were 20. His blood pressure was 139/74, his O2 sats were 90% on 2 liters of O2. He appeared alert and oriented. He seemed to have tolerated the procedure well. Skin, HEENT, NAD. Chest: CTA bilateral but decreased airflow on the left. CV: No murmurs. Abdomen: Soft, nontender. No peripheral edema was noted. The assessment and plan noted as above. The patient was discharged to home with family with the above mentioned medications and followup as noted.
CTA|clear to auscultation|CTA|176|178|PHYSICAL EXAMINATION|Otherwise unremarkable. NECK: No obvious cervical, supraclavicular, axillary or inguinal adenopathy. HEART: Regular rate and rhythm. No obvious murmurs or extra sounds. LUNGS: CTA throughout. ABDOMEN: Soft, no obvious tenderness to palpation. Bowel sounds are normal. No palpable masses or hepatosplenomegaly. EXTREMITIES: Warm, dry, no obvious edema.
CTA|clear to auscultation|CTA.|208|211|PHYSICAL EXAMINATION|The right ear dry with a tube in place. TM itself appears well healed. Evidence of multiple surgeries. Nasal mucosa pink. OROPHARYNX: Non-erythematous. NECK: Supple; no lymphadenopathy or thyromegaly. LUNGS: CTA. HEART: Regular rate and rhythm without appreciable murmur, gallop, or rub. ABDOMEN: Positive bowel sounds; soft; nontender without mass or HSM.
CTA|clear to auscultation|CTA.|162|165|PHYSICAL EXAMINATION|HEAD, EYES, EARS, NOSE AND THROAT: NC/AT. Tympanic membranes, EACs are clear. EOMI, PERRLA. Oropharynx is negative. NECK: No nodes, thyromegaly or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs, gallops or clicks. ABDOMEN: Is was soft, non-tender without masses or organomegaly. Normal bowel sounds present.
CTA|computed tomographic angiography|CTA|378|380|INVESTIGATIONS|INVESTIGATIONS: CBC: Hemoglobin 15.2, platelets 198, white blood cell count 8.7. Electrolytes showed a sodium of 141, potassium 4.2, PTT 30, INR 0.91. AST 33, glucose 116. EKG showed normal sinus rhythm with no ST elevation. CT of the head shows an old area of infarct in the anterior right parietal lobe, most likely consistent with the patient's old stroke in 2005 and then a CTA of the head and neck was discussed with the radiologist on call. The findings were consistent with a possible narrowing of the right PCA, maybe representing clot.
CTA|computed tomographic angiography|CTA|264|266|HOSPITAL COURSE|The risks and benefits of both interventions, medical versus angioplasty with stent placement were discussed thoroughly with the patient by the Interventional Neurology team. The diagnostic angiogram did show a 60% to 70% stenosis in the M1 as seen on the MRA and CTA as well as hypoplastic basilar artery and fetal origins of her posterior cerebral arteries. To assist in the decision making, the patient underwent a CT perfusion scan with acetazolamide challenge to better assess the regulatory reserve of the territory distal to the stenosis.
CTA|clear to auscultation|CTA|150|152|PHYSICAL EXAMINATION ON ADMISSION|NECK: Soft, supple. CARDIOVASCULAR: Regular rate and rhythm. No murmurs. LUNGS: Hickman to the right upper chest with the site clean, dry and intact. CTA bilaterally. GI: Positive bowel sounds, soft, nondistended, nontender without masses. SKIN: Without rashes. LYMPHATICS: No lymphadenopathy. NEURO: Cranial nerves intact, normal gait, with all extremities moving equally.
CTA|clear to auscultation|CTA|174|176|HOSPITAL COURSE|Seen on rounds on postoperative day #1 the patient was still tachycardiac and having some difficulty with decreased oxygen saturation and increased requirements for O2 and a CTA chest was ordered to completely rule out pulmonary embolism. The CT was negative and it was thought that the majority of his symptoms were related to anxiety.
CTA|clear to auscultation|CTA|189|191|ADDENDUM|He does c/o a slight stuffiness/cold. He has no c/o's otherwise. He has been wearing the CPAP most of the noc, he states. No, CP, SOB, N/V, diarrhea or constipation. Voids w/o probs. Lungs CTA with good air exchange today, s1/S2 with soft semi 2/6, +1 pedal edema to mid calves bilat. Abd soft, nontender +Bt's, Neuro: focally intact. VSS today_ 98.2, 59-60's mostly, 136/94, 18 and 98%/3l nc.
CTA|computed tomographic angiography|CTA|190|192|HOSPITAL COURSE|She did have some issues with some chest pain that were not fully elucidated. She did not have any evidence of myocardial infarction by EKG or cardiac enzymes and had no evidence of a PE by CTA or DVT by ultrasound. At the time of discharge, her pain was well controlled.
CTA|clear to auscultation|CTA.|144|147|PHYSICAL  EXAMINATION|He has no delay in in his speech. Cranial nerves II through XII are intact. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: ABDOMEN: Lungs aAre CTA. SKIN: Without edema. He does have some bruising present some bruising and abrasions present on his left upper extremity and lower extremity.
CTA|computed tomographic angiography|CTA.|264|267|HISTORY OF PRESENT ILLNESS|At the Stroke Clinic, the patient was evaluated in _%#MM2005#%_ and she was placed on aspirin for stroke prevention, and it was felt that the symptoms were more related to a TIA. She was referred to Dr. _%#NAME#%_ for bilateral periophthalmic aneurysm followup by CTA. On the day of admission in the clinic, she had 2 transient episodes of weakness. According to the patient, that triggered by heat, generalized tiredness.
CTA|computed tomographic angiography|CTA|167|169|HOSPITAL COURSE|There was a possible hypodensity in the right rostral midbrain although no vascular significant abnormalities were seen on MRA. The MRI did not show any acute stroke. CTA was obtained to evaluate for a possible stenosis that showed stenosis of the right posterior cerebral artery. No acute infarct. No cervical internal carotid artery stenosis. A TTE was obtained that showed ejection fraction over 55%, left ventricle normal in size, the left ventricular systolic function was normal, mild aorta regurgitation.
CTA|clear to auscultation|CTA|209|211|PHYSICAL EXAMINATION ON ADMISSION|GENERAL: Comfortably sitting in bed. HEENT: NCAT. Alopecia. PERL. EOM full. Anicteric. Moist mucous membranes. NECK: No cervical lymphadenopathy. CARDIOVASCULAR: RRR. No murmur. Brisk capillary refill. LUNGS: CTA bilaterally. ABDOMEN: Nondistended, normal bowel sounds, soft and nontender. No masses, no hepatosplenomegaly. SKIN: No rashes. NEUROLOGIC: Alert. LABORATORY DATA ON ADMISSION: WBC 5.9, hemoglobin 12.1, platelets 313, ANC 4.5, differential 76 N, 13 L, 9 M, 2 E, 0 B.
CTA|clear to auscultation|CTA|204|206|PHYSICAL EXAMINATION|He is poorly responsive. HEENT: PERRL. Conjunctivae clear. OP with very dry, tacky mucous membranes. Neck: Supple. No thyromegaly. No lymphadenopathy. Carotids strong and symmetric, without bruit. Lungs: CTA bilaterally anteriorly. Heart: Regular rate and rhythm, no murmur. Abdomen: Soft, nontender, nondistended. Normal active bowel sounds. No mass, no hepatosplenomegaly.
CTA|clear to auscultation|CTA|142|144|SUBJECTIVE|Posterior oropharynx pink and moist without lesions or exudate. NECK: Supple with full range of motion. No adenopathy. No thyromegaly. LUNGS: CTA bilaterally. CV: RRR without murmur, rub or gallop. ABDOMEN: Positive bowel sounds, soft, non-tender, non-distended, no hepatosplenomegaly. EXTREMITIES: Warm with good perfusion.
CTA|computed tomographic angiography|CTA|153|155|HISTORY OF PRESENT ILLNESS|In addition, there was a fullness to the neural foramen which was suggestive of a vertebral artery loop. Successive follow-up MRA, formal angiogram, and CTA revealed a loop of the left vertebral artery into the C5-6 neural foraminal area with possible compression of the C6 nerve root.
CTA|computed tomographic angiography|CTA|239|241|PAST MEDICAL HISTORY|So, the patient was placed on Cipro and Flagyl. PAST MEDICAL HISTORY: The patient has a past medical history of some abdominal discomfort stating that she was hospitalized in 2001 with tests at that time including possible colonoscopy and CTA of the abdomen and upper endoscopy. All the tests were essentially normal and she was to follow up if she had any recurrent discomforts with emergent laboratory tests looking for any signs of liver inflammation.
CTA|clear to auscultation|CTA.|181|184|PHYSICAL EXAMINATION|Her vital signs are stable, she is afebrile. EARS: Are grossly normal. EOMI, PERRLA. Nasal passages are clear. Oropharynx is negative. NECK: No nodes, thyromegaly or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs, gallops or clicks. ABDOMEN: Is soft, without rebound or guarding. There are no masses or organomegaly noted.
CTA|clear to auscultation|CTA|162|164|PHYSICAL EXAMINATION|GENERAL: The patient is a frail-appearing elderly male in no acute distress. HEENT: PERRL, conjunctivae clear. OP with dry mucous membranes. NECK: Supple. LUNGS: CTA bilaterally. HEART: Irregularly irregular. ABDOMEN: Soft, nontender, no organomegaly. EXTREMITIES: Bilateral lower extremities with no edema. SKIN: Warm and dry. LABORATORY: A CBC with a white count of 800 and 47% neutrophils.
CTA|clear to auscultation|CTA,|134|137|DISCHARGE EXAMINATION|HEENT: Facial asymmetry, PERRL, EOMI, slight nystagmus with left gaze. Right facial droop. Flat right nasal labial fold. Respiratory: CTA, no wheezes, rales or rhonchi. Cardiovascular: RRR, no murmur, rub or gallop. Abdomen: Positive bowel sounds, soft, non- tender, non-distended.
CTA|clear to auscultation|CTA|213|215|EXAMINATION|Eyes - PERRL. EOMI. Fundi benign. NECK: There is no obvious cervical, supraclavicular, axillary, or inguinal adenopathy noted to palpation. HEART: RRR. No click, murmur, or extra sounds noted at this time. LUNGS: CTA throughout. No flank tenderness. ABDOMEN: Soft and nontender. No masses. No bowel sounds. No hepatosplenomegaly to palpation. EXTREMITIES: Warm and dry.
CTA|clear to auscultation|CTA|117|119|PRIMARY CARE PHYSICIAN|PERRL. Healing eye. Neck: LAD zero, thyromegaly zero, carotids x 2 zero. CV: RRR, S1 and S2 normal, MRG zero. Lungs: CTA bilaterally. Abdomen: Supple, NTND. Skin: Diffuse dry scaly lesions with underlying erythema of the skin covering most of the trunk and the proximal limbs.
CTA|clear to auscultation|CTA.|130|133|HOSPITAL COURSE|HEENT: much improved edema of the oral soft tissue. Decrease in pharyngeal erythema as well. LUNGS: No shortness of breath. Chest CTA. CARDIAC: No murmurs. ABDOMEN: Soft. SKIN: Skin was normal color, normal temperature. EXTREMITIES: No peripheral edema. The patient is thus being sent home with prescriptions and follow up plan.
CTA|clear to auscultation|CTA|233|235|PHYSICAL EXAMINATION|HEENT: Eyes, PERL. Extraocular muscles are intact. Ears, canals and tympanic membranes normal. Nasal mucosa normal. Mouth and throat unremarkable. No palpable cervical, supraclavicular, axillary or inguinal adenopathy. CHEST: Lungs, CTA throughout. No back or flank tenderness. HEART: Regular rate and rhythm. No murmurs, clicks or extra sounds noted at this time.
CTA|clear to auscultation|CTA|150|152|PHYSICAL EXAMINATION|SKIN: She is slightly pale. HEENT: PERRLA, conjunctivae are clear with dry mucous membranes. NECK: Supple, no lymphadenopathy, no thyromegaly. LUNGS: CTA bilaterally. HEART: RRR, no murmur. ABDOMEN: Soft, non-tender, non-distended, no mass. Rectal with black stool in the rectal vault which was guaiac positive.
CTA|clear to auscultation|CTA|150|152|PHYSICAL EXAMINATION|GENERAL: The patient was initially resting comfortably when I approached her. HEENT: Normocephalic, atraumatic; OP dry. NECK: Supple; no mass. LUNGS: CTA bilaterally anteriorly. HEART: RRR with 2/6 systolic ejection murmur. ABDOMEN: Soft; nontender; no guarding, no rebound. EXTREMITIES: Bilateral lower extremities with no edema. Right lower extremity is shortened and internally rotated.
CTA|computed tomographic angiography|CTA|165|167|HOSPITAL COURSE|He was therefore evaluated with a CT angiogram of brain with attention to posterior circulation, which was negative for vertebral basilar artery insufficiency. Head CTA did demonstrate a hypoplastic A1 segment of the right anterior cerebral artery and no anterior communicating artery; mild stenosis within the M2 branches of the right MCA; 50-60% stenosis within the cavernous segment of the right ICA and a 50-70% stenosis within the cavernous segment of the left ICA.
CTA|computed tomographic angiography|CTA|316|318|HOSPITAL COURSE|Head CTA did demonstrate a hypoplastic A1 segment of the right anterior cerebral artery and no anterior communicating artery; mild stenosis within the M2 branches of the right MCA; 50-60% stenosis within the cavernous segment of the right ICA and a 50-70% stenosis within the cavernous segment of the left ICA. Head CTA further demonstrated significant calcification within the vertebral arteries bilaterally, most significant on the left at the C5-C6 level with an 80% stenosis and on the right at the C6 level also with an approximate 80% stenosis.
CTA|clear to auscultation|CTA|142|144|PHYSICAL EXAMINATION ON ADMISSION|GENERAL: +O x 4, periorbital ecchymosis. HEENT: MMM. NECK: Supple. CARDIOVASCULAR: RRR, slight S2, grade 2/6 systolic ejection murmur. LUNGS: CTA bilaterally. ABDOMEN: Soft. EXTREMITIES: Right upper extremity in a sling. Painful to move it. SKIN: Warm and dry. NEUROLOGICAL: Cranial nerves II-XII intact. LABORATORY: Complete blood count: White blood count ___, hemoglobin 11.3, MCV 113, platelet count 319,000, PTT 25, INR 1.02. Chem-7 normal.
CTA|clear to auscultation|CTA.|198|201|PHYSICAL EXAMINATION|HEENT: His tympanic membranes are moderately occluded with cerumen but clear otherwise. EOMI. PERRLA. Nasal passages are clear. Oropharynx is negative. Neck: No nodes, thyromegaly or bruits. CHEST: CTA. COR: Regular rate without murmurs, gallops or rubs. ABDOMEN: Morbidly obese. I did not appreciate any masses or organomegaly. The patient was largely nontender. No rebound or guarding. GU: Normal male.
CTA|clear to auscultation|CTA|190|192|PHYSICAL EXAMINATION|GENERAL: The patient is a pleasant female in no acute distress. HEENT: PEERL, conjunctivae clear; OP slightly dry, dentition intact. NECK: Supple; no lymphadenopathy; no thyromegaly. LUNGS: CTA bilaterally. HEART: RR with 2/6 systolic ejection murmur. ABDOMEN: Soft; nondistended; mild epigastric tenderness to palpation with no rebound or guarding, no masses, no hepatosplenomegaly; normal active bowel sounds bilateral lower extremities without edema.
CTA|clear to auscultation|CTA|200|202|PHYSICAL EXAMINATION|General: The patient is a pleasant female, in no acute distress. HEENT: PERRL. Conjunctiva, clear. TMs, OP, clear with moist mucous membranes. Neck: Supple. No lymphadenopathy, no thyromegaly. Lungs: CTA bilaterally. Heart: Irregularly, irregular, with rate controlled on diltiazem. Loud 3/6 systolic murmur at the left lower sternal border. Abdomen with old surgical scars, soft, non-tender, non- distended, normoactive bowel sounds, no mass, no hepatosplenomegaly.
CTA|clear to auscultation|CTA|249|251|PHYSICAL EXAMINATION|Blood sugar was 138 upon arrival to the floor. GENERAL: The patient is a pleasant male in no acute distress. HEENT: PERRL, conjunctivae clear. OP with dry mucous membranes. NECK: Supple, no lymphadenopathy, no thyromegaly, no carotid bruits. LUNGS: CTA bilaterally. HEART: Regular rate and rhythm with occasional premature beat and harsh 3/6 systolic ejection murmur at the right upper sternal border, radiating into the neck.
CTA|clear to auscultation|CTA|287|289|PHYSICAL EXAMINATION|FAMILY HISTORY: Not significant. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 96.6; pulse 82; blood pressure 111/62; respiratory rate 12; oxygen saturation at 97% on room air. HEENT: PERRLA, EOMI, mildly dehydrated, oral mucosa slightly dry. CV: RRR; S1, S2 audible; no murmur. LUNGS: CTA bilaterally, no wheeze, no crepitation. ABDOMEN: Soft, positive tenderness in the right upper quadrant on deep palpation. Bowel sounds are present. NEUROLOGIC: Reflexes +2 bilaterally. Cranial nerves III, IV, VI, X, XI, and XII were grossly intact.
CTA|clear to auscultation|CTA|173|175|PAST MEDICAL HISTORY|HEENT: NAD. No Battle dor sign. No raccoon eyes. No discharge is noted from the ear, nose, or throat. Other HEENT exam NAD. NECK: Supple. Full range of motion noted. CHEST: CTA bilateral. HEART: No murmurs are noted. ABDOMEN: Appears distended secondary to her pregnancy. No pain. Bowel sounds are present. No CV tenderness. No bladder/flank area tenderness.
CTA|computed tomographic angiography|CTA,|152|155|IMAGING|Moderate amorphous phosphate crystals in the urine. No gross signs of infection at this time. Valproic acid level is 55. IMAGING: On repeat head CT and CTA, there appears to be a slightly increased intraparenchymal bleed in the left frontal area. This appears to be steady at this time. However, it warrants careful observation considering that it is only being held back from the ventricles from the corpus callosum.
CTA|computed tomographic angiography|CTA|130|132|ASSESSMENT AND PLAN|4. Frequent neuro checks. If mental status changes, then will consider surgical intervention, EVD, or both. 5. Repeat head CT and CTA on admission and again in 12 hours.
CTA|clear to auscultation|CTA|225|227|PHYSICAL EXAMINATION|GENERAL: The patient is a very frail elderly female who seems quite confused and cannot answer questions or interact appropriately. HEENT: PERRL; conjunctivae clear. OP dry with poor dentition. NECK: Supple; no bruit. LUNGS: CTA bilaterally. HEART: Regular rate and rhythm with 2/6 systolic ejection murmur. ABDOMEN: Mildly and diffusely tender with no rebound or guarding.
CTA|clear to auscultation|CTA|380|382|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Most recent vitals include a blood pressure of 115/61, heart rate 62, respiratory rate 16, oxygen saturations 97%, and temperature 100.1. GENERAL: The patient is a pleasant healthy appearing male who is lying in his hospital bed. HEENT: PERRL. Conjunctiva clear. OP clear with moist mucous membranes. NECK: Supple. No lymphadenopathy. No thyromegaly. LUNGS: CTA bilaterally. HEART: RRR, no murmur. ABDOMEN: Soft, non-tender, non- distended. Normoactive bowel sounds. No organomegaly. EXTREMITIES: Bilateral lower extremities without edema. SKIN: Hot and moist.
CTA|clear to auscultation|CTA|208|210|PHYSICAL EXAM|His oxygen saturations are 95% on room air. He is asleep with his mouth open. He responds when awakened. He responds appropriately. SKIN: Normal color and temperature. HEENT: Dry mouth, missing teeth. CHEST: CTA bilaterally. CVS: No murmurs are noted. ABDOMEN: Soft nontender. Bowel sounds are present. Abdomen is slightly bulging.
CTA|clear to auscultation|CTA|187|189|REVIEW OF SYSTEMS|HEENT: PERRLA, conjunctivae clear, EOMI. TMs and canals clear bilaterally. OP clear with dry mucous membranes and poor dentition. NECK: Supple, no lymphadenopathy, no thyromegaly. LUNGS: CTA bilaterally. HEART: Regular rate and rhythm with 2/6 systolic ejection murmur. ABDOMEN: Soft, nontender, nondistended; normoactive bowel sounds, no mass, no hepatosplenomegaly.
CTA|clear to auscultation|CTA|241|243|ADMISSION PHYSICAL EXAMINATION|HEENT: Head normocephalic, atraumatic. Ear clear bilaterally with some scarring of the tympanic membranes. Eyes normal. Nose and throat oropharynx clear, no ulcerations. Neck supple. CARDIOVASCULAR: S1, S2 without appreciable murmur. LUNGS: CTA bilateral crackles. ABDOMEN: Soft, nontender, no palpations liver, spleen. SKIN: No bruising. No rashes. NEUROLOGIC: Cranial nerves II through XII are grossly intact.
CTA|clear to auscultation|CTA|182|184|SOCIAL HISTORY|GENERAL: Not alert to person, time, or place. HEAD: Abrasion on top of head. EARS: Tympanic membranes normal. NECK: No thyromegaly. CARDIOVASCULAR: S1 and S2. RRR. No murmur. LUNGS: CTA bilaterally. ABDOMEN: Soft, empty, and deep positive bowel sounds. SPINE: Tender point over the spine. NEUROLOGIC: CN II to XII intact. Sensory intact. MUSCULOSKELETAL: Tender point over left-right femur, right knee, and left ankle.
CTA|clear to auscultation|CTA.|237|240|PHYSICAL EXAMINATION    VITAL SIGNS|She has history of arrest for illicit drug use. PHYSICAL EXAMINATION VITAL SIGNS: Stable. GENERAL: NAD, conversing well, and cognition appropriate. Appears somewhat irritable. Affect slightly flat. CARDIOVASCULAR: RRR. No murmur. LUNGS: CTA. ABDOMEN: Soft, no mass, and mild lower abdominal tenderness. EXTREMITIES: No edema. Left calf is tender to palpation, Homans sign positive.
CTA|clear to auscultation|CTA|127|129|PHYSICAL EXAM AT TIME OF ADMISSION|Tonsils symmetric but enlarged 2-3+ with exudate. NECK - supple with shotty lymphadenopathy only. No clavicular nodes. LUNGS - CTA bilaterally. CV - SRRR, tachycardiac but no murmur appreciated. Good pulses times four. Cap. refill 2 seconds. ABDOMEN - soft, NT, NABS, no HSM, no masses.
CTA|clear to auscultation|CTA|173|175|PHYSICAL EXAMINATION|He is lying on his hospital bed in Trendelenburg. He does appear somewhat pale. HEENT: PEERL, conjunctivae clear, OP clear with moist mucous membranes. NECK: Supple, LUNGS: CTA bilaterally. HEART: Regular rate and rhythm. ABDOMEN: Soft, with nicely healing surgical wound midline and ostomy site with bag on the left.
CTA|clear to auscultation|CTA|209|211|PHYSICAL EXAMINATION|General: Alert, uncomfortable. Head: Normocephalic and atraumatic. Eye: PERRLA and extraocular muscles intact. Neck: Supple. No cervical lymphadenopathy. Heart: S1, S2, RRR, no murmur, gallops, or rubs. Lung: CTA bilaterally. No wheezes, rhonchi, or crackles. Abdomen: Morbid, tender to palpation. Right abdomen, active bowel sounds, no rebound or guarding, nondistended.
CTA|clear to auscultation|CTA.|164|167|PHYSICAL EXAMINATION|NECK: LAD. CARDIOVASCULAR: Regular rate and rhythm. No murmurs, rubs, or gallops. LUNGS: Slight crackles and decreased breath sounds at left lower base; otherwise, CTA. ABDOMEN: Soft, nontender, nondistended, no CVA tenderness. NEUROLOGIC: Cranial nerves II-XII are intact, including all extremities; no focal deficits.
CTA|clear to auscultation|CTA|174|176|PHYSICAL EXAMINATION  VITAL SIGNS|Lying in bed with legs pulled to abdomen. HEENT: Head is normocephalic and atraumatic. Eyes: PERRLA, EOMI. Mucous membranes are moist. CARDIOVASCULAR: RRR. No murmur. LUNGS: CTA bilaterally. ABDOMEN: No guarding or rebound. Soft, flat. Bowel sounds present. Mild tenderness in the right lower quadrant and left lower quadrant on admission.
CTA|clear to auscultation|CTA.|207|210|PHYSICAL EXAMINATION  VITAL SIGNS|Gait not assessed. Fully oriented. Speech is clear. Tongue midline. No focal deficits or weaknesses. NOSE, MOUTH, AND THROAT: Mucous membranes are moist. CARDIOVASCULAR: Irregularly irregular rhythm. LUNGS: CTA. ABDOMEN: Soft and nontender. LABORATORY DATA: Labs on admission: Hemogram: White count was 7.7, hemoglobin 13.4, platelets 213, sodium 144, and potassium 3.4. Glucose of 108, creatinine 0.98, BUN 18, GFR estimated 57.
CTA|clear to auscultation|CTA|223|225|PHYSICAL EXAMINATION|She is afebrile. GENERAL: The patient is a pleasant, obese female in no acute distress. HEENT: PERRL. Conjunctiva clear. OP clear with somewhat dry mucous membranes. NECK: Supple. No lymphadenopathy. No thyromegaly. LUNGS: CTA bilaterally. HEART: Somewhat irregular with mechanical S1, S2. ABDOMEN: Soft, non-tender. The lower abdominal surgical wound has already been examined by GYN and was dressed so I did not re-examine that area.
CTA|clear to auscultation|CTA|316|318|PHYSICAL EXAMINATION   VITAL SIGNS|PHYSICAL EXAMINATION VITAL SIGNS: Stable. GENERAL: Pleasant male, conversing well, cognition and affect appear appropriate, dressed in T-shirt and shorts, actively walking through the halls of the floor. CVS: Late systolic murmur, grade 3/6 heard maximally at apex, S1 and S2. No rubs or thrills appreciated. LUNGS: CTA bilaterally. ABDOMEN: Soft. No mass. No tenderness. EXTREMITIES: No edema. SKIN: No visible rashes, absence of splinter hemorrhages. No visible Janeway or Osler nodes. LABORATORY: Chest x-ray dated _%#MM#%_ _%#DD#%_, 2006, shows clear lungs and normal-sized heart with a PICC line with tip in the SVC, left-sided.
CTA|computed tomographic angiography|CTA|215|217|HOSPITAL COURSE|Slight headache that was controlled with pain medications. The patient later on postoperative day #1 left the SICU and was brought to 5D. On postoperative day #2, once again no overnight events. The patient had the CTA of the head, which showed no residual aneurysm. On postoperative day #3, the patient once again did well overnight. However, the blood pressure seemed to go up into the 150s and 160s systolic.
CTA|computed tomographic angiography|CTA|116|118|BRIEF HISTORY|She had no medical or anatomic contraindications to donation and she had favorable anatomy on physical examination. CTA demonstrated she has single renal artery, renal vein and ureter. She had no masses or cyst in either kidney. HOSPITAL COURSE: The patient was admitted on the morning of surgery and underwent an uneventful left hand-assist laparoscopic donor nephrectomy.
CTA|clear to auscultation|CTA|143|145|PHYSICAL EXAMINATION|It is difficult to tell whether he has any aphasia. He did follow my commands 100% in examination. Cranial nerves II-XII appear intact. CHEST: CTA throughout. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Soft, nontender and nondistended. SKIN: He had a moderate amount of edema present in the fourth digit on his left hand, third digit on his right hand, right knee and both wrists.
CTA|clear to auscultation|CTA.|162|165|PHYSICAL EXAMINATION|GENERAL EXAM: Nasal cannula. Tympanic membranes, EACs were clear. Nasal passages are clear. Oropharynx is negative. NECK: No nodes, thyromegaly or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs, gallops or clicks. ABDOMEN: Is soft, non-tender without masses or organomegaly. GENITOURINARY: Exam was deferred. EXTREMITIES: With no swelling SKIN: Grossly normal NEUROLOGIC: Cranial nerves, motor sensation, deep tendon reflexes and cerebellar functions are all within normal limits.
CTA|clear to auscultation|CTA|168|170|PHYSICAL EXAMINATION ON ADMISSION|Appearance: Alert and oriented, NAD. Eyes: PERRL, EOMI, without icterus. ENT: Oral mucosa moist and pink. Neck: LAD-0. Supple. Possible fullness of the thyroid. Chest: CTA bilaterally. Cardiovascular: RRR, S1, S2 normal. Abdomen: Bowel sounds positive, moderate distention with some right upper quadrant tenderness to palpation and involuntary guarding.
CTA|clear to auscultation|CTA,|136|139|PHYSICAL EXAMINATION|EARS: TM normal. EYES: PERRLA. NOSE, MOUTH AND THROAT: Within normal limits. NECK: No JVD seen. CARDIOVASCULAR: RRR, no murmurs. LUNGS: CTA, breath sounds positive. ABDOMEN: Soft, nontender and nondistended, no mass. SKIN: No obvious lesions seen. NEUROLOGIC: Intact, MMSE is 24/30. LABORATORY/X-RAY RESULT ON ADMISSION: WBC 6.1, hemoglobin 10.2, hematocrit 29.4, platelet 360,000, INR 0.95, PTT 26, ethanol level less than 0.01, sodium 136, potassium 3.8, chloride 102, CO2 25, blood urea nitrogen 9, creatinine 1 and blood glucose 114, troponin less than 0.04, amylase less than 30, chest x-ray normal, CT of head normal, EKG within normal limits.
CTA|computed tomographic angiography|CTA|75|77|HISTORY|It was felt that she could be treated medically and has done well. MRI and CTA revealed a greater than 70% stenosis of the proximal left internal carotid artery. Approximately 50% stenosis of the origin of the left common carotid artery off the aortic arch.
CTA|clear to auscultation|CTA|130|132|PHYSICAL EXAMINATION ON ADMISSION|Neck: Supple, bilateral submaxillary glands. Thyromegaly: Zero. Increased IJV: Zero. CV: RRR. S1 and S2 normal. MRC: Zero. Chest: CTA bilaterally. Abdomen: Supple. NTND. Positive bowel sounds. Organomegaly: Zero. Skin: No rashes, normal color. Diaphoresis, spider angiomas: Zero. Collateral venous circulation: Zero. Palmar erythema: Zero.
CTA|clear to auscultation|CTA|177|179|PHYSICAL EXAMINATION|Injected conjunctivae. Mucous membranes were moist. Neck: No masses or tenderness. The neck was supple with good range of movement without pain. COR: Tachy, regular. Pulmonary: CTA bilaterally. Abdomen: Soft, nontender, nondistended, positive bowel sounds. Midline laparotomy scar, right lower quadrant scar, well healed. Extremities were without edema.
CTA|clear to auscultation|CTA|204|206|DIAGNOSIS|Head is normocephalic. Neck examination reveals a small hardened lymph node on the right anterior cervical chain which the patient describes as having for many years. No bruits. Euthyroid. Respiratory is CTA bilaterally. Cardiovascular examination: regular rate and rhythm, no murmurs, gallops, or rubs. Abdomen: soft, nontender, nondistended, positive bowel sounds, no masses. GU: there is no CVA tenderness.
CTA|clear to auscultation|CTA|126|128|PHYSICAL EXAMINATION|Oropharynx clear. Neck: LAD: 0, (_______________): 0, thyromegaly: 0. CV: RR, S1, S2 normal, systolic ejection murmur. Lungs: CTA bilaterally. Abdomen: Soft, NTND, positive bowel sounds. Skin: No rashes. Neuro: Grossly intact. LABORATORY: CBC: WBC 12,700, hemoglobin 14.1, platelets 506,000.
CTA|clear to auscultation|CTA|167|169|HISTORY OF PRESENT ILLNESS|ADMISSION MEDICATIONS: None. ALLERGIES: NONE. SOCIAL HISTORY: None. PHYSICAL EXAMINATION GENERAL EXAM: In no acute distress. HEENT: Pupils PERRLA. Neck supple. LUNGS: CTA bilateral. CARDIOVASCULAR: RRR. ABDOMEN: Soft, nontender, and nondistended. Bowel sounds present. No abdominal masses palpated. GENITOURINARY: No CVA tenderness. External genitalia within normal limits. Bimanual exam and pelvic exam within normal limits.
CTA|clear to auscultation|CTA|210|212|OBJECTIVE|EOM's intact. Funduscopic exam; sharp discs, normal vasculature. Posterior oral pharynx is pink and moist without lesions or exudate. Neck is supple. Full range of motion. No adenopathy. No thyromegaly. LUNGS: CTA bilaterally. CARDIOVASCULAR: RRR without murmur, rub, or gallop. BREASTS AND GENITALIA: Are within normal limits _%#MM2001#%_. ABDOMEN: Positive bowel sounds.
CTA|clear to auscultation|CTA|145|147|PHYSICAL EXAM ON ADMISSION|ENT reveals dental repair mediocre. Neck is supple. Thyromegaly zero. LAD zero. Carotid bruit zero. Distended jugular veins plus. Respiratory is CTA bilaterally. CV is irregular heart sounds. S1 and S2 normal. Blowing systolic murmur radiating to the axilla without S3 gallop or rubs.
CTA|clear to auscultation|CTA|184|186|PHYSICAL EXAMINATION|No thrush. Moist. No sinus tenderness upon pressure or percussion. Neck is supple without LAD. No DJV or bilateral carotid bruits. Cardiovascular: RRR. S1 and S2 normal. MRG 0. Chest: CTA bilaterally. Abdomen: Supple. NTND. ROM 0. Bowel sounds positive. Rectal: Deferred. Spine: History of DJD. Extremities: Mild pitting edema. Peripheral pulses x 4 positive.
CTA|clear to auscultation|CTA|227|229|OPERATIONS/PROCEDURES PERFORMED|Vital signs at the time of examination are blood pressure 110/72, pulse 72, and temperature 99.0. HEENT was normocephalic. Oropharynx: No erythema, no exudates. Heart regular rate and rhythm. No murmurs, rubs or gallops. Lungs CTA bilaterally. Abdomen: Midline incision, soft, nondistended, positive bowel sounds. Extremities revealed no excess debris. Neurologic examination was nonfocal. Skin examination showed no rash or lesions.
CTA|clear to auscultation|CTA|240|242|ALLERGIES|MEDICATIONS: Synthroid 0.125 mcg p.o. q.d., Estratest, Zoloft 150 mg p.o. q.d. PHYSICAL EXAMINATION: The patient was alert and oriented, well appearing. Head was normocephalic. CV was regular rate and rhythm, mid-systolic click. Lungs were CTA bilaterally. Abdomen was soft, nontender, ileal conduit and colostomy bags. Bowel sounds present. Extremities: Pedal pulses positive bilaterally. Right medial thigh was erythematous and hard in comparison to the left.
CTA|clear to auscultation|CTA|173|175|PHYSICAL EXAMINATION|HEENT: PERRL. EOMI. Conjunctivae clear. OP clear, with slight dry mucous membranes. She wears dentures up and down. NECK: Supple; no lymphadenopathy; no thyromegaly. LUNGS: CTA bilaterally; no respiratory distress. HEART: bradycardic, with occasional premature beats. ABDOMEN: soft. EXTREMITIES: bilateral lower extremities without edema. SKIN: with poor turgor and tenting.
CTA|clear to auscultation|CTA.|166|169|PHYSICAL EXAMINATION|Head is otherwise normocephalic other than the bruise. Nasal passages are clear. EOMI. PERRLA. Oropharynx is negative. NECK: No nodes, thyromegaly, or bruits. CHEST: CTA. COR: Regular rate without murmurs, gallops, or clicks. May be a very soft 1/6 systolic murmur that I could appreciate at times.
CTA|clear to auscultation|CTA|177|179|ADMISSION PHYSICAL EXAMINATION|GENERAL: NED; lying in bed. HEENT: ATNC; PERRL; EOMI. Oropharynx: clear. Neck: supple; JVD flat; no nodes. Mild epistaxis. CARDIOVASCULAR: RRR; S1, S2 normal. MRG: zero. LUNGS: CTA bilaterally. ABDOMEN: positive bowel sounds; soft; NTND; OM: zero. SPINE: non-tender. EXTREMITIES: 2+ pitting edema bilaterally. SKIN: petechiae. NEUROLOGIC: Cranial nerves, II-XII: intact.
CTA|clear to auscultation|CTA.|164|167|PHYSICAL EXAMINATION|He is in no acute distress. EARS: Are grossly normal. EOMI, PERRLA. Nasal passages are clear. Oropharynx is negative. NECK: No nodes, thyromegaly or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs, gallops or clicks. ABDOMEN: Is soft, non-tender without masses or organomegaly. GENITOURINARY: Exam was deferred at present.
CTA|clear to auscultation|CTA|145|147|ADMISSION PHYSICAL EXAMINATION|Carotid artery x 2: zero. DJV, with an estimated CVP 15 cm of water. Thyromegaly: zero. CARDIOVASCULAR: RRR, S1 and S2 normal. MRG: zero. LUNGS: CTA bilaterally. ABDOMEN: supple, NTND. LOM: zero. BS: positive. EXTREMITIES: LEE: 1+; hammer toes. SPINE: Low back incision, no pain to percussion.
CTA|clear to auscultation|CTA.|170|173|PHYSICAL EXAMINATION|HEAD, EYES, EARS, NOSE AND THROAT: NC/AT. Tympanic membranes are clear. EOMI, PERRLA. Nasal passages are clear. Oropharynx is negative. NECK: No nodes, or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs, gallops or clicks. ABDOMEN: Is tender, diffusely across the upper portion of the abdomen. There is no rebound, mild guarding, no masses or hepatosplenomegaly.
CTA|clear to auscultation|CTA.|129|132|OBJECTIVE|HEENT: Ears are grossly normal. EOMI. PERRLA. Nasal passages are clear. Oropharynx is negative. NECK: No nodes or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs, gallops, or clicks. ABDOMEN: Soft, nontender without masses or organomegaly. The patient has had occasional trouble about 2x weekly with some heartburn.
CTA|clear to auscultation|CTA.|156|159|PHYSICAL EXAMINATION|The left ear was normal. EOMI, PERRLA. Nasal passage are clear. Oropharynx - showed dentures upper and lower. NECK: No nodes, thyromegaly or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs, gallops or clicks. ABDOMEN: Is soft, with mild tenderness in the mid epigastrium. I do not appreciate any masses or organomegaly. GENITOURINARY: Exam was deferred.
CTA|clear to auscultation|CTA|161|163|PHYSICAL EXAMINATION|Moist mucous membranes, oropharynx visualized. Neck: Supple, SROM, LAD 0, thyromegaly 0, carotid bruit x 2 0. CV: RRR, tachycardic. S1, S2 normal. MRG 0. Lungs: CTA bilaterally. Abdomen: Obese, BS positive. NTND, OM: 0. Breast exam: Deferred. Spine: Negative for FROM. Heme: No cervical, inguinal, or axillary 0.
CTA|clear to auscultation|CTA.|215|218|PHYSICAL EXAMINATION|Her vital signs are stable. HEAD: Normocephalic, atraumatic. Tympanic membranes, EACs are clear. EOMI, PERRLA. Dentures upper and lower in mouth, no other oral lesions. NECK: No thyromegaly, bruits or nodes. CHEST: CTA. CORONARY: Regular rate without murmurs, gallops or clicks. ABDOMEN: Is soft, non-tender without masses or organomegaly GENITOURINARY: Exam was deferred.
CTA|clear to auscultation|CTA.|194|197|PHYSICAL EXAMINATION|He seems to be comfortable lying in bed. His vital signs are as noted. EARS: Are grossly normal. EOMI. PERRLA. Nasal passages are clear. Oropharynx is negative. NECK: No nodes or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs, gallops or clicks. ABDOMEN: Is soft, a little bit of guarding at times. No rebound, no masses or organomegaly are noted. Bowel sounds are normal.
CTA|clear to auscultation|CTA.|152|155|PHYSICAL EXAMINATION|HEAD, EYES, EARS, NOSE AND THROAT: NC/AT. EOMI, PERRLA. Nasal passages are clear. Oropharynx is negative. NECK: No nodes, thyromegaly or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs, gallops or clicks. ABDOMEN: Is soft, non-tender without masses or organomegaly. Bowel sounds are normal GENITOURINARY: Exam was deferred at present.
CTA|clear to auscultation|CTA|225|227|EXAMINATION|Nasal mucosa normal. Mouth and throat unremarkable. NECK: No obvious cervical, supraclavicular, or inguinal adenopathy. No obvious thyromegaly. HEART: RRR. No obvious click, murmur, or extra sounds noted at this time. LUNGS: CTA throughout. No obvious slight tenderness. ABDOMEN: Soft, nontender. No masses. Normal bowel sounds. No hepatosplenomegaly. EXTREMITIES: The patient moves all extremities well.
CTA|clear to auscultation|CTA|217|219|PLAN|The admission physical examination was significant for excessive oral secretions and drooling from the corners of the mouth, a grade II/VI systolic murmur at the left lower sternal border, and a poor suck. Lungs were CTA without increased work of breathing. Problems during the hospitalization included the following: 1. FEN- _%#NAME#%_ was initially made NPO secondary to feeding intolerance and respiratory concerns.
CTA|clear to auscultation|CTA|245|247|PHYSICAL EXAMINATION|She is mumbling semi-coherently. She seems to be mumbling about a family member with diabetes who lost his toes. HEENT: Eyes with crusty matter at the inner epicanthus bilaterally. OP with dry mucous membranes, no dentures. NECK: Supple. LUNGS: CTA anteriorly. HEART: Regular rate and rhythm. ABDOMEN: Soft, non-tender, non-distended, normoactive bowel sounds. EXTREMITIES: Right lower extremity without edema, warm and dry. Left lower extremity shortened and externally rotated.
CTA|clear to auscultation|CTA|196|198|PHYSICAL EXAMINATION|General: The patient is a pleasant female in no acute distress. HEENT: PERRL, OP, with moist mucous membranes after rehydration in the ER. Neck: Supple, no lymphadenopathy, no thyromegaly. Lungs: CTA bilaterally. Heart: RRR, no murmur. Abdomen: Soft, with tenderness in the right lower quadrant, no rebound, no guarding, no mass, no hepatosplenomegaly.
CTA|clear to auscultation|CTA|213|215|PHYSICAL EXAMINATION|GENERAL: The patient is a pleasant, obese, African woman in no acute distress. HEENT: PERRLA, conjunctivae are clear. OP with moist mucous membranes. NECK: Supple. Thyroid slightly enlarged with no nodule. LUNGS: CTA bilaterally, no respiratory distress. HEART: RRR. ABDOMEN: Obese, soft, normoactive bowel sounds, non-tender. EXTREMITIES: Bilateral lower extremities with no edema, no calf tenderness to palpation.
CTA|clear to auscultation|CTA.|152|155|DISCHARGE EXAMINATION|DISCHARGE EXAMINATION: Vitals are stable. The patient is afebrile. She is in no acute distress. HEENT exam is grossly normal. Neck - No bruits. Chest - CTA. Coronary - Grade 1-2/6 systolic murmur unchanged from previous. Abdomen is soft, nontender without masses. Extremities without swelling. The patient reports that her right knee is markedly improved.
CTA|clear to auscultation|CTA|372|374|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: In the emergency room her blood pressure was 153/100; pulse 100; respiratory rate 16; oxygen saturations within normal limits, temperature 100.2. GENERAL: The patient is a pleasant female in no acute distress. HEENT: PERRL, conjunctivae are clear, OP with moist mucous membranes. NECK: Supple, no lymphadenopathy, no thyromegaly. LUNGS: CTA bilaterally. HEART: RRR, no murmur. ABDOMEN: Distended, but soft with mild diffuse tenderness to palpation. No focal tenderness to palpation. No rebound. No guarding. No organomegaly.
CTA|clear to auscultation|CTA|184|186|PHYSICAL EXAMINATION|HEENT: Pupils are oblong and consistent with history of cataract surgery. OP with moist mucous membranes and partial dentures: NECK: Supple; no lymphadenopathy, no thyromegaly. LUNGS: CTA bilaterally. HEART: RRR with II/VI systolic ejection murmur. ABDOMEN: Soft; nontender; no mass; no hepatosplenomegaly. EXTREMITIES: Bilateral lower extremities without edema.
CTA|clear to auscultation|CTA|185|187|OBJECTIVE|GENERAL: The patient is a pleasant female in no acute distress. HEENT: PERRL, conjunctivae clear, OP with dry mucous membranes. NECK: Supple. No lymphadenopathy. No thyromegaly. LUNGS: CTA bilaterally. HEART: RRR with holosystolic murmur at the apex. ABDOMEN: Soft; nontender; nondistended; normal active bowel sounds; no mass, no hepatosplenomegaly.
CTA|clear to auscultation|CTA|155|157|DISCHARGE EXAMINATION|Blood pressure 137/70. O2 saturations 91%. General: NAD, alert, decreased hearing, decreased vision, decreased memory. HEENT: No new changes noted. Chest: CTA bilateral. CVS: No new changes. Abdomen: Soft, non-tender. Extremities: No peripheral edema. ASSESSMENT/PLAN: Vioxx seems to be helping the patient.
CTA|clear to auscultation|CTA|205|207|PHYSICAL EXAMINATION|Mouth is moist, pink, with no gross oral lesions. Neck is thick, soft with no gross thyromegaly or masses can be appreciated. Pupils equal, round, and reactive to light. Fundoscopic exam is normal. LUNGS: CTA and P. No gross wheezes, rhonchi or rales. HEART: Regular rate and rhythm, positive S1, S2. No gross rubs, murmurs or gallops.
CTA|clear to auscultation|CTA|200|202|PHYSICAL EXAMINATION|HEENT: Bilateral boggy turbinates, obstructive nasal passages. Throat was unremarkable. No hyperemic pustules, clear bilaterally. NECK: Supple, no rigidity, masses, thyromegaly, or adenopathy. LUNGS: CTA bilaterally. Heart: Regular rate and rhythm, no rubs or murmurs. Normal S1, S2; no S3. ABDOMEN: Soft, normal bowel sounds, no organomegaly, tenderness, or masses detected.
CTA|clear to auscultation|CTA|191|193|PHYSICAL EXAMINATION|There is no proptosis. Pupils are equal and reactive. Corneal reflex is crisp. EOMI. Oropharynx is clear with moist mucous membranes. NECK: Supple, no lymphadenopathy, no thyromegaly. LUNGS: CTA bilaterally. HEART: RRR, no murmur. ABDOMEN: Soft, nontender, no mass, no hepatosplenomegaly. Bilateral lower extremities with no edema. Pedal pulses are strong and symmetric.
CTA|clear to auscultation|CTA,|144|147|PHYSICAL EXAMINATION|Pupils are equal, round and reactive to light. Neck: Supple. OP is clear. Cardiovascular: S1, S2 are normal. No murmur, gallops or rubs. Lungs: CTA, abdomen, soft, nontender, nondistended bowel sounds are positive. Extremities: Trace edema noted. Neurologic: No focal, neurologic deficits. Cranial nerves 2 to 12 are intact.
CTA|clear to auscultation|CTA.|171|174|SKIN|NECK: Supple with anterior cervical lymphadenopathy. Tenderness in submental area laterally. Tender submandibular lymph nodes bilaterally. LUNGS: Clear to auscultation or CTA. ABDOMEN: Soft, nontender, no masses. SKIN: Skin is warm and dry. LABORATORY: On admit, white count 17.6, hemoglobin 15.3, 73 neutrophils, 17% lymphocytes, and platelets 299.
CTA|clear to auscultation|CTA|272|274|DISCHARGE DIAGNOSIS|On the face, there was a right side facial swelling which was hard upon palpation from cheek bone down in and around the right ear,anterior and below the right ear. NECK: Supple, no cervical lymphadenopathy. No mass in the neck. CARDIOVASCULAR: RRR without murmur. LUNGS: CTA bilaterally. ABDOMEN: Bowel sounds werepresent, soft, and benign. No CVA tenderness. LYMPHATIC: Right posterior auricular lymph node enlargement.
CTA|computed tomographic angiography|CTA|280|282|SOCIAL HISTORY|He continued to have a normal exam. He had serial troponins that were negative, so he was admitted and had a TIA workup, admitted to telemetry, and was in normal sinus rhythm and had negative serial troponins. EKG reveals right bundle-branch block, which was not new. Head CT and CTA of the head were negative for any acute abnormalities or significant stenoses of the vessels. We spoke with patient's primary care physician, Dr. _%#NAME#%_, and per his recommendations, he was discharged to home on half the dose of Prinivil.
CTA|clear to auscultation|CTA|196|198|PHYSICAL EXAMINATION|HEENT: Head was normocephalic and atraumatic. Hard of hearing. Eyes were amniotic pupil (the patient received Dilaudid although symmetric), EOMI. NECK: Supple. CARDIOVASCULAR: S1, S2, RRR. LUNGS: CTA bilaterally. No wheezes, rhonchi or crackles. ABDOMEN: Positive bowel sounds, soft, nontender, nondistended. SPINE: No CVA tenderness. NEUROLOGIC: Cranial nerves II-XII grossly intact. Grossly no focal deficit.
CTA|clear to auscultation|CTA.|128|131|ALLERGIES|Speech: Rate and rhythm normal. HEENT: Normocephalic, atraumatic. Upper and lower dentures in situ. CVS: RRR. No murmur. LUNGS: CTA. ABDOMEN: Soft. No mass, no tenderness. EXTREMITIES: Left hip dressing in situ, absence of erythema or edema. Bilateral pneumonic antithrombotic pumps in situ. LABORATORY: Hemoglobin 10.5. Basic metabolic panel: Sodium 140, potassium 3.7, chloride 105, bicarbonate 28, and glucose 115.
CTA|clear to auscultation|CTA.|216|219|PHYSICAL EXAMINATION|Otherwise afebrile. General: Awake, cognition appropriate. Affect slightly blunted. Excessively verbose during examination at times. Appears mildly anxious. Presents with wife at bedside. CVS: RRR, no murmur. Lungs: CTA. Abdomen: Soft, no mass, no tenderness. Extremities: No edema. LABORATORY: BMP: Sodium 141, potassium 3.5, chloride 114, bicarbonate 18, glucose 97, BUN 18, creatinine 2.4. Lipase 679.
CTA|clear to auscultation|CTA.|227|230|PHYSICAL EXAMINATION|Eyes: Extraocular movement intact. Ears: Within normal limit. Nose, mouth and throat: Within normal limit. NECK: His collar was in place and lymphadenopathy on the supraclavicular region. CARDIOVASCULAR: RRR, no murmur. LUNGS: CTA. Breath sounds positive. ABDOMEN: Soft and nontender. No mass palpable. BREASTS: Deferred. SPINE: Deferred, because he was lying down. SKIN: Hydrated, no obvious lesion. NEUROLOGIC: Intact. II through XII nerves are intact.
CTA|computed tomographic angiography|CTA|437|439|PROCEDURES|On _%#MMDD2006#%_, an MRI and MRA of the base of the brain and neck, dissection protocol revealing arterial dissection in a horizontal portion of the right vertebral artery at C1-C2. On _%#MMDD2006#%_, CT angio of the neck reveals findings consistent with a dissection of the right vertebral artery with intramural hematoma and enhancement of the adventitia between the level of C2 and the skull base with 60% luminal narrowing and head CTA relatively unremarkable. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 32-year-old female who presented with a worsening headache over the past 2 weeks.
CTA|computed tomographic angiography|CTA.|167|170|HISTORY OF PRESENT ILLNESS|Typically, this chest pain will respond to nitroglycerin. The patient was seen at an outside hospital first where she was ruled out for pulmonary embolism by means of CTA. Otherwise, the patient denied orthopnea, PND, palpitations, lightheadedness or dizziness. ALLERGIES: Tramadol and . MEDICATIONS: Prior to this admission: 1. Nitroglycerin 0.4 mg p.r.n.
CTA|computed tomographic angiography|CTA|176|178|HISTORY OF PRESENT ILLNESS|The patient was being evaluated at the _%#CITY#%_ _%#CITY#%_ Hospital in Iowa for this upcoming surgery. She was found to have an 11 cm juxtarenal abdominal aortic aneurysm on CTA The patient had also complained of a chronic right calf-hip claudication at one to two blocks with variable incidence. She was seen by Dr. _%#NAME#%_ _%#NAME#%_, who is a general surgeon at the _%#CITY#%_ _%#CITY#%_ Clinic.
CTA|computed tomographic angiography|CTA|161|163|HOSPITAL COURSE|The neuro interventional team was consulted for evaluation of the left MCA stenosis. A CT angiogram was obtained. There was right pons ischemic stroke. The head CTA showed small irregular left middle artery. The left A1 segment is small and regular as well. The anterior communicating artery is small but patent. Regarding the posterior communicating artery, those are not visualized.
CTA|computed tomographic angiography|CTA|152|154|HOSPITAL COURSE|The distal left internal carotid artery remained small compared to the right and is irregular in the coronal segment at the left carotid terminus. Head CTA demonstrated narrow and regular left middle cerebral artery on left A1 segment. There was focal narrowing of the distal right vertebral artery.
CTA|computed tomographic angiography|CTA|172|174|PROCEDURES ON THIS ADMISSION|Neck MRA, no definite stenosis in the major cervical arteries. Scattered T2 hyperintensities in the paraventricular white matter. 4. CT angio of the head. Impression, head CTA demonstrates anterior focal widening of left internal carotid artery just above supraclinoid process, most likely atherosclerotic irregularity.
CTA|clear to auscultation|CTA|128|130|OBJECTIVE|Nasal mucosa: There is a deviated septum to the left. Neck: Supple, full range of motion, no adenopathy, no thyromegaly. Lungs: CTA bilaterally. CV: RRR, without murmur, gallop or rub. Abdomen: Positive bowel sounds, soft, nontender, nondistended, no hepatosplenomegaly. Normal pelvic, as well as breast exam _%#MMDD2002#%_.
CTA|clear to auscultation|CTA|174|176|HISTORY OF PRESENT ILLNESS|Eyes: PERL, EOMI. Icterus 0. ENT/Mouth: OP moist, pink. No petechiae over the palate. No tonsillar exudates. Neck: LAD: 0, thyromegaly 0, radiating carotid bruit x 2. Chest: CTA bilaterally. CV: RRR, S1, S2 normal. Holosystolic ejection murmur, 2/6. Abdomen: Bowel sounds positive, obese, bulging with fluid. Liver 10 cm below the costal margin.
CTA|computed tomographic angiography|CTA|233|235|PROCEDURES AND RESULTS|There is a regular the regularity and narrowing of the proximal left vertebral artery that was more normal on the prior exam. This may be due to an artifact and does not correlate with the new findings. If there is clinical concern, CTA of the neck could be obtained. Mild NuvaRing narrowing of the left proximal internal carotid artery and is not significantly changed.
CTA|clear to auscultation|CTA.|191|194|PHYSICAL EXAMINATION|HEAD, EYES, EARS, NOSE AND THROAT: NC/tympanic membranes clear. EACs are normal. EOMI, PERRLA. Nasal passages are clear. Oropharynx is negative. NECK: No nodes, thyromegaly or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs ABDOMEN: Is soft, with right flank discomfort. There is also right CVA discomfort. There are no masses or organomegaly appreciated.
CTA|clear to auscultation|CTA.|169|172|PHYSICAL EXAMINATION|GENERAL: No acute distress. HEENT: NCAT. Ears are normal. EOMI. PERRLA. Nasal passages are clear. Oropharynx is negative. NECK: No nodes, thyromegaly, or bruits. CHEST: CTA. Coronary regular rate without murmurs. ABDOMEN: Soft, nontender without masses or organomegaly. GU: Deferred. EXTREMITIES: With no swelling. Symmetric pulses. SKIN: Clear.
CTA|clear to auscultation|CTA.|261|264|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Reveals an alert, young woman in NAD. Blood pressure 102/68, weight 153 pounds, height 5'6" and temperature 97.7 degrees tympanic. PERRL, the TMs are gray, shiny. Pharynx is normal. Neck: Supple and without adenopathy, thyromegaly. Chest: CTA. CD: RRR, no M. Abdomen: Soft, non-tender, no HSM or masses, no rebound, rigidity. Examination of the right hand: Reveals significant swelling of the right thumb with moderate redness as well and warmth.
CTA|clear to auscultation|CTA.|133|136|PHYSICAL EXAM|HEENT: TM's are clear. EOMI, PERRLA. Nasal passages are clear. Oropharynx is negative. NECK: No nodes, thyromegaly or bruits. CHEST: CTA. CORONARY regular rate without murmurs. ABDOMEN is soft with some mid epigastric discomfort to palpation. There are no masses or organomegaly noted. Bowel sounds are present in all four quadrants.
CTA|clear to auscultation|CTA|205|207|PHYSICAL EXAMINATION|She has oxygen on. She is afebrile. HEAD, EYES, EARS, NOSE AND THROAT: Tympanic membranes, EACs were clear. Nasal passages were clear. Oropharynx is negative. NECK: No nodes, thyromegaly or bruits. CHEST: CTA at this time. CORONARY: Regular rate without murmurs ABDOMEN: Is soft, non-tender without masses or organomegaly. She does have a left lower quadrant colostomy from her previous surgery.
CTA|clear to auscultation|CTA|186|188|PHYSICAL EXAMINATION|EOMI: Conjunctiva clear. OP clear with normal landmarks and moist mucous membranes. Neck: Supple, no lymphadenopathy, no thyromegaly. Carotids strong and symmetric without bruit. Lungs: CTA bilaterally, no respiratory distress. Heart: Regular rate and rhythm, no murmur. Abdomen: Soft, nontender, nondistended, normal active bowel sounds, no mass, no hepatosplenomegaly.
CTA|clear to auscultation|CTA|196|198|PHYSICAL EXAMINATION|HEENT: no scleral injection. No oropharyngeal lesions: Neck: supple. Adenopathy 0. Thyromegaly 0. Cardiovascular: RRR. S1, S2 normal. MRG: 0. Lungs: Decreased breath sounds on the left; otherwise CTA bilaterally. Abdomen: Bowel sounds positive, soft, nontender, nondistended. Extremities: no edema. Skin: no lesions. Neurological: grossly normal. LABS ON ADMISSION: WBC 5300, hemoglobin 9.9. Chem 7: BUN 64, creatinine 1.8. HOSPITAL COURSE: PROBLEM #1: Left lower lobe pneumonia.
CTA|clear to auscultation|CTA|159|161|CHIEF COMPLAINT|PAST MEDICAL HISTORY: PUD, polio, appendectomy, hysterectomy, back surgery. ALLERGIES: NKDA. HOSPITAL COURSE: On admission, an elderly female in obvious pain. CTA bilaterally, RRR, diffuse pain with minimal palpation and rigid guarding. Plan at the time was transfer to ICU, resuscitate and correct elevated INR of 4.47, and plan for possible exploration.
CTA|clear to auscultation|CTA|143|145|PHYSICAL EXAMINATION|He has a lot of facial telangiectasias. Pupils are equal and reactive to light. Fundoscopic exam is normal. conjunctivae are normal. Lungs are CTA and P. Heart is RRR, positive S1, S2, no gross rubs, murmurs, or gallops. Abdomen is obese. He has a large healed scar in his anterior abdominal wall.
CTA|clear to auscultation|CTA|162|164|PHYSICAL EXAMINATION|PAST MEDICAL HISTORY: None. ALLERGIES: No known drug allergies. SOCIAL HISTORY: None. PHYSICAL EXAMINATION: No acute distress. HEENT: PERRLA. Neck supple. Lungs: CTA bilaterally. Cardiovascular: RRR. Abdomen: Soft, nontender, nondistended, bowel sounds present. Large gutted abdomen. Genitourinary examination was noncontributory. HOSPITAL COURSE: On postoperative day #1, the patient was complaining of some pain, no nausea, no vomiting, no bowel movements.
CTA|clear to auscultation|CTA|136|138|PHYSICAL EXAMINATION|He wears dentures but does not currently have them in his mouth. NECK: Supple, carotids are strong and symmetric with no bruits. LUNGS: CTA bilaterally, no respiratory distress. HEART: RRR, no murmurs, rubs, or gallops. ABDOMEN: Obese, soft, non-tender, non-distended, normoactive bowel sounds, no mass, no hepatosplenomegaly.
CTA|clear to auscultation|CTA.|177|180|PHYSICAL EXAMINATION|It is still oozing a little bit of blood. EOMI, PERRLA. Ears are grossly normal. Nasal passages are clear. Oropharynx is negative. NECK: No nodes, thyromegaly or bruits. CHEST: CTA. CORONARY: Showed an irregular rate and EKG did show premature atrial contractions. ABDOMEN: Is soft, non-tender without masses or organomegaly. GENITOURINARY: Showed normal female EXTREMITIES: Showed marked changes in the joints consistent with osteoarthritis.
CTA|clear to auscultation|CTA.|140|143|PHYSICAL EXAMINATION|HEAD, EYES, EARS, NOSE AND THROAT: NC/AT. EOMI, PERRLA. Nasal passages are clear. Oropharynx is negative. NECK: No nodes, or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs, gallops or clicks. ABDOMEN: Is soft, non-tender without masses or organomegaly GENITOURINARY: Exam normal male EXTREMITIES: Showed symmetric pulses, no swelling.
CTA|clear to auscultation|CTA.|196|199|PHYSICAL EXAMINATION|She denies numbness, tingling, weakness or paresthesias. HEAD, EYES, EARS, NOSE AND THROAT: NC/AT. EOMI, PERRLA. Ears are grossly normal. Oropharynx is negative. NECK: No nodes, or bruits. CHEST: CTA. CORONARY: Regular rate without murmurs, gallops or clicks. ABDOMEN: Is soft, non-tender without masses. Normal bowel sounds. GENITOURINARY: Exam was deferred.
CTA|clear to auscultation|CTA.|215|218|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: No acute distress. Vital signs are stable. The patient is afebrile. HEENT: Her tympanic membranes are clear. EOMI. PERRLA. Oropharynx is negative. Neck: No nodes, thyromegaly or bruits. CHEST: CTA. COR: Regular rate without murmurs, gallops or clicks. ABDOMEN: Soft without rebound or guarding. I did not appreciate any masses. She has hypoactive bowel sounds. She has diffuse tenderness, right side, left side and epigastric, a little bit more so on the right side.
CTA|clear to auscultation|CTA|139|141|PHYSICAL EXAMINATION|Scleral icterus: 0. OP: Clear, without exudates. Neck: Supple. JVD: 0. Carotid bruit x 2: 0. CV: Irregular. S1, S2: normal. MRG: 0. Lungs: CTA bilaterally. Abdomen: BS, plus, soft, minimal tenderness in the lower half quadrant. OM: 0. Skin: 1.5 ulcer on the upper right buttocks, without drainage, greyish, and .........at base.
CTA|clear to auscultation|CTA|263|265|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 126/66, heart rate 117, respiratory rate 18, temp 101 degrees, 98% O2 sats in the ER. GENERAL: The patient is a pleasant male in no acute distress. HEENT: PERRL, conjunctivae clear, OP clear. NECK: Supple. LUNGS: CTA bilaterally. HEART: Regular rate and rhythm, no murmur. ABDOMEN: Mild epigastric tenderness to palpation, no rebound, no guarding, normoactive bowel sounds.
CTA|clear to auscultation|CTA|136|138|PHYSICAL EXAMINATION|Oral pharynx, no findings of significance. Palate intact by palpation. Single uvula. Neck is supple. No masses, no defects. Chest exam: CTA bilaterally. Cardiovascular: Normal S1 and S2, rhythm regular, no murmur appreciated. Femoral pulses strong. Cap refill brisk. Abdomen: Soft with active bowel sounds.
CTA|clear to auscultation|CTA|181|183|PHYSICAL EXAMINATION|She is able to answer my questions in full sentences. HEENT: PERRL; conjunctiva clear; OP clear with moist mucus membranes. Neck: supple, no lymphadenopathy; no thyromegaly. Lungs: CTA bilaterally with slightly diminished breath sounds. Heart: RRR; no murmur. Abdomen: soft, nontender. Extremities: bilateral lower extremities without edema; pedal pulses strong and symmetric.
CTA|clear to auscultation|CTA|167|169|IDENTIFICATION|HEENT: Right eye ectropion which is slightly red. Matted material noted at the bases of the eyelashes. Other HEENT exam NAD. Neck supple. Full range of motion. Chest: CTA bilaterally. Heart: No murmurs are noted. Abdomen: Soft, nontender. Extremities as follows: Right lower extremity has slight bruising on the lateral aspect noted.
CTA|clear to auscultation|CTA.|129|132|PHYSICAL EXAMINATION|HEENT: She has an NG tube in her right nostril. NECK: She has a triple lumen in her left neck. No facial asymmetry noted. LUNGS: CTA. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Soft, nontender, bowel sounds present. EXTREMITIES: She has Ted hose on in her lower extremities, she has 1+ pedal edema in the lower extremities.
CTA|clear to auscultation|CTA.|129|132|PHYSICAL EXAMINATION|He responds well to cues and commands, sometimes requiring cues to be repeated. Cranial nerves II through XII are intact. CHEST: CTA. CV: Regular rate and rhythm without murmur. ABDOMEN: Soft and nontender, nondistended. EXTREMITIES: He has no Foley catheter in place. MUSCULOSKELETAL: He has full active range of motion in his bilateral upper extremities and left-lower extremity.
CTA|clear to auscultation|CTA|208|210|PHYSICAL EXAMINATION|Otherwise, skin is intact and incision is healing well, with staples in place over her cranium. MUSCULOSKELETAL: Appears to have functional range of motion x4 extremities. ABDOMEN: Soft and nontender. LUNGS: CTA bilaterally. NEUROLOGIC: Motor strength is 4+/5 throughout except for 4/5 at the right elbow flexor and 4/5 bilateral hip flexors, also 4/5 for right knee extensors.
CTA|clear to auscultation|CTA|203|205|PHYSICAL EXAMINATION|Pharynx not inflamed. Uvula midline. Voice is resonant without hoarseness. NECK: Full range of motion without weakness. Smooth and supple without lymphadenopathy. Thyroid is smooth, not enlarged. CHEST: CTA without crackles, rhonchi, or wheezes. HEART: Regular rate and rhythm without murmurs, gallops, or rubs. Peripheral vascular: Posterior tibial pulses present bilaterally and symmetrical, no pretibial edema.
CTA|clear to auscultation|CTA|147|149|PHYSICAL EXAMINATION|He has a normal swallow. He clears his throat x1 during the examination. His tongue is midline. EOMI. Normal full cervical range of motion. CHEST: CTA with normal respiratory effort. Good chest excursions observed. CARDIOVASCULAR: Regular rate and rhythm without murmurs. He has good profusion. There is no ankle edema. ABDOMEN: Soft, nontender, nondistended, he has no HSM.
CTA|computed tomographic angiography|(CTA)|245|249|REASON FOR CONSULTATION|She was evaluated by Dr. _%#NAME#%_ immediately. She went for CT scanning of the brain and CT angiography disclosing no acute hemorrhage, mass or intracranial pathology as far as I can discern from looking at her computed tomography angiography (CTA) and I do not see any gross occlusions. Of note, however, since admission her blood pressure has been rather uncontrolled with admission blood pressure of 190/155 and the best I have seen since that time is 184/130.
CTA|clear to auscultation|CTA.|143|146|PHYSICAL EXAMINATION|She follows instructions well. Her mood appears even and normal. NEUROLOGIC: Cranial nerves II-XII are grossly intact. Speech is clear. CHEST: CTA. CARDIOVASCULAR: Regular rate and rhythm, no murmur. ABDOMEN: Soft, nontender and nondistended. MUSCULOSKELETAL: She has decreased active range of motion in her bilateral ankles to a neutral dorsiflexion position and 30 degrees of plantar flexion in the right greater than the left.
CTA|clear to auscultation|CTA|199|201|PHYSICAL EXAMINATION|She is cooperative with examination. She cognitively appears intact. She was examined in the supine position. CARDIOVASCULAR: Regular rate and rhythm with S1 and S2 distant, no murmurs heard. LUNGS: CTA bilaterally. ABDOMEN: Bowel sounds are quiet but present. She is soft and nontender. She is obese. SKIN: Without significant edema.
CTA|clear to auscultation|CTA|204|206|HEENT|Pt is afebrile and normotensive. HEENT: At, NC, pupils equally reactive to light bilaterally. EOM intact. No lid lag or lid retraction. Neck: No JVD, no lyphadenopathy. Thyroid gland not palpable. Chest: CTA bilaterally, normal CW motion CVS: S1+S2. No mrumur rub or gallop Abdomen: Soft, non tender, no visceromegaly. BS +ve. Ext: No edema. No tremor of the outstretched hands.
CTA|clear to auscultation|CTA|206|208|PHYSICAL EXAMINATION|The patient is very conversive. No cognitive dysfunction appreciated. HEENT: EOMI. Faces is symmetrical. Cranial nerves II-XII grossly intact. CARDIOVASCULAR: Regular rate and rhythm without murmur. CHEST: CTA bilaterally good effort noted. ABDOMEN: Positive bowel sounds, soft, nontender, nondistended. SKIN: Moderate edema noted in her lower extremities below the knee.
CTA|clear to auscultation|CTA|244|246|PHYSICAL EXAMINATION|She is nonverbal. She appears to attend to objects and people in conversations taking place on her left side, no spontaneous head movement to the right or eye tracking to the right was noted. CARDIOVASCULAR: Regular rate and rhythm. PULMONARY: CTA with some coarse breath sounds. NEUROLOGIC: Exam is limited because of the patient's low level of response. Manual muscle testing: She is flaccid in her right arm and leg and left leg.
CTA|clear to auscultation|CTA|276|278|PHYSICAL EXAMINATION|The patient is right-handed. PHYSICAL EXAMINATION: VITAL SIGNS: T-max 36.3, blood pressure 126/63, heart rate is 88, respiratory rate 20, 98% O2 sats on room air. GENERAL: He is alert and oriented, no acute distress. CARDIOVASCULAR: Regular rate and rhythm, no murmur. LUNGS: CTA bilaterally. ABDOMEN: Benign, positive bowel sounds, flat, nontender. SKIN: 2+ edema in lower extremities. MUSCULOSKELETAL: Full active range motion x4 extremities.
CTA|clear to auscultation|CTA.|196|199|PHYSICAL EXAMINATION|Cranial nerves II-XII show right facial droop with an asymmetric smile. He has a depressed nasolabial fold on the right. His tongue deviates slightly to the right. Shoulder shrug is equal. CHEST: CTA. CV: Regular rate and rhythm. ABDOMEN: Soft and flat, nontender. Normal bowel sounds present. SKIN: Without edema. MUSCULOSKELETAL: Full active range of motion x4 extremities. NEUROLOGIC: Strength on the side.
CTA|clear to auscultation|CTA|205|207|PHYSICAL EXAMINATION|NECK: Smooth and supple without lymphadenopathy. Thyroid not enlarged and without nodularity. The patient had full range of motion without weakness including strong shoulder shrug without weakness. LUNGS: CTA bilaterally without wheeze, rhonchi, rales. HEART: Regular rate and rhythm without murmur, rubs, gallops. ABDOMEN: Positive bowel sounds throughout, non-tender, non-distended, soft, without organomegaly.
CTA|clear to auscultation|CTA|175|177|PHYSICAL EXAMINATION|Patient is unable to look up or down or towards the right. She has significant right facial droop and asymmetric mouth opening. CARDIOVASCULAR: Irregular regular rate. LUNGS: CTA bilaterally. ABDOMEN: Decreased bowel sounds, flat, nondistended, soft. SKIN: No edema. MUSCULOSKELETAL: Full active range of motion in left upper and lower extremities.
CTA|clear to auscultation|CTA.|276|279|PHYSICAL EXAMINATION|GENERAL: No acute distress. Hypophonic. No significant agitation seen. Overall, mood is flat but the patient remains interactive throughout the examination. HEENT: Atraumatic, normocephalic. Hypophonia noted. No dysphagia seen. CARDIOVASCULAR: Regular rate and rhythm. CHEST: CTA. ABDOMEN: Benign, positive bowel sounds, flat. SKIN: No edema. MUSCULOSKELETAL: Full active range of motion x4 extremities. NEUROLOGIC: Manual motor testing 5/5 strength x4 extremities.
CTA|clear to auscultation|CTA|149|151|PHYSICAL EXAMINATION|She is still confused. She forgets who the examiner is despite several introductions. CARDIOVASCULAR: Regular rate and rhythm without murmur. LUNGS: CTA bilaterally. ABDOMEN: Normoactive bowel sounds; soft, nontender, nondistended. EXTREMITIES: She has digital clubbing. She has dusky fingers. She has no lower extremity edema.
CTA|clear to auscultation|CTA|219|221|PHYSICAL EXAMINATION|Pharynx not inflamed. Uvula midline. Voice: Normal without hoarseness. NECK: Supple, full range of motion without weakness or lymphadenopathy. Thyroid is smooth without enlargement. Good shoulder shrug strength. LUNGS: CTA bilaterally without wheeze, rhonchi, or rales. HEART: Regular rate and rhythm without murmur, rub, or gallop. ABDOMEN: Positive bowel sounds throughout, non- tender, non-distended, soft, no organomegaly, no masses.
CTA|clear to auscultation|CTA|226|228|ALLERGIES|Affect is acceptable and within normal limits. Cranial nerve examinations grossly are intact 2 through 12. No dysarthria or dysphagia present. Normal conversational hearing. Normal visual acuity. Face is symmetrical. Chest is CTA bilaterally. CV is regular rate and rhythm. Sternal incision is clean, dry, and intact. Examination of her extremities shows no significant edema in her lower extremities.
CTA|clear to auscultation|CTA.|161|164|PHYSICAL EXAMINATION|He is oriented to self. He has mild to moderate dysarthria. He has some word-finding difficulties. He has delayed response. He appears somewhat fatigued. CHEST: CTA. CARDIOVASCULAR: CV is normal sinus rhythm. ABDOMEN: Soft, nontender, bowel sounds present. EXTREMITIES: Without edema. NEUROLOGIC: Neurologically, the patient demonstrated overall slightly decreased strength in his bilateral upper extremities to 4 to -5-/5.
CTA|clear to auscultation|CTA.|170|173|PHYSICAL EXAMINATION|The face appears symmetrical. She has an equal smile. She is swallowing her secretions. Her speech is not dysarthric. EOMI. She has full cervical range of motion. CHEST: CTA. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Flat and nontender. EXTREMITIES: She has full strength in the upper and lower extremities bilaterally at 5/5.
CTA|clear to auscultation|CTA|213|215|PHYSICAL EXAMINATION|HEENT: Face is symmetric. Speech is slightly dysarthric but easily understood. Slight dysphasia was seen. The patient coughed after swallowing her pills with water. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: CTA bilaterally. ABDOMEN: Soft, nontender, nondistended, bowel sounds present. SKIN: Without significant edema. MUSCULOSKELETAL: Full active range of motion x 4 extremities except for limited upper extremity, shoulder abduction, and flexion to 90 degrees.
CTA|clear to auscultation|CTA|154|156|PHYSICAL EXAMINATION|HEENT: EOMI. Cranial nerves II through XII appear intact. Speech is clear, nondysarthric. No dysphagia, cervical rotation in all directions fully. CHEST: CTA bilaterally. CARDIOVASCULAR: Regular rate and rhythm, no murmur. ABDOMEN: Soft, nontender, nondistended, positive bowel sounds. SKIN: Without significant edema except for left arm, hand and forearm.
CTA|clear to auscultation|CTA|199|201|PHYSICAL EXAMINATION|She is alert and oriented. She is irritable because of her being n.p.o. for her TEE procedure. HEENT: EOMI Cranial nerves II-XII intact. Speech clear. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: CTA bilaterally. ABDOMEN: Soft, obese, nontender, nondistended; positive bowel sounds. SKIN: No significant edema. MUSCULOSKELETAL: Full active range motion x4 extremities.
CTA|clear to auscultation|CTA.|179|182|CRANIAL NERVES|Her responses to questions and directions are appropriate. CRANIAL NERVES: Cranial nerves II through XII are intact except for some left facial droop and asymmetric smile. CHEST: CTA. CV: Regular rate and rhythm. ABDOMEN: Soft and nontender. SKIN: She has some edema and ecchymoses in her left hand. EXTREMITIES: She has no lower extremity edema. MUSCULOSKELETAL: She has full active range of motion in bilateral upper and lower extremities.
CTA|clear to auscultation|CTA|154|156|PHYSICAL EXAMINATION|No dysphasia or dysarthria noted. HEENT: Atraumatic, normocephalic. Slight jaundice noted in the face and eyes. EOMI. CV: Regular rate and rhythm. LUNGS: CTA bilaterally. ABDOMEN: Decreased bowel sounds, flat. EXTREMITIES: Have 2+ edema in lower extremities. MUSCULOSKELETAL: Full active range of motion x4 extremities.
CTA|clear to auscultation|CTA|143|145|PHYSICAL EXAMINATION|HEENT: Cushingoid facies present. EOMI. Cranial nerves II-XII appear intact. CARDIOVASCULAR: Regular rate and rhythm with a 3/6 murmur. CHEST: CTA bilaterally with good efforts. ABDOMEN: Positive bowel sounds, diffusely tender to palpation. Superior horizontal incision which is dressed. Insulin pump and a G-tube taped also. EXTREMITIES: Negative edema x4 extremities.
CTA|clear to auscultation|CTA|175|177|PHYSICAL. GENERAL|Speech is fluent but requires increased processing time. He remembers the name of his RN and nursing assistant. CARDIOVASCULAR: Regular rate and rhythm without murmur. LUNGS: CTA bilaterally. ABDOMEN: Normoactive bowel sounds, soft, nontender, nondistended. Liver edge is palpable about 5 cm down. He has palpable spleen tip. EXTREMITIES: Well perfuse. He has pitting edema in the right foot and ankle without tenderness.
CTA|clear to auscultation|CTA|139|141|PHYSICAL. EXAMINATION|Cognitively she appears intact. NEUROLOGIC: Cranial nerve exam II-XII are normal except for a slight right central VII nerve palsy. LUNGS: CTA bilaterally. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Soft and nontender. SKIN: Without significant edema. MUSCULOSKELETAL: She has full passive range of motion in both lower extremities.
CTA|clear to auscultation|CTA|216|218|PHYSICAL EXAMINATION|He is able to follow conversation well and help to make some decisions regarding his medical care. HEENT: Atraumatic, normocephalic. EOMI. Mild left ptosis. CARDIOVASCULAR: Regular rhythm with 1 skipped beat. LUNGS: CTA bilaterally. ABDOMEN: Positive bowel sounds, nondistended. SKIN: No significant edema. MUSCULOSKELETAL: Full active range of motion, right upper extremity and bilateral lower extremities.
CTA|clear to auscultation|CTA|211|213|PHYSICAL EXAMINATION|HEENT: PERRL. Slightly decreased left nasolabial fold. She does have a left facial droop. Otherwise, cranial nerves II-XII were intact. Shoulder shrugs are equal. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: CTA bilaterally, good effort noted. ABDOMEN: Positive bowel sounds, soft, nontender, nondistended. EXTREMITIES: Without edema. MUSCULOSKELETAL: Full active range of motion in bilateral lower extremities, full active range of motion in the right upper extremity, active assisted range of motion in the left upper extremity.
CTA|computed tomographic angiography|CTA|253|255|HISTORY OF PRESENT ILLNESS|I was contacted for a preoperative exam. She does not have any known history of coronary artery disease or congestive heart failure. About 5 years ago she went into one of the local hospitals and had quite a bit of cardiac testing including stress test CTA and all of these tests were reportedly negative. I do not have the results of these tests, but the patient tells me they were negative.
CTA|clear to auscultation|CTA|140|142|PHYSICAL EXAMINATION|He appears slightly fatigued. Cognitively and conversationally he is intact. His judgment appears good. His reasoning appears sound. CHEST: CTA except for end expiratory squeaks. HEART: Regular rate and rhythm without murmur. ABDOMEN: Soft, nontender, bowel sounds are present.
CTA|clear to auscultation|CTA|253|255|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: On exam, vitals as noted, which are afebrile, pulse 77, respirations 18, blood pressure 135/73, 95% on room air. A very talkative, great talker and historian, alert, pleasant, oriented. SKIN: Warm. HEENT: NAD. NECK: Supple. CHEST: CTA bilateral. CVS: No murmurs. ABDOMEN: Soft and nontender. No organomegaly is noted. EXTREMITIES: Left lower extremity is warmer. Slight swelling. Tender posterior aspect. Increased girth compared to the right.
CTA|clear to auscultation|CTA|179|181|PHYSICAL EXAMINATION|Cognitively she appears intact. Conversation skills are intact. Cranial nerves II-XII were tested and intact. CARDIOVASCULAR: Regular rate and rhythm without murmur. CHEST: Lungs CTA bilaterally. ABDOMEN: Soft, nontender and nondistended. SKIN: Without lesions or edema. EXTREMITIES: She has full active range of motion in both upper extremities.
CTA|clear to auscultation|CTA|148|150|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Pleasant female in moderate distress, crying. VITAL SIGNS: Within normal limits. HEENT: Normal. NECK: Supple. LUNGS: CTA ABDOMEN: Soft; exam is normal. SKIN: Warm, moist. Pschy: normal mood and affect MUSCULOSKELETAL: Warm extremities. ASSESSMENT: 31-year-old female with several stones in the left kidney with left flank pain.
CTA|clear to auscultation|CTA|243|245|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: T-max 97.7, blood pressure 131/66, heart rate is 128, O2 sats 93% on room air. GENERAL: He was in no severe distress but perseverated on getting home. CARDIOVASCULAR: Distant heart sounds auscultated. LUNGS: CTA bilaterally except for minimal coarse breath sounds in the upper lobes. HEENT: Normocephalic, atraumatic. Speech occasionally mumbled. ABDOMEN: Positive bowel sounds, flat, nontender, nondistended.
CTA|computed tomographic angiography|CTA|163|165|PAST MEDICAL HISTORY|3. No history of coronary artery disease. He has been followed by Minnesota Heart and apparently has undergone a stress test which was normal. He also underwent a CTA which apparently revealed normal coronary arteries, though those results are not available to me 4. Problem with obesity. SOCIAL HISTORY: The patient is a former smoker but quit over nine years ago.
CTA|clear to auscultation|CTA.|157|160|PHYSICAL EXAMINATION|He has no evidence of aphagia or dysarthria. HEENT: Examination of cranial nerves II through XII are intact. He has equal shoulder shrug bilaterally. CHEST: CTA. CARDIAC: Regular rate and rhythm. ABDOMEN: Soft with normal bowel sounds. EXTREMITIES: He has no edema in his lower extremities. He is on a bed 15 degrees raised at the head secondary to surgery precautions.
CTA|clear to auscultation|CTA.|162|165|PHYSICAL EXAMINATION|She has more spontaneous movement noted on the left side in her arm and leg. Cranial nerves II-XII appear intact; however, I am unable to test this fully. CHEST: CTA. CARDIOVASCULAR: Regular rate and rhythm, with good perfusion. ABDOMEN: Soft, nontender, nondistended. Bowel sounds present. SKIN: Without edema. MUSCULOSKELETAL: She has full passive range of motion and active range of motion with slight limitation at the right shoulder on active range of motion.
CTA|clear to auscultation|CTA|186|188|PHYSICAL EXAMINATION|Sensation is intact however. She has asymmetrical smile. Her tongue is midline. She has and equal shoulder shrug. She does have end gaze nystagmus when looking towards the right. CHEST: CTA with distant breath sounds. CARDIOVASCULAR: CVA is Regular rate and rhythm. She has good perfusion, no murmur detected. ABDOMEN: Soft and slightly tender in the left upper quadrant area near the incision site.
CTA|clear to auscultation|CTA.|140|143|PHYSICAL EXAMINATION|He has decreased visual field on the left to the nasal midline. Cranial nerve VII - he has a left facial droop and asymmetric smile. CHEST: CTA. CARDIOVASCULAR: Regular rate and rhythm without murmur. ABDOMEN: Negative, soft and nontender. EXTREMITIES: He has full active range of motion in his left upper extremity.
CTA|clear to auscultation|CTA|241|243|PHYSICAL EXAMINATION|The patient appeared slightly confused talking about living over at student housing at the University of Minnesota in addition to being at _%#COUNTY#%_ recently. HEENT: Cranial nerves II-XII intact, EOMI. No dysarthria, no dysphagia. LUNGS: CTA bilaterally. CV: Regular rate and rhythm. ABDOMEN: Obese, soft, nontender. Colostomy site looks good. SKIN: Atrophic changes noted over her left lower extremity and left hand and forearm secondary to diffuse right BKA well-healed.
CTA|clear to auscultation|CTA|141|143|PHYSICAL EXAMINATION|She is in no significant distress. She is cooperative for the exam. Mood and affect are appropriate. Cognitively, she is appropriate. CHEST: CTA bilaterally throughout. CARDIOVASCULAR: L-VAD machine throughout precordial area. ABDOMEN: Bowel sounds present, soft, non-tender in right lower quadrant, left lower quadrants.
CTA|clear to auscultation|CTA.|192|195|PHYSICAL EXAMINATION|He was alert and oriented to his situation. He was very pleasant and cooperative throughout examination. Cranial nerves II through XII were intact. No nystagmus was noted. He had EOMI. CHEST: CTA. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Flat and nontender. SKIN: Without edema. EXTREMITIES: Were full range of motion x4 limbs. NEUROLOGIC: Manual motor testing is 5/5 x4 limbs. There are no focal sensory deficits.
CTA|clear to auscultation|CTA|217|219|PHYSICAL EXAMINATION|GENERAL: He is in no significant distress, very pleasant. He is alert and oriented, cognitively intact. HEENT: Minimal vision present. Cranial nerves II-XII intact. EOMI, speech clear. No dysphagia, GIA. RESPIRATORY: CTA bilaterally. CARDIOVASCULAR: Regular rate and rhythm. SKIN: No significant lower extremity edema. MUSCULOSKELETAL: Full active range of motion x4 extremities.
CTA|clear to auscultation|CTA|219|221|PHYSICAL EXAMINATION|She is appropriate throughout exam. She is oriented and worked well with me today. HEENT: Cranial nerves II-XII intact. She has hypophonia. No significant dysphagia seen. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: CTA bilaterally. SKIN: Mild lower extremity edema at the ankles, +1. MUSCULOSKELETAL: Full active range of motion x4 extremities. NEUROLOGIC: Upper and lower strength was 5/5 bilaterally.
CTA|computed tomographic angiography|CTA|161|163|IMPRESSION|The patient is not a candidate for MRI due to ICD placement. If he were to have recurrent symptoms, I would be happy to reconsult and also recommend obtaining a CTA of the head and neck to evaluate for posterior circulation blood flow. Of course, the patient would probably require premedication due to his chronic renal insufficiency and at this time I do not think it is worth the risk to do it without further symptoms or problems.
CTA|clear to auscultation|CTA|251|253|PHYSICAL EXAMINATION|GENERAL: She is in no acute distress. She has somewhat delayed responses on questioning but the patient is appropriate with her answers and follows commands well. HEENT: Atraumatic, normocephalic. EOMI. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: CTA bilaterally. ABDOMEN: Positive bowel sounds, flat, nontender, nondistended. SKIN: No significant edema. MUSCULOSKELETAL: Full active range of motion x4 extremities. NEUROLOGIC: Manual muscle testing is 4+/5 in bilateral upper extremities and lower extremities except for ankle dorsiflexion is 1/5 bilaterally.
CTA|clear to auscultation|CTA|180|182|REASON FOR CONSULTATION|Cranial nerve exam appears intact. He has no dysarthria or dysphasia apparent. Chest exam shows a variable rate. No evidence of murmur. There is no lower extremity edema. Chest is CTA throughout. Abdomen is soft and nontender. Extremities: The patient has no edema in his lower extremities; however, he does have significant swelling in the right popliteal fossa with an area of ecchymosis above the fossa.
CTA|clear to auscultation|CTA|184|186|PHYSICAL EXAMINATION|The patient was comfortable on room air. SKIN: No abnormalities detected, except that she does have a recent surgical scar that is healing okay. HEENT: Dry lips and dry tongue. CHEST: CTA bilaterally. HEART: No murmurs are noted. ABDOMEN: Soft, non-tender. Sluggish bowel sounds are noted. EXTREMITIES: Peripheral pulses and movement intact; no edema is noted.
CTA|computed tomographic angiography|CTA|299|301|IMPRESSION|The motor, sensory, coordination, reflex testing showing a peripheral neuropathy and some modest gait ataxia, otherwise negative exam. IMPRESSION: Recurring syncope, most likely orthostatic or related basis. Will add an MRA of the circle of Willis to his upcoming MRI and he may well require MRA or CTA of the carotid/vertebral system in addition, to his ultrasound depending on our findings. I will order an EEG for completeness sake, although his presentation seems somewhat less than suggestive of seizure.
CTA|clear to auscultation|CTA|153|155|PHYSICAL EXAMINATION|GENERAL: She is in no acute distress. She is resting easily in bed. She has visitors present. CARDIOVASCULAR: Regular rate and rhythm, no murmur. LUNGS: CTA bilaterally. ABDOMEN: Positive bowel sounds, obese, soft, nontender, nondistended. EXTREMITIES: No edema in bilateral lower extremity. HEENT: Frontal incision with staples, no erythema or drainage.
CTA|computed tomographic angiography|CTA|200|202|PHYSICAL EXAMINATION|Reflexes are 2+ and symmetric. CT and MRI/MRA were reviewed revealing known left petrous ICA aneurysm with no flow through the aneurysm. There are no new intracranial lesions and no changes since the CTA in _%#MM#%_ 2005. ASSESSMENT AND PLAN: The patient is a 20-year-old female with history of left petrous ICA aneurysm, status post embolization in 2003.
CTA|clear to auscultation|CTA|144|146|PHYSICAL EXAMINATION|HEENT: Hair is dyed yellow; PERRL, conjunctivae clear; OP with moist mucous membranes. NECK: Supple; no lymphadenopathy, no thyromegaly. LUNGS: CTA bilaterally. HEART: RRR, no murmur. ABDOMEN: Obese; soft; nontender. EXTREMITIES: Bilateral lower extremities without edema. SKIN: The flexion creases of her elbows bilaterally show a papular erythematous rash with no well-defined areas.
CTA|clear to auscultation|CTA|191|193|PHYSICAL EXAMINATION|GENERAL: Well appearing female in no acute distress. No asterixis. HEENT: Eyes: There is scleral icterus present. CARDIOVASCULAR: Regular rate and rhythm. No murmurs, rubs or gallops. LUNGS: CTA bilaterally. ABDOMEN: Moderately distended, soft, mildly tender over epigastric region. No hepatosplenomegaly on examination. No rebound or guarding. EXTREMITIES: No clubbing, cyanosis.
CTA|clear to auscultation|CTA.|155|158|PHYSICAL EXAMINATION|Face is clear. There is no dysarthria or dysphagia. Answers are appropriate for an 11-year-old. Cranial nerve examination II through XII is intact. CHEST: CTA. CARDIOVASCULAR: Regular rate and rhythm. Perfusion is good. ABDOMEN: Soft and non-tender. EXTREMITIES: Her residual limb was not examined. The residual limb is encased in a heavy bandage with an ace wrap.
CTA|clear to auscultation|CTA.|177|180|PHYSICAL EXAMINATION|He was minimally responsive. He did open his eyes on voice command. He appears to have decreased gaze to the right. He appears to focus on objects presented to the left. CHEST: CTA. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Soft and non-tender with bowel sounds present. EXTREMITIES/MUSCULOSKELETAL: : He had no significant edema in his extremities.
CTA|computed tomographic angiography|CTA|157|159|ASSESSMENT/PLAN|This was discussed extensively with the son and family. They totally understand the plan. He will be transported urgently to HCMC. We will get a CT scan and CTA as soon as he arrives and we will proceed with the workup and care as indicated. We would like to thank Dr. _%#NAME#%_ and the Fairview Emergency Room for their excellent stabilization and for referring the patient.
CTA|clear to auscultation|CTA|171|173|PHYSICAL EXAMINATION|HEENT: Cranial nerves II-XII intact. Speech clear, no dysarthria, no dysphasia. EOMI. Significant facial bruising on the left side and submandibular regions noted. CHEST: CTA bilaterally. CARDIOVASCULAR: Regular rate and rhythm. 2/6 systolic murmur over left sternal border. ABDOMEN: Soft, nontender, positive bowel sounds. SKIN: No significant edema.
CTA|clear to auscultation|CTA.|136|139|PHYSICAL EXAMINATION|She was not swallowing her secretions or coughing much during their during the examination. Cranial nerves II-XII appear intact. CHEST: CTA. CV: Regular rate and rhythm. ABDOMEN: Soft, flat, nontender and nondistended. SKIN: Without significant edema or ecchymoses. MUSCULOSKELETAL: She has full active range of motion at all joints except for the shoulders and hips.
CTA|computed tomographic angiography|CTA|140|142|IMPRESSION REPORT AND PLAN|I would recommend a follow-up echocardiogram in 4-6 weeks and consideration for evaluation of his coronaries, which would include a cardiac CTA versus a noninvasive evaluation with a nuclear stress test. I think the risk of invasive coronary angiography is too high at this point, given that my clinical suspicion is so low for ischemia.
CTA|clear to auscultation|CTA|131|133|PHYSICAL EXAMINATION|NECK: Supple. No lymphadenopathy. 7CARDIOVASCULAR: Regular rate and rhythm, S1 and S2 present. No murmurs, rubs or gallops. LUNGS: CTA bilaterally. ABDOMEN: Soft, non-distended, surgical incision is dry and clean, slightly tender to deep palpation, no organomegaly. EXTREMITIES: No edema, clubbing or cyanosis. LABORATORY AND X-RAY RESULTS: CBC: WBC 13.8, hemoglobin 9.7, platelets 1023.
CTA|computed tomographic angiography|CTA|176|178|IMPRESSION|3. Back pain, unclear etiology. Could still be infection or could be radiated pain. Could be related to coughing. MRI was fairly unremarkable for cough, possible pneumonia but CTA more compatible with atelectasis. RECOMMENDATIONS: 1. Start colchicine 0.6 mg p.o. b.i.d. and ibuprofen 800 mg p.o. t.i.d. versus gout.
CTA|clear to auscultation|CTA|246|248|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: T-max 98.9, blood pressure 132/80, pulse 87, respiratory rate 20, O2 sats 95% on room air. GENERAL: He is in no acute distress, resting in a cardiac chair. HEART: Regular rate and rhythm without murmurs. LUNGS: CTA bilaterally, good effort noted. ABDOMEN: Positive bowel sounds, soft, nontender, nondistended. EXTREMITIES: Without edema. NEUROLOGIC: Alert and oriented x3. Initially stated it was 1977 but quickly corrected to 2007.
CTA|clear to auscultation|CTA.|157|160|EXAMINATION|The patient states that she is trying "to pull the curlers out of her hair." NEUROLOGIC: Cranial nerve exam appears intact throughout II through XII. CHEST: CTA. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Negative. EXTREMITIES: She is moving all extremities well. She has full active range of motion when allowed to move her arms.
CTA|clear to auscultation|CTA.|162|165|PHYSICAL EXAMINATION|She had some word finding difficulties and paraphasias. She was oriented to place, name and reason for admission. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: CTA. ABDOMEN: Benign. SKIN: Without edema. MUSCULOSKELETAL: Full active range of motion x4 extremities. NEUROLOGIC: Strength is 4/5 in right upper extremity, normal elsewhere.
CTA|clear to auscultation|CTA|152|154|EXAMINATION|HEENT: Bilateral temporal regions with intact bandages. EOMI. Speech clear. No dysarthria or dysphagia. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: CTA bilaterally. ABDOMEN: Positive bowel sounds, nontender to touch. SKIN: No significant edema x4 extremities. MUSCULOSKELETAL: Full active range of motion x4 extremities except for limited at both hips.
CTA|clear to auscultation|CTA.|164|167|PHYSICAL EXAMINATION|He has a delayed speed of processing language, but his answers are appropriate. Cognitively he appears intact. NEUROLOGIC: Cranial nerves II-XII are intact. CHEST: CTA. CARDIOVASCULAR: Regular rate and rhythm without murmur. ABDOMEN: Nondistended; bowel sounds were present. MUSCULOSKELETAL: He had full active range of motion except for a 10-degree contracture of the right knee and possibly 5 degrees at right hip.
CTA|clear to auscultation|CTA.|188|191|ALLERGIES|She has a normal swallow. Her responses appear appropriate, although slow. Memory is intact. She has good recall. She is oriented times 3. Cranial nerves 2 through 12 are intact. Chest is CTA. CV is regular rate and rhythm. Abdomen is soft and nontender. Extremities are without any edema. Motor strength exam shows approximately 4+ to 5- strength present throughout her muscle groups in her upper and lower extremities.
CTA|clear to auscultation|CTA|193|195|PHYSICAL EXAMINATION|He is lying in bed but cooperates and awakens easily for examination. His speech is slightly slowed with mild dysarthria. His skin is jaundiced. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: CTA bilaterally. EXTREMITIES: Without edema. Ecchymoses are present on his arms. He has full active range of motion x4 limbs. NEUROLOGIC: Strength examination: Overall, he 5/5 in his upper extremities and 4/5 in his bilateral lower extremities.
CTA|clear to auscultation|CTA|172|174|PHYSICAL EXAMINATION|She is satting at 97% on room air. GENERAL: She is in no acute distress. She is sitting up in bed. CARDIOVASCULAR: Heart egular rate and rhythm. No murmurs present. LUNGS: CTA on the right. A few wheezes present on the left. She is coughing she has a congested cough. She has a strong cough.
CTA|clear to auscultation|CTA.|229|232|PHYSICAL EXAMINATION|His responses appear appropriate. He needs multiple cues to follow directions on examination. HEENT: No focal deficits noted. Speech is clear, nondysarthric. Face is symmetrical. EOMI present. CV: Regular rate and rhythm. CHEST: CTA. ABDOMEN: Soft and flat and nontender. Bowel sounds present. EXTREMITIES: Without significant edema. MUSCULOSKELETAL: Full active range of motion x4 extremities.
CTA|clear to auscultation|CTA|182|184|PHYSICAL EXAMINATION|Visual fields appear intact. Cranial nerve exam appears intact except for absent shoulder shrug on the left side versus the right. CV: Regular rate and rhythm without murmur. LUNGS: CTA bilaterally. ABDOMEN: Soft and obese. She was nontender. She had bowel sounds present. MOTOR EXAM: In the left upper extremity she was 0/5 for abduction, elbow flexion and extension, and hand intrinsics to grip was 1/5.
CTA|clear to auscultation|CTA|148|150|PHYSICAL EXAMINATION|His responses to questions were intact. Mood and affect appear appropriate. HEART: Irregular rate, distant heart sounds present, no murmurs. LUNGS: CTA bilaterally. Good effort seen. ABDOMEN: Positive bowel sounds. Soft, nontender, nondistended. Obese. SKIN: +1 edema in bilateral lower extremities. He has Ted hose on.
CTA|clear to auscultation|CTA|161|163|PHYSICAL EXAMINATION|Uvula was midline. Voice was resonant without hoarseness. NECK: The neck was smooth and supple with a full range of motion. No adenopathy or thyromegaly. LUNGS: CTA bilaterally without wheeze, rhonchi, rales. HEART: Regular rate and rhythm without murmur, rubs, or gallops. ABDOMEN: Positive bowel sounds throughout, non-tender, mildly distended due to adipose tissue, soft, no organomegaly, no masses.
CTA|clear to auscultation|CTA|188|190|PHYSICAL EXAMINATION|HEENT: Decreased hearing as noted. Cranial nerves II-XII intact. Speech nondysarthric, no dysphagia noted. Cervical rotation in all directions. CHEST: Decreased breath sounds on the left. CTA on the right posteriorly on my examination. CARDIOVASCULAR: Tachycardic but regular rhythm. No significant murmur. ABDOMEN: Flat, nontender. Positive bowel sounds. SKIN: Edema of 2+ in lower extremities.
CTA|UNSURED SENSE|CTA|136|138|SOCIAL HISTORY|SOCIAL HISTORY: Patient is married. She has 3 kids. She had no trouble with her pregnancies. She works as an accountant assistant for a CTA company. She does not smoke and does not drink alcohol. REVIEW OF SYSTEMS: CARDIOVASCULAR: Denies any chest pain, any angina or any shortness of breath.
CTA|clear to auscultation|CTA.|234|237|PHYSICAL EXAMINATION|His comprehension also appears to be improving. PHYSICAL EXAMINATION: GENERAL: On examination the patient was awake, alert and cooperative. He was in no acute distress. Cognitive exam was difficult to assess given his aphagia. CHEST: CTA. CARDIOVASCULAR: Regular rate and rhythm. Patient has a healing site where his Port-A-Cath has previously been. ABDOMEN: Soft, flat, nontender. EXTREMITIES: Without edema. MUSCULOSKELETAL: He has full range of motion.
CTA|clear to auscultation|CTA|233|235|PHYSICAL EXAMINATION|She is afebrile and weighs 187 pounds. GENERAL: The patient is a pleasant female in no acute distress. HEENT: PERRL. Conjunctiva clear. Oropharynx with moist mucous membranes. NECK: Supple. No lymphadenopathy. No thyromegaly. LUNGS: CTA bilaterally. HEART: RRR. No murmur. ABDOMEN: Soft, obese, non-tender, and non-distended. EXTREMITIES: Bilateral lower extremities without edema. SKIN: Warm and dry. BREAST: Examination was deferred. LABORATORY: Upon admission included TSH, complete blood count, and UPT which were all within normal limits.
CTA|clear to auscultation|CTA.|167|170|PHYSICAL EXAMINATION|GENERAL: She is awake, alert, pleasant, cooperative. She has good insight. There are no gross cognitive deficits present. No dysarthria present. HEENT: Intact. LUNGS: CTA. CV: Regular rate and rhythm. ABDOMEN: Soft and slightly tender to palpation and she has positive bowel sounds. EXTREMITIES: Without significant edema. MUSCULOSKELETAL: Range of motion is limited in the hip and knee extension on the left.
CTA|clear to auscultation|CTA.|177|180|PHYSICAL EXAMINATION|Her responses are appropriate. She is able to follow commands. HEENT: Cranial nerves II-XII appear intact. Chest is decreased breath sounds on my examination, but appears to be CTA. CARDIOVASCULAR: Regular rate and rhythm; no murmurs apparent on my examination. ABDOMEN: Soft, nondistended. EXTREMITIES: She does not have extensive edema in her lower extremities.
CTA|clear to auscultation|CTA|218|220|PHYSICAL EXAMINATION|Communication skills are adequate. He exhibits some slow processing of information, but his general mentation or cognition appears in intact and adequate. CARDIOVASCULAR: Regular rate and rhythm without murmur. CHEST: CTA bilaterally, good effort noted. ABDOMEN: Soft, nontender. Bowel sounds present, no significant distention. HEENT; Cranial nerves II-XII are present.
CTA|clear to auscultation|CTA|206|208|PHYSICAL EXAMINATION|She was very cooperative with the examination. I did not detect significant word substitution during the examination. She is able to follow directions well. No significant dysarthria was also noted. CHEST: CTA throughout. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Flat with bowel sounds present. Her incision was clean, dry and intact with staples. MUSCULOSKELETAL: She has full active range of motion x4 extremities.
CTA|clear to auscultation|CTA|203|205|PHYSICAL EXAMINATION|He is cooperative throughout the examination. HEENT: Cranial nerves II-XII grossly intact, EOMI. Speech: No dysarthria, no dysphagia noted. CARDIOVASCULAR: Regular rate and rhythm without murmur. LUNGS: CTA bilaterally. ABDOMEN: Positive bowel sounds, nondistended. SKIN: Significant diffuse sclerodermal changes noted in the patient. MUSCULOSKELETAL: Upper and lower extremity active range of motion within functional limits.
CTA|computed tomographic angiography|CTA|197|199|ALLERGIES|She did indicate that she did not wish to pursue further therapy; however, this may be revisited at her next appointment. A Pap smear and pelvic exam should be obtained at her next visit. IMAGING: CTA of the chest, abdomen, and pelvis on _%#MM#%_ _%#DD#%_, 2005, showing no residual tumor in the surgical site or metastasis.
CTA|computed tomographic angiography|CTA|211|213|HISTORY OF PRESENT ILLNESS|His blood pressure was elevated and a CT scan was obtained which showed a left posterior frontal intraparenchymal hemorrhage with adjacent left frontal and fifth ventricle hemorrhage. There is no hydrocephalus. CTA was done under suspicion of an aneurysm, however CTA showed a normal circle of Willis with no evidence of aneurysm or AVM.
CTA|computed tomographic angiography|CTA.|146|149|ASSESSMENT AND PLAN|We recommend cardiology consultation to evaluate the patient's cardiac risk for surgery. We also recommend further imaging to either angiogram or CTA. This will be discussed with Dr. _%#NAME#%_ and further recommendations will be left in the chart.
CTA|clear to auscultation|CTA.|217|220|PHYSICAL EXAMINATION|On the left side, however, some apraxia or decreased motor planning is seen on command with the left side. On the right side he follows commands quite well for motor testing. HEENT: He has no facial asymmetry. LUNGS: CTA. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Soft and nontender, nondistended. SKIN: Without edema. He has pustular lesions in the left thorax.
CTA|clear to auscultation|CTA|135|137|PHYSICAL EXAMINATION|GENERAL: He is in no acute distress. He is quiet. He is resting in bed. CARDIOVASCULAR: Regular rate and rhythm without murmur. LUNGS: CTA on the left. He has a few wheezes and crackles at the right base. ABDOMEN: Soft, has bowel sounds present. It is soft, nontender and nondistended.
CTA|clear to auscultation|CTA.|163|166|PHYSICAL EXAMINATION|Her cognitive status appears intact. Communication skills were intact. Her answers were appropriate. NEUROLOGIC: Cranial nerves II through XII were intact. CHEST: CTA. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Obese but nondistended. It was soft and with normal bowel sounds. SKIN: Without significant edema. She has full active range of motion x4 extremities.
CTA|clear to auscultation|CTA.|313|316|PHYSICAL EXAMINATION|The patient's handwriting is back to baseline. PHYSICAL EXAMINATION: VITAL SIGNS: T-max is 96, blood pressure 139/87, heart rate 55, respiratory rate 16 with O2 sat 98% on room air. HEENT He has a minimal right facial droop but a symmetric smile. Extraocular movements intact. Visual fields intact. LUNGS: Clear: CTA. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Benign. SKIN: Without edema. EXTREMITIES: Full active range of motion x4. Good pulses. NEUROLOGIC: Cranial nerves II-XII were intact. His tongue was midline.
CTA|clear to auscultation|CTA|228|230|PHYSICAL EXAMINATION|The patient has slow, dysarthric speech. His responses appeared appropriate to the questions asked. He was able to follow 1 to several step commands. CRANIAL NERVES: He has dysarthric speech but otherwise appears intact. CHEST: CTA CV: Regular rate and rhythm. He has good perfusion. ABDOMEN: Soft, non-tender and non-distended. EXTREMITIES: He has no edema. He has tenderness over the anteroinferior aspect of his left lateral malleolus.
CTA|computed tomographic angiography|CTA|183|185|IMAGING|There is tenderness to palpation of the left frontal and maxillary sinuses. IMAGING: Head CT shows no intracranial pathology. Skin also shows left maxillary sinus mucosal thickening. CTA shows no aneurysm. ASSESSMENT AND PLAN: The patient is a 61-year-old female with headache and red blood cells in cerebrospinal fluid.
CTA|clear to auscultation|CTA,|208|211|PHYSICAL EXAMINATION|GENERAL: He was seen in the morning and he was initially sleeping but awoke easily. He was alert and oriented, conversation and cognitive skills were intact. He was cooperative throughout examination. CHEST: CTA, no rales or rhonchi were present. CARDIOVASCULAR: Regular rate and rhythm with a 1/5 murmur at the left sternal border. ABDOMEN: Soft, slightly distended but without significant tenderness. Bowel sounds are present.
CTA|clear to auscultation|CTA|197|199|PHYSICAL EXAMINATION|GENERAL: She is in no acute distress. She is resting in bed. She is difficult to arouse to get her to participate in her assessment. CARDIOVASCULAR: Regular rate and rhythm without murmurs. LUNGS: CTA bilaterally, good effort seen. ABDOMEN: Soft, bowel sounds present, nontender. DERMATOLOGY: The patient has dark patches of skin throughout that are flaking off.
CTA|clear to auscultation|CTA|197|199|PHYSICAL EXAMINATION|GENERAL: She is in no acute distress, very pleasant, easily awoken, alert and oriented, cognitively intact. HEENT: EOMI, AT/NC. HEART: Regular rate and rhythm, no murmurs, rubs, or gallops. LUNGS: CTA bilaterally. ABDOMEN: Positive bowel sounds, obese. SKIN: 2+ edema in bilateral lower extremities. MUSCULOSKELETAL: Full active range of motion in upper extremities. Limited active range of motion in lower extremities secondary to recent surgery.
CTA|clear to auscultation|CTA.|193|196|EXAMINATION|She was able to stand for 10 minutes with some anterior-posterior sway seen. Her Romberg exam was negative. Functionally, I did not attempt to have this patient ambulate in the hallway. CHEST: CTA. CARDIOVASCULAR: Bradycardia with 52 beats per minute and no murmur. ABDOMEN: Soft, non-tender. EXTREMITIES: Without edema. She had good perfusion.
CTA|computed tomographic angiography|CTA|121|123|HISTORY OF PRESENT ILLNESS|The patient had good distal pulses, no evidence of ischemic bowel. It was felt that she should be admitted and undergo a CTA to delineate the process further this morning. The patient was placed in the Intensive Care Unit and seen by Dr. _%#NAME#%_ of the hospitalist service. She saw my associate Dr. _%#NAME#%_ _%#NAME#%_ at midnight and I am seeing her now for evaluation.
CTA|computed tomographic angiography|CTA|126|128|PHYSICAL  EXAMINATION|The patient denies a history of TIA or CVAs. PHYSICAL EXAMINATION: GENERAL: The patient was examined in the CICU prior to her CTA and again following this. She is alert and oriented. VITAL SIGNS: Afebrile, vital signs stable. CHEST: Clear. CARDIOVASCULAR: Fairly regular rate. She has a left-sided pacemaker.
CTA|clear to auscultation|CTA.|159|162|PHYSICAL EXAMINATION|Intact wision in the right quadrant. Intact vision in the left upper and lateral quadrants but not lower left. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: CTA. ABDOMEN: Flat, positive bowel sounds. EXTREMITIES: Mild edema in lower extremities, moderate edema in the left upper extremity in the hand and forearm.
CTA|clear to auscultation|CTA|136|138|PHYSICAL EXAMINATION|GENERAL: He is in no acute distress sitting in his bed eating his lunch. CARDIOVASCULAR: Regular rate and rhythm without murmur. LUNGS: CTA bilaterally. Good effort noted. ABDOMEN: Positive bowel sounds, soft, nontender, and nondistended. EXTREMITIES: No edema in lower extremities. He has a splint on his left lower extremity.
CTA|clear to auscultation|CTA|172|174|PHYSICAL EXAMINATION|She has hypophonation. Cognitively she responds appropriately to questions and follows commands, but responses are delayed. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: CTA bilaterally. ABDOMEN: Positive bowel sounds. MUSCULOSKELETAL: Upper extremity active range of motion within functional limits. EXTREMITIES: Active range of motion and decreased mild foot drop noted at both ankles.
CTA|clear to auscultation|CTA|181|183|PHYSICAL EXAMINATION|In general she appeared to be tired. She kept her eyes closed for much of the examination, but opened them when asked to. Cranial nerve examination II through XII is intact. CHEST: CTA bilaterally. CARDIOVASCULAR: Regular rate and rhythm without murmurs. ABDOMEN: Soft without any apparent tenderness. She had a colostomy bag in place on the right side.
CTA|clear to auscultation|CTA|163|165|PHYSICAL EXAMINATION|Mood and affect seem depressed and flat. HEENT: Cranial nerves II-XII intact, EOMI present. CARDIOVASCULAR: Tachycardic, no murmur present. Regular rhythm. LUNGS: CTA bilaterally. SKIN: Left foot is completely covered in its dressing. MUSCULOSKELETAL: Full active range of motion x4 extremities. Strength in upper extremities is 5/5, lower extremities 5/5, however, the patient still has some tremor on manual muscle testing.
CTA|clear to auscultation|CTA|200|202|PHYSICAL EXAMINATION|He is very cooperative throughout exam. Cognitive quick screen is intact. He follows directions well. HEENT: Normal. Face is symmetrical. EOMI. CARDIAC: Regular rate and rhythm without murmur. CHEST: CTA bilaterally, good effort noted. ABDOMEN: Decreased bowel sounds but non-tender, non-distended. SKIN: Moderate edema and tenderness noted at the medial and lateral edges of his stump incision.
CTA|clear to auscultation|CTA|240|242|PHYSICAL EXAMINATION|GENERAL: No acute distress. HEENT: Atraumatic, normocephalic. EOMI. Gaze preference to the right as before but this has also improved. CHEST: He does attend to the left. CARDIOVASCULAR: Regular rate and rhythm. Distant heart sounds. LUNGS: CTA bilaterally. MUSCULOSKELETAL: Right upper extremity and lower extremity is 5/5. Left upper extremity proximally 4/5, distally 4+. Left lower extremity is distally 4+/5, sensation intact to light touch.
CTA|clear to auscultation|CTA.|162|165|PHYSICAL EXAMINATION|GENERAL: He is awake and alert and in no acute distress. He is oriented to self, place and year. NEUROLOGIC: Cranial nerve exam II through XII was intact. CHEST: CTA. CV: Regular rate and rhythm, no murmur detected. ABDOMEN: Benign. Bowel sounds present. He is nondistended. SKIN: Without significant edema.
CTA|clear to auscultation|CTA|239|241|PHYSICAL EXAMINATION|GENERAL: No acute distress. Alert and oriented, very cooperative with examination, very appropriate. HEENT: Atraumatic, normocephalic. EOMI speech. CHEST: Clear, no dysphagia, no dysarthria. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: CTA bilaterally. ABDOMEN: Incision clean, dry and intact, nontender to touch. SKIN: No significant edema in lower extremities. Flat intact stage II to stage III ulcer at the lateral aspect of her left heel.
CTA|clear to auscultation|CTA|173|175|PHYSICAL EXAMINATION|GENERAL: In no acute distress, pleasant woman. HEENT: Atraumatic, normocephalic. EOMI. Cranial nerves II-XII intact grossly. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: CTA bilaterally. ABDOMEN: Positive bowel sounds. SKIN: No significant edema. MUSCULOSKELETAL: Full active range of motion x4 extremities. NEUROLOGIC: Strength 5/5 in upper and lower extremities.
CTA|clear to auscultation|CTA.|183|186|EXAMINATION|Her Romberg exam was negative. On gait examination her balance increases with using a walker. Without the walker this patient is tending to pitch forward and to the left side. CHEST: CTA. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Soft, non-tender, non-distended. SKIN: Without lower extremity edema. MUSCULOSKELETAL: Selective range of motion in all joints.
CTA|clear to auscultation|CTA,|192|195|PHYSICAL EXAMINATION|GASTROINTESTINAL: No dysphagia noted. CARDIOVASCULAR: Regular rate and rhythm, no murmur detected. RESPIRATORY: Slight expiratory wheeze heard on auscultation, left greater than right. LUNGS: CTA, no crackles discerned. ABDOMEN: Soft, flat, nontender, nondistended. Positive bowel signs. SKIN: No edema. MUSCULOSKELETAL: Full active range motion x4 extremities.
CTA|clear to auscultation|CTA|143|145|PHYSICAL EXAMINATION|CARDIOVASCULAR: Regular rate and rhythm without murmur. RESPIRATORY: Decreased lung sounds at the base where the chest tube was present. Right CTA with good effort. ABDOMEN: Positive bowel sounds, soft, tender the right side secondary to recent Lovenox injection. SKIN: No significant lower extremity edema. MUSCULOSKELETAL: Full active range of motion in her upper extremities.
CTA|clear to auscultation|CTA.|125|128|PHYSICAL EXAMINATION|Her tongue is midline. Cranial nerves 5 and 7 are intact. She has a normal swallow. She has and equal shoulder shrug. CHEST: CTA. CARDIOVASCULAR: CV Regular rate and rhythm. ABDOMEN: Negative, she is soft and nontender. LOWER EXTREMITIES: Without edema. She has full range of motion.
CTA|clear to auscultation|CTA|164|166|PHYSICAL EXAM|Alert and oriented x3. Cognitively intact. HEENT: Normocephalic, atraumatic. EOMI, speech clear, no dysphagia, GIA. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: CTA bilaterally. ABDOMEN: Benign, flat and nontender. SKIN: Incision is clean, dry and intact with staples. No significant edema. MUSCULOSKELETAL: Full active range motion x4 extremities. NEUROLOGIC: Manual motor testing full strength 5/5 x4 extremities.
CTA|clear to auscultation|CTA|161|163|PHYSICAL EXAMINATION|He sats at 96% on room air. GENERAL: He is in some discomfort sitting in a slight incline in bed. CARDIOVASCULAR: Regular rate and rhythm without murmur. LUNGS: CTA bilaterally. Some decreased breath sounds at the bases. Right chest tube is in place. ABDOMEN: Positive bowel sounds, soft, nontender. EXTREMITIES: Positive swelling in bilateral upper extremities.
CTA|clear to auscultation|CTA|182|184|PHYSICAL EXAMINATION|No significant cognitive or communication difficulties noted. HEENT: Cranial nerves II-XII intact. CARDIOVASCULAR: Regular rate and rhythm with a 2/6 murmur throughout. RESPIRATORY: CTA bilaterally with good effort noted. ABDOMEN: Soft with bowel sounds present. She is mildly tender in the left lateral region. SKIN: She has abdominal midline incision with nonhealing open areas x2 that has some mild erythema and is not draining.
CTA|clear to auscultation|CTA.|142|145|PHYSICAL EXAMINATION|He was able to follow directions with repeated cues only 10% of the time on my examination. Cranial nerve exam appeared intact II-XII. CHEST: CTA. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Soft and non-tender and non-distended. EXTREMITIES: Slightly cachectic, but good muscle bulk. He had full active range of motion in all extremities.
CTA|clear to auscultation|CTA|287|289|ROS|_%#NAME#%_ has an older sister who is in college. _%#NAME#%_ had a Make-a-Wish trip to Disney World with her parents and sister. Physical Exam: _%#NAME#%_ was answering questions appropriately without confusion. She overall appears tired but in no apparant distress HEENT deferred Chest CTA CV without murmur Abdomen distended, soft, nontender Ext nontender Back tender to palpation predominantly in mid-back but also noted throughout back Impression: _%#NAME#%_ is a 14 year old with history of ALL, S/P transplant, now with 4th relapse.
CTA|clear to auscultation|CTA|154|156|PHYSICAL EXAMINATION|She is cooperative through exam. She did not appear overtly depressed. HEENT: PERRL, EOMI. CARDIOVASCULAR: Regular rate and rhythm without murmur. LUNGS: CTA bilaterally, good effort noted. ABDOMEN: Flat, soft, nontender, nondistended. Bowel sounds present. SKIN: Without significant edema. EXTREMITIES: Full passive range of motion x4 extremities and all joints.
CTA|clear to auscultation|CTA.|191|194|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: T-max 98.6, heart rate 85, blood pressure 118/71, O2 sats 95%, respiratory rate 16. GENERAL: She is awake, alert and oriented, in no acute distress. LUNGS: CTA. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Soft and bowel sounds are present. EXTREMITIES: Without edema. She has full active range of motion x4 extremities.
CTA|clear to auscultation|CTA|262|264|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Stable. T-max is 37, pulse 64-80, blood pressure 125-154 over 82-98 and respiratory rate 18-20. GENERAL: He is in no acute distress. He is alert and active and oriented. His conversation and cognitive status are intact. CHEST: CTA throughout. CARDIOVASCULAR: Regular rate and rhythm without murmur. ABDOMEN: Soft, nontender, nondistended. SKIN: Without significant edema in the lower extremities. He does have some flaking epidermis in the scalp and facial area.
CTA|clear to auscultation|CTA.|153|156|PHYSICAL EXAMINATION|GENERAL: He was cooperative, alert and oriented. He was cognitively intact. His answers to questions were appropriate. He followed commands well. CHEST: CTA. CARDIOVASCULAR: Regular rate and rhythm. Perfusion was good. ABDOMEN: Benign. SKIN: Without edema. MUSCULOSKELETAL: Full range of motion x4 extremities.
CTA|computed tomographic angiography|CTA|243|245|RECOMMENDATIONS|At this time, however, he informs me that he has only been wearing his compression stockings for one week, and has tried an increased salt diet for one week, so he has not failed this. I recommend that he continue with these modifications. If CTA is negative, the patient is cleared to be dismissed. Thank you for the consultation.
CTA|computed tomographic angiography|CTA|224|226|PAST MEDICAL HISTORY|No other symptoms were experienced by the patient or described by his parents. PAST MEDICAL HISTORY: Grade 4 left temporal arteriovenous malformation. This arteriovenous malformation was imaged and assessed by CT as well as CTA and MRI scanning in _%#MM2004#%_. MEDICATIONS: Valproate. ALLERGIES: Dilantin. SOCIAL HISTORY: The patient lives a home in the care of his mother and father.
CTA|clear to auscultation|CTA.|205|208|PHYSICAL EXAMINATION|SKIN: Somewhat ruddy complexion. LYMPH NODES: No palpable lymphadenopathy. HEENT: Normocephalic. PERRL. EOMs intact. ENT unremarkable. NECK: Supple without carotid bruits. CHEST: Without deformity. LUNGS: CTA. HEART: Regular rate and rhythm without murmurs, rubs or gallops. Pulses 2+ and symmetrical. ABDOMEN: Soft, nontender without palpable organomegaly.
CTA|clear to auscultation|CTA.|157|160|PHYSICAL EXAMINATION|She appears to have a midline tongue. She appears to have EOMI intact. Her pupils are slightly asymmetric with the right at 4 mm on the left at 3 mm. CHEST: CTA. CARDIOVASCULAR: Regular rate and rhythm without murmur. Perfusion was good. Pulses were 2. ABDOMEN: Soft, nontender, nondistended. She had moderate bowel sounds present.
CTA|clear to auscultation|CTA.|183|186|VS|Switched to oral prednisolone 40 mg once daily yesterday. Exam: VS:Afebrile, vitals stable, on room air Gen: Resting comfortably in bed Neck: Dressing on prior CVL site C/D/I. Chest: CTA. Good air entry thruout. Cor: S1, S2, no murmur Abd: Soft, NT, ND, no hepatosplenomegaly. VAC still on. Ext: WWP. Ulcerations on fingertips healing. Labs: no new labs since _%#MMDD#%_.
CTA|clear to auscultation|CTA|212|214|PHYSICAL EXAMINATION|She had no significant dysphagia. Her speech was quiet and although I required the patient to repeat her answers, she did not appear to have significant dysarthria. She was not coughing on her secretions. CHEST: CTA bilaterally. CV: Atrial fibrillation with normal S1 and S2. ABDOMEN: Non-distended. She had normal bowel sounds. EXTREMITIES: She had full passive range of motion in all extremities bilaterally.
CTA|clear to auscultation|CTA|183|185|ALLERGIES|She is afebrile, and in no acute physical distress. HEENT: PERRL. Conjunctivae clear. OP is clear with moist mucous membranes. Neck supple, no lymphadenopathy, no thyromegaly. Lungs: CTA bilaterally. Heart: RRR, no murmur. Chest wall with focal chest wall tenderness to palpation in the left anterior axillary line. Skin: No rashes in this general area. Abdomen: Soft, nontender, nondistended.
CTA|clear to auscultation|CTA|188|190|PHYSICAL EXAMINATION|He is tired-appearing. He is sitting at a 45 degree inclination angle in bed. HEENT: Cranial nerve examination appears to be intact II-XII. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: CTA bilaterally. ABDOMEN: Soft and slightly obese, but nondistended. EXTREMITIES: No clubbing or edema present. Examination of his right upper extremity shows pain with passive range of movement to 45 degrees of abduction and flexion at the shoulders.
CTA|computed tomographic angiography|CTA|140|142|IMPRESSION|He did receive vancomycin and Rocephin in the ER and it will be continued. His head CT is most suspicious for a vascular malformation and a CTA is pending. He will need an angiogram in the morning. In the meantime, will control his blood pressure to less than 120 as it is 110 on admission.
CTA|computed tomographic angiography|CTA|135|137|IMPRESSION/PLAN|IMPRESSION/PLAN: Neurologically this patient appears to be intact. There is a repeat CT scan already ordered for today. We would add a CTA to evaluate for any other causes of bleed as her fall was unwitnessed and she does not recall if she fell by losing consciousness first or if she simply tripped.
CTA|clear to auscultation|CTA|164|166|PHYSICAL EXAMINATION|She has she is hard of hearing. CARDIOVASCULAR: She has 2/6 systolic ejection murmur and an occasional skipped beat. Perfusion is good. Pulses are +2. RESPIRATORY: CTA bilaterally. She is not dyspneic examination. ABDOMEN: She has bowel sounds present. She is soft, non-tender, and non-distended. EXTREMITIES: WWS. Trace edema bilateral feet. She has some muscle atrophy diffusely consistent with age.
CTA|clear to auscultation|CTA|150|152|PHYSICAL EXAMINATION|He had just finished a physical therapy session and walked back from physical therapy area on the floor to his room at the end of the hallway. LUNGS: CTA bilaterally but he had decreased inspiratory effort. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Morbidly obese. Bowel sounds present. EXTREMITIES: Without edema. SKIN: He had no rash.
CTA|computed tomographic angiography|CTA|153|155|LABORATORY DATA|Troponin was negative. BNP was elevated at 3320. CT scan of her head on admission revealed small vessel ischemic disease with no changes. I reviewed the CTA with the patient and her family. This has revealed some very mild dilatation of the thoracic aorta. The ascending aorta measures 35.7 cm and the descending 27.9 cm.
CTA|cerebellopontine angle:CPA|CTA|228|230|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD We are asked to see _%#NAME#%_ _%#NAME#%_, a 79-year-old male who was admitted for nausea and vomiting. As part of his work up, he underwent a brain MRI which demonstrated a right CTA angle lesion, consistent with an acoustic neuroma. The patient unfortunately does not speak any English. I called his son on the phone, who states the nausea was relatively acute in onset over the past one to two weeks.
CTA|clear to auscultation|CTA|163|165|PHYSICAL EXAMINATION|He has a slightly depressed left nasolabial fold, however, a symmetric smile. He has slightly decreased left shoulder shrug, but this improves with cueing. CHEST: CTA throughout. CARDIOVASCULAR: Regular rate and rhythm without murmur. ABDOMEN: Soft and nontender, nondistended. SKIN: Without significant edema. MUSCULOSKELETAL/NEUROLOGIC: He has full active range of motion x4 extremities.
CTA|clear to auscultation|CTA|185|187|PHYSICAL EXAMINATION|GENERAL: She is alert and oriented, very pleasant, no acute distress. Cognitively appears appropriate. Her responses appear appropriate. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: CTA bilaterally. ABDOMEN: Positive bowel sounds, flat, nondistended. SKIN: No lower extremity edema. MUSCULOSKELETAL: Full active range of motion in her right arm and left leg.
CTA|clear to auscultation|CTA|178|180|PHYSICAL EXAMINATION|GENERAL: No acute distress. HEENT: Atraumatic, normocephalic. EOMI, cranial nerves II-XII intact. CV: Regular rate and rhythm, PVCs noted with increased activity with PT. LUNGS: CTA bilaterally. MUSCULOSKELETAL: Full active range of motion x5 extremities except for right knee flexion restricted secondary to pain. Strength is 5/5 x4 extremities except right lower extremity is 4/5 currently.
CTA|clear to auscultation|CTA.|123|126|REASON FOR CONSULTATION|No dysarthria or dysphagia present. EOMI present. Face is symmetrical. CV is regular rate and rhythm bilaterally. Chest is CTA. Extremities show no clubbing or edema. She has full functional range of motion in her upper extremities and lower extremities.
CTA|clear to auscultation|CTA|217|219|ROS|Comfortably lying in bed; A/O X 3; cooperative and answers questions appropriately. EOMI, VFI, PERRL; funduscopic not performed. MMM, o/p clear, normal dentition. Neck supple without cervical/jugular LAN/thyromegaly. CTA b/l without crackles or wheezes. RRR, nl S1/prominent S2 without obvious murmur; no extra heart sounds. Trace pedal edema. NABS, ND/NT/S without HSM or masses. FROM in all joints without tenderness or swelling; mild erythema and tenderness at base or large L great toe.
CTA|computed tomographic angiography|CTA|241|243|ASSESSMENT/PLAN|IBD does not usually occur every three months. With her symptoms, colonoscopy will be undertaken. We can then make a determination what is needed. Should she have evidence of ischemic disease, clotting workup can be undertaken and an MRA or CTA can be done looking for evidence of segmental vascular narrowing. We would be happy to make further recommendations pending the above.
CTA|computed tomographic angiography|CTA|213|215|HISTORY OF PRESENT ILLNESS|He had an echocardiogram done on that hospitalization and it showed an ejection fraction of 45-50% with impaired diastolic function and an abnormal septal motion consistent with bundle branch block. He also had a CTA done during that hospital stay to rule out aortic dissection and it showed no such problem, although there were reportedly some pleural parenchymal fibrotic changes.
CTA|clear to auscultation|CTA|128|130|PHYSICAL EXAMINATION|GENERAL: He is in no acute distress sitting up in his chair. HEART: Regular rate and rhythm, no murmurs detected. LUNGS: Clear: CTA bilaterally except for fine crackles at the left posterior base. ABDOMEN: Positive bowel sounds, soft, nontender, nondistended. EXTREMITIES: Bilateral bruising in the right lower extremity greater than the left.
CTA|clear to auscultation|CTA|193|195|OBSERVATION/EXAMINATION|She follows commands well. HEENT: No significant asymmetry seen. Speech is clear, no dysphagia seen. EOMI. CARDIOVASCULAR: 2/6 systolic ejection murmur at the left upper sternal border. LUNGS: CTA bilaterally. SKIN: Good perfusion, no edema in lower extremities. MUSCULOSKELETAL: Full active range of motion x4 limbs. NEUROLOGIC: Strength exam 4-5/5 x4 extremities.
CTA|clear to auscultation|CTA|143|145|PHYSICAL EXAMINATION|GENERAL: He is in no acute distress sitting at the edge of the bed eating his lunch CARDIOVASCULAR: Regular rate and rhythm, no murmur. LUNGS: CTA bilaterally, good effort noted. ABDOMEN: Positive bowel sounds, soft, nontender, nondistended. EXTREMITIES: No edema in the lower extremities. Small eschar at the left shin area.
CTA|clear to auscultation|CTA|208|210|PHYSICAL EXAMINATION|She is satting at 94% on room air. GENERAL: She is alert and oriented, very pleasant woman. HEENT: Atraumatic and normocephalic. EOMI. CARDIOVASCULAR: Regular rate and rhythm. No murmur, rub or bruit. LUNGS: CTA bilaterally. ABDOMEN: Benign, positive bowel sounds. SKIN: Without edema. MUSCULOSKELETAL: Full active range of motion x4 extremities. NEUROLOGIC: Manual motor testing 5/5 strength x4 extremities. Intact sensation.
CTA|clear to auscultation|CTA|830|832|PE|PMHx: ALD diagnosed _%#MM2007#%_ Medications: Zofran IV 1 mg/hour Phenergan 20 mg IV Q 4 hour Kytril 400 mg IV Q 12 hour Decadron 6 mg IV x1 yesterday and today Protonix 20 mg IV Qday Morphine sulfate IV 0.06 mg/kg/hour and 1 mg Q 15 min prn Ativan 0.25 mg IV Q 6 hour prn nausea Ceftazidine 1259 mg IV Q 8 hour Ancef 625 mg IV Q hour Fluconazole 75 mg Q day Bactrim 80 mg TMP BID Q Mon/Tues Acyclovir 250 mg Q 8 hour Florinef 0.1 mg Q day po Urosodiol 300 mg TID MMF 400 mg Q 8 hour Selenium 200 mcg Qday Clofarabine 37.6 mg IV ROS: a 12 point review of systems was negative other than noted in the HPI Family Hx: Social Hx: lives with parents and sister _%#NAME#%_ (donor) in _%#CITY#%_ Nebraska PE: weight 24.6 kg Sleeping initially. Woke up uncomfortable but easily consoled by parents. No acute distress HEENT deferred chest CTA CV no murmur Abd + bs, soft, nontender, nondistended, no organomegaly Labs: BMP unremarkable other than gluc 129 ALT 508, AST 340, t bili 0.5 lipase 54, amylase 62 Abdominal xray: stool in colon, no obstruction Impression and recommendations: 8 year old boy ALD day - 4 HLA identical carrier sibling related transplant Potential contributing factors to nausea and vomiting include chemotherapy and morphine sulfate.
CTA|clear to auscultation|CTA|166|168|PHYSICAL EXAMINATION|HEENT: Cranial nerves II-XII intact. Speech clear, no dysphagia. CV: 3/6 systolic ejection murmur over the left upper sternal border. Regular rate and rhythm. LUNGS: CTA bilaterally. ABDOMEN: Soft, mobile mass noted approximately baseball sized in the mid abdomen, old scar tissue present. Otherwise, abdominal exam negative. SKIN: No significant edema seen. MUSCULOSKELETAL: Full active range of motion x4 extremities.
CTA|computed tomographic angiography|CTA|279|281|INVESTIGATIONS|Gait examination was not performed. INVESTIGATIONS: CT of the head showed some evidence of an early findings consistent with a left middle cerebral territory infarct, specifically showing changes in the parietal lobe laterally as well as the left temporal lobe posterolaterally. CTA showed a tapering occlusion of the left internal carotid artery consistent with dissection. There is also moderate to severe stenosis at the proximal origin of the right internal carotid artery.
CTA|clear to auscultation|CTA.|237|240|PHYSICAL EXAMINATION|She is able to follow commands well. She has word finding difficulties noted in the course of the examination and her speech is somewhat garbled and difficult to understand. Her comprehension, however, appears quite good overall. CHEST: CTA. CARDIOVASCULAR: Regular rate and rhythm, I did not detect a murmur. EXTREMITIES: Without edema. ABDOMEN: Soft, nontender. HEENT: Cranial nerve examination is intact throughout.
CTA|clear to auscultation|CTA|153|155|PHYSICAL EXAMINATION|No redness seen in the distal end of the incision. Cervical collar is a good fit. No significant redness seen along the lower edge of the collar. CHEST: CTA bilaterally. CARDIOVASCULAR: Regular rate and rhythm. No murmur. Pulses +2 x4 extremities. SKIN: He has slight redness of the left heel compared to the right.
CTA|computed tomographic angiography|CTA|279|281|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 51-year-old Caucasian male, right hand dominant, who presented to an outside hospital with sudden onset of headache, described as the worst headache of his life. He had a CT of his head performed, which showed a subarachnoid hemorrhage, and CTA showed an anterior communicating aneurysm. Consequently, the patient was transferred to the University of Minnesota Medical Center for further management on _%#MMDD2007#%_.
CTA|computed tomographic angiography|CTA|330|332|IMAGING|On _%#MMDD#%_ a chest x-ray showed clear lungs. Most recent head CT on _%#MMDD#%_ showed further evolution of left parasagittal anterior frontal and left caudate infarct with stable amounts of mass effect and midline shift. Perfusion imaging demonstrates infarct of the cortex of the left parasagittal anterior frontal lobe. Head CTA demonstrates mild attenuation of the distal ICA and MCA, right greater than left. There is some limitation of the study due to a bolus timing, however, early component of spasm cannot be excluded.
CTA|computed tomographic angiography|CTA|211|213|IMAGING|Head CTA demonstrates mild attenuation of the distal ICA and MCA, right greater than left. There is some limitation of the study due to a bolus timing, however, early component of spasm cannot be excluded. Neck CTA demonstrated approximately 50% stenosis by NASCET criteria of the left internal carotid artery 2 cm distal to the origin. Abdominal x-ray on _%#MMDD#%_ showed nasogastric tube tip in the stomach.
CTA|clear to auscultation|CTA|173|175|PHYSICAL EXAMINATION|She is fatigued appearing. She has a depressed mood, but she was cooperative with examination. CARDIOVASCULAR: Regular rate and rhythm without murmur, gallop or rub. LUNGS: CTA bilaterally. ABDOMEN: Flat, non-tender, non-distended. Bowel sounds present. SKIN: Without significant edema in the lower extremities. MUSCULOSKELETAL: Full active range of motion in her left upper extremity.
CTA|computed tomographic angiography|CTA|343|345|ASSESSMENT AND RECOMMENDATIONS|ASSESSMENT AND RECOMMENDATIONS: CT of the head is reviewed, which reveals the aforementioned findings of subarachnoid hemorrhage, which in all likelihood is traumatic, but given its distribution in the sylvian fissure, and the fact that he does not remember the precipitating events or the accident, I do think it would be prudent to obtain a CTA to rule out an underlying aneurysm. He will need physical therapy, occupational therapy, and a cognitive evaluation, and certainly could be discharged to home if that is negative.
CTA|clear to auscultation|CTA.|178|181|PHYSICAL EXAMINATION|The patient coughing on secretions. NEUROLOGIC: Full cranial nerves II-XII examination deferred secondary to decreased level of arousal. CHEST: Rhonchi throughout, but otherwise CTA. CARDIOVASCULAR: Regular rate and rhythm, no murmur. ABDOMEN: Soft, flat, nontender, positive bowel sounds. EXTREMITIES: No significant edema. MUSCULOSKELETAL: Full active range of motion x2 extremities right upper and lower limbs, full passive range of motion times in his left side.
CTA|clear to auscultation|CTA.|156|159|ADMISSION PHYSICAL EXAMINATION|HEENT: Head was normocephalic and atraumatic. PERRLA, EOMI. Mucous membranes are dry. NECK: No JVD, no LAD. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: CTA. ABDOMEN: Soft, tender with palpation over all 4 quadrants. Bowel sounds were positive. SKIN: No rash. NEUROLOGIC: Cranial nerves II-XII grossly intact bilaterally.
CTA|clear to auscultation|CTA|103|105|PHYSICAL EXAMINATION|NECK: No thyromegaly, no lymphadenopathy. CARDIOVASCULAR: S1 and S2 heard. No S3, no M, G or R. LUNGS: CTA bilaterally. ABDOMEN: Right upper quadrant tenderness, no abdominal distention, no HSM, bowel sounds hypoactive. CVA/SPINE: No CVA tenderness. SKIN: No rash, a right Port-A-Cath is in place with no erythema.
CTA|creatine phosphokinase:CPK|CTA|139|141|HOSPITAL COURSE|Infectious Disease recommended CT scans of the chest and abdomen to look for possible abscesses. His head CT was negative for sinusitis. A CTA level was checked for possible neuro-malignant syndrome and was negative. His abdominal scans were negative for any abscesses. The patient underwent an echocardiogram and TEE to evaluate for endocarditis, and both turned out to be negative, with no evidence of other possible sources of infections as the most likely source for his foot ulcer.
CTA|computed tomographic angiography|CTA|286|288|PROCEDURES|Findings, right middle cerebral territory and right head of caudate nucleus subacute infarct approximately 3 days old, right internal carotid artery long segment of irregularity from the common carotid artery bifurcation past the bulb demonstrates appearance of dissection. I recommend CTA of the neck, the carotid and circle of Willis arteries. 4. CT angio of the head and neck. Neck CTA demonstrates dissection of the right internal carotid artery extending from the bulb to C2 approximately 4 cm in length.
CTA|computed tomographic angiography|CTA|111|113|PROCEDURES|I recommend CTA of the neck, the carotid and circle of Willis arteries. 4. CT angio of the head and neck. Neck CTA demonstrates dissection of the right internal carotid artery extending from the bulb to C2 approximately 4 cm in length. CTA of the head demonstrates no definite aneurysm or stenosis of major intracranial arteries.
CTA|computed tomographic angiography|CTA|164|166|PROCEDURES|4. CT angio of the head and neck. Neck CTA demonstrates dissection of the right internal carotid artery extending from the bulb to C2 approximately 4 cm in length. CTA of the head demonstrates no definite aneurysm or stenosis of major intracranial arteries. 5. CT brain perfusion study with contrast on _%#MMDD2007#%_, showed evolving subacute infarcts involving the right middle cerebral artery distribution.
CTA|computed tomographic angiography|CTA|154|156|HOSPITAL COURSE|There was a concern that the results of the MRI were consistent with a right carotid dissection. Therefore, further imaging studies were obtained such as CTA of the neck confirming the diagnosis of right internal carotid artery dissection approximately 4 cm in length. However, on the MRI imaging, there was concern of areas of possible ischemia that would not be consistent with the area of dissection, unless there was some sort of embolic phenomenon.
CTA|clear to auscultation|CTA|132|134|PHYSICAL EXAMINATION|There is no supraclavicular lymphadenopathy noted. CARDIOVASCULAR: Regular rate and rhythm with no murmurs, rubs or gallops. LUNGS: CTA bilaterally without wheezes, rales or rhonchi. ABDOMEN: Positive bowel sounds. The abdomen is soft, nontender and nondistended with no hepatosplenomegaly.
CTA|computed tomographic angiography|CTA|135|137|HOSPITAL COURSE|An intracardiac shunt was ruled out based on this bubble study. Recommendations were made by Pulmonary to follow up with an MRA versus CTA with contrast if Ms. _%#NAME#%_ develops hemoptysis or has optimal control of the CHF and is still considerably hypoxic with a further workup for an intrapulmonary shunt might be in order.
CTA|computed tomographic angiography|CTA|135|137|HOSPITAL COURSE|Pulmonary is recommending that if Ms. _%#NAME#%_ develops hemoptysis or becomes profoundly hypoxic, we should consider doing an MRA or CTA with contrasts to evaluate for a possible intrapulmonary shunt. However, at this time, I would not change her management. Home oxygen therapy was initiated to help with these desaturations.
CTA|computed tomographic angiography|CTA|175|177|HOSPITAL COURSE|Additionally, infectious etiologies were investigated, and Clostridium difficile and stool cultures for SFCE were negative. The CMV, shell virus viral culture was negative. A CTA was checked and was normal. Bowel biopsies were taken from the ileum, jejunum, sigmoid, right colon, and rectum on _%#MM#%_ _%#DD#%_, 2004; these had normal pathology; however, electron microscopy is pending at the time of this dictation.
CTA|clear to auscultation|CTA|194|196|PHYSICAL EXAMINATION|EOMI, PERRLA. TMs clear. Oropharynx is clear with dentures in place. NECK: Supple with no thyromegaly or lymphadenopathy. BREAST: Dense fibrocystic changes noted and few masses palpable. CHEST: CTA bilaterally. HEART: Regular rate and rhythm with normal S1 and S2. No murmur. ABDOMEN: Positive bowel sounds. Abdomen is obese, soft and diffusely tender.
CTA|clear to auscultation|CTA|125|127|PHYSICAL EXAMINATION|HEENT: PERRLA. CV: RR, MRG 0, JVD 0, radial pulses x2 bilateral, distal pulses 2+ on the left, 1+ on the right. RESPIRATORY: CTA bilaterally. ABDOMEN: Positive for bowel sounds, soft, non- distended, tender to palpation throughout, no peritoneal signs. EXTREMITIES: Warm and dry. NEUROLOGICAL: AO x3, no focal motor deficits.
CTA|clear to auscultation|CTA|141|143|ADMISSION PHYSICAL EXAMINATION|Eyes EOM I, no scleral icterus. Ears TMs clear bilaterally. Nose clear. Mouth/throat no oral lesions. OP clear. NECK: Supple. No LAD. LUNGS: CTA bilaterally. CARDIOVASCULAR: Regular rate and rhythm. No murmurs. Regular S1, S1. ABDOMEN: Soft, mild left lower quadrant tenderness. No rebound or guarding. Bowel sounds are normoactive. SPINE: Straight.
CTA|clear to auscultation|CTA|138|140|PHYSICAL EXAMINATION|Pacer defib outlines. No reproducible tenderness. Regular rate and rhythm though occasional dropped beat. Present S3. Lateral PMI. LUNGS: CTA with upper airway transmitted congestion. ABDOMEN: Soft, nontender, no masses, bowel sounds are normal, no HSM. BREAST: Not examined. GENITOURINARY: Not examined. No CVA tenderness. LYMPHATICS: No cervical lymphadenopathy, no supraclavicular LA, no axillary LA, inguinal was not checked.
CTA|computed tomographic angiography|CTA,|187|190|PROCEDURES|6. Conjunctivitis, resolved. 7. Right upper extremity edema and swelling, resolving. 8. Urinary retention. PROCEDURES: 1. Head CT shows left frontal parenchymal hemorrhage, no change. 2. CTA, no definite aneurysm or stenosis. 3. GJ tube placement. 4. Feeding tube placement, removed when GJ tube placed. Initial feeding tube placement was complicated by obstruction of the pylorus.
CTA|clear to auscultation|CTA|119|121|PHYSICAL EXAMINATION ON ADMISSION|HEENT: ACMT, PERRLA, EOMI, oropharynx is clear. NECK: Supple. LAD was 9. JVP was 0. CV: RRR; S1, S2 are normal. LUNGS: CTA bilaterally. ABDOMEN: Diffuse tenderness, positive bowel sounds, left upper quadrant colostomy, midline incision with granulation tissues. LOWER EXTREMITIES: Laceration of the left lower extremity. SKIN: Hyperpigmented spots on the upper extremities.
CTA|computed tomographic angiography|CTA,|215|218|OPERATIONS/PROCEDURES PERFORMED|This is also encasing the main portal vein and the portion of the superior mesenteric vein and splenic vein. However, this is a limited evaluation of the venous structures, mainly due to early scanning. A dedicated CTA, or MRV, should be considered to confirm the obstruction along the portal system. 2. Limited evaluation of hepatic veins and IVC, due to early scanning.
CTA|clear to auscultation|CTA|137|139|HOSPITAL COURSE|Her Coumadin was discontinued on admission, and she was continued on aspirin and added Plavix to this regimen. With the results from the CTA and CTP previously described, it was decided that she would have a formal cerebral angiogram with the possibility of angioplasty and stent of the symptomatic carotid artery.
CTA|clear to auscultation|CTA|183|185|PHYSICAL EXAMINATION|No dysphasia or dysarthria seen. He was not coughing or choking on his food. EOMI showed limited bilateral upward gaze. PERRL present. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: CTA bilaterally. ABDOMEN: Positive bowel sounds, soft, nontender, nondistended, obese. NEUROLOGIC: The patient was oriented to place, self and stated _%#MMDD2006#%_.
CTA|clear to auscultation|CTA|155|157|PHYSICAL EXAMINATION|She is a cachectic elderly appearing woman. HEENT: Her right eye has an inferior hemorrhage. EOMI present. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: CTA except for a few crackles at the right base. RESPIRATORY: Good respiratory excursion seen. ABDOMEN: Positive bowel sounds, soft, nontender, nondistended.
CTA|clear to auscultation|CTA.|152|155|PHYSICAL EXAMINATION|Cognitively she appears intact. Her thought processes appear intact. Her fund of knowledge appears adequate. Conversational skills are adequate. CHEST: CTA. CV: Regular rate and rhythm. ABDOMEN: Soft and nontender. SKIN: She had mild edema in her extremities. She had some edema in her fingers with some thinning of skin with cutaneous changes.
CTA|clear to auscultation|CTA.|157|160|PHYSICAL EXAMINATION|She can follow commands with minimal assistance, she still is hesitant to. Cranial nerves II-XII appear intact. CHEST: Her chest on anterior examination was CTA. I deferred examination of her posterior chest. CARDIOVASCULAR: Regular rate and rhythm. Perfusion seemed acceptable. SKIN: She has some ecchymosis in both arms secondary to blood draws.
CTA|clear to auscultation|CTA.|178|181|PHYSICAL EXAMINATION|She appeared to have difficulty following commands. Multiple attempts to get her to squeeze my fingers were unsuccessful. Her speech appeared clear but inappropriate. CHEST: Was CTA. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Soft, non-tender, non-distended. She had normal bowel sounds. EXTREMITIES: No significant edema noted in her extremities.
CTA|clear to auscultation|CTA|204|206|PHYSICAL EXAMINATION|Cognition appears intact. Communication is intact. HEENT: Cranial II- XII intact. Speech is clear, nondysarthric. No dysphasia present. CHEST: 1/6 systolic murmur present. Regular rate and rhythm. LUNGS: CTA bilaterally. ABDOMEN: Flat, nontender. Well-healed abdominal incisions. SKIN: No significant edema, stasis changes to bilateral lower extremities. MUSCULOSKELETAL: Bilateral foot deformities secondary to Charcot nerve neuropathy present, full active range of motion x4 extremities except for both ankles.
CTA|clear to auscultation|CTA|234|236|PHYSICAL EXAMINATION|GENERAL: The patient is in moderate pain secondary to bladder spasms but is cooperative with examination. Exam limited though because of her pain. HEENT: Sclerae icterus. EOMI intact.. Speech clear, no dysarthria or dysphasia. CHEST: CTA bilaterally, no crackles, no wheezes. CARDIOVASCULAR: Regular rate and rhythm, no murmur. ABDOMEN: Obese, positive bowel sounds in all quadrants.
CTA|clear to auscultation|CTA.|142|145|EXAMINATION|NEUROLOGIC: Cranial nerve exam II through XII appears intact. She has no nystagmus. Her tongue is midline. Her facies are symmetrical. CHEST: CTA. CARDIOVASCULAR: Regular rate and rhythm without murmur. ABDOMEN: Soft, slightly tender in the right lower quadrant just at the top of the inguinal line just medial to the anterior iliac crest.
CTA|clear to auscultation|CTA|176|178|PHYSICAL EXAMINATION|Visual fields are full. She does react to visual threat from the left. Shoulder shrug is slightly unequal, with the left side being slightly down compared to the right. CHEST: CTA throughout. CARDIOVASCULAR: Regular rate and rhythm, without murmur. Perfusion was good. ABDOMEN: Soft, nontender, and obese. It was not distended.
CTA|clear to auscultation|CTA|221|223|GENERAL|GENERAL: She is in no acute distress sitting in bed and at the edge of the bed earlier. Her father was present for the examination. She has significant cushingoid features. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: CTA bilaterally, good effort seen. ABDOMEN: Positive bowel sounds, soft, nontender; wound vac in place in the midline ventral area. EXTREMITIES: On examination of the left hand, fingers and right toes are black and necrotic at the tips of the fingers and the entire toes.
CTA|clear to auscultation|CTA|233|235|PHYSICAL EXAMINATION|Cognitively she is intact. Her responses are somewhat slow. Her affect is flat but she participates well in the evaluation. Conversational skills are intact. She follows commands well. HEENT: EOMI. No dysarthria or dysphagia. CHEST: CTA bilaterally with some decreased sounds bases at both bases. CARDIAC: Regular rate and rhythm without murmur. ABDOMEN: Positive bowel sounds but decreased.
CTA|clear to auscultation|CTA.|177|180|PHYSICAL EXAMINATION|She has no dysmorphic features. Her smile is symmetrical. Tongue is midline. She is able to turn her head equally to the right and left. She has an equal shoulder shrug. CHEST: CTA. CV: Regular rate and rhythm. ABDOMEN: Soft, nontender. EXTREMITIES: Without edema, rashes or bruises. Range of motion is full in all extremities and joints.
CTA|clear to auscultation|CTA.|174|177|PHYSICAL EXAMINATION|Formal neurocognitive testing was unable to be completed. Cranial nerves II through XII were unable to be fully evaluated. He does have a left-sided facial droop. PULMONARY: CTA. CV: Regular rate and rhythm. ABDOMEN: Flat and nontender. EXTREMITIES: Without edema. NEUROLOGIC: Range of motion in the right upper and lower extremity revealed full active range of motion.
CTA|clear to auscultation|CTA.|146|149|PHYSICAL EXAMINATION VITAL SIGNS|He is cooperative throughout examination. Cognitively and with communication he is fully intact. NEUROLOGIC: Cranial nerves II-XII intact. CHEST: CTA. CV: Regular rhythm with slight tachycardi a noted. Peripheral pulses are +2 and bounding and peripheral radial pulses were +2.
CTA|clear to auscultation|CTA|158|160|PHYSICAL EXAMINATION|He follows directions well, understands verbal cues well. HEENT: Unremarkable. EOMI, no dysphasia or dysarthria: Cranial nerves II-XII grossly intact. CHEST: CTA bilaterally, no crackles appreciated. LUNGS: Good lung excursions seen. No rhonchi present. CARDIOVASCULAR: Regular rate and rhythm without murmur.
CTA|clear to auscultation|CTA.|131|134|PHYSICAL EXAMINATION|GENERAL: He is in no acute distress, sitting comfortably in his chair. HEART: Regular rate and rhythm without murmurs. LUNGS: Left CTA. Right has decreased breath sounds at the base. Good effort noted. He has a right chest tube in place. ABDOMEN: Soft and nontender, bowel sounds present.
CTA|clear to auscultation|CTA.|150|153|PHYSICAL EXAMINATION|His conversational skills appear to be appropriate. VITAL SIGNS: Stable. See resident record. HEENT: Cranial nerves II through XII are intact. CHEST: CTA. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Soft and nontender. EXTREMITIES: Without edema. He has muscle atrophy in the left intrinsics and forearm muscles.
CTA|clear to auscultation|CTA.|138|141|ALLERGIES|The patient is very cautious when asked to rotate her head to the left. Cardiovascular exam has regular rate and rhythm at rest. Chest is CTA. Abdomen is soft and nontender with normal bowel sounds. Extremities have no clubbing or edema. Motor strength is full in all extremities at 5/5. Range of motion is full in all extremities at all joints.
CTA|clear to auscultation|CTA|161|163|PHYSICAL EXAMINATION|HEENT: Speech was slightly dysarthric. She has a slight right facial droop. Otherwise, EOMI present. She had a normal swallow function with thin liquids. CHEST: CTA throughout. CARDIOVASCULAR: Regular rate and rhythm, no murmur detected. She had good perfusion. ABDOMEN: Slightly distended. Slightly tender. She has a well-healing abdominal incision.
CTA|clear to auscultation|CTA|174|176|PHYSICAL EXAMINATION|HEENT: Neck incisions with staples in place. One JP in place. Trach in place. All areas clean, dry and intact. CARDIOVASCULAR: Regular rate and rhythm without murmur. LUNGS: CTA bilaterally. ABDOMEN: Decreased bowel sounds but soft, nondistended. EXTREMITIES: No edema. TED stockings in place up to thigh level. MUSCULOSKELETAL: Passive range of motion within normal limits. Ankle dorsiflexion is easily obtained through passive range of motion past the neutral position.
CTA|clear to auscultation|CTA.|168|171|PHYSICAL EXAMINATION|Her responses appeared appropriate. Her ability to follow commands appeared intact. Cognitively she seemed intact. Cranial nerves examination II-XII was intact. CHEST: CTA. CARDIOVASCULAR: Heart is regular rate and rhythm. ABDOMEN: Large, soft and nontender on my examination. She does have abdominal distention. The patient is also moderately obese.
CTA|clear to auscultation|CTA|160|162|PHYSICAL  EXAMINATION|He is pleasant and cooperative with examination. His cognition is intact. Communication skills are intact. NEUROLOGIC: Cranial nerves II-XII are intact. CHEST: CTA on my examination today. CARDIOVASCULAR: CV is slightly tachycardic with good bounding pulses present, no murmur was detected. ABDOMEN: Distended. His ostomy bags have clear fluid in them.
CTA|clear to auscultation|CTA.|207|210|PHYSICAL EXAMINATION|Towards the end of the examination she was falling asleep on me and this was 30 minutes into the examination. Cranial nerves II-XII appear intact. CHEST: Showed some fine crackles at the bases but otherwise CTA. CV: she was slightly tachycardic but normal rhythm noted. She had good radial pulses. ABDOMEN: Soft and slightly distended with normal bowel sounds present.
CTA|clear to auscultation|CTA|169|171|PHYSICAL EXAMINATION|GENERAL: He is in no acute distress. Cognitively appears intact. He is alert and oriented. He is cooperative throughout examination. CV: Regular rate and rhythm/ LUNGS: CTA bilaterally, good effort noted. ABDOMEN: Positive bowel sounds, soft, nontender, nondistended. SKIN: Without edema. MUSCULOSKELETAL: Decreased active and passive range of motion in the right ankle.
CTA|clear to auscultation|CTA|233|235|PHYSICAL EXAMINATION|EOMI present, PEERL. No dysarthria, dysphagia noted. CARDIOVASCULAR: Regular rate and rhythm with a 2/6 systolic murmur heard best at the left precordial area, left sternal border. Pulse is bounding in his left radial artery. CHEST: CTA throughout. No crackles appreciated at the back bases. ABDOMEN: Benign, flat, bowel sounds present, nontender. EXTREMITIES: Mild edema noted at both ankles, left worse than right, +1 edema.
CTA|clear to auscultation|CTA.|196|199|PHYSICAL EXAMINATION|She maintained a good mood and was able to joke with me at times about the testing. HEENT: Extraocular movements were intact. There is no dysarthria or dysphagia. Her face was symmetrical. CHEST: CTA. CARDIOVASCULAR: Regular rate and rhythm without murmur. ABDOMEN: Positive bowel sounds, soft, nontender, nondistended. SKIN: Without edema x4 extremities.
CTA|clear to auscultation|CTA.|171|174|ADMISSION PHYSICAL EXAMINATION|ABDOMEN: Normal active bowel sounds, soft, nontender, nondistended. LUNGS: Diffuse inspiratory crackles throughout the right rhonchi in the left base but otherwise clear. CTA. BACK: There was no spinal tenderness. The patient did have 1-2+ pitting edema bilateral lower extremities. On his left forearm and arm, there was surgical site that looked well-healed without any erythema or exudate.
CTA|computed tomographic angiography|CTA|254|256|IMPRESSION|I suspect the patient is most likely anti-coagulable due to oral contraceptives and that will lead to anticoagulation of the patient, but will hold anticoagulation until I get those results back. Addedum 18:00 CT head - distal L M1 clot. No acute stroke CTA - distal L MCA clot, normal carotids I have discussed treatment options with the patient and her husband. At this point she is a candidate only for MERCI retrival of the clot, which has 9-10% risk of ICH.
CTA|computed tomographic angiography|CTA.|124|127|PROCEDURES PERFORMED DURING HOSPITAL STAY|4. MRA of brain which revealed a chronic occlusion of M1 segment of right middle cerebral artery. This was seen on previous CTA. 5. Telemetry during entire hospital stay which was notable for sinus bradycardia during her entire hospital stay. COMPLICATIONS: None. DISCHARGE MEDICATIONS: Aspirin 325 mg p.o. daily.
CTA|clear to auscultation|CTA|169|171|PHYSICAL EXAMINATION|Vitals were temperature 98.0, blood pressure 133/86, pulse 80, respirations 18. HEENT unremarkable. No JVD, no LAD. CVS: Normal S1, S2, no murmurs, rubs, gallops. Lungs CTA bilaterally. Abdomen: nontender, nondistended. No masses. Extremities had no edema, pulses felt bilaterally 4/4. Neuro had no focal deficits. Rectal exam and anoscopy revealed grade 2 hemorrhoids, no masses.
CTA|clear to auscultation|CTA.|188|191|MEDICATIONS|She has her hearing aid in. Face is symmetrical. Tongue is midline. She has a symmetric smile. Shoulder shrug is equal bilaterally. Speech is nondysarthric. She has no dysphasia. Chest is CTA. CV is regular rate and rhythm. Abdomen is soft and nontender. Extremities are without edema. Motor examination is 5/5 in upper and lower extremities throughout all muscle groups.
CTA|clear to auscultation|CTA|201|203|PHYSICAL EXAMINATION|GENERAL: Sleepy but easily arouseable, no acute distress. Cooperative patient, cognitively intact. HEENT: EOMI. Atraumatic and normocephalic. No dysphasia or dysarthria. Cervical rotation full. CHEST: CTA bilaterally. CARDIOVASCULAR: Regular rate and rhythm, no murmur. Perfusion good. SKIN: Without significant edema. MUSCULOSKELETAL: Full active range of motion x3 extremities, moderate passive range of motion of her left lower extremity.
CTA|computed tomographic angiography|CTA.|89|92|LABORATORY  DATA|The liver, spleen, gallbladder, spleen, kidneys were unremarkable. We just performed the CTA. This confirmed the markedly calcified infrarenal aorta with a probable plaque rupture. Blood goes into the periadventitial area consistent with a localized dissection and extends down to the origin of the left common iliac artery.
CTA|clear to auscultation|CTA|457|459|VITALS|White blood cell count 9.3. Glucose 133. Creatinine 0.83. GFR greater than 90%. Sodium 134. Potassium 3.3. Calcium 8.4. VITALS: HR 105-120 BP 140-150 systolic 90-100 diastolic RR 16-20 99% RA EYES: EOMI HEAD: NC/AT NECK: Scar from radical neck disection evident: staples in place; wound does not appear infected; JP drain intack; tracheostomy site has some drainage but no evidence of surrounding infection MOUTH: Not examined CVS: s1s2 RRR tachy PULM: b/l CTA no crackles ABD: NABS, soft, Surgical incision evident EXT: hands/feet appear warm EKG: suggestion of LAE and LVH; sinus tach ASSESSMENT: The patient is a 29-year-old postoperative for radical neck dissection with a glossectomy.
CTA|clear to auscultation|CTA|261|263|PHYSICAL EXAMINATION|He is able to follow instructions well. VITAL SIGNS: Temperature of 37.2, pulse 79, respiratory rate 16, blood pressure 118/76. HEENT: Generally, he has bright yellow jaundice and scleral icterus. CARDIOVASCULAR: Regular rate and rhythm, without murmur. LUNGS: CTA bilaterally. ABDOMEN: Soft and distended. He has healing paracentesis incisions. He has bowel sounds present. SKIN: He has significant +3 edema in both legs. He has bright yellow jaundice.
CTA|clear to auscultation|CTA|152|154|EXAMINATION|HEENT: Bilateral temporal regions with intact bandages. EOMI. Speech clear. No dysarthria or dysphagia. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: CTA bilaterally. ABDOMEN: Positive bowel sounds, nontender to touch. SKIN: No significant edema x4 extremities. MUSCULOSKELETAL: Full active range of motion x4 extremities except for limited at both hips.
CTA|computed tomographic angiography|CTA|290|292|HOSPITAL COURSE|Her INR was normalized with the use of blood products and vitamin K given the bleed as it was initially 2.17. From a neurological standpoint, the patient remained asymptomatic during her hospital stay complaining only of a headache which continually improved and resolved. Follow up CT and CTA the day after admission revealed a minimal increase in the size in the right infratentorial subdural hematoma which appears to have risen from an adjacent small venous angioma.
CVA|costovertebral angle|CVA|159|161|PHYSICAL EXAMINATION|The uterus is soft and nontender. Fetal heart tones are auscultated just to the right of midline in the right lower quadrant at 140 beats per minute. BACK: No CVA tenderness, no spinal tenderness with fair range of motion. EXTREMITIES: Show fair range of motion. She does have 2+ edema today which is nontender.
CVA|cerebrovascular accident|CVA.|130|133|ASSESSMENT AND PLAN|At this point, I will not obtain an MRI. We will observe him over the next period of 24 hours for any physical changes indicating CVA. Will continue aspirin but will not initiate Aggrenox. Resume all his home medications. If his symptoms progress and change, will obtain the MRI.
CVA|costovertebral angle|CVA|233|235|ADMISSION PHYSICAL EXAMINATION|Abdomen is soft, minimally distended with no masses or hepatosplenomegaly and no tenderness to palpation at the time of admission. GU: Exam revealed normal female external genitalia with normally placed anus. SPINE: Straight with no CVA tenderness. SKIN: Pink without jaundice or petechiae. NEUROLOGIC: Exam revealed the patient to be alert with the exam, moving all extremities equal with normal deep tendon reflexes.
CVA|costovertebral angle|CVA|194|196|FAMILY HISTORY|PHYSICAL EXAMINATION VITAL SIGNS: On admission, the patient's vital signs were within normal limits. Her exam was unremarkable. She had no evidence for bruits, murmurs, abdominal tenderness, or CVA tenderness. Her mini-mental status exam was 24/30. She was unable to remember the date, unable to draw intersecting octagons, and scored a 3 out of 5 in spelling the word "world" backwards.
CVA|cerebrovascular accident|CVA|111|113|IMPRESSION|The PTT is 30. The INR is 1.78. Electrolytes and comprehensive metabolic panel entirely normal. IMPRESSION: 1. CVA with expressive aphasia and dysarthria. 2. History of atrial fibrillation, on Coumadin, with subtherapeutic INR. 3. Hypertension with LVH. 4. Obesity. 5. Hyperlipidemia. 6. Urinary urge incontinence.
CVA|costovertebral angle|CVA|171|173|PHYSICAL EXAMINATION|ABDOMEN: Soft with some slight tenderness in the right mid-quadrant and left mid-quadrant area. There is no guard or rebound noted. Bowel sounds are present. She has mild CVA tenderness on the left side. EXTREMITIES: Show no cyanosis, clubbing or edema. NEUROLOGIC: The patient is grossly nonfocal. LABORATORY: Urinalysis shows multiple bacteria with 10-25 WBC and positive nitrates and increased leukocyte esterase.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|She seems to have adequate strength. Is not frail. HEENT: Grossly normal. NECK: No bruits. HEART: Regular S1 and S2 with a soft systolic murmur. LUNGS: Clear. ABDOMEN: Without hepatosplenomegaly or masses. No CVA tenderness. BREAST, PELVIC, RECTAL: Not done. EXTREMITIES: There is some shakiness that is fairly coarse noted. Deep tendon reflexes are symmetric. Sensation is intact. Peripheral pulses are intact.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: No masses, tenderness, skin, nipple or areolar changes. ABDOMEN: Without hepatosplenomegaly, masses, or tenderness.
CVA|cerebrovascular accident|CVA|175|177|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: 1. Syncopal episode probably related to vagal stimulation followed by anoxic episode with a prolonged period of unresponsiveness. Workup negative for any CVA or arrhythmia. 2. Mild Alzheimer's disease. 3. Depression. 4. Hypothyroidism, treated with replacement therapy. 5. Hypertension. CODE STATUS: DNR/DNI. HISTORY OF PRESENT ILLNESS: The patient is an 87-year-old woman who had a prolonged episode of syncope after a choking episode at the nursing home.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: No masses, tenderness, skin, nipple or areolar changes. ABDOMEN: Without hepatosplenomegaly, masses, or tenderness.
CVA|cerebrovascular accident|CVA|179|181|PAST MEDICAL HISTORY|He denies any abdominal pain. He states he is not hungry. PAST MEDICAL HISTORY: Significant for: 1) Severe ischemic cardiomyopathy. 2) History of atrial fibrillation. 3) Previous CVA in _%#MM#%_, 2000 with some residual left-sided weakness. 4) Status post coronary artery bypass surgery. 5) Chronic obstructive pulmonary disease and history of smoking.
CVA|costovertebral angle|CVA|289|291|PHYSICAL EXAMINATION|NECK: Supple without lymphadenopathy, no JVD. CARDIOVASCULAR: Revealed irregular rate with normal S1 and S2, and a 2/6 systolic murmur at the left upper sternal border radiating to the left buttock. LUNGS: Clear to auscultation. ABDOMEN: Soft, nontender, nondistended. No organomegaly. No CVA tenderness or suprapubic tenderness. SKIN: Exam revealed a well-healed scar on the left shoulder, no rash, no jaundice. NEUROLOGIC: Exam revealed normal muscle tone and strength, no focal sensory, or motor deficit.
CVA|costovertebral angle|CVA|160|162|PHYSICAL EXAMINATION|HEART: Regular rhythm. Grade 2/6 aortic systolic murmur. ABDOMEN: Protuberant, soft and nontender. Liver and spleen not palpable. Active bowel sounds. BACK: No CVA tenderness. EXTREMITIES: Feet are cool. No edema. NEUROLOGIC: Alert. No focal findings. SKIN: Negative. DIAGNOSIS: 1. Upper abdominal/lower left chest pain. Rule out cardiac basis.
CVA|costovertebral angle|CVA|384|386|ADMISSION PHYSICAL EXAMINATION|2. Tonsillectomy at age 28. Review of systems: Positive only for seasonal allergies; she needs glasses for night driving; has loose stools, though has no history of colonoscopy; occasional arthritic pain, and history of depression. ADMISSION PHYSICAL EXAMINATION: GENERAL: On admission the patient was extremely uncomfortable, turning back and forth in her bed, had sharp right-sided CVA tenderness and mild mid right-sided abdominal tenderness; the remainder of her examination was unremarkable. ADMISSION LABORATORY DATA: Initial electrolytes revealed sodium 144, potassium 3.3, white blood cells 11.2, hemoglobin 14.7. All other liver function tests were within normal limits.
CVA|cerebrovascular accident|CVA|192|194|FAMILY HISTORY|4. Transvaginal hysterectomy with diagnostic laparoscopy on _%#MMDD2006#%_. CURRENT MEDICATIONS: 1. Augmentin. 2. Flagyl. ALLERGIES: Codeine. FAMILY HISTORY: Father has hypertension and had a CVA in his 40s. Mother has emphysema. Maternal grandmother has a history of breast cancer. SOCIAL HISTORY: The patient is married with two children. She is a realtor and a designer.
CVA|costovertebral angle|CVA|134|136|PHYSICAL EXAMINATION ON ADMISSION  VITAL SIGNS|GENERAL: She is alert and oriented x3. HEART: Regular. LUNGS: Clear. ABDOMEN: Gravid and soft. It is nontender to palpation. BACK: No CVA tenderness. EXTREMITIES: No tenderness to palpation. External fetal monitor revealed baseline heart rate in the 150s with accelerations and positive long-term variability, reassuring for gestational age.
CVA|costovertebral angle|CVA|145|147|PHYSICAL  EXAMINATION|CARDIOVASCULAR: S1, S2. Regular rate and rhythm. No audible murmurs. ABDOMEN: Soft and benign. No organomegaly. BACK: Healed coccygeal ulcer. No CVA tenderness. EXTREMITIES: No peripheral edema. Peripheral pulses are palpable. SKIN: Warm and dry. NEUROLOGIC: The patient is grossly nonfocal.
CVA|costovertebral angle|CVA|149|151|HISTORY OF PRESENT ILLNESS|The patient does have a distant history of appendectomy. The patient's exam in the Emergency Room showed a soft nontender abdomen. She did have left CVA tenderness in her back. The rest of her exam was normal. The patient did have an ultrasound done which showed a viable 14-week fetus with fetal heart rate of 150.
CVA|cerebrovascular accident|CVA|214|216|PAST MEDICAL HISTORY|3. Status post several arthroscopies. Medical: 1. Atrial fibrillation with pacemaker implantation some time ago. She has been off of Coumadin since the rectus hematoma. 2. Type II diabetes mellitus. 3. Status post CVA with right frontal temporal arch and small vessel disease. ALLERGIES: Morphine causes hallucinations. MEDICATIONS: Prinivil 5 mg daily, Glucotrol 5 mg daily, potassium 10 mEq daily, Lasix 40 mg daily, atenolol 50 mg b.i.d., Lanoxin 0.125 mg daily.
CVA|costovertebral angle|CVA|160|162|PHYSICAL EXAMINATION|HEART: Tones seemed regular with no definite murmurs, no axillary masses. ABDOMEN: Nontender although it is quite obese. No definite liver and no spleen and no CVA tenderness and no bruits. EXTREMITIES: Without edema. Pedal pulses were not palpable. RECTAL: The rectal and groin exam deferred. EKG showed changes from when we had compared _%#MM#%_ 2000 with QS waves in the VL 2, 3 and 4, particularly 3, L4, 5 and 6 QS okay but the T waves were suppressed.
CVA|costovertebral angle|CVA|174|176|PHYSICAL EXAMINATION|ABDOMEN: Shows bowel sounds to be present. The abdomen is soft and nontender. No mass or hepatosplenomegaly noted. No hernias noted. BACK: Shows full range of motion with no CVA tenderness. EXTREMITIES: Show full range of motion. No edema is noted. NEUROLOGICAL: He is intact. ASSESSMENT: 1. Exacerbation of chronic obstructive pulmonary disease.
CVA|costovertebral angle|CVA|194|196|PHYSICAL EXAMINATION|LUNGS: Clear to auscultation. CARDIOVASCULAR: Regular rate and rhythm with a 1/6 ejection murmur, no rub. ABDOMEN: Soft, nontender, no hepatosplenomegaly or no masses. EXTREMITIES: No edema, no CVA tenderness. He has left great toe inflammation extending to the base of his toe with no lymphangitic streaking, no bony exposure.
CVA|costovertebral angle|CVA|123|125|HISTORY OF PRESENT ILLNESS|He has seen the ophthalmologist in the last year. The only other complaint the patient has is that today he has some right CVA tenderness in his back. He, however, denies dysuria. The patient does have chronic lumbosacral back pain which he has had for years.
CVA|cerebrovascular accident|CVA.|202|205|PHYSICAL EXAMINATION|His gait appears to be normal. He could do Romberg and tandem very well. I reviewed personally his CT scan from Glencoe Medical Center which shows no evidence of bleed and no evidence of large ischemic CVA. LABORATORY DATA: His labs on admission from Glencoe show that his EKG shows normal sinus rhythm with ST-T segment changes which probably are old since they have been documented before.
CVA|cerebrovascular accident|CVA|116|118|CAUSE OF DEATH|However, the patient went on to expire at 1755 p.m. on _%#MMDD2003#%_. CAUSE OF DEATH: Acute large left hemispheric CVA with underlying cause being widely metastatic lung cancer.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|LYMPHATIC: No lymphadenopathy in cervical, supraclavicular, axillary, epitrochlear or inguinal areas. NEUROLOGICAL: Alert and oriented. Sensory and motor grossly intact in all extremities. MUSCULOSKELETAL: No CVA or spinal tenderness. SKIN: Limited skin exam, no rash and no petechiae. He has a few ecchymoses on the upper extremities. ANCILLARY DATA: Chest x-ray as detailed above.
CVA|costovertebral angle|CVA|199|201|PHYSICAL EXAM|ABDOMEN: Exam shows bowel sounds are present. Abdomen shows generalized tenderness throughout. No mass or hepatosplenomegaly. No rebound or guarded noted anywhere. No hernias noted. BACK: Benign. No CVA tenderness. EXTREMITIES: Show full range of motion. NEUROLOGIC: Shows a slight tremor only. Initial laboratory evaluation shows a sodium of 133, potassium of 3.5, chloride of 96, bicarb of 30, BUN of 7, creatinine of 0.7. Glucose was 126 on a nonfasting specimen.
CVA|costovertebral angle|CVA|180|182|PHYSICAL EXAMINATION|Hemoglobin is 12.1. HEENT: Pupils are equally correct and accommodate. EOMs intact and symmetrical. No adenopathy. Pharynx and thyroid are normal. LUNGS: Clear to A&P. There is no CVA tenderness. CARDIOVASCULAR: Audible S1, S2, S3, S4, 2/6 systolic ejection murmur loudest at the left sternal border. ABDOMEN: Bowel sounds soft. Singleton infant, vertex presentation. Fundal height of 39 cm.
CVA|costovertebral angle|CVA|227|229|PHYSICAL EXAMINATION|LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, nondistended, nontender. There are no scars noted on his abdomen. BACK: No tenderness over the spinous processes of the cervical, thoracic, or lumbar spines. There is no CVA tenderness. EXTREMITIES: Peripheral pulses are strong in all 4 extremities. He has no pedal edema. NEUROLOGICAL: Patient is alert and oriented x3.
CVA|costovertebral angle|CVA|148|150|PHYSICAL EXAMINATION|Rectal exam without gross blood or mass. Several sinus tracts in the gluteal cleft. GENITOURINARY: No suprapubic tenderness. SPINE/CVA: No spine or CVA tenderness. LYMPHATICS: No cervical, supraclavicular, or inguinal adenopathy. SKIN: Right candidal rash in groin. NEUROLOGIC: Alert and oriented x 3. Cranial nerves II through XII intact.
CVA|costovertebral angle|CVA|178|180|PHYSICAL EXAMINATION AT THE TIME OF ADMISSION|No wheezing or rales. ABDOMEN: Distended, profound hepatosplenomegaly. There is tenderness in the left upper quadrant and is tympanic. SPINE: Spine is straight and a slight left CVA tenderness. EXTREMITIES: There is 3 pitting edema in both lower extremities. SKIN: Hypopigmented areas. Color is darker in general. NEUROLOGIC: Oriented to time, place and person.
CVA|costovertebral angle|CVA|200|202|PHYSICAL EXAMINATION|2. Cochlear implant x2. PAST MEDICAL HISTORY: Otherwise negative. ALLERGIES: Iodine and codeine. PHYSICAL EXAMINATION: VITALS SIGNS: Stable. NECK: Supple, no masses. BACK: Normal spinal curvature. No CVA tenderness. HEART: S1 and S2, no S3 or S4. No murmur. Regular rhythm. CHEST: Clear to auscultation. ABDOMEN: Soft and nontender.
CVA|cerebrovascular accident|CVA,|188|191|REVIEW OF SYSTEMS|DERMATOLOGIC: No rash. ENDOCRINE: No unexplained sweats, tremors or weight loss. MUSCULOSKELETAL: See HPI. No other joint complaints, joint swelling or erythema. NEUROLOGIC: No history of CVA, paresthesias, weakness, syncope. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 136/68.
CVA|cerebrovascular accident|CVA.|144|147|PAST MEDICAL HISTORY|4. History of chronic renal insufficiency. 5. Chronic lower extremity edema with recurrent cellulitis. 6. Hyperlipidemia. 7. TIA. 8. History of CVA. 9. History of benign prostatic hypertrophy. 10. Osteoporosis 11. Questionable history of polymyalgia rheumatic. PAST SURGICAL HISTORY: 1. Status post pacemaker placement in 1998, replaced by an AICD in _%#MM2001#%_.
CVA|cerebrovascular accident|CVA.|165|168|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. CVA in _%#MM2006#%_, found to have PFO. 2. Tobacco dependence, one-half pack per day. 3. Mild aphasia and right-sided weakness secondary to CVA. 4. Status post appendectomy. SOCIAL HISTORY: He is married and works as a truck driver.
CVA|cerebrovascular accident|CVA,|180|183|SOCIAL HISTORY|SOCIAL HISTORY: The patient was currently living in a nursing home at the time of her rehabilitation. Her son also had an accident about 6-7 years ago around the time when she had CVA, as well. FAMILY HISTORY: Not significant. OUTPATIENT MEDICATIONS: 1. Benadryl 25 mg p.o. q. 6h. p.r.n. for pruritus.
CVA|cerebrovascular accident|CVA|221|223|HISTORY OF PRESENT ILLNESS|LARGE GAP IN AUDIO AFTER HPI; PLEASE DICTATE AN ADDENDUM CHIEF COMPLAINT: Right arm weakness and numbness. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is a 70-year-old white male with a history of left thalamic CVA with left-sided weakness back in _%#MM2006#%_. According to the patient, for the past few weeks he has not felt well. In fact, he was seen here on _%#MMDD#%_ by Dr. _%#NAME#%_ _%#NAME#%_, one of our Fairview Southdale ED doctors, complaining of acute mental status change and difficulty with ambulating.
CVA|cerebrovascular accident|CVA.|100|103|FAMILY HISTORY|This is a baby aspirin. She does not take a daily aspirin. DRUG ALLERGIES: None. FAMILY HISTORY: No CVA. SOCIAL HISTORY: The patient lives with her son. She is divorced. She is a nonsmoker and nondrinker. REVIEW OF SYSTEMS: Please see HPI for details.
CVA|cerebrovascular accident|CVA,|158|161|FAMILY HISTORY|9. Spinal stenosis PAST SURGICAL HISTORY, appendectomy, cholecystectomy, hysterectomy. SOCIAL HISTORY: No tobacco, no alcohol. FAMILY HISTORY: Sister died of CVA, parents died of old age but they are unsure of the causes. REVIEW OF SYSTEMS: CONSTITUTIONAL: Negative for fevers, chills, night sweats.
CVA|cerebrovascular accident|CVA|138|140|FAMILY HISTORY|Chronic medical problems include hypertension, elevated cholesterol and prostate cancer. FAMILY HISTORY: Significant for father who had a CVA at age 55 and MI at age 65. Mom with CHF in her 80's. Died at age 91. REVIEW OF SYSTEMS: Otherwise negative. Throat, including respiratory, GI, GU CV as above.
CVA|cerebrovascular accident|CVA|135|137|PAST MEDICAL HISTORY|2. Hypertension. 3. Status post cholecystectomy. 4. Status post hysterectomy. 5. Status post tonsillectomy. 6. History of glaucoma. 7. CVA in 2002. 8. History of hypernatremia. 9. An echo in _%#MM2003#%_ showed normal systolic function and mild mitral regurgitation.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: No masses, tenderness, skin, nipple or areolar changes. ABDOMEN: Without hepatosplenomegaly, masses or tenderness.
CVA|costovertebral angle|CVA|170|172|PHYSICAL EXAMINATION|LUNGS: Clear to auscultation. ABDOMEN: Non-distended, non-tender. No guarding. Stools are guaiac positive. RECTAL: Not described. BREASTS: Bilateral mastectomy sites. No CVA tenderness or spinous process tenderness. SKIN: Without rashes, jaundice, or ecchymosis. No peripheral edema. NEUROLOGICAL: Revealed the patient being alert and oriented.
CVA|cerebrovascular accident|CVA|125|127|FAMILY HISTORY|PAST SURGICAL HISTORY: 1. C-sections times three. 2. Bilateral cataract surgery in _%#NAME#%_. FAMILY HISTORY: Father with a CVA at 77 years old. Dementia. ALLERGIES: CODEINE, rash. ERYTHROMYCIN. AMOXICILLIN, rash. SOCIAL HISTORY: She is a homemaker with three children, married, and lives in _%#CITY#%_.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: No masses, tenderness, skin, nipple or areolar changes. ABDOMEN: Without hepatosplenomegaly, masses or tenderness.
CVA|costovertebral angle|CVA|234|236|PHYSICAL EXAMINATION|MUSCULOSKELETAL: There is an about 5 cm palpable mass on the left anterior chest wall that is nontender to palpation. There is a hard nodule on the right anterior or radial wrist that is nontender to palpation. BACK: No flank pain or CVA tenderness. SKIN: There is no erythema, clubbing, or edema but the patient is pale in color. NEUROLOGY: The patient is alert and oriented x 3. Cranial nerves II-XII intact.
CVA|cerebrovascular accident|CVA|190|192|HISTORY OF PRESENT ILLNESS|1. IV antibiotics. 2. Transitions and Life Care consult. HISTORY OF PRESENT ILLNESS: In brief, Ms. _%#NAME#%_ is a 74-year-old Cambodian female with the past medical history significant for CVA and polymicrobial pneumonias in the past including both pseudomonas, who presented to the University of Minnesota Medical Center with symptoms of worsening cough, fever and failure to thrive for approximately 2 weeks prior to presentation.
CVA|cerebrovascular accident|CVA|174|176|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Asthma, she has had a few ER visits, never intubated. 2. Type 1 diabetes since age 3. 3. History of CVA x2, details are unclear. Apparently her last CVA was in _%#MM2006#%_. She had some leg weakness and apparently some left ptosis and maybe some cognitive affect. 4. Hyperlipidemia. 5. History of anemia. 6. Left tibial fracture within the last few months with surgical repair.
CVA|cerebrovascular accident|CVA.|249|252|HOSPITAL COURSE|She had been scheduled by her primary care physician to follow up with Gastroenterology and she will do so in the next couple of weeks. 2. Type 2 diabetes. She will resume her outpatient oral medication. 3. History of vertebral artery occlusion and CVA. She will continue with her previous follow-up plan. DISCHARGE MEDICATIONS: 1. Lisinopril 10 mg a day. 2. Glipizide 10 mg a day.
CVA|cerebrovascular accident|CVA|262|264|HISTORY OF PRESENT ILLNESS|2. Hypoxic respiratory failure re-intubation. 3. Quadriplegia. 4. Change of code status to DNR/DNI. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 63-year-old male with a history of progressive myelopathy resulting in severe quadriparesis and history of CVA and explosive personality and anxiety disorders who presented on _%#MMDD2007#%_ after decrease level of consciousness and difficulty breathing at his nursing facility.
CVA|cerebrovascular accident|CVA|145|147|PAST MEDICAL HISTORY|He did not have any nausea or vomiting or hematemesis. He denied having any known hemorrhoids. PAST MEDICAL HISTORY: 1. Dementia. 2. Question of CVA last _%#MM#%_ of 2002. 3. Status post CABG with pacemaker placement and St. Jude aortic valve replacement in 1991. 4. Hypertension and multiple aneurysms, significantly of 5 cm abdominal aortic aneurysm and a 6 cm left femoral aneurysm.
CVA|cerebrovascular accident|CVA|185|187|PHYSICAL EXAMINATION|ALLERGIES: None known. MEDICATIONS: Depo-Provera. REVIEW OF SYSTEMS: Otherwise negative. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. NECK: Supple. No masses. Normal spinal curvature. No CVA tenderness. HEART: S1, S2, no S3, S4. No murmurs or irregular rhythm. CHEST: Clear to auscultation. ABDOMEN: Soft and nontender, no hepatosplenomegaly.
CVA|costovertebral angle|CVA|190|192|PHYSICAL EXAMINATION|There is some induration around the incision and drainage line, but no crepitus or fluctuance at this point. There is no sign of phlebitis in the lower extremity on that side. BACK: Free of CVA tenderness. NEUROLOGIC: She was alert, oriented, and with no focal cranial or peripheral neuro signs on this screening examination.
CVA|costovertebral angle|(CVA)|171|175|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: HEENT: Negative. NECK: No palpable masses. CHEST: Lungs are clear. HEART: Sinus rhythm. ABDOMEN: No palpable masses. BACK: Left costovertebral angle (CVA) tenderness. GENITALIA: Normal. RECTAL: Normal. EXTREMITIES: Normal. IMPRESSION: Nonopaque left ureteral stone.
CVA|cerebrovascular accident|CVA|166|168|FAMILY HISTORY|Mother was also a type 2 diabetic and had coronary artery disease in her 50s. Brother has coronary artery disease and type 2 diabetes mellitus. Another brother had a CVA of unknown type and was also diabetic. CARDIOVASCULAR RISK FACTORS: Positive for former smoking, quit in 1980, age, hyperlipidemia, hypertension, diabetes mellitus, prior history of heart disease, obesity.
CVA|costovertebral angle|CVA|138|140|ADMISSION PHYSICAL EXAMINATION|She had pain over the right upper quadrant with palpation. There is a negative Murphy's sign. She had some pain over her rib and possible CVA tenderness. NEUROLOGIC: Nonfocal. LABORATORY DATA: White count 8.5, hemoglobin 13.6, platelets 230.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: No masses, tenderness, skin, nipple or areolar changes. ABDOMEN: Without hepatosplenomegaly, masses or tenderness.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: No masses, tenderness, skin, nipple or areolar changes. ABDOMEN: Without hepatosplenomegaly, masses or tenderness.
CVA|cerebrovascular accident|CVA|111|113|FAMILY HISTORY|He quit his 1/2 to 1 pack per day smoking habit 3 weeks ago. FAMILY HISTORY: Father died of complications of a CVA at the age of 63. There is no family history of symptomatic coronary artery disease, bleeding diathesis, or significant rashes to anesthetics.
CVA|cerebrovascular accident|CVA|224|226|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSIS: Vertigo secondary to either GI versus peripheral etiology. HISTORY OF PRESENT ILLNESS: Briefly, _%#NAME#%_ _%#NAME#%_ is a 79- year-old female with underlying Parkinson's disease as well as a history of CVA in the past, brought to the emergency room on the day of admission due to abrupt and sudden onset of vertiginous symptoms.
CVA|cerebrovascular accident|CVA|116|118|SECONDARY DIAGNOSES|PRINCIPAL DIAGNOSIS: Weakness. SECONDARY DIAGNOSES: History of depression, hypertension, B12 deficiency, history of CVA x2. History of dementia. SYNOPSIS OF HISTORY AND PHYSICAL: The patient is an 88-year-old female who resides at Carefree assisted living.
CVA|costovertebral angle|CVA|190|192|PHYSICAL EXAMINATION|HEENT: Clear with no thyromegaly. CHEST: Clear to auscultation and percussion. HEART: Regular sinus rhythm with no murmurs. BREASTS: Normal. No galactorrhea, masses, or tenderness. BACK: No CVA tenderness. ABDOMEN: Benign. Pregnancy approximately 7 pounds 2 ounces estimated fetal weight with normal fetal heart tones. CERVIX: 50%, 1 cm, -1 station, vertex presentation. EXTREMITIES: Slightly edematous.
CVA|costovertebral angle|CVA|233|235|PHYSICAL EXAMINATION|Cardiovascular was tachycardiac with no murmurs or gallops. Lungs were clear to auscultation bilaterally with no crackles or wheezes. Abdomen was soft, non-tender, non-distended, positive bowel sounds, and no masses. Spine showed no CVA tenderness or spine tenderness. Skin was diaphoretic with no rashes. Neurological exam was grossly intact. LABORATORY STUDIES: Showed a hemoglobin of 7.4 with MCV of 118, alkaline phosphatase 102, ALT 48, AST 49, lipase 46, amylase 90, total bilirubin 1.6, albumin 3.8. Electrolytes were normal.
CVA|cerebrovascular accident|CVA,|114|117|IMPRESSION|Strength is equal as is his coordination. LABORATORY DATA: BMP and CBC are pending. IMPRESSION: 1. Right temporal CVA, likely embolic. Plan is for IV Heparin and Coumadin. 2. Atrial fibrillation, probable source of his emboli. 3. IHSS with moderate outflow tract obstruction.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: No masses, tenderness, skin, nipple or areolar changes. ABDOMEN: Without hepatosplenomegaly, masses or tenderness.
CVA|cerebrovascular accident|CVA|114|116|IMAGING|AST 31, ALT 15, alkaline phosphatase 103, bilirubin 0.4, protein 1.9, albumin 4.1. IMAGING: CT of head showed old CVA on left side. No acute changes. HOSPITAL COURSE: PROBLEM #1: UTI: The patient was given ciprofloxacin 500 mg b.i.d. for 3 days out of a 7 day course.
CVA|cerebrovascular accident|CVA|234|236|LABORATORY STUDIES|LABORATORY STUDIES: His electrolytes were physiologic. His blood sugar was 143, creatinine was 0.l75. His hemoglobin was 14.4. His electrocardiogram was essentially within normal limits. He had an MRI to further evaluate for subacute CVA which was unremarkable. ASSESSMENT: 1. Hypertension. 2. Adult onset diabetes. 3. Valvular heart disease with coronary artery disease stable.
CVA|costovertebral angle|CVA|163|165|OBJECTIVE|TMs were clear. Nasal mucosa within normal limits. Oral cavity without erythema or exudate. NECK - supple, no adenopathy or thyromegaly is present. BACK - without CVA or spinal tenderness. LUNGS - clear. No rales, rhonchi or wheezing is present. CHEST - without lesions. CARDIOVASCULAR - regular rate and rhythm, no murmurs or gallops are appreciated.
CVA|cerebrovascular accident|CVA|156|158|ASSESSMENT|She returns with similar symptomatology of nausea, vomiting, dizziness, and inability to get up out of bed. I suspect these are continued symptoms from her CVA as there is no other evidence that this is an extension or progression. 2. Atherosclerotic cerebrovascular disease. 3. Chronic atrial fibrillation. 4. Left ventricular hypertrophy.
CVA|costovertebral angle|CVA|149|151|PHYSICAL EXAMINATION|Normal S1 and S2. No S3 or S4 is present. ABDOMEN: Soft, with positive bowel sounds, nondistended, nontender to palpation. No hepatosplenomegaly. No CVA tenderness bilaterally. EXTREMITIES: Warm. She has no clubbing, cyanosis or edema. She has some pain noted over the right shoulder with some mild deformity.
CVA|cerebrovascular accident|CVA.|208|211|REVIEW OF SYSTEMS|ORTHOPEDIC: She denies any fractures. NEUROLOGIC: Status post cerebrovascular accident, no history of MI. HEMATOLOGIC: No history of DVT. PSYCHIATRIC: Possibly early mild dementia as a result of her previous CVA. PHYSICAL EXAMINATION: GENERAL: An elderly white female, alert and oriented to person and self.
CVA|costovertebral angle|CVA|200|202|PHYSICAL EXAMINATION|Right tympanic membrane is clear, left tympanic membranes is not visualized secondary to hearing aid. Oral cavity without erythema or exudate, neck supple, no adenopathy or thyromegaly. BACK: Without CVA or spinal tenderness. LUNGS: Clear; I do not hear any wheezes, rales or rhonchi. She is moving air well. CARDIOVASCULAR: Irregularly irregular, no murmur or gallop appreciated.
CVA|cerebrovascular accident|CVA.|173|176|PAST MEDICAL HISTORY|3. History of coronary artery disease, for which she is status post bypass surgery in 1990. She had a recent negative stress test. 4. Right-sided weakness secondary to left CVA. 5. History of meningioma, necessitating multiple surgeries. This has been stable with follow-up MRIs. 6. Seizure disorder. 7. Hypertension. PAST SURGICAL HISTORY: 1. Surgery for colon cancer, many years ago.
CVA|cerebrovascular accident|CVA|97|99|FAMILY HISTORY|CURRENT MEDICATIONS: 1. Lipitor. 2. Aspirin. ALLERGIES: No known drug allergies. FAMILY HISTORY: CVA and cancer. SOCIAL HISTORY: The patient is a 90 pack-year tobacco smoker; no alcohol or drugs.
CVA|costovertebral angle|CVA|216|218|HOSPITAL COURSE|She was ambulating. She was voiding per her routine and her pain was well controlled on oral medications. On exam, she is afebrile, vital signs are stable and normal. Her abdomen was soft and nontender. There was no CVA tenderness. Her extremities were warm and dry with CMS intact x4. Repeat white count was 16, which is decreased from her preop of 20.
CVA|cerebrovascular accident|CVA|233|235||The patient's illnesses include sarcoidosis with hypercalcemia which is steroid dependent, hyperlipidemia, hypothyroidism, diabetes mellitus type 2, controlled on oral agents, dementia requiring medications for agitation, history of CVA and history of depression. The patient's list of medications is extensive as is the list of allergies. The patient on admission had a temperature of 99.6. Exam was fairly unremarkable except for right lower quadrant tenderness without rebound or guarding.
CVA|cerebrovascular accident|CVA.|177|180|FAMILY HISTORY|8. Uroxatral 24 hour 10 mg q.day. FAMILY HISTORY: Negative for allergic reactions to anesthesia or bleeding diathesis. Mother deceased old age. Father deceased 86, prostate CA, CVA. Sister deceased 74 of leukemia. Sister deceased 50 MVA. Brother deceased at 63, CABG. Four living brothers. One living sister alive and well. SOCIAL HISTORY: Grew up in _%#CITY#%_ and moved to a farm in _%#CITY#%_ _%#CITY#%_, 4 years in the Navy.
CVA|cerebrovascular accident|CVA.|219|222|PAST MEDICAL HISTORY|The patient denies orthopnea. PAST MEDICAL HISTORY: 1. Angiogram ? four months ago at Abbott Northwestern Hospital. 2. Cataract surgery OU. 3. C-section x2. 4. Recent hospitalization for syncope though to be related to CVA. 5. Hypertension. 6. Son recalls the patient had head CT, head MRI, and a TEE study done. ALLERGIES: None known. CURRENT MEDICINES: 1. Atenolol 100 mg p.o. q.d.
CVA|cerebrovascular accident|CVA.|186|189|ASSESSMENT|2. Doubt congestive heart failure; ________ false-positive BNP. 3. Hypercalcemia, rule out myeloma. 4. Hyperthyroidism. Hyperparathyroidism. 5. Malnutrition. 6. High INR. 7. Status post CVA. 8. Degenerative joint disease (DJD). 9. Leg weakness probably due to hypercalcemia. 10. Presbycusis. 11. Heart murmur, type unknown. 12. Heavy alcohol use.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: No masses, tenderness, skin, nipple or areolar changes. ABDOMEN: Without hepatosplenomegaly, masses or tenderness.
CVA|cerebrovascular accident|CVA.|180|183|OTHER DIAGNOSES|OTHER DIAGNOSES: 1. Chronic anemia. 2. Coronary artery disease. 3. Ischemic cardiomyopathy. 4. Status post ICD placement. 5. Chronic atrial fibrillation. 6. History of hemorrhagic CVA. 7. Hypertension. 8. Gastroesophageal reflux disease. 9. History of colon cancer. 10. Hypothyroidism. 11. Non insulin dependent diabetes, diet controlled.
CVA|costovertebral angle|CVA|210|212|PHYSICAL EXAMINATION|The uterus measures 22 cm fundal height. There is positive bowel sounds. The abdomen is tender throughout, mostly on the uterus. Fetal heart tones are positive. PELVIC: Deferred. EXTREMITIES: Minimal edema. No CVA tenderness. LABS: Urinalysis within normal limits (trace blood, few bacteria, many spinous epithelial cells.
CVA|cerebrovascular accident|CVA|167|169||Surgery done by Dr. _%#NAME#%_. The patient tolerated procedure without complication. Decreased ADLs, admitted to acute rehab. PAST MEDICAL HISTORY: Status post right CVA with residual left hemiparesis, lupus with Raynaud, arthralgias, GERD, cardiomyopathy, ASD, osteoporosis, chronic neuropathic pain, hypothyroid, irritable bowel syndrome, hyperlipidemia, depression.
CVA|costovertebral angle|CVA|122|124|REVIEW OF SYSTEMS|There is no pleuritic component to the discomfort. The patient has not had significant abdominal pain other than the left CVA costal margin area pain. She denies other abdominal symptoms at present. She was ill with an acute gastroenteritis found to be due to a Norwalk A agent, approximately 2 weeks ago after eating at a restaurant in _%#CITY#%_, Wisconsin.
CVA|costovertebral angle|CVA|145|147|OBJECTIVE|HEENT: Exam was unremarkable. NECK: Thyroid was not enlarged. CARDIOVASCULAR: Heart rate was regular without murmur. LUNGS: Clear. BACK: Without CVA tenderness bilaterally. ABDOMEN: Soft and nontender with fundus nonpalpable. SKIN: Normal. NEUROPSYCH: Exam revealed appropriate mood and affect. PELVIC: Exam was deferred.
CVA|cerebrovascular accident|CVA.|277|280|HISTORY OF PRESENT ILLNESS|Because of this, she was sent to the ER for further evaluation where she was found to have an elevated white count, with a chest x-ray showing a left lower lobe infiltrate, and a urine that suggests a UTI. She subsequently will be admitted. Head CT showed no evidence of acute CVA. I am seeing the patient on the floor at approximately 4:30 in the evening. She seems to be much the same as in the past.
CVA|costovertebral angle|CVA|150|152|PHYSICAL EXAMINATION|Pulses appear regular in bilateral upper and lower extremities. No carotid bruits. ABDOMEN: Good bowel sounds, soft, non-tender and non-distended. No CVA tenderness. EXTREMITIES: No rash, no edema. Patellar reflex 2+ bilaterally NEUROLOGIC: Further neurological exam: Cerebellar exam is negative. No asterixis and no pronator drift. Of note, some unclearness of details when he tries to recall recent medical history.
CVA|cerebrovascular accident|CVA.|175|178|IMPRESSION|Chest x-ray done in the ER reveals right lower lobe infiltrate and retrocardiac infiltrate. IMPRESSION: 1. Pneumonia. 2. Dysphagia with likely aspiration risks. 3. History of CVA. 4. Heart disease. 5. High cholesterol. 6. Hypertension. 7. Organic brain syndrome. PLAN: We will admit, start antibiotics. A swallow evaluation pending. We will hold her p.o. meds at this time until speech and swallowing is evaluated.
CVA|costovertebral angle|CVA|139|141|PHYSICAL EXAMINATION|BREASTS - no masses. ABDOMEN - standard near-term size fetus, vertex presenting. Fetal heart tones normal. BACK - normal configuration. No CVA tenderness. EXTREMITIES - trace edema. NEUROLOGIC exam - grossly normal. PELVIC examination - cervix 1.5 cm dilated, 50% effaced, vertex -3. IMPRESSION AT THE TIME OF ADMISSION: 38+ week gestation, labor and outbreak of genital herpes.
CVA|costovertebral angle|CVA|211|213|DISCHARGE DIAGNOSES|Her lungs are clear to auscultation, equal bilaterally. Abdomen has positive bowel sounds, soft, with midepigastric tenderness and a well-healed midline scar. Her spine is without spinal tenderness, stepoff, or CVA tenderness. Her skin is without erythema or breakdown. She has a port that is clean, dry, and intact. Her neurological exam is nonfocal and her strength is 5/5 throughout.
CVA|costovertebral angle|CVA|143|145|PHYSICAL EXAMINATION|BREASTS: No masses. ABDOMEN: Soft, nontender, no masses. The liver, spleen and kidneys not felt to be enlarged. BACK: Normal configuration. No CVA tenderness. EXTREMITIES: No cyanosis or edema. SKIN: Normal color and turgor. NEUROLOGIC: Grossly normal. PELVIC: External genitalia normal, vagina clean, cervix difficult to get to because of patient discomfort.
CVA|costovertebral angle|CVA|239|241|PHYSICAL EXAMINATION|Chest is clear to auscultation bilaterally. CV: Regular rate and rhythm, with an equivocal faint systolic ejection murmur left upper sternal border. Abdomen: Bowel sounds are positive, soft, non-tender, non-distended, no HSM or masses, no CVA tenderness. Skin: Unremarkable. Neurologic: Non-focal. Cranial nerves are intact. Motor of lower extremities is intact. LABORATORY DATA: UA reveals moderate blood, with 10 to 25 cells and moderate squamous epithelial cells.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: No masses, tenderness, skin, nipple or areolar changes. ABDOMEN: Without hepatosplenomegaly, masses, or tenderness.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: No masses, tenderness, skin, nipple or areolar changes. ABDOMEN: Without hepatosplenomegaly, masses, or tenderness.
CVA|cerebrovascular accident|CVA.|119|122|FAMILY HISTORY|MEDICATIONS: 81 mg ASA, currently on hold. FAMILY HISTORY: Mother deceased at 63 of leukemia. Father deceased at 67 of CVA. No siblings. Two daughters are alive and well. No family history of allergic reactions to anesthesia or bleeding diathesis.
CVA|costovertebral angle|CVA|173|175|OBJECTIVE|Fundi sharp. TMs are clear. Nasal mucosa within normal limits. Oral cavity without erythema or exudate. NECK: Supple. No adenopathy or thyromegaly is present. BACK: Without CVA or spinal tenderness. LUNGS: Clear. She has no rales or rhonchi or wheezing present. BREAST: Deferred. CARDIOVASCULAR: Regular rate and rhythm. No murmurs or gallops are appreciated.
CVA|costovertebral angle|CVA|216|218|PHYSICAL EXAMINATION|HEART: Regular rate and rhythm, no murmurs, rubs or gallops are heard. Normal S1, S2, no S3 or S4 is present. ABDOMEN: Soft with positive bowel sounds, nondistended, nontender to palpation, no hepatosplenomegaly, no CVA tenderness. EXTREMITIES: Warm, she has no clubbing, cyanosis and no edema. She has palpable dorsalis pedis, posterior tibial pulses, she has some redundancy of the skin, probably secondary to weight loss.
CVA|cerebrovascular accident|CVA.|169|172|FAMILY HISTORY|8. Combivent MDI 2 puffs q.i.d. 9. Celexa 20 mg daily. 10. Advair 250/50 one puff b.i.d. FAMILY HISTORY: Father and mother with history of ASCVD. Mother with history of CVA. Brother with history of peptic ulcer disease and brother with history of ASCVD. SOCIAL HISTORY: The patient as noted currently lives in a memory care unit.
CVA|costovertebral angle|CVA|157|159|PHYSICAL EXAMINATION|Abdominal exam demonstrates mild epigastric pain without rebound tenderness. There is no hepatosplenomegaly. Spine shows no gross deformity, and there is no CVA tenderness. Skin is warm and dry. Neurologic exam demonstrates, he is alert and oriented x3 with cranial nerves 2 through 12 intact.
CVA|cerebrovascular accident|CVA|142|144|PLAN|I will ask Neurology to see her for their opinion on how we should proceed with workup and treatment and risk stratification for debilitating CVA in the future. I will go ahead and order an MRI and MRA as recommended by Dr. _%#NAME#%_, when the ER physician discussed the patient's case with him today.
CVA|costovertebral angle|CVA|172|174|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Well-developed, well-nourished female in some amount of distress, actively vomiting small amounts of mucus/saliva. Abdomen soft. Uterus nontender. No CVA tenderness to percussion but she does not some tenderness in the right flank area. Cervical exam deferred. LABORATORY VALUES: ALT 9, amylase 52, hemoglobin 11.5, white blood cell count 13,100, platelet count 178,000.
CVA|cerebrovascular accident|CVA.|171|174|REVIEW OF SYSTEMS|No known diabetes or thyroid disease. MUSCULOSKELETAL: See HPI. No other joint pain or joint swelling or erythema. NEUROLOGIC: No focal paresthesias, weakness, history of CVA. No headaches. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 142/89, pulse 65, respiratory rate 20, temperature 97.4. GENERAL: The patient is alert and oriented, no acute distress.
CVA|costovertebral angle|CVA|154|156|OBJECTIVE|It is difficult to determine specific rebound or guarding as the patient is in quite a bit of pain. Bowel sounds are positive as noted above. There is no CVA or flank tenderness to palpation. EXTREMITIES: Reveal no edema. SKIN: Reveals no rashes and I do not see any specific edema elsewhere, although the patient feels her face is somewhat puffy.
CVA|costovertebral angle|CVA|206|208|PHYSICAL EXAMINATION|Oropharynx is clear. NECK: Supple with no adenopathy. HEART: Rate and rhythm are regular with no murmurs or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft and nontender with no organomegaly. There is no CVA tenderness. She has no peripheral adenopathy. SKIN: Without rashes or petechia. NEUROLOGIC: Nonfocal. LABORATORY: On admission white count is 700, hemoglobin 10.5 and platelet count 187.
CVA|cerebrovascular accident|CVA|211|213|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 57-year-old developmentally delayed gentleman who is known to our team week as we did see him back in _%#MM2007#%_. He also has schizophrenia, a history of CVA including small multiple lacunar infarcts and prior to this hospitalization had a stroke in _%#MM#%_ of this past year. Apparently in _%#MM2004#%_ he did have a stroke, which left him with some left-sided weakness.
CVA|cerebrovascular accident|CVA|254|256|BRIEF INITIAL HISTORY OF PRESENTATION|DISCHARGE DIAGNOSES: Angina. PROCEDURES DONE: Telemetry monitoring, serial cardiac enzymes. BRIEF INITIAL HISTORY OF PRESENTATION: Ms. _%#NAME#%_ _%#NAME#%_ is an 82-year-old female patient with a history of coronary artery disease, hypertension, recent CVA with physical therapy on the day before admission and developed chest pain. She presented to the hospital and evaluated in outside hospital and evaluation.
CVA|costovertebral angle|CVA|172|174|PHYSICAL EXAMINATION|ABDOMEN: Positive bowel sounds, tenderness on deep palpation in the left upper quadrant and epigastric area. No rebound or guarding noted. No distention noted. No flank or CVA tenderness noted. EXTREMITIES: Very mild lower extremity pitting edema. NEUROLOGICAL: No focal findings. SKIN: No rashes. LABORATORY REVIEW: The patient's lab evaluation demonstrates BUN 8/0.96, white blood cell count 5.3, hemoglobin 10.4, platelet count of 338,000, urinalysis negative, ESR 37.
CVA|cerebrovascular accident|CVA|128|130|FAMILY HISTORY|FAMILY HISTORY: Son with diabetes and hypertension. Half sister with CVA, mother with ovarian cancer, now deceased. Father with CVA and coronary artery disease. REVIEW OF SYSTEMS: GENERAL: The patient states she has had fevers and chills since yesterday.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: Right chest wall over new implant and left breast are negative for masses, tenderness, skin, nipple or areolar changes.
CVA|costovertebral angle|CVA|230|232|PHYSICAL EXAMINATION|There is depression in her mother. PHYSICAL EXAMINATION: VITALS: Height is 5'6", weight 132 pounds, body mass index 21.31, blood pressure 148/90. HEENT: Within normal limits. LUNGS: Clear to auscultation. BACK: Spine straight. No CVA tenderness. HEART: Regular rate and rhythm. No murmur. ABDOMEN: Uterus is firm below the umbilicus. Overall, the abdomen is nontender.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: Right chest wall over implant and left breast over implant negative for masses, tenderness, skin, nipple or areolar change.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: Right breast and left chest wall negative for mass, tenderness; skin changes on the right.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: Right chest wall over implant and left breast negative for mass, tenderness, skin, nipple or areolar change.
CVA|costovertebral angle|CVA|178|180|PHYSICAL EXAMINATION|No exudate or active bleeding at this time. Lower scar from previous drain appears intact. She also has a left buttock scar from a previous drain. SPINE: No point tenderness. No CVA tenderness. SKIN: Left double lumen PICC line to the brachial. Incision site free of redness, exudate, or tenderness. NEUROLOGIC: Sensation intact.
CVA|cerebrovascular accident|CVA|219|221|DISCHARGE DIAGNOSES|2. Tinea cruris. 3. Chronic problems with hemorrhagic cerebrovascular accident with residual hemiplegia and spasm. 4. History of grand mal seizures. Mr. _%#NAME#%_ _%#NAME#%_ is a 59-year-old male who since hemorrhagic CVA in 2000 resides at the Good Samaritan Nursing Home. The patient presented to Southdale Hospital Emergency Room with a febrile illness.
CVA|costovertebral angle|CVA.|139|142|PHYSICAL EXAMINATION|BREASTS: No masses. SPINE: CVA tenderness bilaterally, but nonspecific since the patient reported tenderness on multiple areas besides the CVA. LYMPH: Mild pitting edema at the mid calf level. SKIN: Multiple bruises and ecchymosis of varying ages noticed on the patient's extremities.
CVA|cerebrovascular accident|CVA|256|258|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: Mr. _%#NAME#%_ is an 84-year-old man who today had episode of lightheadedness and vomiting which has resolved. He also has a history of coronary artery disease, abdominal aortic aneurysm, hypertension, prostate cancer, diverticulosis, CVA and apparent chronic kidney disease with creatinines from 1.6 to 2. 1. Vomiting and lightheadedness. Differential diagnosis includes gastroenteritis versus arrhythmia versus other.
CVA|cerebrovascular accident|CVA|162|164|PAST MEDICAL HISTORY|That was reviewed. PAST MEDICAL HISTORY: 1. Diabetes mellitus. 2. Small cerebrovascular accident in 2004 with no residual deficit. 3. Seizure associated with the CVA with no recurrence. 4. Gastroesophageal reflux disease. 5. Chronic back pain. 6. Anxiety disorder. MEDICATIONS: 1. Glucotrol-XR 5 mg p.o. b.i.d.
CVA|cerebrovascular accident|CVA|153|155|PAST MEDICAL HISTORY|MEDICATIONS: Hydrochlorothiazide 25 mg a day, atenolol 100 mg a day, Premarin 0.625 mg a day, and aspirin one q.d. PAST MEDICAL HISTORY: Significant for CVA in 1999. She initially had weakness on the left side of her body which resolved. However, she continues to have problems with persistent proximal upper extremity weakness and occasional urinary incontinence.
CVA|cerebrovascular accident|CVA|154|156|PAST MEDICAL HISTORY|She doesn't know why she is in the hospital. PAST MEDICAL HISTORY: 1. Status post right hemiarthroplasty. 2. History of intracranial bleed. 3. History of CVA with right hemiparesis. 4. Hypertension. 5. Status post left mastectomy. 6. History of skin cancer. 7. Recent history of weight loss and malnutrition.
CVA|cerebrovascular accident|CVA,|213|216|REVIEW OF SYSTEMS|Gastrointestinal: History of GERD and status post cholecystectomy. Genitourinary: No history of nocturia, infection, or frequency. Orthopedic: No history of musculoskeletal complaints. Neurological: No history of CVA, TIA, syncope, or stroke. Integumentary: No history of skin cancer. Endocrine: No history of diabetes or thyroid disease. Hematologic: No history of DVT, thrombophlebitis, or pulmonary emboli. Allergy: No history of asthma.
CVA|cerebrovascular accident|CVA,|238|241|PAST MEDICAL HISTORY|The patient had said he was feeling much better with urinary symptoms and during the examination patient said he is feeling better with his shortness of breath also. PAST MEDICAL HISTORY: History of CHF, chronic renal failure, history of CVA, COPD, diabetes, atrial fibrillation, history of hypertension, coronary artery disease, history of macular degeneration, history of glaucoma. History of left-sided pleural effusion, status post pleurodesis, history of BPH.
CVA|cerebrovascular accident|CVA|247|249|ASSESSMENT|Per last lab _%#MMDD2007#%_ prior to today showed a BUN of 31, creatinine of 1.3, sodium 141, potassium 3.8, glucose of 108, and a hemoglobin of 11. ASSESSMENT: 1. Total knee replacement due to arthritis. 2. Hypertension controlled. 3. History of CVA stable. 4. Carotid artery stenosis asymptomatic on Aggrenox. 5. Clinical gastritis on TPI. 6. Cough variant asthma.
CVA|cerebrovascular accident|CVA,|213|216|PAST MEDICAL HISTORY|She basically is a walker and can walk across her apartment but when she does that she does not feel short of breath nor does she have any chest pain. PAST MEDICAL HISTORY: 1. Diabetes mellitus type 2 2. Previous CVA, though she has recovered from this. 3. Dyslipidemia. 4. Glaucoma. 5. Colon cancer, status post hemicolectomy and chemo in 1990
CVA|cerebrovascular accident|CVA,|157|160|LABORATORY DATA|LABORATORY DATA: White count 5.5. Hemoglobin 9/27. Platelets 131. Electrolytes: Creatinine 7.89. Potassium 6.3. Preliminary head CT showed frontal posterior CVA, which was presumed to be old. Neurology was consulted. They advised that his mental status changes were not from a primary ischemic neurologic disease.
CVA|cerebrovascular accident|CVA,|158|161|FAMILY HISTORY|16. Congestive heart failure. Last echo _%#MM2004#%_ showed left ventricular hypertrophy and normal left ventricular function. FAMILY HISTORY: Father died of CVA, mother died of congestive heart failure. Daughter with bipolar affective disorder. SOCIAL HISTORY: She lives with her husband. They have a large amount of private home care. No tobacco, no alcohol.
CVA|cerebrovascular accident|CVA|184|186|REVIEW OF SYSTEMS|GASTROINTESTINAL: Positive for dyspepsia and GERD. GENITOURINARY: Denies dysuria or nocturia. MUSCULOSKELETAL: Some discomfort in his legs at night when sleeping. NEUROLOGIC: Previous CVA in _%#MM#%_ of 2005 with ongoing slurred speech when he is tired, as well as emotional lability. PSYCHIATRIC: Would be positive for mood change since his recent CVA as noted above.
CVA|cerebrovascular accident|CVA|132|134|HOSPITAL COURSE|No syncope or presyncope. The patient just states he felt weak and lowered himself to the floor. The patient had a history of prior CVA with residual right-sided weakness and altered gait. The patient stated he had a mild cold for the week prior to admission. He denied productive cough. The patient, in the emergency room, was found to have pneumonia on CT scan, which showed mild bilateral lower lobe infiltrates.
CVA|costovertebral angle|CVA|183|185|PHYSICAL EXAMINATION|GENITOURINARY: Her genital exam reveals normal female genitalia, which is Tanner I-II. Her breast exam is Tanner I. There is no blood seen at the vaginal opening. Her back reveals no CVA tenderness. LABORATORY DATA: Hemoglobin is 13.1. White blood cell count is 23.2 with 77% neutrophils and 22% lymphocytes.
CVA|cerebrovascular accident|CVA,|246|249|PAST  MEDICAL HISTORY|Her INR was found to be subtherapeutic at 1.62. The patient was completely asymptomatic and neurologically stable at the time of presentation, however, she is being admitted for further observation and workup. PAST MEDICAL HISTORY: 1. History of CVA, recent left occipital infarct with resultant left homonomous hemianopsia. 2. History of coronary artery disease, status post four vessel CABG with subsequent multivessel PTCA
CVA|cerebrovascular accident|CVA.|190|193|ASSESSMENT|SKIN: No skin rashes or obvious actinic lesions. NEUROLOGIC: He is alert, oriented and has visible weakness in the grip of his left hand and on holding out his outstretched arm. ASSESSMENT: CVA. PLAN: Neuro consult and MRI scan. Cardiology evaluation because of tachycardia, hypertension and question of cardiac source for emboli.
CVA|costovertebral angle|CVA|223|225|PHYSICAL EXAMINATION|NECK: Supple, no adenopathy. CHEST: Clear. Respirations normal. CARDIOVASCULAR: Regular rhythm, S1, S2, no S3, S4 or murmur. Carotids full, no bruits. ABDOMEN: Soft, nontender, no mass, no hepatosplenomegaly. BACK: Without CVA tenderness. EXTREMITIES: Normal form, no edema. NEUROLOGIC: Cranial nerves II-XII intact. Motor intact. DTRs normoactive throughout. ASSESSMENT: Pre-anesthesia consult, suitable candidate for surgery and anesthesia.
CVA|costovertebral angle|CVA|118|120|PHYSICAL EXAMINATION|EOMs intact and symmetrical. There is no adenopathy. Pharynx and thyroid are normal. LUNGS: Clear to A&P. There is no CVA tenderness. CARDIOVASCULAR: Audible S1, S2, S3, S4, 2/6 systolic ejection murmur loudest at the left sternal border. ABDOMEN: Bowel sounds soft. Singleton infant in breech presentation. Fetal heart tones are 148 with a Doptone.
CVA|cerebrovascular accident|CVA,|110|113|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 53-year-old male with history of CVA, hypertension, sleep apnea and hyperlipidemia as well as aortic root dilatation followed by Cardiology who was admitted through the ER with complaints of sudden onset of chest pain.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION ON ADMISSION|The breasts were approximately Tanner Stage III. The heart was regular rate and rhythm, without murmurs, rubs or gallops. The abdomen was benign, without hepatosplenomegaly. The spine was midline, without any CVA tenderness. There was no cervical lymphadenopathy. There was no focal joint pain or bone pain. Examination of the skin revealed the incision site to be clean, dry, and intact, without any discharge, swelling, or erythema.
CVA|cerebrovascular accident|CVA.|136|139|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: 1. Syncope. 2. Left cerebellar cardiovascular accident. 3. Hypertension. 4. Deconditioning and gait imbalance from CVA. PROCEDURES DONE: 1. Cardiac echo with normal left ventricular systolic function. EF is 60- 65%.
CVA|cerebrovascular accident|CVA,|97|100|ASSESSMENT/PLAN|He has the mild facial droop noted. I did not attempt to ambulate him today. ASSESSMENT/PLAN: 1. CVA, with residual left-sided weakness, now mostly resolved after a few hours. 2. He is already on Plavix and I am going to add aspirin to this.
CVA|costovertebral angle|CVA|219|221|ALLERGIES|LUNGS: Decreased breath sounds at bilateral bases. ABDOMEN: Obese but soft, nontender, nondistended, with positive bowel sounds. No hepatosplenomegaly or masses were appreciated. SPINE: Spine and CVA did not reveal any CVA tenderness. The spine was straight without stepoff or bony deformity. SKIN: Multiple facial pustules and multiple old scars. NEUROLOGIC: Significant for retardation of movement with no spontaneous conversation but was able to answer yes/no question.
CVA|cerebrovascular accident|CVA.|122|125|HISTORY OF THE PRESENT ILLNESS|She had evidence of some facial drooping, right-sided weakness, and thought it best to admit her to rule out a continuing CVA. Also noticed to have high blood pressure. HOSPITAL COURSE: The patient was admitted to med-surg in stable condition.
CVA|costovertebral angle|CVA|220|222|PHYSICAL EXAMINATION|ABDOMEN: Soft, nontender, nondistended with a small 3 cm healed incision along her upper mid epigastrium. She had no bladder tenderness and no abdominal masses. GENITOURINARY: Her kidneys did not have any palpitation or CVA tenderness. Her external genital exam was not performed. EXTREMITIES: She had no clubbing, cyanosis or edema. She has had some chronic left leg pain and cramping that she says gets worse when she sits for long periods of time.
CVA|costovertebral angle|CVA|152|154|PHYSICAL EXAMINATION|CURRENT MEDICATIONS: Atenolol and spironolactone. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. NECK: Supple, no masses. BACK: Normal spinal curvature, no CVA tenderness. HEART: S1/S2, no S3/S4, no murmur, regular rhythm. CHEST: Clear to auscultation. ABDOMEN: Soft, nontender, no hepatosplenomegaly. PELVIC: Deferred to surgery. IMPRESSION: Dysfunctional uterine bleeding.
CVA|cerebrovascular accident|CVA.|142|145|BRIEF HISTORY AND HOSPITAL COURSE|I did discuss his potential risk for future strokes in that the PFO may be a culprit, although it also can be a coincidental finding with his CVA. He is scheduled to have an outpatient transesophageal echo at Fairview Southdale on _%#MMDD2006#%_ with Cardiology follow up shortly thereafter to consider other modalities of treatment.
CVA|costovertebral angle|CVA|156|158|PHYSICAL EXAMINATION|CHEST: Clear to auscultation and percussion. HEART: Regular sinus rhythm with no murmurs. BREASTS: Normal. No galactorrhea, masses, or tenderness. BACK: No CVA tenderness. ABDOMEN: Benign. No scars, masses, or tenderness. PELVIC: Vagina normal. Cervix normal, nontender on motion. Uterus was retroflexed, nontender, but with irregularities so that it felt like there might be a small fibroid in the uterus.
CVA|cerebrovascular accident|CVA|172|174|PAST MEDICAL HISTORY|2. Fractured ankle. 3. Left hip fracture in _%#MM#%_ of 2004. PAST MEDICAL HISTORY: 1. Insulin dependent diabetes mellitus for approximately 20 years. 2. Remote history of CVA with no residual. MEDICATIONS: Humulin Insulin 12 units a.m., 12 units p.m. ALLERGIES: None known.
CVA|cerebrovascular accident|CVA.|164|167|PAST MEDICAL HISTORY|2. Hyperlipidemia. 3. In 1987 he had a small myocardial infarction medically managed. 4. PCI in 2000 with stent. 5. No prior history of congestive heart failure or CVA. SOCIAL HISTORY: He is a nonsmoker. ALLERGIES: Sulfa.
CVA|cerebrovascular accident|CVA,|149|152|DISCHARGE DIAGNOSES|Hemoglobin A1C pending. Calcium, albumin, liver function tests normal. Cholesterol 299. LDL 225. Lipids showed a LDL of 205. DISCHARGE DIAGNOSES: 1. CVA, right cerebellum with aphasia. 2. Hyperlipidemia. 3. Osteoporosis. 4. Scoliosis. 5. Hypertension. 6. Edema. 7. Restrictive lung disease from scoliosis.
CVA|costovertebral angle|CVA|212|214|PHYSICAL EXAMINATION|LUNGS: Clear to auscultation and percussion bilaterally. ABDOMEN: There is mild epigastric tenderness present with deep palpation. Otherwise soft, nondistended, no masses or hepatosplenomegaly are felt. BACK: No CVA tenderness. EXTREMITIES: There is no cyanosis, clubbing or edema. Peripheral pulses are 2+ and symmetric in both upper and lower extremities bilaterally.
CVA|costovertebral angle|CVA|242|244|PHYSICAL EXAMINATION|VITAL SIGNS: Height 5 feet 3, weight 123, blood pressure 120/60, hemoglobin 8.2. HEENT: Pupils are equally reactive and accommodate. EOMs intact and symmetrical. No adenopathy. Pharynx and thyroid are normal. LUNGS: Clear to A&P. There is no CVA tenderness. BREASTS: Free of any suspicious masses, skin changes or nipple discharge. CARDIOVASCULAR: Audible S1, S2 without S3, S4. No murmur, no edema, negative Homans'.
CVA|cerebrovascular accident|CVA|245|247|ASSESSMENT AND PLAN|Differential diagnosis includes central versus peripheral source of vertigo, such as benign positional vertigo or labyrinthitis. He did not have any focal neurologic deficits and coordination is normal, which would make a central source such as CVA seem less likely. We discussed MRI, but the patient refuses, as he is concerned about finances. He will therefore be empirically treated with an aspirin a day.
CVA|costovertebral angle|CVA|141|143|PHYSICAL EXAMINATION|CHEST: Clear to auscultation and percussion. HEART: Regular sinus rhythm with no murmurs. BREASTS: Normal. No masses or tenderness. BACK: No CVA tenderness. ABDOMEN: Benign. No scars, masses or tenderness. Estimated fetal weight is 7 pounds 4 ounces. The patient is thought to have a female infant from ultrasound.
CVA|costovertebral angle|CVA|172|174|PHYSICAL EXAMINATION|NECK: Supple without thyromegaly, lymphadenopathy, masses. HEART: Regular rate and rhythm without murmurs, gallops or rubs. LUNGS: Clear to auscultation bilaterally. BACK: CVA is nontender, but it does cause some tenderness in the lower abdomen when percussing over the CVA. EXTREMITIES: Warm without clubbing, cyanosis, edema. ABDOMEN: Bowel sounds are present but hypoactive throughout, and she is tender diffusely below the umbilicus, both left lower quadrant, right lower quadrant as well as the midline.
CVA|costovertebral angle|CVA|247|249|PHYSICAL EXAMINATION|LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm without murmurs, rubs or gallops. GASTROINTESTINAL: Abdomen is nondistended with normoactive bowel sounds, soft and nontender with no hepatosplenomegaly, inguinal hernias or CVA tenderness. PELVIC: Deferred to the operating room, however, previously on _%#MMDD2006#%_, her bimanual exam revealed a uterus was that was 6-8 weeks' size, retroverted and very fixed in the pelvis.
CVA|costovertebral angle|CVA|223|225|ADMISSION PHYSICAL EXAMINATION|NECK: Supple. CARDIOVASCULAR: Regular rate and rhythm, no murmurs, gallops or rubs. LUNGS: Clear to auscultation with good air entry bilaterally. ABDOMEN: Soft, nontender, nondistended, normoactive bowel sounds. FLANKS: No CVA tenderness. LYMPHATICS: No lymphadenopathy. SKIN: No rashes. MUSCULOSKELETAL: Left leg, status post rotationplasty at the knee joint. NEUROLOGIC: Cranial nerves II-XII intact. ADMIT LABORATORY: CBC, white count 3.4, differential was 30% neutrophils, 48% lymphocytes, 20% monocytes, absolute neutrophil count 1.0, hemoglobin of 11.3, platelets 343,000.
CVA|cerebrovascular accident|CVA.|165|168|ASSESSMENT|Given her history, this is almost certainly GI, but given her known vascular disease, I think we need to rule out MI. 2) Known cerebrovascular disease with previous CVA. 3) Hiatal hernia and gastroesophageal reflux, recently well controlled on Prilosec. 4) Hyperlipidemia. 5) History of cardiac arrhythmias with no active beat today.
CVA|cerebrovascular accident|CVA.|230|233|HOSPITAL COURSE|During this hospital this was not a problem. She responded to physical therapy and her pain was easily controlled. She will be discharged to rehab for further physical therapy and then discharge back to her home. 2. Left parietal CVA. When admitted to the hospital, the patient did have complaints of left arm weakness and left hand clumsiness. Initially she thought that maybe this was an old finding.
CVA|cerebrovascular accident|(CVA)|179|183|REVIEW OF SYSTEMS|No constipation or diarrhea. GU: No dysuria or hematuria. No frequency or urgency in urination. Neurologic: No headache. No double vision. No symptoms of cerebrovascular accident (CVA) or transient ischemic attack (TIA). Constitutional: No fever. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 166/95.
CVA|costovertebral angle|CVA|163|165|OBJECTIVE|Lungs: Clear to auscultation bilaterally. Abdomen: Positive bowel sounds. Soft with significant left lower quadrant tenderness and suprapubic tenderness. Back: No CVA tenderness. Extremities: No calf tenderness. Further review of systems is positive for a couple of episodes of vomiting yesterday and the day before.
CVA|cerebrovascular accident|CVA|206|208|HOSPITAL COURSE|She was afebrile. Her lungs showed crackles at the right lower lobe. By _%#MMDD2002#%_ the patient described some feeling of congestion in the bronchial area. She continued previous expressive aphasia post CVA in past. By _%#MMDD2002#%_, the patient had noted some persistent occasional cough. She was anxious for discharge due to situational factors with family.
CVA|cerebrovascular accident|CVA|389|391|CHRONIC DISEASE/MAJOR ILLNESSES|MEDICATIONS: Zyprexa 20 mg q.h.s., Ditropan 10 mg t.i.d., Coumadin 5 mg q.d. except 2.5 mg on Tuesdays and Saturdays; temazepam 60 mg q.h.s., Senna 4 tablets q.a.m. Doculax 5 mg q.a.m. baclofen 10 mg b.i.d., CTZ 25 mg q.o.d., Sorbitol 30 cc q.d., and Combivent inhaler 2 puffs q.i.d. and q4h p.r.n. CHRONIC DISEASE/MAJOR ILLNESSES: 1. Severe COPD. 2. Chronic schizophrenia. 3. Status post CVA with mild residual left hemiparesis due to paradoxic embolus. 4. Chronic anticoagulation therapy due to #3. REVIEW OF SYSTEMS: Other than HPI is unremarkable.
CVA|cerebrovascular accident|CVA|124|126|PAST MEDICAL HISTORY|ALLERGIES: No known drug allergies. PAST MEDICAL HISTORY: 1. Status post four vessel bypass surgery in 1997. 2. Status post CVA with some temporary speech deficit with recovery shortly after the surgery. It was thought that this was postoperative changes. 3. Hypertension, poorly controlled.
CVA|costovertebral angle|CVA|179|181|PHYSICAL EXAMINATION|Decreased breath sounds on the right. ABDOMEN: Soft, nontender and nondistended. Positive bowel sounds. No hepatosplenomegaly is noted. MUSCULOSKELETAL: His spine is straight. No CVA tenderness. SKIN: Without lesions, no rashes. NEUROLOGIC: Cranial nerves are grossly intact. Answers questions appropriately and moves all extremities well. ADMISSION LABS: White count of 3, hemoglobin of 10.9 and platelets 84,000.
CVA|cerebrovascular accident|CVA|241|243|IMPRESSION  AND PLAN|No acute ST changes. IMPRESSION AND PLAN: Ms. _%#NAME#%_ is an 89-year-old female with a history of hypertension admitted through the emergency department with acute onset of confusion. 1. Confusion: I am suspicious for the possibility of a CVA or TIA. Differential diagnosis would include something like transient global amnesia, although this seems a bit less likely. There is no obvious metabolic or infectious cause. No evidence of cardiac ischemia.
CVA|costovertebral angle|CVA|125|127|PHYSICAL EXAMINATION|ABDOMEN: Soft, nondistended and nontender. Positive bowel sounds, PEG tube in place which looks clear. BACK: No vertebral or CVA tenderness. EXTREMITIES: Warm and well perfused, no lower extremity edema, no joint effusions. SKIN: No rash or jaundice. NEUROLOGIC: Cranial nerves II-XII are intact.
CVA|cerebrovascular accident|CVA|184|186|PAST MEDICAL HISTORY|She does have some chronic low back pain that is unchanged. PAST MEDICAL HISTORY: Diabetes type 2, ASCVD, hyperlipidemia, hypertension, hypothyroidism, right eye blindness, history of CVA with resultant dysarthria. PAST SURGICAL HISTORY: CABG x4 in 1991.
CVA|costovertebral angle|CVA,|171|174|PHYSICAL EXAMINATION|No murmurs. LUNGS: Clear to auscultation bilaterally. No wheezing. ABDOMEN: Soft and distended. Tenderness present over the lower abdomen and bowel sounds present. SPINE: CVA, no tenderness present. NEUROLOGIC: Grossly intact. Alert and oriented x3. LABS AT THE TIME OF ADMISSION: CBC with the WBC of 5.1, hemoglobin of 12, hematocrit of 36.1, platelets of 195,000, BMP with the sodium of 138, potassium 4.2, chloride 106, CO2 25, BUN 11, creatinine of 0.8 and glucose 104.
CVA|costovertebral angle|CVA|171|173|PHYSICAL EXAM|Decreased bowel sounds. Mild tenderness in the epigastric area. No tenderness in the right upper quadrant area. No peritoneal or guarding. EXTREMITIES: No edema. BACK: No CVA tenderness. Troponin I negative. Albumin 4.1. Alkaline phosphatase 61. ALT 27.
CVA|costovertebral angle|CVA|193|195|PHYSICAL EXAMINATION|Ileostomy was big, full of air. Positive bowel sounds and she was tender suprapubically. There were no bruises on her abdomen. Her pelvis was stable to rocking. Back, there was no bruising, no CVA tenderness. Extremities: She has normal pulses, no edema. no obvious bone abnormalities. LABS ON ADMISSION: Potassium of 3.7, Bun of 14, creatinine .6, hemoglobin 13.9, and white count 10.8 and platelets 190.
CVA|costovertebral angle|CVA|196|198|PHYSICAL EXAMINATION|HEENT: Clear. NECK: No thyromegaly. CHEST: Clear to auscultation and percussion. HEART: Regular sinus rhythm with no murmurs. BREASTS: Normal, with no galactorrhea, masses or tenderness. BACK: No CVA tenderness. ABDOMEN: Benign. No scars, masses or tenderness. PELVIC: Vagina normal. Cervix normal and nontender on motion. Uterus anterior, normal size and shape, nontender.
CVA|cerebrovascular accident|CVA|158|160|PAST MEDICAL HISTORY|2. COPD 3. Congestive heart failure. Echo in _%#MM#%_ 2004 shows mildly decreased LV function with an ejection fraction of 45%. 4. Hypertension 5. History of CVA in 1987 with residual right-sided deficits. 6. History of pericardial effusion. 7. Abnormal colon by CT on her last hospital admission.
CVA|costovertebral angle|CVA|149|151|PHYSICAL EXAMINATION|The patient has mild tenderness to palpation in he right lower quadrant. There is no rebound, no guarding. BACK: Positive right CVA tenderness. Left CVA is nontender this morning. SKIN: No rash. NEUROLOGI: Cranial nerves II-XII are grossly intact; no focal deficit. LABS: Urine pregnancy test is negative. Urine culture and blood culture are pending.
CVA|costovertebral angle|CVA|152|154|PHYSICAL EXAMINATION|LUNGS: Clear to auscultation bilaterally without wheezes, rales, or rhonchi. BACK: Shows no spinous or paraspinous tenderness to palpation. There is no CVA tenderness. Axillae are free of lymphadenopathy. BREASTS: Deferred. ABDOMEN: Positive bowel sounds in all four quadrant; soft; nontender; nondistended.
CVA|cerebrovascular accident|CVA|166|168|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Surgeries include transurethral resection of the prostate twice, a TUNA, recent cardioversion. Major diagnoses include atrial fibrillation, MS, CVA in 2001 with paraesthesia of the hands, and some ataxia in the right leg and hands, seizures non-active, hypertension, depression, prostatism, cognitive disorder, memory loss from CVA, urinary retention, and chronic perineal pain of unknown cause.
CVA|costovertebral angle|CVA|216|218|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITALS: Temperature 100.3. HEENT: Normal. CHEST: Clear. HEART: Grade 2/6 systolic ejection murmur. ABDOMEN: Soft, gravid. No rebound tenderness or rigidity. The uterus is soft and nontender. No CVA tenderness to percussion. Cervix: Fingertip to 1 cm dilated. Muscle stretch reflex is 2+/4. LABORATORY DATA: White blood cell count was 14,100.
CVA|costovertebral angle|CVA|168|170|PHYSICAL EXAMINATION|NECK: supple without adenopathy. LUNGS: Clear. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Soft with right lower quadrant tenderness and guarding, no rebound, no CVA tenderness, no hernias noted, no organomegaly is noted. LABORATORY: White count is elevated at 19,000. IMAGING: CT scan showed fluid in the pelvis and along the gutter around the appendix, but could not definitely call it appendicitis, based on the scan.
CVA|costovertebral angle|CVA|249|251|PHYSICAL EXAMINATION|Heart is regular rate and rhythm. She has about a 2/6 systolic murmur, best heard in the upper sternal border, consistent with a flow murmur. Abdomen - soft with positive bowel sounds, nondistended, nontender to palpation, no hepatosplenomegaly. No CVA tenderness bilaterally. Extremities - she has 1+ edema bilaterally. Skin - multiple lesions that are well healed noted on the trunk as well as the arms and legs.
CVA|cerebrovascular accident|CVA|271|273|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Surgery includes wrist surgery of unknown type, thoracic aneurysm repair, PEG feeding tube, ear surgery bilaterally of unknown type, hernia repairs, cataract extraction. Major diagnosis includes dementia, TIAs, GERD, expressive aphasic secondary to CVA with aphasia. She has history of CHF, atrial fibrillation, positive MRSA, hypertension, hypothyroidism. FAMILY HISTORY: Unobtainable in chart or by patient. ALLERGIES: Ceftin, Protonix.
CVA|costovertebral angle|CVA|226|228|PHYSICAL EXAMINATION|Otherwise unremarkable. Neck: Supple without lymphadenopathy or thyromegaly. No evidence of JVD. Cardiovascular: Regular rate and rhythm without murmurs. Lungs: Clear to auscultation bilaterally. No rales or wheezes. Back: No CVA tenderness to percussion. Abdomen: Normoactive bowel sounds. Soft and flat. Mild lower abdominal distention. No significant tenderness to palpation. No definite masses are noted, but there is a question of a mildly dilated bladder still at this point.
CVA|costovertebral angle|CVA|245|247|ADMISSION PHYSICAL EXAMINATION|Lungs: Diffuse expiratory wheezes and crackles. Abdomen: Distended; symmetric; bowel sounds audible; minimally tender in the right upper quadrant; hepatomegaly with liver edge palpable with liver edge palpable below the costal margin. Spine: No CVA tenderness. Skin: No rashes. Extremities: Lower extremity 1+ edema, non-tender. Neurologic: Cranial nerves II-XII intact. ADMISSION LABORATORY DATA: White count 8.1. Hemoglobin 9.5. Hematocrit 28.2. Platelets 324.
CVA|costovertebral angle|CVA|216|218|ADMISSION PHYSICAL EXAMINATION|LUNGS: Clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate, and rhythm, normal S1, and S2, no murmurs. ABDOMEN: Positive bowel sounds, soft, non-tender, non-distended, and no hepatosplenomegaly. BACK: No CVA tenderness. SKIN: No rashes, or bruising noted. NEUROLOGIC: No focal deficits. ADMISSION LABORATORIES: CBC revealed WBC 5.8. Hemoglobin 12.5. Platelet counts 215.
CVA|cerebrovascular accident|(CVA)|204|208|PAST MEDICAL HISTORY|She was stabilized and brought to the Intensive Care Unit (ICU) for observation. PAST MEDICAL HISTORY: 1. Apparent history of diabetes, type 2. 2. Hyperlipidemia. 3. Glaucoma. 4. Cerebrovascular accident (CVA) with aphasia in the past several years ago. 5. GI bleeding. a. She has had at least a couple of admissions in the last two years for GI bleeding and the best that has been able to be assessed is that she has had some gastric ulcerations and bled.
CVA|costovertebral angle|CVA:|159|162|REVIEW OF SYSTEMS|Endocrine: No temperature intolerances, hot flashes, night sweats. Immune: No fevers, chills. Respiratory: Some shortness of breath noted, no wheezing, cough. CVA: No palpitations, chest pain, DLE. GI: Abdominal pain as above. Normal bowel movements. Nausea and vomiting as above. No diarrhea, hematochezia, melena. Breasts: Moderate tenderness bilaterally. No palpable masses per patient, no nipple discharge.
CVA|costovertebral angle|CVA|142|144|PHYSICAL EXAMINATION|BREASTS - no masses. ABDOMEN - soft, nontender, no masses. Liver, spleen and kidneys not felt to be enlarged. BACK - normal configuration, no CVA tenderness. EXTREMITIES - no cyanosis or edema. SKIN - normal color and turgor. NEUROLOGIC - grossly normal. PELVIC - external genitalia normal, vagina clean.
CVA|cerebrovascular accident|CVA|165|167|REASON FOR ADMISSION|He was quite hypotensive and hypoxic. He has had aspirations in the past with a past history of aspiration pneumonia about eight months ago. He also heart disease a CVA in the past with right hemiparesis and expressive aphasia and some dysphagia. He uses nectar-thick fluids but otherwise eats normally. He has had tachypnea lately.
CVA|costovertebral angle|CVA|171|173|PHYSICAL EXAMINATION|No murmur, JVD, or carotid bruit. ABDOMEN: Obese. Normal bowel sounds. No guarding, mass, rigidity, rebound, or organomegaly. RECTAL: Deferred to Dr. _%#NAME#%_. BACK: No CVA tenderness. Good strength and range of motion. EXTREMITIES: Pulses and sensation are intact. Good strength and range of motion. Deep tendon reflexes are symmetric and 2 on a scale of 0-4+ __________ clonus.
CVA|costovertebral angle|CVA|199|201|PHYSICAL EXAMINATION|LUNGS are clear. HEART - regular rate and rhythm without murmur. ABDOMEN is soft. Normal bowel sounds. No hepatosplenomegaly. Mild right lower quadrant tenderness and mild right flank tenderness. No CVA tenderness. GU exam is deferred. EXTREMITIES are without edema. NEUROLOGIC - mild generalized weakness with no focal deficits noted.
CVA|costovertebral angle|CVA:|212|215|ADMISSION PHYSICAL EXAM|GENERAL: no acute distress. HEENT: unremarkable. CARDIOVASCULAR: regular rate and rhythm with normal S1, S2, no murmur. LUNGS: clear to auscultation bilaterally. ABDOMEN: soft, non-tender, positive bowel sounds. CVA: no CVA tenderness. SKIN: no rashes. NEUROLOGICAL: alert and oriented, cranial nerves were intact. ADMISSION LABS: Hemoglobin 8.1, white count 14.5, platelets 364; differential 66% neutrophils, 23% lymphocytes, 10% monocytes.
CVA|cerebrovascular accident|CVA.|145|148|FAMILY HISTORY|ALLERGIES: No known drug allergies. FAMILY HISTORY: Negative for coronary disease. His mother had rectal cancer, and father had hypertension and CVA. SOCIAL HISTORY: The patient quit smoking 30 years ago, used to smoke about a pack per week.
CVA|cerebrovascular accident|CVA|173|175|FAMILY HISTORY|2. Tonsillectomy, remote. FAMILY HISTORY: Significant for tobacco-related lung disease in her mother. Her father is deceased at age 67; from heart disease with a history of CVA and myocardial infarction. She has one brother who is alive and well. There is no family history of colon, breast, or ovarian cancer.
CVA|cerebrovascular accident|CVA|208|210|PAST MEDICAL HISTORY|Thankfully, _%#NAME#%_ quit drinking alcohol shortly after. PAST MEDICAL HISTORY: Surgeries: Portal bypass shunt placed and removed, eye surgery at age 5, TKA on the right knee. Medical diagnoses include the CVA in 2000, which left him with partial left hemiparesis; then the progressing CVA on _%#MMDD2003#%_ that gave him dense hemiparesis on the left.
CVA|costovertebral angle|CVA|184|186|OBJECTIVE|Tympanic membranes are clear. Nasal mucosa within normal limits. Oral cavity is without erythema or exudate. NECK: Is supple. No adenopathy or thyromegaly is present. BACK: Is without CVA or spinal tenderness. LUNGS: Were clear to auscultation. No rales, rhonchi or wheezing is present. CHEST: Without lesions. CARDIOVASCULAR: Regular rate and rhythm, he has a II-III/VI systolic ejection murmur heard throughout the entire precordium, but loudest at the right second intercostal space.
CVA|costovertebral angle|CVA|148|150|PHYSICAL EXAMINATION|Abdomen: Diffusely tender, hyperactive bowel sounds, soft, not distended, no hepatosplenomegaly. Skin: Diaphoretic. No rashes or lesions. Spine: No CVA tenderness. Neurological: Cranial nerves 2-12 intact. Motor and sensory, grossly intact and symmetric. ADMISSION LABORATORY: WBC 16.0, hemoglobin 13.2, platelets 151, % neutrophils 97, sodium 132, potassium 4.4, chloride 104, bicarbonate 17, BUN 13, creatinine 2.16, glucose 98.
CVA|cerebrovascular accident|CVA|187|189|ASSESSMENT|He likely will require a cysto at some point. 2. Hypertension secondary to above, now stable. 3. Hypercoagulable state requiring chronic Coumadin therapy. 4. History of right hemispheric CVA with sequela, as noted above. 5. History of PE/DVT. PLAN: Administer fresh frozen plasma until his bleeding has subsided.
CVA|costovertebral angle|CVA|274|276|PHYSICAL EXAMINATION|ABDOMEN: Soft, nontender, and nondistended with positive bowel sounds. Liver edge was noted to be 6 cm below the costal margin and spleen about 7 cm below the costal margin. GENITALIA: Deferred and this is to be done by Obstetrical/Gynecology Consultation. SPINE: Showed no CVA tenderness. LYMPH: Showed no lymphadenopathy. MUSCULOSKELETAL: Showed no clubbing, cyanosis, or edema, and 2+ distal pulses x four extremities. SKIN: No rashes. NEUROLOGIC: She was grossly intact. LABORATORY/X-RAY: CBC showed white count of 4.1. Hemoglobin 6.2. Platelets 329.
CVA|cerebrovascular accident|CVA|197|199|PAST MEDICAL HISTORY|2. Hepatocellular cancer, status post resection in _%#MM2002#%_. He underwent a left liver lobectomy. He has had abdominal CTs and alpha fetoproteins on a regular basis in follow up. 3. History of CVA in 2000. 4. Type 2 diabetes mellitus with neuropathy. 5. Peripheral vascular disease. 6. Hypertension. 7. Dyslipidemia. 8. History of MRSA, positive sputum in 2003.
CVA|cerebrovascular accident|(CVA),|196|201|HOSPITAL COURSE|c. It was recommended that the patient continue with a dysphagia level I diet. The patient is at increased risk for further aspiration as well as aspiration pneumonia. 3. Cerebrovascular accident (CVA), long-standing and with no evidence for worsening during this hospitalization although global mental status was ratehr poor throughout her hospital stay, at least when I evaluated her.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: Right chest wall and left breast negative for masses, tenderness, skin, nipple or areolar changes.
CVA|costovertebral angle|CVA|198|200|PHYSICAL EXAMINATION|Lymph node survey negative. Pulmonary clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm without murmurs, rubs, or gallops. Neck is without thyromegaly or mass. Back without CVA tenderness. Abdomen soft and nontender. There is no hepatosplenomegaly, hernia, or masses. Pelvic: External genitalia within normal limits. There is no urethral prolapse.
CVA|cerebrovascular accident|CVA.|187|190|ASSESSMENT/PLAN|We will address tighter blood pressure control for the long term. 5. Prostate CA staging evaluation is currently unknown. This obviously impacts the long term management of the patient's CVA. 6. Elevated myoglobin and elevated CK, this is most likely secondary to the patient having been down for prolonged period of time, this is unlikely to be secondary to a coronary event.
CVA|cerebrovascular accident|CVA.|162|165|PLAN|3. Urinary tract infection. PLAN: Will admit the patient to the hospital. Given his history of a previous stroke will obtain an MRI of the head to rule out a new CVA. Will check a TSH, Tegretol level, will check a complete metabolic panel in the morning. I will continue him on IV fluids and will obtain PT, OT as well as a speech evaluation on the patient.
CVA|cerebrovascular accident|CVA|149|151|FAMILY HISTORY|No particular musculoskeletal complaints, no recent headaches, occasionally has some slight dizziness. FAMILY HISTORY: Father died at 48, mother had CVA at age 62 and history of hypertension. Brother had coronary disease and hypertension. SOCIAL HISTORY: The patient works at the University and does not smoke.
CVA|cerebrovascular accident|CVA|181|183|FAMILY HISTORY|ALLERGIES: No known allergies. HABITS: Non-smoker. He does not drink alcohol to excess. He has maybe a couple of drinks per week. FAMILY HISTORY: Father died at an early age from a CVA at 54 years of age. SOCIAL HISTORY: He has been married since 1963. He has two daughters.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: Right breast and left chest wall negative for masses or tenderness.
CVA|costovertebral angle|CVA|131|133|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Negative. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. NECK: Supple. No masses. BACK: Normal spinal curvature. No CVA tenderness. HEART: S1, S2, no S3, S4. No murmurs, regular rhythm. CHEST: Clear to auscultation. ABDOMEN: Soft and nontender, no hepatosplenomegaly.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: Right breast and left chest wall negative for mass, tenderness, skin, nipple or areolar change.
CVA|cerebrovascular accident|CVA|165|167|REASON FOR CONSULTATION|HEMATOLOGY CONSULTATION: REASON FOR CONSULTATION: I have been asked to see _%#NAME#%_ by his consulting neurologist (Dr. _%#NAME#%_ _%#NAME#%_) regarding his recent CVA and possible underlying hypercoaguable state. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 53-year-old white male who is in his usual state of health prior to this admission.
CVA|cerebrovascular accident|CVA|316|318|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: A 53-year-old white male with recent CVA and newly diagnosed cardiomyopathy with history of previous undiagnosed TIA/CVA (based on recent CT scanning) - It is quite likely that _%#NAME#%_ may possess an underlying hypercoaguable state given his long family history and current presentation with CVA at a fairly young age. His history of heavy tobacco use also likely increased his risk of both cerebrovascular and cardiovascular disease and therefore, smoking cessation was discussed at length today.
CVA|cerebrovascular accident|CVA,|220|223|ASSESSMENT|Per _%#CITY#%_ _%#CITY#%_ Clinic verbal report, INR is 6.9 and potassium is 5.4. There is also mention of elevated creatinine from baseline. ASSESSMENT: Mr. _%#NAME#%_ is a 67-year-old gentleman with a history of recent CVA, hypertension, cardiomyopathy and dyslipidemia. He presents with worsening renal function, hyperkalemia and supratherapeutic INR 1. Acute renal failure: This is most likely prerenal in origin and contributed by ACE inhibitors.
CVA|costovertebral angle|CVA|173|175|ADMISSION PHYSICAL EXAMINATION|Cardiovascular: Normal with regular rate and rhythm. No murmurs and a normal S1 and S2. Abdomen: Benign and soft. No hepatomegaly. Positive bowel sounds. The patient had no CVA tenderness. Skin: No rashes, petechiae, or bruising. Neurologic: This is an alert, oriented, and interactive male with cranial nerves II through XII intact, good motor strength, and normal reflexes.
CVA|costovertebral angle|(CVA)|174|178|PHYSICAL EXAMINATION|ABDOMEN: Soft with positive bowel sounds, nondistended. Some tenderness to palpation around the umbilicus subjectively. No rebound or guarding. BACK: No costovertebral angle (CVA) tenderness. EXTREMITIES: Extremities are warm. No clubbing, cyanosis or edema. SKIN: No evidence of rash. PSYCHIATRIC: Difficult to talk with as she kind of writhes around in the bed and is somewhat evasive with my questions.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: Right breast is negative for masses, tenderness, skin, nipple or areolar changes.
CVA|cerebrovascular accident|CVA|305|307|PAST MEDICAL HISTORY|However, she will be discharged to TCU for ongoing evaluation and for further consideration for possible need for assisted living at discharge versus more aggressive placement options. PAST MEDICAL HISTORY: 1. Diabetes mellitus 2. 2. Hypertension. 3. Paroxysmal atrial fibrillation. 4. Hyperlipidemia. 5. CVA times two 5-6 years ago. FAMILY HISTORY and SOCIAL HISTORY: Reviewed without change. See admit H & P for further details.
CVA|cerebrovascular accident|CVA|275|277|REVIEW OF SYSTEMS|She denies any urinary tract problems, has not had any frequent or dysuria, denies any blood clotting or history of hemorrhage, denies any rash or changes in her skin or joints. No thyroid disease or history of diabetes. No muscle pains or joint aches. She did have a recent CVA but has had no residual symptoms from that. Denies any problems with concentration or thinking. She is postmenopausal and does not have any hot flashes.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: Right chest wall negative for masses, tenderness, skin changes.
CVA|costovertebral angle|CVA|196|198|CHIEF COMPLAINT|No murmur. Abdominal exam reveals somewhat decreased bowel sounds, but soft with some tenderness and guarding with palpation on the epigastrium and right upper quadrant. Spine is straight with no CVA tenderness. Neurologic Exam: Mental status, alert and oriented x3. Cranial nerves 2 through 12 are grossly intact with no papilledema.
CVA|costovertebral angle|CVA|236|238|DISCHARGE DIAGNOSIS|NECK: No lymphadenopathy. CARDIOVASCULAR: Regular, rate, and rhythm with occasional dropped beats and a 2/6 holosystolic murmur. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender with bowel sounds. SPINE/CVA: He had no CVA tenderness. No lymphadenopathy. SKIN: No lesions other than those on the chin mentioned above. NEUROLOGIC : Cranial nerves II through XII grossly intact. Strength and sensation were equal bilaterally.
CVA|costovertebral angle|CVA|166|168|PHYSICAL EXAMINATION|NECK: Supple. LUNGS: Clear to auscultation. HEART: Heart rate was irregularly irregular without murmur. ABDOMEN: Soft. There was no rebound or guarding. There was no CVA tenderness. EXTREMITIES: Legs show no evidence of calf tenderness. No evidence of deep vein thrombosis or paresthesias. As mentioned above, radial pulse was irregularly irregular. There was good cap refill on nailbeds.
CVA|cerebrovascular accident|CVA|132|134|PAST MEDICAL HISTORY|The patient now is on two liters nasal cannula with 96% O2 saturations. PAST MEDICAL HISTORY: 1. Hypertension. 2. Right hemispheric CVA ten years ago with residual left hemiparesis. The patient normally ambulates with a walker. 3. Thalassemia. ALLERGIES: PENICILLIN. MEDICATIONS: 1. Verapamil extended release 120 mg p.o. daily.
CVA|costovertebral angle|CVA|168|170|PHYSICAL EXAMINATION|No lymphadenopathy. Mouth and throat normal. Thyroid is normal size. LUNGS: Clear. CARDIOVASCULAR: S1 and S2 normal. No S3, S4 or murmurs. ABDOMEN: There is mild right CVA tenderness. Liver and spleen not palpable. Normal bowel sounds. EXTREMITIES: Shows a prominent venous pattern which extends up into the lower abdomen.
CVA|cerebrovascular accident|CVA|114|116|IMPRESSION AND PLAN|We will add aspirin therapy for now in addition to his Coumadin. We will perform a brain MRI scan to evaluate for CVA and perform bilateral carotid ultrasounds to rule out significant carotid artery stenosis. We will have PT and OT see the patient as well to ambulate.
CVA|cerebrovascular accident|CVA|254|256|PHYSICAL  EXAMINATION|LUNGS: Clear to auscultation bilaterally. CARDIOVASCULAR: Regular rhythm. ABDOMEN: Some tenderness, without rebounding noted in the epigastric and right upper quadrant. Bowel sounds are noted in all four quadrants. The patient has discomfort in the left CVA region as well. No significant tenderness elsewhere. DERM: No ecchymotic or petechial lesions. EXTREMITIES: Without cyanosis, clubbing or edema in either lower extremity.
CVA|cerebrovascular accident|CVA|186|188|ASSESSMENT AND PLAN|We will check a thyroid level and echocardiogram. He received Lovenox in the Emergency Room and we will continue that and start Coumadin today. 2. It is unclear whether this is a TIA or CVA and so we will get a neurologist to see this patient. Carotid duplex has been ordered as have MRI and MRA of the brain.
CVA|cerebrovascular accident|CVA.|158|161|FAMILY HISTORY|FAMILY HISTORY: Significant for rheumatic fever in the patient's mother, as well as depression in the patient's mother. The patient's father had a history of CVA. REHAB COURSE: During her Transitional Care stay, she did receive physical therapy, occupational therapy, and nursing care with the goal of increasing her functional status.
CVA|costovertebral angle|CVA|185|187|DISCHARGE PHYSICAL EXAMINATION|She is menstruating. DISCHARGE PHYSICAL EXAMINATION: ABDOMEN: Soft, scaphoid and nondistended. She has tenderness 4-5/10 in the suprapubic area, potentially related to menstruating. No CVA tenderness. ASSESSMENT: This is a 14-year-old with ah x of constipation, now with an e. coli pyelonephritis, improved.
CVA|costovertebral angle|CVA|136|138|PHYSICAL EXAMINATION|EXTREMITIES: Showed no clubbing, cyanosis or edema. She had 1+ pulses. BACK: Diffusely tender in the lumbar and sacral area. She had no CVA tenderness. NEUROLOGIC: Grossly intact. ASSESSMENT/PLAN: 1. Intractable back pain associated with weakness and possibly a bladder infection.
CVA|cerebrovascular accident|CVA.|157|160|PAST MEDICAL HISTORY|4. Ataxia. 5. Diverticulosis of the colon. 6. Esophageal reflux with Barrett's. 7. Hypertension. 8. Esophageal stricture. 9. Depression. 10. Past history of CVA. 11. Peripheral neuropathy. 12. History of syncope. 13. Memory loss. 14. Ischemic colitis. PAST SURGICAL HISTORY: Bilateral hip replacement, abdominal hysterectomy, bunion removal, repair of rectum and prolapsed mucosa, repair of inguinal hernia, femoral, tonsillectomy and adenoidectomy.
CVA|cerebrovascular accident|CVA.|226|229|CARDIAC  RISK FACTORS|Her she is on atenolol which suggests that she has a history of hypertension despite her denial. She has never been a smoker and states that she has no family history of coronary artery disease; her mother died at age 85 of a CVA. PHYSICAL EXAMINATION: GENERAL: This is an obese, late middle-aged patient appearing her stated age.
CVA|cerebrovascular accident|CVA|121|123|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Fall at home. HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old female with a recent history of CVA in _%#MM2007#%_, otherwise fairly healthy living at home, who complains of a fall earlier in the day. She states that around 7 a.m. she slipped on her kitchen floor and was only able to crawl into her bedroom where she then waited five hours until her daughter came.
CVA|cerebrovascular accident|CVA.|270|273|PAST MEDICAL HISTORY|5. Osteoporosis. Patient had been on Fosamax in the past and this was being considered on the next patient's follow-up with her primary care physician. 6. Urinary tract infections. The patient had been on Bactrim 1 po bid since _%#MMDD2002#%_. 7. Dysphasia secondary to CVA. 8. History of a fall at _%#CITY#%_ Care Center on _%#MMDD2002#%_ and hospitalized overnight. 9. DNR/DNI. MEDICATIONS: 1. Bactrim D-S 1 po bid for ten days.
CVA|cerebrovascular accident|CVA.|35|38|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Right-side CVA. 2. Occlusion of right internal carotid artery. PROCEDURES DURING HOSPITALIZATION: 1. Transesophageal echo, _%#MMDD2002#%_, which showed normal global LV systolic function, small region of mild hypokinesis present involving inferior segment, mild mitral regurgitation.
CVA|cerebrovascular accident|CVA|113|115|PAST MEDICAL HISTORY|During his hospitalization, prior to surgery we will achieve a workup for his cachexia. PAST MEDICAL HISTORY: 1) CVA x 4; his last was in 1996. He has residual symptoms of dysarthric speech and decreased muscle tone, also diplopia.
CVA|costovertebral angle|CVA|174|176|PHYSICAL EXAMINATION|ALLERGIES: SULFA AND PENICILLIN. REVIEW OF SYSTEMS: Otherwise negative. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. NECK: Supple, no masses. BACK: Normal spinal curvature, no CVA tenderness. HEART: S1, S2, no S3, S4, no murmur, regular rhythm. CHEST: Clear to auscultation. ABDOMEN: Soft, nontender, no hepatosplenomegaly. PELVIC: Deferred to surgery.
CVA|cerebrovascular accident|CVA,|180|183|FAMILY HISTORY|2. Right tubal pregnancy in _%#MM1992#%_, and laparoscopy with lysis of adhesions in 1995. 3. Last menstrual period is _%#MMDD2007#%_. FAMILY HISTORY: Father with lymphoma, MI and CVA, mother with liver disease, siblings with heart disease and high cholesterol. Daughter with diabetes. GYNECOLOGICAL HISTORY: As above. PHYSICAL EXAMINATION: GASTROINTESTINAL: Abdomen is distended.
CVA|costovertebral angle|CVA|164|166|PHYSICAL EXAMINATION|ALLERGIES: Penicillin. REVIEW OF SYSTEMS: Otherwise negative. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. NECK: Supple, no masses. BACK: Normal spinal curvature, no CVA tenderness. HEART: S1, S2, no S3, S4, no murmur, regular rhythm. CHEST: Clear to auscultation. ABDOMEN: Contains a term intrauterine pregnancy in the vertex presentation.
CVA|costovertebral angle|CVA|178|180|ASSESSMENT/PLAN|Will check urine cultures as well as blood cultures. Likely source is urinary tract, more specifically I am concerned about the left kidney as a source as patient does have left CVA tenderness on exam. 2. Urinary tract infection. Will begin patient on Levaquin. Patient does have left-sided CVA tenderness on exam as well as a history of kidney stones.
CVA|cerebrovascular accident|CVA.|197|200|IMPRESSION|6. MRSA in the stump side of the right second toe amputation and also nares. He should be on contact isolation. 7. History of rheumatoid arthritis. 8. History of lupus anticoagulant. 9. History of CVA. 10. History of retroperitoneal hemorrhage on heparin. 11. History of bilateral DVT. 12. History of Greenfield filter placed in inferior vena cava.
CVA|cerebrovascular accident|CVA.|160|163|FINAL DIAGNOSES|FINAL DIAGNOSES: 1. Transient ischemic attack with evidence of a tiny infarct in the left frontal region. 2. White matter changes. 3. Hypertension. 4. Previous CVA. DISCHARGE FOLLOW-UP: We will follow her very carefully in the clinic and will of course follow her blood pressure especially carefully.
CVA|cerebrovascular accident|CVA,|243|246|REASON FOR ADMISSION|REASON FOR ADMISSION: _%#NAME#%_ _%#NAME#%_ is an 85-year-old white female with a past medical history including colon cancer, status post recent hemicolectomy with secondary wound infection, O2 dependent COPD, paroxysmal atrial fibrillation, CVA, congestive heart failure, and hypothyroidism. She was discharged to the nursing home following her surgery in _%#MM#%_, only to be readmitted because of the abdominal wound infection.
CVA|cerebrovascular accident|CVA|96|98|PAST MEDICAL HISTORY|No previous episodes like this and no abdominal surgeries. PAST MEDICAL HISTORY: 1. Right-sided CVA in 1995 when he was paralyzed for two days and now has mild right-sided weakness. 2. Chronic atrial fibrillation. 3. ___________, which caused left deafness and facial paralysis in 1978.
CVA|costovertebral angle|CVA|190|192|PHYSICAL EXAMINATION|HEENT: Clear with no thyromegaly. CHEST: Clear to auscultation and percussion. HEART: Regular sinus rhythm with no murmurs. BREASTS: Normal. No galactorrhea, masses, or tenderness. BACK: No CVA tenderness. ABDOMEN: Benign. No scars, masses, or tenderness. PELVIC: Vagina is normal. Cervix is normal and nontender on motion. Uterus is anterior and of normal size. Adnexal area is normal with slight nodularity at the right uterosacral ligament with slight tenderness.
CVA|cerebrovascular accident|CVA|315|317|PAST MEDICAL HISTORY|REVIEW OF SYSTEMS: The rest of constitutional, eyes, ears, nose, mouth, throat, respiratory, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, neurologic, endocrine, hematologic, lymphatic, psychiatric and allergic review of systems are negative other than as listed above. PAST MEDICAL HISTORY: 1) CVA on _%#MM#%_ _%#DD#%_, 2003, diagnosed with right posterior/inferior cerebellar infarct. 2) Echocardiogram performed _%#MM#%_ _%#DD#%_, 2003 showed normal left ventricular size and function, no wall-motion abnormalities.
CVA|cerebrovascular accident|CVA|204|206|REVIEW OF SYSTEMS|ENT negative. GI as mentioned above. Genitourinary negative. No dysuria or hematuria, no frequency or urgency of urination. Musculoskeletal - no active arthritis. Neurologic - no headache, no symptoms of CVA or TIA. Constitutional - no fever or chills. Upon presentation to the Emergency Room, heart rate was 128-130.
CVA|cerebrovascular accident|CVA.|121|124|FAMILY HISTORY|Surgeries include a right mastectomy. She is a gravida 6 para 4024. FAMILY HISTORY: Mother with hypertension, history of CVA. Father and brother with abdominal aortic aneurysm, brother with CVA. MEDICATIONS: 1. Prinivil 10 mg qd. 2. Albuterol inhaler prn.
CVA|cerebrovascular accident|CVA|177|179|PHYSICAL EXAMINATION|It is difficult to palpate for organomegaly. EXTREMITIES: Trace peripheral edema is noted. Peripheral pulses are intact. Weakness is noted in the lower extremities secondary to CVA history. PSYCHIATRIC: flat affect. Mood, energy, concentration are down. He has no suicidal or homicidal ideation. Some degree of anhedonia is noted. STUDIES: 1. Labs: Albuminuria.
CVA|costovertebral angle|CVA:|189|192|ADMISSION PHYSICAL EXAMINATION|HEART: Regular rate and rhythm, without murmur. Normal S1 and S2. ABDOMEN: Positive bowel sounds; soft, nondistended, and nontender. No hepatosplenomegaly or other masses. SPINE: Straight. CVA: No tenderness. MUSCULOSKELETAL: No swollen joints or bony pain. SKIN: No rashes, petechia, or bruises. NEUROLOGIC: Mental status is normal.
CVA|cerebrovascular accident|CVA|173|175|DOB|She was very confused. She lost her urine. Her daughter helped her into the bathroom, and at that time, they noticed her left leg - she was having to drag it. She has had a CVA in the past; this affected her right side. The patient's daughter states she is still not doing well today and brings her into the clinic.
CVA|cerebrovascular accident|CVA.|147|150|ASSESSMENT/PLAN|I cannot rule out a small TIA. Could be a combination of both. The treatment will be the same. She is already on aspirin for TIA from her previous CVA. Obviously we will hold the 70/30 insulin and monitor glucoses with q.i.d. Accu-Chek and sliding scale coverage as needed. There is no evidence of any cardiac etiology or obvious infection to account for her symptoms.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|LUNGS: Clear to auscultation bilaterally. ABDOMEN: Positive pain with palpation in all quadrants, particularly when palpated with hands, but less so when palpated with stethoscope. No rebound, no rigidity, no CVA tenderness, no lymphadenopathy. SKIN: No rashes. NEUROLOGIC: Cranial nerves II-XII are intact. ADMISSION LABS: White blood cell count 9.3 with 77% neutrophils, hemoglobin 15.1, hematocrit 44.4, platelets 389.
CVA|costovertebral angle|CVA|160|162|PHYSICAL EXAMINATION ON ADMISSION|LUNGS: Diffuse end-expiratory wheezes. ABDOMEN: Distended and slightly tympanitic. Positive bowel sounds. Nontender. No masses or hepatosplenomegaly. SPINE: No CVA tenderness. There is some tenderness in the mid to lower back. SKIN: There is an inflamed and warm area over the right foot and ankle.
CVA|costovertebral angle|CVA|152|154|PHYSICAL EXAMINATION|ABDOMEN: Positive bowel sounds. She is slightly tender on the right upper quadrant, no rebound, no guarding. BACK: She is tender on the right flank and CVA area. However, also tender throughout her back including from her shoulders down. EXTREMITIES: No edema. DP pulses are palpable. CT of her abdomen was unremarkable.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. RIGHT CHEST WALL OVER TISSUE EXPANDER: Negative for masses, tenderness or skin changes. LEFT BREAST: She has some nodularity that she states is relatively stable.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: No masses, tenderness, skin, nipple or areolar changes. ABDOMEN: Without hepatosplenomegaly, masses, or tenderness.
CVA|costovertebral angle|CVA|176|178|PHYSICAL EXAMINATION|SKIN without rashes or sore. NEURO: Cranial nerves II-XII are intact. Reflexes are within normal limits. Strength is grossly normal. Gait not tested. BACK is without spinal or CVA tenderness. LABORATORY: Includes a white count of 900, absolute neutrophil count 600, hemoglobin 10.2, platelets 49,000, INR 1.22, PTT 38.
CVA|costovertebral angle|CVA|195|197|PHYSICAL EXAMINATION|LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: Right chest wall and left breast negative for mass, tenderness, skin, nipple or areolar change.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: Bilateral chest wall negative for masses, tenderness or changes.
CVA|costovertebral angle|CVA|141|143|SERVICE|The patient is afebrile. Head: Alopecia, no rhinorrhea, no sores or erythema of oropharynx. Genital: Normal female, Tanner stage 1. Back: No CVA tenderness. Lymphatics: Minimal femoral lymphadenopathy. No cervical lymphadenopathy. Musculoskeletal: Normal strength in upper and lower extremities. Skin: No rashes or sores. Neuro: Cranial nerve are grossly intact as is light sensation.
CVA|costovertebral angle|CVA|176|178|PHYSICAL EXAMINATION|Belly was soft, nondistended. He did have hyperactive bowel sounds in all 4 quadrants. He was slightly tender in the midepigastrium. He had no paraspinous muscle tenderness or CVA tenderness. There was no edema on the extremities or trunk. No skin rash. Strength was 5 out of 5 throughout with normal knee jerk reflexes.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Grade II/VI murmur. BREASTS: No masses, tenderness, skin, nipple or areolar changes. ABDOMEN: Without hepatosplenomegaly, masses, or tenderness.
CVA|cerebrovascular accident|CVA|154|156|REVIEW OF SYSTEMS|GI: shows no diarrhea or constipation. GU: Unremarkable. SKIN: No rashes, but there is bruising. MUSCULOSKELETAL: Significant as above. NEURO: History of CVA with some weakness in both legs. PSYCHE: History of depression. PHYSICAL EXAMINATION: GENERAL: The patient is a well- developed female with good mental status, alert and oriented x3.
CVA|costovertebral angle|CVA|144|146|PHYSICAL EXAMINATION|Thus I think her surgeon needs to look at that again. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: Bilateral chest wall is tender. She has lymphedema on the left chest wall.
CVA|cerebrovascular accident|CVA.|180|183|PHYSICAL EXAMINATION|The patient has 2+ reflexes bilaterally with the exception of an absent ankle jerk bilaterally. Gait is wide based with short steps. The patient has a spastic gait due to previous CVA.
CVA|cerebrovascular accident|CVA|231|233|PAST MEDICAL HISTORY|Cardiovascular: History of a myocardial infarction but no specific history of heart failure but does state he has had PND, orthopnea and a prior vasovagal event. ALLERGIES: Penicillin (GI upset and hives). PAST MEDICAL HISTORY: 1. CVA in 2003 after percutaneous transluminal coronary angioplasty leading to dysphagia. 2. Diabetes mellitus. 3. Atherosclerotic coronary artery disease, status post non________ myocardial infarction with two stents placed in his right coronary artery.
CVA|costovertebral angle|CVA|214|216|PHYSICAL EXAMINATION|PULMONARY exam shows lungs are clear. CARDIOVASCULAR exam demonstrates regular rate and rhythm. BREAST exam is negative. ABDOMEN is soft with no palpable masses. No rebound or guarding. No localized tenderness. No CVA tenderness. Exam of the EXTREMITIES shows peripheral pulses to be bilaterally symmetrical and intact. NEUROLOGIC exam shows deep tendon reflexes to be 2+/4+ and symmetrical.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: Bilateral chest wall over implants negative for masses, tenderness, skin changes.
CVA|cerebrovascular accident|CVA.|138|141|HOSPITAL COURSE|Cardiology recommended enoxaparin for anticoagulation, and I suspect he will likely be on Coumadin given his significant risk factors for CVA. Echocardiogram did not demonstrate any significant valvular lesions, but did demonstrate significant left ventricular dysfunction as mentioned above. The patient was transferred to Fairview Southdale Hospital by Cardiology on _%#MMDD2005#%_ for consideration of coronary angiogram.
CVA|costovertebral angle|CVA|210|212|PHYSICAL EXAMINATION|ABDOMEN: soft, normoactive bowel sounds, diffuse tenderness to minimal palpitation, pain worse in right upper quadrant. There is no guarding. Rebound, Murphy sign, pulsatile mass, or hepatosplenomegaly. GU: no CVA or suprapubic tenderness. SKIN without rash and edema. NEUROLOGIC: alert and oriented X3. Strength 5/5 X4 extremities. LABORATORY DATA: WBC 16.1, hemoglobin 12.1 (down from 16 months ago), hematocrit 37.7, platelet count 582, 93% neutrophils, 4% lymphocytes, 2% monocytes, 1% basophils.
CVA|costovertebral angle|CVA|188|190|BACK|ABDOMEN: Positive bowel sounds. Soft, nontender, and no mass palpable. BREAST: Normal anatomy. GU: I did not palpate any inguinal lymphadenopathy. BACK: Spine: No anatomic deformities. No CVA tenderness. LYMPHATICS: Palpable, indurated lymphadenopathy in the left axillary area, 6 x 4 cm approximately, attached to underlying tissue, nonmobile.
CVA|cerebrovascular accident|CVA.|177|180|HOSPITAL COURSE|The patient did have a headache during her hospitalization as noted and did get a CT of her head which was negative for any intracranial hemorrhage or any acute process such as CVA. An EKG to evaluate the lightheadedness showed normal sinus rhythm at 64 and was read as a normal EKG. The patient had normal hemogram and basic metabolic panel throughout her hospitalization.
CVA|cerebrovascular accident|CVA,|242|245|ASSESSMENT|Urine showed some white cells with clumps and many bacteria. Urine culture is pending. ASSESSMENT: A _%#1914#%_ with left lower quadrant pain, mass, and guaiac positive stool, dementia, depression, abdominal aortic aneurysm, tibial fracture, CVA, seizures, and hypertension. PLAN: She has well-documented DNR/DNI in her chart, and this has been signed recently by nurse with power of attorney.
CVA|cerebrovascular accident|CVA,|270|273|IMPRESSION AND PLAN|Obviously symptoms are consistent with an acute cerebrovascular accident. There is no bleed on the CT scan and the preliminary report of the MRI showed a right acute brain infarct and no evidence of bleeding. Definitely atrial fibrillation is the highest risk for acute CVA, also the severe hypertension. We will keep the patient on heparin at this time after 5 hours of onset of symptoms and being on heparin for few hours now, he is not a candidate for tissue plasminogen activator (tPA) and the risk from thrombolytics definitely outweighs the benefit at this time, and this was discussed and agreed by Dr. _%#NAME#%_ _%#NAME#%_ from Neurology service.
CVA|costovertebral angle|CVA|188|190|PHYSICAL EXAMINATION|Peripheral pulses diminished in the ankles. LYMPHATIC: No lymphadenopathy in cervical, supraclavicular, axillary, epitrochlear or inguinal areas. MUSCULOSKELETAL: No spinal tenderness. No CVA tenderness. SKIN: Limited skin examination. No petechiae, ecchymosis, no rash. NEUROLOGIC: Alert and oriented. Mental status normal and appropriate.
CVA|cerebrovascular accident|CVA.|188|191|HISTORY OF PRESENT ILLNESS|Diagnosis was that of hyponatremia. As that was corrected to a serum sodium of 129, her confusion improved. Also, as part of her evaluation, she was found to have a cerebellar hemorrhagic CVA. Serial CT exams were performed. There was no enlargement or mass, and therefore she did not require surgical intervention.
CVA|cerebrovascular accident|CVA|330|332|PAST MEDICAL HISTORY|She was admitted for UTI, possible urosepsis, but also for increased level of care and now needing a nursing home. PAST MEDICAL HISTORY: Major diagnoses include hypertension, pulmonary hypertension, legally blind from ischemic optic neuropathy, hypothyroidism, depression, atrial fibrillation, CHF, breast cancer, TIAs, dementia, CVA on at least 2 different occasions, hallucinations and delusions. PAST SURGICAL HISTORY: Include left breast mastectomy, thyroid surgery and cataract removal.
CVA|costovertebral angle|CVA|189|191|PHYSICAL EXAMINATION|CARDIAC: Cardiac exam regular rate and rhythm; S1, S2 are heard; no murmurs, rubs or gallops. ABDOMEN: Soft with positive bowel sounds, nontender, nondistended. SPINE: Significant for left CVA tenderness. NEUROLOGIC: Negative for any significant cranial nerve deficits. MUSCULOSKELETAL: Does reveal right ankle Charcot foot deformity and the left foot is dressed for a chronic wound at this time.
CVA|cerebrovascular accident|CVA|110|112|FAMILY HISTORY|She is married and is accompanied by her husband today. She is retired. FAMILY HISTORY: Father had an embolic CVA and mother had pancreatic cancer. CARDIAC RISK FACTORS: Positive for hypertension and obesity as well as age and postmenopausal.
CVA|costovertebral angle|CVA|198|200|PHYSICAL EXAMINATION|NECK: No lymphadenopathy. LUNGS: Clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm, S1, S2. ABDOMEN: Bowel sounds positive, nontender, nondistended. BACK: She had some left CVA tenderness. EXTREMITIES: No edema. LABORATORY DATA: Urine hCG is negative. Urinalysis showed 12 white cells, 7 red cells, few bacteria, many calcium oxylate crystals and 6 squamous epis.
CVA|costovertebral angle|CVA|212|214|PHYSICAL EXAMINATION|HEENT: He has very poor dentition. As above, there is evidence of for some bleeding in his left lower gum area. LUNGS: Clear. CARDIAC: Regular rate and rhythm without murmurs. ABDOMEN: Soft, obese, nontender, no CVA tenderness. GU: A Foley catheter is in place. EXTREMITIES: Lower extremity exam reveals no edema. Pulses are intact. NEUROLOGIC: He is alert, oriented to person.
CVA|cerebrovascular accident|CVA|148|150|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Respiratory distress. HISTORY OF PRESENT ILLNESS: This pleasant 76-year-old female, known to our service with a history of a prior CVA with chronic right-sided hemiparesis and expressive aphasia, chronic dizziness, chronic left lower extremity pain as well as asthma versus COPD; presents to the ER with some respiratory difficulties. She lives in a group home and reports being short of breath for the past few days.
CVA|cerebrovascular accident|CVA|177|179|PAST MEDICAL HISTORY|4. Hypertension. 5. History of vascular dementia. 6. Rheumatoid arthritis. 7. Anemia of chronic disease. 8. Osteoarthritis of left knee. 9. History of DVT. 10. History of right CVA in 1998. 11. Hyperlipidemia. 12. Distant history of gastric ulcers. 13. Colonoscopy in 2000 showed diverticulosis. 14. Hemoptysis in _%#MM#%_ of 2006, at that time felt to be secondary to bronchitis.
CVA|costovertebral angle|CVA|163|165|PHYSICAL EXAMINATION UPON ADMISSION|No accessory muscle use. ABDOMEN: Soft, nontender, nondistended and no organomegaly. GENITOURINARY: Tanner 1 normal female external genitalia. SPINE: Straight. No CVA tenderness. SKIN: No rashes. Skin is warm and dry. MUSCULOSKELETAL: Full range of motion of all 4 extremities. No joint swelling or pain with palpation. NEUROLOGIC: Face is symmetric.
CVA|cerebrovascular accident|CVA.|265|268|FAMILY HISTORY|5. Multiple vitamin one daily. 6. Yesterday, was started on prednisone 60 mg t.i.d. FAMILY HISTORY: Please see copy of my H&P transcript dictated on _%#MMDD2007#%_, it is on chart. Basically, the family history includes mother deceased at 76, she died from embolic CVA. Father deceased at 60 of brain hemorrhage. Five sisters, one of them has hyperlipidemia. Two children, one son and one daughter. Her daughter lives in town and works for Cargill.
CVA|cerebrovascular accident|CVA.|151|154|PAST MEDICAL HISTORY|No history available from the patient. REVIEW OF SYSTEMS: Cannot be obtained. PAST MEDICAL HISTORY: 1. Insulin-dependent diabetes mellitus. 2. CHF. 3. CVA. 4. Aphasic. 5. Hypothyroidism. 6. GERD. 7. Hypertension. 8. History of urosepsis in the past. ALLERGIES: Quinolone, Cipro, Levaquin and Avelox.
CVA|cerebrovascular accident|CVA|209|211|PHYSICAL EXAMINATION ON ADMISSION|ABDOMEN: Soft, nondistended and unable to appreciate any organomegaly due to fussiness with exam. Normoactive bowel sounds. GU: Normal male external genitalia, Tanner stage 1. SPINE: Straight with no apparent CVA tenderness. SKIN: No rashes or jaundice. EXTREMITIES: Warm and well perfused. LABORATORY DATA ON ADMISSION: CBC showed a white count of 16.6, hemoglobin 11, platelets 536,000 with a differential 67% neutrophils, 22% lymphocytes and 10% monocytes.
CVA|cerebrovascular accident|CVA,|169|172||_%#NAME#%_ _%#NAME#%_ is a 78-year-old who was admitted with chest pain, shortness of breath, and radiation of her discomfort to the jaws. She had a remote history of a CVA, hypertension, and she has had unsteadiness and wobbliness at home walking. She was admitted on _%#MMDD#%_ and subsequently had coronary angiography.
CVA|costovertebral angle|CVA|203|205|PHYSICAL EXAMINATION|Pharynx is unremarkable; she has dentures, with just a few intact teeth at the lower alveolar ridge. No cervical nodes, no JVD, no neck rigidity. Lungs are clear, with no E to A changes. Back is without CVA tenderness, it is supple. Heart: She has a soft systolic ejection murmur, no gallop, no displacement of the PMI. Abdomen is soft, positive bowel sounds, no organomegaly, tenderness or masses.
CVA|cerebrovascular accident|CVA|143|145|PAST MEDICAL HISTORY|No recent complaints of fever, nausea, vomiting, diarrhea or other symptoms. The patient denies pain. PAST MEDICAL HISTORY: 1. Left hemisphere CVA and secondary right-sided weakness. CVAs in 1993 and 1995. 2. Coronary artery disease. 3. Recurrent pulmonary embolus and deep venous thromboses with inferior vena cava filter in place and on Coumadin.
CVA|costovertebral angle|CVA|135|137|PHYSICAL EXAMINATION|HEENT: Atraumatic, PERRL. Mouth is moist, neck is supple, thyroid not enlarged. BACK: Back and spine are palpably nontender. He has no CVA tenderness. LUNGS: Clear to percussion and auscultation. HEART: Cardiac rhythm is now regular, PMI laterally displaced about 1 cm. There is a normal S1 and S2; an S4 is present.
CVA|cerebrovascular accident|CVA.|142|145|FAMILY HISTORY|2. Tubal ligation in 1977 at North Memorial Medical Center. FAMILY HISTORY: Her father died at 65 of sudden death. He did have a history of a CVA. Her mother had multiple sclerosis and died of a CVA in 1986. She has two brothers. One brother has known atherosclerotic heart disease treated by stenting at age 59.
CVA|costovertebral angle|CVA|198|200|PHYSICAL EXAMINATION ON ADMISSION|Lungs: fair air exchange, positive expiratory wheezes, diffuse rhonchi, positive E:A changes on the left middle and lower regions. Abdominal examination: soft and nontender, nondistended. Spine: no CVA tenderness. Lymphatics: no lymphadenopathy. Skin: no cyanosis, clubbing, or edema. No bruising. Neurological examination: no focal deficits. LABS ON ADMISSION: White count 8.8, hemoglobin 12.4, platelets 198, MCV 89, 95% neutrophils, 4% lymphocytes, 1% monocytes.
CVA|cerebrovascular accident|CVA.|119|122|HISTORY OF PRESENT ILLNESS|The patient has had a known 50% bifurcation stenosis increasing to 85% by ultrasound. He has had no symptoms of TIA or CVA. He is now on aspirin therapy and scheduled for elective carotid endarterectomy. He currently denies any GU, GI or respiratory or infectious symptoms.
CVA|cerebrovascular accident|CVA.|179|182|IMPRESSION|IMPRESSION: 1. Bilateral carpal tunnel syndrome. 2. Essential hypertension. 3. Hypothyroidism. 4. Non-insulin-dependent diabetes mellitus. 5. Hypercholesterolemia. 6. Status post CVA. 7. Right bundle branch block.
CVA|cerebrovascular accident|CVA,|269|272|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. COPD. 2. Osteoporosis. 3. History of apparent intolerance due to Fosamax (constipation), therefore on Miacalcin Nasal Spray. 4. DJD. 5. Intermittent atrial fibrillation, no recent symptoms. 6. Ongoing tobacco abuse. 7. Scoliosis. 8. TIA versus CVA, the patient cannot recall any residual or significant neurological events. 9. Hypertension. 10. Anxiety disorder. 11. Hyperlipidemia.
CVA|costovertebral angle|CVA|172|174|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: TMs normal. Thyroid normal. Lungs clear. Normal first and second heart sounds. No rubs, murmurs, or extra sounds. Tender right upper quadrant, 2+. No CVA tenderness. Normal bowel sounds. He is eating, liquids. No calf or thigh tenderness. No icterus. No regional adenopathy. ASSESSMENT: Acute biliary colic with ultrasound. Evidence of multiple gallstones, but no evidence of either hepatobiliary obstruction or thickening of the gallbladder wall.
CVA|costovertebral angle|CVA|195|197|OBJECTIVE|SKIN: no rashes or concerning lesions noted. CARDIOVASCULAR: regular S1 and S2, no murmur, gallop, or rub noted. LUNGS: bilaterally clear to auscultation, no wheezes, rhonchi, or rales. BACK: no CVA or spinal tenderness. BREASTS: bilaterally symmetric, no masses or nodules felt, no nipple retraction or skin changes. ABDOMEN: normal active bowel sounds, soft, non-tender, no hepatosplenomegaly, no masses noted.
CVA|costovertebral angle|CVA|189|191|PHYSICAL EXAMINATION|Carotids full without bruits. ABDOMEN: Normal bowel sounds. Soft and nontender. No masses, no hepatosplenomegaly. Multiple abdominal and truncal lipomas. GU/RECTAL: Deferred. BACK: Without CVA tenderness. EXTREMITIES: Normal form, no edema. Bilateral bunions. NEUROLOGICAL EXAM: Cranial nerves II-XII are intact. Motor intact. Deep tendon reflexes normoactive throughout.
CVA|costovertebral angle|CVA|167|169|PHYSICAL EXAMINATION ON ADMISSION|Heart rate is regular, with no murmurs. Abdomen is soft, non-tender, non-distended. GU examination reveals the testes descended and uncircumcised. There is no obvious CVA tenderness. Skin reveals no rash. Neuro: He is fussy, but alert. LABORATORY DATA ON ADMISSION: Urinalysis shows 10-25 WBC's, 0-2 RBC's, positive leukocyte esterase, negative nitrite.
CVA|cerebrovascular accident|CVA|171|173|FAMILY HISTORY|Hyperlipidemia. Hypertension. Obesity. FAMILY HISTORY: Father died at 55 of myocardial infarction and had one at 44 from a heart rupture, sounds like an aneurysm. Mother, CVA died at age 83 with hyperlipidemia. ALLERGIES: Penicillin and Novocain
CVA|cerebrovascular accident|CVA|165|167|REVIEW OF SYSTEMS|Lower extremities no swelling or color change. No pain symptoms. Neurology: no headache and no change in the level of consciousness. No confusion and no symptoms of CVA or TIA. Constitutional: no fevers or chills. PHYSICAL EXAMINATION: VITAL SIGNS: Upon presentation blood pressure 188/74, pulse 60, respiratory rate 20, temperature orally 97.5 and oxygen sat on room air 90%.
CVA|costovertebral angle|CVA|134|136|PHYSICAL EXAMINATION|His bowel sounds are normal. He does have a G-tube its site is clean, dry, and intact. His spine is straight. There is no evidence of CVA tenderness. His skin is without rashes. His neurological exam reveals normal muscle strength and tone. His reflexes are symmetric bilaterally. His gait is normal. LABORATORY EXAMINATION ON ADMISSION: Reveals a hemoglobin of 13.4, platelet count of 271,000, white count of 5.7 with 64% neutrophils, 35% lymphocytes, and 1% monocytes.
CVA|cerebrovascular accident|CVA|243|245|ASSESSMENT|ASSESSMENT: Two episodes of TIA affecting the left vision, question bilateral left hemianopsia versus blindness in the left eye, accompanied also by some numbness and at least clumsiness in the left arm. Some risk with her mother having had a CVA but only at advanced age. This woman also apparently with hypercholesterolemia, on treatment for that, with a past history of coronary vessel disease and angioplasty was well as abdominal aortic aneurysm repair, all within the last few years and, of course, an MI.
CVA|costovertebral angle|CVA|206|208|ADMISSION PHYSICAL EXAMINATION|CARDIOVASCULAR: regular rate and rhythm; 3/6 ejection murmur at left sternal border. LUNGS: Bibasilar rales; no wheeze. ABDOMEN: non-distended; normoactive bowel sounds; non-tender. SPINE/CVA: straight; no CVA tenderness. LYMPHATICS: No lymphadenopathy. 2+ right lower extremity edema; at baseline, after hip fracture three years ago; +1 in left lower extremity.
CVA|costovertebral angle|CVA|177|179|PHYSICAL EXAMINATION|Abdomen: Normal, bowel sounds are present. Abdomen is soft without rebound or guarding. There is no palpable hepatosplenomegaly or masses. Spine: Straight with no deformity. No CVA tenderness. Skin: No rash. Neurologic: The patient is alert and oriented x3, appropriate for age. Cranial nerves II through XII are intact. He has 5+/5 strength in bilateral upper and lower extremities.
CVA|cerebrovascular accident|(CVA)|192|196||The patient does have a past history of idiopathic hypertrophic subaortic stenosis (IHSS) and atrial fibrillation. He was hospitalized in _%#MM#%_ of this year with a cerebrovascular accident (CVA) involving a left field cut, likely an embolic CVA. He apparently had no chest pain and this was restricted to shortness of breath on exertion.
CVA|costovertebral angle|CVA|210|212|OBJECTIVE|Fundi are sharp bilaterally. Tympanic membranes are clear. Nasal mucosa within normal limits. Oral cavity is without erythema or exudate. NECK: Is supple. No adenopathy or thyromegaly is present. BACK: Is will CVA or spinal tenderness. LUNGS: Were clear to auscultation. No rales, rhonchi or wheezing is present. CHEST: Without lesions CARDIOVASCULAR: Regular rate and rhythm, no murmurs, gallops are appreciated.
CVA|cerebrovascular accident|CVA,|334|337|HOSPITAL COURSE|She came to the hospital for evaluation. HOSPITAL COURSE: The patient was treated for lower extremity edema, thought to be due to venous insufficiency, with a combination of diuretic therapy and external compression. She was treated for her chronic obstructive pulmonary disease with the usual measures, anticoagulation for her prior CVA, and with her usual treatment program for her schizophrenia. She was stable throughout her stay. She was transferred to the rehab unit, with the aim of returning her to her independent living status.
CVA|cerebrovascular accident|CVA.|157|160|PAST MEDICAL HISTORY|She has had no recent injuries. PAST MEDICAL HISTORY: Her past medical history is significant for: 1. Polymyalgia rheumatica. 2. Hypertension. 3. History of CVA. 4. Osteoporosis. 5. Status post lumbar compression fractures, most recently of L3. 6. Blindness. 7. Coronary artery disease, status post coronary artery bypass.
CVA|costovertebral angle|CVA|214|216|PHYSICAL EXAMINATION|Extraocular motions intact. Fundi sharp bilaterally. TM's are clear. Nasal mucosa within normal limits. Oral cavity without erythema or exudate. NECK: Supple, no adenopathy or thyromegaly is present. BACK: Without CVA or spinal tenderness. CHEST: Lungs are clear. No wheezes, rales or rhonchi present. BREASTS: Without masses. She does have a few lesions present just inferior to her right breast, as well as along the inferior right breast margin itself, some inflamed apocrine glands.
CVA|cerebrovascular accident|CVA.|248|251|PROBLEM #5|She received bowel prep. The patient did well postoperatively and was advanced to a regular diet without difficulty. PROBLEM #5: Genitourinary. The patient had difficulty remembering to do her peri-cares given her neurologic deficits following her CVA. Thus she was able to get up appropriately and go to the bathroom. However, she was not able to perform her own peri-cares, and decision was made to transfer her to a nursing home for more intensive supervision, and aid, as there was a worry that she would be unable to care for her peri-cares herself.
CVA|cerebrovascular accident|CVA|146|148|ASSESSMENT|CBC was normal. Troponin and EKG were normal. ASSESSMENT: 1. New onset of seizure disorder, probably related to small-vessel disease and/or small CVA suffered in the past. There is no evidence of acute neurologic problems based on current CT scan. 2. Fracture dislocation of left humerus probably related to either the seizure or fall from the seizure.
CVA|costovertebral angle|CVA|212|214|OBJECTIVE|Extraocular motion intact. Fundi sharp bilaterally. TMs are clear. Nasal mucosa within normal limits. Oral cavity without erythema or exudate. NECK: Supple. No adenopathy or thyromegaly is present. BACK: Without CVA or spinal tenderness. LUNGS: Clear. No rales, rhonchi, or wheezing is present. Chest without lesions. CARDIOVASCULAR: Regular rate, rhythm. No murmurs or gallops are appreciated.
CVA|cerebrovascular accident|CVA|225|227|PAST MEDICAL HISTORY|2. The patient is status post CVA in _%#MM#%_ 1997 with residual motor deficit in the left hand with digits 1 through 3. 3. The patient also notes recently that she has had excessive salivation. 4. Carpal tunnel syndrome. 5. CVA as delineated above. 6. Meniere's disease. 7. Diabetic neuropathy. As delineated above. 8. Diabetic retinopathy. As delineated above. PAST SURGICAL HISTORY: 1. Total knee arthroplasty, _%#MMDD2003#%_, by Dr. _%#NAME#%_.
CVA|costovertebral angle|CVA|141|143|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Otherwise negative. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. NECK: Supple, no masses. BACK: Normal spinal curvature, no CVA tenderness. HEART: S1, S2. No S3, S4, no murmur. Regular rhythm. CHEST: Clear to auscultation. ABDOMEN: Contains a term intrauterine pregnancy in the vertex presentation.
CVA|costovertebral angle|CVA|147|149|PHYSICAL EXAMINATION|Lungs are clear to auscultation bilaterally. Abdomen: Positive epigastric tenderness to palpation, nondistended, obese. Bowel sounds x4. Spine: No CVA tenderness. Skin: No rashes. Neuro: Cranial nerves II-XII are intact. LABORATORY: White blood cell count 10.7, hemoglobin 16.2, hematocrit 47.6, platelet count 299, 77% neutrophils.
CVA|costovertebral angle|CVA|166|168|PHYSICAL EXAMINATION|The ABDOMINAL EXAM shows bowel sounds are present. The abdomen is soft and nontender. No mass or hepatosplenomegaly noted. No hernia is noted. The BACK exam shows no CVA tenderness. EXTREMITIES show full range of motion. No bone, joint, or soft tissue abnormalities are apparent. NEUROLOGIC exam shows poor memory, otherwise no problems noted there.
CVA|cerebrovascular accident|CVA.|35|38|REASON FOR HOSPITALIZATION|REASON FOR HOSPITALIZATION: TIA vs CVA. PAST MEDICAL HISTORY: 1. Cardiovascular disease. She has had myocardial infarctions twice, stenting times two with her most recent myocardial infarction although I do not have dates.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: Bilateral chest wall negative for masses, tenderness, skin changes.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: Bilateral chest wall has healing incisions. ABDOMEN: Without hepatosplenomegaly, masses, or tenderness.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: Bilateral chest wall negative for masses, tenderness or skin changes.
CVA|costovertebral angle|CVA|131|133|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Negative. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. NECK: Supple, no masses. BACK: Normal spinal curvature. No CVA tenderness. HEART: S1, S2, no S3 or S4, no murmur, regular rhythm. CHEST: Clear to auscultation. ABDOMEN: The abdomen contains a term intrauterine pregnancy with the baby's head in the left upper quadrant.
CVA|costovertebral angle|CVA|146|148|PHYSICAL EXAMINATION|NECK: Supple without lymphadenopathy or thyromegaly. HEART: Regular without murmurs, rubs, gallops. LUNGS: Clear bilaterally. BACK: No midline or CVA tenderness. ABDOMEN: Has a previous surgical scar that is well-healed, soft, nontender, no hepatosplenomegaly and positive bowel sounds. EXTREMITIES: No clubbing, cyanosis or edema. GENITOURINARY: Rectal exam was done in the Emergency Department and was guaiac positive.
CVA|cerebrovascular accident|CVA|137|139|FAMILY HISTORY|14. Percocet 1-2 tablets q.4-6h. p.r.n. for pain. DRUG ALLERGIES: None. FAMILY HISTORY: Heart disease on her father's side, father had a CVA at age 67. Mother has diabetes. There is no cancer in the family. SOCIAL HISTORY: The patient is single. She has no children.
CVA|costovertebral angle|CVA|265|267|PHYSICAL EXAMINATION|HEAD: Normocephalic. NECK: Supple without adenopathy. LUNGS: Clear. CARDIOVASCULAR: 2/6 systolic murmur (this is an old finding that dates back to age 15). ABDOMEN: Soft with very slight right lower quadrant tenderness. He has no guarding and no rebound. He has no CVA tenderness. White count is slightly elevated at 10,000. IMPRESSION: Early acute appendicitis with tenderness localized to the right lower quadrant, now a consistent finding between both the emergency room and myself.
CVA|cerebrovascular accident|CVA|286|288|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 83-year- old female who currently is hospitalized on senior treatment program for the evaluation of depression with suicidal ideation. I have been asked to see her by Dr. _%#NAME#%_ to assess medical problems including history of CVA x2, hypertension, and hypothyroidism. Please see Dr. _%#NAME#%_'s notes in the chart for details regarding the patient's psychiatric history and circumstance that led to admission.
CVA|costovertebral angle|CVA|124|126|EXAMINATION|She has experienced no right flank pain and is seeing no gross hematuria. EXAMINATION: The patient is afebrile. There is no CVA tenderness, and her abdomen is flat and nontender. ASSESSMENT: Possible right UPJ stone. This could be either calcium or uric acid.
CVA|cerebrovascular accident|CVA|235|237|HISTORY OF PRESENT ILLNESS|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD CONSULTANT: _%#NAME#%_ _%#NAME#%_, MD REASON FOR CONSULTATION: ICU management. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 84-year-old nursing home patient who is status post CVA with dense left hemiparesis and inability to eat. She is maintained in a nursing home on G-tube feedings. She was brought to the Emergency Room with depressed mental status, hypotension, fever and hypoxia, also complaints of abdominal pain.
CVA|cerebrovascular accident|CVA.|153|156|PAST MEDICAL HISTORY|He was placed on Plavix and Coumadin. 2. He presented again in _%#MM2006#%_ with dysphasia and dysarthria. At that time, he had a left lateral medullary CVA. He had a left Horner's syndrome. A PEG was placed. He was eventually discharged on a regular diet with thick liquids.
CVA|cerebrovascular accident|CVA,|126|129|CHIEF COMPLAINT|REASON FOR CONSULTATION: Asked to see the patient by Dr. _%#NAME#%_ _%#NAME#%_ for Rehab consultation. CHIEF COMPLAINT: Right CVA, status post right lung transplant. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 59-year-old male who underwent right lung transplant on _%#MMDD2002#%_.
CVA|cerebrovascular accident|CVA,|143|146|REASON FOR CONSULTATION|I think she used to smoke cigarettes, but quit almost 40 years ago. She's a little bit difficult to get a history from, I think because of the CVA, but basically I think has been found on a swallow study here to have aspiration despite being NPO, I think she was sneaking some fluid or liquid and yesterday complained of shortness of breath and increased cough.
CVA|cerebrovascular accident|CVA|238|240|HISTORY|I was asked by Dr. _%#NAME#%_ to see Mr. _%#NAME#%_ for his known diagnosis of stage 3 non-small cell lung cancer. HISTORY: _%#NAME#%_ _%#NAME#%_ is an 83-year-old gentleman who was admitted on the _%#DD#%_ of _%#MM#%_ with an acute left CVA and currently has right hemiparesis, with aphasia, with a slow recovery. He was discharged from the hospital on _%#MM#%_ _%#DD#%_, at which time he underwent elective wedge resection of the right lower lobe lesion and the pathology revealed a _____ adenocarcinoma with positive ____ node.
CVA|cerebrovascular accident|CVA.|253|256|PAST MEDICAL HISTORY|She denies any pain previous to this. She denies any loss of consciousness, chest pain, shortness of breath with the fall. PAST MEDICAL HISTORY: 1. ASCVD. 2. Severe aortic stenosis. 3. Chronic renal insufficiency. 4. Chronic anemia. 5. Hypertension. 6. CVA. 7. Hyperlipidemia. 8. Spinal stenosis. ALLERGIES: Penicillin. MEDICATIONS: Medications are reviewed and documented in the chart.
CVA|costovertebral angle|CVA|135|137|PHYSICAL EXAMINATION|No thyromegaly. Lungs: Clear. Cardiovascular: Regular rate and rhythm without murmur. Abdomen: Soft, obese, and nontender. There is no CVA tenderness. Extremities: No sign of recent injury. Neurologic: Difficult to assess secondary to language barrier. She is calm and cooperative. She is not tremulous. There is no rigidity.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: Bilateral chest wall over implants show healing nipple reconstruction, otherwise negative.
CVA|cerebrovascular accident|CVA.|173|176|PAST MEDICAL HISTORY|MRI of the brain on _%#MMDD2005#%_ revealed mild atrophy of the brain, moderate white matter changes consistent with sequelae of small vessel ischemic disease, and no acute CVA. 3. Hypertension. 4. I am not aware of a history of coronary artery disease. 5. History of mild hyponatremia. 6. Questionable history of atrial fibrillation.
CVA|cerebrovascular accident|CVA,|118|121|REVIEW OF SYSTEMS|HABITS: He smokes a pack of cigarettes a day. He drinks alcohol on occasion. REVIEW OF SYSTEMS: Negative for any TIA, CVA, hemoptysis, hematemesis, hematochezia, melena, bright red blood per rectum, recent unexplained weight loss, dyspnea on exertion, orthopnea, PND, claudication, peripheral edema, or skin rash.
CVA|cerebrovascular accident|CVA|230|232|ASSESSMENT|The significance of the history that the patient has not been taking his medications reliably for the last few days is not clear. I certainly doubt that the syncopal episode represented either a primary neurologic event such as a CVA or seizure or a primary cardiac event. The patient currently feels quite well and feels ready to be discharged back to the Lodging Plus unit.
CVA|cerebrovascular accident|CVA|135|137|REASON FOR CONSULTATION|She was admitted to Northland Regional Health Care Hospital with CVA. She had left arm weakness and visual changes. CT showed vascular CVA in the right posterior parietal area which was consistent with her symptoms. She also had Q waves in the inferior leads and elevated troponin, and was believed to have an MI at the same admission.
CVA|cerebrovascular accident|CVA|124|126|CHRONIC DISEASE/MAJOR ILLNESS|3. Ulcerative colitis, status post total colectomy in 1980 with satisfactory bowel function since that time. 4. Status post CVA with minimal residual; initially he had expressive aphasia and mild right upper extremity weakness. 5. The patient denies any history of hypertension, diabetes, cardiac or pulmonary disease.
CVA|cerebrovascular accident|CVA|198|200|CHRONIC DISEASE/MAJOR ILLNESSES|2. Coronary artery disease. Bypass grafts done in 1976 and 1991 with an angiogram last time in 1997. 3. Type 2 diabetes mellitus. Maintained on insulin. 4. Longstanding hypertension. 5. Status post CVA ten years ago with evidence of multi-vessel ischemic vascular disease on MRI of brain done at the Mayo Clinic in _%#MM#%_. 6. Status post right carotid endarterectomy. 7. Status post cholecystectomy and appendectomy.
CVA|cerebrovascular accident|CVA|156|158|ASSESSMENT|ASSESSMENT: 1. Dementia with agitation. 2. Renal insufficiency. This appears stable. 3. Hypertension under great control. 4. Hyperlipidemia. 5. Status post CVA and patent ductus arteriosis, with goal INR of 2 to 2.5 per my recommendations. PLAN: We will recheck the INR tomorrow. Also will check a TSH and T-4, secondary to the patient's TSH being elevated in the past.
CVA|costovertebral angle|CVA|130|132|PHYSICAL EXAMINATION|There is no mass or fullness. There is no costochondral tenderness that I can elicit at this time on the ribs or on the spine. No CVA or spinal tenderness. She has no cyanosis, clubbing, or edema. She is oriented times three moving well. LABORATORY DATA: Normal LFT's.
CVA|cerebrovascular accident|CVA.|231|234|FAMILY HISTORY|She lives alone. MEDICATIONS: Glyburide, lisinopril, metformin, Zetia and Azmacort. ALLERGIES: REPORTED TO CRESTOR, LIPITOR AND LEVAQUIN (NAUSEA AND DIARRHEA) FAMILY HISTORY: Positive for vascular disease in a daughter, possibly a CVA. REVIEW OF SYSTEMS: Is as noted above, plus a 40 pound weight loss over the last 6-12 months, of unclear etiology.
CVA|cerebrovascular accident|CVA.|131|134|IMPRESSION|This is consistent with a left hemisphere old TIA. He has multiple risk factors for cerebrovascular disease and a history of prior CVA. The chart mentions a history of atrial fibrillation, which would justify the Coumadin treatment. However, the past charts available through 2006 do not indicate any atrial fibrillation on his EKGs.
CVA|costovertebral angle|CVA|196|198|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: 1. Depression, suicidal ideation, substance dependence. Per Dr. _%#NAME#%_. 2. Urinary tract infection. The patient reports frequency, urgency yesterday. The patient has some CVA tenderness on the right side today. The patient is started on Cipro 250 mg b.i.d. times three days on _%#MMDD2003#%_. The patient reports some resolution in symptoms since beginning this medication yesterday.
CVA|costovertebral angle|CVA|127|129|PHYSICAL EXAMINATION|Her suprapubic area was somewhat tender to palpation but the remainder of her abdominal exam was relatively benign. She had no CVA tenderness. EXTREMITIES: No lower extremity cyanosis, clubbing, or edema. SKIN: No rash. ADMISSION LABORATORY DATA: White count 15.1. Hemoglobin 11.2. Platelets 292.
CVA|costovertebral angle|CVA|124|126|PHYSICAL EXAMINATION|HEART: Regular rate and rhythm without murmurs, rubs or gallops, normal S1 and S2, no S3 or S4 present. ABDOMEN: She has no CVA tenderness bilaterally. Abdomen is obese with positive bowel sounds, nondistended. She has tenderness to palpation over the mid epigastrium and the right upper quadrant without any rebound or guarding.
CVA|costovertebral angle|CVA|289|291|PHYSICAL EXAMINATION|Normal respiratory effort. HEART: Regular rate and rhythm. She has about a 2/6 systolic murmur, best heard in the left sternal border, without any radiation. No S3 or S4 is present. ABDOMEN: Soft, with positive bowel sounds, nondistended, nontender to palpation, no hepatosplenomegaly, no CVA tenderness. EXTREMITIES: Warm. She has 1+ edema bilaterally. Her left hip has deformity noted. She has palpable dorsalis pedis and posterior tibial pulses. LABORATORY DATA: She has absolutely no labs that have been done, nor does she have an EKG done.
CVA|cerebrovascular accident|CVA|185|187|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Significant for the above-mentioned problems. He does have a history of atherosclerotic heart disease with prior stent placement. Apparently, he developed a small CVA at the time of the stent placement, but has had a fairly complete recovery. SOCIAL HISTORY: He is widowed and lives in an assisted-living situation.
CVA|cerebrovascular accident|CVA|158|160|DOB|A CT of the brain was unremarkable. EKG and troponin were consistent with an infarct which revealed itself to be a minor MI and the question of an associated CVA was then raised. There has been no note of seizure activity. The patient has been on Diprivan which has been only recently stopped.
CVA|cerebrovascular accident|CVA|79|81|PAST MEDICAL HISTORY|She did not have any trauma to her head or elsewhere. PAST MEDICAL HISTORY: 1. CVA about one year ago. 2. Hypertension. 3. Type 2 diabetes mellitus. 4. Glaucoma. 5. Status-post cholecystectomy. 6. Osteoporosis. 7. Status-post hemorrhoidectomy. 8. Arthritis involving the knee and back.
CVA|cerebrovascular accident|CVA,|346|349|PAST MEDICAL HISTORY|However, upon my review of records in this patient that I have seen in clinic in the aftermath of her CVA, she has had previous complaints of headache which have brought her to the hospital and to the clinic in the past year. PAST MEDICAL HISTORY: Notable for depression, coronary artery bypass, pulmonary emboli, hysterectomy, appendectomy, and CVA, as well as diverticulitis. She has had pacemaker placement and coronary stenting. She is married, is a homemaker, she smokes half a pack of cigarettes a day.
CVA|cerebrovascular accident|CVA.|165|168|REVIEW OF SYSTEMS|As noted she has calf cramping on the right with walking which was relieved with rest. She has some difficulty hearing and speaking at times related to her previous CVA. She has had some limiting arthritis of the knees. Otherwise is per HPI or negative. FAMILY HISTORY: Notable mainly for coronary disease in her father in his 60s and a brother.
CVA|cerebrovascular accident|CVA.|161|164|ASSESSMENT AND PLAN|CBC was totally unremarkable. ASSESSMENT AND PLAN: 1. Behavioral issues, which seem consistent with the patient's apparent organic brain disorder related to his CVA. 2. History of hypertension. He is normotensive presently without the use of any antihypertensive medications. We will continue to monitor and make additions as indicated.
CVA|cerebrovascular accident|CVA|193|195|PAST MEDICAL HISTORY|In the Emergency Room his blood pressure was 115/75. He has a rapid pulse at 110. PAST MEDICAL HISTORY: Notable for panhypopituitarism after pituitary tumor resection, obstructive sleep apnea, CVA with left hemiparesis, UTI, GERD, appendectomy, total left hip arthroplasty and left knee arthroplasty, TURP vasectomy. Carotid ultrasound on _%#MM2007#%_ showing no significant carotid stenosis.
CVA|cerebrovascular accident|CVA|152|154|PAST MEDICAL HISTORY|She has not been responding very well to chemotherapy and now returns to the Radiation Oncology Clinic for further management. PAST MEDICAL HISTORY: 1. CVA in 1993 with resultant right-sided hemiparesis. 2. Significant memory loss since stroke. 3. CHF. 4. Hypertension. MEDICATIONS: 1. Norvasc 5 qd. 2. Lasix 40 qid.
CVA|cerebrovascular accident|CVA|186|188|REVIEW OF SYSTEMS|He is relatively anxious, but is more so about his incisional pain. He has had no bleeding history. He has had no recent productive cough, wheeze or hemoptysis. He has had no history of CVA or TIA symptoms. The remainder of the review of systems is otherwise as per HPI or noncontributory. STUDIES: Blood pressure 120-130 systolic, pulse 60. Monitor demonstrates underlying sinus rhythm with either sinus dysrhythmia or fairly frequent PACs.
CVA|costovertebral angle|CVA|259|261|PHYSICAL EXAMINATION|HEART: Regular rhythm. ABDOMEN: Is soft, non-tender, no organomegaly. EXTREMITIES: No clubbing, cyanosis or edema. LYMPHATIC: No lymphadenopathy in cervical, supraclavicular, axillary, epitrochlear or inguinal areas. MUSCULOSKELETAL: No spinal tenderness, no CVA tenderness. SKIN: Limited skin examination, no particular ecchymosis, no rash. NEUROLOGIC: Awake, less alert than normal, appropriate. She has generalized weakness, no focal deficit.
CVA|cerebrovascular accident|CVA,|202|205|PAST  MEDICAL HISTORY|PAST MEDICAL HISTORY: Has been well outlined on previous consultations but include: 1. Moderate obesity. 2. History of systemic lupus erythematosus - SLE. 3. Borderline diabetes. 4. Previous history of CVA, which resolved uneventfully. 5. There is a vague history of congestive heart failure in the past, although old records are not available to document.
CVA|cerebrovascular accident|CVA|143|145|PAST MEDICAL HISTORY|He tells me that he has not had any cardiac issues previously. PAST MEDICAL HISTORY: He does have the following past medical history: 1. Right CVA x2. 2. Osteoarthritis. 3. Hypertension 4. Hyperlipidemia. 5. Mild to moderate dementia. 6. Gastroesophageal reflux disease. 7. Diabetes mellitus.
CVA|cerebrovascular accident|CVA,|241|244|ASSESSMENT|ASSESSMENT: 1. Senile dementia, most likely Alzheimer's type, with secondary period of agitation and intercurrent depression. 2. History of atrial fibrillation, maintained on anticoagulation therapy. 3. Medical record revealing a history of CVA, but no CT scan confirmation of this. 4. History of hypertension, per review of medical record. 5. History of BPH, status post TURP. 6. Weight loss, probably due to poor dietary practice related to his dementia, I suspect.
CVA|cerebrovascular accident|CVA,|205|208|IMPRESSION AND PLAN|His troponins are marginally elevated and he has S segment depression. He should be managed invasively. The risk of coronary angiography and percutaneous revascularization including but not limited to MI, CVA, death, peripheral vascular injury, allergic reaction were explained in detail to the patient. I also explained to him that there is a small possibility he may require coronary artery bypass surgery.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: She has fullness in the area of the biopsy in her left breast at 3 o'clock.
CVA|cerebrovascular accident|CVA,|302|305|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Type 1 diabetes mellitus, onset at age 28 complicated by peripheral neuropathy, retinopathy with laser treatments and end-stage renal disease. 2. Dilated cardiomyopathy. 3. Coronary artery disease. 4. Hypertension. 5. Erectile dysfunction, status post penile implant. 6. Right CVA, _%#MM2004#%_. 7. History of peripheral vascular disease and bilateral foot ulcers. 8. Right hand fracture, 2006. 9. Right wrist fracture. 10.Right meniscectomy complicated by hematoma of his knee for osteoarthritis.
CVA|cerebrovascular accident|CVA.|202|205|PAST  MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Recent hospital stay for bradycardia and hypotension due to medications. 2. She had a herniated disk surgery. 3. Alzheimer's dementia. 4. Pernicious anemia. 5. Hypertension. 6. CVA. 7. She had at least 2 abdominal operations judging by the scars on her abdomen. CURRENT MEDICATIONS: 1. Actonel weekly. 2. Aspirin 81 mg.
CVA|cerebrovascular accident|CVA|179|181|PAST MEDICAL HISTORY|The patient had had a fall prior to admission and this actually prompted the hospital evaluation. PAST MEDICAL HISTORY: Relevant for metastatic prostate cancer. The patient had a CVA three years ago. There had been a history of back pain, hypertension, coronary artery disease, atrial fibrillation, hyperlipidemia.
CVA|cerebrovascular accident|CVA,|146|149|FAMILY HISTORY|9. Presently she has IV morphine, Toradol and Dilaudid ordered p.r.n. 10. Zofran 4 mg IV q.6 hours p.r.n., nausea. FAMILY HISTORY: Remarkable for CVA, hypertension, heart disease on paternal side. HABITS: She is a 1/2 to 1 pack per week smoker.
CVA|cerebrovascular accident|CVA|189|191|HISTORY OF PRESENT ILLNESS|She had also had an MRI/MRA, which showed small vessel ischemic disease with focused stenosis of the right proximal ICA, mild to moderate of the left ICA. There was no evidence of an acute CVA event.
CVA|cerebrovascular accident|(CVA)|169|173|PAST MEDICAL HISTORY|5. Open reduction and internal fixation (ORIF). 6. Tonsillectomy and adenoidectomy. 7. Previous apparent transient ischemic attack (TIA) and/or cerebrovascular accident (CVA) requiring support for ambulation. ADMISSION MEDICATIONS: Home medications include: 1. Lopid. 2. Colace.
CVA|cerebrovascular accident|CVA.|87|90|FAMILY HISTORY|He does not drink alcohol and his caffeine use is mild. FAMILY HISTORY: Father died of CVA. Mother died with history of breast cancer and CVA. One brother died of lung cancer. One brother died of an myocardial infarction.
CVA|costovertebral angle|(CVA)|188|192|PHYSICAL EXAMINATION|She has had no previous stones or problems with urinary tract infections (UTI). At the present time she is pain-free. PHYSICAL EXAMINATION: On examination, she has no costovertebral angle (CVA) tenderness. She is afebrile. PLAN: We discussed that fact that spontaneous passage of this stone is very likely and she will very likely be dismissed later today on pain medications to be seen in our office in follow-up.
CVA|cerebrovascular accident|CVA.|182|185|HISTORY OF PRESENT ILLNESS|The patient otherwise feels well. He denies any fever, chills, cough, melena, bright red blood per rectum, abdominal pain or discomfort, or neurologic symptoms. No history of TIA or CVA. No recent bleeding or motor vehicle accident. No significant weight change or skin changes. REVIEW OF SYSTEMS: Otherwise negative.
CVA|cerebrovascular accident|CVA.|52|55||The patient has the diagnosis of right hemi after a CVA. The patient is seen on rounds. Treatment continues. The patient had a fall over the weekend, with no injuries. The patient was seen with therapist. The patient is able to put a puzzle together.
CVA|cerebrovascular accident|CVA|9|11|PROBLEM|PROBLEM: CVA right hemi-cognitive changes. The patient was seen on rounds. No new problems. Notes dermatitis in his right leg not responding to Keflex.
CVA|costovertebral angle|CVA|157|159|PHYSICAL EXAMINATION|No rubs or gallops are noted with murmur as above. ABDOMEN: Soft with positive bowel sounds, nondistended, nontender to palpation, no hepatosplenomegaly, no CVA tenderness. EXTREMITIES: Warm on the left, a little bit cooler on the right side and he has dopplerable pulses in the right lower extremity.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. BREASTS: She has some lymphedema in her left breast, otherwise exam is routine.
CVA|costovertebral angle|CVA|187|189|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.4, pulse 120, respirations 22. Blood pressure 100/54. GENERAL: She is alert and does appear to be in pain. ABDOMEN: Pregnant. She has no CVA tenderness. She does have more low back tenderness. EXTREMITIES: No lower extremity tenderness. ASSESSMENT/PLAN: Left-sided pain. Question if this is due to renal colic.
CVA|costovertebral angle|CVA|195|197|PHYSICAL EXAMINATION|LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. ABDOMEN: Without hepatosplenomegaly, masses, or tenderness. The patient has normal bowel sounds.
CVA|cerebrovascular accident|CVA|237|239|HISTORY OF PRESENT ILLNESS|She woke up with the above complaint, and called her daughter and was brought to the University of Minnesota Medical Center, Fairview. Her workup has included a CT scan of the head and MRA which has shown her to have a silent left-sided CVA and a new small right cerebellar CVA. Her abdominal CT scan also showed her to have diverticulosis. She apparently had a fall at home on her left side when out any loss of consciousness.
CVA|cerebrovascular accident|CVA|186|188|PHYSICAL EXAMINATION|MUSCULOSKELETAL: He is able to move upper extremities fairly well. Lower extremities have limited range of motion. NEUROLOGIC: He is oriented x1, he is confused secondary to status post CVA and dementia. ADVANCED DIRECTIVE: The patient is currently DNR/DNI. PERTINENT LABORATORY DATA: Sodium 142, potassium 3.5, creatinine 1.24, BUN 22.
CVA|cerebrovascular accident|CVA|164|166|PAST MEDICAL HISTORY|She was brought to the emergency room where radiographs showed the above abnormalities. PAST MEDICAL HISTORY: Otherwise notable for emphysema. She has a history of CVA in 1991. She has a history of easy bleeding secondary to being on Plavix because of her CVA. She has had a fracture of her left humerus. She has a history of stress incontinence.
CVA|costovertebral angle|CVA|154|156|PHYSICAL EXAMINATION|Abdomen: Positive bowel sounds. Mild diffuse abdominal tenderness in all 4 quadrants. It is nondistended and soft with no organomegaly, no masses, and no CVA tenderness. Extremities: No clubbing, cyanosis, or edema. Neurological: Cranial nerves II-XII are grossly intact. Sensation is intact to light touch. Strength 5/5 bilaterally. Reflexes 1+ bilaterally.
CVA|cerebrovascular accident|CVA.|191|194|FAMILY HISTORY|13. Citrucel 1 tablespoon q.a.m. 14. BuSpar 10 mg 2 tablets t.i.d. 15. Amaryl 2 mg 2 tablets q.a.m. FAMILY HISTORY: Paternal grandfather with cancer. Mother with pacemaker. Grandmothers with CVA. HABITS: Prior 2-pack-per-day smoker, has since cut down.
CVA|costovertebral angle|CVA|175|177|PHYSICAL EXAM|EYES: Pupils equal, round, reactive to light. Sclerae are clear. PHARYNX: No oral ulcerations. NECK: Supple, no cervical or supraclavicular nodes, no sentinel nodes. BACK: No CVA tenderness spinous process tenderness or SI joint tenderness. CHEST: Clear. HEART: S1 and S2 without murmurs. ABDOMEN: Nondistended, active bowel sounds, soft and nontender, no Murphy's sign.
CVA|costovertebral angle|CVA|240|242|PHYSICAL EXAMINATION|Otherwise, looks normal. Bowel sounds are present. EXTREMITIES: No clubbing, cyanosis or edema. LYMPHATIC: No lymphadenopathy in cervical, supraclavicular, axillary, epitrochlear or inguinal areas. MUSCULOSKELETAL: No spinal tenderness, no CVA tenderness. SKIN: Limited skin examination, no particular ecchymosis, no rash. NEUROLOGIC: Nonfocal. ANCILLARY DATA: Blood counts are normal, creatinine 1.4, BUN 32, potassium 3.6.
CVA|costovertebral angle|CVA|227|229|PHYSICAL EXAMINATION|HEART: Regular rate and rhythm without murmurs or gallops. ABDOMEN: Pear-shaped, scars present from hysterectomy and open cholecystectomy. Positive bowel sounds heard throughout. Abdomen is soft and nontender, nondistended, no CVA tenderness. MUSCULOSKELETAL: The patient has joint tenderness and some limited range of motion of the lower back and right knee. No swelling present, steady gait. VASCULAR: The patient has no carotid bruits, no aortic bruits, no ankle edema.
CVA|cerebrovascular accident|CVA|241|243|IMPRESSION|2. Diverticuli noted but no diverticulitis. 3. Abdominal wall hernia but not apparently obstructed or incarcerated. 4. Enlarge common bile duct but no abnormalities of lipase or liver function tests. 5. No evidence for posterior circulation CVA (coronary vascular disease). 6. No offensive medications. 7. No alcohol or NSAID (nonsteroidal anti-inflammatory drug) use. 8. Overall, if possible this is just gastroenteritis possibly transmitted by her daughter who apparently is in the hospital.
CVA|cerebrovascular accident|CVA|138|140|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Significant for the following: 1. Hypertension. 2. Hyperlipidemia. 3. History of atrial fibrillation. 4. History of CVA with complete resolution. 5. Left carotid artery stenosis 70%. 6. History of right thigh hematoma with drainage surgery a few months ago.
CVA|cerebrovascular accident|CVA|516|518|PAST MEDICAL HISTORY|She reports she has had some weight gain. She admits to dietary indiscretion. PAST MEDICAL HISTORY: Significant for total colectomy and ileostomy secondary to Crohn's, ORIF left hip, cholecystectomy, and a C-section x2, VRE in the stool, history of myocardial infarction, type 2 diabetes on oral hypoglycemic agents and chronic renal impairment on hemodialysis, hypertension, hyperlipidemia, osteoporosis, afib, degenerative joint disease, chronic bicarbonate loss from ileostomy, tobacco use, COPD and history of a CVA and history of a solitary kidney, congestive heart failure and an aortic aneurysm. MEDICATIONS: Admission included Entocort, fish oil, Gemfibrozil, glipizide, hydroxyzine, hyoscyamine, Isosorbide, loperamide, Magnesium oxide, Remeron, Nephrocaps, Niaspan, Phoslo, prednisone, B12 injections monthly, Zetia, allopurinol, Ambien, aspirin, Epogen, Calcium with vitamin D, Coreg and Creon.
CVA|cerebrovascular accident|CVA,|17|20|CHIEF COMPLAINT|CHIEF COMPLAINT: CVA, gastroesophageal reflux disease exacerbated by morbid obesity. HISTORY OF PROBLEM: _%#NAME#%_ _%#NAME#%_ is a 36-year-old female referred by her primary-care physician, Dr. _%#NAME#%_ _%#NAME#%_ of Fairview _%#CITY#%_ Clinic.
CVA|cerebrovascular accident|CVA.|146|149|HISTORY OF PRESENT ILLNESS|He was seen at Community Hospital and transferred to University of Minnesota Medical Center, Fairview. CT evaluation revealed a right hemorrhagic CVA. MRI was positive again for right frontoparietal hemorrhage. He was loaded with Dilantin and Ativan for seizures and rehab evaluation was done.
CVA|costovertebral angle|CVA|150|152|PHYSICAL EXAMINATION|Estimated fetal weight was 10-11 pounds. CERVICAL EXAM: Performed earlier by the family practice physicians; please refer to this note. BACK: Without CVA tenderness bilaterally. EXTREMITIES: Lower extremities with trace edema bilaterally and reflexes normal bilaterally. LABORATORY DATA: Documented in the chart and include a hemoglobin of 8.6 today.
CVA|cerebrovascular accident|CVA.|164|167|SUMMARY|He was re-admitted this time because of a seizure secondary to subtherapeutic levels of Dilantin. His neurologic examination is consistent with his left hemisphere CVA. CT scan of the head shows no acute changes. His initial blood work reveals no other abnormalities. I feel that his seizure was secondary to subtherapeutic Dilantin.
CVA|cerebrovascular accident|CVA,|192|195|PAST MEDICAL HISTORY|The patient has no prior cardiac history and denies dyspnea on exertion, orthopnea, palpitations, edema, or chest discomfort. PAST MEDICAL HISTORY: 1. Seizure disorder as above. 2. History of CVA, 2001. Also a history of TIAs in 1999. 3. Hypertension. 4. Degenerative joint disease. 5. Osteoporosis with history of vertebral fracture.
CVA|cerebrovascular accident|CVA.|168|171|CHIEF COMPLAINT|REASON FOR CONSULTATION: Asked to see patient by Dr. _%#NAME#%_ _%#NAME#%_ from Neurology for rehab evaluations. CHIEF COMPLAINT: Status post left posterior branch MCA CVA. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 78-year-old male who was admitted to Fairview-University Hospital on _%#MMDD2002#%_.
CVA|cerebrovascular accident|(CVA)|190|194|REASON FOR CONSULTATION|REASON FOR CONSULTATION: I am asked by Dr. _%#NAME#%_ to evaluate _%#NAME#%_ _%#NAME#%_ for left upper extremity infection. Mr. _%#NAME#%_ is 83 years old. He had a cerebrovascular accident (CVA) and a fall on _%#MMDD2001#%_ and was found to have left hemiparesis. He is admitted at this time because his hemiparesis was increasing.
CVA|cerebrovascular accident|CVA|160|162|MEDICATIONS|ALLERGIES: No known drug allergies. MEDICATIONS: 1. Accupril 20 mg po qday. 2. Low molecular weight Heparin and Coumadin. (The patient was on aspirin after his CVA but had not been taking this for the past few months). FAMILY HISTORY: Notable for chronic obstructive pulmonary disease and congestive heart failure in his father and mother respectively.
CVA|cerebrovascular accident|CVA|209|211|PAST MEDICAL HISTORY|7. History of atypical chest pain with negative cardiac evaluation in the past. 8. History of cardiogenic syncope, status post pacemaker placement for treatment. 9. Hypothyroidism. 10. Questionable history of CVA in the past with secondary disequilibrium. Recent past. CT scan done during hospitalization at Methodist showed no definitive infarct on her CT, however.
CVA|cerebrovascular accident|CVA|159|161|CHRONIC DISEASE/MAJOR ILLNESSES|ALLERGIES: None. MEDICATIONS: Listed in the current orders. CHRONIC DISEASE/MAJOR ILLNESSES: 1. History of progressive dementia over the past year with recent CVA approximately a month ago complicated also by recent seizure disorder likely related to underlying CVA. 2. Type II diabetes mellitus. 3. Hypertension. 4. History of aspiration with secondary dietary change.
CVA|cerebrovascular accident|CVA|219|221|PAST MEDICAL HISTORY|Physical and occupational therapy consults are underway. As she is below her functional baseline, a physical medicine and rehab consult was requested. PAST MEDICAL HISTORY: 1. Multiple strokes. In 1993, she had a right CVA with left-sided weakness. She was admitted to subacute rehab at Maranatha Care Center. She was then transferred to St. Teresa's Care Center. She was going to be discharged to assisted-living in 1996 when she had a second CVA.
CVA|cerebrovascular accident|CVA|246|248|CHIEF COMPLAINT|TLC consulted to work with the patient and family on goals of care and advanced care planning. Consult requested purpose is to the patient secondary to his nonsmall cell lung carcinoma and having pulmonary emboli also developed a left hemisphere CVA ischemic stroke, which has left the patient with right-sided paralysis, as well as expressive aphasia. Family needs some discussion of goals of care and advanced care planning.
CVA|costovertebral angle|CVA|152|154|PHYSICAL EXAMINATION|HEART: Regular rate and rhythm without murmurs or rubs. ABDOMEN: Pear-shaped. Positive bowel sounds heard throughout. Soft, nontender, nondistended. No CVA tenderness. VASCULAR: No carotid bruits, no aortic bruits, good distal pulses bilaterally. No pitting ankle edema noted. EXTREMITIES: Full range of motion of all joints.
CVA|costovertebral angle|CVA|208|210|PHYSICAL EXAMINATION|Bowel sounds are present. EXTREMITIES: No clubbing, cyanosis or edema. LYMPHATIC: No lymphadenopathy in cervical, supraclavicular, axillary, epitrochlear or inguinal areas. SKELETAL: No spinal tenderness. No CVA tenderness. GENITALIA: Normal external genitalia. No testicular masses. NEUROLOGICAL: Sensory and motor are grossly intact. SKIN: No petechiae, ecchymosis or rash. ANCILLARY DATA: CT scan of the chest shows no evidence of pulmonary embolus.
CVA|cerebrovascular accident|CVA|170|172|FAMILY HISTORY|No environmental exposures. No pets, no hobbies, no travel. He received a flu vaccine in the last year and a Pneumovax in the last year. FAMILY HISTORY: Father died from CVA at age 83. Mother died with diabetes at age 80. No history of lung disease. He has a brother with prostate cancer who died and another brother who has coronary artery disease.
CVA|costovertebral angle|CVA|209|211|PHYSICAL EXAMINATION|NECK: Supple. LYMPH NODES: No anterior cervical, posterior cervical, supraclavicular, axillary or inguinal adenopathy. LUNGS: Normal breath sounds to auscultation and percussion. No rhonchi or rales. BACK: No CVA or vertebral tenderness. HEART: Regular rhythm without murmurs or gallops. ABDOMEN: Without hepatosplenomegaly, masses, or tenderness. The patient has normal bowel sounds.
CVA|cerebrovascular accident|CVA|225|227|HISTORY OF PRESENT ILLNESS|She denies any history of fever. She has had occasional cough and a slight blood-tinged hemoptysis but none for the past 3 days. She denies any abdominal pain or discomfort, melena, bright red blood per rectum. No history of CVA or TIA or neurological changes. She denies any recent trauma or surgery. She denies any history of kidney or liver disease, bowel or bladder disorder.
CVA|costovertebral angle|CVA|237|239|PHYSICAL EXAMINATION|VITAL SIGNS: Normal with a blood pressure of 155/69, respirations 18 and temperature 97.7. HEENT: No scleral icterus. CHEST: Clear to auscultation. ABDOMEN: Protuberant with some mild right subcostal tenderness, no peritonitis. BACK: No CVA tenderness. EXTREMITIES: There is no calf tenderness. She appears to have had knee surgery on the right side. LABORATORY DATA: The patient's amylase is elevated at 216, lipase of 2,169, and her sed rate is elevated at 86.
CVA|costovertebral angle|CVA|115|117|ASSESSMENT AND PLAN|Her abdomen is soft and flat and her midline wound is being packed with wet to dry gauze and is clean. There is no CVA tenderness or complaints of pain. Her ultrasound last night shows moderate bilateral hydronephrosis which I assume is related to refluxing ureteral anastomoses.
CVA|costovertebral angle|CVA|128|130|PHYSICAL EXAM|MEDICATIONS: Lisinopril. LABORATORY DATA: Urinalysis revealed microhematuria. Previous creatinine was 1.3. PHYSICAL EXAM: Right CVA tenderness with radiation to his right groin area. No peritoneal signs noted, no shortness of breath. External genitalia and extremities are normal.
CVA|costovertebral angle|CVA|209|211|PHYSICAL  EXAMINATION|LUNGS: Clear to auscultation. No use of accessory muscles of respiration. COR: S1, S2 normal. No S3, S4 or murmur. ABDOMEN: Soft, nontender. No mass or hepatosplenomegaly. Bowel sounds normal. EXTREMITIES: No CVA punch tenderness, 2+ ankle edema bilaterally. For further details of the patient's history, please refer to the chart.
CVA|cerebrovascular accident|CVA.|162|165|PAST MEDICAL HISTORY|5. Three toes amputated from right foot for Staph infection. 5. Previous MRSA colonization. 6. Atrial fibrillation. 7. History of GI bleed. 8. DJD. 9. History of CVA. 10. GERD. ALLERGIES: Novocain. SOCIAL HISTORY: Married and lives at home. REVIEW OF SYSTEMS: Unobtainable.
CVA|cerebrovascular accident|CVA,|165|168|PAST MEDICAL HISTORY|She did undergo a repeat MRI scan. PAST MEDICAL HISTORY: Significant for having had a previous lumbar decompression approximately 20 years ago. She has a history of CVA, hypertension, bilateral lumpectomies, and right oophorectomy. MEDICATIONS: At the time of admission include: 1. Ecotrin.
CVA|cerebrovascular accident|CVA|146|148|PAST MEDICAL HISTORY|His original disease was polycystic kidney disease. He is status post bilateral native kidney nephrectomy. There is a history of hypertension and CVA in the past. He has a history of degenerative joint disease. He has been on Celebrex. He is status post right total knee arthroplasty. He has no medical allergies.
CVA|cerebrovascular accident|CVA,|272|275|PAST MEDICAL HISTORY|She denies any loss of consciousness. She does not report that she does have any new visual problems with the exception of the left old visual field cut or she does not describe any balance problems, falls or any other new issues. PAST MEDICAL HISTORY: Includes seizures, CVA, pacemaker, CHF, UTI, subdural hematomas. I am not sure why she is on Risperdal and Effexor. It may include depression with psychotic features. SOCIAL HISTORY: Shows she is on the waiting list for assisted living but apparently there is someone who is staying in her home now.
CVA|cerebrovascular accident|CVA.|143|146|IMPRESSION/PLAN|At this time the patient's beta blocker is on hold. Will continue to hold this. This could be a possible CNF component in a setting with a new CVA. The patient did develop the bradycardia following a fosphenytoin injection. She also has her Digoxin on hold, would continue to monitor.
CVA|cerebrovascular accident|CVA.|279|282|ASSESSMENT|ECG - This shows sinus bradycardia, biatrial enlargement, partial right bundle branch block, left anterior hemiblock, and probable LVH by voltage criteria with some nonspecific ST segment changes consistent with LVH. ASSESSMENT: This is a 38-year-old patient who presents with a CVA. She does not have any other known sources of CVA, and it is likely that this is due to a cardiac embolism.
CVA|costovertebral angle|(CVA)|205|209|PHYSICAL EXAMINATION|She has no abdominal or chest pain right now. HEENT: Sclerae: Anicteric. Mucosal membranes are moist. Hearing and vision are good. CHEST: Nontender. LUNGS: Lungs move air well. BACK: Costovertebral angles (CVA) are nontender. ABDOMEN: Abdomen is full but soft and nontender with no guarding or rebound. ULTRASOUND: Ultrasound is reviewed with the radiologist. This shows a large gallbladder but no stones.
CVA|cerebrovascular accident|CVA|124|126|FAMILY HISTORY|No seasonal allergies. ALLERGIES: Codeine and LATEX. FAMILY HISTORY: Father died of carcinoma in his 70's. Mother died of a CVA at age 76; she also had a myocardial infarction. REVIEW OF SYSTEMS: Other review of systems - She is unaware of snoring.
CVA|cerebrovascular accident|CVA.|188|191|HISTORY OF PRESENT ILLNESS|She was seen by neurology. She was noted to have right hemiparesis and dysarthria. MRI and the rest of the workup for stroke are pending at this time. She is presumed to have a left-sided CVA. Physical occupational and speech therapy consults are pending. As she is below her functional baseline, a physical medicine and rehab consult was requested.
CVA|cerebrovascular accident|CVA,|288|291|PAST MEDICAL HISTORY|HISTORY OF PRESENT ILLNESS: This patient is a 44-year-old male who is a patient of Dr. _%#NAME#%_ and voluntarily presented secondary to recent exacerbation of psychosis versus paranoid schizophrenia. PAST MEDICAL HISTORY: 1. Psychosis versus paranoid schizophrenia. 2. Right hemispheric CVA, 2003. PAST SURGICAL HISTORY: Hernia repair x2 in 1980.. The patient denied seizures, HIV, hepatitis or other major medical problems.
CVA|cerebrovascular accident|CVA|148|150|ASSESSMENT|Potassium 4.4. Chloride 106. Bicarbonate 25. BUN 36. Creatinine 1.75. Glucose 88. ASSESSMENT: The patient is a _%#1914#%_ female, status post right CVA with left hemiparesis, dysphagia, and cognitive deficits. RECOMMENDATIONS: 1. Mobility. Continue PT as you are. 2. Dependent activities of daily living.
CVA|cerebrovascular accident|CVA|186|188|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: As you know Mr. _%#NAME#%_ is a Mr. A 550-year-old gentleman with a history of drug abuse who has been admitted to the hospital after sustaining a cerebellar CVA secondary to cocaine-induced hypertensive hemorrhagic secondary to hypertensive hemorrhage crisis. The patient had hydrocephalus and shunt placement. He was transferred to acute rehab for continued care.
CVA|costovertebral angle|(CVA)|180|184|PHYSICAL EXAMINATION|LUNGS: Lungs move air fairly well. ABDOMEN: Soft and nontender with minimal right flank and right lower quadrant discomfort. No intra-abdominal masses. BACK: Costovertebral angles (CVA) are nontender. EXTREMITIES: Legs move well. There are peripheral pulses. There is minimal edema of the legs. CT SCAN: CT scan reveals retroperitoneal fluid collection, probably a hematoma.
CVA|cerebrovascular accident|CVA|126|128|HISTORY|The patient had some evidence of congestive heart failure on admission, which has been relieved. In the distant past, she had CVA syndrome. She is status post cholecystectomy. She had fracture of the left arm a year ago. In 1996, she had a left mastectomy. Through all of these problems, the patient has continued doing well.
CVA|costovertebral angle|CVA|191|193|PHYSICAL EXAMINATION|I don't detect thyromegaly. There are no carotid bruits. Lungs: Clear. Cardiovascular: reveals a regular rate and rhythm without murmurs. Abdomen: Soft, non-tender. There is no suprapubic or CVA tenderness. Extremities: Reveals no edema. There is no clubbing. Neurologically: She is sleepy, but easily alerts and is superficially pleasant.
CVA|cerebrovascular accident|CVA|177|179|PAST MEDICAL HISTORY|On presentation, the patient was breathing rapidly and oxygen was administered and antibiotics started. PAST MEDICAL HISTORY: 1. Type 2 diabetes. 2. Hypertension. 3. History of CVA with right hemiplegia and expressive aphasia in 2001. 4. History of aspiration pneumonia. 5. Depression. 6. Left artificial eye.
CVA|cerebrovascular accident|CVA.|256|259|FAMILY  HISTORY|13. Vitamin D 400 units daily 14. Fish oil daily. FAMILY HISTORY: Strongly positive for premature coronary artery disease, strokes and diabetes. Mother died at age 79 of CVA. Grandfather had a myocardial infarction in his 80s and another grandfather had a CVA. SOCIAL HISTORY: The patient is currently living with friends. She is active gardening.
CVA|cerebrovascular accident|CVA.|263|266|SOCIAL HISTORY|MEDICATIONS: 1. Gatifloxacin. 2. Morphine p.r.n. 3. Protonics. SOCIAL HISTORY: She lives with her husband independently. She is wheelchair bound due to her neuropathy. FAMILY HISTORY: Obtained from admission history and physical and is history of lung cancer and CVA. REVIEW OF SYSTEMS: General: There are no fevers, chills or sweats.
CVA|cerebrovascular accident|CVA|166|168|FAMILY HISTORY|10. History of vaginal hysterectomy. 11. Gastroesophageal reflux disease. ALLERGIES: Penicillin and Darvocet. FAMILY HISTORY: Positive for lung cancer in her father, CVA in grandfather. SOCIAL HISTORY: The patient is married and lives with her husband in a one-level home in _%#CITY#%_.
CVA|costovertebral angle|CVA|155|157|PHYSICAL EXAMINATION|CARDIOVASCULAR: Regular rate and rhythm without murmurs or rubs. No S3. ABDOMEN: Soft, positive bowel sounds heard throughout, nontender, nondistended. No CVA tenderness. Incision noted from two C-sections. VASCULAR: No carotid bruits. No aortic bruits. Good distal pulses bilaterally. No pitting ankle edema. MUSCULOSKELETAL: Full range of motion of all joints.
CVA|costovertebral angle|CVA|145|147|PHYSICAL EXAMINATION|She did have some periumbilical tenderness, which she had since her panniculectomy surgery but nothing acute per the patient. BACK: She has mild CVA tenderness. EXTREMITIES: 1 edema. NEUROLOGIC: Nonfocal. PSYCHOLOGICAL: Normal mood and affect. LABORATORY DATA: White blood cell count 15, hemoglobin 8.4, hematocrit 25.8, platelet count 354, sodium 141, potassium 4.2, chloride 109, bicarb 26, glucose 132, BUN 22, creatinine 1.3, magnesium 2.4, phosphorus 3.4. Her urinalysis showed small blood, moderate leukocyte esterase, negative nitrates, 113 white blood cells, 34 red blood cells, moderate bacteria.
CVA|costovertebral angle|CVA|150|152|PHYSICAL EXAMINATION|Liver and spleen are not enlarged. There is no palpable fullness or mass. He has no cyanosis, clubbing or edema. SKIN: No liver stigmata. There is no CVA or spinal tenderness. He is alert and oriented times three. LAB DATA: White count 7.5, hemoglobin 12, electrolytes are normal.
CVA|cerebrovascular accident|CVA.|218|221|PAST MEDICAL HISTORY|1. Tonsillectomy and adenoidectomy. 2. Six vessel coronary artery bypass with valve surgery of some type. 3. Some renal artery and possibly iliac artery stents. (Major Diagnosis) 1. PVD. 2. Coronary artery disease. 3. CVA. 4. Hypertension. 5. GERD. 6. Depression. 7. Presbycusis. 8. Prostatism. 9. Bladder neck obstruction. ALLERGIES: Dimetapp. MEDICATIONS: 1. Norvasc 5 mg a day.
CVA|cerebrovascular accident|CVA,|226|229|PAST MEDICAL HISTORY|She clearly, however, is quite debilitated from her underlying tumor and malaise. PAST MEDICAL HISTORY: Dominated by above mentioned lymphoma as well as a history of diabetes mellitus, peripheral vascular disease, status post CVA, retinopathy, angioplasties of the left common iliac and external iliac arteries bilaterally, right common femoral to anterior tibial bypass surgery and I believe a remote history of left breast cancer.
CVA|cerebrovascular accident|CVA|199|201|PAST MEDICAL HISTORY|Echo performed in _%#MM2005#%_ showed a left ventricular ejection fraction of 55%. 3. Chronic renal failure with baseline creatinine of 2.0. 4. Moderate-to-severe rheumatoid arthritis. 5. History of CVA in 2003. 6. History of peptic ulcer disease 33 years ago. 7. History of chronic anemia. 8. Hyperlipidemia. 9. History of liver granulomas. 10. Status post bioprosthetic aortic valve replacement.
CVA|cerebrovascular accident|CVA,|267|270|REASON FOR CONSULTATION|He has an extensive past medical history that is well-outlined in the old chart. He has had proximal atrial fibrillation, renal insufficiency, coronary artery disease, pulmonary hypertension, mitral regurg, hyperlipidemia, peripheral vascular disease, a history of a CVA, pleural effusion of unclear etiology and history of gout as well. MEDICATIONS: Lasix, potassium, Atenolol, Imdur, Norvasc, iron sulfate, Coumadin, aspirin previously.
CVA|cerebrovascular accident|CVA.|204|207||He had a persistent leak and a VATS was considered but he had significant coronary artery disease. Chest tube was removed with plans surrounding this and his anticoagulation had been stopped and he had a CVA. He also had blood in his stool. Workup revealed a sigmoid mass which was noted on biopsy. He was admitted for surgery, canceled secondary to his coronary artery disease.
CVA|cerebrovascular accident|CVA|206|208|IMPRESSION|Her electrolytes show normal sodium, glucose, BUN, and creatinine. Her urine analysis is positive for UTI. IMPRESSION: This lady presents with new onset of neurological deficits which point to left frontal CVA in the MCA distribution causing left gaze preference and right-sided weakness. At this point I will plan to obtain head CT scan to make sure the patient does not have bleed.
CVA|cerebrovascular accident|CVA;|192|195|FAMILY HISTORY|There has been no history of vomiting, heartburn or dysphagia, and as stated above no history of peptic ulcer disease. FAMILY HISTORY: The patient has three living sisters; one sister died of CVA; she had diabetes mellitus and some type of cancer. There is no family history of colonic carcinoma. The patient's wife did have colon cancer.
CVA|costovertebral angle|CVA|177|179|PHYSICAL EXAMINATION|LUNGS: Clear to auscultation. No use of accessory muscles of respiration. ABDOMEN: Soft, nontender, no mass or organomegaly. GENITALIA: Foley catheter in place. EXTREMITIES: No CVA punch tenderness. For further details of the patient's history, please refer to the chart.
CVA|cerebrovascular accident|CVA|114|116|PAST MEDICAL HISTORY|I am now being asked to evaluate this lesion for debridement. PAST MEDICAL HISTORY: Significant for malnutrition, CVA with hemiparesis, hypertension, urinary incontinence, anxiety, multiple aspiration pneumoniae. PAST SURGICAL HISTORY: Spinal surgery, head injury in 1980 and two craniectomies.
CVA|cerebrovascular accident|CVA|225|227|PHYSICAL EXAMINATION|SKIN: There is a healing lesion on the left chest from a recent excisional biopsy by Dermatology for squamous cell cancer. HEENT: There is no scleral icterus. NECK: Supple. NEUROLOGIC: Cranial nerves grossly intact. BACK: No CVA tenderness. CHEST: Clear to auscultation. CARDIOVASCULAR: Regular rhythm without murmur. EXTREMITIES: Warm with good peripheral pulses. ABDOMEN: Exquisitely tender with guarding throughout the lower abdomen and little bit of guarding in the upper abdomen.
CVA|cerebrovascular accident|CVA|188|190|HISTORY|The patient also was found to have a bladder capacity of 674 cc, and he voided 749 cc. On examination today, his abdomen was filled with multiple well-healed abdominal scars. There was no CVA tenderness, no abdominal tenderness, the genital area appeared to be normal. IMPRESSION: Most likely this represents a vesical J-pouch fistula with recurring urinary tract infections.
CVA|cerebrovascular accident|CVA|156|158|REFERRING PHYSICIAN|She is a smoker and has been on estrogen intermittently for several years for menopausal symptoms. No previous history of DVT or clot. No family history of CVA or DVT. PAST MEDICAL HISTORY: 1. DJD of lumbar spine. 2. Depression.
CVA|costovertebral angle|CVA|113|115|PHYSICAL EXAMINATION|During the night, the patient was able to void in amounts up to 150 cc. PHYSICAL EXAMINATION: The patient has no CVA tenderness or abdominal masses. The abdomen is soft and flat. There is a well-healed midline infraumbilical scar that goes nearly to the top of the symphysis pubis.
CVA|cerebrovascular accident|CVA|178|180|PAST MEDICAL HISTORY|Norvasc 5 mg p.o. qd. Nitrostat, Allegra, Advair, Singulair, Albuterol, Prevacid, aspirin, folic acid and vitamin E. PAST MEDICAL HISTORY: Asthma and hypertension. He did have a CVA with thrombolytic therapy. REVIEW OF SYSTEMS: Negative for weight loss, fever, chills. No skin changes.
CVA|cerebrovascular accident|CVA|138|140|PAST  MEDICAL HISTORY|3. TPN dependent. 4. History transient afib. 5. History of iatrogenic Addison's. 6. History of hypercoagulability, history of DVT, PE and CVA status post IVC filter. 7. CVA in 1985 with residual left weakness, greater in her upper extremity versus lower extremity.
CVA|cerebrovascular accident|CVA|176|178|HISTORY OF PRESENT ILLNESS|There were no ventricular arrhythmias. The patient denied shortness of breath. She denied any recent fever, chills, cough or melena. No recent trauma or surgery. No history of CVA or TIA. No bleeding or bright red blood per rectum. She denied any history of lung, kidney or liver disease. Review of systems otherwise noncontributory. PAST MEDICAL HISTORY: No other current or past medical problems.
CVA|costovertebral angle|CVA|164|166|PHYSICAL EXAMINATION|LUNGS: Clear to auscultation bilaterally. ABDOMEN: Positive bowel sounds; soft; tender to palpation the right left upper quadrant. No splenomegaly noted. There was CVA tenderness, although it is difficult to discern if this is radiated pain from her tailbone. EXTREMITIES: Without edema. SKIN: No rashes noted. NEUROLOGIC: Alert and oriented x 3; with cranial nerves II-XII intact.
CVA|cerebrovascular accident|CVA|201|203|PAST MEDICAL HISTORY|INDICATION: We are asked to evaluate the patient for coffee ground emesis as well as a guaiac-positive stool. PAST MEDICAL HISTORY: 1. His pertinent past medical history is remarkable for a history of CVA with right-sided hemiplegia. He has been anticoagulated on Coumadin since. 2. He has a history of atrial fibrillation, once again on Coumadin.
CVA|cerebrovascular accident|CVA|138|140|PAST MEDICAL HISTORY|She is currently on an LP10. PAST MEDICAL HISTORY: 1. MRSA pneumonia treated at Methodist Hospital in _%#MM2005#%_. 2. She has also had a CVA in 2001 with no apparent neurologic residual. 3. She has known aortic valve sclerosis COPD, having just stopped smoking within the last few years.
CVA|costovertebral angle|CVA|196|198|PHYSICAL EXAMINATION|No use of accessory muscles of respiration HEART: Normal S1, S2, no S3, S4 or murmur. ABDOMEN: Soft, nontender, no mass or organomegaly. The patient is four months pregnant. EXTREMITIES: There is CVA punch tenderness on the right. No calf tenderness or pedal edema. For further details of the patient's history, please refer to the chart.
CVA|costovertebral angle|CVA|227|229|PHYSICAL EXAMINATION GENERAL|NECK: Supple, no abnormal palpable lymphadenopathy, no jaundice. THORAX: Symmetric breasts, no palpable mass. LUNGS: Essentially clear. HEART: Regular sinus rhythm. ABDOMEN: Soft and there is no tenderness or palpable mass. No CVA tenderness. No spinal tenderness. EXTREMITIES: Unremarkable. NEUROLOGIC: CNS II-XII within normal limits. No motor or sensory deficit. ASSESSMENT AND PLAN: Tentative diagnosis of the pancreas cancer in the body, encasing the blood vessel with markedly elevated CA19-9.
CVA|cerebrovascular accident|CVA|110|112||She states that she was planning to go to Southdale shopping center yesterday. She is two years status post a CVA and has some left hemiparesis. Her ride did not show up and she, therefore, tried to walk since it was only a few blocks.
CVA|cerebrovascular accident|CVA|230|232|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Dysphagia and hoarseness. HISTORY OF PRESENT ILLNESS: The patient is an 87-year-old male admitted on _%#MMDD2007#%_ with a history of increased difficulty of swallowing and pneumonia. He has had a past history of CVA and TIAs. His recent workup at Fairview Ridges Emergency Room with an MRI/MRA showed decreased vertebral arteries. The remainder of the past medical history, social history, family history and review of systems is as noted in the chart.
CVA|cerebrovascular accident|CVA|46|48|SUBJECTIVE|SUBJECTIVE: This is a 77-year-old with a left CVA giving right hemiparesis, gout, hypertension. Seen on rounds. No new problems. The patient was able to write family names today with his right hand and was very excited.
CVA|costovertebral angle|CVA|201|203|PHYSICAL EXAMINATION|GENERAL: He is a generally well-appearing 45-year-old gentleman who is approximately 6 foot 4 and 205 pounds. RESPIRATORY: No respiratory distress. HEART: His heart rate is regular. BACK: Negative for CVA tenderness. ABDOMEN: Soft, nontender, and nondistended. EXTREMITIES: His lower extremities show no clubbing, cyanosis, or edema. GU/RECTAL: Deferred at this time. ASSESSMENT AND PLAN: Mr. _%#NAME#%_ _%#NAME#%_ is a 45-year-old gentleman with a history of multiple sclerosis and question of urinary retention, as well as urgency and frequency.
CVA|cerebrovascular accident|CVA,|153|156|REVIEW OF SYSTEMS|She is on thyroid replacement therapy. MUSCULOSKELETAL: See HPI. No focal no other new joint pain, joint swelling or erythema. NEUROLOGIC: No history of CVA, falls, syncope, focal paresthesias, weakness, headache or visual changes. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 136/78, pulse 70-80, respiratory rate 16, temperature 93% on 2 liters nasal cannula.
CVA|cerebrovascular accident|CVA|174|176|PAST MEDICAL HISTORY|She describes her pain as just plain pain. She denies any burning, prickling and tingling and states that it is a shooting type of pain. PAST MEDICAL HISTORY: Remarkable for CVA with left carotid complete stenosis and right carotid at 50-69% stenosis, right lower extremity weakness after her stroke that resolved and then autoimmune vestibular cochlear dysfunction, shingles and hypertension.
CVA|cerebrovascular accident|CVA,|240|243|ASSESSMENT|HEART: Irregularly irregular. ASSESSMENT: I would agree with Dr. _%#NAME#%_ that there are really no rehab needs from his TIA. However, from a deconditioning standpoint with his history of multiple illnesses and that complicated by his old CVA, his small vessel disease and sternal precautions has resulted in him not being safe for returning home. He has been able to tolerate a rehab program as well.
CVA|cerebrovascular accident|CVA|163|165|HISTORY OF PRESENT ILLNESS|He was transferred to the University of Minnesota Medical Center, Fairview, on _%#MMDD2007#%_ where further workup showed him to have a left posterior circulation CVA with a CT angiogram. He underwent decompression for his left PICA CVA on _%#MMDD2007#%_. His ventriculostomy was removed. He has had improvement and on _%#MMDD2007#%_ he was noted to have right hemiparesis.
CVA|costovertebral angle|CVA|188|190|PHYSICAL EXAMINATION|GENERAL: Appearance: He is well appearing, no apparent distress. HEENT: Negative. RESPIRATORY: Unlabored breathing. HEART: Regular rhythm. ABDOMEN: Soft, nontender, nondistended. BACK: No CVA tenderness. GU AND RECTAL: Exam deferred at this time. EXTREMITIES: Patient is wearing a knee immobilizer for his right knee. His lower extremities show no edema. LABORATORY DATA: Sodium 140, potassium 4.5, chloride 107, CO2 28, glucose 131, BUN 20 and creatinine 1.2. UA with microscopic was performed on _%#MMDD#%_ that shows 1 white blood cell per high power field and 1 red blood cell per high power field.
CVA|cerebrovascular accident|CVA.|140|143|PAST MEDICAL HISTORY|He has significant LAD disease, diffuse RCA disease. He is status post bypass graft in the LAD in 2001. History of depression following his CVA. Hypertension. Admission in _%#MM#%_, 2004, for gastroenteritis and dehydration. Fairview Ridges hospitalization in _%#MM#%_, 2005, for E. coli bacteremia associated with chronic cholecystitis.
CVA|costovertebral angle|CVA|228|230|ADMISSION PHYSICAL EXAMINATION|LUNGS: There is slight wheeze in the left lower base, otherwise clear to auscultation on the right. ABDOMEN: Small amount of erythema around G-tube, guarding, but denied pain, positive bowel sounds, abdomen nontender. SPINE: No CVA tenderness. SKIN: There are scratches and cuts on the right knuckles as well as tattoos. NEUROLOGIC: Cranial nerves II through XII are intact. He is alert and oriented to person, place, and year.
CVA|costovertebral angle|(CVA)|151|155|PHYSICAL EXAMINATION|Some mild distention. Nontender to palpation. Previous surgical scars. I am unable to appreciate the liver edge on exam. BACK: No costovertebral angle (CVA) tenderness bilaterally. EXTREMITIES: Extremities are warm. Left above-the-knee amputation stump with a dressing. Right ankle and foot ulcer, dressing over the ankle, foot is nice and warm.
CVA|cerebrovascular accident|CVA|137|139|HOSPITAL  COURSE|4. Anesthesiology. 5. Physical therapy. HOSPITAL COURSE: Right lower extremity pain. The patient is an 87-year-old woman with history of CVA and right lower extremity weakness, previously healthy who presented with sudden onset right groin and right thigh and leg pain. She was unable to elevate her leg or walk since the onset of the pain.
CVA|costovertebral angle|CVA|165|167|PHYSICAL EXAMINATION|There is no murmur appreciated. No rub or click. ABDOMEN: Bowel sounds are present. The abdomen is soft, nontender, nondistended. There is no hepatosplenomegaly. No CVA tenderness. BREAST: Not performed. GENITOURINARY: Not performed. EXTREMITIES: No clubbing, cyanosis or edema. NEUROLOGIC: Cranial nerves II-XII are intact. Sensory and motor exams are normal.
CVA|cerebrovascular accident|CVA.|197|200|HOSPITAL COURSE|Zosyn was continued. He remained unresponsive. EEG apparently initially showed very slow waves. It was somewhat improved 24 hours later with slight activity. CT scan showed no bleed or significant CVA. It was felt that there was diffuse cortical injury due to the hypoxia. It was unclear as to the severity of the anoxic insult as to what the possibility for recovery was.
CVA|cerebrovascular accident|CVA.|208|211|PROBLEM #9|On _%#MMDD2006#%_, the patient was found to be minimally responsive by family and nursing staff. A stat head CT was performed and revealed no intracranial pathology; however, a stat MRI revealed a left-sided CVA. Final read on MRI was acute infraction of the left frontal lobe, left caudate nucleus, left internal capsule, posterior left inferior cortex and white matter deep to the inferior cortex.
CVA|costovertebral angle|CVA|120|122|ADMISSION PHYSICAL EXAMINATION|On bimanual exam she did not have cervical motion tenderness and she had a normal uterus and ovaries. SPINE: She had no CVA tenderness. SKIN: She had a rash on her face, which was raised and non-painful, was slightly itchy. NEUROLOGIC: The patient does not know the date, but knows the year and where she is.
CVA|costovertebral angle|CVA|189|191|PHYSICAL EXAMINATION|ABDOMEN: Liver/kidney/spleen are not enlarged. There is no rebound or rigidity present. There are no palpable masses and bowel sounds are normal. BACK: No scoliosis or focal tenderness. No CVA tenderness or palpable masses. LYMPHATIC: No axillary or inguinal lymphadenopathy present. NEUROLOGIC: The cranial nerves are intact. The deep tendon reflexes are bilaterally equal and negative toe signs.
CVA|costovertebral angle|CVA|265|267|PHYSICAL EXAMINATION|Does appear to be systolic and also down at the left lower sternal border there is a diastolic component as well. Also, in her neck she has no bruits bilaterally. ABDOMEN: Soft, positive bowel sounds, nondistended, nontender to palpation, no hepatosplenomegaly, no CVA tenderness. EXTREMITIES: Warm, she has no clubbing, cyanosis or edema. She has palpable dorsalis pedis and posterior tibial pulses.
CVA|cerebrovascular accident|CVA|204|206|PAST MEDICAL HISTORY|No tobacco or alcohol use. FAMILY HISTORY: Noncontributory. PAST MEDICAL HISTORY: 1. Paroxysmal atrial fibrillation status post cardioversion in _%#MM2004#%_, echo in 2004. 2. Hypertension. 3. History of CVA with residual left hemiparesis and aphasia. 4. History of folliculitis. 5. Hyperlipidemia. 6. History of renal insufficiency. 7. History of left atrial thrombus diagnosed in 2004.
CVA|costovertebral angle|CVA|185|187|PHYSICAL EXAM|ABDOMEN - benign, soft, nontender, nondistended, no hepatosplenomegaly. LOWER EXTREMITIES - skin is warm and dry, intact, no cyanosis, no edema, no rash. BACK -no spinal tenderness, no CVA tenderness. NEUROLOGIC - cranial nerves II-XII grossly intact. Tongue is midline. Face appears symmetric, possibly a right nasal labial fold droop, very subtle.
CVA|cerebrovascular accident|CVA|172|174|HISTORY OF PRESENT ILLNESS|Patient is on a humidified face mask to keep sats greater than 90% with frequent suctioning. HISTORY OF PRESENT ILLNESS: This is a 58-year-old male with a history of MCAD, CVA with right-sided hemiparesis, and aphasia who has been in Good Samaritan Nursing Home for the last 2 weeks. He was transferred here after he had brown secretions in his mouth and appeared to in respiratory distress with sats at approximately 81%.
CVA|cerebrovascular accident|CVA|124|126|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: Please see HPI for details. Notable for some subjective fevers and diaphoresis. No DVT or PE history. No CVA history. She does complain of some diffuse body complaints which she relates to her fibromyalgia history. Review of systems is otherwise negative for cardiovascular, respiratory, GI, renal, urinary, hematologic, integument, endocrine, musculoskeletal, neurologic and cognitive complaints besides that mentioned above.
CVA|costovertebral angle|CVA|172|174|ADMISSION PHYSICAL EXAMINATION|LUNGS: Clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm without murmur. ABDOMEN: Soft, non-tender, non-distended, positive bowel sounds. BACK: No CVA tenderness. LYMPHATICS: No cervical, inguinal, or axillary lymph nodes on exam. LABORATORY DATA: CBC: white count 9.4, hemoglobin 12.6, platelets 449, ANC 3.9, ALT 4.3. BMP was within normal limits.
CVA|cerebrovascular accident|CVA|191|193|PAST MEDICAL HISTORY|He has been seen in the Emergency Department here and at Fairview Southdale 7 times in the past 2 months for various issues, most prominent issue being constipation. PAST MEDICAL HISTORY: 1. CVA with right Emmy paresis x2 in _%#MM2006#%_ and _%#MM2006#%_. He was seen at Abbott Northwestern Hospital. 2. Hypertension.
CVA|costovertebral angle|CVA|220|222|PHYSICAL EXAMINATION|PAST OB HISTORY: Negative. PAST SURGICAL HISTORY: Diagnostic laparoscopy. CURRENT MEDICATIONS: Vioxx on a p.r.n. basis. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. NECK: Supple. No mass. BACK: Normal spinal curvature. No CVA tenderness. HEART: Normal. LUNGS: Normal. ABDOMEN: Soft and nontender. No hepatosplenomegaly. PELVIS: The pelvic exam is deferred to surgery. IMPRESSION: Normal physical examination. PLAN: We will proceed with laparotomy.
CVA|cerebrovascular accident|CVA|187|189|PHYSICAL EXAMINATION|Her general appearance showed a 66-year-old female in no apparent distress, with a baseline of shortness of breath due to COPD. Pertinent positives on physical exam showed positive right CVA tenderness of palpation, positive right upper quadrant pain with palpation, as well as suprapubic pain with palpation. Chest/thorax with an increased AP diameter and marked kyphosis with lung sounds slightly decreased in bilateral lung fields.
CVA|costovertebral angle|CVA|166|168|PHYSICAL  EXAMINATION|Sinuses nontender. Oropharynx unremarkable. NECK: Supple and benign, no thyromegaly or masses. No lymphadenopathy. LUNGS: Clear to auscultation and percussion. BACK: CVA negative. HEART: Irregularly irregular heart tones without S3, S4, murmur, click or rub. Peripheral pulses are intact. No bruits, jugular venous distention. The patient has 1-2+ pitting edema of the lower extremities up to the knee and some mild erythema as well.
CVA|cerebrovascular accident|(CVA),|156|161|PAST MEDICAL HISTORY|2. Hypertension. 3. Borderline elevation of cholesterol. Her husband denies that she has any history of cancer, diabetes mellitus, cerebrovascular accident (CVA), myocardial infarction (MI), peptic ulcer disease, deep vein thrombosis (DVT). pulmonary embolus (PE), asthma or emphysema. IMMUNIZATIONS: Other relevant factors include the fact that the patient has not had a Pneumovax per her husband.
CVA|costovertebral angle|CVA|257|259|PHYSICAL EXAMINATION|She did have a tunnel dialysis line in her right upper chest without any evidence of infection or inflammation at the line site. ABDOMEN: Belly was firm, nontender, and tympanitic to percussion. GENITOURINARY: Normal female anatomy. SPINE: Exam revealed no CVA tenderness. She had no lymphadenopathy. SKIN: Quite icteric throughout with palm erythema. NEUROLOGIC: She was somewhat difficult to arouse, but oriented x 2.
CVA|costovertebral angle|CVA|150|152|PHYSICAL EXAMINATION|No rubs or gallops appreciated. Abdominal: Normal active bowel sounds, non- tender, non-distended, no organomegaly or masses. Spine: Midline, without CVA tenderness. Lymphatics: No axillary, cervical, or supraclavicular lymphadenopathy. Musculoskeletal: Grossly normal range of motion in upper extremities and left lower extremities.
CVA|cerebrovascular accident|CVA.|210|213|FAMILY HISTORY|No recreational drug use. The patient does have a sister, _%#NAME#%_, who lives in _%#CITY#%_, Minnesota but is estranged. He also has a guardian and cousin, _%#NAME#%_. FAMILY HISTORY: Mother deceased age 82, CVA. Father deceased, aortic aneurysm rupture in his 80s. ALLERGIES: NKDA. MEDICATIONS: 1. Mucinex 600 mg p.o. b.i.d. 2. Colace 100 mg p.o. each day at bedtime.
CVA|cerebrovascular accident|CVA,|235|238|HISTORY OF PRESENT ILLNESS|DOB: _%#MMDD1920#%_ CHIEF COMPLAINT: Loss of consciousness. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a very pleasant 84-year-old gentleman with a history of coronary artery disease, moderate Alzheimer's dementia, occipital CVA, and a prior history of syncope. The patient had been doing well lately, and in fact, woke up doing well this morning.
CVA|costovertebral angle|CVA|267|269|PHYSICAL EXAMINATION|Normal respiratory effort. HEART: Regular rate and rhythm. He has about a 2/6 systolic murmur best heard in the left lower sternal border without any radiation. ABDOMEN: Soft with positive bowel sounds, nondistended, nontender to palpation, no hepatosplenomegaly, no CVA tenderness. Negative hepatojugular reflux. LOWER EXTREMITIES: He has what appears to be evidence of both chronic venous stasis changes as well as peripheral vascular disease.
CVA|cerebrovascular accident|CVA|166|168|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Pacemaker placed in _%#MM2002#%_ secondary to sick sinus syndrome. 2. Hypertension. 3. Hyperlipidemia. 4. Atrial fibrillation. 5. History of CVA in 1992. 6. Congestive heart failure. 7. Pulmonary disease noted as well. 8. Systolic dysfunction noted to be mild. 9. Interstitial lung disease.
CVA|cerebrovascular accident|CVA|205|207|PAST MEDICAL HISTORY|2. Sacral decubitus ulcer, chronic. 3. Chronic constipation. 4. Benign prostatic hypertrophy. 5. Neurogenic bladder with placement of chronic suprapubic catheter. 6. Recurrent urinary tract infections. 7. CVA in _%#MM2005#%_. 8. Subdural hematoma requiring a lengthy recovery at _%#COUNTY#%_ Rehabilitation. 9. Hypertension. 10. Atrial fibrillation by history. 11. Malnutrition.
CVA|cerebrovascular accident|CVA,|276|279|HISTORY OF PRESENT ILLNESS|DOB: _%#MMDD1934#%_ CHIEF COMPLAINT: Cough, fever, weakness. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a very pleasant 69- year-old Caucasian gentleman with a complex medical history including diet-controlled diabetes, hypertension, dyslipidemia, status post right CVA, who presents with several day history of feeling ill. Patient states that he was at his baseline health status until several days ago when he began noticing some dysuria and possibly a dry cough.
CVA|cerebrovascular accident|CVA|197|199|HISTORY OF PRESENT ILLNESS|Her left canal is entirely closed. 2. Interstitial lung disease in the past with recurrent lung infections including MRSA pneumonia. 3. Type 2 diabetes, poorly controlled on insulin. 4. History of CVA in _%#MM#%_ 2004. 5. Hypertension. 6. Depression and anxiety. 7. Chronic "bone" pain in the legs, arms, head, and chest. 8. Hypothyroidism. 9. Restless legs syndrome. 10. Tobacco abuse.
CVA|costovertebral angle|CVA|189|191|PHYSICAL EXAMINATION|The ostomy site appears to have no active bleeding and no gross blood noted in the ostomy bag. The ostomy bag does show some loose watery brown stools. Again, no gross blood. SPINE/CVA: No CVA tenderness, no spinal tenderness, no stepoff noted. EXTREMITIES: The patient has full range of motion, no edema of the upper or lower extremities.
CVA|costovertebral angle|CVA:|206|209|ALLERGIES|Regular rate, 3/6 holosystolic murmur with bounding pulses. Lungs: Good air entry bilaterally. Abdominal or Rectal: Bowel sounds positives, soft, nontender, and nondistended. Splenomegaly present. Spine or CVA: No CVA tenderness bilaterally. Skin: No rashes. Jaundice present. Neurological Examination: Cranial nerve 2 through 12 intact. Strength 5 over 5. Reflexes 1+ in the upper and lower extremities.
CVA|costovertebral angle|CVA|191|193|PHYSICAL EXAMINATION|RESPIRATORY: Tachypnea, coarse breath sounds in all fields with increased work of breathing. ABDOMEN: Soft, nontender, and nondistended. Appropriate bowel sounds. SPINE AND CVA: Straight, no CVA tenderness. SKIN: No rashes, lesions, new hematomas. NEUROLOGIC: Confused, slow to answer questions. LABORATORY: On admission, white count was 14.4 with 94% neutrophils, 2% lymphocytes, and 2% monocytes; absolute neutrophil count was 13.6, hemoglobin was 14.0, and platelets 194.
CVA|costovertebral angle|CVA|208|210|PHYSICAL EXAMINATION ON ADMISSION|His G-tube was in place, there was no erythema or induration noted around the G-tube. There was no rebound, no guarding on abdominal exam. RECTAL: Was without tenderness and was guaiac negative. There was no CVA tenderness on exam. SKIN: Unremarkable, no rashes noted. MENTAL STATUS EXAMINATION: Revealed that he was alert and oriented to person, time, and place.
CVA|cerebrovascular accident|CVA|149|151|IMPRESSIONS AND RECOMMENDATIONS|This likely reflects cerebrovascular involvement, as well as resolving acute confusional state, that may be associated with the acute effects of her CVA (e.g., edema) or medication effects. This likely reflects an evolving picture, and it may be helpful to repeat her neuropsychological evaluation in three months to determine whether her cognitive difficulties progress, remit, or remain stable.
CVA|cerebrovascular accident|CVA.|134|137|CLINICAL IMPRESSION|5. History of anemia and distant GI bleed. 6. History of peripheral vascular disease with renal artery stenosis. 7. History of TIA, ? CVA. 8. History of hyperlipidemia. 9. History of mild renal insufficiency. DISCUSSION: The patient presents with multiple medical problems with chest discomfort with elevated heart rate and EKG changes consistent with subendocardial injury or ischemia.
CVA|cerebrovascular accident|CVA|194|196|PAST MEDICAL HISTORY|Indicates no knowledge of known coronary artery disease. Apparently last underwent objective cardiac evaluation in the form of a dobutamine stress echocardiogram subsequent to the above alleged CVA which was apparently negative (per patient). 4. Mitral insufficiency. Indicates last echocardiogram allegedly "better than the prior study," presumably done around the time of the above "CVA" in _%#MM#%_ of this year.
CVA|cerebrovascular accident|CVA|166|168|FAMILY HISTORY|10. Vistaril 50 mg q.6h p.r.n. anxiety. FAMILY HISTORY: Father died from congestive heart failure at age 80. Course complicated by leukemia. Mother died at 74 from a CVA without known coronary artery disease. HABITS: Non-smoker. Issue of potential alcohol dependency. The patient does admit to prior alcohol excess.
CVA|cerebrovascular accident|(CVA)|238|242|RECOMMENDATIONS|I believe that there is a 1-2% mortality risk, and a 3-5% risk of significant morbidity related mostly to the patient's obesity and lower extremity swelling and diabetes mellitus. Also he is at increased risk for cerebrovascular accident (CVA) because of his past history of cerebrovascular disease and cerebellar infarct. I have discussed risks, benefits and indications of surgery with the patient.
CVA|cerebrovascular accident|CVA,|142|145|SYMPTON REVIEW|Married with 3 children. SYMPTON REVIEW: Denies fever, chills, or sweats. No headache or dizziness. Did have diplopia subsequent to the above CVA, since resolved. Denies chest discomfort. She has had intermittent dyspnea with chronic exertional dyspnea, i.e., with stairs. No orthopnea or PND. She has had a cough productive of nondescript sputum.
CVA|cerebrovascular accident|CVA|356|358|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Seizure and headache. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 56-year-old white female with a history of insulin-dependent diabetes mellitus, coronary artery disease, hypertension and elevated cholesterol, who is status post an L2-L3 and L4-L5 anterior fusion on _%#MMDD2001#%_ by Dr. _%#NAME#%_ _%#NAME#%_, and status post CVA on _%#MMDD2001#%_. The patient's primary physician is Dr. _%#NAME#%_ _%#NAME#%_ of Lakeview Clinic in _%#CITY#%_.
CVA|cerebrovascular accident|CVA|276|278|ASSESSMENT|Platelet count 254,000. Basic metabolic profile same date was normal with a sodium of 142, potassium 3.9, BUN 15, creatinine 1.02. Homocystine level 8.3. ASSESSMENT: 1. Depression/anxiety with reduced ability to function. Deferred to Psychiatry. 2. Status post right phalamic CVA without lingering clinical sequelae. 3. Patent foramen ovale for which the patient underwent successful closure (as above). Off Coumadin. 4. History of recurrent angioedema since early childhood.
CVP|cyclophosphamide, vincristine, prednisone|CVP|185|187|PLAN|Briefly, she presented during pregnancy in 2000 with inguinal lymphadenopathy and a B cell follicular lymphoma small cleave type with stage IV involvement. Multiple therapies including CVP subsequently Rituximab CVP, fludarabine, mitoxantrone, dexamethasone, all yielded serial partial remissions. She received RICE in the fall of 2006 that produced further regression of her lymphoma but she still had multiple PET avid sites of lymphadenopathy.
CVP|central venous pressure|CVP|245|247|HISTORY OF PRESENT ILLNESS|The patient has cardiac arrest during the catheterization lab, intra-arterial balloon pump was placed. The patient was placed on norepinephrine, vasopressin, and dobutamine was started. Initial pulmonary artery catheterization readings showed a CVP of 12 and 16, PA pressures between 35 and 40 over 15 to 20 with pulmonary capillary wedge pressure of 15, cardiac output of 5.
CVP|central venous pressure|CVP.|138|141|DISCHARGE DIAGNOSES|The patient's transthoracic echocardiogram performed on _%#MM#%_ _%#DD#%_, 2005, revealed an EF of 10% to 15%, moderate TR, and increased CVP. The patient was started on metoprolol and discharged home on _%#MM#%_ _%#DD#%_, 2005. Three hours after discharge, per the patient, he started to experience increased shortness of breath, dyspnea on exertion, and abdominal fullness and presented to the Fairview Lakes ER for further evaluation.
CVP|central venous pressure|CVP|210|212|DISCHARGE DIAGNOSIS|Central venous and arterial lines placed. Hydrocortisone given. Overnight got greater than 4 liters fluid since midnight. Normal saline at 500 per hour plus platelet plus RBCs. Urine output 75 mL over 8 hours. CVP 4 to 6 to 7 to 7 to 5 to 9 to 9. Mean arterial pressure is 58 to 78. Troponin negative first set.
CVP|central venous pressure|CVP|205|207|RELEVANT LABS ON ADMISSION|BNP was 439 increased from 37 from previous hospitalization. All his troponins remained negative. EKGs did not show any new change. Right heart catheterization showed a pulmonary artery pressure of 46/28. CVP remained between 16 and 18 and cardiac index was between 3.2 and 3.6. HOSPITAL COURSE AND PROBLEMS: Lower extremity edema and scrotal swelling secondary diastolic heart failure: Mr. _%#NAME#%_ was admitted to our service for the above reasons.
CVP|central venous pressure|CVP|114|116|HOSPITAL COURSE|Postoperatively the patient was admitted to the ICU due to oliguria in the operating room. She was at the ICU for CVP monitoring and serial hemoglobin monitoring. On postoperative day 1, the pain was not well-controlled by PCA. This was improved by increasing her basal rate. Otherwise drain output was appropriate.
CVP|central venous pressure|CVP|368|370|DIAGNOSES|IMPRESSION: This is a 54-year-old diabetic, now with new onset of hypotension, cold and poorly perfused extremities, with increased abdominal pain of unclear etiology, with elevation of her liver function tests, as well as metabolic acidosis, possibly related to decreased perfusion versus renal dysfunction versus increased ketones. DIAGNOSES: 1. Hypotension. With a CVP of 22, the patient appears to be volume- resuscitated, but still has marginal blood pressures, and very cool and poorly perfused extremities.
CVP|central venous pressure|CVP|132|134|HOSPITAL COURSE|She went to the ICU postoperatively and had problems with low urine output and hypotension. Vigorous volume replacement found and a CVP line was placed. Because of high pressures, diuresis found. Urine output continued to be sluggish. Renal ultrasound did not reveal obstruction. On the second postop day, her urine output dramatically improved.
CVP|central venous pressure|CVP|214|216|HOSPITAL COURSE|He came in on14 nanograms of Flolan. The initial goal was for his Flolan to be discontinued about 5 p.m. last evening; however, his PA pressures actually did go up and his pressures were in the 130/60 range with a CVP of 12. The Flolan was not discontinued at that time and later on in the evening his PA pressures were again down to his usual range of 110/50.
CVP|cyclophosphamide, vincristine, prednisone|CVP,|220|223|HISTORY OF PRESENT ILLNESS|In 2004, his right elbow mass recurred, and also in the spring of 2004 he developed a right axillary mass. The patient was reevaluated at the Mayo Clinic and was diagnosed with Hodgkin lymphoma. He underwent 5 cycles of CVP, the first 2 cycles with Rituxan. In 2005, he had recurrent disease and underwent 6 cycles of ABVD which finished in _%#MM#%_ 2005.
CVP|central venous pressure|CVP|249|251|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: She is afebrile and blood pressure is currently 147/62, heart rate is 95, respiratory rate 18. HEENT: Normocephalic, no trauma. Extraocular movements are intact. Oropharynx with dry mucous membranes. NECK: Supple. CVP is approximately 5 cm of water. CARDIOVASCULAR: Normal S1, S2, respiratory rate without murmurs, rubs, or gallops. CHEST: Clear bilaterally. ABDOMEN: Soft and nontender with normal bowel sounds.
CVP|central venous pressure|CVP|162|164|DATE OF EVALUATION|From a cardiac standpoint, the patient does have cardiac failure with known left ventricular failure and now an elevation in the right ventricular pressures. Her CVP was 26 yesterday and is about 18 to 20, which is her standard baseline. We have aggressively diuresed her and again she has some pulmonary congestion on her chest x-ray.
CVP|cardiovascular pulmonary|CVP:|134|137|REVIEW OF SYSTEMS|She has one other child, she has two sons I believe. REVIEW OF SYSTEMS: HEENT: Functional vision and hearing. She has upper dentures. CVP: Denies any chronic cough or shortness of breath. As mentioned, her activity is limited because of her joints. She has not had any anginal symptoms. She had the angioplasty close up, and she had to be replastied again about 4 months later, has had no trouble ever since.
CVP|central venous pressure|CVP|198|200|OBJECTIVE|HEAD, EARS, EYES, NOSE, and THROAT: Extraocular muscles intact. Pupils equally round and reactive to light. The posterior oropharynx is clear. The NECK is supple. No lymphadenopathy, no masses. The CVP is difficult to assess because his neck is somewhat thick. The CHEST is with bibasilar crackles. The HEART has a regular rate and rhythm with a split S1; no murmur.
CVP|central venous pressure|CVP|166|168|PHYSICAL EXAMINATION|He can respond briefly to questions, but cannot give any detailed history. VITAL SIGNS: His temperature is 91.2, blood pressure 78/47, pulse 54, respiratory rate 14, CVP is 10-12. SKIN: Negative. HEENT: Head shows no trauma. The eyes show pupils constricted. The mouth shows good dentition, the mucous membranes are dry, the posterior pharynx is clear.
CVP|central venous pressure|CVP|199|201|HOSPITAL COURSE|The patient continues to diurese with his regimen. His milrinone was increased to 0.375 mcg/kg per minute in an attempt to drop his pulmonary pressures. Swan-Ganz catheter had been discontinued. His CVP was measured by the PEG to be 13. He was maintaining good hemodynamics. His bilateral edema had decreased to near nonexistence.
CVP|central venous pressure|CVP|136|138|HOSPITAL COURSE|2. Cardiovascular. The patient was hypotensive on admission and her pressor support was able to be weaned off eventually. Our goals for CVP had been between 10-12. On _%#MMDD2007#%_, she went back in the AFib with RVR. She was placed on diltiazem drip and is now currently being rate controlled on oral diltiazem.
CVP|central venous pressure|CVP|231|233|PHYSICAL EXAM|HEENT: Extraocular muscles intact. Pupils equally round and reactive to light, no icterus. Neck: No lymphadenopathy or masses. CHEST: Clear to auscultation, without obvious crackles. HEART: Regular rate and rhythm, without murmur. CVP is estimated at 10 or 11 cm. ABDOMEN: Bowel sounds present, nontender, nondistended. EXTREMITIES: Show no lower extremity edema.
CVP|cyclophosphamide, vincristine, prednisone|CVP|224|226||He was initially diagnosed in 1995 with a large cell lymphoma and responded to CHOP chemotherapy but had residual low-grade lymphoma in the bone marrow. He has since been extensively treated with oral Cytoxan, Rituxan, FMD, CVP and COPE. He still has residual disease and our plan is to try cytoreductive treatment with systemic chemotherapy, using Rituxan plus DHAP and if he does get a good response, he will be transferred to the University of Minnesota for non- myoablative bone marrow transplantation from an unrelated donor or cord blood.
CVP|central venous pressure|CVP|131|133|SPECIFIC DISCHARGE INSTRUCTIONS|The patient has been transferred to the Intensive Care for further management. In the ICU his management was the following: He had CVP between 6 and 10, pulmonary capillary right pressure between 12-14, and pulmonary artery pressure 30/15, mean systemic vascular resistance was 700 dyne/cm2.
CVP|central venous pressure|(CVP)|200|204|PHYSICAL EXAMINATION|No thrush. NECK: Supple. No adenopathy or thyromegaly. LUNGS: Clear anterior breath sounds with a normal respiratory pattern. HEART: Regular rate and rhythm, normal S1 and S2. Central venous pressure (CVP) is estimated to be about 5.0-cm of water. No murmur or rub. ABDOMEN: Normal bowel sounds, soft, and nontender.
CVP|central venous pressure|CVP|138|140|PHYSICAL EXAMINATION|Her speech was clear. NECK: Supple. Her jugular vein pulse was visible approximately 10 cm above the clavicle angle, which gave rise to a CVP of at least 18. There were no bruits on either side. No lymphadenopathy. No thyromegaly. CHEST: Revealed diffuse crackles bilaterally formed at the base and at least 1/2 up.
CVP|central venous pressure|CVP|143|145|PHYSICAL EXAMINATION|Denies alcohol use. REVIEW OF SYSTEMS: Not obtainable due to the patient's altered mental status. PHYSICAL EXAMINATION: Blood pressure 125/98, CVP 14, heart rate 89, temperature 99.7, 98% on non-rebreather mask, respirations 28. General - the patient is somnolent but rousible and does respond to questions.
CVP|central venous pressure|CVP.|139|142|HOSPITAL COURSE|There was mild to moderate mitral regurgitation. There was mild tricuspid regurgitation with pulmonary hypertension with a pressure of 41+ CVP. The trileaflet aortic valve was noted to have aortic valvular sclerosis and there was mild stricture of the opening of the aortic valve leaflets.
CVP|central venous pressure|CVP|193|195|MAJOR IMAGING AND PROCEDURES|There was interval atrophy of kidneys with elevated left-sided resistive indices. Unable to exclude hypoperfusion of the right. 2. A right heart catheterization done on _%#MMDD2007#%_ showed a CVP of 13, PA pressure 48/16, a wedge pressure of 23, a cardiac index of 2.5. BRIEF HISTORY OF PRESENT ILLNESS: This is a 62-year-old obese, African-American female with known severe diastolic dysfunction who was admitted electively due to volume overload.
CVP|central venous pressure|CVP|162|164|HOSPITAL COURSE|The patient's creatinine was noted to increase to 5. However, he maintained adequate urine output with the Bumex _____. He was felt to be fluid overloaded as his CVP was elevated. Renal consult was obtained. They thought his acute renal insufficiency was most likely secondary to ATN. The patient did undergo cardiac echo. He did undergo right heart biopsy on _%#MMDD#%_.
CVP|central venous pressure|CVP|194|196|HOSPITAL COURSE|He was challenged with intravenous fluid and albumin with no improvement in renal function initially and he was also having central venous pressure monitoring with no decrease in CVP noted. His CVP ranged from 12-16 during monitoring. The renal consult team was called and followup has been established. Possible explantation for his improvement in renal function might have been resolving acute tubular necrosis, another possibility is cryoglobulinemia with mesangial proliferative glomerulonephritis.
CVP|central venous pressure|CVP|222|224|PAST MEDICAL HISTORY|Well tolerated. PAST MEDICAL HISTORY: 1. Primary pulmonary hypertension, severe on Flolan, last straight heart cath _%#MM2006#%_, PA systolic 58, diastolic 29 with the mean of 42, pulmonary capillary wedge pressure of 10, CVP 26 and cardiac index 1.3. 2. Coronary artery disease status post left circumflex stent placement. 3. Glucose intolerance. 4. Recurrent acute renal failure, baseline creatinine 1.0-1.1, this admission peak of 1.4.
CVP|central venous pressure|CVP|226|228|ALLERGIES|Sodium 134, potassium 4.4, chloride 101, bicarbonate 24, BUN 29, creatinine 1.4, glucose 285. HOSPITAL COURSE: The patient's invasive hemodynamic monitoring remained favorable during ICU monitoring with cardiac output of 8.3, CVP of 14, pulmonary artery pressures of 44/26 with pulmonary vascular resistance of 58 and SVR 491. The patient continued to complain of vague, poorly-described chest pain during the short stay in the intensive care unit, this seemed more costochondral in nature with exacerbation by coughing and deep breath.
CVP|central venous pressure|CVP|177|179|ASSESSMENT  AND PLAN|UA is clear. Blood cultures are pending. White count was definitely high and his pressures has been low despite fluid resuscitation. a. We will continue volume resuscitate. His CVP is currently 12 and that is probably low for him given his lung disease. Will try to get to around 18 if possible.
CVP|central venous pressure|CVP.|135|138|ASSESSMENT AND PLAN|4. Hypotension, matter of grave concern. She is on pressers already. We will give her a significant amount of IV fluids and monitor on CVP. We will definitely keep it at 12. 5. Acute renal insufficiency secondary to more likely than not it is prerenal in nature at this point in time.
CVP|central venous pressure|CVP|215|217|PROBLEM #3|PROBLEM #3: Cardiovascular. The patient did have some transient hypotension early in her stay, which did respond to fluids. I believe she also did get pressors for a short amount of time. We did attempt to keep her CVP about 10, and she did get some torsemide early on in her stay. Because of the renal failure. Echocardiogram, from what they could see was probably normal; however, it was difficult a difficult study due to her size.
CVP|central venous pressure|CVP|204|206|ASSESSMENT/PLAN|ASSESSMENT/PLAN: 1. Agitation with shortness of breath. I suspect this patient has aspiration pneumonia. Congestive heart failure is not completely excluded but I feel it is much less likely. Will obtain CVP monitoring to further understand whether there is a component of CHF here, but I strongly suspect it is aspiration pneumonia.
CVP|central venous pressure|CVP|204|206|PHYSICAL EXAMINATION|HEENT: Head shows no trauma. The eyes show pupils round and reactive to light. Mouth shows a coated tongue. Posterior pharynx appears clear. NECK: Supple. LUNGS: Clear breath sounds bilaterally. CARDIAC: CVP is about 5. Normal S1 and S2. No murmur, rub or gallop. ABDOMEN: Normal bowel sounds, no bruits, soft and nontender, no hepatosplenomegaly.
CVP|central venous pressure|CVP|151|153|PHYSICAL EXAMINATION|He is passing gas. He has very little pain. No shortness of breath. PHYSICAL EXAMINATION: VITAL SIGNS: Pulse is 80 and regular. Blood pressure 129/60, CVP is elevated at 20. HEENT: Normocephalic, atraumatic. LUNGS: Clear to auscultation and percussion. CARDIOVASCULAR: Regular rate and rhythm.
CVP|central venous pressure|CVP,|268|271|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: The patient's past medical history is remarkable for chronic lymphocytic leukemia, diagnosed in 1998 with tender lymphadenopathy and leukocytosis. The patient was treated with fludarabine, but had poor response. Then he was given eight cycles of CVP, with good response. The patient was in remission for approximately one year, but his disease recurred. At that time, he was given chlorambucil, with poor response, but eight additional cycles of CVP given in the middle of 2000 produced pretty satisfactory disease control.
CVP|central venous pressure|CVP|218|220|PHYSICAL EXAMINATION ON THE DAY OF DISCHARGE|6. COPD. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION ON THE DAY OF DISCHARGE: Temperature 98.9. Pulse 90. Blood pressure 140/85. Respirations 22. The patient was satting comfortably on room air. Estimated CVP of 6-8 cm. Lungs were clear to auscultation bilaterally. CARDIAC: Regular rate and rhythm with distant heart sounds but no murmurs.
CVP|central venous pressure|CVP|212|214|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Unobtainable. PHYSICAL EXAMINATION: The patient is a middle-aged, morbidly obese female. She is intubated and sedated. Temperature 98.9; blood pressure 111/86; heart rate 108; respirations 14; CVP 15. The patient has saturations of 100%. She is being ventilated on SIMV tidal volume of 800, respiratory rate of 10, PEEP of 5, pressor support of 5 and FIO2 of 100%.
CVP|cyclophosphamide, vincristine, prednisone|CVP|138|140|HISTORY OF PRESENT ILLNESS|2. Neutropenic fever. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 75-year-old man with B-cell lymphoma who is status post 4 cycles of CVP and most recently one cycle of Rituxan and CHOP. He presents with neutropenic fevers. He was discharged from the hospital on _%#MM#%_ _%#DD#%_, 2005, after getting his first cycle of Rituxan/CHOP.
CVP|central venous pressure|CVP|267|269|HOSPITAL COURSE|He had an echocardiogram on _%#MM#%_ _%#DD#%_, 2005, which showed an ejection fraction of 25%, mild MR, mild MS, moderate RV dysfunction, and moderate (_____________) failure. On _%#MM#%_ _%#DD#%_, 2005, he also did have a right heart catheterization, which showed a CVP of 15, RV pressures of 60/15, PA 60/38, wedge 18, cardiac index 1.7, by thermodilution, and 1.5 by FIC. Of note, he had an angiogram _%#MM#%_ _%#DD#%_, 2004, which showed normal coronaries at that time.
CVP|central venous pressure|CVP|162|164|PLAN|Gram stain and culture results are unavailable. 3. Discontinue dopamine. Start Levophed to titrate to a mean arterial pressure greater than 65 mmHg. In addition, CVP is placed and will keep between 8-12 mmHg of central venous pressure. 4. She will lay flat for 12 hours post-lumbar puncture.
CVP|central venous pressure|CVP|220|222|HISTORY OF PRESENT ILLNESS|Any attempt to pull fluid off along with the continuous ultrafiltration resulted in decreased blood pressures, and the patient began to become fairly volume up. At 5 in the morning, the patient had been a net 15 L up. A CVP at this point was in the low 20s. Vasopressin was initiated, as the patient's blood pressure was not being supported with dopamine or Levophed.
CVP|cyclophosphamide, vincristine, prednisone|CVP|177|179|IMPRESSION|The last time he was treated by Dr. _%#NAME#%_ was in _%#MM2004#%_ via chlorambucil. We will talk to Dr. _%#NAME#%_ about the next step in the patient's treatment, using either CVP with or without Rituxan versus Rituxan alone versus fludarabine and Rituxan together, in combination. Fludarabine was used a while ago. 4. Anemia, most likely from the disease, but we have to make sure that there is no element of hemolysis.
CVP|cyclophosphamide, vincristine, prednisone|CVP|173|175|ASSESSMENT/PLAN|SKIN: He has crusted healing lesions on his right leg consistent with prior zoster outbreak. ASSESSMENT/PLAN: 1. Peripheral T-Cell lymphoma. He has received three cycles of CVP chemotherapy. He has had a nice response to this. His last treatment was two weeks ago. No additional treatment is needed in this regard. He is currently not neutropenic, however, given his underlying doses, we would consider him to be immunocompromised.
CVP|cyclophosphamide, vincristine, prednisone|CVP|181|183|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|A chest CT and bone marrow evaluation were not done at that time. Initially there were no B symptoms, and he was followed clinically. In _%#MM2002#%_ he underwent chemotherapy with CVP with no response after 3 cycles. He was later switched to cyclophosphamide, fludarabine, and Rituxan, and again there was no response.
CVP|cyclophosphamide, vincristine, prednisone|CVP|207|209|PAST MEDICAL HISTORY|Overall, she states she is feeling well. PAST MEDICAL HISTORY: 1. Non-Hodgkin lymphoma, stage III, morphology showing a low-grade follicular lymphoma with small-cell morphology. She underwent treatment with CVP x6 cycles, with Rituxan, treatment completed in _%#MM2004#%_. The patient had further Rituxan therapy on a quarterly basis over the last 6 months.
CVP|central venous pressure|(CVP)|129|133|PLAN|6. Chronic renal failure. a. His urine is dark but his creatinine is currently stable. b. Will check his central venous pressure (CVP) off the central line and determine his volume status and determine whether he is actually dry or wet.
CVP|central venous pressure|CVP|205|207|HISTORY|She had a rocky course in the Intensive Care Unit with metabolic acidosis. Acute renal failure developed probably from the decreased intravascular volume that seemed to improve with fluid resuscitation. A CVP was used for monitoring volume status and eventually she stabilized hemodynamically. She remained ventilator dependent, however. On the fifth hospital day, she developed increasing abdominal distention, hypotension and peripheral mottling.
CVP|central venous pressure|CVP|147|149|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 130/70, pulse 90, respirations 18, temperature 98.8, O2 saturations 95% on room air. His initial CVP was 9. GENERAL: The patient is a little bit uncomfortable from the chest discomfort, however, does not appear to be in any significant distress.
CVP|central venous pressure|CVP|133|135|HISTORY OF PRESENT ILLNESS|2. During the initial part of the patient's admission, the patient was very hypotensive with systolic blood pressure in the 80s. His CVP through the PICC line was 6, and it was felt that most of his hypotension was due to hypovolemia. We bolused the patient with lots of fluids, and the pressures initially did improve a little bit, but the patient did require a low dose of dopamine.
CVP|central venous pressure|CVP|150|152|HOSPITAL COURSE BY PROBLEM LIST|We therefore have established that his new dry weight is 72 kilograms and would expect that he would gain 2 or 3 kilograms between dialysis runs. His CVP at his dry weight was 8. Given his new dry weight, we also have found that he needs less antihypertensive medication and therefore, I have cut his Avapro and Coreg doses in half.
CVP|central venous pressure|CVP:|146|149|REVIEW OF SYSTEMS|Mother alive at age 90 with heart trouble and had second-hand cigarette smoke exposure. No CVA in the family. REVIEW OF SYSTEMS: HEENT: Negative. CVP: Negative but patient does not exercise regularly to check herself out. She has smoked for most of her life. GI: Has had constipation since surgery.
CVP|central venous pressure|CVP,|311|314|HISTORY OF PRESENT ILLNESS|A Swan was also placed, and initial readings showed relatively normal pulmonary artery pressures, with a wedge of 18, a CVP between 8 and 10, and a cardiac index of 3.4. Following this, there were no more pulmonary capillary wedge pressure readings as the balloon was unable to be fully inflated. Given his low CVP, fluids were given fairly liberally in order to resuscitate his blood pressure, and the patient eventually came off dopamine fairly easily.
CVP|cyclophosphamide, vincristine, prednisone|CVP|260|262|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 66-year-old male with Stage IV non-Hodgkin's lymphoma since _%#MM#%_ 1994 who presents to Hem Oncology, with a two week history of fatigue, poor appetite, decreased urine output, and slow speech. The patient last received CVP chemotherapy, _%#MMDD2002#%_. He was well for approximately two weeks, then developed the above symptoms. He has had recurrent episodes of shortness of breath, bilateral pleural effusions requiring thoracentesis since his diagnosis in _%#MM#%_ 1994.
CVP|cyclophosphamide, vincristine, prednisone|CVP.|172|175|PAST MEDICAL HISTORY|Rituxan on _%#MM#%_ 2001 through _%#MM#%_, 2001 with transient effect and now increased pleural effusions after three months. Last chemo, _%#MMDD2002#%_, with reduced dose CVP. 2. Hypercalcemia. 3. Bilateral pleural effusions. 4. Sinusitis/otitis, followed by ENT. 5. Glaucoma. REVIEW OF SYSTEMS: Reports fatigue. Reports trouble swallowing solids, which is a chronic problem with increased activity of his lymphoma, shortness of breath, no cough, decreased appetite, nausea, no vomiting, or diarrhea.
CVP|central venous pressure|CVP|217|219|PHYSICAL EXAMINATION ON DISCHARGE|PHYSICAL EXAMINATION ON DISCHARGE: Temperature 37.8, pulse 105, blood pressure 124/60, respirations 21, oxygen saturation 91% on room air. Fingersticks overnight have been between 177 and 261. Neck shows an estimated CVP of 8 to 10 cm. Lungs clear to auscultation bilaterally. Cardiac: regular rate and rhythm; no murmurs. Abdomen: nontender and nondistended. Knees: nontender to palpation. Ankles: nontender to palpation.
CVP|central venous pressure|CVP|195|197|IMPRESSION|It should be noted a previous hemodynamic evaluation has included a negative stress echo performed in _%#MM#%_ of 2002. There is some question regarding the patient's low volume status. He has a CVP that is currently running in the range of 6-8. 3. Long standing history of hypertension. 4. History of tobacco use, smoking up until this admission
CVP|central venous pressure|CVP|233|235|PHYSICAL EXAMINATION AT THE TIME OF DISCHARGE|ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION AT THE TIME OF DISCHARGE: Vital signs: Temperature 98.1. Pulse 88. Blood pressure 111/65. Respirations 18. The patient's oxygen saturation is fine on room air. Neck: Estimated CVP is 8 to 10 cm. Lungs: Mild bibasilar crackles, otherwise clear. Cardiac: Regular rate and rhythm with a 1 to 2 out of 6 systolic murmur at the left sternal border.
CVP|central venous pressure|CVP|133|135|HOSPITAL COURSE|In the emergency room her blood pressure was originally in the 50s-60s, but then came up to the 70s with several liters of IV fluid. CVP was placed and it was in the 15 range and dopamine was started briefly and then she had a round of V-tach requiring defibrillation.
CVP|central venous pressure|CVP|177|179|ASSESSMENT AND PLAN|Per Nephrology recommendations, if in the morning there is no good urine output, Metolazone 5 mg p.o. should be given prior to the next dose. Also recommended by Nephrology isw CVP monitoring with goal of CVP of 9-10. 1. 1. Castleman's syndrome. The patient will continue with prednisone 60 mg daily.
CVP|central venous pressure|CVP|278|280|PROBLEM #2|PROBLEM #2: Acute Renal Failure. At the time of admission the patient had a creatinine of 2.4. She was felt to be nauseated with a poor appetite and dehydrated. She had a right heart catheterization and an echocardiogram as described above that revealed volume depletion with a CVP of 2. The patient had fluid resuscitation and her creatinine decreased to 1.8 at the time of discharge. PROBLEM #3: Pulmonary VOD. During the patient's hospitalization she was seen by the Cardiology Service with the above complaints.
CVP|cyclophosphamide, vincristine, prednisone|CVP;|208|211|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ is a 73-year-old male with a longstanding history of follicular lymphoma with recent transformation. Originally diagnosed in 2001, he has been treated in the past with chlorambucil; rituximab; CVP; and fludarabine, Novantrone, dexamethasone (FND). He received 4 cycles of FND from _%#MM#%_ 2004 through _%#MM#%_ 2005. He received another course of fludarabine and mitoxantrone in _%#MM#%_ 2006.
CVP|central venous pressure|CVP|184|186|ADDENDUM|The patient was able to tolerate a regular diet by postoperative day #5 and has continued to move his bowels well. In concern of his previous coronary artery disease, we monitored his CVP for the first three postoperative days to maintain adequate fluid status without fluid overloading and causing congestive heart failure.
CVP|cyclophosphamide, vincristine, prednisone|CVP|198|200|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Arthritis. 2. Chest pain with negative workup. 3. Waldenstrom's/lymphoplasmacytic lymphoma diagnosed in _%#MM#%_ 1998. Presented with rash, pallor and fatigue. Treated with CVP and chemotherapy in _%#MM#%_ 1998, fludarabine x 6 in _%#MM#%_ 2000, and Rituxan x 4. Also treated again with CVP in _%#MM#%_ 2001 to _%#MM#%_ 2001.
CVP|cyclophosphamide, vincristine, prednisone|CVP|127|129|PAST MEDICAL HISTORY|Treated with CVP and chemotherapy in _%#MM#%_ 1998, fludarabine x 6 in _%#MM#%_ 2000, and Rituxan x 4. Also treated again with CVP in _%#MM#%_ 2001 to _%#MM#%_ 2001. For further details please see prior discharge summary dated _%#MM#%_ _%#DD#%_, 2002. 4. CMV negative. HSV negative. 5. MUGA with an ejection fraction of 64%.
CVP|central venous pressure|CVP.|165|168|ASSESSMENT/PLAN|Also in setting of probable dehydration as the patient has not been eating for the last three days. Will resuscitate with fluids and place a central line to monitor CVP. 4. Renal. Elevated BUN and creatinine may be secondary to dehydration. The BUN/creatinine ratio is 4. We will check a FENA, give IV fluids and follow CVP.
CVP|central venous pressure|CVP|184|186|HISTORY|This was done on _%#MMDD2007#%_. Right heart cath showed pulmonary artery wedge pressure of 15 mmHg. There was mild pulmonary hypertension with a mean PA pressure of 30 mmHg. His mean CVP was about 14 mmHg. Cardiac index was 3.3 by both Fick and thermodilution. Coronary angiography showed right dominant system. The left main LAD and circumflex had mild diffuse atherosclerosis with no significant lesions.
CVP|central venous pressure|CVP|179|181|HOSPITAL COURSE|He was extubated that same evening of surgery and chemo to the operating room on milrinone at 0.25 mcg particular per minute and dopamine and epinephrine and amiodarone drip. His CVP was elevated the first 24 hours, but did decrease with diuresis. He was transferred to the floor and on _%#MMDD2007#%_, had his chest tubes, milrinone and Bumex discontinued.
CVP|central venous pressure|CVP|127|129|HOSPITAL COURSE|He also received a total of 2 g of Solu-Medrol. The patient improved remarkably on hospital day #2. His rash had resolved. His CVP had normalized. Blood pressure is also normalized. He had no further symptoms. He had a routine infection workup, which was negative. The patient was discharged to home and was informed that he should inform future physicians that he had an anaphylactic reaction to Toradol and Compazine.
CVP|central venous pressure|CVP|246|248|HOSPITAL COURSE|A preoperative echocardiogram revealed 2+ TR, RVSP of 27+, CVP, decreased RV function, RVE value approximately 37 x 24 mm, 2 to 3+ PI, and good left ventricular function. Echocardiogram postoperatively on _%#MM#%_ _%#DD#%_, 2002, revealed 1+ TR, CVP of 10, RVSP of approximately 35, 1+ MR, 1+ PI, good LV function, improved right ventricular wall function with persistent decreased apical motion.
CVP|cyclophosphamide, vincristine, prednisone|CVP|211|213|HISTORY OF PRESENT ILLNESS|Unfortunately, over two years, he had progressive adenopathy. He was referred to Dr. _%#NAME#%_ in _%#MM#%_ 2002, who recommended CVP and Rituxan followed by allogeneic transplant if responsive to chemotherapy. CVP and Rituxan ended on _%#MMDD2002#%_, and now, he is admitted for umbilical cord blood transplant. He had no match siblings. ALLERGIES: The patient has no known drug allergies.
CVP|central venous pressure|CVP.|173|176|PHYSICAL EXAMINATION ON ADMISSION|Pupils are equal, round, and reactive to light. Extraocular movements are intact. Conjunctivae x 2 are normal. Upper and lower dentures; no lesions. Neck: supple; DJV 12 cm CVP. Lymphadenopathy: zero. Thyromegaly: zero. Heart: regular rate and rhythm; S1, S2 normal. ______: zero. Lungs: clear to auscultation bilaterally. Abdomen: supple; non-tender and non-distended; no masses; no organomegaly.
CVP|central venous pressure|CVP|279|281|PROCEDURES PERFORMED|2. Status post implantable cardioverter-defibrillator and pacer placement. PROCEDURES PERFORMED: 1. Right heart catheterization on _%#MMDD2002#%_ showing mild secondary pulmonary hypertension from congestive cardiomyopathy of unknown etiology; left systolic dysfunction, severe; CVP of 8; RA of 7; PCW of 13; cardiac output 4.7; mildly increased filling pressures with normal CI of 2.5.
CVP|central venous pressure|CVP|155|157|HOSPITAL COURSE|In the morning, his ratio was switched from 1:1 to 1:3 with PA pressure of 30/17, a FICK of 2.5, cardiac output of 3.2, cardiac index of 2.1, wedge of 12, CVP of 9, and a MAP of 73. The patient also had stable troponins. Thus, he had the pump removed. The patient remained in the MICU overnight and was transferred to the floor the following day.
CVP|cyclophosphamide, vincristine, prednisone|CVP.|197|200|PAST MEDICAL HISTORY|She reports no other recent symptoms. PAST MEDICAL HISTORY: 1. Atrial fibrillation. 2. Hypertension. 3. Marginal zone non-Hodgkin's lymphoma, with previous treatment, including cladribine and also CVP. Her last chemotherapy treatment was approximately three weeks ago. 4. Distant history of breast cancer without recurrence. ALLERGIES: Stated allergy to nitrates.
CVP|central venous pressure|CVP|210|212|ADMISSION EXAMINATION|HEENT: Unremarkable. CARDIAC: Regular rate and rhythm with distant heart sounds and 2/6 systolic ejection murmur heard at the right upper sternal border, and also at the apex. No gallop or rub was appreciated. CVP was estimated about 5 cm. LUNGS: Sounds clear with good air movement on the right, and clear with diminished breath sounds on the left with absent breath sounds and dullness to percussion at the left base.
CVP|cyclophosphamide, vincristine, prednisone|CVP,|185|188|PAST MEDICAL HISTORY|The patient was, hence, admitted for intravenous antibiotics and fluid hydration. PAST MEDICAL HISTORY: 1. CLL diagnosed in _%#MM2001#%_, status post multiple chemotherapies, including CVP, rituximab, and fludarabine. Last course of chemotherapy was on _%#MMDD2003#%_ with vincristine, Cytoxan, and prednisone; and _%#MMDD2003#%_ with vincristine and prednisone alone.
CVP|central venous pressure|CVP|226|228|ASSESSMENT AND PLAN|For his sepsis, will initiate D5 normal saline at 150 cc an hour. We will get a second fluid bolus. Will initiate steroids and place a Foley catheter and monitor his urine output and check a FENa and check a lactate level and CVP monitoring with his central line and follow his blood sugars closely and insulin drip if need be, will check his ABG serially.
CVP|central venous pressure|CVP|137|139|HISTORY  OF PRESENT ILLNESS|The patient had a triple lumen right IJ catheter placed and was given 2 liters of normal saline, cooling blanket was applied. He had his CVP measured at 15 and subsequently admission was requested. The patient reports feeling much better. At this point he denies any abdominal pain.
CVP|central venous pressure|CVP|242|244|PLAN|8. Code status was discussed; the patient is still discussing his code with his family and at this time would like to remain full code. PLAN: 1. Admit to the Intensive Care Unit. 2. Start aggressive IV fluid replacement. 3. I would aim for a CVP of around 10. CVP currently is 2 after three liters of normal saline. 4. I will start him on renally-dosed Zosyn and vancomycin.
CVP|central venous pressure|CVP|124|126|PLAN|PLAN: 1. Admit to the Intensive Care Unit. 2. Start aggressive IV fluid replacement. 3. I would aim for a CVP of around 10. CVP currently is 2 after three liters of normal saline. 4. I will start him on renally-dosed Zosyn and vancomycin. 5. I will continue his Lovenox at 1 mg/kg b.i.d.
CVP|central venous pressure|CVP|169|171|HOSPITAL COURSE|The patient was also started on spironolactone and continued on his Lasix dose. The Liver Service suggested the transjugular hepatic vein wedge pressure measurement and CVP pressures. This was performed and a liver biopsy is planned for next week. 2. Hepatitis secondary to hepatitis C virus. A hepatitis C RNA quantification is pending.
CVP|central venous pressure|CVP|152|154|PLAN|The patient has had multiple abdominal surgeries, and this may be cause for bowel obstruction, possible scar tissue formation. For CHF symptoms, obtain CVP pressures, provide Lasix. Monitor fluid balance with the I&Os, daily weights. CODE STATUS: Discussed DNR/DNI code status with the patient. She wishes to have no CPR, shocking, or other cardiac intervention if her status declines.
CVP|central venous pressure|CVP|204|206|HOSPITAL COURSE|After the bicarbonate drip was stopped a few days ago he was started on Diamox and his acid base state was more normal. He is currently getting Lasix for diuresis for a worsening chest x-ray. He does not CVP monitor at this time. The patient was initially getting TPN and was then started on tube feeds. The feeding tube was placed in the stomach and he had some abdominal distension and his tube feeds were held.
CVP|cyclophosphamide, vincristine, prednisone|CVP,|138|141|HISTORY OF PRESENT ILLNESS|The patient's non-Hodgkin's lymphoma was diagnosed in 1992. The patient was treated from 1992 through 1999 with multiple courses of CHOP, CVP, and rituxan. Since 1999, the patient has had no chemotherapy and no evidence for recurrence of her lymphoma on her q. 3-6 month follow-up CT scans.
CVP|central venous pressure|CVP|260|262|ASSESSMENT/PLAN|We ordered an abdominal CT scan without contrast. Her renal function is quite poor and we need a CT scan for evaluation purposes, but I am concerned that she may be going into acute renal failure. Will also continue aggressive fluid resuscitation, keeping her CVP anywhere from 12 to 15. Will start XIGRIS intravenous therapy. I spoke to Dr. _%#NAME#%_ _%#NAME#%_, her surgeon from the University of Minnesota.
CVP|central venous pressure|CVP|167|169|DATE OF DISCHARGE|There she remained on room air and bottle fed throughout. On hospital day #4 an echocardiogram was repeated and the pressures had dropped considerably, with a 26 mmHg CVP (central venous pressure) and only trace pulmonary and tricuspid insufficiency, which had been considerable before. These results are preliminary and will be reviewed by Children's Heart later today.
CVP|cardiovascular pulmonary|CVP|150|152|CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS|He is fully retired because he really cannot function. Since our last visit, he has had no colds or sore throats and no headaches or lightheadedness. CVP as above. GI: There has been no new choking or bowel changes. GU: No dysuria or urinary symptoms. _______ and joint: He has had some physical therapy for his ongoing shoulder problems but this couldn't be continued because of the angina.
CVP|cyclophosphamide, vincristine, prednisone|CVP,|163|166|HISTORY|The patient has been treated since _%#NAME#%_ of 1997 when the diagnosis was made. He has taken several medications in the past, starting with chlorambucil, later CVP, and most recently fludarabine. His last course has been in 2001, and that was of course fludarabine. The patient improved markedly then and his nodes have basically not been palpable since that time.
CVP|cyclophosphamide, vincristine, prednisone|CVP.|220|223|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old male with a history of lymphoplasmacytic lymphoma. He received 4 cycles of rituximab without benefits before and subsequently he has been receiving rituximab with CVP. He has had 2 cycles of this therapy and currently this is after his 2nd cycle of chemotherapy. The patient presented with complaint of fever and malaise for 2 days.
CVP|cyclophosphamide, vincristine, prednisone|CVP,|222|225|HISTORY OF PRESENT ILLNESS|Unfortunately, despite multiple courses of chemotherapy, he has gone on to develop progressive refractory disease. Further biopsies have confirmed recurrent persistent non-Hodgkin's lymphoma. Prior chemotherapies included CVP, Rituxan-CHOP, maintenance Rituxan, fludarabine, Zevalin, and Rituxan-ZVP. The patient currently notes ongoing fatigue, malaise, weakness, nausea, and diarrhea alternating with constipation.
CVP|central venous pressure|CVP|129|131|LABORATORY|His original CVP was 2. He received aggressive fluids, half normal saline with 75 mEq of sodium bicarbonate to achieve a goal of CVP of 12 to 15. Over the course of the next day his creatinine improved to 4.65 and continued to improve gradually as we continued his hydration.
CVP|central venous pressure|CVP|143|145|OBJECTIVE|He does not smoke or drink. REVIEW OF SYSTEMS: Positive for tender heels. OBJECTIVE: VITAL SIGNS: Blood pressure 85 systolic in arterial line, CVP 7, temperature 99 rectally. GENERAL: He alert, oriented x 3, but occasionally inappropriate comment. HEENT: Eyes are clear. Hearing grossly normal. Nose benign. NECK: Nontender.
CVP|central venous pressure|CVP:|157|160|PROCEDURES|3. Pulmonary arterial hypertension. 4. Normal left ventricular function on LV-gram. 2. Right heart catheterization, with hemodynamic evaluation. Results: 1. CVP: 8. 2. PA pressures: 39/22. 3. Pulmonary artery wedge pressures: 16. 4. Cardiac output: 5.6, with an index of 3.4. 3. Transesophageal echocardiogram. Results: 1. Normal global LV systolic function.
CVP|central venous pressure|CVP|131|133|PHYSICAL EXAMINATION ON DISCHARGE|PHYSICAL EXAMINATION ON DISCHARGE: Temperature 96.1, pulse 63, blood pressure 114/78, respirations 16. The patient is on room air. CVP estimated at 6 cm. Lungs clear to auscultation bilaterally. Cardiac: Regular rate and rhythm, with a slight tenderness at the right scapular area.
CVP|cyclophosphamide, vincristine, prednisone|CVP|232|234|SUMMARY|She underwent surgery and had a slow recovery time. Her lymphoma workup was completed while she was in the hospital, and she was eventually started on Rituxan followed by chemotherapy. She had three doses of Rituxan and one dose of CVP regimen. Her performance status remained poor at ACOG level III, but it has improved slightly toward the end of the hospitalization.
CVP|central venous pressure|CVP|331|333|BRIEF HISTORY|Cardiology consultation was obtained while she was in the surgical intensive care unit, and they felt, again, the patient's hypotension and bradycardia due to anesthesia induction was of non-cardiac etiology and was most likely related only to the induction that she received. They noted recent normal echocardiogram with a normal CVP of 7 while the patient was in the surgical intensive unit. Therefore, they thought it was unlikely to show any new changes by repeating an echocardiogram at this time.
CVP|central venous pressure|CVP,|146|149|ASSESSMENT AND PLAN|Pain control will be with morphine. Cardiovascular: The patient's blood pressure is normal. He will continue to be followed with blood pressures, CVP, pulmonary artery pressure, and urine output. We will get a postoperative EKG. Respiratory, the patient is ventilated on SIV. He still is on an FIO2 of 60%. We will wean this down as tolerated.
CVP|cyclophosphamide, vincristine, prednisone|CVP.|195|198|DISCHARGE DIAGNOSES|DOB: _%#MMDD1938#%_ DISCHARGE DIAGNOSES 1. Sepsis syndrome, unclear etiology, possibly oral source. 2. Pancytopenic. 3. Stage IV lymphoplasmacytic lymphoma; recent chemotherapy with Rituxan plus CVP. 4. Neutropenic fever. Status post recent Neulasta injection. PROCEDURES: Chest x-ray. Critical care consultation. Hematology- oncology consultation. Blood transfusion of two units of packed rbc.
CVP|cyclophosphamide, vincristine, prednisone|CVP.|284|287|HOSPITAL COURSE|Bone marrow biopsy _%#MMDD2004#%_ showed 30 percent involvement with a low-grade lymphoproliferative disorder with plasmacytic differentiation consistent with a lymphoplasmacytic lymphoma or possible Waldenstrom's macroglobulinemia. The patient was recently treated with Rituxan plus CVP. Her second cycle was administered about a week prior to her admission. She received a dose of Neulasta the day after her chemotherapy.
CVP|central venous pressure|CVP|136|138|PROBLEMS|PA pressures and CVP were both high. The patient was treated with nesiritide and IV diuretics with good response. Both PA pressures and CVP decreased. The patient was transitioned to 60 mg p.o. b.i.d. of Lasix. The patient was started on Coreg and titrated up to 12.5 mg in the morning, 25 mg at night.
CVP|cyclophosphamide, vincristine, prednisone|CVP|349|351|HISTORY|REASON FOR ADMISSION: Fever, shortness of breath, cough and chest pain HISTORY: _%#NAME#%_ _%#NAME#%_ is an 81-year-old Caucasian man with a history of stage IV chronic lymphocytic leukemia who presented initially with anemia, thrombocytopenia and packed bone marrow with leukemic cells since _%#MM#%_ 2003. He was treated with chemotherapy, failed CVP and Rituxan regimen, and subsequently failed Fludarabine and was treated eventually with Campath. He had good response but had significant hypoplastic marrow in _%#MM#%_ 2003.
CVP|central venous pressure|CVP|206|208|PHYSICAL EXAMINATION|Neuromuscular - The patient has a history of seizures. Denies current paresis, paraesthesia, vertigo. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 72/31, heart rate 105 and regular, O2 saturation 91%, CVP 10, temperature 95.9, respirations 16. GENERAL APPEARANCE: Obese, middle-aged white female, somewhat lethargic, in no other acute distress. SKIN: Normal with respect to color and moisture and temperature, except for ecchymosis in abdomen.
CVP|cyclophosphamide, vincristine, prednisone|CVP|291|293|PAST MEDICAL HISTORY|Right lower lobe infiltrate was noted during those initial imaging studies and he was therefore admitted for treatment of this right lower lobe pneumonia. PAST MEDICAL HISTORY: 1. Well-differentiated B cell lymphoma, diagnosed in 2001. Extensive pelvic lymphadenopathy. Status post 4 cycles CVP chemotherapy. 2. Splenic infarct secondary to lymphoma, status post splenectomy _%#MM#%_ _%#DD#%_, 2005. Pathology shows mantle cell lymphoma. 3. History of prostate cancer, status post prostatectomy.
CVP|central venous pressure|CVP|154|156|PLAN|The patient will be given vitamin K on protocol should his INR be above 1.5. 2. The patient will be rehydrated with the blood and IV fluids, aiming for a CVP in the 8-12 range. 3. Empiric Levaquin has been started. This should cover most Staph and gram negative rods. Blood cultures have been done. Will recheck the chest x-ray in the a.m.
CVP|central venous pressure|CVP.|163|166|HOSPITAL COURSE|He had good urine output during the remainder of his hospitalization. 4. Dehydration. On admission the patient was noted to be significantly dehydrated with a low CVP. This was thought secondary to infection and decreased oral intake due to feeling poorly prior to admission. With aggressive fluid hydration, his volume status improved. During the remainder of his hospitalization he was able to take in adequate oral intake and was euvolemic.
CVP|central venous pressure|CVP|276|278|PROCEDURES PERFORMED|PROCEDURES PERFORMED: 1. Right heart catheterization on _%#MMDD2004#%_ performed in the catheterization laboratory showed right atrial pressure of 6, PA pressure of 62/23, wedge of 23, and cardiac index of 1.5 by Fick. 2. Repeat heart catheterization on _%#MMDD2004#%_ showed CVP of 6, PA pressure of 63/32, and wedge of 20. HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old female with ischemic cardiomyopathy, ejection fraction of 10%, NYHA class 3 out of 4, on home milrinone infusion.
CVP|central venous pressure|CVP|197|199|HOSPITAL COURSE|This was improved by changing her Imdur dosing to the evening rather than the morning. Her pulmonary artery catheter was replaced x 1 for further monitoring. She was gently diuresed to improve her CVP as well as wedge pressures. Her pulmonary artery catheter was removed and she was transferred to the floor for further observation.
CVP|central venous pressure|CVP,|236|239|ADMISSION DIAGNOSIS|DISCHARGE DIAGNOSIS: Hypoplastic left heart status post Norwood and Sano procedures. OPERATIONS/PROCEDURES PERFORMED: 1. Echocardiogram on _%#MM#%_ _%#DD#%_, 2004, showing 2+ to 3+ tricuspid regurgitation, RV systolic pressure 100 plus CVP, aortic arch narrowing with a gradient of 20 mmHg, peak 70 mmHg, 78 mmHg Sano gradient. 2. Cardiac catheterization showed good anatomy of the branch pulmonary arteries status post Norwood-Sano.
CVP|central venous pressure|CVP|171|173|PHYSICAL EXAMINATION|HEENT: Extraocular muscles intact. Pupils equal, round, reactive to light. Posterior oropharynx is clear. NECK is thick, no lymphadenopathy or masses, difficult to assess CVP but there does not appear to be jugular venous distention. CHEST clear to auscultation bilaterally without crackles. HEART is regular rate and rhythm without murmur.
CVP|central venous pressure|CVP|194|196|HISTORY OF PRESENT ILLNESS|This was titrated up to assess for reversibility of his pulmonary hypertension. His pulmonary pressures did respond and prior to removing the Swan-Ganz catheters, PA pressures were 46/16 with a CVP of 14 and a cardiac index of 2.9. These numbers were done while off of any drips. As his nitroprusside was weaned off, he was titrated upon p.o. vasodilators consisting of hydralazine and Imdur.
CVP|central venous pressure|CVP|114|116|HOSPITAL COURSE|The antibiotic regimen was changed to vancomycin, Levaquin and Flagyl. The patient _____ status was set to a goal CVP between 10-12. The patient required multiple vasopressors to continue to maintain her blood pressure in the normal range. The patient remained intubated at this time. By postoperative day #2, the patient's white count continued to rise.
CVP|central venous pressure|CVP.|177|180|HOSPITAL COURSE|Problem # 3: Cardiovascular. _%#NAME#%_ had an echocardiogram on _%#MMDD2005#%_ due to a grade III holosystolic murmur which revealed 2+ Tricuspid regurgitation with RVSP >50 + CVP. The murmur resolved on day two of life and was thought to be secondary to delayed transition and transient pulmonary hypertension.
CVP|central venous pressure|CVP|191|193|HOSPITAL COURSE|She was ruled out for MI and her tachycardia was thought to be secondary to inadequate resuscitation. She was transferred to the SICU and a central line was placed for further resuscitation. CVP was used for monitoring the adequacy of the resuscitation. Laboratory analysis showed that patient's creatinine was elevated, likely secondary to prerenal failure.
CVP|central venous pressure|CVP|175|177|PHYSICAL EXAMINATION|EYES: Pupils equal, round and reactive to light. Extraocular movements intact. No scleral icterus noted. EARS: Normal. OROPHARYNX: Shows dry mucous membranes. NECK: Estimated CVP 14 cm. Supple. No lymphadenopathy or thyromegaly. CARDIOVASCULAR: There is a 1/6 systolic ejection murmur heard best at the right upper sternum border.
CVP|central venous pressure|CVP.|183|186|ASSESSMENT/PLAN|I had good return in all three ports and the CVP was approximately 0 to -1 mmHg. ASSESSMENT/PLAN: 1. Hypovolemic shock, most likely septic and the tamponade is unlikely given the low CVP. We definitely need to rule out intra-abdominal source, as well as chest source, possibly mediastinitis, although, the subacute did open up the symptoms would speak against mediastinitis.
CVP|cyclophosphamide, vincristine, prednisone|CVP|148|150||Mr. _%#NAME#%_ _%#NAME#%_ is a 79-year-old gentleman with a history of stage II B non-Hodgkin's lymphoma for which he has been on chemotherapy with CVP and Rituxan. He also has a history of BPH and had an indwelling catheter in place pending TURP procedure in the future.
CVP|cyclophosphamide, vincristine, prednisone|CVP,|206|209|HISTORY OF PRESENT ILLNESS|Lymph node biopsy revealed follicular center B cell lymphoma, which was positive for CD20, and negative for CD5 and CD23, with kappa light chain and BCL2 positive. The patient was treated with 10 cycles of CVP, however developed peripheral neuropathy associated with vincristine. Repeat bone marrow biopsy in _%#MM1999#%_ showed 5-10% involvement, then was treated at Mayo Clinic with Zevalin x1 cycle, with response.
CVP|central venous pressure|CVP|162|164|ASSESSMENT AND PLAN|10. Monitor in the ICU closely with serial hemoglobins q3 hours. Start to transfuse once his hemoglobin is below 10. Will place a triple-lumen catheter for close CVP monitoring. Surgery assistance appreciated in this case. 2. History of hypertension. Given his labile blood pressure, will hold his blood pressure medications.
CVP|central venous pressure|CVP|226|228|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: On the date of discharge includes vital signs: Temperature 37.0, pulse of 79, blood pressure 120/60, heart rate of 18, 94% sats on room air, fingersticks between 170 and 270. HEENT: Notable for estimated CVP of about 8 centimeters. Lungs have mild crackles bibasilar. Cardiac exam: Regular rate and rhythm with II out of VI systolic murmur in the right upper sternal border.
CVP|central venous pressure|CVP|190|192|HOSPITAL COURSE|Her blood pressure was a bit low. She needed to be maintained on dopamine at 5 mcg/kg/min. Her urine output postoperatively remained adequate at 500 and 900 an hour, it remained cherry red. CVP was within normal limits. The patient was weaned off the ventilator on postoperative day #1. The patient was started on Thymoglobulin intraoperatively and received a full dose on postop day #2.
CVP|central venous pressure|CVP.|175|178|DISCHARGE FOLLOW-UP|A trileaflet evaluation with mild sclerosis, mild mitral calcification with mild regurgitation. Normal right atrium and right ventricle with good function. PA pressure of 28+ CVP. The patient responded well to the above mentioned therapy. As stated, she did have some problems with bradycardia but her beta blocker dose was adjusted and was felt to be nonsymptomatic and without requiring therapy.
CVP|central venous pressure|CVP|220|222|HOSPITAL COURSE|She was initiated on dopamine. Neurology was consulted. She was transferred to the hospitalist service. Pulmonary was consulted given her ventilation requirements. Vitals at that time showed that she was normotensive on CVP 13, heart rate in the 90s, on dopamine. Patient had temperature of 101-102 at that time. On exam, she had dilated but slightly reactive pupils.
CVP|cyclophosphamide, vincristine, prednisone|CVP|141|143|DISCHARGE FOLLOW-UP|1. The patient will follow up with Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2003#%_ at 8:30 in the morning. She will be evaluated for cycle #2 of CVP at that time. 2. The patient is scheduled for a CT without contrast on _%#MMDD#%_ at 11:30 a.m. She will see Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD#%_. 3. The patient had a previously scheduled cardiology appointment and will keep this appointment.
CVP|central venous pressure|CVP.|196|199|HISTORY OF PRESENT ILLNESS|She had a CABG 2001. Recent catheterization in _%#MM#%_ 2003 with angiogram. She had a right heart catheterization that showed normal wedge pressures, normal pulmonary artery pressures and normal CVP. She had also a BNP on this admission that was 48. She had an echocardiogram that was normal ejection fraction in _%#MM#%_ 2003.
CVP|central venous pressure|CVP|152|154|IMPRESSION|It is unclear if this is secondary to dehydration versus other. I do recommend pursuing a FENA, renal ultrasound, and attempting fluid hydration if his CVP is low. 3. Infection disease: There is obvious concern for possible infectious etiology. I agree with broad-spectrum antibiotic therapy given the patient's history of immunosuppression.
CVP|central venous pressure|CVP|207|209|EXAMINATION ON DISCHARGE|GENERAL: The patient is in no acute distress. HEENT: Head is atraumatic, normocephalic. EENT examination is within normal limits. NECK: Neck examination demonstrates no significant JVD with an approximately CVP of 6. No bruits are appreciated. CARDIOVASCULAR: Irregularly irregular rhythm without the presence of murmurs, rubs, or gallops. Heart tones are soft. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Benign without the presence of distention or tenderness and bowel sounds are present.
CVP|cyclophosphamide, vincristine, prednisone|CVP,|219|222|PLAN|He has since received multiple courses of chemotherapy, as his disease has proven to be refractory. Multiple biopsies have confirmed progressive relapses of follicular lymphoma. Prior chemotherapy regimes have included CVP, Rituxan- CHOP, maintenance Rituxan, Fludarabine, Zevalin, etc. Recently, the patient was scheduled for a salvage chemotherapy with ICE, with plans to consider an mini-allo bone marrow transplantation if he responds to that treatment.
CVP|central venous pressure|CVP|153|155|OBJECTIVE|CHEST is clear to auscultation with a few faint scattered bilateral wheezes but no crackles. Vasculature and peripheral pulses are normal and symmetric. CVP is normal. HEART is regular rate and rhythm without murmur. ABDOMEN: Bowel sounds present, nontender, nondistended. EXTREMITIES: Show no clubbing or cyanosis but there is 1/4 symmetric edema.
CVP|cyclophosphamide, vincristine, prednisone|CVP|193|195|HOSPITAL COURSE|The patient was admitted to the hospital and started on IV heparin for the deep vein thrombosis. Further discussion with Dr. _%#NAME#%_ lead to the decision to initiate treatment following the CVP protocol for the patient's lymphoma. The patient, on _%#MM#%_ _%#DD#%_, received cyclophosphamide, 750 mg per meter squared for a total dose of 1500 mg intravenously.
CVP|central venous pressure|CVP|239|241|HISTORY OF PRESENT ILLNESS|ACE inhibitor was titrated up during the admission. A right heart catheterization was performed to evaluate pressures and cardiac outputs. The right heart catheterization showed a pulmonary artery pressure of 25/15 with a wedge of 8 and a CVP of 7. The patient's cardiac index was 3. The patient received a transthoracic echocardiogram, which was performed on _%#MM#%_ _%#DD#%_, 2005.
CVP|cyclophosphamide, vincristine, prednisone|CVP|216|218|HISTORY OF PRESENT ILLNESS|Again she relapsed in _%#MM#%_ 2004 and received another course of Rituxan with a partial response. In _%#MM#%_ 2004, disease recurred with a hilar lymphadenopathy at the left inguinal node. She received 3 cycles of CVP at that time. The bone marrow biopsy done on _%#MM#%_ _%#DD#%_, 2005, did show a 15% trilineage hematopoiesis and no evidence of lymphoma.
CVP|cyclophosphamide, vincristine, prednisone|CVP|169|171|HOSPITAL COURSE|Dermatology was consulted on the day of admission and the left mandible lesion was biopsied. Therefore, the patient received Rituxan on _%#MM#%_ _%#DD#%_, 2005, but the CVP was held until further biopsy results would be available. The patient was followed carefully for his electrolyte for possible tumor lysis syndrome.
CVP|central venous pressure|CVP|202|204|HOSPITAL COURSE BY PROBLEM LIST|Her Nipride was titrated up as her blood pressure tolerated and her pressures responded as follows: Her PA pressure decreased from 44/22 to 30/16, her wedge pressure decreased to 16 and then to 12. Her CVP decreased from 10 to 7, and her cardiac index improved from 1.5 to 2.4. Her Swan was DC'd after 1 day. Her oral medications were titrated up. Her Lisinopril was continued at 5 mg twice day and Coreg was added at 3.125 mg twice daily.
CVP|central venous pressure|CVP|211|213|PHYSICAL EXAMINATION VITAL SIGNS|PSYCHIATRIC: History of anxiety. PHYSICAL EXAMINATION VITAL SIGNS: She is afebrile. Pressure is 144/86, heart rate 69, respiratory rate 20. HEENT: Normocephalic, atraumatic. Sclerae is nonicteric. NECK: Supple. CVP is elevated at 15+ and can be appreciated right at the mastoid bone. CARDIOVASCULAR: Normal S1, S2. Regular rate and rhythm. CHEST: Crackles halfway up both lung fields.
CVP|central venous pressure|CVP,|308|311|BRIEF HOSPITAL COURSE|Serial EKGs were unchanged. His hemoglobin postoperatively was 10.9. At the time of evaluation by the cardiology resident, the patient's blood pressures were 90-100/40-50 with a normal sinus rhythm on his EKG. At that time, it was thought that it would be best to continue volume resuscitation following the CVP, check hemoglobins, troponins and EKG. The patient remained in the ICU overnight due to his hypotension. On postoperatively day #1, adult nephrology did see the patient.
CVP|central venous pressure|CVP|248|250|PROCEDURES DONE WHILE INPATIENT|3. History of bronchiolitis obliterans pneumonia x2. 4. Chronic prednisone therapy with iatrogenic adrenal insufficiency. 5. Diabetes mellitus type 1. PROCEDURES DONE WHILE INPATIENT: 1. Extensive care, admission for sepsis protocol and continuous CVP monitoring. 2. CT of the chest on _%#MMDD2006#%_. This did demonstrate slight increase in interseptal thickening on right middle lobe with decrease in the ground glass opacity but improvement in alveolar opacities in the left lower lobe and right lower lobe with stable borderline mediastinal lymphadenopathy and minimal pleural effusion.
CVP|cyclophosphamide, vincristine, prednisone|CVP|145|147|BRIEF HISTORY OF PRESENT ILLNESS|She received 8-week course of rituximab followed by 4 cycles of CVP with the last dose of CVP on _%#MMDD2006#%_. She is actually due for further CVP course #5 out of 6 on _%#MMDD2006#%_. She presented to Fairview University Medical Center 1 week following the _%#MMDD2006#%_ cycle of CVP with fever spike up to 104 degrees Fahrenheit with chills but without cough, nausea, vomiting, or bowel or bladder dysfunction.
CVP|cyclophosphamide, vincristine, prednisone|CVP|192|194|HISTORY OF PRESENT ILLNESS|In _%#MM#%_ 2006, a CT scan did reveal significant improvement in her left hypopharyngeal mass and associated cervical adenopathy. Because of poor tolerance to Rituxan, she went on to receive CVP alone. She received her fifth cycle of treatment in late _%#MM#%_ 2007. Unfortunately, over the last 2 weeks, _%#NAME#%_ has noted significant progression of her left cervical mass.
CVP|central venous pressure|CVP|318|320|LABORATORY DATA ON ADMISSION FROM OUTSIDE HOSPITAL|Pregnancy test is negative. EKG shows sinus tachycardia with rate 108, right bundle branch block with ST depressions in lateral leads. ECHO on _%#MMDD2006#%_ no pericardial effusion, good biventricular systolic function, mild diastolic dysfunction, no mitral regurgitation, right ventricular systolic pressure 25 plus CVP 1 tricuspid regurgitation (stable from prior exam in _%#MM#%_). HOSPITAL COURSE: 1. Cardiac. Shortly after admission, Amber underwent cardiac catheterization and biopsy.
CVP|central venous pressure|CVP.|165|168|PHYSICAL EXAMINATION|His biggest complaint is his left lower quadrant abdominal pain. HEENT: Atraumatic, sclerae nonicteric, oropharynx is moist. NECK: Thick and difficult to appreciate CVP. CARDIOVASCULAR: Normal S1, S1, regular in rate and rhythm. CHEST: Diminished at the left base, otherwise clear. ABDOMEN: Soft and slightly distended, but does have some bowel sounds present.
CVP|central venous pressure|CVP|331|333|HOSPITAL COURSE|His albumin was 2.3 in _%#MM#%_. To further optimize his PA pressures and to attempt minimizing his full length side effects, which have included chronic diarrhea, we increased his _____ 100 mg 3 times daily and decrease the Flolan to 34 ng/kg per minute. His PA pressures at the time of discontinuing the Swan read 48/14 with the CVP of 18. The report of his cardiac MRI is pending at the time of discharge. Preliminary review showed greatly dilated pulmonary arteries and persistent ASD shunting.
CVP|central venous pressure|CVP|175|177|ASSESSMENT|He is seen postop day 0 after an exploratory laparotomy and colostomy. Note that he was stated on ertapenem by Dr. _%#NAME#%_. He still remains hypotensive, shocky and with a CVP of 15-16. He received 1 dose of Hespan intraoperative and was given an additional liter of normal saline by Dr. _%#NAME#%_. The Intensivist group has already been consulted. At this time, pressures remain 90s/40s-50s on dopamine drip.
CVP|cyclophosphamide, vincristine, prednisone|CVP|132|134||Mrs. _%#NAME#%_ _%#NAME#%_ is an 82-year-old woman with a diagnosis of T-cell non-Hodgkin's lymphoma for which she was treated with CVP alone and had an excellent response. She unfortunately developed significant peripheral neuropathy and declining performance status for which the patient was admitted in the hospital.
CVP|central venous pressure|CVP,|146|149|ASSESSMENT AND PLAN|Will also pan culture her. 4. Sepsis. The patient has hypotension. Her renal function is impaired, and her volume status is unknown. Will place a CVP, with goals to get her CVP 11-12. 5. Renal failure. The etiology of her renal failure is unclear. Sarcoid can affect the kidney by causing interstitial granulomas, and also DI, but also the patient could have hypercalcemia, which could cause renal insufficiency.
CVP|cyclophosphamide, vincristine, prednisone|CVP.|159|162|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Non-Hodgkin's lymphoma diagnosed in 1997 initially treated with eight cycles of CHOP. The patient relapsed. He then had six cycles of CVP. The patient also had right humerus involvement. The patient had partial remission treated with six cycles CVP. 2. Coronary artery bypass graft. 3. Hypertension. 4. Hyperlipidemia. MEDICATIONS ON ADMISSION: See admission H and P.
CVP|cyclophosphamide, vincristine, prednisone|CVP|153|155|SUMMARY OF HOSPITAL COURSE|It was felt that his ascites was most likely related to progression of his CLL and after review of treatment options he underwent chemotherapy using the CVP regimen on _%#MMDD2002#%_. He tolerated this treatment quite well and had marked resolution of the ascites and decrease in abdominal discomfort.
CVP|central venous pressure|CVP|164|166|ASSESSMENT/PLAN|Will continue Septra prophylaxis as well. 5. Hypotension. This may be due to sepsis syndrome versus autonomic instability. A central line was placed to monitor her CVP and it is low. We will volume resuscitate to bring her CVP up and then maintain her blood pressure with pressors, if needed.
CVP|central venous pressure|CVP|223|225|ASSESSMENT/PLAN|Will continue Septra prophylaxis as well. 5. Hypotension. This may be due to sepsis syndrome versus autonomic instability. A central line was placed to monitor her CVP and it is low. We will volume resuscitate to bring her CVP up and then maintain her blood pressure with pressors, if needed. Will also check a Cortisol to make sure she is not adrenally insufficient.
CVP|central venous pressure|CVP|157|159|ASSESSMENT AND PLAN|6. Hemodynamics: Swan-Ganz catheter placed due to hypotension and acute renal failure, to assess volume status. Initial reading shows a wedge of 5 to 8, and CVP of 3 to 4. This was after almost 4 liters of fluid. We will continue to give her crystalloid, and follow her hemoglobin.
CVP|central venous pressure|CVP|190|192|HOSPITAL COURSE|He was moderately hemodynamically unstable in the emergency room, requiring significant IV fluid replacement in addition to orotracheal intubation, arterial line placement, and left femoral CVP line placement. He was volume resuscitated aggressively in the Intensive Care Unit, to which he responded well, and he was extubated on _%#MMDD2002#%_.
CVP|central venous pressure|CVP|235|237|OPERATIONS/PROCEDURES PERFORMED|DISCHARGE DIAGNOSIS: Congestive heart failure. OPERATIONS/PROCEDURES PERFORMED: Right heart catheterization by Dr. _%#NAME#%_ _%#NAME#%_ on the day of _%#MM#%_ _%#DD#%_, 2003. Please see official report. PA pressures were 32/18 with a CVP of 16 and a wedge of 18-20. HISTORY OF PRESENT ILLNESS: A 40-year-old gentleman with a history of lupus and aortic valve replacement who has cardiomyopathy, is on the transplant list 2 with an EF of 15% who comes in for his 1-year evaluation and was found to have pulmonary hypertension.
CVP|central venous pressure|CVP,|674|677|HISTORY|The patient has a history of severe deforming arthritis, severe kyphosis, hypercholesterolemia and hypertension. She underwent an echocardiogram in _%#MM#%_ 2003 which demonstrated mild-to-moderate posterior mitral annular calcification, severely decreased left ventricular systolic function with an estimated ejection fraction of 10-15%, mild-to-moderate decrease in right ventricular systolic contractility, but size was within normal limits, and she had moderate mitral regurgitation and trileaflet aortic valve with moderate aortic sclerosis, moderate tricuspid insufficiency with severe pulmonary hypertension with right ventricular systolic pressures of 49 mm Hg plus CVP, and there was no evidence of pericardial effusion. She was admitted to Fairview Southdale Hospital on _%#MMDD2004#%_ with an exacerbation of her congestive heart failure.
CVP|central venous pressure|CVP|198|200|PHYSICAL EXAMINATION|Pupils are equal, round, and reactive to light. No scleral icterus. Nares and throat clear. Mucous membranes are slightly dry. NECK: Supple. Full range of motion. No lymphadenopathy or thyromegaly. CVP appears to be somewhat elevated at approximately 8- 9. LUNGS: It is painful for him to turn over. He has crackles in the bases bilaterally.
CVP|central venous pressure|CVP|157|159|PLAN|Will follow blood gas intermittently. 3. Cardiovascular: Will monitor patient closely from cardiovascular standpoint including blood pressure monitoring and CVP monitoring. Given patient's excellent cardiac status postoperatively, patient is likely to do well. 4. Gastrointestinal: Will make patient n.p.o. at this time and give him Zantac q.8 h.
CVP|central venous pressure|CVP.|111|114|PLAN|He will be transfused for anything less than 9.5. 3. A central line will be placed for access and to monitor a CVP. 4. Protonix 40 mg IV q 12 hours will be given. 5. Blood work will also be monitored on a q four hour basis for hemoglobin, calcium and potassium.
CVP|central venous pressure|CVP|191|193|PLAN|5. Blood work will also be monitored on a q four hour basis for hemoglobin, calcium and potassium. 6. The patient will be hydrated with half-normal saline at 150 cc an hour. Will monitor the CVP adding boluses based on this and urine output. 7. Primaxin will be continued at 500 IV piggyback q eight hours pending cultures.
CVP|central venous pressure|CVP.|338|341|HISTORY OF PRESENT ILLNESS|Specific findings on echocardiography from the day of admission include a left ventricular ejection fraction of 44%, left ventricular and diastolic diameter of 6.2 cm, moderate mitral regurgitation and left atrial enlargement, mild tricuspid regurg and pulmonary insufficiency, and pulmonary artery pressures estimated at 75/32 mmHg plus CVP. Subsequent catheterization revealed right atrial pressures of 10/8, right ventricular pressures of 67/6, pulmonary artery pressures of 65/27 with a mean of 40, and pulmonary artery wedge pressures of 28/32 with a mean of 22.
CVP|central venous pressure|CVP|186|188|HOSPITAL COURSE|Postoperatively, the patient was taken back to the ICU. His tremors were not longer present. The patient was on Zosyn for prophylaxis. A central line was placed to monitor the patient's CVP on the evening of _%#MMDD2006#%_. The patient was transferred back to the floor on _%#MMDD2006#%_, he continued to have low-grade temperatures, but is blood pressure was stable.
CVP|central venous pressure|CVP|252|254|HOSPITAL COURSE|Immediately prior to his transfer, a cardiac echo was obtained to evaluate for any cardiac dysfunction, as possible cause of renal failure secondary to cardiac failure. This study was unremarkable, and relatively unchanged from a prior echocardiogram. CVP was measured at 15. Mr. _%#NAME#%_ was then brought to the Surgical Intensive Care Unit and a central line and dialysis access were placed.
CVP|central venous pressure|(CVP)|194|198|PLAN|PLAN: Our plan at this point will be to continue generous IV fluids, continue broad antimicrobial therapy while awaiting cultures, continue stress-dose corticosteroids. Central venous pressures (CVP) will be monitored. Generous potassium and magnesium supplementation will be given and certainly nutritional support via parenteral route may also be indicated.
CVP|central venous pressure|CVP|168|170|PHYSICAL EXAMINATION|(The patient is sedated and on a ventilator.) PHYSICAL EXAMINATION: HEMODYNAMICS: Hemodynamics most recently show a cardiac output of 2.9; cardiac index 1.5; SVR 1212; CVP 13; PAWP 20. (Thus, she has a low cardiac output, a relatively normal SVR, and a high pulmonary artery wedge pressure and a high CVP.) VITAL SIGNS: Blood pressure 95/45.
CVP|central venous pressure|CVP|125|127|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Current blood pressure 105/55, pulse 110 to 115, respiratory rate 12 and unlabored, PA pressure 30/13, CVP 8, cardiac output 7.3, SVR 1029. In general, the patient is a somewhat- agitated white male bucking the ventilator, orally intubated, and otherwise in no acute distress.
CVP|central venous pressure|CVP|144|146|PHYSICAL  EXAMINATION|VITAL SIGNS: Temperature 97.8, pulse 90, blood pressure 91/51, respirations 20, oxygen saturations 95% on 4 liters per minute by nasal cannula. CVP is 4 central venous oxygen saturation is 80%. HEENT: Pupils are round and reactive, sclerae white, conjunctiva moist, pink.
CVP|central venous pressure|(CVP)|303|307|PHYSICAL EXAMINATION|Father died at age 72. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature maximum in the last 24 hours has been 101.2 with a temperature currently of 99.8. Blood pressure has been 90- 130/40-60. Respirations 18-22. Pulse is in the 80s. Pulse oximeter is 88- 98% on 3-4 liters of O2. Central venous pressure (CVP) has ranged from 4-12. Intake and output (I&O) over the last 24 hours has been 7060-cc in, 3500-cc out. He is receiving D5 LR with 20 of potassium at 125-cc per hour.
CVP|central venous pressure|CVP|257|259|PHYSICAL EXAMINATION|Currently she is awake, alert, and oriented to person, place, and time with a blood pressure of 159/75, pulse rate 70, temperature 97.4 and afebrile since midnight at least, respiratory rate of 20, and saturation 99 percent on IMV eight breaths per minute. CVP is 14. The pupils are equal and reactive to light. The extraocular muscles are intact. The neck is supple. There is no visible jugular venous distention.
CVP|central venous pressure|CVP|146|148|PHYSICAL EXAMINATION|VITAL SIGNS: Temperature 99.0, respirations 22, blood pressure most recently 90/40, heart rate in the 120s. Pulmonary artery pressures are 32/18. CVP is 13. Most recent pulmonary capillary wedge pressure is 14. HEENT: She has had some alopecia. Her head is notable for the Ommaya reservoir, but is otherwise without trauma.
CVP|central venous pressure|CVP.|137|140|PLAN|6. Recent atrial fibrillation and atrial flutter, status post cardioversion currently on Lovenox. PLAN: 1. Volume resuscitation based on CVP. 2. Central line. 3. Norepinephrine for blood pressure support. 4. Check adrenal function. 5. MRI of the cervical and thoracic spine. 6. Consult with the _%#CITY#%_ Clinic of Neurology as discussed above.
CVP|central venous pressure|(CVP)|321|325|RECOMMENDATIONS|She required volume resuscitation in the form of 2 liters of saline and ultimately was placed on dopamine and her current blood pressure is in the range of 115 and her dopamine has subsequently been discontinued. RECOMMENDATIONS: 1. Ongoing IV fluids. 2. IV colloid as needed to maintain elevated central venous pressure (CVP) in addition to blood pressure. 3. Calcium gluconate for cardiac protection. 4. Insulin and glucose for reduction of potassium, in addition to correction of her pH.
CVP|central venous pressure|CVP|149|151|RECOMMENDATIONS|5. We will DC furosemide at this time. 6. We will continue his antibiotics. 7. Blood cultures need to be drawn. 8. We will document urine sodium. 9. CVP reading might be beneficial in this setting. However, I think placement of a central line would be quite difficult given his current clinical status and his level of agitation.
CVP|central venous pressure|CVP|162|164|RECOMMENDATIONS|7. Apparent ongoing cerebrovascular process, question of left occipital involvement. MRI being attempted complicated by anxiety issues. RECOMMENDATIONS: 1. Check CVP as line is already in place to estimate volume status and if CVP less than 8 would increase volume resuscitation to goal in the range of 10-12.
CVP|cyclophosphamide, vincristine, prednisone|CVP|166|168|CHEMO/RADIATION TREATMENT HISTORY|LABORATORY DATA: Normal. FAMILY HISTORY/SOCIAL HISTORY: No change. CHEMO/RADIATION TREATMENT HISTORY: He had six cycles of chemotherapy ending in _%#MMDD2005#%_ with CVP (cyclophosphamide, vincristine and prednisone) and Rituxan. He is due in three months for his first of four Rituxan weekly. ALLERGIES: No known allergies. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 130/80, pulse 72, respirations 18, temperature 97.4, height 6 foot 1 inches and weight 252.
CVP|central venous pressure|CVP|175|177|RECOMMENDATIONS|5. IV plus TPN to equal 100 an hour. 6. Diprivan. 7. Check urine sodium. 8. Proton pump inhibitor. 9. Teds plus pneumoboots. 10. Serial hemoglobins. 11. Check fibrinogen. 12. CVP goal in the range of 12. HISTORY: Limited as we note. 68-year-old female awoke this morning from sleep complaining of abdominal pain and back pain.
CVP|central venous pressure|CVP|138|140|IMPRESSION|His estimated tidal volumes have been in the range of 500-600 and his ventilation has been adequate. 3. Mild hypotension with a decreased CVP and decreased urine output which had previously responded to IV colloid infusion. 4. History of hypertension. 5. Requirement for fresh frozen plasma and PRBC's intraoperatively with a hemoglobin initially on presentation of 7.7, now currently 10.
CVP|central venous pressure|CVP|197|199|EXAMINATION|HEENT: No significant thrush, although maybe a patch in the right palate noted. Pupils are round, react to light. Extraocular muscles intact. No facial skin rashes. NECK: Supple and nontender. His CVP line has presumably been in place for some time. Slight redness around the site, but no drainage or obvious abnormality.
CVP|central venous pressure|CVP|135|137|PHYSICAL  EXAMINATION|REVIEW OF SYSTEMS: As above. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature is 97.9, pulse 104, blood pressure 92/46, respirations 12, CVP is 3. HEENT: No evidence of head trauma. Pupils are round and reactive, sclerae are nonicteric. NECK: Veins are not distended, carotids are full without bruit.
CVP|central venous pressure|CVP|196|198|PHYSICAL EXAMINATION|No increased respiratory effort. CARDIOVASCULAR: Distant heart sounds, S1, S2 without murmur, gallop or rub. There is JVD of approximately 6-7 cm with HJR. There is also a late Kussmaul's rise in CVP with deep inspiration. ABDOMEN: Quite obese, but soft, tender without bruits, organomegaly or mass. Femoral pulses are grossly normal without bruits. EXTREMITIES: Pedal pulses are 1-2+ and symmetrical.
CVP|central venous pressure|CVP|267|269|HISTORY|His blood pressure did respond to that. He was initially on 20 of dopamine, that has been decreased to 12 and his blood pressure is in the range of 90-95 systolic. He is still tachyacrdiac but his rate is decreased from 160 to 130. CV line was placed and his initial CVP rate was in the range of 4, and internal line has also been placed by anesthesiology. He is awake and alert, is lethargic complaining of a sore throat, persistent abdominal pain and diarrhea.
CVP|central venous pressure|CVP|168|170|PHYSICAL EXAMINATION|Temperature 99.7, heart rate 115-125, respirations 26- 28. Oxygen saturation is 26 percent on 2 liters nasal cannula. Systolic blood pressure is 100-110 (no pressors). CVP is 7. Accu-Cheks are running in the high 200 range (on TPN). Sclerae are clear. SKIN shows no jaundice. NECK shows no gross mass.
CVP|central venous pressure|(CVP)|201|205|ASSESSMENT|ASSESSMENT: Etiology of the primary condition is not clear. He has a cardiomyopathy with a very low ejection fraction and chest x-ray looks like congestive heart failure though central venous pressure (CVP) has been low and he seems to have responded to volume. He may be septic and this could be an acute respiratory distress syndrome (ARDS) picture.
CVP|central venous pressure|CVP|181|183|HISTORY|He was becoming obtunded and confused. In the ER he was noted to be hypoxic and hypotensive and was intubated and placed on a ventilator. He did, in fact, receive 2800 cc of fluid. CVP was low. Initial chest x-ray showed diffuse bilateral alveolar infiltrates. Two hours later there was some clearing postintubation. He is known to have a severe cardiomyopathy with ejection fractions in the 15% range.
CVP|central venous pressure|CVP|141|143|PHYSICAL EXAMINATION|Blood pressure is 121/65. Swan numbers show P-A 35/18, CVP 11. Her core temperature is 97. SKIN: Exam benign. HEENT: Nonicteric. NECK: Has a CVP line and Swan in the right neck. There is no thyromegaly or adenopathy. CHEST: Chest exam is clear anteriorly and laterally.
CVP|central venous pressure|CVP.|335|338|RELEVANT LABORATORY DATA|Left ventricle is normal in size. Moderate to severe aortic stenosis with aortic insufficiency, mild to moderate mitral regurgitation, moderate tricuspid regurgitation with estimated pulmonary pressures estimated at 73 mmHg. plus RA. The inferior vena cava is dilated and does not collapse with inspiration consistent with an elevated CVP. IMPRESSION/RECOMMENDATIONS: See above. It is likely that the patient has atypical pneumonia with an additional component of congestive cardiac failure possibly related to her anemia and underlying valvular abnormalities.
CVP|central venous pressure|CVP|164|166|PLAN & RECOMMENDATIONS|6. Possible aspiration pneumonia; right pleural effusion vs diffuse right lung infiltrate. 7. Possible Macrodantin toxicity. PLAN & RECOMMENDATIONS: 1. Fluids with CVP as guide for volume. 2. Low dose dopamine has been started to support blood pressure. 3. On Zosyn. 4. Vent per pulmonary. 5. Monitor renal function closely.
CVP|central venous pressure|CVP|203|205|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: He grimaces during the exam, but opens eyes, but cannot communicate. The blood pressure is 110/50, pulse is 85-95, he is now afebrile. Respiratory rate is 18. O2 saturation is 100% CVP 10-12, previously now 9. His urine output has been 68 to 100 ccs. per hour. His vent settings are CMV at 9, FiO2 at 50%.
CVP|central venous pressure|CVP|135|137|IMPRESSION|He is on a low dose of dopamine for blood pressure support. We are going to give him two units of packed cells. This will increase his CVP and perhaps the Dopamine can be weaned off. 6. Peritonitis. He is on Flagyl and Levaquin. We will send blood, sputum and urine cultures now.
CVP|central venous pressure|CVP|264|266||Mr. _%#NAME#%_ is seen in followup visit and is a 42-year-old gentleman who is status post DeBakey LVAD inserted as a bridge transplant on _%#MMDD2005#%_. The patient is currently hemodynamically stable. He had elevation of pulmonary artery pressures with rise in CVP at the time, but was awake yesterday and required use of nitric oxide. PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile, blood pressure 18 x 60 with a mean of 74.
CVP|central venous pressure|CVP|178|180|PHYSICAL EXAMINATION|Temperature is 98.6, heart rate around 100 in sinus rhythm, blood pressure 110/60, respiratory rate was between 8 and 14 overnight, increasing to 20-30 while on a weaning trial. CVP is 5. HEENT: No evidence of head trauma. Pupils are round and reactive. Sclerae are white. Conjunctivae are moist and pink. Extraocular movements could not be fully assessed nor could funduscopic exam.
CVP|central venous pressure|(CVP)|234|238|ASSESSMENT|ASSESSMENT: The patient at the present time appears to be relatively stable in the postoperative period. She still has evidence of significant intravascular volume depletion, however, with her tachycardia, low central venous pressure (CVP) and low fractional excretion of sodium (FENa). Meanwhile, her surprisingly elevated INR is presumably on the basis of recent nutrition deficit.
CVP|central venous pressure|CVP|117|119|CHEST X-RAY|Arterial blood gases are excellent: pH 7.4, pO2 128, pCO2 34. CHEST X-RAY: Satisfactory postoperative chest x-ray. A CVP line is in good position. Thank you for the opportunity to assist in Ms. _%#NAME#%_'s care.
CVP|central venous pressure|CVP.|181|184|IMPRESSION|6. Non-anion gap metabolic acidosis from GI bicarbonate losses. RECOMMENDATIONS: 1. Continue sodium bicarbonate replacement. 2. Intravenous fluids for volume replacement monitoring CVP. 3. Checking fractional excretion of sodium though it looks like it will be high (initial urine sodium was greater than 90 suggesting ATN).
CVP|central venous pressure|CVP|142|144|PHYSICAL EXAMINATION|Temperature is 101. There is a regular tachycardia at 135 by monitor. P waves are noted. Blood pressure is 140/90, respirations are about 20. CVP is 8-10. SKIN: Warm. Perfusion throughout seems satisfactory. HEENT: Unremarkable NECK: Unremarkable CHEST: Lungs demonstrate bilateral rhonchi in the bases.
CVP|central venous pressure|CVP|146|148|PHYSICAL EXAMINATION|The neck is supple. There is no adenopathy. LUNGS: Clear bilateral breath sounds, no wheezes or rales. CARDIAC: Regular rate and rhythm. He has a CVP of about 10. He has a I/VI systolic murmur across the precordium and no rub. ABDOMEN: No bruits, normal bowel sounds. Soft and nontender. No hepatosplenomegaly.
CVP|central venous pressure|CVP|194|196|PHYSICAL EXAMINATION|NECK: Supple. LUNGS: Show clear bilateral breath sounds, although there are bronchial breath sounds in both bases. CARDIAC: Regular rate and rhythm, normal S1, S2. No murmur, rub or gallop. The CVP is approximately 5. ABDOMEN: Obese, normal bowel sounds, there is diffuse mild tenderness. GU: Foley catheter in place. EXTREMITIES: Her feet and hands are cold.
CVP|central venous pressure|CVP|189|191|RECOMMENDATIONS|6. Recent stroke with no residual with left hemiparesis and stenotic RCA and LICA. 7. Hypertension. RECOMMENDATIONS: 1. Continue aggressive hydration. Will increase his IV rate. 2. Monitor CVP if possible with the Port-A-Cath he has present. 3. Followup potassiums. If it is coming down with the treatment given in the Emergency Room (calcium and bicarbonate and oral Kayexalate) we will be able to decrease the Kayexalate frequency and give only on a prn basis.
CVP|central venous pressure|CVP|257|259|PHYSICAL EXAMINATION|ALLERGIES: None known. PHYSICAL EXAMINATION: VITAL SIGNS: He is hypothermic with a temperature of 96, blood pressure approximately 90-100 systolic on 7 of dopamine. Respiratory 16. Vent settings are as previously noted. Pulmonary pressures 32/20, wedge 20, CVP 12. I's and O's: 459 in, 0 out. GENERAL: Vented via trach, unresponsive. HEENT: Normocephalic and atraumatic. Pupils are very, very sluggish. They have a glazed look.
CVP|central venous pressure|CVP|136|138|PHYSICAL EXAMINATION|Augmented mean pressure is running between 50 and 60. Cardiac output 5.3 liters/minute, SVR 693, pulmonary capillary wedge pressure 24, CVP 11. HEENT: No evidence of trauma. He has a nasogastric tube in place. He is orally intubated. Pupils are approximately 3 mm in diameter and sluggishly reactive.
CVP|central venous pressure|CVP|237|239|NECK|VITAL SIGNS: Temperature was initially 34.2 degrees Centigrade, respiratory rate initially 12 and increased to 16, blood pressure has been somewhat labile but has settled out around 110/60, heart rate in the 80s, oxygen saturation 100%, CVP is 12, weight 93 kg. NEUROLOGIC: She is sedated, does not respond to even painful stimuli. LABORATORY DATA: Sodium 141, potassium 5.6, chloride 115, bicarbonate 20, glucose 157, BUN 16, creatinine 1.56, calcium 5.3, initial pH of 7.17 rising to 7.25, initial pCO2 of 55, falling to 45, pO2 of 60 rising to 117 and bicarbonate 20 on both measurements.
CVP|central venous pressure|CVP,|214|217|RECOMMENDATIONS|4. Metabolic and respiratory acidosis, immediately postop. RECOMMENDATIONS: 1. Fluid orders, per Surgery protocol, but with potential for acute tubular necrosis would eliminate potassium-containing fluids. 2. With CVP, we will monitor and use as guide for fluid replacement. 3. He will remain on a ventilator through the evening of _%#MMDD2003#%_, and in the a.m. determine whether he is weanable.
CVP|central venous pressure|CVP|206|208|PHYSICAL EXAMINATION|She has normal lids, conjunctivae and sclerae. Her mouth shows good dentition. The posterior pharynx is good. NECK: Neck is supple, no adenopathy. CHEST: There are clear bilateral breath sounds. HEART: The CVP is about 13. She has a regular rate and rhythm. Normal S1 and S2. There is a II/VI systolic murmur. ABDOMEN: The abdomen is distended and she has an umbilical hernia.
CVP|central venous pressure|CVP|175|177|RECOMMENDATIONS|8. Hyponatremia, probably also volume-related. RECOMMENDATIONS: 1. Ventilator. Will try weaning when she is more hemodynamically stable. 2. Hypotension. Need central line and CVP monitoring. Will push IV fluids and colloid if CVP is running low, which I suspect. She is on Dopamine. Will try to taper as able.
CVP|central venous pressure|CVP|226|228|RECOMMENDATIONS|8. Hyponatremia, probably also volume-related. RECOMMENDATIONS: 1. Ventilator. Will try weaning when she is more hemodynamically stable. 2. Hypotension. Need central line and CVP monitoring. Will push IV fluids and colloid if CVP is running low, which I suspect. She is on Dopamine. Will try to taper as able. 3. Oliguria. Check urine sodium, creatinine and fractional excretion of sodium.
CVP|central venous pressure|CVP|243|245|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is sedated. His mean heart blood pressure is around 80 with a heart rate of 87 in atrial fibrillation. CARDIOVASCULAR SYSTEMS: RVAD flow is 5.1 liters per minute. LVAD flow is 5.24 liters per minute. CVP 8. His drips include amiodarone and heparin. RESPIRATORY SYSTEM: Bilateral breath sounds. His FiO2 was 50% with a pO2 of 120. ABDOMEN: Soft, nontender, nondistended; bowel sounds present.
CVP|central venous pressure|CVP|162|164|PHYSICAL EXAMINATION|Temperature 98.8, blood pressure 87/52, heart rate 150 and sinus tachycardia, respiratory rate in the 20s. She is intubated orally. Nasogastric tube is in place. CVP is running 8- 10. HEENT: She has obvious alopecia. Pupils are about 3 mm and reactive. Extraocular movements could not be fully assessed. Sclerae are white.
CVP|central venous pressure|CVP|173|175|HISTORY OF PRESENT ILLNESS|Cardiovascular System: LVAD flows 5.1 at a fixed rate of 16. Stroke volume is greater than 80. His drips include nesiritide, milrinone, amiodarone. P-pressures are 40 x 21. CVP is 12. His cardiac index is 2.4. Respirations from bilateral breath sounds, a few crepitations. Abdomen is soft. Bowel sounds present, nondistended, nontender. Lower extremities warm.
CVP|central venous pressure|CVP|167|169|HISTORY OF PRESENT ILLNESS|Intraoperatively, the patient experienced hypotension with systolics less than 80s for about 30 minutes, then rebounded to systolic pressures in the 160s to 180s. His CVP reached a nadir of 17, a maximum of 19 and when he left, it was 14. He did have good urine output throughout. His estimated blood loss was 1500 cc, 1000 cc were returned via Cell Saver.
CVP|central venous pressure|CVP|233|235|HISTORY OF PRESENT ILLNESS|He has actually received labetalol x1 dose as well. The patient was paralyzed during the procedure and may require further paralyzation through the night if he develops any bucking of the vent to prevent to abdominal dehiscence. His CVP is currently 13-17. He did make a 1000 cc of urine during the case. He received a lot of fluid and blood products intraoperatively.
CVP|central venous pressure|CVP|174|176|PHYSICAL EXAMINATION|Mouth: Good dentition. Posterior pharynx clear. NECK: Supple. LUNGS: Show clear breath sounds. CARDIAC: Regular rate and rhythm, normal S1, S2. No murmur, rub or gallop. His CVP looks to be about 5 based on his neck veins. ABDOMEN: Normal bowel sounds. No bruit in the epigastrium. Soft and nontender.
CVP|central venous pressure|(CVP)|266|270|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Unobtainable. PHYSICAL EXAMINATION: VITAL SIGNS: Present blood pressure is in the range of 100-110 systolic/70 diastolic. Pulse is in the range of 80 and appears to be sinus rhythm. Pulmonary artery (PA) pressure is 29/17. Central venous pressure (CVP) is 7.0. GENERAL: The patient is an acutely ill-appearing female who is unresponsive secondary to anesthesia. HEENT: Normocephalic, atraumatic. Pupils are equal, round and reactive to light and accommodation.
CVP|central venous pressure|CVP.|226|229|HISTORY OF PRESENT ILLNESS|There was normal function and a small patent foramen ovale with a left to right shunt. On _%#MMDD2007#%_ she had an echocardiogram which showed pulmonary hypertension with estimated right ventricular pressures of 50 mmHg plus CVP. She did have good left ventricular and right ventricular function with a small patent foramen ovale. In reviewing her recent chest x-rays, she did have a chest x-ray on _%#MMDD2007#%_, which shows hazy coarse opacities through both lungs which suggested possible edema superimposed on BPD with an increasing heart size.
CVP|central venous pressure|CVP|210|212|LABS|Platelet count 84,000. Electrolytes within normal limits. Creatinine 0.8. I reviewed his right heart catheterization which was performed by Dr. _%#NAME#%_, which shows cardiac index of 2.1, PA pressures 45/20, CVP 12. He currently has cardiac failure with history of lymphoma leading to Adriamycin-induced cardiomyopathy with decompensating congestive heart failure.
CVP|central venous pressure|CVP|136|138|HISTORY|Urine output was initially 75-100 per hour as that dwindled in the past six or seven hours. This corresponds with a slow decline in his CVP which was 22 at midnight and is more currently in the 9 to 10 range. He is being supported on a ventilator and now oxygenating well.
CVP|central venous pressure|CVP|141|143||The patient underwent re-measurement of his right heart hemodynamics, which continued to show elevated pulmonary pressures of 50 x 34 with a CVP of 14. In view of this, we recommend left ventricular assist device placement as a bridge to transplant because of his moderate to severe pulmonary hypertension.
CVP|cyclophosphamide, vincristine, prednisone|CVP|203|205|HPI|My key findings: CC: Follicular lymphoma. HPI: This is a 61-year-old male patient who has been diagnosed to have follicular lymphoma since 1979. The patient was treated with some chemotherapy, including CVP and CHOP. He also received radiation to the left axilla for the development of dedifferentiated large B-cell lymphoma in _%#MM2002#%_.
CVP|central venous pressure|CVP|122|124|CHEST X-RAY|CHEST X-RAY: Chest x-ray shows left upper lobe infiltrate which has improved since yesterday by my reading. A pacer and a CVP are in. ECHOCARDIOGRAM: Echocardiogram done two days ago shows an ejection fraction of 50% and left ventricular hypertrophy (LVH).
CVP|central venous pressure|CVP|199|201|IMPRESSION|His electrolytes, BUN and creatinine are normal. Will give him IV fluids and replace potassium and magnesium will recheck these in the morning. 3. Hypotension: We will volume expand him with measure CVP and use pressors as needed.
CVP|central venous pressure|CVP|189|191|RECOMMENDATIONS|5. Potential for ATN on her previous chronic renal failure. RECOMMENDATIONS: 1. Continue IV fluids with normal saline, Hespan/albumin. 2. Check a fractional excretion of sodium. 3. Monitor CVP with the current readings at 17-18 would look at readings in the 20-22 range. 4. On Bi-PAP adjusting for elevated pCO2. She may need reintubation if she tires out.
CVP|central venous pressure|CVP|181|183|PHYSICAL EXAMINATION|PAST MEDICAL HISTORY: Past medical history is documented in the chart. PHYSICAL EXAMINATION: On physical examination, she seems to have a normal volume status regarding fluid, with CVP repeated by me at 10 to 11. She does have a soft systolic murmur and some irregularity of the heartbeat which I took to be ectopic beats.
CVP|central venous pressure|CVP|266|268|RECOMMENDATIONS|3. Coagulopathy with Factor 5 Leiden mutation, previous DVT. Recent VQ study tends to rule out pulmonary embolism as cause of current symptoms. RECOMMENDATIONS: 1. _%#NAME#%_ _%#NAME#%_ is on epinephrine for blood pressure support. Will try to taper if possible. 2. CVP monitoring. A Swan-Ganz catheter may be helpful on optimizing her fluid therapy. Will discuss with Cardiology. 3. Currently receiving Levaquin. Klebsiella and urine blood and urine cultures obtained.
CVP|central venous pressure|CVP|224|226|PHYSICAL EXAMINATION|Heart rate 86. GENERAL: He is awake, following commands. CARDIOVASCULAR: LVAD flow is 4.2 liters/minute at a fixed rate of 9200 RPM. :Pulsatility index is 4.2. Mixed venous oxygen saturation is 61. PA pressure is 30/21, and CVP is 18. RESPIRATORY: There are bilateral breath sounds. He is on FIO2 of 30%. Arterial blood gas: pH 7.41/34/125/21/97%. ABDOMEN: Bowel sounds present.
CVP|central venous pressure|CVP|189|191|PHYSICAL EXAMINATION|Heart rate 86. GENERAL: He is awake, alert, oriented x3 and appears comfortable at rest. CARDIOVASCULAR: Some LVAD flows, 3.9 liters per minute at a fixed rate of 9400. Pulse index is 4.8, CVP is 12. Sternal wound appears stable. RESPIRATORY: Breath sounds both bases, few crepitations. O2 sat 98%-97% on 4 liters nasal cannula.
CVP|central venous pressure|CVP|252|254|IMPRESSION|His oncologist is at the University. 2. Neutropenia with a white blood cell count of most recently 1.1 and absolute neutrophil count of 200, presumed secondary to above. 3. Hypotension associated profound intravascular volume depletion with documented CVP in the range of 3-4 associated tachycardias. 4. Severe diarrhea over the past several days in the setting of recent chemotherapy and recent oral antibiotic course of unknown drug and indication.
CVP|central venous pressure|CVP|162|164|RECOMMENDATIONS|7. Document urine sodium, urine creatinine, assuming that his urine sodium will be low. 8. Wean dopamine as able to maintain systolic blood pressure. 9. Maintain CVP in the range of 8-10. 10. Discussion should be entertained regarding his code status and advanced directive as there has been none in this regard.
CVP|central venous pressure|CVP|162|164|PHYSICAL EXAMINATION|Raised JVP. Cardiac index 1.9 with full intraaortic balloon pump support, no pressors or anti-trops. She is also on Amiodarone and heparin. PA pressure is 32/15, CVP 14. RESPIRATORY: Bilateral breath sounds. Basilar scattered crepitations. ABDOMEN: Bowel sounds present, nondistended, nontender. No hepatomegaly. LOWER EXTREMITIES: Warm, slightly cool, mild edema. NEUROLOGICAL: Unable to assess completely as the patient is confused.
CVP|central venous pressure|CVP|246|248|OBJECTIVE|OBJECTIVE: VITAL SIGNS: T max and current is 101.6, blood pressure 80s-90s/30s-50s, heart rate 100s-110s, respiratory rate 10-14, sats 100% on 40% FiO2. Weight is 66.7 kg. In OR she had 9850 in, 300 of urine out and 2400 of blood loss noted. Her CVP is currently 3. GENERAL: She is awake and alert. She follows all commands. She can moves all extremities. She is intubated but currently not sedated.
CVP|central venous pressure|CVP|139|141|HISTORY OF PRESENT ILLNESS|Her postoperative course has been remarkable for hypotension in the ICU. The patient currently has systolic pressures in the mid 80s and a CVP of 4 to 5. The patient states that the surgery went well. In review of the operative records no significant complications are identified.
CVP|central venous pressure|CVP|237|239|PHYSICAL EXAMINATION|C-spine was dictated as normal. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 100, respiratory rate 14, SpO2 100%, blood pressure is 100/50, pulse 60. Cardiac output 3.3, cardiac index 1.6, SVR 1501, pulmonary artery pressure is 26/14, CVP 7, pulmonary capillary wedge pressure 13. NEUROLOGIC: The patient does follow some commands. HEAD: Unremarkable. NECK: Supple. Nontender. LUNGS: Clear to auscultation. HEART: Normal S1 and S2.
CVP|central venous pressure|CVP|160|162|CARDIOVASCULAR|On examination, he is afebrile. VITAL SIGNS: Blood pressure 90/60. CARDIOVASCULAR: LVAD flow is 4.5 liters/minute, RVAD flow is 4.3 liters/minute. DRIPS: None. CVP 15, PA pressure 40/26, cardiac index 2.1. LOWER EXTREMITIES: Cool; mottling of right lower extremity. LABORATORY DATA: White count 9, hemoglobin 9.5, platelet count 99,000, INR 1.29. Electrolytes are within normal limits.
CVP|cyclophosphamide, vincristine, prednisone|CVP|200|202|HISTORY OF PRESENT ILLNESS|Biopsy revealed follicular non-Hodgkin lymphoma. Bone marrow biopsy was positive. Mrs. _%#NAME#%_ did well until 1997, when she developed B-symptoms and decreased platelet count. She was treated with CVP chemotherapy with no response. Chemotherapy was changed to Rituxan without response, and was then changed to fludarabine with a good response.
CVP|cyclophosphamide, vincristine, prednisone|CVP|240|242|HISTORY OF PRESENT ILLNESS|DOB: _%#MMDD1930#%_ HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 74-year-old male with non-Hodgkin's lymphoma diagnosed in _%#MM2005#%_, recently followed at Mayo Clinic. He has been receiving chemotherapy at the Mayo Clinic with either CVP or CHOP with Rituxan, with his last treatment given in early _%#CITY#%_. He was hospitalized at Fairview Ridges shortly after his last treatment for febrile neutropenia, and his blood counts improved after several days in the hospital.
CVP|central venous pressure|CVP|233|235|REQUESTING PHYSICIAN|Overall he feels quite well. Perimeters demonstrate that his blood pressure is running in the 90s to 100s on phenylephrine 0.55. His cardiac output is 4.9. Systemic vascular system is 1,027. His pulmonary artery pressures are 21/10. CVP is 9. Urine output has been approximately 35 cc for the last four hours. His weight is up 1.7 kilograms from yesterday. He is in normal sinus rhythm in the 80s.
CVP|central venous pressure|CVP|148|150|PHYSICAL EXAMINATION|He is extubated. VITAL SIGNS: Current blood pressure is 110/56, pulse is 78 and regular, temperature 99, respiratory rate 20, PA pressure is 38/14, CVP 11. HEENT: Normocephalic, atraumatic without xanthoma. No arcus senilis. Moist mucous membranes. NECK: Neck is supple without thyromegaly. His CVP line has now been pulled and pressure is being held on his right neck CHEST: The chest demonstrates diminished breath sounds, left greater than right base, otherwise clear, with increased AP diameter and prolonged expiratory phase.
CVP|central venous pressure|CVP|144|146|RECOMMENDATION|F) Hypovolemia or ATN. 3. Pulmonary infiltrate right middle lobe, ? related. RECOMMENDATION: 1. Will continue to push IV saline, monitoring her CVP and back off on pressors if possible. 2. VP support currently with dopamine and norepinephrine. 3. CPAP support if able.
CVP|central venous pressure|CVP|217|219|IMPRESSION|3. Potential for ATN. 4. Hyponatremia preop secondary to diuretics. 5. History of congestive heart failure with reduced LV function. 6. Leukocytosis possible sepsis. RECOMMENDATIONS: Continue normal saline monitoring CVP and clinical status. Check urine sodium, creatinine and urine osmolality. We will calculate fractional excretion of sodium. Antibiotic coverage has been started by the medical service and cultures obtained.
CVP|central venous pressure|CVP|240|242|RECOMMENDATIONS|5. Concentrated infusions of Ativan and fentanyl rather than propofol may be less apt to the accentuate the hypotension and less likely to depress LV function than propofol. 6. Watch IV fluids and CVP and would avoid overhydration once the CVP gets higher than the high teens. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 42-year-old male, a never smoking engineer, who developed viral type symptoms two days prior to admission, which evolved into high fevers and increasing shortness of breath.
CVP|central venous pressure|CVP|151|153|PHYSICAL EXAMINATION|Significant alcohol use. FAMILY HISTORY: Is noncontributory PHYSICAL EXAMINATION: Afebrile. Blood pressure by ART line is 110's/50's, heart rate 70's. CVP is 11, O2 sats are 97% on the ventilator. A comfortable appearing man who is awake, is having some coughing fits. HEAD, EYES, EARS, NOSE AND THROAT: Is remarkable for telangiectasias of the face.
CVP|central venous pressure|CVP|229|231|ASSESSMENT/PLAN|Check EKG. I would recommend we keep the patient on the relatively dry side due to his concomitant pulmonary disease, attempt to extubate as able. Probable fluid management needs to be watched closely with daily weights, connect CVP monitor to watch closely the CVP pressures. Thank you for having us see this patient. Will continue to follow with you as needed.
CVP|central venous pressure|CVP|162|164|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 100.0. Pulse is regular with sinus tachycardia of 110. An occasional ectopic beat is noted. Blood pressure 110/55. CVP 10. Oxygen saturation 96% on FIO2 by ventilator of 0.7. GENERAL: On exam now the patient is alert. She is calm. She seems comfortable. SKIN: Skin shows good turgor.
CVP|central venous pressure|CVP|132|134|PHYSICAL EXAMINATION|Intake and output on _%#MMDD#%_ were 4633 in and 6500 out; on _%#MMDD#%_, it was 200 in and 2400 out, so he has volume deficit. His CVP is now 11. He is afebrile, pulse 99, blood pressure 86/57 per cuff, and 99/40 on A-line, and his respiratory rate is 12.
CVP|central venous pressure|CVP|200|202|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: In the ICU initially: Temperature 97.9, blood pressure 90s-50s on multiple pressors, heart rate 100, respiratory rate 24, sats 96% on 100% FiO2. PA pressures 40/11, CVP 12. GENERAL: She is intubated and sedated. HEENT: Shows significant facial and periorbital edema. Pupils are reactive. She moves her head a little bit. NEUROLOGIC: Unable to do an exam given all the sedation she is on.
CVP|central venous pressure|CVP|283|285|COMMENT|She has moderate to severe MR but I wonder how severe it actually is because the left atrium is not enlarged. As noted in the previous notes, the right-sided pressures were essentially mildly elevated but the CVP quite low at 4 when she had her heart catheterization and her current CVP on the echo that I reviewed is likely to be less than 5 as the IVC is small and collapses easily. It may be that we cannot diurese here altogether that fully because of low right-sided pressures but that close observation of weight and breathlessness and status may keep her out of trouble for the next few years.
CVP|central venous pressure|CVP|250|252|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature Max was 100.8, temperature current 99.6. Blood pressure is currently 120/70 on 1.2 mcg of Nipride. Respirations 20s, greater than 98% on 50% face mask. Swan-Ganz catheter readings: PA pressure is 31/11, CVP 9. Input 5800, output 2800. Weight this morning is 54.9 kg. On admission her weight was 50.6 kilos. GENERAL: The patient is awake, somewhat uncomfortable but in no respiratory distress.
CVP|central venous pressure|CVP|136|138|PHYSICAL EXAMINATION|Further history is not obtainable. PHYSICAL EXAMINATION: GENERAL: She is unresponsive. She is on the ventilator with an FIO2 of 80% Her CVP is 10. She is in A-fib at 97. VITAL SIGNS: Blood pressure 94/51, O2 sat is 100%, she is not febrile. SKIN: Negative except for herpetic lesion on the right lower lip.
CVP|central venous pressure|CVP|215|217|EXAMINATION|REVIEW OF SYSTEMS: Not obtainable. SOCIAL HISTORY: Not obtainable. EXAMINATION: Intubated, sedated. Will open his eyes, but not respond to commands. Blood pressure 80 and 110/56-60. Pulse is 80. He is afebrile. His CVP is 16. His blood sugars have been less than 200. He is on tube feedings at 30 cc/hr with 50 cc q. 4 hour water flush in addition to some IV fluid.
CVP|central venous pressure|CVP.|161|164|RECOMMENDATIONS|Would recommend infectious disease follow up for further advice on antibiotic treatment. She will need a central venous catheter for IV access and monitoring of CVP. Blood pressure support would maximize Dopamine at 10 MCG/KG/MIN and then go to Norepinephrine. Consider the addition of Vasopressin. Will check urine sodium and creatinine fractional secretion of sodium.
CVP|central venous pressure|CVP|152|154|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: At this time, his heart rate is 90, blood pressure 154/84, he is afebrile, and oxygen saturation is 95% on room air. CVP is 9. His pulmonary capillary wedge pressure is 6. PA pressure is 47/18. However, I believe that this CVP and PA pressure were before diuresis, and this wedge pressure was after diuresis.
CVP|central venous pressure|CVP.|135|138|BRIEF HISTORY|The chest x-ray was reviewed. Neurologically, the patient is alert and oriented. From a cardiac standpoint, he does have some elevated CVP. Initially, it was at 10 at 18 hours postoperatively, but as of this morning it is at 16. He does have some significant hypertension as well. Systolic blood pressure is 180/80 with a low of 119/58.
CVP|central venous pressure|CVP|260|262|BRIEF HISTORY|We will resume cardiac rehab. From a gastrointestinal standpoint, the patient is tolerating p.o. Genitourinary: The creatinine has reached a high of 3.78 yesterday and is now at 3.61. As stated previously, we will increase his diuresis, particularly since his CVP is high and his urinary output has trickled off. Transplant Nephrology is managing his renal transplant medications. From an infectious disease standpoint, he has no specimens to date and no cultures.
CVP|central venous pressure|CVP,|368|371|PLAN|He was evaluated by Dr. _%#NAME#%_ _%#NAME#%_ at _%#CITY#%_ _%#CITY#%_ at the Fairview _%#CITY#%_ _%#CITY#%_ Hospital. An echo obtained on _%#MM#%_ _%#DD#%_, 2002, demonstrated normal LV systolic function, mild mitral regurg, trace aortic regurgitation, mild to moderately decreased RV function, moderate to severe RV dilatation, RV systolic pressure that was 49 plus CVP, mild to moderate pulmonary stenosis, and then severe pulmonary regurgitation and a moderately dilated right atrium. The patient is having right heart complications associated with pulmonary insufficiency from the pulmonary valvectomy performed at the age of 6, and he is now becoming symptomatic.
CVP|central venous pressure|CVP|224|226|RECOMMENDATIONS|2) Push sodium bicarbonate to correct acidemia if possible. If not possible, consider follow-up CT and perhaps even a re-exploration. 3) On pressors. Use Dopamine at a maximum of 12 and then continue with Levophed. 4) Using CVP as volume monitor which I think is adequate at this point. We will use saline and albumin to push the CVP to the 15- 16 range.
CVP|central venous pressure|CVP|122|124|RECOMMENDATIONS|4. Follow ICU protocol for insulin infusion. 5. Bolus fluids; if BP drops she probably will be third spacing. 6. May need CVP monitoring if she becomes hypotensive. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 53-year-old woman who underwent elective splenectomy early this morning for a diagnosis of autoimmune hemolytic anemia.
CVP|central venous pressure|CVP|179|181|ASSESSMENT/PLAN|Lastly, he meets the criteria for activated protein C for sepsis, and we will start this today. To support his blood pressure, we will place him on Levophed as he has an adequate CVP and appears to be volume resuscitated. 2. Pulmonary hypertension. Echo during his hospital stay showed some pulmonary hypertension with PA systolics in the 40s and a dilated RV.
CVP|central venous pressure|CVP|136|138|PHYSICAL EXAMINATION|NEUROLOGICAL: She has been moving all four extremities without obvious focal motor weakness. SKIN: No petechiae, purpura or nodularity. CVP is in place. The readings have been in the 7-8 cm range since arrival here at 0300 from the post-anesthetic recovery room.
CVP|central venous pressure|CVP|196|198|RECOMMENDATIONS|I do not feel that we should aggressive pursue extubation or weaning at this time given her above clinical state. RECOMMENDATIONS: 1. IV fluid in the form of crystalloid normal saline to maintain CVP greater than or equal to 10. We will use colloid as indicated. 2. Serial hemoglobins. 3. Fresh frozen plasma. 4. Cryoprecipitate. 5. Up date chem 7.
CVP|central venous pressure|CVP.|146|149|RECOMMENDATIONS|6. Severe pulmonary hypertension. 7. Dementia. 8. Seizure disorder. 9. Code status of do not resuscitate. RECOMMENDATIONS: 1. Volume based on his CVP. We expect a high CVP, given his pulmonary hypertension. 2. Ventilator support, as orders. 3. DVT prophylaxis as long as coagulations return normal tonight.
CVP|central venous pressure|CVP|127|129|PHYSICAL EXAMINATION|Currently I have reprogrammed the pacer. He is now 100% AV paced at a rate of 88. Blood pressure is 110/66, PA pressure 51/19. CVP is 16. Temperature is 98.2. Cardiac output 3.9, SVR 1312. SKIN: Benign. HEENT: Nonicteric. NECK: Relatively supple. He has a Swan-Ganz in his right neck.
CVP|central venous pressure|CVP|402|404|PHYSICAL EXAMINATION|MEDICATIONS: Dopamine drip, aspirin 325, Demerol p.r.n., morphine sulfate 2-4 mg I.V. q.5minutes p.r.n. chest pain, nitroglycerin, Zofran, Lasix, lansoprazole, midazolam, Neo-Synephrine, and amiodarone. PHYSICAL EXAMINATION: She is intubated and unresponsive, pulse 140, blood pressure 108/64, SPO2 99% on mechanical ventilator, respiratory rate 16 to currently 30, pulmonary artery pressure is 45/27, CVP 14, mechanical ventilator settings are assist control, tidal volume of 700, rate 9, PEEP 5, FIO2 100%. General appearance, she is unresponsive. HEENT - unremarkable. NECK - supple, nontender.
CVP|central venous pressure|CVP|122|124|RECOMMENDATIONS|RECOMMENDATIONS: 1. Continue I.V. Lasix for the present, watching for over-diuresis. 2. May need a central line, possible CVP or even Swan-Ganz catheter for optimal fluid management. 3. She is hypokalemic. Will continue to replace potassium as long as she does not become oliguric.
CVP|central venous pressure|CVP|268|270|PHYSICAL EXAMINATION|No alcohol or drugs. PHYSICAL EXAMINATION: VITAL SIGNS: T-max in the ER was 101, currently 99.3, pressure 60s-80s/40s-50s, heart rate 130s, respiratory rate 17-21, sats 100% on 15 liters, 90% on 2 liters. Weight 82.4 kg. So far he has had 2800+ in, only 25 urine out. CVP is 14. GENERAL: He is awake and alert, but moaning. He is conversant. He does move all his extremities. HEENT: Exam is remarkable for face mask oxygen.
CVP|central venous pressure|CVP|141|143|HISTORY|Pulmonary is following along and think that volume overload is playing a major role here also. Her pulmonary artery pressures are 77/20, and CVP is 20, indicating marked volume overload. The patient is also hypertensive now at 160/80 and is on no pressors. The patient is somewhat sedated but appears depressed and sounds depressed.
CVP|central venous pressure|CVP.|233|236|RECOMMENDATIONS|5) Coagulopathy secondary to acute liver disease. 6) Rule out some type of drug toxicity, though initial tox screen apparently was negative. RECOMMENDATIONS: 1) Continue volume replacement; will need a central venous line to monitor CVP. 2) Correct coagulopathy; INR is elevated; will give fresh frozen plasma and vitamin K. 3) Calcium replacement, monitoring periodic checks of calcium and albumin.
CVP|central venous pressure|CVP|199|201|PHYSICAL EXAMINATION|She is on the vent. VITAL SIGNS: Her weight is 82.9. Her admission weight was 79.0. She is on CMV 10, 5 of PEEP, tidal volume 600, 60% FiO2. Blood pressure unassisted is 108/61. Her pulse is 90. Her CVP is 14. Her PAD is 26. Her PAWP is 24. Cardiac output is 5.7. Her maximum temperature today was 101.4, and now it is 100.4. Her urine output is 75 cc an hour.
CVP|central venous pressure|CVP|127|129|PHYSICAL EXAMINATION|CARDIOVASCULAR: LVAD flows 4.5 L/minute and RPM is 8600. Pulsatility index is 4.8. Drips milrinone 0.2. He is off epinephrine. CVP 12. PA pressure is 14 x 22. RESPIRATIONS: Bilateral breath sounds, no rhonchi, no crepitations. ABDOMEN: Soft, bowel sounds present, nondistended, nontender. LOWER EXTREMITIES: Warm, well perfused, no edema.
CVP|cyclophosphamide, vincristine, prednisone|CVP|234|236|HISTORY OF PRESENT ILLNESS|She noticed at that time inguinal lymph nodes which were biopsied showing follicular small cleaved cell type non-Hodgkin's lymphoma. At that time, she also had bone marrow involvement and was Stage IVA. She then underwent 8 cycles of CVP and did have a good response and did well until 2004. In 2004, she noticed left axillary node which was biopsied and did not show any transformation.
CVP|central venous pressure|CVP.|167|170|RECOMMENDATIONS|4. Hypotension probably volume related. 5. Oliguria, probably also volume related. RECOMMENDATIONS: 1. Need a central line and CVP monitoring and A line placement. 2. CVP. 3. Saline slush for hypotension. Fluids per CVP monitor. 4. Discussed with Dr. _%#NAME#%_. Will also get a CT abdomen to be certain that no significant abdominal trauma occurred.
CVP|central venous pressure|CVP|119|121|PHYSICAL EXAMINATION|GENERAL: He is awake and follows all commands. CARDIOVASCULAR: Some LVAD flows 4.1 liters at a fixed rate of 1900 RPM. CVP 9. RESPIRATORY: SIMV 12, FIO2 40%, arterial blood gas 7.40/44/170/27/98 percent. ABDOMEN: Soft, bowel sounds present, nondistended, nontender. EXTREMITIES: Lower extremities warm, well perfused.
CVP|central venous pressure|CVP|195|197|HISTORY OF PRESENT ILLNESS|He was found to also have extensive retroperitoneal adenopathy and his bone marrow biopsy was again positive for a recurrent follicular non- Hodgkin lymphoma. Mr. _%#NAME#%_ received 3 cycles of CVP chemotherapy, followed by 6 doses of Rituxan and reportedly had a partial response. He was re-staged in _%#MM2003#%_ which revealed persistent extensive intra- abdominal involvement by lymphoma, right pleural effusion and he also had hepatosplenomegaly.
CVP|central venous pressure|CVP|236|238|PHYSICAL EXAMINATION|No orthopedic problems, no neurologic problems. PHYSICAL EXAMINATION: GENERAL: The patient is completely asleep on the ventilator, post-surgery he is in a sinus rhythm at 66 with bundle branch block. VITAL SIGNS: Blood pressure 114/51, CVP is four temperature 36.2. SKIN: Benign. HEENT: Benign. NECK: Relatively supple, again though he is intubated. CHEST: Clear anteriorly and laterally. CARDIAC: Reveals a soft rub.
CVP|central venous pressure|CVP|153|155|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: He is afebrile, respiratory rate is 28, pulse is 161, SP02 is unmeasurable, blood pressure 70/40, pulmonary artery pressure 20/13, CVP 7, pulmonary capillary wedge pressure 10. GENERAL: He is extremely pale and unresponsive. NECK: Supple and nontender. LUNGS: Clear to auscultation. HEART: Normal S1 and S2. Regular rhythm but tachycardiac.
CVP|central venous pressure|CVP|250|252|IMPRESSION|He is status post T7 corpectomy, T7-8 discectomy with placement of a structural intervertebral device and right thoracotomy. 2. He has a long history of thoracic myelopathy. 3. New fevers, source uncertain, but possibly from a right internal jugular CVP line, which has been in place for several days. The blood cultures done on _%#MMDD2004#%_ showed gram-positive cocci to be identified.
CVP|central venous pressure|CVP|314|316|PHYSICAL EXAMINATION|HABITS: No tobacco or drug usage. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 100.0 degrees Fahrenheit, blood pressure 120s-140s/60s-80s, heart rate in the 80s, respiratory rate 22-26. Sats 98% on 100% BiPAP which has since been reduced. Weight is 105.7 kilograms. PA pressures 57-61/27-32. Wedge is around 30. CVP 13-15. GENERAL: He is pleasant, in no acute distress. Alert and oriented x3. Mood is good. Affect appropriate. He is lying flat on his back.
CVP|central venous pressure|CVP.|155|158|ASSESSMENT|The patient has been receiving intravenous fluids with maintenance of his blood pressure but worsening peripheral edema and inability to further raise the CVP. The patient also remains on pressors. This is a patient who is likely nutritionally depleted.
CVP|central venous pressure|CVP.|98|101|RECOMMENDATIONS|1. Postpartum hemorrhage. 2. Hemorrhagic shock. 3. DIC. RECOMMENDATIONS: Transfuse p.r.n. Monitor CVP. Fluids per CVP and clinical status; currently getting normal saline at 200 cc per hour. We will give additional boluses and colloid, if necessary. Monitoring hematology and coagulation parameters.
CVP|central venous pressure|CVP|220|222|RECOMMENDATIONS|Ultimately will need further workup under the direction of gastrointestinal service. 2. DVT prophylaxis. 3. Invanz for coverage of penicillin allergic patient. 4. IV crystalloid. 5. Continuous CVP monitoring to maintain CVP in the range of 10. 6. Update laboratories including renal panel to reassess creatinine postoperatively in addition to potassium and bicarbonate and further intervention as indicated.
CVP|central venous pressure|CVP|273|275|LABORATORY DATA|The LV-gram shows a globally dilated left ventricle with reduced ejection fraction of approximately 20% with grade 2+ mitral regurgitation. Review of the right heart catheterization reveals a cardiac index of 1.8 with a cardiac output of 2.8, a PA pressure of 35/18 with a CVP of 6 and a pulmonary artery wedge mean of 18. ASSESSMENT AND PLAN: A 55-year-old female with a new diagnosis of nonischemic dilated cardiomyopathy.
CVP|central venous pressure|CVP|136|138|PHYSICAL EXAMINATION|VITAL SIGNS: Weight is 54.3 kg, temperature 98.6 rectally currently, blood pressure 110/50, heart rate in the 80s, respiratory rate 20, CVP is 9. HEENT: She has both feeding tube and NG tubes in place. No evidence for head trauma. She has bitemporal wasting. She would not open her eyes for me and so I could not get a good pupillary or funduscopic exam.
CVP|central venous pressure|CVP|230|232|RECOMMENDATIONS|RECOMMENDATIONS: 1. Update chemistries to determine current level of renal function and electrolytes, likely to require some bicarbonate infusion on the basis of acidosis. 2. Aggressive crystalloid colloid replacement to maintain CVP greater than or equal to 10. 3. Pan culture, including blood and urine. 4. Adjust vent to decrease CO2 and attempt to normalize pH.
CVP|central venous pressure|CVP|109|111|PHYSICAL EXAMINATION|CARDIOVASCULAR: LVAD flow is 4.6 L/minute at a fixed rate of 3650. RVAD flow is 4.8 at a fixed rate of 3250. CVP 12. RESPIRATORY: Bilateral breath sounds. Increased right basilar crepitations. Oxygen saturations 98% on 4 L nasal cannula. ABDOMEN: Soft. Bowel sounds present. Nondistended and nontender. EXTREMITIES: Lower extremities are warm and well perfused.
CVP|central venous pressure|CVP|201|203|IMPRESSION|Will have to consider this, though I am not anxious to give him another contrast load as he is already just had one. 4. Volume status. He currently initially looks volume up with high neck veins, high CVP of 14-15 and a chest x-ray showing plump pulmonary vasculature, however later as his blood pressure fell so does his CVP and with continuing possible hemorrhage he may need volume and red cells.
CVP|central venous pressure|CVP|122|124|RECOMMENDATIONS|8. Previous episode of acute renal failure a month ago under similar circumstances. RECOMMENDATIONS: 1. IV fluid watching CVP closely. 2. Dopamine and subsequent norepinephrine if needed to support VP. 3. _%#NAME#%_ _%#NAME#%_ received Rocephin in the Emergency Department with Zithromax.
CVP|central venous pressure|CVP|188|190|RECOMMENDATIONS|She is at the present time hemodynamically unstable with evidence of significant nutritional compromise in the backdrop of both CLL and CML. RECOMMENDATIONS: 1. Central line placement for CVP monitoring and IV access. 2. Continue IV fluid infusion in the form of saline. 3. Replace NG output with half normal saline and 10 of potassium.
CVP|central venous pressure|CVP|286|288|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is awake and alert. VITAL SIGNS: Mechanical ventilation, SIMV tidal volume 900, FiO2 40% rate of 12, PEEP of 5, pressure support 5. Minute ventilation 10 liters/minute. No auto-PEEP. Temperature is 100.4, respiratory rate is 12, SpO2 is 100%. CVP is 3. Pulmonary pressure 20/8, pulmonary capillary wedge pressure 4. Blood pressure 180/60, pulse 80. HEENT: Unremarkable. NECK: Neck is supple and nontender.
CVP|central venous pressure|CVP|153|155|PHYSICAL EXAMINATION|She is alert and oriented times three, complaining of pain. VITAL SIGNS: Blood pressure 100/50, pulse 70 and regular, temperature 98.4, respirations 12, CVP line is in place and measures 10 cm. HEENT: There is no obvious scleral icterus. NECK: No JVD or bruits. LUNGS: Clear to P&A. HEART: Normal sinus rhythm. No definite murmur.
CVP|central venous pressure|CVP|169|171|PHYSICAL EXAMINATION|She lives with her boyfriend. FAMILY HISTORY: The patient unable. She is sedated on the ventilator. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 101.3, pulse 100-105, CVP 13-14, blood pressure 83/43, respiratory rate 22, drips are Ativan and Levophed. Blood sugars today are 234 and 235. She is on the ventilator on 40% FIO2 with a PEEP of 7.
CVP|central venous pressure|CVP|193|195|IMPRESSION|Her current phosphorus is 2.6, magnesium 1.7, potassium 3.1, BUN 8, creatinine 0.69. IMPRESSION: 1. Hypotension. We will transfuse her 2 units of packed cells and wean her Levophed to off. Her CVP is acceptable and we will monitor this. She has gotten a lot of fluids over the last few days as is appropriate.
CVP|central venous pressure|CVP|169|171|HISTORY OF PRESENT ILLNESS|She is currently ventilating easily on assist-control of 12 with a tidal volume of 450, PEEP of 5 and an FiO2 of 30%. Her saturations on these settings are 97-100%. Her CVP is 10. Her peak pressures are not high. Her minute ventilation is 10-12 L. Her past pulmonary history is fairly benign. She indicates that she did have Valley fever years ago while in Arizona.
CVP|central venous pressure|CVP|215|217|PHYSICAL EXAMINATION|Temperature is 37.6, respirations are 24 on assist control rate setting of 24, tidal volume is 600, PEEP of 15, FIO2 of 1.0, yielding an arterial blood gas of pH 7.32, pCO2 of 23, pO2 130 derived bicarbonate of 11, CVP is 24. HEENT: Alopecia, otherwise normocephalic, atraumatic. The eyes are taped shut with paper tape. This was not removed. Nose has packing in bilaterally. Oropharynx, endotracheal tube and orogastric tube are in place, otherwise clear.
CVP|central venous pressure|CVP.|153|156|RECOMMENDATIONS|3. Will probably attempt to rapid wean in the a.m. with stopping propofol, if unable to wean we will need to consider some nutrition support. 4. Monitor CVP. 5. IV fluids with normal saline. 6. Neurosurgery has seen and immediate surgical procedures not felt indicated. 7. Follow-up CT's and other neuro testing per neurosurgery service.
CVP|central venous pressure|CVP|150|152|REVIEW OF SYSTEMS CONSTITUTIONAL|The right coronary artery has about 50% mid segment lesion. The patient has elevated PA pressures, 56/31 at the pulmonary artery, wedge of 34, raised CVP as well as decreased cardiac index. ASSESSMENT AND PLAN: A 68-year-old female with past medical history of left lung transplant, end-stage renal failure on dialysis, diabetes mellitus with severe triple-vessel coronary artery disease admitted with pulmonary edema with cardiogenic shock.
CVP|central venous pressure|CVP|194|196|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: She is obese. She is unresponsive on the ventilator. She is afebrile. VITAL SIGNS: Pulse is 135 and sinus tachycardia. Blood pressure 112/60, respiratory rate 16. CVP 13. Her blood sugar was initially 416 but is now 107 on insulin drip. Her urine output was 150 cc for the first shift.
CVP|cyclophosphamide, vincristine, prednisone|CVP|166|168|HISTORY OF PRESENT ILLNESS|He received several courses of chemotherapy and had recurrence in _%#MM2004#%_. He responded somewhat to four doses of rituximab. Most recently, the patient received CVP and rituximab. The patient did respond and the mass in the right knee area had decreased in size temporarily and grew back again.
CVP|central venous pressure|CVP|184|186|PHYSICAL EXAM|Mouth shows good dentition. The posterior pharynx is clear. The NECK is supple. There is no adenopathy or thyromegaly. The LUNGS show bibasilar rales but no wheezes. CARDIAC EXAM: Her CVP is about 10, normal S1, S2, no murmur. ABDOMEN: Obese, normal bowel sounds, soft and nontender. No hepatosplenomegaly.
CVP|central venous pressure|CVP|223|225|PHYSICAL EXAMINATION|No consumption of alcohol or tobacco products currently. PHYSICAL EXAMINATION: GENERAL: Elderly female, currently lying in bed. VITAL SIGNS: Weight 50.8 kg, temperature 96, pulse 90, blood pressure 100/60, respirations 15, CVP is 2. HEENT: Pupils are 3-4 mm and reactive. There is arcus senilis. Sclera are white. Funduscopic and extraocular movements could not be fully assessed.
CVP|central venous pressure|CVP|130|132|IMPRESSION|Review of his I's and O's during both the surgery and subsequent recover reveal approximately 5,000 in and 1,000 out. His current CVP is noted to be approximately 15. His blood pressure is in the range of 90 and 100 systolic. 6. Known atherosclerotic disease with a recent Adenosine Thallium performed demonstrating cardiomyopathy with an ejection fraction in the range of 40% and significant wall motion abnormalities and reversible changes inferior, inferior septum and inferior lateral.
CVP|central venous pressure|CVP|210|212|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Not obtainable. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure in the range of 90 to 100 systolic. His rhythm is irregularly irregular, but rate controlled, less than 100. He is afebrile. CVP is running in the range of 14. GENERAL: He is orally intubated. He has an NG placed. He has a right IJ triple lumen catheter in place with some oozing at the site.
CVP|cyclophosphamide, vincristine, prednisone|CVP.|230|233|HISTORY|This was treated and felt to be resolved, but about a year ago he redeveloped diffuse lymphadenopathy and was found to have recurrence of his lymphoma. He was given Rituxan and then chemotherapy plus Rituxan. The chemotherapy was CVP. The patient has had bilateral total knee arthroplasties done in 2003. In the last one and a half to two weeks he has spontaneously noted swelling and discomfort of the knees bilaterally along with fever up to 102 degrees.
CVP|central venous pressure|CVP|141|143|ASSESSMENT AND PLAN|He probably has a combination of prerenal and ATN. a. Will check a FEna. b. Follow urine output and labs. c. Will continue hydration to keep CVP around 15 or so. 3. Metabolic acidosis. The patient has a significant lactic acidosis which is driving this. There is a mild component of respiratory acidosis but not significant.
CVP|central venous pressure|CVP|155|157|PHYSICAL EXAMINATION|The ejection fraction is 75% with hyperdynamic left ventricular systolic function. There is mild to moderate aortic insufficiency and evidence of elevated CVP with moderate pulmonary hypertension. The PA systolic pressure is estimated at 45 to 50 mmHg with normal right ventricular function and size.
CVP|central venous pressure|CVP|362|364|PAST HISTORY|Currently now, a few days post admission, on the _%#DD#%_ of _%#MM#%_, now the _%#DD#%_, she remains not thriving altogether that well in terms of alertness, continues to be on the respirator, is not arousable easily in any way that I can identify and has rapid atrial fibrillation with intermittent wide complexes that to my view are likely aberrant beats. The CVP initially placed, showed a CVP of 22, suggesting that fluid depletion was not a problem. Pulmonary embolus was considered in the differential diagnosis but the INR was 10 on admission which would make that diagnosis actually quite unlikely.
CVP|central venous pressure|CVP,|195|198|RECOMMENDATIONS|RECOMMENDATIONS: 1. Weaning attempt with ventilator to extubation if possible. 2. Fluid and colloid boluses as pressors are reduced. 3. Will give more sodium bicarbonate this morning. 4. Monitor CVP, basic IV is normal saline and volume pending CVP readings. 5. Nutrition support, will start TPN. 6. IV Protonix for GI prophylaxis.
CVP|central venous pressure|CVP|189|191|PHYSICAL EXAMINATION|His weight today is 73 kilograms which is up 1.5 from yesterday. Up 10 kilograms since his admission. Blood pressure runs between 100 and 110 systolic. Temperature 99.6, PA pressure 43/29, CVP 14. Urine put, however, is improving. SKIN: Benign. HEENT: Non-icteric. NECK: Supple. No thyromegaly or adenopathy. Bilateral bruits are noted. There is a Swan-Ganz catheter in the right neck.
CVP|central venous pressure|CVP|167|169|IMPRESSION/PLAN|His goal LDL cholesterol is less than 70. 3. Hypotension. This is likely secondary to fluid shifts postoperatively, along with some cardiac stunning postop. Since his CVP and wedge pressure were low earlier today, we will plan for a fluid bolus if needed if he has symptomatic hypotension.
CVP|central venous pressure|CVP|171|173|PHYSICAL EXAMINATION|VITAL SIGNS: He is febrile to 101.8 at the present time with a max of 102.6. His systolic blood pressure has been as low as 60-80 and is currently in the 90-95 range. His CVP is 9-10. His respiratory rate is 20-30. HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive to light and accommodation. Extraocular muscles appear intact.
CVP|central venous pressure|CVP|131|133|PHYSICAL  EXAMINATION|He has a regular rate and rhythm but bradycardia. Normal S1 and S2 with an S4 gallop. No S3 or murmur. There is no JVD or HJR. His CVP is currently 2. Pulses were all intact even peripherally. ABDOMEN: Soft, nontender. Bowel sounds are absent. No obvious organomegaly.
CVP|central venous pressure|CVP|150|152|IMPRESSION|IMPRESSION: 1. The patient is postoperative. Her blood pressure has decreased. She got her normal saline bolus and 2 units of packed cells. Since her CVP is low we are going to give her colloid and change her IV over the normal saline. 2. Respiratory anesthesia. Will be weaning her because she has this double bore ETT in place and they will manage this.
CVP|central venous pressure|CVP|211|213|IMPRESSION|Flat and upright abdomen shows some loops of bowel with some air fluid levels, but no obvious free air by my reading. We will treat him with IV fluids, colloid and blood. We will wean his pressures will monitor CVP SVO2 and his blood gases. He is on antibiotics. 2. Acute renal failure. This is mild, likely secondary to sepsis and being prerenal.
CVP|central venous pressure|CVP|217|219|PHYSICAL EXAMINATION|Currently the patient is unable to give any review of systems, as he is intubated. PHYSICAL EXAMINATION: VITAL SIGNS: Current blood pressure 108/52, pulse 80 and regular, respirations 12, temperature 101.3, PA 26/16, CVP 11, cardiac output 5.8 liters/minute, cardiac index 2.8 L/minute/m squared, SVR 1,214. GENERAL: The patient is a somnolent, orally-intubated white male in no acute distress.
CVP|central venous pressure|CVP|158|160|SKIN|Today she is on the ventilator. She is not sedated but minimally responsive. She is on 100% Fi02 and 10 of PEEP. Her cardiac output is 3.5. SVR 1004. PAD 22. CVP 13. She is on dopamine, neo- synephrine, and insulin drip. She is also getting some IV fluids. Right now her pulse is 115.
CVP|central venous pressure|CVP|182|184|PHYSICAL EXAMINATION|Normal lips, gums and tongue. LUNGS: There are clear breath sounds with a normal respiratory effort. There is no CVA tenderness. CARDIAC: Shows mild jugular venous distention with a CVP estimated at 10 cm. She has a II/VI systolic ejection murmur across the precordium. Normal S1 and S2. ABDOMEN: There is a large ventral hernia.
CVP|central venous pressure|CVP|110|112|RECOMMENDATIONS|7. Requirement for anticoagulation on the basis of her rhythm. RECOMMENDATIONS: 1. Central line placement. 2. CVP monitoring. 3. IV fluids. 4. Nonsteroidals as previously ordered paying close attention to her urine output and her underlying baseline serum creatinine.
CVP|central venous pressure|CVP|194|196|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Is negative except as noted above. PHYSICAL EXAMINATION: Today on exam, he is alert, he is oriented, he is laying comfortably in bed. His pulse is 107, his O2 sat is 95%, his CVP is less than 0, blood pressure is 96/62, he is afebrile. SKIN: Is unremarkable HEAD: Shows no trauma EYES: Show pupils round and react to light.
CVP|central venous pressure|CVP|148|150|PHYSICAL EXAMINATION|LUNGS: The lungs show clear bilateral breath sounds and a normal respiratory effort. CARDIAC: Regular rate and rhythm. Normal S1 and S2. There is a CVP of approximately 7-8. Pacer in the infraclavicular region. ABDOMEN: Obese, it is soft and nontender. There is no hepatosplenomegaly. GU: Exam is a normal female pattern.
CVP|central venous pressure|CVP|162|164|PHYSICAL EXAMINATION|His blood sugar is 217. His weight is 45.5 kg from 45.1 yesterday. His blood pressure is 106/48, pulse 77. He has had no fever. His respiratory rate is 8-12. His CVP is 14. He is getting TPN at 65 cc/hr and D5 normal saline at 100 cc/hr. His intake and output yesterday was 7430/1210. His urine output for the first shift today was 900 cc.
CVP|central venous pressure|CVP|134|136|PHYSICAL EXAMINATION|CHEST: The lungs show a few scattered wheezes and some bronchial breath sounds in the bases. HEART: No jugular venous distention. The CVP is less than 5. Normal S1 and S2. No murmur. ABDOMEN: Bowel sounds are normal, no bruits. Abdomen is soft and nontender. No hepatosplenomegaly. GENITAL/RECTAL: GU exam shows a normal male pattern.
CVP|cyclophosphamide, vincristine, prednisone|CVP|131|133|HISTORY OF PRESENT ILLNESS|The patient was treated initially with fludarabine and stopped after two cycles with a poor response. Chemotherapy was switched to CVP and he received eight cycles with a good response. The patient was off chemotherapy for one year when he was found to have progression of the disease.
CVP|central venous pressure|CVP|165|167||I would consider milrinone at 0.25 mcg/kg/min to support the failing RV and further enhance the vasodilatation of the pulmonary circulation. 2. Volume overload. The CVP is in the 10-14 mmHg range. Continue PRISMA and unloading to prevent third-spacing. Please call if you have questions.
CVP|cyclophosphamide, vincristine, prednisone|CVP|220|222|HISTORY OF PRESENT ILLNESS|Bone marrow biopsy was positive. Through her workup it was also detected that she had cardiomyopathy which was a new diagnosis for her. Mrs. _%#NAME#%_ received four cycles of CHOP chemotherapy followed by two cycles of CVP chemotherapy. In _%#MM#%_, 1999, she received radiation at the St. Francis Cancer Center. The area treated was the mediastinum. Her records are not available for our review.
CVP|central venous pressure|CVP|145|147|RECOMMENDATIONS|5. Hypocalcemia, question etiology. RECOMMENDATIONS: 1. Will continue IV fluids with normal saline and continue bolus Hespan and N-S. 2 May need CVP monitoring. 3. Surgery to see. 4. Follow-up CT if clinical parameters deteriorate. 5. Blood cultures, urine culture, then cover for potential sepsis with intravenous Zosyn.
CVP|central venous pressure|CVP|109|111|DISCUSSION|The patient has received a 20 mg dose of furosemide in the last hour or two and has had a good diuresis. Her CVP at that time has fallen from 18 to 14. EXAMINATION: When examined the patient is sleeping on the ventilator, but awakens quickly to voice.
CVP|central venous pressure|CVP|236|238|RECOMMENDATIONS|3. A CT scan of her abdomen could be done to evaluate for any sort of fluid collection within her abdomen or pelvis or other problems. 4. I would resume systemic antibiotic therapy using vancomycin, Flagyl, and ceftazidime. 5. Consider CVP line exchange or replacement. HISTORY OF PRESENT ILLNESS: This is a 39-year-old woman who has been here since _%#MM#%_ _%#DD#%_, 2003, to have the surgical procedure noted above carried out.
CVP|central venous pressure|CVP|87|89|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: The patient is unable to report. PHYSICAL EXAMINATION: VITAL SIGNS: CVP in place, pulse 84, blood pressure 134/50. Respirations: The patient is vented. Weight is up to 109 kg from 105.9. Temperature 97 currently, and that is the max.
CVP|central venous pressure|CVP|125|127|LABORATORY  DATA|His blood pressure initially upon my evaluation of him was systolic in the 80 to 90 range and diastolic in the 50 range. The CVP at that time was about 13. I decreased the milrinone to 0.25 mg/kg/minute and the blood pressure increased to systolic greater than 110 and diastolic in the 60 to 70 range.
CVP|central venous pressure|CVP|137|139|PHYSICAL EXAM|She has no fever, her respiratory rate is 16. Urine output has been quite low over the first shift. She has oximizer in place and NG and CVP in the right IJ vein. HEAD - shows no trauma. EYES - pupils equal, round, reactive to light. MOUTH - shows good dentition. The posterior pharynx is clear.
CVP|central venous pressure|CVP|345|347|PHYSICAL EXAMINATION|FAMILY HISTORY: Not obtainable. REVIEW OF SYSTEMS: Not obtainable. PHYSICAL EXAMINATION: VITAL SIGNS: She is hemodynamically stable at the present time with a blood pressure in the range of 110-130 systolic over 40-60 diastolic, her pulse rate is in the 60s. She is intubated with a respiratory rate of 60 and her saturations are excellent. Her CVP is in the range of 15-22, most recently noted to be 19. She has a low-grade temperature maximum of 99.0. Her I's and O's yesterday were positive and today they are 704 in and 140 out, making approximately 10-20 cc of urine the past several hours.
CVP|central venous pressure|CVP|222|224|PHYSICAL  EXAMINATION|REVIEW OF SYSTEMS: Not currently possible. PHYSICAL EXAMINATION: GENERAL: She is a thin, frail, elderly female currently lying in bed. VITAL SIGNS: Temperature 98 degrees, pulse 64, blood pressure 106/59, respirations 12, CVP is 9. Weight is 42.5 kilograms. HEENT: No evidence of head trauma. Pupils are round and reactive. There is arcus senilis, sclerae white.
CVP|central venous pressure|CVP|166|168|ASSESSMENT AND PLAN|Following this, the patient Demonstrated excellent hemodynamics with no change in his blood pressure with mean pressure remaining the 70-80s, as well as no change in CVP from which ranged between 8-11. We further had extensive discussion with the family and the patient regarding all options including attempting to explant today all withdrawal of support.
CVP|central venous pressure|CVP|87|89|RECOMMENDATIONS|She also appears to have a large right ventricle. RECOMMENDATIONS: 1. Central line and CVP monitoring keeping in mind that she does have tricuspid valve disease. 2. Atrial line placement. 3. Panculture. 4. IV fluids.
CVP|central venous pressure|CVP.|258|261|IMPRESSION|IMPRESSION: 1. Postoperative she is shocky. She likely has extracellular fluid depletion due to her recent surgery with perforated ulcer and also her diffuse rash and scaling of the skin with loss of fluid that way. a. We will give her saline and follow her CVP. b. We will use pressors to maintain blood pressure greater than 95 systolic. c. We will transfuse her for a hemoglobin greater than 10.0.
CVP|central venous pressure|CVP|128|130|PHYSICAL EXAMINATION|She is on Neo-Synephrine and vasopressin. PHYSICAL EXAMINATION: VITAL SIGNS: Her blood pressure is 110/70, pulse 90, CVP 9. Her CVP was initially 3, respiratory rate 29. She is afebrile. Urine output for the first shift was 545 cc with 525 cc NG. GENERAL: She is alert and oriented. HEENT: Head shows no trauma.
CVP|central venous pressure|CVP|163|165|PHYSICAL EXAMINATION|LUNGS: Show rales in the right base and left base greater on the right side. There are some bronchial breath sounds on the right as well are no wheezing. CARDIAC: CVP about 8. Normal S1, S2, no murmur, rub or gallop. ABDOMEN: Shows normal bowel sounds, soft and nontender, no hepatosplenomegaly.
CVP|central venous pressure|CVP|220|222|LABORATORY DATA|The D1 has 40 to 50% proximal disease. The left circumflex has a 70% osteal lesion with a large distal OM/PDA. The right coronary artery is a small vessel and non-dominant. Right heart catheter hemodynamics shows normal CVP and mildly elevated PA pressures. Her cardiac output is low, approximately 3 by thermodilution.
CVP|cyclophosphamide, vincristine, prednisone|CVP|175|177|HISTORY OF PRESENT ILLNESS|He was treated with rituxan intermittently. In _%#MM2004#%_ he was treated with fludarabine and rituxan for continued disease progression. In _%#MM2006#%_ he was treated with CVP and rituxan. In _%#MM2006#%_ a lymph node biopsy showed transformed diffuse large B-cell lymphoma. Mr. _%#NAME#%_ was treated with 4 cycles of ICE chemotherapy and was able to achieve a remission.
CVP|central venous pressure|CVP|164|166|LABORATORY DATA|EXTREMITIES: Reveal no edema. Legs are considerably wasted in the aftermath of her polio. LABORATORY DATA: Chest x-ray is the same as before. Endotracheal tube and CVP catheter in good position. Left upper lobe infiltrate predominates. EKG is nondiagnostic. Troponin I is normal. CBC shows white blood cell count elevated to 19,000, differential is strongly left-shifted, platelets are normal.
CVP|central venous pressure|CVP|202|204|LABORATORY DATA|Patient underwent right heart catheter on _%#MMDD2005#%_ which revealed pulmonary artery pressure of 26 x 12 with a mean of 19 and pulmonary artery capillary wedge pressure of 7. Cardiac index was 1.6. CVP was 7. There is also a report of the patient undergoing a cath in _%#MM#%_ 2005 that revealed approximately no coronary artery disease.
CVP|cyclophosphamide, vincristine, prednisone|CVP|209|211|PROBLEM|This was observed and followed by left leg swelling. A biopsy showed a transformation to large cell lymphoma and he was treated with R-CHOP for eight cycles. The patient had also been treated with 2 cycles of CVP in 2006. The patient now presents to last for bone marrow transplant on protocol 2004-24, which is autologous and requires total body irradiation of 165 Gy b.i.d. over four days for a total of 1320 cGy.
CVP|central venous pressure|CVP|136|138|ASSESSMENT/PLAN|We also discussed the possibility of needing right ventricular support, though I didn't think this was likely given the PA pressure and CVP difference. The patient has no further questions and would like to proceed with device implantation. The patient has been on device support in the past.
CVP|central venous pressure|CVP|212|214|DATA|White blood cell count 7.6. Echocardiogram dated _%#MMDD2004#%_ shows ejection fraction of 25% with global hypokinesis with trace mitral regurgitation, mild aortic sclerosis, pulmonary artery pressure at 31 plus CVP that is unchanged from prior study. BNP is 530. PHYSICAL EXAMINATION: He is awake, alert and no acute distress.
CVP|central venous pressure|CVP|238|240|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: In general, she is an ill- appearing, intubated female who is having rhythmic contractions of the body. VITAL SIGNS: Blood pressure 125/67, pulse 87, respiratory rate 22, temperature 98.3, weight 89 kg. Her CVP is 20. She is right handed. Oxygen saturations are 95%. NEUROLOGIC: She is intubated and unresponsive to any noxious stimuli.
CVP|central venous pressure|CVP|223|225|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: Mr. _%#NAME#%_ is a 62-year-old man who is critically ill, status post ruptured left iliac aneurysm repair. 1. Hypotension. The patient is responding to IV fluid boluses and still oxygenating well. His CVP is pretty low, so we will continue aggressive fluid resuscitation. There is no clear evidence of sepsis at this point, though he is developing a bit of a fever, as his temperature has gone from 97.8 the 99.2. Cultures have not yet been drawn and he is on cefazolin.
CVP|central venous pressure|CVP.|263|266|ASSESSMENT|In light of the patient's previous adverse reactions, specifically hallucinations to Ativan therapy, will avoid benzodiazepine sedation and instead use haloperidol. Our plan will be to continue the same IV fluids strategy tonight, monitoring fluid balance with a CVP. Chemistries will continue to be closely monitored. No medication changes were otherwise indicated at this time. Will expect, as mentioned above, improving renal indices.
CVP|central venous pressure|CVP|335|337|IMPRESSION|She has remained nonoliguric throughout her course, as viewed by review of her flow sheets and, as such, she almost assuredly has ATN secondary to decreased renal perfusion related to her respiratory/cardiac arrest. 3. Moderately elevated serum sodium. 4. Hemodynamically stability without requirement for IV pressor medications and a CVP noted in the 12-15 range. 5. Status post arrest, as previously outlined in the chart, as per cardiology, pulmonary and primary care medicine.
CVP|central venous pressure|CVP|159|161|PHYSICAL EXAMINATION|She has an NG and an ET tube. She is noted to have a right IJ triple lumen catheter and two right femoral lines, including an arterial line and a venous line. CVP is 12-15. Her blood sugars have been in the range of 130. Her I&Os demonstrate 3,047 in and 1,325 out yesterday; today 570 in, 270 out.
CVP|central venous pressure|CVP|121|123|REVIEW OF SYSTEMS|He is concerned about having a repeat pericardial effusion, as this was quite symptomatic for him. He has a double-lumen CVP line. PHYSICAL EXAMINATION: Alopecia. Large bruises on left knee.
CVP|central venous pressure|CVP|161|163|PHYSICAL EXAMINATION|She is sleepy but rousable. She answers some limited Yes or No questions. Temperature is as high as 102.2, respirations 18, pulse 50, blood pressure 130's/60's. CVP is 13, weight is 92.8 kilograms. SKIN: No rash or inflammatory lesions. HEENT: No evidence of head trauma. She is orally intubated.
CVP|central venous pressure|CVP|132|134|ASSESSMENT AND PLAN|Her urine output has dropped off through the day and her creatinine is slightly up. Her urinalysis shows concentrated urine and her CVP is kind of low, suggesting prerenal etiology. Chest x-ray does appear worse than before, but it is possible this is noncardiogenic pulmonary edema related to acute lung injury.
CVP|central venous pressure|CVP|132|134|PLAN AND RECOMMENDATIONS|He has a bleeding risk from thrombocytopenia and therefore, we will defer the use of Xigris . 7. Aggressive fluid replacement using CVP monitor and normal saline as basic IV. 8. Insulin drip per intensivist protocol. 9. Pressors, probably norepinephrine if he becomes hypotensive with adequate fluid volumes and CVP.
CVP|central venous pressure|(CVP)|304|308|RECOMMENDATIONS|Note a normal BNP was measured earlier. 3. Review his tuberculosis medications for renal failure and adjustments may need to be made (doubt that any of the medications were primarily responsible for ATN though pyrazinamide has been reported to produce interstitial nephritis). 4. Central venous pressure (CVP) would be helpful if we continue to moderately aggressive care short of intubation and cardiopulmonary resuscitation (CPR).
CVP|central venous pressure|CVP|98|100|RECOMMENDATIONS|7. Consider bacterial endocarditis in a man with an aortic valve replacement. RECOMMENDATIONS: 1. CVP and arterial line. 2. Fluids per CVP. 3. Norepinephrine as primary pressor with decreasing dopamine as able. 4. Follow sepsis protocol including adrenal studies. 5. CT head when unable.
CVP|central venous pressure|CVP|141|143|PHYSICAL EXAMINATION|Her blood pressure is 90/50, pulse is 95 and respiratory rate is 18. She had a temperature up to 102.7 this morning and is now afebrile. Her CVP is 11-14. GENERAL: She is thin. She is alert. She can answer questions. She moans frequently during the exam, although she denies specific pain.
CVP|central venous pressure|CVP|203|205|RECOMMENDATIONS|4. Acute renal failure started as prerenal, may now be acute tubular necrosis (ATN), although she is beginning to show some urine output. RECOMMENDATIONS: 1. Insulin IV per DKA protocol. 2. Will monitor CVP and continue volume replacement with normal saline. She may need potassium replacement. 3. Antibiotics were started in the emergency room.
CVP|central venous pressure|CVP|242|244|OBJECTIVE|OBJECTIVE: VITAL SIGNS: T max 101.8, current 99.3, blood pressure 80s to 130s/30s to 50s, heart rate 60s-90s, respiratory rate 16, set rate 16, tidal volume 550, PEEP of 5. Sats 96% at 50% FiO2. Weight 51.3 kilograms, up from 50.3 yesterday. CVP anywhere from 5-14. Currently, it is 7. Overnight she had 1550 in, 525 out, so far today 2000+ in, 550 out. GENERAL: She is intubated, sedated, lying in a bed. She has a Foley catheter in with clear yellow urine.
CVP|central venous pressure|CVP|204|206|PHYSICAL EXAMINATION|8. Dopamine. 9. Phenylephrine. REVIEW OF SYSTEMS: Unable to obtain. This patient is intubated. PHYSICAL EXAMINATION: The patient is intubated. She is awake. Vital signs: Blood pressure 111/67, pulse 110, CVP 15, respiratory rate 12-20. She is on full ventilatory support with SIMV rate of 12, tidal volume 600, PEEP of 5, FiO2 30%.
CVP|central venous pressure|CVP|245|247|PHYSICAL EXAMINATION|Blood pressure is in the range of 100-120 systolic/40-60 diastolic, with a pulse rate in the range of 60-80 and appear sinus but is paced. He is febrile to 101.3. His respiratory rate is 12. He is vented. His SAT is 100%. P-A pressure is 57/29. CVP is 17. His Is and Os today are 1225 in and 975 out. Yesterday they were 16,000 in and 4,000 out. GENERAL: Intubated but arousable.
CVP|central venous pressure|CVP|140|142|VITAL SIGNS|LUNGS: Clear bilateral breath sounds. There are no wheezes or rales. CARDIAC: Bradycardia with is irregular. Normal S1, S2, no murmurs. The CVP is about 5 based on his neck veins. ABDOMEN: Normal to depressed bowel sounds. It is soft and nontender. There is no hepatosplenomegaly. GU: Foley catheter in place. Normal male pattern.
CVP|central venous pressure|CVP|115|117|RECOMMENDATIONS|1. Continue IV fluids with change from lactated Ringer's to normal saline in case he does go into full ATN. 2. Use CVP as guide for IV fluids. See orders. 3. Check fractional excretion of sodium. 4. On broad-spectrum antibiotic coverage.
CVP|central venous pressure|CVP|151|153|HISTORY|He did require several liters of fluid during surgery. An 1,800 cc EBL was estimated for which he received two units of packed cells during surgery. A CVP is in place and it has been in the 10-11 range. The surgery was done on _%#MMDD#%_ and postoperatively his urine output has been practically nil.
CVP|central venous pressure|CVP.|134|137|RECOMMENDATIONS|6. Will monitor renal function closely at this point. It would not seem that dialysis is eminent. 7. Will less fluid criteria per his CVP. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 44-year-old man who initially presented to the emergency room on _%#MMDD2007#%_ with some symptoms of viral illness including headaches, nausea, fever.
CVP|central venous pressure|CVP|365|367|PHYSICAL EXAMINATION|Chest x-ray dated _%#MMDD2003#%_ is unchanged. ABG 7.49/32/172/25. Total protein 3.6, albumin 1.4. White blood cell count 9.0. PHYSICAL EXAMINATION: Mechanical ventilator settings SIMV, Fi02 40s, rate of 12, PEEP of 5, respiratory support of 5, tidal volume 500, minute ventilation 10 L per minute. Respiratory rate is 24. She is afebrile. Pulse is 134. SP02 100%. CVP 4. Blood pressure 120/80. GENERAL APPEARANCE: She is an elderly female who appears older than her stated age. HEENT: Unremarkable. NECK: Supple, nontender. No lymphadenopathy. LUNGS: Clear to auscultation bilaterally.
CVP|central venous pressure|CVP|156|158|PHYSICAL EXAMINATION|He is on dobutamine 8 mcg/kg/min and dopamine 5 mcg/kg/min. Heart rate is around 70. Cardiac output 4.9, cardiac index 2.1. His PA pressures are 31/20 with CVP of 15. GENERAL: Obese man who is sedated. HEENT: No evidence of head trauma. Pupils are 2 mm and reactive. Sclera are white. Extraocular movements could not be assessed.
CVP|central venous pressure|CVP|222|224|PHYSICAL EXAMINATION|She is uncomfortable with the tube in her throat and she feels anxious. PHYSICAL EXAMINATION: She is awake, responds to questions, temperature 101 degrees, blood pressure in the 90's/40's, pulse is 130, sinus tachycardia, CVP is 8, weight is 50 kilos, respiratory rate is 20 (backup rate is 10). HEENT: She has an NG tube through the nose. There is no external evidence of bleeding.
CVP|central venous pressure|CVP|176|178|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Intubated, cachectic gentleman, tachypneic. Blood pressure 116/85, pulse 120-130, sinus tachycardia, temperature 39 Celsius, saturations 94% on 40% FiO2, CVP 11. HEAD and NECK exam: No supraclavicular adenopathy. CHEST reveals coarse airway sounds, no definite crackles or wheezes. CARDIAC - S1, S2, tachycardic without murmurs, rubs or gallops.
CVP|central venous pressure|CVP|215|217|PHYSICAL EXAMINATION|No skin rash. No acute arthritis. PHYSICAL EXAMINATION: She is an elderly female lying in bed. She appears older than her stated age. Temperature 96.7, respirations 19, blood pressure 85/49. Heart rate in the 120s. CVP from a femoral approach is 24. Weight yesterday was 103.7 kg. HEENT: Normocephalic. No evidence of head trauma. Pupils are round and reactive. Sclerae are slightly icteric. Extraocular movements are intact.
CVP|central venous pressure|(CVP)|173|177|PHYSICAL EXAMINATION|Blood pressure is most recently 95/60 on a dopamine dose of 10 mcg/kg/minute. Respirations are controlled Oxygen saturation is excellent at 98-100%. Central venous pressure (CVP) is relatively low at 5-mmHg. GENERAL: The patient is currently sedated with Diprivan. He stirs to vigorous tactile stimulation.
CVP|central venous pressure|CVP|130|132|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 96.8 axillary, blood pressure 89/34, heart rate 90% AV paced, respiratory rate 12, CVP of 7. Patient is currently on a ventilator at dragger mode SIMV rate of 12, 40% O2, total volume of 600, and PEEP of 5.
CVP|central venous pressure|CVP|185|187|PHYSICAL EXAMINATION|No varicosities. NEUROLOGIC: No Focal motor or sensory deficit. NECK: JVP 6 cm. No carotid bruits Review of prior investigations: Right heart hemodynamics from _%#MMDD2004#%_ - Reveals CVP of 26, pulmonary wedge 40, PA pressure 70/40 with cardiac index of 1.73. IMPRESSION: The patient is a 41-year-old male with severe dilated cardiomyopathy with pulmonary hypertension.
CVP|central venous pressure|CVP|175|177|RECOMMENDATIONS|RECOMMENDATIONS: 1. Off Hespan. CVP now 16-20. 2. IV Lasix p.r.n. She responded to 80 mg IV and renal function appears to be normal at baseline. 3. PRN bolus normal saline if CVP and blood pressure drop. 4. She will need TPN soon; probably start this evening. 5. Weaning parameters. Start weaning per pulmonary service. Diprivan will be turned off.
CVP|central venous pressure|CVP|160|162|PHYSICAL EXAMINATION|GENERAL: He is intubated and sedated. CARDIOVASCULAR: LVAD flows 5.86 liters per minute at a fixed rate of 3400. RVAD flow is 5.75 at a fixed rate of 3150 RPM. CVP is 18. Sternal wound appears clean and dry. RESPIRATORY: Bilateral breath sounds, scattered crepitations PEO2 70% on 100% FIO2. ABDOMEN: Nondistended, obese, no organomegaly. EXTREMITIES: Warm, well perfused bilateral edema.
CVP|central venous pressure|CVP|154|156|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile. T max 98.6. Blood pressure 86/74. Pulse 90. CARDIOVASCULAR: LVAD flow is 6.2 liters at a fixed rate of 3400. CVP 14. Pulmonary artery pressure is 13/21. Cardiac index 3.4. RESPIRATORY: Bilateral breath sounds. A few crepitations. Improved saturation of approximately 96%. ABDOMEN: Soft, nondistended; no hepatomegaly.
CVP|central venous pressure|CVP|137|139|ASSESSMENT AND PLAN|We will attempt to wean the vasopressin and epinephrine as needed to maintain a mean arterial pressure greater than 60. Based on his low CVP and his recovery of the other organ systems, our plan is to do an RVAD turndown tomorrow. 2. Respiratory: His chest x-ray shows widening out of his left pleural space.
CVP|central venous pressure|CVP|131|133|PHYSICAL EXAMINATION|Preoperative weight was 106 kilograms. Temperature is 98.6, respirations 12, heart rate in the 60's, blood pressure 100-110/50-60. CVP is 6. HEENT: No evidence of head trauma. Pupils are round and reactive. Sclera are white. Extraocular motions appear to be fully intact.
CVP|central venous pressure|CVP.|211|214|HISTORY OF PRESENT ILLNESS|There was mild mitral regurgitation, trivial to mild aortic insufficiency, sclerotic aortic valve and moderate to severe tricuspid regurgitation with estimated pulmonary artery pressure of 58 mm of mercury plus CVP. The patient was noted in right heart. Because of findings of significant tricuspid regurgitation and pulmonary hypertension, cardiology consultation was requested.
CVP|central venous pressure|CVP.|127|130|RECOMMENDATIONS|4) Coronary heart disease, previous myocardial infarction, ICD in place. RECOMMENDATIONS: 1) Continue IV saline. Will push his CVP. 2) Checking urine indices, including fractional excretion of sodium. 3) He will be transfused; will monitor his lytes and renal function.
CVP|central venous pressure|CVP|194|196|PHYSICAL EXAMINATION|ABDOMEN: Modest tenderness in the upper abdominal area in particular, and in the right upper quadrant specifically. EXTREMITIES: No significant redness or significant tenderness around her left CVP site. No significant edema. Pulses are relatively intact. No peripheral embolic type lesions. JOINTS: Normal other than for some mild osteoarthritic type changes, but nothing specific in any joint.
CVP|central venous pressure|CVP.|143|146|HISTORY OF PRESENT ILLNESS|The patient has a history of moderate to severe aortic insufficiency, severe pulmonary hypertension with PA pressure estimates of 87 mmHg plus CVP. Status post pacemaker insertion. Moderate mitral regurgitation. History of intermittent atrial fibrillation who claims that over the past few months the patient has had recurrent episodes of syncopal spells.
CVP|central venous pressure|CVP|245|247|PHYSICAL EXAMINATION|Ceftazidime from _%#MM#%_ _%#DD#%_ to _%#MM#%_ _%#DD#%_. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature maximum is 102.0, temperature current is 98.4; respiratory rate 16; pulse 123; blood pressure 92/58; her CVP is 10; oxygen saturations at 97 to 98% on 0.3 FiO2; her dry weight is 19 kilograms. GENERAL: She is intubated, sedated, although moves slightly with examination.
CVP|central venous pressure|CVP|240|242|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Lethargic. BiPAP in place. Unresponsive. Appears to move all extremities. Unresponsive. VITAL SIGNS: Temperature 98.8. Temperature maximum 99.3. Blood pressure anywhere from 80-110. Pulse anywhere from 60-90. CVP 15-16. Blood sugar in the range of 150. Intake & Output (I&O): I&O over the past 2 days have been positive at 649-cc in and 2290-cc out today.
CVP|central venous pressure|CVP|212|214|PHYSICAL EXAMINATION|She formerly was a receptionist. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 95/30. Pulse 145. Temperature 102.2. Respiratory rate 16. Urine output for the first two shifts is 1155-cc. VENTILATOR SETTINGS: CVP 12-14. O2 saturation 83%. She is on 100% FIO2 and 10 of PEEP. GENERAL: She is unresponsive on the ventilator. She is sedated.
CVP|central venous pressure|CVP,|125|128|CHEST X-RAY|BUN 16, creatinine 0.9, albumin 3.5. White count 15.0, hemoglobin 11.0, platelet count 320. CHEST X-RAY: Chest x-ray shows a CVP, endotracheal tube (ETT) and nasogastric (NG) tube in place. Bilateral infiltrates and effusions consistent with pulmonary edema. ECHOCARDIOGRAM: Echocardiogram done today showed normal left ventricular function with an ejection fraction of 65%.
CVP|central venous pressure|CVP|140|142|IMPRESSION|3. At present, hemodynamically stable. Systolic blood pressure is noted in the range of 100. Her pulmonary artery pressure is 32/50 and her CVP is in the range of 9-10. Her I's and O's are balanced at 2800 in and 2900 out. Today they are 800 in and 600 out, while her weight is up approximately 5 kg post-procedure.
CVP|central venous pressure|CVP|215|217|PHYSICAL EXAMINATION|VITAL SIGNS: She has a low-grade temperature of 101. Blood pressure is in the range of 105-120 systolic, pulse is approximately 90, it appears to be sinus. Pulmonary artery pressure is in the range of 30- 34/14-15. CVP is in the range of 9. Her I's and O's as previously mentioned were balanced yesterday and appear to be near balanced today.
CVP|central venous pressure|CVP.|212|215|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITALS: He is obtunded, unresponsive, afebrile, sp02 is 93% on 15 liter rebreather mask, pulse 78, blood pressure is now 70/50, pulse is 64. NECK: Neck is supple and nontender with elevated CVP. LUNGS: Diminished breath sounds bilaterally. HEART: Normal S1, S2, regular rate and rhythm. ABDOMEN: Soft and nontender. EXTREMITIES: Warm without clubbing or edema. Thank you for this consultation.
CVP|central venous pressure|CVP|132|134|PHYSICAL EXAMINATION|He has been afebrile. His temperatures up to 103, his white count is up to 15,000 with a left shift. He is somewhat dehydrated. His CVP is a little bit low, his blood pressure is holding in the 160/40 range. The balance of his clinical examination reveals him to be awake; he will orient to visual stimuli, does not follow any simple commands.
CVP|central venous pressure|CVP|184|186|PHYSICAL EXAMINATION|Her urine output is increasing. Her blood pressure is now in a satisfactory range. PHYSICAL EXAMINATION: On exam, temperature is now normal. Pulse is regular. Sinus rhythm of 100-110. CVP is about 15. Oxygen saturation is excellent, but on a high oxygen requirement of 0.8. SKIN is warm. Good turgor is noted throughout. LUNGS are essentially clear. The patient seems to be tolerating assisted ventilation well.
CVP|central venous pressure|(CVP)|282|286|PLAN|PLAN: Our plan will be to continue the present course with broad antibiotic therapy while awaiting cultures, IV insulin p.r.n., stress hydrocortisone therapy after cosyntropin stimulation test, pressor therapy as needed, generous saline infusion, monitoring central venous pressure (CVP) and SVO2. We will give the patient's usual L-thyroxine dose in IV format. We will add an empiric H2 blocker. For now we will allow small amounts of clear liquids p.o. and advance diet as appropriate.
CVP|central venous pressure|CVP|181|183|PHYSICAL EXAMINATION|She is calm. She is lucid. VITAL SIGNS: Temperature has fallen a bit to 99.0. Pulse is a little bit higher at about 100 per minute; it is sinus. Blood pressure has risen to 130/70. CVP previously 8 is now 11. SKIN: Warm with good color and turgor. HEENT: Negative. NECK: Unremarkable. Neck is supple. No jugular venous distention (JVD). LUNGS: Clear.
CVP|central venous pressure|CVP|120|122|PHYSICAL EXAMINATION|She is somewhat hypothermic, axillary temperature 34.5 on a ventilator with FiO2 of 0.5. Her oxygen saturation is 100%. CVP with generous crystalloid intake has been in the range of 2-5. SKIN: Warm, except for her cool distal right lower extremity.
CVP|cyclophosphamide, vincristine, prednisone|CVP|194|196|HISTORY OF PRESENT ILLNESS|The patient at that time did not have a bone marrow biopsy, however, he had disease above and below the diaphragm. He also had a large mediastinal mass. The patient was treated with 8 cycles of CVP chemotherapy and Rituxan, completed in _%#MM2005#%_ with a partial response, especially with residual disease in the mediastinal area. In _%#MM2006#%_ he presented with hoarseness, and examination revealed vocal cord paralysis on the left side, which is most likely due to mediastinal mass.
CVP|central venous pressure|CVP.|138|141|RECOMMENDATIONS|RECOMMENDATIONS: 1. Continue aggressive fluid management with saline to expand volume and subsequently IV sodium bicarbonate - monitoring CVP. 2. He got an initial 50 mEq of NaHCO3 in the ER; we will add another 50 mEq bolus and continue a drip with sodium bicarbonate.
CVP|central venous pressure|CVP.|144|147|HISTORY|He subsequently had adrenal insufficiency. He has received chemotherapy for this. His last chemotherapy was _%#MMDD2002#%_. That was cycle 3 of CVP. The patient had been having problems with mental status change and irritability, possibly related to his chemotherapy or his prednisone.
CVP|central venous pressure|CVP|215|217|RECOMMENDATIONS|6. History of cardiomyopathy, CHF. 7. Elevated BNP is difficult to interpret in this situation with acute renal failure, fluctuating volumes and cardiac instability. RECOMMENDATIONS: 1. Need central venous line for CVP monitoring. 2. Follow arterial blood gases. 3. Bicarbonate replacement; will give as IV pushes and bicarbonate-containing IV. 4. Continue aggressive volume replacement with saline . 5. Will check fractional excretion of sodium.
CVP|central venous pressure|CVP|203|205|OBJECTIVE|OBJECTIVE: VITAL SIGNS: Temperature 101, blood pressure 60s-90s/30s-40s on norepinephrine. Heart rate 140s-160s, breathing 28-46, oxygen saturation 96-97% on five liters. There is no current weight yet. CVP is 2. GENERAL: He is obtunded, lying in bed flat on his back. HEENT: Dry mucous membranes. Very cachectic. LUNGS: Coarse bilateral breath sounds, right side worse than the left.
CVP|central venous pressure|CVP|224|226|REASON FOR CONSULTATION|6. Renal insufficiency, mild. Current GFR approximately 43. 7. Malnutrition based on poor oral intake postoperatively. RECOMMENDATIONS: 1. We will follow up on culture data with you. 2. I would discontinue her right jugular CVP line which has been in place since the time of surgery and culture of the tip. 3. The patient currently is on low-dose Levaquin which could be continued for now but discontinued soon unless an obvious reason to use it emerges.
CVP|central venous pressure|CVP|146|148|PHYSICAL EXAMINATION|NECK: Is supple. LUNGS: Show clear bilateral breath sounds. There are no rales or wheezes. CARDIAC EXAMINATION: No jugular venous distention. The CVP is less than 5. Normal S-1 and S-2, no murmur ABDOMEN: Is distended and tympanitic. There are minimal bowel sounds. It is tender to palpation but there is no rebound or guarding.
CVP|central venous pressure|CVP|181|183|OBJECTIVE|OBJECTIVE: VITAL SIGNS: Temperature 96.6., blood pressure 50-120S/30s-50s, heart rate 110-120s, respiratory rate 31, sat rate of 12, tidal 700, PEEP of 5. Sats 99% at 70% FiO2. His CVP is 9. GENERAL: He is intubated and not sedated. He grimaces to pain. He moves his extremities. He has an NG tube and Foley catheter.
CVP|central venous pressure|CVP|146|148|PLAN|A slight decreased LV function (40% EF on echo) probably nonspecific effect of sepsis, though must consider a primary myocardial injury. PLAN: 1. CVP is in, we will direct his fluids based on CVP readings. If necessary, can be converted to a Swan-Ganz catheter.
CVP|central venous pressure|CVP|213|215|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Could not be obtained. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure in the range of 110/70, heart rate 90, peak temperature earlier today 101.8, respiratory rate 18, oxygen saturation 99%, CVP 12. He is currently on dopamine and Levophed. He has gotten some Hespan and is now on medication for sepsis. LUNGS: Demonstrate bilateral crackles without wheezes. HEART: Heart rhythm is regular, no cardiac murmurs obvious to me.
CVP|central venous pressure|CVP|152|154|DISCUSSION|His blood pressure initially was approximately 90/50 with a paced rhythm. Overnight he has generally been stable. Blood pressure is not much different. CVP has been monitored closely. Initially it was less than 0 and now is somewhat greater than 0 after close monitoring.
CVP|central venous pressure|CVP.|117|120|RECOMMENDATIONS|d. Recent urinary tract infection, doubt urosepsis. RECOMMENDATIONS: 1. The patient needs a central line. 2. Monitor CVP. 3. Attempt diuresis with Lasix. 4. Would reduce IV fluid volume. 5. Check urine indices, urine sodium, and fractional excretion of sodium.
CVP|cyclophosphamide, vincristine, prednisone|CVP,|159|162|IMPRESSION/RECOMMENDATIONS|He has had multiple prior treatments including surgical excision, radiotherapy as well as systemic chemotherapy including multiple agents and regimens such as CVP, CEPP with poor tolerance, as well as investigational agents. Most recently he has been on his usual CDE chemotherapy with the second cycle administered last roughly one month ago.
CVP|central venous pressure|(CVP)|170|174|ASSESSMENT|The patient will require some p.r.n. sedation while on ventilator therapy. Will continue with generous amounts of isotonic IV fluids, monitoring central venous pressures (CVP) closely. Heparin therapy will be continued. Meanwhile the reteplase (rPA) infusion as per our conversation with Dr. _%#NAME#%_ will probably be discontinued later this morning.
CVP|central venous pressure|CVP|238|240|PHYSICAL EXAMINATION|FAMILY HISTORY: Positive for ASCVD. Negative for renal disease. PHYSICAL EXAMINATION: GENERAL: The patient is alert. She is intubated. VITAL SIGNS: Blood pressure 105/50, pulse 80, temperature maximum today is 101.4. Respiratory rate 17. CVP 14. She is on dopamine and amiodarone IV. The output for the first shift was only 35 cc. Her CVP is between 12 and 14. Weight has gone from on _%#MMDD2004#%_, 89.7 to today 87.8. SKIN: Negative.
CVP|cyclophosphamide, vincristine, prednisone|CVP|229|231|SUBJECTIVE|DOB: _%#MMDD1926#%_ HEMATOLOGY/ONCOLOGY CONSULTATION SUBJECTIVE: This is a 77-year-old white female patient of Dr. _%#NAME#%_'s who has a history of recurrent non-Hodgkin's lymphoma. Originally her non-Hodgkin's was treated with CVP chemotherapy, but she subsequently had recurrent disease in her small bowel. She went on to fail Rituxan immunotherapy and single-agent gemcitabine (Gemzar) and is now on oral etoposide.
CVP|central venous pressure|CVP|142|144|IMPRESSION|4. Hemodynamically stable. I&Os reviewed. Blood pressure in the range of 120, off pressors. Rate and rhythm seem adequate. Good urine output. CVP in the range of 6. 5. Respiratory failure. Vented for airway protection, with adequate oxygenation and ventilation on most recent blood gas of 7.33/36/172. Current vent settings: SIMV 10, pressure support 5, PEEP 5, FiO2 of 50%, tidal volume 600.
CVP|central venous pressure|CVP|174|176|ASSESSMENT AND PLAN|a. Will add vancomycin. b. Increase Zosyn to q.8h. c. Will pan culture again. 3. End-stage kidney disease. The patient dialyzes Monday-Wednesday-Friday. He is volume down by CVP and wedge. His K is 5.1 today. a. Will do dialysis today for chemistries only. b. Will probably need to plus him in volume.
CVP|central venous pressure|CVP|163|165|REVIEW OF SYSTEMS|The arthritis occasionally flares. The pain can be quite severe, and affecting many joints throughout his body. He has had some relief from the arthritis with the CVP chemotherapy. Neurologic: No headache or dizziness. PHYSICAL EXAMINATION: Well-developed, well-nourished, alert and oriented male in no acute distress.
CVP|central venous pressure|CVP|125|127|RECOMMENDATIONS|Consider a paraproteinemia such as myeloma once she stabilizes. RECOMMENDATIONS: 1. Continue IV normal saline and monitoring CVP criteria set for fluid volumes depending on CVP reading. 2. Will check urine indices including sodium, creatinine, fractional excretion of sodium.
CVP|central venous pressure|CVP|175|177|PHYSICAL EXAMINATION|He is awake, alert, oriented x3, and appears comfortable at rest. CARDIOVASCULAR: LVAD flow is 5 L per minute at a fixed RPM of 10,000. Drips: Milrinone 0.5 as well as Bumex, CVP is 14 (w have earlier removed this once this catheter and switched it to a triple lumen which gave us a more accurate CVP reading of 14).
CVP|central venous pressure|CVP|216|218|ASSESSMENT AND PLAN|Electrolytes were within normal limits. Creatinine 1.14. ASSESSMENT AND PLAN: The patient is a 35-year-old gentleman status post HeartMate 2 LVAD is doing well. We will start weaning his milrinone in 12 hours if his CVP remains low. We will also continue heparin drip and maintain a therapeutic PTT. We will also remove his chest tube today. Otherwise, I am pleased with progress.
CVP|cyclophosphamide, vincristine, prednisone|CVP|242|244|HISTORY OF PRESENT ILLNESS|At that time his bone marrow had 5-10% involvement. He received no further therapy until _%#MM2001#%_ when he had further disease progression. He was treated with 4 weeks of Rituxan, but had continued disease progression. He was treated with CVP chemotherapy from _%#MM2001#%_ until _%#MM2001#%_. He was observed until _%#MM2003#%_ when he was found to have further disease progression. He was treated again with CVP. He received seven cycles ending _%#MM2004#%_.
CVP|central venous pressure|CVP|130|132|RECOMMENDATIONS|4. Previous steroid use for rheumatoid arthritis. 5. Postop ventilator dependent. 6. History of hypertension. RECOMMENDATIONS: 1. CVP monitor and may need to convert her double-lumen to triple lumen line because of multiple medications being given. 2. IV rate per CVP, criteria set. 3. Will be transfused for a hemoglobin of 7.5.
CVP|central venous pressure|CVP|162|164|PHYSICAL EXAM|PHYSICAL EXAM: He is somnolent but arouses to voice and can answer simple questions. His blood pressure is 110/60, pulse 95. He is afebrile. Respiratory rate 22, CVP is 5-8. His urine output for the first shift was 700 cc. His weight is up about 5 kilograms since admission. HEAD showed no trauma.
CVP|central venous pressure|CVP|200|202|IMPRESSION|REQUESTING PHYSICIAN: Dr. _%#NAME#%_. IMPRESSION: 1. Postop day #1 from aortic graft repair. 2. Modest hemodynamic instability, with apparent reasonably normalized filling pressures on the basis of a CVP in the range of 14-16. I would suggest we continue to keep it in this range. 3. Current systolic blood pressure on 4 of dopamine (micrograms per kilograms per minute), 130.
CVP|cyclophosphamide, vincristine, prednisone|CVP|194|196|HISTORY OF PRESENT ILLNESS|She did not require treatment until 2002. She was treated with Cytoxan for 3 months and had a good partial response. In 2004 she had progression of her abdominal adenopathy and was treated with CVP and Rituxan. Once again, she had a good partial response. Unfortunately, in _%#MM2004#%_ she had a rapid growth of a lymph node in her right groin.
CVP|central venous pressure|CVP|188|190|PHYSICAL EXAMINATION|She is intubated and sedated. CARDIOVASCULAR SYSTEM: LVAD flow is 5.6 liters/min at a fixed rate of 70. Stroke volume greater than 80 cc. LVAD flow is 6.1 liters and a fixed rate of 3400, CVP 15. PA pressure 38/18. Drips of vasopressin 3 units/hr and nitric oxide. RESPIRATIONS: Bilateral breath sounds. Scattered crepitations. Arterial blood gas 7.40, 3, 90.
CVP|central venous pressure|CVP|171|173|PHYSICAL EXAMINATION|She was intubated and sedated. CARDIOVASCULAR: LVAD flow is 5.4 liters, with a fixed rate of 65 with stroke volume greater than 80 cc. RVAD flow is 5.8 liters, rate 3200, CVP 14. ABDOMEN: Soft, bowel sounds presents, nondistended, nontender. LOWER EXTREMITIES: Warm, well- perfused. GENITOURINARY: Intake/outpatient 24 hours 3541/4480 cc.
CVP|central venous pressure|CVP|185|187|PHYSICAL EXAMINATION|CARDIOVASCULAR: LVAD flow is 5.7 liters per minute at a fixed rate of 75 with stroke volumes greater than 75 cc. Right ventricular assist device flow 5.6 liters at an RMP of 30 to 100, CVP 14. She is off Neo-Synephrine. RESPIRATORY: Bilateral breath sounds, crepitations. Arterial blood gas 7.38, 4.4, 25, 95 on 40% FIO2. ABDOMEN: Soft, mildly distended NJ-tube positive. EXTREMITIES: Lower extremities warm, well perfused.
CVP|central venous pressure|CVP.|217|220|ASSESSMENT/PLAN|Cardiac index was only 1.8. With intra-aortic balloon pump support and inotropes, his index has improved. However, he continues to be slightly hypertensive requiring inotropes and pressors. Of concern is his elevated CVP. I recommend that if we cannot get his CVP down with his current medical management, we should institute CVVH/D in order to remove the extra volume.
CVP|central venous pressure|CVP|208|210|RECOMMENDATIONS|We would note a serum bicarbonate to be 26 and perhaps there is a modest metabolic acidosis component in this clinical setting. We will follow up with serial chemistries. 3. I.V. fluids to include saline. 4. CVP readings. 5. Proton pump inhibitor and TEDS to prevent DVT. 6. Agree with MI rule out protocol. 7. Await diagnostic imaging in the form of head CT, echocardiogram and Dopplers of lower extremity.
CVP|central venous pressure|CVP|184|186|PHYSICAL EXAMINATION|GENERAL APPEARANCE: She is a pleasant female in no acute distress. HEENT: She does have a shiny color to her skin, which would suggest some edema in the face. NECK: Supple, nontender. CVP is 10 cm. LUNGS: She has coarse crackles bilaterally, as well as rhonchi. She has dullness to percussion of the lower portion of her left chest.
CVP|central venous pressure|CVP|149|151|PHYSICAL EXAMINATION|CARDIOVASCULAR: LVAD flow is 4.4 liter per minute, with a fixed rate of 55 with stroke volumes greater than 80. DRIPS: Epinephrine 0.02, dopamine 3, CVP 14, PA pressure 13 x 16, respirations and bilateral breath sounds - a few basal crepitations. Chest tube output per last 8 hours - about 400 cc.
CVP|central venous pressure|CVP|251|253|LABORATORIES|The left main system is normal. There is a 25% block in the left anterior descending proximal prior to large first diagonal branch. The aortic valve was heavily calcified. Gradient across the aortic valve with 75 mmHg pressure. A right heart catheter CVP of 10, PA pressure 15 by 20 with mean of 33, and pulmonary artery wedge of 21. Cardiac output was 2.5. A previous echocardiogram performed elsewhere revealed a peak gradient of 62, with aortic valve area of approximately 0.5 cm2 with normal left ventricular size and function.
CVP|central venous pressure|CVP|206|208|HISTORY OF PRESENT ILLNESS|She did not have any treatment until 1993, and at that time apparently had disseminated adenopathy and a subcarinal mass. She was treated with chlorambucil until _%#MM#%_ 1993, and then was switched to the CVP regimen, which she received from _%#MM#%_ through _%#MM#%_ 1993, and the available records indicate a partial response. She was then treated with the CHOP regimen for a total of 8 cycles, with attainment of a sustained response until 1996.
CVP|central venous pressure|CVP.|284|287|HISTORY OF PRESENT ILLNESS|Workup included an echocardiogram which interestingly showed concentric left ventricular hypertrophy, left atrial enlargement, but normal left ventricular size and function, ejection fraction of 65%. There was mild right ventricular hypertrophy, PA pressure estimates of 27 mmHg plus CVP. EKG was obtained which showed LVH with repolarization abnormalities, but no acute changes. The patient now was admitted on _%#MM#%_ _%#DD#%_, 2002 with abdominal pain.
CVP|central venous pressure|CVP|153|155|IMPRESSION|Again, blood and urine cultures have been sent. We will check sputum cultures. Will repeat a chest x-ray in the morning. 3. Hypotension. We will monitor CVP and volume expander. We will change IV to normal saline and will give her hetastarch. Will wean the Dopamine as tolerated. 4. Glomerulonephritis. Renal function has improved with high dose steroids.
CVP|cyclophosphamide, vincristine, prednisone|CVP|138|140|HISTORY OF PRESENT ILLNESS|However, when he stopped the prednisone the mass grew back. After prednisone the patient was treated with chemotherapy for 4 months using CVP and Rituxan, which continued until _%#MMDD2004#%_. Initially, the mass has reduced in size, however, it increased again. The patient also started having pain and a burning sensation after alcohol drink, which is one of the symptoms that Hodgkin's disease can create.
CVP|central venous pressure|CVP|275|277|SUMMARY|More recently he has had problems with the IV infusion in that the PICC line has become difficult to sample blood from and when an antibiotic is infused he will get a burning sensation in his chest and upper arms. Yesterday a chest x-ray was done which showed the tip of his CVP line in his superior vena cava in an acceptable location. The site of entry for his PICC line does not show any overt inflammatory signs and there is no tenderness in the upper arm or axilla.
CVP|central venous pressure|CVP|141|143|PHYSICAL EXAMINATION|The patient has demonstrated atrial fibrillation since admission. Current rate is about 100, as has been the case. Blood pressure is 110/70. CVP is 10-12. Oxygen saturation is 97%. SKIN: Warm with good turgor and color. LUNGS: Reduced sounds on the right, the left is clear.
CVP|central venous pressure|CVP|207|209|PHYSICAL EXAMINATION|Blood pressure 84/62. Mean of 63. Pulse 75. GENERAL: He is alert and follows commands, moves all extremities. CARDIOVASCULAR: LVAD flow is 4.8 liters at a fixed rate of 8400. _________________ index if 4.2. CVP 13. PA pressure is 42/20. _______________ 0.03. Mixed venous oxygen saturation 61. RESPIRATORY: Bilateral breath sounds; no rhonchi or crepitations.
CVP|central venous pressure|CVP|214|216|PHYSICAL EXAMINATION|He is awake with minimal response. He does not follow commands consistently. Moves all extremities. No focal, motor, or sensory deficit. CARDIOVASCULAR: Cardiac index 1.8 on dobutamine with an intraaortic balloon, CVP 14. RESPIRATORY: Bilateral breath sounds, basal crepitations, nasal cannula 2 liters, oxygen saturations at 98%. ABDOMEN: Soft, bowel sounds are present, nondistended, nontender, no hepatomegaly.
CVP|central venous pressure|CVP|161|163|PHYSICAL EXAMINATION|Mean 96. Heart rate 90s. GENERAL: Awake, alert, oriented x 3. He is comfortable at rest. CARDIOVASCULAR: LVAD flow 5.1 liters per minute at a fixed rate of 100. CVP 18. SpO2 65. RESPIRATORY: Bilateral breath sounds; no rhonchi or crepitations. ABDOMEN: Soft, nontender, nondistended; bowel sounds present. EXTREMITIES: Lower extremities warm.
CVP|central venous pressure|CVP|136|138|PHYSICAL EXAMINATION|He has ecchymoses over the skin and some limited mobility of his feet from contractures. Swan-Ganz remains in place with a PA pressure, CVP of 6, PA pressure 28/12. LABORATORY RESULTS: Blood gas: pH 7.41, pCO2 48, pO2 89, bicarb 30.
CVP|central venous pressure|CVP|129|131|PHYSICAL EXAMINATION|GENERAL: He is awake, alert, following commands. CARDIOVASCULAR: LVAD flow is 5.1 liters per minute at a fixed rate of 8800 RPM. CVP is 9. PA pressure 35/10, cardiac output by Swan is 5.6 with mixed venous oxygen saturation of 50. RESPIRATORY: Bilateral breath sounds, few crepitations. O2 sat 98% on 40% FIO2.
CVP|central venous pressure|CVP|129|131|PHYSICAL EXAMINATION|LUNGS: Diminished breath sounds in the left base with E to A changes, the right is clear. CARDIAC: No jugular venous distention. CVP is less than 5. Normal S1, S2. No murmur. ABDOMEN: Firm with normal bowel sounds, but no palpable liver or spleen.
CVP|central venous pressure|CVP|183|185|RECOMMENDATIONS|I would remove potassium and replace with crystalloid IV fluid given her tenuous potassium situation. 3. Repeat urine sodium to assess renal perfusion. 4. Hespan x1 given her current CVP is in the range of 5-6. 5. IV plus saline plus TPN as fluids. 6. Follow INR. 7. Blood cultures performed and antibiotics given. Follow-up as indicated.
CVP|central venous pressure|CVP|169|171|IMPRESSION|She is hypotensive and probably needs a large volume replacement. We are going to give her saline, albumin and hetastarch and we will wean the Levophed as possible. Her CVP is 5-8 and probably needs to be more like 15-20. She has acute renal failure and is oliguric. This is probably prerenal.
CVP|central venous pressure|CVP|172|174|PHYSICAL EXAMINATION|Does not smoke. ALLERGIES: NONE. MEDICATIONS: Apparently atenolol, Aldactone. PHYSICAL EXAMINATION: GENERAL: He is sedated and nonresponsive, pulse is 97%, O2 sat is 100%, CVP is 5-6. VITAL SIGNS: Blood pressure 151/98 initially driving down 125/70 after propofol. Respiratory rate 12. HEENT: Head shows no trauma. Pupils are mid position and fixed.
CVP|central venous pressure|CVP.|101|104|PLAN|There may very well be an element as well of aspiration pneumonia. PLAN: Our plan will be to monitor CVP. We will give a trial of diuretic therapy. Empiric Zosyn therapy while awaiting sputum culture. We will check an echocardiogram.
CVP|cyclophosphamide, vincristine, prednisone|CVP|185|187|HISTORY OF PRESENT ILLNESS|She developed right neck lymphadenopathy that was biopsied in _%#MM2004#%_, and she was found to have transformed large B-cell non-Hodgkin's lymphoma. The patient was then treated with CVP and Rituxan for maintenance therapy. Unfortunately, in _%#MM2005#%_, she was diagnosed with an enlarging lesion in the mesentery and peripancreatic area despite the chemotherapy.
CVP|central venous pressure|CVP.|185|188|REQUESTING CARDIOLOGIST|ASSESSMENT AND PLAN: A 57-year-old gentleman with severe nonischemic cardiomyopathy who is now currently on milrinone and admitted for elevated pulmonary artery pressures with elevated CVP. I agree with the plan that he will need a left ventricular assist device placement with transplant. I discussed the risks and benefits of left ventricular assist device transplantation including the risk of death, stroke, bleeding, wound infection, renal failure arrhythmias, and the possibility of right ventricular failure.
CVP|central venous pressure|CVP|213|215|EXAMINATION|FAMILY HISTORY AND REVIEW OF SYSTEMS: Not obtained. EXAMINATION: VITAL SIGNS: At present, his blood pressure is in the range of 80-90 systolic. His heart rate is in the 130s and irregularly irregular. His initial CVP is in the range of 12-14. Positive urine output noted but concentrated. GENERAL: Elderly gentleman lethargic, BiPAP dependent. HEENT: Ecchymoses over his face.
CVP|central venous pressure|CVP|178|180|PHYSICAL EXAMINATION|Her extremities are cool. HEENT: Otherwise normal. CHEST: Has bilateral rales. CARDIOVASCULAR: There is a soft S1 but a loud systolic ejection murmur, which is late peaking. Her CVP is 14. ABDOMEN: She has significant truncal obesity but no significant hepatosplenomegaly, at least on palpation. LOWER EXTREMITIES: Cool with nonpalpable pulses. MUSCULOSKELETAL: Grossly within normal limits.
CVP|central venous pressure|CVP|214|216|RECOMMENDATIONS|1. Continue fluid replacement with saline and colloids as attempting to support blood pressure this way. 2. Pressers only if the above is not affective. 3. Normally I would consider placement of a central line for CVP monitoring, but this almost seems too aggressive in this patient. 4. Would not recommend dialysis if his kidneys continue to deteriorate.
CVP|central venous pressure|CVP|124|126|PHYSICAL  EXAMINATION|His blood pressure range is mean pressure in the mid 60s. His systemic pressure is 90/51. His oxygen saturation is 98%. His CVP is 13. The total urine output was 3000. Chest tube output was over 1100. The total intake was 9515 and output was 5220 cc.
CVP|central venous pressure|CVP|168|170|PHYSICAL  EXAMINATION|4. Insulin drip. 5. Propofol drip. PHYSICAL EXAMINATION: GENERAL: The patient's T-max is 37.1, heart rate 66 to 95 in atrial fibrillation rhythm, blood pressure 85/50, CVP is 17 to 13 range. The oxygen saturation is 88-100%. The patient is still intubated and sedated. His total intake is 13,891 mL, total output is 4784.
CVP|cyclophosphamide, vincristine, prednisone|CVP|129|131|PAST MEDICAL HISTORY|The patient received multiple courses of chemotherapy, including six cycles of CVP with partial remission, and then 15 cycles of CVP with complete remission. 2. Large rectoperineal mass and splenomegaly in _%#MM2002#%_ with pulmonary biopsy revealing non-Hodgkin's lymphoma.
CVP|central venous pressure|CVP|242|244|ADDENDUM|Therefore intubated. Massive emesis occured. Aspiration occurred. Central line attempt reattempted and then aborted anesthia called for placement. Arterial line placed by anesthia also. Dopamine changed to levophed after central line placed. CVP 14-16. Svo2 monitor placed mixed venous sat 86 % on FiO2 100. Oxygen weaned. Recheck labs revealed worsening metabolic acidosis with slight lactate elevation and resolved hyperkalemia but evidence of DIC and shock liver.
CVP|central venous pressure|CVP|133|135|PHYSICAL EXAMINATION|Initial vital signs at the Medicine ICU was temperature 96.6, pulse was 93, blood pressure 138/89. Her body weight is 138 pounds and CVP was 2. Saturation was 99% with 3 liters nasal cannula. GENERAL: Alert and oriented X3. HEENT: Normocephalic; unremarkable. NECK: Supple; no jugular venous distention. CARDIOVASCULAR: Questionably positive for systolic murmur at left parasternal border but otherwise normal S1 and S2; no gallops; no rales.
CVP|central venous pressure|CVP|151|153|HOSPITAL COURSE|There was also some mention in his old dictation of an echo on _%#MM#%_ _%#DD#%_, 2001, which showed a right ventricular systolic pressure of 35, plus CVP and a PA pressure of 15 plus CVP. However, in investigating this with the echo lab, they did not have record of this.
CVP|central venous pressure|CVP.|184|187|HOSPITAL COURSE|There was also some mention in his old dictation of an echo on _%#MM#%_ _%#DD#%_, 2001, which showed a right ventricular systolic pressure of 35, plus CVP and a PA pressure of 15 plus CVP. However, in investigating this with the echo lab, they did not have record of this. This may have been done elsewhere. 4. Infectious disease: His RSV wash and influenza were both negative on admission, and the viral culture was still negative and pending final study at discharge.
CVP|central venous pressure|CVP|236|238|STUDIES PERFORMED DURING THIS HOSPITALIZATION|2. Right heart catheter _%#MM#%_ _%#DD#%_, 2006. Swan Ganz catheter was placed and a cortis was positioned without complication. The patient's pulmonary artery pressure was 75/26 with pulmonary capillary wedge pressure of 15. Patient's CVP was 15. 3. On _%#MM#%_ _%#DD#%_, 2006, Patient underwent a transthoracic echocardiogram. Conclusions were: a. Technically difficult exam. b. Global left ventricular systolic function.
CVP|cyclophosphamide, vincristine, prednisone|CVP|165|167|HISTORY OF PRESENT ILLNESS|He was then taken off of therapy for nearly one year when his disease recurred and he had a poor response to chlorambucil. He received an additional eight cycles of CVP given in the middle of the year of 2000 with satisfactory disease control. Again, in _%#MM2001#%_, his disease was active with lymphadenopathy. He had a white cell count of 248,000 at that time.
CVP|central venous pressure|CVP|503|505|DISCHARGE DIAGNOSES|b. Good clinical improvement. 4. Cor pulmonale secondary to late ASD repair in 1962 and underlying chronic obstructive pulmonary disease. a. Echocardiogram _%#MMDD2002#%_ showed normal LV chamber size with mild concentric LVH with no noted wall motion abnormalities, EF estimated at 60%, mild right ventricular enlargement with moderate right ventricular systolic dysfunction, sclerotic aortic valve, significantly dilated IVC with lack of normal respiratory variation suggesting significantly elevated CVP and marked right-sided pressures with pulmonary artery pressure approaching 80 mmHg corresponding with severe pulmonary hypertension. 5. Chronic atrial fibrillation for which she had a pacemaker implanted approximately five years ago.
CVP|central venous pressure|CVP|171|173|ASSESSMENT/PLAN|The Pulmonary is closely following the patient and their conclusion was that pulmonary embolism is unlikely since the patient is therapeutic on Coumadin at that time. His CVP tonight is 9 to 11. The patient probably is still dehydrated. I am also concerned about possible early sepsis syndrome. The patient will receive 1-2 liters of bolus intravenous fluid and then will be kept on maintenance fluids at 150 mL/hour overnight.
CVP|central venous pressure|CVP.|194|197|PROBLEM #2|An echo was obtained during hospitalization which showed some ventricular thickening at the top end of normal, normal systolic function, normal anatomy, increased pulmonary pressures 47/14 plus CVP. Given the echo findings a Cardiology consultation was obtained. Per their recommendations an EKG was obtained, which showed normal sinus rhythm, left ventricular hypertrophy, borderline prolonged QT.
CVP|central venous pressure|CVP,|256|259|OPERATIONS/PROCEDURES PERFORMED|Repeat bronchoscopy on _%#MM#%_ _%#DD#%_, 2002, showed an open right mainstem bronchus with a left mainstem bronchus obstruction of 40%. Echocardiogram on _%#MM#%_ _%#DD#%_, 2002, showed good right ventricular and left ventricular function, RVFP = 31 plus CVP, 15 mmHg branch pulmonary artery gradient, trace pulmonary insufficiency, and tricuspid regurgitation. The patient also received multiple packed red blood cells and platelet transfusions during his hospitalization.
CVP|cyclophosphamide, vincristine, prednisone|CVP,|366|369|PROBLEM #3|For example, her anticardiolipin IgG on _%#MMDD2004#%_ was back up to 99.6. The goal is to find a stable pheresis schedule, perhaps two or three times a week, which will keep the antibody levels as low as possible, but allow her to achieve the quality of life she requests, which does not include, in her mind, daily pheresis. Additionally, she will receive cycle 2 CVP, as well as dose #4 of Rituxan, in the Masonic Clinic on _%#MMDD2004#%_. It is hoped that as the chemotherapy begins to decrease antibody production, the pheresis schedule can be lightened.
CVP|central venous pressure|CVP.|150|153|FOLLOW-UP|Pulmonology was notified and recommended a repeat ECHO in the future. A repeat ECHO on _%#MMDD#%_ revealed a Pulmonary artery pressure of 32mmHg plus CVP. An Echo on _%#MMDD2005#%_ revealed normal cardiac anatomy with low normal left ventricular function; pulmonary pressures could not be estimated.
CVP|central venous pressure|CVP|273|275|PROCEDURES PERFORMED DURING THIS HOSPITALIZATION|There was a small pericardial effusion. RV pressures are moderately to severely increased with 52 mmHg over the right atrial pressure. 2. Cardiac catheterization performed _%#MMDD2004#%_, right and left heart catheterization, with the right side showing right pressures of CVP of 17, RV of 63/18, PA of 65/31, with a wedge of 29, this decreased to 50/21 with a wedge of 22 after being given Nipride.
CVP|central venous pressure|CVP.|126|129|PROBLEM #3|An echo shortly after admission showed poor function, with an ejection fraction approximately 20% and PA pressures of 52 plus CVP. Subsequent EKG's showed Q waves in the lateral leads, as well as left atrial enlargement. His BNP level steadily decreased during his hospitalization, and the most recent at the time of discharge was 575.
CVP|central venous pressure|CVP|215|217|HOSPITAL COURSE|From a cardiac standpoint, the patient did very well in the early postoperative course. His dopamine postoperatively was required only at 2 mics/kilo/minute and was weaned off quickly, and by _%#MM#%_ _%#DD#%_, his CVP was down to 10 with systolic pressures ranging from 28-40 with an acceptable wedge of 12-18. The patient's creatinine did increase postoperatively to a peak of 2.1 on _%#MM#%_ _%#DD#%_, despite adequate cardiac output.
CVP|central venous pressure|CVP|172|174|HOSPITAL COURSE|Subsequent follow-up biopsy on _%#MM#%_ _%#DD#%_ revealed grade 1B rejection. Hemodynamically, the follow-up right heart cath on _%#MM#%_ _%#DD#%_ was very acceptable with CVP and pulmonary capillary wedge pressures that were quite low. However, follow-up right heart cath biopsy on _%#MM#%_ _%#DD#%_ did show fairly markedly elevated PA pressures as compared to _%#MM#%_ _%#DD#%_ with systolic of 51 and a wedge pressure (mean) of 24.
CVP|cyclophosphamide, vincristine, prednisone|CVP|271|273|HISTORY OF PRESENT ILLNESS|He achieved a partial remission with his rituximab therapy. He underwent watchful waiting and in _%#MM2006#%_, presented with increasing abdominal pain. At that time, he was noted to have significant progression of disease and was treated with 8 cycles of rituximab plus CVP chemotherapy. That ended in _%#MM2007#%_. He again achieved a partial remission. Imaging done on _%#MMDD2007#%_ demonstrated some increase in his retroperitoneal lymphadenopathy increasing in size from 1.5 x 1.3 cm to 3.0 x 2.2 cm.
CVP|cyclophosphamide, vincristine, prednisone|CVP,|184|187|PAST MEDICAL HISTORY|5. Ultrasound of bilateral upper extremities, _%#MM#%_ _%#DD#%_, 2004: No evidence of DVT. PAST MEDICAL HISTORY: 1. Chronic lymphocytic leukemia, diagnosis in 1994, treated with CHOP, CVP, chlorambucil, and rituximab on _%#MM#%_ _%#DD#%_, 2003. 2. Pulmonary nodules on _%#MM#%_ _%#DD#%_, 2003 with Candida glabrata and parainfluenza which was sensitive to voriconazole.
CVP|central venous pressure|CVP|165|167|PROBLEM #1|Subsequent to the addition of milrinone and nitric oxide on 100% of IO2. Systolic blood pressure was 113/71. PA pressure of 38/11. Mean of 20. Wedge pressure of 10. CVP of 2. Cardiac output of 1.5. Index of 1.4. Pulmonary vascular resistance of 6.6. TPG of 10 revealed responsiveness of the pulmonary vascular resistance.
CVP|central venous pressure|CVP|267|269|PHYSICAL EXAMINATION|He has a previous history of heavy alcohol consumption. PHYSICAL EXAMINATION: VITAL SIGNS: On admission to the ICU, the patient's temperature was 95.9, pulse is in the 90s, BP was 90/50 on dopamine, respiratory rate was 20, O2 saturation is 96% on 1 L nasal cannula, CVP was 15 and weight was 84.5 kg. GENERAL: The patient was awake but groggy. Attempts to answer the question were difficult with his hoarse voice and difficult to understand speech.
CVP|central venous pressure|CVP|408|410|8. ID.|This may signify inflammation, infectious or even carcinomatosis, although again, this was read officially as diffuse dural enhancement of the cerebral hemispheres and could be seen in someone after head trauma or surgery or spontaneous intracranial hypotension, uncertain if this is a real finding. 7. Hypotension. Again, the patient was very hypotensive upon admission with blood pressures in the 50s. Her CVP upon admission was 4-6. She was hydrated aggressively and despite being hydrated aggressively and her creatinine coming down, she is still requiring some Dopamine.
CVP|central venous pressure|CVP|134|136|PROBLEM # 2|We will volume resuscitate him tonight. He will need levophed which we will do titrate to a MAP greater than 60. He will need to have CVP checked later and he may need fluid tap, which could certainly lower his blood pressure at some point. His lactate is elevated 3.7. I would like to avoid any peripheral squeezers for the time being and continue levophed.
CVP|central venous pressure|CVP.|267|270|PROBLEMS|An immediate postprocedure echocardiogram on _%#MM#%_ _%#DD#%_, 2005, showed antegrade flow across the pulmonary valve, and 3+ pulmonary insufficiency. There was right-to-left shunting across the PFO versus AFP. Right ventricular systolic pressures were 44 mmHg plus CVP. The maximum gradient across the pulmonary valve was 21 mmHg. An echocardiogram was repeated both on _%#MM#%_ _%#DD#%_, 2005, and on _%#MM#%_ _%#DD#%_, 2005, which showed 1 to 2+ pulmonary insufficiency with good function of both the right and left ventricle bilaterally.
CVP|central venous pressure|CVP|180|182|ASSESSMENT|Plan to evaluate for intravascular hypovolemia we will check orthostatics on admission. We will also have a PICC line placed and monitor the patient's CVPs q.6 h. If the patient's CVP drops below 6 we will bolus her fluids and we will also challenge her with fluids on admission to see if her blood pressure responds.
CVP|central venous pressure|CVP|174|176|IMPRESSION AND PLAN|A central line is being placed at this moment by Anesthesia. We will check her CVP. It is difficult with her liver failure to estimate her volume status, but we will get her CVP and replace her fluids accordingly. Next we will get an echocardiogram to evaluate her left ventricular function and wall motion abnormality.
CVP|central venous pressure|CVP.|150|153|PROBLEM #5|There was no tricuspid regurgitation. There was mild pulmo nary insufficiency. The patient's pulmonary artery diastolic pressure was equal to 20 plus CVP. The patient's mean pulmonary artery pressure was 32 plus CVP. The patient's septal motion was consistent with systemic right ventricular pressure.
CVP|central venous pressure|CVP|160|162|PHYSICAL EXAMINATION|No paresthesias noted. Psychiatric: Please see review of systems and HPI. The patient is calm and engaged in conversation. IV lines: Patient has a triple lumen CVP in the left subclavian. This site is covered; dressings dry and intact. PERTINENT LABORATORY DATA: 1. _%#MMDD2002#%_ - Liver function tests: Albumin 2.8, protein 5.6, alkaline phosphatase 90, ALT 101, AST 32 - apparently, these have been improving quickly.
CVP|central venous pressure|(CVP)|152|156|PLAN|4. Urinalysis and urine culture. 5. Systemic antibiotics. Zosyn has been ordered and we will continue this. 6. Central line for central venous pressure (CVP) monitoring. 7. Head CT scan to evaluate for possible hemotympanum. 8. Protonix for gastric ulcer prophylaxis. 9. ENT consultation concerning epistaxis and auditory bleeding. TOTAL CRITICAL CARE TIME: 60 minutes was spent in critical care at the bedside.
CVP|central venous pressure|CVP|157|159|IMPRESSION|The echo does raise the question was admitted to the pulmonary embolus given some right ventricular dilatation, severe tricuspid regurgitation and very high CVP pressures. However, she was on some anticoagulation and her clinical story as well as the lack of any difficulty in ventilating and oxygenating her seems less likely to support pulmonary embolus.
CVP|central venous pressure|CVP.|226|229|HISTORY OF PRESENT ILLNESS|There was LVH and diastolic dysfunction of left ventricle. Her right ventricular systolic pressure was 22 mmHg plus right atrial pressure with right heart enlargement and increased inferior vena cava size consistent with high CVP. She had severe tricuspid insufficiency and marked right ventricular enlargement and dysfunction. There was no evidence of pulmonary emboli at that time.
CVP|central venous pressure|CVP|158|160|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 96.4, respiratory rate 10, she is on the ventilator with settings previously described. The saturation is 98%. CVP 12, pulmonary capillary wedge pressure is 36. Accu-Chek 107. Blood pressure systolic in 160-180 range with pulse being in the 60-70 range.
CVP|central venous pressure|CVP|359|361|ASSESSMENT AND PLAN|The lung parenchyma appears to be clear. On review of CT scan from 2006 the lung parenchyma appeared to be essentially normal with no evidence of pleural effusions at that time. ASSESSMENT AND PLAN: 1. Severe pulmonary hypertension: Ms. _%#NAME#%_ is a 46-year-old woman with evidence of severe right ventricular failure as evidenced by her markedly elevated CVP on _%#MM#%_ _%#DD#%_ as well as her relatively low mean pulmonary artery pressures, which is likely indicative of her frank RV failure.
CVP|central venous pressure|CVP|118|120|PHYSICAL EXAMINATION|His blood pressure was 60s/40s on admission to the ICU, and more recently has been in the 90/30s to 110s/40s range. A CVP was as high as 20 to 22, but over the course of the day has come down to 14. His respiratory rate has ranged from 14 to 35. He has a saturation of 100% on 4 liters.
CVP|central venous pressure|CVP|151|153|IMPRESSION|We have added colloid therapy in the form of a bolus infusion of Hespan following which we will add continuous infusion for now of 5% albumin. Initial CVP readings are quite low in support of the diagnosis of intravascular volume depletion. Will monitor central venous pressures on an ongoing basis in hopes of optimizing volume status.
CVP|central venous pressure|CVP|136|138|HISTORY OF PRESENT ILLNESS|She was started on ceftriaxone and vancomycin. In the ER and in the Intensive Care Unit, she was given about 20 liters of fluid and her CVP has come up, but she still remains on norepinephrine. She is now making urine after being pretty significantly dehydrated it appears.
CVP|central venous pressure|CVP|182|184|PHYSICAL  EXAMINATION|He is afebrile. T-max is 98.5. HEENT: Oral cavity is clear. NECK: Supple. Bilateral carotid bruits are equal. Could not evaluate jugular venous pressure secondary to the presence of CVP line. CHEST: Auscultation is clear anteriorly. No rales or rhonchi heard. CARDIAC: Reveals regular S1, S2 with soft S3. No S4 or murmurs heard.
CVP|central venous pressure|CVP|366|368|PHYSICAL EXAMINATION|The daughter, _%#NAME#%_, is the designated decision maker and works at a group home as well as going to school and is quite busy. Three care conferences have been completed to date. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature maximum is 97.0 at 8 p.m. on _%#MM#%_ _%#DD#%_, current temperature is 95.1; heart rate 60; blood pressure 110/65; respiratory rate 20; CVP was 20 this morning; oxygen saturations at 100% on pressure support at _%#MMDD#%_ with 30% FiO2. GENERAL: The patient is lying in bed, obtunded, with marked jaundice and scleral icterus.
CVP|central venous pressure|CVP,|239|242|IMPRESSION|6. Acute renal insufficiency, on the basis of previously documented creatinines in the range of 1.0, with a value today noted to be 1.6. She was oliguric, but we do note increasing improvement in her urine output with stabilization of her CVP, and she did receive one dose of diuretic after volume loading. 7. Re-elevation of both ALT and AST, on the basis of laboratory studies.
CVP|central venous pressure|CVP|130|132|ASSESSMENT  AND PLAN|There is no need for dialysis at this point. All of this was discussed with the family. a. Will hold diuretics for now. b. If the CVP drops a little more than will give some albumin. c. We will follow a urine output and renal function closely.
CVP|central venous pressure|CVP|194|196|HISTORY OF PRESENT ILLNESS|His urine output was pretty good up until the past 8-10 hours when it has dropped about 30 cc an hour. His urine was concentrated with hyaline casts and some granular casts. A FENA was low. His CVP peaked at eighteen earlier today and is twelve currently. The patient was given furosemide yesterday and I think he received some torsemide today.
CVP|central venous pressure|CVP|160|162|PHYSICAL EXAMINATION|24 hour ins and outs 2550 in and 1400 of urine out, 600 from the chest tube and 50 from the NG. So far today 600 in, 300 of urine out, 300 from chest tube. His CVP has been twelve currently and peaked at eighteen. GENERAL: He is pleasant, lying in bed. He is not in any acute distress. He has a face mask oxygen and a nasal trumpet in.
CVP|central venous pressure|CVP.|407|410|REVIEW OF SYSTEMS|No headaches. All other review of systems are only as above. It should be noted that this patient did have an echocardiogram _%#MM#%_ _%#DD#%_, 2000, which showed normal left ventricular size and function with ejection fraction of 60%, trace aortic insufficiency, trace mitral insufficiency with MAC, normal right heart, mild tricuspid insufficiency with pulmonary artery pressures of 21 mm of mercury plus CVP. PHYSICAL EXAMINATION: Current blood pressures lying is 165/80, sitting 175/81, standing 177/83, pulse 55 and regular.
CVP|central venous pressure|CVP|170|172|DISCUSSION|It does not appear to have impaired her respiratory status. Hopefully her urine output, which had been sluggish overnight, will improve with the hydration and the higher CVP of approximately 14-15. If the patient does require intervention for her pleural and/or pericardial effusion, this may better be done possibly surgically to provide a window, especially with regards to the pericardium, to prevent recurrence of the effusion, especially in light of her previous history of therapy, as well as radiation.
CVP|central venous pressure|CVP|267|269|PLAN|8. Twitching prior to his sedation. I suspect this may be a drug toxicity effect given all that he is on chronically, especially the gabapentin, the dose of which would be quite excessive for his current level of kidney function. PLAN: 1. Volume support based on his CVP via the sepsis protocol. 2. Vasopressors. 3. Continuous monitoring of his mixed venous oxygen saturation. 4. Cosyntropin stem test and empiric stress dose steroid.
CVP|central venous pressure|CVP|323|325|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: T-max 101.1, currently 100.4, blood pressure is 70s to 120s/30s to 50s, heart rate 90s-100s, respiratory rate 18-24 with a sedimentation rate of 18, tidal of 600, PEEP of 8, sats 98% at 40% FIO2. Weight today is 134.5 kilograms, down from 135.9 yesterday but up from 126 kilograms preop. CVP is 18-22. PA pressure is 43-49/24-28. 24 hour ins 18,750+, outs 3,750 of urine and 2,800 from the chest tube and 13,000 blood loss in the OR.
CVP|central venous pressure|CVP|222|224|PHYSICAL EXAMINATION|No family with the patient. PHYSICAL EXAMINATION: VITAL SIGNS: Now is suggestive of a blood pressure of 90-100 systolic by 68 diastolic. Pulse ox is 100% and 40% FIO2, respiratory rate of 18-20 per minute. T-max is 101.3. CVP was 17. Her weight was 62.6 kg and yesterday it was 61.6 kg. HEENT: Normocephalic and atraumatic. No pallor noted. Spontaneous eyelid movements noted.
CVP|cyclophosphamide, vincristine, prednisone|CVP|243|245|PAST MEDICAL HISTORY|Chemotherapy was stopped from _%#MM2002#%_ through _%#MM2002#%_. The patient stated that he tolerated his CVP chemotherapy extremely well. He had not had any problems with cytopenias. However, he had been told that he had reached the limit of CVP that he could receive because of substantial peripheral neuropathy. The patient had received some response to his last cycles of CVP with shrinkage of his tumor mass.
CVP|central venous pressure|CVP|237|239|PAST MEDICAL HISTORY|He had not had any problems with cytopenias. However, he had been told that he had reached the limit of CVP that he could receive because of substantial peripheral neuropathy. The patient had received some response to his last cycles of CVP with shrinkage of his tumor mass. He had resumed a macrobiotic diet in _%#MM2003#%_. The patient had a bone marrow biopsy done on _%#MMDD2002#%_.
CVP|central venous pressure|CVP|194|196|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Current blood pressure 100 to 105/50, pulse 85 and regular, respiratory rate currently 20, cardiac output 2.7, cardiac index 1.5, SVR 1184, PA pressure 55/28, CVP 22. The patient is 96% saturated and temperature is 98 degrees rectally. Current weight 73.7 kg compared to 73 kg yesterday. GENERAL; The patient is an elderly-appearing white female orally intubated, in no acute distress.
CVP|central venous pressure|CVP|153|155|PHYSICAL EXAMINATION|No oropharyngeal lesions. He has a nasogastric tube in place. Mucous membranes are moist. Neck is supple without thyromegaly. He does have a right-sided CVP line. CHEST: Clear to auscultation without kyphosis or scoliosis. CARDIAC: Regular rate and rhythm with occasional ectopic, likely paroxysmal ventricular contractions.
CVP|central venous pressure|CVP|128|130|HISTORY OF PRESENT ILLNESS|He has received multiple fluid challenges, blood products and diuretics but to no avail. Today, his fluids were cut off has his CVP has risen from 8 to 16. Luckily his oxygenation has remained stable with an FIO2 of 68%. The patient was noted to have a small right kidney versus the left or the aortogram.
CVP|cyclophosphamide, vincristine, prednisone|CVP|173|175|HISTORY OF PRESENT ILLNESS|In 2001, he developed cervical adenopathy and was treated with Cytoxan and prednisone. In 2002, he was treated with Chlorambucil and prednisone In 2003, he was treated with CVP chemotherapy, apparently without response. His treatment was changed to CHOP chemotherapy. He received 3 cycles without response. His therapy was then changed to RICE chemotherapy without response.
CVP|central venous pressure|CVP|178|180|PHYSICAL EXAMINATION|VITAL SIGNS: Blood pressure 107/56, pulse 96, temperature is 94.6, respirations are 18 on CMV set rate of 18, tidal volume of 400, FIO2 of 55%, no PEEP yielding an SpO2 of 100%. CVP is 8. Initial arterial blood gas obtained before these ventilator settings initiated showed a pH of 7.04, pCO2 of 132, pO2 of 477 and bicarbonate 34.
CVP|central venous pressure|CVP|205|207|PLAN|PLAN: 1. The patient is admitted to the Intensive Care Unit under diabetic ketoacidosis protocol orders. This includes insulin drip. 2. Vigorous rehydration. 3. Rule out myocardial infarction protocol. 4. CVP monitoring. 5. Will add TSH and Free T4 to admitting labs, as well as a Tox screen, EKG, and alcohol level. 6. The patient is pan-cultured. No antibiotics will be given at this time.
CVP|central venous pressure|CVP|129|131|PHYSICAL EXAMINATION|Temperature remains elevated greater than 102. Respirations are calm at about 20 with nasal cannula oxygen saturation at 100%. A CVP line has been placed and pressures are about 10. The patient's pulse is sinus in the 90s. NEUROLOGIC: Previously he was felt to be confused.
CVS|cardiovascular system|CVS:|142|145|1. FEN|She was loaded with caffeine prior to transfer from _%#CITY#%_ _%#CITY#%_ and was continued on maintenance caffeine therapy upon transfer. 3. CVS: Blood pressures have remained stable since arrival. Pt is on PGE1 drip at 0.05 mcg/kg/hr to maintain PDA. Goal O2 saturation is 70- 90%. 4. HEME: Hemoglobin has been 17-18.
CVS|cardiovascular system|CVS:|166|169|SOCIAL HISTORY|Pupils equal, round, and react to light. Extraocular movements normal. Mucus membranes moist. Neck supple. No lymphadenopathy. No carotid bruit. No elevation of JVD. CVS: Distant heart sounds. Bradycardia. S1, S2. No murmurs appreciated. Lungs were clear to auscultation bilaterally. Abdomen: Bowel sounds present.
CVS|cardiovascular system|CVS:|209|212|PHYSICAL EXAMINATION ON ADMISSION|HEENT: Head: Atraumatic, normocephalic. Pupils equal, round and reactive. Extraocular movements normal. Mucous membranes moist. Neck: Supple. No lymphadenopathy. No carotid bruits. JVP was approximately 8 cm. CVS: Irregularly irregular rhythm, tachycardic. Could not appreciate any murmurs. Lungs: Clear to auscultation bilaterally. Abdomen: Bowel sounds positive, soft, nondistended, and nontender, no hepatosplenomegaly.
CVS|cardiovascular system|CVS:|215|218|PHYSICAL EXAMINATION ON ADMISSION|Head: Normocephalic and atraumatic. Pupils equal, round and reactive. Extraocular movements normal. Mucous membranes are moist. No lesion in oropharynx. Neck: Supple without lymphadenopathy. No thyromegaly. No JVD. CVS: Regular rate and rhythm, S1, S2. No murmurs appreciated. Lungs are clear to auscultation. Abdomen: Bowel sounds positive, soft, nondistended, and nontender.
CVS|cardiovascular system|CVS,|226|229|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: 1. The patient is a 77-year-old female with history of pig mitral valve replacement who was brought in with symptoms and signs consistent with congestive heart failure and gastroesophageal reflux disease. CVS, congestive heart failure, and bilateral pleural effusions. I would start her on Lasix 40 mg IV b.i.d. If no response I would increase the dose.
CVS|cardiovascular system|CVS|136|138|HOSPITAL COURSE|An intraaortic balloon pump was placed in the Cath Lab and the patient was transferred to the cardiovascular intensive care unit with a CVS consultation. The patient was taken to the operating room on _%#MMDD2006#%_ for a 4-vessel CABG and mitral valve repair. Postoperatively the patient was transferred to the cardiovascular intensive care unit for postoperative care.
CVS|cardiovascular system|CVS,|117|120|REVIEW OF SYSTEMS|10. Primidone 250 mg, 1/2 a tablet 3 times a day. REVIEW OF SYSTEMS: Denies any discomfort. Reviewed general, chest, CVS, abdomen and denies any pain of any sort. Again, the history is very limited. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 128/76, heart rate 71, respirations 16, temperature 36.1, saturations are 97% on room air.
CVS|chorionic villus sampling|CVS|238|240|HISTORY|HISTORY: The patient is a 27-year-old female G-1, P-0 who presented at 40 +3 with active labor. Prenatal course was uncomplicated. The patient made regular visits. Her prenatal labs included O positive, antibody negative, rubella immune, CVS negative per patient. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: None. SOCIAL HISTORY: Married.
CVS|cardiovascular system|CVS.|65|68|PROBLEM #3|The patient was maintaining 97-98% on 2 L of oxygen. PROBLEM #3: CVS. Atrial fibrillation with rapid ventricular response. The patient had atrial fibrillation with rapid ventricular response at the time of admission to the ICU probably due to her acute sickness.
CVS|cardiovascular system|CVS:|132|135|PHYSICAL EXAMINATION ON ADMISSION|Extraocular movements are intact. Positive pallor. No icterus. Mucus membranes moist. Neck: Supple. Elevated JVP. No carotid bruit. CVS: Regular rate and rhythm. S1, S2. She had a 3/6 wholly systolic murmur at the left sternal border and a crescendo to decrescendo murmur in the aortic area.
CVS|cardiovascular system|CVS|161|163|PHYSICAL EXAMINATION|HEENT: Pupils equal, round, and reactive to light and accommodation. HEENT unremarkable. CARDIAC: No carotid bruits. 2+ bilateral lower extremity edema. No JVD. CVS irregularly irregular. CHEST: Bilateral basilar crackles. There is also expiratory wheezes which I can hear especially on right upper side. ABDOMEN: Obese, nondistended. Bowel sounds are present. EXTREMITIES: Pedal pulses are palpable.
CVS|cardiovascular system|CVS:|189|192|PHYSICAL EXAMINATION|NECK: supple, with no palpable adenopathy or thyromegaly. CHEST / LUNGS: clinically clear to auscultation, with normal vesicular (?) breath sounds; no wheezing, rhonchi, or crackles heard. CVS: S1 and S2 are regular, with no appreciable murmur, gallop, or rub heard. ABDOMEN: distended; has mild diffuse tenderness in the left lower quadrant and the mid umbilical area, with no guarding or rebound tenderness; bowel sounds are not heard.
CVS|cardiovascular system|CVS:|205|208|PROBLEM #2|If the patient is not feeling any better as outpatient, the patient needs evaluation on obstructive sleep apnea, may be a sleep study and an echocardiogram to rule out any right heart problem. PROBLEM #2: CVS: Hypertension. The patient has a history of hypertension, was on metoprolol 50 mg b.i.d. While in the hospital, the patient's blood pressures were stable, only one elevated blood pressure probably due to withdrawal of alcohol.
CVS|cardiovascular system|CVS:|279|282|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: She appears comfortable lying in bed. Her vital signs are temp 96.7, pulse 92, blood pressure 150/93, respirations 16, pulse 99 percent. HEAD AND NECK: Pupils equal, reactive to light and accommodation. Extraocular movements intact. Neck is supple. No JVD. CVS: S1, S2. Irregularly irregular. LUNGS: A few creps at the right base. ABDOMEN is soft, nontender, no organomegaly. Bowel sounds present. EXTREMITIES: No edema.
CVS|cardiovascular system|CVS:|104|107|PROBLEM #2|The patient additional to antibiotic treatments. She was treated with DuoNeb and albuterol. PROBLEM #2: CVS: The patient gave a history of hypertension. She was on valsartan 40 mg, we increased the dose of valsartan to 80 mg by mouth every day.
CVS|cardiovascular system|CVS|317|319|HOSPITAL COURSE AND LABS|Today her blood sugar was 98. On examination, hospital course and further work-up today, the patient's temperature is 36.6, blood pressure is 148/70, respiratory rate 20, and O2 saturation is 98 on three liters nasal cannula. Her lungs are quite clear to auscultation. Although breath sounds are extremely diminished CVS examination is normal. S1 and S2. No gallop or murmur. Abdomen is soft and non-tender. No hepatosplenomegaly or hernia. Normal bowel sounds. Extremities are without any edema.
CVS|cardiovascular system|CVS,|156|159|PHYSICAL EXAMINATION|GENERAL: Patient appears comfortable and in no obvious distress. CHEST: Decreased breath sounds at bases, otherwise no wheezes or crackles. CARDIOVASCULAR: CVS, S1 and S2 are audible. There is a faint systolic murmur. No S3. JVP is about 9-10 cm. ABDOMEN: Soft, nontender and nondistended.
CVS|cardiovascular system|CVS,|139|142|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: As stated she has had a 20 pound weight loss in the past year. Denies any visual disturbance. No difficulty swallowing. CVS, no recent complaints of palpitations, chest pain, orthopnea, PND. Respiratory denies any cough, hemoptysis, shortness of breath. GI, denies any abdominal pain, change in her bowel habits.
CVS|cardiovascular system|CVS:|147|150|PHYSICAL EXAMINATION|HEAD: Atraumatic, normocephalic: EYES: Pupils are equal, round, and reactive to light. EOMI. CHEST: Bilateral inspiratory and expiratory wheezing. CVS: Distant heart sound, S1, S2. ADOMEN: Morbidly obese. Bowel sounds are positive. Non-tender. EXTREMITIES: Trace edema. NEUROLOGIC: Non-focal. SKIN: No purpura or rashes noted. LABORATORY ON ADMISSION: Hemoglobin 13.1, platelets 145.
CVS|cardiovascular system|CVS:|166|169|GYN HISTORY|Pulse rate of 96 per minute. Blood pressure of 154/82, repeat 151/87, respiratory rate of 20. General: Alert, active, and oriented and comfortable with contractions. CVS: Regular rate and rhythm. Lungs: Clear to auscultation bilaterally. Abdomen: Gravid, nontender. Estimated fetal weight of 2600 g. Well-healed Pfannenstiel scar. Extremities: Reflexes +2 bilaterally, trace edema. Fetal heart tracings 150 beats/minute.
CVS|cardiovascular system|CVS|153|155|ADMISSION DIAGNOSIS|Oral cavity showed no mucositis and no tonsillar enlargement. Cranial nerves were all intact. Neck was supple. There was no thyromegaly. JVP was normal. CVS showed first and second heart sounds that were normal, regular rate and rhythm. Lungs were clear to auscultation bilaterally with good air entry.
CVS|customer, value, service|CVS|173|175|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 16-year-old white male with a known history of depression who presents to our service following an acute ingestion of approximately 40 CVS brand cold and flu pills containing dextromethorphan as well as acetaminophen. The patient was apparently reported to be found combative and hallucinating and required wrist restraints.
CVS|cardiovascular system|CVS:|144|147|PHYSICAL EXAMINATION|Pulse ox is 98 percent. HEAD AND NECK: Pupils equal, reactive to light and accommodation. Extraocular movements intact. Neck is supple. No JVD. CVS: S1, S2 not well heard. S3 is heard. LUNGS: Fair air entry except at bases. There are rales at both lung bases. ABDOMEN: Soft, nontender.
CVS|cardiovascular system|CVS:|219|222|PHYSICAL EXAMINATION ON ADMISSION|General: The patient appeared in no acute distress. HEENT: Head normocephalic, atraumatic. Pupils equal, round and reactive. Extraocular movements normal. Neck: Supple, no lymphadenopathy. Had bilateral carotid bruits. CVS: Regular rate and rhythm, normal S1 plus S2. Holosystolic murmur at second intercostal space on the right. Lungs: Clear to auscultation bilaterally.
CVS|chorionic villus sampling|CVS|143|145|PRENATAL LABS|RPR, HIV, hepatitis B all negative. Urine culture positive for contamination. Pap smear within normal limits. Cystic fibrosis screen negative. CVS was performed that revealed 46 XY. Amnio showed a normal alpha protein GCT was 105. Ultrasounds on _%#MMDD2007#%_ the patient had an ultrasound at 5 weeks that showed a small gestational sac.
CVS|cardiovascular system|CVS|141|143|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: As in history of present illness. His weight has been stable. Denies any chronic headaches. Denies difficulty swallowing. CVS Negative. RESPIRATORY: Negative. GI: Negative. GU: Negative. Neurologically: As in history of present illness. Psychiatry negative. The rest of the 10 review of systems is negative.
CVS|chorionic villus sampling|CVS.|177|180|ADMISSION DIAGNOSES|2. History of previous cesarean section and desires a trial of labor after cesarean section. 3. Seizure disorder on Dilantin. 4. Advanced maternal age, with normal karyotype on CVS. 5. Latent labor. DISCHARGE DIAGNOSIS: Status post normal spontaneous vaginal delivery.
CVS|cardiovascular system|CVS|149|151|PHYSICAL EXAMINATION|Skin was warm and dry with no xanthoma. HEENT was benign. Neck was supple without thyromegaly or adenopathy. Chest clear anteriorly and posteriorly. CVS examination revealed normal S1 and S2. Occasionally irregular rhythm. No S3, S4 or murmurs heard. Femoral pulses are 2+ as were carotid pulses.
CVS|chorionic villus sampling|CVS|184|186|PATIENT IDENTIFICATION|She was seen in the office for an initial examination _%#MMDD2004#%_, and fetal heart tones were audible. It should be mentioned the patient had declined any genetic testing including CVS and amniocentesis, quad. screen and level II ultrasound as reported were normal. A GBS culture in the third trimester was negative.
CVS|cardiovascular system|CVS:|202|205|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Temperature 100.3, pulse 100, blood pressure 84/56, respiratory rate 16, oxygen saturation 93% at room air. HEENT: A/T, N/C, PERRLA, extraocular muscles intact. Moist oral mucosa. CVS: RRR, S1, S2 audible. LUNGS: Clear to auscultation, no wheeze, no crepitations. ABDOMEN: Positive bowel sounds, distended, tympanic. No tenderness on deep palpation.
CVS|cardiovascular system|CVS:|187|190|ADMISSION DIAGNOSIS|PHYSICAL EXAMINATION: Vital Signs: Stable. Afebrile. Pulse of 82, respiratory rate of 18, and blood pressure of 109/72. General: Alert, active, and oriented. HEENT: Within normal limits. CVS: Regular rate and rhythm. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, gravid, and nontender. Fetal heart tracings 130 beats per minute, reactive, and good viability.
CVS|cardiovascular system|CVS|180|182|REVIEW OF SYSTEMS|HEENT - does have some trouble with his vision, and this has been going on for the last few years. Chest - denies any shortness of breath but does have a history of tobacco abuse. CVS - denies any chest pain at this time. Abdomen - denies any nausea, vomiting or diarrhea. GU - denies any urinary complaints. Endocrine - denies any diabetes or thyroid disease.
CVS|cardiovascular system|CVS:|93|96|PROBLEM #3|Also CD and psych was consulted while in the hospital. Recommended CD treatment. PROBLEM #3: CVS: Hypertension. The patient's blood pressure was stable while in the hospital, was kept on atenolol his home medication. DISCHARGE FOLLOWUP: The patient needs follow up with his primary care doctor, Dr. _%#NAME#%_ at Park Nicollet Clinic.
CVS|cardiovascular system|CVS.|242|245|PEDIATRIC INTENSIVE CARE UNIT|Our goal today is to try pressure support trials _%#MMDD#%_ t.i.d. with a plan of extubating him on _%#MMDD2007#%_ if he is diuresed and does well with life support. He does have small volumes of lungs secondary to his hepatosplenomegaly. 3. CVS. The patient has a history of hypertension. His atenolol was held secondary to concern regarding bleeding and inability of body to compensate.
CVS|cardiovascular system|CVS:|130|133|HOSPITAL COURSE|The patient did not need any sliding scale while in the hospital stay. We resumed her metformin back at the time of discharge. 3. CVS: Hypertension: The patient had few episodes of low blood pressure. The patient's blood pressure medications were held because of the low blood pressures, received IV fluids.
CVS|chorionic villus sampling|CVS.|204|207|DOB|Patient's EDC is _%#MMDD2002#%_ making the patient 39 weeks. Patient's pregnancy has been of note for maternal age greater than 35 and was offered antenatal testing, but patient declines amniocentesis or CVS. Patient's pregnancy has been of note for pregnancy induced hypertension and that has engendered the admission. PAST MEDICAL HISTORY: ALLERGIES: None. MEDICATIONS: Prenatal vitamins. MEDICAL ILLNESSES: None.
CVS|cardiovascular system|CVS.|159|162|HISTORY OF PRESENT ILLNESS|PROBLEM #2: Gastrointestinal. The patient was tolerating a general diet. PROBLEM #3: Genitourinary. The patient was voiding spontaneously. PROBLEM #4: CNS and CVS. Stable. PROBLEM #5: Cardiac. Stable. DISMISSAL PHYSICAL FINDINGS: The patient was doing well on discharge. She did not have any significant nausea. Her vital signs were stable.
CVS|cardiovascular system|CVS|147|149|PHYSICAL EXAM ON ADMISSION|Pupils are equal, round and reactive. Extraocular movements are normal. Neck is supple. No lymphadenopathy. No carotid bruit. No elevation of JVP. CVS is S1 plus S2 plus zero. No murmur is appreciated. Lungs were clear to auscultation. Abdomen revealed the bowel sounds were positive.
CVS|cardiovascular system|CVS:|199|202|DISCHARGE PHYSICAL EXAMINATION|Respiratory rate is 16. Weight is 78.2. I's and O's are 3800 and not being recorded out. GENERAL: In no apparent distress. Pleasant. Alert and oriented x 3. LUNGS: Clear to auscultation bilaterally. CVS: Regular rate and rhythm, no murmurs, rubs, or gallops. ABDOMEN: Soft, non-distended. Mild tenderness in the right upper quadrant. Positive bowel sounds. The patient is alert and oriented x 3.
CVS|cardiovascular system|CVS:|155|158|PHYSICAL EXAMINATION|NECK: Supple. No jugular venous distention. No carotid bruits. No thyromegaly. CHEST: Reduced air entry bilaterally and wheezing bilaterally. No crackles. CVS: Regular rate and rhythm. Normal S1 and S2. She is tachycardic. No S3 or S4. ABDOMEN: Soft. Nontender. Positive bowel sounds.
CVS|cardiovascular system|CVS:|240|243|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: As noted, afebrile, pulse 89, respirations 22, blood pressure 148/78, sat 97% on three liters of O2, weight 264.5 pounds, obese. Obvious wheezing is noted. SKIN: NAD. HEENT: NAD. CHEST: Positive wheezing. CVS: No murmurs are noted. ABDOMEN: Soft, nontender. No peripheral edema is noted. NEURO: Grossly within normal limits. PERIPHEROVASCULAR: Peripheral pulses are intact.
CVS|cardiovascular system|CVS:|209|212|PHYSICAL EXAMINATION|Positive thoughts of hurting self but no plans. Positive for urinary tract infection through the pregnancy. Positive for carpal tunnel syndrome bilaterally. PHYSICAL EXAMINATION: Vital signs stable, afebrile. CVS: Regular rate and rhythm, no murmur. Lungs: Clear to auscultation bilaterally. Abdomen: Gravid, nontender, obese, soft, difficult to palpate the fundus.
CVS|cardiovascular system|CVS:|178|181|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: Positive for occasional chills. No fever. Positive for nausea, but no vomiting. Positive for intermittent constipation. Chest: Denies any shortness of breath. CVS: Denies any palpitations or angina. GI: As noted in the HPI. GU: No dysuria. Heme/Lymphatics: History of anemia of chronic disease.
CVS|cardiovascular system|CVS:|107|110|ADMISSION PHYSICAL|Ears: Bilateral tympanic membranes are clear and opaque. Neck: Soft and supple. No thyromegaly adenopathy. CVS: Regular rate and rhythm. No murmur, gallop, or rub. Lungs: Clear to auscultation both sides. Abdomen: Soft, nontender, nondistended.
CVS|cardiovascular system|CVS:|255|258|PHYSICAL EXAMINATION|VITAL SIGNS: Blood pressure 99/75, pulse rate of 100 and regular, temperature 96.2, respiratory rate 18, pulse ox 95% on room air. HEENT: Pupils are equal, round, and reactive to light. EOMI. NECK: Supple. CHEST: Reduced breaths sounds on the right side. CVS: S1 and S2 . ABDOMEN: Distended. Bowel sounds are positive. shifting dullness is present. Left-sided abdominal Port-A-Cath is in place.
CVS|cardiovascular system|CVS,|150|153|PHYSICAL EXAMINATION|HEENT: Pupils are equal, round, reactive to light. EOMI. NECK: Supple. CHEST: Clear bilaterally. ABDOMEN: Soft, nontender, bowel sounds are positive. CVS, regular rate and rhythm. EXTREMITIES: No edema, no cyanosis, no clubbing. SPINE/CVA: No tenderness. NEUROLOGIC: Cranial nerves II through XII grossly intact and no focal deficits.
CVS|cardiovascular system|CVS:|204|207|HOSPITAL COURSE|There were no rectal fissures noted and no bloody stools were noted throughout the admission. The patient was started on Colace as a stool softener since the mother complained of constipation at home. 2. CVS: The patient received a fluid bolus with normal saline x1 and was maintained for 24 hours on 1-1/2 maintenance fluids.
CVS|chorionic villus sampling|CVS.|254|257|G  1  P 0000				LMP|The absence of any such markers can provide reassurance. Level II ultrasound cannot definitively diagnose or exclude the presence of any chromosome condition. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|(CVS)|181|185|RE|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|206|208|DISPOSITION|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|158|160|ADDENDUM 5-23-2007|To state this another way, the risk for Down syndrome increased from 2% to approximately 3%. We discussed several possible options for follow up. I did offer CVS if _%#NAME#%_ wanted a definitive yes or no answer in the soonest time-frame possible. We did discuss the risk of miscarriage and possibility of ambiguous results from this procedure.
CVS|chorionic villus sampling|CVS|441|443|G  4  P 2012				LMP|We contrasted this with the amniocentesis, which has a slightly lower risk of miscarriage, and can be performed as early as 15 or 16 weeks' gestation. _%#NAME#%_ was initially scheduled for CVS today; however, after discussing this with her husband which regarding the concern for the risk of miscarriage as well as the fact that _%#NAME#%_ was recently diagnosed with colitis and was not feeling well at all today, they opted to not do the CVS today and plan for an amniocentesis, which was scheduled today in a few weeks. As soon as those final results become available we will contact them by phone and fax you a copy.
CVS|chorionic villus sampling|CVS|166|168|G  4  P 2012				LMP|Specific examples of Down syndrome, trisomy 13, trisomy 18, and sex chromosome abnormalities were reviewed. I reviewed differences between diagnostic testing such as CVS and amniocentesis versus screening procedure such as first trimester screening or quad screen. As you know amniocentesis and CVS are diagnostic for chromosome abnormalities with greater than 99% accuracy.
CVS|chorionic villus sampling|CVS|272|274|RE|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|115|119|G  1  P 0000				LMP|A detailed ultrasound survey of fetal anatomy is recommended at 18-20 weeks gestation. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS|206|208|IN SUMMARY|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|305|307|IN SUMMARY|First trimester screening is a means to adjust a patient's age related risk for Down syndrome and trisomy 18 utilizing a nuchal translucency ultrasound and maternal blood work measuring free beta hCG and PAPP-A. Patients found to be at increased risk from first trimester screening can then be re-offered CVS and/or amniocentesis depending on the gestational age. Because first trimester screening does not screen for neural tube defects a maternal serum AFP and a detailed ultrasound around 18 to 20 weeks is recommended.
CVS|chorionic villus sampling|CVS|247|249|IN SUMMARY|Chorionic villa sampling, as you know, is performed between ten and 11 weeks of gestation, and has an approximately 0.5 to 1.0 risk of miscarriage. Her one in 3,000 risk for limb deformities was also discussed. OTC DNA testing can be performed on CVS with cultured cells, and results take approximately three to four weeks. The accuracy of CVS testing was discussed with limitations based on their specific mutations in which the rare event that her mutation is a polymorphism; thus, there could be false positives or false negatives possible.
CVS|chorionic villus sampling|CVS|129|131|IN SUMMARY|OTC DNA testing can be performed on CVS with cultured cells, and results take approximately three to four weeks. The accuracy of CVS testing was discussed with limitations based on their specific mutations in which the rare event that her mutation is a polymorphism; thus, there could be false positives or false negatives possible.
CVS|chorionic villus sampling|(CVS)|157|161|G  5  P 4004				LMP|We discussed testing options for definitively diagnosing a numerical chromosome abnormality in the pregnancy. These options include chorionic villi sampling (CVS) and amniocentesis. These procedures allow for direct fetal chromosomal analysis with greater than 99% accuracy. CVS is offered around 12 weeks of gestation, and amniocentesis is offered after 15 weeks of gestation.
CVS|chorionic villus sampling|CVS|158|160|G  5  P 4004				LMP|There is an approximately 1% lidocaine risk of miscarriage associated with chorionic villous sampling. We also discussed the 1 in 3000 risk for limb defects. CVS is typically performed by insertion of a thin cannula into the cervix to remove the chorionic villa which are on top of the placenta.
CVS|chorionic villus sampling|CVS.|254|257|G  3  P 2002				LMP|The absence of any such markers can provide reassurance. Level II ultrasound cannot definitively diagnose or exclude the presence of any chromosome condition. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS,|202|205|PLAN|She reported no smoking, alcohol use or medications during her pregnancy aside from prenatal vitamins. She had an amniocentesis with her previous pregnancy and desired earlier screening, which would be CVS, which was planned today with Dr. _%#NAME#%_. We reviewed that at the age of 40 her chance to have a baby with any type of chromosome abnormality is approximately 1 in 65.
CVS|chorionic villus sampling|CVS|212|214|IN SUMMARY|Dr. _%#NAME#%_ _%#NAME#%_ Merit Care _%#CITY#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_ _%#CITY#%_, MN _%#56600#%_ Dear Dr. _%#NAME#%_: This letter will summarize your patient, _%#NAME#%_ _%#NAME#%_'s, CVS results indicating that her developing baby girl has a normal number of chromosomes (46, XX). As you know _%#NAME#%_ was referred to the Maternal-Fetal Medicine Center due to her age to have a CVS performed.
CVS|chorionic villus sampling|CVS|136|138|IN SUMMARY|I also discussed approximately 1% of the time there may be ambiguous results which may need a follow-up amniocentesis. I discussed that CVS does not screen for spina bifida thus a follow-up AFP and/or Level II ultrasound should be performed to assess spina bifida at 18 to 20 weeks gestation.
CVS|chorionic villus sampling|CVS|119|121|PLAN|We also discussed cystic fibrosis carrier screening which they were interested in pursuing today. PLAN: _%#NAME#%_ had CVS performed today by Dr. _%#NAME#%_. To note the fetus's nuchal translucency measurement was measured at 3.4, which is greater than a 95th percentile.
CVS|chorionic villus sampling|(CVS)|115|119|G  3  P 2002				LMP|A detailed ultrasound survey of fetal anatomy is recommended at 18-20 weeks gestation. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS.|179|182|G  2  P 1001				LMP|Therefore, a maternal serum alpha fetoprotein is recommended at 16 weeks gestation. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS|174|176|G  4  P 3003				LMP|She stated that she and her husband were planning to continue and go to counseling due to numerous other issues in their family and marriage. As you know, individuals having CVS should have a follow-up AFP drawn at 15 weeks and/or a Level II ultrasound at 18 to 20 weeks to screen for spina bifida.
CVS|chorionic villus sampling|(CVS)|159|163|IN SUMMARY|Prenatal testing available to the patient at this gestational age includes chorionic villi sampling (CVS) and amniocentesis. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only ways to definitively diagnose a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|187|189|G  1  P 0000				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|115|119|G  2  P 1001				LMP|A detailed ultrasound survey of fetal anatomy is recommended at 18-20 weeks gestation. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS,|153|156|ASSESSMENT|I reviewed various types of prenatal testing and screening which is available, including first trimester screening, quad screening, level II ultrasound, CVS, and amniocentesis. I reviewed that first trimester screening is performed between 11 and 13 weeks' gestation, and involves both the nuchal translucency measurement by ultrasound, as well as biochemical blood testing, which can assess one's risk for Down's syndrome, trisomy 18, and heart defects.
CVS|chorionic villus sampling|CVS|281|283|ASSESSMENT|We discussed that first trimester screening does not screen for spina bifida; this a follow-up level II ultrasound and/or AFP would be drawn to assess for this risk. We also discussed that if any of these screening modalities showed increased risk, then follow-up amniocentesis or CVS would be offered. We discussed various options available if the baby was found to have an abnormality prenatally, including continuation of the pregnancy, termination of the pregnancy, or adoption.
CVS|chorionic villus sampling|CVS|187|189|G  3  P 2002				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|197|199|IN SUMMARY|We reviewed her age-related risk of being approximately 2% for any type of chromosome abnormality including Down syndrome, trisomy 13, trisomy 18, and sex chromosome abnormalities. We reviewed the CVS procedure along with its approximately 1:200 risk of miscarriage. We also discussed the possibility the cells would not grow in the lab or the rate possibility of ambiguous results.
CVS|chorionic villus sampling|CVS|215|217|G  3  P	1021				LMP|_%#NAME#%_ indicated that it is important for her to know for certain if there is a chromosome problem in this pregnancy; therefore, _%#NAME#%_ chose to proceed with the CVS procedure. The patient was informed that CVS is able to diagnose structural chromosome abnormalities with 99% accuracy, but is not able to test for all causes of mental retardation and birth defects in a pregnancy.
CVS|chorionic villus sampling|CVS|318|320|ASSESSMENT|She was given a prescription for Prometrium capsules 200 mg, to be placed intravaginally b.i.d. The patient was given an appointment for first trimester screen at about 11 weeks gestation, and will schedule a new OB visit within the next 2 weeks. We discussed availability of genetic diagnostic testing including both CVS and amniocentesis, to rule out possibility of an unbalanced karyotype in the fetus. Unfortunately, on the day of this dictation (_%#MMDD2005#%_), the patient called stating that she started having some bleeding, and thought she was likely miscarrying.
CVS|chorionic villus sampling|CVS|235|237|G  2  P 1001				LMP|We discussed options available in the event an abnormality is found including continuation of her pregnancy, termination of her pregnancy up to 22 weeks gestation, or adoption. _%#NAME#%_ stated that they were interested in having the CVS which was performed today by Dr. _%#NAME#%_. As soon as the results come back, in approximately 10 to 14 days, we will notify them by phone.
CVS|chorionic villus sampling|CVS|130|132|G  2  P 1001				LMP|The patient stated her wish to know genetic information, early in her pregnancy, of this developing baby and is scheduled to have CVS on University Specialists with Dr. _%#NAME#%_ on _%#MMDD2004#%_. As soon as results become available in seven to ten days, I will contact her with results.
CVS|chorionic villus sampling|CVS,|325|328|G  4  P 1021				LMP|Test results: Revised Down syndrome risk: 1:133 (abnormal) Revised Trisomy 13/18 risk: 1:4281 (normal) We discussed the fact that the screen had not significantly altered _%#NAME#%_'s risk for Down syndrome from her prior age related risk of 1:125. We discussed follow-up options including modified sequential screen, amnio, CVS, and level II ultrasound. _%#NAME#%_ indicated that she would like a definitive answer and chose to schedule an amniocentesis at our _%#CITY#%_ location.
CVS|chorionic villus sampling|CVS|347|349|G  1  P 0000				LMP|I spent approximately 60 minutes with them today. As you know _%#NAME#%_ is a 42-year-old gravida 4, para 0-0-3-0, who is currently 13-1/2 weeks' gestation based on estimated date of delivery of _%#MMDD2008#%_. As you know, she had been seen previously at the Maternal Fetal Medicine Center specifically for CVS. Unfortunately, the results of her CVS did reveal that their developing baby girl has trisomy 18. The specific karyotype was follows: 47, XX,9ph,+18, thus these represent a female karyotype with trisomy 18.
CVS|chorionic villus sampling|CVS|187|189|G  2  P 1001				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|187|189|G  2  P	0010				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS.|190|193|46,XX.|A pamphlet was given to her regarding this. The patient stated that she was concerned regarding the risk of miscarriage associated with the more invasive procedure such as amniocentesis and CVS. Thus she decided to start with first trimester screening which was scheduled for tomorrow, Friday, _%#MM#%_ _%#DD#%_, 2005, here at the Maternal-Fetal Medicine Center.
CVS|chorionic villus sampling|CVS.|254|257|G  2  P	0010				LMP|The absence of any such markers can provide reassurance. Level II ultrasound cannot definitively diagnose or exclude the presence of any chromosome condition. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS|177|179|G  2  P	1001				LMP|We revisited the option of cystic fibrosis carrier screening, which she was interested in having drawn today, which will be sent to Genzyme Genetics. _%#NAME#%_ planned to have CVS performed today by Dr. _%#NAME#%_. She also had her blood drawn for cystic fibrosis carrier screening. As soon as the results become available, we will notify them by telephone and fax you a copy.
CVS|chorionic villus sampling|CVS|272|274|IN SUMMARY|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS.|254|257|G  2  P	0010				LMP|The absence of any such markers can provide reassurance. Level II ultrasound cannot definitively diagnose or exclude the presence of any chromosome condition. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS|206|208|RE|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|206|210|G  2  P	1001				LMP|We went on to discuss the availability of both prenatal testing and screening options for the pregnancy. Prenatal testing available to the patient at this gestational age includes chorionic villus sampling (CVS) and amniocentesis. These procedures were discussed as the only ways to definitively diagnosis a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|(CVS)|181|185|IN SUMMARY|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|(CVS)|181|185|G  1  P 0000				LMP|Patients who elect to forgo modified sequential screening should still be offered maternal serum AFP screening for spina bifida in the second trimester. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS|187|189|G  2  P	0010				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|115|119|G  2  P 0010				LMP|A detailed ultrasound survey of fetal anatomy is recommended at 18-20 weeks gestation. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS|148|150|G  7  P 2042				LMP|Both false positives and false negatives occur. If first trimester screening shows increased risk, then we would offer her further testing, such as CVS or amniocentesis, or follow-up level II ultrasound. We reviewed that first trimester screening does not screen for spina bifida; this a follow-up AFB and/or level II ultrasound should be performed.
CVS|chorionic villus sampling|CVS|187|189|G  1  P 0000				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|200|202|G  1  P 0000				LMP|As you know, she was referred for the CVS procedure due to the fact that she had a previous pregnancy with trisomy 21. Due to the fact that she had some recent bleeding and some chorionic hemorrhage, CVS was not performed today, and she is scheduled for a first trimester screen for _%#MMDD2006#%_ with Dr. _%#NAME#%_. I spent approximately 50 minutes with this patient today.
CVS|chorionic villus sampling|CVS|219|221|PLAN|_%#NAME#%_ is 0 negative, and there was some initial confusion on whether or not she had positive antibodies. Her most current type and screen indicates that she has negative antibodies and did wish to proceed with the CVS today. They have a 3-1/2-year-old son who is healthy but does have 2/3 toe syndactly, as well as _%#NAME#%_'s brother and _%#NAME#%_'s mother.
CVS|chorionic villus sampling|CVS|157|159|PLAN|This specific testing will be done through Gene Diagnostics. After contacting them specifically, they stated that their preferential samples would be direct CVS samples, direct amniocentesis fluid samples or cultured amniocytes. Following receipt of the prenatal sample, results would be expected to take approximately two weeks.
CVS|chorionic villus sampling|CVS|176|178|G  3 P	0020				LMP|She also had her blood drawn for cystic fibrosis carrier screening, as well as Tay- Sachs disease, which results will take approximately two weeks. We will hold cells from the CVS in case they are needed for further testing. We also discussed options available if the baby was found to have abnormality prenatally, including continuation of pregnancy, termination of pregnancy up to 22 weeks gestation, or adoption.
CVS|chorionic villus sampling|CVS.|254|257|G  1  P 0000				LMP|The absence of any such markers can provide reassurance. Level II ultrasound cannot definitively diagnose or exclude the presence of any chromosome condition. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS|206|208|IN SUMMARY|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|187|189|G  2  P 0010				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|205|207|SUMMARY|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks gestation, and amniocentesis is offered after 15 weeks gestation. Due to their invasive nature, CVS is nationally associated with a 1 in 200 (0.5%) to 1 in 100 (1%) risk of miscarriage, and amniocentesis is nationally associated with a 1 in 200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|115|119|G  3  P 1011				LMP|A detailed ultrasound survey of fetal anatomy is recommended at 18-20 weeks gestation. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS|163|165|G  1  P 0000				LMP|We reviewed first trimester screening and its limitations, as well as both false/positives, false/negatives. We also reviewed further diagnostic testing including CVS and amniocentesis along with their respective risk of miscarriage. As you know, first trimester screen does not screen for spina bifida thus a follow-up AFP and/or level II ultrasound should be performed at 18-20 weeks' gestation.
CVS|chorionic villus sampling|CVS|128|130|G  3  P	1011				LMP|_%#NAME#%_ is a stay-at-home mom, and her husband was relocated here from L.A., as he works at Trader Joe's. _%#NAME#%_ had her CVS performed today, and cells will be cultured and sent to Quest Diagnostics for CAH analysis. Her blood was also drawn and used for maternal cell contamination studies.
CVS|chorionic villus sampling|CVS|272|274|IN SUMMARY|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1 in 200 (0.5%) to 1 in 100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1 in 200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|337|339|ADDENDUM|Both false positives and false negative can occur. We also discussed the option of modified sequential screening in which an individual would come back for follow-up blood test as early as 15 weeks performed at our center which would be integrated along with the first trimester screen. We discussed further diagnostic testing including CVS and amniocentesis along with the respective risk of miscarriage. We thoroughly reviewed her family history during our genetic counseling session.
CVS|chorionic villus sampling|CVS|187|189|G  3  P 1011				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|270|272|G  1  P	0000				LMP|According to Gene Care Laboratories the detection rate for first trimester screening is thought to be approximately 90% for Down's syndrome and greater than 95% for trisomy 18. Patients found to be at an increased risk by first trimester screening can then be offered a CVS and/or amniocentesis depending on the gestational age. Because first trimester does not screen for neural tube defects, a maternal serum AFP and a detailed ultrasound around 18 weeks is available to the patient for follow up.
CVS|chorionic villus sampling|CVS|202|204|G  1  P	0000				LMP|Given the patient's early gestational age we discussed the availability of either CVS at 10 to 12 weeks gestation or amniocentesis after 15 weeks gestation. The risks, benefits, and limitations to both CVS and amniocentesis were compared for the patient. We discussed that this is the only prenatal test that will definitively diagnosis a chromosome abnormality.
CVS|chorionic villus sampling|CVS|187|189|G  4  P 1021				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|198|200|G  3  P	2002				LMP|We reviewed 1st trimester screening and its limitations. We also reviewed the false positives and false negatives of the screen. Further diagnostic testing was discussed including amniocentesis and CVS along with their respective risks of miscarriage. We thoroughly reviewed her family history during our genetic counseling session.
CVS|chorionic villus sampling|CVS|338|340|IN SUMMARY|In light of this risk we discussed the availability of prenatal testing and screening, prenatal testing that would be available to the patient includes chorionic villus sampling between 10 to 12 weeks' gestation and amniocentesis around 16 weeks gestation. The risk, benefits, and limitations to CVS and amniocentesis were compared. Both CVS and amniocentesis have the risk of miscarriage of 1:200. In addition, we briefly discussed prenatal screening options available specifically we focused on the availability of first trimester screening.
CVS|chorionic villus sampling|CVS|315|317|IN SUMMARY|Dear Dr. _%#NAME#%_: Thank you for the kind referral of your patient, _%#NAME#%_ _%#NAME#%_, who was seen for genetic counseling at the Maternal-Fetal Medicine Center at the University of Minnesota Medical Center, Fairview, on _%#MMDD2006#%_. As you know, Ms. _%#NAME#%_ came to us for a second opinion regarding a CVS result, which was mosaic for trisomy 2. This CVS was performed at Abbott Northwestern Hospital. This letter will summarize our 45-minute discussion.
CVS|chorionic villus sampling|CVS|272|274|RE|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1 in 200 (0.5%) to 1 in 100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1 in 200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|181|185|IN SUMMARY|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|206|208|IN SUMMARY|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|181|185|RE|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|272|274|DISPOSITION|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|206|208|IN SUMMARY|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|187|189|G  4  P 2012				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS.|254|257|G  2  P 0010				LMP|The absence of any such markers can provide reassurance. Level II ultrasound cannot definitively diagnose or exclude the presence of any chromosome condition. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS.|254|257|G  3  P 1011				LMP|The absence of any such markers can provide reassurance. Level II ultrasound cannot definitively diagnose or exclude the presence of any chromosome condition. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS|272|274|IN SUMMARY|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1 in 200 (0.5%) to 1 in 100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1 in 200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|181|185|DISPOSITION|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|272|274|G  4  P 2012				LMP|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1 in 200 (0.5%) to 1 in 100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1 in 200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|206|208|IN SUMMARY|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|195|197|G  1  P 0000				LMP|Finally, chorionic villa sampling (CVS) is best performed between 10 and 12 weeks gestation, and involves insertion of a catheter into a woman's cervix to remove a small portion of the placenta. CVS is diagnostic for chromosome abnormalities with greater than 99 % accuracy. I discussed the 1 % risk of miscarriage associated with CVS.
CVS|chorionic villus sampling|CVS.|136|139|G  1  P 0000				LMP|CVS is diagnostic for chromosome abnormalities with greater than 99 % accuracy. I discussed the 1 % risk of miscarriage associated with CVS. I also discussed that in approximately 1 to 2 % of the time, there may be some ambiguous results that may need to be confirmed by an amniocentesis.
CVS|chorionic villus sampling|CVS|210|212|G  1  P 0000				LMP|I also discussed that in approximately 1 to 2 % of the time, there may be some ambiguous results that may need to be confirmed by an amniocentesis. We also reviewed the 1 in 3000 risk for limb defects. Because CVS does not test for spina bifida, usually a level 2 ultrasound and/or triple screen blood test is recommended to test for these.
CVS|chorionic villus sampling|CVS|187|189|G  1  P 0000				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|206|208|G  2  P 0101				LMP|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1 in 200 (0.5%) to 1 in 100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1 in 200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|187|189|G  5  P 3013				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|268|270|IN SUMMARY|At age 42 the patient has a mid-trimester risk of carrying a baby with Down syndrome of 1 in 41, and a mid-trimester risk of carrying a baby with any chromosome abnormality of 1 in 25. In light of this risk we discussed various prenatal testing and screening options. CVS and amniocentesis are available to the patient. CVS is performed between 10 and 12 weeks of a pregnancy and has a miscarriage risk of 1 in 200.
CVS|chorionic villus sampling|(CVS)|231|235|IN SUMMARY|Therefore an AFP only blood screen after 14 weeks' gestation and a level II ultrasound at 18-20 weeks gestation are both recommended to screen for this possibility, as well as other birth defects. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|336|338|IN SUMMARY|First- trimester screening does not screen for spina bifida, so thus a follow-up AFP should be drawn at 15 weeks gestation, and/or a level II ultrasound at 18 to 20 weeks to assess for spina bifida. We discussed diagnostic testing available in the event first-trimester screening comes back "increased risk" for chromosome abnormality. CVS and amniocentesis are both available, and which each carry approximately 1 in 200 risk of miscarriage, but are diagnostic for chromosome abnormalities.
CVS|chorionic villus sampling|CVS|182|184|MMC 395|We reviewed that this is a screening test and both false-positives and false-negatives can occur. If, in the event the first trimester screening shows increased risk, then follow-up CVS or amniocentesis can be used for confirmatory studies for chromosome abnormalities. First trimester screening does not screen for spina bifida. Thus, a follow- up AFP drawn at 15 weeks and/or a Level II ultrasound can be performed to assess this.
CVS|chorionic villus sampling|CVS|153|155|MMC 395|Risk of miscarriage in experienced hands is 1 in 200. We reviewed the 1% chance for ambiguous results which may need some follow up by an amniocentesis. CVS does not screen for spina bifida, thus a follow up AFP and/or level 2 ultrasound should be performed. We obtained _%#NAME#%_'s previous records and updated her previous family history that was taken by myself approximately 1 year ago.
CVS|chorionic villus sampling|CVS|227|229|MMC 395|Both false positives and false negatives can occur. First trimester screen does not screen for spina bifida thus a follow-up AFP and/or Level II ultrasound should be performed. We discussed more diagnostic procedures including CVS and amniocentesis, each with their associated risk of miscarriage. I thoroughly reviewed her family history during our genetic counseling session.
CVS|chorionic villus sampling|(CVS)|181|185|G  4  P 2012				LMP|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|(CVS)|115|119|G  4  P 1021				LMP|A detailed ultrasound survey of fetal anatomy is recommended at 18-20 weeks gestation. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS.|248|251|G  4  P 1021				LMP|Patients who elect to forgo modified sequential screening should still be offered maternal serum AFP screening for spina bifida in the second trimester. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS.|153|156|G  3  P 1011				LMP|We discussed CVS vs. completing the screen. I explained that if _%#NAME#%_ elects to complete the screen, she may place herself outside the window to do CVS. _%#NAME#%_ understood this and decided that she would like to complete the first trimester screen to receive a formal risk assessment.
CVS|chorionic villus sampling|CVS|206|208|RE|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|182|186|G  2  P 1011				LMP|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villus sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|154|156|SUGGESTIONS|I also discussed the 1 to 2% chance of ambiguous results which may need follow-up with an amniocentesis. Results take approximately seven to ten days. As CVS does not test for spina bifida, a follow-up triple-screen blood test and/or a level two ultrasound, at 18 to 20 weeks, can be performed to assess for spina bifida.
CVS|chorionic villus sampling|CVS|187|189|G  2  P 0010				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|224|226|IN SUMMARY|Patients that are found to be at increased risk from first trimester screening can then offered more invasive prenatal diagnosis. We briefly discussed the patient's prenatal testing options, including CVS and amniocentesis. CVS is available between 10 and 12 weeks' gestation and has a miscarriage risk of 1 in 200. Amniocentesis is available around 16 weeks' gestation and also carries a 1 in 200 risk of miscarriage.
CVS|chorionic villus sampling|CVS|187|189|G  5  P 4004				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS.|254|257|G  4  P 2012				LMP|The absence of any such markers can provide reassurance. Level II ultrasound cannot definitively diagnose or exclude the presence of any chromosome condition. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS|160|162|IN SUMMARY|If you have any further questions with which I can be of assistance, please feel free to contact me at _%#TEL#%_. Addenduem: According to Genzyme genetics, the CVS results indicate the fetus is homozygous for delta F508 which is consistent with being affected with cystic fibrosis. According to University MN, cytogenetic laboratory, this developing fetus also has 3 copies of chromosome 21, which is consistent with having Down syndrome.
CVS|chorionic villus sampling|(CVS)|180|184|SUMMARY|Markers are seen in approximately50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|244|246|IN SUMMARY|I reviewed 1st trimester screening, which can assess one's risk for Down syndrome, trisomy 13, trisomy 18, and some congenital heart defects. Both false positives and false negatives can occur. We also reviewed further diagnostic testing being CVS and amniocentesis along with their risk factor risks of miscarriage. We thoroughly reviewed their family history during out genetic counseling session.
CVS|chorionic villus sampling|CVS|272|274|IN SUMMARY|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|270|272|IN SUMMARY|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|181|185|IN SUMMARY|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|242|244|SUGGESTIONS|It was also explained to the couple that while CVS is 99% accurate in detection of numerical chromosome abnormalities in a pregnancy, it is not able to test for all causes of mental retardation and birth defects in a pregnancy. Additionally, CVS does not have the ability to screen for the occurrence of open neural tube defects in a pregnancy. Therefore, an AFP blood screen after 15 weeks gestation is recommended to screen for this possibility.
CVS|chorionic villus sampling|CVS|133|135|G  5  P 1031				LMP|We reviewed the limitations of first trimester screening, as well as the differences of diagnostic testing such as amniocentesis and CVS along with their associated risk of miscarriage. We discussed follow-up AFP testing to screen for spina bifida as first trimester screen does not screen for spina bifida.
CVS|chorionic villus sampling|CVS|206|208|G  4  P 2012				LMP|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS.|254|257|G  1  P 0000				LMP|The absence of any such markers can provide reassurance. Level II ultrasound cannot definitively diagnose or exclude the presence of any chromosome condition. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS.|248|251|G  5  P 3013				LMP|Patients who elect to forgo modified sequential screening should still be offered maternal serum AFP screening for spina bifida in the second trimester. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS|81|83|G  4  P	1021				LMP|Results of first trimester screen take approximately one week. We explained that CVS and amniocentesis are diagnostic procedures for chromosome abnormalities. We discussed the timing of the procedures and the accuracy. CVS has an associated risk of miscarriage of 0.5 to 1% and can be performed between 10-12.6 weeks gestation.
CVS|chorionic villus sampling|CVS|247|249|PLAN AND SUGGESTIONS|Triple-screen blood test is typically performed between 15 and 18 weeks gestation and can screen for Down syndrome, trisomy 18 and open spina bifida. For women who perform CVS, they may wish to pursue the triple-screen to screen for spina, as the CVS does not detect this birth defect. Level II ultrasound is best performed between 18 and 20 weeks gestation and uses sound waves to examine the baby's developing anatomy.
CVS|chorionic villus sampling|(CVS)|181|185|IN SUMMARY|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|272|274|IN SUMMARY|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|187|189|G  3  P 1011				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|206|208|RE|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS|178|181|G  3  P 2002				LMP|Therefore, her screen was reported as positive for Down syndrome. I explained that a definitive diagnosis or exclusion of Down syndrome can only be made through invasive testing (CVS or amniocentesis). We discussed the relative risks and benefits of these two procedures. We also discussed additional screening options including drawing blood through our clinic for a modified sequential screen, or using level II ultrasound as an additional screening tool.
CVS|chorionic villus sampling|CVS|208|210|G  3  P 2002				LMP|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS was offered at 11 to 13 weeks gestation and amniocentesis is offered after 15 weeks gestation. Due to their invasive nature, CVS is naturally associated with a 1 in 200 to a 1 in 100 risk of miscarriage and amniocentesis is naturally associated with a 1 in 200 risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|115|119|G  1  P 0000				LMP|A detailed ultrasound survey of fetal anatomy is recommended at 18-20 weeks gestation. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS|193|195|G  3  P 2002				LMP|Risk of miscarriage is 1:200. We also discussed the rare possibility of ambiguous results or the cells do not grow in the lab, which we would then offer a subsequent amniocentesis. As you know CVS does not test for spina bifida thus a followup AFP and/or level II ultrasound should be performed. Na stated they wished to have the CVS today, which was planned with Dr. _%#NAME#%_.
CVS|chorionic villus sampling|CVS.|179|182|G  2  P 0010				LMP|Therefore, a maternal serum alpha fetoprotein is recommended at 16 weeks gestation. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS|187|189|G  3  P 2002				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS.|254|257|G  5  P 4004				LMP|The absence of any such markers can provide reassurance. Level II ultrasound cannot definitively diagnose or exclude the presence of any chromosome condition. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS.|300|303|G  2  P	0101				LMP|_%#NAME#%_ had previously met with Dr. _%#NAME#%_ to review options including issues regarding age as well as the option of multi fetal reduction. This couple is still in the process of considering these options and information may be useful to help with her decisions based on the results of todays CVS. We did review various types of chromosome abnormalities that can be tested for including Down syndrome, trisomy 13, trisomy 18, and sex chromosome abnormalities.
CVS|chorionic villus sampling|CVS|197|199|PLAN|Examples of Down syndrome, trisomy 13, trisomy 18 and sex chromosome abnormalities were reviewed. We reviewed the limitations of first trimester screening as well as the diagnostic capabilities of CVS and amniocentesis along with its 1/200 risk of miscarriage. Level 2 ultrasound was also reviewed as well. AFP was reviewed as first trimester screen does not screen for spina bifida.
CVS|chorionic villus sampling|CVS.|254|257|G  3  P 1011				LMP|The absence of any such markers can provide reassurance. Level II ultrasound cannot definitively diagnose or exclude the presence of any chromosome condition. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|(CVS)|181|185|G  5  P 3013				LMP|Patients who elect to forgo modified sequential screening should still be offered maternal serum AFP screening for spina bifida in the second trimester. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS|187|189|G  3  P 2002				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|179|183|MMC #395|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomy 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as way of definitely diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|(CVS)|181|185|IN SUMMARY|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|272|274|RE|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|181|185|IN SUMMARY|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|(CVS)|181|185|G  2  P 0010				LMP|Patients who elect to forgo modified sequential screening should still be offered maternal serum AFP screening for spina bifida in the second trimester. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS|157|159|IN SUMMARY|The risks, benefits, and limitations to CVS and amniocentesis were compared. The couple was counseled regarding the risk of miscarriage of 1 in 200 for both CVS and amniocentesis. In addition, we discussed the availability of screening options, specifically first trimester screening was discussed.
CVS|chorionic villus sampling|CVS|151|153|IN SUMMARY|Prenatal testing that is available includes chorionic villous sampling between 10-12 weeks gestation and amniocentesis around 16 weeks gestation. Both CVS and amniocentesis carry a risk of miscarriage of 1:200. In addition, prenatal screening that is available to the patient currently includes first trimester screening.
CVS|chorionic villus sampling|CVS|138|140|SUMMARY|We reviewed that a woman with either an abnormal nuchal translucency or an abnormal combined first trimester screen would then be offered CVS or amniocentesis depending on the gestational age of the pregnancy. Because first trimester screening does not screen for neural tube defects, a maternal serum AFP and a detailed ultrasound is recommended in follow-up.
CVS|chorionic villus sampling|CVS|206|208|IN SUMMARY|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1 in 200 (0.5%) to 1 in 100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1 in 200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS.|254|257|G  3  P 2002				LMP|The absence of any such markers can provide reassurance. Level II ultrasound cannot definitively diagnose or exclude the presence of any chromosome condition. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS|272|274|SUMMARY|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|206|208|PLAN|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|227|229|SUMMARY|A nuchal translucency ultrasound is performed as well as maternal blood work to measure free beta-hCG and PAPP-A. At the conclusion of our discussion, the patient elected to proceed with first trimester screening. She declined CVS and will use first trimester screening results to help her decide regarding amniocentesis. The results of her first trimester screening will be called to the patient as soon as they become available.
CVS|chorionic villus sampling|CVS|166|168|SUMMARY|At the conclusion of our discussion, the patient stated that she wished to proceed with first trimester screening as a means to help her decide about pursuing either CVS or amniocentesis. She stated that she was most likely going to pursue some form of definitive prenatal diagnosis, more likely the amniocentesis.
CVS|chorionic villus sampling|(CVS)|181|185|G  5  P 4004				LMP|Patients who elect to forgo modified sequential screening should still be offered maternal serum AFP screening for spina bifida in the second trimester. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS|208|210|G  1  P	0000				LMP|_%#NAME#%_ indicated that it is important for her to know for certain if there is a chromosome problem in this pregnancy; therefore, she chose to proceed with the CVS procedure. The patient was informed that CVS is able to diagnose structural chromosome abnormalities with 99% accuracy, but is not able to test for all causes of mental retardation and birth defects in a pregnancy.
CVS|chorionic villus sampling|CVS|251|253|IN SUMMARY|The patient was informed that CVS is able to diagnose structural chromosome abnormalities with 99% accuracy, but is not able to test for all causes of mental retardation and birth defects in a pregnancy. It was also explained that approximately 1% of CVS results are inconclusive and require follow-up testing, such as amniocentesis. Additionally, as you know, CVS does not have the ability to screen for the occurrence of open neural tube defects in a pregnancy.
CVS|chorionic villus sampling|CVS|227|229|IN SUMMARY|Therefore, an AFP only blood screen after 14 weeks' gestation is recommended to screen for this possibility. We discussed options of continuation of pregnancy, termination of pregnancy up to 24 weeks' gestation, or adoption if CVS results are abnormal. Finally, a detailed family history was also obtained at the time of visit.
CVS|chorionic villus sampling|CVS|219|221|IN SUMMARY|The clinical features and autosomal recessive inheritance of cystic fibrosis were briefly described. IN SUMMARY: 1) The patient's age-related chance for fetal chromosome abnormality is 1:105 (1%). 2) Your patient had a CVS procedure today for fetal karyotype analysis. 3) Karyotype results should be available in 10-14 days, at which time I will call the patient directly and fax you a copy.
CVS|chorionic villus sampling|CVS|272|274|ASSESSMENT|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|272|274|PLAN|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|206|208|SUMMARY|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy, CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1 in 200 (0.5%) to 1 in 100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1 in 200 risk of miscarriage.
CVS|chorionic villus sampling|CVS.|248|251|G  3  P 2002				LMP|Patients who elect to forgo modified sequential screening should still be offered maternal serum AFP screening for spina bifida in the second trimester. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS|181|183|PLAN|We recognize that this can be a difficult time for this couple given their losses. If they decide to embark on another pregnancy, this couple felt that they seem most interested in CVS as this would provide them with early definitive information regarding the chromosomes. If you have any further questions or we can provide any additional support please feel free to contact me at _%#TEL#%_.
CVS|chorionic villus sampling|(CVS)|165|169|SUMMARY|We discussed various types of prenatal testing and screening that is available to the patient. Prenatal testing that is available includes chorionic villus sampling (CVS) and amniocentesis. CVS is scheduled at 10-12 weeks gestation and has a risk of 1/200 for miscarriage. Amniocentesis is scheduled at 16 weeks gestation with a 1/200 risk of miscarriage.
CVS|chorionic villus sampling|CVS|390|392|G  2  P	0010				LMP|CVS does not screen for open neural tube defects. Screening for open neural tube defects can be accomplished through an AFP only blood test in the second trimester or by a Level II ultrasound at around 18 to 20 weeks. We also reviewed amniocentesis procedure. This is a procedure that is done beginning at 15 weeks and has associated risk of miscarriage of 0.5%. Lise preferred the earlier CVS procedure. The family history was reviewed. _%#NAME#%_ and _%#NAME#%_ are both healthy.
CVS|chorionic villus sampling|CVS|206|208|IN SUMMARY|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1 in 200 (0.5%) to 1 in 100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1 in 200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|187|189|G  1  P 0000				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|187|189|G  1  P	0000				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|272|274|G  1  P	0000				LMP|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|277|279|HPI|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only way to definitively diagnose a numerical chromosome abnormality in a pregnancy. Both of these procedures allows for direct fetal chromosome analysis with 99% accuracy. CVS is offered at 11-13 weeks gestation and amniocentesis is offered after 15 weeks gestation. It was explained to Antoinette because of the invasive nature of prenatal testing options, they are associated with a risk of miscarriage.
CVS|chorionic villus sampling|CVS|153|155|HPI|It was explained to _%#NAME#%_ because of the invasive nature of prenatal testing options, they are associated with a risk of miscarriage. The risks for CVS is between 1:200, and 1:100, and the risk for amniocentesis is nationally quoted as 1:200. Karyotype results obtained from these procedures are received approximately 10-14 days after the procedure.
CVS|chorionic villus sampling|(CVS)|181|185|RE|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS.|179|182|G  1  P 0000				LMP|Therefore, a maternal serum alpha fetoprotein is recommended at 16 weeks gestation. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|(CVS)|181|185|SUMMARY|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS.|195|198|IN SUMMARY|It was certainly a pleasure to meet her and we wish her and her husband the best in the remainder of their pregnancy. I will plan on calling Dawn directly as soon as I receive the results of her CVS. A copy of these results will also be faxed to your office. Please do not hesitate to contact me at _%#TEL#%_ should you or the patient have any questions.
CVS|chorionic villus sampling|CVS|171|173|IN SUMMARY|Risk of miscarriage is approximately 1:200. We reviewed the rare possibility of ambiguous results of slow growth and the possibility of needing a follow up amniocentesis. CVS does not test for all birth defects as we all face a 3 to 4 percent risk to have a baby with a birth defect.
CVS|chorionic villus sampling|(CVS)|182|186|ASSESSMENT|Markers are seen I n approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS.|129|132|G  2  P 1001				LMP|We discussed that, based on her age, and if the results of the serum screening indicate, she is able to have an amniocentesis or CVS. We discussed the risks and limitations of the CVS and amnio, including the risk for miscarriage, which is 1% and 0.5% respectively.
CVS|chorionic villus sampling|CVS|187|189|G  3  P 1011				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|191|193|ASSESSMENT|We also discussed the rare possibility of ambiguous results, which may need follow up from an amniocentesis. We also discussed alternative testing, which would be amniocentesis. As you know, CVS does not screen for spina bifida thus a followup AFP and/or level II ultrasound should be performed. We discussed options available if the baby was found to have an abnormality prenatally including continuation of pregnancy or termination of pregnancy after 24 weeks in the state of Minnesota.
CVS|chorionic villus sampling|CVS|146|148|G  4  P 1021				LMP|Therefore, the screen was reported as positive for Down syndrome. I explained that individuals who are looking to avoid invasive testing, such as CVS and amnio, may tend to focus on the fact that the screen provided a significant reduction in risk. Couples who feel inclined to do invasive testing may focus on the fact the risk still exceeds the screening threshold.
CVS|chorionic villus sampling|CVS|270|272|G  2  P 0101				LMP|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS,|124|127|IN SUMMARY|Both of them are of European ethnicity and we provided them a pamphlet on cystic fibrosis carrier screening. _%#NAME#%_ had CVS, which was performed today by Dr. _%#NAME#%_. As soon as final results become available we will notify her by phone and fax you a copy.
CVS|chorionic villus sampling|CVS|272|274|G  4  P 3003				LMP|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|115|119|G  3  P 1011				LMP|A detailed ultrasound survey of fetal anatomy is recommended at 18-20 weeks gestation. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|(CVS)|181|185|PLAN|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|136|138|IN SUMMARY|CVS is performed between 10 and 12 weeks of pregnancy and has a risk of miscarriage of 1 in 200. The risks, benefits and limitations to CVS were reviewed. We also discussed the risk of maternal cell contamination and/or confined placental mosaicism and the possible need for further follow-up testing.
CVS|chorionic villus sampling|CVS|230|232|IN SUMMARY|I reviewed chorionic villa sampling as this patient desired to have this procedure as it is offered earlier in gestation given this is an unexpected pregnancy. Rose has not shared knowledge of her pregnancy with many individuals. CVS is diagnostic for chromosome abnormalities with greater than 99% accuracy. The risk of miscarriage is 1%. We reviewed the 1 to 2% risk of ambiguous results and the less than 1:3000 risk for limb abnormalities.
CVS|chorionic villus sampling|CVS,|231|234|IMPRESSION|Because spina bifida is not detected with the CVS, a thorough follow-up level 2 ultrasound at 18 to 20 weeks gestation, can be performed and/or a serum AFP, to screen for spina bifida. I reviewed amniocentesis as an alternative to CVS, which is performed at 15 weeks and beyond, and is also very accurate for a diagnosis of chromosome abnormalities.
CVS|chorionic villus sampling|CVS|187|189|G  1  P	0000				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|187|189|G  2  P 0101				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|166|168|PLAN|Prenatal testing that is available to the patient includes chorionic villous sampling between 10-12 weeks gestation and amniocentesis around 16 weeks gestation. Both CVS and amniocentesis carry a risk of miscarriage of 1:200. In addition, prenatal screening that is available to the patient includes first trimester screening.
CVS|chorionic villus sampling|(CVS)|181|185|G  1  P	0000				LMP|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|272|274|G  2  P 1001				LMP|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS.|179|182|G  1  P	0000				LMP|Therefore, a maternal serum alpha fetoprotein is recommended at 16 weeks gestation. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|(CVS)|115|119|G  3  P 2002				LMP|A detailed ultrasound survey of fetal anatomy is recommended at 18-20 weeks gestation. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|(CVS)|145|149|IN SUMMARY|I reviewed specific examples of Down syndrome, trisomy 13, trisomy 18, and sex-chromosome abnormalities. I reviewed the chorionic villa sampling (CVS) procedure which is diagnostic for chromosome abnormalities with greater than 99% accuracy. I reviewed the 1 to 2% risk of ambiguous results, as well as 1: 3000 risk for limb abnormalities.
CVS|chorionic villus sampling|CVS.|254|257|G  3  P 1011				LMP|The absence of any such markers can provide reassurance. Level II ultrasound cannot definitively diagnose or exclude the presence of any chromosome condition. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS|110|112|G  3  P 3003				LMP|Addenduem: Nuchal translucency measurement was 2.4 mm, above the 95% percentile. _%#NAME#%_ decided to have a CVS performed today and preliminary FISH results are normal. Final results are pending.
CVS|chorionic villus sampling|(CVS)|181|185|G  2  P 0101				LMP|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|234|236|IN SUMMARY|She was interested in having first trimester screening to obtain more information regarding this pregnancy which was performed today by Dr. _%#NAME#%_. She stated that she would be unlikely interested in more invasive testing such as CVS or amniocentesis. As soon as the results become available we will notify her by phone as well as put a copy in her chart. If you have any further questions regarding this patient please feel free to contact me at _%#TEL#%_.
CVS|chorionic villus sampling|(CVS)|115|119|G  3  P 2002				LMP|A detailed ultrasound survey of fetal anatomy is recommended at 18-20 weeks gestation. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS|214|216|IN SUMMARY|First-trimester screening does not screen for spina bifida; thus, a follow-up AFP should be drawn at at least 15 weeks gestation. We discussed that if first-trimester screening shows increased risk, then follow-up CVS and/or amniocentesis could be used for further confirmation. We also discussed cystic fibrosis carrier screening, which we offer to all couples of European ethnicity.
CVS|chorionic villus sampling|CVS|270|272|IN SUMMARY|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|110|112|IN SUMMARY|Examples of Down syndrome, trisomy 13, trisomy 18 and sex-chromosome abnormalities were reviewed. We reviewed CVS as well as its limitations as well as the 1:200 risk of miscarriage. We discussed alternative testing including amniocentesis along with its less than 1:200 risk of miscarriage.
CVS|chorionic villus sampling|CVS|187|189|G 4  P	0030				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS,|117|120|IN SUMMARY|We briefly discussed cystic fibrosis carrier screening, and a pamphlet was provided to them. Eva decided to have the CVS, which was performed today by Dr. _%#NAME#%_. As soon as results become available from the CVS, in approximately 10-14 days, we will notify her by phone.
CVS|chorionic villus sampling|CVS|206|208|IN SUMMARY|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|270|272|G  1  P	0000				LMP|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS.|254|257|G  1  P	0000				LMP|The absence of any such markers can provide reassurance. Level II ultrasound cannot definitively diagnose or exclude the presence of any chromosome condition. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS.|179|182|G  2  P 0101				LMP|Therefore, a maternal serum alpha fetoprotein is recommended at 16 weeks gestation. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS.|248|251|G 4  P	0030				LMP|Patients who elect to forgo modified sequential screening should still be offered maternal serum AFP screening for spina bifida in the second trimester. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|(CVS)|111|115|G  4  P 3003				LMP|_%#NAME#%_ should her first trimester screening come back at increased risk. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|206|208|RE|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|181|185|G  2  P 1001				LMP|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|144|146|IN SUMMARY|Prenatal testing available includes chorionic villus sampling between 10-12 weeks' gestation and amniocentesis around 16 weeks' gestation. Both CVS and amniocentesis carry a risk of miscarriage of 1 in 200. In addition we discussed the availability of prenatal screening; specifically, first trimester screening in the first trimester and a quad screen in the second trimester would be available.
CVS|chorionic villus sampling|CVS|179|181|IN SUMMARY|I emphasized that first-trimester screening is not diagnostic, and false positives and false negatives can occur. In the event of an abnormal first-trimester screen, confirmatory CVS or amniocentesis are available. The risk of miscarriage is 1 in 200. Spina bifida is not screened for with first-trimester screening, thus an follow-up AFP and/or level II ultrasound at 18 to 20 weeks should be performed.
CVS|chorionic villus sampling|CVS,|230|233|IN SUMMARY|I discussed that these abnormalities do not usually run in a family history, and are not caused by anything a woman does during pregnancy. I reviewed specific types of prenatal testing and screening, which is available, including CVS, amniocentesis, triple screen, and a level two ultrasound. CVS and amniocentesis are diagnostic for chromosome abnormalities with greater than 99% accuracy.
CVS|chorionic villus sampling|CVS|150|152|G  3  P	2002				LMP|We discussed other screening including quad screen, modified sequential screen and level II ultrasound. We also reviewed diagnostic testing including CVS and amniocentesis along with the respected risk of miscarriage. We thoroughly reviewed their family history during our genetic counseling session.
CVS|chorionic villus sampling|CVS)|132|135|G  3  P	2002				LMP|Amniocentesis can be performed at 15 weeks and beyond. There is a risk of 1 in 200 for miscarriage. Chorionic villous sampling, (or CVS) is done between 10 and 12 weeks gestation and is also diagnostic for chromosome problems. The risk of miscarriage is 1%. I also reviewed your family history during your genetic counseling session.
CVS|chorionic villus sampling|CVS.|254|257|G  4  P 3003				LMP|The absence of any such markers can provide reassurance. Level II ultrasound cannot definitively diagnose or exclude the presence of any chromosome condition. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS|187|189|G  4  P 3003				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|272|274|RE|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|272|274|IN SUMMARY|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1 in 200 (0.5%) to 1 in 100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1 in 200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|115|119|G  1  P 0000				LMP|A detailed ultrasound survey of fetal anatomy is recommended at 18-20 weeks gestation. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS|221|223|G  1  P 0000				LMP|Both false positives and false negatives were discussed. We also discussed further screening such as modified sequential screen, AFP or comprehensive level 2 ultrasound. We also reviewed more diagnostic testing including CVS and amniocentesis along with their respective risks of marriage. We thoroughly reviewed her family history during our genetic counseling session.
CVS|chorionic villus sampling|CVS|161|163|G  1  P	0000				LMP|Prenatal testing that is available to the patient includes chorionic villous sampling between 10-12 weeks gestation and amniocentesis around 16 weeks gestation. CVS and amniocentesis both carry a risk of miscarriage of 1:200. In addition, we discussed the availability of first trimester screening.
CVS|chorionic villus sampling|CVS|187|189|G  2  P 1001				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|271|273|G  3  P 1011				LMP|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analys8is with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1 in 200 (0.5%) to 1 in 100 (2.0%) risk of miscarriage and amniocentesis is nationally associated with 1 in 200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|181|185|IN SUMMARY|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|272|274|ASSESSMENT|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|214|216|IN SUMMARY|The risks, benefits and limitations to the CVS procedure were described, as was the procedure-related risk of a miscarriage of 1:200. The patient was counseled that given her late gestational age, a transabdominal CVS would most likely be performed. The accuracy of CVS is thought to be approximately 99%. The possibility of confined placental mosaicism was discussed with the patient.
CVS|chorionic villus sampling|CVS|187|189|G  1  P	0000				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|150|152|G  2  P 1001				LMP|In light of this risk, the patient's prenatal testing and screening options were reviewed. Prenatal testing that is available to the patient includes CVS between 10-12 weeks gestation and amniocentesis around 16 weeks gestation. The risks, benefits and limitations to CVS and amniocentesis were discussed.
CVS|chorionic villus sampling|CVS|173|175|G  1  P 0000				LMP|We reviewed further prenatal testing and screening available. The nature, scope, limitations, hazards and cost of chorionic villus sampling and amniocentesis were compared. CVS is scheduled at 10 to 12 weeks gestation and has a risk of 1:200 for miscarriage. Possibility of chromosome mosaicism on analysis of CVS was discussed.
CVS|chorionic villus sampling|(CVS)|112|116|G  3  P 1011				LMP|Therefore, a maternal serum alpha fetoprotein is recommended at 16 weeks gestation. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|(CVS)|180|184|MMC 935|Makers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|262|264|IN SUMMARY|We had initially talked about screening versus diagnostic testing; that is first trimester screening, chorionic villus sampling, or amniocentesis. Soon after our initial discussions, it became clear that _%#NAME#%_ was interested in diagnostic testing; that is, CVS or amniocentesis. Both can diagnose chromosome abnormalities with greater than 99% accuracy and carry a risk of 1 in 200 for miscarriage. Her ultrasound revealed that she was 17 weeks gestation; thus, _%#NAME#%_ decided to have an amniocentesis, which was performed today by Dr. _%#NAME#%_.
CVS|chorionic villus sampling|(CVS)|188|192|DOB|Markers are seen in approximately 50-60% of babies with Down syndrome, and approximately 80-90% of babies with more severe trisomies 13 and 18. Both the chorionic villi sampling procedure (CVS) and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|246|248|G  2  P 1001				LMP|According to GeneCare laboratories first trimester screening is thought to have a sensitivity of 90% for Down syndrome and greater than 95% for trisomy 18. Patient's found to be at increased risk for first trimester screening can then be offered CVS and/or amniocentesis depending on the gestational age. Because first trimester screening does not screen for neural tube defects a maternal serum AFP and a detailed Level II ultrasound are recommended in follow-up.
CVS|chorionic villus sampling|CVS|187|189|G  2  P	0010				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|183|185|G  2  P	0010				LMP|We counseled her regarding alternative diagnostic testing procedures as well as screening procedures including amniocentesis, first trimester screening, and quad screen. As you know, CVS does not screen of spina bifida, thus a follow up AFP and/or level II ultrasound should be performed. We thoroughly reviewed her family history during our genetic counseling session.
CVS|chorionic villus sampling|CVS|206|208|SUMMARY|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|319|321|G  1  P	0000				LMP|First trimester screening is a means to adjust a patient's age related risk for Down syndrome and trisomy 18 utilizing a nuchal translucency ultrasound and blood work measuring free beta hCG and PAPP-A. Patient's found to be at increased risk from first trimester screening can then be offered prenatal testing through CVS and/or amniocentesis depending on the gestational age. Because first trimester screening does not screen for neural tube defects a maternal serum AFP and a detailed ultrasound around 18 to 20 weeks is recommended.
CVS|chorionic villus sampling|CVS.|179|182|G  2  P 1001				LMP|Therefore, a maternal serum alpha fetoprotein is recommended at 16 weeks gestation. ? I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|(CVS)|115|119|G  2  P 0101				LMP|A detailed ultrasound survey of fetal anatomy is recommended at 18-20 weeks gestation. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS.|179|182|G  1  P	0000				LMP|Therefore, a maternal serum alpha fetoprotein is recommended at 16 weeks gestation. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS|187|189|G  2  P 1001				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|112|116|G  2  P 1001				LMP|Therefore, a maternal serum alpha fetoprotein is recommended at 16 weeks gestation. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS|270|272|G  5  P 2022				LMP|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|206|208|G  1  P	0000				LMP|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|115|119|G  4  P 1021				LMP|A detailed ultrasound survey of fetal anatomy is recommended at 18-20 weeks gestation. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS|302|304|G  1  P 0000				LMP|I reviewed her age related risks of approximately 1% to have any type of chromosome abnormality including Down syndrome, trisomy 13, trisomy 18 or sex chromosome abnormalities. We reviewed first trimester screening and its limitations. We also reviewed diagnostic capabilities of the amniocentesis and CVS along with their appropriates risks and miscarriage. We thoroughly reviewed her family history during our genetic counseling session.
CVS|chorionic villus sampling|CVS|304|306|IN SUMMARY|We discussed that in the event that the screening test showed an elevated risk above her age related risk for Down syndrome or other chromosome abnormalities she could elect to have diagnostic testing options such as CVS and amniocentesis. We discussed the risks and limitations of the amniocentesis and CVS including the risk for miscarriage which is 1% and 0.5% respectfully. We discussed that these are the only two diagnostic tests for chromosome problems.
CVS|chorionic villus sampling|CVS|161|163|IN SUMMARY|It was explained to _%#NAME#%_ that because of the invasive nature of the prenatal testing options, they are associated with a risk of miscarriage. The risk for CVS is between 1:200 (0.5%) and 1:100 (1.0%) and the risk for miscarriage with amniocentesis is nationally quoted as 1:200 (0.5%). Karyotype results obtained from these procedures are received approximately 10-14 days after the procedure.
CVS|chorionic villus sampling|CVS|187|189|G  2  P	0010				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|187|189|G  4  P 1021				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|220|222|IN SUMMARY|Initially there was a twin gestation, however, currently there is a single pregnancy. _%#NAME#%_ stated that this pregnancy was not planned, wished to know the baby's chromosomal information early, and decided to have a CVS done. I reviewed that based on her age of 38, her risk of having a baby with Down syndrome is one in 173, and her risk of having a baby with any type of chromosome abnormality is one in 102, or approximately one percent.
CVS|chorionic villus sampling|CVS|298|300|IN SUMMARY|Carrier screening was discussed and declined at our visit. I reviewed available options if a baby is found, prenatally, to have an abnormality, including continuation of a pregnancy or termination of a pregnancy (up to 22 weeks gestation in the state of Minnesota). _%#NAME#%_ is scheduled to have CVS performed with you on _%#MMDD2003#%_ at 8:30 a.m. As soon as results become available, I will notify them by phone. If you have any further questions regarding this patient, please feel free to contact me at _%#TEL#%_.
CVS|chorionic villus sampling|(CVS)|115|119|G  2  P 0102				LMP|A detailed ultrasound survey of fetal anatomy is recommended at 18-20 weeks gestation. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS|166|168|RE|Prenatal testing that is available to the patient includes chorionic villous sampling between 10-12 weeks gestation and amniocentesis around 16 weeks gestation. Both CVS and amniocentesis carry a risk of miscarriage of 1:200. We also focused on the availability of prenatal screening through first trimester screening.
CVS|chorionic villus sampling|CVS|161|163|IN SUMMARY|It was explained to Ms. _%#NAME#%_ that because of the invasive nature of prenatal testing options, they are associated with a risk of miscarriage. The risk for CVS is between 1 in 200 (0.5%) and 1 in 100 (1.0%) and the risk for amniocentesis is nationally quoted as 1 in 200 (0.5%). Karyotype results obtained from these procedures are received approximately 10-14 days after the procedure.
CVS|chorionic villus sampling|CVS|187|189|G  2  P 0102				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|206|208|ASSESSMENT|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1 in 200 (0.5%) to 1 in 100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1 in 200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS,|237|240|REVIEW OF SYSTEMS|SOCIAL HISTORY: The patient is widowed. She has two children. She is a retired secretary for Cargill. REVIEW OF SYSTEMS: Negative for gastrointestinal, genitourinary (except for above), constitutional symptoms, neuro, ear, nose, throat, CVS, pulmonary, musculoskeletal, and skin. HABITS: The patient denies alcohol or tobacco abuse. PHYSICAL EXAMINATION: General: She is healthy, alert, and quite comfortable at this point and in no acute distress.
CVS|chorionic villus sampling|CVS.|191|194|PLAN|A quad screen is not necessary. A Level II ultrasound and/or AFP test is recommended to screen for spina bifida. _%#NAME#%_ is opened to the option of diagnostic testing via amniocentesis or CVS. Thank you for the opportunity to work with you patient.
CVS|chorionic villus sampling|CVS|187|189|G  2  P 0010				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|112|116|G  2  P 0010				LMP|Therefore, a maternal serum alpha fetoprotein is recommended at 16 weeks gestation. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS.|179|182|G  2  P	0010				LMP|Therefore, a maternal serum alpha fetoprotein is recommended at 16 weeks gestation. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS|251|253|MMC 395|Both false positives and false negatives can occur. First trimester screening does not screen for spina bifida. Thus, a followup AFP and/or level 2 ultrasound should be performed. We did review further diagnostic screening including amniocentesis and CVS along with their associated risk of miscarriage. We thoroughly reviewed her family history during our genetic counseling session.
CVS|chorionic villus sampling|(CVS)|96|100|G  5  P 2022				LMP|A detailed fetal anatomy survey between 18-20 weeks is recommended. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS|206|208|G  4  P 3003				LMP|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|272|274|RE|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1 in 200 (0.5%) to 1 in 100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1 in 200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|270|272|G  2  P	1001				LMP|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|228|230|G  1  P	0000				LMP|_%#NAME#%_ and _%#NAME#%_ indicated that it is important for them to know for certain if there is a chromosome problem in this pregnancy; therefore, they chose to proceed with the CVS procedure. The couple was informed that the CVS is able to diagnose structural and chromosome abnormalities with 99% accuracy, but it is not able to test for all causes of mental retardation and birth defects in a pregnancy.
CVS|chorionic villus sampling|CVS.|179|182|G  2  P 1001				LMP|Therefore, a maternal serum alpha fetoprotein is recommended at 16 weeks gestation. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS|187|189|G  3  P	1011				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|112|116|G  2  P 0010				LMP|Therefore, a maternal serum alpha fetoprotein is recommended at 16 weeks gestation. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS.|248|251|G  2  P	0010				LMP|Patients who elect to forgo modified sequential screening should still be offered maternal serum AFP screening for spina bifida in the second trimester. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|(CVS)|181|185|G  4  P 2012				LMP|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure are the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|206|208|G  2  P 1001				LMP|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|181|185|G  1  P	0000				LMP|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|312|314|G  5  P 2022				LMP|First trimester screening is a means to address the patient's age-related risk for Down syndrome and trisomy 13 and 18 utilizing a nuchal translucency ultrasound and maternal blood work measuring free beta-hCG and PAPP-A. Patients found to be at increased risk from first trimester screening can then be offered CVS and/or amniocentesis, depending on the patient's gestational age. Because first trimester screening does not screen for neural tube defects, a maternal serum AFP and a detailed Level II ultrasound is recommended for followup.
CVS|chorionic villus sampling|CVS|206|208|G  1  P	0000				LMP|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|299|301|IN SUMMARY|Dr. _%#NAME#%_ _%#NAME#%_: Thank you for the referral of your patient _%#NAME#%_ _%#NAME#%_, who was seen along with her husband, _%#NAME#%_ _%#NAME#%_, on _%#MMDD2007#%_ at the Maternal Fetal Medicine Center at University of Minnesota Medical Center, Fairview. As you know they were referred for a CVS procedure specifically because _%#NAME#%_ has a known mutation in the NF1 gene. I spent approximately 45 minutes with them today. I have previously met with this couple in Genetics Clinic at University of Minnesota Medical Center, Fairview, on _%#MMDD2007#%_ when _%#NAME#%_ initially had his blood drawn to look for specifically NF1 mutations.
CVS|chorionic villus sampling|CVS|187|189|G  5  P 2022				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|181|185|G  3  P 2002				LMP|Patients who elect to forgo modified sequential screening should still be offered maternal serum AFP screening for spina bifida in the second trimester. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS|206|208|ASSESSMENT|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|181|185|IN SUMMARY|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|206|208|IN SUMMARY|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1 in 200 (0.5%) to 1 in 100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1 in 200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|175|177|FOLLOW-UP|We discussed the options of CVS or amniocentesis. These options can be used for diagnostic purposes for chromosomal abnormalities with greater than 99% accuracy. As you know, CVS and amniocentesis also carry a risk of miscarriage in experienced hands, of 1 in 200. We thoroughly reviewed the family history during our genetic counseling session.
CVS|chorionic villus sampling|CVS:|144|147|PHYSICAL EXAMINATION|HEENT: Eyes: Sclerae and conjunctivae are normal. Mouth: Normal oral mucosa. Neck: Thyroid not palpable. Chest: Clear, no evidence of wheezing. CVS: Normal heart sounds with no murmur or gallop. Rhythm: No bruits about the neck. Abdomen is obese with no masses, tenderness or organomegaly. Skin: Clear.
CVS|chorionic villus sampling|(CVS)|115|119|G  2  P 1001				LMP|A detailed ultrasound survey of fetal anatomy is recommended at 18-20 weeks gestation. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS|176|178|G  4  P	1021				LMP|It does, however, mean that the risks for chromosome conditions are much more likely to be abnormal on the first trimester screen. We discussed two possible courses of action: CVS vs. completing the screen before making a decision about invasive testing. I did discuss the risks of CVS with _%#NAME#%_. We also discussed the fact that there is a possibility that the screen could return with a normal risk assessment in spite of _%#NAME#%_'s abnormal nuchal translucency measurement.
CVS|chorionic villus sampling|CVS|169|171|G  1  P 0000				LMP|As you recall, she had a CVS performed on _%#MMDD2007#%_ at the University of Minnesota Medical Center, Fairview, _%#CITY#%_ Maternal Fetal Medicine Center. She had the CVS due to an abnormal nuchal translucency measurement of 3.2 mm. The final chromosome results indicated a normal female karyotype (46, XX).
CVS|chorionic villus sampling|CVS|239|241|G  1  P 0000				LMP|As you know unfortunately _%#NAME#%_'s recent pregnancy had an unbalanced karyotype similar to her first baby boy, _%#NAME#%_, who was born and passed away at 6 days of age. I spent approximately 60 minutes with this patient reviewing the CVS results as well as recurrence risks for future pregnancies. As you know _%#NAME#%_ _%#NAME#%_ is a known balanced translocation carrier, specifically being 46, XXt(16;22)(p11.2)q11.21. This was discovered following the birth of their son, _%#NAME#%_, who had an unbalanced karyotype of 47, XY+der(22)t(16;22)(p11.2)q11.21. Her most recent pregnancy she had chorionic villus sampling and as you know the day of the sampling we were concerned regarding this pregnancy because of an increased nuchal translucency.
CVS|chorionic villus sampling|CVS|206|208|G  2  P	1001				LMP|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|272|274|IN SUMMARY|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1 in 200 (0.5%) to 1 in 100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1 in 200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|270|272|G  2  P 1001				LMP|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|206|208|RE|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|206|208|IN SUMMARY|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|83|85|IN SUMMARY|They also have a 75% chance for this pregnancy to be unaffected. We discussed that CVS is available which can test for Zellweger syndrome with greater 99% accuracy. Cultured cells are needed and will be sent to Kennedy-Krieger Institute for enzymatic testing for Zellweger syndrome.
CVS|chorionic villus sampling|CVS|186|188|IN SUMMARY|Cultured cells are needed and will be sent to Kennedy-Krieger Institute for enzymatic testing for Zellweger syndrome. Results will take approximately 3-4 weeks. Risk of miscarriage with CVS in experienced hands such as Dr. _%#NAME#%_ is approximately 1 in 200. CVS can also test for other chromosome abnormalities such as Down syndrome.
CVS|chorionic villus sampling|CVS|165|167|PLAN|As you know, she was referred to discuss the influence of maternal age on pregnancy outcome and was here for CVS. Unfortunately, a very small sample was obtained on CVS today and this patient may need a followup amniocentesis. I spent approximately 45-minutes with them today. _%#NAME#%_ is a 36-year-old gravida 3, para 0-0-2-0 who is currently 11 weeks and 3 days gestation based on an estimated date of delivery of _%#MM#%_ _%#DD#%_, 2008.
CVS|chorionic villus sampling|CVS|206|208|MMC 935|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1 in 200 (0.5%) to 1 in 100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1 in 200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS,|228|231|SUMMARY|I also reviewed the risk for limb defects of one in 3,000; and the potential risk of ambiguous results, of 1% to 2%, which may need to be clarified by following amniocentesis. Amniocentesis was reviewed as an alternative to the CVS, which can be performed at 15 weeks and beyond. I reviewed the one in 200 risk of miscarriage associated with amniocentesis.
CVS|chorionic villus sampling|(CVS)|251|255|SUMMARY|_%#NAME#%_ _%#NAME#%_ _%#NAME#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#ADDRESS#%_ _%#CITY#%_, Minnesota _%#55000#%_ Dear _%#NAME#%_ and _%#NAME#%_, I spoke with you on the phone on _%#MMDD2003#%_ regarding results of your chorionic villa sampling (CVS) testing. According to Genzyme Genetics, your developing baby boy has a normal number of chromosome, 46 XY. You reported no complications due to the procedure. If you have any further questions with which I can be of assistance, please do not hesitate to contact me at _%#TEL#%_.
CVS|chorionic villus sampling|CVS|317|319|SUMMARY|The patient expressed that she and her husband had discussed prenatal screening and decided that if they were to elect for any prenatal diagnosis that they would elect for a diagnostic procedure. Thus, the focus of our discussion was the availability of CVS and amniocentesis. The risks, benefits, and limitations to CVS and amniocentesis were discussed as was the procedure related risk of a miscarriage with CVS of 0.5% to 1% and amniocentesis risk of miscarriage of 0.5%. The timing of CVS is between 10-12 weeks gestation and amniocentesis around 16 weeks gestation was discussed.
CVS|chorionic villus sampling|CVS.|349|352|PLAN|First trimester screening is a means to adjust a patient's age related risk for Down syndrome and trisomy 18 utilizing nuchal translucency ultrasound and blood work measuring free beta hCG and PAPP-A. Patient's found to be at increased risk from first trimester screening can then be offered diagnostic prenatal testing such as amniocentesis and/or CVS. At the conclusion of our discussion the patient elected to proceed with first trimester screening.
CVS|chorionic villus sampling|CVS|187|189|G  2  P 0010				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|206|208|IN SUMMARY|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|151|153|ADDENDUM|ADDENDUM: First trimester screen results show 1/53 risk for Twin B for Down syndrome. Twin A results are within normal limits. Patient decided to have CVS scheduled for _%#MM#%_ _%#DD#%_, 2006.
CVS|chorionic villus sampling|CVS|136|138|G  2  P 0010				LMP|The risks, benefits, and limitations to CVS and amniocentesis were compared as was the procedure related risk of a miscarriage for both CVS and amniocentesis of 1 in 200. The patient indicated that she was hoping to pursue CVS thus we went on to discuss in more detail the CVS procedure.
CVS|chorionic villus sampling|CVS|190|192|SUMMARY|We discussed various types of prenatal testing and screening that is available to the patient. Prenatal testing that is available includes chorionic villus sampling (CVS) and amniocentesis. CVS is scheduled at 10-12 weeks gestation and has a risk of 1/200 for miscarriage. Amniocentesis is scheduled at 16 weeks gestation with a 1/200 risk of miscarriage.
CVS|chorionic villus sampling|CVS.|379|382|G  2  P 1001				LMP|Dear Ms. _%#NAME#%_: Thank you for the referral of your patient _%#NAME#%_ _%#NAME#%_, who was seen along with her mother _%#NAME#%_, on _%#MM#%_ _%#DD#%_, 2007, at the Maternal-Fetal Medicine Center at the University of Minnesota Medical Center, Fairview. As you know, she was referred to discuss the influence of maternal age on pregnancy outcome and was here specifically for CVS. She has had previous genetic counseling with _%#NAME#%_ _%#NAME#%_, at Southdale, in 2004. Her records were reviewed and updated. _%#NAME#%_ is a 38-year-old gravida 3, para 1-0-1-1 who is currently almost 12 weeks' gestation, based on an estimated date of delivery of _%#NAME#%_ _%#DD#%_, 2008.
CVS|chorionic villus sampling|CVS|262|264|G  2  P 1001				LMP|Both of them are of European ethnicity. We discussed options available if the baby was found to have an abnormality prenatally, including continuation of pregnancy or termination of pregnancy up to 24 weeks' gestation in the state of Minnesota. _%#NAME#%_ had a CVS which was performed today by Dr. _%#NAME#%_. As soon as final results become available, we will contact her by phone and fax you a copy.
CVS|chorionic villus sampling|(CVS)|115|119|G  2  P 1001				LMP|A detailed ultrasound survey of fetal anatomy is recommended at 18-20 weeks gestation. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS|274|276|IN SUMMARY|The sensitivity of first trimester screening according to GeneCare Laboratories is thought to be 90% for Down syndrome and greater than 95% for trisomy 18. Patient's found to be at increased risk from first trimester screening can then be offered additional testing such as CVS and/or amniocentesis. Because first trimester screening does not screen for neural tube defects a maternal serum AFP and detailed Level II ultrasound are recommended.
CVS|chorionic villus sampling|CVS,|294|297|G  3  P 2002				LMP|Both false positives and false negatives can occur. First trimester screen does not screen for spina bifida, thus a follow-up AFP and/or level II ultrasound should be performed. We discussed if first trimester screen shows increased risk, then we would offer further diagnostic testing, either CVS, which can be done up to 13 weeks' gestation, or amniocentesis, starting as early as 15 weeks' gestation. We discussed their appropriate risk of miscarriage with each of those procedures.
CVS|chorionic villus sampling|CVS|361|363|G  5  P	1031				LMP|First trimester screening is a means to address the patient's age-related risk for Down syndrome, trisomy 13 and trisomy 18, utilizing a nuchal translucency ultrasound and maternal blood work measuring free beta-hCG and PAPP-A. Patients found to be at increased risk from first trimester screening can then be offered more definitive prenatal diagnosis through CVS and/or amniocentesis. Because first trimester screening does not screen for neural tube defects, a maternal serum AFP and a detailed ultrasound is recommended in followup.
CVS|chorionic villus sampling|(CVS)|181|185|ASSESSMENT|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|(CVS)|207|211|IN SUMMARY|We went on to discuss the availability of both prenatal testing and screening options. Prenatal testing includes chorionic villi sampling (CVS) and amniocentesis. Both the chorionic villi sampling procedure (CVS) and the amniocentesis procedure were discussed as the only ways to definitively diagnose a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|354|356|IN SUMMARY|Prenatal testing includes chorionic villi sampling (CVS) and amniocentesis. Both the chorionic villi sampling procedure (CVS) and the amniocentesis procedure were discussed as the only ways to definitively diagnose a numerical chromosome abnormality in a pregnancy. Both of these procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11 to 13 weeks gestation and amniocentesis is offered after 15 weeks gestation. It was explained to _%#NAME#%_ that because of the invasive nature of prenatal testing options, they are associated with the risk of miscarriage.
CVS|chorionic villus sampling|CVS|186|188|IN SUMMARY|We reviewed the CVS procedure along with its 1:200 risks of miscarriage. We reviewed the rare possibility of ambiguous results, which may need follow up by an amniocentesis. As you know CVS does not test for spina bifida thus a follow up AFP and/or level 2 ultrasound should be performed. We also reviewed alternatives, testing and screening including first trimester screening and amniocentesis as well as follow up level II ultrasound.
CVS|chorionic villus sampling|(CVS)|181|185|G  5  P 2022				LMP|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|206|208|RE|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|272|274|SUMMARY|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|181|185|RE|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|187|189|IMPRESSION AND PLAN|The risks, benefits and limitations to CVS and amniocentesis were compared. We discussed the risk of miscarriage of both CVS and amniocentesis of 1:200. The discrepancies and accuracy of CVS and amniocentesis was also discussed with the couple. We discussed the obvious emotional nature of the patient's first trimester screening in light of her history of anxiety and OCD.
CVS|chorionic villus sampling|CVS.|248|251|G  4  P 1021				LMP|Patients who elect to forgo modified sequential screening should still be offered maternal serum AFP screening for spina bifida in the second trimester. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS|143|145|ADDENDUM|If you have any further questions regarding this patient please feel free to contact me at _%#TEL#%_. ADDENDUM: According to Genzyme Genetics, CVS results on both twins were normal 46,XY.
CVS|chorionic villus sampling|CVS.|254|257|G  2  P 0102				LMP|The absence of any such markers can provide reassurance. Level II ultrasound cannot definitively diagnose or exclude the presence of any chromosome condition. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS|182|184|G  1  P	0000				LMP|We discussed the option of CVS and/or amniocentesis as a means to test the fetal chromosomes. The risks, benefits and limitations to CVS and amniocentesis were compared. The risk of CVS performed abdominally given the patient's gestational age was discussed as a 1:200 to 1% risk. Amniocentesis around 16 weeks' gestation was discussed, as was the 1:200 risk of miscarriage.
CVS|chorionic villus sampling|CVS.|254|257|G  2  P 0010				LMP|The absence of any such markers can provide reassurance. Level II ultrasound cannot definitively diagnose or exclude the presence of any chromosome condition. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS|272|274|G  2  P 1001				LMP|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|163|165|IN SUMMARY|_%#NAME#%_ stated that they have shared this news with some of their families and do have some support from their families and friends. _%#NAME#%_ planned to have CVS today performed by Dr. _%#NAME#%_. As soon as results become available, I will notify them by phone and fax you a copy. If you have any further questions with which I can be of assistance, please feel free to contact me at _%#TEL#%_.
CVS|chorionic villus sampling|CVS|146|148|ADDENDUM|We reviewed first trimester screening and its limitations as well as false positives and positive negatives. Further diagnostic testing including CVS and amniocentesis were reviewed as well. We thoroughly reviewed her family history during our genetic counseling session.
CVS|chorionic villus sampling|CVS|187|189|G  1  P	0000				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS.|179|182|G  3  P	1011				LMP|Therefore, a maternal serum alpha fetoprotein is recommended at 16 weeks gestation. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|(CVS)|181|185|G  4  P 1021				LMP|Patients who elect to forgo modified sequential screening should still be offered maternal serum AFP screening for spina bifida in the second trimester. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS|206|208|IN SUMMARY|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|187|189|G  3  P 2002				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|142|144|MMC 402|Amniocentesis also can detect spina bifida. Chorionic villous sampling is another diagnostic tool to examine a baby's chromosomes prenatally. CVS is typically performed between 10 and 12 weeks gestation and involves a 1% risk of miscarriage. I reviewed that individuals of varying ethnic backgrounds have increased risk for certain genetic conditions.
CVS|chorionic villus sampling|CVS|270|272|G  5  P 1031				LMP|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|139|141|ADDENDUM|I reviewed the chorionic villa sampling is greater than 99% accurate for diagnosing chromosome abnormalities. The risk of miscarriage with CVS is one percent. I reviewed the one to two percent risk of ambiguous results, which may require a follow-up amniocentesis.
CVS|chorionic villus sampling|CVS|193|195|ADDENDUM|The patient is scheduled for CVS at University Specialists on _%#MMDD2003#%_with you. _%#NAME#%_ decided to have cystic fibrosis carrier screening on _%#MMDD2003#%_. Cells should be saved from CVS for possible CF testing, if needed. As soon as results from the CVS become available, I will contact them. If you have any further questions regarding this patient, please feel free to contact me at _%#TEL#%_.
CVS|chorionic villus sampling|CVS|201|203|IN SUMMARY|Risk of miscarriage in experienced hands, such as Dr. _%#NAME#%_, is estimated to be 1 in 200. We reviewed the approximate 1% chance of ambiguous results which may need followup from an amniocentesis. CVS does not test for spina bifida, thus a followup AFP and/or Level II ultrasound should be performed. We reviewed alternative testing and screening, including first trimester screening, quad screen, Level II ultrasound and amniocentesis.
CVS|chorionic villus sampling|CVS|187|189|G  2  P 1001				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|185|189|G  2  P	1001				LMP|Markers are seen in approximately 50-60% of babies with Down syndrome, and in approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|272|274|RE|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS.|272|275|IN SUMMARY|We discussed that at the age of 42 the mid-trimester risk for Down's syndrome would be in 1:45, the mid-trimester risk for any chromosomal abnormality would be 1:30. We discussed the availability of first trimester screening, multiple marker screening, amniocentesis, and CVS. We discussed that amniocentesis and CVS are diagnostic tests which do give precise karyotypic results, but carry a risk of pregnancy loss of 1:200.
CVS|chorionic villus sampling|CVS|272|274|PLAN AND SUGGESTIONS|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 10-12 weeks gestation and amniocentesis is offered after 15 weeks gestation. Due to their invasive nature, CVS is nationally associated with a 1 in 100 risk of miscarriage and amniocentesis is nationally associated with a 1 in 200 risk of miscarriage.
CVS|chorionic villus sampling|CVS|422|424|SUMMARY|We discussed that first trimester screening does not screen for spina bifida so it would be imperative for _%#NAME#%_ to have an AFP drawn at 15 weeks gestation as well as a Level II ultrasound at 18 to 20 weeks gestation to assess this pregnancy for open neural tube defects such as spina bifida. We discussed that diagnostic testing is available which can detect chromosome abnormalities with greater than 99% accuracy. CVS can be performed between 11 and 13 weeks gestation and carries a 1 in 200 risk of miscarriage. Amniocentesis can test for both chromosome abnormalities as well as open neural tube defects with greater than 99% accuracy.
CVS|chorionic villus sampling|(CVS)|113|117|G  4  P 2012				LMP|Therefore, a maternal serum alpha fetoprotein is recommended at 16 weeks gestation. * Chorionic villous sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS|153|155|G  3  P 1011				LMP|The risks, benefits and limitations to amniocentesis were compared for the patient as was the procedure-related risk of miscarriage of 1 in 200 for both CVS and/or amniocentesis. Because first-trimester screening does not screen for neural tube defects, a detailed ultrasound around 18-20 weeks is available.
CVS|chorionic villus sampling|(CVS)|181|185|G  1  P 0000				LMP|Patients who elect to forgo modified sequential screening should still be offered maternal serum AFP screening for spina bifida in the second trimester. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS|206|208|G  2  P 1001				LMP|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|189|191|G  5  P	4003				LMP|CVS is a diagnostic tool that is available to women between 11-13 weeks of gestation. There is approximately a 1:200 or 0.5% risk of miscarriage due to the procedure. We discussed that the CVS procedure is 99% accurate in detecting chromosome abnormalities. In rare cases, the CVS results are inconclusive and amniocentesis is required as a follow-up test for diagnostic accuracy.
CVS|chorionic villus sampling|CVS|185|187|G  5  P	4003				LMP|We discussed that reasons for pursuing amniocentesis include reassurance, for preparation, or to make decisions about the pregnancy. _%#NAME#%_ will use the information gained from the CVS in order to make further decisions about the pregnancy. We discussed the difference between the preliminary results via FISH (fluorescent in situ hybridization) in comparison to a karyotype result.
CVS|chorionic villus sampling|CVS.|179|182|G  5  P 2022				LMP|Therefore, a maternal serum alpha fetoprotein is recommended at 16 weeks gestation. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS|206|208|MMC 395|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS.|179|182|G  2  P 0010				LMP|Therefore, a maternal serum alpha fetoprotein is recommended at 16 weeks gestation. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS|272|274|IN SUMMARY|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1 in 200 (0.5%) to 1 in 100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1 in 200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|206|208|G  3  P	1011				LMP|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1 in 200 (0.5%) to 1 in 100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1 in 200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|142|144|IN SUMMARY|A detailed ultrasound survey of fetal anatomy is recommended at 18-20 weeks gestation. We briefly discussed invasive testing options, such as CVS and amniocentesis. I indicated to _%#NAME#%_ that if she is interested in a definitive yes or no answer regarding Down syndrome, we can only achieve this through one of these 2 invasive procedures.
CVS|chorionic villus sampling|CVS|272|274|G  3  P	2002				LMP|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|181|185|IN SUMMARY|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|270|272|IN SUMMARY|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|187|189|G  2  P 1001				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS.|377|380|PLAN|Dear Dr. _%#NAME#%_: Thank you for the referral of your patient, _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, who was seen along with her partner, _%#NAME#%_, on _%#MMDD2007#%_ at the Maternal Fetal Medicine Center at University of Minnesota Medical Center, Fairview. As you know, she was referred to discuss the results of maternal age on pregnancy outcome and was here specifically for CVS. I spent approximately 60 minutes with this patient today. _%#NAME#%_ is a 41-year-old gravida 4, para 2-0-1-2, whoseis 11 weeks gestation based on estimated date of delivery of _%#MMDD2008#%_.
CVS|chorionic villus sampling|CVS|187|189|G  4  P 1021				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|181|185|G  2  P 1001				LMP|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|270|272|IN SUMMARY|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|187|189|G  1  P 0000				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|181|185|SUMMARY|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|187|189|G  3  P 2002				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|272|274|G  1  P 0000				LMP|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS.|272|275|ALLERGIES|3. Neurology. Multiple sclerosis. He was diagnosed 25 years ago, chronically progressing since 3 years as he was started on interferon. He was doing fine and was stable regarding his multiple sclerosis. He was following Dr. _%#NAME#%_ regarding his multiple sclerosis. 4. CVS. Hypertension was stable while in the hospital, restarted on his home medications, lisinopril, and was doing fine while in the hospital.
CVS|chorionic villus sampling|CVS:|284|287|PHYSICAL EXAMINATION|She denies nausea or vomiting. Tolerating sips of water. Vital signs: Temperature was 95.2, pulse rate of 71, blood pressure 108/64, respiratory rate of 16, and O2 saturations 99% on 2 L oxygen. General: Alert, active, and oriented x3. Respiratory: Clear to auscultation bilaterally. CVS: Regular rate and rhythm, no murmurs, rubs, or gallops. Abdomen: Soft, appropriately tender at the incision. Incision intact with Steri-Strips.
CVS|chorionic villus sampling|CVS|206|208|SUMMARY|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|206|208|G  5  P 1031				LMP|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|213|215|IN SUMMARY|The results of the screen will be available approximately one week from the date of visit and a copy will be faxed under separate cover to your office. _%#NAME#%_ and I spent much time discussing amniocentesis or CVS as a follow-up to an abnormal first trimester screen. She indicated that she would not pursue amniocentesis due to the miscarriage risk associated with the procedure.
CVS|chorionic villus sampling|(CVS)|181|185|G  2  P 1001				LMP|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|206|208|IN SUMMARY|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|181|185|G  5  P 1031				LMP|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|187|189|G  5  P 3013				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|191|195|RE|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling procedure (CVS) and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|(CVS)|181|185|IN SUMMARY|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|270|272|ASSESSMENT AND PLAN|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|270|272|MMC 395|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|240|242|IN SUMMARY|The risk of miscarriage nationally associated with CVS is 1 in 100 (1%) and the nationally associated risk for amniocentesis is 1 in 200 (0.5%). Results from these procedures are received approximately 10-14 days after the procedure. 1% of CVS results are inconclusive and require follow-up amniocentesis. We also discussed prenatal screening options, such as first trimester screening, maternal serum screening ("quad" screen) and level II ultrasound.
CVS|chorionic villus sampling|(CVS)|179|183|G  3  P	2002				LMP|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomy 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|237|239|G  1  P	0000				LMP|Chorionic villi sampling (CVS) procedure and the amniocentesis procedure are ways of definitely diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS.|179|182|G  5  P 1031				LMP|However, an abnormal screen is not an inevitable outcome with a nuchal translucency measurement of 2.8mm. We reviewed options of completing the screen vs. proceed ing directly to CVS. _%#NAME#%_ and _%#NAME#%_ indicated that they would like to complete the screening before making a decision about invasive testing. I discussed the fact that comprehensive ultrasound at 18-20 weeks and fetal echocardiogram are recommended due to this increased nuchal translucency measurement.
CVS|chorionic villus sampling|CVS|270|272|G  2  P 0010				LMP|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|220|222|IN SUMMARY|The limitations of generalizing these reports to the couple's case given the break points are not similar were discussed. Given the current pregnancy, the availability of prenatal diagnosis for the couple through either CVS or amniocentesis was discussed. CVS is performed between 10 to 12 weeks of pregnancy and carries a risk of miscarriage of 1 in 200.
CVS|chorionic villus sampling|(CVS)|181|185|IN SUMMARY|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|272|274|G  3  P	1011				LMP|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|181|185|G  1  P 0000				LMP|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|206|208|G  3  P	2002				LMP|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|187|189|G  1  P	0000				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|256|258|G  5  P 1031				LMP|She stated that this information would be helpful to her and _%#NAME#%_, as it would allow them to prepare for the birth of a child with a chromosome abnormality. _%#NAME#%_ decided to do first trimester screening today, but wants to discuss the option of CVS and amniocentesis with you at her next OB visit. I assured her that while there is a miscarriage risk associated with both procedures, our perinatologists have performed both procedures numerous times.
CVS|chorionic villus sampling|CVS|145|147|SUMMARY|We first reviewed diagnostic testing for chromosome problems during a pregnancy. We briefly talked about the CVS procedure. We talked about that CVS has a 99 percent accuracy in diagnosing these types of chromosome abnormalities prenatally. However, the risk of miscarriage associated with CVS has been estimated to be approximately 0.5 to 1 percent.
CVS|chorionic villus sampling|CVS|248|250|G  3  P 0020				LMP|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure are ways of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|181|185|ASSESSMENT AND PLAN|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|customer, value, service|CVS|162|164|IN SUMMARY|Late last week I had a call on Friday that he had run out of his medications. We made significant attempt to be sure that medication of his opioids were faxed to CVS on _%#STREET#%_. However, there was some problem and _%#NAME#%_ states to me that "MA refused me" and stated that he was too early to have his medications, and thus he went over the weekend without any opioid coverage.
CVS|chorionic villus sampling|CVS|187|189|G  4  P	2012				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS.|254|257|G  1  P	0000				LMP|The absence of any such markers can provide reassurance. Level II ultrasound cannot definitively diagnose or exclude the presence of any chromosome condition. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS|187|189|G  2  P	0010				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|269|271|G  5  P 2022				LMP|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures will offer direct fetal chromosome analysis with 9% accuracy. CVS is offered at 11-13 weeks gestation, and amniocentesis is offered after 15 weeks gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1%) risk of miscarriage, and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|187|189|G  2  P	1001				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|181|185|MMC 395|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|239|241|RE|Chorionic villi sampling (CVS) procedure and the amniocentesis procedure are ways of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|181|185|G  1  P	0000				LMP|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|187|189|G  3  P	1021				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS|212|214|G  1  P 0000				LMP|_%#NAME#%_ and _%#NAME#%_ indicated that the screen results would not be useful to them at this point in time. They have made the decision that they want either CVS or amnio. Tentative appointments were made for CVS on _%#MMDD2007#%_ at _%#CITY#%_ and for amnio on _%#MM#%_ _%#DD#%_, 2007 at Southdale. _%#NAME#%_ and _%#NAME#%_ plan to discuss these two options and let me know which one of these appointments they will keep.
CVS|chorionic villus sampling|(CVS)|181|185|G  3  P 2002				LMP|Patients who elect to forgo modified sequential screening should still be offered maternal serum AFP screening for spina bifida in the second trimester. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS|270|272|PROBLEM #4|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|206|208|G  1  P 0000				LMP|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|270|272|IN SUMMARY|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|206|208|ASSESSMENT AND PLAN|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|270|272|IN SUMMARY|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|227|229|G  3  P	1021				LMP|Therefore, an AFP only blood screen after 14 weeks' gestation is recommended to screen for this possibility. We discussed options of continuation of pregnancy, termination of pregnancy up to 24 weeks' gestation, or adoption if CVS results are abnormal. Family History: A detailed family history was obtained during the visit.
CVS|chorionic villus sampling|CVS|147|149|IN SUMMARY|However, without additional medical records or information regarding this child it is hard to suggest a specific risk for this pregnancy. When the CVS procedure was attempted today, it was determined that there was not enough sample obtained. Dr. _%#NAME#%_ offered to perform an amniocentesis at 14 to 15 weeks of pregnancy.
CVS|chorionic villus sampling|CVS|206|208|G  1  P	0000				LMP|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|205|207|PHYSICAL EXAMINATION|The neck is supple with no increase in JVP. No thyromegaly noted. Bilateral carotid pulses are equal without bruits. The respiratory system reveals decreased air entry bilaterally with bilateral wheezing. CVS examination reveals a normal S1. The second heart sound is loud, especially the P2 component, with a soft ejection systolic murmur which is short in the aortic area.
CVS|chorionic villus sampling|CVS|187|189|G  3  P 1011				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|CVS.|254|257|G  3  P 2002				LMP|The absence of any such markers can provide reassurance. Level II ultrasound cannot definitively diagnose or exclude the presence of any chromosome condition. * I explained that some couples prefer the definitive information provided by amniocentesis or CVS. Other couples may be uncomfortable with the risk of miscarriage and are sufficiently reassured by screening options. I emphasized that prenatal testing decisions are personal decisions and each couple must make the choice that is right for them.
CVS|chorionic villus sampling|CVS|206|208|G  3  P 0020				LMP|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|323|325|G  1  P	0000				LMP|I indicated that I could provide her with an "information sheet" for an adoptive family that could detail the disease, sources of information, physicians who are familiar with the condition, and what is known about the genetic basis of the condition in _%#NAME#%_'s family. * If _%#NAME#%_ decides that she wants to pursue CVS or amnio for sarcoglycan epsilon mutations, we would need to obtain a blood sample both from her and from another family member who is known to carry the familial sarcoglycan epsilon mutation.
CVS|chorionic villus sampling|CVS|211|213|G  1  P	0000				LMP|A NT measurement was not made, and the frist trimester screen was not attempted. Following the ultrasound, I met with _%#NAME#%_ and discussed her options. We scheduled an appointment at Fairview _%#CITY#%_ for CVS on Monday, _%#MM#%_ _%#DD#%_ with Dr. _%#NAME#%_. A preliminary result will be available 24 to 48 hours following the procedure and a final result will be available in 2 weeks.
CVS|chorionic villus sampling|(CVS)|115|119|G  5  P 3013				LMP|A detailed ultrasound survey of fetal anatomy is recommended at 18-20 weeks gestation. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS|246|248|G  1  P 1001				LMP|2. Prader Willi testing by methylation sensitive Southern blot or PCR would exclude almost all known causes of Prader Willi syndrome (thus it is more sensitive). However, most laboratories are reluctant to perform methylation-sensitive assays on CVS samples. Thus, if _%#NAME#%_ and _%#NAME#%_ desire exclusion of the type of Prader Willi seen in their son as early as possible, CVS would be an option.
CVS|chorionic villus sampling|CVS|270|272|LABORATORY DATA|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1 in 200 (0.5%) to 1 in 100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1 in 200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|181|185|G  2  P 0010				LMP|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|272|274|RE|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1 in 200 (0.5%) to 1 in 100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1 in 200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|181|185|G  3  P	1011				LMP|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|(CVS)|181|185|G  3  P 0020				LMP|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|206|208|IN SUMMARY|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|181|185|RE|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|(CVS)|181|185|PROBLEM #4|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|206|208|RE|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|178|180|G  1  P 0010				LMP|Testing options in future pregnancies: We limited our discussion to first trimester screening/testing options as _%#NAME#%_ clearly indicated that she is very likely to consider CVS in any future pregnancies. I explained that CVS can provide definitive diagnosis or exclusion of numerical chromosome abnormalities with 99% accuracy.
CVS|chorionic villus sampling|CVS|187|189|G  3  P 1011				LMP|Screening tests, such as first trimester screen, provide risk assessments for specific conditions, but cannot definitively diagnose or exclude these conditions. Diagnostic tests, such as CVS and amniocentesis can definitively diagnose or exclude the presence of certain chromosome conditions, but are associated with a small risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|181|185|IN SUMMARY|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|272|274|IN SUMMARY|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 10 to 12 weeks of gestation, and amniocentesis is offered after 15 weeks gestation. Due to their invasive nature, CVS is nationally associated with a 1 in 100 risk of miscarriage and amniocentesis is nationally associated with a 1 in 200 risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|181|185|IN SUMMARY|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|270|272|PLAN|Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitely diagnosing a numerical chromosome abnormality in a pregnancy. Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|CVS|172|174|IN SUMMARY|4. AFP only blood screening is recommended after 14 weeks to screen for open neural tube defects in the pregnancy. 5. I am happy to report that the results of the couple's CVS have been received and are found to be balanced. CVS karyotyping reveals that this pregnancy is a female with the same balanced chromosome translocation as the patient's.
CVS|chorionic villus sampling|CVS|222|224|G  4  P 2011				LMP|However, data from the FASTER study has indicated that NT measurements between 2-3mm still result in normal screens often enough that it is usually worthwhile to complete the biochemical portion of the screen. I did offer CVS as a diagnostic testing option, which _%#NAME#%_ declined. We also discussed the association between increased nuchal translucency measurements and congenital problems, such as congenital heart problems.
CVS|chorionic villus sampling|(CVS)|181|185|LABORATORY DATA|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
CVS|chorionic villus sampling|CVS|218|220|G  3  P 2002				LMP|Both procedures allow for direct fetal chromosomal analysis with greater than 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 18 weeks gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|115|119|G  3  P 1011				LMP|A detailed ultrasound survey of fetal anatomy is recommended at 18-20 weeks gestation. * Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
CVS|chorionic villus sampling|CVS|240|242|RE|As you know, she was referred today because a routine first trimester screen ultrasound performed at your clinic today revealed a large cystic hygroma, fetal hydrops and enlarged bladder. I met with them today prior to their ultrasound and CVS procedure performed by Dr. _%#NAME#%_. Preliminary results should be available in the next few days. _%#NAME#%_ is a 34-year-old gravida 2, para 0-0-1-0 who is currently 13 weeks' and 3 days' gestation based an estimated date of delivery of _%#MMDD2008#%_.
CVS|chorionic villus sampling|CVS|191|193|IN SUMMARY|First trimester screening does not screen for spina bifida thus a follow-up Level II ultrasound and/or AFP should be performed. We also discussed options of diagnostic testing which would be CVS or amniocentesis which is diagnostic for chromosome abnormalities with greater than 99% accuracy. Risk of miscarriage is 1 in 200 in experienced hands.
CVS|chorionic villus sampling|CVS|206|208|IN SUMMARY|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 11-13 weeks' gestation and amniocentesis is offered after 15 weeks' gestation. Due to their invasive nature, CVS is nationally associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage.
CVS|chorionic villus sampling|(CVS)|181|185|IN SUMMARY|Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18. Both the chorionic villi sampling (CVS) procedure and the amniocentesis procedure were discussed as the only means of definitively diagnosing a numerical chromosome abnormality in a pregnancy.
DC|direct current|DC|90|91|ADMITTING DIAGNOSIS|Discharge planned _%#MMDD2007#%_ ADMITTING DIAGNOSIS: Atypical atrial flutter status post DC cardioversion. FINAL DIAGNOSIS: Atypical atrial fibrillation status post DC cardioversion REASON FOR ADMISSION: _%#NAME#%_ _%#NAME#%_ is a 73-year-old white male with a history of hypertension and hyperlipidemia.
DC|direct current|DC|248|249|PROCEDURES|PROCEDURES: 1. Transesophageal echocardiogram. _%#MMDD2006#%_. Significant findings include normal global LV systolic function with no atrial or left atrial appendage thrombus identified. Small PFO with left to right shunts was also identified. 2. DC cardioversion. _%#MMDD2006#%_. Indication was atypical atrial flutter with rapid ventricular response. The patient was cardioverted with 1 shock of 120 joules.
DC|discharge|DC|478|479|PERTINENT  LABORATORY TESTS|She feels "all of my problems are since I had my original leg surgery and this is not related to my smoking." PERTINENT LABORATORY TESTS: _%#MMDD2007#%_: sodium 137, potassium 3.2, chloride 108, creatinine 1.40, BUN 24, glucose 93, calcium 8.3. WBC 9.7, hemoglobin 9.4, platelet count 283,000. INR 3.04. _%#MMDD2007#%_: INR 1.63. _%#MMDD2007#%_: INR 1.34. _%#MMDD2007#%_: INR 2.66. _%#MMDD2007#%_: INR 2.67. _%#MMDD2007#%_ INR 3.30. _%#MMDD2007#%_: Hemoglobin 10.4. ****SEE THE DC SUMMARY ADDENDUM I DICTATED THIS AM ON _%#MMDD2007#%_))**
DC|direct current|DC|228|229|HOSPITAL COURSE|It was believed that his numerous medications were preventing him from developing rapid ventricular rate and then also causing his hypotension. Given this information he underwent a TE to rule out clot and that was successfully DC cardioverted. Once in normal sinus rhythm his blood pressure's improved nicely and his dopamine was weaned off. 2. Uncontrolled hypertension - the patient was on numerous blood pressure medications on admission.
DC|direct current|DC|156|157|IMPRESSION AND PLAN|Mr. _%#NAME#%_ is a pleasant 51-year-old gentleman coming in for a history and physical prior to DC cardioversion scheduled for today. Atrial fibrillation: DC cardioversion scheduled for 2:00 today with Dr. _%#NAME#%_ at Fairview Southdale Hospital. Risks, benefits, alternatives and outcomes were discussed in detail with the patient.
DC|discontinue|DC|121|122|HOSPITAL COURSE|At this time, feels ready to be discharged and I am in agreement with that. The patient will be discharged to home. Will DC her IV and DC her to home with her oral medicines. She will be followed up with Dr. _%#NAME#%_ in 3 days. DISCHARGE MEDICATIONS: 1. Norvasc 10 mg daily, for hypertension.
DC|direct current|DC|304|305|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 32-year-old male with a history of congential cardiac disease, including hypoplastic right ventricle, tricuspid atresia, pulmonary atresia, status post aortic pulmonic shunt, as well as intermittent atrial fibrillation, for which he has undergone multiple DC cardioversions (_%#MM2002#%_, _%#MM2003#%_, _%#MM2003#%_, _%#MM2003#%_). The patient had been chronically rate controlled and anticoagulated. During initial DC cardioversion, his antiarrhythmic medication was held secondary to relative infrequency of episodes.
DC|direct current|DC|142|143|PROCEDURES|PROCEDURES: 1. Echocardiogram, which showed intact left ventricular function, normal chamber size and no significant valvular dysfunction. 2. DC cardioversion of rapid ventricular response and correction of wide complex tachycardia. 3. Electrophysiology study with attempted radiofrequency ablation of WPW.
DC|discontinue|DC.|197|199|DISCHARGE MEDICATIONS/PLAN|g. Prinivil 5 daily for atherosclerotic vascular disease. h. Sorbitol 15 p.o. prn constipation. i. Prednisone taper 20 p.o. b.i.d. for four days, 20 daily for four and then 10 daily for four, then DC. j. Augmentin 500 p.o. b.i.d. for seven more days. k. Oxygen as needed to keep the percent saturation greater than 90%.
DC|direct current|DC|147|148|PROCEDURE|2. Hypothyroidism. PROCEDURE: 1. Echocardiogram on _%#MMDD2005#%_ with normal global systolic LV function, no intracardiac thrombus identified. 2. DC cardioversion on _%#MMDD2005#%_ without complications. Restoration of sinus rhythm noted. 3. Chest x-ray on _%#MMDD2005#%_: normal chest. HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old Caucasian male with history of ventricular arrhythmia and nonsustained ventricular tachycardia in _%#MM#%_ 2004 who presents with atrial fibrillation with rapid ventricular response.
DC|discontinue|DC.|125|127|DISCHARGE MEDICATIONS|11. Protonix EC 20 mg p.o. daily. 12. Zocor 20 mg p.o. q. h.s. 13. Lovenox 40 mg subcutaneous through _%#MM#%_ _%#DD#%_ then DC. 14. Aspirin 81 mg p.o. daily x5 weeks. 15. Milk-of-Magnesia 30 mL suspension p.r.n. 16. Percocet 1-2 tablets p.o. q. 4 hours p.r.n. for pain.
DC|discontinue|DC|217|218|FINAL DIAGNOSIS|She will be discharged on IV Vancomycin, as well as to continue on her Levaquin and Flagyl. 3. Bilateral pleural effusions, status-post tap, resolved. 4. Alcohol withdrawal resolved. 5. Acute confusion resolved after DC Ativan. 6. Poor nutrition. Placed on stage I diet after swallow evaluation. 7. Tremor, chronic stable. 8. Subdural hygromas, stable. 9. Esophagitis. 10. Anemia, status-post endoscopy.
DC|discontinue|DC|148|149|MEDICATIONS|4. Estrace, 2 mg daily. 5. Synthroid, 100 mcg daily. 6. Prednisolone, 1% ophthalmic suspension. 7. Lexapro, 10 mg daily. 8. Zyrtec, 10 mg daily. 9. DC the prednisolone eye drops. SOCIAL HISTORY: Does not use tobacco. Alcohol - only on occasion.
DC|discontinue|DC;|261|263|SUBJECTIVE|Other than above stated the patient is doing well. He is ambulatory, tolerating p.o., pain is well-controlled, and demonstrating bowel function. He patient has no signs of infection. The patient does have a small pneumothorax on the left status post chest tube DC; however, the patient is asymptomatic and the small pneumothorax is stable. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q.24 h.
DC|discontinue|DC|160|161|PLAN|Encourage clear liquids and diet for age in the morning. Strict I&O. Weigh every 24 hours and on admission. Rocephin 500 mg IV piggyback. Unable to start IV so DC the Rocephin and the D5 and a half. Start azithromycin 100 mg p.o. the morning of _%#MMDD#%_ and 50 mg p.o. _%#MMDD#%_ through _%#MMDD#%_.
DC|direct current|DC|222|223|HOSPITAL COURSE|This showed medium lineal occlusion. Night prior to his death, the patient spontaneously went into atrial fibrillation with rapid ventricular response and the rate in the 200s. He was hemodynamically unstable and required DC cardioversion with initial return of normal sinus rhythm; however, his rhythm did deteriorate again into RVR. At this point, the family felt that the treatment most compatible with his wishes would be comfort care and no resuscitation.
DC|discontinue|DC.|248|250|HOSPITAL COURSE|She is on room air, saturation 94%. She is not dyspneic on exertion and is back to her baseline respiratory status with markedly decreased cough. She will be discharged on p.o. Levofloxacin and p.o. prednisone 40 mg p.o. q day times one week, then DC. The patient to followup with her primary in 1-2 weeks. Chest x-ray obtained on admission showed no acute infiltrate.
DC|District of Columbia|_%#CITY#%_|283|292|DISCHARGE DIAGNOSIS|The patient was treated with intravenous fluids. The patient 10 days prior to admission had started a new oral third generation cephalosporin, and right at the end of his treatment he developed the diarrheal illness. The patient also 3 days prior to admission had been in _%#CITY#%_ _%#CITY#%_ and had eaten raw shellfish in the form of oysters on the half shell. The patient's abdomen was firm but nontender. His vital signs were within normal limits although he did show evidence of intravascular volume contraction.
DC|discontinue|DC|128|129|PLAN|No focal signs. ASSESSMENT: Anorexia, nausea, weight loss and unsteadiness - all possibly secondary to medication effect. PLAN: DC above medications. Observe. PT evaluation. OT evaluation. Neurology consult. ADDENDUM: Patient had a B12 level done in the office recently which was normal as well as a folic acid level.
DC|discontinue|DC|194|195|DISCHARGE MEDICATIONS|4. Syncope. 5. Nonsustained ventricular tachycardia. 6. Urinary tract infection. 7. Orthostatic hypotension. DISCHARGE MEDICATIONS: Same as on admission except hold today's Coumadin, DC Tequin, DC Macrodantin. Decrease Paxil to 20 mg p.o. q.d. for 2-3 days and 10 mg p.o. q.d. for 2-3 days, then off, and KCl 20 mEq p.o. b.i.d. DISCHARGE PLAN: Patient to follow up with Dr. _%#NAME#%_ as per previous order.
DC|discontinue|DC|342|343|PLAN|PLAN: Will get an abdominal CT to rule out particularly any pancreatitic masses with the epigastric pain or any other stomach or gallbladder incidental problem and a GI consult for an EGD to look for esophagitis. Will go with IV pain control with Morphine which is already ordered, Zofran for nausea, IV Protonix and wait for the near future DC nonsteroidals.
DC|discontinue|DC|245|246|ASSESSMENT/PLAN|2. Wheezing with a history of asthma; will add Xopenex nebs as well as the above steroids; will hold on her prednisone while she is on IV steroids. 3. Recent history of pneumonia. She has had a 16 days of Levaquin which should be adequate, will DC Levaquin and recheck a chest x-ray 4. Hypothyroidism; will need to recheck what her doses is of Synthroid 5. Hypertension. 6. Chronic pain syndrome.
DC|direct current|DC|252|253|HOSPITAL COURSE|It was felt that because of the patient's diastolic dysfunction and refusal of anticoagulation for her atrial fibrillation in the past that it would be worthwhile to undergo cardioversion in the hope of improving her atrial kick. The patient underwent DC cardioversion on the day of discharge and an EKG check post procedure was reported to be a sinus rhythm. The patient underwent 1 shock for cardioversion at 100 joules with conversion to sinus rhythm.
DC|direct current|DC|228|229|HOSPITAL COURSE|_%#MM#%_ _%#DD#%_, 2006, was quite a significant day. She also had problems with more atrial arrhythmias with a heart rate in the 200s. It was difficult to know if it was truly atrial fibrillation or an accelerated MAT. She was DC cardioverted during the night and an amiodarone drip started at that time. She did not maintain in sinus rhythm after cardioversion, but immediately went back into the atrial arrhythmia.
DC|direct current|DC|162|163|HISTORY OF PRESENT ILLNESS|She has had multiple admissions for atrial fibrillation, the most recent one being in _%#MM#%_ 2006. She spontaneously converted at that time and did not require DC cardioversion. During that hospitalization she had an echocardiogram done which showed that her ejection fraction was preserved at 65-70% with mild concentric LV hypertrophy, normal RV size and function, no significant valvular disease although she did have some diastolic dysfunction.
DC|discontinue|DC|150|151|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Augmentin 875 mg p.o. q. 12 hours for 14 days or until DCd by pulmonary. 2. Diflucan 100 mg p.o. daily for 14 days or until DC by pulmonary. 3. Toprol XL 50 mg p.o. daily. 4. Lisinopril 10 mg p.o. daily. 5. Nicotine patches 21 mg daily for 2 weeks, then 14 mg daily for 2 weeks, then 7 mg daily for 2 weeks.
DC|District of Columbia|_%#CITY#%_,|173|183|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Headache and fever. HISTORY OF PRESENT ILLNESS: The patient is a 30-year-old white female that returned 1 week ago from a 2-month internship in _%#CITY#%_, _%#CITY#%_, by plane. In _%#CITY#%_, _%#CITY#%_, she did live in a dorm on the campus. The day after returning from her trip, she developed chills and then progressively developed a worsening headache over the course of the week as well as spiking fevers to 102 for the past 4 days.
DC|discontinue|DC|213|214|HOSPITAL COURSE|At the previous upper endoscopy, they were unable to visualize exact point of bleeding but presumably is secondary to large paraesophageal hernia. Therefore, again would indefinitely b.i.d. proton pump inhibitor, DC the Plavix indefinitely and at least hold aspirin for at least 6 weeks. 3. Hypoxia secondary to pulmonary fibrosis and paraesophageal hernia. Most of her stomach is actually up into her chest, certainly contributing to shortness of breath and hypoxia.
DC|direct current|DC|155|156|OPERATIONS/PROCEDURES PERFORMED|6. Transthoracic echocardiogram dated _%#MM#%_ _%#DD#%_, 2006, which showed normal LV function and no signs of re-accumulation of pericardial effusion. 7. DC cardioversion on _%#MM#%_ _%#DD#%_, 2006, which was successful in reverting the patient's rhythm to normal sinus rhythm. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 52-year-old male who was admitted to our service on _%#MM#%_ _%#DD#%_, 2006, directly from the electrophysiology lab.
DC|discontinue|DC|124|125|ASSESSMENT AND PLAN|1. Acute pancreatitis. Maintain patient NPO except for ice chips. Continue pain meds. Follow labs and monitor patient. Will DC HCTZ as that may be exacerbating as well. 2. Generalized anxiety disorder. Continue Paxil. 3. Gastritis. Protonix 40 mg daily.
DC|discontinue|DC|205|206|ASSESSMENT AND PLAN|Continue pain meds. Follow labs and monitor patient. Will DC HCTZ as that may be exacerbating as well. 2. Generalized anxiety disorder. Continue Paxil. 3. Gastritis. Protonix 40 mg daily. 4. Hypertension. DC HCTZ. Start patient on atenolol. Side effects were reviewed with patient. 5. Chronic loose stools. Will check a TTG and consider outpatient colonoscopy as patient is due.
DC|discontinue|DC|114|115|DISCHARGE MEDICATIONS|12. Mepron 750 mg suspension p.o. b.i.d. for thirteen days, then DC 13. Levaquin 500 mg p.o. daily for 6 days and DC 14. Zyvox 600 mg p.o. b.i.d. for six days and DC 15. Potassium chloride 20 mEq p.o. daily 16. Duonebs three cc inhalation therapy q.6h. p.r.n. shortness of breath.
DC|District of Columbia|_%#CITY#%_:|199|209|1. FEN|Given the family history of an undiagnosed metabolic disorder and the failure of _%#NAME#%_ to produce 100% normal ammonias, the above genetic analysis was sent to Dr. _%#NAME#%_'s lab in _%#CITY#%_ _%#CITY#%_: tel. (_%#TEL#%_) _%#TEL#%_. A second serum orotic acid assay was sent to the Mayo clinic's "clinical molecular laboratory" and is currently pending: tel. (_%#TEL#%_) _%#TEL#%_ _%#TEL#%_.
DC|discontinue|DC|210|211|IMPRESSION|Emergency room x-ray is a very poor quality inspiration. Most likely, no pulmonary emboli, but will rule out with a CT scan of the chest, obtain a D-dimer test. More likely a gastrointestinal etiology. We will DC nonsteroidal anti-inflammatory medications, replace with glucosamine chondroitin. He will probably need a substitute medication for pain in the meantime as it takes a while for the glucosamine chondroitin to be effective and for the primary treatment of proton pump inhibitors with reduction in avoiding the alcohol and caffeine.
DC|direct current|DC|245|246|HOSPITAL COURSE|During her current hospitalization, she was anticoagulated, and her rate was controlled by increasing her metoprolol dose. After doing a transesophageal echo and confirming that there are no clots, the patient was successfully cardioverted with DC shock on _%#MMDD2003#%_, after which her symptoms have improved and she has remained in sinus rhythm at the time of discharge.
DC|direct current|(DC)|214|217|PAST MEDICAL HISTORY|She describes having a flexible sigmoidoscopy 5-10 years ago for screening purposes, but is not aware of any findings. PAST MEDICAL HISTORY: 1. Hypertension. 2. Atrial fibrillation with prior failed direct-current (DC) cardioversion. She has no known history of heart attack or valvular heart disease.
DC|direct current|DC|196|197|OPERATIONS/PROCEDURES PERFORMED|The patient had coronary angiography on _%#MM#%_ _%#DD#%_, 2003, which revealed normal coronaries. The patient gives a history of ablation of atrial flutter in 2000 and he also gives a history of DC cardioversion of his episodes of atrial fibrillation, which have not been successful. The patient has been on chronic amiodarone. The patient was admitted to the hospital for ablation of atrial fibrillation.
DC|discontinue|DC.|168|170|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Include Advair 500/50 one puff b.i.d., prednisone 30 mg daily for two days, then 20 mg daily for two days, and then 10 mg daily for two days and DC. Singulair 10 mg daily, Lisinopril 2.5 mg daily, Protonix 40 mg daily, amiodarone 200 mg daily, Humulin R per sliding scale as needed for hyperglycemia, Lasix 60 mg b.i.d, Augmentin 875 b.i.d. times ten days, and Liquibid 600 mg b.i.d. The patient will be followed at nursing home by Dr. _%#NAME#%_.
DC|discontinue|DC|245|246|HOSPITAL COURSE|Her platelet level has improved and at discharge her hemoglobin is 13.4 with a platelet count of 129 and INR 1.28. She has had some Lovenox teaching and will follow up with Dr. _%#NAME#%_ in cardiology for further adjustment of her Coumadin and DC her Lovenox when INR is greater than 2. Follow up with Dr. _%#NAME#%_ regarding further management of her atrial fibrillation.
DC|discontinue|DC|154|155|DISCHARGE MEDICATIONS|15. Colace 200 mg daily, hold if loose stools or diarrhea. 16. Milk of Magnesia 1 ounce q.12h. p.r.n. 17. Vancomycin 800 mg intravenously every 48 hours. DC on _%#MMDD2006#%_. Mechanical soft diet. The patient will require a great deal of assistance with feedings.
DC|discontinue|DC|188|189|ASSESSMENT/PLAN|ASSESSMENT/PLAN: 1. Pulmonary embolism probably secondary to her risk factors of birth control pills smoking, plus or minus her long distance travel although this was in _%#MM#%_. We will DC her birth control pill. She will be started on heparin with the pulmonary embolism nomogram and Coumadin to be dosed by pharmacy.
DC|discontinue|DC|153|154|PLAN|Will recheck her blood pressure and forward the results to the hospital. At this time, she is really only using her Advair Discus on a daily basis. Will DC that and instead switch her over to Spiriva 18 mcg inhalation every day.
DC|discontinue|DC.|132|134|DISCHARGE MEDICATIONS|8. Lisinopril 20 mg p.o. q. day. 9. Protonix 40 mg p.o. q. day. 10. Prednisone 20 mg p.o. q. day on _%#MMDD#%_ and _%#MMDD#%_, then DC. 11. Tylenol 650 mg p.o. PR q.6 hours. 12. Oxygen 2 liters by nasal cannula. DISCHARGE FOLLOW-UP: 1. The patient is to have a CBC with diff, platelets, basic metabolic panel on _%#MMDD2006#%_ with results to Dr. _%#NAME#%_ _%#NAME#%_.
DC|District of Columbia|_%#CITY#%_.|135|145|PAST MEDICAL HISTORY|When she woke up she was awake and alert and oriented. PAST MEDICAL HISTORY: 1. Gastric banding in _%#MM#%_ of 2006 done in _%#CITY#%_ _%#CITY#%_. She has lost at least about 80 pounds since then. 2. Cholecystectomy in _%#MM2007#%_ by Dr. _%#NAME#%_ at Southdale Hospital. 3. History of syncope as a child of unclear etiology.
DC|discontinue|DC|181|182|ASSESSMENT AND PLAN|Also Benadryl. The patient states the swelling is a lot better and he is able to talk properly. Prednisone 20 mg in the morning. Give Atarax 25 mg t.i.d. p.r.n. for itching. I will DC ACE inhibitors ___________. 2. Hypertension, stable. Currently on hydrochlorothiazide. 3. History of diabetes. Continue Glucophage. Take Accu-Cheks. The patient and his wife were informed that the patient should not take ACE inhibitors any more, that he is allergic.
DC|discontinue|DC|145|146|FOLLOW UP|She is also discharged on Ringer's lactate IV at 75 cc/hr, which is a continuous infusion for 2 weeks. FOLLOW UP: 1. Instructions were given for DC IV fluids in 2 weeks and DC PICC line in 3 weeks. 2. She is asked to follow with her Southside Community Clinic for her OB visit in 1 week.
DC|direct current|DC|109|110|OPERATIONS/PROCEDURES PERFORMED|2. Hypertension. 3. Oral candidiasis. 4. Hyperlipidemia. OPERATIONS/PROCEDURES PERFORMED: 1. TEE. 2. TPE. 3. DC cardioversion. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 76-year-old female with a history of hypertension, hyperlipidemia, intermittent atrial fibrillation who presented from transitional care unit in atrial fibrillation with rapid ventricular response with a heart rate in the 160s.
DC|District of Columbia|_%#CITY#%_|278|287|HOSPITAL COURSE|She also stated that she was going to give 60 days to have "80% attendance at counseling." She also stated that if he did not comply with these guidelines, that she would change her name and move to a different state. She talked about a job that she might obtain in _%#CITY#%_, _%#CITY#%_ where she will make twice her current salary at the VA. DISCHARGE CONDITION: Patient in fair condition. General grooming is fair.
DC|discontinue|DC|125|126|DISCHARGE MEDICATIONS|9. Lactulose 15 mL p.o. b.i.d. 10. Protonix 40 mg p.o. q.d. 11. Lasix 20 mg p.o. q.d. 12. Tequin 200 mg p.o. q.d. x 10 days. DC on _%#MM#%_ 16. HOSPITAL COURSE: The patient is a _%#1914#%_ white female who presented to the Fairview Southdale Hospital emergency room on _%#MMDD2004#%_ with complaints of chest pain and shortness of breath.
DC|discontinue|DC|128|129|HOSPITAL COURSE|Her hospitalization was without complication. HOSPITAL COURSE: The patient was started on clears on postoperative day #1, after DC of nasogastric tube. The patient tolerated this well. The patient, at the time of discharge, was on a full liquid diet. The patient is also afebrile, ambulating, and tolerating p.o. and pain is well controlled on oral pain medications.
DC|District of Columbia|_%#CITY#%_.|194|204|HISTORY OF PRESENT ILLNESS|More recently she has had one to several episodes a day. She has not noted any relation to exertion. However, she was in _%#CITY#%_ _%#CITY#%_ about two weeks ago and subsequently in _%#CITY#%_ _%#CITY#%_. She complained of shortness of breath to her husband while she was pulling her suitcase and walking on an incline at the train station.
DC|discontinue|DC|177|178|MEDICATIONS|ALLERGIES: SULFA CAUSES A RASH. LUPRON IS SUSPECTED TO HAVE CAUSED A FEVER. MEDICATIONS: 1. Lisinopril 20 mg daily 2. Furosemide 20 mg daily. 3. Amoxicillin 500 mg t.i.d. to be DC on _%#MMDD2007#%_. 4. Tylenol 650 mg extended release q.i.d. p.r.n. 5. Simvastatin 20 mg daily. 6. Baby aspirin 81 mg daily. 7. Etodolac 400 mg 1 daily.
DC|discontinue|DC|236|237|PLAN|The patient desires full code at this time. Her prognosis is guarded, awaiting response to blood pressure to fluids. Will hold patient's blood pressure medications until blood pressure is adequate and will reduce patient's medications, DC the Elavil for now, holding the Ativan unless absolutely needed and just giving her Remeron and Halcion for her insomnia and depression and Neurontin for her neuropathy.
DC|discontinue|DC.|163|165|IMPRESSION/PLAN|Nitroglycerin has been started in the emergency room and she is presently pain-free and her blood pressure is well controlled, therefore we will wean the drip and DC. 2. Recurrent atrial fibrillation. It has been just one month since her last cardioversion which raises the question as to whether or not another attempt would be futile.
DC|direct current|DC|205|206|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: History of congenital heart disease. Possible ASD repair at age 5, the patient is not clear on past history. History of borderline hypertension. History of atrial flutter status post DC cardioversion in 2003 on Coumadin. History of dyslipidemia. Fatty liver per ultrasound in _%#MM#%_ of 2003. Diabetes mellitus diet controlled per patient. History of DVT but was on OCPs then.
DC|direct current|DC|204|205|PAST MEDICAL HISTORY|The patient has been taking Gemfibrozil 600 mg b.i.d. for his triglycerides. PAST MEDICAL HISTORY: Hyperlipidemia, hypertension, coronary artery disease, ischemic cardiomyopathy, atrial fibrillation with DC cardioversion in _%#MM#%_ of 2004, cholecystectomy, hernia repair. SOCIAL HISTORY: The patient denies drinking and has never smoked.
DC|direct current|DC|111|112|LABORATORY DATA|No evidence of right to left shunt on echocardiogram contrast study. Grade 2 atheroma in the descending aorta. DC cardioversion was performed on _%#MMDD2004#%_. She received three shocks, 120, 200 and 200 joules. Effective. Increased PR intervals. The procedure was tolerated well. She remained in normal sinus rhythm.
DC|discontinue|DC|149|150|DISCHARGE MEDICATIONS|2. Robitussin with codeine 5 cc q 4 hours p.r.n. 3. Liquibid 600 mg p.o. b.i.d. 4. Azithromycin 250 mg p.o. daily on _%#MMDD#%_ and _%#MMDD#%_, then DC The patient is to follow up with Dr. _%#NAME#%_ within one week. HOSPITAL COURSE: Please see dictated history and physical for patient's initial presentation.
DC|direct current|DC|185|186|ASSESSMENT/PLAN|Dr. _%#NAME#%_ had discussed the options with him such as proceeding with cardioversion after he had 4 therapeutic weekly INRs which he has now had, and he will plan on proceeding with DC cardioversion later today at Fairview Southdale Hospital. I have reviewed this procedure with him today in thorough detail including all the risks and benefits.
DC|direct current|DC|164|165|PROCEDURES PERFORMED|2. Abnormal thyroid function tests. PROCEDURES PERFORMED: 1. Transesophageal echocardiogram: The left atrial appendage was well visualized and free of thrombus. 2. DC cardioversion with 75 joules resulting in conversion from atrial fibrillation to normal sinus rhythm. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is a 23-year-old man with no significant past medical history who presents to the Emergency Department with palpitations for the past 72-hours.
DC|direct current|DC|227|228|CARDIOLOGY SUMMARY|The transesophageal echocardiogram showed that she had a mobile cord, partially flail, noted at tender tip of the anterior mitral leaflet. She also had 3+ mitral regurgitation. No clots were noted and she then proceeded with a DC cardioversion which was successful. She has maintained in a normal sinus rhythm with the assistance of amiodarone during her hospitalization.
DC|discontinue|DC|153|154||The last 2 1/2 days he tolerated the gastric feeding tube without any difficulties. Thus his enteral medications were all restarted. The plan will be to DC Zosyn on the morning of the _%#DD#%_ of _%#MM#%_ and start the patient on Augmentin 850 or 875 whatever the doses is for those pills, every 8 hours x4 days.
DC|District of Columbia|_%#CITY#%_.|210|220|SOCIAL HISTORY|Two brothers and one sister, alive and well with no history of multiple sclerosis. SOCIAL HISTORY: The patient works in sales. She has lived in various parts of the country including _%#CITY#%_ and _%#CITY#%_, _%#CITY#%_. She is divorced and has no children. She recently moved back to the _%#CITY#%_ area about one year ago. HABITS: Tobacco: One pack per day for 25 years. Alcohol: One glass of wine a week.
DC|discontinue|DC|337|338|ADMISSION DIAGNOSIS|The cultures came back from the first surgery as rare diphtheroids from the broth only as well as pan-sensitive Staphylococcus aureus. He was continued on his Timentin and vancomycin. On _%#MM#%_ _%#DD#%_, 2002, the ID staff recommended changing his regimen to Ancef 2 g IV q.8h. x 8 weeks and Rifampin 600 mg p.o. q.d. x 8 weeks and to DC the Timentin and vancomycin and to follow up with the staff in 6 to 8 weeks. These changes were made. The patient was then deemed stable for discharge on _%#MM#%_ _%#DD#%_, 2002, and discharged home.
DC|discharge|DC|299|300|ASSESSMENT AND PLAN|He has not had any other concerning markers regarding his abdominal pain except for a slightly high white blood count. We will follow this and recheck tomorrow. If the patient is doing well and Neurology does not feel further workup is needed and most likely this is from Wellbutrin, he will likely DC tomorrow.
DC|discharge|DC|208|209|SYNOPSIS OF HISTORY AND PHYSICAL|Vitals were stable. Saturations were 95% on room air. His INR was 2.14. WBC 4.3 and hemoglobin 10.4. The patient was discharged to home. Discussed with Dr. _%#NAME#%_ regarding the anticoagulation, okayed to DC home on Coumadin. Also, on Lovenox 1.5 mg/kg once a day up to three days. DISCHARGE INSTRUCTIONS: Activity as tolerated. Continue home medications. Coumadin 2.5 mg once daily and Lovenox 1.5 mg/kg subcu daily for three days.
DC|direct current|DC|240|241|HOSPITAL COURSE|It was determined that in fact the patient had been in A flutter with 1:1 conduction, which most certainly caused his syncopal episodes and a cardiomyopathy. It was recommended that the patient undergo a transesophageal echocardiogram with DC cardioversion. This was accomplished on _%#MMDD2005#%_ with resolution and achieving normal sinus rhythm. Social Work continued to work with the patient on disposition and were able to find placement for the patient on _%#MMDD2005#%_.
DC|direct current|DC|182|183|ASSESSMENT/PLAN|2. Hypertension, currently well controlled. We will continue her chronic meds, monitor blood pressures and adjust medications as needed. 3. Uncontrolled diabetes mellitus 2. We will DC Metformin with upcoming surgery and will place her on Accu-Cheks and sliding scale coverage for now. 4. Hyperlipidemia. We will continue patient's Lipitor use. DISPOSITION: We will obtain PT, OT, and social work consults.
DC|District of Columbia|_%#CITY#%_|162|171|HISTORY OF PRESENT ILLNESS|If he did, it must have been a very small branch vessel, as it did not affect his electrocardiogram or echocardiogram. Discharge follow-up will be in _%#CITY#%_, _%#CITY#%_ with his family doctor. He will be leaving for _%#CITY#%_, _%#CITY#%_ pretty soon. DISCHARGE MEDICATIONS: 1. Toprol XL 25 mg p.o. once a day. 2. Aspirin 325 mg p.o. once a day.
DC|discharge|DC|127|128|ASSESSMENT  AND PLAN|She is feeling well, and we will try to change to her p.o. chronic Dilaudid and see if she is able to get off of the PCA. Will DC home when tolerating orals and her pain is controlled with oral medication and hopefully later today but possibly not until tomorrow.
DC|discontinue|DC|174|175|IMPRESSION|Will guaiac her stools, will advance her diet, will follow her CBC and electrolytes. Will check a sed. rate. Will put her empirically on Prevacid. Will use Tylenol for pain. DC the Toradol. 2. Asthma, currently stable. Continue Advair.
DC|direct current|DC|240|241|HOSPITAL COURSE|HOSPITAL COURSE: The patient was monitored on telemetry. In the morning, the patient had a transesophageal echo that revealed no intracardiac thrombus, but there was moderate mitral regurgitation, normal LV function, then he had successful DC cardioversion to normal sinus rhythm. The patient received teaching regarding enoxaparin and was discharged to home. DISCHARGE MEDICATIONS: 1. Lisinopril 2.5 mg p.o. q.d. 2. Warfarin 5 mg p.o. q.d.
DC|District of Columbia|_%#CITY#%_.|239|249|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 73-year-old male resident of _%#CITY#%_, _%#CITY#%_ with a history of Meniere's disease. He is admitted with a history of the onset of vertigo after getting off the plane after arriving from _%#CITY#%_, _%#CITY#%_. He indicates that the flight was unusually high at 39,000 feet with a rapid descent. He continued to have some difficulty with exiting the airport.
DC|discontinue|DC|132|133|DISCHARGE MEDICATIONS|7. Aspirin 81 mg p.o. daily. 8. Nexium 40 mg p.o. daily. 9. Zofran 4 mg p.o. t.i.d. given one hour prior to giving the valacyclovir DC when off valacyclovir. DISCHARGE DISPOSITION: _%#NAME#%_ _%#NAME#%_ will require nursing home placement, because of his acute condition and it appears that his wife is ready for him to be placed in a nursing facility on a permanent basis.
DC|discontinue|DC|122|123|PLAN|4. CT chest, abdomen and pelvis tomorrow. 5. Neuro checks. 6. Bed rest tonight with ambulation only with nurse's help. 7. DC Coumadin. 8. Check liver tests and sugar in the morning.
DC|discharge|DC|110|111|DISCHARGE DIAGNOSES|ANTICIPATED DISCHARGE DATE: _%#MMDD2006#%_. This discharge summary will be reviewed tomorrow. _%#MMDD2006#%_: DC summary reviewed, no changed except f/u appt listed with PCC below. Pt ready for dc. See my progress note in chart for further data.
DC|discontinue|DC.|112|114|MEDICATIONS AT THE TIME OF DISCHARGE|3. Decadron taper 4 mg p.o. q.12h. on _%#MMDD2006#%_ and x2 days. 4. Decadron 2 mg p.o. q.12h. x4 days and then DC. 5. Zantac 150 mg p.o. b.i.d. 6. Dilantin 300 mg p.o. q. day. FOLLOWUP CARE: 1. Follow up with Dr. _%#NAME#%_ in 2 weeks' time for re-evaluation in clinic.
DC|discontinue|DC|126|127|DISCHARGE MEDICATIONS|14. Vicodin 5/500 1-2 tabs q.6h. p.r.n., not to exceed 4 grams in 24 hours 15. ertapenem 100 mg p.o. q.24h. for 4 doses, then DC 16. K-Dur 20 mEq p.o. daily. 17. Restoril 7.5 mg p.o. in the evening p.r.n. 18. Nystatin swish and swallow 5 cc p.o. swish and swallow q.i.d. for two weeks.
DC|discontinue|DC|144|145|DISCHARGE MEDICATIONS|2. Valium 4 mg p.o. t.i.d., in two days reduce to 4 mg p.o. b.i.d. and then in 1 more week reduce it to 2 mg p.o. b.i.d. and in one week he can DC that. 3 Colace 100 mg p.o. daily for constipation 4. Hydrocortisone topical cream 0.5% to his back for a contact dermatitis secondary to sheets
DC|direct current|DC|156|157|SECONDARY DIAGNOSIS|4. Pulmonary edema. 5. Coronary artery disease. 6. Chronic lymphocytic leukemia. 7. Hypertension. 8. Hypoparathyroidism. 9. Atrial fibrillation status post DC cardioversion. 10. Steroid-induced hyperglycemia, resolved. 11.HyperLipidemia DISCHARGE MEDICATIONS: 1. Vytorin 10/40 one tablet daily.
DC|discontinue|DC|185|186|PLAN|Does not require NG tube for decompression at this time because she is not nauseated. I will also start her on Senokot-S 2 tablets p.o. q.a.m. and Dulcolax 10 mg PR daily p.r.n. I will DC morphine and start her on Tylenol 1000 mg p.o. q.8h. p.r.n. Her recurrent ileus or small bowel obstruction is related to her previous history of gastric bypass surgery.
DC|discontinue|DC|218|219|HISTORY|I have asked that she follow-up with Dr. _%#NAME#%_ in 1-2 weeks to re-check her basic metabolic profile. She already has an appointment to Dr. _%#NAME#%_ in _%#MM#%_. As stated above, I have also recommended that she DC her Piroxicam. Thank you for allowing me to participate in her care.
DC|District of Columbia|_%#CITY#%_|237|246|SOCIAL HISTORY|Neither she nor her sister have any children. SOCIAL HISTORY: She lives alone in an apartment and has for 25 years. She is retired from the Federal Government where she worked as a stenographer and administrative assistant in _%#CITY#%_ _%#CITY#%_ for 36 years. She returned to the _%#CITY#%_ _%#CITY#%_ to help her elderly parents and has remained. She is not on Medicare. She was taking care of all of her own activities of daily living, including driving up until the time that she was hospitalized.
DC|direct current|DC|67|68|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Atrial fibrillation status post successful DC cardioversion after Sotalol loading 2. Permanent pacemaker with complete AV block 3. Coronary artery disease 4. Hypertension 5. Hyperlipidemia 6. Diabetes mellitus DISMISSAL MEDICATIONS: 1. Sotalol 80 mg p.o. b.i.d.
DC|discontinue|DC.|154|156|DISCHARGE MEDICATIONS|12. Prednisone 40 mg p.o. daily for 2 days, then 30 mg p.o. daily for 2 days, then 20 mg p.o. daily for 2 days, then 10 mg p.o. daily for 2 days and then DC. 13. Benadryl 25 to 50 mg p.o. q.6h p.r.n. rash. 14. Macrodantin, Mirapex, simvastatin and lisinopril is being held. Follow with primary care physician, Dr. _%#NAME#%_, in 2-3 days for followup.
DC|District of Columbia|_%#CITY#%_,|65|75|PRIMARY CARE PHYSICIAN|PRIMARY CARE PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_ in _%#CITY#%_, _%#CITY#%_, address is: _%#STREET#%_ _%#STREET#%_ _%#STREET#%_. CHIEF COMPLAINT: Nausea and vomiting. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 79-year-old female patient who presents to the ER today not feeling well and suffering from nausea and vomiting.
DC|discontinue|DC|195|196|ASSESSMENT|2. Diabetes mellitus. Fingerstick blood sugar twice a day. Check hemoglobin A1c, continue Glynase. 3. Urinary tract infection. Ciprofloxacin times three days. 4. Hypertension, poorly controlled. DC Lisinopril and Dyazide. Start Prinzide 20/12.5 b.i.d.
DC|discontinue|DC|108|109|MEDICATIONS|6. Atenolol 25 mg daily. 7. Prevacid 30 mg daily. 8. Lasix was at 40 mg daily. decreased to 20 mg daily and DC as of _%#MMDD#%_ 9. Ferrous sulfate 325 mg daily. 10. Colace 100 mg b.i.d. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 99.9, heart rate 79, respiratory rate 20, blood pressure 114/59, sats 97% on room air.
DC|direct current|DC|113|114|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Syncope secondary to atrial fibrillation with rapid ventricular response. a. Status post DC cardioversion _%#MMDD2005#%_ with 120 joules. b. Normal sinus rhythm was maintained throughout the remainder of her hospitalization and through the time of discharge.
DC|direct current|DC|176|177|ASSESSMENT AND PLAN|His heart rate is currently not excessively fast and has been primarily in the low 100s but sometimes up to the 140s. He discussed at length with the emergency room physicians DC cardioversion. He has elected to stay in the hospital for rate control treatment. He is currently asymptomatic other than feeling palpitations. His TSH and echocardiogram have been normal in the past year.
DC|District of Columbia|_%#CITY#%_,|255|265|FOLLOW-UP APPOINTMENTS AND REFERRALS|1. Two more days of methylprednisolone treatment to be set up in _%#CITY#%_ Wisconsin or here at the University for the next 2 days. 2. Multiple scleroses specialist, first available within 1 month, to be made by the patient as he is moving to _%#CITY#%_ _%#CITY#%_, will attempt to provide referral.
DC|discontinue|DC.|183|185|DISCHARGE MEDICATIONS|6. Percocet 5/325 mg 1-2 tablets every 4-6 hours as needed for pain. 7. Protonix 40 mg p.o. daily. 8. Lovenox 70 mg subcu b.i.d. until the patient is therapeutic on Coumadin and then DC.
DC|direct current|DC|299|300|BRIEF INITIAL HISTORY OF PRESENTATION|DISCHARGE DIAGNOSIS: Paroxysmal atrial fibrillation. PROCEDURES PERFORMED: Continuous telemetry monitoring. BRIEF INITIAL HISTORY OF PRESENTATION: Mr. _%#NAME#%_ _%#NAME#%_ is a 55-year-old male patient with significant past medical history of paroxysmal atrial fibrillation (status post successful DC cardioversion in _%#MM#%_ 2007 and conversion with IV diltiazem in _%#MM2007#%_), hypertension, dyslipidemia, obstructive sleep apnea on CPAP, who works at the University as a respiratory therapist, presented on _%#MMDD2007#%_ with new onset palpitations that were identical to his previous episodes of atrial fibrillation with rapid ventricular response.
DC|direct current|DC|364|365|COURSE OF HOSPITALIZATION|The patient was relatively asymptomatic. The patient was admitted to the Cardiology Service for further evaluation of atrial flutter and further management. The patient was started on a diltiazem drip to slow down the heart rate with good results and bringing down the heart rate to 100-110, but the patient still remained in atrial flutter overnight and next day DC cardioversion was considered after the patient was started on amiodarone with assisting atrial flutter. A TEE and DC cardioversion was done, the patient initially reverted to sinus rhythm, but very soon converted back to atrial flutter/fibrillation.
DC|District of Columbia|_%#CITY#%_|307|316|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: This is a 51-year-old white male with a history of type 2 diabetes, retinopathy, hypertension and "asbestos," who presents with approximately 1 week of increasing work of breathing. He states that about 1 week ago while he was in _%#CITY#%_ _%#CITY#%_ for a business trip, he began to have shortness of breath worse with exertion. He had some sinus congestion and mild cough and thought that he just had an upper respiratory infection, but his dyspnea on exertion began to worsen over the last several days.
DC|discontinue|DC|202|203|ASSESSMENT/PLAN|9. Hypertension. Will continue patient's home medications, which include enalapril as well as atenolol and adjust medications as needed for now because of the concern for ongoing cardiac ischemia. Will DC the nitro patch that he has been on and place him on a nitro drip for closer titration.
DC|direct current|DC|125|126|DISCHARGE DIAGNOSES|ADMISSION DIAGNOSIS: Atrial fibrillation with rapid ventricular rate DISCHARGE DIAGNOSES: 1. Atrial fibrillation status post DC cardioversion 2. Polymorphic ventricular tachycardia induced by Sotalol REASON FOR ADMISSION: _%#NAME#%_ _%#NAME#%_ is a 76-year-old white female who was admitted for atrial fibrillation with rapid ventricular rate.
DC|discontinue|DC|165|166|HOSPITAL  COURSE|The patient does have problems with BPH and slow urine stream. He had a Foley placed and a traumatic Foley with some hematuria. At this point we are going to try to DC his Foley and recommendations per urology is that the patient be on Uroxatral and Proscar. 4. Chronic renal failure. The patient's creatinine is slightly elevated after the urinary tension problem.
DC|discontinue|DC|150|151|PHYSICAL EXAMINATION|Abdominal examination shows nontender, no distention, increased bowel sounds. No vascular bruit. He has no peripheral edema. The EKG monitoring after DC cardioversion showed sinus rhythm. Only 2 brief episodes, last one of 2 seconds of brief atrial fibrillation. The patient otherwise is stable, to be discharged home.
DC|discontinue|DC|174|175|HISTORY OF PRESENT ILLNESS|He noted marked improvement following the initiation of these antibiotics and aggressive trach cares. As a side effects, he developed mild diarrhea which should resolve post DC of IV imipenem. He is on Coumadin for his history of aortic valve replacement and secondary to disruption of normal colonic flora and vitamin K carboxylation and metabolism within the gut.
DC|discharge|DC|145|146|H&P ON ADMISSION|Mom felt that the patient's hands looked a little grayish-blue in color. The patient also had complaint of abdominal and leg pain since hospital DC nine days prior. Mom stated that it often keeps him awake at night and is not resolved by Tylenol. The patient also had one episode of diarrhea the day of admission.
DC|direct current|DC|216|217|HOSPITAL COURSE|The etiology for his atrial fibrillation might be related to the infection versus the stress from his chronic pain syndrome. At this point, there is no need for antiarrhythmic agent. He will be back in six weeks for DC cardioversion if he is still in atrial fibrillation. In the meantime, he should continue his anticoagulation with Coumadin.
DC|discharge|DC|138|139|LABORATORY|Subsequently, a decision was made to change antibiotics to Nafcillin. Patient had remained afebrile for 48 hours and decision was made to DC patient to home. Her general exam was within normal limits and redness around port site was noted to be decreased. Decision was made to leave Port-A-Cath in place as patient has responded to treatment.
DC|discontinue|DC|204|205|ASSESSMENT AND PLAN|Consider adhesions secondary to colon resection. General surgery consultation. NG tube to low intermittent suction if nausea persists. 2. Urinary tract infection, recurrent, complicated by chronic Foley. DC Foley. Begin Tequin IV. Urine culture pending. 3. Spastic quadriparesis. Well controlled with baclofen. Baclofen on hold as the patient is NPO. Begin Ativan IV p.r.n. spasm until able to take p.o.
DC|discharge|DC|182|183|DISCHARGE INSTRUCTIONS|ABDOMEN: Soft and nontender. LABORATORY DATA: Hemoglobin 12.4, hematocrit 36, WBC 3.6, platelets 135, INR 1.05, PTT 95. Blood sugar reading also was seen. DISCHARGE INSTRUCTIONS: 1. DC the patient home. 2. Diet: 1,800 ADA diet. 3. Activity as tolerated. 4. Follow up with neurologist, as they recommended, maybe within 3 weeks or so.
DC|discharge|DC|177|178|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Zantac 75 mg every day for itching. 2. Sarna lotion apply to skin twice daily p.r.n. itching. 3. Zyrtec 10 mg p.o. every day(Insurance substitution on DC to Claritan 10mg po daily prn). 4. Sodium chloride 0.65% 2 sprays every hour p.r.n. nasal dryness. 5. Lasix 20 mg by mouth every day 6. Vitamin B12 1000 mcg every morning p.o.
DC|discontinue|DC|137|138|ASSESSMENT/PLAN|3. Weakness after the patient's angina is excluded his continued weakness can be evaluated as an outpatient. 4. Tobacco abuse. He should DC smoking. The patient will receive smoking cessation therapy and consultation.
DC|direct current|DC|298|299|ASSESSMENT AND RECOMMENDATIONS|I will reschedule her for possible repeat catheter ablation of atrial fibrillation after the patient is fully alert. I will have further discussion with the patient tomorrow. She will continue Coumadin for the time being and I may put her flecainide on hold at least for the time being, before the DC cardioversion.
DC|direct current|DC|157|158|PROBLEM #1|She is hemodynamically stable at this time. PROBLEM #1: Cardiovascular. Paroxysmal atrial fibrillation with recent RVR. She is now normal sinus rhythm after DC cardioversion twice. Continue amiodarone, diltiazem and Coumadin. PROBLEM #2: Cardiovascular. No known coronary artery disease but has hypertension.
DC|District of Columbia|_%#CITY#%_.|134|144|HISTORY OF PRESENT ILLNESS|The patient is single. He lives alone. He is unemployed. He had lived many years in California. He was also been living in _%#CITY#%_ _%#CITY#%_. He came to the _%#CITY#%_ _%#CITY#%_ to go to Hazelden over 10 years ago. Alcohol and heroin were his drugs of choice then. He went through treatment and was sober for a period but then relapsed when he met an individual who was using heroin.
DC|discharge|DC|190|191|PLAN|1. Facial fractures as above. That is fractures of the zygomatic floor and orbital floor. 2. Right wrist fracture and right rib fracture. PLAN: Analgesics. PT to see. Home health to follow. DC to home. Orthopedic follow-up. Above plan is pending consultation from the Oral and Maxillofacial Department at the University of Minnesota.
DC|discontinue|DC|138|139|PROBLEMS|3. Chronic atrial fibrillation. The patient remained in atrial fibrillation but her heart rate is well-controlled on diltiazem drip. Will DC diltiazem drip and restart the patient's metoprolol and diltiazem oral outpatient dose for heart rate control. The patient is on aspirin for anticoagulation. She is unable to take Coumadin because of increased risk of falls.
DC|discontinue|DC|199|200|ASSESSMENT/PLAN|Will elevate lower extremities, place Ted stockings, will check urine for protein and if indeed there is protein present on urine will perform 24 hour urine to rule out nephrotic syndrome. Will also DC Lasix currently as this may be contributing to his prerenal dehydration status.
DC|direct current|DC|132|133|HISTORY OF PRESENT ILLNESS|The patient was admitted recently in the last 2 months, at least twice, for atrial fibrillation with rapid ventricular rate and had DC cardioversions on _%#MM#%_ _%#DD#%_, 2005, and _%#MM#%_ _%#DD#%_, 2005. There was also associated chest pain, and he had his last stress test 2 years ago.
DC|direct current|DC|136|137|HOSPITAL COURSE|The patient had had previously poor p.o. intake due to upset stomach and some nausea. The patient was sent downstairs for an additional DC cardioversion with his internal defibrillator which was ultimately unsuccessful. He was discharged on 200 mg b.i.d. of amiodarone to follow up with Dr. _%#NAME#%_ in clinic as he is symptomatically improved and currently rate controlled with the rate in the 70s-80s.
DC|direct current|DC|207|208|DISCHARGE DIAGNOSES|2. Ischemic cardiomyopathy causing #1. There is significant akinetic and hypokinetic regions of the left ventricle. 3. History of mitral valve repair. 4. Atrial fibrillation - converted to sinus rhythm with DC cardioversion this admission. It was explained to the family that it is possible for the atrial fibrillation to recur spontaneously.
DC|District of Columbia|_%#CITY#%_.|120|130|HOSPITAL COURSE|The patient was also very eager to get discharged as he has a flight to catch today for attending wedding in _%#CITY#%_ _%#CITY#%_. In view of this, we discharged the patient home so that he can attend the wedding party. The patient will be followed by his primary MD, Dr. _%#NAME#%_, after he returns from the wedding party.
DC|direct current|DC|187|188|IMPRESSION AND PLAN|IMPRESSION AND PLAN: A 67-year-old gentleman with a history of persistent atrial fibrillation and rapid ventricular response despite combination therapy with failed anti-arrhythmic after DC cardioversion and a recent diagnosis of lung cancer. He is status post AV node ablation and pacemaker implant that was successful 1. Post ablation instructions are reviewed in detail with the patient.
DC|discontinue|DC|168|169|ADMISSION DIAGNOSIS|Her dressings were dry and intact. She is being discharged to home on _%#MM#%_ _%#DD#%_, 2003. Plan is for her activity to be ad lib and be on a regular diet. She will DC her dressings in 3 days. DISCHARGE MEDICATIONS: She is being discharged with Vicodin 1-2 tabs p.o. q.4-6h. p.r.n. for pain, total of 80 tabs, and Vistaril 1-2 tabs p.o. q.4-6h., as well as Colace 100 mg p.o. b.i.d. FOLLOW UP: The patient will follow up with Dr. _%#NAME#%_ in his clinic in 4-6 weeks.
DC|discontinue|DC|145|146|HOSPITAL COURSE|The patient had a soft abdomen and no abdominal pain. Therefore, I thought this was probably due to gastric irritation from her aspirin and will DC the aspirin and start her on Plavix. Her last hemoglobin on _%#MMDD#%_ was 13.1. Will have a hemoglobin followed up with her primary care physician in 1-2 weeks.
DC|discontinue|DC|256|257|IMPRESSION|Get physical therapy and occupational therapy involved tomorrow. She will ultimately need nursing home placement and I did discuss this with her. 2. Anorexia due to pain. Check electrolytes, BUN and creatinine, and hold her Lasix for now. 3. Hypertension. DC Cardura, continue Lisinopril. 4. Code status discussed with the patient. She would like to be DNR/DNI. 5. Dysphagia. Obtain a speech evaluation.
DC|discontinue|DC|124|125|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Vitamin B12 1000 mg p.o. q. day. 2. Diltiazem ER 120 mg p.o. q. day. 3. Lovenox 80 mg subq q.12h. DC when INR greater than 2. 4. Lasix 40 mg p.o. q. day. 5. Haldol 0.5-1 mg p.o. q.6h. p.r.n. 6. Ativan 0.5-1 mg p.o. q.6h. p.r.n. 7. Lopressor 50 mg p.o. b.i.d.
DC|discharge|DC|148|149|DISCHARGE  PLANS|DISCHARGE PLANS: 1. Discharged to TCU on _%#MMDD2007#%_, follow up with Dr. _%#NAME#%_ at one month postop 2. continue ambulation for therapy, then DC from TCU when independent with ADLs and independent with ambulation. 3. Wound care should include just daily dressing changes with 4 x 4s and tape.
DC|discharge|DC|381|382|CONSULTATIONS.|1. Neurosurgery assessment. A 33-year-old male with ventriculomegaly and a stable Neuro exam. Plan, recommended plan was a brain MRI and to follow up with Dr. _%#NAME#%_ in Neurosurgery Clinic at next available appointment. Phone number is _%#TEL#%_. 2. Psychiatry consult _%#MMDD2007#%_. Impression: A. Alcohol dependence. B. Depression, not otherwise specified. Recommendations: DC to MICD when medically stable. ADMISSION HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ isa 33-year-old male brought by the police because he was found at bus stop at around 6:00 p.m. unable to walk.
DC|direct current|DC|318|319|IMPRESSION|He has organic heart disease and is status post myocardial infarction and cardiogenic shock treated at another hospital and then transferred to the University of Minnesota Medical Center, Fairview. 2. He is status post placement of right ventricular assist device on _%#MMDD#%_ with subsequent removal. 3. Status post DC cardioversion _%#MMDD2007#%_. 4. History of Hodgkin lymphoma greater than 30 years ago. He is status post chemo, radiation therapy and has also had a splenectomy.
DC|discontinue|DC|209|210|RECOMMENDATIONS|4. Metoprolol plus or minus lisinopril. 5. Check lipid profile and thyroid function tests. 6. Echo to check left ventricular function. 7. Strongly consider cardiac catheterization and coronary angiography. 8. DC cigarette smoking.
DC|discontinue|DC|117|118|DISCHARGE MEDICATIONS|5. Coumadin 2 mg p.o. q. day 6. Darvocet-N 100 1 p.o. p.r.n. 7. Pepto-Bismol 1-2 tabs p.o. q.i.d. times 5 days, then DC 8. Flagyl 250 mg p.o. q.i.d. times 6 days, then DC.
DC|direct current|DC|347|348|ASSESSMENT AND PLAN|4. Left shoulder x-ray. Possible fracture involving the lesser tuberosity of the left humerus. CT scan of the shoulder is recommended. ASSESSMENT AND PLAN: 78-year-old morbidly obese white male with past medical history significant for ischemic cardiomyopathy, congestive heart failure, peripheral vascular disease, A fib, and A flutter requiring DC cardioversion, diabetes mellitus, hyperlipidemia, and numerous other medical conditions had an episode of fall while sitting on his walker. One of the wheels came off the walker, resulting in the patient's fall.
DC|discontinue|DC|167|168|HOSPITAL  COURSE|8. Hematuria that is chronic. The patient had some hematuria from his Foley catheter which is likely multifactorial due to his low platelets and elevated INR. We will DC his Foley. 9. Deconditioning. The patient has not walked much during the course of his hospitalization despite seeing physical therapy.
DC|discontinue|DC|129|130|IMPRESSION|Will continue IV Heparin protocol. Will begin Coumadin on _%#MMDD#%_. Will watch her in the ICU. Will keep her on bed rest. Will DC her Depo-Provera, DC her cigarettes, consider genetic work-up, if there are other family members with clots. ADDENDUM: The patient stated that she had an ultrasound that was done at an outside clinic prior to coming to the Emergency Department that confirmed the right deep venous thrombosis.
DC|direct current|DC|248|249|IMPRESSION/ PLAN|The patient has no history of swallowing difficulty. He is aware of risks of anesthesia and need for IV sedation and also risk of esophageal perforation. The patient is willing to proceed. If no thrombus is found, we did discuss the possibility of DC cardioversion. Again, risks, benefits, alternatives and outcomes of this procedure were discussed and he is aware of risk of risking burns, arrhythmia or changes in heart rhythm or difficulties with anesthesia.
DC|discontinue|DC|241|242|IMPRESSION|Consider HIDA scan. If the ultrasound is not definitive, await results of blood cultures, urinalysis and urine culture. Will empirically treat the patient with Levaquin and Flagyl pending his workup. Will keep on sliding scale insulin. Will DC his metformin and continue his Lantus. Will keep him on continuous Lantus at a reduced dose. Will continue him on clear liquids until the gallbladder issue is resolved.
DC|direct current|DC|178|179|FOLLOWUP|The patient had originally presented in _%#MM#%_ with profound bradycardia and underwent permanent pacemaker implantation. She was noted to have atrial flutter at that time, but DC cardioversion was unsuccessful. The patient had had her pacemaker implanted. She did have IV hydration secondary to her kidney dysfunction that on admission had a creatinine of 3.39. This improved to 1.75 on discharge.
DC|discontinue|DC|178|179|HOSPITAL COURSE|Pulmonary recommended that he have his Trach down sized to a # 6 Shiley on _%#MMDD2006#%_ and they recommended in about a week to 10 days, decreasing again to #4 Shiley and then DC completely. Pulmonary said this could be handled as an outpatient at _%#COUNTY#%_ _%#COUNTY#%_ Medical Center. At the time of this dictation, the patient will need to follow up with _%#COUNTY#%_ _%#COUNTY#%_ Medical Center later this week for the change to the #4 Shiley and they can follow and decide when to discontinue he trach completely.
DC|discontinue|DC|152|153|PLAN|The patient has been improving since admission on IV antibiotics and her white blood cell count is improving as well. 2. Hormonal migraines. PLAN: Will DC the PC pump and start oral Percocet. She will continue on a regular diet and I feel that we need to repeat the hemoglobin at 12:00 today to assure that the hemoglobin is stable.
DC|direct current|DC|79|80|DISCHARGE MEDICATIONS|The patient was not loaded, rather will have low-dose amiodarone. I anticipate DC cardioversion in approximately one month. He will have Cardiology visit in three to four weeks and DC cardioversion arranged thereafter.
DC|discontinue|DC|224|225|PLAN|3. Elevated creatinine possibly secondary to lisinopril. The patient states he has not been told in the past he had an elevated creatinine. 4. History of GERD. 5. Hypertension. PLAN: 1. Continue the Tequin and Zithromax. 2. DC lisinopril and increase atenolol if systolic blood pressures increase. 3. Recheck creatinine and BUN in the morning. 4. Discharge planner to see.
DC|direct current|DC|121|122|IMPRESSION|We can stop his Lanoxin once he gets back into sinus rhythm. We can decrease his amiodarone to 200 mg a day. IMPRESSION: DC cardioversion planned, hopefully restoring sinus rhythm. Decrease amiodarone to 200 mg a day. Stop Lanoxin, continue Warfarin, Altace and Coreg.
DC|discontinue|DC|123|124|ASSESSMENT/PLAN|She will also continue on Prevacid. Because of possible costochondriasis, I will start her on Vioxx 25 mg p.o. q.d. I will DC her Morphine. We will replace her potassium as needed. The patient may be discharged home after her third set of troponin is negative.
DC|discontinue|DC|306|307|IMPRESSION|If there are cells seen, the patient would be started on vancomycin Dr. _%#NAME#%_ was contacted from Infectious Disease and he recommends vancomycin 1 gm IV q 12 and Fortaz 2 gm IV q 8 hours. I will also be obtaining some laboratories tonight - CBC, differential, CRP, sed rate, chem-7. Will go ahead and DC the old IV and start a new one at another site. If the patient has septic meningitis antibiotics will be necessary.
DC|discontinue|DC|120|121|ASSESSMENT|9. Hypertension, continue lisinopril. Perimeters written. 10. Diarrhea, none in the last week per nursing home. We will DC Questran and see how his diarrhea does off antibiotics. 11. Chronic obstructive pulmonary disease. Plan: Continue nebs. 12. Malnutrition.
DC|direct current|DC|287|288|DISCHARGE MANAGEMENT PLAN|7. He will continue with his current dose of Coumadin 3 mg p.o. q.d. for the next three days, followed by an INR check with his primary care physician on _%#MMDD2003#%_. 8. He will continue on Coumadin for the next four weeks, and then follow up with Minnesota Heart Clinic for elective DC cardioversion in four to six weeks, if his INR remains therapeutic, and if he remains in atrial fibrillation. MEDICATIONS AT DISCHARGE: 1. Atenolol 50 mg p.o. q.d.
DC|direct current|DC|356|357|FOLLOW UP|The patient will followup with the Fairview Northeast Clinic for INR check, the nex one being _%#MM#%_ _%#DD#%_, 2004, and will followup with her primary care physician, Dr. _%#NAME#%_ _%#NAME#%_ at the Fairview Northeast Clinic in 1 week. The patient will be scheduled to followup with Dr. _%#NAME#%_ _%#NAME#%_ in 1 month at which time consideration for DC cardioversion will take place. The patient, for rate monitoring, will present to the EKG lab on Friday, _%#MM#%_ _%#DD#%_, 2004, for Holter monitor placement.
DC|direct current|DC|155|156|HOSPITAL COURSE|The patient had a transesophageal echocardiogram performed the next day to rule out any intracardiac thrombus, which was negative study. The patient had a DC cardioversion performed in the Cath lab for his atrial flutter. The patient converted into normal sinus rhythm and during the course of his hospitalization remained in sinus rhythm with brief runs of atrial fibrillation.
DC|direct current|DC|249|250|HOSPITAL COURSE|9. Cosopt eye drops twice daily to right eye. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a very pleasant 68-year-old gentleman coming in for A-flutter ablation. Please see above for procedural information. The A-flutter ablation was unsuccessful but DC cardioversion did achieve AV sequential pacing in sinus rhythm. He has maintained sinus rhythm over his hospital course. On morning of discharge the patient was feeling well, alert and in no acute distress.
DC|direct current|DC|268|269|IMPRESSION/PLAN|WBCs 6.5, platelets 251,000, hemoglobin 13.6 and hematocrit 41.7. EKG revealed normal sinus rhythm with rate of 68 with QT stable at 440. IMPRESSION/PLAN: This is a 68-year-old gentleman who is status post attempted ablation of atypical flutter that was unsuccessful. DC cardioversion did successfully achieve AV sequential pacing and normal sinus rhythm. 1. Medications will be continued except increase Sotalol to 160 mg p.o. b.i.d. QT was checked at morning EKG and is stable.
DC|direct current|DC|187|188|PAST MEDICAL HISTORY|Adenosine thallium _%#MM1999#%_ showed no evidence of ischemia. Ejection fraction at that time 83%. 2. History of paroxysmal atrial fibrillation since at least 1993. Status post multiple DC cardioversions, most recently maintained in sinus rhythm on Rythmol 225 t.i.d. She is off Coumadin since one week before admission. 3. Hypertension. 4. History of breast cancer. Status post left modified radical mastectomy.
DC|discontinue|DC|217|218|PLAN|8. Recent coronary artery bypass, mitral valve replacement, tricuspid valve replacement and pacemaker insertion. 9. Glaucoma. 10. Recent C. Difficile. PLAN: Continue current medication with the exception of DC Vioxx, DC Reglan. No contraindications to planned procedure. She will follow up in the office. I will be in contact with her daughter, _%#NAME#%_ at _%#TEL#%_.
DC|discontinue|DC.|129|131|MEDICATIONS AT DISCHARGE|4. Sodium bicarb 650 mg p.o. b.i.d. 5. Os-Cal with vitamin D 500 mg p.o. t.i.d. 6. Mycelex 1 troche p.o. q.i.d. x 6 months, then DC. 7. Colace 100 mg p.o. b.i.d. p.r.n. constipation. 8. Enteric coated aspirin 325 mg p.o. q.d. 9. Percocet 1-2 tabs p.o. q. 4-6h p.r.n. pain. 10. Zofran 4 mg sublingual q. 4-6h p.r.n. nausea.
DC|direct current|DC|236|237|HISTORY OF PRESENT ILLNESS|Additionally, a CT scan of his chest showed evidence of this mass, and a subcarinal lymphadenopathy, as well as pedunculated mass near his carina. Additionally, his hospital course was complicated by atrial fibrillation, which required DC cardioversion. The patient was transferred to Fairview-University Medical Center for further evaluation of this mass and possible ways of reduction. MEDICATIONS: His medications were reviewed by me. Please see his chart.
DC|discontinue|DC|134|135|ASSESSMENT/PLAN|He will be placed on Coronary Intensive Care Unit protocol, be ruled out for MI by enzymes. Will keep on the nitroglycerin drip. Will DC the heparin, given his recent new history of the coffee ground emesis and all the retching that he had so as not to cause acute GI bleed.
DC|discontinue|DC|149|150|IMPRESSION|Will check an ECG in the morning. Will get liver function tests and a lipase if the patient rules out. Will check a stress echo in the morning. Will DC cigarettes. Use nicotine patch. Continue aspirin. Check a urinalysis and a TSH. Further orders based on the results of the patient's pending laboratory tests.
DC|discontinue|DC|253|254|DISCHARGE MEDICATIONS|11. Lasix 20 mg p.o. b.i.d., basic metabolic panel should be obtained on _%#MMDD2004#%_ to follow up on her renal status while taking Lasix. If the patient does not show any clinical signs of congestive heart failure, it could be strongly considered to DC this medication at that time. The patient's creatinine on the day prior to discharge was 0.93. Her BUN was 15.
DC|discontinue|DC|126|127|ASSESSMENT/PLAN|I will also empirically give him some Protonix and Maalox. I will have him ambulate in the halls and will observe him. I will DC his nitroglycerin drip. I suspect he will be OK to continue his flight tomorrow to Florida. At this time I will not reevaluate his valve. I do not think his symptom complex is related to the valve and it is obviously followed quite closely in Florida.
DC|direct current|DC|180|181|DISCHARGE INFORMATION|Her strep throat swab was negative. DISCHARGE INFORMATION: The patient was discharged home. Her discharge diagnosis is atrial fibrillation with rapid ventricular rate, status post DC cardioversion. DISCHARGE MEDICATIONS: 1. Diltiazem long acting 480 mg p.o. daily.
DC|direct current|DC|233|234|HOSPITAL COURSE|She was initially rate-controlled pharmacologically, and on postoperative day #6, the patient underwent transesophageal echocardiography to evaluate for thrombi. The echocardiogram was negative for thrombi, and the patient underwent DC cardioversion. She converted to normal sinus rhythm with one shock at 200 Joules. For the rest of her stay, the patient maintained a normal sinus rhythm.
DC|discontinue|DC|214|215|ASSESSMENT AND PLAN|3. Diabetes: The patient has very high insulin needs. His outpatient regimen includes Lantus 98 units b.i.d. and Novolog 32 units with meals t.i.d. Will continue the Lantus, however due to decreased PO intake will DC the Novolog and start patient on insulin sliding scale. 4. Tachycardia: This is likely secondary to dehydration. EKG with no evidence of arrhythmias.
DC|discharge|DC|158|159|DISCHARGE DISPOSITION|Her incision had the normal amount of post-operative drainage and she progressed without difficulty until discharge on _%#MMDD2007#%_. DISCHARGE DISPOSITION: DC to home on p.o. pain meds. Follow-up in two weeks as well as DC on Coumadin for deep venous thrombosis prophylaxis.
DC|discontinue|DC|111|112|PLAN|IMPRESSION: Intrauterine pregnancy, 34-2/7 weeks' gestation. Preterm labor stopped on magnesium sulfate. PLAN: DC the Foley catheter. Continue the mag sulfate. Bed rest with bathroom privileges.
DC|discontinue|DC|291|292|HOSPITAL COURSE|On further talking with the patient, she had no significant frank red blood per rectum, likely hemorrhoids which she does have on physical examination. She had no evidence of any fissures. The plan at this time is for managing this patient's diarrhea by discontinuing her Asacol, DC Nexium, DC nonsteroidals and place the patient on Bismuth two tablets po b.i.d. for 8 weeks. This is usually adequate coverage for microscopic colitis in the elderly population.
DC|direct current|DC|248|249|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Crohn's disease, status post resection of the terminal ileum and partial right hemicolectomy in 1976, status post exploratory laparotomy and appendectomy in 1975. 2. Vasectomy. 3. Kidney stones. 4. Atrial fibrillation with DC cardioversion x 4 (_%#MM1998#%_, _%#MM1998#%_, _%#MM2001#%_, _%#MM2002#%_). 5. History of St. Jude's DDD pacemaker on _%#MMDD2001#%_ for sick sinus syndrome.
DC|discontinue|DC.|124|126|DISCHARGE MEDICATIONS|3. Bactrim SS one p.o. q.d. 4. Valcyte 900 mg p.o. q.d. X 3 months. 5. Mycelex Troche 10 mg p.o. q.i.d. X 3 months, then to DC. 6. Prevacid 30 mg p.o. q.d. 7. Calcium carbonate with Vitamin D 500 mg p.o. t.i.d. 8. Quinine sulfate 260 mg p.o. q.h.s. prn muscle spasm.
DC|discontinue|DC|176|177|PLAN|I suspect this is combination side effect to the antibiotic and resolving ileus/obstipation. PLAN: Hydrate overnight, then clear liquids, advance as tolerated to regular. Will DC antibiotics, and not restart or change to different antibiotic as he is unlikely to need any with nonperforated appendicitis.
DC|direct current|DC|143|144|HISTORY OF PRESENT ILLNESS|With her symptoms and this identification of atrial fibrillation, the patient was transferred to the cardiac catheterization lab for a planned DC cardioversion. The patient is chronically on oral anticoagulation with Coumadin and was therefore deemed safe for a direct cardioversion.
DC|discontinue|DC|146|147|PLAN|The patient is an ASA 2. At this time, we will have him DC his Norvasc. We will switch him over to ___________ _%#MMDD#%_ one a day. We will also DC his Lipitor. He will follow up in our clinic in one month for a blood pressure check.
DC|discontinue|DC.|262|264|DISCHARGE MEDICATIONS|4. Urinary tract infection possible DISCHARGE MEDICATIONS: 1. Coumadin 2.5 mg p.o. daily, INR check in two days and further dosing based on INR per PMD. 2. Aricept 5 mg p.o. daily 3. Seroquel 25 mg p.o. q.h.s. 4. Tequin 200 mg p.o. daily on _%#MMDD2004#%_, then DC. The patient is to have home physical therapy, occupational therapy, home health aide and home RN for evaluation and treatment.
DC|discontinue|DC|120|121|DISCHARGE MEDICATIONS|She will need a hemoglobin in two weeks; call us if less than 8.5. She will need to see Dr. _%#NAME#%_ in a month. Will DC the catheter. Will check her saturations and use oxygen if necessary. With the rising hemoglobin and stability she looks very good at the time of discharge with clear lungs and regular heart, no pedal edema.
DC|discharge|DC|224|225|PLAN|Routine CSC orders. Gently diurese. Continue with antibiotics, Cipro 400 mg IV q.d. Blood cultures, urine cultures pending. Follow lytes, CBC, and creatinine. Nitro paste on currently. Will continue with this, maybe able to DC after diuresis. Will also continue with her home meds and also with Zofran 4 mg IV q.4-6h. as needed. Morphine 1-3 mg IV q.2.h. as needed.
DC|direct current|DC|282|283|HOSPITAL COURSE|He was started on a diltiazem and heparin drip. After being rate controlled, we just opted to increase his metoprolol and we started him on Coumadin 5 mg q day as well as amiodarone 400 mg t.i.d. for a week, then he was to be taken down to 200 mg q day. He proceeded to go down for DC cardioversion which was successful. It was decided to discharge him home with some Lovenox until his INR is therapeutic. He should proceed with the Lovenox for three more weeks and then have it discontinued.
DC|direct current|DC|149|150|ASSESSMENT|In discussion with Dr. _%#NAME#%_ they have planned to do a direct-current (DC) cardioversion with the start of flecainide. The patient will undergo DC cardioversion at Fairview Southdale Hospital today. I did review the risks and benefits of proceeding with DC cardioversion and these risks do include arrhythmias, stroke, or superficial burns.
DC|discontinue|DC|185|186|IMPRESSION/PLAN|Will place the patient on oral prednisone which should help with her wheezing and also help with the headache and her sinusitis. Will continue the patient on DuoNebs or albuterol nebs. DC cigarettes. Nicoderm if needed. Empiric Protonix. Hold Glucovance. Check a hemoglobin A1c. Use sliding scale insulin and Avandia. Oxygen as needed. Patient can possibly be discharged in the morning if she has responded appropriately.
DC|direct current|DC|288|289|HOSPITAL COURSE|Please refer to Dr. _%#NAME#%_ _%#NAME#%_'s history and physical of _%#MMDD2004#%_, as well as Dr. _%#NAME#%_ _%#NAME#%_'s cardiology consultation of _%#MMDD2004#%_ in the ER visit for full details concerning the patient's presentation and admission. The patient was admitted after being DC cardioverted. He ruled out for myocardial infarction. A cardiology consultation was undertaken regarding the need for anticoagulation and antiarrhythmics.
DC|direct current|DC|143|144|HOSPITAL COURSE|FAMILY HISTORY: Father died of heart failure in his 60s due to an unknown cause. HOSPITAL COURSE: PROBLEM #1. Atrial fibrillation, status post DC cardioversion. As noted above, the patient was admitted with atrial fibrillation as an outpatient for scheduled transesophageal echocardiogram followed by a DC cardioversion which was successful in converting him to normal sinus rhythm.
DC|direct current|DC|205|206|IMPRESSION|She understands and agrees to proceed. My plan was that if her stress Thallium study was normal, that I would place her on 100 mg b.i.d. of Tambocor followed by a low level stress test before or after her DC cardioversion. When the nurse practitioner sees her, if she is willing, I would start her on Tambocor and then do the DC cardioversion a couple days later.
DC|direct current|DC|144|145|PROCEDURE|During her stay she experienced chest pain typical of angina and became anemic secondary to blood loss. On _%#MMDD2004#%_ she received elective DC cardioversion and one unit of packed red blood cells. This was tolerated well and the patient was discharged to Minnesota Masonic Home TCU on _%#MMDD2004#%_.
DC|(diltiazem) DC|DC|266|267|DISCHARGE MEDICATIONS|At one point, the patient had E. coli sepsis which was treated with intravenous antibiotics. The patient ultimately improved the point where we could transfer her to a nursing facility. DISCHARGE MEDICATIONS: 1. Atenolol 25 mg daily for blood pressure. 2. Diltiazem DC 180b mg daily for blood pressure. 3. Lexapro 20 mg daily for depression. 4. Lorazepam 0.5 mg t.i.d. p.r.n. for anxiety.
DC|discontinue|DC|202|203|RECOMMENDATIONS|Therefore, given the need for surgery, I do believe we may be able to proceed with the procedure with the use of beta blockers, cardioprotection and close intraoperative monitoring. RECOMMENDATIONS: 1. DC atenolol. Change to Toprol XL. Give metoprolol IV for additional beta blockade, as well as elevated blood pressures initially. 2. Given underlying dementia, to be placed on a delirium protocol as is a high likelihood he will have some issues with this.
DC|discontinue|DC|141|142|RECOMMENDATIONS|3. Consider echo to check left ventricular function 4. Beta blocker therapy and aspirin 5. Check lipid profile and thyroid function tests 6. DC cigarette smoking and caffeine 7. Cardiac catheterization and coronary angiography. Risks and benefits including heart attack, death and stroke have been explained to the patient and family.
DC|direct current|(DC)|380|383|PLAN|3. If the patient does spontaneously convert overnight, she potentially could be discharged for further outpatient treatment which could involve a long-term antiarrhythmic although the infrequency of her symptoms would negate the benefit of an antiarrhythmic. 4. If she is still in atrial fibrillation by the morning, we should consult Cardiology for potentially a direct current (DC) cardioversion. Since she is already on Coumadin and if she is therapeutic, there may not be a need to perform a transesophageal echocardiogram (TEE).
DC|discontinue|DC|137|138|DISCHARGE MEDICATIONS|1. Atenolol 25 per feeding tube b.i.d. 2. Miacalcin one spray to nares q. day, alternating nares. 3. Cefzil 250 per feeding tube b.i.d., DC in 17 doses. 4. Duragesic patch 25 mcg per hour q.72 hours. 5. FeSO4, 324 mg per feeding tube q. day. 6. Lasix 40 mg per feeding tube q. day.
DC|discontinue|DC|174|175|DISCHARGE MEDICATIONS|E. On _%#MM#%_ _%#DD#%_, 2006, 40 mg at 8 a.m. and 20 mg at 1400 p.m. F. On _%#MM#%_ _%#DD#%_, 2006, through _%#MM#%_ _%#DD#%_, 2006, 20 mg p.o. at 8 a.m. and 1400 p.m. then DC after _%#MM#%_ _%#DD#%_, 2006, dose. FOLLOWUP CARE: 1. Follow up with Dr. _%#NAME#%_ in the clinic by calling _%#TEL#%_ to confirm her appointment which is scheduled at this point for _%#MM#%_ _%#DD#%_, 2006, at 9 o'clock a.m.
DC|direct current|DC|226|227|DISCHARGE DIAGNOSES|Please refer to Dr. _%#NAME#%_ _%#NAME#%_'s detail angio report for his documentation of the coronary disease. c) Transesophageal echocardiogram _%#MMDD2006#%_ showed no evidence of clot, which was followed by an attempt at a DC cardioversion in which patient converted to sinus rhythm for 30-60 seconds, but reverted back to atrial fibrillation. A second attempt at DC cardioversion placed the patient in a normal sinus rhythm for 20 seconds and then reverted back to atrial fibrillation.
DC|discontinue|DC|223|224|IMPRESSION|IMPRESSION: 1. Chronic peripheral vascular occlusive disease, probably with chronic rest pain in the right foot. There does not be appear to be an acute ischemic limb. At this point he still has collateral filling. We will DC the high a dose heparin after discussion with Dr. _%#NAME#%_ and I will place the patient on low dose heparin aiming for a PTT of 50-60.
DC|direct current|DC|241|242|IMPRESSION/PLAN|We have agreed on the patient to be admitted for initiation of flecainide 150 mg b.i.d. He will stop Metoprolol but will continue diltiazem 240 mg a day for ventricular rate control in case of atrial fibrillation recurrence. He will receive DC cardioversion after four doses of flecainide. Because of previous pulmonary embolism and stroke, I think that the patient needs Coumadin therapy indefinitely regardless of how we treat the atrial fibrillation.
DC|direct current|DC|285|286|SUMMARY OF HOSPITAL COURSE|SUMMARY OF HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 70-year-old woman with chronic medical problems, including chronic oral anticoagulation due to prior history of pulmonary embolism as well as additional more recent onset of atrial fibrillation. She had been anticipating elective DC cardioversion in mid _%#MM#%_. The patient on the date of admission developed acute nausea and very diffuse abdominal pain, also gross hematuria.
DC|discharge|DC|140|141|PLAN|No evidence of acute infectious process whatsoever. ASSESSMENT: 73-year-old male with bilateral lower extremity edema and cellulitis. PLAN: DC home. He will follow up with Dr. _%#NAME#%_, pulmonologist, in one week as well as up with Dr. _%#NAME#%_ at _%#CITY#%_ Family Physicians in one week and Dr. _%#NAME#%_ of the Wound Healing Institute in one week.
DC|direct current|DC|134|135|HOSPITAL COURSE|Because of persistent rapid ventricular rate, she was then admitted for initiation of antiarrhythmic drug loading with sotalol repeat DC cardioversion following atrial fibrillation. Following sotalol loading an attempt was made for cardioversion after a 50 joule synchronized shock.
DC|discontinue|DC.|130|132|DISCHARGE MEDICATIONS|7. Darvocet-N 100 one tablet every four to six hours p.r.n. moderate pain. 8. Augmentin 875 mg p.o. b.i.d. for five days and then DC. 9. Actos 15 mg p.o. daily. 10. Aspirin 81 mg p.o. daily. 11. Multivitamins one p.o. daily. DISCHARGE DIAGNOSES: 1. Choledocholithiasis.
DC|discontinue|DC|293|294|REASON  FOR ADMISSION AND HOSPITAL COURSE|It might be a secondary to urine tract infection that she had, however, she also can have a detrusor muscle dysfunction or she is not emptying her bladder normally. I would recommend keeping the Foley for now since the patient is not mobile and once she is ambulating and moving better we can DC the Foley at the transitional care unit and have a bladder scan post-void to rule out any urinary retention in the bladder.
DC|direct current|DC|195|196|ASSESSMENT|EKG: EKG shows atrial fibrillation with rapid ventricular response. LABORATORY DATA: Laboratory studies are pending. ASSESSMENT: 74-year-old female with atrial fibrillation, status post previous DC cardioversion who now presents with recurrent atrial fibrillation with rapid response. PLAN: We will admit her to the Cardiac Special Care Unit at Fairview Southdale Hospital and start diltiazem intravenously for rate control as well as Lovenox.
DC|discharge|DC|172|173|ASSESSMENT  AND PLAN|The patient has been placed on heparin and will try to wean that off also. We will ambulate the patient and again if no recurrent symptoms and troponins are negative, will DC home later today and follow up with cardiology and his primary care clinic as this is fairly atypical pain, probably unlikely to be cardiac.
DC|direct current|DC|218|219|REASON FOR ADMISSION|4. Status post ICD implantation. REASON FOR ADMISSION: Mr. _%#NAME#%_ _%#NAME#%_ is a 65-year-old white male with history of hypertension. He presented to the emergency room with sustained monomorphic VT that required DC cardioversion. He was ruled out of acute myocardial infarction and was admitted for further management. HOSPITAL COURSE: After his admission he had no recurrence of ventricular tachycardia.
DC|discontinue|DC|72|73|RECOMMENDATIONS.|I would be more suspicious of a vasculitic problem. RECOMMENDATIONS. 1. DC all antibiotics. 2. Will check an echocardiogram as ordered by Dr. _%#NAME#%_. 3. Will do blood cultures and urine cultures. 4. EKG and chest x-ray . 5. Would strongly consider temporal artery biopsy; though the patient has been treated with steroids there is still a good chance of obtaining a diagnostic sample; see Annals of Internal Medicine 1994, _%#MMDD#%_, pages 987 to 992.
DC|direct current|DC|311|312|HOSPITAL COURSE|4. Rythmol 225 mg t.i.d. 5. Vicodin. HOSPITAL COURSE: After admission, the patient was placed on 600 mg of Rythmol times one, followed by 225 mg t.i.d. Unfortunately, he remained in atrial fibrillation. Rythmol was increased to 300 mg b.i.d. He remained in atrial fibrillation. The patient underwent successful DC cardioversion with a single 200 joule biphasic shock. The patient remains in sinus rhythm after the cardioversion. Therapeutic plan is to discharge the patient today.
DC|direct current|DC|195|196|HOSPITAL COURSE|No diabetes or hypertension. HOSPITAL COURSE: PROBLEM #1: Paroxysmal atrial fibrillation associated with hyperthyroidism. The patient was in atrial fibrillation with a rate of 150. Diltiazem and DC cardioversion was attempted at _%#CITY#%_ ER without success. The patient was then transferred here. However, soon the patient converted to sinus rhythm on diltiazem drip.
DC|direct current|DC|170|171|OPERATIONS/PROCEDURES PERFORMED|DISCHARGE DIAGNOSES: 1. Atrial flutter with rapid ventricular rate. 2. Diabetes mellitus type 2. OPERATIONS/PROCEDURES PERFORMED: 1. Transesophageal echocardiography. 2. DC cardioversion. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 33-year-old female with a history of congenital heart disease status post ASD repair at 5 years of age, history of atrial flutter status post DC cardioversion in _%#MM#%_ of 2003, who presents with a 1-week history of palpitations and epigastric and mid-chest pain.
DC|direct current|DC|205|206|ASSESSMENT AND RECOMMENDATIONS|As long as the QT interval remains below 500 milliseconds, he may continue the same dose of sotalol. If he has recurrence with sotalol 120 mg b.i.d., the next recommendation will be amiodarone with repeat DC cardioversion or AV node ablation.
DC|discontinue|DC|151|152|DISCHARGE MEDICATIONS|1. Hydrocodone/acetaminophen 5/500 1-2 tablets p.o. q.4-6h. p.r.n. pain, not to exceed 4 grams in 24 hours. 2. Augmentin 1 tablet p.o. b.i.d. for UTI, DC after 6 doses. 3. Norvasc 5 mg p.o. daily for hypertension. 4. Atenolol 50 mg p.o. daily for hypertension. 5. Bisacodyl 10 mg PR daily p.r.n. constipation. 6. Docusate 100 mg p.o. b.i.d. for constipation.
DC|discontinue|DC|130|131|ASSESSMENT AND PLAN|At this time will continue patient on her lactulose as well as evaluate ammonia levels. Will also continue rifampin. However will DC Inderal-S that may contribute to hypotension. Will continue to monitor. Additional GI consult requested for further treatment and therapeutic options.
DC|discontinue|DC|125|126|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Coumadin as directed daily. Dose pending. 2. Lovenox 30 mg subq b.i.d. if INR is less than 2. Will DC when INR greater than 2.5. Pharmacy to dose. 3. Atenolol 50 mg daily. 4. Miacalcin nasal spray 200 units daily alternating nostrils.
DC|discontinue|DC|172|173|ASSESSMENT AND PLAN|Will do the rule out myocardial infarction protocol; if this is negative will proceed with a stress echocardiogram via Minnesota Heart Clinic in the morning. I am going to DC his atenolol and hydrochlorothiazide due to the negative side effects he is complaining about, as noted above. I will start him on lisinopril instead, 20 mg dose.
DC|discontinue|DC|121|122|MEDICATIONS|5. Flagyl 500 mg PO q12 hours times six more days. 6. Colace 200 mg PO b.i.d. 7. Erythromycin ointment OD times ten days DC on _%#MMDD#%_. 8. Iron Sulfate 325 PO qd. 9. Diflucan 100 mg PO qd times three days. 10. Flovent MDI 2 puffs b.i.d. 11. Glyburide 5 mg PO qd.
DC|direct current|D.C|170|172|CHIEF COMPLAINT|"Smoke" was seen in the atria with the transesophageal echo and accordingly it was felt safest to anticoagulate him for a month and then have him come in for an elective D.C cardioversion to return to sinus rhythm. The patient was discharged with atrial fibrillation and heart rate of 90-100 and he did get a bit tachycardic with exercise.
DC|direct current|DC|325|326|HISTORY OF PRESENT ILLNESS|While they were attending to the patient's respiratory insufficiency, she developed a pulseless state without blood pressure, after initially having had a pulse of 100 and a blood pressure of 80 systolic upon their initial arrival. Treatment followed with CPR. She was noted to have a ventricular fibrillation, and was given DC countershocks x 3. An endotracheal tube was placed with some difficulty. Further shocks were given along with epinephrine and atropine.
DC|discontinue|DC|129|130|DISCHARGE MEDICATIONS|3. Hypertension. 4. Recent bunion surgery. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg PO qd. 2. Lovenox 90 mg subcutaneously b.i.d. DC when INR greater than 2. 3. Coumadin 7.5 mg PO times one on _%#MMDD#%_. The patient received 7.5 mg times one on _%#MMDD#%_.
DC|discharge|DC|113|114|IMPRESSION|IMPRESSION: 1. End stage renal disease. I saw her on dialysis today. We will run her today and tomorrow and then DC her to outpatient dialysis. She is on the transplant list and we will send her a home dialysis unit for consideration of peritoneal dialysis.
DC|discharge|DC.|155|157|DISCHARGE MEDICATION|DISCHARGE MEDICATION: 1. Percocet. 2. Iron. 3. Prenatal vitamins. 4. Colace. 5. Ibuprofen. Her staples were removed, and Steri-strips were placed prior to DC.
DC|discontinue|DC|146|147|DISCHARGE MEDICATIONS|1. Alprazolam 0.25 mg p.o. t.i.d. p.r.n. take as previously directed. 2. Cephalexin (Keflex) 500 mg p.o. q6h x 10 days. 3. DC phenazopyridine. 4. DC ciprofloxacin. 5. Tylenol 650 mg p.o. q4-6h p.r.n. PROCEDURES: None. HISTORY OF PRESENT ILLNESS: This is a 54-year-old woman who presents with a rash on her left anterior shin.
DC|discontinue|DC|134|135|ASSESSMENT/PLAN|At this point we will continue with IV fluid resuscitation. She has received about 500 cc of fluids so far. Blood pressures are okay. DC the arterial line and transfer out of Intensive Care if her night is uneventful. 2. Rheumatoid arthritis. No change in current treatment. 3. Vision injury left eye from rheumatoid arthritis, continue her multiple eye drops, unchanged.
DC|discontinue|DC|139|140|IMPRESSION AND PLAN|Continue her Toprol XL, lisinopril and Lasix. 4. Code status discussed with the patient and POA. She is DNR/DNI . 5. Polypharmacy. We will DC the Pletal. She is not ambulatory so should not need claudication treatment.
DC|discontinue|DC.|119|121|DISCHARGE MEDICATIONS|1. Aricept 10 mg at h.s. 2. Neurontin 300 mg at h.s. 3. Trifluridine 1% eye drops, one drop q.i.d. for three days then DC. 4. Darvocet N-100, one p.o. q.i.d. HOSPITAL COURSE: The patient was admitted per family and wife because of increasing difficulty getting along at home.
DC|discontinue|DC|241|242|ADDENDUM|The patient did not feel as though she could return to her home and was quite depressed. We had psychiatry come by and assess the patient. They recommended that we increase her Paxil CR to 25 mg q.a.m., continue with Xanax 0.25 p.o. b.i.d., DC her Ambien and start using trazodone 50 mg p.o. q.h.s. It was recommended that she follow up with psychiatry, with Dr. _%#NAME#%_ or _%#NAME#%_, _%#TEL#%_ _%#TEL#%_.
DC|direct current|DC|222|223|HISTORY OF PRESENT ILLNESS|Results normal sinus rhythm without complications. CHIEF COMPLAINT: Shortness of breath and irregular heart beat. HISTORY OF PRESENT ILLNESS: 70-year-old female with history of paroxysmal atrial fibrillation , status post DC conversion 12 times, currently on amiodarone. She was admitted with an irregular heart beat and shortness of breath. She has been on Coumadin for many years and diagnosed with atrial fibrillation.
DC|direct current|DC|269|270|PROBLEM #4|Also, he did grow out a coag-negative Staph from blood, which was initially treated with vanco for three days; but, since then, this has been discontinued. PROBLEM #4: Cardiovascular: The patient had an episode of a-fib flutter prior to transfer from HCMC and did have DC cardioversion there. Since his admission here, this has been a stable issue, and he has continued to be in sinus rhythm. PROBLEM #5: Heme. The patient did receive two units FFP prior to his interventional procedure.
DC|direct current|DC|78|79|PROCEDURE IN HOSPITAL|DISCHARGE DIAGNOSIS: Atrial fibrillation. PROCEDURE IN HOSPITAL: Synchronized DC cardioversion. HISTORY & HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ is a delightful 35- year-old gentleman who was found to have asymptomatic atrial fibrillation approximately six weeks ago.
DC|discontinue|DC|178|179|ASSESSMENT/PLAN|4. Gout, likely hydrochlorothiazide related. We will hold these. Cannot use colchicine or any nonsteroidals with his acute renal failure. We will give him a prednisone burst and DC the hydrochlorothiazide. 5. Code Status. In the past he has always been DNR/DNI. We will continue to honor those wishes.
DC|direct current|DC|244|245|ASSESSMENT/PLAN|ASSESSMENT/PLAN: Paroxysmal atrial fibrillation. Today I did do an EKG and the patient is confirmed to be in atrial fibrillation with a ventricular rate of 88 beats per minute. I have reviewed with her the risks and benefits of proceeding with DC cardioversion and the patient verbally understands all of these risks and is willing to proceed. She has been through this procedure before and these risks were also reviewed by Dr. _%#NAME#%_ earlier this week.
DC|direct current|DC|165|166|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Dilated idiopathic cardiomyopathy. 2. Status post coronary angiogram revealing normal coronary arteries. 3. Atrial fibrillation, status post DC cardioversion after transesophageal echocardiogram revealed no thrombi. HOSPITAL COURSE: Please refer to the admission history and physical and Cardiology consultation for full details concerning the patient's presentation at admission.
DC|discontinue|DC|165|166|IMPRESSION|Lipase 51, INR 0.97. The patient has been cross matched for two units of blood. IMPRESSION: Anemia, elevated MCV. Check B-12, folate, retic count, peripheral smear. DC all NSAIDS and aspirin. This could be secondary to an upper duodenal ulcer or severe gastritis. Will have GI involved. The patient with allergies, exercise induced anaphylaxis and eczema.
DC|direct current|DC|65|66|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: Paroxysmal atrial fibrillation, status post DC cardioversion. PROCEDURE PERFORMED: DC cardioversion on _%#MDMD2004#%_. SUMMARY: This is a 65-year-old male with history of paroxysmal atrial fibrillation diagnosed six years ago, with a normal ejection fraction function was admitted to Cardiology Telemetry Unit for recurrent paroxysmal atrial fibrillation.
DC|direct current|DC|217|218|INITIAL LABORATORY DATA|The patient reported some mild shortness of breath, but no orthopnea, and no paroxysmal nocturnal dyspnea. INITIAL LABORATORY DATA: INR 2.52. CBC and electrolytes were within normal limits. The patient had successful DC cardioversion and was discharged to home in stable condition. PAST MEDICAL HISTORY: 1. Diabetes type 2 since 1993.
DC|direct current|DC|236|237|INDICATION FOR CARDIOVERSION|He has been followed by Dr. _%#NAME#%_, and I did an INR today in our office at the Minnesota Heart Clinic in _%#CITY#%_, which was unfortunately low at 1.7. The patient is going to have his INR increased and subsequently scheduled for DC cardioversion. He has had several cardioversions in the past and has had no trouble with them. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Recent five vessel bypass, _%#MM#%_ 2004.
DC|discontinue|DC|146|147|ASSESSMENT/PLAN|2. Her elevated liver function tests secondary to alcohol. Also given the extensive Tylenol use, we will check a Tylenol level and an INR. I will DC Ibuprofen, place her on acid blocker. I question whether maybe she has an element of gastritis. 3. Alcoholism. She needs a CD evaluation. She needs rehab.
DC|discontinue|DC|181|182|ASSESSMENT AND PLAN|If by three cycles her markers are going down, we will continue that program. If they are stable, we will continue for three more cycles and reassess. If they are going up, we will DC the Xeloda and go with either carboplatin or Gemzar. The patient seems comfortable with this. She is in the hopes that if we can get her markers down to normal with some form of chemotherapy, that she could ultimately go on just hormone therapy.
DC|discontinue|DC.|274|276|MEDICATIONS|Check electrolytes. Review Coumadin use. He will also be on Lovenox daily self-administered, 100 mg of Lovenox subq q.12. Also will be on a sliding scale Solu-Medrol with prednisone 40 mg q. day x21 days, 30 mg q. day x5 days, 20 mg q. day x3 days, 10 mg q. day x3 days and DC. Take with food. Also should take calcium supplement and multivitamins.
DC|direct current|DC|208|209|OTHER DIAGNOSES|Urinary tract infection. Ischemic cardiomyopathy with ejection fraction of roughly 35% on presenting echocardiogram. Cardiopulmonary arrest in emergency department and this was in the context of sedation and DC cardioversion as well as respiratory failure requiring initial mechanical ventilatory support. SUMMARY OF HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was an 81- year-old woman presenting to the emergency department on _%#MM#%_ _%#DD#%_ with constitutional weakness and a fall and presenting with abnormalities in the emergency department including peripheral cyanosis, diffuse abdominal pain, atrial fibrillation with rapid ventricular rate leading to hypoxia and hypotension.
DC|discontinue|DC|172|173|DISCHARGE MEDICATIONS|2. Lisinopril 20 mg p.o. q. day. 3. Cephalexin 500 mg p.o. t.i.d. x 3 days. 4. Furosemide 40 mg p.o. q. day. 5. KCl 20 mEq p.o. q. day. 6. Gabapentin 300 mg p.o. t.i.d. 7. DC enalapril.
DC|direct current|DC|140|141|IMPRESSION AND PLAN|The patient verbally understands all of these options and the risks and benefits that go along with each. She has decided to proceed with a DC cardioversion today. She does understand all of the risks of going through DC cardioversion and is willing to proceed. We have reviewed the risk of stroke today as well.
DC|direct current|DC|265|266|HOSPITAL COURSE|The patient had over 24 hours of IV treatment with his heart rate coming down into the 90 range but remaining in atrial fibrillation. The patient, therefore, underwent a transesophageal echocardiogram which revealed no atrial thrombus. The patient was successfully DC cardioverted into normal sinus rhythm. 2. Anticoagulation. The patient was previously only on aspirin. Given the fact that the patient has recently been cardioverted and the long-term risks of not anticoagulating with warfarin, the patient was started on warfarin therapy.
DC|direct current|DC|88|89|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Atrial fibrillation with rapid ventricular response. Successful DC cardioversion. 2. Metastatic adenocarcinoma of the lung. PROCEDURES PERFORMED: 1. Transesophageal echo. No evidence for a left atrial thrombus.
DC|direct current|DC|161|162|PROCEDURES PERFORMED|Successful DC cardioversion. 2. Metastatic adenocarcinoma of the lung. PROCEDURES PERFORMED: 1. Transesophageal echo. No evidence for a left atrial thrombus. 2. DC cardioversion of atrial fibrillation with achievement of normal sinus rhythm. HISTORY OF PRESENT ILLNESS: A 46-year-old male with adenocarcinoma of the lung.
DC|direct current|DC|202|203|RECOMMENDATIONS|RECOMMENDATIONS: I predict that he will need aggressive titration of his medications and ultimately I would cardiovert him trying to restore sinus rhythm. This may be done with Amiodarone plus or minus DC cardioversion. With his diminished ejection fraction, he may need more than just a beta blocker. I will leave this to the judgment of primary care and cardiology in Florida.
DC|discontinue|DC|189|190|SYNOPSIS OF HISTORY AND PHYSICAL|Also MCP joints of the right hand. During the hospital stay wound care consult was also taken for the right foot wound. Also, infection disease consultation was obtained who recommended to DC all the antibiotics. The patient also has had increased INR during the hospital stay so her Coumadin was on hold. On _%#MMDD2006#%_, patient up in chair said weakness slightly better.
DC|discontinue|DC|208|209|DISPOSITION|DISPOSITION: Discharge to home in a stable condition. Follow-up with primary MD in one week p.r.n. Avoid NSAID use for 2 weeks as it as described above. Protonix 40 mg p.o. daily for 2 weeks and then she may DC indefinitely.
DC|direct current|DC|211|212|PROCEDURES AND OTHER TESTS|Please note we left the patient off any anticoagulation, no baby aspirin, no aspirin at this point because of his multiple ecchymoses. Discharge hemoglobin is pending at this time PROCEDURES AND OTHER TESTS: 1. DC cardioversion by cardiology. 2. Echocardiograms x2. First, echocardiogram showed decreased ejection fraction although it was slightly suboptimal secondary to elevated heart rate but showed an ejection fraction at that time of 35-40%.
DC|discontinue|DC|139|140|ASSESSMENT AND PLAN|We will hold his p.o. medications as I do not think he is absorbing any of those. 1. 1. Acute renal failure on chronic renal failure. Will DC the metformin with his elevated creatinine. When he is discharged this time I would consider discontinuing this medication if his creatinine is higher than 1.6. Also, with his hydrochlorothiazide it is very unlikely to be effective if his creatinine is greater than 1.6 so we will hold that.
DC|direct current|DC|103|104|PROBLEM #3|Her INR just prior to discharge was 1.77 on _%#MMDD2006#%_. She subsequently had TEE and then elective DC cardioversion with restoration of sinus rhythm. I reviewed her situation with Dr. _%#NAME#%_ and we agreed to start her on Tambocor - flecainide 50 mg p.o. b.i.d. An EKG done the next day showed no significant change in the QT interval or QRS interval.
DC|direct current|DC|263|264|PROCEDURE|He had pulmonary main common os that was isolated, a mitral isthmus line created, right superior pulmonary vein isolated, right inferior pulmonary vein isolated anteriorly and superiorly. There were no complications with the procedure. After the procedure he was DC cardioverted and remained in sinus rhythm. HOSPITAL COURSE: The patient was admitted to the Care Suites and followed in the CSC until the following day.
DC|discontinue|DC|178|179|HOSPITAL COURSE|Pulmonary recommended that he have his Trach down sized to a # 6 Shiley on _%#MMDD2006#%_ and they recommended in about a week to 10 days, decreasing again to #4 Shiley and then DC completely. Pulmonary said this could be handled as an outpatient at _%#COUNTY#%_ _%#COUNTY#%_ Medical Center. At the time of this dictation, the patient will need to follow up with _%#COUNTY#%_ _%#COUNTY#%_ Medical Center later this week for the change to the #4 Shiley and they can follow and decide when to discontinue he trach completely.
DC|direct current|DC|239|240|BRIEF HISTORY OF PRESENT ILLNESS|4. Mycoplasma pneumoniae antibodies were negative. 5. Legionella pneumophila antibodies were negative and antigens were negative. 6. ECG was unremarkable. BRIEF HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 46-year-old male, status post DC cardioversion for paroxysmal atrial fibrillation on _%#MMDD2006#%_ who was admitted for a 3-day history of increasing precordial pleuritic chest pain, with no other associated symptoms whatsoever.
DC|direct current|DC|345|346|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ _%#NAME#%_ is a very pleasant, 78-year-old gentleman, young-looking, with history of hypertension and atrial fibrillation and also coronary artery disease, presented with epigastric pain and irregular heartbeat. Regarding his cardiac history, ten years ago he had exertional dyspnea, was found to have atrial fibrillation. He had DC cardioversion and had been briefly on Coumadin and then on Rythmol since then. He has been doing well, no recurrent. He checked his blood pressure every day, sometimes a couple times a day, has never been showing any irregular heart beat.
DC|direct current|DC|586|587|ASSESSMENT/PLAN|He had some other labs earlier at the Fairview Lakes Emergency Room which showed troponin less than 0.04, INR is 0.97, his liver function tests were normal, WBC 7.5, hemoglobin 15.3, platelets 206,000, sodium 142, potassium 4.3, chloride 12, bicarbonate 25, glucose 172, BUN 17, creatinine 1.4, calcium 9.4. ASSESSMENT/PLAN: This is a very pleasant, 78-year-old gentleman with history of atrial fibrillation and recurrent atrial fibrillation, and had CAD, history of coronary stent and presented with epigastric pain. 1. Regarding CAD and epigastric pain, I will do a stress echo after DC cardioversion, if the patient's stress echo is fairly unremarkable there is no need for cath. On the other hand, if it is a pretty dramatic positive dobutamine stress echo, I will go ahead to have a coronary angiogram.
DC|direct current|DC|201|202|ASSESSMENT/PLAN|I will stop Rythmol because of patient's history of coronary artery disease. I will replace with amiodarone. I will check thyroid function, chest x-ray and pulmonary function test as a baseline. After DC cardioversion if the patient decided to not have coronary angiogram, he should be a candidate for Coumadin for anticoagulation because of his increased risk for stroke.
DC|discontinue|DC|407|408||Another suggestion was that patient did take her 5:00 p.m. Dilantin, but did not take her 9:00 p.m. medications and that her evening medications be given at earlier hour reducing the risk of a sundowning event preventing her from taking her p.m. dose of medications. Her blood pressure ran somewhat high at one point so for one day her blood pressure medicines were altered and in the end it was decided to DC the Florinef for now, continue the beta blocker but give a full dose of 50 mg q.a.m. to avoid night time dose with that medication.
DC|discontinue|DC|147|148|ASSESSMENT AND PLAN|4. I would give him acyclovir 10 mg/kg q8 hours, pending the HSV PCR. If the MRI confirms an acute cerebrovascular accident, I believe that we can DC the acyclovir. Otherwise it should continue until we have the HSV PCR back. 5. I would request from Neurology to see him for evaluation.
DC|discontinue|DC|145|146|PLAN|3. Hypertension. PLAN: 1. Will initiate fluid restriction. 2. Start gentle IV fluids. 3. Continue psychiatric medications 4. Continue Cozaar. 5. DC hydrochlorothiazide and Ciprofloxacin . 6. Will check a urine osmolality, serum osmolality and urine sodium in addition to TSH. 7. Will follow electrolytes.
DC|direct current|DC|209|210|HISTORY|He had a return appointment with Dr. _%#NAME#%_ _%#MMDD2007#%_. There was some concern given his reduced ejection fraction of 30% by recent echo for tachy-induced cardiomyopathy. He was admitted for TE guided DC cardioversion. HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted for TE guided cardioversion. He had no intracardiac clots.
DC|discontinue|DC|235|236|IMPRESSION AND PLAN|I would start him on Lasix IV 40 mg q.8h. I would keep him on strict input and output and check his weight on a daily basis. 5. I would get an echocardiogram in the morning to evaluate his LV function and valvular function. 6. I would DC Actos that is contraindicated in a known patient with stage III and IV heart failure. 7. Renal failure: Creatinine at baseline is not at this time known and his renal failure is likely contributing to his fluid overload.
DC|discontinue|DC.|177|179|MEDICATIONS|12. Potassium 20 mEq q.d. 13. Coumadin alternating with 3 mg four a days, 2.5 three days a day. 14. Prednisone weaning 30 mg three days, 20 mg three days, 10 mg three days, and DC. 15. Mag citrate p.r.n. The patient is full code.
DC|discontinue|DC,|146|148|DISCHARGE MEDICATIONS|At the time of discharge, he was fully baseline and anxious to go home. DISCHARGE MEDICATIONS: Levaquin 250 mg p.o. q.d. times five days and then DC, prednisone taper starting at 60 mg and decreasing by 10 mg per day until off. Combivent inhaler, two puffs p.o. q.i.d., Levoxyl 0.112 mg p.o. q.d., Imdur 30 mg p.o. q.d., Lasix 40 mg p.o. q.d., Prinivil 5 mg p.o. q.d., Cordarone 200 mg p.o. q.d., allopurinol 100 mg p.o. q.d., digoxin 0.125 mg p.o. every Monday-Wednesday-Friday- Saturday and aspirin 325 mg p.o. q.d. He was discharged home with home care to evaluate.
DC|discontinue|DC|181|182|DISCHARGE MEDICATIONS|Follow-up with Dr. _%#NAME#%_ or other PMD if headache doesn't improve. The patient will further evaluation and treatment the phone number and address of Dr. _%#NAME#%_ _%#NAME#%_. DC over the counter diet pills. HOSPITAL COURSE: The patient was admitted through the Emergency Department.
DC|District of Columbia|_%#CITY#%_|201|210|HISTORY OF PRESENT ILLNESS|The patient also reports she has gained about 20 pounds over the past few months because she started feeling better. She does have a history of mild depression treated by a psychiatrist in _%#CITY#%_, _%#CITY#%_ two years ago. She does not remember the name of the psychiatrist at this point. I had a long discussion with the patient's mother about medication usage and the possibility of abuse of medication, but no clear pattern emerges.
DC|discontinue|DC|167|168|DISCHARGE MEDICINES|DISCHARGE MEDICINES: Zantac 150 one p.o. b.i.d., Prinivil 20 mg once a day. We anticipate that next week when she is seen in the clinic we will be able to diminish or DC the metoprolol and hopefully over time we will be able to stop the Zantac for her stomach discomfort. At this time, catecholamine 24 hours pending and will follow from here.
DC|direct current|DC|439|440|PHYSICAL EXAMINATION|I will hold her Glucophage prior to cardiac cath. I think in view of her atrial fibrillation and left bundle branch block, the intense nature of her symptoms, her multiple risk factors including hypertension, diabetes mellitus, hyperlipidemia associated with a prolonged episode of tightness in the chest going into both arms associated with dyspnea, I believe angiography would be the most accurate and focused way to proceed. We will do DC cardioversion tomorrow before her INR is completely reversed. I think I will give her a dose of IV amiodarone to get her blood level up prior to cardioversion.
DC|discontinue|DC|194|195|ALLERGIES|His platelets were 59. His Folate was discontinued; however, does not tolerate that well, therefore was given a tincture of bethanechol to help with that. After two days of that, his Folate was DC and he tolerated this well, without further medications. On postop day #8, the patient was doing well. His vitals were within normal limits.
DC|direct current|DC|181|182|DISCHARGE MEDICATIONS|10. Amiodarone, 400 mg b.i.d. for a week, 400 mg daily for 2 weeks, and then 200 mg a day thereafter. We will get a 24-hour Holter monitor in a week or so. He will need to consider DC cardioversion in three to four weeks. I will hope to see him myself in three to four weeks. He will follow-up with Dr. _%#NAME#%_ acutely to follow his INR's, his heart rate response, looking for obviously side effects, blood pressure.
DC|discontinue|DC|195|196|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Ampicillin 500 p.o. q.i.d. times five days, Risperdal 0.5 mg p.o. b.i.d. The family requests that the Risperdal because continued because of her behavioral issues. We will DC her other medications. Hospice will be writing orders with regard to her comfort care meds.
DC|discontinue|DC.|156|158|DISCHARGE MEDICATIONS|2. Requip 4 mg per G tube t.i.d. 3. Bactrim DS Suspension 160 mg per G tube b.i.d. x 7 days, then DC. 4. Nystatin Suspension 5 cc per G tube x 14 days then DC. 5. Diflucan Suspension 150 mg per G tube q.d. x 7 days. 6. Ferrous sulfate liquid 300 mg per G tube b.i.d.
DC|discontinue|DC|285|286|HOSPITAL COURSE|The patient was placed on an LP10, which he was on an assist-control mode, tidal volume of 500, a rate of 12, and a PEEP of 5, and O2 of 2 liters per minute. The patients overall respiratory status improved. He continued to have mucus plugging secondary to medications which following DC of the medications improved. There was some discussion about transferring the patient to _%#COUNTY#%_ for a further wean; however, we discussed it with the wife and patient and they felt that his overall status is much improved on his overnight ventilatory support.
DC|District of Columbia|_%#CITY#%_,|199|209|FAMILY HISTORY|HABITS: No alcohol, drugs, smoking tobacco, caffeine. FAMILY HISTORY: They lived in Hawaii until 1951 when they moved here. They have one son born in 1961 who is now flying back her from _%#CITY#%_, _%#CITY#%_, where he is a computer guru with IBM. He does a lot of big government accounts. OBJECTIVE: Short, very moderately overweight Oriental female who does respond to me appropriately.
DC|District of Columbia|_%#CITY#%_|102|111||_%#NAME#%_ _%#NAME#%_ is a 74-year-old Caucasian female who was reportedly traveling from _%#CITY#%_, _%#CITY#%_ to Montana to visit family members. Apparently the patient had become weak on a lay over in the airport in _%#CITY#%_ and the patient was subsequently seen by the airport medics.
DC|direct current|DC|94|95|PROCEDURES PERFORMED|DIAGNOSES: Paroxysmal atrial fibrillation status post DC cardioversion. PROCEDURES PERFORMED: DC cardioversion which was successful. HISTORY OF PRESENT ILLNESS: This is a 76-year-old gentleman with ischemic cardiomyopathy with an EF of less than 40% who has a DDD/ICD in place since 2001 who was being followed as an outpatient over the last six months or so.
DC|direct current|DC|160|161|HOSPITAL COURSE|The cyanosis around his lips appeared to be decreased and his 2+ pitting edema was also decreased. He underwent TE the following morning and later on underwent DC cardioversion. Immediately it was successful having him back to sinus rhythm; however, on further examination later in the day it appeared that he was going in paroxysms of atrial fibrillation.
DC|discharge|DC,|206|208|HISTORY OF PRESENT ILLNESS|EGD was negative. Colonoscopy revealed a stigmata of diverticular bleed in the mid-transverse colon. The patient discontinued on _%#MMDD2003#%_, with a hemoglobin of 10.3. The patient states that since the DC, he has been fine, with no episodes of bloody stools until on the day prior to admission. He was asymptomatic at that time. On the admit of admission, he had approximately 1400.
DC|discontinue|DC|171|172|IMPRESSION|Will check serial troponins. Will check a hepatic panel. Will check her TSH and thyroid function tests. Will DC her Atenolol and begin Lopressor at 50 mg p.o. b.i.d. Will DC her quinidine. Will continue Coumadin for now. However, since her INR is elevated at 3.8, will hold her Coumadin dose today.
DC|discharge|DC|149|150|HOSPITAL COURSE|The patient is suffering from mild hyperglycemia. This is probably due to the five doses of IV steroids on top of the rejection. The patient will be DC with sliding scale Lispro to cover in interim. As stated earlier, the patient's remainder of the hospital course was unremarkable except for above noted events.
DC|discharge|DC|195|196|PROBLEM #3|Denies homicidal or suicidal ideation. The patient wishes to go home today and states he will make arrangements for appropriate follow up with his own physician. PROBLEM #4: Disposition. We will DC him to home and allow the patient to follow up at Fairview-Northeast Clinic with his own physician, Dr. _%#NAME#%_ and his psychiatrist in _%#CITY#%_ _%#CITY#%_, Dr. _%#NAME#%_ _%#NAME#%_.
DC|direct current|DC|141|142|PROCEDURES PERFORMED|3. Urinary tract infection with methicillin resistant Staphylococcus aureus and enterococcus. 4. Urinary retention. PROCEDURES PERFORMED: 1. DC cardioversion on _%#MMDD2004#%_ which was successful. 2. Pacer backup rate increased to 80 on _%#MMDD2004#%_. CONSULTATIONS: 1. Electrophysiology for electric cardioversion. 2. Urology for urinary retention and cares of indwelling Foley catheter.
DC|District of Columbia|_%#CITY#%_.|163|173|SOCIAL HISTORY|FAMILY HISTORY: His mother has depression. His father was an alcoholic who died at the age of 39. ALLERGIES: Ampicillin. SOCIAL HISTORY: He grew up in _%#CITY#%_, _%#CITY#%_. When his father died they moved here to Minnesota. He currently works nights at Target. He monitors alarms. He states he started the job about 3 weeks ago.
DC|discontinue|DC|152|153|DISCHARGE INSTRUCTIONS|3. Staples may be discontinued three weeks after surgery. 4. Wound care consists of wet to dry dressings to wound b.i.d. 5. Routine PICC line cares. 6. DC PICC line after IV vancomycin is discontinued. 7. Labs to be drawn per lab letter x 2 per week. 8. Repeat CT scan of abdomen to reassess for fluid collection in two weeks.
DC|deceased donor:DD|DC|176|177|PAST MEDICAL HISTORY|3. Peripheral neuropathy. 4. Hypertension. 5. End-stage renal disease secondary to diabetic nephropathy. 6. Hyperthyroidism. 7. Osteoporosis. 8. History of detached retina. 9. DC stoner pancreas transplant with enteric drainage _%#MMDD#%_. 10. Status post bilateral retinal photocoagulation. 11. Status post bilateral retinal repair. 12. Status post bilateral foot surgery.
DC|discontinue|DC|213|214|RECOMMENDATIONS|3. Cardiac catheterization with coronary angiography. The risks and benefits were explained to the patient. 4. Check lipid profile and liver function tests. 5. Will need beta blocker and Ace inhibitor therapy. 6. DC cigarette smoking.
DC|discontinue|DC|144|145|RECOMMENDATIONS|7) Start enteric Flagyl 250 mg q.i.d. pending C. difficile toxin. 8) If drug rash develops, would change Zosyn to clindamycin and aztreonam. 9) DC ciprofloxacin for now. Thank you for involving me in his care. Discussed in detail with family.
DC|discontinue|DC|279|280|PLAN|GI concern is with regards to his ileus that is multifactorial with his multiple medical problems, recent decrease in activity level as well as narcotic use and other medications. He also has elevated INR. PLAN: After review with Dr. _%#NAME#%_, discontinue narcotics as we can. DC anticholinergic containing nebs and inhalers. Will check a magnesium and would consider colonoscopy for possible decompression, though INR is currently 6.
DC|discontinue|DC|140|141|PLAN|4. Hyperkalemia. This is mild and secondary to IV fluid and lisinopril. PLAN: The patient will be transferred to the tele floor today. Will DC the art line and DC lisinopril. The patient will be discontinued from Demerol and will use Dilaudid plus the Percocet for his post operative pain control.
DC|discontinue|DC|140|141|ASSESSMENT/PLAN|Regarding beta blocker, he has been on Lopressor chronically but I really don't know how much he has been taking. For the time being I will DC the IV Lopressor but continue p.o. If it turns out that it is difficult to control for bronchospasm, we have to titrate that down or even discontinue that.
DC|direct current|DC|210|211|HISTORY OF PRESENT ILLNESS|Furthermore, he has a history of mild coronary artery disease without hemodynamically significant stenosis in _%#MM#%_ 2003 (40% LAD). Furthermore, he had a history of paroxysmal atrial flutter, which required DC cardioversion last week. He did well post-procedure. However, since this morning, he has felt very tired and dizzy, and perceived an irregular heart rhythm.
DC|discontinue|DC|256|257|ASSESSMENT/PLAN|I recommend a trial of Neurontin gel 8% applied to the left arm t.i.d. If this is ineffective alone, can also add topical ketoprofen 10% gel in combination with the Neurontin gel or a combination of Neurontin and ketamine gel. Also would recommend that we DC his Duragesic patch and try him on methadone which is much more effective for neuropathic pain. Would start him on 2.5 mg of methadone q 8 hours and continue his Dilaudid for break through pain.
DC|discontinue|DC|148|149|PLAN|This is uncontrolled secondary to pain. PLAN: Will recheck the potassium in the morning. The patient is receiving IV fluids with potassium. We will DC the hydrochlorothiazide and consider beta blockers if the SVT is over 170 tonight. The case was discussed with the patient's family.
DC|discontinue|DC|170|171|PLAN|9. Hypertension. 10. Hypothyroidism, euthyroid on replacement. 11. Methicillin-resistant Staph aureus colonization. PLAN: 1. Vancomycin dose currently. Follow levels. 2. DC Tequin based on the urine isolette being resistant and the glucose problems. Use aztreonam for this purpose currently at high dose but decreased dose as kidney function clinically dictates.
DC|direct current|DC|207|208|HISTORY|Earlier today he developed atrial fibrillation/atrial flutter with rapid ventricular response and he was transferred to the ICU for treatment of this. He received a number of different mortalities including DC cardioversion, metoprolol and amiodarone and he is now back in sinus rhythm. Following doses of metoprolol he did develop hypotension with blood pressures down as low as into the 80s.
DC|discontinue|DC|193|194|ASSESSMENT  AND PLAN|2. Urinary tract infection. We will treat for a complicated UTI given stent and history of obstructive uropathy, for Enterococcus and increased Gram-negative coverage. We will change to Zosyn. DC Levaquin. We will discuss case with Urology. Stent is in place. Doubt pyelonephritis. His white blood cell count is elevated, possibly from increasing dehydration versus lack of coverage.
DC|discontinue|DC|165|166|ASSESSMENT|However, the patient's liver function tests are normal and no acute treatment is indicated. PLAN: I will place the patient on aspirin for her headache pain. We will DC the Ibuprofen. The patient will colace on a prn basis and she will magnesium citrate this a.m. Also write for simethicone prn flatus.
DC|District of Columbia|_%#CITY#%_|211|220|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This 58-year-old male is seen in consultation with Dr. _%#NAME#%_ due to fever of unknown origin. The patient has a history of being in usual state of health and he was in _%#CITY#%_ _%#CITY#%_ when 2 weeks ago from this last Monday he developed an acute fever. Initially, he had some ear, throat and neck discomfort as well as some degree of headache.
DC|discontinue|DC|269|270|OTHER RECOMMENDATIONS|OTHER RECOMMENDATIONS: 1. Stop Cardizem. This drug is negatively inotropic and is probably not beneficial in the setting of depressed left ventricular systolic function. 2. I will increase the Coreg to 31.25 mg p.o. b.i.d. in effort for better rate control. 3. We will DC the IV nitro and increase his Imdur to 90 mg p.o. q.d. 4. Continue with IV heparin for the time being. 5. If agreeable with his renal physician, I think we should start an ACE inhibitor.
DC|discontinue|DC|142|143|ASSESSMENT/PLAN|Recommend Haldol Solution 2 mg/ml 0.5 mg sublingual q. 12 hours scheduled and 0.5 mg q. 6 hours p.r.n. 5. Other comfort care recommendations: DC vital signs, DC all labs, DC IV at discharge and frequent oral care. 6. Plan: Met with sons, _%#NAME#%_ and _%#NAME#%_. Would like hospice care.
DC|discontinue|DC|233|234|PLANS|9. History of recurrent gout 10. anemia 11. Recent episode of aspiration pneumonia, no evidence of that currently 12. Prior renal failure resolved. PLANS: For now would ignore the Abiotrophia, discontinue IV vancomycin. I would also DC the Levaquin after the current dose. Both these infections are of some concern but the C-Difficile probably takes prior here.
DC|discontinue|DC|173|174|RECOMMENDATIONS|Consider Cipro or Bactrim. 6. If the blood pressure tolerates, consider restarting nonselective beta blockers. 7. Continue Rifaximin. 8. Check C. diff toxin and culture. 9. DC IV fluids. 10. Transplant Surgery is also aware of the patient. 11. Depending on the consult, we will expedite his listing on the transplant.
DC|discontinue|DC|207|208|ASSESSMENT/PLAN|Will change IV fluids to normal saline. 4. Hypertension: Will resume preoperative nebs and check blood pressures. 5. Hyperlipidemia: Will continue statin therapy. 6. Fluids, electrolytes and nutrition: Will DC IV fluids once PO well tolerated.
DC|discontinue|"DC|167|169|IMPRESSION|Occurred at a time when neuroleptics were started for confusion and depression. Unclear psychiatric diagnosis. Confusing psychiatry notes. Note from _%#MMDD#%_ states "DC Seroquel and use Risperdal elixir" and then the note from today says, "Start Seroquel 25 t.i.d. and continue Paxil". I believe this patient may have a temporal lobe syndrome or a frontal lobe syndrome.
DC|discontinue|DC|160|161|PLAN|ASSESSMENT: Postoperative pain, left knee. PLAN: 1. We will discontinue the Celebrex because of the elevated creatinine and also her blood loss from the OR. 2. DC the Vicodin because I will be using Tylenol separately and dosing it high. 3. Schedule Tylenol 500 mg q.4h, 6 doses a day to equal 3000 mg a day and give that on schedule.
DC|discontinue|DC|112|113|PLAN|He is at high risk for under medication with analgesics due to his high tolerance to pain medications. PLAN: 1. DC the pain pump as this may be contributing to urinary retention and patient reports that this is painful process for him.
DC|discontinue|DC|221|222|ACTION AND PLAN|ACTION AND PLAN: 1. As discussed with Dr. _%#NAME#%_ DC fentanyl patch and after 12 hours start methadone intensol 10 mg sublingual every eight hours. Continue morphine bolus for breakthrough at 3 mg IV every 20 minutes. DC continuous MS infusion when start methadone. Call daughter, is agreeable to meet with team tomorrow at 3 p.m. and discuss medication changes and she is agreeable to those changes as well.
DC|discontinue|DC|174|175|ASSESSMENT/PLAN|At this point I have recommended some changes in his medications to try to better limit his exposure to these issues. I am going to ask for neuro checks every shift. We will DC his Dilaudid, Percocet and Valium and start him on OxyContin 10 mg b.i.d. with Vicodin prn for break-through pain and Vistaril as ordered.
DC|discontinue|DC|134|135|PLAN|4. Elevated liver function tests currently better, appear to be medication related. 5. Seizure disorder on chronic Dilantin. PLAN: 1. DC Rocephin and Zithromax (had an adequate course for any expected community-acquired pneumonia). 2. Only acute bacterial issue here is whether there is some nosocomial process.
DC|discontinue|DC|261|262|ACTION/PLAN|CARDIOVASCULAR: Irregularly irregular. ABDOMEN: Bowel sounds are positive, nontender. EXTREMITIES: Left lateral hip hematoma, not moving lower extremities secondary to pain. ACTION/PLAN: Discussed with Dr. _%#NAME#%_: 1. Pain secondary to hip fracture. We will DC Ativan and Demerol and start low-dose methadone with morphine for break-through. 2. Bowels. Monitor ability to take p.o. and rectal check after patient is more comfortable.
DC|discontinue|DC|197|198|RECOMMENDATIONS|3. DVT being treated by Oncology. 4. Liver cancer being treated by Oncology. RECOMMENDATIONS: 1. Change Glucotrol to 5 mg a day. 2. Q.i.d. Accu-Cheks with house sliding scale insulin as needed. 3. DC her Maxzide. 4. Monitor her blood pressure. I would like to thank Dr. _%#NAME#%_ for asking me to see this patient. We will follow along.
DC|District of Columbia|_%#CITY#%_.|247|257|RECOMMENDATIONS|2. Continue IV Zosyn pending culture results. 3. She will likely need 6 weeks of IV antibiotic therapy but will await surgical findings. This is a 63-year-old female who splits her time living between _%#CITY#%_ and Maryland outside of _%#CITY#%_ _%#CITY#%_. She has a history of diabetes mellitus and has developed Charcot right foot. For several weeks she has had bilateral plantar ulcerations, which have been treated conservatively.
DC|discontinue|DC|130|131|PLAN|2. Coronary artery disease, recent CABG, stabler coronary-wise. 3. Benign prostate hypertrophy. PLAN: 1. Nafcillin in high doses, DC Ancef and Tequin he is on currently. 2. Follow-up serial blood cultures until clear. Low grade sepsis occurring currently.
DC|direct current|DC|192|193|ASSESSMENT  AND PLAN|Although initially 12 lead EKG revealed no suggestion of ischemia, later telemetry showed she did have some ST depression. Although she has been ruled out for myocardial infarction, she got a DC cardioversion. Right now she is in sinus rhythm. Regarding long-term care, she should be on Coumadin anticoagulation permanently, since she does not have any symptoms other than chest pain.
DC|direct current|(DC)|172|175|REASON FOR CONSULTATION|CARDIOLOGY CONSULTATION REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD (_%#CITY#%_ Medical Group) REASON FOR CONSULTATION: Atrial fibrillation, status post direct-current (DC) cardioversion, persistent hypertension and dyspnea. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a pleasant 64-year-old male with a past medical history remarkable for hyperlipidemia, known Hodgkin's lymphoma, status post chemotherapy in 2000, and remote history of sarcoidosis.
DC|discontinue|DC|116|117|ASSESSMENT AND PLAN|We are awaiting the A1C to see what her blood sugar has really been running like over the last three months. I will DC the Avandia and start glipizide as initial agent at 5 mg b.i.d. Metformin should likely be titrated as an outpatient.
DC|discontinue|DC|132|133|SUGGESTIONS|Her creatinine is normal. ASSESSMENT: 1. Urinary retention. 2. Insulin dependent diabetes mellitus. 3. Dehydration. SUGGESTIONS: 1. DC Ditropan XL. 2. DC Foley Friday am before discharge. 3. See me in the office Friday afternoon at 2:00 pm for office cystoscopy.
DC|direct current|DC|220|221|IMPRESSION REPORT & PLAN|If she does have a thrombus on her TEE, then obviously she would need several weeks of anticoagulation and would have to be brought back for another TEE and DC cardioversion. If there is no thrombus, we can proceed with DC cardioversion tomorrow. In the meantime, I would rate control with IV Cardizem, and I would also start Coumadin. Will discuss with Dr. _%#NAME#%_.
DC|discontinue|DC|161|162|RECOMMENDATIONS|RECOMMENDATIONS: 1. The Lasix has been reduced. The dose will have to be carefully titrated monitoring renal function and fluid volume. Heart failure status. 2. DC NSAIDs and Do not resume. 3. No IV contrast. 4. No ARB or Ace inhibitors. 5. Transfuse and diurese as necessary to allow room for blood transfusions.
DC|direct current|DC|162|163|RECOMMENDATIONS|I will add Coumadin as I think he should have anticoagulation given his risk factors for thromboembolism of hypertension and left atrial enlargement. 3. Consider DC cardioversion in approximately one month or if this needs to be done sooner, do a TEE next week and if no LA thrombus, do cardioversion at that time.
DC|discontinue|DC|125|126|ASSESSMENT AND PLAN|1. Postop day number zero from colorectal surgery. His blood sugars are elevated as they have been drawn in the ICU. I would DC the D5 in his IV fluids. We will not start IV insulin at this point. Likely his blood sugars will come down into the 100-120 range.
DC|discontinue|DC|204|205|PLANS|Does not look particularly toxic, so doubt ATN. 4. Thrombocytopenia, reason for this not clear either, does not seem that toxic. PLANS: 1. Follow the abnormal labs through the process. 2. Continue Zosyn, DC tobra and add Levaquin orally as a reasonable alternative. Would probably treat for approximately 10 more days following removal of stone and resolution of fever.
DC|direct current|DC|157|158|PAST MEDICAL HISTORY|She comes to the emergency room here and found to have atrial fibrillation and started Lovenox. PAST MEDICAL HISTORY: Includes atrial fibrillation, multiple DC cardioversions, history of CHF. Ejection fraction per report, once in 30 and the comes back to 50, presumably a tachycardia induced cardiomyopathy.
DC|direct current|DC|387|388|ASSESSMENT  AND PLAN|Down the road the decision should be made regarding long-term therapy, whether or not she should be on Coumadin, although we can argue this as a long atrial fibrillation if her ejection fraction is okay, but if her ejection fraction is down she should be on Coumadin. Whether or not to do another DC cardioversion at this point to me is probably unnecessary because of patient's several DC cardioversions, at least 6-7 times in the past and she has been fairly asymptomatic from her atrial fibrillation.
DC|discontinue|DC|214|215|RECOMMENDATIONS|Venous Doppler was negative for DVT. I agree that this almost certainly represents erythema secondary to venostasis disease rather than cellulitis given the rapid resolution with leg elevation. RECOMMENDATIONS: 1. DC clindamycin. 2. Could proceed with surgery from the infectious disease standpoint. HISTORY OF PRESENT ILLNESS: This is an 81-year-old female with chronic venostasis disease who is requiring an osteotomy of the left foot.
DC|discontinue|DC|128|129|PLAN AND SUGGESTIONS|b. On ACE inhibitor therapy. 4. Hypertension. 5. Hypercholesterolemia. 6. Tobacco abuse. 7. Depression PLAN AND SUGGESTIONS: 1. DC Avandia. If the patient needs an agent in this class of medications, TZD agents, will switch him to Actos For now, though we will hold the medication
DC|discontinue|DC|464|465|PLAN|PLAN: I am doing to discontinue the IV Demerol. We will go back to her previous medication of OxyContin 40 mg q.12h. I would also like to put the Lidoderm patch over the upper left quadrant of her abdomen as well as start her on Lyrica to settle down the neuronal membrane 25 mg p.o. q.8h. She also has had a long-standing habit and practice of using IM Benadryl 4 times a day to counteract itching from the OxyContin. We have been currently getting an IV, I will DC that and she can go back to her at home practice of IM injections; nursing to provide medication and the patient can administer at bedside.
DC|discontinue|DC|443|444|RECOMMENDATIONS/PLAN|I would suggest sending the patient home on p.r.n. albuterol in the form of a metered dose inhaler (two puffs q.4 h. p.r.n. shortness of breath/wheeze), and would also recommend a controller inhaler in the form of Advair 100/50, one inhalation b.i.d. I would continue the p.r.n. albuterol MDI and the twice daily Advair for three to four months empirically. If the patient remains stable with her breathing and is doing much better, one could DC the Advair and observe how she does. HISTORY AND PHYSICAL EXAMINATION: I have spoken at length with the patient.
DC|discontinue|DC|195|196|ASSESSMENT/PLAN|If patient discharges, recommend Dilaudid solution 2 mg per ml, 1-4 mg sublingual q2h p.r.n. 2. Dyspnea. Appears comfortable. Recommend Dilaudid as above for dyspnea. 3. Anxiety. Would recommend DC with Ativan solution 0.5-1 mg sublingual q.4 hours p.r.n. and Haldol solution 0.5 to 1 mg. sublingual q 4 hours p.r.n. 4. Psychosocial, spiritual support. Met with patient's daughter and granddaughter for significant amount of time.
DC|discontinue|DC|162|163|PLAN|1. Clinically, the patient appears stable for transfer to 3 Rehab. 2. Continue Coumadin anticoagulation with serial follow-up INR. 3. Parameters for verapamil 4. DC Vistaril. Change Percocet to oxycodone 5 mg 1-2 tablets q.3h p.r.n. 5. Bowel program. 6. Encourage incentive spirometry. 7. PT/OT with mobilization as tolerated.
DC|discontinue|DC|139|140|ASSESSMENT AND PLAN|4. Chronic pain. When changing to p.o. medication would resume the patient's home dose of Kadian as this is her long-acting medication and DC the continuous Dilaudid given IV. 5. Urinary tract infection with Klebsiella and E. coli, both sensitive to Levaquin. Since this was diagnosed Foley has been DC'd. For now would continue Levaquin and recheck urinalysis.
DC|discontinue|DC|77|78|RECOMMENDATIONS|All these are quite virulent particularly in a diabetic. RECOMMENDATIONS: 1. DC Zosyn. 2. Indocin 3 grams I.V. q.6h. 3. Clindamycin 900 mg I.V. q.8h. 4. Continue elevation. Thank you for involving me in his care.
DC|direct current|DC|271|272|RECOMMENDATIONS|No obvious causes are present at this time. I suspect this is most likely lone atrial fibrillation. RECOMMENDATIONS: 1. Echocardiogram. 2. Check thyroid function tests. 3. As this is new-onset atrial fibrillation, I think the patient is a good candidate for synchronized DC cardioversion today. Further recommendations may follow depending on the results of further investigations.
DC|direct current|DC|135|136|HISTORY OF PRESENT ILLNESS|She subsequently came to the emergency room. In the emergency room, her blood pressure was a bit on the low side, and they recommended DC cardioversion. This frightened her, and just as they were getting ready to put her to sleep to do the DC cardioversion, she spontaneously reverted to sinus rhythm before any significant treatment was given.
DC|discontinue|DC|138|139|IMPRESSION|We will check his laboratories and then start him on EPO and IV iron. 3. Hypertension. We will DC Cozaar because of hyperkalemia. We will DC hydrochlorothiazide because this will not be effective. We will start Norvasc and a beta-blocker. 4. Diabetes. He is on insulin and oral agents per his primary care physician.
DC|discontinue|DC|146|147|RECOMMENDATIONS|I will order a hypotonic fluid to help correct his mild hypernatremia, sodium of 149. 2. I will DC diuretics and ACE inhibitor for now. 3. I will DC his gabapentin given his altered mental status. 4. I will also stop his oral hypoglycemics until he is eating better, and he will be covered with regular insulin sliding scale for the time being.
DC|discharge|DC|145|146|DISPOSITION|Also could consider methadone 5 mg sublingual q8h. DISPOSITION: Expect the patient to die over the next day or two. If not, did discuss possible DC options with family. Two and a half hours spent.
DC|discharge|DC|139|140|PHYSICAL EXAMINATION|We will go ahead and get a repeat x-ray in 7-10 days to make sure that the fracture is stable in position. Social Service will see her for DC planning. Thank you very much for allowing us to participate in Ms. _%#NAME#%_'s care.
DC|discontinue|DC|144|145|MEDICATIONS|MEDICATIONS: At the nursing home included Fosamax 10 mg q.d., Pepcid 20 mg p.o. b.i.d., Lasix 20 mg q.d., Calcitonin spray, Duragesic patch was DC on _%#MMDD2002#%_. Ativan prn. Risperdal was started on _%#MMDD#%_. Prednisone was started on _%#MMDD#%_. Cipro was started on _%#MMDD2001#%_. CHRONIC DISEASE/MAJOR ILLNESSES: 1. Senile dementia.
DC|discontinue|DC|88|89|PLAN|3. Major stress/anxiety that may be contributing substantially to above symptoms. PLAN: DC antibiotics and watch. Await cultures and observe. Dermatology should probably see to try and figure out the skin lesions. HISTORY: This 30-year-old male is relatively poor historian. His wife is with and able to relate the history in some detail.
DC|discontinue|DC|206|207|RECOMMENDATIONS|2. Echo to check left ventricular function. 3. Check lipid profile and thyroid function tests. 4. Continue IV nitroglycerin and Aggrastat. 5. Beta blocker therapy and aspirin. 6. Cardiac rehabilitation. 7. DC cigarette smoking. 8. Cardiac catheterization and coronary angiography today. The risks and benefits have been explained to the patient.
DC|discharge|DC|235|236|ASSESSMENT/PLAN|1. Pain. The patient denies pain currently. Continue with p.r.n. Tylenol as ordered. 2. Dyspnea. The patient appears to be breathing comfortably. Will continue to monitor. 3. Constipation. Last bowel movement _%#MMDD2005#%_. Recommend DC with bisacodyl suppository 10 mg per rectum daily p.r.n. 4. CODE STATUS: THE PATIENT IS DNR/DNI. 5. Goals of care. Met with patient's children at length, both feels that they do not want to do anything to prolong their mother's life.
DC|discontinue|DC|151|152|ASSESSMENT/PLAN|I will hold the Amaryl for now to make sure this may not be contributing to his nausea. I will perform Accu-Cheks and sliding scale. 5. Nausea. I will DC all narcotics and pain pills and will treat him only with Tylenol. Continue his Protonex. I will DC his Isordil. As stated above, we will hold his Amaryl for now.
DC|discontinue|DC|96|97|PLAN|2. Vancomycin red man's syndrome earlier of no clinical significance. PLAN: Restart vancomycin, DC Zosyn, get a culture of the wound and will see if any significant pathogens grow, overall would doubt there is major deep infection present HISTORY: This 40-year-old female is seen in consultation at the request Dr. _%#NAME#%_ _%#NAME#%_ due to possible left breast infection.
DC|direct current|DC|199|200|REASON FOR CONSULTATION|At that time she was in atrial fibrillation and was presenting with symptoms of fatigue, shortness of breath, and leg swelling. As her INRs have been therapeutic for at least 4 weeks, a synchronized DC cardioversion was carried out on _%#MM#%_ _%#DD#%_, 2002. She continued to have the same symptoms after cardioversion despite being in normal sinus rhythm, and when she came to the hospital she was found to have a creatinine of 4 and potassium of 5.9. Her blood pressure was low and heart rate was in the 50s.
DC|direct current|DC|306|307|PAST MEDICAL HISTORY|We are asked to address her paroxysmal atrial fibrillation. REVIEW OF SYSTEMS: As described in history of present illness, otherwise all were asked and are negative. PAST MEDICAL HISTORY: 1. Hypertension, poorly controlled secondary to multiple medical intolerances. 2. Paroxysmal atrial fibrillation with DC cardioversion in _%#MM2005#%_. 3. Hyperlipidemia. 4. Hypothyroidism. 5. Osteoporosis. 6. Anxiety. 7. Obstructive sleep apnea, currently on CPAP. 8. Transient ischemic attack in _%#MM2002#%_. 9. Stress test four years ago that was negative.
DC|discontinue|DC|205|206|PLAN|It is probably reasonable to treat with antibiotics even though it is not clear what we are treating exactly. I would agree with Levaquin alone and go to oral with it. Probably do another 7 days. Probably DC the Flagyl at this point in time as diverticulitis does not seem very likely. If fever relapses or worsens, again needs a bigger FUO workup, as diagnosis is unclear at this point.
DC|discontinue|DC,|163|165|PLAN|PLAN: 1. Psychiatric interventions per Dr. _%#NAME#%_. 2. Replace potassium. Check magnesium with next labs. 3. Continue Zantac 150 mg b.i.d. for reflux symptoms, DC, p.r.n. Zantac. 4. Clinical observation. Thank you for the consultation. We will follow along as indicated.
DC|discontinue|DC|203|204|RECOMMENDATIONS|4. EP evaluation of carotid function, i.e., a tilt table test and question the need of placement of a pacemaker. 5. Consider carotid ultrasound. 6. Oncologic followup with radiation and chemotherapy. 7. DC cigarette smoking.
DC|direct current|DC|160|161|ASSESSMENT AND PLAN|I will start the patient on Lopressor at 25 mg b.i.d. for better heart rate control. If patient remains in atrial fibrillation, I will consider proceeding with DC cardioversion after 3 weeks of full anticoagulation. Thank you for asking me to participate in the care of this patient.
DC|direct current|DC|199|200|ASSESSMENT|I will continue IV Amiodarone at 1 mg per minute for another 24 hours for better rate control and hopefully for pharmacologic conversion. If the patient does not convert in 24 hours, we may consider DC cardioversion. The patient had a normal echo on _%#MM#%_ _%#DD#%_. Consider repeating an echo if her condition does not improve. 2. ARDS. Primary consult is on case. The patient requires vent support.
DC|discontinue|DC|204|205|LABORATORY|Ongoing issue of suspected urinary tract infection. The patient indicates symptoms of urinary frequency q. 2 hours prior to overdose. Foley catheter placement as above. Urinalysis at the time of catheter DC demonstrated in excess of 3,000 white cells with 137 RBCs, 2 squamous epithelial cells, moderate bacteria with large leukocyte esterase, negative nitrate.
DC|discontinue|DC|191|192|ASSESSMENT/PLAN|At this point will check a head CT and an ECG and also send the patient to the floor with a sitter as she appears to be stable and does not appear to need continued ICU monitoring. Will also DC her Aricept as her son says that this has not been tolerated well in the past. Will ask the psych opinion about Risperdal. Although she does need medicine for agitation, it is possible that this was a side effect.
DC|District of Columbia|_%#CITY#%_,|227|237|REASON FOR CONSULTATION|The patient was on a trip with a group to _%#CITY#%_, _%#CITY#%_ where they had an appointment in the White House. The patient was accompanied by her father. Prior to the patient's departure, she was well. While in _%#CITY#%_, _%#CITY#%_, she was also in good health. They were in a motel/hotel type setting and ate all of their meals out, but Sunday, one day prior to her return to the _%#CITY#%_ _%#CITY#%_, the patient had noted some abdominal distress and nausea.
DC|discontinue|DC|159|160|IMPRESSION AND PLAN|We most likely can DC him tomorrow when we do get an organism. We will DC him most likely on amoxicillin and watch for sensitivities. He may be up and we will DC the immobilizer.
DC|discharge|DC|170|171|PLAN|No proprioception at toes. ASSESSMENT: As above. PLAN: Continue therapies. Working on ADL, strength, equipment needs, and transfers. The patient continues to make gains. DC planning and conference continues next week.
DC|direct current|DC|186|187|SUMMARY|I would consider electrical DC cardioversion if her atrial fibrillation persists despite ibutilide therapy. However, Ms. _%#NAME#%_ expresses a strong preference for avoiding electrical DC cardioversion unless her rhythm fails to convert either spontaneously or after ibutilide. A lipid profile will be obtained while she is in the hospital for further cardiovascular risk stratification.
DC|discontinue|DC|202|203|RECOMMENDATION|5. Continue IV nitroglycerin and subcu Lovenox. 6. Metoprolol, Lipitor, and aspirin. 7. Obtain old medical/cath records. 8. Strongly consider repeat cardiac catheterization and coronary angiography. 9. DC cigarette smoking. 10. Potassium supplementation.
DC|discontinue|DC|139|140|RECOMMENDATIONS|Therefore, not really compatible with endometritis but I suspect this is a very early process and likely led to labor. RECOMMENDATIONS: 1. DC gentamicin, she got one dose of 300 mg of gentamicin. 2. Continue Zosyn. 3. Recheck white blood count on _%#MMDD#%_. If temperature and white blood count down, okay for discharge on _%#MMDD#%_ with Augmentin 875 mg p.o. b.i.d. x10 days.
DC|direct current|DC|220|221|INDICATIONS FOR PROCEDURE|His INRS have been greater than 2.0 documented. He came today, unfortunately had a bit of a meal around 11:00 requiring a six hour wait. Accordingly he returned to Fairview Southdale's outpatient department for elective DC cardioversion. Has been relatively asymptomatic although slowed down by achy knee from previous sports injuries and chronic swelling of the right lower leg due to venous insufficiency and previous venous thrombotic disease.
DC|direct current|DC|144|145|IMPRESSION|He is currently recovering from anesthesia. He is still a bit somnolent but no obvious complications have been noted. IMPRESSION: 1. Successful DC cardioversion PLAN: 1. Continue amiodarone 20 mg a day and titrate up metoprolol for his decreased ejection fraction.
DC|discontinue|DC|343|344|PLAN|I think it is fairly likely that episode was angioedema as well and it is quite typical for several episodes to occur before diagnosis is made, the likely etiology here despite the ongoing use for 10 years is the lisinopril, a fairly classic drug for this occurrence. 3. Hypertension. PLAN: 1. IV Benadryl. Hold on steroids. Start if worsens. DC lisinopril. Consider alternative hypertension treatment neither ACE or ARBs; both of which are associated with this. Ancef for now but likely DC soon. DC Valtrex. HISTORY: This 50-year-old female seen in consultation from Dr. _%#NAME#%_ due to possible cellulitis or zoster.
DC|discontinue|DC|154|155|PLAN|DC lisinopril. Consider alternative hypertension treatment neither ACE or ARBs; both of which are associated with this. Ancef for now but likely DC soon. DC Valtrex. HISTORY: This 50-year-old female seen in consultation from Dr. _%#NAME#%_ due to possible cellulitis or zoster.
DC|discharge|DC|173|174|ASSESSMENT AND PLAN|This involved the common bile. No other labs. ASSESSMENT AND PLAN: 86-year-old female patient with biliary cancer. 1. Pain. The patient denies pain. Will monitor, recommend DC with Roxanol 5-10 mg p.o./sublingual q.2 hours p.r.n. 2. Dyspnea monitor. 3. Constipation. Denies constipation, no BM since admission.
DC|discontinue|DC|152|153|PLAN|5. Diabetes mellitus. 6. New confusion, etiology not clear, but it seems to be clearing currently. PLAN: 1. Imipenem for now acceptable, adjust dosage. DC Ancef. Cellulitis should be well covered by this as well. Re-adjust as cultures dictate in his clinical course. 2. Mycobacterium avium intracellulare, question treat, will review old records and reassess as an outpatient.
DC|discontinue|DC|345|346|PLANS|2. Peptic ulcer disease. PLANS: 1. Rocephin treating CAP, the failure of Zithromax in no way eliminates that diagnosis as a significantly high percentage of pneumococcus is fully resistant to Zithromax. 2. Await bronchoscopy results but overall would doubt TB , keep in isolation until the result is back but assuming AFB smear is negative, can DC isolation. HISTORY: This 29-year-old male is seen in consultation due to pneumonia.
DC|discontinue|DC|253|254|RECOMMENDATIONS|I have reviewed his head CT dated this morning, he does have a left anterior lateral MCA stroke with within Broca's area, however, the cisterns are entirely full, there is no evidence of significant midline shift. His sodium is 140. RECOMMENDATIONS: 1. DC the heparin. He should be placed on #2. 2. Aspirin 325 mg by mouth once a day and this should protect from the "stump effect."
DC|direct current|DC|247|248|HISTORY OF PRESENT ILLNESS|He was recently in the hospital and discharged after being found to have a pericardial effusion and atrial fibrillation. During that hospitalization he underwent transesophageal echocardiogram which showed no evidence of intracardiac clot. He was DC cardioverted and initiated on amiodarone. Since that time he has remained in sinus rhythm. However, he feels like he has had difficulty sleeping related to the amiodarone.
DC|discontinue|DC|78|79|PLANS|6. Hypertension. 7. Prior small-cell lung CA. 8. Diabetes mellitus. PLANS: 1. DC isolation. 2. Switch to Unasyn; at least one or two more days IV. Then options include: a. Treat four weeks as though endocarditis regardless (probably the Rocephin for ease of outpatient therapy).
DC|discontinue|DC|231|232|ASSESSMENT/PLAN|I have no reason to suspect at this point in time significant structural heart disease or dysrhythmia as the cause. She has been in complete sinus rhythm throughout. Preliminary results of her echocardiogram were normal. Recommend DC hydrochlorothiazide, consider neurology consultation. Probably very little to do for her extensive intracranial disease other than make sure her blood pressure may need to error leaving her blood pressure on the high side, particularly if her nutrition and hydration status is marginal.
DC|discontinue|DC|210|211|RECOMMENDATIONS|The patient has started taking orally and the drip is not sufficient to treat his prandial increases in sugar. RECOMMENDATIONS: 1. The patient will be transferred out of the ICU and therefore will go ahead and DC his drip upon doing so. 2. Check blood sugar and give him an appropriate dose of NovoLog subcutaneously based on his sugar.
DC|direct current|DC|157|158|PAST MEDICAL HISTORY|He has two sons. He does have a glass of wine daily. PAST MEDICAL HISTORY: 1. Atrial fibrillation, treated three years ago with Coumadin for six weeks, then DC cardioversion, now in sinus rhythm. 2. Stress test three years ago was normal, per the patient report. 3. Hypertension. 4. Hyperlipidemia. FAMILY HISTORY: No family history for early coronary artery disease or known atrial fibrillation.
DC|discontinue|DC|144|145|PLANS|7. Cardiomyopathy. 8. Prior toe osteomyelitis and amputation with no active infection currently. 9. Sulfa and erythromycin allergies. PLANS: 1. DC the vancomycin, no need to treat coag negative staph, probably reasonable to treat longer here both from the biliary standpoint and for the strep salivarius but do not need IV antibiotics in this setting.
DC|discontinue|DC|157|158|RECOMMENDATIONS|Would probably not go any further in terms of heart imaging, etc. 2. Recheck blood cultures from both the Pseudomonas and coag negative Staph standpoint. 3. DC Zosyn and switch over to imipenem and tobramycin. Would not feel committed to double coverage here but will cover double while she is in the hospital.
DC|District of Columbia|_%#CITY#%_.|199|209|SOCIAL HISTORY|She lives on the 10th floor with access via elevator and no stairs required. She is retired from having worked for the federal government as a stenographer and administrative assistant in _%#CITY#%_ _%#CITY#%_. FUNCTIONAL HISTORY: Prior to these hospitalizations, she was fully independent with her mobility without assistive device, independent with all activities of daily living, including meals, finances and driving, though the latter was only done in non-rush hour and not on freeways or at night.
DC|discontinue|DC|169|170|RECOMMENDATIONS|4. Check lipid profile and thyroid function tests. 5. Adenosine Cardiolite stress test in a.m. to check his status. 6. Diabetic therapy. 7. Antihypertensive therapy. 8. DC cigarette smoking.
DC|direct current|DC|137|138|IMPRESSION/REPORT AND PLAN|He had many questions regarding surgical maze, catheter based ablation, and AV node ablations. Mr. _%#NAME#%_ is willing to proceed with DC cardioversion today. I did tell him that it would be useful to obtain a transthoracic echo to evaluate for any structural heart disease since it has been many years since his last echocardiogram.
DC|discontinue|DC|143|144|PLANS|2. Chronic renal failure; on dialysis. 3. Three weeks of right eye vision loss; question embolic lesions. PLANS: 1. Vancomycin dose currently. DC Tequin. 2. Follow up serial blood cultures until clear. If not clear, she needs the Quinton out definitively; even if not clearing, may be best to remove it.
DC|discontinue|DC|140|141|PLAN|PLAN: 1. Eventual pulmonary function tests. 2. Agree with Xopenex nebs. 3. Agree with Solu-Medrol dose. 4. Agree with antibiotic choice. 5. DC Atrovent MDI and change to nebulizer therapy. 6. Could eventually change this to Combivent MDI upon discharge, as well as steroid MDI upon discharge.
DC|direct current|DC|306|307|RECOMMENDATIONS|They were well aware of these. RECOMMENDATIONS: 1. In view of the fact that the patient had begun treatment with amiodarone, I would continue the combined treatment of calcium channel blocker, beta blocker, and amiodarone IV. The patient should be planned for a transesophageal echocardiogram and elective DC cardioversion after about three days of amiodarone loading. At that point, assuming cardioversion is successful, she should be maintained on amiodarone at 400 mg a day for two weeks and then 200 mg daily.
DC|discontinue|DC|203|204|RECOMMENDATIONS|RECOMMENDATIONS: 1. Suction posterior oral pharynx. 2. Recheck chest x-ray per patient's family's wishes. 3. It would be appropriate for comfort care, given the patient's previously expressed wishes, to DC IV fluids, antibiotics, nutrition and initiate morphine sulfate therapy with hospice consult. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is an 80-year-old female who was brought into the emergency room via EMS after she had some vomiting at the nursing home which progressed to brown emesis.
DC|discontinue|DC|211|212|PLAN|ASSESSMENT: Potentially overmedication with decreased mental status and with an unclear etiology as to cause, and pain secondary to metastatic bone disease with a primary CA site in the lung. PLAN: 1. Recommend DC the Duragesic patches. 2. I recommend IV Dilaudid 0.4 mg every 4 hours p.r.n. After she is awake, which should probably be about midnight or 3:00 this morning that she may awakens, if her decreased mental status is related to the Duragesic patches.
DC|discontinue|DC|369|370|ASSESSMENT/PLAN|He has a creatinine here that is 1.52, BUN 18, glucose 100, hemoglobin 12.8. Hemoglobin on _%#MM#%_ 26 was noted to be 13.8. ASSESSMENT/PLAN: The patient is an 80-year-old male with a history of BPH and hypertension and coronary artery disease, who presents for cystoscopy and TURP. He is postoperative day #1. Problems are as follows: 1. Postoperative day #1. We will DC his IV fluids as the patient is taking p.o. well. The patient has a history of coronary artery disease and hypertension and likely has some element of diastolic dysfunction and therefore we should be very careful with the fluids.
DC|direct current|DC|178|179|IMPRESSION|2. Digoxin added at 0.25 mg a day after loading dose of 0.75 mg a day. 3. Continue betapace and Coumadin. 4. Followup with Dr. _%#NAME#%_ for decision with regards to subsequent DC cardioversion and antiarrhythmic therapy. I have spoken to the patient and his wife and I have spoken to Dr. _%#NAME#%_.
DC|discontinue|DC|226|227|PLAN|4. Penicillin allergy and Sulfa allergy. 5. Recent Herpes stomatitis which looks relatively controlled presently although considerable crusting is still present. 6. Crohn's disease. 7. Atrial fibrillation. PLAN: 1. Agree with DC acyclovir, watch closely and add back as needed. 2. Vancomycin for the MRSA and intra-abdominal coverage along with Tequin and Flagyl he is on.
DC|direct current|DC|173|174|ASSESSMENT AND RECOMMENDATIONS|His ejection fraction is only 30%. At the present time I would recommend an EP study, mainly because there was a description of sustained ventricular tachycardia before the DC shock. If he had inducible ventricular tachycardia or ventricular fibrillation I would recommend an ICD implantation. If his EP study is negative I would then recommend repeat echocardiogram in about one month.
DC|discontinue|DC|187|188|ASSESSMENT/PLAN|She probably has angina in and her anginal equivalent is the right shoulder pain that the patient attributed to surgery. Currently, the patient is on aspirin and lisinopril would like to DC her the calcium channel blocker and start Toprol 25 b.i.d. In addition, she will be on aspirin and we have restarted her heparin and her nitroglycerin, given the fact that she has pain.
DC|direct and consensual|DC.|157|159|PHYSICAL EXAMINATION|Her neck is supple. There are no carotid bruits. Her fundi are benign with intact visual fields to confrontation. Her pupils are equal and reactive to light DC. Eye movements are full without nystagmus. Her face appears symmetrical with equal sensation and motion bilaterally. Hearing is intact on bedside observation. Her palate and uvula elevate in the midline.
DC|direct current|DC|320|321|IMPRESSION|He had been in atrial fibrillation for 12 hours. He has been on chronic Coumadin, albeit his INR has been low at 1.8. We would like to have his INR between 2.0 and 3.0. The patient will be discharged likely later tonight and I will discuss further anti-arrhythmic therapy with him. IMPRESSION: 1. Uncomplicated elective DC cardioversion, rapid atrial fibrillation. 2. AV conduction system dysfunction. PLAN: As above.
DC|discontinue|DC|93|94|PLANS|2004 episodes similar to above without clearcut diagnosis made. PLANS: Continue Rocephin but DC if culture negative. Despite the recent antibiotics this does not fit with a partially treated meningitis; try to get herpes simplex and enterovirus PCRs on the CSF.
DC|discontinue|DC|186|187|RECOMMENDATIONS|Fortunately these are reversible factors and his renal function should return to baseline. RECOMMENDATIONS: 1. Dialysis today and tomorrow with reassessment after that. 2. DC Diovan. 3. DC Lasix.
DC|discontinue|DC|227|228|ASSESSMENT/PLAN|Hyponatremia, probably secondary to dehydration. Patient seems to have a combination of things causing her hyponatremia. She has been continued on her regular Lasix and spironolactone which is known to cause hyponatremia. Will DC her spironolactone for the time being and cut down her Lasix to half at 40 b.i.d. Will try to obtain old records to make sure that she has had an evaluation for lower extremity edema and would suggest that she might just be discharged on Lasix and TED stockings as a combination of the two probably is too dehydrating for her as she does say she has had an ongoing problem with dry mouth and certainly if she gets in situations where she is not taking good p.o. like presently, she is going to be certainly at risk for hyponatremia and/or acute renal failure.
DC|discontinue|DC|191|192|ASSESSMENT/PLAN|6. Disposition. Waiting list at NC Little, they are looking at a nursing home with hospice. 7. Other recommendations. a. DC all labs. b. DC all other p.o. meds, except above and Decadron. c. DC Lovenox. Thank you for the opportunity to assist in the care of this pleasant gentleman.
DC|discontinue|DC|179|180|RECOMMENDATION|3. Continue to hold both lisinopril and metoprolol in this clinical setting. 4. No ongoing use of diuretics at this point. 5. Normal saline as IV fluid of choice at this time. 6. DC Toradol. 7. Blood cultures. 8. Continue antibiotics. 9. No K supplements. 10. Check troponin. 11. No need for ongoing or emergent ICU transfer at this point.
DC|discontinue|DC|100|101|PLAN|3. New rash, imipenem, likely suspect here. 4. Prior candidemia gram negative rod bacteremia. PLAN: DC imipenem switch to vancomycin, Levaquin and tobramycin until further culture information is available and adjust antibiotics at that time as well on line viability.
DC|direct current|DC|344|345|HISTORY OF PRESENT ILLNESS|Prior to _%#MM2006#%_ he was able to perform all his daily activities including climbing several flights of stairs and walking briskly but currently he is unable to do any of that secondary to his significant shortness of breath. He has never been presyncopal or syncopal. He was cardioverted in _%#MM2006#%_ and has subsequently undergone two DC cardioversions, most recently on _%#MMDD2006#%_. He is also on Metoprolol 50 mg twice daily and Rythmol 150 mg 3 times daily. His INR has been poorly controlled. When he was admitted yesterday, his INR was 5.69 and is currently 4.51. The patient notes that he is quite fed up with this and is unable to carry on with his life and would like some form with definitive therapy performed if at all possible.
DC|discontinue|DC|170|171|RECOMMENDATIONS|4. Check lipid profile. 5. Continue Atenolol, probably taper, DC Cardizem. 6. Continue IV Heparin. 7. Stress test, probable Adenosine Cardiolite. 8. Review old drugs. 9. DC caffeine and alcohol use. Thank you very much for this cardiology consultation.
DC|discontinue|DC|192|193|IMPRESSION|I will give her Terbutaline for now. If she has greater than six uterine contractions per hour, would consider short term magnesium sulfate until 36 weeks. 3. Gestational diabetes on insulin. DC insulin drip for now. Get endocrine consult. PLAN: 1. Endocrine consult. 2. Terbutaline 2.5 mg PO q three.
DC|discontinue|DC|234|235|RECOMMENDATIONS|6. Gout currently on both colchicine and prednisone. Certainly exacerbated by the use of hydrochlorothiazide in this setting. RECOMMENDATIONS: 1. No nonsteroidals. 2. Discontinue hydrochlorothiazide. 3. Decrease ARB. 4. Repeat UA. 5. DC Septra. 6. Will follow chemistries with you on attempt to alleviate any further nephrotoxic infusions. HISTORY: Please see detailed history and physical regarding the circumstances surrounding the admission of Mr. _%#NAME#%_ _%#NAME#%_ in the setting of known congestive heart failure and valvular heart disease.
DC|discontinue|DC|130|131|ASSESSMENT/PLAN|Call Dr. _%#NAME#%_ if abnormal. Perform postvoid bladder scan today, _%#MMDD#%_. Call Dr. _%#NAME#%_ if residual is over 150. 7. DC previous Tylenol orders. Start Tylenol 1000 mg q.i.d. p.r.n. for pain.
DC|discontinue|DC|405|406|PLANS|2. Joint inflammatory process, doubt infected joints including tap which does not show this, possibly a reactive process to infection, but Staph bacteremia would be relatively unlikely; seems more likely this is a primary connective tissue disease or secondary joint problem to some other noninfectious process. PLANS: 1. Vancomycin for now, but if _%#MMDD2002#%_ blood culture is still negative, I would DC on _%#MMDD2002#%_ and watch; re-culture in 2-3 days. I do not think the UTI per se needs significant lengthy therapy.
DC|discontinue|DC|218|219|ASSESSMENT/PLAN|Neurology is following. 6. Elevated blood sugars. The patient has no known previous history of diabetes. This is possible related to her acute stressors and IV fluids and tube feeds, which did contain glucose. We will DC her NPH and start Lantus for continuous insulin therapy. We will perform Accu-Cheks q.i.d. and we will continue sliding scale regular insulin along with check of hemoglobin A1C.
DC|discontinue|DC|256|257|PLANS|2. Prior splenectomy for spherocytosis and anemia, thus any febrile illness including current illness must be assumed to be bacterial based on risk level. PLANS: Levaquin alone. This should be acceptable cover usual splenectomy related infection syndrome. DC vancomycin and Rocephin. DC isolation. We will check CMB, but hold off on a bigger FUO workup as it appears she is likely getting better and yield will be very low workup here.
DC|discontinue|DC|190|191|PLAN|PLAN: 1. I would like to intervene at those inflammatory mediators with topical ketoprofen gel t.i.d. and then follow as needed. 2. I would be to maximize the Tylenol to 3000-4000 mg a day, DC the Vicodin and instead use oxycodone without Tylenol in it, but I will follow with her as needed. ADDENDUM PHYSICAL EXAMINATION: GENERAL: The patient is alert and oriented.
DC|direct current|DC|25|26|PROCEDURE|PROCEDURE: Semi-elective DC cardioversion for acutely controlled atrial fibrillation. INDICATION FOR PROCEDURE: Recurrent atrial fibrillation in a patient who previously has not been on anticoagulation.
DC|discontinue|DC|161|162|PLAN|3. Hypertension. 4. Coronary artery disease. 5. Penicillin allergy. PLAN: Await lumbar puncture but assuming it shows no evidence of infection, DC isolation and DC antibiotics. Start Flagyl 250 p.o. q.i.d. as though we are treating C. Difficile. Follow white count, fevers, etc. HISTORY: This 71-year-old female has had a complicated history over the last couple of months.
DC|discontinue|DC|257|258|PLAN|PLAN: I would simply focus on the pneumonia issue, treat with Levaquin, would check a urine culture if there has not been one and make sure there is not a more resistant organism, but would focus on the pneumonia. Would do a 7-day course of Levaquin. Could DC Zithromax. Has had adequate coverage. I would ignore the MRSA other than continued isolation and not treat the resistant organisms in the leg for now.
DC|discontinue|DC|135|136|ASSESSMENT/PLAN|2. Uncontrolled diabetes mellitus 2. Will DC patient's metformin will cover with insulin sliding scale and Accu-Cheks q.i.d. will also DC the D5 in his IV fluids. 3. Possible acute renal failure. Unclear if this represents chronic kidney disease with patient's simply being unaware of his chronic diagnoses.
DC|direct current|DC|147|148|ASSESSMENT AND PLAN|At this point a few options are available. We can try anticoagulation with rate control with diltiazem and it may be reasonable to do a TEE guided DC cardioversion since her symptoms have not been very specific. We are not sure whether or not this is really paroxysmal atrial fibrillation, but she has symptoms for a couple of days.
DC|discontinue|DC|129|130|IMPRESSION|If she goes for an angiogram, will treat her with Mucomyst and IV fluids. Will hold the Lasix and DC the Aldactone. We will also DC the Cozaar and will follow up on labs and urinary output post angiogram.
DC|direct current|DC|155|156|HISTORY|She was brought into the Clinic where resuscitation was initiated immediately for what was determined to be ventricular fibrillation. She received several DC electric shocks until the paramedics arrived and brought her to the Fairview Southdale emergency room where several more shocks were required.
DC|discontinue|DC|146|147|ASSESSMENT AND PLAN|He does appear asymptomatic in this regard. I would note however, if he does continue to exhibit significant ortho stasis it may be beneficial to DC the clonidine in favor of some other less vasoactive drug. 3) Viral URI now resolving. I would be happy to follow-up with other concerns if they may arise during the hospitalization.
DC|discontinue|DC|140|141|PLAN|5. Prior relapsing C. difficile colitis, but seems controlled. PLAN: I agree with Levaquin and Flagyl. We will also add vancomycin back and DC the Septra for now. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 48-year-old female seen in consultation for the hospitalist service due to apparent new sepsis syndrome.
DC|direct current|DC|271|272|IMPRESSION, REPORT AND PLAN|She has been chronically anticoagulated with Coumadin. Since she has had relatively few episodes of atrial fibrillation, she is asymptomatic now, I would favor rate control over an antiarrhythmic drug at this time. If she remains in atrial fibrillation, I would consider DC cardioversion but would maintain only the dose of atenolol. Since she has been chronically anticoagulated she would most likely not require DC cardioversion, we would request her previous INRs over the last 3 weeks and if her INRS have been therapeutic we could proceed with DC cardioversion tomorrow if she is still in atrial fibrillation.
DC|discontinue|DC|71|72|PLAN|5. Steroid-induced diabetes. 6. Gastroesophageal reflux disease. PLAN: DC antibiotics and watch. Reculture again next spike. If continued fever will check CT scan of the abdomen soon. Question what are the bone marrow results, certain he is still in remission.
DC|discontinue|DC|134|135|PLANS|Most likely a viral meningitis although with confusion, have to consider herpes simplex. PLANS: 1. Agree with continuing acyclovir 2. DC isolation 3. DC antibiotics. 4. Check PPD and enterovirus on the CSF 5. Await the herpes simplex. Will rely on it to further clarify.
DC|discontinue|DC|146|147|PLANS|3. DC antibiotics. 4. Check PPD and enterovirus on the CSF 5. Await the herpes simplex. Will rely on it to further clarify. If negative, probably DC acyclovir as well. If he continues to have fever, may have to investigate further. HISTORY: This 40-year-old male was in his usual state of health until two weeks ago.
DC|discontinue|DC|136|137|PLANS|4) LEVAQUIN ALLERGY. PLANS: 1) Check blood cultures, parvovirus serologies, CMV serology, ANA, rheumatic factor, ASO and Lyme titer. 2) DC antibiotics and watch. 3) Follow for next symptoms to develop; suspect this is some type of viral syndrome; it is certainly an acute rheumatologic illness, rheumatic fever, etc.
DC|discontinue|DC|202|203|IMPRESSION|I would recommend an ENT consult. Apparently Dr. _%#NAME#%_ was called by the nursing staff for this and he declined to pursue. I would put the patient on lemon drops or lemon wedges. I would recommend DC of Decadron. I would also recommend DC of Benadryl as the Benadryl may decrease salivary secretions and actually slow the patient's response.
DC|discontinue|DC|158|159|PLAN|All occurred one week after an animal bite (fisher) from trapping, question viral illness, histoplasmosis, blasto, _______________ or leptospirosis. PLAN: 1. DC Zosyn. No obvious bacterial etiology of conventional sort and has already had negative blood cultures, check serologies and watch closely.
DC|discontinue|DC|138|139|5. TPN.|2. IV colloid. 3. Obtain echocardiogram to evaluate for left ventricular function. 4. Change antibiotics from Invanz to Zosyn. 5. TPN. 6. DC the nonsteroidals if she is currently receiving Toradol. 7. Proton pump inhibitor. 8. Obtain urinalysis and urine sodium. 9. Change IV fluid. 10. Change dopamine to norepinephrine. 11. We will attempt increase in her perfusion and her blood pressure and deal with her extravascular volume as able to at a later date.
DC|District of Columbia|_%#CITY#%_.|131|141|SOCIAL HISTORY|She works as an aircraft cleaner for Northwest Airlines. For the last two weeks she has been commuting between here and _%#CITY#%_ _%#CITY#%_. Her husband works at Ford Motors. FUNCTIONAL HISTORY: She was independent in ADLs mobility.
DC|discontinue|DC|148|149|RECOMMENDATIONS|Hopefully, these represent an atypical pneumonia. I doubt that this is secondary to his underlying fibrosis. RECOMMENDATIONS: 1. Echocardiogram. 2. DC the Solu-Medrol and start lower dose prednisone. 3. Sputum culture. 4. Empiric antibiotics. Thank you for the opportunity to participate in the care of this patient.
DC|discontinue|DC|192|193|RECOMMENDATIONS|4. Congestive heart failure, reduced ejection fraction, probably ischemic cardiomyopathy. 5. MRSA urinary tract infection. RECOMMENDATIONS: Spironolactone has already been discontinued. Would DC I.V. fluids. Limit his total fluids to less than 1200 cc daily. Follow up urine sodium and urine osmolality. If K continues in current range, probably okay to continue the ACE inhibitor.
DC|discontinue|DC|76|77|RECOMMENDATIONS|There is no evidence of active urinary tract infection. RECOMMENDATIONS: 1. DC Foley. 2. Consider trial on oral intake today as tolerated. 3. We will repeat the CT scan with and without contrast a bit down the road.
DC|discontinue|DC|147|148|IMPRESSION|Would try to slow her rate prior to surgery by starting her on a low dose of a beta blocker, will start 12.5 mg p.o. b.i.d. with parameters. Would DC her metformin and place her on Accu-Cheks q.4h. per the protocol. Will keep her n.p.o. in anticipation that she will be going to surgery.
DC|discontinue|DC|122|123|PLANS|Previous MRSA colonization but likely has cleared, this was some time ago. Will add vancomycin to the Zosyn currently and DC the Rocephin. Would normally agree with waiting on any amputations as further tissue salvage is certainly possible, but if the legs turn out to be the source of this fever, almost certainly will need earlier intervention.
DC|discontinue|DC|112|113|RECOMMENDATIONS|2. Rash, resolved, likely nafcillin. 3. Diabetes. 4. NonST elevation myocardial infarction. RECOMMENDATIONS: 1. DC vancomycin and ceftriaxone. 2. Ortho to followup and to arrange reimplantation. 3. Will notify Dr. _%#NAME#%_ of the patient's admission. Thank you for involving me in his care.
DC|discontinue|DC|138|139|PLAN|The line has been pulled, fever has resolved. 2. Urinary tract infection, question resolved. 3. Hyperlipidemia. 4. Hypertension. PLAN: 1. DC vancomycin. 2. Start caspofungin and recheck blood cultures. If Candida albicans turns out to be the organism we will switch to oral Diflucan with a plan for approximately 2 weeks, even if follow-up blood culture is positive, that might extend the duration but Diflucan is still acceptable.
DC|direct current|DC|160|161|DISCUSSION|She was also noted at the scene to have a wide-complex tachyarrhythmia for which paramedics first tried adenosine without any change and subsequently 100 joule DC countershock which dropped the heart rate to 110. The patient was admitted to the Intensive Care Unit with a suspicion of sepsis, chest x-ray showing a right basilar infiltrate not present previously.
DC|discontinue|DC|244|245|PLAN|MPRESSIONS: 1. This is a 46-year-old male with progressive, likely chronic pneumonia, certainly not a conventional bacterial process with some degree of ongoing fever, etiology unclear. 2. Prior renal transplant so is a compromised host. PLAN: DC doxycycline (You are looking in not the differential diagnosis here.) Smear is negative. Platelets are not low and he has not been in an endemic area.
DC|discontinue|DC|258|259|REVIEW OF SYSTEMS|Unsure of what children do to support themselves. REVIEW OF SYSTEMS: She is receiving morphine, 10 mg IV, over the last 24 hours p.r.n. No bowel movement since rectal tube removed on _%#MMDD#%_. Not weaning well and family needing to make decision regarding DC tube or DC trach or tracheostomy. The son relates that Dr. _%#NAME#%_ told them a decision did not have to be made until Monday _%#MMDD2004#%_.
DC|discontinue|DC|269|270|REVIEW OF SYSTEMS|Unsure of what children do to support themselves. REVIEW OF SYSTEMS: She is receiving morphine, 10 mg IV, over the last 24 hours p.r.n. No bowel movement since rectal tube removed on _%#MMDD#%_. Not weaning well and family needing to make decision regarding DC tube or DC trach or tracheostomy. The son relates that Dr. _%#NAME#%_ told them a decision did not have to be made until Monday _%#MMDD2004#%_.
DC|discontinue|DC|178|179|PLAN|The patient's bleeding also appears to have stabilized and ceased. She has a good hemoglobin, which will be followed with hydration. 2. Provide supportive care, IV Protonix, and DC the NG tube. 3. Will follow hemoglobins and clinical parameters. No need currently for EGD and was continuing to have evidence of ongoing GI bleeding.
DC|direct current|DC|167|168|PHYSICAL EXAMINATION|Will try to treat him with amiodarone. Perhaps try intravenous magnesium. Will check a digoxin level. If he has not converted by tomorrow, will anticipate low voltage DC cardioversion. IMPRESSION: 1. Chest pain associated with ventricular tachycardia. Hard to know which comes first, the tachycardia or the chest pain.
DC|discontinue|DC|160|161|PLANS|10. Erythromycin and sulfa listed allergies. Would suspect erythromycin is GI related rather than a true allergy. PLANS: 0. V1. ancomycin and Rocephin for now. DC the Cleocin (even if this is aspiration very unlikely to be anaerobes given she has been in the hospital and nursing home substantially recently.
DC|discontinue|DC|146|147|ASSESSMENT/PLAN|3. Congestion. The patient is congested. I recommend scopolamine patch, change q.72h. 4. Other comfort care recommendations include DC IV fluids, DC IV antibiotics, DC all labs, vital signs and all therapies. 5. Family support. Met with the entire family who want the patient to be comfort care.
DC|discontinue|DC|126|127|RECOMMENDATIONS|RECOMMENDATIONS: 1. PICC on Monday, if blood cultures are negative. 2. Follow up cultures. 3. Continue vancomycin for now. 4. DC Tequin. 5. Six weeks of IV antibiotic treatment. 6. Consider chronic suppressive treatment with Penicillin V if sensitive organism.
DC|discontinue|DC|100|101|RECOMMENDATIONS|Doubt this is a sign of some other systemic infection process or part of #1 above. RECOMMENDATIONS: DC isolation. Doubt this has been community-acquired MRSA and we have no positive cultures. No antibiotics for now. Benadryl hold on steroids for now.
DC|discharge|DC|202|203|ASSESSMENT AND PLAN|3. Agitation, recommend Haldol solution 2 mg per ml. 0.5 to 1 mg sublingual q 4 hours p.r.n. Also recommend Ativan solution 2 mg per ml. 0.5 to 1 mg sublingual q 4 hours p.r.n. 4. Secretions. Recommend DC with scopolamine patch, have available if gets congested. 5. Fever. Recommend DC with p.r.n. Tylenol suppository for fever 6. Psychosocial, spiritual needs. TLC Chaplain _%#NAME#%_ _%#NAME#%_ met with the patient's family this a.m. to offer support.
DC|discharge|DC|146|147|ASSESSMENT AND PLAN|0.5 to 1 mg sublingual q 4 hours p.r.n. 4. Secretions. Recommend DC with scopolamine patch, have available if gets congested. 5. Fever. Recommend DC with p.r.n. Tylenol suppository for fever 6. Psychosocial, spiritual needs. TLC Chaplain _%#NAME#%_ _%#NAME#%_ met with the patient's family this a.m. to offer support.
DC|discontinue|DC|274|275|ASSESSMENT/PLAN|ASSESSMENT/PLAN: 1. Chest pain, unlikely acute coronary syndrome, most likely due to gastroesophageal reflux disease (GERD) and gastritis with hiatal hernia. Will start empiric therapy with PO Protonix. Troponin and ECG are negative. Will also treat with Maalox p.r.n. Will DC his vitamin C and vitamin E. 2. Nausea. Will continue p.r.n. IV Zofran and will DC Morphine. Would switch to IV Dilaudid p.r.n. to see if nausea will improve with change in narcotic and also with treatment of GERD.
DC|District of Columbia|_%#CITY#%_.|149|159||_%#NAME#%_ _%#NAME#%_ is a 33-year-old young woman seen for evaluation of seizure. She moved here in _%#MM#%_ following her divorce from _%#CITY#%_. _%#CITY#%_. She is on the methadone program and also been followed by psychiatry for substantial depression. Her methadone clinic is the Alliance Clinic. I don't recall the name of her psychiatrist.
DC|discontinue|DC|89|90|PLANS|2. Prior major leg infection. 3. Penicillin allergy. PLANS: Add Fortaz to vancomycin and DC clindamycin. Will also give one dose of tobramycin. If we do another I&D or dressing change, it would be of value to do swab culture of the wound to see what is colonizing it superficially.
DC|discontinue|DC|128|129|RECOMMENDATIONS|Medically she is quite stable. She has numerous chronic medical issues but these are stable. RECOMMENDATIONS: 1. Agreement with DC of Aleve. I would increase her Prevacid to 30 mg b.i.d. I would follow her blood pressure and would not change her medications currently.
DC|discontinue|DC|120|121|PLAN|He states it has been 2 weeks. He has been a patient here since _%#MMDD2007#%_, will follow up with that. PLAN: 1. Will DC all the Tylenol because he is at risk with his polysubstance abuse of liver dysfunction. 2. Will start Lidoderm patches, one in the epigastrium, one in the right upper quadrant.
DC|direct current|(DC)|231|234|REASON FOR CONSULTATION|His initial rhythm appeared to be atrial flutter. An atrial flutter ablation was attempted. It turns out that the patient has atypical atrial flutter. Actually, he reverted into atrial fibrillation immediately after direct-current (DC) cardioversion. The patient had a long sinus asystolic period noted and a dual-chamber permanent pacemaker was implanted. Since discharge, the patient continued to experienced pleuritic-type chest pain.
DC|direct current|DC|243|244|IMPRESSION, REPORT AND PLAN|This should be followed in three to six months. In addition, we will keep her magnesium greater than 2 and her potassium greater than 4. At this point, there is no indication for initiating anti-arrhythmic drug. In addition, no indication for DC cardioversion. This is consistent with the AFFIRM trial for rate control and anticoagulation. We will discuss this with attending.
DC|discontinue|DC|124|125|IMPRESSION|We will continue the Azactam and Tequin for now. 3. Renal. There are no recent laboratories. We will recheck these. We will DC the Lasix and Vioxx. I am going to change the IV fluids to D5 normal saline at 150 cc an hour. We will volume expand her for her low blood pressure.
DC|discontinue|DC|167|168|PLAN|2. Acute influenza which is resolving after adequate Tamiflu therapy. 3. Hypertension. PLAN: 1. DC Tamiflu and DC droplet precautions, has been treated adequately. 2. DC vancomycin, switch to Zyvox 500 mg p.o. b.i.d. Would do 5 more days. If he does not have coverage for this at discharge tomorrow, switch to trimethoprim, sulfamethoxazole DS b.i.d. for another 5 days.
DC|discontinue|DC|265|266|IMPRESSION AND PLAN|In the future, if his symptoms of prostatism are relieved by the surgery, I would consider stopping his alpha blocker (Cardura) and switching to an ACE inhibitor. 2. Prostate carcinoma, status-post prostatectomy, per Dr. _%#NAME#%_. He is on a PCA analgesia. Would DC his IV fluids when he is taking p.o. well, check hemoglobin as you are doing. Encourage incentive spirometry q 2 hours while awake.
DC|discontinue|DC|141|142|PLAN|2. Diabetes mellitus. 3. Hypertension. 4. Atherosclerotic cardiovascular disease. PLAN: Rocephin one more day but if all negative, still can DC it. Check LFTs, sed rate, parvovirus serology, likely a viral syndrome and so would go slow on a major workup unless hematology things differently.
DC|discontinue|DC|85|86|RECOMMENDATIONS|The possibility of small bowel to periumbilical fistula. RECOMMENDATIONS: 1. DC 6MP, DC methotrexate and decrease steroids. 2. Maximize lipids and total parenteral nutrition. 3. He will need surgery during this hospitalization. 4. NG tube for decompression.
DC|discontinue|DC|58|59|PLAN|6. Prior total hip arthroplasty. PLAN: 1. Continue Ancef, DC vancomycin, await cultures and adjust. Orthopedics to see. Likely needs hip removal, at the very least needs a hip tap. No options for outpatient treatment at this point. She failed outpatient therapy from my standpoint and needs something different than vancomycin anyway, given the failure here.
DC|discontinue|DC|150|151|ASSESSMENT/PLAN|He will be on the potassium replacement protocol. He will have his magnesium checked and magnesium will be replaced if low. 3. Insomnia. Patient will DC his Restoril. He will continue Ambien as needed. 4. Obstructive sleep apnea: The patient does not use BiPAP. He will be monitored for hypercapnia. 5. Pain. The patient will continue on morphine.
DC|District of Columbia|_%#CITY#%_.|179|189|SOCIAL HISTORY|He states he smokes for special occasions and drinks occasionally, usually during the game and limits himself to a few beers. He has 1 daughter who currently lives in _%#CITY#%_, _%#CITY#%_. He did have a lengthy cognitive exam and evaluation during his last hospitalization, although there was some disagreement between the hospital providers assessment of his ability to make self decisions.
DC|direct current|DC|377|378|IMPRESSION|I am confident that with the use of Cardizem alone, we should bring his heart rate under good control. He has already been started on IV heparin. I think the safest plan would be to therapeutic anticoagulate him with Coumadin, aiming for an INR of between 2 to 3, and once this has been achieved for a period of 3-4 weeks, we can readmit him again to have him undergo elective DC cardioversion. There is little in his history to point to a contributing cause for his atrial fibrillation.
DC|District of Columbia|_%#CITY#%_.|181|191|SOCIAL HISTORY|4. Status post ankle surgery. ALLERGIES: Augmentin - hives. FAMILY HISTORY: Sister with diabetes mellitus. Brother with ITP. SOCIAL HISTORY: Married and lives at home in _%#CITY#%_ _%#CITY#%_. She is a stay at home mother. Tobacco none. REVIEW OF SYSTEMS: Recent fever, chills, cough, chest pain, dyspnea, no dysuria or diarrhea.
DC|discontinue|DC|172|173|RECOMMENDATIONS|She certainly could be bacteremic but thus far, blood cultures are negative. RECOMMENDATIONS: 1. DC vancomycin and acyclovir. 2. Ceftriaxone to 1 gram IV q. day, and would DC if blood cultures remain negative tomorrow. 3. DC isolation. 4. Check liver tests. 5. Follow blood and urine cultures. 6. Probable discharge tomorrow if temperature remains down and blood cultures remain negative.
DC|discontinue|DC|385|386|PLAN|The parents are using it and the nurses are using it, and in our system review of medication safety, incidences occur with the patient is accidentally overdosed when that scenario exists, so will get rid of that variable right now, increase the basal rate of the hydromorphone to 0.6 mg an hour and then have nursing give nurse-administered hydromorphone 0.4 mg every hour p.r.n. Will DC the IV morphine due to pressure problems. 7. Ketoprofen gel around the dressings every 4 hours. 8. When I can see that his pain is under control, I will reduce the basal rate, as I want to also then reduce the risk of respiratory depression.
DC|discontinue|DC|133|134|PLANS|5. Diabetes mellitus. 6. Alcohol abuse. 7. Atelectasis in the bases of the lungs. I doubt significant pneumonia. PLANS: I agree with DC of Zosyn and not using broad antibiotics at this point, vancomycin alone. I would doubt for need for long-term antibiotics to recheck blood cultures now to see if he has ongoing bacteremia.
DC|discontinue|DC|311|312|PLANS|2. Anemia. 3. Depression. 4. Sulfa allergy. In addition, during her last hospitalization developed a rash on the third hospital day while on penicillin; that was discontinued, the end conclusion with this was more likely to be a toxic strep type reaction than penicillin reaction but still not clear. PLANS: 1. DC all antibiotics. The known infections have all been treated. No obvious new infection. If there is infection in the fluid collections of the lungs we will need significant drainage/surgical intervention more than the antibiotics.
DC|discontinue|DC|154|155|IMPRESSION AND RECOMMENDATION|c. Keep her on insulin sliding scale, medium intensity with Accu-Chek while she is in the hospital. d. Out continue Actos at 50 mg p.o. daily. 3. I would DC any IV fluid that contains D5. 2. Hypothyroidism. Continue Synthroid 25 mcg daily. 3. Hyperlipidemia, continue Zocor. 4. I would recommend the patient follow up with her primary care physician in the next week.
DC|discontinue|DC.|152|154|PLAN|Check CPT. Monitor for any cognitive issues given the recent history MI. 2. Bladder: He currently has Foley catheter. Once his transfers are easier can DC. At that point check PVRs x3. I do not anticipate any issues. Bowel: Place on a bowel program. Initiate rehab nursing.
DC|direct current|DC|192|193|ADDENDUM|ADDENDUM The second troponin was negative The patient was taken to Red Room 1 where he was sedated with Etomidate. He had mild myoclonus from the Etomidate. He was given a single 120 Joule of DC cardioversion. He went straight into normal sinus rhythm. Following this he felt a little nauseated and needed Zofran. I also did a bedside echo. The echo machine is available in the ER.
DC|discontinue|DC|286|287|PLANS|IMPRESSION: 1. 36-year-old male with acute meningitis consistent with viral etiology, little to suggest alternative causes, no significant encephalitis, relatively mild abnormality in CSF and improving clinically. 2. Hypothyroidism, on replacement. PLANS: DC antibiotics and isolation, DC acyclovir, even if his HSV was positive in the CSF. Would interpret this to be a milder version of this than true herpetic meningitis.
DC|discontinue|DC|142|143|ASSESSMENT AND PLAN|7. Diabetes type 2: Uncontrolled. Will put patient back on metformin 1000 mg p.o. b.i.d. Hold metformin for blood glucose less than 100. Will DC previous glipizide orders and start glipizide EX 10 mg p.o. q.a.m. starting _%#MMDD2007#%_; hold for blood glucose less than 100.
DC|discontinue|DC|71|72|PLANS|2. Rash, doubt drug-induced. 3. Adenocarcinoma of the colon. PLANS: 1. DC Zosyn. Will start Flagyl empirically as though we are treating C. diff despite the negative toxin. Recheck blood cultures and further stool studies.
DC|discontinue|DC|159|160|PLAN|2. Lyrica 25 mg p.o. twice daily. Petition can be made to pharmaceutical company for receiving assistance for payment of this medication on the outpatient. 3. DC the Percocet per patient's request for now and she can be restarted back on the Percocet upon discharge.
DC|direct current|DC|98|99|SUMMARY|5. Simvastatin 20 mg p.o. each night. 6. Aspirin 81 mg p.o. each day. I would consider electrical DC cardioversion to restore a normal sinus rhythm after a therapeutic anticoagulation on warfarin for 1 month. Alternatively, he may require transesophageal echocardiography to exclude a left atrial thrombus, followed by early cardioversion if his ventricular response does not respond to medical therapy or he remains highly symptomatic due to his atrial fibrillation.
DC|discontinue|DC|185|186|RECOMMENDATIONS|6. Penicillin, sulfa, Levaquin allergies, just finished a course of Levaquin, so I am not sure if that was a new allergy. 7. History of seizure disorder. RECOMMENDATIONS: I would favor DC Ancef and watch off antimicrobials for now. Check C. diff toxin and follow the white count, fever, pulmonary function and see if anything evolves that requires antibiotic intervention.
DC|discontinue|DC|125|126|ASSESSMENT AND PLAN|We did decrease the dose to 100 mg twice a day, and this seems to have improved. In light of his persistent symptoms, I will DC the voriconazole and start him in itraconazole 200 mg solution twice a day as he is on Prilosec. 8. Deconditioning. He might benefit from inpatient PT/OT consult while further workup is being done.
DC|direct current|DC|180|181|HISTORY OF PRESENT ILLNESS|At that time she was found to be in respiratory distress, hypertensive, lethargic, confused, and tachycardiac. The patient was also found to be in supraventricular tachycardia and DC cardioverted secondary to unresponsiveness. The patient was also intubated secondary to respiratory distress. She was hospitalized for about three to four weeks prior to discharge.
DC|discharge|DC.|224|226|DISCHARGE DIAGNOSIS|4. History of thalassemia traits presumed to gene deletion alpha thalassemia with low MCV and normal iron stores. 5. Fever of unknown origin. 6. Status post bone marrow biopsy with AFD fungal and routine cultures pending on DC. 7. Congestive heart failure with an ejection fraction of 40%. 8. History of acute renal failure, multifactorial secondary to hypertension, diabetes mellitus, ________ with a peak creatinine of 4.7 on _%#MMDD2003#%_ with a creatinine on the day prior to discharge of 2.0.
DC|direct current|DC|147|148|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: 1. Respiratory failure secondary to hypercapnia. 2. Persistent renal failure, on hemodialysis. 3. Atrial flutter, status post DC cardioversion. 4. Pulmonary hypertension. 5. Heparin-induced thrombocytopenia. 6. Diarrhea secondary to gastric bypass surgery. 7. Decubitus ulcer. 8. History of right upper lobe collapse.
DC|direct current|DC|360|361|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Scheduled for right cataract extraction. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 76-year-old male who on _%#MMDD2004#%_ will undergo right cataract extraction with IOL implantation at Fairview Eye Center by Dr. _%#NAME#%_ _%#NAME#%_. His medical history includes paroxysmal atrial fibrillation - currently in sinus rhythm since DC electrocardioversion _%#MMDD2000#%_, coronary artery disease - acute non-Q wave myocardial infarction _%#MMDD1998#%_ - status post coronary angiography with documentation of thrombotic occlusion of OM branch of left circumflex - status post PTCA with complete opening of thrombotic occlusion with no stent required - normal left ventriculogram, CAD risk factors (age - male gender - elevation of total cholesterol - elevation of LDL cholesterol, now normal on Lipitor), type 2 diabetes mellitus - diet-controlled, chronic cough with postnasal drip - chronic rhinitis - chronic maxillary sinusitis, possible Ménière's disease - decreased auditory acuity with hearing aids - chronic tinnitus in right ear, small goiter - biochemically euthyroid, status post-op appendectomy - removal of benign sebaceous cyst from back, osteoarthritis - cervical osteoarthrosis with decreased range of motion of neck - chronic low back pain secondary to osteoarthritis without radicular features, left carpal tunnel - osteoarthritis.
DC|direct current|DC|174|175|PAST MEDICAL HISTORY|2. Parathyroid adenoma for which she had surgery in 2002. 3. Coronary artery disease in _%#MM2002#%_. She had angioplasty of the mid LAD, PTCA of the second diagonal and had DC cardioversion at that time. She also has a history in _%#MM2003#%_ of ejection fraction 55%. She had a stress test at that time showing an inferolateral defect, and a large reversible anterolateral defect, consistent with ischemia.
DC|District of Columbia|_%#CITY#%_,|176|186|HISTORY OF PRESENT ILLNESS|She started to ask her husband what his name was, were they traveling, what day is today, and what were they doing at an airport. Apparently, they were flying from _%#CITY#%_, _%#CITY#%_, to _%#CITY#%_. They made a transient stop in _%#CITY#%_. Their plane was delayed, and they missed their plane to _%#CITY#%_. The patient was not really stressed by that travel issue.
DC|discontinue|DC|184|185|FOLLOWUP AND RECOMMENDATIONS|2. On Monday, the patient is to get his INR, CRP and sed rate drawn. 3. Based off the above results, on Monday, _%#MM#%_ _%#DD#%_, 2002, I will adjust his Coumadin dosing and possibly DC his Lovenox injections. 4. The patient is to follow up with me, Dr. _%#NAME#%_, _%#MM#%_ _%#DD#%_, 2002, at 2:30 at Smiley's Clinic.
DC|discontinue|DC|161|162|PLAN|PLAN: 1. Will clarify her outpatient followup. 2. Restart Effexor at 112.5 mg. p.o. q day. 3. Start trazodone 50-100 mg q h.s. 4. Start Zyprexa 2.5 mg q h.s. 5. DC 15 minute checks. 6. Continue ITC care. Axis I: 1. Bipolar disorder, rapid cycling, currently depressed.
DC|direct current|DC|196|197|DIAGNOSTIC PROCEDURES|3. Portable chest x-ray on _%#MMDD2007#%_: Increased right pleural effusion with adjacent atelectasis and/or consolidation. Decreased left pleural effusion. 4. Transesophageal echocardiogram with DC cardioversion for atrial fibrillation on _%#MMDD2007#%_: Following adequate sedation, the patient was successfully cardioverted with a single shock of 120 joules.
DC|discharge|DC|338|339|HOSPITAL COURSE|Both strains are sensitive to both Ceptaz and Cipro. Since admission, the patient has been treated with TOBI nebulizers, Ceptaz 2 g IV q.8h., and Cipro 750 mg p.o. b.i.d. Doxycycline was DC's during this hospital course. The patient's PFT improved back to baseline and the patient['s symptoms had progressively gotten better. Plan was to DC the patient onCeptaz, but there was an issue of IV access. The patient did not have any central IV and since she had a history of left subclavian thrombus and stenosis from PICC line and subsequently had angioplasty and stent placed, the decision was made notto place another PICC line on the right upper extremity.
DC|District of Columbia|_%#CITY#%_|254|263|HISTORY OF PRESENT ILLNESS|She has a history of diplopia on left gaze when reading. _%#NAME#%_ receives 3 doses of Temodar. Due to concerns about the lack of reduction in size of the optic glioma after reviewing the MRIs and discussing the case with neuro-oncologist in _%#CITY#%_ _%#CITY#%_ and _%#CITY#%_ by our heme-onc oncologist here at University of Minnesota Medical Center, Fairview, the decision was made to discontinue the Temodar and begin chemotherapy with vincristine and carboplatin.
DC|discontinue|DC,|188|190|MEDICATIONS|MEDICATIONS: Alprazolam, she has taken 2 tablets a day for last 2-3 days with increasing pain. She has been off that otherwise for the last 5 months. Cymbalta, did self DC, trazodone self DC, Motrin p.r.n., Tylenol p.r.n. She has also been taking Vicodin and tramadol on a p.r.n. basis. She obtained these online as her "survival pack." REVIEW OF SYSTEMS: CARDIOVASCULAR: No known heart disease, chest pain, shortness of breath.
DC|discontinue|DC|172|173|DISCHARGE MEDICATIONS|8. Mycogen topical 2% powder applied to feet b.i.d. 9. Multivitamin one tablet p.o. q day 10. Protonix 40 mg p.o. q day 11. Ceftin 500 mg p.o. b.i.d. times seven days then DC 12. Metamucil 1 Tbsp p.o. q a.m. 13. Avandia 4 mg p.o. q a.m. 14. Otic solution, resume same as used outpatient prior to admission, two drops bilateral ears q p.m. p.r.n.
DC|direct current|DC|206|207|HOSPITAL COURSE|On hospital day number five the patient had placement of a PICC line secondary to poor peripheral axis as well as need for a more permanent IV access for additional chemotherapy. The patient also underwent DC cardioversion by the Cardiology Service for atrial fibrillation. The patient tolerated this procedure without incident, and remained in normal sinus rhythm.
DC|direct current|DC|222|223|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. History of coronary artery disease, status post stent placement of LAD and first diagonal branch on _%#MM#%_ _%#DD#%_, 2001. 2. History of paroxysm and atrial flutter and fibrillation. Status post DC cardioversion on _%#MM#%_ _%#DD#%_, 2001. 3. Hypertension. 4. Hypothyroidism. 5. Diabetes mellitus. 6. Mild mitral regurgitation. 7. History of chronic renal failure but now the patient has normal kidney function.
DC|direct current|DC|199|200|HOSPITAL COURSE|The patient subsequently developed atrial fibrillation with rapid ventricular response, which remained refractory to medical management secondary to hypotension as well as two subsequent attempts at DC cardioversion. Following digoxin loading, the patient was successfully cardioverted. She maintained a sinus rhythm with a normal QT interval. Of note, the patient was on amiodarone at the time of the QT prolongation as well as Risperidone and bupropion for outpatient management of schizophrenia.
DC|discontinue|DC|136|137|ASSESSMENT AND PLAN|She is afebrile. We will continue to follow. 4. Hypertension: Will continue her lisinopril, will give low dose beta blocker for now and DC if unnecessary. 5. Anemia stable. This is likely secondary to postoperative blood loss from her recent surgery. 6. Bilateral pleural effusions. I suspect this is related to fluid resuscitation during her last hospitalization.
DC|discontinue|DC|165|166|ASSESSMENT AND PLAN|In patient with a prior history of gastritis and gastroesophageal reflux disease. It could be related to side effects of naproxen causing erosive gastritis. We will DC naproxen. We will start her on Protonix 40 mg daily. The patient's nausea and vomiting could be related to side effect to medications like metformin and also Zocor.
DC|discontinue|DC|305|306|IMAGING|Ideally, we suggest: a. Methadone 10 mg p.o. sublingual or per rectum q. 8 hours, and we can follow her up in 48 to 72 hours to reevaluate her response to this, however, we will see her sooner than that. b. Dilaudid, as mentioned before, 0.2 mg IV in the PCA q. 10 minutes p.r.n. without a basal rate. c. DC the Fentanyl patch and MS Contin. d. Dulcolax suppository now as she has been constipated and continue it for p.r.n. use q. day as well.
DC|District of Columbia|_%#CITY#%_.|167|177|SOCIAL HISTORY|He does not drink alcohol. He is a retired geologist who lives in _%#CITY#%_. He sees physicians in _%#CITY#%_ _%#CITY#%_. His daughter is a physiatrist in _%#CITY#%_ _%#CITY#%_. FAMILY HISTORY: Remarkable for a father and paternal grandfather dying of coronary artery disease.
DC|discontinue|DC|93|94|RECOMMENDATIONS|Intra-operative cultures are currently pending. Gram stain was negative. RECOMMENDATIONS: 1. DC Toradol in an elderly patient with increased risk for renal insufficiency. 2. Would recommend checking CBC with differential and BNP, as well as alkaline phosphatase today.
DC|discontinue|DC|245|246|IMPRESSION|I would recommend discontinuing gentamicin or aminoglycosides in this patient who already has an elevated creatinine and evidence of acute renal failure and is a diabetic. Would recommend using tobramycin if an aminoglycoside is needed. We will DC the Cipro p.o. and we will use Zosyn currently pending the results of his cultures. We will check a UA/UC realizing that he has already been given a dose of gentamicin and that he has been given a dose of Ancef.
DC|discontinue|DC|173|174|RECOMMENDATIONS|RECOMMENDATIONS: 1. Intravenous Lasix 40 b.i.d. for today. Add potassium supplementation. 2. Low dose beta blocker 25 mg b.i.d. Watch tele. closely for any heart blocks. 3. DC intravenous fluids. 4. Continue monitoring of CBC. 5. When deemed safe, patient should be restarted on antiplatelet agent, especially Plavix.
DC|discontinue|DC|66|67|PLAN|7. ATN resolving. 8. Diabetes mellitus. 9. Hypertension. PLAN: 1. DC antibiotics and watch. No clear cut cause. Fever has recurred in the face of Tequin. Does not have a clear cut pneumonia which would have been treated adequately already anyway.
DC|discontinue|DC|369|370|PLAN|So what I would like to do, is to maximize the Tylenol 650 mg every 4 hours on schedule, give her Cox II inhibitor, Celebrex 200 mg b.i.d., give her Zofran p.o. for nausea on schedule every 6 hours and give her Lyrica starting with 25 mg and see how nauseated she is. If she can tolerate that, then I will go up to 50 t.i.d. We will check an AST today. I would like to DC the Vicodin, DC the IV Dilaudid, DC the IV morphine, DC the Toradol and have her just get the 50 mcg Duragesic patch, which actually after we block the pain pathway at more than just the opioid receptor sites, we can probably reduce that back to baseline which is 37 mcg of fentanyl patch.
DC|direct current|DC|269|270|PHYSICAL EXAMINATION|Still and all, he should probably be on low-dose Coumadin shooting for an INR of 2.0 to 2.5 and we should control his heart rate as needed. If restoration to sinus rhythm is needed subsequently after a safe period of anticoagulation and monitoring and decision making, DC cardioversion could be performed in three to four weeks. If he needs consideration of DC cardioversion sooner, he would need a transesophageal echocardiogram.
DC|discontinue|DC|145|146|REVIEW OF SYSTEMS|Denies abdominal pain. Starting to pass flatus as above. Has had urinary hesitancy in the past with slow stream. He has not voided subsequent to DC her Foley. Skin rash consistent with folliculitis as above. No focal neurologic complaint. OBJECTIVE: GENERAL: Adult male lying on his left side in bed in no distress.
DC|discontinue|DC|79|80|PLANS|4. Chronic interstitial changes, nothing for acute/active infection. PLANS: 1. DC Septra watch off antibiotics. 2. Bone marrow for AFB and fungi TB is issue; very likely will have granulomas present.
DC|discontinue|DC|220|221|ASSESSMENT AND PLAN|The blood in his stool is likely of benign etiology. Discussed the case with Dr. _%#NAME#%_ of Minnesota Gastroenterology with curbside discussion, and it was deemed that appropriate management at this point would be to DC antibiotic therapy, check a.m. hemoglobin and consult for colonoscopy on an outpatient basis, or if significant hemoglobin drop or persistent diarrhea while inpatient.
DC|(drug) DC|DC|155|156|MEDICATIONS AT THE TIME OF DISCHARGE|The patient should have a chest x-ray at the time of his followup with Dr. _%#NAME#%_ and Dr. _%#NAME#%_. MEDICATIONS AT THE TIME OF DISCHARGE: 1. Bactrim DC 1 tab p.o. b.i.d., Monday and Tuesday. 2. Zofran 8 mg p.o. q.6 h. p.r.n. nausea. 3. Peridex 1.5 mL swish and spit b.i.d.
DC|direct current|DC|202|203|REASON FOR ADMISSION|After the transesophageal echocardiogram that showed no left atrial clot, she had successful DC cardioversion of the atrial fibrillation. Her ejection fraction was estimated to be around 40%. After the DC cardioversion, she was given Sotalol 120 mg b.i.d. for maintenance of sinus rhythm. She developed several episodes of polymorphic ventricular tachycardia with one episode that degenerated into ventricular fibrillation.
DC|discontinue|DC|150|151|IMPRESSION|It is unlikely, however, that the patient would have ulcer disease as she has been maintained on Prevacid and Aciphex. Will check stool guaiacs. Will DC her Premarin with her having a deep venous thrombosis. Will get blood cultures x2 for leukocytosis and also check a UA and UC.
DC|discharge|DC|210|211|DISPOSITION|7. Bactrim DS one tab p.o. b.i.d. x5 days. 8. OxyFAST 2.5 to 5 mg p.o. q.6h. p.r.n. DISPOSITION: 1. The patient will follow up with TCU MD upon arrival. 2. She will follow up with her PMD, Dr. _%#NAME#%_, upon DC from rehab. 3. BNP, TSH, free T4 will be rechecked in one week with results to TCU MD or patient's care MD for follow-up.
DC|discontinue|DC|313|314|FOLLOW-UP VISITS|Either the physician from the TCU or her primary care provider will follow up on the final culture results in 3 days when these are expected to be back from the lab but as stated above, those were negative at the time of discharge. The patient is to have an INR checked in 2-3 days with goal INR of 2-3. She will DC the Lovenox when the INR is greater than 2. She additionally will have a CBC checked in 2-3 days. The hematocrit on the day of discharge was 29.
DC|District of Columbia|_%#CITY#%_,|152|162|ASSESSMENT/RECOMMENDATIONS|Mr. _%#NAME#%_ is a 51-year-old gentleman who was evaluated for dyspnea and for hypertension. Over the past week while on a business trip to _%#CITY#%_ _%#CITY#%_, Mr. _%#NAME#%_ has been disturbed by exertional dyspnea as well as generalized fatigue and weakness. In the early morning hours today he suffered from the onset of severe dyspnea at rest.
DC|direct current|(DC)|323|326|HISTORY OF PRESENT ILLNESS|Regarding the patient's coronary artery disease it was first detected in early _%#MM#%_ with a stress test because of an incidental finding of atrial fibrillation and coronary angiogram reported as listed above. He has been on Coumadin for his atrial fibrillation since _%#MM#%_. In addition, one attempt at direct current (DC) cardioversion was performed but without success. He has been on a beta blocker and digoxin as well as Coumadin for rate control and anticoagulation.
DC|direct current|DC|214|215|HOSPITAL COURSE|His home doses of metoprolol and lisinopril were continued. Heparin was started for anticoagulation. On the second hospital day he received a transesophageal echocardiogram with results as above. He then underwent DC cardioversion with successful conversion to sinus rhythm after 1 shock. DISCHARGE MEDICATIONS: 1. Toprol XL 25 mg daily. 2. Aspirin 325 mg daily.
DC|direct current|DC|432|433|ASSESSMENT/PLAN|2. Age indeterminate atrial fibrillation without rapid ventricular response (a) Suspect related to pre-syncope as described above (b) Evaluate by TSH, echocardiogram (c) Hold on negative chronotropic agents as she does not exhibit rapid ventricular response, and as I wonder if she will have spontaneous bradycardia (d) Anticoagulate to reduce the risk of TIA. I feel she is an acceptable risk for Coumadin and Lovenox (e) Consider DC cardioversion later, but no antiarrhythmics are recommended at this time. 3. Hypertension (a) Poor control at this time, but could be anxiety elements (b) Continue current dose of Atacand but higher dose may be required.
DC|discontinue|DC|148|149|DISCHARGE MEDICATIONS|8. History of tonsillectomy. DISCHARGE MEDICATIONS: 1. Cymbalta 30 mg p.o. daily. 2. Enoxaparin 40 mg subq each day at bedtime each day at bedtime, DC after 2 weeks. 3. Lopressor 25 mg p.o. q.a.m. and 50 mg p.o. each day at bedtime. 4. Omeprazole 20 mg p.o. daily. 5. Paxil 10 mg p.o. twice daily.
DC|discontinue|DC,|380|382|ASSESSMENT/PLAN|2. Uncontrolled diabetes The patient by report with significant weight loss since initially diagnosed with diabetes mellitus type 2. Probably this is not an active issue for patient. Her hemoglobin A1c outpatient _%#MMDD2006#%_ was 5.9, will perform Accu-Cheks for the next 24 hours to ensure no elevation in blood glucose in relation to stress of surgery and if normal will then DC, Accu-Cheks will not start empiric insulin sliding scale unless blood glucoses are elevated. 3. Alzheimer dementia. Will place the patient on empiric delirium protocol and continue Aricept.
DC|discontinue|DC.|170|172|MEDICATION|5. Kaletra 4 tablets p.o. b.i.d. 6. Lamivudine 150 mg 1 tablet b.i.d. 7. Zerit 20 mg 1 tablet b.i.d. 8. Enoxaparin 70 mg subcu q. 12 h. until INR is between 2 to 3, then DC. 9. Folate 1 mg p.o. q.d. 10. Pravachol 40 mg q.h.s. 11. Zoloft 50 mg p.o. q.h.s. 12. Valacyclovir 500 mg b.i.d.
DC|direct current|DC|205|206|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 58-year-old male who was transferred from Fairview Northland Hospital for treatment of his atrial fibrillation with rapid rate. Here he had undergone DC cardioversion and was placed on amiodarone, beta blockers and digoxin. The patient is obese, has hypertension and atrial fibrillation and nocturnal oximetry was ordered which was suboptimal because the patient did not sleep very much because he had received a colonic prep of GoLYTELY the night of this evaluation.
DIP|distal interphalangeal|DIP|225|227|PHYSICAL EXAMINATION|MUSCULOSKELETAL: There is mild ulnar deviation of her fingers bilaterally with mild swelling of her fingers on the right hand but no tenderness appreciated. There is decreased flexion at the shoulders and the MCP and PIP and DIP joints of the upper extremity. NEUROLOGIC: She is awake, alert, oriented x3. Speech is intact. Cranial nerves II-XII are intact grossly. Motor strength 5/5 in lower extremities, 4/5 in upper extremities likely secondary to underlying rheumatoid arthritis.
DIP|distal interphalangeal|DIP|315|317|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Pain in hand and foot. HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old female with a history of gouty arthropathy and status post right hand surgery on _%#MMDD2007#%_, who presents from clinic with complaints of right hand and foot pain. The pain is predominantly in her right first digit DIP joint, third digit PIP joint and DIP joint of her foot. The right hand joint pain has been present for some time and she actually had surgery on _%#MMDD2007#%_, of the second and third digits but since the surgery the pain has increased and she has noticed new pain, swelling in redness of her first digit that was not present before.
DIP|distal interphalangeal|DIP|352|354|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Pain in hand and foot. HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old female with a history of gouty arthropathy and status post right hand surgery on _%#MMDD2007#%_, who presents from clinic with complaints of right hand and foot pain. The pain is predominantly in her right first digit DIP joint, third digit PIP joint and DIP joint of her foot. The right hand joint pain has been present for some time and she actually had surgery on _%#MMDD2007#%_, of the second and third digits but since the surgery the pain has increased and she has noticed new pain, swelling in redness of her first digit that was not present before.
DIP|distal interphalangeal|DIP|135|137|PHYSICAL EXAMINATION|It is difficult to examine the actual joints. The first digit is visible and there is significant erythema, warmth and swelling of the DIP joint. The left hand shows some tophi at the second PIP and multiple Heberden's nodes, but there are no areas of erythema or warmth in the left hand or wrist.
DIP|distal interphalangeal|DIP,|176|179|ADMISSION MEDICATIONS|NEUROLOGIC: Well oriented x3. Cranial nerves grossly intact. Normal color, tone, and reflexes in all 4 extremities. SKIN AND MUSCULOSKELETAL: Synovitic involvement of her PIP, DIP, and MCP joints. Also involvement of the bilateral elbows, knees, and ankles. All these joints were warm and erythematous; however, no effusion is noted.
DIP|distal interphalangeal|DIP|158|160|PHYSICAL EXAMINATION|SKIN: Across the extremities, but not the trunk, there is a macular papular rash with water blisters. Her nails are without splinter hemorrhages. JOINTS: Her DIP and PIP joints are tender and she cannot close her fingers fully. She does have some deformity from arthritis. Her elbows and toes are nontender.
DIP|distal interphalangeal|DIP|173|175|HOSPITAL COURSE|HOSPITAL COURSE: 1. Cellulitis. On admission, the patient had a mild fever with an elevated white cell count. Her right hand was notable for some erythema, primarily at the DIP joint of the right thumb. She was treated with Zosyn IV and her erythema and swelling improved. Blood cultures remained negative. She was afebrile 24 to 48 hours prior to discharge.
DIP|distal interphalangeal|DIP|289|291|PHYSICAL EXAMINATION|HEART: Regular rate and rhythm. LUNGS: Clear to auscultation. EXTREMITIES: There is a laceration along the palmar aspect of the long finger running transversely at the PIP flexion crease. There is diminished sensation on the radial border of the digit and no obvious active flexion of the DIP joint. IMPRESSION: Right long finger laceration with possible digital nerve and tendon injury.
DIP|distal interphalangeal|DIP|144|146|PHYSICAL EXAMINATION|She has a tender painful nodule at the MP joint, likely the remnant of her flexor profundus. She is stable to radial and ulnar deviation at the DIP and PIP joint as well as at the MP joint. She has full active extension at therapy MP, PIP and DIP joint.
DIP|distal interphalangeal|DIP|150|152|PHYSICAL EXAMINATION|She is stable to radial and ulnar deviation at the DIP and PIP joint as well as at the MP joint. She has full active extension at therapy MP, PIP and DIP joint. IMPRESSION: Flexor tendon laceration that is only retracted to the MP joint level.
DIP|distal interphalangeal|DIP|129|131|PHYSICAL EXAMINATION|She has significant tenderness over proximal phalanx and tenderness of the middle phalanx. She has a healed surgical scar at the DIP crease. She has pain with some passive flexion as well as with passive extension. IMPRESSION: Infected flexor sheath. PLAN: I&D tomorrow, _%#MM#%_ _%#DD#%_, at Fairview Southdale Hospital.
DIP|distal interphalangeal|DIP|232|234|PHYSICAL EXAMINATION|HEART: Is regular rate and rhythm EXAMINATION OF HIS LEFT UPPER EXTREMITY: Reveals a laceration on the ulnar side of his finger more towards the dorsal aspect along the PIP joint and then a large volar laceration extending from the DIP crease on the radial side just to about 1 cm. distal to the MP crease of the finger. He does have a positive Tinel's proximally at the finger.
DIP|distal interphalangeal|DIP|166|168|REVIEW OF SYSTEMS|Hematology: History of multiple transfusions. Endocrine: Diabetes mellitus. Skin: No new rash. Left thumb erythema, as noted above. Musculoskeletal: Arthritis in the DIP joints without stiffness. Neurologic: Negative. Psychiatric: Negative. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.8. Pulse 106.
DIP|distal interphalangeal|DIP|225|227|RIGHT UPPER EXTREMITY|She has quite a bit of redness, tenderness and swelling on the fat pad of the thumb, extending slightly into the thumb itself. The right second digit is red, swollen, and tender at the PIP joint. It is red and swollen at the DIP joint, but not particularly tender, nor is it tender at the MCP joint, but it is red. There is streaking redness up the anterior aspect of the right arm, and a very small localized area extends to the popliteal fossa, but not above it.
DIP|distal interphalangeal|DIP|160|162|PHYSICAL EXAMINATION|Pelvic: Not done. Extremities: There is a tender and injured right shoulder which is immobilized. She has deformed fingers consistent with osteoarthritis. Both DIP and PIP joints seem to be involved. Skin: No disease evident. Neurologic: She is able to cooperate on the exam and is quite alert mentally.
DIP|distal interphalangeal|DIP|134|136|HISTORY OF PRESENT ILLNESS|He has some numbness across the most distal portion of the tip. He has good range of motion of his profundus and superficialis at the DIP and PIP joints. He is tender to palpation distally. Review of his x-rays show that he has a nonunion of the distal phalanx along the radial portion, as well as a spike of bone likely giving him the tenderness in the medial aspect.
DIP|distal interphalangeal|DIP|265|267|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Cellulitis right ring fever. HISTORY OF PRESENT ILLNESS: The patient is a 26-year-old right hand dominant otherwise healthy gentleman currently unemployed, usually works as a construction worker, who cut the dorsal aspect of his ring finger at the DIP joint approximately 36 hours ago on his tool box. Since that time he has had progressive pain, swelling and loss of function in his finger.
DIP|distal interphalangeal|DIP|190|192|PHYSICAL EXAMINATION|Examination of his right upper extremity showed a small punctate wound from his previous laceration measuring approximately 5 mm across on the dorsal aspect of his hand just proximal to his DIP joint of his ring finger. He had mild erythema throughout the dorsal aspect of his finger extending down to his PIP joint.
DIP|distal interphalangeal|DIP|180|182|PHYSICAL EXAMINATION|Extremities: diffuse PIP swelling, which is nontender and nonerythematous. She also has markedly decreased range of motion on her wrists bilaterally. She has no MCP involvement or DIP involvement. Her right leg has very mild tenderness at this point in the medial aspect of her right upper thigh. LABORATORY DATA: Her hemoglobin is 8.3. Her white count is 3.0. Her TSH is normal.
DIP|distal interphalangeal|DIP|108|110|PHYSICAL EXAMINATION|His right hand reveals significant ecchymosis and bruising on that ring finger. He is unable to flex at his DIP joint, but he does have flexion at the PIP joint. His tenderness is over the volar aspect of the proximal phalanx.
DIP|distal interphalangeal|DIP|124|126|PHYSICAL EXAMINATION|She is quite thin, obvious rheumatoid changes in several of the fingers on each hand and also degenerative arthritis at the DIP joints in most of her fingers. HEENT: Unremarkable. NECK: Supple. No nodes or abnormal masses. Somewhat increased thoracic kyphosis.
DIP|distal interphalangeal|DIP|133|135|PHYSICAL EXAMINATION|He has a palpable radial pulse and good perfusion to all digits. Examination of his right hand demonstrates 2 small lesions over the DIP joint of the right index finger as well as the PIP joint of the ring finger, both on the radial borders of these that are dry and scaly in appearance.
DIP|distal interphalangeal|DIP|232|234|PHYSICAL EXAMINATION|EXTREMITIES: Examination of the right upper extremity has some generalized swelling of the dorsum of her right hand up into her wrist and into her forearm. She does have some chronic changes of osteoarthritis. Then on her right the DIP joint actually is quite red, swollen and painful with touch. She is unable to completely flex her hand to make a fist because of the edema in all of her joints and question if this edema may be synovitis.
DIP|distal interphalangeal|DIP|275|277|LABORATORY DATA|Uric acid was 5.7. Urinalysis has 25-50 WBCs, Klebsiella pneumoniae isolated. X-ray of the hand on _%#MMDD#%_ shows no hand fractures or osseous lesions, however, has pretty significant degenerative joint changes, the first CMC joint as well as the IP joint of the thumb and DIP joint of all the remaining fingers have pretty significant degenerative joint changes. CBC is really unremarkable with a normal hemoglobin of 12.5. Basic metabolic panel is normal with a BUN of 18, creatinine 0.99. An ultrasound of right upper extremity is unremarkable.
DIP|desquamative interstitial pneumonia|DIP,|152|155|HISTORY OF PRESENT ILLNESS|Since his symptoms were stable at that time, he was seen at a followup visit on the _%#MMDD2006#%_. Due to his hemoptysis which is not commonly seen in DIP, he underwent a bronchoscopy to look for other causes of interstitial lung disease. At that time, a rheumatologic panel was sent out which showed an elevated ESR of 87, CRP of 17.1, elevated ANA screen was 3.1, aldolase was 23.4 and high.
DIP|distal interphalangeal|DIP|219|221|HISTORY OF THE PRESENT ILLNESS|This patient therefore presented to the emergency room earlier today with increasing problems with the digit. He was seen by the emergency room physician, Dr. _%#NAME#%_ who noted an area of dorsal epidermolysis on the DIP joint where he was cut. She unroofed this region and got some purulent material that was cultured. Because of concern over failure to respond to oral treatment, he is admitted at this time for a course of intravenous antibiotics.
DIP|distal interphalangeal|DIP|153|155|PHYSICAL EXAMINATION|EXAMINATION OF The Right HAND: Reveals no abnormalities other than the index finger. There is a 5 x 15 mm. area of skin loss dorsally just radial to the DIP joint. Some of this has what appears to be underlying exposed distal phalanx. There is no exposed extensor tendon. The nail appears normal.
DIP|distal interphalangeal|DIP|192|194|OPERATIVE PROCEDURES|1. Irrigation and debridement and nailbed repair, left index finger. 2. Open reduction and percutaneous pinning, left index finger, distal phalanx fracture. 3. Amputation, left long finger at DIP joint. HISTORY OF PRESENT ILLNESS: Please refer to this patient's admitting H&P for details.
DIP|distal interphalangeal|DIP.|120|123|PHYSICAL EXAMINATION|The patient does have bluish discoloration from her plantar PIP in second digit out to the tip and on the dorsal distal DIP. There is evidence of underlying ecchymosis. There is no evidence of infection. The area is tender to touch. The rest of the digits are unremarkable.
DIP|distal interphalangeal|DIP|189|191|PHYSICAL EXAMINATION|Excursion equal bilaterally. LUNGS: Clear at the base. HEART: Regular rhythm. No murmur. ABDOMEN: Soft and nontender with no masses. BACK: No CVA tenderness. EXTREMITIES: Arthritic changes DIP of the hands. Arthritic change of the right knee and postsurgery on the left. No edema. Distal pulses intact. NEUROLOGIC: Alert and oriented. No focal findings.
DIP|distal interphalangeal|DIP|141|143|PHYSICAL  EXAMINATION|EXTREMITIES: Minimally palpable dorsalis pedis and posterior tibial pulses. No edema. Skin is dry. Osteoarthritic changes are noted with the DIP and PIP joints of the hands. No peripheral cyanosis. SKIN: A few small ecchymoses and dry lower extremity skin bilaterally.
DIP|distal interphalangeal|DIP|171|173|PHYSICAL EXAMINATION|HEENT: Normocephalic and atraumatic. Lungs clear. Heart has regular rate and rhythm. Examination of his left upper extremity reveals the ring finger unable to bend at the DIP joint. He has tenderness over the proximal phalanx, and at the A1 pulley level due to some swelling. He has normal two-point discrimination distally. He has good radial and ulnar pulses.
DIP|distal interphalangeal|DIP|269|271|HOSPITAL COURSE|She was able to ambulate without difficulty. Patient's right hand function was unchanged after the operation and continues to include significant difficulty to dexterity, wrist flexion and extension. She does have an intact flexion at the IP joint of the thumb and the DIP at the index finger as well as flexion and extension and extension. Patient's sensation is intact throughout her right upper extremity medial, radial, and ulnar nerve distributions.
DIP|distal interphalangeal|DIP|143|145|PHYSICAL EXAMINATION|HEART: Regular S1, S2, no murmurs. LUNGS: Clear bilaterally EXTREMITIES: Warm, no peripheral edema. There is some mild bony hypertrophy of the DIP and PIP joints of the hands. SKIN: Is normal. NEUROLOGIC: Exam is nonfocal. EKG shows normal sinus rhythm, rate 100, slight T-wave inversion in lead III and QTC of 464, recent cholesterol 255, triglycerides 83, LDL 134, HDL 104, myoglobin 29, WBC 6.6, hemoglobin 13.8, platelets 308,000.
DIP|distal interphalangeal|DIP|187|189|PHYSICAL EXAMINATION|EXTREMITIES: No cervical, axillary or femoral nodes. Femoral, DP and PT pulses normal. Warm, pink, dry, no edema. ORTHOPEDICS: Joints without inflammation. He has got some deformities of DIP probably from injuries. NEUROLOGIC: Patellar reflexes 2 , paresthesia right fourth and fifth digits which is subjective. SKIN: Dryness on feet, otherwise normal. ASSESSMENT: 1. Ulnar neuropathy at the elbow with impingement.
DIP|distal interphalangeal|DIP|130|132|PHYSICAL EXAMINATION|Abdomen is soft without hepatosplenomegaly, masses, or tenderness. Extremity exam shows some synovial thickening over her PIP and DIP and MCP in both hands bilaterally. Lower extremities are normal. Neurologic is intact. Her admitting white count was 7.3, hemoglobin 12.5. Electrolytes are normal.
DIP|distal interphalangeal|DIP|133|135|PAST SURGICAL HISTORY|4. Anal biopsy, benign, 1997. 5. Procedure on his left long finger in _%#MM2001#%_ and that was an incision of a mass and bone spur, DIP joint. 6. Prostate biopsy, as noted. MEDICATIONS: Zocor 20 mg q day, Prevacid 30 mg q day, Viagra p.r.n., aspirin on hold, p.r.n. Vioxx 25 mg q day.
DIP|distal interphalangeal|DIP|255|257|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished female, who is alert and oriented x 3, and in no acute distress. HEART: Regular rate and rhythm. LUNGS: Clear. LEFT RING FINGER: There is an obvious flexion contracture at the DIP joint. She has tenderness dorsally. She is unable to fully extend. IMPRESSION: Soft tissue mallet. Given that the patient is a surgeon, the indication is for pinning of her DIP joint to allow her to continue to do surgery over the next four weeks.
DIP|distal interphalangeal|DIP|166|168|IMPRESSION|She has tenderness dorsally. She is unable to fully extend. IMPRESSION: Soft tissue mallet. Given that the patient is a surgeon, the indication is for pinning of her DIP joint to allow her to continue to do surgery over the next four weeks. PLAN: She is scheduled to just to have K-wire pinning of the DIP joint for the soft tissue mallet.
DIP|distal interphalangeal|DIP|242|244|PLAN|IMPRESSION: Soft tissue mallet. Given that the patient is a surgeon, the indication is for pinning of her DIP joint to allow her to continue to do surgery over the next four weeks. PLAN: She is scheduled to just to have K-wire pinning of the DIP joint for the soft tissue mallet. This will need to be done with power under local, and is being scheduled for _%#MMDD2002#%_.
DIP|distal interphalangeal|DIP|230|232|LABORATORY DATA|There was some mid-cervical spine increased activity which may be related to his old cervical spine surgery. _%#MM#%_ _%#DD#%_, 2002 wound cultures growing heavy growth of MRSA. Finger x-ray revealed osteoarthritic changes in the DIP joint but no lytic, blastic or ulcerative changes. The CBC on _%#MM#%_ _%#DD#%_ showed white count 5.3, hemoglobin 13.8, platelets 279.
DIP|distal interphalangeal|DIP|255|257|IMPRESSION|CHEST: Clear. ABDOMEN: Benign. PERIPHERAL VASCULAR SYSTEM: Normal. SKIN: Significant fingertip injuries to the left index and long finger, see office note. GENITAL/PELVIC: Deferred. IMPRESSION: Left index finger severe mutilating almost amputation at the DIP joint level. Left long finger significant pad injury. The patient and his wife were given full instructions with respect to the option of no treatment and nonoperative treatment, as well as the possibility of operative treatment.
DIP|distal interphalangeal|DIP|160|162|PHYSICAL EXAMINATION|EXTREMITIES: Examination of his left ring finger reveals a soft tissue defect from the area where the skin meets the nail/lunula and then carried back over the DIP joint. He is able to actively extend the finger as a portion of the extensor mechanism is still intact. He has good motion in his PIP and MP joint.
DIP|desquamative interstitial pneumonia|DIP.|148|151|HOSPITAL COURSE|After the transbronchial biopsy were out it was felt that the most likely cause of the patient's worsening shortness of breath is recurrence of his DIP. In view of this, the patient is being discharged on high-dose steroid which is prednisone 30 mg p.o. b.i.d. The patient is to follow up with pulmonary service as an outpatient for further followup.
DIP|desquamative interstitial pneumonia|DIP|270|272|HISTORY OF PRESENT ILLNESS|6. Ablation _%#MMDD2007#%_: Performed under general anesthesia. Resulted in successful ablation of the electrical focus located near the left atrial appendage. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is a 33-year-old man with bilateral lung transplant for DIP and UIP, idiopathic dilated cardiomyopathy with an EF less than 25%, type 2 diabetes, hypertension, hyperlipidemia, history of pulmonary embolism who presented to the emergency department with shortness of breath and was found to be in a supraventricular tachycardia at a rate of 150 beats per minute.
DIP|desquamative interstitial pneumonia|DIP|175|177|PROBLEM #2|Coumadin therapy was initiated. PROBLEM #2: Bilateral lung transplant: The patient is status post bilateral lung transplantation in _%#MM2006#%_ for pathology consistent with DIP and UIP. His immunosuppressant regimen includes CellCept, Prograf and prednisone. A tacrolimus level was obtained on _%#MMDD2007#%_ and was subtherapeutic.
DIP|distal interphalangeal|DIP|131|133|PHYSICAL EXAMINATION|There are multiple stitches of approximately 8-10 and it is a rather large wound mainly in the fingertip, but extending beyond the DIP joint. The finger is a bit swollen and palpation of the finger pad is quite painful. As I palpate the wound, I do not get any gross purulence but there is quite a bit of drainage on the recently placed bandage except purulence.
DIP|distal interphalangeal|DIP|244|246|PHYSICAL EXAMINATION|As I palpate the wound, I do not get any gross purulence but there is quite a bit of drainage on the recently placed bandage except purulence. There is no signs of cellulitis extending up the arm or into the hand. It is difficult to assess the DIP joint as he is so tender to palpation of the fingertip. Otherwise, no systemic rashes or ulcerations. NEURO: Power is 5/5 throughout.
DIP|distal interphalangeal|DIP|129|131|PHYSICAL EXAMINATION|Otherwise skin exam is normal except for some facial acne. EXTREMITIES: Normal except for right 4th finger in splint status post DIP dislocation. PSYCHIATRY: Alert and oriented, no acute distress. Appears relatively well groomed, casually dressed in hospital gown. Affect is normal, not particularly depressed, in good humor and laughs appropriately.
DIP|distal interphalangeal|DIP|202|204|PHYSICAL  EXAMINATION|2+ pedal and radial pulses. Left middle finger from the tip to the DIP with violaceous coloring and marked swelling with two incisions from the incision and drainages. The patient has erythema from the DIP to the PIP and very little to almost no movement of the DIP joint. His finger is nontender but he has been anesthetized. He has a large ulceration at the base of his left foot over second, third and fourth metatarsal heads with surrounding callus.
DIP|distal interphalangeal|DIP|262|264|PHYSICAL  EXAMINATION|2+ pedal and radial pulses. Left middle finger from the tip to the DIP with violaceous coloring and marked swelling with two incisions from the incision and drainages. The patient has erythema from the DIP to the PIP and very little to almost no movement of the DIP joint. His finger is nontender but he has been anesthetized. He has a large ulceration at the base of his left foot over second, third and fourth metatarsal heads with surrounding callus.
DIP|distal interphalangeal|DIP|203|205|PHYSICAL EXAMINATION|LUNGS: Clear to auscultation. HEART: Regular rate and rhythm. ABDOMEN: Soft, nontender with good bowel sounds. MS: Examination of the right small finger reveals that he has a bony amputation through the DIP joint. There is soft tissue degloving which is oblique in nature, beginning at the junction of the middle and proximal 1/3 of the middle phalanx.
DIP|distal interphalangeal|DIP|178|180|PHYSICAL EXAMINATION|Range of motion is painful. He has negative lymphatic nodes in that hand. Emergency Department evaluation includes three views of the right hand. This shows an amputation to his DIP joint. There is no bony injury of the middle phalanx or proximal phalanx. DIAGNOSTIC IMPRESSION: At this time is soft tissue degloving injury right small finger with amputation to the DIP joint.
DIP|distal interphalangeal|DIP|220|222|DIAGNOSTIC IMPRESSION|This shows an amputation to his DIP joint. There is no bony injury of the middle phalanx or proximal phalanx. DIAGNOSTIC IMPRESSION: At this time is soft tissue degloving injury right small finger with amputation to the DIP joint. We discussed this at length. We discussed nonsurgical treatment which would be dressing changes and antibiotics. We discussed surgical management. We discussed the fact that replantation is likely not an option now due to the significant soft tissue crushing injury and the oblique nature of his wound edges.
DIP|distal interphalangeal|DIP.|145|148|PHYSICAL EXAMINATION|Temperature 97.5, blood pressure 90/50, respiratory rate 18, pulse 70 and regular. SKIN: Purplish discoloration of right middle finger below the DIP. The other fingers or toes did not show any discoloration. HEENT: Unremarkable. Anicteric. LUNGS: Clear. HEART: Regular rate and rhythm without murmur, gallop, or rub.
DIP|distal interphalangeal|DIP.|142|145|EXAM|Left knee showed very slight erythema. There was no tenderness or swelling. There were tophi on bilateral hands, left third and PIP and right DIP. LABORATORY DATA: His labs showed a white count of 10.1, hemoglobin 10.9, hematocrit 31.9, platelets 196,000, sodium 140, potassium 4.8, CO2 17, BUN 50, creatinine 1.93, blood sugar 135.
DIP|desquamative interstitial pneumonia|DIP.|159|162|BRIEF HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ is a 33-year-old gentleman with a complicated past medical history including bilateral sequential lung transplant performed in _%#MM2006#%_ for DIP. He has a history of heart failure as well as atrial fibrillation/atrial flutter and had recently undergone an EP study in _%#MM2007#%_.
DIP|desquamative interstitial pneumonia|DIP.|159|162|PROBLEM #4|The patient will transfer to acute rehab for physical therapy. PROBLEM #4: Pulmonary. As noted above, the patient is a bilateral lung transplant recipient for DIP. He is on high-dose prednisone for worry of recurrence of DIP. However, his pulmonary status remained remarkably stable throughout this hospitalization.
DIP|desquamative interstitial pneumonia|DIP.|158|161|PROBLEM #4|PROBLEM #4: Pulmonary. As noted above, the patient is a bilateral lung transplant recipient for DIP. He is on high-dose prednisone for worry of recurrence of DIP. However, his pulmonary status remained remarkably stable throughout this hospitalization. DISCHARGE INSTRUCTIONS: The patient is discharged to acute rehab with physical therapy to evaluate and treat activity level.
DIP|distal interphalangeal|DIP|215|217|PHYSICAL EXAMINATION|7. History of nephrolithiasis. 8. Chronic headaches. 9. Depression. PHYSICAL EXAMINATION: Vitals all within normal limits. The patient has cyanotic distal fingertips, as well as toes. She has joint effusions to the DIP and PIP joints, mainly involving the right hand. The rest of her physical exam was essentially normal. LABORATORY: On discharge, hemoglobin 9.2, platelets are 139, white blood cell count is 6.2. Creatinine 1.47, BUN is 30.
DIP|distal interphalangeal|DIP|130|132|HISTORY OF PRESENT ILLNESS|I took the top of the eschar material off, and there was obvious necrotic liquified tissue right down to the dorsal aspect of the DIP joint. With slight flexion of the skin, you could actually see right into the joint space. Therefore, the patient was redressed in sterile fashion and set up for admission to the hospital.
DIP|distal interphalangeal|DIP|228|230|PHYSICAL EXAMINATION|There is a small puncture wound there; and he does have tenderness over his flexor sheath at the middle phalanx site, none over the proximal phalanx or at the A1 pulley level. He does have pain with range of motion again at the DIP crease. He is able to deviate ulnarly and radially to stress and has normal two-point discrimination with full active distension.
DIP|distal interphalangeal|DIP|198|200|PHYSICAL EXAMINATION|She has not seen any bleeding. PHYSICAL EXAMINATION: Her blood pressure is 125/70, respiratory rate 16, pulse 80. She is a pleasant lady laying in bed. She has some changes of osteoarthritis in the DIP joints of her hands. She does look a little pale. HEENT: Atraumatic. Mouth is moist. NECK: Supple. Thyroid is not enlarged. BACK AND SPINE: Palpably nontender.
DIP|distal interphalangeal|DIP|207|209|PHYSICAL EXAMINATION|In the left upper extremity he does have marked swelling in his left hand with a streak extending up to his left elbow. His flexion, especially in the second, third and fourth finger, is very limited at the DIP and the PIP joint and as well as the MTP joints. He does have evidence of at least 2 puncture wounds, one is concerning to be at the second MTP joint involving the joint, and another one on the dorsum of the third finger between the MTP and the PIP.
DIP|desquamative interstitial pneumonia|DIP|200|202|PROBLEM #1|HOSPITAL COURSE: PROBLEM #1: Lung transplant. Mr. _%#NAME#%_ appeared to be doing well from a pulmonary standpoint as he was not requiring supplemental oxygen. He had recently had a recurrence of his DIP and therefore he was on increased doses of steroids. He was continued on his Prograf and CellCept and with the intent of decreasing his steroids as soon as possible given a concern for wound infection by the presentation of the chest x-ray and chest CT.
DIP|desquamative interstitial pneumonia|DIP,|214|217|HISTORY OF PRESENT ILLNESS|Linear ablation was performed from the left inferior pulmonary vein to the mitral annulus. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 33-year-old man with history of bilateral lung transplantation for UIP and DIP, idiopathic cardiomyopathy with an EF less than 25% and atypical flutter, status post ablation _%#MMDD2007#%_ of a focus near the left atrial appendage, type 2 diabetes, hypertension who presented with asymptomatic flutter to Clinic on _%#MMDD2007#%_.
DIP|desquamative interstitial pneumonia|DIP.|347|350|HISTORY OF PRESENT ILLNESS|_%#MM#%_ _%#DD#%_ the patient came back to the University of Minnesota Medical Center, Fairview, for a CT of his chest, which showed small right-sided pneumothorax and tiny left apical pneumothorax and additionally showed centrilobular nodules and ground-glass nodules bilaterally. The differential diagnosis included infection, bronchialitis and DIP. The patient had chest x-ray upon admission to the ER today, _%#MMDD2007#%_ and the chest x-ray showed an increase in the right apical pneumothorax with a stable left apical pneumothorax.
DIP|distal interphalangeal|DIP|159|161|HISTORY OF PRESENT ILLNESS|She still has swelling from the PIP joint to the proximal aspect of the fingernail. She also has a large open area on the medial aspect of the finger near the DIP joint. The pain is significantly improved. She did not have any pain with movement of the finger, is only difficult to move due to swelling.
DIP|distal interphalangeal|DIP|155|157|PHYSICAL EXAMINATION|ABDOMEN: Soft, nontender with active bowel sounds. EXTREMITIES: Right index finger has swelling in the distal area with some erythema primarily around the DIP joint. She has an open wound medial to the DIP joint. Minimal proximal swelling of the finger. She had normal sensation in the finger and has normal range of motion, given the swelling.
DIP|distal interphalangeal|DIP|202|204|PHYSICAL EXAMINATION|ABDOMEN: Soft, nontender with active bowel sounds. EXTREMITIES: Right index finger has swelling in the distal area with some erythema primarily around the DIP joint. She has an open wound medial to the DIP joint. Minimal proximal swelling of the finger. She had normal sensation in the finger and has normal range of motion, given the swelling.
DIP|distal interphalangeal|DIP|355|357|PHYSICAL EXAMINATION|HEAD, EYES, EARS, NOSE, THROAT: Unremarkable with clear oropharynx NECK: Is supple without adenopathy CHEST: Clear throughout all four fields HEART: Regular rate and rhythm without audible murmurs ABDOMEN: Soft, non-tender, no hepatosplenomegaly. EXAM OF The Left HAND: Reveals no abnormalities other than the ring finger. PFP motion is 34-65 degrees and DIP motion is 0 to 36 degrees. There is tenderness and swelling about the proximal phalanx and some scant purulent drainage from a pin hole along the ulnar aspect.
DIP|distal interphalangeal|DIP|169|171|PHYSICAL EXAMINATION|No rebound tenderness, no organomegaly or masses. All four EXTREMITIES normal on inspection and palpation with both knees status post knee arthroplasty. She does have a DIP joint of one of her hands that she injured in recent weeks which is slightly tender but not visibly deformed.
DIP|distal interphalangeal|DIP|203|205|PHYSICAL EXAMINATION|MEDICATIONS: 1. Detrol. 2. Klor-Con. 3. Furosemide. 4. Amoxicillin. 5. Multivitamin. 6. Aspirin. ALLERGIES: Morphine. PHYSICAL EXAMINATION: On examination today, she does have obvious swelling about the DIP area of her left middle finger. This is minimally tender to palpation. I am not able to express any purulent drainage on examination today.
DIP|distal interphalangeal|DIP|197|199|ASSESSMENT|It does not progress proximal to this. X-RAYS: X-ray evaluation shows the fusion screw still in good position. ASSESSMENT: Left little finger infection three weeks status post a left middle finger DIP fusion. PLAN: We will plan to admit her to the floor tonight.
DIP|distal interphalangeal|DIP|270|272|PHYSICAL EXAMINATION|There is no fluctuance appreciated. There is erythema and cellulitis over the dorsum of the left hand involving the small ring and long finger area, which extends over the dorsum of the hand to the wrist joint. There was no pain with range of motion of the MCP, PIP, or DIP joints. There is no pain with range of motion of the wrist or elbow. His sensation is intact to light touch throughout the left upper extremity, 2+ radial pulses.
DIP|distal interphalangeal|DIP|182|184|PHYSICAL EXAMINATION|No hernias. Bowel sounds are normal. SKIN: Without any significant rashes. BONES/JOINTS: There are some changes of osteoarthritis in her fingers, particularly the right index finger DIP joint. NEUROLOGIC: Cranial nerves II-VII and IX-XII are intact. She is a little hard-of-hearing. She moves all extremities and follows commands well. Finger-to-nose and heel-to-shin are normal.
DIP|distal interphalangeal|DIP|265|267|IMPRESSION|The tissue does appear viable, however. Radial pulse 2+. X-RAYS: The x-rays were reviewed, 3 views of his left hand does show a distal tuft-type fracture with comminution and significant bone loss as well as soft tissue injury. IMPRESSION: Left middle finger, open DIP crush injury with comminuted fracture, nail bed laceration and complex laceration. PLAN: I discussed with mother the best options to explore this in the operating room to attempt a nail bed repair, an open reduction debridement and fixation of this fragment.
DIP|distal interphalangeal|DIP|149|151|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old right-hand dominant female who back at the end of _%#MM#%_ had an inoculate injury over the DIP joint on the left side of the index finger. This developed into tenosynovitis. This was treated appropriately with irrigation and debridement, IV antibiotics course over 3-4 days and she was discharged on Keflex.
DIP|distal interphalangeal|DIP|123|125|PHYSICAL EXAMINATION|VITAL SIGNS: Stable. EXTREMITIES: Examination of the left upper extremity shows a well healed inoculate injury down at the DIP flexor surface. There is a surgical wound over the palmar aspect, zone 3 in standard oblique fashion. There was no drainage. There is erythema around the MCP region.
DIP|distal interphalangeal|DIP|138|140|DISCHARGE PLAN|She can remove or replace the finger dressings p.r.n., but she will leave the cast clean, dry, and intact. I will plan to begin MCP, PIP, DIP joint active, active- assisted, and passive range of motion as well as a edema control and FDS and FDP independent gliding under the direction of an occupational therapist 2 times per week.
DIP|distal interphalangeal|DIP|120|122|HOSPITAL COURSE|3. Orthopedic. The patient had been followed in clinic prior to her admission for a right second finger swelling at the DIP joint. She has known degenerative osteoarthritis but has not ever had swelling and pain in a joint similar to this. Orthopedic Surgery, Dr. _%#NAME#%_, did visit the patient in this visit, and felt that all of her problems were related to this degeneration, and there was no evidence of infectious etiology there.
DIP|distal interphalangeal|DIP|205|207|PHYSICAL EXAMINATION|CARDIOVASCULAR: S1 and S2 in a regular rhythm. No murmurs, gallops or rubs are present. ABDOMEN: Soft, nontender. Bowel sounds present. There is no hepatosplenomegaly. SKIN AND JOINTS: Noted for a swollen DIP of third digit, right hand, with the redness extending to the wrist. Range of motion is somewhat impaired by the swelling, though not by pain.
DIP|distal interphalangeal|DIP|234|236|PHYSICAL EXAMINATION|LUNGS: Clear to auscultation and percussion. CARDIOVASCULAR: S1 and S2 in a regular rhythm, no murmurs, gallops or rubs are present. ABDOMEN: Soft, nontender, bowel sounds present, there is no hepatosplenomegaly. EXTREMITIES: Swollen DIP third finger on the right. It is tender to palpation. NEUROLOGIC: The patient is somewhat slow to respond but is alert and oriented x3.
DIP|distal interphalangeal|DIP|167|169|HISTORY OF PRESENT ILLNESS|I saw him in my office on _%#MMDD2007#%_ and felt that this injury required open reduction. Today the patient complains of pain and swelling in his left little finger DIP joint. No numbness. No prior history of problems with the area. PAST MEDICAL HISTORY: ADHD. MEDICATIONS: He takes Metadate 20 mg p.o. q. day.
DIP|distal interphalangeal|DIP|185|187|PHYSICAL  EXAMINATION|CHEST: Clear throughout all four fields. HEART: Regular rate and rhythm without audible murmur. ABDOMEN: Soft, nontender, no hepatosplenomegaly. EXTREMITIES: The left little finger has DIP joint at 20-30 degrees. There is swelling and tenderness of the DIP joint. Neurovascular exam is intact. X-rays of the left little finger taken at _%#CITY#%_ Family Physicians on _%#MMDD2007#%_ reveal a dorsal dislocation of the DIP joint without associated fracture.
DIP|distal interphalangeal|DIP|157|159|PHYSICAL  EXAMINATION|ABDOMEN: Soft, nontender, no hepatosplenomegaly. EXTREMITIES: The left little finger has DIP joint at 20-30 degrees. There is swelling and tenderness of the DIP joint. Neurovascular exam is intact. X-rays of the left little finger taken at _%#CITY#%_ Family Physicians on _%#MMDD2007#%_ reveal a dorsal dislocation of the DIP joint without associated fracture.
DIP|distal interphalangeal|DIP|205|207|PHYSICAL  EXAMINATION|There is swelling and tenderness of the DIP joint. Neurovascular exam is intact. X-rays of the left little finger taken at _%#CITY#%_ Family Physicians on _%#MMDD2007#%_ reveal a dorsal dislocation of the DIP joint without associated fracture. IMPRESSION: Chronic dislocation left V distal interphalangeal (DIP) joint. The patient presents at this time for open reduction and internal fixation of his injury.
DIP|distal interphalangeal|DIP|166|168|PHYSICAL EXAMINATION|HEART: Regular rhythm, no murmur. ABDOMEN: Abdomen is soft and nontender with no masses. BACK: No CVA tenderness. EXTREMITIES: Full motion. Osteoarthritic changes of DIP joints of all of her fingers. NEUROLOGICAL: Reflexes intact and equal. No focal neurological findings. SKIN: No urticarial eruptions at this time.
DIP|distal interphalangeal|DIP.|181|184|IMPRESSION|NEUROLOGIC: Reflexes are normal. SKIN: There are some scars on her face secondary to spider bites. IMPRESSION: 1. Cellulitis of right second digit. 2. Possible joint involvement of DIP. X-rays of the finger were apparently not documented at this time.
DIP|distal interphalangeal|DIP,|234|237|PHYSICAL EXAMINATION|Perhaps there is some slight synovitis as well. There is some redness overlying the MCP joints as well. There is not much in the way of tenderness to palpation to these areas and passive range of motion of these joints, including the DIP, PIP, MCP, wrist, and elbow of the bilateral upper extremities does not elicit any tenderness. Examination of the patient's ankles does reveal what appears to be some swelling and small bilateral joint effusions.
DIP|distal interphalangeal|DIP|289|291|PHYSICAL  EXAMINATION|EXTREMITIES: Significant for the right lower extremity, he has a fairly bright red erythema over the dorsum of the foot involving all his toes with only mild involvement of the great toe. There is a small 3 x 3 mm circular open lesion on the anterior aspect of the right fourth toe at the DIP joint. There is some yellowish serous appearing drainage coming from this. On the dorsum of the foot there is an approximately 1 x 1 1/2 cm area of dusky and dark region.
DIP|desquamative interstitial pneumonia|DIP.|190|193|PAST SURGICAL HISTORY|3. She previously had a voluntary interruption of pregnancy. PAST SURGICAL HISTORY: 1. Primary low-segment transverse cesarean section in 2000. 2. Vacuum curettage also in 2000. 3. Previous DIP. ALLERGIES: No known drug allergies. MEDICATIONS: Prenatal vitamins.
DIP|distal interphalangeal|DIP|195|197|PHYSICAL  EXAMINATION|It is well perfused and sensate, but it definitely has a different shape than the contralateral little finger. He is unable to meaningfully flex the MP and PIP joints, although he can wiggle the DIP joint. I reviewed Park Nicollet x-rays which show an oblique or spiral fracture through the mid portion of the proximal phalanx.
DIP|distal interphalangeal|DIP|402|404|PHYSICAL EXAMINATION|EXTREMITIES: No cyanosis or clubbing, lower extremities were very thin, muscle strength in the lower extremities was decreased, hip flexion was positive 3/5 bilaterally, knee extension was positive 4/5 bilaterally and ankle plantarflexion was positive 5/5 bilaterally. Upper extremities were 4-5 bilaterally. The patient's fingertips were very cool to the touch, the patient had discoloration from the DIP joint forward where it was paler than the rest of the hand, no edema present. NEUROLOGIC: Cranial nerves II-XII grossly intact. LABORATORY DATA: Chem 10 sodium 137, potassium 3.6, chloride 105, bicarb 27, BUN 11, creatinine 0.92, glucose 77, calcium 8.2. CBC white blood cell count 5.3, hemoglobin 10.8, platelets 260.
DIP|distal interphalangeal|DIP|485|487|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 75-year-old female with advanced degenerative joint disease involving the right mid foot along with clot deformities of the third, fourth and fifth toes admitted to the University of Minnesota Medical Center, Fairview, surgery performed by Dr. _%#NAME#%_ on _%#MMDD2007#%_ status post fusion of the navicular to the cuneiform, PIP joint, excision of the third and fourth toes on the right, percutaneous flexor tenotomy at the DIP and the right fifth toe currently heal bearing for balance and ADLs. HOSPITAL COURSE: The patient was on Lovenox, use compression stockings and ASA.
DIP|distal interphalangeal|DIP.|264|267|PHYSICAL EXAMINATION|He is cooperative with the exam. Examination of the left hand shows a well perfused hand with an entrance from the gunshot wound at the radial side of the PIP joint of his left index finger. Sensation is intact distally. He has full range of motion at the PIP and DIP. Motor is intact to his PIP and DIP joints. The bullet entered the medial aspect of the left thigh. There is an approximately 2 cm circular entrance wound. No exit wound is seen.
DIP|distal interphalangeal|DIP|109|111|PHYSICAL EXAMINATION|Sensation is intact distally. He has full range of motion at the PIP and DIP. Motor is intact to his PIP and DIP joints. The bullet entered the medial aspect of the left thigh. There is an approximately 2 cm circular entrance wound. No exit wound is seen.
DIP|distal interphalangeal|DIP|181|183|OBJECTIVE|There is no flank tenderness today, no CVA tenderness. There are normal bowel sounds. EXTREMITIES: Full and symmetric range of motion throughout. He does have the left fifth finger DIP amputation. He also has a healed anterior left shin scar. He has just a trace of effusion in both lower extremities, which apparently is chronic.
DIP|distal interphalangeal|DIP|136|138|PLAN|She is pleased with the outcome and states it has worked out well for her. With regard to her left long finger, she has a cyst over the DIP of the left long finger that looks to be a mucus cyst/ganglion cyst. She has had this cyst since _%#MM#%_ of 2001. It changes in size and has spontaneously drained.
DIP|distal interphalangeal|DIP|160|162|PLAN|She states it has been incised and drained, but has recurred. On examination she has a small 7 mm cyst along the dorsal and ulnar aspect of the finger near the DIP joint. The skin is thinned out over the cyst as is typically present. There is no ridging of the nail. Range of motion in the DIP joint is intact.
DIP|distal interphalangeal|DIP|119|121|PLAN|The skin is thinned out over the cyst as is typically present. There is no ridging of the nail. Range of motion in the DIP joint is intact. Neurovascular examination is normal in the finger. I concur with Dr. _%#NAME#%_'s recommendation for excision of the cyst, and coverage with a local advancement flap.
DIP|distal interphalangeal|DIP|144|146|HISTORY OF PRESENT ILLNESS|He apparently had an extensor tendon injury in addition to that of the skin. This patient presents at this time for percutaneous pinning of his DIP joint as he lacks full extension (because of his skin problem) he is not a candidate for splint wear. PAST MEDICAL HISTORY: No medical problems. MEDICATIONS: None. ALLERGIES: No known drug allergies.
DIP|distal interphalangeal|DIP|146|148|PHYSICAL EXAMINATION|No hepatosplenomegaly. EXTREMITIES: Exam of the right hand reveals moderate swelling of the middle finger. The skin over the dorsal aspect of the DIP joint does appear viable but it is somewhat dusky. He has a 20 degree extensor lag of the DIP joint. Neurovascular status is otherwise intact. IMPRESSION: Irregular laceration, dorsal aspect of the right long finger with underlying terminal extensor tendon deficit.
DIP|distal interphalangeal|DIP|225|227|IMPRESSION|Neurovascular status is otherwise intact. IMPRESSION: Irregular laceration, dorsal aspect of the right long finger with underlying terminal extensor tendon deficit. _%#NAME#%_ _%#NAME#%_ presents at this time for pinning his DIP joint and extensor tendon repair. I reviewed the operative procedure with him in the office and answered questions to the best of his satisfaction.
DIP|distal interphalangeal|DIP|194|196|PHYSICAL EXAMINATION|X-rays of the left hand (three views) taken at Queen of Peace Hospital earlier this evening reveal a tuft fracture of the index finger. The long finger has a fracture going directly through the DIP joint. There is comminution and bone loss. IMPRESSION: Saw injury, left II/III fingertips. This patient will be taken to the Operating Room for exploration of his wounds.
DIP|distal interphalangeal|DIP|132|134|EXAMINATION OF HER FINGER|EXAMINATION OF HER FINGER: Her index finger is swollen when compared to the other finger. She has erythema surrounded mostly at the DIP joint, both dorsally and volarly. She does not have tenderness along the flexure sheath at the middle phalanx or the proximal phalanx.
DIP|distal interphalangeal|DIP|157|159|LABORATORY DATA|Chest x-ray was negative. X-ray of the left shoulder showed old fracture of distal clavicle. C-spines were also negative. Did show a healing fracture on the DIP joint of his left ring finger. The patient was admitted and found to have phenytoin and valproic acid levels of undetectable levels.
DIP|distal interphalangeal|DIP|148|150|PHYSICAL EXAMINATION|Limited thumb extension primarily at the DIP joint bilaterally. Decreased in range finger flexion at the metatarsal phalangeal joint as well as the DIP joints with complaints of significant pain. The patient does have increased swelling, primarily at the distal wrist bilateral as well as throughout her thumb on the dorsal aspect.
DIP|distal interphalangeal|DIP|167|169|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Crush avulsion type injury to the right ring finger distal phalanx. DISCHARGE DIAGNOSIS: Same. OPERATIONS/PROCEDURES PERFORMED: Right ring finger DIP amputation. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 62-year-old right-handed male who works as a trucker. He was unloading some pallets on _%#MM#%_ _%#DD#%_, 2002, in the a.m. when his right hand was caught in what he described to be a gate and sustained a crush avulsion type injury distal to his DIP joint on his right ring finger.
DIP|distal interphalangeal|DIP|192|194|ADMISSION DIAGNOSIS|He was unloading some pallets on _%#MM#%_ _%#DD#%_, 2002, in the a.m. when his right hand was caught in what he described to be a gate and sustained a crush avulsion type injury distal to his DIP joint on his right ring finger. He was seen in the ER and evaluated. His wound was debrided at that time.
DIP|distal interphalangeal|DIP|167|169|PHYSICAL EXAMINATION|ABDOMEN: Soft, negative hepatosplenomegaly, no palpable mass and no bruits. Negative CVAT. PELVIC: Not done. EXTREMITIES: Does have some osteoarthritis changes in her DIP of hands, otherwise pretty much unremarkable. ASSESSMENT/PLAN: 1. Patient with several chronic medical conditions as outlined above.
DIP|distal interphalangeal|DIP|166|168|PHYSICAL EXAMINATION|PULSES: Normal carotid pulses without bruits. Normal femoral, posterior tibial, and dorsalis pedis pulses. EXTREMITIES: No edema. Degenerative changes of some of the DIP joints of the hands. REFLEXES: Symmetric. Electrocardiogram: Sinus tachycardia with frequent PACs and some PVCs.
DIP|distal interphalangeal|DIP|140|142|PHYSICAL EXAMINATION|Blood pressure 130/72, respirations 20, pulse of 78. EXTREMITIES: Examination of her right hand showed an eschar on the ulnar aspect of her DIP joint. Her finger was markedly swollen and erythematous, the erythema tracking approximately along her thenar eminence, but not up into her forearm.
DIP|distal interphalangeal|DIP|186|188|PHYSICAL EXAMINATION|EXTREMITIES: No edema. Peripheral pulses are intact. There are fungal nail thickening changes to the feet bilaterally. Orthopedic examination shows mild Heberden's node formation at the DIP joints of the hands. NEUROLOGIC: The patient is alert and oriented x 3. No deficits on cranial nerve examination. Strength, light touch sensation and deep tendon reflexes are symmetrically normal in the upper and lower extremities.
DIP|distal interphalangeal|DIP|144|146|PHYSICAL EXAMINATION|Has ome marked white nodules, one draining, white chalky fluid from the distal third finger, with some warm erythematous changes in the PIP and DIP and some warmth and erythematous changes in the proximal hand. Some mild warmth noted in the forearm. IMPRESSION: Patient with what appears to be some gouty arthritis changes along with cellulitis, complicating it in the right hand, as well as tinea pedis and cellulitis of the right foot with bilateral lower extremity swelling.
DIP|distal interphalangeal|DIP,|297|300|PHYSICAL EXAMINATION|There is no erythema on the other aspects of the hand or the forearm; however, there is cellulitis about 15 x 6 cm over the biceps of the upper extremity which is very tender to palpation and slightly warm, and he also has tenderness in the left armpit. The patient is able to flex and extend the DIP, the PIP and the MP of all digits on the left hand. His range of motion is normal in the wrist as well.
DIP|distal interphalangeal|DIP|240|242|PHYSICAL EXAMINATION|He has 3+ edema beginning about a third of the way below his knees and there is some skin breakdown in the right fifth toe. Some slight sausaging of the right second and left second toe is non-tender. On _%#MM#%_ _%#DD#%_, his right second DIP and fifth PIP were moderately tender and erythematous at the time of his preoperative evaluation. LABORATORY DATA: White count 9600, hemoglobin 11.9. MCV 85, platelets 256,000.
DIP|distal interphalangeal|DIP|149|151|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: Positive for occasional apnea at night, although he has never been diagnosed as having sleep apnea. He has some discomfort of his DIP of one of his fingers. This is over the past two weeks. Review of systems is essentially negative otherwise.
DIP|distal interphalangeal|DIP|189|191|PAST MEDICAL HISTORY|She has since done well on antiplatelet therapy. 9) Osteopenia demonstrated on bone density x-ray. SURGICAL: 1) Status post bladder surgery x 2 for incontinence. 2) Status post dislocation DIP joint left fifth digit. 3) Status post cosmetic laser surgery for facial wrinkles in 1998. 4) Status post facelift in _%#MM#%_, 1999. 5) She denies other surgery or other known serious illnesses.
DIP|distal interphalangeal|DIP,|169|172|IMPRESSION|There is a 5 mm ganglion type cyst coming off the ulnar aspect of the DIP joint. The cyst is tender, but neurovascular examination is intact. IMPRESSION: Ganglion cyst, DIP, left long finger. _%#NAME#%_ presents at this time for cyst excision. Potential risks and complications of surgery were discussed/reviewed with her in the office and she wishes to proceed.
DIP|distal interphalangeal|DIP|164|166|PHYSICAL EXAM|Pedal pulses are intact. NEUROLOGIC - she is nonfocal. SKIN - shows no lesions or nodules. RHEUMATOLOGIC -shows some evidence for degenerative joint disease in the DIP and PIP joints. LABORATORIES: Sodium 136, potassium 3.2, chloride 98, bicarb 23, BUN 74, creatinine 4.3, glucose 102, platelets 206,000, white blood cell count 8.4, hemoglobin 11.4. Urinalysis shows 0-2 reds and 0-2 white cells per high-powered field.
DIP|distal interphalangeal|DIP|153|155|ADMISSION PHYSICAL EXAM|He has no edema or swelling of his ankles or feet. He has good dorsalis pedis pulses and radial pulses bilaterally. He has osteoarthritic changes of his DIP joints in his fingers. ADMISSION LABORATORY DATA: EKG reveals sinus bradycardia, T wave flattening in V1 and aVF, otherwise normal.
DIP|distal interphalangeal|DIP|217|219|PHYSICAL EXAMINATION|I do not hear a significant murmur. ABDOMEN: Soft, nontender, nondistended, with positive bowel sounds. GENITOURINARY: Deferred. EXTREMITIES: He has an abnormal left fifth finger. He is missing what appears to be the DIP joint, although there is a little bit of a nail growing just distal to the PIP joint. No lower extremity edema. No significant chronic venostasis changes. Dorsalis pedis pulses are there, but slightly, about 2/4.
DIP|distal interphalangeal|DIP|186|188|PHYSICAL EXAMINATION|Left hand shows the index, long and ring fingers all have cool, bluish tips. Right long finger has an irregular appearance to the nail. There is a boggy fingertip and instability of the DIP joint. SKIN: Skin diffusely shows some excoriated areas on the back of her arms and legs. Also, on the legs there are some multiple dry lesions that were previously weeping sores, she ways.
DIP|distal interphalangeal|DIP|195|197|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 51-year-old female with a longstanding history of rheumatoid arthritis. She has developed painful nodules on her left second MCP joint, left third DIP joint and a locking phenomena of her left third finger. She is admitted at this time for rheumatoid nodule excision and trigger finger release.
DIP|distal interphalangeal|DIP|198|200|PHYSICAL EXAMINATION|ABDOMEN: Soft, nontender. No hepatosplenomegaly. EXTREMITIES: Examination of the left hand reveals a full passive motion of the left little finger. There was no active flexion however of the PIP or DIP joints. NEURO: Exam is normal. He has a 1.0 cm transverse incision which is well-healed along the volar aspect of the PIP joint.
DIP|distal interphalangeal|DIP|244|246|ADMITTING DIAGNOSES|ADMITTING DIAGNOSES: 1. Status post traumatic amputation of right long finger with contractures and degenerative joint disease of the PIP joints of index, small and ring fingers. 2. Degenerative joint disease of the small finger, ringer finger DIP joints. 3. Status post fusion of right long finger PIP joint. DISCHARGE DIAGNOSES: (SAME). PROCEDURES PERFORMED: 1. Right long finger PIP joint osteotomy with re-fusion at approximately 50 degrees of flexion.
DIP|distal interphalangeal|DIP|169|171|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a pleasant 58-year- old female who presents for pre-operative history and physical. She is having left index finger DIP Joint fusion for osteoarthritis by Dr. _%#NAME#%_ at Fairview Southdale Hospital on _%#MM#%_ _%#DD#%_, 2004. The patient has had surgery on this finger before, but the pain has returned.
DIP|distal interphalangeal|DIP|237|239||_%#NAME#%_ _%#NAME#%_ is a 17-year-old right hand dominant junior in school who slammed his right long finger in the car door a few days ago. He was seen in the emergency room. He was found to have an extensor tendon laceration over the DIP joint. Simple skin suture was placed into his long finger, but the extensor tendon was not repaired. He comes in now for follow up. He does not have any complaints of pain.
DIP|distal interphalangeal|DIP|239|241|PHYSICAL EXAMINATION|HEART: Is regular rate and rhythm EXAMINATION OF HIS RIGHT UPPER EXTREMITY: Reveals a swaning deformity at the PIP joint of his right long finger. He has got a laceration across his DIP joint. He has got a significant extensor lag and his DIP joint cannot actively extend it. He is stable to radial and ulnar deviation stress. He has normal two point discrimination.
DIP|distal interphalangeal|DIP.|139|142|PHYSICAL EXAMINATION|EXTREMITIES: No edema. His right hand, fifth digit, is remarkable for a lesion approximately 5 X 7 mm in diameter. It is located along the DIP. It is firm and non-mobile. Deep tendon reflexes are equal. SKIN: Within normal limits. ASSESSMENT: A finger lesion, uncertain etiology at this time.
DIP|distal interphalangeal|DIP|189|191|PHYSICAL EXAMINATION|HEENT: Normocephalic, atraumatic. LUNGS: Clear. HEART: Regular rate and rhythm. RIGHT INDEX FINGER: Examination of the index finger on the right side reveals a very short laceration at the DIP crease. Normal two-point discrimination of 4.0-mm on both the radial and ulnar side. He is unable to flex at the distal joint. Full superficialis pulses.
DIP|distal interphalangeal|DIP|132|134|IMPRESSION|He is unable to flex at the distal joint. Full superficialis pulses. IMPRESSION: Flexor profundus rupture at the insertion into the DIP joint. PLAN: The plan is to do a flexor tendon repair which is scheduled for _%#MMDD2005#%_ under a Bier block anesthetic.
DIP|distal interphalangeal|DIP|186|188|PHYSICAL EXAMINATION|There are no focal deficits noted. Deep tendon reflexes are 2+ bilaterally in the upper and lower extremities. EXTREMITIES: There is a partial thickness burn over and just distal to the DIP in the right middle finger on the extensor surface. There is erythema, warmth, and tense edema on the dorsal aspect of the right hand.
DIP|distal interphalangeal|DIP|145|147|PHYSICAL EXAMINATION|It is very tender to palpation over the sides. However, I do not detect any swelling, redness. All the joints in the area, including the PIP and DIP joints are normal and without tenderness. Chest x-ray shows no sign of effusion or infiltrate. LABORATORY DATA: The patient did have a colonoscopy as part of her transplant work-up a month ago and this was normal.
DIP|distal interphalangeal|DIP|223|225|HISTORY OF PRESENT ILLNESS|ATTENDING PHYSICIAN: Dr. _%#NAME#%_. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 54-year-old female who underwent, approximately 3 weeks prior to admission, a left thumb CMC arthroplasty as well as a left middle finger DIP fusion. She presented to clinic on the day of her admission with increased erythema and swelling of her middle finger despite oral antibiotic therapy.
DIP|distal interphalangeal|DIP|59|61|DIAGNOSIS|Ultimately, I think it is going to need to be fused at the DIP joints of the index and long fingers. There is the possibility of amputation if his vascularity gets worse. Right now, though, things are pink and look reasonable. Slight active bleeding was encountered.
DIP|distal interphalangeal|DIP|258|260|PHYSICAL EXAMINATION|His profundus and superficialis are intact. On the right side he has tenderness over the index metacarpal neck, he has no foreshortening or rotation. He has full profundus and superficialis pull through, he also has full active extension at the MIP, PIP and DIP joints. Review of his x-rays show transverse fracture of his metacarpal of the small finger with significant angulation, it is not keyed in, on the ring finger his fracture is at the metacarpal base.
DIP|distal interphalangeal|DIP|219|221|LABORATORY DATA|She did have some imaging studies, including a hand x-ray that indicated that there was evidence of severe osteoarthritis at the first, second and third CM___ and subluxation at the first MTP. Moderate arthritis of the DIP and PIP joints and moderate diffuse osteopenia. The foot indicated that there was overgrowth of the head of MTP, degenerative changes of the first MTP, and moderate diffuse osteopenia.
DIP|distal interphalangeal|DIP|153|155|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ presented with a severe fixed boutonierre deformity contracture of her hand with PIP flexion contractures and DIP hyperextension with secondary hygiene issues resulting. She was felt to be a candidate for the aforementioned operation. The risks, benefits and alternatives were discussed, and she elected to proceed.
DIP|distal interphalangeal|DIP|183|185|HISTORY OF PRESENT ILLNESS|The pain and swelling progressively got worse over the last few days. She also started developing some erythema. The pain, swelling, and erythema is located mainly in the area of her DIP joint of the left thumb. She also complains that she has felt 3 nodules in this joint, and it is those nodules that are most tender and painful.
DIP|distal interphalangeal|DIP|215|217|ADMISSION PHYSICAL EXAMINATION|RESPIRATORY: Lungs are clear to auscultation bilaterally. No wheezing and no crackles. ABDOMEN: Soft, nontender, nondistended, with positive bowel sounds. SPINE: No CVA tenderness. SKIN: No rashes. EXTREMITIES: The DIP joint of the left thumb is erythematous. There are 3 palpable nodules in this area. There are 2 nodules on the dorsal surface and 1 on the palmar surface of that joint.
DIP|distal interphalangeal|DIP|109|111|ADMISSION PHYSICAL EXAMINATION|The swelling also spreads all the way down slightly past the PIP joint. The patient is unable to flex at the DIP joint. She is able to flex the PIP joint. She has normal sensation and capillary refill. The thumb is also warm to palpation, and the nodules described are tender to palpation.
DIP|distal interphalangeal|DIP|191|193|HOSPITAL COURSE|His pain had much improved. The splint was removed. His forearm compartments were not tensed. He had painless, active range of motion at both the wrist joints as well as at the MCP, PIP, and DIP joints. This was not painful to him nor was passive range of motion at this joint either. The patient was tolerating his diet. The patient was discharged home on _%#MM#%_ _%#DD#%_, 2005, with instructions about the signs and symptoms of compartment syndrome.
DIP|distal interphalangeal|DIP,|252|255|PHYSICAL EXAMINATION|Skin dorsally was intact, however volarly he had a small area of ecchymosis and eschar either from abrasion or possible puncture wound He had a +3 radial pulse and normal sensation of the radial, ulnar and median nerves. He had normal strength in FPL, DIP, and dorsal interossei. X-RAYS: Outside x-rays from the pediatric clinic including AP and lateral deformed, show a transverse slightly comminuted fracture at the same level of the mid radius and ulna.
DIP|dipropionate|DIP|191|193|UNCHANGED MEDICATIONS|3. GMP 100 mg p.o. daily, 4. Sertraline 50 mg p.o. daily. 5. Zolpidem 5 mg p.o. q.h.s. p.r.n. insomnia, 6. Albuterol inhaler 2 puffs inhaled p.r.n. for shortness of breath. 7. Beclomethasone DIP inhaler 2 puffs b.i.d. DISCONTINUED MEDICATIONS: None. CHANGED DOSES: None. PHYSICIAN FOLLOW-UP: Follow up with Dr. _%#NAME#%_ in one week.
DIP|distal interphalangeal|DIP|128|130|PROCEDURE|SURGEON: The surgeon will be Dr. _%#NAME#%_ on _%#MMDD2007#%_ at Fairview Southdale Hospital. PROCEDURE: Repair of first finger DIP joint under sedation with regional block. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 53-year-old female who tripped over a welding wire at work and fell really hard on her hand and her face.
DIP|distal interphalangeal|DIP|168|170|HOSPITAL COURSE|He was admitted to the hematology/oncology service. HOSPITAL COURSE: 1. Left middle finger cellulitis: The patient's left middle finger was quite erythematous from the DIP joint to the MIP joint. There was also an area of the size of a penny on the dorsal aspect of his middle finger that was purplish.
DIP|distal interphalangeal|DIP|169|171|PHYSICAL EXAMINATION|She does have hypoactive bowel sounds but otherwise present throughout. EXTREMITIES: Warm, without clubbing, cyanosis or edema. She does have deformities of the PIP and DIP joints of the fingers bilaterally and just about all of them are affected. LABORATORY: Blood sugar checked in the Emergency Department was 168.
DIP|distal interphalangeal|DIP|239|241|HOSPITAL COURSE|CONSULTATIONS: Orthopedic surgery, Dr. _%#NAME#%_ _%#NAME#%_. HOSPITAL COURSE: The patient is a 52-year-old gentleman who suffered a hot wire puncture wound to his left index finger accidentally. The puncture wound was between his PIP and DIP joints on the left. It did not go all the way through. In the recent past he had received a tetanus vaccination.
DIP|distal interphalangeal|DIP|195|197|OBJECTIVE|PELVIC/RECTAL: Deferred. EXTREMITIES: No cervical, axillary or femoral nodes. Femoral, DP and PT pulses are normal. Extremities are warm, pink and dry with no edema. She has some swelling of the DIP joints. No other active inflammation. SKIN: Without lesions. X-rays: There is a questionable apple core lesion in the right upper colon with air fluid levels.
DIP|distal interphalangeal|DIP|246|248|PAST MEDICAL HISTORY|At the time that I saw her in _%#MM#%_ 2000, she was noted to be extremely obese and dyspneic with just walking across the examining room. I did do an echocardiogram, which showed normal LV function. She had tophaceous deposits on her left third DIP joint, on 100 mg of allopurinol, and thus we increased her to 300 mg. She was also noted to have aortic stenotic murmur, but was not of great significance on the echocardiogram.
DIP|distal interphalangeal|DIP|232|234|PHYSICAL EXAMINATION|Review of his x-rays show a long spiral oblique fracture of the index middle phalanx noted on both the AP and lateral. If the fracture is allowed to heel in the present position, the patient will have a bony block to flexion at his DIP joint and will go on to a significant shortening. The plan is to do a closed reduction and percutaneous pinning and this is being scheduled at Fairview Southdale, hopefully for _%#MMDD2002#%_.
DIP|distal interphalangeal|DIP|187|189|PHYSICAL EXAMINATION|ABDOMEN: Nontender without organomegaly or mass. PULSES: Normal carotid pulses without bruits. Normal posterior tibial and dorsalis pedis pulses. EXTREMITIES: Degenerative changes of the DIP joints of the hands. The right knee is in a hinged knee brace; just placed 30-60 minutes ago. I did not remove it. No peripheral edema. NEUROLOGIC: Symmetric reflexes (except unable to test the knee reflexes for symmetry).
DIP|distal interphalangeal|DIP|120|122|PAST SURGICAL HISTORY|PAST SURGICAL HISTORY: 1. Is significant for bilateral vein ligation. 2. She also had a L4-L5 laminectomy 3. Left index DIP fusion on _%#MM#%_ _%#DD#%_ at Fairview Southdale. MEDICATIONS: 1. She is on Zoloft 150 2. Astelin Nasal spray QD.
DIP|distal interphalangeal|DIP|175|177|PHYSICAL EXAMINATION|Negative for hepatosplenomegaly. Negative CVAT. Bowel sounds are positive. EXTREMITIES: No cyanosis or edema. She has significant signs of osteoarthritis, particularly in the DIP joints of all fingers. NEUROLOGICAL: There is some residual weakness on the left side but no focal neurologic findings. She does have extreme gait disturbances, but this has not changed from before.
DIP|distal interphalangeal|DIP|153|155|PHYSICAL EXAMINATION|PULSES: Normal. Carotid pulses without bruits. Normal femoral, dorsalis pedis, and posterior tibial pulses. EXTREMITIES: Heberden's nodes in some of the DIP joints of the hands. No pretibial or ankle edema. REFLEXES: Symmetric. LABORATORY DATA: Hemoglobin 12.7. White count 6400.
DIP|distal interphalangeal|DIP.|161|164|DOB|He had intact sensation distal to that, in the SECOND DIGIT. He had normal strength with regard to extension of the FINGER. He had normal flexion of the PIP and DIP. He had less than two-second cap refill. COURSE IN THE EMERGENCY DEPARTMENT: The wound was anesthetized using 2+ Lidocaine without Epinephrine.
DIP|distal interphalangeal|DIP|134|136|OBJECTIVE|EXTREMITIES: No edema. Right index finger is remarkable for a cystic-type structure located along the ulnar side of the finger at the DIP joint. Her deep tendon reflexes are equal. SKIN: Within normal limits. Chest x-ray reveals what appears to be atelectasis involving the right lower lobe.
DIP|distal interphalangeal|DIP,|176|179|PAST MEDICAL HISTORY|She has two children who are married. FAMILY HISTORY: Hypertension and strokes. PAST MEDICAL HISTORY: 1. History of chronic low back pain. 2. Degenerative joint disease of the DIP, PIP, and MCP joints. 3. Non-Hodgkin's lymphoma, which was diagnosed in _%#MM2001#%_ or _%#MM2001#%_ and status post six cycles of R-CHOP. 4. Status post left parotid gland removal in 1999.
DIP|distal interphalangeal|DIP|173|175|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Significant for right knee arthroscopy in _%#MM2002#%_. 2. Tonsillectomy as a child. 3. Jaw surgery in 1971. 4. Right ring finger amputation at the DIP due to a lawnmower injury at age 6. HEALTH HABITS: He does smoke one-pack-per-month of cigarettes. He drinks alcoholic beverages occasionally.
DIP|distal interphalangeal|DIP|204|206|PHYSICAL EXAMINATION|No hepatosplenomegaly. No pulsatile mass. LOWER EXTREMITIES: No peripheral edema. Peripheral pulses are palpable and symmetric. Also, the patient has a quite significant degenerative joint disease in her DIP joints of the hands and her toes. NEUROLOGICALLY: She appears to be intact. Cranial nerves II-XII are grossly intact.
DIP|distal interphalangeal|DIP|182|184|HOSPITAL COURSE|He did not have any apparent deep space infection. He was started on IV antibiotics. His swelling and erythema markedly regressed, but he was left with one area just proximal to the DIP flexion crease on the right ring finger that remained intensely painful and very erythematous. When this did not resolve after four days of IV antibiotics, he underwent surgical irrigation and debridement.
DIP|distal interphalangeal|DIP|129|131|PLAN|I would recommend surgical stabilization of this injury to control rotation and overall alignment of the digit. Stiffness at the DIP joint was discussed. Will proceed with surgery at Southdale Hospital tomorrow.
DIP|distal interphalangeal|DIP|152|154|PHYSICAL EXAMINATION|Normal S1 and S2 without murmur or gallop. ABDOMEN soft and nontender. No organomegaly or masses. The EXTREMITIES show some hypertrophic changes of the DIP joints of the fingers and some venous stasis skin changes in both lower legs. He has a well-healed right lower extremity surgical scar. He has trace to 1+ pretibial and pedal pitting edema bilaterally.
DIP|distal interphalangeal|DIP|223|225|ADMISSION HISTORY AND DATA|On admission, temperature was 102 degrees Fahrenheit. She otherwise appeared in no apparent distress and examination of the fifth finger demonstrated swelling with protrusion of the skin and subcutaneous tissue between the DIP and PIP joints of her fifth finger. There was erythema and warmth extending up the ulnar aspect of her hand to the level of her wrist.
DIP|distal interphalangeal|DIP|171|173|HISTORY OF PRESENT ILLNESS|He was sutured and referred to me for further evaluation and treatment. He complains of inability to feel on the radial side of the small finger and inability to bend the DIP joint. Review of systems is negative in detail with the exception of asthma. MEDICATIONS: He is on medications as noted on the medication sheet which would be: Allegra.
DIP|distal interphalangeal|DIP|173|175|REVIEW OF SYSTEMS|She has several grown children. She does not smoke cigarettes. REVIEW OF SYSTEMS: Negative for any abdominal pain or urinary symptoms. Positive for some pain in her MCP and DIP joints since she has not had the Motrin for a day or so. Negative for any recent fluid retention, although she states that she has edema if she is off her Lasix.
DIP|distal interphalangeal|DIP|153|155|REVIEW OF SYSTEMS|She has pain in her hands, but otherwise no joint pain to speak of. The pain in the hands is mostly stiffness in the proximal interphalangeal joints and DIP joints. She has had no diplopia, amaurosis fugax, localizing weakness, incoordination or dysphagia. PHYSICAL EXAMINATION: This is a pleasant lady whose mucous membranes are moist, but less than normal.
DIP|distal interphalangeal|DIP|152|154|PHYSICAL EXAMINATION|Normal S1, S2. No murmurs, no gallops or rubs. ABDOMEN: Benign. EXTREMITIES: Right first toe shows diffuse erythema around the toe up to the MTP, first DIP joint. No streaking up the forefoot of the ankle. IMPRESSION: The patient is a 65-year-old white female with a history of diabetes mellitus who now presents with cellulitis of the 1st right toe.
DIP|distal interphalangeal|DIP|146|148|PHYSICAL  EXAMINATION|EXTREMITIES: Without clubbing, cyanosis or edema other than his left middle finger. His left middle finger has marked edema and erythema from the DIP extending downward onto the finger, onto the dorsal and palmar aspect of the hand with lymphangitic streak up the forearm almost to the elbow.
DIP|distal interphalangeal|DIP|217|219|PHYSICAL EXAMINATION|EXTREMITIES: Exam of the left hand reveals swelling but essentially no tenderness of the left middle finger PIP joint. There is about a 40 degree flexion contracture of the joint itself and some mild stiffness of the DIP joint. Neurovascular exam is intact. X-rays of the left middle finger (AP, lateral) taken at Queen of Peace on _%#MMDD2007#%_ and interpreted by me reveal a volar dislocation of the PIP joint.
DIP|distal interphalangeal|DIP|138|140|PHYSICAL EXAMINATION|Additionally, she has an effusion in her left wrist. Her wrist is painful to flexion and extension. Additionally, her third MCP and third DIP joints are painful to movement. The palmar aspect of her hand is nontender. When I palpate her left wrist joint, she is actually not all that tender.
DIP|distal interphalangeal|DIP|240|242|PHYSICAL EXAMINATION|CARDIAC - normal to precordial palpation and auscultation with no jugular venous distension and no carotid bruits. ABDOMEN - soft, nontender. No organomegaly or masses. EXTREMITIES - left hand index finger shows traumatic amputation at the DIP joint level, otherwise all four extremities appear normal to inspection and palpation without tremor. SKIN - normal to inspection and palpation. NEUROLOGIC - the patient is alert and seems well oriented without obvious dysarthric speech.
DIP|distal interphalangeal|DIP|173|175|PHYSICAL EXAMINATION|HEART: Regular rate and rhythm without murmur, rub or gallop. ABDOMEN: Soft, nontender, nondistended, without mass. EXTREMITIES: Arms reveal extensive synovitis of the MCP, DIP and PIP joints of both hands. Wrists also have synovitis. There are scattered abrasions to the knuckles on both hands.
DIP|distal interphalangeal|DIP|168|170|PHYSICAL EXAMINATION|Cervix appears intact. Uterus is introverted, normal size. Adnexae are clear. RV confirms. EXTREMITIES: Unremarkable other than the mild tenderness and swelling in the DIP joints in both hands. She has good peripheral pulses. Her reflexes are symmetric and normoactive. Her gait is normal. LABORATORY DATA: Hemoglobin on this date was drawn and will be faxed over as well as her EKG prior to surgery.
DIP|distal interphalangeal|DIP.|202|205|PHYSICAL EXAMINATION|EXTREMITIES: No edema noted. SKIN: Generalized erythematous macular papular rash on her trunk and legs. MUSCULOSKELETAL EXAM: The patient has tenderness in her PIPs. No tenosynovitis in the MCP and the DIP. No rheumatoid nodules noted. The patient has full range of motion in both upper and lower extremities. LABORATORIES: None available at this time.
DIP|distal interphalangeal|DIP|161|163|PHYSICAL EXAMINATION|There is a neatly sutured, transverse laceration along the volar aspect of the proximal phalanx, 15 mm in length. She has no active flexion of either her PIP or DIP joints. There is diminished sensation along the radial pulp. Circulation is intact, however. IMPRESSION: Probable Zone II flexor tendon lacerations, right V radial digital nerve.
DIP|distal interphalangeal|DIP|214|216|OBJECTIVE|ABDOMEN: Mild distention without tenderness, without hepatosplenomegaly. Bowel sounds are intact. EXTREMITIES: There is ulnar deviation noted of the upper extremities. There was no erythema present over the PIP or DIP joints. There is tenderness with palpation, however, tenderness noted over both knees without erythema, without evidence of effusion. Pain mainly involves the left knee. Distal pulses +2. NEURO: Motor exam limited secondary to joint pain.
DIP|distal interphalangeal|DIP|168|170|PHYSICAL EXAMINATION|Negative hepatosplenomegaly. No rebound or _________ present. LOWER EXTREMITIES: No peripheral edema. The patient's fingers show some degenerative joint disease in his DIP joints. NEUROLOGIC: Mental status normal. No focal deficit. LABS: Sodium 139, potassium 4.0, creatinine 1.2, calcium 9.1, glucose 97, WBC 9.5, hemoglobin 14.0, myoglobin 41, troponin less than 0.07. EKG was unremarkable with a normal sinus rhythm.
DIP|distal interphalangeal|DIP|191|193|PHYSICAL EXAMINATION|ABDOMEN: Benign without masses or organomegaly. EXTREMITIES: Left hand - there are large wounds involving the long finger. He has an oblique soft tissue amputation at nearly the level of the DIP joint. It is a little proximal to that area. This wound has been scrubbed out by Dr. _%#NAME#%_, but there is still some contamination. The ring finger has some smaller lacerations on it, as does the index finger.
DIP|distal interphalangeal|DIP|188|190|REVIEW OF SYSTEMS|Has had intermittent low back pain for many years, in particularly since _%#MM#%_ of 2003 where she strained her back lifting her husband. Also fairly severe osteoarthritis in the PIP and DIP joints of most of her fingers bilaterally. Currently these are not giving her any pain but occasionally there is some flare.
DIP|distal interphalangeal|DIP|195|197|PHYSICAL EXAM|SPINE: Normal contour and stability. Good range of motion. Some low lumbar paraspinous tenderness bilaterally. Straight leg raising is negative. EXTREMITIES: Remarkable for nodularity in PIP and DIP joints throughout both hands. None in the MP joints however. Has fairly good range of motion throughout these joints. The remaining joints throughout the body unremarkable aside from some crepitus in both knees.
DIP|distal interphalangeal|DIP|116|118|MAJOR PROCEDURE|DISCHARGE DIAGNOSES: Macrodactyly of the left index and long finger. MAJOR PROCEDURE: 1. Left index and long finger DIP fusion debulking. 2. Left long finger osteotomy. HOSPITAL COURSE: After the patient underwent the above- mentioned procedure the patient tolerated the procedure well.
DIP|distal interphalangeal|DIP|157|159|PHYSICAL EXAMINATION|EXTREMITIES: Examination of his left hand demonstrates a complex laceration involving the volar aspect of his index finger at the level just proximal to the DIP flexion crease. He has intact sensation on the radial aspect of the digit distal to the injury. He has diminished sensation in the ulnar aspect. The laceration is open but there is little soft tissue loss.
DIP|distal interphalangeal|DIP|173|175|PHYSICAL EXAMINATION|HEART: Is regular rate and rhythm EXAMINATION OF HER Left THUMB: Reveals a laceration between the metacarpal phalangeal and PIP joint. She is unable to fully extend at that DIP joint of the thumb. She has full APL strength. She has some good ETB, but she has loss of her ETL to the distal tendon.
DIP|distal interphalangeal|DIP|226|228|PLAN|Alert, cooperative, NAD Sclera clear, oralphayrnx clear Neck supple, no LAD Lungs clear, no crackles or wheezes. Heart regular, no murmur. Abdomen soft, non-tender. Good pulses and perfusion. Swelling at tip of 4th digit from DIP to end, warm and painful to touch, mucous membranes moist. No focal neurologic deficits. 2 and 1/2 year old with felon of right 4th digit.
DIP|distal interphalangeal|DIP|186|188|PHYSICAL EXAMINATION|LUNGS: Clear bilaterally. CARDIOVASCULAR: Regular rate and rhythm, no murmurs. ABDOMEN: Hypoactive bowel sounds, soft, nontender. EXTREMITIES: Positive edema along the patient's PIP and DIP joints of her hands. SKIN: No rashes. NEUROLOGIC: Cranial nerves II through XII grossly intact. Sensation intact to light touch. Gait deferred. Grip approximately 4 out of 5.
DIP|distal interphalangeal|DIP|139|141|PHYSICAL EXAMINATION|The cellulitis is located primarily dorsally, centering over the distal phalanx and distal aspect of the proximal phalanx. He can move the DIP joint from 0 through 50 degrees. He can move his PIP joint normally from 0 through 100 degrees. There is no fluctuance or definite joint space fluid palpable There is no involvement on the flexor side of the finger.
DIP|distal interphalangeal|DIP|132|134|HISTORY|Since receiving IV cefazolin in the hospital, he has had marked improvement with rescinding of the erythema to just proximal of the DIP joint. He has good range of motion of the MCP and PIP. He has had no fevers while here in the hospital but was mildly febrile prior to presentation.
DIP|distal interphalangeal|DIP|270|272|PHYSICAL EXAMINATION|Nondistended. No organomegaly or masses. EXTREMITIES: No edema noted. Examination of the patient's feet there was hammer toe noted bilaterally at the second toe. She did have good sensation in her feet and pulses were intact bilaterally. There was a callus noted at the DIP joint of the second toe bilaterally. Nails were poorly groomed. SKIN: No rashes noted. NEUROLOGICAL: She was alert and oriented times three.
DIP|distal interphalangeal|DIP|283|285|PHYSICAL EXAMINATION|The callouses on his elbows are not substantially changed. Overlying the extensor surfaces of his hands, he has areas that are slightly raised and similar to Gottron's papules but not as well demarcated. These are mainly over his PIP joints, but he has some changes over his MCP and DIP joints. He has no active synovitis of his finger joints. He is still restricted in motion in his right wrist more so than his left, and he also has some restriction in his digits.
DIP|distal interphalangeal|DIP|212|214|PHYSICAL EXAMINATION|No open wounds, particularly on the toes, interspaces, etc. There is 1+ pitting edema. RIGHT KNEE: Negative. Foot negative. RIGHT HAND: Multiple PIP and DIP joint deformities, particularly the right index finger DIP joint shows gouty tophi, acutely inflamed as well. No skin breakdown. Not septic. X-RAYS: X-rays are pending of the knees, but most likely show osteoarthritic changes which is my recollection in the office.
DIP|distal interphalangeal|DIP|151|153|PHYSICAL EXAMINATION|Examination of her left foot showed her third toe is very erythematous and mildly swollen. She had a small punctate lesion on the dorsal aspect of her DIP joint with some slight purulent drainage. There did appear to be some mild cellulitis on the dorsal aspect of her foot, but this appeared to be improved from the day before.
DIP|distal interphalangeal|DIP|197|199|PHYSICAL EXAMINATION|MUSCULOSKELETAL: She has significant grade 2 synovitis of her first through fifth MCP joints bilaterally as well as the first through fifth PIP joints bilaterally. Mild hypertrophic changes in the DIP joints, grade 1 synovitis of both wrists. Large effusions in both elbows. Significant joint effusions in both knees, more so on the left than the right.
DIP|distal interphalangeal|DIP|145|147|PHYSICAL EXAMINATION|He is S0, T0 at the PIP joints, MCP joints, right wrist, elbows, shoulders, hips, knees, ankles, mid feet, and MTP joints. The left fifth finger DIP joint has moderate Heberden's node formation. LABORATORY DATA: Demonstrates a sedimentation rate of 76, performance _%#MMDD2003#%_.
DIP|distal interphalangeal|DIP|206|208|PHYSICAL EXAMINATION|Elbows and wrists are normal. Degenerative changes at the first carpometacarpal (CMC) joints bilaterally. Metacarpophalangeal (MCP) joints are normal. Mild degenerative changes are scattered in the PIP and DIP joints; none of these joints are particularly tender. She still has reasonable grip strength. HIPS: Nontender to palpation/punch.
DIP|distal interphalangeal|DIP|212|214|PHYSICAL EXAMINATION|No scalp tenderness. EYES: Unremarkable. Temporomandibular joint and carotids are not enlarged. NECK: Shows no thyroid enlargement. The peripheral joint examination revealed some very minimal bony changes of the DIP and PIP joints. There is chronic thickening of the right wrist from prior surgery. There is decreased flexion and extension of the right wrist.
DIP|distal interphalangeal|DIP|164|166|OBJECTIVE|Nails are normal. There is no bruising or ulceration. There is no lymphadenopathy. There is no lymphangitis. The upper extremities show minimal bony changes of the DIP and PIP joints, but no synovitis. MCPs, wrist, elbows are normal, both shoulders move well. There is no nodularity. No tophi are noted. HIPS: Move normally. The knees show chronic changes from total joint arthroplasty.
DIP|distal interphalangeal|DIP|224|226|HISTORY|The index finger demonstrates some moderate edema. There is some devitalized tissue along the distal and radial aspect of the index finger. No obvious purulence is expressed. There is tenderness along the distal phalanx and DIP joint. She is able to move the digits. No significant tenderness along the palmar surface of the flexor tendons in the palm.
DIP|distal interphalangeal|DIP|145|147|PHYSICAL EXAMINATION|He is in no acute distress. At the right long finger, there is an oblique wound through the volar surface of the right long finger distal to the DIP joint. This runs from palmar distal to dorsal proximal. There is complete loss of the soft tissues in this region with exposed distal phalanx.
DIP|distal interphalangeal|DIP|172|174|PHYSICAL EXAMINATION|The distal phalanx itself is almost completely intact with only a small fracture at the distal tip. The extensor tendon is not visualized in the wound. He does have intact DIP and PIP flexion. His sensation at his forearm and other fingers is intact, but the block prohibits testing of his sensation on his ring finger.
DIP|distal interphalangeal|DIP|202|204|PHYSICAL EXAMINATION|He is awake, alert and oriented x 3, relaxed and cooperative to the examination. His right hand has been cleaned in the Emergency Room. His index and middle finger have dorsal lacerations distal to the DIP joint at the level of the eponychial folds. The nails are intact but they are attached only distally and not proximally.
DIP|distal interphalangeal|DIP|138|140|ASSESSMENT|ASSESSMENT: Polyarticular gout: The patient has had a recurrence of disease with marked inflammation in the knees, ankles and right fifth DIP joint. I do not think it is necessary to again aspirate one of her inflamed joints despite the normal uric acid level.
DIP|distal interphalangeal|DIP,|178|181|PHYSICAL EXAM|He does have some mild decrease on the ulnar border of the finger, however the radial border is intact. He is unable to actively extend at the PIP joint. He can flex the PIP and DIP, 2+ radial pulse. X-rays today, multiple views obtained in the ER were reviewed.
DIP|distal interphalangeal|DIP|237|239|EXAM|The sterile matrix appears to be gone along the ulnar aspect with some preservation of the radial aspect of the sternal matrix. Greater than 3 cm soft tissue defect remained, and saw injury into the middle phalanx and distal phalanx and DIP joint evident. X-rays: Three views of the hand demonstrate bony defect created by the saw in the middle phalanx and DIP joint.
DIP|distal interphalangeal|DIP|198|200|PHYSICAL EXAMINATION|Moist mucus membranes. Carotid upstroke is brisk. There is no thyromegaly or lymphadenopathy. SKIN: An approximate 2-mm puncture wound over the dorsum of the right second digit just proximal to the DIP joint. Mild surrounding erythema. No drainage. No lymphangitic streaking. No soft tissue swelling. CHEST: Clear lung fields. CARDIAC: Regular without gallop or murmur.
DIP|distal interphalangeal|DIP.|165|168|PHYSICAL EXAMINATION|There is an approximately 3-4 Inch scar on the patient's right arm in the popliteal area. There is also a laceration on her right index finger that is distal to the DIP. It is approximately an inch. There is no sign or erythema, swelling, or infection noted. SKIN: No rashes noted. The patient has multiple bruises on both of her lower legs and knees.
DIP|distal interphalangeal|DIP,|244|247|PHYSICAL EXAMINATION|No wheezes. CV: Regular rate and rhythm. Normal S1, S2. No murmur. LYMPHATICS: No axillary or groin adenopathy. JOINTS: The following joints were examined and were found to be without synovitis or effusions and had full range of motion; finger DIP, PIP, MCP bilaterally, wrists, elbows, shoulders, AC, TMJ, SC, hip, knee, subtalar, tibiotalar, and toe MTP and IP. She had no edema, cyanosis or clubbing. IMPRESSION: The patient has a one-month history of neck pain.
DIP|distal interphalangeal|DIP|187|189|HISTORY OF PRESENT ILLNESS|The patient is currently having an exacerbation of this in her feet, legs, and hands. She rates her pain as a 5/10 and is more of a burning pain. She has some redness and swelling in the DIP and PIP joints on her hands and feet. Her knees are also red. She has tried NSAID and methotrexate in the past per her rheumatologist with little success.
DIP|distal interphalangeal|DIP|125|127||There is still an open linear area along the incision and drainage plane, and he has markedly limited range of motion at the DIP and PIP joints. The digit is still about twice the size of normal. However, this all represents an improvement compared to during his hospital stay.
DIP|distal interphalangeal|DIP|158|160|ADDENDUM|At this point I believe the patient has second toe osteomyelitis and it involves both the proximal and middle phalanges, and there is a draining sinus to his DIP joint. He also has cellulitis on the dorsum and arthritic change in his first MTP joint. With regard to his left side, he has a fracture at the base of the distal phalanx of the great toe and there is a blister above the fracture.
DIP|distal interphalangeal|DIP|133|135|PHYSICAL EXAMINATION|His most significant injury occurred to the long finger where he has a volar soft tissue loss in the PIP joint distally exposing the DIP joint grossly. He has also angular deformity at the level of PIP joint. The ring finger injury involves the soft tissues volarly distal to the DIP joint.
DIP|distal interphalangeal|DIP|128|130|PHYSICAL EXAMINATION|He has also angular deformity at the level of PIP joint. The ring finger injury involves the soft tissues volarly distal to the DIP joint. There was no evidence of more proximal injury. The index finger injury is less significant in terms of soft tissue loss.
DIP|distal interphalangeal|DIP|197|199|PHYSICAL EXAMINATION|Exploration of it shows that the extensor tendon hood is severed from radial to ulnar, but is not completely severed on the most ulnar aspect, which allows her extension. Distally she can flex her DIP and her PIP joints. Remainder of her hand sensation and motor are intact. Normal wrist extension and flexion. Normal elbow motion. ASSESSMENT: Laceration of the right index finger including the extensor hood of the index finger.
DIP|distal interphalangeal|DIP|156|158|PLAN|She is otherwise healthy. She is right-hand dominant. On examination, the splint was removed. She has a healed laceration over the dorsum of the left index DIP joint. The sutures are still in the wound. There is no evidence of infection. She is unable to actively extend her DIP joint but she has full passive extension at the DIP joint as well as the PIP and MP joints.
DIP|distal interphalangeal|DIP|181|183|PLAN|She has a healed laceration over the dorsum of the left index DIP joint. The sutures are still in the wound. There is no evidence of infection. She is unable to actively extend her DIP joint but she has full passive extension at the DIP joint as well as the PIP and MP joints. Her finger is somewhat stiff in flexion because of being in the splint but she is able to flex her finger without too much discomfort.
DIP|distal interphalangeal|DIP|160|162|PLAN|The sutures are still in the wound. There is no evidence of infection. She is unable to actively extend her DIP joint but she has full passive extension at the DIP joint as well as the PIP and MP joints. Her finger is somewhat stiff in flexion because of being in the splint but she is able to flex her finger without too much discomfort.
DIP|distal interphalangeal|DIP|175|177|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: A healthy-appearing gentleman. He has obvious injury to the right long finger with a complex laceration extending from the PIP joint distally toward the DIP joint obliquely. There is noted ulnar deviation to the digit. There appears to be a little rotational deformity. He has exposed extensor tendon with zone 2 extensor tendon laceration.
DIP|distal interphalangeal|DIP|265|267|PLAN|She is also on oral doxycycline and oral fluconazole. In the interval since I had last seen her, she seems to have continued her improvement with diminished redness and swelling in the distal phalangeal area. There is still notable decreased range of motion at the DIP and PIP. The nailbed itself has a slight disruption to it, and the nail is slightly loose, but does still appear to be viable.
DIP|distal interphalangeal|DIP|190|192|PHYSICAL EXAMINATION|Positive pain with palpation of right lower ribs. EXTREMITIES: Inflammation that appears chronic of the patient's PIP joints of his hands bilaterally. There is also some inflammation of his DIP joints. No edema noted. NEUROLOGIC: Cranial nerves II through XII grossly intact. Sensation intact to light touch. Gait within normal limits. LABORATORY DATA: Pending. ASSESSMENT: 1. Bipolar disorder.
DIP|distal interphalangeal|DIP|204|206|PHYSICAL EXAMINATION|ABDOMEN: Benign. No rebound or guarding. PELVIS: Stable. EXTREMITIES: Upper extremities, shoulders, elbows, wrists normal with exception of left long finger shows some degenerative changes of the PIP and DIP joint. All flexors and extensors intact. Nailbeds without deformities or clubbing. Lower extremities short rotators right hip. Circulation intact. Skin and lymphatic intact.
DIP|distal interphalangeal|DIP|157|159|PHYSICAL EXAMINATION|COR: Regular rate and rhythm without murmur, gallop or rub. ABDOMEN: Bowel sounds are present. Mild diffuse tenderness. No hepatosplenomegaly noted. JOINTS: DIP joints are normal. PIP joints show grade 1 swelling but grade 2 pain. There are no chronic deformities noted. MCPs normal. Wrists: Grade 1 synovitis along with T2 pain.
DIP|distal interphalangeal|DIP|200|202|PHYSICAL EXAMINATION|PAST MEDICAL HISTORY: Otherwise healthy. PHYSICAL EXAMINATION: GENERAL: A healthy-appearing young man has obvious injury to the index finger. There is a transverse laceration through the level of the DIP joint from the saw injury. It appears to extend through both neurovascular bundles. However, there is some capillary refill to the distal digit.
DIP|distal interphalangeal|DIP|151|153|PHYSICAL EXAMINATION|It appears to extend through both neurovascular bundles. However, there is some capillary refill to the distal digit. It is at the level distal to the DIP joint. It is not amendable to microvascular repair, but capillary refill does indicate collateral flow maintaining perfusion. Flexor tendon is lacerated and there is obvious segmental injury to the DIP joint.
DIP|distal interphalangeal|DIP|191|193|PHYSICAL EXAMINATION|It is not amendable to microvascular repair, but capillary refill does indicate collateral flow maintaining perfusion. Flexor tendon is lacerated and there is obvious segmental injury to the DIP joint. He has diminished sensibility to the distal digit. Dorsal skin bridge, nail matrix and nail structures remained intact. X-rays, 3 views, of the digit demonstrated segmental loss from the saw injury of the DIP joint.
DIP|distal interphalangeal|DIP|205|207|PHYSICAL EXAMINATION|He has diminished sensibility to the distal digit. Dorsal skin bridge, nail matrix and nail structures remained intact. X-rays, 3 views, of the digit demonstrated segmental loss from the saw injury of the DIP joint. IMPRESSION: 1. Complex laceration with traumatic arthrotomy, segmental loss of the distal interphalangeal joint secondary to the saw injury.
DIP|distal interphalangeal|DIP|165|167|PHYSICAL EXAMINATION|There are no masses palpable. There is no tenderness particularly in the right upper quadrant or epigastrium. MUSCULOSKELETAL exam shows the fourth finger left hand DIP to be damaged with extreme ulnar deviation of the distal phalanx. This is completely healed, patient having undergone surgery in the distant past, including a skin graft to the area.
DIP|distal interphalangeal|DIP|213|215|ASSESSMENT AND PLAN|I explained this to the patient and his family. I explained that there is a chance that he may require some partial amputation of the digit in order to obtain skin closure, particularly of the index finger as his DIP joint was clearly violated. They express understanding of our plan as well as the potential risks, benefits, and complications of surgery.
DIP|distal interphalangeal|DIP,|223|226|HISTORY|There are no cuts or abrasions over the hand. There is evidence of an old puncture, approximately 3 mm in diameter in the flexor crease of the PIP joint. She has swelling in her finger. The finger is held in flexion at the DIP, PIP and MP joints. Attempts at extension resulted in significant pain. Her neurologic exam, including sensory motor function is normal.
DIP|distal interphalangeal|DIP|126|128|HISTORY OF PRESENT ILLNESS|That area has responded very well to this, and he has minimal pain now and full range of motion of the distal phalanx and the DIP joint of the third finger. On physical examination, the remainder of his digits are without deficit. He had no skin lesions. He has full range of motion and no swelling.
DIP|distal interphalangeal|DIP|172|174|HISTORY OF PRESENT ILLNESS|She has been maintained on high-dose prednisone therapy, currently 50 mg a day, and methotrexate. Approximately 2 weeks ago, she developed redness at the left index finger DIP joint area and this had been present for apparently 1 week prior to that. She presented to the emergency room 2 weeks ago for evaluation of this and was given an oral antibiotic (I believe Keflex 4 times a day) and sent home.
DIP|distal interphalangeal|DIP|195|197|REVIEW OF SYSTEMS|There is no erythema or induration. The patient is unable to make a fist secondary to pain; however, examination of his flexor tendons show them to all be intact with good range of motion at the DIP and PIP joints throughout the left hand. He notes some tenderness to palpation in his left forearm; however, there is no streaking or signs of infection.
DIP|distal interphalangeal|DIP|221|223|PHYSICAL EXAMINATION|Two vessels are noted to be bleeding profusely. These are separated by approximately 4 cm and appear to be different vessels. No tendons are visible within the wound. The patient is able to flex all of his fingers at the DIP and PIP joints independently. The patient is able to cross his index and middle fingers. The patient is able to fully extend all of his fingers.
DIP|distal interphalangeal|DIP|199|201|PHYSICAL EXAMINATION|The patient has normal radial and ulnar pulses. The patient has normal capillary refill in all of his digits and sensation. Sensation is also within normal limits. The patient is able to flex at the DIP and PIP joints in all of his digits, although with some pain with flexion and extension of his thumb. RADIOGRAPHIC IMAGING: The patient had AP, lateral, and oblique films taken in the ER.
DIP|distal interphalangeal|DIP|194|196|PAST MEDICAL HISTORY|The patient has no other complaints at this time. PAST MEDICAL HISTORY: 1. Two prior psychiatric admissions to Fairview _%#CITY#%_ and included previous suicide attempts. 2. Previous surgery of DIP fusion of right hand. 3. Frost bite in youth, which caused much pain in her late teens, and thus necessitated need for surgery.
DIP|distal interphalangeal|DIP|177|179|HISTORY|He was brought into the emergency room where obvious injury was noted. X-rays demonstrated a complex fracture involving the proximal phalanx, middle phalanx and distal phalanx, DIP and PIP joints. Complex laceration was noted with extensor tendon involvement. Orthopedic consultation was requested. PAST MEDICAL HISTORY: He reports on chronic illnesses, otherwise healthy.
DIP|distal interphalangeal|DIP|383|385|PHYSICAL EXAM|No previous surgeries. ALLERGIES: No known drug allergies. PHYSICAL EXAM: He has a complex laceration with longitudinal split and ulnarly based flap that extends from the proximal germinal matrix region to past the PIP joint with obvious comminuted fracture with displacement and deformity, excessive flexion deformity indicating loss of tenodesis and extensor mechanism at both the DIP and PIP joint. There appears to be some subluxation of portions of the joint surface and the middle phalanx. Sensibility was not tested because of numbness from the digital block in the emergency room but was reported to have sensibility.
DIP|distal interphalangeal|DIP,|188|191|PHYSICAL EXAMINATION|No murmur. LUNGS: Bibasilar crackles. ABDOMEN: Soft and nontender. Positive bowel sounds. JOINTS: The following joints were examined for range of motion, swelling, redness and tenderness. DIP, PIP, MCP, wrist, elbow, shoulder, acromioclavicular (AC), temporomandibular joint (TMJ), hip, knee, ankle, MTP, PIP and DIP of the feet. These were found to be without abnormality with the exception of some mild-to-moderate Heberden's and Bouchard nodes bilaterally.
DIP|distal interphalangeal|DIP|215|217|PHYSICAL EXAMINATION|There is no splinter hemorrhages. LYMPHATICS: None palpable. HEAD: Is normocephalic, no scalp tenderness. EYES: Are unremarkable. ORAL MUCOSA: Is somewhat dry. The peripheral joint examination reveals fairly normal DIP and PIP joints. There is Grade I thickening of the second and third MCP joints. Bilaterally and a hint of thickening of the left wrist.
DIP|distal interphalangeal|DIP,|114|117|PHYSICAL EXAMINATION|She is in a splint and I have been instructed to leave the splint on. She has good finger and thumb motion at the DIP, PIP, and MP joints. There is no evidence of distal instability. Strength is 5 out of 5 in all finger flexors, deep and superficial, both sides, as well as finger extensors and all extrinsics.
DIP|distal interphalangeal|DIP.|183|186|PHYSICAL EXAMINATION|ABDOMEN: Soft, slightly round, nontender, nondistended to my exam. Bowel sounds are low-pitched and present. MUSCULOSKELETAL: Slight kyphosis. There are some arthritic changes in the DIP. LABORATORY DATA: White blood count 18.8, hemoglobin 12, MCV 87, platelets 260, INR 1.81. Electrolytes on _%#MM#%_ _%#DD#%_: Sodium 135, potassium 4.0, chloride 102, cO2 26.
DIP|distal interphalangeal|DIP|180|182|PHYSICAL EXAMINATION|Range of motion is noted to be flexion to approximately 90 degrees at the MCP, 90 degrees at the PIP and near 90 at the DIP joint. He is nontender to palpation at the MCP, PIP and DIP joints. He is nontender to palpation over the proximal and middle phalanx. On palpation there is noted to be an area of induration, which is consistent with scar tissue where the patient was bitten and had his incision and drainage.
DIP|distal interphalangeal|DIP|201|203|PHYSICAL EXAMINATION|ABDOMEN: Soft, nontender. No hepatosplenomegaly. No rebound tenderness. EXTREMITIES: No palpable edema. Good pulses. MUSCULOSKELETAL: She has evidence of osteoarthritis in her hands, especially in her DIP joints and she has evidence of heberdens node. There is also evidence of crepitance in both her knees. Other than that all her joints are without any synovitis and the range of motion in all the joints is normal, and there is no evidence of any deformity.
DIP|distal interphalangeal|DIP|136|138|PLAN|He does not appear to have any disruption of the extensor mechanism at this time. The infection of wound is at the level of the PIP and DIP joint level. On the rest of the foot plantar-wise there is a prominent ____ head but no open wounds or just a bit of a callus.
DIP|distal interphalangeal|DIP|134|136|PHYSICAL EXAMINATION|These joints are not tender. There is associated bony change. There are no shoulder effusions. There is some mild bony changes of the DIP joints. Both hips move fairly well. There is chronic thickening and bony change of the knees. I do not find any synovitis involving the ankles or the MTP joints.
DIP|distal interphalangeal|DIP|128|130|PHYSICAL EXAMINATION|The right index finger has circumferential necrosis beginning at the distal portion of the middle phalanx, just proximal to the DIP joint. There is no sign of spreading erythema. The middle finger has slow capillary refill, measuring approximately 3 seconds with normal sensation and no signs of skin lesion.
DIP|distal interphalangeal|DIP|128|130|PHYSICAL EXAMINATION|The right index finger has circumferential necrosis beginning at the distal portion of the middle phalanx, just proximal to the DIP joint. There is no sign of spreading erythema. The middle finger has slow capillary refill, measuring approximately 3 seconds with normal sensation and no signs of skin lesion.
DIP|distal interphalangeal|DIP|146|148|PHYSICAL EXAMINATION|Her range of motion is from 0-90 degrees of flexion at the MCP joint, 0-95 degrees of flexion at the PIP joint and 0-40 degrees of flexion at the DIP joint. She has mild tenderness to palpation along the entire finger, particularly at the PIP joint, but really no pain with gentle range of motion from 0 to about 70 degrees.
DIP|distal interphalangeal|DIP,|239|242|PHYSICAL EXAMINATION|Since admission he has also been started on Rocephin. VITAL SIGNS: He is currently afebrile with otherwise normal vital signs. HEENT: Normal. No lymphadenopathy. CHEST: Clear to auscultation. HEART: Regular currently. JOINT EXAM: Multiple DIP, PIP and MCP joints in both hands with grade 1-2 swelling and grade 1-2 tenderness. These joints also had overlying nodules either soft or hard.
DIP|distal interphalangeal|DIP|141|143|PHYSICAL EXAMINATION|ABDOMEN is soft, nontender without palpable mass. BACK examination is deferred. The peripheral joint examination showed some bony changes of DIP joints, however, there is no active synovitis. The range of motion of joints is normal. Grip strength is normal. Proximal muscle strength of the upper EXTREMITIES actually seems fairly good.
DIP|distal interphalangeal|DIP|216|218|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: A healthy-appearing gentleman with full range of motion of the wrist and digits with the exception of the long finger. He has swelling and tenderness along the DIP joint. He is able to move the DIP joint but has some limited motion secondary to swelling. He has tense and exquisite tenderness over the nail bed proximally.
DIP|distal interphalangeal|DIP|229|231|PHYSICAL EXAMINATION|He maintains very healthy, active lifestyle. He lives independently. PHYSICAL EXAMINATION: He is a healthy, elderly appearing gentleman who has obvious injury to his left hand. There is a traumatic oblique amputation through the DIP to the small finger with the obliquity extending to the ring finger through the DIP joint and portion of the middle phalanx of the ring finger.
DIP|distal interphalangeal|DIP|233|235|PHYSICAL EXAMINATION|The index finger appears spared. Arthritic changes are noted in the PIP and MP joints but no injury proximal to this site. X-rays, AP, lateral and oblique were reviewed and confirm the traumatic amputations through the levels of the DIP joints. IMPRESSION: Amputation long, ring and small fingers secondary to saw.
DIP|distal interphalangeal|DIP|236|238|EXAMINATION|Insight and judgment are poor but intact. Examination of the right hand: No swelling, erythema, symmetric with left hand. There is a plantar/flat wart on the right middle finger. The right ring finger is tender to palpation most at the DIP and PIP. Range of motion is about 10 percent flexion secondary to pain lacking 90 percent of the flexion. Extension is normal. Medial and lateral movement of the finger is normal.
DIP|distal interphalangeal|DIP.|175|178|EXAMINATION|Patient ambulates normally. Mentates as per above. X-ray of the finger shows an oblique fracture of the middle phalanx extending through the distal articular surface into the DIP. There is 1-mm of separation at the distal articular surface. Of note, listed in the computer dated _%#MMDD2005#%_ is an x-ray report of the right ring finger with clinical history of injury possible fracture, ordered by her primary physician, Dr. _%#NAME#%_ _%#NAME#%_ with exactly the same findings.
DIP|distal interphalangeal|DIP|203|205|PHYSICAL EXAMINATION|Also, underwent left inguinal hernia repair. Distal lower extremities are well perfused, no cyanosis, clubbing or edema. Musculoskeletal: Demonstrates some minor tenderness of the MCP and PIP joints. No DIP joint synovitis to indicate active psoriatic change. Genitalia/rectal: Exams deferred. Neurologic: No facial asymmetry, no lateralizing extremity weakness. Romberg negative.
DIP|distal interphalangeal|DIP|152|154|PROCEDURE NOTE|The sterile dressing was applied and a Bunnell type of splint was fashioned using the equipment available in the emergency department. This allowed the DIP to be free. This procedure was done with sterile technique after preparation with Betadine swabs. ASSESSMENT: Status post repair of central slip of the extensor mechanism of the PIP joint.
DIP|distal interphalangeal|DIP|193|195|PHYSICAL EXAMINATION|LUNGS: Clear. HEART: Regular rate and rhythm. LEFT UPPER EXTREMITY: Examination of his left upper extremity reveals a laceration to his ring and small fingers. At the small finger it is at the DIP crease and at the ring finger it is at the middle phalangeal level. He is able to flex both fingers today against resistance at both the DIP and PIP joint.
DIP|distal interphalangeal|DIP|174|176|PHYSICAL EXAMINATION|At the small finger it is at the DIP crease and at the ring finger it is at the middle phalangeal level. He is able to flex both fingers today against resistance at both the DIP and PIP joint. Two-point discrimination is intact. He has good capillary refill. IMPRESSION: Laceration without flexor tendon involvement or only partial flexor tendon involvement.
DIP|distal interphalangeal|DIP|307|309|PHYSICAL  EXAMINATION|VITAL SIGNS: Blood pressure 125/85, pulse 99, respirations 20, temperature 96.1. EXTREMITIES: Examination of the right hand reveals stiffness involving multiple fingers. In regard to the little finger, there is reddish/purplish discoloration from the proximal phalanx distally. There is fluctuance over the DIP joint but the overlying skin is intact. Upon squeeze and DIP joint I am able to express yellowish pus from underneath the nail fold.
DIP|distal interphalangeal|(DIP)|108|112|IMPRESSION|Potassium 2.7, glucose 179, creatinine 4.4, BUN 141. IMPRESSION: 1. Septic arthritis distal interphalangeal (DIP) joint right V with probable osteomyelitis. 2. Chronic renal failure. 3. Diabetes mellitus. 4. Morbid obesity. 5. Gout. With this constellation of circumstances I believe that the most appropriate treatment would be to do an amputation of the finger at the level of the PIP joint.
DIP|distal interphalangeal|DIP|210|212|IMPRESSION|5. Gout. With this constellation of circumstances I believe that the most appropriate treatment would be to do an amputation of the finger at the level of the PIP joint. I do not believe that a mere I&D of the DIP joint would be appropriate and quite honestly would be totally ineffective. The patient is interested in proceeding along these lines. I therefore reviewed the operative procedure with this patient in his room and answered questions to the best of his satisfaction.
DIP|distal interphalangeal|DIP|183|185|PHYSICAL EXAMINATION|ABDOMEN: positive bowel sounds. Normoactive. Nontender, nondistended, and soft. No organomegaly or masses. EXTREMITIES: No cyanosis, clubbing, or edema. Right fourth finger distal to DIP joint is slightly deviated laterally. SKIN: No rashes noted. NEUROLOGIC: alert. Cranial nerves II through XII are grossly intact. Sensation is intact to light touch. Strength is 5/5 bilaterally.
DIP|distal interphalangeal|DIP|184|186|HISTORY OF PRESENT ILLNESS|Distally, he has slightly diminished sensation in radial, median, and ulnar nerve distributions. He demonstrates intact function of his anterior interosseous nerve with flexion of the DIP joint of the index finger and difficult but intact flexion of the thumb IP joint. I initially performed a closed reduction under propofal sedation, administered by the emergency room physician.
DIP|distal interphalangeal|DIP|184|186|REQUESTING PHYSICIAN|Also on the right foot she does as well. The left second toe is swollen to about twice its normal size compared to the other toes. There is a draining area in the medial aspect at the DIP joint level with surrounding erythema and some maceration. The adjoining side of the first toe is somewhat erythematous but the skin is intact and the third, fourth and fifth toes are intact.
DIP|distal interphalangeal|DIP|182|184|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: The patient is a healthy appearing 39- year-old male. His right index finger has an avulsion of the soft tissue on the volar aspect from about the level of the DIP joint distal and on the dorsal aspect from about the proximal aspect of the nailbed distally with exposed bone. It is essentially a degloving injury of the distal phalanx.
DIP|distal interphalangeal|DIP|181|183|PHYSICAL EXAMINATION|VITAL SIGNS: He is afebrile. Vital signs are stable. EXTREMITIES: Examination of his right upper extremity reveals fusiform swelling primarily from the base of the PIP joint to the DIP joint with an area of the puncture wound. There is no obvious drainage or purulence noted. I am unable to express any out, however, is quite painful to palpation along the sides.
DIP|distal interphalangeal|DIP|141|143|PHYSICAL EXAMINATION|There is no tenderness along the volar sheath. He has very little motion in the fingers sitting with the PIP flexed about 45 degrees and the DIP at neutral. He has no tenderness into the palm. He has good sensation and capillary refill is somewhat sluggish.
DIP|distal interphalangeal|DIP|241|243|PHYSICAL EXAMINATION|He denies diabetes or other chronic illnesses. PHYSICAL EXAMINATION: He is alert and oriented and has an obvious injury to the index finger. Adjacent digits are unharmed. The right index finger demonstrates an amputation at the level of the DIP joint with disarticulation. The proximal wound demonstrates articular cartilage of the middle phalanx with some abrasion to the cartilage, but overall appears preserved.
DIP|distal interphalangeal|DIP|112|114|PHYSICAL EXAMINATION|Inspection of the amputated digit demonstrates the amputation just proximal to the nail bed at the level of the DIP joint, some obliquity extending just distal to the digital crease. There is some evidence of avulsion-type injury to the skin, particularly along the palmar surface.
DIP|distal interphalangeal|DIP|165|167|PHYSICAL EXAMINATION|This is crusted over. There is no active drainage. He has minimal if any tenderness over the volar aspect of the third finger. He has almost no motion at the PIP or DIP joints because of the swelling. ASSESSMENT: Left third finger infection with abscess over the PIP joint.
DIP|distal interphalangeal|DIP|198|200|HISTORY OF PRESENT ILLNESS|He was trimming an object with a knife, sustaining a laceration to the ulnar aspect of his volar wrist. He was seen at Fairview Southdale Hospital Emergency Room with difficulty with flexion of the DIP joint of the small finger. He had significant pain as well and potentially some paresthesias. He was subsequently referred for evaluation. The patient was seen in the holding area of Fairview Southdale Hospital.
DIP|distal interphalangeal|DIP|228|230|PHYSICAL EXAMINATION|MUSCULOSKELETAL: The following joints were examined and found to be without crepitus, synovitis, swelling or decreased range of motion except as noted. Temporomandibular, cervical spine, glenohumeral, elbow, wrist, MCP, PIP and DIP joints of the hands bilaterally, hips, knees, ankles, MTP and ITP joints of the feet. Her cervical spine had very limited range of motion in all planes.
DIP|distal interphalangeal|DIP|145|147|PHYSICAL EXAMINATION|The patient is able to extend at the MCP, PIP and DIP joints. The patient is able to flex at the MCP and PIP joint. She is unable to flex at the DIP joint. It appears that the joint is involved with this laceration and open. There is also evidence of torn flexor digitorum profundus tendon in the wound.
DIP|distal interphalangeal|DIP|123|125|PHYSICAL EXAMINATION|It does appear that the joint is involved with this laceration, as well. The patient is able to extend at the MCP, PIP and DIP joints. She is unable to flex at the MCP, PIP or DIP joints. Middle finger: There is a small ulnar side laceration just proximal to the PIP joint.
DIP|distal interphalangeal|DIP|103|105|PHYSICAL EXAMINATION|The patient is able to extend at the MCP, PIP and DIP joints. She is unable to flex at the MCP, PIP or DIP joints. Middle finger: There is a small ulnar side laceration just proximal to the PIP joint.
DIP|distal interphalangeal|DIP|143|145|PHYSICAL EXAMINATION|The patient is able to extend to MCP, PIP and DIP joints. The patient is able to flexion at the MCP and PIP joints but not able to flex at the DIP joint. This wound is fairly superficial, does not appear there is evidence for joint involvement. RADIOGRAPHIC EVALUATION: Hand x-rays, 2 views: There does not appear to be any acute fracture or subluxation.
DIP|distal interphalangeal|DIP.|185|188|ASSESSMENT|This laceration entails both the flexor digitorum superficialis and flexor digitorum profundus. The middle finger laceration is fairly superficial. The patient is unable to flex at the DIP. Does not appear that the tendons are lacerated. PLAN: Full assessment and plan were discussed with both _%#NAME#%_ _%#NAME#%_ and attending physician, _%#NAME#%_ _%#NAME#%_.
DIP|distal interphalangeal|DIP|174|176|OBJECTIVE|There are chronic changes through the MCPs diffusely, without any active synovitis. PIPs and DIPs show significant degenerative changes and there is marked angulation of the DIP joints. She still makes good fists and is not uncomfortable doing this. Her grip strength is fair. Her hips are nontender and move well.
DIP|distal interphalangeal|DIP|229|231|PHYSICAL EXAMINATION|One option of course would be to try to align the fracture with a K-wire, and to try to close these complex lacerations. It is unlikely that he would regain normal sensation in his fingertip, and he will likely have a very stiff DIP joint. The expected results of this finger will be nonfunctional and for fine manipulations he will bypass his finger and use his long finger.
DIP|distal interphalangeal|DIP|251|253|PHYSICAL EXAMINATION|The expected results of this finger will be nonfunctional and for fine manipulations he will bypass his finger and use his long finger. Another option is to try to salvage what is a very large palmar flap, and disarticulated the distal phalanx of the DIP joint, and allow this to heal up primarily as a short finger. Of note, this is his nondominant hand. I think this is far likely more likely to lead to a more functional result more quickly, and in fact that is the treatment I have recommended.
DIP|distal interphalangeal|DIP|174|176|PHYSICAL EXAMINATION|SOCIAL HISTORY: He is retired and lives with his wife in _%#CITY#%_. PHYSICAL EXAMINATION: Examination of the right fifth finger shows nodularity at the dorsal aspect of the DIP joint. There is no fluctuance or fluid. There is no redness. He has discomfort with palpation of these areas of nodularity which have a whitish tint under the skin, consistent with gouty tophi.
DIP|distal interphalangeal|DIP|239|241|PHYSICAL EXAMINATION|He has discomfort with palpation of these areas of nodularity which have a whitish tint under the skin, consistent with gouty tophi. Examination of his right long finger shows a 1.5 cm area of white blistering and fluctuance dorsal to the DIP joint. It is significantly tender to palpation. He has no tenderness along the flexor or extensor tendon and no tenderness in the palm.
DIP|desquamative interstitial pneumonia|DIP,|193|196|IMPRESSION|2. Snoring. 3. Morbid obesity. He has paucity of pulmonary symptoms or signs but an abnormal CT scan of the chest. We should consider inflammatory etiologies of alveolar of the lungs including DIP, UIP, and sip, hypersensitivity, pneumonitis, BOOP. A bronchoscopy may be warranted, but first I would like some further diagnostic profile, laboratory studies, as well as pulmonary function tests, and then an arterial blood gas.
DIP|distal interphalangeal|DIP|134|136|PHYSICAL EXAMINATION|She is able to actively flex and extend the finger. She has mostly radial sided swelling and erythema. Passive range of motion of the DIP joint is not painful. There is no obvious evidence of tendon sheath involvement. No x-rays were available at the time of this dictation.
DIP|distal interphalangeal|DIP|162|164|PHYSICAL EXAMINATION|No mass. EXTREMITIES: Reveals normal muscular bulk. Peripheral pulses intact. He does have a healing wound on his left lateral fifth digit, about the area of the DIP joint. No apparent infection. LABORATORY DATA: Comprehensive metabolic panel, CBC, TSH without abnormality.
DIP|distal interphalangeal|DIP|196|198|EXAMINATION|TMJ is nontender. The parotids are not enlarged. Eyes show EOMs intact. The sclera and conjunctiva are normal. NECK: Shows no thyroid enlargement. PERIPHERAL JOINT: Reveals minimal bony change of DIP and PIP joints. There is no synovitis of this area. The MCP joints are normal. The wrists are normal, and I could not find any tenderness.
DIP|distal interphalangeal|DIP|144|146|HISTORY|Denies other injuries. Right-hand dominant. Works as a buyer using keying on a computer a lot. X-rays taken in ER revealed comminuted fractures DIP joints II and III, soft tissue injuries to II, III and IV. PAST MEDICAL HISTORY: ALLERGIES: NKDA. REVIEW OF SYSTEMS: 12-category medical review of system includes: Constitutional, skin, lymphatic all negative.
DIP|distal interphalangeal|DIP|158|160|PHYSICAL EXAMINATION|GENERAL: He is very pleasant and cooperative with the exam. EXTREMITIES: His right upper extremity is within normal limits. He does have some swelling in his DIP and PIP joints of his fingers, but he has full function of his FTS and FTP with good strength. EIP, ADM, APB are all with normal strength in the right upper extremity.
DIP|distal interphalangeal|DIP|285|287|PHYSICAL EXAMINATION|There is no dorsal swelling. He has 2 significant areas of mild skin involvement, which include a slightly necrotic center approximately 1.0 mm in diameter with blanched white surrounding tissue apparently secondary to pressure. There is no drainage. He has no significant pain at his DIP joint with DIP flexion or at the MCP joint with MCP flexion and is nontender to palpation over his flexor tendons during passive and active range of motion of the left index finger.
DIP|distal interphalangeal|DIP|183|185|LABORATORY DATA|Extremity warm Right great toe amputation is well healed. LABORATORY DATA: White blood count 10, creatinine 1.9. Blood cultures from _%#MMDD2002#%_ negative. X-ray: Osteopenia of the DIP of the left great toe, cannot exclude osteomyelitis. IMPRESSION: 1. Severe gouty arthritis with bony disruption, possible superimposed infection and cellulitis.
DIP|distal interphalangeal|DIP|191|193|PHYSICAL EXAMINATION|There are no ulcerations. There is no sclerodactyly. There is no vasculitis. LYMPHATICS: No major lymph nodes are enlarged. The peripheral joint examination reveals some mild bony changes of DIP and PIP joints bilaterally as well as the first MCP joints bilaterally. The right wrist is normal. There is marked inflammatory synovitis involving the left wrist which I would grade as III+.
DIP|distal interphalangeal|DIP|147|149|PHYSICAL EXAMINATION|There is a callus on the medial aspect of the fourth PIP joint. The toe has a minimal flexion deformity. This is passively correctable on both the DIP and PIP joints. There is no callus at the tip of the toe. Her range of motion of this toe is limited to flexion and extension, apparent to pain in the ankle.
DIP|distal interphalangeal|DIP|141|143|HISTORY OF PRESENT ILLNESS|I was asked by Dr. _%#NAME#%_ to address left hand pain. The patient describes pain in his left thumb along the thenar eminence and into the DIP and PIP joints for about the past three weeks. He denies any injury to the area. He has not noted any numbness or tingling, but does report a decrease in strength and inability to open things.
DIP|distal interphalangeal|DIP,|375|378|PHYSICAL EXAMINATION|LUNGS: Clear to auscultation bilaterally, no wheezes or crackles. CARDIOVASCULAR: Regular rate and rhythm, normal S1 and S2, no murmurs, rubs or gallops. ABDOMEN: Soft and nontender, no hepatosplenomegaly, positive bowel sounds. EXTREMITIES: The following joints were examined for range of motion, swelling, tenderness and stability and found to be without abnormality: PIP, DIP, MCP, wrists, elbows, shoulder, AC, hip, knee, ankle, MTP, DIP, IP of the feet. IMPRESSION: The patient with Churg-Strauss vasculitis which has been quiescent on Cellcept and glucocorticoids for some time.
DIP|distal interphalangeal|DIP,|438|441|PHYSICAL EXAMINATION|LUNGS: Clear to auscultation bilaterally, no wheezes or crackles. CARDIOVASCULAR: Regular rate and rhythm, normal S1 and S2, no murmurs, rubs or gallops. ABDOMEN: Soft and nontender, no hepatosplenomegaly, positive bowel sounds. EXTREMITIES: The following joints were examined for range of motion, swelling, tenderness and stability and found to be without abnormality: PIP, DIP, MCP, wrists, elbows, shoulder, AC, hip, knee, ankle, MTP, DIP, IP of the feet. IMPRESSION: The patient with Churg-Strauss vasculitis which has been quiescent on Cellcept and glucocorticoids for some time.
DIP|distal interphalangeal|DIP,|254|257|PHYSICAL EXAMINATION|Normal S1 and S2 and a 2/6 systolic ejection murmur. No rub. ABDOMEN: Soft and nontender. No hepatosplenomegaly. EXTREMITIES: The following joints were examined and found to be without synovitis or effusions and they had full range of motion throughout: DIP, PIP, MCP, wrist, elbow, AC, GH, TMJ, SC, hip, knee, tibiotalar, subtalar, MPP, toe, IP joints bilaterally. Extremities showed no edema or cyanosis. There was also no Raynaud's noted.
DIP|distal interphalangeal|DIP|141|143|SURGERY|She has been on three different antibiotic trials without improvement. She has continued to develop increasing swelling and stiffness at the DIP joint level. She has had x-rays done which do not show any abnormalities such as osteomyelitis or joint erosions.
DIP|distal interphalangeal|DIP|112|114|SURGERY|On physical examination the patient does have redness and swelling over the palm side of the long finger at the DIP joint level. There is superficial skin cracking running in a transverse fashion across the flexion crease at the DIP joint but no full thickness skin break.
DIP|distal interphalangeal|DIP|224|226|SURGERY|There is superficial skin cracking running in a transverse fashion across the flexion crease at the DIP joint but no full thickness skin break. There is no drainage. There is mild surrounding cellulitis and stiffness in the DIP joint. She has full PIP and MP joint motion and there is no extension of tenderness or swelling down along the finger into the palm.
DIP|distal interphalangeal|DIP|127|129|PHYSICAL EXAMINATION|The peripheral joint examination is essentially normal in terms of synovitis and thickening. There is some mild bony change at DIP and PIP joints as well in the toes. She has lost a little bit of flexion-extension of the fingers. Muscle strength testing reveals diffuse grade III/V weakness in both upper and lower extremities.
DIP|distal interphalangeal|DIP|132|134|PHYSICAL EXAMINATION|The nailbed is intact, however. Range of motion of motion is intact with full flexion and extension at the PIP joint, IP joint, and DIP joint of the left third digit. He has full unrestricted pain-free range of motion of all other digits of both hands. Sensation is intact in the radial, median, and ulnar nerve distributions bilaterally.
DIP|distal interphalangeal|DIP|135|137|PHYSICAL EXAMINATION|With regard to the middle finger, there was a complex 5-cm long curvilinear laceration, proximally based, over the radial sides of the DIP joint and middle phalanx. This joint did not appear to be subluxed. The edges were tattered and it was not a clean cut.
DIP|distal interphalangeal|DIP|175|177|PHYSICAL EXAMINATION|ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: Some erythema involving the distal aspect of her right fourth digit. She has diminished ability to flex her finger at the DIP joint. There is no sign of acute injury or infection. NEUROLOGIC: She is alert and fully oriented. She is up ambulating without difficulty. Cranial nerves grossly intact.
DIP|distal interphalangeal|DIP|200|202|PHYSICAL EXAMINATION|There is mild diffuse soft tissue swelling. There is dorsal eschar and necrotic tissue with minimal fluctuance. This is primarily dorsal to the DIP joint. There is no pain with range of motion of the DIP joint and no visible fusion. IMPRESSION: Cellulitis and skin necrosis, right long finger. RECOMMENDATION: I see no evidence of a septic joint or flexor tenosynovitis.
DIP|distal interphalangeal|DIP|166|168|PHYSICAL EXAMINATION|PAST MEDICAL HISTORY: Unremarkable. MEDICATIONS: He is currently on Zestril. No known drug allergies. PHYSICAL EXAMINATION: On examination, drainage is seen from the DIP joint. It appears that the extensor tendon has been eroded with the posture of the joint. There is flexion and extension at the PIP joint. Fluctuance along the middle dorsal aspects of the phalanx.
DIP|distal interphalangeal|DIP|242|244|PHYSICAL EXAMINATION|He has sutures but the wound is healed. He has tenderness along the volar aspect of the joint from the PIP joint extending proximally to the level of the MP flexion crease. Distally, he has no pain with range of motion or palpation about the DIP joint. He does have pain with motion of the PIP joint. X-rays were not available for review. IMPRESSION: Left ring finger laceration with joint infection, possible flexor tenosynovitis.
DIP|distal interphalangeal|DIP|224|226|DISCUSSION|There is a history of 1. Atypical chest pain felt secondary to anxiety versus gastroesophageal reflux disease. 2. Gastroesophageal reflux disease 3. History of bilateral bunionectomy 4. History of recent right second finger DIP joint arthrodesis. MEDICATION ALLERGIES: Are to sulfa and Wellbutrin, codeine and Percocet caused gastrointestinal upset.
DIP|distal interphalangeal|DIP,|147|150|PHYSICAL EXAMINATION|There was no injury of the thenar or hypothenar eminence. NEUROLOGIC: The patient's neurological examination was normal with a 5/5 strength at the DIP, FPL, dorsal or SI. The patient has normal sensation on the radial, ulnar and median nerve sites with 3+ radial pulses.
DIP|distal interphalangeal|DIP|202|204|PHYSICAL EXAMINATION|On the index finger, he has 2 small lacerations measuring 4 to 5 mm at the very tip of the index finger. He has erythema extending down to the middle of the proximal phalanx. He does have motion at the DIP and PIP joint without pain. He has 2+ swelling of the entire digit. He does not have tenderness over the flexor sheath at the MP joint or at the index at the proximal phalanx level.
DIP|distal interphalangeal|DIP|157|159|PHYSICAL EXAMINATION|There is no erythema pus or swelling. The skin is otherwise unremarkable. Her joints disclose typical changes of severe rheumatoid arthritis in the proximal DIP joints of her hands. Chest x-ray discloses interstitial infiltrates consistent with pulmonary edema and cardiomegaly.
DIP|distal interphalangeal|DIP|158|160|PHYSICAL EXAMINATION|Examination of his left upper extremity shows lacerations of the dorsal aspect of the index, long, and ring fingers. These are irregular lacerations over the DIP joints. Bone is exposed at the long and ring fingers. He has diminished sensation over the ulnar aspects of the tip of the index finger as well as diffusely about the tips of the long and ring fingers.
DIP|distal interphalangeal|DIP|206|208|PHYSICAL EXAMINATION|No organomegaly or masses. Extremities: No edema noted. Skin: No rashes noted. There was a small laceration which was vertical approximately 0.5 centimeters on the patient's right hand first digit over the DIP joint. There were two erythematous papules noted on the right side of her abdomen in the lower quadrant. There was no drainage present and no bullae. Neurologic: She was alert and oriented times three with cranial nerves II-XII intact.
DIP|distal interphalangeal|DIP.|166|169|PHYSICAL EXAM|The germinal matrix of the nailplate does appear intact. There is bone distally. His sensation is intact to light touch. He has flexion and extension in both PIP and DIP. X-rays obtained today, multiple views in the ER show a comminuted tuft fracture which is displaced into the soft tissue.
DIP|distal interphalangeal|DIP|204|206|PHYSICAL  EXAMINATION|I do not elicit any tenderness currently or rigidity. PELVIC/RECTAL: Not performed. EXTREMITIES: Show no edema. She has changes of degenerative joint disease in the joints of her hands, including PIP and DIP joints. NEUROLOGIC: She is nonfocal. Skin shows no acute inflammatory lesions. LABORATORY DATA: Urinalysis is bland. Urine chemistries have not been performed.
DIP|distal interphalangeal|DIP|124|126|PHYSICAL EXAMINATION|The extensor tendons appeared intact. There is also a long laceration over the middle finger. He has slight weakness of his DIP extension, otherwise his tendons appear intact. He has a laceration and deformity involving the fourth finger at the level of the middle phalanx, and there is a laceration over the dorsum of the fifth finger as well as over the tip of the radial aspect of the fifth finger, both of which appear relatively superficial.
DIP|distal interphalangeal|DIP|174|176|PHYSICAL EXAMINATION|X-ray examination of the left hand reveals a comminuted fracture involving the middle phalanx. It involves the mid portion of the phalanx. The articular surfaces at both the DIP joint and the PIP joint appeared intact. ASSESSMENT: Multiple lacerations with a comminuted open fracture involving the fourth finger of the left hand in this 50-year-old gentleman.
DIP|distal interphalangeal|DIP|153|155|HISTORY OF PRESENT ILLNESS|She is status post PIP joint excisions of the 3rd, 4th toes and right foot. She is status post percutaneous flexure tenotomy of the right 5th toe at the DIP joint level. She has a significant past medical history including chronic low back pain. She had an acute exacerbation of her low back causing her to be admitted to the hospital and then to Fairview Transitional care unit back in _%#MM#%_ 2007.
DIP|distal interphalangeal|DIP|186|188|PHYSICAL EXAMINATION|There was a negative tenodesis effect. He does have intact extensor pollicis longus function. He has full ability to extend the MCP joints. He has intact FPL function and flexion of the DIP joint of the index finger. He has intact sensation about the palm of his hand. The wound was cleaned.
DIP|distal interphalangeal|DIP|204|206|PHYSICAL EXAMINATION|There is no erythema in the palm, but she does have some mild tenderness over the flexor tendons in the palm over the third finger flexor tendon. There is a tiny puncture wound on the volar aspect of the DIP joint. She has mild to moderate tenderness about the finger. ASSESSMENT: Left third finger infection in this 54-year-old otherwise healthy female.
DIP|distal interphalangeal|DIP,|152|155|PHYSICAL EXAMINATION|She has no rotational deformity. She has no flexion contractures. She has full profundus and superficialis pulses. She has slow active extension at the DIP, PIP, and MP joints. X-RAYS: Review of her x-rays show a small impacted fracture to the proximal phalanx of the small finger.
DIP|distal interphalangeal|DIP,|140|143||I was told by the ER staff that she had intact sensation to light touch in all of her fingers distally. She was able to flex and extend the DIP, PIP and MCP joints of all of the fingers with the exception of the ring finger. She is otherwise healthy with no chronic medical problems. CURRENT MEDICATIONS: None.
DIP|distal interphalangeal|DIP|230|232|PLAN|I also discussed the level of the injury may result in some denervation of segments of the muscle and could result in some weakness. There appears to be intact function of the posterior osseous nerve, at least to the level of the DIP and EPL, which are the more distal innervated muscles. Therefore, from a neurologic standpoint, he should have preserved muscle function.
DIP|distal interphalangeal|DIP|195|197|PHYSICAL EXAMINATION|VITAL SIGNS: His blood pressure was 119/53, heart rate 79, respirations 24, temperature 97.7. RIGHT HAND: Complete avulsion and degloving of the distal tip of his right ring finger distal to the DIP joint. The soft tissue cap was being held on just by a thin skin bridge but circumferentially the vessels and soft tissue were degloved down to the bone dorsally and the flexor tendon volarly.
DIP|distal interphalangeal|DIP|206|208|ASSESSMENT/PLAN|We will have him see Dr. _%#NAME#%_ _%#NAME#%_, my partner and a hand surgeon, tomorrow in the clinic. I explained to him that it was likely that he would lose the distal tip of his phalanx likely from the DIP joint down. In addition, further exploration of the extensor tendon laceration on the dorsal aspect of the hand will need to be performed.
DIP|distal interphalangeal|DIP|234|236|PHYSICAL EXAMINATION|JOINT EXAMINATION: Reveals Grade I-II synovial swelling of all of the PIPs and metacarpal phalangeals of both hands with grade II tenderness on those joints. There is grade I swelling and grade II tenderness in the left second finger DIP joint as well. Other PIP joints seem to have been spared. Both metacarpal phalangeal and PIP joints are grade II swollen and grade II tenderness in the thumbs.
DIP|distal interphalangeal|DIP|169|171|PHYSICAL EXAMINATION|There is ecchymosis about the dorsal and side of his index finger. There is a small puncture wound in the DIP flexion crease. With gentle passive range of motion of his DIP joint, there is only mild pain. There is no drainage from the puncture site. Skin is otherwise intact. He demonstrates active flexion of his DIP joint. X-rays reviewed.
DIP|distal interphalangeal|DIP|188|190|PHYSICAL EXAMINATION|With gentle passive range of motion of his DIP joint, there is only mild pain. There is no drainage from the puncture site. Skin is otherwise intact. He demonstrates active flexion of his DIP joint. X-rays reviewed. Three views of the left hand were unremarkable. There was no acute bony abnormality.
DIP|distal interphalangeal|DIP|143|145|PHYSICAL EXAM|There is significant tenderness diffusely about the volar aspect of the index finger as well as along the ulnar and dorsal ulnar aspect of the DIP joint. There is only mild pain with gentle movement of the DIP joint. The FDS and FTP flexor tendons are intact clinically. IMPRESSION: Left index finger infection involving flexor tendon synovial sheath with inadequate response to IV antibiotics over the past two days.
DIP|distal interphalangeal|DIP|206|208|PHYSICAL EXAM|There is significant tenderness diffusely about the volar aspect of the index finger as well as along the ulnar and dorsal ulnar aspect of the DIP joint. There is only mild pain with gentle movement of the DIP joint. The FDS and FTP flexor tendons are intact clinically. IMPRESSION: Left index finger infection involving flexor tendon synovial sheath with inadequate response to IV antibiotics over the past two days.
DIP|distal interphalangeal|DIP|170|172|PHYSICAL EXAMINATION|He was alert and oriented x 3. On examination of the left hand, there was more of a crushing type laceration with maceration of the skin edges from the PIP just past the DIP on the radial aspect of the ring finger. No exposed tendon or bone was noted. I was able to examine him at this time as the digital block had been in.
DIP|distal interphalangeal|DIP|203|205|PHYSICAL EXAMINATION|He has slightly limited finger flexion in the fifth finger secondary to swelling in the finger. He has a significant amount of swelling of the right fifth finger, and a dorsal wound proximal between the DIP and PIP joints. Sensation is grossly intact. Extensor and flexor tendons are clearly intact. He has no significant pain with passive range of motion of the DIP and PIP joints.
DIP|distal interphalangeal|DIP|140|142|PHYSICAL EXAMINATION|Sensation is grossly intact. Extensor and flexor tendons are clearly intact. He has no significant pain with passive range of motion of the DIP and PIP joints. DIAGNOSTICS: Plain x-rays are reviewed, which are unremarkable. ASSESSMENT AND PLAN: Right fifth finger dorsal infection.
DIP|distal interphalangeal|DIP|129|131|PHYSICAL EXAMINATION|Distal alignment of her hands, however, shows ulnar deviation at the distal interphalangeal joints and areas of deformity of her DIP joints of multiple fingers. Her toes have significant bunion and hammer toe deformities and calluses plantarly, as well as dorsally in the hammer toe regions.
DIP|distal interphalangeal|DIP|179|181|PHYSICAL EXAMINATION|ABDOMEN: Soft, nontender. EXTREMITIES: No edema. SKIN: No rashes noted. The patient does have what appeared to be lichenification over anterior fingertips as well as both PIP and DIP joints of both hands secondary to nail biting. No signs of infection noted. Rest of exam negative. NEUROLOGIC: Alert and oriented.
DIP|distal interphalangeal|DIP|168|170|PHYSICAL EXAMINATION|EXTREMITIES: On his right hand, there is diffuse swelling from the PIP joint of his right long finger distally to the tip. He has intact range of motion at the PIP and DIP joints, except for a loss of active extension at the DIP joint. There is FDP and FDS strength of 5/5. The sensation to light touch is intact.
DIP|distal interphalangeal|DIP,|138|141|PHYSICAL EXAMINATION|LUNGS: Clear to auscultation bilaterally. CARDIAC: Regular rate and rhythm. Normal S1 and S2. No murmur, gallop, or rub. EXTREMITIES: The DIP, PIP, and MCP joints of the hands, wrists, elbows, shoulders, TMJ, knees, ankles and MTP, PIP, and DIP joints of the toes were all examined for range of motion, crepitance, warmth, redness, swelling.
DIP|distal interphalangeal|DIP|241|243|PHYSICAL EXAMINATION|LUNGS: Clear to auscultation bilaterally. CARDIAC: Regular rate and rhythm. Normal S1 and S2. No murmur, gallop, or rub. EXTREMITIES: The DIP, PIP, and MCP joints of the hands, wrists, elbows, shoulders, TMJ, knees, ankles and MTP, PIP, and DIP joints of the toes were all examined for range of motion, crepitance, warmth, redness, swelling. There were no abnormalities with the exception of the left knee which had a large effusion.
DIP|distal interphalangeal|DIP|281|283|PHYSICAL EXAMINATION|Extremities were intact to light touch. Biceps and patellar reflexes were 2/4 and symmetric. JOINT EXAMINATION: The following joints were examined for swelling, warmth, erythema, tenderness, range of motion, and effusion: Shoulders, elbows, wrists, metacarpal phalangeal, PIP, and DIP joints of the hands, hips, knees, ankles, MTP, PIP, and DIP joints of the feet. The patient's right second and third PIP joints were mildly swollen but not tender.
DIP|distal interphalangeal|DIP|247|249|PHYSICAL EXAMINATION|Lungs are clear to auscultation. Abdomen is soft, non-tender. Extremities reveal normal muscular bulk, peripheral pulses intact. There is noted ulnar deviation of the digits of the hands bilaterally as well as increasing nodularity at the PIP and DIP joints. No apparent erythema or edema at this time. She does have limited grip strength secondary to pain. Knees appear unremarkable. Foot exam is essentially unremarkable. Gait appears normal.
DIP|dipropionate|DIP|121|123|MEDICATIONS|6. Levothyroxine 50 mcg in the morning. 7. Depakote 1000 mg. 8. Clonazepam 3 mg. 9. Ranitidine 300 mg. 10. Betamethasone DIP AUG 0.05% ointment p.r.n. ALLERGIES: No known drug allergies. SOCIAL HISTORY: She is in a relationship with her partner.
DIP|distal interphalangeal|DIP|158|160|PHYSICAL EXAMINATION|She has passive finger motion. She does have small multiple bites which have no evidence of purulence. Motion of the metatarsophalangeal (MP), PIP as well as DIP joints show no evidence of septic joint. There is no evidence of purulent flexor tenosynovitis with negative Kanavel's sign.
DIP|distal interphalangeal|DIP|217|219|PHYSICAL EXAMINATION|CARDIOVASCULAR: Regular rate and rhythm. No murmur. ABDOMEN: Positive bowel sounds in all four quadrants. Nontender, nondistended, and soft. No organomegaly. EXTREMITIES: Osteoarthritic changes noted in the MCP, PIP, DIP joints of her hands bilaterally. SKIN: No rashes noted. NEUROLOGIC: Alert and oriented. Cranial nerves II through XII grossly intact.
DIP|distal interphalangeal|(DIP),|251|256|PHYSICAL EXAMINATION|The following joints were examined for synovitis, range of motion, crepitus or pain: temporomandibular, acromioclavicular, glenohumeral, sternoclavicular, elbow, wrist, metacarpophalangeal (MCP), proximal interphalangeal (PIP), distal interphalangeal (DIP), hip, knee, ankle, metatarsophalangeal (MTP) and toe interphalangeal (IP) joints. They were found to be without abnormality. NEUROLOGIC: Neurologic strength was 5/5 throughout.
DIP|distal interphalangeal|DIP|193|195|PHYSICAL EXAMINATION|She, however, is quite obese. Examination of her upper extremity reveals that it is splinted. Her fingers are in a flexed posture as well as her fingers. In this position I am able to move her DIP quite well but her PIP joints are quite spastic. SKIN: Intact. SENSATION: Intact to light touch. Cap refill less than 2 seconds.
DIP|distal interphalangeal|DIP.|179|182|HISTORY OF PRESENT ILLNESS|He was seen in the emergency room immediately. It was noted at that time that all digits excluding the thumb were involved. The ring and long finger were split in half beyond the DIP. Slight laceration to the index and to the little finger. He reports pain. He states his fingers are numb, but he has had a digital block.
DIP|distal interphalangeal|DIP|202|204|PHYSICAL EXAMINATION|Neurologic status is unknown as the block is in, but damage to the flaps on the ring finger are inevitable. X-rays show split distal phalanx fracture and a fracture that splits in a diagonal across the DIP joint from distal to proximal on the ring finger. IMPRESSION AND PLAN: We will need IND with primary closure.
DIP|distal interphalangeal|DIP,|235|238|PHYSICAL EXAMINATION|Gait is within normal limits. Reflexes are 1+ bilaterally. He does state that his sensation is greater in his left than his right when I attempt light touch. On the fourth finger of his left hand, he does have inability to flex at the DIP, PIP, or MCP joint. His laboratory data was essentially negative, with the exception of mucous present on the UA, with negative WBC in the urine.
DIP|distal interphalangeal|DIP|162|164|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old female who presents status post left foot surgery which consisted of a left triple fusion and second toe DIP surgery. The patient apparently tolerated the surgery well without complications that I can see. At the present time the patient is complaining of constipation.
DIP|distal interphalangeal|DIP|135|137|HISTORY OF PRESENT ILLNESS|His distal phalanx is nearly completely absent. There is significant comminution of the remaining fragments of the distal phalanx. The DIP joint is largely gone. I discussed the nature of surgery with the patient, to include I&D and percutaneous pinning for now.
DIP|distal interphalangeal|DIP|294|296|PHYSICAL EXAMINATION|Some radial and volar based flaps. Some devitalized tissue distal to the flaps, bony debris, significant bone loss and complete loss of the nail plate and matrix. X-rays demonstrate a comminuted fracture involving the distal phalanx and condyles of the middle phalanx with complete loss of the DIP joint and loss of the distal phalanx. IMPRESSION: Right index finger partial finger amputation with mangled distal tip soft tissue.
DIP|distal interphalangeal|DIP|201|203|PHYSICAL EXAMINATION|LEFT HAND: There is still a little hint of dusky discoloration along the ulnar aspect of the thumb. The thumb is warm. Sensation is intact. MUSCULOSKELETAL: Minimal degenerative changes in some of the DIP and PIP joints. She does have some tenderness of the right hip trochanter to palpation. LABORATORY DATA: Normal urine sediment and a sedimentation rate of 3.0. There are a number of rheumatologic tests that have been drawn and are pending.
DIP|distal interphalangeal|DIP|149|151|PHYSICAL EXAMINATION|It begins distally on the radial side of the index finger and enters the skin here moving cephalad and ulnarward to exit the distal phalanx near the DIP joint ulnarly. It then proceeds into the long finger in the middle phalanx level, but does not penetrate the far side.
DIP|distal interphalangeal|DIP|192|194|PHYSICAL EXAMINATION|Can actively extend it and dorsally displace it. She can actively flex and extend nearly fully. Both flexor and extensor mechanisms are intact. No subluxation of it. The nail beds are normal. DIP and PIP joints show some osteoarthritic conditions, but nothing significant. There is no evidence of any neurologic deficit. Motor and sensory reflexes are intact in both upper extremities.
DIP|distal interphalangeal|DIP|173|175|PHYSICAL EXAMINATION|She is very pleasant and a good historian. HEENT exam: Normocephalic/atraumatic. Extremities are soft and nontender. No edema. No erythema. The patient has multiple PIP and DIP joint deformities consistent with arthritis. Neuromuscular examination: Mental status: The patient is oriented to person, place and time and reason for hospitalization.
DIP|distal interphalangeal|DIP|213|215|HISTORY|DOB: _%#MMDD1914#%_ HISTORY: This is an 89-year-old gentleman with a history of chronic deformity involving his right long finger. He has had increasing pain, swelling, erythema, and induration to the area of the DIP joint of the left long finger. He has been on oral antibiotics for several days and has noted some mild improvement, but continues to have significant erythema and induration.
DIP|distal interphalangeal|DIP|194|196|IMPRESSION|X-rays demonstrate no obvious bony erosions or osteomyelitis. There are significant arthritic changes with large osteophyte formation and bone-on-bone articulation. IMPRESSION: Left long finger DIP joint and distal phalanx erythema and induration. Rule out gout. Rule out infection.
DIP|distal interphalangeal|DIP.|171|174|HISTORY OF PRESENT ILLNESS|Grossly, sensation is intact, slightly decreased on the ulnar aspect. The second has a flap-type laceration, approximately 2 cm, starting at the PIP, flapping up over the DIP. There is a question of tenderness involvement. Neurologically he is intact grossly on this. There are some abrasions to the ring finger. X-rays are unremarkable for fracture.
DIP|distal interphalangeal|DIP,|221|224|PHYSICAL EXAMINATION|There is no gross atrophy of the hypothenar eminences. Neurologic exam was normal with ___________ , normal sensation of the radial, ulnar, and median nerves and 3+ radial pulse. The patient has gross deformities of PIP, DIP, and CMC. It appears that his right hand is worse than that of his left hand. His hands are clearly in a flexion contracture state bilaterally.
DIP|distal interphalangeal|DIP,|134|137|PHYSICAL EXAMINATION|NEURO: Strength 5/5 bilaterally with the exception of the left wrist and hand which were not tested due to pain. MUSCULOSKELETAL: The DIP, PIP, MCP, wrist, elbow, glenohumeral, acromioclavicular, TMJ, sternoclavicular, knee, subtalar, tibial talar, MTP and toe IP joints bilaterally were all examined and found to be normal with the exception of the left wrist which was red, warm and had a grade II effusion.
DIP|distal interphalangeal|DIP|206|208|PHYSICAL EXAMINATION|Everything is benign. Elbows negative. Left hand splint and dressings were taken down showing a deep near circumferential laceration probably going about 70% around the thumb beginning just proximal to the DIP joint crease. The tendon is exposed and bony fragments are exposed. X-rays were reviewed showing comminuted fracture with volar subluxation of the distal phalanx of the left thumb.
DIP|distal interphalangeal|DIP|238|240|PHYSICAL EXAMINATION|There are no nail fold infarcts or splinter hemorrhages. There is no sclerodactyly or ulceration. There are no tophi, nor are there any evidence of subcutaneous nodules. EXTREMITIES: The upper extremities show degenerative changes in the DIP and PIP joints. There are also degenerative changes of both CMC joints. The right wrist shows 2+ synovial thickening with tenderness, redness and some warmth.
DIP|distal interphalangeal|DIP,|220|223|PHYSICAL EXAMINATION|HEART: Cardiac rhythm is occasionally irregular; I am not sure I am hearing a definite murmur. BACK: Moderate dorsal kyphosis, but there is no tenderness. JOINTS: Peripheral joint examination reveals bony changes of the DIP, PIP, and knee joints without any active synovitis. MUSCULOSKELETAL: There is some diffuse widespread muscle atrophy consistent with age.
DIP|distal interphalangeal|DIP|195|197|EXAMINATION|The incisions are well healed. The hand appears normal. There is no focal area of tenderness. There is no obvious swelling in any of the joints. She does have reduced flexion at the MP, PIP, and DIP joints. Her neurologic exam disclosed hypesthesia to light touch and pinprick predominantly in the ulnar two innervated digits but across the hand in general.
DIP|distal interphalangeal|DIP|139|141|PHYSICAL EXAMINATION|The patient has cap refill of less than 2 seconds. Her fingers are warm. She has 4/5 strength in flexion and extension at both the PIP and DIP joints of each finger. She does have some limitation in her ability to flex and extend the PIP joints of each finger.
DIP|distal interphalangeal|DIP|182|184|PHYSICAL EXAMINATION|She has no olecranon adenopathy. No tenderness up the forearm. No tenderness through the palmar surface of the hand. There is erythema, warmth and tenderness from the knuckle to the DIP joint. Distal to this joint, there is diffuse swelling and purulence with some gas noted and it is exquisitely tender. NEUROLOGIC: She is alert and oriented times three. SKIN: Reveals no other rashes or other lesions.
DIP|distal interphalangeal|DIP|179|181|IMPRESSION|No bony abnormalities identified. IMPRESSION: Ms. _%#NAME#%_ is a 51-year-old African-American woman with extensive infection of the right fourth finger, especially distal to the DIP joint. She may and probably does have involvement of that joint with evidence of infection proximal to that joint as well.
DIP|distal interphalangeal|DIP|171|173|PHYSICAL EXAMINATION|I see no evidence of purulence in this area. Examination of the right third toe indicates a cellulitis in the toe itself. There is an eschar over the dorsal aspect of the DIP joint and as well has a region of purulence as well as joint exposed. ASSESSMENT AND PLAN: Likely osteomyelitis with chronic drainage of right third toe.
DIP|distal interphalangeal|DIP|161|163|PHYSICAL EXAMINATION|COR: Regular rate and rhythm with a soft systolic ejection murmur. ABDOMEN: Without hepatosplenomegaly. JOINTS: Hand joints - Mild osteoarthritic changes in the DIP and PIP joints. No active synovitis and no evidence of chronic synovitis in her MTPs or wrists. Elbows normal. Shoulders normal. Hips were difficult to evaluate secondary to her back pain, but appears to have fairly good range of motion.
DIP|distal interphalangeal|DIP|210|212|PHYSICAL EXAMINATION|He works for _%#CITY#%_ Auto Auction. PHYSICAL EXAMINATION: GENERAL: Today, the patient appears to be generally healthy. MUSCULOSKELETAL: Examination of the left finger indicates ecchymosis and swelling at the DIP joint and distal to this. The DIP joint itself not painful. He has evidence of paronychia. Some purulent material can be expressed from the radial aspect of the finger in the region of the previous partial resection of the nail.
DIP|distal interphalangeal|DIP|123|125|PHYSICAL EXAMINATION|MUSCULOSKELETAL: Examination of the left finger indicates ecchymosis and swelling at the DIP joint and distal to this. The DIP joint itself not painful. He has evidence of paronychia. Some purulent material can be expressed from the radial aspect of the finger in the region of the previous partial resection of the nail.
DIP|distal interphalangeal|DIP|117|119|HISTORY OF PRESENT ILLNESS|He and his father have been caring for it. He had a heat ulcer on the right great toe, on the plantar surface of the DIP joint, which healed. He has an area of non-healing ulcer at the DIP joint of the tibial side of the right second toe as well, but no sign of infection or skin break-down.
DIP|distal interphalangeal|DIP|185|187|HISTORY OF PRESENT ILLNESS|He and his father have been caring for it. He had a heat ulcer on the right great toe, on the plantar surface of the DIP joint, which healed. He has an area of non-healing ulcer at the DIP joint of the tibial side of the right second toe as well, but no sign of infection or skin break-down. On the left foot, the skin itself was completely necrotic on the plantar surface of the great toe, and there is a purulent draining area on the plantar surface of the first metatarsal head, along with a web space abscess also which is draining.
DIP|distal interphalangeal|DIP|208|210|PHYSICAL EXAMINATION|There are no rubs. Peripheral pulses are normal. ABDOMEN: Is soft and non-tender. There are no masses palpable. There is no hepatosplenomegaly. BACK: Examination is deferred. UPPER EXTREMITIES: Reveal normal DIP and PIP joints bilaterally. The right metacarpal phalangeal joints are normal. There is Grade 2+ synovitis at the left third metacarpal phalangeal joint along with some extensor tenosynovitis on the top of the left hand that extends toward the wrist.
DIP|distal interphalangeal|DIP|134|136|PHYSICAL EXAMINATION|No organomegaly or masses. Extremities: No cyanosis, clubbing or edema. The fourth digit of the patient's left hand is missing at the DIP joint from a childhood accident. Skin: No rashes noted. Neurologic: Alert and oriented. Cranial nerves II through XII grossly intact.
DIP|distal interphalangeal|DIP|293|295|HISTORY OF PRESENT ILLNESS|She was seen in the emergency room at Fairview Ridges 48 hours ago, given IV antibiotics and sent home, returned to the ER the next day as her symptoms were no better, and she was admitted to the hospital. The ER physicians debrided some skin on the dorsal aspect of her index finger over the DIP joint. She says she has had no fevers or chills. Per the patient, her hand is looking better, swelling has gone down, and the redness has gone down after being admitted to the hospital and started on some Unasyn.
DIP|distal interphalangeal|DIP|156|158|PHYSICAL EXAMINATION|She had mild selling of the dorsal aspect of index and along MCP joints. On the dorsal aspect of her index finger distal to the PIP joint and dorsal of the DIP joint showed what looked like superficial skin loss with underlying dermal tissue. It looked as though she lost a blister. There was mild ring of erythema around it but no proximal streaking.
DIP|distal interphalangeal|DIP|239|241|PHYSICAL  EXAMINATION|Pulse 71, respirations 20. EXTREMITIES: On examination of his upper extremities, specifically the left hand, he does have dark ecchymosis involving the tip of the finger extending circumferential around the finger back to the level of the DIP joint or just a few mm proximal to it. It is very well demarcated and the skin is as if it could be a bleed that has extended below the epidermis and has discolored the finger but may be stable at this point.
DIP|distal interphalangeal|DIP.|276|279|PHYSICAL EXAMINATION|Examination of the bite wound on the index finger of the right hand reveals an approximately 4 centimeter largely healed linear laceration without fluctuance or notable tenderness. There is no swelling. There is full range of motion at the MCP joint as well as at the PIP and DIP. Sensation is intact to light touch distally. LABORATORY EVALUATION: Pending. ASSESSMENT AND PLAN: 1. Poly-substance abuse.
DIP|distal interphalangeal|DIP|181|183|HISTORY OF PRESENT ILLNESS|She has limited finger flexion and extension but only because of the mass effect dorsally. She has no significant pain with flexion or extension of the finger including the PIP and DIP as well as MP joints. Plain x-rays were obtained through the emergency department. (_______________) index finger contraction with a gross purulence dorsally.
DIP|distal interphalangeal|DIP|166|168|HISTORY OF PRESENT ILLNESS|The patient's hand was thoroughly irrigated and debrided after digital blocks were performed. Following this, the flaps of the ring finger which was amputated at the DIP joint level was then trimmed and fashioned to cover the defect. I did not rongeur the remaining bone at this time as it was at the DIP joint level.
DIP|distal interphalangeal|DIP|207|209|HISTORY OF PRESENT ILLNESS|Following this, the flaps of the ring finger which was amputated at the DIP joint level was then trimmed and fashioned to cover the defect. I did not rongeur the remaining bone at this time as it was at the DIP joint level. This was externally sutured with multiple Steri-Strips. Attention was then directed toward the little finger and the same procedure was performed with a debridement of the tissue and refashioning of the flaps to accommodate a closure.
DIP|distal interphalangeal|DIP.|136|139|FOLLOWUP ENDOCRINE CONSULTATION|She will be transferred to a TCU at Masonic Home in _%#CITY#%_. The patient is currently on prednisone at 30 mg b.i.d. for treatment of DIP. I followed her for type 2 diabetes while she was in the hospital. Please see my original endocrine consultation dated _%#MMDD2006#%_ and my progress notes as well as diabetes management orders.
DIP|distal interphalangeal|DIP|176|178|FOLLOWUP ENDOCRINE CONSULTATION|While not taking high doses of glucocorticoids her blood sugars came down into excellent range and she required relatively low doses of insulin. However, once the diagnosis of DIP was made and she was started on very high doses initially of Solu-Medrol and then switched to prednisone, her blood sugars rose again and she required much higher levels of insulin to manage hyperglycemia.
DIP|desquamative interstitial pneumonia|DIP|238|240|ASSESSMENT|c. History of Hodgkin's disease. d. Questionable history of bleomycin lung; differential diagnosis includes this as well as BOOP (bronchitis obliterans-organized pneumonia), Hodgkin's disease or even non-Hodgkin's disease, UIP/IPF, NSIP, DIP or possible asbestos. 2. Anasarca. 3. Dyspnea secondary to above - clinically he feels better over the past 24 hours. a. Possible chronic obstructive pulmonary disease, thought pulmonary function tests in the past were consistent with restrictive physiology.
DIP|desquamative interstitial pneumonia|DIP,|130|133|PLAN|PLAN: 1. We will have Dr. _%#NAME#%_ see for a VATS/wedge biopsy to rule out a steroid sensitive interstitial lung disease (NSIP, DIP, BOOP, non- Hodgkin's lymphoma, Hodgkin's disease, bleomycin possibly). 2. Steroids are okay for now. 3. Diuresis. Question whether diuresis might be beneficial.
DIP|distal interphalangeal|DIP|172|174|INTERNAL MEDICINE CONSULTATION|She states what generally works for her is steroid eyedrops, and if that doesn't work she gets injections. She is also reporting some pain in her right first finger at the DIP and PIP. She just noticed this about a week ago, and states that her doctor, Dr. _%#NAME#%_, had told her that she could except some digit pain eventually.
DIP|distal interphalangeal|DIP,|348|351|PHYSICAL EXAMINATION|Normal S1, S2. No murmur, gallop, or rub. ABDOMEN - slightly tender in the lower abdomen, otherwise the exam was somewhat limited by her obesity but I saw no hepatosplenomegaly or masses. EXTREMITIES - the following joints were examined for range of motion, tenderness, and swelling and were found to be without abnormality except where noted: The DIP, PIP, MCP, wrist, elbow, glenohumeral, acromioclavicular, sternoclavicular, temporomandibular, hip, knee, tibiotalar, subtalar, MTP, and IP joints bilaterally. The exceptions were the right first MCP joint had grade II swelling and tenderness, was warm and erythematous.
DIP|distal interphalangeal|DIP|271|273|REVIEW OF SYSTEMS|GI: No current hepatitis. Does have a past history of peptic ulcer disease and a history of what she calls terrible gastroesophageal reflux disease. No daily alcohol consumption. HEMATOLOGIC: Bruises from her prednisone. MUSCULOSKELETAL: Some arthritis and points to her DIP joints. REVIEW OF SYSTEMS: Otherwise negative. MEDICATIONS: 1. Premarin. 2. Zestril.
DIP|distal interphalangeal|DIP|134|136|HISTORY OF THE PRESENT ILLNESS|She was see in the emergency room last night and diagnosed with an infection of her long finger on the right. She was lanced over the DIP joint in the volar aspect in the emergency room and placed on Unasyn. I am seeing her this morning. She reports pain immediately relieved after the superficial I and D but now, increasing pain.
DIP|distal interphalangeal|DIP|181|183|PHYSICAL EXAMINATION|The middle finger has been amputated. The ring and little fingers appear normal with good function. The index finger has an area of complete necrosis and dry gangrene distal to the DIP joint; this area is nontender and there is no erythema. The thumb has mild swelling. The pulp is intact. He has an area of full thickness gangrene dorsally, however, at the level of the IP joint.
DIP|distal interphalangeal|DIP|132|134|PHYSICAL EXAMINATION|On her left hand she shows no erythema or streaking lymphangitis in her forearm. She does have a very swollen index finger from the DIP crease. Distally she has a blister dorsally with some erythema and ecchymotic bruising. On the volar aspect she is fluctuant. There is a small laceration along the radial edge.
DIP|distal interphalangeal|DIP|205|207|ASSESSMENT AND PLAN|4. The Medicine Service should see her for preoperative clearance. 5. Occupational therapy will be consulted for a wrist extension block splint, as well as passive inactive range of motion of the MP, PIP, DIP joints.
DIP|distal interphalangeal|DIP,|216|219|CURRENT PHYSICAL EXAMINATION|There are no ulcerations. There is no sclerodactyly. HEAD: Is normocephalic and there is no scalp tenderness. EYES: Are normal Carotids are not enlarged. The thyroid is not enlarged. UPPER EXTREMITIES: Reveal normal DIP, PIP and metacarpal phalangeal joints bilaterally. There is no synovitis or effusion. There is soft tissue swelling of the right hand from infiltrated intravenous.
DIP|distal interphalangeal|DIP|204|206|PHYSICAL EXAMINATION|X-rays today, three views obtained, show some mild intercarpal degenerative changes. No significant radiocarpal degenerative changes. She does have multiple areas of degenerative arthritis throughout her DIP and PIP joints. There is no evidence for soft tissue air but there is significant dorsal soft tissue swelling.
DIP|distal interphalangeal|DIP|241|243|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Hypertension for 3 years. 2. She does have a history of mitral valve prolapse and although she does not have a murmur she is on Depo-Provera prophylaxis. 3. Significant osteoarthritis with involvement of the PIP and DIP joints of her fingers. She denies any history of elevated cholesterol. She was a smoker in college, but does not smoke now.
DIP|distal interphalangeal|DIP|227|229|PHYSICAL EXAMINATION|I am not able to fully assess sensation at this time, as the patient is very jumpy with initial physical examination and will not let me do it; however, she will flex at her MCP, at her PIP, and is able to slightly flex at her DIP as well. Otherwise, no other abnormalities are associated with her hand or right upper extremity. IMAGING: Imaging reveals a fracture of the distal tuft of her distal ring distal phalanx; otherwise, no other injury.
DIP|distal interphalangeal|DIP|114|116|PHYSICAL EXAMINATION|When she makes a fist she is unable to pull the distal phalanx down. She can bend at the PIP joint but not at the DIP joint. She has pain and tenderness over the mid portion of the ring finger of the middle phalanx. She does not have tenderness at the base of the A-1 pulley.
DIP|distal interphalangeal|DIP|134|136|PHYSICAL EXAMINATION|More importantly, there is a non-healing ulcer over the palmar aspect of the distal phalanx. There is some guarding and motion at the DIP joint. He has left below knee amputation level. There is also an ulceration on the medial tibial on the right side.
DIP|distal interphalangeal|DIP|182|184|LABORATORY DATA|He has poor healing potential given his peripheral vascular disease, chronic renal failure, and history of alcohol abuse. I recommended that he have an amputation either through the DIP joint or through the mid portion of the middle phalanx. The osteomyelitis could be eradicated with a disarticulation, but I don't think there is enough soft tissue to close the wound without going to the middle of the middle phalanx level.
DIP|distal interphalangeal|DIP|152|154|HISTORY OF PRESENT ILLNESS|He obviously noted onset of pain in the area. Mr. _%#NAME#%_ was brought to the emergency room where x-rays confirmed an amputation at the level of the DIP joint. His wound was cleansed and Dr. _%#NAME#%_ has requested I assume further care. This gentleman denies any prior history of problems with the hand.
DIP|distal interphalangeal|DIP|209|211|PHYSICAL EXAMINATION|Vital signs, blood pressure 132/79, pulse 82, respirations 18, temperature 98.4. Exam of the left hand reveals no abnormalities other than the index finger. There was an oblique laceration at the level of the DIP joint with a longer radial flap. This is clean without any residual foreign material. Motion of the MP and PIP joints is full.
DIP|distal interphalangeal|DIP|124|126|PHYSICAL EXAMINATION|VITAL SIGNS: Stable. Examination of the hand shows extensive damage to the sterile matrix with a proximal laceration to the DIP joint. The third digit has complex injury to the sterile matrix and the nail itself no apparent damage, although there is though the appearance of tissue missing from the sterile matrix on the ulnar aspect of the distal quadrant of the nail.
DIP|distal interphalangeal|DIP|328|330|PHYSICAL EXAMINATION|Small toe has some contusion but appears intact. Sensitivity to the fourth toe is diminished, difficult to assess secondary to the degloving injury. X-rays, three views of the foot, demonstrate a transverse fracture through the proximal phalanx, as well as what appears to be a fracture and possible fracture dislocation of the DIP joint. IMPRESSION: Crush injury to the right fourth toe. PLAN: I had a lengthy discussion with _%#NAME#%_ and his family regarding the nature of the crush and degloving avulsion injury.
DIP|distal interphalangeal|DIP,|181|184|PHYSICAL EXAMINATION|LYMPH: No cervical or axillary lymphadenopathy but there are palpable lymph nodes in the groin bilaterally. JOINTS: TMJ, AC, glenohumeral, sternoclavicular, elbow, wrist, MCP, PIP, DIP, hips, knees, ankles, MTP and toe IP joints all examined bilaterally. The right elbow had grade 1 swelling and tenderness and was warm to the touch.
DIP|distal interphalangeal|DIP.|131|134|PHYSICAL EXAMINATION|She is obese. EXTREMITIES: She has a mild peripheral edema bilaterally. SKIN: She does have evidence of tophi near her left fourth DIP. She is non-tender to palpation of the left acromioclavicular joint. She is tender to movement of the shoulder joint and seems somewhat restricted in movement.
DIP|distal interphalangeal|DIP|203|205|REASON FOR CONSULTATION|She is somewhat confused. Her right upper extremity is in a short arm splint. She is able to wiggle all her fingers to command. All fingers are well-perfused. She has obvious degenerative changes of the DIP joints. The splint goes a bit distal to the MP joints. I am therefore not able to evaluate the more proximal joints.
DIP|distal interphalangeal|DIP|201|203|PHYSICAL EXAMINATION|ABDOMEN: Bowel sounds are active. SKIN: Without evidence of vasculitic lesions. JOINTS: No active synovial swelling in any of the peripheral joints. She has moderate hypertrophic changes of all of the DIP and PIP joints of the fingers without significant tenderness there. Both wrists are normal. Elbows are normal. Shoulders have full, passive range of motion without pain.
DIP|distal interphalangeal|DIP|250|252|PHYSICAL EXAMINATION|His vital signs are stable. There is no fever. SKIN: Examination is unremarkable JOINT: Exam shows no active synovitis in the shoulders, elbows, wrists, or MCPs. There is mild bony hypertrophy in the PIPs and DIPS. The worse joint is the left second DIP joint. The right knee is visibly swollen. There is a tense effusion and it is slightly warm. The knee is tender on the lateral aspect of the joint.
DIP|distal interphalangeal|DIP|127|129|HISTORY OF PRESENT ILLNESS|The amputated piece is available and was inspected. It is oblique. The level of the injury of the distal fragment involves the DIP joint, and there is moderate comminution of the bony fragment of the remaining remnant of the middle phalanx on the ulnar portion of the digit.
DIP|distal interphalangeal|DIP|208|210|ALLERGIES|Examination of the left fingers reveals that the left second digit has mild swelling; however, there is no erythema, ecchymoses, or visible deformity. The patient does have full extension at the PIP, IP, and DIP joint. The patient has decreased flexion at the IP joint secondary to pain and swelling of the left second digit. There is no pain in the other 4 digits of the left hand.
DIP|distal interphalangeal|DIP,|244|247|OBJECTIVE|He has mild swelling. Skin is intact. He has a normal neurovascular exam with normal sensation to his ulnar, median, and radial nerves. He has good capillary refill and then normal +3 radial pulse. His motor exam shows 5/5 strength in his FPL, DIP, and his dorsal and ossei. X-RAYS X-rays showed a bicortical buckle-type fracture of his distal radius with mild dorsal angulation, less than 20 degrees, and a concomitant complete distal ulnar fracture, which was angulated dorsally as well.
DIP|distal interphalangeal|DIP|119|121|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Healthy-appearing 24-year-old is able to flex and extend the MCP joints and the IP joints in the DIP joint of all small fingers of the left hand. You can clearly see the profundus tendons of both the index and long fingers through the lacerations.
DIP|distal interphalangeal|DIP|158|160|PHYSICAL EXAMINATION|HEART: Irregular heart rhythm. Diminished heart sounds in general. ABDOMEN: Soft and nontender. No mass felt. EXTREMITIES: Mild osteoarthritic changes in the DIP and PIP joints and at the base of the thumb(that is, the carpometacarpal (CMC) joint). Slight restriction in range of motion in the cervical spine.
DIP|distal interphalangeal|DIP|155|157|PHYSICAL EXAMINATION|We will be taking him to the operating room on an urgent basis. He will need irrigation and debridement. I would expect that we will be trying to fuse the DIP joint to the index finger. On x-ray, it is completely destroyed. He will be shortening the long finger and I hope to simply debride the ring finger.
DIP|distal interphalangeal|DIP|236|238|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: On exam, first of all, the third, at the DIP there is soft tissue loss and bone loss that is obvious. The finger appears viable. No other injury is proximal. The fourth has injury transverse laceration between the DIP and the PIP volarly. There is also a flap injury to the volar aspect of that digit. This appears viable as well. Sensation in both digits and both tufts is very decreased.
DIP|distal interphalangeal|DIP|127|129|PHYSICAL EXAMINATION|There was moderate erythema all the way up to his MCP joint, and it was easily able to express pus from this area. His PIP and DIP joint appeared to be normal with just some mild swelling, but really no pain with passive or active range of motion. His neurologic exam is grossly intact. X-rays per report were unremarkable.
DIP|distal interphalangeal|DIP|189|191||_%#NAME#%_ _%#NAME#%_ is an 81-year-old who was brought to the minor procedure unit for the possibility of a incision and drainage of her right small finger. She has had a red small finger DIP joint for the past several weeks. She is on clindamycin. She saw Dr. _%#NAME#%_ yesterday, who was able to extract some white material from the subcutaneous tissue, and evaluate it under polarizing microscope with a diagnosis of uric acid, thus establishing the diagnosis of gout.
DIP|distal interphalangeal|DIP|358|360||She is on clindamycin. She saw Dr. _%#NAME#%_ yesterday, who was able to extract some white material from the subcutaneous tissue, and evaluate it under polarizing microscope with a diagnosis of uric acid, thus establishing the diagnosis of gout. On physical examination today, there is no flexor tendon or fingertip pulp redness, tenderness, edema or pain. DIP joint redness radially, ulnarly and somewhat dorsally continues, but is decreased in intensity and space versus my office evaluation on Tuesday.
DIP|distal interphalangeal|DIP|153|155||DIP joint redness radially, ulnarly and somewhat dorsally continues, but is decreased in intensity and space versus my office evaluation on Tuesday. The DIP joint is not particularly tender, although all her DIP joints are tender as she has severe osteoarthritis. There are punctate white spots visible in the ulnar side of the small finger, which were the area of the uric acid diagnosis by Dr. _%#NAME#%_.
DIP|distal interphalangeal|DIP|123|125|PHYSICAL EXAMINATION|There is some segmental loss of the soft tissue in the pulp as well. Active flexion indicates distal phalanx intact at the DIP joint and flexor and extensor tendon preserved. PIP joint appears preserved. The amputated tissue was macerated and crushed. IMPRESSION: Right index finger, crush avulsion and degloving injury. PLAN: I discussed with him the nature of the injury and that it will require revision amputation with soft tissue closure.
DIP|distal interphalangeal|DIP|122|124|PHYSICAL  EXAMINATION|There is also some erosion in the base of the middle phalanx into the PIP joint. Also, of note is some destruction of the DIP joint of the adjacent third toe. LABORATORY DATA: White blood cell count (_%#MMDD2006#%_) was 12.9. Uric acid on the same date was 10.5 (normal maximum 8.5). IMPRESSION: Gout attack involving right fourth toe.
DIP|desquamative interstitial pneumonia|DIP|229|231|FEV1		FVC|GI: No nausea. Pain controlled. Lymph: No swelling prior to surgery. The reminder of a complete ROS is negative. PMHx: 1) Bilateral single lung trxplt _%#MMDD2006#%_ -Initial diagnosis of IPF -Now felt to be more consistent with DIP -Recurrence of DIP in _%#MM#%_ 2007, responded to corticosteroids (prednisone 40mg BID) -Had been tapering down slowly, recently 20mg-25mg -Post-trxplt course complicated by episodes of heart failure and one episode of possible acute rejection.
DIP|desquamative interstitial pneumonia|DIP,|284|287|PE|Soft, ND. Lymph: Trace LE edema. Skin: Warm, dry Neuro: Somnolent, but arousable and appropriate. Labs reviewed in FCIS. Creat 0.96 Mg 1.6 Fingerstick glc 167 @ 1700 Pre-op Hgb 15.3 WBC 7.7 on 6/5 Last tacrolimus level 6/5 = 7.4 (13.5 hour trough) A/Recs: 33 y/o M with bilat SLT for DIP, POD#0 lap chole and umbilical hernia repair. 1) Lung transplant Missed a.m. dose of tacrolimus. On usual pre-op MMF and prednisone doses.
DIP|desquamative interstitial pneumonia|DIP|185|187|HISTORY OF PRESENT ILLNESS|The patient's post-transplant course has been complicated by heart failure secondary to idiopathic cardiomyopathy. His ejection fraction is less than 25%. He also has recurrence of his DIP in his transplanted lung requiring steroid treatment. The patient was admitted 2 times in _%#MM#%_, once for atrial flutter with 2 ablations performed.
DIP|desquamative interstitial pneumonia|DIP.|137|140|ASSESSMENT AND RECOMMENDATIONS|ASSESSMENT AND RECOMMENDATIONS: This is a 33-year-old male who is status post bilateral lung transplant on _%#MMDD2006#%_ because of the DIP. He was admitted on _%#MMDD2007#%_ because of a right groin hematoma, which was a complication of his recent cardiac ablation treatment twice in _%#MM2007#%_ for atrial flutter and fib.
DIP|desquamative interstitial pneumonia|DIP|373|375|HISTORY OF PRESENT ILLNESS|He was admitted to the University of Minnesota Medical Center, Fairview, on _%#MMDD#%_ with right groin and right lower extremity hematoma secondary to supratherapeutic INR. Hospital course was pertinent for correction of his anticoagulation with fresh frozen plasma and vitamin K, a lymphedema consult for treating his lower extremity swelling, possible recurrence of his DIP and placed on large dose steroids. PAST MEDICAL HISTORY: Pertinent for the lung transplant secondary to DIP, congestive heart failure, pulmonary embolus, insulin-dependent diabetes mellitus with gastroparesis, hypertension, history of colitis and chronic diarrhea and umbilical hernia repair.
DIP|desquamative interstitial pneumonia|DIP,|307|310|PAST MEDICAL HISTORY|Hospital course was pertinent for correction of his anticoagulation with fresh frozen plasma and vitamin K, a lymphedema consult for treating his lower extremity swelling, possible recurrence of his DIP and placed on large dose steroids. PAST MEDICAL HISTORY: Pertinent for the lung transplant secondary to DIP, congestive heart failure, pulmonary embolus, insulin-dependent diabetes mellitus with gastroparesis, hypertension, history of colitis and chronic diarrhea and umbilical hernia repair.
DIP|distal interphalangeal|DIP|147|149|EXAMINATION|Her radial styloid is tender. Her circulation, motor and sensory functions are intact. She has arthritic changes in the hands, particularly in the DIP joints. Radiographs show an undisplaced distal radius fracture. This is a very simple fracture, which should be stable, can be treated in a cast.
DIP|desquamative interstitial pneumonia|DIP|242|244|IMPRESSION|1. Ongoing smoker. 2. One-year history of progressive dyspnea on exertion and wheezing. 3. No constitutional symptoms, no arthritis or arthralgias. 4. Differential includes early IPF ILD (respiratory bronchiolitis interstitial lung disease), DIP (desquamative interstitial pneumonitis). Both are interstitial lung diseases that are more common in smokers. RB ILD does improve with smoking cessation plus/minus steroids. DIP may be steroid-sensitive as well.
DIP|desquamative interstitial pneumonia|DIP|133|135|IMPRESSION|Both are interstitial lung diseases that are more common in smokers. RB ILD does improve with smoking cessation plus/minus steroids. DIP may be steroid-sensitive as well. Sarcoidosis could also do this as well. PLAN: 1. Pulmonary function tests. 2. Combivent MDI 2 to 4 puffs q.8h and q.4h. p.r.n. Prescription given today.
DIP|distal interphalangeal|DIP|205|207|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Examination demonstrates mild tenderness. There is no significant surrounding erythema but slight fluctuance in the area of the ulnar nail fold. She has normal range of motion of the DIP and PIP joints without pain. There is no evidence of flexor tendon signs. X-RAYS: X-rays were reviewed which demonstrated no significant abnormality of the ring finger.
DIP|distal interphalangeal|DIP,|448|451|PHYSICAL EXAMINATION|CARDIOVASCULAR: Regular rate and rhythm. No murmur or rub. CHEST: Breath sounds were heard bilaterally and there was no wheezing or crackles. ABDOMEN: Soft and non-tender. No hepatosplenomegaly appreciated. EXTREMITIES: The following joints were examined for range of motion, crepitance, tenderness, redness, warmth and swelling, and were found to be without abnormality: Temporomandibular, glenohumeral, acromioclavicular, elbow, wrist, MCP, PIP, DIP, knee, ankle, MTP and toe IP joints. LABORATORY DATA: Metabolic panel was all without abnormality with the exception of a slightly elevated glucose and a CBC was within normal limits, with the exception of an absolute lymphocyte count of 0.6. A CT of his chest, abdomen and pelvis showed lymphadenopathy in both axilla, groin, pericardial, hilar, mediastinal regions, as well as some hydronephrosis with prostatic enlargement.
DIP|distal interphalangeal|DIP|234|236|IMAGING|IMAGING: AP, lateral and oblique views of the right hand demonstrate a fracture involving the distal phalanx of the right ring finger with longitudinal extension of the fracture from distal to proximal with unclear if it involves the DIP joint. The longitudinal fracture is nondisplaced. There is also a small tuft fracture at the end of the distal phalanx. PHYSICAL EXAMINATION: GENERAL: The patient is alert and oriented x3.
DIP|distal interphalangeal|DIP|196|198|PHYSICAL EXAMINATION|Examination of the left hand reveals that the left 4th digit does show a mild degree of angulation as compared to the other digits. The patient does have full, unrestricted range of motion at the DIP joint as compared to the right. The patient is noted to have a significant decrease in range of motion at the left 4th IP joint.
DIP|distal interphalangeal|DIP|197|199|PHYSICAL EXAMINATION|There is no evidence of any overlying erythema or purulence. She has subtle range of motion although does not move her hand actively at all first through fifth MCP joints as well as PIP joints and DIP joints. She does not appear to have intact sensation and she has no significant discomfort with palpation of the dorsal aspect of her hand.
DIP|distal interphalangeal|DIP|135|137|PHYSICAL EXAMINATION|It is not fusiform, however, and there is no tenderness in the palmar aspect of the flexor tendon. The inoculate injury is between the DIP and PIP. No pus is coming from this, but there is some erythema. Erythema is waning on the dorsum of the hand. IMPRESSION/PLAN: We will go with another 24-48 hours of IV antibiotics.
DIP|distal interphalangeal|DIP|187|189|PHYSICAL EXAMINATION|The nail had been removed in the emergency room from the right ring finger, and there is a small oblique wound on the pulp of the finger. It is not over a joint. He is able to wiggle the DIP joint, he is able to make a fist. There is erythema and tenderness at the tip of the finger. X-rays have not been done. This appears to be a felon, secondary to a human hand bite.
DIP|distal interphalangeal|DIP|281|283|IMAGING|They demonstrate a small fracture of the very most distal aspect of the left right and long finger with approximately 3 mm of displacement, which appears to be associated with the finger tip laceration. No evidence of foreign bodies in the wound. No evidence of involvement of the DIP joint or the ......of the distal phalynx. PHYSICAL EXAM: GENERAL: The patient is alert and oriented x 3.
DIP|distal interphalangeal|DIP|227|229|PHYSICAL EXAMINATION|He generally appears comfortable. EXTREMITIES: Left hand, there is an obvious extensor lag of his left DIP joint of the ring finger. There is minimal to no swelling. There is no tenderness. He has full passive extension of his DIP joint. He is able to easily flex his PIP joint without difficulty. He has full extension of his PIP joint. There is no deformity of his PIP joint.
DIP|distal interphalangeal|DIP|131|133|HISTORY OF PRESENT ILLNESS|X-rays revealed tiny tuft fractures of the index and ring pulps, but of most note was a totally macerated extensor tendon over the DIP joint of the middle finger. He therefore asked me to come by and see the patient as well. This gentleman denies prior problems with his left hand. This is an isolated injury.
DIP|distal interphalangeal|DIP|184|186|PHYSICAL  EXAMINATION|This does not appear to significantly involve the nail or the underlying bone. The middle finger has a stellate laceration dorsally. The extensor tendon underneath at the level of the DIP joint is entirely destroyed and the DIP joint is exposed. Nail is intact. The ring finger has a superficial laceration which appears to involve mainly the pulp.
DIP|distal interphalangeal|DIP|145|147|PHYSICAL  EXAMINATION|The middle finger has a stellate laceration dorsally. The extensor tendon underneath at the level of the DIP joint is entirely destroyed and the DIP joint is exposed. Nail is intact. The ring finger has a superficial laceration which appears to involve mainly the pulp.
DIP|distal interphalangeal|DIP|210|212|CURRENT PHYSICAL EXAMINATION|She has a negative C sign. She does have tenderness to palpation over the volar aspect of her finger from the A1 pulley distally. No open wounds are noted. There is a small healing paper cut possibly about the DIP joint that does not appear to be significantly erythematous. There is some mild erythema noted. She is neurologically and vascularly intact distally with no rashes or skin breakdown other than that noted above.
DIP|distal interphalangeal|DIP|158|160|PHYSICAL EXAMINATION|EXTREMITIES: No edema. MUSCULOSKELETAL: The patient's wrists seem somewhat stiff. There is no tenderness or swelling of the wrist joints, MCP joints, PIP, or DIP joints. There is no swelling or erythema of the knees or elbows. The patient is not tender to palpation of the large muscle groups.
DIP|distal interphalangeal|DIP|164|166|PHYSICAL EXAMINATION|SKIN: No clear rashes. He is slightly diaphoretic. Pedal pulses present, no edema. MUSCULOSKELETAL: Upper extremities notable for swelling about the wrist, MTP and DIP and PIP joints in the upper extremities bilaterally and about the elbow, olecranon and forearm. He is focally tender in the muscles primarily in the proximal leg muscles and the forearm and slightly in the triceps, biceps.
DIP|distal interphalangeal|DIP|168|170|HISTORY OF PRESENT ILLNESS|At that time it had improved. She had a chest x-ray which was read as negative. Left hand x-ray showed moderate to severe osteoarthritis in the first and fifth MCP and DIP joints with otherwise degenerative joint disease also noted, otherwise the x-ray was unremarkable. An ultrasound of the upper extremity was performed to look for clot and this was normal.
DIP|distal interphalangeal|DIP|169|171|PULMONARY|The buttock's hematoma appears larger than a softball. EXTREMITIES: Radials are 2/4 bilaterally. He has no clubbing however there are some osteoarthritis changes in his DIP and PIP joints. Lower extremities are hyperpigmented with thick tight skin with edema that is nonpitting. Below the knees the skin is very tense. The right knee joint is very enlarged, however, the incisional area is well healed without any erythema.
DIP|distal interphalangeal|DIP|165|167|PHYSICAL EXAMINATION|There is no cyanosis. Suggestion of some clubbing is seen. SKIN: No rashes or other unusual lesions. MUSCULOSKELETAL: Findings compatible with osteoarthritis in the DIP joints diffusely, otherwise unremarkable. NEUROLOGIC: Alert and oriented x3. No focal abnormalities. LABORATORY: The blood counts are normal. The electrolytes are normal. BUN is 24 with a creatinine of 1.8, which is near her baseline.
DIP|distal interphalangeal|DIP,|152|155|PHYSICAL EXAMINATION ON ADMISSION|She had an erythematous rash on her nasal bridge. She was warm to palpation all over. MUSCULOSKELETAL: Significant for very small effusions in her PIP, DIP, and toe joints. ADMISSION LABORATORY: Hemoglobin 10.3, ESR 42. Electrolytes normal. HOSPITAL COURSE: PROBLEM #1: Chills and cough: We thought that this could represent a viral infection, and this was resolving by the time of admission.
DIP|desquamative interstitial pneumonia|DIP|198|200|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Status post single bilateral lung transplant, _%#MMDD2006#%_, secondary to DIP. Post transplant, he required IV Solu-Medrol for acute rejection in _%#MM2006#%_. 2. Possible DIP recurrence, which was diagnosed by bronchoscopy in _%#MM2007#%_. The patient has been on high-dose prednisone since. His pulmonary function tests have shown some improvement.
DIP|desquamative interstitial pneumonia|DIP.|175|178|PAST MEDICAL HISTORY|The patient has been on high-dose prednisone since. His pulmonary function tests have shown some improvement. Repeat bronchoscopy on _%#MMDD2007#%_ showed a recurrence of his DIP. Hence, kept on prednisone at 30 mg p.o. b.i.d. 3. Congestive heart failure secondary to idiopathic cardiomyopathy. His last known ejection fraction is 25%.
DIP|distal interphalangeal|DIP|142|144|PHYSICAL EXAMINATION|Exam is significantly limited by the diminished range of motion and severe pain. There is also focal pain with palpation over the left fourth DIP joint and the right fourth MCP joint. No nodes, swelling or bony hypertrophy is appreciated in the hand joints. LABORATORY: Admission laboratory, white blood cell count 14.9 with 77% neutrophils and 11% lymphocytes, hemoglobin 11.7 with MCV 90, platelets 334.
DIP|distal interphalangeal|DIP|164|166|PHYSICAL EXAMINATION|No rebound tenderness or guarding. No appreciable organomegaly. No obvious masses. EXTREMITIES: No clubbing or cyanosis. She had sclerodactyly mainly distal to the DIP joints. No evidence of subungual erythema or capillary loops. Trace bilateral lower extremity edema. NEUROLOGIC: Cranial nerves II through XII intact, appropriate with questions; sensation intact to light touch.
DIP|distal interphalangeal|DIP|292|294|PHYSICAL EXAM|ABDOMEN: Soft, nontender. No hepatosplenomegaly. No abnormal masses. EXTREMITIES: The left upper extremity reveals significant erythema involving the entire dorsum of the third finger, milder degree on the palmar side. Marked tenderness of the distal finger, particularly between the PIP and DIP joints. Joints are quite painful with movement but also significant soft tissue tenderness. Mild erythema extending to the dorsal hand over the MCPs of the second through fourth fingers.
DIP|distal interphalangeal|DIP|279|281|PHYSICAL EXAMINATION|First and second MTP joints are grossly boggy with nodules that appear to be possibly emerging tophi, these are fluctuant and discrete, approximately 1 cm in size. He has bogginess and tender with his PIP joints but no change. Mild erythema but no bogginess or tenderness in his DIP joints. SKIN: No rash other than erythema about joints described above. See musculoskeletal exam. LABORATORY DATA: Blood cultures drawn, sed rate is 91, BNP 813, INR 4.41, troponin 0.51, subsequent troponin 0.6. Sodium 138, potassium 4.0, bicarbonate 25, chloride 101, BUN and creatinine 29 and 2.0, blood sugar is 252, calcium 8.6, CRP 353, uric acid 5.6. EKG reviewed by myself shows some mild ST depression in V5 and 1, possibly V6 but in a sinus rhythm.
DIP|desquamative interstitial pneumonia|DIP.|185|188|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ is status post bilateral sequential lung transplantation performed on _%#MMDD2006#%_. The etiology of his prior lung disease at this time is suspected to be secondary to DIP. Since his last hospital admission on _%#MMDD2007#%_, he was started on 30 mg twice a day of prednisone for recurrence of DIP in his transplanted lung.
DIP|desquamative interstitial pneumonia|DIP|121|123|HISTORY OF PRESENT ILLNESS|Since his last hospital admission on _%#MMDD2007#%_, he was started on 30 mg twice a day of prednisone for recurrence of DIP in his transplanted lung. He was admitted at that time for shortness of breath, which was thought to be most likely due to DIP and possibly heart failure.
DIP|desquamative interstitial pneumonia|DIP|248|250|HISTORY OF PRESENT ILLNESS|Since his last hospital admission on _%#MMDD2007#%_, he was started on 30 mg twice a day of prednisone for recurrence of DIP in his transplanted lung. He was admitted at that time for shortness of breath, which was thought to be most likely due to DIP and possibly heart failure. His post-transplant course has been complicated by heart failure secondary to idiopathic cardiomyopathy, and he has an EF of less than 25%.
DIP|desquamative interstitial pneumonia|DIP.|180|183|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: His past medical history is extensive and includes: 1. Status post bilateral sequential lung transplantation done on _%#MMDD2006#%_, most likely secondary to DIP. He was treated with IV solumedrol for acute rejection in _%#MM2006#%_. 2. Possible DIP recurrence diagnosed both on bronchoscopy in _%#MM2007#%_ and was treated with high-dose prednisolone with increased PFTs noted.
DIP|desquamative interstitial pneumonia|DIP|194|196|PAST MEDICAL HISTORY|1. Status post bilateral sequential lung transplantation done on _%#MMDD2006#%_, most likely secondary to DIP. He was treated with IV solumedrol for acute rejection in _%#MM2006#%_. 2. Possible DIP recurrence diagnosed both on bronchoscopy in _%#MM2007#%_ and was treated with high-dose prednisolone with increased PFTs noted. In addition he was readmitted to the hospital on _%#MMDD2007#%_ at which time a repeat bronchoscopy showed recurrence of his DIP; hence he was put on prednisone 30 mg twice daily and has been on that dose since then.
DIP|desquamative interstitial pneumonia|DIP.|257|260|ASSESSMENT AND PLAN|Platelet is 177. His CBC shows white count of 12.1, hemoglobin of 7.2 (his hemoglobin prior to this was 11.5 approximately 5 days ago). ASSESSMENT AND PLAN: Mr. _%#NAME#%_ is a 33-year-old gentleman status post bilateral sequential lung transplantation for DIP. Currently comes to the clinic with significant weakness/shortness of breath and right groin pain and right lower extremity swelling. 1. Right lower extremity swelling/pain. This is most likely secondary to repeated punctures in the right femoral vein and most likely developed hematoma both in his groin and possibly retroperitoneal hematoma.
DIP|desquamative interstitial pneumonia|DIP|177|179|ASSESSMENT AND PLAN|3. Bilateral sequential lung transplantation. Will continue with Prograf with the therapeutic goal of 10-12. He will also continue on CellCept. Since he has had a recurrence of DIP he was put on 30 mg of prednisone twice daily. I would like to decrease this to 25 mg twice daily. Pertinent to plan 2, will also stop all anticoagulation at this time.
DIP|distal interphalangeal|DIP|248|250|IMPRESSION|b. Long-term NSAID use. c. Osteoarthritis with past right ankle sprains superimposed on chronic instability of right ankle/bilateral shoulder pain/bilateral knee joint pain with bony joint deformities. d. Posttraumatic deformities/empiric function DIP joint first finger right hand. 8. Bilateral corneal arcus. a. Hypercholesterolemia. b. No documented coronary artery disease. 9. Bilateral decreased auditory acuity. a. Bilateral hearing aids.
DIP|distal interphalangeal|DIP|218|220|PHYSICAL EXAMINATION|There is diffuse mild papular rash present on the patient's thighs, abdomen, and trunk/back. ORTHOPEDIC: Mild tenderness to palpation over the paralumbar musculature. The patient has Heberden's nodes present bilateral DIP joints. LABORATORY DATA: WBC 7.9, hemoglobin 14.5, platelets 128, sodium 130, potassium 4.7, chloride 97, CO2 of 24, BUN 28, creatinine 1.91, glucose 120, calcium 8.8, digoxin 0.9. Urinalysis shows trace leukocyte esterase with 10-25 white blood cells per high powered field and 5-10 red blood cells.
DIP|distal interphalangeal|DIP|190|192|PROCEDURES|There was also depressed anterior left maxillary wall fracture with possible nondisplaced lateral maxillary fracture as well. 7. X-ray of her left hand showed moderate osteoarthritis at the DIP and PIP joints, but no acute fractures or dislocations. 8. X-ray of her right knee showed no acute fracture dislocation.
DIP|desquamative interstitial pneumonia|DIP|111|113|HISTORY OF PRESENT ILLNESS|He presents with increasing shortness of breath going on for the last 2 weeks at least. Since his diagnosis of DIP in _%#MM#%_ 2007, he was started on high-dose steroids and had significant improvement in his PFTs and actually had his best FEV-1 since transplant.
DIP|desquamative interstitial pneumonia|DIP|174|176|PAST MEDICAL HISTORY|11. PSYCHOLOGICAL: No depression noted. PAST MEDICAL HISTORY: Extensive and includes: 1. Status post bilateral sequential lung transplant done on _%#MMDD2006#%_ secondary to DIP at this time. Has had questionable episode of acute rejection in _%#MM2006#%_. His DIP recurrence was documented in _%#MM2007#%_ and was treated with high-dose steroids with significant improvement in his PFTs.
DIP|desquamative interstitial pneumonia|DIP|175|177|PAST MEDICAL HISTORY|1. Status post bilateral sequential lung transplant done on _%#MMDD2006#%_ secondary to DIP at this time. Has had questionable episode of acute rejection in _%#MM2006#%_. His DIP recurrence was documented in _%#MM2007#%_ and was treated with high-dose steroids with significant improvement in his PFTs. 2. CHF secondary to dilated cardiomyopathy. Last EF was 40% on _%#MMDD2007#%_.
DIP|desquamative interstitial pneumonia|DIP|216|218|ASSESSMENT/PLAN|His FEC was 2.08 on 40% of predicted. His FEV-1 was 1.76 and 42% of predicted with a ratio of 85. ASSESSMENT/PLAN: Mr. _%#NAME#%_ is a 33-year-old gentleman with a history of bilateral sequential lung transplant for DIP admitted with increasing shortness of breath. PROBLEM #1: Shortness of breath: The etiology of his shortness of breath is not clear to me at this time.
DIP|desquamative interstitial pneumonia|DIP.|225|228|PROBLEM #1|There is some ground glass opacities noted in the lung fields, predominantly in the right upper lobe and also in the lower lobes. The differential at this time of course includes heart failure rejection and recurrence of his DIP. Based on the history that his shortness of breath had been going on at least for the last month and a half, and this coincided with the tapering of the steroids (which were aggressively tapered because of the need for surgery), it is possible that this is DIP.
DIP|distal interphalangeal|DIP|231|233|PHYSICAL  EXAMINATION|No hepatosplenomegaly or masses palpable. EXTREMITIES: Show no edema and peripheral pulses are intact. Some varicose veins are noted. SKIN: Shows no rash along the left chest wall or elsewhere. RHEUMATOLOGIC examination shows some DIP and PIP and thickening of the joints consistent with an osteoarthritis appearance. No joint warmth or erythema. The patient has good range of motion of the joints overall.
DIP|distal interphalangeal|DIP|141|143|PHYSICAL EXAMINATION|There was no trochanteric or other hip joint tenderness or swelling on the right or left side. Her hands including her wrists, MCP, PIP, and DIP joints were free of effusions or tenderness to palpation. However, she had Heberden's nodes on her right fifth DIP no acute distress her left fourth DIP.
DIP|distal interphalangeal|DIP|191|193|PHYSICAL EXAMINATION|No abdominal bruits. NODES: Exam shows no supraclavicular, axillary or inguinal adenopathy. EXTREMITIES: Show no current edema. Peripheral pulses are intact. RHEUMATOLOGIC: Examination shows DIP and PIP joint thickening, consistent with osteoarthritis. Minimal tenderness to range of motion of the left shoulder. NEUROLOGIC: Examination shows the patient to be alert and oriented x3.
DIP|distal interphalangeal|DIP|198|200|PHYSICAL EXAMINATION|No pulsatile abdominal masses; no hepatosplenomegaly. MUSCULOSKELETAL: No cyanosis, clubbing, or edema. There is some joint deformity of the metatarsal joints of the feet bilaterally as well as the DIP joints of the index fingers of both hands. There is some bony thickening noted. No joint effusions were appreciated.
DIP|distal interphalangeal|DIP|134|136|PHYSICAL EXAMINATION|She has S0T0 at the PIP, MCP, wrists, elbows, shoulders, hips, knees, ankles, mid feet and MTP joints. She is S1T0 of the right fifth DIP joint with mild angulation deformity and moderate Heberden's node formation. The joints all move well without limitation. Strength is 5/5 throughout without limitation.
DIP|distal interphalangeal|DIP|153|155|PRIMARY PHYSICIAN|PAST SURGICAL HISTORY: 1. Left rotator cuff repair on _%#MM#%_ 2004. 2. History of having his left ring finger and left middle finger amputated from the DIP distally on both fingers from a work accident at 19 years of age. MEDICATIONS: 1. Zocor 40 mg p.o. daily. 2. Dyazide 37.5/25 mg p.o. take a half tablet daily.
DIP|distal interphalangeal|DIP|200|202|PRIMARY PHYSICIAN|No palpable masses or organomegaly. EXTREMITIES: Acyanotic without clubbing or peripheral edema. It is noted that on this left hand, the left ring finger, and left middle finger are amputated for the DIP distally. SKIN: No rashes noted. NEUROLOGIC: Alert and oriented. Cranial nerves 2 through 7 are grossly intact. Subjectively sensation to light touch on his left thumb and pointer finger are decreased when compared to the contralateral hand, otherwise sensation to light touch is intact and equal throughout the upper extremities and lower extremities bilaterally.
DIP|distal interphalangeal|DIP|173|175|PAST SURGICAL HISTORY|The patient denies diabetes mellitus. PAST SURGICAL HISTORY: Remarkable for: 1. Resection of the left upper lobe nodule adenocarcinoma. 2. Also remarkable for excision of a DIP right third mucocyst by Dr. _%#NAME#%_ in 2002. 3. The patient's also had left cataract in _%#MM2005#%_ and right cataract in _%#MM2006#%_.
DIP|distal interphalangeal|DIP|229|231|PHYSICAL EXAMINATION|In the left upper extremity tone is normal. Strength testing was limited due To the pain but the hand grip was around 2+ To 3- in the left. There was limited active extension at the left 4th and 5th digits at the MCP and PIP and DIP joints. Partly due To pain and partly due To swelling and perhaps due To weakness also. There is decreased sensation in the left ulnardistribution extending up To the tinel sign at elbow for the ulnar nerve was negative.
DIP|distal interphalangeal|DIP,|272|275|PHYSICAL EXAMINATION|No hepatosplenomegaly. Positive bowel sounds. EXTREMITIES: No peripheral edema. MUSCULOSKELETAL: The following joints were examined for range of motion, tenderness, erythema, crepitance, swelling and tenderness. Temporomandibular, acromioclavicular, shoulder, elbow, MCP, DIP, hip, knees, ankles, MTP and IP joints of the toes were found to be without abnormality. DATA: On admission, the patient had a slightly positive rheumatoid factor of 24 with less than 20 being negative.
DIP|distal interphalangeal|DIP|183|185|PHYSICAL EXAMINATION|The second through fifth fingers have PIP swelling and she has mild restriction of motion of MCP and PIP joints, and the right index finger DIP joint and left index and middle finger DIP joints. She cannot make a full tuck and it is painful if it is forced manually. She cannot fully extend these DIP joints the way she can other DIP joints.
DIP|distal interphalangeal|DIP|212|214|PHYSICAL EXAMINATION|There are no obvious vasculitic skin lesions although she does have numerous areas of hyperpigmentation with some scarring that she describes as "dry patches" previously. JOINTS: Mild degenerative changes in the DIP and PIP joints without tenderness there. Small synovial cysts on both the volar and dorsal aspect of the right wrist with grade 1 tenderness there.
DIP|distal interphalangeal|DIP|178|180|PHYSICAL EXAMINATION|Sternoclavicular and acromioclavicular joints are nontender. Elbows have full range of motion without swelling, pain on range of motion or increased warmth. Wrists: MCP, PIP and DIP joints of the hands are similarly reassuring. His grip strength is excellent. His SI joints are nontender. He has smooth but limited flexibility of his spine. There is no focal tightness to suggest lumbar ankylosis.
DIP|distal interphalangeal|DIP|341|343|PHYSICAL EXAMINATION|Nail changes were appreciated. MUSCULOSKELETAL: The following joints were examined for swelling, warmth, erythema, tenderness and range of motion: Cervical spine, shoulders, elbows, wrists, small joints of the fingers, hips, knee, ankles, toes. The examination was significant for Bouchard's and Heberden's nodes associated with the PIP and DIP joints respectively. Otherwise it was unremarkable. NEUROLOGICAL EXAM: Speech was appropriate in rate and tone. There was some difficulty answering questions but responses were appropriate.
DIP|distal interphalangeal|DIP|219|221|PHYSICAL EXAMINATION|No evidence of cyanosis. INTEGUMENT: Significant for multiple bruises reportedly secondary to IV site. The patient also has numerous yellow/white nodules characteristic for tophi. These are localized to the right fifth DIP joint, the left olecranon bursa, the second toe on the left foot. No other rashes, nodules, nor lesions were noted. MUSCULOSKELETAL: The following joints were examined for swelling, warmth, erythema, tenderness and range of motion, shoulders, elbows, wrists, MCP, PIP and DIP joints of the hands, hips, knees, ankles, mid feet, forefeet, and joints of the toes.
DIP|distal interphalangeal|DIP|315|317|PHYSICAL EXAMINATION|These are localized to the right fifth DIP joint, the left olecranon bursa, the second toe on the left foot. No other rashes, nodules, nor lesions were noted. MUSCULOSKELETAL: The following joints were examined for swelling, warmth, erythema, tenderness and range of motion, shoulders, elbows, wrists, MCP, PIP and DIP joints of the hands, hips, knees, ankles, mid feet, forefeet, and joints of the toes. It should be noted that the patient was not asked to sit nor stand.
DIP|distal interphalangeal|DIP|142|144|PHYSICAL EXAMINATION|The joint itself was mildly swollen and tender. Range of motion was intact. Examination of the right wrist was unremarkable. The MCP, PIP and DIP joints of the right hand were significant only for the swelling, warmth, erythema and tenderness associated with the left DIP joint.
DIP|distal interphalangeal|DIP|192|194|PHYSICAL EXAMINATION|Examination of the right wrist was unremarkable. The MCP, PIP and DIP joints of the right hand were significant only for the swelling, warmth, erythema and tenderness associated with the left DIP joint. A yellow/white nodule characteristic of a gouty tophus is noted. Examination of the left upper extremity revealed significant decrease in abduction and flexion of the left shoulder.
DIP|distal interphalangeal|DIP|138|140|HISTORY OF THE PRESENT ILLNESS|X-rays of her knee showed significant degenerative change. In fact her right knee is bone on bone. She has had some bony prominent in her DIP joints, but this has been fairly tolerable. In the last several years, she has had problems with her feet, particularly.
DIP|distal interphalangeal|DIP|190|192|PHYSICAL EXAMINATION|The right MCPs are normal as are the left. The exception is the right thumb metacarpal phalangeal which is S1T1Ltrace. The patient's right fourth finger is inflamed in the PIP joint and the DIP joint with some erythema, warmth, tenderness and synovial thickening. The right second DIP joint is erythematous and tender as well. There is mild bony prominence here. The patient is not able to make a full fist on the right hand.
DIP|distal interphalangeal|DIP|162|164|PHYSICAL EXAMINATION|The patient's right fourth finger is inflamed in the PIP joint and the DIP joint with some erythema, warmth, tenderness and synovial thickening. The right second DIP joint is erythematous and tender as well. There is mild bony prominence here. The patient is not able to make a full fist on the right hand.
DIP|distal interphalangeal|DIP|147|149|REVIEW OF SYSTEMS GENERAL|GASTROINTESTINAL: Abdomen is rounded. Positive bowel sounds, soft, nontender, and nondistended with no palpable masses. EXTREMITIES: There is some DIP enlargement in her hands, unable to appreciate any clubbing, cyanosis, or lower extremity edema. SKIN: She is pale; however, I am unable to appreciate any rashes or lesions.
DIP|distal interphalangeal|DIP|206|208|ASSESSMENT|2. History of systemic lupus erythematosus with digital and wrist arthralgias. No evidence of dramatic synovitis on exam. 3. Psoriasis with history of psoriatic arthritis. Again, no synovitis involving the DIP joints appreciated. The patient presently not using topical therapy for psoriasis as "not effective." 4. History of irregular heartbeat with question of mitral valve prolapse.
DIP|distal interphalangeal|DIP,|177|180|PHYSICAL EXAMINATION|ABDOMEN: Soft and nontender, normal bowel sounds. NEUROLOGIC: Grossly normal reflexes. JOINT: She has diffuse puffiness in her hands with changes of osteoarthritis noted in her DIP, PIP and CMC joints. She also has some soft tissue swelling in the second and third MCPs, more prominent on the right.
DIP|distal interphalangeal|DIP|202|204|PHYSICAL EXAMINATION|JOINTS: No swelling, redness, warmth, or evidence of inflammatory joint changes in the shoulders, elbows, wrists, hands, hips, knees, ankles or feet. Scattered degenerative change in the PIP joints and DIP joints, none of which are tender. There is also degenerative change with some limitation of motion in the first metatarsophalangeal (MTP) joints.
DIP|distal interphalangeal|DIP|150|152|PHYSICAL EXAMINATION|Elbows and wrists are nor mal although one has an IV board on it so range of motion cannot be checked. Neither one ha swelling. Finger, MCP, PIP, and DIP joints are normal. Hips are easily rolled without any guarding nor specific complaint. The left knee has a 2+ effusion without redness, heat, or tenderness.
DIP|distal interphalangeal|DIP|189|191|PHYSICAL EXAMINATION|Cervical spine, TMJ, sternoclavicular, acromioclavicular, shoulder, elbow and wrist joints are normal. Fingers are tight in their ability to fully extend. With flexion, she is tight in her DIP joints and cannot reach a full tuck position. With forced flexion, she has mild discomfort in her DIP joints. This seems to be more than just the discomfort seen with tightness and may indicate some mild synovitis.
DIP|distal interphalangeal|DIP|201|203|PHYSICAL EXAMINATION|Extension is normal. In the left hand there are similar findings, but I think the little finger is also involved, as may the thumb IP joint. I am not convinced she has any significant MCP involvement. DIP joints appear to be completely normal. Hips, knees, ankles, and toes are normal. ASSESSMENT: _%#NAME#%_ is a 14-year-old female with history of malar rash, arthritis, lymphopenia, leukopenia, anti-double stranded DNA antibody, positive ANA, low C3, low C4, hematuria (SLE) (possible contamination from menses), profound fatigue, and headaches suggestive of systemic lupus erythematosus or possibly mixed connective tissue disease.
DM|dextromethorphan|DM|136|137|MEDICATIONS|26. Mucinex 600 mg p.o. b.i.d. 27. Ultram 100 mg p.o. q 8 hours p.r.n. pain 28. Nitroglycerin 0.04 mg. sublingual p.r.n. 29. Robitussin DM two teaspoons p.o. q 4 hours 30. Miconazole nitrate 2% topical powder b.i.d. p.r.n. 31. Albuterol nebs q.i.d. p.r.n. REVIEW OF SYSTEMS: A complete review of systems is performed and is negative with the exclusion of the elements as listed in the history of the present illness PHYSICAL EXAMINATION: Blood pressure 110/64, pulse 72, O2 sats two liters at 98% GENERAL APPEARANCE: Elderly female lying in bed in no acute distress.
DM|dextromethorphan|DM|149|150|DISCHARGE MEDICATIONS|5. Metoprolol 50 mg b.i.d. 6. Keppra 1000 mg b.i.d. 7. Flovent 1-2 puffs b.i.d. 8. Keflex 250 mg b.i.d. until _%#MM#%_ _%#DD#%_, 2004. 9. Robitussin DM 1-2 teaspoons q.4 hours p.r.n. 10. Lipitor 20 mg nightly. 11. Lantus 10 units nightly. 12. Sliding scale Lispro standard sliding scale.
DM|dextromethorphan|DM|173|174|MEDICATIONS|3. Status post bilateral cataract extraction with lens implant. MEDICATIONS: 1. Coumadin 2.5 mg po q day. 2. Atenolol 50 mg po q day. 3. Paxil 20 mg po q day. 4. Robitussin DM 200 mg po q4 to 6h prn. 5. Advair 250/50, one puff b.i.d. 6. Guaifenesin tablets, 1 to 2 tablets po q12h prn.
DM|dextromethorphan|DM|142|143|CURRENT OUTPATIENT MEDICATIONS|11. Tylenol Extra Strength 1 tablet every 4 hours. 12. Milk of Magnesia 30 cc p.o. daily. 13. Dioctyn 100 mg 1 tab p.o. daily. 14. Meditussin DM 100/10 per 5 cc 5 cc every 4 to 6 hours p.r.n. ALLERGIES: PREDNISONE, question of sensitivity. She appears to have been on this recently, however, at her assisted living facility.
DM|diabetes mellitus|DM|77|78|PAST MEDICAL HISTORY|4. Depression. Remained stable throughout his stay. PAST MEDICAL HISTORY: 1. DM 2. 2. History of neck injury. 3. Nephrectomy of a nonfunctional kidney. FAMILY HISTORY/SOCIAL HISTORY: Reviewed without change. See admit H&P for further details.
DM|dextromethorphan|DM|119|120|MEDICATIONS ON DISCHARGE|12. Rolaids 2 tabs p.o. q. 4 hours p.r.n. 13. Aricept 5 mg p.o. daily. 14. Toprol XL 100 mg p.o. daily. 15. Robitussin DM 2 tsp p.o. q. 4 to q. 6 hours p.r.n. 16. Albuterol nebs b.i.d. and p.r.n. 17. Mucinex 600 mg p.o. q. 12 hours. 18. Coumadin 2.5 mg on Monday, Wednesday and Friday and 1.25 mg on other days.
DM|dextromethorphan|DM|171|172|DISCHARGE MEDICATIONS|6. Lisinopril 20 mg p.o. daily. 7. Protonix 40 mg p.o. daily. 8. Albuterol MDI 2 puffs q. 4 hours p.r.n. shortness of breath. 9. Doxepin 25 mg p.o. q. h.s. 10. Robitussin DM 10 mL p.o. q. 4 hours p.r.n. cough. 11. Advair 1 puff b.i.d. 12. Combivent 2 puffs q.i.d. HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old male who came in with worsening cough.
DM|diabetes mellitus|DM|272|273|PAST MEDICAL HISTORY|REVIEW OF SYSTEMS: Rest of constitutional, eyes, ears, nose, mouth, throat, respiratory, cardiovascular, GI, GU, musculoskeletal, neurologic, endocrine, hematologic, lymphatic and psychiatric review of systems otherwise negative. PAST MEDICAL HISTORY: 1. Hypertension. 2. DM 2 with diabetic neuropathy and retinopathy. The patient unclear as to his hemoglobin A1C. 3. Depression, anxiety and PTSD. 4. Tobacco use. 5. Chronic wound posterior heel, right foot.
DM|diabetes mellitus|(DM)|280|283|ASSESSMENT/PLAN|Will also treat his tinea pedis with Mycostatin. The patient with multiple risk factors for peripheral vascular disease and Vascular Surgery consult is pending. The patient may benefit from eventual TCU placement for full recovery/wound healing. 2. Uncontrolled diabetes mellitus (DM) 2. The patient states he has labile blood sugars and unknown hemoglobin A1C. Will check hemoglobin A1C. Hold his metformin for now. Continue his other chronic medications and place on aggressive insulin sliding scale.
DM|dextromethorphan|DM|135|136|HISTORY OF PRESENT ILLNESS|9. Vitamin C 500 mg b.i.d. 10. Glucose/Chondroitin 500/400 one b.i.d. 11. Mucinex 1 b.i.d. 12. Metoprolol 100 mg b.i.d. 13. Robitussin DM 2 t. at bedtime. 14. Cipro 500 mg b.i.d. through _%#MM#%_ _%#DD#%_, 2005. 15. Dulcolax suppository daily as needed. 16. Cepacol lozenge p.r.n.
DM|dextromethorphan|DM|160|161|DISCHARGE MEDICATIONS|5. Megase 40 mg daily. 6. Multivitamins daily. 7. Spiriva two inhalations from one capsule daily. 8. Xanax 0.25 mg daily. 9. Vicodin one tablet. 10. Robitussin DM q.4-6 hours p.r.n. DISCHARGE INSTRUCTIONS: She was advised to follow up with me in a week and with Pulmonary in a couple of weeks.
DM|diabetes mellitus|DM|324|325|PAST MEDICAL HISTORY|The patient does have a baseline chronic renal insufficiency with a creatinine of 1.8. After discussing the risks and benefits of the procedures the patient decided to undergo the procedure. PAST MEDICAL HISTORY: 1. Status post 4-vessel coronary artery bypass graft in _%#MM2005#%_. 2. Postoperative atrial fibrillation. 3. DM type 2. 4. Chronic obstructive pulmonary disease. 5. Peripheral vascular disease. 6. Hypertension since 2002. 7. CVA in 2002, no residual deficits.
DM|diabetes mellitus|DM|129|130|PAST MEDICAL HISTORY|The patient also denied hematuria, dysuria, or hematochezia. PAST MEDICAL HISTORY: 1. Asthma. 2. Migraines. 3. Hiatal hernia. 4. DM type 2. 5. Hypertension. 6. Fatty liver. 7. Bipolar affective. 8. Dysfunctional uterine bleeding. 9. Hypercholesterolemia. 10. Depressive disorder. 11. Lupus with arthritis.
DM|dextromethorphan|DM,|144|146|DISCHARGE MEDICATIONS|Enzymes were negative. EKG did show first degree AV block. DISCHARGE MEDICATIONS: 1. Zithromax 250 mg p.o. q.d. for two more days. 2. Phenergan DM, one teaspoon q. 4 h. p.r.n. cough. 3. Tessalon 200 mg p.o. t.i.d. 4. Atenolol 25 mg p.o. b.i.d. 5. Lasix 40 mg p.o. q. day. 6. Insulin 25 mg subcu q.a.m. Regular insulin p.r.n. for home sliding scale.
DM|diabetes mellitus|DM|100|101|PAST MEDICAL HISTORY|2. Hyperlipidemia. 3. BPH. 4. GERD. 5. Status post appy. The patient denies past medical history of DM or hypertension. FAMILY HISTORY: Negative for CAD. SOCIAL HISTORY: Single, nonsmoker, office worker, has 1-2 drinks per day.
DM|diabetes mellitus|DM|369|370|HISTORY OF PRESENT ILLNESS|3. Cholecystectomy. HISTORY OF PRESENT ILLNESS: This is a 54-year-old woman with morbid obesity and related sleep apnea, diabetes, and lymphedema who has been evaluated at Fairview University Medical Center and has been scheduled for gastric banding and cholecystectomy. PAST MEDICAL HISTORY: 1. PE in _%#MM#%_ of 2001 after a hysterectomy. 2. Sleep apnea, on CPAP. 3. DM type 2. 4. Asthma. 5. DJD of the knees. 6. She is a G2, P2. PAST SURGICAL HISTORY: 1. Carpal tunnel on the right.
DM|dextromethorphan|DM|132|133|DISCHARGE MEDICATIONS|2. Albuterol inhaler 2 puffs twice a day to 4 times a day and p.r.n. every 1-12 hours. 3. Albuterol nebs twice a day. 4. Robitussin DM cough syrup 1 teaspoon every 4 hours as needed. 5. Her home meds, Effexor XR 75 mg 1 capsule daily. 6. Rhinocort nasal spray once a day. 7. Lotrel 5/20 one capsule a day.
DM|dextromethorphan|DM|176|177|DISCHARGE MEDICATIONS|18. Terazosin 1 mg p.o. q.p.m. 19. Allopurinol 100 mg p.o. daily. 20. Metoprolol 50 mg p.o. b.i.d. 21. Colace 100 mg p.o. b.i.d. 22. Epoetin 10,000 units per week. 23. Humibid DM 1 capsule b.i.d. for cough, and he will take for 1 week. 24. Dilaudid 2 mg p.o. q.4 to 6 h. p.r.n. for pain.
DM|dextromethorphan|DM|408|409|DISCHARGE MEDICATIONS|DISCHARGE DIAGNOSIS: Asthmatic bronchitis. DISCHARGE MEDICATIONS: Prednisone 60 mg daily, 3 days/40 mg, 3 days/20 mg, 3 days,/10 mg, 3 days/discontinue; DuoNebs (albuterol 2.5 mg, Atrovent 0.5 mg - new prescription for her) nebulize 4 times a day; Zoloft 100 mg once a day; Lyrica 75 mg once a day; Advair Disk inhaler 500/50 one puff twice a day; Ambien 10 mg one at bedtime as needed for sleep; Robitussin DM 2 teaspoons 4 times a day. COURSE IN HOSPITAL: This patient who has had a history of asthmatic bronchitis since a teenager was hospitalized for the first time in the last couple of years because of increasing shortness of breath.
DM|dextromethorphan|DM|178|179|CURRENT MEDICATIONS|12. Status post bunion removal bilaterally. ALLERGIES: 1. Penicillin. 2. Sulfa. 3. Tetracycline. 4. Codeine. CURRENT MEDICATIONS: 1. Metoprolol 25 mg 1 p.o. daily. 2. Robitussin DM 1 to 2 teaspoons by mouth p.r.n. every 4 to 6 hours. 3. Nitroglycerin spray, 1 spray onto or under tongue p.r.n. for chest pain.
DM|diabetes mellitus|DM.|207|209|SURGERIES|2) CIDP. Stable. 3) Anemia. Multifactorial. Dysfunctional uterine bleeding on medroxyprogesterone with long-term excessive menstrual losses. Iron supplementation. Also, plasmapheresis can lead to anemia. 4) DM. Low sugar this am. Otherwise good control.
DM|dextromethorphan|DM|197|198|DISCHARGE MEDICATIONS|2. Albuterol nebulizer 2.5/3 ml inhaled q.3-4 hours p.r.n. 3. Levaquin 750 mg p.o. daily for 2 more days. 4. Protonix 20 mg p.o. daily. 5. Prednisone 60 mg p.o. daily for 1 more day. 6. Robitussin DM 10 ml q.4-6 hours p.o. p.r.n. 7. Tylenol 500 mg 1-2 tablet p.o. q.6 hours p.r.n. ALLERGIES: No known drug allergies.
DM|dextromethorphan|DM|135|136|TRANSFERRING MEDICATIONS|8. Status post right carpal tunnel release. 9. History of spinal stenosis and dextroscoliosis. TRANSFERRING MEDICATIONS: 1. Robitussin DM 5 mL p.o. q.4 h. p.r.n. cough. 2. Lexapro 20 mg p.o. daily. 3. Colace 100 mg p.o. q.h.s. 4. Neurontin 100 mg p.o. q.h.s. 5. Trazodone 100 mg p.o. q.h.s.
DM|diabetes mellitus|DM|160|161|ASSESSMENT/PLAN|Continue to monitor her progress. Will start antibiotics empirically for possible left lower lobe infiltrate. 5. Endocrine. Hypothyroidism, continue Synthroid. DM II, continue insulin. 6. ID. Fever. Possibly a left lower lobe infiltrate on x-ray. However, could also be bronchitis as the x-ray was read as clear by radiologist.
DM|dextromethorphan|D.M.|141|144|NURSING HOME MEDICATIONS|7. Advair Diskus 250/50 1 puff b.i.d. 8. Ambien 2 mg p.o. q.h.s. 9. Klonopin 1 mg p.o. t.i.d. 10. Effexor XL 300 mg p.o. q.d. 11. Robitussin D.M. 5 to 10 cc p.o. q.h.s. 12. KCL 40 mEq p.o. b.i.d. 13. Prevacid 30 mg p.o. q.d. 14. Remeron 30 mg p.o. q.h.s.
DM|diabetes mellitus|DM|180|181|PAST MEDICAL HISTORY|1. CAD, status post cath _%#DDMM2003#%_. Circumflex and its branches with diffuse disease RCA 90% proximal stenosis, normal left ventricular function, status post stent of RCA. 2. DM II. 3. Hypertension. 4. Depression. 5. Obesity. 6. Plantar callus seen by Dr. _%#NAME#%_, podiatry, and at last admission by Dr. _%#NAME#%_ in Ortho.
DM|dextromethorphan|DM|189|190|HOSPITAL COURSE|Her white count returned to normal. The patient had continued persistent cough and right-sided pain thought to be related to pleurisy. She was given Percocet for pain as well as Robitussin DM for her cough. She had relief with these medications. She will be sent home with 60 pills of Percocet as well as 150 cc of Robitussin DM for persistent cough and right-sided chest pain.
DM|dextromethorphan|DM|119|120|HOSPITAL COURSE|She had relief with these medications. She will be sent home with 60 pills of Percocet as well as 150 cc of Robitussin DM for persistent cough and right-sided chest pain. She will continue on gatifloxacin for a course of 10 more days following discharge.
DM|dextromethorphan|DM|190|191|DISCHARGE MEDICATIONS|These tests were both negative. DISCHARGE MEDICATIONS: 1. Gatifloxacin 400 mg p.o. q.d. x10 days. 2. Percocet 60 pills prescribed 1 to 2 pills p.o. q. 6h. p.r.n. for pleurisy. 3. Robitussin DM 1 tsp. every four to six hours p.r.n. for cough. She was given 150 cc of Robitussin DM. PLAN: She is to follow up with her primary care physician in one week or sooner if her symptoms progress.
DM|dextromethorphan|DM|152|153|PLAN|PLAN: 1. Admit to Medicine. 2. Sputum culture and sensitivity. 3. Start Zithromax. 4. IV steroids. 5. Albuterol/Atrovent by nebulization. 6. Robitussin DM for cough. 7. O2 to keep sat greater than or equal to 90%. 8. Review chest x-ray with radiologist. 9. Empiric Prevacid for intermittent epigastric discomfort, possibly acid peptic in origin.
DM|dextromethorphan|DM|166|167|DISCHARGE MEDICATIONS|9. Combivent inhaler, two puffs q.i.d. 10. Vicodin, one or two every six hours p.r.n. 11. MiraLax 17 grams mixed with water daily p.r.n. constipation. 12. Robitussin DM 10 cc q. 4 h. p.r.n. FOLLOW-UP PLAN: Follow-up will be in the _%#CITY#%_ _%#CITY#%_ Dialysis Unit where he will dialyze on Mondays, Wednesdays and Fridays.
DM|dextromethorphan|DM|120|121|DISCHARGE MEDICATIONS|2. Prinivil 5 mg po q d. 3. Levoxyl .05 mg po q d. 4. Prozac 10 mg po q d. 5. Iron Sulfate 240 mg po q d. 6. Robitussin DM 2 tsp po q 4-6 hours prn cough or congestion. 7. Tylenol 1-2 tablets po q 4 hour prn. DISPOSITION: Patient will be discharged to a TCU for her PT, OT rehab given her significant weakness and deconditioning.
DM|dextromethorphan|DM|568|569|DISCHARGE MEDICATIONS|Medication was considered, but it was not something he needed and actually on the day of discharge, his blood pressure has been within normal limits throughout the night. DISCHARGE MEDICATIONS: Include albuterol metered dose inhaler two puffs every 4-6 hours as needed for shortness of breath and cough, Advair 500/50 one puff p.o. b.i.d., Singulair 10 mg p.o. q day, prednisone 40 mg p.o. q day times three days, 20 mg p.o. q day times three days, and 10 mg p.o. q day times six days, Robitussin AC 1-2 tsp every 4-6 hours as needed for cough at night and Robitussin DM 1-2 tsp p.o. every 4-6 hours as needed for cough during the daytime. The patient is to follow-up for evaluation of the PPD in _%#CITY#%_ _%#CITY#%_ Health Partners Clinic on the nurse schedule tomorrow if it cannot be read prior to his discharge today.
DM|diabetes mellitus|DM|149|150|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: 1. Atypical chest pain most likely related to GERD. 2. Renal cell carcinoma with metastases. 3. History of DVT. 4. Uncontrolled DM 2. 5. Pancreatic cancer. 6. Hypertension. PROCEDURE PERFORMED DURING THIS ADMISSION: 1. Stress thallium dated _%#MMDD2006#%_. Formal report is still pending at time of discharge dictation.
DM|diabetes mellitus|DM|183|184|HOSPITAL COURSE|The infection should be reevaluated by her primary care provider Dr. _%#NAME#%_ _%#NAME#%_ next week. Her course of antibiotics may be adjusted based on her response. 2. Uncontrolled DM type 2: The patient was fairly hyperglycemic in the 300 to 400 range during her admission. This was likely attributed to infection. Her glycemic control improved in the 24 to 48 hours prior to discharge.
DM|dextromethorphan|DM,|158|160|MEDICATIONS|5. Prednisone 5 mg every other day. 6. Lasix 20 mg daily. 7. Senna, one as needed p.r.n. 8. Albuterol nebs p.r.n. 9. Anusol suppository p.r.n. 10. Robitussin DM, 1 tsp p.o. p.r.n. 11. Tramadol 50 mg, 1/2 tab p.o. q day. 12. Nitroglycerin sublingually, one p.r.n. for chest pain.
DM|dextromethorphan|DM|131|132|DISCHARGE MEDICATIONS|4. Astelin 1 spray to each nostril daily. 5. Miacalcin 1 spray daily alternating nostrils. 6. Digoxin 125 mcg daily. 7. Robitussin DM OTC 1-2 teaspoons q.6.h. p.r.n. cough. 8. Ensure one bottle daily. 9. Timoptic 1 drop to each eye q.a.m. 10. Timolol 0.25 eye drop, 1 drop to each eye daily.
DM|dextromethorphan|DM|147|148|CURRENT MEDICATIONS|13. Colace 100 mg p.o. b.i.d. (hold for diarrhea). 14. Imodium AD 2 mg q.i.d. p.r.n. for diarrhea. 15. Calcium Plus D 500 mg t.i.d. 16. Robitussin DM 10 cc q.i.d. 17. Multivitamin with minerals, one p.o. q.d. 18. Foradil 12 mcg b.i.d. 19. Combivent two puffs q.i.d. 20. Serevent discus, one discus twice daily.
DM|dextromethorphan|DM|168|169|DISCHARGE MEDICATIONS|His symptoms gradually improved and he reported feeling able to go home on the _%#DD#%_. DISCHARGE MEDICATIONS: Augmentin 875 mg p.o. b.i.d. for eight days, Robitussin DM one to two teaspoons p.o. q.6.h. p.r.n., albuterol metered dose inhaler two puffs q.4.h. p.r.n., enteric coated 81 mg p.o. q day, Zocor 40 mg p.o. q day, and Aciphex 20 mg p.o. q day.
DM|dextromethorphan|DM|167|168|DISCHARGE MEDICATIONS|Coumadin had been discontinued in the past. Her hemoglobin is stable x 48 hours following her transfusion, which she tolerated well. DISCHARGE MEDICATIONS: Robitussin DM 5 ml p.o. q.i.d. p.r.n. cough, Xanax 0.25 mg q. 8 hours p.r.n., Zoloft 100 mg q. day, Imdur 90 mg p.o. q. day (new dose, up from 30 mg q. day), digoxin 0.125 mg p.o. q. day, Cozaar 50 mg p.o. q. day, Demadex 20 mg p.o. b.i.d.
DM|diabetes mellitus|(DM)|111|114|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. GI bleed. 2. Aspiration pneumonia. 3. Alcohol abuse. 4. Uncontrolled diabetes mellitus (DM) 2. 5. Staphylococcus epidermidis line infection. 6. Thrush. 7. Encephalopathy with persistent cognitive deficits.
DM|diabetes mellitus|DM|218|219|HOSPITAL COURSE|3. Alcoholic intoxication and abuse. The patient admitted in florid withdrawal. Psychiatry was consulted and they are currently pursuing commitment proceedings due to patient's self-injurious behavior. 4. Uncontrolled DM 2. The patient is currently on NPH, as well as regular insulin sliding scale with stable blood sugars at this point.
DM|dextromethorphan|DM|188|189|DISCHARGE MEDICATIONS|2. Tessalon Perles 1 tablet p.o. q.8h. for cough. 3. Albuterol 2 puffs q.i.d. p.r.n. to be used before going out in cold air. 4. Advair 1 puff b.i.d., rinse mouth after use. 5. Robitussin DM 5 to 10 mL p.o. t.i.d. FOLLOW UP: The patient is to have followup with Dr. _%#NAME#%_ next week.
DM|dextromethorphan|DM|159|160|DISCHARGE MEDICATIONS|11. Neurontin 300 mg p.o. t.i.d. 12. Ambien 5 mg p.o. each day at bedtime p.r.n. insomnia. 13. Imodium 1-2 tablets p.o. q.6 h. p.r.n. diarrhea. 14. Robitussin DM taken by mouth p.o. q.4 h. p.r.n. cough. 15. Vicodin 1 tablet p.o. q. 6 h. p.r.n. pain. 20 pills, no refill.
DM|diabetes mellitus|DM|179|180|FAMILY|SOCIAL: h/o ETOH abuse, stopped drinking about _%#MM2006#%_. Quit tobacco about 1 year ago, 10 PY history. No IVDU. Divorced, has one son. FAMILY: Father: PE, ETOH abuse. Mother: DM ROS: As above in HPI, o/w denies F/C, N/V, dysphagia, heartburn, CP, SOB, cough, numbness/tingling.
DM|diabetes mellitus|DM|192|193|HOSPITAL  COURSE|4. Diabetes mellitus. The patient was given a new diagnosis of diabetes this admission. It was noted that he was hyperglycemic on admission. Although the patient's age would indicate possible DM type 2, on review of labs it was noted the patient had ketones in his blood and urine, which would be atypical for type 2 DM.
DM|diabetes mellitus|DM.|229|231|HOSPITAL  COURSE|It was noted that he was hyperglycemic on admission. Although the patient's age would indicate possible DM type 2, on review of labs it was noted the patient had ketones in his blood and urine, which would be atypical for type 2 DM. It is possible he also has type 1 DM. Therefore patient will be discharged on insulin to cover for this possibility.
DM|diabetes mellitus|DM.|267|269|HOSPITAL  COURSE|It was noted that he was hyperglycemic on admission. Although the patient's age would indicate possible DM type 2, on review of labs it was noted the patient had ketones in his blood and urine, which would be atypical for type 2 DM. It is possible he also has type 1 DM. Therefore patient will be discharged on insulin to cover for this possibility. Noteably, he needed a small amount of insulin to correct his hyperglycemia, also more consistent with type 1 DM.
DM|dextromethorphan|DM|122|123|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1. Keflex 500 mg b.i.d. for one week. 2. Vicodin 1-2 tabs p.o. q three hours prn pain. 3. Robitussin DM prn cough. 4. Glucotrol 5 mg p.o. b.i.d. 5. Catapres 0.1 mg p.o. q h.s. 6. Caltrate 600 plus D one tab daily.
DM|dextromethorphan|DM|173|174|HOSPITAL COURSE|HOSPITAL COURSE: The patient was started on IV gatifloxacin. Albuterol nebs were used p.r.n. for wheezing. She was also on supplemental oxygen per nasal cannula. Robitussin DM was used to treat her cough. She was also IV rehydrated. The patient did well with the above-mentioned treatments, and she improved within two days.
DM|dextromethorphan|DM|129|130|DISCHARGE MEDICATIONS|9. Tylenol 500 mg p.o. q. 6h. p.r.n. low back pain. Limit p.r.n. and routine Tylenol to 4 gm in a 24-hour period. 10. Robitussin DM 5 mL p.o. q. 4h. p.r.n. cough. ALLERGIES: Codeine. DISCHARGE PLANS: 1. The patient's discharge is planned for Friday, and he will return to his assisted living setting.
DM|dextromethorphan|DM|247|248|DISCHARGE MEDICATIONS|4. Hypertension. 5. Hyperlipidemia. 6. Osteoarthritis. 7. Possible depression, although the patient denies during this hospitalization. DISCHARGE MEDICATIONS: 1. Azithromycin 250 mg p.o. on _%#MMDD#%_ and _%#MMDD#%_ then discontinue 2. Robitussin DM 2 Tbsp p.o. q 6 hours p.r.n. cough 3. Tessalon Perles 100 mg p.o. b.i.d. times three days 4. Toprol XL 150 mg p.o. q day 5. Lipitor 10 mg p.o. q day
DM|dextromethorphan|DM|208|209|LABORATORY DATA|Her primary symptom was cough. It was suspected that she had a viral bronchitis. She was taken off the ceftriaxone on the day of discharge and will complete a course of azithromycin. She was given Robitussin DM and Tessalon Perles for symptomatic treatment of her cough. She was advised to follow up for any further problems. Her O2 sat had been low on admission, requiring oxygen.
DM|dextromethorphan|DM|320|321|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: 1. The patient is to continue home antibiotics with Zosyn 3.375 gm q.6h. for a total of 10 days (through _%#MMDD2005#%_). 2. Continue all previous medications with the addition of Zosyn, as mentioned above, Abreva to be applied topically to herpes simplex lesions above the upper lip, Robitussin DM 1-2 teaspoons p.o. q.4-6h. p.r.n. cough, and Diflucan 150 mg p.o. daily through _%#MMDD2005#%_. 3. The patient is to continue at home with home oxygen and nebulizers as needed (he has been on these chronically).
DM|diabetes mellitus|DM|181|182|FAMILY HISTORY|3. Bilateral inguinal hernia repair, _%#MM2001#%_. 4. Tobacco abuse disorder, has tried quitting multiple times. FAMILY HISTORY: Father and mother died of CAD. No family history of DM 2. SOCIAL HISTORY: The patient is here with her best friend, as she drinks very rare alcohol.
DM|dextromethorphan|DM|148|149|MEDICATIONS|6. History of left femoral fracture. MEDICATIONS: 1. Novalog insulin, sliding scale 2. Lantus insulin 100 units subcutaneously q h.s. 3. Robitussin DM p.r.n. 4. Tylenol p.r.n. 5. Avandia 4 mg p.o. q h.s. 6. Betimol 0.5% drops, one drop both eyes 7. Multivitamins one p.o. q day
DM|dextromethorphan|DM|150|151|MEDICATIONS|15. Loperamide 2 mg p.o. q. hour p.r.n. diarrhea, not to exceed 16 mg in 24 hours. 16. Ranitidine 150 mg p.o. b.i.d. p.r.n. gastritis. 17. Robitussin DM 10 mg p.o. q.4 hours p.r.n. cough. 18. Diphenhydramine 50 mg p.o. q.4 hours p.r.n. itching. 19. 2% viscous lidocaine 5 mL p.o. q.6 hours p.r.n. pain by mouth.
DM|dextromethorphan|DM|138|139|DISCHARGE MEDICATIONS|Discharge condition - satisfactory. DISCHARGE MEDICATIONS: 1. Vitamin B12 1000 mcg p.o. daily 2. Folic acid 1 mg p.o. daily 3. Robitussin DM 5 ml every 4 hours p.r.n. cough 4. Hydrochlorothiazide lisinopril 15/12.5 mg p.o. daily 5. Maalox 30 ml every 4 hours as needed for stomach upset
DM|diabetes mellitus|DM|243|244|1) N/V|1) N/V: Most likely secondary to Gastroparesis - continues to be a problem as she is not tolerating her PO meds as well. On IV ativan and remeron zydis, and does not tolerate any other antiemetics. The etiology is multifactorial involving CF, DM and narcotics. The narcotics being the only reversible factor. The possible factor that could be playing a role is DIOS and she is willing to drink golytely today.
DM|dextromethorphan|DM|266|267|DISCHARGE INSTRUCTIONS|The patient agreed with discontinuing the Synthroid since previous TSH was normal prior to her fever and stress illness and then on recheck the TSH was also normal. She will get a followup TSH in 1 month. DISCHARGE INSTRUCTIONS: DISCHARGE MEDICATIONS: 1. Robitussin DM 10 mL p.o. q. 4h p.r.n. cough. 2. Claritin 10 mg p.o. q. day p.r.n. allergies. 3. Multivitamin 15 mL p.o. daily.
DM|diabetes mellitus|DM.|158|160|HOSPITAL COURSE|This was covered with IV Ancef. Given persisiten urinary symptoms, will change to levofloxacin upon discharge. During the stay the patient was diagnosed with DM. She was started on glipizide. Hgb A1C as 6.8. On admission the patient was found to have a supratherapeutic INR of 4.82. Her Coumadin was held and this was allowed to drop.
DM|dextromethorphan|DM|219|220|MEDICATIONS|7. I believe that she has had an echocardiogram in the last year or two, which was poor quality, but did suggest pulmonary hypertension. 8. GERD. 9. Peptic ulcer disease. MEDICATIONS: (At the nursing home). 1. Guaituss DM 30 cc at bedtime. 2. KCl 40 mEq twice a day. 3. Adalat 60 mg twice a day. 4. OxyContin now down to 10 mg at hs only.
DM|dextromethorphan|DM|199|200|PROBLEMS|5. On hospital day #2, postop day #2, the patient was tolerating clears, voiding, and ambulating. She had a cough at 4 a.m. lasting 15 minutes with pain at the incision site. She received Robitussin DM and Cepastat lozenges for the cough, which improved her symptoms. On postoperative day #2, her IV was Hep-Locked, and she was ambulating t.i.d. and using incentive spirometry.
DM|diabetes mellitus|(DM)|254|257|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Acute myocardial infarction, status post percutaneous transluminal coronary angioplasty (PTCA) and stent right coronary artery (RCA). 2. Congestive heart failure (CHF) exacerbation. 3. Pneumonia. 4. Uncontrolled diabetes mellitus (DM) 2. 5. Acute renal insufficiency. 6. Atrial fibrillation. PROCEDURES DONE DURING THIS ADMISSION: 1. Chest x-ray _%#MMDD2004#%_ showing left hemidiaphragm with hazy appearance and retrocardiac pulmonary infiltrate.
DM|diabetes mellitus|DM|130|131|PAST MEDICAL HISTORY|He was started on amiodarone and is currently at sinus rhythm at the time of discharge. PAST MEDICAL HISTORY: 1. Hypertension. 2. DM 2. 3. Hyperlipidemia. 4. Dementia. FAMILY HISTORY/SOCIAL HISTORY: Reviewed without change. See admit H&P for further details.
DM|dextromethorphan|DM,|158|160|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Tequin, 200 mg p.o. q. day times 8 days. 2. Effexor XR, 75 mg p.o. q. day. 3. Albuterol nebs, q. 4 hours while awake. 4. Robitussin DM, 1-2 teaspoons p.o. q. 6 hours p.r.n. 5. Tylenol, 650 mg p.o. q. 6 hours p.r.n. 6. Senna, 2 p.o. q.h.s. p.r.n. 7. Aspirin, 81 mg p.o. q. day.
DM|dextromethorphan|DM|162|163||She was seen in the emergency room and diagnosed with pneumonia. She was given an Albuterol nebulization treatment there and treated with Levaquin and Robitussin DM since then. She got a little better, but then progressively got worse and feels quite weak and short of breath, gasping for air frequently and feels more ill today than when first seen in the emergency room.
DM|dextromethorphan|DM|175|176|HISTORY OF PRESENT ILLNESS|At bed time she takes Chlortrimeton 4 mg q at bed-time, daily Flonase two sprays in each nostril, Tessalon Pears, one every 4 hours as needed for cough, as well as Robitussin DM 5-10 cc every fours hours as needed for cough. For anxiety she takes Lorazepam 0.5 mg at bed time, as well as every 8 hours as needed for anxiety and is on Zoloft.
DM|dextromethorphan|DM|215|216|PLAN|3. She is will be started on physical therapy and occupational therapy treatment for deconditioning. 4. I will send TSH, as well as start her on IV fluids for her tachycardia. 5. I will also start her on Robitussin DM for her cough.
DM|dextromethorphan|DM|140|141|DISCHARGE MEDICATIONS|1. MSSA protocol Ativan oral. 2. Ventolin four puffs inhaled q. 4 h p.r.n. for shortness of breath. 3. Folic acid 1 mg daily. 4. Robitussin DM 15 mg p.o. q. 6 h p.r.n. for cough. 5. Protonix EC 40 mg p.o. daily. 6. Thiamin 100 mg p.o. daily. FOLLOW-UP CARE: The patient needs to be followed by University of Minnesota Medical Center, Fairview Psychiatry team for further recommendation regarding her depression and medication management.
DM|diabetes mellitus|DM|164|165|PAST MEDICAL HISTORY|9. Right carpal tunnel syndrome. 10. Bilateral cataract surgery. 11. CAD, status post PTCA _%#MM1993#%_ and _%#MM1994#%_. 12. Hypertension. 13. Osteoarthritis. 14. DM II. 15. Hyperlipidemia. FAMILY HISTORY: Mother and father passed away from CAD.
DM|dextromethorphan|DM|130|131|HISTORY OF PRESENT ILLNESS|He has had pneumonia and finished a Z-pack recently, and was started on Levaquin since Monday. He has also been taking Robitussin DM since Monday, one or two times a day. No history of atrial fibrillation. Last night he was very hot and did not sleep well.
DM|dextromethorphan|DM|274|275|DISCHARGE MEDICATIONS|Further renal evaluation depending on results of outpatient urine. Patient will be on diet and activity as tolerated regimen with return to work when he is able and feeling better. DISCHARGE MEDICATIONS: 1. Tequin 400 mg p.o. q.d. x 10 days. 2. Tylenol p.r.n. 3. Robitussin DM p.r.n.
DM|diabetes mellitus|(DM)|207|210|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Congestive heart failure (CHF) exacerbation. 2. Nasal congestion and postnasal drip. 3. Bronchitis. 4. Chronic obstructive pulmonary disease (COPD). 5. Uncontrolled diabetes mellitus (DM) 2. 6. Hyperlipidemia. 7. Coronary artery disease (CAD) with recent acute myocardial infarction (MI). 8. Tobacco use. PROCEDURES PERFORMED DURING THIS ADMISSION: 1. Echo dated _%#MMDD2005#%_ shows decreased left ventricular systolic performance, EF 32-35%, normal left ventricular cavity size, mild concentric LVH, posterior wall motion abnormality, severely hypokinetic to akinetic extending to the left ventricular apex and moderate in size inferior wall motion abnormality severely hypokinetic, left atrial enlargement mild, no clinically significant AS, mitral valve abnormality of the posterior mitral leaflet, mitral insufficiency moderately severe 3+, tricuspid insufficiency, which is trace to mild, no pulmonic stenosis, normal right ventricular systolic size and function, evidence of pulmonary hypertension, small right pleural effusion.
DM|dextromethorphan|DM|119|120|MEDICATIONS|9. Zinc 220 mcg p.o. t.i.d. 10. Lactulose 45 mL q. 8 h. 11. Pulmicort two sprays in each nostril daily. 12. Robitussin DM 15 mL p.o. q. 4 h. p.r.n. 13. Ursodiol 300 mg p.o. daily. PAST MEDICAL HISTORY: 1. End-stage liver disease secondary to primary sclerosing cholangitis secondary to ulcerative colitis.
DM|diabetes mellitus|(DM)|108|111|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Cholelithiasis. 2. Coronary artery disease (CAD). 3. Uncontrolled diabetes mellitus (DM) 2. 4. Obstructive sleep apnea. 5. Hypertension. 6. Alcoholism. 7. Gastroesophageal reflux disease (GERD). 8. Psoriasis. PROCEDURES PERFORMED DURING THIS ADMISSION: 1. CT of abdomen and pelvis, _%#MMDD2005#%_, showing diffuse fatty infiltration of liver, dense lesion, right kidney, which has the appearance of a small metallic object.
DM|diabetes mellitus|DM|234|235|HOSPITAL COURSE|Echocardiogram obtained with results per above. Also patient's records from _%#COUNTY#%_ _%#COUNTY#%_ Medical Center were also requested and have arrived just prior to discharge. The patient is currently asymptomatic. 3. Uncontrolled DM 2. While inpatient, the patient was initially NPO and his NPH dose was decreased. Currently he is stable, and he will resume his previous outpatient medications.
DM|diabetes mellitus|DM|177|178|PAST MEDICAL HISTORY|5. Delirium. The patient was admitted with acute hallucinations. Most likely this was all related to sepsis and has since resolved throughout his stay. PAST MEDICAL HISTORY: 1. DM 2 diagnosed at age 60. 2. Hyperlipidemia. 3. Left cataract surgery. 4. Osteoarthritis. 5. Varicella zoster viral infection, left groin distribution with severe post herpetic neuralgia.
DM|diabetes mellitus|DM.|159|161||He was d/c home and re-admitted for pneumonia and placed on levofloxacin. He then had elevated blood glucose and was discharged on glimipramide. He has no h/o DM. Over the next 4 days he developed intermittent confusion, urinary incontinence and mental status changes and was found to be hypoglycemic.
DM|dextromethorphan|DM|124|125|ADMISSION DIAGNOSIS|Impression was bronchitis. Bactrim double strength b.i.d. for 10 days was begun on _%#MM#%_ _%#DD#%_, 2006. Also Robitussin DM 5 to 10 mL q.6 h. p.r.n. was also ordered. She continued with the antibiotics throughout her hospital stay. On _%#MM#%_ _%#DD#%_, 2006, she had adaptation session and that was completed without incident.
DM|dextromethorphan|DM|164|165|ASSESSMENT/PLAN|I have requested a physical therapy consult. 2. Upper respiratory infection. The patient has clearly improved. We will complete a course of Bactrim. Use Robitussin DM p.r.n. 3. Asthma and allergic rhinitis. Stable. Continue current present medications. 4. Hypertension. The patient's blood pressure appears low today.
DM|dextromethorphan|DM.|132|134|CURRENT MEDICATIONS|4) Hypothyroidism. 5) Status post mitral valve replacement with St. Jude's mitral valve in 1994. CURRENT MEDICATIONS: 1) Robitussin DM. 2) Ativan 0.5 mg b.i.d. p.r.n. 3) Potassium chloride 20 Meq p.o. b.i.d. 4) Levoxyl 88 mcg p.o. q.day, two tablets on Saturday.
DM|dextromethorphan|DM|221|222|DISCHARGE MEDICATIONS|The goal will be to increase up the toprolol and lisinopril and eventually add spironolactone if he tolerates it. DISCHARGE MEDICATIONS: 1. Aspirin 82 mg p.o. every day. 2. Toprolol XL 50 mg p.o. every day. 3. Robitussin DM 10 mL p.o. every 6 hours as needed for cough. 4. Lipitor 80 mg p.o. q.h.s. 5. Zantac 150 mg p.o. b.i.d.
DM|dextromethorphan|DM|158|159|MEDICATIONS|8. Vantin 200 mg p.o. daily. 9. Diovan 40 mg p.o. daily. 10. Tylenol 650 mg p.o. q. 4-6 h p.r.n. 11. Albuterol inhaler two puffs q. 4 h p.r.n. 12. Robitussin DM 10 ml p.o. q. 4 h p.r.n. 13. Vicodin 5/500 mg p.o. one to two tablets q. 4-6 h p.r.n. 14. Milk of Magnesia 30 mg p.o. daily.
DM|dextromethorphan|DM,|198|200|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Mr. _%#NAME#%_ is a 19-year-old single Caucasian male who resides in _%#CITY#%_ _%#CITY#%_, Minnesota, with his mother and sister. His drugs of choice are marijuana, Robitussin DM, and Coricidin. He has had one previous chemical dependency treatment 2 years ago in the STOP program. He was treated at that time for marijuana dependence. He denies any history of being on antidepressants ever.
DM|diabetes mellitus|DM|231|232|FAMILY  HISTORY|PAST MEDICAL HISTORY: 1. Hypertension. 2. Occasional GERD, usually relieved with over-the-counter Pepcid. 3. Status post hysterectomy for menorrhagia. FAMILY HISTORY: Mother with DM 2 and acute MI at age 58, multiple siblings with DM 2, father with a CABG at age 76 and passed away from bladder cancer. SOCIAL HISTORY: Married, no tobacco, no alcohol, 5 children. She was currently on her way to a conference in a different state and has flight scheduled for later today.
DM|dextromethorphan|DM|295|296|HOSPITAL COURSE|N-terminal proBNP was slightly up at 1220. Thyroid function was normal with TSH of 0.99. The thinking was that she had a one-time episode of accelerated hypertension that rapidly resolved with one dose of clonidine. It may have been related to her recent use of both nasal sprays and Robitussin DM for upper respiratory infection. She had no history of coronary disease, strokes, peripheral vascular disease, but does have a longstanding history of diabetes, so she is at risk for renovascular hypertension.
DM|dextromethorphan|DM|145|146|HOME MEDICATIONS|3. Digoxin 0.125 mg daily. 4. Potassium chloride 20 mEq daily. 5. Lasix 80 mg b.i.d. 6. Lescol 40 mg daily. 7. Lisinopril 5 mg daily. 8. Mucinex DM 2 tablets in am and p.m. p.r.n. and Mucinex DM 1 tablet daily and at bedtime. 9. Nasonex 2 sprays in each nostril daily.
DM|diabetes mellitus|DM|140|141|STAFF ADDENDUM NOTE|Morbid obesity. Heart regular, no murmur. Lungs clear, no crackles. Abdomen soft, non-tender. Skin clear. Assessement New diagnosis type II DM with non-ketotic, hyperosmolar, hyperglycemia. Plan Aggressive IVF rehydration. Follow blood glucose and osmolarity levels.
DM|diabetes mellitus|DM|226|227|STAFF ADDENDUM NOTE|Abdomen soft, non-tender. Skin clear. Assessement New diagnosis type II DM with non-ketotic, hyperosmolar, hyperglycemia. Plan Aggressive IVF rehydration. Follow blood glucose and osmolarity levels. Endocrine consultation for DM management. Initiate insulin therapy per endocrine. DM teaching and training.
DM|diabetes mellitus|DM|159|160|STAFF ADDENDUM NOTE|Plan Aggressive IVF rehydration. Follow blood glucose and osmolarity levels. Endocrine consultation for DM management. Initiate insulin therapy per endocrine. DM teaching and training.
DM|diabetes mellitus|DM,|209|211|DISCHARGE MEDICATIONS|4. Zydis 5 mg sublingual q.h.s. p.r.n. agitation. 5. Lasix 20 mg via G-tube daily. 6. Sorbitol 70% solution 15-mL via G-tube daily. 7. Tramadol 50 mg p.o. q.i.d. p.r.n. The patient was placed back on ReSource DM, however, it was felt that he would meet his calorie needs better if he were on 70-mL/hour for 24 hours continuously.
DM|dextromethorphan|DM.|157|159|DISCHARGE DIAGNOSES|Furosemide 40 mg a day. 3. Diovan 320 a day. 4. Toprol XL 100 a day. 5. Cleocin 150 t.i.d. for five days. 6. Zantac 150 daily. 7. Allegra 180. 8. Robitussin DM. 9. Mirapex 1 1/2 tabs as needed for restlessness. 10. Roxanol 5/20 mg sublingual as needed. 11. Imdur 120 a day. The patient presented to Southdale with signs and symptoms of progressive congestive heart failure.
DM|diabetes mellitus|DM|209|210|HOSPITAL COURSE|2. He had mild increase in shortness of breath and received transient diuresis. Otherwise he was maintained on his chronic oral medications and is currently euvolemic at the time of discharge. 3. Uncontrolled DM 2. The patient was placed on Lantus. Is currently also being covered with regular insulin sliding scale, and blood sugars are currently stable.
DM|dextromethorphan|DM,|124|126|DISCHARGE MEDICATIONS|6. K-Dur 20 mEq p.o. daily. 7. Tylenol 500 mg p.o. q.4-6 h. p.r.n. pain, not to exceed 4 g in 24-hour period. 8. Robitussin DM, a tablespoon p.o. q.6 h. as needed for cough. 9. Ambien 5 mg p.o. nightly as needed. 10. Mylicon 160 mg p.o. twice daily as needed.
DM|dextromethorphan|DM|123|124|DISCHARGE MEDICATIONS|2. Trazodone 150 mg p.o. nightly for insomnia. 3. Cefepime 500 mg p.o. b.i.d. finish after 10 days of using. 4. Robitussin DM 10 mg p.o. to take q.6-8 h. p.r.n. cough. DISCHARGE DIET: As tolerated. DISCHARGE ACTIVITY: Ad lib.
DM|dextromethorphan|DM|157|158|ADDENDUM|13. Insulin NovoLog sliding scale. 14. Flovent 220 mcg one puff b.i.d. 15. One Touch Glucometer. 16. One Touch Strips. 17. One Touch Lancets. 18. Robitussin DM 1 tablet p.o. q.6 h. p.r.n.
DM|diabetes mellitus|DM|145|146|HPI|Pt has no concerns or complaints. He feels well. His last chest pain episode was over a month ago, he previously has had a normal angiogram. His DM is well controlled. Hospital Course: 1) Post-operative course: Pt had no difficulties overnight.
DM|diabetes mellitus|DM.|244|246|IMPRESSION|I would with his hypotension keep him at this time on antibiotic coverage, awaiting the culture and the repeat a chest x-ray tomorrow, and the official reading on the x-ray done tonight by the radiologist. 6. Dehydration. Likely from new onset DM. PLAN: 1. Would admit him to the Intensive Care Unit because he is on dopamine at this time and we cannot wean off the dopamine without his pressure dropping in the low 70s.
DM|diabetes mellitus|DM|292|293|DISCHARGE FOLLOWUP|She was a 2000 gm, 33 + 6/7 week gestational age female infant born at Fairview-_%#CITY#%_ in _%#CITY#%_, MN to a 43-year-old, B positive, gravida G3, para 0-0-2-0, divorced white female whose LMP was _%#MMDD2006#%_ and whose EDC was _%#MMDD2006#%_. The mother's pregnancy was complicated by DM type 2, chronic back pain with use of Vicodin, and PIH. The infant was delivered by cesarean section with Apgar scores of 4 at one minute and 9 at five minutes.
DM|dextromethorphan|DM|197|198|DISCHARGE MEDICATIONS|1. Levaquin 250 mg daily through _%#MMDD2007#%_. 2. Sinemet 25/100 one in the a.m., one-half in the afternoon, one-half at bedtime. 3. Mirapex 0.25 mg t.i.d. 4. Detrol LA 4 mg daily. 5. Robitussin DM 1-2 teaspoons q.i.d. p.r.n. 6. Senokot-S one daily for constipation. 7. Milk of Magnesia. 8. Fleets enema p.r.n. TIME SPENT ON DISCHARGE: Greater than one-half hour spent with discharge management.
DM|diabetes mellitus|DM|190|191|PAST MEDICAL HISTORY|No chest pain. Otherwise overall essentially negative review of systems. ALLERGIES: No known drug allergies. PAST MEDICAL HISTORY: 1. Ascites/anasarca with hepatorenal sclerosis. 2. ARF. 3. DM 5-6 years ago diagnosis. 4. Hypothyroidism. 5. Enterococcal UTI/VRE. FAMILY HISTORY: Father deceased at 64 secondary to complications of diabetes.
DM|diabetes mellitus|DM|155|156|PAST MEDICAL HISTORY|The patient is not sure how long this has been ongoing. 3. Chronic renal insufficiency with baseline creatinine 1.9 to 2.4. 4. Hypertension. 5. History of DM type II diagnosed 1999. Recent glycohemoglobin 6.4. 6. Hypercholesterolemia. 7. Elevated PSA. 8. History of gout. 9. Status post chole. ALLERGIES: He has no known drug allergies. MEDICATIONS: 1. Coumadin 2.5 mg Monday, Wednesday, Friday and 5 mg Tuesday, Thursday, Saturday, Sunday.
DM|dextromethorphan|DM|183|184|DISCHARGE MEDICATIONS|10. Diltiazem CR 180 mg p.o. daily. 11. Cosopt one drop into each eye daily. 12. Lasix 80 mg p.o. daily. 13. Glucotrol 10 mg p.o. q.a.m. 14. Mucinex 600 mg p.o. daily. 15. Robitussin DM 10 ml p.o. q.h.s. p.r.n. 16. Lorazepam scheduled 1 mg p.o. three times a day and 0.5 mg q6h as needed. 17. Protonix 20 mg p.o. daily. 18. Paxil 60 mg p.o. daily.
DM|diabetes mellitus|DM,|234|236|HOSPITAL COURSE|CONSULTATIONS: Nephrology. HOSPITAL COURSE: Mr. _%#NAME#%_ is a 64-year-old WM with multiple medical problems as delineated above, including CAD - status post stenting in 2004 by Dr. _%#NAME#%_, hypertension, type 2 insulin requiring DM, hyperlipemia who was admitted to University of Minnesota Medical Center, Fairview on _%#MMDD2007#%_ for hyperkalemia. He had presented to his PCP on _%#MMDD2007#%_ for a preoperative evaluation in anticipation of ENT surgery (per patient has a history of recurrent/chronic otitis media for which he had ventilation tubes first placed approximately 6 years ago and Dr. _%#NAME#%_ _%#NAME#%_ intended to replace ventilation tubes in right ear and rebuild TM on left)and at that time was found to have a potassium of 6.8.
DM|dextromethorphan|DM|315|316|HISTORY OF PRESENT ILLNESS|She saw Dr. _%#NAME#%_ informally while Dr. _%#NAME#%_ was seeing her fiance, _%#NAME#%_ _%#NAME#%_, and she reports that he offered her a course of oral antibiotics and antitussive agents. She then saw Dr. _%#NAME#%_ _%#NAME#%_ in early _%#MM#%_ for initial appointment, at which time she was treated with Mucinex DM and a Combivent inhaler, but was not felt to have signs of an acute bacterial infectious process. Just this morning, the patient was feeling more of a constant sense of dyspnea and also an intermittent left-sided chest discomfort.
DM|diabetes mellitus|DM.|194|196|PROBLEM #3|I would check CBC with differential and blood cultures. PROBLEM #3: Hyperglycemia: I will do check of blood sugars again and HBAIC. If his blood sugars are still elevated, then he has new onset DM. If so, I will start him on Metron. CODE STATUS: I have discussed code status extensively with Mr. _%#NAME#%_, he told me that he would like to be DNR.
DM|dextromethorphan|DM|168|169|TRANSFER/DISCHARGE MEDICATIONS|2. Benadryl 25 mg capsules q.6 h. p.r.n. itching. 3. Neupogen 480 mcg injection daily. 4. Flonase 0.05% nasal spray, two inhalations both nostrils daily. 5. Robitussin DM 5 cc q.4 h. p.r.n. cough. 6. Zyprexa 2.5 mg tablets p.o. t.i.d. p.r.n. agitation. 7. Zyprexa 5 mg tablets daily at bedtime for sleep disturbance.
DM|dextromethorphan|DM|143|144|DISCHARGE MEDICATIONS|3. Primidone as previously dosed. 4. Clonazepam 0.5 mg 3 times daily. 5. Aspirin 325 mg daily. 6. Vitamin E as previously dosed. 7. Robitussin DM 10 mL p.o. every 4 hours p.r.n. cough. 8. Levaquin 750 mg p.o. daily, x 9 more days. Followup chest x-ray in 5 weeks. Followup CBC next week with his primary MD.
DM|diabetes mellitus|DM.|95|97|PAST MEDICAL ILLNESS|PAST SURGERIES: Include gastrostomy and a PDA repair. PAST MEDICAL ILLNESS: 1. Recent onset of DM. 2. Mental retardation with secondary likely to cerebral palsy. She was also premature. 3. Hyalin membrane disease and pneumonia.
DM|diabetes mellitus|DM.|127|129|PAST MEDICAL HISTORY|The patient presents for overnight observation and correction of INR to therapeutic levels. PAST MEDICAL HISTORY: 1. ASCVD. 2. DM. 3. Hypertension. 4. Hypercholesterolemia. 5. Chiari malformation. 6. Carpal tunnel syndrome. 7. Cataracts. PAST SURGICAL HISTORY : 1. Posterior fossa craniectomy with laminectomy at the C1-2 level for Chiari decompression with duraplasty performed _%#MM#%_ _%#DD#%_, 2002.
DM|dextromethorphan|DM|149|150|DISCHARGE MEDICATIONS|8. Tylenol 325 mg 2 tablets p.o. t.i.d. as needed for pain. 9. Albuterol nebulizers 1 vile inhaled q.6h. p.r.n. shortness of breath. 10. Guaifenesin DM 100 mg/5mL, 5 mL p.o. q.4h. p.r.n. cough. 11. Lacrilube ointment apply to corners of eyes as needed. 12. Amoxicillin 1000 mg p.o. 1 hour before dental procedure.
DM|dextromethorphan|DM|281|282|DISCHARGE MEDICATIONS|Laboratory work shows slight elevation of his liver functions. His creatinine was 1.6, which could be related to his previous nephrectomy and/or his hypertension. DISCHARGE MEDICATIONS: He was discharged on, 1. Trazodone 150 mg at bedtime. 2. Clonidine 0.1 mg b.i.d. 3. Robitussin DM and Allegra 60 mg b.i.d. p.r.n. for cough and cold. 4. He was given ibuprofen 600 mg q. 6h. p.r.n. for pain.
DM|diabetes mellitus|DM|142|143|FAMILY HISTORY|SOCIAL HISTORY: He is married for 64 years. He lives with his wife in a condominium in _%#CITY#%_. They have 3 children. FAMILY HISTORY: CAD, DM , ischemic CVA. HABITS: Does not use alcohol or cigarettes. REVIEW OF SYSTEMS: No fever, chills, current incontinence, cough, or sore throat.
DM|dextromethorphan|DM|164|165|MEDICATIONS ON ADMISSION|5. MVI 1 q.d. 6. Zantac 150 mg p.o. b.i.d. 7. Timentin 3.1 gm q.8h. 8. Azithromycin 500 mg IV q.d. 9. Albuterol nebs q.i.d. 10. Atrovent nebs q.i.d. 11. Robitussin DM 1 teaspoon q.8h. 12. Artificial Tears. 13. Resource. 14. Tylenol p.r.n. PAST MEDICAL HISTORY: 1. Osteoarthritis. 2. COPD. 3. Cachexia. 4. Low back ache.
DM|dextromethorphan|DM|145|146|MEDICATIONS ON DISCHARGE|6. MVI p.o. q.d. 7. Zantac 150 mg p.o. b.i.d. 8. Digoxin 0.125 mg p.o. q.d. 9. Albuterol neb q.i.d. 10. Combivent inhalers p.r.n. 11. Robitussin DM q.4h. p.r.n. 12. Resource t.i.d. 13. Artificial Tears t.i.d. 14. Tylenol q.6h. p.r.n.
DM|dextromethorphan|DM|208|209|ASSESSMENT|2. Lung mass. Will consult Oncology. Would like to get a biopsy done prior to Coumadin reaching effectiveness. Will discuss with Radiology as well. 3. Resolving upper respiratory infection. Plan - Robitussin DM for comfort. 4. Allergy, unknown antibiotic, probably clindamycin. Check old chart as patient was seen here at Wound Clinic where he did report this allergy.
DM|diabetes mellitus|DM|241|242|PAST HISTORY|Symptomatically, this seems a bit high to relate to his acute symptoms. PAST HISTORY: ASCVD with triple CABG some years ago. Also, the advancing Alzheimer dementia now probably moderate intensity; hypothyroidism, on treatment; and very mild DM 2 which is stable with diet alone. SOCIAL HISTORY: He lives with his wife in their own apartment.
DM|diabetes mellitus|DM.|217|219|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Chest pain likely secondary to cough, but possible cardiac component. 2. Two to one heart block likely secondary to vasovagal affect from coughing. 3. Hypertension. 4. Hypertriglyceridemia. 5. DM. PROCEDURES PERFORMED: Chest x-ray on _%#MMDD2003#%_ showed no evidence of acute infiltrate.
DM|diabetes mellitus|DM|295|296|PAST MEDICAL HISTORY|REVIEW OF SYSTEMS: Rest of constitutional, eyes, ears, nose, mouth, throat, respiratory, cardiovascular, GI, GU, musculoskeletal, neurologic, endocrine, hematologic, lymphatic, psychiatric, neurologic, and lymphatic review of systems otherwise negative. PAST MEDICAL HISTORY: 1. Cervicalgia. 2. DM II. 3. COPD. 4. BPH. 5. Gastritis. 6. Hypertension. 7. OSA. 8. History of retinal hemorrhage. 9. History of pneumonia. 10. Constipation. 11. CAD, status post CABG 1988.
DM|diabetes mellitus|DM|131|132|HOSPITAL COURSE|Problem #5: History of varices. Remained stable throughout his stay with stable hemoglobin. Will continue PPI therapy. Problem #6: DM 2 also remained stable throughout patient's stay. PAST MEDICAL HISTORY: 1. Status post tonsillectomy. 2. GI bleed from esophageal and gastric varices.
DM|diabetes mellitus|DM,|160|162|FAMILY HISTORY|4. GERD. 5. Non-alcoholic steatotic hepatitis. 6. Osteopenia. 7. Diverticulosis. 8. DM 2. 9. Status post appy. 10. Status post TAH. FAMILY HISTORY: Father with DM, CAD, and CHF. Sister with CHF. SOCIAL HISTORY: Quit smoking 10 years ago, sedentary, drinks occasional alcohol.
DM|diabetes mellitus|DM|100|101|HOSPITAL COURSE|Constipation was an issue and has been addressed with Colace and MiraLax and Dulcolax p.r.n. Type 2 DM has also been a problem during hospital course. He came in on oral hypoglycemic agents. However, because of persistently high glucoses and his inability to take oral medications, he was started on Glargine/Lantus insulin which has been steadily increased to current dosage of 15 units subcutaneously b.i.d. Today, his blood glucoses are still suboptimally controlled; although they had been in the high 100s, he is now tottering in the 150-250 ballpark but increase in insulin was made last evening.
DM|diabetes mellitus|DM|246|247|HISTORY OF PRESENT ILLNESS|2. Gout. PROCEDURES PERFORMED: Chest x-ray on _%#MMDD2007#%_: Clear lungs. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 64-year-old woman status post renal transplant in 2003 for diabetic and hypertensive nephropathy, mechanical aortic valve, DM 2, chronic atrial fibrillation, hypertension and hypothyroidism, who presented to the emergency department with dyspnea and was found to be mildly fluid overloaded a few days after starting prednisone for a gout flare.
DM|diabetes mellitus|DM,|296|298|ASSESSMENT AND PLAN|5. PULMONARY HYPERTENSION: Continue Viagra, prn Ventolin. 6. FLUID OVERLOAD (multifactorial: right-sided heart failure, hypoalbuminemia, proteinuria, and recent IVF) - Okay per Nephrology to gently diurese with oral Lasix and monitoring of creatinine, weight, and Is and O's carefully. 7. TYPE 2 DM, diet-controlled. 8. Cardiovascular: a. HYPERTENSION well controlled with present meds. b. History of ATRIAL FIBRILLATION with rapid ventricular rate. Continue beta blocker, aspirin, and amiodarone.
DM|diabetes mellitus|DM|153|154|ASSESSMENT/PLAN|Question if this is a version of some sort of mesenteric ischemia. I would generally expect more pain than this. ?possible gatroparesis (even though his DM II labs look good). Question if this could be related to some sort of duodenal/gastric ulcer. The patient was recommended to be on a chronic proton pump inhibitor, but he has not been taking it regularly so we will ersume it and have him continue it indefinitely.
DM|diabetes mellitus|DM|274|275|HISTORY OF PRESENT ILLNESS|2. Chest x-ray _%#MMDD2007#%_: Stable cardiomegaly and pulmonary edema. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is an 82-year-old man with chronic diastolic heart failure, coronary artery disease, status post coronary artery bypass grafting in 2005, atrial fibrillation, DM 2 who presented to the Emergency Department 3 days after discharge from rehab facility with complaints of increasing shortness of breath and unsteadiness on his feet.
DM|dextromethorphan|DM|203|204|DISCHARGE MEDICATIONS|8. Colace 100 mg p.o. p.r.n., constipation. 9. Lasix 20 mg p.o. daily for edema. 10. HCTZ 25 mg p.o. daily. 11. Lisinopril 20 mg p.o. daily. 12. Tylenol p.r.n. 13. Cepacol lozenges p.r.n. 14. Robitussin DM 10 mL syrup p.o. q.4h. p.r.n., cough. ADMISSION HISTORY OF PRESENT ILLNESS: The patient is a 27-year-old African-American man with a history of diabetes mellitus type 1 who had been experiencing fevers subjectively, sore throat, runny nose and generalized body aches for the last 1 day.
DM|diabetes mellitus|DM|259|260|PAST MEDICAL HISTORY|Rest of constitutional, eyes, ears, nose, mouth, throat, respiratory, cardiovascular, GI, GU, neurologic, endocrine, hematologic, and allergic review of systems negative other than as listed above. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hyperlipidemia. 3. DM II with triopathy. 4. History of right 5th metatarsal resection secondary to chronic infection. 5. History of right-sided blindness secondary to diabetic retinopathy.
DM|dextromethorphan|DM|467|468|ADMISSION MEDICATIONS|6. Status post pleurodesis 1 to 2 times. 7. Poor hearing. 8. Peripheral vascular disease. 9. Home O2. ADMISSION MEDICATIONS: Prednisone 20 mg p.o. q.d., Lasix 140 mg p.o. q.a.m. and 60 mg p.o. q.p.m., spironolactone 150 mg p.o. q.a.m. and 50 mg p.o. q.p.m., K-Dur 80 mg p.o. b.i.d., Combivent 120/21 mcg 2 puffs q.6h., albuterol inhaler 1 to 2 puffs q.1-2h., Bactrim Double- Strength 1 tablet p.o. every Monday and Thursday, ranitidine 150 mg p.o. b.i.d., Robitussin DM 10 cc q.6h. p.r.n. for cough. ALLERGIES: No known drug allergies. FAMILY HISTORY: The patient denies a family history of coronary artery disease, cancer, or hypertension.
DM|dextromethorphan|DM|423|424|DISCHARGE MEDICATIONS|The daughter seemed to understand the proper dosing for the diuretics. DISCHARGE MEDICATIONS: Prednisone 20 mg p.o. q.d., Lasix 120 mg p.o. q.a.m. and 60 mg p.o. q.p.m., spironolactone 150 mg p.o. q.a.m. and 50 mg p.o. q.p.m., K-Dur 80 mEq p.o. b.i.d., Combivent 125/21 mcg 2 puffs q.6h., albuterol inhaler 1 to 2 puffs q.1-2h., Bactrim DS 1 tablet p.o. every Monday and Thursday, ranitidine 150 mg p.o. b.i.d., Robitussin DM 10 mL p.o. q.6h. p.r.n.
DM|dextromethorphan|DM|327|328|CURRENT MEDICATIONS|ALLERGIES: Penicillin and sulfa. CURRENT MEDICATIONS: Paxil 10 q.d. Dyazide one q.d. Prednisone 5 mg q.d. Ultram 50 mg q.h.s. p.r.n. Doxepin 10 mg q.h.s. Tylenol #3 p.r.n. pain. Glucosamine chondroitin sulfate two tablets b.i.d. Albuterol metered dose inhaler two puffs b.i.d. Ambien 5 mg q.h.s. K- Phos 500 mg q.d. Robitussin DM p.r.n. Tylenol Extra Strength p.r.n. Labunelol (sp?) drops one drop OU b.i.d. HEALTH HABITS: She quit smoking 25 years ago. She has never heard that she has had emphysema. Alcohol use - half glass of wine per day.
DM|diabetes mellitus|DM|187|188|SOCIAL HISTORY|The patient will have undergone tube-feeding classes and he should continue feeding tube cares as instructed. The patient will be sent out on tube feedings cycled at night using Resource DM between the hours of 18:00 and 10:00 at rate of 100 cc an hour as tolerated. The patient is instructed to attempt a soft diet as tolerated.
DM|dextromethorphan|DM|248|249|INSTRUCTIONS|She had evidence of a small pericardial effusion, some thickening of her left ventricle and evidence for biatrial enlargement, right greater than left. The patient had had some problems with bronchial congestion. She was on Levaquin and Robitussin DM prior to her admission. This was continued. She remained afebrile during her hospitalization. The patient is known to have chronic lymphocytic leukemia and with the stress related to her recent illness her white count increased dramatically into the 90,000 range.
DM|dextromethorphan|DM,|139|141|DISCHARGE MEDICATIONS|3. Metoprolol, one-half of a 25 mg tablet b.i.d. 4. Protonix 40 mg daily. 5. Tequin 400 mg daily. 6. Isosorbide 10 mg b.i.d. 7. Robitussin DM, two teaspoons t.i.d. as necessary. 8. Aspirin 81 mg daily. 9. Home oxygen therapy with flow rate of six liters/minute.
DM|dextromethorphan|DM|475|476|MEDICATIONS ON DISCHARGE|A consultation with Social Services and family agreed for nursing home placement. She is discharged to Minnesota Masonic Home. MEDICATIONS ON DISCHARGE: Ceftin 250 mg two tablets b.i.d. for two more days, prednisone 60 mg times two days, 40 mg times five days, 20 mg times five days, 10 mg times five days, then discontinued, Atrovent nebs q.4.h. and p.r.n., Xopenex nebs 1.25 mg/3 ml q.4.h. p.r.n., Celebrex 200 mg q day, Pletal 100 mg q day, Celexa 10 mg q day, Robitussin DM 2 teaspoons q.i.d. p.r.n., magnesium oxide 400 mg p.o. q Monday, Wednesday, and Friday, potassium 10 meq a day, and Lasix 40 mg a day.
DM|dextromethorphan|DM|162|163|PLAN|3. Cough, dry in nature. This was thought secondary to viral in nature. Will do symptomatic treatment at this point. Will continue ______________ with Robitussin DM 5-10 ml q 4-6 hours prn as needed for cough. Assessment and plan of care was well discussed with patient.
DM|diabetes mellitus|DM.|144|146|DISCHARGE DIAGNOSES|2. severe pulmonary hypertension secondary to patent ductus arteriosus. 3. Chronic obstructive pulmonary disease. 4. Morbid obesity. 5. OSA. 6. DM. PROCEDURES PERFORMED: 1. Abdominal ultrasound _%#MMDD2007#%_: Small amount of ascites. 2. Chest x-ray _%#MMDD2007#%_: Prominent hilar regions.
DM|diabetes mellitus|DM|65|66|HOSPITAL COURSE|He continues on a very low dose of lisinopril 5 mg daily. Type 2 DM has been fairly well controlled on glipizide 5 mg daily. In fact, blood sugars have been in an ideal range from 90-140.
DM|diabetes mellitus|DM|121|122|FAMILY HISTORY|SOCIAL HISTORY: No tobacco, no alcohol, works for the phone company. She is married. FAMILY HISTORY: Mother, 69, died of DM type 2. Father, 76, died of hypertension, MI. REVIEW OF SYSTEMS: CONSTITUTIONAL: Negative for fevers, chills or night sweats.
DM|dextromethorphan|DM|169|170|MEDICATIONS|9. Propine one drop each eye b.i.d. 10. Quinapril 10 mg p.o. daily, 11. Timolol 1 drop each eye daily. 12. Tylenol Extra Strength p.r.n. 13. Vitamin C b.i.d. 14. Tussin DM cough syrup two teaspoons q.4-6h. p.r.n. PAST MEDICAL HISTORY: 1. History CVI. 2. History of atrial fibrillation, status post pacer.
DM|dextromethorphan|DM|154|155|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: 1. Community-acquired pneumonia: The patient will be on antibiotics with Rocephin and Zithromax and provide 02 as needed. Robitussin DM for cough. 2. Uncontrolled diabetes: Home dose of Novolin will be started. The patient will be on intense sliding scale insulin for close monitoring.
DM|UNSURED SENSE|DM|156|157|PROCEDURE PERFORMED|She tolerated the procedure well with no complications and no blood loss apart from the specimens obtained. I was present for and supervised the procedure. DM
DM|diabetes mellitus|DM|173|174|DISCHARGE PLANNING|Dr. _%#NAME#%_ was notified of these pending laboratory results. The patient also needed assistance with feedings with aggressive pushing of fluids and offering of Resource DM b.i.d. with meals thickened. Also, incentive spirometry t.i.d.
DM|dextromethorphan|DM|163|164|DISCHARGE MEDICATIONS|8. Torsemide 20 mg p.o. q.d. 9. Tylenol 500 mg p.o. q.i.d. scheduled. 10. Protonix 40 mg p.o. q.d. 11. Os-Cal with vitamin D one tablet p.o. b.i.d. 12. Robitussin DM 5 ml p.o. q4h p.r.n. for coughing. ALLERGIES: The patient has allergies to Aldomet and Augmentin.
DM|dextromethorphan|DM|165|166|MEDICATIONS ON ADMISSION|11. Multivitamin 1 p.o. every day. 12. Protonix 40 mg p.o. every day. 13. Nasonex 2 sprays each nostril every day. 14. Aspirin 325 mg p.o. every day. 15. Robitussin DM p.r.n. 16. Lomotil 2.5 mg every day p.r.n. 17. Metamucil 1 tsp p.o. every day. ALLERGIES: Demerol. SOCIAL HISTORY: The patient lives at the Senior Board and Care Center and has 2 daughters and 2 sons, most of her children are not involved in her care, though she does have a daughter who is involved.
DM|dextromethorphan|DM|150|151|DISCHARGE MEDICATIONS|7. Metamucil one packet daily. 8. Milk of Magnesia, 30 cc p.o. daily. 9. Glucosamine chondroitin 500/400 one tablet three times a day. 10. Robitussin DM 1 tsp every four hours as needed. 11. Vicodin one tablet q h.s. every six hours for significant cough. PAST SURGICAL HISTORY: Left inguinal hernia repair in 1996, a hysterectomy in 1960.
DM|dextromethorphan|DM.|161|163|DISCHARGE MEDICATIONS|Negative ketones. Left arm PICC site without erythema. Her uterus was gravid, approximately 15-week size. DISCHARGE MEDICATIONS: 1. Tylenol No. 3. 2. Robitussin DM. 3. Benadryl. FOLLOW UP: She is to follow up with Dr. _%#NAME#%_ in 1 week and to continue IV fluids through Home Health as previously prescribed.
DM|dextromethorphan|DM|150|151|MEDICATIONS|3. Effexor XR 150 mg per day. 4. Lipitor 10 mg per day. 5. Glucotrol 20 mg per day. 6. Prednisone 5 mg per day. 7. Colace 100 mg b.i.d. 8. Robitussin DM prn. 9. Coricidin. 10. Pepto-Bismol. 11. Aspirin 325 mg per day. ALLERGIES: None to medications but swelling with strawberries and rash to tape.
DM|dextromethorphan|DM|177|178|TRANSFER MEDICATIONS|3. Baza cream topically b.i.d. p.r.n. to his perineal rash. 4. Dulcolax suppository 10 mg q.3 days p.r.n. no bowel movement. 5. Senna 2 tablets p.o. q.h.s. p.r.n. 6. Robitussin DM 10 mL p.o. q.6 h. p.r.n. ALLERGIES: Unknown except to Zyprexa, so no neuroleptics will be given.
DM|dextromethorphan|DM|164|165|DISCHARGE MEDICATIONS|I do fully agree with that, but it is going to be a problem with future care. DISCHARGE MEDICATIONS: 1. Ocean mist nasal spray every two hours p.r.n. 2. Robitussin DM 5-10 mL every 4 hours p.r.n. 3. Cepacol Lozenges one q.i.d. p.r.n. 4. Tylenol 650 mg q.i.d. p.r.n. 5. Protonix 40 mg daily.
DM|dextromethorphan|DM|156|157|DISCHARGE MEDICATIONS|4. GenTeal artificial tears 1 to 2 drops both eyes q.i.d. 5. Azithromycin 250 mg p.o. daily, stop _%#MMDD2005#%_. 6. Celexa 40 mg p.o. daily. 7. Robitussin DM 10 mL p.o. q. 6 hours p.r.n. cough. 8. Lisinopril 10 mg p.o. daily. 9. Maalox Extra Strength 30 mL p.o. q. 4 hours p.r.n. indigestion.
DM|dextromethorphan|DM|186|187|HISTORY OF PRESENT ILLNESS|She has had an occasional productive cough with rare shortness of breath not associated with chest pain. She states that she was not febrile at home. She was using occasional Robitussin DM but states that she had not been specifically abusing this cough medicine. PAST MEDICAL HISTORY: Is significant for previous chemical dependency treatments, last in _%#MM#%_ of 2000.
DM|diabetes mellitus|DM|180|181|PAST MEDICAL HISTORY|HISTORY OF PRESENT ILLNESS: This is a 61-year-old woman with a history of coronary artery disease, who presents for coronary artery bypass grafting. PAST MEDICAL HISTORY: Includes DM Type II, CAD, hysterectomy, hypothyroidism, hypertension, morbid obesity, psoriasis, and hypercholesterolemia. REVIEW OF SYSTEMS: No shortness of breath and no chest pain at the time of admission.
DM|diabetes mellitus|DM|136|137|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Diabetes mellitus type 1. 2. Hypertension. 3. Coronary artery disease. 4. End-stage renal disease secondary to DM type 1. 5. Retinopathy. The patient is blind in the right eye due to detached retina. PAST TRANSPLANT HISTORY: Living-related kidney transplant in 2002.
DM|dextromethorphan|DM|172|173|DISCHARGE MEDICATIONS|3. Cipro 500 mg p.o. b.i.d for 9 days to finish 10-day course of treatment. 4. Oxycodone 5 mg p.o. q.4 to 6 h. p.r.n. pain. 5. Duragesic patch 75 mcg q.72 h. 6. Robitussin DM 10 mL p.o. q.4 h. p.r.n. 7. Decadron at home dose. 8. Compazine 10 mg p.o. q.6 h. p.r.n. nausea. DISCHARGE FOLLOWUP AND INSTRUCTIONS: 1. Follow up with her primary oncologist, Dr. _%#NAME#%_, in 1 week as scheduled on _%#MM#%_ _%#DD#%_, 2005, at 10:30 a.m.
DM|dextromethorphan|DM|112|113|DISCHARGE MEDICATIONS|5. Advair one puff twice a day, 250/50. 6. Lasix 20 mg once a day. 7. Glyburide 5 mg twice a day. 8. Robitussin DM 10 ml q.i.d. 9. Insulin Lantus 38 units at bedtime. 10. Prevacid 30 mg once a day. 11. Toprol XL 25 mg once a day. 12. Zyprexa 10 mg at bedtime and 5 mg in the morning
DM|dextromethorphan|DM.|181|183|IMPRESSION|NEUROLOGIC: No focal deficit. IMPRESSION: 1. Increased weakness secondary to: a. Respiratory infection. Chest x-ray with no infiltrate. Normal WBC. Agree with Tequin and Robitussin DM. b. Decreased p.o. intake. Agree with IV fluids. c. Rule out acute myocardial infarction. Check cardiac enzymes and echocardiogram. 2. Chronic back pain with underlying osteoporosis.
DM|diabetes mellitus|DM|152|153|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Small cell lung cancer diagnosed _%#MM2003#%_, status post chemotherapy and XRT. History of pancytopenia with chemotherapy. 2. DM 2. 3. History of colitis with gram negative sepsis with hospitalization, _%#MM2003#%_. 4. CHF. 5. CAD. 6. Chronic A fib. 7. Osteoporosis.
DM|dextromethorphan|DM|166|167|ASSESSMENT/PLAN|He denied any pleurisy or fever. He denied any sore throat or headache. He denied any significant hemoptysis. He is taking aspirin and Plavix. He is using Robitussin DM and throat lozenges and developed some shortness of breath as well as some abdominal distention early in the evening on Saturday.
DM|dextromethorphan|DM|129|130|DISCHARGE MEDICATIONS|4. Orthostatic hypotension. 5. Hypertension. 6. Anxiety disorder. 7. Chronic low back pain. DISCHARGE MEDICATIONS: 1. Robitussin DM 5-10 cc p.o. q. 6 h. 2. Paxil 20 mg p.o. q. day. 3. Zestril 40 mg p.o. q. day to resume on Sunday, _%#MM#%_ _%#DD#%_. 4. The patient had recently been started on a diuretic by his primary physician.
DM|dextromethorphan|DM|122|123|ALLERGIES|REVIEW OF SYSTEMS: Otherwise is negative except for dry cough that has been present for many weeks. ALLERGIES: Robitussin DM caused respiratory problem. PAST MEDICAL HISTORY: 1. Type 1 diabetes not on medications. 2. Status post pancreas transplant in 1995.
DM|UNSURED SENSE|DM|222|223|PROCEDURES PERFORMED|DISCHARGE DIAGNOSIS: Coronary artery disease. PROCEDURES PERFORMED: On _%#MMDD2006#%_ a coronary angiogram showed 3-vessel coronary artery disease without a left main lesion. The stenosis include LAD of 70%, RCA 100%, and DM 100%. The second procedure performed was coronary artery bypass grafting surgery with a LIMA-LAD, saphenous vein graft to PDA and a saphenous vein graft to an obtuse marginal.
DM|diabetes mellitus|DM|124|125|HOSPITAL COURSE|Will DC with decreased dose of prednisone if blood sugars remain consistently less than 140. The patient with no history of DM 2. PAST MEDICAL HISTORY: 1. Autoimmune hemolytic anemia diagnosed _%#MMDD2006#%_. 2. Right hip fracture with hemiarthroplasty, 2004.
DM|dextromethorphan|DM|213|214|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Coreg 25 mg p.o. b.i.d. 2. Lisinopril 5 mg p.o. b.i.d. 3. Otsuka __________ trial one tablet p.o. daily. 4. Colchicine 0.6 mg p.o. daily, discontinue when symptoms resolve. 5. Robitussin DM 10 mL p.o. q. 4h. p.r.n. 6. Flonase one spray each nostril b.i.d. 7. Bacitracin topical to forehead laceration, discontinue once healed.
DM|medical doctor:MD|DM|121|122||Primary care physician: _%#NAME#%_ _%#NAME#%_, MD - Allina Medical Clinic, _%#CITY#%_ Oncologist: _%#NAME#%_ _%#NAME#%_, DM - Mayo Clinic CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: All of the history is obtained from Mrs. _%#NAME#%_ _%#NAME#%_'s children who are present at the hospital at this time.
DM|dextromethorphan|DM|167|168|DISCHARGE MEDICATIONS|14. Ativan 0.25 mg p.o. q.i.d. 15. Ambien 5 mg p.o. q.h.s. 16. Oxycodone 5 mg, 1-2 tablets p.o. q. 4-6 h. p.r.n. 17. Tylenol 650 mg p.o. q. 6 h. p.r.n. 18. Robitussin DM 5-10 cc p.o. q. 2 h. p.r.n. 19. Norvasc 5 mg p.o. daily. 20. DuoNeb q. 2 h. p.r.n. 21. Albuterol MDI two puffs q. 4 h. p.r.n. 22. Levaquin 500 mg p.o. daily, a ten day supply.
DM|diabetes mellitus|DM|179|180|HOSPITAL COURSE|Prosthetic Services to follow up with patient on an outpatient basis. They have ordered an additional part for his prosthesis, which is pending arrival next week. 5. Uncontrolled DM 2. The patient currently stable on discharge regimen, including Lantus and NovoLog. 6. Hypocalcemia. The patient with diminished ionized calcium at 3.9 most likely related to malnutrition and to multiple blood cell transfusions.
DM|dextromethorphan|DM|221|222|MEDICATIONS|No symptoms of nausea associated with the pain. MEDICATIONS: Currently are Allopurinol 100 mg once a day, Atenolol 25 mg 1 a day, Calcitonin nasal spray one spray in one nostril alternating nostrils every day. Robitussin DM for cough prn. Cozaar 100 mg once a day, multivitamin, Protonix 20 mg a day, Paxil 40 mg a day, Prednisone 5 mg a day and Renagel 1600 mg with meals, Vitamin E and Ambien 5 mg one at bedtime.
DM|dextromethorphan|DM|289|290|PROBLEMS|2. History of gastroesophageal reflux disease: The patient was continued on her Prevacid 30 mg p.o. q. day and the patient was told to take these medications 30 minutes before meals in order to get the best benefit. 3. Sinus congestion: The patient was given a prescription for Robitussin DM and was advised to continue taking her Sudafed, Flonase, and Allegra as an outpatient. 4. History of cardiomyopathy: The patient's Toprol was continued, and she is being followed by Dr. _%#NAME#%_ _%#NAME#%_ at an outside institution.
DM|dextromethorphan|DM|312|313|PROBLEMS|There was a concern that this could possibly be contributing to the patient's symptoms and this is to be addressed upon the patient's follow up with her primary care physician or with follow up with the patient's cardiologist. DISCHARGE MEDICATIONS: Same as admission medications with the addition of Robitussin DM p.r.n., prednisone 40 mg p.o. q. day x5 days total, and Bactrim double strength 1 tablet p.o. b.i.d.
DM|dextromethorphan|DM|172|173|DISCHARGE MEDICATIONS|11. Multivitamin one daily. 12. Protonix 40 mg daily. 13. Prednisone 5 mg daily. 14. Pamelor 25 mg each day at bedtime. 15. Augmentin 875 mg b.i.d. x2 days. 16. Robitussin DM 1 tsp q.4h. p.r.n. 17. Warfarin 3 mg daily. Greater than one half spent on discharge management.
DM|diabetes mellitus|DM,|38|40|HOSPITAL COURSE|HOSPITAL COURSE: Admitted for DVT and DM, nontherapeutic on the second day of his admission, but proceeded rather well. We continued his heparin for the next several days. Also, noticed to have some hip pain, this did improve over the next several days.
DM|dextromethorphan|DM|142|143|DISCHARGE MEDICATIONS|We will discharge him with oral Nystatin to continue at home. DISCHARGE MEDICATIONS: 1. Azithromycin 250 p.o. daily for 3 days. 2. Robitussin DM 10 mL p.o. q.6h. as needed for cough. 3. Nystatin 500,000 units 6 ML p.o. q.6h. The patient is to keep it in his mouth as long as possible and to continue to take for 40 hours after the thrush has disappeared.
DM|dextromethorphan|DM|240|241|ADMISSION DIAGNOSIS|His incisions are clean and dry, and he is complaining of mild incisional pain, otherwise he feels that he is getting some benefit from the intrathecal morphine infusion. DISCHARGE MEDICATIONS: 1. Metoprolol 25 mg p.o. daily. 2. Robitussin DM p.r.n. 3. Nitroglycerin spray p.r.n. 4. Plavix 75 mg p.o. q. day. This should be restarted on _%#MM#%_ _%#DD#%_, 2006. 5. Aspirin 81 mg p.o.
DM|diabetes mellitus|DM|200|201|PAST MEDICAL HISTORY|This remained stable throughout her stay and her creatinine is actually 1.3 on day of discharge. PAST MEDICAL HISTORY: 1. Hip fracture _%#MM2005#%_: 2. Colon cancer, status post partial colectomy. 3. DM 2. 4. Osteoarthritis. 5. OSA, not on CPAP. 6. Hypertension. 7. Osteoporosis. 8. Chronic kidney disease with baseline creatinine of 1.8.
DM|dextromethorphan|DM|119|120|DISCHARGE MEDICATIONS|6. Clothiapine 25 mg q. bedtime. 7. Cepacol 1-2 lozenges p.r.n. 8. Guaifenesin 30 cc p.o. q. 4 h. p.r.n. 9. Robitussin DM 15 cc q. 4 h. p.r.n. 10. Haloperidol 0.5 to 1 mg q. 6 h. p.r.n. anxiety or agitation. 11. Ondansetron ODT 4 mg q. 6 h. p.r.n.
DM|dextromethorphan|DM|224|225|HOSPITAL COURSE|He was started on Bactroban and Vanicream for this. Discharge medications include DuoNebs 2.5/0.5 in 3 cc inhaled neb solution q. 4 hours, Maalox 30 cc p.o. daily p.r.n., Milk of Magnesia 30 cc p.o. daily p.r.n., Robitussin DM 10 cc p.o. q. 6 hours p.r.n. cough, Restoril 7.5 mg p.o. at bedtime as needed for sleep, Tylenol 50 to 60 mg p.o. q. 4 hours p.r.n. pain, total dose not to exceed 4000 mg, Lopid 1 tablet by mouth twice daily for hyperlipidemia, Coreg 12.5 mg by mouth daily for congestive heart failure, Protonix 1 tablet by mouth daily for reflux, Plavix 75 mg by mouth daily for coronary artery disease, Allopurinol 300 mg 1 tablet by mouth daily for gout, K-Dur 40 mEq 1 tablet by mouth daily, Cozaar 100 mg 1 tablet by mouth daily, aspirin 325 mg by mouth daily, Os-Cal D 1250 mg 1 tablet by mouth daily, vitamin B12 1000 mcg 1 tablet by mouth daily, Advair 500/50 1 puff inhaled b.i.d., Lasix 40 mg 1 tablet by mouth daily, Neurontin 300 mg 1 tablet by mouth three times a day, Bactroban 2% topically t.i.d., Vanicream t.i.d., Ceftin 500 mg p.o. b.i.d. times four days, last dose _%#MMDD2005#%_.
DM|dextromethorphan|DM|151|152|DISCHARGE MEDICATIONS|She was also encouraged to do incentive spirometry regularly while awake. DISCHARGE MEDICATIONS: Cefuroxime 500 mg p.o. b.i.d. x12 days and Robitussin DM 10 cc q.4 h. p.r.n. Lastly, she was instructed to seek medical attention should her cough worsen, recurrent fevers, increased pain, shortness of breath, or generalized worsening in condition.
DM|dextromethorphan|DM|108|109|DISCHARGE MEDICATIONS|9. Imdur 120 mg p.o. q. day. 10. Klonopin 0.125 mg p.o. q.h.s. 11. Plavix 75 mg p.o. q. day. 12. Robitussin DM 1 to 2 teaspoons p.o. q.4-6 h. p.r.n. cough. 13. Senna 1 to 4 tablets p.o. b.i.d. p.r.n. constipation. 14. Seroquel 200 mg p.o. nightly. 15. Stadol NS 1 spray each nostril q. day p.r.n.
DM|diabetes mellitus|DM|165|166|PAST MEDICAL HISTORY|8. Previous AV node ablation with pacemaker placed. PAST MEDICAL HISTORY: 1. Non-ischemic cardiomyopathy. 2. Chronic atrial fibrillation. 3. Nonsustained V tach. 4. DM 2. 5. Osteoarthritis. 6. Hypertension. 7. Asthma. 8. Hiatal hernia. 9. Peripheral neuropathy. 10. History of breast cancer. 11. Known renal calculus. 12. Diverticulosis. 13. Glaucoma. 14. Right and left mastectomy in 1988 and 1979.
DM|dextromethorphan|DM|114|115|DISCHARGE MEDICATIONS|2. Tylenol 500 mg p.o. q.6 hours p.r.n., pain and fever. 3. Motrin 600 mg p.o. q.i.d. p.r.n., pain. 4. Robitussin DM 5 mL to 10 mL p.o. q.6 hours p.r.n., cough. DISCHARGE DIAGNOSIS: Community-acquired pneumonia. OPERATIONS/PROCEDURES PERFORMED: 1. CT abdomen and pelvis without contrast showing one left lower lobe infiltrate.
DM|dextromethorphan|DM,|155|157||I've discussed the patients care with the resident and agree with the note. My key findings: CC:right eye surgery HPI: 47 yo man with h/o OSA, chest pain, DM, here for observation following vitrectomy and cataract repair. Pt had midazolam, etomidate and fentanyl during the procedure and anesthesia was concerned about problems overnight given his OSA and h/o chest pain.
DM|dextromethorphan|DM|179|180|DISCHARGE MEDICATIONS|10. Vicodin 1 to 2 tablets p.o. q.4 h. p.r.n. pain, not to exceed 1 week following discharge. 11. Ativan 0.5 mg p.o. q.i.d. p.r.n. anxiety with wean as tolerated. 12. Guaifenesin DM 100 to 100 mg p.o. q.4 h. p.r.n. cough. 13. Maalox 30 mL p.o. q.6 h. p.r.n. abdominal upset. 14. Milk of Magnesia 30 mg p.o. q.6 h. p.r.n. constipation.
DM|diabetes mellitus|DM|357|358|PAST MEDICAL HISTORY|REVIEW OF SYSTEMS: Rest of constitutional, eyes, ears, nose, mouth, throat, respiratory, cardiovascular, GI, GU, musculoskeletal, neurologic, endocrine, hematologic, lymphatic and psychiatric review of systems otherwise negative. PAST MEDICAL HISTORY: 1. Pacemaker 2004 placed at Abbott Northwestern. This was done for syncopal episode with bradycardia. 2. DM 2. 3. Hypertension. 4. Patient denies past medical history of CAD, no hyperlipidemia, no previous surgery. FAMILY HISTORY: Mother died of CVA, no family history of CAD or DM 2.
DM|dextromethorphan|DM|181|182|DISCHARGE MEDICATIONS|She tolerated that well, and her hydrochlorothiazide was going to be restarted as an outpatient. DISCHARGE MEDICATIONS: 1. Cipro 500 mg p.o. b.i.d. for 10 more days. 2. Guaifenesin DM 1 to 2 teaspoons p.o. q.4 to 6 hours, p.r.n. cough. 3. Clonidine 0.2 mg p.o. b.i.d. 4. Lisinopril 40 mg p.o. b.i.d. and she could restart her hydrochlorothiazide 25 mg p.o. daily as an outpatient.
DM|dextromethorphan|DM|168|169|DATE OF PROBABLE DISCHARGE|She is to be discharged to a skilled nursing facility on 1. Tenormin 50 mg daily. 2. Bupropion 75 mg b.i.d. 3. Aricept 5 mg daily. 4. Lasix 40 mg b.i.d. 5. guaifenesin DM for cough p.r.n. 6. Imdur 30 mg daily. 7. Lorazepam 0.25 mg q.6h. p.r.n. 8. Cozaar 50 mg b.i.d. 9. Namenda 5 mg b.i.d. 10. Remeron 22.5 mg at h.s.
DM|diabetes mellitus|DM|216|217|A/P|Attending addendum: I interviewed and examined patient and confirmed presentation, history and pertinent examination and I agree with findings as outlined above. A/P: 1. Acute hyperglycemia, suspect new diagnosis of DM - no evidence for DKA or HHNK. Agree with starting insulin for acute BG control as most oral medications are contra-indicated in this setting of acute renal failure.
DM|dextromethorphan|DM|156|157|DISCHARGE MEDICATIONS|14. Voriconazole 200 mg by mouth/J-tube twice a day for the next 2 days. 15. Ventolin 2.5 mg inhaled every 4-6 hours as needed for wheezing. 16. Robitussin DM 10 mL by mouth every 6 hours as needed for coughing. 17. Oxycodone 5 mg by mouth every 4 hours as needed for pain, dispensed 60.
DM|diabetes mellitus|DM|162|163|OTHER CHRONIC DIAGNOSES|6. Atrial fibrillation. 7. Urinary tract infection. 8. Gross hematuria, probably related to Foley trauma. OTHER CHRONIC DIAGNOSES: 1. Coronary artery disease. 2. DM II. 3. h/o seizures. KEY IMAGING AND PROCEDURES: 1. Echocardiogram performed on _%#MMDD2007#%_, please see FCIS for complete details.
DM|dextromethorphan|DM|178|179|HISTORY OF PRESENT ILLNESS|4. Wellbutrin XL 300 mg daily. 5. Klonopin 1 mg t.i.d. 6. Cymbalta 90 mg daily. 7. Lovenox 80 mg subcutaneous q.12 h. with discontinuation once INR greater than 2. 8. Robitussin DM one teaspoon q.4 h. p.r.n. 9. Dilantin 400 mg b.i.d. 10. Coumadin to be adjusted based on INR. CONDITION AT DISCHARGE: Stable.
DM|dextromethorphan|DM|177|178|DETAILS|It was P-2, N-0, M-0 lesion with 8 of 8 mesenteric lymph nodes negative. The patient was sent home on a low residue diet and was sent home on Darvocet N 100, #35 and Robitussin DM cough medicine. Skin clips were left in. We will see her in the office in a couple of weeks. The patient had an excellent intraoperative course.
DM|diabetes mellitus|DM.|121|123|PLAN|PLAN: I did discuss the patient's risk for surgery with the family but we are in agreement to go ahead with surgery. For DM. insulin sliding scale novolog . For CV risk use a beta-blocker atenolol 25 mg daily.
DM|dextromethorphan|DM|146|147|DISCHARGE MEDICATIONS|8. Depakote Sprinkle 500 mg p.o. q.i.d. 9. Ortho-Novum 28/7/7/7 one tablet p.o. daily. 10. Zantac 150 mg p.o. each day at bedtime. 11. Robitussin DM 1-2 table spoons p.o. q.6-8h. p.r.n. cough. 12. Ativan 0.5 mg p.o. b.i.d. p.r.n. agitation. 13. Tylenol 650 mg p.o. q.6h. p.r.n. pain and fever.
DM|dextromethorphan|DM,|181|183|DISCHARGE MEDICATIONS|Change in Dose: Coumadin, 3 mg p.o. daily. Chronic Medications: 1. Baclofen, 15 mg p.o. t.i.d. 2. Digoxin, 0.125 mg p.o. every other day. 3. Colace 100 mg p.o. daily. 4. Robitussin DM, p.o. p.r.n. q. 4 hours for cough. 5. Fiber tablets, 2 tablets p.o. daily. 6. Rolaids p.o. p.r.n. q. 4 hours for reflux disease.
DM|diabetes mellitus|DM|201|202|PLAN|We will continue 02, Albuterol and Atrovent nebs. The patient is currently at baseline. We await CT results. 2. Coronary artery disease currently stable. She will continue her multiple medications. 3. DM II stable. We will Accu-Check q.i.d. and arrange for routine insulin as per her routine as well as Regular insulin sliding scale.
DM|dextromethorphan|DM.|170|172|CURRENT MEDICATIONS|5. Combivent inhaler 2 puffs q.2-4h. 6. Hydrochlorothiazide 25 mg a day. 7. She started Keflex three days ago and has noted no improvement. 8. She has been taking Tussin DM. SOCIAL HISTORY: She is a nonsmoker. No alcohol use. She is a geriatric social worker and has done a lot of volunteer work for different places such as halfway houses.
DM|dextromethorphan|DM.|152|154|NEW MEDICATIONS UPON DISCHARGE|NEW MEDICATIONS UPON DISCHARGE: 1. Increase Lasix dose and change dosing schedule. 2. Spironolactone - change dosing schedule. 3. Tequin. 4. Robitussin DM. PAST MEDICAL HISTORY: 1. Sarcoidosis with secondary effect in lung, liver, heart, and eyes.
DM|dextromethorphan|DM,|160|162|MEDICATIONS|3. Lisinopril, 7.5 mg per day. 4. Metoprolol, 12.5 mg b.i.d. 5. Milk of Magnesia, 30 cc p.o. q. day p.r.n. 6. Multiple vitamin, 1 tablet per day. 7. Robitussin DM, 1-2 teaspoons p.o. q. 4-6 hours p.r.n. 8. Robitussin Plain 2 teaspoons p.o. q. 4 hours p.r.n. 9. Sorbitol, 15 cc p.o. q.d.
DM|dextromethorphan|DM|975|976|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|She will finish the Z-pack empirically for pneumonia. I also am going to continue her on metoprolol 12.5 mg p.o. b.i.d. Otherwise, I am really not making any changes to her medications. At the time of discharge, her medications are as follows: Guaifenesin 600 mg p.o. b.i.d., Zantac 75 mg p.o. b.i.d., Sinemet 25/100 one p.o. t.i.d., Lanoxin 0.125 mg p.o. daily, aspirin 325 mg p.o. daily, multivitamin one p.o. daily, Macrobid 100 mg p.o. b.i.d., Effexor 75 mg p.o. q.h.s., Os-Cal 500 mg p.o. b.i.d., Metamucil one tablespoon p.o. with 8 ounces of water b.i.d., Lasix 20 mg p.o. daily p.r.n. with 10 meq of potassium daily p.r.n. for weights above 138 lb, Miacalcin spray one spray daily in alternating nostrils, albuterol/Atrovent nebs one neb t.i.d., Tylenol Extra Strength 1000 mg p.o. q.4.h. p.r.n., Dulcolax suppository one p.r. p.r.n. for no bowel movement in three days, Fleets enema one p.r. if no bowel movement in four days, Seroquel 50 mg p.o. q.h.s., Robitussin DM two teaspoons p.o. q.4.h. p.r.n., prednisone 50 mg p.o. b.i.d., Coumadin 2 mg p.o. q day - note this dose was increased slightly, metoprolol 12.5 mg p.o. b.i.d., and Zithromax 250 mg p.o. daily for two more days.
DM|dextromethorphan|DM|162|163|DISCHARGE MEDICATIONS|DOB: _%#MMDD1931#%_ DISCHARGE DIAGNOSIS: 1. Right upper lobe pneumonia. 2. Type 2 diabetes. DISCHARGE MEDICATIONS: Zithromax 250 mg po daily x 5 days, Robitussin DM 2 tsp po q 4-6 hours prn cough. The patient is a 72-year-old white female who is admitted after 4-5 day history of cough, fever, vomiting, chills prior to admission.
DM|dextromethorphan|DM|361|362|DISCHARGE MEDICATIONS|DISCHARGE DIAGNOSES: 1. Hemoptysis, resolved. 2. Recurrent esophageal cancer. 3. Atrial fibrillation. 4. Status post jejunal tube placement. DISCHARGE MEDICATIONS: Vicodin half a tablet q.4h. p.r.n. for cough and pain;prednisone 20-mg taper 3 tablets q.d. x3 days, then 2 tablets for 3 days, then 1 tablet for 3 days, then half a tablet for 3 days; guaifenesin DM 10 cc per J-tube q.4h. p.r.n. for cough; Combivent 4 puffs b.i.d.; albuterol nebs 2.5 mg q.i.d. p.r.n. for cough or shortness of breath; clindamycin for 4 more days postdischarge for possible aspiration pneumonia; ranitidine 10 cc per J-tube q.d.; Lotensin 20 mg per J-tube daily; hydrochlorothiazide 12.5 mg per J-tube q.d.; Isosource tube feeds 40 cc/hr with free water boluses of 50 cc q.6h.; atenolol 50 mg per J-tube q.d.; Compazine 10 mg per J-tube q.i.d. p.r.n. nausea; Ativan 0.5-1 mg per J-tube t.i.d. as needed for anxiety or insomnia; Reglan 10 mg per J-tube t.i.d. to increase motility; Tylenol p.r.n. for pain and fever; Dulcolax suppository pr p.r.n. for constipation.
DM|dextromethorphan|DM|132|133|DISCHARGE MEDICATIONS|2. History of chronic knee pain. 3. History of chronic headache. 4. History of heart problems. DISCHARGE MEDICATIONS: 1. Robitussin DM 10 ml p.o. q. 6 hours. 2. Albuterol 2 puffs q. 6 hours. 3. Tylenol 650 mg p.o. p.r.n. HISTORY OF PRESENT ILLNESS: This is a 46-year-old woman brought into the emergency room because today her initial chief complaint was knee pain.
DM|dextromethorphan|DM.|150|152|DISCHARGE MEDICATIONS|4. Ventolin MDI 2 puffs q.i.d. 5. Zantac 150 mg p.o. b.i.d. 6. Tylenol 1000 mg q4-6h p.r.n. for pleuritic pain. 7. ...........Lozenges and Robitussin DM. 8. Prednisone 40 mg q.d. for 3 days. 9. Xanax .25 mg p.o. h.s. HISTORY OF PRESENT ILLNESS: This patient is a 28-year-old lady who presented to Smiley's Clinic two days prior to her admission for increasing shortness of breath, fever and cough.
DM|diabetes mellitus|DM.|165|167|FAMILY HISTORY|2. Status post appendectomy 3. Migraine and tension headaches. FAMILY HISTORY: Mother died of cancer. Maternal grandmother died of cancer. Paternal grandfather with DM. Brother died in his 30's. He had systematic lupus erythematosus with associated heart attacks and CVA. SOCIAL HISTORY: Positive tobacco use, one pack per day. She is married.
DM|dextromethorphan|DM|166|167|DISCHARGE MEDICATIONS|2. Coumadin 5 mg po qday or as directed. 3. Pulmicort two puffs inhaled b.i.d. 4. Serevent two puffs inhaled b.i.d. 5. Albuterol/Atrovent nebs q4h prn. 6. Robitussin DM prn. 7. Percocet prn. 8. Tylenol prn. 9. Fosamax 70 mg every Monday. 10. Calcium with vitamin D one tablet b.i.d. DISCHARGE FOLLOW-UP: 1. INR in two days with call for adjustment of Coumadin.
DM|dextromethorphan|DM|129|130|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Coumadin 10 mg q.h.s. 2. Lovenox 40 q. day. 3. Z-pack x 5 days. 4. Tylenol #3 q6h p.r.n. 5. Robitussin DM one teaspoon q4h p.r.n. FOLLOW-UP: The patient will follow up with his primary physician, _%#NAME#%_ _%#NAME#%_, MD, on _%#MMDD2004#%_ for INR check at which time his Coumadin dose will be adjusted accordingly.
DM|dextromethorphan|DM|147|148|HOSPITAL COURSE|The diet recommended is regular but with a 1,000 cc fluid restriction for the next week. He is discharged on the following medications: Robitussin DM 10 ml p.o. q.i.d. p.r.n., Restoril 7.5 mg p.o. q.h.s. p.r.n., albuterol inhaler two puffs q.i.d. p.r.n., Tequin 400 mg p.o. q day for four more days, Liquibid or generic equivalent 600 mg p.o. b.i.d., Levothyroxine 100 mcg p.o. q day.
DM|diabetes mellitus|DM|114|115|FAMILY HISTORY|His primary physician is Dr. _%#NAME#%_ at Smiley's Clinic. FAMILY HISTORY: 1. Positive for CAD, and positive for DM 2. Positive for cancer. HISTORY OF PRESENT ILLNESS: For full history of presenting illness, see admission history and physical.
DM|diabetes mellitus|DM,|250|252|HISTORY OF PRESENT ILLNESS|The patient was started on neoadjuvant chemotherapy and completed 2 cycles of ifosfamide to Adriamycin on _%#MM#%_ _%#DD#%_, 2003. CT from an outside hospital showed multiple lung nodules, with indeterminate significance. These are type negative. 2. DM, type 2, since the age of 19, well controlled on p.o. meds. 3. Hyperlipidemia. 4. Hypothyroidism. 5. Recurrent vaginal yeast infection. ALLERGIES: Flu shot, Techni-Care scrub.
DM|dextromethorphan|D.M.|90|93|DISCHARGE MEDICATIONS|DISCHARGE DIAGNOSES: Pneumonia, severe bronchospasm. DISCHARGE MEDICATIONS: 1. Robitussin D.M. one to two teaspoons p.o. q.4h p.r.n. 2. Azithromycin 500 mg p.o. daily x 1. 3. Serevent discus one puff daily. 4. Albuterol nebs q.4h. 5. Ferrous sulfate 325 mg p.o. b.i.d.
DM|dextromethorphan|DM|196|197|HISTORY OF PRESENT ILLNESS|She is unable to provide any other information, and no other notes were sent with the patient. In EPPA, there is a phone message she apparently she had some cough and was provided with Robitussin DM on _%#MMDD2003#%_. She has also had a UTI relatively recently treated with Cipro. She currently states she feels fine. She cannot tell where she is.
DM|dextromethorphan|DM|194|195|HOSPITAL COURSE|Pulmonary toileting was instituted and she was switched over to some po Tequin thereafter. She was titrated off to room air a few days prior to her discharge. She was also given some Robitussin DM to use as an expectorant for clearance of secretions. Her cough had improved and she defervesced. White count has been down- trending prior to discharge.
DM|diabetes mellitus|DM|240|241|HOSPITAL COURSE|This will also need further outpatient follow-up. 4. Hyperglycemia. The patient with non-fasting blood sugar in the 180s at the time of admission. Likely this was reactive and further blood testing did not show any evidence of diagnosis of DM 2. PAST MEDICAL HISTORY: 1. Esophageal narrowing with surgical repair at age 20 per patient report.
DM|dextromethorphan|DM|176|177|DISCHARGE MEDICATIONS|The patient was discharged to home in good condition. She may have a usual diet as tolerated. DISCHARGE MEDICATIONS: 1. Gatifloxacin 400 mg p.o. daily x 10 days. 2. Robitussin DM 10 mL p.o. q.4h. p.r.n. cough. 3. Levothyroxine 200 mcg p.o. daily. 4. Niaspan 2000 mg p.o. daily. 5. Aspirin 325 mg p.o. daily 30 minutes prior to Niaspan dose.
DM|dextromethorphan|DM|149|150|DISCHARGE MEDICATIONS|10. Aspirin 81 mg p.o. daily. 11. Theophylline 250 mg p.o. daily. 12. Metformin 500 mg p.o. q.a.m. 13. Allopurinol 200 mg p.o. daily. 14. Robitussin DM 10 mL p.o. q.4 h. p.r.n. cough. The patient should have a diabetic diet. His activity should be as tolerated.
DM|dextromethorphan|DM|148|149|DISCHARGE MEDICATIONS|PENDING RESULTS: The cultures as mentioned above, especially the AFB smears. DISCHARGE MEDICATIONS: 1. Clindamycin 450 mg p.o. q.i.d. 2. Robitussin DM 10 cc p.o. q.4 h. p.r.n. 3. Percocet 1 to 2 tabs p.o. q.6 h. p.r.n. for pain, #15 dispensed. 4. Loestrin birth control pills, 1 daily as previously taken.
DM|diabetes mellitus|(DM)|149|152|ASSESSMENT/PLAN|3. Chronic renal failure. Currently no significant change. Will continue to monitor with recheck BUN tomorrow a.m. 4. Uncontrolled diabetes mellitus (DM) 2. Patient with minimal p.o. secondary to nausea and vomiting. Will hold his glyburide until adequate p.o. is resumed and place patient on Accu-Cheks and sliding scale coverage for now.
DM|dextromethorphan|DM|106|107|DISCHARGE MEDICATIONS|Follow-up chest x-ray showed her pneumonia had essentially resolved. DISCHARGE MEDICATIONS: 1. Robitussin DM 5 mL p.o. q. 4 hours p.r.n. cough. 2. Klonopin 1 mg p.o. q. h.s. 3. Lidocaine 3 patches to back on 8 a.m. off 8 p.m. q. day.
DM|diabetes mellitus|DM|190|191|FAMILY HISTORY|6. Status post appy. 7. Osteoarthritis. 8. Pulmonary hypertension with right ventricular dysfunction. 9. Acne rosacea. FAMILY HISTORY: Maternal grandfather died of CAD. No family history of DM 2. Father died of PE. SOCIAL HISTORY: Married. Quit smoking 37 years ago. Drinks occasion alcohol.
DM|diabetes mellitus|DM|178|179|FAMILY HISTORY|5. Mild asthma. 6. Tubal ligation. 7. GERD. 8. Achilles tendinitis. FAMILY HISTORY: Paternal grandfather died of CAD. Father died of renal failure, but also had hypertension and DM 2. Maternal grandmother died of CVI. SOCIAL HISTORY: Married, two children. Positive tobacco use, one pack per day. Occasional alcohol. ALLERGIES: Penicillin.
DM|dextromethorphan|DM.|134|136|HISTORY OF PRESENT ILLNESS|Mrs. _%#NAME#%_ states that over the last few weeks she has had a "cold". The last three nights she states she took Robitussin CF and DM. She denies taking any decongestant. She denies taking any over-the-counter medications or indeed any new medications. She has a history of asthma, which has been controlled without medications.
DM|diabetes mellitus|DM|198|199|PAST MEDICAL HISTORY|3. Status post bilateral knee replacement _%#MM#%_ 1996, right knee revision _%#MM#%_ 2002. 4. Status post right femur fracture _%#MM#%_ 2002, status post ORIF. 5. Dyslipidemia. 6. Osteoporosis. 7. DM type 2. 8. Status post right inguinal hernia repair. 9. History of anemia. 10. History of pulmonary hypertension and cardiomegaly.
DM|dextromethorphan|DM|113|114|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|I am going to discharge him home today to complete a 10 day course of Levaquin. He also is using some Robitussin DM as needed and his Coumadin dose has changed from 7.5 mg daily to 6 mg daily. With the Levaquin, I suspect that his INR may continue to increase.
DM|dextromethorphan|DM|442|443|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|His other medications are unchanged and include albuterol 2 puffs every four hours as needed, Os-Cal 500 mg p.o. b.i.d., digoxin 250 mcg p.o. daily, Lasix 20 mg daily, Glyburide 5 mg daily, Metformin dose uncertain but he thinks it is 1000 mg once daily, Coumadin 6 mg as mentioned above daily, prednisone dose uncertain but he thinks it is 10 mg daily, he is going to resume his prior dose, Levaquin 500 mg daily for six days and Robitussin DM 10 mg p.o. every six hours as needed. He is going to follow-up with Dr. _%#NAME#%_ for INR checks in three and in eight days.
DM|dextromethorphan|DM|132|133|MEDICATIONS|6. Bisacodyl 5 mg b.i.d. 7. Tylenol 650 mg q.i.d. 8. Senna two tabs b.i.d. 9. Fleet enema or Dulcolax suppository p.r.n. 10. Tussin DM p.r.n. cough 11. Loperamide p.r.n. 12. Maalox p.r.n. 13. Os-Cal 500 mg t.i.d. 14. Albuterol inhaler two puffs q.4 h p.r.n.
DM|diabetes mellitus|DM|273|274|PAST MEDICAL HISTORY|No nausea, vomiting or diarrhea. Rest of constitutional, eyes, ears, nose, mouth, throat, respiratory, cardiovascular, GI, GU, musculoskeletal, neurologic, endocrine, hematologic, lymphatic and psychiatric review of systems are otherwise negative. PAST MEDICAL HISTORY: 1. DM 2 on insulin. 2. History of gallstone pancreatitis with ERCP with sphincterotomy and stone removal in _%#MM2002#%_. 3. Peptic ulcer disease in 1941. 4. Hypertension. 5. Chronic ETOH dependence.
DM|diabetes mellitus|DM|142|143|ASSESSMENT/PLAN|We will place the patient on alcohol withdrawal protocol and start him on empiric p.o. PPI with his history of ulcer disease. 2. Uncontrolled DM 2. We will check hemoglobin A1C, continue his chronic insulin and add sliding scale coverage. 3. Hypertension. We will continue Toprol. 4. Pneumonia. Possible aspiration pneumonia with multiple falls and acute alcohol intoxication.
DM|dextromethorphan|DM|223|224|HOSPITAL COURSE|Patient was improving significantly. 2. Because the patient at the time of admission had right lower lobe infiltrate, we started the patient on IV antibiotics in the form of ceftriaxone and oral azithromycin and Robitussin DM for coughing. However, by the time the patient was discharged, his chest x-rays were clear, so we discontinued the oral antibiotics.
DM|dextromethorphan|DM|166|167|DISCHARGE MEDICATIONS|7. Spiriva 18 mcg 1 puff daily. 8. Albuterol MDI versus neb q.i.d. p.r.n. 9. Imodium 2 mg p.o. t.i.d. p.r.n. diarrhea. 10. Singulair 10 mg p.o. daily. 11. Robitussin DM cough syrup 5-10 cc p.o. q.i.d. p.r.n. 12. Lisinopril changed to 40 mg p.o. daily. DISPOSITION: The patient will be discharged to Walker Methodist.
DM|dextromethorphan|DM|160|161|CURRENT MEDICATIONS|3. Combivent inhaler two puffs inhaled q.i.d. 4. Spiriva inhaler one puff daily 5. Advair diskus 500/50 one puff b.i.d. 6. Dilantin 300 mg b.i.d. 7. Robitussin DM p.r.n. cough 8. Paxil 30 mg daily 9. DuoNeb p.r.n. 10. Prednisone 20 mg daily. 11. Protonix 40 mg daily. 12. Darvocet one to two tablets p.o. q.4h p.r.n.
DM|dextromethorphan|DM|133|134|MEDICATIONS|2. Sleepwell 2-nite (over-the-counter sleeping pill) 25 mg, 3 tabs at h.s. 3. Nasonex 50 mcg, 1 spray each nostril daily. 4. Mucinex DM 600 mg p.o. q. day. 5. Iron tablet 65 mg p.o. q. day. 6. Combivent inhaler inhaled q.i.d. 7. Evista 60 mg p.o. daily.
DM|diabetes mellitus|DM|338|339|HISTORY OF THE PRESENT ILLNESS|The patient has a complicated history of chronic abdominal pain, chronic pancreatitis and multiple abdominal surgeries including partial pancreatectomy, partial gastrectomy, partial colectomy and splenectomy as well as history of obstructive jaundice with stents placed in _%#MM2003#%_ and _%#MM2003#%_. The patient also has a history of DM 1 and his blood sugars have been elevated in the past few days, however, he also has a history of severe hypoglycemia with need for hospitalization and due to low blood sugars in the past.
DM|dextromethorphan|DM|358|359|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Aspirin 81 mg a day, Zithromax 250 p.o. on _%#MMDD#%_, then discontinue, citalopram 30 mg daily, folic acid 0.4 mg daily, Tazidime FC 8 mg p.o. after breakfast, Risperdal 0.5 mg daily, Namenda 10 mg b.i.d., Advair 250/50 1 puff b.i.d., Duonebs q.i.d., Tylenol 500 mg 2 tablets p.o. t.i.d., albuterol inhaler 2 puffs p.r.n., Robitussin DM 2 tsp q. 4 hours p.r.n., prednisone 40 mg for 3 days, 20 mg x 5 days and 10 mg for 5 days, then discontinue.
DM|dextromethorphan|DM,|148|150|DISCHARGE MEDICATIONS|7. Extra Strength Tylenol twice a day. 8. Albuterol inhaler, 2 puffs 4 times a day and q. 4 hours p.r.n. 9. Zithromax, 250 mg daily. 10. Robitussin DM, 10 ml q. 4 hours p.r.n. DISCHARGE INSTRUCTIONS: Continue monitoring her weight closely, follow cardiac diet with salt restriction, and to follow up with me later this week.
DM|dextromethorphan|DM|121|122|DISCHARGE MEDICATIONS|8. Tylenol 325-650 mg every 4 hours as needed pain. 9. Restoril 7.5 mg at bedtime as needed for insomnia. 10. Robitussin DM 10 cc q6-8h as needed cough 11. Zofran 4 mg by mouth q.4-6 h. as needed for nausea. 12. Protonix 40 mg once a day. 13. Hydralazine 25 mg 4x daily.
DM|dextromethorphan|DM|182|183|TRANSFERRING MEDICATIONS|1. Colace 100 mg p.o. b.i.d. 2. Tenormin 25 mg p.o. daily. 3. Zofran 4 mg p.o. q.8h. p.r.n. nausea and vomiting, dissolvable tablet. 4. Vitamin D 400 units p.o. b.i.d. 5. Robitussin DM 5 mL p.o. q.4h. p.r.n. cough. 6. Lexapro 20 mg p.o. daily. 7. Neurontin 100 mg p.o. each day at bedtime. 8. Trazodone 100 mg p.o. each day at bedtime.
DM|dextromethorphan|DM|145|146|PLAN|If she does confirm urinary tract infection we will need outpatient urologic workup with renal ultrasound, etc. We will give her some Robitussin DM for cough. Dr. _%#NAME#%_ _%#NAME#%_ will see the patient on _%#MMDD2006#%_.
DM|dextromethorphan|DM,|155|157|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Enteric coated aspirin, 81 mg daily. 2. Plavix, 75 mg daily. 3. Nasacort Nasal Spray, 2 sprays each nostril daily. 4. Robitussin DM, 10 ml q. 4 hours p.r.n. 5. Levofloxacin, 500 mg daily for 7 days. 6. Mag oxide, 400 mg daily. 7. Lopressor, 75 mg b.i.d. 8. Lipitor, 20 mg daily.
DM|dextromethorphan|DM|187|188|DISCHARGE MEDICATIONS|13. Tenormin 50 mg p.o. daily. 14. FiberCon 625 mg p.o. for constipation daily. 15. Lovenox 30 mg subq q.24h. until the patient walks actively. 16. Lasix 20 mg p.o. b.i.d. 17. Robitussin DM q.6h. p.r.n. for cough. 18. Imdur 60 mg p.o. daily. 19. Singulair 10 mg p.o. daily. 20. Advair 250/50 one puff b.i.d. Follow-up by PCP in 1 week's time.
DM|dextromethorphan|DM|132|133|DISCHARGE MEDICATIONS|11. Multivitamin one tab p.o. daily. 12. Calcium with vitamin D 500 mg p.o. t.i.d. 13. Pravastatin 50 mg p.o. daily. 14. Robitussin DM 10 ml p.o. q. four to six hours p.r.n. for cough. DISCHARGE INSTRUCTIONS: The patient should follow up with the ID fellow clinic in one week.
DM|diabetes mellitus|DM|168|169|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Diabetes mellitus type 2, poorly controlled, with blood sugars running in the 200s. She is on oral medications of glyburide and Glucophage. 2. DM perpherial neuropathy. 3. Hypertension. poorly controlled, with systolic pressures usually running in the 160s, she tells me. 4. Asthma, controlled. 5. Bladder tumor history, with what appears to be removal of a small bladder tumor just a day ago; however, she continues to take aspirin throughout all of this.
DM|diabetes mellitus|DM|178|179|ASSESSMENT/PLAN|Hemoglobin 12.5 and platelet count 199,000. ASSESSMENT/PLAN: 73-year-old, white female with past medical history significant for CHF, ischemic heart disease, ESRD on chronic HD, DM type 2 and numerous other medical conditions. She was hospitalized at Fairview Ridges Hospital from _%#MMDD#%_ to _%#MMDD#%_ with MSSA pneumonia, Strep pyogenes pneumonia with bacteremia, acute on CRI resulting in ESRD, cellulitis/thrombophlebitis.
DM|diabetes mellitus|DM|163|164|PAST MEDICAL HISTORY|2. 1998, right tibial fracture with intramedullary rod placement. 3. 2003, right total knee arthroplasty. Illnesses: 1. Hypertension. 2. Hyperlipidemia. 3. Type 2 DM (original diagnosis in 2000, glycosylated hemoglobin 6.2 on _%#MMDD2007#%_). 4. Rheumatic fever in childhood, without murmur or need for dental prophylaxis.
DM|diabetes mellitus|DM|165|166|PAST MEDICAL HISTORY|3. Hypertension on Atacand therapy. 4. Diabetes mellitus, type 2, apparently well controlled normally but now it appears to be too well controlled. No diarrhea with DM medications. 5. Weight loss, probably 15 pounds over the last year. 6. Elevated cholesterol. 7. Organic brain syndrome. Dementia of unknown etiology.
DM|dextromethorphan|DM|135|136|DISCHARGE MEDICATIONS|7. Neurontin 200 mg t.i.d. 8. Oxycodone 5 mg q. 4-6 hours p.r.n. 9. Robitussin AC 1-2 teaspoons q. 3-4 hours p.r.n. and try Robitussin DM 1-2 teaspoons q. 3-4 hours p.r.n. first. 10. Cepacol lozenges daily. There is also a note for x-rays of the neck status post incomplete C1-C2 fusion to be done on _%#MMDD2007#%_.
DM|dextromethorphan|DM|156|157|DISCHARGE MEDICATIONS|She declined home care and transitional unit care. DISCHARGE MEDICATIONS: 1. Vicodin 5/500, 1-2 every 4-6h. p.r.n., #30, prescription written. 2. Phenergan DM as a cough suppressant 1-2 tsp. p.o. q.4-6h. 3. Prilosec 20 mg 1 p.o. daily. As well as resumption of her home medications which are: 1. Topol XL 50 mg 1 daily.
DM|dextromethorphan|DM|430|431|DISCHARGE MEDICATIONS|Of note, the patient upon presentation did have a workup in the Emergency Department for the weakness initially including a CBC should show slight anemia, which is _____ as well as a completely normal electrolyte panel, normal iron studies, normal lipid panel and a UA, which showed no evidence of infection, a chest x-ray, which showed clear lungs, a normal INR and a normal head CT for age. DISCHARGE MEDICATIONS: 1. Robitussin DM 10 mL p.o. q.4h. p.r.n. cough. 2. Nasonex one spray each nostril daily. 3. Naphcon-A one drop each eye t.i.d. 4. Dulcolax 10 mg p.r. daily p.r.n. constipation. 5. Cepacol 1 lozenge p.o. q.1h. p.r.n. sore throat.
DM|dextromethorphan|DM|168|169|MEDICATIONS|7. Aspirin 81 mg p.o. daily. 8. Cardia XT 240 mg p.o. daily. 9. Seroquel 37.5 mg p.o. q.i.d. 10. Klor-Con 10 mEq p.o. daily. 11. Tylenol 1000 mg p.o. t.i.d. 12. Tussin DM one and one-half teaspoons p.o. q.6h. p.r.n. cough. SOCIAL HISTORY: The patient lives at a residential care facility.
DM|diabetes mellitus|DM|180|181|FOLLOWUP|2. Dr. _%#NAME#%_ IP in 2-3 months' time as well as Minnesota Heart nurse practitioner in 1-2 weeks' time and have possible titration up of his cardiac medications by MN Heart. 3. DM management already arranged by primary MD for next week.
DM|dextromethorphan|DM|197|198|PRE-ADMISSION MEDICATIONS|12) Phenytoin EX 100 mg tablets, 275 mg p.o. q.a.m. 13) Phenytoin EX 100 mg tablets, 200 mg p.o. q.p.m. 14) Fungoid tincture 2% solution applied to all nails q.d. times two months. 15) Guaifenesin DM syrup, 5 cc p.o. q.4h. p.r.n. for cough. 16) Artificial Tears, instill 1 to 2 drops OU q.i.d. p.r.n. (keep at bedside). 17) Ambien 5 mg, one tablet p.o. q.h.s. ALLERGIES: Ditropan.
DM|dextromethorphan|DM|176|177|MEDICATIONS|9. Claritin 10 mg q.day. 10. Beconase inhaler 42 micrograms one puff to each nostril q.h.s.. 11. Tylenol p.r.n. 12. Docusate 100 mg b.i.d. 13. Zyprexa 5 mg q.day. 14. Guiatuss DM 100 mg/5mg 1-2 tablets q6 hours p.r.n. 15. Albuterol and Atrovent nebs p.r.n. ALLERGIES: None SOCIAL HISTORY: Lives in nursing home, demented.
DM|dextromethorphan|DM|240|241|DISCHARGE MEDICATIONS|5. Metoprolol 25 mg b.i.d. 6. Prednisone taper 40 mg q.d. times 3 days, then 20 mg q.d. times 3 days, then DC. 7. Metformin 500 mg po b.i.d. times 6 days. 8. Insulin regular, sliding scale standard, with q.i.d. finger sticks. 9. Robitussin DM 10 cc po q4 hours p.r.n. cough. 10. Prempro 0.625/5 one po q.d. 11. Zoloft 100 mg po q.d. 12. Combivent metered dose inhaler 2 puffs q.i.d. with spacer.
DM|diabetes mellitus|DM|135|136|FAMILY HISTORY|6. Hypertension. 7. DJD. 8. Status post ORIF, left ankle. 9. Status post left inguinal herniorrhaphy. FAMILY HISTORY: Father with CAD, DM II and maternal uncle with DM II. SOCIAL HISTORY: Divorced. No children. He is a customs agent.
DM|diabetes mellitus|DM,|142|144|REVIEW OF SYSTEMS/PAST MEDICAL HISTORY|He has a long history of unsteady walking. ALLERGIES: Please see previous dictation for allergies. REVIEW OF SYSTEMS/PAST MEDICAL HISTORY: 1. DM, type 2, Insulin-dependent. 2. History of CHF. 3. Multiple past CVA's. 4. Hypertension. 5. Kidney failure, secondary to CHF, resolved. PHYSICAL EXAMINATION: On exam, blood pressure was 109/49.
DM|dextromethorphan|DM|222|223|PROBLEM #2|The patient's highest temperature was 100.3. The chest x-ray did not appear to be consistent with a consolidated pneumonia. It was thought that this cough could be viral-related. The patient was discharged with Robitussin DM to be used as necessary for cough. PROBLEM #3: Gastrointestinal. The patient was continued on his Prevacid, which he uses for GERD as an outpatient.
DM|dextromethorphan|DM|155|156|DISCHARGE MEDICATIONS|DISCHARGE DIAGNOSIS: Cough, likely secondary to viral illness. DISCHARGE MEDICATIONS: 1. Aspirin 325 p.o. q.d. (This is a new prescription.) 2. Robitussin DM (10/100/5 ml) 10 ml p.o. q.4h. p.r.n. cough (new prescription). 3. Lansoprazole 30 mg p.o. q.d. 4. Lisinopril 10 mg p.o. q.d. 5. Atorvastatin 20 mg p.o. q.d. (The patient is unsure if this is the dose he is taking at home but thinks he is taking 20 mg.) DISCHARGE INSTRUCTIONS: The patient is discharged to home in stable condition.
DM|dextromethorphan|DM|164|165|DISCHARGE MEDICATIONS|3. Glyburide 5 mg p.o. q.d. 4. Relenza two puffs b.i.d. x 5 days total. Stop date _%#MMDD2003#%_. 5. Tylenol 325 mg, one to two tabs p.o. q.4h p.r.n. 6. Robitussin DM two teaspoons p.o. q.4h p.r.n. DISCHARGE INSTRUCTIONS: 1. The patient is scheduled for follow-up with her primary physician, Dr. _%#NAME#%_, at Smiley's on _%#MMDD2003#%_.
DM|dextromethorphan|DM|139|140|DISCHARGE MEDICATIONS|12. Tylenol 500 mg q.i.d. for pain. 13. Lasix 20 mg b.i.d. 14. Senokot S one to two tablets b.i.d. p.r.n. for constipation. 15. Robitussin DM 10 cc q4-6h p.r.n. for cough. ALLERGIES: The patient is allergic to codeine and contrast dye.
DM|dextromethorphan|DM.|331|333||No specific associated other symptoms. The patient started taking cough medicines and increased fluid intake over the weekend but continued to have increasing coughing at night time with limitations of sleep and increasing wheezes. She went to Urgent Care Center on Sunday night. The patient was placed on Zithromax and Robitussin DM. The following day she presented to the office with some rib discomfort presumably from her coughing. She was found to have a temperature of 101. Her chest at that time had bilateral chest rhonchi.
DM|diabetes mellitus|DM|293|294|PAST MEDICAL HISTORY|REVIEW OF SYSTEMS: Rest of constitutional, eyes, ears, nose, mouth, throat, respiratory, cardiovascular, GI, GU, musculoskeletal, neurologic, psychiatric, hematologic, endocrine, and lymphatic review of systems negative other than as listed as above. PAST MEDICAL HISTORY: 1. Hypertension. 2. DM II _%#MMDD2003#%_. Hemoglobin A1C 6.1. 3. Hyperlipidemia. 4. Diverticulitis, status post partial colectomy, 1999 by Dr. _%#NAME#%_ _%#NAME#%_. 5. Status post C-section, 1986. 6. Status post tonsillectomy.
DM|dextromethorphan|DM|161|162|DISCHARGE MEDICATIONS|2. Advair discus 500/50 one puff b.i.d. 3. Atrovent metered-dose inhaler two puffs t.i.d. 4. Albuterol metered-dose inhaler two puffs q.4h. p.r.n. 5. Robitussin DM 10 mL p.o. q.4h. p.r.n. 6. Ativan 1 mg p.o. t.i.d. 7. Ranitidine 150 mg p.o. b.i.d. 8. Enalapril 5 mg p.o. q.d. 9. Furosemide 20 mg p.o. q.d.
DM|dextromethorphan|DM|145|146|DISCHARGE MEDICATIONS|5. Insulin NPH 3 U q.h.s., Insulin Sliding Scale as previously ordered. TPN cycle previously ordered. 6. Aspirin 81 mg q.d. (new). 7. Robitussin DM 10 cc p.r.n. q4h for cough. FOLLOW-UP: The patient will follow up with Dr. _%#NAME#%_ as previously scheduled. DIET: The patient currently can only tolerate a liquid diet.
DM|diabetes mellitus|DM|335|336|PAST MEDICAL HISTORY|REVIEW OF SYSTEMS: Rest of constitutional, eyes, ears, nose, mouth, throat, respiratory, cardiovascular, GI, GU, musculoskeletal, neurologic, endocrine, hematologic, lymphatics, psychiatric review of systems negative per patient report. PAST MEDICAL HISTORY: 1. Colon cancer, status post colon resection x2 with colostomy takedown. 2. DM 2. 3. EOTH with chem dep commitment _%#MM2003#%_. 4. CAD, status post distant history of MI. 5. Prostatitis. 6. Hypertension. 7. History of PE and DVT with workup positive for hypercoagulable state.
DM|dextromethorphan|DM|147|148|MEDICATIONS|7. Wellbutrin ER 200 mg p.o. q.d. 8. Protonix 40 mg p.o. q.d. 9. Vitamins daily. 10. ReNeph 4 oz p.o. t.i.d. 11. Ocean Nasal Spray. 12. Robitussin DM cough syrup, one teaspoon p.o. q. 4 h. p.r.n. 13. Tylenol 1000 mg p.o. q.i.d. p.r.n. 14. Carbidopa/Levodopa 25/100, one p.o. t.i.d.
DM|diabetes mellitus|DM|144|145|SYSTEM REVIEW|GU: Incomplete emptying of her bladder. She has improved with Urecholine. She has had recurrent UTIs. ENDOCRINE: See the above. Long history of DM type 2. Began insulin therapy just within the past two months. Thyroid studies have been normal. HEME: No anemia. She has had elevated white count for no obvious reason.
DM|dextromethorphan|DM|155|156|DISCHARGE MENTAL STATUS EXAM|4. Atrovent MDI 2 puffs every 8 hours. 5. Risperdal 0.5 mg p.o. b.i.d. as needed for anxiety. 6. Vistaril 50 mg p.o. q.h.s. p.r.n. insomnia. 7. Robitussin DM 10 mL p.o. q.6h. p.r.n. cough. 8. Zithromax 250 mg p.o. for 2 more days. FOLLOW UP: The patient was discharged to a Sober Friends Home on _%#MM#%_ _%#DD#%_, 2003.
DM|dextromethorphan|DM|147|148|ASSESSMENT/PLAN|The patient was started on azithromycin 500 mg IV q. day and ceftriaxone 1 gram IV q. day. We will keep O2 sats more than equal to 95%. Robitussin DM for cough p.r.n. 2. Nausea and diarrhea thought secondary to viral gastroenteritis. We will keep a close eye on hydration and IV fluids, D5 and half normal saline with 20 mEq KCl per liter at 75 cc per hour.
DM|dextromethorphan|DM|220|221|DISCHARGE MEDICATIONS|Regimens were tapered during hospitalization. 9. Extra Strength Tylenol 500 mg 2 p.o. q.4h p.r.n. with Vistaril 25 mg q.4h p.r.n. 10. Naprosyn 500 mg b.i.d. ...... 11. Temazepam 30 mg q.h.s. p.r.n. sleep. 12. Robitussin DM p.r.n. cough. RECOMMENDATIONS: We recommended a check on urinalysis, urine culture, basic metabolic panel, and complete blood count in 1 week.
DM|dextromethorphan|DM|167|168|HOSPITAL COURSE|The plan was to be as conservative as possible and definitely avoid prednisone or other steroids. Ultimately the patient responded best to throat lozenges, Robitussin DM and Tessalon Perles. She was able to be discharged to her home after a three day hospital stay and actually was cleared on the last day for a surgical procedure, cataract removal, which she would have in the upcoming week.
DM|dextromethorphan|DM|135|136|PLAN|IMPRESSION: 1. Viral syndrome. 2. Left otitis media. PLAN: Home on Azithromycin 200 1 tsp po now then 1/2 tsp po q day x 4. Robitussin DM 1/2 tsp po q 6 hours prn cough. Check oral temp q 3- 4 hours while awake. Give Tylenol 160 provide 2 tsp po q 6, alternate with ibuprofen 105 2 tsp po q 6.
DM|diabetes mellitus|DM|151|152|ASSESSMENT AND PLAN|Telemetry will be ordered for the patient. The patient will be reassessed later on for chest pain. Thi seesm musculoskeletal in nature 2. UNCONTROLLED DM ; The patient will need insulin now to be started for him and then we will put him on insulin sliding scale.
DM|UNSURED SENSE|DM,|203|205|HOSPITAL COURSE|The patient underwent this procedure on _%#MMDD2005#%_. She did tolerate this procedure well without complication. Four artery grafts were done: the LIMA to the LAD, the GSV to the ramus, the GSV to the DM, and the GSV to the PDA. The patient was transferred to the intensive care unit initially following the operation.
DM|diabetes mellitus|DM|239|240|HISTORY OF PRESENT ILLNESS|8. Lipitor 20 mg p.o. q.h.s. HISTORY OF PRESENT ILLNESS: The patient complains of headaches now, nausea, vomiting, and floaters in her left eye. She is blind in her right eye. No dysuria or change in urination. She has a history of type I DM onset at age 15, proliferative retinopathy, detached retina, blind in the right eye, peripheral neuropathy is mild. Hypertension and ESRD secondary to post streptococcal glomerulonephritis and diabetic nephropathy.
DM|diabetes mellitus|DM|146|147|FAMILY HISTORY|CODE STATUS: This patient is full code. SOCIAL HISTORY: Married 3 times. He used to smoke ____ packs a day. FAMILY HISTORY: Father and mother had DM type II, hypertension, coronary artery disease. REVIEW OF SYSTEMS: Unable due to mental status change. PHYSICAL EXAMINATION: Temperature 101, blood pressure 97/50, HR 90, respirations 20, oxygen saturations 93% on 5 L via nasal cannula.
DM|diabetes mellitus|DM|459|460|ASSESSMENT AND PLAN|64 yo female with left ankle fracture and history of frequent falls, likley related to orthostatic hypotension and exacerbated by poor glycemic control. Plan Ankle Fracture - Cast - Outpatient ortho in one week Frequent falls, orthostatic hypotension - Advised to go slowly to a standing position and beware of orthostatic effects - Maintaing good oral hydration - Discontinue namenda - Check B12 and folate Poor glycemic control, does not carb count, type I DM - Increase FSBG checks with addition of post-meal checks - Has appt with endocrinologist this next week. Discharge plan as reviewed with the pt - Home today with close follow-up with primary care and endocrinology
DM|dextromethorphan|DM,|121|123|IDENTIFICATION|He resides in _%#CITY#%_ _%#CITY#%_, Minnesota with his mother and sister. His drugs of choice are marijuana, Robitussin DM, and Coricidin. He has had one previous chemical-dependency treatment two years ago in the STOP Program. He was treated at that time for marijuana dependence. He denies any history of being on antidepressants ever.
DM|dextromethorphan|DM|220|221|HISTORY OF PRESENT ILLNESS|He currently has been on Adderall for attention-deficit/hyperactivity disorder. HISTORY OF PRESENT ILLNESS: His mother brought him to the hospital after he had taken 48 tablets of Coricidin and two bottles of Robitussin DM to get high. He first started the Coricidin and Robitussin DM in the seventh grade. He states he currently for the last several months has been using this combination five to seven times a week.
DM|dextromethorphan|DM|282|283|HISTORY OF PRESENT ILLNESS|He currently has been on Adderall for attention-deficit/hyperactivity disorder. HISTORY OF PRESENT ILLNESS: His mother brought him to the hospital after he had taken 48 tablets of Coricidin and two bottles of Robitussin DM to get high. He first started the Coricidin and Robitussin DM in the seventh grade. He states he currently for the last several months has been using this combination five to seven times a week.
DM|diabetes mellitus|DM|168|169|PAST MEDICAL HISTORY|11. Zelnorm 6 t.i.d. PAST MEDICAL HISTORY: 1. Diabetes mellitus type 1. 2. Retinopathy. 3. Neuropathy. 4. Diabetic gastroparesis. 5. Hypertension. 6. ESRD secondary to DM type 1. 7. CAD. 8. Hyperlipidemia. 9. Hepatitis C. 10. Ureteral allograft stenosis with hydronephrosis in _%#MM2001#%_. 11. Candida esophagitis in _%#MM2001#%_. 12. CMV viremia in _%#MM2001#%_.
DM|dextromethorphan|DM.|162|164|CURRENT MEDICATIONS|4. Rifaximin 400 mg p.o. t.i.d. then venlafaxine 150 mg q.a.m. 5. Tylenol p.r.n. 6. Ducolox p.r.n. 7. Diphenhydramine p.r.n. 8. Colace. 9. EpiPen. 10. Robitussin DM. 11. Ibuprofen. 12. Imodium. 13. Milk of magnesia. 14. Zantac. 15. Trazodone. FAMILY HISTORY: Positive for a father with coronary artery disease and negative for cancer, diabetes and hypertension in father.
DM|diabetes mellitus|DM.|221|223|PLAN|Noted symptoms of polydypsia and polyuria with a 9 lb wt loss three days prior while vacationing in Madeline Island. No abdominal pain, fevers, chills, or URI symptoms. Eating and sleeping unchanged. No family history of DM. Feeling much better today after aggressive fluid resuscitation and initiation of insulin yesterday.
DM|diabetes mellitus|DM,|172|174|PLAN|Heart regular, no murmur. Abdomen soft, non-tender. Good pulses and perfusion. Skin clear, mucous membranes moist. No focal neurologic deficits. 16 year old with new onset DM, here with mild DKA, serum bicarb and ketones much improved with rehydration and insulin therapy. DKA - Continue fluid rehydration - Increase insulin therapy - Follow bicarb and ketones DM - Endocrine following - Continue self administration of insulin - Increase glargine from 10-12 units QDay - Continue mealtime bolus injections Discharge plan as reviewed with the pt - Home when ketones normalize, likely later today
DM|dextromethorphan|DM|149|150|MEDICATIONS ON DISCHARGE|10. Prednisone 5 mg p.o. daily. 11. Zocor 40 mg p.o. daily. 12. Bactrim 1 tab p.o. daily. 13. Valcyte 400 mg p.o. q. every other day. 14. Robitussin DM 10 mg p.o. q.4h. as needed. INSTRUCTIONS: The patient was instructed with the following: 1. Regular diet as tolerated.
DM|dextromethorphan|DM|118|119|HISTORY OF PRESENT ILLNESS|She states also her last use was one week ago. She has been drinking three bottles 8 to 12 ounces daily of Robitussin DM for the last two years. Her last use was _%#MMDD2005#%_. She denies any legal consequences associated with her use. She does continue to use despite consequences. She shows loss of control and increasing tolerance.
DM|diabetes mellitus|DM.|81|83|P|On IV insulin infusion overnight after OR. BS low 200 - 75 this am. A/P - Type 1 DM. Will resume sc insulin pump at usual settings per orders. DC IV insulin infusion 2 hrs after sc pump is restarted.
DM|diabetes mellitus|DM|73|74|B			L			S			HS|BS record B L S HS _%#MMDD#%_ 83 147 119 162 _%#MMDD#%_ 107 A/P - Type 1 DM s/p L femur fx repair. Will continue current insulin pump regimen. Avoid giving pain meds and benzodiazepams together.
DM|diabetes mellitus|DM|126|127|B			L			S			HS|Site clean. Abd soft. BS record B L S HS _%#MMDD#%_ 83 147 119 162 _%#MMDD#%_ 107 109 176 173 _%#MMDD#%_ 115 142 A/P - Type 1 DM s/p L femur fx repair. BS controlled, no significant hypoglycemia. Will continue current insulin pump regimen.
DM|dextromethorphan|DM|191|192|ASSESSMENT AND PLAN|A TSH, complete blood count, and a basic metabolic panel will be checked tomorrow _%#MMDD2004#%_. 2. Viral upper respiratory infection with productive cough, improving. Will start Robitussin DM 10 mL q6h p.r.n. for cough. 3. Migraine headaches, intermittent. We will start Advil 400 to 800 mg p.o. q6h p.r.n. for headaches.
DM|dextromethorphan|DM.|128|130|ASSESSMENT AND PLAN|3. Slight lipodystrophy as noted above. Plan: 1. I made no medication changes today. I did suggest that he could use Robitussin DM. 2. Get a chest x-ray to evaluate pulmonary status. 3. See him in follow-up in about six months or p.r.n.
DM|dextromethorphan|DM.|146|148|CURRENT MEDICATIONS|3. Bilateral total hip arthroplasties. 4. Right ACL repair. CURRENT MEDICATIONS: 1. Tylenol. 2. Dulcolax. 3. Wellbutrin. 4. Colace. 5. Robitussin DM. 6. Imipramine hydrochloride. 7. Lidocaine patch. 8. Imodium. 9. Mylanta/Maalox. 10. Milk of Magnesia. 11. Singulair. 12. Naproxen. 13. Zantac.
DM|diabetes mellitus|DM|100|101|PAST MEDICAL HISTORY|She feels 3 hours per day be difficult to do. PAST MEDICAL HISTORY: 1. Arthritis. 2. Depression. 3. DM (diabetes mellitus). 4. GERD. 5. Hyperlipidemia. 6. Hypertension. 7. Hypothyroidism. 8. Right shoulder postherpetic neuralgia. 9. Status post appendectomy. 10. Status post 5 lower back surgeries and 1 thoracic.
DM|diabetes mellitus|DM|643|644|PMH/PSH|HEENT: no dysphagia, odonophagia, diplopia, neck pain or tenderness, dry/scratch eyes, URI, cough, sinus drainage, tinittus, sinus pressure CV: no chest pain, pressure, palpitations, skipped beats, LOC LUNGS: no SOB, DOE, cough, sputum production, wheezing ABDOMEN: no diarrhea, constipation, abdominal pain EXTREMITIES: no rashes, ulcers, edema NEUROLOGY: no changes in vision, tingling or numbness in hands or feet. MSK: no muscle aches or pains, weakness PMH/PSH 1) Tongue - Squamous cell -s/p Chemo therapy (TAF) X 1 (_%#MMDD#%_?_%#MMDD#%_) -with Dexamethasone 2) Orthostatic Hypotension (dehydration and BB) 3) Gout 4) Nephrolithiasis 5) DM 6) Hlipids 7) Gout 8) Colon Ca s/p resection with chemotherapy Family Hx CAD: + mother HTN: + mother Cancer: no Thyroid disease: no DM2: + Social Hx Smoke: +pipe (quit years ago) OH: occ Other drugs: no Married: + Kids: + Job: stage actor Meds at home: 1) Allopurinol 2) Actos 3) TCF 4) Prandin 5) Mydradin 6) Lipitor 7) Byetta 8) Prevacid Meds at the Hospital 1) Valtrex 2) Tylenol 3) ASA 4) Allopurinol 5) Reglan 6) Midodrine 7) MVI 8) Protonix 9) Simvasiatin 10) Byetta 11) Actos 12) Prandin ALL: NKDA Labs: CBC: 7.7, 10.2, 30, 158 BMP: 133, 3.9, 101, 26, 13, 1.66, 127, 8.1 TSH: 2.73 Cortisol 6pm: 13.9 Cortisol 7pm: 32.8 HbA1c: 6.9 Physical Exam VS: 36.3, 94, 20, 100% Orthostatic: 124/66 *85)m 94/54 (67) GENERAL: Alert and oriented X3, NAD, well dressed, answering questions appropriately, appears stated age.
DM|dextromethorphan|DM|163|164|RECOMMENDATIONS|The significance of this is not clear, but it certainly could be related to acute viral illness. Recommendations would be to change Sudafed to Allegra. Robitussin DM will be offered for her cough. We will repeat a CBC in the next couple of days. Thank you for asking me to see this patient. DISCUSSION: _%#NAME#%_ is a 20-year-old female who currently is hospitalized on station 22 for treatment of depression.
DM|dextromethorphan|DM|153|154|PLAN|Thiamine daily for three days. Atenolol p.r.n. 3. Amoxicillin 500 mg t.i.d. for 10 days. 4. Salt water gargles and Cepacol lozenges p.r.n. 5. Robitussin DM p.r.n. 6. Protonix 40 mg daily for possibility of recent alcohol-related gastritis. 7. Re-check liver profile on Monday. 8. Clinical observation. Thanks for the consultation.
DM|diabetes mellitus|DM|131|132|T - 99 P - 78  135/81|Endocrine consult Pt feels well, eating, no N/V. T - 99 P - 78 135/81 Up walking, alert BS 115 105 117 149 overnight, this am. A/P DM on pump. Ok for dc on current pump settings - 0.9 u/hr 1u/9 g cho, correction factor 1 u to decr 50.
DM|dextromethorphan|DM|152|153|MEDICATIONS|1. Augmentin 500 mg b.i.d. x 14 days. 2. Zantac 150 mg b.i.d. 3. Actigall 250 mg b.i.d. 4. Vitamin E 400 IU q.d. 5. Vitamin C 250 mg q.d. 6. Robitussin DM on a p.r.n. basis. ALLERGIES: Sulfa and clindamycin, both of which cause hives. FAMILY AND SOCIAL HISTORY: Per the chart.
DM|diabetes mellitus|DM|51|52|B			L			S			HS|Endocrine consult followup Current Problem: Type 1 DM admitted with severe hyperglycemia. HPI: Feels well. No complaints. Eating well. No N/V. Now on Levemir 18 units QAM, and 10 units QPM, and aspart 1.5 unit/15 gm CHO for meals and 1.5 unit/15 gm CHO for snacks (usu aft, evening at hs).
DM|diabetes mellitus|DM,|206|208|HPI|CC: We were asked to see this patient by Dr. _%#NAME#%_ for evaluation for intraop bronchoscopy in pt with recent pancreatic transplant and abnormal CXR. HPI: 29 yo woman w/ medical history including SCID, DM, celiac disease, s/p 3 pancreas transplants. Has perhaps 20% residual function of her kidneys due to tacrolimus toxicity, so a kidney transplant might be in the future.
DM|dextromethorphan|DM|198|199|ASSESSMENT AND PLAN|3. Cough, possibly secondary to sinusitis. We will obtain a chest x-ray to rule out tuberculosis and pneumonia. 4. The patient was started on Amoxicillin 500 mg p.o. t.i.d. x10 days, and Robitussin DM 10 cc q.4-6h. p.r.n. cough. 5. Nausea, likely secondary to alcohol withdrawal. The patient was given Zofran p.r.n. nausea. 6. Gastroesophageal reflux disease. The patient was given Zantac 150 mg p.o. p.r.n. heartburn.
DM|dextromethorphan|DM.|163|165|ALLERGIES|2. History of burn wound to the chest sustained as an infant and requiring skin grafting. MEDICATIONS: Adderral. ALLERGIES: 1. Penicillin. 2. Sulfa. 3. Robitussin DM. 4. Question Depakote allergy. He believed this caused some type of skin outbreak. SOCIAL HISTORY: The child lives at home in the care of his mother.
DM|dextromethorphan|DM.|122|124|MEDICATIONS|1. Vitamin D. 2. Zolpidem. 3. Mylanta. 4. Imodium. 5. Milk of magnesia. 6. Bisacodyl. 7. Colace. 8. Zantac. 9. Robitussin DM. 10. Mirapex. 11. Propranolol 40 mg p.o. b.i.d. 12. Ursodiol. 13. Prospium. 14. Prevacid. 15. Detrol L.A. 16. Tacrolimus 2 mg 1 tablet q.a.m., 2 mg q.p.m.
DM|diabetes mellitus|DM|136|137|BS|A/Plan Mr. _%#NAME#%_ is a 59yo male with DM2. 1) agree with d/c D5 in IV fluids 2) Aspart 15Units with each meal 3) Continue Lantus 4) DM education 5) Will discuss with Dr. _%#NAME#%_ Pt seen and examined by me and discussed with Fellow, Dr. _%#NAME#%_.
DM|diabetes mellitus|DM.|42|44||Endocrine consult Current Problem: Type 2 DM. Lupus, hyperglycemia on high dose steroid therapy. HPI: Pt reports feels ok. Good appetite. No n/v. BS 50's this am - pt did not note sx.
DM|diabetes mellitus|DM|138|139|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. IgA nephropathy as described above, starting approximately 15 years ago, status post DDKT is described above. 2. DM type 2. 3. Hypertension. 4. Gout. 5. CMV and BK viremia. 6. Pancytopenia. 7. Anemia. ALLERGIES: No known drug allergies. MEDICATIONS: These were reviewed on his EMR and include Lantus, Protonix, ciprofloxacin, leflunomide, prednisone, tacrolimus, ganciclovir, and Darbepoetin.
DM|diabetes mellitus|DM|202|203|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Autoimmune hepatitis. 2. Chronic renal insufficiency. Baseline creatinine is 2.5. 3. Anemia, the patient is on Procrit. 4. Cholelithiasis. 5. BPH. 6. Pulmonary hypertension. 7. DM type 2 with nephropathy and neuropathy. 8. Esophageal varices and portal gastropathy. 9. Dyslipidemia. ALLERGIES: No known drug allergies.
DM|diabetes mellitus|DM|156|157|ASSESSMENT/RECOMMENDATIONS|ASSESSMENT/RECOMMENDATIONS: This is a 67-year-old man with autoimmune, hepatitis, chronic renal insufficiency, weakness of one year that is progressing and DM type 2. Although the etiology of this progressive weakness is still under investigation it is thought to be diabetic polyneuropathy.
DM|dextromethorphan|DM|214|215|RECOMMENDATIONS|RECOMMENDATIONS: _%#NAME#%_ will continue on her usual insulin regimen. Her blood sugars will be followed q.i.d. I will be available to see her and review her blood pressures during her hospitalization. Robitussin DM has been started for her bronchitic symptoms. At this point I don't think she requires antibiotics. Thank you for having me see this patient. DISCUSSION: _%#NAME#%_ _%#NAME#%_ is 29-year-old female who is currently hospitalized on station 30 for evaluation of depression.
DM|diabetes mellitus|DM|141|142|PAST  MEDICAL HISTORY|They would like to do rehab in the _%#CITY#%_ _%#CITY#%_ area. PAST MEDICAL HISTORY: 1. History of CAD, status post CABG in 1990. 2. History DM type 2 since 1990. 3. History of hypertension. 4. Hyperlipidemia. 5. Osteoarthritis of the left hip and right shoulder. 6. Glaucoma, status post cataract surgery. ALLERGIES: Tetanus and lisinopril, reactions unknown.
DM|dextromethorphan|D.M.|135|138|OUTPATIENT MEDICATIONS|ALLERGIES: 1. Penicillin. 2. Sulfa. 3. Tetracycline. 4. Codeine. OUTPATIENT MEDICATIONS: 1. Metoprolol 25 mg p.o. daily. 2. Robitussin D.M. p.r.n. 3. Nitroglycerine spray p.r.n. 4. Plavix 75 mg p.o. daily. This has been on hold. 5. Aspirin 81 mg p.o. daily. This has been on hold.
DM|diabetes mellitus|DM|108|109|FAMILY HISTORY|2. Bumex, general aching. MEDICATIONS: Please see resident note in chart. FAMILY HISTORY: Positive for CAD, DM and cancer. SOCIAL HISTORY: The patient lives with his significant other, _%#NAME#%_, in a 1-level home in _%#CITY#%_ _%#CITY#%_, Minnesota.
DM|diabetes mellitus|DM|162|163|B		L		S		HS|P: 69 BP: 149/67 T: 99.8 Alert, abd soft, nontender, active BS Lab - cr = 3.3, BS B L S HS _%#MMDD#%_ 168 (7glar) 75-4 am _%#MMDD#%_ 189 (8glar/5 Nov) A/P Type 1 DM with diarrhea, cdiff colitis, labile bs, decr hypoglycemia awareness. Pt now back on sc insulin regimen. Would continue this current regimen.
DM|dextromethorphan|DM|147|148|MEDICATIONS|7. History of right total knee arthroplasty. MEDICATIONS: 1. Prevacid 30 mg daily. 2. Ritalin 10 mg at noon and 4 p.m., 20 mg q.a.m. 3. Robitussin DM 1 teaspoon q.i.d. 4. Seroquel 300 mg b.i.d. 5. Zyrtec 10 mg daily. 6. Ativan 1-2 mg b.i.d. p.r.n. 7. Zofran p.r.n. 8. Advair 250/50 one puff b.i.d. 9. Albuterol inhaler p.r.n.
DM|dextromethorphan|DM.|159|161|MEDICATIONS|7. Protonix 40 mg p.o. b.i.d. 8. Senna one to two tablets p.o. b.i.d. 9. Medications on a p.r.n. basis include: Acetaminophen, Maalox, Dulcolax and Robitussin DM. ALLERGIES: Amoxicillin, Ocuvite, Neurontin, Sudafed, penicillin and penicillamine. FAMILY HISTORY: Noncontributory.
DM|diabetes mellitus|DM,|42|44|ASSESSMENT/PLAN|Endocrine consult Current Problem: Type 1 DM, S/P Pancreas Tx, and Kidney Tx. HPI: Feeling ok. Not eating a lot yet mainly due to mouth pain from pharyg ulcers.
DM|diabetes mellitus|DM|67|68|B			L			S			HS|Endocrine consult Current Problem: Panc tx s/p enteric conversion. DM requiring insulin therapy. HPI: Feeling ok. Mouth pain better with lidocaine.
DM|diabetes mellitus|DM|50|51|B			L			S			HS|Endocrine consult Panc tx s/p enteric conversion. DM requiring insulin therapy. HPI: Feeling ok. Mouth still hurts, using lidocaine. Eating about "50-50".
DM|diabetes mellitus|DM|261|262|IMPRESSION|IMPRESSION: 1. _%#NAME#%_ _%#NAME#%_ is a 54-year-old white married male and father of three admitted on _%#MMDD2004#%_ with decreased blood pressure, which occurred during hemodialysis. Very recent hospitalizations. 2. Multiple medical problems all related to DM 1. a. Note a CAD, CHF, cardiomyopathy with EF of 10-15%. b. PVD, PVD, open wound, left foot and status post amputation of toes.
DM|diabetes mellitus|DM|60|61|PMH|She also has OSA, that is treated with CPAP set at 13. PMH: DM type 2, HTN, metabolic syndrome, lymphedema with chronic bilat cellulitis, OSA, presumed BOOP/COP with chronic steroid use tapered in _%#MM2007#%_ PSH: hemorroidectomy, cholecystecomy, bilat salpingoophrectomy Family hx: father - metastatic penile CA; mother - HTN Social hx: negative tobacco hx, rare ETHOH, no illicit drug use.
DM|dextromethorphan|DM|141|142|PLAN|Requests cough syrup. Possible contribution from nicotine addiction. PLAN: 1. Psychiatric intervention, as per Dr. _%#NAME#%_. 2. Robitussin DM p.r.n. cough. 3. Continue atenolol 25 mg daily. Use of large cuff for blood pressure monitoring. 4. Clinical observation. Staff to call p.r.n. for persistent blood pressure elevation.
DM|dextromethorphan|DM|188|189|PLAN|PLAN: 1. Psychiatric intervention per Dr. _%#NAME#%_. 2. Resume Flovent 2 puffs b.i.d. followed by rinse in addition to albuterol metered dose inhaler, 2 puffs q.4 h. p.r.n. 3. Robitussin DM p.r.n. cough. 4. Atenolol 25 mg per day with parameters. 5. Clinical observation. 6. Patient advised to notify staff p.r.n. progressive URI symptoms, secretion purulence, etc.
DM|dextromethorphan|DM|165|166|ALLERGY|3. History of blood pressure elevation without treatment or diagnosis of hypertension. 4. Peptic ulcer disease. ALLERGY: Iodine, shell fish, Dimetapp and Robitussin DM both results in nausea, vomiting and urticaria. OUTPATIENT MEDICATIONS: 1. Nardil. 2. Ativan. 3. Prevacid 30 mg p.o. b.i.d.
DM|dextromethorphan|DM|207|208|ASSESSMENT|Present headache seems most consistent with a tension/muscle contraction state. 3. History of blood pressure elevation without diagnosis of hypertension. Adequate control presently. 4. Iodine and Robitussin DM allergy. 5. THC and alcohol use with abstention as above. 6. Nicotine addiction. 7. MAO inhibitor therapy. PLAN: 1. If ECT planned by the psychiatric service, there are no complaints or findings on exam to contraindicate.
DM|diabetes mellitus|DM|210|211|PAST MEDICAL HISTORY|4. Calcium supplements 5. Multivitamins 6. Omega 3 fish oil 7. Advil p.r.n. 8. Fosamax 35 mg a week. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Osteopenia/porosis. 4. Apparent report of DM 2. 5. Recurrent urinary tract infections. FAMILY HISTORY: The patient denies any hereditary neurological problems.
DM|dextromethorphan|DM|233|234|CURRENT MEDICATIONS|5. Loperamide 2 mg p.o. q.1 h. p.r.n. diarrhea. 6. Milk of Magnesia 30 mL suspension p.o. p.r.n. 7. Dulcolax 10 mg suppository PR daily p.r.n. for constipation. 8. Zantac 150-mg tablet p.o. b.i.d. p.r.n. for gastritis. 9. Robitussin DM 10 mL syrup p.o. q.4 h. p.r.n. cough. 10. Trazodone 50 mg each day at bedtime p.r.n. insomnia. 11. Seroquel 25 mg p.o. t.i.d. p.r.n. anxiety. 12. Colace 100-mg capsule p.o. b.i.d. for constipation.
DM|dextromethorphan|DM.|74|76|MEDICATIONS|MEDICATIONS: 1. Flonase. 2. Albuterol. 3. Astelin. 4. Avelox. 5. Muco-Fen DM. 6. Diltiazem 120 mg q. day. 7. Tylenol p.r.n. 8. Lasix 20 mg p.r.n. He states he does not actually take it.
DM|dextromethorphan|DM|129|130|MEDICATIONS|11. Hemorrhoidectomy. 12. Left knee meniscus repair. MEDICATIONS: 1. Flonase 2. Albuterol 3. Astelin spray 4. Avelox 5. Muco-Fen DM 6. Diltiazem 120 mg daily 7. Tylenol 8. Lasix 9. Toprol 10. Synthroid 11. Amoxicillin 12. Zocor ALLERGIES: Altace, but no other ACE inhibitors.
DM|diabetes mellitus|DM,|113|115|PMH|Has recently had a C-section on _%#MM#%_ _%#DD#%_ when she gave birth to her baby. No sick contacts. PMH: Denies DM, HTN, CAD, or other medical problems. Only significant for +PPD about 4 years ago. PSxH: C section x 1 otherwise denied Allergies:NKDA Meds: Nothing at home.
DM|diabetes mellitus|DM.|143|145|FH|PSxH: C section x 1 otherwise denied Allergies:NKDA Meds: Nothing at home. Inpatient: Zosyn, Levofloxacin, protonix, albuterol FH: Mother with DM. Father died in an accident. SH: married. Denies tobacco or ETOH abuse. Has one month old child ROS: Completely reviewed and Negative PE: BP: 137/94 HR: 85 RR: 24 T: 98 degree F.
DM|dextromethorphan|DM.|212|214|CURRENT MEDICATIONS|PAST MEDICAL HISTORY: Her past medical history includes: 1. Hypertension. 2. Hypercholesterolemia. 3. Pneumonia history. CURRENT MEDICATIONS: Her current medications include: 1. Zosyn. 2. Catapres. 3. Robitussin DM. 4. Ativan. 5. Milk of Magnesia. 6. Metamucil. ALLERGIES: No known drug allergies. FAMILY HISTORY: No family history of colon cancer or colon polyps, inflammatory bowel disease, liver/pancreatic/gallbladder disease, peptic ulcer disease.
DM|diabetes mellitus|DM.|75|77|B			L 			S   			HS|Endocrine consult Depression/concern for suidcide risk, ETOH abuse. Type 1 DM. Pt wishing to go back on sc insulin pump. Refused long acting insuin this am as wished to restart pump.
DM|diabetes mellitus|DM.|256|258|11/23 		128 (3N)			301 (7N),  15 NPH|Exam - No distress. Lying in bed. Alert, appropriate. B L S HS _%#MMDD#%_ 115 (3N/45Glar) 498 (8+1) 467 (4+8) 331 (3+4) 310 at 3 am _%#MMDD#%_ 478 (4+12/55 glar) 391 (14N, 10N, 20 NPH) 95 48 - 2 am Total 55+40+20=115 11/23 128 (3N) 301 (7N), 15 NPH Type 1 DM. Pts DM has been difficult to control on unit. I am concerned that there may have been some problems with the insulin injections yesterday.
DM|dextromethorphan|DM|161|162|PLAN|ASSESSMENT AND PLAN: 1. Depression. 2. Viral upper respiratory infection with probably right eustachian tube dysfunction. PLAN: The patient will have Robitussin DM on a p.r.n. basis. He will be given Sudafed. I feel comfortable doing this on a p.r.n. basis, given his blood pressure is in the normal range at this time.
DM|dextromethorphan|DM|148|149|PRESENT MEDICATIONS|ALLERGIES: Vicodin causes a rash. PRESENT MEDICATIONS: 1. Nicotine gum. 2. Prozac 20 mg daily. 3. Benadryl 50 mg q.h.s. p.r.n. sleep. 4. Robitussin DM p.r.n. cough. 5. MSSA withdrawal protocol using Ativan, thiamine 100 mg daily for three days, atenolol for heart rate greater than 100.
DM|dextromethorphan|DM|141|142|PLAN|We will hold sliding scale coverage for now with parameters for which nursing staff should call. 3. Parameters for lisinopril. 4. Robitussin DM p.r.n. cough. 5. Clinical observation. Thank you for the consultation. I will follow along as indicated.
DM|dextromethorphan|DM|140|141|CURRENT MEDICATIONS|3. Dulcolax suppository 10 mg per rectum daily p.r.n. 4. Magic mouthwash 5-10 mL p.o. q.2h. p.r.n. 5. Nexium 20 mg p.o. daily 6. Robitussin DM 5 mL p.o. q 4 hours p.r.n. 7. Maalox extra strength 30 mL p.o. q 4 hours p.r.n. 8. Reglan 20 mg IV q.4-6h. p.r.n. 9. Reglan 20 mg p.o. q 4 hours p.r.n.
DM|dextromethorphan|DM|145|146|CURRENT MEDICATIONS|8. Tylenol 650 mg by mouth every 4 hours as needed. 9. Ducolox 10 mg as needed. 10. Colace 100 mg by mouth twice a day as needed. 11. Robitussin DM 10 mL by mouth as needed. 12. Ibuprofen 400 mg by mouth as needed. 13. Imodium 2 mg by mouth every hour as needed.
DM|dextromethorphan|DM|143|144|MEDICATIONS|MEDICATIONS: 1. Nicotine patch 7 mg per 24 hours. 2. Klonopin 1-2 mg as needed for insomnia. 3. Lamotrigine 25 mg every morning. 4. Robitussin DM 10 mL syrup every 4 hours as needed for cough. 5. Ambien 10 mg every evening as needed. 6. Geodon 80 mg every evening.
DM|diabetes mellitus|DM.|165|167|PAST MEDICAL HISTORY|A chest x-ray showed bilateral pleural effusion with atelectasis. PAST MEDICAL HISTORY: 1. Status post kidney transplant x2. 2. End-stage renal disease secondary to DM. 3. History of CMV colitis in 2002. 4. Diabetes mellitus. ALLERGIES: Cephalosporins, doxycycline: Reactions unknown. MEDICATIONS: Medications were reviewed on her EMR.
DM|diabetes mellitus|DM|69|70||We are asked to consult regarding the outpatient mangement of type 2 DM in this 77 yearo old woman by her primary care team. Mrs. _%#NAME#%_ has had a chronic course of head aches for the past number of weeks.
DM|diabetes mellitus|DM|135|136|PAST  MEDICAL HISTORY|With regard to the pancytopenia, Hematology feels that is secondary to his Imuran. PAST MEDICAL HISTORY: 1. Pancreas transplant x2. 2. DM type 1, diagnosed in 1970. 3. End-stage renal disease, status post kidney transplant. 4. Cataracts. 5. Hypothyroid. 6. Hypogonadism. 7. History of hepatitis C.
DM|diabetes mellitus|DM|158|159|PAST MEDICAL HISTORY|He tells me he lives over in _%#CITY#%_ _%#CITY#%_. He is unable to state other surgeries besides Gamma Knife treatment for his AVM. PAST MEDICAL HISTORY: 1. DM type 2. 2. Glaucoma. 3. Atrial fibrillation/flutter. 4. CVA 4 years ago. 5. Seizure x1 in his 20s. 6. Gamma Knife stereotactic radiosurgery for the AVM at UMMC-F in 2001.
DM|diabetes mellitus|DM|208|209|PAST MEDICAL HISTORY|He reports he needs the BiPAP now also. He also has urinary retention with post-void residuals noted and requiring catheterization. PAST MEDICAL HISTORY: 1. CHF with diastolic dysfunction. 2. OSA on CPAP. 3. DM type 2. 4. Chronic kidney disease secondary to DM. 5. Chronic osteomyelitis of the left foot. 6. BPH. 7. History of community acquired pneumonia. 8. Carpal tunnel syndrome.
DM|diabetes mellitus|DM.|126|128|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. CHF with diastolic dysfunction. 2. OSA on CPAP. 3. DM type 2. 4. Chronic kidney disease secondary to DM. 5. Chronic osteomyelitis of the left foot. 6. BPH. 7. History of community acquired pneumonia. 8. Carpal tunnel syndrome.
DM|diabetes mellitus|DM.|217|219|FAMILY HISTORY|ALLERGIES: Iodine (makes him "sick"), Sulfa (rash), contrast dye (unknown reaction) codeine (unknown reaction). MEDICATIONS: See resident note. FAMILY HISTORY: Mother had cardiac disease and hypertension. Father with DM. SOCIAL HISTORY: The patient lives alone in the 1st floor of a duplex in _%#CITY#%_.
DM|dextromethorphan|DM|151|152|PLAN|4. Hypercholesterolemia. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Chest x-ray PA and lateral. 3. Allegra 60 mg b.i.d. 4. Robitussin DM (alcohol free) p.r.n. 5. Clinical observation. Thank you for the consultation. Will follow up on the patient's chest x- ray and clinical status.
DM|diabetes mellitus|DM|63|64|T 100  90  115/67|Endocrine consult Line infection, staph aur bacteremia. Type 1 DM on sc insulin pump. Feels well. Some nausea, no emesis. Estimates ate about 15 gm cho for breakfast.
DM|dextromethorphan|DM.|528|530|MEDICATIONS|She also is receiving concurrent lisinopril 20 mg twice a day, Levoxyl 50 mcg a day, methenamine 500 mg a day, clonidine 0.4 mg twice a day, Colace, tramadol 100 mg q.i.d., Prevacid 30 mg a day, multivitamins once a day, OxyContin 20 mg twice a day. I would add that she was receiving OxyContin prior to her fall for back pain purposes, Paxil 10 mg a day, Norvasc 10 mg a day, Lasix 40 mg twice a day, KCl 20 mEq twice a day, nitroglycerin on a p.r.n. basis, Rocephin 1 gram IV a day, Percocet on a p.r.n. basis, and Robitussin DM. FAMILY AND SOCIAL HISTORY: Are as per the chart. PHYSICAL EXAMINATION: On examination, she is a very hard of hearing woman who is quite pleasant.
DM|dextromethorphan|DM.|175|177|PRESENT MEDICATIONS|1. Albuterol metered-dose inhaler 2 puffs q.4h. p.r.n. 2. Flovent 2 puffs b.i.d. (110 mcg). 3. Tylenol p.r.n. 4. Nebulizer p.r.n. 5. Sudafed 60 mg t.i.d. p.r.n. 6. Robitussin DM. 7. Trazodone p.r.n. 50-100 mg q.h.s. p.r.n. FAMILY HISTORY: Remarkable for cancer and depression.
DM|dextromethorphan|DM,|101|103|ASSESSMENT|ASSESSMENT: 1. Chemical abuse. The patient was admitted after ingesting ethanol, aspirin, Robitussin DM, and Nyquil. He has been hemodynamically stable since admission. 2. Nausea and vomiting secondary to above, now resolved. 3. Overall apparent good medical health. RECOMMENDATIONS: The patient's physical status will be monitored.
DM|diabetes mellitus|DM|305|306|PAST MEDICAL HISTORY|No shortness of breath. Rest of constitutional, eyes, ears, nose, mouth, throat, respiratory, cardiovascular, GI, GU, musculoskeletal, neurologic, endocrine, hematologic, lymphatic and psychiatric review of systems otherwise negative. PAST MEDICAL HISTORY: 1. Chronic pedal edema. 2. Intermittent SVT. 3. DM 2 with peripheral neuropathy. 4. Hypothyroidism. 5. Depression. 6. Chronic pain syndrome. 7. Hyperlipidemia. 8. Status post tonsillectomy. 9. Right bunionectomy. 10. Status post TAH/BSO. FAMILY HISTORY: Mother died of CHF.
DM|diabetes mellitus|DM|169|170|CHIEF COMPLAINT|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD CHIEF COMPLAINT: Asked by Dr. _%#NAME#%_ to consult on patient for evaluation of medical issues including CAD, A fib and DM 2. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 79-year-old female with left supracondylar elbow fracture after a fall on uneven ground on _%#MMDD2005#%_.
DM|diabetes mellitus|DM|207|208|PAST MEDICAL HISTORY|1. CAD, acute MI in 1995. 2. Complete AV block with AV node ablation and pacemaker placement. 3. Atrial fibrillation on Coumadin. 4. COPD. 5. Hypothyroidism. 6. Osteoarthritis. 7. History of tobacco use. 8. DM 2. 9. Hyperlipidemia. 10. CHF, unknown EF. 11. Urinary stress incontinence. 12. Mitral regurgitation, presumably due to rheumatic fever as a child.
DM|diabetes mellitus|DM|186|187|PLAN|HbA1C has already been checked. I would use insulin with a corrective sliding scale as well as low-dose insulin at bedtime. Agree dietien consult helpful but do not send patient home on DM medications. The patient should have his blood sugars checked as an outpatient in the morning.
DM|dextromethorphan|DM|258|259|PLAN|He does not have any recollection of this problem. Given the patient's other medical issues, I feel that this may be best evaluated by a repeat urinalysis by his primary care physician as an outpatient. In addition, the patient will be started on Robitussin DM 10 cc p.o. q4h p.r.n. cough. He states that he responded to some degree with an antibiotic given to him secondary to the cough and we will give him a course of Zithromax.
DM|dextromethorphan|DM|213|214|MEDICATIONS|9. Status post surgery for lid ptosis 10. Status post seven carpal tunnel surgeries for complications secondary to nerve entrapment. MEDICATIONS: 1. Actos 15 mg p.o. q day. 2. Avapro 150 mg p.o. q day. 3. Mucinex DM 400 mg p.o. q day. 4. Paxil controlled release 25 mg p.o. q day. 5. Premarin 0.3 mg p.o. q day. 6. Spironolactone and hydrochlorothiazide 25/25 one tablet p.o. q day.
DM|dextromethorphan|DM|171|172|ASSESSMENT|5. Chronic Dilantin therapy. 6. Ongoing upper respiratory infection with rhinitis/bronchitis. Suspect viral in origin. For now, will treat symptomatically with Robitussin DM (alcohol free) and Humibid LA to help mobilize secretions. If symptoms persist or progress, will consider antibiotic coverage. However, it does not appear to be indicated at this time.
DM|diabetes mellitus|DM|105|106|PAST MEDICAL HISTORY|Speech therapy, as stated above, has followed him for his diet recommendations. PAST MEDICAL HISTORY: 1. DM type 2. 2. History of GERD with peptic ulcer disease. 3. Benign pituitary tumor removed 3 years ago. 4. Prostate cancer, status post prostatectomy in 1994.
DM|dextromethorphan|DM.|204|206|OUT-PATIENT MEDICATIONS|2. History of congenital heart murmur. 3. History of gastroesophageal reflux disease. 4. Status post three cesarean sections. OUT-PATIENT MEDICATIONS: 1. Remeron. 2. Prevacid. 3. Zithromax. 4. Robitussin DM. SOCIAL HISTORY: The patient smokes a half pack of cigarettes a day.
DM|dextromethorphan|DM|269|270|HISTORY OF PRESENT ILLNESS|Mental health diagnoses have included borderline personality disorder. She has a history of self-cutting to the upper extremities and abdomen. On _%#MMDD2004#%_ the patient overdosed on approximately 50 tablets of extra strength Tylenol and a half-bottle of Robitussin DM cough medicine. She experienced nausea with emesis at home and associated abdominal discomfort. She was taken to Ridgeview Medical Center in _%#CITY#%_ where initial exam demonstrated stable hemodynamics with blood pressure 120/62, elevated heart rate in the 120s, respirations unlabored, normal temperature, with oxygen saturation 97% on room air.
DM|dextromethorphan|DM|181|182|ADMISSION MEDICATIONS|6. Glipizide ER 5 mg daily. 7. Metformin 1000 mg p.o. b.i.d. 8. Thiamine 100 mg q.d. x 3 days. 9. Trazodone. 10. Atenolol 50 mg for heart rate over 100 beats/minute. 11. Robitussin DM 2 teaspoons p.o. q.4h p.r.n. 12. Kaopectate 1 ounce po. p.r.n. 13. Maalox 1 ounce p.o. p.r.n. indigestion. 14. Tylenol 325 mg 1-2 tablets p.o. q.4h p.r.n. pain.
DM|diabetes mellitus|DM|181|182|PMH|PMH: 1. ESKD secondary to FSGS, bx proven, s/p DDKT _%#MMDD2007#%_ with DGF and remained on dialysis until late _%#MM2007#%_. s/p several kidney transplant biopsies showing ATN. 2. DM type 2 with triopathy 3. HTN 4. CAD, s/p CABG three vessel '04 5. h/o CVA '02 6. Hypothyroidism 7. Anemia 8. h/o medication non-compliance. PSH 1. s/p DDKT _%#MMDD2007#%_ 2. s/p CABG '04 3. s/p atrial septal defect repair '74.
DM|diabetes mellitus|DM,|175|177|PAST MEDICAL HISTORY|He currently is clean. 2. Past alcohol dependency. The patient may drink one to two alcoholic beverages per month. 3. The patient denies any past surgeries, hypertension, CA, DM, heart disease, or dyslipidemia. ADMISSION MEDICATIONS: None. HOSPITAL MEDICATIONS: 1. Remeron. 2. Zyprexa. ALLERGIES: No known drug allergies.
DM|dextromethorphan|DM|123|124|ASSESSMENT|2. Upper respiratory infection, likely viral in etiology. Recommend Sudafed on a p.r.n. basis as well as use of Robitussin DM q.h.s. p.r.n. Push p.o. fluids and monitor his symptoms. 3. History of hepatitis C, currently with normal liver function test.
DM|diabetes mellitus|DM,|183|185|FH/SH|2. HTN 3. CAD, aute MI 1980s 4. CHF, ? EF 5. OA 6. benighn left cerebellopontine angle cistern mass FH/SH Lives alone No OH No smoke Used to work as a cleaner No h/o CAD, HTN, Ca, no DM, no thyroid disease Medications 1. ASA 2. Enoxaparin 3. Keppra 4. Levothyroxine 50mcg po qday
DM|diabetes mellitus|DM|193|194|HISTORY OF PRESENT ILLNESS|REASON FOR CONSULTATION: I was asked by Dr. _%#NAME#%_ to evaluate this patient for her rehab needs. HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old woman with longstanding history of DM type 1 who is status post single kidney pancreatic transplant for end-stage renal disease. She underwent her transplant on _%#MMDD2007#%_. Postoperatively she has been stable with no significant complications.
DM|diabetes mellitus|DM|191|192|PAST MEDICAL HISTORY|She does some word substitution according to her husband. Her husband has a somewhat flexible work schedule, which will allow him to be home to assist with her care. PAST MEDICAL HISTORY: 1. DM type 1, with end-stage renal disease, status post single pancreatic cadaver kidney transplant. 2. History of retinopathy. 3. History of neuropathy. 4. History of anemia of chronic disease.
DM|diabetes mellitus|DM|197|198|PAST MEDICAL HISTORY|He has been out of bed with the easy lift into the chair. He refuses much questioning. PAST MEDICAL HISTORY: 1. Nonischemic cardiomyopathy. 2. Atrial fibrillation/flutter, status post ablation. 3. DM type 2. 4. Chronic renal failure. 5. Hyperlipidemia. 6. History of left CVA with right weakness. 7. Gout. ALLERGIES: No known drug allergies. MEDICATIONS: See resident note in chart.
DM|dextromethorphan|DM|193|194|ASSESSMENT AND PLAN|Discussed with patient the importance of following safe sex practices and using condoms with each and every sexual encounter. 5. Cough and pleuritic chest pain: The patient may take Robitussin DM 10 mL p.o. q.4 hour p.r.n. for cough. In addition will obtain a PA and lateral view chest x-ray to evaluate for possible pneumonia.
DM|diabetes mellitus|DM|342|343|11/25		177(30NPH/10N)	223(11N)|Abd flat, nontender. BS B L S HS _%#MMDD#%_ 306 446 457 195 _%#MMDD#%_ 294 (20/10R) 451(20R) 407 308 (30NPH/6N) Total insulin 86 units _%#MMDD#%_ 115 295(15 NPH) 414 (_%#DDMM#%_) 323(15NPH/5N)/MN-276 Total insulin 47 units _%#MMDD#%_ 191 (30NPH/6N) 234(7N) 426(8N) 275(10N/15NPH) Total insulin 76 units _%#MMDD#%_ 177(30NPH/10N) 223(11N) A/P DM insulin treated. Still requires increased insulin. Will increase to NPH 40u am and 20 u hs. Novolog 10 units with meals + medium correction. Decreased vision.
DM|diabetes mellitus|DM,|207|209||She was awake but drowsy during our interview making it difficult to get a primary history. PMxH: PBC, HCC, recent admission with positive bile and blood cultures, pulmonary HTN secondary to HPS, GERD, CHF, DM, HTN, a. fib with RVR, hx of alcoholism, right hip fx PSxH: liver transplant, strangulated hernia repair _%#MMDD#%_, R hip fx fixation _%#MMDD#%_ Allergies: percocet, zofran codeine, HCTZ Meds: actigail, paxil, lopressor, albuterol, augmentin, valcyte, batrim, asa, protonix, calcium carbonate, cordarone, cell cept, prograft, mycelex, sildenafil.
DM|diabetes mellitus|DM.|168|170|(15NPH)|DId not eat breakfast; emesis this am. Prednisone dose at 25 mg daily 97.8 86 144/94 BS B L S HS _%#MMDD#%_ 65 139 166 155 (10G) _%#MMDD#%_ 100 (15NPH) Steroid induced DM. Changed to NPH this am as primary problem for diabetes control is daytime hyperglycemia, trend to hypoglycemia overnight.
DM|diabetes mellitus|DM.|149|151|ADMISSION MEDICATIONS|PAST MEDICAL HISTORY: 1. Status post tubal ligation. 2. Status post C-section x 2. 3. Status post appendectomy. ADMISSION MEDICATIONS: 1. Robitussin DM. 2. Kaopectate p.r.n. diarrhea. 3. Maalox p.r.n. indigestion. 4. Tylenol p.r.n. pain. 5. Milk of magnesia p.r.n constipation. 1. Multivitamin, prenatal, one daily ALLERGIES: No known drug allergies.
DM|dextromethorphan|DM|170|171|CURRENT MEDICATIONS|4. Calcium carbonate p.o. b.i.d. 5. Fibercon 1 tablet p.o. b.i.d. 6. Fibercon 625 mg p.o. p.r.n. 7. mycelex 10 mg p.o. q.i.d. 8. Diflucan 100 mg p.o. daily 9. Robitussin DM 5 ml. p.o. q 4 hours p.r.n. 10. Imipenem/cilastatin 500 mg IV q 8 hours. 11. Maalox extra strength 30 ml. p.o. q.4 hours p.r.n.
DM|dextromethorphan|DM.|120|122|MEDICATIONS|15. Dextrose 50% 25-50 mL injection. 16. Glucagon 1 mg injection. 17. Glucose 40% gel. 18. Glucose tabs. 19. Robitussin DM. 20. Imodium. 21. Ativan. 22. Mylanta/Maalox. 23. Milk of magnesia. 24. Zantac. 25. Sodium chloride 0.65% nasal spray. 26. Trazodone 50 mg p.o. every night as needed for sleep.
DM|diabetes mellitus|DM|261|262|PAST MEDICAL HISTORY|The patient now transfers with min assist. She has not had any PT for the last 2 days due to staffing problem and because of her surgery yesterday, but prior to surgery she was walking 30 feet with a rolling walker with PT. PAST MEDICAL HISTORY: Low back pain, DM type 2, hypertension, appendectomy, hypothyroidism, hyperlipidemia, diverticulosis, THA right side, TAH 1974, left knee surgery. FAMILY HISTORY: Mother with an MI and diabetes. MEDICATIONS: See resident note in chart.
DM|dextromethorphan|DM.|204|206|PLAN|We suggested that she keep her voice at rest, that she sip warm liquids such as tea with lemon and honey, and avoid dairy products. 2. She will use an over-the-counter cough medication such as Robitussin DM. 3. Will prescribe azithromycin 250 mg once a day for a 10-day course for full treatment of relapsed bronchitis and laryngitis.
DM|dextromethorphan|DM|187|188|PLAN|PLAN: We will observe the patient at this time. I will write to change her hydrocortisone cream to t.i.d. scheduled until the rash resolves. In addition, the patient will have Robitussin DM 10 cc p.o. q4h p.r.n. cough. No further medical intervention is required at this time.
DM|dextromethorphan|DM|104|105|PLAN|It is probably neuromuscular in origin. 4. No evidence of other acute medical problems. PLAN Robitussin DM p.r.n. cough. No medical intervention indicated. I will be happy to see the patient during this hospitalization for any intercurrent medical issues.
DM|diabetes mellitus|DM.|293|295|PAST MEDICAL HISTORY|With OT, she was maximum assistance to roll to her right side, sitting at the edge of the bed with a rolling to her right side and sitting at the edge of the bed is with standby assistance. PAST MEDICAL HISTORY: 1. Status post hysterectomy. 2. Status post cholecystectomy. 3. Hypertension. 4. DM. 5. DJD of the lumbar spine. 6. Diverticulosis. 7. Hypercholesterolemia. ALLERGIES: Sulfa. MEDICATIONS: 1. Docusate. 2. Atenolol. 3. Zocor. 4. Zantac. 5. Aspirin. 6. Cipro 500 mg b.i.d..
DM|diabetes mellitus|DM.|156|158|FAMILY HISTORY|8. Catapres patch. 9. Travoprost. 10. Docusate. 11. Insulin sliding scale. 12. Metformin. FAMILY HISTORY: His mother is deceased at age 75; she had CVA and DM. His dad is deceased at age 73; he had colon cancer and DM. Sister has CVA. FUNCTIONAL HISTORY: The patient lives with his brother.
DM|diabetes mellitus|DM.|140|142|FAMILY HISTORY|12. Metformin. FAMILY HISTORY: His mother is deceased at age 75; she had CVA and DM. His dad is deceased at age 73; he had colon cancer and DM. Sister has CVA. FUNCTIONAL HISTORY: The patient lives with his brother.
DM|diabetes mellitus|DM|212|213|PAST MEDICAL HISTORY|She lives alone and needs to be completely independent prior to discharge from the hospital. PAST MEDICAL HISTORY: 1. End-stage liver disease as above, status post liver transplant. 2. Depression. 3. Anxiety. 4. DM type 2 x10 years. 5. Hypertension. 6. History of bilateral oophorectomy. 7. History of cholecystectomy. 8. History of bilateral nephrolithiasis. 9. History of complications related to cirrhosis including encephalopathy and ascites.
DM|diabetes mellitus|DM|241|242|PAST MEDICAL HISTORY|These have resolved fairly quickly. He feels that overall his strength is improving in the last few days, especially since Sunday, and he notes that that he is goal-oriented and very motivated for doing acute rehab. PAST MEDICAL HISTORY: 1. DM x5 years, non-compliant. 2. Hypertension. 3. Depression. 4. Status post appendectomy. ALLERGIES: No known drug allergies. MEDICATIONS: Please see resident note in the chart. FAMILY HISTORY: Diabetes present in his maternal grandfather.
DM|dextromethorphan|DM|147|148|MEDICATIONS|13. History of asthma. 14. History of right-sided deafness. MEDICATIONS: 1. Norvasc 5 mg p.o. q day. 2. Adderall-SR 30 mg p.o. q day. 3. Guaifenex DM one tablet p.o. q.12h. 4. Detrol-LA 4 mg p.o. q day. 5. Nexium 40 mg p.o. q. day. 6. Prednisone 4 mg p.o. q. day.
DM|dextromethorphan|DM.|222|224|MEDICATIONS|8. Vancomycin 700 mg IV q.12h. 9. Acetaminophen 500-1000 mg p.o. every 3-4 hours as needed for pain. 10. Albuterol inhaler 2.5 mg per 3 ml nebulizer q.4h. as needed. 11. Cepacol lozenges. 12. Robitussin AC. 13. Robitussin DM. 14. Zofran. 15. Oxycodone 5 mg p.o. every 4-6 hours as needed for pain. 16. Compazine ALLERGIES: No known drug allergies. SOCIAL HISTORY: She denies any alcohol or tobacco use.
DM|diabetes mellitus|DM,|153|155|FAMILY HISTORY|FAMILY HISTORY: This is remarkable for her mother having cervical cancer. Also, a history of depression and alcoholism in the family. The patient denies DM, hypertension, or coronary artery disease. REVIEW OF SYSTEMS: This is otherwise negative except for the nausea mentioned in the "History of Present Illness." Last menstrual period was one week ago.
DM|dextromethorphan|DM|169|170|ASSESSMENT AND PLAN|LABORATORY DATA: First serial troponin negative. ASSESSMENT AND PLAN: 1. Schizophrenia. Per Dr. _%#NAME#%_. 2. Chest pain; probably secondary to cough. Order Robitussin DM 10 cc p.o. q. six hours p.r.n. cough. Cepacol cough lozenges, 1 p.o. q. one hour p.r.n. cough; max 12 per day. The patient may have at bedside. 3. Diabetes mellitus type 2.
DM|dextromethorphan|DM|158|159|PLAN|The patient will be given a copy of her labs. She will be given a p.r.n. albuterol inhaler, as well as Zithromax 350 mg p.o. daily for 4 days, and Robitussin DM 10 mL p.o. q.4h. p.r.n. coughing. The patient agrees to these plans. In addition she will be given a copy of her labs at discharge and a nicotine patch to assist with smoking cessation.
DM|dextromethorphan|DM,|143|145|PLAN|PLAN: 1. Psychiatric intervention, per Dr. _%#NAME#%_. 2. CBC, CMP, TSH. 3. Albuterol metered dose inhaler 2 puffs q.4 h. p.r.n. 4. Robitussin DM, alcohol free, 2 tsp q.4 h. p.r.n. 5. Patient advised to notify staff p.r.n. secretion purulence, in which case will likely cover with antibiotics with underlying airway reactivity.
DM|diabetes mellitus|DM|136|137|FAMILY HISTORY|7. Left inguinal herniorrhaphy as an infant. 8. Status post T&A. 9. History of uterine artery embolization. FAMILY HISTORY: Mother with DM 2 and hypertension. Father with CAD. SOCIAL HISTORY: Married. No tobacco. No alcohol. ALLERGIES: Tetracycline, Darvon, Thorazine, Combid. MEDICATIONS: 1. Estradiol suppository two times a week.
DM|diabetes mellitus|DM.|135|137|PAST MEDICAL HISTORY|She walked 50 feet. She is being followed by the Pain Service and Medicine Service. PAST MEDICAL HISTORY: 1. Chronic low back pain. 2. DM. 3. Diabetic retinopathy. 4. Bilateral cataracts. 5. Hypertension. 6. Foot ulcers. 7. CAD, quadruple bypass in 2001. 8. Left toe amputation.
DM|dextromethorphan|DM.|178|180|PLAN|4. Mild exogenous obesity. 5. Mild facial acne. 6. Nicotine addiction. 7. Surgeries as above. PLAN: 1. Symptomatic treatment for URI with p.r.n. Tylenol, Sudafed, and Robitussin DM. 2. Psychiatric intervention as per Dr. _%#NAME#%_. 3. Copy of labs to patient at discharge with primary MD follow-up (HealthPartners) regarding issues of iron deficiency.
DM|diabetes mellitus|DM|217|218|CHIEF COMPLAINT|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD and _%#NAME#%_ _%#NAME#%_, MD CHIEF COMPLAINT: Asked by Dr. _%#NAME#%_ and Dr. _%#NAME#%_ to consult on the patient for evaluation of multiple medical issues, including DM 2. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 48-year- old male with multiple cardiac disease risk factors, admitted with dyspnea on exertion for the past two evenings while he was walking his dog.
DM|diabetes mellitus|DM|128|129|ASSESSMENT AND PLAN|As of the time I am in the room seeing _%#NAME#%_, around noon, it hasn’t been started. _%#NAME#%_ says she has not yet had any DM education. She tells me that it was scheduled for today but it was cancelled due to plan to start IV insulin. Review of the paper chart chows she was seen by _%#NAME#%_ _%#NAME#%_ RN from Daibetes education on _%#MMDD2007#%_.
DM|diabetes mellitus|DM|838|839||She is now off iv insulin. 2. Tube feeling, cycling 12 hours during the night I recommend the following DM related orders Continue glucose monitoring to before meals (or at the same time as meals if she doesn’t eat), HS and 3 AM. Continue Lantus 7 units/day, given at HS Increase NPH/Regular 70/30 insulin dose to 9 units sq to be given 10 minutes after start of nightly tube feeding Continue Novolog 3 units sq to be given 10 minutes after start of night tube feeding Continue Novolog 1 unit/15 grams of carbohydrate taken by mouth or by boluses of Ensure into feeding tube during the day Add Novolog correction scale, to be given only before meals or 3 AM (in addition to the Novolog given to cover meals): < 200 mg/dl 0 units 201-250 1 units 251-300 2 units >300 3 units note this correction is not given at HS She needs to have final DM education in house (I have written orders for this today) and after that, from purely DM point of view, she would be safe for discharge.
DM|diabetes mellitus|DM|225|226||Hence, these types of differences may alter the response significantly and it also impairs my ability to tell if I am doing the right thing or not. 2. Tube feeling, cycling 12 hours during the night I recommend the following DM related orders Continue glucose monitoring to before meals (or at the same time as meals if she doesn’t eat), HS and 3 AM. Increse Lantus to 8 units/day, given at HS Increase NPH/Regular 70/30 insulin dose to 11 units sq to be given 10 minutes after start of nightly tube feeding Increase Novolog to 4 units sq to be given 10 minutes after start of night tube feeding Continue Novolog 1 unit/15 grams of carbohydrate taken by mouth or by boluses of Ensure into feeding tube during the day Increase Novolog correction scale, to be given only before meals or 3 AM (in addition to the Novolog given to cover meals): Note.
DM|dextromethorphan|DM|169|170|MEDICATIONS|5. Dulcolax 10 mg suppository as needed for constipation. 6. Colace 100 mg twice daily for constipation as needed. 7. Zantac 150 mg twice daily as needed. 8. Robitussin DM 10 mL every 4 hours as needed for cough. 9. Trazodone 50 mg as needed for sleep. 10. Haldol 2 mg tablet every 4 hours for agitation, 2 mg IM every 4 hours as needed for agitation.
DM|dextromethorphan|DM|203|204|RECOMMENDATIONS|5. Hypokalemia of unclear etiology. 6. Recent evaluation for STD with results pending. RECOMMENDATIONS: _%#NAME#%_ will be started on Tylenol for her pain. She will also be given Claritin and Robitussin DM for her respiratory symptoms. She will be given potassium supplementation. Accu-Cheks will be obtained. The patient will contact the Red Door Clinic in a couple of days to determine the results of her STD testing.
DM|diabetes mellitus|DM,|138|140|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 71-year-old gentleman who has multiple medical problems including, but not limited to, OSA, CML, CAD, DM, HTN, ARF and obesity. The patient has been hospitalized since _%#MMDD2007#%_ with respiratory failure and hypoxia after sustaining a fall at home.
DM|dextromethorphan|DM|145|146|MEDICATIONS|12. Compazine 5 mg q.i.d. 13. Kaopectate 30 cc p.r.n. 14. Maalox p.r.n. 15. Nitroglycerin p.r.n. chest pain. 16. Phenergan p.r.n. 17. Robitussin DM p.r.n. 18. Sorbitol 10 cc per day p.r.n. 19. Clozaril 100 mg at h.s. 20. Cymbalta 60 mg every morning. ALLERGIES: Penicillin, Haldol, codeine, and Rocephin. SOCIAL AND FAMILY HISTORY: As per the chart.
DM|dextromethorphan|DM.|134|136|SOCIAL HISTORY|PAST MEDICAL HISTORY: Asthma. SOCIAL HISTORY: The patient occasionally uses tobacco. His drugs of choice are marijuana and Robitussin DM. FAMILY HISTORY: Non-contributory. MEDICATIONS: 1. Trazodone. 2. Zoloft. 3. Albuterol. ALLERGIES: No known drug allergies.
DM|diabetes mellitus|DM|117|118|FAMILY HISTORY|3. ASA. 4. Flovent. 5. Pantoprazole. 6. Spiriva. 7. Vancomycin. 8. Warfarin. 9. Unasyn. FAMILY HISTORY: Positive for DM and CAD. SOCIAL HISTORY: About five months ago, the patient was independent with ambulation and ADLs.
DM|dextromethorphan|DM|153|154|MEDICATIONS|2. Lamictal 125 mg (home medication, discontinued). 3. Klonopin 1 mg in the evening. 4. Zantac 150 mg twice daily as needed for gastritis. 5. Robitussin DM 10 mL every 4 hours as needed for cough. 6. Mylanta/Maalox 30 mg every 6 hours as needed. 7. Imodium 4 mg every 6 hours as needed. 8. Divalproex ER 1000 mg twice daily.
DM|dextromethorphan|DM|182|183|MEDICATIONS|8. Serzone 150 mg p.o. q.p.m. 9. Depakote sprinkles 500 mg p.o. at 0800 hours and 1400 hours. 10. Depakote sprinkles 1250 mg p.o. q.h.s. 11. Ativan 0.5 mg p.o. t.i.d. 12. Robitussin DM 2 teaspoons p.o. q.i.d. 13. Lasix 40 mg p.o. q. day. 14. K-Dur 20 mEq p.o. q.d. 15. Flomax 4 mg p.o. q.d.
DM|dextromethorphan|DM|209|210|PLAN|2. Resume enteric-coated aspirin 81 mg daily. 3. Stool for Clostridium difficile p.r.n. recurrent diarrhea. 4. Resume Atenolol and Clonidine with parameters. Complete course of Zithromax. 5. P.r.n. Robitussin DM with albuterol metered-dose inhaler 2 puffs q.i.d. p.r.n. 6. Recommendation on smoking reduction. 7. Clinical observation. Thanks for the consultation.
DM|dextromethorphan|DM.|192|194|PLAN|4. Recheck EKG now that potassium is replaced to assess for continued QT prolongation. 5. Observe with regard to suspected viral bronchitis. Symptomatic treatment with alcohol-free Robitussin DM. Thank you for the consultation. We will follow along as clinically indicated.
DM|dextromethorphan|DM|184|185|RECOMMENDATIONS|3. Continue current retroviral medications. 4. Recheck liver function tests, HIV CD4 count. 5. Give azithromycin 250 mg daily for a 10-day course for bronchitis. 6. Provide Robitussin DM for cough on a p.r.n. basis. SUMMARY OF CASE: This is a 39-year-old gentleman who came back to this facility for management of the above noted psychiatric symptoms.
DM|diabetes mellitus|DM|144|145|HISTORY OF PRESENT ILLNESS|PAST MEDICAL HISTORY: 1. Significant for surgical repair rectocele in _%#NAME#%_ 2003. 2. Hypertension. 3. Hyperlipidemia. 4. Hiatal hernia. 5. DM 2. 6. History of rib fracture secondary to MVA. MEDICATIONS: Reviewed and documented on chart. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: On examination, neurologically she is intact including the radial nerve.
DM|diabetes mellitus|DM|178|179|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Right cataract surgery. 2. Left shoulder surgery. 3. Status post cholecystectomy. 4. Hyperlipidemia. 5. Hypertension. 6. Glaucoma. 7. Osteoarthritis. 8. DM 2. 9. History of nephritis. FAMILY HISTORY: Positive for prostate cancer. SOCIAL HISTORY: No tobacco. No alcohol. ALLERGIES: No known drug allergies.
DM|diabetes mellitus|DM,|187|189|ASSESSMENT AND PLAN|3. Hyperlipidemia re-start statin agent. 4. Depression re-start her trazodone and Prozac 5. Multiple cardiovascular risk factors- check urinary microalbumin levels. Aggressive control of DM, HTN, lipids, and encourage smoking cessation. 5. Tobacco abuse- offer patient patch acutely.
DM|dextromethorphan|DM|158|159|MEDICATIONS|3. Aspirin 81 mg daily. 4. Zantac 150 mg twice daily. 5. Trazodone 50 mg p.r.n. 6. Imodium 2 mg every hour as needed. 7. Zoloft 50 mg everyday. 8. Robitussin DM 10 mL every 4 hours as needed for cough. 9. Milk of magnesia/Mylanta/Maalox as needed for gastrointestinal symptoms. ALLERGIES: None.
DM|dextromethorphan|DM|166|167|CURRENT MEDICATIONS|2. Bisacodyl suppositories 10 mg per rectum daily. 3. Keflex 500 mg p.o. q.i.d. 4. Benadryl 25 mg IV q 4h p.r.n. 5. Lovenox 40 mg subcutaneously daily. 6. Robitussin DM 5 ml p.o. q 4h p.r.n. 7. Maalox 30 ml p.o. q 4h p.r.n. 8. Demerol 12.5 to 25 mg IV q 15 minutes p.r.n.
DM|dextromethorphan|D.M.|144|147|MEDICATIONS|16. Restoril 15 mg p.o. each day at bed-time p.r.n. for sleep. 17. P.r.n. Tylenol. 18. Milk of Magnesia. 19. Reglan. 20. Maalox. 21. Robitussin D.M. 22. Benadryl. 23. Dulcolax. 24. Cepacol. SPIRITUAL SOURCES OF STRENGTH: She is Lutheran. REVIEW OF SYSTEMS: Some drowsiness.
DM|dextromethorphan|DM|186|187|PLAN|PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Start amoxicillin 500 mg t.i.d. times ten days. 3. Nasal saline irritation p.r.n. 4. Sudafed p.r.n. congestion. 5. Robitussin DM p.r.n. cough. 6. Albuterol meter dose inhaler two puffs q.i.d. p.r.n. 7. Recommended reduction in smoking. 8. Clinical observation. Thank you for the consultation.
DM|NAME|D.M.|36|39|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Patient D.M. is a 50-year-old male admitted to station 3A from Fairview _%#CITY#%_ ER. The patient relapsed on alcohol after 3 years of sobriety in mid _%#MM#%_.
DM|diabetes mellitus|DM,|135|137|FAMILY HISTORY|12. History of gastroparesis. ALLERGIES: No known drug allergies. MEDICATIONS: See resident note in chart. FAMILY HISTORY: Mother with DM, father with hyperlipidemia. No family history for lung disease. Twin brother is healthy. SOCIAL HISTORY: The patient lives with his parents in a multilevel home with 2 stairs to enter.
DM|dextromethorphan|DM|194|195|ASSESSMENT AND PLAN|3. Migraine headaches. Imitrex 50 mg one tablet at headache onset, may repeat X1 in 2 hours if headache returns or persists. 4. Bronchitis. Chest x-ray was negative. D-dimer pending. Robitussin DM 2 teaspoons q. 4 hours p.r.n. cough. Allegra D 12 hour one tablet p.o. b.i.d. p.r.n. rhinorrhea/nasal congestion.
DM|diabetes mellitus|DM,|76|78|PMH|Has no pets and chops wood as he heats his home with wood. PMH: Denied HTN, DM, or any other medical problems. PSxH: appy Allergies: PCN-->rash, ASA -->epistaxis Meds: MVI, and in the hospital --> Levaquin, Zithromax, Fluconazol.
DM|diabetes mellitus|DM,|193|195|FH|PMH: Denied HTN, DM, or any other medical problems. PSxH: appy Allergies: PCN-->rash, ASA -->epistaxis Meds: MVI, and in the hospital --> Levaquin, Zithromax, Fluconazol. FH: Denied FH of HTN, DM, or cancer with the exception of his brother who has DM and seizure disorder SH: denies smoking. Drinks beer occasionally. No exposure to second hand smoke. Exposed to wood, concrete.
DM|diabetes mellitus|DM|214|215|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Diabetes was diagnosed in 1992 when she presented with BS in the 600's and a sinus infection. She has always been on insulin. She has never had DKA. She has been told she is type 1. Her DM is followed by endocrinologist Dr _%#NAME#%_ at Merit Care in _%#CITY#%_. She has been on an insulin pump prior to admission.Her pump settings were Basal 12 AM 1.4, 3 AM 1.7, 6 AM 1, 12 PM 1.1, 4 PM 1.15, 8 PM 1.2, sensitivity 30 mg/dl, 3 units/CHO unit; Her last A1c was 7.9-low 8?s ? in _%#NAME#%_.
DM|diabetes mellitus|DM|193|194|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 52-year-old gentleman who was admitted on _%#MMDD2007#%_ with complaints of groin cellulitis. He was started on antibiotic therapy on admission.He has had DM x 20 years. Was orginally on oral therapy but currently on Levamir 200mg SQ bid, Novolog 60 U with breakfast, 40 U with lunch and 60 U with supper.
DM|diabetes mellitus|DM,|160|162|HPI|The patient was being followed for an ileal stricture with imaging and noted to have a 5 x 3 cm complex left adnexal mass. She has never been told that she has DM, does not check her BS at home. No h/o of GDM (no children). Other than OP and Crohn's she has no other medical problems.
DM|dextromethorphan|DM|152|153|ADMIT MEDICATIONS|8. Gengraf 100 mg p.o. b.i.d. 9. Lomotil 2 mg at each loose stool. 10. Simethicone 80 mg p.o. q.i.d. 11. Magnesium oxide 400 mg p.o. b.i.d. 12. Mucinex DM 1-2 tablets p.o. q.12h. 13. Oxycodone 5 mg p.o. q.4-6h. p.r.n. pain. SOCIAL HISTORY: The patient is married and lives in _%#CITY#%_, Maryland.
DM|dextromethorphan|DM|122|123|DISCHARGE MEDICATIONS|8. Tylenol 1000 mg p.o. t.i.d. 9. Calcium 500 mg t.i.d. with meals. 10. Milk of Magnesia 30 mg p.o. p.r.n. 11. Robitussin DM 5 to 10 mL p.o. q.4h p.r.n. 12. Hydrocortisone cream 2.5% apply to effected areas p.r.n. 13. Nystatin powder applied to skin folds daily p.r.n.
DM|dextromethorphan|DM|129|130|REVIEW OF SYSTEMS|6. Advair 250/50 mcg inhaled b.i.d. 7. Tessalon perles 200 mg p.o. t.i.d. 8. Ortho-Novum 1/35 one tablet p.o. q.d. 9. Robitussin DM 10 cc p.o. q.4h. 10. Prednisone taper beginning at 40 mg and tapering to 10 mg over nine days. FOLLOW-UP: The patient will follow up with Dr. _%#NAME#%_. She should have pulmonary function tests when she is well and encouraged to treat her asthma daily regardless of her symptomatology.
DM|dextromethorphan|DM|160|161|DISCHARGE MEDICATIONS|9. Prednisone 5 mg p.o. daily. 10. Prilosec 40 mg p.o. daily. 11. Sudafed hydrochloride 30 mg 1 to 2 tabs every 6 hours p.r.n. nasal congestion. 12. Robitussin DM 2 Tbs. up to 3 times daily. 13. Sprintec 28 tabs, 1 tab p.o. daily. 14. Vitamin D 400 unit tabs p.o. daily.
DM|diabetes mellitus|DM.|172|174|PLAN|Confirm with the patient's husband the exact dosing of prednisone she was taking at home as she should have been on 50 mg a day at this point 3. For Poor gylcemic control/ DM. Initiate insulin drip. Aggressive insulin treatment after the insulin drip is discontinued. Probably will need at least 100 units of lantus daily even on discharge.
DM|dextromethorphan|DM|130|131|CURRENT MEDICATIONS|3. History of hypertension. 4. History of colon polyps. CURRENT MEDICATIONS: 1. Temazepam 7.5 mg p.o. q.h.s. p.r.n. 2. Robitussin DM p.r.n. 3. Mucinex 600 mg p.o. b.i.d. 4. Recently completed a course of Metronidazole for C. difficile colitis. 5. Dual nebs q4h p.r.n. 6. Ativan 0.5 to 1 mg t.i.d. p.r.n.
DM|dextromethorphan|DM|145|146|PROBLEM #2|In addition, during his hospitalization, starting on hospital day # 1, epinephrine nebs were ordered p.r.n. The patient also received Robitussin DM p.r.n. for cough. He was discharged on Pediapred, 1 mg/kg b.i.d. for 1 day, with the plan to decrease the dose to q.d., until follow up in Pulmonary Clinic.
DM|dextromethorphan|DM|166|167|DISCHARGE MEDICATIONS|13. Albuterol 2.5 mg nebulized q.4h and q.2h p.r.n. 14. Pediapred 5 mg down G tube b.i.d. for 1 day, then q.d., until follow up with Pulmonary Clinic. 15. Robitussin DM 2.5 ml down G tube q.4h p.r.n. 16. Oxygen 1 liter/minute via nasal cannula.
DM|diabetes mellitus|DM|206|207|PAST MEDICAL HISTORY|2. Cholesterol embolization to lower extremities with changes to his toes which are now permanent since his bypass. 3. End-stage renal disease on hemodialysis most likely due to cholesterol embolization or DM and Hypertension. 4. Hypertension with multiple adjustments made in his medications over the last few months. 5. Multiple sclerosis, stable. 6. Hyperlipidemia. 7. Diabetes mellitus type 2, however patient is not on any diabetic medications right now.
DM|diabetes mellitus|DM|204|205|PROBLEM #4|Because of his difficulty swallowing, the patient was kept NPO, and had a GJ tube placed, and was initiated on J-tube feeds. These were worked up, and at the time of discharge, the was receiving Resource DM at a rate of 75 cc/hour, and tolerating this well. We did note that he occasionally had some hiccups, thought to be secondary to supine positioning with the tube feeds.
DM|dextromethorphan|DM|132|133|OUTPATIENT MEDICATIONS|5. Lexapro 10 mg p.o. q day 6. Clomitrazole 10 mg troches 3-4 times per day 7. Ranitidine 150 mg p.o. q. at bed-time 8. Guaifenesin DM 5 ml. p.o. b.i.d. 9. Lorazepam 1 mg p.o. t.i.d. 10. Albuterol metered dose inhaler p.r.n. 11. Nasacort AQ 1-2 sprays each nostril daily 12. Vicodin 1-2 tabs p.o. q 4 -6 hours p.r.n.
DM|dextromethorphan|DM|155|156|PROBLEM #5|Mucositis has resolved. PROBLEM #5: Pulmonary. _%#NAME#%_ experienced intermittent dry cough. Chest x-ray on _%#MMDD2007#%_ showed clear lungs. Robitussin DM was given p.r.n. for cough. Cough has since improved and resolved. No other pulmonary issues to-date. PROBLEM #6: Hematology. The patient was transfused to keep hemoglobin greater than or equal to 8 and platelets greater than or equal to 30 due to increased vaginal bleeding status post cone colposcopy procedure done on _%#MMDD2007#%_ with intermittent breakthrough bleeding.
DM|diabetes mellitus|DM|271|272|PLAN|Aggressively hydrate the patient. Continue vancomycin and Zosyn. Monitor blood cultures, obtain stool cultures, and start the patient on oral Flagyl therapy and cholestyramine to bind toxin. 6. For hyperglycemia, diabetes type 2. Initiate insulin iv therapy.He will need DM teaching later. 7. For recent right shoulder surgery. Will probably need to get physical therapy involved in the patient's treatment prior to discharge.
DM|dextromethorphan|DM|238|239|PROBLEM #4|She will continue on Maxzide. PROBLEM #4: Pain. The patient complained of primarily right-sided chest pain, worsened by cough and deep breathing. This was most likely musculoskeletal, as she was ruled out for an MI. I gave her Robitussin DM and Tylenol #3 to help with the cough. She was also given these medications on discharge. PROBLEM #5: Fluids, electrolytes, and nutrition.
DM|dextromethorphan|DM|155|156|DISCHARGE INFORMATION|I. Albuterol 2.5 mg nebulizer b.i.d. and q.4h. p.r.n. J. Cefixime 15 mg G-tube b.i.d. x 10 days. K. Pulmicort Respules 250 mcg b.i.d. p.r.n. L. Robitussin DM 2.5 cc G-tube q.6h. p.r.n. M. Maalox 5 cc G-tube q.i.d. p.r.n. N. Ibuprofen 100 mg G-tube q.6h. p.r.n. O. Tylenol 160 mg G-tube q.4h. p.r.n. 4. Follow up with primary physician via phone or appointment as already scheduled and as needed.
DM|diabetes mellitus|DM.|137|139|DISCHARGE INFORMATION|The mother's pregnancy history was significant for maternal age 45 years, blood type A- (received Rhogam) and history of HTN and type II DM. The infant was delivered cesarean section secondary to fetal distress with Apgar scores of 5 at one minute and 8 at five minutes. Baby _%#NAME#%_ was a term LGA female infant, 4336 gm at 40 3/7 weeks gestation.
DM|diabetes mellitus|DM,|212|214|GI|It is still unclear if we are going to manage this patient with Trauma Surgery or take over the care of this patient. Mrs. _%#NAME#%_ Lillemoe is a 62-year-old WF with past medical history significant for type 2 DM, hypertension, morbid obesity resulting in gastric bypass surgery on _%#MMDD2007#%_ who was initially admitted to University of Minnesota Medical Center, Fairview _%#CITY#%_ on _%#MMDD2007#%_ with weakness and orthostatic hypotension felt to be secondary to volume depletion (in turn secondary to diarrhea).
DM|diabetes mellitus|DM.|130|132|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. History of morbid obesity - indication for gastric bypass Roux-en-Y surgery on _%#MMDD2007#%_. 2. Type 2 DM. 3. Hypertension. 4. Hyperlipidemia. 5. History of breast cancer, status post left lumpectomy in 2001. Surgery was followed by chemotherapy and 35 sessions of radiation therapy.
DM|dextromethorphan|DM|202|203|MEDICATIONS ON TRANSFER|9. Robitussin AC 5 mL syrup p.o. q.8 h. p.r.n. cough. 10. Lactulose 30 mL syrup p.o. daily p.r.n. for constipation. 11. Synthroid 150 mcg p.o. daily. 12. Hydrocortisone/chloroheniramine. 13. Robitussin DM 5 mL suspension p.o. q.12 h. p.r.n. for cough. 14. Ativan 0.5 mg IV q.4 h. p.r.n. anxiety. 15. Ativan 1 mg p.o. q.4 h. p.r.n. for anxiety.
DM|dextromethorphan|DM|150|151|DISCHARGE MEDICATIONS|22. Phenergan 12.5 to 25 mg p.o. q.6h p.r.n. 23. Trazodone 2 5 mg p.o. q.h.s. p.r.n. sleep. 24. Morphine elixir 10 mg p.o. q.4h p.r.n. 25. Robitussin DM 10 cc p.o. q.4h p.r.n. 26. Maalox 15 to 30 cc p.o. q.i.d. p.r.n. 27. Celluvisc eyedrops OU b.i.d. p.r.n.
DM|diabetes mellitus|DM,|160|162|ALLERGIES|5. Temazepam 30 mg q.h.s. 6. L-glutamine 500 mg p.o. q.d. 7. Epogen. 8. Neulasta. ALLERGIES: No known drug allergies. FAMILY HISTORY: Mother deceased at 74, of DM, CAD, HTN, history of MI, and CVA. Father deceased at 75 of MI and CVA. Siblings, 2 brothers with hypertension and 2 sisters with hypertension.
DM|diabetes mellitus|DM|202|203|PAST MEDICAL HISTORY|Status post radiation in 1975. 5. Status post splenectomy. Status post mediastinal resection. 9. History of uterine cancer. 10. History of basal CA of of back. 11. History of gastroparesis secondary to DM type 2. 12. Depression. 13. History of carpal tunnel syndrome. 14. Status post appey in 1975. 15. History of inflammatory arthritis. 16. Restrictive lung disease. PFTs _%#MMDD#%_.
DM|dextromethorphan|DM|133|134|DISCHARGE MEDICATIONS|1. Percocet 1-2 p.o. q.4-6h. p.r.n. for pain. 2. Lovenox 60 mg subcu q.12h. x2 weeks. 3. Synthroid 150 mcg p.o. daily. 4. Robitussin DM 10 mL p.o. q.4h. p.r.n. cough. 5. Pantoprazole 20 mg p.o. b.i.d. FOLLOW UP: Patient was discharged on _%#MM#%_ _%#DD#%_, 2004, in good condition.
DM|diabetes mellitus|DM|286|287|ASSESSMENT AND PLAN|He was a 1877 gm, 29 week 0 day gestational age male infant born at University of Minnesota to a 31-year-old, gravida 2, para 1, blood type O+, Caucasian female whose EDC was _%#MM#%_ _%#DD#%_, 2008 by ultrasound. The mother's pregnancy was complicated by preeclampsia and known type 1 DM on an insulin pump. The mother received betamethasone x 2 doses prior to delivery. The infant was delivered by Cesarean section with Apgar scores of 7 at one minute and 8 at five minutes.
DM|diabetes mellitus|DM|167|168|SIGNIFICANT PAST MEDICAL HISTORY NOT MENTIONED IN DISCHARGE DIAGNOSES INCLUDES|1. History of bleeding ulcers. 2. History of a right CVA with a visual deficit. 3. Atrial fibrillation. 4. Pacemaker with defibrillator placement. 5. CABG in 1964. 6. DM controlled by diet. 7. Anemia with history of transfusion in _%#MM#%_ of 2001. 8. Baseline creatinine is 2, due to her chronic renal insufficiency.
DM|dextromethorphan|DM|146|147|INPATIENT MEDICATIONS|10. Tylenol 650 mg p.o., take 1 q.4-6 h. p.r.n. pain. 11. Albuterol inhaler 2.5 mL take 2 puffs q.4 h. p.r.n. shortness of breath. 12. Robitussin DM take p.o. q.4-6 h. p.r.n. cough. 13. Vicodin 5 mg/500 p.o. take 1 to 2 tablets q.4-6 h. p.r.n. pain. 14. Milk of Magnesia 30 mg p.o. daily p.r.n. constipation.
DM|dextromethorphan|DM,|231|233|HOSPITAL COURSE|The opioids, however, are typically tested with a glucurone ___________ assay, which we do not use. We use an immunoassay screen by Abbott Labs. Still, the medications that he took prior to arrival that he admits to are Robitussin DM, Tylenol Cold Sinus, and two pills from a friend upstairs, which later were identified as Seroquel. He did not on further testing turn up positive for dextromethorphan on his initial urine.
DM|dextromethorphan|DM|184|185|DISCHARGE MEDICATIONS|9. Rythmol 150 mg two times per day. 10. Maxzide 37.5/25 one p.o. q day. 11. Prednisone 20 mg daily for five days total. 12. Tessalon Perles 200 mg three times per day. 13. Robitussin DM syrup 5 ml 3x per day as needed. 14. Albuterol MDI 1-2 puffs inhaler every six hours as needed. 15. Colace 100 mg one p.o. b.i.d. 16. Protonix 40 mg p.o. q day while still on the prednisone.
DM|diabetes mellitus|DM|240|241|PLAN|PLAN: 1. Hospitalize the patient in the Cardiac Intensive Care Unit (CICU) to rule him out for any acute coronary syndrome. 2.. Anti-coagulate the patient and will replace the patient's electrolytes aggressively. 3. Insulin drip. Stop home DM medications and check HbA1C. 4. Diltiazem drip as I am reluctant to give him any long-acting medications due to the fact that he may have alternating bundle-branch block.
DM|diabetes mellitus|DM,|125|127|FAMILY HISTORY|Lives with his nephew, widowed, wife died approximately 4 years ago with AML. Retired last year. FAMILY HISTORY: Denies CAD, DM, or malignancy. REVIEW OF SYSTEMS: As described in HPI above. Denies vision changes, orthopnea, or PND.
DM|diabetes mellitus|DM.|187|189|PAST MEDICAL HISTORY|3. Pancreatic transplant, _%#MM#%_ 2002. 4. Coronary artery disease, status post PTCA to the right coronary artery. 5. Right total hip. 6. Diabetes mellitus. 7. Retinopathy, secondary to DM. 8. Nephropathy, secondary to DM, requiring transplant. 9. Neuropathy secondary to DM. 10. History of multiple urinary tract infections. 11. History of cystitis.
DM|dextromethorphan|DM|131|132|DISCHARGE MEDICATIONS|10. Naproxen 500 mg orally twice daily as needed back pain. 11. Tylenol 650 mg orally every 6 hours as needed pain. 12. Robitussin DM 1-2 tsp orally every 6 hours as needed cough. 13. Nystatin 100,000 units swish and swallow four times a day as long as on antibiotics.
DM|diabetes mellitus|DM.|248|250|HOSPITAL COURSE|As patient did have low grade fevers and elevated white count, we discontinued the Foley the day before she was discharged to the TCU. Patient was started on Urecholine 10 mg p.o. twice a day by urologist for neurogenic bladder which could be from DM. pt creatinine has been stable over the last few days before discharge at 2.39 and 2.38. patient was started on Lasix and hydrochlorothiazide initially for probable heart failure with the shortness of breath.
DM|dextromethorphan|DM.|204|206|CURRENT MEDICATIONS|c. Reglan 10 mg tablets Q 4-6 hours prn. d. Reglan 20 mg intravenous Q 4-6 hours prn. e. Ativan 1-2 mg intravenous Q 2-4 hours prn. f. Prn. Acetaminophen g. Maalox h. Dulcolax suppositories i. Robitussin DM. j. Milk of Magnesia k. Compazine suppositories l. Restoril QHS SPIRITUAL SOURCES OF STRENGTH: The patient is Catholic.
DM|dextromethorphan|DM|279|280|PLAN|3. Discontinue ranitidine. Start Protonix 40 mg daily. 4. Wi th chronic headaches and no prior evaluation we will obtain a head CT to ensure no gross abnormalities. 5. Pain service consultation. 6. Lidoderm patch to lumbar discomfort, 12 hours on and 12 hours off. 7. Robitussin DM p.r.n. cough. 8. Chest x-ray and O2. 9. The patient was advised to obtain a primary care provider subsequent to discharge.
DM|dextromethorphan|DM|183|184|MEDICATIONS|MEDICATIONS: 1. Lisinopril 5 mg p.o. daily. 2. Ranitidine 150 mg p.o. daily. 3. Aldactone 50 mg p.o. b.i.d. 4. Detrol LA 2 mg p.o. daily. 5. Tylenol 1000 mg p.o. t.i.d. 6. Robitussin DM 5 to 10 cc p.o. q.4-6 h. p.r.n. 7. Imodium AD 2 mg p.o. p.r.n. with each loose stool. 8. Oxycodone/acetaminophen 2.5 mg p.o. daily. REVIEW OF SYSTEMS: A 10-point review of systems is positive for left-sided weakness, impaired gait, impaired vision of her right eye, and frequent awakening from sleep.
DM|dextromethorphan|DM|207|208|CURRENT MEDICATIONS|15. Compazine 25 mg suppositories q four hours p.r.n. 16. Zofran 4 mg IV b.i.d. p.r.n. 17. Reglan 20 mg p.o. q four to six hours p.r.n. 18. Acetaminophen 19. Maalox 20. Dulcolax suppositories 21. Robitussin DM 22. Milk of Magnesia 23. Demerol p.r.n. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.4, pulse 128, respirations 32, blood pressure 112/81.
DM|dextromethorphan|DM|195|196|PLAN|Titrate upward by 300 mg every 2-3 days. 5. Follow-up CMP and lipase on _%#MMDD#%_. Add lipase to this morning's labs to ensure improved toward normal as I would expect clinically. 6. Robitussin DM for cough. 7. Primary MD follow-up subsequent to discharge. Thank you for the consultation. Will follow along as indicated.
DM|diabetes mellitus|DM|186|187|PAST MEDICAL HISTORY/PAST SURGICAL HISTORY|PAST MEDICAL HISTORY/PAST SURGICAL HISTORY: 1. Diabetes mellitus, type 2. 2. End-stage renal disease on hemodialysis, status post kidney transplant as stated above on _%#MMDD2007#%_. 3. DM retinopathy. 4. Graves' disease secondary to radioactive iodine. 5. Hypothyroidism. 6. Hypopituitarism secondary to resection of pituitary adenoma in 2005.
DM|dextromethorphan|DM.|178|180|CURRENT MEDICATIONS|13. Warfarin. 14. Prn medications are: a. Tylenol. b. Albuterol nebs q 4 hours prn. c. Maalox. d. Bisacodyl suppositories. e. Clonidine 100 mcg q eight hours prn. f. Guaifenesin DM. g. Haldol 2 mg IV q one hour prn. h. Ativan 0.5 mg IV q three to four hours prn as well as Ativan 1-4 mg p.o. q one to two hours prn.
DM|diabetes mellitus|DM.|236|238|PAST MEDICAL HISTORY|5. Status-post laparoscopic GI bypass in _%#MM2004#%_, Roux-en-Y. 6. Status-post laparoscopic appendectomy. 7. Status-post pancreatic transplant _%#MM2004#%_. 8. Hypothyroidism. 9. Hypogonadism. 10. End-stage renal disease secondary to DM. 11. History of autonomic neuropathy. 12. History of GI bleed (source unclear) in _%#MM2007#%_. 13. Status post C. diff colitis in _%#MM2007#%_. 14. Status post CMV colitis _%#MM2007#%_.
DM|dextromethorphan|DM|208|209|HISTORY OF PRESENT ILLNESS|Chest x-ray demonstrated no active disease. No clear secretion purulence. Normal oxygen saturation on room air. Apparent improvement following administration of DuoNeb with reduced cough following Robitussin DM and Percocet (unable to take codeine?). Started on prednisone taper beginning with 40 mg q. day, Zithromax and DuoNebs. The patient continued with intractable cough prompting presentation for unscheduled visit to the office on _%#MMDD2004#%_.
DM|dextromethorphan|DM|128|129|PLAN|PLAN: 1. Admit to medicine. 2. Intravenous fluid support. 3. IV steroids. 4. DuoNeb q.4 h. 5. Continue Zithromax. 6. Robitussin DM and Percocet for cough (unable to take codeine). 7. Resume home medications. 8. Pulmonary consultation. 9. Add Humibid, consider mucolytic.
DM|diabetes mellitus|DM|113|114|PAST MEDICAL HISTORY|He is tolerating one hour of therapy per day, and he is willing to try 3 hours per day. PAST MEDICAL HISTORY: 1. DM type 1; nephropathy; neuropathy and retinopathy; status post kidney pancreas transplant 1998; status post pancreas repeat transplant in _%#MM2006#%_ secondary to pancreatic failure; longstanding diabetic foot ulcers; history of end-stage renal disease; patient was on dialysis prior to kidney transplant.
DM|dextromethorphan|DM|179|180|CURRENT MEDICATIONS|8. Senokot S two tablets q. 12 h. 9. Trazodone 150 mg q.h.s. 10. Bactrim DS one tablet b.i.d. x 7 days. 11. Tylenol 650 mg p.r.n. 12. Dulcolax suppositories p.r.n. 13. Robitussin DM p.r.n. 14. Oxycodone 5 mg p.o. q. 4 h. p.r.n. 15. Compazine 10 mg p.o. q. 6 h. p.r.n. 16. Milk of Magnesium p.r.n. 17. Fleets enema p.r.n.
DM|dextromethorphan|DM|204|205|CURRENT MEDICATIONS|4. Bipolar disorder. 5. Episodes of bronchitis versus pneumonia starting earlier this year as per HPI resulting in hospital admissions. CURRENT MEDICATIONS: 1. Levofloxacin 500 mg IV q.24h. 2. Robitussin DM as needed. 3. Levothyroxine 75 micrograms orally daily, currently on hold. 4. Metronidazole 500 mg IV q.8h. 5. Propofol drip at 8 microgram/kilogram/minute.
DM|diabetes mellitus|DM|246|247|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Exacerbation of chronic lower back pain. HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ is a 55-year-old female with multiple medical problems including CAD, status post CABG followed by stents, hypertension, hyperlipidemia, type 2 DM with peripheral neuropathy admitted to University of Minnesota Medical Center, Fairview, last eve with exacerbation of chronic lower back pain felt to be due to lumbar diskitis - osteomyelitis.
DM|diabetes mellitus|DM,|231|233|PHYSICAL EXAMINATION|Sclerae anicteric. Ears are normal set; EAC patent; able to hear the rustle of fingers in both ears. Mouth and oropharynx clear, nonexudative, nonerythematous. Edentulous upper; own lower teeth. NECK: Supple without adenopathy, no DM, no carotid bruits, no JVD. BACK: Straight with tenderness to palpation of lower lumbar spine. CHEST: Clear to auscultation at the bases. HEART: Normal S1, S2; RRR without murmur, gallop or rub.
DM|diabetes mellitus|DM|111|112|HOSPITAL COURSE|The patient will need this followed up as an outpatient by his primary cardiologist, _%#NAME#%_ _%#NAME#%_. 5. DM 2, insulin independent: The patient's glucose was maintained less than 200 on 30 units of Lasix daily with the need for sliding scale insulin.
DM|dextromethorphan|DM|133|134|CURRENT MEDICATIONS|16. ____________200 mg p.o. q. h.s. 17. Tylenol 325 mg p.o. q. 4 hours p.r.n. 18. Maalox 30 cc p.o. q. 4 hours p.r.n. 19. Robitussin DM p.o. q. 6-8 hours p.r.n. 20. Milk of Magnesia 30 cc p.o. daily p.r.n. 21. _____________7.5 mg p.o. q. h.s. p.r.n. for insomnia. ALLERGIES: PENICILLIN; MACRODANTIN; LATEX; IODINE.
DM|dextromethorphan|DM.|260|262||The patient initially became sick on _%#MMDD2004#%_ and she developed cough, non-productive, sore throat, nausea, fever and exertional shortness of breath. At that time she had some mild congestion of the lung bases and was started on Zithromax and Robitussin DM. Yesterday, the patient became rather ill with high fevers, close to 104, dizziness with motion or even vertigo, nausea. At one time she vomited and was not able to keep any food or medication down in the stomach.
DM|dextromethorphan|DM|146|147|ASSESSMENT AND PLAN|We will also give him a trial of bronchial drainage and percussion to see if this can help loosen the sputum and help him cough it up. Robitussin DM p.r.n. 2. Depression. The patient has a history of depression. He currently denies suicidal ideation, but is worried that he may die from this current illness.
DM|diabetes mellitus|DM|131|132|PAST MEDICAL HISTORY|2. Hypertension. 3. GERD. 4. History of gastric ulcer related to NSAID use. 5. Obstructive sleep apnea. The patient is on CPAP. 6. DM 2 with peripheral neuropathy per patient report. 7. Psoriasis. The patient is on light therapy. 8. Dyslipidemia. 9. Morbid obesity.
DM|dextromethorphan|DM|127|128|DISCHARGE MEDICATIONS|7. Albuterol MDI 2 puffs q.4h. x48 hours and then q.4h. p.r.n.. 8. Prednisone taper. 9. Augmentin x4 more days. 10. Robitussin DM 10 cc p.o. q.4h. p.r.n. DISCHARGE INSTRUCTIONS: Diet, low sodium. Activity as tolerated. FOLLOWUP: Followup with primary MD and she will need to follow up with her primary surgeon for her new breast lump.
DM|diabetes mellitus|DM|73|74|PAST MEDICAL HISTORY|He is now back to his baseline creatinine of 1. PAST MEDICAL HISTORY: 1. DM 2. 2. Hypertension. 3. Hyperlipidemia. 4. Right pontine cerebellar peduncular CVA _%#MM2002#%_. 5. Presumed obstructive sleep apnea. 6. Obesity. 7. Hypothyroidism. 8. Right lower lobe pneumonia with pleural effusion and sepsis, _%#MMDD2005#%_.
DM|diabetes mellitus|DM,|301|303|DISCHARGE DIAGNOSES|5. History of depression. 6. History of hyperlipidemia. 7. Chronic renal insufficiency-baseline creatinine 1.5. 8. Dysphagia-on honey-thickened liquid diet. 9. UTI HOSPITAL COURSE: Ms. _%#NAME#%_ is an 80-year-old female with multiple medical problems including hypertension, type 2 insulin-requiring DM, multi-infarct dementia, depression, hyperlipidemia and chronic renal insufficiency who was having lunch on the day of admission when she fell out of her wheelchair and landed on her forehead.
DM|diabetes mellitus|DM|161|162|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Hypertension. 2. Hyperlipidemia. 3. Osteoarthritis. 4. GERD. 5. Non-alcoholic steatotic hepatitis. 6. Osteopenia. 7. Diverticulosis. 8. DM 2. 9. Status post appy. 10. Status post TAH. FAMILY HISTORY: Father with DM, CAD, and CHF. Sister with CHF.
DM|dextromethorphan|DM,|281|283|MEDS ON ADMISSION|He had clear-cut directives of DNR/DNI. PAST SURGERIES: Included a cholecystectomy, hernia repair, appendectomy. ALLERGIES: Iodine and colored soap. MEDS ON ADMISSION: Included digoxin, Glucotrol, Effexor, Aricept, Florinef, Ditropan, Proscar, Xanax, Risperdal, Paxil, Robitussin- DM, Tropol XL. He was admitted then with a diagnosis of increasing confusion, possible aspiration pneumonia versus viral infection.
DM|dextromethorphan|DM|150|151|DISCHARGE MEDICATIONS|Special cares will be applied for her Foley catheter, which is chronic, and a PICC line which is only temporary. DISCHARGE MEDICATIONS: 1. Robitussin DM 2 tsp q 6 hours p.r.n. 2. Vancomycin 1100 mg IV q day through _%#MMDD2004#%_. 3. Lasix 40 mg b.i.d. 4. Albuterol/Atrovent nebulizer q.i.d. 5. Ativan 1 mg at h.s.
DM|diabetes mellitus|DM|156|157|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Glaucoma. 2. Right cataract surgery 1999. 3. Right hip fracture, status post open reduction and internal fixation _%#MM2005#%_. 4. DM 2, diagnosed _%#MM2005#%_. 5. Moderate to severe aortic stenosis. 6. Echocardiogram _%#MM2005#%_ showed solid area of 0.9 cm sq and gradient of 22 mmHg, diastolic dysfunction and possible PFO.
DM|diabetes mellitus|DM|197|198|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Ancef 2 gm IV q.8h. x 12 days, Neupogen 300 mcg SQ q.d. x 10 days, Neurontin 100 mg q.d., Claritin, Rhinocort, Senokot, Percocet 1-2 tablets q.4-6h. p.r.n. pain, Robitussin- DM p.r.n. cough.
DM|diabetes mellitus|DM|265|266|HOSPITAL COURSE|As he has received over six months of Coumadin therapy and as an isolated source for clot, recommendation per Vascular Surgery is to discontinue Coumadin during this hospitalization, and patient will not be restarted on this on an outpatient basis. 4. Uncontrolled DM 2. The patient was discharged on Amaryl with excellent blood sugar control. 5. Hypertension. The patient's medications were adjusted. Currently he is on lisinopril and Norvasc with excellent blood pressure control.
DM|dextromethorphan|DM|169|170|DISCHARGE MEDICATIONS|10. Ranitidine 300 at bedtime. 11. Tylenol 116 mg per 5 ml, 20 ml per G tube q.6h. p.r.n. pain. 12. Ambien 5 mg at bedtime p.r.n. 13. Guaifenesin liquid and guaifenesin DM as needed for cough. 14. Cefzil 500 b.i.d. for 5 days for his infection. Follow up with Dr. _%#NAME#%_ as needed.
DM|dextromethorphan|DM|140|141|DISCHARGE MEDICATIONS|3. Zantac 150 mg p.o. b.i.d. 4. Actigall 250 mg p.o. b.i.d. 5. Vitamin C 250 mg p.o. q. day. 6. Vitamin E 400 IU p.o. q. day. 7. Robitussin DM 10 mL p.o. q4h p.r.n. cough. DISPOSITION: The patient was transferred to Fairview-University Medical Center, _%#CITY#%_ campus, inpatient psychiatry on _%#MMDD2003#%_ in stable condition.
DM|dextromethorphan|DM|129|130|MEDICATIONS|12. Augmentin 875 p.o. daily x 7 days for sinus infection. 13. Afrin nasal spray 3 puffs q. nare b.i.d. x 3 days. 14. Robitussin DM 10 ml p.o. q.4h. p.r.n. SOCIAL HISTORY: Smokes one pack of cigarettes per day.
DM|diabetes mellitus|DM.|180|182|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. History of fracture as described above. 2. History of hypertension. 3. History of hypothyroidism. 4. History of obesity. 5. History of COPD. 6. History of DM. MEDICATIONS/ALLERGIES: Reviewed and documented on chart.
DM|diabetes mellitus|DM,|227|229|HISTORY OF PRESENT ILLNESS|She had no residual from this. For past medical, surgical and social history, please see the detailed admission note from Drs. _%#NAME#%_ and _%#NAME#%_, as well as numerous consultations detailing her coronary artery disease, DM, hypertension, and renal insufficiency. PHYSICAL EXAMINATION: She is alert and pleasant in no acute distress.
DM|dextromethorphan|D.M.|177|180|PLAN|3. Zithromax with an issue of protracted upper respiratory infection, lingering secretion purulence, and question of underlying airway reactivity. 4. Chest x-ray. 5. Robitussin D.M. (alcohol free). 6. Albuterol metered-dose inhaler p.r.n. 7. Check O2 saturations on room air. 8. Clinical observation. Review screening labs as ordered.
DM|dextromethorphan|DM.|93|95|ASSESSMENT|ASSESSMENT: 1. Depression status post suicide attempt by hanging and ingestion of Robitussin DM. There is no physical sequelae from his ingestion and hanging attempt. 2. Cervical lymphadenopathy does not appear to be clinically significant.
DM|dextromethorphan|DM|182|183|REQUESTING PHYSICIAN|Her echocardiogram showed well preserved systolic function, mild MR, ejection fraction 60%. She had been having symptoms of URI, had used some OTC nasal decongestants and Robitussin DM and it was thought that she may have had an episode of accelerated hypertension causing brief cardiac decompensation.
DM|dextromethorphan|DM|194|195|PLAN|10. Headaches, likely mixed, with tension/muscle contraction and vascular component. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Zofran (Zydis form) p.r.n. nausea. 3. Robitussin DM for cough. 4. Start Zithromax. 5. Continue metered dose inhaler therapy, as above. 6. Duo-Nebs q. 4h. p.r.n. 7. Midrin for headache.
DM|dextromethorphan|DM|163|164|ADMISSION MEDICATION|5. Levoxyl 25 mcg q. day. 6. Miacalcin nasal spray q. day, alternating nares. 7. Milk of Magnesia 30 mg p.r.n. constipation. 8. Remeron 45 mg q.h.s. 9. Robitussin DM 2 teaspoons p.r.n. q. 4 h. cough. 10. Senokot S one tablet b.i.d. 11. Seroquel 12.5 mg q. day. 12. Toprol XL 25 mg q. day.
DM|diabetes mellitus|DM.|209|211|PAST MEDICAL HISTORY|14. Status post recent hospitalization from _%#MMDD2007#%_ through _%#MMDD2007#%_ for acute mental status changes, which were felt to be due to narcotic overdose and responded to Narcan. 15. History of type 2 DM. MEDICATIONS: 1. Tizanidine 6 mg q.i.d. 2. Plaquenil 200 mg b.i.d. 3. Oxycodone CR 20 mg b.i.d.
DM|diabetes mellitus|DM,|220|222|PAST MEDICAL HISTORY|3. Pancreatic transplant, _%#MM#%_ 2002. 4. Coronary artery disease, status post PTCA to the right coronary artery. 5. Right total hip. 6. Diabetes mellitus. 7. Retinopathy, secondary to DM. 8. Nephropathy, secondary to DM, requiring transplant. 9. Neuropathy secondary to DM. 10. History of multiple urinary tract infections. 11. History of cystitis. ADMISSION MEDICATIONS: 1. CellCept 750 mg p.o. b.i.d. 2. Neoral 75 mg p.o. q.a.m. and 50 mg p.o. q.p.m.
DM|diabetes mellitus|DM|140|141|PAST MEDICAL HISTORY|She has impaired ADLs. The patient is very motivated and her husband is very supportive to continue her therapies. PAST MEDICAL HISTORY: 1. DM type 2. 2. End-stage renal disease, hemodialysis 3 times per week, status post failed kidney transplant x2 and pancreas transplant.
DM|diabetes mellitus|DM|159|160|PAST MEDICAL HISTORY|He is somewhat-to-not motivated with therapy. He complains of fatigue and is below baseline with gait and transfers. PAST MEDICAL HISTORY: 1. Hypertension. 2. DM type 2. 3. Chronic graft versus host disease. 4. AML with M3. 5. Hypogonadism. 6. Peripheral neuropathy. 7. Cataracts. 8. Leukemic meningitis.
DM|dextromethorphan|DM.|169|171|CURRENT MEDICATIONS|3. Pulmicort nebulizers 0.5 mg p.o. daily. 4. Xopenex 0.3 mg q. 4 h p.r.n. 5. Omnicef 187.5 mg daily. 6. P.r.n. dextromethorphan, Pseudoephedrine preparation of Z-cough DM. REVIEW OF SYSTEMS: Remarkable for slight corneal clouding; PE tubes, as noted above; reactive airway disease, as noted above; and mitral valve regurgitation, as noted above; hypospadias; hydrocele; and hernia, status post repair, with mild joint limitations and dysostosis multiplex, as well as eczema.
DT|diphtheria-tetanus|DT|247|248|IMMUNIZATION|He only took part of his antibiotics. For the last two days, he has been going to the bathroom more as well but does not wish to take diuretics because he has to go to the bathroom a lot. ALLERGIES: To Lisinopril, Actos and Isordil. IMMUNIZATION: DT booster in 2005, pneumovax in 1996, flu shot every year. MEDICATIONS: 1. Coumadin 5 mg. daily 2. Diovan 80 mg daily
DT|diphtheria-tetanus|DT|87|88|IMMUNIZATIONS|She is not on aspirin or steroids and had no general bleeding problems. IMMUNIZATIONS: DT booster _%#MMDD1997#%_. PHYSICAL EXAMINATION: Shows a well appearing middle age white female.
DT|diphtheria-tetanus|DT|96|97|IMMUNIZATIONS|With current medications he feels content. IMMUNIZATIONS: He has had a Pneumovax before. He had DT in 2003. He had hepatitis A vaccine #1 and #2 in 2003. PHYSICAL EXAMINATION: VITAL SIGNS: Weight 181 pounds. Blood pressure 124/80.
DT|delirium tremens|DT|207|208|2. HTN|He may need to be considered for possibly commitment, as he has failed multiple alcohol treatments outpatient. At this time, we will defer this decision to the psychiatric evaluation. We will keep him under DT precautions and use Ativan p.r.n. We will start him on IV fluids for dehydration, which is evidenced by his hypernatremia.
DT|delirium tremens|DT.|217|219|2. HTN|At this time, he will be initially admitted to the Intensive Care Unit for overnight close observation due to high risk for potential complications because of drug overdose and alcohol intoxication, and high risk for DT. In the morning, I suspect that if he stays stable, he will be transferred to step-down. 2. HTN: will maintain current regime and monitor BP for now.
DT|delirium tremens|DT,|115|117|ASSESSMENT/PLAN|He had a small bowel loop without obstruction suggesting underlying ileus. ASSESSMENT/PLAN: 1. Alcohol withdrawal, DT, and depression. We will admit him to the ICU for observation and management of alcohol tremors. 2. Dehydration secondary to gastroenteritis. Stool culture was obtained.
DT|diphtheria-tetanus|DT|172|173|REVIEW OF SYSTEMS|Neurologic - had hydrocephalus, treated with a shunt, improved with her memory, although still has some problems. Has depression. Sees Dr. _%#NAME#%_ _%#NAME#%_. She had a DT in 1998. SOCIAL HISTORY: She is a retired RN. She lives by herself.
DT|delirium tremens|DT|163|164|PLAN|1. Recent seizure: At this point in time, I would watch him overnight and make sure that he doesn't have any more seizure activity. He is not currently having any DT type symptoms, but he obviously was placed on the alcohol withdrawal protocol. 2. I will go ahead and have chemical dependency see the patient as well and try to get him hooked up with some sort of rehab.
DT|diphtheria-tetanus|DT|106|107|HISTORY|Orthopedic consultation was requested regarding the open elbow fracture. He was given a gram of Ancef and DT toxoid booster. PAST MEDICAL HISTORY: Negative for any chronic medical problems. He has had some eye surgery in the past.
DT|delirium tremens|(DT)|245|248|IMPRESSION|It appears that he has left leg cellulitis and has had this in the past with fairly good results after he has been started on antibiotics. He also has a fairly extensive past medical history of alcohol use but no history of any delirium tremens (DT) in the past. PLAN: 1. Left foot cellulitis. a. I will go ahead and start him on antibiotics with Zosyn 3.375-g IV q.8h.
DT|delirium tremens|DT|129|130|HOSPITAL COURSE|He continued to be afebrile after initiating antibiotics for 48 hours until discharge. 5. Alcohol use. The patient was placed on DT prophylaxis and did have some DT with some tachycardia and elevated blood pressure and was transferred to the ICU for that.
DT|delirium tremens|DT|162|163|HOSPITAL COURSE|He continued to be afebrile after initiating antibiotics for 48 hours until discharge. 5. Alcohol use. The patient was placed on DT prophylaxis and did have some DT with some tachycardia and elevated blood pressure and was transferred to the ICU for that. His temperature resolved and was stable upon discharge. 6. Hepatosplenomegaly secondary to alcohol use and strongly recommended to quit drinking alcohol.
DT|diphtheria-tetanus|DT|118|119|IMMUNIZATIONS|2. Allopurinol 300 mg daily. 3. Desipramine 50 mg at night. 4. OxyContin 10 mg, 2 tablets twice a day. IMMUNIZATIONS: DT booster in _%#MM2000#%_. SOCIAL HISTORY: The patient was married in 2002. He works as a consultant for the disabled out of his home.
DT|diphtheria-tetanus|DT|238|239|ASSESSMENT AND PLAN|Liver function tests are normal. CBC is within normal limits except for the WBC elevated at 18,400, with 6% neutrophils and 9% lymphocytes. Right wrist x-ray: negative. ASSESSMENT AND PLAN: 1. Right hand cellulitis secondary to cat bite. DT was given in the emergency room. I agree with the use of clindamycin and Cipro. The orthopaedic surgeon, Dr. _%#NAME#%_, is aware of this patient, and will see her.
DT|diphtheria-tetanus|DT|173|174|HABITS|There is no family history of diabetes, breast cancer, or colon cancer. HABITS: She neither smokes nor drinks. She eats a balanced diet. Immunizations are up to date with a DT in 1995 and a Pneumovax in 2000. Advanced directives are in place. CURRENT MEDICATIONS: 1. Fosamax 70 mg a week for osteoporosis.
DT|diphtheria-tetanus|DT|114|115|IMMUNIZATIONS|SOCIAL HISTORY: The patient is married and has three grown children. IMMUNIZATIONS: Immunizations are up to date. DT in 1997. Pneumovax in 1994. REVIEW OF SYSTEMS: The patient has had some recent congestion and sneezing (onset on Sunday) with chills; no known fever.
DT|delirium tremens|DT|300|301|ASSESSMENT AND PLAN|We will interrogated his AICD and insure adequate function. Check echocardiogram to rule out new wall motion abnormality and evaluate left ventricular function as well as check EKG as possible preoperative preparations. 3. Delirium tremens. A patient with recent alcohol intake. We will place him on DT precautions and alcohol withdrawal protocol. 4. Chronic obstructive pulmonary disease exacerbation. Question aspiration with recent increase in alcohol. We will check chest x-ray PA, and lateral. We will continue O2, respiratory therapy nebs and arrange for physical therapy evaluation.
DT|delirium tremens|DT;|200|202|PLAN|Antiemetics and Protonix IV. Keep NPO but start full liquids slowly, but it persistent will keep NPO and consult GI for endoscopy and also will check pancreatitis enzymes. Also, make sure there is no DT; even though she denied any alcohol, we should make sure that she doesn't go into DT. Will check abdominal ultrasound for liver, gallbladder and pancreatic evaluation.
DT|delirium tremens|DT.|285|287|PLAN|Antiemetics and Protonix IV. Keep NPO but start full liquids slowly, but it persistent will keep NPO and consult GI for endoscopy and also will check pancreatitis enzymes. Also, make sure there is no DT; even though she denied any alcohol, we should make sure that she doesn't go into DT. Will check abdominal ultrasound for liver, gallbladder and pancreatic evaluation. Plain abdominal x-ray to see if there is any sign of obstruction.
DT|delirium tremens|DT|243|244|PLAN|PLAN: 1. Hyponatremia: At this point in time he has received a banana bag in the ED and I would go ahead and switch him over to normal saline and check his electrolytes in the morning. 2. Chronic alcohol use: We will go ahead and put him on a DT protocol but again he has done well in the past without alcohol and has not seemed to have gone through any DTs on his prior hospitalizations.
DT|delirium tremens|DT|161|162|PLAN|Clearly sounds like he is a typical alcoholic and underestimates how much he drinks. 5. Told he has hepatitis C. PLAN: Will admit, replete magnesium, telemetry, DT protocol, CD consult. I went back to the charts back to a year ago and allegedly this happened in the recent past and there is nothing on the labs indicating hepatitis C titer was ever done, so we will do one of those.
DT|delirium tremens|DT.|144|146|HISTORY OF PRESENT ILLNESS|He says he has detoxed x10 in the past. Mostly by getting Librium from his doctor, one time by going to a detox. He has not had any seizures or DT. He now enters for further evaluation and therapy. He has gone to AA in the past. His longest sobriety is 5 months.
DT|diphtheria-tetanus|DT|191|192|HABITS|Illnesses - hypertension, hyperlipidemia, status post MI and ASCVD which is stable. Osteoarthritis. ALLERGIES: None HABITS: Former smoker, occasional coffee, no alcohol, no regular exercise. DT in 2003, Pneumovax in 1996. CURRENT MEDICATIONS: 1. Calcium and vitamin D 2. Zocor 40 mg q.day 3. Niacin SR 500 mg q.day
DT|diphtheria-tetanus|DT.|251|253|ADMISSION PHYSICAL EXAMINATION VITAL SIGNS|Surgeries per H and P. ADMISSION PHYSICAL EXAMINATION VITAL SIGNS: Blood pressure 124/90, heart rate 80 and regular, respirations are normal and O2 saturation 96% on room air. HEENT: Right frontal superificial abrasion measuring 3-4 cm. Up-to-date on DT. Pupils are equal and reacting symmetrically. Fundi deferred. CHEST: Clear. CARDIAC: Regular without gallop, murmur, or click. No jugular venous distention.
DT|diphtheria-tetanus|DT|178|179|HABITS|2. Hypertension 3. Hyperlipidemia 4. Postmenopausal 5. Osteoarthritis 6. Multi-infarct dementia. ALLERGIES: Doxycycline, penicillin, sulfa. HABITS: Nonsmoker. Pneumovax in 1995, DT in 2003. MEDICATIONS: 1. KCl 10 mEq q day. 2. Protonix 40 mg b.i.d.
DT|delirium tremens|DT|138|139|PLAN|7. Status post code blue. 8. Dehydration. 9. Generalized myoclonic activity. 10. Chronic sinusitis. PLAN: Continue ventilator management. DT protocol on Ativan drip. Maximize controlling the seizure-like activity. Consulted Neurology, and they recommended if Ativan drip does not work, to add Depakote.
DT|diphtheria-tetanus|DT|112|113|IMMUNIZATIONS|Otherwise, she manages to cook for herself. HEALTH HABITS: Non-smoker, no alcohol. IMMUNIZATIONS: The patient's DT booster is due, flu shot every year. Pneumovax 2001 REVIEW OF SYSTEMS: CARDIAC, RESPIRATORY, GASTROINTESTINAL, GENITOURINARY: Unremarkable MUSCULOSKELETAL: As above PSYCHIATRIC AND NEUROLOGIC: Negative SYSTEMIC: Negative HEMATOLOGIC: Negative.
DT|diphtheria-tetanus|DT|178|179|IMMUNIZATION HISTORY|5. Aspirin. 6. Neurontin. 7. Tylenol. 8. Sublingual nitroglycerin. ALLERGIES: Nausea to codeine and Vicodin. IMMUNIZATION HISTORY: The patient had a Pneumovax in 2000. She had a DT in 2000. She has an annual flu shot. FAMILY HISTORY: Non-contributory. SOCIAL HISTORY: The patient is a 1-2 pack per day smoker and discontinued a few days ago.
DT|diphtheria-tetanus|DT|80|81|IMMUNIZATIONS|11. Amoxicillin 2 gm 1 hour SBE prophylaxis when appropriate. IMMUNIZATIONS: 1. DT in 1995. 2. Pneumovax in 1999. REVIEW OF SYSTEMS: Musculoskeletal: Katy continues to have quite an amount of pain with her arthritis.
DT|diphtheria-tetanus|DT|187|188|REVIEW OF SYSTEMS|He has not had problems with chest pain, shortness of breath, abdominal pain, fevers or chills and no coughing or cold symptoms. He did have Pneumovax on _%#MMDD2003#%_ and also his last DT was _%#MMDD2003#%_ for immunizations. OBJECTIVE: GENERAL: Pleasant, cooperative man in no acute distress. VITAL SIGNS: BP today was 122/72 in the right arm, sitting position.
DT|dorsalis pedis:DP|DT|182|183|PHYSICAL EXAMINATION|HEART: Regular S1 and S2, no murmurs. LUNGS: Clear bilaterally. ABDOMEN: Soft. There is good bowel sounds. No tenderness whatsoever. EXTREMITIES: Warm, there is no peripheral edema. DT pulses are strong and equal. MUSCULOSKELETAL: There is obvious leg shortening of the left hip. The patient is lying in bed and is not trying to sit up or bear weight.
DT|delirium tremens|DT|301|302|PAST MEDICAL HISTORY|He was put on MSSA protocol and Valium was given on schedule basis. PAST MEDICAL HISTORY: History of chronic alcohol abuse and dependency with a history of severe alcohol withdrawal and symptom with 1 episode of seizure in 1993, history of repeated alcohol detox more than 10 times, second history of DT in 2005, bipolar disorder on triple medication Seroquel, Depakote and Zoloft. PAST SURGICAL HISTORY: 1. History of left toe fracture.
DT|diphtheria-tetanus|DT|105|106|IMMUNIZATIONS|Other hospitalizations: 1. Normal spontaneous vaginal delivery times two. IMMUNIZATIONS: Up to date with DT in 1994. ALLERGIES: None known. OTHER MEDICAL PROBLEMS: Include a 1. History of mitral valve prolapse
DT|dorsalis pedis:DP|DT,|175|177|OBJECTIVE|Normal bowel sounds. No carotid or abdominal bruit. Liver is 10 cm height by percussion. RECTAL, GENITALIA: Deferred. LEGS: Excellent nutrition, hair growth, no pretib edema. DT, popliteal pulses are 4/4+ bilaterally. He has cluster purple, superficial small not bulging varicosities of the left ankle like a stocking.
DT|delirium tremens|DT|115|116|FINAL DIAGNOSES|The biggest issues were his medical problems. For years he has been a heavy drinker. He was not having significant DT problems while recovering from the first shoulder surgery. Repeatedly he would forget to show up for surgery or not medically be stable for surgery from his ETOH problems.
DT|delirium tremens|DT|219|220|IMPRESSION AND PLAN|However, should he develop that, he will be treated. Should his pain remain protracted, at that time, he would warrant further evaluation by a possible upper endoscopy. 2. History of alcohol abuse. He will be placed on DT precautions and continue with Ativan as needed. 3. History of pulmonary embolism. He will continue with his Coumadin at the current dose with therapeutic INR.
DT|diphtheria-tetanus|DT|173|174|DOB|He was given Benadryl and Reglan with headache and did have improvement. He was also given IV thiamine, folic acid and multivitamin in the emergency room. He was also given DT tetanus prophylaxis. Patient apparently had a previous seizure in _%#MM#%_ of 2005. Was seen at St. Joseph's Hospital Emergency Room. He does not recall all of those events.
DT|delirium tremens|(DT)|218|221|HEALTH HABITS|As far as alcohol, he says he drinks about 4-6 drinks a night for the last few years, but he did drink heavier prior to that. He has been in outpatient treatment before. He apparently has a history of delirium tremens (DT) according to his primary care physician, however, he does not admit to that. SOCIAL HISTORY: He is currently working as a car dealer.
DT|diphtheria-tetanus|DT|335|336|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Significant for asthma, mental retardation, coronary artery disease with myocardial infarction in 2001, congestive heart failure, secondary to diastolic dysfunction, sleep apnea untreated, severe anxiety, dyspepsia with esophagitis. History of current tinea pedis. In the past she has received her immunizations, DT as well as pneumonia vaccine. MEDICATIONS: At the time of admission are: 1. Prevacid 30 mg daily.
DT|delirium tremens|DT|126|127|ASSESSMENT AND PLAN|I will also obtain a psychiatry consultation for evaluation of his panic attack as well as alcoholism. He is also at risk for DT (delirium tremons) . We will keep him on DT precaution as per protocol. We will also put him on some Ativan 0.5 mg p.o. b.i.d. and p.r.n. for anxiety episodes.
DT|delirium tremens|DT|170|171|ASSESSMENT AND PLAN|I will also obtain a psychiatry consultation for evaluation of his panic attack as well as alcoholism. He is also at risk for DT (delirium tremons) . We will keep him on DT precaution as per protocol. We will also put him on some Ativan 0.5 mg p.o. b.i.d. and p.r.n. for anxiety episodes.
DT|diphtheria-tetanus|DT|147|148|CONSULTATIONS|Recently spent 60 days at Twin Towers Rehab Facility and had been sober for an additional 140 days. Requesting admission to detox. Apparently last DT around _%#MM#%_ 2004. Last seizure was _%#MM#%_ 2004. Seizures reported as bilateral tonic- clonic. Patient also reports feeling depressed, but without suicidal ideation.
DT|delirium tremens|DT.|185|187|CONSULTATIONS|Last seizure was _%#MM#%_ 2004. Seizures reported as bilateral tonic- clonic. Patient also reports feeling depressed, but without suicidal ideation. PAST MEDICAL HISTORY: 1. History of DT. 2. Seizure disorder since birth. 3. Hypertension. 4. Depression. 5. Gout-this is whenever he eats anything "that I shouldn't." 6. Alcohol abuse. 7. Asthma. 8. Left knee arthroplasty for DJD.
DT|delirium tremens|DT,|173|175|DISCHARGE MEDICATIONS|After a heavy intake, she went out for a fresh air, when she had the syncopal episode. HOSPITAL COURSE: At the time of arrival, she was extremely tremulous and for possible DT, she was transferred to the ICU. On _%#MM#%_ _%#DD#%_, 2005, the patient was transferred to the medical floor for further assessment and treatment.
DT|delirium tremens|DT|199|200|PLAN|IMPRESSION/PLAN: 1. ETOH intoxication. 2. Old cerebrovascular accident. 3. Likely dementia, multifactorial etiology secondary to alcohol/CVA. PLAN: Admit the patient and watch for DTs and put him on DT precautions and also delirium protocol. Get social worker consult for discharge planning. Adult Protection report was filed. Will get PT, OT to evaluate and treat and will continue his Plavix.
DT|(drug) DT|DT|213|214|HOSPITAL COURSE|If not already noted, the patient was on TPN for 1 week after her surgery and then was transitioned to tube feeds which ended up as one half teaspoon of Viokase per can of tube feed. The tube feeds being Peptinex DT cycled for 12 hours overnight at a rate of 100 mL per hour. In terms of pain control, the patient initially had trouble weaning off of her PCA, however, at the time of discharge was maintained well on a regimen of methadone 20 mg 3 times a day with Roxicet 5-10 mL q. 6 hours p.r.n. pain for breakthrough.
DT|diphtheria-tetanus|DT|116|117|FOLLOWUP|Father died at 78 of dementia. Mother died at 52 of polycystic kidneys. Virginia had a Pneumovax in 1998. She had a DT in 1999. She has had cholecystectomy, probable cervical disc diverticular disease. Weight stable.
DT|delirium tremens|(DT)|171|174|HOSPITAL COURSE|Chemical Dependency counselor and Psychiatry were consulted and patient will be admitted for inpatient chemical dependency treatment. He has a history of delirium tremens (DT) but remained stable throughout his stay with no need for supplemental Ativan at the time of discharge. He will be discharged to Detoxification. 3. Diabetes mellitus: The patient is medically noncompliant.
DT|diphtheria-tetanus|DT|119|120|IMMUNIZATIONS|Ultrasound shows fluid in the pelvis, probably from gynecologic source. This has not had any follow up. IMMUNIZATIONS: DT immunization _%#MMDD2003#%_. Has apparently had just one hepatitis B; this was on _%#MMDD2002#%_. FAMILY HISTORY: Unavailable. Mother has already gone home. Apparently no one else in the family has any asthma.
DT|diphtheria-tetanus|DT|152|153|LABORATORY STUDIES|Chest x-ray is negative. LABORATORY STUDIES: Today these include UA with micro, hematocrit, STAT potassium, basic metabolic panel, CA19-9, all pending. DT is given. Laboratory reports from _%#MMDD????#%_ show CBC normal except for MCH of 33.3, hemoglobin 15.0, non-fasting glucose was 193, BUN 21, creatinine 1.3, GFR 58, potassium 4.0. Liver function total protein 7, albumin 4.4, globulin 2.6, total bili 15.3, direct bili 8.7, bili indirect 6.6, alkaline phosphatase 171, AST 101, ALT 171, TSH 1.72, PSA 0.7, amylase is 55, hemoglobin A1c is 6.2, an urinalysis is negative.
DT|diphtheria-tetanus|DT|114|115|PAST MEDICAL HISTORY|2) Hyperlipidemia. 3) He has been intentionally losing weight the past year. He had a Pneumovax in 2001. He had a DT in 2001. HABITS: Tobacco: None. Alcohol: Infrequent. FAMILY HISTORY: Father suffered a stroke at age 80 after a carotid endarterectomy, and passed away.
DT|delirium tremens|DT|146|147|HISTORY OF PRESENT ILLNESS|He has been drinking heavily and cannot eat over the last 4 days. He has had some nausea. He is tremulous. He has no history of hallucinations or DT or seizures. PAST MEDICAL HISTORY: Essentially negative, except for that stated above.
DT|diphtheria-tetanus|DT|159|160|DISCHARGE FOLLOW-UP|DISCHARGE INSTRUCTIONS: Diet will regular. DISCHARGE FOLLOW-UP: Follow up as planned above. Otherwise, the patient states that she is up to date on Pneumovax, DT booster and flu shot. She is advised to confirm that when she visits with Dr. _%#NAME#%_. Time spent on this patient's discharge is over 35 minutes.
DT|diphtheria-tetanus|DT|100|101|IMMUNIZATIONS|He has heavy alcohol use. He was in remission as mentioned above for about one year. IMMUNIZATIONS: DT booster was due in 2005. The last one was given in 1995. Influenza shot: Every year. He has not been given a Pneumovax.
DT|delirium tremens|DT|176|177|IMPRESSION AND PLAN|The patient did not require any anti-seizure medications in the emergency room. Will admit the patient to the neuro floor monitor for further seizures, put on seizure and ETOH DT protocol. Hold off on anti-seizure medication for now. We will request neuro consult given her past history of AVM and possibly at risk for further seizures and if she would be a candidate for anti-seizure medication.
DT|delirium tremens|DT|135|136|IMPRESSION AND PLAN|Will check labs and monitor her labs and also schedule an ultrasound of the abdomen. 4. History of alcohol abuse. We will place her on DT precautions. Add thiamine and folic acid and request CD consult which the patient was in agreement to. 5. Normocytic normochromic anemia. Check for GI loss. Will monitor her hemoglobin but would do iron studies as well as B12 and folate levels.
DT|delirium tremens|(DT)|245|248|PAST MEDICAL HISTORY|7. Allergic rhinitis. 8. Cataract. 9. Nephritis. 10. Alcoholism. a. Her husband gives a history of treatment programs x 3, presently undergoing outpatient therapy, apparently trying to quit. b. The patient denies any history of delirium tremens (DT) or seizures, as does her husband. She has had several episodes of acute agitation and possible confusion and her husband feels these are related to alcohol withdrawal type symptoms.
DT|delirium tremens|DT|206|207|FINAL DIAGNOSES|Nausea with recurrent emesis over the 2 weeks prior to presentation with inability to hold down liquids. No hematemesis. Periumbilical to lower abdominal pain. History of alcohol withdrawal, but unaware of DT or withdrawal-related seizures. No prior history of upper GI blood loss. ER evaluation included metabolic profile with normal electrolytes, elevated total bilirubin of 5.6 with conjugated bilirubin of 2.0, alkaline phosphatase 307, ALT of 55, AST of 287, lipase 387, INR of 1.19. Thrombocytopenia with platelet count of 56,000, white count of 3600, and hemoglobin of 12.8 gm%.
DT|diphtheria-tetanus|DT|164|165|CURRENT MEDICATIONS|1. Status post varicose veins times two. 2. Appendectomy 3. Fractured left hip in 2003 CURRENT MEDICATIONS: 1. Calcium 2. Actonel 35 mg weekly Immunizations - last DT in 1996, Pneumovax in _%#MM2004#%_. ALLERGIES: None known SOCIAL HISTORY: The patient has one daughter and one stepdaughter.
DT|delirium tremens|DT|177|178|DOB|His initial lipase was not too high but the next day went to 5627, gradually falling to 65 at the time of discharge. He was placed in the ICU, placed on IV fluids, treated with DT protocol and pain was controlled with morphine. A consultation was obtained with Nephrology, Gastroenterology and Infectious Disease to assist in his management.
DT|delirium tremens|DT.|176|178|HISTORY OF PRESENT ILLNESS|Has had prior withdrawal symptoms, with attempt at abstention over 1-2 days as an outpatient. Manifested by insomnia, tremor, nausea, vomiting, and sweats. Denies knowledge of DT. No history of withdrawal seizures. Without known alcohol-related liver disease, pancreatitis or GI bleed. Presently denies shakes or sweats. Did have recurrent nausea and emesis for at least three days prior to admission.
DT|diphtheria-tetanus|DT|116|117|IMMUNIZATIONS|INJURIES: Right knee injury (1993, skiing with subsequent reconstruction with right ACL). IMMUNIZATIONS: Current on DT (_%#MMDD1998#%_). DIET: None. EXERCISE: Unable to exercise or even walk because of limiting knee pain and effusion.
DT|delirium tremens|DT|145|146|HISTORY OF PRESENT ILLNESS|The patient had been sober for 9 months up to 3 days ago and since then he has been drinking 1 quart of vodka per day. The patient did have some DT and withdrawal seizures in the past. PAST MEDICAL HISTORY: 1. Chronic alcoholism. 2. History of hypernatremia.
DT|diphtheria-tetanus|DT|165|166|PAST MEDICAL HISTORY|4. History of urethral stricture. 5. History of pancreatitis 1978. 6. 1996 hospitalized for chest pain with a negative exercise tolerance test at that time. 7. Last DT _%#MM1998#%_. 8. Flexible sigmoidoscopy _%#MM1999#%_ negative. PAST SURGICAL HISTORY: 1. Vasectomy with left epididymectomy _%#MM1988#%_ for left epididymal mass.
DT|dorsalis pedis:DP|DT|161|162|PHYSICAL EXAMINATION|Abdomen was soft, nontender, and obese. Positive bowel sounds. Port sites from her previous surgery were well-healed. Extremity showed no cyanosis or edema. Her DT and PT pulses were 2+ and equal bilaterally. Radial pulses were 2+ and equal bilaterally. Femoral pulses were 2+ and equal bilaterally as well.
DT|diphtheria-tetanus|DT|123|124|IMMUNIZATIONS|Her husband died of a heart attack. She has one son and two daughters. IMMUNIZATIONS: Pneumovax in 2002, flu shot in 2002, DT booster unclear. FAMILY HISTORY: Breast cancer in sister and mother. REVIEW OF SYSTEMS: CARDIAC: No chest pain or palpitations.
DT|delirium tremens|DT.|207|209|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Asthma, steroid dependent. 2. Osteoporosis, secondary to steroid use. 3. Depression. 4. Hepatitis C. 5. History of alcoholism with last admission here approximately one year ago for DT. The patient has not had any admissions or denies any alcohol since that admission. He has no history of blood transfusions. The etiology of his type C hepatitis is felt secondary to previous tatoo history.
DT|diphtheria-tetanus|DT|95|96|IMMUNIZATIONS|Complains of a dry mouth. PAST SURGICAL HISTORY: No significant surgeries. IMMUNIZATIONS: Last DT was only several years ago. SOCIAL HISTORY: Husband of 55 years died five years ago.
DT|dorsalis pedis:DP|DT|184|185|PHYSICAL EXAMINATION|Exam was remarkable for some central obesity with abdominal striae. Cardiac exam was normal S1, S2 without murmur. Lungs are clear to auscultation. No lower extremity edema was noted. DT pulses were 2+ bilaterally. No radial femoral delay. Labs were remarkable only for elevated glucose at 208 mg/dl. Troponins throughout admission were consistently less than 0.07. HOSPITAL COURSE: As previously mentioned, patient was admitted for blood pressure control which was achieved with IV labetalol.
DT|delirium tremens|(DT)|131|134|HOSPITAL COURSE|She did well. She has a cemented total knee arthroplasty. Because of her recurring alcoholism she had significant delirium tremens (DT) while here. She took a few extra days to recover because of that. Right now she is alert and oriented x 3. Her pulmonary function is improving.
DT|diphtheria-tetanus|DT|83|84|IMMUNIZATIONS|Denies any gastrointestinal or genitourinary concerns at this time. IMMUNIZATIONS: DT _%#MM2003#%_. Pneumovax given on _%#MMDD2007#%_. Flu shot given _%#MMDD2007#%_. PHYSICAL EXAMINATION: GENERAL: He does not appear in any acute distress.
DT|delirium tremens|DT|184|185|IMPRESSION|2. Abnormal LFTs, most likely again alcoholic hepatitis. Will continue monitoring it. 3. Alcohol abuse. At risk for DTS given her last drink being about a week ago. We will put her on DT precautions. 4. Thrombocytopenia likely again alcohol related 5. Mild depression, will continue monitoring that. 6. Acute psychosis. 7. Vulnerable adult secondary to electrolyte imbalance. The patient will be admitted to the hospitalist service and after correction of the electrolytes, the patient will be transferred to the psychiatric service.
DT|diphtheria-tetanus|DT|160|161|PAST MEDICAL HISTORY|1. Osteoporosis. 2. Hypertension. 3. Hypothyroidism. 4. Kyphosis. 5. Hypertension. 6. Usual childhood illnesses including whooping cough and pneumonia. 7. Last DT was in the last several years. FAMILY HISTORY: She has had no children. She has one adopted son who is a patient at the VA Hospital with schizophrenia.
DT|diphtheria-tetanus|DT|187|188|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: The patient is a 59 years young female. She is 5 foot 3 1/4 inches, 104 pounds. Blood pressure 108/74, pulse 108. The patient is afebrile. Last Tetanus DT was in 1999. GENERAL: The patient is alert and oriented to time, place and person. She looks older than her stated age. HEENT: Normocephalic. Maxillary and frontal sinuses nontender.
DT|dorsalis pedis:DP|DT|158|159|OBJECTIVE|It is soft and nontender and obese. PELVIC and RECTAL deferred. EXTREMITIES: No cervical or axillary or femoral nodes. Femoral pulses present but weak and no DT or PT pulses present. EXTREMITIES: Warm, pink, and dry; no edema. ORTHOPEDICS: Joints without inflammation. NEUROLOGIC: Patellar reflexes 2+. SKIN: No lesions. ECG: Apical ischemia on one lead only.
DT|UNSURED SENSE|DT|229|230|PROBLEMS|3. CKD, stage 4. 4. Anemia, hemoglobin decreased from 13.3 to 10.8 and 9.9 after pacemaker placement and left cardiac cath. 5. Third-degree heart block with junctional escape beats, status post pacemaker _%#MMDD2007#%_. AAI with DT rate 175, lower rate 60, upper at 130. DISCHARGE MEDICATIONS: 1. Colchicine 0.6 mg oral Friday, Wednesday, Monday.
DT|delirium tremens|DT.|140|142|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|Mr. _%#NAME#%_ _%#NAME#%_ is a 45-year-old gentleman who has a chronic history of alcoholism. He quit drinking a few days ago and went into DT. He had a fall without any major injuries and also had a seizure for which he was brought into the ER. He was admitted on the 8th floor for DT precautions.
DT|delirium tremens|DT|139|140|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|He had a fall without any major injuries and also had a seizure for which he was brought into the ER. He was admitted on the 8th floor for DT precautions. He was kept on alcohol withdrawal protocol which resolved in the next 24 hours. The patient has had such admission in the past when he quit drinking on his own and had a seizure and was admitted.
DT|deep vein thrombosis:DVT|DT.|161|163|HISTORY OF PRESENT ILLNESS|There was also a hypointensity within the left vasoganglia suggestive of a hemorrhage. He did have ultrasounds of the lower extremities, which were negative for DT. She was, of note, a patient with atrial fibrillation who had been on Coumadin in the past and the transferring physicians were unsure why her Coumadin had been stopped, but she was not on it apparently upon admission though unclear how long she had not been on it.
DT|diphtheria-tetanus|DT|170|171|IMMUNIZATION|The patient has one living brother. SOCIAL HISTORY: The patient is retired, unmarried, and has no children. She quit smoking in 1989. IMMUNIZATION: Up-to-date, with last DT in 1995. PHYSICAL EXAMINATION: GENERAL: The patient is alert, comfortable and in no acute distress.
DT|delirium tremens|DT.|219|221|HISTORY|The patient also denies fever, chills, and abdominal pain. The patient, however, does have a significant history of alcohol use. He has been drinking for about 15 years. He has no prior history of alcohol withdrawal or DT. His last drink was this morning. PAST MEDICAL HISTORY: Fracture of his collar bone many years ago.
DT|physical therapy:PT|DT,|205|207|PLAN|Patient may need 1 mg daily Warfarin or Coumadin for Port-A-Cath and thrombosis that seems to solve it. The patient was on Coumadin for about one year. Will continue radiation treatments and patient needs DT, OT and physical therapy. Will consider placement with a nursing home versus rehab. The patient needs a diabetic diet, Accu-Chek p.o. q.i.d. without coverage and will continue other home medications and decrease Decadron 4 mg p.o. b.i.d., continue Lipitor and Avapro.
DT|delirium tremens|DT|203|204|ASSESSMENT/PLAN|We talked to the sober home manager and confirmed this and he was not using alcohol this period of time, and the sober home manager is wiling to take the patient back if there is no immediate danger for DT or any other serious intoxication on our assessment. Since this is first time alcohol intoxication of the abuse, the patient at present time is detoxified and he is stable.
DT|delirium tremens|DT,|195|197|ASSESSMENT/PLAN|Also, his liver function tests and pancreatic tests support that this is an acute intoxication due to that we consider that there is not immediate danger or unlikely to have delirium tremens, or DT, or significant withdrawal because of the acute episodes of alcohol intoxication. So, the patient will be staying here in the hospital until 1800, and he will be discharged at 1800.
DT|diphtheria-tetanus|DT|148|149|HISTORY OF PRESENT ILLNESS|He does not know how a nail got there, but as he took the next step. He got a puncture injury. He went to urgent care. Tetanus shot, he states that DT booster was given and he was also put on Bactrim double strength 1 tablet b.i.d. Yesterday he noticed that his foot was swelling more, his pain was becoming more pronounced and this morning he came to the emergency room.
DT|delirium tremens|DT|203|204|ASSESSMENT/PLAN|We talked to the sober home manager and confirmed this and he was not using alcohol this period of time, and the sober home manager is wiling to take the patient back if there is no immediate danger for DT or any other serious intoxication on our assessment. Since this is first time alcohol intoxication of the abuse, the patient at present time is detoxified and he is stable.
DT|delirium tremens|DT,|195|197|ASSESSMENT/PLAN|Also, his liver function tests and pancreatic tests support that this is an acute intoxication due to that we consider that there is not immediate danger or unlikely to have delirium tremens, or DT, or significant withdrawal because of the acute episodes of alcohol intoxication. So, the patient will be staying here in the hospital until 1800, and he will be discharged at 1800.
DT|diphtheria-tetanus|DT|116|117|IMMUNIZATIONS|MEDICATIONS: 1. Vitamins. 2. Lisinopril. 3. Aspirin. ALLERGIES: None. HABITS: Nonsmoker, no alcohol. IMMUNIZATIONS: DT booster in 1998. Flu shot and pneumovax in 2005. SOCIAL HISTORY: The patient is married. His wife is present at the bed side.
DT|UNSURED SENSE|DT|240|241|LABORATORY DATA|Echocardiogram shows LVE, LVH, decreased LV function, estimated ejection fraction of 35 to 40%, moderate mitral regurgitation, akinetic posterior wall, hypokinetic inferior wall, and hypokinetic lateral base. Diastolic function, ESA 81/73, DT 25%. No clots found. He underwent nuclear scan which was not available at the time of this dictation.
DT|delirium tremens|DT,|194|196|SUMMARY OF HOSPITAL COURSE|The patient was also seen by the Psychiatry Department due to some minor mental status changes and a long history of ethanol abuse with symptoms of withdrawal. However, the patient was never in DT, and Psychiatry suggested an outpatient follow up following hospitalization for his rehabilitation, due to renal failure and surgery. The patient is currently being dialyzed x 3 a week.
DT|diphtheria-tetanus|DT|101|102|IMMUNIZATIONS|10. Mild labile hypertension. 11. Mild obesity. 12. Known right inguinal hernia. IMMUNIZATIONS: Last DT 1997 at the Quello Clinic, and Pneumovax in 1995. CURRENT MEDICATIONS: 1. Proventil inhaler 2 puffs q.d. 2. Azmacort MDI 2 puff q.h.s.
DT|diphtheria-tetanus|DT|173|174|FAMILY HISTORY|Mother with coronary artery bypass and cancer. The patient's father had some kind of intestinal cancer. There is diabetes in an aunt. Immunizations are up to date with last DT in 1996. REVIEW OF SYSTEMS: Essentially unremarkable except for those symptoms mentioned.
DT|diphtheria-tetanus|DT|106|107|HISTORY|Orthopedic consultation was requested regarding the open elbow fracture. He was given a gram of Ancef and DT toxoid booster. PAST MEDICAL HISTORY: Negative for any chronic medical problems. He has had some eye surgery in the past.
DT|diphtheria-tetanus|DT|103|104|IMMUNIZATIONS|PAST SURGICAL HISTORY: 1. Tonsillectomy and adenoidectomy. 2. Hysterectomy. IMMUNIZATIONS: She updated DT in 1999. Pneumovax in 1994. She should be getting a flu shot after her surgery. FAMILY HISTORY: Two sons and a daughter who are well.
DT|delirium tremens|(DT)|271|274|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: The patient presents with increasing alcohol use over the last two weeks. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 64-year- old white male with a history of hypertension and at least one-to-two prior episodes of delirium tremens (DT) who presents today to the Intensive Care Unit (ICU) after being transferred from Fairview Ridges Hospital. He notes that over the last couple of weeks he has been drinking fairly steadily with no other problems.
DT|delirium tremens|(DT)|174|177|PLAN|If he is doing well tomorrow I would feel comfortable having him go to the floor, and at this point in time he surely does not look like he is going through delirium tremens (DT) and he is not having any neurological changes. I also will start him on a proton pump inhibitor (PPI) for just general stomach protection.
DT|diphtheria-tetanus|DT,|242|244|PAST MEDICAL HISTORY|Hospitalizations - above surgery and childbirth times five. Medical illnesses - see history of present illness. Injuries - motor vehicle accident with loss of consciousness and post concussion syndrome in her 30's. Immunizations - current on DT, Pneumovax six years ago. MEDICATIONS: 1. Flonase one puff q.d. 2. Cozaar 75 mg q.d.
DT|delirium tremens|DT|149|150|ASSESSMENT AND PLAN|Get sputum cultures. Blood culture was done in ER, pending results. 2. COPD. Start nebulizer treatment. 3. History of alcohol dependence. Will start DT protocol and also social worker consult. 4. History of hypertension, stable. Discuss with the patient and her husband.
DT|diphtheria-tetanus|DT|150|151|PROBLEM #4|PROBLEM #4: Immunology. CRP on admission was 2.5, and by the day of discharge it had rapidly come down to within normal at 0.7. She also had repeated DT titers checked as well as H. flu titer. All of these came back showing a positive response. PLAN: We will have her see Dr. _%#NAME#%_ from Immunology to see whether evaluations might be necessary in her care.
DT|diphtheria-tetanus|DT|126|127|IMMUNIZATIONS|PAST SURGICAL HISTORY: She is status post cholecystectomy in 1996 and a cesarean section early this year 2004. IMMUNIZATIONS: DT booster in 2000, and she has had a hepatitis B series and a varicella vaccine x 2. SOCIAL HISTORY: The patient is a single mother. She works at a Fon-du-lac Head Start Program.
DT|delirium tremens|DT|200|201|PLAN|However, this certainly could still happen. I will start her on thiamine and folic acid, and if she starts to exhibit signs of mental status changes of hallucinations, she will have to go through the DT protocol. 3. Elevated liver function tests: At this point in time, I do not have any recent liver function tests and these may be related to her alcohol use as well.
DT|dorsalis pedis:DP|DT|190|191|PHYSICAL EXAMINATION|No rebound or guarding is noted. EXTREMITIES: Without any cyanosis or clubbing or edema. There is generalized coolness past both shins bilaterally. I cannot palpate the posterior tibials or DT pulses bilaterally. Popliteal pulses are palpable. The left second toe is erythematous, mildly warm and swollen. There appears to be some scaling on the toe and with pressure, one can produce some purulent appearing discharge.
DT|diphtheria-tetanus|DT|169|170|IMMUNIZATIONS|PAST HOSPITALIZATIONS: 1. Above surgeries. 2. Childbirth. GYN: Current on pelvic exam, Pap smear, breast exam and mammography. INJURIES: None. IMMUNIZATIONS: Current on DT (nine years ago), but not Pneumovax. DIET: High protein, low carbohydrate. EXERCISE: A few times per week with trainer.
DT|delirium tremens|(DT)|163|166|HOSPITAL COURSE|The patient left the operating room in stable condition and was admitted to the Intensive Care Unit (ICU). His hospital course was complicated by delirium tremens (DT) secondary to alcohol withdrawal and he was placed on the alcohol withdrawal protocol.. Mr. _%#NAME#%_ did make improvements daily. His activity slowly increased.
DT|doppler echo:DE|DT|200|201|HISTORY OF PRESENT ILLNESS|She had no spells during this period. Her EEG showed questionable normal EEG reports. A cardiology consult was also obtained to evaluate her spells. After a normal EKG, cardiology service recommended DT echo and tilt-table testing. These were scheduled for an outpatient workup. DISCHARGE INSTRUCTIONS: The patient was discharged back home after the EEG monitoring.
DT|delirium tremens|DT|165|166|HISTORY OF PRESENT ILLNESS|The patient's boyfriend decided to present her to ED because she is afraid of undergoing alcohol withdrawal. She has had multiple episodes of alcohol withdrawal and DT in the past. On questioning by me today, the patient complained of nausea, diaphoresis, anxiety, and visual hallucinations.
DT|diphtheria-tetanus|DT|231|232|HISTORY OF PRESENT ILLNESS|Patient presently feels sleepy but is able to respond to questions appropriately. Also indicates recent self-cutting over the dorsal aspect of the left wrist in the last few days with a "butter knife." Believes to be up to date on DT prophylaxis. PAST MEDICAL HISTORY: 1. Psychiatric illness (as above). Has received ECT previously.
DT|diphtheria-tetanus|DT|243|244|IMMUNIZATIONS|ALLERGIES: None. He has had no bleeding problems other than slight anal bleeding at the onset of his ulcerative colitis with frequent stools. He is not on aspirin or steroids. IMMUNIZATIONS: He has had the usual childhood immunizations plus a DT booster on _%#MMDD2006#%_ and on _%#MMDD2006#%_. PHYSICAL EXAMINATION: GENERAL: He is a well-appearing 26- year-old white male.
DT|diphtheria-tetanus|DT|138|139|PLAN|Preoperative basic metabolic panel, CBC, and prothrombin time were drawn. Those too will be faxed to Same Day Surgery, and he was given a DT booster.
DT|diphtheria-tetanus|DT|172|173|HABITS|3) Remote history of left hand tendon laceration. 4) History of left dorsal hand osteophyte formation. ALLERGIES: NONE. HABITS: Nonsmoker, occasional coffee, rare alcohol. DT in 1999. MEDICATIONS: 1) Aspirin 81 mg q day. 2) Dental prophylaxis.
DT|diphtheria-tetanus|DT|202|203|IMMUNIZATIONS|MEDICATIONS: None. ALLERGIES: No known drug allergies. INJURIES: Fractured right hand, comminuted fracture right calcaneus bone, avulsion biceps muscle from right forearm. IMMUNIZATIONS: Not current on DT (greater than 10 years ago). HEALTH HABITS: Diet is regular. Exercise is walking. Tobacco: Smokes 1 to 2 packs of cigarettes per day.
DT|diphtheria-tetanus|DT|175|176|HISTORY OF PRESENT ILLNESS|Two days ago, he stopped on a nail that went through his tennis shoe into his foot. He pulled it out, that being Sunday. He was seen at a convenience care somewhere and got a DT shot and was placed on Keflex. He, however, presented to the emergency room yesterday evening as he was having some increasing redness.
DT|delirium tremens|DT,|164|166|PROBLEM #3|Discussion with patient per No. 1. The patient understood risks of leaving before complete detoxification from alcohol was complete including the risks of seizure, DT, and death. The patient also understood the benefits of staying including benzodiazepine to ease withdrawal symptoms. The patient reiterated these risks and still stated he needed to leave to go to work.
DT|(drug) DT|DT|166|167|DISCHARGE MEDICATIONS|19.TPN every day over 24 hours. 20.Free water flushes will now be at increased to 300 cc down feeding tube 4 times a day. 21.The patient also gets 4 cans of Peptonex DT 70 cc a hour for 14 hours on and then 10 hours off. DISCHARGE INSTRUCTIONS/FOLLOW-UP: 1. The patient will follow up with the Pain Clinic as scheduled.
DT|delirium tremens|DT|186|187|ADMISSION HISTORY AND PHYSICAL|She claims that she has been heavily drinking for the last 2 days, but denies any frequent use over the last few years. But she is also giving a history of a shaky hand. She had been in DT program in 1978 and 1995. She claims that she was alcohol-free after that. ADMISSION MEDICATIONS: None. ALLERGIES: No known drug allergies. FAMILY HISTORY: None relevant. SOCIAL HISTORY: She is single.
DT|delirium tremens|DT.|156|158|SOCIAL HISTORY|The patient failed one alcohol outpatient treatment in 2005. No prior seizure with alcohol withdrawals. Patient has a history of alcohol withdrawals but no DT. REVIEW OF SYSTEMS: The patient is a poor historian and is now still sleepy and lethargic; difficult to obtain history.
DT|diphtheria-tetanus|DT|144|145|IMMUNIZATIONS|1. Vytorin 10/40 combination daily. 2. Lisinopril 20 mg daily. 3. Toprol 12.5 mg b.i.d. 4. Baby aspirin. 5. Nitroglycerin p.r.n. IMMUNIZATIONS: DT booster in 1998, Pneumovax in 2006. ALLERGIES: Lovastatin, food extracts, niacin. REVIEW OF EXAMINATION: VITAL SIGNS: The patient's blood pressure is 150/80, pulse 70, respirations 16.
DT|diphtheria-tetanus|DT|81|82|IMMUNIZATIONS|Dad also had a stroke when he was 60 years old. CODE STATUS: Full IMMUNIZATIONS: DT booster 1997, _%#NAME#%_ Pneumovax 2005, flu shot every year REVIEW OF MEDICATIONS: 1. Slow-Mag 64 mg daily 2. Synthroid 112 mcg. daily
DT|diphtheria-tetanus|DT|173|174|HABITS|3. Gastroesophageal reflux disease 4. Erectile dysfunction 5. Hyperlipidemia. ALLERGIES: None. HABITS: Former smoker, former alcohol abuse, none for eight years, no coffee, DT in 2004. MEDICATIONS: 1. Trazodone 50 mg at h.s. for insomnia
DT|diphtheria-tetanus|DT|221|222|IMMUNIZATIONS|Otherwise no hospitalizations. CHRONIC MEDICAL PROBLEMS: Hypertension, erectile dysfunction, elevated cholesterol and triglycerides. Injuries: Only his right second metacarpal fracture. IMMUNIZATIONS: Hepatitis B series, DT 1998. INFECTIOUS DISEASE: Chickenpox. FAMILY HISTORY: Mother died of alcoholism at age 56.
DT|diphtheria-tetanus|DT|119|120|IMMUNIZATIONS|4. Toprol 25 mg daily. 5. Baby aspirin daily. 6. Vitamin B. 7. Folic acid. 8. Erythropoietin injections IMMUNIZATIONS: DT booster in 2003, Pneumovax in 2006, flu shot every year ALLERGIES: OXYBUTYNIN. HABITS: Nonsmoker, no alcohol. SOCIAL HISTORY: The patient is a widower.
DT|diphtheria-tetanus|DT|132|133|OTHERS|5. Norvasc, 5 mg daily. 6. Hydrochlorothiazide, 25 mg in divided doses. 7. Niaspan, 1,000 mg daily. OTHERS: The patient was given a DT booster as well in the hospital. He takes chromium as a supplement and a baby aspirin. Diet will be low-cholesterol as before at home.
DT|diphtheria-tetanus|DT|129|130|ALLERGIES|Vein stripping on the left in 1986 and thyroid nodule biopsied in 1999. ALLERGIES: None known. Immunizations are up to date with DT in 1994. CURRENT MEDICATIONS: 1. Pravachol 40 mg po q.day. 2. Glucosamine.
DT|diphtheria-tetanus|DT|181|182|PAST MEDICAL HISTORY|A sister, _%#NAME#%_ _%#NAME#%_, has thyroid disease. PAST MEDICAL HISTORY: 1. Tubal ligation. 2. Thymus gland removal in 1970. 3. Para 4-0-0-4. She has nine grandchildren. 4. Last DT was 1993. 5. Bone index that showed osteopenia in _%#MM1998#%_. HABITS: Alcohol none. She has coffee, 1-2 cups per day. Recently she has had none.
DT|dorsalis pedis:DP|DT|183|184|PHYSICAL EXAM|LUNGS clear to auscultation. CARDIAC S1-S2. No murmur or gallop. ABDOMEN no hepatosplenomegaly, masses, tenderness, rebound, or abnormal bowel sounds. Good inguinal pulses as well as DT and posterior tibia. There is no calf tenderness. Moves all EXTREMITIES equally. EKG is within normal limits. First set of enzymes from the E.R. were reported as negative.
DT|diphtheria-tetanus|DT,|135|137|IMMUNIZATIONS|ANESTHESIA COMPLICATIONS: None. ALLERGIES: Pine, pollen, cats listed. Paxil caused hives. Prozac caused weight gain. IMMUNIZATIONS: 1. DT, _%#MM1995#%_. 2. Pneumovax _%#MMDD2002#%_. 3. Flu shot _%#MMDD2003#%_. CURRENT MEDICATIONS: 1. Lantis 20 to 25 units q.h.s.
DT|diphtheria-tetanus|DT|203|204|PAST MEDICAL HISTORY|SOCIAL HISTORY: She is married with three children. Cigarettes denied. Alcohol denied. She is a housewife. PAST MEDICAL HISTORY: ALLERGIES: CODEINE GIVES "BAD DREAMS". FLOXIN CAUSES SHORTNESS OF BREATH. DT IS POORLY TOLERATED. MEDICATIONS: Voltaren 75 mg bid, Imodium prn, low strength aspirin daily, Calcium on a regular basis.
DT|diphtheria-tetanus|DT,|218|220|IMPRESSION|She is interested in proceeding ahead with this. She states she has had a fairly significant reaction against Sulfa in the past. Ancef was started in the emergency room. I believe she was updated on her immunizations, DT, etc.
DT|diphtheria-tetanus|DT|213|214|VACCINATIONS|Endocrine - diabetes. Blood sugars have been fair. Her last hemoglobin A1C was 6.3 - that was in _%#MM#%_ 2003. Neurologic - negative. Musculoskeletal - above. VACCINATIONS: She had a Pneumovax in 1996. She had a DT in 1999. PHYSICAL EXAMINATION: Her blood pressure is 130/84.
DT|diphtheria-tetanus|DT|153|154|PAST MEDICAL HISTORY|Cigarettes denied. Alcohol denied. She is a housewife who owns an antique business. PAST MEDICAL HISTORY: ALLERGIES: FLOXIN (codeine causes nightmares). DT causes very high fever. Hospitalizations: Hepatitis in Japan at age 6. C-sections times two. Baker's cyst surgery bilaterally, age 3. Laparoscopic tubal insufflation in 1981.
DT|delirium tremens|DT|163|164|HISTORY OF PRESENT ILLNESS|He has been in two previous inpatient treatment programs before and has been in the hospital numerous times for detoxification. He does report having a history of DT with alcohol withdrawal and having numerous times approximately fifteen in the last year. Denies any seizures with withdrawal. The patient reports that he often drinks and gets drunk because the alcohol seems to help his symptoms from Tourette's syndrome.
DT|delirium tremens|DT.|122|124|PROBLEM #1|PROBLEM #1: Alcohol withdrawal. The patient reports his last drink as being at 11 p.m. tonight and does have a history of DT. We will need to be closely monitored tonight and tomorrow. We will start him on MSSA protocol. We will also get a CD consultation, the patient is interested in returning to CD treatment for his alcohol abuse.
DT|delirium tremens|DT|202|203|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1: Seizures: The patient was found to be subtherapeutic and valproic levels and these were loaded upon admission. He was also thought to be withdrawing from alcohol in obvious DT which was probably contributing to his seizures after several days on benzodiazepine prophylaxis his delirium tremens resolved. PROBLEM #2: Sinusitis: The patient did receive approximately 7 to 10 days of ceftriaxone empirically for what was thought to be potentially an ammonia when he arrived.
DT|dorsalis pedis:DP|DT,|199|201|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Afebrile, vital signs stable, alert and oriented x 3. No acute distress. Appeared appropriate and communicative. RIGHT LOWER EXTREMITY: Capillary refill less than 2 seconds. 2+ DT, 1.5 cm to 2 cm shortened compared to the left. 5/5 dorsiflexion, plantar flexion, knee flexion, knee extension, EHL, EDD.
DT|dorsalis pedis:DP|DT|128|129|PHYSICAL EXAMINATION|There is some stasis change or abrasion on the anterior shin on the right that looks like an older abrasion. He has fairly good DT pulses. NEUROLOGIC: Shows no focal changes on neuro exam, but they do admit to some memory loss at times. LABORATORY DATA: Hemoglobin 7.9 with MCV of 66, white count 6,100, platelets 237,000.
DT|deep vein thrombosis:DVT|DT|167|168|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|His hemoglobin remained stable. CMS was intact and he was basically in the hospital for physical therapy and pain control. He was placed on enteric-coated aspirin for DT prophylaxis, given 24 hours of IV antibiotics. Once he is pain was well controlled, he passed in physical therapy and was discharged.
DT|delirium tremens|DT.|216|218|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|Her cellulitis is improving much with the Levaquin. Also, the patient has a history of alcoholism, for which she was kept on the alcohol withdrawal protocol, which is discontinued now. She does not show any signs of DT. She will be discharged to the nursing home for physical therapy.
DT|dorsalis pedis:DP|DT|189|190|PHYSICAL EXAMINATION ON ADMISSION|He is nontender and nondistended. He does have a palpable liver edge. SPINE: Straight with no CVA tenderness. No lymphadenopathy. He has no rash. MUSCULOSKELETAL: He has 2 radial pulses, 2 DT and PT pulses. The left ankle capillary refill is less than 3 seconds, 2 patella reflex on the right. Full range of motions of both toes. ADMITTING LABORATORY DATA: White blood cell count 3.9, ANC of 1.7, hemoglobin of 12.3, platelets of 423,000, total bilirubin of less than 0.1, albumin 4.4, protein 7.3, alkaline phosphatase of 106, ALT of 99, AST of 25.
DT|dorsalis pedis:DP|DT,|244|246|OBJECTIVE|There is a colostomy present and below that is a suture which looks like it is wanting to perforate the skin with a small pyogenic granuloma. GENITAL/RECTAL: Deferred. EXTREMITIES: No cervical, axillary or femoral nodes. Femoral pulses normal. DT, PT pulses normal. Warm, pink, dry, no edema. ORTHO: Normal. Normal patella reflexes 2+. Right shoulder pain with any movement.
DT|diphtheria-tetanus|DT|189|190|IMMUNIZATIONS|DISCHARGE DIAGNOSES: 1. Left femoral and popliteal deep venous thrombosis 2. Hypertension 3. Gout 4. Hyperlipidemia 5. Renal insufficiency 6. Frequent falls IMMUNIZATIONS: DT booster 2006, DT booster 2004, Pneumovax 2006, flu shot every year DISCHARGE MEDICATIONS: 1. Hydrochlorothiazide 25 mg daily 2. Allopurinol 100 mg daily. This is a change in dose
DT|delirium tremens|DT|137|138|PLAN|5. Alcohol overuse. The patient advised to decrease his alcohol consumption. We will start him on thiamine and folic acid and put him on DT precautions. 6. Tobacco abuse. The patient might benefit from incentive spirometry per surgery.
DT|delirium tremens|DT|119|120|LABS|He improved enough to tolerate a liquid diet and then a regular diet on _%#MMDD#%_. 2. Alcohol abuse. He was placed on DT precautions, started on thiamine and Foley catheter CD consultation obtained. For details of that consult, please see separate report. Apparently patient refused outpatient alcohol treatment.
DT|diphtheria-tetanus|DT|98|99|IMMUNIZATIONS|7. History of colposcopy in 1995. 8. History of acne rosacea. IMMUNIZATIONS: Up to date with last DT in _%#MM2000#%_ and Pneumovax in _%#MM2000#%_. REVIEW OF SYSTEMS: The patient has not had any chest pains.
DT|diphtheria-tetanus|DT|183|184|ALLERGY|11. Powder multivitamin that has variety of C 1500 mg, E 800 units, garlic, ginseng, takes coku 10 50 mg a day, calcium twice daily of unknown dose, multivitamin. ALLERGY: Quinidine. DT in 1995, Pneumovax in 1993. FAMILY HISTORY: He has daughter with asthma. SOCIAL HISTORY: He is the first of seven siblings, two died at infancy, sister with diabetes and three brothers are well.
DT|diphtheria-tetanus|DT|190|191|SOCIAL HISTORY|3) Vocal cord lumpectomy. FAMILY HISTORY: Unchanged; no children. One brother died of heart and cirrhosis; another with back problems. SOCIAL HISTORY: She is up to date on her vaccinations: DT in 1995, Pneumovax in 1996. PHYSICAL EXAMINATION: VITAL SIGNS: Weight 178 pounds, blood pressure 108/60, pulse 80 and regular.
DT|diphtheria-tetanus|DT|111|112|PAST SURGICAL HISTORY|3. Left arm abscess I&D. 4. ORIF left foot fracture. He is up to date on his vaccinations including Pneumovax, DT and flu shot. SOCIAL HISTORY: He has 4 children, all well. One brother died at 83, another one is still alive, older than he.
DT|diphtheria-tetanus|DT|116|117|STUDIES DONE PREOPERATIVELY|Father died at 78 of dementia. Mother died at 52 of polycystic kidneys. Virginia had a Pneumovax in 1998. She had a DT in 1999. She has had cholecystectomy, probable cervical disc diverticular disease. Weight stable.
DT|delirium tremens|DT|295|296|HISTORY OF PRESENT ILLNESS|DOB: _%#MMDD1938#%_ CHIEF COMPLAINT: Quit drinking, now shaking. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 65-year-old white male with hypertension, a long history of alcoholism, who quit drinking Tuesday. Since then he has developed lots of shaking. He was admitted for detox. and DT prophylaxis. He has been drinking for many years, probably really began heavily drinking when his mother died. He did quit maybe about eight years ago for one year, but then started drinking again.
DT|deep vein thrombosis:DVT|DT|173|174|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: The patient was instructed that he may perform 50% weight bearing on the left lower extremity with the use of crutches. He was to be on Coumadin for DT prophylaxis for two weeks. The patient's INR will be followed by the Coumadin Clinic. The patient was discharged on a regular diet. Prescriptions for Percocet for pain control were provided.
DT|delirium tremens|DT|190|191|IMPRESSION/PLAN|4. Alcohol abuse with possible alcoholic cirrhosis. This causing increasing liver function tests. Rule out cholelithiasis. a. Will check gallbladder ultrasound and watch for DTs and use the DT precaution protocol. 5. History of MS, possible with worsening symptoms. a. Will request Neurology go see the patient and consider MRI of the head in the morning.
DT|diphtheria-tetanus|DT|215|216|HABITS|No oophorectomy. Illnesses: Reversible obstructive airway disease (ROAD); (triggers are respiratory infection, cat, horse, dog, and smoke). ALLERGIES: None. HABITS: Nonsmoker. Five coffee a day. Five drinks a week. DT less than 10 years ago. MEDICATIONS: Albuterol inhaler p.r.n. A.S.A. 81 mg q.d. FAMILY HISTORY: Mother, age 84, with hypertension, breast CA, vaginal CA, depression, and valvular heart disease.
DT|delirium tremens|DT.|255|257|SOCIAL HISTORY|13. Valtrex p.r.n. ALLERGIES: 1. Serzone. 2. Lamictal. SOCIAL HISTORY: The patient uses tobacco 5 to 18 cigarettes per day, has been sober from alcohol for the last 17 months. She has a previous history of CD detoxes. No history of withdrawal seizures or DT. Illicit drugs. She has been sober for 17 months, but has a history of using acid, methamphetamine, cocaine, heroin, and marijuana.
DT|delirium tremens|DT|361|362|PAST MEDICAL HISTORY|Last seizure for patient was _%#MMDD2007#%_. The patient denied using any other drugs; marijuana, cocaine, amphetamines and he denied using any other drugs. PAST MEDICAL HISTORY: The patient has history of job fracture, left ulnar compression status post surgery in 2006, bilateral inguinal hernia repair as a child, history of hemorrhoids, seizure history and DT history. FAMILY HISTORY: He reports that his cousin on the mother's side has problems with manic and she was hospitalized.
DT|diphtheria-tetanus|DT.|178|180|HISTORY OF PRESENT ILLNESS|The patient allegedly threatened self-hanging. Two days prior to admission she did self-inflict superficial abrasions to the volar aspect of the left wrist. She is up to date on DT. This is her first mental health hospitalization. She has had no prior treatment for depression.
DT|diphtheria-tetanus|DT.|166|168|HISTORY|Auditory hallucinations instructing her to cut her wrists. Resultant superficial self-cutting over the last week to the volar aspect of the left wrist. Up-to-date on DT. Presentation to the emergency room with admission to inpatient psychiatry as above. No other active self-harm. Indicates that she has been med compliant.
DT|diphtheria-tetanus|DT.|225|227|ASSESSMENT|1. History of paranoid schizophrenia with decompensation. 2. Self-cutting volar aspect left wrist. On exam, superficial linear abrasion. No gaping wound requiring sutures. No evidence for soft tissue infection. Up-to-date on DT. No treatment intervention required. 3. Recent this nasal/sinus surgery as above with residual secretion purulence. Will check culture of a nasal secretions. Start Levaquin. ENT follow-up.
DT|diphtheria-tetanus|DT|165|166|HISTORY|She has had recent active self-harm manifested by self-induced cutting superficially to the left upper abdomen three days ago using a clean straight razor. Her last DT was approximately three years ago. No suturing required. PAST MEDICAL HISTORY: 1. Major depression with psychotic features. Details as per psychiatry.
DT|diphtheria-tetanus|DT.|207|209|ASSESSMENT|1. Major depressive disorder, recurrent. Details as per psychiatry. 2. Self-induced cutting left upper abdomen. Secondary superficial abrasions. No evidence of infection. No need for suturing. Up to date on DT. 3. No other serious illness. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. With Geodon therapy, will check EKG to ensure normal QT interval.
DT|diphtheria-tetanus|DT|190|191|PLAN|4. Soap and water cleanse to areas of abrasions/laceration. Staff to monitor for signs of soft tissue infection. No other intervention appears required at this time. The patient did receive DT in the ER. Thank you for the consultation. Will follow-up as clinically indicated.
DT|diphtheria-tetanus|DT.|172|174|HISTORY|Associated self-cutting to the dorsum aspect of the left forearm with the use of a kitchen knife. Superficial abrasions not requiring intervention. Indicates up to date on DT. PAST MEDICAL HISTORY: 1. Psychiatric illness (as above).
DT|delirium tremens|DT,|215|217|HISTORY|Alcohol intake varies as well, consisting of a couple of drinks to 10 drinks per setting, not daily. She will drink to the point of intoxication. No recent blackouts. She is without a history of alcohol withdrawal, DT, withdrawal related seizures, known alcohol related liver disease, pancreatitis, or upper gastrointestinal blood loss. The patient has used marijuana on 2 occasions over the last 6 months.
DT|delirium tremens|DT.|196|198|ALLERGIES|5. Inderal 20 mg b.i.d. for (_______________). ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: He does not smoke, drink, or do drugs. He is married and has no children. No history seizures or DT. FAMILY HISTORY: Maternal family history: Mother had hypothyroidism. Sister and niece also had hypothyroidism on the maternal side. Paternal: CHF, died at 76, that was his father. REVIEW OF SYSTEMS: He has auditory and visual hallucinations, palpitations, and he had an echocardiogram and EKG done both at the Mayo and it was okay.
DT|delirium tremens|DT|176|177|HISTORY|Asked to leave his facility on _%#MMDD#%_. The last drink early the morning of _%#MMDD2004#%_. He has had alcohol withdrawal with shakes and insomnia. Prior question regarding DT with a "dream- like state." Unaware of alcohol-related liver disease, pancreatitis, or upper GI bleeding. Denies other drug use. He has had an issue of anxiety and depression, for which, the patient has since been placed on Effexor by Dr. _%#NAME#%_.
DT|delirium tremens|DT.|262|264|HISTORY|He had 2 years of sobriety until this past week at which time the patient indicates consuming two 12-packs of beer, off lithium for 2 to 3 weeks, increasing despondency, alleged suicide ideation, no active self-harm. He denies a history of alcohol withdrawal or DT. He is without known history of alcohol-related liver disease, pancreatitis, or upper gastrointestinal blood loss. No other ongoing drug use. Remote use of marijuana. Clinical concern regarding hypertension, off hydrochlorothiazide for approximately 6 months.
DT|delirium tremens|DT.|211|213|DISCUSSION|The patient describes binge use of alcohol. She denies other chemical use with the exception of cigarettes. _%#NAME#%_ describes history of tremors following discontinuation of ethanol use. She denies seizures, DT. She denies knowledge of liver function test abnormalities. PAST MEDICAL HISTORY: Primarily remarkable for depression and for ethanol abuse.
DT|diphtheria-tetanus|DT.|258|260|HISTORY|Sutures were not required. Repeat cutting to the volar aspect of the right wrist using an Exacto knife the morning of _%#MMDD2004#%_. Prompted presentation to the ER from where the patient was hospitalized. No sutures were required. Presumably up to date on DT. However, the patient is to review this with her primary MD. Associated issue of eating disorder dating back five years ago.
DT|diphtheria-tetanus|DT|180|181|ASSESSMENT|2. Self-injurious behavior with superficial cutting to the volar aspect of the right wrist. No suturing required. No evidence for soft tissue infection. The patient is to check on DT status. 3. Mildly elevated AST (as above), basis for which unclear. Doubt relates to alcohol intake. No implicated medications. Will need follow- up to ensure normalization.
DT|diphtheria-tetanus|DT.|202|204|PLAN|7. Question regarding childhood seizure, inactive into adulthood. 8. Gastroesophageal reflux, clinically quiescent. 9. Zantac allergy. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Update DT. 3. Review urethral trauma with University of Minnesota Urology. 4. Continue CPAP as at home. 5. Flonase 2 sprays each nostril daily for chronic rhinitis related symptoms.
DT|delirium tremens|DT,|154|156|HISTORY OF PRESENT ILLNESS|Occasional use of cocaine and marijuana. CD intervention on 5 or 6 occasions. His longest sobriety was 8 months. He denied history of alcohol withdrawal, DT, or withdrawal-related seizures, alcohol-related liver disease, hepatitis, or upper GI blood loss. PAST MEDICAL HISTORY: 1. Polysubstance abuse (as above). 2. No serious illness or surgery.
DT|diphtheria-tetanus|DT|192|193|HISTORY|No problems with reduced alertness. With lying in bed has noted mild paracervical stiffness bilaterally. No upper extremity radicular complaints of pain, weakness, or paresthesias. Updated on DT while in the emergency department. Hemoglobin 13.1 g% on _%#MMDD2004#%_. Tolerated surgical procedure with stable hemodynamics. Estimated blood loss less than 50 cc.
DT|diphtheria-tetanus|DT,|211|213|OBJECTIVE|SKIN: She has 2 very superficial linear abrasions over the volar aspect of the left wrist, measuring approximately 1-1/2 cm each. No gaping wounds, no evidence for soft tissue infection. No clear indication for DT, based on the above wounds. CHEST: Clear lung fields. CARDIAC: Regular without gallop or murmur, no click, no jugular venous distention.
DT|diphtheria-tetanus|DT|240|241|HISTORY|Indicates compliant with medications over the last six weeks. Off medication for two months prior to that time. Self-cutting to the lateral aspect of the left humerus proximally with a clean razor. Sutured in the Emergency Department. Last DT 6-7 months ago. No other injuries/act of self-harm. PAST MEDICAL HISTORY: 1. Psychiatric illness (as above).
DT|delirium tremens|DT,|127|129|DISCUSSION|She denies knowledge of history of peptic ulcer disease or liver disease. She states she has been hospitalized on one occasion DT, several years ago. Angela denies chronic medical concerns. Specifically, she denies hypertension, cardiac or pulmonary disease.
DT|diphtheria-tetanus|DT.|164|166|HISTORY|Incarcerated, as "people were trying to set me up." Self-inflicted superficial abrasions to the left upper extremity from a tape dispenser. Indicates up to date on DT. Also indicates that he swallowed needles, staples, screws, and one nail. PAST MEDICAL HISTORY: 1. Psychiatric illness (as above), with details per Dr. _%#NAME#%_.
DT|diphtheria-tetanus|DT|131|132|HISTORY|Similar act to the left forearm one week ago. Not requiring sutures. No evidence of soft tissue infection. I believe up to date on DT within the last 10 years. PAST MEDICAL HISTORY: 1. Psychiatric illness as above, details per Dr. _%#NAME#%_.
DT|delirium tremens|DT.|178|180|ASSESSMENT/PLAN|4. The patient will need counseling regarding smoking cessation and drug counseling, as well as alcohol cessation counseling. We will need to closely observe in case he develops DT. DT precautions should be in place. We will continue to follow this patient in the hospital.
DT|delirium tremens|DT|182|183|ASSESSMENT/PLAN|4. The patient will need counseling regarding smoking cessation and drug counseling, as well as alcohol cessation counseling. We will need to closely observe in case he develops DT. DT precautions should be in place. We will continue to follow this patient in the hospital.
DT|diphtheria-tetanus|DT|213|214|HISTORY OF PRESENT ILLNESS|Suturing to the left forearm laceration was not required. It is not clear if a laboratory evaluation was obtained. She was transferred for inpatient psychiatric hospitalization. She indicates she is up to date on DT as of 2002. No other active self- harm. PAST MEDICAL HISTORY: 1. Psychiatric illness, as above.
DT|diphtheria-tetanus|DT.|191|193|PAST SURGICAL HISTORY|PAST SURGICAL HISTORY: 1. Cholecystectomy. 2. Self-injurious behavior with extensive self-cutting to left upper extremity, last cutting prior to last hospitalization. Indicates up to date on DT. 3. No known history of coronary artery disease, hypertension or pulmonary disease. ALLERGIES: No known drug allergies. PRESENT MEDICATIONS: 1. Neurontin 300 mg t.i.d.
DT|diphtheria-tetanus|DT.|296|298|PLAN|5. Left hand paresthesias earlier today, gradually improving. These may related to local neuropraxia from positioning with sleep or swelling from tetanus toxoid administered in the Emergency Department. PLAN: 1. Continue Bacitracin ointment b.i.d. to anterior cervical abrasion. 2. Up to date on DT. 3. Clinical observation with psychiatric intervention as per Dr. _%#NAME#%_. Further medical intervention does not appear necessary at this time.
DT|delirium tremens|DT|131|132|MEDICATIONS|3. Phoslo 2 with meals. 4. Calcium and vitamin D. 5. Clonidine 0.1 mg b.i.d. 6. Lexapro. 7. Insulin. 8. Clindamycin given once. 9. DT protocol medications. REVIEW OF SYSTEMS: This is completed for 10 systems and negative except as noted in the history of present illness.
DT|diphtheria-tetanus|DT.|260|262|HISTORY OF PRESENT ILLNESS|Anger and frustration with her boyfriend prompted self-cutting to the volar aspect of the forearms bilaterally with a "clean razor." In retrospect, denies suicidal intent. Taken to Fairview-Ridges Emergency Department, where wounds were sutured. Up to date on DT. Noted to be quite agitated, for which Haldol 2.5 mg IV was administered x 2. Stable hemodynamics, with blood pressure 116/75, heart rate low 100s, respiratory rate 18, and O2 sat 98%.
DT|diphtheria-tetanus|DT.|130|132|HISTORY|Indicates that she was angry. Self-cutting with a disposable razor to the volar aspect of her forearms bilaterally. Up-to-date on DT. No gaping wounds. No suturing required. Denies despondency. A remote history of self-injurious behavior with cutting and scratching several years ago.
DT|diphtheria-tetanus|DT.|157|159|ASSESSMENT|2. Superficial abrasions, bilateral upper extremities. Will treat topically with bacitracin. No other treatment intervention appears required. Up to date on DT. No evidence for soft tissue infection. 3. Asthma, well compensated. 4. 3-month gestation pregnancy. Uneventful to date. Minor compromise secondary to morning sickness.
DT|diphtheria-tetanus|DT.|130|132|ASSESSMENT|Defer to Psychiatry. 2. Self-cutting, volar aspect of the wrists bilaterally. No evidence of soft tissue infection. Up to date on DT. 3. Migraine headaches, fairly well controlled with Imitrex. 4. Obesity. Rule out hypothyroidism. 5. Mild facial acne. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_.
DT|diphtheria-tetanus|DT.|182|184|HISTORY|Resident of a group home. Increasing despondency. Self-cutting to the dorsum of the right wrist last evening with an "old" razor blade. No suturing required. Indicates up to date on DT. No other active self-harm. PAST MEDICAL HISTORY: 1. Obstructive sleep apnea on CPAP.
DT|diphtheria-tetanus|DT|199|200|ASSESSMENT|6. Erythromycin intolerance/sulfa allergy. 7. Nicotine addiction. 8. Linear superficial abrasions of upper extremities. No treatment intervention required. Due to minor nature of injury, do not feel DT necessary at this time. PLAN: 1. Psychiatric intervention per Dr. _%#NAME#%_. 2. Allegra 60 mg p.o. b.i.d. p.r.n. allergic rhinitis symptoms.
DT|diphtheria-tetanus|DT|122|123|REVIEW OF SYSTEMS|She indicates a "domestic" rat bite sustained three days ago at a pet shop. Painful area, dorsum right second digit. Last DT in 1999. No focal neurologic complaints. PHYSICAL EXAMINATION: Thin but otherwise generally healthy- appearing adult female in no distress, alert and oriented.
DT|diphtheria-tetanus|DT.|161|163|PLAN|PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Suture removal, left upper extremity wound in approximately 7-10 days out from occurrence. 3. Update DT. 4. Review labs as ordered. 5. Continue MSSA withdrawal protocol. 6. Clinical observation. RN to call p.r.n. persistent blood pressure elevation.
DT|diphtheria-tetanus|DT.|234|236|PLAN|10. Status post laparoscopic cholecystectomy. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Right shoulder x-ray. 3. Orthopedic consultation regarding right shoulder pain. May benefit from cortisone injection. 4. Update DT. 5. Enterostomal therapy consult regarding left medial malleolus and great toe ulcer. For now, will cleanse with soap and water and apply sterile gauze dressing.
DT|diphtheria-tetanus|DT.|199|201|HISTORY|History of bipolar affective disorder with decompensation, self-inflicted superficial linear lacerations to the upper extremities. No wounds requiring suturing. I believe patient to be up-to-date on DT. Significant issue of bilateral lower extremity edema for the last approximately two months.
DT|delirium tremens|DT|162|163|SOCIAL HISTORY|5. Prilosec OTC at home. ALLERGIES: Sulfa (throat swells and she breaks out). SOCIAL HISTORY: Tobacco on and off. Alcohol: No alcohol use. No detox, seizures, or DT history. DRUG OF CHOICE: Methamphetamine. She relapsed in _%#MM2006#%_ with methamphetamine. Otherwise, she had a 2-year sobriety before that.
DT|diphtheria-tetanus|DT|243|244|HISTORY|Occasional mild headache relieved with Tylenol. No problems with anesthesia. No recent URI or flu-like symptoms. History of self-injurious behavior with "digging with her nails to the volar aspect of the left forearm over the last week." Last DT two weeks ago. PAST MEDICAL HISTORY: 1. Psychiatric illness (as above). Details per Dr. _%#NAME#%_.
DT|diphtheria-tetanus|DT,|233|235|ASSESSMENT|1. Major depressive disorder, recurrent. Associated diagnosis of borderline personality disorder, per record. Deferred to Dr. _%#NAME#%_. 2. Recent self-cutting, right upper abdomen. No treatment intervention required. Up to date on DT, per patient. 3. History of Benadryl overdose, _%#MM2006#%_. 4. History of lithium-induced hypothyroidism. Euthyroid off lithium. 5. Exogenous obesity. 6. Minimally elevated ALT of doubtful clinical significance.Consider medication effect.
DT|diphtheria-tetanus|DT.|197|199|HISTORY|Prior history of drug overdose. Also self cutting. Self inflicted linear abrasion to the left anterior cervical region on the night prior to admission (with a clean knife). Indicates up-to-date on DT. No prior ECT. No other act of self- harm. PAST MEDICAL HISTORY: 1. Psychiatric illness (as above). Details per Dr. _%#NAME#%_.
DT|diphtheria-tetanus|DT.|293|295|ASSESSMENT|1. Depression NOS (per Psychiatry). 2. History of self cutting with a self inflicted linear abrasion measuring approximately 6 cm over the left anterior cervical region. There is no gapping of the skin. No evidence of soft tissue infection. Anticipate it will heal uneventfully. Up to date on DT. 3. Elevated TSH consistent with probable lithium induced subclinical hypothyroidism. With normal Free T4 1.05 would monitor for now with recheck thyroid function in approximately 3 months.
DT|UNSURED SENSE|DT|186|187|HISTORY OF PRESENT ILLNESS|The density is rather homogenous, which is also consistent with melanoma. The patient was referred to Dr. _%#NAME#%_ _%#NAME#%_, who reported a BM of 8.0, an MT of 1.5, a BD of 9.9, and DT of 2.71, with a maximum height of 4.56, and a base diameter of 9.9. She is now referring the patient to the Radiation Oncology Department for possible I-125 eye plaque therapy.
DT|diphtheria-tetanus|DT|166|167|HISTORY|He had paresthesias involving the right second through fifth digits early-on, which have since resolved. He has normal function of the left hand. He is up-to-date on DT as of _%#NAME#%_, 2003. He has moderate right wrist pain, controlled reasonably well with Extra Strength Tylenol. The issue of alcohol abuse dates back to his divorce two years ago.
DT|diphtheria-tetanus|DT|131|132|HISTORY OF PRESENT ILLNESS|She was taken to St. Joseph's Emergency Department, where a head CT was obtained (presumably negative). I will request the report. DT was administered. The left temporal laceration was sutured. She had a Breathalyzer of 296, ethyl alcohol of 19. She was hypertensive on presentation, with blood pressure 189/105, with heart rate in the 115 range.
DT|diphtheria-tetanus|DT|163|164|ASSESSMENT|Possible prior history. 4. Superficial linear abrasions of volar aspect of the left wrist. No intervention required. Fairview Southdale records do indicate that a DT was administered. 5. Allergy history, as above. Caution is required with antibiotic usage. Avoidance of seafood. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_.
DT|delirium tremens|DT|183|184|SOCIAL HISTORY|Uses alcohol for the last 11 days, he was on an alcohol binge, also with cocaine and marijuana. He denies a history of IV drug use. He also denies a history of withdrawal seizures or DT in the past. Prior to the last 11 days he was sober for 28 months. Currently divorced. He has a daughter and has been living in an apartment prior to admission.
DT|delirium tremens|DT,|151|153|HISTORY|Alcohol consisting of 1 to 1 1/2 liters per day with last drink the afternoon of _%#MMDD2006#%_. He has had withdrawal with mild shakes. No history of DT, withdrawal related seizures, known alcohol related liver disease, pancreatitis, or upper gastrointestinal blood loss. He has an associated issue of major depression. The patient indicates being depressed since childhood.
DT|diphtheria-tetanus|DT.|169|171|HISTORY|Associated self- injurious behavior with self-cutting to the upper extremities for one week up to _%#MMDD2005#%_. Use of a new razor. No sutures required. Up to date on DT. No other active self-harm. Indicates possible weight loss over two days prior to admission, otherwise relatively stable. Admits to reduced p.o. intake. PAST MEDICAL HISTORY: 1. Depression (as above)..
DT|diphtheria-tetanus|DT.|120|122|ASSESSMENT|Superficial abrasions/lacerations. No suturing required. No evidence of soft tissue infection. Up to date by history on DT. 3. Finding on exam in addition to the above included intermittent faint systolic ejection murmur at left sternal border thought to be physiologic, possibly related to increased/bounding heart rate.
DT|delirium tremens|DT|322|323|HISTORY OF PRESENT ILLNESS|He said that he has never thrown up blood before, has never had an upper endoscopy and he has had no further emesis since he came into the hospital, which appears to be true and has been eating which again appears to be true. Looks like he is urinating okay and has had 2 black stools yesterday but none today. He is on a DT protocol and has a sitter. Said he has not been getting any medical care because he does not have insurance any longer.
DT|diphtheria-tetanus|DT|134|135|HISTORY|Superficial cutting to the volar aspect of left forearm and right forearm to a lesser degree on _%#MMDD#%_ with a foldout knife. Last DT in approximately 2004. Has not received ECT previously. PAST MEDICAL HISTORY: 1. Psychiatric illness (as above) details per Psychiatry.
DT|diphtheria-tetanus|DT.|219|221|HISTORY OF PRESENT ILLNESS|Evaluated in the Emergency Department at Fairview Southdale. Stable hemodynamics. Left wrist wounds extending through the skin thickness. No indication that deeper structures were involved. Skin wounds sutured. Updated DT. A moderate degree of localized discomfort. Denies compromise in motor function or digital paresthesias of the left hand. LABORATORY EVALUATION: Included a negative salicylate level, acetaminophen level less than 10.
DT|diphtheria-tetanus|DT.|156|158|ASSESSMENT|Self-inflicted skin lacerations, volar aspect left forearm. Sutured. No evidence for soft tissue infection. No involvement of deeper structures. Updated on DT. 4. Cocaine abuse with 6 months of sobriety. 5. Seizure disorder since childhood. Type not clear (not grand mal). Controlled on Neurontin. 6. Thoracic spine strain subsequent to work-related fall (as above).
DT|dorsalis pedis:DP|DT|157|158|PHYSICAL EXAMINATION|No obvious bruits. LUNGS: Decreased breath sounds at the bases. ABDOMEN: Nontender. No masses or palpable organs or vessels. No bruits present. EXTREMITIES: DT pulses present. I cannot feel DP's. NEURO: No obvious focal signs. LABORATORY DATA: The creatinine is 2.8. BUN is 54 mg/dl.
DT|diphtheria-tetanus|DT|133|134|HISTORY OF PRESENT ILLNESS|No loss of consciousness. No headache. He denies nausea or vomiting. No visual change. He has no local soreness. He is up to date on DT within the past year. Recommendation on suture removal in approximately 5 days. PAST MEDICAL HISTORY: 1. Bipolar illness (as described above); details per Dr. _%#NAME#%_.
DT|diphtheria-tetanus|DT.|153|155|ASSESSMENT|2. Self-injurious behavior with 3 midforehead lacerations (as described above). No signs of soft tissue infection. no neurologic sequelae. Up to date on DT. 3. Resolving upper respiratory infection. No intervention required. 4. Nicotine addiction. 5. Chemical dependency/polysubstance abuse. 6. Lamictal allergy. 7. Status post INH treatment for positive PPD.
DT|diphtheria-tetanus|DT.|253|255|ASSESSMENT|1. Major depressive disorder (details per Dr. _%#NAME#%_). 2. Recent avulsion injury to the right fourth and fifth digits by history progressing satisfactorily. No signs of soft tissue infection on most recent follow-up on _%#MMDD2002#%_. Up to date on DT. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_.
DT|diphtheria-tetanus|DT|158|159|HISTORY|Self-induced cutting with superficial lacerations to the volar aspect of the wrists bilaterally at 2 a.m. on _%#MMDD2002#%_. No suturing required. Updated on DT in the Emergency Room. No other act of self-harm. Concern by Psychiatry Service regarding issue of hypertension with blood pressure on presentation of 156/70.
DT|diphtheria-tetanus|DT.|247|249|HISTORY|She indicates that she has been compliant with medication. Self-induced cutting to the upper extremities over the last three weeks. Last cutting on _%#MMDD#%_. Use of an old razor and box cutter. No need for suturing. She indicates up- to-date on DT. No other active self-harm. Clinically, she is of "water retention," with fluids in the face and legs, particularly in the morning.
DT|diphtheria-tetanus|DT|180|181|SYMPTOM REVIEW|SYMPTOM REVIEW: On _%#MMDD#%_, the patient self-inflicted a laceration to the left mid humerus region anteriorly. Too late for suturing in the emergency room. Indicates updated on DT at that time. More superficial laceration over the dorsum of the left forearm. All lacerations with a clean razor blade. Self-induced cigarette burn to the left proximal humerus anteriorly.
DT|delirium tremens|DT|157|158|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Extensive chemical dependency history primarily for alcoholism and opiate abuse, and benzodiazepine abuse. He has a past history of DT and apparently a history of alcohol withdrawal seizures. 2. Hepatitis C. 3. Gastroesophageal reflux disease. 4. Allergic rhinitis.
DT|delirium tremens|DT|163|164|HISTORY OF PRESENT ILLNESS|Since admission she has had a CT scan of the brain which was unremarkable and she was loaded with intravenous Dilantin. Thiamine was started and she was placed on DT protocol. She has remained Posey'd and delirious. PAST MEDICAL HISTORY: Unclear. The patient reports previous back surgery, total abdominal hysterectomy and bilateral salpingo-oophorectomy and appendectomy.
DT|diphtheria-tetanus|DT.|297|299|HISTORY|Inconsistently medication compliant. First mental health hospitalization. Emergency room evaluation at Fairview _%#CITY#%_ on _%#MMDD2005#%_ subsequent to a self-inflicted laceration to the volar aspect of the left wrist. Use of a "clean razor." Suturing not required (used Dermabond). Updated on DT. The patient apparently felt appropriate for discharge. Started on a regimen of Paxil and Ambien. Continued depression with suicidal thoughts prompting referral for admission by primary-care provider Dr. _%#NAME#%_.
DT|diphtheria-tetanus|DT.|188|190|HISTORY OF PRESENT ILLNESS|She has had increasing despondency. She has had use of a razor with self- cutting to the volar aspect of the left forearm one night prior to admission. No suturing required. Up to date on DT. No other active self-harm. Alleged "scuffle in the ambulance, with bilateral paracervical and right forearm discomfort. Associated numbness into the right hand. Her last mental health hospitalization was at University of Minnesota Medical Center, Fairview, _%#CITY#%_ in _%#MM2006#%_.
DT|diphtheria-tetanus|DT.|216|218|ASSESSMENT|1. Bipolar illness, depressed. Issue of medication noncompliance. 2. Self-injurious behavior with superficial self-cutting of the volar aspect of the left wrist. Resultant superficial linear abrasions. Up to date on DT. No other intervention required. 3. Alleged "scuffle" in the ambulance with a contusion of the volar aspect of the right wrist.
DT|diphtheria-tetanus|DT.|176|178|ASSESSMENT|2. Self-inflicted linear superficial lacerations of the volar aspect of the forearms bilaterally. No lesions require suturing. No evidence for soft tissue infection. Update on DT. 3. Chronic constipation, likely related to dietary factors. Potential medication effect. Not hypothyroid based on normal TSH. 4. Chronic left lower quadrant abdominal discomfort, subsequent to laparoscopic surgery for endometriosis and left ovarian cystectomy.
DT|diphtheria-tetanus|DT.|202|204|HISTORY|Resumed self- cutting with the use of a razor blade to the bilateral upper extremities one week after discharge. Suturing required on _%#MMDD2002#%_ and again today after further cutting. Up to date on DT. No other act of self-harm. PAST MEDICAL HISTORY: 1. Major depressive disorder with self-injurious behavior.
DT|diphtheria-tetanus|DT.|213|215|ASSESSMENT|1. Major depressive disorder with self-injurious behavior. 2. Self-inflicted lacerations bilateral upper extremities (as above). Sutures required to both arms. No evidence for soft tissue infection. Up to date on DT. 3. Chronic constipation related to dietary factors and perhaps medications. Normal TSH of 1.51 on _%#MMDD2002#%_. 4. Chronic left lower quadrant abdominal discomfort with benign exam presently.
DT|diphtheria-tetanus|DT.|237|239|ASSESSMENT|ASSESSMENT: 1. Major depressive disorder, with self-injurious behavior. 2. Self-inflicted lacerations, bilateral upper extremities, as above, with suturing of right antecubital fossa; no evidence for soft-tissue infection; up to date on DT. 3. Anemia, potentially multifactorial. Possibilities include chronic disease, blood loss, and/or iron deficiency; however, serum iron, as above, is normal.
DT|diphtheria-tetanus|DT.|168|170|HISTORY|Does indicate depression 2 weeks ago. Self-cutting to the right upper extremity at that time. No treatment intervention required. Believes that he is up-to-date on his DT. Does indicate auditory hallucinations. No other active self-harm. Associated issue of polysubstance abuse. Drugs of choice include marijuana and alcohol. Denies recent marijuana ingestion.
DT|diphtheria-tetanus|DT,|126|128|OBJECTIVE|Skin: There are multiple superficial abrasions over the upper extremities (related to above altercation). He is up to date on DT, last administered approximately three years ago. Chest: Sonorous upper airway rhonchi/wheeze. No rales. A rib belt is in place. Splinting with limited inspiratory effort. Exquisite tenderness with direct palpation over the left lateral thorax.
DT|diphtheria-tetanus|DT.|226|228|ASSESSMENT|ASSESSMENT: 1. Depression/self-injurious behavior. Details per Dr. _%#NAME#%_. 2. Superficial linear abrasions bilateral upper extremities. No evidence for soft tissue infection. No need for suturing. Up to date by history on DT. 3. Recent GI illness manifested by nausea, vomiting, fevers, chills and sweats. Essentially resolved. More protracted diarrhea (by history), etiology unclear. Allegedly did not improve with discontinuation of Protonix.
DT|diphtheria-tetanus|DT.|135|137|HISTORY|Self-inflicted burns with a toaster oven to the right third digit, and right second MCP in the last two weeks. Indicates up-to-date on DT. No other act of self-harm. PAST MEDICAL HISTORY: 1. Psychiatric illness as above. Details per Dr. _%#NAME#%_. 2. Hypertension dating back years.
DT|diphtheria-tetanus|DT.|178|180|HISTORY|Lab data available indicates acetaminophen level of less than 1. She was referred to Fairview _%#CITY#%_ for inpatient admission. No other active self-harm. She is up to date on DT. PAST MEDICAL HISTORY: 1. Psychiatric illness (as above). Details per _%#NAME#%_. 2. History of endometriosis.
DT|diphtheria-tetanus|DT.|159|161|HISTORY|Self- cutting to the left lateral humerus with a razor two weeks ago. No sutures required. No signs of soft tissue infection. She believes to be up-to-date on DT. No other act of self-harm. She has a prior history of self-cutting. She also took pills in an excessive quantity dispensed.
DT|diphtheria-tetanus|DT.|228|230|ASSESSMENT|ASSESSMENT: A 22-year-old female with the following: 1. Bipolar affective disorder with decompensation. 2. Self-cutting lateral humerus, superificial lacerations healing nicely. No need for intervention. Allegedly up-to-date on DT. 3. History of glucose intolerance on Glucophage. Normal fasting blood sugar this morning. 4. History of clinical bronchial asthma, clinically well-compensated.
DT|diphtheria-tetanus|DT|198|199|HISTORY OF THE PRESENT ILLNESS|Alleged suicidal threats. Self-injurious behavior with superficial abrasions to the dorsum of the left thumb and anterior aspect of the right shoulder with a "clean-appearing" knife. Indicates last DT potentially in excess of ten years. Denies overdose except for Celexa, excess of 60 mg in addition to 3 to 4 Klonopin. Denies other chemical use. PAST MEDICAL HISTORY: 1. Major depressive disorder with other psychiatric diagnoses as above.
DT|delirium tremens|DT,|264|266|HISTORY|Denies significant alcohol intake prior to that time. In the interim has consumed either 4-6 beers, one half bottle of wine or 8 ounces of scotch daily. Last drink at noon on _%#MMDD#%_. Has had no prior history of alcohol withdrawal, withdrawal-related seizures, DT, known alcohol-related liver disease, pancreatitis or upper GI hemorrhage. Has had an ongoing tremor which she attributes to her antidepressant therapy.
DT|diphtheria-tetanus|DT.|190|192|HISTORY|Last used a razor to cut the volar aspect of the left wrist and bilateral proximal upper extremities on _%#MMDD2002#%_. Evaluated in the emergency room, suturing not required. Up to date on DT. No other self-injurious act. PAST MEDICAL HISTORY: 1. Major depressive disorder (details per Psychiatry).
DT|delirium tremens|DT.|391|393|ASSESSMENT/PLAN|Extremities reveal no peripheral edema. LABORATORY DATA: Sodium 137, potassium 4.5, chloride 100, bicarbonate 28, glucose 151, BUN 7, creatinine 1.07, calcium 8.9, total bilirubin 0.6, albumin 3.7, total protein 7.4, alkaline phosphatase 68, ALT 25, AST 42, magnesium 2, INR 1.91, hemoglobin of 12.4. ASSESSMENT/PLAN: Highly complex 61-year-old gentleman with: 1. Alcohol abuse with current DT. Will place the patient on a multivitamin, thymine, folate and tranxene. At this point in time he is further out in his withdrawal process and is currently having hallucinations.
DT|diphtheria-tetanus|DT.|203|205|HISTORY OF THE PRESENT ILLNESS|Patient relates a prior history of major depression since her second year in college. No prior hospitalizations. Self-induced cutting, volar aspect, left wrist one and one-half months ago. Up-to-date on DT. No present active self-harm. Issue of ongoing marital problems. PAST MEDICAL HISTORY: 1. Major depression (details per Psychiatry).
DT|diphtheria-tetanus|DT.|200|202|ASSESSMENT|1. Depression/suicidal ideation. Details per Psychiatry. 2. Self-induced cutting of volar aspect, left forearm with healing superficial abrasions. No evidence for soft tissue infection. Up-to-date on DT. 3. Tension/muscle contraction headache. 4. Nicotine addiction. 5. Facial acne. 6. Nausea correlating with anxiety. Benign abdominal exam. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_.
DT|delirium tremens|DT|179|180|INDICATION|Most of the history therefore was obtained by looking at the chart. The patient was admitted on _%#MMDD2003#%_. He appeared to be in the delirium tremens and got sedation per the DT protocol. This resulted in some obtundation, and the patient had to be intubated and placed on the respirator. He has been currently extubated. He has been started on total parenteral nutrition.
DT|diphtheria-tetanus|DT|354|355|HISTORY|No prior act of self harm. Indicates that on an impulse he self inflicted a laceration to the volar aspect of the left wrist with a potato peeling knife "to get attention." This was after a breakup with his girlfriend. Laceration inflicted at 1845. Evaluated in the emergency room at Fairview Ridges. Multiple "dissolvable" sutures placed (per patient). DT administered. Transferred for inpatient psychiatric hospitalization. PAST MEDICAL HISTORY: 1. Exercise-induced asthma. Typically does not use a metered-dose inhaler.
DT|delirium tremens|DT|170|171|RECOMMENDATIONS|4. Nutrition support with TPN. RECOMMENDATIONS: 1. Would reduce IV fluids. 2. Dose of Lasix. 3. Prn Haldol, increasing doses as necessary. For the present would continue DT protocol though history from the family would seem that this is unlikely. 4. Follow chest x-rays. 5. Will adjust TPN as appropriate.
DT|diphtheria-tetanus|DT.|238|240|HISTORY OF PRESENT ILLNESS|She has had increasing despondency with superficial laceration on the volar aspect of her left wrist with a steak knife on the afternoon of _%#MMDD#%_. The wound was "glued" in the emergency department. She indicates she is up to date on DT. She also ingested six baby aspirin. She developed mild dizziness. There are no other malingering sequelae and no other medication ingestion.
DT|diphtheria-tetanus|DT.|137|139|ASSESSMENT|3. Self-inflicted superficial laceration of the volar aspect of the left forearm. No further intervention required. She is up to date on DT. 4. Some type of renal disease (question IgA nephropathy). Significant proteinuria on urinalysis. It does not appear nephrotic presently except for perhaps some mild puffiness about the eyes.
DT|diphtheria-tetanus|DT.|145|147|PLAN|Will treat empirically with a proton pump inhibitor and see how patient does. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Update DT. 3. STD check per patient request. 4. Protonix 40 mg daily for 2 weeks. 5. Resume Synthroid 50 mcg daily, with recommended recheck TSH in 6 weeks.
DT|diphtheria-tetanus|DT.|212|214|ASSESSMENT|3. Self-induced cutting to the anterior cervical region and volar aspect of the forearms bilaterally. No gaping lesions requiring suturing. No evidence for soft tissue infection. It appears appropriate to update DT. 4. Nicotine addiction. 5. Bilateral hand paresthesias at h.s., potentially related to early carpal tunnel syndrome. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Keep wounds clean and dry.
DT|diphtheria-tetanus|DT|193|194|HISTORY|She has had prior drug overdose and self-cutting. She has superficial linear abrasions to the volar aspect of the wrist with a steak knife over one week ago. She indicates she is up to date on DT within the last few months. She has had no other active self harm. PAST MEDICAL HISTORY: 1. Depression (as above). Details per Dr. _%#NAME#%_. 2. The patient has received two of there hepatitis B vaccine injections.
DT|diphtheria-tetanus|DT.|215|217|ASSESSMENT|1. Major depressive disorder (details per Dr. _%#NAME#%_). 2. Self-injurious behavior with self-inflicted superficial linear abrasions, volar aspect of the wrist bilaterally. No intervention required. Up to date on DT. 3. Superficial abrasion, mid thoracolumbar region. Healing without evidence for infection. 4. Tendency toward constipation. Normal thyroid function.
DT|diphtheria-tetanus|DT|177|178|HISTORY OF PRESENT ILLNESS|She is compliant with medication. She had self-cutting to the lower aspect of the left forearm three days ago with a paring knife. Sutures were not required. She was updated on DT in the ER. PAST MEDICAL HISTORY: 1. Depression (as above). Details per Dr. _%#NAME#%_.
DT|diphtheria-tetanus|DT.|196|198|HISTORY OF PRESENT ILLNESS|While in the emergency room at Fairview Southdale Hospital, the patient did inflict superficial abrasion over the volar aspect of the left forearm with a pop can tab. The patient is up to date on DT. She has prior history of self- cutting. There is no history of alcohol withdrawal, DTs, or alcohol related liver disease.
DT|diphtheria-tetanus|DT.|138|140|ASSESSMENT|2. Self-inflicted stab wound, left upper abdomen. Superficial. No suturing required. No evidence for soft tissue infection. Up to date on DT. 3. Polysubstance abuse (ongoing), as above. No signs of drug withdrawal presently. 4. Facial acne. 5. Suppressed TSH. May relate to a sick euthyroid state.
DT|dorsalis pedis:DP|DT|92|93|OBJECTIVE|He denies any bleeding or drainage from his toenails. OBJECTIVE: The patient has a palpable DT and PT pulses. He does have diffuse, nonpitting edema to the bilateral lower extremities. The patient has resolved ulcerations at the posterior aspect of his right calcaneous, as well as to the plantar aspect of his left midfoot arch.
DT|delirium tremens|DT.|191|193|SOCIAL HISTORY|The patient does not use any other recreational drugs, other than 2 cups of coffee per day. Alcohol history is on average 18 beers per day for the past 3 years without withdrawal seizures or DT. Last use was last night at 7 p.m. FAMILY HISTORY: Significant for blood disorder (type unspecified).
DT|delirium tremens|DT|176|177|IMPRESSION/PLAN|If this has not been evaluated further may need further evaluation. 3. Possible past history of alcohol abuse. It is unclear when his last drink was; therefore will put him on DT precautions and start him on thiamine. 4. Anemia, normocytic, normochromic secondary to acute blood loss from recent surgery; will continue to monitor.
DT|diphtheria-tetanus|DT.|166|168|ASSESSMENT|1. Depression (details per psychiatry). 2. Self cutting volar aspect of the left forearm, no evidence for soft tissue infection. Suturing not required. Up to date on DT. 3. History of silicone breast implants (removed) with alleged secondary mixed connective tissue disorder. No clinical stigmata presently. 4. History of herpes vaginalis.
DT|diphtheria-tetanus|DT|206|207|HISTORY|On _%#MMDD2003#%_ the patient, using a disposable razor, self- inflicted numerous superficial lacerations to the forearms bilaterally and right lateral humus. No suturing was required. She is up-to-date on DT within the past year. No other act of self-harm. She indicates she has been compliant with medication. PAST MEDICAL HISTORY: 1. Psychiatric illness as above; details per Dr. _%#NAME#%_.
DT|diphtheria-tetanus|DT.|223|225|ASSESSMENT|1. Depression/suicidal ideation. History of schizoaffective disorder. Defer to Psychiatry. 2. Self-cutting to the upper extremities bilaterally. Just superficial wounds. No evidence for soft tissue infection. Up-to-date on DT. To keep wounds clean and dry. Otherwise no intervention required. 3. Exogenous obesity. 4. Constipation, possibly related to diet/medication effect.
DT|diphtheria-tetanus|DT.|164|166|OBJECTIVE|SKIN: A well approximated laceration over the volar aspect of the left wrist. Two sutures are in place; no gaping. No signs of soft tissue infection. Up to date on DT. Normal motor and sensory function of the digits of the left hand against tendon or nerve involvement. CHEST: Clear lung fields. CARDIAC: Regular without gallop or murmur.
DT|diphtheria-tetanus|DT|121|122|HISTORY|Protected with a "glue-type" topical agent. Subsequently noted to have gaping wounds with drainage. She is up to date on DT as of _%#MM#%_ of this year. PAST MEDICAL HISTORY: 1. Depression (as above). Details per Dr. _%#NAME#%_.
DT|diphtheria-tetanus|DT.|150|152|ASSESSMENT|Creamy drainage as above. Doubt secondary infection. Will nonetheless prophylax with Keflex, hydrogen peroxide cleanse, and Bacitracin. Up to date on DT. 4. Eating disorder in remission. 5. Constipation attributed to prior laxative abuse. 6. History of "rheumatoid arthritis" per record. No active synovitis. 7. Birth control pill usage. 8. Alcohol excess.
DT|diphtheria-tetanus|DT.|195|197|HISTORY|No other drug use. Self-inflicted superficial lacerations to the volar aspect of the left forearm the evening of _%#MMDD2004#%_ as well. Use of a "new razor." No suturing required. Up-to-date on DT. The patient has associated history of eating disorder dating back 4 years, manifested primarily by bulimia.
DT|diphtheria-tetanus|DT.|143|145|ASSESSMENT|3. History of self-cutting with superficial linear abrasions, lower aspect, left forearm. No evidence for soft tissue infection. Up-to-date on DT. At low risk, has used a "new razor." No treatment or intervention required. 4. Eating disorder, in remission, by history. 5. Constipation attributed to prior laxative abuse.
DT|diphtheria-tetanus|DT.|196|198|ASSESSMENT|5. Suppressed TSH. Rule out hyperthyroidism (down clinically). 6. Superficial self-cutting volar aspect left forearm. Linear superficial abrasions as described. No intervention required. Declined DT. At low risk for tetanus. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. The patient is to keep appointment with gender therapist as planned with intent for subsequent endocrinology follow up.
DT|diphtheria-tetanus|DT.|166|168|HISTORY|Presented to the ER. Sutures were required. Indicates no knowledge of major structure involvement. Indicates a good sensation and function of the hand. Up-to-date on DT. No other active self-harm. PAST MEDICAL HISTORY: 1. Psychiatric illness as above.
DT|delirium tremens|DT.|235|237|SOCIAL HISTORY|ALLERGIES: Which cause a rash. 1. Lamictal. 2. Serzone. SOCIAL HISTORY: The patient uses tobacco, 5 to 18 cigarettes per day, has not used alcohol for 17 months. She has been in CD treatments in the past. Denies withdrawal seizures or DT. She has a history of using cocaine and heroin by IV, currently not active. She is single with five children. All five of her children have been adopted by her parents.
DT|delirium tremens|DT.|210|212|SOCIAL HISTORY|SOCIAL HISTORY: The patient smokes tobacco. per records, greater than one pack per day, although the patient would not quantify an amount. He denied a history of IV drug use. He denied a history of seizures or DT. He is currently married. He states he has no children and he lives with his wife. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: GENERAL: The patient denies fevers, chills, or significant weight although per records it is stated that the patient had lost a significant amount of weight secondary to his medication changes.
DT|diphtheria-tetanus|DT.|189|191|HISTORY|Promptly transported to Fairview- Southdale Hospital Emergency room from where patient was referred for inpatient psychiatric hospitalization. Denies other act of self-harm. Up- to-date on DT. History of chemical dependency with history of polysubstance abuse. Indicates past use of acid, mushrooms, cocaine, glass, methamphetamine, marijuana, and prescription pain pills.
DT|diphtheria-tetanus|DT.|147|149|ASSESSMENT|Deferred to Dr. _%#NAME#%_. 2. Self-injurious behavior with recent self-inflicted superficial abrasions of palmar aspect, left hand. Up to date on DT. No evidence for soft tissue infection. No treatment intervention required. 3. Posttraumatic areas of ecchymotic bruising, distal left medial lower extremity, consistent with localized contusion.
DT|diphtheria-tetanus|DT|135|136|RECOMMENDATIONS|We will also recommend that she complete her hepatitis B vaccine series. We reviewed her ER records and noted that she also received a DT booster while there.
DT|delirium tremens|DT|88|89|IMPRESSION|With her creatinine now, she is at increased risk for problems and it is not necessary. DT precautions are in order. If she should change, certainly blood cultures looking for an infectious process would be in order. I would also recommend that her phosphorus, magnesium, calcium be followed as these will probably drop abruptly.
DT|delirium tremens|DT|122|123|IMPRESSION|I would also recommend that her phosphorus, magnesium, calcium be followed as these will probably drop abruptly. With the DT precautions, hopefully she will remain stable, although she does have some tremor at this point. I suspect her course will probably give a little rockier before she improves.
DT|diphtheria-tetanus|DT.|245|247|ASSESSMENT|1. Major depressive disorder, deferred to psychiatry. 2. Self-injurious behavior with self-cutting on bilateral upper extremities and left lower extremity. Wounds appear to be superficial, no evidence for soft-tissue infection. Is up to date on DT. 3. History of chemical dependency with polysubstance abuse. Lingering marijuana and alcohol use, as above. 4. History of "borderline hypertension" with blood pressure elevation on presentation.
DT|diphtheria-tetanus|DT|229|230|HISTORY|The patient presently denies active self-harm except for self-induced cutting to the volar aspect of the left forearm on _%#MMDD#%_ using a piece of metal that he found on the street. He indicates quite certain that he had had a DT within the past ten years. PAST MEDICAL HISTORY: 1. Asthma, variable degree of control. Presently well compensated.
DT|diphtheria-tetanus|DT|150|151|ASSESSMENT|2. Self-induced cutting volar aspect of left forearm with superficial linear abrasions as above. No evidence for soft tissue infection. Up to date on DT by history. 3. Prior issue of hemoptysis, potentially related to prior upper respiratory infection (question rhinitis, question bronchitis), quiescent.
DT|diphtheria-tetanus|DT.|131|133|ASSESSMENT|7. Asthma, well compensated. Resolving URI as above. 8. Nicotine addiction. 9. Repair right external ear laceration. Up to date on DT. 10. STD risk. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Monitor hemodynamics on multiple medications. 3. Insulin as above.
DT|dorsalis pedis:DP|DT|167|168|PHYSICAL EXAMINATION|Unable to assess varus and valgus instability secondary to obesity. Sensation intact from L3 to S1, 5/5 EHL, EDB, gastroc psoas, tibialis anterior, and quadriceps, 2+ DT pulses, and capillary refill less than 2 seconds. X-RAYS: She is break through with a tibial stem through the lateral cortex on the right.
DT|delirium tremens|DT.|258|260|RECOMMENDATIONS|3. Chewing tobacco use. The patient states she has been diagnosed with leukoplakia and is aware of the need to quit with the risk of oral head and neck cancers. RECOMMENDATIONS: _%#NAME#%_ will be monitored for alcohol withdrawal. She does have a history of DT. I will be happy to see her should she have further abdominal discomfort. She otherwise will follow-up with her primary physician. DISCUSSION: _%#NAME#%_ _%#NAME#%_ is a 36-year-old female who currently is hospitalized on Station 3B for the evaluation of suicidal ideation in the setting of ethanol use.
DT|delirium tremens|DT|177|178|DISCUSSION|She was at Hazelden late last year for 4 1/2 months in total. She states that she was only abstinent for two days after discharge from Hazelden. She states she has a history of DT for which she was hospitalized in ICU late last year. She denies knowledge of liver function test abnormalities or seizures.
DT|diphtheria-tetanus|DT.|258|260|HISTORY OF PRESENT ILLNESS|Allegedly, he took the medication for right foot pain attributed to the foot being run over by a 4 wheeler on _%#MM#%_ _%#DD#%_, 2006. No subsequent evaluation. Since has been able to bear weight with discomfort, but no significant compromise. Up-to-date on DT. Associated ingestion of 2 to 3 beers. Indicates average of 3 to 4 beers weekly. Indicates intoxicated only 3 times his entire life.
DT|diphtheria-tetanus|DT.|281|283|HISTORY OF PRESENT ILLNESS|Apparently called a treatment facility in Michigan from whom concern was raised regarding a potential suicidal nature of patient prompting referral to the emergency department. No other present act of self-harm. Indicates that she has been compliant with medication. Up-to-date on DT. Prior suicide attempt with overdose on Xanax. PAST MEDICAL HISTORY: 1. Psychiatric illness (as above). Details per Dr. _%#NAME#%_.
DT|delirium tremens|DT|136|137|REASON FOR CONSULTATION|We will start him on Lantus insulin in the morning. 3. Alcohol abuse. Will start him on IV thiamine and Foley catheter and put him on a DT precautions. 4. Thrombocytopenia, likely secondary to alcohol bone marrow suppression. His repeat platelets were 113 up from 83 earlier in the morning.
DT|diphtheria-tetanus|DT|174|175|HISTORY OF PRESENT ILLNESS|Evaluated at Fairview Ridges ER where records indicated that the palmaris tendon was involved. Sutured. Dressed with Kerlix. Placed on Keflex which patient has not filled. A DT was administered. Recommended orthopedic follow-up in five to seven days with suture removal in ten days. She has had minor localized wound discomfort. Paresthesias of the fourth and fifth digits as well as reduction in hand grasp yesterday which have since improved.
DT|diphtheria-tetanus|DT.|105|107|PLAN|3. Status post tonsillectomy. 4. Issue of suicide gesture deferred to Psychiatry. PLAN: 1. Up to date on DT. 2. With issue of flexor tendon involvement, will request Ortho follow-up with Dr. _%#NAME#%_ from Orthopedics. 3. Start Keflex 250 mg qid X5 days.
DT|delirium tremens|DT|198|199|HISTORY|He takes Coumadin for atrial fibrillation, he apparently had a mitral valve repair in _%#NAME#%_ 2005, but it has not been a valve replacement. At the time of his cardiac surgery he was in a severe DT and spent 10 days intubated in the ICU. The family states he has just become more confused over the last several days with the nausea, vomiting and a bit belligerent and his wife has been unable to get him to come to the ER.
DT|delirium tremens|DT,|142|144|SOCIAL HISTORY|She also admits to occasional alcohol use such as a glass of wine when she is out for dinner. She denies any history of alcohol abuse, detox, DT, or seizures. She denies any current or past drug history. FAMILY HISTORY: The patient admits to heart disease in both her mother and father, although was unable to provide any other details concerning the heart disease.
DT|diphtheria-tetanus|DT.|174|176|ASSESSMENT|7. Remote history of peptic ulcer disease. 8. Two linear abrasions over the volar aspect of the right wrist. Not gaping. No evidence for soft tissue infection. Up to date on DT. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_ or associate.
DT|diphtheria-tetanus|DT|216|217|HISTORY OF PRESENT ILLNESS|No chest discomfort or dyspnea. Has been tolerating a diet with regular bowel movements. No evidence for gross hematuria. Did sustain an abrasion to the left forearm which has been treated with Bacitracin topically. DT administered at Fairview Southdale. The patient presently denies lingering symptoms of withdrawal. Did have mild shakes while at Fairview Southdale. No history of withdrawal seizures.
DT|diphtheria-tetanus|DT.|190|192|ASSESSMENT|Rule out substance induced mood disorder. Problems with anger management (per record). 2. Self-inflicted superficial linear abrasion volar aspect of the left wrist. Up-to-date by history on DT. There is no evidence for soft tissue infection. There is no suturing or other intervention at this point required. 3. Polysubstance abuse. There are no signs presently of alcohol withdrawal.
DT|diphtheria-tetanus|DT.|205|207|HISTORY|Presented to the emergency department where patient was found to be hemodynamically stable with blood pressure 119/81, heart rate 90s, respirations normal, temperature 99.2 degrees. O2 sat 99%. Updated on DT. Wounds were sutured bilaterally. Concern regarding tendon/nerve involvement. Presently the patient notes retained ability to move her digits. Some restriction of the right thumb, which remains numb. Paresthesias of the left middle digit.
DT|diphtheria-tetanus|DT|113|114|HISTORY|The patient presented too late for suturing; has bandage over a large gaping wound. The patient is up to date on DT as of _%#MM#%_ 2002. PAST MEDICAL HISTORY: 1. Psychiatric illness as above. Details per Dr. _%#NAME#%_.
DT|diphtheria-tetanus|DT|253|254|HISTORY OF PRESENT ILLNESS|She indicates she last received ECT last week. She had interval onset of auditory hallucinations with self-inflicted superficial laceration on the volar aspect of the left wrist with a "clean razor." There was no suturing required. The date of her last DT was not clear. There was an alleged threat to jump off a balcony. She presented to the emergency room from where patient was hospitalized.
DT|diphtheria-tetanus|DT.|193|195|HISTORY OF PRESENT ILLNESS|She presented to the emergency room at Fairview _%#CITY#%_. It was too late to suture her wounds. She was treated with antibiotic salve and sterile dressing. She indicates she is up-to-date on DT. No other active self-harm. PAST MEDICAL HISTORY: Major depressive disorder. Details per Dr. _%#NAME#%_. PAST SURGICAL HISTORY: None. She is gravida 0, para 0.
DT|diphtheria-tetanus|DT|220|221|ASSESSMENT|1. Major depressive disorder details per psychiatry. 2. Superficial lacerations volar aspect left wrist. Again no evidence for soft tissue infection or need for suturing. Anticipate will heal uneventfully. Exact date of DT unknown. Use of a "new razor." No clear indications for DT update. 3. Issue of electroconvulsive therapy clearance. No complaints or findings to contraindicate.
DT|diphtheria-tetanus|DT|174|175|ASSESSMENT|Again no evidence for soft tissue infection or need for suturing. Anticipate will heal uneventfully. Exact date of DT unknown. Use of a "new razor." No clear indications for DT update. 3. Issue of electroconvulsive therapy clearance. No complaints or findings to contraindicate. The patient has tolerated in the past without compromise.
DT|delirium tremens|DT|153|154|RECOMMENDATIONS|7) Hyponatremia, hypokalemia, possible SIADH. RECOMMENDATIONS: 1) Continue support with vent, weaning as the patient level of consciousness improves. 2) DT protocol. 3) Continue IVF; will increase his rate a bit. He appears a little dry. 4) Will need nutrition support, probably with tube feedings if he is not able to take oral feedings within the next 24 hours.
DT|diphtheria-tetanus|DT.|161|163|HISTORY OF PRESENT ILLNESS|The patient has 1-1/2 months of sobriety. Self-induced cutting of the volar aspect left forearm approximately four days ago. No suturing required. Up to date on DT. No other active self-harm. PAST MEDICAL HISTORY: 1. Psychiatric illness, as described above. Details per Dr. _%#NAME#%_.
DT|dorsalis pedis:DP|DT|167|168|PHYSICAL EXAMINATION|There is no hepatosplenomegaly. I could not appreciate the abdominal aorta, there were no bruits. EXTREMITIES: Exam revealed 2+ bilateral pitting edema to the thighs. DT pulses were difficult to appreciate. The patient was alert and oriented, answered questions and followed commands. Affect was appropriate. ASSESSMENT AND PLAN: 1. The patient is a 73-year-old man with progressive dyspnea on exertion and lower extremity edema and normocytic anemia who has low iron stores and who began to have heme positive stool after initiation of Aggrastat and Heparin.
DT|diphtheria-tetanus|DT|221|222|HISTORY|She self- inflicted superficial lacerations to the upper extremities bilaterally with broken glass from a candle. Taken to Fairview Southdale Emergency Department, where suturing was not required. Indicates last received DT approximately one year ago. Breathalyzer was 0.125. Urine tox screen was otherwise negative. No other active self-harm. Referred for inpatient hospitalization as above.
DT|diphtheria-tetanus|DT.|148|150|ASSESSMENT|Defer to Psychiatry. 2. Bilateral superficial upper extremity abrasions. No evidence for soft tissue infection. No need for suturing. Up-to-date on DT. 3. Alleged history of seizure (remote), inactive. 4. Gravida 1 para 1. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Clinical observation. Specific intervention with regard to upper extremity abrasions does not appear required.
DT|diphtheria-tetanus|DT.|194|196|HISTORY|The patient denies prior treatment. Self-injurious behavior with cutting to the left upper extremity with a kitchen knife on _%#MMDD2003#%_ or _%#MMDD2003#%_. No sutures required. Up to date on DT. Last administered approximately 4- 5 years ago. No other act of self-harm. Associated polysubstance abuse with drugs of choice alcohol and crack cocaine.
DT|diphtheria-tetanus|DT.|232|234|ASSESSMENT|No ongoing pulmonary compromise. 7. Nicotine addiction. 8. Status post exploratory laparotomy for abdominal stab wound without sequelae. 9. Superficial linear abrasions, left upper extremity. No need for intervention. Up to date on DT. PLAN: 1. Serial blood pressure monitoring for now.
DT|diphtheria-tetanus|DT.|244|246|OBJECTIVE|No thyromegaly or lymphadenopathy. SKIN: Two linear healing lacerations over the volar aspect of the left forearm, measuring approximately 5 cm in length. Areas are "scabbed over." No evidence for soft tissue infection. Indicates up to date on DT. Scattered tattoos. CHEST: Clear lung fields. CARDIAC: Regular without gallop or murmur. No click. No jugular venous distention. ABDOMEN: Benign without tenderness, organomegaly or masses. Bowel sounds normal.
DT|diphtheria-tetanus|DT,|148|150|HISTORY|There is self-induced cutting to the volar aspect of her left wrist with a box cutter on _%#MMDD2003#%_. It was a clean blade. She is up to date on DT, approximately two years ago. She has had no other active self-harm. PRIOR HOSPITALIZATIONS: Fairview _%#CITY#%_ and Abbott Northwestern.
DT|diphtheria-tetanus|DT.|209|211|ASSESSMENT|1. Major depressive disorder, recurrent. Details per Psychiatry. 2. Self-inflicted superficial abrasions of volar aspect, left wrist. No need for suturing. No evidence for soft tissue infection. Up to date on DT. 3. Mixed headaches with tension/muscle contraction and vascular component. 4. Right-sided hearing loss (chronic). 5. Family history of diabetes and breast cancer.
DT|diphtheria-tetanus|DT.|230|232|HISTORY|Indicates that she missed 2 days of medication. Self-cutting to the left upper extremity on _%#MMDD#%_ on _%#MMDD#%_. ER evaluation at North Memorial with placement of Steri-Strips and sutures. Indicates that she is up-to-date on DT. No other present act of self-harm. Did jump out of a moving vehicle in the past. PAST MEDICAL HISTORY: 1. Psychiatric illness( (as above) Details per Dr. _%#NAME#%_.
DT|diphtheria-tetanus|DT.|128|130|HISTORY|Self-cutting to the volar aspect of the left forearm on _%#MMDD2004#%_ with a razor blade. Suturing not required. Up to date on DT. ECT administered during last hospitalization. The patient believes he did have a treatment one week ago and again today. He has tolerated general anesthesia without ill effect. No post ECT headache.
DT|diphtheria-tetanus|DT|245|246|HISTORY OF PRESENT ILLNESS|He had an argument with his wife on _%#MMDD2004#%_. He had a suicide gesture with self-cutting to the volar aspect of the left wrist with a hunting knife. He presented to Fairview Northland Emergency Department, where suturing was not required. DT was administered. He was started on Zoloft, with which the patient indicates he was compliant. He had recurrent suicidal thoughts on _%#MMDD2004#%_, prompting re-presentation to the emergency room, with transfer to Fairview _%#CITY#%_, as above.
DT|diphtheria-tetanus|DT,|177|179|HISTORY|He has had no overt stigmata of alcohol withdrawal (perhaps mild symptoms in the past). Indicates that he has gone up to a month without drinking in the past. Denies history of DT, withdrawal seizures, known alcohol-related liver disease, or pancreatitis. He did have upper GI hemorrhage for which the patient was hospitalized at North Memorial Medical Center at age 21.
DT|diphtheria-tetanus|DT|241|242|SOCIAL HISTORY|She has been in detox x2 in the past in 2003 at University of Minnesota Medical Center - Fairview, for 28 days duration, and the second time again at University of Minnesota Medical Center - Fairview, for 3 days in _%#MM#%_ 2005. She denies DT or seizures. She denies drug use at this time and admits to cocaine use 2 years ago. FAMILY HISTORY: Significant for hypertension and quadruple bypass surgery in her mother.
DT|diphtheria-tetanus|DT.|135|137|ASSESSMENT|No evidence for soft tissue infection. I would keep the areas clean and dry for now. No treatment intervention required. Up to date on DT. 3. Mild facial acne. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Clinical observation. Further medical intervention at this point is not required.
DT|diphtheria-tetanus|DT.|218|220|HISTORY|More recently admitted _%#CITY#%_ _%#CITY#%_ with discharge one week ago after a 2-week hospital stay. Compliant with medication. Prior to that, self-cutting to both wrists (approximately one month ago). Up to date on DT. On the evening of _%#MMDD2006#%_, the patient overdosed on at least 10 Ambien CR 12.5 mg tablets. Developed a "drunk-like sensation" with unsteady gait. Associated somnolence. No falls/head trauma.
DT|diphtheria-tetanus|DT.|231|233|ASSESSMENT|ASSESSMENT: 1. Bipolar illness, depressed. Deferred to psychiatry. 2. Self-inflicted laceration right lower extremity. No evidence for soft tissue infection. Anticipate will granulate in and heal unremarkably. In need of update on DT. 3. History of migraine headache, clinically quiescent. 4. History of typhoid related to prior live vaccine administration. 5. Mild hypotension undoubtedly related to medications. Asymptomatic. Appears to be tolerating well clinically.
DT|diphtheria-tetanus|DT.|149|151|ASSESSMENT|1. Depression/suicidal ideation. Deferred to psychiatry. 2. Self-inflicted superficial linear abrasions of volar aspect of left wrist. Up to date on DT. No intervention required. 3. Asthma which clinically appears well compensated. Moving air well. No bronchospasm. 4. Question regarding endometriosis manifested by dysmenorrhea and menorrhagia.
DT|delirium tremens|DT.|172|174|PAST MEDICAL HISTORY|5. Hospitalized for pneumonia in 1990. 6. Tonsillectomy. 7. No history of seizures, asthma, heart attacks, diabetes, or cancer. 8. History of withdrawal, hypertension, and DT. ADMISSION MEDICATIONS: 1. Paxil 20 mg p.o. daily for depression. 2. Antabuse.
DT|diphtheria-tetanus|DT|191|192|HISTORY|Anticipated to have ECT on _%#MMDD2004#%_. Alleged suicidal ideation with self-cutting using an exacto-knife to the lower aspect of the left forearm on _%#MMDD2004#%_. Suturing not required. DT administered in the emergency department. PAST MEDICAL HISTORY: 1. Major depressive disorder (as above). Details per Dr. _%#NAME#%_.
DT|diphtheria-tetanus|DT.|174|176|HISTORY|She denies suicidal ideation. She does admit to self-injurious behavior with recent "bloodletting" from the left antecubital fossa. The use of a "clean razor." Up to date on DT. She has not received ECT in the past. She has no prior problems with general anesthesia. She has no recent upper respiratory infection or flu-like symptoms except for occasional cough attributed to smoking.
DT|diphtheria-tetanus|DT.|212|214|ASSESSMENT|Defer to Dr. _%#NAME#%_. 2. Self-cutting with superficial abrasion/laceration dorsal aspect left forearm. Wound margin erythema likely related to inflammatory change. Doubt soft tissue infection. Needs update on DT. 3. Exogenous obesity. 4. Hypertension, adequate control. 5. Hypothyroidism, on replacement. Borderline elevated TSH level. Reasonable to continue present regimen with recheck TSH in one month as planned by primary MD.
DT|diphtheria-tetanus|DT|200|201|PLAN|Will check EKG pre-anesthesia with results called prior to proceeding. 2. Increased Metamucil to b.i.d. 3. Follow-up thyroid function with primary care physician in approximately one month. 4. Update DT 0.5 cc IM. 5. Bacitracin ointment to left forearm wound b.i.d. 6. Alert Anesthesia regarding nausea/vomiting with anesthetic. Consider prophylaxis with IV Zofran.
DT|diphtheria-tetanus|DT.|118|120|HISTORY OF PRESENT ILLNESS|Self-cutting to the dorsal aspect of the left forearm with a clean kitchen knife. No suturing required. Up to date on DT. Allegedly had been driving on a 4-lane highway with her eyes closed. Also thinking about setting herself on fire. No other specific act of self-harm.
DT|diphtheria-tetanus|DT.|201|203|ASSESSMENT|1. Schizoaffective disorder, depressed. Further diagnoses per Psychiatry. 2. Self-cutting, dorsal aspect of left forearm. No intervention required. No evidence for soft-tissue infection. Up to date on DT. 3. Hypothyroidism, with suppressed TSH. Normal T3 and T4 values. May require a reduction in her Synthroid dose. I will provide a copy of labs to the patient at discharge for a primary MD followup.
DT|diphtheria-tetanus|DT|232|233|PLAN|Watch for signs of soft tissue infection. 2. HIV antibody (if patient agreeable) in addition to hepatitis B and C studies and RPR. 3. Clinical observation with psychiatric intervention per Dr. _%#NAME#%_. The patient indicates last DT was within the past few years (?). Thank you for the consultation. Will follow along as clinically indicated.
DT|diphtheria-tetanus|DT.|154|156|ASSESSMENT|3. Motor vehicle accident with secondary abrasion volar and dorsal aspect left wrist. No evidence of infection. Nothing requiring suturing. Up to date on DT. No history of head trauma, blunt chest trauma or injury to the cervical spine. 4. Gastroesophageal reflux, symptomatically controlled with p.r.n. antacids. 5. Lumbar disk disease with intermittent discomfort.
DT|diphtheria-tetanus|DT.|169|171|HISTORY|Superficial self-cutting to the upper extremities prior to this admission with "scratching" of the upper extremities since hospitalization. Believed to be up to date on DT. Indicates that she has purged several times since this admission. She indicates laxative abuse on two occasions over six weeks prior to this admission.
DT|diphtheria-tetanus|DT|207|208|HISTORY|This is the patient's first mental health hospitalization. Increased stressors. Self-cutting to the left forearm approximately two weeks ago. Sutured in the emergency room at Fairview _%#CITY#%_ _%#CITY#%_. DT administered. He was seen by a psychologist on _%#MMDD2002#%_. Concern regarding suicidal ideation. Prompting referral to the emergency room and admission.
DT|diphtheria-tetanus|DT.|105|107|HISTORY OF PRESENT ILLNESS|She indicates that on _%#MMDD2007#%_ she "clawed" her face and neck with her nails. She is up to date on DT. No other active self-harm. She does have a prior history of self cutting and "slashing her wrists." She has the issue of eating disorder since age 13, which has been more severe over the last three to four years manifested by restriction.
DT|delirium tremens|DT,|147|149|HABITS|Alcohol consists of heavy intake approximately once weekly. Up to eight to ten drinks, to the point of intoxication. Denies history of withdrawal, DT, alcohol-related liver disease, pancreas, or upper GI hemorrhage. No history of DUI. Denies other drug use. SOCIAL HISTORY: Married, two children.
DT|delirium tremens|DT,|200|202|ASSESSMENT AND PLAN|5. Nutritional consultation ordered. 6. Acute alcohol intoxication. The patient has been on D5/.05 normal saline with 20 mg KCl at 150 mL/hr x12 hours and is currently alert and oriented. No signs of DT, we will monitor. 7. Recent urinary tract infection. We will order a UA and UC. 8. Tachycardia. We will continue the patient on Toprol XL 50 mg p.o. daily.
DT|diphtheria-tetanus|DT|156|157|HISTORY|He was not treated with activated charcoal. Application of 4 sutures to the right 3rd digit, which the patient lacerated when the patient broke a vase (?). DT administered per patient. After a period of observation, the patient was felt to be clinically stable.
DT|diphtheria-tetanus|DT.|197|199|HISTORY OF PRESENT ILLNESS|Was momentarily dazed. No loss of consciousness. Evaluated at _%#CITY#%_ _%#CITY#%_ Hospital ER with placement of a sutures, which were to be removed on _%#MMDD2007#%_. Alleges to be up-to-date on DT. Indicates a generalized headache discomfort, which is more prominent when he is angry. Also indicates reduction right-sided hearing subsequent to the above closed head injury.
DT|delirium tremens|DT.|184|186|SOCIAL HISTORY|SOCIAL HISTORY: The patient uses tobacco one-half pack per day. He has been drinking alcohol a liter per day. He has no previous detox treatments. No history of withdrawal seizures or DT. He states he last used heroin 4 weeks ago, cocaine monthly, marijuana weekly, methamphetamines x6, and acid in high school.
DT|delirium tremens|DT,|222|224|HISTORY|When "unable to get high", the patient would drink to the point of intoxication. She denies knowledge of alcohol related liver disease, pancreatitis, or upper gastrointestinal blood loss. No history of alcohol withdrawal, DT, or seizures. She indicates she will use other drugs when available including Xanax, Haldol, and Ativan. She has had a more recent onset of auditory hallucinations not appreciated in the past.
DT|delirium tremens|DT|156|157|RECOMMENDATIONS|3. We will also check an ammonia level to look for evidence for hepatic encephalopathy. 4. I will order a chemical dependency consultation. 5. I agree with DT precautions and seizure precautions at this point.
DT|diphtheria-tetanus|DT.|188|190|OBJECTIVE|SKIN: Demonstrates multiple transverse superficial lacerations, some of which are gaping, involving the volar aspect of left forearm. Self-inflicted on _%#MMDD#%_. Indicates up-to-date on DT. No erythema or increased warmth to suggest soft tissue infection. CHEST: Clear lung fields. CARDIAC: Regular without gallop or murmur.
DT|diphtheria-tetanus|DT|174|175|RECOMMENDATIONS|3. Questionable pulmonary nodule as an incidental finding on her admission chest x-ray. RECOMMENDATIONS: 1. We will follow up on culture data with you. 2. We will give her a DT booster since it has been 10 years since her last one. 3. I would agree with the use of intravenous Unasyn at the current dose and schedule.
DT|diphtheria-tetanus|DT.|122|124|HISTORY|Associated issue of self-cutting with a razor to the radial aspect of the left wrist. Sutures not required. Up to date on DT. PAST MEDICAL HISTORY: 1. Major depressive disorder/PTSD (as above). Details per Dr. _%#NAME#%_.
DT|diphtheria-tetanus|DT,|171|173|HISTORY|Indicates he has shared needles. Last tested for HIV in 1999. Denies a history of drug withdrawal. Does note mild shakes and sense of anxiety presently. Denies history of DT, withdrawal-related seizures, alcohol related liver disease, pancreatitis, or upper GI hemorrhage. PAST MEDICAL HISTORY: 1. Polysubstance abuse (as above). 2. Asthma relatively well compensated.
DT|diphtheria-tetanus|DT|118|119|IMMUNIZATIONS|He lives in the rural Belgrade area with his parents and siblings. There is no recent acute stressors. IMMUNIZATIONS: DT 1997, MMR 1997, hepatitis B _%#MM#%_ 2000, yearly flavicin. REVIEW OF SYSTEMS: General: No recent acute illnesses. Head, eyes, ears, nose and throat: Scheduled for left ear surgery as above.
DT|diphtheria-tetanus|DT.|213|215|PLAN|3. Multivitamin 1 daily. 4. Dental appointment with Dr. _%#NAME#%_ on Monday, _%#MMDD2006#%_, if the patient desires. 5. P.r.n. Tylenol or ibuprofen for discomfort. Anbesol topically p.r.n. dental pain. 6. Update DT. 7. Nicotine lozenge. 8. Empiric Protonix 40 mg daily for question of alcohol-related gastritis during hospitalization.
DT|diphtheria-tetanus|DT.|191|193|ASSESSMENT|1. Depression/suicidal ideation. Details per Dr. _%#NAME#%_. 2. Self-induced cutting, volar aspect of the left wrist. Superficial laceration. There is no intervention required. Up to date on DT. 3. Asthma, well compensated. 4. Seasonal allergies. 5. Nicotine addiction with history of polysubstance abuse. 6. Penicillin and sulfa allergies (question). 7. Remote history of Chlamydia, HPV, and gonorrhea.
DT|diphtheria-tetanus|DT,|263|265|PAST MEDICAL HISTORY|2. Hypertension, on Prinivil. 3. Restless legs syndrome. 4. Denies history of heart disease, diabetes, asthma, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, thyroid disease, seizure, tuberculosis, or anemia. Specifically without history of DT, alcohol withdrawal seizures, known alcohol-related liver disease, pancreatitis, or upper GI hemorrhage. 5. Surgeries: none. ALLERGIES: None. PRESENT MEDICATIONS: Include: 1. MSSA withdrawal protocol using Ativan.
DT|diphtheria-tetanus|DT.|132|134|HISTORY OF PRESENT ILLNESS|She did pursue self-cutting to the left leg I believe one month ago, with a gaping wound requiring 16 sutures. She is up to date on DT. PAST MEDICAL HISTORY: 1. Psychiatric illness, as above. Details are per Dr. _%#NAME#%_.
DT|delirium tremens|DT,|287|289|HISTORY|Used 4-5 nights in a row prior to admission. Alcohol use consisting of anywhere from 1/2 liter to 1 liter of bourbon with daily intake prior to admission. Denies intravenous or other drug use. He has had mild alcohol withdrawal in the past. No appreciated symptoms presently. Unaware of DT, withdrawal-related seizures, pancreatitis, alcohol-related liver disease, or upper GI hemorrhage. PAST MEDICAL HISTORY: 1. Poly-substance abuse as above. 2. History of depression.
DT|diphtheria-tetanus|DT.|125|127|REVIEW OF SYSTEMS|No signs of GI blood loss. No voiding complaints. No rash. No focal neurologic complaint. Believes that she is up-to-date on DT. OBJECTIVE: GENERAL: Obese adult female lying supine in bed in no distress.
DT|delirium tremens|DT|223|224|SOCIAL HISTORY|He has had a significant history of chemical dependency, and most recently has been drinking up until about 3 days ago. He was using about 18 beers a day as well as smoking pot about 5 times a day. He denies any history of DT or seizures associated with alcohol withdrawal. FAMILY HISTORY: Unremarkable. REVIEW OF SYSTEMS: He notes difficulty with consistent sleep, particularly the past several days.
DT|diphtheria-tetanus|DT.|225|227|ASSESSMENT|Healing nicely, without evidence for soft tissue infection. 3. Multiple abrasions with blistering feet bilaterally secondary to protracted ambulation in "plastic sandals." No evidence for soft tissue infection. Up to date on DT. 4. History of cocaine and alcohol abuse, which the patient denies. 5. History of migraine headaches (presently quiescent). 6. History of skull fracture without neurologic sequela.
DT|diphtheria-tetanus|DT.|124|126|ASSESSMENT|No evidence for soft tissue infection. Intervention does not appear required. The patient is not certain as to time of last DT. With superficial nature of wound, does not appear required at this time. 3. Asthma, well compensated. 4. Hypothyroidism, euthyroid on Synthroid replacement.
DT|delirium tremens|DT.|187|189|HISTORY OF PRESENT ILLNESS|The patient has had 19 previous chemical dependency treatment for alcohol. She has had a history of withdrawal seizures, but that was several years back. No seizures since. No history of DT. She recently had been drinking 3/4 of a liter of alcohol per day since _%#MM#%_. She has a lot of increased stress in her life.
DT|diphtheria-tetanus|DT.|152|154|PLAN|PLAN: 1. Screening labs as ordered. 2. Outside records as requested by Psychiatry. 3. Ask staff to check on the patient's immunization status regarding DT. Soak the puncture wound in Betadine for 30 minutes and observe for signs of soft tissue infection. 4. Clinical observation. Thank you for this consultation. I will follow the patient as indicated.
DT|delirium tremens|DT.|201|203|SOCIAL HISTORY|5. Seroquel. 6. Zantac. ALLERGIES: Sulfa and penicillin which causes hives. SOCIAL HISTORY: The patient denies tobacco use. Relapsed on alcohol drinking vodka. Denies history of withdrawal seizures or DT. No illicit drugs. She is currently married, she has four children from a previous marriage, and living with her husband in _%#CITY#%_ _%#CITY#%_.
DT|delirium tremens|DT|173|174|PAST MEDICAL HISTORY|Internal Medicine consult was requested for a medical consultation and for admission to the medical unit. PAST MEDICAL HISTORY: 1. Alcohol dependence. 2. History of alcohol DT with tremors and hallucinations. 3. History of a previous chemical-dependency treatment in Hazelden in 2004. 4. Alcoholic hepatitis history. 5. Hypertension. 6. Insomnia. 7. Speech impediment.
DT|delirium tremens|DT|206|207|SOCIAL HISTORY|She has been sober from alcohol for 6 months with a relapse on Wednesday, _%#MMDD2006#%_, drinking 1 L of vodka on that day, as described above. She has had previous CD treatment. She also has had previous DT in the past. No history of withdrawal seizures. Illicit drugs including remote history of cocaine use once or twice, and marijuana use once.
DT|diphtheria-tetanus|DT|172|173|HISTORY|Resultant left leg laceration as above, sutured in the emergency department at Mercy Hospital. The patient subsequently taken to jail. Advised suture removal in two weeks. DT administrated. The patient indicates that she was treated initially with Keflex for possibility of wound infection. She has had mild surrounding wound erythema, as well as drainage involving the more proximal lesion.
DT|diphtheria-tetanus|DT.|127|129|HISTORY|Suicidal ideation. Superficial self-cutting to the volar aspect of the wrists bilaterally. No suturing required. Up to date on DT. PAST MEDICAL HISTORY: 1. Psychiatric illness (as above). Details per Dr. _%#NAME#%_. 2. History of migraine headache, usually manifested as a throbbing discomfort in the left temple region.
DT|diphtheria-tetanus|DT.|196|198|ASSESSMENT|1. Major depressive disorder, recurrent. Generalized anxiety disorder. Defer to Dr. _%#NAME#%_. 2. Self-injurious behavior with superficial linear abrasions to forearms bilaterally. Up to date on DT. No intervention required. 3. History of migraine headaches. 4. Facial discomfort as described. Suspect represents manifestation of migraine or tension/ muscle contract headache.
DT|diphtheria-tetanus|DT.|151|153|HISTORY|Within the last one to two weeks, the patient has inflicted cigarette burns to the volar and extensor aspect of the left forearm. She is up to date on DT. Last administered apparently one month ago. Another act of self-harm. With regard to ECT, the patient has since received a second psychiatric opinion regarding treatment.
DT|diphtheria-tetanus|DT|168|169|HISTORY|At the time of overdose, he did inflict superficial abrasions using a kitchen knife to the left upper extremity and upper abdomen/anterior chest. No suturing required. DT administered in the emergency department. PAST MEDICAL HISTORY: 1. Serious illness: None. 2. Surgeries: None. 3. He denies heart disease, diabetes, asthma, hypertension, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, thyroid disease, seizure, tuberculosis, or anemia.
DT|diphtheria-tetanus|DT|174|175|ASSESSMENT|No lingering clinical sequelae. Normal follow-up liver profile. 2. Superficial self-inflicted linear abrasions to the left upper extremity and upper abdomen/ anterior chest. DT administered. No signs of soft tissue infection. No suturing required. Anticipate will heal uneventfully. 3. Depression/anxiety (per Psychiatry). 4. Marijuana use (based on urine tox screen).
DT|delirium tremens|DT,|122|124|SOCIAL HISTORY|He denies using alcohol at this time, but admits he abused alcohol from the ages of 18 to 21 years old. Denies detox, any DT, or seizures in the past. The patient also used marijuana from the age of 18 to 21 years old. However, admits that he has been sober for 2 years.
DT|diphtheria-tetanus|DT.|148|150|HISTORY OF PRESENT ILLNESS|She had self-cutting to the volar aspect of the right forearm on _%#MMDD2004#%_ with a clean razor. Suturing was not required. She is up to date on DT. No other active self-harm. PAST MEDICAL HISTORY: 1. Psychiatric illness, as above.
DT|diphtheria-tetanus|DT.|188|190|HISTORY|Treatment in the past with Celexa. More recently on Clonazepam, which the patient has been compliant with. There is a past issue of self-cutting to the left upper extremity. Up-to-date on DT. No recent acts of self-harm. PAST MEDICAL HISTORY: 1. Psychiatric illness (as above). Details per psychiatry. 2. Question of some type of thyroid abnormality during last hospitalization.
DT|diphtheria-tetanus|DT.|178|180|HISTORY OF PRESENT ILLNESS|History of self-injurious behavior with self cutting to the volar aspect of the left forearm last evening. Used a broken candlestick holder. Suturing not required. Up to date on DT. No other act of self harm. Does relate prior history of drug overdose. PAST MEDICAL HISTORY: 1. Psychiatric illness, as above. Details per Dr. _%#NAME#%_.
DT|diphtheria-tetanus|DT.|200|202|HISTORY|Cats put to sleep two months ago. Financial loss. Apparently prompted self-cutting to the volar aspects of the wrists bilaterally with a shaving razor. Suturing not required. Indicates up-to- date on DT. Hospitalized at Fairview Southdale under the care of Dr. _%#NAME#%_ _%#NAME#%_ with subsequent transfer to Fairview _%#CITY#%_ 3A for issues regarding chemical dependency.
DT|diphtheria-tetanus|DT.|271|273|ASSESSMENT|ASSESSMENT: 38-year-old male admitted with the following: 1. Depression in the setting of bipolar affective disorder (per Psychiatry). 2. Self-induced cutting of volar aspect of wrists bilaterally. Healing nicely, without evidence of soft tissue infection. Up-to-date on DT. 3. Fusiform mass right anterior cervical region felt most likely to represent a reactive lymph node. May be secondary to the chin abrasion. The patient indicates recent viral URI.
DT|diphtheria-tetanus|DT.|153|155|ASSESSMENT|3. Superficial laceration, digital tuft, left 4th digit. The patient will cleanse with soap and water. Otherwise no intervention required. Up to date on DT. 4. History of closed-head injury sustained a motor vehicle accident without lingering clinical sequela. 5. Surgeries as above. 6. Nicotine addiction. 7. Polysubstance use/abuse (?).
DT|delirium tremens|DT.|165|167|PAST MEDICAL HISTORY|2. Questionable coronary artery disease. 3. Hypertension. 4. Status post appendectomy. 5. Questionable history of diabetes mellitus. 6. History of alcohol abuse and DT. He quit drinking 2 months ago. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Digoxin 0.25 mg p.o. each day, discontinued 1 week ago.
DT|diphtheria-tetanus|DT.|242|244|OBJECTIVE|There is no thyromegaly or lymphadenopathy. Skin exam shows two linear superficial abrasions over the dorsum of the left forearm, measuring approximately 10 cm. Wounds non-gaping. No evidence of soft tissue infection. Indicates up to date on DT. Chest: clear lung fields. Cardiac exam: regular without audible gallop or murmur. No click or jugular venous distention. Abdomen is soft and non-tender without palpable organomegaly or mass.
DT|diphtheria-tetanus|DT.|128|130|ASSESSMENT|2. Self-inflicted laceration volar aspect left forearm. Well approximated. No evidence for soft tissue infection. Up to date on DT. 3. Elevated GGT potentially related to fatty change. 4. Alcohol dependency with successful sobriety since _%#MM#%_. 5. Ongoing Vicodin requirement.
DT|delirium tremens|DT|87|88|PLAN|May represent an inflammatory process of viral syndrome. PLAN: 1. Place the patient on DT precautions using Valium since the patient had adverse affect with Ativan. Valium dose will be 5 mg IV q.i.d. p.r.n. 2. Re-start his Seroquel and Cymbalta and continue it. 3. Request psych consult.
DT|delirium tremens|DT,|184|186|PAST MEDICAL HISTORY|3. Hyperlipidemia. 4. Myocardial infarction in 1999. He had stents placed at that time at HCMC. 5. Alcoholism. He had previous CD treatment in 2004 in Hibbing. No history of seizures, DT, or withdrawal. PAST SURGICAL HISTORY: Negative. ADMISSION MEDICATIONS: 1. Enteric-coated aspirin 325 mg daily. 2. Prevacid 30 mg p.o. daily.
DT|diphtheria-tetanus|DT.|229|231|HISTORY|She now presents with 7-10 days of self-cutting to the volar aspect of the left forearm with the use of a fairly new razor blade. One laceration required suturing in the emergency department on _%#MMDD2003#%_. She was updated on DT. No other act of self-harm. PAST MEDICAL HISTORY: 1. Psychiatric illness as above. (Details per Dr. _%#NAME#%_.)
DT|delirium tremens|DT.|197|199|SOCIAL HISTORY|ALLERGIES: 1. Penicillin. 2. Amoxicillin. 3. Codeine. SOCIAL HISTORY: The patient denies tobacco use. She has been using alcohol x3 a week, if it is available. No history of withdrawal seizures or DT. She has not been in detox treatment before. She has abused Xanax x2, methamphetamines once, and marihuana 3 months ago.
DT|diphtheria-tetanus|DT.|161|163|OBJECTIVE|There is a 3-4 mm very superficial linear abrasion over the dorsum of the right third digit. There is no evidence for soft tissue infection. He is up to date on DT. CHEST: Clear lung fields without bronchospasm. CARDIAC: Regular without gallop or murmur, no click, no jugular venous distention. ABDOMEN: Non-distended, soft with mild tenderness along the mid abdomen bilaterally.
DT|delirium tremens|DT,|154|156|HISTORY OF PRESENT ILLNESS|The patient had a breathalyzer of 0.16. The patient reports drinking 12-pack of beer and 4 to 5 shots of rum daily. Per the patient, she has a history of DT, prior 10 outpatient treatments with the last one 2 months ago, and a possible history of angina 2 months ago. The patient has a history of depression, asthma, and status post back surgery with current low back pain that radiates to the left leg.
DT|diphtheria-tetanus|DT.|221|223|SYMPTOM REVIEW|SYMPTOM REVIEW: This morning spilled hot tea over the dorsum aspect of the left ankle/foot after taking the tea out of the microwave. Secondary blistering. Moderately severe pain. Applying a local ice pack. Up to date on DT. Denies fevers, chills, or sweats. No headache or dizziness. No visual change. Without chest discomfort, dyspnea, cough, or palpitations.
DT|diphtheria-tetanus|DT.|184|186|HISTORY|While in the Emergency Department on _%#MMDD2007#%_. The patient self-inflicted two lacerations to the volar aspect of the left forearm, both of which required suturing. Up-to-date on DT. Prior history of self-cutting in conjunction with self-burning and drug overdose. No other present act of self-harm.
DT|diphtheria-tetanus|DT.|180|182|ASSESSMENT|5. Prior salicylate overdose x2 with recurrent self-cutting left upper extremity. Multiple superficial lacerations (as above). No evidence for soft tissue infection. Up-to-date on DT. No treatment intervention required. 6. Surgeries as above. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_ (or associate).
DT|diphtheria-tetanus|DT.|292|294|HISTORY|Mental health diagnosis of major depressive disorder, recurrent, severe with associated borderline personality disorder and generalized anxiety disorder (per patient). Self-injurious behavior with self-inflicted left upper extremity lacerations requiring suturing at that time. Up-to-date on DT. In the interim, the patient indicates that she has been medication compliant. A group home resident. Increasing despondency. Alleged suicidal ideation. Recurrent self-injurious behavior with cutting and self-inflicted burns to the left upper extremity over the last 3 weeks.
DT|diphtheria-tetanus|DT|165|166|ASSESSMENT|2. Self-injurious behavior with inflicted superficial linear abrasions and second-degree burns on left forearm. No evidence for soft tissue infection. Up-to-date on DT by history. 3. History of exercise and cold induced asthma, well compensated. 4. Exogenous obesity. 5. Past history of crack cocaine abuse.
DT|diphtheria-tetanus|DT|225|226|HISTORY|Indicates interval compliance with medication. Recurrent self cutting with an "old razor blade" to the forearms bilaterally the morning of _%#MMDD#%_. Lacerations that have required suturing in the emergency department. Last DT approximately one year ago. No other act of self-harm. PAST MEDICAL HISTORY: 1. Psychiatric illness as above.
DT|diphtheria-tetanus|DT.|152|154|HISTORY OF PRESENT ILLNESS|She engaged in superficial cutting to the upper extremities bilaterally with a razor on _%#MMDD2004#%_; sutures were not required. She is up to date on DT. No other active self- harm. There is an associated issue of eating disorder manifested by bulimia. She indicates this is active with daily purging. She is on chronic laxatives including Colace, fiber, and Dulcolax.
DT|diphtheria-tetanus|DT|168|169|HISTORY|Most recent cutting on _%#MMDD2003#%_ with a kitchen knife to the volar aspect of the left wrist and bilateral shoulders. Did not seek medical attention. Up to date on DT within the past three years. Associated history of chemical dependency with polysubstance abuse. Drugs in addition to alcohol have included cocaine, crystal, methamphetamine, acid, mushrooms, ectasy, and marijuana.
DT|diphtheria-tetanus|DT.|240|242|HISTORY OF PRESENT ILLNESS|The patient allegedly became more depressed with suicidal thoughts and self-inflicted superficial laceration to the volar aspect of her left elbow on the morning of _%#MM#%_ _%#DD#%_, 2006, with scissors. No sutures required. Up to date on DT. Upon presentation to the ER from where the patient was admitted for first mental health hospitalization. PAST MEDICAL HISTORY: 1. Depression (as above). Details per Dr. _%#NAME#%_.
DT|diphtheria-tetanus|DT.|163|165|HISTORY|Onset of auditory and visual hallucinations on _%#MMDD#%_. Self-cutting to the volar aspect of left forearm with a clean knife. No sutures required. Up to date on DT. No other specific act of self-harm. Recent significant history of chronic lumbar pain (see below) for which patient has been on OxyContin since _%#MM2007#%_.
DT|diphtheria-tetanus|DT.|207|209|HISTORY|Remarked that she "wanted to die." Out-of-control behavior requiring restraining at the group home. Points out secondary bruising to the right upper extremity. Multiple abrasions noted in the ER. Updated on DT. PAST MEDICAL HISTORY: 1. Psychiatric illness (as above).
DT|dorsalis pedis:DP|DT|273|274|PHYSICAL EXAMINATION|HEENT: Negative. CARDIOVASCULAR/PULMONARY/GI: Negative. INTEGUMENTARY: Previous history of right hand cellulitis, history of previous chronic foot pain. PHYSICAL EXAMINATION: VITAL SIGNS: T-max is 98, heart rate 71, blood pressure 101/60. She has pulses that are palpable, DT and PT to touch. They are faint but they are palpable. EXTREMITIES: She has a little bit of guarding noted with muscle strength and range of motion to her lesser metatarsal phalangeal joints and her ankle joint bilateral.
DT|diphtheria-tetanus|DT.|119|121|ASSESSMENT|Linear abrasions as described. No evidence for soft tissue infection. No need for suturing. Up to date, by history, on DT. 3. Anorexia nervosa, with "less control with restriction." Actual weight gain over the last year. No evidence for metabolic compromise. 4. Seizure episodes as described.
DT|diphtheria-tetanus|DT.|141|143|HISTORY OF PRESENT ILLNESS|Self-cutting to the lateral aspect of the left humerus using a" clean craft blade." No gaping wounds or sutures were required: Up to date on DT. Indicates a past history of self-injurious behavior, manifested by cutting. No other act of self-harm. PAST MEDICAL HISTORY: 1. Psychiatric illness (as above) Details per Dr. _%#NAME#%_.
DT|diphtheria-tetanus|DT|386|387|HISTORY|He denies heavy alcohol consumption over the last few months, except for last evening when he allegedly consumed "two and one-half drinks." Record indicates consumption of one pint of Captain Morgan's followed by self-inflicted cutting with a "flat razor" (clean blade) to the left forearm. Evaluated in the emergency room where five of the multiple lacerations required suturing. Last DT last year (per patient). Another act of self-harm. PAST MEDICAL HISTORY: 1. Psychiatric illness as above. Details are per Dr. _%#NAME#%_.
DT|diphtheria-tetanus|DT.|198|200|HISTORY OF PRESENT ILLNESS|He has had noted insomnia. He was somewhat euphoric two nights prior to admission, allegedly self-cutting his left arm with a razor after coming out of the Gay 90s. He indicates he is up to date on DT. No other active self-harm. His issue of alcohol abuse dates back to the mid-1980s. He has had chemical dependency intervention on seven occasions. His longest sobriety was 2-1/2 years.
DT|diphtheria-tetanus|DT.|161|163|ASSESSMENT|There is a 3-4 mm very superficial linear abrasion over the dorsum of the right third digit. There is no evidence for soft tissue infection. He is up to date on DT. CHEST: Clear lung fields without bronchospasm. CARDIAC: Regular without gallop or murmur, no click, no jugular venous distention.
DT|diphtheria-tetanus|DT|187|188|REVIEW OF SYSTEMS|She has no arthralgias. She has no rash; however, the patient did self-cut to the dorsum of the left forearm with a dull clean knife prior to presentation to the ER. She is up to date on DT within the last 5 years. She has no focal neurologic complaint. OBJECTIVE: She is a mildly overweight adult female in no distress.
DT|diphtheria-tetanus|DT|136|137|REVIEW OF SYSTEMS|Without cardiopulmonary, gastrointestinal or genitourinary complaints. Musculoskeletal symptoms as above. Indicates he is up to date on DT within the past ten years. No focal neurologic complaints. PHYSICAL EXAMINATION: The patient is a healthy-appearing adult male in no distress.
DT|diphtheria-tetanus|DT|176|177|ASSESSMENT/PLAN|3. Superficial lacerations to the anterior thighs. There is no sign of acute infection. I recommend using bacitracin on a daily basis and monitoring the wound. She does have a DT which is up to date. Old laceration well-healed over the left anterior hip may have the sutures removed at this time. I will be happy to follow up with other issues as they may arise during the hospitalization.
DT|diphtheria-tetanus|DT|235|236|HISTORY|Increasing despondency with self- induced cutting, the patient indicating at least 50 superficial lacerations to the anterior aspect of the right thigh with an Exacto knife between Wednesday, _%#MMDD2002#%_ and Sunday, _%#MMDD2002#%_. DT updated in ER. No suturing required. She denies drug ingestion. PAST MEDICAL HISTORY: 1. Major depression. Details per psychiatry.
DT|delirium tremens|DT.|180|182|PAST MEDICAL HISTORY|She states recently she has been drinking approximately a bottle of scotch weekly for many years. To her knowledge she has had no history of withdrawal effects such as seizures or DT. She does note occasional sensation of tremulous in the morning until she begins to drink. 2. COPD. 3. Hypertension with history of echocardiogram and EKG apparently both normal.
DT|diphtheria-tetanus|DT.|167|169|HISTORY|Alleged suicidal remarks. Self-cutting with a "tack" to the anterior aspect of the right thigh the morning of _%#MMDD2005#%_. No other active self-harm. Up to date on DT. No suturing required. No prior history of chemical dependency intervention. Denies known alcohol-related liver disease, alcohol withdrawal, withdrawal seizures, pancreatitis, or upper GI hemorrhage.
DT|diphtheria-tetanus|DT.|198|200|HISTORY OF PRESENT ILLNESS|Two days prior to admission, the patient self-inflicted lacerations to the volar aspect of her left forearm and medial aspect of the left leg with a scissors. She believes that she is up to date on DT. No suturing was required. No localized pain. She has an associated history of methamphetamine abuse. Her first use was at age 13. No use subsequently until age 15.
DT|diphtheria-tetanus|DT|180|181|HISTORY|Does indicate daily use of alcohol, drinking three beers nightly, usually over a five-hour period. No prior history of alcohol withdrawal. Denies other chemical use. Up to date on DT within the last year. PAST MEDICAL HISTORY: 1. Childhood asthma, inactive. 2. Surgeries none. 3. Other known serious illness: None.
DT|diphtheria-tetanus|DT.|192|194|ASSESSMENT|Self-injurious behavior in the setting of alcohol intoxication. Details per Psychiatry. 2. Bilateral upper extremity lacerations/superficial abrasions. Should heal uneventfully. Up-to-date on DT. 3. Childhood asthma, inactive. 4. Moderate alcohol intake. PLAN: 1. Psychiatric intervention per Dr. _%#NAME#%_. 2. Clinical observation. 3. Further medical intervention does not appear necessary at this time.
DT|diphtheria-tetanus|DT|198|199|HISTORY OF PRESENT ILLNESS|Remote of use of cocaine. Increasing despondency with self-induced cutting with razor (used for art work), at approximately 9:00 PM on _%#MMDD2003#%_. She was evaluated in the emergency department; DT administered. Not felt to require sutures. No other active self-harm. PAST MEDICAL HISTORY: 1. Depression (as described above).
DT|dorsalis pedis:DP|DT.|144|146|PHYSICAL EXAMINATION|The apical impulse does not to be enlarged in supine position. She does not have lower extremity edema but her pulses are absent on both PT and DT. Dr. _%#NAME#%_ tells me that he had difficulty palpating femoral artery pulses and his attempt to obtain femoral artery access eventually failed.
DT|diphtheria-tetanus|DT|155|156|ASSESSMENT|No appreciable musculoligamentous spasm. No compromise with mobility on observation. 4. Superficial abrasion, dorsal aspect, left great toe. Up to date on DT (by history). 5. History of asthma, well compensated clinically. 6. History of heart murmur, not appreciated presently on exam. 7. History of remote seizure episode attributed to medication effect.
DT|diphtheria-tetanus|DT|158|159|HISTORY|Feeling of tenseness following work until he returned home and began drinking again. He has had withdrawal manifested by sweats and shakes. Denies history of DT or withdrawal seizures. Unaware of alcohol related liver disease, pancreatitis or upper GI hemorrhage. Denies other drug use. Denies history of depression; however, admits to feeling despondence.
DT|diphtheria-tetanus|DT.|223|225|ASSESSMENT|1. Depression with alleged suicidal ideation. Deferred to Psychiatry. 2. Self-inflicted superficial abrasions over the volar aspect of the wrist bilaterally. No treatment intervention required. Believed to be up-to-date on DT. 3. 6 week 2 day gestation pregnancy. Spotting as above. Complex right ovarian cyst. Prior history of miscarriage. Will request OB consult at University of Minnesota Medical Center, Fairview.
DT|diphtheria-tetanus|DT.|282|284|HISTORY|Question withdrawal seizures. Denies knowledge of alcohol-related liver disease. Does indicate a past history of pancreatitis, as well as rectal bleeding (while drinking). Presently indicates superficial abrasions to the left forearm. Suturing not required. Indicates up-to-date on DT. PAST MEDICAL HISTORY: 1. Psychiatric illness (as above).
DT|diphtheria-tetanus|DT.|188|190|SOCIAL HISTORY|Unprotected. Irregular menses with last period 1-1/2 months ago. Indicates that she does undergo STD check and PPD testing yearly in light of prior exposure to tuberculosis. Up-to-date on DT. REVIEW OF SYSTEMS: Remarkable for hot flashes. No fever or chills. Headache related to situational stress. No dizziness, no visual change.
DT|diphtheria-tetanus|DT.|230|232|ASSESSMENT|No ongoing symptoms to warrant treatment intervention. 4. Self-inflicted second-degree burn volar aspect left wrist. Possible secondary soft tissue infection. Reasonable to cover with Keflex as well as Silvadene cream. Updated on DT. 5. Bounding palpitations, clinically benign. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Five days of Keflex 500 mg q.i.d.
DT|diphtheria-tetanus|DT.|435|437|HISTORY|The patient relates a longstanding history of a psychiatric illness, major depression diagnosed at age 12, bipolar illness diagnosed last year, alleged auditory hallucinations since age 14, hospitalized at 3 different state mental health facilities, compliant with medication, and self-cutting to the left forearm with a cassette tape and pen prior to admission. The wound "was glued shut" in the emergency room and she was updated on DT. No other active self-harm. PAST MEDICAL HISTORY: 1. Psychiatric illness (as above).
DT|diphtheria-tetanus|DT.|239|241|ASSESSMENT|No rigidity. LAB DATA: None. ASSESSMENT: 1. Command auditory hallucinations with a history of bipolar illness (deferred to psychiatry). 2. Self-cutting volar aspect of the left forearm. No evidence for soft tissue infection. Up to date on DT. 3. Status post fall with right wrist sprain. Continued soft tissue swelling and localized pain. Mobility limitation potentially contributed to by protracted use of wrist splint.
DT|diphtheria-tetanus|DT.|219|221|HISTORY|Past history of self-cutting. Recent increase in despondency with cutting using a knife to the volar aspect of the left wrist 1 day prior to admission. Superficial without gaping wound requiring suturing. Up-to-date on DT. No other present act of self-harm. PAST MEDICAL HISTORY: 1. Psychiatric illness (as above). Details per Dr. _%#NAME#%_.
DT|diphtheria-tetanus|DT|117|118|HISTORY|Self-injurious behavior with burning using a lighter and candle to the right forearm over this past week. Updated on DT in the emergency department. No other active self-harm. PAST MEDICAL HISTORY: 1. Psychiatric illness (as above). Details per Psychiatry.
DT|diphtheria-tetanus|DT|137|138|HISTORY|Superficial cutting with a scissors 2 days ago to the right lower extremity. Less recent cutting to the left lower extremity. Updated on DT in the Emergency Department. No other act of self-harm. PAST MEDICAL HISTORY: 1. Psychiatric illness( (as above).
DT|diphtheria-tetanus|DT.|241|243|ASSESSMENT|2. Self-inflicted superficial abrasions bilateral lower extremities, more recent on the right with left upper extremity laceration 2 weeks ago requiring sutures. No gaping wounds at present. No evidence for soft tissue infection. Updated on DT. 3. Headache discomfort likely tension/muscle contraction in origin. No pattern to suggest progressive involvement. Potentially related to situational stress.
DT|diphtheria-tetanus|DT|121|122|IMMUNIZATIONS|INJURIES: Right knee injury in 1996 while skiing, with subsequent reconstruction of right ACL. IMMUNIZATIONS: Current on DT (_%#MMDD1998#%_). DIET: Sensible. EXERCISE: None, but for physical therapy for knees.
DT|diphtheria-tetanus|DT|217|218|PLAN|2. Right calf abrasions without secondary infection evident. PLAN: The patient will be treated with IV Doxycycline initially 100 mg b.i.d. Will then convert to oral. Total course of care 10 days. Will also administer DT immunization. Will use Ativan p.r.n. for muscle spasm. Will watch for any neurologic deterioration. Discussed with Infectious Disease who relate that this is less an infection and more of a toxin reaction and treatment is mainly supportive care.
DT|delirium tremens|DT.|112|114|PAST MEDICAL HISTORY|PAST SURGICAL HISTORY: Status post cholecystectomy 3 years ago. PAST MEDICAL HISTORY: 1. Alcoholism, history of DT. See HPI for details. 2. Hypertension, poor control on atenolol of unknown dose. She states her blood pressure runs at 150s/100s on the atenolol.
DT|diphtheria-tetanus|DT|123|124|IMMUNIZATIONS|INJURIES: Loss of consciousness x3 secondary to horseback riding related falls without sequelae. IMMUNIZATIONS: Current on DT (_%#MMDD1998#%_) and Pneumovax (2003). HABITS: Discontinued smoking 30 years ago, had smoked less than 1 pack per day.
DT|dorsalis pedis:DP|DT|180|181|PHYSICAL EXAMINATION|ABDOMEN: Soft, nontender, nondistended, normal active bowel sounds. Liver percusses to the costal margin. Spleen not palpable. EXTREMITIES: Warm, no cyanosis, clubbing or edema. 2 DT pulses bilaterally. LABORATORY DATA: Pending. IMAGING: Chest x-ray pending.
DT|diphtheria-tetanus|DT|120|121|IMMUNIZATIONS|Versed (prolonged sedation). Fentanyl (prolonged sedation). Zofran. INJURIES: Not determined. IMMUNIZATIONS: Current on DT (_%#MMDD1992#%_) and Pneumovax (2003). DIET: Regular. EXERCISE: Three times per week with aqua aerobics and Nautilus.
DT|diphtheria-tetanus|DT|181|182|IMMUNIZATIONS|6. Keflex 500 mg b.i.d. ALLERGIES: None to medications. INJURIES: Fracture of PIP joint, first finger, left hand with residual impairment of function. IMMUNIZATIONS: Not current on DT (_%#MMDD1991#%_). Current on Pneumovax (_%#MMDD2000#%_). DIET: None. EXERCISE: Golf in summer. HABITS: Tobacco, discontinued cigarette smoking _%#MM1998#%_, prior to that smoked 10 cigarettes per day.
DT|diphtheria-tetanus|D.T.|141|144|IMMUNIZATIONS|7. Vitamin D. 200 International Units q day ALLERGIES: None to medication INJURIES: Traumatic arthritis left knee. IMMUNIZATIONS: Current on D.T. (1999), Pneumovax (_%#MMDD2002#%_) DIET: Regular EXERCISE: None TOBACCO: Discontinued cigarette smoking 1986 (was smoking one pack per day at the time) ALCOHOL: Two glasses or wine per day CAFFEINE: Two cups of decaffeinated coffee per day and two cups of tea daily BLEEDING TENDENCIES: None.
DT|diphtheria-tetanus|DT|149|150|IMMUNIZATIONS|Mild diarrhea with Metformin. INJURIES: Fracture of right fibula, fracture of left MCP bone, left thumb and left clavicle. IMMUNIZATIONS: Current on DT (_%#MM#%_ 2001) but not Pneumovax. DIET: Regular with reduced carbohydrate. EXERCISE: Every other day at The Marsh, both strength and aerobic exercises.
DT|diphtheria-tetanus|DT|141|142|IMPRESSION|NEUROLOGIC EXAM is normal. IMPRESSION: Cellulitis of the left prepatellar area secondary to an infected abrasion. The patient has received a DT booster in the ER and has been started on Ancef IV. We will continue the IV Ancef and elevation of the leg and request surgery to assist us with any further care of this wound.
DT|diphtheria-tetanus|DT|121|122|IMMUNIZATIONS|Also the records from Dr. _%#NAME#%_'s office visits are also reviewed. IMMUNIZATIONS: Pneumovax has been given in 1980. DT booster is overdue. Flu shot she has taken every year the last one in _%#MM#%_ 2006. CODE STATUS: Not available. The patient does have a living will and says that a copy is with her daughter.
DT|diphtheria-tetanus|DT,|258|260|IMMUNIZATIONS|5. Metamucil daily p.r.n. 6. Lipitor 10 mg q p.m. meal ALLERGIES: None to medication INJURIES: Fracture left elbow/open reduction and internal fixation with excellent functional result, non-displaced fracture lateral right patella. IMMUNIZATIONS: Current on DT, (_%#MMDD2001#%_) and Pneumovax (_%#MMDD2001#%_) DIET: Regular EXERCISE: Aerobics three times per week TOBACCO: Discontinued cigarette smoking 56 years ago ALCOHOL: One drink per day CAFFEINE: Three to four cups of decaffeinated tea per week.
DT|diphtheria-tetanus|DT.|263|265|HISTORY|Is status post bilateral lower extremity fasciotomies for documented compartment syndrome in 1996, subsequent to a heroin overdose while in _%#CITY#%_, Washington. Residual numbness involving the lateral aspect of the left foot to the present time. Up to date on DT. PAST MEDICAL HISTORY: 1. Depression. Details per Psychiatry. 2. Polysubstance abuse, consisting primarily of intravenous cocaine and alcohol as above.
DT|diphtheria-tetanus|DT|252|253|PLAN|2. Continue Relafen for musculoskeletal complaints (reviewed dose). 3. Start Protonix 40 mg daily for epigastric tenderness/symptoms of acid reflux. 4. Advised reduced sodium diet for tendency toward leg edema. Knee- high support hose p.r.n. 5. Update DT (patient requests). Has tolerated previously. With recent knife wound on left buttock and puncture wound to the foot, this appears reasonable.
DT|diphtheria-tetanus|DT.|151|153|ASSESSMENT|No evidence for soft tissue infection with extensive nature of bite and multiple puncture wounds. Would keep on antibiotics for 10 days, up-to-date on DT. Animal control looking into whether the dog is up-to-date on shots, etc. 7. History of recurrent urinary tract infection, clinically quiescent.
DT|diphtheria-tetanus|DT.|146|148|HISTORY OF PRESENT ILLNESS|Resumed self-cutting last evening to the anterior tibial surface bilaterally with the use of a "twin blade." Suturing not required. Up to date on DT. Alcohol relapse with 6 to 7 drinks of vodka and Diet Coke. Prompted the patient to call 911 and was transferred to the emergency department followed by subsequent admission (as above).
DT|dorsalis pedis:DP|DT|149|150|PHYSICAL EXAMINATION|His apical impulse does not appear to be enlarged. ABDOMEN: Soft and nontender. There is no hepatosplenomegaly. EXTREMITIES: Lower extremity pulses, DT and PT, are 3 and 3 bilaterally. He does not have any lower extremity edema. He has full and symmetrical radial artery pulses.
DT|diphtheria-tetanus|DT|180|181|HISTORY OF PRESENT ILLNESS|The patient indicates this resulted from a knife. This was sustained during a "fight" with her ankle. She presented to _%#CITY#%_ _%#CITY#%_ ER where the laceration was sutured. A DT was apparently administered. She returned to the emergency department on _%#MMDD2002#%_ after injuring her right great toe. The patient indicates that the toe was "stubbed" by kicking things around in her room apparently during an emotional upset.
DT|diphtheria-tetanus|DT.|242|244|HISTORY OF PRESENT ILLNESS|There is an issue of self-cutting to the upper and lower extremities over the last 2 weeks with extensive cutting to the right thigh in the setting of recent alcohol excess. There is no suturing required. He indicates he is up to date on his DT. He has had no prior problems with alcohol-related liver disease, pancreatitis, or upper gastrointestinal hemorrhage. He perhaps has had mild sweats correlating with alcohol withdrawal.
DT|diphtheria-tetanus|DT.|198|200|ASSESSMENT|Unremarkable chemistries. 3. Self-injurious behavior with self-inflected superficial laceration right anterolateral thigh. No need for suturing. No evidence for soft tissue infection. Up-to-date on DT. 4. Isolated PVC on prior EKG. No symptoms to suggest significant cardiac arrhythmia. 5. Facial/frontal parietal headache discomfort. Steady character consistent most with a tension/muscle contraction like state.
DT|diphtheria-tetanus|DT|211|212|HISTORY OF PRESENT ILLNESS|No reduction in mental alertness. He does note left lateral thoracic pain and tenderness aggravated by cough. In the emergency department, the patient was found to be hemodynamically stable. He was treated with DT 0.5 mg IM in addition to ibuprofen 800 mg. LABORATORY DATA: X-rays not obtained. Screening laboratory studies included sodium 142, potassium 3.2, chloride 106, CO2 28, glucose 100, BUN 7, creatinine 0.9. Elevated AST of 195 with total bilirubin of 1.5, GGT 15, magnesium 2.3, phosphorous 3.5, total cholesterol 136, elevated CPK at 16,673.
DT|diphtheria-tetanus|DT.|151|153|HISTORY OF PRESENT ILLNESS|Presently indicates "no fight left." Has been picking at her fingers with a razor and clipper for the last 8 to 10 months. No infection. Up to date on DT. Associated issue of eating disorder manifested by anorexia. Indicates not an issue over the last year. Denies restriction. Has dropped approximately 8 pounds since Thanksgiving. Admits to ongoing anorexia.
DT|diphtheria-tetanus|DT.|210|212|ASSESSMENT|1. Major depressive disorder, recurrent, severe. Details per psychiatry. 2. Self-injurious behavior with self-inflicted destruction of multiple fingernails. No evidence for soft tissue infection. Up to date on DT. 3. Anorexia nervosa, clinically not an issue per patient. Does have ongoing anorexia; however, with recent weight loss likely related to problem #1.
DT|delirium tremens|DT|152|153|SOCIAL HISTORY|She admits to going to detox treatment x3 in the past. She admits to having alcohol withdrawal seizures x2 in the past. She also admits to experiencing DT when withdrawing from alcohol. The patient denies current drug use. She admits to using cocaine occasionally in the past, but states she has been sober for 4 years.
DT|(drug) DT|DT|117|118|CURRENT MEDICATIONS|16. Lidocaine ointment to the G-J tube site twice a day and as needed. 17. Current tube feeds: Four cans of Peptinex DT at 70 cc an hour for 14 hours on and then 10 hours off. 18. TPN every other day over 24 hours. 19. Free water flushes, 100 cc, given with Peptinex in G-J tube.
DT|diphtheria-tetanus|DT.|190|192|HISTORY|Presented to Fairview Ridges Emergency Department early the morning of _%#MMDD2005#%_. Wrist lacerations were approximated with Steri-strips, suturing not required. Indicates up- to-date on DT. Head CT obtained demonstrating no intracranial hemorrhage or fracture. A subcutaneous left frontal hematoma was noted. Screening laboratory studies included an unremarkable complete metabolic profile with negative serum pregnancy test.
DT|diphtheria-tetanus|DT.|173|175|ASSESSMENT|3. Self-inflicted lacerations volar aspect of the wrists bilaterally. Well approximated with Steri-strips. No evidence for soft tissue infection. Historically up-to-date on DT. 4. Status post assault from boyfriend with the following: A. Left frontal/scalp contusion. B. Laceration of lower lip left side (sutured).
DT|diphtheria-tetanus|DT.|208|210|PLAN|Complete course of Augmentin as ordered. 3. Review screening labs as ordered on _%#MMDD2004#%_. 4. Continue MSSA withdrawal protocol. No signs presently of alcohol withdrawal. 5. The patient is up to date on DT. 6. Clinical observation. Thank you for the consultation. We will follow along with you.
DT|diphtheria-tetanus|DT|419|420|HISTORY OF PRESENT ILLNESS|The patient indicates that he has been medication compliant. Record indication that patient has "cheeked meds." Indicates that he sustained multiple lacerations to the anterior cervical region and the volar aspect of the wrist bilaterally on _%#MMDD2007#%_ after "climbing in a tree to help a cat." Denies suicidal ideation. Wounds evaluated in the Emergency Department at Fairview Southdale. Not sutured. No record of DT administration. Was given Ancef 1 gram IV with placement on Duricef 500 mg b.i.d. Blood glucose in excess of 500 for which regular insulin 10 units was administered.
DT|diphtheria-tetanus|DT.|185|187|HISTORY|Last drink included 1 liter of schnapps/brandy _%#MMDD#%_ with self cutting to the volar aspect of her left wrist. This was sutured in the emergency department. Indicates up-to-date on DT. No other act of self-harm. Since maintained on alcohol withdrawal protocol using Valium. PAST MEDICAL HISTORY: 1. Psychiatric illness (as above); details per psychiatry.
DT|diphtheria-tetanus|DT|163|164|PLAN|3. Extra Strength Tylenol for pain. Ice pack to areas of swelling. 4. Cleanse wounds with soap and water daily. 5. Keflex 500 mg q.i.d. x 7 days. 6. Up to date on DT administered in ER. 7. As assailant's knife potentially may have been contaminated with blood products, it is reasonable to check HIV, hepatitis B, and C studies at this time with follow-up surveillance in the future.
DT|diphtheria-tetanus|DT|183|184|HISTORY|As it had been approximately four to five hours since the wounds were inflicted it was elected to defer suturing of the wounds which were packed and dressed. One gram of Ancef IV and DT were administered. Also given intravenous fluids in the setting of reduced p.o. intake over the few days prior to admission. Laboratory evaluation at HCMC included a serum sodium 135 with potassium 4.2, chloride 103, CO2 25, anion gap 13.
DT|diphtheria-tetanus|DT|175|176|HISTORY OF PRESENT ILLNESS|She has soft tissue swelling. She denies altered sensation of the hand/digits. No motor compromise, except for pain with flexion of the digits and wrist. She is up to date on DT as of _%#MMDD#%_. No other active self-harm presently. PAST MEDICAL HISTORY: 1. Psychiatric illness (as above).
DT|diphtheria-tetanus|DT,|183|185|ASSESSMENT AND PLAN|There is no sign of infection, it is healing well. We discussed with the patient his tetanus status. He said he could not remember when his last tetanus shot was, but tetanus booster DT, was ordered today and to be given. _%#MM#%_ _%#DD#%_, PA, with Dr. _%#DD#%_ also saw this patient and agrees with the assessment and plan.
DT|diphtheria-tetanus|DT|158|159|HISTORY OF PRESENT ILLNESS|With increasing despondency, the patient allegedly self inflicted a "cut" to the volar aspect of the left wrist with a candle holder on _%#MMDD#%_. Update on DT at that time. No sutures required. Family apparently concerned regarding patient's potential abuse of treatment medications. Family apparently wants the patient considered for commitment. No apparent chemical dependency history.
DT|diphtheria-tetanus|DT.|209|211|HISTORY OF PRESENT ILLNESS|She does use marijuana on occasion. She has had apparent increasing despondency with self-cutting to the upper extremities bilaterally with the use of a "clean razor." Sutures were not required. Up to date on DT. She overdosed on a "full bottle" of Seroquel (question 25 mg, per patient) at approximately 4:30 p.m. on _%#MM2006#%_. She presented to the emergency department in St. Peter, where patient was found to be clinically stable.
DT|diphtheria-tetanus|DT.|165|167|ASSESSMENT|1. Major depressive disorder, recurrent, severe. Details per Psychiatry. 2. Bilateral self-inflicted lacerations to the volar aspect of the wrists. a. Up to date on DT. b. Tendon involvement on the left, apparently sutured in the ER at Fairview Southdale Medical Center. c. Paresthesias of the digits bilaterally, probably on the basis of swelling with associated neuropraxia.
DT|diphtheria-tetanus|DT|186|187|HISTORY OF PRESENT ILLNESS|No significant hematoma. Allegedly felt to be neurologically intact. CT scan of the head without contrast was negative for acute change. The patient indicates that he is up to date with DT within the past 5 years. PAST MEDICAL HISTORY: 1. Polysubstance abuse with drug of choice opiates (as above).
DT|diphtheria-tetanus|DT.|145|147|HISTORY OF PRESENT ILLNESS|Two superficial chest wounds were sutured. No penetration of the chest cavity. Chest x-ray demonstrated no evidence for pneumothorax. Updated on DT. Lethargy with stable hemodynamics. The patient declined activated charcoal. Admission to the Intensive Care Unit. LABORATORY DATA: Included a normal CBC. INR 0.96, PTT of 39.
DT|diphtheria-tetanus|DT.|208|210|ASSESSMENT|Issue of opiate dependence. Possible component of opiate withdrawal. 4. Self-inflicted superficial stab wounds anterior chest. Sutured. Well approximated. No evidence for soft tissue infection. Up-to-date on DT. 5. Asthma, fairly well compensated. 6. Gastroesophageal reflux disease (per outside records). 7. Drug-seeking behavior (per outside records). 8. Nicotine addiction.
DT|diphtheria-tetanus|DT,|179|181|HISTORY|Has had increasing despondency over the last two weeks, self-cutting with a utility knife to the volar aspect of the left wrist. No sutures required. Uncertain as to time of last DT, not within 5 years. Recent issues of a change in psychiatrist as well as a recent unavailability of patient's therapist.
DT|diphtheria-tetanus|DT.|195|197|PLAN|14. Remote history of peptic ulcer disease. 15. Superficial linear abrasions volar aspect left wrist. No intervention required. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Update DT. 3. Hepatitis C antibody. 4. Continue medications as ordered. Clinical observation. Thank you for the consultation. We will follow along as indicated.
DT|diphtheria-tetanus|DT|231|232|HISTORY|Denies intravenous drug use. Indicates attempted suicide recently by carbon monoxide poisoning, as well as self cutting to the upper extremities with a razor approximately 1 week ago. Did not seek medical attention. Indicates last DT approximately 3 years ago. Also, indicates that she has been driving recklessly under the influence of alcohol. PAST MEDICAL HISTORY: 1. Psychiatric illness (as above). Details per Dr. _%#NAME#%_.
DT|diphtheria-tetanus|DT.|145|147|ASSESSMENT|2. Self-cutting to the upper extremities bilaterally. Wounds granulating in/healing nicely. No evidence for soft tissue infection. Up-to-date on DT. 3. Polysubstance abuse with drugs of choice alcohol and crack cocaine: a. Clinical stigmata consistent with mild alcohol withdrawal. b. History of elevated liver function consistent with possible alcoholic hepatitis in _%#MM#%_.
DT|diphtheria-tetanus|DT.|250|252|HISTORY|She has had increasing despondency with self-injurious behavior, manifested by self-cutting with a "blade" to cut pictures, to the volar aspect of the left forearm on _%#MMDD2005#%_ and _%#MMDD2005#%_. Suturing was not required. She is up to date on DT. Eating disorder remained well compensated until 2 weeks ago when the patient began purging 1 to 2 times daily; no restriction.
DT|diphtheria-tetanus|DT.|254|256|OBJECTIVE GENERAL|SKIN: Demonstrates multiple transverse superficial linear abrasions over the volar aspect of the forearms bilaterally as well as across the mid abdomen above the umbilicus. No gaping wounds. No evidence for soft tissue infection. Indicates up to date on DT. CHEST: Clear lung fields without bronchospasm. CARDIAC: Regular without gallop or murmur. No click, No jugular venous distention. BREASTS: Deferred. ABDOMEN: Nondistended, soft, nontender, No organomegaly or mass.
DT|diphtheria-tetanus|DT.|226|228|ASSESSMENT|a. Head injury without clinical sequela. No areas of appreciable soft tissue trauma involving the occiput on exam. b. Multiple superficial linear abrasions involving the upper extremities and abdomen (as above). Up to date on DT. Would keep clean and dry. Otherwise, no specific treatment required. 3. Type 2 diabetes with excellent control based on recent hemoglobin A1c.
DT|diphtheria-tetanus|DT.|212|214|HISTORY|3. Two lacerations over the dorsum of the right forearm measuring approximately 6 centimeters; gapping per patient. Approximated with staples. Removal apparently recommended at this time. Indicates up to date on DT. PAST MEDICAL HISTORY: 1. Psychiatric illness as above. Details per Dr. _%#NAME#%_.
DT|diphtheria-tetanus|DT.|192|194|HISTORY|Alleged history of "treatment resistant depression." Numerous hospitalizations in the past year. Prior history of self-cutting primarily to the abdomen. No sutures are required. Up to date on DT. ECT in _%#MM#%_ of 2002 which was "ineffective." Associated history of eating disorder manifested by anorexia. The patient indicates "some restriction" which she is trying to avoid.
DT|dorsalis pedis:DP|DT|178|179|OBJECTIVE|LUNGS: Clear to auscultation bilaterally. ABDOMEN: Benign without masses or tenderness. HEAD: Atraumatic/normocephalic. LEGS: Not tender. He has no lower extremity edema and his DT and PT pulses are 2+ and symmetric. Sensation appears to be intact at his lower extremity.
DT|diphtheria-tetanus|DT.|148|150|HISTORY|A right thigh burn secondarily infected treated by primary care provider with topical and oral antibiotics with interval improvement. Up-to-date on DT. No other specific act of self-harm. PAST MEDICAL HISTORY: Extensive (as follows). 1. Psychiatric illness as above. 2. Polycystic ovarian syndrome.
DT|diphtheria-tetanus|DT.|231|233|HISTORY|Indicated ongoing depression. Indicated self-injurious behavior with self-inflicted burns with a "Zippo lighter" to the volar aspect of his left forearm 1 week ago. Three weeks ago also burned himself with a lighter. Up-to-date on DT. PAST MEDICAL HISTORY: 1. Psychiatric illness as above (details per Dr. _%#NAME#%_).
DT|diphtheria-tetanus|DT.|316|318|HISTORY|She has not required intravenous fluids for dehydration. She was amenorrheic for six months prior to mental health hospitalization in _%#MM#%_ of 2004, at which time the patient resumed menses. She has a history of self-injurious behavior with superficial self-cutting to the upper extremities. She is up-to-date on DT. She did have the issue of dizziness with profound orthostatic blood pressure drop into the 60s systolic during her last mental health hospitalization in _%#MM#%_, thought likely related to Zyprexa, with possible component of decrease in intravascular volume.
DT|diphtheria-tetanus|DT.|134|136|ASSESSMENT|3. Self-injurious behavior with self-inflicted abrasion, left lateral humerus. No overt signs of soft tissue infection. Up-to-date on DT. 4. History of cardiac irregularity, with outside records demonstrating a bicuspid aortic valve on echocardiogram, dated _%#MMDD2003#%_. There is mild dilatation of the ascending aorta, with trace aortic insufficiency.
DT|delirium tremens|DT|132|133|HISTORY OF PRESENT ILLNESS|3. A 20-pound weight loss in 3 months secondary to poor oral intake. 4. History of many blackouts related to alcohol. 5. History of DT related to alcohol. 6. Depression, n.o.s. 7. Anxiety, n.o.s. 8. Alcohol dependence. 9. Appendectomy. 10. Right knee arthroscopic surgery and left pleuroscopy. The patient continues to have right knee pain.
DT|delirium tremens|(DT).|183|187|HOSPITAL COURSE|His postoperative course did include being placed on ETOH protocol secondary to him repeatedly asking for alcoholic beverages. He did, however, not show any signs of delirium tremens (DT). The rest of his hospital course included blood sugar management, physical therapy and occupational therapy.
DT|delirium tremens|(DT)|197|200|DISCHARGE DIAGNOSIS|PRIMARY CARE PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD (Fairview EdenCenter Clinic) DISCHARGE DIAGNOSIS: 1. Acute alcohol withdrawal with possible alcohol withdrawal seizure at home or delirium tremens (DT) leading to encephalopathy, now resolved. 2. Diastolic dysfunction with mild lower extremity edema. a. Echocardiogram on _%#MMDD2007#%_ showed mild concentric left ventricular hypertrophy (LVH) as well as diastolic dysfunction.
DT|delirium tremens|(DT).|229|233|CHIEF COMPLAINT|The patient tells me he has a history of heavy alcohol use with about fifteen beers a day for 15 years. He has no history of any medical problems from alcoholism such as jaundice, liver disease, pancreatitis, or delirium tremens (DT). He has had had no chemical dependency treatment such as detoxification or encounters with Alcoholics Anonymous (AA). He was, however, brought in by ambulance for heat exhaustion about a year ago and his liver function tests at that time were elevated.
DT|diphtheria-tetanus|DT|185|186|IMMUNIZATIONS|2. Hyperlipidemia 3. Hypertension 4. Type 2 ALLERGIES: None. MEDICATIONS: Are Glucophage XR500 one a day in the morning. SURGERIES: 1. Appendectomy 2. Lumbar laminectomy IMMUNIZATIONS: DT is current. He is not receiving Pneumovax. Screening colonoscopy is recommended to him and he can decide on that FAMILY HISTORY: His father died in his late 70s of a cerebrovascular accident.
DT|diphtheria-tetanus|DT|149|150|IMMUNIZATIONS|11. Lasix 80 mg qd. 12. Celebrex 200 mg q a.m. ALLERGIES: None to medications. INJURIES: Multiple fractures - see HPI. IMMUNIZATIONS: Not current on DT but is current on Pneumovax (_%#MMDD1996#%_). HEALTH HABITS: Diet none, exercise none. Tobacco never smoked. Alcohol very occasional.
DT|diphtheria-tetanus|DT|138|139|IMMUNIZATIONS|10. Glipizide 5 mg daily 11. Atenolol 50 mg daily IMMUNIZATIONS: Review that he gets a flu shot every year, Pneumovax in 2000. He needs a DT booster REVIEW OF SYSTEMS: CARDIAC: Negative RESPIRATORY: No difficulty breathing, cough or expectoration.
DT|diphtheria-tetanus|DT|624|625|PROBLEM #6|Her irritability resolved nicely overnight. PROBLEM #6: Immune: On presentation she had a red patch on her left lateral-anterior thigh, which was where her DTaP was given, and this resolved after Benadryl and ibuprofen were given and was completely gone and nontender on the morning of discharge. Her symptoms were thus attributed to a vaccine response or allergic reaction to the acellular pertussis component of the vaccine, most likely, and so our recommendation at this time would be to consider checking pertussis titers prior to the next vaccination, and if they are in the immunogenic range, then just giving her the DT booster and foregoing further doses of pertussis, since subsequent reactions could be more severe. This was discussed with the parents. FOLLOWUP: The parents will watch for fevers, increased pain or swelling, alterations in her mental status, increasing irritability, or other concerning signs or symptoms, and will follow up immediately in the ER should any of these develop.
DT|dorsalis pedis:DP|DT|142|143|ALLERGIES|His troponins were negative x3. The left foot was warm and capillary refill was less than 2 seconds. There were positive Doppler tones in the DT and PT. Movement and sensation were intact in both lower extremities. The patient underwent segmental pressures and was cleared for discharge.
DT|dorsalis pedis:DP|DT,|168|170|PHYSICAL EXAM|RECTUM: External anus digital normal. Prostate 1+/4. No nodules or rectal lesions. Testes and penis normal. No inguinal hernia. EXTREMITIES: No femoral nodes. Femoral, DT, PT pulses normal. ORTHO: Normal. Neural patellar reflexes not checked. Extremities 1-2+ edema of feet. LAB: CT of the abdomen shows peritoneal fluid.
DT|diphtheria-tetanus|DT.|256|258|ASSESSMENT|ASSESSMENT: A 27-year-old female admitted with the following: 1. Psychiatric diagnoses as above with increased despondency/dissociation. 2. History of self-injurious behavior with self-inflicted superficial lacerations right lateral humerus. Up-to-date on DT. 3. Alleged near frank syncopal episode. Unwitnessed. Possible right temporal parietal scalp contusion. Issue per patient of disequilibrium since last ECT which I believe was in _%#MM2002#%_ or early _%#MM2002#%_.
DT|diphtheria-tetanus|DT.|262|264|ASSESSMENT|5. Polysubstance abuse, with unsuccessful sobriety (as above). 6. History of apparent seizure related to drug overdose (the patient denies). 7. Superficial self-inflicted abrasions, left forearm; no evidence for soft tissue infection. Indicates recent update on DT. PLAN: 1. Psychiatric intervention, as per Dr. _%#NAME#%_. 2. The patient was advised to follow up at the Red Door Clinic subsequent to hospital discharge.
DT|diphtheria-tetanus|DT.|136|138|PLAN|3. Clinical observation. Further medical intervention at this point does not appear to be required. The patient indicates up to date on DT. Thank you for the consultation. We will follow along as indicated.
DT|diphtheria-tetanus|DT.|200|202|HISTORY OF PRESENT ILLNESS|Suicidal gesture with wrapping a shirt around his neck. No sequelae/loss of consciousness. Indicates self-inflicted cutting through the left upper extremity with a paper clip. Indicates up to date on DT. Another specific act of self-harm. Has, however, demonstrated self-injurious behavior in the past with apparent prior suicide attempts. PAST MEDICAL HISTORY: 1. Psychiatric illness (as above) details per Dr. _%#NAME#%_.
DT|delirium tremens|DT|187|188|HOSPITAL  COURSE|5. History of hyperlipidemia with elevated lipids, but secondary to elevated liver function tests medications will be held. 6. ETOH abuse with alcoholic hepatitis. The patient was put on DT precautions. CD consultation was obtained. The patient will be committed to continue treatment after being discharged from here. 7. Chronic anemia with a stable hemoglobin. 8. Thrombocytopenia on admission secondary to alcohol abuse.
DT|delirium tremens|DT|225|226|IMPRESSION|For this reason an MRI of the brain with and without contrast and an EEG would be appropriate. 2. The patient does have some tremors, high temperature and tachycardia, all signs of impending delirium tremens. They agree with DT precautions at this point. RECOMMENDATIONS: 1. MRI of the brain with and without contrast. 2. EEG.
DT|delirium tremens|DT|136|137|HOSPITAL  COURSE|She was cleared by neurosurgery for an acute fracture and she then started physical therapy and occupational therapy. She was placed on DT precautions and given thiamine, folic acid and Ativan as needed. Except for mild transient dizziness which is mostly positional when she first changed positions and mild right hip pain with initial ambulation the patient tolerated physical and occupational therapy, who recommended that she would qualify for TCU to continue with therapy there.
DT|delirium tremens|DT.|140|142|PLAN|We will place her on the alcohol withdrawal protocol, given a past history of minor withdrawal symptoms. There is no history of seizures or DT. 3. Cardiomegaly with pericardial friction rub: The patient describes what sounds like a history of pericardial effusion which has been stable and followed by serial imaging.
DT|delirium tremens|DT;|265|267|HISTORY|Intermittent use since _%#MM#%_ with "two shots of vodka and a bottle of wine the day of hospitalization." Abbott Northwestern Hospital records indicate one liter of hard liquor prior to calling 911. Denies overt symptoms of alcohol withdrawal. No clear history of DT; however, had one episode where he had a gray spot distortion to his vision. Unaware of alcohol withdrawal related seizures, alcohol related liver disease, pancreatitis, or upper GI hemorrhage.
DT|diphtheria-tetanus|DT|305|306|PAST MEDICAL HISTORY|Mother had a history of diverticular disease. PAST MEDICAL HISTORY: _%#NAME#%_ has had a kidney stone, hypertension, coronary angiogram that was normal and had a stroke from an atrial septal defect that was repaired surgically by Dr. _%#NAME#%_ in 2001. He has had previous cervical laminectomy. He had a DT in 1999. SOCIAL HISTORY: He is employed. He is married. REVIEW OF SYSTEMS: SKIN: Unremarkable.
DT|diphtheria-tetanus|DT|154|155|HISTORY|No recent steroids. Status post recent URI without lingering symptoms except for mild cough productive of scant secretions attributed to smoking. Updated DT at Mercy Medical Center. 600 mg of clindamycin IV administered. Presently maintained on clindamycin 150 mg p.o. q.i.d. in addition to p.r.n. Percocet for pain.
DT|delirium tremens|DT|230|231|PLAN|Make sure his hemoglobin does not drop. He came in with a 14.5 hemoglobin, negative urine analysis, normal white count and a 175,000 platelet count. 2. I will ask chemical dependency counselors to see him, get him detoxified. Use DT protocol if necessary although at this point it does not appear that he needs that.
DT|diphtheria-tetanus|DT|205|206|IMPRESSION|Unasyn should provide good coverage for staph and strep as well as for Pasteurella and any anaerobes in the cats mouth. I agree with the patient getting a tetanus booster as she is uncertain when her last DT was. Will get blood cultures times two if the patient spikes a temperature. Will obtain the x-rays with markers to see if the foreign body appears to be a cat tooth.
DT|dorsalis pedis:DP|DT|144|145|PHYSICAL EXAMINATION|ABDOMEN: No organomegaly, guarding, rigidity, masses or bruits. GENITOURINARY: Deferred. EXTREMITIES: No cervical or axillary or femoral nodes. DT pulses normal. Warm, pink, dry and no edema. ORTHO: Normal. NEUROLOGIC: Cranial nerves II through XII intact. Normal fundi. Pupils are equal, round, reactive to light. EOM's intact.
DT|diphtheria-tetanus|DT|150|151|HISTORY|Laceration sustained after he punched his fist through a glass window. Complete laceration of the extensor tendon. Temporary wound closure performed. DT administered. Orthopedic consultation pending. The patient apparently has had history of alcohol withdrawal denying withdrawal-related seizures or DTs.
DT|delirium tremens|DT.|165|167|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Significant for recurrent pneumonia approximately x10 within the last 10 years. Also reports a 12-year history of alcohol abuse complicated by DT. He has been through chemical-dependency centers. ALLERGIES: He reports no known drug allergies. MEDICATIONS: He only takes Tylenol as needed on a p.r.n. basis.
DT|diphtheria-tetanus|DT|284|285|HISTORY|He apparently has had issues regarding gender identify. On _%#MMDD2005#%_, the patient self- inflicted a laceration with a clean kitchen knife to the dorsum of the left forearm. He has areas of abrasion involving both upper extremities secondary to excoriation; no suturing required. DT was administered in the emergency department. No other present active self-harm. PAST MEDICAL HISTORY: 1. Psychiatric illness (as above). Details per _%#NAME#%_.
DT|diphtheria-tetanus|DT.|220|222|HISTORY|No other chemical use. Increasing despondency, with self- induced cutting to the volar aspect of the left wrist on the evening prior to admission. Evaluated in the emergency department. Suturing not required. Updated on DT. Has had shakes, with hot and cold flashes. Indicates remote history of DTs. No prior history of withdrawal seizures. Unaware of alcohol-related liver disease.
DT|UNSURED SENSE|DT|120|121|IMPRESSION|IMPRESSION: Choroidal melanoma in the right eye. Dr. _%#NAME#%_'s measurements are MT 4.99 mm, MB 11.7 mm, BD 13.98 mm, DT zero, maximum height 6.32 mm and maximum base 14.65 mm. Dr. _%#NAME#%_ offered enucleation versus a plaque versus proton beam therapy.
DT|diphtheria-tetanus|DT|188|189|SYMPTOM REVIEW|No voiding complaints. Arthralgias involving the wrists. Ulcers over the anterior tibial surfaces bilaterally. Self inflicted abrasion with a knife over the left forearm in the last week. DT three months ago. No other focal neurologic complaint. OBJECTIVE: Moderately overweight adult male in no distress.
DT|delirium tremens|DT|124|125|IMPRESSION AND PLAN|For his history of smoking, he will be placed on the nicotine patch. For his history of alcohol abuse, he will be placed on DT precautions. He will continue with his Paxil for his anxiety. Regarding his abdominal pain, this seemed to have resolved and was not on exam.
DT|delirium tremens|DT|130|131|HISTORY|CD treatment in _%#MM#%_ of 2001. Recent stay on Lodging Plus as above. He has had withdrawal symptoms in the past. No history of DT or withdrawal related seizures. Unaware of alcohol related disease, pancreatitis or upper GI hemorrhage. He has had polysubstance use in the past including crystal methamphetamine, heroin, ectasy, cocaine.
DT|delirium tremens|DT|212|213|RECOMMENDATIONS|Will also initiate metoprolol and continue digoxin. 2. Subcutaneous Lovenox for anticoagulation. 3. Cardiac catheterization in the a.m. Will hold Lovenox after tonight's dose. 4. Alcohol cessation counseling. 5. DT precautions. 6. Warfarin will be initiated after the catheterization and consider elective cardioversion in 4-6 weeks of anticoagulation. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 46-year-old pleasant male who is a pilot for Northwest Airlines.
DT|diphtheria-tetanus|DT|132|133|IMMUNIZATIONS|1. Amoxicillin (rash, pruritus, sore joints). 2. Penicillin (at age 6, unknown reaction). INJURIES: None. IMMUNIZATIONS: Current on DT (_%#MMDD2002#%_). Has not had Pneumovax. DIET: Regular. EXERCISE: Swims two miles three times per week, tennis one to two times per week, golf two times per week, outdoor activities, including hunting.
DT|diphtheria-tetanus|DT.|306|308|HISTORY|Remote history of self-induced cutting. Several year abstention until _%#MMDD2003#%_ when the patient inflicted superficial lacerations to the volar aspect of her right forearm with a "used razor." She was evaluated in the emergency room at _%#CITY#%_ Campus. Suturing was not required. She was updated on DT. She denies other act of self-harm. PAST MEDICAL HISTORY: 1. Major depressive disorder (details per psychiatry).
EC|enteric-coated|EC|141|142|DISCHARGE MEDICATIONS|3. Inspra 50 mg p.o. daily. 4. Vasotec 10 mg p.o. b.i.d. 5. Hydrochlorothiazide 12.5 mg p.o. daily. 6. Asacol 800 mg p.o. t.i.d. 7. Entocort EC 9 mg p.o. daily. 8. Coumadin 7 mg p.o. q. Tuesdays, Thursdays and Saturdays; otherwise 5 mg on the remaining days.
EC|enteric-coated|EC|118|119|DISCHARGE MEDICATIONS|1. Clonidine 200 mcg b.i.d. 2. Lipitor 80 mg per day. 3. Aspirin 325 mg per day. 4. Zyrtec 10 mg per day. 5. Depakote EC 500 mg in the morning and 250 mg in the evening . 6. Reglan 10 mg q.i.d. 7. Singulair 10 mg per day.
EC|enteric-coated|EC|201|202|HOSPITAL COURSE|She will also be maintained on a TPN pump with limited oral intake, consisting mostly of Boost 3 times a day. She has been instructed on how to manage the TPN pump. DISCHARGE MEDICATIONS: 1. ASA 81 mg EC p.o. q.day by mouth. 2. Fentanyl 150 mcg q.72 hours. 3. Ketoprofen 5% in PLO gel, which the pharmacy will prepare. 4. Oxycodone elixir 30 mL to 40 mL p.o. q.4 hours p.r.n. for pain.
EC|enteric-coated|EC|137|138|DISCHARGE MEDICATIONS|At that time, he is felt stable to be discharged with close followup. DISCHARGE MEDICATIONS: 1. Prednisone 20 mg p.o. daily. 2. Entocort EC 9 mg p.o. every morning. 3. Gabapentin 300 mg orally a few times per day, 1 month's supply dispensed with further management by Pain Clinic.
EC|enteric-coated|EC|144|145|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Albuterol inhaler 2 puffs q.4h. 2. Miconazole 2% powder to scrotum b.i.d. 3. Metoprolol 25 mg p.o. b.i.d. 4. Depakote EC 500 mg p.o. b.i.d. 5. Trazodone 50 mg p.o. q.h.s. 6. Senokot-S 2 tablets p.o. q.h.s. 7. PhosLo 667 mg, 2 tablets p.o. t.i.d. 8. Lac-Hydrin 12% lotion to skin b.i.d.
EC|enteric-coated|EC|174|175|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Zyprexa 20 mg p.o. daily. 2. Thiothixene 10 mg p.o. q. h.s. 3. Nasonex spray each nostril twice daily. 4. Adderall XR 20 mg p.o. daily. 5. Depakote EC 750 mg p.o. q. h.s. 6. Percocet 1-2 tabs p.o. q. 4-6 hours p.r.n. pain. 7. Colace 100 mg p.o. b.i.d.
EC|enteric-coated|EC|129|130|DISCHARGE MEDICATIONS|7. Flonase 1 spray b.i.d. 8. Lasix 10 mg p.o. b.i.d. 9. Synthroid 25 mcg p.o. daily. 10. Metoprolol XL 25 mg daily. 11. Protonix EC 20 mg p.o. daily. 12. Zocor 20 mg p.o. q. h.s. 13. Lovenox 40 mg subcutaneous through _%#MM#%_ _%#DD#%_ then DC.
EC|UNSURED SENSE|EC|159|160|MEDICATIONS|7. Lipitor 10 mg qd. 8. Cosopt two eye drops 0.5%, one GTT OU b.i.d. 9. Lotril 520 mg PO qd. 10. Glucose 500 mg PO b.i.d. 11. Multi vitamins without iron. 12. EC and folate supplements. 13. Volemium PAST SURGICAL HISTORY: 1. History of left cataract 2000, 2. Right foot 1988.
EC|enteric-coated|EC|109|110|DISCHARGE MEDICATIONS|4. Hypertension. DISCHARGE MEDICATIONS: 1. Cozaar 50 mg p.o. q.a.m. 2. Atenolol 25 mg p.o. q.a.m. 3. Aspirin EC 225 mg p.o. q.a.m. 4. Combivent metered-dose inhaler 2 puffs q.i.d. p.r.n. cough. 5. Albuterol metered-dose inhaler 2 puffs q.i.d. p.r.n. cough.
EC|enteric-coated|EC|124|125|DISCHARGE MEDICATIONS|Her affect was congruent. Her insight and judgment intact. Her mood improved and stable. DISCHARGE MEDICATIONS: 1. Depakote EC 500 mg twice daily. 2. Zyprexa 10 mg bedtime daily. 3. Lexapro 40 mg 1 time daily. 4. Seroquel 50 mg twice daily. 5. Effexor-XR 112.5 mg 1 time daily on _%#MM#%_ _%#DD#%_, 2005, and _%#MM#%_ _%#DD#%_, 2005.
EC|enteric-coated|EC|151|152|MEDICATIONS|4. Lumbar diskectomy. MEDICATIONS: 1. Advair 500/50 one puff b.i.d. 2. Spiriva one daily. 3. Glipizide 10 mg daily. 4. Effexor 75 mg b.i.d. 5. Aspirin EC 81 mg daily. 6. Plavix 75 mg daily. 7. Vytorin 10/10 one h.s. daily. 8. Metformin 1000 mg b.i.d. He has been off during his dye studies.
EC|enteric-coated|EC|143|144|MEDICATIONS|ALLERGIES: Adhesive tape. MEDICATIONS: 1. BuSpar 40 mg p.o. b.i.d. 2. Soma 350 mg p.o. t.i.d. 3. Cymbalta 60 mg p.o. q.a.m. 4. Ferrous sulfate EC 325 mg p.o. q. day. 5. Gabapentin 1,800 mg p.o. b.i.d. 6. Lantus insulin 26 units q. day. 7. Metoclopramide 10 mg p.o. q.i.d.
EC|enteric-coated|EC|150|151|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Atenolol 50 mg daily. 2. Lipitor 20 mg daily. 3. Levothyroxine 0.175 mg daily. 4. Ranitidine 150 mg twice daily. 5. Aspirin EC 325 mg daily. 6. Paxil 40 mg daily. 7. Campral 666 mg 3 times daily. 8. Albuterol inhaler 1 to 2 puffs as needed.
EC|enteric-coated|E.C.|123|126|DISCHARGE MEDICATIONS|2. Metoprolol 75 mg p.o. b.i.d. 3. Losartan 100 mg daily. 4. Neurontin 300 mg b.i.d. 5. Amlodipine 10 mg daily. 6. Aspirin E.C. 81 mg daily. 7. Naproxen 250 mg daily. 8. Acetaminophen 650 mg p.o. q.4 h. p.r.n. 9. Prevacid 30 mg 1 p.o. daily.
EC|enteric-coated|EC|179|180|ADMISSION DIAGNOSIS|She will take ferrous gluconate on discharge; the patient has done this in the past and buys this over-the- counter. DISCHARGE MEDICATIONS: 1. Asacol 800 mg PO t.i.d. 2. Entocort EC 9 mg PO daily. 3. Multivitamins 1 tablet PO daily. 4. Prednisone 40 mg PO daily x 7 days, then prednisone 30 mg PO daily x 7 days, then prednisone 20 mg PO daily x 7 days, the prednisone 10 mg PO daily x 7 days.
EC|enteric-coated|EC|221|222|MEDICATIONS|4. Clonazepam 1 mg p.o. b.i.d. p.r.n. 5. gatifloxacin 400 mg p.o. daily, although he does not remember being on this medication and does not know why he would be an antibiotic 6. Antabuse 250 mg p.o. daily. 7. Divalproex EC 500 mg p.o. q.a.m. 750 mg p.o. each day at bed-time 8. Bupropion 150 mg p.o. t.i.d. 9. p.r.n. nitroglycerin. 10. In addition, he also reports being on several medications which are not on his medication list including aspirin 81 mg p.o. daily, lisinopril 40 mg p.o. daily, p.r.n. ibuprofen and p.r.n. oxycodone which for which he takes 5-10 mg p.o. q.6h. up to 40 mg p.o. daily.
EC|enteric-coated|EC|145|146|PAST MEDICAL HISTORY|The groin was satisfactorily closed with an Angio-Seal device. DISCHARGE MEDICATIONS: 1. Nitroglycerin 0.4 mg sublingual as required. 2. Aspirin EC 81 mg p.o. once daily. 3. Plavix 75 mg once daily for at least 1 year (not to be ceased without knowledge of attending cardiologist).
EC|enteric-coated|EC|161|162|DISCHARGE MEDICATIONS|5. Albuterol 2 puffs q.i.d. p.r.n. 6. Celexa 20 mg q. day for depression. 7. Glucotrol 2.5 mg b.i.d. 8. Cozaar 50 mg daily. 9. Singulair 10 mg daily. 10. Asacol EC 800 mg t.i.d. for Crohn. 11. Procardia XL 30 mg daily for blood pressure. FOLLOW UP: The patient will be followed by _%#COUNTY#%_ _%#COUNTY#%_ Home Health and there is a house keeper involved.
EC|enteric-coated|EC|232|233|DISCHARGE MEDICATIONS|Single kidney, hypertension, chronic diarrhea. PROCEDURES: IV fluids. CAT scan demonstrating mega colon and AAA. The patient also receiving antibiotics. DISCHARGE MEDICATIONS: The patient's discharge medications include 1. Entocort EC 9 mg p.o. q.a.m. 2. Gabapentin 300 mg one p.o. b.i.d. 3. Levaquin 250 mg one p.o. daily 4. Ranitidine 150 mg one p.o. b.i.d.
EC|enteric-coated|EC|126|127|DISCHARGE MEDICATIONS|2. Vasotec 5 mg 1 p.o. b.i.d. 3. Lasix 60 mg p.o. daily. 4. Cilostazol 100 mg p.o. b.i.d. 5. Spironolactone 25 mg 1 daily. 6. EC ASA 325 mg one daily. 7. Lipitor 20 mg p.o. daily. 8. Nicotine patch 21 mg replace daily. 9. Albuterol MDI 2 puffs q.4 h. p.r.n.
EC|enteric-coated|EC|133|134|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1. Verapamil 240 mg one tablet q. day. 2. Warfarin 5 mg p.o. q. day. 3. Cymbalta 60 mg p.o. q. day. 4. Depakote EC 1500 mg t.i.d. 5. Digoxin 0.25 mg q. day. 6. Nexium 40 mg p.o. q. day. 7. Furosemide 40 mg p.o. q. day. 8. Potassium chloride 20 mEq one tablet q. day.
EC|enteric-coated|EC|191|192|DISCHARGE MEDICATIONS|10. Status post appendectomy. 11. Status post spinal surgery. 12. History of atypical chest pain with normal coronary angiogram on _%#MM#%_ _%#DD#%_, 2002. DISCHARGE MEDICATIONS: 1. Entocort EC three tablets p.o. q.d. 2. Accupril 20 mg p.o. q.d. 3. Toprol XL 100 mg p.o. b.i.d. 4. Pentasa 250 mg three p.o. t.i.d. 5. Trileptal 300 mg p.o. b.i.d.
EC|enteric-coated|EC|159|160|PAST MEDICAL HISTORY|For this reason, she was transferred to the University of Minnesota on _%#MMDD2002#%_. PAST MEDICAL HISTORY: 1. Bipolar affective disorder with a trend toward EC toxicity on lithium presently stable since _%#MM#%_. 2. Diabetes mellitus with no triopathy. 3. Hypothyroid. 4. Congestive heart failure, not otherwise specified.
EC|enteric-coated|EC|151|152|DISCHARGE MEDICATIONS|9. Protonix 40 mg p.o. q.d. 10. Colace 100 to 200 mg p.o. b.i.d. prn constipation. 11. Calcium carbonate with Vitamin D 500 mg p.o. t.i.d. 12. Aspirin EC 81 mg p.o. q.d. 13. Paxil 20 mg p.o. q.d. 14. Tylox one to two p.o. 4-6 hour prn incision pain. DISPOSITION AT DISCHARGE: _%#NAME#%_ _%#NAME#%_ was discharged to home in stable condition.
EC|enteric-coated|EC|181|182|MEDICATIONS|18. Glyburide 10 mg q.d. 19. Lecithin 19 grains b.i.d. 20. Medroxyprogesterone 2.5 mg q.d. 21. Miacalcin 200 units nasal spray, 1 spray q.d. (alternate nostril q.d.). 22. Bisacodyl EC 10 mg b.i.d. 23. Alfalfa 1 t.i.d. 24. Zithromax 250 mg q.d. x 4 (first dose 500 mg on _%#MMDD2002#%_). 25. Combivent 2 q.i.d. 26. Diazepam 5 mg t.i.d.
EC|enteric-coated|EC|189|190|HISTORY OF PRESENT ILLNESS|He is on a variety of medications, including acyclovir, Paxil, Zithromax on a weekly basis, Megace on a daily basis, Coumadin, Kaletra 3 capsules b.i.d., Tenofavir 300 mg per day and Videx EC 400 mg per day. He has also been restarted on oral antibiotics recently in the form of Levaquin 500 mg per day. He takes albuterol MDI as an inhaler and Azmacort as an inhaler.
EC|enteric-coated|EC|180|181|DISCHARGE MEDICATIONS|Monday/Wednesday/Friday x 3 months. 5. Mycelex Troches 10 mg p.o. q.i.d. x 6 months. 6. Norvasc 10 mg p.o. q.d. 7. Imdur 90 mg p.o. q.d. 8. Lopressor 125 mg p.o. b.i.d. 9. Aspirin EC 325 mg p.o. q.d. 10. Lantis insulin 25 units subcutaneous q.d. 11. Lispro insulin sliding scale subcutaneous q.i.d. p.r.n. hyperglycemia, 1 unit subcutaneous for every 50 mg per deciliter glucose greater than 150 mg per deciliter.
EC|enteric-coated|EC|157|158|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Percocet 1 to 2 tablets p.o. q.4-6h. 2. Ibuprofen 600 mg 1 tablet p.o. q.6-8h. 3. Pentasa 250 mg 4 tablets p.o. q.i.d. 4. Entocort EC 3 mg 1 tablet p.o. b.i.d. 5. Ranitidine 150 mg 1 tablet b.i.d. 6. Paroxetine 20 mg 1 tablet p.o. q.d. 7. Arimidex 1 mg 1 tablet p.o. q.d.
EC|enteric-coated|EC|118|119|DISCHARGE MEDICATIONS|She is discharged on the same medications that she arrived on with minimal changes. DISCHARGE MEDICATIONS: 1. Aspirin EC 81 mg p.o. q. day. 2. Ferrous sulfate 325 mg 2 tablets p.o. q. day. 3. Lasix 40 mg p.o. b.i.d. 4. MVI 1 tablet p.o. q. day.
EC|enteric-coated|EC|198|199|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Discharge medications will be the same as on admission and include: 1. Zantac 150 mg p.o. daily. 2. Penicillin VK 250 mg p.o. b.i.d. 3. Lipitor 10 mg p.o. q.h.s. 4. Pancrease EC three capsules p.o. with meals and Pancrease EC two capsules p.o. q.h.s. 5. Levaquin 500 mg daily for 7 days. 6. Zithromax 250 mg for four more doses.
EC|enteric-coated|EC|171|172|DISCHARGE MEDICATIONS|8. Simvastatin 80 mg orally daily. 9. Detrol 4 mg orally twice daily. 10. Medrol 250 mg orally every week Mondays. 11. Senokot S 1 tablet orally twice daily. 12. Depakote EC 1000 mg orally twice daily. 13. Carnitine 330 mg orally three times daily. 14. Tegretol XR 300 mg orally at 2:00 p.m. and 9:00 p.m.
EC|enteric-coated|EC|185|186|HISTORY|13. Cogentin 1 mg nightly. 14. Os-Cal with vitamin D 500 mg b.i.d. 15. Celexa 60 mg daily. 16. Clozaril 100 mg in the morning, 175 mg nightly, and 200 mg in the afternoon. 17. Depakote EC 500 mg t.i.d. CONDITION AT DISCHARGE: Stable.
EC|enteric-coated|EC|162|163|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Lovenox 100 mg subcutaneously daily until INR is between 2 and 3. 2. Coumadin 10 mg p.o. tonight with INR recheck tomorrow. 3. Protonix EC 20 mg p.o. daily. 4. Paxil 30 mg p.o. daily. 5. Budesonide EC 9 mg p.o. q.a.m. 6. Ambien 5 mg p.o. nightly p.r.n. for sleep.
EC|enteric-coated|EC|132|133|DISCHARGE MEDICATIONS|2. Coumadin 10 mg p.o. tonight with INR recheck tomorrow. 3. Protonix EC 20 mg p.o. daily. 4. Paxil 30 mg p.o. daily. 5. Budesonide EC 9 mg p.o. q.a.m. 6. Ambien 5 mg p.o. nightly p.r.n. for sleep.
EC|enteric-coated|EC|155|156|MEDICATIONS|ALLERGIES: No known drug allergies. MEDICATIONS: 1. Pentaza 2 mg b.i.d., 2. Alprazolam, 1 q. at h.s. 1 mg. 3. Warfarin on various doses daily, 4. Entocort EC 3 mg t.i.d. 5. Purinethol 50 q. day. 6. Six MP 25 q. day. REVIEW OF SYSTEMS: The patient lives with his wife, doing well and has normal activities of daily living up to the present time prior to this admission.
EC|enteric-coated|EC|148|149|DISCHARGE MEDICATIONS|ALLERGIES: Flagyl, amoxicillin, Biaxin, Levaquin, aspirin, which all cause GI upset. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Depakote EC 500 mg p.o. b.i.d. 3. Folate 1 mg p.o. q.d. 4. Prevacid 30 mg p.o. q.d. 5. Methotrexate 2.5 mg, 9 tablets p.o. q. Wednesday. 6. Toprol XL 50 mg p.o. q.d.
EC|enteric-coated|EC|98|99|DISCHARGE MEDICATIONS|SOCIAL HISTORY: Ex-smoker. ALLERGIES: No known drug allergies. DISCHARGE MEDICATIONS: 1. Depakote EC 1000 mg p.o. t.i.d. 2. Dilantin 500 mg p.o. b.i.d. 3. Multivitamin 1 p.o. q.d. 4. Thiamine 100 mg p.o. q.d. 5. Folate 1 mg p.o. q.d. 6. Zantac 150 mg p.o. b.i.d.
EC|enteric-coated|EC|173|174|DISCHARGE MEDICATIONS|The results of this will need to be followed up by Dr. _%#NAME#%_ in Cardiology Clinic in one month's time. DISCHARGE MEDICATIONS: 1. Bonola (??) 10 mg p.o. q.d. 2. Aspirin EC 325 mg p.o. q.d. 3. Prempro one tablet p.o. q.d. 4. Lisinopril 20 mg p.o. q.d. 5. Toprol XL 150 mg p.o. q.d. 6. Zocor 80 mg p.o. q.d.
EC|enteric-coated|EC|126|127|DISCHARGE MEDICATIONS|At he time of discharge, the patient did not appear to be competent to be asked about this. DISCHARGE MEDICATIONS: 1. Aspirin EC 325 mg 1 p.o. q.d. 2. Multivitamin one p.o. q.d. 3. Tylenol 1000 mg p.o. q.d. 4. Imdur 60 mg p.o. q.d. 5. Lasix 40 mg p.o. q.d.
EC|enteric-coated|EC|186|187|DISCHARGE MEDICATIONS|2. Congestive heart failure. 3. Hypokalemia. 4. Chronic obstructive pulmonary disease. DISCHARGE MEDICATIONS: 1. Senokot S 2 tablets p.o. q.h.s. 2. Timolol 20 mg p.o. b.i.d. 3. Protonix EC 40 mg p.o. daily. 4. Furosamide 40 mg p.o. daily. 5. Tylenol 650 mg p.o. q.4h p.r.n. pain. 6. Ultram 50 mg p.o. q.4h p.r.n. pain. 7. Aspirin 81 mg p.o. daily.
EC|enteric-coated|EC|183|184|DISCHARGE MEDICATIONS|6. Eucerin cream to the heels and feet b.i.d. for dryness p.r.n. 7. Remeron 45 mg p.o. q.h.s. for depression and sleep. 8. Multivitamin with minerals 1 tablet p.o. daily. 9. Protonix EC 1 tablet 40 mg p.o. daily. 10. Senokot 1 tablet p.o. q. daily p.r.n. 11. Percocet 1 to 2 tablets p.o. q.6h p.r.n. pain.
EC|enteric-coated|EC|137|138|DISCHARGE MEDICATIONS|3. Singulair 10 mg p.o. q. p.m. 4. Lisinopril 20 mg p.o. daily. 5. Triamterene hydrochlorothiazide 37._%#MMDD#%_ p.o. daily. 6. Protonix EC 40 mg p.o. daily. 7. Flomax 400 mcg p.o. daily. 8. Advair 250/50 one puff inhaled b.i.d. 9. Combivent 2 puffs inhaled q.i.d.
EC|enteric-coated|EC|90|91|DISCHARGE MEDICATIONS|At the time of discharge, his condition was improving. DISCHARGE MEDICATIONS: 1. Entocort EC 6 mg q.a.m. and 3 mg q.p.m. 2. Bupropion XL 150 mg p.o. q.a.m. 3. Benzonatate 100 mg p.o. t.i.d. p.r.n. for cough.
EC|enteric-coated|EC|320|321|MEDICATIONS AT THE TIME OF DISCHARGE|Ultimately the patient indicated that if her disease once again flares, then she would present to the emergency department, likely Abbott Northwestern, where she had received much of her previous psych care. MEDICATIONS AT THE TIME OF DISCHARGE: 1. Oxycodone 20 mg q.4h. p.r.n. 2. Azathioprine 125 mg daily. 3. Entocort EC 9 mg daily. 4. Multivitamin 1 daily. CONDITION AT DISCHARGE: Stable. PLAN: Primary care followup as above with appointment to see Dr. _%#NAME#%_, the patient's previous gastroenterologist at Abbott Northwestern in 3 to 4 weeks.
EC|enteric-coated|EC|125|126|MEDICATIONS|4. Vitamin C, taking daily. 5. Multivitamin 1 p.o. p.o. daily. 6. Afrin half a spray in each nostril at bed time. 7. Aspirin EC 81 mg p.o. daily. ALLERGIES: No drug allergies but nasal steriods lead to headache.
EC|enteric-coated|EC|135|136|DISCHARGE MEDICATIONS|2. Zetia 10 mg p.o. q.h.s. 3. Simvastatin 40 mg p.o. q.h.s. 4. Levothyroxine 25 mcg daily 5. Metoprolol 12.5 mg p.o. b.i.d. 6. Aspirin EC 81 mg daily 7. Bactrim DS 800/160 one b.i.d. for a total of 3 days The patient was unable to tolerate an ACE inhibitor or ARB secondary to his hypotension.
EC|enteric-coated|EC|174|175|DISCHARGE MEDICATIONS|She has no known drug allergies. DISCHARGE MEDICATIONS: 1. Xanax 0.25 mg q.8 hours p.r.n. anxiety. 2. Klonopin 0.5 mg twice a day. 3. Zyrtec 10 mg tablets daily. 4. Protonix EC 40 mg daily. 5. Lexapro 10 mg tablets daily. 6. Cardizem 90 mg tablets q.i.d. 7. Senokot 1 tablet daily. 8. Dulcolax 10 mg suppository 1 per rectum daily p.r.n. for constipation.
EC|enteric-coated|EC|98|99|MEDICATIONS|We have set her up for surgery at this time again. ALLERGIES: Penicillin MEDICATIONS: 1. Depakote EC 500 mg t.i.d. 2. Ranitidine 150 mg p.r.n. 3. Ibuprofen on a p.r.n. basis. 4. Premphase 0.625/5 daily. 5. Aspirin on a p.r.n. basis but this will be on hold for 10 days before surgery.
EC|enteric-coated|EC|161|162|DISCHARGE MEDICATIONS|Patient may need to go slower towards the end of the taper. DISCHARGE MEDICATIONS: 1. Celexa 20 mg p.o. q. day. 2. Colace 100 mg p.o. q. day p.r.n. 3. Pancrease EC 3 tablets p.o. with each meal. 4. OxyContin 60 mg p.o. q.8 hours p.r.n. pain. 5. Oxycodone 10 to 20 mg p.o. q.4 hours p.r.n. pain.
EC|enterocutaneous|EC|228|229|HISTORY OF PRESENT ILLNESS|The patient was transferred to Fairview-University Medical Center for further management of his enterocutaneous fistulas and abdominal pain. On admission, the patient was on TPN for nutrition. All enteral output was through his EC fistula and he tolerated only clears and popsicles p.o. PAST MEDICAL HISTORY: 1. Morbid obesity. 2. Depression. 3. Anxiety. 4. History of candida sepsis from Hickman.
EC|enterocutaneous|EC|142|143|HOSPITAL COURSE|4. Appendectomy as a child. HOSPITAL COURSE: On admission, the patient was found to have 2 large sections of small bowel contained within his EC fistula with mucosa showing and positive peristalsis. His abdomen was obese, soft, nontender, but was tender around his fistulas. An Upper GI performed on hospital day #2 showed contrast in the patient's right lower quadrant drainage bag within 10 minutes.
EC|enteric-coated|EC|164|165|DISCHARGE MEDICATIONS|2. Albuterol two to four puffs before activity and as necessary. 3. Q-Vas 80 mcg MDI two puffs b.i.d. (inhaled steroid). 4. Toprol XL 25 mg p.o. q. day. 5. Aspirin EC 325 mg p.o. q. day. 6. Percocet p.r.n. pain. FINAL DIAGNOSES: 1. Ruptured infrarenal abdominal aortic aneurysm.
EC|enteric-coated|EC|172|173|CURRENT MEDICATIONS|2. Depakote EC 250 mg in the a.m. 3. Lasix 80 mg one p.o. daily. 4. Aspirin 81 mg p.o. daily. 5. Ibuprofen 600 mg p.o. b.i.d. 6. Klor-Con SA 10 mEq p.o. b.i.d. 7. Depakote EC 500 mg one o q.h.s. 8. Vicodin 5/500 one tab q.4h. p.r.n. pain. 9. Ranitidine 100 mg b.i.d. p.r.n. for influenza prophylaxis.
EC|enteric-coated|EC|355|356|DISCHARGE MEDICATIONS|3. Prednisone 30 mg twice a day for six days, and then 30 mg in the morning and 20 mg in the evening for seven days, then 20 mg in the morning and 20 mg in the evening for seven days, then 20 mg in the morning and 10 mg in the evening for seven days, and 10 mg in the morning for seven days, and 10 mg in the morning, and then taper as per MD. 4. Aspirin EC 81 mg p.o. daily. Chronic medications: 1. Advair 500/50 one inhalation twice a day. 2. Proventil two puffs q. 4 hours p.r.n. for cough or wheeze.
EC|enteric-coated|EC|120|121|DISCHARGE MEDICATIONS|4. Zetia 10 mg daily. 5. Lasix 20 mg daily. 6. Amaryl 0.5 mg p.o. daily. 7. Fosamax 70 mg p.o. q. week. 8. Pancrelipase EC 2 capsules t.i.d. with meals. 9. Vitamin D 400 international units p.o. daily. 10. Metamucil 1 tablespoon with water daily.
EC|enteric-coated|EC|191|192|DISCHARGE MEDICATIONS|13. Enteric-coated aspirin 81 mg daily. 14. Cymbalta 60 mg p.o. daily. 15. Lipitor 80 mg p.o. each day at bedtime. 16. Lantus 70 units subcutaneously at bedtime, 2 units per carb unit t.i.d. EC and low correction scale with Aspart. A dobutamine stress echo on _%#MMDD2007#%_. Office followup with myself the following week.
EC|enteric-coated|EC|122|123|ADMISSION MEDICATIONS|3. Synthroid 200 mcg p.o. q.d. 4. Toprol XL 50 mg p.o. q.d. 5. Flomax 0.4 mg p.o. b.i.d. 6. Clonidine 0.1 mg p.o. q.d. 7. EC aspirin 81 mg p.o. q.d. 8. Multivitamin. 9. Vitamin E 400 IU b.i.d. 10. Trazodone 50 mg p.o. q.h.s. 11. Niacin 500 mg p.o. t.i.d.
EC|enteric-coated|EC|135|136|HISTORY OF PRESENT ILLNESS|3. Iron-deficiency anemia. The patient's hemoglobin has been stable at 9 while he was in the hospital. DISCHARGE MEDICATIONS: Entocort EC 9 mg p.o. q.d., lansoprazole 30 mg p.o. q.d., and Tylenol 650 mg p.o. q.4-6h. p.r.n. FOLLOW UP: The patient was discharged home under stable condition and he will follow up with his primary MD Dr. _%#NAME#%_ _%#NAME#%_ in GI Clinic in 1-2 weeks.
EC|enteric-coated|EC|163|164|PAST MEDICAL HISTORY|She does not think she has always taken this properly. PAST MEDICAL HISTORY: Medicines: Seroquel 75 mg three times daily. Amitriptyline 50 mg at bedtime. Depakote EC 1250 mg at bedtime. Effexor XR 225 mg every morning. Klonopin 1 mg every morning. Klonopin 2 mg at bedtime. Protonix 40 mg daily. Robaxin 750 mg at bedtime p.r.n. headaches.
EC|enteric-coated|EC|277|278|AXIS II|On _%#MM#%_ _%#DD#%_, 2004, the opiate withdrawal protocol was discontinued per the physician. His medications that he had been taking prior to admission were re-ordered which included lithium carbonate 300 mg b.i.d., loratadine 10 mg daily, Lexapro 10 mg daily, Depakote tabs EC 500 mg daily at bedtime, Seroquel 100 mg daily at bedtime, and Trazodone 100 mg daily at bedtime. By _%#MM#%_ _%#DD#%_, 2004, it was determined he was medically stable and ready for discharge to Bristol Place.
EC|enteric-coated|EC|167|168|AXIS II|His mood was stable. DISCHARGE MEDICATIONS: 1. Lithium carbonate 300 mg b.i.d. 2. Protonix 40 mg daily x12 doses then discontinue. 3. Lexapro 20 mg daily. 4. Depakote EC 500 mg daily at bedtime. 5. Loratadine 10 mg daily. DISCHARGE PLAN: 1. He is to take his medications as ordered.
EC|enteric-coated|EC|163|164|ADMISSION DIAGNOSIS|The patient was tolerating p.o. intake and had good urine output. DISPOSITION: The patient was discharged to home with her husband. DISCHARGE MEDICATIONS: Aspirin EC 325 mg p.o. daily, hydrochloride 25 mg p.o. daily. FOLLOW UP: The patient has a followup appointment with Dr. _%#NAME#%_ _%#NAME#%_ in 4 weeks. Patient also had a followup appointment with Dr. _%#NAME#%_ in 1-2 weeks.
EC|enteric-coated|EC|230|231|ADMISSION SUMMARY|A 16-French standard Foley catheter was placed by urology without difficulty, although a urethral false passage was thought probable. DISCHARGE MEDICATIONS: (Same as admission medication). 1. Calcium 500 mg p.o. daily. 2. Aspirin EC 325 mg p.o. daily. 3. Atenolol 50 mg p.o. daily. 4. Lexapro 20 mg p.o. daily. 5. Lisinopril 40 mg p.o. daily.
EC|enteric-coated|EC|109|110|DISCHARGE MEDICATIONS|5. Namenda 10 mg daily. 6. Alprazolam 0.5 mg 1 q. a.m. and 2 at bedtime. 7. Aspirin 81 mg daily. 8. Entocort EC 3 mg p.o. at bedtime. 9. Levaquin 500 mg daily for the following five days.
EC|enteric-coated|EC|176|177|PAST MEDICAL HISTORY|It is possible she may not get the desired effect with the labioplasty. PAST MEDICAL HISTORY: 1. Cervical dysplasia and especially in an endocervical component with a positive EC in the past. ECC and Pap smear were normal most recently 2. Anxiety 3. Smokes cigarettes 4. Recurrent miscarriages with an abnormal cytotoxic cross match test PAST SURGICAL HISTORY: 1. LEEP x 3
EC|enteric-coated|EC|149|150|DISCHARGE MEDICATIONS|4. Flonase 2 sprays each nostril daily. 5. Neurontin 200 mg daily. 6. Hydrochlorothiazide 15 mg daily. 7. Multivitamin 1 tablet daily. 8. Pancrecarb EC cap MS-8 two capsules with meals. 9. MiraLax 17 g p.o. b.i.d. 10. Zofran 4 mg to 8 mg p o q.8h. p.r.n. for nausea and vomiting.
EC|enteric-coated|EC|164|165|DISCHARGE MEDICATIONS|2. Pancrease Ultrase MT 20 ten capsules p.o. daily when tube feeding is complete along with 20-25 capsules p.o. daily before administering tube feeds. 3. Pancrease EC cap MT 20 two to three capsules p.r.n. with snacks and 8-10 capsules with meals. 4. Bactrim DS 2 tablets twice daily. 5. Cipro 750 mg twice daily.
EC|enteric-coated|EC|182|183|DISCHARGE MEDICATIONS|18. Tiotropium 18 mcg inhaled daily. 19. Gabapentin 200 mg p.o. at bedtime. 20. Desonide 0.05% cream topical 2 times per day as needed for redness and itching on face. 21. Bisacodyl EC 5 mg p.o. 2 times a day as needed for constipation. 22. Lorazepam 1 mg p.o. 4 times a day as needed for anxiety.
EC|enteric-coated|EC|180|181|CURRENT MEDICATIONS|9. Levothyroxine 50 mcg daily. 10. Lisinopril 30 mg b.i.d. 11. Remeron 15 mg at bedtime. 12. Seroquel 75 mg at bedtime. 13. Spiriva 1 capsule daily. 14. DuoNeb b.i.d. 15. Entocort EC 3 mg 3 in the morning, which was resumed _%#MMDD2007#%_. 18. Nexium 40 mg daily. 19. Artificial Tears in affected eyes b.i.d.
EC|enteric-coated|EC|133|134|DISCHARGE  MEDICATIONS|7. Multivitamin 1 tab p.o. q. day. 8. Nitroglycerin 400 mcg p.r.n. chest pain. 9. Nitroglycerin SA 6.5 mg p.o. b.i.d. 10. Pancrecarb EC cap MS-8, one cap p.o. b.i.d. with meals. 11. Zantac 75 mg p.o. b.i.d. 12. Simethicone 80 mg 4 times a day p.r.n.
EC|enteric-coated|EC|118|119|DISCHARGE MEDICATIONS|6. Levsin sublingual tablets before meals and bedtime. 7. Synthroid 112 mcg daily. 8. Cozaar 50 mg daily. 9. Depakote EC 250 mg daily. 10. Citracal 1500 mg daily. 11. Colace p.r.n. 12 Citrucel. 13. Multivitamin 1 tablet daily. 14. Pravastatin 80 mg daily.
EC|enteric-coated|EC|107|108|DISCHARGE MEDICATIONS|2. Crohn's disease. 3. Hypertension. 4. Gastroesophageal reflux disease DISCHARGE MEDICATIONS: 1. Entocort EC 3 mg 3 times a day. 2. Vitamin B12 1000 mcg daily. 3. Hydrochlorothiazide 25 mg daily. 4. Metoprolol 25 mg b.i.d.
EC|enteric-coated|EC|204|205|MEDICATIONS|She has had bilateral cataract procedures; on the left in _%#MM2005#%_ and on the right in _%#MM2005#%_ at Fairview Southdale Hospital by Dr. _%#NAME#%_. MEDICATIONS: 1. Atenolol 50 mg q. day. 2. Aspirin EC 81 mg q. day. 3. Prevacid 30 mg b.i.d. a.c. 4. Zetia 10 mg q. day. 5. Evista 60 mg q. day. 6. Aricept 10 mg q. day.
EC|enteric-coated|EC|95|96|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Pancrecarb EC cap MS-8 10-15 capsules p.o. with meals. 2. Pancrecarb EC cap MS-8 4-8 capsules p.o. with snacks. 3. Fluticasone propionate 0.05% 2 sprays per nostril daily. 4. Omeprazole 10 mg capsules p.o. every morning.
EC|enteric-coated|EC|179|180|DISCHARGE MEDICATIONS|9. Zofran 16 mg JT/p.o. t.i.d. 10. Carafate 1 gram p.o. t.i.d. 11. Erythromycin 333 mg JT/p.o. t.i.d. 12. Prilosec 40 mg JT/p.o. t.i.d. 13. MiraLax 34 grams JT b.i.d. 14. Aspirin EC 81 mg JT/p.o. q.d. 15. Sodium bicarbonate 1.3 grams JT/p.o. q.i.d. 16. Calcium carbonate with vitamin D 500 mg JT/p.o. t.i.d.
EC|enteric-coated|EC|157|158|MEDICATIONS AT THE NURSING HOME|MEDICATIONS AT THE NURSING HOME: 1. Albuterol and ipratropium nebulizer treatments on a p.r.n. basis. 2. Cogentin 2 mg three times a day. 3. Depakote 500 mg EC in the morning and 1000 mg EC in the h.s. 4. Ditropan XL 10 mg a day. 5. Syndrome 0.075 mg a day. 6. Maalox 30 cc twice a day. 7. Multivitamins once a day.
EC|enteric-coated|EC|152|153|DISCHARGE MEDICATIONS|2. Sustiva 600 mg p.o. daily. 3. Prednisolone 20 mg p.o. daily. 4. Epivir 300 mg p.o. daily. 5. Neupogen 300 mg subcutaneously two x per week. 6. Videx EC 400 mg p.o. daily. 7. Fluconazole 600 mg p.o. daily. 8. Sulfadiazine 1 g q. 6 h. p.o. 9. Promethazine 100 mg p.o. daily.
EC|enteric-coated|EC|153|154|DISPOSITION|4. Constanzi's solution 5 cc swish and spit q.i.d. for 7 days. 5. K-CL 10 mEq b.i.d. 6. Senna S one tablet b.i.d. 7. Protonix 40 mg per day. 8. Depakote EC 500 mg at nigiht and 250 mg in the morning. PLAN: 1. Labs with CBC and differential every Monday and Thurstday to be faxed to Dr. _%#NAME#%_.
EC|enteric-coated|EC|213|214|PLAN|2. History of schizophrenia, off medications. 3. HIV, under care from Infectious Disease. PLAN: As per above plus discharge medications to include: Calcium 500 mg 200 two times a day, clonazepam 1 mg daily, Videx EC 125 mg one time daily, Benadryl 50 mg 2 tablets at bedtime, Depakote 500 mg 3 tabs at bedtime, fluoxetine 1 capsule every morning, hydrocortisone 1% two times a day p.r.n., lorazepam 1 mg b.i.d., Nelfinavir 625 mg 2 tablets b.i.d., Zyprexa 1 tablet daily, prenatal vitamin with folate 1 tablet daily, Septra 400 mg/80 mg tablets 1 tablet every Monday, Wednesday and Friday and Viread 300 mg 1 tablet daily.
EC|enteric-coated|EC|162|163|MEDICATIONS ON DISCHARGE|MEDICATIONS ON DISCHARGE: Includes allopurinol 300 mg p.o. daily, Zofran 4 mg p.o. q.6 h. p.r.n. for nausea, vitamin B12 injection IM 100 mcg q.1 month, Entocort EC 9 mg p.o. q.a.m., Imuran 100 p.o. daily, abd Vicodin 1 to 2 tablets q.6 h. p.r.n., 10 tablets total. FOLLOWUP: 1. With primary physician, Dr. _%#NAME#%_ Smiley's Clinic in 1 week.
EC|enteric-coated|EC|134|135|DISCHARGE MEDICATIONS|1. Lovenox 130 mg subcutaneous q.12h. Continue for 48 hours after the INR is more than 2. 2. Toprol XL 100 mg p.o. daily. 3. Protonix EC 40 mg p.o. daily. 4. Vicodin 1-2 mg p.o. q.6h. p.r.n. for pain. 5. Coumadin 7.5 mg p.o. daily. 6. The patient had been on Coumadin 5 mg given on _%#MMDD2005#%_.
EC|enteric-coated|EC|164|165|DISCHARGE MEDICATIONS|1. Lasix 80 mg one p.o. daily. 2. Metoprolol 50 mg p.o. b.i.d. 3. Prednisone 20 mg daily. 4. Zantac 150 mg p.o. daily. 5. Diltiazem ER 240 mg one daily. 6. Aspirin EC 81 mg daily. 7. Potassium chloride 20 mEq one daily. 8. Warfarin, which is usually 1 mg a day, was on hold and will be resumed on _%#MMDD#%_.
EC|enteric-coated|EC|91|92|DISCHARGE MEDICATIONS|3. Folic acid 1 mg daily. 4. Robitussin DM 15 mg p.o. q. 6 h p.r.n. for cough. 5. Protonix EC 40 mg p.o. daily. 6. Thiamin 100 mg p.o. daily. FOLLOW-UP CARE: The patient needs to be followed by University of Minnesota Medical Center, Fairview Psychiatry team for further recommendation regarding her depression and medication management.
EC|enteric-coated|EC|219|220|DISCHARGE MEDICATIONS|13. LacriLube ointment to both eyes nightly. 14. Reglan 5 mg p.o. q.i.d. p.r.n. nausea and vomiting. 15. Acetaminophen 500 mg b.i.d. 16. Maalox 30 mg p.o. nightly p.r.n. dyspepsia. 17. Atenolol 25 mg daily. 18. Aspirin EC 81 mg daily. 19. Celebrex 200 mg daily. 20. Celexa 20 mg daily. 21. Colace 100 mg q.a.m. CONSULTATIONS: Consult with speech pathology as well as PT and OT.
EC|enteric-coated|EC|101|102|DISCHARGE MEDICATIONS|2. No fluid restriction. ALLERGIES: Codeine, lisinopril and Coreg. DISCHARGE MEDICATIONS: 1. Aspirin EC 81 mg p.o. daily. 2. Ferrous sulfate 325 mg p.o. three times per day. 3. Lasix 40 mg p.o. twice daily. 4. Hydralazine 50 mg p.o. three times per day.
EC|UNSURED SENSE|EC|280|281|PRENATAL LABORATORIES|Attended 10 total visits. Total weight gain 22 pounds. PRENATAL LABORATORIES: Blood type O negative, antibody screen negative. She received RhoGAM on _%#MM#%_ _%#DD#%_, 2006. Rubella immune, RPR negative, hepatitis C surface antigen negative, HIV negative, GC/chlamydia negative, EC negative. PAP showed CIN 2, GBS negative. OB HISTORY: In _%#MM#%_ 2005, she had a spontaneous AB which required a suction D and C.
EC|enteric-coated|EC|198|199|DISCHARGE MEDICATIONS|He was comfortable at all times and did not require administration of diastat or other abortive agents. PENDING STUDIES: None. DISCHARGE MEDICATIONS: 1. Focalin XR 20 mg p.o. every day. 2. Depakote EC 375 mg p.o. t.i.d. 3. Felbamate solution 720 mg p.o. q. a.m. 4. Felbamate solution 600 mg p.o. at noon and at 5 p.m. each day.
EC|enteric-coated|EC|169|170|CURRENT MEDICATIONS|6. Pantoprazole 40 mg every morning. 7. Folic acid 1 mg by mouth daily. 8. Multivitamin with minerals 1 tablet daily. 9. Cyclobenzaprine 10 mg p.o. t.i.d. 10. Valproate EC 1000 mg by mouth every night at bedtime. 11. Valproex 500 mg by mouth every morning. 12. Lidocaine patch 5% q.24 h. for pain.
EC|enteric-coated|EC|175|176|MEDICATIONS ON ADMISSION|4. Furosemide 40 mg p.o. t.i.d. 5. Glipizide 5 mg p.o. daily. 6. Hydralazine 10 mg p.o. daily. 7. Lisinopril 40 mg p.o. daily. 8. Metformin 850 mg p.o. b.i.d. 9. Pantoprazole EC 40 mg p.o. daily. 10. Potassium chloride tablets 20 mEq p.o. daily. 11. Percocet 5/325 mg 1-2 tablets p.o. q. 4h. p.r.n. pain. 12. Ativan 0.5 mg p.o. q. 4h. p.r.n. anxiety.
EC|enteric-coated|EC|163|164|DISCHARGE MEDICATIONS|8. Hydralazine 10 mg p.o. daily. 9. Lisinopril 40 mg p.o. daily. 10. Metformin 850 mg p.o. twice daily. 11. Potassium chloride 20 mEq p.o. daily. 12. Pantoprazole EC 40 mg p.o. daily. 13. Ativan 0.5 mg p.o. every 4 hours as needed for anxiety. 14. Warfarin 5 mg p.o. daily. FOLLOW-UP: The patient should follow up with Dr. _%#NAME#%_ in clinic in 2 weeks.
EC|enteric-coated|EC|120|121|HOME MEDICATIONS|7. Remeron Zydis q.i.d. as 7.5 mg by mouth at bedtime. The patient to take half of the 15 mg tablet. 8. Pancrease MT 16 EC cap 1-3 capsules by mouth with meals. 9. Protonix 40 mg by mouth twice a day. 10. MiraLax 17 g by mouth in 8 ounces of water 3 times a day p.r.n. for constipation.
EC|enteric-coated|EC|101|102|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Zoloft 150 mg p.o. q day. 2. Pantoprazole 40 mg p.o. q day. 3. Lipram 4500 EC three to six tablets with meals, two tablets with snacks. 4. Lantus 12 units subcu q a.m. 5. Humalog 1/2 unit subcu after eating for each 15 gm of carbohydrates consumed.
EC|enteric-coated|EC.|153|155|ADMISSION MEDICATIONS|10. Chemical dependency. 11. Chronic pain secondary to neurosurgery procedures and limb girdle muscular dystrophy. ADMISSION MEDICATIONS: 1. Lipram 4500 EC. 2. Methadone 40 mg q6h. 3. Protonix 40 mg q day. 4. Klonopin 2 mg q.i.d. 5. Ativan 1 mg t.i.d. 6. Zoloft 100 mg q day.
EC|enteric-coated|EC|115|116|ADMISSION DIAGNOSES|DISCHARGE MEDICATIONS: 1. Oxybutynin 10 mg t.i.d. 2. Tegretol-XR 200 mg t.i.d. 3. Aspirin 81 mg daily. 4. Depakote EC 1000 mg b.i.d. 5. Ranitidine 150 mg b.i.d. 6. Carnitine 330 mg t.i.d. 7. Colace 1 tablet b.i.d. 8. Lipitor 20 mg daily.
EC|enteric-coated|E.C.|263|266|DISCHARGE MEDICATIONS|Appointment with Dr. _%#NAME#%_ was scheduled on _%#MM#%_ _%#DD#%_, 2005. DISCHARGE MEDICATIONS: Ciprofloxacin 500 mg p.o. b.i.d. for 2 weeks, glipizide 10 mg p.o. b.i.d., multivitamin 1 p.o. daily, metformin 1000 mg p.o. b.i.d., Flomax 0.4 mg p.o. once, aspirin E.C. 81 mg p.o. once, Synthroid 125 mcg p.o. once, Zocor 20 mg p.o. once, Abilify 10 mg p.o. once a day, Neurontin 300 mg p.o. 3 times a day, and ibuprofen 800 mg p.o. q.8 h. p.r.n.
EC|enteric-coated|EC|132|133|DISCHARGE MEDICATIONS|ACTIVITY ON DISCHARGE: As tolerated. DIET ON DISCHARGE: Regular. DISCHARGE MEDICATIONS: Mercaptopurine 100 mg p.o. q. day, Entocort EC 3 mg p.o. t.i.d., Boniva 150 mg p.o. q. month and prednisone taper. He was started on prednisone 40 mg p.o. q. day for 2 weeks and 30 mg p.o. q. day for 1 week, then 20 mg p.o. q. day for 1 week, then 10 mg p.o. q. day for 1 week, then 5 mg p.o. q. day for 1 week, then stop.
EC|enteric-coated|EC|149|150|DISCHARGING MEDICATIONS|7. Compazine 5 mg p.o. q.6 hours p.r.n. nausea and vomiting. 8. Metoprolol 25 mg p.o. twice daily. 9. Isordil 10 mg p.o. 3 times daily. 10. Protonix EC 40 mg p.o. twice daily. 11. Zocor 40 mg p.o. every evening. 12. Ferrous sulfate 325 mg twice daily. 13. Ascorbic acid and vitamin C 250 mg every day.
EC|enteric-coated|EC|233|234|DISCHARGE MEDICATIONS|Transplant Surgery was consulted, they were not very concerned about this mass, but they suggested continuing patient on Levaquin for two weeks to cover any possible infection. DISCHARGE MEDICATIONS: 1. Imuran 100 mg daily. 2. _____ EC 400 mg p.o. t.i.d. 3. Multivitamins one p.o. daily. 4. Prednisone 5 mg p.o. daily. 5. Seroquel 50 to 100 mg p.o. at bedtime p.r.n. insomnia.
EC|enterocutaneous|EC|251|252|HOSPITAL COURSE|Once this is successful today on _%#MMDD2007#%_, the patient will be ready to go home on her regular home medications as well as Lovenox. She is to follow up with Dr. _%#NAME#%_ after she has followed up with Dr. _%#NAME#%_ _%#NAME#%_ at Mayo for her EC fistulas. She is also going to follow up with Dr. _%#NAME#%_ in Neurology for her restless legs. DISCHARGE MEDICATIONS: 1. Vitamin B12.
EC|enteric-coated|EC|171|172|DISCHARGE  MEDICATIONS|DISCHARGE MEDICATIONS: Include the following: 1. Zyloprim 100 mg daily. 2. Amylase, lipase, protease, in the form of Creon 22 capsules by mouth 3 times daily. 3. Entocort EC this I believe has been discontinued. 4. Coreg 6.25 mg b.i.d. 5. Epogen for correction of anemia, end-stage renal disease 100 mcg subcutaneously every dialysis treatment.
EC|enteric-coated|EC|182|183|MEDICATIONS|2. Neurontin 600 mg p.o. t.i.d. 3. Prilosec 20 mg p.o. every day. 4. Premarin 625 mg every other day. 5. Celexa one-half tablet b.i.d. 6. Quinine sulfate 325 mg daily. 7. Diclofenac EC 75 mg twice daily. SOCIAL HISTORY: She lives in _%#CITY#%_ ND and is currently visiting her daughter in the _%#CITY#%_ _%#CITY#%_.
EC|enteric-coated|EC|92|93|DISCHARGE MEDICATIONS|3. Arthritis associated with inflammatory bowel disease. DISCHARGE MEDICATIONS: 1. Entocort EC 9 mg daily. 2. Cholestyramine 4 g per scoop, 1 scoop, 4 times daily. 3. Benadryl 25 mg every 6 hours as needed and 50 mg at bedtime.
EC|enteric-coated|EC|301|302|DISCHARGE MEDICATIONS|He was brought up to an INR of 2.4 at which point he was discharged to continue Coumadin 5 mg daily and to have a follow-up INR two days later. DISCHARGE MEDICATIONS: His discharge medications are Coumadin 5 mg daily, metoprolol 25 mg b.i.d., lisinopril 5 mg daily, Zocor 40 mg every evening, aspirin EC 81 mg daily. A venous doppler of his left lower extremity where he had had a vein harvested and was having some leg discomfort was negative.
EC|enteric-coated|EC|210|211|ADMISSION MEDICATIONS|IMMUNIZATION STATUS: Up to date. PAST MEDICAL HISTORY: Ulcerative colitis diagnosed 5 years ago, and well-controlled until early 2005. ADMISSION MEDICATIONS: 1. Hydrocortisone enema 100 mg p.r. 2. Sulfadiazine EC 500 mg 2 tablets p.o. t.i.d. 3. 6-Mercaptopurine 50 mg p.o. q.a.m. 4. Prilosec 20 mg 2 tablets p.o. q.a.m.
EC|enteric-coated|EC|167|168|DISCHARGE MEDICATIONS|The patient is to call MD with temperatures greater than 100.5, increased tenderness, swelling, or redness around the incision site. DISCHARGE MEDICATIONS: 1. Aspirin EC 325 mg p.o. q. day. 2. Metoprolol 100 mg p.o. b.i.d. 3. Lipitor 40 mg p.o. q. day. 4. Vancomycin 1.2 g IV q. day x 8 doses.
EC|enteric-coated|EC|186|187|DISCHARGE MEDICATIONS|Outpatient evaluation and treatment is anticipated. CONSULTATIONS: Gastroenterology and Urology. DISCHARGE MEDICATIONS: Nadolol 40 mg p.o. once daily, Lopid 600 mg p.o. b.i.d., Entocort EC 9 mg p.o. each a.m. dispensed as written, Imodium 2 mg p.o. b.i.d. p.r.n. diarrhea, Metamucil 1 tablespoon sugar free in fluid p.o. daily.
EC|enteric-coated|EC|177|178|TRANSFERRING MEDICATIONS|TRANSFERRING MEDICATIONS: 1. Percocet 5/325 one or two tablets q.4-6 h. p.r.n. pain. 2. Colace 100 mg p.o. b.i.d. p.r.n. constipation. 3. Vistaril 25 mg p.o. t.i.d. 4. Depakote EC 250 mg t.i.d. 5. Hydrochlorothiazide 25 mg p.o. each day. 6. Atenolol 25 mg p.o. each day. 7. Potassium chloride 10 mEq p.o. each day. 8. Ferrous sulfate 325 mg p.o. b.i.d.
EC|enteric-coated|EC|141|142|DISCHARGE MEDICATIONS|We also placed him on high-dose Protonix prior to discharge. DISCHARGE MEDICATIONS: 1. Azathioprine 75 mg p.o. every other day. 2. Bisacodyl EC 5 mg p.o. every day. 3. Bupropion 75 mg p.o. b.i.d. 4. Plavix 75 p.o. q. day. 5. Lasix 20 mg p.o. q. day.
EC|enteric-coated|EC|135|136|DISCHARGE MEDICATIONS|5. Ibuprofen 600 mg p.o. at 6 a.m., 2 p.m., and 10 p.m. for pain. 6. Multivitamin 1 tablet p.o. daily for supplementation. 7. Protonix EC 40 mg p.o. q.a.m. for GERD. 8. Senokot-S 2 tablets p.o. b.i.d. for constipation. 9. Zoloft 100 mg p.o. daily for depression.
EC|enteric-coated|EC|354|355|DISCHARGE MEDICATIONS|3. Echocardiogram: Preliminary reports mildly decreased left ventricular systolic function, mild to moderate increasing left ventricular thickness - diastolic dysfunction, mild left atrial enlargement, turbulent flow at subaortic level with estimated left ventricular ejection fraction of 45% to 50%. Final was pending. DISCHARGE MEDICATIONS: 1. Aspirin EC 325 mg p.o. daily. 2. Vicodin 5/500 one to two p.o. q.6 h. p.r.n. pain, given #20. HISTORY OF PRESENT ILLNESS: This is a 62-year-old male with history of cardiac arrest, details unclear, who was transferred from _%#CITY#%_ emergency department secondary to shortness of air and chest pain.
EC|enteric-coated|EC|124|125|MEDICATIONS|ALLERGIES: He has no known drug allergies. MEDICATIONS: 1. Pentasa 8 b.i.d. 2. Alprazolam one daily at bedtime. 3. Entocort EC 3 t.i.d. 4. 6MP 25 mg q. day. 5. Warfarin in varying doses SOCIAL HISTORY: The patient lives with his wife.
EC|enteric-coated|EC|114|115|DISCHARGE MEDICATIONS|Clonazepam 0.5 mg each day at bedtime. 8. Depakote 250 mg b.i.d. 9. Digoxin 0.125 mg per day. 10. Ferrous sulfate EC 325 mg b.i.d. 11. Fluticasone 50 mcg nasal spray 2 sprays daily. 12. Vicodin 1 tab q.4h. p.r.n. 13. Isosorbide mononitrate 120 mg a day. 14. Lantus insulin 20 units subcutaneous each day at bedtime.
EC|enteric-coated|EC|116|117|DISCHARGE MEDICATIONS|DISCHARGE DIAGNOSES: 1. Hypotension. 2. Dehydration. 3. Schizoaffective disorder. DISCHARGE MEDICATIONS: 1. Aspirin EC 81 mg per oral q.a.m. 2. Calcium 600 plus vitamin D 200 mg 1 tablet per oral q.a.m. 3. Gabapentin 300 mg per oral q.a.m. and each day at bedtime.
EC|enteric-coated|EC|194|195|DISCHARGE MEDICATIONS|His CBC from the same date showed hemoglobin of 11.8 and white cell count of 12.9 and a platelet count of 431,000. DISCHARGE MEDICATIONS: His medications at the time of discharge were 1. Asacol EC 400 mg 3 times daily. 2. Reglan 10 mg 4 times daily. 3. Protonix 40 mg once daily. 4. Prednisone reduced from 40 mg to 30 mg one time daily with instructions to take this dosage for 10 days and then lower again to 20 mg daily.
EC|enterocutaneous|EC|213|214|HOSPITAL COURSE|HOSPITAL COURSE: The patient was at home on total parenteral nutrition with a low output enterocutaneous fistula. The patient adamantly wanted this fistula repaired and so that he could continue going on with his EC fistula as it was getting more and more difficult for his mother to help look after him and he desperately wanted to have his kidney transplant performed as he identified his brother as a donor.
EC|enteric-coated|EC|129|130|MEDICATIONS|6. Flovent 2 puffs b.i.d. 7. Glucosamine 1500 mg p.o. b.i.d. 8. Acetaminophen extra strength 500 mg p.o. q.6h. p.r.n. 9. Aspirin EC 81 mg p.o. daily. 10. Calcarb 1250 mg p.o. daily. 11. Hydrochlorothiazide 12.5 mg p.o. daily. 12. Metamucil 1 p.o. b.i.d. REVIEW OF SYSTEMS: A 10-point review of systems at this point is negative.
EC|enteric-coated|EC|148|149|DISCHARGE MEDICATIONS|2. Lisinopril 500 mg p.o. daily 3. Metoprolol 25 mg b.i.d. 4. Nitroglycerin 400 mcg sublingually p.r.n. 5. Simvastatin 40 mg at bed-time 6. Aspirin EC 81 mg daily 7. Insulin NPH 40 units every morning, NPH 20 units every night. Novolin R insulin 5-10 units subcu p.r.n. based on his glucose level.
EC|enteric-coated|EC|158|159|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Hydrochlorothiazide 25 mg p.o. q. day. 2. Potassium chloride 10 mEq p.o. q. day. 3. Vitamin D 50,000 units p.o. q. day. 4. Depakote EC 1000 mg p.o. q.a.m. and 500 mg p.o. each day at bedtime. 5. Benadryl 25 mg p.o. q. 6 hours p.r.n. itching.
EC|enteric-coated|EC|163|164|DISCHARGE MEDICATIONS|1. Zetia 10 mg p.o. daily. 2. HCTZ 25 mg p.o. daily. 3. Atenolol 50 mg p.o. daily. 4. Synthroid 0.75 mg p.o. daily. 5. Allopurinol 100 mg p.o. q. day. 6. Entocort EC p.o. daily. 7. Norvasc 5 mg p.o. daily. 8. Oxycodone 5-10 mg p.o. q.4h. p.r.n. #20 dispensed. DISCHARGE FOLLOW-UP: 1. The patient will follow up with Dr. _%#NAME#%_.
EC|enteric-coated|EC|181|182|DISCHARGE MEDICATIONS|7. Tylenol 650 mg q.6h. p.r.n. pain. 8. Sinemet 25/100 2 tabs b.i.d. 9. Aspirin 325 mg a day. 10. Colace 100 mg b.i.d. 11. Oxycodone 5 mg four times a day scheduled. 12. Divalproex EC 500 mg b.i.d. 13. OxyContin 10 mg b.i.d. 14. Senna 1 tablet b.i.d. 15. Lisinopril 2.5 mg a day. 16. Lipitor 40 mg a day.
EC|enteric-coated|EC|174|175|MEDICATIONS ON ADMISSION|4. Anxiety. 5. Depression. MEDICATIONS ON ADMISSION: 1. Nitro p.r.n. 2. Toprol XL 50 mg. 3. Lisinopril 10 mg. 4. Lipitor 80 mg. 5. Amitriptyline 20 mg p.o. nightly. 6. Lidex EC 400 mg p.o. daily. 7. Cyclobenzaprine 10 mg p.o. t.i.d. p.r.n. 8. Depakote 500 mg p.o. b.i.d. 9. Viramune 200 mg p.o. b.i.d. 10. Zerit 40 mg p.o. b.i.d.
EC|enteric-coated|EC|161|162|DISCHARGE MEDICATIONS|His discharge medications are repeatedly reviewed with him and the importance in maintaining control of his CHF is emphasized. DISCHARGE MEDICATIONS: 1. Aspirin EC 325 mg p.o. daily. 2. Lipitor 80 mg p.o. daily. 3. Coreg 3.125 mg p.o. b.i.d. 4. Plavix 75 mg p.o. daily. 5. Lasix 20 mg p.o. twice daily.
EC|enteric-coated|EC|128|129|HOSPITAL COURSE|2. Prinivil 10 mg p.o. q.day. 3. Pravachol 20 mg p.o. q.day. 4. Singulair 10 mg p.o. q.day. 5. Atrovent MDI two puffs a day. 6. EC ASA 325 mg p.o. q.day. 7. Albuterol MDI with spacer two puffs q.4h. p.r.n. for shortness of breath. 8. Nitroglycerin 0.4 mg p.o. p.r.n. for chest pain.
EC|enteric-coated|EC|143|144|DISCHARGE  MEDICATIONS|3. Calcium carbonate 500 mg p.o. daily. 4. Metoprolol XL 25 mg p.o. b.i.d. for atrial fibrillation. 5. Lisinopril 20 mg p.o. daily. 6. Aspirin EC 325 mg p.o. daily starting _%#MMDD2007#%_. 7. Prilsec 20 mg p.o. daily as long as taking aspirin. DIET: Cardiac diet. ACTIVITY: As tolerated. Remove sutures on _%#MMDD2007#%_.
EC|enteric-coated|EC|128|129|DISCHARGE MEDICATIONS|2. Nicotine patch 14 mg topical daily for the next 4 weeks. 3. Nicotine gum 2 mg q.4h. p.r.n. for smoking cessation. 4. Aspirin EC 325 mg p.o. daily. 5. Miralax 17 grams p.o. daily. 6. Senna two tablets p.o. t.i.d. p.r.n.
EC|enteric-coated|EC|146|147|DISCHARGE MEDICATIONS|3. Risperdal 1 mg each day at bedtime. 4. Protonix 40 mg a day. 5. Furosemide 20 mg twice daily. 6. Spironolactone 25 mg twice daily. 7. Entocort EC 9 mg every morning. 8. Fentanyl patch 25 mcg every 3 days. 9. Tylenol on a p.r.n. basis. 10. Darvocet 1 q. 4h. p.r.n. pain.
EC|enteric-coated|EC|150|151|DISCHARGE/TRANSFER MEDICATIONS|11. Multiple vitamin with minerals 1 tablet daily. 12. Zofran ODT 4 mg tablets 1 or 2 tablets by mouth q.6 hours p.r.n. nausea/vomiting. 13. Protonix EC 40 mg tablets 1 tablet b.i.d. 14. Senokot-S 1-2 tablets by mouth b.i.d. p.r.n. constipation, hold if loose stools.
EC|enteric-coated|EC|175|176|MEDICATIONS ON ADMISSION|FAMILY HISTORY: Significant for his father who died of heart attack and his mother who is diabetic and grandparents died of colon cancer. MEDICATIONS ON ADMISSION: 1. Aspirin EC 81 mg daily. 2. Glucophage 500 mg b.i.d. 3. Actos 15 mg daily. 4. Geodon 80 mg b.i.d. 5. Zocor 80 mg at bedtime.
EC|enteric-coated|E.C.|160|163|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Bumex 2 mg p.o. b.i.d. 2. Diltiazem ER 180 mg p.o. daily. 3. Lisinopril 2.5 mg p.o. daily. 4. Toprol-XL 100 mg p.o. daily. 5. Aspirin E.C. 162 mg p.o. daily. 6. Potassium chloride 20 mEq p.o. daily. The patient's discharge planning and followup were discussed with the patient who verbalized understanding.
EC|enteric-coated|EC|150|151|DISCHARGE MEDICATIONS|10. NPH insulin 25 units sub cu every night at bedtime. 11. Levothroid 50 mcg p.o. every morning. 12. Klor-Con 20 mcg p.o. every morning. 13. Aspirin EC 325 mg p.o. every morning. 14. Seroquel 25 mg p.o. every night at bedtime. 15. Multivitamin 1 capsule p.o. every morning. 16. Calcium with vitamin D 600 mg p.o. b.i.d.
EC|enteric-coated|EC|193|194|DISCHARGE MEDICATIONS|The patient is to call MD with increased temperatures of 100.5 degrees or greater, any chills, tenderness, redness, or warmth around the incision site. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg EC p.o. q. day. 2. Metoprolol 50 mg p.o. b.i.d. 3. Colace 100 mg p.o. b.i.d. 4. Flomax 0.4 mg p.o. q. day. 5. Magnesium oxide 400 mg p.o. q. day.
EC|enteric-coated|EC|172|173|DISCHARGE MEDICATIONS|10. Atrovent nebulizer 0.5 mg inhaled q.i.d. 11. Meropenem 1g IV every 8 hours x3 weeks. 12. Multivitamin 1 tablet p.o. daily. 13. Prilosec 40 mg p.o. b.i.d. 14. Pancrease EC 7 capsules p.o. with meals, 4 capsules with snacks. 15. Vitamin E 400 units p.o. daily. 16. Coumadin 1 mg p.o. daily.
EC|enteric-coated|EC|129|130|DISCHARGE MEDICATIONS|10. Compazine 5 mg q.6 h. p.r.n. 11. Diphenoxylate and atropine 2 tablets t.i.d. p.r.n. 12. Ditropan XL 5 mg daily. 13. Entocort EC 3 mg tablets, 3 tablets daily. 14. Azathioprine 150 mg daily. 15. Fluoxetine 20 mg daily. 16. Folic acid 1 mg daily.
EC|enteric-coated|EC|197|198|ASSESSMENT AND PLAN|Notes from clinic available on Epic shows that she has chronic complaints of this type of pain. We will consult Dr. _%#NAME#%_ of Gastroenterology to see the patient. We will continue her Entocort EC 3 mg tablets 3 times daily. Nexium for her esophageal reflux disease. 4. Endocrine. For her diabetes mellitus type 2, the patient is unclear of her medications.
EC|enteric-coated|EC|187|188|MEDICATIONS|3. Fluoxetine 40 mg p.o. q. day. 4. Levalbuterol inhaler 1 puff q.8h. p.r.n. 5. Aspirin enteric-coated 81 mg p.o. q. day. 6. Mometasone furoate 220 mcg 2 puffs twice a day. 7. Omeprazole EC 20 mg p.o. q. day. 8. Multivitamin 1 tablet p.o. q. day. 7. Neurontin 300 mg p.o. b.i.d. 8. Nitroglycerin sublingually p.r.n. chest pain.
EC|enteric-coated|E.C.|187|190|MEDICATIONS AT DISCHARGE|5. Compazine 5 mg p.o. q. 6h. p.r.n. for nausea and vomiting. 6. Sudafed PE 10 mg p.o. q. 4h. p.r.n. for congestion. 7. Erythromycin ethylsuccinate solution 250 mg p.o. q. 6h. 8. Aspirin E.C. 325 mg p.o. every other day. 9. Vitamin C 400 mg p.o. daily. 10. Vitamin E 500 mg p.o. daily. 11. Zofran 4-8 mg sublingual q. 8h. p.r.n. for nausea and vomiting.
EC|enteric-coated|EC|185|186|DISCHARGE MEDICATIONS|9. Neurontin 400 mg p.o. b.i.d. 10. Guaifenesin FA 600 mg p.o. q. 12 hours p.r.n. cough. 11. Ativan 0.5 mg p.o. q.i.d. p.r.n. anxiety. 12. Hexavitamin 1 tablet p.o. daily. 13. Protonix EC 40 mg p.o. daily. 14. Seroquel 25 mg p.o. each day at bedtime. 15. Seroquel 12.5 mg p.o. t.i.d. p.r.n. anxiety. 16. Senna 2 tablets p.o. q. 48 hours for constipation.
EC|enteric-coated|EC|149|150|ADMISSION MEDICATIONS|2. Right breast lumpectomy. 3. Double ovarian wedge resection for PCL. 4. Tonsillectomy. ADMISSION MEDICATIONS: 1. Pentasa 250 mg q.i.d. 2. Entocort EC 3 mg q.d. 3. Ranitidine 150 mg b.i.d. 4. Paroxetine 20 mg q.a.m. 5. Glucosamine chondroitin. 6. Arimidex 1 mg q.d.
EC|enteric-coated|EC.|189|191|ASSESSMENT AND PLAN|No evidence of malignancy now. 3. Crohn's disease, stable. The patient is being followed and has had a colonoscopy recently. She will require intraoperative steroids due to use of Entocort EC.
EC|enteric-coated|EC|159|160|HOME MEDICATION|5. History of hiatal hernia. 6. History of DVT 2 years ago. HOME MEDICATION: 1. Asacol 800 mg t.i.d. 2. Benadryl 25-50 mg p.o. q.4 p.r.n. itching. 3. Entocort EC 9 mg q.a.m. 4. Iron 25 mg q.a.m. 5. Lonox 1 tab q.4 p.r.n. diarrhea. 6. Nasonex 50 mcg 2 sprays daily.
EC|enteric-coated|EC|182|183|MEDICATIONS ON DISCHARGE|8. Ondansetron for Zofran 4 mg dissolved tablet by mouth every 6 hours p.r.n. for nausea/vomiting. 9. Zofran 4 mg injection IV every 6 hours p.r.n. for nausea/vomiting. 10. Protonix EC 40 mg tablet by mouth twice a day p.r.n. 11. Ranitidine for Zantac 150 mg tablet by mouth every day. 12. Senna/docusate for Senokot-S 2 tablets by mouth every night at bedtime p.r.n. for constipation.
EC|enterocutaneous|EC|162|163|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 45-year-old female with a history of perforated appendix in 1976 followed by multiple small bowel obstructions and a recent EC fistula takedown on _%#MMDD2007#%_. The patient presented with a three-day history of lower abdominal pain that was exacerbated with walking.
EC|enterocutaneous|EC|136|137|PAST SURGICAL HISTORY|6. Ventral hernia repair in 2000. 7. Bowel obstruction and stricture in 2006. 8. Small bowel resection in 2007 followed by formation of EC fistula. 9. EC fistula takedown in _%#MM2007#%_. Upon admission, the patient was started on ertapenem and Flagyl for possible diverticulitis versus C.
EC|enteric-coated|EC|108|109|MEDICATIONS|8. Lasix 20 mg p.o. q. day. 9. Potassium 10 mEq p.o. q. day. 10. Fenofibrate 50 mg p.o. q. day. 11. Aspirin EC 325 mg p.o. q. day. 12. Plavix 75 mg p.o. q. day. 13. Xanax 0.25 mg p.o. t.i.d. p.r.n. 14. Lipitor 80 mg p.o. q.h.s. 15. Toprol-XL 100 mg p.o. b.i.d. SOCIAL HISTORY: The patient is divorced, he remarried 3 weeks ago.
EC|enteric-coated|EC|132|133|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Protonix AC 20 mg p.o. daily. 2. Trusopt ophthalmic solution 2% one drop in both eyes b.i.d. 3. Bisacodyl EC 10 mg p.o. daily p.r.n. 4. Cardizem 30 mg p.o. q. 6h. 5. Xalatan 0.005% ophthalmic solution 2 drops to both eyes each day at bedtime.
EC|enteric-coated|EC|174|175|DISCHARGE MEDICATIONS|3. Prilosec 20 mg p.o. daily. 4. Seroquel 100 mg p.o. in the morning and 600 mg at bedtime. 5. Clonazepam 0.5 mg p.o. at bedtime. 6. Remeron 15 mg p.o. at bedtime. 7. Asacol EC 800 mg p.o. b.i.d. 8. Imodium 4 mg p.r.n. 9. Magnesium citrate p.r.n. 10. Imuran 100 mg p.o. daily. 11. Cymbalta 60 mg p.o. daily. 12. Detrol-LA 4 mg p.o. daily.
EC|enteric-coated|EC|192|193|DISCHARGE MEDICATIONS|DISCHARGE CONDITION: Fair. DISCHARGE DISPOSITION: Discharge to station 32 north, a lock psychiatry unit at University of Minnesota Medical Center, Fairview. DISCHARGE MEDICATIONS: 1. Depakote EC 500 mg p.o. q.a.m. 2. Depakote EC 1,000 mg p.o. q.h.s. 3. Zantac 150 mg p.o. b.i.d. 4. Psychiatry to restart all other psychiatric medications as they feel appropriate.
EC|enteric-coated|EC|226|227|DISCHARGE MEDICATIONS|DISCHARGE CONDITION: Fair. DISCHARGE DISPOSITION: Discharge to station 32 north, a lock psychiatry unit at University of Minnesota Medical Center, Fairview. DISCHARGE MEDICATIONS: 1. Depakote EC 500 mg p.o. q.a.m. 2. Depakote EC 1,000 mg p.o. q.h.s. 3. Zantac 150 mg p.o. b.i.d. 4. Psychiatry to restart all other psychiatric medications as they feel appropriate.
EC|enteric-coated|EC|130|131|DISCHARGE MEDICATIONS|5. Aldactone 25 mg p.o. daily. 6. Albuterol MDI 90 mcg 2 puffs with spacer 4 times per day. 7. Coreg 3.125 p.o. b.i.d. 8. Aspirin EC 81 mg p.o. q. day. 9. She is also given a small prescription of Tylenol No. 3 30/300 one to two tablet p.o. q6 to 8 h p.r.n. pain.
EC|enteric-coated|EC|142|143|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Verapamil 240 mg 1 tablet every day. 2. Warfarin 5 mg p.o. every day. 3. Cymbalta 60 mg p.o. every day. 4. Depakote EC 1500 mg 3 times a day. 5. Digoxin 0.25 mg every day. 6. Nexium 40 mg p.o. every day. 7. Furosemide 40 mg p.o. every day. 8. Potassium chloride 20 mEq 1 tablet every day.
EC|enteric-coated|EC|185|186|DISCHARGE MEDICATIONS|4. She is also continued on her Vistaril 25 mg to 50 mg p.o. q.4 hours for pain as well. 5. Advair 250/50 one puff b.i.d., rinse mouth after use. 6. Nexium 40 mg p.o. daily. 7. Aspirin EC 81 mg p.o. daily. 8. Spiriva 18 mcg inhaled daily. 9. Singulair, i.e. montelukast 10 mg p.o. daily. 10. Depakote 500 mg p.o. b.i.d. 11. Ultram 50 mg p.o. q.i.d. p.r.n., pain.
EC|enteric-coated|EC|310|311|DISCHARGE MEDICATIONS|7. Otherwise, he may contact his transplant coordinator, _%#NAME#%_ _%#NAME#%_ or _%#NAME#%_ _%#NAME#%_ at _%#TEL#%_ in case of nausea, vomiting, increasing abdominal pain, temperature above 101, or problems with his incision such as increased redness, drainage, or swelling. DISCHARGE MEDICATIONS: 1. Aspirin EC 81 mg p.o. q. day. 2. Mycelex troche 10 mg p.o. q.i.d. 3. Lamivudine 100 mg p.o. q. day. 4. Multivitamins 1 p.o. q. day. 5. CellCept 1000 mg p.o. b.i.d.
EC|enteric-coated|EC|238|239|ADMISSION MEDICATIONS|FAMILY HISTORY: Father has mental status changes, has "heart problems." Mother has hypertension and "type 2 diabetes mellitus." ADMISSION MEDICATIONS: The patient's medications on admission: 1. Lortab 7.5/550 mL p.o. p.r.n. 2. Pangestyme EC 4 tablets p.o. with each meal. 3. Albuterol inhaler 2 puffs p.o. p.r.n. q.4 hours. 4. Synthroid 50 mcg p.o. q. day. 5. Lantus 10 units subcutaneously daily.
EC|enteric-coated|EC|203|204|DISCHARGE MEDICATIONS|1. Xanax 0.5 mg p.o. each day at bedtime. 2. Artificial tears, isopto 0.5% 1-2 drops to both eyes q.12 hours p.r.n. dryness. 3. Astelin one spray to both nostrils b.i.d. p.r.n. for dry nose. 4. Dulcolax EC 5 mg p.o. t.i.d. p.r.n. for constipation. 5. Cyclosporine ophthalmologic drops 0.05% one drop to both eyes daily. 6. Colace 100 mg p.o. b.i.d. 7. Lasix 200 mg p.o. daily.
EC|enteric-coated|EC|445|446|DISCHARGE MEDICATIONS|The patient will be discharged back to Augustana Nursing Home. DISCHARGE MEDICATIONS: Prednisone 50 mg twice a day to be tapered off over the next 8 days, Levaquin 500 mg a day for 5 days, albuterol nebs 2.5 mg 2 mL q.i.d. and q.2h. p.r.n., Norvasc 2.5 mg a day, senna S 2 a day, Ativan 1 mg t.i.d. and at bedtime, Dilantin 200 mg twice a day, Advair Diskus 250/50 mcg 1 puff twice a day, Clozaril 200 mg in morning, 600 mg every p.m., Depakote EC 500 mg in the morning, 1000 mg q.p.m., Haldol 1 mg at bedtime, multivitamins once a day, Os-Cal 500 mg with vitamin D 1 twice a day.
EC|enterocutaneous|EC|195|196|PAST MEDICAL HISTORY|He is also deconditioned significantly. He is now transferred to transition services for wound management, nutritional monitoring, and physical and occupational therapy. PAST MEDICAL HISTORY: 1. EC fistula following multiple bowel surgeries. 2. Surgery _%#MMDD2002#%_ for adenoma of the lower sigmoid colon/rectum. 3. AVM of GI tract, status post cauterization. 4. History of abdominal injury due to shrapnel from World War II.
EC|enteric-coated|EC|196|197|MEDICATIONS|He smokes approximately three packs per day. Denies any recent alcohol use, but states he had previous chemical dependency. MEDICATIONS: 1. Clonazepam, 1 mg p.o. b.i.d. 2. Depakote, 500 mg tablet EC 2 tablets q.a.m. 3. Depakote, 500 mg EC 3 tablets p.o. q.h.s. 4. Dilantin Extended Release, 100 mg capsule 3 capsules p.o. b.i.d.
EC|enteric-coated|EC|236|237|MEDICATIONS|He smokes approximately three packs per day. Denies any recent alcohol use, but states he had previous chemical dependency. MEDICATIONS: 1. Clonazepam, 1 mg p.o. b.i.d. 2. Depakote, 500 mg tablet EC 2 tablets q.a.m. 3. Depakote, 500 mg EC 3 tablets p.o. q.h.s. 4. Dilantin Extended Release, 100 mg capsule 3 capsules p.o. b.i.d. 5. Remeron, 15 mg tablet p.o. q.h.s. 6. Risperdal, 4 mg 2 tablets p.o. q.h.s.
EC|enteric-coated|EC|123|124|MEDICATIONS UPON DISCHARGE|1. Paxil 50 mg p.o. q.d. 2. Decadron 10 mg p.o. q.d. 3. Zantac 150 mg p.o. b.i.d. 4. Colace 100 mg p.o. b.i.d. 5. Depakote EC 500 mg p.o. b.i.d. 6. Xanax 0.5 mg p.o. t.i.d. 7. Vicodin 1-2 tablets p.o. q.6h. p.r.n. 8. Restoril 45 mg p.o. q.h.s. EXAMINATION UPON DISCHARGE: The patient was awake and alert, and her speech was fluent.
EC|enteric-coated|EC|294|295|MEDICATIONS ON DISCHARGE|1. Decadron 4 mg p.o. q.6h. on _%#MM#%_ _%#DD#%_, 2003, 2 mg p.o. q.6h., on _%#MM#%_ _%#DD#%_ and _%#DD#%_, 2003, 2 mg p.o. b.i.d. on _%#MM#%_ _%#DD#%_ and _%#DD#%_, 2003, 2 mg p.o. q.d. on _%#MM#%_ _%#DD#%_ and _%#DD#%_, 2003, and then to discontinue. 2. Zantac 150 mg p.o. b.i.d. 3. Depakote EC 500 mg p.o. b.i.d. 4. Percocet 1-2 tablets p.o. q.6h. p.r.n. DISCHARGE INSTRUCTIONS AND FOLLOW-UP PLAN: 1. The patient will not lift more than 10 pounds for the next six weeks.
EC|UNSURED SENSE|EC|180|181|OPERATIONS/PROCEDURES PERFORMED|Prenatal labs were O positive, antibody screen negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, hemoglobin 11.9, GC and chlamydia both negative, UA EC negative. Pap smear within normal limits. HIV nonreactive, AFP declined. GCT 70 and wet prep negative. Issues this pregnancy include a history of 2 previous cesarean sections.
EC|enterocutaneous|EC|172|173|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 45-year-old female well known to the General Vascular Service was recently discharged on _%#MMDD2007#%_, status post EC fistula takedown. She presents with abdominal pain and drainage from old JP sites, nausea, chills and low-grade fever. She denies vomiting. The patient is admitted for further workup.
EC|enterocutaneous|EC|164|165|PAST SURGICAL HISTORY|6. Cholecystectomy in 2003. 7. Ventral hernia repair in 2000. 8. Bowel obstruction and stricture in 2006. 9. Small bowel resection in 2007 followed by formation of EC fistula. 10. EC fistula takedown in _%#MM2007#%_. HOSPITAL COURSE: The patient was admitted on _%#MMDD2007#%_ with complaint of abdominal pain and increased drainage from her old JP site.
EC|enteric-coated|EC|162|163|MEDICATIONS ON DISCHARGE|2. O&P, which was negative. 3. Colonoscopy with biopsies, which were positive for collagenous colitis. COMPLICATIONS: None. MEDICATIONS ON DISCHARGE: 1. Entocort EC 9 mg p.o. daily x6 weeks. 2. Synthroid 25 mcg p.o. daily. 3. Lisinopril 20 mg p.o. daily. 4. Metoprolol 50 mg p.o. b.i.d. 5. Paxil 10 mg p.o. daily.
EC|enteric-coated|EC|120|121|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Celexa 60 mg p.o. each day at bedtime. 2. Zyprexa 20 mg p.o. each day at bedtime. 3. Depakote EC 500 mg p.o. b.i.d., dose increased. 4. Colace 100 mg p.o. b.i.d. 5. Vistaril 50 mg p.o. each day at bedtime. 6. Prilosec 20 mg p.o. b.i.d. DISPOSITION: The patient is being discharged to Teen Challenge Home.
EC|enteric-coated|EC|136|137|DISCHARGE MEDICATIONS|6. Senokot-S 1 tablet p.o. b.i.d. p.r.n. constipation. 7. Verapamil 360 mg p.o. daily. 8. Percocet 1-2 tablets p.o. q.4h. p.r.n. 9. ASA EC 325 mg p.o. daily to be started on _%#MMDD2007#%_ for 4 weeks. 10. Celebrex 200 mg p.o. daily. HOSPITAL COURSE: Ms. _%#NAME#%_ _%#NAME#%_ is a 54-year-old white female with history of morbid obesity, degenerative joint disease, paroxysmal atrial fibrillation, hypertension and rheumatoid arthritis.
EC|enteric-coated|EC|160|161|MEDICATIONS UPON TRANSFER|8. Hydrocortisone cream 1% applied to affected area t.i.d. 9. Linezolid 600 mg p.o. q. 12 hours. 10. Ativan 0.5-1 mg p.o. q. 4 hours p.r.n. anxiety. 11. Asacol EC 1600 mg p.o. t.i.d. 12. Metoprolol 50 mg p.o. b.i.d. 13. Flagyl 750 mg p.o. q.i.d. 14. Multivitamin 1 tablet p.o. daily. 15. Mycophenolate mofetil 360 mg p.o. b.i.d.
EC|enteric-coated|EC|197|198|DISCHARGE MEDICATIONS|PROBLEM #5: History of DVTs. The patient was on pneumoboots and embolization due to her GI bleeding. DISCHARGE MEDICATIONS: 1. Asacol 800 t.i.d. 2. Benadryl 25-50 as needed for nausea. 3. Entocort EC 9 mg in the morning. 4. Iron 325 mg daily. 5. Nasonex 50 mcg daily. 6. Prevacid 30 mg b.i.d. 7. Tylenol Arthritis 650 mg every 6 hours as needed for pain.
EC|enteric-coated|E.C.|162|165|DISCHARGE MEDICATIONS|2. Aricept 10 mg tablet by mouth every night. 3. Hydrochlorothiazide 12.5 mg capsule by mouth everyday. 4. Pravastatin 20 mg tablet by mouth everyday. 5. Aspirin E.C. 81 mg tablet by mouth everyday. 6. Protonix E.C. 20 mg tablet by mouth everyday. 7. Amaryl (glimepiride) 2 mg tablet by mouth everyday.
EC|enteric-coated|E.C.|165|168|DISCHARGE MEDICATIONS|3. Hydrochlorothiazide 12.5 mg capsule by mouth everyday. 4. Pravastatin 20 mg tablet by mouth everyday. 5. Aspirin E.C. 81 mg tablet by mouth everyday. 6. Protonix E.C. 20 mg tablet by mouth everyday. 7. Amaryl (glimepiride) 2 mg tablet by mouth everyday. DISCHARGE DIAGNOSES: 1. Community-acquired pneumonia. 2. Elevated prostate-specific antigen.
EC|enterocutaneous|EC|153|154|DISCHARGE MEDICATIONS|6. Kefzol 30 mL swish and spit t.i.d. as needed. 7. OxyContin 10 mg b.i.d. 8. Oxycodone 5-10 mg q. 6h. as needed. 9. Protonix 20 mg daily. 10. Bisacodyl EC 5 mg b.i.d. p.r.n. 11. Docusate sodium 100 mg b.i.d. FOLLOWUP: 1. CBC with differential and platelets to be drawn on _%#MMDD2007#%_ and _%#MMDD2007#%_.
EC|enteric-coated|EC|85|86|DOSE CHANGE|4. Avodart 0.5 mg p.o. daily. 5. Foley catheter to Foley bag. DOSE CHANGE 1. Aspirin EC 81 mg daily p.o. (down from 325 mg while on coumadin) CHRONIC MEDICATION: 1. Fosamax 70 mg p.o. daily. 2. Plavix 75 mg p.o. daily.
EC|enterocutaneous|EC|241|242|DISCHARGE INSTRUCTIONS|6. The patient should report to the Emergency Department and/or call _%#TEL#%_ and ask for the general surgery resident on-call should any problems develop. Problems consist of increased pain, increased erythema around the ostomy as well as EC fistula site, increased drainage, increased swelling, elevated temperature greater than 101.5 degrees Fahrenheit or any other concerns. DISCHARGE MEDICATIONS: 1. Vitamin B12 injection 1000 mcg IM every 4 weeks.
EC|enteric-coated|EC|161|162|MEDICATIONS|ALLERGIES: Dilantin, penicillin, Prozac, and Tegretol. MEDICATIONS: 1. Advil. 2. Androderm 10 mg patch q. day. 3. Centrum. 4. Clonazepam 1 mg daily. 5. Depakote EC 500 mg one tablet b.i.d. 6. Paxil 7.5 mg daily. 7. Compazine 10 mg t.i.d. 8. Tylenol. 9. Zelnorm 3 mg q.i.d. SOCIAL HISTORY: Denies tobacco use, reports no alcohol use for greater than 10 years.
EC|enteric-coated|EC|146|147|DISCHARGE MEDICATIONS|9. Anxiety. 10. History of urinary tract infections. 11. Anemia of chronic disease. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. daily. 2. Entocort EC 9 mg p.o. daily. 3. Lexapro 10 mg p.o. daily. 4. Lasix 20 mg p.o. daily. 5. Synthroid 125 mcg p.o. daily. 6. Lisinopril 20 mg p.o. daily.
EC|enteric-coated|EC|161|162|DISCHARGE MEDICATIONS|DISCHARGE DIAGNOSES: 1. Pyelonephritis. 2. Anemia, probable iron deficiency. 3. Depression. DISCHARGE MEDICATIONS: 1. Cymbalta 60 mg p.o. daily. 2. Pantoprazole EC 20 mg p.o. daily. 3. Trazodone 100 mg p.o. each day at bedtime. 4. Augmentin 875/125 p.o. q. 12h. b.i.d. x2 weeks for pyelonephritis.
EC|enteric-coated|E.C.|127|130|DISCHARGE MEDICATIONS|3. Azathioprine 100 mg p.o. each day at bedtime. 4. Rocaltrol 0.5 mg p.o. q. day. 5. Colchicine 0.6 mg p.o. q. day. 6. Aspirin E.C. 81 mg p.o. q. day. 7. Zithromax 250 mg p.o. q. day x1 day. 8. Novolog 4 units subcutaneous t.i.d. with meals.
EC|enteric-coated|EC|126|127|HOME MEDICATIONS|3. Benefiber 1 packet by G-tube 2 times daily. 4. Prevacid 50 mg p.o. b.i.d. 5. MiraLax 17 g G-tube p.o. daily. 6. Pancrecarb EC 1-2 caps p.o. with meals. 7. Cytotec 100 mcg p.o./G-tube twice a day. 8. Mucomyst 30 mL G-tube q. day. (20%). 9. ADEK vitamin 1 mL p.o. G-tube q. day.
EC|enteric-coated|EC|177|178|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Reglan 1.5 mg b.i.d. 2. Benefiber 1 packet through G-tube 2 times a day. 3. Prevacid 50 mg p.o. b.i.d. 4. MiraLax 17 g p.o. twice a day. 5. Pancrecarb EC cap 1-2 caps p.o. with meals. 6. Cytotec 100 mcg p.o. G-tube twice a day. 7. Mucomyst 30 mL G-tube q. day. 8. ADEK 1 mL p.o. G-tube q. day.
EC|enteric-coated|EC|126|127|CURRENT MEDICATIONS|2. Zyrtec 5 mg tablets p.o. daily. 3. Lactobacillus 1 capsule p.o. daily. 4. Prevacid 15 mg packet p.o. daily. 5. Pancreacarb EC capsule. 6. Morphine Sulfate 4 capsules p.o. with meals and formula. 7. Tamiflu 30 mg suspension p.o. b.i.d. to complete a 5-day course.
EC|enteric-coated|EC|156|157||The patient is on antibiotics and so she is going to go to surgery today to get a T-tube drainage and to take her gallbladder out. She has been on Entocort EC for about 4-5 months and before that, was on several short courses of steroids. Before that, she was on several short courses of steroids.
EC|enteric-coated|EC|117|118|DISCHARGE MEDICATIONS|5. Mycelex troche 10 mg p.o. q.i.d. x 6 months. 6. Lopressor 25 mg p.o. b.i.d. 7. Zocor 20 mg p.o. q.h.s. 8. Aspirin EC 81 mg p.o. q.day. 9. Calcium carbonate with vitamin D 500 mg p.o. t.i.d. 10. K-Phos-Neutral 250 mg p.o. t.i.d. x 1 month. 11. Aciphex 20 mg p.o. q.day.
EC|enterocutaneous|EC|169|170|HOSPITAL COURSE|HOSPITAL COURSE: 1. Acute ischemic stroke. The patient symptoms progressively improved over the course of the next five days. He was treated conservatively with aspirin EC 325 mg p.o. q. day. Of concern was prior history of hemorrhagic strokes times two. 2. Hypertension. The patient was hypertension was left untreated for the first 24 hours.
EC|enteric-coated|EC|152|153|DISCHARGE MEDICATIONS|He states that he has all other home medications. DISCHARGE MEDICATIONS: 1. Tylenol Extra Strength p.o. p.r.n. pain. 2. Aspirin 81 mg q.d. 3. Pancrease EC q.d. 4. Ambien 5 mg p.r.n. sleep. HISTORY: Mr. _%#NAME#%_ _%#NAME#%_ is a 71-year-old white male who normally sees Dr. _%#NAME#%_ _%#NAME#%_.
EC|enteric-coated|EC|159|160|DISCHARGE MEDICATIONS|3. Singulair 10 mg q.d. 4. Celexa 60 mg q.d. 5. Amitriptyline 25 mg q.h.s. 6. Levaquin 500 mg q.d. for bronchitis. 7. Guaifenex LA 600 mg b.i.d. 8. Diclofenac EC 75 mg q.d. 9. Zanaflex 4 mg b.i.d. which is new for her. 10. Soma 350 t.i.d. at home. DISCHARGE FOLLOW-UP: Patient will contact Dr. _%#NAME#%_ for further follow-up and will see me in the office at the end of this week or the following week.
EC|enteric-coated|EC|123|124|MEDICATIONS|His discharge medications included: 1. Artificial tears 0.5% p.r.n. dryness. 2. Lacri-Lube for p.r.n. dryness. 3. Dulcolax EC 10 mg by mouth every other day. 4. Dulcolax suppositories twice a week per rectum. 5. Sinemet 25/100 3 tablets by mouth 4 times a day.
EC|enteric-coated|EC|151|152|MEDICATIONS UPON DISCHARGE|DISPOSITION: Discharge to home. MEDICATIONS UPON DISCHARGE: Include the following, 1. Topiramate 25 mg p.o. daily. 2. acetaminophen p.r.n. 3. Entocort EC 3 mg p.o. daily. 4. Vitamin B-12 2000 mg p.o. daily. 5. fluoxetine 20 mg p.o. daily. 6. Fish oil. INSTRUCTIONS: Activity up ad lib. Diet regular.
EC|enteric-coated|EC|197|198|DISCHARGE MEDICATIONS|PROBLEM #5: History of DVTs. The patient was on pneumoboots and embolization due to her GI bleeding. DISCHARGE MEDICATIONS: 1. Asacol 800 t.i.d. 2. Benadryl 25-50 as needed for nausea. 3. Entocort EC 9 mg in the morning. 4. Iron 325 mg daily. 5. Nasonex 50 mcg daily. 6. Prevacid 30 mg b.i.d. 7. Tylenol Arthritis 650 mg every 6 hours as needed for pain.
EC|enteric-coated|EC|129|130|DISCHARGE MEDICATIONS|6. Aleve 2 tablets by mouth twice daily. 7. NovoLog sliding scale as directed. 8. Multivitamin 1 by mouth once daily. 9. Aciphex EC 20 mg by mouth once daily. 10. Simvastatin 80 mg by mouth at bedtime. 11. Aspirin 81 mg by mouth once daily.
EC|enteric-coated|EC|160|161|MEDICATIONS AT DISCHARGE|MEDICATIONS AT DISCHARGE: 1. Warfarin 5 mg daily. 2. Senokot 1 tablet p.o. b.i.d. 3. Amiodarone 400 mg p.o. b.i.d. 4. Metoprolol 37.5 mg b.i.d. 5. Pantoprazole EC 40 mg p.o. b.i.d. 6. Oxycodone 5-10 mg p.o. q. 4 h. p.r.n. for pain. 7. Percocet 1-2 tabs q.4-6 h. p.r.n. 8. Methadone 40 mg p.o. b.i.d. 9. Fentanyl patch, 100-mcg patch q. 72 hours.
EC|enteric-coated|EC,|94|96|DISCHARGE MEDICATIONS|His hemoglobin was stable at the time of discharge at 10.8. DISCHARGE MEDICATIONS: 1. Aspirin EC, 81 mg p.o. daily. 2. Clopidogrel, 75 mg daily. 3. Lisinopril, 5 mg daily. 4. Metoprolol XL, 50 mg daily. 5. Zocor, 40 mg daily. DIET: Cardiac diet. ACTIVITY: Standard post-MI restrictions.
EC|enteric-coated|EC|129|130|CURRENT MEDICATIONS|8. Herpes zoster in _%#MM#%_ 2002. CURRENT MEDICATIONS: Include 1. Folic acid 1 mg per day 2. Aspirin 81 mg per day 3. Pancrease EC 4500 MU 10 capsules Q day ALLERGIES: Penicillin causes edema, otherwise no other allergies SOCIAL HISTORY: He is married and lives independently.
EC|enteric-coated|EC|256|257|PAST MEDICAL HISTORY|He has also had two previous lumbar spine surgeries. I believe they were laminectomies, one at the level of L3-4 and one at the level of L5-S1, he believes. Medications include sulfasalazine 500 mg p.o. b.i.d., potassium chloride 20 mEq p.o. b.i.d., Zocor EC 9 mg p.o. q. d., Celebrex 100 mg p.o. b.i.d., Aciphex 20 mg p.o. q. d, and prednisone 5 mg p.o. q. d. NO KNOWN DRUG ALLERGIES.
EC|enterocutaneous|EC|127|128|SOCIAL HISTORY|Otherwise negative. She was afebrile and her vital signs were stable upon admission and her exam revealed above wounds and the EC fistula. HOSPITAL COURSE: After informed consent was obtained, she was taken to the OR for above procedure and she tolerated the procedure well.
EC|enteric-coated|EC|162|163|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Norvasc 10 mg daily. 2. Vitamin C 1000 mg daily. 3. Cogentin 1 mg twice a day. 4. Dulcolax 10 mg daily suppository rectally 5. Depakote EC 500 mg twice a day 6. Colace 100 mg twice a day. 7. Prolixin 4 mg every night and 2 mg every morning
EC|enterocutaneous|EC|190|191|HOSPITAL COURSE|Her enterocutaneous fistula output was controlled with an applier and a consult was placed to refer Dr. _%#NAME#%_ _%#NAME#%_ to see and evaluate Ms. _%#NAME#%_ for future management of her EC fistula. He suggested TPN n.p.o. with the exception of 2 popsicles per shift and possible surgery in _%#MM#%_ or _%#MM#%_. The next few days, Ms. _%#NAME#%_ was in the hospital was finding placement ultimately decided did agree to accept her.
EC|epirubicin|(EC|132|134|PAST MEDICAL HISTORY|Status post left sided radiation and mastectomy at 4 out of 12 lymph nodes positive. At that time she was treated with chemotherapy (EC plus Taxol). Lung metastasis was diagnosed in _%#MM#%_ of 2001 with pulmonary nodules seen on follow up computed tomography. The patient has had lung and mediastinal metastases diagnosed in _%#MM#%_ of 2002.
EC|enteric-coated|EC|190|191|DISCHARGE MEDICATIONS|3. Fluconazole 400 mg p.o. q.d. This dose can be decreased to 100 mg p.o. q.d. on _%#MMDD2002#%_ for prophylaxis. 4. Keletra three tablets p.o. b.i.d. 5. Tenofivir 200 mg p.o. q.d. 6. Videx EC 200 mg p.o. q.d. 7. Zithromax 1250 mg p.o. Monday for MAI prophylaxis. 8. Albuterol MDI two puffs inhaled b.i.d. 9. Azmacort MDI two puffs inhaled b.i.d.
EC|enteric-coated|EC,|123|125|PAST MEDICAL HISTORY|Please see the discharge summary dated _%#MMDD2002#%_ for more details. PAST MEDICAL HISTORY: 1. AIDS x 15 years. On Videx EC, Kaletra, and tenofivir. His last CD4 count on _%#MMDD2002#%_ was 4, and viral load was 111,433. 2. Disseminated Kaposi's sarcoma, on cyclical chemotherapy with Dr. _%#NAME#%_.
EC|enteric-coated|EC|234|235|CURRENT MEDICATIONS|ALLERGIES: She has severe drug allergies to amoxicillin, penicillin, sulfa, abacavir, nevirapine, Reglan, and anaphylactic reactions to ceftriaxone. She is also allergic to Cipro. CURRENT MEDICATIONS: 1. Viread 300 mg a day. 2. Videx EC 400 mg daily, once. 3. Kaletra 5 mg b.i.d. through gastrostomy. 4. Epivir 150 mg twice a day orally. 5. Nepron (??) for Pneumocystis prophylaxis 750 mg twice a day through gastrostomy.
EC|enteric-coated|EC|116|117|MEDICATIONS|2. Premarin 0.9 mg, one p.o. daily. 3. Prinivil 10 mg one p.o. daily. 4. Prilosec 20 mg one p.o. daily. 5. Entocort EC 3 mg three tablets p.o. daily. 6. Aspirin and NSAID therapy, none in the past 10 days. PERTINENT PAST HISTORY: The patient has had a hysterectomy and bladder repair in 1975, cholecystectomy in 1968, breast biopsy which was benign in 1986, bilateral ankle arthrodesis in 1996, right ankle arthrodesis with plate screw in 1998.
EC|enteric-coated|EC|270|271|ALLERGIES|MRCP showed no evidence of common bile duct obstruction or gallstone. Bilirubin decreased to 4.5 on discharge. DISCHARGE MEDICATIONS: Esctialopram 20 mg p.o. daily, ferrous sulfate 325 mg p.o. t.i.d., propranolol 10 mg p.o. b.i.d., niacin 50 mg p.o. daily, pantoprazole EC 40 mg p.o. daily, phytonadione 10 mg p.o. daily, pyridoxine 50 mg p.o. daily, spironolactone 25 mg p.o. b.i.d., thiamine 100 mg p.o. daily.
EC|enteric-coated|EC|157|158|TRANSFERRING MEDICATIONS|9. Lopressor 25 mg p.o. b.i.d. 10. Multivitamin 1 tablet p.o. daily. 11. Zantac 150 mg p.o. daily. 12. Percocet 1 tablet p.o. q.4-6 h. p.r.n. 13. Didanosine EC 200 mg 200 mg daily. 14. Vancomycin 800 mg IV q.12 h., last dose on p.m. of _%#MMDD2005#%_. 15. Milk of Magnesia 30 mL p.o. q.6 h. p.r.n. ALLERGIES: No known drug allergies.
EC|enteric-coated|EC|173|174|MEDICATIONS|FAMILY HISTORY: Mother died at 96 of complications from hip surgery. Father died at age 81 from Paget's disease. MEDICATIONS: Amiodarone 200 mg q.d., lisinopril 10 mg q.d., EC ASA 325 mg q.d., Hytrin 5 mg q.d. SOCIAL HISTORY: Tobacco: The patient recently resumed smoking again.
EC|enteric-coated|EC|255|256|ASSESSMENT|She will therefore resume her usual dose of Coumadin which she has been taking for paroxysmal atrial fibrillation as well as her dose of Rythmol. All of her other medications will also remain the same; Ziac, Zocor, Premarin. She was due to start Entocort EC for his colitis and that is also fine to resume. She will follow-up with her usual Quello doctor until if any issue should arise.
EC|enterocutaneous|EC|209|210|PAST MEDICAL HISTORY|The patient was admitted for an infectious work up. The patient had three prior episodes of Lyme sepsis previously with similar presentations. PAST MEDICAL HISTORY: 1. Arterial venous malformation adenoma. 2. EC fistula. 3. Small bowel obstruction. 4. Hypertension. 5. Anemia. 6. Short bowel syndrome. PAST SURGICAL HISTORY: Rectosigmoid resection in _%#MM#%_ of 2002. Exploratory laparotomy and EC fistula takedown in _%#MM#%_ of 2002.
EC|enterocutaneous|EC|175|176|PAST SURGICAL HISTORY|3. Small bowel obstruction. 4. Hypertension. 5. Anemia. 6. Short bowel syndrome. PAST SURGICAL HISTORY: Rectosigmoid resection in _%#MM#%_ of 2002. Exploratory laparotomy and EC fistula takedown in _%#MM#%_ of 2002. MEDICATIONS ON ADMISSION: Metamucil, Imodium, calamine and TPN. ALLERGIES: No known drug allergies.
EC|enterocutaneous|EC|173|174|PHYSICAL EXAMINATION|Normal S1, S2. ABDOMEN: Soft, non-tender, non-distended, hypoactive bowel sounds, no guarding or rebound tenderness. There are well-healed incisions. No hepatosplenomegaly. EC fistula pouch was intact. EXTREMITIES: No cyanosis, clubbing, or edema. NEUROLOGICALLY: The patient was intact, examination was non-focal. The patient had a normal white blood cell count on admission.
EC|enteric-coated|EC|93|94|DISCHARGE MEDICATIONS|DISPOSITION: The patient was discharged to the group home. DISCHARGE MEDICATIONS: 1. Aspirin EC tablet. 2. Bacitracin and zinc topical ointment. 3. Wellbutrin SR 150 mg tablet q.p.m. 4. Multivitamin tablet. 5. Nitrofurantoin 50 mg tablet q.a.m. 6. Ditropan 5 mg b.i.d. FOLLOW-UP: The patient will be seen in follow-up in two to three weeks with _%#NAME#%_ in the office, and with Dr. _%#NAME#%_ in six to eight weeks.
EC|enteric-coated|EC|94|95|DISCHARGE MEDICATIONS|4. Paracystic atrial fibrillation. 5. Essential thrombocytosis. DISCHARGE MEDICATIONS: 1. ASA EC 81 mg p.o. q.d. 2. Hydrochlorothiazide 25 mg p.o. q.d. 3. Hydroxyurea 1000 mg p.o. q.d. 4. Ocean nasal spray one to two sprays nasal t.i.d.
EC|enteric-coated|EC|125|126|MEDICATIONS|14. Lipitor 10 mg q hs. 15. Albuterol inhaler 90 mcg 2 puffs q.i.d. 16. Allegra 180 mg qd. 17. Aricept 10 mg qd. 18. Aspirin EC 81 mg qd. 19. Azmacort 100 mcg inhaler 2 puffs b.i.d. OBJECTIVE: GENERAL: He is alert and in no distress at the present time.
EC|enteric-coated|EC,|158|160|ALLERGIES|6. Iron, 150 mg p.o. b.i.d. 7. B12 shots monthly. 8. Calcium, 500 mg, 3 tabs p.o. daily. 9. Imodium p.r.n. 10. Mercaptopurine, 50 mg p.o. daily. 11. Entocort EC, 9 mg p.o. daily. 12. Loperamide, 4 mg p.o. b.i.d. 13. Folic acid, 1 mg p.o. daily. 14. Avalide 150/12.5, 1 p.o. daily. 15. ________ multivitamin, 1 p.o. daily.
EC|enteric-coated|EC|143|144|DISCHARGE MEDICATIONS|8. Spironolactone 25 mg daily. 9. Tylenol 250 mg q.4 h. p.r.n. 10. Ergocalciferol 50,000 units p.o. every other day x3 doses. 11. Pantoprazole EC 20 mg p.o. b.i.d. 12. Lasix 40 mg q.a.m., 20 mg q.p.m. daily. 13. Metformin 500 mg p.o. b.i.d.
EC|enteric-coated|EC|157|158|DISCHARGE MEDICATIONS|4. Chlorhexidine 0.12%, 5 mL swish and spit t.i.d. 5. Lidoderm patch 5% one to three patches topically daily. Must be off for at least 12 hours. 6. Protonix EC 40 mg p.o. daily. 7. Claritin 10 mg p.o. daily. 8. Lasix 20 mg p.o. b.i.d. 9. K-Dur 20 mg b.i.d. 10. Detrol LA 2 mg p.o. daily. 11. OxyContin 40 mg p.o. t.i.d.
EC|enteric-coated|EC|161|162|DISCHARGE MEDICATIONS|On _%#MM#%_ _%#DD#%_, 2005, he showed increasing alertness. He was able to take the evening medication dose and did eat well. DISCHARGE MEDICATIONS: 1. Depakote EC 500 mg once daily. 2. Topamax 200 mg p.o. b.i.d. 3. Cortef 5 mg p.o. b.i.d. 4. Florinef 0.1 mg p.o. once daily. 5. Guanfacine 1mg p.o. b.i.d.
EC|enteric-coated|EC,|157|159|LONG TERM PLAN|LONG TERM PLAN: 1. Transition to once daily medication. This will include in a step wise fashion maintaining his stability with seizure control. 2. Depakote EC, transition of Topamax if needed from b.i.d.to Zonegran once daily medication. 3. Transition of Risperdal from t.i.d. medication to once daily neuroleptic if needed.
EC|enteric-coated|EC|135|136|DISCHARGE MEDICATIONS|3) Calcium carbonate one tablet twice a day. 4) Feosol 325 mg daily. 5) Nexium 20 mg daily. 6) Flovent 220 two puffs t.i.d. 7) Aspirin EC 81 mg daily. 8) Dipyridamole 75 mg daily. 9) Singulair 10 mg at bedtime. 10) Quinine sulfate 325 mg at bedtime. 11) Lasix 40 mg once daily.
EC|enteric-coated|EC|116|117|OUTPATIENT MEDICATIONS|14. Ativan 0.5 mg one-half tablet daily p.r.n. anxiety. 15. Septra DS one tablet b.i.d. x 7 days. 16. Asacol 400 mg EC one tablet p.o. b.i.d. 17. Calcium acetate one tablet daily. 18. Sinemet 25/100 two tablets p.o. t.i.d. ALLERGIES: Codeine.
EC|enteric-coated|EC|234|235|DISCHARGE MEDICATIONS|Dr. _%#NAME#%_ also saw the patient during the hospitalization. CONDITION AT TIME OF DISCHARGE: Good. DISCHARGE MEDICATIONS: Prednisone 20 mg a day, Pentasa 250 mg q.i.d., Purinethol 6-MP 50 mg three tablets one time a day, Entocort- EC 9 mg each day and Flagyl 500 mg three times a day. PLAN: He will follow up with Dr. _%#NAME#%_ in two weeks.
EC|enteric-coated|EC|252|253|DISCHARGE MEDICATIONS|His hospital course was uneventful, and he was discharged, ambulating and tolerating p.o. intake, on _%#MMDD2003#%_, with instructions to follow-up with the Surgery Center. DISCHARGE MEDICATIONS: 1. Trazodone 50 mg two tablets p.o. q.h.s. 2. Pancrease EC three caps q.a.c. 3. Zetia 10 mg p.o. daily. 4. Avandia 8 mg p.o. q.a.m. 5. Paxil 40 mg p.o. daily. 6. Lithium 300 mg p.o. q.a.m. 7. Atenolol/chlorthalidone 50/25 mg p.o. q.a.m.
EC|extensor carpi|EC|149|150|PHYSICAL EXAMINATION|No acute distress. HEENT: Normocephalic and atraumatic. LUNGS: Clear. HEART: Regular rate and rhythm. RIGHT UPPER EXTREMITY: Reveals snapping of his EC tendon over the ulnar sheath. It is aggravated by wrist flexion and rotation. There is visible snapping of the EC as it slides over.
EC|extensor carpi|EC|113|114|PLAN|He did have an MRI which does demonstrate some swelling in that sheath but no sign of any TICC tear. PLAN: Do an EC sheath repair and it is being scheduled for _%#MMDD2004#%_ under Bier block anesthetic.
EC|enteric-coated|EC|185|186|DIAGNOSTIC STUDIES|She will also continue on Baclofen 10 mg q.i.d., BuSpar 10 mg q.i.d., Neurontin 300 mg t.i.d., and 600 mg at bedtime, Oxybutynin 10 mg XL, Ondansetron 4 mg q. 4 h. p.r.n., Pantoprazole EC 40 mg q. day. As mentioned previously, she was started on Glyburide 5 mg p.o. b.i.d. which she given a strip for and will continue this while she is on the Medrol taper.
EC|enteric-coated|EC|239|240|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Coumadin. This dose will vary today and will be monitored by the HealthPartners _%#CITY#%_ Community Clinic. 2. Bactrim SS 1 tablet twice weekly every Monday and Thursday. 3. Valcyte 450 mg p.o. daily. 4. Aspirin EC 81 mg daily. 5. Procrit 5000 units subcu three times weekly, Tuesday, Thursday and Saturday. 6. Zoloft 150 mg daily. 7. Protonix 40 mg p.o. daily.
EC|enteric-coated|EC|264|265|DISCHARGE PLANS|DISCHARGE PLANS: The patient can return home at this time on a high fiber, adequate fluid intake diet along with other diet measures that she typically uses. Her medications will include Lipitor 10 mg p.o. q.h.s., Anusol HC cream 1% ointment p.r.n. q.h.s., Asacol EC 800 mg p.o. t.i.d., Corgard 20 mg p.o. q.h.s., Pamelor 75 mg p.o. q.h.s., Nexium 20 mg p.o. q. day, Imitrex 50 mg p.o. p.r.n. migraine, Zomig nasal spray p.r.n.
EC|enteric-coated|EC|316|317|DISCHARGE MEDICATIONS|She is to resume her usual outpatient regimen with careful monitoring of her cell counts, given the fact that she is on Clozaril. DISCHARGE MEDICATIONS: Colace 100 mg p.o. b.i.d., Protonix 40 mg p.o. q day, Naltrexone 50 mg p.o. b.i.d., Clozaril 50 mg p.o. q.A.M., 100 mg p.o. noon, and 200 mg p.o. q.h.s., Depakote EC (not ER) 750 mg p.o. t.i.d., Cogentin one tablet p.o. b.i.d., Effexor XR 225 mg p.o. q day, Celexa 40 mg p.o. q day. I did note that she was on Nexium and Protonix and recommended discontinuing the Nexium.
EC|enteric-coated|EC|148|149|DISCHARGE MEDICATIONS|Finally, a dobutamine stress echo was done with no remarkable findings of ischemia. PENDING STUDIES AND LABS: None. DISCHARGE MEDICATIONS: 1. Videx EC 400 mg p.o. once a day. 2. Sustiva 600 mg p.o. once a day. 3. Hydrochlorothiazide 25 mg p.o. once a day.
EC|enteric-coated|EC|130|131|OPERATIONS/PROCEDURES PERFORMED|DISCHARGE MEDICATIONS: 1. Clindamycin 600 mg p.o. t.i.d. 2. Ceftazidime 2 g IV q.8 h. 3. Tobramycin 180 mg IV q.12 h. 4. Creon 10 EC 6 to 7 capsules with meals. 5. Creon 10 EC 3 to 4 capsules with snacks. 6. Albuterol nebulizer q.i.d. 7. Mucomyst nebulizer q.i.d., 20% solution.
EC|enteric-coated|EC|173|174|OPERATIONS/PROCEDURES PERFORMED|DISCHARGE MEDICATIONS: 1. Clindamycin 600 mg p.o. t.i.d. 2. Ceftazidime 2 g IV q.8 h. 3. Tobramycin 180 mg IV q.12 h. 4. Creon 10 EC 6 to 7 capsules with meals. 5. Creon 10 EC 3 to 4 capsules with snacks. 6. Albuterol nebulizer q.i.d. 7. Mucomyst nebulizer q.i.d., 20% solution. 8. Cromolyn nebulizer q.i.d. 9. MiraLax 17 g in 8 ounces of water p.o. q. day.
EC|enteric-coated|EC,|149|151|PRIMARY ONCOLOGIST|DISCHARGE MEDICATIONS: The patient was discharged with instructions to resume her previous medications. These include trazodone, OxyContin, Entocort EC, Aciphex, Atacand, metoclopramide, sodium bicarbonate, multivitamin, Asacol, Lipitor, folic acid, aspirin, vitamin E, acidophilus, Extra Strength Tylenol, loratadine, Lutein, Refresh Tears, nitroglycerin, Depo-Provera, Imuran, Lantus and NovoLog Insulin, Diflucan, Azelex, Combivent inhaler, B complex vitamin, and super cranberry fruit.
EC|enteric-coated|EC|204|205|CURRENT MEDICATIONS|16. Clean inner cannula of trach b.i.d. as directed. 17. Oxygen 3 L while awake, 5 L while asleep, hooked up to humidifier and compressor with temperature between 30 and 30 degrees C. 18. Ferrous sulfate EC 325 mg b.i.d. 19. Avelox 400 mg each day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives in a group home.
EC|enteric-coated|EC|192|193|REVISED DISCHARGE MEDICATIONS LIST|4. Levaquin 500 mg p.o. daily x10 days. 5. Nicotine patch 21 mg per 24 hours; patch on 24 hours x2 days at 14 mg daily x2 weeks. Will follow up per patient's primary care physician. 6. Asacol EC 400 mg p.o. q. 6 hours. 7. Multivitamin 1 tablet p.o. daily. 8. Protonix 40 mg p.o. daily. 9. Prednisone 8 mg p.o. q. a.m. 10. Trazodone 25 mg p.o. q. h.s.
EC|enteric-coated|EC|126|127|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Synthroid 25 mcg p.o. q.day. 2. Lipitor 20 mg p.o. q.h.s. 3. Seroquel 25 mg p.o. q.a.m. 4. Depakote EC 125 mg p.o. q.p.m. 5. Aricept 10 mg p.o. q.day. 6. Dilantin 300 mg p.o. q.h.s. 7. Tylenol 650 mg p.o. q.6h. p.r.n. 8. Ferrous sulfate 325 mg p.o. b.i.d.
EC|enteric-coated|EC|150|151|MEDICATIONS|MEDICATIONS: 1. Septra-DS one b.i.d. for five days, then q. day prophylaxis 2. Effexor XR 37.5 mg q. day. 3. Ferrous gluconate 325 q. day 3. Entocort EC 9 mg a day4. 5. Gabapentin 300 mg b.i.d. 6. Cholestyramine 4 mg q. day. 7. Prilosec 20 mg b.i.d. x3 months and then 1 p.o. q. day.
EC|enteric-coated|EC|96|97|DISCHARGE MEDICATIONS|4. Omeprazole 20 mg p.o. twice daily for prophylaxis while he remains on prednisone. 5. Aspirin EC 25 mg p.o. each day. 6. Acyclovir 400 mg p.o. three times per day. 7. Mycelex troche 10 mg p.o. 4 times per day.
EC|enteric-coated|EC|134|135|DISCHARGE MEDICATIONS|2. Neupogen 480 mcg subcutaneously q. day. 3. Bactrim double strength 1 tablet p.o. q. day. 4. Protonix 40 mg p.o. b.i.d. 5. Depakote EC 500 mg 5 times per day. 6. Multivitamin 1 tablet p.o. daily. 7. Decadron 0.5 mg p.o. t.i.d. 8. Nystatin swish and swallow p.o. b.i.d. 9. Zofran 12 mg p.o. q.8 hours p.r.n. nausea.
EC|enteric-coated|EC|120|121|MEDICATIONS|ALLERGIES: No known drug allergies. MEDICATIONS: 1. Aspirin 81 mg p.o. daily. 2. Calcium 500 mg p.o. t.i.d. 3. Entocort EC 3 caps p.o. daily. 4. FiberLax 1250 mg p.o. daily. 5. furosemide 40 mg daily. 6. Glipizide ER 10 mg p.o. daily. 7. Lipitor 10 mg p.o. daily.
EC|enteric-coated|EC|190|191|DISCHARGE MEDICATIONS|8. Hypertension: She is currently on diltiazem and lisinopril with good blood pressure control. ALLERGIES: Carboplatin. DISCHARGE MEDICATIONS: 1. Diltiazem ER 480 mg p.o. daily. 2. Depakote EC 250 mg p.o. b.i.d. 3. Colace 100 mg p.o. b.i.d. 4. Lidocaine 5% patch 1-2 patches daily with patch free period of at least 12 hours to avoid toxicity.
EC|enteric-coated|EC|126|127|MEDICATIONS|4. Laparotomy for adhesions in 1999. 5. Left inguinal hernia repair. MEDICATIONS: Tylenol 1000 mg three times a day, Entocort EC 3 mg 3 tablets daily, Synthroid 0.025 mg daily, Senna S 1 a day, Ativan 0.5 mg q. 12 hours p.r.n. anxiety. ALLERGIES: Histamines, Lomotil and Cipro. TRANSFUSION HISTORY: None.
EC|enteric-coated|EC|125|126|DISCHARGE MEDICATIONS|3. Urinary tract infection. CONSULTS: None. PROCEDURES: EKG. DISCHARGE MEDICATIONS: 1. Atenolol 25 mg p.o. b.i.d. 2. Aspirin EC 81 mg p.o. daily. 3. Multivitamin 1 p.o. daily. 4. Cardizem 240 mg p.o. daily. 5. Maxzide 37.5/25 1 tablet p.o. daily. 6. Flovent 2 puffs b.i.d.
EC|enteric-coated|EC|279|280|DISCHARGE MEDICATIONS|The patient did understand the plan. It was decided that his Depakote ER would be changed to 250 mg p.o. q.a.m. and 500 mg p.o. q.p.m. An ammonia level was checked, and it was within normal limits. The hospital course has been stated as above. DISCHARGE MEDICATIONS: 1. Depakote EC 250 mg p.o. q.a.m. and 500 mg p.o. q.p.m. 2. Trileptal 300 mg 2 tablets p.o. q. day. 3. Lexapro 20 mg p.o. q. day.
EC|enteric-coated|EC|200|201|DISCHARGE MEDICATIONS|4. Atrovent 0.5-mg nebulizer 4 times a day. 5. Pulmozyme 2.5-mg nebulizer daily. 6. Colimycin M nebulizer 150 mg twice a day x28 days, then 28 days off alternating with TOBI nebulizers. 7. Pancrecarb EC MS 8 to 9 capsules with meals and 4 to 5 capsules with snacks. 8. Vitamin E 100 units daily. 9. Vitamin K 5-mg tablets q. Sunday.
EC|enteric-coated|EC|183|184|PROCEDURE DURING HOSPITAL COURSE|Otherwise, he will receive home care to assess for his incision, hydration, and nutrition status as well as lab work. DISCHARGE MEDICATIONS: 1. Adefovir 10 mg p.o. q. day. 2. Aspirin EC 81 mg p.o. q. day. 3. Mycelex troche 10 mg p.o. q.i.d. 4. Senna-S 1 to 2 tablets p.o. q. day while on narcotics to be held for loose stools.
EC|enteric-coated|EC|175|176|DISCHARGE MEDICATIONS|5. Celebrex 100 mg p.o. b.i.d. 6. Colace 100 mg p.o. b.i.d. 7. Lidoderm patch 5% patch on 12 hours and off 12 hours. 8. Nasonex 50-mcg spray daily in the morning. 9. Protonix EC 40 mg p.o. daily. 10. Synacort-S 2 tablets p.o. at bedtime. 11. Timoptic 1 drop daily. 12. Vitamin E 400 units p.o. daily.
EC|enteric-coated|EC|146|147|DISCHARGE MEDICATIONS|2. Colace 200 mg 1 tab p.o. q.h.s. 3. Provigil 200 mg 1 tab p.o. b.i.d. 4. Fish oil 1000 mg p.o. b.i.d. 5. Toprol XL 50 mg p.o. daily. 6. Aspirin EC 325 mg p.o. daily. 7. Quinine 260 mg p.o. q.h.s. 8. Ibuprofen 800 mg p.o. q.a.m. and 600 mg p.o. q.p.m. p.r.n.
EC|enteric-coated|EC|154|155|DISCHARGE MEDICATIONS|The patient's Depakote acid level on 500 mg p.o. b.i.d. was 79 and repeat on _%#MMDD2008#%_ was low therapeutic at 43. DISCHARGE MEDICATIONS: 1. Depakote EC 500 mg p.o. b.i.d. 2. Neurontin 800 mg p.o. q.i.d. 3. Zyprexa 35 mg p.o. each day at bedtime. 4. Aspirin 325 mg p.o. b.i.d. p.r.n. pain. 5. Macrodantin 25 mg p.o. each day at bedtime.
EC|enteric-coated|EC|131|132|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1) Aspirin 81 mg daily. 2) Plavix 75 mg daily. 3) Atenolol 25 mg daily. 4) Lipitor 40 mg q h.s. 5) Protonix EC 40 mg daily. 6) Senna two tabs h.s., hold if diarrhea. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 63-year-old woman who presented to the Emergency Department on the morning of _%#MM#%_ _%#DD#%_ within an hour of developing right-sided weakness and total inability to speak.
EC|enteric-coated|EC|199|200|DISCHARGE MEDICATIONS|She is quite claustrophobic and intolerant of that, but given the degree of pain that she is having and the lack of narcotics because of this she may consider CPAP. DISCHARGE MEDICATIONS: 1. Aspirin EC 81 mg daily. 2. Coreg 6.25 mg p.o. b.i.d. 3. Furosemide 80 mg p.o. b.i.d. at 5 a.m. and noon. 4. Lisinopril 20 mg p.o. daily. 5. K-Dur 10 mEq p.o. t.i.d.
EC|enteric-coated|EC|112|113|DISCHARGE MEDICATIONS|She is also ordered home physical therapy to continue her cardiac rehabilitation. DISCHARGE MEDICATIONS: 1. ASA EC 325 mg. 2. Coreg 3.125 mg mg b.i.d. 3. Colace 100 mg p.o. b.i.d. 4. Lasix 60 mg p.o. b.i.d. 5. Imdur 60 mg p.o. q. day. 6. Lisinopril 5 mg p.o. b.i.d.
EC|enteric-coated|EC|381|382|HISTORY OF PRESENT ILLNESS|This is a similar case this time. It appears that she does not take her MiraLax or lactulose when she is at home, and so we will try to manage her outpatient with Zelnorm 6 mg p.o. b.i.d. For the remainder of details of this admission, please see my admission history and physical dated _%#MM#%_ _%#DD#%_, 2006. DISCHARGE MEDICATIONS: 1. Clonazepam 0.5 mg p.o. q. day. 2. Depakote EC 500 mg 2 tablets nightly. 3. Colace 100 mg p.o. b.i.d. 4. Effexor XR 75 mg tablets, 3 tablets daily. 5. Protonix 40 mg p.o. daily.
EC|enteric-coated|EC|162|163|DISCHARGE MEDICATIONS|8. Nicotine patch 14 mg q.24h., apply daily. 9. Zofran 4 mg IV q.6h. p.r.n. for nausea, or Zofran ODT 4 mg under the tongue q.6h. p.r.n. nausea. 10. Pantoprazole EC 40 mg by mouth daily. 11. Senokot-S 2 tablets twice daily. 12. Simvastatin 80 mg every evening. 13. Desyrel 25 mg p.r.n. at bedtime for insomnia.
EC|enteric-coated|EC|172|173|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Aspirin 81 mg p.o. daily, ferrous sulfate 100 mg p.o. daily, Asacol 400 mg p.o. t.i.d., Protonix 40 mg p.o. daily, Zocor 10 mg p.o. q.h.s., Entocort EC 6 mg p.o. daily, Actonel 35 mg p.o. q. week, calcium plus vitamin D 2 times p.o. b.i.d., Centrum 1 tablet p.o. daily, vitamin E 400 international units p.o. daily, vitamin B12 500 mcg p.o. daily, Lutein 20 mg p.o. daily and vitamin C 1000 mg p.o. daily.
EC|enteric-coated|EC|161|162|DISCHARGE MEDICATIONS|The patient is to follow up with the cardiologist. The patient is to follow up with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2005. DISCHARGE MEDICATIONS: 1. Aspirin EC 325 mg p.o. q. day. 2. Mycelex Troche 1 tablet p.o. q.i.d. 3. Colace 100 mg p.o. b.i.d. 4. Ferrous sulfate 325 mg p.o. b.i.d. 5. Glyburide 2.5 mg p.o. q. day.
EC|enteric-coated|EC|116|117|DISCHARGE MEDICATIONS|DISCHARGE DIAGNOSES: 1. Seizure disorder. 2. History of glioblastoma multiforme. DISCHARGE MEDICATIONS: 1. Depakote EC 1000 mg p.o. at 8 a.m., 500 mg at 4:30 p.m., 1000 mg at 10 p.m. 2. Keppra 1000 mg p.o. b.i.d. 3. Diazepam Intensol 2 mL p.o. at onset of seizure aura.
EC|enteric-coated|EC|174|175|DISCHARGE MEDICATIONS|2. Metamucil 1 tablespoon liquid daily. 3. Vitamin B12 1000 mcg IM 1 time q. month. 4. Acetaminophen 625 mg p.o. q.4 h. p.r.n. pain, fever. 5. Amlodipine 5 mg p.o. q.p.m. 6. EC ASA 81 mg p.o. daily. 7. Clopidogrel 75 mg p.o. daily. 8. Lasix 40 mg p.o. daily. 9. Metoprolol 25 mg p.o. b.i.d. 10. Ranitidine 150 mg p.o. b.i.d.
EC|enteric-coated|EC|123|124|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Lasix 20 mg b.i.d. 2. CsA 50 mg b.i.d. 3. Synthroid 100 mcg daily. 4. Plavix 75 mg daily. 5. ASA EC 325 mg daily. 6. Pravachol 10 mg p.o. daily. 7. Protonix 20 mg p.o. b.i.d. 8. Neulasta subcutaneous q. week. 9. Fluconazole 100 mg p.o. daily until _%#MM#%_ _%#DD#%_, 2006.
EC|enteric-coated|EC|169|170|DISCHARGE MEDICATIONS|15. Lipitor 10 mg p.o. q.day. 16. Clobetasol ointment b.i.d. to lower extremities. 17. Calcium carbonate 1 tablet p.o. b.i.d. 18. Plavix 75 mg p.o. q. day. 19. Entocort EC 3 tablets p.o. q. day. 20. Fexofenadine 180 mg p.o. q. day. 21. Folic acid 1 mg p.o. q. day. 22. Gabapentin 600 mg p.o. t.i.d. 23. Isosorbide mononitrate 30 mg p.o. b.i.d.
EC|enteric-coated|EC|162|163|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Os-Cal with vitamin D 1 orally daily. 2. Synthroid 88 mcg orally daily. 3. Ativan 0.5 to 1 mg orally twice daily for anxiety. 4. Asacol EC 800 mg twice daily for her ulcerative colitis. 5. Multivitamin with minerals 1 daily. 6. Levaquin 500 mg orally daily. This will continue through _%#MMDD2006#%_, and was started after the ERCP she had in the hospital.
EC|enteric-coated|EC|131|132|CURRENT MEDICATIONS|5. Calcium carbonate 500 mg 1 tablet p.o. twice a day. 6. Prilosec 20 mg p.o. every day. 7. Actos 15 mg p.o. every day. 8. Aspirin EC 81 mg p.o. every day. 9. Vitamin E 200 units p.o. every day. 10. Ibuprofen 200 mg p.o. three times a day p.r.n. pain.
EC|enteric-coated|EC,|128|130|DISCHARGE MEDICATIONS|7. Nitroglycerin on a p.r.n. basis for chest pain and shortness of breath. 8. Xanax 0.125 mg t.i.d. p.r.n. anxiety. 9. Entocort EC, 6 mg a day for 3 days, then to be decreased to 3 mg daily for 1 week, then to be discontinued. 10. Sinemet 25/100 1 b.i.d. p.r.n. restless legs syndrome.
EC|enterocutaneous|EC|209|210|PHYSICAL EXAMINATION|ABDOMEN: Bowel sounds are positive. She is obese. She has 2 stoma sites, one on the left-hand side which would be her colostomy and the other on the right side of her abdomen which is her stomatization of the EC fistula. EXTREMITIES: Trace edema. NEUROLOGICAL: Cranial nerves II through XII are grossly intact. LABORATORY DATA: White blood cell count 4.4, hemoglobin 8.4, hematocrit 25.5, MCV 78, platelet count 114, sodium 131, potassium 4.2, chloride 103, CO2 22, BUN 19, creatinine 0.9, calcium 8.4. Ionized calcium was low at 2.2. Venous blood gases showed pH of 7.38, PCO2 28, PO2 27.
EC|enteric-coated|EC|34|35|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Aspirin EC 81 mg p.o. q. day. 2. Lisinopril 20 mg p.o. q.a.m. 3. Hydrochlorothiazide 12.5 mg p.o. q.a.m. 4. Plavix 75 mg p.o. q.a.m. 5. Toprol-XL 50 mg p.o. q.a.m.
EC|enteric-coated|EC|185|186|DISCHARGE MEDICATIONS|4. Norvasc 2.5 mg p.o. each day at bedtime. 5. CellCept 250 mg p.o. b.i.d. 6. Bupropion SR 100 mg p.o. daily. 7. Prednisone 5 mg p.o. daily. 8. Zinc sulfate 220 mg p.o. daily. 9. Creon EC 5 mg caps p.o. to take 2 tabs with meals and 1 capsule with snacks. 10. Protonix 40 mg p.o. daily. 11. Calcium 500 with Vitamin D, 3 tablets p.o. q.i.d.
EC|enteric-coated|EC|366|367|MEDICATIONS ON DISCHARGE|The blood pressure was 106/68 with a heart rate of 68, which is regular, respiratory rate was 16. JVP was not elevated. MEDICATIONS ON DISCHARGE: Fexofenadine 180 mg orally daily, fluoxetine 40 mg orally daily, Lipitor 40 mg orally daily, lisinopril 20 mg orally daily, Nexium 20 mg orally daily, quinine 3-5 mg orally at bedtime, Plavix 75 mg orally daily, aspirin EC 81 mg orally daily, Coreg 6.25 mg p.o. twice a day and nitroglycerin 0.4 mg sublingual p.r.n. The patient will be following with his primary care physician in 2 days time and will be seeing Dr. _%#NAME#%_ in clinic again in 4 weeks from now.
EC|enteric-coated|EC|175|176|MEDICATIONS ON DISCHARGE|5. Lisinopril 20 mg b.i.d. 6. Metoprolol 100 mg in the morning. 7. Multivitamins 1 tablet daily. 8. NovoLog insulin p.r.n. 9. Omega 3 one capsule orally daily. 10. Pangestyme EC 4500 unit capsule 2 capsules for snacks and 3 capsules before meals. 11. Procrit 10,000 units subcutaneously every 2 weeks. 12. Viagra 100 mg orally as needed.
EC|enteric-coated|EC|156|157|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Lipitor 40 mg daily. 2. Prozac 20 mg q.a.m. 3. Senokot 2 tabs p.o. at bedtime p.r.n. 4. Citrucel 1 tablespoon daily . 5. Protonix EC 40 mg daily. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 47-year-old woman with a known history of chronic constipation who has been admitted in the past multiple times for enemas because of severe obstipation.
EC|enterocutaneous|EC|214|215|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSIS: Enterocutaneous fistula with a skin LET. PROCEDURES PERFORMED: Wound/stoma/EC fistula. Care by wound care nurse. HISTORY OF PRESENT ILLNESS: A 62-year-old female well-known to MIS Service with EC fistula developed after hernia repair early 2006, who was discharged 6 days before presentation from this hospital. Fistula has been managed by NPO and home care. However, it was not contained and was draining to the surrounding skin.
EC|enteric-coated|EC|141|142|DISCHARGE MEDICATIONS|He was referred to his new primary doctor. DISCHARGE MEDICATIONS: 1. Hydrochlorothiazide 25 mg a day. 2. Lisinopril 20 mg a day. 3. Protonix EC 40 mg a day. 4. Clonazepam 2 mg at bedtime. DISPOSITION: To home with rule 25 in the morning. I strongly suggested that he also obtain a primary care clinic and he is reportedly going to go to Smiley's.
EC|enteric-coated|EC|133|134|DISCHARGE MEDICATIONS|7. Cipro 500 mg p.o. b.i.d. x 10 days/20 doses, then discontinue. 8. Prevacid 30 mg p.o. q.d. 9. Zocor 40 mg p.o. q.h.s. 10. Aspirin EC 81 mg p.o. q.d. 11. Wellbutrin 200 mg p.o. q.a.m. 12. Wellbutrin 100 mg p.o. q.noon. 13. Calcium carbonate with vitamin D 500 mg p.o. t.i.d.
EC|enteric-coated|EC|138|139|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS AS FOLLOWS: The patient will be discharged to home. DISCHARGE MEDICATIONS: 1. Vicodin 1-2 tabs p.o. q.4h. p.r.n. 2. EC ASA 325 mg p.o. q.d. x8 weeks. FOLLOW UP: Follow up with Dr. _%#NAME#%_ as scheduled. The patient is to be nonweightbearing on his left lower extremity x8 weeks.
EC|enterocutaneous|EC|166|167|ADMISSION DIAGNOSIS|On _%#MM#%_ _%#DD#%_, 2002, the patient was taken to the operating room. The procedure that was done was a laparotomy with extensive lysis of adhesions, resection of EC fistula off Roux limb, with reconstruction of abdominal wall. The procedure was performed without complication. Findings were extensive adhesions, EC fistula originating from the Roux limb.
EC|enterocutaneous|EC|243|244|ADMISSION DIAGNOSIS|The procedure that was done was a laparotomy with extensive lysis of adhesions, resection of EC fistula off Roux limb, with reconstruction of abdominal wall. The procedure was performed without complication. Findings were extensive adhesions, EC fistula originating from the Roux limb. The patient was sent to the SICU for cardiopulmonary resuscitation, fluid resuscitation, and intensive monitoring.
EC|enteric-coated|EC|125|126|DISCHARGE MEDICATION|3. CellCept 500 mg p.o. q.i.d. 4. Prednisone 5 mg p.o. q.d. 5. Bactrim SS 1 p.o. q.d. 6. Valcyte 450 mg p.o. q.d. 7. Aspirin EC 81 mg p.o. q.d. 8. Calcium carbonate with Vitamin D, 500 mg p.o. t.i.d. 9. Sodium bicarbonate 1.95 gm p.o. q.i.d. 10. Prevacid 30 mg p.o. q.d.
EC|enteric-coated|EC|268|269|DISCHARGE MEDICATIONS|5. Anemia: The patient continued on his iron for iron deficiency anemia confirmed by iron studies from his _%#MM#%_ _%#DD#%_, 2002, to _%#MM#%_ _%#DD#%_, 2002, hospital stay. DISCHARGE MEDICATIONS: 1. Iron sulfate 325 mg p.o. t.i.d. 2. Multivitamin 1 tab p.o. q.d. 3. EC ASA 325 mg p.o. q.d. 4. Prozac 40 mg p.o. q.d. 5. Metoprolol 25 mg p.o. b.i.d. 6. Zantac 150 mg p.o. b.i.d. 7. Haldol (new medication) 0.5 mg p.o./IM b.i.d.
EC|enteric-coated|EC|121|122|ADMISSION MEDICATIONS|4. Hypothyroidism. 5. GERD. ADMISSION MEDICATIONS: 1. K-Dur 20 mEq q.d. 2. Zantac 150 mg b.i.d. 3. Lipitor 80 mg q.d. 4. EC aspirin 325 mg q.d. 5. Synthroid 50 mcg q.d. 6. Colace 100 mg q.d. 7. Unifiber 2 tsp p.o. h.s. 8. Lactulose 30 cc q.d. 9. Avapro 150 mg q.d.
EC|enteric-coated|EC|122|123|DISCHARGE MEDICATIONS|1. Labetalol 500 mg b.i.d. 2. Imdur 120 mg p.o. q day. 3. Lasix 20 mg p.o. q day. 4. Lipitor 10 mg p.o. q day. 5. Aspirin EC 81 mg p.o. q day. 6. Norvasc 10 mg p.o. q day. 7. Fiber-Con two tablets per day. 8. Prozac 10 mg p.o q day.
EC|enterocutaneous|EC|137|138|OPERATIONS/PROCEDURES PERFORMED|ADMISSION DIAGNOSIS: Enterocutaneous fistula. DISCHARGE DIAGNOSIS: Enterocutaneous fistula. OPERATIONS/PROCEDURES PERFORMED: Excision of EC fistula and abdominal exploration. HISTORY OF PRESENT ILLNESS: The patient is male who is well known to the Bariatric Service.
EC|enteric-coated|EC|270|271|MEDICATIONS ON DISCHARGE|4. The patient was asked to report any signs or symptoms, including, but not limited to, increased drainage, increased pain, increased swelling, elevated temperature above 101.5, and any questions or concerns. MEDICATIONS ON DISCHARGE: 1. Norvasc 10 mg p.o. q.d. 2. ASA EC 81 mg p.o. q.d. 3. Calcium carbonate with vitamin D 500 mg p.o. t.i.d. 4. Mycelex troche one tablet q.i.d. 5. Lopressor 100 mg b.i.d. p.o.
EC|enteric-coated|EC|223|224|HOSPITAL COURSE|She was hydrated with normal saline. She also had a Clostridium difficile culture and toxin which were checked and were negative. She was continued on her Asacol. Her diarrhea failed to improve, and she was put on Entocort EC (budesonide) to treat her collagenous colitis, as per Dr. _%#NAME#%_ _%#NAME#%_'s previous suggestion. She was initially started on 9 mg p.o. q.d. by Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2003#%_, and the dose was reduced to 4.5 mg p.o. q.d. on _%#MMDD2003#%_.
EC|enteric-coated|EC|115|116|DISCHARGE MEDICATIONS|1. Darvon N-100, 1-2 tablets p.o. q.4-6h. p.r.n. 2. Atenolol 50 mg p.o. q.d. 3. Celexa 20 mg p.o. q.d. 4. Entocort EC 4.5 mg p.o. q.d. 5. Protonix 40 mg p.o. q.d. 6. Sinemet 25/100, 1 p.o. q.h.s. 7. Lomotil 1-2 tablets p.o. q.6-8h. p.r.n. diarrhea. 8. Tequin 200 mg p.o. q.d. on _%#MMDD#%_, _%#MMDD#%_ and _%#MMDD#%_.
EC|enteric-coated|EC|116|117|MEDICATIONS|ALLERGIES: Penicillin causes diffuse edema. MEDICATIONS 1. Folate 1 mg a day 2. Aspirin 81 mg PO Q day 3. Pancrease EC 4500 MU ten capsules PO Q day 4. Vicodin prn. 5. Zovirax 800 mg PO five times a day started six days ago. PHYSICAL EXAMINATION: Objective: Vital signs - temperature is 95.8, pulse is 68, respiratory rate is 18, blood pressure is 140/82.
EC|enteric-coated|EC|248|249|HOSPITAL COURSE|Organically, as reported above, the patient never had nausea/vomiting or bloody diarrhea. Having said that, during this hospitalization, we gave her one dose of steroids, prednisone 20 mg, and we discharged her two days after admission on Entocort EC 9 mg p.o. q.d., as well as some Dilaudid 2 mg p.o. as needed for pain. We gave the patient a set number of Dilaudid pills, given the fact that we were suspecting the patient's excessive demand for narcotic medications.
EC|enteric-coated|EC|138|139|DISCHARGE MEDICATIONS|ALLERGIES: No known drug allergies. DISCHARGE MEDICATIONS: 1. Vicodin one to two p.o. q4h p.r.n. 2. Colace 100 mg p.o. b.i.d. 3. Depakote EC 500 mg p.o. b.i.d. 4. Zantac 150 mg p.o. b.i.d. HOSPITAL COURSE: The hospital course was uneventful for neurological, hematological, or infectious complications.
EC|enteric-coated|EC|98|99|DISCHARGE MEDICATIONS|She is a smoker and was strongly encouraged to quit completely. DISCHARGE MEDICATIONS: 1. Aspirin EC 325 mg p.o. q. day 2. Dipyridamole 75 mg p.o. b.i.d. times 4 weeks 3. Neurontin 100 mg p.o. q.h.s. 4. Trazodone 50 mg p.o. q.h.s. 5. Propanolol 40 mg p.o. q.h.s.
EC|enteric-coated|EC|204|205|DISCHARGE MEDICATIONS|Chest x-ray showed clear lung fields, no pneumonia suspected. DISCHARGE CONDITION: Stable. DISPOSITION: Discharge back to Ebenezer Home. DISCHARGE MEDICATIONS: 1. Vitas 5 mg sublingual q.h.s. 2. Protonix EC 40 mg p.o. daily. 3. Elemental calcium 500 mg p.o. daily 4. Calcium carbonate with vitamin D 12.5 mg p.o. t.i.d.
EC|UNSURED SENSE|EC:|230|232|PRENATAL LABS|ALLERGIES: No known drug allergies. SOCIAL HISTORY: Unknown SO/partner. The patient denies any tobacco, alcohol, or drug use. PRENATAL LABS: O positive, antibody negative, rubella immune, VDRL negative, GC and Chlamydia negative. EC: No growth. Hepatitis surface antigen negative, HIV negative. Platelets 292. GBS negative. Pap within normal limits. Hemoglobin ranged from 13.7 to 12.6. Sonograms at 11-12 weeks showed an EDC of _%#MM#%_ _%#DD#%_, 2004.
EC|enterocutaneous|EC|200|201|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: The patient has a past medical history significant for chronic abdominal pain with multiple abdominal operations, short bowel syndrome, status post multiple bowel resections for EC fistula, status post colonoscopy, and status post diverting jejunostomy. She is status post TAH/BSO, status post appendectomy, anemia, seizure disorder, depression, and recent hepatic insufficiency secondary to cholestasis, and onset of jaundice relation to treatment with caspofungin Cardidata glabrata fungicemia.
EC|enteric-coated|(EC)|212|215|CURRENT MEDICATIONS|14. Type 2 diabetes mellitus 15. History of aspiration pneumonia (2003, complicating gastric hemorrhage) 16. Uterine prolapse (Dr. _%#NAME#%_ _%#NAME#%_). CURRENT MEDICATIONS: 1. Vitamin E 400 IU q.d. 2. Aspirin (EC) 81 mg p.o. q.d. 3. Folic acid 1 mg p.o. q.d. 4. Calcium 500 mg p.o. q.d. 5. Pepcid 40 mg p.o. q.d.
EC|enterocutaneous|EC|168|169|HISTORY OF PRESENT ILLNESS|3. Development of an enterocutaneous fistula, secondary to above. 4. GI endoscopy with attempted endoscopic ablation of fistula (_%#MM#%_ _%#DD#%_, 2004), secondary to EC fistula. 5. Multiple imaging studies of the fistula (dated _%#MM#%_ 2004 and _%#MM#%_ _%#DD#%_, 2004). 6. History of obesity. HOSPITAL COURSE: Patient was admitted on _%#MM#%_ _%#DD#%_, 2004, for her noted subphrenic abscess on the right.
EC|enterocutaneous|EC|135|136|DISCHARGE INSTRUCTIONS|5. For wound and drain care for her abscess drain, please flush with 10 mL sterile water b.i.d. to keep open. 6. G-tube to gravity. 7. EC fistula care per home health nursing. FOLLOW UP: 1. Patient is to follow up with Dr. _%#NAME#%_ in 1 week's time on Thursday, _%#MM#%_ _%#DD#%_, 2004, for follow up and future planning of surgery (treatment of right lower lobe abscess to be coordinated with bariatric reconstruction).
EC|enteric-coated|EC|171|172|HOSPITAL COURSE|She was followed medically by the staff from Smiley's Clinic. On _%#MMDD2004#%_, after being seen by the medical staff, the following medications were added: pantoprazole EC 40 mg daily, pyridoxine 50 mg daily, and thiamine 100 mg daily. Escitalopram 20 mg daily was added. Additional lab studies were also added as she has end-stage liver disease because of her chronic abuse of alcohol.
EC|enteric-coated|EC|150|151|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Multivitamin daily. 2. Spironolactone 25 mg daily. 3. Propranolol 10 mg twice daily. 4. Niacin 50 mg daily. 5. Pantoprazole EC 40 mg daily. 6. Pyridoxine 50 mg daily. 7. Thiamine 100 mg daily. 8. Folic acid 1 mg daily (folic acid restarted on day of discharge by medical staff).
EC|enteric-coated|EC|147|148|ALLERGIES|4. Fluoxetine 20 mg p.o. daily. 5. Quetiapine 25 mg p.o. every night. 6. Neurontin 300 mg p.o. t.i.d. 7. Nadolol 40 mg p.o. daily. 8. Pantoprazole EC 40 mg p.o. daily. 9. Senna 15 mg p.o. every night 10. Lantus 40 units subcutaneous every night. 11. OxyContin CR 10 mg p.o. b.i.d.
EC|enteric-coated|EC|131|132|DISCHARGE MEDICATIONS|1. Percocet 5/325 1 to 2 tablets p.o. q.4-6 h. p.r.n. pain. 2. Colace 100 mg p.o. daily. 3. Protonix 40 mg p.o. daily. 4. Depakote EC 750 mg p.o. daily. 5. Desipramine 50 mg p.o. daily. 6. Diphenhydramine 100 mg p.o. q.h.s. 7. Zyprexa 5 mg p.o. daily. 8. Enteric-coated aspirin 81 mg p.o. daily. 9. Senokot S 2 tablets p.o. b.i.d.
EC|enteric-coated|EC|192|193|MEDICATIONS|1. Os-Cal with vitamin D 1 tablet p.o. b.i.d. 2. Clopidogrel 75 mg p.o. daily. 3. Folic acid 1 mg p.o. daily. 4. Lisinopril 2.5 mg p.o. daily. 5. Metoprolol 100 mg p.o. daily. 6. Pantoprazole EC 40 mg p.o. daily. 7. Vitamin E 400 units p.o. daily. 8. Alendronate 75 mg p.o. q. week on Sundays. 9. Methotrexate 10 mg p.o. q. week on Fridays.
EC|enteric-coated|EC|153|154|AXIS I|DISCHARGE MEDICATIONS: 1. Topamax 100 mg p.o. b.i.d. 2. Trazodone 100 mg p.o. nightly. 3. Zoloft 200 mg p.o. q. day. 4. Klonopin 0.5 mg p.o. nightly. 5. EC aspirin 5 g p.o. q. day. 6. Docusate sodium 100 mg p.o. b.i.d. 7. Lactulose 30 mL p.o. b.i.d. 8. Ferrous sulfate 5 g p.o. q. day.
EC|enteric-coated|EC|150|151|DISCHARGE MEDICATIONS|9. For hypercholesterolemia, she is given Zocor 20 mg p.o. daily. 10. For chronic leg pain, oxycodone 5 mg q.4h. p.r.n., generally q.i.d. 11. Aspirin EC 325 mg p.o. daily. 12. For hypertension, also she is given atenolol 25 mg p.o. daily. 13. She is given a multivitamin 1 daily. 14. For diarrhea, Imodium 1-2 tablets p.o. p.r.n.
EC|enteric-coated|EC|154|155|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prednisone 40 mg p.o. daily for 3 days. 2. Augmentin 875 mg p.o. b.i.d. for 5 days. 3. Atenolol 50 mg p.o. q.a.m. 4. Divalproex EC 500 mg p.o. t.i.d. 5. Remeron 15 mg p.o. daily at bedtime. 6. Risperdal 1 mg p.o. q.a.m. and at bedtime. DISPOSITION: Transfer back to group home in a stable condition.
EC|enteric-coated|EC|213|214|DISCHARGE MEDICATIONS|The patient's INR goal is between 2 and 3. The patient is to call MD with increased temperatures of 101.5 degrees or greater, any redness, swelling or pain from the incisional site. DISCHARGE MEDICATIONS: Aspirin EC 81 mg p.o. daily, darbepoetin 16 mcg subcutaneous q. Mondays once a week, Colace 100 mg p.o. b.i.d., ferrous sulfate 325 mg p.o. t.i.d. with meals, lisinopril 2.5 mg p.o. daily, mexiletine 150 mg p.o. t.i.d., Nexium 40 mg p.o. daily, Paxil 10 mg p.o. daily, Demadex 20 mg p.o. b.i.d., Coumadin 4 mg p.o. daily, potassium chloride 20 mEq daily, magnesium oxide 5 mg p.o. daily, Reglan 5 mg p.o. t.i.d.
EC|UNSURED SENSE|EC.|144|146|PLAN|3. Continue regular medications including Coumadin. 4. CBC with diff and platelets, BNP, magnesium phosphate, INR or PTT. Blood cultures and UA EC. HOSPITAL COURSE: 1. Disease. Stage IIIC, grade 3 endometrial cancer, status post staging procedure and 6 cycles or Taxol/carbo.
EC|enteric-coated|EC|282|283|DISCHARGE MEDICATIONS|It is recommended that he go to a TCU for four to five days to regain his strength completely. DISCHARGE MEDICATIONS: Include Coreg 6.25 mg p.o. b.i.d., glipizide 10 mg p.o. b.i.d., spironolactone 12.5 mg p.o. q.a.m., lisinopril 5 mg p.o. b.i.d., Lasix 20 mg p.o. b.i.d., pancrease EC 3-5 cap p.o. with each meal, Percocet 5/325 one to 2 p.o. q.4h. p.r.n. Colace 100 mg p.o. b.i.d., Senokot-S one tablet p.o. b.i.d. The patient will have his blood sugars checked on a b.i.d. basis.
EC|enteric-coated|(EC)|177|180|PHYSICAL EXAMINATION|His hypertension was controlled in the hospital on lisinopril and Lopressor. The patient was otherwise chest pain-free during hospitalization. DISCHARGE MEDICATIONS: 1. Aspirin (EC) 325 mg p.o. daily. 2. Zocor 40 mg p.o. q.p.m. 3. Sublingual nitroglycerin 0.4 mg, 3 tablets every 5 minutes p.r.n. chest pain.
EC|enteric-coated|EC|284|285|DISCHARGE DIAGNOSIS|Her coronaries were clean as per the report above. Since the etiology of the chest pain is noncardiac but may be related to her viral illness preceding her symptoms. She should have follow up with her primary care physician in the next 1 to 2 weeks. DISCHARGE MEDICATIONS: 1. Aspirin EC 325 mg p.o. q. day. 2. Calcium carbonate/vitamin D 1250 mg p.o. b.i.d. 3. Celexa 20 mg p.o. q. day. 4. Lisinopril 10 mg p.o. q. day. 5. Methotrexate 2.5 mg p.o. q. week.
EC|enteric-coated|EC|170|171|DISCHARGE MEDICATIONS|Somatostatin can cause EKG irregularities also. She has no known documented coronary disease. DISCHARGE MEDICATIONS: 1. Combivent inhaler 2 puffs q.6h p.r.n. 2. Valproic EC 1,000 mg p.o. b.i.d. 3. Drisdol 50,000 units p.o. q. week. 4. Florinef 100 mcg p.o. daily (this is new). 5. Advair 250/50 mcg 1 puff b.i.d. 6. Synthroid 125 mcg p.o. daily (this is a new dose).
EC|enteric-coated|EC|139|140|ADMISSION MEDICATIONS|MSSA and pseudomonas multi-resistant to penicillin, susceptible to imipenem. ALLERGIES: No known drug allergies. ADMISSION MEDICATIONS: 1. EC aspirin 81 mg daily. 2. Furosamide 40 mg b.i.d. 3. Fosamax 70 mg daily. 4. Metoprolol 12 mg b.i.d. 5. Omeprazole 20 mg daily. 6. KCL 20 mEq daily.
EC|enteric-coated|EC|162|163|DISCHARGE MEDICATIONS|5. Acetaminophen 625 mg p.o. q.6h as needed. 6. Senna docusate 2 tablets p.o. at bedtime if needed. 7. Potassium chloride 20 mEq p.o. every other day. 8. Aspirin EC 81 mg p.o. daily. 9. Colace 100 mg p.o. two times a day. 10. Metoprolol 12.5 mg p.o. two times a day.
EC|enteric-coated|EC|134|135|DISCHARGE MEDICATIONS|2. Multivitamins 1 tablet p.o. daily. 3. Vitamin C 750 mg 1 tablet p.o. b.i.d. 4. Hydrochlorothiazide 12.5 mg p.o. daily. 5. Entocort EC 3 mg p.o. 3 tablets q.a.m. 6. Calcium citrate 500 mg p.o. daily. 7. Nystatin 100,000 U/g cream 2-3 times a day, apply to affected areas.
EC|enteric-coated|EC|191|192|CURRENT MEDICATIONS|16. Oxygen 3 liters nasal cannula while awake and 5 liters while asleep, hooked up to humidifier and decompressor with temperature between 30 and 30-some degrees Celsius. 17. Ferrous sulfate EC 325 mg 1 tablet b.i.d. ALLERGIES: None known. PHYSICAL EXAMINATION: GENERAL: The patient is alert but easily falls asleep .......his caregiver is present.
EC|enteric-coated|EC|199|200|DISCHARGE MEDICATIONS|The patient is to check a vancomycin trough level on _%#MM#%_ _%#DD#%_, 2005, and the patient's pacemaker is to be checked through the primary clinic close to home. DISCHARGE MEDICATIONS: 1. Aspirin EC 325 mg p.o. daily. 2. Coreg 3.125 mg p.o. b.i.d. 3. Colace 100 mg p.o. b.i.d. 4. Synthroid 137 mg p.o. q.day. 5. Klor-Con 10 mEq 3 tablets p.o. b.i.d.
EC|enteric-coated|EC|143|144|MEDICATIONS|3. Hypertension. 4. Macular degeneration. 5. Incontinence. 6. Probable depression. 7. Gastroesophageal reflux disease. MEDICATIONS: 1. Aspirin EC 81 mg. 2. Atenolol 25 mg. 3. Avandia 4 mg. 4. Detrol LA 2 mg q. day. 5. Exelon 2 mg q. day. 6. Lantus 14 units each day at bedtime.
EC|enteric-coated|EC,|157|159|3. FEN|Prior to discharge, _%#NAME#%_'s Protonix dose was increased because of the results on endoscopy, demonstrating duodenitis. She was also started on Entocort EC, due to concerns about a flare in her Crohn disease. 3. FEN: Due to her history of poor p.o. and dehydration, she was rehydrated with IV fluids.
EC|enteric-coated|EC|191|192|DISCHARGE MEDICATIONS|Following her procedures and imaging studies, her diet was advanced to her regular diet. DISCHARGE MEDICATIONS: 1. Colazal 750 mg 3 tablets p.o. tid 2. Protonix 40 mg p.o. b.i.d. 3. Entocort EC 9 mg p.o. q.a.m. x8 weeks. FOLLOW UP: _%#NAME#%_ was instructed to follow up with Dr. _%#NAME#%_ and at her previously scheduled appointment in _%#CITY#%_ _%#CITY#%_ at the end of _%#MM#%_.
EC|enteric-coated|EC|199|200|DISCHARGE MEDICATIONS|12. Glucosamine 750 mg p.o. daily for osteoarthritis. 13. Os-Cal with vitamin D 500 mg of elemental calcium 1 tablet twice daily p.o. 14. Tylenol No. 3, 2 every 8 hours p.r.n. p.o. pain. 15. Aspirin EC 81 mg p.o. daily for atrial fibrillation. 16. Magnesium oxide 400 mg p.o. daily of 1600 mg. DISCHARGE INSTRUCTIONS: She is to have a 2-g sodium diet and to be evaluated by physical therapy and occupational therapy.
EC|enteric-coated|EC|177|178|DISCHARGE MEDICATIONS|10. Levofloxacin 250 mg p.o. q.4-8h. until _%#MM2007#%_ (give after dialysis on dialysis day). 11. Levothyroxine 75 mcg p.o. daily. 12. Losartan 100 mg p.o. daily. 13. Protonix EC 20 mg p.o. daily. 14. Simvastatin 40 mg p.o. each day at bed-time. 15. Warfarin 2.5 mg p.o. daily. 16. Tylenol 650 mg 1 tablet p.o. q.4h. p.r.n.
EC|enteric-coated|EC|263|264|DISCHARGE MEDICATIONS|She denied any nausea or vomiting or significant pain. Laboratory tests remained within acceptable range, with a calcium level at the lower normal limit. She was discharged home in stable condition. DISCHARGE MEDICATIONS: 1. Aciphex 20 mg p.o. daily. 2. Entocort EC 3 mg p.o. daily. 3. OxyContin 10 mg p.o. b.i.d. 4. Trazodone 50 mg p.o. q.h.s. 5. Calcitrol 25 mg p.o. Monday and Wednesday. 6. Coreg 12.5 mg p.o. b.i.d.
EC|enteric-coated|EC|192|193|DISCHARGE MEDICATIONS|5. Hydralazine 100 mg p.o. q.i.d. 6. Lantus 12 units subcutaneous injection each night. 7. Imdur 60 mg p.o. daily. 8. Protonix 40 mg p.o. daily. 9. Simvastatin 20 mg p.o. nightly. 10. Aspirin EC 325 mg p.o. daily. Hold if there is any bleeding. 11. Carvedilol 3.125 mg p.o. b.i.d. 12. Insulin syringes. 13. Okay to not take NovoLog sliding scale insulin on _%#MM#%_ _%#DD#%_, 2006.
EC|enteric-coated|EC|244|245|DISCHARGE MEDICATIONS|Her previous dose was Keppra 500 b.i.d. and Depakote ER 500, 1 in the morning and 2 at bedtime. DISCHARGE MEDICATIONS: Atrial fibrillation the time of discharge her medications were calcium and vitamin D, Celexa 40 mg p.o. daily, Valproic acid EC 250 b.i.d., hydrochlorothiazide 25 mg p.o. daily, Keppra 250 mg b.i.d., Lidoderm patch to left arm q.24h for 12 hours only, nicotine patch 21 mg daily, Ranitidine 150 mg b.i.d., potassium chloride 20 mEq p.o. daily, oxycodone 5 mg p.o. q.4h. p.r.n. for pain.
EC|enteric-coated|EC|143|144|DISCHARGE MEDICATIONS|9. Lovenox 120 mg p.o. subcutaneously injection q.d. until his INR is greater than 2 for 48 hours. 10. Toprol XL 25 mg p.o. daily. 11. Aspirin EC 325 mg p.o. daily. 12. Lamisil 1% cream topically ad lib twice daily until rash clears. 13. Glucotrol XL 5 mg p.o. daily. Dispense 1 glucometer, testing supplies, and blood-sugar fingersticks before breakfast and before supper.
EC|enteric-coated|EC|165|166|MEDICATIONS|MEDICATIONS: The patient has been on numerous medications and has been relying on azathioprine 150 mg each day for immunosuppressive maintenance. She is on Entocort EC 3 capsules per rectum each day. She also has used p.r.n. Ativan for anxiety. She takes Benadryl 25 mg each day, folate 1 mg each day, Prozac 20 mg each day, iron supplements, loperamide 2 capsules three times per day, Reglan 3 to 4 times per day and she uses ranitidine.
EC|enteric-coated|EC|112|113|DISCHARGE MEDICATIONS|2. Lovenox 120 mg subcutaneously daily. 3. Lisinopril 40 mg p.o. daily. 4. Coreg 6.25 mg p.o. b.i.d. 5. Aspirin EC 81 mg p.o. daily. 6. Lasix 20 mg p.o. q.a.m. 7. Aldactone 25 mg p.o. daily. It has been a great pleasure taking care of Ms. _%#NAME#%_ and I sincerely wish her the best in her oncoming years in her management of care.
EC|enteric-coated|EC|132|133|DISCHARGE MEDICATIONS|2. Xanax 0.25 mg p.o. each day at bedtime q.h.s. p.r.n. anxiety. 3. Tessalon Perles one 1 tab p.o. t.i.d. p.r.n. cough. 4. Entocort EC 9 mg p.o. daily. 5. Lonox/Lomotil Flomax 6. slow mag 3 tabs p.o. b.i.d. 7. Cymbalta 90 mg p.o. q. day . (increased dose). 8. Enpresse one 1 tab p.o. daily.
EC|enteric-coated|EC|181|182|DISCHARGE  MEDICATIONS|The patient will therefore be discharged to home. Risk factors for esophageal reflux were reviewed with the patient. DISCHARGE MEDICATIONS: 1. Prilosec OTC 20 mg daily. 2. Entocort EC 3 mg daily. 3. Asacol 400 mg daily. DISCHARGE INSTRUCTIONS: The patient is to avoid caffeine use.
EC|enteric-coated|EC|164|165|DISCHARGE MEDICATIONS|He should follow a cardiac low-salt diet. DISCHARGE MEDICATIONS: 1. Coreg 12.5 mg p.o. b.i.d. 2. Cozaar 25 mg p.o. daily. 3. Digoxin 0.25 mg p.o. daily. 4. Aspirin EC 81 mg p.o. daily. 5. Warfarin as directed (5 mg on Sundays, Tuesdays, Thursdays and Saturdays; 2.5 mg on Mondays, Wednesdays, Fridays).
EC|enteric-coated|EC|197|198|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. The patient will be given a prescription for Vicodin 1 to 2 tablets p.o. 4-6 hours p.r.n. pain. He will be given 60 tablets. He was instructed to take aspirin. 2. Aspirin EC 325 mg oral daily. 3. Lipitor 80 mg oral once at bedtime. 4. Colace 100 mg oral twice daily. 5. Neurontin 100 mg oral 3 times daily.
EC|enteric-coated|EC|178|179|DISCHARGE MEDICATIONS|5. Sinemet-CR 25/100 mg p.o. b.i.d. 6. Clonazepam 0.5 mg p.o. at bedtime. 7. Digoxin 125 mcg p.o. daily q.a.m. 8. Lomotil 2.5/0.025 mg q.4-6h. p.r.n. for diarrhea. 9. Divalproex EC 250 mg p.o. b.i.d. 10. Aricept 10 mg p.o. daily. 11. Lexapro 30 mg p.o. daily q.a.m. 12. Ferrous sulfate 325 mg p.o. b.i.d.
EC|enteric-coated|EC|130|131|MEDICATIONS|14. Chronic constipation. MEDICATIONS: 1. Hydromorphone 2 mg p.o. q.4h. p.r.n. for pain. 3. Methadone 5 mg p.o. q.12h. 3. Aspirin EC 81 mg p.o. daily. 4. Gabapentin 300 mg at bedtime. 5. Carbidopa/levodopa 25/100 p.o. b.i.d. 6. _______ 100 mg half a tablet p.o. daily. 7. Metoprolol 50 mg b.i.d.
EC|enteric-coated|EC|148|149|MEDICATIONS AT DISCHARGE|May repeat x2, five minutes apart, for a total of 3 tabs. If the pain persists, call 911. 6. Simvastatin 40 mg p.o. each day at bedtime. 7. Aspirin EC 81 mg daily. 8. Chantix month starter pack. The patient was given instructions that he is to have subsequent refills done by his primary care physician who will also follow his kidney function tests.
EC|enteric-coated|EC,|155|157|DISCHARGE MEDICATIONS|3. Colace, 100 mg b.i.d. p.r.n. 4. Lasix, 20 mg b.i.d., this has been decreased from 40 mg p.o. b.i.d. today. 5. Maalox, 30 cc q.i.d. p.r.n. 6. Mesalamine EC, 400 mg p.o. b.i.d. 7. Milk of Magnesia, 30 ml p.o. daily p.r.n. 8. Nitroglycerin, 400 mcg sublingual p.r.n.
EC|enteric-coated|EC|309|310|DISCHARGE MEDICATIONS|We talked to the patient and we decided that was a good approach to send her home because she was asymptomatic and perform a Doppler ultrasound as an outpatient and be seen in the next 1-2 weeks by Dr. _%#NAME#%_ and her primary care physician. DISCHARGE MEDICATIONS: 1. Xanax 0.75 mg p.o. t.i.d. 2. Protonix EC 40 mg p.o. b.i.d. 3. Coumadin 5 mg p.o. daily. DISCHARGE PLAN: The patient have the Doppler ultrasound within 7 days of her abdomen just to be sure there is no clot in there.
EC|UNSURED SENSE|EC,|217|219|PHYSICAL EXAMINATION|Lungs: CT bilaterally CVRRR without murmur, rub or gallop. Abdomen: Positive bowel sounds, soft, nontender, nondistended, no hepatosplenomegaly. Extremities: Warm with good perfusion. No clubbing, cyanosis, or edema, EC, II through XII grossly intact. Hemoglobin was normal at 13.3. The remainder of CBC was normal. Urinalysis was completely within normal limits. ASSESSMENT: Healthy female medically prepared for septoplasty and turbinoplasty on _%#MMDD2002#%_.
EC|enteric-coated|EC|148|149|HOSPITAL COURSE|She will continue her home meds that will include: 1. Plavix 75. 2. Aspirin 81. 3. Protonix 40. 4. Lyrica 75. 5. Zocor 40. 6. Diovan 80. 7. Aspirin EC 81. 8. Vicodin an as needed. 9. Ultram as needed. 10. Refresh Tears for dryness of the eyes. She will be followed up with the nurse practitioner in 1-2 weeks, Dr. _%#NAME#%_ in 2-3 months, lipids panel in 6-8 weeks and an echocardiogram at Minnesota Heart in 1-2 weeks.
EC|enteric-coated|EC|122|123|DISCHARGE MEDICATIONS|3. Rule out myocardial infarction. 4. Chronic renal insufficiency. DISCHARGE MEDICATIONS: 1. Allopurinol 100 mg q day. 2. EC ASA 325 mg q day. 3. Azithromycin 250 mg q.d. times one day. 4. Ceftin 500 mg b.i.d. times seven days. 5. Digoxin 0.125 mg q.d. 6. Imdur 90 mg q a.m.
EC|enteric-coated|EC|180|181|MEDICATIONS|15. Glyburide 10 mg q.day. 16. Lecithin 19 grains b.i.d. 17. Medroxyprogesterone 2.5 q.d. 18. Miacalcin 200 units nasal spray one spray q. day in alternate nostrils. 19. Bisacodyl EC 10 mg b.i.d. 20. Alfalfa one tablet t.i.d. 21. Combivent two puffs q. 22. Diazepam 5 mg t.i.d. 23. Diltiazem 240 mg q.day.
EC|enteric-coated|EC|247|248|ADMISSION DIAGNOSIS|REVIEW OF SYSTEMS: Otherwise unremarkable. ADMISSION MEDICATIONS: Comtan 200 mg p.o. t.i.d., Zoloft 500 mg q.a.m., Celebrex 200 mg q.d., Protonix 40 q.d., Neurontin 500 t.i.d., Zyrtec 10 q.d., Dulcolax suppository 1 PR b.i.d., Oxy-Contin 30 h.s., EC ASA 81 mg q.d., Oxy-Contin 10 a.m. ALLERGIES: VOLTAREN. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: No tobacco, no alcohol, no illicit drugs.
EC|enterocutaneous|EC|277|278|PROCEDURE|Neuro examination was non-focal. ADMITTING SURGEON: Dr. _%#NAME#%_ _%#NAME#%_ OPERATIVE PROCEDURE PERFORMED: _%#MMDD2003#%_ PREOPERATIVE DIAGNOSIS: Chronic enterocutaneous fistula. POSTOPERATIVE DIAGNOSIS: Chronic enterocutaneous fistula. PROCEDURE: Takedown and repair of the EC CONTACT fistula. SURGEONS: Drs. _%#NAME#%_ and _%#NAME#%_ HOSPITAL COURSE: The patient tolerated the procedure well, tolerated general anesthesia well, and was transferred to the general surgery floor in stable condition.
EC|enteric-coated|EC|154|155|MEDICATIONS AT THE NURSING HOME|MEDICATIONS AT THE NURSING HOME: 1. Tegretol 600 mg twice a day. 2. Lorazepam 1 mg q.6h. p.r.n. anxiety. 3. DDAVP nasal spray (for polyuria). 4. Depakote EC 1000 mg in the morning, 1250 mg at h.s. 5. Propranolol 360 mg twice a day which he takes for behavioral concerns.
EC|enteric-coated|EC|174|175|DISCHARGE MEDICATIONS|8. Ferrous sulfate 325 mg p.o. t.i.d. 9. Sodium bicarbonate 350 mg p.o. b.i.d. 10. Protonix 40 mg p.o. q.d. 11. Zoloft 100 mg p.o. q.d. 12. Lisinopril 5 mg p.o. q.d. 13. ASA EC 81 mg p.o. q.d. 14. Insulin Lantus 18 units subcutaneous q.h.s. 15. Lispro insulin sliding scale subcutaneous t.i.d. with meals p.r.n. hyper leukemia less than 150 none, 150 to 200 6 units, 200 to 250 8 units, 250 to 300 10 units, 300 to 350 12 units, 350 to 400 14 units, more than 400 16 units.
EC|enteric-coated|EC|172|173|DISCHARGE MEDICATIONS|10. Status post pacemaker placement for bradycardia. 11. History of nephrogenic diabetes insipidus secondary to long-term treatment with lithium. DISCHARGE MEDICATIONS: 1. EC ASA 325 mg p.o. q.d. 2. Metoprolol 50 mg p.o. b.i.d. 3. Depakote 250 mg p.o. q.h.s. 4. Risperidone 2 mg p.o. q.h.s. 5. Plavix 75 mg p.o. q.d.
EC|enteric-coated|EC|210|211|DISCHARGE MEDICATIONS|This was discussed with her primary GI physician, Dr. _%#NAME#%_, who approved the Remicade infusion, as per the patient's request, and the patient's abdominal pain improved. DISCHARGE MEDICATIONS: 1. Entocort EC 3 mg p.o. b.i.d. 2. Colestid 1 gm p.o. q.d. 3. Trazodone 2.5 mg p.o. q.h.s. 4. Lorazepam 1 mg p.o. q.h.s. 5. Lexapro 10 mg p.o. q.h.s.
EC|enteric-coated|EC|171|172|MEDICATIONS|5. Dr. _%#NAME#%_, rheumatologist was going to decrease this to 8 mg. b.i.d. next week. He said that is the lowest he would go according to the husband. 6. Sulfadine[sic] EC three tabs b.i.d. 7. Vitamin E 8. Omega 3 9. Crab shell for her hemoglobin and calcium PAST MEDICAL HISTORY: 1. Long history of hypertension but in good control the last time it was taken was maybe a week ago, at 150/82 or so.
EC|enteric-coated|EC.|277|279|HOSPITAL COURSE|Gastrointestinal Consultation was obtained on _%#MMDD2003#%_, and recommendations were noted with repeat colonoscopy with a plan of treatment and biopsies with plan of treatment that if biopsies will be negative to try Lotronex and if biopsies will be positive to try Entocort EC. Dr. _%#NAME#%_ and colonoscopy was scheduled as an outpatient. On _%#MMDD2003#%_ the rest of orthopedic evaluation was noted as MRI of cervical, thoracic, and lumbar spine were completed, which disclosed no signs of any claudication noted in the cervical cord, as previously mentioned study.
EC|enteric-coated|EC,|246|248|DISCHARGE PLAN|5. Status post carcinoma of the breast. DISCHARGE PLAN: _%#NAME#%_ _%#NAME#%_ was discharged to a skilled nursing home on medications documented on the interagency transfer form, including Atenolol, Colace, ferrous gluconate, Lasix, Pantoprazole EC, potassium Seroquel, Vioxx, Zoloft, Synthroid, Depakote, Coumadin and Klonopin. Medical follow-up with Dr. _%#NAME#%_ _%#NAME#%_. Psychiatric follow-up with Dr. _%#NAME#%_.
EC|enteric-coated|EC|186|187|MEDICATIONS|8. Benadryl 25 mg p.o. b.i.d. to be taken with the next medication. 9. Bactrim DS 2 tabs b.i.d. 10. Metronidazole powder b.i.d. with dressing changes; sprinkle on wounds. 11. Divalproex EC 1500 mg b.i.d. due to history of seizure disorder. 12. Phenytoin 300 mg b.i.d. 13. Simethicone 80 mg 1/2 tab t.i.d. with meals.
EC|enteric-coated|EC|127|128|HOSPITAL COURSE|7. Neuro. The patient has a history of petit mal seizures and has not seen a neurologist in several years. He is on divalproex EC and phenytoin, and is aware that his seizures occur and does not experience post-ictal state after these seizures.
EC|enteric-coated|EC|129|130|CURRENT MEDICATIONS|11. Status post repair of multiple ventral abdominal hernias (Dr. _%#NAME#%_). 12. Hypertension. CURRENT MEDICATIONS: 1. Aspirin EC 81 mg p.o. q.d. 2. Metoprolol 50 mg p.o. b.i.d. 3. Diovan/HCT 160/12.5, one p.o. q.d. 4. Niaspan 2000 mg p.o. q.h.s. 5. Bextra 20 mg p.o. q.d.
EC|enteric-coated|EC|205|206|HISTORY OF PRESENT ILLNESS|Her distal neurovascular exam was intact. DISCHARGE PLAN: She will be discharged to home and continued on the same regimen that she had when discharged on the _%#DD#%_. DISCHARGE MEDICATIONS: 1. Pancrease EC 4 tabs p.o. t.i.d. with meals. 2. atenolol 50 mg p.o. daily. 3. Neurontin 1200 mg p.o. t.i.d. 4. fluconazole 400 mg IV daily. 5. Flagyl 1 g p.o. b.i.d.
EC|enteric-coated|EC|146|147|DISCHARGE MEDICATIONS|9. Metoprolol XL 25 mg p.o. daily. 9. 10. Multivitamin with minerals 1 p.o. daily. 11. Viokase 8 3-4 tablets p.o. q.i.d. with meals. 11. Protonix EC 40 mg p.o. daily.12. 12. Prednisone 5 mg p.o. day.13. 14. Compazine 10 mg p.o. q.6 hours p.r.n., nausea, vomiting.
EC|enteric-coated|EC|160|161|NON-PSYCHIATRIC MEDICATIONS PRIOR TO ADMISSION|History of gallbladder and colon problems. History of mesenteric vein thrombosis. NON-PSYCHIATRIC MEDICATIONS PRIOR TO ADMISSION: 1. Viread 2. Sustiva 3. Videx EC 4. Epivir 5. Coumadin FAMILY HISTORY OF MENTAL HEALTH AND CHEMICAL- DEPENDENCY PROBLEMS: Bipolar disorder in a brother and anxiety disorder in a sister.
EC|enteric-coated|EC|196|197|CURRENT MEDICATIONS|CURRENT MEDICATIONS: Depakote, Dilantin, Zyprexa, chloral hydrate, and Senokot; she cannot recall the doses. A copy of the patient discharge instruction sheet from her old record reveals Depakote EC 250 mg q.a.m. and 1250 mg q.h.s., Dilantin 100 mg b.i.d., Zyprexa 5 mg q.h.s., and chloral hydrate 250 mg q.h.s. SOCIAL HISTORY: The patient lives alone in a senior high-rise in _%#CITY#%_ in south _%#CITY#%_.
EC|enteric-coated|EC|124|125|DISCHARGE MEDICATIONS|3. Bactrim single-strength 1 tab p.o. daily. 4. Valcyte 900 mg p.o. b.i.d. times 14 days then 900 mg p.o. daily. 5. Aspirin EC 325 mg p.o. daily. 6. Calcium carbonate with vitamin D 500 mg p.o. t.i.d. 7. Colace 100 mg p.o. b.i.d. 8. Fentanyl patch 25 mcg transdermal to be changed every 72 hours.
EC|enteric-coated|EC|140|141|MEDICATIONS|Queifinesin 2 teaspoons four times a day as occasion requires. Verapamil extended release 120 mg twice a day. Multivitamin q day. Pancrease EC two caps three times a day. Methylphenidate (?) 5 mg one tab twice a day (for Ritalin). Extra- Strength Tylenol two tablets four times a day for pain.
EC|enteric-coated|EC|126|127|MEDICATIONS|8. Lipitor 20 mg p.o. q. 24 h. 9. Prednisone 250 mg p.o. q.a.m Monday. 10. Prednisone 250 mg p.o. q.p.m. Monday. 11. Depakote EC 1,000 mg p.o. q. 12 h. 12. Coumadin 2 mg p.o. q. Tuesday, Thursday, Saturday and Sunday. 13. Coumadin 3 mg p.o. q. Monday, Wednesday, and Friday.
EC|enteric-coated|EC|156|157|CURRENT MEDICATIONS|9. Zocor 80 mg p.o. daily. 10. Prednisone 250 mg p.o. q. b.i.d. on Mondays. 11. Pulmicort Respules 0.5 mg in 12 mL daily. 12. Duo-Neb 1 t.i.d. 13. Depakote EC 1000 mg p.o. b.i.d. 14. Coumadin 2 mg Tuesday, Wednesday, Thursday, Saturday, Sunday; and 3 mg Monday and Friday. REVIEW OF SYSTEMS: He also has some complaints of burning on urination.
EC|enteric-coated|EC|136|137|PRESENT MEDICATIONS|PRESENT MEDICATIONS: 1. Zyprexa Zydis 5 mg t.i.d. p.r.n. 2. Eskalith CR 450 mg tablets 1-1/2 q.h.s. 3. Nicotine gum. 4. Depakote 125 mg EC six tablets q.a.m. and 8 tablets q.h.s. 5. Remeron 15 mg q.h.s. 6. Trazodone 50/100 mg q.h.s. p.r.n. 7. Tylenol p.r.n. 8. Maalox p.r.n. 9. Milk of Magnesia p.r.n. FAMILY HISTORY: Remarkable for depression and bipolar disorder.
EC|enteric-coated|EC|124|125|MEDICATIONS|1. Norvir 4 mg p.o. b.i.d. 2. Zantac 150 mg p.o. b.i.d. 3. Fortovase 400 mg p.o. b.i.d. 4. Zerit 40 mg p.o. b.i.d. 5. Videx EC 400 mg p.o. q.d. 6. Multivitamin one tab p.o. q.d. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: GENERAL: The patient is a well- developed, pleasant male, appearing his stated age, in no apparent distress.
EC|enteric-coated|EC|186|187|PRESENT MEDICATIONS|2. Multivitamin daily. 3. Metamucil 1 capsule b.i.d. 4. Vitamin B6 100 mg daily. 5. Celexa 60 mg daily. 6. Coumadin adjusted based on INR. 7. Buspirone 15 mg q.a.m. and p.m. 8. Depakote EC 250 mg at h.s. alternating with Depakote EC 500 mg q.h.s. 9. Datril LA 4 mg daily. 10. Diphenhydramine 75 mg q.h.s.
EC|enteric-coated|EC|143|144|ADMISSION MEDICATIONS|PAST SURGICAL HISTORY: Port-A-Cath placement, placed _%#MM#%_ 2005 and subsequently removed 6-9 months ago. ADMISSION MEDICATIONS: 1. Entocort EC 3 mg 3 tablets p.o. q.a.m. 2. Plaquenil 200 mg p.o. b.i.d. 3. CellCept 1000 mg p.o. b.i.d. 4. Requip 1 mg p.o. q.h.s. 5. Lomotil 2.5 mg 2 tablets p.o. q.i.d. p.r.n. diarrhea.
EC|enteric-coated|EC|156|157|ADMISSION  MEDICATIONS|3. Synthroid 150 mcg p.o. q.a.m. 4. Vicodin 5/500 p.o. q.h.s. p.r.n. pain. 5. Multivitamin 1 tab p.o. daily. 6. Calcium carbonate 500 mg p.o. q.a.m. 7. ASA EC 81 mg p.o. q.a.m. 8. Melatonin 5 mg p.o. q.h.s. for sleep. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient denies smoking, illicit drug use, and any past IV drug use.
EC|enteric-coated|EC|173|174|MEDICATIONS|7. One multivitamin by mouth every morning. 8. Navane 10 mg by mouth at bedtime. 9. Effexor 25 mg by mouth twice daily. 10. Clozaril 100 mg by mouth at bedtime. 11. Aspirin EC 81 mg by mouth every morning. 12. Carbidopa/levodopa 25/250 mg 4 times daily. 13. Flomax 0.8 mg by mouth at bedtime. 14. Tylenol 650 mg twice daily. 15. Sliding scale Novolin Regular injected subcu per sliding scale of: A. Blood sugars 150-200, give 3 units.
EC|enteric-coated|EC|268|269|MEDICATIONS|PAST SURGICAL HISTORY: Bilateral inguinal hernia repair. Denies heart disease, diabetes, asthma, renal disease, hepatitis, gallbladder disease, thyroid disease, seizure, tuberculosis, or anemia. ALLERGIES: Zoloft intolerance (nausea). MEDICATIONS: 1. Depakote 1000 mg EC at h.s. with 500 mg q.a.m. 2. Zyprexa 10 mg q.i.d. 3. Paxil 20 mg daily. 4. Risperdal 3 mg b.i.d. 5. A number of p.r.n. medications.
EC|enteric-coated|EC|168|169|INDICATION FOR CONSULTATION|His other medications include Purinethol 150 mg per day and Pentasa 16 tablets a day, at 1 gram four times day. He has not been on any folic acid. He did take Entocort EC for about two to three weeks in the past and he cannot remember what kind of response he had to that. EXAMINATION: ABDOMEN - nontender with no palpable masses or enlarged organs present.
EC|enteric-coated|EC|156|157|ASSESSMENT|He is asymptomatic now and is interested in trying some food. I am going to add some folic acid to his medications, and I am going to start him on Entocort EC 9 mg per day, decrease his Solu-Medrol now to every 12 hours, and advance his diet and see how he tolerates it.
EC|enteric-coated|EC|126|127|CURRENT MEDICATIONS|She denies any fevers, chills, sore throat, or cough. PAST MEDICAL HISTORY: As listed above. CURRENT MEDICATIONS: 1. Depakote EC 750 mg b.i.d. 2. Minocycline 100 mg q morning. 3. Seroquel 400 mg h.s. 4. Zyprexa 30 mg h.s. 5. Clonazepam 1 to 2 mg at h.s. 6. Colace 1 h.s.
EC|enteric-coated|EC,|127|129|MEDICATIONS|He denies alcohol use. MEDICATIONS: 1. Depakote ER 2000 mg at h.s. 2. Viread 200 mg q. day. 3. Sustiva 600 mg at h.s. 4. Videx EC, 250 mg at h.s. 5. Epivir 300 mg q. day. 6. Prozac 20 mg q. day. 7. Seroquel 250 mg at h.s. 8. Coumadin 4 mg q. day. 9. Klonopin 0.5 mg q.i.d., 1 mg at h.s. ALLERGIES: None.
EC|enteric-coated|EC,|128|130|RECOMMENDATIONS|He has had no recent changes in his retroviral therapy and is adherent. 2. He was on 4 retroviral drugs including Viread, Videx EC, Epivir, and Viramune. The most likely problem drugs are Videx and Viramune, but it is unusual to develop pancreatitis after being on them for an extended period of time.
EC|epirubicin|EC|131|132|HISTORY OF PRESENT ILLNESS|In total, 1 of 16 lymph nodes showed involvement of metastatic disease. After her surgery Ms. _%#NAME#%_ has undergone 6 cycles of EC chemotherapy and has thus far completed 2 cycles of dose-dense Taxol out of a planned 4 cycles. She is scheduled to finish her fourth cycle on _%#MMDD2007#%_.
EC|enteric-coated|EC|190|191|MEDICATIONS|3. Hypertension. 4. Convulsion disorder. 5. Schizoaffective disorder. 6. Asthma. 7. Anxiety disorder. MEDICATIONS: 1. Lisinopril 20 mg p.o. daily. 2. Seroquel 200 mg at bedtime. 3. Depakote EC 250 three times a day. 4. Hydrochlorothiazide 25 mg p.o. every day. 5. Glucophage 500 mg p.o. twice a day. 6. Advair 250/50 one puff b.i.d. 7. Ventolin 2.5 mg q.i.d. p.r.n. ALLERGIES: Noted to penicillin.
EC|enteric-coated|EC|155|156|ADMISSION MEDICATIONS|7. Metoprolol 50 mg b.i.d. 8. Protonix 40 mg b.i.d. 9. Lisinopril 5 mg daily. 10.Hydrochlorothiazide 12.5 mg daily. 11.Simvastatin 40 mg daily. 12.Aspirin EC 81 mg daily. 13.Platol 100 mg daily. 14.Magnesium oxide 400 mg b.i.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient smokes a pack a day. He drinks alcohol, a fifth of vodka and he denies the use of illegal or recreational drugs.
EC|enteric-coated|EC|165|166|HISTORY OF PRESENT ILLNESS|Again the current episode has been approximately 3 weeks ago and has varied in intensity. She was seen on Friday outside of the hospital and was started on entocort EC 9 mg daily. She thinks that has probably helped her symptoms somewhat. At the time of my evaluation the patient's status has improved.
EC|enteric-coated|EC|214|215|ASSESSMENT/RECOMMENDATIONS|1. We recommend allowing the patient to advance her diet prior to discharge to see if she is able to maintain symptom control after the initiation of her food. 2. We recommend that patient be continued on Entocort EC at 9 mg daily for 8 weeks. 3. We recommend that potassium be continued 1500 mg p.o. b.i.d. 4. We recommend arranging an outpatient appointment for Ms. _%#NAME#%_ with Dr. _%#NAME#%_ _%#NAME#%_ in 4 weeks after discharge.
EC|enteric-coated|EC|261|262|ASSESSMENT AND RECOMMENDATIONS|We discussed this with her at length. We will attempt a colonoscopy tomorrow however if she has significant difficulty or discomfort, we will abandon the procedure and plan for a colonoscopy under general anesthesia on Friday of this week. 2. Continue Entocort EC at 9 mg daily for 8 weeks. 3. Continue electrolyte replacement as needed for the persistent diarrhea. At the time of discharge, patient should continue to have an outpatient appointment scheduled with Dr. _%#NAME#%_ _%#NAME#%_ approximately 4 weeks after discharge.
EC|enteric-coated|EC|98|99|MEDICATIONS|8. History of multiple surgeries for an anal fistula. ALLERGIES: Aldara. MEDICATIONS: 1. Depakote EC 1000 mg twice a day. 2. Gabapentin 1200 mg twice a day. 3. Risperdal 0.5 mg in the morning, 0.5 mg at noon and 4 mg each day at bedtime.
EC|enteric-coated|EC|345|346|SUMMARY OF CASE|She also had renal insufficiency on entry to the hospital on this occasion on _%#MM#%_ _%#DD#%_, but her renal function has improved. Prior to admission she was on a variety of medications including Ativan on a p.r.n. basis, azathioprine 150 mg daily, Wellbutrin 150 mg twice a day, Compazine on a p.r.n. basis, Ditropan XL 5 mg daily, Entocort EC 3 mg capsules per rectum daily, Prozac 20 mg per day, Benadryl 25 mg, folate 1 mg a day, Vicodin p.r.n., iron supplements, loperamide 2 capsules 3 times daily.
EC|enteric-coated|EC.|172|174|OUTPATIENT MEDICATIONS|12. Coronary artery disease. 13. Hematuria. 14. Cholecystectomy. 15. History of anal sphincter dilatation. ALLERGIES: Ibuprofen, ASA. OUTPATIENT MEDICATIONS: 1. __________ EC. 2. Lisinopril. 3. Wellbutrin. 4. Cozaar. 5. ___________. 6. Zantac. 7. Loperamide. 8. Zofran. 9. Lomotil. 10. Reglan. 11. Percocet. FAMILY HISTORY: Prostate cancer, cholangiocarcinoma, celiac disease, and neurofibromatosis.
EC|enteric-coated|EC|163|164|MEDICATIONS|3. Bentyl 20 mg b.i.d. 4. Ferrous gluconate 324 mg p.o. once a day. 5. Vicodin 5/500 1-2 tablets every 4-6 hours p.r.n. 6. Magnesium oxide 400 mg t.i.d. 7. Asacol EC 400 mg b.i.d. 8. Lopressor 50 mg b.i.d. 9. Viokase 8 formula 1 t.i.d. 10. Protonix 40 mg once a day. 11. Prednisone 20 mg once a day.
EC|enteric-coated|EC|136|137|MEDICATIONS|5. Ketoprofen gel t.i.d. to the chest and the back. 6. Lidoderm in magnesium oxide 400 mg t.i.d. 7. Megace 800 mg once a day. 8. Asacol EC 800 mg b.i.d. 9. Lopressor 100 mg b.i.d. 10. Remeron 15 mg at bedtime. 11. Viokase 8, 3 tablets p.o. with meals.
EC|enteric-coated|EC,|238|240|RECOMMENDATIONS|3. She has chronic pain syndrome. She is status post lumbosacral decompression and has associated dysesthesia in the lower extremities. RECOMMENDATIONS: 1. I reviewed her retroviral medications wit her. She has been using Viracept, Videx EC, and Zerit for over 5 years. She claims to be adherent to the regimen, but the exception is that she only uses Videx for about 10 days per month.
EC|enteric-coated|EC|287|288|SUMMARY OF CASE|She has raised concerns about her medications and feels as though she is developing a buffalo hump and fatty deposits around her abdomen. She thinks it is related to her retroviral medications. On quizzing her, she tells me that she has been using Viracept 5 capsules twice daily, Videx EC once a day, and Zerit 40 mg twice daily for over 5 years. She is convinced that the Zerit or the Videx are contributing to her body changes.
EC|enteric-coated|EC|143|144|MEDICATIONS|No low back pain at this time. MEDICATIONS: Current list: 1. Allegra p.r.n. 2. Nasacort. 3. Cyanocobalamin. 4. Albuterol. 5. Asacol tab 400 mg EC p.o. t.i.d. 6. Tigan suppositories p.r.n. 7. Zoloft 100 mg p.o. q.d. 8. A.S.A. 9. Questran. 10. Tricor 160 mg per day.
EC|enteric-coated|EC|123|124|ADMISSION MEDICATIONS|ADMISSION MEDICATIONS: 1. Keppra 1000 mg p.o. b.i.d. 2. Neurontin 300 mg p.o. t.i.d. 3. Aspirin 81 mg p.o. q.a.m. 4. Creon EC 30 mg p.o. with meals and 10-20 mg p.o. with snacks. 5. Clonazepam. 6. Paxil-CR. 7. Prilosec 20 mg p.o. each day at bedtime.
EC|enteric-coated|EC|147|148|ADMISSION MEDICATIONS|He had a small bowel resection and revision of the ileocolic anastomosis. ADMISSION MEDICATIONS: 1. Mercaptopurine 150 mg a day. 2. Enteric coated EC 3 mg t.i.d. 3. Misoprostol 200 mcg p.o. daily. DRUG ALLERGIES: Sulfa, penicillin, Ceclor and Augmentin because one of these medications caused his Stevens-Johnson syndrome.
EC|enteric-coated|EC|118|119|ADMISSION MEDICATIONS|20. Tylenol 650 mg p.o. q.i.d. p.r.n. pain or fever. 21. Colace 100 mg p.o. b.i.d. p.r.n. constipation. 22. Bisacodyl EC 5 mg p.o. daily p.r.n. constipation. 23. Lactase 250 mg p.o. with meals, lactose intolerance. ALLERGIES: Penicillin causes her throat to close.
EC|enteric-coated|EC|188|189|SUMMARY OF CASE|The patient is taking his retroviral medications fairly regularly but, in fact, when his prescription ran out about a week or so ago, he stopped them. He is using Sustiva, Zerit and Videx EC and is also on trazodone. He is not convinced that the trazodone is helpful to him. REVIEW OF SYSTEMS: He denied fevers or toxic symptoms. He has had no nausea or vomiting.
EC|enteric-coated|EC|154|155||4. Recommendations: - Discontinue IVF - Lasix 20 mg IV BID today, will change to 40 mg PO QD tomorrow - Continue treatment with lisinopril and metoprol - EC ASA 81 mg QD 5. I will follow up again tomorrow. I do not recommend any invasive diagnostic procedures from a CV point of view.
EC|enteric-coated|EC|193|194||2. Minimal fluid overload. 3. Acute on chronic renal failure, now improving. 4. Recommendations: - NS 75 cc/h for 6 hours only - Hold lasix today - Discontinue lisinopril - Continue metoprol - EC ASA 81 mg QD
EC|enteric-coated|EC|165|166|ADMISSION MEDICATIONS|5. No history of cardiopulmonary disease, hypertension or diabetes. PAST SURGICAL HISTORY: None. ADMISSION MEDICATIONS: 1. Seroquel. 2. BuSpar. 3. Haldol. 4. Asacol EC 800 mg p.o. t.i.d., patient states he has been noncompliant with this medication. ALLERGIES: No known drug allergies. SOCIAL HISTORY/HABITS: The patient is single with no children.
EC|enteric-coated|EC|206|207|ADMISSION MEDICATIONS|6. No history of cardiopulmonary disease, hypertension or diabetes. PAST SURGICAL HISTORY: None. ADMISSION MEDICATIONS: 1. Risperdal. 2. Zoloft. 3. Prevacid. 4. Ferrous sulfate 325 mg p.o. b.i.d. 5. Asacol EC 800 mg p.o. t.i.d. ALLERGIES: Ibuprofen (nausea and stomach pain). SOCIAL HISTORY: The patient is single. No children. States he is sexually active and has a history of unprotected sex and would like STD testing on this admission.
EC|enteric-coated|EC|136|137|OUTPATIENT MEDICATIONS|2. Status post cesarean section. 3. History of ECT. OUTPATIENT MEDICATIONS: 1. Levaquin 250 mg p.o. q.h.s. X 4 days. 2. Depakote 500 mg EC at h.s. 3. Paxil. 4. Zyprexa. 5. Albuterol two puffs prn. 6. Advair Discus 250/50 one puff p.o. b.i.d. 7. Albuterol neb. 8. Imodium prn. 9. Ketoconazole cream at h.s. to skin folds.
EC|enteric-coated|EC.|239|241|ADMISSION MEDICATIONS|PAST SURGICAL HISTORY: 1. Tonsillectomy/adenoidectomy. 2. Cataract surgery. 3. Eyelid surgery secondary to exophthalmos. 4. Thyroid ablation, 1973 (as above). ADMISSION MEDICATIONS: 1. Timolol eyedrops. 2. __________ eye drops. 3. Aspirin EC. 4. Amlodipine. 5. Atenolol. 6. Quinapril. 7. Synthroid 8. Seroquel. 9. Antabuse. 10. Wellbutrin SR. 11. Docusate. ALLERGIES: No known drug allergies. SOCIAL HISTORY/FAMILY HISTORY: Reviewed, as documented per FCIS and per chart.
EC|enteric-coated|EC|129|130|MEDICATIONS|4. Prochlorperazine 10 mg p.o. p.r.n. q. 6h. 5. Diltiazem HCl ER 120 mg p.o. b.i.d. 6. Allopurinol 300 mg p.o. daily. 7. Aspirin EC 81 mg p.o. daily. 8. Hydrochlorothiazide 25 mg p.o. daily. 9. Lisinopril 40 mg p.o. daily. 10. Folic acid 1 mg p.o. daily. 11. Lexapro 20 mg p.o. daily.
EC|enteric-coated|EC|276|277|MEDICATIONS INCLUDE|Her troponins so far as negative. The patient has not been complaining of chest pain or chest pressure and she has not been complaining of shortness of breath on this admission. MEDICATIONS INCLUDE: 1. Atenolol 100 mg PO Q day 2. Hydrochlorothiazide 25 mg PO Q day 3. Aspirin EC 81 mg PO Q day 4. Nifedipine 20 mg PO t.i.d. 5. Lipitor 10 mg PO Q day 6. Levothyroxine 75 mcg. PO Q day 7. Plavix 75 mg PO Q day PAST MEDICAL HISTORY : Includes 1. Hyperlipidemia
EC|enteric-coated|EC|237|238|DISCUSSION|We then turned our attention to the various treatment regimens available to her, and I specifically discussed with her the possibility of enrolling in a national cancer clinical trial entitled MA-21. This is a phage 3 trial of sequenced EC followed by Taxol versus sequenced AC followed by Taxol versus CEF. This is for patient who are either premenopausal or early post-menopausal who have node-positive disease.
EC|enteric-coated|EC|127|128|MEDICATIONS|ALLERGIES: Penicillin (swelling). MEDICATIONS: Preoperatively: 1. Lisinopril 20 mg daily. 2. Zoloft 200 mg daily. 3. Arthrotec EC 75 mg b.i.d. 4. Synthroid 125 mcg daily. 5. Vytorin 10/40 mg 1 daily. 6. Fosamax 70 mg weekly, on Mondays. 7. Lorazepam 0.5 mg b.i.d.
EC|enteric-coated|EC|175|176|CURRENT MEDICATIONS|2. Type 2 diabetes. 3. Gastroesophageal reflux disease 4. History of DVT. 5. Unspecified right eye surgery in the 1970s. CURRENT MEDICATIONS: 1. Asacol 800 t.i.d. 2. Entocort EC 9 mg daily. 3. Prevacid 30 mg b.i.d. 4. Ferrous sulfate 325 mg daily. 5. Benadryl 25-50 mg q.4 h. p.r.n. 6. Compazine 5 mg IV q.6 h. p.r.n.
EC|enteric-coated|EC|155|156|MEDICATIONS|3. Albuterol MDI 2 puffs q.i.d. 4. Atrovent 2 puffs t.i.d. 5. Risperdal 4 mg p.o. b.i.d. 6. Soriatane 35 mg q.d. 7. Depakote 1000 mg p.o. q.d. 8. Depakote EC 1250 mg q.h.s. FAMILY HISTORY: His family history is non-contributory with no history of colon cancer.
EC|enteric-coated|E.C.|169|172|ADMISSION MEDICATIONS|5. Prevacid 30 mg daily. 6. Provigil 200 mg daily. 7. Acetaminophen 500 mg 2 tablets each day at bedtime p.r.n. 8. Acidophilus caps. 9. M-lactin 12% lotion. 10. Aspirin E.C. 325 mg daily. 11. Benefiber 2 tablespoons daily. 12. Calcium carbonate/vitamin D 600/200 mg twice daily. 13. Cranberry pills 1 tab daily. 14. Senna 1-2 tablets p.r.n.
EC|enterocutaneous|EC|178|179|PHYSICAL EXAMINATION|Alert and oriented. CARDIOVASCULAR: Heart regular rate and rhythm. RESPIRATORY: Clear. ABDOMEN: Soft and non-tender. The patient has a large right chronic abdominal wound with 2 EC fistulas. EXTREMITIES: Warm and well perfused. NEUROLOGIC: No focal neurologic deficit detected. IMAGING: CT scan of the abdomen demonstrated a 3 mm stone in the lower pole collecting system of the right kidney.
EC|enteric-coated|EC|141|142|ADMISSION MEDICATIONS|2. Diovan 160 mg p.o. q. tabs q.a.m. 3. Tenex 2 mg p.o. b.i.d. 4. Dipyridamole 50 mg b.i.d. 5. Lipitor 10 mg p.o. daily in the afternoon. 6. EC ASA 325 mg p.o. 2 times weekly. 7. Sinemet CR 25/100 p.o. q. Monday through Friday 5 days a week. 8. Nasacort nasal spray, 2 sprays each nostril every afternoon.
EC|enteric-coated|EC|118|119|MEDICATIONS|3. Dobutamine drip 3 mcg per kilogram per minute 4. Furosemide 40 mg IV q8h 5. Zofran 4 mg IV q6h prn 6. Pantoprazole EC 40 mg po q a.m. 7. Paroxetine 10 mg po every night 8. Potassium chloride 20 mEq po twice daily 9. Prednisone 4 mg po daily ALLERGIES: She has a sensitivity to Cipro which causes diarrhea.
EC|enteric-coated|EC|222|223|ASSESSMENT AND PLAN|Other than that, it is unremarkable. I reviewed the CT report, which suggests that the patient has some type of inflammatory bowel disease in the small intestine. At this point, I am going to start the patient on Entocort EC 9 mg per day and check her stool for culture and C. difficile toxin. Since she is relatively comfortable now, I am going to try her back on her diet and see if she can tolerate that.
EC|enterocutaneous|EC|210|211|PHYSICAL EXAMINATION|ABDOMEN: Soft. She has a GJ tube in place. She also has a percutaneous jejunostomy tube in place, which is proximal to her current enterocutaneous fistulas. She has an open midline wound due to her most recent EC fistula. She has no obvious suprapubic tenderness. GU: She has a Foley catheter in place, which is yellow in color. NEUROLOGICAL: Nonfocal. LABORATORY ANALYSIS: A creatinine on _%#MM#%_ _%#DD#%_ shows a level of 0.72. A urine culture dated _%#MM#%_ _%#DD#%_ shows greater than 100,000 colonies of group D Enterococcus.
EC|enteric-coated|EC|141|142|MEDICATIONS|6. Perforated colon, status post colostomy. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Ditropan XL 10 mg one p.o. q day 2. Depakote EC 250 mg q a.m. 3. Lasix 80 mg p.o. q day 4. Aspirin 81 mg p.o. q day 5. Ibuprofen 600 mg p.o. b.i.d.
EC|enteric-coated|EC|162|163|MEDICATIONS|2. Depakote EC 250 mg q a.m. 3. Lasix 80 mg p.o. q day 4. Aspirin 81 mg p.o. q day 5. Ibuprofen 600 mg p.o. b.i.d. 6. Klor-Con Sax 10 mEq p.o. b.i.d. 7. Depakote EC 500 mg one p.o. q h.s. 8. Vicodin p.r.n. SOCIAL HISTORY: She resides in assisted living in a nursing home.
EC|enteric-coated|EC|235|236|MEDICATIONS AT TIME OF TRANSFER HERE|She does not recall having had stroke procedure like activity in the past, she is now known to be diabetic, she has not been treated for hypertension. PSYCHIATRIC HISTORY: Unremarkable. MEDICATIONS AT TIME OF TRANSFER HERE: 1. Aspirin EC 325 mg daily. 2. Lipitor 40 mg daily. 3. Colace 100 mg b.i.d. 4. Bactrim double strength 1 tablet twice daily to complete therapy _%#MMDD2005#%_.
EC|enteric-coated|EC|155|156|ADMISSION MEDICATIONS|9. Multivitamin one p.o. daily. 10. Vytorin 10/20 mg p.o. each day at bedtime. 11. Ambien CR 12.5 mg p.o. each day at bedtime p.r.n. insomnia. 12. Aspirin EC 81 mg p.o. daily. ALLERGIES: No known drug allergies except for codeine, he gets GI symptoms with that.
EC|enteric-coated|EC.|262|264|CURRENT MEDICATIONS|Respiratory rate is 20. LUNGS: Clear. CURRENT LABORATORY DATA: INR 2.67. WBC 8.7, hemoglobin 10.5. His electrolytes are all normal. Creatinine 0.79. Calcium level is 8.1. CURRENT MEDICATIONS: 1. Vancomycin. 2. Flagyl. 3. Ciprofloxacin. 4. Digoxin. 5. Divalproex EC. 6. Imipenem/cilastatin. 7. Itraconazole. 8. Metronidazole. 9. Phenytoin. 10. Psyllium. 11. Ranitidine. 12. Warfarin. 13. Tylenol p.r.n. 14. Percocet. 15. Simethicone.
EC|MISTAKE:EZ PAP|EC|141|142|RECOMMENDATIONS|This bronchial stent has mucous secretions adherent to it or possible tumor within it. RECOMMENDATIONS: 1. Sputum culture. 2. Mucolytics and EC PAP device. 3. Limited follow-up CT scan of chest, after a day of nebs and mucolytics to reevaluate bronchial stent.
EC|enteric-coated|EC|178|179|CURRENT MEDICATIONS|4. Albuterol inhaler 2 puffs q.i.d. p.r.n. Additional medications in the hospital include: 1. Ancef 1 gram IV q.8h. Stop after 3 doses. 2. Cepacol lozenges p.o. q.1h. 3. Aspirin EC 325 mg p.o. daily. 4. D5 half with 20 of K at 125 cc an hour. 5. Dilaudid 0.1 to 0.2 mg injected q.1h. p.r.n. severe pain.
EC|enteric-coated|EC|191|192||No murmurs heard. Abdomen was soft, with normal bowel sounds. Neuro check was unremarkable. The patient's medications were reviewed, including Tricor 108 mg daily, Viread 300 mg daily, Videx EC 400 mg daily, Viramune 200 mg b.i.d., and Epivir 150 mg b.i.d. He had laboratory studies done in _%#MM#%_ that showed HIV viral load of 5800 and CD4 count of 725.
EC|enteric-coated|EC|249|250|REASON FOR VISIT|REASON FOR VISIT: Mr. _%#NAME#%_ came in for follow-up of his HIV disease and hyperlipidemia. In the interval since I last saw the patient, he has reinitiated retroviral therapy with four drugs; namely, Viramune 200 mg b.i.d. and 200 mg q.d., Videx EC 400 mg q.d., Viread 300 mg q.d., and Epivir 50 mg b.i.d. His antilipid medication at the present time is Tricor 2 tablets daily.
EC|enteric-coated|EC|152|153|PRESENT MEDICATIONS|4. Maalox p.r.n. 5. Trilafon 2 mg b.i.d. 6. Baclofen 10 mg q.i.d. 7. Bupropion SR 150 mg b.i.d. apparently started for smoking cessation. 8. Divalproex EC 500 mg daily. 9. Tolterodine LA 4 mg daily. 10. Atacand 2 mg daily. 11. Macrobid 100 mg b.i.d. x 10 days started at home on _%#MMDD2003#%_ presumably for urinary tract infection.
EC|enterocutaneous|EC.|180|182||Mr. _%#NAME#%_ came in for follow-up of his HIV disease. In the interval since I last saw him, he has been on retroviral therapy using a combination of Viramune, Ziagen, and Videx EC. He has also been on Zoloft 100 mg daily. Unfortunately, he reports daily constant and intractable nausea that seems to be worse after he uses his medications.
EC|enteric-coated|EC|175|176|OUTPATIENT MEDICATIONS|6. Migraines 2 years. 7. Incontinence 2 years. 8. Nausea 2 years. 9. Sleep problems 5 years. OUTPATIENT MEDICATIONS : 1. Albuterol inhaler 2 puffs q.4 hours p.r.n. 2. Aspirin EC 81 mg p.o. q. day. 3. Calcium 500 mg p.o. nightly. 4. Clozapine 100 mg p.o. nightly. 5. Docusate sodium 100 mg p.o. b.i.d.
EC|enteric-coated|EC|228|229|MEDICATIONS|He has had radiation treatment. 6. Status post cataract operations affecting both the left and the right eye in _%#MM2006#%_. MEDICATIONS: 1. Atenolol 25 mg p.o. daily. 2. Selegiline 5 mg p.o. b.i.d. 3. Lupron shots. 4. Aspirin EC 81 mg daily. ALLERGIES: No known drug allergies. FAMILY HISTORY: The patient's sister had a myocardial infarction. It appears that the patient's sons are relatively healthy.
EC|enteric-coated|EC|183|184|CURRENT MEDICATIONS|She does not smoke or drink alcohol. FAMILY HISTORY: Noncontributory. ALLERGIES: Lomotil, Cipro and histamines. CURRENT MEDICATIONS: Tylenol Extra Strength 1 gram t.i.d. and Entocort EC 9 mg q. day, Synthroid 0.025 mg daily, Senokot 1 daily, Ativan 0.5 mg q. 12 hours p.r.n.. REVIEW OF SYSTEMS: Cardiovascular: No chest pain, shortness of breath or history of hypertension or heart disease.
EC|enterocutaneous|EC.|140|142|MEDICATIONS ON ADMISSION|ALLERGIES/INTOLERANCES: 1. Percocet. 2. Sea food. MEDICATIONS ON ADMISSION: 1. Celebrex 2. Avandia. 3. Atenolol. 4. Enalapril. 5. Sulfazine EC. 6. Aspirin low dosage. 7. She had been on methotrexate in times past but no longer uses it and is not on steroid therapy.
EC|enteric-coated|EC|118|119|MEDICATIONS|He denies using any street drugs. MEDICATIONS: 1. Calcium plus vitamin D. 500 three tablets p.o. q. daily 2. Depakote EC per 200 mg in the evening 3. Estazolam 2 mg p.o. q. at bed-time p.r.n. 4. Glucosamine chondroitin 500/400 two tabs p.o. daily
EC|enteric-coated|EC.|159|161|ADMISSION MEDICATIONS|14. History of genital herpes. 15. History of left great toe gout. 16. Lactose intolerant. ADMISSION MEDICATIONS: 1. Docusate sodium. 2. Acyclovir. 3. Aspirin EC. 4. Effexor XR. 5. Lactase enzyme. 6. Bactrim SS. 7. Benadryl. 8. Prevacid. 9. Dyazide. 10. Calcium carbonate. 11. Trazodone. 12. Fish oil. ALLERGIES: No known drug allergies.
EC|enteric-coated|EC,|138|140|PLAN|I told him he could use ibuprofen, if necessary, as well. We will change his lamivudine to once a day dosing schedule, continue his Videx EC, and I encouraged him to take his Crixivan more compliantly. The patient seemed agreeable to this plan. We will see him in follow-up in about six months' time or p.r.n.
EC|enteric-coated|EC.|193|195|ADMISSION MEDICATIONS|2. Terminal ileum and ascending colon resection in 1974 with subsequent revision. ADMISSION MEDICATIONS: 1. Seroquel. 2. Lexapro. 3. Lamictal. 4. Folic acid. 5. Aciphex. 6. Asacol. 7. Entocort EC. 8. Methotrexate. 9. Protonix. 10. Prednisone. 11. Diflucan. 12. Ativan. 13. Multivitamin. ALLERGIES: No known drug allergies. SOCIAL HISTORY/FAMILY HISTORY: Reviewed as documented per FCIS and chart.
EC|enteric-coated|EC|189|190|CURRENT MEDICATIONS|2. Clozaril 100 mg at h.s. (Vivian was on Zyprexa earlier, but this has been weaned off.) 3. Medroxyprogesterone 2.5 mg a day. 4. Cogentin 0.5 mg twice a day on a p.r.n. basis. 5. Depakote EC 250 mg in the morning and 500 mg at h.s. 6. Estrogen 0.75 mg a day. 7. Sinemet ER 50/200 1 t.i.d. 8. Sonata 5-10 mg at h.s. MEDICATION ALLERGIES: None. FAMILY AND SOCIAL HISTORY: As per the chart.
EC|enteric-coated|EC|121|122|ADMISSION MEDICATIONS|2. Digoxin 250 mcg daily. 3. Flovent 110 mcg twice daily. 4. Diltiazem ER 120 mg by mouth daily. 5. Seroquel 6. Depakote EC 7. Risperdal. 8. Coumadin 2 mg by mouth daily. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient denies smoking.
EC|enterocutaneous|EC|163|164|ADMISSION MEDICATIONS|3. Norvasc 10 mg p.o. q.a.m. 4. Estratest 1.25/2.5 mg p.o. daily. 5. Nasonex 1 spray each nostril q. day p.r.n. rhinitis. 6. Prilosec 20 mg p.o. daily. 7. Aspirin EC 81 mg p.o. daily. 8. Ibuprofen 200 mg, 4 tabs p.o. q.8 h. p.r.n. pain. ALLERGIES: 1. Bextra. 2. Ultram. SOCIAL HISTORY: The patient is married.
EC|enteric-coated|EC|205|206|MEDICATIONS|He has risk factor from hypertension. He is also noted to have a history of dementia. MEDICATIONS: His medications on this admission include lisinopril, doxazosin, atenolol, HTCZ, Plavix 75 mg q. day, and EC aspirin 1 q. day. PAST MEDICAL HISTORY: Other than the neurological history noted above, is notable for cataract repair and benign prostatic hypertrophy.
EC|enteric-coated|EC|95|96|MEDICATIONS|5. There is no history of history of hypertension or cardiac disease. MEDICATIONS: 1. Depakote EC 250 mg four times a day. 2. Sertraline 150 mg twice a day. 3. Glatiramer injections 20 mg q. day. 4. Aricept 10 mg a day. 5. Premarin .625 mg a day.
EC|enteric-coated|EC|153|154|MEDICATIONS|1. Synthroid 100 mcg daily, 2. Sertraline 100 mg daily, 3. Atenolol 10 mg daily. 4. Lisinopril 40 mg daily. 5. Tapavite 1 tablet p.o. daily. 6. Depakote EC 250 mg b.i.d., 7. Lorazepam 0.5 mg b.i.d. 8. Proctosol HC 2.5% cream, apply as directed, 9. Imodium p.r.n. 10. Hydrochlorothiazide 12.5 mg. 11. Microbid 100 mg p.o. b.i.d. x10 days begin _%#MM2003#%_.
EC|enterocutaneous|EC|180|181|MEDICATIONS|This was noted in _%#MM#%_ 2002. MEDICATIONS: 1. House supplement q.i.d. _________ 2. _____________ 3. Refresh eyedrops, one to two drops in both eyes five times a day. 4. Aspirin EC one tab p.o. q day. 5. Erythromycin ointment, half inch ribbon to both eyes qhs. 6. Cerovite liquid 15 cc p.o. q day for anemia.
EC|enteric-coated|EC|280|281|MEDICATIONS|At that time she had had an overall decline and again seemed a bit obtunded and limited in terms of her overall level of cooperation. MEDICATIONS: As listed at home include aspirin, baclofen 10 mg t.i.d., calcium carbonate, clonazepam in the early afternoon and morning, Depakote EC 500 mg t.i.d. Detrol LA, estradiol, Lipitor, Prevacid, Rebif subcutaneous Monday, Wednesday, Fridays, triamterene/hydrochlorothiazide, Vicodin and a vitamin B complex.
EC|enteric-coated|EC.|169|171|ADMISSION MEDICATIONS|10. Eucerin cream. 11. Synthroid. 12. Metoprolol SR. 13. Lasix. 14. Potassium chloride. 15. Ferrous sulfate. 16. Topamax. 17. Oxybutynin ER. 18. Omeprazole. 19. Aspirin EC. 20. Multivitamins. ALLERGIES: Lasix. Otherwise no known drug allergies.
EC|enteric-coated|EC.|224|226|PRESENT MEDICATIONS|The patient is not on any sort of antibiotic therapy. He does take his retroviral medications faithfully. PRESENT MEDICATIONS: Kaletra, Zerit, Carafate, Lipitor, Dapsone, Diflucan p.r.n., Prilosec, Avandia, metformin, Videx EC. EXAM: VITAL SIGNS: He is afebrile and normotensive. FOOT EXAM: The right foot shows the swelling in the toe, the erythema surrounding the ulcerated area, and the small streak into the medial arch or instep.
EC|enteric-coated|EC|127|128|PHYSICAL EXAMINATION|5. Lipitor 10 mg daily. 6. Metformin 500 mg twice daily. 7. Omeprazole 20 mg daily. 8. Sucralfate 1 gram twice daily. 9. Videx EC 1 capsule daily. 10. Zerit 40 mg twice daily. 11. Nebupent inhalation 300 mg every month. We had a long discussion today about his medications and asked him to get some labs done including a CBC, lipid profile, chemistry panel, and HIV viral load plus CD4 lymphocyte count.
EC|enteric-coated|EC|160|161|PREOPERATIVE MEDICATIONS|Plaquenil 200 mg daily. Clonazepam 0.5 mg daily. Evoxac 30 mg q.i.d. for Sjogren syndrome. Sinemet 25/100 1/2-tablet 3 times a day and 1 tablet q.h.s. Entocort EC 3-mg capsules 2 twice a day. Boniva 1 injection per month. Celebrex. Aspirin - which was on hold. SOCIAL HISTORY: The patient is retired. She lives with her husband.
EC|enteric-coated|EC|152|153|MEDICATIONS|He has had HIV screening in the past which has been negative. There is no history of IV drug use. MEDICATIONS: 1. Multivitamins once a day. 2. Depakote EC 1000 mg each day at bedtime. 3. Disulfiram 250 mg each day at bedtime. ALLERGIES: None. SOCIAL HISTORY: _%#NAME#%_ rents a room in the Highland area.
EC|enterocutaneous|EC|112|113|PRESENT MEDICATIONS|3. Clozaril 100 mg qam; 200 mg at 4 pm; 600 mg qhs. 4. Trileptal 600 mg bid. 5. Zestril 10 mg qam. 6. Bisacodyl EC 1 qhs. 7. Colace 100 mg bid. 8. Theophylline ER 200 mg qam. 9. Protonix 40 mg qd. 10. Xenical 120 mg tid. 11. Glucophage 1000 mg qhs; 850 mg qam.
EC|enteric-coated|EC|175|176|MEDICATIONS|No other known past medical history. PAST SURGICAL HISTORY: Double hernia repair as a child. MEDICATIONS: (1) Seroquel (2) Clonazepam (3) Melatonin (4) Risperdal (5) Depakote EC ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient denies any tobacco, alcohol, or street drug use.
EC|enteric-coated|EC|192|193|ADMISSION MEDICATIONS|PAST SURGICAL HISTORY: Umbilical hernia repair in _%#MM2006#%_. ADMISSION MEDICATIONS: 1. Altace 10 mg p.o. b.i.d. 2. Toprol-XL 100 mg p.o. daily. 3. Prilosec OTC 20 mg p.o. daily. 4. Aspirin EC 325 mg p.o. daily. 5. Lexapro. 6. Lorazepam. ALLERGIES: The patient has no known drug allergies.
EC|enteric-coated|EC|145|146|CURRENT MEDICATIONS|4. Status post excision of a Morton's neuroma of the right foot, _%#MM#%_ of 2004. CURRENT MEDICATIONS: 1. Atenolol 25 mg p.o. q day 2. Depakote EC 750 mg p.o. q p.m. 3. Depakote AC 1,000 mg q a.m. 4. Flonase nasal spray two sprays q day 5. Glucosamine chondroitin sulfate one p.o. b.i.d.
EC|UNSURED SENSE|EC|149|150|SOCIAL HISTORY/HABITS|PAST SURGICAL HISTORY: None. ADMISSION MEDICATIONS: Celexa. ALLERGIES: No known drug allergies. SOCIAL HISTORY/HABITS: The patient is a sophomore at EC High School. States her last menstrual period is"now." Denies reasons for STD testing. Smokes 3 packs of cigarettes per week. Last used alcohol on _%#MMDD2007#%_.
EC|enteric-coated|EC|162|163|DISCHARGE MEDICATIONS|5. Triamcinolone 0.1% lotion applied to affected area twice a day. 6. Nystatin oral suspension 100,000 units/mL, 10 mL swish and spit 4 times a day. 7. Pancrease EC 1-3 caps by mouth with meals (lipase 4500 units, amylase 25,000 units, proteus 2000 units per cap). 8. Morphine 1-2 mg IV q.2h as needed for pain.
EC|enteric-coated|EC,|144|146|OUTPATIENT MEDICATIONS|10. Novolog insulin, 2 units subcu per sliding scale. 11. Slow-Fe 160 mg p.o. daily. 12. Ativan, 0.25 mg p.o. p.r.n. every 8 hours. 13. Aspirin EC, 81 mg p.o. daily. 14. Lantus, 9 units subcu once a day. ALLERGIES: Codeine. REVIEW OF SYSTEMS: Weight gain as noted above and worsening shortness of breath.
EC|enteric-coated|EC|142|143|MEDICATIONS ON DISCHARGE|4. Lasix 20 mg p.o. daily. 5. Synthroid 200 mcg p.o. daily. 6. Lisinopril 40 mg p.o. daily. 7. Simvastatin 80 mg p.o. q.p.m. 8. Aspirin 81 mg EC p.o. daily. 9. Serevent 50 mcg 2 puffs inhaled twice a day. 10. Combivent 1-2 puffs 4 times a day as needed for shortness of breath, chronic obstructive pulmonary disease.
EC|enteric-coated|EC|183|184|DISCHARGE MEDICATIONS|5. Organic brain syndrome, possible secondary opioid analgesia/toxicity. 6. Somatoform pain disorder. 7. Cognitive disorder, not otherwise specified. DISCHARGE MEDICATIONS: 1. Asprin EC 81 mg p.o. daily. 2. Lipitor 10 mg p.o. daily, may q.h.s. 3. Clonazepam 1 mg p.o. b.i.d. q. 12h. 4. Diltiazem 180 mg ER p.o. daily. 5. Estropipate 0.625 mg p.o. daily.
EC|enteric-coated|EC|177|178|DISCHARGE MEDICATIONS|7. Supplement magnesium oxide 140 mg by mouth b.i.d. 8. Gabapentin 300 mg by mouth t.i.d. pain. 9. Metformin 1000 mg by mouth b.i.d. diabetes mellitus, type 2. 10. Pantoprazole EC 40 mg by mouth b.i.d. gastritis. 11. Psyllium one packet by mouth q.a.m. constipation. 12. Magnesium citrate liquid 120 mg by mouth b.i.d. constipation.
EC|enteric-coated|EC|359|360|ADMISSION DIAGNOSES|She had bilateral hip surgery in 1995 and then in 2000. She has also had an open tubal ligation. ADMISSION MEDICATIONS: Inderal LA 60 mg p.o. daily, Paxil CR 25 mg p.o. daily, Lasix 20 mg p.o. daily, Fiorinal as needed for migraines, Vicodin as needed for neck pain, Neurontin 100 mg once daily, Prinivil 20 mg once daily, Prevacid 30 mg once daily, Entocort EC 3 mg b.i.d., Allegra 180 mg once daily, Levbid 0.375 mg as needed twice weekly. ALLERGIES: MACROBID which causes a rash and DOLOBID which causes mild agitation.
EC|enteric-coated|EC|275|276|DISCHARGE INSTRUCTIONS|She was asked to call with a temperature greater than 100.4, pain not controlled with oral medications, or increased drainage or swelling. DISCHARGE MEDICATIONS: Inderal LA 60 mg p.o. daily, Paxil 20 mg p.o. daily, Lasix 20 mg p.o. daily, Protonix 40 mg p.o. daily, Entocort EC 3 mg p.o. b.i.d., Allegra 180 mg p.o. daily, Colace 100 mg p.o. b.i.d. p.r.n., Prinivil 20 mg p.o. daily, Neurontin 100 mg p.o. at bedtime, Vicodin 1 to 2 tablets p.o. q.4-6h. p.r.n., ibuprofen 600 mg p.o. q.6h. p.r.n. FOLLOW UP: The patient was instructed to follow up with Dr. _%#NAME#%_ in 2 to 3 weeks.
EC|UNSURED SENSE|EC|154|155|HOSPITAL COURSE|The patient received Versed and Haldol IV, but they did not appeared to help. There were some concern that this episode could have been a seizure and the EC Team recommended EEG and a neurology consult before continuing with ECT. The concern of that she may have a lower seizure threshold especially in light of her having pretty long ECT seizures at low voltage.
EC|enterocutaneous|EC|245|246|HOSPITAL COURESE|After the placement of these, the patient began receiving tube feedings, however, this was complicated by pain at the tube site at the skin. As tube feedings increased, the patient was weaned from TPN over the next several weeks maintaining her EC fistula in the same intermittent dressing in VAC manner as discussed previously. By _%#MMDD2007#%_, tube feedings had reached goal, TPN was discontinued.
EC|enteric-coated|EC|185|186|DISCHARGE MEDICATIONS|Adjust as necessary per Coumadin Clinic for target INR of 2 to 3. 8. Lipitor 40 p.o. daily. 9. Lantus 72 units subcu q.h.s. 10. Lispro Humalog as previously dosed. 11. MVI. 12. Aspirin EC 81 mg p.o. daily. 13. Protonix 40 p.o. daily. 14. Claritin 10 p.o. q.h.s. for control of her seasonal allergies and rhinorrhea.
EC|enterocutaneous|EC|196|197|DISCHARGE MEDICATIONS|6. Folic acid 1 mg p.o. daily. This is also a new medication for anemia recommended by GI. 7. Lamictal 75 mg p.o. b.i.d. 8. Lithium carbonate 600 mg p.o. each day at bedtime. 9. Mesalamine Asacol EC 2400 mg p.o. b.i.d. 10. Mesalamine Canasa 1 g suppository p.r. each day at bedtime, if the patient is unable to take the medication p.o.
EC|enteric-coated|EC|171|172|CURRENT MEDICATIONS|SHE IS SENSITIVE TO AVAPRO WITH HYPOTENSION, NAUSEA AND DIARRHEA, CAPOTEN WITH COUGH, EES AND CODEINE WITH UPSET STOMACH. CURRENT MEDICATIONS: 1) Insulin pump. 2) Aspirin EC 81 mg p.o. daily. 3) Amiodarone 200 mg p.o. daily. 4) Carvedilol 6.25 mg in the a.m. and 12.5 mg in the p.m. 5) Torsemide 100 mg p.o. b.i.d. 6) Spironolactone 25 mg p.o. daily.
EC|enteric-coated|EC|179|180|DISCHARGE MEDICATIONS|13. Normal saline spray, two sprays each nostril 3 times a day. 14. Nitrostat, 1 million units suspension p.o. q.i.d. 15. Olanzapine 5 mg p.o. every day at bedtime. 16. Pancrease EC 10 one capsule p.o. twice a day take with each dose of Prograf. 17. Albuterol nebs twice a day. 18. Azathioprine 25 mg p.o. q.h.s.
EC|enteric-coated|EC|192|193|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Norvasc 10 mg p.o. daily. 2. Augmentin 500/875 p.o. twice a day for 10 days. 3. Metoprolol XL 50 mg p.o. daily. 4. Ibuprofen 200 mg p.o. q.4 h. as needed. 5. Aspirin EC 81 mg p.o. daily. FOLLOW-UP PLAN: 1. Continue Augmentin for a total of 10 days. 2. Continue blood pressure medications as described above per primary-care physician.
EC|enteric-coated|EC|129|130|DISCHARGE MEDICATIONS|I think it may be appropriate to pursue hospice for this patient. DISCHARGE MEDICATIONS: 1. Zoloft 100 mg p.o. daily. 2. Aspirin EC 81 mg p.o. daily. 3. Glargine insulin 18 units subcutaneously q.h.s. 4. Aspart insulin sliding scale subcutaneously three times per day, before meals, as delineated above.
EC|enterocutaneous|EC|143|144|DISCHARGE MEDICATIONS|2. Prednisone 20 mg PO daily. 3. Oxycodone 20 mg PO 3 times per day. 4. Oxycodone 5 mg PO twice per day, p.r.n. breakthrough pain. 5. Entocort EC 3 mg PO three times a day. 6. Colazal 2.25 g PO three times a day. 7. Prevacid SoluTab 15 mg sublingual daily. 8. Fish oil 1 g PO b.i.d.
EC|enteric-coated|EC|146|147|MEDICATIONS ON TRANSFER|16. Lopressor 50 mg p.o. b.i.d. 17. MOM 30 mL suspension p.o. p.r.n. for constipation. 18. Nasonex 2 sprays for both nostrils daily. 19. Protonix EC 40 mg p.o. daily. 20. Prednisone 40 mg p.o. daily. Stop after 3 times, administer between _%#MMDD#%_ to _%#MMDD2007#%_. 21. Prednisone 30 mg p.o. daily. Stop after 3 times, administer between _%#MMDD#%_ to _%#MMDD2007#%_.
EC|enteric-coated|EC|223|224|PROBLEM LIST|Our goal is to keep this patient's hemoglobin over 10 g due to his underlying severe coronary artery disease. 7. GI. Recent history of GI bleed but EGD showed grade B esophagitis and gastritis. He will continue on Protonix EC 40 mg p.o. b.i.d. 8. The patient will be seen by both Physical and Occupational Therapy in the a.m.
EC|enteric-coated|EC|336|337|PROBLEM #4|He was discharged on no diabetes medications and asked instead to keep close track of his blood sugars over the next two weeks and make an appointment with his primary physician at the end of that period to evaluate the need for restarting diabetes medications. PROBLEM #4: Seizure disorder. The patient was continued on his divalproex EC 750 mg t.i.d. It is unclear what the patient's initial presentation was in terms of his seizure disorder. He states that his last seizure was in 1986. Given his profound cytopenia, consideration may be given to a trial of medications or at least a review of the events leading up to his original placement on antiseizure medications.
EC|enteric-coated|EC|98|99|DISCHARGE MEDICATION|DISCHARGE DIAGNOSIS: Alcohol intoxication, recurrent chest pain. DISCHARGE MEDICATION: 1. Aspirin EC 81 mg p.o. daily. 2. Lipitor 20 mg p.o. q.h.s. 3. Metoprolol XL 25 mg p.o. b.i.d. 4. Nitroglycerin 0.4 mg sublingual p.r.n.
EC|enterocutaneous|EC|183|184|CURRENT OUTPATIENT MEDICATIONS|2. GoLYTELY one gallon daily p.r.n. 3. Colace 100 mg b.i.d. p.r.n. constipation. 4. Marinol 10 mg b.i.d. 5. Flonase 2 sprays each nostril b.i.d. 6. Keppra 1000 mg b.i.d. 7. Pancrease EC capsules MT16 one to three tablets before meals. 8. Protonix 40 mg p.o. b.i.d. 9. MiraLax 17 gm p.o. t.i.d. 10. Seroquel 75 mg each day at bedtime. 11. Senna 2 tablets twice daily.
EC|enteric-coated|EC|125|126|ADMISSION MEDICATIONS|1. Lactulose 30 cc p.o. t.i.d. 2. Protonix 40 mg p.o. daily. 3. DuoNebs p.r.n. 4. Neomycin1000 mg po b.i.d. 5. Aspirin 81 mg EC p.o. daily. 6. Bumex 4 mg p.o. b.i.d. 7. Mg 500 mg b.i.d. 8. Metoprolol 25 mg b.i.d. 9. Amiloride 10 mg b.i.d.
EC|enterocutaneous|EC|166|167|HISTORY OF PRESENT ILLNESS|The patient has difficulty getting out of bed. She is tired and weak. Head edema was resolved. The patient was complaining of lower abdominal pain on the side of the EC fistula. This is getting better. She had persistent nausea with and without food intake but no vomiting. She denies any chest pain, shortness of breath or hemoptysis.
EC|enterocutaneous|EC|187|188|HEART|The location of the enterocutaneous fistula is in the lower abdomen in the mid area. There is a Foley catheter in place. There are several small wounds in the lower abdomen (right o fthe EC fistula) was covered with eschar. EXTREMITIES: Mild edema and bilateral lower extremities with mild calf tenderness. NEUROLOGIC: The patient is oriented x 2. The patient is moving all extremities.
EC|enterocutaneous|EC|548|549|IMPRESSIONS AND PLAN|Electrolytes within normal limits except for chloride of 110, glucose 117, BUN 46, creatinine 1.20, calcium 11.4. Liver functions within normal limits except elevated alkaline phosphatase of 268, magnesium 2.4, phosphorus 6.8, and INR 1.83. IMPRESSIONS AND PLAN: 1. This is a 69-year-old female with history of chronic disease with multiple surgeries, with present RBC history of small-bowel obstruction and suspected ischemic bowel, status post abdominal surgery complicated with persistent abdominal abscess, status post drainage with sequela of EC fistula who is admitted to University of Minnesota Medical Center, Fairview, for continuation of medical care and reevaluation. The patient was admitted to medical floor, and patient will be kept n.p.o. with resumed total parenteral nutrition and lipids with electrolytes adjustment.
EC|enterocutaneous|EC|221|222|IMPRESSIONS AND PLAN|We will obtain ET nurse for wound care. We will optimize the patient's nutrition through total parenteral nutrition and lipids. We will keep n.p.o. except for medications. We will keep the ostomy and also check output of EC fistula. When the evaluations are done, we will have social work evaluate and placement to LTAC placement at the Regency Hospital, which is close to the patient's home.
EC|enteric-coated|EC|175|176|MEDICATIONS ON DISCHARGE|8. Ondansetron (Zofran) 4 mg oral tablet by mouth every 6 hours p.r.n. for nausea/vomiting. 9. Zofran 4 mg injection IV every 6 hours p.r.n. for nausea/vomiting. 10. Protonix EC 14 mg tablet by mouth twice a day p.r.n. 11. Ranitidine (Zantac) 150 mg tablet by mouth every day. 12. Senna/docusate (Senokot) 2 tablets by mouth every night at bedtime p.r.n. for constipation.
EC|enteric-coated|EC|158|159|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Benefiber one packet p.o./G-tube twice a day. 2. Prevacid 15 mg p.o. twice a day. 3. MiraLax 17 gm G-tube/p.o. daily. 4. Pancrecarb EC Caps 1-2 caps p.o. with meals. 5. Cytotec 10 mcg p.o./G-tube twice a day. 6. Mucomyst 30 mL G-tube q. day. 7. ADEK 1 mL p.o./G-tube q. day. 8. Albuterol 2.5 mg nebulizer twice a day.
EC|enteric-coated|EC|157|158|DISCHARGE MEDICATIONS|3. Levaquin 750 mg p.o. daily and after _%#MMDD2006#%_. 4. Clindamycin 450 mg p.o. q. 8 h and after _%#MMDD2006#%_. 5. Atenolol 50 mg p.o. b.i.d. 6. Aspirin EC 81 mg p.o. daily. 7. Lasix 20 mg p.o. daily. 8. Spironolactone 25 mg p.o. daily. 9. Albuterol 90 mcg inhaler two puffs with spacer q. 4 h and q. 2 h p.r.n. shortness of breath.
EC|enteric-coated|EC|177|178|MEDICATIONS|9. Clotrimazole cream 1%, apply twice a day. 10. Protonix 40 mg p.o. daily. 11. Hydrochlorothiazide 25 mg p.o. daily. 12. Ibuprofen, none appeared be taken recently. 13. Asprin EC 81 mg daily. ALLERGIES: No known drug allergies. FAMILY HISTORY: Not known by the caretaker. SOCIAL HISTORY: The patient does not smoke or drink.
EC|enteric-coated|EC|162|163|DISCHARGE MEDICATIONS|24. Rapamune 7 mg p.o. daily. 25. Trazodone 150 mg p.o. each day at bedtime. 26. Ambien 10 mg p.o. each day at bedtime. 27. Ritalin 10 mg p.o. t.i.d. 28. Aspirin EC 81 mg p.o. daily. 29. Norco 1-2 tabs p.o. q.4-6h. p.r.n. for pain. 30. Lidoderm patch 5%, change q.24h. 31. Fluconazole 150 mg p.o. daily.
EC|enteric-coated|EC|161|162|MEDICATIONS|12. Nexium 40 mg p.o. daily. 13. advair 250/50 bid 14. aricept 10mg daily 15. asmanex one daily. 16. deltrol 2 md daily. 17. ferrous sulfate 325 bid. 18. asprin EC STOPPED 7/5. The patient was on oxygen up until _%#MMDD#%_ and then that was discontinued.
EC|enteric-coated|EC|191|192|DISCHARGE MEDICATIONS|His discharge medications are essentially unchanged except this addition. DISCHARGE MEDICATIONS: 1. Seroquel 12.5 mg p.o. daily at 8:30 p.m. 2. Amiodarone 400 mg a.m. and 200 p.m. 3. Aspirin EC 81 mg p.o. daily. 4. Docusate 100 mg p.o. b.i.d. 5. Lexapro 10 mg p.o. daily for depression. 6. Synthroid 150 mcg p.o. daily.
EC|UNSURED SENSE|EC|103|104|IDENTIFICATION|She is accompanied by her mother, _%#NAME#%_ _%#NAME#%_ and her younger sister. She is a 9th grader at EC High School in _%#CITY#%_ _%#CITY#%_. Her primary physician is _%#NAME#%_ _%#NAME#%_. Her psychiatrist is _%#NAME#%_ _%#NAME#%_. Her therapist is _%#NAME#%_ _%#NAME#%_. History is provided by her mother as she is quite somnolent at this time.
EC|UNSURED SENSE|EC|174|175|SCHOOL HISTORY|Her mother states that one week prior to starting the 8th grade the patient told her mother "I think there is something wrong with my mind." She is currently a 9th grader at EC High School in _%#CITY#%_ _%#CITY#%_. She has had to withdraw from some honors courses because of her academic difficulty.
EC|enteric-coated|EC|336|337|PROBLEM #4|He was discharged on no diabetes medications and asked instead to keep close track of his blood sugars over the next two weeks and make an appointment with his primary physician at the end of that period to evaluate the need for restarting diabetes medications. PROBLEM #4: Seizure disorder. The patient was continued on his divalproex EC 750 mg t.i.d. It is unclear what the patient's initial presentation was in terms of his seizure disorder. He states that his last seizure was in 1986. Given his profound cytopenia, consideration may be given to a trial of medications or at least a review of the events leading up to his original placement on antiseizure medications.
EC|enteric-coated|EC|412|413|DISCHARGE MEDICATIONS|3. Gastroenterology. He had elevated lipase while he was in the hospital but was asymptomatic but we continued following his lipase which were improved while he was in the hospital, so we did not discontinue his antiretroviral medications, so we did continue on them though antiretroviral medications have a significant risk of pancreatitis. DISCHARGE MEDICATIONS: 1. Amprenavir 750 mg p.o. b.i.d. 2. Didanosine EC 250 mg p.o. daily. 3. Stavudine 40 mg p.o. b.i.d. 4. Bactrim single strength 1 tablet orally daily x1 month. 5. Tenofovir 300 mg orally daily. 6. Prednisone 40 mg p.o b.i.d.
EC|enteric-coated|EC|62|63|DISCHARGE MEDICATION|DISCHARGE MEDICATION: 1. Prevacid 30 mg p.o. q.d. 2. Depakote EC 500 mg p.o. t.i.d. 3. Fiber-Lax 625 mg p.o. b.i.d., hold if loose stools. 4. Flomax .4 mg p.o. q.d. 5. Metoprolol 25 mg p.o. b.i.d., hold if systolic blood pressure less than 100 or heart rate less than 60.
EC|enteric-coated|EC|164|165|MEDICATIONS|4. IVP dye (anaphylaxis). MEDICATIONS: 1. Adderall 40 mg at 8:00 a.m. and 12:00 noon. 2. Wellbutrin 150 mg b.i.d. 3. Lamictal 300 mg at h.s. 4. Mesalamine (asacol) EC 400 mg q.i.d. 5. Routine p.r.n. meds. FAMILY HISTORY: Per oral records. HABITS: Nonsmoker. No alcohol and no other drug use.
EC|enteric-coated|EC|169|170|MEDICATIONS|4. Status post resection of AAA. 5. Status post appendectomy in 1937. MEDICATIONS: 1. Cozaar 25 mg daily. 2. Allopurinol 100 mg x 2 daily. 3. Furosemide 80 mg daily. 4. EC ASA 81 mg daily. 5. Protonix 40 mg daily. 6. Fexofenadine (Allegra) 60 mg b.i.d. 7. Lipitor 10 mg daily. 8. Trazodone 50 mg daily.
EC|enteric-coated|EC|134|135|MEDICATIONS|ALLERGIES: Sulfa, Reglan, Compazine, Abilify and Risperdal. MEDICATIONS: 1. Klonopin 1 mg t.i.d. 2. Clonidine TTS1 patch. 3. Depakote EC 250 mg a.m. and 2200. 4. Cymbalta 30 mg daily. 5. Neurontin 1200 mg at bedtime. 6. P.r.n. ibuprofen and Zofran. The latter apparently quite effective in reducing patient's nausea.
EC|enteric-coated|EC|134|135|MEDICATIONS|8. Vicodin p.r.n. 9. 3% hypertonic saline. 10. Compazine p.r.n. 11. Tylenol p.r.n. 12. Dulcolax p.r.n. 13. Zofran p.r.n. 14. Depakote EC 750 mg t.i.d. 15. Labetalol p.r.n. SOCIAL HISTORY: The patient lives with his 18-year-old adopted daughter.
EC|enteric-coated|EC|174|175|MEDICATIONS|MEDICATIONS: On admission 1. Synthroid 25 micrograms q.d. 2. Flagyl 250 mg t.i.d. 3. Cholestyramine powder 1/2 scoop b.i.d. for diarrhea. 4. Aspirin 81 mg q.d. 5. Divalproex EC 500 mg b.i.d. 6. Metoprolol 25 mg b.i.d. 7. Tamsulosin 0.4 mg q.d. 8. Celexa 10 mg q.d. 9. Albuterol inhaler two puffs q.i.d. 10. Combivent inhaler two puffs q.i.d.
EC|enteric-coated|EC|141|142|MEDICATIONS|6. Metoprolol 50 mg p.o. b.i.d. 7. Tamsulosin 0.4 mg p.o. q h.s. 8. Simvastatin 40 mg q.h.s. 9. Bumetanide 2 mg p.o. b.i.d. 10. Pantoprazole EC 40 mg p.o. b.i.d. 11. Algin AC 2 tablets q.i.d. p.r.n. 12. Simethicone 40 mg q.i.d. 13. Oxybutynin chloride 5 mg p.o. b.i.d.
EC|enteric-coated|EC,|213|215|HISTORY OF PRESENT ILLNESS|Afterwards he then used Crixivan, 3TC, and Zerit for about two years. From _%#MM#%_ through _%#MM#%_ of 2001, he was on no medications; from _%#MM#%_ of 2001 to _%#MM#%_ of 2002, here in _%#CITY#%_, he took Videx EC, Viramune, and Viread; from _%#MM#%_ of 2002 until the present time, he has been sporadically using one or all of his most recent three medications.
EC|enteric-coated|EC|128|129|MEDICATIONS PRIOR TO ADMISSION|MEDICATION ALLERGIES: None. Possible intolerance to milk products. MEDICATIONS PRIOR TO ADMISSION: 1. Ultram as above. 2. Videx EC 400 mg daily in the morning. 3. Cogentin 1 mg b.i.d. 4. Haldol 5 mg q.h.s. 5. Ibuprofen 800 mg q.8h p.r.n. using this rarely. 6. Prevacid 30 mg daily.
EC|enterocutaneous|EC|229|230|BRIEF HISTORY OF PRESENT ILLNESS|She was oriented to person and place only. Her heart had a 3/6 holosystolic crescendo/decrescendo murmur at the left sternal border. Her lungs were clear to auscultation bilaterally. Her abdomen had a colostomy and a high-output EC fistula bags. The abdomen was otherwise soft and nontender with positive bowel sounds. Admission labs were significant for a white count of 8.8 and a hemoglobin of 12.3. Her UA initially had many bacteria, 53 white cells and moderate leukocyte esterase.
EC|enterocutaneous|EC|205|206|ADMISSION PHYSICAL EXAMINATION|CARDIOVASCULAR: Normal S1 and S2, III/VI systolic murmur, tachycardia. LUNGS: Clear to auscultation. ABDOMEN: Extensive scars and large central area of healing tissue. Right-sided ostomy clean. Left-sided EC fistula also clean. Bowel sounds normal. Non-tender. Obese. LYMPHATICS: Trace lower extremity edema. SKIN: Right arm hand-sized erythema around PICC line and around antecubital fossa and superior.
EC|enteric-coated|EC|130|131|DISCHARGE MEDICATIONS|4. Multivitamins daily. 5. Librax 5/2.5 q.i.d. 6. Lasix 40 mg daily. 7. Norvasc 5 mg daily. 8. Lisinopril 10 mg daily. 9. Aspirin EC 81 mg daily. 10. Nexium 40 mg daily. 11. Fosamax 70 mg orally on Sundays. 12. Metamucil one packet orally one to three times per day.
EC|enteric-coated|EC|138|139|HOSPITAL COURSE|She will continue to follow her same current medications, which include: 1. Neurontin 300 mg b.i.d. 2. Effexor 37.5 mg daily. 3. Entocort EC 9 mg capsule each morning. 4. Questran four gram packet daily. 5. Imodium AD as needed. 6. Lasix 20 mg each a.m.
EC|UNSURED SENSE|EC|120|121|MEDICATIONS|MEDICATIONS: 1. Pentasa 2 time-released capsules b.i.d. 2. Aspirin 81 mg a day. 3. B12 shots monthly. 4. Supplements of EC and iron. 5. He is known to have prednisone for 20 years or more. The rest of his history is uncomplicated and unrelated. PHYSICAL EXAMINATION: Cooperative well-developed male patient with a flattened nose who has a palpable partially reducible parastomal hernia on the left with an ileostomy on the left.
EC|enteric-coated|EC.|218|220||He is not a smoker. He has been taking his medication, although he frequently skips or misses Crixivan. He is able to take his other drugs fairly well. He occasionally misses a lamivudine dose. He is also taking Videx EC. The patient is alert, oriented, and afebrile today. Oral cavity was bland.
EC|enteric-coated|EC|119|120|DISCHARGE MEDICATIONS|4. Flonase one spray each nostril q. day. 5. Lisinopril 20 mg p.o. q. day. 6. Metoprolol 25 mg p.o. b.i.d. 7. Protonix EC 40 mg p.o. q. day. 8. Oxycodone, acetaminophen 5/325 1-2 tablets p.o. q.4h. p.r.n. 9. Diflucan 100 mg p.o. q. day, to continue for five additional days.
EC|enterocutaneous|EC|161|162|HOSPITAL COURSE|HOSPITAL COURSE: The patient was able to gradually transition from TPN to oral feedings. He tolerated this well. He showed gradually decreased drainage from his EC fistula site. Due to progressive decrease in drainage and improving nutritional status, he was able to be discharged home for management via home care and follow up with his surgical team.
EC|enteric-coated|EC|157|158|DISCHARGE MEDICATIONS|She should have her hemoglobin checked periodically over the next few weeks to determine if further workup is indicated. DISCHARGE MEDICATIONS: 1. Pancrease EC 1 tablet t.i.d. with meals. 2. Potassium chloride 20 mEq per day. 3. K-phos 1 tablet per day. 4. Nicotine patch per protocol 21 mg patch daily for 7 days, then 14 mg patch daily for 7 days, then 7 mg patch daily for 7 days, then stop.
EC|enteric-coated|EC|137|138|DISCHARGE MEDICATIONS|DOB: _%#MMDD1947#%_ DISCHARGE MEDICATIONS 1. Augmentin 875 mg b.i.d. through _%#MMDD2005#%_. 2. Phenytoin 200 mg p.o. b.i.d. 3. Depakote EC 500 mg p.o. t.i.d. 4. Tigan suppositories 200 mg per rectum p.r.n. nausea. Patient is a 58-year-old white female with a history of previous seizure disorder who is admitted with repetitive seizures on the day of admission.
EC|enteric-coated|EC|123|124|CURRENT MEDICATIONS|5. Xalatan 0.005% ophthalmic solution, one drop q.d. in each eye at bedtime. 6. Betoptic 0.25% eye drops b.i.d. 7. Aspirin EC 80 mg q.d. ALLERGIES: None. HABITS: Patient does not smoke. Drinks a half cup of coffee per day.
EC|enteric-coated|EC|118|119|DISCHARGE MEDICATIONS|Her old medications remain as follows: 1. Kaletra 33.3/133.3 three tablets b.i.d. 2. Zerit 40 mg p.o. q.12h. 3. Videx EC 1 tablet q.a.m. DISCHARGE FOLLOW-UP: Follow up will be arranged by the patient.
EC|enteric-coated|EC.|148|150|ADMISSION MEDICATIONS|4. Hypothyroidism: Diagnosed _%#MM2007#%_. 5. Fetal alcohol syndrome. PAST SURGICAL HISTORY: None. ADMISSION MEDICATIONS: 1. Risperdal. 2. Depakote EC. 3. Seroquel. 4. Synthroid 25 mcg p.o. daily. 5. Cytomel 25 mcg p.o. daily. ALLERGIES: No known drug allergies. SOCIAL HISTORY/HABITS: The patient is going to be a 7th-grader next year.
EC|enteric-coated|EC|176|177|DISCHARGE MEDICATIONS|5. Flonase 2 sprays each nostril daily. 6. Multivitamin with minerals 1 tablet daily. 7. Pancrease (Ultrase MT20) 12 capsules with meals, 6 capsules with snacks. 8. Pancrecarb EC cap MS-8 12 capsules with meals, 6 capsules with snacks. 9. Protonix 40 mg twice daily. 10. Vitamin K 5 mg daily. 11. Depo-Testosterone cypionate 200 mg injection IM q.2 weeks.
EC|enterocutaneous|EC|387|388|HOSPITAL COURSE|The patient adamantly wanted this fistula repaired and so that he could continue going on with his EC fistula as it was getting more and more difficult for his mother to help look after him and he desperately wanted to have his kidney transplant performed as he identified his brother as a donor. The patient was admitted in the morning of surgery and underwent attempted closure of the EC fistula. Please see the dictated operative note for full details of the operation. After this, subsequently the patient broke down his enterocutaneous fistula on several occasions although which required re-exploration and center closure of the fistula.
EC|enteric-coated|EC|197|198|DISCHARGE MEDICATIONS|The patient is to call MD if temperature is greater than 100.5 degrees, any fevers or chills, drainage, tenderness, or redness or warmth around the incision site. DISCHARGE MEDICATIONS: 1. Aspirin EC 81 mg p.o. q. day. 2. Metoprolol 12.5 mg p.o. b.i.d. 3. Coumadin 5 mg p.o. q. day.
ER|extended release|ER|133|134|DISCHARGE MEDICATIONS|3. Trazodone 50 mg p.o. each day at bedtime. 4. Tylenol 625 mg p.o. daily. 5. Clonidine patch 0.3 mg transdermal weekly. 6. Depakote ER 2000 mg p.o. each day at bedtime. 7. Protonix 40 mg p.o. daily. 8. Vitamin C 500 mg p.o. b.i.d. 9. Iron sulfate 325 mg p.o. b.i.d. 10. Neurontin 600 mg p.o. with dialysis.
ER|emergency room|ER|170|171|HISTORY OF PRESENT ILLNESS|This has been nonbloody. She has had about 4 episodes here. The last few episodes have been lesser in volume. She has been lightheaded and weak and then presented to the ER today for further evaluation. In the ER, the patient had a low potassium of 2.8 and abdominal CT which did not show any acute abnormalities.
ER|emergency room|ER|180|181|LABORATORY DATA|SOCIAL HISTORY: She is a child, lives with parents. Her grandparent is here with her today. LABORATORY DATA: Her initial laboratory evaluation showed a positive Rapid Strep in the ER which would be expected. Her white blood cell count was 13,100 which came down to 9,400 the morning after admission at 0810 hours.
ER|emergency room|ER.|333|335|HISTORY OF PRESENT ILLNESS|The patient has a history of cardiomyopathy with congestive heart failure (CHF) with previous echocardiogram having been done in 2003, at which point her ejection fraction was 30% with global hypokinesis and left ventricular enlargement. There was also the possibility of a right lower lobe infiltrate seen on her chest x-ray in the ER. She was given IV Lasix, dosed empirically with Levaquin, and admitted for further treatment of CHF and pneumonia prior to any potential orthopedic intervention.
ER|emergency room|ER|134|135|DISCHARGE SUMMARY AND HOSPITAL COURSE|For details about his ER visit, please refer to the history and physical dictated by Dr. _%#NAME#%_. The patient was evaluated in the ER and had a CT scan of head done, which showed stable hydrocephalus with VP shunt. His labs showed white blood cell count to 4.9, hemoglobin 12.6, hematocrit 36.8. Electrolytes within normal limits.
ER|emergency room|ER|141|142|HISTORY OF PRESENT ILLNESS|The bleeding was severe and did not stop. Some of the bleeding oozed up through the lacrimal ducts and came out in his tears. He came to the ER by ambulance for evaluation. In the ER, he had bilateral posterior packing with inflation of the packing. He still had a little bit of oozing of blood tinged tears through his lacrimal duct on the left side.
ER|emergency room|ER|161|162|HISTORY OF PRESENT ILLNESS|He did take nitroglycerin at home and that has helped a bit but did not make it go away. Initially the pain was 7/10 improved some and by the time he got to the ER was a 5/10. He then was given more nitroglycerin and a nitropatch and now his pain is gone and his initial troponin was negative.
ER|emergency room|ER.|218|220|SUMMARY OF HOSPITAL COURSE|SUMMARY OF HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ was admitted to my service with hematemesis and complaints consistent with small-bowel obstruction, which was suggested by the CT scan that was performed on him in ER. Please see my full H&P for full details on that. The patient himself gave more of a history of hematemesis when talking to me and as such I did place the patient on IV Protonix and did contact gastroenterology.
ER|emergency room|ER|166|167|HISTORY OF PRESENT ILLNESS|She states she usually wears a lifeline, but had taken this off. A neighborhood man found her and informed her son who brought her here to the emergency room. In the ER documentation they stated she was unsure if she had a loss of consciousness. The patient did not clarify this for me further. REVIEW OF SYSTEMS: GENERAL: She denies any fevers, sweats or chills.
ER|emergency room|ER|138|139|ADMISSION DIAGNOSIS|He also began to notice photophobia and neck stiffness and was starting to have mental status changes. He presented to Methodist Hospital ER on _%#MM#%_ _%#DD#%_, 2004, where a lumbar puncture was done and revealed 6950 white cells. Culture of his fluid was ultimately negative. The patient was admitted to Methodist Hospital, placed on metronidazole, vancomycin, ceftriaxone.
ER|emergency room|ER.|214|216|HISTORY OF PRESENT ILLNESS|The patient awoke at 5 a.m. on the day of admission, drank Pedialyte and then had a red emesis. The patient proceeded to have 2 more episodes of red emesis so the patient's mother brought the patient to _%#CITY#%_ ER. On the drive to the ER the patient had 2 more episodes of brown emesis. The patient did have 1 black tarry stool the day prior to admission.
ER|emergency room|ER|88|89|CHIEF COMPLAINT|DOB: CHIEF COMPLAINT: _%#NAME#%_ _%#NAME#%_ is a 69-year-old woman who presented to the ER with three days of dizziness, chest pain, and nausea. PAST MEDICAL HISTORY significant for: 1. COPD with an FEV1 of 0.44 and FVC of 1.6.
ER|emergency room|ER|175|176|HISTORY OF PRESENT ILLNESS|She continued to feel worse each day with in aches, nausea, abdominal discomfort. On _%#MMDD#%_ she felt extremely bad and even worse on _%#MM#%_ _%#DD#%_ and she came to the ER on _%#MMDD#%_ for evaluation. Her last dose of TMP sulfa was on the am of _%#MM#%_ _%#DD#%_. The patient states that she had dry heaves and nausea.
ER|emergency room|ER,|103|105|HISTORY OF PRESENT ILLNESS|Her dizziness is worse when she is standing. She came to the emergency room earlier in the day. In the ER, she had a head CT which was negative. CBC, electrolytes, EKG all within normal limits. She got some relief with Meclizine, Ativan, Zofran, and IV fluids.
ER|emergency room|ER.|166|168|PLAN|ASSESSMENT: New onset pneumonia in a 62-year-old female with rheumatoid arthritis. PLAN: 1. Pneumonia. We will continue the Levaquin that the patient received in the ER. She has already had blood and urine cultures drawn. We will check another BMP in the morning, as she has had some IV fluid rehydration.
ER|emergency room|ER|248|249|DOB|DOB: _%#MMDD1921#%_ _%#NAME#%_ _%#NAME#%_ is an 80-year-old male, status post left knee surgery secondary to chronic left quadriceps rupture, admitted with one day history of left knee pain and swelling. The patient was seen initially at the local ER in _%#CITY#%_, where he was seen for a concern of septic arthritis in the left knee. The patient was eventually transferred to Fairview Ridges Hospital for evaluation and treatment.
ER|emergency room|ER|177|178|HOSPITAL COURSE|She was seen in the Emergency Room, treated with one dose of IV antibiotics and discharged with Doxycycline. She had no improvement at the site and presented to Fairview Ridges ER for further evaluation. She was admitted for treatment of cellulitis. She was initiated on Unasyn. Vital signs were essentially within normal limits with exception of low grade temperature of 99.5. The patient was observed overnight.
ER|emergency room|ER,|80|82|HISTORY OF PRESENT ILLNESS|She was sent to the emergency department for evaluation because of this. In the ER, the patient had a chest film performed. Her saturations were noted to be 86% on 2.5 L oxygen. She was given Levaquin and Ativan IV. She is being admitted to the hospital service for further evaluation and care.
ER|emergency room|ER|119|120|HOSPITAL COURSE|He should be on a low salt diet and activity limited. He should not be doing any heavy lifting. He is to return to the ER if he has increasing fever or abdominal pain, or for any other concerns. Also I recommended repeat CT scan to be done at the discretion of whoever follows him up in terms of his abdomen and the fluid collections.
ER|emergency room|ER|142|143|PHYSICAL EXAMINATION|He is afebrile. He is alert, no acute distress. Skin, there is multiple blister lesions in the right forehead and the right periorbital area. ER physician states that there is no apparent corneal involvement on dye staining of the cornea. Neurologic - patient is nonfocal mental status alert, appropriate, oriented.
ER|emergency room|ER|125|126|HISTORY|She described her leg feeling numb as well. Her left arm symptoms are emphasized less in the history this morning but in the ER they were supposedly both equally affected. She had no headache. She had no speech problems. She has never had a previous CVA.
ER|emergency room|ER|126|127|HISTORY OF PRESENT ILLNESS|She admits to progression of adverse effects and inability to control. She has been drinking mostly rum. She presented to the ER with a blood alcohol level of 0.2. The patient also has a history of depression and posttraumatic stress disorder.
ER|emergency room|ER.|154|156|HISTORY OF PRESENTING COMPLAINT|He had pain in the abdomen which was mostly epigastric, got worse. He felt somewhat nauseous, and he kind of doubled over because of pain and came to the ER. He did not throw up yet. He does not have any fever, chills, chest pain, shortness of breath, dizziness, or palpitations.
ER|emergency room|ER.|154|156|HISTORY OF PRESENT ILLNESS|No chest pain or palpitations. She denies any recent changes in her medication. She currently is symptom-free after receiving Valium and meclizine in the ER. She has never had anything like this before. PAST MEDICAL HISTORY: 1. Nephrolithiasis. 2. Hypertension. 3. Hiatal hernia. 4. Acid reflux.
ER|emergency room|ER|190|191|HISTORY OF PRESENT ILLNESS|She actually went to go see Dr. _%#NAME#%_ today for followup. Patient reports that she is continuing to take her Keflex, however, because the wound was looking bad she was sent over to the ER for further evaluation. REVIEW OF SYSTEMS: No fevers, chills or sweats. No HEENT complaints.
ER|emergency room|ER,|305|307|HISTORY OF PRESENT ILLNESS/BRIEF HOSPITAL COURSE|CPR was initially initiated and paramedics were called. On initial evaluation, the patient was found to be in asystole and a transcutaneous pacemaker was placed, but the paramedics were unable to get the capture. Subsequently, they were able to get the heartbeat and the blood pressure. On arrival to the ER, the patient was noted to be in the GCS of 3 and intubated. The patient was noted to be hypoglycemic with a blood sugar of 10.
ER|emergency room|ER|171|172|PHYSICAL EXAMINATION|MUSCULOSKELETAL: Negative. ENDOCRINE: Negative. CENTRAL NERVOUS SYSTEM: Dizziness in the a.m., currently no dizziness. PHYSICAL EXAMINATION: VITAL SIGNS: Initially in the ER heart rate was 35, blood pressure 94/40. Currently her blood pressure is 135/72, pulse 59, respirations 13. GENERAL: The patient is alert and oriented x3. HEENT: Head atraumatic, normocephalic.
ER|extended release|ER|128|129|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q. day. 2. Lipitor 20 mg p.o. q. day. 3. Toprol-XL 50 mg p.o. q. day. 4. Depakote ER 1500 mg p.o. nightly. 5. Keppra 1500 mg p.o. b.i.d. 6. Lisinopril 2.5 mg p.o. q. day. 7. Lansoprazole 30 mg p.o. q. day.
ER|emergency room|ER.|317|319||He went home, however, and was sitting at the table, got up to bring his dishes to the sink, got to the sink and started having some lysis pain in his right neck and then he reports he got dizzy and remembers hitting the floor and stayed awake during the entire episode. She called 911 and he was brought back to the ER. Hemoglobin at that point was 9.8. His discharge hemoglobin was 11.7 earlier that day. PAST MEDICAL HISTORY: 1. Coronary artery disease with stent placement.
ER|emergency room|ER|124|125|HISTORY OF PRESENT ILLNESS|The patient is currently not on Coumadin, however, he does take a daily aspirin. He has no documented ulcer history. In the ER this morning, the patient's vital signs were notable for initial blood pressure of 139/84 with a pulse of 118. The patient was given some gentle IV fluid rehydration, and followed blood pressure and heart rate were 134/77 with a heart rate of 77.
ER|emergency room|ER,|253|255|HOSPITAL COURSE|8. BNP was 522. HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ is an 82-year-old male who came in with shortness of breath and feeling lousy all day long. He was having coughing yesterday which was nonproductive. He also had some nausea and vomiting in the ER, which had some blood tinge to it. He was getting more short of breath, for which he came to the ER. He was admitted to Fairview Southdale Hospital with respiratory failure secondary to pneumonia.
ER|emergency room|ER|119|120|HISTORY OF PRESENT ILLNESS|He said that he had a loose bowel movement early in the evening which he did not look at. The patient presented to the ER for further evaluation. In the ER the patient had a bowel movement which was grossly bloody and large in volume. He again had one about 20 minutes ago. The patient did not have any chest pain and was recovering well after surgery before last night's event.
ER|emergency room|ER|124|125|HISTORY OF THE PRESENT ILLNESS|The pain was worse with urinating. No radiation. He felt nauseated from the pain. The patient was seen and evaluated in the ER and abdominal CT showed a calculus in the right ureter. He was discharged to home with oral narcotics. This controlled the pain for four days, but after he ran out of the medicine he developed severe pain again.
ER|emergency room|ER|167|168|HISTORY OF PRESENT ILLNESS|He had a negative exercise stress test during both the episodes. The current episode was not associated with exertion and not relieved by rest. He was directed to the ER today by primary MD as they thought there were some EKG changes. The patient had minimal chest pain at the time of examination on nitro TDP.
ER|emergency room|ER|125|126|HISTORY OF PRESENT ILLNESS|Later on when he was taking a shower, he noted his right leg to be red and swollen compared to the left. He presented to the ER where they found extensive deep venous thrombosis extending from the right popliteal vein into the right common femoral vein. He has no previous history of DVT or clots. There is no family history of DVT, clots, or miscarriages.
ER|emergency room|ER|220|221|LABS|Appears to be in moderate respiratory distress. Most likely has pneumonia with concomitant CHF. The patient was given Tequin 400 mg IV in the Emergency Room. Has been hypotensive in the Emergency Room which required the ER physician to start Dopamine drip at 10 mics per hour and her blood pressure has been stabilized. Her oxygenation and ventilation seems adequate but appears to be tiring out.
ER|emergency room|ER|76|77||_%#NAME#%_ _%#NAME#%_ is a 37-year-old woman who we are asked to see in the ER by Dr. _%#NAME#%_ and Dr. _%#NAME#%_. She presents with 48 hours of abdominal pain, acute on onset initially and initially diffuse and epigastric in location.
ER|emergency room|ER,|131|133|LABORATORY DATA|Sensation is intact to the lower extremities. Distal motor strength seems normal. LABORATORY DATA: Lumbosacral spine x-rays in the ER, as well as pelvic x-rays in the ER did not reveal acute fracture, though her bones were quite osteoporotic.
ER|emergency room|E.R.|209|212|PAST MEDICAL HISTORY MEDICINES|EARS, NOSE, THROAT, and RESPIRATORY: Negative. CARDIOVASCULAR: No symptoms. History of possible rhythm disturbance at Methodist Hospital as noted above. Also, blood pressures up recently as noted above in the E.R. GI: See Past Medical History, but no symptoms now. GU: No urinary symptoms. MUSCULOSKELETAL: Severe rheumatoid arthritis. NEUROLOGIC: See above.
ER|emergency room|ER,|87|89|BRIEF HISTORY AND HOSPITAL COURSE|These progressive symptoms made her concerned and prompted her visit to the ER. In the ER, she was noted to have had an elevated troponin of 0.71. Her initial EKG did not demonstrate any clear ST segment elevation to suggest a transmural infarct.
ER|emergency room|ER|319|320|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|The medications were tapered off and again he developed the symptoms of depression and had come to the point that he started having suicidal ideation. The patient has recently seen psychiatrist as an outpatient and he was started back on his depression medication, however, symptoms got worse and he was brought to the ER from where he was admitted to the medical floor with one-to-one observation and 72-hour hold to rule out any medical problems.
ER|emergency room|ER.|239|241|HISTORY OF PRESENT ILLNESS|She states that these symptoms were similar to when she had her acute MI 1 month ago as she did not have any chest pain at that time as well. Her shortness of breath was not improving with any positioning thus she called ambulance for the ER. Pertinent positives in her HPI included pneumonia 2 weeks ago that was found on incidental chest x-ray after placing a PPD at rehab facility.
ER|emergency room|ER|119|120|HISTORY OF PRESENT ILLNESS|This was obtained because she seemed quite confused and was not making much sense initially. However, after 2 hours of ER time she seemed to "sober up" and was much more lucid and answered questions appropriately. She is complaining of left hip pain and x-rays did confirm a left femoral neck fracture.
ER|emergency room|ER|159|160|IMPRESSION|At this point in time, she appears to be stable from a cardiovascular point of view and she did have a scan of her head that showed an intracranial bleed. The ER physician did contact neurosurgery and a repeat head CT has been planned for today but my suspicion is that this is something that will just need further watching.
ER|emergency room|ER,|213|215|HISTORY OF PRESENT ILLNESS|She denies any significant pain, shortness of breath; specifically no chest pain, nausea, headache, fevers, sweats, chills, focal neurological deficits, loss of consciousness or palpitations. On evaluation in the ER, the patient was stable; however, she was admitted for further observation and evaluation by Gastroenterology for possible further intervention.
ER|emergency room|ER|155|156|HISTORY OF PRESENT ILLNESS|This time he was brought in to the emergency room and given the repetitive nature of his problems and his low glucose that was somewhat slow to respond to ER therapy. He was admitted for more definitive treatment of his hypoglycemic episodes. In general, he reports he has been feeling well. In the last several months he has even returned to weekly trips in to his law practice, which is a big step forward for him.
ER|emergency room|ER|154|155|HISTORY OF PRESENT ILLNESS|She has never had abdominal pain like this in the past. She reports she was in the ER about a week ago with some chest pain and some throat symptoms. The ER notes are not available for review. Apparently, she had a negative strep culture, chest x-ray and had a laryngoscopy which was normal.
ER|emergency room|ER.|152|154|EMERGENCY DEPARTMENT COURSE|He does have intermittent diaphoresis without any accompanying nausea or emesis. EMERGENCY DEPARTMENT COURSE: He remained hemodynamically stable in the ER. He had a chest x-ray which showed right-sided pleural effusion and later on underwent chest CT to rule out pulmonary embolism.
ER|emergency room|ER|132|133|IMPRESSION AND PLAN|We will send off stool studies including bacterial and C diff toxin and culture, fecal leukocytes, and a stool guaiac. Notably, the ER physician did do a rectal exam in ER and remarked that her stool was unremarkable appearing with no evidence of blood.
ER|emergency room|ER|136|137|HISTORY AND HOSPITAL COURSE|He is quite demanding of his wife and actually expects full cares from her. He has a history of narcotic dependence and has had several ER visits in the past for some drug seeking behavior. He was seen last here with nonspecific back and neck pain which is chronic.
ER|emergency room|ER|247|248|PHYSICAL EXAMINATION|Strength is symmetric throughout all EXTREMITIES. NEUROLOGIC exam is nonfocal with the exception of some mild short term memory problems. A chest x-ray in the ER was negative. Ultrasound of the right lower extremity is reported as negative in the ER report. EKG shows sinus bradycardia and nonspecific ST-T wave changes, some LVH. During the ER visit, the patient has a brief run of what appears to be junctional rhythm lasting a few seconds during which the patient was asymptomatic.
ER|emergency room|ER|184|185|ASSESSMENT|She does need dialysis today. There is an element of drug-seeking behavior. The patient is extremely knowledgeable about medications and narcotics in particular, and has made multiple ER visits in the recent past for problems that the use of narcotics is the appropriate course for. PLAN: 1. She will get her dialysis today. Hope to discharge her tomorrow.
ER|emergency room|ER.|182|184|HISTORY|This was associated with photophobia, had nausea and vomiting after she was treated with IV morphine in the hospital. No associated neurological symptoms. She had lumbar puncture in ER. Was given symptomatic treatment, however, her headache continued to be significant and she continues to have considerable nausea and emesis.
ER|emergency room|ER|164|165|DOB|He suffered a deep gash to his proximal left forearm. He then, I believe, continued the race. Given the significance of the wound and pain, he presented to a local ER near _%#CITY#%_, Wisconsin. The wound was cleaned and irrigated. At the time he was given Keflex 1 g p.o. b.i.d., which the patient has been taking up until this morning.
ER|emergency room|ER.|191|193|HOSPITAL COURSE|6. Hypertension. 7. Hernia repair in 2000. 8. Varicose vein repair also in 2000. HOSPITAL COURSE: 1. COPD. The patient was initially treated with nebulizers and improved quite rapidly in the ER. She was also given IV Solu-Medrol which was continued for 1 dose on the floor. CT angiogram was performed in the ED which was negative as above.
ER|estrogen receptor|ER|158|159|COURSE TO DATE|COURSE TO DATE: In _%#MM2001#%_, _%#NAME#%_ _%#NAME#%_ was diagnosed with breast cancer. A needle biopsy revealed infiltrating ductal carcinoma grade 2 of 3, ER positive, PR negative. She had a bone scan at that time that was negative, a CT scan at that time which was negative.
ER|emergency room|ER,|130|132|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|His wife called his primary care physician's office and they recommended that he go into the ER for evaluation. On the way to the ER, the patient was somewhat anxious but had recurrence of his symptoms. Specifically, he had some light headedness with some diaphoresis and then actually had an episode where he lost consciousness for a few seconds while in the car in the parking lot in the emergency department.
ER|emergency room|ER,|191|193|PLAN|2. Asthma and not doing all that poorly at this time. 3. Depression, treated. PLAN: Admit. We will treat the hypoxia with some oxygen, continue Rocephin and Zithromax that was started in the ER, nebulization him and give him another dose of Solu-Cortef 125 mg tonight and then put him on 50 mg of prednisone. We will get a nasal smear for influenza, isolate if appropriately positive.
ER|emergency room|ER|259|260|ASSESSMENT AND PLAN|Liver function tests were normal. CT of the abdomen for renal stone protocol showed no stone or hydronephrosis, negative looking appendix. ASSESSMENT AND PLAN: 1. Intractable low back pain, sudden onset yesterday. Required large amounts of medications in the ER with continued pain and inability to ambulate. Will admit the patient for IV medicine pain control. Will get a pain management consult.
ER|emergency room|ER|155|156|PLAN|1. The patient has been admitted. 2. Will assess to see if she can return to assisted living. 3. Will start aspirin. 4. Continue antibiotic started in the ER and observe how she does.
ER|emergency room|ER|226|227|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|The patient is on a Dilantin therapy for prevention of the seizures. The patient was found to be increasingly confused and also had increased clumsiness of the legs and some vision changes and the patient was brought into the ER for further evaluation. In the ER, the patient was found to have a Dilantin level of 31.7 and hence was admitted for Dilantin toxicity and worsening neurological symptoms.
ER|emergency room|ER|123|124|HISTORY OF PRESENT ILLNESS|She was treated with amoxicillin and Nasonex and went home. Her symptoms persisted so she came into the ER last night. Her ER workup last night revealed normal basic metabolic panel, CBC, chest x-ray, urinalysis and head CT. Lumbar puncture was performed and showed 5 white blood cells.
ER|emergency room|ER|238|239|PLAN|Current care, diagnoses and prognosis was discussed with patient and his .mother There is questionable history of GI bleed. We will continue Protonix 40 mg IV q.12 h. Will follow-up closely, and patient's guaiac stool was negative as per ER doctor. Follow up Hgb closely q 12hrs, and obtain GI consult if indicated. Will obtain CD consultation for possible inpatient psych admission. In addition, will obtain psychiatric consultation.
ER|emergency room|ER|148|149|HISTORY OF PRESENT ILLNESS|After dinner last night they found her confused in her pajama top and shoes but without pajama bottoms. They sent her to the ER for evaluation. Her ER workup showed a urinalysis that was suggestive of UTI and leukocytosis. No fractures or serious injuries were noted from the fall.
ER|emergency room|ER.|214|216|PLAN|ASSESSMENT: Cellulitis. PLAN: I did unroof one of the vesicular lesions and send a culture for bacteria and MRSA. We will talk to Infectious Disease. Currently, he did get a some clindamycin and ceftriaxone in the ER. They feel like there is a little decreased erythema, but we will talk to Infectious Disease to see if we want to put him on vancomycin to cover for MRSA to cover while the cultures are pending.
ER|emergency room|ER,|241|243|HISTORY OF PRESENT ILLNESS|She has had associated nausea with emesis over the last two days, with inability to tolerate a diet except for some sips of water. Chilling and sweats over the last two days, with temperature at home to 100 degrees on _%#MMDD2002#%_. In the ER, stable hemodynamics with a blood pressure of 137/68 and temperature 101.2 degrees. Elevated white count of 16,400, with 88 PMNs. Normal renal function with a BUN of 7 and creatinine of 0.9. Active urinary sediment with positive nitrite, moderate bacteria, greater than 100 white cells, 100 mg percent of protein, and large leukocyte esterase.
ER|emergency room|ER|367|368|HISTORY OF PRESENT ILLNESS|DOB: _%#MMDD1948#%_ HISTORY OF PRESENT ILLNESS: The patient is a 55 year old female who is status post kidney transplant, cholecystectomy, tonsillectomy, compression fractures, gastroesophageal reflux disease, sleep apnea, dysphagia, osteoporosis and coronary artery disease. She was admitted with acute fever and GI bloating. She was also having some chills. In the ER she was found to have a creatinine down to 1.6 and potassium was 2.3. She was admitted for evaluation and treatment.
ER|emergency room|ER|159|160|HISTORY OF PRESENT ILLNESS|Patient does admit to having a few words slurred but he was not convinced that he was weak on one side or the other. In any event, he is asymptomatic now. His ER course consisted of a work-up for stroke with a negative head CT. EKG showed the chronic atrial fibrillation. His myoglobin was elevated to 242 although interestingly, it was also elevated during his hospitalization in _%#MM#%_ for the arrhythmia.
ER|emergency room|ER|138|139|PATIENT INFORMATION|Patient's wife, _%#NAME#%_, is followed by me. Information obtained entirely from wife, office record and the case was discussed with the ER physician. Patient has dementia and is unable to provide any useful information. PAST MEDICAL HISTORY: 1. Mild organic brain syndrome. Patient has been driving with the assistance of his wife.
ER|estrogen receptor|ER|185|186|HISTORY OF PRESENT ILLNESS|The patient felt a lump in her breast on _%#MM#%_ _%#DD#%_, went directly to the doctor. She was found to have a Nottingham grade 3/3 with 0 of 2 lymph nodes positive, greater than 90% ER positive, greater than 30% PR positive, and negative by FISH. She has no family history because she is adopted and does not know her family.
ER|estrogen receptor|ER|258|259|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 46-year-old woman who is in today for followup of her right infiltrating ductal carcinoma, diagnosed _%#MMDD2001#%_. She had bilateral mastectomies. Her cancer was grade 2 of 3, with 0 of 2 lymph nodes, ER positive at 78.2%, PR positive at 64.2%. REVIEW OF SYSTEMS: GENERAL: She has had a urinary tract infection, and has a low-grade fever.
ER|emergency room|ER|157|158|HOSPITAL COURSE|HSV antibodies were negative. Pelvic ultrasound as outlined above. _%#NAME#%_ _%#NAME#%_ is a 45-year-old woman who presented to Fairview Southdale Hospital ER on _%#MMDD2007#%_ with fevers, chills and dysuria. The patient currently does not have a primary physician but will be following up with Dr. _%#NAME#%_ at _%#CITY#%_ Medical Group.
ER|emergency room|ER|256|257|HOSPITAL  COURSE|He also had some light-headedness but denied any facial droop or weakness of his extremities or falling or numbness or tingling or blurred vision. He initially did not want to come to the ER but because he has a significant speech problems, he came to the ER for further evaluation. In the ER, his CT scan of the head demonstrated subacute right frontal infarct. The patient was admitted for further evaluation. 1. Right subacute infarct.
ER|emergency room|ER|154|155|PLAN|5. Hypothyroidism on treatment.. PLAN: 1. Will admit to CSC and follow serial troponins. 2. Continue his Nexium and he did receive a GI "cocktail" in the ER which seemed to help some, 3. Dialysis _%#MMDD#%_. 4. Discussed with Dr. _%#NAME#%_ _%#NAME#%_. Cardiology will see if necessary and on _%#MMDD#%_ will get followup 12 lead EKG in a.m. and possibly another echocardiogram pending his course.
ER|emergency room|ER|216|217|IMPRESSION AND PLAN|Etiology is unclear at this point in time. Differential diagnosis includes pneumonia including typical, atypical, other infections and pulmonary emboli. He was given Levaquin in the ER. He was also given nebs in the ER without improvement in his breathing. We will wait for the CT scan of the chest to have a more definite idea about the etiology of his febrile illness with dyspnea.
ER|emergency room|ER|127|128|DISPOSITION|The daughter and son were instructed to give her a snack or some orange juice if she becomes hypoglycemic and to come into the ER if she is persistently below 80s. Instruction on glipizide as above. Otherwise followup with primary MD within 1 weeks. She is encouraged to eat now that she is back on her oral medications.
ER|emergency room|ER|226|227|PRIMARY DIAGNOSES|2. A dermatology biopsy. 3. CT of the abdomen as well. HISTORY OF PRESENT ILLNESS: This is a 39-year-old female with advanced AIDS with a CD4 absolute cell count of less than 10 and she is usually at zero who presented to our ER for left-sided flank pain x approximately 1 week and persistent nausea and vomiting x 1 month despite an extensive workup. The patient was recently discharged from Unity for a 3-day hospitalization for the nausea and vomiting.
ER|emergency room|ER.|319|321|DISCHARGE MEDICATIONS|12. Sliding scale insulin, regular insulin if fingerstick blood glucose less than 60 drink a glass of juice or eat, if 61-150 no units, if 151-200 1 unit, if 201-250 3 units, if 251-300 6 units, if 301-350 10 units, if 351-400 14 units, if 401-450 18 units, if greater than 450 call primary care physician or go to the ER. 13. Hexavitamin 1 po qd. DISCHARGE FOLLOW-UP: 1. She should follow-up with Dr. _%#NAME#%_ in 7-10 days for her dysfunctional uterine bleeding.
ER|emergency room|ER|243|244|HISTORY OF PRESENT ILLNESS|She had a CT scan, which showed possible diverticulitis, was put on ciprofloxacin, Flagyl, and Dilaudid, with the urine culture showing possible E. coli later. On _%#MMDD2004#%_, though she developed rash and intense itching, came back to the ER for her distress. No nausea, vomiting, diarrhea, or constipation. Did have some urinary frequency. Temperature 100. She was admitted because of her abdominal pain, possible diverticulitis, and possible pyelonephritis, as well as allergic reaction.
ER|emergency room|ER.|159|161||It went to 184 and he developed a headache and he called a nurse at the V-A. She told him to check it again and when it was over 200 she told him to go to the ER. In the emergency room here at Fairview Southdale Hospital the patient's blood pressure was noted to be elevated at 215/109.
ER|extended release|ER|199|200|DISCHARGE STATUS|Her affect varied from stable to agitated and irritable. Her insight and judgment were impaired and her mood stable to irritable. DISCHARGE MEDICATIONS: 1. Seroquel 200 mg daily bedtime. 2. Depakote ER 1500 mg daily bedtime. 3. Celebrex 200 mg twice daily. 4. Lidoderm patch 5%, on 12 hours and off 12 hours. 5. Abilify 45 mg at bedtime. 6. Trazodone 50 mg at bedtime with a repeat x2 if needed to aide sleep.
ER|emergency room|ER,|123|125|HISTORY OF PRESENT ILLNESS|In the ER she was not tachypneic and she was saturating well on room air. In addition, she complained of a headache in the ER, and a CT scan was performed at Fairview Ridges and was read as negative. Of note, she was in a motor vehicle accident 2 days ago with her dad, but no hospitalization was needed.
ER|emergency room|ER|132|133|HISTORY OF PRESENT ILLNESS|This morning her pain significantly increased in severity and she had associated chills prompting her to present to Fairview Ridges ER for further evaluation. She is not aware of any prior UTIs. She denies any hematuria. No prior history of renal stones. No family history of renal stones.
ER|emergency room|ER|274|275|HISTORY OF PRESENT ILLNESS|Estimated EF 55%. HISTORY OF PRESENT ILLNESS: This is a 52-year-old male with a history of cocaine abuse and atrial fibrillation who presented to the _%#CITY#%_ ER from his inpatient chemical dependency program with chest pain and palpitations. The patient was noted in the ER to be in atrial fibrillation and therefore admitted to the cardiology service for further evaluation and treatment. On arrival to the floor, he was in atrial fibrillation with a ventricular rate of 150 and blood pressure 100/72.
ER|emergency room|ER|184|185|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSIS: Low back pain. HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old female with a history of rheumatoid arthritis and history of sciatica who presented to the ER with a sudden onset of right low back and buttock pain which he characterized as sharp and stabbing with 10/10 severity, nonradiating. Sensation was similar to previous episode of sciatica, but she rated this pain as being much worse.
ER|emergency room|ER|153|154|ASSESSMENT AND PLAN|This is my read and not the formal read. ASSESSMENT AND PLAN: 1. Brain mass. The etiology of this mass is uncertain. The next step is to get an MRI. The ER physician has already ordered it. In the differential would be bleed, stroke, malignancy or infectious lesion. He is at higher risk of opportunistic infections and lymphoma, given his methotrexate and Humira use.
ER|emergency room|ER|205|206|HISTORY OF PRESENT ILLNESS|Despite that she has had persistent problems with worsening facial swelling, pain and bilateral tender anterior chain cervical adenopathy. As a result she came to the emergency room for evaluation. In the ER she was seen to have fairly substantial facial cellulitis that by history has been getting worse. On that basis she is admitted for IV antibiotics. She tells me that she does a lot of things to prevent cellulitis from developing.
ER|emergency room|ER|274|275|HISTORY OF PRESENT ILLNESS|Patient tells me that she feels a little bit better, but her throat hurts a lot. When the blood work reveals came back she was unfortunately found to be in acute renal insufficiency with creatinine at 3.4, but this was after the Toradol had already been given to her by the ER physician. REVIEW OF SYSTEMS: Significant for sore throat, fever, nausea, vomiting, pain on swallowing and pain radiating to her ears.
ER|emergency room|ER|381|382|HOSPITAL COURSE|Apparently no abdominal cellulitis or infection was noted. She returned to the ER on _%#MMDD2007#%_ at which time she was noted to have low abdominal wall erythema thought to be an early cellulitis and was given IV clindamycin as well as Zofran and morphine in the ER. She had also been complaining of low abdominal, right lower quadrant and right flank pain. A white count in the ER was 14,300. The patient was admitted for IV antibiotics and further management. Her lab work was essentially normal except for very slight elevation of alkaline phosphatase of 166, ALT of 75, AST of 55.
ER|extended release|ER|136|137|MEDICATIONS|12. Colace 100 mg p.o. b.i.d. 13. BuSpar 5 mg p.o. t.i.d. 14. Zyrtec 10 mg p.o. daily p.r.n. 15. Celexa 40 mg p.o. daily. 16. Diltiazem ER 120 mg p.o. daily. 17. Fosamax 70 mg p.o. q. week. 18. Vitamin C 1,000 mg p.o. daily. 19. Astelin nasal spray 1 spray bilateral naris b.i.d. p.r.n.
ER|emergency room|ER|284|285|DISCHARGE DIAGNOSES|Also electrolyte panel was unremarkable. HOSPITAL COURSE: 1. Asthma exacerbation. _%#NAME#%_ was in acute respiratory distress when she went to the ER and her peak flow was 170 and increased to 275 after 2 doses of albuterol nebulizer q.1h. Eventually, her asthma exacerbation in the ER got much better after Solu-Medrol 125 mg IV, prednisone 40 mg p.o., and 4 doses of dual nebulizer. When she was admitted on the floor, her physical examination was pretty much unremarkable except for very rare wheezes, but she was absolutely comfortable and in no acute distress any longer.
ER|emergency room|ER|86|87|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a white woman who was admitted from the ER today. She gives a history that she has been shaking over her whole body, especially this morning. She has been having night sweats and difficulties with the usage of her hands and arms.
ER|emergency room|ER|192|193|LAB  AND DIAGNOSTIC DATA|BNP 213, white count 11.3, hemoglobin 13.9, platelets 256,000. Sodium 139, potassium 3.9, chloride 102, bicarbonate 23, BUN 25, creatinine 1.25, glucose 204, LFTs normal. EKG initially in the ER showed 1 mm of ST depression in V3 through 5. Repeat showed resolution in EKEG changes. ASSESSMENT/PLAN: 1. Acute coronary syndrome.
ER|estrogen receptor|ER|201|202|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of a well differentiated, infiltrating lobular carcinoma and LCIS, diagnosed _%#MMDD2004#%_, grade 1/3, lymph node negative, ER greater than 90%, PR greater than 80%. REVIEW OF SYSTEMS: GENERAL: No fevers, sweats, weight change, or fatigue.
ER|emergency room|ER|272|273|HOSPITAL COURSE|Gait disturbance lasted for approximately two hours. Because of vision changes, the patient went to see an ophthalmologist, but had a negative exam, was referred to Fairview Southdale for further evaluation. The patient was completely neurologically intact by the time of ER evaluation. He was admitted, workup here is negative for any acute neurologic event. Etiology of symptoms is unclear. May have been possible neurologic event, but unclear.
ER|emergency room|ER|185|186|HISTORY|Postoperatively, she had done quite well, although did have some excessive drainage the day after surgery which required re-exploration of the mediastinum. The patient presented to the ER with increasing shortness of breath and large white pleural effusion. The patient noted gradual increasing shortness of breath over the past week prior to admission.
ER|emergency room|ER.|147|149|HISTORY|She has now been treated as an outpatient for the last 5-6 days with Flagyl and Avelox. She had increasing pain, though, and presented back to the ER. Her white count was not dramatically inflamed, but she clearly had a lot of left lower quadrant tenderness and guarding.
ER|emergency room|ER|226|227|HOSPITAL COURSE|Apparently on the day of admission he had woken up from a nap with increased tremulousness and weakness. There were no associated symptoms and by the time the patient was evaluated by admitting physician at Fairview Southdale ER he was back at baseline status. The patient is seen this a.m. by follow-up internal medicine physician and he states that he is still back at baseline and anxious for discharge as he has no acute issues.
ER|extended release|ER|181|182|DISCHARGE DIAGNOSES|HOSPITAL COURSE: The patient was admitted through the emergency room with uncontrolled pain at home. She was evaluated by the pain clinic with TLC team and was started on OxyContin ER t.i.d. 20 mg added IV or p.o. Dilaudid for breakthrough pain. She was also given Ativan 0.5 mg q.4. hours p.r.n. and gradually her pain came under control.
ER|emergency room|ER|206|207|HISTORY OF PRESENT ILLNESS|He was seen in the ER on _%#MMDD2006#%_, at which time he stated he had been using cocaine heavily and desired CD treatment. However, he left the ER prior to being admitted. He was subsequently seen in the ER on _%#MMDD2006#%_ for the evaluation of paranoia which was felt to be secondary to crack cocaine use. There was also a question of methadone ingestion. At any rate the patient was monitored for quite a bit of time in the ICU and also was felt to be non-holdable and was allowed to go home, where he lives with his mother.
ER|emergency room|ER,|225|227|REVIEW OF SYSTEMS|ADMISSION MEDICATIONS: He is on allopurinol, Lopressor, Prograf, CellCept, Lasix, Bactrim, bicarbonate, aspirin. ALLERGIES: HE IS ALLERGIC TO VANCOMYCIN. REVIEW OF SYSTEMS: His temperature is 100.9. He was hypotensive in the ER, 83/30. Heart rate of 120. Saturating 94% on 2-L nasal cannula. His physical condition looked septic on admission. He has soft abdomen.
ER|emergency room|ER,|245|247|PROCEDURES/INVESTIGATIONS|She denied any weakness in the extremities or numbness. Also, she denied any headaches, neck stiffness, blurring of vision, or fevers or chills. While en route in the ambulance, she was treated with intravenous Dilaudid and Versed twice. In the ER, she was somnolent and sleepy, and the oxygen saturations were in the low 90s. Therefore, the emergency room physicians then decided to admit her because of low oxygen saturations and for further treatment of her lower back pain.
ER|emergency room|ER|129|130|HISTORY OF PRESENT ILLNESS|They treated her with albuterol and O2 and Atrovent nebs which were only slightly beneficial. O2 sats were 96 on arrival. In the ER she was given more oxygen and some pain medication and she is feeling slightly better but not at the point to go home.
ER|emergency room|ER|198|199|HOSPITAL COURSE|She had been having nausea and had been vomiting for 3-4 days, unable to keep down food. She was seen by primary MD in clinic and was noted to have a sodium of 125. She presented to Fairview Ridges ER for further evaluation. She was normotensive, nonfocal neurologic exam, afebrile. She was placed on normal saline, antiemetics and azithromycin for possible ethmoid sinusitis.
ER|emergency room|ER,|152|154|REASON FOR ADMISSION|The patient stopped drinking the day prior to admission and felt he was going through withdrawals prompting his appearance in the ER. Apparently in the ER, the patient developed some chest discomfort which prompted the ER physician to admit the patient to the hospitalist service. HOSPITAL COURSE: 1. Alcohol withdrawal: The patient did have mild alcohol withdrawal during his stay.
ER|emergency room|ER|143|144|FOLLOWUP APPOINTMENT|At this followup, the patient should have his labs drawn, which included CBC with differential and chemistry parallel. He knows to come to the ER within an hour if he notices leg weakness or fevers. 2. With Dr. _%#NAME#%_ with the Department of Neurosurgery. This followup should be in 4 weeks time at the neurosurgery.
ER|emergency room|ER,|242|244|HOSPITAL COURSE|HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is an 87-year-old female who was admitted to Fairview Southdale Hospital after falling at the Gardens at St. Gertrude's. You are referred to my admission H&P dated _%#MMDD2007#%_. On presentation to the ER, the patient had the following laboratory tests performed: She had a CBC with hemoglobin of 12.3 and a white count of 8.6 with a normal differential.
ER|emergency room|ER|133|134|HISTORY OF PRESENT ILLNESS|She has had pain all day. She has had some nausea and emesis with her pain. No significant fevers or chills. The patient came to the ER for evaluation. Vital signs in the ER were stable. She was afebrile. Abdominal CT scan obtained in the ER shows evidence for pancreatitis.
ER|emergency room|ER|143|144|PLAN|It would be beneficial for him to be on that medication if he will tolerate that long-term. Neurosurgery has been notified and informed by the ER of the patient's condition. The neurosurgeon on-call informed the ER physician that they will see the patient in the morning. I have discussed this with Dr. _%#NAME#%_ and Dr. _%#NAME#%_ at length and discussed this with the family as well.
ER|emergency room|ER|154|155|HISTORY OF PRESENT ILLNESS|The patient did make eye contact with her brother-in-law but was minimally responsive. When the paramedics arrived and the patient was transferred to the ER she was evaluated by Dr. _%#NAME#%_ who noted the patient was mildly incontinent of bladder. Dr. _%#NAME#%_ loaded the patient with fosphenytoin in the ER.
ER|emergency room|ER,|214|216|HOSPITAL COURSE|HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 63-year-old male who was admitted by Dr. _%#NAME#%_ on _%#MMDD#%_ for fever and abdominal pain and dysuria, you are referred to his admission H&P. On presentation to the ER, the patient had the following laboratory tests on the day of admission. He had a urinalysis from the prior day that was growing E. coli 50,000-100,000 colonies that was pansensitive.
ER|emergency room|ER|196|197|HOSPITAL COURSE|For details of Ms. _%#NAME#%_'s admission history and physical and assessment on admission, please see my dictated note. HOSPITAL COURSE: _%#NAME#%_ was admitted from the nursing home through the ER to the medical unit for evaluation of decreased level of consciousness beyond even her baseline. The etiology of this is not clear. Initial evaluation in the ER did suggest a possible right lower lobe infiltrate versus atelectasis.
ER|emergency room|ER|141|142|HOSPITAL COURSE|3. Pulmonary. 4. Palliative care. HOSPITAL COURSE: Mr. _%#NAME#%_ is an 81-year-old gentleman who was admitted on _%#MMDD2007#%_ through the ER with fever, confusion and diarrhea. Soon after admission, his mental status declined very quickly over the next day. He was subsequently transferred to the ICU where he had difficulty breathing and was put on BiPAP overnight.
ER|emergency room|ER.|148|150|PLAN|5. Alcohol abuse with recent binge 2 days ago. No overt signs of alcohol withdrawal. PLAN: 1. Aspirin on a daily basis, first dose was given in the ER. 2. Frequent neurological checks. 3. We will obtain MRI/MRA of the brain and neck in the morning. We will also fax release of information for CT scan results from St. Francis Hospital in _%#CITY#%_ for comparison.
ER|emergency room|ER|172|173|HOSPITAL COURSE|He had no obvious respiratory or cardiovascular problems despite known history there. His cephalosporin allergic reaction which occurred after some Keflex was given in the ER is resolved and no rashes or problems are occurring at the time of discharge. Examination is otherwise normal at discharge except for the hand which is wrapped.
ER|emergency room|ER|184|185|ASSESSMENT|An EKG showed sinus bradycardia; otherwise appeared within normal limits. ASSESSMENT: 52-year-old with headache, diplopia, and uncontrolled hypertension. 1. Headache and diplopia. The ER physician spoke with Neurology in the emergency room, who recommended further evaluation as an inpatient. I will officially consult them to proceed. They had discussed possible LP; however, the patient is declining this procedure at this time.
ER|emergency room|ER|148|149|PHYSICAL EXAMINATION|There is an S3 as well. Peripheral pulses are normal and symmetric throughout. Abdomen: Positive bowel sounds, soft, non-tender. Rectal exam in the ER was normal with heme- negative stools. Back shows no CVA tenderness, ulcerations or skin breakdown. Extremities: There is some trace edema in the lower extremities.
ER|emergency room|ER|147|148|SYNOPSIS OF HISTORY AND PHYSICAL|He had a chest x-ray done in ER which showed right lung infiltrate, and also possible retrocardiac infiltrate. Patient received I.V. fluids in the ER and the ER physician reviewed his paperwork and according to that, he was DNR/DNI, but he wanted I.V. fluids and antibiotics.
ER|emergency room|ER.|212|214|HISTORY OF PRESENT ILLNESS|Along with this she had two mixed alcohol drinks. She started having palpitations and she called a friend and told that she had taken all this medications and the friend called 911 and patient was brought to the ER. The patient said that her boyfriend moved out from her place a week ago. The patient does have history of depression for about 3-4 years and has never attempted suicide before.
ER|extended release|ER|218|219|ADMISSION DIAGNOSIS|Supplies were given in the form of prescription for self-catheterization including Betadine, K-Y Jelly, and female catheter. She should follow up with Dr. _%#NAME#%_ in 2 to 4 weeks. DISCHARGE MEDICATIONS: 1. Depakote ER 750 mg PO b.i.d. 2. Lithium 400 mg PO at night. 3. Seroquel 200 mg PO at night. 4. Temazepam 15 to 30 mg PO at night.
ER|emergency room|ER|177|178|DISCHARGE DIAGNOSIS|HISTORY OF PRESENT ILLNESS: This is a 72-year-old male who was followed by Dr. _%#NAME#%_. He has a history of coronary artery disease status post PCI in 2000. He came into the ER as he has been complaining of palpitations for the last 1 week. He has also been having chest pressure associated with this and at the local ER, he was found to be in atrial fibrillation.
ER|emergency room|ER|225|226|HISTORY OF PRESENT ILLNESS|Concern was high enough that rescue squad was called. Initial oxygen saturation measured in the field was in the mid-80s on room air, and the patient was transferred to the emergency department for further evaluation. In the ER the patient's temperature was mildly elevated at just under 100, white cell count was found to be slightly elevated at 11.6 where it was normal only earlier today, and repeat chest x-ray again showed diaphragmatic hernia on the left side with apparent loops of bowel in the left hemithorax, no obvious infiltrate.
ER|emergency room|ER|179|180|HISTORY OF PRESENT ILLNESS|He had been diagnosed recently with moyamoya disease and bilateral hemispheric stroke, including frontal and parietal areas in both hemispheres. Apparently, he was brought to the ER yesterday by family in the evening, stating that he was less coherent, was unable to answer any questions, and later appeared even more confused.
ER|emergency room|ER|165|166|HOSPITAL COURSE|He said he had been receiving nebulizer treatments in the transitional care facility and did not have these at home. He was treated with nebs treatments here in the ER and he said his breathing returned to normal. He has chronic dyspnea on exertion due to his multiple medical issues. He felt his breathing was at his baseline throughout his hospital stay.
ER|emergency room|ER,|172|174|HISTORY OF PRESENT ILLNESS|He became worried that he was suffering a recurrence of the rhythm problems that had plagued him previously, rescue squad was notified and he was transported to ER. In the ER, EKG revealed sinus with occasional PACs, and he was hypertensive initially in the 170 systolic. His EKG showed no ischemic changes, routine labs were unremarkable, including a troponin I of less than 0.04. Given his symptoms and risk factors, he is being admitted for further evaluation and therapy.
ER|emergency room|ER|158|159|HISTORY OF PRESENT ILLNESS|He has had recurrence of fevers and fatigue. He also has had some dark, even bloody, stools in his colostomy bag. It is for these reasons that he came to the ER for evaluation. His ER workup revealed a hemoglobin of 9, but was otherwise unremarkable. He was afebrile. He reports that he has had fevers up to 102 at home.
ER|emergency room|ER|139|140|PROBLEM #3|Then they can repeat the Dilaudid 2 mg in 30 minutes if his pain is not getting better, but from _%#MMDD#%_, he is limited to once a month ER visit and I talked to Dr. _%#NAME#%_ in person. He admitted that they are trying to commit the patient only to show up in 1 ER, Fairview Southdale ER only or North Memorial and he is not allowed to come to all the ERs.
ER|emergency room|ER,|245|247|HISTORY OF PRESENT ILLNESS|She has had back pain more on the right side, chills, aches with the fever, urinary frequency but this is not new for her, however, she notes that last week she was not voiding as often as she usually does. No dysuria. No other symptoms. In the ER, her blood pressure actually decreased after a liter of fluid. PAST MEDICAL HISTORY: Is remarkable for hypertension, stress incontinence, possible mild arthritis.
ER|emergency room|ER,|172|174|BRIEF  HISTORY AND HOSPITAL COURSE|She denied any associated dyspnea or other areas of rash or blistering but the pain had gotten somewhat more progressive and she presented to our ER for evaluation. In the ER, Dr. _%#NAME#%_ did discuss the case with numerous specialties including the burn specialist, general surgery and radiology as well as orthopedic surgery.
ER|emergency room|ER|205|206|PAST MEDICAL HISTORY|2. Obstructive sleep apnea on BiPAP with a setting of 15/13. 3. Poor dentition. 4. Morbid obesity. 5. History of thyroid-induced hyperglycemia. 6. Hypertension. 7. History of narcotic-seeking behavior per ER note. ALLERGIES: The patient is allergic to penicillin, which causes anaphylaxis.
ER|emergency room|ER|167|168|ASSESSMENT AND PLAN|I will continue her Levaquin such that she will complete a 10 day course. She has already had six or 7 of those days. She has improved a bit since she has been in the ER and thus I wouldn't anticipate a long stay. In fact, it may be possible for her to be discharged tomorrow with a tapering prednisone course.
ER|emergency room|ER|164|165|HOSPITAL  COURSE|DISCHARGE DISPOSITION: The patient will return to a TCU. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 71-year-old woman who presented to Fairview Southdale Hospital ER on _%#MMDD2007#%_ with complaints of increased dyspnea, left lower quadrant pain and confusion. Please refer to Dr. _%#NAME#%_'s dictated H&P for details. The patient was noted to be volume overloaded.
ER|emergency room|ER.|182|184|HISTORY OF PRESENT ILLNESS|No shortness of breath. On arrival to the ER, the patient was found to have fever of 101 degrees, and he was hypotensive. The patient was given IV fluid and a workup was done in the ER. The patient was then evaluated for admission. In the ER he was found to have urinary tract infection, with possible sepsis.
ER|emergency room|ER.|161|163|HISTORY OF PRESENT ILLNESS|The patient was exhibiting erratic behavior over the last 2 weeks, which has gotten worse. He was brought in for evaluation. The patient was given Ativan in the ER. He was lethargic during examination. History was obtained from medical records. PAST MEDICAL HISTORY: History of cerebral palsy, seizure disorder, mental retardation.
ER|emergency room|ER,|134|136|HISTORY OF PRESENT ILLNESS|The patient has no history of similar pain or complaints. No history of abdominal surgeries. No history of bowel obstructions. In the ER, the patient's vital signs were stable. He was afebrile. He was given Zofran, Toradol and Dilaudid for pain control. Abdominal CT scan obtained showed what appeared to be dilated loops of small bowel consistent with mechanical SBO.
ER|emergency room|ER|143|144|HISTORY OF PRESENT ILLNESS|He has had a steady and significant decline in his cardiovascular function and overall quality of life prior to admission and presented to the ER with shortness of breath on the day of admission. Please see my dictated history and physical for details regarding the patient's presentation.
ER|emergency room|ER,|174|176|HOSPITAL COURSE|There was some mild photophobia. No history of a headache. She had a similar headache years ago when she had meningitis. No fevers or chills. She was seen in Fairview Ridges ER, underwent spinal tap which was unremarkable, she was discharged home. However, there was an erroneous read of her gram stain, thought to be showing 2 different types of bacteria.
ER|emergency room|ER|209|210|HISTORY OF PRESENT ILLNESS|The patient has no previous history of fevers within the past 48 hours. The patient had rigors in the emergency room. The patient was reportedly hospitalized for pneumonia for 20 days three weeks ago, per the ER report, however, with the discharge summary that was readily available, it is determined the patient actually had a seronegative arthritis and possible vertebral fluid collection that was believed to possibly be infectious.
ER|emergency room|ER|213|214|LABORATORY STUDIES|Toes down going bilaterally. LABORATORY STUDIES: Hemoglobin 8.6, white blood cell count 4.7, normal differential. Platelet count 225. MCV 92. RDW 11.6, INR 0.92, PTT 25, D-Dimer negative. Chest CT obtained in the ER shows no pulmonary embolus. There is mild anterior pericardial thickening. Troponins negative. Myoglobin 17. EKG reviewed by myself shows normal sinus rhythm, no ischemic changes.
ER|emergency room|ER|323|324|HISTORY OF PRESENT ILLNESS|DOB: CHIEF COMPLAINT: Vomiting bright red blood. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 18- year-old, who, prior to this evening, was in his usual state of health when he began having profuse nausea and vomiting x 10 episodes, starting at around 11 o'clock. The majority of the history is obtained via the ER report as well as some history from the patient. However, at this point, he is asleep due to his anti-nausea medicine, and it is difficult to obtain a detailed history at this point.
ER|emergency room|ER|220|221|HISTORY OF PRESENT ILLNESS|The pain moved to her neck and chest. She then developed palpitations on her way home from work in the car. She denies any shortness of breath. Her symptoms persisted, and she ultimately presented to the Fairview Ridges ER for further evaluation. The patient denies any history of pneumothorax. She has not been told she has Marfan's syndrome. She denies any known lung disease. No trauma. Her initial chest x-ray and subsequent x-ray showed pneumothorax on the left.
ER|emergency room|ER.|284|286||The patient has had restlessness due to the pan. She is unable to cough or expectorate because of the pain. The patient had no lab done in the ER. Chest x-ray report says that she has a right middle lobe infiltrate compatible with pneumonia, which was not mentioned or noticed in the ER. MEDICATIONS: The patient's chronic medications include: 1. Nexium 40 mg b.i.d. for reflux.
ER|emergency room|ER|175|176|SUMMARY OF HOSPITAL STAY|Troponin was drawn which was negative and EKG showed early repolarization in the precordial leads. The patient was admitted to the cardiology floor for further workup. In the ER the patient was given sublingual nitroglycerin with which the pain did resolve, but the EKG changes did not go away; and therefore, the patient was taken to coronary angiogram from the ER and was admitted to cardiology afterwards.
ER|emergency room|ER|152|153|LABORATORY & DIAGNOSTIC DATA|Urinalysis, EKG, basic metabolic panel unremarkable. He does have a bilirubin of 12.7, the remainder of his LFTs are completely normal. Chest x-ray per ER is negative, though the final report is still pending. IMPRESSION: _%#NAME#%_ _%#NAME#%_ is a very pleasant, 23-year-old man with sickle cell disease, admitted with a sickle cell crisis.
ER|emergency room|ER,|195|197|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|They had been instructed to seek medical evaluation if he required 3 tablets so they called the paramedics. They brought him to the ER. His symptoms had resolved by the time they arrived. In the ER, he had routine evaluation including basic metabolic panel and CBC, all of which were unremarkable. He had a chest x-ray which showed no acute process.
ER|emergency room|ER,|271|273|HISTORY OF PRESENT ILLNESS|According to nursing home records, the patient was having increasing shortness of breath on the date of admission and was noted to have a temperature of 100.8. Because of these findings, they elected to send her to the emergency department for further assessment. In the ER, pertinent finding was 87% oxygen saturation on her usual 3 liters per nasal cannula. There was increased subjective dyspnea. The patient reports that her cough is "not too bad" although she does have a chronic productive cough and is bringing up more sputum than usual.
ER|emergency room|ER|427|428|ADMISSION HISTORY|The patient was offered a blood patch, however, she continued to decline that even on the day of discharge when she still had somewhat of a headache, but she was having no visual changes, no nausea and vomiting and her headache was relieved with Percocet. On postpartum day #4, she was discharged home with precautions given that should she develop nausea, vomiting, visual changes or any neurologic symptoms, to return to the ER immediately, otherwise to followup in 6 weeks and she should expect epidural headache to resolve by postop day #5. The patient was understanding this and was discharged home on Percocet #15 tablet, Ambien, albuterol, Singulair and ibuprofen.
ER|emergency room|ER.|133|135|PLAN|Certainly this can be done after her discharge. 5. Hypothyroidism: I will go ahead and get a TSH and added to the blood drawn in the ER. 6. Weight loss: This certainly is concerning in a woman her age with a vertebral collapse and a history of renal cell carcinoma.
ER|emergency room|ER|146|147|HISTORY OF PRESENT ILLNESS|She describes as feeling like a small child was sitting on her chest. They realized later that her nitroglycerine was expired. She came in to the ER and her pressure resolved with nitroglycerine and morphine, however, after arrival in the ICU she did report return of a slight pressure.
ER|emergency room|ER|136|137|DISCHARGE MEDICATIONS|PROBLEM #2: Gastroenteritis. The patient probably did suffer adverse effect from the soba noodles which he ate. He vomited twice in the ER and once on the floor but not since then. At the time of discharge, he was tolerating a regular diet without vomiting.
ER|emergency room|ER|134|135|HISTORY OF PRESENT COMPLAINT|Patient or family member did not notice anything or complain about anything. While discussion that with the family members as per the ER physician, one of the son's did think that it might be new but nobody is sure about that. Other than that, the patient does not have any active complaints at this point.
ER|emergency room|ER|196|197|HISTORY OF PRESENT ILLNESS|On the date of admission, the patient developed severe crushing chest pain, 5/10, in the substernal area with no shortness of breath and the chest pain had been at rest. The patient went into the ER with 1 nitro sublingual and the chest pain relieved. HOSPITAL COURSE: 1. Chest pain. The patient was ruled out MI by serial negative troponin.
ER|emergency room|ER|155|156|ASSESSMENT|This may all be viral. He is not immune suppressed. Nothing obvious in terms of source of bacterial infection at this time. No signs of meningitis. In the ER blood cultures were obtained and urine cultures were obtained. He was given Levaquin although I do not know the source that we are treating.
ER|emergency room|ER,|112|114|HISTORY OF PRESENT ILLNESS|No history of myocardial infarction. She has had some emesis and dry heaves as well with no hematemesis. In the ER, the patient's vital signs were stable. She was afebrile. She was given Zofran and 12 mg of IV morphine and is being admitted to the hospital service for further care.
ER|emergency room|ER|264|265|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Unstable C7-T1 fracture status post fall. HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old gentleman with Alzheimer dementia, living in assisted living, who was walking today and fell landing on his head. He was brought to the _%#CITY#%_ ER where a cervical spine CT demonstrated unstable C7-T1 fracture. He denies loss of consciousness with the fall. Neurosurgery was consulted regarding management of the fracture.
ER|emergency room|ER|299|300|IMPRESSION AND PLAN|CBC normal. The patient did have lipid panel done about 3 weeks ago which is notable for an LDL of 106 and triglyceride level 161 with a total cholesterol 183 and an HDL 44. IMPRESSION AND PLAN: Mr. _%#NAME#%_ is a 70-year-old male with a history of diabetes and hyperlipidemia admitted through the ER with an episode of presyncope. 1. Presyncopal: I suspect the patient's symptoms are likely related to an orthostatic or vasovagal type event.
ER|emergency room|ER|158|159|HOSPITAL COURSE|He has chronic dysarthria and left-sided weakness which was essentially unchanged. HOSPITAL COURSE: 1. CVA: The patient did have an MRI scan performed in the ER which demonstrated what appeared to be an acute or recent left thalamic CVA. The patient's course was one of gradual improvement. By the day of discharge, he does have a bit of imbalance still subjectively, but his symptoms were much improved compared to when they started.
ER|emergency room|ER.|117|119|HISTORY OF PRESENT ILLNESS|The pain started suddenly at 4:30 this afternoon. The abdominal pain was slightly improved with a GI cocktail in the ER. The patient complains of continued chest pain at 5/10 but improving. The patient was found to have a blood pressure of 250/131 upon presentation to the ER.
ER|emergency room|ER|113|114|HISTORY OF PRESENT ILLNESS|Some associated nausea. Low-grade fevers. No emesis or diarrhea. She has some light stools prior to going to the ER on _%#MMDD2007#%_. She has had about a 15 pound weight loss over the past several months. Her pain, she states is increased today after she ate a ham and cheese sandwich.
ER|emergency room|ER|193|194|HISTORY OF PRESENT ILLNESS|Apparently she was in her usual level of functioning, which is unknown to this examiner, but when the staff checked on her around 4:30, they found her lethargic and febrile. Accordingly to the ER doctor's, her temperature was 103.3 when she arrived in the emergency room. Physical exam and laboratory data were suspicious for urosepsis and she was now admitted for further evaluation.
ER|extended release|ER|118|119|MEDICATIONS|9) Cholecystectomy. 10) Open reduction and internal fixation right femur. MEDICATIONS: 1. Lasix 40 t.i.d. 2. Depakote ER 1000 every day. 3. Kay Ciel 40 daily. 4. Lisinopril 10 a day. 5. Neurontin 600 t.i.d. 6. Zanaflex 8 at bedtime.
ER|emergency room|ER.|168|170|HISTORY  OF PRESENT ILLNESS|He fell onto a carpeted area with no head trauma, no loss of consciousness, no preceding chest pain, palpitations or focal weakness. He presented to Fairview Southdale ER. At that time, head CT was performed which showed no acute change. This a.m. the patient awoke and felt that he was too weak to get up out of bed.
ER|emergency room|ER,|190|192|HISTORY OF PRESENT ILLNESS|He awoke on _%#MMDD2006#%_ with difficulty expressing himself clearly. Family brought the patient to University of Minnesota Medical Center, Fairview, Emergency Department. Initially in the ER, the patient had difficulty with word finding, but his speech was fluent. He also had mild impaired comprehension and could not follow 3-step commands.
ER|extended release|ER|211|212|HOSPITAL COURSE|On _%#MMDD2006#%_ his hemoglobin stabilized at 9.9. He was converted to normal sinus rhythm since _%#MMDD2006#%_ with stable rate. We decided to send him home on Lovenox 1 mg/kg subcutaneous b.i.d. and Cardizem ER 120 mg p.o. daily. Antibiotics were initiated in IV form during his hospitalization the setting of possible postobstructive pneumonia and it will be continued as oral antibiotics at home.
ER|emergency room|E.R.|220|223|PHYSICAL EXAMINATION|NEUROLOGICAL: Nonfocal. ABDOMEN: Distended and soft with significant tenderness in the lower quadrants, right greater than left. Early peritoneal possible. No herniae or masses are appreciated. PELVIC EXAM: Deferred per E.R. SKIN: Turgor is decreased, no cyanosis or edema. LABORATORY DATA: White count is elevated at 18.5. CT SCAN: Showed fluid in the pelvis and what appeared to be a dilated appendix.
ER|emergency room|ER|175|176|HOSPITAL COURSE|10. Folic acid and vitamin B12. DISCHARGE FOLLOW-UP: Dr. _%#NAME#%_. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is an 81-year-old man who presented to Fairview Southdale Hospital ER on _%#MMDD2007#%_ and was admitted by Dr. _%#NAME#%_ for vomiting and bloody stool. Please refer to her dictated H&P for details.
ER|emergency room|ER|283|284|HISTORY OF PRESENT ILLNESS|Subsequently paramedics brought the patient to the ER. At the ED, the patient was still unresponsive but was able to wake up briefly to tell the ER physician that he took Elavil, quantity or dose unknown. He had no gag reflex and had very sluggish pupil. The patient's vitals at the ER were stable except for sinus tachycardia with heart rate of 110 to 120's. He was intubated in the ER for airway protection. The patient was also treated with activated charcoal and gastric lavage.
ER|emergency room|ER|115|116|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Joint pain. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 48-year-old male admitted through the ER with recent onset of swelling and pain of the hands, feet, and also neck pain. The patient reports that 3-4 days ago, he began to develop left upper extremity swelling, primarily localized to the hands and the wrist.
ER|emergency room|ER|187|188|HISTORY OF PRESENT ILLNESS|She had relief for approximately 1 year and then over the next 5-6 years, up until _%#MM#%_, she has had chronic low-grade back pain with occasional exacerbations requiring narcotics and ER visits. In _%#MM#%_ she fell off an office chair at home and landed on a metal part of the chair on her low back.
ER|emergency room|ER|131|132|HISTORY OF PRESENT ILLNESS|_%#NAME#%_ _%#NAME#%_ is an 81-year-old white male. This admission is for unconsciousness. HISTORY OF PRESENT ILLNESS: Is from the ER physician as well as family. As I understand the sequence of events, the patient was at a rehab unit convalescing from weakness from a recent gram negative urinary tract infection.
ER|emergency room|ER|190|191|HISTORY OF PRESENT ILLNESS|She underwent abdominal CT without contrast which showed bilateral nephrolithiasis, greater on the right. No evidence of ureteral obstruction. The patient has received some narcotics in the ER and is currently feeling better. She has had no bowel movement for 4 days. She has been having a hard stool. She is on MiraLax. Previously, her back pain has been well controlled on extra strength Tylenol.
ER|emergency room|ER,|201|203|DISCHARGE INSTRUCTIONS|The patient will continue to receive home health services from the Intrepid Agency for assistance with medication set up and home assessment. The patient is instructed to follow-up with PMD, return to ER, if she again experiences acute shortness of breath, fevers, chills, cough with sputum production, or if there is an acute change in her mental status.
ER|emergency room|ER|182|183|HISTORY OF PRESENT ILLNESS|The patient was told to increase her Advair to 2 puffs b.i.d. but she did also recently have approximately 2 weeks prior to admission sinus surgery. The patient had been seen in the ER at FUMC yesterday and she said she was diagnosed with a broken rib secondary to coughing. She was at the ENT Clinic today for her scheduled followup from her sinus surgery.
ER|emergency room|ER.|126|128|PHYSICAL EXAMINATION|Extremities: no cyanosis, clubbing, or edema. EKG showed a new left bundle branch block with a bradycardia in the 50's at the ER. Chest x-ray showed clear lungs with a normal cardiac silhouette. TTE showed normal LV function. LABORATORIES: Sodium 142, potassium 3.7, chloride 109, bicarb 21, glucose 104, calcium 8.8, BUN 14, creatinine 0.8. Hemoglobin 14, INR 3.13, platelets 319.
ER|estrogen receptor|ER|111|112|SUMMARY OF HOSPITAL COURSE|At this time, a treatment modality for this tumor has not been completely decided upon. It is felt that if the ER receptor types were positive in this cancer that the patient should be started on Femara 2.5 mg orally daily for treatment of this tumor.
ER|emergency room|ER|192|193|PRIMARY CARE PHYSICIAN|PRIMARY CARE PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a poor historian and unable to give me any history. The information is obtained from records in the hospital and the ER records. The patient was recently admitted to Fairview Southdale Hospital on _%#MMDD#%_ for confusion and weakness, had a prolonged hospital stay.
ER|emergency room|ER|183|184|LABORATORY DATA|ABDOMEN: Soft. EXTREMITIES: Pedal pulses are full and symmetric. NEUROLOGIC: Grossly normal. Chest x-ray is unremarkable. LABORATORY DATA: No laboratory studies have been done in the ER so far. ASSESSMENT: Status asthmaticus. PLAN: 1. I am going to move to the attentive care unit.
ER|emergency room|ER.|140|142|ASSESSMENT AND PLAN|He used to be on Norvasc and atenolol. I will plan on starting him back on atenolol. Additionally, he did get a dose of IV Lopressor in the ER. He may need a second agent for long-term but I will just start with atenolol. Also make p.r.n. clonidine available through the alcohol withdrawal protocol.
ER|emergency room|ER|135|136|LABORATORY AND DIAGNOSTIC|Differential count, neutrophils 74%, and lymphocytes decreased at 11%, and monocytes increased to 14%. Chest x-ray was obtained in the ER which showed no focal infiltrates, a shallow inspiration with mild scarring versus atelectasis in the right lung. There is elevation of the right hemidiaphragm. A12-lead EKG was obtained which showed sinus bradycardia.
ER|emergency room|ER|187|188|PLAN|3. Surgical consultation was obtained with Dr. _%#NAME#%_ in the ER and he will be admitting the patient for further care. 4. Intravenous antibiotics with Unasyn which was started in the ER at 3 grams IV q. 6 hours. 5. Will continue hypertensive medications and p.r.n. parenteral of hypertension medications as well.
ER|emergency room|ER|153|154|IMPRESSION AND PLAN|She did recently increase her Protonix again to b.i.d. dosing, which I would continue with at the present time. She did have a significant workup in the ER including abdominal CT scan which is essentially unremarkable, as well as a negative abdominal ultrasound. No evidence of obstruction or any other concerning findings on imaging studies as well as unremarkable complete metabolic panel with normal LFTs and lipase level.
ER|extended release|ER|158|159|DISCHARGE MEDICATIONS|Her activities were advanced in the hospital. Her cardiovascular status did appear stable. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. q. day. 2. Metoprolol ER 25 mg p.o. q. day. 3. Cozaar 50 mg p.o. q. day. 4. Simvastatin 20 mg p.o. each night. 5. Hydrochlorothiazide 12.5 mg p.o. each day.
ER|emergency room|ER.|157|159|HISTORY OF PRESENT ILLNESS|He indicated that she was unwilling to help her from the car into a wheelchair. She then drove off from the emergency room and did not accompany here in the ER. Clinic staff at my clinic also relate that in the waiting room at our clinic, he is often rather rude with staff and demeaning to her verbally.
ER|emergency room|ER,|86|88|HOSPITAL COURSE|Blood pressure was noted to be low at Ebenezer Ridges, and she was transferred to the ER, and initial blood pressure was 53/35. She responded to several boluses of fluid. She was feeling well the day prior, was in physical therapy from a recent fall.
ER|emergency room|ER|159|160|HOSPITAL COURSE|He came here and he was dialyzed 2 days prior at _%#CITY#%_, Washington, and he did not have any location where to go for his dialysis. So, he walked into the ER and was admitted for a hemodialysis. The patient was asymptomatic. His potassium was 4.5, and we consulted the renal team, and he had hemodialysis the following day.
ER|emergency room|ER.|131|133|IMRPESSION|The plan is to check orthostatics to try to assess more fluid status than adrenal status, but he did receive hydrocortisone in the ER. Check an echo to assess his cardiac function and possibility of aortic stenosis. Rule out protocol and monitor for dysrhythmia. We will request Minnesota Heart consult to evaluate and consider further evaluation.
ER|emergency room|ER.|176|178|PHYSICAL EXAMINATION|4. Lisinopril 10 mg each day. 5. Novolin N insulin 110 units subcutaneously q.a.m. PHYSICAL EXAMINATION: VITAL SIGNS: The patient is afebrile, blood pressure was 138/80 in the ER. Recheck on the floor blood pressure was 150/78, pulse 115, and came down to 92. Respiratory rate was normal. Oxygen saturation normal on room air.
ER|emergency room|ER|283|284|PHYSICAL  EXAMINATION|MUSCULOSKELETAL: The patient states he has chronic left-sided weakness. It is unclear if this is related to his CVI in 1999 or possibly due to arthritis as he complains of chronic left hip pain. Chest x-ray reveals hyperinflated lungs. No acute infiltrate. Hip and pelvic x-rays per ER report reveal right superior pubic ramus fracture. LABORATORY DATA: INR 0.96, white count 11.8, hemoglobin 14.7, platelets 272,000.
ER|extended release|ER|245|246|DISCHARGE MEDICATIONS|We think that this is a reasonable plan. 2. Follow up with cardiology in 2 weeks to discuss restarting medication that was discontinued while hospitalized including Cardura and Atenolol. DISCHARGE MEDICATIONS: 1. Imuran 200 mg q.h.s. 2. Niaspon ER 500 mg q.h.s. 3. Zetia 10 mg daily. 4. Aggrenox one tablet b.i.d. 5. Prednisone 30 mg b.i.d. 6. Lantus 20 units subcutaneous b.i.d.
ER|emergency room|ER,|172|174|HOSPITAL COURSE|The patient was sent from the nursing home with concerns about possible pneumonia. He was having increasing shortness of breath and hypoxia and seemed more sedated. In the ER, chest x-ray was compared to his previous, and there was no change noted. It was felt that his respiratory depression and somnolence were related to his narcotics.
ER|emergency room|ER.|178|180|HISTORY OF PRESENT ILLNESS|This was fairly steady, though did wax and wane slightly, it was constant, it did not go away. He was able to sleep, but it was still present this morning so he presented to the ER. It did finally go away after receiving metoprolol, aspirin and nitroglycerine. He reports that he has never had pain like that before and has not had any since it went away in the ER.
ER|emergency room|ER.|137|139|HISTORY OF PRESENT ILLNESS|The patient did have one episode at rest which is what prompted to have call her nurse line at her clinic which then referred her to the ER. Patient did have this episode during rest. She then took 2-3 hour nap and awoke and had some improvement. She was not entirely better which prompted the call to the nurse line.
ER|emergency room|ER|220|221|BRIEF HISTORY|In _%#MM#%_ _%#DD#%_, 2002, she was admitted for a Port-A-Cath as she began her first dose of Taxol- carbo x 1. On _%#MM#%_ _%#DD#%_, 2002, she underwent Taxol-carbo x 2. On _%#MM#%_ _%#DD#%_, 2002, she presented to the ER with uncontrollable pain. She stated that she had lost approximately 25 pounds in 4 months, increasing fatigue, hair loss, anxiety and depression.
ER|emergency room|ER,|154|156|HISTORY OF PRESENT ILLNESS|Reportedly, the suicide attempt was instigated by an argument with her mother regarding math homework. She was given a bolus of Mucomyst in the Southdale ER, and transferred to Fairview- University Medical Center Pediatrics ICU. PHYSICAL EXAMINATION ON ADMISSION: Temperature 99.5. Pulse 102. Respirations 20.
ER|emergency room|ER|127|128|PHYSICAL EXAMINATION|Hepatosplenomegaly is noted. No tenderness to palpation. No rebound or guarding. RECTAL: Done by Dr. _%#NAME#%_ earlier in the ER with guaiac-positive stool that was blackish in color. EXTREMITIES: There was 2+ pitting edema to the midcalves which patient describes as much improved compared to previous.
ER|emergency room|ER|172|173|PRIMARY CARE PHYSICIAN|PRIMARY CARE PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ has underlying mental retardation and is a poor historian. Most of the history is obtained from the ER docs, old records and also from the patient. CHIEF COMPLAINT: Lightheadedness, nausea and vomiting since this afternoon. HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old gentleman who has underlying mental retardation, does admit that the patient has been here multiple times and feels he may not get adequate attention and therefore is concerned.
ER|emergency room|ER|149|150||He continued boarding but developed over the rest of the day and into the night some significant abdominal pain that subsequently brought him to the ER where a CT scan showed a splenic injury. I have personally reviewed the scan. It does show a small amount of free blood in the left upper quadrant and what looks like a small fracture in the posterior corner of the spleen.
ER|emergency room|E.R.|196|199|ASSESSMENT|ASSESSMENT: The patient is a 22-year-old female with community acquired pneumonia. 1. Community acquired pneumonia: The patient has received ceftriaxone 1 gram and azithromycin 500 mg once in the E.R. The community acquired pneumonia protocol will be followed with completion of 4 additional days of azithromycin 250 mg daily. The patient will also receive normal saline and her fever curve will be monitored.
ER|emergency room|ER|199|200|HOSPITAL COURSE|She apparently has been very functional at home up until about few days before admission when she became very weak and unable to function at home, unable to do her ADLs. She was admitted through the ER after getting some IV labetolol. She was transferred to the floor for observation and treatment. She was started on lisinopril 10 mg p.o. daily and increased her atenolol to 75 mg daily from 50 mg daily from her previous dose.
ER|emergency room|ER.|196|198|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: CONSTITUTIONAL: No fever. HEENT: Eyes, no visual disturbances. Ears, no tinnitus. CARDIOVASCULAR: No chest pain. RESPIRATORY: Had this acute shortness of breath but resolved in ER. Has history of lung cancer, getting chemo treatment. Next chemotherapy due on _%#MMDD2007#%_. GASTROINTESTINAL: Had nausea, currently resolved. GENITOURINARY: No dysuria. HEMATOLOGIC: No anemia.
ER|emergency room|ER|240|241|HISTORY OF PRESENT ILLNESS|Ms. _%#NAME#%_ is an 88-year-old female with a history of dementia, hydrocephalus requiring VP shunt, and has been admitted through the ER with complaints of left hip pain. The patient was ultimately diagnosed with left hip fracture in the ER and is being admitted to the hospitalist service with plans for orthopedic consultation. The patient is demented and difficult to obtain history from.
ER|emergency room|ER|140|141||She started bleeding and cramping on the evening of _%#MMDD2002#%_. The patient's husband called me at 10:15 when he got off work. He is an ER nurse and stated that his wife was bleeding heavily and cramping. At that point if the bleeding did not cease within 15 minutes that she needed to go to the ER.
ER|emergency room|ER|155|156|SURGEON|SURGEON: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD This patient has a combined deformity of pectus excavatum and carinatum and most importantly has been in the ER several times because of marked pain over her left chest wall which is markedly increased in its diameter with a carinatum-type deformity. She had a pectus repair with sternoplasty and brace, advancement of muscle flaps, and intercostal block on _%#MM#%_ _%#DD#%_, 2003.
ER|emergency room|ER|220|221|HISTORY OF PRESENT ILLNESS|In the process of talking to the patient, it was discovered that he had taken 14 tablets of an antihistamine called Coricidin. He last took these pills at approximately 12 noon on _%#MMDD2003#%_. He was evaluated in the ER with concerns about anticholinergic toxicity. On interview now, he denies any fevers or chills. He denies any headache or vision changes.
ER|emergency room|ER|174|175|HISTORY OF PRESENT ILLNESS|Increased weakness. Tonight the patient was too weak to get out of the chair and therefore paramedics were called. Oxygen saturation upon arrival was 79% on room air. In the ER found to have elevated BUN, creatinine, and BNP as well as elevated troponins and INR of 17. Hemoglobin of 9.6 is down from baseline of greater than 11.
ER|emergency room|ER,|191|193|HISTORY OF PRESENT ILLNESS|The patient states she walks frequently and does not experience any dyspnea on exertion or chest pain with walking but otherwise does not have a regular exercise regimen. On arrival into the ER, the patient was given sublingual nitroglycerin which she states did not have any significant effect on her discomfort though the report from the ER physician states that she noted some mild improvement in her discomfort.
ER|emergency room|ER|202|203|HISTORY OF PRESENT ILLNESS|PRIMARY CARE PHYSICIAN: Dr. _%#NAME#%_ at Silver Lake Clinc CHIEF COMPLAINT: Possible drug overdose. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a _%#1914#%_ female patient who presents to the ER after being found at her assisted living facility with an empty bottle of Tylenol. The patient does have a past history of cancer, and is apparently undergoing treatment with Arimidex; dementia; GERD, status post pacemaker placement; and a recent hospitalization at Fairview University Medical Center from _%#MM#%_ _%#DD#%_ to _%#MM#%_ _%#DD#%_ with a MRSA UTI.
ER|emergency room|ER|195|196|HISTORY OF PRESENT ILLNESS|His friend's daughter, who is a pastor, picked the patient up and they drove him around for approximately 1 hour until the patient ultimately was agreeable to be brought into the Fairview Ridges ER for further evaluation. In the emergency room, he was hemodynamically stable, though slightly hypertensive and slightly somnolent. Creatinine was 1.6, pH 7.35, bicarbonate 20, anion gap 20, sodium 149.
ER|emergency room|ER|257|258|HOSPITAL COURSE|She initially presented to _%#CITY#%_ _%#CITY#%_ Medical Center Clinic with complaints of shortness of breath, cough productive of yellow sputum and chills for approximately 2 days. She was noted to be hypoxic at 88%. She was transferred to Fairview Ridges ER for further evaluation. She on presentation was noted to have a slight trivial elevation in her troponin. She was given a dose of Levaquin and duonebs and an aspirin.
ER|emergency room|ER|164|165|HISTORY OF PRESENT ILLNESS|Symptoms began several days prior to admission and only worsened over time. In addition, she noted some sweats, fevers and some abdominal pain. She was seen in the ER and noted to be quite dehydrated and unfortunately continued to vomit. She was given considerable amount of IV fluids and his CT of the abdomen was done given her pain; this revealed multiple loops of small bowel in the mid and lower abdomen with wall thickening and mesenteric edema and ascites suspicious for inflammatory versus infectious small bowel process.
ER|emergency room|ER,|142|144|HISTORY OF PRESENT ILLNESS|She has had 2 previous heart attacks which presented with right upper extremity pain. She has not had any right arm pain this evening. In the ER, the patient's vital signs were stable. Workup included labs which were notable for a lipase elevated at 31,000. The patient is being admitted to the hospital service for further care.
ER|emergency room|ER|243|244|REASON  FOR ADMISSION|Incidentally, his wife was admitted to this hospital several days prior to his admission and other family members were helping take care of him at home. Given his complaints of back pain and difficulty with ambulation, he was brought into the ER and subsequently admitted to the hospital. HOSPITAL COURSE: 1. Back pain: Radiographs indicated a T12 compression fracture, which I suspect is likely the etiology for his pain.
ER|emergency room|ER|199|200|BRIEF HISTORY|There is 1:1 capture between the P and subsequent QRS complex. The patient tolerated the procedure without any complications. His blood pressure, heart rate, respiratory status were monitored by the ER staff. His blood pressure at the time of disposition is 116/77, heart rate of 80, respiratory rate of 16 and sating 100%.
ER|emergency room|ER.|134|136|MEDICATIONS|Fluid was slightly cloudy, Gram stain did not show any organisms. The patient was admitted, he was given 1 dose of IV Rocephin in the ER. During the hospital course, the patient started feeling better with this knee pain. Knee fluid analysis came back positive for pseudogout. The patient had physical therapy during the hospital stay.
ER|emergency room|ER,|200|202|SOCIAL HISTORY|Next of kin is a sister-in-law and a niece. By the time I got to the CICU, she had already been evaluated by Cardiology and was sent to CT scan. Putting together an exam from the cardiologist and the ER, heart and lungs basically clear. She had some EKG changes, but her troponin was negative. Abdomen was unremarkable. No edema. Neuro intact. The patient was put on heparin and Cardiology consulted.
ER|emergency room|ER|125|126|HISTORY OF PRESENT ILLNESS|Was unable to bear weight due to pain in his right hip and pelvis. Preliminary x-rays in the ER were read as negative by the ER doctor, pending official report for further treatment and evaluation. It was noted in the ER he also had a bout of atrial fibrillation which corrected with some IV Diltiazem.
ER|emergency room|ER.|138|140|LAB  DATA|Liver function tests were normal. Urine was negative. Lipase was normal at 86. He has 90% PMN's He did have ultrasound and CT through the ER. Preliminary reports are negative outside of a 2 cm hemangioma of the right lobe of the liver. ASSESSMENT: 52-year-old with fever, leukocytosis, right sided pleuritic type chest pain.
ER|emergency room|ER|159|160|LABORATORY DATA|LABORATORY DATA: Labs show a urinalysis with many bacteria. A white count and urine culture was sent. Blood cultures were sent x 2. A head CT was negative per ER doctor, as were an abdominal x-ray. A Foley was placed, and 1600 cc of urine was returned. Other labs showed normal electrolytes, other than a creatinine of 2.8 and BUN 36.
ER|emergency room|ER,|172|174|HISTORY OF PRESENT ILLNESS|Upon followup with his primary care physician 2 days later, his primary care physician sent him directly to the Fairview-University Medical Center's emergency room. In the ER, he had a CAT scan which showed a right thalamic internal capsule infarct. HOSPITAL COURSE: He was admitted under the neurology service and went through a full stroke workup.
ER|emergency room|ER|310|311|DISCHARGE DIAGNOSIS|She has no history of migraines in the past. The patient states that this nausea and vomiting continued and persisted to the point where she decided to go with her mother to the Emergency Department at _%#CITY#%_. The patient also had a concomitant complaint of transient right arm numbness. Evaluation in the ER led to some slight concern of meningeal irritation but an LP performed there was unrevealing as the CSF protein was 19, glucose 57, white cells 0 per dL, red blood cells 1 per dL, gram stain negative.
ER|emergency room|ER|197|198|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 53-year-old Caucasian female who was seen today initially in the Fairview Ridges Hospital Emergency Room and evaluated by Dr. _%#NAME#%_, the ER physician for presentation of exacerbation of her chronic musculoskeletal pain. The patient states that 4 days ago when she was at home she fell down on her anterior chest wall and had a contusion; however, she was able to get around and did not seek medical help.
ER|emergency room|ER|195|196|DISCHARGE DIAGNOSES|2. Cardiac monitoring. HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old female with past medical history significant for end stage liver disease secondary to hepatitis C who presented to ER secondary to change in mental status. She was found by her teenage children unresponsive and was brought to the emergency department.
ER|emergency room|ER.|231|233|MAJOR DIAGNOSIS|Around two hours later she started feeling light headed, diaphoretic, upper chest pressure sensation and the patient denied any discomfort or palpitations in the past. She was seen the nurse practitioner in her job and was sent to ER. The pain and bad sensation was actually gone by the time she was seen by medicine department. She had one episode of hypertension two years ago, status post urinary tract infection.
ER|emergency room|ER,|170|172|PROBLEM #6|Therefore, please feel free to review this in the future. The patient could possibly be seen and assessed and without EKG changes or any significant troponin leak in the ER, it is unlikely the patient to gain any further benefit for readmission. DISCHARGE MEDICATIONS: 1. Nadolol 20 mg p.o. q. day.
ER|emergency room|ER|323|324|LABORATORY DATA|No immature forms. Her sodium was 142, potassium 4.4, chloride 109, CO2 25, blood sugar 107, BUN 12 and creatinine 0.7. Calcium was 9.9. B type natriuretic peptide was 15, negative troponin, negative D-dimer. INR was normal. EKG showed normal sinus rhythm. She was not tachycardic. Occasional PVC. No PACs. Chest x-ray per ER report was significant for COPD changes in the upper lobes. No acute infiltrates and no evidence for heart failure. PHYSICAL EXAMINATION: The physical exam shows an alert woman in no acute distress, who is talking rapidly now and without any difficulty breathing.
ER|emergency room|ER|286|287|LABORATORY DATA|Albumin is mildly low at 2.7. Lactate is pending. EKG demonstrates a sinus tachycardia, baseline artifact, nonspecific ST- T wave changes, not significantly changed from _%#MMDD2004#%_, but more marked when compared from _%#MMDD2004#%_. Flat and upright of the abdomen nonspecific, per ER physician. ASSESSMENT: A 65-year-old female admitted with the following: 1. Febrile illness.
ER|emergency room|ER.|247|249|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 73-year-old white male, with severe chronic obstructive pulmonary disease who came in with shortness of breath, recurrent respiratory failure, requiring BiPAP and his 02 was 100% after being seen briefly in the ER. He was admitted to ICU with BiPAP. The patient had a fall about two days ago. He was unable to get up and had emergency team come and get him up.
ER|emergency room|ER|163|164|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient has been troubled with what she describes as vertigo for two years. This has been slowly progressive. She has had multiple ER visits for this as documented in the chart. She has also been working with her primary care physician, Dr. _%#NAME#%_, in this regard. He ordered a CT scan done Monday.
ER|emergency room|ER|147|148|HISTORY|It turns out that was indomethacin. Again he is quite clear in saying no antibiotics were used for his coughing episodes in early _%#MM#%_. In the ER the patient had laboratory work including CBC basically normal other than 18% eosinophils in his white count. His total WBC count was 7900. His electrolytes were within normal limits, the glucose 110, creatinine 1.2, liver function tests normal except the protein a little elevated at 8.5, with an albumin of 4.5. The urinalysis was within normal limits with no white cells.
ER|emergency room|ER|161|162|HOSPITAL COURSE|EKG shows sinus tachycardia. HOSPITAL COURSE: The patient was admitted to the ICU for alcohol withdrawal precautions. 1. Alcohol intoxication/withdrawal. In the ER the patient received Valium and folate and a multivitamin. He was started on IV fluids and given Ativan. He was transferred to the ICU where was placed on the MSSA protocol with Valium.
ER|emergency room|ER,|123|125|OBJECTIVE|She has no cognitive impairment. She is postmenopausal without any recurrent bleeding. She has no edema. OBJECTIVE: In the ER, her blood pressure was essentially 80/58, heart rate 154, respiratory rate 32, and temperature 95.6. In the ICU, her heart rate has been in the 80s, and she has been in sinus rhythm.
ER|emergency room|ER|175|176|DOB|She has had no radiation of pain down her leg or numbness down her leg. She denies significant back discomfort. The patient required Toradol and morphine several times in the ER for pain relief. The patient denies any recent fall or injury. The patient is generally well; however, she does have severe hypertension and presently is on Hyzaar 50/12.5 b.i.d. and Catapres-TTS 3 patches, two patches weekly two at a time.
ER|emergency room|ER.|190|192|HISTORY OF PRESENT ILLNESS|A couple of days ago the patient noticed a very small area of redness just below the antecubital fossa on the right arm. It was somewhat red. This increased last night and she went into the ER. In the ER she was noted to have some "red streaking up the arm" and was admitted for "cellulitis." She has no history of trauma or injury to the arm.
ER|emergency room|ER|165|166|HOSPITAL COURSE|7. Keppra 750 mg p.o. b.i.d. 8. Depakote 500 mg p.o. q day. 9. OCP. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 45-year-old woman who presents to Fairview Southdale ER after syncopal episode and difficulty walking because she incurred some soft tissue trauma to the bilateral hip area. In the ER, she had no seizure activity. Her electrolytes were normal.
ER|emergency room|ER|210|211|HISTORY OF PRESENT ILLNESS|She use to feel like she had control over it but lately has realized that she does not have control. For the last five days she has been unable to make herself stop vomiting. She now feels weak and came to the ER for evaluation. In the ER, she was found to have a sodium of 135, potassium 2.4, chloride 75, bicarb 35, BUN 53 and creatinine 1.6. Her anion gap was elevated at 25.
ER|extended release|ER|146|147|HOSPITAL COURSE|HOSPITAL COURSE: Ms. _%#NAME#%_ was admitted to station 30 north, adult mental health treatment unit. On admission, Cogentin 1 mg daily, Depakote ER 1500 mg daily at bedtime and amitriptyline 20 mg daily at bedtime were reordered. Her Cymbalta dose was clarified and ordered at 60 mg daily, as she had been previously taking.
ER|emergency room|ER,|124|126|HISTORY OF PRESENT ILLNESS|She had an exercise stress echo done at the United Hospital which was interpreted as being normal. During her course in the ER, she experienced a severe abdominal pain, which was further evaluated by the surgery team. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Albuterol MDI.
ER|emergency room|ER.|203|205|PHYSICAL EXAM|Echocardiogram shows normal LV function. Ejection fraction 65%, no wall motion abnormalities, moderate concentric LVH. Mild to moderate TR, no clot or shunts noted. Telemetry initially shows SVT down in ER. EKG reviewed by myself shows atrial fibrillation with rapid ventricular rate. No ischemic changes. ASSESSMENT AND PLAN: 1. Atrial fibrillation, possible "alone atrial fibrillation", however, the patient does have some moderate concentric left ventricular hypertrophy suggestive of underlying hypertension and she carries the diagnosis of borderline hypertension.
ER|emergency room|ER,|186|188|HISTORY OF PRESENT ILLNESS|After receiving nitroglycerin, the symptoms resolved and have not returned. He came to the emergency department were he was evaluated and admitted for further care and treatment. In the ER, he had a normal troponin. He did have a supertherapeutic INR of 3.93. He had an EKG that showed atrial fibrillation with a ventricular rate of about 90.
ER|emergency room|ER.|307|309|HISTORY OF PRESENT ILLNESS|She has problems with ambulation secondary to rheumatoid arthritis. She was stepping on into the snow earlier on the day of presentation which was on _%#MM#%_ _%#DD#%_, 2006, and fell on the snow in her front yard. She was lying there for about 2 hours until somebody called 911, and she was brought to the ER. In the ER, her EKG showed nonspecific ST-T changes, mild ST elevation in I, aVL, and V6. The patient had a recent adenosine thallium stress test in _%#MM#%_ 2005 which was negative for ischemia.
ER|emergency room|ER|135|136||On Saturday, again, the patient became mentally sleepy and confused and walking in the nursing home. That is why the family brought to ER and ER physician admitted the patient to ICU for observation. CURRENT MEDICATIONS: 1. Remeron 7.5 mg at bedtime. 2. Prednisone 5 mg once a day.
ER|emergency room|ER,|166|168|LABORATORY DATA|You are referred to Dr. _%#NAME#%_ _%#NAME#%_'s admission H&P dated _%#MMDD2006#%_ for the details surrounding his admission. LABORATORY DATA: On presentation to the ER, the patient had the following tests. He had an EKG that showed SVT with a rate of 166. His hemoglobin was 15.8 with an MCV of 91, white count was 9,700 with 83% neutrophils, 10% lymphocytes, 7% monocytes, and platelet count was 209,000.
ER|extended release|ER|142|143|IDENTIFICATION|He has his first one scheduled for _%#MM#%_ _%#DD#%_, 2004. On _%#MM#%_ _%#DD#%_, 2004, an order was written to begin a taper of the Depakote ER and then to be discontinued after the taper. A meeting was held on _%#MM#%_ _%#DD#%_, 2004, with the staff from the facility with the case manager and his physician.
ER|emergency room|ER|143|144|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is s 53-year-old female with a past medical history of hypothyroidism and depression. The patient came to the ER with a one-day history of left lower quadrant abdominal pain. The patient started having pain after lunch. She ranked the pain as 7/10 with radiation to the back, dull and constant.
ER|emergency room|ER.|112|114|DISCHARGE INSTRUCTIONS|LOWER EXTREMITIES: Skin is warm, dry, intact. No rash. DISCHARGE INSTRUCTIONS: 1. Levaquin as prescribed in the ER. The patient is to take all 13 doses. He was also prescribed p.r.n. Percocet and ibuprofen. 2. Activity level as tolerated.
ER|emergency room|ER|191|192|DIAGNOSTIC IMPRESSION|5. Chronic bronchitis believed to be present. Currently, she is not a bit dyspneic. She is on steroids that were started last night as well as an antibiotic, levofloxacin. 6. As noted in the ER report, she is a vulnerable adult and probably needs some sort of arrangement present to keep her out of situations that will have her medications misused.
ER|emergency room|ER.|366|368|HISTORY OF PRESENT ILLNESS|The patient's daughter is present with her in the emergency room and thinks the patient may have actually passed out during her fall and, in fact, has had some further episodes of syncope within the last year or so that have been evaluated by Dr. _%#NAME#%_ in the clinic but the details of this work-up are not available. Patient currently is feeling better in the ER. She was found to have abnormal urinalysis consistent with a UTI. She was given a dose of Levaquin. She was also found to be dehydrated and started on IV fluids.
ER|estrogen receptor|ER|156|157|ASSESSMENT/PLAN|The risks and benefits of this were reviewed for the patient as were her prognosis without chemotherapy. It was also explained to the patient that with her ER PR negative cancer that hormonal therapy would be of no benefit to her. Recommendations would be that the patient undergo chemotherapy and then radiation therapy.
ER|emergency room|ER,|174|176|SYNAPSE OF HISTORY AND PHYSICAL|After that, the patient started noticing this epigastric substernal pain. At home, the patient took three nitroglycerin, which was not relived, so she came to the ER. In the ER, the patient had blood pressure of 141/68 and pulse was 66. She had EKG with a new first-degree AV block. She was admitted to the hospital, and her troponins and myoglobins were checked.
ER|emergency room|ER,|170|172|HISTORY OF PRESENT ILLNESS|Then, she seemed to calm down, got more sleepy. Parents also felt that some of the increasing attack when she came here was just from anxiety ____________ the ambulance, ER, etc. She slept from about 3 until 6 this morning and then took another nap between 9 and 11. PAST MEDICAL HISTORY: 1. Had a swollen left salivary gland which was treated with antibiotics fairly recently at Children's.
ER|emergency room|ER.|145|147|HISTORY OF PRESENT ILLNESS|No diaphoresis, no dizziness or lightheadedness. She tried nitroglycerin x3 at home, which did not make much difference and decided to go to the ER. While in the ER she was given nitro and morphine sulfate and this did resolve her pain and it has not recurred since.
ER|emergency room|ER|166|167|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|He also has a history of chronic renal insufficiency with baseline creatinine of 2.7 to 3. There is also history of benign prostatic hypertrophy. He presented to the ER on the _%#MMDD2006#%_ for evaluation of bilateral flank pain and right hip pain. His initial workup included a basic metabolic panel revealing hypokalemia, with potassium of 2.8 and hypercalcemia with calcium of 12.2. He also had acute renal failure with a BUN of 26 and creatinine of 4.5. CBC showed leukocytosis with white blood cell count of 14.3 and a mild anemia with hemoglobin of 12.1. He had a CT scan of the abdomen in the Emergency Department and this revealed a well defined mass in the left upper abdomen that extends up to the wall of the stomach and may be arising from the wall of the stomach.
ER|emergency room|ER|230|231|HISTORY OF PRESENT ILLNESS|She told the ER doctor that she was not able to go to the pharmacy and she tells me that the pharmacy did not carry fentanyl and was going to order it for her. After this event happened yesterday, patient decided to come into the ER this evening in the hopes of being admitted with complaints of inability to walk, however I must mention at this time that the patient did walk into the emergency room herself.
ER|emergency room|ER|125|126|HISTORY OF PRESENT ILLNESS|He was hypertensive initially. He was given 2 mg IV x1. He had a nonfocal neurologic exam. He was brought to Fairview Ridges ER for further evaluation. EKG showed sinus tachycardia. Laboratory studies showed elevated liver enzymes. CT was unremarkable. He was transferred to detox. There, however, he was mildly hypertensive, tachycardic and unsteady gait and confused with what appeared to be worsening alcohol withdrawal.
ER|estrogen receptor|ER|215|216|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 53-year-old woman who is in today for followup of her infiltrating ductal carcinoma, diagnosed _%#MMDD2000#%_, grade III of III, 14 of 23 lymph nodes positive, ER positive at 47%, PR positive at 50%, HER-2/neu positive. REVIEW OF SYSTEMS: GENERAL: No fevers, sweats, weight change, or fatigue.
ER|extended release|ER|326|327|MEDICATIONS|She has history of hyperlipidemia, hypertension, glaucoma, osteopenia, diverticulitis and anxiety. MEDICATIONS: Isosorbide 60 mg in the morning, lisinopril 10 mg in the morning and 20 mg in the afternoon, Glucophage 500 mg b.i.d., Toprol XL 100 mg daily, Lipitor 20 mg daily, aspirin 81 mg daily, Zetia 10 mg daily, Glipizide ER 2.5 mg in the morning, lorazepam as needed, folate 400 mg a day. ALLERGIES: MORPHINE, MACRODANTIN AND BUPRENEX, unknown reactions. FAMILY HISTORY: Not helpful at this time.
ER|emergency room|ER,|238|240|DISCHARGE SUMMARY|The patient is careful about taking his medications, however, he relates he does not always take medication for acid suppression. The patient at the time of admission did not know whether or not antacids gave him relief. When seen in the ER, he had an EKG which was unchanged and compatible with a prior inferior MI. The patient was taken Protonix but not on a consistent daily basis.
ER|emergency room|ER,|152|154|HOSPITAL COURSE|This did seem to improve with nitroglycerin. No associated shortness of breath, radiation or nausea. This lasted for several hours. Upon arrival to the ER, she was chest pain free. She had negative troponins, negative EKG. She had no further chest pain during her hospital stay.
ER|emergency room|ER|160|161|SUMMARY|SUMMARY: This is a 74-year-old Vietnamese male with history of hypertension and diabetes, known to be poorly compliant to his medications, who presented to the ER with few days of anorexia, malaise, and increasing urinary frequency. He presented with a serum glucose of over 1000 with no serum or urine ketone.
ER|emergency room|ER|178|179|HOSPITAL COURSE|He did not feel that she could be committed at this time nor did he feel like she should be admitted to psychiatry at the current time. Therefore, the 72-hour hold placed in the ER was lifted. Her current psychiatrist is Dr. _%#NAME#%_ _%#NAME#%_. She was recently admitted to Fairview Southdale and was seen at that time, and a chemistry dip evaluation was done and was not recommended for a CD treatment at that time.
ER|emergency room|ER,|174|176|REVIEW OF SYSTEMS|Before that he was not having any exertional chest pain. NEUROLOGIC: Denies seizures or strokes. He has never had any alcohol withdrawal seizures. CHEST: On admission to the ER, patient felt he was somewhat short of breath but now lying in bed he states his breathing is OK. No known intrinsic lung disease. CARDIOVASCULAR: Denies recent exertional chest pain.
ER|emergency room|ER|198|199|LABORATORY DATA|Creatinine 0.8, troponin 0.12, then 0.11. UA negative with an exception of 2-5 red cells. Urine cultures and blood cultures pending. Chest x-ray negative and head CT, no acute changes per report of ER physician. ASSESSMENT AND PLAN: A 63-year-old male with decreased mental status, increasing respiratory drive, fevers, hypernatremia and hypokalemia.
ER|emergency room|ER|134|135|PHYSICAL EXAMINATION|MEDICATIONS: Insulin, metformin and Synthroid. PHYSICAL EXAMINATION: At the time I saw the patient, she had been admitted through the ER and had received Zofran and IV fluids. Her pulse was still elevated at 130s, so the house MD was called and felt that this could be explained by volume depletion and fever.
ER|emergency room|ER|295|296|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 36-year-old male, poor, and unreliable historian, who presents intoxicated with alcohol and high-on cocaine, to the ER with complaints of left-sided chest pain. He also had some shortness of breath which has resolved. Blood alcohol level done in the ER was 0.27 and U-Tox was positive for cocaine and alcohol only. HOSPITAL COURSE: 1. Chest pain: The patient was admitted to Telemetry floor to rule out any ischemic causes.
ER|emergency room|ER.|183|185|HISTORY OF PRESENT ILLNESS|The patient was sent home after the bleeding had stopped, then but within 2 hours after that the bleeding started again at which time he came to the ER. He was seen by the ENT in the ER. The packing that was previously placed was removed and the area was flushed with Afrin in the ER. He was then noted to have bleeding again. The patient is on chronic anticoagulation with Coumadin.
ER|emergency room|ER|122|123|HISTORY OF PRESENT ILLNESS|No laboratory data has been set as of yet, but the patient has been admitted to the Hospitalist Service. I have asked the ER physicians to keep her in the ER until I can see what her workup shows. The patient denies any headache. She denies any seizure activity.
ER|emergency room|ER.|153|155|ASSESSMENT AND PLAN|As she appears somewhat dry based on her mucous membranes, we will have to watch her fluid status closely. 4. Diabetes. Blood sugars are elevated in the ER. We will use a sliding scale insulin to help control her sugars, as we will need to hold her metformin while she is in the hospital.
ER|emergency room|ER|171|172|HISTORY|She has been having slowly progressive severe hip and back pain for a number of months, basically reports that the pain is getting worse and worse. She was brought to the ER by ambulance after she decided she was unable to function at home. She had no other complaints in the hospital this morning.
ER|emergency room|ER|120|121|HISTORY OF PRESENT ILLNESS|She does have a history of falls and multiple fractures in the past. No other severe injuries at this time. X-rays, per ER doctor, were negative for any fractures. PAST MEDICAL HISTORY: Significant for: 1. Dementia. 2. Osteoporosis.
ER|emergency room|ER|143|144|BRIEF  HISTORY AND HOSPITAL COURSE|This seems to be quite a bit of a chronic component. Both her calves have become quite painful secondary to the swelling. She presented to the ER and had a hemoglobin of 5.9. She was admitted for further evaluation and treatment. HOSPITAL COURSE: The patient was admitted and was given 2 units of packed RBCs.
ER|emergency room|ER|137|138|HISTORY OF PRESENT ILLNESS|The Fairview Ridges Emergency Room was particularly concerned because of his general lethargic appearance. His temperature at the Ridges ER was 104.7 and blood glucose 133. He was given Zofran and Tylenol/ibuprofen for the temperature and a normal saline (02:02) 20 mL/kg flush.
ER|emergency room|ER|217|218|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: Patient is a 74-year-old female with a history of aortic valve replacement with mechanical valve, and a previous smoker with COPD admitted through the ER with complaints of shortness of breath. The patient reports that she became ill Tuesday night, 2 days prior to admission. Symptoms have included a nonproductive cough, audible crackles with breathing, muscle aches, feeling of chills and feeling of warmth, and fatigue.
ER|emergency room|ER|182|183|HISTORY OF PRESENT ILLNESS|Since being here, he noted being progressively more short of breath, short winded and cannot even walk across the room. He was unable to speak in full sentences. He presented to the ER with shortness of breath and tachypnea. He was placed initially on some BiPAP and was titrated as high up as 18 and 12. He was given 1 dose of Lasix as well as Ativan and empirically.
ER|emergency room|ER|120|121|REVIEW  OF SYSTEMS|Orthopedic review is positive for chronic right knee pain and right shoulder pain. The patient had recently been in the ER about a few weeks ago for treatment with recent cortisone injections done. Dermatologic review is negative for recent rashes. Psychiatric review is negative for depression or anxiety.
ER|emergency room|ER,|158|160|HISTORY OF PRESENT ILLNESS|He states he may have had some diaphoresis and has clearly shortness of breath. He had no nausea or vomiting. He insisted on having his wife drive him to the ER, although she wanted to call 911. He was brought to the Emergency Room, triaged and EKG demonstrated an acute inferior wall myocardial infarction with ST segment elevation inferiorly.
ER|emergency room|ER|164|165|HOSPITAL COURSE|The recommendation was transfer to Adolescent Chemical Dependency treatment at _%#CITY#%_ Hospital. The patient had been placed on 72-hour hold at Fairview Ridge's ER and was transferred medically stable to Fairview _%#CITY#%_ University of Medical Center, STOP Unit or the Mental Health Behavioral Unit. DISCHARGE MEDICATIONS: None. It has been a pleasure to work with the patient.
ER|emergency room|ER|271|272|SUMMARY|SUMMARY: _%#NAME#%_ _%#NAME#%_ is a 55-year-old female who was admitted by Dr. _%#NAME#%_ from surgery with a diagnosis of right breast cellulitis which happened after she had a partial mastectomy for atypical ductal hyperplasia on _%#MM#%_ _%#DD#%_. She was seen in the ER for the same and was started on Rocephin and given oral Keflex. She was sent home but started having nausea and fever so came to the emergency room.
ER|emergency room|ER|191|192|HISTORY OF THE PRESENT ILLNESS|The diarrhea consists of about five stools per day of large volume watery stools without blood or mucus. He has been rather washed out or listless at times during this illness. He was in the ER and received 40 per kilo bolus total two days ago. Starting to have similar degree of symptoms today prompting re-evaluation and re- bolus in the emergency room.
ER|extended release|ER|129|130|DISCHARGE MEDICATIONS|2. Hydrochlorothiazide 12.5 mg daily. 3. Prinivil 20 mg daily. 4. Zegerid one tablet b.i.d. 5. Topamax 75 mg b.i.d. 6. Verapamil ER 240 mg daily. 7. Methadone 5 mg q. 8 hours. This is a dose increase from the q. 12 hours previously, as he had been reporting substantial pain.
ER|emergency room|ER|291|292|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|5. Hypothyroidism. 6. Renal failure with creatinine 1.52. HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is an 87-year-old white gentleman who had come in with sudden onset of left upper extremity weakness along with left lower extremity weakness. The patient came to the ER for further evaluation. By the time the patient came to the ER his strength in the left lower extremity improved and came back to baseline, however, left upper extremity remained weak.
ER|extended release|ER|114|115|PAST MEDICAL HISTORY|Carisoprodol 350 mg 3 x daily. Toprol XL 100 mg 3 x daily. Hyzaar 100/25 1 pill daily, aspirin 81 mg daily. Imdur ER 30 mg daily, Norvasc 10 mg daily. Ambien 5 mg at bedtime prn sleep. ALLERGIES: None. SURGERY: Coronary artery bypass surgery as noted.
ER|emergency room|ER|123|124|HISTORY OF PRESENT ILLNESS|No abdominal pain or distention. No chest pain or palpitations. Today the patient called her son and he brought her to the ER for evaluation. The headache seemed to have resolved. In the ER she arrived. IV fluid with one dose of Zofran and one dose of Meclizine orally.
ER|emergency room|ER|172|173|HISTORY OF PRESENT ILLNESS|She was started on Zantac. That initially seemed to help, along with changing the formula. The patient was initially scheduled to see Dr. _%#NAME#%_ of GI, but came to the ER instead. MEDICAL HISTORY: Normal delivery. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION ON ADMISSION: The patient was afebrile.
ER|emergency room|ER|156|157|HISTORY OF PRESENT ILLNESS|It was an unwitnessed event. The patient was able to crawl on the bed for help. She had an extreme amount of back pain thereafter. She has been sent to the ER for further evaluation and admitted. For further details regarding the patient's presentation, please see the dictated history and physical by Dr. _%#NAME#%_ _%#NAME#%_.
ER|extended release|ER|146|147|CURRENT MEDICATIONS|ALLERGIES: Sulfa, Macrodantin, penicillin, erythromycin, Seldane, and Novocaine. CURRENT MEDICATIONS: 1. Zocor 20 mg p.o. every day. 2. Diltiazem ER 240 mg p.o. every day. 3. Hydrochlorothiazide 25 mg p.o. every day. 4. K-Dur 20 mEq p.o. every day. 5. Protonix 40 mg p.o. every day. 6. Flonase nasal spray p.r.n.
ER|emergency room|ER|179|180|HISTORY OF PRESENT ILLNESS|He came to the University of Minnesota on _%#MMDD2003#%_. He has been complaining of headaches most of the time with pain to bright light and loud sounds. He was evaluated in the ER and thought possibly to have a picture similar to meningitis. His vitals were stable. He was slightly febrile on the day of admission.
ER|emergency room|ER|166|167|HISTORY OF PRESENT ILLNESS|She does not wear oxygen at home. Patient had also complained of fevers measured to 102 as well as right upper quadrant tenderness. Initial chest x-ray at _%#CITY#%_ ER showed evidence of both pulmonary congestion as well as possible alveolar infectious process. The patient was transferred given her significant amount of respiratory distress to University Medical Center for further management.
ER|emergency room|ER|66|67||_%#NAME#%_ _%#NAME#%_ is a 54-year-old female who presents to the ER with a long history of low back pain radiating to the right thigh and calf and top of her foot. She is a very poor historian and very vague historian.
ER|emergency room|ER|136|137|PHYSICAL EXAMINATION|Immunizations: Tetanus on _%#MMDD2003#%_. PHYSICAL EXAMINATION: He is nontoxic and afebrile. Initial vital signs on presentation to the ER revealed a blood pressure of 150/90, temperature 97.7, pulse 96, respirations 14, O2 saturations of 98%. TMs bilaterally are clear. ___________. Pupils are equal, round, and reactive to light.
ER|emergency room|ER.|165|167|FOLLOW UP|FOLLOW UP: 1. With Dr. _%#NAME#%_ of her partners at _%#CITY#%_ Clinic on Monday or Tuesday If he needs medical attention sooner than that, he should be seen in the ER. 2. Follow up with Psych. Call BHP number and get connected and as well. Also discuss this with primary attending.
ER|emergency room|ER|333|334|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Asthma. 2. Probable RSV. 3. Hypothyroidism on replacement. 4. Hypertension. _%#NAME#%_ _%#NAME#%_ is a 52-year-old white female with longstanding asthma, hypertension, and hypothyroidism on replacement, who was recently exposed to RSV, hospitalized in Tennessee the week prior to admission and returns to the ER because of increasing respiratory distress with noted decreased peak flows in the range of 240-350 with a status asthmaticus that was slow to improve with bronchodilators in the ER.
ER|emergency room|ER|195|196|HISTORY OF PRESENT ILLNESS|He had no shortness of breath. He was not nauseated as mentioned above, but did try to vomit for relief, but this did not help. He also tried some antacids at home without relief. He came to the ER and had evaluation which revealed pancreatitis with a lipase of greater than 26,000. He reports that he used to drink alcohol substantially, but has not had anything to drink for over five years.
ER|emergency room|ER|116|117|X-RAYS|No hepatosplenomegaly noted. No hernias were noted. Multiple scars were noted. EXTREMITIES: Normal. X-RAYS: Per the ER doctors, they thought it looked like partial small bowel obstruction with air-fluid levels, but no Radiology report back yet. ASSESSMENT AND PLAN: Abdominal pain, question bowel obstruction versus. Much better already.
ER|emergency room|ER|220|221|HOSPITAL COURSE|4. I am recommending that he take Omega-3 fatty acid supplements for his elevated triglycerides. PRIMARY MD: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD HOSPITAL COURSE: The patient presented on _%#MM#%_ _%#DD#%_, 2005, to the ER complaining of chest pain. He was found to be tachycardic. A CT angiogram showed probable PE in the left lower lobe although the contrast was less than optimal on this study.
ER|estrogen receptor|ER|126|127|HISTORY OF PRESENT ILLNESS|She had two tumors, one was grade III/III, and one was grade I/III, and she had 1 in 28 lymph nodes involved, _%#MMDD2003#%_. ER negative, PR slightly positive, HER-2/neu negative. The patient has had AC and Taxol. Now has some lung lesion. Whether it is secondary to metastatic breast or a new process, we are not sure, but she had pneumonia on _%#MMDD2005#%_, and we have not been able to get a biopsy of the lung lesion.
ER|emergency room|ER|154|155|PHYSICAL EXAMINATION|She does readily recognize me. She often shakes her fist at me, which she historically has been prone to do when I try to examine her. Temperature in the ER is 103.5 degrees, heart rate 117, blood pressure was normal, room air saturations were in the 90s. HEENT exam was unremarkable. Neck was supple. Lungs reveal crackles at both bases.
ER|emergency room|ER|223|224|BRIEF HISTORY AND HOSPITAL COURSE|3. History of adult-onset Still's disease. BRIEF HISTORY AND HOSPITAL COURSE: A 31-year-old female with an apparent history of adult-onset Still's disease who presented for complaints of abdominal pain. She was seen in the ER four days ago and was treated with Solu-Medrol as well as prednisone for Still's disease flare-up. She was scheduled to see her rheumatologist in late _%#MM#%_.
ER|emergency room|ER|221|222|REASON FOR ADMISSION|The patient had been evaluated at the _%#CITY#%_ _%#CITY#%_ Medical Center Urgent Care, where she was given vancomycin and Unasyn and then transferred to the Fairview Ridges Emergency Department. She was evaluated in the ER and subsequently admitted to the Hospital Service for further evaluation and care of presumed right upper extremity cellulitis. HOSPITAL COURSE: 1. Right upper extremity cellulitis. The patient was initially febrile on admission.
ER|emergency room|ER|137|138|IMPRESSION AND PLAN|She has not been taking her Flovent regularly and she is an occasional smoker, both of which likely contributed to her appearance in the ER today. She does not have a pneumonia on exam. She does work at a nursing home, but denies any influenza contact.
ER|emergency room|ER|158|159|HISTORY OF PRESENT ILLNESS|The patient saw her primary medical doctor in the clinic today and the chest x-ray showed bilateral pleural effusions. The primary MD sent the patient to the ER for shortness of breath, effusions, diuresis, and admission to the hospital. I discussed the patient with her nursing facility where she resides.
ER|emergency room|ER,|245|247|HISTORY|At the nursing home she was noted to have fever, seemed to show decreased level of consciousness and then she pulled her tube out partially because of these factors. She was sent back to the emergency room. She had a fever of 102 degrees in the ER, was slightly hypoxic and very tachycardic, she looked quite dry. Chest x-ray did not show any clearcut infiltrate, white count was 5,900 but left-shifted.
ER|emergency room|ER.|149|151|PLAN|White count 4.9, hemoglobin 13.5, platelet count 228, normal differential, INR 1.074. PLAN: The patient had received Lovenox 110 mg subcu x 1 in the ER. We will continue Lovenox, 1 mg/kg subcu b.i.d. At the same time, the patient will be getting Coumadin, 5 mg p.o. q. day.
ER|emergency room|ER,|185|187|HISTORY OF PRESENT ILLNESS|In view of the unclear significance of the patient's acknowledged ingestion of chemicals and in view of his mental status concerns, the patient was admitted to the medical unit. In the ER, he was noted to be quite sedated, though did have stable vital signs. Laboratory evaluation in the ER was unremarkable. An ethanol level was less than 0.1. Upon admission to the medical unit, the patient became quite a bit more alert.
ER|emergency room|ER|185|186|PLAN|PLAN: 1. The patient is pan cultured in the Emergency Room and started on the pneumonia pathway with Levaquin. 2. The patient will be transferred to Coronary Special Care Unit from the ER for rule out MI protocol. He was started on Lovenox and a beta blocker pending return of further studies. 3. Will check his uric acid and treat appropriately.
ER|emergency room|ER|143|144|BRIEF HISTORY AND HOSPITAL COURSE|It started on the evening prior to admission. This is generalized with associated nausea and vomiting. There is no fevers. They stopped by the ER because the pain had gotten worse. His CT did demonstrate dilated loops of small bowel consistent with bowel obstruction.
ER|emergency room|ER|134|135|HISTORY OF PRESENT ILLNESS|The patient has a history of asthma. She took two albuterol nebs at home without relief and therefore presented to Fairview Southdale ER for further evaluation. The patient quit smoking two months ago. Has had no recent travel, no recent immobility. No sick contacts. REVIEW OF SYSTEMS: Rest of constitutional, eyes, ears, nose, mouth, throat, respiratory, cardiovascular, GI, GU, musculoskeletal, neurologic, endocrine, hematologic, lymphatic and psychiatric review of systems otherwise negative.
ER|extended release|ER|199|200|MEDICATIONS|3. Oxycodone 5 mg p.o. q. 6 hours p.r.n. 4. Sliding scale NovoLog insulin for diabetes type 2. 5. Tramadol 50-100 mg q. 6 hours p.r.n. for breakthrough pain. 6. Colace 100 mg p.o. b.i.d. 7. Depakote ER 250 mg t.i.d. for phantom pain. 8. Sulindac. ALLERGIES: Not obtained. SOCIAL HISTORY: The patient does not smoke, does not drink alcohol, does not use recreational drugs.
ER|emergency room|ER|186|187|HISTORY OF PRESENT ILLNESS|PRIMARY ATTENDING: _%#NAME#%_ _%#NAME#%_, MD. CHIEF COMPLAINT: Shortness of breath and chest pain. HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old white male who was brought to ER with the complaints of having shortness of breath and chest pain which started 2 days ago. The patient states that chest pain is substernal without any radiation and not associated with nausea or vomiting.
ER|emergency room|ER|143|144|HISTORY OF PRESENT ILLNESS|She is known to our service from an admission a week ago. She had a C-section in _%#MM#%_ of this year. On _%#MMDD#%_ she was evaluated in the ER for right upper quadrant pain. She was found to have elevated liver function tests and gallstones by ultrasound. She was admitted for further evaluation. Her gallbladder wall was perhaps somewhat thickened.
ER|emergency room|ER.|162|164|IMPRESSION AND PLAN|1. Gastrointestinal bleed: I suspect an upper GI source given his melena. Hemoglobin is currently slightly low normal. Notably, the patient is orthostatic in the ER. His vital signs are stable at rest. PLAN: 1. Serial hemoglobin q.6h. overnight. 2. Transfusion for hemoglobin less than 8.5. 3. Gastrointestinal consultation for consideration of endoscopy.
ER|emergency room|ER,|105|107|HISTORY OF PRESENT ILLNESS|The paramedics were also unable to rouse her. They brought her immediately to the Emergency Room. In the ER, she did wake up to some extent, but did not know any of her family by name, where she was, what year it was, she was completely disoriented.
ER|emergency room|ER|133|134|MEDICATIONS|16. Heparin drip started in the ER this evening. 17. Nitroglycerin drip started in the ER this evening. 18. Ondansetron given in the ER this evening. SOCIAL HISTORY: The patient reports that he is a life-long nonsmoker.
ER|emergency room|ER|139|140|HISTORY OF PRESENT ILLNESS|There are also some concerns about family being able to continue caring for her with her significant dementia. From my discussion with the ER MD, it sounds as if the family may be interested in pursuing nursing home placement. Otherwise, the patient is currently denying fevers, chills, headache, dizziness, chest pain, shortness of breath, urinary symptoms, leg pain, or swelling.
ER|emergency room|ER|101|102|HISTORY OF PRESENT ILLNESS|DIAGNOSIS: Asthma exacerbation. HISTORY OF PRESENT ILLNESS: This 3-year-old was admitted through the ER with an asthma exacerbation. He is a known asthmatic but had been off medications for awhile and had done very well and mom no longer had a nebulizer machine or any other medications at home for asthma.
ER|emergency room|ER,|112|114|SYNOPSIS OF HISTORY AND PHYSICAL|The patient did not have any fever or chills. The patient had numerous watery stools, so she came to ER. In the ER, the patient's blood pressure was stable. She was afebrile. She had an abdominal x-ray, which showed normal bowel gas pattern, 1or 2 nonspecific fluid-fluid level on upright view, some of which include colon.
ER|emergency room|ER|231|232|PHYSICAL EXAMINATION|CARDIOVASCULAR: Reveals a regular rhythm and a regular rate with normal S1 and S2 with no distinct audible S3 or S4. ABDOMEN: Reveals active bowel sounds. He is nontender. There is no distinct palpable liver or spleen. RECTAL: Per ER physician is negative for blood, but notable small hemorrhoid. EXTREMITIES: Reveal no obvious edema, cyanosis nor clubbing. NEUROLOGIC: Nonfocal.
ER|emergency room|ER,|115|117|LABORATORY DATA|ALT, AST, bilirubin, albumin, total protein were all normal. Lumbar and thoracic spine films were negative per the ER, but the final results are pending. A UA was completely negative. ASSESSMENT AND PLAN: 1. Acute onset of back pain: This may be secondary to some arthritis or other chronic problems.
ER|emergency room|ER|372|373|HISTORY|Heart Clinic in 1-2 weeks. HISTORY: _%#NAME#%_ _%#NAME#%_ is a very pleasant 87-year-old white male with a distant history of coronary angiogram showing tree three-vessel disease, history of flash pulmonary edema who presented with acute onset of shortness of breath which occurred in the middle of the night. He had some chest pressure with that and was brought into the ER where he was felt to have acute pulmonary edema and subsequently admitted. Initial labs revealed a normal CBC, INR of 2.6. A BNP at 520 and negative troponin.
ER|emergency room|ER|195|196|HISTORY OF PRESENT ILLNESS|At that time, the plan was for her to continue her oral antibiotics and see how she does over the weekend. Her pain progressed over the course of the weekend and she presented to Fairview Ridges ER for further evaluation. In the emergency room, she had left lower quadrant tenderness. She was afebrile. She required Zofran, Toradol and Dilaudid. She underwent abdominal CT scan which showed an abscess formation approximately 4 x 4 cm.
ER|emergency room|ER.|238|240|HISTORY OF PRESENT ILLNESS|He described this as both a sharp pain on the right shoulder shooting through towards his back as well as a diffuse aching pain on the right side. The pain became more and more severe and he subsequently went to the _%#CITY#%_ _%#CITY#%_ ER. At that time he was thought to have had musculoskeletal pain and was given morphine, Toradol and Dilaudid. His troponin was within normal limits and his ECG showed some very slight ST elevation in leads 3 and aVF only which were less than a millimeter.
ER|emergency room|ER|167|168|HISTORY OF PRESENT ILLNESS|Approximately 5 days after the onset of fever, the mother noticed swelling on the left side of her child's neck. She went to _%#CITY#%_ _%#CITY#%_ Children's Hospital ER and was diagnosed with lymphadenitis and treated with p.o. antibiotic. The mother does not recall the name of this antibiotic. Over the next several days, the neck mass became more firm and erythematous.
ER|emergency room|ER.|133|135|HISTORY OF PRESENT ILLNESS|She was discharged to home, but she has been having anxiety attacks several times a day. Her family finally brought her in to Ridges ER. She did fall about a week ago and struck the left side of her chest. She does have some discomfort over that area, but this has been improving.
ER|emergency room|ER|215|216|HISTORY OF PRESENT ILLNESS|He did require 02 at 1 liter to keep saturation at a reasonable level in the mid 90s. Respiratory rates were initially in the 60s, but came down to the 40s with the above-mentioned interventions. Temperature in the ER was 101. PAST MEDICAL HISTORY: No hospitalizations, surgeries or major medical illnesses.
ER|emergency room|ER|157|158|HISTORY OF PRESENT ILLNESS|He was noted to be tachycardic, 106-120, slightly hypertensive initially and satting 92% on room air. He was given oxygen. He was brought to Fairview Ridges ER for further evaluation. In the emergency room, he was quite agitated, confused, he had a nonfocal neurologic exam. Vital signs, except for tachycardia were essentially within normal limits.
ER|emergency room|ER|192|193|HISTORY OF PRESENT ILLNESS|There are several hepatitis C RNA studies in the computer. 3. Hypertension. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 54-year-old man who presented to Fairview Southdale Hospital ER today when he developed dizziness around noon and some visual changes such that when he looked to the left he was unable to see very well.
ER|emergency room|ER|220|221|HISTORY OF PRESENT ILLNESS|Last evening, she contacted our partner (Dr. _%#NAME#%_ _%#NAME#%_) regarding symptoms of worsening abdominal pain and fever. She was asked to present to Fairview Southdale Emergency Room and was evaluated there. In the ER she was found to be febrile (temperature 102-103), tachycardic heart rate 120s-130s and mildly hypotensive. Her CBC was fairly stable except for anemia likely related to disease and/or treatment.
ER|emergency room|ER|220|221|REASON  FOR ADMISSION|6. Blood cultures which were without growth. REASON FOR ADMISSION: Please see dictated history and physical by Dr. _%#NAME#%_. In brief, Ms. _%#NAME#%_ is a 65-year-old female with a history of COPD who presented to the ER complaining of shortness of breath. Symptoms started about 3 days prior to admission when she had productive yellow sputum as well.
ER|emergency room|ER|181|182|HISTORY OF PRESENT ILLNESS|PRIMARY CARE PROVIDER: _%#NAME#%_ _%#NAME#%_, MD. CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 77-year-old female, presenting to the ER with cyanosis and respiratory distress. She was treated in the ER for COPD exacerbation by Dr. _%#NAME#%_ after a CT for PE was negative. The patient was placed on BiPAP in the emergency department with improvement in her symptoms.
ER|emergency room|ER|174|175|HISTORY OF PRESENT ILLNESS|The patient denies any hemoptysis. He was seen in Minnesota Heart Clinic this a.m. by a nurse practitioner and sent over to the emergency room for further evaluation. In the ER he was evaluated by Dr. _%#NAME#%_ who has admitted the patient to the hospitalist service for further evaluation of atypical chest pain.
ER|emergency room|ER|214|215|HISTORY OF PRESENT ILLNESS|The patient developed some shortness of breath at home over the past few days which worsened yesterday morning. Her daughter called the Dialysis Unit in _%#CITY#%_ _%#CITY#%_ and asked whether she should go to the ER or come for dialysis. It was decided the patient would go for dialysis to see if fluid removal would help her breathing, which it did initially.
ER|emergency room|ER|265|266|HOSPITAL COURSE|He had associated reactive airway disease and fever. He was discharged with a short course of steroids, p.r.n. Albuterol inhaler and a course of Levaquin. Prior to that, he had noted some intermittent abdominal pain and skin rash. This was not evaluated during his ER course. His pneumonia symptoms have improved. He, however, continued to have cough intermittent of purulent sputum. That is now resolved today, though he was noted to have this over the last few days.
ER|emergency room|ER|162|163|HISTORY OF PRESENT ILLNESS|According to the son, he doubts that his mother has eaten or taken her meds recently. Therefore, EMS was called and the patient was brought to Fairview Southdale ER for evaluation. At that time she was found to be severely dehydrated and also found to be anemic with a hemoglobin of 7.3. A chest x-ray was negative for acute infiltrates but showed possible mild congestive heart failure.
ER|emergency room|ER.|154|156|HISTORY OF PRESENT ILLNESS|She has had significant issues with narcotics in the past. However, her narcotics were negative in the urine and she had little response to Narcan in the ER. Upon discharge she was supposed to be going to outpatient treatment last visit. However, she is unable to drive due to a DWI.
ER|emergency room|ER;|139|141|IMPRESSION|Will have pharmacy dose her Coumadin. Will have to follow up on her urine culture tomorrow. She did get one dose of fluoroquinolone in the ER; will hold off on further antibiotics until we get the culture back, as the urinalysis itself was not too remarkable. The patient's potassium is low; this is likely related to loss from her GI tract and diuretic use.
ER|emergency room|ER.|191|193|HISTORY OF PRESENT ILLNESS|She had some associated shortness of breath after the pain began, but this seems to have resolved. The patient does report that she continues to have some discomfort. She is currently in the ER. She says her chest pressures is about a 1 at this point. The patient had a similar episode of chest pressure in _%#MM2006#%_.
ER|emergency room|ER|197|198|HISTORY OF PRESENT ILLNESS|She came to the emergency room after seeing her psychiatrist, Dr. _%#NAME#%_ _%#NAME#%_ at the CUHCC Clinic as she was complaining of abdominal pain and somnolence. The patient was examined by the ER staff as well as the medicine resident and was found to be reluctant to answer questions. She, however, clearly stated that she did not overdose on any of her opioid medications.
ER|emergency room|ER|152|153|OBJECTIVE|No headaches. No vision disturbances. No bowel or bladder difficulties. OBJECTIVE: VITAL SIGNS: He is afebrile. Blood pressure initially was 212 in the ER and is now 130/78. Pulse is normal. Respirations are fine. GENERAL: The patient is alert and oriented. HEENT: Normal. NECK: Supple. Thyroid appeared normal. LUNGS: Clear. HEART: Regular rate and rhythm with no murmurs.
ER|emergency room|ER|166|167|PAST MEDICAL HISTORY|He lives in _%#CITY#%_ with his family. No illicit drugs. He drinks 1 beer a day, does not smoke. PAST MEDICAL HISTORY: Noted to have hypertension in urgent care and ER visits. MEDICATIONS: None. No over-the-counter medicines. ALLERGIES: No food allergies. No known drug allergies.
ER|emergency room|ER,|317|319|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is an 83-year-old female with past medical history of hypertension, diabetes, hyperlipidemia, who presented to the ER today with complaints of headache and high blood pressure. When the paramedics picked up the patient, her initial systolic blood pressure was noted to be 204. In the ER, the patient also mentioned that she was having trouble getting words out. These symptoms had began since last night, but had now improved and resolved completely.
ER|emergency room|ER|178|179|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 48-year-old male patient with history of hypertension and hyperlipidemia, who presents to the ER today with chest pain. The patient says the chest pain developed in the evening after the patient got home from some type of gathering.
ER|emergency room|ER|187|188|HOSPITAL COURSE|Please see his dictated H&P for past medical history and presenting complaints. HOSPITAL COURSE: The patient presented with decreased mental status and consciousness. Upon arrival to the ER she was found to have elevated cardiac enzymes. Chest x-ray demonstrated right lower lobe infiltrate. A CT scan of the head shows an acute or subacute right occipital infarct.
ER|emergency room|ER,|225|227|PHYSICAL EXAMINATION ON ADMISSION|No abnormal vaginal discharge or pruritus. She complained of bilateral headache, but no focal neurologic symptoms and positive depressed mood. PHYSICAL EXAMINATION ON ADMISSION: Blood pressure 99/58 after 4 L of fluid in the ER, pulse 98, respirations 24, with sats 97% on room air, and temperature 96.3 after being under the bear hugger. General appearance. The patient is ill appearing with disheveled appearance in no acute distress and intoxicated.
ER|emergency room|ER|215|216|PHYSICAL EXAMINATION|GI: Negative. GU: Nocturia x 5. EXTREMITIES: He requires a walker for ambulation because of balance. PHYSICAL EXAMINATION: Reveals a pleasant obese White male in no acute distress. His initial blood pressure in the ER was 168/89. HEENT: Aphakia bilaterally. His disks were flat bilaterally. The right was poorly visualized. His nose and throat were clear. His gag reflex was questionable.
ER|emergency room|ER|115|116|HISTORY OF PRESENT ILLNESS|He also has a significant history in that he smokes two packs per day and drinks caffeine. He was evaluated in the ER and felt to be stable with a good hemoglobin, blood pressure, and stool now which was brown and slightly guaiac positive and is admitted for further treatment and evaluation.
ER|emergency room|ER|219|220|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature was 98.6, blood pressure was 123/72, pulse rate was 99, respiratory rate was between 20 and 24 with an oxygen saturation at 97% on 2 L nasal cannula. Her saturation in the ER was 84% to 89% on room air. HEENT: Unremarkable. LUNGS: Coarse, bilateral crackles. CARDIAC: Regular rate and rhythm without any jugular venous distention.
ER|emergency room|ER|117|118||No fevers, chills, or pleurisy. She was seen in the office on the _%#DD#%_ diagnosed with a URI. She returned to the ER late on the _%#DD#%_ or early the _%#DD#%_, and the family called up today noting that the patient continues to have a poor appetite, very weak difficulty doing her daily activities using the bathroom and eating.
ER|emergency room|ER|213|214|HISTORY OF PRESENT ILLNESS|He had immediate pain. He later in the day was being transported and sitting on his walker, but was not strapped in. They stopped abruptly and he fell backwards over his walker. He apparently was evaluated at the ER for the knee problem and an x-ray there showed degenerative changes only. He was given a knee immobilizer and Ace wrap and Tramadol for pain.
ER|emergency room|ER.|189|191|HOSPITAL COURSE|The patient had been seen by General Surgery in the ER, who felt that his pain was non-surgical. The patient's abdominal pain did improve significantly with IV morphine administered in the ER. He continue to have some pain requiring low- dose morphine in the first 12-24 hours after admission. Thereafter he had no pain whatsoever. He was seen by Urology, who felt that his symptoms could have been a manifestation of renal stones, though his CT scan and urinalysis were not suggestive of such.
ER|emergency room|ER|247|248|DISCHARGE PLAN|2. He was sent home with instructions to follow up in Smiley's Clinic with either me or any of the faculty or residents for reassessment of his right lower extremity. He has a current prescription for Augmentin 875 mg p.o. b.i.d. from his initial ER visit, so one was not written for this visit. 3. The patient was also instructed to continue Vicodin, which he also had from his previous visit, as needed for pain, and was instructed to use ibuprofen or Tylenol.
ER|emergency room|ER|179|180|ASSESSMENT AND PLAN|5. Gastroesophageal reflux disease. 6. Benign prostatic hypertrophy. Patient will be admitted to Fairview Ridges for further workup and evaluation. He was given some FFP from the ER to get his INR down so he can hopefully get a lumbar puncture today. If the lumbar puncture is negative, will probably need a MRI/MRA.
ER|emergency room|ER|139|140|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old male admitted for off and on chest pain earlier today. The patient comes into the ER free of chest pain. The patient is status post stent placement x 2. The last event was _%#MMDD2003#%_ with an myocardial infarction in _%#MMDD#%_.
ER|emergency room|ER|168|169|HOSPITAL COURSE|He is discharged home in stable condition with plans for the patient to get an outpatient tilt table as recommended by Dr. _%#NAME#%_ _%#NAME#%_ of Cardiology , to the ER physicians at Fairview Ridges. This again was confirmed with Dr. _%#NAME#%_ when the patient was admitted here. The patient has been advised that he should not pursue a trip to _%#CITY#%_ that he is scheduled to go on _%#MMDD2003#%_ until he has had a tilt table test.
ER|emergency room|ER|171|172|HISTORY OF PRESENT ILLNESS|He reports passing out and hitting his head on one occasion, falling to the floor. This was a few days prior to admission. The day before admission, he was brought to the ER by his son. He has also had shortness of breath worse with exertion. He denies chest pain or palpitations. He was admitted approximately one month ago with atrial fibrillation.
ER|emergency room|ER|167|168|LABORATORY DATA|MCV 93. UA: specific gravity 1.014, otherwise negative. Urine culture pending. C-spine films showed DJD per ER MD. Head CT showed normal C1 and C2 and old atrophy per ER MD. Sodium 140, potassium 4.6, chloride 106, bicarb 23, BUN 52, creatinine 1.5, glucose 182. Calcium 8.7, gap 11. EKG by my interpretation shows normal sinus rhythm with a rate of 65, axis of -29, first degree AV block, old left bundle branch block, inverted T's in V4 through V6.
ER|emergency room|ER.|194|196|HISTORY OF PRESENT ILLNESS|He found that liquids were leaking out the left corner of his mouth when he tried to drink. He went to bed last night with these symptoms, woke up with the same symptoms, decided to come to the ER. In the ER, MRI showed no bleeding, but two small lacunar infarcts in the right hemisphere.
ER|emergency room|ER.|157|159|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Incoherent thoughts. HISTORY OF PRESENT ILLNESS: The patient is a 20-year-old male student at the University of Minnesota admitted from the ER. He was brought in by his sister because he was having disorganized thoughts. The patient has recently been feeling depressed because of a "girl problem." He cannot remember exactly when he started feeling depressed.
ER|emergency room|ER.|133|135|CHIEF COMPLAINT|They wanted to do a chest x-ray but were not able to do that because the _______________ machine is not working. She was sent to the ER. In the ER, she was noted to have increasingly worsening shortness of breath, and she was given an albuterol inhaler, albuterol Atrovent neb and another albuterol neb _______________________.
ER|emergency room|ER|130|131|HISTORY OF PRESENT ILLNESS|She was reassured, and asked to increase her Percocet. Her husband found her unresponsive on _%#MMDD2003#%_. She was taken to the ER emergently. At the time of evaluation, she was moving all four extremities, but no responding to verbal commands. She was profoundly acidotic, with pH of 7.0, blood sugars in the 800s, and anion gap of 34.
ER|extended release|ER|209|210|MEDICATIONS|5. Senna one to two caps twice daily, 6. Ferrous sulfate 325 mg twice daily, 7. Apresoline 100 mg 3 times a day, 8. Imdur 30 mg p.o. daily. 9. Albuterol inhaler q.4h. p.r.n. shortness of breath, 10. Diltiazem ER 300 mg p.o. daily, 11. multivitamins once a day 12. Pulmicort inhaler 0.25 mg twice a day. 13. The patient is also on insulin. SOCIAL HISTORY: The patient recently was sent home from Masonic home as mentioned above.
ER|emergency room|ER|146|147||At least his daughter was also ill at home with respiratory but more GI symptoms. I thought he had a viral illness. He also had headache . In the ER a chest x-ray was obtained and initially read as clear but did show bilateral infiltrate. CT scan shows current bilateral alveolar infiltrates. The patient has developed progressive hypoxia and was seen by the house MD on _%#MMDD#%_ for chest pain and then subsequent hypoxemia.
ER|extended release|ER|328|329|MEDICATIONS|He has had congestive heart failure in the past, chronic atrial fibrillation status-post pacemaker, diabetes mellitus, mild chronic renal failure, remote history of tobacco use 22 years ago, hypertension, dyslipidemia, arthritis, not active. In 2003, he had an ejection fraction of 45-50%. MEDICATIONS: On admission: 1. Niaspan ER 1,000 mg q h.s. 2. Coreg 25 mg b.i.d. 3. Lisinopril 40 mg q.d. 4. Spironolactone 25 mg a day. 5. Furosemide 40 mg a day. 6. Potassium chloride 20 mEq a day.
ER|extended release|ER|161|162|MEDICATIONS|6. Seroquel 600 mg p.o. q.h.s. 7. Clozaril 250 mg p.o. q.a.m. 8. Clozaril 200 mg p.o. at 1:00 and 8:00 p.m. 9. Potassium chloride 20 mg p.o. b.i.d. 10. Depakote ER 1500 mg p.o. q.a.m. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient denies any tobacco, alcohol or drug use.
ER|emergency room|ER.|143|145|HISTORY OF PRESENT ILLNESS|He had undergone two colonoscopies within the last five years that had been negative as well. With his increasing symptoms he presented to the ER. A CAT scan performed showing evidence of thickening of the cecum and distal small bowel. With this we are seeing him. ALLERGIES: Has no allergies.
ER|estrogen receptor|ER|199|200|HISTORY OF PRESENT ILLNESS|On _%#MMDD2003#%_, she had a left modified mastectomy which demonstrated grade 3 cancer involving all areas of the breast. The largest tumor focus was 4.5 cm. The margins were positive. The tumor is ER PR negative. She had a prophylactic right simple mastectomy which was negative. She received two more cycles of Adriamycin and Taxol. Her last dose was given approximately 14 days prior to the consultation.
ER|emergency room|ER.|234|236|LABORATORY DATA|CHEST: Clear. HEART: S1 and S2 without murmurs. ABDOMEN: Nondistended, active bowel sounds, soft and nontender, liver and spleen not enlarged, no masses, rebound or guarding. LABORATORY DATA: Hemoglobin is 11.1 on presentation in the ER. MCV of 91, white count 4.6. Follow-up hemoglobin is 9.6 and 10.0. INR is 0.99. Electrolytes, BUN, creatinine and LFTs are all normal.
ER|emergency room|ER|162|163|IMPRESSION|He has dyspnea on exertion. He sleeps upright in a chair. He states he has been weighing himself and his weight has not changed at all, although according to the ER records, his weight is up 8 pounds. He denies having any ankle edema. He lives with his daughters who follow a low salt diet and give him excellent care with excellent compliance on his medications, although he states he has been doing poorly.
ER|emergency room|ER|150|151|HISTORY OF PRESENT ILLNESS|It is not clear whether he had any fevers, chills, or sweats - they are not recorded as having been present. The patient was subsequently seen in the ER when the swallowing became even worse. He was felt to have swelling on the lateral film. ENT saw the patient and felt that this was epiglottitis and he was intubated for airway protection.
ER|emergency room|ER|135|136|MEDICATIONS|Patient was treated with Asacol at that time. MEDICATIONS: 1. Abilify 20 mg p.o. q. day. 2. Klonopin 0.25 mg p.o. q.h.s. 3. Divalproex ER 1500 mg p.o. q. day. 4. Vancomycin 250 mg p.o. q.6h. p.r.n. SOCIAL HISTORY: The patient does not drink or smoke.
ER|emergency room|ER,|225|227|IMPRESSION|Creatinine is 1.2, BUN 24, calcium 8.3, hemoglobin 13.8, platelets 250, white count 7.5. IMPRESSION: 1. Stage 2B right breast cancer status post resection, mastectomy and lymph node dissection, 4 cm, one lymph node involved. ER, PR positive. 2. Severe Alzheimer's dementia. 3. Right hip fracture status post internal fixation. 4. Poor ECoG performance status of 3 with tendency for sedentary life at the assisted living.
ER|emergency room|ER|161|162|HISTORY OF PRESENT ILLNESS|The patient had increased diarrhea for two weeks from his chronic levels. He also had more nausea and vomiting. He was becoming more weak, so he presents to the ER for further evaluation. The patient does have chronic kidney disease. His creatinine was 2.4 in _%#MM2006#%_.
ER|emergency room|ER|160|161|CHIEF COMPLAINT|In the ER they gently reduced it and splinted her. She denies numbness or tingling. Aggravating factors include dependency, moving it. Medications given in the ER include morphine, and elevation have helped. ALLERGIES: NO KNOWN DRUG ALLERGIES. PAST MEDICAL HISTORY: 1) Migraines.
ER|emergency room|ER.|121|123|DOB|He was noted to have high blood pressure in the ER that was coming down without any medications. He was given TPA in the ER. His initial strength was noted to be 0-1/5 in the right upper extremity and right lower extremity. He shows dramatic improvement now from his initial presentation. He continues to be aphasic but can bring out some words at present.
ER|emergency room|ER|143|144|REFERRING PHYSICIAN|REFERRING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD HISTORY OF PRESENT ILLNESS: The patient is a 22-year-old admitted from (_______________) to the ER where the patient presented with increased paranoia. The patient has been thinking that people are out to hurt him. He has been isolating himself in his room until late at night and does not sleep because he is afraid somebody might hurt him.
ER|emergency room|ER|153|154||His Tegretol was increased up to 600 mg t.i.d. from initially 200 mg daily to a gradual increase to 300 mg b.i.d. over the last week. He has been in the ER 3-4 times. He was in the ER on _%#MMDD2007#%_ with increased seizures, so zonisamide was thus added. His father reports his episodes have changed such that he has now had atonic spells.
ER|emergency room|ER|139|140|ASSESSMENT|REQUESTED BY: _%#NAME#%_ _%#NAME#%_, MD ASSESSMENT: 1. Dementia with delirium. The patient has been quite lethargic since admission to the ER following a period of extreme agitation at the nursing home. She apparently received only 1 mg Ativan on top of her usual oral medications.
ER|emergency room|ER|113|114|CONSULTATION|Called into the clinic and was told, because of the progressive abdominal pain, to go to the ER. She came to the ER about 6:45, had a popsicle at about 8:00 and seemed to be doing a little bit better, but then was seen, and because of concerns about abdominal discomfort, did have white blood count drawn, which was 14,500 with percent neutrophils 88%, 7% lymphocytes.
ER|emergency room|ER|179|180|DISCUSSION|Please see Dr. _%#NAME#%_'s notes in the chart for details regarding the patient's psychiatric history and circumstances leading up to admission. The patient was assessed at HCMC ER prior to admission here. He had presented there in police restraints after he was kicking and spitting at people in the shopping area.
ER|emergency room|ER|191|192|HISTORY OF PRESENT ILLNESS|REASON FOR CONSULTATION: I was asked to see this very pleasant young man by Dr. _%#NAME#%_. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 35-year-old male from Ecuador. He presented to the ER following one week of extreme emotional upset, subsequent to breaking up with his girlfriend. PAST MEDICAL HISTORY: 1. Emotionality, per Dr. _%#NAME#%_. 2. Palpitations.
ER|emergency room|ER.|374|376|REFERRING PHYSICIAN|Currently she is on carboplatinum, Gemzar and Avastin. Her last dose was last week and the patient's husband said she was doing fine until Thanksgiving night she went to a hockey game and then Saturday morning she was just feeling very weak, very exhausted and got progressively worse, very lethargic, very weak, progressively decreased mentation and she was brought to the ER. There her temperature was 101.2 and respiratory rate 34. Looking at her vitals, her heart rate went up to 162, respiratory rate up to 38, blood pressure was 116/93, but it slowly started dropping.
ER|estrogen receptor|ER|127|128|HPI|As you know, she presented back in _%#MM2004#%_ with a right breast mass. It was a large 9 cm centrally located lesion. It was ER positive and PR negative, also by FISH analysis it was HER-2 negative. PET scan revealed that she had metastatic disease to bone, as well as periaortic and superior mediastinal lymphadenopathy.
ER|emergency room|ER.|189|191|RECOMMENDATION|2. Hypertension, stable. 3. Hyperlipidemia. 4. Unclear coronary artery status. RECOMMENDATION: Patient will be started on Ancef 1 gm IV p.o. t.i.d. Blood cultures have been obtained in the ER. A urine culture has also been obtained. He will be continued on Accupril for hypertension as his blood pressure dictates.
ER|emergency room|ER,|198|200|HISTORY OF PRESENT ILLNESS|The patient had an office visit where he was presenting with shortness of breath and some lower extremity swelling. CT scan apparently was obtained and was negative. He was subsequently sent to the ER, where a VQ scan was obtained and was a high probability scan. The patient was admitted, started on heparin and was started on Coumadin.
ER|emergency room|ER|133|134|HISTORY|He was afebrile. His Hohmann sign was negative. His leg was still swollen and tender, however. The patient was worked up through the ER last night and admitted for pain control and the possibility of infection. His work up in the ER last night included a repeat venous Doppler study which was also negative for DVT.
ER|emergency room|ER,|213|215|HISTORY OF PRESENTING ILLNESS|Because of this, lasting for approximately 30-60 minutes, she came into the Urgent Care, at which time they were concerned and transported her via ambulance to the Fairview Ridges Hospital ER. Upon arrival to the ER, they gave her sublingual nitroglycerin with relief of her chest discomfort. An EKG was done, which showed no changes. Her vital signs were stable with, however, mild elevation of her blood pressures at 144/82 and 156/77.
ER|emergency room|ER|209|210|HISTORY OF PRESENT ILLNESS|She has a history of several suicide attempts and was actually seen here at University of Minnesota Medical Center, Fairview _%#CITY#%_ campus _%#MM2006#%_ for an overdose of Ativan. She also visited the HCMC ER approximately 2 weeks ago for chest pain and GI upset with nausea and vomiting. They gave her Maalox with lidocaine, diagnosed her with gastritis, and recommended she "get her GI tract checked out." She has not since done so.
ER|emergency room|ER|216|217|ADDENDUM|Our standard adverse drug reaction protocol was followed with bolus steroids, antihistamines and a dose of Epi was given. Patient's symptoms worsened and we needed to Call 911. Patient was stabilized and sent to RMC ER for further evaluation and admission. She was reported to be stable and alert in the ER later. Sincerely,
ER|emergency room|ER|147|148|REASON FOR CONSULTATION|He had history of MI and bypass surgery in the past. His platelet count was 85 on admission, which was done at 2110. This was close to the time of ER evaluation. He was started on heparin since he was in the ER and this was discontinued today. His platelet count today is 73,000. Review of the old records show platelet count over 200,000 in the outpatient clinic and 186,000 in _%#MM#%_.
ER|emergency room|ER:|153|155|LABORATORY DATA|Sensation was intact to light touch. Strength was 5 out of 5 bilaterally in the upper and lower extremities. LABORATORY DATA: Obtained from the Fairview ER: Basic metabolic panel showed some hyponatremia which was replaced and she currently has a potassium of 3.8, and her basic metabolic panel looked within normal limits on _%#MM#%_ _%#DD#%_.
ER|extended release|ER|103|104|PAST MEDICAL HISTORY|4. History of peptic ulcer. 5. Chronic migraine headaches. MEDICATIONS are supposed to be: 1. Depakote ER 2000 mg at h.s. 2. Geodon 80 mg at h.s. 3. Seroquel 150 mg at h.s. He has not taken his psychiatric medications for 2 weeks.
ER|estrogen receptor|ER|178|179|IMPRESSION|The left breast is without any masses, skin ulcerations, skin edema or nipple retraction. IMPRESSION: T1c, N0 infiltrating ductal carcinoma, status post lumpectomy. The tumor is ER positive, PR negative,HER2/neu negative. The patient is going to have ovarian ablation by Dr. _%#NAME#%_. PLAN: We discussed with the patient the benefit of radiation therapy and lumpectomy with the patient.
ER|extended release|ER|84|85|PRESENT MEDICATIONS|15. Wellbutrin 150 mg q. a.m. 16. Effexor XR 75 mg q. a.m. Change today in Depakote ER to 500 mg 2 at hs with Lithium 750 mg at h.s. FAMILY HISTORY: Father status post MI. HABITS: Nonsmoker. Denies alcohol or other drug use. SOCIAL HISTORY: Single.
ER|emergency room|ER|158|159|HISTORY OF PRESENT ILLNESS|The patient had been admitted to _%#CITY#%_ Hospital and was discharged on _%#MMDD#%_. Because of continued symptoms, she came to Fairview Southdale Hospital ER on _%#MMDD#%_. She has known severe aortic stenosis with a gradient that is around 45-46 mmHg with a valve area of 0.4. She was previously thought to have an ejection fraction of 30-35% but her current echo shows an EF of 50-55%.
ER|emergency room|ER|130|131|HISTORY|She had a full workup at that time, was otherwise unremarkable and was placed on Levaquin. The next day she was seen again in the ER when she was not improved at all and in particular was having diffuse generalized body aches. She had significant muscle aches all over but was even more so in her upper extremities.
ER|emergency room|ER,|184|186|DISCUSSION|She had not been taking her psychiatric medications for approximately one week. She states she has been taking her blood pressure medications, although this is not clear to me. In the ER, she was noted to be quite anxious and to be hypertensive. _%#NAME#%_ has acknowledged also drinking "occasional" alcohol, though is vague in this regard.
ER|emergency room|ER|229|230|HISTORY OF PRESENT ILLNESS|According to the patient, he has stopped using cocaine, although in _%#MM2007#%_, the urine was studied for tox screen and demonstrated cocaine. The patient claims he has not used it since. He was admitted in _%#MM2007#%_ in the ER for chest pain and at that time he left against medical advice. He urine there showed cocaine. PAST MEDICAL HISTORY: 1. Coronary disease and lateral wall MI.
ER|emergency room|ER|112|113|MEDICATIONS|He has had hypertension, appendectomy, and herpes zoster. ALLERGIES: No known drug allergies. MEDICATIONS: From ER notes, verapamil, Norvasc, aspirin, isosorbide, Wellbutrin, albuterol, and Duonebs. He is unable to give a social history, family history, review of systems.
ER|emergency room|ER.|207|209||She has a long ago history of GI surgery, hemicolectomy which resulted in short bowel syndrome. Since that time she has had nausea, vomiting and diarrhea intermittently, and this is what brings her into the ER. She was brought in on _%#MMDD#%_ to our ER having chronic diarrhea with some nausea and vomiting and was admitted. She currently is having other symptoms as well. She has a thrombus in her right atrium of her heart and is on heparin therapy but complications of GI bleed, so the heparin has been stopped for a day and will be restarted again later today at a low dose, hoping that she will not continue to have GI bleed.
ER|emergency room|ER.|178|180|MEDICATIONS|Smokes cigarettes one-half pack per day. PHYSICAL EXAMINATION: He is a pleasant male who does not appear acutely ill. He is eating his dinner voraciously. He was normotensive in ER. HEENT exam reveals several missing teeth. Pharynx benign. There is no adenopathy. Lungs are clear with good breath sounds bilaterally. Cardiac exam reveals regular rhythm without murmurs.
ER|extended release|ER|238|239|CURRENT MEDICATIONS|PAST SURGICAL HISTORY: Tonsillectomy. ALLERGIES: Penicillin. CURRENT MEDICATIONS: 1. Clozaril 50 mg q.h.s. with an order for Haldol if refused. 2. Naltrexone 50 mg b.i.d. 3. Colace 100 mg b.i.d. 4. Effexor XR 300 mg q. daily. 5. Depakote ER 1000 mg q.h.s. FAMILY HISTORY: No known serious illness. HABITS: She is a non-smoker. She denies alcohol or other drug use.
ER|emergency room|ER|174|175|HISTORY OF PRESENT ILLNESS|He denied head trauma or any obvious loss of consciousness. Had note of left-sided chest discomfort, shoulder discomfort and leg injury. He was brought to Fairview Southdale ER and underwent a trauma evaluation which included head CT, cervical thoracic spine CT, chest, abdomen and pelvic CT. He did not require resuscitation other than with fluids. He has remained hemodynamically stable.
ER|emergency room|ER|178|179|HISTORY OF PRESENT ILLNESS|The patient reports that she has had no similar problems and that this has been evolving over the last two weeks. She worsened markedly in the last few days. She had required an ER visit with IV hydration earlier. PAST MEDICAL HISTORY: 1. The patient reports that her general health has been good.
ER|emergency room|ER,|131|133|HISTORY|She describes a history of arthritis, although both her hips do move around quite well on examination at the bedside today. In the ER, she was stable and the fracture is moderately displaced. From the record, she has had extensive x-ray studies here before, but does not appear to have too many admissions.
ER|extended release|ER|154|155|ADMISSION MEDICATIONS|Since then, the patient has not re-experienced this pain. PAST MEDICAL HISTORY: 1. Schizophrenia. 2. Diabetes type 2. ADMISSION MEDICATIONS: 1. Glipizide ER 10 mg p.o. daily. 2. Actos 15 mg p.o. daily, which will be held for blood sugar levels lower than 90. 3. Seroquel. 4. Bupropion. 5. Geodon. ALLERGIES: No known allergies.
ER|emergency room|ER.|146|148|DISCUSSION|She broke a Pyrex pie plate and then apparently unintentionally slashed her right forearm in the process. She did require several stitches in the ER. _%#NAME#%_ denies weakness or numbness of her right hand.
ER|emergency room|ER|142|143|DISCUSSION|The patient is a very poor historian and is unable to clarify this with me at the current time. Mr. _%#NAME#%_ was assessed in the _%#CITY#%_ ER prior to admission here. He did present to the ER seeking detox. He had been drinking beer on a daily basis. Blood alcohol level in the ER by breathalyzer was .17 gm/dl.
ER|estrogen receptor|ER|168|169|ASSESSMENT AND PLAN|An ultrasound guided thoracentesis at that time, however, revealed a metastatic adenocarcinoma. Additional immuno stains showed that the tumor was negative for BRST-2, ER and PR but was cytokeratin CA positive most consistent with an adenocarcinoma of non-breast origin. At any rate over the last month, the patient has done relatively well, but has now been readmitted to the hospital with increasing dyspnea and fatigue as well as weakness.
ER|estrogen receptor|ER|285|286|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 74-year-old postmenopausal female who was found to have right breast abnormality on mammogram and ultrasound showed a 1.2 cm lesion at the 10 o'clock position, 7 cm distant from the nipple. She had a biopsy which showed invasive carcinoma, grade 2, ER positive, HER-2/neu negative. She underwent surgical resection with bilateral mastectomy on _%#NAME#%_ _%#DD#%_. Final pathology is pending including the lymph node status. She has moderate pain in her mastectomy area and had nausea and emesis today which responded to antiemetics.
ER|emergency room|ER|230|231|HISTORY OF PRESENT ILLNESS|He said he "couldn't move my left side". He called for his brother, who took him to a nearby urgent care. There the patient was evaluated and then transferred to Fairview Southdale Hospital ER for further acute management. In the ER initial blood pressures were in the 300s/200s. He was given labetalol and placed on a drip. The patient was seen by neurology urgently.
ER|emergency room|ER|170|171|HISTORY OF PRESENT ILLNESS|She had weakness, cough, and fever and was seen in clinic. She was given Zithromax. One day later, her daughters noticed that she was confused and she was brought to the ER with coughing, chills, and decreased appetite. She had a low blood sugar at that time. She had been told to have mild diabetes or borderline diabetes.
ER|emergency room|ER|163|164|HISTORY|He and his wife have subsequently been withholding blood pressure medications and using blood pressure medications as needed to control his blood pressure. In the ER last evening, his systolic blood pressure was over 200 mm of mercury. He notes that when he went to bed, his blood pressure was 140/80 mm of mercury and then rose to 200 mm of mercury when he went to the bathroom.
ER|emergency room|ER|264|265|PHYSICAL EXAMINATION|X-rays were reviewed, showing an impacted ___________ fracture on one view, but given the shortening of it very suspicious, and on the lateral it certainly was about 45 degrees posterior tilted. The bony architecture does not line up. Skull x-rays and CT scan per ER were reportedly negative. PROBLEMS: 1) Acute hip fracture left side, osteoporosis. Will require surgical intervention, most likely a prosthesis, bipolar.
ER|extended release|ER|170|171|MEDICATIONS|All were normal except as above. ALLERGIES: Sulfa. HABITS: Tobacco negative, alcohol negative. MEDICATIONS: 1. Vicodin 5/500, 1-2 p.o. q.4-6h. p.r.n. 2. Morphine sulfate ER 15 mg 2-3 times a day (discontinued recently). 3. Ambien 10 mg q.h.s. p.r.n. 4. Tizanidine 4 mg 1-3 times a day p.r.n.
ER|emergency room|ER|115|116|HISTORY OF PRESENT ILLNESS|REQUESTING PHYSICIAN: Dr. _%#NAME#%_. HISTORY OF PRESENT ILLNESS: This is a 50-year-old female who presents to the ER at _%#CITY#%_ on _%#MMDD2006#%_ because she "wanted to get clean." We were requested to see this patient by Dr. _%#NAME#%_ as an Internal Medicine consult. The patient states that she wanted to go through detox to try and get off of heroin.
ER|emergency room|ER.|202|204|HISTORY OF PRESENT ILLNESS|REQUESTING PHYSICIAN: Dr. _%#NAME#%_. CHIEF COMPLAINT: Unresponsiveness, rule out seizure. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 5-month-old female admitted for possible seizure activity from the ER. _%#NAME#%_ has a complicated past medical history. She was the product of a full-term pregnancy to a G5, P4 female with pregnancy complicated by gestational diabetes.
ER|emergency room|ER|318|319|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old male who was admitted with altered mental status, baseline dementia, Alzheimer's-type, fever, malaise, and possible urinary tract infection. The patient complained of some urinary retention symptoms. A standard Foley catheter was attempted several times by the ER staff without success. The patient then began to complain of pain secondary to retention-type symptoms. Urological Surgery Service was consulted for placement of difficult urinary catheter.
ER|emergency room|ER.|264|266|HISTORY OF PRESENT ILLNESS|DOB: _%#MMDD1938#%_ HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a pleasant 66-year- old woman who was discharged from Fairview Southdale Hospital yesterday to a nursing home. She developed worsening shortness of breath over night and was sent to Fairview Ridges ER. When she was admitted to Fairview Southdale Hospital on _%#MMDD2004#%_ she had had greater than 6 hours of chest pain. She had an acute inferior myocardial infarction combined with cardiogenic shock and severe bradycardia.
ER|emergency room|ER.|146|148|CHIEF COMPLAINT|She had the left hip bipolar replacement for hip fracture in _%#MM2007#%_ by Dr. _%#NAME#%_. On admission she was hypertensive. Also A-fib in the ER. Therefore, I thought we should off Sunday surgery and defer until Monday _%#MMDD#%_. PAST MEDICAL HISTORY: 1. Left hip fracture _%#MM2007#%_. 2. Coronary artery bypass grafting.
ER|emergency room|ER|243|244|HISTORY|She cleaned out the area and then observed. She called her clinic regarding tetanus status and no antibiotics were started at that time. By that evening, she had significant erythema, swelling and redness evolve over that hand and went to the ER for evaluation. She was given Augmentin orally after a dose of IV antibiotics, not clear what was given. Over the next 24 hours, it simply progressed and worsened and she saw Dr. _%#NAME#%_.
ER|emergency room|ER|164|165|DISPOSITION|Her mother is present and they both understand and agree with the plan. At this time there is no indication for admission to the hospital as was discussed with the ER doctor.
ER|emergency room|ER|160|161|HISTORY|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD. HISTORY: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 66-year-old gentleman admitted with severe pain. He went to the ER _%#MMDD2004#%_. Dr. _%#NAME#%_ has evaluated him. He is well-known to him because of treatment of POEMS syndrome. The patient is atraumatic. He has been worked up for renal lithiasis, intrapelvic problems, and the basic workup has been negative.
ER|emergency room|ER|351|352|IMPRESSION|5. C. diff diarrhea during the last hospital stay, on treatment still had a positive C. diff culture on _%#MMDD#%_, had another 5 days of Flagyl scheduled as an outpatient but the diarrhea has resolved without further recurrence and without other antibiotics being given. 6. History of rectal bleeding. 7. Active hematuria, catheter in place from the ER yesterday currently. 8. Diabetes mellitus. 9. Large cell leukemia. PLANS: Zosyn and tobramycin. Await cultures and adjust accordingly. If the urine culture is positive for the same organism in the blood, assume urinary source and treat accordingly including going to oral therapy if he is doing well, if organism is sensitive to usual oral agents.
ER|emergency room|ER,|111|113|CHIEF COMPLAINT|Multiple examples of this wide QRS rhythm show a clear underlying QRS pattern compatible with artifact. In the ER, electrocardiograms were normal. Since admission, she has had a quieting of her substernal chest pressure with nitroglycerin and Lovenox.
ER|estrogen receptor|ER|173|174|HISTORY OF PRESENT ILLNESS|She had a chest wall recurrence _%#MMDD2003#%_, grade 3 of 3. Her original tumor was 2 of 3. She had high grade DCIS also initially. She had two of 12 lymph nodes positive, ER positive, PR negative and HER-2/neu negative. REVIEW OF SYSTEMS: GENERAL: She had hot flashes, but sweating varies.
ER|emergency room|ER,|192|194|LABORATORY DATA|NEUROLOGIC: He is alert and oriented. Cranial nerves II through XII are grossly intact. Sensation intact to light touch. Strength is 5/5 bilaterally. LABORATORY DATA: Upon presentation to the ER, urinary toxicology screen was done, which was positive for barbiturates, benzodiazepines, cocaine and ethanol. EKG also done in the ER showed sinus tachycardia with a rate of 140.
ER|emergency room|ER|137|138|ASSESSMENT AND PLAN|Will restart Vistaril 25 mg p.o. t.i.d. p.r.n. No need for MRI or CT. 4. Increased liver enzymes: The patient denies alcohol intake, but ER report shows patient stated that she had several drinks before admission. She has a questionable hepatitis C diagnosis, and hepatitis B, syphilis, HIV 1 and 2 were negative in _%#MM2006#%_; however, will recheck this panel while currently admitted.
ER|emergency room|ER|147|148|HISTORY|He occasionally would drink to the point of intoxication. He ingested 1 pint of whiskey on _%#MM#%_ _%#DD#%_, 2004. He presented to North Memorial ER for help with regard to issue of ongoing alcohol abuse. He was transferred, subsequently, to inpatient psychiatry at Fairview _%#CITY#%_.
ER|emergency room|ER|93|94|PAST  MEDICAL HISTORY|The patient denies knowledge of cardiac or pulmonary disease. She was evaluated at Southdale ER in _%#MM#%_ of this year for chest pain. This was felt related anxiety. EKGs in the past have been normal. MEDICATIONS: 1. Ativan 0.5 mg q.6 hours p.r.n. anxiety.
ER|emergency room|ER|177|178|HISTORY OF PRESENT ILLNESS|First mental health hospitalization on _%#MMDD2006#%_. The patient allegedly overdosed on 610 mg of Seroquel (exact quantity not clear) in addition to alcohol. Presented to the ER at _%#CITY#%_ _%#CITY#%_ Hospital. No gag reflex, prompting intubation. Admitted to the critical care service. Mechanical ventilation support. Propofol sedation.
ER|emergency room|ER.|279|281|HISTORY OF PRESENT ILLNESS|Ms. _%#NAME#%_ was admitted to Fairview Ridges Hospital again today after she woke up at about 0730 in the morning and felt tired and was quite immediately aware of palpitations. Because of her profound fatigue and palpitations, she was evaluated in the Fairview Ridges Hospital ER. The rhythm strips from the emergency room suggest atrial fibrillation, although full 12-lead electrocardiogram shows monomorphic atrial tachycardia.
ER|emergency room|ER|132|133|PAST MEDICAL HISTORY|She is taking doxycycline, Vicodin, tramadol, and was on Depo-Provera. The patient says the pain is worse today and she came to the ER after her pelvic ultrasound which was apparently scheduled as an outpatient. The pain is in the back and across the lower abdomen.
ER|emergency room|ER|103|104|RECOMMENDATIONS|I have been asked by Dr. _%#NAME#%_ to see _%#NAME#%_ _%#NAME#%_. This 74-year-old lady came in to the ER with musculoskeletal chest pain that has been bothering her severe enough. She also has back pain that radiates into the anterior chest wall.
ER|emergency room|ER.|241|243|HISTORY|ER record at Fairview University indicates subsequent ingestion of 20 pills (question ibuprofen, question vicodin) over a two- day period. Nausea and emesis on three or four occasions. A sense of wanting to give up, with presentation to the ER. Persistent left ankle, and to a lesser extent left knee pain to the present time. Aggravated by weight bearing. The patient indicates x-rays at HCMC, indicated a fracture of the left ankle.
ER|emergency room|ER|98|99|PHYSICAL EXAMINATION|The rest of her review of systems is otherwise negative. PHYSICAL EXAMINATION: She came in to the ER with a blood pressure of 123/79, temperature 96. In general, she appears to be healthy, alert, but in mild distress. HEENT: No scleral icterus. No oral lesions. NECK: Supple. CHEST: Clear to auscultation bilaterally.
ER|emergency room|ER|237|238|REVIEW OF SYSTEMS|Patient denied chest pain, syncope, palpitations or near syncope. Also noticed a little more fluid retention in his lower extremities, but denies pain in the extremities. REVIEW OF SYSTEMS: Otherwise was unremarkable. The patient in the ER was noticed in atrial fibrillation and with bradycardia, heart rate somewhere between 30-40, up to 50 and patient was admitted for further evaluation.
ER|emergency room|ER.|186|188|CHIEF COMPLAINT|CHIEF COMPLAINT: Shortness of breath. Asked by Dr. _%#NAME#%_ _%#NAME#%_ at Fairview Southdale Hospital ER to evaluate the patient's shortness of breath prior to possible discharge from ER. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 73-year-old male whose primary-care physician is Dr. _%#NAME#%_ _%#NAME#%_ at Fairview Ridges Internal Medicine, seen today for evaluation of intermittent symptoms of inability to "catch my breath".
ER|extended release|ER|197|198|OUTPATIENT MEDICATIONS|The patient was treated aggressively on the University campus and then discharged back to the _%#CITY#%_ campus. ALLERGIES: Effexor. OUTPATIENT MEDICATIONS: 1. Remeron. 2. Flovent MDI. 3. Depakote ER 500 mg p.o. b.i.d. 4. Ativan p.r.n. 5. Benadryl 50 mg p.o. q.h.s. 6. Protonix 40 mg p.o. daily. 7. Iron sulfate 325 mg p.o. daily. 8. Synthroid 25 mcg p.o. daily.
ER|emergency room|ER|140|141|HISTORY OF PRESENT ILLNESS|It is unclear how long that period of unresponsiveness may have been. The patient could not be intubated on site and was transported to the ER where he was noted to be pulseless and CPR was initiated. He was intubated in the Emergency Room and has remained unresponsive.
ER|extended release|ER|197|198|SUMMARY|For control of her ventricular response, I would recommend using a combination of long-acting metoprolol and digoxin. Thus the following cardiovascular medications have been ordered: 1. Metoprolol ER 50 mg p.o. each day. 2. Digoxin 0.125 mg p.o. each day. I would recommend obtaining a digoxin level in 1 week.
ER|emergency room|ER,|91|93|CHIEF COMPLAINT|Her heart rate was 80-90 beats per minute. Her electrocardiogram is totally normal. In the ER, potassium was 3.0. TSH was upper limits of normal. Potassium is 3.3, sodium 140, creatinine 1.08. BNP 70. Troponin normal, myoglobin normal, TSH 4.18. Chest x-ray report shows what was called a small nodule overlying the lateral projection of the superior half of T7.
ER|emergency room|ER|188|189|HISTORY OF PRESENT ILLNESS|5. History of depression. 6. History of diverticulitis. Status post partial colon resection in 2002. HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old gentleman, who came in to the ER with atypical chest pain. Troponin I was negative x 3. We were asked by Dr. _%#NAME#%_ to help evaluate for this atypical chest pain. The patient denied any dysphagia, odynophagia.
ER|emergency room|ER|160|161|HISTORY|He has had three seizure episodes, initially thought related to withdrawal. One event was after ten days of sobriety in early _%#MM#%_. He was evaluated in the ER with alleged negative head CT. He never underwent EEG. His last seizure was on _%#MMDD2003#%_, approximately 16 hours after his last drink.
ER|estrogen receptor|ER|122|123||The patient underwent a lumpectomy on _%#MMDD2005#%_. Primary tumor was 2.5 cm with evidence of focal DCIS. Her tumor was ER and PR negative and by FISH analysis was also HER-2 negative. A bone scan was normal. Beginning on _%#MMDD2005#%_, the patient was started on combination chemotherapy in adjuvant setting and she received regimen which compromised of 5FU, epirubicin, and Cytoxan.
ER|emergency room|ER|119|120|DISCUSSION|Also now with worsening depression, suicidal ideation with a plan to jump off a bridge. The patient was brought to the ER this afternoon and was noted to have abnormal labs including glucose 593, anion gap 14, sodium 133. Liver function tests were normal. CBC was unremarkable. Urine tox screen was positive for cocaine.
ER|emergency room|ER,|168|170|PHYSICAL EXAMINATION|SOCIAL/FAMILY HISTORY: As per the chart. PHYSICAL EXAMINATION: Reveals a chronically ill-appearing female who is lying in bed sleeping. She resists examination. In the ER, prior to admission, she was afebrile. Vital sings have not yet been checked here. HEENT exam was not permitted secondary to lack of cooperation.
ER|extended release|ER|143|144|MEDICATIONS ON ADMISSION|2. Tums on a p.r.n. basis. 3. Lamictal 100 mg each day at bedtime. 4. Ativan 1 mg twice a day p.r.n. and 2 mg each day at bedtime. 5. Depakote ER 1000 mg each day at bedtime. 6. Seroquel 100 mg each day at bedtime. 7. Peri-Colace 100 mg every morning and 50 mg each day at bedtime.
ER|emergency room|ER|171|172|HISTORY OF PRESENT ILLNESS|He has been on interferon for three weeks. In the Emergency Department he was found to be tachycardic and dehydrated. He was weak for the last three weeks. He did see the ER on _%#MMDD2005#%_. At that time, he was found to be dizzy. He had been having low-grade temperatures. They thought he was likely dehydrated. He was discharged to home.
ER|emergency room|ER|144|145|HISTORY OF PRESENT ILLNESS|He was also still taking his lisinopril daily. Yesterday the patient felt dizzy when he would get up and is feeling more weak so he came to the ER for evaluation. In the ER he was found to be pretty dry and given volume. His ACE inhibitor was held overnight and hydration has continued.
ER|extended release|ER|268|269|MEDICATIONS|1. Psychiatric illness. 2. Polysubstance abuse. 3. Hypertension. 4. History of motor vehicle accidents in the late 1980s and late 1990s, for which the patient has chronic neck and low back pain. MEDICATIONS: 1. Paxil 40 mg daily. 2. Atenolol 50 mg daily. 3. Procardia ER at 30 mg daily. 4. Allegra 60 mg b.i.d. 5. Geodon 80 mg q.h.s. 6. Naprosyn on a p.r.n. basis. ALLERGIES: Medication allergies are to cortisone which she states causes a rash.
ER|emergency room|ER|155|156|HISTORY  OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 51-year-old woman who was in her usual state of health. She had some had company last night and the ER reports that she had 4 alcoholic drinks last night. The patient went to bed, was feeling fine. In the middle of the night she was up walking down the stairs in the dark when she tripped over her cat and fell.
ER|emergency room|E.R.|304|307|SHE HAS NO ALLERGIES.|Respirations are regular and nonlabored with oxygen in place. The abdomen is flat, soft, nondistended, tender in the right lower quadrant with voluntary guarding with no peritoneal irritation. CVAs are nontender. EKG has been obtained which showed normal sinus rhythm which is confirmed by review of the E.R. physician. Chest x-ray showed no infiltrate. White blood cell count is 16.5 with 86% PMNs. Hemoglobin is 9.5. Electrolytes are normal. Creatinine is 1.0. CT scanning showed "a dilated tubular structure in the right lower quadrant consistent with appendicitis.
ER|emergency room|ER|126|127|LAB|UA showed glucose, UC was negative on preliminary report. EKG showed normal sinus rhythm. Preliminary chest x-ray done in the ER showed a right pulmonary nodule. MRI done on _%#MMDD2002#%_ showed moderate external supratentorial white matter and changes, these were non-specific likely secondary to chronic small vessel ischemic disease.
ER|emergency room|ER|153|154|HISTORY OF PRESENT ILLNESS|On admission in the ER he complained of pain everywhere, including head and chest, for many weeks. He has also been off his Risperdal for many weeks per ER and psychiatric reports. Patient reports sharp, intermittent chest pain in both the left and right chest since _%#MM#%_ 2006.
ER|emergency room|ER,|181|183|PLAN|I believe his hemoglobin was 6.2 on admission. The patient denies any obvious history of gastrointestinal blood loss. There is some indication that Hemoccults were sent through the ER, but they are not available. The patient and his wife deny any knowledge of hematemesis or melena. The patient has a known hiatal hernia. He had previously had more significant heartburn.
ER|emergency room|ER|292|293|PHYSICAL EXAMINATION|FAMILY HISTORY: Reviewed and noncontributory to his present situation. REVIEW OF SYSTEMS: Positive for the left thigh pain, otherwise complete review of systems is negative. PHYSICAL EXAMINATION: GENERAL: _%#NAME#%_ is a healthy appearing young man who is visibly uncomfortable resting on an ER cot with a Hare traction splint on his left-lower extremity. His breathing is nonlabored. ABDOMEN: Soft and nontender. EXTREMITIES: His upper extremities are without pain to palpation.
ER|emergency room|ER|207|208|PHYSICAL EXAMINATION|Dorsal pedal pulses were 2+. The patient did not have any foot ulcers or evidence of severe peripheral vascular disease or peripheral neuropathy. The patient's initial blood glucose value at the time of the ER evaluation was 143. This has increased to over 400 despite insulin therapy. The patient has been receiving insulin through his cardiac GEC infusion at approximately 5 units an hour.
ER|emergency room|ER.|189|191|HISTORY OF PRESENT ILLNESS|He said he was probably going about 20 mph. He does not recall which part of his body hit the ground. He his unsure about loss of consciousness. He was brought in by ambulance to the F-UMC ER. He denies any headaches. He states that his neck is a little bit sore, but no particular pain or tenderness.
ER|emergency room|ER,|171|173|HISTORY OF PRESENT ILLNESS|He was unable to keep any food down and states that he had lost about 25 pounds within 2 weeks and so he came to the emergency room because he was feeling so weak. In the ER, his blood pressure apparently was below 100 systolic and after some IV fluids, the patient began to feel a little bit better.
ER|emergency room|ER.|141|143|HISTORY OF PRESENT ILLNESS|Emergent STAT chest CT upon arrival to the ER had shown large bilateral pulmonary embolus. The patient was given Lovenox 100 mg sub-Q in the ER. PAST MEDICAL HISTORY: 1. History of DVT at 21-years-old on birth control pills.
ER|emergency room|ER|202|203|SOCIAL  HISTORY|13. Lisinopril 20 mg p.o. q. day. 14. Remeron 15 mg p.o. each day at bedtime. 15. Levothyroxine 150 mg p.o. q. day. SOCIAL HISTORY: She lives with her son and daughter-in-law. Her daughter-in-law is an ER nurse. The patient has a history of 14 year history of cigarette use. She drinks wine on a daily basis. She quit smoking in the 1980s.
ER|emergency room|ER),|190|193|PRIOR HOSPITALIZATIONS|Cranial nerves were grossly intact. His face was symmetric. He was moving all extremities. Patellar reflexes were 2+ bilaterally. LABORATORY: White blood count 14.4 (down from 27 at outside ER), hemoglobin 11.7, platelets 344. Differential on the white count showed 62% neutrophils, 29% lymphocytes, 6% monocytes, 2% eosinophils. Electrolytes: Sodium 140, potassium 4.1, chloride 105, bicarbonate of 25, BUN 11, creatinine 0.32, glucose of 81, and calcium total of 9.9. Blood cultures were drawn on admission.
ER|emergency room|ER|294|295||_%#NAME#%_ _%#NAME#%_ is a 38-year-old White male who is followed by Dr. _%#NAME#%_ for a history of cerebral palsy, seizure disorder, recurrent left olecranon bursitis with or without cellulitis, constipation and a right Bell's palsy since _%#MM2001#%_. The patient initially presented to the ER for lethargy on _%#MMDD2002#%_ and was evaluated by Dr. _%#NAME#%_ _%#NAME#%_. At that time the patient had a chest x-ray which was negative.
ER|extended release|ER|234|235|MEDICATIONS|3. Bilateral cataract extraction. ALLERGIES: 1. Doxycycline (rash-pruritus). 2. Intolerant to Aleve. MEDICATIONS: 1. Zestoretic (lisinopril, hydrochlorothiazide) _%#MMDD#%_.5 daily. 2. Multivitamin daily. 3. Advil p.r.n. 4. Glipizide ER 5 mg q.a.m. with sliding scale regular insulin coverage. 5. Citrucel one teaspoon daily. 6. Mylanta gel caps one daily. 7. Stool softener b.i.d. FAMILY HISTORY: Noncontributory. HABITS: Non-smoker without significant alcohol intake.
ER|emergency room|ER|177|178|HISTORY OF PRESENT ILLNESS|She has had no burning with urination. She has had no urinary frequency. She was just in the hospital recently with a urinary tract infection. She has had several visits to the ER for various things over the last few months. Last week she had had a course of melphalan and prednisone, which I believe was around _%#MMDD2005#%_ and I think was the last dose.
ER|emergency room|ER|187|188|HISTORY OF PRESENT ILLNESS|She presented to Renal Clinic with right lower extremity tenderness and swelling. She did receive an ultrasound of the right lower extremity, which showed a DVT. She was then sent to the ER for a CT angiogram of the chest, which did show PE. The patient had noticed the right leg tenderness and swelling approximately two weeks ago.
ER|emergency room|ER|178|179|HISTORY OF PRESENT ILLNESS|The patient at that time was confused with a postictal confusion, and he was not oriented to place and time. His speech was soft. The patient did receive some Ativan 1 mg in the ER at 0030 and also fosphenytoin for 1400 mg IV piggyback infusion at 0045. The patient did not have any further seizure activity. He was admitted to Med/Surg as he was stable.
ER|emergency room|ER,|176|178|PROBLEM #3|We are discontinuing the IV antibiotic. PROBLEM #3: Type 2 diabetes mellitus: Hold the oral medicine. Accu-Chek q.i.d. The patient was started on regular insulin. Early in the ER, her blood sugar was 296. No serum ketones <____________________>, although her urinary ketones were mild 5, but could be due to dehydration, as the patient reports drinking water enough or taking liquid enough.
ER|emergency room|ER|173|174|ASSESSMENT AND PLAN|We will consider a surgical consult. For now, we will consider reversing his INR partially. We will certainly hold his Coumadin at this time. He did receive Rocephin in the ER and stress dose steroids. At this time, he does have a low-grade temperature and a mild leukocytosis. His leukocytosis could simply be stress related, but he does have a mild temperature and was having temperatures last night.
ER|emergency room|ER|168|169|HISTORY OF PRESENT ILLNESS|Chest x-ray was unremarkable. Laboratory studies showed the patient to appear a little bit dry but otherwise unremarkable. See below for details. The wife informed the ER staff that she felt that she was not able to care for the patient at home in his current state, and the decision was made to admit the patient for further management.
ER|extended release|ER|226|227|MEDICATIONS|MEDICATIONS: These are documented in her electronic medical record and I have reviewed them. She is on prednisone 5 mg daily, prograf 1 mg b.i.d., and CellCept 1500 mg b.i.d. She is also on voriconazole 200 mg b.i.d., Effexor ER 225 mg daily, and also takes Fosamax on a weekly basis and took her last dose yesterday in the morning. SOCIAL HISTORY: The patient lives in _%#CITY#%_ _%#CITY#%_ in _%#CITY#%_.
ER|emergency room|ER|189|190|ASSESSMENT AND PLAN|1. Acute shortness of breath. Likely this is secondary to rapid atrial flutter. He is on diltiazem drip. The patient is with a low blood pressure. I have started digoxin loading him in the ER since his blood pressure is low to control his rate better. I question the etiology of his rapidly atrial flutter. I question whether this is related to valvular disease.
ER|emergency room|ER|364|365|HISTORY OF PRESENT ILLNESS|At that time, due to the fact that the patient has had a prolonged hospitalization in _%#MM#%_ of this year for a poorly defined febrile illness, it was felt appropriate by myself to instruct the patient to seek medical attention this evening in the emergency room. In the emergency room, the patient was noted to have an oral temperature of 100.4 degrees per the ER physician of record. Due to the fact that the patient continued to feel progressively fatigued and has had discomfort in the area of the left shoulder since his tunnel catheter insertion, it was felt appropriate to admit the patient for further evaluation and management.
ER|extended release|ER|114|115|MEDICATIONS|2. Status post ectopic pregnancy surgery. MEDICATIONS: 1. Lasix 40 p.o. q.d. 2. Lipitor 10 p.o. q.d. 3. Verapamil ER 120 mg p.o. q.d. 4. Metoprolol 50 p.o. b.i.d. 5. Prevacid 30 mg p.o. q.d. FAMILY HISTORY: The patient has a mother with questionable ovarian cancer.
ER|emergency room|ER|159|160|LABORATORY STUDIES|Total protein is 36, normal. Glucose was 52, normal. MRI of her brain results are pending. The family states that this was essentially normal as stated by the ER physician. Neuroradiology is yet to read it. IMPRESSION: 1. Neurologic. The patient has an "acute" complaint of short-term memory loss and difficulty with concentration.
ER|emergency room|ER|147|148|PHYSICAL EXAMINATION GENERAL|PHYSICAL EXAMINATION GENERAL: Caucasian. Alert and oriented. No slurred speech. VITAL SIGNS: Pulse is 72, blood pressure 163/85, 97% on O2, in the ER just a couple liters. HEENT: Essentially within normal limits. Extraocular movements intact. The patient with decreased sensation on the left side of his face.
ER|emergency room|ER.|138|140|HISTORY OF PRESENT ILLNESS|In the ER, she received Solu-Medrol, Cardizem 15 mg IV, and 16 mg p.o., albuterol nebs, and potassium. Her heart rate was 103-160s in the ER. She was transferred to the floor on telemetry; however, given her persistent elevated heart rate in the 130s, she was transferred to the CCU for further management.
ER|emergency room|ER|154|155|FAMILY HISTORY|Initial blood work - myoglobin 214 above normal, troponin 1 is negative less than 0.1. The patient was started on IV heparin drip plus Nitro paste by the ER physician. We are planning to admit him to rule out MI with serial EKGs and troponin levels. If the patient rules out for MI will arrange for nuclear stress test tomorrow and will schedule the patient for 2-D echocardiogram evaluation.
ER|emergency room|ER|181|182|ASSESSMENT/PLAN|Two hours from departure from the clinic he unfortunately received 3 shocks from his device. The patient called 911 and was transported to Ridges Emergency Room. We did contact the ER physician and also Dr. _%#NAME#%_, who was covering our Ridges Service at this time. The plan is to transfer Mr. _%#NAME#%_ to Fairview Southdale Hospital where he can continue with evaluation with Dr. _%#NAME#%_, his electrophysiologist.
ER|emergency room|ER|195|196|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.9, pulse 90-95, blood pressure 97/63, respiratory rate 18, oxygen saturation 88% on 4 liters per minute. It should be noted she presented to the ER saturating at 70% on room air. GENERAL: Cachectic appearing 82-year-old female, alert and oriented, resting comfortably in bed on oxygen.
ER|emergency room|ER|153|154|HISTORY OF PRESENT ILLNESS|She is being admitted to the hospitalist service for further evaluation and concern about possible pyelonephritis. Notably, she did have a workup in the ER including an abdominal and pelvic CT scan without contrast which showed no stones. She also had a pelvic ultrasound which showed no evidence of torsion of the ovaries.
ER|emergency room|ER|198|199|PHYSICAL EXAMINATION|Denies any GYN problems or history of hot flashes. PHYSICAL EXAMINATION: GENERAL: A woman who seems to be relatively calm in bed at present. Alert and interactive, oriented 4/4. VITAL SIGNS: In the ER showed blood pressure 150/95, heart rate 109, respiratory rate 16, temperature 99.1 with O2 sats 97%. Current blood pressure is improved, in the 130/88 range and heart rate improved down to 70s.
ER|emergency room|ER|220|221|INDICATION FOR CONSULTATION|She denies chest pain, palpitations, dizziness or syncope. Towards the evening, however, she got a little more tight in the chest, a little short of breath and subsequently came to the Emergency Room. An EKG done in the ER showed rapid atrial fibrillation without any obvious ST-T changes. The EKG was morphologically normal otherwise. She subsequently converted to sinus rhythm on her own.
ER|emergency room|ER|165|166|HISTORY OF PRESENT ILLNESS|The patient was evaluated at that time. His vital signs were normal in the ER including blood pressure 131/81 and heart rate 67. Blood sugar per the EMS was 98. The ER physician felt that he had an episode of transient global amnesia. An MRI/MRA of the brain was performed, which showed an old left cerebellar lacune and no other abnormal areas of diffusion, weighted imaging, or enhancement.
ER|estrogen receptor|ER|262|263|HISTORY OF PRESENT ILLNESS|On _%#MMDD2003#%_, the patient had a right modified mastectomy which demonstrated infiltrating ductal carcinoma 4 cm in greatest dimension, grade 3. It extended to the skin and the closest margin was 0.2 cm. Lymphatic vascular invasion was absent. The tumor was ER negative, PR negative and HER-2/neu negative. The patient also underwent an axillary dissection at that time and 0 of 7 lymph nodes were positive for disease.
ER|estrogen receptor|ER|140|141|HISTORY OF PRESENT ILLNESS|There was vascular invasion identified as well as an area of high-grade DCIS with necrosis, comedo type. As mentioned before, the tumor was ER positive, PR negative, and HER2/neu negative. The margins were negative. The largest area of metastases was in the sentinel node that measured 1.6 cm in diameter.
ER|emergency room|ER.|207|209|HISTORY OF PRESENT ILLNESS|In the ER the patient's presenting blood pressure was in the 70s with a temperature of 95.6. En route in the rig, he did vomit and thereafter had trouble breathing. He was eventually started on BiPAP in the ER. He initially had a pH of 6.97 which improved to 7.04 after starting the BiPAP. His skin was mottled. His toes and fingers were blue, but this improved a little bit after starting BiPAP.
ER|emergency room|ER|234|235|PAST MEDICAL HISTORY|She has occasional left-sided abdominal pain as well. She had a tendency previously to diarrhea, which has diminished with reduced p.o. intake. No melena or hematochezia. She was noted to have guaiac-positive stool on digital exam by ER physician. No prior history of peptic ulcer disease. She indicates she underwent a colonoscopy approximately two years ago, which was unremarkable.
ER|emergency room|ER|131|132|DEMOGRAPHICS AND BACKGROUND INFORMATION|Evidently this patient has exhibited this threatening behavior multiple times in the past to the point where he was brought to the ER 4 or 5 times. The last time he did so 6 months ago. He was not able to determine why this occurred.
ER|emergency room|ER.|264|266|DIET|DIET: He is to follow a bland diet for the next couple of days, to not eat any fatty foods. He does not require any follow up for this but he was informed that if he has significant increase or recurrence in this abdominal pain, then he should present back to FSH ER. ACTIVITY: No restrictions. He can return to work on Monday and a note was given to him to justify the time off.
ER|emergency room|ER|145|146|LABORATORY DATA|Chest x-ray shows small bilateral effusions and some possible pulmonary congestion. No clear consolidation. CT of the chest was also done in the ER with bilateral pleural effusions, small bilateral atelectasis, some nonspecific opacities, possible pulmonary edema, a right paratracheal lymph node and 1-2 a subcarinal nodes.
ER|emergency room|ER|169|170|HISTORY OF PRESENT ILLNESS|She presented to the emergency room with a history of nausea and vomiting starting on _%#MMDD2007#%_, and was in extreme pain. She was seen in the emergency room by the ER physician. Potassium was down to 3.1. X-ray of the abdomen, flat and upright, shows air and fluid levels and dilation of the small bowel.
ER|emergency room|ER|212|213|DISCHARGE INSTRUCTIONS AND FOLLOW UP|The patient currently denies nausea and shortness of breath. She says she has a cough productive of thick white sputum. She received IV erythromycin in the emergency room as well as an albuterol neb. SATs in the ER were 90% on room air. After admission to the floor, she informed the nurse, "I am going to have a spell," all of her muscles appeared to get rigid.
ER|emergency room|ER.|169|171|PROCEDURES DONE DURING THE HOSPITALIZATION|She denied any blood or mucus in the stool. Denies any blood in the emesis. The patient because of this was concerned. The patient took 4 Imodium before she came to the ER. The patient recently had completed a course of vancomycin p.o. 3 days ago for her recurrent C. difficile. Denied any fever, chills, and no sick contact.
ER|extended release|ER|139|140|DISMISSAL MEDICATIONS|TIMI-3 flow without residual stenosis. DISMISSAL MEDICATIONS: 1. Plavix 75 mg daily for nine months. 2. Aspirin 325 mg daily. 3. Diltiazem ER 240 mg daily. 4. Lasix 40 mg daily. 5. Wellbutrin 150 mg daily. 6. Lisinopril 40 mg daily. 7. Vytorin 10/80 daily.
ER|emergency room|ER,|141|143|MEDICATIONS|He is sexually active and had an HIV test done about 2 years ago which was negative. ALLERGIES: No known drug allergies. MEDICATIONS: In the ER, the patient was given 30 mg of Toradol, 4 mg IV morphine, and 500 mg IV Levaquin. SOCIAL HISTORY: The patient does not smoke or drink. He is sexually active and works as a tech.
ER|emergency room|ER|456|457|HISTORY OF PRESENT ILLNESS|According to the husband since the fall she complained of left leg pain, was unable to move the left leg, paramedics were called and she was brought into the emergency room via ambulance where she was found to have a left hip fracture and is being admitted for management of left hip fracture. Review of systems not obtained. The patient was sleeping, wakes up to calling her name but does not give any further history and received 2 mg of morphine in the ER 3 hours ago. PAST MEDICAL HISTORY: Significant for benign hypertension, general osteoarthrosis, spondylolisthesis, osteoporosis, ASCVD, ischemic heart disease after MI postoperative _%#MM2003#%_, echo in _%#MM2004#%_ shows an anteroapical hypokinesis and estimated EF of 35% and spinal stenosis.
ER|extended release|ER|161|162|DISCHARGE MEDICATIONS|3. Klonopin 1 mg p.o. q. h.s. 4. Cymbalta 120 mg p.o. q. h.s. 5. Trazodone 600 mg p.o. q. h.s. 6. Aspirin 81 mg daily. 7. Prevacid 30 mg p.o. daily. 8. Depakote ER 500 mg p.o. q. h.s. 9. _______ 100 mg p.o. q. h.s. 10. Neurontin 300 mg p.o. t.i.d. 11. Levaquin 500 mg p.o. daily for 5 days. 12. Metformin 1000 mg p.o. b.i.d.
ER|emergency room|ER.|170|172|ASSESSMENT AND PLAN|It is pertinent in light of his underlying past cardiac history to rule him out for myocardial infarction. Will admit him to CICU. A nitro drip has been initiated in the ER. Will keep it as such to maintain systolic blood pressure more than 100. Also give him IV Lasix. Initiate ACE inhibitor and lisinopril 10 mg daily.
ER|emergency room|ER|157|158|DOB|After evaluation in the emergency room, it was felt he needed admission because of no oral intake and dehydration. He was given a 550 ml saline bolus in the ER and started on IV fluids. He was noted to have bilateral otitis media and was given IV Rocephin, 550 mg. Since admission, the patient has had one wet diaper. He is still fairly irritable, but has not been febrile.
ER|emergency room|ER|107|108|LABORATORY DATA|Strength 5/5 bilaterally, and gait within normal limits. Reflexes not done. LABORATORY DATA: Labs from the ER showed hemogram with diff within normal limits. Urine toxicology was positive for alcohol, and a GGT of 152. ASSESSMENT AND PLAN: 1. Alcohol abuse/withdrawal. Per Dr. _%#NAME#%_'s assessment.
ER|estrogen receptor|ER|236|237|HISTORY OF PRESENT ILLNESS|The specimen showed infiltrating lobular carcinoma, which measured about 0.7 x 0.6 x 0.4, grade 2, with angiolymphatic invasion and associated LCIS. The margin was clear with 6.0 mm from nearest margin. Tumor revealed strongly positive ER and negative PR. Her ......was negative. Two sentinel nodes were taken, which showed no tumor. The patient is staged at stage 1 breast cancer, left sided T1 N0 M0 infiltrating lobular carcinoma with an ER receptor positive.
ES|(drug) ES|ES|136|137|DISCHARGE MEDICATIONS|2. Triamterene with hydrochlorothiazide 75/50 p.o. q. day. 3. Loratadine 10 mg p.o. q. day. 4. Fenofibrate 50 mg p.o. q. day. 5. Nexium ES 40 mg p.o. b.i.d. 6. Hydrocortisone 1% cream to affected area b.i.d. 7. MetroCream 0.75% to affected area b.i.d. 8. Glipizide 5 mg p.o. b.i.d. 9. Atenolol 25 mg q. day.
ES|extra strength|ES|112|113|MEDICATIONS|9. Risperdal 0.5 mg p.o. q.h.s. 10. _________ 20 mg p.o. q.h.s. 11. Spiriva 18 mcg one puff q. day. 12. Tylenol ES one to two p.o. q.6 hours p.r.n. 13. Zoloft 50 mg p.o. q. day. ALLERGIES: No known drug allergies. FAMILY HISTORY: Father died of TB young. Sister died of congestive heart failure at an elderly age.
ES|extra strength|ES|126|127|MEDICATIONS|4. Aciphex 20 mg p.o. daily. 5. Lasix 40 mg p.o. b.i.d. 6. Paxil 20 mg p.o. daily. 7. Synthroid 88 mcg p.o. daily. 8. Tylenol ES 1-2 tabs p.o. p.r.n. 9. Macrobid 100 mg p.o. b.i.d. The patient had previously been on Coumadin, which has been discontinued.
ES|extra strength|ES|190|191|DISCHARGE MEDICATIONS|The patient was seen and followed by inpatient Psychiatry. They recommended that she be transferred to inpatient Psychiatry for treatment and evaluation. DISCHARGE MEDICATIONS: 1. Augmentin ES 600, 900 mg p.o. b.i.d. x 13 days for pneumonia. 2. Ibuprofen 400 mg p.o. q. 6 h p.r.n. pain. DISCHARGE INSTRUCTIONS: 1. She is being transferred to inpatient Psychiatry at United Hospital.
ES|extra strength|ES|101|102|MEDICATIONS|7. Lomotil. 8. Fentanyl patch 150 mcg q. 72h. 9. Lasix 40 mg. 10. Zofran 4-8 mg q. 6-8h. 11. Ritalin ES 25 mg p.o. t.i.d. 12. Valium 10 mg p.o. q. 6h. SOCIAL HISTORY: The patient denies smoking, drinking, or other drug use.
ES|ejection fraction:EF|ES|172|173|HISTORY OF PRESENT ILLNESS|She also had coronary angiography, showing severe coronary artery disease, and she was also worked up for possible pulmonary embolism at this time, which was negative. Her ES by angiography was 65%, and there was moderate mitral regurgitation at this time. She presents at this time for elective coronary artery bypass grafting.
ES|extra strength|ES|135|136|MEDICATIONS|3. Timoptic 0.5% one drop OU b.i.d. 4. Coumadin 5 mg on all days except 2.5 mg on Mondays, 5. Peri-Colace one tablet b.i.d. 6. Tylenol ES 500 mg two tablets Q6 hours prn. 7. Eye moisturizing drops. 8. Vicodin 1-2 tablets every 4 hours as needed. 9. Pepto-Bismol prn. 10. Loperamide prn. 11. Meclizine prn.
ES|extra strength|ES|92|93|DISCHARGE MEDICATIONS|DISCHARGE PLAN: Thatcher was discharged on _%#MMDD2005#%_. DISCHARGE MEDICATIONS: Augmentin ES 600 1.5 cc twice daily for six additional days. Mrs. _%#NAME#%_ will follow-up with Thatcher at Fairview _%#CITY#%_ Clinic in one week.
ES|extra strength|ES|161|162|PLAN|EXTREMITIES: Well perfused. Chest x-ray shows infiltrate in the left lower lobe. ASSESSMENT: Left lower lobe pneumonia. PLAN: 1) Discharge to home. 2) Augmentin ES x seven days. 3) Follow up with primary-care physician _%#MM#%_ _%#DD#%_ or _%#MM#%_ _%#DD#%_. 4) Activity as tolerated. 5) Plan discussed with Dr. _%#NAME#%_.
ES|extra strength|ES|120|121|MEDICATIONS|6. Advair 500/50 one puff b.i.d. 7. Tricor 145 mg daily. 8. Toprol XL 100 mg daily. 9. Demadex 40 mg daily. 10. Vicodin ES one b.i.d. p.r.n. back pain. 11. Hydralazine 50 mg four times daily. 12. Flonase two sprays q nares q day. 13. Potassium chloride 20 mEq daily.
ES|extra strength|ES|148|149|MEDICATIONS|7. Multivitamin one capsule p.o. q. day. 8. Neurontin 300 mg p.o. t.i.d. 9. Protonix 40 mg p.o. b.i.d. 10. Synthroid 50 mcg p.o. daily. 11. Tylenol ES two tabs p.o. t.i.d. 12. Vitamin D 400 international units two tabs p.o. q. day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Nonsmoker, nondrinker.
ES|extra strength|ES|150|151|MEDICATIONS|12. Reglan 10 mg b.i.d. 13. Prevacid 30 mg daily. 14. Senokot S 1 tablet b.i.d. 15. Augmentin 875/125 mg 1 tablet b.i.d. for 12 more days. 16. Megace ES 625 mg daily, recently started. REVIEW OF SYSTEMS: She denies recent bleeding. She reports easy bruising. She has a history of paraplegia with loss of sensation from lower torso down.
ES|extra strength|ES|158|159|IMPRESSION|IMPRESSION: 1. Eight-month-old with initially diagnosed bronchiolitis which developed into a right middle lobe pneumonia. She will be discharged on Augmentin ES 600 mg per 5 ml, 300 mg p.o. b.i.d. x10 days. Of note, this is a change since she had been treated with Unasyn IV in the hospital.
ES|extra strength|ES|128|129|HOME MEDICATIONS|2. Vitamins one daily 3. Lanseptic barrier cream topical t.i.d. 4. Senokot one tablet daily 5. Baclofen 15 mg t.i.d. 6. Tylenol ES two orally q.i.d. p.r.n. PHYSICAL EXAMINATION: Shows a very pleasant and cooperative 65-year-old female.
ES|ejection fraction:EF|ES|177|178|HOSPITAL COURSE|An echo was obtained. It showed moderate-to-severe left atrial enlargement. Mild left ventricular dilatation, mild mitral regurgitation. Moderate right atrial dilatation and an ES of 60%. DISCHARGE PLAN: The patient discharged in stable condition on ferrous gluconate 320 mg one tablet p.o. b.i.d. She is to follow with Dr. _%#NAME#%_ _%#NAME#%_ at Smiley's Clinic in one week, _%#MM#%_ _%#DD#%_, 2002 at 2:30 p.m.
ES|extra strength|ES|201|202|DISCHARGE MEDICATIONS|1. Coumadin 5 mg p.o. tonight, per Dr. _%#NAME#%_'s instructions, and then INR tomorrow, with Coumadin dose as per Dr. _%#NAME#%_'s instructions. 2. Lovenox 100 mg SQ b.i.d. (5-day supply). 3. Vicodin ES 1 tab p.o. q.4-6h. p.r.n. pain (30-tab supply). 4. Colace 10 mg p.o. b.i.d. 5. Flexeril 10 mg p.o. t.i.d. p.r.n.
ES|extra strength|ES|166|167|PROCEDURES DONE|3. Adenosine thallium which showed a profusion defect. 4. Echocardiogram which showed mild to moderate LV dilatation. Moderate to severely decreased LV function with ES of about 35%. Mild mitral regurg. Large region of akineses to dyskinesis involving the inferior apical segments. HISTORY OF PRESENT ILLNESS: This is a 47-year-old man with a history of coronary disease as well as coronary artery bypass graft, CVA and atrial fibrillation who was transferred from an outside hospital at _%#CITY#%_ _%#CITY#%_ with two to three day history of angina.
ES|ejection fraction:EF|ES|266|267|HISTORY OF PRESENT ILLNESS|Two weeks ago the patient was hospitalized with similar pain. At that time, she had been go-carting and at the time she had some electrocardiogram changes with T wave inversion in V2 through V4 and borderline prolonged QT transthoracic echo at that time revealed an ES of 35%. Post hospitalization the last time the patient reports she had cardiac magnetic resonance imaging which showed ejection fraction of approximately 50%, however, I do not have documentation of that at this time and possible resolving myocardial contusion.
ES|extra strength|ES|161|162|DISCHARGE MEDICATIONS|2. Diabetes mellitus. The patient's diabetes was well controlled during his stay. He remained on tube feeds during his stay. DISCHARGE MEDICATIONS: 1. Augmentin ES 600 mg per teaspoon, 1-1/2 tsp per G-tube b.i.d. 2. Vitamin C 500 mg G-tube q.d. 3. Avandia 4 mg G-tube q.d.
ES|extra strength|ES|346|347|REASON FOR HOSPITALIZATION|With rest and pulmonary cares, _%#NAME#%_ had significant improvement and was discharged in stable condition on _%#MM#%_ _%#DD#%_, 2002. DISCHARGE MEDICATIONS: Prednisone 40 mg p.o. q.d. x 7 days, Combivent 2 puffs q.i.d., Serevent 2 puffs b.i.d., Flovent 2 puffs b.i.d., Lasix 40 mg p.o. q.d. p.r.n., lorazepam 0.5 mg p.o. q.6h. p.r.n., Vicodin ES 7.5/750 1-2 q.4-6h. p.r.n., quinine sulfate 325 mg p.o. q.d. p.r.n., Prilosec 20 mg p.o. b.i.d., Prozac 20 mg p.o. q.d. FOLLOW UP: She is to see Dr. (_______________) in clinic in 1 week.
ES|extra strength|ES|138|139|DISCHARGE MEDICATIONS|4. Senokot 1 tablet p.o. b.i.d. 5. Effexor 37.5 mg p.o. q.d. 6. Nicotine patch 7 mg q.d. x 1 week. 7. Protonix 40 mg p.o. q.d. 8. Tylenol ES 1-2 tablets p.o. q.4h. p.r.n.
ES|extra strength|ES|159|160|HOSPITAL COURSE|Otitis media has cleared and the parapharyngeal swelling is markedly decreased. She will be discharged and followed as an outpatient. She will be on Augmentin ES 600 a teaspoon b.i.d. and Floxin Otic.
ES|extra strength|ES|245|246|DISCHARGE MEDICATIONS|She was held in the hospital just for pain management, and when she was tolerating p.o. pain medicine very well, she was deemed ready for discharge. CONDITION ON DISCHARGE: Stable. DISCHARGE MEDICATIONS: 1. Continue home medications. 2. Vicodin ES 1-2 p.o. q.4-6h. p.r.n. pain. DISCHARGE ACTIVITY LEVEL: Toe touch weightbearing with walker ambulation.
ES|extra strength|ES|137|138|DISCHARGE INSTRUCTIONS|CONDITION ON DISCHARGE: Stable. DISCHARGE INSTRUCTIONS: 1. He is to continue all his home medications. In addition, he will take Vicodin ES 1-2 p.o. q.4-6h p.r.n. pain, and Vistaril 50 mg p.o. q.4-6h p.r.n. 2. He is to resume his prior home diet. 3. Activities will be to use his sling, except when he is in therapy, which he will start on Monday.
ES|extra strength|ES|187|188|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Minocycline 100 mg p.o. q.d. 2. Prednisone 5 mg p.o. q.d. 3. Methocarbamol 750 mg p.o. t.i.d. 4. Effexor-XR 75 mg p.o. q.d. 5. OxyContin 40 mg b.i.d. 6. Vicodin ES 750 mg p.o. q.6h. p.r.n. 7. Imitrex 100 mg p.o. b.i.d. p.r.n. 8. Lasix 40 mg p.o. q.d. 9. Prinivil 5 mg p.o. q.d. 10. Bextra 20 mg p.o. q.d.
ES|extra strength|ES,|149|151|MEDICATIONS|7. Nitro, 0.4 p.r.n. 8. Coumadin, variable dose. 9. Amaryl, 6 mg 1 1/2 tablets q.p.m. 10. Zantac, 150 mg q. day. 11. Zocor, 20 mg q.h.s. 12. Tylenol ES, 2 q.i.d. p.r.n. SOCIAL HISTORY: She is married. Three pregnancies, two children. Does not smoke or drink. FAMILY HISTORY: Father - MI.
ES|extra strength|ES,|262|264|MEDICATIONS|4. Treated hypothyroidism. 5. Dyslipidemia. 6. Hypertension. 7. Recent depressive symptoms, started on Celexa. ALLERGIES: No known medical allergies. MEDICATIONS: Toprol, Cozaar, Synthroid, Centrum Silver, Ambien, calcium, magnesium, Actonel, oxycodone, Tylenol ES, Senna, Nexavar, OxyContin and Decadron, as well as Celexa. PHYSICAL EXAMINATION: GENERAL: On examination today, the patient is alert and oriented x3.
ES|extra strength|ES|219|220|DISCHARGE MEDICATIONS|4. Weightbearing as tolerated without restrictions using walker and physical therapy and nursing staff to do home visits. DISCHARGE MEDICATIONS: 1. Lidoderm patch 1 to 3 patches topically every 24 hours #30. 2. Tylenol ES 3 times daily as needed. 3. Calcium carbonate with vitamin D 1250 mg 3 times a day. 4. Protonix 40 mg daily. 5. Risedronate 35 mg once weekly.
ES|extra strength|ES|245|246|DISCHARGE MEDICATIONS|She is to follow up with Dr. _%#NAME#%_ in 1-2 weeks, to follow up with myself in the next 1-2 months for a complete physical, with arrangements made for a CT of the chest in approximately 3 months as a follow up. DISCHARGE MEDICATIONS: Vicodin ES 1 p.o. q 6 hours p.r.n., #15. Ibuprofen 800 mg every 8 hours with food, #30. Zomig ZMT 5 mg, one q 2 hours p.r.n. migraines, max 10 mg per day.
ES|extra strength|ES|83|84|DISCHARGE MEDICATIONS|2. Augmentin 875 mg p.o. b.i.d. x7 days. 3. Enalapril 5 mg p.o. q. day. 4. Niaspan ES 500 mg p.o. q. day. 5. Protonix 40 mg p.o. q. day. 6. Benadryl p.r.n. itching. 7. Tylenol p.r.n. pain, fever. 8. Vicodin 1 tablet p.o. q. 6 hours p.r.n. pain, 30 days, no refills.
ES|extra strength|ES|166|167|DISCHARGE MEDICATIONS|5. Fer-in-Sol 20 mg p.o. twice daily. 6. Albuterol 2.5 mg nebs 4 times daily. 7. Mucomyst 4 mL nebs 4 times daily. 8. Pulmozyme 2.5 mg nebs twice daily. 9. Augmentin ES 600 mg p.o. b.i.d. x7 days. 10. Calciferol 400 IU p.o. daily. FOLLOWUP INSTRUCTIONS: _%#NAME#%_ is to follow up with Dr. _%#NAME#%_ _%#NAME#%_ of Behavioral Pediatrics.
ES|extra strength|ES|215|216|DISCHARGE MEDICATIONS|5. Lisinopril 20 mg p.o. b.i.d. for hypertension. 6. Viactiv tablets chew one tablet p.o. t.i.d. for calcium supplementation. 7. Tylenol with Codeine #3 one to two tablets p.o. p.r.n. q.4 hours for pain. 8. Tylenol ES 1000 mg p.o. q.4 hours p.r.n. for pain. 9. Docqlace for constipation 100 mg p.o. b.i.d. 10. Clotrimazole 1% cream topical b.i.d. to fungal rash.
ES|extra strength|ES|139|140|MEDICATIONS|4) Glucophage 500 mg two tabs b.i.d. 5) Pravachol 40 mg daily. 6) Clonazepam 0.5 mg two h.s. 7) Trazodone 50 mg one or two h.s. 8) Vicodin ES p.r.n. pain. 9) Clarinex 5 mg one daily. REVIEW OF SYSTEMS: HEENT: No recent change in vision or hearing.
ES|extra strength|ES|177|178|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Tylenol 120 mg p.o./PR q.4-6h p.r.n. pain/fever. 2. Ibuprofen 80 mg p.o. q.6h p.r.n. pain/fever. 3. Iron 22 mg elemental iron p.o. b.i.d. 4. Augmentin ES 360 mg p.o. b.i.d. x 10 days. DISCHARGE DIAGNOSIS: Adenitis.
ES|extra strength|ES|221|222|DISCHARGE MEDICATIONS|Her nausea resolved, and she was able to be discharged home with no significant neurologic sequelae whatsoever on _%#MMDD2003#%_. DISCHARGE MEDICATIONS: 1) Reglan 10 mg one tablet p.o. q.6- 8.h. p.r.n. nausea. 2) Vicodin ES 7.5/750 one tablet p.o. q.6-8.h. p.r.n. pain. FOLLOW-UP: She is to follow-up with me, her primary medical doctor, in one week.
ES|extra strength|ES|130|131|MEDICATIONS|MVI 5 cc daily. ProMod one tablespoon daily down the G tube. Calcium carbonate 1000 mg mixed with fluids down the G tube. Vicodin ES one per G tube one hour prior to bath. Ditropan 10 mg per tsp. down the G tube three times daily. For diarrhea, Imodium will be used p.r.n. For constipation, bisacodyl suppositories.
ES|extra strength|ES|121|122|DISCHARGE MEDICATIONS|3. Toprol XL 200 mg p.o. q.d. 4. Atacand 8 mg p.o. q.d. 5. Lasix 20 mg p.o. b.i.d. 6. Aspirin 81 mg p.o. q.d. 7. Tylenol ES 1000 mg p.o. q.8h. p.r.n. pain. REVIEW OF SYSTEMS: The patient still has a mild cough.
ES|extra strength|ES|154|155|MEDICATIONS|He has some wheezing after factor IX treatments (Feiba combination). MEDICATIONS: 1. Vioxx 25 mg b.i.d. 2. Vitamin B12 1000 mg p.o. every day. 3. Tylenol ES for pain. 4. Tylenol #3 for pain. 5. NovoSeven p.r.n. SOCIAL HISTORY: The patient does not smoke or drink on a regular basis.
ES|extra strength|ES|152|153|MEDICATIONS|ALLERGIES: Allergies none. MEDICATIONS: 1. Synthroid .05 mg q day. 2. Gemfibrozil 600 mg bid. 3. Atenolol 25 mg a day. 4. Imdur 30 mg a day. 5. Tylenol ES 1-2 qid prn. 6. Aspirin 81 mg q day. 7. Nitroglycerin 0.4 mg prn. 8. Tequin 400 mg q day given for UTI. SOCIAL HISTORY: She is a widow, smokes 1/4 pack a day, does not drink.
ES|extra strength|ES|206|207|CURRENT MEDICATIONS|No cancer or heart disease. NO KNOWN DRUG ALLERGIES. Has bee sting allergy, Steri-Strips allergy CURRENT MEDICATIONS: 1. Diovan 80 mg once a day 2. Estradial 1 mg once a day 3. Prn Benadryl 4. Prn Excedrin ES SOCIAL HISTORY: Divorced, works as an assembler at General Dynamics disk drive.
ES|extra strength|ES|116|117|MEDICATIONS|6. Esomeprazole (Nexium) 40 mg daily. 7. Fosrenol 1000 mg with meals and snacks. 8. Nephrocaps one daily. 9. Megace ES 625 mg daily. 10. Alprazolam 1 mg t.i.d. 11. Cyclobenzaprine 10 mg t.i.d. p.r.n. 12. Lortab 7.5/500 mg, 1 to 2 tablets q. 6-8 hours p.r.n.
ES|extra strength|ES|140|141|DISCHARGE MEDICATIONS|2. Toprol-XL 25 mg p.o. daily. 3. OxyContin CR 10 mg p.o. b.i.d. 4. Protonix 20 mg p.o. b.i.d. 5. Effexor XR 150 mg p.o. daily. 6. Excedrin ES 2 tablets p.o. q.6 h. as needed for pain.
ES|extra strength|ES|156|157||Cultures were sent and the patient is doing great today on _%#MMDD2006#%_ and he will be discharge home. He will be sent home on oral antibiotics Augmentin ES 600 and he will be asked to follow with his pediatrician on the day after discharge and also with ENT a month from now.
ES|extra strength|ES|173|174|DISCHARGE MEDICATIONS|11. Dexamethasone with viscous Lidocaine swish down feeding tube. 12. Temazepam 7.5 mg p.r.n. sleep. 13. Oxycodone 5 mg tablets every four hours for pain p.r.n. 14. Tylenol ES p.r.n. to a maximum of 4 gm a day. 15. Plaquenil 200 mg once a day. PROCEDURES: MRI/MRA of the brain. HOSPITAL COURSE: The patient was admitted with an increasing confusional state and dizziness with inability to walk straight; these symptoms were of fairly sudden onset.
ES|extra strength|ES|134|135|MEDICATIONS|DISCHARGE DIAGNOSIS: Pneumonia. MAJOR PROCEDURE: Chest x-ray. DISCHARGE DIET: Regular. ACTIVITY: As tolerated. MEDICATIONS: Augmentin ES 600 mg p.o. b.i.d. x10 days. His followup is with Dr. _%#NAME#%_ in 1-2 weeks as needed.
ES|extra strength|ES.|171|173|MEDICATIONS|MEDICATIONS: 1. Milk of magnesia. 2. Actonel. 3. Loratadine. 4. Lorazepam. 5. Toprol. 6. Prevacid. 7. Albuterol. 8. Potassium chloride. 9. Calcium. 10. Lasix. 11. Tylenol ES. 12. Lipitor. Doses are not immediately available. SOCIAL HISTORY: The patient resides in a chronic nursing home facility.
ES|extra strength|ES|178|179|MEDICATIONS|6. Aspirin 81 mg p.o. daily. 7. Potassium 20 mEq p.o. t.i.d. 8. Neurontin 300 mg p.o. t.i.d. 9. Gengraf 100 mg p.o. b.i.d. 10. Polysaccharide-iron 150 mg p.o. b.i.d. 11. Tylenol ES 500 mg p.o. b.i.d. 12. Bumex 1 mg p.o. b.i.d. 13. CellCept 1000 mg p.o. b.i.d. 14. Nitro patch 0.4 mg p.o. q.a.m. x12 hours and then remove.
ES|extra strength|ES|136|137|DISCHARGE MEDICATIONS|5. Lidoderm patch 5% to right knee on 12 hours, off 12 hours, #15, no refill. 6. Synthroid 75 mcg 1 p.o. daily, #30, no refill. 7. Tums ES 1 p.o. b.i.d., do not refill. 8. Fosamax 70 mg 1 p.o. weekly, #4, no refill. 9. Bactrim single strength 1 p.o. daily, we did not refill.
ES|ejection fraction:EF|ES|198|199|BONE MARROW TRANSPLANT WORKUP|3. Retinal hemorrhage. 4. Cortical blindness. 5. Encephalopathy. 6. Pulmonary nodules; possible fungal infection. BONE MARROW TRANSPLANT WORKUP: Echo, _%#MMDD2007#%_, shows no valvular vegetations. ES of 70%. Chest CT scan, _%#MMDD2007#%_, shows bilateral infiltrates tree-in-bud opacities. Chest CT, _%#MMDD2007#%_, shows near resolution of ground-glass opacities in the superior segments of lower lobes and posterior segments right upper lobe likely post-infections.
ES|extra strength|ES|185|186|MEDICATIONS|Mammogram done in _%#MM#%_ was normal. MEDICATIONS: 1. Trazodone 50 mg one at HS 2. Actonel 35 mg per week 3. Calcium plus vitamin D. 600/200 two daily 4. Multivitamin daily 5. Vicodin ES one to two PO Q day prn. arthritis pain 6. Atenolol 50 mg one PO Q day 7. Norvasc 5 mg a day 8. Protonix 40 mg daily
ES|extra strength|ES|266|267|MEDICATIONS|This was accomplished on hospital day #1 without complication. She was kept in the hospital for use of an interscalene catheter, and when the catheter had become ineffective she was deemed ready for discharge. CONDITION ON DISCHARGE: Stable. MEDICATIONS: 1. Vicodin ES one to two p.o. q.4-6h p.r.n. pain 2. Continue home medications ACTIVITIES/DIET: Keep dressing in place for two more days, then remove it and cover the incision with Betasept.
ES|extra strength|ES|121|122|DISCHARGE MEDICATIONS|6. Protonix 40 per day. 7. Timolol eyedrops 0.5% 1 drop per day. 8. Vicodin 1-2 q. 4-6 for breakthrough pain. 9. Tylenol ES for less severe pain. 10. Fiber supplements to deal with her constipation. DISPOSITION: Patient was discharged to Masonic home to be followed there by Quello Clinic.
ES|extra strength|ES|187|188|MEDICATIONS|PAST MEDICAL HISTORY: 1. Stent placed in 1993. 2. Back surgery x 2 about 20 years ago, about one year apart. MEDICATIONS: 1. Lipitor 40 mg one day, and 20 mg the next day. 2. Glucosamine ES with chondroitin 1 b.i.d. 3. Aspirin 325 mg q.d. 4. Atenolol 50 mg q.a.m. 5. Sulindac 200 mg b.i.d. 6. Aciphex 20 mg q.d. 7. Ranitidine 75 mg q.h.s.
ES|extra strength|ES|154|155|DISCHARGE MEDICATIONS|11. Lorazepam 1 mg t.i.d. prn. 12. Senokot two tablets daily HS 13. Milk of Magnesia one ounce Q 2 hours prn. 14. Ibuprofen 600 mg daily prn. 15. Vicodin ES one tablet Q4H. prn. or plain Tylenol 650 mg. Q 4 hours prn. 16. Darvocet N. 100 q.i.d. prn.
ES|extra strength|ES|139|140|DISCHARGE MEDICATIONS|3. Lithium 300 mg p.o. daily 4. Clarinex 5 mg p.o. daily p.r.n. 5. Ambien 10 mg p.o. at h.s. 6. Fiorinal 1 p.o. p.r.n. headache 7. Vicodin ES 1 p.o. q.6h. p.r.n. 8. Nasacort AQ 1 spray each nostril p.r.n. 9. Zovirax cream topically t.i.d. p.r.n. 10. Entex LA p.o. daily FOLLOW-UP: The patient will make an appointment with Dr. _%#NAME#%_ in 7 to 10 days.
ES|extra strength|ES,|159|161|MEDICATIONS|3. Vitamin E 4. Neuro replete which is apparently an over the counter preparation, probably gingko 5. Zinc products 6. Several Tylenol products including P.M. ES, Sinus at least 7. Also Vicodin which he had stopped taking two days prior to admission. 8. He was also taking some Zantac. 9. He had several different antihistamines.
ES|extra strength|ES.|113|115|MEDICATIONS|6) Back surgery in _%#MM#%_, 2003. MEDICATIONS: 1) Cozaar 100 mg per day. 2) Toprol XL 50 mg per day. 3) Vicodin ES. 4) Neurontin. 5) Celebrex. 6) Glucosamine. 7) She denies other over-the-counter products. HEALTH HABITS: Little exercise because of back pain. No alcohol, no tobacco.
ES|extra strength|ES|164|165|DISCHARGE MEDICATIONS|2. Hypertension. 3. Some degree of depression but she is not on any medication for that and (_______________) . DISCHARGE MEDICATIONS: Dyazide 1 p.o. q.d., Tylenol ES one to two p.o. q.6h. p.r.n., same q.4-6h. p.r.n. pain, Percocet 1 to 2 p.o. q.4-6h. p.r.n. pain. Total acetaminophen 3 grams per 24 hours, not to exceed this limit.
ES|extra strength|ES.|164|166|CONSULTANTS|DISCHARGE MEDICATIONS: 1. Macrobid SR 100 mg p.o. b.i.d. for 1 week then q.h.s., #45 given with 2 refills. 2. Metoprolol. 3. Robaxin. She was given #50. 4. Vicodin ES. She was given #25. 5. Protonix. 6. Amitriptyline. 7. Sodium bicarbonate. 8. Colace. 9. Imodium as before. DISCHARGE INSTRUCTIONS: 1. See Dr. _%#NAME#%_ in 1 week.
ES|extra strength|ES|173|174|DISCHARGE MEDICATIONS|2. Infectious disease: _%#NAME#%_ has a partially treated otitis media and sinusitis and was continued on Augmentin for a 10-day course. DISCHARGE MEDICATIONS: 1. Augmentin ES 600 mg/5 mL six milliliters p.o. b.i.d. x8 days. 2. Clonidine (0.1 mg tablets) 1/4-tablet p.o. daily. FOLLOW UP: Followup with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2004, and with audiology as soon as possible.
ES|extra strength|ES|182|183|MEDICATIONS|MEDICATIONS: 1. Guaifenesin 600 mg b.i.d. prn. 2. Albuterol two puffs q.i.d. prn. 3. Atrovent two puffs q.i.d. prn. 4. Lorazepam 1 mg t.i.d. prn. 5. Darvon 65 mg q4h prn. 6. Vicodin ES one q.i.d. prn. 7. Norvasc 5 mg daily. 8. Thyroid extract 120 mg daily. 9. Prednisone 5 mg daily. 10. Premarin 0.625 mg daily.
ES|extra strength|ES|169|170|CURRENT MEDICATIONS|10. Colace 100 mg p.o. b.i.d. 11. Duragesic patch 75 mcg q.48h. 12. MiraLax 17 grams q. day 13. Vicodin 5/500 two tablets q.4h. p.r.n. for breakthrough pain 14. Tylenol ES 2 tablets q.6h. p.r.n. for fever ALLERGIES: Penicillin, sulfa, Ultram, and Cipro. HABITS: The patient is not a cigarette smoker and does not drink alcohol.
ES|extra strength|ES,|284|286|CURRENT MEDICATION|3. Partial colectomy. Patient is not sure why he had that done, but looking back at his old chart, it does look like he had some gastroparesis and for that he had that done. ALLERGIES: MRI dye, sulfa and Trilafon. CURRENT MEDICATION: Includes Lisinopril, atenolol, Prevacid, Depakote ES, Seroquel, Questran, trazodone, NPH insulin and regular insulin sliding scale, Detrol, calcium, Remeron and Vicodin. None of the dosing of the medications are available at this point.
ES|extra strength|ES|149|150|DISCHARGE MEDICATIONS|6. Asthma. DISCHARGE MEDICATIONS: 1. Same as on admission, except hold aspirin. 2. She is also going to get Toradol 10 mg one po q6h prn. 3. Vicodin ES one po q6h prn. DISCHARGE FOLLOW-UP: Follow up with Dr. _%#NAME#%_ in one week. HOSPITAL COURSE: Please see dictated history and physical for the patient's initial presentation.
ES|extra strength|ES|185|186|DISCHARGE MEDICATIONS|She has +1 ankle edema. LABORATORY DATA: On discharge - Sodium is 141, potassium 4.1, chloride 103, cO2 30, BUN 31, creatinine 1.3. BNP 336, INR 1.85. DISCHARGE MEDICATIONS: 1. Tylenol ES two p.o. q.i.d. 2. Aricept 10 mg p.o. q day 3. Coreg 37.5 b.i.d. 4. Lasix 20 mg p.o. q day 5. Lisinopril 2.5 mg q day 6. Lantus insulin 18 units subcu q a.m.
ES|extra strength|ES|205|206|ALLERGIES|2. Follow up with Dr. _%#NAME#%_ in 4 days, on Tuesday, in the neurosurgery clinic for staple removal. 3. Continue all home medications including ASA 81 mg p.o. q.day. 4. Discharge medications are Vicodin ES and Senna-S. 5. Return if any weakness, numbness, speech problems, mental status changes, or vision problems. 6. No lifting greater than 15 pounds for 6 weeks.
ES|extra strength|ES,|344|346|HOSPITAL COURSE|HOSPITAL COURSE: The patient is a 44-year-old female who was admitted on _%#MMDD2006#%_ for worsening dyspnea which was thought to be multifactorial, pulmonary edema and pleural effusion secondary to worsening cardiac status. She was initiated on IV Lasix and had an echocardiogram done the same night which showed a significant decline in the ES, septal and global hypokinesis mainly in the septum in the left ventricle. Cardiology was consulted. The patient had some improvement in her symptoms status post thoracocentesis on _%#MMDD#%_ in the a.m. and on diuresis.
ES|extra strength|ES|135|136|DISCHARGE MEDICATIONS|8. Advair 500/50 one puff b.i.d. 9. Spiriva 18 mcg one capsule inhaled daily. 10.Calcium with vitamin D 500/200 p.o. b.i.d. 11.Vicodin ES 7.5/750 one p.o. q.4-6h p.r.n. 12.Albuterol nebulizers q.i.d. p.r.n. 13.Albuterol MDI two puffs q.4h p.r.n. 14.Ativan 1 mg p.o. q.6h p.r.n. HOSPITAL COURSE: The patient is a 64-year-old female who came to the hospital complaining of progressively worsening shortness of breath.
ES|extra strength|ES|158|159|MEDICATIONS|3. Ferrous gluconate 324 mg p.o. every day. 4. Synthroid 88 mcg p.o. every day. 5. Flomax 0.4 mg p.o. every day. 6. Aspirin 325 mg p.o. every day. 7. Tylenol ES 500 mg p.o. q.4h. p.r.n. 8. Enablex 7.5 mg p.o. every day. REVIEW OF SYSTEMS: CONSTITUTIONAL: Energy has been good. He has been eating well, no fevers or chills.
ES|extra strength|ES|189|190|DISCHARGE MEDICATIONS|6. Mineral oil three tablespoons mixed with juice one hour prior to breakfast. 7. Synthroid 0.088 mg per os every day. 8. Climara 0.1 mg per day patch, change every three days. 9. Gaviscon ES three to four tabs with hot water four times a day as occasion requires with meals and bedtime. 10. Bentyl 20 mg per os three times a day as occasion requires.
ES|extra strength|ES|206|207|MEDICATIONS|The remainder of review of systems is negative. ALLERGIES: ACE INHIBITORS, BIAXIN, CEPHALOSPORINS, IVP DYE, SEPTRA, SODIUM PENTHOTHAL, VOLTAREN. MEDICATIONS: 1) Tylenol #3 one to two p.o. p.r.n. 2) Tylenol ES two p.o. q6h p.r.n. 3) Combivent inhaler two puffs q.i.d. 4) Ecotrin one p.o. q day. 5) Detrol LA 4 mg q day. 6) Diovan 160 mg q day.
ES|extra strength|ES|127|128|DISCHARGE MEDICATIONS|10. Aspirin 325 mg daily. 11. Robaxin 500 mg tablets one tablet every day 8 hours p.r.n., #15 tablets, no refills. 12. Vicodin ES one tablet q.i.d. p.r.n. only, #16 with no refills. PRINCIPAL DIAGNOSES: 1. Acute intractable low back pain. 2. Extensive osteoarthritis of lumbar spine and degenerative disc disease, but nothing acute on the MRI.
ES|extra strength|ES,|285|287|CURRENT MEDICATIONS|CURRENT MEDICATIONS: Include Combivent MDI, 2 puffs q.i.d.; Flovent inhaler, one puff b.i.d.; isosorbide, 40 mg, one orally daily; hydrochlorothiazide, 25 mg, one orally daily; atenolol, 50 mg, one orally b.i.d.; Norvasc, 10 mg, one orally daily; Valtrex, 500 mg orally daily; Tylenol ES, one orally q. 6 hours p.r.n. for her degenerative joint symptoms. Most recently, she has been on Keflex 500 mg b.i.d. SOCIAL HISTORY: She has been widowed for about the past four years.
ES|extra strength|ES|145|146|DISCHARGE MEDICATIONS|2. Lovenox 70 mg subcutaneously every 12 hours as directed. 3. Jasmine one tablet daily 4. Coumadin 2 mg tablets to take as directed. 5. Vicodin ES one tablet every four hours prn. or but not both of them 6. Tylenol two tablets Q4 hours prn. 7. Milk of Magnesia one ounce prn.
ES|extra strength|ES|187|188|HOSPITAL COURSE|Asymmetric wheezing was noted on several exams but lateral decubitus films were obtained, which revealed no evidence for obstructing foreign body. 2. Otitis media. He was given Augmentin ES during this hospitalization and will complete a 10-day course of antibiotics following discharge. 3. Failure to thrive. Growth charts were obtained from his primary care clinic, which reveals no weight gain for at least 3 months prior to this admission.
ES|extra strength|ES|287|288|DISCHARGE MEDICATIONS|DISCHARGE PLAN: _%#NAME#%_ _%#NAME#%_ was noted to be clinically well on _%#MM#%_ _%#DD#%_, 2005, and was discharged home with the following discharge plan: DISCHARGE MEDICATIONS: 1. Albuterol 2.5 mg, nebulized q.4 h. as needed. 2. Prednisolone 8 mg p.o. b.i.d. for 4 days. 3. Augmentin ES 300 mg p.o. b.i.d. x8 days to complete the 10-day course. 4. Pulmicort 500 mcg nebulized b.i.d. FOLLOW UP: He will follow up with his primary care physician, Dr. _%#NAME#%_ _%#NAME#%_ 2 days following discharge.
ES|extra strength|ES|137|138|MEDICATIONS AT HOME ARE|2. She has osteoporosis 3. Osteoarthritis 4. Hypothyroidism MEDICATIONS AT HOME ARE: 1. Vicodin 1-2 tabs every 4 hours p.r.n. 2. Tylenol ES two tabs p.o. q. four hours while awake on a p.r.n. basis. 3. Zinc one tab daily 4. Premarin 0.625 p.o. daily 5. Synthroid 0.075 daily 6. One multivitamin daily
ES|extra strength|ES|148|149|ADMISSION EXAMINATION|_%#NAME#%_ then began eating cake in her room and had no problems with that. She was discharged to home on _%#MMDD2005#%_ with Augmentin suspension ES 600 mg per 5 mls one teaspoon p.o. b.i.d. times seven days. She will taken Tylenol p.r.n. for pain and will follow-up in the clinic in one week for a recheck.
ES|extra strength|ES|144|145|DISCHARGE MEDICATIONS|6. Niaspan 1,000 mg h.s. 7. Claritin 10 mg p.o. once day p.r.n. 8. Potassium Chloride 200 mEq p.o. b.i.d. 9. Aspirin 81 mg per day. 10. Tylenol ES 1,000 mg p.o. q6hours p.r.n. pain. FOLLOW-UP: 1. INR on _%#MMDD2005#%_ or _%#MMDD2005#%_ with home care.
ES|extra strength|ES|191|192|DISCHARGE MEDICATIONS|She should then be seen by a health profession in 3-4 days following that for reassessment of the wounds to ensure that there is no evidence of infection. DISCHARGE MEDICATIONS: 1. Augmentin ES 540 mg p.o. b.i.d. through _%#MMDD2007#%_. 2. Oxycodone 5 mg per 5 mL 1 mg p.o. q.6 hours p.r.n., pain. 3. Tylenol 160 mg p.o. q.6 hours p.r.n., pain.
ES|extra strength|ES|126|127|ALLERGIES|3. He had a colonoscopy in _%#MM2006#%_. 4. He also had an upper endoscopy in 2006. ALLERGIES: Elavil, unknown. Atorvastatin. ES citalopram. FAMILY HISTORY: This is noncontributory to this illness.
ES|extra strength|ES|150|151|DISCHARGE MEDICATION|7. Zantac 150 mg b.i.d. 8. Anzemet 100 mg b.i.d. 9. Atenolol 50 mg q.d. 10. Reglan 10 mg b.i.d. The patient was also given a prescription for Vicodin ES on a p.r.n. basis. The patient is discharged to home without complications.
ES|extra strength|ES|146|147|MEDICATIONS|4. Nitrostat sublingual 0.4 mg prn. 5. Lotensin 20 mg PO Q day 6. Hydrochlorothiazide 50 mg PO Q day 7. Synthroid 0.1 mg PO Q day 8. Erythromycin ES 400 mg two tabs two hours before any procedure and one tab 6 hours after each procedure prn. 9. Evista 60 mg PO Q day 10. Atenolol 25 mg PO Q day
ES|extra strength|ES|504|505|DISCHARGE MEDICATIONS|Her renal function remained intact and we really made no other changes to her medicine regimen. DISCHARGE MEDICATIONS: Lasix 80 mg p.o. b.i.d., Synthroid 0.1 mg p.o. q.d., Avapro 300 mg p.o. q.d., Imdur ER 120 mg p.o. q.d., estropipate 0.625 mg p.o. q.d., Lanoxin 0.25 mg every other day alternating with 0.125 mg every other day, Zocor 5 mg p.o. q.d., Lopressor 50 mg p.o. b.i.d., piroxicam 20 mg p.o. q.d, Norvasc 10 mg p.o. q.d., and Prevacid 30 mg p.o. q.d., Centrum with Silver one per day, Ecotrin ES one p.o. q.d., and ferrous gluconate 324 mg p.o. q.d. At the time of discharge, the patient was directed to follow up with Dr. _%#NAME#%_ in one to two weeks with a basic metabolic panel and Digoxin level at that time.
ES|extra strength|ES|176|177|PAST MEDICAL HISTORY|His peripheral edema, dermatitis etc. have cleared reasonably well. The patient relates that his pain has been pretty well controlled with OxyContin 100 mg b.i.d. with Vicodin ES every four hours p.r.n. for break-through pain. The only pain that he has is in the lower back. It bothers him more when he lays down. He has had chronic back problems in the past and has a known lumbar disc disease.
ES|extra strength|ES|106|107|CURRENT MEDICATIONS|3. Hydrochlorothiazide 25 mg p.o. qd. 4. Atenolol. 50 mg p.o. qd. 5. Benicar 20 mg p.o. q a.m. 6. Vicodin ES 7.5, one or two q.i.d. prn for migraine headaches. 7. Neurontin 600 mg q h.s. for migraine prevention. 8. Seroquel 25 mg q h.s. 9. Vistaril 75 mg q h.s.
ES|extra strength|ES|144|145|DISCHARGE MEDICATIONS|8. Reglan 10 mg t.i.d. 9. Toprol XL 50 mg daily 10. Protonix 40 mg daily 11. Flomax 400 micrograms daily 12. Trazodone 50 mg at hs. 13. Vicodin ES one q4-6 hours p.r.n. back pain
ES|extra strength|ES|107|108|DOB|Throughout the night he was up complaining of left leg pain. He has had no fever. He has been on Augmentin ES for left otitis media for about six days and had some cold symptoms. He has had no rashes. He has otherwise been fairly healthy except for a couple episodes of wheezing.
ES|extra strength|ES|122|123|HOSPITAL COURSE|He went to PT b.i.d. Low-grade temperature at one point. He did not get great pain management, we switched him to Vicodin ES and OxyContin, although the OxyContin made him a little groggy, he felt it was better. He rated his pain as a 2-3/10 in the average days.
ES|extra strength|ES|164|165|ALLERGIES|Her last weight taken here at Fairview-University Medical Center was 15.3 kg, and this was unchanged from her admission weight. DISCHARGE MEDICATIONS: 1. Augmentin ES 600 mg/5 mL. Give 1-1/4 teaspoon b.i.d. until _%#MM#%_ _%#DD#%_, 2004, for a total of 10 days treatment. 2. Ciprofloxacin otic drops 3 drops in the right ear b.i.d. per previous instructions from her primary care physician for otitis externa.
ES|extra strength|ES|150|151|MEDICATIONS|2. Allopurinol 300 mg q day. 3. Hytrin 5 mg. 4. Lisinopril 10 mg. 5. Metamucil, a tablespoon q day. 6. Percocet 5/325, one to two q4h prn. 7. Tylenol ES 1 to 2 q8 prn. SOCIAL HISTORY: He is married and lives at Minnesota Masonic.
ES|extra strength|ES|124|125|DISCHARGE MEDICATIONS|I will see her back in the office on Friday, _%#MM#%_ _%#DD#%_, 2005, for a dressing change. DISCHARGE MEDICATIONS: Vicodin ES and Vistaril.
ES|extra strength|ES|147|148|MEDICATIONS|11. Amoxicillin for antibiotic prophylaxis. 12. Albuterol MDI and neb p.r.n. 13. Metamucil 1 tablespoon daily. 14. Ultram 50 mg daily. 15. Tyelnol ES 500 mg 2 tablets three times a day. 16. Colace 100 mg twice a day. 17. Coumadin 5 mg Sat, Sun, Tue, Thu, 2.5 mg on M/W/F
ES|extra strength|ES|201|202|DISCHARGE INSTRUCTIONS|His white count was 24,500 at the time of admission and decreased to 18,000 at the time of discharge. DISCHARGE INSTRUCTIONS: 1. He was discharged home to parents' care in good condition. 2. Augmentin ES Suspension, 1/2 tsp p.o. b.i.d. for a total ten-day course. 3. Tylenol p.r.n. 4. Follow up with primary MD in 1-2 weeks.
ES|extra strength|ES|175|176|DISCHARGE MEDICATION|When she was tolerating the pain and all pain medicines, she was deemed ready for discharge. CONDITION ON DISCHARGE: Stable. DISCHARGE MEDICATION: Medications include Vicodin ES 1-2 p.o. q. 4 to 6 h. p.r.n. pain. In addition, she will resume her home medicines. DISCHARGE INSTRUCTIONS: Her activity will be Codman's exercises for physical therapy.
ES|extra strength|ES|201|202|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: At the time of discharge she was stable on her postoperative pain medications and had been restarted on her usual outpatient medications. Her additional medications were Vicodin ES 1-2 tablets q.4-6h. p.r.n. severe pain and Valium 2-mg tablets 1-2 tablets p.o. q.4-6h. p.r.n. spasm in addition to her usual home medications as listed in the chart.
ES|extra strength|ES|735|736|HOSPITAL COURSE|There were also some logistical problems with family arranging for continuous care for her as the grand-daughter who was caring for her during the summer has to go back to school now. Her discharge medications are going to be albuterol and Atrovent nebs, Kay Ciel 20 meq b.i.d., Prilosec 20 mg b.i.d., Lasix 40 mg b.i.d., Zaroxolyn 10 mg daily, diltiazem CD 360 mg daily, Actos 45 mg a day, spironolactone 50 mg a day, Neurontin 300 mg t.i.d., Tegretol 200 mg b.i.d., Paxil 30 mg a day, Xanax 0.125 mg b.i.d., Baclofen 10 mg b.i.d., Advair 500/50 one puff b.i.d., albuterol inhalers as needed, prednisone will go from 30 mg a day for four days, then back to her baseline of 20 mg a day, Tequin 400 mg daily for five days more, Vicodin ES 7.5 mg t.i.d., morphine sulfate solution 2 mg/ml 2.5 cc every six hours as needed for the jaw pain. We are hoping for a short transitional stay. We will continue with physical therapy and occupational therapy there.
ES|extra strength|ES|143|144|HOSPITAL COURSE|6. Respiratory: _%#NAME#%_ was maintained on albuterol MDI 2 puffs 4 times a day with slight relief in cough. Patient was started on Augmentin ES 600 mg p.o. b.i.d. x10 days for a possible pneumonia. As stated above, patient was afebrile throughout hospitalization and maintained adequate oxygen saturations on room air.
ES|extra strength|ES|164|165|DISCHARGE MEDICATIONS|4. Allegra 30 mg p.o. b.i.d. 5. Colace 50 mg p.o. b.i.d. 6. GCSF 90 mcg subcutaneously daily until told to discontinue, start _%#MM#%_ _%#DD#%_, 2003. 7. Augmentin ES 600 mg p.o. b.i.d. x10 days. FOLLOW UP: _%#NAME#%_ will be seen in oncology clinic on _%#MM#%_ _%#DD#%_, 2003.
ES|extra strength|ES.|139|141|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Included 1. Aspirin 2. Lipitor 3. Zantac 4. Atenolol 5. Hydrochlorothiazide 6. Allopurinol 7. Lisinopril 8. Tylenol ES. She had follow-up appointments with her primary care physician Dr. _%#NAME#%_ the following week after discharge. She was to see Dr. _%#NAME#%_ in one month.
ES|extra strength|ES.|128|130|MEDICATIONS|She was seen in the Emergency Room 1 day ago. ALLERGIES: Sulfa, penicillin. MEDICATIONS: 1. Wellbutrin 450 mg daily. 2. Tylenol ES. 3. Advil p.r.n. 4. Methotrexate 5 mg q. week. 5. Vicodin 1 q.4h. p.r.n. PAST MEDICAL HISTORY/SURGERIES: Appendectomy, tonsillectomy, D&C, one miscarriage, 2 vaginal deliveries.
ES|extra strength|ES|199|200|MEDICATIONS|3. Multi-vitamins daily. 4. _______ one tablet t.i.d. 5. Sliding scale with Novolog and Lantus insulin 22 units in the morning, Novolog before lunch and b.i.d. 6. Tramadol 50 mg for pain and Tylenol ES for pain. SOCIAL HISTORY: His wife died several years ago. He has been living in a nursing home for the last two years.
ES|extra strength|ES|306|307|HOSPITAL COURSE|8. Albuterol 2 puffs every 4-6 hours as needed. HOSPITAL COURSE: This is an 80-year-old female who was hospitalized about 2 months ago for chronic obstructive pulmonary disease exacerbation. At that time she was put on prednisone and antibiotics and seemed to get better. However, she was put on Augmentin ES and continued to have difficulty tasting food and felt that food tasted very salty. She had no appetite and she has continued to lose weight over the last 2 months.
ES|extra strength|ES|143|144|OPERATIONS/PROCEDURES|CONSULTATIONS: Cardiology OPERATIONS/PROCEDURES: Patient had a transesophageal echocardiogram on _%#MMDD2006#%_ that showed no clot, showed an ES of 45%. Showed mild LVH. It showed mild to moderate mitral insufficiency. The patient underwent cardioversion on _%#MMDD2006#%_. The patient had had an abnormal stress echocardiogram but was not felt to be a candidate for cardiac catheterization due to his renal disease.
ES|extra strength|ES|166|167|DISCHARGE MEDICATIONS|5. Fer-in-Sol 20 mg p.o. twice daily. 6. Albuterol 2.5 mg nebs 4 times daily. 7. Mucomyst 4 mL nebs 4 times daily. 8. Pulmozyme 2.5 mg nebs twice daily. 9. Augmentin ES 600 mg p.o. b.i.d. x7 days. 10. Calciferol 400 IU p.o. daily. FOLLOWUP INSTRUCTIONS: _%#NAME#%_ is to follow up with Dr. _%#NAME#%_ _%#NAME#%_ of Behavioral Pediatrics.
ES|extra strength|ES|147|148|DISCHARGE MEDICATIONS|6. Spiriva 18 mcg per cap inhaled daily. 7. Coumadin as directed 8. Cipro for urinary tract infection, 500 mg p.o. b.i.d. x5 days. 9. Take Tylenol ES 500 mg 1-2 tablets q.4-6h. p.r.n. for pain.
ES|extra strength|ES|177|178|DISCHARGE MEDICATIONS|11. Zocor 40 mg daily. 12. Plain Darvon 65 mg 1 capsule q.4-6h. p.r.n. 13. Lantus insulin 18 units q.12h. subacute. 14. Humalog 5-10 units before meals as directed. 15. Vicodin ES one tablet q.i.d. p.r.n. 16. Metoprolol 25 mg tablets to take 50 mg twice a day and on the day of dialysis take 25 mg in the morning.
ES|extra strength|ES|206|207|MEDICATIONS|2. Fluconazole 100 mg daily for fungal infection. 3. Coumadin 1 mg every other day for chronic atrial fibrillation. 4. Detrol LA 4 mg for urinary incontinence. Note the patient self-caths b.i.d. 5. Tylenol ES p.r.n. 6. Imodium p.r.n. REVIEW OF SYSTEMS: Blood pressure generally runs in the 85-90/60 range.
ES|extra strength|ES|196|197|DISCHARGE MEDICATIONS|Certainly, she should be seen sooner if having difficulties. Urology does not need to see her in follow-up unless she has recurrent pain complaints or problems. DISCHARGE MEDICATIONS: 1. Percocet ES 1-2 p.o. q.6h. p.r.n. severe pain. 2. Colace 100 mg p.o. b.i.d. 3. Tequin 400 mg p.o. daily x 7 days.
ES|extra strength|ES|146|147|MEDICATIONS|2. Prozac 20 mg per day. 3. Allegra 180 mg per day. 4. Lipitor 20 mg per day. 5. Furosemide 80 mg b.i.d. 6. Synthroid 125 mcg per day. 7. Vicodin ES p.r.n. pain. 8. Duragesic patch 25 mcg/hr, 1 patch q72h. 9. Percocet 325 mg p.r.n. 10. Detrol 2 mg per day. 11. Clonidine 0.1 mg q.h.s.
ES|extra strength|ES|192|193|DISCHARGE PLAN|DISCHARGE PLAN: The patient is discharged to home. His medications include Prilosec 20 mg p.o. q.day, Prozac 20 mg p.o.q. a.m., trazodone 50 mg p.o. q.h.s., Maxzide 25 mg p.o.q. a.m., Vicodin ES 1 p.o.q. 4-6 hours p.r.n. pain. I am switching from a Medrol Dose Pak to prednisone and he can take 40 mg for 2 days, 30 mg for 3 days, 20 mg for 3 days, and 10 mg for 3 days, then discontinue.
ES|extra strength|ES|142|143|CURRENT MEDICATIONS|3. Endapamide 2.5 mg per day. 4. Lipitor 20 mg q.h.s. 5. Atenolol 25 mg per day. 6. Prilosec 20 mg per day. 7. Reglan 10 mg b.i.d. 8. Vicodin ES 1 b.i.d. 9. Avandia 4 mg b.i.d. 10. Cardura 2 mg q.h.s. 11. Voltaren 50 mg b.i.d. (which he is holding). 12. Aspirin (which he is holding).
ES|extra strength|ES|150|151|DISCHARGE MEDICATIONS|The patient is being transferred to a rehab facility for Physical Therapy, Occupational Therapy and Speech Therapy. DISCHARGE MEDICATIONS: 1. Vicodin ES 1-2 p.o. q6 p.r.n. 2. Lovenox 30 mg subcu daily for 2 weeks. 3. Colace 100 mg p.o. b.i.d. 4. Levaquin 250 mg p.o. daily for 7 days. 5. Ferrous Gluconate 325 mg p.o. daily.
ES|extra strength|ES|107|108|MEDICATIONS|MEDICATIONS: 1. Baclofen 15 mg b.i.d. 2. Colace 100 mg at p.m. 3. Senokot one tablet at p.m. 3. 4. Tylenol ES q4h p.r.n.
ES|extra strength|ES|159|160|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Baclofen 15 mg t.i.d. 2. Colace 100 mg daily orally and at bedtime p.r.n. 3. Senokot 1 tablet daily and at bedtime p.r.n. 4. Tylenol ES 1 tablet q.4h p.r.n. 5. First Step air mattress. 6. Use a special boot, right foot and a regular shoe on the left foot during the day.
ES|extra strength|ES|157|158|MEDICATIONS|7. Zoloft 50 mg p.o. q.i.d.? 8. Clonazepam 0.5 mg p.o. q.i.d. 9. Potassium chloride 10 mEq p.o. q. day. 10. Multivitamin one tablet p.o. q. day. 11. Tylenol ES 1-2 tablets p.o. at bedtime. 12. Advair 250/50 one puff inhaled daily. 13. Humalog 75/25 70 units in a.m. and 79 units in the p.m. which she does little bit on the sliding scale.
ES|extra strength|ES|153|154|DISCHARGE MEDICATIONS|He is active and alert, happy and playful. He is tolerating a regular diet. He is afebrile. His vital signs are normal. DISCHARGE MEDICATIONS: Augmentin ES 120 mg of amoxicillin per cc. Patient will take 4.5 cc p.o. b.i.d. x 5 days. CONSULTATIONS: Dr. _%#NAME#%_ of Metropolitan Pediatrics. DIET: Regular diet upon discharge.
ES|extra strength|ES|149|150|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Ferrous sulfate 325 mg p.o. b.i.d. 2. Remeron 15 mg p.o. each day at bedtime. 3. OxyContin CR 20 mg p.o. q.12h. 4. Tylenol ES 1000 mg p.o. q.6h. p.r.n. fever or pain. 5. Lorazepam 1 mg p.o. each day at bedtime. 6. Oxycodone 5 mg p.o. q.4h. p.r.n. pain. 7. Senokot S 1-2 tablets p.o. b.i.d.
ES|extra strength|ES|165|166|DISCHARGE MEDICATIONS|1. Calcitriol 0.25 mcg p.o. daily. 2. Calcium carbonate 250 mg p.o. q.i.d. 3. Ferrous sulfate 10 mg p.o. b.i.d. 4. Kayexalate 2.5 teaspoons p.o. daily. 5. Augmentin ES 300 mg p.o. b.i.d. x10 days. 6. Bacitracin thin layer topically applied twice a day to the wound. DIET: The patient is to resume his renal diet and a Similac 60/40.
ES|extra strength|ES|114|115|DISCHARGE MEDICATIONS|1. Zofran 4-8 mg p.o. q. 8h. p.r.n. nausea. 2. Bupropion 150 mg p.o. daily. 3. Paxil 20 mg p.o. daily. 4. Vicodin ES 7.5/750 mg p.o. q. 4-6h. p.r.n. pain. 5. Senokot 2 tablets p.o. daily while taking narcotics. 6. Albuterol MDI inhaler with spacer 2 puffs p.o. b.i.d. and 2 puffs p.o. p.r.n. q. 4h. shortness of breath.
ES|extra strength|ES|192|193|DISCHARGE MEDICATIONS|DISCHARGE DISPOSITION: To home. DISCHARGE MEDICATIONS: 1. Singulair 5 mg chewables 1 p.o. at bedtime. 2. Pulmicort 0.5 mg per 2 mL b.i.d. 3. Albuterol Nebs q. 4 to 6 hours p.r.n. 4. Augmentin ES 600 mg per 5 mL p.o. b.i.d. for 10 days. FOLLOW-UP: With Dr. _%#NAME#%_ next week. Discussed in detail with mom, who agrees to the plan.
ES|extra strength|ES|297|298|DISCHARGE MEDICATIONS|This was agreeable to the primary treatment team, including Occupational Therapy, Physical Therapy and primary M.D. Patient will be discharged home with home physical therapy, occupational therapy and a nurse's aide. Patient is at home with his wife and two sons. DISCHARGE MEDICATIONS: Augmentin ES 120/8.6 mg/ml p.o. b.i.d., give 7.3 ml times 12 days, aspirin 325 mg p.o. q. day, Risperdal 0.5 mg p.o. q. day (this is new dose, down from 1 mg as the patient appeared to have some Parkinsonism related to the Risperdal and 0.5 may be adequate enough).
ES|extra strength|ES|114|115|CURRENT MEDICATIONS|6. Klor-Con 10 mEq daily. 7. Lasix 40 mg daily. 8. Prilosec 20 mg daily. 9. Synthroid 0.125 mg daily. 10. Tylenol ES 500 mg tablets, two tablets at noon and bed time. 11. Soma 25 mg hs. PHYSICAL EXAMINATION: GENERAL: Pleasant 90-year-old white female.
ES|extra strength|ES|155|156|DISCHARGE MEDICATIONS|14. Sinemet CR 50/100 1 p.o. t.i.d. and 1/2 q.h.s. 15. Tobradex eye drops 1 drop left eye t.i.d. 16. Voltaren eye drops 1 drop left eye q.i.d. 17. Tylenol ES 500 to 1000 mg q.4-6 h. p.r.n. pain. 18. Seroquel 12.5 mg at 5 p.m. and may repeat at h.s. p.r.n. anxiety. 19. Ambien 5 mg p.o. q.h.s. p.r.n. insomnia.
ES|extra strength|ES|208|209|DISCHARGE MEDICATIONS|Given this, we felt that her renal failure was likely secondary to the combination of infection and the nonsteroidal anti-inflammatory drugs. DISCHARGE MEDICATIONS: 1. Ortho Tri-Cyclen Lo 1 daily. 2. Tylenol ES 500 mg to 1000 mg q.4 h. p.r.n. pain. 3. Levaquin 250 mg orally for 7 days. 4. Oxycodone 5 mg q.4 h. p.r.n. pain #10 were given without any refills.
ES|extra strength|ES|178|179|PHYSICAL EXAMINATION|This was continued. The patient was changed to Augmentin 875 mg q 12 h and will be discharged on that dose, and 25 mg of Tenormin a day q a.m. as well as Tylenol #3 with Tylenol ES two q.i.d. for less severe pain. He will use chlorpromazine tablets, 25 mg, 1/2 tablet if he has nausea. A follow up visit will be scheduled with Dr. _%#NAME#%_ in approximately one week.
ES|extra strength|ES|274|275|CURRENT MEDICATIONS|FAMILY HISTORY: Not obtained. ALLERGIES: No true allergies, but ibuprofen does cause stomach upset and Serzone caused some problems with sleep. CURRENT MEDICATIONS: Zoloft 200 mg daily, Avapro 150 mg daily, Glucatrol XL 10 mg bid, Glucophage 500 mg 3 every morning, Vicodin ES 2 tabs q 4 h prn. EXAMINATION: Massively obese, middle aged male in no acute distress, weight 408, temp 100.5, pulse 88, respirations 20, blood pressure 130/80.
ES|UNSURED SENSE|ES|70|71|ALLERGIES|11. Sominex at night. 12. She may also be on Evista daily. ALLERGIES: ES and Zoloft. PAST MEDICAL HISTORY: Significant for the following surgeries: She had a right mastectomy.
ES|extra strength|ES|174|175|MEDICATIONS|2. Previous right total hip 3. Bilateral intraocular lens implants. MEDICATIONS: On admission include: 1. Glycerin 120 cc p.o. t.i.d. 2. Pulmicort Respules b.i.d. 3. Tylenol ES 500 mg p.o. t.i.d. 4. Vicodin 5/500 1 p.o. t.i.d. 5. Calcium with D 500/200 1 tab p.o. t.i.d. 6. Vicodin 5/500 2 tabs at h.s.
ES|extra strength|ES|232|233|DISCHARGE MEDICATIONS|Again, repeat UA with consideration of 24-hour urine/protein collection if he still has persistent proteinuria despite treatment of his urinary tract infection. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. daily. 2. Vicodin 7.5/750 ES 1 tab every 4-6h. p.r.n. 3. Levaquin 500 mg p.o. daily for 12 additional days. 4. Combivent inhaler 2 puffs 4 times daily. 5. Metoprolol 50 mg p.o. b.i.d.
ES|extra strength|ES|132|133|MEDICATIONS|4. Lisinopril 10 mg one a day 5. Hydrochloride 25 mg one a day 6. Prilosec 20 mg twice a day 7. Centrum Silver one a day 8. Tylenol ES 500 mg two twice a day 9. Aspirin 325 mg one a day 10. Oscal 500 mg two tablets daily 11. Lovastatin 20 mg one a day
ES|extra strength|ES|90|91|DISCHARGE MEDICATIONS|DISCHARGE CONDITION: Condition on discharge was good. DISCHARGE MEDICATIONS: 1. Augmentin ES 7 mg per 5 ml, 2.5 ml p.o. twice a day for 7 days. 2. DesOwen lotion. 3. Hydrocortisone ointment. DISCHARGE INSTRUCTIONS: Mother was instructed in care of the skin including the use of a nondrying soap such as Dove or Purpose, liberal use of a moisturizer over damp skin using either an ointment such as Aquaphor or a lotion such as Eucerin and also discussed the use of steroids to decrease the redness and inflammation.
ES|extra strength|ES|159|160|DISCHARGE MEDICATIONS|He had 95% saturation on room air and normal activity and moving around the room quite well. DISCHARGE MEDICATIONS: He was discharged to home on: 1. Augmentin ES 600 mg per 5 cc, 8 cc twice a day. 2. Albuterol MDI 1-2 puffs q4h. 3. Singulair 5 mg q.a.m. DISCHARGE INSTRUCTIONS: He will be following up in the next few days with Dr. _%#NAME#%_ _%#NAME#%_, his primary care physician.
ES|extra strength|ES|170|171|DISCHARGE MEDICATIONS|She had no significant electrolyte abnormalities suggesting an acidosis. DISCHARGE MEDICATIONS: 1. Diphenhydramine 50 mg p.o. q.6h p.r.n. itching or rash. 2. Amoxicillin ES component 600 mg b.i.d. x10 days. 3. Hydrocortisone 1% cream to be applied to the patient's contact dermatitis b.i.d. to t.i.d.
ES|extra strength|ES|149|150|ADMISSION MEDICATIONS|During admission she was also found to have extensive effusions and there may have been a pneumonia there as well. ADMISSION MEDICATIONS: 1. Tylenol ES 1000 mg p.o. t.i.d. 2. Aricept 10 p.o. q. day. 3. Calcium with vitamin D 600 p.o. t.i.d. 4. Coreg 25 p.o. b.i.d. 5. Lisinopril 5 mg p.o. q. day.
ES|extra strength|ES|200|201|DISCHARGE MEDICATIONS|DISCHARGE DISPOSITION: She is discharged to home in the care of her mother in good condition. DISCHARGE MEDICATIONS: She is to continue with digoxin at her home dose of 0.05 mg p.o. b.i.d., Augmentin ES 600 1-1/2 tsp p.o. b.i.d. for 7 more days. DISCHARGE FOLLOW-UP: With Dr. _%#NAME#%_ next week or in 3-7 days, sooner if any worsening or if she fails to continue with improvement over the next week.
ES|extra strength|ES|158|159|MEDICATIONS|MEDICATIONS: 1. Serevent inhaler, two puffs b.i.d. 2. Flovent inhaler, two puffs b.i.d. 3. Ambien 5 mg at bedtime. 4. Guaifenesin LA 600 mg b.i.d. 5. Tylenol ES 1-2 tablets t.i.d. 6. Prevacid 30 mg once a day. 7. Paxil 20 mg once a day. 8. Senegin, two tablets b.i.d.
ES|ejection fraction:EF|ES|367|368|PAST MEDICAL HISTORY|2. Diabetes, type 2. Suspected mild renal insufficiency. In _%#MM#%_ of 2002, creatinine was 1.1. Subsequently in _%#MM#%_, it was 1.3. Even at these values though would strongly suspect renal insufficiency based on the patient's age and diabetic status. 3. Moderate pulmonary hypertension. The patient has had lower extremity edema for at least a year now. Reported ES normal with diastolic dysfunction on echocardiogram _%#MM2002#%_. 4. Multiple orthopaedic surgeries. The patient has also had remote appendectomy. REVIEW OF SYSTEMS: Mr. _%#NAME#%_ generally feels well at this time.
ES|extra strength|ES,|184|186|MEDICATIONS|She did very well postoperatively and when she was ambulating well with a walker, she was ready for discharge. CONDITION ON DISCHARGE: Stable. MEDICATIONS: Medications include Vicodin ES, one to two p.o. q.4- 6h. p.r.n. pain. Aspirin 325 mg p.o. q.d. As well as to continue any home medicines and medicines that Dr. _%#NAME#%_ has placed her on.
ES|extra strength|ES,|234|236|HOSPITAL COURSE|On day of discharge, his mass was significantly diminished, but the firm mass seemed to be centered around the parotid gland rather than a submandibular node. He had no contralateral corresponding mass. Did discharge on Augmentin 600 ES, 9 cc, b.i.d. times 10 days. Will follow up in clinic in one week. Anticipate continuing oral antibiotics until mass is completely resolved and then some.
ES|extra strength|ES|170|171|DISCHARGE MEDICATIONS|_%#NAME#%_ _%#NAME#%_ is being transferred to _%#CITY#%_, Wisconsin Mercy Hospital system. DISCHARGE MEDICATIONS: 1. Valium 5 mg p.o. prn q 6 hours for spasm. 2. Vicodin ES 1-2 p.o. q 3-4 hours prn severe pain. She is weightbearing as tolerated. She is being transported via Life Link.
ES|extra strength|ES|314|315|MEDICATIONS ON ADMISSION|DRUG ALLERGIES: Include Demerol, codeine, morphine and Darvocet which all cause hallucinations. MEDICATIONS ON ADMISSION: Prevacid 30 mg p.o. q.d., Prinivil 20 mg p.o. b.i.d., Adalat 60 mg p.o. q.d., metoprolol 25 mg p.o. b.i.d., Premarin 0.625 mg p.o. q.d., Plavix 75 mg p.o. q.d., Nephrocaps one p.o. q.d., Tums ES two tabs p.o. b.i.d., minoxidil 2.5 mg p.o. q.h.s., Zocor 40 mg p.o. q.h.s. PAST MEDICAL HISTORY: 1. Chronic renal failure. Patient is dialyzed Monday, Wednesday, Friday. Renal failure due to hypertension and renal artery stenosis.
ES|extra strength|ES|111|112|DISCHARGE/TRANSFER MEDICATIONS|5. Protonix 40 mg 1 tablet daily. 6. Inderal 40 mg 1 tablet b.i.d. 7. Zocor 20 mg daily at bedtime. 8. Tylenol ES 500 mg tablets 1 or 2 tablets q. 4h. p.r.n. pain, maximum Tylenol dose 4 g daily. 9. Aspirin 325 mg 1 tablet daily with food. PERTINENT LABORATORY WORK: On _%#MMDD2007#%_, the patient had a sodium of 140, potassium 4.9, chloride 105, total CO2 25 and BUN is 51 (this represents an increase during his stay from his baseline of approximately 25).
ES|extra strength|ES|154|155|DISCHARGE MEDICATIONS|13. Senokot-S 2 tablets p.o. each day at bedtime p.r.n. constipation. 14. Tylenol 500 mg p.o. q6 hours p.r.n. 15. Aspirin 81.5 mg p.o. q day. 16. Vicodin ES 7.5/750 p.o. q8 hours p.r.n. 17. Lidocaine patch 5% 1 patch topically q24 hours p.r.n. pain with a 12-hour patch-free time.
ES|extra strength|ES|190|191|DISCHARGE MEDICATIONS|4. Lyrica 50 mg twice a day. 5. Senokot 1 tablet twice a day p.r.n. constipation. 6. Zemplar 1 mcg injection during dialysis. 7. Dilaudid 2 mg by mouth every 4 hours p.r.n. pain. 8. Tylenol ES p.r.n. pain, not to exceed 4 gm in 24 hours. 9. PhosLo 667 mg capsule by mouth with meals. 10. Ventolin inhaler p.r.n.
ES|extra strength|ES|120|121|DISCHARGE MEDICATIONS|11. Carafate 1 g p.o. b.i.d. 12. Oxycodone 15 mg p.o. q.4 h. p.r.n. pain. 13. Senokot-S 1 tablet p.o. b.i.d. 14. Megace ES 625 mg p.o. daily for appetite stimulation. This is a new medication. 15. Augmentin 875/125, 875 mg p.o. b.i.d. for 14 days for urinary tract infection.
ES|extra strength|ES|138|139|DISCHARGE MEDICATIONS|He was also noted to have elevated blood sugars which will be treated with Glipizide and sliding scale insulin. DISCHARGE MEDICATIONS: 1. ES citalopram 10 mg down the feeding tube daily. 2. Hydroxyurea 2500 mg down the feeding tube daily. 3. Labetalol 200 mg feeding tube b.i.d. 4. Lisinopril 20 mg down the feeding tube daily.
ES|extra strength|ES|278|279|MEDICATIONS|PAST MEDICAL HISTORY: Remarkable for diabetes mellitus type 2, coronary disease, status post acute MI and CABG in 1996, hypertension, history of obstructive sleep apnea. ALLERGIES: Clonidine. MEDICATIONS: 1. Terazosin 4 mg p.o. daily. 2. Glimepiride 4 mg p.o. daily. 3. Tylenol ES 1000 mg p.o. b.i.d. 4. Aspirin 325 mg p.o. daily. 5. Verapamil CR 240 mg p.o. b.i.d. 6. Torsemide 40 mg p.o. b.i.d. 7. Lisinopril 40 mg p.o. daily.
ES|extra strength|ES|123|124|DISCHARGE MEDICATIONS|4. Clonidine 0.1 mg t.i.d. 5. Allopurinol 300 mg q. day. 6. Alprazolam 1 mg t.i.d. 7. Esomeprazole 40 mg q. day. 8. Megace ES 625 mg/5 liters q. day. 9. Lanthanum (Fosrenol) 1000 mg with meals and snacks. 10. Nephrocaps one q. day. 11. Cyclobenzaprine 10 mg t.i.d. p.r.n. 12. Lortab 7.5/500 mg one to two tablets q.6-8 hours p.r.n.
ES|extra strength|ES|156|157|DISCHARGE MEDICATIONS|6. Lexapro 5 mg p.o. q. day 7. Omeprazole 20 mg p.o. q. day 8. Toprol-XL 50 mg p.o. q. day by mouth. 9. Zyprexa 2.5 mg every 2 days at bedtime. 10. Tylenol ES 500-1000 q.6h p.r.n. DISCHARGE FOLLOW-UP: The patient will follow up with an esophagram in 6 to 8 weeks via Minnesota GI.
ES|extra strength|ES|116|117|MEDICATIONS|18. Peyronie's disease. ALLERGIES: Penicillin (rash), Cipro (rash). MEDICATIONS: 1. Pletal 100 mg b.i.d. 2. Tylenol ES 2 tablets b.i.d. for pain from knees. 3. Iron t.i.d. with meals (since knee surgery). 4. Folic acid. 5. Calcium supplement. 6. Saw palmetto. 7. Many, many vitamin supplements.
ES|extra strength|ES|261|262|DISCHARGE MEDICATIONS|(The patient had been treated with antibiotics prior to his surgery.) ELECTROCARDIOGRAM: Electrocardiogram is abnormal with left atrial dilation, prolonged Q-T interval, and left ventricular strain or ischemic type of pattern. DISCHARGE MEDICATIONS: 1. Vicodin ES 1 tablet q.4h. p.r.n. 2. Demadex 20 mg daily in a.m. 3. Potassium chloride 20 mEq daily. 4. Synthroid 0.175 mg daily. 5. Allopurinol 300-mg tablet, 1/2 tablet daily.
ES|extra strength|ES|139|140|DISCHARGE MEDICATIONS|4. Vitamin C 500 mg p.o. once in the morning. 5. Vitamin B6 50 mg p.o. once in the morning. 6. Folic acid 1 mg p.o. once a day. 7. Tylenol ES 500 mg p.o. once a day as needed for pain. DISCHARGE INSTRUCTIONS: CODE STATUS: Full. DIET: Regular. PHYSICAL ACTIVITY: As tolerated.
ES|extra strength|ES|133|134|MEDICATIONS|3. Ambien 10 mg p.r.n. 4. Darvocet 1 tablet q.4-6h. p.r.n. 5. Percocet one tablet q.4-6h. p.r.n. 6. Prilosec 20 mg p.r.n. 7. Tylenol ES 1000 mg q.4-6h. p.r.n. ALLERGIES: She is allergic to codeine which causes chest tightness.
ES|extra strength|ES|375|376|HOSPITAL COURSE|You are referred to Dr. _%#NAME#%_ _%#NAME#%_'s admission H&P. On presentation to the ER, the patient had the following laboratory tests performed: CBC showed a hemoglobin of 15.4 with an MCV of 92, white count of 5200 with a normal differential, platelet count 298,000. INR 1.02. Electrolytes were normal with a BUN of 17 and a creatinine 1.05. LFTs were normal. Troponin-I ES was less than 0.012, myoglobin 34. Ethanol level of 0.10. Magnesium 2.2, TSH 0.42. Chest x-ray showed no definitive infiltrate.
ES|extra strength|ES|337|338|LABORATORY DATA|LABORATORY DATA: That are currently available, include a hemoglobin of 13.9 with an MCV of 84, white count of 14,500 with 80% neutrophils, 14 lymphs, 4 monos, 1 eo, 1 basophil, platelet count is 443,000. INR is 0.95. Electrolytes are normal with the exception of a glucose of 131, BUN is 13, creatinine is 1.04, calcium is 9.8. Troponin ES is less than 0.012. TSH is 1.35. Magnesium is 1.9. Urinalysis is negative. Urine culture is pending. Blood cultures x2 have been performed to rule out endocarditis, which I think is unlikely with the patient's history.
ES|extra strength|ES|168|169|PROBLEM #5|5. Tylenol extra strength 1 gram p.o. q.4h. p.r.n. pain. 6. Terazosin 2 grams p.o. q.a.m. 7. Prevacid 30 mg p.o. daily. 8. Nystatin 500,000 units p.o. q.i.d. 9. Megace ES 625 mg p.o. daily. 10. OxyContin 30 mg p.o. t.i.d. 11. Oxycodone 10 mg p.o. every 4 hours as needed for pain. 12. Ciprofloxacin 500 mg p.o. b.i.d. x7 days total (through _%#MMDD2007#%_).
ES|extra strength|ES|206|207|HISTORY OF PRESENT ILLNESS|On presentation, her EKG was not particularly interpretable, given she is paced. On admission she had a normal leukocytosis. INR was 2.73. LFTs, BMP, creatinine normal limits, proBNP was 15,000. Troponin I ES was 0.04, alkaline mildly elevated, digoxin levels 1.7. The echocardiogram showed normal left ventricular ejection, though regional wall motion abnormalities could not be entirely excluded.
ES|extra strength|ES|100|101|PROCEDURES|Stress Cardiolite with Dr. _%#NAME#%_ site in Arizona as soon as he returns. PROCEDURES: Troponin-I ES less than 0.012 three times. TSH 6.45. Total cholesterol 109, triglycerides 50, HDL 29.
ES|extra strength|ES|158|159|MEDICATIONS|5. Levoxyl 0.075 mg daily. 6. Multivitamin one daily. 7. Senokot 2 tabs daily. 8. Neurontin 600 mg 3 times a day. 9. MS Contin 60 mg twice daily. 10. Tylenol ES 2 tabs q.3-4h. as needed. 11. Tylenol PM, 2 tablets p.o. every h.s. as needed. 12. Nitroglycerin spray 0.4 mg sublingually p.r.n. 13. Levaquin 500 mg daily.
ES|extra strength|ES|280|281|MEDICATIONS|MEDICATIONS: From the nursing home are as follows: 1. Primidone 125 mg p.o. t.i.d. This is a new medication, which had been started on _%#MMDD#%_ after Dilantin had been discontinued. 2. Warfarin 4 mg q. Monday, Wednesday, Friday, and Sunday. 3. OxyContin 20 mg b.i.d. 4. Tylenol ES 2 tablets p.o. t.i.d. 5. Diovan 160 mg p.o. daily. It had been started today. 6. Toprol XL 100 mg daily. 7. Lasix 20 mg daily.
ES|extra strength|ES|244|245|PLAN|PLAN: We discussed with Dr. _%#NAME#%_ and recommended to go ahead and approve her preoperatively on the basis of the physical findings today, which such was done. Preoperative hemoglobin was 10.9, hematocrit 30.17. She was placed on Augmentin ES 600 per 5 ml 3/4-teaspoon b.i.d. for 10 days. She is approved preoperatively provided there is no intercurrent high fever or cough for above noted surgery on _%#MMDD2006#%_ with Dr. _%#NAME#%_.
ES|extra strength|ES|185|186|DISCHARGE MEDICATIONS|6. Protonix 40 mg suspension down G-tube daily. 7. KCl 10% 20 mEq down G-tube b.i.d., 8. Prednisone 10 mg down the G-tube q.a.m. for two days, then discontinue. 9. Augmentin suspension ES 120/8.6 mg/mill down the G-tube b.i.d. for ten days. 10. Cipro 0.3% apply ointment to both eyes t.i.d. for possible conjunctivitis.
ES|extra strength|ES|152|153|PLAN|ASSESSMENT: Cellulitis, status post dog bite with a fracture of the fourth metacarpal of the right hand. PLAN: He will be discharged today on Augmentin ES 600 mg/5 ml 400 mg p.o. b.i.d. times ten days. He is to follow-up with his primary care giver, Dr. _%#NAME#%_ on Friday, _%#MM#%_ _%#DD#%_ and he should return immediately if there is increased erythema or swelling.
ES|extra strength|ES|165|166|CURRENT MEDICATIONS|4. Actonel 35 mg p.o. q. week. 5. Verapamil 240 mg p.o. daily. 6. ASA 81 mg p.o. daily. 7. Metformin 500 mg p.o. b.i.d. 8. Allopurinol 300 mg p.o. daily. 9. Tylenol ES 1-2 p.o. q.i.d. FAMILY HISTORY: Noncontributory. DRUG ALLERGIES: Codeine and morphine. REVIEW OF SYSTEMS: As above.
ES|extra strength|ES|521|522|CURRENT MEDICATIONS|Neurologic: She has a history of left hemispheric CVA with mild residual hemiparesis on the right side. Minimal dysarthria. ALLERGIES: Penicillin and sulfa. CURRENT MEDICATIONS: (Copied from discharge summary from Colonial Acre Health Care Center) - Cozaar 100 mg p.o. q.d., Actose 15 mg p.o. q.d., KCl 20 mEq p.o. q.d., prednisone 5 mg p.o. q.d., Lipitor 10 mg p.o. q.d., Plavix 75 mg p.o. q.d., Lasix 20 mg p.o. q.d., Neurontin 400 mg p.o. q h.s., Zoloft 50 mg p.o. q p.m., hydrochlorothiazide 25 mg p.o. q.d., Tylenol ES 500 mg one to two p.o. t.i.d. p.r.n., Colace 100 mg p.o. p.r.n. b.i.d., Senokot one tab p.o. p.r.n. b.i.d. SOCIAL HISTORY: She is married and lives with her husband.
ES|extra strength|ES,|270|272|CURRENT MEDICATIONS|She takes 7.5 mg at bedtime. PAST MEDICAL HISTORY: HOSPITALIZATIONS: Multiple hospitalizations for shortness of breath with final diagnosis second hand induced chronic obstructive pulmonary disease. Hypertension. Degenerative joint disease. CURRENT MEDICATIONS: Vicodin ES, doxepin 25 bedtime a long standing medication that I have been unable to get her to discontinue, Atenolol 50, Azmacort 2 puffs twice a day, Combivent 4 puffs twice a day, and Ultracet.
ES|extra strength|ES|148|149|PRIMARY PHYSICIAN|3. Peptic ulcer disease. ADMISSION MEDICATIONS: 1. Zantac 150 mg p.o. q.d. 2. Norvasc 2.5 mg p.o. q.d. 3. Chlorthalidone 50 mg p.o. q.d. 4. Tylenol ES p.r.n. ALLERGIES: NO KNOWN DRUG ALLERGIES. FAMILY HISTORY: Noncontributory.
ES|UNSURED SENSE|ES|129|130|PROCEDURES|1. Right upper quadrant ultrasound with common bile duct measuring 12.6 mm with a 3.5 centimeters right renal cyst. 2. ERCP with ES and stent placement that revealed a fibrotic ampulla versus small tumor, questionable cholecystitis. 3. Cholecystectomy. 4. Computed tomography of abdomen and pelvis to evaluate for ampullar Vater.
ES|extra strength|ES|253|254|1. FEN|It is recommended he continue on this formula until 6 months corrected gestational age or until he is at the 50th percentile for his weight. He is also to continue Fer-Gen-Sol as an outpatient as he had prior to his admission. 2. ID: Continue Augmentin ES through _%#MMDD2002#%_ for treatment of his urinary tract infection. 3. GI: Discontinue lactulose, as he has been stooling regular, soft stools.
ES|extra strength|ES|172|173|MEDICATIONS|When his elbow motion was out to 0 degrees CPM and his pain was well controlled, he was deemed ready for discharge. CONDITION ON DISCHARGE: Stable. MEDICATIONS: 1. Vicodin ES 1-2 p.o. q.4-6h. p.r.n. pain. 2. Vistaril 50 mg p.o. q.4h. p.r.n. pain, nausea and vomiting. He is to keep his incision clean and dry except with showering.
ES|extra strength|ES|203|204|PROBLEM #2|He was initially treated with IM ceftriaxone and IV cefotaxime in treatment of his rule out sepsis workup as well as his left lower lobe pneumonia. He was continued on a full 10- day course of Augmentin ES for the pneumonia on discharge. PROBLEM #3: Infectious disease. He ruled out for a 48-hour period with negative urine culture, negative blood culture, and negative CSF culture.
ES|extra strength|ES|184|185|PROBLEM #3|PROBLEM #3: Infectious disease. He ruled out for a 48-hour period with negative urine culture, negative blood culture, and negative CSF culture. He was then switched to oral Augmentin ES as noted above for the treatment of the pneumonia. PROBLEM #4: Neuro. It was felt that Ahmed had two typical febrile seizures and therefore did not have an indication for further workup including MRI or EEG at the time of hospitalization or after discharge unless new symptoms developed.
ES|extra strength|ES|160|161|DISCHARGE MEDICATIONS|DISCHARGE DIAGNOSES: 1. Febrile seizures x 2. 2. Left lower lobe pneumonia. 3. Rule out sepsis/meningitis, workup negative. DISCHARGE MEDICATIONS: 1. Augmentin ES 600 mg p.o. b.i.d. for eight days, to complete a 10-day course of antibiotics. 2. Tylenol 200 mg p.o. q4-6h for fever. 3. Ibuprofen 120 mg p.o. q6-8h p.r.n. fever DISCHARGE INSTRUCTIONS: 1. He had no specific restrictions to his diet or activity.
ES|extra strength|ES|135|136|HISTORY|CRP from last night is not available. The plans are for repeated CRP's in the morning. His current medications are the Tequin, Vicodin ES , usual home medications including Atenolol, Lisinopril, Lipitor, Betoptic, Xalatan, Prilosec, Lexapro, Vitamin D. multivitamin, vitamin E, Metamucil, Ambien, quinine sulfate and Lovenox. Dr. _%#NAME#%_ is following.
ES|extra strength|ES|399|400|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Lasix 60 mg p.o. q.d. Coumadin will be restarted at 3 mg daily when INR is less than 3. Atacand 32 mg p.o. q.d. Atenolol 50 mg p.o. q.d. Norvasc 5 mg p.o. q.d. Klor-Con 10 mEq two tablets p.o. q.d. Cosopt eye drops, one drop OU b.i.d. Xalatan eye drops, one drop OU q.h.s. Calcium 600 mg p.o. q.d. Multivitamin one p.o. q.d. Zantac 75 mg p.o. b.i.d. Darvon 1-2 q.6.h. Tylenol ES 1-2 p.o. q.4-6.h. p.r.n. Dulcolax 5 mg p.o. q.h.s. p.r.n. The patient will get an INR, BUN, and creatinine on _%#MMDD2003#%_ with the results to be called to Dr. _%#NAME#%_ _%#NAME#%_ as the hospital rounder.
ES|extra strength|ES.|187|189|HISTORY|He then laid down on the concrete floor for about an hour. He tried bedrest and ibuprofen as well as heat. He called his primary care clinic, HealthPartners, and they recommended Vicodin ES. He had persistent pain. Therefore, graduated to Percocet. However, he started having dizziness and nausea with that. Due to persistent symptoms and his inability to care for himself, he was seen at FSH ER.
ES|extra strength|ES|197|198|MEDICATIONS|In the emergency room today she received 10 mg of morphine, Zofran, Cipro and one liter of normal saline. MEDICATIONS: 1. Metoprolol 50 mg p.o. b.i.d. 2. Robaxin 750 mg two pills q.i.d. 3. Vicodin ES one to two p.o. q.4-6h p.r.n. pain 4. Protonix 40 mg p.o. b.i.d. 5. Amitriptyline 75 mg p.o. q.h.s. 6. Sodium bicarbonate 650 mg tabs three p.o. t.i.d. and two q.h.s.
ES|extra strength|ES|136|137|MEDICATIONS|2. Iodine. Caused GI upset. 3. Levaquin. Caused GI upset. MEDICATIONS: 1. Neurontin 400 mg q.h.s. 2. Trazodone 300 mg q.h.s. 3. Vicodin ES 7.5/750 two to three tablets per day. 4. Fiorinal p.r.n. for headaches. SOCIAL HISTORY: The patient is widowed. She continues to smoke almost 2 packs of cigarettes a day.
ES|extra strength|ES|142|143|CURRENT MEDICATIONS|CURRENT MEDICATIONS: Prevacid 30 mg q. day initiated on last hospitalization given EGD findings of achalasia. Aspirin 81 mg q. day, Augmentin ES liquid 900 b.i.d., last dose _%#MMDD#%_. REVIEW OF SYSTEMS: The patient unable to provide accurate review of systems.
ES|extra strength|ES.|174|176|DISCHARGE MEDICATIONS|She eventually converted to a sinus rhythm and was discharged home on the fourth post-operative day on _%#MM#%_ _%#DD#%_. DISCHARGE MEDICATIONS: Atenolol, oxycodone, Tylenol ES. She had appointments to see Dr. _%#NAME#%_ in one week, Dr. _%#NAME#%_ in one month, Minnesota Heart Clinic in _%#CITY#%_ in eight weeks.
ES|extra strength|ES|150|151|SUMMARY  OF HOSPITALIZATION|Her chest x-ray was unremarkable. EKG showed poor R-wave progression anteriorly as well as possible old ischemic changes laterally. Repeat troponin I ES x 3 were negative. The patient's liver function tests, basic metabolic profile and CBC were also unremarkable.
ES|enhanced sensitivity|ES|211|212|PROCEDURES|The patient and husband understand this but are planning on flying back to _%#CITY#%_ _%#CITY#%_ at 5:00 this afternoon PROCEDURES: Stress Echocardiogram 12 minutes of exercise no inducible ischemia. Troponin I ES <0.012 x 3 D-dimer <0.3
ES|enhanced sensitivity|ES|134|135|LABORATORY  DATA|LABORATORY DATA: All labs reviewed by myself. Initial EKG shows normal sinus rhythm, no evidence of old or acute ischemia. Troponin I ES at 11:10 p.m. is less than 0.012, myoglobin 91. D-dimer less than 0.2. Hemoglobin 15, white count 7, platelet count 265,000, INR 1, PTT 29.
ES|enhanced sensitivity|ES|88|89|LABORATORY|Sodium 141, potassium 4.2, glucose 107, BUN 11, creatinine 1.1, calcium 9.7. Troponin I ES is less than 0.012, myoglobin 28. D-dimer is 1.4. IMPRESSION: A 51-year-old gentleman with premature family history of ischemic heart disease.
ES|extra strength|ES|162|163|MEDICATIONS|6. Reglan 5-10 mg PO t.i.d. 7. Detrol LA 4 mg PO each day at bedtime. 8. Requip 1 mg PO each day at bedtime. 9. Zofran 8 mg PO t.i.d. p.r.n. nausea. 10. Estroven ES 1 tablet PO each day at bedtime. 11. Cranberry pills 1 tablet in the morning and 1 at night. 12. Tigan 300 mg PO t.i.d. 13. Imitrex 100 mg PO p.r.n. headache.
ES|extra strength|ES|173|174|DISCHARGE MEDICATIONS|6. Prednisone 40 mg p.o. x5 days. 7. Vitamin D 400 international units a day. 8. Coumadin 10 mg today, then her usual 7.5 mg everyday with a goal INR of 2.5-3.5. 9. Vicodin ES 1-2 tablets p.o. q.6h. p.r.n. pain. She was given 15 with no refills.
ES|enhanced sensitivity|ES|145|146|LABORATORY  DATA|LABORATORY DATA: INR of 0.9, normal. BMP was normal with a sodium of 134, potassium 4.0. Follow-up potassium after diatheses was 4.3. Troponin I ES was less than 0.020, three times. TSH 1.14 which indicates she is taking enough levothyroxine replacement. White count was 9000, hemoglobin 14.2. Echocardiogram as mentioned before.
ES|enhanced sensitivity|ES|109|110|PERTINENT LABORATORY STUDIES|EKG portion of the stress test was negative for inducible ischemia. PERTINENT LABORATORY STUDIES: Troponin I ES negative x3, myoglobin normal. ProBNP 539. BUN and creatinine 22 and 1.1, respectively. INR and PTT normal. CBC was normal, white blood cell count 10.3, hemoglobin 13.1. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 78-year-old woman with history of COPD, known coronary artery disease, Barrett esophagus, osteoporosis on Boniva.
ES|extra strength|ES|167|168|DISCHARGE  MEDICATIONS|2. Oxycodone 10-20 mg p.o. q.3h. as needed for breakthrough pain 3. Ibuprofen 600 mg p.o. q.6h. as needed for pain. 4. She was directly advised to stop taking Vicodin ES which I think she had had for previous surgeries at home.
ES|extra strength|ES|150|151|DISCHARGE MEDICATIONS|7. Celexa 20 mg p.o. daily. 8. Levaquin 750 mg p.o. daily for prophylaxis. 9. Voriconazole 300 mg p.o. b.i.d. 10. Norvasc 5 mg p.o. daily. 11. Megace ES 625 mg/5 mL p.o. b.i.d. 12. TriCor 48 mg p.o. daily. 13. Metformin ER 500 mg p.o. daily. 14. Prednisone 20 mg p.o. daily for 4 additional days.
ES|extra strength|ES|159|160|MEDICATIONS|3. Coumadin 4 mg tablets. He takes 6 mg daily 4. Lipitor 20 mg daily 5. Furosemide 40 mg daily. 6. Metoprolol 100 mg tablets. He takes 50 mg b.i.d. 7. Vicodin ES 1 q.i.d. p.r.n. 8. Ceftin 500 mg b.i.d. prescribed on _%#MMDD2007#%_ for ten days. PHYSICAL EXAMINATION: Examination shows a very pleasant 80-year-old male. Height is 6 feet 1 inch, weight is 245 pounds.
ES|extra strength|ES|94|95|MEDICATION|She was ready for discharge the next day. CONDITION ON DISCHARGE: Stable. MEDICATION: Vicodin ES 1 to 2 p.o. q. 4 hours prn pain. PLAN: She is to keep her dressings in place. She is to keep her ankle elevated except when ambulating on crutches.
ES|ejection fraction:EF|ES.|219|221|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Vascular dementia. 2. UTI. 3. Primary hyperparathyroidism, with calcium of 10.8. 4. Anemia, iron deficiency, and anemia of chronic disease. 5. Hyperlipidemia. 6. Dilated cardiomegaly, with a 20% ES. 7. Hemoccult positive stools. MEDICATIONS ON DISCHARGE: 1. Seroquel 25 mg p.o. q.i.d.
ES|extra strength|ES|307|308|MEDICATIONS|Additionally, the plan is to transfer her to a rehabilitation facility until she can either be straight and non-weight bearing with walker ambulation or until six weeks at which time we feel that we can institute some weight bearing. CONDITION ON TRANSFER TO REHABILITATION: Stable. MEDICATIONS: 1. Vicodin ES 1-2 p.o. q. 4-6h. 2. Keflex 500 mg p.o. q.i.d. She is to continue her home medications. ACTIVITY: Elevate her right lower extremity above her heart except for when she is up ambulating with straight non-weight bearing ambulation of the right lower extremity with a walker.
ES|extra strength|ES|159|160|MEDICATIONS|When the patient was tolerating the pain with oral pain medication she was deemed ready for discharge. CONDITION ON DISCHARGE: Stable. MEDICATIONS: 1. Vicodin ES one to two tablets p.o. q4-6h p.r.n. pain. 2. Resume her preoperative medications as well. ACTIVITIES: This will be pinwheel exercises only.
ES|extra strength|ES|151|152|DISCHARGE MEDICATIONS|ENT consultation was obtained. A fine needle aspiration was done on _%#MMDD2003#%_, which did not grow any pathogens. DISCHARGE MEDICATIONS: Augmentin ES 600/42.5 per 5 cc, 1 tsp p.o. b.i.d. for 14 days. DISCHARGE: The patient is to follow-up at Fairview _%#CITY#%_ Clinic with Dr. _%#NAME#%_ in two weeks or sooner if she develops a fever.
ES|extra strength|ES|196|197|DISCHARGE MEDICATIONS|By the following day, the fever resolved. The patient was tolerating p.o. food in the liquid form, as well as pain medicine. The patient had good pain control. DISCHARGE MEDICATIONS: 1. Augmentin ES elixir 4 cc p.o. b.i.d. x 10 days. 2. Tylenol with codeine elixir 0-7.5 cc p.o. q.4h p.r.n. 3. Floxin Otic five drops bilaterally b.i.d. x 5 days. DISCHARGE FOLLOW-UP: He will have an appointment with Dr. _%#NAME#%_ _%#NAME#%_ in three weeks.
ES|UNSURED SENSE|ES,|192|194|DISCHARGE INSTRUCTIONS|He was encouraged to continue his mobility and try to improve his overall pulmonary function following his thoracotomy. Medications at the time of discharge included MiraLax, Bactrim, Colace, ES, Neurontin, K-phos, fluconazole, Zantac. Fentanyl patch 75 mcg q. 72 hours. Percocet one to two tabs p.o. q. 4-6h. p.r.n.
ES|extra strength|ES|133|134|MEDICATIONS|5. Dyazide 37.5/25 PO Q day 6. Clonazepam 1 mg PO QHS prn. 7. Metamucil one scoop PO QD prn. 8. Vioxx 25 mg PO Q day prn. 9. Tylenol ES 500 PO q.i.d. prn. 10. OxyContin 15 mg PO b.i.d. PHYSICAL EXAMINATION: Blood pressure is 152/71, pulse is 68, respiratory rate of 20 and temperature is 97.6. GENERAL: She is resting comfortably, currently in bed, not in much acute pain, not dyspneic.
ES|extra strength|ES|144|145|MEDICATIONS ON ADMISSION|2. Prozac 40 mg daily 3. Prednisone 40 mg daily 4. Lisinopril 2.5 mg daily 5. Ativan is 0.25 at bedtime daily 6. Remeron 15 mg at HS 7. Tylenol ES 1,000 mg prn. 8. Metoprolol 25 mg b.i.d. 9. Protonix 45 mg daily 10. Detrol LA 4 mg daily 11. Fioricet 1-2 PO prn headaches
ES|extra strength|ES|167|168|MEDICATIONS|4. Ferrous sulfate 324 mg p.o. t.i.d. 5. Lexapro 20 mg p.o. q.d. 6. Diltiazem 240 mg p.o. daily. 7. Aricept 10 mg p.o. daily. 8. K-Tab 10 mEq two p.o. q.d. 9. Tylenol ES two tabs p.o. p.r.n. 10. Vicodin 5/500 one to two tablets p.o. p.r.n. 11. Triamterene/hydrochlorothiazide 37._%#MMDD#%_ one p.o. daily
ES|extra strength|ES|121|122|MEDICATIONS ON ADMISSION|10. OxyContin 10 mg p.o. q.12 h. 11. Amitriptyline 50 mg p.o. q.h.s. 12. Hexavitamin one tablet p.o. q.24 h. 13. Tylenol ES 500 mg q.i.d. p.r.n. 14. Meclizine 25 mg p.o. q.i.d. p.r.n. 15. Ferrous sulfate 325 mg p.o. q.24 h. 16. Protonix 40 mg p.o. q.24 h. 17. Clarinex 5 mg p.o. q.24 h. p.r.n.
ES|extra strength|ES|160|161|MEDICATIONS|6. Ibuprofen 800 mg t.i.d. 7. Topamax 100 mg q.i.d. 8. Hydroxyzine 50 mg, 4 to 5 tablets qhs prn for insomnia. 9. Ambien 10 mg q.o.d. prn insomnia. 10. Vicodin ES (7.5/750) one or two q6h prn for pain. 11. Fioricet one to two q.i.d. prn for migraine headache. 12. Diazepam 10 mg q6h prn for tension or spasm.
ES|extra strength|ES|173|174|ASSESSMENT|ASSESSMENT: Pneumonia with wheezing. Due to her significant increased secretions, will admit for albuterol and BDs overnight. Oxygen as needed. Will prescribe Augmentin 600 ES 5 mL b.i.d. Albuterol nebs q.4h and q.2h p.r.n. Will obtain Topamax and Keppra level in the morning (last levels were 44.5 and 11.1 respectively on _%#MMDD2006#%_ per Park Nicollet record.
ES|extra strength|ES|138|139|DISCHARGE MEDICATIONS|8. Seroquel 12.5 mg q.4h. p.r.n. agitation 9. Zoloft 25 mg p.o. daily 10. Trazodone 25 mg at bedtime. 11. Aspirin 81 mg daily 12. Tylenol ES 500-1000 mg q.4-6h. p.r.n. Medications that were discontinued or changed during this hospitalization: Desyrel was decreased from 50 to 25.
ES|extra strength|ES|157|158|MEDICATIONS|8. K-Dur 10 mEq b.i.d. 9. Fentanyl patch 75 mcg q.3 days 10. Ketoprofen gel applied to left knee t.i.d. 11. Ambien 5 mg p.o. each day at bedtime 12. Tylenol ES 500 mg p.o. p.r.n. 13. Zofran p.r.n. 14. Vicodin 1 to 2 p.r.n. PAST MEDICAL HISTORY: Atrial fibrillation, hypertension, recent cerebrovascular infarction involving her left middle cerebral artery.
ES|enhanced sensitivity|ES|169|170|LABORATORY AND  IMAGING STUDIES|LABORATORY AND IMAGING STUDIES: Blood and urine cultures are pending. Carbon monoxide level is 3 (the patient stated that he may have had some exposure to it). Troponin ES is less than 0.012, myoglobin 37. Lipase is 33. Albumin is 4.7. LFTs within normal limits. Electrolytes unremarkable. White count is elevated at 20,800, hemoglobin is elevated at 17.9, platelets 290,000, MCV elevated at 101.
ES|enhanced sensitivity|ES|165|166|LABORATORY AND IMAGING STUDIES|EXTREMITIES: Nonpitting edema going up her legs bilaterally, 2+. NEUROLOGIC: The patient is grossly nonfocal. LABORATORY AND IMAGING STUDIES: Myoglobin 49, troponin ES is 0.230. N-terminal proBNP 199. INR 1.17. Lipase 175. Electrolytes significant for sodium 122. LFTs normal. BUN and creatinine normal. CT scan of abdomen and pelvis showed distended stomach with thickening gastric antrum preliminarily.
ES|enhanced sensitivity|ES|163|164|LABORATORY AND IMAGING STUDIES|NEUROLOGIC: The patient is able to move all four extremities, and is grossly nonfocal with regards to her cranial nerves. LABORATORY AND IMAGING STUDIES: Troponin ES less than 0.12. BNP 1100. INR 1.25. White count 9.3, hemoglobin 7.8, platelets 14,000. Phosphorus is 2.2, magnesium 1.9. Electrolytes are unremarkable.
ES|enhanced sensitivity|ES|192|193|SUMMARY OF HOSPITAL COURSE|The patient was treated with n.p.o. status and numerous consultations obtained as above. She had transient atrial fibrillation with rapid ventricular rate and a slight elevation in troponin 1 ES which was felt due to demand ischemia from the said atrial fibrillation, in turn related to her acute illness and dehydration.
ES|extra strength|ES|123|124|MEDICATIONS AT ADMISSION|5. Ambien 5 mg p.o. q.h.s. 6. Atenolol 25 mg p.o. q.d. 7. Digoxin 0.125 mg p.o. q.d. 8. Paxil 10 mg p.o. b.i.d. 9. Tylenol ES 500 mg p.o. t.i.d. 10. Detrol 4 mg p.o. q.d. 11. Sinemet 25/250 p.o. q.i.d. 12. Coumadin 2 mg p.o. q.o.d. alternating with 1.5 mg p.o. q.o.d. SOCIAL HISTORY: The patient is an Extended Care Facility resident.
ES|extra strength|ES|170|171|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1) Zithromax 250 mg p.o. x1 day to complete a five day course. 2) Gatifloxacin 400 mg p.o. q.d. x3 days to complete a seven day course. 3) Vicodin ES one to two tablets every 6- 8 hours as needed for pain secondary to preexisting sciatica, #25 with no refill.
ES|extra strength|ES|145|146|PRESENT MEDICATIONS|9. Dilantin 300 mg h.s. 10. Iron sulfate 325 mg b.i.d. 11. Albuterol inhaler and/or nebs q.i.d. as needed. 12. Home 02 rarely needs. 13. Tylenol ES two tabs b.i.d. one set at bedtime. HABITS: He absolutely denies any alcohol, cigarettes, or chewing tobacco.
ES|extra strength|ES|151|152|DISCHARGE MEDICATIONS|He tolerated the procedure well and was discharged home on _%#MMDD2002#%_. DISCHARGE MEDICATIONS: 1. Flagyl 250 mg orally four times a day. 2. Vicodin ES 1-2 tablets p.o. q.4-6h. p.r.n. pain. 3. Imodium 5 mg orally four times a day if needed. 4. Valium 5 mg p.o. q.6h. spasms. BRIEF HISTORY: _%#NAME#%_ _%#NAME#%_.
ES|extra strength|ES|217|218|DOB|He clinically had a gradual improvement of his parotid gland induration, tenderness, redness and swelling with only minimal edema at the time of discharge on _%#MMDD2002#%_. He will be sent home on oral Augmentin 600 ES 1 tsp bid starting tonight and follow up with his doctor, Dr. _%#NAME#%_ next week. Did discuss his plan with Pediatric Hematology, Dr. _%#NAME#%_ _%#NAME#%_ who recommended that we repeat his CBC in one week and obtain a baseline chest x-ray, LDH and uric acid and also will obtain a monospot and HIV study as well on discharge.
ES|extra strength|ES|348|349|DISPOSITION|Combivent inhaler with AeroChamber spacer device was started one day prior to discharge, teaching by RT was requested and asthma education was reiterated. DISPOSITION: Patient will be discharged home with her regular maintenance of Advair 250/50 one inhalation q.12h, and switched to Combivent MDI with AeroChamber two puffs q.4-6h p.r.n., Bactrim ES one p.o. b.i.d. for ten days, prednisone taper as ordered, Liquibid 600 mg p.o. q.12h p.r.n., and Flonase nasal spray two puffs each nostril once daily for chronic congestion.
ES|extra strength|ES|221|222|HOSPITAL COURSE|Due to persistent low grade fevers despite an elevation in white count, concern was raised for aspiration pneumonia. Antibiotics were changed to Zosyn and she defervesced and did well. She tolerated a switch to Augmentin ES suspension and remained afebrile. At the time of discharge, she denies any specific complaints, she reports minimal cough, afebrile with a temperature of 98.6 since switching to oral antibiotics.
ES|extra strength|ES|155|156|HOSPITAL COURSE|The patient is ready for discharge and will be discharged to home on her home medications as listed above. In addition, she will be treated with Augmentin ES 600 mg suspension 16 ml per feeding tube b.i.d., dispensed #250 ml with no refills. Medication and dose chosen not to provide semi-coverage as Augmentin XR.
ES|extra strength|ES|118|119|DISCHARGE MEDICATION|He was discharged to home on postoperative day number 4 with the following medications: DISCHARGE MEDICATION: Vicodin ES 1 to 2 tablets p.o. q.4-6h. p.r.n. for pain. He was expected to take this for 2 or 3 days and then decrease to regular Vicodin 1 to 2 p.o. q.6h. for pain.
ES|extra strength|ES|142|143|DISCHARGE MEDICATIONS|15. Major anxiety, depressive disorder with panic attacks. 16. Acute pseudomembranous colitis and diarrhea. DISCHARGE MEDICATIONS: 1. Vicodin ES one tablet q.i.d. p.r.n. 2. Demadex 20 mg daily in a.m. 3. Potassium 20 mEq t.i.d. 4. Synthroid 0.175 mg daily. 5. Allopurinol 300 mg tablets, 1/2 tablet daily.
ES|extra strength|ES.|171|173|HPI|Provider noted right mandibular adenopathy/adenitis, patient otherwise well-appearing and adequately hydrated. Given Rocephin 50 mg/kg IM times one and begun on Augmentin ES. Seen in follow up Friday, _%#MMDD2004#%_, afebrile, continued slightly fussy but nursing well. No change in the size or consistency of the adenopathy.
ES|extra strength|ES|194|195|COURSE IN THE HOSPITAL|Her aspirin (81 mg q.d.) is discontinued, and the patient is advised that she needs to avoid ibuprofen, Naprosyn, alcohol, caffeine, and chocolate. She is advised that Tylenol 325 mg or Tylenol ES (500 mg) is safe to take at 1 or 2 q.4-6h. p.r.n. for pain or fever. Discharge activity is without restriction. DISCHARGE MEDICATIONS: 1. Plavix 75 mg p.o. q.d.
ES|extra strength|ES,|144|146|DISCHARGE MEDICATIONS|The patient in retrospect feels that her problem is related to that activity. She did a lot of heavy lifting. DISCHARGE MEDICATIONS: 1. Vicodin ES, one tablet every 3 to 6 hours prn. #30 with one refill. 2. Robaxin 750 mg, one tablet q.i.d. prn. #30 with one refill. The patient will be seen in follow-up in the office.
ES|extra strength|ES|134|135|DISCHARGE MEDICATIONS|11. Colace 100 mg b.i.d. 12. Multivitamin 1 q.d. 13. Os-Cal D 600 mg q.d. 14. Vicodin 5/500 mg 1 q.4-6h. p.r.n. for pain. 15. Tylenol ES 500 mg 1 or 2 q.i.d. p.r.n. for mild pain or fever. The patient will follow up at my office on _%#MM#%_ _%#DD#%_, 2004.
ES|extra strength|ES|122|123|MEDICATIONS|2. Lotrel 10/20 mg one PO Q day 3. Lopressor 50 mg PO Q day 4. HCTZ 12.5 mg PO Q day 5. Aspirin 81 mg PO Q day 6. Vicodin ES 1-2 tablets Q 6 hours prn. shoulder and hand pain 7. Hydroxyzine 50 mg PO b.i.d. prn. 8. Plavix 75 mg PO Q day 9. Lexapro 10 mg PO Q day SOCIAL HISTORY: She is currently living with a relative.
ES|extra strength|ES|134|135|ASSESSMENT AND PLAN|5. Hypertension. Start lisinopril. Cardiac prophylactic medication, aspirin 81 mg. Nitro as needed. 6. Other orders as written by the ES physician. The patient is a Full Code patient.
ES|extra strength|ES|130|131|DISCHARGE MEDICATIONS|3. Vytorin 10/40, one daily. 4. Lasix 40 mg daily. 5. Coumadin 15 mg daily. 6. Vicodin one to two q four to six hours. 7. Tylenol ES q six hours p.r.n. for fever. 8. Keflex 500 mg q six hours for 14 days. Orders for physical therapy and occupational therapy were given.
ES|enhanced sensitivity|ES|131|132|HOSPITAL COURSE BY PROBLEM|This was complicated following this by yet another bump in her troponin and non-ST segment elevation MI. At this point, Troponin I ES assay was utilized which peaked at 0.2. Once again medical therapy was undertaken. This was thought to be demand ischemia and in the end, medical therapy was considered to be the treatment of choice, rather than an interventional approach.
ES|extra strength|ES|120|121|CURRENT MEDICATIONS|Allegra 60 mg q.d. 6. Lipitor 20 mg q.d. 7. Lasix 20 mg q.d. 8. Synthroid 125 mcg q.d. 9. Estrace 1 mg q.d. 10. Vicodin ES p.r.n. pain. 11. Duragesic patch 25 mcg per hour q.72h. 12. Percocet two tabs t.i.d. 13. Detrol 2 mg q.d. 14. Clonidine 0.1 10 mg q.d.
ES|ejection fraction:EF|ES|240|241|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|I suspect that she had some congestive heart failure mostly due to this anemia in the setting of mild diastolic dysfunction. Echocardiogram was obtained which actually showed an improvement of her ejection fraction since her last echo. Her ES at this time is 60-65%. There were no significant abnormalities on her echocardiogram aside from left atrial enlargement of 48 mm.
ES|extra strength|ES|165|166|DISCHARGE MEDICATIONS|She will go to the Pain Clinic for some minor reprogramming. DISCHARGE MEDICATIONS: 1. Quinine 325 mg p.o. q.h.s. 2. Flexeril 10 mg p.o. b.i.d. to t.i.d. 3. Vicodin ES one to two p.o. q.4-6h p.r.n. pain. 4. Vitamin E one p.o. q.d. 5. Excedrin p.r.n. 6. Keflex 500 mg p.o. q.i.d. x five days.
ES|extra strength|ES|148|149|DISCHARGE INSTRUCTIONS|The patient has been having problems with shoulder pain for many months and conservative approaches have not relieved the symptoms. He uses Vicodin ES (7.5 mg) sparingly for pain, but he finds that he is awakened by pain at least once or twice during the course of the night.
ES|extra strength|ES|151|152|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1. Multivitamins with iron 1 p.o. q.d. 2. Iron sulfate 324 mg p.o. q.d. 3. Vitamin E 400 International Units p.o. q.d. 4. Vicodin ES (7.5) 1 p.o. q.4h. p.r.n. for pain. 5. Temovate cream 0.05% b.i.d. p.r.n. for rash. 6. Temazepam 15 mg q.h.s. p.r.n. for insomnia.
ES|extra strength|ES|247|248|DISCHARGE INSTRUCTIONS|She requested early release on the second postoperative day. CONDITION OF THE PATIENT AT THE TIME OF DISCHARGE: The patient is ambulatory and able to perform self cares without difficulty. DISCHARGE INSTRUCTIONS: 1. Discharge medications: Vicodin ES 1 p.o. q. 4-6 hours p.r.n. pain, Peri-Colace 1 p.o. b.i.d. 2. Diet restrictions: No relevant. 3. Physical activity restrictions: The patient is instructed to avoid vigorous exercise or heavy lifting.
ES|extra strength|ES|221|222|DISCHARGE MEDICATIONS|The social worker met with the patient and gave her phone numbers and various resources to contact for assistance. DISCHARGE MEDICATIONS: 1) Diastat 2.5 mg per rectum p.r.n. seizure greater than 3-5 minutes. 2) Augmentin ES 600 mg per teaspoon, one teaspoon p.o. b.i.d. for seven days. DISCHARGE FOLLOW-UP: The patient is to follow-up with Fairview _%#CITY#%_ Clinic to review MRI scan and consider pursuing a voiding cystourethrogram.
ES|extra strength|ES,|152|154|PLAN|PLAN: 1. Lipitor, 10 mg q.h.s. 2. Avandia, 4 mg p.o. q.d. 3. Macrobid, 100 mg b.i.d. for 3 days. 4. Toradol, 10 mg q.6h. p.r.n. pain relief. 5. Vicodin ES, 1-2 every 4 hours p.r.n. pain relief. 6. Pyridium, 200 mg q.8h. p.r.n. urine symptoms. 7. Aspirin, 81 mg uncoated q.d. with food.
ES|extra strength|ES|174|175|HOSPITAL COURSE|Prior to discharge, _%#NAME#%_ was stable on room air for 24 hours and was breast feeding well. He will be discharged to complete a course of oral antibiotics, Augmentin 600 ES 90 mg/kg for an additional six days to complete a 10 day course. FOLLOW-UP PLAN: Patient will follow-up with primary care M.D. at Fairview _%#CITY#%_ Clinic in one week and mother will call clinic in the next few days for final pertussis result.
ES|extra strength|ES|124|125|DISCHARGE MEDICATIONS|2. Toprol XL 50 mg p.o. q day. 3. Ceftin 250 mg b.i.d. through _%#MMDD2005#%_. 4. Fluoxetine 20 mg p.o. q day. 5. Tylenol - ES 500 mg one or two q six hours prn pain or fever. 6. Senokot tablet one b.i.d. 7. MiraLax one capful or one packet q day.
ES|extra strength|ES|193|194|REVIEW OF SYSTEMS|She denies any significant recent increased shortness of breath or change from her usual edema. Musculoskeletal: She has chronic diffuse pain mostly in her back, knees. She has been on Vicodin ES q.i.d. but a couple of weeks ago was decreased to t.i.d. per son because she had been getting a little more confused.
ES|erythrocyte sedimentation rate:ESR|ES|103|104|ALLERGIES|CT of the chest was performed and was negative for any PE. She had a D-dimer of 17.3, a CRP of 15.9, a ES of 85, INR 1.24 and a PTT of 54. Alkaline phosphatase was 246, AST and ASG were normal, lipase was 619, and amylase was 105.
ES|extra strength|ES|172|173|DOB|DISCHARGE DISPOSITION: Discharged to home, where he will continue to ambulate. He will receive Oxycontin 40 mg twice a day, and receive 60 of those, in addition to Vicodin ES for which he will receive 100. Additionally, he had a decreased hemoglobin and was started on iron at the time of discharge and this will be rechecked on his return to clinic.
ES|extra strength|ES|116|117|DISCHARGE MEDICATIONS|4. Cogentin 1 mg p.o. daily. 5. Wellbutrin 100 mg p.o. b.i.d. 6. Levaquin 500 mg daily for 10 days p.o. 7. Depakote ES 125 mg p.o. each day at bed time. 8. Aricept 10 mg p.o. each day at bed time. 9. Ferrous sulfate 325 mg p.o. daily. 10. Folic acid 1 mg p.o. daily.
ES|extra strength|ES|206|207|DOB|Blood culture was drawn and he was placed on ceftriaxone while awaiting the results of that culture. He had two full days of I.V. antibiotics, at which time he was switched to oral Augmentin 600 mg/5 cc of ES suspension, taking 3/4 tsp twice a day for ten days. On this, he came off of oxygen and is discharged to finish off a full seven more days of oral Augmentin.
ES|extra strength|ES.|199|201|HOSPITAL COURSE|2. Tonsillitis. Initially he did have a fever but his fever defervesced. He has been afebrile for more than 24 hours. He was initially given Bicillin. He was started on _%#MMDD2004#%_ with Augmentin ES. He was also started on Solu-Medrol. He did have ENT #2 and he did have tonsillitis with left tonsillar enlargement.
ES|extra strength|ES|267|268|CHIEF COMPLAINT|History of carpal tunnel surgery on the right times two, the left times one in 1994. History of peptic ulcer disease in 1989. His current medications are Flexeril 10 mg b.i.d. to t.i.d. OxyContin 10 mg b.i.d. Neurontin 800 mg t.i.d. Zantac 150 mg p.o. b.i.d. Vicodin ES b.i.d. to t.i.d. p.r.n. breakthrough pain. He has no drug allergies. He has no pertinent family history.
ES|extra strength|ES|150|151|DISCHARGE MEDICATIONS|1. Lantus 4 units, we will start that and sliding scale Regular. 2. Aspirin 81 mg. 3. Colace 100 mg. 4. Paxil 40 mg. 5. Coreg 3.125 b.i.d. 6. Tylenol ES 1000 q.i.d. 7. Namenda 10 mg b.i.d. 8. Lasix 20 mg twice a week. 9. Potassium with each Lasix 10 mEq. 10. Metamucil 1 tablespoon q. day.
ES|extra strength|ES|193|194|HOSPITAL COURSE AND MANAGEMENT|He also received prednisolone. He also did desaturate down to 85% or so for two nights in a row and hence, received some supplemental oxygen. 3. Infectious Disease. He was started on Augmentin ES in Urgent Care. On the floor, due to persistent tachypnea and persistent fevers, he was also started on Zithromax. X-RAY: The final report was right lower lobe pneumonia with bilateral perihilar infiltrates.
ES|extra strength|ES|161|162|DISCHARGE|DISCHARGE DIAGNOSIS: This is a 21-month-old male with pneumonia, wheezing and hypoxia. DISCHARGE: He was discharged on _%#MM#%_ _%#DD#%_ on Zithromax, Augmentin ES and albuterol nebs. He was asked to follow-up with his primary pediatrician in one to two days and was instructed to return to clinic for fevers greater than 101, worsening cough, wheezing, difficulty breathing, chest pain or other concerns.
ES|extra strength|ES|170|171|DISCHARGE MEDICATIONS|He was seen by speech pathology who recommended outpatient video fluoroscopic swallow study with upper GI to assess the above issues. DISCHARGE MEDICATIONS: 1. Augmentin ES 480 mg; amoxicillin component to be taken orally twice daily for 7 days; to complete a 10-day course of antibiotics.
ES|extra strength|ES|197|198|ADMISSION MEDICATIONS|2. Atenolol. 3. Chlorthalidone 100 mg/25 one p.o. daily. 4. Norvasc 10 mg p.o. daily. 5. Prednisone 5 mg p.o. daily. 6. Lactinex one tablet p.o. t.i.d. 7. Allopurinol 100 mg p.o. daily. 8. Tylenol ES 500 mg p.o. b.i.d. 9. Tylenol PM one p.o. q.h.s. 10. Aspirin 81 mg p.o. daily. 11. Lasix 20 mg p.o. t.i.d. 12. Vitamin E 400 units one tablet p.o. daily.
ES|extra strength|ES|167|168|MEDICATIONS|MEDICATIONS: 1. Jantoven 5 mg, 1 tablet daily. 2. Lasix 40 mg p.r.n. edema daily. 3. Potassium chloride 20 mEq, 1-2 tablets p.o. daily as needed for edema. 4. Vicodin ES 7.5/750, 1 tablet every 4-6 hours as needed. 5. Coumadin 5 mg daily for 6 days and then Coumadin 2.5 mg 1x per week on Thursdays.
ES|extra strength|ES|145|146|HISTORY/HOSPITAL COURSE|She is afebrile at this point, range of motion past 100 degrees, walking with good reciprocal gait pattern. Pain is controlled well with Vicodin ES p.r.n. DISCHARGE MEDICATIONS: 1. Vicodin for pain. 2. Anticoagulation prophylaxis will be discontinued with Coumadin and INRs that were drawn here, and will be initiated with Ascriptin to be taken one tablet daily.
ES|extra strength|ES|143|144|MEDICATIONS|10. Spiriva, one capsule inhaled q. day. 11. DuoNeb 2.5/5 mg solution in neb q.i.d. 12. Rozerem 8 mg one-half hour before bedtime. 13. Tylenol ES 500 mg, one q.i.d., up to eight a day. ALLERGIES: None. SOCIAL HISTORY: He is divorced. He quit smoking 12 years ago.
ES|extra strength|ES,|145|147|MEDICATIONS ON ADMISSION INCLUDE|ALLERGIES: Patient is allergic to ACE inhibitors. MEDICATIONS ON ADMISSION INCLUDE: 1. Calcium 600 with vitamin D 200, one p.o. daily 2. Vicodin ES, one p.o. every 4-6 hours as needed 3. Prilosec 20 mg p.o. daily 4. Lasix 40 mg p.o. daily 5. Potassium chloride 20 mEq daily 6. Diazepam 5 mg at 3:00 a.m. and 2.5 mg at 3:00 p.m.
ES|extra strength|ES|154|155||Sensitivities were available prior to discharge. _%#NAME#%_ is being discharged to home today with a diagnosis of UTI. She will be sent home on Augmentin ES 600 mg per 5 ml, 2 ml p.o. b.i.d. for 10 days. She will need to have a VCUG arranged as an outpatient.
ES|extra strength|ES,|230|232|DISCHARGE MEDICATIONS|11. Prednisone 40 mg p.o. daily x5 days, then 20 mg p.o. daily x5 days, then 10 mg p.o. daily x5 days, then 5 mg p.o. daily x5 days, then stop. 12. Vitamin C, 500 mg p.o. daily. 13. Multivitamin one tablet p.o. daily. 14. Tylenol ES, one tablet p.o. q 4 hours p.r.n. DISPOSITION: The patient will be discharged to home.
ES|extra strength|ES|156|157|DISCHARGE MEDICATIONS|5. Levothyroxine 125 mcg per day. 6. Plavix 75 mg per day. 7. Prinivil 20 mg per day. 8. Protonix 40 mg per day. 9. Septra-DS one tablet daily. 10. Tylenol ES two tablets q.4h. p.r.n. pain. 11. Norvasc 5 mg per day. DISCHARGE INSTRUCTIONS: 1. WanderGuard System will be initiated.
ES|extra strength|ES|211|212|REVIEW OF SYSTEMS|FAMILY HISTORY: Remarkable for cerebrovascular disease, gynecological cancer, pancreatic cancer, bone cancer, diabetes. REVIEW OF SYSTEMS: HEENT - negative. Neck - the patient uses ibuprofen or Aleve or Tylenol ES for her osteoarthritic neck symptoms. Cardiac - negative. Respiratory - negative. GI - negative. GU - the patient is concerned about the effect of her over-the-counter medications on her kidneys.
ES|extra strength|ES|124|125|PLAN|Electrolytes normal. CBC normal. FINAL DIAGNOSIS: Post LEEP procedure-induced endometritis PLAN: Discharged on 1. Augmentin ES 875 b.i.d., 14 days. 2. Flagyl 500 mg b.i.d., 14 days 3. Zofran 8 mg sublingually q8 hours p.r.n., #10 She will follow up with Dr. _%#NAME#%_ _%#NAME#%_.
ES|extra strength|ES|165|166|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Metoprolol XL 50 mg q.d. 2. Protonix 40 mg q.a.m. 3. Lescol 40 mg q.h.s. 4. Tylenol PM 1 or 2 q.h.s. p.r.n. for insomnia. 5. Plain Tylenol ES 500 mg 1 or 2 q.6h. p.r.n. for mild pain or fever. 6. Vicodin (5/500) 1 or 2 q.4-6h. p.r.n. for intense pain.
ES|extra strength|ES|228|229|DISCHARGE MEDICATIONS|This procedure was completed without difficulty. The patient had an uneventful recovery and was discharged on the first postoperative day. DISCHARGE MEDICATIONS: 1. Percocet 1 to 2 tablets p.o. q. 4 to 6 hours p.r.n. 2. Tylenol ES 500 mg q.i.d. p.r.n. FOLLOW-UP: I have asked the patient to follow-up with her primary care physician, Dr. _%#NAME#%_ _%#NAME#%_ at the Fairview _%#CITY#%_ Clinic next week.
ES|extra strength|ES|173|174|MEDICATIONS|3. Nitroglycerine 6.5 mg t.i.d. 4. Spironolactone 6.25 mg daily. 5. Metoprolol 100 mg b.i.d. 6. Captopril 50 mg b.i.d. 7. Prilosec 20 mg daily. 8. Mylicon p.r.n. 9. Tylenol ES p.r.n. 10. Glucosamine t.i.d. 11. He had been on Coumadin; I believe this was for a CVA in the past; however, he had been told to stop it at the time of discharge previously.
ES|enhanced sensitivity|ES|158|159|HOSPITAL  COURSE|5. Small demand ischemia. The patient during her respiratory status had a slight elevation in her troponin which is likely demand ischemia. Her peak troponin ES was 0.190, which downtrended further. The patient had no cardiac symptoms since that time.
ES|extra strength|ES|116|117|MEDICATIONS|2. Status post bladder repair for urinary incontinence. MEDICATIONS: 1. Dyazide 37.5/25, 1 p.o. q. day. 2. Gaviscon ES 1 p.o. q. day p.r.n. 3. Nexium 40 mg p.o. b.i.d. 4. Refresh eye drops p.r.n. 5. Risperdal 0.5 mg p.o. q. day. 6. Synthroid 75 mcg p.o. q. day.
ES|extra strength|ES|121|122|DISCHARGE MEDICATIONS|7. K-Lorcon 10 mEq daily in am. 8. Lasix 40 mg daily. 9. Prilosec 20 mg daily. 10. Synthroid 0.125 mg daily. 11. Tylenol ES 500 mg tablet b.i.d. 12. Soma 25 mg daily in hs. 13. Darvon plane 65 mg q 4 h p.r.n. 14. Neosporin ointment to lubricate Foley catheter once daily. 15. Plavix 75 mg daily.
ES|extra strength|ES|121|122|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Vaseretic 10/25 one daily. 2. Amitriptyline 10 mg daily. 3. Lovastatin 40 mg daily. 4. Vicodin ES 750 mg/500 one q.6-8h. 5. Ativan 1 mg one-half to one tab q.4-6h as needed for anxiety. 6. Prednisone three tablets by mouth daily with a taper downward.
ES|extra strength|ES|177|178|DISCHARGE MEDICATIONS|4. Lisinopril 2.5 daily. 5. Metoprolol 25 mg daily. 6. Prilosec 20 mg daily. 7. Guaifenesin 600 mg b.i.d. 8. Synthroid 0.025 daily. 9. Spiriva one inhalation daily. 10. Tylenol ES one to two every four to six hours. 11. Vicodin one p.o. q four hours prn pain. 12. Ferrous Sulfate 325 mg daily with small orange juice.
ES|extra strength|ES|185|186|DISCHARGE MEDICATIONS|5. Hypertension. 6. Osteoarthritis. ALLERGIES: Include codeine. DISCHARGE MEDICATIONS: 1. Amaryl 4 mg PO b.i.d. 2. Spironolactone 25 mg PO q. day. 3. Dulcolax one PO q. day. 4. Tylenol ES 1000 mg PO t.i.d. 5. Oxycodone 10 mg PO b.i.d. 6. Synthroid 100 mcg PO q. day. This is a dose reduction. The patient was previously on 125 mcg PO q. day and was over replaced.
ES|extra strength|ES|138|139|DISCHARGE MEDICATIONS|4. Albuterol metered-dose inhaler 90 mcg 2 puffs q. 4-6 hours p.r.n. 5. Zoloft 100 mg p.o. daily. 6. Zantac 150 mg p.o. b.i.d. 7. Tylenol ES 500-1000 mg p.o. q.4-6 hours p.r.n. for pain, maximum 4 g per day. 8. Aquatears 2 drops per eye p.r.n. 9. Ibuprofen 800 mg p.o. daily.
ES|extra strength|ES,|127|129|MEDICATIONS|7. Colace, 100 mg. 8. Xalatan, 0.005% one drop each eye q. day. 9. Plavix, 75 mg a day. 10. Aspirin, 325 mg a day. 11. Tylenol ES, two tablets t.i.d. She is full code. SOCIAL HISTORY: She stopped smoking 40 years ago. She is a widow.
ES|extra strength|ES|173|174|MEDICATIONS|MEDICATIONS: 1. Hydrocodone chronically for back pain. 2. Albuterol inhaler and nebs every day p.r.n. 3. Naproxen 500 mg b.i.d. p.r.n. 4. Multivitamin every day. 5. Tylenol ES p.r.n. 6. Ferrous sulfate. 7. Dristan. ALLERGIES: PENICILLIN. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She has been a smoker for decades.
ES|extra strength|ES|227|228|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Piperacillin/tazobactum 3.375 g IV q.6h. to be stopped on _%#MM#%_ _%#DD#%_, 2005. 2. Levofloxacin 100 mg IV q. day to be stopped on _%#MM#%_ _%#DD#%_, 2005. 3. Metoprolol 50 mg p.o. b.i.d. 4. Lexapro ES 40 mg p.o. q. day. 5. CellCept 500 mg p.o. b.i.d. 6. Prednisone 2.5 mg p.o. q. day. 7. Protonix 40 mg p.o. q. day. 8. Prograf 1 mg p.o. b.i.d.
ES|extra strength|ES|160|161|MEDICATIONS|6. Ferrous sulfate 325 mg p.o. daily. 7. Gabapentin 600 mg p.o. t.i.d. 8. Lidocaine 5% patch, 2 over the right thigh q. 24 hours for 12 hours only. 9. Protonix ES 40 mg p.o. daily. 10. Prednisone 60 mg p.o. daily, to be followed by primary care. The patient needs to follow up with her primary care, Dr. _%#NAME#%_, at the Park Nicollet _%#CITY#%_ Clinic in 1 week.
ES|extra strength|ES|131|132|DISCHARGE MEDICATIONS|DISCHARGE INFORMATION: Discharge date: _%#MM#%_ _%#DD#%_, 2006. Discharge diagnoses: As above. DISCHARGE MEDICATIONS: 1. Augmentin ES 750 mg p.o. b.i.d. x14 days. 2. Lactobacillus one-quarter to one teaspoon orally 1 to 2 times a day with liquid for 14 days.
ES|extra strength|ES|241|242|MEDICATIONS|She brought the patient here for evaluation. The patient reports that otherwise she had been feeling well, no other troubles or problems. MEDICATIONS: Currently she takes 1. Caltrate 600/200 one tablet daily 2. Coreg 25 mg b.i.d. 3. Tylenol ES one tablet every four hours as needed 4. Lasix 40 mg daily. 5. Hydroxyzine 25 mg 3 times daily. 6. Multivitamin 1 tablet in daily. 7. Norvasc 5 mg daily.
ES|extra strength|ES|111|112|DISPOSITION|The rash is actually the biggest issue at the time of discharge. Discharge medications include Augmentin 600/5 ES two teaspoons p.o. b.i.d. for 10 days and albuterol nebs q.4h. We will increase the Zyrtec to 10 mg p.o. daily and also continue the Atarax throughout 10-15 mg p.o. q.6h. p.r.n. itching.
ES|extra strength|ES|120|121|CURRENT MEDICATIONS|7. Ultram p.r.n. 8. Zoloft 200 mg p.o. every day. 9. Celebrex 200 mg p.o. every day. 10. Combivent two puffs b.i.d. 11. ES Tylenol 1,000 mg p.o. q.4h. p.r.n. 12. Advair discus 500/50 one puff b.i.d. 13. Trazodone 100 mg p.o. at bedtime. 14. Aricept 5 mg p.o. every day.
ES|extra strength|ES|207|208|MEDICATIONS|She was admitted yesterday. Moist dressings have been applied and we were asked to see her in consultation. MEDICATIONS: 1. Baclofen 15 mg t.i.d. 2. Colace 100 mg daily p.r.n. 3. Senokot 1 daily. 4. Tylenol ES q.i.d. p.r.n. ALLERGIES: No chronic allergies. PAST MEDICAL HISTORY: 1. In 1972, tubal ligation. 2. In 1996, varicose vein surgery on the right leg with history of a deep venous thrombosis treated with Coumadin.
ES|extra strength|ES|113|114|UNCHANGED MEDICATIONS|5. Metoprolol 12.5 mg p.o. b.i.d. 6. Phenytoin 200 mg p.o. daily. 7. Loperamide 2 mg p.o. q12h p.r.n. 8. Tylenol ES 500 mg two tabs p.o. t.i.d. 9. Calcium with vitamin D 400 mg p.o. daily. 10. Aricept 10 mg p.o. daily. 11 Calcium carbonate 600 mg p.o. daily. 12. Preparation H as needed to hemorrhoids daily p.r.n. PHYSICIAN FOLLOWUP: Follow up with TCU physician in one week to assess blood sugars, which will be checked b.i.d. and his overall progress.
ES|extra strength|ES|177|178|MEDICATIONS|17. Megace 20 mg p.o. q. day 18. Metoprolol 25 mg p.o. b.i.d. 19. Milk of Magnesia p.r.n. 20. Multivitamin one p.o. q. day 21. Nitroglycerin p.r.n. 22. Senna p.r.n. 23. Tylenol ES p.r.n. PHYSICAL EXAMINATION: GENERAL: She is sitting in a wheelchair, she is thin.
ES|extra strength|ES|133|134|MEDICATIONS|8. Prednisone 1 mg daily. 9. Lasix 40 mg p.o. daily p.r.n. 10.Calcium carbonate 500 mg t.i.d. 11.Avista 60 mg p.o. daily. 12.Vicodin ES 7.5/750 mg q.4-6h p.r.n. 12.Albuterol neb 4 times daily p.r.n. ALLERGIES: Fluoroquinolones. FAMILY HISTORY: Cervical and colon cancer. SOCIAL HISTORY: Positive tobacco use, quit in 1999 after a 4 pack a day habit.
ES|extra strength|ES|149|150|DISCHARGE MEDICATIONS|DISCHARGE FOLLOWUP: With Dr. _%#NAME#%_ _%#NAME#%_ at Fairview Children's Clinic on Tuesday following discharge. DISCHARGE MEDICATIONS: 1. Augmentin ES 1 teaspoon (600 mg) p.o. b.i.d. x6 more days to complete a 10-day course. 2. Captopril suspension 3 mg p.o. t.i.d. 3. Flovent 110 mcg 2 puffs b.i.d.
ES|extra strength|ES|109|110|PLAN|Singulair 5 mg q. a.m. Zithromax 200 mg per 5 mL, 6.5 mL p.o. for one more dose at 8 p.m. tonight. Augmentin ES 600/5 mL, 8.5 mL p.o. b.i.d. x5 days. Orapred 15 mg/5 mL, 8 mL p.o. b.i.d. x3 days, 8 mL p.o. daily x3 days.
ES|extra strength|ES|174|175|DISCHARGE MEDICATIONS|5. Lisinopril 10 mg daily. 6. Halcion 125 mcg 1-2 p.o. at bedtime, sleep. 7. Warfarin was held. 8. Morphine sulfate 0.1% gel applied to the abdomen q.4h for pain. 9. Vicodin ES 1-2 tablets every 6 hours p.r.n. pain. 10. Ketoprofen gel 10% topical to hands, knees and abdomen as needed. 11. Potassium chloride 40 mEq daily. ALLERGIES: None known. FAMILY HISTORY: Is significant for coronary artery disease in mother.
ES|extra strength|ES.|225|227|HOSPITAL COURSE|His last hemoglobin was 15 on _%#MMDD#%_ and also noted was a sodium of 140, potassium 3.9. His medication list included Allegra one daily, multivitamins one daily, Celebrex 200 mg daily, Vicodin 5/50 p.o. p.r.n. and Tylenol ES. These were all discontinued. He was changed over to Lortab liquid 1-2 teaspoons q. 4-6 hours p.r.n. for pain, 300 cc dispensed. Also ranitidine 75 mg per 5 cc, 2 teaspoons b.i.d. for 3 months.
ES|extra strength|ES|131|132|DISCHARGE MEDICATIONS|2. Os-Cal with vitamin D 500 mg p.o. q. day. 3. Metoprolol 25 mg p.o. b.i.d. 4. Remeron 15 mg p.o. each day at bedtime. 5. Tylenol ES 500 mg 1-2 p.o. q.i.d. p.r.n. 6. Bisacodyl laxatives suppositories 10 mg PR every other day. 7. Multivitamins 1 p.o. q. day. DISCHARGE FOLLOW-UP: 1. To be with Dr. _%#NAME#%_ _%#NAME#%_ per his discretion .
ES|extra strength|ES,|282|284|HOSPITAL COURSE|Her E. coli urinary tract infection was resistant on sensitivities to ampicillin, trimethoprim sulfamethoxazole, but susceptible to all other antibiotics tested, including nitrofurantoin and Augmentin, also cefazolin, ceftriaxone, cefuroxime, etc. She will go home on Augmentin 600 ES, 3/4 tsp b.i.d., which she has tolerated in the past, and continue on that to complete 10 days of therapy, then continue it at a once a day basis until follow up with her primary, Dr. _%#NAME#%_.
ES|extra strength|ES|179|180|MEDICATIONS|Other significant problems in the recent past have been the lumbosacral neuritis due to degenerative disk disease. She is using oxygen at night presently. MEDICATIONS: 1. Vicodin ES 7.5 mg. She is taking two of those every four hours. 2. She uses Spiriva HandiHaler. 3. She is taking Duonebs twice a day.
ES|extra strength|ES|307|308|MEDICATIONS|He has a history of schizophrenia. He has a history also of hypertension which has been under good control. MEDICATIONS: He is on Remeron 30 mg at bedtime, Toprol XL 50 mg daily, Prevacid 30 mg daily, Zyprexa 30 mg at bedtime, Ambien 10 mg at bedtime, Neurontin 900 mg 3x daily, and he's been using Vicodin ES 1 every 4 hours or so as needed for pain, he's been using 4-5 per day. ALLERGIES: He says he's allergic to phenothiazine's, however, it sounds more like a toxic reaction rather than a true allergy.
ES|extra strength|ES,|159|161|DISCHARGE MEDICATIONS|9. Wellbutrin Sustained Action 150 mg q.d. 10. Risperdal 0.5 mg q.d. 11. Albuterol nebs, 2.5 mg b.i.d. 12. Nitroglycerin 0.4 mg p.r.n. chest pain. 13. Tylenol ES, two q.i.d. p.r.n. pain. 14. Levaquin 250 mg daily x 7 days. PRINCIPAL DIAGNOSES: 1. Acute influenza. 2. Acute exacerbation of chronic lung disease.
ES|extra strength|ES|127|128|DISCHARGE MEDICATIONS|9. Pulmozyme 2.5-mg nebs. 10. Vitamins A, D, E and K. 11. Pancrecarb MS 7-8 tabs with meals and 4-5 tabs with snacks. 12. Tums ES 2 tabs p.o. with meals. 13. Ranitidine 150 mg p.o. b.i.d. 14. Folic acid 1 mg p.o. q.d. 15. Colace 100 mg p.o. b.i.d.
ES|extra strength|ES|160|161|DISCHARGE MEDICATIONS|3. Aspirin 81 mg p.o. daily. 4. Lasix 80 mg p.o. daily. 5. Synthroid 100 mg p.o. daily. 6. Tums 2 tablets p.o. t.i.d. 7. Atenolol 100 mg p.o. daily. 8. Tylenol ES 500 mg p.o. b.i.d. 9. Protonix 200 mg p.o. daily. 10. Calcitriol 0.25 mcg p.o. daily. 11. PhosLo 667 mg p.o. t.i.d. with meals. FOLLOW-UP CARE: Hemodialysis at DaVita _%#CITY#%_ Tuesday, _%#MMDD2007#%_.
ES|extra strength|ES|137|138|DISCHARGE MEDICATIONS|5. Lisinopril 10 mg daily. 6. Metamucil daily. 7. Simvastatin 80 mg daily. 8. Flomax 400 mcg daily. 9. Aspirin 325 mg daily. 10. Tylenol ES 500-1000 mg as needed for pain. 11. Oxycodone 5-10 mg every 4 hours as needed for pain. 12. He has discontinued his Lovenox. DISCHARGE DISPOSITION: 1. He will follow up with Dr. _%#NAME#%_, as before, regarding his postoperative knee.
ES|extra strength|ES|114|115|DISCHARGE MEDICATIONS|3. X-ray of right lower extremity. CONSULTATIONS: Include social work services. DISCHARGE MEDICATIONS: 1. Tylenol ES 500 mg p.o. q. 4-6h. p.r.n. pain/fever. 2. Albuterol inhaler 1-2 puffs inhale q. 4h. p.r.n. shortness of breath. 3. Cephalexin 500 mg p.o. q. 6h. to take for 3 days after all symptoms have resolved.
ES|extra strength|ES|129|130|DISCHARGE MEDICATIONS|10. Combivent 1 puff inhaled every 6 hours as needed for shortness of breath. 11. Aciphex 20 mg oral in the morning. 12. Vicodin ES 7.5/750 mg oral every 6 hour as needed for pain. 13. _____ 500 mg oral every 4 hours as needed for pain. 14. Nitroglycerin 0.5 mg sublingually every 5 minutes as needed for chest pain up to 3 times.
ES|extra strength|ES|154|155|DISCHARGE MEDICATIONS|3. Ethambutol 200 mg p.o. daily for 2 months. 4. Pyrazinamide 250 mg p.o. daily for 2 months. 5. Pyridoxine 6.25 mg p.o. daily for 6 months. 6. Augmentin ES (suspension) 440 mg p.o. twice daily through _%#MMDD2007#%_. FOLLOW UP: 1. _%#NAME#%_ was discharged with one-week worth of her tuberculosis medication and _%#NAME#%_ _%#NAME#%_ of Minnesota Department of Health was arranging a public health nurse in _%#NAME#%_'s home area of _%#CITY#%_ _%#CITY#%_ to bring the medications for her home for direct observed therapy.
ES|extra strength|ES|128|129|DISCHARGE MEDICATIONS|6. Norvasc 5 mg po q day. 7. Insulin NPH 20 units sub q q.a.m., 18 units sub Q q.p.m. 8. Vicodin 1-2 po q 4-6 hours. 9. Tylenol ES po q 8 hours prn. DISCHARGE FOLLOW UP: The patient is to follow up with the Fairview _%#CITY#%_ Clinic with Dr. _%#NAME#%_ in one week and Dr. _%#NAME#%_ per his recommendation.
ES|extra strength|ES|189|190|MEDICATIONS|He was deemed ready for discharge on postoperative day #1. CONDITION ON DISCHARGE: Stable. MEDICATIONS: He is to continue any home medications he was on as well as I have given him Vicodin ES 1-2 p.o. q.4-6h. p.r.n. pain. He is to resume his previous diet. ACTIVITIES: He is to maintain his arm in his abduction brace.
ES|extra strength|E.S.|434|437|MEDICATIONS|Two sisters, one deceased of liver cancer. ALLERGIES: She has drug sensitivities to injectable iron. MEDICATIONS: Her other medications at this time include Norvasc 10 mg orally daily, Prempro 0.625/2.5 p.o. every other day, vitamin B12 500 mg orally two times a day, folic acid 400 mcg orally daily, Lipitor 10 mg orally daily, Celexa 40 mg orally daily, Nephrocaps one orally daily, Xanax 0.5 1-2 t.i.d. p.r.n. for anxiety, Vicodin E.S. 7.5/500 mg one p.o. q.4-6.h. p.r.n. for pain, ASA 81 mg orally daily, cyproheptadine 4 mg p.o. q.6.h. p.r.n. for itching, PhosLo 157 mg two orally b.i.d., Calcitriol 0.25 mg one orally t.i.d., vitamin B6 100 mg one orally daily.
ES|extra strength|ES|137|138|LABORATORY|6. Epogen 40,000 units subcutaneously every Wednesday. 7. Nystatin cream 10,000 units t.i.d. to a wound in his rectal area. 8. Augmentin ES 600 mg b.i.d. 9. Roxicodone elixir 10-20 mg q.3h. as needed. 10. Reglan syrup 10 mg q.6h. as needed. DISCHARGE INSTRUCTIONS: The patient will follow up with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2002, at 8:30 a.m.
ES|extra strength|ES,|146|148|DISCHARGE MEDICATIONS|10. Tequin 200 mg daily for eight days. 11. Advair 50/250, one puff b.i.d. 12. Nebulizer to be used q.i.d. 13. Liquibid 600 mg b.i.d. 14. Tylenol ES, two q.i.d. p.r.n. headache. 15. Maalox, one tablespoon q. 2-6 p.r.n. gastroesophageal reflux or equivalent for chest discomfort. She may very well need some more adjustments on her antianxiety medications as that seems to play a significant role here.
ES|extra strength|ES|264|265|DISCHARGE MEDICATIONS|She also had developed some nausea. When her nausea was under control and the pain was tolerable and she was on p.o. pain medicine she was ready for discharge. CONDITION ON DISCHARGE: Stable. DISCHARGE MEDICATIONS: Percocet 1-2 p.o. q.4-6h. p.r.n. pain or Vicodin ES 1-2 p.o. q.4-6h. p.r.n. pain (whichever is easier on her stomach. She is to resume any home medication she was on.
ES|extra strength|ES|295|296|DISCHARGE MEDICATIONS|Her prior dose for polymyalgia was 15 and 13 mg. DISCHARGE MEDICATIONS: 1. Continuation of home medications, such as Advair 500/50 b.i.d., Combivent two puffs q.i.d., albuterol nebs, Ambien 10 for sleep, Tessalon Pearles for protracted cough, Klonopin 0.5 h.s. p.r.n., Senokot S p.r.n., Vicodin ES p.r.n. pain, proton pump inhibitor or Zantac150 b.i.d. protection while she is on her chronic steroids. 2. Oral Lasix 20 mg b.i.d. 3. Dulcolax suppository may be used if needed, if she is unresponsive to the Senokot S, Dulcolax suppository or Fleets enema may be given.
ES|extra strength|ES|146|147|DISCHARGE MEDICATIONS|The patient will be discharged home today, _%#MMDD2002#%_. He is to follow-up in two weeks with Dr. _%#NAME#%_. DISCHARGE MEDICATIONS: 1. Vicodin ES 1-2 p.o. q. 3-4h p.r.n. pain. 2. Colace 100 mg. twice a day for 10 days.
ES|extra strength|ES|209|210|DISCHARGE MEDICATIONS|When she was up ambulating well with physical therapy, using a walker, she was deemed ready for transfer to the Masonic Home for further care. CONDITION ON DISCHARGE: Stable. DISCHARGE MEDICATIONS: 1. Vicodin ES 1-2 p.o. q.4h. p.r.n. pain. 2. Lovenox 30 mg SQ q.12h. 3. Prevacid 30 mg p.o. q.d. 4. Synthroid 0.05 mg p.o. q.d. 5. Norvasc 10 mg p.o. q.d.
ES|extra strength|ES|159|160|MEDICATIONS|She was deemed ready for discharge. CONDITION ON DISCHARGE: Stable. MEDICATIONS: She is to continue on home medications and in addition she will be on Vicodin ES one to two tablets PO q four to six hours p.r.n. Her diet will be regular. ACTIVITY: She will use her CPM for home use from 5 degrees of hyperextension to 140 degrees of flexion as much as possible with minimum being 21 hours per 24 hour period.
ES|extra strength|ES,|111|113|MEDICATIONS|5. Xalatan, 0.005% 1 drop q.p.m. OU. 6. Zoloft, 50 mg p.o. q. day. 7. Aricept, 10 mg p.o. q. 4 p.m. 8. Tylenol ES, 2 tablets t.i.d. p.r.n. 9. Vicodin, 1-2 tablets b.i.d. p.r.n. 10. Aciphex, 20 mg p.o. q.a.m. 11. Norvasc, 2.5 mg 1 p.o. q.a.m. SOCIAL HISTORY: No alcohol.
ES|extra strength|ES|229|230|ADMISSION DIAGNOSIS|She was kept overnight for pain management. When she was tolerating the pain on oral pain medicines she was deemed ready for discharge. Her condition on discharge is stable. DISCHARGE MEDICATIONS: Her medications include Vicodin ES 1 to 2 p.o. q4-6h. p.r.n. pain as well as Toradol 10 mg p.o. q.i.d. with food x 5 days. Additionally, she will continue any home medications she was on.
ES|extra strength|ES|143|144|MEDICATIONS|On postoperative day number three, she was deemed ready for transfer to rehabilitation. CONDITION ON TRANSFER: Stable. MEDICATIONS: 1. Vicodin ES one to two p.o. q.4-6h. p.r.n. pain. 2. Preoperative medications. DIET: Resume that of prior. ACTIVITY: Use her sling and Cryocuff except when doing therapy, which will consist of active, assisted, and passive range of motion of her left upper extremity, limiting her external rotation to her side to neutral.
ES|extra strength|ES|115|116|MEDICATIONS|MEDICATIONS: 1. Zantac 150 mg q.d. 2. Zestril 10 mg q.d. 3. Colace 100 mg q.d. 4. Multiple vitamin q.d. 5. Tylenol ES p.r.n. 6. Calcium carbonate b.i.d. 7. Ativan 0.5 mg p.r.n. 8. Remeron 15 mg q.d. 9. Senokot 1 tablet q.h.s. REVIEW OF SYSTEMS: Unobtainable. PHYSICAL EXAMINATION: GENERAL: The patient is an 84-year-old female who is alert, answers simple questions, oriented to person, in no acute distress.
ES|extra strength|ES|153|154|DISCHARGE MEDICATIONS|When his pain was under control from surgery, he was deemed ready for discharge. His condition on discharge is stable. DISCHARGE MEDICATIONS: 1. Vicodin ES one to two p.o. q.4-6h p.r.n. pain. 2. Clindamycin 600 mg IV q.8h per PICC line, which has been placed prior. DISCHARGE INSTRUCTIONS: 1. He is instructed to keep his wound clean and dry.
ES|extra strength|ES|328|329|MEDICATIONS|PAST MEDICAL HISTORY: COPD, though she has not smoked in the last 15 years; coronary artery bypass in 1989; history aortic stenosis; gastroesophageal reflux disease; hypertension. MEDICATIONS: Norpace 100 mg bid, Lanoxin 0.125 mg qd, Imdur 120 mg qd, Cardizem 240 mg qd, Ecotrin 325 mg qd, Prilosec 20 mg qd, Advair 50/150 bid, ES Tylenol. ALLERGIES: She states that she has numerous allergies, including penicillin, sulfa, codeine; and has had adverse GI reaction to Levaquin, apparently.
ES|extra strength|ES|133|134|CURRENT MEDICATIONS|5. Ambien 10 mg at HS prn. for sleep 6. Demerol 50 mg two PO Q 4 hours prn. for pain. 7. Fiorinal one prn. for headaches. 8. Vicodin ES one Q 6 hours for pain 9. Nasacort AQ one spray each nostril prn. 10. Zovirax cream which she had been using t.i.d. for genital herpes.
ES|extra strength|ES,|154|156|DISCHARGE MEDICATIONS|He will be allowed to shower and wash the wound on postoperative day #3. He was cleared by physical therapy for discharge. DISCHARGE MEDICATIONS: Vicodin ES, Valium for spasms, and his usual home medications.
ES|extra strength|ES|162|163|CURRENT MEDICATIONS|8. Centrum Silver one daily. 9. Coumadin. This has been discontinued six days prior to surgery. 10. Claritin 10 mg daily. 11. Quinidine 324 mg daily. 12. Tylenol ES prn. FAMILY HISTORY: Mother deceased at 82 of MI. Father deceased at 52 of MI. Two brothers, one is a full brother and the other is a half- brother.
ES|extra strength|ES|130|131|MEDICATIONS|3. Tums 500 mg b.i.d. 4. Multivitamin daily. 5. Betagan 0.5% drops left eye b.i.d. 6. Actinal 35 mg weekly on Fridays. 7. Vicodin ES 7.5/750 mg q.i.d. 8. Senokot one tablet hs. 9. Prednisone Forte 1% one drop left eye q.o.d. 10. Nystatin Swish and Swallow po intermittently, not currently taking.
ES|extra strength|ES,|184|186|CURRENT MEDICATIONS|12. Status post tonsillectomy. 13. Status post hysterectomy. CURRENT MEDICATIONS: 1. Lanoxin, 0.125 mg p.o. q.d. 2. Fosamax, 10 mg p.o. q.d. 3. Premarin, 0.625 mg p.o. q.d. 4. Tylenol ES, 1,000 mg q.a.m. 5. Regular Tylenol, 650 mg q. 4 hours p.r.n. for pain or fever. 6. K-Dur, 20 mEq b.i.d. 7. Atenolol, 12.5 mg q.d.
ES|extra strength|ES,|158|160|MEDICATIONS|5. Atrovent, 2 puffs q.i.d. 6. Darvocet-N 100, 1-2 tablets q. 6 hours p.r.n. hip pain. 7. Uniphyl (theophylline extended release), 400 mg per day. 8. Tylenol ES, 2 tablets q. day in the morning, and q. 6 hours p.r.n. 9. Metamucil, 1 teaspoon per day. 10. Synthroid, 0.1 mg per day. 11. Triavil, 2-10, 1 tablet b.i.d.
ES|extra strength|ES|196|197|DISCHARGE MEDICATIONS|Foley catheterization was removed and the patient continued to mobilize. DISPOSITION: She was discharged home. DISCHARGE MEDICATIONS: She will be on the following medications: 1. Iron. 2. Vicodin ES for pain control. 3. Motrin for lesser pain. 4. Vitamin D plus calcium for fracture healing. 5. Colace for constipation.
ES|extra strength|ES|177|178|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Tylenol 120 mg p.o./PR q.4-6h p.r.n. pain/fever. 2. Ibuprofen 80 mg p.o. q.6h p.r.n. pain/fever. 3. Iron 22 mg elemental iron p.o. b.i.d. 4. Augmentin ES 360 mg p.o. b.i.d. x 10 days. DISCHARGE DIAGNOSIS: Adenitis.
ES|extra strength|ES|200|201|HOSPITAL COURSE|On admission he was also started on Zithromax for which he received three days. On _%#MMDD2003#%_ his ears appeared still to be bulging and acutely infected. At that time he was switched to Augmentin ES suspension. He did continue to have fevers after hospital night #1. He spiked a temperature on _%#MMDD2003#%_ to 102. He also spiked a temperature on _%#MMDD2003#%_ to 102.6. He has been afebrile for almost 24 hours prior to discharge.
ES|extra strength|ES|125|126|DISCHARGE INSTRUCTIONS|The father was instructed to follow up sooner if he continues to have high spiking fevers. He will be sent home on Augmentin ES suspension 1/2 tsp. p.o. b.i.d. to complete seven additional days.
ES|extra strength|ES.|189|191|HOSPITAL COURSE|D-Dimer from _%#MMDD2003#%_ was 6.4. The patient had an echocardiogram which showed no evidence of pericarditis. Moderate AI. Blood cultures negative. Adenosine thallium was normal. Normal ES. Due to her decreased appetite and also complaint of epigastric discomfort she had EGD on _%#MMDD2003#%_ which showed mild gastritis and a small hiatal hernia.
ES|extra strength|ES|165|166|MEDICATIONS|The patient was doing very well the day after surgery and was deemed ready for discharge on oral pain medicine. CONDITION ON DISCHARGE: Stable. MEDICATIONS: Vicodin ES 1-2 p.o. q.4-6h. p.r.n. pain, Serzone one p.o. every evening, Prevacid 30 mg p.o. q.d., and potassium 500 mg four tablets p.o. q.d. He will keep his incision clean and dry.
ES|extra strength|ES|121|122|ADMISSION MEDICATIONS|PAST SURGICAL HISTORY: 1. Cholecystectomy. 2. Appendectomy. 3. Right shoulder surgery. ADMISSION MEDICATIONS: 1. Tylenol ES 1 p.o. t.i.d. 2. Zocor 10 mg p.o. q.h.s. 3. Os-Cal D 500 mg t.i.d. 4. Cozaar 25 mg p.o. q.d. 5. Plavix 75 mg p.o. q.d. 6. Aspirin 81 mg p.o. q.d.
ES|extra strength|ES|215|216|SUMMARY|SKIN is clear. SUMMARY: Six year old with pyelonephritis, afebrile after two days of antibiotics with a normal renal ultrasound. Will be discharged home to complete the course of ten days antibiotics with Augmentin ES 600 mg per 5 ml, 5 ml bid for seven more days, then she is instructed to switch to Bactrim Suspension 25 mg per 5 ml, 8 ml po q hs for one month or until VCUG is done.
ES|extra strength|ES|134|135|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Lexapro 10 mg daily 2. Prempro 0.625 mg daily 3. Dulcolax suppositories one daily prn. rectally. 4. Vicodin ES one tablet Q 3-6 Hours prn. 5. Plain Tylenol 650 mg q.i.d. prn. 6. Colace 200 mg daily 7. Milk of Magnesia one ounce Q 12 Hours prn.
ES|extra strength|ES,|171|173|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Urecholine 10 mg b.i.d. 2. Lanoxin 0.125 daily. 3. Tequin 200 mg daily times ten days. 4. Amaryl 2 mg daily. 5. Protonix 40 mg a day. 6. Vicodin ES, one q 4 h. HISTORY: The patient is 84 years old. She was admitted to the hospital with a high fever, abdominal pain, generalized body aches.
ES|extra strength|ES|457|458|CURRENT MEDICATIONS|ALLERGIES: He has no known allergies to medications. CURRENT MEDICATIONS: Include potassium replacement 20 mEq b.i.d., Glucophage 500 mg one orally b.i.d., Lantus insulin 26 units q.h.s., Humulin-R insulin per sliding scale t.i.d., Avalide 300 mg one orally each morning, Toprol XL 35 mg orally each evening, Lasix 40 mg one orally each morning and 20 mg orally each evening. Lipitor 10 mg one orally each evening, Protonix 40 mg one orally b.i.d., Tylenol ES one to two every 4-6 hours p.r.n. not to exceed 4 grams per day. His study medication is Bosethen 62.5 mg b.i.d. and we will have him take his own supply of that while in the hospital.
ES|extra strength|ES|106|107|MEDICATIONS|5. Lasix 20 mg p.o. q. day. 6. Levothyroxine 0.1 p.o. q. day. 7. Lisinopril 10 mg p.o. q. day. 8. Tylenol ES she will received 2 p.o. q.i.d. 9. Metoprolol 25 mg p.o. q. day. 10. Warfarin 2 mg per day. 11. Methylprednisolone taper for treatment of potential sciatica. 12. She has received basically a Medrol Dosepak.
ES|extra strength|ES|133|134|DISCHARGE MEDICATIONS|3. Hirschsprung disease status post colostomy and ileostomy takedown. 4. Pneumonia. 5. Diarrhea. DISCHARGE MEDICATIONS: 1. Augmentin ES 360 mg. 2. Amoxicillin component p.o. b.i.d. x7 days. 3. Zantac 15 mg p.o. b.i.d. 4. Reglan 2 mg p.o. t.i.d. Restart when diarrhea resolves for two days.
ES|extra strength|ES|226|227|DISCHARGE MEDICATIONS|No other changes were made to his medications with the exception to encourage him to discontinue the orphenadrine if possible. DISCHARGE MEDICATIONS: 1. Celebrex 200 mg p.o. q.day. 2. Tegretol XR 400 mg p.o. b.i.d. 3. Tylenol ES 1000 mg p.o.q. 8 hours p.r.n. 4. (_______________) 3 tablets p.o. t.i.d. 5. Dilantin 200 mg p.o. b.i.d. 6. Iron sulfate 325 mg p.o. t.i.d.
ES|extra strength|ES|145|146|DISCHARGE MEDICATIONS|3. Nicotine patch 30 mg daily for ten days. 4. Protonix 40 mg daily am. 5. Ativan 1 mg tablets to take 1/2 tap 1 tablet t.i.d. p.r.n. 6. Vicodin ES 1 tablet q 4 h p.r.n. 7. Milk of Magnesia 1 ounce b.i.d. p.r.n. 8. Multiple vitamins, one daily. 9. Lantus insulin 35 units daily hs or as directed.
ES|extra strength|ES|149|150|DISCHARGE MEDICATIONS|5. Lasix 80 mg b.i.d. 6. Lantus 20 units subcu h.s. 7. Humalog 20 units with meals. 8. Monopril 20 mg q.d. 9. Vicodin, 1-2 q.i.d. p.r.n. 10. Tylenol ES q.i.d. p.r.n. two tabs. 11. Zantac 300 mg h.s. 12. Potassium 20 mEq q.d. 13. Triamcinolone cream .1% b.i.d. to psoriasis. 14. Protopic ointment b.i.d. to psoriasis.
ES|extra strength|ES|256|257|HOSPITAL COURSE|A CMP on admission was 2.52 and a repeat on the day of discharge after 36 hours of IM ceftriaxone was 0.6. Tate became afebrile shortly after admission and remained afebrile until discharge on day #2 of hospitalization. He was discharged home on Augmentin ES (90 mg/kg/day) to complete a 14-day course for treatment of bacterial pneumonia. 2. Nephrotic syndrome: _%#NAME#%_ was continued on his Gengraf and torsemide on admission.
ES|extra strength|ES|126|127|DISCHARGE MEDICATIONS|6. Return if fevers, drainage from incision, excessive redness or swelling of the incision. DISCHARGE MEDICATIONS: 1. Vicodin ES 1 to 2 tablets q.4 hours p.r.n. 2. Senna-S. 3. Aspirin 81 mg p.o. daily.
ES|extra strength|ES|232|233|PLAN|ASSESSMENT: 1. Right middle lobe and right lower lobe pneumonitis. 2. Right otitis. PLAN: He was discharged to home with instructions for albuterol nebs to be given q.i.d. In addition, he is to continue a 10-day course of Augmentin ES 600 mg per 5 ml, 4 cc p.o. b.i.d. and Orapred 15 mg per 5 ml, 12 mg p.o. b.i.d. times three days. In addition, he should complete the series of Zithromax 200 mg per 5 ml, 3 cc p.o. per day times only one more additional dose.
ES|extra strength|ES|239|240|ADMISSION DIAGNOSIS|Her hemoglobin stabilized at 10.8 on postoperative day #2. She tolerated physical therapy nicely with a standard total shoulder protocol. She was discharged to home in good condition on postoperative day #3. DISCHARGE MEDICATIONS: Vicodin ES and Vistaril. FOLLOW UP: She will follow the standard phase #1 total shoulder therapy protocol and wear her sling for protection.
ES|extra strength|ES,|143|145|DISCHARGE MEDICATIONS|7. Colace, 100 mg b.i.d. 8. Xalatan, 0.005%. 9. Multi-vitamins. 10. Plavix, 75 mg daily. 11. Enteric coated aspirin, 325 mg daily. 12. Tylenol ES, 2 p.o. t.i.d. She continues to be a full code at the nursing home and will be taken back there and physical therapy will be continued as before.
ES|extra strength|ES|168|169|ADMISSION MEDICATIONS|Throughout this time TPN was weaned from postoperative day #7 through postoperative day #9. On postoperative day #9 patient was switched to oral antibiotics, Augmentin ES 100. This formulation was chosen to help decrease diarrhea. At this point, patient's GI function had completely stabilized, was taking breast milk without any emesis.
ES|extra strength|ES|173|174|DOB|9. Lipitor 20 mg p.o. daily. 10. Lantus insulin 44 units subcu at h.s. 11. Novolog 6 units subcu t.i.d. before meals. 12. Vicodin one to two every 4 hours p.r.n. or Tylenol ES 1000 mg p.o. t.i.d. p.r.n. 13. Constipation treated with Senokot granules and Colace. 14. Aspirin 81 mg daily 15. Dyazide one orally daily. CONDITION ON DISCHARGE: Satisfactory. FINAL DIAGNOSES: Pneumonia with hypoxia; respiratory failure.
ES|extra strength|ES|347|348|ASSESSMENT/PLAN|Will obtain a chest x-ray. Will also check a sed rate and CRP and am giving consideration whether she is having an active vasculitic process with her history of temporal arthritis and her red purpuric lesions noted on her lower extremities. We will continue her prednisone 7.5 mg daily. We will need to consider a steroid burst and will await the ES sed rate and CRP and consult rheumatology. 2. Dehydration. Patient will be hydrated with IV fluids. She is slightly ketotic on her urine.
ES|extra strength|ES|141|142|DISCHARGE MEDICATIONS|7. Aspirin 81 mg p.o. daily. 8. Vitamin E 400 mg p.o. daily. 9. Digoxin 0.25 mg p.o. daily. 10. Mineral oil 1 ounce daily p.r.n. 11. Tylenol ES 2 tabs q. 6h. p.r.n. 12. Multivitamin daily. 13. Xalatan 0.005% solution, 1 drop left eye daily. 14. Alphagan 0.15% solution, 1 drop left eye daily. 15. Cosopt 2/0.5% solution, 1 drop left eye b.i.d.
ES|extra strength|ES|143|144|DISCHARGE MEDICATIONS|3. Neurontin 600 mg p.o. daily. 4. Lasix 60 mg p.o. q.a.m. and 40 mg p.o. q.p.m. 5. Glargine insulin 25 units subcutaneous q.h.s. 6. Pancrease ES two caps p.o. t.i.d. with meals and one cap p.o. t.i.d. with snacks. 7. Potassium 20 mEq p.o. b.i.d. 8. Aldactone 25 mg p.o. q.i.d.
ES|extra strength|ES|193|194|DISCHARGE MEDICATIONS|6. Wellbutrin-XL 150 mg daily in the a.m. 7. Calcium with vitamin D 1 tablet b.i.d. 8. Lasix 20 mg daily, orally. 9. Lisinopril 20 mg daily. Zocor 20 mg daily. 10.Imdur 30 mg daily. 11.Tylenol ES 1000 mg orally t.i.d. PRINCIPAL DIAGNOSES: 1. Unstable angina. 2. Two-vessel severe coronary stenosis plus other less severe areas of stenosis.
ES|extra strength|ES|197|198|DISCHARGE MEDICATIONS|Routine wound care of left finger and hand per orthopedic MD, to be kept clean, dry, and dressed with wick removal on the day of discharge in Orthopedic Clinic. DISCHARGE MEDICATIONS: 1. Augmentin ES 600/400 mg p.o. b.i.d. x7 days. 2. Lactobacillus GG one capsule with food p.o. daily until off Augmentin. 3. Tylenol 160 mg p.o. q.4h hours p.r.n. pain. FOLLOW-UP: 1 With hand surgeon in Orthopedic Clinic on _%#CITY#%_ campus on the day of discharge for wick removal and dressing change.
ES|extra strength|ES|171|172|PREHOSPITAL MEDICATIONS|6. Atenolol 25 mg q.a.m. 7. Renafro 1 capsule q.a.m. 8. Alphagan eyedrops 0.15% one drop each eye t.i.d. 9. Acular eye eyedrops 0.5% one drop right eye q.i.d. 10. Tylenol ES 1,000 mg t.i.d. 11. PhosLo 1,334 mg b.i.d. with meals and 2,001 mg at noon. 12. Hydralazine 25 mg b.i.d. 13. Docusate sodium 100 mg b.i.d.
ES|extra strength|ES|179|180|CURRENT MEDICATIONS|4. Flecainide 50 mg b.i.d. 5. Lasix 20 mg as needed for fluid retention (the patient has not taken this in over 1 month). 6. Calcium + vitamin D 1000 mg calcium daily. 7. Tylenol ES as needed. SOCIAL HISTORY: The patient lives independently. She is a nonsmoker. She does not consume significant amounts of alcohol.
ES|extra strength|ES|204|205|CURRENT MEDICATIONS|ALLERGIES: To penicillin. CURRENT MEDICATIONS: 1. He is still on Coumadin and was not stopped for his eye operation. Today, INR was 2.21. 2. Furosemide 40 mg daily. 3. Caltrate 600 mg 1 daily. 4. Vicodin ES 1 q.i.d. p.r.n. 5. Colchicine 0.6 mg daily. 6. Dexamethasone 0.5 mg daily. 7. __________ 300 mg daily. 8. Lisinopril 20 mg daily.
ES|extra strength|ES|111|112|DISCHARGE MEDICATIONS|7. Bactrim 20 mg NG daily. 8. Valganciclovir 100 mg NG daily. 9. Flagyl 90 mg NG q.6h. x24 days. 10. Augmentin ES 500 mg NG q.12h. x14 days. 11. Pulmicort 0.25 mg neb twice daily. 12. Albuterol 2.5 mg neb q.6h. as needed. DIET: 500 mL PediaSure plus 515 mL water, 260 mL NG 4 times daily.
ES|extra strength|ES|157|158|DISCHARGE MEDICATIONS|4. Actonel 35 mg p.o. q. week. 5. Verapamil 240 mg q. day. 6. ASA 81 mg q. day. 7. Metformin 500 mg p.o. b.i.d. 8. Allopurinol 300 mg p.o. daily. 9. Tylenol ES p.r.n. FINAL DISCHARGE DIAGNOSES: 1. Nausea and vomiting. 2. Weakness. 3. Bronchitis. 4. Diabetes mellitus.
ES|extra strength|ES|192|193|DISCHARGE MEDICATIONS|9. Levaquin 500 mg orally daily for UTI and right upper lobe pneumonia to complete a 10-day course, 4 days remaining. 10. Flexeril 10 mg orally 3 times daily as needed for spasms. 11. Senokot ES 1-2 tablets orally daily for constipation. 12. Coumadin. The patient's INR was supratherapeutic, greater than 3.5. Hold the Coumadin until the INR is in the therapeutic range.
ES|extra strength|ES|153|154|CURRENT MEDICATIONS|4. Lasix 40 mg p.o. daily. 5. Remeron 22.5 mg p.o. at bedtime. 6. Arginaid 80 mg p.o. b.i.d. 7. Calcium with vitamin D 600/200 mg p.o. b.i.d. 8. Tylenol ES 1,000 mg p.o. b.i.d. 9. Lutein 6 mg p.o. daily at 5:00 p.m. 10. Multivitamin 1 tab p.o. daily. 11. Senna 1-2 tabs p.o. b.i.d. p.r.n.
ES|extra strength|ES|119|120|DISCHARGE MEDICATIONS|10. Potassium gluconate 595 mg daily. 11. Sotalol HCL 120 mg b.i.d. 12. Benadryl on a p.r.n. basis, along with Tylenol ES and Tums. 13. She is also being sent home now on Percocet one q.4-6 hours p.r.n. for pain, dispensed #30. 14. Keflex 500 mg one q.i.d. x10. DISCHARGE INSTRUCTIONS: The patient had good looking viable surgical flaps.
ES|extra strength|ES|216|217|DISCHARGE MEDICATIONS|2. Clindamycin 300 mg t.i.d. for 4 days. 3. Ceftin 250 mg b.i.d. for 4 days for presumed pneumonia. 4. He was also instructed to resume his preoperative medications including Aspirin 81 mg p.o. each day. 5. Gaviscon ES 1 tab p.o. each day. 6. HCTZ 25 mg p.o. each day. 7. Lexapro 10 mg p.o. each day. 8. Lisinopril 20 mg p.o. each day.
ES|extra strength|ES|78|79|MEDICATIONS|10. Depression. 11. Hypothyroidism. 12. Hypertension. MEDICATIONS: 1. Tylenol ES 500 mg p.o. each day at bedtime as needed for discomfort. 2. Zymar 0.3% one drop right eye 4x daily. 3. Pred-Forte 1% one drop right eye 4x daily. 4. Toprol XL 75 mg p.o. daily.
ES|extra strength|ES|122|123|MEDICATIONS|MEDICATIONS: Medications at the time of transfer are: 1. Lovenox 30 mg p.o. q. 12h. until mobile. 2. Augmentin suspension ES 120/8.6 mg per mL down her G-tube b.i.d. for 9 additional days. 3. Compazine p.r.n. 4. Roxicet 5 mL solution q. 6h. scheduled.
ES|extra strength|ES|167|168|MEDICATIONS|10. Omeprazole 40 mg p.o. daily. 11 . ASA 81 mg p.o. daily. 12. Multivitamin 1 p.o. q. day. 13. Fish oil 1000 mg p.o. t.i.d. 14. MiraLax 17 mg p.o. daily. 15. Tylenol ES 1-2 p.o. q.i.d. p.r.n. 16. Colace 200 mg p.o. q. day h.s. 17. Plavix 75 mg p.o. daily. 18. Hydrochlorothiazide 12.5 mg p.o. q. day. 19. Reglan 5 mg p.o. q. day.
ES|extra strength|ES|107|108|MEDICATIONS AT THE NURSING HOME|5. Os-Cal with Vitamin D 500 mg x2 daily. 6. Chlorocon 20 mEq x2 daily. 7. Coumadin 5 mg daily. 8. Tylenol ES 1-2 q.6 h. p.r.n. pain. 9. Renagel 800 mg x3 daily. 10. Combivent 2 puffs q.i.d. (the patient per the chart does have history of COPD though she denies any history of cigarette use).
ES|extra strength|ES|172|173|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: On _%#MMDD2007#%_, discharge medications include, 1. Lasix 5 mg p.o. t.i.d. 2. Enalapril 0.4 mg q. 12h. p.o. 3. Zantac 5 mg p.o. t.i.d. 4. Augmentin ES 200 mg p.o. q. 12h. FOLLOW-UP: The patient is going to follow up with Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2007#%_, then with Dr. _%#NAME#%_ _%#NAME#%_ in two weeks and with myself following if there are any outstanding issues.
ES|extra strength|ES|399|400|CURRENT MEDICATIONS|9) Erythrocytosis. She has been seen by Dr. _%#NAME#%_ and gets scheduled phlebotomies. ALLERGIES: Rythmol. Sulfa. Macrodantin. Ancef. Anspor. Erythromycin. Trimpex. Fulvicin. CURRENT MEDICATIONS: 1) Hydrochlorothiazide 50 mg p.o. q.d. 2) Monopril 20 mg p.o. q.d. 3) Lanoxin 0.125 mg p.o. q.d. 4) Atenolol 50 mg p.o. q.d. 5) Coumadin 2.5 mg alternating with 5 mg q.d. 6) Nitrostat p.r.n. 7) Vicodin ES 1 to 2 q.8h. p.r.n. 8) Tylenol #3, 1 to 2 q.6h. p.r.n. 9) Quinine 325 mg p.o. q.h.s. p.r.n. 10) Vioxx 25 mg p.o. q.d. FAMILY HISTORY: Negative for DVT or cancer.
ES|extra strength|ES|106|107|CURRENT MEDICATIONS|Currently living with his parents; he is considered permanently disabled. CURRENT MEDICATIONS: 1. Vicodin ES (7.5/750 mg tabs) one tablet every 4-6 hours p.r.n., maximum of 5 per day. This is primarily for neck and lower extremity pain.
ES|extra strength|ES|174|175|MEDICATIONS|Condition: Stable. Activity: Out of bed as tolerated, right arm protected in sling except to do pendulum and Codman range of motion. Diet is regular. MEDICATIONS: 1. Vicodin ES 1-2 tablets p.o. q.6h. p.r.n. pain. 2. Toradol 10 mg p.o. q.6h. p.r.n. 3. Synthroid, as mentioned in the previous medication section.
ES|extra strength|ES|180|181|DISCHARGE MEDICATIONS|3. Lanoxin 0.125 mg p.o. q.d. 4. Vioxx 25 mg p.o. q.d. 5. Atenolol 50 mg p.o. q.d. 6. Quinine 325 mg p.o. q.d. 7. Nitroglycerin 0.4 mg sublingual p.r.n. for chest pain. 8. Vicodin ES 1-2 q.6h. p.r.n. 9. Albuterol 2 puffs q.i.d. p.r.n. 10. Hydrochlorothiazide 50 mg p.o. q.d. DISPOSITION: The patient was discharged in stable condition to follow up with Dr. _%#NAME#%_ or Dr. _%#NAME#%_ in 1 week.
ES|extra strength|ES.|169|171|MEDICATIONS|ALLERGIES: Sulfa. MEDICATIONS: 1) Prevacid. 2) Toprol. 3) Fosamax. 4) Miacalcin nasal sprays. 5) Synthroid. 6) Plaquenil. 7) Citrucel. 8) Lasix. 9) Calcium. 10) Tylenol ES. 11) Enbrel. 12) Prednisone. 13) OxyContin. 14) Colace. PAST MEDICAL HISTORY: 1) Left humerus fracture eight weeks ago, in sling, and being treated conservatively.
ES|extra strength|ES|201|202|HOSPITAL COURSE|Since she was improving quite a bit though it was elected to plan for discharge. She was very comfortable with that approach. Her discharge meds will be Cipro 500 mg bid for a full 10-14 days, Tylenol ES as needed for pain and discussed the option of Pyridium but she decided not to pursue that. She will continue pushing extra fluids and recheck in clinic in 1-2 weeks.
ES|extra strength|ES|335|336|HISTORY OF PRESENT ILLNESS|The pain in the right thigh continued, but moved into the right hip this morning and became much worse. He denies any past medical history of osteoarthritis. He says that he has had multiple x-rays taken of his knees, which have been his only problem up until now, and claims that is why he started the Celebrex and also takes Tylenol ES 3 tabs t.i.d. He states that his orthopedic surgeon in _%#CITY#%_ _%#CITY#%_, California, from where he and his wife moved in _%#MM#%_ 2001, has taken multiple x-rays, and these are all "negative for arthritis." It was through his wife about a week ago that he finally began taking some Celebrex.
ES|extra strength|ES|120|121|DISCHARGE MEDICATIONS|Condition on discharge is stable. DISCHARGE MEDICATIONS: 1. Ancef 1 gm IV piggyback q 8 hours per PICC line. 2. Vicodin ES one p.o. q 6 hours prn pain. 3. Hydroxyzine 25 mg p.o. q h.s. prn insomnia. 4. Sulindac 150 mg p.o. b.i.d. 5. Propranolol 40 mg p.o. q.i.d.
ES|extra strength|ES|121|122|CURRENT MEDICATIONS|2. Neurontin 100 mg, six of them daily for pain control. 3. OxyContin 20 mg at bedtime. 4. Vioxx 25 mg daily. 5. Vicodin ES on a p.r.n. basis for pain control. FAMILY HISTORY: Her mother expired at age 86 of congestive heart failure (CHF).
ES|extra strength|ES|148|149|HOSPITAL COURSE|No evidence of hydronephrosis or increased echogenicity, "slightly prominent wall thickness of 4 mm". Discharged with parents on oral Augmentin 600 ES 1-1/2 teaspoon twice daily for seven days. Dad has already scheduled an appointment with Mayo Clinic urology for _%#MMDD2002#%_.
ES|extra strength|ES|187|188|DISCHARGE MEDICATIONS|DISCHARGE DIAGNOSIS: Lumbar strain. DISCHARGE MEDICATIONS: Dr. _%#NAME#%_ Wei wrote prescriptions for Senokot-S 2 tablets p.o. q.h.s., diazepam 10 mg p.o. q.8h. p.r.n. spasm, and Vicodin ES 1-2 tablets p.o. q.6h. p.r.n. Due to the patient's recent diagnosis of bronchitis, she already has prescriptions for Levaquin 500 mg p.o. q.d. and Liquibid p.r.n. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 41-year-old woman who presented to the emergency department via ambulance on _%#MMDD2002#%_ with low back pain. Her physical exam supported lumbar strain and muscle spasm. She was started on IV morphine and oral Valium.
ES|extra strength|ES|131|132|HISTORY OF PRESENT ILLNESS|FOLLOW UP: She was instructed to follow up with Dr. _%#NAME#%_ in 2-3 weeks' time in the clinic and was instructed to take Vicodin ES 1-2 tabs p.o. q.6h. p.r.n. for pain, do a prednisone taper which was written out for the patient, to have home care for ileostomy teaching 1-2 times a week with visit and instructed on pouch change.
ES|extra strength|ES|170|171|DISCHARGE MEDICATIONS|6. Effexor XR 75 mg p.o. q.d. for anxiety and depression. 7. Prinivil 5 mg p.o. q.d. for hypertension. 8. Bextra (?) 20 mg p.o. q.d. for rheumatoid arthritis. 9. Imitrex ES 100 mg p.o. p.r.n. for headaches. 10. Zantac 75 mg p.o. q.d. p.r.n. heartburn. 11. Vicodin 750 mg p.o. q.6-8h. p.r.n. pain.
ES|extra strength|ES,|172|174|MEDICATIONS|As soon as her wound was dry, and she was ambulating well, she was deemed ready for discharge. CONDITION ON DISCHARGE: Stable. MEDICATIONS: Her medications include Vicodin ES, one to two p.o. q.4-6h. p.r.n. pain. Lovenox 30 mg subq every 12 hours. She is to continue her home medications.
ES|extra strength|ES|149|150|DISCHARGE MEDICATIONS|She had decrease in her cervical adenitis. She is being discharged on oral Augmentin to follow-up as an outpatient. DISCHARGE MEDICATIONS: Augmentin ES 400 mg b.i.d. for ten days. Follow-up in our office in one week.
ES|extra strength|ES|170|171|ADMISSION MEDICATIONS|ADMISSION MEDICATIONS: 1. Minocycline 100 mg q day 2. Prednisone 5 mg q day 3. Methocarbamol 250 mg t.i.d. 4. Effexor XR 35 mg q day 5. OxyContin 40 mg b.i.d. 6. Vicodin ES p.r.n. 7. Imitrex 100 mg p.r.n. 8. Lasix 40 mg b.i.d. 9. Prinivil 5 mg q day 10. Zantac 50 mg q day 11. Coumadin 2.5 mg and 5 mg on alternating days
ES|extra strength|ES|156|157|DISCHARGE MEDICATIONS|10. Zantac 150 mg p.o. b.i.d. 11. Procrit 40,000 units subcu q Thursday 12. Miconazole powder apply to groin p.r.n. 13. Lasix 80 mg p.o. q.a.m. 14. Vicodin ES one tab p.o. q.6h p.r.n. 15. Imitrex 100 mg p.o. q day p.r.n. 16. Compazine 10 mg p.o. t.i.d. p.r.n. 17. Tylenol 650 mg p.o. q.8h p.r.n. FOLLOW UP: Follow up in clinic this coming Monday for her Neulasta injections.
ES|extra strength|ES|143|144|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: 1. She is to keep the wound clean and dry. 2. She should continue her home medications, with the addition of Augmentin ES 600 mg down the PEG b.i.d. for five days. 3. She should follow-up with Dr. _%#NAME#%_ in one to two weeks.
ES|extra strength|ES|164|165|MEDICATIONS|2. Ranitidine 150 mg per day. 3. Amoxapine 200 mg at h.s. 4. Multiple vitamin one per day. 5. Vitamin B12, ?1000 mcg per day. 6. Calcium 500 mg per day. 7. Tylenol ES two tablets p.o. h.s. prn. 8. Lexapro 10 mg p.o. q day. ALLERGIES: None. HEALTH HABITS: Stopped smoking one year ago after peripheral artery bypass.
ES|extra strength|ES|164|165|MEDICATIONS|Condition on discharge is stable. MEDICATIONS: 1. Sular 20 mg p.o. q.d. 2. Prinivil 10 mg p.o. q.d. 3. Vioxx 25 mg p.o. q.d. 4. Aspirin 325 mg p.o. q.d. 5. Tylenol ES 1-2 p.o. q.4-6h. p.r.n. pain. 6. Lovenox 30 mg subq q.12h. 7. Percocet 1-2 p.o. q.4-6h. p.r.n. Her activity will be by the total knee protocol.
ES|extra strength|ES|594|595|MEDICATIONS|ABDOMEN - no nausea or vomiting, occasional constipation. PSYCHIATRIC - depression, follows with a therapist - mood stable; musculoskeletal - chronic pain with numbness and tingling of her lower extremities, history of lumbar disc disease. MEDICATIONS: Neurontin 300 mg po tid, trazodone 50 mg po qhs, Advair 100/500 1 inhalation bid, albuterol inhaler 2 puffs q4-6h prn, Lasix 40 mg po bid, Zaroxolyn 5 mg on M-W-F, Prilosec 20 mg po qd, guaifenesin 1 tablet po bid, Singulair 10 mg po qd, Wellbutrin 100 mg po bid, Paxil 30 mg po qd, Nasonex 2 sprays each naris qd, Colace 100 mg po bid prn, ES Tylenol 2 tablets q4-6h prn, tramadol 50 mg po qd. ALLERGIES: Penicillin, CT dye, tetracycline and EES. FAMILY HISTORY: Noncontributory.
ES|extra strength|ES|173|174|CURRENT MEDICATIONS|14. Bumetanide 2 mg q.d. 15. Calcium/vitamin D (500 mg/200 international units) 2 tablets b.i.d. 16. Lanoxin 0.125 mg q.o.d. 17. Vicodin 1 tablet q.4-6h. p.r.n. 18. Tylenol ES p.r.n. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 149/91, pulse 79, respiratory rate 18, afebrile, oxygen saturation 99%.
ES|extra strength|ES|128|129|PLAN|PLAN: The patient will be discharged to home at this time on Keflex 500 mg q.8.h. and is given a small prescription for Vicodin ES to use on a p.r.n. basis for pain. She will follow-up if she is not improving.
ES|extra strength|ES|202|203|MEDICATIONS|4. Hypercholesterolemia. 5. High blood pressure. 6. Diabetes mellitus 2. He quit smoking at the time of his coronary artery bypass graft. ALLERGIES: None. MEDICATIONS: 1. Xanax 0.5 mg t.i.d. 2. Vicodin ES two tablets b.i.d. 3. Folic acid 1 mg q.d. 4. Amaryl 4 mg q.d. 5. Lanoxin 0.125 mg q.d. 6. Actos 30 mg q.d.
ES|extra strength|ES|113|114|MEDICATIONS|5) RSO in 1999. MEDICAL ILLNESSES: No history of serious illness. ALLERGIES: NONE KNOWN. MEDICATIONS: 1) Tylenol ES p.r.n. 2) Centrum vitamins. 3) The patient has had no aspirin preop. REVIEW OF SYSTEMS: HEENT: No recent change in vision or hearing.
ES|extra strength|ES|167|168|CURRENT MEDICATIONS|Flat and upright of the abdomen today shows multiple areas in the right upper quadrant of air fluid levels and lots and lots of stool. CURRENT MEDICATIONS: 1. Tylenol ES two, q.i.d. 2. Percocet, previously two to three a day, now requiring up to five or six over the last few weeks. 3. Advair Diskus 250/50. 4. Lopid 600 mg b.i.d.
ES|extra strength|ES|130|131|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Cozaar 100 mg q.d. 2. Toprol 50 mg b.i.d. 3. Neurontin 300 mg t.i.d. 4. Celebrex 200 mg q.d. 5. Vicodin ES p.r.n. 6. Glucosamine p.r.n. DISCHARGE FOLLOW UP: The patient is to follow up with her cardiologist in _%#CITY#%_ _%#CITY#%_ sometime in the next month to discuss further management options for her supraventricular tachycardia.
ES|extra strength|ES|167|168|CURRENT MEDICATIONS|4. Zithromax 250 mg daily for the last several days 5. Protein powder 1 scoop 6. Levothyroxine 0.075 mg daily 7. Trazodone 75 mg at bedtime for sleep [sic] 8. Tylenol ES 500 mg t.i.d. 9. Milk of magnesia 5 cc at bedtime The patient has had dyspnea and decreased level of consciousness on the p.m. shift at the nursing home.
ES|extra strength|ES,|185|187|DISCHARGE MEDICATION|DISPOSITION: She should follow up with Dr. _%#NAME#%_ at _%#CITY#%_ Otolaryngology on _%#MMDD2004#%_. Follow up with Dr. _%#NAME#%_ next week. DISCHARGE MEDICATION: Augmentin 600 per 5 ES, 3.5 mL p.o. b.i.d. for eight more days, for a total of 10 days of antibiotics.
ES|extra strength|ES|203|204|HOSPITAL COURSE BY PROBLEMS|He did initially have an IV in place for fluids as well as methylprednisolone. 2. Left purulent otitis media: The patient had been given Rocephin previously. In the hospital he was switched to Augmentin ES 600 4 cc p.o. b.i.d. At the time of discharge the TM was no longer bulging and it was flat, thickened, with decreased mobility.
ES|extra strength|ES|169|170|DISCHARGE MEDICATIONS|2. ranitidine 150 mg p.o. b.i.d. 3. Compazine 10 mg p.o. t.i.d. p.r.n. nausea, vomiting. 4. Compazine 25 mg p.r. b.i.d. p.r.n. nausea if unable to take oral. 5. Tylenol ES 1 to 2 tabs p.o. every 6 hours p.r.n. pain. DISPOSITION: The patient was discharged to home. DISCHARGE INSTRUCTIONS: Diet is as tolerated, nonspicy foods, banana, toast, rice, applesauce, pudding.
ES|extra strength|ES|159|160|NURSING HOME MEDICATIONS|NURSING HOME MEDICATIONS: 1. Lasix 20 mg p.o. daily. 2. Combivent inhaler 2 puffs b.i.d. 3. Azmacort 2 puffs b.i.d. 4. Neurontin 300 mg p.o. t.i.d. 5. Tylenol ES 500 mg 2 tabs p.o. q.i.d. 6. Isosorbide 120 mg p.o. daily. 7. NPH insulin 6 units subcu q.h.s. and 10 units subcu q.a.m.
ES|extra strength|ES,|184|186|MEDICATIONS|She has been hard of hearing for many years and uses a hearing aid on the right. MEDICATIONS: 1. Lorazepam, 0.5 mg h.s. 2. Levothroid, 100 mcg daily. 3. Tums, 2 tabs p.r.n. 4. Tylenol ES, 2 b.i.d. 5. Milk of Magnesia, 1 oz p.r.n. 6. Multivitamins once daily. 7. Albuterol inhaler, 2 puffs q.4h. p.r.n. 8. Albuterol with Atrovent in a nebulizer b.i.d.
ES|extra strength|ES|178|179|DISCHARGE MEDICATIONS|3. Protonix 40 mg p.o. q day 4. Decadron 1 mg p.o. b.i.d. on _%#MMDD#%_ through _%#MMDD#%_; then 1 mg p.o. q day on _%#MMDD#%_ and on _%#MMDD#%_ and then discontinue 5. Excedrin ES one to two p.o. p.r.n. headache q 6 hours 6. Vicodin one to two tablets p.o. p.r.n. headache pain, q 4 hours Dr. _%#NAME#%_ should be tagged to have him follow the patient at Sister Kenny.
ES|extra strength|ES|188|189|PROBLEM #2|Her WBC at hospital day #2 was 5.4, 70% neutrophils, 19% lymphocytes, and on the day of discharge her WBC was 3.0 with 67% neutrophils and 27% lymphocytes. She was discharged on Augmentin ES 600 mg p.o. b.i.d. x10 days. She did remain afebrile during her entire hospital stay. PROBLEM #3: Hematology/Oncology: _%#NAME#%_ continued on her 6- mercapturine 25 mg p.o. q. day during her hospital stay without difficulties.
ES|extra strength|ES,|205|207|HISTORY OF PRESENT ILLNESS|She has been seen by pain clinics in the past, and non-narcotic treatments of the pain have been recommended, but she is still able to get narcotics from doctors. In any event, she has been taking Vicodin ES, Valium, and Fiorinal #3 lately. She needs detox and treatment. PAST MEDICAL HISTORY: 1. Sarcoidosis. She states this gives her chronic chest pain, for which she is able to obtain the narcotics.
ES|extra strength|ES|157|158|MEDICATIONS|7. Warfarin 5 mg six days a week and 7.5 mg every Wednesday. She last took warfarin _%#MMDD2007#%_. 8. Neurontin 300 mg p.o. each day at bedtime. 9. Tylenol ES 500 mg p.o. each day at bedtime. 10. Alphagan eyedrops one drop each eye twice daily. 11. Trusopt eyedrops one drop each eye twice daily. 12. Pilotine 1/8% gel each eye at night.
ES|extra strength|ES.|185|187|MEDICATIONS|PAST SURGICAL HISTORY: Include hysterectomy and tonsillectomy. ALLERGIES: Intolerant of morphine and codeine. MEDICATIONS:Include lisinopril, HCTZ, Zantac, Compazine, Citrucel, Tylenol ES. SOCIAL HISTORY: She is widowed. She used to smoke, she quit 20 years ago. She lives in a senior apartment in _%#CITY#%_, Minnesota.
ES|extra strength|ES,|229|231|CURRENT MEDICATIONS|She has never tried a TENS unit. ALLERGIES: Pruritus to most narcotics except for morphine. CURRENT MEDICATIONS: Klonopin, Prozac, Celexa, multi vitamin, Vivelle, Allegra D, Flexeril, Dilaudid, Levothyroxine, Cephalexin, Tylenol ES, Ibuprofen, Neurontin. PAST MEDICAL HISTORY: See history of present illness Child birth.
ES|extra strength|ES.|257|259|HISTORY|Subsequent Vicodin and Darvocet, followed by Extra Strength Vicodin, taking 3 tablets q.a.m. to q.p.m. Meds apparently dispensed by MATTS. Indicates associated right upper extremity radicular pain and paresthesia with sleep. Presently requiring her Vicodin ES. Indicates that she has tried muscle relaxants, without benefit. This has included Flexeril. Presently on Vioxx, without appreciable effect.
ES|extra strength|ES,|190|192|LABORATORY  DATA|No clubbing or cyanosis was noted. LABORATORY DATA: Chest x-ray today showed some old rib fractures. Heart and lungs were unremarkable. The first set of troponins was less than 0.012 on the ES, where the upper limits reference range is 0.034, sodium was 138, potassium 3.6, BUN 27, creatinine 1.16. Total bilirubin was slightly elevated at 1.7 although other liver function tests were normal.
ES|extra strength|ES|132|133|MEDICATIONS|He denies any visual symptoms or cranial nerve dysfunction. ALLERGIES: None. MEDICATIONS: 1. Fentanyl patch 75 mcg/hour. 2. Vicodin ES for break-through pain. 3. Zofran 4 mg p.o. q 6 prn. 4. MOM prn. 5. Fleet's prn. 6. Peri-Colace prn. 7. Trazodone 200 mg q h.s.
ES|UNSURED SENSE|ES|174|175|PAST MEDICAL HISTORY|The patient denies any other acute medical problems. PAST MEDICAL HISTORY: 1. Habits: The patient is a 1/2-pack-per-day smoker. She denies alcohol or drug use. 2. Allergies: ES and sulfa. 3. Medications are listed in the current orders. 4. Prior hospitalizations: 1997 for abdominal hysterectomy; 1979 knee surgery.
ES|extra strength|ES|206|207|LABORATORY DATA|2. Hyperlipidemia (stable): Continue current medication and treatment. Will obtain fasting lipid panel. 3. Tension headache secondary to withdrawal symptoms: Continue current medications/treatment (Tylenol ES p.r.n.).
ES|extra strength|ES.|201|203|MEDICATIONS|She had been taking Dilaudid 2 mg p.r.n. as an outpatient. She comes in now with increasing discomfort. ALLERGIES: Sulfa. MEDICATIONS: Dyazide, nitrofurantoin, Dilantin, ibuprofen, aspirin and Tylenol ES. PAST MEDICAL HISTORY: Recurrent UTIs, delivery or children, hypertension. FAMILY HISTORY, SOCIAL HISTORY, REVIEW OF SYSTEMS: Unremarkable.
ES|extra strength|ES|314|315|MEDICATIONS AT HOME|With these procedures, she did have prolonged hospital stays related to ileus, fevers, but no documented deep venous thrombosis. MEDICATIONS AT HOME: Fosamax 10 mg q.d., Plaquenil 400 mg q.d., Zyrtec 10 mg q.d., Prevacid 30 mg p.r.n., calcium 1000 mg q.d., vitamin C 500 mg q.d., vitamin E 400 units q.d., Tylenol ES q.i.d. p.r.n. ALLERGIES: Celebrex causes a rash and GI bleeding.
ES|extra strength|ES|554|555|MEDICATIONS|She denies any difficulty in breathing at present. PAST MEDICAL HISTORY: She has history of diabetes, congestive heart failure, hypothyroidism, hypertension, degenerative joint disease, and depression. MEDICATIONS: She has been using aspirin 81 mg p.o. q.d., Neurontin 300 mg p.o. t.i.d., spironolactone 12.5 mg p.o. q.o.d., Pletal 50 mg p.o. b.i.d., vitamin E, Zocor 40 mg, one-half tablet p.o. b.i.d.; Glucotrol XL 10 mg p.o. b.i.d., metformin 500 mg p.o. q.a.m., metformin 500 mg p.o. q.p.m., Imdur 30 mg p.o. q.d., Coreg 12.5 mg p.o. b.i.d., Tylenol ES 500 mg p.o. b.i.d., Avandia 80 mg p.o. q.d., Norvasc 5 mg p.o. q.a.m., Synthroid 0.1 mcg p.o. q.a.m., lisinopril 20 mg p.o. q.a.m., Lasix 40 mg p.o. q.d., cyclobenzaprine 10 mg, one-half tablet p.o. q.h.s., ranitidine 150 mg p.o. b.i.d., Celexa 20 mg p.o. q.d., Lantus insulin 10 units subcu q.p.m., Humalog 5 units subcu for blood sugars more than 250.
ES|extra strength|ES|127|128|ADMISSION MEDICATIONS|2. Status post endoscopies. 3. Status post appendectomy, cholecystectomy, and tonsillectomy. ADMISSION MEDICATIONS: 1. Vicodin ES 7.5 mg, she was taking 10 to 15 tablets per day, which has been discontinued. 2. Protonix 40 mg p.o. b.i.d. 3. Ranitidine 300 mg p.o. q.h.s.
ES|extra strength|ES|203|204|ADMISSION MEDICATIONS|4. Hytrin 2.5 mg p.o. every day. 5. Vasotec 5 mg p.o. 1/2 tablet every day. 6. Coumadin 5 mg p.o. every day. This medication was held for surgery, but will be restarted today, _%#MMDD2005#%_. 7. Tylenol ES 2 tabs p.o. p.r.n. pain. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient denies smoking cigarettes or using alcohol, marijuana, or other recreational drugs.
ES|extra strength|ES|173|174|MEDICATIONS|She takes methotrexate weekly. Synthroid 75 mcg. Iron one tablet daily. Fosamax 70 mg once a week. Flonase two sprays each nostril once daily. Prilosec. Folic acid. Tylenol ES three tablets q.i.d. Prednisone 1 mg two t.i.d. Her current medication list includes Rocephin 1 g IV q.24h., Zithromax 500 mg IV daily for a total of 5 days, Solu-Medrol 125 mg IV q.12h., and albuterol and Atrovent nebulizations q.4h. p.r.n. Spirometry on her _%#MMDD2002#%_ pulmonary clinic visit with Dr. _%#NAME#%_ was stable from a year earlier with an FEV-1 of 35% of predicted value and an FVC 51% of predicted value, according to his clinic note.
ES|extra strength|ES|178|179|CURRENT MEDICATIONS|3. Prozac 40 mg a day. 4. Fosamax 35 mg q.weekly. 5. Trazodone 50 mg p.o. at bedtime. 6. Lyrica 25 mg tabs 50 mg taken b.i.d. 7. Lactulose-Hydrin cream applied b.i.d. 8. Tylenol ES as needed. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is a former smoker who stopped in _%#MM2008#%_.
ES|extra strength|ES|214|215|OUTPATIENT MEDICATIONS|This was done on _%#MMDD2002#%_ secondary to symptomatic fibroids. The patient denies broken bones, diabetes, liver problems, kidney problems, or other significant medical history. OUTPATIENT MEDICATIONS: 1. Aleve ES b.i.d. 2. Tylenol b.i.d. 3. Estrogen 0.625 mg p.o. q. noon. ALLERGIES: Codeine produces projectile emesis and aspirin produces stomach discomfort.
ES|extra strength|ES.|100|102|ALLERGIES|4. B12 shots monthly. 5. Darvocet since the 1970s. ALLERGIES: ALLERGIES ARE TO REGLAN AND COMPAZINE ES. SOCIAL HISTORY: She is a retired secretary. She lives alone in her own home. REVIEW OF SYSTEMS: Remarkable for headaches this morning, however, not typical of her usual migraine headache.
ES|extra strength|ES|142|143|OUTPATIENT MEDICATIONS|17. Risperdal 9 mg p.o. q.h.s. 18. Ritalin. 19. Seroquel. 20. Symmetrel 1000 mg p.o. t.i.d. 21. Tylenol #3 one tablet p.o. q.h.s. 22. Tylenol ES p.r.n. 23. Valium 5 mg one tablet p.o. t.i.d. 24. Zyrtec 10 mg p.o. q.d. SOCIAL HISTORY: The patient denies smoking, alcohol use, or illegal drug use.
ES|extra strength|ES|200|201|RECOMMENDATIONS|She demonstrated hyporeflexia in both knee and ankle jerks. Strength testing was difficult due to guarding. IMPRESSION: Acute lumbar strain. RECOMMENDATIONS: 1) Restart diazepam 10 mg q8h. 2) Vicodin ES 7.5 mg one to two p.o. q6h. 3) Senokot-S two tabs h.s. 4) She may be discharged tomorrow of the following day depending upon how she does.
ES|extra strength|ES.|109|111|ALLERGIES|4. Zyprexa 5 mg at hs. 5. Tessalon pearls p.r.n. 6. BuSpar 50 mg b.i.d. ALLERGIES: 1. Claritin D. 2. Bactrim ES. 3. Motrin. SOCIAL HISTORY: The patient does not smoke cigarettes nor drink alcohol.
ES|extra strength|ES|160|161|OUTPATIENT MEDICATIONS|3. Coumadin 6 mg p.o. q. Monday, Wednesday, Friday, Saturday, and Sunday and 4 mg p.o. q. Tuesdays and Thursdays. 4. Multivitamin 1 tab p.o. q. day. 5. Tylenol ES 500 mg p.o. 1 to 2 tablets p.r.n. 6. Atenolol 25 mg p.o. q. day. 7. Celexa 40 mg p.o. nightly. 8. Zyrtec 10 mg p.o. nightly. 9. Lasix 40 mg p.o. b.i.d.
ES|extra strength|ES|165|166|MEDICATIONS|4. Hyperlipidemia. The patient's coronary status is not known. MEDICATIONS: Medications preoperatively were Naprosyn on a p.r.n. basis, ibuprofen 800 mg and Tylenol ES on a p.r.n. basis. ALLERGIES: None. SOCIAL HISTORY: As per the chart. FAMILY HISTORY: As per the chart. PHYSICAL EXAMINATION: On examination, he is a very pleasant man.
ES|extra strength|ES|166|167|MEDICATIONS|6. Plavix 75 mg daily. 7. Imdur 30 mg daily. 8. Metoprolol 25 mg p.o. b.i.d. 9. 70/30 NovoLog 16 units subq q.a.m. 10. 20/30 NovoLog 12 units subq q.p.m. 11. Tylenol ES 1 1000 mg p.o. q.i.d. 12. Trazodone 75 mg q.h.s. 13. Ativan 0.5 mg p.o. q.h.s. 14. Lovastatin 40 mg p.o. q.h.s. 15. Amitriptyline 10 mg p.o. t.i.d.
ES|extra strength|ES|120|121|MEDICATIONS|12. Requip 1 mg p.o. bedtime 13. Toprol XL 100 mg p.o. daily 14. Tramadol XL 50 mg three times daily p.r.n. 15. Tylenol ES two tablets every 4-6 hours p.r.n. ALLERGIES: To Avandia, has fluid retention, ACE inhibitor has cough.
ES|UNSURED SENSE|ES.|105|107|ADMISSION MEDICATIONS|6. Degenerative joint disease (DJD). 7. Osteoporosis. ADMISSION MEDICATIONS: 1. Prinivil. 2. Calcium, 3. ES. 4. Tylenol. 5. Milk of Magnesia. 6. Glyburide. 7. Multivitamin. 8. Prilosec. 9. Iron. 10. Robitussin. FAMILY HISTORY: Unobtainable and noncontributory, versus her baseline chart record.
ES|extra strength|ES|163|164|MEDICATIONS|3. BPH. MEDICATIONS: 1. Metamucil 2 teaspoons twice a day. 2. Klonopin 2 mg twice a day. 3. Detrol 2 mg every morning. 4. Cymbalta 60 mg every morning. 5. Tylenol ES 1000 mg t.i.d. 6. Amantadine 200 mg t.i.d. 7. Prolixin 10 mg every morning and 30 mg at h.s. 8. Dicloxacillin 500 mg twice a day which apparently was just recently ordered I presume for his left toe.
ES|extra strength|ES|195|196|STUDIES|Also noted was the presence of a small amount of peri-infarct ischemia within the same vascular territory with some overall dilatation of a left ventricle arrest. LVS was moderately reduced with ES of 33% and anterior and anterior septal hyperkinesis was noted on the gated SPECT images. IMPRESSION: Mr. _%#NAME#%_ is a 68-year old gentleman with a history of myocardial infarction and stenosis of the left anterior descending which has been previously stented.
ES|extra strength|ES|133|134|ADMISSION MEDICATIONS|15. Aspirin 81 mg daily. 16. Combivent inhaler 2 puffs daily. 17. Tylenol 3 one to two tablets q4h p.r.n. 18. Tylenol Extra Strength ES two tablets q.h.s. p.r.n. 19. Robitussin q.4h p.r.n. 20. Milk of Magnesia 15 to 30 mL p.r.n. 21. Discol suppositories 10 mg rectally p.r.n.
ES|extra strength|ES|157|158|PREOPERATIVE MEDICATIONS|16. Hydralazine 10 mg which she takes up to 6 times per day for systolic blood pressure greater than 160. 17. Lidex 0.05% solution to her scalp. 18. Tylenol ES PM 500/25 one at h.s. p.r.n. 19. Asacol 800 mg three times a day. 20. Vitamin B2 25 mg per day. 21. Alphagan eye drops 0.15% 1 drop left eye two times a day.
ES|extra strength|ES|110|111|MEDICATIONS|11. Retinal detachment in the left eye. 12. Left inguinal hernia repair. MEDICATIONS: 1. Glargine 6 units. 2. ES omeprazole (Nexium 40 mg daily). 3. Metoprolol 50 mg b.i.d. 4. Zosyn grams q.8h. 5. Diltiazem drip. 6. Half normal saline +20 of K at 100 an hour
ES|extra strength|ES|165|166|ADMISSION MEDICATIONS|9. Head trauma in 1981. 10. Status post Botox injections to the face. ADMISSION MEDICATIONS: 1. Neurontin. 2. Trazodone. 3. Phentermine 15 mg p.o. daily. 4. Vicodin ES 2 tabs p.o. p.r.n. ALLERGIES: Penicillin causes hives. SOCIAL HISTORY: She smokes approximately 3 packs of cigarettes a day.
ES|extra strength|ES|132|133|MEDICATIONS AT THE TIME OF TRANSFER HERE|4. Depakote 250 mg b.i.d. 5. Lumigan 0.03% one drop each eye at bedtime. 6. MiraLax once daily. 7. Seroquel 25 mg b.i.d. 8. Tylenol ES 1000 mg b.i.d. as well as Humeral injections q.2 weeks. Her last injection was 3 weeks ago. MEDICATIONS AT THE TIME OF ADMISSION: (To Ridgeview 3 weeks ago).
ES|extra strength|ES|160|161|MEDICATIONS|MEDICATIONS: 1. Atenolol 50 mg p.o. b.i.d. 2. Norvasc 5 mg p.o. daily. 3. Sinemet 25/100 mg p.o. each day at bed-time. 4. Aspirin 325 mg p.o. q day. 5. Tylenol ES and Motrin p.r.n. ALLERGIES: She has no known drug allergies. FAMILY HISTORY: Positive for coronary artery disease as mentioned above.
ES|extra strength|ES|173|174|ADMISSION MEDICATIONS|5. Simethicone 80 mg chew one tablet p.o. q2h p.r.n. gas. 6. DDAVP 0.2 mg tablet one p.o. q.h.s. 7. Tap water enemas (Monday, Wednesday, and Friday) twice a day. 8. Lactaid ES 4500 unit caplets, two caplets p.o. t.i.d. 9. Prune juice. ALLERGIES: Haldol and lactose intolerance. SOCIAL HISTORY: The patient states he smokes as much as he can afford since the age of 18.
ES|extra strength|ES|148|149|ASSESSMENT/PLAN|4. Gastroesophageal reflux disease. Will restart Zantac 150 mg one tablet p.o. b.i.d. Will monitor. 5. Lactose intolerance. We will restart Lactaid ES 4500 unit caplets, two caplets p.o. t.i.d. 6. Left hip pain related to healing fracture. We will continue to treat the patient's pain with Extra Strength Tylenol as he declines any other medications at this time.
ES|extra strength|ES|162|163|PLAN|The patient seemed agreeable to this plan. I will put him on oral ciprofloxacin as well at 500 mg b.i.d. I wrote him a prescription for a small supply of Vicodin ES to carry him over until his surgical date. Otherwise we will continue to follow up with him during his hospitalization and post op.
ES|extra strength|ES|137|138|OUTPATIENT MEDICATIONS|The patient denies active symptoms of tuberculosis. OUTPATIENT MEDICATIONS: 1. Klonopin. 2. Robaxin 750 mg p.o. q.i.d. p.r.n. 3. Vicodin ES 750/7.5 mg one tab p.o. q.i.d. 4. Zoloft. 5. Synthroid 225 mcg p.o. daily. 6. Allegra 180 mg p.o. daily. 7. Wellbutrin XL 8. BuSpar. 9. Guaifenesin 600 mg p.o. b.i.d.
ES|extra strength|ES|138|139|MEDICATIONS|He is not able to contribute to the history in this regard. MEDICATIONS: 1. Cenogen 1 b.i.d. p.r.n. 2. Omeprazole 20 mg q.h.s. 3. Tylenol ES 2 q.4-6h.p.r.n. pain. 4. Atenolol 50 mg daily. 5. Lisinopril 5 mg daily. 6. Lipitor 20 mg a day. 7. NovoLog 70/30 9 units q.a.m. and in the q.p.m. The patient does not use sliding scale coverage.
ES|extra strength|ES,|187|189||He is presently taking Neurontin 100 mg p.o. q.i.d. along with Methadone 8 mg daily. Ativan has been weaned. He was previously on Ativan 3 mg p.o. t.i.d. He is also on Toprol XL, Vicodin ES, Ecotrin, Lopid, and Restoril at bedtime. He complains of having pains and numbness in the lower extremities, mostly the sole of his feet and he has difficulty putting weight on his feet.
ES|extra strength|ES|121|122|MEDICATIONS|5. Glucotrol XL 20 mg q day 6. Lasix 20 mg b.i.d. 7. Digoxin 0.125 mg q.o.d. 8. Klonopin 0.5 mg b.i.d. p.r.n. 9. Tylenol ES p.r.n. 10. Zestril 20 mg q day 11. Remeron 7.5 mg at h.s. 12. Ativan p.r.n. 13. Actos 30 mg q day ALLERGIES: Sulfa; penicillin; IVP dye; all of which cause hives.
ES|extra strength|ES|141|142|LABORATORY EVALUATIONS|Chest x-ray shows opacities with a very small right consolidation and effusion. Outside records showed a TEE, which showed a normal LV size, ES of 66% and no vegetations. A CT scan of his right shoulder on _%#MMDD2007#%_ showed degenerative joint disease, he did have a pulmonary consolidation at the right base.
ES|extra strength|ES|140|141|MEDICATIONS|MEDICATIONS: 1. Colace 100 mg twice a day. 2. Neurontin 300 mg twice a day. 3. Symmetrel 100 mg t.i.d. 4. Cogentin 0.5 mg t.i.d. 5. Tylenol ES 500 mg q.i.d. 6. Benadryl 50 mg q.i.d. 7. Lorazepam 1 mg q.i.d. 8. Lidoderm patch to the feet, on in the morning, off at bedtime.
ES|extra strength|ES.|174|176|CURRENT MEDICATIONS|2. Enalapril. 3. Actose. 4. Lipitor. 5. Casodex. 6. Cipro. 7. Glyburide. 8. Flomax. 9. Clinoril. 10. Percocet. 11. Magnesium citrate. 12. Phenergan. 13. Sudafed. 14. Tylenol ES. 15. Maalox. ALLERGIES: Sulfa, horse serum and antitoxins. PHYSICAL EXAMINATION: Skin- in good condition. No lesions seen. Well-healed surgical scars noted.
ES|extra strength|ES|131|132|CURRENT MEDICATIONS|2. Asthma medications. 3. Sudafed. 4. Maalox. 5. Magnesium citrate prn. 6. Senokot prn. 7. Colace prn. 8. Clinoril prn. 9. Tylenol ES prn. 10. Zantac. 11. Vasotec. 12. Lipitor. 13. Casodex 50 mg po qd. 14. Glyburide 25 mg po qd. 15. Actose. 16. Flomax 0.4 mg po qd prn.
ES|extra strength|ES|130|131|...MISSING FIRST PART OF DICTATION...|The patient also complained of occasional indigestion and gas. He states that he takes Gaviscon for indigestion and Alka- Seltzer ES for gas. Both provide good relief. The patient's chart also notes that he takes Zantac 150 mg b.i.d. The patient complained of occasional diarrhea, for which he takes loperamide and gets good relief.
ES|extra strength|ES|161|162|ADMISSION MEDICATIONS|Multivitamin 1 p.o. q.d. 7. Zantac 150 mg p.o. b.i.d. 8. Benadryl 100 mg p.o. q.h.s. 9. L-Synthroid 150 mcg p.o. q.d. 10. Lisinopril 10 mg p.o. q.d. 11. Tylenol ES p.r.n. 12. Trazodone 50 mg p.o. q.h.s. 13. Haldol 20 mg p.o. q.a.m. and 2 mg p.o. q.h.s. 14. Haldol Decanoate 100 mg/ml, 2 ml IM q. 2 weeks.
ES|extra strength|ES|180|181|HISTORY OF PRESENT ILLNESS|He denies fever or chills. He complains of some indigestion for which he takes Zantac 150 mg b.i.d. and Gaviscon. He also complains of gas at times for which he takes Alka-Seltzer ES with relief. The patient also complains of some diarrhea for which he takes Loperamide. He denies hematochezia or melena. The patient complains of allergies.
ES|extra strength|ES|185|186|MEDICATIONS|MEDICATIONS: 1. Enteric-coated aspirin 325 mg p.o. q.d. 2. Claritin 10 mg p.o. q.d. 3. Gemfibrozil 600 mg p.o. b.i.d. 4. Glucophage 500 mg q. AM. 5. Multivitamin 1 p.o. q.d. 6. Tylenol ES p.r.n. 7. Lisinopril 10 mg p.o. q.d. 8. Loperamide 2 mg p.o. q.d. p.r.n. 9. Beconase nasal spray 1 puff to each nostril b.i.d.
ES|extra strength|ES|116|117|MEDICATIONS|As above, she is restarted on Sinemet, as well. 6. I am not aware of known cardiac disease. MEDICATIONS: 1. Tylenol ES 1,000 mg b.i.d. 2. Calcium with vitamin D b.i.d. 3. Depakote ER 1500 mg q.h.s. 4. Aricept 5 mg daily. 5. Pepcid 20 mg daily. 6. Synthroid 25 mcg daily.
ES|extra strength|ES.|231|233|CURRENT MEDICATIONS|6. History of heart failure. FAMILY HISTORY: Noncontributory. ALLERGIES: Penicillin, codeine, morphine, ____________. CURRENT MEDICATIONS: Home oxygen, OxyContin, Celexa, Evista, Lasix, lisinopril, multivitamin, Plavix and Tylenol ES. SOCIAL HISTORY: She does not smoke, does not drink alcohol or use caffeine.
ES|extra strength|ES|124|125|PRN MEDICATIONS|7. Phenergan 100 mg po qhs. 8. Trazodone 200 mg po qhs. PRN MEDICATIONS: 1. Milk of Magnesia prn. 2. Maalox prn. 3. Tylenol ES prn. 4. Sulindac prn. 5. Midrin prn. 6. Trazodone prn. 7. Periactin prn. Additionally, she is also receiving electroconvulsive therapy.
ES|extra strength|ES|151|152|ADMISSION MEDICATIONS|3. Metformin 1000 mg p.o. b.i.d. 4. Multivitamin one tablet p.o. daily. 5. Aspirin 325 mg p.o. daily. 6. Glucosamine one tablet p.o. daily. 7. Tylenol ES 2 tablets p.o. p.r.n. ALLERGIES: No known drug allergies, except the patient says he gets a cough from Lipitor.
ES|extra strength|ES|144|145|MEDICATIONS|5. History of congestive heart failure, with unknown details in this regard. 6. Question of more chronic mild dementia. MEDICATIONS: 1. Tylenol ES two q.i.d. 2. Ecotrin 81 mg a day. 3. Calcium + D one a day. 4. Pravachol 40 mg. 5. Multivitamins once a day.
ES|extra strength|ES|161|162|ADMISSION MEDICATIONS|4. Pituitary adenoma. 5. Panic attacks. ALLERGIES. 1. Penicillin. 2. Ether. 3. Anchovies. ADMISSION MEDICATIONS: 1. Ibuprofen 200 mg to 600 mg p.r.n. 2. Tylenol ES p.r.n. for pain. 3. Multivitamin and then supplements of calcium, magnesium, and glucosamine. SOCIAL HISTORY: The patient is a nonsmoker. PHYSICAL EXAMINATION: GENERAL: The patient is in no acute distress.
ES|extra strength|ES.|254|256|MEDICATIONS|He does have some loose stools. His review of systems is otherwise negative. ALLERGIES: He has no known drug allergies. MEDICATIONS: His current medications include Zithromax, Vioxx, Decadron, Unasyn, Mycostatin, clindamycin, Diflucan, Benadryl, Tylenol ES. SOCIAL HISTORY: He, as mentioned, has lived on his own for the past two months and has had unprotected sexual contacts as mentioned.
ES|extra strength|ES|120|121|MEDICATIONS|4. Prometrium 100 mg p.o. q.3 days. 5. Zanaflex 4 mg one p.o. q. day. 6. MS Contin CR 15 mg one p.o. q. day. 7. Tylenol ES p.r.n. pain. 8. Glucosamine chondroitin 500 mg t.i.d. ALLERGIES: No known drug allergies. FAMILY HISTORY: The patient's father has a history of stomach cancer, mother has a history of cardiac disease, including atrial fibrillation and CVA.
ES|extra strength|ES|131|132|ADMISSION MEDICATIONS|3. Trazodone 50 mg p.o. q.h.s. 4. Lamictal 75 mg q.a.m.; the dose is going to be increased to 100 mg on _%#MMDD2004#%_. 5. Vicodin ES one tablet q.4-6 h. p.r.n. pain. ALLERGIES: Tetracycline and all its derivatives, with a rash as a complication.
ES|extra strength|ES|148|149|PAST MEDICAL HISTORY|3. Cartia p.o. daily 4. Furosemide p.o. daily 5. Alprazolam 2 tablets daily 6. Cozaar 1 tablet p.o. daily 7. Megestrol 40 mg p.o. b.i.d. 8. Tylenol ES 1 or 2 tablets p.o. every 4 hours as needed 9. Ambien 10 mg p.o. q.h.s. as needed ALLERGIES: She reported allergies to penicillin, sulfa medications, and to codeine.
ES|extra strength|ES|132|133|PLAN|This is probably secondary to environmental factors. 4. Chronic abdominal pain. This is stable. PLAN: The patient will have Tylenol ES q.6 hours p.r.n. pain and artificial tears p.r.n.
ES|extra strength|ES|311|312|CURRENT MEDICATIONS|6. History of GI bleed. 7. Degenerative joint disease for which he has undergone several surgeries and joint replacements including both knees, right hip, right ankle fusion, lumbar laminectomy and shoulder surgery. 8. Status post cholecystectomy. CURRENT MEDICATIONS: 1. Vicodin 5/500 q.3 h. p.r.n. 2. Tylenol ES 500 mg q.3 h. p.r.n. 3. Senna S 2 tabs 2 times per day. 4. Benicar 20 mg daily for hypertension.
ES|extra strength|ES|119|120|MEDICATIONS|MEDICATIONS: 1. Clonidine 0.1 mg q.h.s. 2. Adderall XR 20 mg daily. 3. Seroquel 25 mg daily, 50 mg q.h.s. 4. Augmentin ES one teaspoon p.o. b.i.d. for three more days. ALLERGIES: No known drug allergies. SOCIAL AND FAMILY HISTORY: Available in the old record.
ES|extra strength|ES|124|125|MEDICATIONS|CHEMOTHERAPY HISTORY: None. RADIATION HISTORY: None. MEDICATIONS: 1. Benzonatate 100 mg capsule 3 capsules t.i.d. 2. Megace ES 625 mg/5 mL suspension 5 mL daily. 3. Oxycodone 5 mg 1-2 tablets every 4-6 hours p.r.n. ALLERGIES: No known drug allergies.
ES|extra strength|ES|213|214|ALLERGIES|PAST SURGICAL HISTORY: Procedures include repair of a left inguinal hernia, basal cell carcinoma of skin, dilation of a urethral stenosis, cystocele repair and septoplasty. ALLERGIES: Sulfa, cortisone, ofloxacin, ES citalopram oxalate, Actonel, Aspercreme and Lortab. MEDICATIONS: Nexium, Carafate, Ambien, Calcitrate, promethazine, amitriptyline, Trazodone, Lortab and FiberCon.
ES|extra strength|ES|197|198|PLAN|ASSESSMENT: 1. Psychiatric conditions per Dr. _%#NAME#%_. 2. Trigeminal neuralgia 3. Suprapubic pain, unknown etiology. PLAN: 1. Will continue with the patient's outpatient prescription of Vicodin ES 750/7.5 mg, 1 tab p.o. every 6 hours h p.r.n., trigeminal neuralgia. 2. Urine culture. 3. Neosporin ointment to be applied b.i.d. to bilateral wrist x3 days.
ES|extra strength|ES|168|169|MEDICATION LIST|13. Advair 250/50 mg a day 14. Isosorbide 15 mg daily 15. Flomax 400 mg daily 16. Aspirin 81 mg daily 17. Zocor 80 mg at bed-time 18. Albuterol 19. Senokot 20. Tylenol ES 21. Vicodin p.r.n. FAMILY HISTORY: Noncontributory ALLERGIES: None known PHYSICAL EXAMINATION: Elderly frail male, blood pressure is 150/70, heart rate is 80 beats per minute.
ES|extra strength|ES|146|147|CURRENT MEDICATIONS|19. Aspirin enteric-coated 81 mg p.o. daily. 20. Zocor 80 mg p.o. daily 21. Senokot 1 tab p.o. b.i.d. 22. Albuterol nebs q.6h. p.r.n. 23. Tylenol ES two tabs p.o. q.6h. p.r.n. 24. Vicodin 1 tab p.o. q.4-6h. p.r.n. FAMILY HISTORY: His mother died in her 20s. Father died in his 60s. SOCIAL HISTORY: The patient is married, he has four children.
ES|extra strength|ES|160|161|MEDICATIONS|3. Zocor 40 mg a day. 4. Hydrochlorothiazide 25 mg a day. 5. Lisinopril 20 mg daily. 6. Metoprolol 25 mg once a day. 7. Klor-Con 10 mEq twice a day. 8. Tylenol ES 1-2 q.4-6 h. p.r.n. 9. Aspirin 325 mg daily. ALLERGIES: None. SOCIAL HISTORY: The patient moved here from _%#CITY#%_ in _%#MM#%_ of this year.
ES|extra strength|ES|193|194|LABORATORY  DATA|LABORATORY DATA: Sodium 138, potassium 3.5, chloride 104, glucose 101, serum creatinine 1.03, total bilirubin 0.7, albumin 4.2, liver function tests normal. Lipase elevated at 3363. Troponin 1 ES negative. Hemoglobin 14.7, white blood count 11,700. IMPRESSION: Probable perforated sigmoid diverticulitis with free intraperitoneal air. The patient needs exploratory laparotomy.
ES|enhanced sensitivity|ES|155|156|HISTORY|Mild mitral insufficiency and mild aortic insufficiency was noted with trace pulmonic insufficiency. The patient did have a troponins drawn and troponin-1 ES assay was 0.070, 0.29 and 0.35, all above the 99th percentile reference range. Electrocardiogram in the emergency room yesterday evening showed atrial fibrillation with a ventricular response of 115 beats per minute.
ES|extra strength|ES|141|142|HISTORY OF PRESENT ILLNESS|The history a month ago before being intervened with this procedure, he had a right upper lobe pneumonia that was treated with Augmentin 600 ES of 120 mg p.o. t.i.d. for 10 days. He had a pressure gradient preangioplasty of 90 and he had a balloon of 6-9 mm used for this procedure.
ES|extra strength|ES.|183|185|CURRENT MEDICATIONS|13. Tylenol extra strength one to two tablets q.i.d. p.r.n. for mild pain or fever. 14. Tylenol 3 with codeine 1-2 tablets every 4-6 hours p.r.n. for pain not controlled with Tylenol ES. 15. Temazepam 15 mg q.h.s. p.r.n. for insomnia. ALLERGIES: Allopurinol, indomethacin, isosorbide, atenolol and Aceon.
ES|extra strength|ES|201|202|PROBLEM #3|CRP was increased at admission and normalized by discharge. In addition to the Unasyn, he was treated with Cipro HC Otic drops. On the day of discharge, he was changed from IV Unasyn to oral Augmentin ES to complete a course to be determined by ENT after follow-up in one week, prescription for a six-week course was given.
ES|enhanced sensitivity|ES|207|208|LAB ASSESSMENT|There is a hemoglobin of 12.9, hematocrit 39.2, platelet count 222,000. Sodium is 133, potassium is 3.8, chloride is 94, CO2 is 28, glucose is 174 with a BUN of 23, creatinine 1.08. Calcium 9.4. Troponin 1, ES is less than 0.012. Urinalysis is positive for nitrates and small leukocyte esterase, 10-20 white cells and many bacteria. ASSESSMENT AND PLAN: 1. Fall with presumed syncopal episode, question secondary to underlying vasovagal episode after bowel movement versus secondary underlying cardiac source less likely any distinct neurological change noted.
ES|extra strength|ES|78|79|MEDICATIONS|Status post Achilles tendon surgery on the right side MEDICATIONS: 1. Tylenol ES 500 mg p.o. daily 2. Tylenol ES two tabs by mouth at night 3. Lumigan eye drop into the left eye once at night
ES|extra strength|ES,|181|183|MEDICATIONS|2. Duonebs one nebulizer twice a day 3. Ferrous sulfate 325 mg 1 tablet daily for 30 days. 4. Lasix 40 mg in the evening. 60 mg in the morning 5. Vicodin every 6 hours with Tylenol ES, not to exceed 4000 mg. 6. Lisinopril 2.5 mg. p.o. every evening 7. metoprolol 25 mg every morning. 8. Remeron 22.5 mg at bedtime 9. multivitamin 1 pill p.o. daily
ES|extra strength|ES|189|190|MEDICATIONS|MEDICATIONS: 1. Cipro 500 mg b.i.d., which will be discontinued at discharge. 2. Colace 100 mg b.i.d. 3. Lovenox 30 mg subq q.12h. to start this evening. 4. Amaryl 1 mg daily. 5. Glipizide ES 5 mg daily. 6. Synthroid 62.5 mcg daily. 7. Protonix 40 mg b.i.d. 8. MiraLax 17 grams daily, which will be discontinued. 9. Quinine sulfate at bedtime for leg cramps.
ES|ejection fraction:EF|ES|198|199|BONE MARROW TRANSPLANT WORKUP|3. Retinal hemorrhage. 4. Cortical blindness. 5. Encephalopathy. 6. Pulmonary nodules; possible fungal infection. BONE MARROW TRANSPLANT WORKUP: Echo, _%#MMDD2007#%_, shows no valvular vegetations. ES of 70%. Chest CT scan, _%#MMDD2007#%_, shows bilateral infiltrates tree-in-bud opacities. Chest CT, _%#MMDD2007#%_, shows near resolution of ground-glass opacities in the superior segments of lower lobes and posterior segments right upper lobe likely post-infections.
ES|extra strength|ES|157|158|MEDICATIONS|MEDICATIONS: 1. Celexa 20 mg p.o. b.i.d. 2. Neurontin 200 mg p.o. b.i.d. 3. Trazodone 100 mg p.o. q.h.s. 4. Soma 350 mg one to two tablets t.i.d. 5. Vicodin ES one to two tablets t.i.d. ALLERGIES: No known drug allergies, but he said that NSAID have caused bleeding ulcers in the past.
ES|enhanced sensitivity|ES|192|193|LABORATORY STUDIES|Sodium 138, potassium 4.2, bicarbonate 23, BUN and creatinine 36 and 1.4, anion gap 12, blood sugars 116, baseline creatinine is 1.3 to 1.5, incidentally. Calcium 8.7, proBNP 3820, troponin I ES is less than 0.012. Blood cultures x2 obtained. Chest x-ray reviewed by myself shows patchy infiltrates left base, mild fibrosis bilaterally.
ES|extra strength|ES|464|465|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|At the time of presentation she was very weak. Her speech was soft and somewhat slurred and she was non- ambulatory. Her medications at the time of admission were aspirin 81 mg daily, Neurontin 300 mg po tid, Spironolactone 12.5 mg po every other day, Platol 50 mg po bid, Vitamin E 400 international units daily, Zocor 40 mg 1 po bid, Glucatrol XL 10 mg po bid, Metformin 500 mg po q.a.m. and 500 mg po q.p.m., Imdur 30 mg po daily, Coreg 12.5 mg po bid, Tylenol ES 500 mg po bid, Avandia 80 mg po daily, Norvasc 5 mg po q.a.m., Synthroid 0.1 mg po q.a.m., Lisinopril 20 mg po q.a.m., Lasix 40 mg po daily, Cyclobenzaprine 5 mg po q hs, Zantac 150 mg po bid, Celexa 20 mg po daily, Lantus Insulin 10 units sub Q every night and Humalog insulin 5 units subcutaneously for blood sugars more than 250.
ES|extra strength|ES|233|234|PAST MEDICAL HISTORY|He was, therefore, sent to Fairview-University Medical Center for admission for workup of hematuria, discrepant renal size, and anemia. PAST MEDICAL HISTORY: 1. Allergies. No known drug allergies. 2. Admission medications: Augmentin ES - 600, 4 ml p.o. b.i.d. times two doses, prior to admission. 3. No prior hospitalizations or surgeries. 4. Otitis media times three in the past.
ES|extra strength|ES|187|188|DISCHARGE MEDICATIONS|DISCHARGE DIAGNOSES: 1. Post-streptococcal glomerulonephritis. 2. Iron-deficiency anemia. DISCHARGE MEDICATIONS: 1. Amlodipine 1.25 mg p.o. b.i.d. 2. Lasix 15 mg p.o. b.i.d. 3. Augmentin ES 600, 4 ml p.o. b.i.d. times a total ten-day course. FOLLOW-UP PLANS: 1. The patient should follow up with their primary physician, Dr. _%#NAME#%_ _%#NAME#%_, on Monday, _%#MMDD2003#%_.
ES|UNSURED SENSE|ES|144|145|PLAN|We will keep the patient NPO for now and start him on Claforan and some Flagyl for what appears to be possible diverticulitis. We will check an ES R and CRP and watch him, and see if he clinically starts to feel better.
ES|extra strength|ES|173|174|ADMISSION MEDICATIONS|18. Xifaxan 400 mg p.o. b.i.d. (since _%#MMDD2005#%_). 19. Flagyl 500 mg p.o. b.i.d. (on day #3 of a 14-day course). 20. Dilaudid 2 mg p.o. q.4-6 h. p.r.n. pain. 21. Pepcid ES 1 tablet p.o. b.i.d. 22. Gas-X p.r.n. SOCIAL HISTORY: Mr. _%#NAME#%_ lives in _%#CITY#%_ with his parents and his daughter.
ES|extra strength|ES|103|104|ADMISSION MEDICATIONS|The patient also has a history of vancomycin-resistant Enterococcus. ADMISSION MEDICATIONS: 1. Tylenol ES p.r.n. 2. Wellbutrin. 3. Depakote 1500 mg b.i.d. 4. Verapamil 240 mg daily. 5. Dilantin 300 mg b.i.d. 6. Warfarin 5 mg q.p.m. 7. Digoxin 0.25 mg daily
ES|extra strength|ES|131|132|ADMISSION MEDICATIONS|4. Asthma, diagnosed at 3 years of age, but requiring no treatment or medications since age 4. ADMISSION MEDICATIONS: 1. Augmentin ES 875 mg by mouth twice a day. 2. Ceftriaxone status post 3 doses. ALLERGIES: RICE POLLEN. FAMILY HISTORY: The patient's father developed Bouchard disease in his early 20s.
ES|extra strength|ES|161|162|DISCHARGE MEDICATIONS|10. Folic acid 1 mg p.o. q day. 11. Lo-Ovral 28, one tablet p.o. q day. 12. Advair 500/50 one puff b.i.d. 13. Nasonex, two sprays to each nares daily. 14. Gas-X ES 125 mg p.o. four times a day. 15. Methotrexate 1 cc subcutaneously every Friday. 16. Singulair 10 mg p.o. q h.s.
ES|extra strength|ES|103|104|CURRENT MEDICATIONS|One of his brothers and sister-in-law have looked after him primarily. CURRENT MEDICATIONS: 1. Vicodin ES one tablet q.4h. p.r.n. 2. Demadex 20 mg daily in a.m. 3. Potassium chloride 20 mEq daily. 4. Synthroid 0.175 mg daily. 5. Allopurinol 150 mg daily.
ES|extra strength|ES|166|167|MEDICATIONS|21. Lamisil. 22. Eucerin cream. 23. Lida-Mantle HC cream for fungus, corns, hands, feet, toenails. 24. NTGSL p.r.n. 25. Xanax .5 mg p.r.n. panic attacks. 26. Tylenol ES p.r.n. 27. Darvocet N 100 with A-PAP 650. 28. Lidoderm 5% patches for arthritis. 29. Phenergan 25 mg NV. 30. Dramamine same. 31. Benadryl 25 mg hs allergies.
ES|extra strength|ES|134|135|MEDICATIONS ON ADMISSION|5. Prevacid 30 mg QD. 6. Folgard one PO QD 7. Niaspan ER 1,000 mg Q p.m. 8. Toprol XL 50 mg Q p.m. 9. Zoloft 25 mg Q p.m. 10. Tylenol ES 1,000 mg QHS 11. Benafiber one teaspoon b.i.d. 12. Omega 3 fatty acids 1,000 mg b.i.d. 13. Multivitamin one PO QD. 14. Magnesium 250 mg QD.
ES|extra strength|ES,|531|533|MEDICATIONS|History of atrial fibrillation, hypertension, pulmonary hypertension, congestive heart failure, chronic lymphedema since 1930s, mostly without major infections and osteomyelitis of the foot, hypothyroidism, chronic renal insufficiency, creatinine has been in the 2s historically most recently 1.86. Atherosclerotic cardiovascular disease has also been fairly stable most recently. Prior hysterectomy and thyroidectomy. ALLERGIES: None. MEDICATIONS: On admission include Prilosec, vitamin A&D, artificial tears, colchicine, Tylenol ES, Coumadin 4 mg daily, gentamicin ointment to the wound erythromycin ophthalmic ointment, Benicar, Lasix, multivitamin, prednisone, ferrous sulfate, Colace, just finished a course of Levaquin, it does appear she has been on chronic antibiotics although apparently has periodically been on them.
ES|extra strength|ES|205|206|LABORATORY DATA|NEUROLOGIC: Grossly nonfocal. LABORATORY DATA: Hematocrit 31.6, WBC 16.3, platelets 456,000. INR 1.32, PTT 42. Electrolytes within normal limits. Glucose 131, creatinine stable at 2.54, BUN 57, troponin 1 ES 1.810. RADIOLOGIC STUDIES: The findings of the bilateral carotid duplex on _%#MMDD2007#%_ as well as the cardiac catheterization and bilateral renal angiograms are noted above.
ES|extra strength|ES|202|203|PROBLEM #1|We will add oxycodone 5 mg 1 tablet q.4 h. p.r.n. for breakthrough pain to see what benefit he does get regarding his restless legs. For his headaches with the oxycodone he can continue to take Tylenol ES 500 mg 2 tablets q.4-6 h. p.r.n. as needed as well. PROBLEM #2: Anxiety disorder. This seems to be really a key component to his decrease in quality of life.
ES|extra strength|ES|178|179|HISTORY OF PRESENT ILLNESS|18. Depakote ER 1500 mg 1 tablet p.o. q. day and 1750 mg 1 tablet p.o. q.h.s. (200 mg q.h.s. will begin on _%#MM#%_ _%#DD#%_). 19. Celexa 20 mg 1 tablet p.o. q. day. 20. Tylenol ES 1000 mg p.o. q.6h. p.r.n. pain. 21. Niaspan ER 500 mg 1 tablet p.o. q.h.s. SOCIAL HISTORY: The patient has never been married and without children.
ES|extra strength|ES|406|407|MEDICATIONS ON ADMISSION|Of note, when he was admitted his INR was 7.04. ALLERGIES: None known about. MEDICATIONS ON ADMISSION: Tetracycline 250 mg q.i.d. for five days for diverticulitis, Arginaid one packet b.i.d., Combivent inhaler two puffs q.i.d., Colace 100 mg q.d., ferrous gluconate one p.o. t.i.d., Lasix 40 mg q.d., multivitamins one p.o. q.d., Synthroid 0.2 mg q.d., Coumadin 7.5 mg q.d., Digitek 0.375 mg q.d., Tylenol ES two p.o. q.h.s., Celexa 20 mg q.d. PAST MEDICAL HISTORY: 1. COPD with patient smoking from his youth until this past _%#MM#%_, slightly less than one pack per day.
ES|extra strength|ES.|352|354|CURRENT MEDICATIONS|Note that the list of nursing home medications is extensive, and none of these have been administered this morning. Medications include: Aspirin, Lasix, Monopril, potassium chloride, Norvasc, atenolol, meclizine, trazodone, Lipitor, Prilosec, Amphojel, sorbitol, Peri-Colace, isosorbide, Tegretol, Neurontin, albuterol nebs, Combivent inhaler, Tylenol ES. ALLERGIES: The patient is unable to state whether he has any allergies.
ES|extra strength|ES|133|134|ADMISSION MEDICATIONS|10) Os-Cal 1 po bid. 11) Prevacid 30 mg po bid. 12) Prempro one po q d. 13) Allegra D one po bid. 14) ASA 81 mg po q am. 15) Tylenol ES 1-2 po q 6 hours prn. 16) Darvocet N-100 one po q 4-6 hours prn. 17) Patient also takes cranberry capsules for urinary tract infection prophylaxis.
ES|UNSURED SENSE|ES|153|154|PAST MEDICAL HISTORY|4. Left occipital subdural hematoma _%#MM2006#%_ with memory deficits and cognitive impairments. 5. Dysphasia. 6. Hypertension. 7. Seizures, status post ES subdural hematoma. 8. Clostridium difficile colitis in _%#MMDD2006#%_ treated with vancomycin. 9. Breast cancer in 1999, status post mastectomy. 10. History of depression.
ES|extra strength|ES|195|196|ADDENDUM|There was a negative agitated saline-contrast study. It also showed a grade 3 atheroma in the descending aorta with no mobile elements identified. There was a normal LV systolic function with an ES of 55%. There was mild mitral regurgitation. No thrombus noted.
ES|extra strength|ES|203|204|DISCHARGE PLAN|Her case will be discussed by the department in the ensuing time and thoughts given to further workup that will be needed as an outpatient. 3. Infectious disease. The patient was discharged on Augmentin ES b.i.d. for roughly 10 days 4.5 cc of the 600 mg/5 mL formulation. This was a replacement dose for the cefpodoxime, which the patient's mother could not afford, and they had no insurance.
ES|extra strength|ES|143|144|MEDICATIONS|MEDICATIONS: 1) Aleve 220 mg p.o. q day. 2) Efudex cream every other day to a wart on his right foot. 3) Vasotec 20 mg p.o. q day. 4) Gaviscon ES p.r.n. 5) Lipitor 10 mg p.o. q h.s. 6) Ongicil 150 mg p.o. q Wednesday for toe fungus. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97, blood pressure 148/73, heart rate 63, respirations 12, weight 199 pounds or 91 kg.
ES|extra strength|ES.|253|255|HOSPITAL COURSE|A repeat gastric emptying study was performed on _%#MM#%_ _%#DD#%_, 2005, and showed mild gastroesophageal reflux, and significant delayed gastric emptying with only 28% clearance from the stomach at 60 minutes. He was therefore started on erythromycin ES. His Protonix was continued throughout hospitalization. 3. Metabolic. The patient has methylmalonic acidemia. He was followed by the metabolic service throughout his hospitalization.
ES|extra strength|ES|117|118|DISCHARGE MEDICATIONS|3. Triamcinolone topical ointment twice a day over scab on the face. 4. Actigall 300 mg p.o. twice a day. 5. Tylenol ES 500 mg as needed daily. 6. Aspirin 81 mg p.o. daily. 7. Potassium chloride 10 mEq p.o. twice a day. DISCHARGE DISPOSITION: Home. DISCHARGE CONDITION: Stable and pain-free. BRIEF HOSPITAL SUMMARY: _%#NAME#%_ _%#NAME#%_ is an 88-year-old female with history of coronary disease who presents with symptoms of right anterior lower chest pain and right upper quadrant pain as well.
ET|enterostomal therapy|ET|156|157|ASSESSMENT AND PLAN|The patient is on midodrine which will be continued. 11. Hyperlipidemia. Continue Zocor. 12. Urinary retention. Continue Flomax. 13. Heel ulcers. Will have ET evaluate and treat the patient. 14. Deconditioning/debilitation. PT and OT consultation and PM&R consultation will be obtained. Over 75 minutes were spent in gathering information about this patient.
ET|endotracheal|ET|275|276|HISTORY OF PRESENT ILLNESS|TIC workup was initiated which was unremarkable. However, subsequent evaluation revealed an INR that went to 8, a low fibrinogen, a platelet count decreased to 24,000, and D-dimer was significantly elevated. The patient also developed oozing from his IV sites and around his ET tube, all consistent with disseminated intravascular coagulation. The patient's CVP was slowly increased to approximately 19, however he still required upwards of 20-30 mcg of norepinephrine or Levophed.
ET|enterostomal therapy|ET|192|193|IMPRESSION/PLAN|Will treat with Rocephin IV. 2. Decubitus ulcer of right foot with mild cellulitis. This should be covered with Rocephin. 3. Nonhealing sacral wound. In addition to the Rocephin, will ask the ET nurse to evaluate and make recommendations. 4. Neurogenic bladder treated with straight cathing. 5. Paraplegia. 6. Colostomy with nonhealing sacral wound. 7. Social issues. Patient's urinary tract infection will likely easily be treated with antibiotics.
ET|enterostomal therapy|ET|200|201|SUMMARY|His pain was initially controlled with PCA and we added Toradol to get good pain control. As his ileostomy began to function his diet was slowly advanced. He was given ileostomy instructions with the ET nurses as his diet was advanced. His Foley catheter was subsequently removed on postoperative day number four, and his IV fluids were turned down.
ET|enterostomal therapy|ET|189|190|FOLLOW UP|2. Protonix 40 mg p.o. q.day. 3. The patient was also instructed to resume all preop medications listed above. FOLLOW UP: The patient was discharged to home. Home care was arranged with an ET nurse to support and teach the patient and to supply ileostomy cares and necessary equipment. In addition, the patient is to follow up with Dr. _%#NAME#%_ in 2 weeks.
ET|enterostomal therapy|ET|146|147|ALLERGIES|The warmth and redness of the right leg improved significantly. However, to prevent future cellulitis, he will need to have better foot care. The ET nurse was consulted and recommended daily soaking of both feet with Eucerin cream applied afterwards. The patient should continue his oral antibiotics for another two weeks.
ET|enterostomal therapy|ET|161|162|LABORATORY DATA|Swab was sent for culture and did grow out MRSA of that wound. The patient also did have an MRI of the right leg, which showed no evidence of osteomyelitis. The ET nurse was consulted, and the enterostomal nurse did come by to provide care of the right leg. The patient received vancomycin and tobramycin, and seemed to have some resolution of her cellulitis during her stay here.
ET|enterostomal therapy|ET|261|262|HOSPITAL COURSE|5) Code status: I did discuss code status with both the patient and his wife The patient has chosen to become DNR/DNI given his chronic medical problems. 6) Decubitus ulcer: The patient was found to have a decubitus ulcer of his buttocks during this admission. ET wound nurse was consulted to assist and recommended routine dressing changes every 48 hours with RepliCare hydrocolloid dressing. This can be followed on discharge at the transitional care unit.
ET|endotracheal|ET|142|143|HOSPITAL TREATMENT COURSE|From a respiratory standpoint, she was initially intubated for her worsening respiratory status and her RSV bronchiolitis, and pneumonia. Her ET tube, sputum culture from _%#MM#%_ _%#DD#%_, 2005, was growing Haemophilus influenza heavy growth and she was treated with IV ceftriaxone for a total of 7 days for her pneumonia.
ET|enterostomal therapy|ET|220|221|HOSPITAL COURSE|The patient developed purulence at the bottom of the wound and pus drained from his abdominal cavity into the wound, relieving intraabdominal fluid collection/abscess. The wound was packed with wet-to-dry dressings. The ET nurse was consulted for placement of wound vac, to be delivered to the patient's home. The patient is able to change dressings at home, and will receive Augmentin p.o. 875 b.i.d. and was instructed to return to the hospital or go to the emergency room if he has increasing fevers, increased wound drainage, or change in wound character, becomes brownish or green, or if he has increased pain in the abdomen.
ET|enterostomal therapy|ET|175|176|HOSPITAL COURSE|The plan was to cautiously diurese patient and follow up effusions with serial studies. 3. Osteomyelitis. The patient has a visible wound open to the bone on the right femur. ET nurse evaluated this and felt that it looked uninfected. Unfortunately, we have little other information regarding patient's previous workup as it was done at the VA Medical Center.
ET|enterostomal therapy|ET|186|187|HOSPITAL COURSE|He has been discharged on Cipro. 4. Skin breakdown with stage II pressure ulcers. He has skin breakdown all along his back due to sitting in a chair at home with urine and feces on him. ET nurse did evaluate this and made recommendations as described above. 5. Seizure disorder. His levels of Dilantin and phenobarbital were extremely low when he came in as he had not been taking his medicines on an outpatient basis.
ET|enterostomal therapy|ET|221|222|HOSPITAL COURSE|The patient is currently significantly improved, approximately back to his baseline behavioral status with clinical and objective findings all consistent with resolution of cellulitis and abscess. In addition, we had the ET nurse evaluate the patient during his stay, and she has made various recommendations for ongoing wound care. 2. Anemia of chronic disease; various lab studies as per above.
ET|endotracheal|ET|158|159|HOSPITAL COURSE|She was a full-term AGA infant with a normal length and head circumference. _%#NAME#%_ was noted to have respiratory distress syndrome. A UAC/UVC line and an ET tube were placed. HOSPITAL COURSE: Her course by systems: FLUIDS/ELECTROLYTES/NUTRITION: _%#NAME#%_ needed to be maintained on Hyperal and peripheral IV.
ET|enterostomal therapy|ET|269|270|HOSPITAL COURSE|The patient said that he had hemorrhoids and this was normal for him whenever he is on Coumadin, with a little bit of bright red blood. No sign of active severe GI bleeding. During his stay in the hospital, his hemoglobin remained stable. 7. Coccygeal decubitus ulcer. ET wound nurse followed up with his wound care and the patient will continue to have dressing changes. DISCHARGE FOLLOW-UP: 1. The patient was discharged to Transitional Care Unit Ebenezer Hall in _%#CITY#%_ to continue rehab.
ET|endotracheal|ET|167|168|DISCHARGE PLAN|PCR and Western Blot for myotonic dystrophy are pending. 2. Resp: _%#NAME#%_ has been stable on the ventilator since his arrival. He did have a small air leak, so his ET tube was replaced with a larger 4.0 tube. After re-intubating, on CXR Kacee had some right middle lobe atelectasis which was resolved with vigorous chest physiotherapy.
ET|endotracheal|ET|165|166|ASSESSMENT/PLAN|3. Diabetes mellitus, q. 6 hour Accu-Cheks with sliding scale insulin coverage. 4. Probable aspiration. We will cover with Zosyn. Repeat chest x-ray. 5. ___________ ET tube placement. This has been pulled back per Dr. _%#NAME#%_ prior to the patient leaving the ER. We will confirm with a chest x-ray. 6. History of severe GERD.
ET|enterostomal therapy|ET|226|227|DISCHARGE DIAGNOSES|Ultrasound was done to rule out a DVT. She was placed on TED hose, and she was given diuretics (Lasix), and this has resolved. Referring back to her wound, she has been followed closely by _%#NAME#%_ _%#NAME#%_, the wound and ET nurse as well as the transplant clinic. Her blood sugars have been quite labile. Occasionally she has dropped low and has required juice or D50W such as yesterday when her blood sugar was 44, but often she has been running into the high 200s to high 300s.
ET|endotracheal|ET|169|170|LABS ON ADMISSION|White count 8.2, platelets 246. Admission ABG revealed a pH of 7.34, pCO2 of 50, PAO2 (?) of 380, and bicarb 27. Chest x-ray on admission revealed good placement of her ET tube, right upper lobe mass, and cardiomegaly with some obscuring of her left hemidiaphragm. HOSPITAL COURSE: PROBLEM #1: Pulmonary: In light of the hemoptysis and blood noted following biopsy, the patient underwent bronchoscopy upon arrival to the MICU.
ET|enterostomal therapy|ET|203|204|HOSPITAL COURSE|Patient will be receiving Neulasta 6 mg subq by the home health nurse on Wednesday, at least 24 hours after completion of his 5FU infusion. Patient denies any further questions. 3. Abdominal wound. Both ET as well as thoracic surgery saw the abdominal wound. Both were comfortable with the care. They simply recommend wet-to-dry dressing from ET.
ET|enterostomal therapy|ET|287|288|FAMILY HISTORY|He required frequent suctioning and very aggressive pulmonary toiletry. He did require bypass for a limited period of time while in the ICU, but was able to do well without requiring further therapy. In addition, it was noted that the patient had a decubitus ulcer, and consultation for ET nurse was begun during his ICU stay. The patient was noted to have a urine culture which had 15 wbc's per high-power field and positive leukocyte esterase, and he was subsequently started on ciprofloxacin for a 7-day course.
ET|enterostomal therapy|ET|167|168|FAMILY HISTORY|He subsequently was followed by the ENT nurse throughout his hospitalization on the medical ward. His decubitus ulcer was addressed with appropriate treatment per the ET nurse during this hospitalization and will continue once discharged. 3. Elevated creatinine levels: It was noted that the patient had an elevated creatinine level at the time of admission.
ET|endotracheal|ET|172|173|PROBLEM #2|Bronchoalveolar lavage done on _%#MMDD2003#%_ and _%#MMDD2003#%_ showed significant pulmonary hemorrhage and on _%#MMDD#%_ she had an episode of bloody hemorrhage from her ET tube with desaturations to 60%. She continued to deteriorate with the need for increased ventilatory support. The exact etiology was unknown. She was given a dose of infliximab on _%#MMDD2003#%_ in an attempt to decrease inflammatory damage to her lungs.
ET|enterostomal therapy|ET|192|193|HOSPITAL COURSE|He did receive a flush of saline from his stoma, and this resulted in some improved motility. Once appropriate, patient was started on clears, fluids, and then advanced to a regular diet. The ET nurse was consulted for ostomy teaching. The patient was planned for discharge on _%#MMDD#%_ after tolerating a regular diet beginning on _%#MMDD2003#%_.
ET|enterostomal therapy|ET|131|132|PROBLEM #2|He will be continued on the Augmentin and minocycline as prescription by the Infectious Disease specialist at the VA Hospital. The ET nurse was consulted for the wound care, and the wound care will continue to be followed as per ET nurse's recommendation.
ET|enterostomal therapy|ET|130|131|HOSPITAL COURSE|She will be converted to Keflex orally to complete an additional ten days. She still had some open sores and will require further ET wound care dressings. Blood cultures were obtained prior to admission and were still negative at the time of discharge. Again, she had Dopplers done on admission, which was negative for any DVT.
ET|enterostomal therapy|ET|146|147|HISTORY OF PRESENT ILLNESS|The patient was seen by the Plastic Surgery Service who recommended placement of a wound vac to promote healing. This was done and changed by the ET nurse q. Monday, Wednesday and Friday. The fascia was not opened and the wound was improving at the time of discharge.
ET|enterostomal therapy|ET|167|168|PLAN|Previous cultures grew out E. coli and .........sensitive to Zosyn. Additionally, we will evaluate the patient's urinalysis. Also the patient will be evaluated by the ET wound care nurse. 2. Left third digital ischemia: The patient will be evaluated by Vascular Surgery for further evaluation for possible surgical options as well as evaluation of the right lower extremity .........base. Other cause of ischemic ..........includes secondary vasculitis from his hepatitis; thus, will initiate further work-up with cryoglobulin levels and FANA levels.
ET|endotracheal|ET|194|195|PAST MEDICAL HISTORY|4. Leukomalacia, periventricular. Last ultrasound was on _%#MMDD2005#%_ and had no change from previous. 5. History of sepsis, treated with antibiotics. History of growing Candida albicans from ET tube, status post treatment with amphotericin B. 6. Retinopathy of prematurity. 7. Right inguinal hernia, eventually requiring repair.
ET|enterostomal therapy|ET|174|175|DISCHARGE INSTRUCTIONS|She will follow a low calorie diet. Activity as tolerated and she will use Aquacel Ag dressing changes to foot wound b.i.d. and her VAC will be changed 3 times a week by the ET nurse. She will follow up with Dr. _%#NAME#%_, her podiatrist for foot debridement on _%#MMDD2006#%_ at HealthPartners. She will also follow up with Dr. _%#NAME#%_, her primary care physician for blood pressure monitoring and this will happen in the few days of discharge.
ET|enterostomal therapy|ET|271|272|ASSESSMENT AND PLAN|She requires a CT scan of the chest. The plan is to perform an exploratory laparotomy, posterior exenteration, including a rectosigmoid resection, and placement of a tissue expander, in preparation for radiation therapy. Prior to this procedure, she will need to see the ET nurses for planning of her ostomy site. As she has been seen recently and once again for her outpatient procedure, the consent will be reviewed with an interpreter and signed by her on the day of surgery, thus a Cantonese interpreter will be required at that time.
ET|enterostomal therapy|ET|169|170|HOSPITAL COURSE|The patient was continued with wound care as recommended and the patient was seen by Plastic Surgery with Dr. _%#NAME#%_. Also the patient's wound was taken care by the ET Nursing team. On last examination by Dr. _%#NAME#%_, the patient's staples and sutures were removed on _%#MMDD2003#%_. There was some hypertrophic granulation near perineal grafts, and silver nitrate treatment was given.
ET|enterostomal therapy|ET|122|123|PLAN|4. Diabetes mellitus, under satisfactory control. PLAN: 1. Admit for parenteral antibiotics. We will start with Ancef. 2. ET nurse to consult on wound care. 3. Continue current medication program. 4. Will arrange discharge planning through Social Work to ensure adequate follow-up with home nursing care.
ET|enterostomal therapy|E.T.|244|247|PLAN|Social situation: I believe that the patient will benefit from a social service evaluation, possibly additional in house care to be arranged and help the patient to feed in her current living environment. Also to appreciate evaluation from the E.T. nurse regarding the patient's sacral ulcers. Will order a first step mattress for this, too. I have also asked Physical Therapy/ Occupational Therapy to evaluate the patient.
ET|enterostomal therapy|ET|166|167|HISTORY OF PRESENT ILLNESS|They felt that the abdominal wound dehiscence most likely was causing patient's abdominal pain due to its purulent drainage. 2. Wound dehiscence. Patient was seen by ET nurse for evaluation of wound, dressing changes, and purulent drainage. She was started on Augmentin 500 mg b.i.d. She will get a 14-day course of this.
ET|endotracheal|ET|235|236|HISTORY OF PRESENT ILLNESS|Pursuant to that, he was intubated. Unfortunately, the tube was down in the right mainstem, and had to be pulled back. During that same time, he became a little bit hypotensive; however, following Narcan administration and pulling the ET tube back a little bit, he returned back to baseline. Unfortunately, he remains comatose and nonresponsive. Inpatient evaluation has been implemented, and he is admitted to the Intensive Care Unit.
ET|enterostomal therapy|ET|208|209|PROBLEM #3|He had decreased diarrhea until the last day of his discharge when he had some increase, we suspect that he still has some of the antibiotic effect. We will send out on Imodium p.r.n. PROBLEM #3: Wound care. ET nurse consultation was placed. ET nurses staged his ulcers as; (1) Right IT stage 4 pressure ulcer. (2) Left IT stage 3 pressure ulcer. (3) Left groin wound stage 3 of questionable etiology.
ET|enterostomal therapy|(ET)|190|193|PLAN|4. Hypertension. a. We will give the patient IV metoprolol as needed to control her blood pressure. 5. Chronic abdominal wound and right leg ulcers. a. We will have the Enterostomal Therapy (ET) nurse see the patient in the morning. b. We will continue her nursing home orders for wound care.
ET|endotracheal|ET|171|172|LABORATORY DATA|Respiratory rate is 12. He does not appear to be breathing over the ventilator at this time but has done previously. LABORATORY DATA: Chest x-ray reviewed by myself shows ET tube in good placement. Head CT is negative. CT of the C-spine is negative. Carbon monoxide was 4% slightly elevated, hemoglobin is 13.8, platelet count 255, white blood cell count 7.3 with normal differential, INR is 0.99 and PTT 32, pH 7.4, pO2 was 311, pCO2 is 31, bicarbonate of 19 and blood sugar is 148.
ET|enterostomal therapy|ET|148|149||The patient did have some wrist pain and an x-ray showed no evidence for fracture. The patient had the JP drain removed prior to her discharge. The ET nursing staff saw the patient for teaching of stoma cares and pouch changes. The patient's staples were removed prior to her transfer. The patient was transferred to Presbyterian Home in _%#CITY#%_ on _%#MMDD2006#%_.
ET|enterostomal therapy|ET|190|191|PLAN|Will follow his Accu-Cheks q.i.d., follow his labs closely. We will only replace his Plavix at this point in time and Zantac; otherwise, other medications will be held. We will range for an ET consult, Neuro consult, Cardiology consult, and echocardiogram in a.m. See orders for full details.
ET|endotracheal|ET|175|176|DEATH SUMMARY|She then became bradycardic and hypertensive at which time a code was called. Anesthesia arrived on the scene and was able to intubate her with difficulty with a 3-0 uncuffed ET tube. Her intubation was confirmed by change of her end-tidal CO2 as well as auscultation and initial improvement in her oxygen saturations.
ET|enterostomal therapy|ET|180|181|PROBLEM #3|He has a history of decubitus ulcers, stage III to IV. The ET nurse was consulted and Plastic Surgery was also consulted and recommended outpatient follow-up just to follow up the ET nurse recommendations. DISCHARGE FOLLOW-UP: The patient has a homecare nurse for his IV antibiotics to complete a 14-day course, as he is on a PICC line.
ET|enterostomal therapy|ET|251|252|ASSESSMENT AND PLAN|Suspect this is related to narcotics. 2. Ischemic toe. Present exam does not look dramatically different from what was described at the time of his discharge, but I can imagine it is quite painful. We will go ahead and do local cares. I will have the ET nurse evaluate and help nursing deal with the toe. Will ask vascular surgery to make sure there is nothing else that we can do, but to my inspection the graft seems to be providing good blood flow.
ET|enterostomal therapy|ET|187|188|HOSPITAL COURSE|4) Oral candidiasis; Mrs. _%#NAME#%_ had started treatment for oral candidiasis prior to admission to hospital. Nystatin swish and swallow was provided. 5) Lower extremity stasis ulcers; ET consultation was obtained. DISCHARGE MEDICATIONS: 1) Hydrochlorothiazide 12.5 mg p.o. q day. 2) Synthroid 75 mcg p.o. q day.
ET|enterostomal therapy|ET|214|215|HISTORY|Otherwise no other abnormality was detected. CT scan of her abdomen and pelvis revealed cirrhosis of the liver with moderate ascites, normal spleen, and small bibasilar pleural effusions. Because of her leg ulcer, ET nurse also followed with the patient while she was in the hospital. Because of her hypothyroidism, she was started on replacement. Her ACE inhibitor was stopped and her renal failure was followed.
ET|enterostomal therapy|ET|171|172|HOSPITAL COURSE|These infections were packed and the patient was discharged to home with home nurse care. The wounds and the stoma will be followed up in the Colorectal Clinic and by the ET nurse. The patient was planned to come back to clinic after two weeks, or sooner if needed.
ET|endotracheal|ET|197|198|PROCEDURES PERFORMED DURING THIS ADMISSION|1. Chest x-ray, _%#MMDD2004#%_, showing slightly improved left basilar infiltrate. 2. Blood cultures, _%#MMDD2004#%_, negative. 3. Chest x-ray, _%#MMDD2004#%_, showing diffuse vascular congestion, ET tube. 4. Chest x-ray, _%#MMDD2004#%_, showing new small left pleural effusion or basilar infiltrate. 5. Sputum culture, _%#MMDD2004#%_, showing Streptococcus pneumoniae. 6. Blood culture, _%#MMDD2004#%_, positive for Staph coag negative.
ET|endotracheal|ET|275|276|ALLERGIES|The patient had also developed renal failure for which she was on dialysis 3 times a week, and her kidneys had not shown any signs of improvement during her long hospital stay. On _%#MM#%_ _%#DD#%_, 2005, after a recent chest therapy, frank blood was seen to come out of her ET tube. The patient was found to be bradycardic and hypotensive at that time. A code was called. Subsequent blood gas also showed severe acidemia and hyperkalemia.
ET|enterostomal therapy|ET|190|191|HOSPITAL COURSE|The patient had drains placed in her incision sites early on in her hospitalization. By postoperative day 16 her Jackson-Pratt drains were able to be discontinued. Plastics recommended that ET nursing get involved and they were following the patient. Staples and sutures were removed on postoperative day #22. By postoperative day 25 the patient was slowly progressed to sitting exercises and able to put pressure and weight on these previous decubiti ulcers.
ET|enterostomal therapy|ET|210|211|SOCIAL HISTORY|He lives with his wife who is very attentive. He also has a son who is also very present in his care. Patient lives at home and will need to address issues regarding specialty beds at home with Social Work and ET Nursing closer to the time of his final discharge from Rehab. For follow up, Dr. _%#NAME#%_ will follow the patient at F-UTS Rehab on a weekly basis.
ET|enterostomal therapy|ET|171|172|PROBLEM #3|She will continue with this as an outpatient. She does have calciphylaxis related to her end-stage kidney disease with resulting multiple skin wounds. She was seen by the ET nurse, and these wounds were dressed according to their instructions. It was also felt that these were secondarily infected, so she was started on a course of vancomycin and amoxicillin clavulanate.
ET|endotracheal|ET|118|119|PLAN|He was maintained on CPAP until surgery, at which point he was intubated. During surgery, he was intubated with a 2.5 ET tube, and this tube was changed to a 3.0 post-operatively. He was maintained on mechanical ventilation overnight, with high vent settings (FiO2 of 60, PIP of 26, PEEP of 6 and a rate of 34 at discharge.) We were not able to wean him from the vent due to poor blood gasses (7.23/75/24/30 this AM).
ET|enterostomal therapy|ET|211|212|WOUND CARE|WOUND CARE: Wound vac needs to be applied to the decubitus ulcer, and the sponge needs to be changed as well as the dressing on Monday, Wednesday, and Friday. If assistance is needed in this, please consult the ET nurses at Fairview-University Medical Center. PNT dressings are to be changed daily. PICC line dressing to be changed every 3 days. Ileal conduit and colostomy are per ET recommendations. The PNTs need to be flushed b.i.d. with 5 cc of normal saline.
ET|enterostomal therapy|ET|303|304|HOSPITAL COURSE|The patient's neurologic status did improve, although very slowly. At the time of discharge, the patient was able to follow very simple commands, as well as move her right side and left leg purposefully, and at times her left arm, as well. The patient does have evidence of sacral decubitus ulcers, and ET nursing was consulted regarding her wound cares and made recommendations, which are specified below. A family conference was held on _%#MMDD2004#%_. Her family agreed to rehabilitation at _%#COUNTY#%_ Rehabilitation Hospital.
ET|enterostomal therapy|ET|143|144|HOSPITAL COURSE|She continued to apply Silvadene cream to her teflon nonadhesive pads 3 to 4 times daily. On the day of discharge, the patient was seen by the ET nurse who felt that this was a good regimen for her wounds. We have changed her over to oral clindamycin which she should continue taking for a week.
ET|enterostomal therapy|ET|106|107|DISCHARGE MEDICATIONS|2. Allopurinol 100 mg p.o. q. day. 3. Lasix 40 mg p.o. q. day. Patient was also given instructions by the ET nurse on how to appropriately dress her wounds. FOLLOW UP: 1. Patient will follow up with Dr. _%#NAME#%_ within a couple of weeks to reassess her hypertension.
ET|enterostomal therapy|ET|121|122|ASSESSMENT AND PLAN|The patient is on the verge of developing decubitus ulcers, and we will order an air bed for her. I have also ordered an ET nurse consult for evaluation and care of her suprapubic catheter. 3. Diabetes. The patient will continue on her Actos and glipizide as at home.
ET|endotracheal|ET|321|322|ADMISSION EXAMINATION|ADMISSION EXAMINATION: VITAL SIGNS: The patient's temperature is 97.8, heart rate 148, blood pressure 76/40, respiratory rate 40, O2 saturations 99% while intubated, weight 4.9 kg. GENERAL: The patient was sedated, but arousable. HEENT: Head, anterior fontanel soft and flat, atraumatic. No conjunctivitis, normal pinna, ET tube in place. NECK: Supple, no lymphadenopathy. CARDIOVASCULAR: Regular rate and rhythm, 2/6 systolic ejection murmur at the left upper sternal border.
ET|endotracheal|ET|204|205|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Patient is currently afebrile. Blood pressure 148/89, pulse 68, oxygen saturation 100% on the ventilator. HEENT: Pupils are pinpoint and minimally reactive. There is an ET tube present in the oral space. Oral mucosa is covered by charcoal. NECK: Supple without adenopathy or thyromegaly. I do not appreciate bruits. LUNGS: Clear to auscultation. HEART: Regular rate and rhythm with a I/VI systolic ejection murmur at the apex.
ET|enterostomal therapy|ET|232|233|HOSPITAL COURSE|A CT Scan of the chest, abdomen and pelvis showed enlargement of the soft tissue mass along the left external iliac vein and artery as compared to previous study on _%#MM#%_ _%#DD#%_, 2002. 2. Vulvar ulcers: The patient was seen by ET nursing and they recommended using Proshield to cover the areas before and after urination. An exam was done by Dr. _%#NAME#%_ in the procedure room under Fentanyl sedation.
ET|enterostomal therapy|ET|214|215|ASSESSMENT|Will recheck in two hours to assure that it is not going up and is normalizing recheck in the morning. 3. Right lower leg edema. Plan: Lasix 40 mg IV should be of assistance in treatment. 4. Pressure ulcers. Plan: ET nurse to see, evaluate, and treat. 5. Will draw blood cultures as needed for high temperatures.
ET|enterostomal therapy|ET|178|179|CONSULTATIONS DURING HOSPITALIZATION|PROBLEM #4: Psychiatric. With dementia and schizophrenia, the patient remained stable on outpatient medications. CONSULTATIONS DURING HOSPITALIZATION: 1. Surgery. 2. Urology. 3. ET nursing. The patient will be followed in the nursing home by Dr. _%#NAME#%_ _%#NAME#%_.
ET|endotracheal|ET|212|213|CONSULTATIONS DURING HOSPITALIZATION|The patient was admitted to the Intensive Care Unit where he underwent aggressive therapy including continued mechanical ventilation. A bronchoscopy was attempted and was without success due to the small caliber ET tube. The patient continued to do poorly over the ensuing several weeks and Critical Care consult, Infectious Disease consult, as well as a Cardiology consult were all obtained.
ET|enterostomal therapy|ET|145|146|HOSPITAL COURSE|His bipolar disorder was controlled with his regular medications, no changes. He was stabilized in terms f his methadone on a dose of 70 q. day. ET nursing attended to his wounds daily, and he showed marked improvement over the course of several days. He was transferred to FUTS improving yet requiring continued inpatient PT, medications, and overall rehab.
ET|enterostomal therapy|ET|155|156|PROBLEM #3|PROBLEM #3: Lower extremity blisters/cellulitis. The patient was noted on exam to have bilateral dorsal pedal bullous lesions. These were evaluated by the ET nurse who thought they were consistent with ulcers, which patients can get with lower extremity edema and concurrent TED hose use.
ET|enterostomal therapy|ET.|124|126|PROBLEM #4|Irrigate with normal saline, clean with Technicare and irrigate again. Lightly pack with Mesalt gauze. This was supplied by ET. Cover with Primapore. The patient was discharged after getting her methotrexate chemotherapy on _%#MMDD#%_ intrathecally.
ET|endotracheal|ET|213|214|LABORATORY DATA|DTRs are 2+ bilateral and symmetric. LABORATORY DATA: That is available so far includes three chest x- rays, which shows a dense right upper lobe infiltrate, also placement of a central line, also placement of an ET tube in adequate position. The patient has a sodium of 130, potassium 4.3, chloride 100, bicarb of 16, glucose of 83, BUN of 55, creatinine of 3.37. Ethanol is less than 0.01. White count is 11,500 with 95% neutrophils, 1 lymphocyte, 1 monocyte, 3 metamyelocytes, platelet count is reported normal at 192.
ET|enterostomal therapy|ET|89|90|ASSESSMENT AND PLAN|Reassess need for antihypertensives throughout hospital course. 3. Skin cares. Will have ET nurse to see. 4. Code status. Did discuss code status with the patient.
ET|enterostomal therapy|ET|150|151|PROBLEM #4|The patient did well and was discharged home. PROBLEM #4: Wound dehiscence. The patient's wound dressing was changed b.i.d., wet-to-dry dressing. The ET nurse did see the patient. The patient will continue his regimen that he had been on at home. The patient will continue to wear an abdominal binder to help protect the wound.
ET|endotracheal|ET|175|176|HISTORY OF PRESENT ILLNESS|Her blood alcohol level was 0.14. Her EKG showed normal sinus rhythm with a rate of about 100. Chest x-ray was done after intubation and showed no infiltrate, but well-placed ET tube. The patient is being admitted to the ICU with Ambien overdose for monitoring and airway management. PAST MEDICAL HISTORY: Includes depression, asthma, gastroesophageal reflux disease, and previous overdose with Ambien on _%#MMDD2004#%_.
ET|enterostomal therapy|ET|96|97|HOSPITAL COURSE|X-ray of the foot ulcer revealed no evidence of osteomyelitis. PROBLEM #5. Perirectal ulcer: An ET nurse was consulted and wound care was begun. CT scan of the abdomen revealed no evidence of fistula or abnormal fluid collection.
ET|enterostomal therapy|ET|392|393|DISCHARGE INSTRUCTIONS|7. Keflex 500 mg p.o. q.12h. 8. Colace 100 mg p.o. b.i.d. DISCHARGE INSTRUCTIONS: Continue activity as tolerated and a regular diet, call if pain is not controlled by topical Lidocaine and oral medications or for a temperature greater than 100.4. She will continue with the lymphedema treatment as scheduled and perform dressing changes twice daily with the Mesalt and Kerlix as explained by ET nursing. She will follow up with Dr. _%#NAME#%_ _%#NAME#%_ on Tuesday, _%#MM#%_ _%#DD#%_, 2005, to review the results of the biopsy taken from the wound edge.
ET|enterostomal therapy|ET|260|261|IMPRESSION AND PLAN|1. Mental status changes, obtundation, most likely secondary to narcotic overuse, as evidenced by the fact that the patient awoke abruptly when given Narcan. We are going to observe him in the ICU, withhold his narcotics for now. 2. Sacral decubiti. Obtain an ET nurse consult. 3. Leukocyte esterase positive urine. Reculture this and observe for now. 4. Social status.
ET|enterostomal therapy|ET|115|116|ASSESSMENT/PLAN|Will obtain PT, OT consultation. 2. Abrasions related to trauma. The patient to have wound treatment and cares per ET nurse. Will place on p.o., Keflex and treat locally with bacitracin ointment. 3. Normal pressure hydrocephalus. VP shunt in place since 1998.
ET|endotracheal|ET|249|250|LABORATORY DATA|White count 9.9, hemoglobin 12.9, platelets 157. EKG reveals sinus rhythm, no acute ST or T wave changes are noted. Initial chest x-ray reveals cardiomegaly, no acute infiltrates; this is personally reviewed. Chest x-ray post intubation reveals the ET tube to be at the carina. There are fluffy bilateral infiltrates noted. IMPRESSION AND PLAN: 1. Acute respiratory failure. This is likely multifactorial in his case due to his severe persistent asthma, morbid obesity and likely obstructive sleep apnea with possible infection.
ET|enterostomal therapy|ET|200|201|PROBLEM #6|PROBLEM #5: Hypertension. Stable. Controlled with metoprolol. PROBLEM #6: Lower extremity stasis dermatitis with areas of open areas. The patient was treated with wound care elevation of her legs and ET nurse for evaluation of her wounds. PROBLEM #7: Hyperlipidemia, stable. PROBLEM #8: Diabetes mellitus, type 2.
ET|elective termination|ET|283|284|PAST SURGICAL HISTORY|PAST MEDICAL HISTORY: Notable for depression, endometriosis, trace mitral regurgitation, and a family history of breast cancer. PAST SURGICAL HISTORY: Cholecystectomy, hysterectomy, tubal ligation, oophorectomy, hernia repair, left distal radial open reduction internal fixation and ET (elective termination of pregnancy). MEDICATIONS: 1. Premarin 0.9 mg a day. 2. Multivitamin
ET|endotracheal|(ET)|133|136|HOSPITAL COURSE|The following day, she was up and walking, speaking clearly, and swallowing food with only mild pain, likely related to endotracheal (ET) tube placement. She did have some atypical facial paresthesias postoperatively, which were unchanged from preoperative and likely unrelated to cerebral ischemia.
ET|enterostomal therapy|ET|216|217|HOSPITAL COURSE|Creatinine was 0.7. INR was 1.05. HOSPITAL COURSE: PROBLEM #1: Sacral decubitus ulcer. A CAT scan of the pelvis was performed on _%#MM#%_ _%#DD#%_, 2003 and revealed no evidence of bony involvement or osteomyelitis. ET wound consultant recommended dressing changes and a cushion seating air mattress overlay to prevent further decubitus wounds. It should be noted that at the time of discharge, her wound had no purulence or odor and was showing some signs of granulation.
ET|enterostomal therapy|ET|173|174|HOSPITAL COURSE|The patient was given a First Start mattress. A swab of vaginal discharge obtained showed MRSA. The patient was continued with IV antibiotics. The patient had wound care by ET nursing and Dr. _%#NAME#%_ of the plastic surgery team. The patient was given a one-month course of IV vancomycin and the vancomycin level was followed by the pharm-D for adjustment of dosage.
ET|endotracheal|ET|146|147|1. FEN|Over night on DOL #1, Lang had difficulty with ventilation/oxygenation, so he was started on HFOV. On DOL #2 yellow sputum was suctioned from the ET tube so sputum cultures were also sent. Weaning off the HFOV was begun on DOL #2. We were able to convert to conventional ventilation on DOL #7.
ET|enterostomal therapy|ET|157|158|DISCHARGE INSTRUCTIONS|She should not drive while taking pain medications. It is okay for her to shower, but should not bathe for the next 3 weeks. She will receive stoma care per ET nurse instructions. FOLLOW UP: The patient was instructed to follow up with Dr. _%#NAME#%_ in 2 weeks.
ET|enterostomal therapy|ET|120|121|CONDITION AT TRANSFER|O2 by nasal cannula to keep saturations greater than or equal to 92%. The patient did have a right leg ulcer, for which ET nursing was involved, with the recommendation of every-other-day cleanse with clinical care spray and application of Allevyn adhesive. CONDITION AT TRANSFER: Stable.
ET|enterostomal therapy|ET|215|216|HOSPITAL COURSE|Her incision was healing nicely. She had minimal output from her Jackson-Pratt drain, so this was removed. She was comfortable with care of her colostomy, so she was discharged home. Follow-up care will be with the ET nurse, her primary care physician, and Dr. _%#NAME#%_.
ET|enterostomal therapy|ET|270|271|DISCHARGE FOLLOWUP|2. Follow up with interventional radiology for biliary catheter evaluation on _%#MM#%_ _%#DD#%_, 2005, at 8:30 a.m. Nothing to eat after midnight. 3. _%#NAME#%_ was instructed to continue with biliary catheter cares including flushing with 10 mL of normal saline daily. ET nursing did see Ms. _%#NAME#%_ while she was having some drainage around the biliary catheter and recommended the use of an ostomy bag if there should be a recurrent problem.
ET|endotracheal|ET|133|134|HISTORY OF PRESENT ILLNESS|The ambulance run sheet shows that she had an initial O2 sat of 58% and respiratory rate of 30. She was rapidly intubated with a 6.0 ET tube, but they were unsuccessful. They retried with a 5.0 ET tube which they were able to get. She was transported into the Fairview Southdale emergency room where she was evaluated by Dr. _%#NAME#%_ who found her to have bilateral infiltrates, and he has subsequently requested admission.
ET|endotracheal|ET|194|195|HISTORY OF PRESENT ILLNESS|The ambulance run sheet shows that she had an initial O2 sat of 58% and respiratory rate of 30. She was rapidly intubated with a 6.0 ET tube, but they were unsuccessful. They retried with a 5.0 ET tube which they were able to get. She was transported into the Fairview Southdale emergency room where she was evaluated by Dr. _%#NAME#%_ who found her to have bilateral infiltrates, and he has subsequently requested admission.
ET|endotracheal|ET|194|195|HISTORY|Upon initial evaluation by the Emergency Room physician, she was found to be in sinus rhythm hemodynamically stable. Diagnostic workup was undertaken, which included a chest x-ray demonstrating ET in the right main stem, which was removed by 2 cm back. There was no evidence of infiltrate or other lesion on the chest film.
ET|enterostomal therapy|ET|181|182|ASSESSMENT AND PLAN|Home health nursing will also be provided. 6. Stage II to III coccyx wound. The patient was noted at the time of admission to have a small coccyx wound thought related to pressure. ET nursing saw the patient during her stay. She is discharged with recommendations by ET nursing as well as a low air loss mattress system to provide her ongoing care needs in this regard.
ET|enterostomal therapy|ET|299|300|DISCHARGE FOLLOW-UP|He is to follow-up with Dr. _%#NAME#%_ _%#NAME#%_ from Orthopaedics two to three weeks after discharge for repeat x-ray and evaluation of left femur. He is to follow-up with Fairview _%#CITY#%_ with Dr. _%#NAME#%_ after discharge for rehabilitation schedule. Wound assessment at _%#COUNTY#%_ by the ET nurse. DISCHARGE ACTIVITY LEVEL: The patient may sit and lie down without restrictions.
ET|enterostomal therapy|ET|156|157|HOSPITAL COURSE|She also had the left knee eschar tissue from previous history from BKA. Patient was seen by ID, who felt Tequin, Flagyl and vanco. were appropriate. Also, ET nurse ordered dressings. Patient also had signs of cellulitis treated with antibiotics. At this time patient has done well with both dialysis and her foot appears to be healing well.
ET|endotracheal|ET|130|131|PHYSICAL EXAMINATION|HEAD: Atraumatic. There is some blood from one of his nares. An NG tube is placed in the left naris. He has an oral bite lock and ET tube in place. TMs appear normal bilaterally. NECK is large but supple with no palpable masses. CHEST: Some coarse upper airway noise and scattered rhonchi, but otherwise clear to auscultation.
ET|enterostomal therapy|ET|165|166|LABORATORY DATA|She did apparently have doppler flow studies of the lower extremity on _%#MMDD2004#%_ that was negative for deep venous thrombosis. I am not sure why that was done. ET nurse note from _%#MMDD2004#%_, who saw her just prior to transfer, shows wound in the right buttocks which is stage 2. The superior wound is about 1.0 cm and then there is another area that is mostly an abrasion with some open areas over a 2.5 cm diameter.
ET|enterostomal therapy|ET|268|269|HOSPITAL COURSE|Cultures were taken, and these were all negative. A Penrose drain was placed, entering in through her previous drain site in her buttock and exiting out this perineal wound. This was tied to itself and left as a seton. Postoperatively, we obtained a consultation from ET nursing and wound care for placement of a Vac drain. This was successfully done, and she has had the Vac draining all week.
ET|endotracheal|ET|166|167|ADMISSION PHYSICAL EXAMINATION|Pupils were equally round and reactive to light with a bilateral red reflex. External auditory canals were patent. Nares were patent. Oropharynx revealed no exudate. ET tube was in place. NECK: Supple. LUNGS: Prolonged expiratory phase bilaterally. He had symmetric breath sounds. HEART: Regular rate and rhythm without murmur.
ET|enterostomal therapy|ET|130|131|HOSPITAL COURSE|The patient was seen by neurology who felt no change in his Parkinson's medication regimen was indicated. He was also seen by the ET nurse because of a left heel ulcer. Other problems addressed included hyponatremia, which is felt secondary to dilute fluids down his G-tube.
ET|enterostomal therapy|ET|209|210|HISTORY OF PRESENT ILLNESS|Please note, the patient had surgical wound issues and subsequently required further debridement and revision of posterior and midline wound. The patient currently has a vacuum placed that has been managed by ET nursing while in the hospital this day. The wounds look fine and have been followed by Plastic Surgery during this hospitalization.
ET|enterostomal therapy|ET|127|128|HISTORY OF PRESENT ILLNESS|After that time, a number of subspecialty services were consulted during her time in the hospital. These services included the ET wound care services to help with dressing to the right upper extremity, nephrology to follow her ongoing hemodialysis on a 2-3 times per week basis, transitional _____ to help with pain management and ultimately general surgery and GI to evaluate the patient for progressive abdominal pain.
ET|endotracheal|ET|145|146|LABORATORY DATA|Cardiac size is somewhat prominent, and otherwise it negative. That was from _%#MMDD#%_. She has a new chest x-ray that shows some haziness. The ET tube looks slightly high, cardiomegaly, with no obvious infiltrate except in the left hilar area there is some haziness but no obvious infiltrate.
ET|enterostomal therapy|ET|116|117|PLANS|5. Risk for osteomyelitis given the pressure sores on the bottom of the right foot. PLANS: We will consult with the ET nurse for wound care orders, and we will consult with Infectious Disease. She will be treated for now with intravenous vancomycin, and we will check into the possibility of ongoing outpatient care with IV vancomycin.
ET|enterostomal therapy|ET|156|157|ASSESSMENT AND PLAN|5. Urinary tract infection. She is on chronic amoxicillin. We will place her on Levaquin and urine culture will be done. 6. Sacral breakdown. Will have the ET nurse see her. She was placed on a First Step mattress and we will have her turned q.2 hours. 7. Code status. I discussed with the patient. She is very vague about this.
ET|endotracheal|ET|259|260|SUMMARY|5. Infection, sepsis. Reese was treated with ampicillin and gentamicin for a total of 6 days, then switched to vancomycin and gentamicin for a total of 2 days as a precaution to rule out cavitary pneumonia. Blood cultures obtained on admission were negative. ET tube culture and gram stain obtained on _%#MMDD2006#%_ was negative. DISCHARGE MEDICATIONS, TREATMENTS, AND SPECIAL EQUIPMENT: None. FEEDING SCHEDULE: Reese is to breast feed ad lib demand at least every 3 hours.
ET|enterostomal therapy|ET|135|136|PLAN|Pain is well controlled with current medications. On Lovenox for DVT prophylaxis and on Protonix for GERD. The patient will be seen by ET nurse for wound care. She will also be seen by Physical/Occupational Therapy in the a.m. Will check electrolytes and CBC in a.m.
ET|enterostomal therapy|ET|173|174|ASSESSMENT AND PLAN|He has midline staples in place and we will review this with Colorectal Service as to when to remove his staples. He will continue b.i.d. dressing changes. We will have the ET nurse consult and assist with his dressing changes. 2. Pain. The patient is followed by the pain team. He continues on Dilaudid, methadone, Celebrex. We will ask them to continue assisting with his pain management.
ET|endotracheal|ET|158|159|PHYSICAL EXAMINATION|VITAL SIGNS: Blood pressure is 177/86. Temperature is 97 degrees, pulse is 100. PACs are noted. HEENT: No scleral icterus. Pupils are 4 mm and react, an oral ET tube is in place. NECK: No JVD, no bruits or lymphadenopathy. LUNGS: A few upper airway rhonchi are heard. HEART: Distant tones, sinus rhythm with extra systoles noted. ABDOMEN: Liver and spleen are not palpable.
ET|electrophysiology:EP|ET|153|154|DISCHARGE DIAGNOSES|1. Bradyarrhythmia, worrisome for heart block, most likely due to antiarrhythmic medications. 2. History of supraventricular tachycardia with history of ET study in the past. Ablation was unable to be performed as the SVT was unable be induced. 3. Suspect viral syndrome with symptoms of light-headedness, weakness, headache, nausea and vomiting later during the hospital stay.
ET|enterostomal therapy|ET|147|148|PROBLEM #4|We will follow up with his primary care physician about it. PROBLEM #4: Wound ulcer. The patient had history of decubitus ulcers and wound ulcers. ET nurse was consulted. The patient was started on local wound care as recommended by ET nurse, which will be faxed to the nursing home so that the local wound care will be continued.
ET|enterostomal therapy|ET|165|166|HOSPITAL COURSE|He remained on IV antibiotics. He has otherwise uncomplicated hospital course. His diet was slowly advanced, which he tolerated well. He does have ostomy placed and ET nurse was also consulted. He will follow up with Dr. _%#NAME#%_ from General Surgery in 10-14 days. 2. Impaired glucose tolerance: The patient was noted to have some elevated blood sugars.
ET|enterostomal therapy|ET|175|176|HISTORY|Stable pulmonary status throughout with occasional upper airway rhonchi. 02 saturations were maintained in the 95% to 96% range. Demonstration of perineal ulcers evaluated by ET nursing with appropriate topical treatment regimen. Plan for wheelchair mapping by physical therapy. Dislodgement of the tracheostomy tube, which was successfully replaced.
ET|enterostomal therapy|ET|139|140|MEDICATIONS AT THE TIME OF TRANSFER|16. Calcium carbonate 1250 mg b.i.d. 17. Aranesp 40 mcg subcutaneously q. weekly. 18. Lasix 20 mg p.o. b.i.d. 19. Wound vac treatments per ET Nursing recommendations/orders, with follow-up management by home health nursing ordered. DISCHARGE STATUS: Stable. ALLERGIES: The patient has a known intolerance to Amoxicillin; therefore his Augmentin will have to be changed.
ET|enterostomal therapy|ET|201|202|PLAN|4. Type 2 diabetes. 5. Hepatitis C, chronic. 6. Gastroesophageal reflux disease with recent bloody emesis. PLAN: We will continue the current wound care as recommended by Dr. _%#NAME#%_. Will have our ET nurses see Mr. _%#NAME#%_ here while he is under our care. He will continue on Augmentin as a suppressive antibiotic and cefazolin will also be continued for the present time.
ET|enterostomal therapy|ET|195|196|ALLERGIES|He was taken off all antibiotics on _%#MM#%_ _%#DD#%_, 2002, and he has remained afebrile. On _%#MM#%_ _%#DD#%_, 2002, he did have a wound vac placed over a sacral wound with consultation of the ET nurse, _%#NAME#%_ _%#NAME#%_. The wound vac has been in place during his hospitalization here. REHAB COURSE: During his rehab course, his wound has progressed well.
ET|enterostomal therapy|ET|150|151|DISCHARGE DIAGNOSES|9. Left heel decubiti ulcer which has been present since her earlier hospitalization at (_______________). Dressing changes have been directed by the ET nurse. 10. Questionable polypharmacy concerns in regards to Xanax and the patient's numerous other medications. CONSUTTANTS: No new consultants during her rehab stay. However, she does see Dr. _%#NAME#%_ _%#NAME#%_ for close following of her pulmonary issues and COPD.
ET|enterostomal therapy|ET|215|216|HOSPITAL COURSE|2. Hypertension: Well controlled with outpatient medications during hospitalization. 3. History of chronic venous insufficiency with venostasis and ulcers, now with bilateral cellulitis: The patient was seen by the ET nurse for dressing changes after debridement of legs; cellulitis was seen, and she was started on Ancef for cellulitis. 4. Endocrine: Hypothyroid: The patient was as recently as one week prior to admission started on a new dose of Synthroid 25 mcg (per patient), and her TSH level on admission was 8.
ET|enterostomal therapy|ET|213|214|PLAN|She is status post fracture of her distal femur currently being treated in the fixator. PLAN: She will be admitted to the floor for cares. Intravenous antibiotics will be started to cover any organisms there. The ET nurse will see her and treat her. We will place her on a Stage I mattress for protection from further ulcer formation.
ET|endotracheal|ET|230|231|REHABILITATION DIAGNOSES|For complete details of his stay while in the rehab unit, please refer to the discharge summary by the Primary Service. REHABILITATION DIAGNOSES: 1. Deconditioning. 2. Dysphagia of unclear etiology, thought to be secondary to the ET tube placement, however, etiology unclear at the time of discharge. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 66-year-old gentleman with a history of duodenal carcinoma status post Whipple procedure in 2000 who presented to an outside hospital on _%#MMDD2007#%_ with abdominal pain.
ET|enterostomal therapy|ET|166|167|PHYSICAL EXAMINATION|ABDOMEN: Soft, nontender with ileostomy in place as previously noted in the right middle quadrant. No focal findings otherwise are identified. Perineum wounds as per ET nursing with dressings intact at the time of discharge. Expose suture lines are stable and clean, dry and intact as well. Distal CMS appears to be intact. EXTREMITIES: No peripheral edema.
ET|electrophysiology:EP|ET|200|201|ASSESSMENT/PLAN|Carvedilol will be decreased to 6.25 mg p.o. b.i.d. if his blood pressure systolic is greater than 80 mmHg. His Bi-V ICD will be interrogated. We have asked Dr. _%#NAME#%_ and Dr. _%#NAME#%_ from the ET department to be consulted to review his case. Warfarin will be regulated through the pharmacy department. He may need dobutamine infusion.
ET|enterostomal therapy|ET|191|192|HOSPITAL  COURSE|Blood cultures from his initial visit at _%#CITY#%_ _%#CITY#%_ Medical Center was requested on the day prior to discharge, but was not available. Nothing new that was reported to myself. The ET wound care nursing staff did see the patient also and instructed the patient on how to do wound cares. He remained otherwise afebrile, nonseptic appearing and his white count had actually been normal during his hospitalization stay here.
ET|endotracheal|ET|179|180|PHYSICAL EXAMINATION|GENERAL: She is sedated, on vent. The patient is a thin, elderly female. HEENT: Her conjunctivae are pink. She has what looks like traumatic intubation with some blood around the ET tube. The ET tube looks like it initially was a right mainstem intubation. We have pulled back the ET tube several centimeters. NECK: She has no JVD, no lymphadenopathy, I see no thyromegaly.
ET|endotracheal|ET|208|209|PHYSICAL EXAMINATION|HEENT: Her conjunctivae are pink. She has what looks like traumatic intubation with some blood around the ET tube. The ET tube looks like it initially was a right mainstem intubation. We have pulled back the ET tube several centimeters. NECK: She has no JVD, no lymphadenopathy, I see no thyromegaly. LUNGS: She has diffuse crackles, especially noted at the bases bilaterally and the posterior fields anteriorly.
ET|enterostomal therapy|ET|231|232|ASSESSMENT/PLAN|This is to rule out PE and to further evaluate for possibility of pneumonia and to rule out intraabdominal abscess. We await results of these scans. Agree with empiric vancomycin, Levaquin and Flagyl started in the emergency room. ET nurse to evaluate wounds, pannus infections, and ostomy cares. We will check stool for Clostridium difficile. We will obtain one set of blood cultures from her Port-A-Cath and label from central line.
ET|enterostomal therapy|ET|113|114|ACTIVITY|The patient should continue with physical and occupational therapy. Ostomy care instructions are provided by the ET nurse. The patient should continue with ostomy teaching as he is not yet independent with ostomy cares. Wound care for bilateral buttock wounds should consist of wet-to-dry dressings b.i.d. with Kerlix dampened with clinical care spray.
ET|enterostomal therapy|ET|141|142|BRIEF HISTORY AND HOSPITAL COURSE|Urology consulted, and she responded well to antibiotics for her cystitis. She was continued on insulin in the hospital, and was followed by ET nurses for her foot ulcer. DISCHARGE PLANS: She was transferred in stable condition to a nursing home to continue her diabetes treatment, foot ulcer treatment, and physical and occupational therapy.
ET|electrophysiology:EP|ET|207|208|HOSPITAL COURSE|Aldactone was added, and the patient was treated with Milrinone for his right-sided heart failure. Magnesium supplements were added and a dual-chamber pacemaker and ICD was placed. The patient underwent and ET study during this hospitalization and was given a trial of CPAP. With stabilization of his condition and diuresis, the patient was subsequently discharged.
ET|enterostomal therapy|ET|178|179|HOSPITAL COURSE|Bone scan on _%#MMDD#%_ was negative. Dr. _%#NAME#%_ of Oncology will be consulted regarding whether chemotherapy is needed. Ostomy and drain care will be attempted to by a home ET nurse. PROBLEM #2: Postoperative ileus. The patient had a postoperative ileus, which was very slow to resolve.
ET|endotracheal|ET|198|199|PHYSICAL EXAMINATION ON ADMISSION|He was on an SIMV vent with a rate of 12, a total volume of 600, an FIO2 of 55%, a peak of 20, and a pressure support of 4. GENERAL: He was laying in bed, somewhat wakeful, and combative. HEENT: An ET had been placed, with no serosanguinous or purulent substance in the ET tube. His NG was in place. Oropharynx: clean of any lesions or abrasions, with no obvious blood.
ET|endotracheal|ET|247|248|HISTORY OF PRESENT ILLNESS|As mentioned above, the patient has seen Dr. _%#NAME#%_ for this in the past and had PE tube placed approximately three years ago. He states that for the next six months after PE tube was placed, he had no episodes of vertigo whatsoever. Once the ET tube fell out his symptoms have recurred. No recent follow up in this regard. Interestingly, when he blows his trumpet, sometimes he will create the same pressure and improve his vertiginous symptoms should they be present.
ET|enterostomal therapy|ET|139|140|HISTORY OF PRESENT ILLNESS|Her creatinine is down to 1.17 on the day of this admission. Her wound dehiscence was treated with wet-to-dry dressing and was followed by ET nurse. She was restarted on Coumadin for anticoag due to history of mechanical AVR, which is being bridged with Lovenox pending therapeutic INR.
ET|enterostomal therapy|ET|200|201|HOSPITAL COURSE BY PROBLEM LIST|IV vancomycin was started for treatment of Enterococcus. For continued improvement, close follow up in Wound Clinic and patient's compliance will be necessary. Infectious Disease, Dr. _%#NAME#%_, and ET nurse were involved with his care. Specific wound care recommendations were given. The patient states he understands how to do the treatment.
ET|endotracheal|ET|491|492|DEATH SUMMARY|Her son _%#NAME#%_ was adamant that she not be transitioned to comfort care only despite her legal power of attorney's desire for this to be done and so the patient remained on pressors, antibiotics and CVVH as she clinically deteriorated was made comfortable with a morphine drip over her last 2 days of life and she had cardiac arrest after prolonged hypotension to mean arterial pressures of less than 30 and died on _%#MMDD2007#%_ with family present. Autopsy was claimed by the family. ET tube was removed and the family grieved in the room. The attending was notified of the patient's death.
ET|enterostomal therapy|ET|232|233|HOSPITAL COURSE|HOSPITAL COURSE: The patient was seen on an ongoing basis by Dr. _____ who converted the patient from an IV antibiotic regimen to an oral regimen. He is otherwise stable during his stay. He was treated in terms of wound care by the ET Nursing Program. There were no other medical issues that developed the cellulitis and the peristomal area was resolving at the time of discharge on _%#MMDD2006#%_ to his group home.
ET|enterostomal therapy|ET|232|233|PLAN|Will check a right upper quadrant ultrasound. Impression the patient does not have any feeling and is unable to give any significant symptomatology. We will hold his Zocor for the time being. 4. Right buttock ulcer. We will have an ET nurse see this ulcer for further recommendation.
ET|enterostomal therapy|ET|160|161|HOSPITAL COURSE|Abdominal incision: He had a T-shaped upside down incision in the right lower quadrant. There was found to be _____ 2.9 cm of tunneling was seen. At this time, ET nurse was consulted and she was able to manage this wound further. He did need a VAC, which he had for about 10 days.
ET|enterostomal therapy|ET|221|222|HISTORY OF PRESENT ILLNESS|She was recently discharged on _%#MMDD2006#%_ following an infected right upper extremity PICC line with a right upper extremity DVT. Upon discharged, her erythematous fistula leaking was refractory to home care and home ET nursing over the past 6 days. Due to the uncontrolled leakage, she was readmitted to Fairview for the information of the fistula skin.
ET|endotracheal|ET|156|157|PHYSICAL EXAMINATION|She is noted to have urine output in her Foley. GENERAL APPEARANCE: This is an elderly, unresponsive female. Pupils are dilated secondary to atropine, oral ET tube, some ecchymosis over the anterior aspect of her nose. External auditory canals and nares appear patent. NECK: Supple. CHEST: Good air movement.
ET|endotracheal|ET|199|200|CLINICAL COURSE|Electrolytes were unremarkable except for modest increase in his CO2 at 35. N-terminal proBNP was really within normal limits at 274. Troponin I was less than 0.04. A portable chest x-ray showed the ET tube in good position and clear lung fields. The patient was cultured and started on antibiotic therapy and treated for an exacerbation of chronic obstructive pulmonary disease, asthmatic-type.
ET|endotracheal|ET|169|170|PHYSICAL EXAMINATION ON ADMISSION TO 4A|There were no obvious lesions. EYES: Pupils were 4 mm and equal, but slowly reactive. EARS: His ear canals were patent. NOSE/OROPHARYNX: Mucous membranes were moist. An ET tube was in place. NECK: Supple. LUNGS: Clear to auscultation bilaterally without wheezes, rales, or rhonchi. HEART: Tachycardic with a regular rate, normal S1, S2, no murmurs, rubs, or gallops.
ET|enterostomal therapy|ET|151|152|ASSESSMENT/PLAN|The patient will be given DVT prophylaxis with Lovenox 40 mg subcu daily. PT/OT to evaluate. 4. Decubitus ulcers. The patient will need wound care and ET nurse to evaluate. The patient needs frequent position change.
ET|enterostomal therapy|ET|201|202|HOSPITAL COURSE|All currently stable, although the PMR is bothering her a little bit. ALLERGIES: NONE. HOSPITAL COURSE: The patient was admitted with cellulitic legs secondary to chronic lymphedema. Consultation with ET nursing was obtained, as well as PT/OT and the patient has been receiving IV antibiotics and topical Silvadene with Adaptic gauze and Ace to the knees to provide some compression.
ET|endotracheal|ET|241|242|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is acutely ill appearing. VITAL SIGNS: Temperature is afebrile, blood pressure is currently 110s/50s, heart rate is in the 120s and in sinus tachycardia. He is 94%, 100% FiO2. HEENT: Remarkable for ET tube and NG. Ocular structure are unremarkable. NECK: Neck is supple without tenderness. CHEST: There are coarse breath sounds bilaterally. HEART: Tachycardic, no appreciable S4.
ET|enterostomal therapy|ET|163|164|HOSPITAL COURSE|The patient's wound was cleaned and assessed, found to have no necrotic tissues, wound edges were pink. The patient was a candidate for having wound VAC replaced. ET nurse was consulted and wound VAC was replaced during this admission. Due to the patient's chronic nausea and anorexia, she had an upper GI endoscopy.
ET|endotracheal|ET|223|224|IMPRESSION AND PLAN|Consider changing her to an ARDS ventilator strategy if she fails to improve over the next couple days as she certainly is at high risk of ARDS and will be difficult to differentiate this radiographically. Will advance her ET tube and get a follow-up chest x-ray. 3. Scleroderma: As noted above, there is no underlying parenchymal lung disease on her CT scans.
ET|endotracheal|ET|188|189|PHYSICAL EXAMINATION|Her sats are adequate while ventilated. GENERAL: Elderly, somewhat chronically ill-appearing female, intubated. HEENT: Normocephalic, atraumatic. Pupils are equal, sclera nonicteric. Oral ET tube. NECK: Supple, JVD is not readily discernable. CHEST: Decreased breath sounds but good air movement bilaterally. CARDIOVASCULAR: Paced, S1, S2 with a systolic murmur. ABDOMEN: Obese, soft and nontender.
ET|enterostomal therapy|ET|166|167|HOSPITAL COURSE|They evaluated him, changed his dressings, and gave instructions on care. The patient is followed by Vascular Surgery, specifically, _%#NAME#%_ _%#NAME#%_, for this. ET nursing was going to call _%#NAME#%_ _%#NAME#%_, to have her see the patient. Through his hospital stay, the patient also had some epigastric discomfort.
ET|enterostomal therapy|ET|198|199|HISTORY OF PRESENT ILLNESS|He was stable from a cardiopulmonary standpoint during his stay. He stayed afebrile throughout his stay. He had antibiotics suggested for culture results. Wound care was recommended and executed by ET nursing. He was discharged back to the group home with ongoing antibiotic therapy, wound care as recommended by ET, to be followed by this physician at the group home.
ET|electrophysiology:EP|ET|219|220|PREVIOUS MEDICAL HISTORY|The patient underwent stent placement of right coronary artery to 10% residual stenosis at that time. 2) Ischemic cardiomyopathy with ejection fraction of 50%. 3) Prophylactic AICD implantation with inducible V. fib at ET study. 4) Hyperlipidemia. 5) Hypertension. 6) COPD. 7) Multiple sclerosis, clinically stable. 8) GERD. PREVIOUS SURGICAL HISTORY: Noncontributory.
ET|enterostomal therapy|ET|114|115|HOSPITAL COURSE|They recommended silver nitrate treatment, which was done prior to her discharge. She will need follow up with an ET nurse on an outpatient basis. Her primary care physician was informed of this and will be able to take care of it in _%#CITY#%_.
ET|enterostomal therapy|ET|480|481|DISCHARGE INSTRUCTIONS AND FOLLOW-UP|DISCHARGE MEDICATIONS: Reglan 10 mg p.o. with meals p.r.n. nausea, lisinopril 20 mg p.o. daily, Lantus 50 units subcutaneously q.A.M., Humalog 15 units subcutaneously t.i.d. with meals, Protonix 40 mg p.o. daily, Liquid Carafate 1 gram p.o. q.i.d., Niaspan 750 mg three tablets p.o. q.h.s., Os-Cal 500 with vitamin D one p.o. daily, Imodium AD one after each loose stool up to q.i.d. p.r.n. DISCHARGE INSTRUCTIONS AND FOLLOW-UP: Continue wound cares to the right ankle region per ET nurse recommendations. Resume home services upon discharge. The patient is encouraged to walk with a walker that she has at home, not with cane.
ET|enterostomal therapy|ET|218|219|HOSPITAL COURSE|However, she was maintained on lower than her typical doses of Humulin until it was better assured that her oral intake was adequate in order to avoid any hypoglycemia to which she has been predisposed in the past. An ET nurse consultation was also obtained on _%#MM#%_ _%#DD#%_, with some specific recommendations for care of the right medial malleolus chronic ulcer.
ET|enterostomal therapy|ET|149|150|HISTORY|His PICC line was placed on _%#MMDD2004#%_. The patient was sent to the care facility on vancomycin, Zantac and Restoril. He will follow up with the ET nurse when he is discharged from the nursing home.
ET|enterostomal therapy|ET|141|142|HOSPITAL COURSE|This patient's penicillin was discontinued on _%#MM#%_ _%#DD#%_. Patient was started on lisinopril on _%#MM#%_ _%#DD#%_. Patient was seen by ET nursing for bilateral feet wound breakdown ulcers. The patient had a computed tomography scan done on _%#MM#%_ _%#DD#%_. Patient was started on his NPH insulin regimen on _%#MM#%_ _%#DD#%_ of _%#DD#%_ units subcutaneous q am with regular insulin 4 units for blood sugars greater than 200.
ET|enterostomal therapy|ET|117|118|PLAN|ASSESSMENT: 1. Right Achilles tendon rupture, treated with surgery. 2. Road rash on face, shoulders, and arms. PLAN: ET nurse to see. We will have the nurses remove the sutures, and the patient will have physical therapy.
ET|enterostomal therapy|ET|203|204|IMPRESSION/PLAN|3. Pain secondary to Indiana pouch and various tubes: Percocet p.r.n. The patient especially complains of discomfort from wearing jeans, so I did suggest he use sweat pants or string pants. Possibly the ET nurse can adjust the tubes to make it more comfortable. 4. Infection prophylaxis: The patient is on Flagyl and Tequin until Dr. _%#NAME#%_ sees him in two weeks.
ET|enterostomal therapy|ET|141|142|DIAGNOSIS|This was treated with daily Silvadene ointment and dressing changes. There was no significant erythema extending beyond the burn itself. The ET nurse will be following this patient in rehabilitation for his wound cares there. The patient was tolerating a regular diet and was ambulating well with his soft-type brace.
ET|enterostomal therapy|ET|174|175|DISCHARGE PLANNING|3. She will perform Clinicare cleaning to her right neck wound and dress this with gauze. 4. She will apply gauze to her breast wound; however, this may be modified when the ET nurse makes recommendations, and these will be included. These are largely conservative wound cares. 5. Follow-up appointment with Dr. _%#NAME#%_ in three days in the ENT Clinic. 6. Her sutures were removed today.
ET|enterostomal therapy|ET|177|178|HOSPITAL COURSE|She will have her electrolytes checked as well as her fluid level checked. Likely she has diastolic dysfunction and she a low normal LV function. 6. Buttock break down. Per the ET nurse she does have some buttock break down and they dressed the Tegasorb or equivalent hydrocolloid dressing to the area two times a week Tuesday and Friday.
ET|enterostomal therapy|ET|105|106|PROBLEM #2|The patient will be sent home on a low-protein, low-salt diet as well. PROBLEM #2: Left decubitus ulcer. ET nurse was consulted. The patient will continue current cares at home which include Technicare wash and rinse every day with a Vaseline gauze over the top, secured by a Tegaderm patch daily.
ET|enterostomal therapy|ET|181|182|HOSPITAL COURSE|This was placed in the patient's left lower quadrant of her abdomen, initially the stoma had some small amount of oozing that was found, as well as a slightly purple discoloration. ET nursing was consulted. The patient's stoma was watched very closely. The patient had normal gas as well as stool in the bag. The patient was taught how to care for this. At the time of discharge, she had home health set up to assist her with stoma care.
ET|enterostomal therapy|ET|157|158|PLAN|4. Rheumatoid arthritis. Continue her on methotrexate and Celebrex. 5. Multiple ulcers, probably poor to heal secondary to poor circulation. I would ask the ET nurse to assist with dressing changes. At this time I would switch her over to IV Ancef for antibiotic coverage.
ET|enterostomal therapy|ET|277|278|HOSPITAL COURSE|All cultures obtained during his hospitalization were negative. In retrospect it was felt that the patient's febrile illness might represent a viral process and less likely pneumonia. As above, the patient's skin condition was monitored closely by the nursing staff and by the ET nurse. It was felt that the patient would benefit from a low air loss mattress. This was communicated to the nursing home staff and discussed with the patient's family.
ET|endotracheal|ET|239|240|ASSESSMENT AND PLAN|The patient was brought to Fairview Ridges Hospital where she initially was tried on CPAP however, this did not adequately treat her respiratory acidosis and she was therefore intubated. She was given Solu-Medrol, Levaquin, and Lasix. Her ET tube has been pulled back here and she is now on a ventilator. Plan to get an ABG in one-half hour. Will continue ceftriaxone and azithromycin as well as Solu-Medrol and DuoNebs with Mucomyst.
ET|enterostomal therapy|ET|197|198|HISTORY|The patient is very obese and she needs extra support to maintain contact with her ileostomy and this was successfully accomplished and, in fact, she was discharged home and will be followed up by ET and by me in the office. For past details of her medical history, which is complex, and her medications, see chart.
ET|endotracheal|ET|179|180|PHYSICAL EXAMINATION|VITAL SIGNS: Blood pressure 120/70, pulse 96, afebrile. 02 sat 98% on FI02 of .4. HEENT: Pupils are equal, round, reactive to light. Anicteric. Mucous membranes are slightly dry. ET tube in place. NECK: No JVD or lymphadenopathy. LUNGS: Scattered wheezing without crackles. Mild rhonchi. CV: S1, S2, regular without murmurs. ABDOMEN: Soft and nontender.
ET|UNSURED SENSE|ET|36|37||DISCHARGE DIAGNOSIS: Lumbar fusion, ET fusion, L4,5. HOSPITAL COURSE: The patient was taken to the operating room for the anterior fusion, posterior instrumentation. The procedure went uneventfully except that the plan was slightly changed to add bone graft posteriorly because the closed method was not possible.
ET|enterostomal therapy|ET|161|162|HOSPITAL COURSE|Infectious Disease recommendations include continuing vancomycin and Cipro for a full four to six weeks. Repeat blood cultures were obtained, and were negative. ET Nursing was consulted regarding wound care, and the wounds were felt to be stable at the time of discharge. PROBLEM #2: Uncontrolled diabetes.
ET|enterostomal therapy|ET|123|124|PROBLEM #2|PROBLEM #2: Decubitus ulcers. At the time of her presentation to rehab, she did have a decubitus ulcer on her buttock. The ET nurse was following that, and by the time of discharge it had begun to heal quite nicely. However, at the time of her discharge, she was found to have decubitus ulcers on her left heel and right lateral malleolus.
ET|enterostomal therapy|ET|195|196|PROBLEM #5|PROBLEM #5: Decubiti. The patient had a number of decubiti on admission that did not appear infected although the largest one of the right lower extremity was down to the subcutaneous tissue. An ET Nurse Consultation was obtained, however, she was unable to see the patient prior to discharge. The case was discussed and given my description of the wounds, and her experience with this very familiar patient it was felt that this was no great change.
ET|enterostomal therapy|ET|344|345|HOSPITAL COURSE|13. Coumadin 5 mg p.o. or down NG q.h.s. HOSPITAL COURSE: The patient was admitted and had wound irrigation and debridement of his wound infection. The patient's wound was left open and was packed. The patient was followed on a daily basis with wound packing and at the time of discharge had a wound vac in place, which is to be changed by the ET nursing staff every Monday, Wednesday, and Friday. While in the hospital the patient was noted to have decreasing WBC counts to about the 2.2 range, as well as decreasing platelets to about 55,000 along with decreasing hemoglobin.
ET|endotracheal|ET|158|159|PHYSICAL EXAMINATION|Pupils are fixed and dilated. VITAL SIGNS: Afebrile. Pulse is from 100-120. Respirations 14. Blood pressure 60s-90s/40s-50s. Oxygen saturation is 97%. HEENT: ET tube in situ. NECK: Supple. LUNGS: Clear to auscultation bilaterally. CARDIAC: Tachycardic with a normal S1 and S2. No S3 or S4. No murmurs, rubs or gallops. ABDOMEN: Soft.
ET|endotracheal|ET|188|189|ASSESSMENT|She does exhibit some impulsive behavior with attention seeking behavior. She is currently intubated, appears comfortable. In reviewing the chest x-ray with Dr. _%#NAME#%_ _%#NAME#%_, her ET tube is apparently 5 cm deep into the right mainstem. After discussing with Dr. _%#NAME#%_ he did pull the ET tube out approximately 2 cm until he could hear equal breath sounds.
ET|enterostomal therapy|ET|165|166|HOSPITAL COURSE|Her intestinal tract was slow to function, but on the fifth postoperative day she began to pass some flatus. Her diet was advanced, and she tolerated this well. The ET nurses were following with us and were able to devise an appropriate appliance system. She was stable, her stoma was healthy appearing, and she was discharged to home.
ET|enterostomal therapy|ET|116|117|IMPRESSION AND PLAN|5. Nutrition. We will get an RD consult, calorie count x 5 days. 6. Decubitus ulcer on her coccyx. We will have the ET nurse see. 7. Perianal and groin rash, which does appear yeast-like. Mycostatin ointment will be started, and we will continue with the moisture barrier creams.
ET|enterostomal therapy|ET|187|188|HOSPITAL COURSE|There was marked improvement in the inflammation and erythema. She was able to change to oral antibiotics with significant improvement. She continued to have some low-grade drainage, and ET nurse recommended a colostomy type bag to catch the drainage. This helped improve the skin markedly. Prior to discharge, she also developed an acute left lower extremity cellulitis in the area she has had previous cellulitis due to ________ This was treated with IV antibiotics with improvement, and she will be changed to oral antibiotics.
ET|enterostomal therapy|ET|138|139|ASSESSMENT AND PLAN|Will also start her on Lasix 40 mg IV q 8 hours for diuresis. 2. History of hypothyroidism. Resume Synthroid. 3. Skin sores. Will ask the ET RN to consult. 4. Hypercholesterolemia. 5. Hypertension, resume Toprol XL for now. Consider other alternative therapy for her heart failure and blood pressure per Cardiology.
ET|enterostomal therapy|ET|208|209|ASSESSMENT/PLAN|The patient will be monitored clinically. 5. Bilateral heel ulcers which are growing MRSA. The patient will be started on vancomycin, and a surgical consultation will be obtained for possible debridement. An ET nurse practitioner consultation will also be obtained. 6. Coagulopathy with increased INR. The patient will be given 1 mg of vitamin K subcu, and a repeat INR will be followed.
ET|enterostomal therapy|ET|280|281|HOSPITAL COURSE|The Plastic Surgery team presented the family with some options regarding management of this, and the family elected to go with continued VAC dressing cares. A new bed, called a Kinair, was ordered. The patient's wheelchair was re-padded and evaluated by the rehabilitation team. ET nurses actually felt that during his hospitalization they were already beginning to make some headway regarding his wound. Regarding his right hip, he did remain afebrile after the irrigation and debridement, and initiation and continuation of antibiotics.
ET|enterostomal therapy|ET|147|148|DISCHARGE PLAN|He should continue to be followed by the ET nurse for his sacral decubitus ulcer. He will need VAC dressing changes, which can be managed with the ET nurse team. He will need follow-up in Dr. _%#NAME#%_'s clinic in 4 weeks for re-evaluation. He can have his sutures out in 10 days from now.
ET|enterostomal therapy|(ET|261|263|PROBLEM #2|He was discharged on _%#MMDD2004#%_. At that time, he was on 5 L nasal cannula with an Oxymizer, and his saturations overnight were greater than 90%. PROBLEM #2: Herpes zoster infection. He was diagnosed with herpes zoster during his last admission. Wound care (ET nurse) was consulted and hydrocolloid was given to cover the coccyx. He was continued on his valsartan during this hospitalization. PROBLEM #3: Atrial fibrillation.
ET|endotracheal|ET|201|202|ASSESSMENT/PLAN|The patient was given high-dose steroids for this, and was able to stabilize on the vent. However, he did not tolerate weaning from the vent and, subsequently, developed more bloody discharge from his ET tube. A repeat bronch showed a 2nd alveolar hemorrhage. In addition to this, the patient remained in a-flutter, with a very rapid rate, and was initiated on multiple medications, including amiodarone, digoxin, metoprolol, and diltiazem.
ET|endotracheal|ET|201|202|PHYSICAL EXAMINATION|HEENT: Head is atraumatic, normocephalic. Eyes - he has a left eye with a pacified cornea, I believe this is the eye he is blind in. His right pupil is about 2 mm, reactive. His right naris is with an ET tube. I am unable to open his mouth, but he does have notable what appears to be lip swelling. NECK: He has no enlargement of the neck, no noted nodes.
ET|enterostomal therapy|ET|153|154|DISCHARGE AND FOLLOW-UP PLANS|The nurse practitioner or physician there will assume her care. 2. She will need wound vac dressing changes 3 times weekly as here until wound heals. 3. ET RN should be consulted in the nursing home setting as well to assist with the management of the wound vac as the assuming physician sees fit.
ET|enterostomal therapy|ET|127|128|HOSPITAL COURSE|He has history of a C7 injury, therefore he was complaining of mild pain. We initially started Ancef IV and also consulted the ET nurse for wound care. The patient also developed fever and a urine culture that came out positive for Pseudomonas infection.
ET|enterostomal therapy|ET|180|181|ASSESSMENT/PLAN|Continue her most recent insulin doses, place on Accu-Cheks and sliding scale coverage, and check hemoglobin A1C. 4. Sacral decubiti and chronic venostasis disease. We will obtain ET nurse consult and place on First Step Mattress. 5. Atrial fibrillation. The patient is currently in sinus rhythm. We will continue her chronic Coumadin. 6. Congestive heart failure.
ET|enterostomal therapy|ET|194|195|HOSPITAL COURSE|This was susceptible to Zosyn, and with ID approval he was switched from IV Unasyn to IV Zosyn, which was continued throughout the course of his hospital stay. He was also visited by Fairview's ET nurse, who recommended specific wound care modalities. The patient was afebrile throughout his hospital stay. He will be discharged to a TCU, with an additional 12 days of Zosyn at 3.75 g q.6h., to complete a 14-day course of this antibiotic.
ET|enterostomal therapy|ET|226|227|DISPOSITION/FOLLOWUP|10. Coumadin 2 mg p.o. every Monday, Wednesday, and Friday and 1 mg p.o. every Tuesday, Thursday, Saturday, and Sunday. DISPOSITION/FOLLOWUP: The patient was discharged in stable condition. The patient will be followed by the ET nurse in one week for wound check. He is to follow with Dr. _%#NAME#%_ _%#NAME#%_ in the ICD Clinic in one month with his primary physician, Dr. _%#NAME#%_ _%#NAME#%_ in 2-4 weeks and with Dr. _%#NAME#%_ _%#NAME#%_ in Heart Failure Clinic in one month.
ET|endotracheal|ET|152|153|PHYSICAL EXAMINATION|Pupils are small, pinpoint, minimally reactive bilaterally. Nares - she has some yellow mucus noted in her nares bilaterally. She is intubated with the ET tube. NECK: Supple. She has full range of motion. No lymphadenopathy. LUNGS: Coarse breath sounds bilaterally. No wheezes are heard at this point.
ET|enterostomal therapy|ET|179|180|HOSPITAL COURSE|He apparently developed increased pain and fecal discharge from the colocutaneous fistula. He was admitted for management. HOSPITAL COURSE: Patient was seen by this physician and ET nursing. He seemed to have a stable colocutaneous fistula. He was stabilized after assessment and transferred to FUTS for wound care.
ET|enterostomal therapy|ET|182|183|ASSESSMENT/PLAN|5. Chronic obstructive asthma exacerbation. The patient to receive IV steroids, O2 support, and scheduled nebs. 6. Foot infection. We will place on empiric IV antibiotics and obtain ET nurse consult. 7. Disposition. We will obtain PT, OT, and social work consults. Unclear if patient can care for herself independently in a safe manner.
ET|endotracheal|ET|223|224|LABORATORY DATA|LABORATORY DATA: From ER: WBC 8.7, hemoglobin 14.9, platelets 143. Valproic acid level 99 random. Sodium 142, potassium 3.5, chloride 102, bicarbonate 20, BUN 13, creatinine 0.8, glucose 141, calcium 8.3. Chest x-ray shows ET at T2 and mild infiltrate right lower lobe. HOSPITAL COURSE: The patient was transferred here intubated on propofol drip overnight and weaned.
ET|enterostomal therapy|ET|177|178|HOSPITAL COURSE|HOSPITAL COURSE: Cellulitis which was treated with a course of Unasyn. The following morning, his toe was much improved. He was also treated with wound care, he was seen by the ET nurse and they provided the patient with instructions on how to do this at home and therefore the patient was discharged home.
ET|enterostomal therapy|ET|164|165|* FEN|The patient's course in the transitional unit was marked by a very slow progress from a standpoint of his debridement of his wounds. He was followed closely by the ET nurse and was also followed by Dr. _%#NAME#%_ of plastic surgery, by the pain service specialist, and by Dr. _%#NAME#%_ of infectious disease. At the time of discharge, there were 7 open areas that were being monitored by the ET nursing staff which include: 1. Stage IV open area in the left trochanter.
ET|enterostomal therapy|ET|83|84|* FEN|At the time of discharge, there were 7 open areas that were being monitored by the ET nursing staff which include: 1. Stage IV open area in the left trochanter. An integral wound matrix material had been stapled over the wound bed, a 3.6-cm deep tunnel over the posterior aspect of the wound that persists.
ET|endotracheal|ET|165|166|PHYSICAL EXAMINATION|HEENT: Normocephalic, atraumatic. His pupils are small. Arcus is present. No icterus. Conjunctivae are not injected. External auditory canals and nares patent. Oral ET tube. Pharynx dry. NECK: Supple. JVD is not discernable. CHEST: Chest with decreased breath sounds. CARDIOVASCULAR: Regular S1, S2.
ET|endotracheal|ET|157|158|INDICATIONS|She was followed closely by the ICU team and on postoperative day #3, it was determined that she would most likely be able to discharge to the floors as her ET tube had been successfully weaned. She had good p.o. pain control. Her hemodynamic status was stable. The patient was transferred to the floors on postoperative day #3 and overall on the floor, she did quite well.
ET|endotracheal|ET|168|169|PHYSICAL EXAMINATION|HEENT: PERL. Extraocular movements intact. She has an ET tube in her mouth. I am unable to see into her mouth. NECK: Large. Given where the tape is located to hold the ET tube in place, I am unable to assess for jugular venous distention. She has a venous catheter in her external jugular on the left.
ET|enterostomal therapy|ET|153|154|HOSPITAL COURSE|His blood sugars have been under better control with his sliding scale insulin. He is stable. His white count has returned to near normal levels and the ET nurse has changed his VAC on _%#MMDD2007#%_ and describes in her note no signs or symptoms of infection. DISCHARGE INSTRUCTIONS: Discharged to Regency Hospital in _%#CITY#%_ on _%#MMDD2007#%_, the phone number is _%#TEL#%_ with a fax number of _%#TEL#%_.
ET|enterostomal therapy|ET|128|129|HOSPITAL COURSE|An x-ray of left lower extremity was performed, on which there was no evidence of osteomyelitis. The patient was followed up by ET nurse and the recommendations were followed. 6. Elevated PTT: The patient was noted to have elevated PTT. The possibility of heparin contamination was ruled out by doing a mixing study, which did not correct PTT.
ET|enterostomal therapy|ET|308|309|HOSPITAL COURSE|1. Chronic abdominal pain, which had been treated with hydromorphone orally on p.r.n. basis was successfully treated with occasional hydromorphone and GI cocktail (Maalox and lidocaine mixture). 2. Known decubitus ulcers, which had been treated with wound VAC as an outpatient, were evaluated and managed by ET nurse. Decubitus ulcers did not appear infected on this admission. DISCHARGE MEDICATIONS: 1. Duloxetine (Cymbalta 60 mg p.o. daily). 2. Zolpidem (Ambien) 10 mg p.o. each day at bedtime p.r.n. insomnia).
ET|enterostomal therapy|ET|177|178|HOSPITAL  COURSE|His hemodynamics improved. He was transferred out of the Intensive Care Unit and had been doing well. Except for some fatigue, there were no other active infectious issues. The ET wound care nurses were consulted who had been doing daily dressing changes. He will need to continue foot cares and dressing changes at TCU as well as on an outpatient basis.
ET|enterostomal therapy|ET|117|118|POSTOPERATIVE COURSE|She was able to tolerate eating and had the wound VAC in place which was working well. This was coordinated with the ET nurses and insurance to obtain home wound VAC system which the patient was able to use after the procedure on _%#MMDD2007#%_.
ET|enterostomal therapy|ET|105|106|PROBLEM #4|Discharged on day #3 along with IV as part of comfort care measures. PROBLEM #4: Sacral and heel ulcers. ET Nursing saw the patient and was placed on Ancef IV on admission. The patient was discharged with Tegaderm to heel ulcers. Replace regularly p.r.n.. Recommendations to cleanse sacral ulcers q.o.d. and p.r.n. with normal saline.
ET|enterostomal therapy|ET|129|130|HOSPITAL COURSE|It progressed and when he saw Dr. _%#NAME#%_ on _%#MMDD#%_ in clinic it had worsened and he was admitted. He was followed by the ET nurse for wound care. He was seen by Dr. _%#NAME#%_ of the Vascular Clinic. At one point there was concern that the wound had spread more deeply into osteomyelitis which was suggested by calcaneal x-ray.
ET|enterostomal therapy|ET|147|148|DOB|She was started on Flagyl 250 mg p.o. t.i.d. Her electrolytes rapidly normalized, her condition rapidly resolved. She was subsequently seen by the ET nurse who felt the care was very appropriate and should be continued. Her condition stabilized and she was subsequently discharged to home on _%#MM#%_ _%#DD#%_.
ET|endotracheal|ET|197|198|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Unable. PHYSICAL EXAMINATION: GENERAL: Elderly female, obtunded, intubated. HEAD: Normocephalic and atraumatic. Pupils react directly and consensually. She is edentulous and the ET tube and the orogastric tube are passing through the mouth which is otherwise unremarkable except for dry mucous membranes.
ET|enterostomal therapy|ET|167|168||He has a whole new outlook on life. He remained afebrile and progressed rapidly with his intake. He has been taught by the ET nurse. The mother has been taught by the ET nurse to take care of the ostomy. He will be sent home with home health care to check on him. He will change his dressing every three days. His wound is healing well.
ET|enterostomal therapy|ET|346|347|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient was admitted on _%#MMDD2002#%_ for ischial ulcers and surgical consultation from a _%#CITY#%_ Hospital, where he presented with a temperature of 101.5. He has a history of a motor vehicle accident and paraplegia since _%#MM2000#%_. He was found to have an E. Coli and UTI as well, and this was treated. An ET nurse was consulted, and a wound vac was instituted on the patient at the University. Plastic surgery consult decided at this time until the wounds have healed and the patient's nutritional status is improved.
ET|enterostomal therapy|ET|157|158|HOSPITAL COURSE|Upon strict restriction of dairy products the patient's diarrhea essentially resolved. The patient had very poor skin integrity on his lower extremities. An ET consult was obtained. Moisturizing creams were applied with improvement of skin integrity. The patient complained of hearing voices on admission. A psychiatry consult was obtained and the patient was diagnosed with depression with psychotic features.
ET|enterostomal therapy|ET|126|127|HISTORY OF PRESENT ILLNESS|The patient presented on _%#MMDD2003#%_ because of concerns for significant oozing from his sacral wound. He was seen by home ET nurse that day, who referred him to the hospital because of this bleeding. The patient reports fatigue and feeling faint. He denied any shortness of breath associated with this.
ET|enterostomal therapy|ET|147|148|PROBLEM #2|Vacuum suction was placed to the wound per their recommendations. The patient continued to have regular changes of this wound dressing by both the ET nurse and Plastics. They were pleased with the healing that was present. The plan is to continue these aggressive wound cares.
ET|enterostomal therapy|ET|192|193|HOSPITAL COURSE|He was eating a regular diet, had no evidence of wound complications and desired to be discharged home. He was seen by ET, arrangements were made for home health care to follow him up for his ET requirements. He was discharged home on the sixth postoperative day, afebrile, fully ambulatory, eating regular diet without evidence of wound complications.
ET|enterostomal therapy|ET|204|205|DISCHARGE INSTRUCTIONS|4. He is instructed to follow up with the ostomy nurse at Fairview- University Transitional Services for instructions on ostomy care after the time of discharge. 5. He is instructed to follow up with the ET nurses at Fairview- University Transitional Services for wound care instructions. 6. Mr. _%#NAME#%_ is instructed to follow up with Dr. _%#NAME#%_ in approximately two weeks for postsurgical evaluation.
ET|enterostomal therapy|ET|215|216|HOSPITAL COURSE|6. Hypertension. 7. History of polymyalgia rheumatica. HOSPITAL COURSE: She was admitted after hospitalization for a lower extremity cellulitis, ulcerations due to chronic venostasis in her legs, and lymphedema. An ET nurse helped direct the care of her legs and she did have gradual improvement of her legs so that they were not as ulcerated at the time of discharge.
ET|enterostomal therapy|ET|149|150|DISCHARGE DIAGNOSES|6. Mild hyponatremia, which has been stable. 7. Coccyx decubiti ulcer. This has been slowly healing and now Proshield ointment is recommended by the ET wound ostomy nurse. 8. Cognitive deficits. Probably due to end-stage liver disease. The patient has become more interactive and is now remembering names of staff people, but still does have some short-term memory and significant problem solving difficulties.
ET|enterostomal therapy|ET|169|170|IMPRESSION|The patient is dehydrated by physical examination. We will hold her blood pressure medication, start normal Saline and await the basic metabolic panel. We will have the ET nurse involved and will start Nystatin powder as this appears to be a yeast component to her perineal inflammation and skin breakdown.
ET|enterostomal therapy|(ET)|475|478|HOSPITAL COURSE|_%#NAME#%_ _%#NAME#%_ _%#NAME#%_ was a 58-year-old man who had a known diagnosis of advanced and metastatic pancreas cancer with hepatic involvement and who was admitted to Fairview Southdale Hospital on _%#MMDD2003#%_ after presenting with hypotension and cardiac and respiratory arrest at his home. (Please refer to the Admission History and Physical for additional details regarding presentation as well as previous treatment.) He was resuscitated, including endotracheal (ET) intubation, by the paramedics in the field prior to transport to Fairview Southdale Hospital. After admission to the hospital at admission to the hospital he was noted to bed hypotensive and was given generous IV fluids.
ET|enterostomal therapy|ET|131|132|HOSPITAL COURSE|All her laboratory values were within normal limits. HOSPITAL COURSE: She was admitted to 7C. A surgical consult was obtained, and ET Nursing was consulted, as well as Physical Therapy. PROBLEM #1: Disease. She has stage IV ovarian cancer, on GOG 182.
ET|enterostomal therapy|ET|207|208|HOSPITAL COURSE|The likely cause of his low potassium was increased gastric secretions from around the gastrostomy tube as well as the drainage from his epigastric area. 2. Gastrostomy tube leakage. Patient was seen by the ET nurse. His gastrostomy tube was much improved by time of discharge with very minimal drainage. 3. Pain management. The patient was continued on his normal Fentanyl patch rate of 300 mcg/h.
ET|enterostomal therapy|ET|187|188|HOSPITAL COURSE|6. Decubitus ulcer: Nursing noted coccygeal ulcer. As mentioned above, the patient had been spending most of her time sitting in a chair, and it was felt to be a pressure sore from that. ET nurse was consulted and made wound care recommendations which will be continued with the home health nurse. 7. Coronary artery disease: Cardiology did see her. She was wishing to re-establish care with a new cardiologist, as she has been not particularly satisfied with her previous cardiology care.
ET|enterostomal therapy|ET|237|238|PROCEDURE|Postoperatively, her arm symptoms have improved. She is not complaining of neck pain nor does she have a headache, though she is still using postoperative medication. Her chief complaint postoperatively has been sore throat secondary to ET tube and ongoing nausea. This seems to have responded recently to conversion to Zofran anti-emetic. With the help of Zofran, she has been able to be up and ambulating in the hall.
ET|enterostomal therapy|(ET|236|238|CONSULTATIONS|DATE OF DISCHARGE IS _%#MMDD2004#%_ PROCEDURES PERFORMED: None. CONSULTATIONS: 1. Physical Therapy, _%#MMDD2004#%_. 2. Occupational Therapy, _%#MMDD2004#%_. 3. Infectious Disease consult, _%#MMDD2004#%_. 4. Enterostomal therapy consult (ET nursing), _%#MMDD2004#%_. DISCHARGE MEDICATIONS: 1. Tequin 400 mg p.o. daily X10 days 2. Miconazole 2% cream apply to affected areas b.i.d.
ET|enterostomal therapy|ET|151|152|HOSPITAL COURSE|Of note, at the time of admission, the patient had increased output and increased erythema from her G-tube site. An ostomy bag was initially placed by ET nurses, but the patient discontinued this and has been very aggressive at dressing changes on her own. Her skin has healed up nicely, and was without erythema or exudate at the time of discharge.
ET|endotracheal|ET|138|139|PHYSICAL EXAMINATION|Her pupils are large but minimally reactive. Sclera not icteric. Conjunctiva not injected. External auditory canals and nares are patent. ET tube is in place. There appears to be some mild periorbital edema. NECK: Supple with good range of motion. CHEST: Good air movement without decreased breath sounds.
ET|enterostomal therapy|ET|147|148|SYNAPSE OF HISTORY AND PHYSICAL|There was no nausea, vomiting. Diarrhea had significantly decreased. She was afebrile. Continued on p.o. vancomycin. Sacral wound was addressed by ET care. On _%#MMDD2004#%_, the patient denied any pain. There was no nausea, vomiting. Tolerating p.o. intake. There was no shortness of breath. Vitals were stable.
ET|enterostomal therapy|ET|193|194|DISCHARGE INSTRUCTIONS|DISCHARGE MEDICATIONS: Prozac 60 mg by mouth daily. DISCHARGE INSTRUCTIONS: 1. The patient is to followup with Dr. _%#NAME#%_ in 2 weeks' time. 2. The patient will have wound VAC placement via ET nursing at home. 3. The patient is to continue wet to dry b.i.d. dressing changes until the VAC is placed. 4. The patient is not to do any heavy lifting greater than 20 pounds for 6 weeks.
ET|enterostomal therapy|ET|243|244|ADDENDUM|Orders for the patient include: 1. Jackson-Pratt drain care, drain tubing q.4h., empty Jackson-Pratt q.4h. and record output daily, and change dressing daily. 2. Colostomy cares, routine ostomy cares, change bag Monday, Wednesday, Friday, and ET to follow and make recommendations as appropriate. 3. Miami pouch cares. Catheterize Miami pouch with red Robinson cathter q.3-4h., no exceptions, and assist the patient with self- catheterization if she needs help.
ET|enterostomal therapy|ET|137|138|OBJECTIVE|HEAD, EYES, EARS, NOSE, THROAT: Extraocular muscles intact. Pupils equally round, reactive to light. Posterior oropharynx is obscured by ET tube. NECK is without lymphadenopathy or masses. CHEST is clear to auscultation bilaterally without crackles. HEART has regular rate and rhythm without murmur.
ET|endotracheal|ET|172|173|LABORATORY DATA|Chest x-ray demonstrates borderline cardiomegaly. There is diffuse bilateral infiltrates and some pulmonary venous cephalization. The costophrenic angles appear clear. The ET tube location may be slightly sub-selective in the right main stem bronchus, although it is difficult to tell. An emergency echocardiogram was performed in the ICU. This demonstrates borderline left ventricular enlargement.
ET|enterostomal therapy|ET|208|209|HOSPITAL COURSE|Patient noted to have tolerated the procedure well. There were no noted complications. Patient was returned to her regular floor bed postprocedure for continued care and monitoring. Patient was seen daily by ET nursing for management of her fistula dressings. Patient was treated with IV antibiotics during her hospital course. Patient was noted to have low-grade temperatures early on in her hospital course, however, was afebrile for greater than 24 hours prior to discharge.
ET|enterostomal therapy|(ET)|204|207|PLAN|2. Continue empiric antibiotics that were started already (Rocephin 1-g every 24 hours). 3. Check BNP. 4. Will get a Physical Therapy and Occupational Therapy assessment and have the Enterostomal Therapy (ET) nursing look at the skin ulcers.
ET|endotracheal|ET|205|206|PHYSICAL EXAMINATION|HEENT: Head is atraumatic, normocephalic. Her pupils are slightly unequal, with the left pupil slightly smaller than the right, but this is minimal, and they are minimally reactive bilaterally. She has an ET tube in place. There were copious secretions suctioned from her after her ET tube was placed. NECK: No neck lesions. LUNGS: Anteriorly, her lungs are actually fairly clear.
ET|endotracheal|ET|161|162|PHYSICAL EXAMINATION|Initially the patient seemed responsive, but was sedated with propofol. As the propofol was decreased, she moved all extremities and did try to bite down on the ET tube. Chest x-ray shows bilateral lower lobe densities. A CT scan of the chest reviewed with Dr. _%#NAME#%_ of radiology, shows bilateral lower lobe infiltrates without evidence of effusion without interstitial edema and a fairly normal heart size.
ET|enterostomal therapy|ET|128|129|DIAGNOSIS|3. Leg ulcers. He has chronic leg ulcers that do not appear to be grossly infected with no evidence for cellulitis. We will get ET nurse to see him in the morning. 4. Atrial fibrillation. The patient at risk given his age and other Comorbidities for stroke, but given his risk for fall, it was determined that rate therapy with metoprolol without anticoagulation with Warfarin would be benefit secondary to high risk of falls.
ET|enterostomal therapy|ET|250|251|PROBLEM #5|The patient had frequent platelet transfusions, and further treatment with Neupogen and Epogen as per Bone Marrow Transplant Team. PROBLEM #5: Right foot cellulitis and infection, left heel wound infection. The patient was treated with wound care by ET nurse. Also, the patient had cultures, which showed Staph and MSSA. The patient was started with vancomycin and ceftriaxone, as above.
ET|endotracheal|(ET)|205|208|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Currently pulse is in the 80s. Blood pressure is stable. She is afebrile. GENERAL: The patient is on the ventilator. HEENT: Ears/Nose/Throat: Remarkable for endotracheal (ET) intubation. Ear canals are clean. Tympanic membranes are unremarkable. NECK: Unremarkable. CHEST: Clear. HEART: Regular rate and rhythm. ABDOMEN: Abdomen is normal size with a few quiet bowel sounds.
ET|enterostomal therapy|ET|156|157|ASSESSMENT AND PLAN|She is transferred to F-UTS for physical rehabilitation and continuation of medical care. 1. Status post loop ileostomy placement. The patient will have an ET nurse consultation and will continue to work with ET nurse in changing the ileostomy pouch. 2. Hyperlipidemia. Continue the Lipitor. 3. Osteoporosis. Continue the Raloxifene and calcium carbonate.
ET|enterostomal therapy|ET|205|206|HOSPITAL COURSE|PROBLEM #3. Perineal skin irritation: Noted to be worse during hospital stay, and was noted to have some vaginal drainage, thought to be residual drainage from the rectovaginal fistula repair. Surgery and ET nurse were consulted. Wound cares were recommended, in addition to antifungal ointment or powder. She needs to be cleansed more aggressively on a regular basis, minimum of twice per day, and apply.............paste q.2 h. p.r.n.
ET|enterostomal therapy|ET,|197|199|SECONDARY DIAGNOSES|SECONDARY DIAGNOSES: Hypertension; history of tobacco, has quit; history of hyperlipidemia; and DJD. CODE STATUS: The patient is full-code. CONSULTATIONS DURING HOSPITALIZATION: Pulmonary, PT, OT, ET, and social services. OPERATIONS/PROCEDURES PERFORMED: Lower extremity Doppler, which was negative. A cardiac echo, which revealed moderately increased right ventricular pressures, and PFTs results are pending.
ET|endotracheal|ET|409|410|DIAGNOSES|At 9:00 p.m. on _%#MM#%_ _%#DD#%_, 2005, his blood gas was 7.23/106/40/42. At that time, I met with the patient's mother to explain to her that we had done all we could to maximize his respiratory support, and it was likely that his acid status would continue to worsen to the point where his heart would stop. 3. Lip wounds growing Serratia and Staph aureus. This was treated with topical bacitracin, and an ET tube that did not rub on the lip wound. 4. Sputum culture growing Staph aureus and Enterobacter. The patient was initially afebrile and was hemodynamically stable.
ET|endotracheal|ET|163|164|LABORATORY DATA|Calcium 7.8. Magnesium within normal limits. Lipase and Amylase within normal limits. INR within normal limits. Troponin 11.07. Chest x-ray shows clear lungs with ET tube in place. ASSESSMENT AND PLAN: This is a 47-year-old female with history of depression and anxiety disorder, and alcohol abuse who presented with an overdose on Seroquel and alcohol.
ET|enterostomal therapy|ET|174|175|IMPRESSION|I will place him on some gentle IV fluids and reassess his basic metabolic panel in the morning. We will need to get his records from the VA Medical Center. We will have the ET nurse see him for his wound. Further investigation and management will depend upon his clinical course.
ET|enterostomal therapy|ET|203|204|HOSPITAL COURSE|Follow-up head CT was without change and plan per neurology is follow-up outpatient head CT in one week with results to PMD for follow-up. The patient remained neurologically stable throughout his stay. ET nurse was consulted and recommended various wound care treatments for patient which will be continued on an outpatient basis. 2. Acute on chronic renal failure. The patient's creatinine increased at the time of admission to 2.26. His baseline creatinine is 1.6 to 1.7. The patient received gentle IV fluid hydration and his diuretics were held short-term.
ET|endotracheal|ET|219|220|PHYSICAL EXAMINATION ON ADMISSION|Blood pressure 105/62, pulse 59, respirations 10, temperature 97.6, pulse oximetry 100% on ventilator support. Skin is warm and dry without rashes. He has multiple tattoos. HEENT: Atraumatic, normocephalic. Eyes: PERL. ET tube in place, also an NG tube in place. Neck is supple without JVD. Lungs clear to auscultation. Heart regular rate and rhythm without murmur.
ET|enterostomal therapy|ET|221|222|DISPOSITION|2. The patient will follow up with Dr. _%#NAME#%_ _%#NAME#%_ at Allina _%#CITY#%_ Medical Clinic up discharge from TCU. 3. She will follow up with radiology per radiology nurse recommendations. 4. She will follow up with ET nurse per ET nurse recommendations. 5. She will follow up with Dr. _%#NAME#%_ _%#NAME#%_, her urologist, next Tuesday. 6. Follow-up UA/UC and hemoglobin check in five days with results to either Fairview University hospitalist or private medical doctor for follow-up.
ET|enterostomal therapy|ET|196|197|ADMISSION DIAGNOSIS|Instructions to call MD p.r.n. temperature greater than or equal to 100.4 degrees or problems with recurrent diarrhea, to have a First-Step mattress. Local care to coccyx wounds as recommended by ET nursing. Stool for C-difficile toxin and culture p.r.n. recurrent diarrhea. Recheck BMP on _%#MM#%_ _%#DD#%_, 2005. A regular diet with Boost for nutritional supplementation. CONDITION AT DISCHARGE: Stable.
ET|endotracheal|ET|197|198|VITAL SIGNS|GENERAL: The patient is sedated and intubated. HEENT: Head: ET tube in place. Normocephalic, atraumatic. Eyes: Pupils equal, round, and reactive to light. Nose: No rhinorrhea. Mouth: Flush throat. ET tube in place. NECK: Supple. No lymphadenopathy. LUNGS: Decreased air entry at the bases, some coarse rhonchi. CARDIOVASCULAR: Regular rate and rhythm. Normal S1, S2. 2/6 systolic murmur with a rub.
ET|enterostomal therapy|ET|135|136|PLAN|1. Will be started on empiric IV imipenem 500 mg q.8 h. adjusted for kidney function. The patient needs wound care and will be seen by ET nursing for wound care. Because of chronic venous stasis of the lower extremities, with chronic skin change including hyperpigmentation and .......thickening, very difficult this wound to heal and slowly.
ET|enterostomal therapy|ET|197|198|ASSESSMENT AND PLAN|2. Anastomotic bile duct leak: The patient is status post laparotomy with washout and repair of the bile leak on _%#MMDD2006#%_. The patient currently has 2 areas which are open on his abdomen. An ET nurse consultation will be obtained to help manage these wounds. 3. Slow liver graft function secondary to reperfusion injury: This seems to be improving.
ET|endotracheal|ET|121|122|DISCHARGE MEDICATIONS|19. Tobramycin 300 mg nebulizer b.i.d. 20. Mucomyst nebs 2 mL inhaled as needed for mucus plugging. 21. Albuterol neb in ET tube b.i.d. 22. Bactrim DS 1 tablet down G-tube t.i.d. DISCHARGE AND FOLLOW UP: Patient was discharged home in stable condition.
ET|enterostomal therapy|ET,|147|149|HOSPITAL COURSE|His vac dressing on his posterior thigh should be changed every 3 to 4 days per ET. Furthermore, his stage 3 heel ulcer, which is being treated by ET, should continue with the same therapies. His dressing over his flap should be changed on a daily basis now with Adaptic, ABDs, and tape.
ET|endotracheal|ET|269|270|DIAGNOSTIC PROCEDURES|DIAGNOSTIC PROCEDURES: 1. Lumbar puncture, _%#MM#%_ _%#DD#%_, 2006, showed 1 nucleated cell, 8 red blood cells, total protein 55, and glucose of 80. 2. Noncontrast head CT showed no abnormality. 3. Chest x-ray, _%#MM#%_ _%#DD#%_, 2006, showing left-sided PICC line and ET tube. No pulmonary abnormality. Contrast head CT, _%#MM#%_ _%#DD#%_, 2006, showed no abnormality. EEG showed diffuse slowing likely secondary to medication, the patient was on propofol at that time.
ET|enterostomal therapy|ET|171|172|BRIEF HISTORY OF PRESENT ILLNESS|Colorectal surgery was consulted regarding her wound. They used vacuum suction to evacuate the abscess, irrigated the abscess with sterile saline, and repacked the wound. ET nurse was also consulted and they recommended the placement of a wound VAC. However, since the patient was admitted over the weekend, they have agreed to see the patient at home Monday or Tuesday morning to place the wound VAC and set her up with home supplies.
ET|endotracheal|ET|126|127|PHYSICAL EXAMINATION|Pupils are fixed and I do not appreciate a corneal reflex at this time. Extraocular muscles are inaccessible. She has an oral ET tube. NECK: Supple. CHEST: Decreased breath sounds. CARDIOVASCULAR: Tachycardic S1, S2. ABDOMEN: Soft. GU: Female genitalia. EXTREMITIES: Mottled, perhaps trace to 1+ edema.
ET|enterostomal therapy|ET|123|124|HOSPITAL COURSE|3. Wound/ calciphylaxis. The patient has a history of calciphylaxis with abdominal wall wounds and this was managed by the ET nurse while the patient was in the hospital. No further complications or other calciphylaxis were noticed while the patient was in the hospital.
ET|enterostomal therapy|ET|153|154|HOSPITAL COURSE|MEDICATIONS: Roxicet. REVIEW OF SYSTEMS: Negative on admission. MEDICATIONS ON ADMISSION: As above. HOSPITAL COURSE: The patient underwent evaluation by ET for wound cares. The patient was placed on t.i.d. wet-to-dry saline, with sharp debridement q.a.m. of any necrotic tissue. The patient's wound gradually improved, with some granulation tissue seen, although there were still continued areas of fibrinous necrosis tissue.
ET|enterostomal therapy|ET|127|128|BRIEF HOSPITAL COURSE|She will need wet-to-dry dressing changes on her abdominal wound. She had good stool in her ostomy bag. She will also need the ET nurse to teach the patient to care for her ostomy. In regards to the retention sutures, Colorectal Surgery would like her to return to clinic to be evaluated on _%#MMDD2002#%_.
ET|enterostomal therapy|ET|202|203|CONSULTS INCLUDED|3. Type 2 diabetes with nephropathy and neuropathy. 4. Ischemic heart disease with compensated heart failure. 5. Peripheral vascular disease. 6. Left foot ulcer. CONSULTS INCLUDED: Vascular surgery and ET nursing. BRIEF HISTORY AND PHYSICAL: Mr. _%#NAME#%_ is a 61-year-old male with a 26 year history of type 2 diabetes, chronic renal insufficiency, peripheral vascular disease, and coronary artery disease.
ET|enterostomal therapy|ET|330|331|PHYSICAL EXAMINATION|His urinalysis showed protein, but was otherwise negative. An ultrasound of his left lower extremity on _%#MM#%_ _%#DD#%_ showed a patent left PT artery at the ankle with patent left dorsalis pedis at the foot with severely decreased arterial flow in both segments. He was admitted to our service for the hyperkalemia and anemia. ET nursing suggested some dressings for the wound which was cultured on admission. For the hyperkalemia an electrocardiogram was checked which showed some evidence of old infarct, but no acute changes.
ET|endotracheal|ET|182|183|PHYSICAL EXAMINATION|His blood pressures are running 70s to 90s systolically. His pulses are running in the 60s. His HEENT is grossly negative. His pupils are fixed and dilated. He is ventilated with an ET tube in place. His NECK appears to be supple. There is no obvious JVD or problems appreciated. His LUNGS are clear to auscultation.
ET|enterostomal therapy|ET|256|257|HOSPITAL COURSE|Did receive a 10-day course of vancomycin and ceftazidime for nosocomial infection source not identified but the patient did improve clinically. No further antibiotics are necessary. Local cares in the lower extremity as outlined on the attached sheet per ET nurse. DISPOSITION: The patient will be discharged to _%#COUNTY#%_ in stable condition.
ET|enterostomal therapy|ET|166|167|HOSPITAL COURSE|ET nursing evaluated the patient and recommended a skin barrier treatment and pressure-relieving mattress. The patient was discharged with skin care instructions per ET recommendations. DISCHARGE MEDICATIONS: 1. OxyFAST 20 mg/mL liquid 5 to 15 mg sublingual p.o. q.2-4h. p.r.n.
ET|enterostomal therapy|ET|137|138|HISTORY OF PRESENT ILLNESS|The wick was subsequently removed and tract allowed to close on its own. No purulence has been observed around G- tube since that point. ET nursing has been consulted to assist with managing gastric secretions surrounding G-tube. Skin looks intact without erythema around the G-tube and the remainder of the wound is without sign of infection.
ET|enterostomal therapy|ET|184|185|PHYSICAL EXAMINATION|Neurologically the patient was grossly intact without focal deficits. The patient was admitted to the Colorectal Service, aggressively hydrated with IV fluids. The patient was seen by ET nursing for wound care. HOSPITAL COURSE: CT scan of the abdomen and pelvis was obtained which showed no abscess.
ET|enterostomal therapy|ET|237|238|REHAB COURSE|The last few weeks he has been in his room and therapies have signed off, as patient was unable to progress secondary to his condition.. On _%#MMDD2003#%_ the patient stated that he did want to be DNR/DNI and that order was written. The ET nurse has been intimately involved, as there have been problems with this patient's ostomies frequently leaking. Yesterday, the patient's left upper quadrant fistula drain did fall out and was replaced by Interventional Radiology.
ET|enterostomal therapy|ET|165|166|DISCHARGE PLANS|She needs to follow- up with her primary physician, Dr. _%#NAME#%_, and she needs to see him next Wednesday, _%#MMDD2003#%_, at an already scheduled appointment. An ET nurse, PT, OT, and a social worker will be involved in her care at home. She needs to follow-up in Wound Clinic for dressing changes.
ET|enterostomal therapy|ET|172|173|PLAN|Will prescribe Tequin 400 mg IV q 24 hours for pneumonia and monitor his vital signs and await for blood culture results. Will treat with wet to dry dressings and have the ET nurse follow him.
ET|enterostomal therapy|ET|228|229|ASSESSMENT/PLAN|1. Status post cadaveric transplant _%#MMDD#%_ for polycystic kidney disease. We will continue his immunosuppressive medications and usual posttransplant lab monitoring. 2. Abdominal wounds. Per transfer order, we will have the ET nurse follow and clarify wound vac management. 3. Hypertension. Control looks pretty good right now, but we will monitor since he has had many medication changes recently.
ET|enterostomal therapy|ET|290|291|HOSPITAL COURSE|The patient's wound was then opened at the bedside with irrigation and excisional drainage of his wound. The opening was carried through the facial layers. The ET nursing service was consulted and a wound pack was put in place which are to be changed every Monday, Wednesday, and Friday by ET nursing as well as checking of his wound. The patient during his hospital stay was found to be eating very little and per family the patient lost approximately 10 pounds over the previous month.
ET|endotracheal|ET|138|139|PHYSICAL EXAMINATION|Rhythm appears to be atrial fibrillation with rapid ventricular response. 02 sats are currently 96% on 100% FI02. He is intubated. HEENT: ET tube is in place. Based on x-ray it needs to be advanced 2 cm. Oral pharynx is clear. Yellow purulent material is being suctioned from the ET tube.
ET|endotracheal|ET|168|169|LABORATORY DATA|ABDOMEN: Unremarkable. EXTREMITIES: No significant edema. NEUROLOGIC: The patient is unable to cooperate. LABORATORY DATA: Chest x-ray shows a profoundly rotated film. ET tube needs to be advanced at least 2 cm. There is bilateral infiltrates at the bases and emphysematous changes.
ET|enterostomal therapy|ET|224|225|HOSPITAL COURSE|The patient had chronic wound infection, which appeared per patient's report improved over the last few months. The patient was started on clindamycin and ciprofloxacin for any bacterial overgrowth. His wound was changed by ET nurse who felt that this was improved from before. His wound did not show any signs of active infection. He will continue on his ciprofloxacin as an outpatient. PROBLEM #2: UTI: The patient has had multiple UA in the past few weeks with multiple different organisms growing out of his UA.
ET|enterostomal therapy|ET|160|161|PROBLEM #2|We did get authorization from his insurance company for the linezolid treatment in _%#MM#%_, which he will pick up upon discharge. PROBLEM #2: Open wounds. The ET nurse did see the patient and leave recommendations, which he will follow at home. PROBLEM #3: Diabetes. We continued his glyburide and glucoses were essentially stable.
ET|enterostomal therapy|ET|185|186|POSTOPERATIVE COURSE|On postoperative day 3, the patient was noted to have a developing left heel ulcer and sacral decubitus ulcer grade 1 early. The left heel ulcer and sacral decubitus ulcer evaluated in ET Nursing secondary to his history of syringomyelia with numbness in the left leg and lower back felt secondary to his immobility.
ET|enterostomal therapy|ET|351|352|TREATMENTS|13. Trazodone 50 mg p.o. q 6 hours prn. 14. Insulin sliding scale with Accu-Cheks t.i.d. The sliding scale is as follows: fingerstick of 201-250 she should get two units of regular insulin, 251-300 four units, 301-350 six units, 351-400 eight units and greater than or equal to 401 ten units of regular insulin. TREATMENTS: 1. Vac care routine as per ET to flush the drains, bowel drain #1, bowel drain #2 and jejunostomy tube with 10 cc of normal saline b.i.d. 2. Routine Foley care. 3. Physical therapy. 4. Accu-Cheks t.i.d.
ET|enterostomal therapy|ET|193|194|PLAN|3. Status post urostomy and colostomy. PLAN: 1. The patient will be admitted to the hospital for IV antibiotic therapy. 2. We will use a low pressure mattress for assistance with skin care. 3. ET nursing will be consulted. 4. We will review the skin condition in the morning to see whether any additional care is needed for his wounds.
ET|enterostomal therapy|ET|145|146|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|He also has an appointment to follow-up with his surgeon at Mayo in the next week or two. I have encouraged him to keep this. He was seen by the ET nurse with his abdominal wound and she is providing some recommendations for dressing changes. Specifically, he has a couple of places where there is granulation tissue and sloughed tissue on the edges.
ET|enterostomal therapy|ET|225|226|PROBLEM #3|The patient did have a PICC line placed for home antibiotics and the patient will finish out a full 2-week course of Zosyn and vancomycin. PROBLEM #3: Decubitus ulcer: The patient continued to have daily dressing changes and ET nurse did see the patient, the patient did have an air mattress to help decrease the pressure on his sore and the patient will continue his dressing changes at his group home.
ET|enterostomal therapy|ET|163|164|PROBLEM #2|She was then started on a steroid taper, which needs to be followed up in clinic. PROBLEM #2: Back ulcer. This was initially VRE positive and repeat was negative. ET nurse managed the ulcer, and it healed well. Repeat VRE swabs are needed to remove her out of the isolation room. PROBLEM #3: Fluid, electrolytes and nutrition. The patient's p.o. intake was decreased.
ET|enterostomal therapy|ET|147|148|DISPOSITION AT DISCHARGE|Packing wound with moist gauze in the evening. Spraying wound with Clinicare and Accuzyme and packing with moist gauze. On Monday, _%#MMDD2006#%_, ET nurse will restart wound vac. Regarding kidney function, the results of the kidney allograft biopsy are pending at this time.
ET|endotracheal|ET|137|138|PHYSICAL EXAMINATION|HEENT: Extraocular muscles intact. Pupils are equally round and reactive to light, but sluggish. The posterior oropharynx is obscured by ET tube. NECK is without lymphadenopathy or masses. CHEST: Coarse breath sounds and bilaterally decreased breath sounds on the right side.
ET|enterostomal therapy|ET|280|281|HOSPITAL COURSE|On the day of discharge, the patient's creatinine was 5.5, which was treated with Kayexalate 30 gm, and creatinine levels were 2.66. The patient also had postop culture from his wound, which showed coag- negative staph, and was sensitive to vancomycin. The patient consulted with ET nurse, who suggested BAC replacement, which will be arranged with home care nurse. The patient also had a bladder distention from his other admission.
ET|enterostomal therapy|ET|129|130|PLAN|His sister has Power of Attorney. The patient is willing to proceed at this point. 4. Will continue all medications. 5. Consider ET nurse evaluation of decubitus care.
ET|enterostomal therapy|ET|167|168|PROBLEM #2|Erythrocyte sedimentation rate was 18. Concern for osteomyelitis is low at this time. Right tib/fib x-ray is requested to evaluate for any bone infection. We will get ET nurse to evaluate and treat this wound, his chronic venous stasis skin change. We will discontinue Keflex that was started last night. CODE STATUS: Full.
ET|endotracheal|ET|137|138|PHYSICAL EXAMINATION|GENERAL: He is intubated and sedated. He looks cyanotic. HEENT: His pupils are equal and reactive to light. No conjunctivitis. He has an ET tube and an orogastric tube. NECK: No thyromegaly. No carotid bruits. No cervical adenopathy. LUNGS: Clear in the anterior fields to auscultation.
ET|enterostomal therapy|ET|201|202|HISTORY OF PRESENT ILLNESS|She was admitted on _%#MMDD2005#%_ with a GI bleed, which has been evaluated with EGD, but no specific source being noted. She has remained very stable. Dr. _%#NAME#%_ felt I should evaluate her foot. ET nursing has placed a leave-in pad over the toe area. PAST MEDICAL HISTORY: Well-documented in the chart. Significant for coronary disease where she undergone prior stenting and is on Plavix and aspirin.
ET|endotracheal|ET|190|191|VITALS|VITALS: Temperature was 97.6; pulse 85; blood pressure 159/100; respiratory 12, sating 100% on room air. Generally, the patient is sedate, intubated, with no evident blood in her NG tube or ET tube. Neck is supple. There is a right triple lumen in the right IJ. Cardiovascular exam shows a regular rate and rhythm. There is no murmurs, gallops, or rubs.
ET|endotracheal|ET|186|187|PHYSICAL EXAMINATION|FAMILY HISTORY: Unable to obtain, the patient is sedated on the ventilator. PHYSICAL EXAMINATION: VITAL SIGNS: Reviewed and stable. GENERAL: Ill-appearing gentleman lying in bed. HEENT: ET tube intact. RESPIRATORY: Decreased breath sounds. CARDIOVASCULAR: Tachycardic. ABDOMEN: Soft. Bowel sounds present. EXTREMITIES: No edema. SKIN: Right chest tube dressing intact.
ET|endotracheal|ET|180|181|PHYSICAL EXAMINATION|Extraocular muscles appear intact. Sclerae are anicteric. Conjunctivae are noninjected. Bilateral arcus is noted. External auditory canals and nares appear patent. She has an oral ET tube in place. NECK: Supple with full range of motion. Jugular venous distention is not discernible. CHEST: Decreased breath sounds at the bases, but otherwise good air movement.
ET|endotracheal|(ET)|185|188|PHYSICAL EXAMINATION|FAMILY HISTORY: Not obtainable. REVIEW OF SYSTEMS: Not obtainable. PHYSICAL EXAMINATION: GENERAL: Intubated, unresponsive female lying in bed. She is noted to have an oral endotracheal (ET) tube, a nasogastric (NG) tube, a right subclavian Cordis, a right radial arterial line, a Foley catheter. HEENT: Normocephalic, atraumatic. Pupils are approximately 5.0-mm and nonreactive. No scleral icterus.
ET|endotracheal|ET|301|302|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Not obtainable. FAMILY HISTORY: Not obtainable. SOCIAL HISTORY: She currently lives at home with her husband who does the majority of her care. PHYSICAL EXAMINATION: GENERAL: The patient is an ill, grayish-appearing female on the ventilator, markedly over-breathing the ventilator. ET and tube and NG are noted in place. She has peripheral IV's. HEENT: Normocephalic and atraumatic. Her pupils are large. They are fixed.
ET|endotracheal|ET.|114|116|PHYSICAL EXAMINATION|They are not reactive. Her sclera are dry. Conjunctiva are not injected. Arcus is present. She has an NG and oral ET. There is no gag present when tongue depressor is advanced down her throat. Neck is supple. CHEST: Coarse breath sounds throughout with bilateral rhonchi noted.
ET|endotracheal|ET|203|204|PHYSICAL EXAMINATION|ABDOMEN: 2+ distended, 1+ tympany, left upper quadrant splenectomy scar noted. Bowel sounds are present. EXTREMITIES: Without cyanosis, clubbing or edema. RECTAL: According to the nurses, stool is brown ET tube reveals coffee-grounds. LABORATORY DATA: Glucose is 608, troponin .07, platelets 494,000, INR 1.08, lipase 86, white blood count 33,000, hemoglobin 14.2, alkaline phosphatase 196.
ET|endotracheal|ET|191|192|HISTORY OF PRESENT ILLNESS|The patient was initially bradycardic (narrow complex), was given Atropine, intubated. Apparently there were food particles prior to intubation in the posterior oropharynx, as well as in the ET tube after extubation. The patient has since failed to wean from mechanical ventilator. Prior to this admit, the patient has been having some difficulty with coughing and choking while eating over the previous month or so.
ET|endotracheal|(ET)|281|284|PHYSICAL EXAMINATION|HEENT: Normocephalic, atraumatic. Pupils are equal, round and reactive to light and accommodation., perhaps nystagmus (difficult to determine). Sclerae: Anicteric. Conjunctivae: Not injected. External auditory canals and nares appear patent. Pharynx: No lesions. Oral endotracheal (ET) tube is in place. NECK: Supple. Jugular venous distention (JVD) is not discernible. CHEST: Clear anteriorly. HEART: Cardiovascular exam shows regular rate and rhythm. ABDOMEN: Mildly obese, but soft and nontender.
ET|endotracheal|ET|191|192|EXAMINATION|The patient unresponsive and on ventilator. EXAMINATION: VITAL SIGNS: The patient is febrile 38.8 axillary. Rest of vital signs reviewed and stable. GENERAL: The patient unresponsive. HEENT: ET tube in place. CARDIOVASCULAR: Heart rate tachycardic. RESPIRATORY: Coarse breath sounds. Patient on a vent. GI: Bowel sounds present. GU: Foley. Urine very amber in color. EXTREMITIES: No edema. SKIN: The patient with large dressing to right side of head.
ET|endotracheal|ET|137|138|EXAMINATION|There is no nuchal rigidity. There is no corneal reflex. There is no doll's eyes reflex. There is no gag reflex with manipulation of the ET tube. There is no jaw jerk. There is no response to caloric stimulation. There is no spontaneous movement. There is no reaction to deep painful stimulation in the supraorbital fissures, the sternum or the nailbeds of the 4 extremities.
ET|endotracheal|ET|201|202|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 120 _________, rate is approximately 100, atrial fibrillation, he is satting adequately on 50%. There is some urine noted in his Foley catheter lines. ET tube, NG, right IJ introducer, left radial A line, Foley catheter. GENERAL: Remains sedated. Appears comfortable. HEENT: Normocephalic and atraumatic. Pupils equal, round, reactive to light and accommodation but small.
ET|endotracheal|ET|180|181|PHYSICAL EXAMINATION|GENERAL: Remains sedated. Appears comfortable. HEENT: Normocephalic and atraumatic. Pupils equal, round, reactive to light and accommodation but small. NG in place. Oral pharynx - ET tube, otherwise not well visualized. NECK: Right IJ introducer. CHEST: Good air movement. CARDIOVASCULAR: Irregularly, irregular.
ET|endotracheal|ET|130|131|HISTORY|She remains paralyzed post-intubation but is slowly regaining movement. She is intubated and appears comfortable. She has an oral ET tube in place, an oral NG, an A-line, a right IJ catheter, a Jackson- Pratt drain in her abdomen and a Foley catheter.
ET|endotracheal|ET,|200|202|PHYSICAL EXAMINATION|FAMILY HISTORY/REVIEW OF SYSTEMS: Unobtainable. PHYSICAL EXAMINATION: VITAL SIGNS: She is afebrile, blood pressures range from 90-100 systolic, and her heart rhythm is sinus. GENERAL: She has an oral ET, an NG, a right subclavian and a Foley catheter. HEENT: Normocephalic, atraumatic. Pupils are small and nonreactive. There is no arcus.
ET|endotracheal|ET|124|125|DATA|He is retired currently. No travel history. No pets. FAMILY HISTORY: Negative for lung disease. DATA: Chest x-ray is clear. ET tube in good position. WBC 7.8, sodium 131, hemoglobin 13.1, platelet count 151,000, INR 1.3, troponin less than .3, albumin 2.4, total protein 6.3. CT of head is negative.
ET|enterostomal therapy|ET|199|200|ASSESSMENT AND PLAN|Will be managed by Dr. _%#NAME#%_. 2. Peripheral vascular disease with multiple open wounds on the lower extremities. For now, the patient was agreeable to do dressing changes qd. He was seen by the ET nurse, who recommended a specific type of dressing to try and heal. She reported this was a special order and might take some time to arrive.
ET|enterostomal therapy|ET|171|172|PHYSICAL EXAMINATION|SKIN: Dry, scaling, reddened skin over entire body. Multiple open areas in the lower extremities including open pressure ulcers on heels. The patient is being seen by the ET nurse for these. NEUROLOGIC: Unable to assess oriented secondary to non-verbal. The patient appears to have had delirium from previous reports of hallucinations.
ET|enterostomal therapy|ET|212|213|ASSESSMENT AND PLAN|4. Pressure ulcers and multiple skin tears secondary to fragile skin from T-cell lymphoma and its treatments. Turn patient q2h to prevent further skin breakdown. Continue dressing changes and recommendations per ET nurse. 5. Itching. Per daughter, Benadryl not helpful for itching. Discontinue Benadryl and use lotions as ordered, per daughter, this was most helpful to patient prior to admission.
ET|enterostomal therapy|ET|205|206|IMPRESSION|IMPRESSION: 1. This is a 61-year-old female with right lower extremity cellulitis improving on vancomycin. 2. Chronic left lower extremity ulcer, with slow wound healing, for which she is receiving weekly ET nursing care and an ET consult here. 3. History of immunosuppression, with a history of prednisone and methotrexate which was sought three weeks ago to facilitate wound healing.
ET|endotracheal|ET|250|251|PHYSICAL EXAMINATION|GENERAL: A young somewhat thin appearing male, intubated and partially sedated and paralyzed for intubation. HEENT: Pupils equal, round, react to light and accommodation, extraocular muscles intact, sclerae nonicteric, conjunctiva not injected. Oral ET tube. NECK: Supple. CHEST: Good air movement. CARDIOVASCULAR: Regular rate and rhythm, S1, S2. ABDOMEN: Soft and nontender. Genitalia is male circumcised. EXTREMITIES: Without cyanosis, clubbing or significant edema.
ET|endotracheal|ET|221|222|LABORATORY DATA|Other family history is not obtainable. LABORATORY DATA: Chest x-ray dated _%#MMDD2002#%_ shows perihilar infiltrates. Chest x-ray dated _%#MMDD2002#%_ shows right upper lobe and left lower lobe alveolar infiltrates with ET tube in good position. Troponin is 5.06, 3.53. White blood cell count is 9.2 (20.9 on arrival), hemoglobin 12.6, arterial blood gas 6.93/26/61/6 upon arrival.
ET|endotracheal|ET|162|163|EXAMINATION|Recent ABG reviewed above. GENERAL: Patient unresponsive. HEENT: Normocephalic, atraumatic. No evidence of trauma. His pupils are fixed. Sclerae nonicteric. Oral ET tube. NECK: Supple. CHEST: With good air movement. CARDIOVASCULAR: Regular. ABDOMEN: Benign. EXTREMITIES: No edema. NEUROLOGIC: Previously well detailed.
ET|endotracheal|ET|186|187|PHYSICAL EXAMINATION|He has pre-existing right-sided upper and lower extremity weakness. He briskly withdraws both legs, left greater than right, to stimulation. His grimace is symmetric. He coughs with the ET Tube. As the sedation wears he becomes increasingly agitated, moving and biting on his tube. SKIN: He is cushionoid in appearance. EXTREMITIES: His extremities are warm and well-perfused.
ET|endotracheal|ET|245|246|HISTORY|He continues to have fevers despite the antibiotics, and has improved in some respects in that he was weaned off of his pressors today. Nursing reports that she was able to suction a moderate amount of thick, blood-tinged secretions through the ET tube. He has no loose stools. He is unresponsive from his sedation. REVIEW OF SYSTEMS: Cannot be obtained because of the patient's condition.
ET|endotracheal|ET|234|235|PHYSICAL EXAMINATION|I's and O's yesterday were 3457 in, 3445 out for approximately an even total. Today he is slightly positive at 255. GENERAL: Elderly, somewhat chronically ill-appearing male, intubated, sedated. HEENT: Normocephalic, atraumatic. Oral ET tube. NECK: Supple. CHEST: Decreased breath sounds bilaterally, prolonged expiration. CARDIOVASCULAR: Tachycardic S1, S2. ABDOMEN: Soft, bowel sounds are present. GU: Male genitalia, Foley catheter in place. EXTREMITIES: Warm without significant edema.
ET|endotracheal|ET|204|205|PHYSICAL EXAM|The patient is unresponsive at this time. PHYSICAL EXAM: VITAL SIGNS: Temperature afebrile, 97% on vent, heart rate 90, respiratory rate 40, blood pressure 130/60. GENERAL: On vent, ill-appearing. HEENT: ET tube. RESPIRATORY: Rhonchi. CARDIOVASCULAR: Tachycardic. ABDOMEN: Obese, soft. EXTREMITIES: No edema. TED hose on. SKIN: Jackson-Pratt drain. MUSCULOSKELETAL: Unable to assess. NEUROLOGIC: Unresponsive to touch at this time.
ET|endotracheal|ET|156|157|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 106.2, heart rate 58, blood pressure 110/48, respiratory rate 18, 97%. GENERAL: Unresponsive on vent. HEENT: ET tube respiratory course. CARDIOVASCULAR: Bradycardic. ABDOMEN: Soft. Bowel sounds present. EXTREMITIES: Bilateral lower extremity edema. SKIN: Intact. MUSCULOSKELETAL: Unable to assess. NEURO: Unresponsive. LABORATORY DATA: No labs today.
ET|endotracheal|ET|155|156|HISTORY OF PRESENT ILLNESS|The neonate was intubated upon delivery. Apparently, by report, after intubation, he immediate had 2 separate episodes of cyanosis for which he required 3 ET tube changes, but eventually was stable with a 2.5 endotracheal tube. This was at Southdale Hospital. He was transferred to Fairview _%#CITY#%_ Neonatal Intensive Care Unit, where he had been stable.
ET|endotracheal|ET|171|172|HISTORY OF PRESENT ILLNESS|He lasted approximately 3 or 4 hours. Upon re-intubation then, he was noted to have severely edematous larynx. He has now been intubated for 2 days, and stable with a 2.5 ET tube through the mouth. PAST MEDICAL HISTORY: Pregnancy history is as above, born at 29 weeks' gestational age with respiratory distress syndrome, hyperglycemia, possible necrotizing enterocolitis.
ET|endotracheal|ET|161|162|PREGNANCY HISTORY|A stat C-section for severe pre-eclampsia was performed. After birth, the patient was intubated with good color. Then, he had some bradycardia cyanosis, and his ET tube was replaced. Cardiac compressions were performed for 3 minutes. __________ 2 x 3. He improved by 10 minutes. He was then taken to SCN and, apparently, self-extubated.
ET|enterocutaneous:EC|ET|280|281|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: A 47-year-old African-American female with advanced esophageal cancer which was diagnosed in _%#MM2005#%_ who has had radiation and chemotherapy and subsequently developed dysphagia, has had significant weight loss, and developed an obstruction and an ET fistula. A stent was placed, but evidently there has been some leakage or some dislodging. She also has recently developed a GI bleed and has needed blood replacements.
ET|endotracheal|ET|146|147|PHYSICAL EXAMINATION|Pulse is 110 in a sinus rhythm. Respirations are 18 per ventilator. She is currently alert, denies significant distress other than not liking the ET tube. HEENT: Reveals a supple neck. Grossly normal carotid upstrokes without bruits. There is no cyanosis. LUNGS: Lungs reveal diffuse crackles posteriorly both sides.
ET|endotracheal|ET|180|181|PHYSICAL EXAMINATION|Patient is unresponsive and on ventilator. PHYSICAL EXAMINATION: Blood pressure 140s-60s/60s, heart rate in the 60s, temperature 98.6. GENERAL: The patient is unresponsive. HEENT: ET tube. No secretions. RESPIRATORY: Decreased breath sounds. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Bowel sounds present. EXTREMITIES: Cool to touch. No edema.
ET|endotracheal|ET|145|146|HISTORY OF PRESENT ILLNESS|She is feeling relatively comfortable. She feels a little short of breath and has some discomfort in her upper chest which she attributes to the ET tube. She denies cough. She has no abdominal pain. REVIEW OF SYSTEMS: No fevers, chills or sweats. No HEENT complaints. No pulmonary, other than outlined above. No cardiac.
ET|endotracheal|ET|146|147|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Vital signs - blood pressure 100/70, heart rate 98, temperature 98, respirations 12. General - unresponsive on vent. HEENT: ET tube. Pupils fixed and dilated. CHEST: Clear to auscultation on vent. HEART: Distant heart sounds. ABDOMEN: Soft. EXTREMITIES: Very cool to touch. SKIN: Intact and pale.
ET|endotracheal|ET|197|198|PHYSICAL EXAMINATION|GENERAL: This is an ill-appearing edematous female in bed in no acute distress. HEENT: Pupils equal, round, reactive to light. She has intact conjugate gaze. She has significant scleral edema. Her ET is in place. Her NG tube is in place. CARDIOVASCULAR: Regular without murmurs, rubs, or gallops. LUNGS: Coarse breath sounds throughout. ABDOMEN: diffusely tender to moderate palpation.
ET|endotracheal|ET|259|260|PHYSICAL EXAMINATION|Monitored with numerous lines present including dialysis line. VITAL SIGNS: Blood pressure is 98/62, pulse 167, temperature 38.1. HEENT: The patient's eyes are closed. He is very active, moving about when I see him. Fontanels are full. Seems to be tolerating ET tube and is currently being suctioned by nurse fairly well. LUNGS: Air entry seems to be symmetric. HEART: Heart sounds show no obvious murmurs to my ear.
ET|endotracheal|ET|231|232|PHYSICAL EXAMINATION|HEENT exam is deferred to Dr. _%#NAME#%_. Lung exam reveals faint crackles at both bases with equally faint expiratory wheezes bilaterally. Air movement appears good. He does have periods of production of frothy red sputum per the ET tube, particularly with coughing. Cardiac exam reveals a regular rate and rhythm without clicks, rubs or murmurs. The abdomen is soft, nontender. Extremity exam reveals intact pedal pulses.
ET|endotracheal|ET|145|146|LABORATORY DATA|2. No previous history of bronchitis. LABORATORY DATA: Chest x-ray shows some mild vascular congestive heart failure, is otherwise unremarkable. ET Tube is too high. ABG 7.43/40/72/27/92% on mechanical ventilator, tidal volume 800, Fi02 60%, rate of 6 IMV, and PEEP of 5, pressure support of 5.
ET|endotracheal|ET|210|211|PHYSICAL EXAMINATION|SOCIAL HISTORY: Nonsmoker, no alcohol. Lives independently. PHYSICAL EXAMINATION: VITAL SIGNS: T-max 37.8, blood pressure 110/57, pulse 79, intubated follows limited commands. NECK: Supple, with gentle flexion ET tube. LUNGS: Fairly clear anteriorly HEART: Harsh 3-4/6 AS murmur ABDOMEN: Soft, nontender. Foley, urine clear. EXTREMITIES: 2+ lower extremity edema, no rash.
ET|endotracheal|ET|207|208||She was quickly defibrillated successfully. The patient was intubated at the scene and was transferred to the Fairview Ridges ER. In the emergency room her rhythm was noted to be sinus tachycardia. When the ET tube was exchanged and the patient was agitated during that exchange. Her pupil was dilated, but responsive to light. EKG, as read by me, shows sinus tachycardia with ST depression noted in the inferior leads and Q wave in I and II and ST elevations.
ET|endotracheal|ET|139|140|PHYSICAL EXAMINATION|Pupils are equal, they are sluggish. There is arcus. Sclerae nonicteric. External auditory canals and nares are visually patent. He has an ET tube as we noted orally. NECK: Supple, thin, with his cervical and strap muscles apparent. CHEST: Decreased breath sounds, primarily on the right greater than the left.
ET|endotracheal|ET|151|152|LABORATORY DATA|LABORATORY DATA: Chest x-ray suggests underlying hyperexpansion consistent with chronic lung disease and some degree of increased vascular congestion. ET tube is adequate. Electrolytes: 144/0.6/105/19/0.8/326. Hemoglobin 10.2, white count 17, initial troponin low, second troponin 0.46. Most recently blood gas: 7.31/40/324/98%.
ET|enterostomal therapy|ET|174|175|HISTORY OF PRESENT ILLNESS|She was operated by Dr. _%#NAME#%_ 2004. She has thereafter has been doing well. No specific health concerns, otherwise. She has, however, been diagnosed (clinically) by her ET nurse that she may have an ileostomy hernia. Yesterday at about 2 p.m. the patient experienced that she got a little bit of abdominal pain, a little bit of cramps in the abdomen, and she stopped having anything out of the ileostomy.
ET|enterostomal therapy|ET|165|166|RECOMMENDATIONS|2) Continue ambulation for now, but ask Orthotics to assess any revisions or replacement of her current devices. 3) Continue current dressing changes as directed by ET nursing. 4) I will recheck her wounds on _%#MM#%_ _%#DD#%_ or _%#MM#%_ _%#DD#%_. Thank you for asking me to see this pleasant young woman.
ET|endotracheal|ET|192|193|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 38.1, heart rate 69, blood pressure 140/58, respiratory rate 19, pulse ox 92% on vent. GENERAL: Elderly appearing gentleman lying in bed. HEENT: ET tube intact. RESPIRATORY: Coarse lung sounds. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Bowel sounds present. EXTREMITIES: No edema. SKIN: Intact. MUSCULOSKELETAL: Unable to assess at this time.
ET|endotracheal|ET|145|146|PHYSICAL EXAMINATION|HEENT: There doesn't appear to be any head trauma. Pupils are 7 mm, fixed and dilated without any reaction. She has blood from her mouth and her ET tube site. LUNGS: It was difficult to appreciate breath sounds. There was a pump in the ventilator. She appears to have coarse breath sounds. She has noise throughout the precordium secondary to the pump.
ET|endotracheal|ET|201|202|PAST INFECTIONS|_%#MM#%_ _%#DD#%_ sputum light growth of Aspergillus fumigatus. _%#MM#%_ _%#DD#%_, 2004, light growth of Candida parapsilosis. _%#MMDD2004#%_, sputum - light growth of Aspergillus fumigatus. 5/111/04, ET tube aspirate - heavy growth of coagulase negative Staphylococcus and a single colony of colony of Aspergillus fumigatus. _%#MMDD2004#%_, urine - no yeast isolated. _%#MMDD2004#%_ throat culture - no yeast isolated.
ET|enterostomal therapy|ET,|166|168|PHYSICAL EXAMINATION|CARDIAC: Regular rhythm without murmurs or gallops. ABDOMEN: Benign. EXTREMITIES: He has 2+ edema throughout the lower extremities. SKIN: Examination will be done by ET, as the patient was on his back in bed at this time. NEUROLOGIC: No changes since my last visit at the nursing home with quadriparesis with minimal movement in the lower extremities approximately 0 to 1 out of 5; upper extremities approximately 1 to 2 out of 5.
ET|endotracheal|ET|152|153|PHYSICAL EXAMINATION|Heart tones are distant. Abdomen is soft, thin, without masses or organomegaly. Extremities show no clubbing, cyanosis, or edema. His chest x-ray shows ET tube to be in good position. He does have a significant calcification of his aorta. There are some patchy infiltrates in his right lower lung field as well as the left mid lung field, which were not present on his admission x-rays in _%#CITY#%_.
ET|endotracheal|ET|147|148|IMPRESSION|Her recent blood gas, as I noted, was 7.34/34/202/97% on 70%. Her settings are CMV 15, tidal volume 60, FiO2 70%, PEEP of 5. Chest x-ray shows the ET tube to be 1 cm above the level of the carina. She has bilateral interstitial infiltrates, likely consistent with pulmonary congestion.
ET|endotracheal|ET|196|197|LABORATORY DATA|No alcohol abuse. No other history obtainable. FAMILY HISTORY: Unobtainable. LABORATORY DATA: Chest x-ray shows questionable left infiltrate versus volume loss versus hyperinflation on the right. ET tube is in good position. BNP is grater than 1,300. White blood cell count is 17.4, hemoglobin is 15.7, platelet count 211.
ET|enterostomal therapy|ET|175|176|RECOMMENDATION|Her nutritional status will need to be closely monitored, particularly as her dehydration and underlying infection is treated. A Nutrition Consultation has been requested. An ET nurse assessment has also been requested in view of an opening (?) on her coccyx. I will follow Ms. _%#NAME#%_ for these acute and chronic medical issues.
ET|endotracheal|ET|223|224|LABORATORY|The physical examination really is unchanged since the previously described one and is more extensively described in Dr. _%#NAME#%_'s note of this date. LABORATORY: New laboratory information includes the "sputum" from the ET tube on _%#MMDD2003#%_. Has grown an unidentified Hemophilus species in addition to a Neisseria species and coagulase-negative Staphylococci making it suspicious as to whether this was truly "sputum." RECOMMENDATIONS: Our current recommendations include continuing the current antibiotics and awaiting further identification and sensitivities of the Hemophilus.
ET|endotracheal|ET|247|248|PHYSICAL EXAMINATION|The abdomen is okay with bowel sounds. This 11-year-old boy with ALD is admitted for status epilepticus, but now has no clinical seizures and none on EEG, but with a low-grade fever. Our recommendation is to discontinue the vancomycin because the ET tube cultures of coag negative staph was reported incorrectly and should have been reported as normal flora. We also recommend continuing the cefotaxime for a total of two weeks until _%#MMDD2003#%_.
ET|electroconvulsive therapy:ECT|ET|372|373|HISTORY OF PRESENT ILLNESS|She is compliant with medication. She has had symptoms of increasing despondency with a self-inflicted cigarette burn of the volar aspect of her left forearm, in addition to self-cutting with a "used razor" approximately four nights ago. She was evaluated in the emergency department at _%#CITY#%_ _%#CITY#%_; gaping wound left forearm, not sutured, discharged home. Last ET _%#MMDD2002#%_. She denies other active self-harm. There is a remote history of drug overdose x 3 during the patient's teens. She has never received ECT. No problems with general anesthesia except that the patient awakened after jaw surgery in 1977 in the ICU; cannot recollect details.
ET|endotracheal|ET|149|150|RESUSCITATION STATUS|Her current vent settings are as follows: Assist control 12, tidal volume 500, 100%, PO2 is 357, FiO2 was decreased to 50%. Her chest x-ray shows an ET tube in adequate position, what appears to be hyperinflation, and some bilateral perihilar infiltrates. Other diagnostic information suggests some degree of intravascular volume depletion, on the basis of a concentrated urine specimen, in addition to elevated BUN-to-creatinine ratio, despite what appears to be significant malnutrition.
ET|endotracheal|ET|286|287|HISTORY|Cardiac echo was obtained and results show hyperdynamic state. She is requiring fluid boluses and has little urine output 37 mL on _%#MMDD2004#%_ and 14 mL by 1 p.m. today. Last dose of lorazepam 0.35 mg, 0.1 mg/kg at 0224; and last dose of morphine 0.1 mg/kg at 0945, previously 0200. ET tube is in place. Foley has been placed. There have been no identified immunologic abnormalities. Low pH of 7.24 was seen at 0210. Glucose has been elevated above 200.
ET|endotracheal|ET|122|123|PHYSICAL EXAMINATION|Sclera nonicteric. Conjunctiva not injected. External auditory canals and nares are patent. Pharynx is moist. There is an ET tube. Neck is supple. There is some fullness anteriorly on both cervical triangles. CHEST: Some decreased breath sounds at the bases.
ET|endotracheal|ET|144|145|PHYSICAL EXAMINATION|ABDOMEN: Obese, markedly decreased bowel sounds, soft and nontender. EXTREMITIES: She does have pulses that are palpable. Her chest x-ray shows ET tube in good position but pulmonary edema. LABORATORY DATA: Sodium is 137, potassium 3.9, chloride 103, bicarbonate 16, BUN 22, creatinine 1.45, glucose 249, troponin less than 0.04, myoglobin 632, white count 5.5, hemoglobin 12.6, platelet count 250, her ABG at 10:19 showed a pH of 738, pCO2 of 29, pO2 of 231 and bicarbonate of 17.
ET|endotracheal|ET|153|154|HISTORY|The peg was placed approximately 10 days ago and has had some scant yellow drainage and this was cultured and grew VRE, MRSA and E. coli. He has had nil ET tube secretions and he has been weaning on CPAP today and doing fairly well. He is currently on IV vancomycin and Septra. He has not had diarrhea.
ET|endotracheal|ET|250|251|HISTORY|He also underwent placement of intra-aortic balloon pump. The patient was extremely unstable and required multiple inotrope suppressors, as well as intra-aortic balloon pump support. On _%#MMDD2004#%_, the patient had significant hemoptysis from his ET tube, and bronchoscopy revealed diffuse pulmonary hemorrhages with large amount of clots that were suctioned out. He remained on inotrope suppressors and also demonstrated elevated white count of 13.
ET|enterostomal therapy|ET|145|146|RECOMMENDATIONS|RECOMMENDATIONS: The patient will be monitored for alcohol withdrawal. He will be maintained on atenolol 50 mg per day for his hypertension. The ET nurse will be asked to see him regarding his abdominal wound. I will be able to see this patient during his hospitalization for these and any other medical issues.
ET|endotracheal|ET|209|210|LABORATORY EVALUATION|LABORATORY EVALUATION: A cardiac echo today showed a normal ejection fraction and normal LV function. A chest x-ray by my reading shows hyperinflated lungs with bilateral infiltrates and a normal heart and an ET tube in place. Her ABGs today showed hypoxia and respiratory alkalosis. Her electrolytes are unremarkable, as is her kidney function.
ET|endotracheal|ET|165|166|PHYSICAL EXAMINATION|She is on the Servo controlled rate, pedal volume 450, respiratory rate 12, FIO2 of 30%, PEEP 5. GENERAL: The patient is sedated and intubated. HEENT: Currently has ET tube and is on the ventilator. She has respiratory pressure controlled and ventilator. She has coarse breath sounds throughout her lung spaces.
ET|endotracheal|ET|122|123|FAMILY HISTORY|The ears are normally formed. Pupils were 2 mm and minimally reactive to light. I did not perform a doll's eyes maneuver. ET tube was in place. There was an air leak. Heart sounds are normal. Abdomen had no organomegaly. UVC line was in place. There was normal circumcised male genitalia, testes down.
ET|endotracheal|ET|121|122|PHYSICAL EXAMINATION|HEENT: Normocephalic/atraumatic. Pupils are small. There is no icterus. She has periorbital edema, lid edema. She has an ET tube. CHEST: Good air movement. CARDIOVASCULAR: Regular rate and rhythm. S1, S2. ABDOMEN: Quiet, but soft. She has a bandaged incision site on her lower abdomen.
ET|electrophysiology:EP|ET|199|200|PLAN|I have therefore advised the patient not to drive for the time being and to reconsider the use of an EKG event monitor if he has further spells. In addition, I have also offered him the option of an ET study if he has another severe attack.
ET|endotracheal|ET|129|130|PHYSICAL EXAMINATION|VITAL SIGNS: Blood pressure is 87/70, heart rate currently 120 and irregular. HEENT: Notable for a nasogastric tube in place and ET tube in place. Pupils are equal, round and reactive to light and accommodation. Oropharynx is clear. NECK: Supple. No trauma. CHEST: Has diffuse crackles on the right, bilateral wheezing.
ET|enterostomal therapy|ET|225|226|ASSESSMENT AND PLAN|5. Elevated alkaline phosphatase related to liver disease. 6. Left buttock sore, looks like a scratch that worsened from immobility and incontinence. We will apply bacitracin to the wound and cover with Tegaderm. We will ask ET nurses to see patient and give suggestions for dressings that can be applied given patient's incontinence. 7. Thrombocytopenia. Likely secondary to anemia versus ETOH. We will recheck CBC in the a.m.
ET|endotracheal|ET|155|156|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: As noted above. He has not had recent constitutional symptoms, with no fever, chills. He does have a dry cough, probably related to his ET tube. He has not had any anorexia, weight loss. No cardiovascular symptoms. No abdominal, GU or GI symptoms. He has chronic lower extremity edema on the site of his distal vein harvesting.
ET|endotracheal|ET|226|227|HISTORY OF PRESENT ILLNESS|He was in respiratory distress and was brought into the emergency room and subsequently intubated for profound hypoxemia. There were some concerns that he may have aspirated food. There are absent breath sounds over the left. ET tube was pulled back a little bit without improvement in hypoxemia. Based on his arterial blood gases, however, his saturations were adequate.
ET|endotracheal|ET|109|110|LABORATORIES|LABORATORIES: Her ECG shows a normal sinus rhythm with a prolonged QT. A chest x-ray by my reading shows the ET tube to be in good position. There is an NG in place. She has surgical clips in the left upper quadrant.
ET|endotracheal|ET|274|275|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Unable to obtain. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature of 98.7, pulse 114, blood pressure of 80/45, 99% on the ventilator. GENERAL: He opens eyes to voice, responds to some commands, intubated. HEENT: Pupils are equal and round. Oropharynx with ET tube and NG tube. NG tube contains dark returns. CARDIOVASCULAR: Tachycardic, irregular. PULMONARY: Clear to auscultation anteriorly. ABDOMEN: Soft, bowel sounds present. The patient grimaces to moderate palpation of the abdomen.
ET|endotracheal|ET|215|216|STUDIES|EXTREMITIES: No edema. He has faint pulses. NEUROLOGIC: He is unresponsive and does not move. STUDIES: Chest x-ray showed a consolidated right lung with volume loss, and increasing infiltrates in the left lung. His ET tube, CVP and NG are in place. Blood gases shows hypoxia which is severe at 52, despite 100% FiO2.
ET|endotracheal|ET|157|158|PHYSICAL EXAMINATION|HEENT: Normocephalic and atraumatic. Pupils are equal, round and reactive to light and accommodation. There is no significant arcus. Sclerae are nonicteric. ET tube in place. External auditory canals and nares are visually patent. NECK: His neck is supple. CHEST: Decreased and coarse breath sounds. Respirations appear labored. ABDOMEN: Soft and nontender.
ET|endotracheal|ET|153|154|IMPRESSION|2. Respiratory failure. Status post intubation for airway protection with apparent adequate oxygenation and ventilation. Some bloody secretions from the ET tube noted. Currently being followed by pulmonary medicine. 3. Underlying and known multiple myeloma, previously treated with VAD chemotherapy and subsequent autologous bone marrow transplant, thought to be in remission, currently being followed by oncology.
ET|endotracheal|ET|158|159|PHYSICAL EXAMINATION|HEENT exam: Normocephalic and atraumatic. The pupils are quite enlarged. They are minimally reactive at this time. There is nystagmus present. He has an oral ET in place. His neck is thick. His JVD is not discernible. The chest has decreased breath sounds. The cardiovascular exam is distant. S1 and S2. The abdomen is markedly obese.
ET|endotracheal|ET|199|200|PHYSICAL EXAMINATION|LUNGS: Demonstrate decreased breath sounds bilaterally. Diminished due to COPD without crackles. Jugular venous distention is noted quite prominently. HEENT: Unremarkable other than the fact that an ET tube was in place. HEART: Rhythm is regular. There are no cardiac murmurs. No S3 or S4 is present. ABDOMEN: Soft and nontender, normal bowel sounds, no masses or hepatomegaly are present.
ET|endotracheal|ET|177|178|PHYSICAL EXAMINATION|Mechanical ventilator settings: Tidal volume 500, FiO2 30%, rate of 12, PEEP of 5, minute ventilation of six liters. GENERAL: Awake and alert. HEENT: There is some blood in the ET tube. NECK: Supple, nontender. LUNGS: Inspiratory squeaks with coarse breath sounds bilaterally. HEART: Normal S1 and S2. Regular rate and rhythm. ABDOMEN: Positive bowel sounds, soft, nontender.
ET|endotracheal|ET|222|223|PLAN|2. Increased respiratory rate to compensate for the metabolic acidosis, however, will need to try to improve cardiac output and blood pressure adequately, reduce acid production if this is even at all possible. 3. Advance ET Tube 2 cm. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 83-year- old female who developed chest pain last evening at the nursing home.
ET|endotracheal|ET|182|183|EVALUATION OF LABORATORY|Today, his hemoglobin is 8.8. His electrolytes are normal with a potassium of 4.6 and bicarbonate 24. His chest x-ray this morning by my reading shows a markedly enlarged heart. His ET tube is probably too far down, and we will pull this back. He has a central line in place. He has a left upper lobe infiltrate.
ET|enterostomal therapy|ET|167|168|ASSESSMENT AND PLAN|3. GI. Unsure of last BM. Rectal check with Dulcolax suppository if positive. Continue to monitor bowel status, especially with narcotic orders. 4. Multiple decubiti. ET NR unsure of ability to save left hand with current measures, continue antibiotics and dressing changes. Will discuss goals of care with guardian and social worker.
ET|endotracheal|ET|224|225|EXAMINATION|He is afebrile. HEENT: Normocephalic, atraumatic. His pupils are fixed and dilated approximately 5 mm. No evidence of doll's eyes. Sclerae non-icteric. Conjunctivae not injected. External auditory canals are patent. An oral ET tube is in place. NECK: Supple. CHEST: Has decreased breath sounds in the bases but generally clear. CARDIOVASCULAR: Regular but bradycardic. ABDOMEN: Benign, soft, and nontender. EXTREMITIES: Without significant cyanosis, clubbing, and edema.
ET|enterostomal therapy|ET|213|214|IMPRESSION|This could be treated with oral antifungals for cosmetic reasons but at this point I would not pursue treatment just for cosmetic reasons. He does have early left medial ankle ulceration for which I would ask the ET nurse to get involved and I would put him on empiric antifungal foot powder for now.
ET|endotracheal|ET|155|156|HISTORY OF PRESENT ILLNESS|911 was called. Apparently at the scene she was noted to be pulseless and an ET tube was placed and pulse returned after administering epinephrine via the ET tube. Since her admission to the hospital she remains unresponsive to verbal stimuli. She does require mechanical ventilation. She has been noted to withdraw to painful stimuli.
ET|endotracheal|ET|181|182|CLINICAL HISTORY|There are no contractures at the knees. Neurologic examination finds her to be unresponsive. There is no response or sign of response to noxious stimuli, to the corneas, moving the ET tube, or compression over the supraorbital ridge or the fingers. Her pupils are 3 mm going to 2 mm. The eyes are dysconjugate and show slow movement with a doll's eye.
ET|endotracheal|ET|126|127|NECK|No bowel sounds. Soft. EXTREMITIES: Trace edema at the ankles bilaterally. Chest x-ray shows some left base infiltrate in the ET tube. LABORATORY DATA: Electrolytes are normal except for a slightly low potassium at 3.3, glucose 231.
ET|endotracheal|ET.|160|162|PHYSICAL EXAMINATION|HEENT: Normocephalic and atraumatic. PERRLA. Sclera non-icteric. Conjunctiva not injected. External auditory canals and nares are patent. He has an NG and oral ET. Neck is thick but supple. Jugular venous distention is not discernible. CHEST: Chest has decreased breath sounds bilaterally at the bases.
ET|endotracheal|ET|194|195|CHEST X-RAY|The skin is benign. Neurologic: The patient is somnolent but alerts and seems oriented. Affect is normal. CHEST X-RAY: There appear to be diminished lung volumes even on the ventilator with the ET tube in place. The initial chest x-ray may show some cephalization, but this may be due to the lung volume status. I do not actually see significant amounts of fluid or pulmonary edema.
ET|endotracheal|ET|201|202|HISTORY OF PRESENT ILLNESS|She had surgical repair done on _%#MMDD2005#%_ and did well initially, but subsequently developed hypoxia,... and respiratory failure, aspiration pneumonia, DVT, and possible small PE. She did have an ET tube placed, but was never put on the ventilator because after the ET tube was placed, it was found to be DNR/DNI, and apparently it was elected to keep the ET tube in.
ET|endotracheal|ET|86|87|HISTORY OF PRESENT ILLNESS|She did have an ET tube placed, but was never put on the ventilator because after the ET tube was placed, it was found to be DNR/DNI, and apparently it was elected to keep the ET tube in. She since has recovered from that, and the ET tube was removed this morning, and she has tolerated that well.
ET|endotracheal|ET|185|186|EXAMINATION|GU: Shows female genitalia. EXTREMITIES: Without cyanosis, clubbing or significant edema. NEUROLOGIC: Nonfocal. Most recent labs - 144, 0.99, 37, 34 and 1.2. BNP 718. Chest x-ray shows ET tube and new right subclavian central line in place.
ET|endotracheal|ET|190|191|PHYSICAL EXAMINATION|GENERAL: He is intubated and sedated, but does not appear to be in distress. He can follow commands. HEENT: PERRL, EOMI. I cannot visualize his oropharynx because of the fact that he has an ET tube in. NECK: He has a right IJ line. No JVD, no carotid bruits, no cervical adenopathy. LUNGS: Clear to auscultation, he is mechanically ventilated. CARDIOVASCULAR: Regular with no murmurs, rubs or gallops.
ET|enterostomal therapy|ET|170|171|GOALS OF CARE|We will discuss this at length today and clarify this today. She does tell us that she wants her husband to be comfortable. 2. I agree with a Psychiatric consult and the ET wound nurse consult as you have done. Benzodiazepines may be over-sedating in this patient given his exam today. However, there has been some difficulty managing his agitation in the past.
ET|enterostomal therapy|ET|195|196|GOALS OF CARE|I agree with your idea of trying Haldol for his agitation and having Psychiatry give us better long-term solutions as he has tried several medications already. He has no apparent pain issues. An ET wound nurse will evaluate his current bed sore. I agree with NPO status for safety now, and would give him a trial of wash-out from his benzodiazepines to see if he can attempt having a safe swallow in the near future.
ET|endotracheal|ET|231|232|PHYSICAL EXAMINATION|FAMILY HISTORY: Not obtainable. REVIEW OF SYSTEMS: Not obtainable. PHYSICAL EXAMINATION: Vital signs - blood pressure in the range of 110-130 systolic, pulse 90, febrile to 102, respiratory rate 20, intubated. She has an NG and an ET tube. She is noted to have a right IJ triple lumen catheter and two right femoral lines, including an arterial line and a venous line.
ET|enterostomal therapy|ET|192|193|PHYSICAL EXAMINATION|Sensation appears to be intact to light touch. Patient has a number of developing decubiti and pressure sores over the left hip and coccyx. These will be attended to by _%#NAME#%_ ______, the ET nurse. LABORATORY EVALUATION: Reveals a sodium of 158, potassium of 3.4, chloride 117, CO2 35, creatinine 1.4, BUN 55, glucose 227, WBC 9.6, hemoglobin 13.8. INR .97. Urinalysis reveals 100 mg/dL of protein, negative nitrites, large leukocyte esterase, greater than 100 WBCs per high powered field.
ET|endotracheal|ET|202|203|OBJECTIVE|OBJECTIVE: VITAL SIGNS: Blood pressure 75/62, pulse is 113, oxygen saturation with the ventilator is 83-89%. No facial grimace, no leg movement and no vocalizations obviously with the vent in, but with ET tube in. He is not responding right now and has very little sedation on board. No mottling to his lower extremities. No movement in his legs.
ET|enterostomal therapy|ET|194|195|RECOMMENDATIONS|RECOMMENDATIONS: 1. Dependent mobility: continue physical therapy as you are. 2. Dependent activities of daily living: continue occupational therapy as you are. 3. Ostomy management: agree with ET nursing. DISPOSITION: The patient has had difficulty managing the ostomy, and has had several leaks since his surgery.
ET|enterostomal therapy|ET|159|160|PHYSICAL EXAMINATION TODAY|ABDOMEN: Soft. No distention. EXTREMITIES: 3+ edema of his left lower leg and 1+ of his right lower leg. Scrotum is erythematous. SKIN: There is breakdown per ET nurse. He was not rolled per his request. NEUROLOGICAL EXAM: Partial quad. Minimal movement of legs. Some movement of gross motor of his upper extremities.
ET|endotracheal|ET|191|192|PHYSICAL EXAMINATION|I&Os demonstrate adequate urine output, and through today's first shift they were 692 in and 1885 out, suggesting diuresis without diuretic. HEENT: Normocephalic, atraumatic. She has an oral ET tube in place. Sclerae are anicteric. Conjunctivae are noninjected. External auditory canals and nares appear patent. NECK: Thin. Accessory muscles are not markedly hypertrophied. CHEST: Good air movement.
ET|endotracheal|ET|143|144|DATA|4. Aspirin 81 mg p.o. q. day 5. Glyburide 2.5 mg p.o. q. day 6. Diet is honey-thickened liquids DATA: Chest x-ray shows severe osteopenia. The ET tube is just above the right mainstem. There appears to be some hazy opacity over the left. ABG 7.39/34/108/21 on 55% O2 on mechanical ventilator. White blood cell count 7700, hemoglobin 11.7, hematocrit 34.2, bicarb 19, anion gap 13.
ET|endotracheal|ET|210|211|HISTORY OF PRESENT ILLNESS|It was however, noted that she was having a fever at the beginning of the case and when she was at the end of the case, she was being extubated and it was noted that she had purulent secretions coming from her ET tube. She also was hypoxic and had a high respiratory rate following the case. Prior to the surgery, she had denied any cough but did have a little bit of shortness of breath.
ET|endotracheal|ET|198|199|PHYSICAL EXAMINATION|HEENT: Normocephalic, atraumatic, pupils are quite small but reactive. Arcus is present. Sclerae nonicteric. Conjunctiva not injected. External auditory canals and nares are patent. She has an oral ET tube. Neck is without jugular venous distention. She has prominent sternocleidomastoids and evidence of muscular wasting with prominent strap muscles around her neck.
ET|endotracheal|ET|264|265|IMPRESSION|3. Vent dependent on the basis of need for airway protection with current vent settings of CMV 12, tidal volume 600, PEEP of 5, and 50% FiO2. Previous blood gas on 100% was 7.0, 34, 532, and 100% saturation. Her chest x-ray shows no evidence of infiltrates and an ET tube in good position above the level of the carina. 4. Myoglobinemia secondary to muscle cell injury on the basis of seizure with a documented myoglobin up greater than 2000.
ET|endotracheal|ET|164|165|PHYSICAL EXAMINATION|HEAD: Normocephalic/atraumatic. EYES: Pupils are equal and round. Lids and sclerae are normal. OROPHARYNX: No thrush or exudate noted. Voice is hoarse secondary to ET tube. NECK: Not examined due to cervical collar placed after surgery. LUNGS: Clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm.
ET|endotracheal|ET|180|181|IMPRESSION|Her current vent settings are a CMV of 50%, respiratory rate 14, tidal volume 650, 5 of PEEP. Her sats are 98%. Chest x-ray by report was without evidence of infiltrate and showed ET tube in adequate position. 3) Apparent history of seizure disorder, followed at the VA Medical Center. 4) Question of seizure out of hospital; some concern regarding whether these represent two true generalized tonic clonic seizures.
ET|enterostomal therapy|ET|242|243|IMPRESSION|Obviously, holding her diuretics is indicated. In regards to the patient's foot ulcerations, I suspect these are on the basis of peripheral vascular disease and irritation from her shoes. They clearly do not appear infected. I would have the ET nurse come by to recommend dressing changes. The patient could have peripheral arterial disease evaluation as an outpatient. Once the patient's blood pressure has improved, will ambulate her and work on disposition.
ET|endotracheal|ET|264|265|PHYSICAL EXAMINATION|He is ventilated, sedated. GENERAL: Unresponsive. HEENT: Normocephalic, atraumatic. Pupils equal, round, reactive to light and accommodation. Extraocular muscles intact, sclerae nonicteric, conjunctiva not injected. External auditory canals and nares patent. Oral ET tube. NECK: Supple. CHEST: Decreased breath sounds. CARDIOVASCULAR: Regular. Balloon pump is audible. ABDOMEN: Quiet GU: Male genitalia, Foley catheter in place.
ET|enterostomal therapy|ET|202|203|PLAN|We will consult Speech as needed. 3. Bowel. We placed her on a mild bowel program. Rehab nursing. 4. Bladder. We will check postvoid residuals and straight catheterization for PVRs more than 300 cc. 5. ET nurse for the abdominal wound and incision care. 6. History of bilateral upper extremity deep vein thromboses. Continue Lovenox for DVT prophylaxis.
ET|endotracheal|(ET)|166|169|PHYSICAL EXAMINATION|Extraocular muscles are intact. Sclerae: Anicteric. Conjunctivae are not injected. Arcus is present. External auditory canals and nares are patent. Oral endotracheal (ET) tube. NECK: Supple. CHEST: Chest has good air movement. ABDOMEN: Soft and nontender. EXTREMITIES: No cyanosis, clubbing or edema.
ET|endotracheal|ET|152|153|GENERAL|EYES: Somewhat swollen and held tight. The sclera and conjunctiva are clear. The ears are normally placed. The nares are patent. There is no discharge. ET tube is in place. A umbilical venous catheter is in place. LUNGS: Clear to auscultation bilaterally. CARDIOVASCULAR: Normal S1 and S2.
ET|endotracheal|ET|192|193|PHYSICAL EXAMINATION|Oxygen saturation 98. Weight 2.64 kg and 35 cm. HEENT: The anterior fontanelle slightly full. This is positional. The ears are normally formed. Sclerae and conjunctivae are clear. There is an ET tube in place. There is hair on the ears. The neck cannot be fully appreciated. Chest is open. Heart sounds are normal.
ET|endotracheal|ET|361|362|PHYSICAL EXAMINATION|ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature maximum is 102.0, temperature current is 98.4; respiratory rate 16; pulse 123; blood pressure 92/58; her CVP is 10; oxygen saturations at 97 to 98% on 0.3 FiO2; her dry weight is 19 kilograms. GENERAL: She is intubated, sedated, although moves slightly with examination. HEENT: ET tube is in place, OG is in place, conjunctivae are clear. Lips are without any lesions. NECK: No lymphadenopathy. LUNGS: Symmetric air entry, coarse breath sounds bilaterally.
ET|endotracheal|ET|178|179|PHYSICAL EXAMINATION|His heart rate is 80 and irregular. HEENT: Normocephalic, atraumatic. Pupils equal, round, react to light and accommodation. Extraocular muscles intact. Sclerae nonicteric. Oral ET tube. NECK: Supple, with a left IJ catheter in place. CHEST: Good air movement. CARDIOVASCULAR: Rhythm is regular, paced. ABDOMEN: Soft and nontender.
ET|endotracheal|ET|208|209|PHYSICAL EXAMINATION|HEENT: Normocephalic, atraumatic, pupils are pinpoint. His sclera and lids are normal, conjunctiva appear normal. External auditory canals appear patent. He has a nasal trumpet in his right naris and an oral ET tube. Pharynx is not visualized. Neck is thick, unable to asses jugular venous distention. CHEST: Chest is also quite thick with a difficult exam, but he is moving adequate air by anterior exam.
ET|endotracheal|ET|201|202|HISTORY|Eventual decision was made to proceed with gastrectomy and vagotomy and this was done on _%#MMDD2002#%_. The operative findings included no signs of infection or similar problems. Postoperatively, the ET tube was in place. There was no definite infection or preop obvious major respiratory problem. She has had a history of some asthma and has had recurrent pneumonias previously as well.
ET|enterostomal therapy|ET|138|139|PHYSICAL EXAMINATION|EXTREMITIES/NEUROLOGIC: Multiple sclerosis changes neurologically and some mental status changes occurring. The IT ulcers as described by ET nurse. LABORATORY: White count currently in the 3000s. She has been as low as 1500-1700 previously, with a bone marrow being negative.
ET|endotracheal|ET|142|143|PHYSICAL EXAMINATION|His CVP is in the range of 5-7. His I's and O's yesterday were noted at 6451 in and 1470 out. Today they are 1170 in and 355 out. HEENT: Oral ET tube. Normocephalic, atraumatic. Pupils are small but reactive. There is no is no icterus. Conjunctivae not injected. There is mild arcus. He has hearing aids in place.
ET|endotracheal|ET|256|257|LABORATORY  DATA|Peripheral pulses are normal. NEUROLOGIC: He is sedated with propofol, although when it is reduced, he appears to move his upper extremities spontaneously and open his eyes. LABORATORY DATA: CT scan results are as reported above. The chest x-ray shows the ET tube in appropriate position. Lung fields are clear heart appears to be normal size. Most recent ABG's are as follows: pH of 7.42, pCO2 of 37, pO2 of 122, bicarbonate 24, O2 sat 96%.
ET|endotracheal|ET|149|150|PHYSICAL EXAMINATION|Nasal and oral mucosa are pink, with some mild swelling with the ET tube in his mouth. NECK: Supple. No detectable masses. No range of motion due to ET tube and unresponsiveness. LUNGS: A slight bit of coarseness in the bases of his lungs but relatively clear throughout other fields.
ET|endotracheal|ET|127|128|EXAMINATION|EXAMINATION: GENERAL: Middle-aged, and not acutely ill-appearing female, resting comfortably, with an NG tube in place, and an ET tube. She is sedated. She does arouse, by report from the nursing staff. HEENT: Normocephalic, atraumatic. Pupils are small, but reactive. There is no scleral icterus.
ET|endotracheal|ET|260|261|PHYSICAL EXAMINATION|GENERAL: Cachectic, chronically ill-appearing female. HEENT: Normocephalic, atraumatic. Pupils equal, round, react to light and accommodation. Arcus is present, there is no scleral icterus. External and auditory canals and nares appear patent. She has an oral ET tube and her pharynx is dry. NECK: Supple, JVD is not discernible. CHEST: Decreased breath sounds bilaterally, predominantly in the bases.
ET|endotracheal|ET|209|210|PHYSICAL EXAMINATION|This is just a homogeneous mass. The larynx and the trachea have some shifting to the right but laryngeal landmarks like the thyroid and cricoid cartilage are palpable. Oral cavity exam was limited due to the ET tube but revealed a soft base of tongue and floor of mouth to palpation, and no lesions, and no bleeding. After adequate decongestion with Afrin spray, a flexible scope was passed through the left nasal cavity to the posterior nasopharynx which was clear.
ET|pressure equalization:PE|ET|139|140|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Psychiatric history. This is per Dr. _%#NAME#%_. 2. Status post bilateral ear surgery as a child. The patient had ET tubes placed that tore through his tympanic membrane, and the patient required surgery to repair the damage. The patient has a history of hearing loss. 3. Status post car accident in _%#MM200_#%_.
ET|endotracheal|ET|153|154|PHYSICAL EXAMINATION|Sclera anicteric. Conjunctiva not injected. Obviously arcus is not present given her age. External auditory canals and nares are patent. She has an oral ET tube. Her pharynx was not well-visualized. NECK: Supple. The right anterior triangle demonstrating the catheter as I noted. Her chest shows some increased breath sounds and a few basilar crackles but otherwise good air movement.
ET|endotracheal|ET|185|186|PHYSICAL EXAMINATION|She is currently intubated. VITAL SIGNS: Pulse 120, blood pressure currently running in the 100 range on pressors. Temperature 101.8 degrees. HEENT: No thrush or oropharyngeal lesions. ET tube in place. NECK: Neck is supple and nontender. HEART: Tachycardic. No significant abnormalities. LUNGS: Lungs are clear bilaterally. ABDOMEN: Abdomen is soft and nontender including the lower abdominal area but she has been on propofol.
ET|endotracheal|ET|127|128|DATA|The patient's mother died at the age of 97 with lung cancer. DATA: Chest x-ray shows extensive bilateral alveolar infiltrates. ET tube is in left mainstem bronchus. PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile, pulse 89, respiratory rate 24, blood pressure 79/53, SPO2 of 97%.
ET|endotracheal|ET|201|202|PHYSICAL EXAMINATION|She has down-slanting palpebral fissures, low set posterior rotated ears of normal size. The eyes are slightly bulbous, rather prominent, with flattening of the maxilla. Nares are normally formed. The ET tube blocked the oropharynx. Teeth are present. Jaw appears normal size. She has normal hair texture. The neck is supple. She has severe S-shaped scoliosis. Lungs are clear bilaterally.
ET|endotracheal|ET|167|168|IMPRESSION|Family was present and 911 was called. After 20-25 minutes of attempted resuscitation the patient developed a rhythm. The patient was intubated and is now in ICU with ET tube in place and to oxygen. 2. 12-year history of breast cancer with several courses of therapy. The patient had been declining the last few days. No hospice was involved.
ET|endotracheal|ET|176|177|LABORATORY|Blood gas from yesterday after surgery 7.32/93/56/29. Chest x-ray from _%#MMDD2004#%_ shows left lower lobe atelectasis and small left pleural effusion. Swan-Ganz catheter and ET tube were seen. ECG from _%#MMDD2004#%_ at 1408 hours shows sinus rhythm and a QS complex from V1 to V3 with small Q waves in V4 and V5 and small Q wave in lead II.
ET|enterostomal therapy|ET|172|173|IMPRESSION|My recommendation would be to continue the antibiotics with elevation and diuretics. I would recommend wrapping his leg with an ACE wrap and continue wound care as per the ET nurse. The patient should have a followup set up with Dr. _%#NAME#%_ of the _%#CITY#%_ Vascular Institute as an outpatient. We will see as needed.
ET|endotracheal|ET|154|155|PHYSICAL EXAMINATION|He does take a beta blocker, as I noted above. GENERAL: The patient is on a ventilator. Settings and sats were previously reviewed. He is intubated (oral ET tube), sedated, and in no overt distress. HEENT: Normocephalic, atraumatic. Pupils are equal, round and reactive to light and accommodation, smallish.
ET|endotracheal|ET|96|97|PHYSICAL EXAMINATION|The ears are mildly low set. I believe he has tape a taper on his mouth or epicanthal folds. An ET tube is in place. NECK: Has no webbing or masses. LUNGS: Clear. HEART: Heart sSound has no murmur that I could appreciate.
ET|endotracheal|ET|528|529|IMPRESSION|He has a severe anoxic encephalopathy. I do not know how long he was out in the field with intermittent perfusing rhythm but it took us in the emergency room at least 20 minutes with CPR to return a perfusing rhythm which is either sinus rhythm, sinus tachycardia or atrial fibrillation, it is very hard to see on the monitor. I think the differential includes pulmonary embolism, not likely, but he did complain about shoulder pain, his RV is somewhat generous but decreased RV function and he also has blood coming out of the ET tube, although that certainly could have been secondary to CPR and the intubation rather than a pulmonary infarction or hemorrhage.
ET|endotracheal|ET|190|191|PROBLEM #8|After again discussion with the family and the husband who is a primary decision maker decided to withdraw support. We did allow family to visit with the patient prior to the removal of the ET tube. The patient's ET tube was removed approximately at 12:08, her saturations immediately started to fall. She took no spontaneous breath of her own. Secondary to hypoxia, her heart rate continued to decrease until there was no palpable or audible heart rate.
ET|enterostomal therapy|ET|215|216|LABORATORY DATA|She was placed on neutropenic precautions. Gentamicin and Ancef were started and the patient received 2 large Bohr IV's. A Foley catheter was placed secondary to incontinence and peri-cares including whirlpools and ET nursing were started on the area of vulvar breakdown. Urine and blood cultures were obtained. HOSPITAL COURSE: PROBLEM #1: Disease.
ET|enterostomal therapy|ET|126|127|OPERATIONS/PROCEDURES PERFORMED|She received Monday, Wednesday, and Friday hemodialysis for the remainder of the hospital stay. 3. Leg wounds and ulcers: The ET nurse was consulted for care of these wounds. The nurse's assessment showed necrotic hematoma of the left leg secondary to old fall and some other complicating processes.
ET|enterostomal therapy|ET|177|178|HOSPITAL COURSE|She returned to the OR on _%#MMDD2006#%_ and _%#MMDD2006#%_ for further debridements of the region of gangrene. Since then, her wound has been managed with large wound vac. Our ET nurses have been following her to see that the wound vac has remained intact throughout her hospital course. There have been some issues with her chronic diarrhea and being unable to manage her stools.
ET|enterostomal therapy|ET|151|152|IMPRESSION AND PLAN|b. Open wound secondary to his Jackson trach. I will order wound care as written, half-strength hydrogen peroxide and normal saline, and also have the ET and wound nurse evaluate in case she has further suggestions. c. Decubiti ulcer on the coccyx. Tegasorb dressings at this time, and the patient is to minimize time on his back side.
ET|enterostomal therapy|ET|192|193|PROBLEM #3|PROBLEM #3: Gastrointestinal. The patient had copious amounts of diarrhea, approximately 3 to 4 L per day. He did have discomfort and skin breakdown with his diarrhea. He was evaluated by the ET nurse, and special cleansing and protective measures were taken. The patient will continue these as an outpatient. In terms of the diarrhea, loperamide and octreotide were tried.
ET|enterostomal therapy|ET|216|217|PLAN|In the meantime, will treat her with nebs as needed, also will give her some Tylenol #3 for analg esia as needed. I am hesitant to use any stronger narcotics given her marginal respiratory status. Will also have the ET nurse see her tomorrow regarding her leg wounds. In the meantime, will treat these with Silvadene and gauze and Levaquin as mentioned above.
ET|enterostomal therapy|ET|169|170|ASSESSMENT AND PLAN|Hemoglobin is stable at 10.1 and likely that she has had profuse bleeding from this wound surface, so we will continue to monitor hemoglobin. We will also be placing an ET Wound Nurse consult as well as a Plastic Surgery consult. 2. End-stage renal disease: The patient dialyzes ...??... Mondays, Wednesdays and Fridays.
ET|enterostomal therapy|ET|133|134|PROBLEM #1|Colostomy appears to be functioning appropriately. The patient also has gastrostomy tube for feeding purpose. He will be seen by the ET nurse in the a.m. for wound and colostomy care. He will follow up with his surgeon after discharge from acute rehab.
ET|endotracheal|ET|124|125|PHYSICAL EXAMINATION|Ears, tympanic membranes are clear bilaterally with light reflex without any erythema. Nose has no rhinorrhea. Mouth has an ET tube. NECK: No masses. No adenopathy on palpation. LUNGS: Clear to auscultation bilaterally. No wheezing, no crackles and no stridor.
ET|enterostomal therapy|ET|152|153|OPERATIONS/PROCEDURES PERFORMED|3. Multiple abdominal wounds: We did continue usual cares for her abdominal wounds and had the ET nurse see the patient during her hospitalization. The ET nurse did recommend that the patient have 3M nonadhesive (_______________) foam placed over her superficial wounds. She also recommended continued packing with NuGauze moistened with clinical care spray to the other abdominal wounds.
ET|enterostomal therapy|ET|136|137|HOSPITAL COURSE|Eventually it was decided, on postop day #18, that the patient may benefit from wound vac placement. This was subsequently performed by ET nursing. There was some concern, at the time the wound vac was placed, about the patient's low albumin. However, following placement of the wound vac, the patient's wound did appear to be contracting and remaining clean.
ET|enterostomal therapy|ET|159|160|ASSESSMENT AND PLAN|Erythromycin might actually help if she does not have an actual allergy to it. 5. Skin care. I will provide an antifungal cream to her stomach and her thighs. ET nursing is going to see her about her decubitus ulcers. 6. Hypercalcemia. This is strange as it is new for her. There is some concern about some lysis of the bones.
ET|enterostomal therapy|ET|214|215|ASSESSMENT AND PLAN|Her recent cultures have been Clostridium difficile negative. Will have to continue to monitor this as she is easily dehydrated. 3. Stage III pressure coccyx wound: This was not directly visualized today. However, ET nursing will be seeing the patient, and I will look at the wound later this afternoon. 4. Complications of end-stage liver disease, including varices and recurrent ascites with associated encephalopathy, are being managed: Her ascites does not appear to be tense at this time, and she does not need paracentesis.
ET|enterostomal therapy|ET|238|239|DISPOSITION|We will draw a CMP and some coag studies prior to Dr. _%#NAME#%_'s appointment, as the patient will have a colonoscopy prior to discharge and prior to the appointment with Dr. _%#NAME#%_. 7. Bilateral venous stasis ulcers. Please see the ET RN's note. The patient will follow up on _%#MMDD#%_ with the Vascular Clinic and continue with dressing changes here. 8. Chronic renal insufficiency. Creatinine today is 1.5, which is improved.
ET|endotracheal|ET|153|154|HISTORY OF PRESENT ILLNESS|There had been no ill contacts in the home. She was taken to Fairview _%#CITY#%_ ED, where she was noted to be tachypneic, tachycardic, and cyanotic. An ET tube was placed, venous access was attempted and unsuccessful, and an intraosseous line was placed. She was given a 20-mL/kg normal saline bolus and Rocephin and was emergently transferred to the pediatric intensive care unit.
ET|endotracheal|ET|188|189|DISCHARGE DIAGNOSIS|CODE STATUS: Full. PHYSICAL EXAMINATION: Temperature 99.3, pulse 37. The patient was intubated. General: Alert, intubated, responds appropriately, obese. HEENT: Normocephalic, atraumatic. ET tube in place. Cardiovascular: Regular rate. Frequent premature contractions. JVP unable to assess. Lungs: On ventilator, bibasilar crackles. Exam difficult due body habitus.
ET|enterostomal therapy|ET|153|154|HOSPITAL COURSE|Right lateral malleolus pressure ulcer 1.5 x 1 with red base, macerated edges (stage 3 pressure ulcer). ET nurse was consulted for wound care. The final ET wound nurse recommendation were as follows, a. Right lateral malleolus: Apply regular dressing, heel lift boots to right leg. b. Skin breakdown in the natal cleft, left buttock: Cleanse with Baza, cleanse and protect, apply thick layer Critic-Aid Clear Barrier Cream every 2-4 hours as needed, turn off back every 2 hours.
ET|enterostomal therapy|ET|111|112|DISCHARGE INSTRUCTIONS|During pouch cleaning, the wound should be cleaned with a clinical care spray (wound cleanser). Any outpatient ET nursing follow-up can be accessed by calling _%#TEL#%_. 5. The stoma is unmatured, so the majority is covered with yellow rough tissue.
ET|enterostomal therapy|ET|274|275|HOSPITAL COURSE|4. Dermatology: During _%#NAME#%_'s stay, it was noted that he was developing a right lateral malleolus pressure sore that progressed to become a solitary 1 x 1-cm fluid-filled vesicular lesion with an erythematous surrounding base. He was placed on a course of Keflex, and ET nurse consult was obtained. The wound care nurses left recommendations that primarily centered around vigilance and strict pressure release from this ankle and also his heels.
ET|enterostomal therapy|ET|166|167|ASSESSMENT/PLAN|8. Failure to thrive. We need to investigate her home care services and her family support. This is likely multifactorial. 9. Areas of skin breakdown and ulcers. The ET nurse will be evaluating the patient. We are going to put her on an air mattress, and take all precautions with frequent turning.
ET|enterostomal therapy|ET|137|138|FOLLOW-UP|3. The patient should follow up with Dr. _%#NAME#%_ _%#NAME#%_, her primary care physician, in one week. 4. She should be followed up by ET nursing for decubitus ulcers. 5. She has been followed by Vascular Surgery for her venous stasis ulcers. This should be continued per her prior schedule. 6. She should be evaluated and treated by both PT and OT to maximize her rehabilitation.
ET|enterostomal therapy|ET|241|242|IMPRESSION|16. Hypertension. The patient was admitted to University of Minnesota Medical Center, Fairview Transitional Care Unit for continuation of medical care, wound care, and rehab. For nonhealing abdominal wound will continue wound vac and obtain ET nurse for wound care. JP drain will be kept. Ostomy in place until see by surgical team and transplant team. For continuing immunosuppressive medications for kidney-pancreas transplant with Prograf, _%#NAME#%_ will be held at this point until transplant team okays resumption of medication.
ET|enterostomal therapy|ET|133|134|PROBLEM #8|This will be continued at discharge. On _%#MMDD2005#%_ there was a red-pink dime-sized spot with a scab found on the patient's back. ET nursing assessed this. A Gaymar mattress was ordered and ulcer protocol was initiated. PROBLEM #9: Orthopedic. The patient had noted a history of hip fractures.
ET|enterostomal therapy|ET|141|142|CONSULTATIONS|6. Neurology Service was consulted for altered mental status. 7. Ophthalmology was consulted to evaluate for ophthalmic candidal disease. 8. ET Wound Nursing Service was consulted for stage 1/2 pressure ulcers. HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old woman with a history of pancreas/kidney transplant in 1998, coronary artery disease, and hypertension.
ET|enterostomal therapy|ET|121|122|PROBLEM #9|Finally, Norflex b.i.d. was prescribed and made a marked improvement in her pain. PROBLEM #9: Stage 1/2 pressure ulcers. ET Nursing was consulted and made recommendations, including every other day saline cleansing, and cleansing p.r.n., then apply RepliCare dressing.
ET|enterostomal therapy|ET|173|174|PLAN|4. CODE STATUS: Full code. 5. Constipation: We will continue Senokot and Colace p.r.n. and give Fleet enema or Dulcolax p.r.n. if needed. 6. Tegaderm to sacro-coccyx wound, ET nurse to evaluate.
ET|endotracheal|ET|175|176|PROBLEM #2|Electrolytes were normal at Ridges. These were repeated the following morning and, again, were normal. PROBLEM #2: Respiratory. His chest x-ray showed normal placement of the ET tube, and lungs were, otherwise, unremarkable. Blood gas on admission here was 7.40 with a pCO2 of 45 and a pO2 of venous. He was weaned off his vent rather quickly and extubated the following night.
ET|endotracheal|(ET)|217|220|PHYSICAL EXAMINATION|Will get blood gas. GENERAL: The patient is sedated and not responding to verbal stimuli or painful stimuli. HEENT: Eyes: Pupils are equal and reactive bilaterally. Gaze is towards the right side. Mouth: Endotracheal (ET) intubation. NECK: No neck vein distention. LUNGS: Air moves bilaterally clear anteriorly. HEART: Regular. No gallop or rub rhythm. ABDOMEN: Soft without distention.
ET|enterostomal therapy|ET|149|150|ASSESSMENT/PLAN|The patient had been on Nystatin previously for this rash and some fungal cream, although it does not appear that it has helped much. We can consult ET nursing to evaluate the patient for further recommendations. 4. Anxiety: Continue Ativan p.r.n. 5. Cardiomyopathy: History of ejection fraction of 50%.
ET|endotracheal|ET|175|176|5. ID|Vancomycin therapy was continued for 2 weeks past last positive culture. Tracheitis - ET aspirate from _%#MMDD2002#%_ grew Klebsiella pneumoniae and Neisseria species. Repeat ET culture _%#MMDD#%_ grew Klebsiella and Enterobacter. He was treated with Cefotaxime for 7 days. Due to increased stool output, stool studies were sent on _%#MMDD#%_ and were negative for C. difficile toxin and culture.
ET|enterostomal therapy|ET|149|150|ASSESSMENT AND PLAN|6. Anemia, hemoglobin is stable. This appears to be chronic. We will check a serum iron, B12 and folate. 7. Lower extremity ulcers. We will have the ET RN see him and appropriate wound care. Once they area able to get him in the bed we will need to check these to check for any evidence of infection.
ET|enterostomal therapy|ET|221|222|IMPRESSION AND PLAN|IMPRESSION AND PLAN: 1. Multiple anal fistulas with subcutaneous extension, had fistulotomy, debridement, marsupialization, sigmoid colostomy, and Hartmann pouch on _%#MMDD2005#%_: Will continue dressing changes and have ET nurse see patient and make recommendations. 2. Myocardial infarction in _%#MM2004#%_ with multiple sequelae including above. 3. Coronary artery disease/CHF/hypertension/atrial fibrillation: Will continue torsemide, Lipitor, aspirin, and diltiazem.
ET|enterostomal therapy|ET|160|161|CONSULTS|3. Drain cultures. 4. Cultures from the patient's bilateral drains placed at the time of her surgery on _%#MMDD2007#%_. COMPLICATIONS: None apparent. CONSULTS: ET wound care consult for wound VAC placement. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is an 82-year-old with stage III grade I squamous cell carcinoma of the vulva who presented on _%#MMDD2007#%_ on postop day #15 from her staging procedure with complaint of greenish brownish discharge from the right groin.
ET|enterostomal therapy|ET|194|195|PHYSICAL EXAMINATION|ABDOMEN: Soft, nontender, nondistended with positive bowel sounds throughout. EXTREMITIES: The patient has bilateral Ace wraps in place on lower extremities. Please see the note dictated by the ET nurse concerning current status of the bilateral lymphedema/cellulitis. The patient has done very well with therapies with significant healing in her wounds.
ET|enterostomal therapy|ET|232|233|HOSPITAL COURSE|She also had noted thrombocytosis of 966 and was started on 81 mg of aspirin on _%#MMDD2007#%_ and continued on this at discharge. 3. Genitourinary: The patient has a right PNT and nonfunctioning left kidney. On _%#MMDD2007#%_, the ET nurse was changing and cleaning the site of the right PNT and was noted to be concerned about the appearance of this site and the UA appeared infected therefore Interventional Radiology was consulted on _%#MMDD2007#%_ to change this right PNT.
ET|endotracheal|ET|226|227|HISTORY OF PRESENT ILLNESS|The spouse called 911. At the time of their arrival, O2 saturations were in the 60% range and she was intubated at the scene. She was brought to the emergency room, where she was reintubated for a problem with the cuff of the ET tube. At that time, she got vecuronium and propofol for sedation. She was noted to have some decreased loss of consciousness and head CT was obtained which was unremarkable for any acute bleeding.
ET|enterostomal therapy|ET|132|133|PHYSICAL EXAMINATION|6. Decubitus ulcer: The patient had a decubitus ulcer on her sacrum. There was two on either side of the sacrum, each about 2-3 cm. ET was following her for that, and she received bacitracin ointment with a Tegaderm dressing. On the day of discharge, the patient had developed black necrotic tissue around the wound on the right side.
ET|enterostomal therapy|ET|203|204|PHYSICAL EXAMINATION|ET was following her for that, and she received bacitracin ointment with a Tegaderm dressing. On the day of discharge, the patient had developed black necrotic tissue around the wound on the right side. ET was consulted, and the patient was being discharged with morphine gel and also oral pain medication and had better pain control.
ET|enterostomal therapy|ET|164|165|HISTORY OF PRESENT ILLNESS|This was also followed by several bedside debridements. Eventually a wound vac was placed and this continues at this time, which will be followed by the wound care ET nurse here at this unit. The patient was also noted to have positive blood cultures early in the course of her hospitalization that were positive for strep pneumoniae .
ET|enterostomal therapy|ET|138|139|ASSESSMENT AND PLAN|C-difficile has not been checked for sometime, but she is also on metronidazole. Will check C-difficile. 8. Decubitus ulcer. Will consult ET nurse and follow their recommendations. Will consider different mattress and turn continuously. 9. Deconditioning. Will consult Physical Therapy and Occupational Therapy, and continue strengthening exercises.
ET|enterostomal therapy|ET|109|110|ASSESSMENT AND PLAN|The patient will be followed by Colorectal Surgery in 1-2 weeks. The patient in the meantime will be seen by ET team for colostomy care. The patient will follow up with Dr. _%#NAME#%_, Oncology, and Radiation Oncology in coming 1-2 weeks for neoadjuvant chemoradiation program.
ET|enterostomal therapy|ET|169|170|DISCHARGE INSTRUCTIONS|3. She is to see Interventional Radiology to assess the pelvic abscess at 7:40 a.m. on _%#MMDD2005#%_. 4. The patient learned some colostomy care while hospitalized, an ET nurse was required to help with this during her stay at the FUTS: A. Pelvic abscess Drain: She was told to flush the drain with 2 mg TPA and 20 cc normal saline as needed, up to 3x per day.
ET|enterostomal therapy|ET|153|154|CONSULTATIONS|10. Prophylaxis: The patient wore TEDs and pneumoboots while on bed. She was also on prophylactic Lovenox throughout her hospitalization. CONSULTATIONS: ET nursing was consulted for stoma teaching. DISCHARGE INSTRUCTIONS: 1. The patient has a followup appointment with Dr. _%#NAME#%_ in 2 weeks.
ET|enterostomal therapy|ET|154|155|HISTORY OF PRESENT ILLNESS|He was also seen to have ongoing headaches. CT scan showed active sinusitis. He was started on ciprofloxacin to manage this. There is question whether an ET consult would be helpful to evaluate with possible sinus aspiration whether this is treatment failure versus fungal in nature. In terms of his nutrition, his abdominal pain required a discontinuation and then slow resumption of his enteral feedings.
ET|enterostomal therapy|ET|213|214|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: Please see the formal discharge instructions for specifics including PICC care, trach care, G-tube care, Isosource HN at 65 mL per hour continuous tube feeds, stoma care as directed by the ET nurse. Physical therapy, occupational therapy, speech therapy to follow with recommendations. Weight bearing as tolerated. DISCHARGE MEDICATIONS: 1. Linezolid 600 mg IV q.24 h. 2. Fluconazole 400 mg per PEG q.24 h.
ET|enterostomal therapy|ET|237|238|ASSESSMENT AND PLAN|13. Deep vein thrombosis prophylaxis: We were unable to anticoagulate patient secondary to history of recurrent GI bleed on enoxaparin. We will use pneumoboots for DVT prophylaxis. 14. Sacral decubitus ulcer/Charcot foot: Wound care per ET nurse. 15. Neurology: The patient appears lethargic and sedated. He was not given any sedatives at _%#COUNTY#%_. He does not have any focal neurological deficit. We will get a head CT without contract to evaluate for intracranial bleed.
ET|enterostomal therapy|ET|97|98|PROBLEM #9|PROBLEM #9: Skin. She had severe excoriation to her p erirectal and perineal area. Skin care per ET recommendations were performed. She was encouraged to get out of bed and also had sitz baths. PROBLEM #10: Deconditioning. She is ambulating in the hallways and was assisted by physical therapy.
ET|enterostomal therapy|ET|179|180|PROBLEM #6|Serum calcium levels should be monitored, however, given apparent iatrogenic hypercalcemia at the time of admission. PROBLEM #6: Chronic skin ulcers. The patient was evaluated by ET nursing with specific recommendations regarding maintenance of skin integrity and avoidance of moisture and further breakdown. She should continue to have frequent position changes and would benefit from an air mattress.
ET|enterostomal therapy|ET|126|127|DISCHARGE MEDICATIONS|Patient is to follow up with me in the office in two to three weeks for a follow-up check and will continue to be followed by ET as necessary. As soon as he is recovered sufficiently, he will begin chemotherapy for his liver metastases. FINAL DIAGNOSES: 1. Recurrent rectal cancer with bilateral liver metastases.
ET|endotracheal|ET|103|104|LAB  DATA|His right is 5/5. Reflexes appear normal and symmetric. LAB DATA: Chest x-ray shows old defibrillator. ET tube appears well placed. There is some pulmonary vascular congestion. There is no infiltration. His admission arterial blood gas showed pH of 7.26, PC02 of 47, P02 of 233, bicarbonate of 21.
ET|enterostomal therapy|ET|335|336|PHYSICAL EXAMINATION|Blood glucoses have ranged from 101-117. Hemoglobin overall stable at 8.4. GENERAL: The patient is well developed, well nourished, no acute distress, alert and oriented x3, pleasant most of the time but can be very manipulative. SKIN: Warm and dry. Abdominal incision is healing well. Please see the complete date noted today from the ET nurse for complete details of the abdominal incision wound. LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm.
ET|endotracheal|ET|161|162|LABORATORY DATA|This is on room air. Intubated, his pH is 7.51, pCO2 18, pO2 246, bicarbonate 14. He is typed and screened. Blood cultures have been obtained. Chest x-ray shows ET tube in place. No infiltrates. There is pulmonary vascular engorgement. Salicylate less than 1. Lactate 2.3. Urine tox screen negative. Tylenol level negative. Urinalysis shows 2 white blood cells, 1 RBC.
ET|endotracheal|ET|135|136|PROCEDURES|On _%#MMDD#%_, the patient developed seizures and EEG at that time showed seizure activity and spikes. 5. Multiple chest x-rays follow ET tube and chest tube placement. 6. Blood products transfusions most recently got RBCs on _%#MMDD2007#%_. 7. BDs and nebs for atelectasis post extubation. 8. Leech therapy _%#MMDD#%_ to _%#MMDD#%_.
ET|enterostomal therapy|ET|173|174|CONSULTATIONS|CONSULTATIONS: Obtained throughout her hospital stay included: 1. Pain Service 2. Cardiovascular Service 3. Anesthesia Service 4. Hematology Service 5. Neurology Service 6. ET Nursing 7. PT and OT. PROCEDURES: 1. GU operative procedure as below. 2. Placement of a PICC line. 3. Multiple CT scans.
ET|enterostomal therapy|ET|171|172|BRIEF HISTORY OF PRESENT ILLNESS AND SUMMARY OF REHAB STAY|He does use a wheeled walker for ambulation. He has been receiving attention to his abdominal wound from his earlier surgery which has had a small open area requiring the ET nursing service follow. The open area has decreased in size and he continues to have a scant amount of serosanguineous drainage along a wick of Nu-Gauze dressing placed in the middle of the small open area which is in the middle of his midline incision.
ET|enterostomal therapy|ET|233|234|ASSESSMENT/PLAN|The patient will be closely monitored postoperatively. If required, we will give a beta blocker and treat her asthma adequately. The patient is on DVT prophylaxis with Lovenox 40 mg subcu daily. The patient needs chronic wound care. ET nurse involvement for her wound and urostomy evaluations. The patient may need short-term rehab admission after the surgery. The patient may need further surgery afterwards. 3. Osteomyelitis. We will continue her current antibiotic with Linezolid at 600 mg b.i.d. and Tequin 400 mg daily.
ET|enterostomal therapy|ET|125|126|PLAN|5. Hypertension, under good control. We will continue medications and continue to monitor. 6. Right heel ulcer. We will have ET Nursing see him. We will continue with wet-to-dry dressing changes for now. We will check with Dr. _%#NAME#%_ _%#NAME#%_'s office or with the patient's son or the primary clinic, to find out his current antibiotic and dose.
ET|endotracheal|ET|170|171|HOSPITAL COURSE|His worsening respiratory distress at the time was thought to be from mucositis and a questionable pneumonia secondary to Enterobacter cloacae which was growing from his ET tube cultures subsequently. Daniel was followed closely, clinically as well as via chest x-rays daily while intubated. He demonstrated evidence of the ability to wean to extubation within 1 week after intubation.
ET|enterostomal therapy|ET|223|224|ASSESSMENT/PLAN|He will continue current medications with Imdur and hydralazine for elevated blood pressure control. 2. Sternal wound infection with coagulase-negative staphylococcus. Will continue current wound care with VAC dressing and ET nurse to follow wound care. Continue IV Vancomycin. Patient is to follow up CT surgery and obtain ID consultation for antibiotic choice and follow up.
ET|enterostomal therapy|ET|163|164|ASSESSMENT/PLAN|There is minimal to moderate amounts of mucopurulent drainage on the dressing. This area is not significantly foul smelling, and there is no surrounding erythema. ET nursing will be involved in monitoring this. 5. Diabetes mellitus: She is currently on multiple agents, with what appears to be poor glycemic control at home, although she denies this.
ET|enterostomal therapy|ET|174|175|PROBLEM #2|They recommended no biopsy at this time, but to follow up as an outpatient in their Clinic and this appointment has been scheduled for her. Wound culture was obtained by the ET nurse, which grew out a Pseudomonas, which was sensitive to Levaquin and she will complete a 14 day course of this medication.
ET|enterostomal therapy|ET|157|158|PROBLEM #1|The plan was initially to leave the JP drains in place until there was no drain output. The patient was kept NPO and started on TPN for complete bowel rest. ET nursing was actively involved in caring for the complicated abdominal wounds. On _%#MMDD2005#%_, the patient was taken back to the OR for exploratory laparotomy and further wound evaluation.
ET|enterostomal therapy|ET|246|247|HISTORY OF PRESENT ILLNESS|6. G-tube site pain. Mr. _%#NAME#%_ was complaining of local tenderness over his G-tube; however, there was just minimal at the site and no drainage. An abdominal x-ray demonstrated nonobstructive bowel gas pattern. The assistance of surgery and ET nurse was elicited to see if there appeared to be any malfunction or question of erosion around this G-tube site. EGD was recommended. However, due to his respiratory acidosis hypercapnia, it was thought to be too risky to place him under any conscious sedation.
ET|electrophysiology:EP|ET|125|126|IMPRESSION|3. Severe pulmonary hypertension, probably due in part to pulmonary issues, but also left-sided heart failure. 4. History of ET status post ICD. 5. Chronic atrial fibrillation history. She does not appear to be on Coumadin at this time, likely secondary to her history of falls.
ET|enterostomal therapy|ET|173|174|PLAN|4. Complete antibiotics as recommended by Fairview University. 5. Depo-Provera injection. 6. Eucerin cream to the feet daily. 7. Bilateral upper extremity wound care as per ET nurse. 8. X-ray of the coccyx with foam cushion as above. Thanks for the consultation. We will follow along as indicated.
ET|enterostomal therapy|ET|125|126|PLAN|PLAN: 1. Medication intervention per Dr. _%#NAME#%_. 2. Monitor blood pressure for now off atenolol. 3. X-ray of the coccyx. ET RN opinion. 4. Boost for nutritional support. 5. EKG (atypical chest pain). 6. Metamucil 1 tablespoon in glass of water daily p.r.n.
ET|enterostomal therapy|ET|183|184|REVIEW OF SYSTEMS|Currently she is being treated for urinary tract infection. SKIN: The patient does have a sacral decubitus ulcer, which is being treated at home, and the patient has been seen by the ET nurse during this hospitalization. MUSCULOSKELETAL: The patient has spasticity. NEUROLOGIC: The patient has history of MS with spastic quadriplegia. She is wheelchair-bound as mentioned before. PSYCHIATRIC: Depression and some mild anxiety.
ET|enterostomal therapy|ET|217|218|RECOMMENDATIONS|RECOMMENDATIONS: 1. Mobility: Continue PT as you are. 2. Activities of daily living: Continue occupational therapy as you are. 3. Cardiac rehab: Agree with cardiac rehab for reconditioning. 4. Buttock wound: Continue ET nursing. 5. Dysphagia: Continue modified diet. Recommend reassessment by Speech. DISPOSITION: As the patient is so far below his functional baseline, I recommend rehabilitation at this time.
ET|endotracheal|ET|194|195|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Current blood pressure is 130/85, pulse 87 and irregular, respiratory rate is 18 and currently is on a ventilator. He has episodes of some posturing and biting down on the ET tube. GENERAL: He is a comatose white male with acrocyanosis ventilated with a nasogastric tube and no other acute distress. He does have blood coming from his left naris. HEENT: Normocephalic, otherwise atraumatic without xanthoma.
ET|enterostomal therapy|ET|147|148|PLAN|8. Close monitoring of pulmonary status postoperatively. 9. Serial follow-up laboratory studies. 10. Depending on orthopedic opinion, will involve ET nursing with regard to decubitus care. Thank you for the consultation. Will follow along with you.
ET|endotracheal|ET|143|144|LABORATORY|Her hemoglobin is 11.5, her platelets are 281. A urine sodium was 42. Urine creatinine was 42. TSH is noted to be 11. Her chest x-ray shows an ET tube and adequate placement and a significant right-sided pleural effusion. No overt or obvious infiltrates.
ET|endotracheal|ET|204|205|PHYSICAL EXAMINATION|Her wedge is 24. GENERAL: Sedate woman on the ventilator who opens eyes to voice and squeezes hands to command. Otherwise little other activity. HEENT: She is nasally intubated. There is blood around the ET tube. Ocular structures are unremarkable. NECK: Supple. LUNGS: Diffuse wheezing bilaterally with poor air flow. There are no focal crackles identified. CARDIAC: Tachycardic. No appreciable murmur, rub, or gallop.
ET|enterostomal therapy|ET|237|238|HISTORY OF PRESENT ILLNESS|She tolerated extubation on _%#MMDD2003#%_, and received total parenteral nutrition, and tolerated oral diet on _%#MMDD2003#%_. On _%#MMDD2003#%_ she was transferred to the medical-surgical floor. Her abdominal wound is being managed by ET nursing, and is currently being treated conservatively with dressing changes. A VAC dressing is anticipated, but is not to be used now due to necrotic tissue.
ET|endotracheal|ET|136|137|PHYSICAL EXAMINATION|She has a trauma to the upper lip secondary to bagging or the intubation. It was reportedly a somewhat difficult intubation. She has an ET tube present. NECK: Supple without masses, thyromegaly, bruits or JVP. LUNGS: Good air exchange. There are crackles throughout all lung fields. No audible wheezing.
ET|enterostomal therapy|ET|140|141|PLAN|2. Foley catheter. 3. Renal ultrasound, question need for stents. He may actually need some type of diversion procedure or a cystostomy. 4. ET nurse to help with decubitus therapy. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 77-year-old man whom we have followed in nephrology over the past several years for intermittent bouts of acute renal failure on top of chronic renal failure.
ET|endotracheal|ET|201|202|PHYSICAL EXAMINATION|He would extend both upper extremities as well as abduct his arms and grip both fists. These occurred with sternal rub and spontaneously. He also appeared to have some chewing or biting motions on the ET tube. ADMISSION LABORATORY DATA: Outside hospital: BN peptide 6. Urine tox was positive for benzodiazepines only.
FISH|fluorescent in situ hybridization|FISH|227|230|ADMISSION HISTORY AND PHYSICAL|The patient's multiple marker screen showed MSAFP of 3.82 multiples at the median, hCG 9.35 multiples at the median and EV3 0.59 multiples of the median and inhibin 24.7 multiples of the median. Amniocentesis was performed and FISH showed 2 signals at age 13, 18 and X and 3 signals at 21. PRENATAL LABORATORY: Blood type A positive, antibody negative, rubella immune, RPR nonreactive, hepatitis B negative, Pap smear was normal, TSH was 3.54, prenatal care was started at 13 plus 6 weeks where she had a total of 3 visits.
FISH|fluorescent in situ hybridization|FISH|153|156|DISCHARGE MEDICATIONS|Problem #6: Genetics. Due to lack of thymus on echocardiogram and presence of truncus arteriosus, chromosomes were sent for several studies, including a FISH for 22q deletion. These revealed a female karyotype with a small deletion on one chromosome 22, involving band 22q11.2 consistent with velocardiofacial or DiGeorge syndrome.
FISH|fluorescent in situ hybridization|FISH|217|220|* FEN|Date of death: _%#MMDD2006#%_ Mr. _%#NAME#%_ was a 46-year-old Native American male diagnosed with atypical CML in _%#MM#%_ 2005. Bone marrow biopsy at that time was 95% cellular with 5% myeloblasts. Cytogenetics and FISH were normal. The patient was treated with hydroxyurea and did well until _%#MM#%_ 2005 when he was found to have accelerated disease.
FISH|fluorescent in situ hybridization|FISH|150|153|1. FEN|This also may represent transient hypoparathyroidism in the infant. Dr. _%#NAME#%_ felt that it would be prudent to check for DiGeorge syndrome and a FISH study is pending at the time of discharge. We would suggest the following cares next week since the calcium level is only 7.9 with ionized calcium 4.2 and increased phosphorus level of 9.3. Magnesium level is now normal at 1.9. Problem #2: Seizures.
FISH|fluorescent in situ hybridization|FISH|193|196|MMC 94|* PKU, galactosemia, hypothyroidism, hemoglobinopathy, adrenal hyperplasia screening was sent on _%#MMDD2005#%_ and the results were pending at the time of discharge. * Chromosome analysis and FISH for DiGeorge Syndrome were pending at time of transfer. * Hearing: _%#NAME#%_ has not received the ABR hearing-screening test. * Immunizations: Hepatitis B vaccine was not given. Discharge medications, treatments and special equipment: * Caffeine 18 mg IV Q24 hrs * Vancomycin 50 mg IV Q24 hrs * Cefotaxime 175 mg IV Q12 hrs * Nystatin 50,000 units PO Q6 hrs * Furosemide 2 mg IV Q12 hrs Discharge measurements and exam: Weight 3370 gm, length 51 cm, OFC 34.5 cm.
FISH|fluorescent in situ hybridization|FISH|192|195|HISTORY OF PRESENT ILLNESS|Her most recent bone marrow done in _%#NAME#%_ 2005 revealed 20-50% cellularity with small hypo-lobulated megakaryocytes, suspicious for low-grade myelodysplastic syndrome, 20% trisomy 8, and FISH 11% trisomy 8. _%#NAME#%_ had a Hickman line placed on _%#MMDD2005#%_. A chest CT done in preparation for transplant was done initially on _%#MMDD#%_ which showed an ill-defined nodular opacity in the right lower lobe.
FISH|fluorescent in situ hybridization|FISH.|328|332|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 42-year-old woman who is in today for followup of her left infiltrating ductal carcinoma, status post bilateral mastectomies, diagnosed _%#MMDD2005#%_, Nottingham grade 3 of 3, with 1 of 3 lymph nodes positive, ER/PR positive at greater than 10%, and HER-2/neu positive by FISH. REVIEW OF SYSTEMS: GENERAL: She is hungry. EYES: She has dry eyes.
FISH|fluorescent in situ hybridization|FISH|136|139|DIET|PAST MEDICAL HISTORY: 1. Reflux. 2. Cervical dysplasia status post a LEEP in _%#MM#%_ of 2004. 3. Burkitt lymphoma, 4 different clones, FISH positive for for MYC rearrangement, MIC positive with translocation A-12, status post 3 rounds of CALGB chemotherapy. Initially diagnosed in _%#MM#%_ of 2005, due to a golf ball-sized left axillary lymph node.
FISH|GENERAL ENGLISH|FISH,|217|221|ALLERGIES|6. Prior prostatectomy. 7. Cholecystectomy. 8. He is anemic. MEDICATIONS: Include only: 1. Clindamycin. 2. Tequin. ALLERGIES: THE PATIENT HAS MULTIPLE ALLERGIES INCLUDING AMOXICILLIN, GABAPENTIN, PENICILLAMINE, SHELL FISH, AND PSEUDEPHRINE. FAMILY HISTORY: Significant for cardiac disease, but is otherwise noncontributory.
FISH|GENERAL ENGLISH|FISH.|257|261|DRUG ALLERGIES|Pain control is adequate with 50 micrograms of Duragesic. She has a list of medications all to be discontinued per family's wishes; Dopamine, Valium, hetastarch, Protonix, Lactulose, Neupogen, Rocephin. DRUG ALLERGIES: IODINE, SULFA, ERYTHROMYCIN AND SHELL FISH. REVIEW OF SYSTEMS: NG tube is placed. Bowel sounds are faint. Patient is less responsive today than yesterday.
FISH|fluorescent in situ hybridization|FISH|205|208|HISTORY OF PRESENT ILLNESS|The lymph node was positive for metastatic cancer and the core biopsy showed an infiltrating lobular carcinoma grade 2. It was estrogen receptor positive and progesterone receptor focally positive, and by FISH analysis it was negative for HER-2. On _%#MM#%_ _%#DD#%_, the patient had a bilateral breast MRI which showed an aggregate of at least 6 tumor nodules over approximately a 2-cm area at the 11 o'clock position of the right mid breast and then also posteriorly and laterally to that at near the 9 or 10 o'clock position another mass of approximately 2.8 cm was identified.
FISH|GENERAL ENGLISH|FISH.|268|272|ALLERGIES|PAST MEDICAL HISTORY/SURGICAL HISTORY: Laparoscopic cholecystectomy in _%#MM#%_ 2005, penis cancer surgery in 1990, MI in 2001, CVA without residual affects, penile cancer, diabetes mellitus, hypercholesterolemia, and osteoarthritis. ALLERGIES: SHELLFISH, IODINE, AND FISH. FAMILY HISTORY: Father with MI, mother alive and healthy at _%#1914#%_ years old.
FISH|fluorescent in situ hybridization|FISH|121|124|DISCHARGE MEDICATIONS|Physical exam on admission confirmed the anomalies as previously noted. Repeat chromosome studies were sent, including a FISH probe for DiGeorge Syndrome, were pending at time of transfer. A genetics consult was also requested, but was not completed at time of transfer.
FISH|fluorescent in situ hybridization|FISH|160|163|ID|Serum amino and organic acids and urine organic acids were normal. His homocysteine level was normal. The screen for Smith-Lemli-Opitz syndrome was negative. A FISH probe for Prader-Willi was sent and is pending. GI: On _%#MMDD2002#%_, he had an Upper GI exam which showed no esophageal dysmotility, stricture or sling and no malrotation.
FISH|fluorescent in situ hybridization|FISH|230|233|HOSPITAL COURSE|5. Genetics: The Genetics Team was consulted secondary to patient's congenital heart defect, and other features. For her sacral dimple, an ultrasound was performed, which revealed no evidence of a tethered cord. Chromosomes and a FISH study for deletion of the 22 q11 region were sent and are pending at time of discharge. The patient will follow up with the Genetics Clinic, with Dr. _%#NAME#%_ in six months' time.
FISH|fluorescent in situ hybridization|(FISH)|399|404|FOLLOW UP|Upon their request, we ordered a pelvic ultrasound, voiding cystourethrogram (VCUG) with retrourethrogram, and the following labs: chromosomal analysis, serum cortisol, 17-hydroxyprogesterone, follicle-stimulating hormone (FSH), lutropin, androstenedione, and dihydrotestosterone. A blood sample was also sent to the endocrinology department's Cytogenetics lab for fluorescent in-situ hybridization (FISH) analysis for the SRY gene. Baby _%#NAME#%_'s peripheral blood karyotype is 46XX, but it is still possible baby may have gonadal mosaicism.
FISH|fluorescent in situ hybridization|FISH|151|154|PAST MEDICAL HISTORY|11. Suspected malignancy, suspected cholangiocarcinoma, status post histology. ERCP with the brushings for histology at the Mayo Clinic. Histology and FISH negative to date. 12. History of Perthes hip, status post right hip replacement in 1990. ALLERGIES: Amoxicillin. HOSPITAL COURSE: Mr. _%#NAME#%_ is a gentleman with ulcerative colitis and primary sclerosing cholangitis, autoimmune variant, status post total colectomy and ileoanal pull-through, who was admitted on _%#MMDD2006#%_ with 2 weeks of low grade fevers and a 3-day history of copious diarrhea.
FISH|fluorescent in situ hybridization|FISH.|258|262|HISTORY OF PRESENT ILLNESS|The patient had no symptoms prior to her cerclage. Ultrasound was performed at the perinatology center to evaluate known omphalocele in the infant. Amniocentesis at that time was performed which ruled out an infection, and cytogenetics demonstrated a normal FISH. The patient presented at the time of her admission with episodic low back pain since the evening of _%#MM#%_ _%#DD#%_, 2006. Each episode lasted approximately one minute. The patient denied any leaking fluid or vaginal bleeding.
FISH|fluorescent in situ hybridization|FISH|302|305|HISTORY OF PRESENT ILLNESS|There was also a prominent left axillary lymph node. She underwent a core biopsy of the mass and the left axillary lymph node, both of which revealed invasive grade 3 infiltrating ductal carcinoma. There was no evidence of lympho-vascular invasion and the tumor was ER positive and PR negative, and by FISH analysis it was positive for Her-2 overexpression. She was seen by Dr. _%#NAME#%_ at the end of _%#MM#%_ and thought that she would be a candidate for neoadjuvant chemotherapy.
FISH|fluorescent in situ hybridization|FISH|256|259|DISCHARGE DIAGNOSES|Immunostaining was done, which suggested that the small foci involved approximately 5% to 10% of the marrow cellularity. The presence or absence of leukemia could not be definitively established based on morphologic criteria alone. Cytogenetic studies and FISH analyses for the patient's known chromosomal abnormality both are normal, and thus there is no molecular or cytogenetic evidence of his disease at this time.
FISH|fluorescent in situ hybridization|FISH|145|148|HISTORY OF PRESENT ILLNESS|There were frequent hour rods noted as well as 30% myeloblasts. There was increased iron stores. There is no evidence of a 1517 translocation by FISH study. She was seen by Dr. _%#NAME#%_ and after review of the options, including supportive care versus attempt at induction as using Gemtuzumab, it was elected to admit her on _%#MMDD2003#%_ to initiate Gemtuzumab.
FISH|fluorescent in situ hybridization|FISH|275|278|HISTORY OF PRESENT ILLNESS|She presented to Labor and Delivery for admission. The fetus was found to have a persistent truncus arteriosus with sequelae of hydrops fetalis, and concomitant findings of low VSD. The patient had seen both Pediatric Cardiology and Genetics. A normal karyotype and negative FISH for DiGeorge was done. The infant had persistent ascites, pericardial effusions, and concern for a single right kidney, as well as persistent polyhydramnios with AFI greater than 25.
FISH|GENERAL ENGLISH|FISH,|168|172|ALLERGIES|She is retired. She lives with her husband and 2 children, who are 34 and 36. CURRENT MEDICATIONS: Include carboplatin and Taxol and vitamins. ALLERGIES: INCLUDE SHELL FISH, IODINE, EGGS, MOLD, AND POLLEN. HEALTH CARE MAINTENANCE: The patient had pap smear in _%#MM#%_, 2005 and last mammogram was in _%#MM#%_, 2004.
FISH|fluorescent in situ hybridization|FISH|262|265|HISTORY OF PRESENT ILLNESS|She presented on _%#MMDD2007#%_ for routine followup ultrasound with findings of discordance of 17% with polyhydramnios in twin A and hydrops in twin A and abnormal Dopplers in twin A. The patient was seen at MSM for reduction amnio of 825 mL which was sent for FISH and karyotype. Plan for admission was then made. The patient was without complaints. She did endorse positive fetal movement and denied contraction, vaginal bleeding or leaking fluid.
FISH|fluorescent in situ hybridization|FISH|160|163|LABORATORY DATA|She denies any alcohol use with her pregnancy. She is smoking 1-1/2 pack of cigarettes per day. LABORATORY DATA: Quad screen, risk of trisomy 21 was 1 and 666. FISH normal. AFP on _%#MMDD2007#%_, 8.5. Amniotic fluid negative for acetylcholine esterase. Admission UA negative. Drug screen positive THC. Culture of urine, greater than 100,000 lactobacillus.
FISH|fluorescent in situ hybridization|FISH|327|330|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1: Acute leukemia. The patient underwent a bone marrow biopsy on _%#MMDD2003#%_ that showed hypercellular bone marrow for age with 70% blasts, and confirmed the diagnosis of acute myeloid leukemia, type M1. Cytogenetics showed 19 of 20 cells characterized by deletion of the long arm of chromosome 9. FISH was performed to rule out a cryptic 8;21 rearrangement. Among the 200 cells, 89.5% had a signal pattern consistent with AML1/ETO gene fusion.
FISH|fluorescent in situ hybridization|FISH|114|117|HOSPITAL COURSE|Head CT pursued for staging was negative. Bone scan is pending at the time of discharge. Also pending is the Her2 FISH test. PROBLEM #2: Hypertension. This was well controlled during her hospital course to the point that we will decrease her dose of Prinzide to one-half tablet each day of a 20/12.5-mg tablet.
FISH|fluorescent in situ hybridization|FISH|395|398|DISCHARGE PLANS|Genetics team did not conclude any specific syndrome changes relating to constipation, encopresis, high nasal bridge and high palate, but because of behavioral issues and facial dysmorphism, they recommended checking for velocardiofacial syndrome and FISH for 22-Q deletion to rule out velocardiofacial syndrome. No follow up was needed unless chromosomes are done and found to be abnormal. The FISH was sent and the results are pending at the time of discharge. TSH, lead, magnesium, and electrolytes were normal except for a phosphorous of 5.1 mg/dL.
FISH|GENERAL ENGLISH|FISH,|135|139|DISCHARGE DIAGNOSES|3. Cardiac arrest secondary to hyperkalemia, post interventional radiology treatment of P-E. 4. Allergies. History of ALLERGY TO SHELL FISH, ERYTHROMYCIN-UNKNOWN REACTION, ASPIRIN-THE PATIENT AVOIDS DUE TO HER HISTORY OF MILD ASTHMA. 5. OCP use. 6. Mild asthma. 7. Family history of coagulopathy.
FISH|fluorescent in situ hybridization|FISH|235|238|1. FEN|Bili at birth was 2.0 with no conjugated portion. He did not develop clinical jaundice, so further bilirubin levels were not checked. 5. Genetics: Chromosomes were obtained prenatally and showed a normal 46 X,Y karyotype with negative FISH for trisomy 13,18, and 21. Chromosomes were repeated post-natally with a FISH for DiGeorge syndrome and were normal. An abdominal U/S was performed given his complex congenital heart disease and heterotaxia, and it was significant for asplenia.
FISH|fluorescent in situ hybridization|FISH|179|182|1. FEN|5. Genetics: Chromosomes were obtained prenatally and showed a normal 46 X,Y karyotype with negative FISH for trisomy 13,18, and 21. Chromosomes were repeated post-natally with a FISH for DiGeorge syndrome and were normal. An abdominal U/S was performed given his complex congenital heart disease and heterotaxia, and it was significant for asplenia.
FISH|GENERAL ENGLISH|FISH,|184|188|PAST MEDICAL HISTORY|Stool culture was obtained. The patient was started on IV fluids and is now being admitted to the hospital. PAST MEDICAL HISTORY: The patient reports she is ALLERGIC TO CODEINE, SHELL FISH, AND STRAWBERRIES. MEDICATIONS: Coumadin 15 mg p.o. q.d., albuterol inhaler, iron, folic acid.
FISH|fluorescent in situ hybridization|FISH|150|153|HOSPITAL COURSE|A growth ultrasound is pending as of the date of discharge. BPP was 8/8 on the date of discharge. An ultrasound has shown club feet and short femurs. FISH and chromosome studies are preliminarily negative and the final result is pending. This will be followed up on. 3. GDM on _%#MM#%_ _%#DD#%_, 2004.
FISH|fluorescent in situ hybridization|FISH.|155|159|HISTORY OF PRESENT ILLNESS|She was found to have a Nottingham grade 3/3 with 0 of 2 lymph nodes positive, greater than 90% ER positive, greater than 30% PR positive, and negative by FISH. She has no family history because she is adopted and does not know her family. She has had two pregnancies and her children are an 11-year-old daughter and a 10-year-old son.
FISH|fluorescent in situ hybridization|FISH|201|204|PAST MEDICAL HISTORY|1. _%#CITY#%_ chromosome positive ALL, _%#MM2004#%_, when she presented for bone pain. A bone marrow biopsy showed 95% cellularity with 90% lymphoblasts. Cells were positive for TdT, CD10, CD20, CD19. FISH study revealed 6% positivity for bcr/abl and cytogenetics revealed 1 of 3 metaphases positive for translocation 9 to 22, and monosomy 7.
FISH|fluorescent in situ hybridization|FISH|205|208|LABORATORIES|LABORATORIES: O-positive, antibody negative, gonorrhea and Chlamydia negative. Urine culture negative. Hepatitis B surface antigen nonreactive. HIV negative. RPR nonreactive, rubella immune. Amniocentesis FISH results were ambiguous with XX and XY cells. Final karyotype pending. PAST OBSTETRIC HISTORY: Spontaneous abortion in 2007, NSVD of a female 8 pound 9 ounce baby in 2005.
FISH|fluorescent in situ hybridization|FISH|232|235|HISTORY OF PRESENT ILLNESS|She ultimately went on to have a bone marrow biopsy performed on _%#MMDD2003#%_ with findings of acute myeloid leukemia with maturation. Final cytogenetic studies are pending, but at present there is no evidence of a 1517 fusion by FISH studies. She has reviewed the diagnosis as well as the options for treatment with Dr. _%#NAME#%_ and Dr. _%#NAME#%_ it was elected to admit her to Fairview Southdale Hospital to begin induction chemotherapy.
FISH|fluorescent in situ hybridization|FISH.|274|278|HISTORY OF PRESENT ILLNESS|Cystoscopy previously done in _%#NAME#%_ had shown a large false passage and urethral tear, and there was concern that having a chronic indwelling Foley catheter was causing the hematuria. Pathology was sent to rule out malignancy of the urinary tract which was negative by FISH. He was therefore admitted for further care of his hematuria. MEDICAL HISTORY: 1. Liver disease with ascites requiring large volume paracentesis intermittently, mild thrombocytopenia, coagulopathy with INR baseline of 2, and acute hepatitis with bilirubin ranging in the 20s.
FISH|GENERAL ENGLISH|FISH,|181|185|AXIS I|Dr. _%#NAME#%_ _%#NAME#%_ did the history and physical, see his dictation. ALLERGIES: 1. DEPAKOTE. 2. ASPIRIN. 3. IBUPROFEN. 4. PENICILLIN. 5. SULFA. 6. PROZAC. 7. IODINE. 8. NUTS, FISH, STRAWBERRIES, AND BEE STINGS. LABORATORY: She had labs drawn on admission, they were noted by Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_. Her urine toxicology screen was positive for cocaine.
FISH|fluorescent in situ hybridization|FISH|148|151|1. F/E/N|Her saturations were consistently in the upper 80's to low 90's. 3. Genetic: Chromosomes were sent for analysis and are reported as being normal. A FISH probe for DiGeorge Syndrome is negative. Ongoing problems and suggested management: 1. Cardiac: The patient will require surgical repair of her heart.
FISH|fluorescent in situ hybridization|FISH|177|180|1. FEN|4. Genetics: Cardiology consultant advised sending chromosomes in order to rule out DiGeorge syndrome. Labs for Calcium (total 8.3, ionized 4.6), Phosphorus (6.6) and karyotype FISH for chromosome 22q11 (pending) were sent. 5. ID: The patient was placed on Ampicillin and Gentamicin upon hospitalization for an initial 48-hour r/o sepsis.
FISH|fluorescent in situ hybridization|FISH|130|133|PROBLEM #6|Upon discharge, he was using minimal amounts of Tylenol only. PROBLEM #6: Genetics. The patient's chromosomes were sent off for a FISH probe to rule out DiGeorge following birth. At the time of dictation, the results of this study are still pending. DISCHARGE DIAGNOSES: 1. Double aortic arch, status post division of vascular ring.
FISH|fluorescent in situ hybridization|FISH|238|241|PROCEDURES PERFORMED|Then, she had consolidation with daunorubicin, ATRA x2 followed by the ATRA, 6-mercaptopurine, and methotrexate. On _%#MM#%_ _%#DD#%_, 2004, she had relapsed on her bone marrow biopsy showing 17% blasts with normal cytogenetics; however, FISH was positive for PML-RAR rearrangement. At this time, her ATRA was increased from 72 mg and repeated biopsy on _%#MM#%_ _%#DD#%_, 2004, showed 5% residual leukemic blast and aspirate with a 15 to 17 translocation on the FISH.
FISH|fluorescent in situ hybridization|FISH.|180|184|PROCEDURES PERFORMED|At this time, her ATRA was increased from 72 mg and repeated biopsy on _%#MM#%_ _%#DD#%_, 2004, showed 5% residual leukemic blast and aspirate with a 15 to 17 translocation on the FISH. The preliminary bone marrow biopsy from _%#MM#%_ _%#DD#%_, 2005, is consistent with an increasing percentage of the blast up to 44%. At this point, the patient was admitted for reinduction chemotherapy.
FISH|fluorescent in situ hybridization|FISH|201|204|ALLERGIES|The one after the induction chemotherapy is 30% blast on astroid and some evidence of immature granulopoiesis with atypical promyelocytes. The bone marrow biopsy on _%#MM#%_ _%#DD#%_, 2005, showed the FISH was positive for presence of the 15/17. 2. Infectious disease complication. The patient developed neutropenic fever during the hospital stay.
FISH|GENERAL ENGLISH|FISH.|160|164|ALLERGIES|She denies any bowel or bladder incontinence or paresthesias. There is no radiation of the pain. Her pain is described as 10/10 with movement. ALLERGIES: SHELL FISH. MEDICATIONS: Mainly over-the-counter meds including glucosamine/chondroitin, sulfate, calcium, multivitamin, vitamins E and C, and flax seed oil.
FISH|GENERAL ENGLISH|FISH,|92|96|ALLERGIES|She was brought in for further evaluation. PAST MEDICAL HISTORY: Negative. ALLERGIES: SHELL FISH, but not shrimp. MEDICATIONS: Tylenol p.r.n. SOCIAL HISTORY: She is married.
FISH|fluorescent in situ hybridization|FISH|234|237|CHIEF COMPLAINT|Review of systems is unremarkable. No fever, URI, diarrhea, vomiting, constipation, rashes, skin breakdown, hematologic disorder, change in sleep or appetite Evaluation in the past for cause of his PDD NOS has included karyotype with FISH for the Angelman region, all of which are normal. He had failure to thrive and GERD treated with nutritional supplements, ranitidine, Prevacid, and is now resolving.
FISH|fluorescent in situ hybridization|FISH|176|179|HOSPITAL COURSE|Bone marrow biopsy was slightly complicated by difficulty obtaining a core sample. Aspirate of the bone marrow biopsy was consistent with chronic myelogenous leukemia. A rapid FISH analysis was obtained and was read as 92% positive for BCR-ABL. At the time of discharge G-bands were still pending. This diagnosis was discussed with the patient and his significant other.
FISH|fluorescent in situ hybridization|FISH|159|162|FOLLOW UP|Due to the association of congenital cardiac anomalies with genetic disorders, chromosomes were sent for analysis (results pending at the time of transfer). A FISH for velocardiofacial syndrome was negative. Problem #7: Renal. _%#NAME#%_ had a renal ultrasound on _%#MMDD2005#%_ to assess for anomalies (midline defects), which was normal.
FISH|fluorescent in situ hybridization|FISH|197|200|HISTORY OF PRESENT ILLNESS|He is currently on Coumadin. CT/PET revealed high metabolic area near angle of right mandible. Bone marrow collected _%#MMDD2005#%_ was negative for mantle cell lymphoma. Cytogenetics were normal; FISH studies were negative. He received 2 cycles of ESHAP chemotherapy, first in early _%#MM#%_ 2006 and secondly in late _%#MM#%_/early _%#MM#%_ 2006.
FISH|fluorescent in situ hybridization|FISH|150|153|HOSPITAL COURSE|Their recommendations included adding calcitriol to increase the calcium absorption from the calcium supplementation. They also recommended getting a FISH assay to evaluate for DiGeorge syndrome. They also recommended getting a cardiac echo due to the increased risk of cardiac structural abnormality in patient's with DiGeorge syndrome.
FISH|fluorescent in situ hybridization|FISH|260|263|DISCHARGE PLAN|Problem # 5: Renal. A renal ultrasound was done on _%#MMDD2007#%_, which revealed mild left pyelectasis (described as "unremarkable" in the radiology dictation). The right kidney was described as normal. Problem # 6: Genetics. Chromosome studies with DiGeorge FISH probe were sent on _%#MMDD2007#%_ and the results are pending. Problem # 7: Screening Examinations/Immunizations. * Newborn Screen: * The Minnesota newborn metabolic screening examination was sent to the State Department of Health on _%#MMDD2007#%_ and the results were pending at the time of transfer.
FISH|fluorescent in situ hybridization|FISH|198|201|HISTORY OF PRESENT ILLNESS|An ultrasound guided biopsy was completed on _%#MMDD2007#%_ with the pathology demonstrating high grade infiltrating ductal carcinoma with positive estrogen and progesterone receptors. HER-2/neu by FISH is still pending. She was ultimately readmitted to the hospital for pain management.
FISH|fluorescent in situ hybridization|FISH|260|263|IMPRESSION AND PLAN|Problem #2: Genetics/Neurology: Upon admission to the NICU, _%#NAME#%_ was seen by both pediatric genetics and pediatric neurology for left sided facial nerve palsy and possible genetic disorder. Chromosomes were obtained, with particular notice request for a FISH test to detect possible 22 q deletion. At the time of discharge, chromosomal tests are still pending. An MRI of the head was obtained on _%#MM#%_ _%#DD#%_, which was normal.
FISH|fluorescent in situ hybridization|FISH|202|205|BRIEF HISTORY AND PHYSICAL|On subsequent PET CT scan, showed multiple enlarged lymph nodes of the neck, chest, abdomen and pelvis with high STV. He had a bone marrow biopsy which confirmed the presence of mantle cell lymphoma by FISH for translocation 11;14. Hence, it was decided to start on the protocol for the use of bortezomib conventional chemotherapy for mantle cell lymphoma.
FISH|fluorescent in situ hybridization|FISH|163|166|PROBLEM #6|PROBLEM #5: Neurologic. _%#NAME#%_ had a head ultrasound on _%#MMDD2007#%_ which was found to be normal. PROBLEM #6: Genetics. _%#NAME#%_ did have chromosomes and FISH testing for DiGeorge syndrome. These are pending at the time of discharge. DISCHARGE DIAGNOSES: 1. Congenital heart disease, type 2 truncus arteriosus. 2. Vomiting likely secondary to gastroesophageal reflux.
FISH|fluorescent in situ hybridization|FISH|145|148|LABORATORY|The amniotic fluid studies returned with a glucose of 42. The Gram stain showed no organisms. There are no signs of intraamniotic infection. The FISH returned as normal. At this point, a plan was made to proceed with the rescue cerclage. This was performed on _%#MM#%_ _%#DD#%_, 2006. The procedure was uncomplicated.
FISH|fluorescent in situ hybridization|FISH|160|163|SECONDARY DIAGNOSES|1. Dehydration. 2. Cellulitis. SECONDARY DIAGNOSES: 1. Truncus arteriosus, status post repair _%#MM2007#%_. 2. Status epilepticus. 3. History of aspiration. 4. FISH negative for _____. DISCHARGE MEDICATIONS: 1. Bumex 0.2 mg GT q.12 hours.
FISH|fluorescent in situ hybridization|FISH|228|231|HOSPITAL COURSE|A standard EEG on _%#MMDD2006#%_ was normal. _%#NAME#%_ received pediatric neurology evaluation in the past from Dr. _%#NAME#%_ _%#NAME#%_ as well. He has undergone karyotype analysis with unremarkable findings. He has also had FISH telomere studies with normal findings. At the present time, his blood has been submitted for comparative genomic hybridization study, with results currently pending.
FISH|fluorescent in situ hybridization|FISH|199|202|HOSPITAL COURSE|Ultrasound findings showed marked right ventriculomegaly and large right atrium. Fetal echo was requested, as well as plans for MRI and neurosurgery consult. Amniocentesis was performed and sent for FISH returning with normal chromosomes. The patient and her husband were offered discharge to home on _%#MMDD2006#%_; however, they declined.
FISH|fluorescent in situ hybridization|FISH|144|147|CHIEF COMPLAINT|The family then came here for further opinion regarding management. As part of the initial workup done at the Mayo Clinic, the patient did have FISH chromosome testing for the NF1 site, which was negative. The patient has also had initial endocrine evaluation by Dr. _%#NAME#%_, which is within normal limits.
FISH|fluorescent in situ hybridization|FISH|247|250|HISTORY|_%#NAME#%_ was last seen in clinic on 2 occasions in mid _%#MM#%_ and as recently as _%#MMDD2007#%_ for herpetic zoster virus (HZV) rash. She had been appropriately placed on Famciclovir with instructions to proceed with recommended follow up for FISH testing for bcr-abl (Philadelphia chromosome). _%#NAME#%_ was informed that her FISH testing revealed complete remission of her CML.
FISH|fluorescent in situ hybridization|FISH|162|165|BRIEF HOSPITAL STAY|The most likely etiology for the hyperbilirubinemia was physiologic and from bacteremia. This problem has resolved. A TSH, free T4, and G6PD were all normal. The FISH for DiGeorge done _%#MMDD2005#%_ was negative. Problem #3: Sepsis. We treated _%#NAME#%_ with ampicillin and gentamicin for a total of 14 days.
FISH|fluorescent in situ hybridization|FISH.|213|217|HOSPITAL COURSE|Of note, no lesions were found in the lumen of the trachea, however, there was mass effect from posteriorly. Two small lymph nodes were found during that procedure, and were sent for lymphoma and cytogenetics for FISH. The patient was managed postoperatively on unit 6D. Her chest tube was pulled on postoperative day #1.
FISH|fluorescent in situ hybridization|FISH.|278|282|HISTORY OF PRESENT ILLNESS|A CT revealed marked splenomegaly. A bone marrow biopsy at the time of diagnosis showed 100% cellular marrow with increased granulocytes and mildly increased fibrosis. Cytogenetics showed 25% metaphases with a 922 translocation and 90% of the cells were positive for BCR-ABL by FISH. She was initially treated with Gleevec and achieved a hematologic remission in _%#MM2003#%_, but still had 57% of her cells positive for BCR-ABL by FISH.
FISH|fluorescent in situ hybridization|FISH|241|244|HISTORY OF PRESENT ILLNESS|She continued with Gleevec, and the dose was increased to 800 mg daily; however, after one month of high-dose therapy, she experienced visual changes and confusion. Her dose was decreased to 400 mg daily until _%#MM2005#%_. In _%#MM2004#%_, FISH still revealed 27% of the cells positive for BCR- ABL, and this continued to increase. Her Gleevec was then increased to 600 mg daily, and she is now being admitted for a full prep myeloablative allogenic sibling peripheral blood stem-cell transplant.
FISH|fluorescent in situ hybridization|FISH|152|155|PAST  MEDICAL HISTORY|At the time of admission, she had a tetraploid clone identified with a gain of one copy of chromosomes 1 and 21 and gain of two copies of chromosome 8. FISH studies showed no evidence of the BCR-ABL gene fusion or the MLL gene rearrangement. Other chromosome abnormalities were described as well. At the time of relapse, the leukemic cells appeared similar to that obtained before with no new chromosome abnormalities reported.
FISH|fluorescent in situ hybridization|FISH|222|225|HOSPITAL COURSE|He did not have true fevers, though. 6. Hematology. The patient's hemoglobin decreased to 12.1 after his cardiac catheterization. He was transfused to maintain his hemoglobin above 14. 7. Genetics. Chromosome analysis and FISH study were sent to check for a 22q deletion and a repeat newborn screen was also sent. 8. Neurology. The patient's head ultrasound showed mildly prominent bilateral periventricular echogenicity consistent with edema from hypoxemia.
FISH|fluorescent in situ hybridization|FISH|185|188|PAST MEDICAL HISTORY|Chemotherapy was restarted due to right eye progression. She is status post cryotherapy in the right eye with the last therapy on _%#MMDD2007#%_. Cytogenetic testing with G-banding and FISH drawn on _%#MMDD2007#%_ was normal showing no 13q14 deletion or other abnormalities. 2. Status post port placement. PHYSICAL EXAMINATION ON ADMISSION: Vital signs on admission were a temperature of 35.8 degree Celsius, pulse of 122, blood pressure 96/52, respiratory rate 34, weight 14.2 kg and height of 88 cm.
FISH|fluorescent in situ hybridization|FISH|407|410|THE PATIENT'S DISCHARGE MEDICATIONS WERE|Even with aggressive IV calcium gluconate replacement, he was persistently hypocalcemic(ionized calcium of 3.6). On _%#MMDD2002#%_, he had a phosphorus of 8.6 with an ionized calcium of 4.2. A parathyroid hormone level drawn on _%#MMDD2002#%_ was within the normal range but not appropriate for the degree of hypocalcemia present. Dr. _%#NAME#%_ _%#NAME#%_, Pediatric Endocrinology, recommended obtaining a FISH study for velo- cardio-facial syndrome, changing _%#NAME#%_'s formula to PM 60/40, increasing the calcium supplement dose, and starting vitamin D supplementation.
FISH|fluorescent in situ hybridization|FISH|147|150|STAGING WORKUP|Small focus of cyclin D1 positivity consistent with minimal involvement of less than 5% by lymphoma. However, cytogenetics did show involvement by FISH of translocation 11;14 suggestive of involvement. 4. MUGA scan prior to chemotherapy showed EF of 50%. PRIOR TREATMENTS: Status post 3 cycles of VCR-CVAD chemotherapy. First cycle was _%#MMDD2007#%_, second cycle _%#MMDD2007#%_, third cycle _%#MMDD2007#%_.
FISH|fluorescent in situ hybridization|FISH|156|159|HISTORY OF PRESENT ILLNESS|An ultrasound at 20+4 weeks in the MFM Clinic showed multiple anomalies consistent with trisomy 18 as well as hypoplastic left heart. An amniocentesis with FISH analysis revealed trisomy 18. The patient initially was planned for an induction of labor.
FISH|fluorescent in situ hybridization|FISH|264|267|BRIEF HISTORY OF PRESENT ILLNESS|He had bone marrow biopsy done on _%#MMDD2007#%_, which was bilateral bone marrow biopsy, showed mantle cell lymphoma, cellularity 95 to 100% with 85% involvement by lymphoma. Residual trilineage hematopoietic maturation. CD 20, CD 5, cyclin D 1 (BCL 1) positive. FISH showed translocation (11:14) and 60.8% in lysed cells. He had PET CT scan done outside the hospital, which showed modest scattered adenopathy (generalized lymphadenopathy with lymph node size generally 1 cm or less.
FISH|fluorescent in situ hybridization|FISH|146|149|4. ID|Her CSF culture was also negative. 5. GI: A total bilirubin level obtained on day 5 of life was 12.7 with a direct bilirubin of 0.0. 6. GENETICS: FISH probes for DiGeorge Syndrome and William's Syndrome were normal. Ongoing problems and suggested management: 1. RESP: It is expected that _%#NAME#%_ may continue to desat during crying episodes and vagal maneuvers.
FISH|fluorescent in situ hybridization|FISH|175|178|HOSPITAL COURSE|Of note we received information about _%#NAME#%_'s initial genetics consult workup from her neonatal course. This consult confirmed that _%#NAME#%_ had a normal karyotype and FISH probe for DiGeorge was negative. DISCHARGE MEDICATIONS: 1. Azithromycin 50 mg J-tube q.day. 2. Bacitracin applied to J-tube site b.i.d.
FISH|GENERAL ENGLISH|FISH.|135|139|ALLERGIES|1. Prednisone 60 mg q.d. for 1 week. Part of a steroid taper. 2. Glyburide 5 mg q.d. ALLERGIES: 1. PENICILLIN. 2. ASPIRIN. 3. EGGS. 4. FISH. FAMILY HISTORY: Positive for coronary artery disease and diabetes in her father and hypertension.
FISH|fluorescent in situ hybridization|FISH|187|190|PAST MEDICAL HISTORY|No residual shunting at the level of the ventricles. Wide open pulmonary regurgitation. 2. Small for gestational age. Birth weight of 2.5 kg. 3. Facial features of DiGeorge syndrome with FISH probe negative. Immunization status is up to date plus influenza vaccine this fall plus Synergist injection x2 this fall. ADMISSION EXAM: VITAL SIGNS: Respiratory rate 24, O2 saturation 95% on room air, temperature 98.6, pulse 142, blood pressure 102/60, weight 6.51 kg.
FISH|fluorescent in situ hybridization|FISH|168|171|FOLLOWUP|_%#NAME#%_ was noted to have hypocalcemia (ionized calcium 4.2) during her hospitalization. Given this finding, along with her cleft palate, chromosomes were sent with FISH for DiGeorge. (see below - Problem #7) Problem #2: Respiratory. _%#NAME#%_'s respiratory status was monitored closely due to her choking spells during feedings while in the newborn nursery.
FISH|fluorescent in situ hybridization|FISH|216|219|1. FEN|Loaded with caffeine on _%#MMDD2004#%_, now getting 5mg/kg QD, with caffeine levels to be checked weekly. 3. CV/heme: Received PRBC's today, recheck hemoglobin tomorrow. Keep on PGE. 4. Genetics: Chromosome studies, FISH probe pending. 5. Access: He requires central line placement. Discharge medications: 1. Prostaglandin E 0.1 mcg/kg/min IV in D10W
FISH|fluorescent in situ hybridization|FISH|151|154|HISTORY OF PRESENT ILLNESS|He eventually had a CT which showed enlarged adenoids. He subsequently had a biopsy which was consistent with undifferentiated hematologic malignancy. FISH studies were consistent with the same translocation as the original leukemic population, (T11:19). The patient complains of a 2-week history of myalgia, generalized proximal muscle weakness.
FISH|fluorescent in situ hybridization|FISH,|205|209|PROCEDURES PERFORMED|The fetal heart has shifted to the right chest wall with apex pointing to the midline. 3. Amniocentesis was performed after informed consent was obtained on _%#MMDD2003#%_. The amniotic fluid was sent for FISH, _____, type, and viral studies. A nonstress test was performed and was reactive 4. On _%#MMDD2003#%_ a renal ultrasound showed moderate right hydronephrosis that is greater than typically seen in pregnancy with no renal stone or cause of obstruction seen.
FISH|fluorescent in situ hybridization|FISH|150|153|LABORATORY DATA|She then underwent another amniocentesis x two with fetal thoracocentesis. The thoracentesis results were negative for CMV, HIV, _____, and provirus. FISH was negative for trisomy 13, 18, and 21. Potassium was 3.6, sodium 1.3, _________. She continued to be stable during her hospitalization. On _%#MMDD2003#%_ the patient was reassessed and AVP fetal thoracocentesis was done showing the yellow amniotic fluid from the left thorax.
FISH|fluorescent in situ hybridization|FISH.|224|228|LABORATORY|Serum calcium on _%#MM#%_ _%#DD#%_, 2004, 8.9. Breast biopsy demonstrated extensive intradermal invasive ductal carcinoma, negative testing for estrogen and progesterone receptors, and pending determination of HER-2/neu and FISH. Lab testing for breast tumor marker CA27.29 was elevated at 308; normal is 0-39. HOSPITAL COURSE: The patient was exceedingly weak, and had a lot of back pain.
FISH|GENERAL ENGLISH|FISH|301|304|HISTORY OF THE PRESENT ILLNESS|CHIEF COMPLAINT: Anaphylaxis. HISTORY OF THE PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 45-year- old male who has no significant medical history other than a previous gun shot wound. He presents to the emergency room tonight with an anaphylactic reaction. Apparently, he has a known ALLERGY TO SHELL FISH BUT HAD A SPOONFUL OF CANNED CRAB MEAT TONIGHT AND SUBSEQUENTLY DEVELOPED SHORTNESS OF BREATH, SWELLING IN The FACE, AND HIVES.
FISH|fluorescent in situ hybridization|FISH|271|274|OPERATIONS/PROCEDURES PERFORMED|3. Nissen fundoplication _%#MM#%_ _%#DD#%_, 2004. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ was a newborn infant who was diagnosed with tetralogy of Fallot and pulmonary atresia, with confluent pulmonary arteries, although they were very small in size. She had a FISH that was negative for DiGeorge syndrome during this hospitalization. She also ended up having severe aspiration and reflux disease. The patient was transferred to the University of _%#MM#%_ _%#DD#%_, 2004, for evaluation of the above identified cardiac anomaly, and the cardiac cath did demonstrate small confluent pulmonary arteries.
FISH|fluorescent in situ hybridization|FISH|141|144|ASSESSMENT/PLAN|We will also plan on rechecking his white count. 5. Genetics: Chromosomes were sent in _%#CITY#%_ _%#CITY#%_ and were reportedly normal, but FISH is still pending at this time and will be followed up on. 6. Social: Given that his mother is a vulnerable adult and has a guardian (though it seems she does have the ability to consent for Davian) and also due to the fact that she has had two previous children who have been removed from the home and adopted, Social Work will be contacted and asked to be involved with _%#NAME#%_'s case.
FISH|fluorescent in situ hybridization|FISH|365|368|PROCEDURES PERFORMED|It was felt that this was not associated with malrotation and for this reason we increased her lactulose and increased her regimen to maintain a higher stool output and decrease her symptomatic constipation, which she presented with. We did obtain a genetics and metabolism consult with Dr. _%#NAME#%_, who recommended that resend high-resolution chromosomes and a FISH for velocardiofacial syndrome. These labs remained pending at the time of this dictation. Furthermore, we did an MRI of the cranium and brain, which was found to be unremarkable with the skull findings to be not consistent with velocardiofacial syndrome despite her constellation of ASD versus PFO, developmental delay, and dysplastic right kidney.
FISH|fluorescent in situ hybridization|FISH|182|185|HOSPITAL COURSE|Serum creatinine was 1.2 gm/dL. Calcium was 10 mg/dL. Bone marrow biopsy demonstrated a normal cellular marrow with 33% plasma cells. Plasma cells were kappa light chain restricted. FISH studies and plasma cell labeling index are pending. For treatment of multiple myeloma, Mr. _%#NAME#%_ initiated dexamethasone 40 mg p.o. daily x4 days.
FISH|fluorescent in situ hybridization|FISH|216|219|1. FEN|Pediatric Oncology was consulted on _%#MMDD2004#%_ and recommended another repeat peripheral smear, peripheral blood evaluation by Molecular Genetics for PML/RARA, and peripheral blood evaluation by Cytogenetics via FISH looking for translocation of 15/17. Dr. _%#NAME#%_ _%#NAME#%_ with Pediatric Hematology/Oncology will follow up with _%#NAME#%_ as an outpatient in his Thursday clinic.
FISH|fluorescent in situ hybridization|FISH|181|184|OPERATIONS/PROCEDURES PERFORMED|Of note, the patient is not on the study due to HIV. The patient was electively admitted for a third course of chemotherapy. The patient was diagnosed with Burkitt lymphoma. It was FISH positive for C-myc and on cytogenetics was positive for translocation of 8-12. On admission vital signs are 98.6, pulse 93, blood pressure 139/88, respiratory rate 19, O2 saturations 97%.
FISH|GENERAL ENGLISH|FISH|103|106|ALLERGIES|2. Protonix 40 mg daily. 3. Coreg 3.125 mg b.i.d. 4. Multiple vitamin, iron, calcium. ALLERGIES: SHELL FISH AND SEAFOOD. QUESTION OF IVP DYE, ALTHOUGH, WE HAVE DONE IT IN THE PAST WITH PRETREATMENT SUFLA DRUGS. HEALTH HABITS: Smoking history none. Alcohol use none. SOCIAL HISTORY: The patient is married.
FISH|fluorescent in situ hybridization|FISH|125|128|HISTORY OF PRESENT ILLNESS|CSF done at that time was negative for malignancy. _%#NAME#%_ had an enucleation of her left eye on _%#MM#%_ _%#DD#%_, 2004. FISH assay did not detect a deletion at her RD1 gene locus. _%#NAME#%_ is currently status post 3 rounds of chemotherapy which she gets monthly with vincristine, etoposide, and carboplatin.
FISH|fluorescent in situ hybridization|FISH|275|278|PROCEDURES PERFORMED|Bone marrow biopsy on _%#MM#%_ _%#DD#%_, 2004, suboptimal showing 5% cellularity with decreased granulopoiesis; and most recent bone marrow biopsy was on _%#MM#%_ _%#DD#%_, 2005, which showed essentially aplastic marrow with less than 5% cellularity and normal cytogenetics. FISH had 2/500 cells with monosomy 7. The patient was admitted for ATG treatment. He had no complaints at the time of admission.
FISH|fluorescent in situ hybridization|FISH|144|147|PLAN|She is going to get an ultrasound. If her ultrasound is consistent with an abnormality, and if she is HER- 2/neu positive, although I think her FISH was HER-2/neu negative, we would consider treating her with a taxane. She has never had Taxol before. I will see her again in _%#MM#%_.
FISH|fluorescent in situ hybridization|FISH.|321|325|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her mixed infiltrating ductal and lobular carcinoma with signet ring features and LCIS, diagnosed _%#MMDD2000#%_, grade 2/3, with 14 of 22 lymph nodes involved. She was ER/PR positive at 83.6 and 16.4% respectively, and HER-2/neu positive by FISH. REVIEW OF SYSTEMS: GENERAL: Appetite is good but her weight is down 3 pounds.
FISH|GENERAL ENGLISH|FISH.|287|291|ALLERGIES|She does have a history of asthma, chronic sinusitis, chronic otitis, IgG sub-class III deficiency, hyperthyroidism, aortic insufficiency, status post right knee surgery. ALLERGIES: CORTISONE, INHALED STEROIDS, IBUPROFEN, IODINE, ZITHROMAX, BIAXIN, DYAZIDE, HYDRALAZINE, CELEBREX, SHELL FISH. MEDICATIONS: 1. Cardizem. 2. Losar. 3. Lopressor. 4. Lisinopril.
FISH|fluorescent in situ hybridization|FISH.|253|257|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her infiltrating ductal carcinoma of the left breast diagnosed _%#MMDD2000#%_, grade 2 of 3 with one of 17 lymph nodes, ER/PR positive at 90% and 10%, respectively, negative FISH. REVIEW OF SYSTEMS: GENERAL: Weight is down 2 pounds with weight loss, but appetite is good.
FISH|fluorescent in situ hybridization|(FISH)|212|217|HOSPITAL COURSE|The procedure had no complications. A post-procedure ultrasound revealed the uterus to be empty. The pathology from this D and C revealed chorionic villi, however, no fetal parts were seen. The cytogenic testing (FISH) on the products of conception did come back as diploid. It is thought that the patient may have passed the products of conception prior to the D and C as final ultrasound immediately after the procedure revealed an empty uterus.
FISH|fluorescent in situ hybridization|FISH|346|349|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Bronchiolitis. 2. Reactive airway disease. 3. Tetralogy of Fallot; status post balloon dilation of pulmonary valve; status post complete repair of the resection of pulmonary valve and infundibular muscle and LPA plasty (_%#MM2007#%_). 4. PDA: Status post ligation. 5. SGA. 6. Concern facial features of DiGeorge syndrome, FISH negative. DISCHARGE MEDICATIONS: 1. Albuterol nebs 2.5 mg q.4h. x3 days, then p.r.n.
FISH|fluorescent in situ hybridization|FISH|259|262|HISTORY OF PRESENT ILLNESS|On _%#MMDD2004#%_ _%#NAME#%_ underwent enucleation of the left eye. Pathology of the eye showed retinoblastoma with diffuse growth pattern and 1 mm invasion into the optic nerve. CT scan of the head showed no evidence for extraglobal spread and normal brain. FISH on peripheral blood showed no deletion at the RB1 locus. _%#NAME#%_ is admitted to Fairview-University Medical Center on _%#MMDD2004#%_ for chemotherapy with vincristine, etoposide, and carboplatin.
FISH|fluorescent in situ hybridization|FISH|126|129|HISTORY OF PRESENT ILLNESS|There was diffuse growth of the tumor. A CT scan was performed which showed no evidence for extra global spread and a normal. FISH on peripheral blood showed no deletion at the RB 1 locus. _%#NAME#%_ is being admitted to Fairview University Medical Center on _%#MM#%_ _%#DD#%_, 2004, for her 2nd of 6 rounds of chemotherapy with vincristine, etoposide, and carboplatin.
FISH|fluorescent in situ hybridization|FISH|206|209|OPERATIONS/PROCEDURES PERFORMED|He has been seen by infectious disease, Dr. _%#NAME#%_ _%#NAME#%_, who specializes in DiGeorge. She has recommended followup in 2 months after discharge. His original IgG levels appear normal. 5. Genetics. FISH chromosomes were sent and positive for DiGeorge syndrome with microdeletion in the proximal long arm of chromosome 22. He is being seen by genetics. DISCHARGE INSTRUCTIONS: Discharge medications include calcium carbonate 80 mg PO q.8 hours, Rocaltrol 0.2 mcg PO q. day, Polytrim ophthalmic drops 2 drops each eye b.i.d. x4 days.
FISH|fluorescent in situ hybridization|FISH|215|218|OPERATIONS/PROCEDURES PERFORMED|CXR showed improved pulmonary fields compared to his _%#MMDD#%_ films. Head CT was normal. ECG showed sinus rhythm with possible right atrial abnormalities and possible left ventricular hypertrophy. Chromosomes and FISH probe to rule out DiGeorge syndrome were drawn on _%#MMDD#%_ prior to transfer. Electrolytes, CBC, and coagulation panels were checked at Rice and were essentially normal with a mild hypokalemia and alkalosis.
FISH|GENERAL ENGLISH|FISH|176|179|ALLERGIES|No other history of arthritis. She does have a history of diabetes mellitus, which is apparently well controlled. ALLERGIES: PENICILLIN, SULFA, CODEINE, VITAMIN A, EGGS, SHELL FISH AND FEATHERS. ADMISSION MEDICATIONS: Lipitor 10 mg p.o. q. day, fluoxetine 10 mg p.o. q. day, dipyridamole 200 mg p.o. b.i.d., propranolol 40 mg p.o. t.i.d., metformin 500 mg p.o. b.i.d., furosemide 20 mg p.o. q. day, aspirin 81 mg p.o. q. day, Norvasc 10 mg p.o. q. day.
FISH|fluorescent in situ hybridization|FISH|265|268|ULTRASOUNDS|PAST OB HISTORY: She is a primigravida. PAST SURGICAL HISTORY: Tonsils and adenoids removed in 1990, wisdom teeth removed in 1997. ULTRASOUNDS: 1. At 7 plus 2 weeks. 2. At 11 plus 0 weeks with an anterior placenta, increased nuchal translucency, CVS performed, and FISH was 46 XY. 3. At 15 plus 4 weeks, anterior placenta, 2-vessel cord, AFI normal. 4. At 19 plus 4 weeks, anterior placenta, normal AFI.
FISH|GENERAL ENGLISH|FISH|93|96|ALLERGIES|Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ did history and physical. See his dictation. ALLERGIES: FISH OIL. DISCHARGE STATUS: He is alert, oriented, and cooperative.
FISH|fluorescent in situ hybridization|FISH|145|148|HISTORY OF PRESENT ILLNESS|These were estrogen receptor negative, progesterone receptor positive in about 70% of the cells. Estrogen-progesterone receptors in HER-2/neu by FISH will be performed and reported in an addendum which is not available at the time of discharge.
FISH|fluorescent in situ hybridization|FISH|159|162|HISTORY OF PRESENT ILLNESS|She then received consolidation with daunorubicin and ATRA followed by methotrexate. The patient relapsed in _%#MM#%_ 2004 with 17% blasts and was noted to be FISH positive for PML/RAR. ATRA was increased at that point. She went on to require induction chemotherapy. She received more therapy in _%#MM#%_ 2005 and was later switched to an Ara-C containing regimen and ATRA.
FISH|GENERAL ENGLISH|FISH,|128|132|ALLERGIES|10. Prilosec. 11. Tetracycline. 12. Relpax. 13. Multivitamin. She does not know any of the doses. ALLERGIES: SEA FOOD AND SHELL FISH, which led to anaphylaxis. IMITREX, which led to hives. SULFA, which leads to swelling. FAMILY HISTORY: Multiple first degree relatives have trouble with coronary artery disease, myocardial infarction, hypertension, hyperlipidemia.
FISH|fluorescent in situ hybridization|FISH|194|197|HISTORY OF PRESENT ILLNESS|CA 27/29 on _%#MM#%_ _%#DD#%_, 2004, was 679. The pathology of her liver biopsy was reviewed here and was found to be ER positive but PR negative. HER- 2/neu was negative on the liver biopsy by FISH analysis. The patient was continued on Femara starting in _%#MM#%_ 2004 with a decrease in CA 27/29. Unfortunately, CT in _%#MM#%_ 2005 showed increase in hepatic metastasis.
FISH|fluorescent in situ hybridization|FISH|209|212|FOLLOW UP|Blood culture obtained on admission was negative. This problem has resolved. Problem #6: Genetics/Evaluation for tuberous sclerosis. Blood samples for newborn chromosome study, tuberous sclerosis markers, and FISH for 22q deletion were sent and are pending at the time of transfer. A blood sample for a "complete tuberous sclerosis evaluation" was sent to Athena Diagnostics (_%#TEL#%_).
FISH|fluorescent in situ hybridization|FISH|141|144|PROBLEM #2|The results of the FISH will come back in 1 to 2 weeks. The patient is going to be discharged home on the hydroxyurea and the results of the FISH will be followed up at his hematology visit in 1 to 2 weeks. We contacted the Hematology Clinic to make an appointment for the patient and the Hematology Clinic will notify the patient with an appointment in the next 2 to 3 days as they are going to have the hematology staff look at the case and decide the need for follow up.
FISH|fluorescent in situ hybridization|FISH|216|219|PAST MEDICAL HISTORY|Subsequent to that, two additional cystoscopies have been negative. Most recent cystoscopy was performed 2 days prior to admission on _%#MM#%_ _%#DD#%_, 2006, which revealed no visual abnormalities, but cytology and FISH returned positive for malignant cells. 2. Status post channel TURP procedure done in _%#MM#%_ 2005 to relieve mild obstructive uropathy symptoms.
FISH|fluorescent in situ hybridization|FISH|141|144|PCU 5C/PICU|Blood cultures were drawn on _%#MMDD2006#%_, and were negative at the time of transfer. Problem #3: Genetics. _%#NAME#%_ had chromosomes and FISH for DiGeorge sent. The results of these studies were pending at the time of transfer. She also had screening renal and head ultrasounds done before transfer.
FISH|GENERAL ENGLISH|FISH,|103|107|ALLERGIES|5. Revision of ileostomy. 6. Hysteroscopy and D and C in 1993. ADMISSION MEDICATIONS: None. ALLERGIES: FISH, SEA FOOD, AND SULFATE PRESERVATIVES. SOCIAL HISTORY: The patient works as a nurse. She worked at a factory for many years, and they moved the business to China, and she is on the end of her benefits package and will be losing her insurance at the end of _%#MM#%_ 2006.
FISH|GENERAL ENGLISH|FISH|112|115|ALLERGIES|2. Chest tube placement x2. CURRENT MEDICATIONS: Prenatal vitamins. ALLERGIES: ERYTHROMYCIN CAUSED HIVES. SHELL FISH CAUSES ERYTHEMAOF THE NECK. KIWI CAUSES THROAT SWELLING. FAMILY HISTORY: Unilateral breast cancer in her mother at age 48.
FISH|GENERAL ENGLISH|FISH|277|280|HOSPITAL COURSE|PATIENT IDENTIFICATION: _%#NAME#%_ _%#NAME#%_ male with history of intermittent bouts of gastroenteritis as a youth who presented for one- and-a-half to two-day history of abdominal pain associated with significant diarrhea. HOSPITAL COURSE: The patient has a history of SHELL FISH ALLERGY, therefore a CT scan of the abdomen was performed without contrast demonstrating probable wall thickening of the terminal ileum.
FISH|GENERAL ENGLISH|FISH|143|146|PLAN|PLAN: 1. Follow-up prn basis. 2. Follow-up with primary care physician for any persistent or worsening GI symptoms. 3. Refill of EpiPen (SHELL FISH ALLERGY). DISCHARGE MEDICATIONS: None.
FISH|GENERAL ENGLISH|FISH,|97|101|ALLERGIES|History of irregular menses. Has been noted to become heavier recently. ALLERGIES: IODINE, SHELL FISH, X-RAY DYE, NAPROSYN, CODEINE. SOCIAL HISTORY: Is married, works for the school district.
FISH|fluorescent in situ hybridization|FISH.|174|178|HOSPITAL COURSE|NICU was in attendance secondary to concern for possible duodenal atresia, as described above. The placenta was delivered intact at 14:10. Blood was sent for chromosomes and FISH. Placenta was sent to pathology. In sum, the first stage of labor was 2 hours 18 minutes, the second stage 7 minutes, and the third stage 5 minutes, for a total of 2 hours 30 minutes.
FISH|fluorescent in situ hybridization|FISH|128|131|2. CV|9. Genetics: Chromosomes have been sent twice (the first sample had inadequate growth) and are currently pending. He did have a FISH probe for DiGeorge that was sent and was negative. Ongoing problems and suggested management: 1. FEN: He is tolerating full feeds with breast milk at 42 cc gavaged q 3 hours.
FISH|fluorescent in situ hybridization|FISH|178|181|HISTORY OF PRESENT ILLNESS|In _%#MM2003#%_ she was treated with idarubicin and Ara-C with high-dose Ara-C consolidation ending in _%#MM2003#%_. Follow-up bone marrow initially revealed remission, however, FISH analysis revealed 11 Q23 gene rearrangement. The initial plan was for an autotransplant, however, in the light of her synergetic abnormality she instead was admitted today for a double-cord transplant non-myeloablative prep.
FISH|fluorescent in situ hybridization|FISH|241|244|BONE MARROW TRANSPLANT WORKUP|5. MUGA revealed ejection fraction of 67%. 6. Bone marrow biopsy on _%#MMDD2003#%_ was 50% cellular with trilineage metapoiesis, no leukemia, 50% of cells had disruption, and deletion of a portion of the MLL locus, identical to the abnormal FISH pattern from _%#MMDD2003#%_. 7. Cerebrospinal fluid on _%#MMDD2003#%_ was normal. 8. Pulmonary function tests revealed minimal obstructive airway disease.
FISH|fluorescent in situ hybridization|FISH|129|132|1. FEN|Antibiotics were discontinued after cultures were negative for 48 hours. 5. Genetics: Chromosomes were sent for karyotpye with a FISH probe for DiGeorge. Renal and abdominal ultrasound and head ultrasound were obtained to look for other congenital anomalies associated with CHD and dextrocardia.
FISH|fluorescent in situ hybridization|FISH|202|205|HISTORY OF PRESENT ILLNESS|An amniocentesis was performed, and the findings were normal female karyotype. Additional metaphase FISH revealed hybridization of number 22 chromosomes to the TUPLE-1 and ARSA probes, and an interface FISH showed a pattern consistent with the presence of two copies of both of those. Thus, no deletion or duplication involving the TUPLE-1 locus in band 22q11.2 was detected.
FISH|GENERAL ENGLISH|FISH,|123|127|ALLERGIES|FAMILY HISTORY: Father murdered at age 39. Mother died at 73 of diabetes and obesity complications. ALLERGIES: PENICILLIN, FISH, LATEX, CEPHALEXIN. MEDICATIONS: Aspirin 325 1 p.o. q. day, Lasix 20 mg p.o. b.i.d., Levothyroxine 100 mcg p.o. daily, metoprolol 50 mg p.o. b.i.d., Protonix 40 mg p.o. daily, Paxil 20 mg p.o. daily, nitroglycerin q. 5 minutes times three p.r.n..
FISH|fluorescent in situ hybridization|FISH.|160|164|HISTORY OF PRESENT ILLNESS|A bone marrow biopsy in _%#MM2004#%_ was consistent with myelofibrosis with atypical megakaryocytes. There were no increased blasts. He was BCR/ABL negative by FISH. His previous hospitalization had been complicated by recurrent ascites of unknown etiology. It was also complicated by acute renal failure of unclear etiology.
FISH|fluorescent in situ hybridization|FISH.|160|164|HISTORY OF PRESENT ILLNESS|She had some DCIS. Thus she was a stage III-A. She was estrogen receptor positive at 18%, progesterone receptor negative at 3.7%, and HER-2/neu was negative by FISH. The patient had a right breast tumor resected and that breast had two tumors. The patient's right breast had two sentinel lymph nodes that were normal.
FISH|GENERAL ENGLISH|FISH.|250|254|ALLERGIES|ALLERGIES: PLEASE NOTE PATIENT TOLERATED IV DYE, NONIONIC DYE, THIS HOSPITALIZATION WITHOUT ANY PREMEDICATION. HE INSISTS THAT HE HAS NOT HAD PROBLEMS WITH IV DYE IN THE PAST BUT AT ONE POINT HE DID REPORT PROBLEMS WITH A SINGLE TIME CONSUMING SHELL FISH. MEDICATIONS: Zanaflex 4 mg in the morning, 8 mg at 1:00 p.m. and h.s.; Azmacort MDI 8 puffs b.i.d. in the vent tube, multivitamin with minerals one tablet through the G tube daily, ferrous sulfate 10 ml (dose unclear) via G tube t.i.d., clonidine 0.3 mg patch q. Wednesday, Detrol 2 mg per G tube t.i.d., Diflucan 100 mg through the G tube q.d., heparin 2500 units subcu b.i.d., Neurontin 600 mg per G tube t.i.d., Senna liquid 15 cc per G tube b.i.d., Colace 100 mg (10 ml) per G tube b.i.d., Promote with fiber 75 cc an hour per G tube q. 7:00 p.m. through 7:00 a.m., water per G tube 100 cc after cares and following any medication, MiraLax powder one capful in 8 ounces of water q.d., Nexium 40 mg per G tube b.i.d., chloral hydrate 2000 mg per G tube q.h.s., Zyrtec 10 mg per G tube q.d., Singulair 10 mg per G tube q.h.s., Atrovent nebs 500 mg t.i.d., Mucomyst nebulizer 20% 0.5 ml t.i.d. in Atrovent nebs, Risperdal 2 mg per G tube b.i.d., Seroquel 300 mg per G tube b.i.d., Levox 50 mg per G tube q.a.m., methadone 5 mg five times daily per G tube.
FISH|fluorescent in situ hybridization|FISH|417|420|HISTORY OF PRESENT ILLNESS|Blood cultures were negative. She was treated with vancomycin and gentamicin for a total of six weeks, and antibiotics were changed to vancomycin and Rocephin because of worsening renal function. She is status post six weeks of antibiotics. Her other medical problems are long-standing hypertension with mild renal insufficiency and recurrent urinary tract infections, with a baseline creatinine from 1.3 to 1.5. Her FISH analysis on the _%#MMDD2004#%_ bone marrow biopsy was positive for translocation of 15; 17. Her last bone marrow biopsy on _%#MMDD2004#%_ showed 90% cellularity with trilineage hematopoiesis and no promyelocytes.
FISH|fluorescent in situ hybridization|FISH|265|268|HISTORY OF PRESENT ILLNESS|Marrow and lymph node biopsies demonstrated mantle cell lymphoma manifested as a diffuse infiltration with lymphoid cells expressing markers compatible with mantle cell lymphoma, specifically, light chain restriction CD20, CD5, but were negative for CD23 and CD10. FISH studies showed 3.8% of 500 cells examined had fusion of CCND1 and IgH signal suggesting a clonal population compatible with mantle cell lymphoma.
FISH|fluorescent in situ hybridization|FISH.|219|223|HISTORY OF PRESENT ILLNESS|She was diagnosed _%#MMDD2005#%_. It was a grade 3/3. She had a cancer that was 1.9 cm in its greatest dimension. She had 1 of 3 lymph nodes positive. She is ER/PR positive at greater than 10% and HER-2/neu positive by FISH. PAST MEDICAL HISTORY: Achalasia peristaltic action and she had Hodgkin's disease in 1990.
FISH|fluorescent in situ hybridization|FISH|321|324|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 46-year-old woman who is in today for followup of her infiltrating lobular carcinoma of the right breast, multicentric, with extensive LCIS, DCIS, status post bilateral mastectomy, diagnosed _%#MMDD2004#%_, grade 2 of 3, with 0 of 3 lymph nodes, ER and PR positive, FISH negative. REVIEW OF SYSTEMS: GENERAL: She is hot all the time.
FISH|GENERAL ENGLISH|FISH,|133|137|ALLERGIES|6. Clonidine 0.2 mg daily. 7. Altace 10 mg daily. 8. Stool softener daily. ALLERGIES: No known drug allergies, but ALLERGIC TO SHELL FISH, AS WELL AS OTHER SEAFOOD. PHYSICAL EXAMINATION: She is pleasant, well-built, well-nourished female who appears to be in no acute distress.
FISH|GENERAL ENGLISH|FISH.|129|133|ALLERGIES|6. Serous cyst adenoma of the left ovary. 7. Fracture of 4th and 5th toes on the right foot. ALLERGIES: PENICILLIN, CHICKEN, and FISH. SOCIAL HISTORY: Lives with her other relatives on the _%#CITY#%_ _%#CITY#%_ Indian Reservation in Northern Minnesota. Patient is a 1-pack-per-day smoker times many years. Denies alcohol or drugs.
FISH|fluorescent in situ hybridization|FISH|277|280|OPERATIONS/PROCEDURES PERFORMED|3. Retinal hemorrhage. 4. Neutropenic fevers. OPERATIONS/PROCEDURES PERFORMED: 1. Bone marrow biopsy - initially performed on _%#MM#%_ _%#DD#%_, 2006, showing marrow cellularity of 95% to 100% with 80% leukemic promyelocytes consistent with acute myeloid leukemia. The initial FISH was negative for the 15;17 translocation; however, repeat probe did show this was positive thus giving the patient diagnosis of APL.
FISH|GENERAL ENGLISH|FISH|100|103|LABORATORY|No virus was isolated from the duodenum and stomach biopsies. Ova and parasites were negative. MILD FISH ALLERGY. Urine organic acid analysis negative. Inflammatory markers normal. Free creatinine and total creatinine decreased. HOSPITAL COURSE: This 6-year-old male was put n.p.o. due to his consistent vomiting after eating.
FISH|fluorescent in situ hybridization|FISH|175|178|FOLLOW UP|Problem # 6: Genetic Evaluation: Chromosome studies were sent because of the ENT abnormalities and the two vessel cord. These results showed a normal karyotype, with negative FISH for DiGeorge and/or velo-cardio-facial syndrome. Problem #7: Renal. _%#NAME#%_ had a renal ultrasound on _%#MMDD2006#%_, which revealed mild left hydronephrosis versus reflux, and mild prominence of the right renal collecting system.
FISH|fluorescent in situ hybridization|FISH|193|196|HOSPITAL COURSE|7. CNS. A head ultrasound was done because of dysmorphic features and uncertainty of chromosome abnormality and a poor suck. On _%#MMDD#%_, the head ultrasound was read as normal. 8. Genetics. FISH chromosomes were sent to rule out trisomy-21 but revealed a duplication of the short arm chromosome 6. Parental chromosomes were sent and are negative for a similar mutation.
FISH|fluorescent in situ hybridization|FISH|147|150|HOSPITAL COURSE|Genetics was consulted and a provisional diagnosis of Pierre-Robin sequence was made. Chromosomes were studied and found to be normal in number. A FISH analysis was also normal. An echocardiogram was significant for mild hypertrophy and tricuspid regurgitation but no other defects. Repeat echocardiogram showed mild right ventricular hypertrophy. A skeletal survey was normal.
FISH|fluorescent in situ hybridization|FISH.|173|177|IMAGING/PROCEDURES|IMAGING/PROCEDURES: 1. Bone marrow biopsy. Immunophenotype consistent with acute myeloid leukemia with t(8; 21). Further studies also revealed CbsA 2T1/RUNX1 gene fusion on FISH. Dental x-rays revealed likely periapical abscess of the inferior teeth. 2. MUGA revealed an ejection fraction of 61% as well as normal left ventricular size and wall motion.
FISH|fluorescent in situ hybridization|FISH|208|211|CLINICAL NOTE|5. _%#MMDD2006#%_: Nissen fundoplication and G-tube. CLINICAL NOTE: _%#NAME#%_ is a newborn baby who was born with an interrupted arch, type B with an aberrant right subclavian artery, bicuspid aortic valve. FISH probe was positive for DiGeorge. The patient went to the operating room on _%#MMDD2006#%_ and had an aortic arch reconstruction.
FISH|fluorescent in situ hybridization|FISH|171|174|DISCHARGE MEDICATIONS|He was also noted to have mild cranial suture overlapping with head molding; and jaundice of his face and upper trunk. Labs pending at discharge: Chromosomes and DiGeorge FISH studies. Follow-up appointments: The parents were asked to make an appointment for _%#NAME#%_ to see you within one week.
FISH|fluorescent in situ hybridization|FISH|159|162|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 9-year-old African-American female with recently diagnosed CML (Philadelphia chromosome positive) with a positive FISH probe. She is being prepared for unrelated bone marrow transplant, but currently receives daily chemotherapy with Gleevec. She was admitted for fever and headache. The headache began on the day prior to admission with low-grade fevers (100.5-100.6) at home.
FISH|fluorescent in situ hybridization|FISH|217|220|1. FEN|Renal ultrasound (_%#MMDD2003#%_) was unremarkable. 6. NEURO: Head U/S on _%#MMDD2003#%_ was normal. 7. ID: Unasyn was given post op x 3 days, prophylactically. 8. Genetics: A repeat chromosome analysis showed 46 XX. FISH probe for DiGeorge syndrome was negative. 9. HEME: Per cardiology recommendations, hemoglobin was kept above 12. She received a transfusion of PRBCs on _%#MMDD#%_, and was then started on iron supplementation.
FISH|fluorescent in situ hybridization|FISH|242|245|DISCHARGE PLANS|This is an undifferentiated acute myelogenous leukemia with over 20% blasts in the bone marrow. There is evidence of multi-linear dysplasia. Initially the immunophenotyping revealed findings consistent with a promyelocytic leukemia, although FISH testing has shown no evidence of the T15-17 translocation. Further cytogenetics are still pending. Currently she notes pain in the left lower extremity with her deep venous thrombosis and pain in the left chest after a Port-A-Cath has been placed.
FISH|GENERAL ENGLISH|FISH.|142|146|ALLERGIES|1. Status post right total hip arthroplasty. 2. Elevated blood pressure. 3. Asthma. 4. Hypothyroidism. ALLERGIES: PENICILLIN, BENZOCAINE, AND FISH. HOSPITAL COURSE: The patient was transferred from the acute orthopedic unit at _%#CITY#%_ Hospital to Fairview University Transitional Services on _%#MM#%_ _%#DD#%_, 2004.
FISH|fluorescent in situ hybridization|FISH|135|138|PROBLEM #9|The patient was to be discharged to home on a bilirubin blanket with a follow-up check two days after discharge. PROBLEM #9: Genetics. FISH analysis interpretation is as follows: Represent a normal male karyotype. No numerical or structural chromosomal abnormalities. Metaphase FISH showed hybridization of both 22 and interface FISH showed two singles for each probe consistent with each chromosome 22 having a single copy of the chromosome.
FISH|GENERAL ENGLISH|FISH.|166|170|PAST MEDICAL HISTORY|He exercises on a regular basis walking his dog as well as working out on a bicycle and using weights. ALLERGIES: He is allergic to the PENICILLINS and also to SHELL FISH. Both of these cause significant diarrhea. FAMILY HISTORY: Of note is the fact that his mother has a history of cancer of the stomach which ultimately caused her death.
FISH|fluorescent in situ hybridization|FISH|191|194|HISTORY OF PRESENT ILLNESS|This included intrathecal chemotherapy prophylaxis. Gleevec was added at day 22. He was an early slow responder. His day 34 bone marrow biopsy was in morphologic remission with 1% BCR/ABL by FISH and 2% monosomy 7. _%#NAME#%_ started consolidation in _%#MM#%_. _%#NAME#%_ is in need of a bone marrow transplant. He was referred to the University of Minnesota Medical Center, Fairview, on _%#MMDD2006#%_.
FISH|GENERAL ENGLISH|FISH,|117|121|ALLERGIES|REVIEW OF SYSTEMS: The patient has remained NPO. She remains mildly dyspneic. She has been febrile. ALLERGIES: SHELL FISH, DARVOCET, TAPE. MEDICATIONS: 1. Metronidazole 500 mg every 8 hours. 2. Ticarcillin/clavulanate 3.1 g IV every 12 hours.
FISH|fluorescent in situ hybridization|FISH|253|256|LOCATION|As you know she was diagnosed back in _%#MM#%_, underwent a lumpectomy and sentinel lymph node biopsy on _%#MMDD2005#%_. Her tumor was estrogen receptor positive and progesterone receptor negative. She had marked over-expression of _________ protein by FISH analysis. Starting on _%#MMDD2005#%_ she was placed on adriamycin and Cytoxan in a q.2 week schedule. She received four cycles. This was then followed by a combination of Taxol weekly with Herceptin for the next 12 weeks.
FISH|fluorescent in situ hybridization|FISH|149|152|PLAN|The ultrasound today revealed a ventricular septal defect, thus _%#NAME#%_ and _%#NAME#%_ decided to have an amniocentesis. Preliminary results from FISH were normal. Final results will be available in 10 to 14 days. A follow-up echocardiogram is recommended due to the heart defect that is seen.
FISH|fluorescent in situ hybridization|FISH|201|204|HISTORY OF THE PRESENT ILLNESS|This was subsequently needle biopsied and positive for infiltrating ductile carcinoma. The tumor was a grade 2 and was estrogen and progesterone receptor negative. It was subsequently also analyzed by FISH analysis and was negative for HER-2 overexpression. The patient was seen by Dr. _%#NAME#%_, and on _%#MM#%_ _%#DD#%_, she underwent a left breast lumpectomy, as well as a sentinel lymph node dissection.
FISH|fluorescent in situ hybridization|FISH|256|259|RECOMMENDATIONS|Sometimes a hypoplastic left heart is part of a chromosomal syndrome, and two examples were reviewed; Down syndrome and trisomy 18. . Sometimes a small portion of the 22nd chromosome is deleted in babies with hypoplastic heart, and this can be detected by FISH through an amniocentesis. Hypoplastic heart can also be associated with other genetic syndromes which do not involve chromosomes, but involve individual genes.
FISH|fluorescent in situ hybridization|FISH|242|245|RECOMMENDATIONS|Printed information regarding unexpected ultrasound findings and congenital heart defects was given to them today. _%#NAME#%_ is scheduled to have an amniocentesis on _%#MMDD2003#%_ by Dr. _%#NAME#%_. I would recommend chromosomes as well as FISH for 22q deletion, because of the hypoplastic left heart on ultrasound. A thorough fetal echocardiogram is scheduled for _%#MMDD2003#%_. _%#NAME#%_ and her husband stated they will attempt to obtain more information regarding this diagnosis.
FISH|fluorescent in situ hybridization|FISH.|174|178|HISTORY OF PRESENT ILLNESS|The patient had further workup and was found to have metastases to her liver and right shoulder. Tumor showed ER/PR positive and HER2/neu 3+ positive by IHC, but negative by FISH. She also had questionable two 4 mm nodules in the left lower lung area. She was started on chemotherapy with Herceptin, and this was changed to Xeloda lately because of progression of the disease.
FISH|fluorescent in situ hybridization|FISH|260|263|HISTORY OF PRESENT ILLNESS|There were also areas of necrosis identified. The specimen did not include portion of the skin, but this clearly is abnormal, as is described below, and is felt to be consistent with an inflammatory breast cancer clinically. The patient's hormone receptor and FISH for HER-2 is still pending. REVIEW OF SYSTEMS: Subjectively, the patient feels fine. BREASTS: She has a slight bruise in the right breast area, but there is no sign of subsequent infection.
FISH|fluorescent in situ hybridization|FISH|228|231|FINAL DIAGNOSIS AND PLAN|These findings are markers for Down syndrome. The chance this baby would be affected with Down syndrome, based on the ultrasound findings is increased. _%#NAME#%_ and _%#NAME#%_ choose to proceed with amniocentesis. Preliminary FISH results will be available within 24 to 48 hours, with final results taking 10 to 14 days. We discussed the options of termination up to 22 weeks, continuing the pregnancy, or adoption.
FISH|fluorescent in situ hybridization|FISH|105|108|ADDENDUM|We have encouraged them to contact us with any questions or concerns at _%#TEL#%_. ADDENDUM: Preliminary FISH results from Fairview-University Medical Center are now available and they are normal. Sincerely, _%#NAME#%_ _%#NAME#%_ Genetic Counseling Intern
FISH|fluorescent in situ hybridization|FISH|254|257||On _%#MM#%_ _%#DD#%_, 2005, a right ultrasound stereotactic core biopsy was obtained, which revealed a grade 1 infiltrating ductal carcinoma. Subsequent evaluation of that proved to be estrogen and progesterone receptor both positive. It was negative by FISH analysis for HER-2 over-expression. On _%#MMDD2005#%_, Dr. _%#NAME#%_ performed a right lumpectomy with a sentinel lymph node biopsy.
FISH|fluorescent in situ hybridization|FISH|200|203|FAMILY HISTORY|As you know, the results of approximately 1% of CVS cases are inconclusive, requiring followup amniocentesis. _%#NAME#%_ questioned whether the "quick" results were available for CVS. I explained the FISH (fluorescence in situ hybridization) test is usually ordered when a chromosome abnormality is suspected. The test results are usually available in 24 to 48 hours after the procedure.
FISH|GENERAL ENGLISH|FISH|89|92|ALLERGIES|15. Aspirin 81 mg p.o. daily which was discontinued prior to hospitalization. ALLERGIES: FISH OIL LEADING TO DIARRHEA, AMIODARONE LEADING TO TOXICITY. SOTALOL LEADING TO FAILED TREATMENT. FAMILY HISTORY: Significant for the patient's mother having heart failure and diabetes.
FISH|fluorescent in situ hybridization|FISH|361|364|IMPRESSION|Dear Dr. _%#NAME#%_: I met with your patient, _%#NAME#%_ _%#NAME#%_, along with her husband _%#NAME#%_ for a follow-up genetic counseling visit on _%#MM#%_ _%#DD#%_, 2005, regarding the results of her abnormal quad screen indicating a 1 in 70 chance for trisomy 18. Following our visit together she had an amniocentesis performed by Dr. _%#NAME#%_. Preliminary FISH results are normal. I spent approximately 45 minutes with this patient. _%#NAME#%_ is a 35-year-old gravida 1, para 0-0-0-0 whose current estimated date of delivery is _%#MM#%_ _%#DD#%_, 2005.
FISH|GENERAL ENGLISH|FISH,|193|197|SULFA.|1. Norvasc 2. Itch pill FAMILY HISTORY: Is not relevant SOCIAL HISTORY: Married, three children. Because of Alzheimer's, the husband is the legal guardian. She IS ALLERGIC TO PENICILLIN, SHELL FISH, SEAFOOD, AND SULFA. REVIEW OF SYSTEMS: Cardiovascular is negative except for hypertension. Pulmonary - non-smoker.
FISH|fluorescent in situ hybridization|FISH|183|186|PLAN|We recognize that this is a very difficult time for this couple and our thoughts are with them during this time. Please do not hesitate to call me at _%#TEL#%_. Addendum: Preliminary FISH results indicate that this developing baby girl has 3 copies of chromosome #21, consistent with Down syndrome. Final results still pending. Patient was informed of these results on _%#MMDD2006#%_.
FISH|GENERAL ENGLISH|FISH.|107|111|ALLERGIES|9. Magnesium. 10. Soy Protein. 11. Echinacea. 12. Multivitamin. 13. Oil of Oregano. ALLERGIES: PENICILLIN; FISH. FAMILY HISTORY: Cancer; notable for breast cancer in her maternal and paternal aunts.
FISH|fluorescent in situ hybridization|FISH|142|145|IN SUMMARY|The couple was comfortable proceeding with the amniocentesis procedure. Results from the amniocentesis take 10-14 days. A preliminary result, FISH result, will be available approximately 48 hours from the procedure time. I will call the patient with the preliminary results and also call your office.
FISH|fluorescent in situ hybridization|FISH|194|197|IN SUMMARY|The couple also opted for cystic fibrosis carrier screening. Carrier screening was performed on the patient. We will hold cells for testing on the fetus from the amniocentesis procedure. If the FISH result is normal, we will proceed with the cystic fibrosis testing on the fetus. These results take 2-3 weeks. FAMILY HISTORY: A family history was obtained during the visit.
FISH|fluorescent in situ hybridization|FISH|129|132|HISTORY OF PRESENT ILLNESS|A bone marrow biopsy at that time showed remission. She had a follow-up bone marrow biopsy in _%#MM#%_ with continued remission. FISH study was negative. Mrs. _%#NAME#%_ indicates that she has tolerated the Gleevec fairly well, but initially had vomiting. Now she has occasional nausea, and she has facial swelling.
FISH|fluorescent in situ hybridization|FISH|206|209|HISTORY OF PRESENT ILLNESS|She apparently presented with very large mass in her left breast on the mammogram. Ultrasound core biopsy showed grade 3 infiltrating ductal carcinoma with ER/PR receptor positive and HER-2/neu positive by FISH analysis. It was not clear initially whether she had inflammatory breast cancer, however, PET scan showed some increased activity in the precarinal internal mammary and axillary lymph node.
FISH|fluorescent in situ hybridization|FISH|206|209|HISTORY OF PRESENT ILLNESS|There was no biopsy of the skin, so it could not be determined from this that this was an inflammatory breast cancer. The tumor is estrogen receptor positive and progesterone receptive weakly positive. The FISH testing is currently in process. The patient has undergone further work-up. A chest x-ray was negative for any metastatic disease on _%#MMDD2005#%_.
FISH|fluorescent in situ hybridization|FISH|249|252|PHYSICAL EXAMINATION|She had one previous miscarriage. Unfortunately, today's ultrasound revealed multiple anomalies including hydrocephalus, diaphragmatic hernia, spina bifida, ambiguous genitalia and abnormal toes. Amniocentesis was performed today, which preliminary FISH results should be available in 1-2 days. Final results will take approximately 10-14 days. We discussed options available in terms of this pregnancy including continuation of pregnancy or termination of her pregnancy up to approximately 23 weeks gestation in the State of Minnesota.
FISH|fluorescent in situ hybridization|FISH.|214|218|HISTORY OF PRESENT ILLNESS|Additional resection was done per surgeon. Initial biopsy report showed a suspicious lymphovascular invasion but the specimen did not show any vascular invasions. Tumor was ER PR positive and HER-2/new negative by FISH. The patient healed nicely and was seen by us for post-lumpectomy radiation treatment and patient is going to be on tamoxifen.
FISH|fluorescent in situ hybridization|FISH|390|393|ASSESSMENT AND PLAN|_%#NAME#%_ _%#NAME#%_, CNM Fairview _%#CITY#%_ Women's Clinic _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_, Minnesota _%#55400#%_ Dear _%#NAME#%_, This will document information left with your office regarding results from _%#MMDD2004#%_ genetic amniocentesis performed on _%#NAME#%_ _%#NAME#%_. Our reference laboratory has reported both the FISH and the final karyotype consistent with a 46, XY, normal male. The alpha fetoprotein has been reported at 1.04 MoM. This value is within the range of normal for our laboratory.
FISH|fluorescent in situ hybridization|FISH|202|205|ASSESSMENT AND PLAN|At the conclusion of our discussion the patient elected to pursue chorionic villi sampling and this was performed by Dr. _%#NAME#%_ _%#NAME#%_, following genetic counseling. The sample will be sent for FISH and chromosome studies. We discussed the preliminary nature of FISH results, the benefits and limitations of FISH studies were specifically described to the patient.
FISH|fluorescent in situ hybridization|FISH|96|99|ASSESSMENT AND PLAN|The sample will be sent for FISH and chromosome studies. We discussed the preliminary nature of FISH results, the benefits and limitations of FISH studies were specifically described to the patient. The patient will be called with those results when they become available.
FISH|fluorescent in situ hybridization|FISH|142|145|ASSESSMENT AND PLAN|The sample will be sent for FISH and chromosome studies. We discussed the preliminary nature of FISH results, the benefits and limitations of FISH studies were specifically described to the patient. The patient will be called with those results when they become available. If I can be of any further assistance, please feel free to contact me at _%#TEL#%_.
FISH|fluorescent in situ hybridization|FISH|146|149|ASSESSMENT AND PLAN|Chromosome results revealed a normal karyotype (46,XX). The patient was contacted by phone with these results on _%#MM#%_ _%#DD#%_, 2004, for the FISH results and on _%#MM#%_ _%#DD#%_, 2004, regarding the final chromosome results. The results were reviewed in detail with the patient as well as her husband, _%#NAME#%_.
FISH|fluorescent in situ hybridization|FISH|188|191|PLAN|Currently _%#NAME#%_ and _%#NAME#%_ are having difficulties in their relationship. PLAN: _%#NAME#%_ planned to have amniocentesis, which was performed today by Dr. _%#NAME#%_. Preliminary FISH results were consistent with Down syndrome. We informed her of these results on Sunday, _%#MM#%_ _%#DD#%_ and provided additional information on Down syndrome and discussed options.
FISH|fluorescent in situ hybridization|FISH|200|203|PLAN|Otherwise, the family history was unremarkable for birth defects or mental retardation. Both of them are of European ethnicity. PLAN: _%#NAME#%_ had CVS performed today by Dr. _%#NAME#%_. Preliminary FISH results were normal. As soon as final results become available we will contact them by telephone and fax you a copy. _%#NAME#%_ planned to do the D & E procedure, which is scheduled for Wednesday _%#MMDD2007#%_.
FISH|fluorescent in situ hybridization|FISH|138|141|PLAN|If you have any further questions, with which I can be of assistance, please feel free to contact me at _%#TEL#%_. Addenduem: Preliminary FISH results are cosisent with a normal male. Sincerely,
FISH|fluorescent in situ hybridization|FISH|205|208|PLAN|Otherwise, their family history was unremarkable, and both of them are from Kenya. _%#NAME#%_ stated that she wished to proceed with amniocentesis, which was performed today by Dr. _%#NAME#%_. Preliminary FISH results were normal. Final results will take approximately 10-14 days. We will notify her by phone. We recognize that this is a difficult time for this couple, given the uncertainty of this baby's prognosis.
FISH|fluorescent in situ hybridization|FISH|232|235|PHYSICAL EXAMINATION|Needle biopsy revealed an invasive ductal carcinoma grade II. It was estrogen and progesterone receptor positive. She had an additional core from another lesion, which was also of similar histology. She did undergo HER2 analysis by FISH and this turned out to be negative. PET CT scan was done on _%#MMDD2007#%_ at University of Minnesota Medical Center, Fairview, which showed several soft tissue nodules in the left breast.
FISH|fluorescent in situ hybridization|FISH|353|356|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her infiltrating ductal carcinoma with DCIS, diagnosed _%#MMDD2000#%_, with bone metastases that developed _%#MMDD2005#%_, and more recently lymph node metastases in her supraclavicular area. She was grade 2/3, with 1 of 4 lymph nodes, ER positive at 80.9, PRR negative and FISH negative. REVIEW OF SYSTEMS: GENERAL: Energy is the same. EYES: Negative, no blurred or double vision EARS: Negative.
FISH|fluorescent in situ hybridization|FISH|239|242|HISTORY OF PRESENT ILLNESS|PROBLEM: CML. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 19-year-old man who was diagnosed with CML in _%#MM#%_, 2001, when he was found incidentally to have a high white count. He had 3.5 million platelets at that time. Peripheral smear FISH analysis was positive for the Philadelphia chromosome. He was initially treated on Hydrea and anagrelide, but this was changed to Gleevec and anagrelide.
FISH|fluorescent in situ hybridization|FISH|132|135|PATHOLOGY|LABORATORY: White count was 3.9, hemoglobin 10.1, platelets 374,000. Creatinine 1.1. PATHOLOGY: 1. UH02-1929: CML in chronic phase. FISH positive T9..22. 2. UH03-0118: Pending sections. IMPRESSION: CML in chronic phase. RECOMMENDATIONS: _%#NAME#%_ is an excellent candidate for consideration of unrelated double cord blood transplantation.
FISH|GENERAL ENGLISH|FISH|184|187|PAST SURGICAL HISTORY|3. Conduct disorder. 4. History of asthma, currently on no medications. PAST SURGICAL HISTORY: None. ADMISSION MEDICATIONS: None. ALLERGIES: NO KNOWN DRUG ALLERGIES. HE IS ALLERGIC TO FISH WHICH CAUSED HIVES. SOCIAL HISTORY: The patient denies tobacco use, alcohol use, and illicit drug use. He is currently single. No children. Lives with his mother, sister, and brother.
FISH|fluorescent in situ hybridization|FISH.|165|169|SUBJECTIVE|The biopsy showed metaplastic carcinoma, Nottingham grade 3/3 without DCIS. There was no vascular invasion. ER/PR was negative and HER-2/neu was negative as well by FISH. Fluid from the breast also showed adenocarcinoma. Then the patient underwent further workup with PET CT on _%#MMDD2006#%_ and an MRI of the breast.
FISH|fluorescent in situ hybridization|FISH|384|387|ASSESSMENT AND PLAN|The risks, benefits, and limitations of chorionic villus sampling were reviewed with the patient; specifically the 1 in 200 risk for pregnancy loss was discussed, as well as the risk for mosaicism through confined placental mosaicism on a CVS result was reviewed. Chorionic villus sampling was performed transabdominally by Dr. _%#NAME#%_ _%#NAME#%_ on the day of genetic counseling. FISH studies as well as chromosome studies will be performed on the sample. FISH studies should be available within 2 days and chromosome studies should be available within 2 weeks.
FISH|fluorescent in situ hybridization|FISH|196|199|ASSESSMENT AND PLAN|Chorionic villus sampling was performed transabdominally by Dr. _%#NAME#%_ _%#NAME#%_ on the day of genetic counseling. FISH studies as well as chromosome studies will be performed on the sample. FISH studies should be available within 2 days and chromosome studies should be available within 2 weeks. The patient will be called with these results. In addition, arrangements for an induction of labor were made, and this induction will be performed at Fairview _%#CITY#%_ Birth Place, beginning on Sunday, _%#MM#%_ _%#DD#%_, 2004.
FISH|fluorescent in situ hybridization|FISH|213|216|HPI|Both of them are of European ethnicity. _%#NAME#%_ is scheduled to come back on _%#MMDD2007#%_ in hopes of tapping the fluid to help distinguish the diagnosis between chylothorax and fetal thorax. Her preliminary FISH results were normal male. Cells will be held for any further studies, if found necessary. Final results are still pending. If you have any further questions of which I can be of assistance, please feel free to contact me at _%#TEL#%_.
FISH|fluorescent in situ hybridization|FISH|375|378|RECOMMENDATIONS|Because of this pregnancy's late gestational age, I discussed having a preliminary FISH test, which can be performed to obtain information regarding this baby through amniocentesis. the patient stated it would be important for them to know the chromosome information in this regard, and plan to have an amniocentesis tomorrow, _%#MMDD2004#%_ with Dr. _%#NAME#%_. Preliminary FISH results for _%#MMDD2004#%_ are normal. Final chromosome analysis is pending. If you have any further questions regarding this patient, please feel free to contact me at _%#TEL#%_.
FISH|fluorescent in situ hybridization|FISH|272|275|RECOMMENDATIONS|At the conclusion of our discussion, the patient elected to proceed with a Level II ultrasound and was unsure as to whether she would consider an amniocentesis. After her ultrasound, Ms. _%#NAME#%_ decided to have the amniocentesis. Preliminary results from this testing, FISH analysis, will be available within 24 to 48 hours. Final results usually take 10 to 14 days, and Ms. _%#NAME#%_ will be notified by phone of these results. If I can be of any further assistance, please feel free to contact me at _%#TEL#%_.
FISH|fluorescent in situ hybridization|FISH|182|185|HISTORY OF PRESENT ILLNESS|At that time, deferred and he was further treated with Imatinib through _%#MM2003#%_, as well as Interferon 3 times weekly. In _%#MMDD#%_, he had normal marrow cytogenetics, but his FISH had 1.4% positive cells and PCR of his marrow was shown to be positive. On _%#MMDD#%_, he showed 1% FISH positive cells, with a morphologically in remission marrow.
FISH|fluorescent in situ hybridization|FISH|163|166|HISTORY OF PRESENT ILLNESS|In _%#MMDD#%_, he had normal marrow cytogenetics, but his FISH had 1.4% positive cells and PCR of his marrow was shown to be positive. On _%#MMDD#%_, he showed 1% FISH positive cells, with a morphologically in remission marrow. In _%#MM2003#%_, FISH studies were negative, though PCR still remained positive, he was then evaluated and prepared for a haploidentical transplant from his half brother.
FISH|fluorescent in situ hybridization|FISH|137|140|HISTORY OF PRESENT ILLNESS|The transplant was uneventful. Unfortunately, in _%#MM#%_ of 2005 bone marrow showed recurrence of the PML/RAR alpha transcript, but the FISH was negative for 15:17 translocation and the marrow was morphologically negative. His blood counts were normal. Mr. _%#NAME#%_ was referred to the University of Minnesota Medical Center, Fairview, on _%#MM#%_ _%#DD#%_, 2006.
FISH|GENERAL ENGLISH|FISH|176|179|ALLERGIES|MEDICATIONS ON ADMISSION: Atenolol, Cardura, Prinivil, Zocor, Plaquenil, Ecotrin, weekly Methotrexate, Prilosec, and Flomax. ALLERGIES: HE ALLERGIC OR INTOLERANT TO IODINE AND FISH OIL. FAMILY HISTORY: Completely negative for malignancy. SOCIAL HISTORY: The patient is a retired Texaco tanker driver.
FISH|fluorescent in situ hybridization|FISH|176|179|HISTORY OF PRESENT ILLNESS|The patient was treated with hyperCVAD plus Gleevec. She was treated with intrathecal methotrexate and Ara-C. One CSF sample showed rare atypical cells, but none on repeat. An FISH was negative. The patient achieved remission. A second cycle of chemotherapy ended 2-1/2 weeks ago. The patient is here to determine eligibility for total-body irradiation prior to allogenic PBSCT, with her brother as donor.
FISH|fluorescent in situ hybridization|FISH|193|196|TIME SPENT|_%#NAME#%_ stated that she wished to have a level II ultrasound today, which was unremarkable. She did go on to decide to have amniocentesis, which was performed by Dr. _%#NAME#%_. Preliminary FISH results are normal. Final results will be available in 10-14 days, and we will contact her by phone. If you have any further questions with which we can be of assistance, please feel free to contact me at _%#TEL#%_.
FISH|fluorescent in situ hybridization|FISH|223|226|SUBJECTIVE|_%#NAME#%_ was a 33-week product of a pregnancy that was complicated by known intrauterine growth retardation, microcephali, and evidence of fetal bowel obstruction with small kidney size. Initial karyotype studies done by FISH analysis only showed a 46XX karyotype. At delivery she clearly had significant anomalies with bilateral microphthalmia, severe microcephali, and severe growth retardation with a birth weight of 1630 grams.
FISH|fluorescent in situ hybridization|FISH|194|197|DISCUSSION|_%#NAME#%_'s blood was also drawn to be used for maternal cell contamination both for a chromosome analysis as well as for CAH. The results will be expected to take up to 3-4 weeks. Preliminary FISH analysis can be performed on gender in order to know whether or not she should discontinue or start tapering off the dexamethasone, if in the event this baby is male.
FISH|fluorescent in situ hybridization|FISH|137|140|DISCUSSION|If you have any further questions with which I can be of assistance, please feel free to contact me at _%#TEL#%_. Addenduem: Preliminary FISH results indicate that this fetus is male, thus _%#NAME#%_ plans to discontinue the use of dexamethazone. Sincerely,
FISH|fluorescent in situ hybridization|FISH|278|281|ASSESSMENT AND PLAN|We also discussed options if the baby was found to have Down syndrome including continuation of her pregnancy or termination of her pregnancy up to 22 or 23 weeks in the State of Minnesota. We discussed results from amniocentesis, which typically take 10-14 days or preliminary FISH results may be available in the next few days. After much discussion, this couple still needed a few days to decide whether or not they should pursue amniocentesis.
FISH|fluorescent in situ hybridization|FISH|154|157|PLAN/RECOMMENDATIONS|4. Single descended testis and curve of penis. 5. Bilateral ankle anomalies with long, narrow foot. PLAN/RECOMMENDATIONS: 1. Chromosome studies. 2. 22q11 FISH studies to rule out velocardiofacial syndrome or DiGeorge syndrome (based on the tetralogy of Fallot); however, this is not a classical presentation of this anomaly but could be a variant of form.
FISH|fluorescent in situ hybridization|FISH|173|176|HISTORY OF PRESENT ILLNESS|The patient indicates that since that time he received an additional cycle of chemotherapy. Follow-up bone marrow biopsy on _%#MMDD2005#%_ showed him to be in remission and FISH was negative. Mr. _%#NAME#%_ is in need of an umbilical cord blood transplant because he has no siblings. He has never received radiation treatments before. Mr. _%#NAME#%_ presents to our clinic today at the request of Dr. _%#NAME#%_ _%#NAME#%_ to determine his eligibility for total body irradiation conditioning.
FISH|fluorescent in situ hybridization|FISH|181|184|RECOMMENDATIONS|In addition, she had an amniocentesis which was performed by Dr. _%#NAME#%_ _%#NAME#%_. Amniotic fluid was sent for chromosome studies as well as amniotic fluid AFP. In addition, a FISH study was performed to look for any numerical abnormalities involving chromosomes 13, 18, 21, X and Y. Results will be called to the patient, as they become available.
FISH|fluorescent in situ hybridization|(FISH)|286|291|RECOMMENDATIONS|The patient was counseled regarding the risk of maternal self-contamination or confined placental mosaicism in the case of CVS procedures. Given the risk of chromosome abnormalities we briefly discussed the availability of preliminary results through fluorescence in situ hybridization (FISH) studies for numerical abnormalities involving 13, 18, 21 X and Y. The couple was counseled about the risks and limitations to FISH studies.
FISH|fluorescent in situ hybridization|FISH|156|159|HISTORY OF PRESENT ILLNESS|He was able to achieve a remission. The CSF cleared. This was confirmed on _%#MMDD2005#%_. His followup bone marrow biopsy on that same date had BCR-ABL by FISH of 1.2%. _%#NAME#%_ is now on Gleevec maintenance. Throughout his chemotherapy, he had multiple infectious complications. _%#NAME#%_ is in need of a bone marrow transplant.
FISH|fluorescent in situ hybridization|FISH|136|139|RECOMMENDATIONS|As soon as final results become available from her amniocentesis, we will contact this patient by phone and fax you a copy. Preliminary FISH results are normal. If you have any further questions of which I can be of assistance please feel free to contact me at _%#TEL#%_.
FISH|fluorescent in situ hybridization|FISH|126|129|HISTORY OF PRESENT ILLNESS|The tumor is estrogen and progesterone receptor positive, which is a favorable thing. It is also apparently HER 2 positive by FISH analysis. I have recommended to the patient that she should have further chemotherapy, and given the fact that she is HER 2 positive, I would recommend that a taxane be incorporated with Herceptin.
FISH|fluorescent in situ hybridization|FISH|196|199|CHIEF COMPLAINT|Laboratory studies showed normal ABG, VBG, mildly elevated INR 1.26, normal electrolytes, BUN, creatinine, calcium, hematogram. Postop echo shows repair. He had karyotype demonstrating 46 XY with FISH study negative for DiGeorge syndrome. Newborn screen was reportedly normal. FAMILY HISTORY: There is report of similar findings in either parents.
FISH|fluorescent in situ hybridization|FISH|164|167|RECOMMENDATIONS|As you know, she presented back in _%#MM2004#%_ with a right breast mass. It was a large 9 cm centrally located lesion. It was ER positive and PR negative, also by FISH analysis it was HER-2 negative. PET scan revealed that she had metastatic disease to bone, as well as periaortic and superior mediastinal lymphadenopathy.
FISH|fluorescent in situ hybridization|FISH|237|240|RECOMMENDATIONS|Helen also has speech issues and is getting some speech therapy. Helen did have chromosomes performed at the Cytogenetics Laboratory at University of Minnesota Medical Center, Fairview, which revealed a 46, XX normal karyotpe and normal FISH studies for 22q deletion. We discussed that congenital heart defects are multifactorial in inheritance and that this pregnancy would be at increased risk for a congenital heart defect, thus we would recommend a fetal echocardiogram at 20-22 weeks' gestation.
FISH|fluorescent in situ hybridization|FISH|145|148|LOCATION OF CONSULTATION|Other parameters of her staging include estrogen and progesterone receptor being positive. It was 2+ HER to by IHC, but subsequently negative on FISH analysis. The patient is thus surgical stage I (TIC,N0, M0). _%#NAME#%_ is currently recovering nicely from her surgery.
FISH|GENERAL ENGLISH|FISH,|140|144|ALLERGIES|3. He is now on Lasix 40 mg daily. 4. Flagyl. 5. Protonix. 6. Flonase nasal spray. ALLERGIES: AMOXICILLIN, GABAPENTIN, PENICILLAMINE, SHELL FISH, PSEUDO-EPHEDRINE. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: He quit smoking 50-60 years ago.
FISH|GENERAL ENGLISH|FISH.|145|149|ALLERGIES/DRUG INTOLERANCES|7) Compazine 10 mg p.o. p.r.n. 8) Accupril 5 mg p.o. q day. 9) Neurontin 300 mg p.o. t.i.d. ALLERGIES/DRUG INTOLERANCES: SULFA, BACTRIM, SEVERAL FISH. HABITS: She does not drink alcohol, does not smoke cigarettes.
FISH|fluorescent in situ hybridization|FISH|144|147|IN SUMMARY|2. Based on the patient's ultrasound findings, she returned later on that day to have an amniocentesis. Amniotic fluid was sent for preliminary FISH studies as well as chromosome studies and amniotic fluid AFP. The patient in your office will be contact as soon as these results become available.
FISH|fluorescent in situ hybridization|FISH|195|198|IN SUMMARY|2. Your patient elected to have an amniocentesis today for fetal karyotype analysis and AF-AFP to test for neural tube defects. 3. Karyotype and AF-AFP results should be available in 10-14 days. FISH analysis was also ordered on this sample, and the preliminary results will be available within 24 to 48 hours. 4. Omphalocele observed on ultrasound in twin B. The ultrasound report was faxed to you under separate cover.
FISH|fluorescent in situ hybridization|FISH.|173|177|HISTORY OF PRESENT ILLNESS|There was no DCIS or vascular invasion. Margin was negative. Estrogen receptor was positive in 95%. However, PR was negative and did not show any HER-2-neu amplification by FISH. The patient underwent oncotype DX since her progesterone receptor was negative which showed high value and decided to receive chemotherapy.
FISH|fluorescent in situ hybridization|FISH|155|158|ASSESSMENT/PLAN|These may be subtle markers of babies with Down syndrome, however, are not definitive. An amniocentesis was performed today by Dr. _%#NAME#%_. Preliminary FISH results are normal. Final results available 10-14 days. If you have any further questions regarding this patient, please feel free to contact me at _%#TEL#%_.
FISH|fluorescent in situ hybridization|FISH|134|137|HISTORY OF THE PRESENT ILLNESS|Further characteristics on that specimen showed that the tumor was estrogen and progesterone, both positive. It was HER-2 negative by FISH technique. On _%#MMDD#%_ an MRI of both breasts was performed. It confirmed the mass in the right breast with no additional lesions, and the left breast was normal.
FISH|GENERAL ENGLISH|FISH|164|167|ALLERGIES|7) Azmacort. 8) Albuterol inhaler. 9) Nasacort. ALLERGIES: SHE IS INTOLERANT OF CODEINE AND PERCODAN, ALTHOUGH DENIES RASH TO THESE. SHE DOES HAVE A STRONG RASH TO FISH AND STATES SHE BREAKS OUT IN HIVES, LIPS SWELL, ETC. SOCIAL HISTORY: The patient is married with four children. She is a retired nursing professor.
FISH|fluorescent in situ hybridization|FISH.|272|276|HISTORY OF PRESENT ILLNESS|The patient was diagnosed with a high-risk stage II breast cancer in _%#MM2004#%_ at which time she underwent a left mastectomy with pathology demonstrating 2 primary tumors and 3 positive axillary lymph nodes. She had negative hormone receptors and positive HER-2/neu by FISH. She was also found to have a solid mass in the right kidney consistent with a renal cell carcinoma, and she underwent cryotherapy for this lesion in _%#MM2005#%_.
FISH|fluorescent in situ hybridization|FISH|392|395|ASSESSMENT AND PLAN|Dear Dr. _%#NAME#%_: This is a brief update on Ms. _%#NAME#%_. As you know she had a recurrence of her left breast cancer this past _%#MMDD#%_ and subsequently underwent a modified radical mastectomy, which revealed a 2.8 grade 3 infiltrating ductal carcinoma, sentinel and axillary lymph node dissection was negative of 17 lymph nodes. The tumor was ER and PR negative, and HER2 negative by FISH Analysis. The patient has undergone further chemotherapy receiving dose Adriamycin and Cytoxan on a q.2 week schedule starting on _%#MMDD#%_ and through _%#MMDD2005#%_ for four cycles.
FISH|fluorescent in situ hybridization|FISH|189|192|PLAN|Thus, these findings would be consistent with 45 X complement and a diagnosis of Turner syndrome. G-banding chromosome analysis was not able to be performed. Thus, these are the results of FISH testing. We reviewed with _%#NAME#%_ that there was nothing either her or her husband did to cause their developing baby girl to have Turner syndrome.
FISH|GENERAL ENGLISH|FISH,|157|161|ALTHOUGH HAS NOT BEEN EXPOSED TO THIS OR ANY|The patient's only other complaint at this time is some pruritis over her face and chest. No rash is currently visible. She DOES HAVE KNOWN ALLERGY TO SHELL FISH, ALTHOUGH HAS NOT BEEN EXPOSED TO THIS OR ANY IODINATED MATERIALS SO FAR TODAY. However, she did undergo a bed bath earlier shortly after which the pruritis started.
FISH|fluorescent in situ hybridization|FISH|166|169|ASSESSMENT AND PLAN|You stated that you are interested in trying to start to have another pregnancy. As you know, you decided to have your blood drawn for chromosome analysis as well as FISH testing for DiGeorge/22q deletion syndrome. The results will take approximately three to four weeks. As soon as results become available, I will notify you by phone.
FISH|fluorescent in situ hybridization|FISH|274|277|ASSESSMENT AND PLAN|We reviewed the amniocentesis procedure as they desire to know definitive information regarding this developing baby. We reviewed the less-than-1:200 risk of miscarriage. We discussed that amniocentesis can test specifically for chromosome abnormalities, as well as special FISH testing could be performed to look for the 22q deletion. We thoroughly updated their family history during our genetic counseling session.
FISH|fluorescent in situ hybridization|FISH|170|173|IN SUMMARY|3. Karyotype and AF-AFP results should be available in 10-14 days, at which time I will call the patient directly and fax a copy to your office. 4. The patient requested FISH studies to be performed for preliminary results on numerical abnormalities involving chromosome 13, 18, 21, X and Y. The benefits and limitations of FISH studies were discussed. Thank you again for allowing us to participate in Ms. _%#NAME#%_'s care.
FISH|fluorescent in situ hybridization|FISH|179|182|IN SUMMARY|4. The patient requested FISH studies to be performed for preliminary results on numerical abnormalities involving chromosome 13, 18, 21, X and Y. The benefits and limitations of FISH studies were discussed. Thank you again for allowing us to participate in Ms. _%#NAME#%_'s care.
FISH|fluorescent in situ hybridization|FISH|164|167|IN SUMMARY|_%#NAME#%_ stated that they wished to obtain information from amniocentesis for this developing baby. Amniocentesis was performed by Dr. _%#NAME#%_ and preliminary FISH results were normal. If you have any further questions of which I can be of assistance please feel free to contact me at _%#TEL#%_.
FISH|fluorescent in situ hybridization|FISH|278|281|IN SUMMARY|She was quite upset about the delay in her receiving the quad screen results and was pretty concerned about the possibility that this baby could have Down syndrome. They plan to have an amniocentesis performed by Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2005, at 1 p.m. Preliminary FISH results were normal. If you have any further questions of which I can be of assistance please feel free to contact me at _%#TEL#%_.
FISH|fluorescent in situ hybridization|FISH|178|181|SUBJECTIVE|This showed a deletion in the distal short arm of the fourth chromosome, extending from then 4p15.32 to the 4p terminus. This deletion was detected by G-banding and confirmed by FISH with probes to both the Wolf-Hirschhorn critical region and to the sub-telomeric lesion of 4p. FISH showed all 10 of the metaphases examined to have a signal pattern consistent with a deletion encompassing both the Wolff-Hirschhorn critical region and the sub-telomeric 4p region.
FISH|fluorescent in situ hybridization|FISH|157|160|SUBJECTIVE|This deletion was detected by G-banding and confirmed by FISH with probes to both the Wolf-Hirschhorn critical region and to the sub-telomeric lesion of 4p. FISH showed all 10 of the metaphases examined to have a signal pattern consistent with a deletion encompassing both the Wolff-Hirschhorn critical region and the sub-telomeric 4p region.
FISH|fluorescent in situ hybridization|FISH|164|167|IMPRESSION|The final chromosome results became available on _%#MMDD2006#%_ and they showed an extra copy of chromosome 21 in all 20 cells examined. This is in addition to the FISH results that demonstrated an extra copy of chromosome 21 in 99% of cells examined. The final karyotype is 47,XY, +21. This is a sporadic form of Down syndrome, and the recurrence risk in future pregnancies would be expected to be approximately the same as _%#NAME#%_'s age-related risk for Down syndrome.
FISH|fluorescent in situ hybridization|FISH|252|255|IMPRESSION|Dear Dr. _%#NAME#%_: I am writing to notify you of results of your patient, _%#NAME#%_ _%#NAME#%_'s genetic amniocentesis, performed on _%#MMDD2004#%_. According to F-UMC Cytogenic Laboratory, amniotic fluid chromosomes were normal, 46 XY. In addition FISH analysis was performed with normal signals for chromosome 13, 18, and 21, X and Y. The amniotic fluid alpha fetoprotein was 1.33 MoM which is in the normal range, as reported by the Foundation for Blood Research.
FISH|fluorescent in situ hybridization|FISH|229|232|ASSESSMENT AND PLAN|If you have any further questions or if I can provide any additional support for this couple, please feel free to contact me at _%#TEL#%_. Addendum: Amniocentesis was performed by Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_. Preliminary FISH results were normal. Sincerely,
FISH|fluorescent in situ hybridization|FISH|125|128|ADDENDUM|If you have any further questions regarding this patient, please feel free to contact me at _%#TEL#%_. Addendum: Preliminary FISH results on babies A & C were normal. Sincerely,
FISH|fluorescent in situ hybridization|FISH|219|222|PHYSICAL EXAMINATION|Studies have shown that women who continue top menstruate following chemotherapy and taking tamoxifen do not do as well as though who become amenorrheic. In addition, this patient's original tumor was HER-2 positive by FISH technique. This also is an adverse factor, and women who have this profile do not respond as well to tamoxifen. For these reasons, I have discussed with _%#NAME#%_ the fact that we should stop her periods with the use of hormonal treatments, ie, Zoladex.
FISH|fluorescent in situ hybridization|FISH|425|428|PHYSICAL EXAMINATION|Location of Consult: _%#CITY#%_ Infusion Center Dr. _%#NAME#%_ _%#NAME#%_ Fairview _%#STREET#%_ Clinic _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_, MN _%#55400#%_ Dear _%#NAME#%_, _%#NAME#%_ returned to see me today for follow up of her breast cancer which was diagnosed back in _%#MM#%_ 2003, it was a stage I breast cancer with no positive lymph nodes, however it was a grade 3 and was HER-2 positive by FISH analysis. It was ER NPR positive. As you will recall she did receive neoadjuvant chemotherapy with Adriamycin and taxotere between _%#MM#%_ 2003 and the end of _%#MM#%_ 2003.
FISH|fluorescent in situ hybridization|FISH|204|207|PHYSICAL EXAMINATION|As you know, this young woman was diagnosed with a grade 3 invasive ductile carcinoma with high grade DCIS back in _%#MM#%_. The tumor, at that time, was also ER/PR positive, and HER2 2+ positive, and on FISH testing, it was positive. We have elected to treat her in a neo-adjuvant fashion, using a dose-dense regimen of adriamycin and taxotere every two weeks, and she has received a total of five doses, including today.
FISH|fluorescent in situ hybridization|FISH|150|153|HISTORY OF PRESENT ILLNESS|Blasts were seen on the peripheral smear. CT scan of the abdomen and pelvis were negative. Bone marrow biopsy revealed B-cell lymphoblastic leukemia. FISH analysis showed bcr/abl positive. A MUGA scan was performed and revealed an ejection fraction of 41%. CSF was negative. Mrs. _%#NAME#%_ was started on hyper-CVAD chemotherapy and Gleevec.
FISH|GENERAL ENGLISH|FISH,|111|115|ALLERGIES|2) Atenolol. 3) Dipyridamole. 4) Lovenox. 5) Lisinopril. 6) Paxil. 7) Maxzide. 8) Coumadin. ALLERGIES: SHRIMP, FISH, MACROBID. HEALT HABITS: No current smoking, stopped 30 years ago.
FISH|fluorescent in situ hybridization|FISH|409|412|ASSESSMENT AND PLAN|A subsequent thorough level-2 ultrasound was performed at the Maternal Fetal Medicine Center on _%#MMDD2004#%_, which revealed this developing baby to have a left diaphragmatic hernia, nuchal fold measuring 5.5 mm, strawberry-shaped skull, bowel and liver seen in the chest, bilateral pyelectasis, fetal heart deviated into the right chest, and micrognathia. Amniocentesis was performed, in which preliminary FISH results indicate in 54% of the cells analyzed, there were 3 chromosome 21 cells, which would be consistent with Down syndrome.
FISH|fluorescent in situ hybridization|FISH|359|362|ASSESSMENT AND PLAN|We discussed the availability of preliminary results through fluorescent in-situ hybridization (FISH) studies are available to look for common chromosome aneuploidies such as trisomy 21, 13, 18, and sex chromosome abnormalities. The patient had an amniocentesis performed by Dr. _%#NAME#%_ _%#NAME#%_ following genetic counseling. Amniotic fluid was sent for FISH studies as well as chromosome studies and amniotic fluid AFP. Results will be called to the patient, as they become available.
FISH|fluorescent in situ hybridization|FISH|205|208|PHYSICAL EXAMINATION|As you know, at your clinic, an ultrasound was performed on _%#MMDD2004#%_, which indicated a large cystic hygroma with possible fetal hydrops. Am amniocentesis was performed at that time, and preliminary FISH studies indicated the baby to have Turner syndrome. Final chromosome analyses are pending at the Mayo Medical Laboratories, and should be available next week, to further confirm the diagnosis and specific karyotype.
FISH|fluorescent in situ hybridization|FISH|252|255|PHYSICAL EXAMINATION|This pregnancy was unexpected and thus, _%#NAME#%_ and the father of the baby are dealing with a lot of unexpected issues. _%#NAME#%_ had an amniocentesis performed today by Dr. _%#NAME#%_, in which FISH was ordered for some early preliminary results. FISH results were reported as normal. If you have any further questions regarding this patient, please feel free to contact me at _%#TEL#%_.
FISH|fluorescent in situ hybridization|FISH|157|160|ASSESSMENT AND PLAN|We had seen her during this previous pregnancy at the Maternal Fetal Medicine Center. _%#NAME#%_ has had normal chromosomal analysis 46 XY as well as normal FISH for 22Q deletion. Thus, it was felt that he had isolated hypoplastic left heart syndrome. We discussed recurrence risk based on empiric information for subsequent pregnancies to have any type of congenital heart defect is approximately 2%.
FISH|fluorescent in situ hybridization|FISH|183|186|ASSESSMENT AND PLAN|We reviewed the termination limit in the state of Minnesota is approximately 22 to 23 weeks. _%#NAME#%_ had an amniocentesis, which was performed today by Dr. _%#NAME#%_. Preliminary FISH results were mormal. As soon as the final results become available, we will notify them by phone. You will get a faxed copy of these results. If you have any further questions with which I can be of assistance, please feel free to contact me at _%#TEL#%_.
FISH|fluorescent in situ hybridization|FISH|115|118|PAST SURGICAL HISTORY|PAST SURGICAL HISTORY: Status post gastrostomy tube placement. Chromosome analysis normal. Routine karyotype and a FISH study for DiGeorge deletion. FAMILY HISTORY: Parents unrelated. There is no previous multiple congenital anomaly syndrome. SOCIAL HISTORY: First child.
FISH|fluorescent in situ hybridization|FISH|301|304|HISTORY OF PRESENT ILLNESS|There was no formal increase in blasts with a blast count of 0.7%. On _%#MMDD2006#%_, she started intensification course #1, which included high dose ARA-C and etoposide. A bone marrow biopsy on _%#MMDD2006#%_ revealed 3% residual leukemic myeloid blasts with negative cytogenetics including negative FISH and G-banding for trisomy 8. She began intensification course #2 following day #41 of intensification course #1. This was _%#MMDD2006#%_, and her chemotherapy was ARA-C and mitoxantrone, including intrathecal ARA-C.
FISH|fluorescent in situ hybridization|FISH|184|187|PLAN|Final results will take approximately 10-14 days. If you have any further questions of which I can be of assistance please feel free to contact me at _%#TEL#%_. Addenduem: Preliminary FISH results were normal on the CVS samples. Final results still pending. Sincerely,
FISH|fluorescent in situ hybridization|FISH|306|309|PLAN|Both _%#NAME#%_ and _%#NAME#%_ are of Caucasian ethnicity.. _%#NAME#%_ felt it would be important to have an amniocentesis in order to obtain further information regarding her developing baby's chromosomes. The patient had an amniocentesis performed today with Dr. _%#NAME#%_; a chromosome analysis, and a FISH test for 22q deletion was ordered. When results become available I will notify them by phone. Written information regarding congenital heart defects as well as "Your Baby has a Problem" was given to them during their session.
FISH|fluorescent in situ hybridization|(FISH)|151|156|DISCUSSION|No other remarkable family history was reported. The patient had an amniocentesis performed today by Dr. _%#NAME#%_. Preliminary results of AneuVysion (FISH) are normal, and final results take 10 to 14 days. We recognize this difficulty time for this couple with this very unexpected birth defect.
FISH|fluorescent in situ hybridization|FISH|271|274|DISCUSSION|The fetus was noted to have low-set ears, abnormal facies, and possible gastroschisis defect, although the defect was thought possibly due to fetal maceration. The family declined autopsy. Karyotype analysis was attempted but fibroblast culture could not be established. FISH was performed for chromosome 13, 16, 18, 21, 22 and X, and there were two copies of each of those chromosomes.
FISH|fluorescent in situ hybridization|FISH.|178|182|HISTORY OF PRESENT ILLNESS|She is undergoing cytoreductive therapy. Her cancer is a grade 2 of 3. She has positive lymph nodes. She is ER/PR positive at 89.5 and 91.8%, respectively, HER-2/neu negative by FISH. REVIEW OF SYSTEMS: GENERAL: She has menopausal hot flashes. Energy is okay.
FISH|fluorescent in situ hybridization|FISH|137|140|ASSESSMENT AND PLAN|If you have any further questions with which I can be of assistance, please feel free to contact me at _%#TEL#%_. Addenduem: Preliminary FISH results are consistent with this developing baby having Down syndrome. Final results are pending. These were communicated to the patient and _%#NAME#%_ plans to continue pregnancy and scheudale a follow up fetal echocardiogram and genetic counseling at 20-22 weeks gestation.
FISH|fluorescent in situ hybridization|FISH|229|232|HISTORY OF PRESENT ILLNESS|Thus far, she has had normal respiratory function. There have been no noticeable rib abnormalities detected. She has no other known specific anomalies beyond those mentioned. Pending at this time is chromosome analysis including FISH for 22q. Also noted is the presence of low calcium values. PAST MEDICAL HISTORY: Noncontributory as this is an infant.
FISH|fluorescent in situ hybridization|FISH|192|195|HISTORY OF PRESENT ILLNESS|This can be arranged through Kennedy Krieger Institute clinical-mass spectrometry laboratory in _%#CITY#%_, Maryland. Specific prenatal testing for X-linked ichthyoses can be arranged through FISH testing at Genzyme Genetics. I reviewed the one in 200 risk of miscarriage associated with amniocentesis. I thoroughly reviewed their family history during our genetic counseling session.
FISH|fluorescent in situ hybridization|FISH|173|176|HISTORY OF PRESENT ILLNESS|This testing was performed at Kennedy Creiger Institute which specifically tested for 70 dehydrocholesterol and measured 4 ng/ml, which is in the normal range. In addition, FISH testing was performed for the steroid sulfatase gene on the X- chromosome, which did not show a deletion. This was normal and makes it unlikely for this baby to have X-linked ichthyoses.
FISH|fluorescent in situ hybridization|FISH|125|128|HISTORY OF PRESENT ILLNESS|If you have any further questions regarding this patient, please feel free to contact me at _%#TEL#%_. Addendum: Preliminary FISH results were normal. Sincerely,
FISH|fluorescent in situ hybridization|FISH.|199|203|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her left-sided infiltrating ductal carcinoma diagnosed _%#MMDD2005#%_, grade 3/3, ER/PR negative, HER-2/neu positive by FISH. REVIEW OF SYSTEMS: GENERAL: She has hot flashes. Appetite is good.
FISH|fluorescent in situ hybridization|FISH|240|243|PHYSICAL EXAMINATION|Because this patient was on 125 mg Lovenox, Dr. _%#NAME#%_ advised that the patient have her amniocentesis scheduled for the following day with Dr. _%#NAME#%_. When results are available, we will notify them by phone. We discussed possible FISH or preliminary results, because this patient is at 20 weeks gestation. If you have any further questions regarding this patient, please feel free to contact me at _%#TEL#%_.
FISH|GENERAL ENGLISH|FISH.|147|151|ALLERGIES|9. Aspirin 325 mg to 650 mg q.4 h. p.r.n. pain, also discontinued. ALLERGIES: CODEINE (HALLUCINATION AND HEADACHE). GI UPSET WITH CERTAIN TYPES OF FISH. SOCIAL HISTORY: Second marriage. On SSPI. Last employed in 1996, working with a radio station. FAMILY HISTORY: Father and sister with history of alcoholism. Two maternal cousins with schizophrenia.
FISH|fluorescent in situ hybridization|FISH|190|193|LABORATORY DATA|LABORATORY DATA: I reviewed the pathology that shows a metastatic adenocarcinoma consistent with a breast primary in 2 out of 18 lymph nodes. Additional immuno stains for BRST2, ER, PR, and FISH for HRT2 are still pending. IMPRESSION: _%#NAME#%_ _%#NAME#%_ is a 51-year-old premenopausal woman who likely has a left breast cancer metastatic to two axillary lymph nodes.
FISH|fluorescent in situ hybridization|(FISH)|162|167|IMPRESSION|We discussed available chromosome studies as well as AFP testing, following amniocentesis. In addition, the patient was offered fluorescent in situ hybridization (FISH) to screen for common chromosome abnormalities, such as trisomy 21, trisomy 13, trisomy 18, and X and Y chromosome abnormalities.
FISH|fluorescent in situ hybridization|FISH|145|148|IMPRESSION|According to the Fairview-University Medical Center Cytogenetic Laboratory chromosome studies were normal (46, XX). This was consistent with the FISH studies which were performed which revealed two normal copies of chromosome 13, 18, 21, and two copies of the X chromosome. In addition, the amniotic fluid alpha-fetoprotein was normal at 1.84 MoM, this is reported as not elevated by Foundation for Blood Research.
FISH|fluorescent in situ hybridization|FISH|244|247|IMPRESSION|_%#NAME#%_ obviously was quite concerned regarding her abnormal quad screen results and a Level II ultrasound, which was performed today, did not show any apparent abnormalities. An amniocentesis was performed by Dr. _%#NAME#%_ and preliminary FISH results were normal. We will contact them with the final results in 10 to 14 days. If you have any further questions with which I can be of assistance, please feel free to contact me at _%#TEL#%_.
FISH|fluorescent in situ hybridization|FISH.|156|160|IMPRESSION|An amniocentesis was performed on that day with Dr. _%#NAME#%_ and fluid was sent to Fairview-University Medical Center for cytogenetic analysis as well as FISH. According the Cytogenetic laboratory at F-UMC their developing baby girl has a normal number of chromosomes, 46 XX, by FISH. Final chromosome analysis will be completed in approximately ten days.
FISH|fluorescent in situ hybridization|FISH.|119|123|IMPRESSION|According the Cytogenetic laboratory at F-UMC their developing baby girl has a normal number of chromosomes, 46 XX, by FISH. Final chromosome analysis will be completed in approximately ten days. _%#NAME#%_ and her husband _%#NAME#%_ were very pleased with the preliminary results as they had been quite worried, given her previous pregnancy with trisomy 18 as well as the abnormal triple-screen blood test with this current pregnancy.
FISH|fluorescent in situ hybridization|FISH|385|388|IMPRESSION|This letter will summarize the information we discussed. As you know, _%#NAME#%_ is a 34-year-old, gravida 1, para 0-0-0-0 who on a routine ultrasound performed at your center revealed congenital heart defect, left pleural effusion, and a choroid plexus cyst. A follow-up Level II ultrasound was performed at the Perinatal Center, as well as an amniocentesis. Preliminary results from FISH analysis from Fairview- University Medical Center Cytogenetics Laboratory indicated that this baby has three copies of chromosome #18, which is consistent with trisomy 18.
FISH|fluorescent in situ hybridization|FISH|170|173|IMPRESSION|I provided them with written information, which can help provide support, including Time to Decide, Time to Heal, as well as information on trisomy 18 and their specific FISH results. I plan to have a follow-up meeting with them after their termination in a few weeks. There are other support resources for this family if needed, including a support group for couples who have terminated a pregnancy due to a genetic condition.
FISH|fluorescent in situ hybridization|FISH|146|149|FINAL DIAGNOSES|A core biopsy showed it was a grade 3 infiltrating ductal carcinoma. It was estrogen and progesterone receptor negative and positive for Her-2 by FISH analysis. After evaluation by yourself, you recommended that she have neoadjuvant treatment. She did have an ultrasound guided biopsy of the left axilla, which also showed metastatic breast cancer.
FISH|fluorescent in situ hybridization|FISH|229|232|FINAL DIAGNOSES|Amniocentesis was performed by Dr. _%#NAME#%_ and preliminary FISH results should be available in a few days. Today's ultrasound revealed possible chorioamnio separation, a large amount of fluid, and a small stomach. Preliminary FISH results were normal. As soon as final results become available, I will notify them by phone. If you have any further questions with which I can be of assistance, please feel free to contact me at _%#TEL#%_.
FISH|fluorescent in situ hybridization|FISH|215|218|IN SUMMARY|No carrier screening was offered today. IN SUMMARY: 1. Your patient had a level II ultrasound today, the report of which was faxed to your office under separate cover. 2. Ha also had an amniocentesis performed with FISH at today's appointment, and I will contact her when these results are available. 3. No carrier screening was offered during this pregnancy as _%#NAME#%_'s MCV value was 94 d/l.
FISH|fluorescent in situ hybridization|FISH|267|270|OPINION|As you will recall, she was diagnosed in _%#MM#%_ 2005 with a new right outer quadrant lesion which on core biopsy showed an invasive lobular carcinoma. The characteristics of it revealed that this was ER- and PR-positive and was negative for HER-2 overexpression by FISH analysis. On mastectomy on _%#MMDD2005#%_, she had a 4 x 3 x 2.1, grade 2 lesion removed, with negative margins.
FISH|fluorescent in situ hybridization|FISH|322|325|REFERRING PHYSICIAN|She ultimately was reevaluated and had a needle biopsy and ultrasound evaluation on _%#MMDD2007#%_, which revealed an infiltrating ductal carcinoma at approximately the 9 o'clock position. A second to biopsy adjacent that was negative. The tumor was estrogen receptor positive, progesterone receptor negative and HER-2 by FISH analysis negative. She subsequently also underwent a bilateral breast MRI and by that study the size of the abnormality in the right breast encompassed approximately 4.7 x 5.1 cm and in addition there was a prominent right axillary adenopathy.
FISH|GENERAL ENGLISH|FISH,|165|169|ALLERGIES|PERTINENT FAMILY HISTORY: Mother, sister, and brother had rheumatoid arthritis. Father had coronary artery disease and multiple myeloma. ALLERGIES: IODINE AND SHELL FISH, hives and breathing problems; BETADINE SOAP, ADHESIVE TAPE, CODEINE, TETRACYCLINE, LEVODAMINE, TALWIN, LATEX, SULFASALAZINE, AUGMENTIN [severe Candida infection which is not an allergy, but she was advised not to take this drug again]/ CURRENT MEDICATIONS: Current medical list consists of 1. Aspirin. 2. Percocet as needed.
FISH|fluorescent in situ hybridization|FISH|183|186|PLAN|Final results will take approximately 10-14 days. If you have any further questions of which I can be of assistance please feel free to contact me at _%#TEL#%_. Addenduem: Prelimiary FISH results were normal. Final CVS results are still pending. Sincerely,
FISH|fluorescent in situ hybridization|FISH.|197|201|PROBLEM|Ms. _%#NAME#%_ is a 37-year-old female with a history of invasive ductal carcinoma of the left breast diagnosed in 2003. She was initially staged T1 N0 M0, was ER/PR negative and HER-2 positive by FISH. However, her breast cancer was multifocal and because of this, she had bilateral mastectomy. This was followed by four cycles of AC chemotherapy followed by Taxol chemotherapy.
FISH|fluorescent in situ hybridization|FISH|239|242|RECOMMENDATIONS|_%#NAME#%_ stated her interest in having an amniocentesis to have more information about her current pregnancy. _%#NAME#%_ is scheduled to have amniocentesis and limited ultrasound by Dr. _%#NAME#%_ on _%#MMDD2003#%_. It is possible to do FISH testing for the SNRPN for Prader-Willi syndrome, at Dr. _%#NAME#%_' discretion through the amniocentesis. A followup level 2 ultrasound at 18 to 20 weeks would be recommended, given the early gestational age, at which time she is scheduled to have amniocentesis.
FISH|fluorescent in situ hybridization|FISH|163|166|HISTORY OF PRESENT ILLNESS|Unfortunately, a follow-up bone marrow biopsy on _%#MMDD2003#%_ (UHH03- 1258) revealed moderate granulopoiesis and a erythroid megakaryocytosis hypoplasia and the FISH was negative for chromosomal abnormalities or evidence of monosomy 7. But, the follow-up bone marrow on _%#MMDD2003#%_ (UHH03-1411) revealed early relapse or possible development of myelodysplastic syndrome.
FISH|fluorescent in situ hybridization|FISH|200|203|IMPRESSION/RECOMMENDATIONS|She underwent a needle core biopsy on _%#MMDD2007#%_, which revealed a grade II infiltrating ductal carcinoma. It was strongly estrogen and progesterone receptor positive and was negative for HER2 by FISH analysis. The patient was referred to Dr. _%#NAME#%_. He suggested a bilateral breast MRI, which was done on _%#MMDD2007#%_. The left breast was abnormal as anticipated, however, there was some suspicion noted on the right breast with an enhancing lesion at approximately the 12 o'clock position.
FISH|fluorescent in situ hybridization|FISH|252|255|IMPRESSION/RECOMMENDATIONS|Ultrasound also was suspicious in that region. She then underwent an ultrasound biopsy on _%#MMDD2007#%_, which revealed a grade I infiltrating lobular carcinoma. This was ER positive and weekly progesterone receptor positive, was negative for HER2 by FISH analysis. The patient had some laboratory studies on _%#MMDD2007#%_ with a CBC, which was unremarkable; however, her CA 2729 tumor marker came back markedly elevated at 654.
FISH|fluorescent in situ hybridization|(FISH|147|151|IDENTIFICATION|The patient was referred for admission secondary to her underlying complicated medical issues. The patient is also known to have DiGeorge syndrome (FISH positive) with mild T-cell deficiency. The last T- and B-cell subset that I can find on the computer is on _%#MMDD2003#%_, which revealed a CD3 of 45% (absolute count 1,909)-low; CD4 count is 32% (1,357); CD8 count 11% (467)- low; CD57 count 5%-low; CD4/CD8 ratio 2.91. The patient has been on Bactrim prophylaxis.
FISH|fluorescent in situ hybridization|FISH|202|205|PHYSICAL EXAMINATION|At the conclusion of our discussion, the patient elected to schedule an appointment for amniocentesis for Wednesday, _%#MM#%_ _%#DD#%_, 2006. The patient declined preliminary chromosome results through FISH studies and stated that she wished to just wished to be informed of the final chromosome results as well as amniotic fluid AFP.
FISH|fluorescent in situ hybridization|FISH|246|249|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her right infiltrating ductal carcinoma , status post mastectomy on _%#MMDD2002#%_, Nottingham grade 2/3, 17 of 20 lymph nodes. She is ER/PR positive at 79.4 and 82%. FISH negative. REVIEW OF SYSTEMS: GENERAL: She has some hot flashes. She is tired.
FISH|fluorescent in situ hybridization|FISH|151|154|HISTORY OF PRESENT ILLNESS|Due to the persistence of a hypotonia and the feeding issues, Genetics consult was obtained. This led to her getting chromosomal analysis. The initial FISH study here was normal, showing no deletion in the 15 chromosome in the PWS region. Subsequently, a ______ilation study was performed at Mayo Clinic, consistent with Prader-Willi syndrome.
FISH|fluorescent in situ hybridization|FISH|178|181|PLAN|Dear Dr. _%#NAME#%_: I met with your patient, _%#NAME#%_ _%#NAME#%_, and her husband on _%#MM#%_ _%#DD#%_, 2007. Unfortunately, we met to review the implications of the abnormal FISH results consistent with a diagnosis of fetal trisomy 21. We began by reviewing the results. We discussed the preliminary nature of FISH results.
FISH|fluorescent in situ hybridization|FISH|201|204|PLAN|Unfortunately, we met to review the implications of the abnormal FISH results consistent with a diagnosis of fetal trisomy 21. We began by reviewing the results. We discussed the preliminary nature of FISH results. I explained that in the context of ultrasound findings (pyelectasis) and serum biochemistry that are suggestive of Down syndrome, these results almost certainly confirm a diagnosis of fetal Down syndrome.
FISH|fluorescent in situ hybridization|FISH|181|184|HISTORY OF PRESENT ILLNESS|She has never required transfusions. She indicates that she has had progressive decline in her blood counts and was told she had worsening chromosome abnormality as determined on a FISH study done in _%#MM#%_. She is in need of a bone marrow transplant. She has 2 siblings, who are not HLA compatible.
FISH|fluorescent in situ hybridization|FISH|128|131|PROBLEM #6|She is status post lumpectomy with a 1.5 cm primary tumor with no evidence of nodal involvement. She was ER and TR positive and FISH HER-2 negative. Because of our uncertainly regarding whether or not she would actually benefit from chemotherapy we did to oncotype testing and her score came back at 24%, which gave her an intermediate risk with an estimated 16% distant recurrence at 10 years without chemotherapy.
FISH|fluorescent in situ hybridization|FISH|263|266|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Born via C-section secondary to transverse lie at 37 and 5/7 weeks, with Apgars of 7 at one minute and 9 at five minutes. The pregnancy was complicated with a history of diabetes. 2. Pierre-Robin sequence with cleft palate. Karyotype and FISH are pending. 3. History of aortic stenosis, VSD, PDA. 4. History of optic nerve hypoplasia bilaterally. 5. Renal hypoplasia as demonstrated by renal ultrasound. MEDICATIONS: 1. Ceftazidime 165 mg q.8h.
FISH|fluorescent in situ hybridization|FISH|191|194|SUMMARY|SUMMARY: 1. Level II ultrasound was performed today and showed echogenic bowel and a fluid-filled area below the kidney. Based on this information, _%#NAME#%_ chose to have an amniocentesis. FISH results are now available and are normal. _%#NAME#%_ is aware of these results. Final results will take 10 to 14 days. 2. Cystic fibrosis carrier screening was performed.
FISH|fluorescent in situ hybridization|FISH|218|221|SUMMARY|She was seen along with her husband, _%#NAME#%_ and son _%#NAME#%_, at the Maternal Fetal Medicine Center, Fairview-University Medical Center, on _%#MMDD2004#%_. As you know, she was referred to review the preliminary FISH results. _%#NAME#%_ was initially referred to our center because of an abnormal quad screen blood test indicating a 1:9 risk for Down syndrome.
FISH|fluorescent in situ hybridization|FISH|214|217|HISTORY OF PRESENT ILLNESS|Her cancer tumor marker was elevated at 1,587. Other parameters included a breast biopsy, which showed an infiltrating ductal carcinoma. It was estrogen and progesterone receptor positive, but was HER2-negative by FISH analysis. Her treatment back then approximately a year ago included rod fixation of the right hip and left tibia and then in _%#MM2005#%_ to early _%#MM2005#%_ she received radiation therapy to the right hip, upper femur, left tibia, thoracic spine region, as well as the skull.
FISH|fluorescent in situ hybridization|FISH|245|248|IMPRESSION|The risks, benefits and limitations of amniocentesis were described to the couple, as was the procedure-related risk of miscarriage of 1: 200. We discussed that amniotic fluid could be sent for chromosome studies, as well as amniotic fluid AFP, FISH studies for in situ hybridization could also be performed to look for common aneuploidy, such as trisomy 13, trisomy 18, and trisomy 21, and sex- chromosome abnormalities.
FISH|fluorescent in situ hybridization|FISH|174|177|IMPRESSION|At the conclusion of our discussion the patient elected to proceed with amniocentesis, which was performed that day by Dr. _%#NAME#%_ _%#NAME#%_. Amniotic fluid was sent for FISH studies as well as chromosome studies and amniotic fluid AFP. The patient will be called results as they become available. If I can be of any further assistance, please feel free to contact me at _%#TEL#%_.
FISH|fluorescent in situ hybridization|FISH|268|271|IMPRESSION|They had previously lost a son who had a congenital diaphragmatic hernia that died in 2003. Unfortunately, this current pregnancy, there are multiple abnormalities seen on ultrasound including a congenital heart defect and clenched hands and amniocentesis preliminary FISH results revealed that this was consistent with trisomy 18. I reviewed the chromosome results and discussed what additional information we would get once the final results are available in approximately 10-14 days.
FISH|fluorescent in situ hybridization|FISH|402|405|HISTORY OF PRESENT ILLNESS|The patient was seen by Dr. _%#NAME#%_ _%#NAME#%_ in Hematology-Oncology at University of Minnesota Oncology Clinic on _%#MMDD2006#%_, which is the day prior to her sentinel lymph node biopsy, and again on _%#MMDD2006#%_. The patient was recommended to undergo neoadjuvant chemotherapy for locally advanced, stage T3 N1 M0 breast cancer, ER positive, PR negative, with apparent HER2/neu amplification, FISH positive, with 1.9 and 2.2. In addition, she was evaluated with pelvic ultrasound for this positive PET scan which was thought to be maybe complex cyst, probably corpus luteum cyst.
FISH|fluorescent in situ hybridization|FISH|215|218|ASSESSMENT AND PLAN|After our discussion, Lesley proceeded with an ultrasound and amniocentesis. Please see the perinatologist's report for more details regarding her ultrasound examination. Lesley then proceeded with amniocentesis. A FISH analysis was ordered, and results of this were normal (two chromosome 21 signals, two chromosome 13 signals and 2 chromosome 18 signals).
FISH|fluorescent in situ hybridization|FISH|187|190|ASSESSMENT AND PLAN|Ultrasound revealed normal fetal anatomy with the exception of mild pyelectasis. Thus, the patient decided to have amniocentesis, which was performed today by Dr. _%#NAME#%_. Preliminary FISH analysis were normal. Final results will take approximately 10 to 14 days. If you have any further questions regarding this patient, please feel free to contact me at _%#TEL#%_.
FISH|fluorescent in situ hybridization|FISH|156|159|HISTORY OF PRESENT ILLNESS|His last chemotherapy was about 3 weeks ago. Chemotherapy was complicated with constipation, rash, mucositis, and neutropenic fever. The BCR/ABL was 94% on FISH with his initial bone marrow biopsy. Since _%#MMDD2006#%_, it has been negative on FISH but a recent quantification of peripheral blood by PCR for BCR/ABL showed evidence of minimal residual disease.
FISH|fluorescent in situ hybridization|FISH|244|247|HISTORY OF PRESENT ILLNESS|His last chemotherapy was about 3 weeks ago. Chemotherapy was complicated with constipation, rash, mucositis, and neutropenic fever. The BCR/ABL was 94% on FISH with his initial bone marrow biopsy. Since _%#MMDD2006#%_, it has been negative on FISH but a recent quantification of peripheral blood by PCR for BCR/ABL showed evidence of minimal residual disease. _%#NAME#%_ is in need of a bone marrow transplant. He has a sister who is not HLA compatible.
FISH|fluorescent in situ hybridization|FISH|235|238|RECOMMENDATIONS|As you know, a routine ultrasound had revealed an echogenic foci and possible fluid around the lung. She subsequently had an amniocentesis at United Hospital and briefly met with a genetic counselor, _%#NAME#%_ _%#NAME#%_. Preliminary FISH results from Abbott Northwestern Hospital indicate that this developing baby has Down syndrome. Final amniocentesis results are still pending. We reviewed these results with her and explained that these are greater than 99% accurate for Down syndrome.
FISH|fluorescent in situ hybridization|FISH|147|150||Otherwise, no abnormality was demonstrated. Newborn metabolic screening was negative. Postnatal karyotype analysis is pending at the present time. FISH testing for velocardiofacial syndrome was negative. Ophthalmology consultation has been requested on _%#NAME#%_. _%#NAME#%_ has been observed to have a poor suck.
FISH|fluorescent in situ hybridization|FISH|185|188|RECOMMENDATIONS|We reviewed amniocentesis as well as the risk of miscarriage which is diagnostic for Down syndrome as well as other chromosome abnormalities with greater than 99% accuracy. Preliminary FISH results should be available in the next few days. We thoroughly reviewed their family history during our genetic counseling session.
FISH|fluorescent in situ hybridization|FISH|164|167|RECOMMENDATIONS|After we discussed these results, _%#NAME#%_ did elect to come back to our clinic for an amniocentesis, which was performed on _%#MM#%_ _%#DD#%_, 2007. Preliminary FISH results from this amniocentesis revealed fetal trisomy 21. I contacted _%#NAME#%_ with the results on _%#MM#%_ _%#DD#%_. I explained that this test result, in the context of the ultrasound findings and serum screen findings, almost certainly confirms the diagnosis of fetal Down syndrome.
FISH|fluorescent in situ hybridization|FISH|176|179|RECOMMENDATIONS|Mammogram revealed a 2.5 cm mass at the 1 o'clock position. On _%#MMDD#%_ a core biopsy revealed a grade 3 infiltrating ductal carcinoma. It was ER and PR negative and also by FISH analysis HER2 negative. There was evidence of angiolymphatic invasion. The left axillary lymph node biopsy proved to be positive. A PET CT scan showed involvement of the left breast as well as the left axillary.
FISH|fluorescent in situ hybridization|FISH|202|205|LABORATORY DATA|INR was 1.54. PTT was initially 71 and 43 on repeat and fibrinogen 219. A cranial ultrasound was obtained on _%#MMDD2007#%_, showing normal intracranial contents. Blood for karyotype analysis and 22q11 FISH testing has been submitted. PHYSICAL EXAMINATION: VITAL SIGNS: _%#NAME#%_'s head circumference was 34 cm, blood pressure 69/33, heart rate 186, temperature 38 degrees, respiratory rate 63, oxygen saturation 95% on room air and weight 2.9 kilograms.
FISH|fluorescent in situ hybridization|FISH|199|202|REASON FOR CONSULTATION|I actually had occasion to be consulted on her and, subsequently, we did do a bone marrow with cytogenetics and FISH analysis for CML. There was no evidence then for CML with normal cytogenetics and FISH negative for the BCR-ABL gene rearrangement. The bone marrow itself was also hypercellular for her age with granulocytic hyperplasia.
FISH|fluorescent in situ hybridization|FISH|170|173|RECOMMENDATIONS|FISH studies were discussed with the patient as a preliminary test for trisomy 21, trisomy 13, trisomy 18, and sex-chromosome abnormalities. The risks and limitations of FISH studies were described to the patient in detail. When results become available the patient will be called. The patient was scheduled for a followup ultrasound at our center on _%#MMDD2005#%_ at 10:45 a.m. In addition, consultation with Dr. _%#NAME#%_, a pediatric nephrologist, was set up for 1:00 p.m. to discuss issues regarding the fetal kidney findings.
FISH|fluorescent in situ hybridization|FISH|202|205|RECOMMENDATIONS|The availability of FISH studies, fluorescence in situ hybridization studies, to look specifically for numerical abnormalities in chromosome 13, 18, 21, X and Y were discussed. The turn around time for FISH studies is approximately 24 to 48 hours. The preliminary nature of FISH results were described to the patient. Given the ultrasound findings we briefly discussed the availability of options for the pregnancy following the amniocentesis results, continuation of the pregnancy, or termination were briefly discussed with the patient.
FISH|fluorescent in situ hybridization|FISH|274|277|RECOMMENDATIONS|The availability of FISH studies, fluorescence in situ hybridization studies, to look specifically for numerical abnormalities in chromosome 13, 18, 21, X and Y were discussed. The turn around time for FISH studies is approximately 24 to 48 hours. The preliminary nature of FISH results were described to the patient. Given the ultrasound findings we briefly discussed the availability of options for the pregnancy following the amniocentesis results, continuation of the pregnancy, or termination were briefly discussed with the patient.
FISH|fluorescent in situ hybridization|FISH|225|228|RECOMMENDATIONS|Acetylcholinesterase was tested given this elevation of amniotic fluid alpha-fetoprotein level and a faint acetylcholinesterase band was detected in the amniotic fluid. The patient was contacted by phone with the preliminary FISH results as well as with the final chromosome studies and alpha-fetoprotein results. These results were discussed in detail with the patient, especially given the ultrasound findings.
FISH|fluorescent in situ hybridization|FISH|184|187|ASSESSMENT/PLAN|A left breast biopsy was performed on _%#MMDD#%_ at approximately the 12 o'clock position and revealed a grade 3 infiltrating ductal carcinoma. It was ER positive, PR positive, and by FISH analysis HER-2 positive with 8 copies present. The patient subsequently on _%#MMDD#%_ underwent a lumpectomy and sentinel lymph node biopsy.
FISH|fluorescent in situ hybridization|FISH|293|296|ASSESSMENT/PLAN|Dear _%#NAME#%_: This is an update on our mutual patient, _%#NAME#%_ _%#NAME#%_, the pleasant lady with stage 3A left breast cancer who was enrolled in a CALGB 49909 clinical trial. Her diagnosis was back in _%#MM#%_ of 2003. Her original tumor was 3+ positive by Herceptin tests confirmed by FISH analysis. She was started on an aggressive regimen using Adriamycin and Cytoxan x4 cycles and then she received 12 weeks of weekly Taxol with chemotherapy of that type ending on _%#MM#%_ _%#DD#%_.
FISH|fluorescent in situ hybridization|FISH|161|164|FOLLOW-UP|Unfortunately, in _%#MM2005#%_, she began to complain of left hip pain. A scan was abnormal and a biopsy of this showed metastatic breast cancer, which was also FISH positive. We switched her at that time from Arimidex to Faslodex, which she took up until _%#MM2006#%_. We also reinitiated Herceptin starting in _%#MM2005#%_, and she still continuing on that at the present time.
FISH|fluorescent in situ hybridization|FISH|187|190|FOLLOW-UP|This patient's history is that back in _%#MM#%_ 2003 she was diagnosed with a stage IIIA left infiltrating ductal carcinoma. It was estrogen-receptor positive and HER-2 3 positive and by FISH also positive. Back then she underwent a lumpectomy. She had a total of 9 more positive lymph nodes that were matted. She was enrolled in the clinical CALGB 49909 study, and she received 4 cycles of Adriamycin and Cytoxan, and then this was followed by 12 weeks of Taxol.
FISH|fluorescent in situ hybridization|FISH|217|220|ASSESSMENT AND PLAN|We will arrange for the necessary treatment planning session. Ms. _%#NAME#%_ will also be taking tamoxifen. Her estrogen receptor was positive, progesterone receptor was negative, and her HER-2/neu was positive, with FISH pending. Thank you for allowing us to participate in the care of this very pleasant patient.
FISH|GENERAL ENGLISH|FISH|189|192|ALLERGIES|She is status post a rotator cuff tear. She has a history of degenerative joint disease and of depression. ALLERGIES: She is allergic to TETANUS TOXOID, which caused swelling, SULFA, SHELL FISH and TOMATOES. She is allergic or intolerant to CODEINE and PENICILLIN. MEDICATIONS: Before admission, lisinopril 20 mg a day, Paxil 10 mg a day.
FISH|fluorescent in situ hybridization|FISH|249|252|RECOMMENDATIONS|Risk of miscarriage is 1 in 200. _%#NAME#%_ stated that they wished to pursue amniocentesis more for piece of mind and for possible planning if an abnormality was found. _%#NAME#%_ had an amniocentesis performed today by Dr. _%#NAME#%_. Preliminary FISH results were normal.. (_%#MMDD2005#%_) If you have any further questions regarding this patient please feel free to contact me at _%#TEL#%_.
FISH|fluorescent in situ hybridization|FISH|171|174|REQUESTING PHYSICIAN|Since the time of initial diagnosis, she has been maintained on Gleevec (Imitinib) for the last two years. Unfortunately, she has never achieved cytogenic remission (with FISH bcr/abl) as high as 90% at one point. Recently, she has thought to be "escaping" chronic phase CML despite an increase in her Gleevec dose to 800 mg PO Q day for approximately the last year.
FISH|fluorescent in situ hybridization|FISH|157|160|PLAN|On _%#MMDD2007#%_ a biopsy was performed and showed an infiltrating ductal and lobular carcinoma. The tumor was both ER and PR-positive and HER2 negative by FISH analysis. She did have bilateral MRIs which showed at least 5 concerning mass-like areas of enhancement in the right breast, with multiple cysts in both breasts, and an area of enhancement in the left breast that was also worsened.
FISH|fluorescent in situ hybridization|FISH|119|122|HISTORY OF PRESENT ILLNESS|Specimen also showed associated DCIS intermediate grade, cribriform without necrosis. ER/PR was positive and HER-2/neu FISH was negative. Margin was negative for tumor. The patient had a 21 right axillary node removed which showed 8 of the lymph nodes positive for malignancy with extracapsular extension.
FISH|fluorescent in situ hybridization|FISH.|218|222|PHYSICAL EXAMINATION|22 Q deletion is associated with learning disabilities and can be associated with psychiatric difficulty, ADHD and is inherited in autosomal dominant fashion. Chromosome studies were sent, specifically requesting 22 Q FISH. Additionally, occasionally metabolic disease can present with psychiatric disturbance, although this would be unusual in a child who has had no other constitutional problems or deterioration in mental status.
FISH|fluorescent in situ hybridization|FISH|224|227|G 4   P 3003				LMP|An amniocentesis was performed that day, in which FISH studies were performed to obtain some preliminary information. According to Fairview-University Medical Center Cytogenic Laboratory, 93% of interphase cells examined by FISH had three signals for chromosome 21, and thus is consistent with trisomy 21. Final chromosome analysis is pending. I reviewed features of babies with Down syndrome, including varying degrees of mental retardation, increased risk for congenital heart defect, and characteristic facial features.
FISH|fluorescent in situ hybridization|FISH|185|188|ASSESSMENT AND PLAN|We discussed that this would be a 2-day procedure at this point in pregnancy. After discussion with Dr. _%#NAME#%_ _%#NAME#%_ did decide to go ahead and have CVS performed. Preliminary FISH results were normal. As soon as final results become available we will contact her by phone and fax you a copy. If you have any further questions of which I can be of assistance please feel free to contact me at _%#TEL#%_.
FISH|fluorescent in situ hybridization|FISH|141|144|ASSESSMENT AND PLAN|CBC today showed a hemoglobin of 11.9, white count 4800, platelets 218,000. We have pending flow cytometry for the leukemia panel, including FISH analysis for the CLL cytogenetic assay. This will be of some value in determining the degree of remission that we have been able to achieve.
FISH|fluorescent in situ hybridization|FISH|329|332|REFERRING PHYSICIAN|Ultrasound-guided needle biopsy was performed at that visit and the results were positive for invasive ductal carcinoma bilaterally. Other parameters performed on the original core biopsy did reveal that both the right and left breast cancer were estrogen and progesterone receptor positive, and they were both negative by HER-2 FISH analysis. The patient was subsequently referred to Dr. _%#NAME#%_ and on _%#MMDD#%_ she underwent modified radical mastectomies with sentinel lymph node biopsies.
FISH|fluorescent in situ hybridization|FISH|126|129|PATHOLOGY|Biopsy of the left breast shows stromal fibrosis. There is no evidence of malignancy. Case CG06-3665 collected _%#MMDD2006#%_ FISH hybridization for HER-2/neu shows amplification. Case U06-10678 sentinel node biopsy and right lumpectomy shows negative sentinel lymph node biopsy.
FISH|fluorescent in situ hybridization|FISH|145|148|ASSESSMENT/PLAN|While the pattern was suggestive of Down syndrome, none of the individual markers was strikingly abnormal (i.e. the NT was still below 95%tile). FISH for common aneuploidies (i.e. Down syndrome, trisomy 13, trisomy 18) was reported as normal on _%#MM#%_ _%#DD#%_, 2006. I was contacted by the cytogenetics lab on _%#MM#%_ _%#DD#%_, 2006, and informed that a marker chromosome was detected in the sample.
FISH|fluorescent in situ hybridization|FISH|236|239|ASSESSMENT/PLAN|Thus, this is a de novo marker chromosome. 2. Multi-color FISH for all 22 autosomes and sex chromosomes was not able to reveal the specific chromosomal origin of this marker. This was likely due to the very small size of the marker. 3. FISH for markers specific to multiple regions of chromosome 15 were not able demonstrate that the marker was from chromosome 15.
FISH|fluorescent in situ hybridization|FISH|180|183|ASSESSMENT/PLAN|This study was undertaken as chromosome 15 is the most common origin for marker chromosomes. This study still does not definitively exclude chromosomes 15 as the origin. 4. Acro-P FISH was performed in order to determine if this marker was derived from an acrocentric chromosome (chromosomes 13,14,15,21,22).
FISH|fluorescent in situ hybridization|FISH|213|216|ASSESSMENT/PLAN|_%#NAME#%_ stated that they had not discussed specifically what they would do if the results did come back abnormal, but did wish to have an amniocentesis, which was performed today by Dr. _%#NAME#%_. Preliminary FISH results were normal. Final results available in 10-14 days and will be faxed to your office. If you have any further questions, of which I can be of assistance, please feel free to contact me at _%#TEL#%_.
FISH|fluorescent in situ hybridization|FISH|155|158|HISTORY OF PRESENT ILLNESS|A CBC revealed a white blood cell count of 113,000, with 90% blasts. Hemoglobin was 6.5, platelet count was 13,000. Bone marrow biopsy revealed pre-B ALL. FISH was positive for MLL re-arrangement. Ms. _%#NAME#%_ was treated under CALGB protocol _%#PROTOCOL#%_. She received intrathecal chemotherapy CNS prophylaxis. Ms. _%#NAME#%_ was in remission in _%#MM2005#%_.
FISH|fluorescent in situ hybridization|FISH|279|282|IMPRESSION|The patient was informed that while the amniocentesis is able to diagnose structural chromosome abnormalities such as Down syndrome with 99.4% accuracy, it is not able to test for all causes of mental retardation and birth defects in a pregnancy. The benefits and limitations of FISH testing were also discussed with the patient, and they elected FISH analysis as well for preliminary result. Family History: _%#NAME#%_ is 37 years old, and will be 38 at delivery.
FISH|fluorescent in situ hybridization|FISH|170|173|IN SUMMARY|3. Karyotype and AFP results should be available in 10-14 days, at which time I will call the patient directly and fax a copy to your office. 4. The patient also elected FISH preliminary analysis on the amniocentesis sample, and those results will be available within 24-48 hours, at which time I will call the patient directly and fax a copy to your office.
FISH|fluorescent in situ hybridization|FISH.|197|201|HISTORY OF PRESENT ILLNESS|There was necrosis present and involved about 20% of the tumor tissue. Vascular invasion was not identified as well as DCIS. ER/PR receptor status was negative, and HER2/neu gene was negative with FISH. The primary lesion was 1.1 cm and closest margin was 1.3 cm.
FISH|GENERAL ENGLISH|FISH|159|162|ALLERGIES|8. Minocycline 200 mg bid (currently not taking). 9. Allegra 180 mg per day. 10. Lopid 600 mg bid. ALLERGIES: HYDROCODONE CAUSES RASH. ALSO ALLERGIES TO SHELL FISH AND MACADAMIA NUTS. FAMILY HISTORY: His brother has coronary artery disease. He has sons with asthma and there is significant vascular disease on his mother's side of the family.
FISH|fluorescent in situ hybridization|FISH|181|184|RECOMMENDATIONS|We have been pleased he was able to undergo his back surgery, which had been giving him a problem for quite some time and he is now able to be off of all of his narcotics. His last FISH analysis for the BCR/ABL mutation was on _%#MM#%_ _%#DD#%_ and still remains negative on 400 cells analyzed. He is in a good hematological remission with his most recent CBC showing hemoglobin of 15.2, white count 6700 with a normal differential and platelets 189,000.
FISH|fluorescent in situ hybridization|FISH|326|329|RECOMMENDATIONS|Since that time, he has been on chemotherapy with alpha interferon and cytosine arabinoside, and I am pleased to report that he remains in a very solid complete remission, both from molecular testing as well as chromosome studies. His last bone marrow on _%#MM#%_ _%#DD#%_, 2003, was normocellular, with normal hematopoiesis. FISH testing for the BCR/ADL gene rearrangement were negative, and cytogenetics also were negative for the Philadelphia chromosome. His only evidence of hematological problems is a decreased white count, but I attribute this to his ara-C and interferon treatments, and he has not had problems with infections.
FISH|fluorescent in situ hybridization|FISH|157|160|RECOMMENDATIONS|This was performed by Dr. _%#NAME#%_ _%#NAME#%_ in addition to chromosome studies, amniotic fluid AFP, and 22q deletion studies. Amniotic fluid was sent for FISH studies. The benefits and limitations to FISH were discussed with the couple. The couple will be called with the results as soon as they become available.
FISH|fluorescent in situ hybridization|FISH|268|271|RECOMMENDATIONS|_%#NAME#%_ had an amniocentesis performed on _%#MM#%_ _%#DD#%_, 2004, due to a positive triple-screen for Down syndrome, and the finding of an AV canal heart defect on level II ultrasound at the Fairview Southdale Maternal-Fetal Medicine Center. We began by reviewing FISH results from the Fairview-University Cytogenetics Laboratory. The FISH results demonstrated 3 copies of chromosome #21. The results for chromosomes 13 and 18 were normal, with 2 copies of each present on FISH.
FISH|fluorescent in situ hybridization|FISH|240|243|RECOMMENDATIONS|The FISH results demonstrated 3 copies of chromosome #21. The results for chromosomes 13 and 18 were normal, with 2 copies of each present on FISH. _%#NAME#%_ and _%#NAME#%_ requested that I withhold the gender that was determined from the FISH study. These test results, in conjunction with a heart defect that is very characteristic of Down syndrome, are highly suggestive of a diagnosis of fetal Down syndrome.
FISH|fluorescent in situ hybridization|FISH|204|207|RECOMMENDATIONS|These test results, in conjunction with a heart defect that is very characteristic of Down syndrome, are highly suggestive of a diagnosis of fetal Down syndrome. We did discuss some of the limitations of FISH testing, and the importance of always following up FISH with a full cytogenetic study. The final results of _%#NAME#%_'s amniocentesis should be available some time next week.
FISH|fluorescent in situ hybridization|FISH|135|138|HISTORY OF PRESENT ILLNESS|Her original cancer was grade 2/3 and she had 1 of 6 lymph nodes positive in 1998. She was ER/PR positive at 55% and 64% respectively. FISH negative. REVIEW OF SYSTEMS: GENERAL: Weight is down 11 pounds. Appetite is poor.
FISH|fluorescent in situ hybridization|FISH|243|246|RECOMMENDATIONS|As you know, she has been now diagnosed with recurrent breast cancer, metastatic to her chest wall with a recent punch biopsy done by yourself on 1/14 consistent with recurrence of breast cancer. The hormone receptors were ER and PR negative; FISH analysis is currently pending. CT scan and a PET scan show that she has also a hypermetabolic foci in the right axilla, probably representing metastatic disease to the axillary vault.
FISH|fluorescent in situ hybridization|FISH.|148|152|HISTORY OF PRESENT ILLNESS|He was an early responder to the induction chemotherapy. His day 15 bone marrow showed 1.5% blasts. He also had 3.4% blasts positive for bcr/abl by FISH. Because of the Philadelphia chromosome, his parents indicate that his protocol was changed to AALL_%#PROTOCOL#%_, a protocol for high-risk ALL.
FISH|fluorescent in situ hybridization|FISH|151|154|LOCATION|Ultrasound guided core biopsy revealed an infiltrating ductal carcinoma grade II. Estrogen- progesterone receiptors were strongly positive and HER2 by FISH analysis was negative. After conferring with Dr. _%#NAME#%_ she elected to have a right sided modified radical mastectomy and a left simple mastectomy with immediate breast saline expanders placed at the time of surgery.
FISH|fluorescent in situ hybridization|FISH|350|353|G  1  P 0000				LMP|Upon review of both of 2 genetic consults notes, one from Dr. _%#NAME#%_ _%#NAME#%_ dysmorphic facial features included long philtrum, small jaw, high-arched palate, long low-set ears, and mid-face hypoplasia. Dr. _%#NAME#%_ ordered additional high resolutation chromosome studies with sub-telomeric probes. In addition, in another genetics consult, FISH studies for velocardiofacial syndrome was ordered by Dr. _%#NAME#%_ _%#NAME#%_. These results were reportedly normal. The patient did report however at the time of our visit that the last diagnosis for _%#NAME#%_ was thought to be that her medical issues were due to a form of a skeletal dysplasia or dwarfism.
FISH|fluorescent in situ hybridization|FISH|240|243|RECOMMENDATIONS|As you know, she was initially referred for a possible cystic hygroma that was seen on their developing baby on an ultrasound performed at your clinic. She had a CVS performed on Wednesday, _%#MMDD2007#%_, by Dr. _%#NAME#%_ and preliminary FISH results did confirm that this developing baby has a Turner's syndrome. I met with them on Friday, _%#MMDD2007#%_, to relay these results in person.
FISH|fluorescent in situ hybridization|FISH|161|164|RECOMMENDATIONS|We emphasized that there was nothing either her or her husband would have done to cause their baby to have a cystic hygroma. A CVS was performed and preliminary FISH results were consistent with a baby girl with Turner's syndrome. In light of this diagnosis we discussed that most babies with Turner's syndrome with a large cystic hygroma do not make it to term and miscarry before birth.
FISH|fluorescent in situ hybridization|FISH|120|123|HISTORY OF PRESENT ILLNESS|It should also be mentioned that on her original tumor the HER2 status was 2+ positive and Dr. _%#NAME#%_ has initiated FISH testing to determine if this is truly an over-expressing HER2 tumor. MEDICATIONS: 1. Vioxx 50 mg q. daily. 2. Arimidex 1 mg q. daily.
FISH|GENERAL ENGLISH|FISH,|121|125|ALLERGIES|SOCIAL HISTORY: The patient is accompanied by his daughter and his son-in-law. He quit smoking. ALLERGIES: IODINE, SHELL FISH, and ZOCOR. CURRENT MEDICATIONS: 1) Aspirin - the patient received 162 mg p.o. times one.
FISH|GENERAL ENGLISH|FISH.|106|110|ALLERGIES|7. Mycostatin swish-and-swallow. 8. Tiotropin. 9. _________. 10. Prn Imodium. ALLERGIES: IODINE AND SHELL FISH. SOCIAL HISTORY: Mr. _%#NAME#%_ is a retired draftsman.
FISH|fluorescent in situ hybridization|FISH|149|152|HISTORY OF PRESENT ILLNESS|Because of apparent absence of testes and hypotonia, along with micrognathia and other dysmorphic features, he had a karyotype, which was 46 XY, and FISH studies for Prader-Willi deletion have been normal. DNA methylation studies are pending. He received TPN for 4 days, had a brief trial on oral feeds, which was discontinued after day 3, when he was unable to tolerate adequate intake, with the suggestion that he was actually doing better, and then lost the ability to feed.
FISH|fluorescent in situ hybridization|FISH|243|246|DISPOSITION|I encouraged _%#NAME#%_ and _%#NAME#%_ to discuss this further with Dr. _%#NAME#%_ and other pediatricians in her area, as a child with Down syndrome may need more frequent follow up visits. We discussed the option of performing a preliminary FISH test on the amniotic fluid in order to diagnose a chromosomal abnormality. _%#NAME#%_ and _%#NAME#%_ wished to have this preliminary test done, as it would facilitate their need to make travel arrangements for additional follow up visits.
FISH|fluorescent in situ hybridization|FISH|227|230|LOCATION|Therefore, we concur with the neurologist who suggested: 1. A cranial MRI scan including mass spectroscopy to document or refute central nervous system lactic acidosis. 2. DNA studies of potential mitochondrial mutations. 3. A FISH analysis has already been sent to Baylor to rule out Galeazzi- Merzbacher disease; although this is not a definitive test, this was included in the neurologist's initial differential diagnosis.
FISH|fluorescent in situ hybridization|FISH|137|140|PLAN|If you have any further questions with which I can be of assistance, please feel free to contact me at _%#TEL#%_. Addenduem: Preliminary FISH results reveal a normal female. Final results are pending. Sincerely,
FISH|fluorescent in situ hybridization|FISH|137|140|G  3 P	2002				LMP|The procedure, accuracy, and associated 0.5% risk of miscarriage were reviewed. _%#NAME#%_ choose to have the amniocentesis. Preliminary FISH and Final results are now available, which is consistent with (45,X) Turner syndrome. Turner syndrome is a chromosome abnormality that is caused by a missing X chromosome.
FISH|fluorescent in situ hybridization|FISH.|146|150|REASON FOR CONSULTATION & HISTORY OF PRESENT ILLNESS|She had 0 of 6 lymph nodes positive. She is ER positive at 90%, and PR positive at 10%. Her cancer was 7 mm in size. She is HER-2/neu positive by FISH. The patient felt the nodule. It was not seen on mammogram, but was seen on MRI. FAMILY HISTORY: The patient's mother is 78 and healthy. Her father is 76, with hypertension and a pacemaker.
FISH|fluorescent in situ hybridization|FISH|153|156|PHYSICAL EXAMINATION|I will make arrangements to share this information with Dr. _%#NAME#%_ and his family as it becomes available. Addendum: The analysis for 7q-deletion by FISH was positive, confirming the diagnosis of Williams syndrome.
FISH|fluorescent in situ hybridization|FISH|203|206|PHYSICAL EXAMINATION|As you know, she was referred to discuss the results of her abnormal quad screen. We met with her for approximately 60 minutes. She had an amniocentesis performed today by Dr. _%#NAME#%_ and preliminary FISH results should be available tomorrow. _%#NAME#%_ is a 29-year-old gravida 2, para 1-0-0-1 who is currently 21 weeks' and 2 days' gestation based on an estimated date of delivery of _%#MM#%_ _%#DD#%_, 2007.
FISH|fluorescent in situ hybridization|FISH|217|220|PHYSICAL EXAMINATION|_%#NAME#%_ stated they wished to begin with a level II ultrasound, which was performed today. A slightly enlarged stomach was visualized and they decided to go forward with the amniocentesis at this time. Preliminary FISH results were normal female pattern (_%#MMDD2007#%_). As soon as the final results become available we will notify them by phone. If you have any further questions, of which I can be of assistance, please feel free to contact me at _%#TEL#%_.
FISH|fluorescent in situ hybridization|FISH.|312|316|HISTORY  OF PRESENT ILLNESS|Ms. _%#NAME#%_ is a 58-year-old Caucasian female who has been diagnosed with a T1C N0 M0 (stage I) infiltrating ductal carcinoma of the left breast who has undergone lumpectomy and sentinel lymph node sampling as well as adjuvant Taxol chemotherapy. Her tumor was ER positive, PR negative, and Her-2 negative by FISH. Oncotype score was 16. She requested to undergo adjuvant chemotherapy after her lumpectomy and was randomized to Taxol x4 on ECOG 40101, receiving dose-dense Taxol x4, the last dose _%#MM#%_ _%#DD#%_, 2007.
FISH|fluorescent in situ hybridization|FISH|256|259|RE|_%#NAME#%_ stated that she was quite worried regarding her abnormal screen and had an ultrasound performed today which did not show any apparent abnormalities, however, she did have an amniocentesis which was performed today by Dr. _%#NAME#%_. Preliminary FISH results should be available in the next few days. If you have any further questions with which I can be of assistance, please feel free to contact me at _%#TEL#%_.
FISH|fluorescent in situ hybridization|FISH|130|133|RE|Chromosome analysis was performed at Genzyme Genetics and revealed a marker chromosome in 11 of the 20 cells examined. Subsequent FISH studies were unable to identify the origin of this marker chromosome. C-banding analysis revealed that this marker chromosome contains active euchromatin.
FISH|fluorescent in situ hybridization|FISH|416|419|RE|_%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD Fairview Oxboro Clinic _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_, Minnesota _%#55400#%_ Dear _%#NAME#%_: This letter is in followup to my phone call and to document results from the _%#MMDD2004#%_genetic amniocentesis performed on your patient, _%#NAME#%_ _%#NAME#%_. Our reference laboratory has reported both the amniotic fluid chromosome analysis and the FISH Aneuscreene consistent with a 46, XX, normal female. The alpha fetoprotein was reported at 0.87 MoM. This value is within the range of normal for our laboratory.
FISH|fluorescent in situ hybridization|FISH|240|243|RE|In light of the couple's anxiety, we discussed that chromosome studies could be performed, as well as FISH studies for preliminary results involving numerical abnormalities of chromosomes 13, 18, 21 X and Y. The benefits and limitations to FISH studies were discussed. The patient will be called with results as they become available.
FISH|fluorescent in situ hybridization|FISH|250|253|RE|As you know, she was diagnosed back in _%#MM#%_ and underwent a modified radical mastectomy and axillary lymph node dissection. She had 3 of 21 positive lymph nodes. The tumor was estrogen and progesterone receptor-positive, and negative for HER2 by FISH analysis. Beginning on _%#MMDD2006#%_ the patient was started on triple chemotherapy with Taxotere, Adriamycin, and Cytoxan, receiving a cycle every 3 weeks, for a total of 6 cycles.
FISH|fluorescent in situ hybridization|FISH|224|227|G  6 P	2032				LMP|We discussed that an amniocentesis can be performed as early as 15 weeks' gestation and we have her scheduled for _%#MMDD2007#%_ at 10 a.m. with Dr. _%#NAME#%_. Hopefully enough fluid can be obtained to get some preliminary FISH information for results. _%#NAME#%_ stated that she has had genetic counseling here before approximately 2 years ago and a family history was taken at that time by _%#NAME#%_ _%#NAME#%_.
FISH|fluorescent in situ hybridization|FISH.|153|157|HISTORY OF PRESENT ILLNESS|There was also evidence of DCIS. The core biopsy was positive for estrogen receptors, negative for progesterone receptors and was also HER-2 positive by FISH. The patient was subsequently seen by Dr. _%#NAME#%_ _%#NAME#%_ and after discussing options it was elected to do a skin-sparing left mastectomy with sentinel lymph node biopsy.
FISH|fluorescent in situ hybridization|FISH|224|227|LOCATION|Beginning on _%#MMDD2006#%_ the patient was started on Adriamycin and Cytoxan and she received four cycles of that regimen through _%#MMDD#%_. Post-chemo MUGA scan was normal at 61%. Because the patient was HER2 positive by FISH analysis she started on weekly Taxol plus Herceptin on _%#MMDD#%_ and has as of today completed 12 weeks of this treatment.
FISH|fluorescent in situ hybridization|FISH|137|140|DATE OF SERVICE|Review of systems is as above and also notable for the following: Chromosome studies were obtained and reported as "normal" as well as a FISH molecular genetics study for the 22q11 deletion syndrome. The remainder of the systems exam was negative or noncontributory. Physical examination shows a sleeping, but arousable infant in no apparent distress in a cot on the Newborn Intensive Care Unit.
FISH|fluorescent in situ hybridization|FISH|199|202|RECOMMENDATIONS|ASSESSMENT: 1. Pierre-Robin anomalad. 2. Midface hypoplasia. 3. Possible velocardiofacial syndrome or other 22q11 deletion syndrome. 4. Possible Stickler syndrome. RECOMMENDATIONS: 1. Chromosome and FISH studies have been completed and are reported as normal but may not reveal all genetic causes of multiple congenital anomalies.
FISH|fluorescent in situ hybridization|FISH|240|243|HISTORY OF PRESENT ILLNESS|Mrs. _%#NAME#%_ is a 47-year-old who was diagnosed in _%#MM#%_ of 2004 with AML with 5Q abnormality felt to be from MDS. Mrs. _%#NAME#%_ was induced with idarubicin and Ara-C chemotherapy she was able to achieve a morphologic remission but FISH remained positive. In _%#MM#%_ 2005 she was found to be in relapse. She was reinduced with mitoxantrone and etoposide. She had 15% residual blasts.
FISH|fluorescent in situ hybridization|FISH|173|176|RECOMMENDATIONS|At the conclusion of our discussion, the patient elected to proceed with amniocentesis. Chromosome studies as well as amniotic fluid AFP were ordered as well as preliminary FISH studies for chromosome abnormalities involving #13, 18, 21, X and Y. The patient will called with the results accordingly. If I can be of additional assistance please feel free to contact me at _%#TEL#%_.
FISH|fluorescent in situ hybridization|FISH|218|221|RECOMMENDATIONS|Twin A had a level 2 ultrasound as well, which revealed a 2-vessel cord and mild unilateral hydronephrosis measuring 6.9 mm. Because of the gender difference, amniocentesis was performed by Dr. _%#NAME#%_. Preliminary FISH results concluded that Twin B's result is consistent with a male with Down syndrome. Twin A had normal female results. Final results are still pending.
FISH|fluorescent in situ hybridization|FISH|211|214|RECOMMENDATIONS|Echogenic foci and echogenic bowel was seen on today's ultrasound, which would increase her chance to have a baby with Down syndrome. She decided to have an amniocentesis, which was performed today. Preliminary FISH results were normal and were communicated to her through an interpreter. Final results are still pending. If you have any further questions with which I can be of assistance, please feel free to contact me at _%#TEL#%_.
FISH|fluorescent in situ hybridization|FISH|274|277|ASSESSMENT|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, MD University of Minnesota Medical Center, Fairview _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_, MN _%#55400#%_ Dear Dr. _%#NAME#%_: Thank you for requesting consultation regarding a "positive FISH test for a 22q delection" and the diagnosis of "velo-cardio-facical syndrome" on your patient, baby girl _%#NAME#%_. I evaluated this child today, _%#MM#%_ _%#DD#%_, 2007, on the Newborn Intensive Care Unit for approximately 60 minutes.
FISH|fluorescent in situ hybridization|FISH|157|160|PLAN/RECOMMENDATIONS|2. Observe for immunologic abnormalities and would also suggest immunoglobulin T cell studies as soon as possible. 3. Both parents should have the same, 22q FISH test in the Cytogenetics Laboratory here at the University of Minnesota Medical Center, Fairview. If this is not sent from the Newborn Intensive Care Unit, it could be sent from Genetics Clinic when they come for that initial clinic visit.
FISH|fluorescent in situ hybridization|FISH.|122|126|HISTORY OF PRESENT ILLNESS|There was also ductal carcinoma in situ with atypia. Again ER was positive, and PR was negative. HER2/neu was negative on FISH. She was found to have 3 of 12 axillary nodes positive with extracapsular extension with infiltrating ductal carcinoma with scattered cells in the nodes.
FISH|GENERAL ENGLISH|FISH|260|263|ALLERGIES|5. Urinary stress incontinence, not being treated 6. Low back pain. 7. Edema of the lower extremities. MEDICATIONS: Albuterol inhaler p.r.n. Advair inhaler daily, Singulair daily and Prozac daily ALLERGIES: NO KNOWN DRUG ALLERGIES, HOWEVER PATIENT IS ALLERGIC FISH AND SEAFOOD FOOD. PAST SURGICAL HISTORY: The patient had a tubal ligation in 1987, laparoscopic cholecystectomy in 1993, abdominal hysterectomy in hysterectomy in 1995.
FISH|fluorescent in situ hybridization|FISH.|134|138|HISTORY OF PRESENT ILLNESS|He was considered a Gleevec failure in 2006. Mr. _%#NAME#%_ was started on dasatinib in _%#MM2007#%_ and had an excellent response by FISH. His positive cells decreased from 71% to 0.25% by _%#MM2007#%_. However, Mr. _%#NAME#%_ developed hypocellular marrow and acute pulmonary dysfunction.
FISH|fluorescent in situ hybridization|FISH|186|189|HISTORY OF PRESENT ILLNESS|A needle biopsy was performed on _%#MMDD2007#%_, which showed an infiltrating ductal carcinoma grade III. The tumor was estrogen receptor positive, progesterone receptor negative and by FISH analysis it was positive. The patient was seen by a Dr. _%#NAME#%_ and given her poor pulmonary status, she was not felt to be an optimal candidate for general anesthesia.
FISH|fluorescent in situ hybridization|FISH|125|128|ADDENDUM|If you have any further questions regarding this patient, please feel free to contact me at _%#TEL#%_. ADDENDUM: Preliminary FISH results indicated that this developing baby has Down syndrome. Patient had D & E at Midwest Womens Clinic. Followup genetic counseling to be scheduled.
FISH|fluorescent in situ hybridization|FISH|205|208||She did have minimal involvement of DCIS. The sentinel lymph node biopsy revealed two lymph nodes, and they were both negative. The patient is thus surgical stage I (T1A, N0, M0). It was HER-2 negative by FISH analysis, and estrogen and progesterone receptors were both positive. She now presents to me for questions regarding adjuvant therapy. She is doing quite well. She did have a little bit of postop swelling, but this has resolved nicely.
FISH|fluorescent in situ hybridization|FISH|172|175|HISTORY OF PRESENT ILLNESS|On _%#MMDD2004#%_ an ultrasound core biopsy was performed revealing an infiltrating ductal carcinoma. That specimen was estrogen and progesterone receptor negative, and by FISH analysis, it was HER-2 positive. The patient was referred to Dr. _%#NAME#%_, and she elected to have a lumpectomy, which was performed on _%#MMDD2004#%_.
FISH|fluorescent in situ hybridization|FISH|230|233|DISCUSSION|DISCUSSION: _%#NAME#%_ has a stage I breast cancer. There are several worrisome features, however. The primary tumor was grade 3. In addition, it was estrogen and progesterone receptor negative, and it over......her to protein by FISH analysis. Furthermore, although the H and E stain of the lymph node was negative, it was positive by immunohistochemical technique.
FISH|fluorescent in situ hybridization|FISH|182|185|FINAL DIAGNOSIS|Several markers were seen including echogenic foci in the left ventricle of the heart, echogenic kidneys, and possible echogenic bowel. Amniocentesis was performed which preliminary FISH results were normal. Final results will take approximately 10 to 14 days. If you have any further questions regarding this patient please feel free to contact me at _%#TEL#%_.
FISH|fluorescent in situ hybridization|FISH|131|134|ADDENDUM|According to F-UMC cytogenetic report, her developing baby girl has a normal number of chromosomes, 46 XX. In addition, a specific FISH test was done for DiGeorge syndrome, which was normal. Thus this baby has normal chromosomes as well as normal FISH analysis for DiGeorge syndrome.
FISH|fluorescent in situ hybridization|FISH|140|143|ADDENDUM|In addition, a specific FISH test was done for DiGeorge syndrome, which was normal. Thus this baby has normal chromosomes as well as normal FISH analysis for DiGeorge syndrome. I explained that a chromosome analysis does not rule out all types of genetic syndromes and therefore, it would be important for this baby to be examined by a medical geneticist following delivery, and/or autopsy, to be performed as needed.
FISH|fluorescent in situ hybridization|FISH|154|157|ADDENDUM|Thus these represent a karyotype with a small interstitial deletion within band 17p11.2 which was first detected by G-band analysis and then confirmed by FISH probing for the specific Smith-Magenis region. I reviewed that this deletion has been seen as a well-documented abnormality associated with Smith-Magenis syndrome.
FISH|fluorescent in situ hybridization|FISH|217|220|ADDENDUM|Ultrasound, which was performed today, showed several soft markers for Down syndrome including an increased nuchal fold, possible heart defect, and club foot. Fluid was obtained from the amniocentesis and preliminary FISH testing was ordered. Preliminary FISH testing was normal. As soon as the final results become available, I will notify the patient by phone.
FISH|fluorescent in situ hybridization|FISH|162|165|ADDENDUM|We did take it upon ourselves to have the University of Minnesota Pathology Department repeat the patient's estrogen and progesterone receptors, as well as doing FISH analysis. The estrogen receptor previously was reported as negative. Our pathologists are calling this weakly positive with about 5% of the cells being positive.
FISH|fluorescent in situ hybridization|FISH|237|240|ADDENDUM|The estrogen receptor previously was reported as negative. Our pathologists are calling this weakly positive with about 5% of the cells being positive. This is sufficient for clinical activity. The progesterone receptor was negative. By FISH analysis, she is HER-2 negative. The patient has been seen by Dr. _%#NAME#%_ _%#NAME#%_, radiation oncology, and will be starting radiation therapy approximately _%#MMDD2005#%_.
FISH|fluorescent in situ hybridization|FISH|178|181|OTHER LAB DATA|_%#NAME#%_ was then hospitalized until _%#MMDD2005#%_. _%#NAME#%_ postoperative course was reported an unremarkable. _%#NAME#%_ was documented as having a normal 46xx karyotype. FISH testing for DiGeorge syndrome was negative. A neonatal head ultrasound examination on _%#MMDD2005#%_ had shown no evidence of intraventricular hemorrhage and otherwise normal intracranial contents.
FISH|fluorescent in situ hybridization|FISH|273|276|HISTORY OF PRESENT ILLNESS|A cranial CT scan was then obtained on _%#NAME#%_, showing marked hydrocephalus with dilation of the lateral, third, and fourth ventricles. _%#NAME#%_ underwent a left ventriculoperitoneal shunt placement on _%#MM#%_ _%#DD#%_, 2006. _%#NAME#%_ has a normal 46XX karyotype. FISH testing for DiGeorge syndrome was negative. A neonatal head ultrasound examination on _%#MM#%_ _%#DD#%_, 2005, showed no evidence of intraventricular hemorrhage and otherwise normal intracranial contents.
FISH|fluorescent in situ hybridization|FISH|175|178|HISTORY OF PRESENT ILLNESS|He was found to have pancytopenia. His white blood cell count was 2.7, hemoglobin was 9.1 and platelet count was 4000. His workup revealed AML-M3 with PMLRAR rearrangement by FISH and 15:17 translocation and loss of 17P by cytogenetics. Mr. _%#NAME#%_ was treated initially with ATRA, ARA-C and Daunorubicin.
FISH|fluorescent in situ hybridization|FISH|128|131|HISTORY OF PRESENT ILLNESS|He was treated with Daunorubicin consolidation along with ATRA. He received two cycles. Then ATRA maintenance for one year. His FISH became negative until _%#MM#%_ 2006 when he relapsed. On _%#MMDD2006#%_, Mr. _%#NAME#%_ was referred to the University of Minnesota Medical Center, Fairview.
FISH|fluorescent in situ hybridization|FISH|216|219|HISTORY OF PRESENT ILLNESS|This treatment was interrupted because of the development of VRE sepsis, which required a 2-day ICU stay. A follow-up bone marrow biopsy on _%#MMDD2006#%_ (UHH06-1914) revealed no morphologic evidence of leukemia. A FISH study revealed no evidence of residual leukemia. Mr. _%#NAME#%_ is in need of a bone marrow transplant. He has no matched sibling or unrelated donors.
FISH|fluorescent in situ hybridization|FISH|183|186|RECOMMENDATIONS|Dear Dr. _%#NAME#%_: I am writing in follow-up to your patient, _%#NAME#%_ _%#NAME#%_. Final results of her amniocentesis confirmed the preliminary findings of Down syndrome from the FISH testing. The final chromosome results indicated that this was a sporadic, rather than familial, form of Down syndrome. At _%#NAME#%_ and _%#NAME#%_' request, I am not reporting the gender from the chromosome study (47, __, +21).
FISH|fluorescent in situ hybridization|FISH|176|179|RECOMMENDATIONS|The risk of miscarriage is one in 200. Results take approximately ten to 14 days. Sometimes preliminary information can be obtained a few days following the procedure, through FISH studies. I reviewed _%#NAME#%_'s family history during our genetic counseling session.
FISH|fluorescent in situ hybridization|FISH|176|179|RECOMMENDATIONS|_%#NAME#%_ will use the information gained from the CVS in order to make further decisions about the pregnancy. We discussed the difference between the preliminary results via FISH (fluorescent in situ hybridization) in comparison to a karyotype result. _%#NAME#%_ was concerned that FISH would not be covered by her insurance company and may not proceed with FISH testing at this time.
FISH|fluorescent in situ hybridization|FISH|121|124|ADDENDUM 9/25/07|If I can be of additional assistance to your clinic please feel free to contact me at _%#TEL#%_. ADDENDUM _%#MMDD2007#%_ FISH study results from Ms. _%#NAME#%_'s amniocentesis was indicative of trisomy 18. These results were reviewed with the patient by phone, as well as her husband on Friday, _%#MM#%_ _%#DD#%_, 2007.
FISH|fluorescent in situ hybridization|FISH.|223|227|HISTORY OF PRESENT ILLNESS|This was followed by an ultrasound-guided biopsy on _%#MMDD2007#%_, which revealed (U07-4035) an infiltrating colloid carcinoma, grade I without angiolymphatic invasion. ERPR receptor status was positive, Her-2 negative by FISH. The patient was seen by Dr. _%#NAME#%_ in consultation on _%#MMDD2007#%_ and decision was proceed with breast conserving therapy.
FISH|fluorescent in situ hybridization|FISH|145|148|KATE HIBBS|At the conclusion of our discussion the patient elected to proceed with amniocentesis. Amniotic fluid was sent for chromosome studies as well as FISH studies for preliminary results regarding chromosome 13, 18, 21 and sex chromosomes. In addition, amniotic AFP will be obtained. The patient will be called with the results as they become available.
FISH|fluorescent in situ hybridization|FISH|347|350|HISTORY OF PRESENT ILLNESS|She did not require radiation for her lymphoma. Unfortunately, _%#NAME#%_ developed progressive pancytopenia, and in _%#MM#%_ was found to have a platelet count of 43,000, hemoglobin of 9.7, differential revealed 54% monocytes. Bone marrow biopsy revealed AML-M4 with 56% promonocytes and 5.2% blasts. Cytogenetics revealed translocation of 7:11. FISH revealed MLL gene rearrangement. _%#NAME#%_ was referred to the University of Minnesota Medical Center, Fairview on _%#MMDD2005#%_, where she saw Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ to discuss treatment options.
FISH|fluorescent in situ hybridization|FISH|272|275|IN SUMMARY|In addition, given the concerns by ultrasound the availability of pregnancy continuation and pregnancy termination was discussed briefly with the family. At the conclusion of our discussion the patient elected to proceed with an amniocentesis. Amniotic fluid was sent for FISH studies as well as chromosome studies and amniotic fluid AFP. The patient will be called with the results as soon as they become available.
FISH|fluorescent in situ hybridization|FISH|108|111|ADDENDUM 12/14/08|If I can be of additional assistance, please feel free to contact me at _%#TEL#%_. ADDENDUM _%#MMDD2008#%_: FISH studies were consistent with the diagnosis of trisomy 18. These results were given to the patient by phone. Given this lethal diagnosis, the option of pregnancy continuation and termination were again discussed.
FISH|fluorescent in situ hybridization|FISH|197|200|ASSESSMENT AND PLAN|The patient elected to proceed with an amniocentesis, which was performed by Dr. _%#NAME#%_ _%#NAME#%_. The patient's amniotic fluid was sent for chromosome studies, amniotic fluid AFP, as well as FISH studies for preliminary results. The patient will be contacted with results as they become available. In addition, the patient was scheduled to come for a follow-up ultrasound in 4 weeks.
FISH|fluorescent in situ hybridization|FISH.|194|198|HISTORY OF PRESENT ILLNESS|Mrs. _%#NAME#%_ received idarubicin and Ara-C complicated with a pleural effusion. A bone marrow biopsy on _%#MMDD2005#%_ revealed 5% blasts. The cytogenetic abnormalities were still present by FISH. On _%#MMDD2005#%_ she was found to be in complete remission with minimal residual disease by FISH. Mrs. _%#NAME#%_ indicates that she received 2 cycles of high-dose Ara-C.
FISH|fluorescent in situ hybridization|FISH.|210|214|HISTORY OF PRESENT ILLNESS|A bone marrow biopsy on _%#MMDD2005#%_ revealed 5% blasts. The cytogenetic abnormalities were still present by FISH. On _%#MMDD2005#%_ she was found to be in complete remission with minimal residual disease by FISH. Mrs. _%#NAME#%_ indicates that she received 2 cycles of high-dose Ara-C. Her last bone marrow biopsy was one month ago and showed continued remission.
FISH|fluorescent in situ hybridization|FISH|290|293|HISTORY OF PRESENT ILLNESS|She then underwent a lumpectomy on _%#MMDD2007#%_ which revealed tumor size 0.8 cm, Grade II/III, left sentinel lymph node biopsy was negative, and no lymphatic or vascular invasion was seen. The tumor was strongly positive for ER and PR receptor status and HER-2/neu positive (IHC 3+) and FISH was not done. She was staged at T1b, N0, Mx stage I. Because of her tumor being Grade II and HER-2/neu positive, ________ DX testing was done and revealed a recurrent score of 37 which in the clinical validation carries an average rate of distant recurrence at 10 years of approximately 25% putting the disease in the high risk category.
FISH|fluorescent in situ hybridization|FISH|140|143|IN SUMMARY|She had a primary tumor measuring 3.6 x 1.5 x 1.1 cm, grade 3. It was estrogen and progesterone receptor positive and negative for HER-2 by FISH analysis. Her Oncotype a recurrence score was 35%. There was a delay in starting adjuvant chemotherapy following her lumpectomy because of infection and the patient applied a heating pad, which actually resulted in a second-degree burn to her breast.
FISH|fluorescent in situ hybridization|FISH|335|338|IMPRESSION/RECOMMENDATIONS.|He has an elevated serum protein level, as well as a markedly elevated IgG level. This is highly concerning for multiple myeloma. For further workup, we would recommend checking the following studies: Metastatic bone survey to evaluate for lytic lesions of multiple myeloma, bone marrow biopsy including plasma cell labeling index and FISH study for myeloma, 24-hour urine for monoclonal protein, serum free light chain analysis, beta 2 microglobulin and LDH. After results of these tests are available, we can make treatment recommendations.
FISH|fluorescent in situ hybridization|FISH|239|242|HOSPITAL COURSE|However, the patient recently had a CT-guided biopsy of a bone lesion done on _%#MMDD#%_ and this showed that this lesion was not ER/PR positive. HER-2/neu status was unable to be detected at this time as the sample was not adequate for a FISH studies. Based on imaging done during this admission, it was suspected that the patient's disease is progressing despite her treatment.
FISH|fluorescent in situ hybridization|FISH|187|190|HISTORY OF PRESENT ILLNESS|A bone marrow biopsy on _%#MMDD2006#%_ showed 85% blasts, hypercellular, and histology and flow were consistent with ALL. Cytogenetics showed trisomy 7 and rearrangement in Y chromosome. FISH was negative for pH chromosome and 83.5% of cells showed trisomy 7. CSF was positive at this time. He was treated with induction chemotherapy with daunorubicin, prednisone, vincristine and L-asparaginase and had a slow decrease in white counts.
FISH|fluorescent in situ hybridization|FISH|205|208|BONE MARROW TRANSPLANT WORKUP|6. EKG on _%#MMDD2007#%_ demonstrated a short PR interval, otherwise normal rate of 75. 7. Bone marrow biopsy on _%#MMDD2007#%_ with 60-70% cellular with trilineage hematopoiesis, no evidence of leukemia. FISH was negative. 8. Virologies: The patient is CMV positive, HSV positive and EBV positive. Remainder of virologies are negative. REVIEW OF SYSTEMS ON ADMISSION: Positive for intermittent vaginal spotting this summer during chemo, last was approximately 1 week prior to admission.
FISH|fluorescent in situ hybridization|FISH|250|253|PRINCIPAL DIAGNOSIS|Following renal ultrasound which identified a cystic and dysplastic right kidney, the patient was begun on Bactrim for UTI prophylaxis. Subsequently, VCUG has shown to be negative for reflux and Bactrim has been discontinued. 5. Genetics. Idil had a FISH for DiGeorge syndrome and Williams syndrome which were both negative. Chromosome study showed normal female 46XX. 6. Immunology. Complete immunodeficiency workup was done and all within normal limits.
FISH|fluorescent in situ hybridization|FISH.|244|248|HOSPITAL COURSE|A bone marrow biopsy on _%#MMDD2006#%_ showed an overall bone marrow cellularity of 10-15% with trilineage hematopoietic maturation and no evidence of leukemia. Cytogenetics from _%#MMDD2006#%_ showed 0 out of 400 cells positive for BCR/ABL by FISH. PROBLEM #2: Fluids, electrolytes, and nutrition: While G-tube and p.o. feeds were not tolerated, _%#NAME#%_ was placed on t.p.n. At the time of discharge, he was tolerating his feeds of Neocate Junior at 50 ml/hour continuously.
FISH|fluorescent in situ hybridization|FISH|168|171|HISTORY OF PRESENT ILLNESS|There was a soft tissue mass in the left hilum, AP window and the preaortic space as well. A bone marrow biopsy was done showing a hypocellular marrow with 40% blasts. FISH studies revealed the presence of deletion 5 and 7 in 15% of his cells. These were the same abnormalities that were present with his initial diagnosis in 2004.
FISH|fluorescent in situ hybridization|FISH|225|228|PAST MEDICAL HISTORY|This treatment was complicated by Candida krusei fungemia/pneumonia, which was treated with caspofungin in _%#MM2006#%_ and then with voriconazole. Bone marrow completed on _%#MMDD2006#%_ was negative for leukemia as well as FISH negative for bcr/able. 2. During the initial admission for bone marrow transplant she had neutropenic fevers with MRSA bacteremia and subsequent removal of Hickman catheter, large volume diarrhea culture negative with scopes revealing no GVH, by gastric or rectal biopsy.
FISH|fluorescent in situ hybridization|FISH|221|224|BRIEF CLINICAL SUMMARY|Blasts were seen on the smear at that time. Bone marrow biopsy at that time showed hypercellular marrow with 100% cellularity with B-cell lymphoblasts. CT scans were negative at that time. She had normal cytogenetics but FISH analysis revealed a BCR-Abel positive. The patient was started on hypertension CVAD and Gleevec x 5 cycles as well as receiving intrathecal methotrexate.
FISH|fluorescent in situ hybridization|FISH|192|195|BONE MARROW TRANSPLANT WORKUP|Fluoroscopy showed blasts positive for CD13, CD15, CD34, CD38, CD56, CD58, HLA-DR and partial CD19, CD33, MPO and CD17. Acute myeloleukemia with positive 8:21, Q22:Q22 and DEL (9) (Q12, Q34). FISH confirmed presence of CBFA2TI/RUN x1 (ETO/AML-1) gene fusion. Bone marrow biopsy on _%#MMDD2007#%_ showed 80-90% cellularity with trilineage hematopoiesis including slight relative myeloid hyperplasia, slight megakaryotypic hyperplasia, no morphologic evidence of leukemia, 0.4% blasts, CD61 immunostain showed slight increase in megakaryocytes.
FISH|fluorescent in situ hybridization|FISH|147|150|STAGING WORKUP|Small focus of Cyclen D1 positivity consistent with minimal involvement of less than 5% by lymphoma, however, cytogenetics did show involvement of FISH of consultation _%#MMDD#%_ suggestive of involvement. 4. MUGA scan prior to chemo showed EF of 50%. PRIOR TREATMENT: 1. Status post 5 cycles of BCR-CV80 chemotherapy.
FISH|fluorescent in situ hybridization|FISH|187|190|HOSPITAL COURSE|The remaining of his findings (hypotonia, poor vision and hearing, and nystagmus) are associated with this syndrome. 7. Genetics. Chromosomal analysis was normal at outside hospital, but FISH for microdeletion associated with Rubinstein-Taybi syndrome done at outside hospital was pending at the time of dictation. 8. Endocrine. The patient has hypothyroidism, which can be associated with Rubinstein-Taybi syndrome.
FISH|fluorescent in situ hybridization|FISH|232|235|PROBLEM #8|His stools were repeatedly guaiac negative. He was receiving adequate iron in his feeds so he was not started on iron supplementation. PROBLEM #8: Endocrine/Genetics. Because of persisting calcium levels in the range of 7.8 to 9.6, FISH for DiGeorge syndrome was done on _%#MMDD2003#%_. Results of this test are pending at the time of discharge. PROBLEM #9: Physical Therapy, Occupational Therapy, Speech Therapy. _%#NAME#%_ was followed by these services while he was an inpatient.
FISH|fluorescent in situ hybridization|FISH|200|203|HISTORY OF PRESENT ILLNESS|_%#NAME#%_ had a 15-pound weight loss, mouth sores, and a wide-based gait during his chemotherapy. A bone marrow aspirate and biopsy done on _%#MMDD2006#%_ showed no Philadelphia chromosome. However, FISH showed 1% of 400 cells to have a signal pattern indicative of BCR-ABL 1 gene infusion and was 5-10% cellular, with 2.5% blasts.
FISH|fluorescent in situ hybridization|FISH|192|195|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. CHARGE syndrome consisting of right choanal atresia, esophageal atresia, unbalanced atrioventricular canal, severe pulmonary stenosis, hypoplastic right ventricle. 2. FISH negative DiGeorge syndrome variant: Pseudohypoparathyroidism, hypothyroidism. 3. Tracheobronchomalacia. 4. Right facial palsy. 5. Hypertension. HOSPITAL COURSE: 1. Fluids, electrolytes, and nutrition.
FISH|fluorescent in situ hybridization|FISH|170|173|HOSPITAL COURSE|The sample was analyzed by RT-PCR and that was negative for the bcr/abl transcript of CML and ALL breakpoint cluster areas. Other cytogenetic studies were done including FISH studies of the bone marrow aspirate and none of the 400 cells examined had a signal pattern indicating bcr/abl gene fusion.
FISH|fluorescent in situ hybridization|FISH|135|138|PROBLEM #7|The patient had a 100-day bone marrow biopsy and lumbar puncture. The lumbar puncture had 10 white cells, no red cells, and no blasts. FISH studies were sent for double AML duplication, looking for cytogenetics similar to his original pre-B cell cancer. However, this FISH study was negative on both the lumbar puncture sample and the bone marrow.
FISH|fluorescent in situ hybridization|FISH|133|136|PROBLEM #7|FISH studies were sent for double AML duplication, looking for cytogenetics similar to his original pre-B cell cancer. However, this FISH study was negative on both the lumbar puncture sample and the bone marrow. Bone marrow was found to be 100% donor in both neutrophils and monocyte subtypes.
FISH|fluorescent in situ hybridization|FISH|175|178|HISTORY OF PRESENT ILLNESS|At that time, he was diagnosed with gout, but also found to have leukocytosis and a palpable spleen. Bone marrow biopsy was 95% cellular with 5% myeloblasts. Cytogenetics and FISH were normal. He was treated with hydroxyurea and did well until _%#MM2005#%_ when he was found to have accelerated disease. At the time, he underwent induction chemotherapy with idarubicin and cytarabine, and did well until _%#MM2006#%_ when on routine follow-up he was found to have a white count greater than 90,000 with 13% peripheral blasts and 90,000 platelets.
FISH|fluorescent in situ hybridization|FISH|162|165|PAST MEDICAL HISTORY|Also note as part of the bone marrow transplant workup, she is EBV positive, CMV positive, HIV negative, HTLP negative, RPR negative, hepatitis B and C negative. FISH studies for _%#MMDD#%_ translocation were negative. She had an ABG done revealing a pH of 7.41, PC02 of 36, and P02 of 98. A MUGA scan revealed an ejection fraction of 63% and a normal chest x- ray.
FISH|fluorescent in situ hybridization|FISH|207|210|FOLLOW-UP|This has resulted in chronic atelectasis in the left lung, which was managed with chest physiotherapy three times daily until _%#MMDD2003#%_ (day of life 67) when the diaphragm was plicated. Also of note, a FISH study for DiGeorge syndrome was sent during _%#NAME#%_'s stay in the PICU and found to be positive. Following her aortic arch repair, pulmonary artery banding, and PDA ligation on _%#MMDD2003#%_, _%#NAME#%_ was transferred to the NICU on _%#MMDD2003#%_ at 40 days of age.
FISH|fluorescent in situ hybridization|FISH|145|148|HISTORY OF PRESENT ILLNESS|The myeloma was CD56 negative, kappa light chain restricted and had no heavy chain expression. Cytogenetic study showed a normal male karyotype. FISH showed translocation at 11 and 14 and monosomy 13. SPEP showed no monoclonal protein. IgG was 867, IgA was 118, IgM was 38.
FISH|fluorescent in situ hybridization|FISH|175|178|HOSPITAL COURSE|A peripheral smear demonstrated blasts. Here, a bone marrow performed here on _%#MMDD#%_ demonstrated 66% blasts. No chromosomal abnormalities were detected by G banding, but FISH revealed signal consistent with the 8:21 translocation. Of note, FLT3 was negative. At this time, a MUGA scan was obtained which demonstrated normal ejection fraction.
FISH|fluorescent in situ hybridization|FISH|184|187|HISTORY OF PRESENT ILLNESS|Bone marrow biopsy revealed 100% infiltration with lymphoblasts and chromosome analysis revealed a 19 of 20 metaphases had translocation of chromosome 11 and 19 as well as trisomy 10. FISH studies showed rearrangement involving MLL locus. CNS was negative. She was treated on an ECOG study. She achieved complete remission by bone marrow biopsy.
FISH|fluorescent in situ hybridization|FISH|149|152|HISTORY OF PRESENT ILLNESS|He underwent a bone marrow biopsy, which showed dysplastic changes and cytogenetics showing the loss of chromosome Y, trisomy 9 and deletion of 13q. FISH studies showed marrow cells with trisomy 9. morphology showed 2.4% myeloid blasts and 40% cellular marrow consistent with MDS, morphologically CMML..
FISH|fluorescent in situ hybridization|FISH,|162|166|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Infiltrating ductal breast cancer, node-positive, diagnosed in _%#MM1997#%_. The tumor was ER-positive, PR-negative, ..??.. -negative by FISH, but positive by IHC. Per clinic notes, she received adjuvant CMF and Tamoxifen for 5 years. She also had a Tram flap reconstruction on the right.
FISH|fluorescent in situ hybridization|FISH|265|268|DISCHARGE DISPOSITION|Problem #11: Genetics. Secondary to Carson's intrauterine growth restriction and Tetralogy of Fallot, a high resolution chromosomal analysis was done. It was normal, however, there was poor growth in the lab and G-banding was unable to be performed. Additionally a FISH for DiGeorge syndrome was negative. Problem # 12: Necrotizing Enterocolitis: On _%#MMDD2007#%_ _%#NAME#%_ was diagnosed with a Stage I clinical diagnosis of necrotizing enterocolitis.
FISH|fluorescent in situ hybridization|FISH.|157|161|HOSPITAL COURSE|Immunophenotyping was negative for leukemia. Her bone marrow RFLP showed 100% donor #1. Cytogenetics with BCR/ABL showed 0/400 or 0% negative for BCR/ABL by FISH. Molecular diagnostics BCR/ABL shows a suspicion for BCR/ABL transcripts of minor breakpoint of ALL type. This was discussed with the attending physician and the decision was made to concentrate on patient's other serious health issues and the patient would be put on desatinib at a later date.
FISH|fluorescent in situ hybridization|FISH.|233|237|HISTORY OF PRESENT ILLNESS|A bone marrow biopsy in _%#MM2006#%_ showed MDS with 60% to 65% marrow cellularity, marked dysmegakaryocytopenia with 2% blasts and marked reticulum fibrosis. Of 200 metaphases, 78% had a signal pattern indicative of dilution 20Q by FISH. She has remained on GCSF and erythropoietin, and requires platelets nearly every other day. Her menorrhagia is now controlled with oral estrogens. She is now being admitted for myeloablative allo-sib peripheral blood stem cell transplant.
FISH|fluorescent in situ hybridization|FISH|199|202|DISCHARGE DISPOSITION|However, he would be happy to see _%#NAME#%_ in follow-up as an outpatient. Problem #3: Genetics. _%#NAME#%_ has a normal XY karyotype with no numerical or structural chromosomal abnormalities seen. FISH probes for 22q11.2 and 22q13.3 showed no deletion or duplication. Dr. _%#NAME#%_, our cranial-facial dental specialist, also examined _%#NAME#%_ and felt his features did not represent any specific syndrome.
FISH|fluorescent in situ hybridization|FISH|131|134|PROBLEMS|9. Genetics: _%#NAME#%_ initially had problems with low calcium levels. Due to the concern that he could have DiGeorge syndrome, a FISH study was sent and found to be negative. Due to the history of the 2-vessel cord as well as his pulmonary atresia, chromosomes were also sent, and are pending at the time of this dictation.
FISH|fluorescent in situ hybridization|FISH|203|206|HOSPITAL COURSE|A lumbar puncture and bone marrow biopsy were done on day -1 (_%#MMDD2007#%_), which revealed normal CSF without any residual disease and a hypocellular marrow with molecular evidence of residual AML by FISH only. RFLP on day -1 (_%#MMDD2007#%_) revealed 24% NK donor and 76% recipient. Marlys became slowly engrafting the white blood cell count 12 days status post transplant, but her neutrophil count remained low with a high monocyte count, which was concerning for persistent leukemia.
FISH|fluorescent in situ hybridization|FISH|276|279|ALLERGIES|He does have some cytogenetics from his bone marrow also from _%#MM#%_ _%#DD#%_, 2006, which showed 0% of the 400 interphase cells examined had a signal pattern indicative of a BCR/ABL gene fusion. Thus no cytogenetic evidence was found of bone marrow involvement by ALL. The FISH studies are still pending. 2. Hematology: His counts have been on a low side most likely secondary to ganciclovir. His white count on the day of discharge is 1.3, hemoglobin is 7.7 with platelets of 15.
FISH|fluorescent in situ hybridization|FISH|173|176|BONE MARROW TRANSPLANT WORKUP|The flow cytometry in the myoblast revealed heterogenous CD13, heterogenous CD33 and 34dim 45 and heterogenous CD117 and heterogenous HLA-DR. Cytogenetics on that sample by FISH revealed 171 of 200 cells having a pattern indicative of the lost chromosome 20. A CSF study near that time showed no evidence of malignancy and cytopathological examination and no blast speculation.
FISH|fluorescent in situ hybridization|FISH,|224|228|HISTORY|Multiple ultrasounds with MSM at the University of Minnesota. Ultrasounds, _%#MMDD2006#%_, fetal ultrasound revealed an increased echogenic focus at the left ventricular septum. Pregnancy issues: Fetal anomalies with normal FISH, normal XY karyotype. OB HISTORY: Spontaneous vaginal delivery at term in 2000 of a male.
FISH|fluorescent in situ hybridization|FISH.|250|254|HISTORY OF PRESENT ILLNESS|He had a right axilla lymph node biopsy on _%#MMDD2006#%_, which demonstrated peripheral T-cell lymphoma, strongly CD3 positive with close expression of CD2, CD4, CD5 and CD7. BC16, CD45 and CD20 were weakly positive. There was no evidence of EBV by FISH. T-cell receptor rearrangement was positive. Complete staging included a bone marrow biopsy on _%#MMDD2007#%_, which showed 60% cellularity, trilineage hematopoiesis and evidence of lymphoma.
FISH|fluorescent in situ hybridization|FISH|138|141|PROCEDURES DURING THIS HOSPITALIZATION|Internal tandem duplication in exon 14 of the FLT-3 gene was found (a poor prognostic sign), G-banded chromosomes were normal as were the FISH probes for aneuploidy. 2: Double lumen tunneled central venous catheter was placed on _%#MMDD2007#%_. 3. Lumbar puncture performed on _%#MMDD2007#%_, which showed 1 white blood cell, no red blood cell, 60 glucose, 44 protein; flow cytometry showed cells consistent with leukemic blasts.
FISH|fluorescent in situ hybridization|FISH|254|257|HISTORY OF PRESENT ILLNESS|Cellularity was mildly elevated at 60%. Cytogenetics showed that 4 of 20 metaphases had a translocation of unknown origin replacing the short arm of chromosome 15 at band 15-P- 11.2. The remainder of the metaphases were karyotypically normal. Subsequent FISH done at the Parker Hughes Cancer Center also demonstrated that a portion of her cells were missing one copy of chromosome 7.
FISH|fluorescent in situ hybridization|FISH|247|250|1. FEN|9. Genetics: Because of the anatomical anomalies on the newborn exam, chromosomes were sent which were normal. A genetics consult was also obtained. Because _%#NAME#%_'s physical appearance was consistent with Rubenstein-Tabes syndrome, a genetic FISH probe was sent which could rule in Rubenstein-Taybi and is still pending. The patient was evaluated by ophthalmology and no evidence of glaucoma was found.
FISH|fluorescent in situ hybridization|FISH|233|236|1. FEN|_%#MMDD2004#%_ Thyroid panel is pending. 2. Growth Hormone deficiency should be evaluated with a growth hormone stimulation test at 6 months of age or earlier if hypoglycemia recurs. 3. Eye Infection with E. Coli 4. Rubenstein-Taybi FISH probe still pending 5. Diaper Dermatitis: Use standard barrier creams Discharge medications, treatments and special equipment: 1. Ferrous Sulfate 7 mg PO q 24 hours
FISH|fluorescent in situ hybridization|FISH|253|256|PROCEDURES PERFORMED|Recommend repeat in 6 weeks. 13. Repeat bone marrow biopsy performed _%#MMDD2004#%_ resulted in 2 of the 20 metaphase cells analyzed having a Philadelphia chromosome, resulting from a 9:22 translocation as the sole karyotypic abnormality. Additionally, FISH revealed 23 of the 400 interface cells, which is 5.75%, having a signal pattern indicative of BCR/ABL gene fusion.
FISH|fluorescent in situ hybridization|FISH|160|163|HOSPITAL COURSE|Neither of these 2 Philadelphia chromosome-positive cells had gains of chromosome X, 4, 14 and 21, as was seen in the patient's diagnostic study. Additionally, FISH analysis revealed 23 of the 400 interface cells examined to have signal pattern indicative of BCR-ABL gene fusion; this is 5.75%. These results would be consistent with continued involvement of this patient's bone marrow by a residual population of leukemic cells.
FISH|fluorescent in situ hybridization|FISH|160|163|MMC 286|At that time she was found to have a 90-95% cellular marrow with approximately 70% blasts with our rods. Molecular study showed that she was FLT-3 negative and FISH showed that she was positive for the translocation (8;21) a core binding factor abnormality. She underwent induction chemotherapy with idarubicin and cytarabine (7+3 regimen).
FISH|fluorescent in situ hybridization|FISH|284|287|ASSESSMENT/PLAN|Dear Dr. _%#NAME#%_: This letter will summarize the information we discussed with your patient, _%#NAME#%_ _%#NAME#%_, who you referred to the Maternal Fetal Medicine Center at Fairview-University Medical Center, on _%#MMDD2004#%_. As you know, she was referred to discuss her recent FISH results from an amniocentesis indicating that her developing baby has Turner syndrome. _%#NAME#%_ was seen along with her husband, _%#NAME#%_. The following information was discussed with them.
FISH|fluorescent in situ hybridization|FISH|246|249|ASSESSMENT/PLAN|Specific levels were as follows: 0.97 MoM AFP, 0.17 MoM estriol, and 0.22 MoM hCG, and free beta hCG was 0.34 MoM. This screen was performed at Mayo Medical Laboratories. You subsequently performed an amniocentesis at your clinic and preliminary FISH results indicate that this baby only has one X chromosome which was seen in 200 nuclei of the FISH testing. Final chromosome analyses are pending. I reviewed with _%#NAME#%_ and _%#NAME#%_ that individuals with Turner syndrome have normal intelligence and infertility.
FISH|fluorescent in situ hybridization|FISH|230|233|ASSESSMENT/PLAN|This screen was performed at Mayo Medical Laboratories. You subsequently performed an amniocentesis at your clinic and preliminary FISH results indicate that this baby only has one X chromosome which was seen in 200 nuclei of the FISH testing. Final chromosome analyses are pending. I reviewed with _%#NAME#%_ and _%#NAME#%_ that individuals with Turner syndrome have normal intelligence and infertility.
FISH|fluorescent in situ hybridization|FISH|410|413|ASSESSMENT/PLAN|I specifically also spent some time discussing the differences between trisomy 18 and Turner syndrome, as their initial triple screen results revealed increased risk for trisomy 18 which, as you know, is a severe syndrome which includes profound mental retardation, congenital heart defects and brain malformation, from which most babies do not survive past one year of age. I discussed the specifics of their FISH results and stressed these are preliminary results. Final chromosome analysis is needed to confirm the diagnosis in their baby. I discussed options available to this couple including continuation of a pregnancy, termination of a pregnancy (up to 22 weeks in the state of Minnesota), or adoption.
FISH|fluorescent in situ hybridization|FISH|190|193|DATE OF CONSULTATION|Please see the ultrasound report for more details regarding this ultrasound examination. After this ultrasound, _%#NAME#%_ decided to proceed with an amniocentesis. In addition, we reviewed FISH analysis and some of its potential benefits and limitations. The results of _%#NAME#%_'s amniocentesis have been relayed to her and faxed to your office.
FISH|fluorescent in situ hybridization|FISH|199|202|HISTORY OF PRESENT ILLNESS|On _%#MMDD2006#%_, she began bleeding. Her HCGs were in the 6000 range. She did undergo dilatation and curettage. During that pregnancy she attempted progesterone supplementation and baby aspirin. A FISH was done that was normal. She had her sensitive TSH checked because she felt like she was hypothyroid and was found to have an elevated sensitive TSH.
FISH|fluorescent in situ hybridization|FISH|168|171|PROCEDURE PERFORMED|11. Clone 4, comprising the remaining 15% of metaphases, had the same abnormalities as clone 3 and an additional copy of chromosome 20. Consistent with these findings, FISH was also performed and revealed 68% of interface cells to have a signal pattern indicative of an extra copy of distal 3Q and 71.5% of interface cells to have a signal pattern indicative of loss of distal 11Q, encompassing band 11Q23.
FISH|fluorescent in situ hybridization|(FISH),|300|306|RE|We talked about that translocation trisomy 21 can sometimes be associated with a familial chromosome translocation, and therefore sometimes associated with a much higher risk of recurrence in subsequent pregnancies. We talked about that from the particular type of testing done on her pregnancy loss (FISH), we cannot tell whether or not her previous pregnancy had nondisjunction trisomy 21, associated with a low risk of recurrence, versus translocation trisomy 21, which may be associated with a higher risk of recurrence.
FISH|fluorescent in situ hybridization|FISH.|158|162|HISTORY OF PRESENT ILLNESS|Pathology revealed infiltrating ductal carcinoma, Nottingham grade 1, score 5. There was angiolymphatic invasion. ER positive, PR negative, HER-2 negative by FISH. On _%#MMDD2007#%_ the patient was taken for right lumpectomy by Dr. _%#NAME#%_ _%#NAME#%_. Right sentinel lymph node sampling was positive and axillary dissection was performed.
FISH|fluorescent in situ hybridization|FISH|134|137|DATE OF CONSULTATION|This is especially in light of both his bone marrow and flow cytometry, which show no clear blast population on either test. Of note, FISH is pending at the time of this dictation. Other organ function appears to be within normal limits. Cardiology assures me that the PFO noted on _%#NAME#%_'s ECHO is minimal and should not put him at risk for pulmonary complications.
FISH|fluorescent in situ hybridization|FISH|308|311|RE|We reviewed that the FISH (fluorescent in situ hybridization) test is a preliminary test that gives us some initial information about whether or not there is an extra chromosome 21 (or an extra chromosome 13, chromosome 18, chromosome X or chromosome Y, as these are other chromosomes that are included in a FISH anaysis). We talked about that FISH results are typically available within 24-48 hours, but that the final chromosome analysis which examines all the chromosomes in more detail take approximately 10 to 14 days to get back.
FISH|fluorescent in situ hybridization|FISH|290|293|RE|We talked about that FISH results are typically available within 24-48 hours, but that the final chromosome analysis which examines all the chromosomes in more detail take approximately 10 to 14 days to get back. _%#NAME#%_ and her husband indicated that they were interested in pursuing a FISH analysis to provide them with some preliminary information in a timely manner, in addition to the full chromosome analysis (karyotype).
FISH|fluorescent in situ hybridization|FISH|244|247|RE|_%#NAME#%_ and her husband indicated that they were interested in pursuing a FISH analysis to provide them with some preliminary information in a timely manner, in addition to the full chromosome analysis (karyotype). As you know, _%#NAME#%_'s FISH analysis from her amniocentesis was consistent with trisomy 21. I called _%#NAME#%_ with these test results. These preliminary FISH findings were later confirmed on the final chromosome analysis, which showed a male complement of chromosomes with an extra chromosome 21 resulting from nondisjunction (47,XY, 21--see report previously faxed to your office).
FISH|fluorescent in situ hybridization|FISH|158|161|RE|As you know, _%#NAME#%_'s FISH analysis from her amniocentesis was consistent with trisomy 21. I called _%#NAME#%_ with these test results. These preliminary FISH findings were later confirmed on the final chromosome analysis, which showed a male complement of chromosomes with an extra chromosome 21 resulting from nondisjunction (47,XY, 21--see report previously faxed to your office).
FISH|fluorescent in situ hybridization|FISH|136|139|PAST MEDICAL HISTORY|They were negative for CV2, CV4, CV8, CV10, CV23, and lambda light chains. 90 of 200 interphase cells had a T (11; 14) rearrangement by FISH analysis done with a cyclin D1 probe in 11Q13 and an immunoglobulin heavy chain probe from 14Q32.3. The patient had a CT of the abdomen and pelvis on _%#MMDD2003#%_ which was compared to a scan from _%#MMDD2003#%_.
FISH|fluorescent in situ hybridization|FISH|171|174|IMPRESSION/RECOMMENDATIONS|Review of results from prior pregnancy (2006): 1. Fetal chromosome studies were performed through the Mayo clinic and revealed a normal male karyotype (46,XY). Additional FISH testing was performed to rule out duplications of 22q11.2 (velocardiofacial syndrome) and this was normal. 2. Fetal autopsy revealed no abnormalities other than confirmation of the bilateral renal agenesis and "rocker bottom feet." Test results from recent pregnancy: 1. Chromosomes- These studies were performed through the cytogenetics lab at the University of Minnesota.
FISH|fluorescent in situ hybridization|FISH.|152|156|ASSESSMENT|She did have 2 positive axillary lymph nodes, without evidence of extracapsular extension. Her tumor was ER positive, PR negative and HER-2 negative by FISH. She is in the process of completing an adjuvant course of AC chemotherapy and has tolerated this course very well.
FISH|fluorescent in situ hybridization|FISH.|220|224|RECOMMENDATION|_%#NAME#%_ indicated that she did not wish to know the gender, therefore I am withholding this information. The finding of 3 cells with a chromosome abnormality prompted a more detailed study; 200 cells were examined by FISH. Of these 200 cells, 18 of them (9%) have both an extra chromosome 7 and chromosome 21. We discussed the meaning of mosaic chromosome results. Mosaicism simply means that there are different populations of cells with different chromosomal compositions.
FISH|GENERAL ENGLISH|FISH.|138|142|REASON FOR CONSULTATION|She is also on GCSF. She is on insulin. In addition, she has the Cytoxan and Solu-Medrol. ALLERGIES: SHE IS ALLERGIC TO IMITREX AND SHELL FISH. SOCIAL HISTORY: The patient was attending school at Concordia College in _%#CITY#%_, Minnesota. She is an English major there. She is in her junior year.
FISH|fluorescent in situ hybridization|FISH|130|133|REASON FOR CONSULTATION|The progesterone receptors were negative in the invasive carcinoma and about 10% positive in the DCIS. There is currently pending FISH testing for the HER-2 status. The patient also had been complaining of some right hip and back discomfort.
FISH|fluorescent in situ hybridization|FISH|131|134|GI|The tube will need to be changed to a button style in early _%#MM#%_ 2002, approximately 3 months after it was placed. Genetics: A FISH probe testing for Prader-Willi is pending at the time of discharge. The test is being run at the University of MN molecular genetic lab.
FISH|fluorescent in situ hybridization|FISH|196|199|HOSPITAL COURSE|Final diagnosis of ANLL was made prior to discharge. The subtype was unclear at the time of discharge. The presentation was suspicious for APL (acute promyelocytic leukemia). However, her initial FISH studies were negative. In anticipation for need for chemotherapy with idarubicin, high dose steroids, and ara-C, a MUGA scan was performed and revealed left ventricular ejection fraction of 58 percent.
FISH|fluorescent in situ hybridization|FISH|145|148|HISTORY OF PRESENT ILLNESS|The AML was with subtype M4 with 5Q abnormality, presumed to come from MDS. Treatment included idarubicin and Ara-C, remission by morphology but FISH was positive. There was relapse in _%#MM2005#%_, and she was reinduced with mitoxantrone and etoposide. She had residual 151 blasts. She received matched unrelated donor transplant on _%#MMDD#%_ and was conditioned with busulfan and Cytoxan.
FISH|fluorescent in situ hybridization|FISH|110|113|FOLLOWUP|Problem #7: Genetics. Due to the finding of hypocalcemia, along with cleft palate, chromosomes were sent with FISH for DiGeorge. A preliminary report suggested a possible duplication at the site for DiGeorge (22q11.2) rather than a deletion. However, the chromosomes were slow to grow and further studies could not be performed using this sample.
FISH|fluorescent in situ hybridization|FISH|228|231|OPERATIONS/PROCEDURES PERFORMED|An echocardiogram performed on day of birth secondary to a murmur showed tetralogy of Fallot with a moderate-sized PDA, left-to-right shunt, 5- to 6-mm pulmonic valve with 20 mmHg gradient, 3- to 4-mm branch pulmonary arteries. FISH chromosomes were sent and were positive for DiGeorge. Saturations in the NICU remained stable in the 80s until the night before transfer to Fairview University Medical Center PICU.
FISH|fluorescent in situ hybridization|FISH|172|175|PAST MEDICAL HISTORY|Tortuous 2-3 mm ductus with left to right shunting and no runoff. Renal ultrasound on _%#MMDD2007#%_ showed mild left pyelectasis. Right kidney was normal. The patient has FISH for DiGeorge, and chromosomes sent on _%#MMDD2007#%_, and Minnesota newborn screen sent on _%#MMDD2007#%_. IMMUNIZATIONS: The patient given hepatitis B vaccination _%#MMDD2007#%_ in _%#CITY#%_.
FISH|fluorescent in situ hybridization|FISH|147|150|HOSPITAL COURSE|A peripheral blood smear and subsequent bone marrow aspiration and biopsy were felt consistent with chronic phase of chronic myelogenous leukemia. FISH studies performed on a bone marrow aspiration were positive for the BCR-ABL protein. Formal cytogenetics were still pending at the time of discharge.
FISH|fluorescent in situ hybridization|FISH|160|163|HISTORY OF PRESENT ILLNESS|The biopsy on _%#MMDD#%_ revealed an invasive ductal carcinoma grade 2. The tumor was estrogen and progesterone receptor positive and was negative for HER-2 by FISH analysis. There was also an ultrasound-guided biopsy of a left axillary enlarged and this revealed replacement by tumor cells. The pathologist was not able to determine whether this represented within the tail of the breast or in a residual lymph node.
FISH|GENERAL ENGLISH|FISH.|186|190|ALLERGIES|PAST MEDICAL HISTORY: 1. Depression. 2. Positive HIV. FAMILY HISTORY: Please see previous records. SOCIAL HISTORY: Lives at home. Single. ALLERGIES: IODINE, PENICILLIN, CEPHOPRIM, SHELL FISH. REVIEW OF SYSTEMS: Recent weight gain. No headaches, cough, dysuria, skin rash.
FISH|fluorescent in situ hybridization|FISH|160|163|BIRTH HISTORY|Carrier status for him is pending to see if he is one of the compound heterozygote mutations. Additional studies performed include normal karyotype with normal FISH study in the 15 Q11 deletion, normal very long chain fatty acid lactate, creatine kinase, ammonia and normal carnitine studies.
FISH|fluorescent in situ hybridization|FISH|173|176|IMPRESSION|_%#NAME#%_ stated that because of this unexpectedness of the pregnancy they definitely wanted to go ahead with CVS, which was performed today by Dr. _%#NAME#%_. Preliminary FISH results, which were relayed to the patient on Monday, _%#MMDD2007#%_, were a normal male. Final results will be available in 10-14 days. If you have any further questions of which I can be of assistance please feel free to contact me at _%#TEL#%_.
FISH|GENERAL ENGLISH|FISH|161|164|ALLERGIES|He smoked 1-2 packs of cigarettes a day for 5 years, then became a "social smoker". He uses alcohol very sparingly. ALLERGIES: PENICILLIN CAUSES DIARRHEA. SHELL FISH CAUSE DIARRHEA. CURRENT MEDICATIONS: Multivitamin, baby aspirin, Cozaar 100 mg po q day and Vitamin E.
FISH|fluorescent in situ hybridization|FISH|221|224|HISTORY OF PRESENT ILLNESS|Chemotherapy was complicated with sepsis, endocarditis, and herpes zoster of the left face. In _%#MM2006#%_, she was found to have a rising white blood cell count. A bone marrow biopsy on _%#MMDD2006#%_ revealed relapse. FISH revealed BCR/ABL. CSF was negative. Mrs. _%#NAME#%_ was treated with salvage chemotherapy, which included high-dose Ara-C and etoposide. She also received intrathecal chemotherapy. Treatment was complicated with pulmonary nodules first noted in _%#MM2006#%_.
FISH|fluorescent in situ hybridization|FISH|260|263|RECOMMENDATIONS|These test results, in conjunction with a heart defect that is very characteristic of Down syndrome, are highly suggestive of a diagnosis of fetal Down syndrome. We did discuss some of the limitations of FISH testing, and the importance of always following up FISH with a full cytogenetic study. The final results of _%#NAME#%_'s amniocentesis should be available some time next week. We spent some time discussing the prognosis and variability for a child with Down syndrome.
FISH|fluorescent in situ hybridization|FISH|174|177|LABORATORY DATA|Bowel sounds were positive. Her liver edge was about 1-2 cm below the right costal margin. NEUROLOGIC: Intact. LABORATORY DATA: At the time of this dictation, positive for a FISH showing DiGeorge syndrome. She also had some chromosomes pending, and she has had some hypocalcemia. ASSESSMENT: This is a 5-day-old with tetralogy of Fallot with absent pulmonary valve as well as DiGeorge syndrome with no current respiratory distress or compromise.
FISH|fluorescent in situ hybridization|FISH|156|159|PAST MEDICAL HISTORY|Complications of chemotherapy included sepsis, MRSA endocarditis, zoster of the left face. In _%#MM2006#%_ the patient relapsed with an increased WBC and a FISH positive test for bcr/able. Spinal fluid at that time was negative. The patient was reinduced with high-dose ara-C and etoposide and also received intrathecal methotrexate.
FISH|fluorescent in situ hybridization|FISH|174|177|HISTORY OF PRESENT ILLNESS|On _%#MM#%_ _%#DD#%_, 2005, a bone marrow aspirate and biopsy were performed which revealed normal cellularity with slight dysgranulopoiesis and 4.6% blasts. Cytogenetic and FISH analysis performed showed a normal female karyotype which was negative for BCR/ABL. Hemoglobin electrophoresis at this time revealed 52.6% hemoglobin F. _%#NAME#%_ was initially treated with homeopathic interventions and then began chemotherapy per protocol AAML _%#PROTOCOL#%_ in late _%#MM#%_ 2005.
FISH|GENERAL ENGLISH|FISH.|144|148|ALLERGIES|MEDICATIONS: Include 1. Iron. 2. Sudafed. 3. Advil Sinus. ALLERGIES: There are no known allergies to medicine. HE DOES HAVE AN ALLERGY TO SHELL FISH. EXAMINATION: CONSTITUTIONAL: His vital signs have remained stable.
FISH|GENERAL ENGLISH|FISH.|130|134|ALLERGIES|ALLERGIES: CODEINE (developed urticaria). The patient denies an allergy to Iodine but states that he FEELS ILL WHEN HE EATS SHELL FISH. He has never developed urticaria or dyspnea. MEDICATIONS: None until admission. He is now on aspirin, Heparin, intravenous Integrelin, and intravenous Nitroglycerin.
FSH|Fairview Southdale Hospital|FSH.|155|158|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is an 86-year-old female originally admitted by my partner, Dr. _%#NAME#%_, at Ridges Hospital. She was then transferred to FSH. She had been complaining of fatigue of quite prominence for the last few weeks before admission. She was noted to be in 2:1 heart block. She was transferred to our hospital for a pacemaker.
FSH|follicle-stimulating hormone|FSH|142|144|PLAN|PLAN: Home health care, home oxygen three liters a minute, immunoglobulin G infusions per Dr. _%#NAME#%_ from the University of Minnesota and FSH IV infusion. Follow up with Dr. _%#NAME#%_ in 1-2 weeks or earlier as needed. Follow up with Dr. _%#NAME#%_ as previously arranged.
FSH|Fairview Southdale Hospital|FSH.|158|161|HOSPITAL COURSE|He continued to have pain when he sought treatment on _%#MMDD2006#%_. He was seen initially at the Fairview Northland ER and then subsequently transferred to FSH. Upon evaluation on _%#MMDD2006#%_, the patient was diagnosed with left angle of mandible fracture and abscess.
FSH|Fairview Southdale Hospital|FSH.|252|255|HOSPITAL COURSE|History of congestive heart failure, hypothyroid. She lives independently. The patient noted that while doing her laundry she noted heart racing. She had had these episodes in the past but none this long. It lasted for 20 minutes for which she came of FSH. The patient was given metoprolol 5 mg IV times one, potassium chloride after which the heart rhythm went into normal sinus rhythm.
FSH|follicle-stimulating hormone|FSH|71|73|HISTORY OF THE PRESENT ILLNESS|No free fluid in the cul-de-sac, ovaries were normal. Her CBC, TSH and FSH is normal. However, her hemoglobins are borderline low at 11 grams. She is on oral iron therapy. Pap smear is normal. We have given her the options of dilatation and curettage, hysteroscopy, Mirena IUD, Novasure endometrial ablation or hysterectomy.
FSH|Fairview Southdale Hospital|FSH|78|80|HISTORY|HISTORY: Ms. _%#NAME#%_ _%#NAME#%_ is a 68-year-old woman who was admitted to FSH on _%#MMDD#%_ with complaints of shortness of breath and chest heaviness. She saw her primary care physician as an outpatient and was directly admitted to the hospital for concerns of coronary artery disease as well as detection of abnormal heart rhythm.
FSH|follicle-stimulating hormone|FSH|233|235|HISTORY OF THE PRESENT ILLNESS|She then had a period of prolonged bleeding for 97 days and did not seek any advise through the MD office. Her hemoglobin at visit in _%#MM#%_ of 2004 was 12.8 and on _%#MMDD2004#%_ it dropped to 10.7. During her initial visit, TSH, FSH were normal and endometrial biopsy showed proliferative endometrium with no evidence of hyperplasia or malignancy. We had placed her on iron therapy and due to her personal scheduled, she is able to do hysteroscopy only now.
FSH|follicle-stimulating hormone|FSH|203|205|HOSPITAL COURSE|The pituitary was somewhat enlarged with a 1-cm area of low signal intensity suggestive of possible microadenoma. This latter finding was evaluated further with some hormone studies which revealed a low FSH and LH (1.4 and less than 0.1 respectively), and an elevated galactin at 64. It was felt that this finding was unrelated to her headache but nevertheless an endocrine consult was obtained for recommendations for further management.
FSH|Fairview Southdale Hospital|FSH.|177|180|REASON FOR HOSPITALIZATION|She had developed chest discomfort at about 9 a.m. that morning. Her EKG shows ST segment elevation in the inferior leads. She was given Metoprolol and Repro and transferred to FSH. HOSPITAL COURSE: On arrival to the hospital she was found to have continued ST segment elevation.
FSH|Fairview Southdale Hospital|FSH|69|71||_%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 20-year-old female admitted to FSH for the surgical treatment of her combined maxillomandibular growth dysplasia. Diagnoses include maxillary hypoplasia and mandibular prognathism. Presurgical orthodontics has been done by Dr. _%#NAME#%_ _%#NAME#%_, DDS, MS, to align and level the teeth in the maxillary mandibular skeletal structures.
FSH|Fairview Southdale Hospital|FSH|56|58||_%#NAME#%_ _%#NAME#%_ is a 71-year-old male admitted to FSH on _%#MMDD2005#%_ and dismissed subsequently on _%#MMDD2005#%_. He was admitted by his primary physician for a urinary tract infection. This patient has a neurogenic bladder and has a long standing suprapubic tube.
FSH|follicle-stimulating hormone|FSH|174|176|IDENTIFYING DATA/HISTORY|The patient wore a panty liner nearly every day and was able to use one panty liner all day long. The patient was evaluated at that time with an examination. We drew a serum FSH that was 71.9, consistent with menopausal status. A pelvic ultrasound was performed to evaluate the endometrial stripe. The uterus was 6.0 x 3.8 x 4.9 cm. The endometrial stripe measured between 12.8 mm and 13.4 mm.
FSH|follicle-stimulating hormone|FSH|281|283|PLAN|Possible mild endometritis with the patient with a normal white blood cell count in the emergency room on _%#MMDD#%_ and currently on antibiotics. PLAN: The patient is scheduled for ultrasound guided cervical dilatation with curettage. Additionally, we will check a hemoglobin and FSH today to document where patient is with regards to menopause. The patient did have a STAT CBC sent on _%#MMDD2005#%_ due to worsening cramping.
FSH|Fairview Southdale Hospital|FSH|124|126|SOCIAL HISTORY|2. NovoLog insulin pump. 3. Prenatal vitamin. SOCIAL HISTORY: The patient is married. She is a nonsmoker. She is a nurse at FSH on the pediatric floor. PHYSICAL EXAMINATION: Weight 160 pounds, blood pressure 122/78, urine dip trace protein, +1 glucose.
FSH|follicle-stimulating hormone|FSH|141|143|HISTORY OF PRESENT ILLNESS|She was then tried on the birth control pill and Provera therapy with no change in her periods. Her hemoglobin was normal, 12.6, TSH normal, FSH normal. The ultrasound showed the uterus is enlarged to 11.5 cm with a fibroid 3.5 cm or larger in the upper part of the uterus that abuts the endometrial canal resulting in submucous location.
FSH|follicle-stimulating hormone|FSH|218|220||Following her yearly exam in _%#MM2002#%_, she was switched from birth control pills to Estrace and Provera because she was having increasing hot flashes in the week off the birth control pills. The patient had had an FSH close to the menopausal range. The patient did very poorly on the hormone replacement therapy and had increasing heavy periods and was still complaining of PMS symptoms and hot flashes as well as break through bleeding.
FSH|follicle-stimulating hormone|FSH|124|126|LABORATORY|LABORATORY: Blood work done just last week showed a hemoglobin of 11.5, white count 7400, platelet count 301,000. TSH 2.07, FSH 2.2 Electrocardiogram today shows sinus bradycardia but otherwise is normal and the T wave changes in V2 and V3 from _%#MM#%_ 1999 have now resolved.
FSH|Fairview Southdale Hospital|FSH|174|176||The risks and benefits of cataract surgery with intraocular lens implant were discussed with Mr. _%#NAME#%_ and he wishes to proceed with the left eye. He was now brought to FSH for this procedure.
FSH|follicle-stimulating hormone|FSH|174|176|HISTORY OF PRESENT ILLNESS|Her serial troponins were negative. Her EKG revealed a normal sinus rhythm and no evidence of pathologic change. 4. Endocrine. Mr. _%#NAME#%_ did complain of hot flashes. An FSH was drawn which was 60.7 which is consistent with the FSH of a postmenopausal woman. For her complaints, she was placed on Effexor. 5. Psych.
FSH|Fairview Southdale Hospital|FSH.|249|252|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Left anterior cruciate ligament tear. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ presents today for preop evaluation requested by Dr. _%#NAME#%_ in anticipation for left anterior cruciate ligament repair on _%#MMDD2005#%_ at FSH. The patient notes that while he was in the Navy in 1993, he had a meniscal injury on the left knee. At that time arthroscopy was done and partial anterior cruciate ligament tear was noted but was not treated.
FSH|Fairview Southdale Hospital|FSH|219|221|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is a 54-year-old gentleman who was admitted via the ER because he was having persistent focal seizures on the left arm. The patient has had two craniotomies, one at FSH and one at _%#CITY#%_ _%#CITY#%_ Hospital for an arteriovenous fistula following a cerebral hemorrhage. He has had a left hemiparesis residual to that and seizure disorder.
FSH|Fairview Southdale Hospital|FSH|168|170|REVIEW  OF SYSTEMS|Her son who is with her today notes that she seems quite confused which was also manifest intermittently during the last hospitalization. Her last dialysis was here at FSH on _%#MMDD#%_. PHYSICAL EXAMINATION: GENERAL: Alert, Spanish-speaking woman whose son functions as an interpreter.
FSH|follicle-stimulating hormone|FSH|211|213|LABORATORY DATA|Glomerular filtration of 44 was all. Otherwise alkaline phosphatase and liver enzymes were mildly elevated. TSH was 29. Free-thyroid was 0.32. Cortisol was less than 0.5. ACTH was less than 10, as is estradiol. FSH and lutropin were also done. Growth factor was noted to be down. Adrenal antibodies were negative. Urinalysis shows trace of ketones, some proteinuria and large amount of microscopic hematuria.
FSH|follicle-stimulating hormone|FSH|167|169|PAST MEDICAL HISTORY|2. In _%#MM2000#%_ a diagnostic laparoscopy which aborted any attempts at lysis of adhesions. 3. EABL x 4. PAST MEDICAL HISTORY: Significant only for unknown elevated FSH at 24.1, consistent with ovarian failure. SOCIAL HISTORY: No alcohol, tobacco or drug use. FAMILY HISTORY: Noncontributory.
FSH|follicle-stimulating hormone|FSH|173|175|PROBLEM #3|PROBLEM #3: History of panhypopituitarism. The patient has a history of hypopituitarism diagnosed by Dr. _%#NAME#%_ during a _%#MM#%_ hospitalization. This was based on low FSH and LH values. The patient had a cosyntropin test at that time which did show response to stimulation and the patient's TSH and free T4 were normal at that time.
FSH|follicle-stimulating hormone|FSH,|212|215|HISTORY OF PRESENT ILLNESS|A CT scan at that time showed a normal appendix, normal uterus, bilateral 3 cm adnexal cyst, and no free fluid. She had also been noted to have amenorrhea of approximately 11 months duration, and TSH, prolactin, FSH, and LH were obtained, which were also within normal limits, confirming a probable hyperthalamic amenorrhea. However, the patient has continued to have pelvic pain, which has not been progressive, but has not improved as well, and she will be admitted for further evaluation by diagnostic laparoscopy with laparoscopic treatment as indicated.
FSH|follicle-stimulating hormone|FSH|251|253|PROBLEM #3|There was mild aneurysmal dilation of the venous end of her AV fistula and otherwise was normal. PROBLEM #3: History of possible panhypopituitarism. Review of previous endocrinologic tests, which included elevated prolactin, normal free T4, decreased FSH and normal head MRI, and equivocal cortisol levels, suggested the diagnosis of panhypopituitarism was likely incorrect. Her hydrocortisone was held, and her a.m. cortisol the next day, approximately 24 hours after her last dose, was 14, which is consistent with normal pituitary functions.
FSH|follicle-stimulating hormone|FSH|230|232|LABORATORY DATA|Labs done _%#MMDD2002#%_ showed a normal CBC with a hemoglobin of 13.8, white count 7.6, platelets 236,000; normal BUN, creatinine, and electrolytes. The patient also had a previous screening glucose in _%#MM#%_ was normal at 87. FSH testing and LH levels have been normal in _%#MM#%_. FSH was again repeated in _%#MM#%_ and was normal and estradiol level which had been less than 32 in _%#MM#%_ was now 60.
FSH|Fairview Southdale Hospital|FSH|181|183||Mr. _%#NAME#%_ is desirous of having the cataract removed in the right eye and the risks and benefits of cataract surgery with intraocular lens were discussed. He is now brought to FSH for this procedure.
FSH|follicle-stimulating hormone|FSH|300|302|PLAN|She had five cycles of intrauterine insemination with good follicles and monitoring without medication and has decided that reevaluation would be sensible. I agreed with this plan considering her past history. She understands the choices, risks and possible complications or surgery, had a day three FSH which showed a FSH of 4.1 and estradiol of 65 within a normal range for a 34 year-old. PAST MEDICAL HISTORY ILLNESSES - The patient denies history of high blood pressure, tuberculosis, heart disease, kidney disease, pulmonary disease, transfusions, hepatitis or diabetes.
FSH|follicle-stimulating hormone|FSH|319|321|PLAN|She had five cycles of intrauterine insemination with good follicles and monitoring without medication and has decided that reevaluation would be sensible. I agreed with this plan considering her past history. She understands the choices, risks and possible complications or surgery, had a day three FSH which showed a FSH of 4.1 and estradiol of 65 within a normal range for a 34 year-old. PAST MEDICAL HISTORY ILLNESSES - The patient denies history of high blood pressure, tuberculosis, heart disease, kidney disease, pulmonary disease, transfusions, hepatitis or diabetes.
FSH|follicle-stimulating hormone|FSH|155|157|HOSPITAL COURSE|Pituitary function studies were also done. His TSH was within normal limits. His thyroxin was low. His prolactin was very mildly elevated at 39 mcg/L. His FSH was low, and LH was low. Human growth hormone was also low, as well as a.m. cortisol. A chest x-ray did not demonstrate any radiographic abnormalities. After this work-up, a craniotomy for debulking of his large right CP angle tumor was elected for diagnosis and also for debulking for radiation therapy.
FSH|Fairview Southdale Hospital|FSH|239|241|HISTORY OF PRESENT ILLNESS|Unfortunately, he has presented several times to HCMC ER over the last week and he has received several rounds of pain therapy for the Crohn's, however, they have not adjusted his medications other than that. He is presenting to the ER at FSH and he is frustrated because the pain is still continuing despite the high doses of Prednisone mesalamine that he is taking.
FSH|follicle-stimulating hormone|FSH|161|163|PHYSICAL EXAMINATION|PELVIC EXAMINATION: Vulva and vagina are normal. Her uterus appeared to be large about 12 week gestation, globular. Both adnexa were clear, no masses were felt. FSH was 18.7, TSH was normal, hemoglobin was 13.8. DIAGNOSES: 1. Menometrorrhagia 2. Simple endometrial hyperplasia, rule out neoplasia and complex hyperplasia PLAN: The patient is undergoing dilatation and curettage.
FSH|Fairview Southdale Hospital|FSH|187|189|HOSPITAL COURSE|The patient continued to have anginal type symptoms. A nuclear stress test was performed. This showed inferolateral and lateral wall ischemia. The patient was subsequently transferred to FSH where she underwent coronary angiography. This showed an occluded right coronary artery which was well collateralized with right to right and left to right collaterals.
FSH|Fairview Southdale Hospital|FSH|130|132|HISTORY|CHIEF COMPLAINT: Acute low back pain. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 55-year-old gentleman who is admitted today through the FSH ER. He complains of acute low back pain. He had a twinge in his back about four weeks ago. He went to his primary care physician. He underwent physical.
FSH|Fairview Southdale Hospital|FSH|227|229|REASON FOR HOSPTIALIZATION|He had another episode of chest discomfort a month or two later while in Florida and had a recurrence of similar chest discomfort leading to his presentation to the Fairview Lakes ER the day of admission. He was transferred to FSH for definitive care. HOSPITAL COURSE: The patient was admitted to FSH.
FSH|Fairview Southdale Hospital|FSH.|297|300|HOSPITAL COURSE|He had another episode of chest discomfort a month or two later while in Florida and had a recurrence of similar chest discomfort leading to his presentation to the Fairview Lakes ER the day of admission. He was transferred to FSH for definitive care. HOSPITAL COURSE: The patient was admitted to FSH. I saw him and arranged a coronary angiogram. That was done by my associate, Dr. _%#NAME#%_. This study showed a mild degree of in stent restenosis in the proximal LAD as well as a moderate degree of stenosis in the mid LAD and the ramus intermediate branch.
FSH|Fairview Southdale Hospital|FSH|490|492|PROCEDURE|DIAGNOSIS: Acute myocardial infarction. PROCEDURE: Coronary artery bypass times three using left internal mammary artery to the LAD, left radial artery to the PDA and saphenous vein to the second obtuse marginal branch on _%#MMDD2006#%_. Mrs. _%#NAME#%_ _%#NAME#%_ is a 62-year-old woman with long standing history of smoking who became symptomatic about four days prior to admission with nausea, vomiting and ruled in for an inferior wall myocardial infarction when she was transferred to FSH Cath Lab for urgent coronary angiography which revealed an occluded right coronary artery, 60% left main stenosis, 40% LAD stenosis, 80% obtuse marginal branch stenosis.
FSH|Fairview Southdale Hospital|FSH|271|273|BRIEF HISTORY OF THIS ADMISSION|BRIEF HISTORY OF THIS ADMISSION: _%#NAME#%_ _%#NAME#%_ is a 58-year-old white female with past medical history significant with end stage renal disease on dialysis, history of diabetes mellitus type 2, dilated cardiomyopathy, COPD. She is admitted to the Heart Center of FSH because of dizziness. For additional information see her detailed history and physical examination by Dr. _%#NAME#%_ for details. PHYSICAL EXAMINATION: Please refer to the progress note on _%#MMDD2006#%_.
FSH|follicle-stimulating hormone|FSH,|206|209|HOSPITAL COURSE|The patient had no signs of bleeding at the time of discharge. 4. Menstrual irregularities: The patient was complaining of menstrual irregularities during her hospital course. Therefore, per endocrine, LH, FSH, and estradiol levels were all checked to evaluate for ovarian failure. These all which are pending at the time of discharge and the patient will follow up with endocrine as an outpatient regarding these studies.
FSH|Fairview Southdale Hospital|FSH.|84|87||_%#NAME#%_ _%#NAME#%_ is a 32 3/7 weeks gestation twin #2 born on _%#MMDD2006#%_ at FSH. Mom was a 26-year-old, G3 P0-0-2-0, blood type 0 positive, serology negative, hepatitis B antigen negative, group B strep unknown.
FSH|follicle-stimulating hormone|FSH|216|218|HISTORY OF PRESENT ILLNESS|This came back as an abnormal result, which was suggestive of the diagnosis of congenital disorder of glycosylation. Other studies that came back in the meantime were a serum transferrin that was 176, prealbumin 12, FSH less than 0.3, LH 0.4, uric acid 4.0, free and total carnitine of 24 and 34 respectively, which are both lower than normal.
FSH|follicle-stimulating hormone|FSH|181|183|HISTORY|Serum qualitative HCG was negative. She had previous investigation of her iron deficiency anemia with colonoscopy which was negative. TSH was also normal. She was perimenopausal by FSH done six months ago. PAST MEDICAL HISTORY: Significant for cesarean section times two. She has had two pregnancies resulting in three children because of one set of twins.
FSH|follicle-stimulating hormone|FSH,|135|138|HISTORY OF PRESENT ILLNESS|She was seen in our office on _%#MMDD2003#%_ where her examination was normal. In evaluation of her heavy periods we did perform serum FSH, LH and TSH, these were all normal. The gonadotropins were all premenopausal. A pelvic ultrasound was performed on _%#MMDD2003#%_. The ultrasound showed a normal sized uterus with an endometrial stripe of 18 mm.
FSH|follicle-stimulating hormone|FSH|144|146||The patient is menopausal at age 38 and thus for five years has been on menopause replacement. She has opted for birth control pills and had an FSH of 102 back at age 38. She has done well for the last two years on birth control pills. She is a non-smoker and understands the risks. She takes baby aspirin, calcium and started having anemia secondary to menorrhagia approximately six months ago.
FSH|follicle-stimulating hormone|FSH|166|168|HISTORY OF PRESENT ILLNESS|These findings are consistent with cirrhosis of the liver. 2. Further work up of the hemachromatosis demonstrated that she did have evidence of hyperpituitarism. The FSH was 2.1 (normal range 2.5 to 10.2), LH was 0.4 (normal range 1.9 to 12.5). The prolactin level is 14 (normal range 2 to 20).
FSH|Fairview Southdale Hospital|FSH|155|157|HOSPITAL COURSE|FINAL DIAGNOSIS: Status post repeat low transverse cesarean section with revision of vertical scar. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was admitted to FSH on _%#MMDD2006#%_ for scheduled cesarean section. Please see operative note for full details. She ultimately delivered a viable 6 pound 5 ounce female.
FSH|follicle-stimulating hormone|FSH,|234|237|2. FEN|Ongoing problems and suggested management: 1. Urology would like to see _%#NAME#%_ in 5-6 months 2. Endocrine is considering 5 a- reductase deficiency, androgen insensitivity, or gonadal dysgenesis. Labs currently pending include LH, FSH, dihydrotestosterone, CAH-6 profile, androstenedione, 11- deoxycortisol, 17-OH-pregnenlone, progesterone, 17-OH-progesterone, testerone. They will call the parents for an appointment in the next 1-2 weeks.
FSH|follicle-stimulating hormone|FSH|188|190|HISTORY OF PRESENT ILLNESS|Mom reports since 2:00 this morning, baby has had four stools and three urine diapers. Baby was discharged from Abbott with a bilirubin level of 12, was followed in outpatient lab here at FSH with a level of 17, and admitted by Dr. _%#NAME#%_ from Metro Peds. Upon arrival to the Unit, baby's weight was 8 pounds 6.1 ounces, which indicates a 6% loss from birth weight.
FSH|follicle-stimulating hormone|FSH,|174|177|ASSESSMENT/PLAN|However, today she has elevated free T4 and also elevated TSH. This suggests a secondary hyperthyroidism and concern for possible pituitary hypersecretion of TSH. Will check FSH, LH, prolactin and insulin-like growth factor. May consider brain MRI. Hold Synthroid. 5. Abdominal pain and elevated LFTs. Unclear etiology of the abdominal pain.
FSH|follicle-stimulating hormone|FSH|229|231|HISTORY OF PRESENT ILLNESS|She is aware of the minor cardiopulmonary and neurological risks from anesthesia and risks of GI injuries, GU injuries, blood loss and possibility of blood transfusion from surgery. Her hemoglobin preoperatively was 12 gm. TSH , FSH and Pap smear was normal. PAST MEDICAL HISTORY: Significant for: 1. Migraine headaches worse during menses.
FSH|follicle-stimulating hormone|FSH|130|132|DISCHARGE DIAGNOSES|She has had evaluation for kidney and thyroid, those tests also were normal. Pending at this time include an estradiol level, LH, FSH and rennin level were also requested. DISPOSITION: At this time of this dictation, it is anticipated that the patient will be discharged at 1800 if she does not have further vomiting.
FSH|follicle-stimulating hormone|FSH|145|147|ADMISSION EVALUATION|His initial EKG did not show any acute changes. However, a rise in his cardiac troponin I level to 0.41 was observed. He was then transferred to FSH for further evaluation. Upon arrival he did appear comfortable at rest. The blood pressure was 120/70. Pulse rate 80. Respiratory rate 16.
FSH|Fairview Southdale Hospital|FSH|185|187|HOSPITAL PROCEDURE|2. Palpitations. 3. Hypercholesterolemia. 4. Tobacco abuse. HOSPITAL PROCEDURE: EP study and successful ablation of a typical AVNRT without complications performed by Dr. _%#NAME#%_ at FSH on _%#MMDD2007#%_. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a pleasant 60-year-old gentleman who had experienced recurrent symptomatic SVT.
FSH|follicle-stimulating hormone|FSH,|239|242|PROBLEM #7|Endocrine was consulted on _%#MMDD2007#%_ and recommended TSH, free T4, T3, total testosterone and pretestoterone and AM cortisol. The labs came back with a low AM cortisol and TSH. Endocrine is subsequently recommended checking an LH and FSH, which came back as high. The patient also had a decreased testosterone level. Endocrine believes that he possibly has primary hypogonadism and had a testosterone 50 mg IM this was given during the hospitalization.
FSH|Fairview Southdale Hospital|FSH|241|243|HOSPITAL COURSE|These results can be followed up by Dr. _%#NAME#%_. HOSPITAL COURSE: Please see dictated history and physical for the patient's initial presentation. The patient was seen by Dr. _%#NAME#%_ at Fairview Ridges Hospital. She was transferred to FSH for an angiogram. At Fairview Ridges Hospital the patient had a normal stress echo test done. She had EKG with some PVC's. The patient had an angiogram done on _%#MMDD2003#%_.
FSH|Fairview Southdale Hospital|FSH|188|190||Mr. _%#NAME#%_ is desirous of having the cataract in the right eye removed and the risks and benefits of cataract surgery with intraocular lens implant were reviewed. He is now brought to FSH for this procedure.
FSH|Fairview Southdale Hospital|FSH|221|223||_%#NAME#%_ _%#NAME#%_ is a 59-year-old patient admitted last evening at Ridges and seen this morning by Dr. _%#NAME#%_. He was admitted with chest discomfort, ruled out for an myocardial infarction and was transferred to FSH for coronary angiography. HOSPITAL COURSE: My care of the patient started when he arrived at FSH.
FSH|Fairview Southdale Hospital|FSH|240|242|PAST MEDICAL HISTORY|He continues to smoke a few cigarettes. It appears that he has been reasonably asymptomatic at the assisted living to the present time. PAST MEDICAL HISTORY: 1. Depression. 2. Hypertension. 3. Alcoholism. 4. Narcotic abuse. 5. Admission to FSH _%#MM2004#%_ with toxic delirium secondary to narcotic abuse. PREVIOUS SURGICAL HISTORY: He had a fall in 2003 with a fracture elbow and repair.
FSH|Fairview Southdale Hospital|FSH|38|40||_%#NAME#%_ _%#NAME#%_ was admitted to FSH on _%#MMDD2004#%_ with previously diagnosed mitral regurgitation and coronary artery disease. On the day of admission he underwent a complex mitral valve repair consisting of resection of P2, repair of P3 with chordal transfers, posterior annuloplasty and insertion of a 32 Carpentier-Edwards annuloplasty ring.
FSH|Fairview Southdale Hospital|FSH|85|87|HOSPITAL COURSE|HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 77-year-old male who was admitted to the FSH on _%#MMDD2004#%_. Two days prior to that he had been discharged from the hospital after he had left total knee replacement performed.
FSH|Fairview Southdale Hospital|FSH|126|128||His intraocular pressure is 18. The risks and benefits of cataract surgery were reviewed and Mr. _%#NAME#%_ is now brought to FSH for this procedure.
FSH|Fairview Southdale Hospital|FSH|163|165||Fundus examination was normal and her intraocular pressure was 15. The risks and benefits of cataract surgery were reviewed and Mrs. _%#NAME#%_ is now brought the FSH for cataract extraction and intraocular lens implant on the left eye.
FSH|Fairview Southdale Hospital|FSH.|223|226|ASSESSMENT/PLAN|4. Cardiovascular: chronic atrial fibrillation for which is chronically anticoagulated with Coumadin. Because of underlying dementia and recurrent fall, I strongly recommend discontinuation of Coumadin after discharge from FSH. The patient's son is agreeable to this plan. Will plan to discharge patient on aspirin. Pt's son is aware of the small but increased risk of stroke for those patients with afib who are not on Coumadin.
FSH|Fairview Southdale Hospital|FSH|271|273|HISTORY OF PRESENT ILLNESS|At that time she was instructed to go home. While she was in the doctors office, she started having some funny feeling in the face and in the arms which she described as a form of numbness. At that time the physician re-evaluated the patient and advised them to drive to FSH ER. On arrival here she was seen by the ED physician. She was confused and agitated at times. Most of the history was obtained through the patient's friend who is accompanying the patient.
FSH|follicle-stimulating hormone|FSH|177|179|LABORATORY DATA|White blood cell count 5.5, hemoglobin 12.9, platelet count 203. Cholesterol 167, triglycerides 169, LDL 99, HDL 36. Prolactin 16. IGF __________ 4.0. Adrenal corticotropin 11. FSH 6.6, LH 30.4, testosterone 149. DISCHARGE INSTRUCTIONS: 1. Full code. 2. Low cholesterol, low salt diet.
FSH|Fairview Southdale Hospital|FSH|149|151|FOLLOW-UP APPOINTMENTS|He was born at Fairview Southdale Hospital (FSH) on _%#MMDD2007#%_ at 2204 hours, transferred to the NICU on _%#MMDD2007#%_, and transferred back to FSH on _%#MMDD#%_. At the time of discharge, the infant's postmenstrual age was 37 weeks and 5 days. He is a 2672 gram, 36 2/7 week gestational age male infant born to a 41 year old, gravida,3, para 2-0-0-2, blood type AB positive, Caucasian female whose LMP was not available and whose EDD was._%#MMDD2007#%_. The mother's pregnancy was uncomplicated.
FSH|follicle-stimulating hormone|FSH|169|171|PHYSICAL EXAMINATION|No masses. The patient does have a history of bilateral galactorrhea, though none was seen at this point. She did have a normal TSH and prolactin. She also had a normal FSH and Estradiol for ovarian function. She has no stress incontinence. NO dyspareunia. Pelvic exam shows normal vagina, normal cervix, nontender on motion.
FSH|follicle-stimulating hormone|FSH|331|333|HISTORY OF PRESENT ILLNESS|PROPOSED PROCEDURE: D&C, diagnostic hysteroscopy HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 44-year-old White female, gravida 1-para 1, who is undergoing D&C, diagnostic hysteroscopy for persistent menometrorrhagia. Patient's history dates back to at age 40 she was diagnosed as perimenopausal or postmenopausal as her FSH was elevated to 80. She had irregular menses and some degree of hot flashes. She tried Prempro 2.5 mg followed by Prempro 5, and then Ortho-Prefest.
FSH|follicle-stimulating hormone|FSH|430|432|HABITS|REVIEW OF SYSTEMS: Negative. HABITS: Tobacco negative. Alcohol negative. _%#NAME#%_ was advised the last time I saw her for her chronic headaches to start Propranolol which she was reluctant to do due to possible side effects and she was encouraged today to start this after her scheduled surgery which she says she will do. Previous hormone testing on _%#MMDD2002#%_ for evaluating her dysfunctional bleeding, her LH was 2.9 and FSH was 6.1 and she was notified in _%#NAME#%_ of those results. PHYSICAL EXAM: _%#NAME#%_ is a 41-year-old Caucasian female in no distress.
FSH|Fairview Southdale Hospital|FSH|200|202|HOSPITAL COURSE|4. Diarrhea. 5. Congestive heart failure. PRINCIPAL PROCEDURES PERFORMED THIS ADMISSION: 1. Pacemaker 2. Video speech evaluation. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was brought to the ER Dept. at FSH for altered mental status. He was noted to have increasing confusion and agitation. They also noted that he had had a distended abdomen and some diarrhea.
FSH|Fairview Southdale Hospital|FSH.|149|152|PATIENT HISTORY|The EKG demonstrated mild inferolateral ST depression. The patient was treated with IV heparin, nitroglycerin, and Aggrastat. She was transferred to FSH. Coronary angiography was performed which failed to demonstrate any significant coronary disease. There was overall normal left ventricular systolic performance on the left ventriculogram with a focal wall motion abnormality demonstrating severe hypokinesis of the distal anterolateral wall.
FSH|Fairview Southdale Hospital|FSH|135|137||The risks and benefits of cataract surgery with intraocular lens implant were discussed and he wishes to proceed. He is now brought to FSH for this procedure.
FSH|follicle-stimulating hormone|FSH|206|208|HISTORY OF PRESENT ILLNESS|She also has had vasomotor symptoms for the past two or three years associated with some weight gain. Patient was evaluated in the GYN Clinic and had laboratory studies that showed a hemoglobin of 15 and a FSH that was 6 and FSH that was in the 6's. A pelvic ultrasound confirmed uterus 9.6 x 8.4 cm endometrial lining of 6 mm, was noted to have multiple myomas through the uterus ranging from 2.6 cm to 9.6 cm.
FSH|Fairview Southdale Hospital|FSH|69|71||_%#NAME#%_ _%#NAME#%_ is a 63-year-old gentleman who was admitted to FSH after he was found on the floor of his bathroom unconscious. The patient had been ill with what appeared to be gastroenteritis.
FSH|follicle-stimulating hormone|FSH,|251|254||Her menstrual periods occur for seven to eight days total with heavy flows for 1 1/2 days, changing every two to three hours. Saline infusion sonography revealed a possible endometrial polyp measuring 5.6 mm. Laboratory studies have revealed a normal FSH, TSH, and prolactin. We discussed the options and the patient wishes to proceed with a hysteroscopy. She understands the risks of infection, bleeding, and possible injury to neighboring structures, the possibility of uterine perforation, and fluid overload.
FSH|Fairview Southdale Hospital|FSH|270|272|HOSPITAL COURSE|This patient's other cardiovascular risk factors are positive for family history of heart disease, hyperlipidemia, prior history of heart disease, obesity, sedentary life style and age. HOSPITAL COURSE: The patient was taken to the Cardiac Catheterization Laboratory at FSH which found a left main coronary artery which had a mild distal 20% stenosis. The left anterior descending artery showed a diffuse proximal disease ending in a 90% stenosis just before the first septal and another 80-90% stenosis just after the first septal.
FSH|follicle-stimulating hormone|FSH|226|228|HISTORY|An ultrasound was obtained on _%#MMDD2004#%_ which showed the fundal portion of the endometrium not well seen, a 5.1-mm endometrial stripe, a 1.5-cm posterior myoma, normal left ovary, and the right ovary not seen. She had an FSH which was 39 and an estradiol was 25. Because of these findings, the recommendation was made to have a fractional D&C and a diagnostic hysteroscopy.
FSH|follicle-stimulating hormone|FSH|329|331|HISTORY OF PRESENT ILLNESS|Her history dated back a few years when she started to have her menses every 22 to 26 days with heavy flow, with moderate to severe dysmenorrhea, menorrhea relieved with analgesics and she works in a school and she had to take four days off each month during her menses. She has had endometrial biopsy which was negative and TSH FSH were normal. Hemoglobin was 12.3. Endometrial biopsy was negative. She was treated with cyclic Provera therapy which did not resolve dysmenorrhea or menorrhagia.
FSH|follicle-stimulating hormone|FSH,|168|171|HISTORY OF PRESENT ILLNESS|Admission was complicated by diaphoresis. The patient was evaluated by Endocrine and found to have a decreased a.m. Cortisol with normal ACTA stem test. Also increased FSH, LH and low testosterone. He was started on testosterone therapy during the hospitalization. The patient has had done well since the last hospitalization and presents today for admission and chemotherapy with methotrexate.
FSH|follicle-stimulating hormone|FSH|158|160||The patient notes no intramenstrual bleeding. She did have a history of galactorrhea, prolactin was performed because of that showing a level of 5.4. TSH and FSH are normal. Ultrasound shows a fundal fibroid away from the endometrium. The patient does note some stress incontinence. Examination shows the uterus to be bulky. There is some descent into the urethrovesical angle.
FSH|follicle-stimulating hormone|FSH|200|202||There is no evidence of any fluid in the cul-de-sac and otherwise the patient feels well. CA-125 was performed with the upper limit of normal being 21, hers was 22. Thyroid function tests are normal. FSH is 33.5, demonstrating menopause. Options were discussed with the patient including laparoscopy with D&C, right salpingo-oophorectomy, hormone replacement therapy was discussed in detail.
FSH|Fairview Southdale Hospital|FSH.|53|56||Transfer to inpatient psych unit on the 7th floor at FSH. PRINCIPAL DIAGNOSIS: 1. Failure to thrive secondary to severe depression and catatonic state.
FSH|follicle-stimulating hormone|FSH|192|194|DOB|She had spontaneous menses in _%#MM#%_, _%#MM#%_ and _%#MM#%_ _%#DD#%_, but has not had a menses since. She wonders whether she might be menopausal due to her history of chemotherapy, however FSH done in our office on _%#MMDD2003#%_, returned normal at 16. I discussed with her that her last sampling still showed complex hyperplasia and I felt she needed sampling to show that this had resolved and that she remained at risk as long as she was premenopausal, overweight and not ovulating with regular menses.
FSH|Fairview Southdale Hospital|FSH|267|269||He had cataract extraction with intraocular lens implant on the left eye on _%#MMDD2004#%_ and now wishes to have the cataract removed from the right eye. The risks and benefits of cataract surgery with intraocular lens implant were reviewed and he is now brought to FSH for this procedure.
FSH|Fairview Southdale Hospital|FSH|195|197||Mrs. _%#NAME#%_ is desirous of having this cataract removed in the right eye. The risks and benefits of cataract extraction with intraocular lens implant were discussed and she is now brought to FSH for this procedure.
FSH|Fairview Southdale Hospital|FSH|181|183|HISTORY OF PRESENT ILLNESS|When he indicated to the nurses he was having chest pain, dialysis was not initiated, nitroglycerin was given, chest pain was not relieved, 911 was called and he was brought to the FSH Emergency Room. He was then given O2, some further nitroglycerin. Lab studies showed a potassium of 6.9, this was treated with IV glucose, insulin, calcium and bicarbonate.
FSH|Fairview Southdale Hospital|FSH.|182|185|BRIEF HOSPITAL COURSE|12 lead EKG shows a ventricular rate of 86 beats per minute. He presented for electrophysiology study and ablation of his atrial tachycardia on _%#MMDD2007#%_ with Dr. _%#NAME#%_ at FSH. He had successful ablation at the mid crystal terminalis. There was injury initially of the phrenic nerve at the successful site.
FSH|follicle-stimulating hormone|FSH|130|132|PLAN|If it is appropriate, stress testing can be arranged as an outpatient but would not be appropriate right now. 7. We will check an FSH and an LH to look for evidence of perimenopause, although she is somewhat at the middle of her cycle right now, and therefore FSH may well be elevated anyway.
FSH|follicle-stimulating hormone|FSH|260|262|PLAN|If it is appropriate, stress testing can be arranged as an outpatient but would not be appropriate right now. 7. We will check an FSH and an LH to look for evidence of perimenopause, although she is somewhat at the middle of her cycle right now, and therefore FSH may well be elevated anyway.
FSH|follicle-stimulating hormone|FSH|182|184|HOSPITAL COURSE|However, her adrenal corticotropin was less than 10 on that day. Given these findings, there is concern for a possible secondary adrenal insufficiency. Further lab studies including FSH and prolactin have been ordered by Dr. _%#NAME#%_. Overall endocrinology was consulted and the patient was started on prednisone 7.5 mg a day.
FSH|follicle-stimulating hormone|FSH,|184|187|ALLERGIES|The pediatric endocrinology service was consulted and they recommended a dose of 0.2 mg p.o. twice a day for outpatient DDAVP dosing. They also had a workup for this patient including FSH, LH, cortisol, adrenocorticotropin, and thyroxin levels. The patient did notice some drainage from her nose and this was sent for beta-2 transferrin which was negative.
FSH|follicle-stimulating hormone|FSH,|185|188|HISTORY|She does not think she took cycloprogesterone for more than one cycle. Her examination was normal. She had a recent Pap smear which was normal without transitional cells. A hemoglobin, FSH, and estradiol were obtained which was normal and she had a pelvic ultrasound on _%#MMDD2003#%_. This showed a solid elongated mass measuring 2 cm x 0.5 cm x 0.5 cm in the lower uterine segment consistent with a cervical lower uterine polyp.
FSH|Fairview Southdale Hospital|FSH|64|66||_%#NAME#%_ _%#NAME#%_ is a 63-year-old male who was admitted to FSH on _%#MMDD2003#%_ with previously diagnosed coronary artery disease. On the day of admission he underwent a triple off pump coronary artery bypass with a left internal mammary artery graft to the left anterior descending and saphenous vein graft to the diagonal and posterior descending branch of the right coronary arteries.
FSH|Fairview Southdale Hospital|FSH|117|119||She was found to have multiple episodes of asystole of 12 to 20 seconds in duration for which she was transferred to FSH for possible electrophysiologic study and pacemaker insertion. She has had episodes of atrial fibrillation that she has not been aware of.
FSH|follicle-stimulating hormone|FSH.|340|343|PLAN|The handclasp strengths are bilaterally diminished somewhat. There was no significant atrophy identified on the muscles of the arms, and I did not identify any spontaneous muscle fiber contractions on inspection. PLAN: Continue the patient's current estrogen hormone replacement therapy. Assess for evidence of adequacy with testing of the FSH. Continue current medication for comfort, namely Neurontin and Vioxx. Get at PT assessment. Review recent medical records from other institutions and clinics in regard to recommendations for further activity.
FSH|follicle-stimulating hormone|FSH,|142|145|BRIEF HISTORY OF PRESENT ILLNESS|4. OB-GYN. OB-GYN performed the exam under anesthesia given the patient's history of amenorrhea x 1 year and history of "vaginal tumors." Her FSH, prolactin, and TSH were all within normal limits. Findings on OB-GYN exam were small, mobile mid-posterior uterus, ovaries that were not palpable, and multiple papillomatous growths in the labia minora, 2 large hemorrhoids, and moderate-to-severe fibrocystic changes of the breast bilaterally.
FSH|Fairview Southdale Hospital|FSH|226|228|HISTORY OF PRESENT ILLNESS|IDENTIFICATION: _%#NAME#%_ _%#NAME#%_ is an 88-year-old white female with chief complaint of shortness of breath and weakness progressive for ten days. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ was hospitalized at FSH from _%#MMDD#%_ - _%#MMDD#%_ for urosepsis. She had been treated prior to this admission with a variety of antibiotics including Cipro.
FSH|follicle-stimulating hormone|FSH.|393|396|HISTORY OF PRESENT ILLNESS|2. Possible sacrospinous fixation. SURGEON: Dr. _%#NAME#%_ ASSISTANT: Dr. _%#NAME#%_ HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old female well known to myself with a history of endometrial hyperplasia and a fibroid uterus who I saw in _%#MM#%_ of this year complaining of worsening uterine prolapse. The patient has also had recurrence of some abnormal bleeding despite an elevated FSH. On pelvic exam at that time the patient was noted to have a grade II uterine prolapse with Valsalva grade III to IV uterine prolapse.
FSH|follicle-stimulating hormone|FSH|204|206|HISTORY OF PRESENT ILLNESS|Endometrial biopsy was then performed which showed focal simple hyperplasia without atypia. She was begun on monthly Provera. She had regular withdrawal bleeds, but these continued to be fairly heavy. An FSH was repeated in _%#MM2005#%_ and was noted to be 4.7. The patient was re-evaluated in _%#MM2006#%_ and requested more definitive therapy for her very heavy menses, causing her to change her pad every hour; she is unable to go out of the house.
FSH|Fairview Southdale Hospital|FSH|247|249|HOSPITAL COURSE|HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is an unfortunate _%#1914#%_ resident of a nursing home who had a fall while riding on his motorized scooter there at that facility. There was a questionable loss of consciousness here. He was transported to FSH for trauma evaluation. Upon arrival here he was fairly cooperative and was answering questions appropriately. He underwent a full trauma radiographic work up including a CT scan of the head which revealed two small 1 cm intraparenchymal bleeds in his right frontal lobe without any mass effect.
FSH|follicle-stimulating hormone|FSH|219|221|HISTORY OF PRESENT ILLNESS|PLANNED PROCEDURE: D&C, hysteroscopy. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 46-year-old para 4-0-1-3 post-menopausal woman who has been having some abnormal bleeding on hormone replacement therapy. Her FSH was 97 in _%#MM#%_ of 2006 and she was started on Prempro. She has been having abnormal bleeding every day for the past several months.
FSH|follicle-stimulating hormone|FSH,|216|219|HISTORY OF PRESENT ILLNESS|Endometrial stripe was 1 cm thick, however,it was very prominent in the mid uterine body with the possibility of endometrial polyp or hyperplasia. The ovaries were normal. The hormonal profile in the office revealed FSH, LH, TSH and prolactin normal. Hemoglobin was 12.8 and pregnancy test was negative. The endometrial biopsy was not performed in the office until the ultrasound was available and since there is abnormality in the endometrium on ultrasound, the patient is undergoing D&C and diagnostic hysteroscopy, possible removal of endometrial polyp.
FSH|Fairview Southdale Hospital|FSH|238|240|HOSPITAL COURSE|Ascending aorta was borderline dilated. CONSULTATIONS DURING HOSPITALIZATION: Cardiology. ADMISSION HISTORY: Please see the H&P by Dr. _%#NAME#%_ on _%#MMDD2007#%_ for complete details. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ presented to FSH with chest pain. This was dissimilar to the chest pressure when he had angina in the past. The patient has had significant left hip pain recently as well.
FSH|Fairview Southdale Hospital|FSH|125|127|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: I had the pleasure of seeing Dr. _%#NAME#%_ _%#NAME#%_, an 82-year-old gentleman who presents to FSH for his weekly nesiritide infusion. He has significant medical history for mild aortic stenosis, severe mitral regurgitation, biventricular heart failure, pulmonary hypertension, peripheral edema and ascites and anemia of chronic disease.
FSH|follicle-stimulating hormone|FSH,|303|306|HISTORY OF PRESENT ILLNESS|5. Para-aortic pelvic lymph node dissection. 6. Omentectomy. HISTORY OF PRESENT ILLNESS: The patient is a 42-year-old woman who has been having periods every month for the past 1-1/2 years. The patient then had amenorrhea for three months. At that time she was followed by a primary doctor who measured FSH, which was 0.5. She was then followed in one year and her FSH continued to be low. She continued to have amenorrhea. The FSH was rechecked and found to be 3.16, with an LH of 25 and testosterone 64.
FSH|follicle-stimulating hormone|FSH|238|240|HISTORY OF PRESENT ILLNESS|The patient then had amenorrhea for three months. At that time she was followed by a primary doctor who measured FSH, which was 0.5. She was then followed in one year and her FSH continued to be low. She continued to have amenorrhea. The FSH was rechecked and found to be 3.16, with an LH of 25 and testosterone 64. She was sent for evaluation with Dr. _%#NAME#%_ _%#NAME#%_. An ultrasound was performed to evaluate the endometrial stripe.
FSH|follicle-stimulating hormone|FSH|221|223|HISTORY OF PRESENT ILLNESS|We discussed that this may not solve her bleeding problems, but hopefully may temporarily relieve them, and that she will hopefully go through menopause soon. Dr. _%#NAME#%_ has also recommended, and I agree, checking an FSH level to see where she is in her perimenopausal state. The surgery itself was reviewed extensively with the patient on _%#MMDD2004#%_ by myself.
FSH|follicle-stimulating hormone|FSH|120|122||She has continued to have irregular and heavy bleeding since that time. She was evaluated hormonally on _%#MMDD2004#%_. FSH was found to be 22.4 and Estradiol is 38.4. She had a sonohysterogram done to rule out endometrial pathology which showed a normal endometrial cavity.
FSH|follicle-stimulating hormone|FSH|149|151|HISTORY OF PRESENT ILLNESS|Mammogram was normal in _%#MM#%_ of 2003 as well. Colonoscopy has not been performed. A chest x-ray was done apparently 2 years ago, and was normal. FSH was 18, and TSH was 1.4 during this workup; and endometrial biopsy was negative, as stated before. PHYSICAL EXAMINATION: On preop physical exam, the patient was 65 inches tall and weighed 141 pounds.
FSH|follicle-stimulating hormone|FSH,|332|335|SUMMARY OF HOSPITAL COURSE|He was then evaluated by Dr. _%#NAME#%_ for endocrinology. He has had no evidence of symptoms of D-I prior to admission, however, he had had some decreased libido and loss of erectile function over the past year. He was found to have hypogonadal levels. His preoperative evaluations did show that he had normal prolactin, cortisol, FSH, and growth factor. However his testosterone was slightly low and his L-H was 1.7. Visual exam was normal. The incidental finding of his pituitary adenoma was discussed with the patient and his wife at the time of his _%#MM#%_ admission.
FSH|Fairview Southdale Hospital|FSH|299|301|HISTORY OF PRESENT ILLNESS|At this time because the fetal vertex was high, fetal scalp electrode was difficult to place and the decision was made to proceed with low dose Pitocin in an attempt to dilate the cervix to place the fetal scalp electrode and further progressive induction. The patient's prenatal care was sought at FSH OB/GYN. LABORATORY: A positive, antibody negative, serology nonreactive, GCT normal.
FSH|follicle-stimulating hormone|FSH|186|188|PAST MEDICAL HISTORY|7. Status post gastric bypass surgery. 8. Status post cholecystectomy. 9. "Pituitary disorder:" Apparently, this is being worked up by her family practitioner who reportedly checked her FSH and LH levels and were very low. She did undergo a brain MRI scan within the past 1-2 weeks, which was reported as normal.
FSH|Fairview Southdale Hospital|FSH.|139|142|HISTORY OF PRESENT ILLNESS|She used several blankets in order to warm herself. Temperature had never been taken. Once she arrived to _%#CITY#%_ she went to the ER at FSH. Her examination revealed slightly positive for urinary tract infection. She had some low grade fever and elevated WBC to 13.3. The patient was admitted to the hospital with UTI, rule out sepsis.
FSH|Fairview Southdale Hospital|FSH|315|317|HOSPITAL COURSE|HOSPITAL COURSE: 82-year-old white male with past medical history significant for coronary artery disease, Parkinson disease, diabetes mellitus type 2 and numerous other medical conditions who presented to the ER complaining of left ankle pain, redness and decreased appetite. Of note, this patient was admitted to FSH for GI symptoms and was hospitalized from _%#MMDD#%_ through _%#MMDD#%_. He was discharged with the diagnosis of viral gastroenteritis. He was readmitted on _%#MMDD2007#%_ with left lateral malleolus redness, pain and decreased appetite.
FSH|follicle-stimulating hormone|FSH|335|337|HOSPITAL COURSE|2. Endocrine: Final diagnosis was pseudohypoparathyroidism likely type 1B, however, PTH stimulation test was done on the day prior to discharge and we will help determine the final typing. Multiple other endocrinopathies were examined including thyroid studies, which were normal, endomysial and gliadin antibodies, which were normal, FSH and LH levels were also tested and were within normal range. DISCHARGE MEDICATIONS: 1. Calcium carbonate (1250 mg tab) 2 tabs p.o. q. 6h.
FSH|follicle-stimulating hormone|FSH|168|170|HISTORY OF PRESENT ILLNESS|The patient has had amenorrhea in _%#MM#%_. Ultrasound was ordered that showed a left ovary with a complex cyst, which encompassed the entire ovary measuring 6 cm. Her FSH at that time was 35 and an endometrial biopsy was normal. A follow up ultrasound done _%#MMDD2006#%_, showed the cyst was persistent measuring 6 x 3 cm.
FSH|follicle-stimulating hormone|FSH,|196|199|PAST MEDICAL HISTORY|He owns his own business and it has been stressful over the past several months. PAST MEDICAL HISTORY: Includes impotence and he was found to have hypotestosteronism with a low TSH and low LH and FSH, presently on no treatment MEDICATIONS: No medications. ALLERGIES: He has a history of penicillin allergy causing angioedema of his hands.
FSH|follicle-stimulating hormone|FSH|117|119|LABORATORY AND DIAGNOSTIC STUDIES|Adnexa without masses and nontender. EXTREMITIES: No clubbing, cyanosis or edema. LABORATORY AND DIAGNOSTIC STUDIES: FSH 48.3, estradiol 91 back on _%#MMDD2007#%_. She also had a negative urine pregnancy test at that time. Her last TSH level was 2.1 on _%#MM#%_ _%#DD#%_, 2007.
FSH|follicle-stimulating hormone|FSH|212|214|HISTORY|She used 50 mg with her first cycle and the second one was 150 mg and it appeared she did ovulate with the 150 mg. She has had a significant workup done for her irregular ovulation. She has had a Prolactin, TSH, FSH all normal. Hemoglobin A1c was 5.1. Her blood type is noted to be A negative. DHEAS is noted to be normal at 121, testosterone total and free are also within normal limits.
FSH|Fairview Southdale Hospital|FSH|188|190|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSIS: Status post hardware removal right hip and right total hip arthroplasty. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 47-year-old female who was admitted to FSH on _%#MMDD2007#%_ after undergoing extensive right hip reconstructive surgery. She has a history of bilateral femoral neck stress fractures of unclear etiology.
FSH|Fairview Southdale Hospital|FSH|256|258|HISTORY OF PRESENT ILLNESS|ADMISSION DIAGNOSIS: Right hip degenerative joint disease. DISCHARGE DIAGNOSIS: Status post right total hip arthroplasty. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_, a 70-year-old gentleman with a history of Parkinson's disease, was admitted to FSH _%#MMDD2007#%_ after undergoing an uneventful right total hip arthroplasty. He has an end-stage degenerative joint disease of his hip. HOSPITAL COURSE: The patient was taken to the OR on _%#MMDD2007#%_.
FSH|Fairview Southdale Hospital|FSH|213|215|BRIEF HISTORY|2. Hypothyroidism. 3. Depression. PRINCIPAL SURGICAL PROCEDURES: Laparoscopic Roux-en-Y gastric bypass. BRIEF HISTORY: _%#NAME#%_ _%#NAME#%_ is a 44-year-old female who underwent the screening process here at the FSH Weight Loss Surgery Clinic and was deemed an appropriate candidate for Roux-en-Y gastric bypass. HOSPITAL COURSE: On the date of admission, the patient was taken to surgery and underwent the above mentioned surgical procedure without complications.
FSH|follicle-stimulating hormone|FSH|181|183|PATIENT IDENTIFICATION|This was normal. The patient was then scheduled for an HSG and also scheduled to have a Clomid challenge test. Clomid challenge test was performed with the current cycle. The day 3 FSH was 14.8, slightly above the desirable level of 12. The day 10 FSH was 8.4. Day 3 estradiol was normal. A hysterosalpingogram was recommended. The patient had an HSG on _%#MMDD2004#%_ performed by myself.
FSH|Fairview Southdale Hospital|FSH|136|138|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: Poorly controlled seizure disorder. Ms. _%#NAME#%_ _%#NAME#%_ is a 26-year-old woman who was initially admitted to FSH around _%#MM#%_ _%#DD#%_. She has a long standing history of a seizure disorder which had done reasonably well on Tegretol.
FSH|Fairview Southdale Hospital|FSH|183|185|ADDENDUM|Postoperative scarring and numbness were discussed. Benefits and alternatives were discussed. Questions were answered. She is interested in proceeding with this which is scheduled at FSH on _%#MMDD2006#%_.
FSH|follicle-stimulating hormone|FSH|173|175|FOLLOW-UP APPOINTMENTS|Other laboratory data acquired at the time of her visit on _%#MM#%_ _%#DD#%_ were a hemoglobin of 12.5 gm%, normal platelets of 350,000, TSH of 2.68 which is normal, and an FSH of 12.7 which is a nonmenopausal level. Because of our inability to treat her cystic hyperplasia with hormone replacement or with progestin agents, it would seem prudent to do a dilatation and curettage, and this is scheduled for _%#MM#%_ _%#DD#%_ at Same Day Surgery.
FSH|Fairview Southdale Hospital|FSH|290|292||The risks and benefits of cataract surgery with intraocular lens implant were discussed with Mr. _%#NAME#%_ especially in light of the possibility of some visual loss due to macular degeneration. Mr. _%#NAME#%_ wishes to proceed with cataract surgery on the right eye and is now brought to FSH for this procedure.
FSH|follicle-stimulating hormone|FSH|193|195|ASSESSMENT|This was subsequently evaluated with an MRI of the abdomen and pelvis in _%#MM#%_ of 2002. Two uterine fibroids were noted with adenomyosis. No endometriosis, no abnormal masses. At this time, FSH was 30.6. She also had a Pap smear which was normal. She did have an ECC which showed microglandular hyperplasia, no evidence for malignancy.
FSH|Fairview Southdale Hospital|FSH|298|300|HISTORY OF PRESENT ILLNESS|Poor historian due to underlying dementia. Work-up at Fairview Southdale revealed abnormal EKG, refractory hypertension requiring nitroglycerin drip, in-stent restenosis of bilateral renal arteries, acute renal failure and anemia. She was seen by Dr. _%#NAME#%_ _%#NAME#%_ of cardiology service at FSH due to the abnormal EKG. She was ruled out for myocardial infarction with serial troponin. Echocardiogram was obtained which revealed normal LV systolic function with normal ejection fraction.
FSH|Fairview Southdale Hospital|FSH|200|202|HISTORY OF PRESENT ILLNESS|Dr. _%#NAME#%_ of Interventional Radiology has placed another stent which the patient tolerated very well. She is currently on Plavix. Her systolic blood pressure was elevated throughtout her stay at FSH requiring nitroglycerin drip and adjustment of her oral medications. She is currently on multiple oral antihypertensive medications and her blood pressure is not yet optimally controlled.
FSH|Fairview Southdale Hospital|FSH|201|203|BRIEF HISTORY|DISCHARGE DIAGNOSES: 1. Acute asthma exacerbation, resolving. 2. Probable bacterial pneumonia, resolving. 3. Chronic asthma (moderate persistent). BRIEF HISTORY: _%#NAME#%_ _%#NAME#%_ presented to the FSH ER Dept. after a two week period of URI symptoms which had progressed to wheezing/mild respiratory distress.
FSH|follicle-stimulating hormone|FSH|237|239|HISTORY OF PRESENT ILLNESS|She is not a candidate for hormonal therapy because of her past history of breast cancer and in fact is on Tamoxifen to try to prevent recurrence. She was also tested to see if she really was menopausal and her blood work shows that her FSH was only 11.7 in _%#MM2005#%_ indicating that she is no longer actually menopausal but is still able to produce sufficient estrogen to produce enlargement of her fibroids.
FSH|follicle-stimulating hormone|FSH|280|282|HISTORY OF PRESENT ILLNESS|Right ovary shows two cysts, one is 1.5 cm with internal echos and another one is 1.1 cm with internal echoes, thought to be hemorrhagic cyst or endometriosis. Left ovary has 9 mm cyst, again with internal echoes, probably endometriosis. The endometrial stripe is normal. Her TSH FSH is normal. She has chronic pelvic pain through most of her cycle. We counseled her in the office regarding possible use of Lupron as apposed to laparoscopy since she already has a diagnosis, but the patient did not want to use the Lupron as she did experience some side effects last time.
FSH|follicle-stimulating hormone|FSH|157|159|HISTORY OF PRESENT ILLNESS|ADMITTING DIAGNOSIS: Worsening menorrhagia and pelvic pain. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 46-year-old gravida 3 para 2-0-1-1 had an FSH level of 40 in _%#MM#%_ of 2005. She has a six month history of worsening menorrhagia and pelvic pain.
FSH|follicle-stimulating hormone|FSH|154|156|PATIENT IDENTIFICATION|_%#NAME#%_ is also maintained on Levoxyl for hypothyroidism. She was evaluated in _%#MM2005#%_ with an examination, which was normal. We did check a TSH, FSH and a quantitative hCG. The FSH was within normal range and the TSH was also normal. Her hCG was negative and her CBC was normal. A pelvic ultrasound was performed for evaluation of the menometrorrhagia.
FSH|follicle-stimulating hormone|FSH|227|229|PHYSICAL EXAMINATION|Adnexal area is clear, also nontender. (The patient did have a history of a hysterosalpingogram that was normal and as stated in her previous laparoscopy she supposedly had normal tubes and ovaries. She also had a normal day 3 FSH and estradiol.) EXTREMITIES: Extremities are within normal limits. LABORATORY DATA: Hemoglobin 13.9. Urinalysis is clear. IMPRESSION: History of endometriosis with increasing dysmenorrhea and dyspareunia.
FSH|Fairview Southdale Hospital|FSH|125|127|DISPOSITION|DISCHARGE DIAGNOSIS: Cervical fracture. DISPOSITION: Deceased _%#NAME#%_ _%#NAME#%_ is an 81-year-old woman who presented to FSH after a fall from a motorized car. She has a long history of autoimmune demyelinization of the spinal cord and presented with a fracture subluxation of C6 on C7.
FSH|follicle-stimulating hormone|FSH|188|190|HISTORY OF PRESENT ILLNESS|Because of these symptoms, the patient underwent imaging of her pelvis with a CT scan which noted a 3 cm a left ovarian cyst on _%#MMDD2006#%_. There were no other abnormalities noted and FSH was drawn, which was normal at 5.7 indicating that the patient continued to have ovarian function despite the history of BSO.
FSH|follicle-stimulating hormone|FSH|69|71|PATIENT IDENTIFICATION|At that time she was examined. She continued to have periods and her FSH was normal. A cystocele was identified on exam with anterior vaginal wall presenting at the introitus. There was a grade II-III cystocele with grade II uterine prolapse and a grade II rectocele.
FSH|follicle-stimulating hormone|FSH|107|109|HISTORY OF PRESENT ILLNESS|She is continuing to have abnormal uterine bleeding. She was seen in the office. Her Pap smear was normal. FSH and LH were mildly elevated indicating perimenopause. TSH was normal. Hemoglobin was 11.6. We were unable to do endometrial biopsy in the office due to nulliparity and marked obesity.
FSH|follicle-stimulating hormone|FSH|143|145|PLAN|2. Lab studies include CMP, CBC, and a repeat CA-125 to assess for ovarian cancer. 3. Additional lab studies to consider will be estradiol and FSH three days after she stops taking Premarin. This is a check to confirm remnant ovarian tissue. 4. We will make the patient NPO for now in preparation for possible surgery.
FSH|Fairview Southdale Hospital|FSH|262|264|BRIEF HISTORY|2. Obstructive sleep apnea. 3. History of depression. 4. Gout. PRINCIPAL SURGICAL PROCEDURES: Laparoscopic Roux-en-Y gastric bypass. BRIEF HISTORY: _%#NAME#%_ _%#NAME#%_ is a 32-year-old gentleman who had undergone the preoperative screening process through the FSH Weight Loss Surgery Clinic and at the conclusion of this process he was deemed an appropriate candidate for Roux-en-Y bypass.
FSH|Fairview Southdale Hospital|FSH|217|219|HOSPITAL COURSE|She had significant ST segment changes with her echocardiogram revealing her apical 1/3 of the left ventricle becoming akinetic. She was seen in consultation by Dr. _%#NAME#%_ _%#NAME#%_ and was emergently brought to FSH care suites to undergo coronary angiogram. Her angiogram was performed by Dr. _%#NAME#%_ _%#NAME#%_. Her angiogram revealed her LAD to be a peculiar vessel.
FSH|Fairview Southdale Hospital|FSH|182|184|SUMMARY OF THE HOSPITAL COURSE|However, if she experiences any further episodes, she should call us or call 911. It is worth noting that Dr. _%#NAME#%_ drew an HIV screen on her and ___ and she is advised to call FSH to get the results of these tests. She does not have a primary care provider. She is advised to establish a primary care provider.
FSH|follicle-stimulating hormone|FSH|209|211||_%#NAME#%_ _%#NAME#%_ is a 49-year-old gravida 4, para 3, presenting with a history of irregular flow. In _%#MM#%_ of this year, the patient had menorrhagia and anemia with a hemoglobin of 11.0. At that time, FSH was 9.6, TSH 2.2 and prolactin was slightly increased at 26.6. The patient had been bleeding for approximately 3 1/2 months straight prior to this, sometimes heavy with clotting and other times less so.
FSH|follicle-stimulating hormone|FSH|199|201||The patient, after trying hormones for several months had an endometrial biopsy which showed no evidence of atypia or malignant changes with benign menstrual endometrium. Her hemoglobin was 11.9 and FSH that was done was 9.0. The patient desired definitive management of her symptoms by hysterectomy. Her CURRENT MEDICATIONS: Include Aleve. She denies any aspirin use.
FSH|Fairview Southdale Hospital|FSH|111|113|HISTORY OF PRESENT ILLNESS|The patient and her daughter present along with her husband who is also having GI problems at this time to the FSH ER. The patient and her daughter describe her developing nausea with vomiting at approximately 6 p.m. on _%#MMDD2003#%_. During the night she was unable to keep any fluids or solid food down.
FSH|Fairview Southdale Hospital|FSH|193|195||Mrs. _%#NAME#%_ is desirous of having the cataract removed from her right eye. The risks and benefits of cataract surgery with intraocular lens implant were discussed and she is now brought to FSH for this procedure.
FSH|follicle-stimulating hormone|FSH|267|269|HISTORY|1. Imperforate hymen. 2. Hematocolpos. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 16-year-old nulligravid female who presented to her pediatrician, Dr. _%#NAME#%_, for evaluation of primary amenorrhea. Preliminary evaluation was performed which included laboratory studies. FSH 4.0, prolactin 11.8, and TSH 2.84. These are all normal lab results and consistent with patient's pubertal age. _%#NAME#%_ reports noticing breast development approximately 3 years ago and has had axillary hair growth for at least the last 2 years.
FSH|follicle-stimulating hormone|FSH|207|209|HISTORY OF PRESENT ILLNESS|She states that she bleeds three out of every four weeks with increased cramps for at least one week and very heavy flow for two out of three weeks. Lab work in the office revealed a negative hCG and normal FSH and TSH level. A Pap smear was normal, a saline infusion sonogram revealed a retroverted uterus and it was very difficult to inflate the uterine cavity but the overall that appeared to have no evidence of fibroids or polyps.
FSH|follicle-stimulating hormone|FSH|253|255|HISTORY OF PRESENT ILLNESS|Her cycles are regular, occurring every 28 days. Her flow lasts for approximately 5 days, then stops for a couple of days and then resumes again for 3-5 days. Both consist of heavy menstrual flow. She has had a hormonal evaluation which revealed normal FSH and estradiol levels. Ultrasound revealed an enlarged uterus with at least 5 fibroids one of which appears to have butt against the endometrial cavity.
FSH|Fairview Southdale Hospital|FSH|166|168||The risks and benefits of cataract surgery with intraocular lens implant were reviewed and Mrs. _%#NAME#%_ wishes to proceed with the left eye. She is now brought to FSH for this procedure.
FSH|follicle-stimulating hormone|FSH|181|183|HISTORY OF PRESENT ILLNESS|No history of pelvic inflammatory disease or intrauterine device (IUD) use. She did have a warning about her being a smoker at this age for general health purposes. She had a day 3 FSH and estradiol which showed an FSH of 26 and an estradiol of 13, thus she was told that she also has poor ovarian reserve.
FSH|follicle-stimulating hormone|FSH.|185|188|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 56-year- old female who has had abnormal uterine bleeding since _%#MM#%_. She has not had any hot flashes and had a recent normal FSH. She underwent a D&C and benign endometrium was found along with endometrial polyp. She also was noted to have a cyst on one of her ovaries.
FSH|follicle-stimulating hormone|FSH|215|217|LABORATORY DATA|NEUROLOGICAL EXAM: Shows symmetric cranial nerves, strength and reflexes. Toes are downgoing bilaterally. LABORATORY DATA: Done about a month ago showed a hemoglobin of 11.5, white count 7400 and platelets 301,000. FSH and TSH were normal. Electrocardiogram done on _%#MMDD2002#%_ showed sinus bradycardia but otherwise normal compared to 1999 electrocardiogram.
FSH|follicle-stimulating hormone|FSH|147|149|HISTORY OF PRESENT ILLNESS|She does desire for a pregnancy at this time and has been warned about the possible situation of her ovarian reserve. The patient will get a day 3 FSH and estradiol ordered. Husband also will have semen analysis ordered. The patient was counseled about diagnostic laparoscopy and tubal dye study to recheck her endometriosis and also a hysteroscopy to evaluate the internal aspect of her uterine cavity.
FSH|follicle-stimulating hormone|FSH|324|326|DOB|She was amenorrheic throughout that time frame. The patient continued to be amenorrheic after she discontinued the Depo- Provera last _%#MM#%_, but developed a problem with abdominal cramping in _%#MM#%_. The patient was evaluated with laboratory tests and a Provera challenge. The laboratory tests, including prolactin and FSH levels were normal. The patient failed to produce withdrawal bleeding from the progesterone challenge. Since that time, the patient has continued to have abdominal cramping symptoms at approximately monthly intervals up to the present.
FSH|Fairview Southdale Hospital|FSH|146|148||The risks and benefits of cataract surgery with intraocular lens implant were reviewed and Mr. _%#NAME#%_ wishes to proceed. He is now brought to FSH for this procedure.
FSH|follicle-stimulating hormone|FSH,|353|356|HOSPITAL COURSE|HOSPITAL COURSE: The patient was admitted on _%#MMDD2003#%_ and an MRI was performed, which showed a decrease in enhancement and edema as compared to the CT scan two days earlier, which was attributed to the dose of steroids the patient had been on, and it was presumed that the lesion was a lymphoma. Lab values, including beta HCG, alpha-fetoprotein, FSH, TSH, prolactin, and human growth hormone, were all normal. Hematology/Oncology was also consulted and saw the patient during his stay. At the time of discharge, HIV I and II antibodies were pending, as well as serum LDH and toxoplasma antibody IgG.
FSH|follicle-stimulating hormone|FSH|142|144|DISCHARGE INSTRUCTIONS|We did an follicle-stimulating hormone and estradiol to evaluate her ovarian function, and she indeed had normal ovarian function on a random FSH and estradiol. The patient wanted a conservative approach at this time and I agreed with her plan. She had been taking Darvocet N100 for pain. PAST MEDICAL HISTORY: Besides endometriosis, the patient does not have history of high blood pressure, tuberculosis, heart disease, kidney disease, pulmonary disease, transfusions or hepatitis.
FSH|follicle-stimulating hormone|FSH|175|177|HISTORY|She has had the same sexual partner since _%#MM#%_ of 2006. They use his vasectomy for birth control. Evaluation has included gonorrhea/Chlamydia cultures which are negative. FSH 9.1, Pap smear which was negative and endometrial biopsy which was negative along with endocervical biopsy which was negative (all benign) _%#NAME#%_ reports that her menstrual cycles have actually been regular now for the last two months with no intermenstrual or irregular bleeding.
FSH|Fairview Southdale Hospital|FSH|117|119|MEDICATIONS|The patient became dehydrated with some decreased level of consciousness. Due to his fragile state he was brought to FSH and admitted. He was treated with intravenous fluids. He promptly responded to that. The diarrhea has spontaneously resolved. C diff studies would be negative.
FSH|Fairview Southdale Hospital|FSH|245|247|HISTORY OF PRESENT ILLNESS|Apparently she fell yesterday although this was unwitnessed. She was found on the floor and at that time complained of left hip pain and inability to walk. X-rays were taken which revealed a femoral neck fracture. She was, therefore, brought to FSH where she was admitted for more definitive treatment. This appears to be an isolated injury. Because of the patient's dementia, I could not ask her any other details such as prior history or problem.
FSH|Fairview Southdale Hospital|FSH.|227|230|IMPRESSION|Problems during his hospitalization included the following: Problem # 1: Fluids/Electrolytes/Nutrition. _%#NAME#%_ had the following lines placed: peripheral IVs. He was initially maintained on a parenteral glucose infusion at FSH. They were able to advance enteral feedings and wean the peripheral TPN. Feedings were started late on _%#MMDD2007#%_, and he tolerated the increase in volume and strength of EPF 24 kcal/oz.
FSH|follicle-stimulating hormone|FSH|176|178|PROBLEM #2|They will follow the patient up within three months with a follow-up MRI and a follow-up Neurophthalmology evaluation. Given the probability of this tumor to the pituitary, an FSH was sent which was normal. PROBLEM #3: Hypertension and atrial fibrillation. The patient initially was on procainamide and nifedipine during his hospitalization.
FSH|follicle-stimulating hormone|FSH|153|155|HISTORY OF PRESENT ILLNESS|She states that her periods are very heavy with many clots. She had lab work done to evaluate her irregular bleeding, revealing a normal TSH, prolactin, FSH and LH. Her free testosterone was slightly above normal, consistent with possible PCOS. An ultrasound was performed as well in _%#MM#%_ of 2002 to evaluate irregular bleeding and dysmenorrhea as well.
FSH|Fairview Southdale Hospital|FSH|151|153|BRIEF HISTORY|BRIEF HISTORY: _%#NAME#%_ _%#NAME#%_ is a 35-year-old gravida 3 para 1-0-1-1 female at 38 5/7 weeks gestation who was brought to Labor and Delivery at FSH for primary cesarean section. Her first pregnancy resulted in a vaginal delivery of a 9 pound 15 ounce female with a 4th degree laceration.
FSH|Fairview Southdale Hospital|FSH|180|182|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ was a 71-year-old female admitted for further treatment of shortness of breath and peripheral edema. The patient had previously been hospitalized at FSH on _%#MMDD2003#%_ with several day course of treatment for congestive heart failure. Prior history of atrial fibrillation and PSVT. Prior extensive evaluation in California for weight loss and GI symptoms also.
FSH|Fairview Southdale Hospital|FSH|198|200|HISTORY|He had persistent pain. Therefore, graduated to Percocet. However, he started having dizziness and nausea with that. Due to persistent symptoms and his inability to care for himself, he was seen at FSH ER. He was becoming nauseous from the Percocet, and he was fearful that if he were to retch that he would have marked increase in back pain.
FSH|Fairview Southdale Hospital|FSH|166|168|SUMMARY|The medics were called. She was found in ventricular fibrillation. She was shocked three times and they were able to get a sinus rhythm. She was brought to the ER at FSH where she was admitted. The patient did not show signs of brain death but at this time did not show any significant supratentorial activity.
FSH|follicle-stimulating hormone|FSH|144|146|HISTORY|This lasted 5 to 6 days and she has had no vaginal bleeding since. The patient was seen in our office on _%#MMDD2003#%_. She had labs drawn. An FSH was normal at 6.9. Estradiol was normal at 312. She had an ultrasound done which was normal. There was a simple cyst measuring 2.6 cm in the left adnexa.
FSH|Fairview Southdale Hospital|FSH|153|155|PHYSICAL EXAMINATION|The patient's EKG initially showed ST elevation in his inferior leads with a history of a syncope as well as dyspnea. He was subsequently transferred to FSH for acute intervention. HOSPITAL COURSE: The patient underwent cardiac catheterization, coronary angiography.
FSH|follicle-stimulating hormone|FSH.|269|272|HISTORY|At her age the statistics for success for one cycle of in vitro was very poor and she and her partner have decided they would like to proceed with reversal which gives them unlimited cycles of trying. She understands that at age 40, she may be less fertile despite her FSH. She understands that even if her tubes are patent, she may not get pregnant because of her age. Increased genetic concerns at her age have also been discussed.
FSH|Fairview Southdale Hospital|FSH|131|133|HISTORY|They discovered a left tibia fracture. I was asked by Dr. _%#NAME#%_ _%#NAME#%_ to assume his care, the patient was transferred to FSH today. He has been in a splint since being in the ER last night. He is otherwise healthy. He is hypothyroid secondary to _%#NAME#%_'s thyroiditis.
FSH|Fairview Southdale Hospital|FSH|199|201|PRESENTATION|2. Recent transient ischemic attack. 3. Status post wing span stent placement left vertebral artery and basilar artery. PRESENTATION: _%#NAME#%_ _%#NAME#%_ is an 85-year-old male who was admitted to FSH in _%#MM#%_ with some TIA symptoms. He was found to have critical stenosis of his left vertebral and basilar arteries at that time.
FSH|Fairview Southdale Hospital|FSH|53|55||_%#NAME#%_ _%#NAME#%_ was admitted through the ER at FSH with severe left flank pain. A CT scan revealed a 10 mm calcified stone in the lower pole calix on the left and a 9 mm calculus impacted at the left UPJ.
FSH|follicle-stimulating hormone|FSH|160|162|HISTORY OF PRESENT ILLNESS|Ultrasound demonstrates a small 1.5 cm fibroid which is posterior and not opposed to the uterine lining. Because the patient did have some menopausal symptoms, FSH was performed and this was 2.8. Patient at the same visit had a Pap smear demonstrating ASCUS. The high-risk HPV is negative, therefore the patient was started on doxycycline 100 mg p.o. b.i.d. and will undergo a repeat Pap smear.
FSH|Fairview Southdale Hospital|FSH|203|205|ADMISSION HISTORY|Over the past months prior to her admission, she had had an exacerbation of her pain and an increase in her narcotic requirement. Therefore, her primary doctor, Dr. _%#NAME#%_ _%#NAME#%_ admitted her to FSH for pain management as well as management of her narcotic dependency. Upon admission, the pain management service was consulted and they began rounding on her and identifying pain management needs.
FSH|Fairview Southdale Hospital|FSH.|94|97|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ comes to the Children's Care Center from the Emergency Room at FSH. She is a patient of South Lake Pediatrics, Dr. _%#NAME#%_. She presents with a chief complaint of fevers and vomiting. She is status post day one T&A and PE tubes, which were placed at Children's West yesterday morning, _%#MMDD2007#%_ a.m. by Dr. _%#NAME#%_, ENT.
FSH|Fairview Southdale Hospital|FSH|135|137|HISTORY OF PRESENT ILLNESS|They did a CT scan and it showed an aneurysm of 5.3 cm. In _%#MM2005#%_ by ultrasound it was measured at 4.1 cm. He was transferred to FSH for possible need of vascular surgery for his abdominal aortic aneurysm. However, there was no rupture on the CT scan. At Fairview Ridges he also received FFP, vitamin K.
FSH|Fairview Southdale Hospital|FSH|254|256||Fundus examination was normal. Her intraocular pressure is 17. The risks and benefits of cataract surgery with intraocular lens implant were discussed and Mrs. _%#NAME#%_ wishes to proceed with the cataract surgery in the left eye. She is now brought to FSH for this procedure.
FSH|follicle-stimulating hormone|FSH|195|197|IMPRESSION|It showed an endometrial stripe of 4-4.6 mm. I explained to the patient that normal was less than 4 and we agreed that she should undergo D&C and hysteroscopy at this time. Also on that date her FSH level was 52.9. PAST MEDICAL HISTORY: (Illnesses) Elevated cholesterol.
FSH|follicle-stimulating hormone|FSH,|169|172|ASSESSMENT AND PLAN|5. Hypogonadism. Check testosterone level, FSH and LH. This most likely represents primary failure, although cannot rule out the possibility of secondary failure. Check FSH, LH, testosterone level.
FSH|follicle-stimulating hormone|FSH|314|316|HISTORY|She had a saline infusion sinography because of ultrasound that showed possible polyp and she did have an intrauterine cavity with what appears to be a 14 X 9 mm polyp and possibly another polyp that was 7 X 6. The patient was apprised of her situation and she also was attempting for a pregnancy. She had a day 3 FSH and estradiol performed and she had elevated FSH earlier this year. A second FSH and estradiol done were within normal limits.
FSH|follicle-stimulating hormone|FSH|246|248|PRIMARY PROCEDURE|She has had increasing symptoms. She was counseled about the surgery, risks and possible complications and understands the situation completely. She did have an operative report that I saw from 1998 which showed mild endometriosis. Her day three FSH and estradiol was also performed prior to surgery and the FSH was 6.5, the estradiol was 60. PAST MEDICAL HISTORY ILLNESSES - The patient denies history of high blood pressure, tuberculosis, heart disease, kidney disease, pulmonary disease, transfusions, hepatitis.
FSH|follicle-stimulating hormone|FSH|302|304|HISTORY OF PRESENT ILLNESS|In _%#MM2003#%_, the patient had an MRI of the pelvis and spine, which revealed disease metastatic to the right acetabulum, femur, and left posterior rib. She was going to continue radiation therapy per Radiation Oncology. An abdominal/pelvic/chest CT revealed no evidence of malignancy thereafter. An FSH performed in _%#MM2003#%_ was less than 0.3, consistent with functional ovaries. The patient met with Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2003#%_ at the Women's Health Center for consultation regarding oophorectomy for hormone control.
FSH|follicle-stimulating hormone|FSH|86|88|HISTORY OF THE PRESENT ILLNESS|She has had endometrial biopsy in _%#MM#%_ of 2002 that showed secretory endometrium. FSH and TSH were done approximately six months ago, they were normal. Since she has abnormal ultrasound and her symptoms persisted of menometrorrhagia, we are doing dilatation and curettage, diagnostic hysteroscopy, which has diagnostic and therapeutic purposes.
FSH|Fairview Southdale Hospital|FSH|168|170||The risks and benefits of cataract surgery with intraocular lens implant were discussed and Mrs. _%#NAME#%_ wishes to proceed with the left eye. She was now brought to FSH for this procedure.
FSH|Fairview Southdale Hospital|FSH.|166|169|PHYSICAL EXAM|REVIEW OF SYSTEMS: Denies all symptoms. Admits to being anxious. He wants to go home. PHYSICAL EXAM: In bed, cachectic complaining of chills, unkempt. Knows he is at FSH. Grew up in _%#CITY#%_. Last documented stool was _%#MMDD2004#%_. Skin is ecchymotic on his arms. CHEST: Decreased breath sounds. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Positive bowel sounds, soft, nontender.
FSH|Fairview Southdale Hospital|FSH|161|163||Cesarean section had been scheduled for _%#MMDD#%_ because of a vertex breech presentation. The patient ruptured membranes and developed labor. She presented at FSH in labor with ruptured membranes. The patient asked that we proceed now to the planned cesarean section. ALLERGIES: Erythromycin and Penicillin. MEDICATIONS: Prenatal vitamins. PHYSICAL EXAMINATION: Weight is 194.5, blood pressure 106/70.
FSH|Fairview Southdale Hospital|FSH|191|193||Mrs. _%#NAME#%_ is desirous of having the cataract removed in this left eye. The risks and benefits of cataract surgery with intraocular lens implant were discussed and she is now brought to FSH for this procedure.
FSH|follicle-stimulating hormone|FSH|229|231|HOSPITAL COURSE|She was placed on I.V. antibiotics and I.V. fluids. She had LAH, FSH, TSH done as she does have a history of a positive pregnancy test once but is status post total abdominal hysterectomy with bilateral oophorectomy. Her LAH and FSH were slightly up consistent more with an early postmenopausal state. Her UPT at this admission was negative. She continued to complain of significant back pain and anesthesiology consult to discussion of nerve block for the sympathetic block of the left foot was obtained.
FSH|Fairview Southdale Hospital|FSH|171|173|HISTORY OF PRESENT ILLNESS|Blood sugar was 225. EKG showed sinus tachycardia with a rate of 106 and blood pressure was 146/74. The patient was, therefore, diverted to the nearest hospital which was FSH as the patient's primary physician cares for patient's through Abbott-Northwestern Hospital. The family was contacted. The patient is DNR/DNI and is indicated on her limited treatment plan to receive no artificial nutrition including nasogastric feeding.
FSH|follicle-stimulating hormone|FSH|232|234|HISTORY OF THE PRESENT ILLNESS|Her periods occur every 26 days. She had ultrasound that showed the uterus is enlarged to 10 cm with two large myomas approximately 4 cm. in size and the hemoglobin was 9.2 grams. The iron indices showed iron deficiency anemia. Her FSH and LH and TSH was normal. She then, was started on iron therapy and she also indicated that she had urinary stress incontinence, she had urological evaluation by Dr. _%#NAME#%_, urologist who confirmed that through the cystometrogram that the patient's findings were consistent with stress urinary incontinence and his recommendation was to do urethropexy.
FSH|Fairview Southdale Hospital|FSH|139|141|HOSPITAL COURSE|HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 63-year-old male with multiple chronic comorbid medical problems. He was initially admitted to FSH on _%#MMDD2007#%_ with increasing weakness and near syncope. Past medical history was significant for end stage renal disease secondary to polycystic kidney disease with renal transplantation performed in the year 2000.
FSH|follicle-stimulating hormone|FSH|183|185|DISCHARGE MEDICATIONS|The patient smokes 15 cigarettes per day and I do not think we can alter this habit. She becomes a band candidate for control with oral contraceptives. Additional work-up was normal. FSH was normal. Prolactin normal. TSH, this was done this past fall. On exam again today, the patient is bleeding with marble sized clots.
FSH|follicle-stimulating hormone|FSH|195|197|HISTORY OF PRESENT ILLNESS|She was seen by my colleague Dr. _%#NAME#%_ in the clinic and had an endometrial biopsy done on _%#MM#%_ _%#DD#%_, 2002 that showed simple and focal complex hyperplasia, negative for atypia. Her FSH was normal and TSH was normal, and estrogen levels were normal. Because of extreme obesity the patient is at risk for endometrial neoplasia.
FSH|follicle-stimulating hormone|FSH|215|217|HISTORY OF PRESENT ILLNESS|In reviewing the records it appears she has had some irregular bleeding, and the pathology confirms the complex endometrial hyperplasia. The patient has had some degree of hot flashes and night sweats; however, the FSH is normal. She was placed on Climara patch by Dr. _%#NAME#%_ and this has been discontinued since the pathology report was obtained.
FSH|follicle-stimulating hormone|FSH|136|138|DOB|The patient had been seen back in our office in _%#MM#%_, when she was scheduled for LAVH, possible TAH-BSO for heavy bleeding. She had FSH that was 34. She had a D&C, hysteroscopy that had been performed back in _%#MM#%_, 2000, which had not resolved her bleeding.
FSH|follicle-stimulating hormone|FSH|240|242|HISTORY OF PRESENT ILLNESS|Both ovaries are normal. After the ultrasound was abnormal, the patient is scheduled to undergo D&C, diagnostic hysteroscopy under general anesthesia. Her menstrual history indicated that she has not had periods in _%#MM#%_ and her TSH and FSH were all normal. She had her preop exam by her internist. She understands the nature of the procedure, risks, benefits, complications associated with anesthesia and the surgical procedure.
FSH|Fairview Southdale Hospital|FSH|258|260||Mr. _%#NAME#%_ is desirous of having this cataract removed so that he can play golf as he has lost his depth perception with the present vision. The risks and benefits of cataract surgery with intraocular lens implant were discussed and he is now brought to FSH for this procedure.
FSH|follicle-stimulating hormone|F.S.H|214|218|PLAN|IMPRESSION: Complex endometrial hyperplasia without atypia. PLAN: The patient at age 50 does not plan on any further children and is ready to have a hysterectomy. Because she has amenorrhea due to her Novasure, an F.S.H was drawn today and when those results are known we will decide on whether she is started on estrogen postoperatively or not.
FSH|Fairview Southdale Hospital|FSH|170|172|HISTORY OF PRESENT ILLNESS|The patient fell today causing a large gash in the back of his head. He describes this as being due to vertigo when he got up. The patient was, therefore, brought to the FSH ER Dept. where a 9 cm complex scalp laceration was sewn up. The patient was given 500 cc of normal saline. They attempted to try to get him to stand up and he was unable to do this because of severe vertigo and light headedness.
FSH|Fairview Southdale Hospital|FSH.|186|189|EXTREMITIES|SKIN: Remarkable for multiple abrasions and ecchymosis from falls. NEUROLOGIC: Shows the patient to be alert and oriented to person and year. He occasionally asks repeatedly if he is at FSH. The patient has decreased short term memory with 1 out of 3 recall at 3 minutes. DTR's are 1+ in the upper extremities and knee area bilaterally.
FSH|follicle-stimulating hormone|FSH,|243|246|ASSESSMENT|She does however eat a fair amount of red meat so again, I think etiology of her iron-deficiency anemia needs to be aggressively evaluated, as far as her gut absorption. 3. Amenorrhea with possible microadenoma. Will evaluate further with LH, FSH, prolactin, thyroid studies, and proceed based on findings. 4. Chronic low-back pain on very large dose of MS-Contin. Patient is agreeable to begin taper of the dose because of complication of constipation she has, and will ask the Pain Service to help regarding other nonnarcotic modalities.
FSH|follicle-stimulating hormone|FSH|83|85|DOB|She is scheduled for D&C for perimenopausal bleeding. Recently, the patient had an FSH level which measured 103.3, confirming her menopausal status. The patient was scheduled for an endometrial biopsy in _%#MM#%_, which was performed, but which showed a nondiagnostic amount of tissue.
FSH|follicle-stimulating hormone|FSH|126|128|LABORATORY|LABORATORY: LDH of 617, beta hCG was less than 3. Her CA-125 was 21. Alpha-fetoprotein was 3.5, prolactin was 10, LH was 1.9, FSH was 3.5, and TSH was 2.9. The risks, benefits, and alternatives to proceeding with a diagnostic laparoscopy with left salpingo-oophorectomy or left ovarian cystectomy was discussed with the patient.
FSH|follicle-stimulating hormone|FSH|169|171|HOSPITAL COURSE|Hemoglobin is reduced at 9.9 but is stable. The patient reports that she has not had a period now for three years, although I see that she is on Provera. We did draw an FSH and this was 5.2 which is in the normal range, 2.5 to 10.2, so it seems to be unlikely that she is in menopause.
FSH|follicle-stimulating hormone|FSH|261|263|FOLLOW-UP|FOLLOW-UP: 1. The patient is to follow-up with her primary OB-GYN for her next Lupron visit in 1 month; this is with Dr. _%#NAME#%_. 2. The patient may also follow-up with Dr. _%#NAME#%_/_%#NAME#%_ in OB-GYN here at the University, at which point the patient's FSH and LH may or may not be checked to follow the efficacy of the patient's Lupron. But this will be discussed at a future visit.
FSH|follicle-stimulating hormone|FSH|221|223|HISTORY OF THE PRESENT ILLNESS|She is now in a new relationship. Her current partner has had vasectomy and is undergoing a reversal of vasectomy in one month. Her periods are irregular every 28-48 days. However, the flow in some periods is heavy. TSH, FSH were normal. Hemoglobin, GC, Chlamydia cultures were normal. Urinalysis, wet prep was negative and the hysterosalpingogram shows bilateral tubal patency with abnormal uterine cavity with the filling defect.
FSH|follicle-stimulating hormone|FSH|233|235|PATIENT IDENTIFICATION|Otherwise, she wished preservation of the ovaries. We also discussed a rectocele repair and suspension of the vaginal vault with a McCall's culdoplasty. The patient was evaluated. She was felt to be perimenopausal due to an elevated FSH level. She also had some intermittent, irregular bleeding. An endometrial biopsy was performed preoperatively and was normal. Patient was counseled regarding the above surgery. She understood and wished to proceed.
FSH|follicle-stimulating hormone|FSH.|132|135|PHYSICAL EXAMINATION|She is unable to conceive through him. The patient is somewhat interested in pregnancy, also, however, it is unlikely with elevated FSH. Besides that, she still has chronic pelvic pain. She wants to undergo above surgery for evaluation of endometriosis and pelvic pain.
FSH|follicle-stimulating hormone|FSH|166|168|LABS|PELVIC EXAMINATION: Is deferred. EXTREMITIES: Are with normal pulses distally. LABS: Hemoglobin was normal on _%#MMDD2004#%_ and was approximately 14 and the TSH and FSH were normal as well then. IMPRESSION: 1. Irregular vaginal bleeding with endometrial biopsy and laboratory evaluation normal to date.
FSH|Fairview Southdale Hospital|FSH|58|60||_%#NAME#%_ _%#NAME#%_ is a 43-year-old female admitted to FSH for the surgical treatment of her combined maxillomandibular growth dysplasia. Diagnoses include maxillary hyperplasia and mandibular retrognathism. She also has maxillary asymmetry.
FSH|follicle-stimulating hormone|FSH|146|148||She has had two D&Cs in the past for irregular bleeding, and endometrial biopsy was performed and was benign. Lab work was done and her CBC, TSH, FSH and prolactin were normal, but her hemoglobin returned at 9.5. The patient was given Provera for 10 days and the bleeding slowed down, but has continued on a daily basis.
FSH|Fairview Southdale Hospital|FSH|139|141|X-RAYS|SOCIAL HISTORY: Married. She does not smoke or drink. REVIEW OF SYSTEMS: Unremarkable. X-RAYS: MRI scan of the cervical spine performed at FSH was reviewed. She does have a widely central patent canal. There is also widely patent foramina. There is slight central disc bulge at C5-6 and to a large extent, C6-7 centrally.
FSH|Fairview Southdale Hospital|FSH,|233|236|ACTIVITY|6. Hypoglycemia - _%#NAME#%_'s serum glucose was as low as 21, and he required boluses of D10W, along with high dextrose infusion to maintain him in euglycemic state. 7. Infectious disease - a blood culture was initially obtained at FSH, and _%#NAME#%_ was started on Ampicillin and Gentamicin. His blood culture was negative at 1 day of age. Because of his multi-system organ failure with very poor neurologic prognosis, the parents elected to discontinue support on _%#MMDD2003#%_.
FSH|follicle-stimulating hormone|FSH|212|214|HISTORY|When I saw her in _%#MM#%_ she had heavy vaginal bleeding for the last couple of months and was spotting. In _%#MM#%_ I recommended she have an endometrial biopsy, an ECC, a Pap smear and a pelvic ultrasound. An FSH was elevated at 38.8, her estradiol was less than 10. A Pap smear was done which was normal. An ultrasound was done which was read as normal except for a thickened endometrial lining measuring 9 mm.
FSH|follicle-stimulating hormone|FSH|191|193|ASSESSMENT/PLAN|We will recheck her electrolytes in the morning. An EKG was performed and showed normal sinus rhythm. We will also check a TSH level. Apparently she is also amenorrheic, and we will check an FSH and LH level. The patient states her current goals are to increase her eating habits to regain her menses. She is at high risk for osteoporosis with an eating disorder.
FSH|follicle-stimulating hormone|FSH|157|159|PROBLEMS|As part of her workup, an amylase level was performed which was less than 30. This was checked to see if she had any evidence suggesting bulimia. Her LH and FSH levels were low. Her thyroid level was normal. After rehydration with IV fluids, her phosphorous level was slightly low. This could be replaced with eating. She will be followed for a refeeding syndrome during her psychiatric care.
FSH|Fairview Southdale Hospital|FSH|191|193||Mr. _%#NAME#%_ is desirous of having the cataract removed from this left eye. The risks and benefits of cataract surgery with intraocular lens implant were discussed and he is now brought to FSH for this procedure.
FSH|follicle-stimulating hormone|FSH|165|167|HISTORY|She also has occasional sharp pains on her right side but denies any significant dyspareunia. She has had a laboratory evaluation which does show an increased LH to FSH ratio and insulin resistance consistent with polycystic ovary syndrome. She has been placed on metformin. She now has increasing dysmenorrhea with more regular cycles and presents for evaluation of the pelvis for possible endometriosis.
FSH|Fairview Southdale Hospital|FSH|145|147|HISTORY|HISTORY: The patient is a 74-year-old Russian speaking only overweight white female with a history of multiple medical problems. She presents to FSH because of increased symptoms of chest pressure like sensation with some shortness of breath, mild nausea but no diaphoresis, dizziness, palpitations or syncope.
FSH|follicle-stimulating hormone|FSH|207|209|RELEVANT LABS ON ADMISSION|Of note, when she was seen in _%#MM#%_, her hemoglobin was between 8 and 9. Her chem panel revealed a sodium of 145, potassium 4.6, creatinine 1.49. Her TSH was 0.12, but her free T4 was normal at 1.02. Her FSH was 50.5. Results of her lumbar spine revealed significant scoliosis and osteoporosis with no definite lumbar compression fracture. She also received a head CT which was unremarkable for any acute bleed.
FSH|follicle-stimulating hormone|FSH|140|142|LABORATORY DATA|SOCIAL HISTORY: The patient is married. PHYSICAL EXAMINATION: Not done in the office. LABORATORY DATA: Hemoglobin 11.2, potassium 3.8. TSH, FSH and LH were normal. Pelvic ultrasound on _%#MMDD2007#%_ reveals an anteverted uterus measuring 9.1 x 5.8 x 4.7 cm with an 18.2 mm endometrial stripe.
FSH|Fairview Southdale Hospital|FSH|237|239|BRIEF HISTORY|7. Systemic inflammatory response. PRINCIPAL SURGICAL PROCEDURE: Attempted laparoscopic appendectomy converted to exploratory laparotomy with appendectomy. BRIEF HISTORY: _%#NAME#%_ _%#NAME#%_ is a 60-year-old gentleman who presented to FSH with a chief complaint of abdominal pain who underwent thorough and appropriate evaluation and was found to have signs and symptoms consistent with acute appendicitis.
FSH|follicle-stimulating hormone|FSH|153|155|HISTORY OF PRESENT ILLNESS|She was found to have a significant sized pituitary tumor. She subsequently had hormone evaluation which showed a normal TSH, adrenal studies as well as FSH consistent with the menopausal change. She has been seen in consultation by Dr. _%#NAME#%_ _%#NAME#%_.
FSH|follicle-stimulating hormone|FSH|257|259|HISTORY OF PRESENT ILLNESS|Also she is having irregular bleeding. She has had ultrasounds in the past that have confirmed the uterus 18.3 cm endometrial stripe 12.4 and large multiple uterine myomata present as large as 8 cm. Her hemoglobins have been in the range of 13.7, and 12.4. FSH is 27.5, TSH is normal, urinalysis is negative. The patient is undergoing total versus subtotal hysterectomy. The risks, benefits, complications of leaving or removing the cervix is notified to the patient and she is aware of that.
FSH|follicle-stimulating hormone|FSH|159|161|CONSULTS/OPERATIONS/PROCEDURES|Endocrine recommended checking an LH, FSH, prolactin, growth hormone, insulin growth factor 1, estradiol, and an anti-TPO antibody. The LH came back at 7. The FSH came back increased at 12.5. The prolactin was normal at 12. The growth hormone was 0.1. IGF-1 was very low at less than 5.
FSH|follicle-stimulating hormone|FSH|178|180|HISTORY OF PRESENT ILLNESS|Skin tags on the hymenal remnant that she'd like to have removed. HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old white female Para 3-0-0-3, LMP of _%#MM2004#%_ with an FSH on _%#MMDD2005#%_ elevated in the post menopausal range who had presented for evaluation of urinary incontinence and pelvic floor relaxation.
FSH|Fairview Southdale Hospital|FSH|193|195|HOSPITAL COURSE|She was evaluated by her primary care and she underwent a CT scan at _%#CITY#%_ Hospital. Upon evaluation in my clinic, the patient was acutely short of breath and so she was sent to the ER at FSH for further evaluation and rule out pulmonary embolism. She had a complete ER work up and there was no evidence of pulmonary embolism or evidence of DVT.
FSH|follicle-stimulating hormone|FSH|320|322|HISTORY|Her hemoglobin was 11.0 on _%#MMDD2006#%_. An FSH level was drawn on the first postoperative day with a value of 16.0. The patient was informed that since the right ovary could not be identified that her FSH level will be followed to see if she were to undergo menopause. The patient was informed to return for a repeat FSH level at her postoperative visit in four weeks. The patient was discharged home on _%#MMDD2006#%_, on her third postoperative day, in stable condition.
FSH|follicle-stimulating hormone|FSH|183|185||The uterus was under 5 cm in length. She has had no pain with intercourse, no urinary stress incontinence. At that time and endometrial biopsy was scheduled. She also had a day three FSH and estradiol which is pending. Endometrial biopsy was performed using a pipelle instrument, and the uterus sounded to approximately 7 cm.
FSH|Fairview Southdale Hospital|FSH.|235|238|HOSPITAL COURSE|3. Hypertension. 4. History of depression. HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ is a 49-year-old Caucasian male who has diabetes mellitus and hypertension. He presented with right great toe infection for which he was admitted at FSH. The patient had a scab on the right great toe which got infected and has not healed since _%#MM#%_ 2006. The patient has had numerous antibiotics and treatment. Finally the patient had amputation of the right great toe on _%#MMDD2006#%_ secondary to osteomyelitis.
FSH|follicle-stimulating hormone|FSH|232|234||She originally saw me in _%#MM#%_ complaining of menstrual periods which were occurring every 3 1/2 weeks and lasting seven days. She would change a Tampax and a pad every two hours. Her uterus at that time was 12-13 weeks size. An FSH value at that time was 1.5. On follow-up exam in _%#MM#%_ of 2004, the patient's hemoglobin was down to 8.5 and endometrial biopsy revealed lytic disordered proliferative endometrium.
FSH|follicle-stimulating hormone|FSH,|156|159|PLAN|Endocrine was consulted to evaluate possible endocrine disorders as a cause of hypoglycemia. The following labs were done and were within the normal range; FSH, LH, estradiol, IGF-1, and cortisol stimulation test. A TSH level was found to be elevated at 14.9; free T4 was normal at 1.17 and consistent with congenital hypothyroidism.
FSH|Fairview Southdale Hospital|FSH|150|152||Fundus examination is normal and her intraocular pressure was 20. The risks and benefits of cataract surgery were reviewed and this is now brought to FSH for this procedure.
FSH|Fairview Southdale Hospital|FSH|106|108|HISTORY OF PRESENT ILLNESS|She said she had a tingling sensation and a heaviness in her left arm as well. She presented to the ER at FSH where her symptoms were dramatically improved by sublingual nitroglycerin. They placed a nitroglycerin patch on her without any benefit and then started her on a Nitro drip with complete resolution of her symptoms.
FSH|follicle-stimulating hormone|FSH|149|151|HISTORY OF PRESENT ILLNESS|Because of the echogenic area she had a CA-125 sent which returned as 6. In addition, she had an FSH and estradiol sent. Her estradiol was 9 and her FSH was 69.1 consistent with menopause. She had a Pap smear from _%#MM#%_ of 2005 which was normal. She presented for her initial preoperative examination on _%#MMDD2005#%_ and during her history she described an incident of prolonged chest pain after physical activity.
FSH|Fairview Southdale Hospital|FSH|38|40||_%#NAME#%_ _%#NAME#%_ was admitted to FSH Special Care Nursery on _%#MMDD2006#%_. She was born at 32 3/7 weeks to a 26-year-old, gravida 3 para 0-0-2-0, female.
FSH|Fairview Southdale Hospital|FSH|213|215|HISTORY OF PRESENT ILLNESS|PREOPERATIVE DIAGNOSIS: Right hip femoral neck fracture. DISCHARGE DIAGNOSIS: Status post right hip hemiarthroplasty. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 81-year-old female who was admitted to FSH on _%#MMDD2007#%_. She was noted to have a right hip femoral neck fracture. She was seen preoperatively by medicine. She was noted to have a pneumonia.
FSH|follicle-stimulating hormone|FSH,|219|222|HISTORY OF PRESENT ILLNESS|The left ovary was enlarged to 5.2 cm and there was a 4 cm cyst in her left ovary. The right ovary was 3.3 with 2 cm simple cysts. Endometrial biopsy shows proliferative endometrium with no evidence of hyperplasia. Her FSH, LH was normal. TSH is normal. She has a past history of Graves disease and was treated with radioactive iodine, and she became hypothyroid.
FSH|follicle-stimulating hormone|FSH|121|123|HISTORY OF PRESENT ILLNESS|On the ultrasound, they were not able to visualize the ovaries. The endometrial stripe was 13 mm. Her TSH was normal and FSH was normal. After iron therapy, the hemoglobin was 11.2 and preoperatively hemoglobin is 12.2 and potassium is normal. The patient was given full information on her surgical procedure.
FSH|Fairview Southdale Hospital|FSH|138|140|NEPHROLOGY/ADMISSION NOTE|He was dialyzed for approximately 60 minutes, but because of persistent symptoms and a temp measured over 103(, he was transported to the FSH emergency room. Temp initially there was 103.9( with some further higher readings at 104.7(. He has had no chilling, nausea or vomiting.
FSH|follicle-stimulating hormone|FSH|303|305|HISTORY OF THE PRESENT ILLNESS|The patient has a personal history of leukemia, 18 years ago diagnoses as acute myelocytic leukemia and she had chemotherapy followed by total body radiation and this occurred in _%#MM#%_ of 1987. The patient took hormone replacement therapy for 18 years which she discontinued in _%#MM#%_ of 2005. Her FSH is markedly elevated to 105 and this is the first episode of her bleeding. Because of abnormal ultrasound and postmenopausal bleeding, she is undergoing dilatation and curettage and diagnostic hysteroscopy.
FSH|follicle-stimulating hormone|FSH|212|214|HOSPITAL COURSE|She did well throughout the hospitalization and was examined by endocrine who performed a number of tests and determined that she had panhypopituitarism. Of note, her cortisone level was less than 0.5, TSH 0.06, FSH less than 0.3, and prolactin 10. A free thyroxine 0.85 and a hemoglobin A1c of 5.4. The imaging was reviewed with neurosurgery who did not feel that the patient would benefit from gamma knife radiation or nonsurgical treatment options.
FSH|Fairview Southdale Hospital|FSH.|261|264|HISTORY OF PRESENT ILLNESS|Chest pain resolved spontaneously after 5.5 hours. The patient denied any shortness of breath, diaphoresis, palpitations, nausea, vomiting, or light headedness. Because of persistent pain, the patient called the EMS and the patient was transported to the ER at FSH. On arrival, the patient's blood pressure was elevated about 177/86. Pulse 54. Respirations 18. Pulse ox 98%, afebrile. On arrival the patient was chest pain free and her symptoms resolved.
FSH|follicle-stimulating hormone|FSH|143|145|HISTORY|She has been troubled with irregular uterine bleeding. After having no bleeding at all for about 2 years ago, on _%#MMDD2005#%_, had bleeding. FSH obtained at that time was compatible with postmenopausal state. An endometrial biopsy was negative. Over the past year, she has had light bleeding about every other month.
FSH|follicle-stimulating hormone|FSH|161|163|HISTORY OF THE PRESENT ILLNESS|She continues to be in remission, but she had an episode of postmenopausal bleeding in _%#MM#%_ of 2006. Endometrial biopsy was normal on _%#MMDD2006#%_ and her FSH was 26. Ultrasound on _%#MMDD2006#%_ showed a 6.4 mm. endometrial lining and the left ovary had a 1.5 cm. area of unclear significance. Her CA125 was 7 in _%#MM#%_ of 2006 and Pap smear was normal.
FSH|follicle-stimulating hormone|FSH|150|152|PLAN|All questions were answered and informed, written consent will be obtained on the day of surgery. The patient is probably perimenopausal based on her FSH and she does have occasional hot flashes but she understands that she would not be a candidate for estrogen replacement therapy after the ovaries are removed due to her history of breast cancer.
FSH|follicle-stimulating hormone|FSH|197|199|HISTORY OF PRESENT ILLNESS|The differential diagnosis is endometrioma hemorrhagic cyst versus solid lesion. The right ovary was obscured by the gas shadow and was not visualized. She had a pregnancy test which was negative, FSH was 6.6 (normal), TSH was normal and CBC was normal. Urinalysis was negative, and GC/chlamydia culture was negative. Her symptoms and the pelvic ultrasound raises the suspicion of endometriosis.
FSH|Fairview Southdale Hospital|FSH|228|230|HISTORY OF PRESENT ILLNESS|He came with direct clinic admit from Dr. _%#NAME#%_ _%#NAME#%_ of Fairview EdenCenter Clinic. Care has been delegated to Pediatric Nurse Practitioners/Dr. _%#NAME#%_. HISTORY OF PRESENT ILLNESS: The patient was discharged from FSH Children's Care Center on _%#MMDD2006#%_ with bili level of 12.9; 0.0. Had been under phototherapy since about noon on _%#MMDD2006#%_.
FSH|Fairview Southdale Hospital|FSH|250|252||She was admitted to Fairview Ridges Hospital with a 6-7 month history of chest pressure and discomfort that had been getting worse over the past 6 months. She had exertional chest pressure that does radiate down her arms. She was then transferred to FSH where she proceeded for an angiogram which showed multi-vessel disease. Dr. _%#NAME#%_ _%#NAME#%_ was then consulted for a coronary angiogram showing severe disease in his proximal LAD and distal left main, diffuse disease to her circumflex coronary artery, right coronary artery showed a 65-70% mid to proximal lesion with some mild disease distally.
FSH|Fairview Southdale Hospital|FSH|230|232|HOSPITAL COURSE|FINAL DIAGNOSIS: Severe pre-eclampsia, status post low transverse cesarean section with delivery of viable 4 pound 7 ounce male, Apgars of 8 and 9. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 38-year-old G1 P0 who was admitted to FSH on _%#MMDD2006#%_ at 32 weeks gestation with severe pre-eclampsia. She had had significant weight gain within the previous week and had developed blood pressures in the 130's to 140's/90's to 100's.
FSH|Fairview Southdale Hospital|FSH|149|151|HOSPITAL COURSE|It was recommended that the patient undergo a staged procedure to try to intervene upon his circumflex lesion. The patient was hospitalized there at FSH on _%#MMDD2006#%_ in which he was noted to have congestive heart failure and was discharged home after diuresis. The patient did have his coronary angiogram performed on _%#MM#%_.
FSH|Fairview Southdale Hospital|FSH|185|187|DISCHARGE DIAGNOSIS|He had the acute onset of left sided head and neck discomfort two weeks ago and then on the day of admission noted numbness and clumsiness of the left side of his body. He presented to FSH ER where he was evaluated by Dr. _%#NAME#%_ _%#NAME#%_ and admitted by my associate, Dr. _%#NAME#%_ _%#NAME#%_. MRI scanning in the ER showed some inflammatory abnormality in the left medulla consistent with a demyelinating lesion.
FSH|follicle-stimulating hormone|FSH,|149|152|HISTORY OF PRESENT ILLNESS|The patient understands that during the course of surgery if any significant pathology found on a ovary,she prefers to be taken care of it. Her TSH, FSH, LH were in normal range. PAST SURGICAL HISTORY: 1. Appendectomy. 2. Benign breast biopsy. PAST MEDICAL HISTORY: 1. Depression.
FSH|follicle-stimulating hormone|FSH|161|163|PHYSICAL EXAMINATION|Rectovaginal exam confirmed the above. There were no other masses that could be felt and there was slight tenderness in the pelvis. The patient did have a day 3 FSH and Estradiol which were normal. EXTREMITIES: Within normal limits IMPRESSION: Severe endometriosis with involvement of the rectum and rectovaginal septum and both ovaries.
FSH|follicle-stimulating hormone|FSH|134|136|PLAN|The patient has had one pregnancy since then with a blighted ovum. She has been on Fertinex and Lupron with poor ovarian reserve. Her FSH were in the 10-14 range and estradiols were in the 40 range on day 3. Because of her history of endometriosis and poor ovarian reserve, and the fact that her symptoms were always mild including when I first examined her, she will be re-evaluated with laparoscopy to make certain her endometriosis did not return.
FSH|follicle-stimulating hormone|FSH|262|264|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 52-year-old white female, gravida 3, para 2-0-1-2, who has ongoing, persistent irregular bleeding on hormone replacement therapy. She was diagnosed perimenopausal approximately one year ago and had elevated FSH associated with hot flashes. She was started on hormone replacement therapy and endometrial biopsy was performed due to irregular bleeding in _%#MM#%_, 2001, which showed disordered, proliferative endometrium.
FSH|follicle-stimulating hormone|FSH,|140|143|PLAN|Diagnostic studies included a hemoglobin of 14. The white count was 13,000. The metabolic panel was otherwise unremarkable. She did have an FSH, which was 4, and that is normal. Urine culture was negative. Chest x-ray was negative, as well. The patient was treated with high-dose Decadron, occupational therapy, physical therapy, our counseling education and speech programs.
FSH|follicle-stimulating hormone|FSH|150|152|HOSPITAL COURSE|She was started on prophylactic Unasyn at that time. Blood cultures were obtained and they were all negative. She was discharged home on Levaquin. An FSH was ordered and it noted a level of 5.2, which does indicate an element of active ovarian tissue. The patient's hemoglobin was stable throughout her hospital stay. Her creatinine did improve after the placement of her right stent.
FSH|Fairview Southdale Hospital|FSH|192|194||The risks and benefits of cataract surgery with intraocular lens implant were reviewed and she understands the guarded result for vision. Her intraocular pressure is 15. She is now brought to FSH for this procedure.
FSH|Fairview Southdale Hospital|FSH|128|130||The risks and benefits of cataract surgery were discussed with Mrs. _%#NAME#%_ and she wishes to proceed. She is now brought to FSH for this procedure.
FSH|follicle-stimulating hormone|FSH|172|174|PROCEDURES DURING HOSPITALIZATION|The long-term use of the benzodiazepine should be evaluated by the outside physician. 3. Endocrinology. Due to the symptoms of hot flashes and increased anxiety, a TSH and FSH were obtained during her hospitalization. These were both found to be within normal limits with a TSH of 2.41 and FSH of 3.5.
FSH|follicle-stimulating hormone|FSH|204|206|PROCEDURES DURING HOSPITALIZATION|3. Endocrinology. Due to the symptoms of hot flashes and increased anxiety, a TSH and FSH were obtained during her hospitalization. These were both found to be within normal limits with a TSH of 2.41 and FSH of 3.5. 4. History of recurrent pneumonia. Chest x-ray was previously done on _%#MM#%_ _%#DD#%_, 2002, which showed interval clearing in the right mid lung.
FSH|follicle-stimulating hormone|FSH|165|167|HISTORY OF PRESENT ILLNESS|Furthermore, the patient had a pelvic ultrasound and sonohysterogram, which also returned normal. Finally patient had some labs done that same day. She had a normal FSH of 2.5, normal prolactin level and a normal TSH. I reviewed with patient the above situation and treatment options.
FSH|follicle-stimulating hormone|FSH|226|228|LABORATORY DATA|No edema or synovitis. NEUROLOGIC: Symmetric cranial nerves, strength, and reflexes with downgoing toes bilaterally. LABORATORY DATA: CBC shows a hemoglobin of 12.2, white count 6100, platelets 290,000. Urine hCG is negative. FSH is drawn but pending at the time of dictation. ASSESSMENT: Menorrhagia. PLAN: The patient otherwise is in good general health and I see no contraindication to the planned surgery or anesthesia.
FSH|follicle-stimulating hormone|FSH|145|147|PLAN|There was a 1.7 cm complex cyst in the left ovary. The anemia profile on _%#MMDD2002#%_ showed her to be iron deficient. Platelets were 434,000. FSH was 7.3. She states that last year she had some mild left lower quadrant discomfort, but has had none since then.
FSH|Fairview Southdale Hospital|FSH.|286|289|PAST MEDICAL HISTORY|REASON FOR HOSPITALIZATION: Dehydration and lethargy. PAST MEDICAL HISTORY: See the admission history and physical. Note that the past medical history list is somewhat inconclusive as the patient has not been able to provide a history and there is no old charts of significance here at FSH. HISTORY OF PRESENT ILLNESS: See the admission H&P. Briefly, _%#NAME#%_ _%#NAME#%_ is an 88-year-old woman admitted with dehydration and lethargy and pain.
FSH|Fairview Southdale Hospital|FSH|161|163|MEDICATIONS|Yesterday while playing tennis, apparently the patient became somewhat confused and had obvious findings of memory disturbance. He was brought to the ER here at FSH from the tennis club where ER physician documented ongoing memory loss for immediate events although this was rapidly clearing.
FSH|follicle-stimulating hormone|FSH|228|230|HISTORY|DOB: _%#MMDD1954#%_ CHIEF COMPLAINT: Postmenopausal vaginal bleeding. HISTORY: The patient is a 48-year-old female, para 4-0-3-4, menopausal for approximately one year. The patient's last menses was in _%#MM#%_ 2002. She had an FSH of 59.4 at that time and an estradiol of 29. She had no vaginal bleeding until _%#MMDD2003#%_. At that time she had what appeared to be a normal menses.
FSH|follicle-stimulating hormone|FSH|203|205|FAMILY HISTORY|FAMILY HISTORY: The patient's mother has high cholesterol, skin cancer, and osteoporosis. The patient's father had a heart attack. She has seven sisters, two who have thyroid disease. The patient's last FSH was within normal limits in _%#MM#%_. SOCIAL HISTORY: The patient works up north. Exercises four to five times a week.
FSH|follicle-stimulating hormone|FSH|205|207|LABORATORY EVALUATION|ABDOMEN: Soft; non-tender; non- distended; no masses are appreciated. No rebound or guarding. EXTREMITIES: Non-tender bilaterally. PELVIC: Deferred at today's visit. LABORATORY EVALUATION: The patient had FSH levels checked in _%#MM#%_ which was elevated at 49 and again in _%#MM#%_ which was 24. She is perimenopausal. Last ultrasound performed _%#MMDD#%_ demonstrated a multi-cystic mass in the pelvis with greatest dimension measuring 6 cm., mass appears to be both ovaries with a cyst, as well as a 3 cm hydrosalpinx.
FSH|follicle-stimulating hormone|FSH|161|163|HISTORY OF PRESENT ILLNESS|An ultrasound showed a uterus of 9 x 6 x 5 cm with an endometrial stripe of 2.8 cm. Her left ovary was 7 x 5 cm with two simple cysts measuring 3.2 x 3.2 cm. An FSH drawn at the time was 1.9, TSH was 1.71, and a prolactin was 6. Endometrial biopsy at this time showed a complex hyperplasia without atypia.
FSH|Fairview Southdale Hospital|FSH|188|190||Mrs. _%#NAME#%_ is desirous of having her cataract removed to improve her vision. The risks and benefits of cataract surgery with intraocular lens were discussed and she is now brought to FSH for this procedure.
FSH|follicle-stimulating hormone|FSH,|250|253|HISTORY OF THE PRESENT ILLNESS|She is somewhat frustrated and she gives me history of stress incontinence surgery, possible Burch procedure or Marshall-Marchetti in 1990 for stress incontinence. She is fairly continent at this time. Her laboratory work-up shows normal TSH, normal FSH, liver profile normal, CBC normal. Hemoglobin 14 grams. The ultrasound shows uterine size 8.6 cm with two myomas, one 15 mm anterior myometrium and 15 mm posterior myometrium and one of the myomas possible submucosal.
FSH|Fairview Southdale Hospital|FSH|165|167|HOSPITAL COURSE|She also had a weak "sick" feeling which was reminiscent of her angina symptoms prior to her previous angioplasties and stents. The patient, therefore, presented to FSH ER. In route to the hospital, nitroglycerin and oxygen were administered with temporary benefit. In the ER, the patient's first troponin level was normal but myoglobin was elevated and the second troponin level was high.
FSH|Fairview Southdale Hospital|FSH|237|239||Following exercise he had a large area of inducible wall motion abnormality involving the mid and distal anterior, anterior septal, and septal and apical walls. The distal lateral wall appeared to be involved as well. He was referred to FSH for a cardiac catheterization. This was completed on _%#MMDD2003#%_ with the following results: 1. Left main coronary has no significant disease. It bifurcates into the left anterior descending artery.
FSH|Fairview Southdale Hospital|FSH|279|281||Fundus examination is normal with no evidence of diabetic retinopathy and her intraocular pressure is 18. Mrs. _%#NAME#%_ is desirous of having her cataract removed. The risks and benefits of cataract surgery with intraocular lens implant were reviewed and she is now brought to FSH for this procedure.
FSH|Fairview Southdale Hospital|FSH|145|147|HISTORY OF PRESENT ILLNESS|He crumbled to the floor without loss of consciousness, and he could not get off the floor. Family members called 911, and he was transported to FSH ER where he was found to be quite short of breath. Several treatments caused improvement, but he was obviously too ill to send home.
FSH|Fairview Southdale Hospital|FSH|228|230|PLAN|PLAN: Discharge to Mount Olivet Nursing Home. Sodium level is to be checked also at the nursing home. She will have fluid restriction, 1,500 cc po qd and also receive psychiatric evaluation in the nursing home at the request of FSH psychiatry. DISCHARGE MEDICATIONS: 1. Norvasc 5 mg po qd. 2. Aspirin enteric coated 81 mg po qd.
FSH|follicle-stimulating hormone|FSH|220|222|HISTORY|Ms. _%#NAME#%_'s electrolytes were otherwise normal with potassium of 4.7, her creatinine 0.9, blood sugar 89, bicarb 25. Calcium was 9.7. Liver tests were normal except for a mildly elevated AST of 36 and an ALT of 50. FSH was also mildly elevated at 11.6. Sed rate mildly elevated at 33 with an upper limit of normal of 25. Dr. _%#NAME#%_ was not sure about the etiology for fatigue and had recommended an endocrine evaluation.
FSH|Fairview Southdale Hospital|FSH|130|132|HISTORY|DOB: _%#MMDD1970#%_ CHIEF COMPLAINT: Low back pain. HISTORY: Mr. _%#NAME#%_ _%#NAME#%_ is a 34-year-old gentleman admitted to the FSH ER last evening with acute low back pain. He has suffered from back pain for the last ten years. He thinks it began when he was working at extruding metal plant and injured his back.
FSH|Fairview Southdale Hospital|FSH|189|191||The risks and benefits of cataract surgery with intraocular lens implant along with the guarded and limited result were discussed and Mr. _%#NAME#%_ wishes to proceed. He is now brought to FSH for this procedure.
FSH|follicle-stimulating hormone|FSH|230|232|REVIEW OF SYSTEMS|She has otherwise been basically healthy. REVIEW OF SYSTEMS: GENERAL: The patient has hot flashes that started just after she finished her radiation, which she completed in _%#MM#%_. In _%#MM#%_ her estradiol level was 90 and her FSH was 8.1 which is premenopausal status. EYES: Negative, no blurred or double vision EARS: Negative. NOSE: Negative. THROAT: Negative. No sore throat or hoarseness. CARDIOVASCULAR: Negative for cardiac pain or irregular heartbeat.
FSH|follicle-stimulating hormone|FSH|183|185|REVIEW OF SYSTEMS|Cardiac is negative for any angina, orthopnea or PND. GI no diarrhea and no nausea or vomiting. GU as noted above. He has had erectile dysfunction. He has had normal testosterone, LH FSH and prolactin. FAMILY HISTORY: Positive for diabetes but otherwise negative. The patient works as a mechanic at a local car dealer.
FSH|follicle-stimulating hormone|FSH|153|155|HISTORY OF PRESENT ILLNESS|Ultrasound on _%#MMDD2004#%_ showed a 6.3 by 6.4 by 5.5 cm left cystic lesion with a possible septation of the left ovary. Her CA125 was less than 5 and FSH was 49 in _%#MM#%_ of 2004. She developed migraine headaches on the birth control pills and was given a Depo Lupron shot in _%#MM#%_ of 2004.
FSH|follicle-stimulating hormone|FSH|120|122|HISTORY OF PRESENT ILLNESS|The patient was also having some menopausal symptoms, some hot flashes. The patient at that time was instructed that an FSH and Estradiol as well as thyroid test would be checked. She then underwent an endometrial biopsy showing simple hyperplasia. She also had an ultrasound and a sonohystogram which showed a small fibroid which did not appear to be impinging on the uterine cavity.
FSH|follicle-stimulating hormone|FSH|245|247|HISTORY OF PRESENT ILLNESS|Endometrial stripe is markedly thickened to 19 mm, and there is an area of decreased echogenicity within the endometrium measuring 8 mm X 4 mm, possibly suggestive of uterine polyp. Hyperplasia cannot be ruled out. Ovaries were normal. Her TSH, FSH and hemoglobin were normal. The patient had the option of doing endometrial biopsy and further management, or do a D&C, hysteroscopy.
FSH|follicle-stimulating hormone|FSH,|130|133|FOLLOWUP|Endocrine was consulted, and it was decided she would obtain a 2-hour glucose tolerance test as well as PCOS lab workup including FSH, LH, DHEA, free and total testosterone. These studies will be performed on _%#MM#%_ _%#DD#%_, 2005, when the patient presents to the Masonic Day Hospital.
FSH|follicle-stimulating hormone|FSH|207|209|DISPOSITION|_%#NAME#%_ _%#NAME#%_ is a 46-year-old, para 2-0-0-2 with LMP _%#MM#%_ 2004 who is admitted at this time for D&C, hysteroscopy, and laparoscopic tubal ligation. She has had no menses since _%#MM#%_ 2004. An FSH at that time was 30 and FSH in _%#MM#%_ 2005 is 41. She did have some spotting on _%#MMDD2005#%_. She understands that the tubal ligation may not be necessary but she is concerned about even the remote possibility of pregnancy, as she feels this would be disastrous for her and her new partner.
FSH|follicle-stimulating hormone|FSH|163|165|HISTORY OF THE PRESENT ILLNESS|This has resulted in low hemoglobins and she has been constantly on iron therapy and her hemoglobin was low and after being on iron therapy, 11.4 to over 12. TSH, FSH is normal. Her other symptom is that she has marked pelvic pressure and pelvic pain. During menses, she gets dysmenorrhea and also discomfort off and on due to the pressure from fibroids.
FSH|follicle-stimulating hormone|FSH|113|115|HISTORY|There were three cysts, one of which was complex, measuring 8 x 6 x 6 mm. A CA-125 at that time was 12.7, and an FSH was 5.2. The decision was made to proceed with bilateral salpingo-oophorectomy by pelviscopy if possible. However, we wanted to check the progress of this one more time, and on _%#MMDD2005#%_ she had a repeat ultrasound which on the right was essentially stable, and the left ovary was slightly enlarged, measuring 4.8 x 4.6 x 2.5 cm.
FSH|follicle-stimulating hormone|FSH|214|216|HOSPITAL COURSE|However, she was not placed on seizure medications at this point, as this may be just a nonspecific finding. Another possibility for these symptoms could be menopausal symptoms, and would recommend that she get an FSH testing from primary care to see if she is truly going through menopause, and if so, could consider hormone replacement therapy.
FSH|Fairview Southdale Hospital|FSH|49|51|NOTATION|NOTATION: The baby was actually transferred from FSH Children's Care Center to _%#CITY#%_ Children's Medical Center. PRINCIPAL DIAGNOSIS: RSV bronchiolitis, sepsis, respiratory failure.
FSH|Fairview Southdale Hospital|FSH|192|194|HOSPITAL COURSE|PROCEDURE: Oxygen therapy, oxygen saturation and cardiorespiratory monitors, IV fluids and IV antibiotics. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a two month old infant who was admitted to FSH Children's Care Center with RSV bronchiolitis. She was seen in the ER Department here and noted to have mild respiratory distress and fever.
FSH|Fairview Southdale Hospital|FSH|199|201|HOSPITAL COURSE|FINAL DIAGNOSIS: Term pregnancy, low transverse cesarean section, delivery of viable 7 pound 2 ounce male. REASON FOR ADMISSION: Labor at term. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was admitted to FSH on _%#MMDD2005#%_ with irregular contractions. She had been contracting over the holiday weekend. She is status post conization times two and has been note to have some scar tissue in her cervix.
FSH|Fairview Southdale Hospital|FSH|193|195|HISTORY|ADMITTING DIAGNOSIS: Acute low back pain. DISCHARGE DIAGNOSIS: Acute low back pain, secondary to disk herniation. HISTORY: Ms. _%#NAME#%_ _%#NAME#%_ is a 55-year-old woman admitted through the FSH Emergency Room _%#MMDD2006#%_ with progressive low back and right buttock symptoms over 24 hours prior to admission. Denies any specific injury. Despite IV morphine and Toradol, she could not ambulate and therefore she was admitted for pain control and evaluation.
FSH|Fairview Southdale Hospital|FSH|133|135|DISCHARGE MEDICATIONS|4. Fluconazole 100 mg p.o. daily times ten days. 5. Folate 1 mg p.o. daily. 6. NPH insulin 6 units subq q a.m., 4 units subq q.h.s., FSH insulin sliding scale. 7. Isordil 60 mg p.o. t.i.d. 8. Norvasc 5 mg p.o. daily. 9. Toprol XL 50 mg p.o. daily. 10. Nystatin swish and swallow 10 cc p.o. q.i.d. times ten days.
FSH|Fairview Southdale Hospital|FSH.|143|146|HISTORY OF PRESENT ILLNESS|He has no prior cardiovascular history. He denies any shortness of breath. He has had no nausea or vomiting. He subsequently came to the ER at FSH. An EKG was done showing acute inferior myocardial infarction with 8 mm of ST segment elevation inferiorly and reciprocal anterior ST segment depression.
FSH|follicle-stimulating hormone|FSH|183|185|IMPRESSION|IMPRESSION: Vaginal bleeding, pelvic pain and dyspareunia, probable adhesion and attachment of ovaries to the top of the vaginal cuff, with pain secondary to retained ovary syndrome. FSH and estradiol were in the normal range. PLAN: Admit the patient for diagnostic laparoscopy, possible bilateral salpingo-oophorectomy and repair of vaginal cuff, possible laparotomy.
FSH|Fairview Southdale Hospital|FSH|192|194|HISTORY OF PRESENT ILLNESS|This patient has a recent history of a cardioversion which was conducted by Dr. _%#NAME#%_ _%#NAME#%_ _%#MMDD2006#%_. The patient called to his friends asking for help and he was delivered to FSH ER. At the FSH ER, EKG showed some questionable inferior myocardial changes. However, it was compatible to his previous EKG. The patient was admitted to CICU to rule out MI.
FSH|Fairview Southdale Hospital|FSH|89|91|HISTORY OF PRESENT ILLNESS|The patient called to his friends asking for help and he was delivered to FSH ER. At the FSH ER, EKG showed some questionable inferior myocardial changes. However, it was compatible to his previous EKG. The patient was admitted to CICU to rule out MI.
FSH|Fairview Southdale Hospital|FSH|144|146|ASSESSMENT|Otherwise no acute pulmonary or cardiac disease. ASSESSMENT: 46-year-old male with complicated medical history. He presented yesterday to ER at FSH with chest pain. He was admitted to the hospital to rule out acute coronary syndrome. PLAN: The patient was examined in the CICU on the morning of _%#MMDD#%_.
FSH|follicle-stimulating hormone|FSH|126|128|HISTORY OF PRESENT ILLNESS|The rest of the ultrasound was normal except there was a possible intramural fibroid in the posterior mid uterus. Her TSH and FSH were normal. Hemoglobin was 13.5. The patient did have the options of doing dilation and curettage (D&C), Provera therapy, or NovaSure ablation, however, she did not want to deal with the periods.
FSH|Fairview Southdale Hospital|FSH|250|252||He recently had aortic valve replacement and an ascending aortic aneurysm repair at Abbott-Northwestern in _%#MM#%_ 2006. The patient initially returned to his group home without any significant postoperative complications but then was readmitted to FSH with atrial flutter after suffering a near syncopal episode. He was found to have a large pericardial effusion which was drained and the ____ was treated.
FSH|follicle-stimulating hormone|FSH|175|177|HISTORY|She was on a study medication and developed an endometrial polyp. She also states that her last menses was _%#MMDD#%_ until she had another menses recently on _%#MMDD#%_. Her FSH hormonal level went from 10 in _%#MM2006#%_ to the 50s now, and she has also gained 10 pounds since the above, and she is anxious for further evaluation and correction of the dysfunctional bleeding.
FSH|Fairview Southdale Hospital|FSH|218|220|HISTORY OF PRESENT ILLNESS|ADMISSION DIAGNOSIS: Degenerative joint disease right knee. DISCHARGE DIAGNOSIS: Status post right total knee arthroplasty. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 72-year-old female who was admitted to FSH _%#MMDD2006#%_ after undergoing elective right total knee arthroplasty. HOSPITALIZATION: The patient was admitted to the hospital after the above mentioned surgery.
FSH|follicle-stimulating hormone|FSH|167|169|LABS|Postoperative pain and recovery were discussed with her from laparoscopy and Novasure and no guarantees of complete relief was given to her. LABS: Her TSH was normal, FSH was normal, ultrasound showed normal endometrial stripe and normal ovaries and uterus. PAST SURGICAL HISTORY: Is significant for appendectomy and Cesarean section.
FSH|follicle-stimulating hormone|FSH,|151|154|HISTORY OF PRESENT ILLNESS|She gets moderate to severe cramping for two days prior to her menses and then throughout her menstrual cycle, although her hemoglobin is normal, TSH, FSH, LH are normal. The patient desires permanent treatment for this problem. During the course of her management, we had offered her D&C hysteroscopy, hysteroscopic resection of submucosal leiomyoma and laparoscopy, and uterine artery embolization, myomectomy, and possible endometrial ablation after the resection, and the patient did not want to employ those measures on herself.
FSH|follicle-stimulating hormone|FSH|196|198||The patient states she has had moderate urinary stress incontinence over the last two years and has to wear a pad, and wants this corrected. She also had some insomnia and night sweats but had an FSH and estradiol which showed her ovaries are working normally; her FSH is 3.3, estradiol was 140. After explaining to the patient the options for repairing a bladder neck because of urinary stress incontinence the patient chose to have a transvaginal taping procedure done as an outpatient procedure.
FSH|follicle-stimulating hormone|FSH|124|126||She also had some insomnia and night sweats but had an FSH and estradiol which showed her ovaries are working normally; her FSH is 3.3, estradiol was 140. After explaining to the patient the options for repairing a bladder neck because of urinary stress incontinence the patient chose to have a transvaginal taping procedure done as an outpatient procedure.
FSH|Fairview Southdale Hospital|FSH|131|133|HISTORY OF PRESENT ILLNESS|He was advised to check her glucose level which was in the 40s. The patient and the patient's husband were then advised to come to FSH ED for further evaluation. On presentation to the Emergency Room, Accu-Chek was 101 and vital signs were BP 115/59, HR 60, RR 18, 97.2 temperature and oxygen saturations of 84% on room air.
FSH|Fairview Southdale Hospital|FSH|194|196|HISTORY OF PRESENT ILLNESS|The patient does not speak English and his son has not been with the father on any of his previous medical visits. From what I can ascertain, Mr. _%#NAME#%_ had surgery right after Christmas at FSH with an amputation done for unknown reasons. It is not clear if this was vascular or due to diabetes. His son notes that he has otherwise been healthy over the years.
FSH|Fairview Southdale Hospital|FSH|156|158|IMPRESSION|IMPRESSION: Mr. _%#NAME#%_ is a 65-year-old Asian male who presents today for preop evaluation for his upcoming leg surgery to be done by Dr. _%#NAME#%_ at FSH next week. At this point in time, it is difficult to get much history from the patient or his family but from what I can ascertain he has been relatively stable since he had his surgery.
FSH|Fairview Southdale Hospital|FSH|267|269|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSES: Pneumonia. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 7-month-old previously healthy infant except for history of RSV one month prior to admission who presented with one day of high fever, T max 105. The patient was initially seen at FSH ER on _%#MMDD2007#%_ diagnosed with possible pneumonia and given Rocephin and Zithromax. The patient returned later that same day with high temperature and mild dehydration.
FSH|Fairview Southdale Hospital|FSH|157|159|FOLLOW-UP APPOINTMENTS|He was referred to do EP study with pulmonary vein isolation over amiodarone therapy. The patient had the procedure with Dr. _%#NAME#%_ on _%#MMDD2007#%_ at FSH without complications. This did require transeptal puncture without complications. The patient does have some minor discomfort in the chest area following the ablation, otherwise, he appears to be doing fine.
FSH|follicle-stimulating hormone|FSH,|178|181|HISTORY OF PRESENT ILLNESS|The pattern of bleeding is very irregular and she had an ultrasound done that showed normal uterus, normal ovaries, endometrial stripe was 11.6 mm and the hormonal profile shows FSH, prolactin, DHEA, testosterone normal. Her pregnancy test is negative. We had offered her a trial of birth control pills or progesterone hormone therapy.
FSH|follicle-stimulating hormone|FSH|170|172|HISTORY|The patient did start on Provera denies had been on a series of Provera doses for ten days and her flows were so heavy that she had to change protection every half hour. FSH 69.4. Endometrial biopsy demonstrates benign disordered proliferative endometrium with chronic endometritis. The patient has been on the birth control pill and notes a lot of bloating for the three weeks that she is on it, as well as cramping during that period of time, but this did lead to regularization of her flows to every 28 days, lasting three days, two of which were heavy, during which time she changed her protection for every one to two hours.
FSH|follicle-stimulating hormone|FSH|287|289|PREADMISSION DIAGNOSIS|Because the patient was unreliable in her follow-up care and does desire definitive therapy, the decision was made to proceed with vaginal hysterectomy and bilateral salpingo-oophorectomy if possible. The patient does have premature ovarian failure, with laboratory results including an FSH of over 50 done sometime ago. She has been amenorrheic for 4+ years, however. On _%#MM#%_ _%#DD#%_, 2002, she underwent a vaginal hysterectomy.
FSH|follicle-stimulating hormone|FSH|172|174|HISTORY OF THE PRESENT ILLNESS|At this time she has developed symptomatic pelvic relaxation and is to undergo surgical treatment. In _%#MM#%_ 2001 she had a complete physical and had menopause symptoms. FSH was 68 and she was given a prescription for Fenestin 0.625 daily and Prometrium 200 mg daily. She has done much better on hormone replacement therapy. However, she does notice that she has classic urinary stress incontinence where she loses a small amount of urine when she coughs, sneezes, laughs, or lifts something heavy.
FSH|Fairview Southdale Hospital|FSH.|192|195|HOSPITAL COURSE|The patient was hypotensive and bradycardic. The EKG was consistent with an acute inferior/posterior myocardial infarction and he received thrombolytic therapy with TNK. He was transferred to FSH. He underwent coronary angiography that day. Dr. _%#NAME#%_ _%#NAME#%_ performed the coronary angiogram which demonstrated an 80% proximal circumflex stenosis which was considered to be the critical lesion.
FSH|follicle-stimulating hormone|FSH|180|182|ALLERGIES|TSH 1.37, normal. Lipid panel showed cholesterol of 182, triglycerides 141, LDL 113, HDL 41. INR was 1.02. Creatinine at discharge was 0.8. LH level was 8.8, within normal limits. FSH level was 5.1 within normal limits. C-reactive protein was slightly elevated at 2.46. Stress echo results were: 1. Normal exercise echo on supine bicycle 4 minutes 48 seconds, 97% predicted for her maximal heart rate without evidence of coronary artery disease or stress-induced ischemia.
FSH|follicle-stimulating hormone|FSH|208|210|LABORATORY DATA|Occasional alcohol. No illicit drug use. REVIEW OF SYSTEMS: Negative except for a history of asthma with recent exacerbation on _%#MMDD2002#%_ for which she was placed on a prednisone taper. LABORATORY DATA: FSH 2.3, TSH 1.12. HCG test was negative. The rest of her tests were all within normal limits. Ultrasound is as mentioned above. PHYSICAL EXAMINATION: VITAL SIGNS: Height 5-feet-2-inches.
FSH|Fairview Southdale Hospital|FSH|207|209|HOSPITAL COURSE|6. Recent shoulder fracture. 7. History of possible reactive airway disease. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 77-year-old woman who has a history of coronary artery disease and was transferred to FSH from Fairview Lakes Regional Health Care Center after presentation with retrosternal chest discomfort. The chest discomfort radiated to her jaws and down her arms and was associated with shortness of breath.
FSH|Fairview Southdale Hospital|FSH|215|217|HISTORY OF PRESENT ILLNESS|No other associated complaints. There was some left arm numbness or discomfort feeling but mostly positional as he described. After midnight he could not sleep. His wife checked with the hospital and brought him to FSH ER for further check up. In the ER, the patient was pain free and they gave him aspirin. They started the initial work up for the chest pain complaint.
FSH|Fairview Southdale Hospital|FSH|275|277|HISTORY|ADMISSION AND DISCHARGE DIAGNOSIS: Morbid obesity. SERVICE: Surgery PROCEDURE: On _%#MMDD2003#%_ the patient was admitted to the hospital and underwent an open Roux-en-Y gastric bypass. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 42-year-old married white female who was admitted to FSH under Dr. _%#NAME#%_ _%#NAME#%_'s care for Roux-en-Y gastric bypass surgery. PAST MEDICAL HISTORY: 1. Obstructive sleep apnea. She was recently begun on BiPAP at night.
FSH|Fairview Southdale Hospital|FSH|186|188||His intraocular pressure is 16 in both eyes. Mr. _%#NAME#%_ is desirous of having the cataract removed from the right eye and the risks and benefits were discussed. He is now brought to FSH for this procedure.
FSH|Fairview Southdale Hospital|FSH|247|249|PLAN|There was moderate shoulder dystocia at delivery. Baby was intubated at 5 minutes of age for poor respiratory effort and for extreme pallor. Perfusion improved with positive pressure ventilation. Infant was admitted to the special care nursery at FSH and umbilical lines were placed. She received Survanta once. She also received two pushes of 10 mL/kg of NS for hypotension. _%#NAME#%_ was a preterm AGA female infant, 3540 gm at 36 weeks gestation, with a length of 52 cm and head circumference of 34.5 cm.
FSH|Fairview Southdale Hospital|FSH|157|159|PLAN|She developed left anterior chest pain that is aggravated by coughing and is relatively absent if she is not deep breathing or coughing. She was seen in the FSH ER and a chest x-ray showed findings compatible with congestive heart failure. Her BNP was markedly elevated, greater than 5,000. She has been started on IV Lasix and at the present time is diuresing.
FSH|follicle-stimulating hormone|FSH|144|146|HISTORY OF PRESENT ILLNESS|She also has a history of hydromenorrhea. In recent months, however, her menses have become lighter and she has had increasing hot flashes. Her FSH indicates menopausal levels. Because of the increasing size of her tumor masses and symptoms she was seen in consultation with Dr. _%#NAME#%_.
FSH|follicle-stimulating hormone|FSH|169|171||Her Pap smear in _%#MM#%_ was normal. She had a mammogram in _%#MM#%_ as well that was also normal. The patient does occasionally have some hot flashes despite a normal FSH level. She is taking Lexapro, which could possibly aggravate hot flashes. We have discussed the potential for possible hysterectomy as an alternative option and the patient does not want to do that right now.
FSH|Fairview Southdale Hospital|FSH|64|66||_%#NAME#%_ _%#NAME#%_ is a 65-year-old lady who was admitted to FSH on _%#MMDD#%_ with chest pain. She had no previous cardiac history and was transferred from _%#CITY#%_ Memorial Hospital presenting with chest pain on the evening prior to admission.
FSH|Fairview Southdale Hospital|FSH|253|255||Fundus examination is normal and intraocular pressure is 22. The risks and benefits of cataract surgery with intraocular lens implant especially in view of the pseudoexfoliation were reviewed and Mrs. _%#NAME#%_ wishes to proceed. She is now brought to FSH for this procedure.
FSH|Fairview Southdale Hospital|FSH|245|247|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: Alzheimer's disease with Parkinsonian features with recent worsening of confusional state, possible related to the use of carbidopa/levodopa. Mr. _%#NAME#%_ _%#NAME#%_ is a pleasant 78-year-old gentleman who was admitted to FSH _%#MMDD2004#%_. He and his wife had been spending some time in Florida. He does have dementia and Parkinsonian features. He had been started on carbidopa/levodopa and this did help with his physical movements considerably.
FSH|Fairview Southdale Hospital|FSH,|211|214|DISCHARGE DIAGNOSES|They, therefore, had to come back early from Florida and needed to deal with Mr. _%#NAME#%_'s worsening confusion and the fact that his wife was not able to care for him. In the course of his hospitalization to FSH, he had electrolytes and CBC which were fairly unrevealing. We were unable to obtain a urine sample. It was felt as though some of the worsening cognitive status may have been attributed to the carbidopa/levodopa so the dose of that medication was cut in half.
FSH|follicle-stimulating hormone|FSH|82|84|HISTORY OF PRESENT ILLNESS|The pain improved but has become worse again over the last year or so. She had an FSH of 31.6 and an estradiol of 20 on _%#MMDD2004#%_. She is having no hot flashes. She is still having the irregular bleeding (last bleeding was on _%#MMDD2004#%_).
FSH|Fairview Southdale Hospital|FSH|58|60|PLAN|_%#NAME#%_ _%#NAME#%_ is a 17-year-old female admitted to FSH for the surgical treatment of her mandibular asymmetry. She has a posterior open bite on the left side resulting in a nonfunctional occlusion.
FSH|Fairview Southdale Hospital|FSH|186|188|REASON FOR HOSPITALIZATION|He has a history of a small non-Q myocardial infarction with subsequent four vessel bypass surgery in _%#MM#%_ 2001. He ruled in for a small myocardial infarction and was transferred to FSH for definitive care. HOSPITAL COURSE: The patient underwent coronary angiography done by Dr. _%#NAME#%_.
FSH|follicle-stimulating hormone|FSH|180|182|HISTORY OF PRESENT ILLNESS|A total abdominal hysterectomy was decided upon and the patient did have a session of counseling about whether to remove her ovaries or to keep her ovaries. She did not do a day 3 FSH or estradiol for ovarian function, but decided to keep her ovaries. She understands the risks of future ovarian cancer and the fact that her ovaries may not continue to work in the near future.
FSH|Fairview Southdale Hospital|FSH|223|225||Her intraocular pressure is 11. Mrs. _%#NAME#%_ is desirous of having the cataract removed in the right eye. The risks and benefits of cataract surgery with intraocular lens implant were discussed and she is now brought to FSH for this procedure.
FSH|follicle-stimulating hormone|FSH|169|171|ASSESSMENT AND PLAN|We had a long discussion about the fact that testosterone would be safe for her. She will continue to stay off of tamoxifen. She appears to be going into menopause. Her FSH is 25. She will see if the testosterone helps her symptoms of low energy and low libido. If she does go into menopause, we can try Arimidex at some point in time in the future, but not at this juncture.
FSH|follicle-stimulating hormone|FSH|120|122|HISTORY OF PRESENT ILLNESS|The patient did well following the last dilatation and curettage and hysteroscopy and wishes to repeat this. She had an FSH drawn which was 2.0. Patient also has multiple fibroids within her uterus that measure between 1.5 and 2 cm. The ovaries had one simple cyst and otherwise were normal.
FSH|Fairview Southdale Hospital|FSH|58|60||_%#NAME#%_ _%#NAME#%_ is a 28-year-old female admitted to FSH for the surgical treatment of her mandibular growth dysplasia diagnosed as mandibular retrognathism. Presurgical orthodontics has been done by Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, DDS, PhD.
FSH|follicle-stimulating hormone|FSH|207|209|PREOPERATIVE DIAGNOSIS|The patient's last menstrual period was _%#MM#%_ 2004. Because of this period of amenorrhea, she did have serum gonadotropins drawn which were both markedly elevated consistent with menopause. The patient's FSH was 70.5. She experienced some spotting in late _%#MM#%_ and a "full blown period" in late _%#MM#%_. For this reason an endometrial biopsy was recommended and was performed on _%#MMDD2004#%_.
FSH|Fairview Southdale Hospital|FSH|142|144||The risks and benefits of cataract surgery were reviewed and Mr. _%#NAME#%_ is desirous of having this cataract removed. He is now brought to FSH for this procedure.
FSH|follicle-stimulating hormone|FSH|188|190|ASSESSMENT|She was reluctant to have any further surgery and the hope was that she would go into menopause and that this would take care of the problem. However, because of ongoing pain and a normal FSH she underwent a laparoscopic procedure in _%#MM#%_ of 2002. She had grade IV out of IV pelvic endometriosis with severe bowel adhesions, adhesions of the ovary, the uterus, a large uterine myoma, bilateral ovarian cyst and an obliterated cul-de-sac.
FSH|follicle-stimulating hormone|FSH|168|170|ASSESSMENT|Significantly abnormal, consistent with endometriosis and a myomatous uterus but of course could also be related to an ovarian malignancy. Surgery was recommended. Her FSH and E2 were still normal, meaning that menopause was relatively far away. The patient was taking iron preoperatively on _%#MMDD#%_, her hemoglobin was 9.1. The patient had discussed with her husband and feels that the recommended total abdominal hysterectomy, bilateral salpingo-oophorectomy, lysis of adhesions, removal of pelvic endometriosis is the only solution at this time.
FSH|follicle-stimulating hormone|FSH|230|232|HISTORY|She has no pain with intercourse, but because of her situation, the patient wanted evaluation before she made a final decision for definitive therapy such as a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Her FSH was 56. Her Estradiol was under 32, and so she was told that she was menopausal but still has had some regular menses.
FSH|follicle-stimulating hormone|FSH|241|243|PLAN|The adnexal areas appear clear without masses felt. IMPRESSION: Increasing dysmenorrhea with a history of recurrent endometriosis. Rule out recurrent endometriosis. PLAN: Admit the patient for diagnostic laparoscopy. The patient had another FSH and Estradiol done prior to surgery and this showed perimenopausal state of her ovaries with an Estradiol of 154 and an FSH of 18.
FSH|follicle-stimulating hormone|FSH|234|236|PLAN|Rule out recurrent endometriosis. PLAN: Admit the patient for diagnostic laparoscopy. The patient had another FSH and Estradiol done prior to surgery and this showed perimenopausal state of her ovaries with an Estradiol of 154 and an FSH of 18.
FSH|Fairview Southdale Hospital|FSH|221|223|ACTION & PLAN|EXTREMITIES: Moving all. SKIN: Moist. ACTION & PLAN: 1. Met with patient and created advanced directive and notarized. Two copies given to patient: For self, for cardiologist, and for internist. Additional copy is in the FSH chart. 2. Referral to Fairview TLC seems appropriate at discharge to assist with managing symptoms of multiple chronic illnesses.
FSH|follicle-stimulating hormone|FSH|285|287|PLAN|PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. If ECT contemplated, the patient has no complaints or findings to contraindicate from a medical standpoint. We will check EKG if plan to proceed. Otherwise, obtain CBC and BMP. Also, HIV with prior "exposure history." LH and FSH as above. 3. Albuterol metered-dose inhaler 2 puffs q.i.d. p.r.n. 4. Clinical observation. Thanks for the consultation. We will follow along as medically indicated.
FSH|follicle-stimulating hormone|FSH|153|155|PAST SURGICAL HISTORY|4. Status post hysterectomy and left salpingo-oophorectomy for cervical cancer. The patient had hormonal testing during her last admission with a normal FSH and LH. 5. Status post appendectomy. 6. Status post urethral dilatation. ALLERGIES: Aspirin and Macrobid. FAMILY HISTORY AND SOCIAL HISTORY: Per old chart. OUTPATIENT MEDICATIONS: 1. Prozac.
FSH|Fairview Southdale Hospital|FSH|158|160||The patient got home late last night tripping over the gate of her son's dog. Went over backwards to her side and fracture her left shoulder. She was seen at FSH ER. She is a rather large woman. X-rays were difficult but it shows a very proximal fracture with angulation without dislocation.
FSH|Fairview Southdale Hospital|FSH|425|427|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 66-year- old woman who has a known diagnosis of ovarian carcinoma and colon cancer and for which she has been receiving palliative chemotherapy using paclitaxel at 80 mg per meter squared weekly for four weeks followed by two week rest. This treatment has been given through Abbott-Northwestern Hospital by my partner, Dr. _%#NAME#%_. Ms. _%#NAME#%_ was admitted to FSH on _%#MMDD2004#%_ with progressive weakness involving the right hand as well as difficulty holding objects. Work up since admission has included an echocardiogram which apparently showed evidence suggestive of a right atrial appendage thrombus.
FSH|Fairview Southdale Hospital|FSH|165|167|RECOMMENDATIONS|We, therefore, compromised on a plan of having her receive her next dose of paclitaxel tomorrow rather this coming _%#NAME#%_ and to see the radiation oncologist at FSH beginning on _%#NAME#%_. This plan is reviewed with Ms. _%#NAME#%_ and her daughter and they are in agreement.
FSH|Fairview Southdale Hospital|FSH|112|114|INDICATIONS|REFERRING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD INDICATIONS: _%#NAME#%_ _%#NAME#%_ is an 85-year-old who came to FSH and was admitted for a month of diarrhea. The patient states that she has diarrhea every time she eats and when she stands up.
FSH|follicle-stimulating hormone|FSH,|222|225|PLAN|That, in conjunction with the long standing history of decreased libido would suggest that he has had an abnormal gonadotrope axis for some time. PLAN: We will add a prolactin level. We will also check an estradiol level, FSH, iron, free T4, cortisol and growth hormone IgF one level. We will also set him up with an MRI of the pituitary and await these results before final recommendations.
FSH|Fairview Southdale Hospital|FSH|163|165|REASON FOR CONSULTATION|I have previously seen this patient for outpatient diabetes evaluations for several years. She developed recent nausea and vomiting, hyperglycemia and went to the FSH emergency department today. The patient recalls having progressive hyperglycemia since yesterday morning and changed her insulin infusion site at that time, though progressive blood glucose levels in the 200-300 mg/dL range despite correction boluses with her external insulin pump.
FSH|follicle-stimulating hormone|FSH|42|44||A consultation was requested to interpret FSH and LH. CHIEF COMPLAINT: Abnormal laboratory values, no menses since _%#MM#%_ 2001.
FSH|follicle-stimulating hormone|FSH|178|180|LABORATORY DATA|PHYSICAL EXAMINATION: Well-developed slightly overweight female who is very talkative and exaggerates in her speech. Detailed physical examination was not done. LABORATORY DATA: FSH 63; LH 25. ASSESSMENT: Laboratory values are consistent with menopause. PLAN: The patient was encouraged to follow the recommendation of having her mammogram repeated in six months.
FSH|follicle-stimulating hormone|FSH|102|104|HISTORY OF PRESENT ILLNESS|The patient came today to follow up with the results. The glucose was 83 mg/dL. The HEAS sulfate 487, FSH 7.3, LH 36.3. Lipid profile: Cholesterol was 201 mg/dL, triglycerides 235 mg/dL.
FSH|follicle-stimulating hormone|FSH|156|158|ASSESSMENT/PLAN|She has been on prophylactic inhalers in the past. I will start her on Flovent scheduled and continue with albuterol p.r.n. 3. Hot flashes. I will check an FSH level to check if the patient has reached menopause, although I doubt this is the case in someone at age 31. I will ask to be called if that level is abnormal.
FSH|follicle-stimulating hormone|FSH|274|276|HISTORY OF PRESENT ILLNESS|Her right axillary node was examined and only two lymph nodes showed low- grade ductal carcinoma or infiltrating lobular carcinoma without extranodal extension. Each lymph node measured less than 2 cm in size. The ER and PR receptor was positive. HER2/neu was 2/3, however, FSH was negative. Therefore, the patient has bilateral breast cancer of the right side, T4, N1, M0 stage IIIB cancer, and left-sided T2, N1, M0 stage IIB breast cancer with both ER, PR positive and HER2/neu negative.
FSH|Fairview Southdale Hospital|FSH|178|180|HISTORY OF PRESENT ILLNESS|REASON FOR CONSULTATION: Uncontrolled blood sugar with past history of diabetes. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 67-year-old gentleman who was examined at FSH on CSC. The patient has undergone triple coronary artery bypass on _%#MMDD2005#%_. I was consulted today by cardiologist who helped manage with fluctuating blood sugars and helping manage uncontrolled diabetes.
FSH|fascioscapulohumeral muscular dystrophy|(FSH)|149|153|IMPRESSION|Currently there is genetic molecular testing, which can sequence the gene, which is located on chromosome 4. Fascioscapulohumeral muscular dystrophy (FSH) is inherited in an autosomal dominant manner. Approximately 70-90% of individuals have inherited this condition from 1 of their parents.
FSH|fascioscapulohumeral muscular dystrophy|FSH,|223|226|IMPRESSION|This is what it appears in Katie's family. Individuals who are affected the fascioscapulohumeral muscular dystrophy will have a 50% chance to have a child affected. Because _%#NAME#%_ is not thought to have any symptoms of FSH, her chance to have a pregnancy that is affected would be low. There is quite some variability within the features of FSH and, if she had any concerns, she certainly could see a neurologist.
FSH|Fairview Southdale Hospital|FSH|296|298|HISTORY|He was treated with intravenous diuretics with improvement in his congestive heart failure, though there was a rise in creatinine from 1.3 to 2.3 between _%#MMDD#%_ and _%#MMDD#%_, which was resolving with reduction in diuretics. He did have evidence of a non-Q-wave MI and he was transferred to FSH for cardiac catheterization, which was done on _%#MMDD2007#%_. Details are included in the cardiology notes. He did require stenting of his LAD.
FSH|Fairview Southdale Hospital|FSH|183|185||He was diagnosed this past _%#MM#%_ of 2002 with rectal cancer. He was initially treated as an outpatient with chemotherapy and radiation and was admitted in _%#MM#%_ of this year to FSH where he underwent resection of his cancer. Immediately postop, however, he had stroke insult. Fortunately that cleared completely, however, in the course of his evaluation was found to have an occluded right carotid artery and a highly stenotic left carotid artery.
FSH|follicle-stimulating hormone|FSH.|156|159|PAST  MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Significant for hypotestosteronism leading to impotence, and there has also been a previously demonstrated low TSH, low LH and low FSH. 2. Tobacco use. ALLERGIES: Penicillin causing angioedema. SOCIAL HISTORY: The patient has his own mortgage company.
FSH|Fairview Southdale Hospital|FSH.|169|172|HISTORY|CHIEF COMPLAINT: Painful hip. HISTORY: _%#NAME#%_ _%#NAME#%_ is a pleasant 78-year-old female. On _%#MMDD#%_ she underwent a right total hip replacement arthroplasty at FSH. She actually tolerated the procedure quite well. She was then transferred to the _%#CITY#%_ Care Center. She was readmitted to the hospital on _%#MMDD#%_ with atrial fibrillation and mild congestive failure.
FSH|Fairview Southdale Hospital|FSH|205|207|HISTORY|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_ CHIEF COMPLAINT: Left proximal leg pain. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 60-year-old woman readmitted today. She was previously been seen in the hospital at FSH in mid _%#MM#%_. She had similar symptoms. Now her symptoms have progressed and are more severe. Originally she complained of some left buttock symptoms wrapping around to the anterior thigh.
FSH|Fairview Southdale Hospital|FSH.|150|153|HISTORY|She had undergone a CT of the abdomen and pelvis to make sure that there was no lumbosacral plexus lesion. None was identified. The study was done at FSH. She then was begun in physical therapy. She underwent two sessions where she received light massage and ultrasound which seemed to be somewhat helpful.
FSH|Fairview Southdale Hospital|FSH|321|323|RECOMMENDATIONS|I have been asked to see _%#NAME#%_ _%#NAME#%_ by his primary admitting family practitioners (Dr. _%#NAME#%_ _%#NAME#%_) regarding his newly observed thrombocytopenia and leukopenia. _%#NAME#%_ is a 78-year-old white male who has a relatively unremarkable past medical history other than for hypertension who presents to FSH yesterday _%#MMDD2004#%_ with the complaint of fevers, nausea, headaches, body aches, urinary difficulty and incontinence. On initial evaluation, the patient was found to be febrile to 102 degrees.
FSH|Fairview Southdale Hospital|FSH|158|160|DISCUSSION|DISCUSSION: The patient needs to undergo open reduction internal fixation with bone grafting. I have scheduled this to occur on Friday, _%#MM#%_ _%#DD#%_, at FSH on a Same Day Surgery basis. We will plan to use cannulated screws for internal fixation and have the osteo set material there for bone grafting.
FSH|fascioscapulohumeral muscular dystrophy|FSH|201|203|PAST MEDICAL HISTORY|I was asked by Dr. _%#NAME#%_ to see this patient for an internal medicine consult. The patient complains of GI pain. PAST MEDICAL HISTORY: 1. Depression, anxiety, OCD, anorexia nervosa x 17 years. 2. FSH muscular dystrophy x 10 years. 3. Chronic fatigue syndrome x 15 years. 4. History of menorrhagia, taking medications, controlled.
FSH|fascioscapulohumeral muscular dystrophy|FSH|178|180|ASSESSMENT|The patient denies suppository. 3. Partial bowel obstruction possible. Possibly secondary to adhesions. Follow-up with primary care physician or specialist on a p.r.n. basis. 4. FSH muscular dystrophy. Follow-up with specialist on a p.r.n. basis.
FSH|Fairview Southdale Hospital|FSH.|188|191|PHYSICAL EXAMINATION|Has had no symptoms suggesting peripheral vascular disease. ALLERGIES: Penicillin. PHYSICAL EXAMINATION: GENERAL: Pleasant, alert 48-year-old man who is seen in the Intensive Care Unit at FSH. VITAL SIGNS: Blood pressure currently 136/82, temperature is 99 degrees. Pulse is 60. HEENT: I did not get a good look at this fundi.
FSH|Fairview Southdale Hospital|FSH|126|128|RECOMMENDATIONS|If I can be of any further assistance in regards to this patient, please let me know. Again, the patient was last admitted to FSH for similar symptoms back in _%#MM2007#%_.
FSH|Fairview Southdale Hospital|FSH|151|153|REASON FOR CONSULTATION|REASON FOR CONSULTATION: Placement of Ommaya reservoir for acute lymphogenous leukemia. _%#NAME#%_ _%#NAME#%_ is a 20-year-old female who presented to FSH _%#MMDD2007#%_ with a lymphoblastic crisis. She has undergone a lumbar puncture which is positive for blast cells within the CSF. There has been a request for placement of an Ommaya reservoir.
FSH|Fairview Southdale Hospital|FSH.|165|168|REASON FOR CONSULTATION|One of us will be following the patient here. She is scheduled to see my colleague, Dr. _%#NAME#%_ _%#NAME#%_ on Wednesday and I will inform him of her admission to FSH.
FSH|Fairview Southdale Hospital|FSH|115|117|REASON FOR CONSULTATION|He does state he had an episode of black stool and was vomiting blood two months ago and had an upper GI series at FSH revealing only hiatal hernia. He denies any prior diverticulitis episodes. He states he had what sounds like a sigmoidoscopy in the doctor's office about two years ago which reportedly was negative and no mention made of diverticulitis at that time.
FSH|Fairview Southdale Hospital|FSH.|174|177|CARDIOVASCULAR|I have advised Mr. _%#NAME#%_ of his torn medial meniscus. We have discussed treatment options and decided to proceed with arthroscopy of his right knee on _%#MMDD2004#%_ at FSH. He is advised on the indications, risks and benefits and time involved for recovery. He is asked that we begin the scheduling process.
FSH|Fairview Southdale Hospital|FSH.|230|233||He stated that he is now incapable of using his right upper and right lower extremities to any degree and as a result last night he feels that he is sufficiently impaired, that he actually called an ambulance and was delivered to FSH. He has a history of spontaneous onset of fairly substantial neck pain. He had been getting chiropractic treatments. It was unclear if those treatments have exacerbated his symptoms.
FSH|follicle-stimulating hormone|FSH|160|162|REVIEW OF SYSTEMS|Denies any fevers or night sweats. She is 52 and is post menopausal, has only had a couple scattered periods over the past 3 years, and Dr. _%#NAME#%_ did do a FSH test on her and it was 92 in the postmenopausal range. ALLERGIES: The patient is allergic to penicillin, sulfa, and erythromycin.
FSH|Fairview Southdale Hospital|FSH.|143|146|HISTORY OF PRESENT ILLNESS|He was placed on antibiotics with resolution of the discomfort, however, he began vomiting blood. He also became dizzy and went into the ER at FSH. He was diagnosed with atrial fibrillation. Prior to any definitive anticoagulation, it was recommended that he have his symptomatic tooth removed.
FSH|Fairview Southdale Hospital|FSH|223|225|HISTORY OF PRESENT ILLNESS|Because of this significant bleeding and his complicated history (see below), it was suggested that he transfer to the Fairview University Medical Center. Unfortunately they did not have a bed and we were contacted here at FSH for further care. The patient has a long standing history of cirrhosis of the liver secondary to alcohol.
FSH|follicle-stimulating hormone|FSH|223|225|ASSESSMENT/PLAN|The patient does have a history of anorexia and bulimia, although I am not aware of recent exacerbation of these issues. She has a normal metabolic workup at this time. I would recommend screening for prolactin levels, LH, FSH and will add a T4 to the labs that have already been drawn. I recommend sending a copy of the patient's labs with her at the time of discharge, and she will require follow-up with her primary care MD within the next one month for further evaluation of this issue.
FSH|Fairview Southdale Hospital|FSH.|195|198|PLAN|We discussed the possibility of chemotherapy and answered all of her questions regarding these issues. She will see her primary care physician before coming in for her procedure on _%#MMDD#%_ at FSH.
FSH|Fairview Southdale Hospital|FSH|106|108|RECOMMENDATIONS|On the right, normal reflexes and down going toes. She has minimal resistance of neck flexion. CT scan at FSH on _%#MMDD#%_ demonstrates a 3 X 5 cm intracerebral hematoma in the right capsular region adjoining the sylvian fissure.
FSH|follicle-stimulating hormone|FSH|193|195||Cycles are regular at this stage with her flows lasting approximately five to six days, three or four of which are heavy. During her heavy days she changes every two hours. The patient has had FSH which is within normal limits. The patient is now fed up with the flow and asks that we proceed on to definitive management.
FSH|Fairview Southdale Hospital|FSH|142|144|BRIEF HISTORY|REASON FOR CONSULTATION: Partial small bowel obstruction. BRIEF HISTORY: _%#NAME#%_ _%#NAME#%_ is a 22-year-old gentleman who was admitted to FSH on _%#MMDD2004#%_ with a chief complaint of abdominal pain. He reports that on the night prior to admission, he had the acute onset of right upper quadrant abdominal pain that was associated with nausea and vomiting.
FSH|Fairview Southdale Hospital|FSH|124|126|HISTORY|When it is well documented in the abnormal kidney function just a few weeks ago. He was here for SVT and transferred to the FSH in late _%#MM#%_ for ablation of AV nodal reentrant tachycardia. He was subsequently discharged on Lasix 40 mg daily, lisinopril 5 mg daily, and developed some GI symptoms including nausea, vomiting and diarrhea.
FSH|follicle-stimulating hormone|FSH,|161|164|PLAN|3. ? postmenopausal. No menses for the past 2 months. PLAN: Will run T4 from stored serum from _%#MMDD2003#%_. Check prolactin, cortisol, growth hormone, IGF-1, FSH, estradiol and anti-TPO antibody. Will increase her T4 to 0.088 mg per day for now. Will follow.
FSH|Fairview Southdale Hospital|FSH|218|220|HISTORY OF PRESENT ILLNESS|Her LMP was in the end of _%#MM#%_ 2005. The bleeding started at its normal time, however, the bleeding did not stop after the normal 5-7 days of flow. The bleeding became very heavy and she was eventually seen in the FSH ER one week prior to admission. At that point the patient was started on Provera in attempts to control her bleeding.
FSH|follicle-stimulating hormone|FSH,|128|131|PLAN|EXTREMITIES: Marked spasticity, no edema, no skin lesions noted. ASSESSMENT: Secondary amenorrhea x 6 months. PLAN: Hemoglobin, FSH, estradiol, prolactin, and TSH with reflex. Pap smear sent.
FSH|follicle-stimulating hormone|FSH,|228|231|COLLECTION OF RETROGRADE SPECIMEN|Therefore, the patient has either anejaculation or nonobstructive azoospermia. I discussed the significance of this with the patient over the phone. We could proceed with a workup of this by obtaining hormonal studies including FSH, and we can also have him go through electroejaculation to try to collect an antegrade specimen. If electroejaculation then fails, we will proceed with testicular sperm extraction surgically.
FSH|Fairview Southdale Hospital|FSH|124|126|REASON FOR CONSULTATION|REASON FOR CONSULTATION: I was asked to see _%#NAME#%_ _%#NAME#%_ in cardiology consultation because of her presentation to FSH with chest discomfort and rapid heart beat. HISTORY: The patient is an 81-year-old overweight pleasant white female who was apparently in her normal state of health until the evening prior to this consultation when she experienced chest discomfort and rapid heart beat.
FSH|Fairview Southdale Hospital|FSH|163|165|PAST MEDICAL HISTORY|He has had good peripheral circulation and no evidence of any obvious CNS dysfunction. PAST MEDICAL HISTORY: 1. Coronary heart disease with a three-vessel CABG at FSH in 2000. Postop atrial fibrillation converted to normal sinus rhythm on that admission. 2. Visit here in 2003 for noncardiac chest pain, myocardial infarction (MI) was ruled out and he was discharged.
FSH|Fairview Southdale Hospital|FSH|227|229|SURGERY|We may need to open the joint and wash it out as well depending on the clinical appearance and findings at the time of surgery. She would like to proceed with the surgery and will schedule it for this Friday, _%#MMDD2003#%_ at FSH on a same day surgery basis.
FSH|Fairview Southdale Hospital|FSH|216|218|PHYSICAL EXAMINATION|If he does recover or if it looks like we need to treat the odontoid fracture, please contact us and we will place the halo vest. This was discussed with his wife in detail. We would like to thank Dr. _%#NAME#%_ and FSH ER for asking us to see this patient in consultation.
FSH|follicle-stimulating hormone|FSH,|153|156|EXAM|Her left breast is normal. There is no evidence of lymphedema in her right arm. Her abdomen is soft and nontender. At today's visit, we did do a CBC, an FSH, LH and an estradiol level. In addition, she was given her q. 3 month Zoladex 10.8 mg pellet subcutaneously. She is going to be started on Effexor 75 mg extended release once a day to see if we can alleviate her hot flushes.
FSH|Fairview Southdale Hospital|FSH.|145|148|SOCIAL HISTORY|SOCIAL HISTORY: She does not drink alcohol or smoke cigarettes. Her husband is the son of Dr. _%#NAME#%_ _%#NAME#%_ on the medical staff here at FSH. Apparently she has had some negative experiences with physicians in the past, which has affected her willingness to seek medical care.
FSH|follicle-stimulating hormone|FSH|145|147|ASSESSMENT|ASSESSMENT: 1. Multiple sclerosis exacerbation. 2. Drenching night sweats for four years. Etiology of this is not clear. The patient did have an FSH level which was low normal, suggesting that she is not menopausal. The differential for her night sweats may include: a. Autonomic instability related to MS.
FSH|follicle-stimulating hormone|FSH|309|311|DISCUSSION|_%#NAME#%_ and her husband confirm that she experiences on a nightly basis night sweats which are quite drenching to the point that she has to change her bed clothes one to two times per evening. _%#NAME#%_ has seen her primary doctor recently for this who thought that this might be hormonal in etiology. An FSH level was obtained and was 4, which is low-normal. Leslie states she has never had sweats during the daytime. She has not been aware of fevers, she denies chills.
FSH|Fairview Southdale Hospital|FSH|154|156|BRIEF HISTORY|She did not notice any changes in strength in her arm. She did notice some significant wrist discomfort shortly after. She was brought to the ER Dept. at FSH where she underwent further evaluation. She continued to complain of neck pain and this prompted a CT with reconstruction of her cervical spine.
FSH|Fairview Southdale Hospital|FSH.|124|127|RECOMMENDATIONS|She currently sees a gynecologist in _%#CITY#%_ _%#CITY#%_ but recently moved to this area of town which is why she came to FSH. The patient has no illnesses, allergies, or surgery. I did not perform a pelvic examination today. Abdominal examination showed the abdomen to be tender throughout with rebound.
FSH|follicle-stimulating hormone|FSH|228|230|REFERRING PHYSICIAN|Dimensions of this tumor were as noted above. There was some extension of the tumor into the suprasellar space as well as into the left sphenoid sinus. Preoperative labs in _%#MM#%_ showed TSH in _%#MM#%_ of 0.27, free T4 0.78, FSH of 5.8, LH 1.1, testosterone 107, prolactin 8, p.m. cortisol 3.5, IGF1 normal at 70. Creatinine was normal at 0.64. A 24 hour urine free cortisol _%#MMDD2007#%_ was low normal at 10.3, normal less than 60.
FSH|Fairview Southdale Hospital|FSH.|235|238|HOSPITALIZATION AND SURGERY|No systemic arthritides. No constitutional symptoms. FAMILY HISTORY: Noncontributory. Negative for anesthesia problems. HOSPITALIZATION AND SURGERY: Left knee scope in 1994, right knee anterior cruciate ligament reconstruction 1995 at FSH. HABITS: Nonsmoker, social drinker. PHYSICAL EXAMINATION: Alert and oriented. Blood pressure 118/70.
FSH|Fairview Southdale Hospital|FSH|180|182|G  1  P 0000				LMP|Pregnancy History: G 1 P 0000 LMP: _%#MMDD2007#%_ Age: 35 EDC (LMP): _%#MMDD2007#%_ Age at Delivery: 35 EDC (U/S): c/w EDC Gestational Age: 12+5 weeks * _%#NAME#%_ was admitted to FSH on _%#MMDD2007#%_ due to a flu-like illness. At the time she had a fever of 101 degrees. No other significant complications or exposures were reported. Risk assessment for chromosome conditions: * We discussed the association between maternal age and an increasing risk for chromosome conditions, such as Down syndrome.
FSH|Fairview Southdale Hospital|FSH|191|193|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 67-year-old man with no known prior history of coronary artery disease but with a history of long standing hypertension was admitted to FSH _%#MMDD2003#%_ with chest pain. This has been happening for several weeks and perhaps months. The patient is a little unclear as to the duration of these sporadic episodes of chest pain which are typically related to activity and do improve with rest.
FSH|follicle-stimulating hormone|FSH|107|109|HISTORY OF PRESENT ILLNESS|They occur every 28 days. However, the bleeding lasts up to 7 to 9 days. Through this work-up, her TSH and FSH were normal. Hemoglobin was normal. She had an ultrasound that showed endometrial stripe to be thickened at 1.5 cm and also heterogenous which is irregular, and the uterus shows intramural fibroid 2.3 cm.
FSH|Fairview Southdale Hospital|FSH,|175|178||That episode was experienced after running up the stairs quickly. Usually these episodes will resolve after rest and taking three baby aspirins. In the emergency room here at FSH, he was found to be markedly hypertensive with blood pressure of 174/117. Risk factors include history of tobacco use which he recently discontinued as well as probable hypertension.
FSH|Fairview Southdale Hospital|FSH|169|171|HISTORY OF PRESENT ILLNESS|He now returned yesterday to Dr. _%#NAME#%_'s office for re-evaluation and apparently had a syncopal episode. He was unresponsive for several minutes and transferred to FSH ER. At this time I cannot gain any useful history from him. He is admitted to the ICU and although he is not extubated, he is not responding appropriately to questions.
FSH|follicle-stimulating hormone|FSH|271|273|HISTORY OF PRESENT ILLNESS|She states she was started on Celexa one week prior to her hospitalization, however this was discontinued and upon being admitted she was changed over to a combination of Seroquel and Effexor. The patient had a TSH level checked which was 1.7 and in the normal range, an FSH checked which was 8.4 and in the pre-menopausal range, an LH was also checked and in the normal range. This is a noncontributory hormone test. The patient has no significant gynecologic history.
FSH|Fairview Southdale Hospital|FSH.|151|154|BRIEF HISTORY|REASON FOR CONSULTATION: Right upper quadrant abdominal pain and gallstones. BRIEF HISTORY: _%#NAME#%_ _%#NAME#%_ is a 51-year-old female who works at FSH. She reports that relatively acutely at approximately 03:00 hours on _%#MMDD2003#%_ she began experiencing severe right upper quadrant and epigastric abdominal pain which had a belt like radiation around to her back.
FSH|Fairview Southdale Hospital|FSH|216|218||She underwent laparoscopic cholecystectomy yesterday and was having some postoperative pain when she was noted to have an elected lipase approximately 5,000 with elevated liver function tests. She was transferred to FSH today for further evaluation and treatment. She was noted to have significant liver function test elevations preoperatively with total bilirubin 3.0 and transaminases of 200-300 on admission but these have been declining prior to her laparoscopic cholecystectomy.
FSH|Fairview Southdale Hospital|FSH|191|193|HISTORY OF PRESENT ILLNESS|She is unable to converse. I spoke with her son who was able to relay a great deal of medical information. Her most recent hospitalization was two years ago at which time she was admitted to FSH for an autoimmune disorder which was subsequently found to be associated with autoimmune hepatitis. She has now been on immunosuppressive agents including Imuran, and her symptoms have improved.
FSH|follicle-stimulating hormone|FSH|218|220|HISTORY OF PRESENT ILLNESS|Upper GI x-ray, _%#MMDD2005#%_, was within normal limits. A chest x-ray on _%#MMDD2006#%_ was stable without active infiltrates. The patient with a history of pituitary tumor. Hormonal studies in _%#MM2006#%_ included FSH of 21.2, lutropin of 26.1, prolactin mildly elevated at 32 with TSH of 4.45. Clinically, at present historical details are difficult to obtain.
FSH|Fairview Southdale Hospital|FSH|205|207|HISTORY|Currently radiation therapy is being completed and plans were made to meet with Dr. _%#NAME#%_ _%#NAME#%_ to discuss chemotherapy. Mr. _%#NAME#%_ became somewhat lethargic and unsteady and was admitted to FSH yesterday. He underwent an MRI scan of the brain. I have been asked to see him regarding surgery. ALLERGIES: None. MEDICATIONS: Zosyn, Tobradex, calcium, Zofran, Zantac, Decadron, Dilantin, aspirin, and Tylenol #3.
FSH|Fairview Southdale Hospital|FSH|138|140|BRIEF HISTORY|REASON FOR CONSULTATION: Question of bowel obstruction. BRIEF HISTORY: _%#NAME#%_ _%#NAME#%_ is an 87-year-old female who was admitted to FSH on _%#MMDD#%_ due to a chief complaint of abdominal pain and abdominal distention. I had seen this patient previously in _%#NAME#%_ of 2005 at which time she was confirmed to have pancreatic cancer.
FSH|Fairview Southdale Hospital|FSH.|172|175|HISTORY|However, she had a difficult time last evening and therefore she had her daughter or granddaughter call my office this morning. I recommended she presentation to the ER at FSH. They gave her 4 mg of Zofran, as well as a mg of IV Dilaudid.
FSH|Fairview Southdale Hospital|FSH|175|177|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ _%#NAME#%_ is a 55-year- old gentleman with no previous history of corneal artery disease but a strong family history of corneal artery disease who presents to FSH ER with chest pain. I am asked by Dr. _%#NAME#%_ to see this patient for cardiology consultation on _%#MMDD2003#%_.
FSH|follicle-stimulating hormone|FSH|208|210|HISTORY OF PRESENT ILLNESS|She has had treatment for approximately five years and starting at the age of 30, noted to have an FSH that was elevated to 18 and estradiol was also elevated to 102 on day #3. She has had fluctuation of her FSH and estradiols for the last few years. Her husband's semen analysis is within normal limits with some decrease in motility.
FSH|Fairview Southdale Hospital|FSH|98|100|PLAN|Requesting physician is Dr. _%#NAME#%_ _%#NAME#%_ Mr. _%#NAME#%_ _%#NAME#%_ was seen in the ER at FSH by Dr. _%#NAME#%_ on _%#MMDD2005#%_. He reports falling from a ladder yesterday and his family brought him in today. He reports neck pain and intrascapular pain. He has numbness in the last two digits of the left hand but no motor weakness and no other sensory abnormalities.
FSH|follicle-stimulating hormone|FSH|213|215|IMPRESSION|If this patient is postmenopausal, certainly a submucous fibroid, even if present, should not be a cause of bleeding. I would suggest the following: Assuming the patient is relatively hormone-free, we will get an FSH and see if the patient is truly menopausal. This obese diabetic lady who always had irregular periods may, in fact, not be postmenopausal at the age of 52, though she probably is.
FSH|follicle-stimulating hormone|FSH|161|163|IMPRESSION|On the other hand, one would prefer not to do any surgical procedure that is not absolutely necessary in this very challenging patient. Once we have her MRI and FSH studies, we will proceed further. As far as her ASCUS Pap smear, this may be repeated in six months.
FSH|Fairview Southdale Hospital|FSH.|223|226||Somewhat surprisingly her symptoms if anything are better. We are asked to see her because of the chest tube and will insert a chest tube catheter. She has no prior history of pulmonary disease. Her meds are per as here at FSH. Chest x-ray is as noted. Vital signs today show her pulse is 68, blood pressure 140/80, room air sat 97%.
FSH|follicle-stimulating hormone|FSH|143|145|PAST GYN HISTORY|PAST GYN HISTORY: Menarche at age 13 to 14 years; please see above. No history of STDs. No history of GYN surgery or any other procedures. Her FSH that was done on this hospital stay was 7.2. REVIEW OF SYSTEMS: As above. PHYSICAL EXAMINATION: The patient is noted to be a morbidly obese female very pleasant, in no acute distress.
FSH|Fairview Southdale Hospital|FSH.|109|112|SOCIAL HISTORY|There is a history of hypertension and strokes in the family. SOCIAL HISTORY: Married. His wife is an ICU at FSH. He works telecommunications and computer work. ALLERGIES: None known. REVIEW OF SYSTEMS: Recent low grade fever and flushing.
FSH|follicle-stimulating hormone|FSH|203|205|RECOMMENDATIONS|She has some residual minor tingling in her feet which is getting better, but I think it is related to the taxane treatment. She has gone into menopause with measurement of her Estradiol level at 16 and FSH is elevated. At today's visit, _%#NAME#%_ looked well. She weighed 153 pounds.
FSH|Fairview Southdale Hospital|FSH,|154|157|CHIEF COMPLAINT|Review of Dr. _%#NAME#%_'s note shows that she reported very significantly different symptoms to him. She is a very unreliable historian. Upon arrival to FSH, the patient's blood glucose was noted to be over 600. Ketones were negative. She was started on an insulin drip. She had an emesis in the ER. She was given Zofran.
FSH|follicle-stimulating hormone|FSH|275|277|SUBJECTIVE|The anesthesia was discussed with her. Minor cardiopulmonary and neurological risks of anesthesia were discussed and also the risks of gastrointestinal injuries, genitourinary injuries, blood loss, infections were discussed with her. Her hemoglobins in the past was 14.6 and FSH and TSH were normal. HPV screening was done and that showed that HPV screen was negative. The patient will have preoperative exam by her internist.
FSH|follicle-stimulating hormone|FSH,|192|195|HISTORY  OF PRESENT ILLNESS|MRA was unremarkable. The patient was subsequently admitted by the Neurosurgical Service for further evaluation and treatment planning. Thus far labs sent off include TSH, free T4, prolactin, FSH, LH, glucose, 24-hour urine for cortisol, IGF 1, CBC and basal metabolic panel. The patient is complaining of increasing headache while in the ICU.
FSH|Fairview Southdale Hospital|FSH|219|221|HISTORY|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD REASON FOR CONSULTATION: Acute pulmonary embolism and paroxysmal atrial arrhythmia. HISTORY: Mr. _%#NAME#%_ _%#NAME#%_ is a 65-year-old white male who was discharged from FSH about two weeks ago after an uneventful bypass surgery. He presented with recurrent shortness of breath of about two days. After the admission, the patient underwent a CT scan that suggested right lower lobe pulmonary embolism.
FSH|Fairview Southdale Hospital|FSH.|190|193|RECOMMENDATIONS|5. Antibiotics have been started, tobramycin and vancomycin. 6. Infectious Disease consultation will be obtained when she is transferred to Fairview Southdale. 7. Neurosurgery evaluation at FSH. 8. We will continue to follow her at Southdale after transfer to the ICU there. HISTORY: Mrs. _%#NAME#%_ _%#NAME#%_ is a 57-year-old whose history is detailed in the notes of the admitting internists.
FSH|Fairview Southdale Hospital|FSH|109|111|HISTORY OF PRESENT ILLNESS|He is on Coumadin for atrial fibrillation. His last fall was several days ago. He was seen in the ER here at FSH two days ago and released. His wife found him unresponsive this morning and was brought into the ER here at FSH. He had emesis. A head CT was obtained and neurosurgical consultation was requested.
FSH|Fairview Southdale Hospital|FSH.|189|192|HISTORY|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD CHIEF COMPLAINT: Right neck and shoulder pain. HISTORY: Ms. _%#NAME#%_ _%#NAME#%_ is a 56-year-old right-hand dominant registration clerk at FSH. She presents FSH on _%#MMDD2004#%_ with intractable and progressive right upper __________ pain. She states it began about two weeks prior to admission, but got dramatically worse over the last week.
FSH|Fairview Southdale Hospital|FSH|364|366|HISTORY OF PRESENT ILLNESS|Her work up revealed ALL. She was found to have Philadelphia chromosome by FISH (62.5%), CSF was negative. _%#NAME#%_ was treated per COG protocol AALL_%#PROTOCOL#%_, she was able to achieve a morphologic remission however her Philadelphia chromosome has been followed over time at _%#NAME#%_ _%#NAME#%_ in the University of Minnesota Medical Center, Fairview, by FSH and PCR and has remained detectable at varying degrees through the course of her disease. _%#NAME#%_ completed her maintenance chemotherapy several weeks ago. Her last evaluation for Philadelphia chromosome was _%#MMDD2006#%_ due to evidence of minimal residual disease _%#NAME#%_ was referred to the University of Minnesota Medical Center, Fairview, she was seen on _%#MMDD2006#%_ by Dr _%#NAME#%_ _%#NAME#%_.
FSH|Fairview Southdale Hospital|FSH.|98|101|SOCIAL HISTORY|Medicines include Lexapro and Tobramax. ALLERGIES: Sulfa. SOCIAL HISTORY: She works as a nurse at FSH. She is a non-smoker and is married. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: HEENT: Migraine headaches as above. No recent changes in her vision or her hearing.
FSH|Fairview Southdale Hospital|FSH|133|135|REASON FOR CONSULTATION|Mr. _%#NAME#%_ is an 83-year-old gentleman who is well known to myself. He was seen in the past in _%#MM#%_. when he was admitted to FSH for bacteremia secondary to staph. At that time it was apparent that he had an infection in his right hip secondary to Methicillin resistant staph.
FSH|Fairview Southdale Hospital|FSH|169|171|HISTORY|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD CHIEF COMPLAINT: Left low back and leg pain. HISTORY: Ms. _%#NAME#%_ _%#NAME#%_ is an 87-year-old woman admitted through FSH ER on _%#MMDD2003#%_. She complains of a one month history of progressive left buttock and posterior thigh and calf pain. Nothing on the right side. No bowel or bladder problems other than constipation.
FSH|Fairview Southdale Hospital|FSH|145|147|PLAN|I explained to him if the erythema extends outside the line, we will need to change his antibiotics for better coverage. He was evaluated in the FSH ER.
FSH|Fairview Southdale Hospital|FSH|132|134|BRIEF HISTORY|REASON FOR CONSULTATION: Gallstones. BRIEF HISTORY: _%#NAME#%_ _%#NAME#%_ is a very pleasant 37-year-old female who was admitted to FSH on _%#MMDD2003#%_ with the chief complaint of abdominal pain. The patient reports that while she was out doing some Christmas shopping she stopped and had a cheeseburger and french fries from Burger King and afterwards had relatively acute onset of right upper quadrant epigastric abdominal pain.
FSH|Fairview Southdale Hospital|FSH|162|164||She fatigued on the way and decided to stop and sit on a bench. She somehow missed the bench when she sat down and fell injuring her left hip. She was brought to FSH where she was found to have a displaced femoral neck fracture and is admitted for orthopedic evaluation and management.
FSH|follicle-stimulating hormone|FSH|151|153|PLAN|Secondary to the surgery, it would be extremely important to evaluate her thyroid status. She has had a hysterectomy in the past and hence, her LH and FSH should be elevated. We will check status of her pituitary hormones. I will get her TSH, free T4, ACTH, prolactin, LH and FSH levels.
FSH|follicle-stimulating hormone|FSH|184|186|PROBLEM #5|Trying to determine whether the source of the adrenal insufficiency primary versus secondary, we did ask for some blood work-up. A TSH was 2.28. We did get ______ (?oxygen) free 0.74. FSH was 59.1, elevated and consistent with menopausal status of the patient. ACTH performed on _%#MMDD#%_ was 16, that was in the low level.
FSH|follicle-stimulating hormone|FSH,|140|143|PROBLEM #5|However, when the ACTH was drawn, the patient had been on hydrocortisone 100 mg IV q. 8 hours for more than 48 hours. We repeated ACTH, LH, FSH, TSH, adrenal antibody, antithyroid antibody and antithyroglobulin antibody, as well as ACTH, just the day of discharge, and those results are pending at the time of this dictation.
FSH|Fairview Southdale Hospital|FSH|196|198|HISTORY OF PRESENT ILLNESS|She called Blue Cross-Blue Shield nurse line and she was advised to have an emergency department evaluation. In the ER she had a CT of her head that was normal. She was admitted onto the floor at FSH in the coronary care section for further evaluation. She was placed on the stroke protocol. Troponins times there were negative.
FSH|follicle-stimulating hormone|FSH|479|481|PROBLEM #7|Urine sodium was obtained. A CTH stim test was obtained and was found to have an abnormal result with cortisol level drawn on _%#MMDD#%_ in the morning, being 1.0, which is low, and stim test with cortisol at 0 minutes being 2.3, 30 minutes being 7, and 60 minutes being 5.2. Vitamin D studies: Vitamin D 125 OH, vitamin D 25 OH, LH, and estradiol were all pending. A pelvic ultrasound of ovaries and adrenals was performed during this hospital admission and found to be normal. FSH level was also checked and found to be less than 0.3. The patient was continued on Synthroid 50 mcg p.o. daily, Calcitriol 0.25 mcg p.o. daily (which is an increase in dose from her admission medications), and hydrocortisone 2.5 mg p.o. b.i.d. DISCHARGE DIAGNOSIS: At discharge, the patient's principal diagnoses were: 1. Congenital heart disease.
FSH|follicle-stimulating hormone|FSH,|125|128|PNMC#|The patient has had a history of secondary in fertility. She previously underwent laboratory testing which included a normal FSH, DHEA sulfate, prolactin, and TSH. Review of the patient's ovulatory patterns showed a history of oligoovulation which was successfully corrected with Clomid.
FSH|Fairview Southdale Hospital|FSH.|147|150|HISTORY OF PRESENT ILLNESS|Her son quickly grabbed her and performed a partial Heimlich causing her to breath and they rushed the patient then immediately directly by car to FSH. There, the patient was noted to have a blood alcohol level of 0.49. Urine tox screen, salicylates and acetaminophen levels were normal.
FSH|follicle-stimulating hormone|FSH,|211|214|OPERATIONS/PROCEDURES THIS ADMISSION|The results are still awaited. The serial active protein was 62.1. Serum LDH was 523. The EKG did not show any conduction defects. A transthoracic echo has been performed and is pending. Hormone analysis of LH, FSH, prolactin, cortisol and estrogen levels are pending. The ANA screen was negative. The cancer screens using AFB, CEA and CA19-9 were negative.
FSH|follicle-stimulating hormone|FSH|122|124|HOSPITAL COURSE|Repeat ultrasound in _%#MM2001#%_ showed the mass to be stable. In _%#MM2001#%_ the mass had increased in size to 3.3 cm. FSH level was 43.4 consistent with menopause. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was recommended for further evaluation of the enlarging complex mass.
FSH|follicle-stimulating hormone|FSH,|198|201|ASSESSMENT/PLAN|The patient is overall hemodynamically stable currently, and so I do not feel that acute hydrocortisone/dexamethasone therapy is necessary. In the morning, we will repeat thyroid studies, and check FSH, LH, and a cosyntropin stimulation test. 3. Diabetes mellitus, type 2, insulin-dependent. Recent A1C was 8.0. If the patient is eating better, reduce insulin doses and cover in addition with sliding scale.
FSH|follicle-stimulating hormone|FSH|218|220|PROBLEM #7|Given the possibility of ovarian failure on chemotherapy, FSH, LH, estradiol, TSH, and T4 levels were obtained. It was discovered that indeed _%#NAME#%_ appears to have at least transient ovarian failure as her LH and FSH were quite elevated at 41.2 and 71.2 respectively. At the time of this dictation her estradiol level was still pending.
FSH|follicle-stimulating hormone|FSH,|232|235|PROBLEM #7|At the time of this dictation her estradiol level was still pending. TSH and T4 were within normal limits. Endocrinology was curbsided for consultation and recommended starting oral contraceptive pills as well as rechecking her LH, FSH, and estradiol levels in two weeks. PROBLEM #8: Psychological. _%#NAME#%_ continues to suffer from severe depression and anxiety.
FSH|follicle-stimulating hormone|FSH,|168|171|DISCHARGE INSTRUCTIONS|3. _%#NAME#%_ was instructed to follow up with Oncology Clinic on _%#MMDD2004#%_. At that time she will have a CBC as well as a complete metabolic panel along with LH, FSH, and estradiol levels drawn. 4. _%#NAME#%_ is instructed to follow up with Radiation Oncology per their plan. It was a pleasure to be involved in _%#NAME#%_'s care.
FSH|follicle-stimulating hormone|FSH,|216|219|DISCHARGE PLAN/FOLLOW UP|Problem #12: Ambiguous Genitalia. Because of the ambiguous genitalia, endocrinology was consulted. A pelvic ultrasound showed no uterus or ovaries but did show bilateral undescended testes. An endocrine panel of LH, FSH, and testosterone was sent. He had a normal testosterone, which points away from an etiology of androgen resistance or congenital adrenal hyperplasia.
FSH|follicle-stimulating hormone|FSH|212|214|ADMISSION LABORATORY|ADMISSION LABORATORY: Low hemoglobin on _%#MMDD2005#%_ requiring transfusion, otherwise, normal CBC and ANC. Normal BNP. Low albumin at 2.8. Normal IG levels. TSH 0.1. Thyroxine 1.27. Hepatitis B and C negative. FSH 20.7, lutropin 6.5, testosterone panel decreased. Low HDL (23). Normal insulin. Low transferrin (81). INR 1.48, PTT 51. Negative Aspergillus gal antigen.
FSH|follicle-stimulating hormone|FSH.|196|199|PAST GYN HISTORY|PAST SURGICAL HISTORY: 1. Tonsillectomy and adenoidectomy. 2. Wisdom teeth extraction. 3. Cystoscopy. PAST GYN HISTORY: She is a gravida 0, menopausal in _%#MM#%_ 2004, confirmed with an elevated FSH. The patient denies any history of sexually transmitted infections. She is never been on any hormone replacements. She is currently sexually active. She denies any history of abnormal Pap smears.
FSH|follicle-stimulating hormone|FSH|444|446|LABORATORY DATA|NEUROVASCULAR: Cranial nerves II through XII intact and nonfocal. Reflexes are intact. Mild tenderness. No drainage or erythema. LABORATORY DATA: On admission, white count 5.0, hemoglobin 14, hematocrit 41.6, platelets of 62,000, sodium is 142, potassium 3.6, chloride 105, CO2 27, BUN 13, potassium 0.86, glucose 106, magnesium 2.1, INR 1.07, PTT 26, AST 35, ALT 43, total protein 6.5, albumin 4, alkaline phosphatase 62, total bilirubin 0.6, FSH 12.4, lutropin 6.9, estradiol 28 and total testosterone 175. HOSPITAL COURSE: Mr. _%#NAME#%_ is a 28-year-old male with CMML/MDS, status post myeloablative peripheral blood stem cell transplant allogeneic sibling on _%#MMDD2007#%_.
FSH|follicle-stimulating hormone|FSH,|238|241|HOSPITAL COURSE|However, given the patient's family history and normal thyroid hormone, it was important to rule out a possible primary hyposecretion of TSH or hypopituitary syndrome. Thus, the patient was drawn for subsequent tropic hormones, including FSH, LH, and prolactin, to be followed by the Endocrine Service and the primary physician alerted if there is any evidence of abnormality and need for subsequent follow-up.
FSH|follicle-stimulating hormone|FSH|152|154|ASSESSMENT AND PLAN|4. Gynecologic: The patient has apparently had vaginal bleeding for the last 6weeks and had workup by gynecology as an outpatient rec ently. Will order FSH and LH at this time. She said she may have ovarian cysts which were noted on ultrasound as an outpatient. Will obtain records or information from patient. Bleeding may be causing some of her anemia, and will continue to monitor blood counts.
FSH|follicle-stimulating hormone|FSH|210|212|HISTORY OF PRESENT ILLNESS|I discussed the patient with Endocrine, with a recommendation that further hormonal studies be obtained to ensure normal pituitary function. Cortisol was normal at 19.8. Prolactin was 3. ACTH was normal at 15. FSH was normal at 4.9, with a mildly- reduced LH of 1.2. He had a normal total testosterone of 339. The basis for a low TSH is uncertain in light of a normal T3 and T4.
FSH|follicle-stimulating hormone|FSH|134|136|PLAN|It is possible that night sweats could be early symptom of menopause and we will check an FSH level to determine this. PLAN: 1. Check FSH (follicle stimulating hormone) to evaluate for early menopause. If this number is elevated above 23, that is consistent with menopause and in _%#NAME#%_'s situation would be considered premature ovarian failure.
FSH|follicle-stimulating hormone|FSH,|175|178|IMPRESSION|I will also arrange for laboratory tests for islet cell antibody. In addition, to these adrenal tests, I requested additional lab testing for TSH, free T4, prolactin IgF one, FSH, LH, estradiol and glucose. She may have autoimmune endocrine dysfunction, characterized by the vitiligo and new adrenal problem. In addition, I will request medical records from Dr. _%#NAME#%_ at the Mayo Clinic -_%#CITY#%_.
FSH|follicle-stimulating hormone|FSH.|276|279|PLAN|Steroids can suppress TSH levels significantly. Her TSH from before _%#MMDD#%_ admission at 1240 was suppressed and that value would seen have been drawn prior to the Solu-Medrol dose which was given later that day. PLAN: 1. Will await prolactin level. 2. To free T3 will add FSH. Given the fact she is certainly postmenopausal her FSH should be high. If it were low, this would be more evidence for hypopituitarism.
FSH|follicle-stimulating hormone|FSH|332|334|PLAN|Steroids can suppress TSH levels significantly. Her TSH from before _%#MMDD#%_ admission at 1240 was suppressed and that value would seen have been drawn prior to the Solu-Medrol dose which was given later that day. PLAN: 1. Will await prolactin level. 2. To free T3 will add FSH. Given the fact she is certainly postmenopausal her FSH should be high. If it were low, this would be more evidence for hypopituitarism. 3. Await previous labs as they are available from thyroid functions a year ago.
FSH|Fairview Southdale Hospital|FSH|253|255|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ _%#NAME#%_ is a very pleasant 57-year-old lady known to me from prior clinic visits, procedures and lastly from a clinic visit with myself two days ago. She was admitted to Fairview Southdale Hospital through FSH emergency room following a recurrent episode of syncope over the last 48 hours. Please see my note from two days ago in Minnesota Heart Clinic for details of her history.
FSH|follicle-stimulating hormone|FSH|223|225|LABORATORY AND OTHER DIAGNOSTIC DATA INCLUDE|Suspicious for seizure foci. 3. Urinalysis _%#MMDD2007#%_: Specific gravity 1.022, negative nitrites, negative leukocyte esterase, 3 white blood cells per high power field. 4. A.m. cortisol _%#MMDD2007#%_: Normal at 23. 5. FSH _%#MM2007#%_: 45. 6. LH _%#MM2007#%_: 37. 7. Prolactin 02/2007: Normal at 18. IMPRESSION: 1. History of simple partial and complex partia l epilepsy.
FSH|follicle-stimulating hormone|FSH|206|208|HISTORY|His morning Cortisol on _%#MMDD2003#%_ was 3.4. An ACTH level was not obtained. His free T4 was low at 0.61 and a TSH low normal at 0.88. In addition, his total testosterone level was low at 100, while his FSH and LH levels were both low normal with an FSH 1.5, LH 1.7. Free testosterone is pending. All other laboratory studies were unremarkable including a complete blood count.
FSH|Fairview Southdale Hospital|FSH|123|125|REASON FOR CONSULTATION|REASON FOR CONSULTATION: I am asked to see _%#NAME#%_ _%#NAME#%_ in cardiology consultation because of her presentation to FSH with upper subscapular discomfort associated with shortness of breath both with exertion and rest consistent with possible angina pectoris. HISTORY: The patient is a 58-year-old mildly overweight white female with a history of moderate to significant coronary artery disease.
FSH|Fairview Southdale Hospital|FSH|173|175|HISTORY|HISTORY: The patient is a 58-year-old mildly overweight white female with a history of moderate to significant coronary artery disease. She was recently was hospitalized at FSH overnight having had PTCA of 60- 70% proximal to mid right coronary artery lesion with a drug eluding stent that went without complication reducing the stenosis to 0%.
FSH|follicle-stimulating hormone|FSH,|229|232|ASSESSMENT|Associated visual blurring and nausea. Reasonable to check head CT to assure no structure abnormality. 7. Bilateral breast discomfort with reduction in axillary/pubic hair, etc. Reviewed with Endocrine. Will check prolactin, LH, FSH, estradiol, free T4, and free testosterone and beta HCG. 8. Gastroesophageal reflux disease. Continue with Zantac p.r.n. 9. Bilateral upper extremity eruption, exact etiology unclear.
FSH|follicle-stimulating hormone|FSH|263|265|LABORATORY|Tobacco and alcohol, none reported. LABORATORY: Serum cortisol - see HPI above. Recent sodium 138, potassium 4.4, glucose 101, creatinine 3.09, calcium 8.4, magnesium 1.9. Total testosterone 106 nanogram per deciliter (normal 241-827), free testosterone pending, FSH 22.1 (normal 1.4-18.1) LH 38.0 (normal 1.5-9.3). Urinalysis with specific gravity 1.025. TSH 0.79, free T4 1.03. ALT 34. FAMILY HISTORY: Cancer - breast, mother. Heart disease - father.
FSH|Fairview Southdale Hospital|FSH|137|139|SOCIAL HISTORY|FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Married, wife is also without site. Does not use alcohol or tobacco. Formerly worked at FSH in the x-ray film room. PHYSICAL EXAMINATION: GENERAL: Alert, somewhat lethargic 51-year-old man is already oriented and able to speak clearly.
FSH|Fairview Southdale Hospital|FSH|205|207|HOSPITAL COURSE|She had received three units of packed red blood cells as an outpatient on _%#MMDD2003#%_ prior to surgery due to anemia preoperatively. Her preoperative hemoglobin was 13.0 and she was taken to the OR at FSH on _%#MMDD2003#%_ where she underwent a total abdominal hysterectomy under general anesthesia. Estimated blood loss was 400 cc and intraoperatively there was an 18-20 week sized uterus with multiple fibroids throughout ranging from 2 cm to 8 cm size.
FSH|follicle-stimulating hormone|FSH|229|231|PREOPERATIVE PHYSICAL EXAMINATION  VITAL SIGNS|EXTREMITIES: Normal. No edema. Nontender. Transvaginal ultrasound done preoperatively showed subserosal fundal fibroid approximately 75 x 73 x 57 mm. There is also a persistent left ovarian cyst measuring 25 x 22 mm. Cycle day 3 FSH was 9.12, and estradiol was less than 20. FAMILY HISTORY: Significant for diabetes, hypertension, and renal problems with her mother.
FSH|follicle-stimulating hormone|FSH|206|208|PROBLEM #3|He did initially receive stress dose steroids for 1 day in the MICU, but this was stopped as he recovered rapidly with antibiotic treatment. He continues on his 10 mg of prednisone per day for replacement. FSH was checked and is normal at 2.5. Total testosterone was checked and was normal at 275. Growth hormone was checked and was normal at 0.2. Lutropin was checked and was normal at 3.4. TSH was checked and is 0.62. The patient continues on his Synthroid.
FSH|follicle-stimulating hormone|FSH|273|275|REASON FOR ADMISSION|DOB: _%#MMDD1957#%_ REASON FOR ADMISSION: The patient is a 46-year-old white female, gravida 4, para 1-0-2-1, who is admitted for a D&C for evaluation of probable postmenopausal bleeding. The patient has had off-and-on bleeding for the past eight weeks. The patient had an FSH test which recently measured 38.4. She was counseled that she was in the perimenopausal state on that basis. The patient had a normal Pap smear in _%#MM#%_ 2003 and all Pap smears have been normal in the past.
FSH|Fairview Southdale Hospital|FSH|196|198|BRIEF HISTORY|BRIEF HISTORY: _%#NAME#%_ _%#NAME#%_ is a 34-year-old, gravida 4 para 2-0-1-2, with EDC of _%#MMDD2006#%_ who was status post two previous cesarean sections who presented to Labor and Delivery at FSH on _%#MMDD2006#%_ in labor. Contractions began and were approximately every 2-5 minutes. She had no known rupture of membranes and no bleeding.
FSH|follicle-stimulating hormone|FSH.|248|251|PLAN|IMPRESSION: Postpartum day #1, status post normal spontaneous vaginal delivery, multipara, desires permanent sterilization, previous left salpingo-oophorectomy. PLAN: Postpartum tubal sterilization, unilateral right fallopian tube, _%#MMDD2005#%_, FSH. The procedure, pros, cons, risks and benefits were thoroughly explained to the patient. She understood the permanence, the failure rate and the essential irreversibility.
FSH|follicle-stimulating hormone|FSH|154|156|LABORATORY|The left side reveals a 2.5 x 1.3 x 2.1 cm cyst, possible endometrioma versus hemorrhagic cyst. LABORATORY: Lipid panel within normal limits. Glucose 87, FSH 3.8, prolactin 6, TSH 3.44 (all within normal limits). ASSESSMENT AND PLAN: A 29-year-old para 1-0-1-1 with a known history of endometriosis, now has persistent pelvic pain, possible endometrioma by ultrasound and subfertility (trying to conceive since _%#MM2005#%_).
FSH|follicle-stimulating hormone|FSH|165|167|LABORATORY DATA|Toes were downgoing. Gait: Normal base, natural and tandem gait. LABORATORY DATA: Cholesterol revealed triglycerides of 110, LDL 111, VLDL 22, HDL 40. Lutropin 1.3, FSH 1.2, TSH 3.59, prolactin 17, AM cortisol 20.2, testosterone level 115. Urinalysis was negative, as well as urine culture. B12 was 471, folate 14.3, ESR 3.
FSH|follicle-stimulating hormone|FSH|184|186|ASSESSMENT|7. History of seizure related to Soma and SSRI medication. 8. Surgeries as above including hysterectomy and left salpingo- oophorectomy for cervical cancer. Reasonable to check LH and FSH with issue of hot flashes. The patient is in need of primary care follow- up. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. If ECT contemplated, the patient has no complaints or findings to contraindicate from a medical standpoint.
FSH|follicle-stimulating hormone|FSH|172|174|RECOMMENDATIONS|Her laboratory evaluation so far included an albumin of 4, ALT 16, bilirubin 0.3. Her creatinine is 0.53, and her BUN is 10. Estradiol is pending. Her ferritin is 825. Her FSH is 2.3. Her thyroxine free is 1.06. Her hemoglobin S is 20.3%. Her white blood count is 11.1 and hemoglobin 9. Her absolute neutrophil count is 4.8. LDH is 1,056. Her TSH is 321.
FSH|Fairview Southdale Hospital|FSH|130|132|REASON FOR CONSULTATION|REASON FOR CONSULTATION: I have been asked to see _%#NAME#%_ _%#NAME#%_ in cardiology consultation because of his presentation to FSH with history of chest discomfort, status post coronary intervention. HISTORY: The patient is a 68-year-old overweight white male with a history of ischemic heart disease dating back to 1989 when he had coronary bypass surgery with a LIMA to the LAD and a sequential saphenous vein bypass graft to the posterolateral and posterior descending branches of the right coronary artery.
FSH|follicle-stimulating hormone|FSH|177|179|PREOPERATIVE LABORATORY DATA|GENITALIA: Penis is normally developed. Testes are 20 mL bilaterally, normal size and consistency. PREOPERATIVE LABORATORY DATA: TSH 0.95, free T4 0.87, total testosterone 157, FSH 4.7, LH 3, prolactin 8, growth hormone 0.1, IgF-1 103( which is in the lower end of normal), alpha-subunit pituitary glycoprotein was 0.19(which is in the normal range), random cortisol 7.2, ACTH 20.
FSH|Fairview Southdale Hospital|FSH|212|214|HISTORY|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD CHIEF COMPLAINT: Low back pain. HISTORY: Mr. _%#NAME#%_ _%#NAME#%_ is a 39-year-old self-employed subcontractor. He is working for Sela Roofing. He was admitted to FSH through the emergency room on _%#MMDD2004#%_ with complaints of low back pain following a fall off a ladder 15-20 feet. He thinks he landed on his feet. There was some possible loss of consciousness.
FSH|follicle-stimulating hormone|FSH|114|116|HISTORY OF PRESENT ILLNESS|2. Endocrine: The patient had some abnormalities in endocrine labs. TSH was 0.19, free T4 was 0.95, T3 of 39, and FSH was 4.4. It was thought that the patient may be hypopituitary, possibly related to her brain metastases and/or previous brain irradiation.
FSH|Fairview Southdale Hospital|FSH|130|132|REASON FOR CONSULTATION|REASON FOR CONSULTATION: I have been asked to see _%#NAME#%_ _%#NAME#%_ in cardiology consultation because of the presentation to FSH with a left lower lobe pneumonia and atrial fibrillation of unclear duration. HISTORY: The patient is a pleasant 84-year-old slender, somewhat frail appearing white male who is admitted to FSH ICU with the diagnosis of left lower lobe pneumonia, presumed new onset atrial fibrillation, melena, COPD, and previous history of colitis.
FSH|follicle-stimulating hormone|FSH|167|169|HISTORY OF PRESENT ILLNESS|The patient's past history is significant in that she had a previous myomectomy done in 1986. Currently she has once again an enlarged uterus. In _%#MM#%_ of 2004 her FSH was 56.5 and estradiol was 25.3. She had a history of abnormal bleeding in the month or two prior to this. Because of her abnormal bleeding and the fact that it is unclear whether she was menopausal or not she had an ultrasound done on _%#MMDD2003#%_ which showed many fibroids, the largest of which was 6.0-cm in size.
FSH|Fairview Southdale Hospital|FSH.|141|144|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Osteoporosis. 2. Palpitations. 3. AV conduction system dysfunction. 4. Previous aortic valve replacement in 1996 at FSH. 5. AV conduction system dysfunction with previous pacemaker placed. 6. Well preserved LV function and no significant coronary disease noted.
FSH|follicle-stimulating hormone|FSH|161|163|ESTIMATED BLOOD LOSS|She was treated with Unasyn initially and then switched to Cipro 500 b.i.d. x7 days. PSYCH: The patient is on Geodon 120 mg b.i.d. for schizophrenia. ENDOCRINE: FSH was measured postoperatively. It was in the normal range. It was 7.3. It is recommended that another FSH be done at her postoperative visit to evaluate her ovarian status.
FSH|follicle-stimulating hormone|FSH|219|221|HISTORY OF PRESENT ILLNESS|She is presently on Paxil and Wellbutrin and under the care of a psychiatrist but her cycles are exacerbating her major depressive disorder. In _%#MM#%_, she had an endometrial biopsy which was benign. At that time, an FSH was 11.3, not consistent with perimenopause. She had an older sister who did not experience menopause until her late 50's.
GT|gastrostomy tube|GT|221|222|PHYSICAL EXAMINATION|His chest exam showed an intact Hickman line without erythema or drainage from the blind site. CARDIOVASCULAR: Showed regular rate and rhythm without murmur. ABDOMEN: His abdomen was soft, tender and nondistended. He has GT site that was clean, dry and intact. GENITALIA: Exam showed normal male anatomy. His testes were descended bilaterally. MUSCULOSKELETAL: Exam showed normal tone and was moving all extremities normally.
GT|gastrostomy tube|GT|214|215|DISCHARGE MEDICATIONS|8. Bilateral pleural effusions. DISCHARGE MEDICATIONS: The patient will have NEPRO tube feedings with two packets of Beneprotein a day at 90 ml per one hour. Changed doses: 1. Carbidopa/levodopa 25/100 two tablets GT daily. 2. Carbidopa/levodopa 25/100 one tablet GT at 1000, at 1400, at 1800, and at 2200. 3. Luvox 300 mg p.o. every day at bed-time, changed from 400 mg daily, as the maximum daily dose of fluvoxamine is 300 mg daily.
GT|gastrostomy tube|GT|264|265|DISCHARGE MEDICATIONS|8. Bilateral pleural effusions. DISCHARGE MEDICATIONS: The patient will have NEPRO tube feedings with two packets of Beneprotein a day at 90 ml per one hour. Changed doses: 1. Carbidopa/levodopa 25/100 two tablets GT daily. 2. Carbidopa/levodopa 25/100 one tablet GT at 1000, at 1400, at 1800, and at 2200. 3. Luvox 300 mg p.o. every day at bed-time, changed from 400 mg daily, as the maximum daily dose of fluvoxamine is 300 mg daily.
GT|gastrostomy tube|GT.|237|239|DISCHARGE MEDICATIONS|3. Luvox 300 mg p.o. every day at bed-time, changed from 400 mg daily, as the maximum daily dose of fluvoxamine is 300 mg daily. Unchanged: 1. Darbepoetin 100 mcg subcutaneous q. 2 weeks. 2. Multivitamin one GT. daily. 3. Protonix 20 mg GT. daily. 4. Quetiapine 75 mg GT every day at bed-time. 5. Trazodone 75 mg GT every day at bed-time. 6 ALL MEDICATIONS MUST BE GIVEN THROUGH G-TUBE.
GT|gastrostomy tube|GT|146|147|DISCHARGE MEDICATIONS|3. Seizure disorder. 4. Dehydration. 5. Nutrition. 6. Magnetic resonance cholangiopancreatography. DISCHARGE MEDICATIONS: 1. Claritin syrup 10 mg GT daily. 2. Trileptal suspension 600 mg GT q.a.m. and 900 mg GT each day at bedtime. 3. Zantac syrup 75 mg GT b.i.d. 4. Phenobarbital tablets 135 mg GT each day at bedtime.
GT|gastrostomy tube|GT|155|156|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Claritin syrup 10 mg GT daily. 2. Trileptal suspension 600 mg GT q.a.m. and 900 mg GT each day at bedtime. 3. Zantac syrup 75 mg GT b.i.d. 4. Phenobarbital tablets 135 mg GT each day at bedtime. 5. Singulair 5 mg GT each day at bedtime. 6. A plus D ointment topical t.i.d. apply to gastrostomy for dermal rash.
GT|gastrostomy tube|GT|140|141|DISCHARGE MEDICATIONS|2. Trileptal suspension 600 mg GT q.a.m. and 900 mg GT each day at bedtime. 3. Zantac syrup 75 mg GT b.i.d. 4. Phenobarbital tablets 135 mg GT each day at bedtime. 5. Singulair 5 mg GT each day at bedtime. 6. A plus D ointment topical t.i.d. apply to gastrostomy for dermal rash.
GT|gastrostomy tube|GT|169|170|DISCHARGE MEDICATIONS|7. Benzoyl peroxide 10% topical q.a.m. apply to affected area. 8. Tretinoin 0.1% cream topical each day at bedtime, apply to affected area. 9. Baclofen suspension 30 mg GT b.i.d. and 20 mg GT q. day. 10. Prednisolone syrup 30 mg GT b.i.d. (5 day course stop on _%#MMDD2006#%_). 11. Tetracycline 500 mg GT b.i.d. 12. Clindamycin solution 450 mg GT q.i.d. as close to q.6h. as possible when awake (stop on _%#MMDD2006#%_).
GT|gastrostomy tube|GT|166|167|DISCHARGE MEDICATIONS|8. Tretinoin 0.1% cream topical each day at bedtime, apply to affected area. 9. Baclofen suspension 30 mg GT b.i.d. and 20 mg GT q. day. 10. Prednisolone syrup 30 mg GT b.i.d. (5 day course stop on _%#MMDD2006#%_). 11. Tetracycline 500 mg GT b.i.d. 12. Clindamycin solution 450 mg GT q.i.d. as close to q.6h. as possible when awake (stop on _%#MMDD2006#%_).
GT|gastrostomy tube|GT|162|163|DISCHARGE MEDICATIONS|9. Baclofen suspension 30 mg GT b.i.d. and 20 mg GT q. day. 10. Prednisolone syrup 30 mg GT b.i.d. (5 day course stop on _%#MMDD2006#%_). 11. Tetracycline 500 mg GT b.i.d. 12. Clindamycin solution 450 mg GT q.i.d. as close to q.6h. as possible when awake (stop on _%#MMDD2006#%_). 13. Pulmicort Respules 1 vial nebulizer b.i.d. 14. Albuterol 2.5 mg/3mL 2.5 mg solution nebulized q.2h. p.r.n. shortness of breath.
GT|gastrostomy tube|GT|144|145|DISCHARGE MEDICATIONS|10. Prednisolone syrup 30 mg GT b.i.d. (5 day course stop on _%#MMDD2006#%_). 11. Tetracycline 500 mg GT b.i.d. 12. Clindamycin solution 450 mg GT q.i.d. as close to q.6h. as possible when awake (stop on _%#MMDD2006#%_). 13. Pulmicort Respules 1 vial nebulizer b.i.d. 14. Albuterol 2.5 mg/3mL 2.5 mg solution nebulized q.2h. p.r.n. shortness of breath.
GT|gastrostomy tube|GT|135|136|HOSPITAL COURSE|4. Nutrition - nutrition consult was placed for this patient. The recommendation was to increase his GT feeds by 10%. As a result, his GT feeds were increased to 330 mL q.i.d. and his free water boluses were reduced to 175 mL q.i.d. 5. Seizure disorder - no further seizure activity was witnessed during the patient's hospital stay.
GT|gastrostomy tube|GT|125|126|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Zovirax 400 mg GT q.8 h. 2. Amiodarone 200 mg GT b.i.d. 3. Aspirin 81 mg GT daily. 4. Cipro 500 mg GT b.i.d. 5. Fluconazole 200 mg GT daily. 6. Lasix 20 mg GT daily. 7. Lantus 400 units subcutaneous q.h.s.
GT|gastrostomy tube|GT|157|158|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Zovirax 400 mg GT q.8 h. 2. Amiodarone 200 mg GT b.i.d. 3. Aspirin 81 mg GT daily. 4. Cipro 500 mg GT b.i.d. 5. Fluconazole 200 mg GT daily. 6. Lasix 20 mg GT daily. 7. Lantus 400 units subcutaneous q.h.s. 8. Nystatin 1 million units GT q.6 h. 9. Protonix 40 mg GT daily.
GT|gastrostomy tube|GT|131|132|DISCHARGE MEDICATIONS|2. Amiodarone 200 mg GT b.i.d. 3. Aspirin 81 mg GT daily. 4. Cipro 500 mg GT b.i.d. 5. Fluconazole 200 mg GT daily. 6. Lasix 20 mg GT daily. 7. Lantus 400 units subcutaneous q.h.s. 8. Nystatin 1 million units GT q.6 h. 9. Protonix 40 mg GT daily. 10. Prednisone 10 mg GT daily. 11. Singulair 10 mg GT daily.
GT|gastrostomy tube|GT|174|175|DISCHARGE MEDICATIONS|10. Prednisone 10 mg GT daily. 11. Singulair 10 mg GT daily. 12. Vancomycin 1 g IV daily. 13. Coumadin 2 mg GT daily. 14. Insulin sliding scale. 15. Tylenol 650 mg rectal or GT q.6 h. p.r.n. The patient has been cultured on _%#MMDD2004#%_. If results are positive, they will be reported to the nursing facility.
GT|gastrostomy tube|GT|193|194|DISCHARGE MEDICATIONS|3. Lost GJ tube. PROCEDURES PERFORMED: Replacement of GJ tube under fluoroscopy. DISCHARGE MEDICATIONS: 1. Nystatin 5 mg per GT t.i.d. 2. Lovenox 12 mg subcutaneous b.i.d. 3. Azulfidine 250 mg GT q.6 h. 4. Betaine 1950 mg GT q.a.m., 658 mg GT q. noon and q.p.m. 5. Pulmicort 0.5 mg nebs b.i.d.
GT|gastrostomy tube|GT|141|142|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Nystatin 5 mg per GT t.i.d. 2. Lovenox 12 mg subcutaneous b.i.d. 3. Azulfidine 250 mg GT q.6 h. 4. Betaine 1950 mg GT q.a.m., 658 mg GT q. noon and q.p.m. 5. Pulmicort 0.5 mg nebs b.i.d. 6. Vancomycin 400 mg IV q.12 h. 7. Gentamicin 70 mg IV q.12 h. x 1 week, then to be discussed with Dr _%#NAME#%_.
GT|gastrostomy tube|GT|134|135|DISCHARGE MEDICATIONS|6. Vancomycin 400 mg IV q.12 h. 7. Gentamicin 70 mg IV q.12 h. x 1 week, then to be discussed with Dr _%#NAME#%_. 8. Tobramycin 50 mg GT t.i.d. FOLLOW-UP PLAN: 1. Follow up with Dr _%#NAME#%_ in one month.
GT|gastrostomy tube|GT|129|130|DISCHARGE MEDICATIONS|He had no other infectious disease issues. Discharge Date: _%#MM#%_ _%#DD#%_, 2005. DISCHARGE MEDICATIONS: 1. Lasix 8 mg p.o. or GT b.i.d. 2. Aldactone 8 mg p.o. or GT b.i.d. 3. Prevacid 7.5 mg p.o. or GT daily. 4. Tylenol 80 mg p.o. or GT q.4-6 h. p.r.n. pain.
GT|gastrostomy tube|GT|118|119|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Lasix 8 mg p.o. or GT b.i.d. 2. Aldactone 8 mg p.o. or GT b.i.d. 3. Prevacid 7.5 mg p.o. or GT daily. 4. Tylenol 80 mg p.o. or GT q.4-6 h. p.r.n. pain. 5. Tylenol 360 mg p.o. or GT q.4-6 h. p.r.n. pain.
GT|gastrostomy tube|GT|149|150|DISCHARGE MEDICATIONS|2. Aldactone 8 mg p.o. or GT b.i.d. 3. Prevacid 7.5 mg p.o. or GT daily. 4. Tylenol 80 mg p.o. or GT q.4-6 h. p.r.n. pain. 5. Tylenol 360 mg p.o. or GT q.4-6 h. p.r.n. pain. FOLLOW UP: _%#NAME#%_ has a follow up appointment with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2005, at 8:30 a.m.
GT|gastrostomy tube|GT|167|168|ADMISSION DIAGNOSIS|Extremities have no clubbing, cyanosis, or edema. Pedal pulses are present. HOSPITAL COURSE: The patient was admitted on _%#MM#%_ _%#DD#%_, 2002, and was continued on GT that she has been at home with the same solution that has been adjusted for her electrolyte status. The patient was started on hydration and an NG tube was inserted that put out about 2 L a day every day.
GT|gastrostomy tube|GT|164|165|PHYSICAL EXAMINATION|Urinalysis shows 2-5 reds and many bacteria, culture pending. PT was 1.08, PTT was 32, lipase 50, AST 82, ALT 53, all of which were improved. Alcohol was negative. GT one month ago was 338. Diabetes hemoglobin A1c one month ago was 4.0. CRP at that point on _%#MMDD#%_ was 0.18. Alk phos today 263, total protein 5.0, albumin 2.0 and bilirubin 2.0. ASSESSMENT: Pneumonia, asthma, asplenic, rule out UTI, hypokalemia, recent TIA, increasing MCV with underlying liver disease, malnutrition, possible hyperparathyroidism, recent TIA see workup with Dr. _%#NAME#%_ _%#NAME#%_ as noted above.
GT|gastrostomy tube|GT|212|213|PAST SURGICAL HISTORY|PAST MEDICAL HISTORY: Muscular dystrophy. Pancreatic pseudocyst. Asthma. MRSA pneumonitis. C. difficile colitis. Adult- onset diabetes mellitus. PAST SURGICAL HISTORY: Appendectomy, cholecystectomy, tracheotomy, GT tube placement, oophorectomy ALLERGIES: Reported to Pneumovax with a reaction of breathing difficulties and increased blood pressure.
GT|gastrostomy tube|GT|148|149|ALLERGIES|2. CellCept 200 mg GT b.i.d. 3. Poly-Vi-Sol 1 mL p.o. daily. 4. Amlodipine 2.5 mg GT b.i.d. 5. Ferrous sulfate 22 mg p.o. t.i.d. 6. Prednisone 4 mg GT q.a.m., continue previously scheduled prednisone taper. 7. Sulfatrim 2.5 mL p.o. daily. 8. Nystatin 4 mL p.o. swish and spit q.i.d. 9. Valcyte 50 mg G tube b.i.d. 10. Prevacid 10 mg p.o. daily.
GT|gastrostomy tube|GT|159|160|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Klonopin 0.125 mg JT b.i.d. 2. Felbamate 240 mg JT nightly, 480 mg JT q.a.m. and q. noon. 3. Keppra 150 mg JT t.i.d. 4. MiraLax 17 g GT daily, dissolved in 8 ounces of water. 5. Zofran 1.5 mg JT b.i.d. 6. Phenobarbital 20 mg JT b.i.d. 7. Reglan 1 mg JT q.i.d. and 0.5 mg 15 minutes prior to melatonin.
GT|gastrostomy tube|GT|122|123|DISCHARGE MEDICATIONS|2. Ceftin 500 mg p.o. suspension shake well b.i.d. x7 days. 3. Cromolyn inhaler 2 puffs inhale t.i.d. 4. Synthroid 25 mcg GT suspension q. day. 5. Loratadine 10 mg p.o. syrup q. day. 6. Depakene 125 mg G-tube syrup t.i.d. 7. Tylenol 325 mg p.o. q.6 h. p.r.n.
GT|gastrostomy tube|GT|138|139|ADMISSION LABORATORY STUDIES|Lipase was 54, albumin 3.7, amylase 66, total bilirubin 0.3, alkaline phosphatase was 97, INR 0.94, fibrinogen 103, D-dimer 0.2, LD 1093, GT was greater than 60 seconds, ALT 73, AST 43. Hepatitis surface antibody was positive. Hepatitis B surface antigen negative.
GT|gastrostomy tube|GT|126|127|DISCHARGE INSTRUCTIONS|3. Tube feeds, Fiber Source HN, 300 cc q.i.d. followed up by 125 cc of free water after each meal. 4. Wound cares: A. Routine GT tube cares. B. Rinse mouth with normal saline a minimum of three times a day and suction mouth with a red rubber catheter.
GT|gastrostomy tube|GT.|221|223|DISCHARGE MEDICATIONS|Problem #5. Chronic interstitial nephritis: Her kidney function was monitored during her stay and creatinine remained in her general baseline of 1.3 to 1.4. DISCHARGE MEDICATIONS: 1. Atenolol 20 mg q. a.m., 30 mg q. p.m. GT. 2. Rocaltrol 0.5 mcg q. p.m. GT. 3. Os-Cal 1500 mg q. p.m. GT. 4. Unifiber 1 tablespoon b.i.d. GT. 5. Cimetidine 120 mg q. h.s. GT.
GT|gastrostomy tube|GT.|254|256|DISCHARGE MEDICATIONS|Problem #5. Chronic interstitial nephritis: Her kidney function was monitored during her stay and creatinine remained in her general baseline of 1.3 to 1.4. DISCHARGE MEDICATIONS: 1. Atenolol 20 mg q. a.m., 30 mg q. p.m. GT. 2. Rocaltrol 0.5 mcg q. p.m. GT. 3. Os-Cal 1500 mg q. p.m. GT. 4. Unifiber 1 tablespoon b.i.d. GT. 5. Cimetidine 120 mg q. h.s. GT. 6. Enoxaparin 15 mg subcutaneous b.i.d. Dosing change, reduced, from 30 mg daily.
GT|gastrostomy tube|GT.|128|130|DISCHARGE MEDICATIONS|2. Rocaltrol 0.5 mcg q. p.m. GT. 3. Os-Cal 1500 mg q. p.m. GT. 4. Unifiber 1 tablespoon b.i.d. GT. 5. Cimetidine 120 mg q. h.s. GT. 6. Enoxaparin 15 mg subcutaneous b.i.d. Dosing change, reduced, from 30 mg daily. 7. Folic acid 1 mg b.i.d. GT. 8. Lactobacillus 1 capsule daily GT.
GT|gastrostomy tube|GT.|104|106|DISCHARGE MEDICATIONS|1. Atenolol 20 mg q. a.m., 30 mg q. p.m. GT. 2. Rocaltrol 0.5 mcg q. p.m. GT. 3. Os-Cal 1500 mg q. p.m. GT. 4. Unifiber 1 tablespoon b.i.d. GT. 5. Cimetidine 120 mg q. h.s. GT. 6. Enoxaparin 15 mg subcutaneous b.i.d. Dosing change, reduced, from 30 mg daily.
GT|gastrostomy tube|GT.|140|142|DISCHARGE MEDICATIONS|1. Atenolol 20 mg q. a.m., 30 mg q. p.m. GT. 2. Rocaltrol 0.5 mcg q. p.m. GT. 3. Os-Cal 1500 mg q. p.m. GT. 4. Unifiber 1 tablespoon b.i.d. GT. 5. Cimetidine 120 mg q. h.s. GT. 6. Enoxaparin 15 mg subcutaneous b.i.d. Dosing change, reduced, from 30 mg daily. 7. Folic acid 1 mg b.i.d. GT. 8. Lactobacillus 1 capsule daily GT.
GT|gastrostomy tube|GT.|108|110|DISCHARGE MEDICATIONS|6. Enoxaparin 15 mg subcutaneous b.i.d. Dosing change, reduced, from 30 mg daily. 7. Folic acid 1 mg b.i.d. GT. 8. Lactobacillus 1 capsule daily GT. 9. Flax seed oil 15 mg q. h.s. GT. 10. Noni juice supplement 30 mL b.i.d. GT. 11. Multivitamin 15 mL q. h.s. GT.
GT|gastrostomy tube|GT.|145|147|DISCHARGE MEDICATIONS|6. Enoxaparin 15 mg subcutaneous b.i.d. Dosing change, reduced, from 30 mg daily. 7. Folic acid 1 mg b.i.d. GT. 8. Lactobacillus 1 capsule daily GT. 9. Flax seed oil 15 mg q. h.s. GT. 10. Noni juice supplement 30 mL b.i.d. GT. 11. Multivitamin 15 mL q. h.s. GT.
GT|gastrostomy tube|GT.|141|143|DISCHARGE MEDICATIONS|7. Folic acid 1 mg b.i.d. GT. 8. Lactobacillus 1 capsule daily GT. 9. Flax seed oil 15 mg q. h.s. GT. 10. Noni juice supplement 30 mL b.i.d. GT. 11. Multivitamin 15 mL q. h.s. GT. 12. Vitamin B 6 25 mg b.i.d. GT. 13. Sodium chloride 2.4 gm q. h.s. mixed in 940 mL of water every night.
GT|gastrostomy tube|GT.|109|111|DISCHARGE MEDICATIONS|9. Flax seed oil 15 mg q. h.s. GT. 10. Noni juice supplement 30 mL b.i.d. GT. 11. Multivitamin 15 mL q. h.s. GT. 12. Vitamin B 6 25 mg b.i.d. GT. 13. Sodium chloride 2.4 gm q. h.s. mixed in 940 mL of water every night. 14. Free water flushes 220 mL 5 times a day.
GT|gastrostomy tube|GT.|147|149|DISCHARGE MEDICATIONS|13. Sodium chloride 2.4 gm q. h.s. mixed in 940 mL of water every night. 14. Free water flushes 220 mL 5 times a day. 15. Diazepam 2 mg q. 6 hours GT. 16. Tylenol with codeine 12.5 mL q. 6 hours GT. 17. Vistaril 15 mg q. 6 hours GT. General diet as tolerated. Activities per Orthopedics. She is discharged with a continuous passive motion machine which she should use 3 times a day flexing her from 0 to 35 degrees.
GT|gastrostomy tube|GT.|122|124|DISCHARGE MEDICATIONS|14. Free water flushes 220 mL 5 times a day. 15. Diazepam 2 mg q. 6 hours GT. 16. Tylenol with codeine 12.5 mL q. 6 hours GT. 17. Vistaril 15 mg q. 6 hours GT. General diet as tolerated. Activities per Orthopedics. She is discharged with a continuous passive motion machine which she should use 3 times a day flexing her from 0 to 35 degrees.
GT|gastrostomy tube|GT.|111|113|DISCHARGE MEDICATIONS|15. Diazepam 2 mg q. 6 hours GT. 16. Tylenol with codeine 12.5 mL q. 6 hours GT. 17. Vistaril 15 mg q. 6 hours GT. General diet as tolerated. Activities per Orthopedics. She is discharged with a continuous passive motion machine which she should use 3 times a day flexing her from 0 to 35 degrees.
GT|gastrostomy tube|GT|170|171|PRINCIPAL DISCHARGE DIAGNOSES|Severe hypercalcemia. 4. History of squamous cell carcinoma of the tongue, recurrent, status post surgery with metastases to the spine. 5. Hypertension. 6. Dysphagia. 7. GT of site infection. 8. Chronic disease anemia. 9. Malnutrition. PROCEDURES PERFORMED: 1. Chest x-ray. 2. X-ray of abdomen. CONSULTATIONS: None. BRIEF HISTORY OF THIS ADMISSION: This is a 54-year-old man with history of recurrent squamous cell carcinoma of the right side of the tongue status post surgery, history of dysphagia, history of aspiration pneumonia, history of respiratory failure, and history of squamous cell carcinoma to bone on radiation treatment who was admitted to the University of Minnesota Medical Center Transitional Care Unit for continuation of medical treatment, physical therapy, occupational therapy for deconditioning, speech therapy, and palliative care.
GT|glutamyl transpeptidase|GT|231|232|PROBLEMS|Creatinine 0.70, K+ 3.3, INR 1.1, lactic 1.1, BNP 121, normal folic acid and B12, phosphorus 2.5. PROBLEMS: 1. Gastrointestinal: He does have elevated transaminases possibly due to high CK or primary hepatic injury. Followup gamma GT was 3815, and his Ferritin was 4869; however, during his hospitalization, the ferritin dropped significantly. Ceruloplasmin 36. The iron saturation was 23 % and diagnosis of hematochromatosis was highly unlikely.
GT|gastrostomy tube|GT|134|135|DISCHARGE MEDICATIONS|The patient was started on half a packet of Lactobacillus q.i.d. until his diarrhea resolved. DISCHARGE MEDICATIONS: 1. Aspirin 41 mg GT q. day. 2. Aldactone 9 mg GT b.i.d. 3. Bumex 0.15 mg GT b.i.d. 4. Captopril 1.5 mg GT t.i.d. 5. Hydrochlorothiazide 5 mg GT t.i.d.
GT|gastrostomy tube|GT|190|191|DISCHARGE MEDICATIONS|The patient was started on half a packet of Lactobacillus q.i.d. until his diarrhea resolved. DISCHARGE MEDICATIONS: 1. Aspirin 41 mg GT q. day. 2. Aldactone 9 mg GT b.i.d. 3. Bumex 0.15 mg GT b.i.d. 4. Captopril 1.5 mg GT t.i.d. 5. Hydrochlorothiazide 5 mg GT t.i.d. 6. Protonix 5 mg GT b.i.d. 7. Reglan 0.6 mg GT q.i.d., held until diarrhea resolves.
GT|gastrostomy tube|GT|168|169|DISCHARGE MEDICATIONS|4. Captopril 1.5 mg GT t.i.d. 5. Hydrochlorothiazide 5 mg GT t.i.d. 6. Protonix 5 mg GT b.i.d. 7. Reglan 0.6 mg GT q.i.d., held until diarrhea resolves. 8. Viagra 5 mg GT q.8 h. 9. Potassium supplements 5 mEq GT b.i.d. 10. Ferrous sulfate 3 mg GT b.i.d. 11. Viokase 6000 units GT q.i.d.
GT|gastrostomy tube|GT|124|125|DISCHARGE MEDICATIONS|8. Viagra 5 mg GT q.8 h. 9. Potassium supplements 5 mEq GT b.i.d. 10. Ferrous sulfate 3 mg GT b.i.d. 11. Viokase 6000 units GT q.i.d. 12. Atrovent 2 puffs nebulizer b.i.d. 13. Flovent 1 puff nebulizer b.i.d. 14. Xopenex 0.2 mg nebulizer t.i.d. p.r.n. shortness of breath.
GT|gastrostomy tube|GT|131|132|DISCHARGE MEDICATIONS|14. Xopenex 0.2 mg nebulizer t.i.d. p.r.n. shortness of breath. 15. Bactroban cream 2% to GT site. 16. Lactobacillus half a packet GT q.i.d. p.r.n. diarrhea. DISCHARGE FOLLOWUP: As previously mentioned, given the patient's hypernatremia on discharge, the patient's mother agreed to try a blood sample for sodium electrolyte levels and bring it to a local lab for processing.
GT|gastrostomy tube|GT|176|177|DISCHARGE MEDICATIONS|DISCHARGE DIAGNOSES: 1. Anemia secondary to liver laceration from displaced G-tube following fastener erosion. 2. Possible pneumonia. DISCHARGE MEDICATIONS: 1. Amlodipine 5 mg GT daily. (Re-started this admission. The patient has been on 10 mg in the past.) 2. Lasix 20 mg p.o. twice a day. (Increased to twice a day from daily this admission - this twice a day is for usual dosage.)
GT|gastrostomy tube|GT|151|152|DISCHARGE MEDICATIONS|2. Lasix 20 mg p.o. twice a day. (Increased to twice a day from daily this admission - this twice a day is for usual dosage.) 3. Gabapentin 300 mg per GT daily. 4. Losartan 75 mg GT daily. (This is increased from 50 mg this admission.) 5. Metoclopramide 10 mg GT four times daily p.r.n. nausea and vomiting added this admission to improve gastric motility.
GT|gastrostomy tube|GT|179|180|DISCHARGE MEDICATIONS|2. Lasix 20 mg p.o. twice a day. (Increased to twice a day from daily this admission - this twice a day is for usual dosage.) 3. Gabapentin 300 mg per GT daily. 4. Losartan 75 mg GT daily. (This is increased from 50 mg this admission.) 5. Metoclopramide 10 mg GT four times daily p.r.n. nausea and vomiting added this admission to improve gastric motility.
GT|gastrostomy tube|GT|245|246|DISCHARGE MEDICATIONS|(This is increased from 50 mg this admission.) 5. Metoclopramide 10 mg GT four times daily p.r.n. nausea and vomiting added this admission to improve gastric motility. 6. Miconazole 2% powder to inner thighs twice a day. 7. Senokot-S 2 tabs per GT daily p.r.n. constipation. 8. Acetaminophen 500 to 1000 mg per GT q.4 h. p.r.n. pain. 9. Naproxen 250 mg per GT daily. 10. Calcium plus D 600/200 1 per GT daily.
GT|gastrostomy tube|GT|143|144|DISCHARGE MEDICATIONS|6. Miconazole 2% powder to inner thighs twice a day. 7. Senokot-S 2 tabs per GT daily p.r.n. constipation. 8. Acetaminophen 500 to 1000 mg per GT q.4 h. p.r.n. pain. 9. Naproxen 250 mg per GT daily. 10. Calcium plus D 600/200 1 per GT daily. 11. ASA 81 mg per GT daily. 12. Metoprolol 75 mg per GT twice a day.
GT|gastrostomy tube|GT|136|137|DISCHARGE MEDICATIONS|7. Senokot-S 2 tabs per GT daily p.r.n. constipation. 8. Acetaminophen 500 to 1000 mg per GT q.4 h. p.r.n. pain. 9. Naproxen 250 mg per GT daily. 10. Calcium plus D 600/200 1 per GT daily. 11. ASA 81 mg per GT daily. 12. Metoprolol 75 mg per GT twice a day.
GT|gastrostomy tube|GT|129|130|DISCHARGE MEDICATIONS|9. Naproxen 250 mg per GT daily. 10. Calcium plus D 600/200 1 per GT daily. 11. ASA 81 mg per GT daily. 12. Metoprolol 75 mg per GT twice a day. 13. Prevacid 30 mg per GT daily. PAST MEDICAL HISTORY: 1. A. fib without Coumadin. 2. CHF with ejection fraction 30% on _%#MMDD2006#%_ with a dilated cardiomyopathy.
GT|gutta|GT|135|136|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Lipitor 10 mg po qhs. 2. Synthroid 175 mcg po qd. 3. Metoprolol XL 25 mg po qd. 4. Ocuflox eye drops 0.3%, 1 GT OS qid. 5. Prednisolone Ace 1%, 1 GT OS qid. 6. Zantac 75 mg po qhs. 7. Sorbitol 70%, 15 mls po qpm. 8. Demadex 50 mg po bid.
GT|gutta|GT|172|173|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Lipitor 10 mg po qhs. 2. Synthroid 175 mcg po qd. 3. Metoprolol XL 25 mg po qd. 4. Ocuflox eye drops 0.3%, 1 GT OS qid. 5. Prednisolone Ace 1%, 1 GT OS qid. 6. Zantac 75 mg po qhs. 7. Sorbitol 70%, 15 mls po qpm. 8. Demadex 50 mg po bid. 9. Lisinopril 10 mg po qd. This was restarted on _%#MMDD2002#%_.
GT|gastrostomy tube|GT|216|217|PLAN|5. Immunizations. _%#NAME#%_'s mother was unsure of his immunization status; he is currently mo. shots. Discharge medications, treatments and special equipment: 1. Spare (=2) pediatric Shiley ET tubes 2. Bumex 80mcg GT q 6hr 3. Diuril 87mg GT q 12hr 4. Aldactone 8.7mg GT q 12hr 5. FeSO4 5mg GT q 24hr 6. Albuterol 2 puffs q 4hr 7. Flovent 2 puffs q12hr
GT|gastrostomy tube|GT|136|137|PLAN|Discharge medications, treatments and special equipment: 1. Spare (=2) pediatric Shiley ET tubes 2. Bumex 80mcg GT q 6hr 3. Diuril 87mg GT q 12hr 4. Aldactone 8.7mg GT q 12hr 5. FeSO4 5mg GT q 24hr 6. Albuterol 2 puffs q 4hr 7. Flovent 2 puffs q12hr
GT|gastrostomy tube|GT|165|166|PLAN|Discharge medications, treatments and special equipment: 1. Spare (=2) pediatric Shiley ET tubes 2. Bumex 80mcg GT q 6hr 3. Diuril 87mg GT q 12hr 4. Aldactone 8.7mg GT q 12hr 5. FeSO4 5mg GT q 24hr 6. Albuterol 2 puffs q 4hr 7. Flovent 2 puffs q12hr 8. Theophylline 12mg GT q 8hr 9. Albuterol 4-6 puffs q 2hr, prn
GT|gastrostomy tube|GT|125|126|PLAN|4. Aldactone 8.7mg GT q 12hr 5. FeSO4 5mg GT q 24hr 6. Albuterol 2 puffs q 4hr 7. Flovent 2 puffs q12hr 8. Theophylline 12mg GT q 8hr 9. Albuterol 4-6 puffs q 2hr, prn 10. Tylenol 60mg GT q 4hr, prn 11. Chloral hydrate 200mg GT q 6hr, prn
GT|gastrostomy tube|GT|121|122|PLAN|8. Theophylline 12mg GT q 8hr 9. Albuterol 4-6 puffs q 2hr, prn 10. Tylenol 60mg GT q 4hr, prn 11. Chloral hydrate 200mg GT q 6hr, prn 12. Ativan 0.2mg GT q 4hr, prn 13. MSO4 1mg GT q 4hr, prn 14. Glycerin 1/4 supp PR q 12hr, prn 15. Bacitracin
GT|gastrostomy tube|GT|115|116|PLAN|10. Tylenol 60mg GT q 4hr, prn 11. Chloral hydrate 200mg GT q 6hr, prn 12. Ativan 0.2mg GT q 4hr, prn 13. MSO4 1mg GT q 4hr, prn 14. Glycerin 1/4 supp PR q 12hr, prn 15. Bacitracin 16. Prednisolone 3.9mg GT QOD Jace is an appropriate candidate to continue receiving Synagis during the upcoming RSV season.
GT|gastrostomy tube|GT|177|178|DISCHARGE MEDICATIONS|2. Ceftriaxone 1 g IV piggyback q24-hours through _%#MMDD2003#%_. 3. Flovent 220 mcg two puffs bid. 4. Lasix 40 mg po bid. 5. Singulair 10 mg po qd. 6. Opcon ophthalmic drops 1 GT qd and HI. 7. Actose 45 mg po qd. 8. Ramipril 2.5 mg po qam. 9. Cilium one package po qd. 10. Serevent two puffs bid.
GT|gastrostomy tube|GT|149|150|DISCHARGE MEDICATIONS|DISCHARGE DIAGNOSES: 1. Influenza A. 2. Leigh's disease. 3. Dehydration and mild acute tubular necrosis. DISCHARGE MEDICATIONS: 1. Cimetidine 300 mg GT t.i.d. 2. Miralax 17 gm GT daily. 3. Reglan 4 mg GT q.i.d. 4. Amantadine 100 mg GT b.i.d. x 2 days. 5. Acidophilus one-fourth teaspoon GT p.r.n. DISPOSITION: Discharge to home on regular diet with Neocate One plus gastrostomy tube feeds at 250 cc q.a.m. and q. afternoon.
GT|gastrostomy tube|GT|175|176|DISCHARGE MEDICATIONS|3. Dehydration and mild acute tubular necrosis. DISCHARGE MEDICATIONS: 1. Cimetidine 300 mg GT t.i.d. 2. Miralax 17 gm GT daily. 3. Reglan 4 mg GT q.i.d. 4. Amantadine 100 mg GT b.i.d. x 2 days. 5. Acidophilus one-fourth teaspoon GT p.r.n. DISPOSITION: Discharge to home on regular diet with Neocate One plus gastrostomy tube feeds at 250 cc q.a.m. and q. afternoon.
GT|gastrostomy tube|GT|97|98|DISCHARGE MEDICATIONS|Primary MD is needed. DISCHARGE MEDICATIONS: He will be on his usual home meds. 1. Decadron 2 mg GT q.a.m. 2. Metamucil one teaspoon p.o./GT daily. 3. Colace 100 mg p.o./GT b.i.d. 4. Hytrin 5 mg p.o./GT at bedtime. 5. Dilantin 150 mg p.o./GT b.i.d. 6. Prevacid Solutabs 15 mg p.o. b.i.d.
GT|gastrostomy tube|GT|100|101|DIET|His parents were instructed to call the clinic for appointments. DIET: _%#NAME#%_ was discharged on GT feeds 115 mL/h. for 7 hours overnight and additional 125 bolus in the afternoon. RESTRICTIONS: _%#NAME#%_ was not restricted in terms of his activity.
GT|gastrostomy tube|GT|242|243|DISCHARGE DIAGNOSIS|ADMISSION MEDICATIONS: Per the family, meds include Prevacid 10 mg b.i.d., Lasix 15 mg b.i.d., Pulmicort 0.5-mg neb b.i.d., albuterol neb 2.5 mg q.4hours p.r.n. wheezing. Note: On patient's last discharge summary there was also Bactrim 20 mg GT daily as well as simethicone, Reglan, and enalapril 400 mcg b.i.d. I have attempted to contact the patient's family multiple times to confirm where these were discontinued and by who and have been unable to do so.
GT|gastrostomy tube|GT|163|164|DISCHARGE DIAGNOSIS|The preceding day patient should have her Mickey placed and tube feeds were restarted per her home regime. 2. CV. Per family, patient has only been on Lasix 15 mg GT b.i.d., however, looking at her last discharge summary, the patient was reported to be on enalapril as well. 3. ID. Again, it looks patient previously has been on Bactrim prophylaxis, and it again is why this has been discontinued and this needs to be addressed at her next visit.
GT|gastrostomy tube|GT,|215|217|IMPRESSION|The patient is actively dying. Per discussion with the son and per her Living Will, we will honor her DNR/DNI. We will not continue BiPAP, as she is not tolerating it. We will provide comfort care and use atropine, GT, morphine sulfate and Ativan as needed to keep the patient comfortable. We will use IV fluids at TKO for the morphine drip. We will use oxygen to keep the patient comfortable. I have advised the son to contact his family members, as I expect that the patient will expire shortly.
GT|glutamyl transpeptidase|GT|128|129|SUMMARY OF HOSPITAL COURSE|The patient had crackles in both of her lungs. She came in with an elevated white count. Her AST was slightly high at 77. Gamma GT was 202. Alkaline phosphatase was 189. Lipase, however, was normal and so was bilirubin. The patient was, therefore, evaluated for possible cholecystitis. Ultrasound scan came back showing biliary sludge, but no evidence of acute cholecystitis.
GT|glutamyl transpeptidase|GT|182|183|SUMMARY OF HOSPITALIZATION|Possible alcohol withdrawal. The patient was on the ventilator for the first few days and therefore no evidence of alcohol withdrawal was noted. However, she did have elevated gamma GT during this hospitalization at 116. Her AST/ALT however were normal 2 days after initial hospitalization at 22 and 30 respectively.
GT|glutamyl transpeptidase|GT.|202|204|LABORATORY AND DIAGNOSTIC DATA|ProBNP 511. Echocardiogram on _%#MMDD2007#%_ revealed moderate pulmonary hypertension with slightly hyperdynamic left ventricle. Liver function tests on _%#MMDD2007#%_ were unremarkable including Gamma GT. Urinalysis was unremarkable on _%#MMDD2007#%_. CEA was 1.4. C-A 99/14 which are normal.
GT|gastrostomy tube|GT,|210|212|3. FEN|Isolette to reduce insensible losses. 2. Heterotaxic Asplenia: Continue antiobiotic prophylaxis against encapsulated organisms; keep vaccinations up to date (none yet). 3. FEN: Similac PM60/40 26 kcal 36cc q3h GT, allow up to 10cc PO 4. Access: PIV (R foot); NGT Discharge medications, treatments and special equipment: 1. PGE1 0.05 mcg/kg/min IV
GT|gastrostomy tube|GT|156|157|3. FEN|Access: PIV (R foot); NGT Discharge medications, treatments and special equipment: 1. PGE1 0.05 mcg/kg/min IV 2. Amiodarone 35 mg IV q24h 3. Caffeine 10 mg GT q24h 4. Amoxicillin 50 mg GT q24h 5. Nystatin 50000U PO q6h 6. Lasix 4 mg GT q6h 7. Aldactone 3 mg PO q12h Discharge measurements: Weight 2116 gms; length 45 cm; OFC 30 cm.
GT|gastrostomy tube|GT|150|151|3. FEN|1. PGE1 0.05 mcg/kg/min IV 2. Amiodarone 35 mg IV q24h 3. Caffeine 10 mg GT q24h 4. Amoxicillin 50 mg GT q24h 5. Nystatin 50000U PO q6h 6. Lasix 4 mg GT q6h 7. Aldactone 3 mg PO q12h Discharge measurements: Weight 2116 gms; length 45 cm; OFC 30 cm.
GT|gastrostomy tube|GT|236|237|FOLLOWUP APPOINTMENTS|25. Pulmozyme 2.5 mg inhaled q.12 h. 26. Neurontin 100 mg down G-tube t.i.d. FOLLOWUP APPOINTMENTS: Please note this replaces previously- dictated following appointments: 1. F-UMC Radiology for CT scan of abdomen and pelvic with IV and GT contrast, _%#MMDD#%_ at 0820 hours. 2. Colorectal at F-UMC on _%#MMDD2005#%_ at 1 p.m. 3. Infectious disease at F-UMC _%#MMDD2005#%_ at 2:30 p.m. 4. Rheumatology _%#MMDD2005#%_ at 1030 hours.
GT|gastrostomy tube|GT|193|194|FEN|* _%#NAME#%_ failed her hearing screen and will need audiology followup outpatient Discharge medications, treatments and special equipment: * Diazepam 0.4mg via GT Tid. * Glycopyrrolate 0.3 mg GT every 6 hours * Tri-vi-sol with Iron 0.5 ml GT everyday * Apnea monitor (Childrens Apnea Program of _%#NAME#%_ _%#NAME#%_ following outpatient) * Reflux positioning was also done to help _%#NAME#%_ to handle oral secretions and parents were trained by Childrens Apnea Program * Oral suction prn to maintain airway * No immunizations were given on the NICU Newborn screening was done at the _%#CITY#%_ _%#CITY#%_ Hospital Discharge measurements and exam: Weight 4098 gm, length 53 cm, OFC 35 cm.
GT|gastrostomy tube|GT|240|241|FEN|* _%#NAME#%_ failed her hearing screen and will need audiology followup outpatient Discharge medications, treatments and special equipment: * Diazepam 0.4mg via GT Tid. * Glycopyrrolate 0.3 mg GT every 6 hours * Tri-vi-sol with Iron 0.5 ml GT everyday * Apnea monitor (Childrens Apnea Program of _%#CITY#%_ _%#CITY#%_ following outpatient) * Reflux positioning was also done to help _%#NAME#%_ to handle oral secretions and parents were trained by Childrens Apnea Program * Oral suction prn to maintain airway * No immunizations were given on the NICU Newborn screening was done at the _%#CITY#%_ _%#CITY#%_ Hospital Discharge measurements and exam: Weight 4098 gm, length 53 cm, OFC 35 cm.
GT|gamma-glutamyltransferase:GGT|GT|171|172|PHYSICAL EXAMINATION|The electrolytes revealed BUN and creatinine of 50 and 2.7, respectively. Calcium was a little low at 7.9. Albumin was also low at 2.7. Liver transaminases were elevated. GT was 190. INR was normal. Magnesium was 2.6. PTT was normal. Troponin was less than 0.3. Sed rate was mildly elevated at 27.
GT|gastrostomy tube|GT|172|173|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Nitro-Dur patch 0.2 mcg q.d. 2. Tylenol 650 mg per GT t.i.d. 3. Metoprolol 25 mg per GT b.i.d. 4. Prevacid 30 mg per GT q.d. 5. Lipitor 10 mg per GT q.d. 6. Augmentin 500 mg per GT b.i.d. 7. Zyprexa 7.5 mg per GT b.i.d. HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old white female who presented to the Geriatric Psychiatry Unit with a history of agitation at the nursing home and striking out.
GT|gutta|GT|117|118|DISCHARGE MEDICATIONS|3. Metoprolol 25 mg per GT b.i.d. 4. Prevacid 30 mg per GT q.d. 5. Lipitor 10 mg per GT q.d. 6. Augmentin 500 mg per GT b.i.d. 7. Zyprexa 7.5 mg per GT b.i.d. HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old white female who presented to the Geriatric Psychiatry Unit with a history of agitation at the nursing home and striking out.
GT|gastrostomy tube|GT|174|175|DISCHARGE DIAGNOSES|5. Atrial fibrillation/atrial flutter. 6. Chronic obstructive pulmonary disease with pulmonary hypertension and obstructive sleep apnea. 7. Jaundice secondary to amiodarone. GT discontinued on _%#MM#%_ 26. 8. Rheumatoid arthritis. 9. History of anemia. 10. Cholelithiasis. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was a 77-year-old white female with multiple medical problems who was admitted on _%#MMDD2004#%_ with a two week history of abdominal pain which has worsened in the last 48 hours.
GT|gastrostomy tube|GT|171|172|MEDICATIONS|8. Dicloxacillin. 9. Prednisone 1 tablet b.i.d., started a few days ago. 10. Prilosec. 11. Reglan. 12. Singulair. 13. Multivitamin. 14. Nutren 2.0, four cans at night via GT and two cans p.o. during the day, for a total of six cans per day. 15. Azithromycin 250 mg each day since _%#MM2005#%_. PAST MEDICAL HISTORY: As described above.
GT|gastrostomy tube|GT|182|183|DISCHARGE INFORMATION|DISCHARGE INFORMATION: Discharge date _%#MM#%_ _%#DD#%_, 2006. DISCHARGE MEDICATIONS: 1. Clonidine patch 100 mcg daily applied to skin, change q. 7 days. 2. Magnesium sulfate 250 mg GT b.i.d. 3. Neo-Oral 65 mg in the a.m., 70 mg in the p.m. 4. Cellcept 250 mg GT b.i.d. 5. Prednisone 1 mg GT daily.
GT|gastrostomy tube|GT|106|107|DISCHARGE INFORMATION|2. Magnesium sulfate 250 mg GT b.i.d. 3. Neo-Oral 65 mg in the a.m., 70 mg in the p.m. 4. Cellcept 250 mg GT b.i.d. 5. Prednisone 1 mg GT daily. 6. Ciprofloxacin 130 mg GT b.i.d. until _%#MM#%_ _%#DD#%_, 2006. 7. Reglan 2 mg GT q.i.d. 8. Omeprazole 10 mg GT daily.
GT|gutta|GT|170|171|DISCHARGE MEDICATIONS|6. Incontinence. 7. Dementia. 8. Inoperable thoracic aneurysm. ALLERGIES: SULFA and ACE INHIBITORS. DISCHARGE MEDICATIONS: 1. Tylenol 1,000 mg po tid. 2. Alphagan 0.2% 1 GT in the right eye bid. 3. Digoxin 125 mcg po qd. 4. Lasix 60 mg po bid. 5. Ditropan 5 mg po bid. 6. Paxil 40 mg po qd.
GT|gastrostomy tube|GT|241|242|PROBLEMS|1. Fluid, electrolytes, nutrition. Dehydration. _%#NAME#%_ was started on IV fluids upon admission and these were continued overnight. Repeat basic metabolic panel in the morning revealed improvement in his BUN and creatinine to 5 and 0.29. GT feeds of Peptamen Junior were restarted and these were tolerated well and advanced during the day following admission. 2. Gastrointestinal. GE reflux status post Nissen x3, status post pyloroplasty with postoperative dumping syndrome, admitted with nonbloody diarrhea, which resolved after overnight IV fluid hydration.
GT|gastrostomy tube|GT|196|197|DISCHARGE MEDICATIONS|3. Infectious disease. GT site erythema. This was treated with topical iLEX with significant improvement by discharge. DISCHARGE PLAN: Discharge to home. DISCHARGE MEDICATIONS: Prevacid 15 mg via GT q. day. DIET: Peptamen Junior via GT 1100 to 1200 mL per day with bolus feeds and overnight drip feeds per home schedule.
GT|gastrostomy tube|GT|114|115|DIET|DISCHARGE PLAN: Discharge to home. DISCHARGE MEDICATIONS: Prevacid 15 mg via GT q. day. DIET: Peptamen Junior via GT 1100 to 1200 mL per day with bolus feeds and overnight drip feeds per home schedule. ACTIVITIES: As tolerated. FOLLOW UP: With primary care physician, _%#NAME#%_ _%#NAME#%_, in 1 to 2 weeks or sooner if recurrent diarrhea or signs of dehydration appear.
GT|gastrostomy tube|GT|380|381|DISCHARGE MEDICATIONS|He will continue all other medications as usual and will follow up with his primary physician on a prn basis. Discharge condition is satisfactory. DISCHARGE MEDICATIONS: Clorazepate 7.5 mg bid for seizure control, Trazodone 50 mg down GT-tube bid, Valproic Acid 250 mg per 5 ml, 10 cc bid, Certovite liquid 15 cc per GT q day, Docusate Sodium 15 cc bid, Robinul 1 mg two tabs per GT tube tid, Glycalox powder 17 grams with water daily, misoprostol 200 mg 2 tabs down GT tube tid, Neurontin 300 mg 2 tabs q hs prn, Cleocin Gel to face bid for acne and Resource 8 ounces bid, Benefiber 2 tablespoons per GT tube bid, prune juice bolus 8 ounces daily prn, 16 ounces of H2O per G tube.
GT|gastrostomy tube|GT|467|468|DISCHARGE MEDICATIONS|He will continue all other medications as usual and will follow up with his primary physician on a prn basis. Discharge condition is satisfactory. DISCHARGE MEDICATIONS: Clorazepate 7.5 mg bid for seizure control, Trazodone 50 mg down GT-tube bid, Valproic Acid 250 mg per 5 ml, 10 cc bid, Certovite liquid 15 cc per GT q day, Docusate Sodium 15 cc bid, Robinul 1 mg two tabs per GT tube tid, Glycalox powder 17 grams with water daily, misoprostol 200 mg 2 tabs down GT tube tid, Neurontin 300 mg 2 tabs q hs prn, Cleocin Gel to face bid for acne and Resource 8 ounces bid, Benefiber 2 tablespoons per GT tube bid, prune juice bolus 8 ounces daily prn, 16 ounces of H2O per G tube.
GT|gutta|GT|128|129|DISCHARGE MEDICATIONS|2. Coumadin 2.5 mg p.o. daily. This is to be resumed. Dr. _%#NAME#%_ had not resumed this on the _%#DD#%_. 3. Timolol 0.25% one GT both eyes daily. 4. Dulcolax suppository 10 mg p.r.n. daily. 5. Synthroid 25 mcg p.o. daily. 6. Ferrous sulfate 325 mg p.o. b.i.d.
GT|glutamyl transpeptidase|GT|143|144|PROCEDURES|Total protein 5.6, albumin 2.9, bilirubin 0.4. C. difficile toxin was negative in the stool and appeared negative for ova and parasites. Gamma GT 27. Urinalysis was unremarkable. No evidence of a growth in the urine culture.
GT|gastrostomy tube|GT|156|157|ADMISSION MEDICATIONS|10. Status post Nissen in _%#MM#%_ 2005 for chronic emesis. 11. Valgus deformity of the knee. 12. Rickets. ADMISSION MEDICATIONS: 1. Rocaltrol 0.25 mcg per GT every Monday,Wednesday, and Friday. 2. Carnitine 50 mg p.o daily. 3. Enalapril 2.5 mg per GT nightly. 4. Epogen 1600 units every Tuesday and Thursday. 5. Ferrous sulfate 8 mg per GT q. 24.
GT|gastrostomy tube|GT|143|144|ADMISSION MEDICATIONS|2. Carnitine 50 mg p.o daily. 3. Enalapril 2.5 mg per GT nightly. 4. Epogen 1600 units every Tuesday and Thursday. 5. Ferrous sulfate 8 mg per GT q. 24. 6. Lactobacillus tablet one tablet per GT q.a.m. 7. KCL 40 mEq per 30 mL, 24 mL per GT every evening feeds.
GT|gastrostomy tube|GT|126|127|ADMISSION MEDICATIONS|4. Epogen 1600 units every Tuesday and Thursday. 5. Ferrous sulfate 8 mg per GT q. 24. 6. Lactobacillus tablet one tablet per GT q.a.m. 7. KCL 40 mEq per 30 mL, 24 mL per GT every evening feeds. 8. Synthroid 62.5 mcg per GT daily. 9. Vitamin E 50 units 2 mL per GT daily.
GT|gastrostomy tube|GT|134|135|ADMISSION MEDICATIONS|6. Lactobacillus tablet one tablet per GT q.a.m. 7. KCL 40 mEq per 30 mL, 24 mL per GT every evening feeds. 8. Synthroid 62.5 mcg per GT daily. 9. Vitamin E 50 units 2 mL per GT daily. 10. Zofran 4 mg tablet two tablets per GT 3 times a day.
GT|gastrostomy tube|GT|156|157|ADMISSION MEDICATIONS|8. Synthroid 62.5 mcg per GT daily. 9. Vitamin E 50 units 2 mL per GT daily. 10. Zofran 4 mg tablet two tablets per GT 3 times a day. 11. Claritin 8 mg per GT daily. 12. Cystagon 150 mg per GT four times a day. 13. Ursodiol 20 mg per mL solution 6.25 mL per GT twice a day.
GT|gastrostomy tube|GT|113|114|ADMISSION MEDICATIONS|10. Zofran 4 mg tablet two tablets per GT 3 times a day. 11. Claritin 8 mg per GT daily. 12. Cystagon 150 mg per GT four times a day. 13. Ursodiol 20 mg per mL solution 6.25 mL per GT twice a day. 14. Sodium bicarbonate 80 mEq added to feedbag. 15. Potassium phosphate 9 mmol or 3 mL of the 15 per 5 mL solution per GT with feeds.
GT|gastrostomy tube|GT|124|125|ADMISSION MEDICATIONS|11. Claritin 8 mg per GT daily. 12. Cystagon 150 mg per GT four times a day. 13. Ursodiol 20 mg per mL solution 6.25 mL per GT twice a day. 14. Sodium bicarbonate 80 mEq added to feedbag. 15. Potassium phosphate 9 mmol or 3 mL of the 15 per 5 mL solution per GT with feeds.
GT|gastrostomy tube|GT|218|219|ADMISSION MEDICATIONS|14. Sodium bicarbonate 80 mEq added to feedbag. 15. Potassium phosphate 9 mmol or 3 mL of the 15 per 5 mL solution per GT with feeds. 15. Acetaminophen 320 mg per GT q. 4-6 hours p.r.n. fever. 16. Riboflavin 50 mg per GT daily. 17. Cephazolin 600 mg IV q. 12 hours for 7 days. 18. Lansoprazole which was weaned after his hospitalization.
GT|gastrostomy tube|GT|119|120|ADMISSION MEDICATIONS|1. Rocaltrol 0.25 mcg per GT every Monday,Wednesday, and Friday. 2. Carnitine 50 mg p.o daily. 3. Enalapril 2.5 mg per GT nightly. 4. Epogen 1600 units every Tuesday and Thursday. 5. Ferrous sulfate 8 mg per GT q. 24. 6. Lactobacillus tablet one tablet per GT q.a.m.
GT|gastrostomy tube|GT|116|117|ADMISSION MEDICATIONS|8. Synthroid 62.5 mcg per GT daily. 9. Vitamin E 50 units 2 mL per GT daily. 10. Zofran 4 mg tablet two tablets per GT 3 times a day. 11. Claritin 8 mg per GT daily. 12. Cystagon 150 mg per GT four times a day. 13. Ursodiol 20 mg per mL solution 6.25 mL per GT twice a day.
GT|gastrostomy tube|GT|156|157|DISCHARGE MEDICATIONS|8. Synthroid 62.5 mcg per GT daily. 9. Vitamin E 50 units 2 mL per GT daily. 10. Zofran 4 mg tablet two tablets per GT 3 times a day. 11. Claritin 8 mg per GT daily. 12. Cystagon 150 mg per GT four times a day. 13. Ursodiol 20 mg per mL solution 6.25 mL per GT twice a day.
GT|gastrostomy tube|GT|204|205|DISCHARGE MEDICATIONS|14. Sodium bicarbonate 80 mEq added to feedbag. 15. Potassium phosphate 9 mmol 331 per 5 mL solution per GT with feeds. 16. Acetaminophen 320 mg per GT q. 4-6 hours p.r.n. fever. 17. Riboflavin 50 mg per GT daily. 18. Cephazolin 600 mg IV q. 12 hours for 7 days.
GT|gastrostomy tube|GT|114|115|DISCHARGE MEDICATIONS|Her H and H were stable. Her vital signs were stable, and she was afebrile. DISCHARGE MEDICATIONS: Atenolol 30 mg GT q.a.m. and atenolol 25 mg GT q.p.m., Cimetidine 120 mg GT nightly, folic acid 1 mg GT b.i.d., flaxseed oil 15 mg GT q. day, Tylenol With Codeine elixir 10 mg p.o./GT q.6 h. Miralax 8.5 gr. in H2O GT q. day, Unifiber, 1 tablespoon in H2O GT b.i.d., Vitamin B6 10 mg GT b.i.d., Lovenox 15 mcg SQ q.h.s.
GT|gastrostomy tube|GT|172|173|DISCHARGE MEDICATIONS|Her H and H were stable. Her vital signs were stable, and she was afebrile. DISCHARGE MEDICATIONS: Atenolol 30 mg GT q.a.m. and atenolol 25 mg GT q.p.m., Cimetidine 120 mg GT nightly, folic acid 1 mg GT b.i.d., flaxseed oil 15 mg GT q. day, Tylenol With Codeine elixir 10 mg p.o./GT q.6 h. Miralax 8.5 gr. in H2O GT q. day, Unifiber, 1 tablespoon in H2O GT b.i.d., Vitamin B6 10 mg GT b.i.d., Lovenox 15 mcg SQ q.h.s.
GT|gastrostomy tube|GT|154|155|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Atenolol 30 mg GT q.a.m. and atenolol 25 mg GT q.p.m., Cimetidine 120 mg GT nightly, folic acid 1 mg GT b.i.d., flaxseed oil 15 mg GT q. day, Tylenol With Codeine elixir 10 mg p.o./GT q.6 h. Miralax 8.5 gr. in H2O GT q. day, Unifiber, 1 tablespoon in H2O GT b.i.d., Vitamin B6 10 mg GT b.i.d., Lovenox 15 mcg SQ q.h.s. She is to be nonweightbearing on her bilateral lower extremities.
GT|gastrostomy tube|GT|296|297|DISCHARGE MEDICATIONS|MEDICATIONS: Atenolol 30 mg GT q.a.m. and atenolol 25 mg GT q.p.m., Cimetidine 120 mg GT nightly, folic acid 1 mg GT b.i.d., flaxseed oil 15 mg GT q. day, Tylenol With Codeine elixir 10 mg p.o./GT q.6 h. Miralax 8.5 gr. in H2O GT q. day, Unifiber, 1 tablespoon in H2O GT b.i.d., Vitamin B6 10 mg GT b.i.d., Lovenox 15 mcg SQ q.h.s. She is to be nonweightbearing on her bilateral lower extremities.
GT|gastrostomy tube|GT|237|238|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Atenolol 30 mg GT q.a.m. and atenolol 25 mg GT q.p.m., Cimetidine 120 mg GT nightly, folic acid 1 mg GT b.i.d., flaxseed oil 15 mg GT q. day, Tylenol With Codeine elixir 10 mg p.o./GT q.6 h. Miralax 8.5 gr. in H2O GT q. day, Unifiber, 1 tablespoon in H2O GT b.i.d., Vitamin B6 10 mg GT b.i.d., Lovenox 15 mcg SQ q.h.s. She is to be nonweightbearing on her bilateral lower extremities.
GT|gastrostomy tube|GT.|140|142|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Norvasc 10 mg per GT once daily. 2. Catapres patch 0.3 mg applied weekly on Thursday. 3. Atenolol 50 mg daily per GT. 4. Minoxidil 2.5 mg daily per GT. 5. Lisinopril 40 mg daily per GT. 6. Plavix 75 mg daily per GT. 7. Aspirin 325 mg daily per GT. 8. Zoloft 50 mg daily per GT.
GT|gastrostomy tube|GT|132|133|DISCHARGE MEDICATIONS|9. Synthroid 75 mcg daily per GT. 10. Acetaminophen 1 g t.i.d. per GT at 8:00 a.m., 2:00 and 8:00 p.m. 11. Prilosec 20 mg daily per GT 20-30 minutes before meals. 12. Miconazole topical 2% vaginal cream applied topically once daily internally and externally to the vaginal area.
GT|gastrostomy tube|GT|191|192|DISCHARGE FOLLOWUPS|She had increasing need reaching a peak of a 1/2 liter of oxygen the day before admission. Mom also noted that _%#NAME#%_ was experiencing nasal congestion and was needing to be fed more via GT because she was sleeping thru her bottle feeds for the three days prior to admission. On the day prior to admission, _%#NAME#%_ saw Dr. _%#NAME#%_ at Fairview Ridges and a nebulizing treatment was done without any improvement of oxygen need.
GT|gastrostomy tube|GT,|236|238|DISCHARGE FOLLOWUPS|* Oxygen at 1/8th of a liter flow. Discharge measurements: Weight 2980 gms; length 47 cm; OFC 34.5 cm. Physical exam was normal except for physical characteristics associated with Trisomy 21, a sacral dimple, externally rotated hips, a GT, and hypotonia (all present on her initial discharge exam). Carly was discharged on breast milk fortified to 24 kcal with Enfacare and beneprotein taking 55 ml every 3 hours via bottle or GT.
GT|gastrostomy tube|GT.|133|135|DISCHARGE FOLLOWUPS|_%#NAME#%_ was discharged on breast milk fortified to 24 kcal with Enfacare and beneprotein taking 55 ml every 3 hours via bottle or GT. The parents have an appointment with you on _%#MMDD2004#%_. Follow-up clinic appointments scheduled include: * Cardiology.
GT|gastrostomy tube|GT|191|192|ADMISSION MEDICATIONS|5. Reactive airway disease. 6. Status post gastrostomy tube placement. ADMISSION MEDICATIONS: 1. Pulmicort 0.25 mg nebulized b.i.d. 2. Albuterol 0.25 mg nebulized b.i.d. 3. Calcitriol 0.6 mL GT t.i.d. 4. Calcium carbonate 0.5 mL GT t.i.d. 5. Bicitra 6 mL GT t.i.d. 6. Epogen 600 units subcutaneous q. Tuesdays/Fridays. 7. Folic acid 0.8 mL GT daily. 8. Poly-Vi-Sol 1 mL GT daily.
GT|gastrostomy tube|GT|135|136|ADMISSION MEDICATIONS|1. Pulmicort 0.25 mg nebulized b.i.d. 2. Albuterol 0.25 mg nebulized b.i.d. 3. Calcitriol 0.6 mL GT t.i.d. 4. Calcium carbonate 0.5 mL GT t.i.d. 5. Bicitra 6 mL GT t.i.d. 6. Epogen 600 units subcutaneous q. Tuesdays/Fridays. 7. Folic acid 0.8 mL GT daily. 8. Poly-Vi-Sol 1 mL GT daily.
GT|gastrostomy tube|GT|170|171|ADMISSION MEDICATIONS|3. Calcitriol 0.6 mL GT t.i.d. 4. Calcium carbonate 0.5 mL GT t.i.d. 5. Bicitra 6 mL GT t.i.d. 6. Epogen 600 units subcutaneous q. Tuesdays/Fridays. 7. Folic acid 0.8 mL GT daily. 8. Poly-Vi-Sol 1 mL GT daily. 9. Ferrous sulfate 0.6 mL GT b.i.d. 10. Nutropin 0.4 mL GT daily. ALLERGIES: NO KNOWN DRUG ALLERGIES. HOSPITAL COURSE: _%#NAME#%_ was admitted to Fairview University Medical Center on _%#MM#%_ _%#DD#%_, 2005.
GT|gastrostomy tube|GT|300|301|ALLERGIES|10. Prednisolone 6 mg p.o./GT b.i.d. x2 days, then 5 mg p.o./GT b.i.d. x3 days, then 4 mg p.o./GT b.i.d. x3 days, then 3 mg p.o./GT b.i.d. x3 days, with further taper to be determined by the transplant coordinator at the time of followup. 11. Calcitriol 0.6 mL GT t.i.d. 12. Calcium carbonate 0.5 mL GT t.i.d. 13. Ferrous sulfate 0.6 mL GT b.i.d. 14. Folic acid 0.8 mL GT daily. 15. Poly-Vi-Sol 1 mL GT daily. FOLLOW UP APPOINTMENT: _%#NAME#%_ has to follow up in the pediatric specialty clinic with Dr. _%#NAME#%_ in 2 to 3 weeks.
GT|gastrostomy tube|GT|337|338|ALLERGIES|10. Prednisolone 6 mg p.o./GT b.i.d. x2 days, then 5 mg p.o./GT b.i.d. x3 days, then 4 mg p.o./GT b.i.d. x3 days, then 3 mg p.o./GT b.i.d. x3 days, with further taper to be determined by the transplant coordinator at the time of followup. 11. Calcitriol 0.6 mL GT t.i.d. 12. Calcium carbonate 0.5 mL GT t.i.d. 13. Ferrous sulfate 0.6 mL GT b.i.d. 14. Folic acid 0.8 mL GT daily. 15. Poly-Vi-Sol 1 mL GT daily. FOLLOW UP APPOINTMENT: _%#NAME#%_ has to follow up in the pediatric specialty clinic with Dr. _%#NAME#%_ in 2 to 3 weeks.
GT|gastrostomy tube|GT|230|231|* FEN|* OPTHO: _%#NAME#%_ needs a ROP eye exam this week. Discharge medications, treatments and special equipment: * FeSO4 3.5 MG pGT Q24 hrs * NaCl 1 mEq pGT Q3 hrs * Ranitidine 4.5 mg pGT Q12 hrs * Gentamicin 1% ointment topically to GT site QID * Bactroban cream topically to GT site TID * Triamcinolone cream 0.5% topically to GT site Q6 hrs * Tylenol 40 mg PR Q6 h prn * Glycerin 1/4 suppository PR Q24 hrs prn LINES: * Anderson O-E tube (on continuous suction, irrigated Q3 hrs) * G-Tube (replaced on _%#MMDD2005#%_) Discharge measurements and exam: Weight 3555 gm, length 51 cm, OFC 36 cm.
GT|gastrostomy tube|GT|325|326|* FEN|* OPTHO: _%#NAME#%_ needs a ROP eye exam this week. Discharge medications, treatments and special equipment: * FeSO4 3.5 MG pGT Q24 hrs * NaCl 1 mEq pGT Q3 hrs * Ranitidine 4.5 mg pGT Q12 hrs * Gentamicin 1% ointment topically to GT site QID * Bactroban cream topically to GT site TID * Triamcinolone cream 0.5% topically to GT site Q6 hrs * Tylenol 40 mg PR Q6 h prn * Glycerin 1/4 suppository PR Q24 hrs prn LINES: * Anderson O-E tube (on continuous suction, irrigated Q3 hrs) * G-Tube (replaced on _%#MMDD2005#%_) Discharge measurements and exam: Weight 3555 gm, length 51 cm, OFC 36 cm.
GT|gastrostomy tube|GT|116|117|DISCHARGE MEDICATIONS|2. Status epilepticus. 3. History of aspiration. 4. FISH negative for _____. DISCHARGE MEDICATIONS: 1. Bumex 0.2 mg GT q.12 hours. 2. Aldactone 6 mg GT b.i.d. 3. Captopril 1.2 mg q.8h. 4. Septra suspension 3 cc b.i.d. x7 days. 5. Reglan 1.25 mg GT q.i.d.
GT|gastrostomy tube|GT|149|150|DISCHARGE MEDICATIONS|2. Status epilepticus. 3. History of aspiration. 4. FISH negative for _____. DISCHARGE MEDICATIONS: 1. Bumex 0.2 mg GT q.12 hours. 2. Aldactone 6 mg GT b.i.d. 3. Captopril 1.2 mg q.8h. 4. Septra suspension 3 cc b.i.d. x7 days. 5. Reglan 1.25 mg GT q.i.d. 6. Prevacid 6 mg GT daily. 7. Phenobarbital 19.95 mg GT daily.
GT|gastrostomy tube|GT|141|142|DISCHARGE MEDICATIONS|2. Aldactone 6 mg GT b.i.d. 3. Captopril 1.2 mg q.8h. 4. Septra suspension 3 cc b.i.d. x7 days. 5. Reglan 1.25 mg GT q.i.d. 6. Prevacid 6 mg GT daily. 7. Phenobarbital 19.95 mg GT daily. 8. Simethicone 20 mg p.r.n. gas. 9. Nestle Good Start 75 mL q.3h. during the day and 25 mL per hour overnight from 10 p.m. to 7 a.m.
GT|gastrostomy tube|GT|123|124|DISCHARGE MEDICATIONS|4. Septra suspension 3 cc b.i.d. x7 days. 5. Reglan 1.25 mg GT q.i.d. 6. Prevacid 6 mg GT daily. 7. Phenobarbital 19.95 mg GT daily. 8. Simethicone 20 mg p.r.n. gas. 9. Nestle Good Start 75 mL q.3h. during the day and 25 mL per hour overnight from 10 p.m. to 7 a.m.
GT|gastrostomy tube|GT|202|203|HISTORY OF PRESENT ILLNESS|There was no blood. The emesis looked bilious. It was not unusual for him heme emesis, however. At the time the symptoms started, as he ran out of his Tolerex formula and was getting bolus feeds to his GT tube of a different formula, the patient's formula was substituted with a formula that was given through his home health plan.
GT|gastrostomy tube|GT|318|319|DISCHARGE MEDICATIONS|They will feed on top of this as well. The only labs obtained at this admission were cultures of the skin site which are pending at the time of discharge, although there was only minimal pus available for culture and these may not accurately reflect the source of the infection. DISCHARGE MEDICATIONS: 1. Ancef 150 mg GT q. 8h. for 5 days, then stop, for GT site cellulitis. 2. Flagyl 50 mg GT q. 6h. for bacterial overgrowth of GI tract, use until directed otherwise by Dr. _%#NAME#%_.
GT|gastrostomy tube|GT|112|113|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Ancef 150 mg GT q. 8h. for 5 days, then stop, for GT site cellulitis. 2. Flagyl 50 mg GT q. 6h. for bacterial overgrowth of GI tract, use until directed otherwise by Dr. _%#NAME#%_. 3. Bactrim 2.5 mL GT daily. 4. Ursodiol 40 mg GT q. 8h.
GT|gastrostomy tube|GT|158|159|DISCHARGE MEDICATIONS|2. Flagyl 50 mg GT q. 6h. for bacterial overgrowth of GI tract, use until directed otherwise by Dr. _%#NAME#%_. 3. Bactrim 2.5 mL GT daily. 4. Ursodiol 40 mg GT q. 8h. 5. ADEKs 0.7 mL GT daily. 6. Prevacid 6 mg GT b.i.d. 7. Vitamin A 2000 units GT daily. DIET: Pregestimil 24 kcal per GT, advance up to 36 mL/hr for 20 hours per day as tolerated.
GT|gastrostomy tube|GT,|117|119|DIET|5. ADEKs 0.7 mL GT daily. 6. Prevacid 6 mg GT b.i.d. 7. Vitamin A 2000 units GT daily. DIET: Pregestimil 24 kcal per GT, advance up to 36 mL/hr for 20 hours per day as tolerated. Okay to feed orally as well ad lib as tolerated.
GT|glutamyl transpeptidase|GT|218|219|SUMMARY OF HOSPITAL COURSE|This also was reduced by Dr. _%#NAME#%_. Alcohol withdrawal. The patient did appear to have alcohol withdrawal symptoms and therefore was on alcohol withdrawal protocol. His liver function tests were checked. His GAMA GT and liver function tests all came back unremarkable. He knows that he has to quit drinking. He does have peripheral neuropathy.
GT|gastrostomy tube|GT|377|378|* FEN|* GI: See above. Discharge medications, treatments and special equipment: * Fer-In-Sol 6 mg PO q24 * Ranitidine 7.5 mg GT BID * Ursodiol 26.5 mg GT q8h * Calmoseptine ointment, apply to GT site daily. * Nystatin 50,000 units PO q6 h * Cefepime 130 mg IV q12h * Tobramycin 10 mg IV q12h * Ca Carb 174 mg suspension GT q8h * Na Phosphate 0.4 mMol GT q12h * Chloral Hydrate 75 mg GT q.h.s. * PRN skin care creams for buttocks. Discharge measurements and exam: Weight 2900 gm, OFC 36 cm.
GT|glutamyl transpeptidase|GT|139|140|LABS|Ultrasound scan of the abdomen on _%#MMDD2007#%_ also unremarkable for liver or gallbladder disease. Liver function tests revealed a Gamma GT of 213, ferritin 392, total iron binding capacity was low at 195, iron saturation 34, ANA less then 1.0. Serum protein electrophoresis was negative, ammonia level less than 3.
GT|gastrostomy tube|GT|151|152|DOSES AS OF 12/16/02|Discharge medications, treatments and special equipment: DOSES AS OF _%#MMDD2002#%_: 1. Digoxin 10 mcg GT q 12 hours (7mcg/kg/day) 2. Aldactone 5.6 mg GT q 12 hours (4 mg/kg/day) 3. Diuril 56 mg GT q 12 hours (40 mg/kg/day) 4. Lasix 5.6 mg GT q 24 hours (2 mg/kg/day)
GT|gastrostomy tube|GT|110|111|DOSES AS OF 12/16/02|1. Digoxin 10 mcg GT q 12 hours (7mcg/kg/day) 2. Aldactone 5.6 mg GT q 12 hours (4 mg/kg/day) 3. Diuril 56 mg GT q 12 hours (40 mg/kg/day) 4. Lasix 5.6 mg GT q 24 hours (2 mg/kg/day) 5. Zantac 2 mg GT tid (2 mg/kg/day) 6. KCl 1 mEq GT q 6 hours (1.4 mg/kg/day)
GT|gastrostomy tube|GT|104|105|DOSES AS OF 12/16/02|3. Diuril 56 mg GT q 12 hours (40 mg/kg/day) 4. Lasix 5.6 mg GT q 24 hours (2 mg/kg/day) 5. Zantac 2 mg GT tid (2 mg/kg/day) 6. KCl 1 mEq GT q 6 hours (1.4 mg/kg/day) 7. NaCl 6 mEq GT q 6 hours (8.2 mg/kg/day) Her most recent electrolytes on _%#MMDD2002#%_ include: Na 137, K 4.6, Cl 99, Creat.
GT|gastrostomy tube|GT|173|174|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Ciprodex 4 drops in right ear t.i.d. 2. Nystatin 100,000 units p.o. q.i.d. 3. Albuterol 2.5 mg nebs t.i.d. p.r.n. wheezing. 4. MiraLax powder 17 g GT p.r.n. constipation. 5. Prednisone 2 mg GT q. day. 6. Prevacid 15 mg p.o. b.i.d. 7. Amlodipine 4 mg p.o. b.i.d. 8. Cyclosporine 25 mg p.o. q. 8h. 9. Lactobacillus half cap by mouth b.i.d.
GT|gastrostomy tube|GT|153|154|DISCHARGE MEDICATIONS|2. Nystatin 100,000 units p.o. q.i.d. 3. Albuterol 2.5 mg nebs t.i.d. p.r.n. wheezing. 4. MiraLax powder 17 g GT p.r.n. constipation. 5. Prednisone 2 mg GT q. day. 6. Prevacid 15 mg p.o. b.i.d. 7. Amlodipine 4 mg p.o. b.i.d. 8. Cyclosporine 25 mg p.o. q. 8h. 9. Lactobacillus half cap by mouth b.i.d.
GT|gastrostomy tube|GT|162|163|DISCHARGE MEDICATIONS|4. IVIG on _%#MMDD2007#%_ per routine. DISCHARGE LABS: Continue previous lab schedule. DISCHARGE MEDICATIONS: 1. CellCept 500 mg JT b.i.d. 2. Cyproheptadine 5 mg GT b.i.d. 3. Ursodiol 150 mg GT b.i.d. 4. Pantoprazole 15 mg GT daily. 5. Plaquenil 100 mg GT daily. 6. Ceftazidime 740 mg IV q.8h.
GT|gastrostomy tube|GT|136|137|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. CellCept 500 mg JT b.i.d. 2. Cyproheptadine 5 mg GT b.i.d. 3. Ursodiol 150 mg GT b.i.d. 4. Pantoprazole 15 mg GT daily. 5. Plaquenil 100 mg GT daily. 6. Ceftazidime 740 mg IV q.8h. 7. Bactrim 11.25 mL GT q. Monday, Wednesday and Friday.
GT|gastrostomy tube|GT|166|167|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. CellCept 500 mg JT b.i.d. 2. Cyproheptadine 5 mg GT b.i.d. 3. Ursodiol 150 mg GT b.i.d. 4. Pantoprazole 15 mg GT daily. 5. Plaquenil 100 mg GT daily. 6. Ceftazidime 740 mg IV q.8h. 7. Bactrim 11.25 mL GT q. Monday, Wednesday and Friday. 8. Fluconazole 80 mg p.o. daily. 9. Vancomycin 240 mg IV q.8h. It was a pleasure to participate in the care of _%#NAME#%_.
GT|glucose tolerance|GT.|346|348|HISTORY OF PRESENT ILLNESS|She presented the morning of admission with ruptured membranes but was not in labor. Her pregnancy had been essentially uncomplicated. Prenatal labs include blood type A+, antibody negative, hemoglobin 12.8, RPR non-reactive, hepatitis surface antigen non-reactive, Rubella immune, HIV non-reactive, Glucola equal to 149 with a normal three hour GT. PAST MEDICAL HISTORY: History of cholecystectomy in 2003. MEDICATIONS: Prenatal vitamins.
GT|gastrostomy tube|GT|126|127|DISCHARGE MEDICATIONS|4. Benefiber 2 tablespoons JT mixed in 3 cans Peptamen Junior. 5. Creon 5 6-7 capsules p.o. with meals. 6. Fer-In-Sol 12.5 mg GT daily. 7. Flonase 50 mcg 1 spray each nostril daily. 8. Mucomyst 20% 10 mL GT at bedtime as needed. 9. Mucomyst 20% 2.5 mL neb q.i.d. with vest therapy.
GT|gastrostomy tube|GT|141|142|DISCHARGE MEDICATIONS|5. Creon 5 6-7 capsules p.o. with meals. 6. Fer-In-Sol 12.5 mg GT daily. 7. Flonase 50 mcg 1 spray each nostril daily. 8. Mucomyst 20% 10 mL GT at bedtime as needed. 9. Mucomyst 20% 2.5 mL neb q.i.d. with vest therapy. 10. Prevacid 15 mg GT b.i.d. 11. ABDEK vitamins 1 capsule GT daily.
GT|gastrostomy tube|GT|158|159|DISCHARGE MEDICATIONS|8. Mucomyst 20% 10 mL GT at bedtime as needed. 9. Mucomyst 20% 2.5 mL neb q.i.d. with vest therapy. 10. Prevacid 15 mg GT b.i.d. 11. ABDEK vitamins 1 capsule GT daily. 12. TOBI 300 mg neb b.i.d. 13. Viokase 1 teaspoon JT per can of Peptamen Junior. 14. MiraLax 8.5 g p.o. b.i.d. as needed for constipation.
GT|gastrostomy tube|GT|169|170|REVIEW OF SYSTEMS|SOCIAL HISTORY: Lives with Mom and younger brother and two sisters and Dad. REVIEW OF SYSTEMS: At time of admission was positive for heme- positive drainage from JP and GT tube. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: She had a temperature of 96.4, pulse 137, respiratory rate 32, blood pressure 97/60, weight 12.6 kg.
GT|gastrostomy tube|GT|138|139|HOSPITAL COURSE|The patient's electrolytes remained stable. From the gastrointestinal view, the patient continued to have output draining from her JP and GT tube. Drainage was brownish to reddish color at times with intermittent frank blood being present in the drains. The patient had an ultrasound of the pancreas and liver done on _%#MM#%_ _%#DD#%_, 2002.
GT|glucose tolerance|GT.|243|245|HISTORY OF PRESENT ILLNESS|Her first visit was at 10 plus two weeks gestational age and she had approximately 11 visits. Her total weight gain was 31 pounds. Prenatal labs were all within normal limits with exception of an elevated GCT of 162, but with normal follow-up GT. PAST OBSTETRICS HISTORY: Significant for two first trimester spontaneous miscarriages that both necessitated a D and C.
GT|gastrostomy tube|GT,|203|205|PROBLEM #3|The patient was discharged one month ago on slow infusion of Isosource, which apparently had not been tapered to intermittent bolus. Although we assessed the patient to have no current problems with his GT, he felt "tied" to his machine. Dietary was consulted and they gave us regimen to taper his GT feedings to intermittent.
GT|gastrostomy tube|GT|165|166|PROBLEM #3|Although we assessed the patient to have no current problems with his GT, he felt "tied" to his machine. Dietary was consulted and they gave us regimen to taper his GT feedings to intermittent. In addition, the patient will continue to take small p.o. as tolerated. DISCHARGE DIET: Please see taper regimen in the discharge summary with the initial goal of Isosource 120 cc q12h.
GT|glutamyl transpeptidase|GT.|200|202|SUMMARY OF HOSPITALIZATION|He should restart a baby aspirin in a couple of weeks' time. Fatty liver. The patient had liver function tests checked during his hospitalization, and they came back unremarkable, including his gamma GT. Chronic cough. The patient apparently has had a cough for the last several months.
GT|glutamyl transpeptidase|GT|102|103|PROCEDURES|EKG showed no ischemic changes. Admission hemoglobin 14.9, discharge hemoglobin 10. Serum labs: Gamma GT 19, AST 30, ALT 38, alkaline phosphatase 80, total bilirubin 0.8. Sodium 139, potassium 4.0, chloride 109, random glucose 173, BUN 16, creatinine 0.9. On second day of hospitalization, hemoglobin 11.0, white count 3.0, platelet count 281,000.
GT|glutamyl transpeptidase|GT|298|299|SERUM LABS|SERUM LABS: INR 1.0, PTT 23, ketones negative. Lactate 2.1. CK 1455, sodium 141, potassium 3.5, chloride 109, bicarbonate 25, anion gap 7, glucose 110, BUN 59, creatinine 2.0, calcium 8.1, phosphate 2.8, magnesium 2.5. Alkaline phosphatase 104, total protein 6.2. ALT 32, AST elevated at 90, gamma GT 28. White count is still pending, hemoglobin 14.9, platelet count 130,000, hemoglobin A1c is 6.0. At Ridges Hospital about 5 hours earlier, this patient's pH was 7.20, pCO2 44, pO2 70, bicarbonate 17, white count 1.8, hemoglobin 16.6, platelet count 162,000, sodium 142, potassium 3.6, anion gap was 20.
GT|glutamyl transpeptidase|GT.|150|152|PLAN|2. Chest x-ray P-A and lateral. 3. CBC with differential. 4. Platelet count. 5. INR. 6. Liver profile. 7. TSH. 8. Glucose. 9. Electrolytes. 10. GAMMA GT. 11. Further evaluation as indicated per these test results.
GT|gastrostomy tube|GT|187|188|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Bicitra 5 ml GT b.i.d. 2. Penicillin VK suspension 250 mg p.o. GT b.i.d. 3. Diflucan 20 mg p.o. GJ daily. 4. Prevacid 10 mg p.o. GJ b.i.d. 5. Vioxx 6.25 mg p.o. GT daily. 6. Baclofen 6 mg p.o. GJ t.i.d. 7. Misoprostol 100 mcg p.o. GT b.i.d. 8. Carafate 500 mg p.o. GT q.i.d.
GT|gastrostomy tube|GT|158|159|DISCHARGE MEDICATIONS|3. Diflucan 20 mg p.o. GJ daily. 4. Prevacid 10 mg p.o. GJ b.i.d. 5. Vioxx 6.25 mg p.o. GT daily. 6. Baclofen 6 mg p.o. GJ t.i.d. 7. Misoprostol 100 mcg p.o. GT b.i.d. 8. Carafate 500 mg p.o. GT q.i.d. 9. Erythromycin 75 mg GJ q.i.d. 10. Flagyl 75 mg GJ q.i.d. through _%#MMDD2004#%_.
GT|gastrostomy tube|GT|337|338|DISCHARGE MEDICATIONS|Normal bowel sounds. NEUROLOGIC: Stable and is significant for some cognitive deficits, anarthria, dysphagia, diffuse weakness more so in the upper extremities in comparison to the lower extremities, brisk symmetric reflexes with bilateral upgoing toes. He is able to walk unassisted. DISCHARGE MEDICATIONS: 1. Hydrochlorothiazide 25 mg GT daily. 2. Tylenol (500 mg per 15 mL), 15 mL G-tube q.6h. p.r.n. pain or fever. SPECIFIC DISCHARGE INSTRUCTIONS: 1. Code status - DNR/DNI. This was discussed with the patient by Dr. _%#NAME#%_ both in the clinic and during his hospital stay.
GT|gastrostomy tube|GT|203|204|PAST MEDICAL HISTORY|3. History of recurrent pleural effusion and chylothorax. 4. Twin birth at 31 weeks. 5. Hydrocephalus, IVH status post VP shunt x2, revision in _%#MM2005#%_. 6. Developmental delay. 7. GERD, status post GT and Nissen in _%#MM2004#%_. 8. Tachycardic syndrome, status post pacemaker in _%#MM2006#%_. 9. Hypothyroidism. 10. Intermittent atrial tachycardia with pacemaker malfunction, treated with amiodarone.
GT|glutamyl transpeptidase|GT|195|196|LABORATORY DATA|On _%#MMDD2007#%_, Hemoglobin A1C was 7.6, TSH less than 0.03, Free T4 was 2.2 which was mildly elevated. T3 level was 93 which is normal. Cortisol 21.7. Hepatitis C antibody was negative. Gamma GT 21. ALT 31. AST 42. Alkaline phosphatase 62. ADDENDUM : Discharged today but januvia too expensive changed to amaryl.
GT|glutamyl transpeptidase|GT.|212|214|LABORATORY DATA|ProBNP was 511. Echocardiogram on _%#MM#%_ _%#DD#%_ revealed moderate pulmonary hypertension with slightly hypodynamic left ventricle. Liver function tests on _%#MM#%_ _%#DD#%_ were unremarkable, including gamma GT. Urinalysis was unremarkable on _%#MM#%_ _%#DD#%_. CEA was 1.4, CA99 was 14, both of which are normal.
GT|gastrostomy tube|GT.|170|172|LABORATORY DATA|At that time he was also circumcised and had a right inguinal hernia repair. _%#NAME#%_ is able to bottle feed but he still needs significant supplementation through the GT. We anticipate improvement in bottle feeding over the coming weeks. 7. Hematology: Due to religious reasons (Jehovah's Witness), _%#NAME#%_ was started on Epogen on day one of life to help exclude the need for blood products.
GT|gastrostomy tube|GT|231|232|LABORATORY DATA|2. Intraventricular hemorrhage: 3. Retinopathy of Prematurity: Follow-up with Ophthalmology in _%#MM#%_ or _%#MM#%_ Discharge medications, treatments and special equipment: 1. Aldactone: 8 mg per GT q 12 hours 2. Diuril: 80 mg per GT q 12 hours 3. Ferrous Sulfate: 8 mg per GT q 12 hours 4. NaCl: 3.5 mEq per GT q 3 hours _%#NAME#%_ is an excellent candidate to receive Synagis during the upcoming RSV season.
GT|gastrostomy tube|GT|274|275|LABORATORY DATA|2. Intraventricular hemorrhage: 3. Retinopathy of Prematurity: Follow-up with Ophthalmology in _%#MM#%_ or _%#MM#%_ Discharge medications, treatments and special equipment: 1. Aldactone: 8 mg per GT q 12 hours 2. Diuril: 80 mg per GT q 12 hours 3. Ferrous Sulfate: 8 mg per GT q 12 hours 4. NaCl: 3.5 mEq per GT q 3 hours _%#NAME#%_ is an excellent candidate to receive Synagis during the upcoming RSV season.
GT|gastrostomy tube|GT|136|137|LABORATORY DATA|1. Aldactone: 8 mg per GT q 12 hours 2. Diuril: 80 mg per GT q 12 hours 3. Ferrous Sulfate: 8 mg per GT q 12 hours 4. NaCl: 3.5 mEq per GT q 3 hours _%#NAME#%_ is an excellent candidate to receive Synagis during the upcoming RSV season.
GT|gastrostomy tube|GT|112|113|MEDICATIONS|Nizoral shampoo to the scalp two times a week for the dry, flaky scalp. She also takes Robinul 1 mg or 2 mg per GT tube t.i.d. p.r.n. times patient's request for secretions. Maalox p.r.n. Baclofen 20 mg t.i.d. Demerol 50 to 150 mg down the G tube q.4.h. for pain.
GT|gastrostomy tube|GT|106|107|DISCHARGE PLAN|DISCHARGE PLAN: 1. Medications: A. Premarin, 0.9 mg GT q.d. B. Accupril, 10 mg GT q.d. C. Prevacid, 30 mg GT q.d. D. Advair, 250/50 one puff b.i.d. E. Nasacort-AQ Spray, one puff each nostril q.d. F. Further consideration of antibiotic at the time of dictation regarding pulmonary infiltrate.
GT|gastrostomy tube|GT|202|203|LABORATORY DATA|6. S/p Nissen fundoplication and gastrostomy tube placement on _%#MMDD2002#%_ 7. Anemia of prematurity Her medications on admission include Digoxin 10 mcg GT bid, Lasix 5.6 mg GT qday, Aldactone 5.4 mg GT bid, Diuril 54 mg GT bid, NaCL 6 mEq GT qid, KCl 1 mEq GT qid, FeSO4 8.4 mg qday. The patient had also been on zantac prior to discharge but had not been sent home on zantac, presumably because her nissen fundoplication should control her reflux.
GT|gastrostomy tube|GT|242|243|LABORATORY DATA|6. S/p Nissen fundoplication and gastrostomy tube placement on _%#MMDD2002#%_ 7. Anemia of prematurity Her medications on admission include Digoxin 10 mcg GT bid, Lasix 5.6 mg GT qday, Aldactone 5.4 mg GT bid, Diuril 54 mg GT bid, NaCL 6 mEq GT qid, KCl 1 mEq GT qid, FeSO4 8.4 mg qday. The patient had also been on zantac prior to discharge but had not been sent home on zantac, presumably because her nissen fundoplication should control her reflux.
GT|gastrostomy tube|GT|147|148|2. CV/RESP|4. GI: The patient was restarted on zantac to control any reflux symptoms. Discharge medications, treatments and special equipment: Digoxin 10 mcg GT bid, Lasix 5.6 mg GT qday, Aldactone 5.6 mg GT bid, Diuril 56 mg GT bid, NaCL 6 mEq GT qid, KCl 1 mEq GT qid, FeSO4 8.4 mg qday, Ranitidine 2 mg GT tid, Bacitracin- apply to G tube site q8 hours.
GT|gastrostomy tube|GT|252|253|2. CV/RESP|4. GI: The patient was restarted on zantac to control any reflux symptoms. Discharge medications, treatments and special equipment: Digoxin 10 mcg GT bid, Lasix 5.6 mg GT qday, Aldactone 5.6 mg GT bid, Diuril 56 mg GT bid, NaCL 6 mEq GT qid, KCl 1 mEq GT qid, FeSO4 8.4 mg qday, Ranitidine 2 mg GT tid, Bacitracin- apply to G tube site q8 hours. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include: 1. _%#MMDD2002#%_ Dr. _%#NAME#%_ _%#NAME#%_, cardiology clinic
GT|gastrostomy tube|GT|168|169|2. CV/RESP|4. GI: The patient was restarted on zantac to control any reflux symptoms. Discharge medications, treatments and special equipment: Digoxin 10 mcg GT bid, Lasix 5.6 mg GT qday, Aldactone 5.6 mg GT bid, Diuril 56 mg GT bid, NaCL 6 mEq GT qid, KCl 1 mEq GT qid, FeSO4 8.4 mg qday, Ranitidine 2 mg GT tid, Bacitracin- apply to G tube site q8 hours.
GT|gastrostomy tube|GT|194|195|2. CV/RESP|4. GI: The patient was restarted on zantac to control any reflux symptoms. Discharge medications, treatments and special equipment: Digoxin 10 mcg GT bid, Lasix 5.6 mg GT qday, Aldactone 5.6 mg GT bid, Diuril 56 mg GT bid, NaCL 6 mEq GT qid, KCl 1 mEq GT qid, FeSO4 8.4 mg qday, Ranitidine 2 mg GT tid, Bacitracin- apply to G tube site q8 hours.
GT|gastrostomy tube|GT|215|216|2. CV/RESP|4. GI: The patient was restarted on zantac to control any reflux symptoms. Discharge medications, treatments and special equipment: Digoxin 10 mcg GT bid, Lasix 5.6 mg GT qday, Aldactone 5.6 mg GT bid, Diuril 56 mg GT bid, NaCL 6 mEq GT qid, KCl 1 mEq GT qid, FeSO4 8.4 mg qday, Ranitidine 2 mg GT tid, Bacitracin- apply to G tube site q8 hours.
GT|gastrostomy tube|GT|234|235|2. CV/RESP|4. GI: The patient was restarted on zantac to control any reflux symptoms. Discharge medications, treatments and special equipment: Digoxin 10 mcg GT bid, Lasix 5.6 mg GT qday, Aldactone 5.6 mg GT bid, Diuril 56 mg GT bid, NaCL 6 mEq GT qid, KCl 1 mEq GT qid, FeSO4 8.4 mg qday, Ranitidine 2 mg GT tid, Bacitracin- apply to G tube site q8 hours.
GT|gastrostomy tube|GT|295|296|2. CV/RESP|4. GI: The patient was restarted on zantac to control any reflux symptoms. Discharge medications, treatments and special equipment: Digoxin 10 mcg GT bid, Lasix 5.6 mg GT qday, Aldactone 5.6 mg GT bid, Diuril 56 mg GT bid, NaCL 6 mEq GT qid, KCl 1 mEq GT qid, FeSO4 8.4 mg qday, Ranitidine 2 mg GT tid, Bacitracin- apply to G tube site q8 hours. Follow-up clinic appointments scheduled at Fairview-University Children's Hospital include: 1. _%#MMDD2002#%_ Dr. _%#NAME#%_ _%#NAME#%_, cardiology clinic
GT|gastrostomy tube|GT|179|180|ADMISSION MEDICATIONS|No wheezing. Her central line site is clean, dry, and intact. CARDIOVASCULAR: Regular rate and rhythm. Normal S1 and S2. No murmurs. ABDOMEN: Midline incision is well healed. Her GT site is clean, dry, and intact. LYMPHATICS: No cervical or axillary lymphadenopathy. SKIN: Skin shows no rashes. Slight irritation at the G-tube site minimal. NEUROLOGICAL: Mental status alert and age appropriate.
GT|gastrostomy tube|GT|301|302|ADMISSION MEDICATIONS|This was accomplished the morning following admission without complication. She recovered well postprocedure and was able to be restarted on her G-tube feeds and was ready for discharge the evening following line replacement. DISCHARGE MEDICATIONS: 1. Enalapril 2 mL GT q. day p.m. 2. Cystagon 150 mg GT t.i.d. 3. Erythromycin 50 mg GT q.i.d. 4. Ursodiol 125 mg GT b.i.d. 5. Vitamin B2 25 mg GT q. day. 6. Culturelle 1 capsule GT q. day. 7. Claritin 3 mg GT q. day.
GT|gastrostomy tube|GT|136|137|ADMISSION MEDICATIONS|DISCHARGE MEDICATIONS: 1. Enalapril 2 mL GT q. day p.m. 2. Cystagon 150 mg GT t.i.d. 3. Erythromycin 50 mg GT q.i.d. 4. Ursodiol 125 mg GT b.i.d. 5. Vitamin B2 25 mg GT q. day. 6. Culturelle 1 capsule GT q. day. 7. Claritin 3 mg GT q. day. 8. Carafate 125 mg GT q.i.d. 9. Iron 8 mg GT q. day.
GT|gastrostomy tube|GT|333|334|ADMISSION MEDICATIONS|This was accomplished the morning following admission without complication. She recovered well postprocedure and was able to be restarted on her G-tube feeds and was ready for discharge the evening following line replacement. DISCHARGE MEDICATIONS: 1. Enalapril 2 mL GT q. day p.m. 2. Cystagon 150 mg GT t.i.d. 3. Erythromycin 50 mg GT q.i.d. 4. Ursodiol 125 mg GT b.i.d. 5. Vitamin B2 25 mg GT q. day. 6. Culturelle 1 capsule GT q. day. 7. Claritin 3 mg GT q. day.
GT|gastrostomy tube|GT|110|111|ADMISSION MEDICATIONS|2. Cystagon 150 mg GT t.i.d. 3. Erythromycin 50 mg GT q.i.d. 4. Ursodiol 125 mg GT b.i.d. 5. Vitamin B2 25 mg GT q. day. 6. Culturelle 1 capsule GT q. day. 7. Claritin 3 mg GT q. day. 8. Carafate 125 mg GT q.i.d. 9. Iron 8 mg GT q. day.
GT|gastrostomy tube|GT|142|143|ADMISSION MEDICATIONS|4. Ursodiol 125 mg GT b.i.d. 5. Vitamin B2 25 mg GT q. day. 6. Culturelle 1 capsule GT q. day. 7. Claritin 3 mg GT q. day. 8. Carafate 125 mg GT q.i.d. 9. Iron 8 mg GT q. day. 10. Zofran 8 mg GT t.i.d. 11. Vitamin E 100 units GT q. day. 12. KCl 48 mEq GT q. day. 13. Potassium phosphate 9 mm GT q. day.
GT|gastrostomy tube|GT|103|104|ADMISSION MEDICATIONS|8. Carafate 125 mg GT q.i.d. 9. Iron 8 mg GT q. day. 10. Zofran 8 mg GT t.i.d. 11. Vitamin E 100 units GT q. day. 12. KCl 48 mEq GT q. day. 13. Potassium phosphate 9 mm GT q. day. 14. Synthroid 62.5 mcg GT q. day. 15. Epogen 0.55 mL SQ two times weekly.
GT|gastrostomy tube|GT|129|130|ADMISSION MEDICATIONS|8. Carafate 125 mg GT q.i.d. 9. Iron 8 mg GT q. day. 10. Zofran 8 mg GT t.i.d. 11. Vitamin E 100 units GT q. day. 12. KCl 48 mEq GT q. day. 13. Potassium phosphate 9 mm GT q. day. 14. Synthroid 62.5 mcg GT q. day. 15. Epogen 0.55 mL SQ two times weekly.
GT|gastrostomy tube|GT|116|117|ADMISSION MEDICATIONS|10. Zofran 8 mg GT t.i.d. 11. Vitamin E 100 units GT q. day. 12. KCl 48 mEq GT q. day. 13. Potassium phosphate 9 mm GT q. day. 14. Synthroid 62.5 mcg GT q. day. 15. Epogen 0.55 mL SQ two times weekly. DISCHARGE DIET: Pediasure with fiber 105 mL per hour for 14 to 16 hours per day, TPN 1100 mL over 8 hours every night.
GT|gutta|GT|201|202|DISCHARGE MEDICATIONS|2. Discharge activity is as tolerated. 3. Discharge is to Transitional Care Unit to be arranged preferably to the Masonic Nursing Home per patient's request. DISCHARGE MEDICATIONS: 1. Alphagan 0.5%, 1 GT right eye b.i.d. 2. Cosopt 1 GT right eye b.i.d. 3. Gabapentin 200 mg p.o. q.a.m., 500 mg p.o. q.p.m. 4. Humulin 70/30 40 units subcu q.a.m., 10 units subcu q.p.m.
GT|gastrostomy tube|GT.|181|183|3. CV|These feeds were continued until _%#NAME#%_ underwent laparoscopic Nissen fundoplication. After this surgery, his Nutramigen feeds were gradually advanced to 70 cc q 3 hours vai8 a GT. _%#NAME#%_ was tried on some po feeds but he did not bottle feed well. 3. CV: He remained stable from a cardiovascular standpoint during his hospitalization.
GT|gastrostomy tube|GT|190|191|1.) CV|2.) GI: _%#NAME#%_ is now tolerating feeds through his GT well. His mother has received training on how to use and maintain the G-tube. She has demonstrated proficiency at administering the GT feeds. _%#NAME#%_ is to follow up with the surgeon who inserted the GT, Dr. _%#NAME#%_, in 2 weeks for post-op follow up. 3.) Hypothyroidism: _%#NAME#%_ is to follow up with endocrinology within 2- 3 weeks.
GT|gastrostomy tube|GT,|125|127|1.) CV|She has demonstrated proficiency at administering the GT feeds. _%#NAME#%_ is to follow up with the surgeon who inserted the GT, Dr. _%#NAME#%_, in 2 weeks for post-op follow up. 3.) Hypothyroidism: _%#NAME#%_ is to follow up with endocrinology within 2- 3 weeks.
GT|gutta|GT|131|132|MEDICATIONS|1. Amaryl 4 mg daily. 2. Aspirin 325 mg daily. He is holding this 5 days prior to surgery. 3. Lisinopril 20 mg daily. 4. Xalatan 1 GT both eyes every day. ALLERGIES: Sulfa. SOCIAL HISTORY: Married. Four children. HABITS: Non-smoker. Occasional alcohol.
GT|gastrostomy tube|GT|176|177|DISCHARGE MEDICATIONS|4. Vertigo. 5. History of cerebrovascular accident (CVA) in _%#MM2002#%_. DISCHARGE MEDICATIONS: 1. Tylenol 650 mg PR q4-6h p.r.n. 2. Atenolol 25 mg GT q.day. 3. Keppra 500 mg GT b.i.d. 4. Valproic acid 1000 mg GT b.i.d. 5. Zinc oxide ointment. 6. Citalopram 30 mg GT q.day. 7. Nystatin ointment. PROCEDURES PERFORMED: 1. Head CT.
GT|gastrostomy tube|GT|134|135|DISCHARGE MEDICATIONS|2. Atenolol 25 mg GT q.day. 3. Keppra 500 mg GT b.i.d. 4. Valproic acid 1000 mg GT b.i.d. 5. Zinc oxide ointment. 6. Citalopram 30 mg GT q.day. 7. Nystatin ointment. PROCEDURES PERFORMED: 1. Head CT. 2. Lumbar puncture. 3. Central line placement. 4. Feeding tube placement.
GT|gastrostomy tube|GT|222|223|DISCHARGE AND FOLLOWUP|She also had an appointment made to follow up with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2005, and with Dr. _%#NAME#%_ in _%#MM#%_ 2005. DISCHARGE MEDICATIONS: 1. Amantadine 90 mg GT q. day for 3 days. 2. Cefuroxime 250 mg GT b.i.d. for 14 days. 3. Lactobacillus 1/2 capsule GT b.i.d. 4. Flonase 50 mcg one spray per nostril b.i.d. 5. Singulair 5 mg GT q. day. 6. Zyrtec 2.5 mg GT q. day.
GT|gastrostomy tube|GT|138|139|DISCHARGE AND FOLLOWUP|DISCHARGE MEDICATIONS: 1. Amantadine 90 mg GT q. day for 3 days. 2. Cefuroxime 250 mg GT b.i.d. for 14 days. 3. Lactobacillus 1/2 capsule GT b.i.d. 4. Flonase 50 mcg one spray per nostril b.i.d. 5. Singulair 5 mg GT q. day. 6. Zyrtec 2.5 mg GT q. day. 7. Artificial Tears, 0.1 to 0.3% solution, 2 drops to each eye b.i.d.
GT|gastrostomy tube|GT|148|149|DISCHARGE AND FOLLOWUP|2. Cefuroxime 250 mg GT b.i.d. for 14 days. 3. Lactobacillus 1/2 capsule GT b.i.d. 4. Flonase 50 mcg one spray per nostril b.i.d. 5. Singulair 5 mg GT q. day. 6. Zyrtec 2.5 mg GT q. day. 7. Artificial Tears, 0.1 to 0.3% solution, 2 drops to each eye b.i.d.
GT|gastrostomy tube|GT|256|257|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Her past medical history is significant for previous evaluations for possible IBD and treatment with sulfasalazine, Prevacid, and Creon 5. She has had feeding intolerance with failure to thrive noted since 6 months of age and has had GT feeds since 7 months of age. Her previous celiac workups have been negative. She had an evaluation in the past in children's hospital, which included repeat endoscopy, which was consistent with small bowel ulceration but with normal biopsies.
GT|gastrostomy tube|GT|199|200|DISCHARGE MEDICATIONS|Her dehydration had resolved, and she had remained afebrile. DISCHARGE DIAGNOSES: 1. Gastroenteritis. 2. Dehydration. DISCHARGE MEDICATIONS: 1. Sulfasalazine 125 mg p.o. GT q.i.d. 2. Prevacid 7.5 mg GT b.i.d. 3. Creon 5, 1 to 2 tabs GT/p.o. with snacks. 4. Creon 5, 3 to 4 tabs GT/p.o. with meals. 5. ADEK 1 mL G tube daily. 6. Triamcinolone 0.5% cream to GT site b.i.d. x9 days.
GT|gastrostomy tube|GT|170|171|DISCHARGE MEDICATIONS|Her dehydration had resolved, and she had remained afebrile. DISCHARGE DIAGNOSES: 1. Gastroenteritis. 2. Dehydration. DISCHARGE MEDICATIONS: 1. Sulfasalazine 125 mg p.o. GT q.i.d. 2. Prevacid 7.5 mg GT b.i.d. 3. Creon 5, 1 to 2 tabs GT/p.o. with snacks. 4. Creon 5, 3 to 4 tabs GT/p.o. with meals.
GT|gastrostomy tube|GT|153|154|DISCHARGE MEDICATIONS|4. Creon 5, 3 to 4 tabs GT/p.o. with meals. 5. ADEK 1 mL G tube daily. 6. Triamcinolone 0.5% cream to GT site b.i.d. x9 days. 7. Erythromycin 50 mg p.o. GT q.6 hours x6 days. DISCHARGE ACTIVITY: As tolerated. DISCHARGE DIET: Peptamen Junior 50 mL per hour overnight with p.o. feeds ad lib in daytime.
GT|gastrostomy tube|GT|122|123|HOSPITAL COURSE|She was seen by Speech Therapy and Nutrition to manage the poor feeding as a result of the recent stroke. She does have a GT tube in place. DISCHARGE MEDICATIONS: 1. Prevacid 30 mg down feeding tube q.12 hours. 2. Cozaar 100 mg down feeding tube q.24 hours.
GT|gastrostomy tube|GT|223|224|DISCHARGE MEDICATIONS|CONDITION UPON DISCHARGE: Good condition and discharged to home. He still had a few crackles in his lungs; however, his heart gallop had disappeared. DISCHARGE MEDICATIONS: 1. Aldactone 10 mg GT twice daily. 2. Lasix 10 mg GT 3 times daily. 3. Captopril 4 mg GT 3 times daily. 4. Bactrim 20 mg GT Monday, Wednesday, and Friday.
GT|gastrostomy tube|GT|109|110|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Aldactone 10 mg GT twice daily. 2. Lasix 10 mg GT 3 times daily. 3. Captopril 4 mg GT 3 times daily. 4. Bactrim 20 mg GT Monday, Wednesday, and Friday. 5. Nystatin 2 mL GT 4 times a day. 6. Zantac 15 mg GT twice daily.
GT|gastrostomy tube|GT|144|145|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Aldactone 10 mg GT twice daily. 2. Lasix 10 mg GT 3 times daily. 3. Captopril 4 mg GT 3 times daily. 4. Bactrim 20 mg GT Monday, Wednesday, and Friday. 5. Nystatin 2 mL GT 4 times a day. 6. Zantac 15 mg GT twice daily. 7. Methadone 0.1 mg GT every 8 hours. 8. Prednisone 1 mg GT twice daily.
GT|gastrostomy tube|GT|102|103|DISCHARGE MEDICATIONS|4. Bactrim 20 mg GT Monday, Wednesday, and Friday. 5. Nystatin 2 mL GT 4 times a day. 6. Zantac 15 mg GT twice daily. 7. Methadone 0.1 mg GT every 8 hours. 8. Prednisone 1 mg GT twice daily. 9. Cyclosporin 23 mg GT every 8 hours. 10. CellCept 250 mg GT twice daily.
GT|gastrostomy tube|GT|138|139|DISCHARGE MEDICATIONS|4. Bactrim 20 mg GT Monday, Wednesday, and Friday. 5. Nystatin 2 mL GT 4 times a day. 6. Zantac 15 mg GT twice daily. 7. Methadone 0.1 mg GT every 8 hours. 8. Prednisone 1 mg GT twice daily. 9. Cyclosporin 23 mg GT every 8 hours. 10. CellCept 250 mg GT twice daily.
GT|gastrostomy tube|GT|124|125|DISCHARGE MEDICATIONS|5. Nystatin 2 mL GT 4 times a day. 6. Zantac 15 mg GT twice daily. 7. Methadone 0.1 mg GT every 8 hours. 8. Prednisone 1 mg GT twice daily. 9. Cyclosporin 23 mg GT every 8 hours. 10. CellCept 250 mg GT twice daily. 11. Metolazone 0.5 mg GT x1 on Friday, _%#MMDD2005#%_. FOLLOW-UP: _%#NAME#%_ should be seen in Dr. _%#NAME#%_ clinic on _%#MMDD2005#%_ where he should also have an echocardiogram.
GT|gastrostomy tube|GT|161|162|DISCHARGE MEDICATIONS|5. Nystatin 2 mL GT 4 times a day. 6. Zantac 15 mg GT twice daily. 7. Methadone 0.1 mg GT every 8 hours. 8. Prednisone 1 mg GT twice daily. 9. Cyclosporin 23 mg GT every 8 hours. 10. CellCept 250 mg GT twice daily. 11. Metolazone 0.5 mg GT x1 on Friday, _%#MMDD2005#%_. FOLLOW-UP: _%#NAME#%_ should be seen in Dr. _%#NAME#%_ clinic on _%#MMDD2005#%_ where he should also have an echocardiogram.
GT|gastrostomy tube|GT|132|133|DISCHARGE MEDICATIONS|7. Methadone 0.1 mg GT every 8 hours. 8. Prednisone 1 mg GT twice daily. 9. Cyclosporin 23 mg GT every 8 hours. 10. CellCept 250 mg GT twice daily. 11. Metolazone 0.5 mg GT x1 on Friday, _%#MMDD2005#%_. FOLLOW-UP: _%#NAME#%_ should be seen in Dr. _%#NAME#%_ clinic on _%#MMDD2005#%_ where he should also have an echocardiogram.
GT|gastrostomy tube|GT|170|171|DISCHARGE MEDICATIONS|7. Methadone 0.1 mg GT every 8 hours. 8. Prednisone 1 mg GT twice daily. 9. Cyclosporin 23 mg GT every 8 hours. 10. CellCept 250 mg GT twice daily. 11. Metolazone 0.5 mg GT x1 on Friday, _%#MMDD2005#%_. FOLLOW-UP: _%#NAME#%_ should be seen in Dr. _%#NAME#%_ clinic on _%#MMDD2005#%_ where he should also have an echocardiogram.
GT|gastrostomy tube|GT|160|161|DISCHARGE DIAGNOSIS|8. Rhinocort AQ 1 spray per naris b.i.d. 9. TOBI neb 5 mL b.i.d. 10. Combivent MDI 2 puffs to spray before vest therapy. 11. ADEK-vitamins 1.5 tabs p.o. or per GT daily. 12. Vitamin E 400 units p.o. or per GT daily. 13. Prevacid 15 mg p.o. or per GT b.i.d. 14. Viokase powder 1.5 teaspoons p.o. per GT per can with tube feeds.
GT|gastrostomy tube|GT|178|179|DISCHARGE DIAGNOSIS|11. ADEK-vitamins 1.5 tabs p.o. or per GT daily. 12. Vitamin E 400 units p.o. or per GT daily. 13. Prevacid 15 mg p.o. or per GT b.i.d. 14. Viokase powder 1.5 teaspoons p.o. per GT per can with tube feeds. SPECIAL INSTRUCTIONS: 1. Chest physiotherapy with incentive spirometry between each frequency 4 times a day. The patient is discharged home with 2 incentive spirometers.
GT|gastrostomy tube|GT|151|152|PHYSICAL EXAMINATION|Cardiovascular: Regular rate and rhythm with 1/6 soft systolic murmur. Lungs clear to auscultation bilaterally. Abdomen with normoactive bowel sounds. GT and PD catheter in place. There was no erythema or guarding. Skin with no rashes. Neurologic: Awake and alert. Lymphatics: No lymphadenopathy.
GT|gastrostomy tube|GT|326|327|DISCHARGE MEDICATIONS|DISCHARGE INSTRUCTIONS: 1. Diet. Resume diet as previously done with Neocate I Plus, 2 packs mixed with 22.5 ounces water with 1 tsp essential amino acids, 130 mL boluses given over 1/2 hour t.i.d. Continue with feedings at night at 45 mL/hr x 10 hours. 2. Activity as tolerated. DISCHARGE MEDICATIONS: 1. Calcitriol 0.25 mcg GT Monday, Wednesday, and Friday. 2. Phenobarbital 60 mg GT b.i.d. 3. Maxitrol ophthalmic to left eye t.i.d. 4. Epogen 1000 units subcutaneously 3 times per week. 5. Lamictal 175 mg GT b.i.d.
GT|gastrostomy tube|GT|175|176|DISCHARGE MEDICATIONS|2. Phenobarbital 60 mg GT b.i.d. 3. Maxitrol ophthalmic to left eye t.i.d. 4. Epogen 1000 units subcutaneously 3 times per week. 5. Lamictal 175 mg GT b.i.d. 6. Folate 0.5 mg GT daily. 7. Ferrous sulfate 25 mg GT daily. 8. Triamcinolone 0.5% cream to G-tube site q.i.d. 9. Emla cream to Epogen site before injection.
GT|gastrostomy tube|GT|135|136|DISCHARGE MEDICATIONS|4. Epogen 1000 units subcutaneously 3 times per week. 5. Lamictal 175 mg GT b.i.d. 6. Folate 0.5 mg GT daily. 7. Ferrous sulfate 25 mg GT daily. 8. Triamcinolone 0.5% cream to G-tube site q.i.d. 9. Emla cream to Epogen site before injection. 10. Calcium carbonate 100 mg GT t.i.d. with feeds.
GT|gastrostomy tube|GT|175|176|DISCHARGE MEDICATIONS|8. Triamcinolone 0.5% cream to G-tube site q.i.d. 9. Emla cream to Epogen site before injection. 10. Calcium carbonate 100 mg GT t.i.d. with feeds. 11. Sodium chloride 25 mEq GT t.i.d. PERITONEAL DIALYSIS: Peritoneal dialysis to be continued as outpatient without changes.
GT|gastrostomy tube|GT|136|137|DISCHARGE MEDICATIONS|This mainly occurs when he is crying or sleeping. Discharge date: _%#MM#%_ _%#DD#%_, 2005. DISCHARGE MEDICATIONS: 1. Lasix 8 mg p.o. or GT b.i.d. 2. Aldactone 8 mg p.o. or GT b.i.d. 3. Reglan 0.6 mg p.o. or GT q.i.d. FOLLOW UP: _%#NAME#%_ has a followup appointment with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2005, at 9 a.m.
GT|gastrostomy tube|GT|172|173|DISCHARGE MEDICATIONS|This mainly occurs when he is crying or sleeping. Discharge date: _%#MM#%_ _%#DD#%_, 2005. DISCHARGE MEDICATIONS: 1. Lasix 8 mg p.o. or GT b.i.d. 2. Aldactone 8 mg p.o. or GT b.i.d. 3. Reglan 0.6 mg p.o. or GT q.i.d. FOLLOW UP: _%#NAME#%_ has a followup appointment with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2005, at 9 a.m.
GT|gastrostomy tube|GT|116|117|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Lasix 8 mg p.o. or GT b.i.d. 2. Aldactone 8 mg p.o. or GT b.i.d. 3. Reglan 0.6 mg p.o. or GT q.i.d. FOLLOW UP: _%#NAME#%_ has a followup appointment with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2005, at 9 a.m.
GT|gastrostomy tube|GT|219|220|DISCHARGE MEDICATIONS|4. Nutrition: The patient was initially made and remained n.p.o. with maintenance IV fluids running through the night and then by noon the next day her feeds were resumed. DISCHARGE MEDICATIONS: 1. Lasix 7.5 mg p.o. or GT b.i.d. 2. Viagra 5 mg p.o. or GT t.i.d. 3. Enalapril 0.6 mg p.o. or GT b.i.d. 4. Digoxin 25 mcg p.o. or GT daily. 5. Aspirin 41 mg p.o. or GT. q. day.
GT|gastrostomy tube|GT|118|119|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Lasix 7.5 mg p.o. or GT b.i.d. 2. Viagra 5 mg p.o. or GT t.i.d. 3. Enalapril 0.6 mg p.o. or GT b.i.d. 4. Digoxin 25 mcg p.o. or GT daily. 5. Aspirin 41 mg p.o. or GT. q. day. 6. Reglan 0.6 mg p.o or GT. b.i.d.
GT|gastrostomy tube|GT|130|131|DISCHARGE MEDICATIONS|4. Digoxin 25 mcg p.o. or GT daily. 5. Aspirin 41 mg p.o. or GT. q. day. 6. Reglan 0.6 mg p.o or GT. b.i.d. 7. Prevacid 15 mg per GT daily and prescription was sent to pharmacy. 7. Omnicef 125 mg p.o. or GT q. day for 10-day duration. 8. Flagyl 60 mg q.i.d x10 days. This was called out as the C. difficile was positive shortly after the patient left the hospital.
GT|gastrostomy tube|GT|131|132|DISCHARGE MEDICATIONS|6. Reglan 0.6 mg p.o or GT. b.i.d. 7. Prevacid 15 mg per GT daily and prescription was sent to pharmacy. 7. Omnicef 125 mg p.o. or GT q. day for 10-day duration. 8. Flagyl 60 mg q.i.d x10 days. This was called out as the C. difficile was positive shortly after the patient left the hospital.
GT|gutta|GT|143|144|DISCHARGE DIAGNOSES|5. H6. aldol 0.5-1 mg p.o. q.6h. p.r.n. 6. T7. ylenol 325 mg 1-2 tablets p.o. q.6h. 7. L8. evothyroxine 25 mcg p.o. q. day. 8. T9. rusopt 2% 1 GT in both eyes each day at bedtime. DISCHARGE FOLLOW-UP: 1. With Dr. _%#NAME#%_ in 1-2 weeks.
GT|gutta|GT|155|156|DISCHARGE MEDICATIONS|5. Prozac 20 mg p.o. daily 6. Levothyroxine 75 mcg p.o. q. day. 7. Magnesium oxide 400 mg p.o. daily. 8. Metoprolol 12.5 mg p.o. b.i.d. 9. Timolol 0.5%, 1 GT in the right eye q. day. 10. Tylenol 650 mg p.o. q.6h. p.r.n. DISCHARGE FOLLOW-UP: 1. See Dr. _%#NAME#%_ in two weeks for removal of ureteral stents.
GT|gastrostomy tube|GT|169|170|DISCHARGE MEDICATIONS|1. Amlodipine 3 mg, G tube b.i.d. 2. Calcium carbonate 500 mg, G tube t.i.d. 3. Enalapril 1 mg, G tube b.i.d. 4. Fer-In-Sol 37.5 mg, GT b.i.d. 5. Multivitamin 1 tablet, GT q. day. 6. Bicitra 20 mL, G tube b.i.d. 7. Amoxicillin 200 mg, G tube t.i.d. x5 days. 8. Milk of magnesia 10 mL, G tube at bedtime p.r.n. constipation.
GT|gastrostomy tube|GT|179|180|DISCHARGE MEDICATIONS|9. Neutra-Phos 1 packet GT t.i.d. 10. Nystatin swish and swallow 10 mL p.o. q.i.d. 11. Fentanyl patch 50 mcg TD q.72 h. 12. Pantoprazole 40 mg p.o./GT daily. 13. Senokot S 2 tabs GT b.i.d. 14. Pilocarpine 5 mg GT b.i.d. 15. Vitamin B6 100 mg GT daily. 16. Cozaar 100 mg GT daily. 17. Atorvastatin 80 mg GT each day at bedtime.
GT|gastrostomy tube|GT|145|146|DISCHARGE MEDICATIONS|13. Senokot S 2 tabs GT b.i.d. 14. Pilocarpine 5 mg GT b.i.d. 15. Vitamin B6 100 mg GT daily. 16. Cozaar 100 mg GT daily. 17. Atorvastatin 80 mg GT each day at bedtime. 18. Benefiber 1 Tbs GT b.i.d. 19. MiraLax 17 grams GT daily. 20. Nicotine patch 21 mg TD daily to be decreased per standard protocol.
GT|gastrostomy tube|GT|127|128|DISCHARGE MEDICATIONS|15. Vitamin B6 100 mg GT daily. 16. Cozaar 100 mg GT daily. 17. Atorvastatin 80 mg GT each day at bedtime. 18. Benefiber 1 Tbs GT b.i.d. 19. MiraLax 17 grams GT daily. 20. Nicotine patch 21 mg TD daily to be decreased per standard protocol. DISCHARGE INSTRUCTIONS: The patient was discharged in stable condition. DIET: As tolerated supplemented by Probalance 3 cans GT b.i.d. The patient was asked to try to avoid high calcium foods.
GT|gastrostomy tube|GT|158|159|DISCHARGE MEDICATIONS|15. Vitamin B6 100 mg GT daily. 16. Cozaar 100 mg GT daily. 17. Atorvastatin 80 mg GT each day at bedtime. 18. Benefiber 1 Tbs GT b.i.d. 19. MiraLax 17 grams GT daily. 20. Nicotine patch 21 mg TD daily to be decreased per standard protocol. DISCHARGE INSTRUCTIONS: The patient was discharged in stable condition. DIET: As tolerated supplemented by Probalance 3 cans GT b.i.d. The patient was asked to try to avoid high calcium foods.
GT|gastrostomy tube|GT|198|199|DIET|20. Nicotine patch 21 mg TD daily to be decreased per standard protocol. DISCHARGE INSTRUCTIONS: The patient was discharged in stable condition. DIET: As tolerated supplemented by Probalance 3 cans GT b.i.d. The patient was asked to try to avoid high calcium foods. The patient is also to have free water 200 cc b.i.d. following his tube feeds as he was doing previously.
GT|gastrostomy tube|GT|127|128|DISCHARGE DIET|8. Resolving malnutrition secondary to medical illnesses and oral aversion. DISCHARGE DIET: Similac PM 60/40 26 kcal, 30 mL/hr GT x 24 hours per day plus PO ad lib. DISCHARGE ACTIVITY: Reflux precautions. DISCHARGE MEDICATIONS: 1. Albuterol 2.5-mg neb b.i.d. and q.1h. p.r.n. dyspnea.
GT|gastrostomy tube|GT|201|202|DISCHARGE MEDICATIONS|DISCHARGE ACTIVITY: Reflux precautions. DISCHARGE MEDICATIONS: 1. Albuterol 2.5-mg neb b.i.d. and q.1h. p.r.n. dyspnea. 2. Pulmicort 0.5-mg neb b.i.d. 3. Atrovent 0.5-mg neb b.i.d. 4. Enalapril 2.5 mg GT b.i.d. 5. Ferr-In-Sol 7.5 mg GT t.i.d. 6. Lasix 10 mg GT t.i.d. 7. Minoxidil 1 mg GT b.i.d. 8. Nifedipine 2.5 mg GT p.r.n. blood pressure greater than 130/80.
GT|gastrostomy tube|GT|166|167|DISCHARGE MEDICATIONS|2. Pulmicort 0.5-mg neb b.i.d. 3. Atrovent 0.5-mg neb b.i.d. 4. Enalapril 2.5 mg GT b.i.d. 5. Ferr-In-Sol 7.5 mg GT t.i.d. 6. Lasix 10 mg GT t.i.d. 7. Minoxidil 1 mg GT b.i.d. 8. Nifedipine 2.5 mg GT p.r.n. blood pressure greater than 130/80. 9. Zantac15 mg GT b.i.d. 10. Mylicon 20 mg GT q.i.d. p.r.n. gas.
GT|gastrostomy tube|GT|136|137|DISCHARGE MEDICATIONS|4. Enalapril 2.5 mg GT b.i.d. 5. Ferr-In-Sol 7.5 mg GT t.i.d. 6. Lasix 10 mg GT t.i.d. 7. Minoxidil 1 mg GT b.i.d. 8. Nifedipine 2.5 mg GT p.r.n. blood pressure greater than 130/80. 9. Zantac15 mg GT b.i.d. 10. Mylicon 20 mg GT q.i.d. p.r.n. gas. 11. Sodium chloride 7 mEq GT q.6h. 12. Atrovent nasal spray to be applied to both nares t.i.d. p.r.n. secretions.
GT|gastrostomy tube|GT|138|139|DISCHARGE MEDICATIONS|2. Pulmicort 0.5-mg neb b.i.d. 3. Atrovent 0.5-mg neb b.i.d. 4. Enalapril 2.5 mg GT b.i.d. 5. Ferr-In-Sol 7.5 mg GT t.i.d. 6. Lasix 10 mg GT t.i.d. 7. Minoxidil 1 mg GT b.i.d. 8. Nifedipine 2.5 mg GT p.r.n. blood pressure greater than 130/80. 9. Zantac15 mg GT b.i.d. 10. Mylicon 20 mg GT q.i.d. p.r.n. gas.
GT|gastrostomy tube|GT|135|136|DISCHARGE MEDICATIONS|6. Lasix 10 mg GT t.i.d. 7. Minoxidil 1 mg GT b.i.d. 8. Nifedipine 2.5 mg GT p.r.n. blood pressure greater than 130/80. 9. Zantac15 mg GT b.i.d. 10. Mylicon 20 mg GT q.i.d. p.r.n. gas. 11. Sodium chloride 7 mEq GT q.6h. 12. Atrovent nasal spray to be applied to both nares t.i.d. p.r.n. secretions.
GT|gastrostomy tube|GT|163|164|DISCHARGE MEDICATIONS|6. Lasix 10 mg GT t.i.d. 7. Minoxidil 1 mg GT b.i.d. 8. Nifedipine 2.5 mg GT p.r.n. blood pressure greater than 130/80. 9. Zantac15 mg GT b.i.d. 10. Mylicon 20 mg GT q.i.d. p.r.n. gas. 11. Sodium chloride 7 mEq GT q.6h. 12. Atrovent nasal spray to be applied to both nares t.i.d. p.r.n. secretions.
GT|gastrostomy tube|GT|158|159|DISCHARGE MEDICATIONS|8. Nifedipine 2.5 mg GT p.r.n. blood pressure greater than 130/80. 9. Zantac15 mg GT b.i.d. 10. Mylicon 20 mg GT q.i.d. p.r.n. gas. 11. Sodium chloride 7 mEq GT q.6h. 12. Atrovent nasal spray to be applied to both nares t.i.d. p.r.n. secretions. DISPOSITION: Transferred to the care of Dr. _%#NAME#%_ _%#NAME#%_, inpatient pediatric ward in _%#CITY#%_ _%#CITY#%_, South Dakota, via air ambulance.
GT|gastrostomy tube|GT|152|153|DISCHARGE MEDICATIONS|4. History of hypertension secondary to immunosuppression medications. DISCHARGE MEDICATIONS: 1. CellCept 200 mg GT b.i.d. 2. Tacrolimus3 mg suspension GT q.a.m. 3. Tacrolimus2 mg suspension GT each day at bedtime. 4. Prednisone 0.5 mg GT b.i.d. 5. Folic acid 30 mg GT daily. 6. Spironolactone 5 mg suspension GT b.i.d.
GT|gastrostomy tube|GT|113|114|DISCHARGE MEDICATIONS|4. History of hypertension secondary to immunosuppression medications. DISCHARGE MEDICATIONS: 1. CellCept 200 mg GT b.i.d. 2. Tacrolimus3 mg suspension GT q.a.m. 3. Tacrolimus2 mg suspension GT each day at bedtime. 4. Prednisone 0.5 mg GT b.i.d.
GT|gastrostomy tube|GT|142|143|DISCHARGE MEDICATIONS|1. CellCept 200 mg GT b.i.d. 2. Tacrolimus3 mg suspension GT q.a.m. 3. Tacrolimus2 mg suspension GT each day at bedtime. 4. Prednisone 0.5 mg GT b.i.d. 5. Folic acid 30 mg GT daily. 6. Spironolactone 5 mg suspension GT b.i.d. 7. Multivitamin with iron 1 mL GT q.p.m. 8. Ganciclovir 90 mg GT b.i.d.
GT|gutta|GT|193|194|DISCHARGE MEDICATIONS|2. Prednisone 2.5 mg po qd. 3. Premarin 0.625 mg q Wednesday and Saturday. 4. Vitamin E 400 Int'l units every other day. 5. The eye drops that were prescribed post cataract surgery, Tobradex 1 GT to left eye qid and Acular 0.5% 1 GT to left eye qid. DISCHARGE FOLLOW-UP: Is to be with Dr. _%#NAME#%_ _%#NAME#%_ either on _%#MMDD2002#%_ or _%#MMDD2002#%_ for a CBC with differential and platelets.
GT|gutta|GT|155|156|DISCHARGE MEDICATIONS|4. Vitamin E 400 Int'l units every other day. 5. The eye drops that were prescribed post cataract surgery, Tobradex 1 GT to left eye qid and Acular 0.5% 1 GT to left eye qid. DISCHARGE FOLLOW-UP: Is to be with Dr. _%#NAME#%_ _%#NAME#%_ either on _%#MMDD2002#%_ or _%#MMDD2002#%_ for a CBC with differential and platelets.
GT|gastrostomy tube|(GT)|201|204|HOSPITAL COURSE|She tolerated these without difficulty and TPN was discontinued. A swallow study on _%#MMDD2002#%_ showed complete obstruction with feeds and patient was made NPO. A 18 Fr Microvasive gastrostomy tube (GT) was placed on _%#MMDD2002#%_ for long term feeding. 2. Cardiac - An echocardiogram performed on admission showed a small PDA with L->R shunt and trace MR otherwise normal anatomy and cardiac function.
GT|gastrostomy tube|GT|197|198|HOSPITAL COURSE|Bronchoscopy was performed by ENT on_%#MMDD2002#%_ which showed a significantly anterior airway but it was felt that surgical repair was not needed urgently. Patient was intubated at this time for GT placement and a sedated head CT. Patient was given a three day course of methylprednisolone around the time of extubation due to multiple attempts at intubation.
GT|gastrostomy tube|GT|152|153|HOSPITAL COURSE|6. ENT - An ENT consult and hearing test was requested on admission and they recommended either tracheostomy vs. jaw advancement. They also felt that a GT would likely be needed in the interim. Following bronchoscopy and head CT that showed that the patient has a first arch syndrome and in particular, she lacks external ear canals bilaterally.
GT|gastrostomy tube|GT|155|156|HOSPITAL COURSE|No colobomas were noted. Ophthalmology wished to follow up around _%#MMDD#%_. Ongoing problems and suggested management: 1. FEN - _%#NAME#%_ is tolerating GT feeds and growing well. She will need to have her feeds adjusted to maintain growth. 2. ENT - _%#NAME#%_ is to follow up with Dr. _%#NAME#%_ in 2 weeks to discuss repair of midline cleft and definitive airway surgery.
GT|gastrostomy tube|GT|200|201|HOSPITAL COURSE|5. Optho - _%#NAME#%_ is to follow up at the ophthalmology regarding her small palpebral fissures in 2 weeks 6. Peds Surgery - Pediatric surgery would like to see _%#NAME#%_ in two weeks to follow up GT placement. Discharge medications, treatments and special equipment: 1. Ranitidine 7 mg NG BID
GT|gastrostomy tube|GT|191|192|HOSPITAL COURSE|6. Peds Surgery - Pediatric surgery would like to see _%#NAME#%_ in two weeks to follow up GT placement. Discharge medications, treatments and special equipment: 1. Ranitidine 7 mg NG BID 2. GT feeds of BM 85 mL every three hours _%#NAME#%_ is a good candidate to receive Synagis during the upcoming RSV season.
GT|gastrostomy tube|GT|169|170|REVIEW OF SYSTEMS|SOCIAL HISTORY: Lives with Mom and younger brother and two sisters and Dad. REVIEW OF SYSTEMS: At time of admission was positive for heme- positive drainage from JP and GT tube. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: She had a temperature of 96.4, pulse 137, respiratory rate 32, blood pressure 97/60, weight 12.6 kg.
GT|gastrostomy tube|GT|209|210|REVIEW OF SYSTEMS|There has been more recently a little bit of a pleural effusion on the left side of his chest, so there is a concern about aspiration as well. No fevers recently. The most recent endoscope was when we put the GT tube in. Prior endoscope did not reveal any problems. We biopsied a shelf like constriction in the esophagus which was benign.
GT|gastrostomy tube|GT|191|192|PHYSICAL EXAMINATION|He has good palatal movement on deep breathing. NECK: Is supple, no adenopathy. LUNGS: Are quite clear. HEART: Is regular, rate is 60, regular without ectopy ABDOMEN: Is soft and non-tender. GT tube is well placed and he has been getting Isosource for that. RECTAL: Exam was not done this evening. He has puffy ankles, no pitting.
GT|glutamyl transpeptidase|GT|260|261|HOSPITAL COURSE|This revealed 250 nucleated cells, 35 RBCs, with a differential showing 4% neutrophils, 40% leukocytes, 56% other nucleated cells. Cultures pending at this time, as well as cytology. Given the patient's increasing alkaline phosphatase and L2 fracture, a gamma GT was obtained, as well. This was elevated at the last check three years ago. Current value is 150; prior was 91. Given perhaps progressing process in the patient's liver and biliary tree, the GI Service at this time was considering endoscopic ultrasound versus ERCP or cholangiogram.
GT|gastrostomy tube|GT|144|145|MEDICATION ON ADMISSION|10. Left cryptorchidism and hypospadia. 11. Strabismus, esotropia, hypotropia. 12. Developmental delay. MEDICATION ON ADMISSION: 1. Lasix 20 mg GT q.i.d. 2. Prevacid 10mg GT q.d. 3. Synthroid 62.5 mcg GT q.d. 4. Nystatin 10 cc p.o. q.d. 5. Serevent 2 puffs inhaled b.i.d.
GT|gastrostomy tube|GT|135|136|MEDICATION ON ADMISSION|2. Prevacid 10mg GT q.d. 3. Synthroid 62.5 mcg GT q.d. 4. Nystatin 10 cc p.o. q.d. 5. Serevent 2 puffs inhaled b.i.d. 6. Tylenol 60 mg GT q. 4 hour p.r.n. pain. 7. Albuterol four puffs inhaled q. 6 hours p.r.n. for wheezing. 8. __________ (?Criticaid) topical paste for skin breakdown t.i.d. p.r.n.
GT|gastrostomy tube|GT|186|187|MEDICATION ON ADMISSION|8. __________ (?Criticaid) topical paste for skin breakdown t.i.d. p.r.n. 9. Miconazole topical cream p.r.n. to buttocks for diaper rash. 10. Bactrim single strength 90 mg TMP component GT Monday, Wednesday, Friday. 11. ________ (?Activin)-on weaning schedule of (?Activin) at 0.2 mg GT q. 8 hours from _%#MM#%_ _%#DD#%_ to _%#MM#%_ _%#DD#%_.
GT|gastrostomy tube|GT|95|96|MEDICATION ON ADMISSION|Then 0.1 mg GT q. 8 hours from _%#MM#%_ _%#DD#%_ to _%#MM#%_ _%#DD#%_. Then decrease to 0.1 mg GT b.i.d. from _%#MM#%_ _%#DD#%_ to _%#MM#%_ _%#DD#%_. He should be off (?Activin) on _%#MM#%_ _%#DD#%_, 2002. 12. Metamucil 36 mg, which is 0.4 cc GT q.d.
GT|gastrostomy tube|GT|172|173|MEDICATION ON ADMISSION|Then decrease to 0.1 mg GT b.i.d. from _%#MM#%_ _%#DD#%_ to _%#MM#%_ _%#DD#%_. He should be off (?Activin) on _%#MM#%_ _%#DD#%_, 2002. 12. Metamucil 36 mg, which is 0.4 cc GT q.d. 13. IV IG q. two weeks. Next dose due on _%#MM#%_ _%#DD#%_, 2002, for thrombocytopenia. His feeding regimen currently is 20 cal/oz peptide 1+, running at 4 T5 cc per hour though a pump.
GT|gastrostomy tube|GT|110|111|DISCHARGE MEDICATIONS|Please see Preadmission Medications. In addition, we discharged him home with Clindamycin at a dose of 135 mg GT t.i.d. for a total of 7 days. He will continue on his Peptide 1+ at 24 cal/oz, 45 cc/hr. In addition, he can receive 50 cc of free hour every 6 to 8 hours.
GT|gastrostomy tube|GT|212|213|1. FEN|4. Genetics: She is to follow up with Dr. _%#NAME#%_ _%#NAME#%_ in Down Syndrome clinic _%#MM#%_ _%#DD#%_, 2003. Discharge medications, treatments and special equipment: Lasix 3.5mg per GT q12h Digoxin 15mcg per GT q12 Fowziya received her first dose of Synagis on _%#MMDD2003#%_.
GT|gastrostomy tube|GT|118|119|2. BPD|Discharge medications, treatments and special equipment: 1. Aldactone 7 mg GT q 12 hours (4mg/kg/day) 2. Diuril 70 mg GT q 12 hours (40mg/kg/day) 3. NaCl 8 mEq GT 4x/day (8A-12N-4P-8P) (NaCl needs to be empirically increased when Aldactone and Diuril are increased)
GT|gastrostomy tube|GT|160|161|2. BPD|Discharge medications, treatments and special equipment: 1. Aldactone 7 mg GT q 12 hours (4mg/kg/day) 2. Diuril 70 mg GT q 12 hours (40mg/kg/day) 3. NaCl 8 mEq GT 4x/day (8A-12N-4P-8P) (NaCl needs to be empirically increased when Aldactone and Diuril are increased) 4. KCl 1.2 mEq GT q 12 hours (adjust as labs indicate)
GT|gastrostomy tube|GT|179|180|2. BPD|2. Diuril 70 mg GT q 12 hours (40mg/kg/day) 3. NaCl 8 mEq GT 4x/day (8A-12N-4P-8P) (NaCl needs to be empirically increased when Aldactone and Diuril are increased) 4. KCl 1.2 mEq GT q 12 hours (adjust as labs indicate) 5. Lasix 7 mg GT q day (2mg/kg/day) 6. Ferrous Sulfate 5 mg GT q day (4mg/kg/day of elemental iron)
GT|gastrostomy tube|GT|115|116|2. BPD|4. KCl 1.2 mEq GT q 12 hours (adjust as labs indicate) 5. Lasix 7 mg GT q day (2mg/kg/day) 6. Ferrous Sulfate 5 mg GT q day (4mg/kg/day of elemental iron) 7. Prune juice 5 ml three times/day 8. Tobradex eye oint. 1 ribbon right eye, four times/day until ophthalmology visit on _%#MMDD2003#%_
GT|gastrostomy tube|GT,|194|196|HOSPITAL COURSE|On hospital day #2, the patient remained stable. Clindamycin was ordered as the patient began to go into labor. The patient continued to receive Dexamethasone. The patient had elevated one hour GT, but normal three hour GT; therefore, blood sugar checks were discontinued. The patient is GC chlamydia negative. Her GBS is pending.
GT|gastrostomy tube|GT|283|284|DISCHARGE MEDICATION|This was due to septicemia. She had continued apnea, bradycardia spells and desaturation spells treated with Theopylline until _%#MMDD2002#%_. She continued to have a dry, unproductive cough. A cardio-respiratory scan done _%#MMDD2002#%_ was normal. _%#NAME#%_ was intubated for her GT and Nissen on _%#MMDD2002#%_ and was extubated on _%#MMDD2002#%_ and developed stridor that was treated with Decadron and epinephrine nebs.
GT|gastrostomy tube|GT|217|218|7. IVH|_%#NAME#%_ had significant reflux spells on _%#MMDD2002#%_ while rooming in with her parents in preparation for discharge so a bronchoscopy was done on _%#MMDD2002#%_, which was consistent with mircroaspiration and a GT and Nissen was performed on _%#MMDD2002#%_. A speech video done _%#MMDD2002#%_ showed aspiration and decompensation after 20cc. _%#NAME#%_ did tolerate thickened formula without aspiration. She is now bottling 30-40cc of thickened formula without problems.
GT|gastrostomy tube|GT|114|115|DISCHARGE MEDICATIONS|His creatinine corrected to 1.2 overnight. DISCHARGE MEDICATIONS: 1. Accupril 10 mg GT q. daily. 2. Lipitor 10 mg GT q. daily. 3. Valtrex 500 mg GT b.i.d. 4. Neurontin 600 mg GT t.i.d. 5. Protonix 40 mg GT q. daily. 6. Senna one to two tabs p.o./GT p.r.n.
GT|gastrostomy tube|GT|145|146|DISCHARGE MEDICATIONS|His creatinine corrected to 1.2 overnight. DISCHARGE MEDICATIONS: 1. Accupril 10 mg GT q. daily. 2. Lipitor 10 mg GT q. daily. 3. Valtrex 500 mg GT b.i.d. 4. Neurontin 600 mg GT t.i.d. 5. Protonix 40 mg GT q. daily. 6. Senna one to two tabs p.o./GT p.r.n.
GT|gastrostomy tube|GT|21|22|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: GT site infection. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 10-month-old female with a history of developmental delay, cleft palate, poor growth, microcephaly, with non-compaction of her left ventricle. The patient was recently admitted to have a PEG placed on _%#MMDD2003#%_.
GT|gastrostomy tube|GT|196|197|DISCHARGE MEDICATION|The Prilosec dose was unchanged. Sucralfate was started during this admission, which seems to resolve some of the symptoms, with better sleeping overnight. DISCHARGE MEDICATION: 1. Prilosec 10 mg GT b.i.d. 2. Keflex 90 mg p.o. GT q.i.d. x 5 days. 3. Sucralfate 150 mg p.o. q.i.d. DISCHARGE INSTRUCTIONS: 1. Diet: Neocate 24 kcals/ounce in baby food, ad lib during the day.
GT|gastrostomy tube|GT|227|228|DISCHARGE MEDICATION|The Prilosec dose was unchanged. Sucralfate was started during this admission, which seems to resolve some of the symptoms, with better sleeping overnight. DISCHARGE MEDICATION: 1. Prilosec 10 mg GT b.i.d. 2. Keflex 90 mg p.o. GT q.i.d. x 5 days. 3. Sucralfate 150 mg p.o. q.i.d. DISCHARGE INSTRUCTIONS: 1. Diet: Neocate 24 kcals/ounce in baby food, ad lib during the day.
GT|gastrostomy tube|GT|175|176|CONDITION ON DISCHARGE|This probably will be the source of his ultimate death in terms of his inability to manage secretions. He does have a GT tube in place. Nutrition is being managed through the GT tube along with his medications. DISCHARGE MEDICATIONS: 1. Synthroid 0.075 mg daily. 2. Vancomycin for pneumonia 1000 mg IV q. 24 hours x 3 days, then will discontinue the IV.
GT|gastrostomy tube|GT|184|185|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Synthroid 0.075 mg daily. 2. Vancomycin for pneumonia 1000 mg IV q. 24 hours x 3 days, then will discontinue the IV. 3. Continue with hydrocortisone10 mg per GT daily x 3 days, then DC. 4. For a new problem with DVT of his right leg, we are going to give him Lovenox 80 mg every 12 hours until his INR moves up with his Coumadin.
GT|gastrostomy tube|GT|200|201|DISCHARGE MEDICATIONS|Will have an INR in two days and we will follow that closely and discontinue the Lovenox when INR is between 2 and 3. 5. For sleep will continue on his home medication of Klonopin, 0.5 mg at h.s. for GT tube. It will be Fiber-Source HTN 70 cc/hr, water flushes 200 cc every four hours. 6. For GERD it will be Prevacid liquid 15 mg per GT.
GT|gastrostomy tube|GT.|126|128|DISCHARGE MEDICATIONS|It will be Fiber-Source HTN 70 cc/hr, water flushes 200 cc every four hours. 6. For GERD it will be Prevacid liquid 15 mg per GT. Use oxygen for saturations under 90. He is regaining his energy and has been afebrile and I think that he is appropriate for going home today.
GT|glutamyl transpeptidase|GT|385|386|COURSE IN EMERGENCY DEPARTMENT|Sodium 139, potassium 3.7, chloride 99, bicarb 27, glucose 118, BUN 12, creatinine 0.9. Bilirubin is markedly elevated at 3.6, albumin is normal at 4.3, total protein is 8.3. Conjugated bili is elevated at 1.8. This is more than 30% of total bili which makes a viral hepatitis more likely. Alkaline phosphatase is elevated at 324, ALT is elevated at 530, AST is elevated at 379, gamma GT is elevated at 356. Mono test is positive. Amylase is 78, lipase 219. These are both within normal limits. INR is prolonged at 1.19, PTT is elevated at 41, maximum normal is 37 seconds.
GT|gastrostomy tube|GT|213|214|DISCHARGE MEDICATIONS|The patient was discharged stable. DISCHARGE MEDICATIONS: The patient is to be discharged on the following medications 1. Viagra 5 mg GT t.i.d. 2. Lasix 4 mg GT t.i.d. 3. Zantac 7.5 mg GT b.i.d. 4. Digoxin 20 mcg GT b.i.d. 5. Poly-Vi-Sol 0.5 mg GT b.i.d. 6. Enalapril 0.5 mg GT q.12 h. 7. Aspirin 41 mg GT q. day. 8. Reglan 0.6 mg GT q.i.d.
GT|gastrostomy tube|GT|126|127|DISCHARGE MEDICATIONS|1. Viagra 5 mg GT t.i.d. 2. Lasix 4 mg GT t.i.d. 3. Zantac 7.5 mg GT b.i.d. 4. Digoxin 20 mcg GT b.i.d. 5. Poly-Vi-Sol 0.5 mg GT b.i.d. 6. Enalapril 0.5 mg GT q.12 h. 7. Aspirin 41 mg GT q. day. 8. Reglan 0.6 mg GT q.i.d. 9. Albuterol nebulizer 2.5 mg q.12 h. 10. Metronidazole 4 mg G-tube q.6 h. x6 days.
GT|gastrostomy tube|GT|156|157|DISCHARGE MEDICATIONS|1. Viagra 5 mg GT t.i.d. 2. Lasix 4 mg GT t.i.d. 3. Zantac 7.5 mg GT b.i.d. 4. Digoxin 20 mcg GT b.i.d. 5. Poly-Vi-Sol 0.5 mg GT b.i.d. 6. Enalapril 0.5 mg GT q.12 h. 7. Aspirin 41 mg GT q. day. 8. Reglan 0.6 mg GT q.i.d. 9. Albuterol nebulizer 2.5 mg q.12 h. 10. Metronidazole 4 mg G-tube q.6 h. x6 days.
GT|gastrostomy tube|GT|108|109|DISCHARGE MEDICATIONS|5. Poly-Vi-Sol 0.5 mg GT b.i.d. 6. Enalapril 0.5 mg GT q.12 h. 7. Aspirin 41 mg GT q. day. 8. Reglan 0.6 mg GT q.i.d. 9. Albuterol nebulizer 2.5 mg q.12 h. 10. Metronidazole 4 mg G-tube q.6 h. x6 days. This would complete a total course of 7 days for the C. difficile.
GT|gastrostomy tube|GT|229|230|DISCHARGE MEDICATIONS|11. Lactobacillus one-fourth packet p.o. GT t.i.d. for approximately 1 week. May refill another week. Medications added during hospital course and only includes metronidazole 4 mg GT and also Lactobacillus one-fourth packet p.o. GT t.i.d. x1 week. DISCHARGE FOLLOWUP: The patient is to follow up with her primary care physician as needed.
GT|gastrostomy tube|GT|261|262|LABORATORY|The father of this baby is not involved in the pregnancy. LABORATORY: O positive, antibody negative, RPR negative, Hep B surface antigen negative, GBS positive, rubella indeterminate, hemoglobin 11, GC and chlamydia negative, Pap negative, HIV negative, 1-hour GT was in 180s. ULTRASOUND: 1. 34 plus 4 weeks consistent with conception date of _%#MM#%_ _%#DD#%_, 2004.
GT|gastrostomy tube|GT|315|316|DISCHARGE MEDICATIONS|DISCHARGE INFORMATION: 1. Discharge activity, as tolerated. 2. Discharge diet,, Lactofree Enfamil 25 g mixed with 110 g of Topamax plus 1450 mL of water plus 1 tablespoon of Benefiber, the above mixture to be run at 70 mL an hour via the J-tube 24 hours a day continuously. DISCHARGE MEDICATIONS: 1. Prevacid 15 mg GT b.i.d. 2. Lamictal 50 mg JT q.a.m., 62.5 mg JT q.p.m. 3. Topamax 50 mg JT q.a.m., 75 mg JT q.p.m.
GT|gastrostomy tube|GT|136|137|ADMISSION MEDICATIONS|Foods and water offered by mouth. 14. Immunizations up to date including Synergis. ADMISSION MEDICATIONS: 1. Poly-Vi-Sol with Iron 1 mL GT daily. 2. Prilosec 8 mg GT b.i.d. 3. Pulmicort 0.25 mg nebulizer b.i.d. 4. Pulmicort 0.5 mg nebulizer b.i.d. HOSPITAL COURSE: 1. Respiratory: Based on increased density in the right middle lobe, the patient was diagnosed initially as aspiration pneumonia versus viral pneumonia.
GT|gastrostomy tube|GT|163|164|ADMISSION MEDICATIONS|Foods and water offered by mouth. 14. Immunizations up to date including Synergis. ADMISSION MEDICATIONS: 1. Poly-Vi-Sol with Iron 1 mL GT daily. 2. Prilosec 8 mg GT b.i.d. 3. Pulmicort 0.25 mg nebulizer b.i.d. 4. Pulmicort 0.5 mg nebulizer b.i.d. HOSPITAL COURSE: 1. Respiratory: Based on increased density in the right middle lobe, the patient was diagnosed initially as aspiration pneumonia versus viral pneumonia.
GT|gastrostomy tube|GT|172|173|DISCHARGE MEDICATIONS|DISCHARGE DIAGNOSES: 1. Laryngotracheal bronchitis. 2. Chronic otitis. 3. Urinary tract infection. DISCHARGE MEDICATIONS: 1. Bactrim 80 mg TMP, 400 mg sulfa suspension per GT b.i.d. x 7 days. 2. Lactobacillus 1/2 capsule daily per GT. 3. Atrovent nasal spray 0.06% 1 spray to each nostril daily.
GT|gastrostomy tube|GT.|160|162|DISCHARGE MEDICATIONS|3. Urinary tract infection. DISCHARGE MEDICATIONS: 1. Bactrim 80 mg TMP, 400 mg sulfa suspension per GT b.i.d. x 7 days. 2. Lactobacillus 1/2 capsule daily per GT. 3. Atrovent nasal spray 0.06% 1 spray to each nostril daily. 4. Nasacort AQ 1 spray b.i.d. to each nostril. 5. Singulair 5 mg 2 tablets per GT daily. 6. Zyrtec 2.5 mg per GT daily.
GT|gastrostomy tube|GT|183|184|DISCHARGE MEDICATIONS|2. Lactobacillus 1/2 capsule daily per GT. 3. Atrovent nasal spray 0.06% 1 spray to each nostril daily. 4. Nasacort AQ 1 spray b.i.d. to each nostril. 5. Singulair 5 mg 2 tablets per GT daily. 6. Zyrtec 2.5 mg per GT daily. 7. Tobramycin nebs 300 mg b.i.d. 8. Pulmicort 0.5 mg neb q.i.d. 9. Duo-Neb 1 vial nebulizer q.i.d. 10. Albuterol 2.5 mg neb p.r.n. shortness of breath.
GT|gastrostomy tube|GT|110|111|DISCHARGE MEDICATIONS|4. Nasacort AQ 1 spray b.i.d. to each nostril. 5. Singulair 5 mg 2 tablets per GT daily. 6. Zyrtec 2.5 mg per GT daily. 7. Tobramycin nebs 300 mg b.i.d. 8. Pulmicort 0.5 mg neb q.i.d. 9. Duo-Neb 1 vial nebulizer q.i.d. 10. Albuterol 2.5 mg neb p.r.n. shortness of breath.
GT|gastrostomy tube|GT|161|162|DISCHARGE MEDICATIONS|6. Mucomyst 20% 30 mL via the G-tube q.i.d. for 1 week, then t.i.d. for 1 week, then b.i.d. until followup with Dr. _%#NAME#%_. 7. Pancrecarb MS-4 four capsules GT with Formula. 8. Pancrecarb MS-4 two to three capsules GT with meals. 9. Butt paste apply to affected skin as needed for irritation.
GT|gastrostomy tube|GT|219|220|DISCHARGE MEDICATIONS|6. Mucomyst 20% 30 mL via the G-tube q.i.d. for 1 week, then t.i.d. for 1 week, then b.i.d. until followup with Dr. _%#NAME#%_. 7. Pancrecarb MS-4 four capsules GT with Formula. 8. Pancrecarb MS-4 two to three capsules GT with meals. 9. Butt paste apply to affected skin as needed for irritation. DIET: Mikayla is to receive Peptamen Junior 10 ounces via her G-tube 3 times a day.
GT|gastrostomy tube|GT|152|153|OPERATIONS/PROCEDURES PERFORMED|2. GERD and poor p.o. intake status post Nissen fundoplication, and G- tube placement. ADMISSION MEDICATIONS: 1. Lasix 3 mg GT t.i.d. 2. Aldactone 5 mg GT b.i.d. 3. Captopril 1.2 mg GT t.i.d. 4. Digoxin 15 mcg GT b.i.d. 5. Zantac 9 mg GT b.i.d. ALLERGIES: NO KNOWN DRUG ALLERGIES.
GT|gastrostomy tube|GT|123|124|OPERATIONS/PROCEDURES PERFORMED|ADMISSION MEDICATIONS: 1. Lasix 3 mg GT t.i.d. 2. Aldactone 5 mg GT b.i.d. 3. Captopril 1.2 mg GT t.i.d. 4. Digoxin 15 mcg GT b.i.d. 5. Zantac 9 mg GT b.i.d. ALLERGIES: NO KNOWN DRUG ALLERGIES. FAMILY HISTORY: Noncontributory to present illness. SOCIAL HISTORY: The patient lives at home with mother and 2 siblings, does not attend daycare.
GT|gastrostomy tube|GT|148|149|OPERATIONS/PROCEDURES PERFORMED|ADMISSION MEDICATIONS: 1. Lasix 3 mg GT t.i.d. 2. Aldactone 5 mg GT b.i.d. 3. Captopril 1.2 mg GT t.i.d. 4. Digoxin 15 mcg GT b.i.d. 5. Zantac 9 mg GT b.i.d. ALLERGIES: NO KNOWN DRUG ALLERGIES. FAMILY HISTORY: Noncontributory to present illness. SOCIAL HISTORY: The patient lives at home with mother and 2 siblings, does not attend daycare.
GT|gastrostomy tube|GT|156|157|FAMILY HISTORY|4. GERD and poor p.o. intake status post Nissen fundoplication and G- tube placement. DISCHARGE MEDICATIONS: 1. Lasix 3 mg GT t.i.d. 2. Spironolactone 5 mg GT b.i.d. 3. ASA 41 mg GT q. day. 4. Captopril 1.2 mg GT t.i.d. 5. Digoxin 15 mcg GT b.i.d. 6. Ranitidine 9 mg GT b.i.d.
GT|gastrostomy tube|GT|179|180|FAMILY HISTORY|4. GERD and poor p.o. intake status post Nissen fundoplication and G- tube placement. DISCHARGE MEDICATIONS: 1. Lasix 3 mg GT t.i.d. 2. Spironolactone 5 mg GT b.i.d. 3. ASA 41 mg GT q. day. 4. Captopril 1.2 mg GT t.i.d. 5. Digoxin 15 mcg GT b.i.d. 6. Ranitidine 9 mg GT b.i.d. 7. Tylenol 75 mg GT q.4 hours. 8. Lactobacillus half a packet GT q.i.d. x5 days.
GT|gastrostomy tube|GT|124|125|FAMILY HISTORY|DISCHARGE MEDICATIONS: 1. Lasix 3 mg GT t.i.d. 2. Spironolactone 5 mg GT b.i.d. 3. ASA 41 mg GT q. day. 4. Captopril 1.2 mg GT t.i.d. 5. Digoxin 15 mcg GT b.i.d. 6. Ranitidine 9 mg GT b.i.d. 7. Tylenol 75 mg GT q.4 hours. 8. Lactobacillus half a packet GT q.i.d. x5 days.
GT|gastrostomy tube|GT|152|153|FAMILY HISTORY|DISCHARGE MEDICATIONS: 1. Lasix 3 mg GT t.i.d. 2. Spironolactone 5 mg GT b.i.d. 3. ASA 41 mg GT q. day. 4. Captopril 1.2 mg GT t.i.d. 5. Digoxin 15 mcg GT b.i.d. 6. Ranitidine 9 mg GT b.i.d. 7. Tylenol 75 mg GT q.4 hours. 8. Lactobacillus half a packet GT q.i.d. x5 days.
GT|gastrostomy tube|GT|128|129|FAMILY HISTORY|3. ASA 41 mg GT q. day. 4. Captopril 1.2 mg GT t.i.d. 5. Digoxin 15 mcg GT b.i.d. 6. Ranitidine 9 mg GT b.i.d. 7. Tylenol 75 mg GT q.4 hours. 8. Lactobacillus half a packet GT q.i.d. x5 days. FOLLOW UP: 1. Followup appointment with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2006.
GT|gastrostomy tube|GT|119|120|FAMILY HISTORY|5. Digoxin 15 mcg GT b.i.d. 6. Ranitidine 9 mg GT b.i.d. 7. Tylenol 75 mg GT q.4 hours. 8. Lactobacillus half a packet GT q.i.d. x5 days. FOLLOW UP: 1. Followup appointment with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2006.
GT|gastrostomy tube|GT|147|148|DISCHARGE MEDICATIONS|Please contact me with any questions, concerns, or updates. DISCHARGE MEDICATIONS: 1. Cefuroxime 200 mg GT q.12 h. x10 days. 2. Clindamycin 100 mg GT q.8 h. x10 days. 3. Lactobacillus 1 capsule G-tube q. day x17 days. 4. Prevacid 10 mg GT b.i.d. 5. Tylenol 140 mg GT/PR q.4 h. p.r.n. pain.
GT|gastrostomy tube|GT|153|154|DISCHARGE MEDICATIONS|1. Cefuroxime 200 mg GT q.12 h. x10 days. 2. Clindamycin 100 mg GT q.8 h. x10 days. 3. Lactobacillus 1 capsule G-tube q. day x17 days. 4. Prevacid 10 mg GT b.i.d. 5. Tylenol 140 mg GT/PR q.4 h. p.r.n. pain. 6. Pulmicort 0.25 mg neb b.i.d. DISCHARGE ACTIVITY: As tolerated.
GT|gastrostomy tube|GT|165|166|DISCHARGE MEDICATIONS|DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg, GT daily 2. Digoxin 40 mcg, GT twice daily. 3. Enalapril 1.2 mg, GT b.i.d. 4. Furosemide 9 mg, GT b.i.d. 5. Lansoprazole 15 mg, GT daily. 6. Metoclopramide7. 0.6 mg, GT q.i.d. 8. Sildenafil 7.5 mg, GT 3 times a day. 9. Sucralfate 100 mg, GT 4 times a day.
GT|gastrostomy tube|GT|119|120|DISCHARGE MEDICATIONS|2. Digoxin 40 mcg, GT twice daily. 3. Enalapril 1.2 mg, GT b.i.d. 4. Furosemide 9 mg, GT b.i.d. 5. Lansoprazole 15 mg, GT daily. 6. Metoclopramide7. 0.6 mg, GT q.i.d. 8. Sildenafil 7.5 mg, GT 3 times a day. 9. Sucralfate 100 mg, GT 4 times a day.
GT|gastrostomy tube|GT|157|158|DISCHARGE MEDICATIONS|2. Digoxin 40 mcg, GT twice daily. 3. Enalapril 1.2 mg, GT b.i.d. 4. Furosemide 9 mg, GT b.i.d. 5. Lansoprazole 15 mg, GT daily. 6. Metoclopramide7. 0.6 mg, GT q.i.d. 8. Sildenafil 7.5 mg, GT 3 times a day. 9. Sucralfate 100 mg, GT 4 times a day. 10. Lactulose 15 mL, GT b.i.d. DIET: "Just For Kids" 1.5 Kcal/mL 60mL/hour x 8 hours overnight and 4 ounces of bolus feeds q.i.d.
GT|gastrostomy tube|GT|163|164|DISCHARGE MEDICATIONS|4. Furosemide 9 mg, GT b.i.d. 5. Lansoprazole 15 mg, GT daily. 6. Metoclopramide7. 0.6 mg, GT q.i.d. 8. Sildenafil 7.5 mg, GT 3 times a day. 9. Sucralfate 100 mg, GT 4 times a day. 10. Lactulose 15 mL, GT b.i.d. DIET: "Just For Kids" 1.5 Kcal/mL 60mL/hour x 8 hours overnight and 4 ounces of bolus feeds q.i.d. FOLLOW UP: The patient will follow up with 1.
GT|gastrostomy tube|GT|139|140|DISCHARGE MEDICATIONS|6. Metoclopramide7. 0.6 mg, GT q.i.d. 8. Sildenafil 7.5 mg, GT 3 times a day. 9. Sucralfate 100 mg, GT 4 times a day. 10. Lactulose 15 mL, GT b.i.d. DIET: "Just For Kids" 1.5 Kcal/mL 60mL/hour x 8 hours overnight and 4 ounces of bolus feeds q.i.d. FOLLOW UP: The patient will follow up with 1.
GT|gastrostomy tube|GT|189|190|DISCHARGE INFORMATION|DISCHARGE INFORMATION: 1. Discharge date is _%#MM#%_ _%#DD#%_, 2006. 2. Discharge diagnoses esophageal atresia, status post stricture repair. 3. Discharge medications include Prevacid 4 mL GT down her GT tube b.i.d., Reglan 2 mL GT q.i.d., erythromycin 2.5 mL GT b.i.d. 4. Followup: The patient is to have an upper GI series for her esophageal atresia on _%#MM#%_ _%#DD#%_, 2006.
GT|gastrostomy tube|GT|201|202|DISCHARGE INFORMATION|DISCHARGE INFORMATION: 1. Discharge date is _%#MM#%_ _%#DD#%_, 2006. 2. Discharge diagnoses esophageal atresia, status post stricture repair. 3. Discharge medications include Prevacid 4 mL GT down her GT tube b.i.d., Reglan 2 mL GT q.i.d., erythromycin 2.5 mL GT b.i.d. 4. Followup: The patient is to have an upper GI series for her esophageal atresia on _%#MM#%_ _%#DD#%_, 2006.
GT|gastrostomy tube|GT|160|161|DISCHARGE INFORMATION|2. Discharge diagnoses esophageal atresia, status post stricture repair. 3. Discharge medications include Prevacid 4 mL GT down her GT tube b.i.d., Reglan 2 mL GT q.i.d., erythromycin 2.5 mL GT b.i.d. 4. Followup: The patient is to have an upper GI series for her esophageal atresia on _%#MM#%_ _%#DD#%_, 2006.
GT|gastrostomy tube|GT|178|179|HOSPITAL COURSE|During this time, IV fluids also contained bicarbonate and urine pH was monitored with goal pH of 7-8.5. 2. Very long chain Acyl-CoA Deficiency. The metabolic team was following GT during his period in the hospital. We did not make any changes to his usual management regimen which includes MCT, L-carnitine and evening cornstarch.
GT|gastrostomy tube|GT|143|144|DISCHARGE MEDICATIONS|Dr. _%#NAME#%_ plans to repeat his catheterization in a couple of months. DISCHARGE MEDICATIONS: 1. Lasix 10 mg GT t.i.d. 2. Metolazone 0.5 mg GT daily. 3. KCl 5 mEq GT b.i.d. 4. Sodium chloride 12 mEq GT t.i.d. 5. Aldactone 10 mg GT b.i.d. 6. Aspirin 81 mg GT daily.
GT|gastrostomy tube|GT|128|129|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Lasix 10 mg GT t.i.d. 2. Metolazone 0.5 mg GT daily. 3. KCl 5 mEq GT b.i.d. 4. Sodium chloride 12 mEq GT t.i.d. 5. Aldactone 10 mg GT b.i.d. 6. Aspirin 81 mg GT daily. 7. Captopril 4 mg GT t.i.d. 8. Amoxicillin 250 mg GT daily.
GT|gastrostomy tube|GT|157|158|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Lasix 10 mg GT t.i.d. 2. Metolazone 0.5 mg GT daily. 3. KCl 5 mEq GT b.i.d. 4. Sodium chloride 12 mEq GT t.i.d. 5. Aldactone 10 mg GT b.i.d. 6. Aspirin 81 mg GT daily. 7. Captopril 4 mg GT t.i.d. 8. Amoxicillin 250 mg GT daily. SPECIAL INSTRUCTIONS: _%#NAME#%_'s mother was instructed to notify Dr. _%#NAME#%_ or the on-call cardiologist if there was any increased pain or slowing at the catheter insertion site, also if she noted any change in color or temperature of his extremities.
GT|gastrostomy tube|GT|165|166|DISCHARGE MEDICATIONS|3. KCl 5 mEq GT b.i.d. 4. Sodium chloride 12 mEq GT t.i.d. 5. Aldactone 10 mg GT b.i.d. 6. Aspirin 81 mg GT daily. 7. Captopril 4 mg GT t.i.d. 8. Amoxicillin 250 mg GT daily. SPECIAL INSTRUCTIONS: _%#NAME#%_'s mother was instructed to notify Dr. _%#NAME#%_ or the on-call cardiologist if there was any increased pain or slowing at the catheter insertion site, also if she noted any change in color or temperature of his extremities.
GT|gastrostomy tube|GT|149|150|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Lasix 10 mg G-tube b.i.d. This medication was restarted this hospitalization and continued on discharge. 2. Captopril 5 mg GT t.i.d. 3. Cyclosporine 40 mg in the a.m. and 35 mg q.h.s., GT. 4. CellCept 300 mg GT b.i.d. 5. Bactrim 3.5 mL GT every Monday, Wednesday, and Friday.
GT|gastrostomy tube|GT|103|104|DISCHARGE MEDICATIONS|2. Captopril 5 mg GT t.i.d. 3. Cyclosporine 40 mg in the a.m. and 35 mg q.h.s., GT. 4. CellCept 300 mg GT b.i.d. 5. Bactrim 3.5 mL GT every Monday, Wednesday, and Friday. 6. Prilosec 10 mg GT b.i.d. 7. Carnitine 500 mg GT b.i.d.
GT|gastrostomy tube|GT.|211|213|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Lasix 10 mg G-tube b.i.d. This medication was restarted this hospitalization and continued on discharge. 2. Captopril 5 mg GT t.i.d. 3. Cyclosporine 40 mg in the a.m. and 35 mg q.h.s., GT. 4. CellCept 300 mg GT b.i.d. 5. Bactrim 3.5 mL GT every Monday, Wednesday, and Friday. 6. Prilosec 10 mg GT b.i.d. 7. Carnitine 500 mg GT b.i.d.
GT|gastrostomy tube|GT|189|190|DISCHARGE MEDICATIONS|2. Captopril 5 mg GT t.i.d. 3. Cyclosporine 40 mg in the a.m. and 35 mg q.h.s., GT. 4. CellCept 300 mg GT b.i.d. 5. Bactrim 3.5 mL GT every Monday, Wednesday, and Friday. 6. Prilosec 10 mg GT b.i.d. 7. Carnitine 500 mg GT b.i.d. 8. Cod liver oil one capsule GT q. day. 9. Multivitamin 1 tablet GT q. day.
GT|gastrostomy tube|GT|152|153|DISCHARGE MEDICATIONS|6. Prilosec 10 mg GT b.i.d. 7. Carnitine 500 mg GT b.i.d. 8. Cod liver oil one capsule GT q. day. 9. Multivitamin 1 tablet GT q. day. 10. Bicitra 10 mL GT b.i.d. DISCHARGE DIET: The patient is to resume his Pediasure home regimen.
GT|gastrostomy tube|GT|169|170|FAMILY HISTORY|SOCIAL HISTORY: Lives with Mom and younger brother and two sisters and Dad. REVIEW OF SYSTEMS: At time of admission was positive for heme- positive drainage from JP and GT tube. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: She had a temperature of 96.4, pulse 137, respiratory rate 32, blood pressure 97/60, weight 12.6 kg.
GT|gastrostomy tube|GT|157|158|DISCHARGE MEDICATIONS|Colchicine 0.6 mg per os per os every day. Zestril 10 mg tabs two tablets by mouth twice a day. Norvasc 5 mg per os twice a day. Cellulose 0.5% drops OU one GT twice a day. Xalatan 0.5% ophthalmic drops one drop to left eye every day. Multivitamin per os every day. Aspirin enteric coated 325 mg per os every day.
GT|gastrostomy tube|GT|176|177|DISCHARGE MEDICATIONS|She was discharged on _%#MM#%_ _%#DD#%_, 2002, in stable condition, breathing room air without any discomfort, and maintaining her sats. DISCHARGE MEDICATIONS: 1. Colace 10 mg GT b.i.d. 2. Poly-Vi-Sol with iron 1 cc GT q.d. 3. Phenobarbital 16 mg GT b.i.d. 4. Theophylline 5 mg GT t.i.d. 5. Spironolactone 5 mg GT b.i.d. 6. Simethicone 20 mg GT t.i.d.
GT|gastrostomy tube|GT|141|142|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Colace 10 mg GT b.i.d. 2. Poly-Vi-Sol with iron 1 cc GT q.d. 3. Phenobarbital 16 mg GT b.i.d. 4. Theophylline 5 mg GT t.i.d. 5. Spironolactone 5 mg GT b.i.d. 6. Simethicone 20 mg GT t.i.d. 7. Lasix 6 mg GT t.i.d. 8. Nystatin 200,000 units p.o. q.i.d.
GT|gastrostomy tube|GT|142|143|DISCHARGE MEDICATIONS|3. Phenobarbital 16 mg GT b.i.d. 4. Theophylline 5 mg GT t.i.d. 5. Spironolactone 5 mg GT b.i.d. 6. Simethicone 20 mg GT t.i.d. 7. Lasix 6 mg GT t.i.d. 8. Nystatin 200,000 units p.o. q.i.d. 9. Cefuroxime 70 mg GT b.i.d. 10. Tylenol 60 mg GT q.4.h. 11. KCL 5 mEq through GT t.i.d. FOLLOW UP: She was asked to follow up with her primary doctor at the Family Practice Clinic on _%#MM#%_ _%#DD#%_, 2002.
GT|gastrostomy tube|GT|146|147|DISCHARGE MEDICATIONS|5. Spironolactone 5 mg GT b.i.d. 6. Simethicone 20 mg GT t.i.d. 7. Lasix 6 mg GT t.i.d. 8. Nystatin 200,000 units p.o. q.i.d. 9. Cefuroxime 70 mg GT b.i.d. 10. Tylenol 60 mg GT q.4.h. 11. KCL 5 mEq through GT t.i.d. FOLLOW UP: She was asked to follow up with her primary doctor at the Family Practice Clinic on _%#MM#%_ _%#DD#%_, 2002.
GT|gastrostomy tube|GT|142|143|DISCHARGE MEDICATIONS|7. Lasix 6 mg GT t.i.d. 8. Nystatin 200,000 units p.o. q.i.d. 9. Cefuroxime 70 mg GT b.i.d. 10. Tylenol 60 mg GT q.4.h. 11. KCL 5 mEq through GT t.i.d. FOLLOW UP: She was asked to follow up with her primary doctor at the Family Practice Clinic on _%#MM#%_ _%#DD#%_, 2002.
GT|gastrostomy tube|GT|306|307|SOCIAL HISTORY|Therefore, an evaluation of questionable bacterial pneumonia in a child who is trach dependent and who has spastic quadriplegia was made, and he was admitted in the PICU for further workup and for observation. HOSPITAL COURSE: PROBLEM #1: Fluids, electrolytes and nutrition. The patient was tolerating his GT feeds and was continued on his home regimen of feeds, and he seemed to have tolerated the feeds well during his entire course of hospitalization.
GT|gastrostomy tube|GT|120|121|MEDICATIONS|ALLERGIES: Sulfa, terazosin. MEDICATIONS: 1. Rocephin 1 gm IV q.d. 2. Vancomycin 1100 mg IV q.24h. 3. Tequin 400 mg per GT q.d. 4. Vicodin 1-2 tablets per GT q.4h. p.r.n. 5. Zantac 150 mg per GT q.d. 6. Digoxin 0.125 mg per GT q.h.s. 7. Lasix 40 mg per GT q.d.
GT|gastrostomy tube|GT|155|156|MEDICATIONS|ALLERGIES: Sulfa, terazosin. MEDICATIONS: 1. Rocephin 1 gm IV q.d. 2. Vancomycin 1100 mg IV q.24h. 3. Tequin 400 mg per GT q.d. 4. Vicodin 1-2 tablets per GT q.4h. p.r.n. 5. Zantac 150 mg per GT q.d. 6. Digoxin 0.125 mg per GT q.h.s. 7. Lasix 40 mg per GT q.d. 8. Plavix 75 mg per GT q.d. 9. Fibersource 60 cc/hr per GT x 20 hours per day.
GT|gastrostomy tube|GT|125|126|MEDICATIONS|2. Vancomycin 1100 mg IV q.24h. 3. Tequin 400 mg per GT q.d. 4. Vicodin 1-2 tablets per GT q.4h. p.r.n. 5. Zantac 150 mg per GT q.d. 6. Digoxin 0.125 mg per GT q.h.s. 7. Lasix 40 mg per GT q.d. 8. Plavix 75 mg per GT q.d. 9. Fibersource 60 cc/hr per GT x 20 hours per day.
GT|gastrostomy tube|GT|157|158|MEDICATIONS|2. Vancomycin 1100 mg IV q.24h. 3. Tequin 400 mg per GT q.d. 4. Vicodin 1-2 tablets per GT q.4h. p.r.n. 5. Zantac 150 mg per GT q.d. 6. Digoxin 0.125 mg per GT q.h.s. 7. Lasix 40 mg per GT q.d. 8. Plavix 75 mg per GT q.d. 9. Fibersource 60 cc/hr per GT x 20 hours per day.
GT|gastrostomy tube|GT|125|126|MEDICATIONS|4. Vicodin 1-2 tablets per GT q.4h. p.r.n. 5. Zantac 150 mg per GT q.d. 6. Digoxin 0.125 mg per GT q.h.s. 7. Lasix 40 mg per GT q.d. 8. Plavix 75 mg per GT q.d. 9. Fibersource 60 cc/hr per GT x 20 hours per day. 10. Senokot 8.6 mg per GT b.i.d. 11. Peri-Colace 100/30 per GT b.i.d.
GT|gastrostomy tube|GT|153|154|MEDICATIONS|4. Vicodin 1-2 tablets per GT q.4h. p.r.n. 5. Zantac 150 mg per GT q.d. 6. Digoxin 0.125 mg per GT q.h.s. 7. Lasix 40 mg per GT q.d. 8. Plavix 75 mg per GT q.d. 9. Fibersource 60 cc/hr per GT x 20 hours per day. 10. Senokot 8.6 mg per GT b.i.d. 11. Peri-Colace 100/30 per GT b.i.d.
GT|gastrostomy tube|GT|117|118|MEDICATIONS|6. Digoxin 0.125 mg per GT q.h.s. 7. Lasix 40 mg per GT q.d. 8. Plavix 75 mg per GT q.d. 9. Fibersource 60 cc/hr per GT x 20 hours per day. 10. Senokot 8.6 mg per GT b.i.d. 11. Peri-Colace 100/30 per GT b.i.d.
GT|gastrostomy tube|GT|163|164|MEDICATIONS|6. Digoxin 0.125 mg per GT q.h.s. 7. Lasix 40 mg per GT q.d. 8. Plavix 75 mg per GT q.d. 9. Fibersource 60 cc/hr per GT x 20 hours per day. 10. Senokot 8.6 mg per GT b.i.d. 11. Peri-Colace 100/30 per GT b.i.d. PAST MEDICAL HISTORY: 1. CVA/TIA with mild residual left-sided weakness. 2. GI bleed.
GT|gutta|GT|237|238|DISCHARGE MEDICATIONS|The patient is then to have an INR on _%#MMDD2002#%_ and the results are to be called to Dr. _%#NAME#%_ and Dr. _%#NAME#%_ is to dose the patient's Coumadin with a desired INR range is 2.0-2.5. 4. Levofloxacin ophthalmic solution 0.5% 1 GT in left eye qd. 5. Erythromycin eye ointment 3.5 mg one-fourth-of-an-inch in the left eye qd. DISCHARGE FOLLOW-UP: 1. The patient is to have an INR checked on _%#MMDD2002#%_ and the results are to be called to Dr. _%#NAME#%_ and he is to dose the patient's Coumadin.
GT|gastrostomy tube|GT|210|211|1. FEN|When blood cultures remained negative, her antibiotics were discontinued. There were no known risk factors for sepsis. Ongoing problems and suggested management: 1. FEN: _%#NAME#%_ is currently tolerating full GT feeds of 120 cc every 4 hours which meets her current fluid and calorie requirements. 2. Neuro: _%#NAME#%_ continues on Phenobarbital. She needs a follow up with neurology.
GT|gastrostomy tube|GT.|168|170|1. FEN|We are allowing her to outgrow this medication, if seizure activity recurs she will need to be reloaded and dose adjusted. 3. GI: _%#NAME#%_ is post op from Nissen and GT. She needs a follow up with surgery. Discharge medications, treatments and special equipment: 1. Phenobarbital 22.5mg PO QD
GT|gastrostomy tube|GT|169|170|4. CV|Follow-up with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_. Discharge medications, treatments and special equipment: 1. Aldactone 5.5 mg. per GT q 12 hours 2. Diuril 55 mg. per GT q 12 hours 3. NaCl 5 mEq per GT q 3 hours 4. KCl 1 mEq per GT q 12 hours 5. Ferrous Sulfate 10 mg. per GT q 24 hours
GT|gastrostomy tube|GT|201|202|4. CV|Follow-up with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_. Discharge medications, treatments and special equipment: 1. Aldactone 5.5 mg. per GT q 12 hours 2. Diuril 55 mg. per GT q 12 hours 3. NaCl 5 mEq per GT q 3 hours 4. KCl 1 mEq per GT q 12 hours 5. Ferrous Sulfate 10 mg. per GT q 24 hours 6. Flovent 1 puff q 12 hours
GT|gastrostomy tube|GT|127|128|4. CV|2. Diuril 55 mg. per GT q 12 hours 3. NaCl 5 mEq per GT q 3 hours 4. KCl 1 mEq per GT q 12 hours 5. Ferrous Sulfate 10 mg. per GT q 24 hours 6. Flovent 1 puff q 12 hours 7. Zantac 5 mg. per GT tid 8. Oxygen: O2 per nasal cannula at 0.05 L/min.
GT|gastrostomy tube|GT|248|249|2. IPV   2/16/03; 4/17/03|_%#NAME#%_ was discharged on Breast milk 28 kcals/oz (BM + Enfacare 4kcal/oz plus microlipid 4 kcal/oz plus protein powder to total 4 g. protein/kg/day) taking 55 ml every 3 hours from 0800-2000 hours and drip feedings of 22 cc/hour by pump to his GT from 2000-0800 hours. The parents were asked to make an appointment for _%#NAME#%_ to see you within one week. Home Care nurse will visit two times per week initially.
GT|gastrostomy tube|GT|212|213|DISCHARGE MEDICATIONS|This was cultured; it is currently pending. DISCHARGE LABORATORY DATA PENDING: Identification and sensitivities of abscess culture. DISCHARGE MEDICATIONS: 1. Fentanyl 25 mcg patch q. 72h. 2. Ciprofloxacin 400 mg GT b.i.d., stop on _%#MMDD2003#%_. 3. Magic mouthwash 10 ml p.o. q. 4h. p.r.n. 4. Combivent metered dose inhaler one to two puffs q. 4h. p.r.n.
GT|gastrostomy tube|GT|101|102|DISCHARGE DIET|6. Fluconazole 200 mg p.o. q. daily for fungus growth in abscess. DISCHARGE DIET: Fibersource 250 ml GT q.i.d. ACTIVITY: Ad lib. FOLLOW-UP: The patient fill follow up with Dr. _%#NAME#%_ in Hematology/Oncology Clinic on _%#MMDD2003#%_.
GT|gutta|GT|105|106|DISCHARGE MEDICATIONS|6. Protonix 40 mg po q d. 7. Dilantin 300 mg po q hs. 8. K-Dur 20 mEq. 9. KCL po q d. 10. Timolol 0.5% 1 GT OU q d. 11. Trazodone 100 mg po q hs. 12. Effexor X-R 150 mg po q am. 13. Tylenol extra-strength 500 mg 1 po q6h.
GT|gutta|GT|123|124|HOSPITAL COURSE|2. Protonix 40 mg p.o. every day. 3. Diovan 160 mg p.o. every day. 4. Magnesium 400 mg b.i.d. 5. Timolol eyedrops 2.5% one GT to each eye b.i.d. 6. Ferrous sulfate 325 mg p.o. every day. 7. Xalatan eyedrops 0.05% one drop each eye at bedtime.
GT|gastrostomy tube|(GT)|162|165|DISCHARGE INSTRUCTIONS|This was continued until eight hours prior to surgery. She was NPO in the immediate post-operative period. TPN was initiated and continued until gastrostomy tube (GT) feeds were at nearly full volumes. GT feeds were started on POD#2 and gradually advanced to a maximum of 120 cc q3 hrs of Enfamil, for approximately 180 cc/kg/day and 120 kcal/kg/day.
GT|gastrostomy tube|GT|202|203|DISCHARGE INSTRUCTIONS|This was continued until eight hours prior to surgery. She was NPO in the immediate post-operative period. TPN was initiated and continued until gastrostomy tube (GT) feeds were at nearly full volumes. GT feeds were started on POD#2 and gradually advanced to a maximum of 120 cc q3 hrs of Enfamil, for approximately 180 cc/kg/day and 120 kcal/kg/day.
GT|gastrostomy tube|GT|142|143|DISCHARGE INSTRUCTIONS|3. GI - Makayla was on Zantac at the time of transfer. This was continued until GT feeds were at full volumes. _%#NAME#%_ was transferred for GT placement and laparoscopic Nissen fundoplication, which was performed on _%#MMDD2003#%_ without complications. GT feeds were advanced without difficulty post-operatively. Parents were trained by the surgery nurse on the use of the gastrostomy tube.
GT|gastrostomy tube|GT|201|202|DISCHARGE INSTRUCTIONS|This was continued until GT feeds were at full volumes. _%#NAME#%_ was transferred for GT placement and laparoscopic Nissen fundoplication, which was performed on _%#MMDD2003#%_ without complications. GT feeds were advanced without difficulty post-operatively. Parents were trained by the surgery nurse on the use of the gastrostomy tube. They roomed in at the NICU on the weekend of discharge to learn how to manage _%#NAME#%_'s feeds.
GT|gastrostomy tube|GT|185|186|ADMISSION MEDICATIONS|4. History of hyperbilirubinemia treated with phenobarbital. 5. Unusual development of transverse sinus as noted on previous MRI and MRA. ADMISSION MEDICATIONS: 1. Furosemide 6 mg p.o. GT t.i.d. 2. Captopril 0.5 mg GT t.i.d. 3. Digoxin 20 mcg po GT b.i.d. 4. Spironolactone 4 mg GT b.i.d. 5. Phenobarbital 23.7 mg GT daily.
GT|gastrostomy tube|GT|108|109|ADMISSION MEDICATIONS|ADMISSION MEDICATIONS: 1. Furosemide 6 mg p.o. GT t.i.d. 2. Captopril 0.5 mg GT t.i.d. 3. Digoxin 20 mcg po GT b.i.d. 4. Spironolactone 4 mg GT b.i.d. 5. Phenobarbital 23.7 mg GT daily. PHYSICAL EXAMINATION: On initial exam, the patient was noted to be intubated with chest wall retractions and blue lips.
GT|gastrostomy tube|GT|141|142|ADMISSION MEDICATIONS|ADMISSION MEDICATIONS: 1. Furosemide 6 mg p.o. GT t.i.d. 2. Captopril 0.5 mg GT t.i.d. 3. Digoxin 20 mcg po GT b.i.d. 4. Spironolactone 4 mg GT b.i.d. 5. Phenobarbital 23.7 mg GT daily. PHYSICAL EXAMINATION: On initial exam, the patient was noted to be intubated with chest wall retractions and blue lips.
GT|gamma-glutamyltransferase:GGT|GT,|150|152|LABORATORY ASSESSMENT|LABORATORY ASSESSMENT: The emergency room did reveal white blood count of 8200, hemoglobin 16.1, normal alkaline phosphatase, albumin, bilirubin, CK, GT, magnesium and phosphorus, as well as normal AST and ALT. BUN and electrolytes were normal. TSH was elevated at 8.3. Cholesterol was elevated at 326.
GT|gastrostomy tube|GT|131|132|DISCHARGE MEDICATIONS|11. Metoprolol 25 mg p.o. b.i.d. 12. Lasix 40 mg p.o. q.h.s. p.r.n. fluid retention. 13. Aspirin 81 mg p.o. daily. 14. Ativan 2 mg GT p.r.n. nausea and anxiety. DISPOSITION AT DISCHARGE: _%#NAME#%_ _%#NAME#%_ was discharged from University of Minnesota Medical Center, Fairview, in stable condition.
GT|gastrostomy tube|GT|749|750|CXR|Uncooperative with neurologic exam, moves all 4 extremeties, good tone and strength CXR: Right pleural effusion, moderate size, continue RML infiltrate Assessment: right parapneumonic effusion with fever and sepsis, RML bacterial pneumonia with S. pneumoniae, acute and chronic feeding intolerance. Plan: Right parapneumonic effusion with RML bacterial pneumonia - Thoracentesis for inspection, cell count, gram stain, culture, protein, LDH, and glucose - Chest tube if empyema - Continue ceftriaxone - Start azithromycin for atypical coverage - Given history of MRSA, start vanco if condition worsens - Consider CT scan if condition worsens FEN, feeding intolerance - Hold feeds now in anticipation of thoracentesis - IVF for maintenance - Restart GT feeds when procedure completed
GT|glutamyl transpeptidase|GT.|170|172|ASSESSMENT AND PLAN|They will need to be monitored. 4. Renal insufficiency seems to be stable currently. New finding today is increased in LFTs. We will check a hepatitis A, B, C, and gamma GT. I will also have a gastrointestinal consultation. 5. Diabetes mellitus. Do Accu-Cheks b.i.d. 6. Diverticulitis. Gastrointestinal consultation. 7. Congestive heart failure, hypotension.
GT|glutamyl transpeptidase|GT|129|130|PLAN|Continue the same previous fluid. The rounder is to closely manage this. We will check his hepatitis A, B, C panel and the gamma GT as well. I will call in the consults at _%#TEL#%_ _%#TEL#%_ regarding the GI consult, pain clinic consult, and internal medicine consult.
GT|gutta|GT|162|163|MEDICATIONS|4. Aspirin 81 mg per the feeding tube daily. 5. Wellbutrin 200 mg per the feeding tube daily. 6. Sinemet 1-1/2, 25/100 mg tablets four times a day. 7. Cosopt one GT both eyes twice daily. 8. Prozac 20 mg per the feeding tube daily. 9. Lasix 40 mg per the feeding tube daily. This was held and switched to IV Lasix on admission to the hospital.
GT|gutta|GT|160|161|MEDICATIONS|10. Tube feedings Fibersource 85 cc x20 hours. 11. Metoprolol 25 mg per tube feeding daily. 12. Plavix 75 mg per the feeding tube daily. 13. Xalatan drops, one GT in both eyes at bedtime. 14. Theophylline 200 mg per feeding tube daily. 15. Tylenol extra strength three times daily.
GT|glutamyl transpeptidase|GT|256|257|LABORATORY DATA|He seems to have reasonable insight, decreased memory, and his mood and affect are subdued and he is currently concerned why no one told him he had a horseshoe kidney. LABORATORY DATA: Normal serum electrolytes, BUN, creatinine and glucose. AST 143; gamma GT 288; normal alkaline phosphatase and ALT; albumin 4.0; calcium 9.1; amylase 59; lipase on admission elevated at 289. Magnesium level is decreased at 1.4 and has responded to supplementation.
GT|gamma-glutamyltransferase:GGT|GT|181|182|LABORATORY DATA|LABORATORY DATA: From Regions Hospital showed a basic metabolic panel within normal limits. Urine tox is negative. ALT 9, AST 18, total bilirubin 0.3, total cholesterol 194, CK 35, GT 30, magnesium 1.9, phosphorus 2.8. TSH 1.03. Hemoglobin 11.6 with a hematocrit 34.3, otherwise within normal limits. Recheck of hemoglobin on _%#MMDD2006#%_ was 12.1. ASSESSMENT: 1. Alcohol detox.
GT|gamma-glutamyltransferase:GGT|GT|145|146|LABORATORY DATA|Urine pregnancy test is negative. EKG showed sinus bradycardia with sinus arrhythmia. Phosphorus at Regions was 3.7, TSH of 1.45, magnesium 1.5, GT 47, CK 47, total cholesterol 150. ASSESSMENT AND PLAN: 1. Post-traumatic stress disorder, depression, anxiety. Treatment to be continued per Dr. _%#NAME#%_.
GT|glutamyl transpeptidase|GT|205|206|LABORATORY|LUNGS: Clear to auscultation bilaterally, good air entry bilaterally. ABDOMEN: Soft. Active bowel sounds. Nontender. LABORATORY: I did order liver function tests prior to seeing the patient, and her gamma GT and liver function tests all appear unremarkable. Magnesium is 2.0, phosphorus 4.4. Sodium 135, potassium 4.0, glucose 87, BUN 14, creatinine 0.6, calcium 8.3. Hemoglobin 11.2, white count 13.4, platelet count 230,000.
GT|gastrostomy tube|GT|129|130|OROPHARYNX|HEART: Sounds were difficult to appreciate because of crying other than the 2 over 6 murmur. LUNGS: Coarse but cleared. ABDOMEN: GT tube in place that was not inflamed. There was no discharge. There was no clear organomegaly. She was wearing a diaper.
GT|gastrostomy tube|GT|133|134|MEDICATIONS|MEDICATIONS: 1. Coumadin 2.5 mg p.o. daily. 2. Calcium 600 mg via GT b.i.d. 3. Synthroid 112 mcg via GT daily. 4. Protonix 40 mg via GT daily. 5. Lisinopril 20 mg via GT daily. 6. Lexapro 10 mg via GT daily. 7. Amlodipine 5 mg via GT daily.
GT|gastrostomy tube|GT|167|168|MEDICATIONS|MEDICATIONS: 1. Coumadin 2.5 mg p.o. daily. 2. Calcium 600 mg via GT b.i.d. 3. Synthroid 112 mcg via GT daily. 4. Protonix 40 mg via GT daily. 5. Lisinopril 20 mg via GT daily. 6. Lexapro 10 mg via GT daily. 7. Amlodipine 5 mg via GT daily. PAST MEDICAL HISTORY: 1. Laryngeal cancer status post laryngectomy in 1998. 2. Esophageal cancer with fistula diagnosed _%#MM2006#%_ squamous cell type.
GT|gastrostomy tube|GT|122|123|MEDICATIONS|3. Synthroid 112 mcg via GT daily. 4. Protonix 40 mg via GT daily. 5. Lisinopril 20 mg via GT daily. 6. Lexapro 10 mg via GT daily. 7. Amlodipine 5 mg via GT daily. PAST MEDICAL HISTORY: 1. Laryngeal cancer status post laryngectomy in 1998. 2. Esophageal cancer with fistula diagnosed _%#MM2006#%_ squamous cell type.
GT|gastrostomy tube|GT|155|156|MEDICATIONS|3. Synthroid 112 mcg via GT daily. 4. Protonix 40 mg via GT daily. 5. Lisinopril 20 mg via GT daily. 6. Lexapro 10 mg via GT daily. 7. Amlodipine 5 mg via GT daily. PAST MEDICAL HISTORY: 1. Laryngeal cancer status post laryngectomy in 1998. 2. Esophageal cancer with fistula diagnosed _%#MM2006#%_ squamous cell type.
GT|gastrostomy tube|GT|232|233|PROBLEM #4|PROBLEM #4: Infectious disease. Consult resulted in advising use of IV antibiotics and aggressive treatment only while he was in the hospital and all forms of further antibiotic therapy will be discontinued upon discharge home. His GT is questionable as to patency. Further management of his GT will be discontinued, but he will continue IV fluid therapy.
GT|gastrostomy tube|GT|292|293|PROBLEM #4|PROBLEM #4: Infectious disease. Consult resulted in advising use of IV antibiotics and aggressive treatment only while he was in the hospital and all forms of further antibiotic therapy will be discontinued upon discharge home. His GT is questionable as to patency. Further management of his GT will be discontinued, but he will continue IV fluid therapy. PROBLEM #5: Social work will discuss with the family specific arrangements and will establish home hospice care to be initiated as soon as possible.
GT|gastrostomy tube|GT|319|320|IMPRESSION|Some ascites. No free air. IMPRESSION: The patient is a 38-year-old male with multiple psychiatric medications, now with apparent small bowel obstruction, possible ileus secondary to psychotic medications. At there is point I see no indications for acute surgical intervention. I agree with you current plan of NPO and GT compression. If he does not resolve here in the next 24 hours I would recommend gastrografin enema for therapeutic as well as possible diagnosis.
GT|glutamyl transpeptidase|GT|118|119|LABORATORY DATA|His INR is 1.64. On subsequent differentials, his monocyte count has not been elevated. ESR was elevated at 38. Gamma GT 29. RBC folate 519. Lipase normal. Head CT without contrast showed extensive white matter changes due to chronic ischemia as well as focal lacunar infarctions.
GT|gastrostomy tube|GT|224|225|MEDICATIONS|ALLERGIES: _%#NAME#%_ has an allergy to cefprozil. MEDICATIONS: In addition to carbamazepine 300 mg t.i.d., _%#NAME#%_ was receiving clonidine 0.15 mg at bedtime, fludrocortisone 100 mg GT every morning, hydrocortisone 5 mg GT t.i.d., trazodone 100 mg GT at bedtime, acetaminophen and MiraLax. As noted above, _%#NAME#%_ is receiving Lovenox. SOCIAL HISTORY: _%#NAME#%_ resides in the _%#NAME#%_ Group Home.
GT|gastrostomy tube|GT|219|220|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 9-month-old male with a history of CHARGE and FISH-negative DiGeorge and AV canal admitted to F-UMC on _%#MMDD2004#%_ with irritability, feeding intolerance, and blood in his GT drainage. He was dehydrated on admission. He was found to have had a new MI, had bradycardia and asystole, requiring CPR.
GT|gamma-glutamyltransferase:GGT|GT|224|225|LABORATORY DATA|LABORATORY DATA: Comprehensive metabolic panel within normal limits. Hemogram, differential, platelet count within normal limits. Reflex TSH 2.13 and T4 1.44. T3 is pending. Urine tox negative. CK 85. Total cholesterol 154. GT 33, magnesium 1.8, phosphorus 3.5. MRI and EEG are pending. ASSESSMENT AND PLAN: 1. Psychoses. Treatment to be continued per Dr. _%#NAME#%_.
GT|gastrostomy tube|GT|173|174|PHYSICAL EXAMINATION|His respiratory rate is 44 with prolonged expiratory phase and somewhat increased work of breathing. His heart has no murmurs. His abdomen is soft without organomegaly. His GT site looks clean. NEUROLOGIC: _%#NAME#%_'s gaze is more midline. He is hypertonic and, at this point, just kind of not smiling or seeming particular happy.
GT|gastrostomy tube|GT|231|232|PROBLEM #2|_%#NAME#%_ continues on his higher protein formula, and as his ammonia is normal and his labs look good, we will continue that until discharge. PROBLEM #2: Hyponatremia. _%#NAME#%_ may have some sodium loss from both diuretics and GT draining. He should be set back his G-tube drainage, but the G-tube should be left to gravity, as it appears that this seems to be helping him.
GT|glutamyl transpeptidase|GT|229|230|REQUESTING PHYSICIAN|Initially he was treated with Zantac and then treated for H. pylori after a positive serology was noted. Abdominal CT scan showed gallstones and gallbladder wall thickening with a minimal elevation of alkaline phosphatase, gamma GT and normal amylase and AST. The symptoms seemed to worsen and he therefore underwent a cholecystectomy at Fairview Ridges.
GT|glutamyl transpeptidase|GT|229|230|LABORATORY DATA|TSH was within normal limits. Lithium level was 0.7. CBC with platelets was significant for a hematocrit of 38.5. All other lab values are within normal limits. Total cholesterol was 188. CK total was within normal limits. Gamma GT was within normal limits. Basic metabolic panel was significant for a chloride of 109. All other lab values within normal limits. Phosphorus was 3.9. Magnesium was within normal limits.
GT|gastrostomy tube|GT|297|298|CURRENT MEDICATIONS|ALLERGIES: Cipro, Thorazine, ampicillin, and cephalosporins. Tolerated imipenem as above. CURRENT MEDICATIONS: Decadron protocol beginning on _%#MMDD2002#%_ with 16 mg IM q.i.d., Prevacid 30 mg q day, Synthroid 0.075 mg q day, Trileptal 150 mg q day, glycerine suppository q.o.d., Zofran 4 mg per GT q 6 hours prn nausea, Albuterol 2.5 mg/Atrovent 500 mcg by nebulization q 4 hours prn. The patient was on DuoNeb at the nursing home containing INH solution.
GT|gastrostomy tube|GT|151|152|CURRENT MEDICATIONS|2. Diabetes mellitus _%#MM#%_ 2004. 3. Recurrent UTI. 4. Recurrent pneumonia. ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: 1. Celexa 20 mg GT q. day. 2. ________________ 25 mg GT t.i.d. 3. Docusate 100 mg GT b.i.d. 4. Glycopyrrolate 1 mg GT t.i.d. 5. _______________ neb. 6. Lantus 100 units subcu q. day.
GT|gastrostomy tube|GT|176|177|CURRENT MEDICATIONS|2. ________________ 25 mg GT t.i.d. 3. Docusate 100 mg GT b.i.d. 4. Glycopyrrolate 1 mg GT t.i.d. 5. _______________ neb. 6. Lantus 100 units subcu q. day. 7. Metoprolol 25 mg GT b.i.d. 8. Pantoprazole 40 mg GT q. day. 9. Scopolamine 1 patch q. 72 hours. 10. Senokot 5 mL GT b.i.d. 11. Kay Ciel 7.5 mEq GT q. h.s. SOCIAL HISTORY: The patient lives in a nursing home.
GT|gastrostomy tube|GT|143|144|CURRENT MEDICATIONS|4. Glycopyrrolate 1 mg GT t.i.d. 5. _______________ neb. 6. Lantus 100 units subcu q. day. 7. Metoprolol 25 mg GT b.i.d. 8. Pantoprazole 40 mg GT q. day. 9. Scopolamine 1 patch q. 72 hours. 10. Senokot 5 mL GT b.i.d. 11. Kay Ciel 7.5 mEq GT q. h.s. SOCIAL HISTORY: The patient lives in a nursing home.
GT|gastrostomy tube|GT|116|117|CURRENT MEDICATIONS|7. Metoprolol 25 mg GT b.i.d. 8. Pantoprazole 40 mg GT q. day. 9. Scopolamine 1 patch q. 72 hours. 10. Senokot 5 mL GT b.i.d. 11. Kay Ciel 7.5 mEq GT q. h.s. SOCIAL HISTORY: The patient lives in a nursing home.
GT|gastrostomy tube|GT|147|148|CURRENT MEDICATIONS|7. Metoprolol 25 mg GT b.i.d. 8. Pantoprazole 40 mg GT q. day. 9. Scopolamine 1 patch q. 72 hours. 10. Senokot 5 mL GT b.i.d. 11. Kay Ciel 7.5 mEq GT q. h.s. SOCIAL HISTORY: The patient lives in a nursing home.
GT|glutamyl transpeptidase|GT,|236|238|PLAN|4. For chronic kidney disease, monitor creatinine. 5. For preoperative and postoperative anemia, monitor hemoglobin and check iron studies as well as vitamin B12 and folate. 6. For alcohol consumption, check liver function tests, gamma GT, monitor for evidence of alcohol withdrawal. We will follow this patient with you. Thank you for this consultation.
GT|glutamyl transpeptidase|GT|196|197|HOSPITAL COURSE|Indeed, the patient had mild transaminasemia, with AST and ALT both greater than 100 on admission, and the ALT was 144 and AST 147. He additionally had an alkaline phosphatase of 475, and a gamma GT of 337. We confirmed that his elevation of alkaline phosphatase was due to liver by testing for specific alkaline phosphatase isozymes.
GT|gastrostomy tube|GT|197|198|PAST MEDICAL HISTORY|4. Interrupted aortic arch, ASD and VSD, all repaired in _%#MM#%_ 2000. 5. Postop complication with mediastinitis and tamponade. 6. Bronchomalacia, status post cardiopexy x 2. 7. GERD, status post GT Nissen in _%#MM#%_ of 2000. 8. History of IVH grade II. 9. Cleft palate, partial repair in _%#MM#%_ of 2001. 10. History of C. difficile colitis. 11. History of UTI.
GT|gastrostomy tube|GT|203|204|DISCHARGE DIET|12. CriticAid q. diaper changes p.r.n. 13. Bactroban ointment to the trach site p.r.n. 14. Racemic epinephrine nebs 0.5 mL of 2.25% q.6 p.r.n. with work of breathing and wheezing. 15. Fluconazole 120 mg GT q.d. x 10 days. 16. TOBI nebs 150 mg b.i.d. x 10 days. 17. Bactrim 60 mg per G tube q.12h. x 10 days.
GT|gastrostomy tube|GT|139|140|DISCHARGE DIET|21. Nystatin ointment to diaper area q.i.d. x 10 days or until rash is gone. 22. Sodium fluoride 0.25 mg down G tube q.d. 23. Bactroban to GT site q.i.d. x 10 days. 24. Robinul 480 mcg down G tube q.h.s. 25. Phenergan 3 mg per G tube b.i.d. x 3 weeks.
GT|gastrostomy tube|GT|163|164|HOSPITAL COURSE|So he was started on Flagyl at 40 mg for three days which were to end on _%#MMDD2007#%_. 6. Neurology. He continue with his phenobarbital per home regimen of 8 mg GT tube daily and these were started due to seizures that were present in his last hospitalization post operation and repair.
GT|gastrostomy tube|GT|135|136|CURRENT MEDICATIONS|2. Trazodone 100 mg G-tube each day at bedtime for insomnia. 3. MiraLax 17 g G-tube daily for constipation. 4. Fludrocortisone 100 mcg GT daily. 5. Clonidine 150 mcg GT each day at bedtime for sleep. 6. Nystatin powder topical on the perianal area b.i.d.
GT|gastrostomy tube|GT|166|167|CURRENT MEDICATIONS|2. Trazodone 100 mg G-tube each day at bedtime for insomnia. 3. MiraLax 17 g G-tube daily for constipation. 4. Fludrocortisone 100 mcg GT daily. 5. Clonidine 150 mcg GT each day at bedtime for sleep. 6. Nystatin powder topical on the perianal area b.i.d. 7. Clindamycin 300 mg G-tube q. 12. 8. Hydrocortisone 5 mg solution G-tube t.i.d. SOCIAL HISTORY: _%#NAME#%_ has been moved due to behavioral difficulties to _%#NAME#%_ Group Home, in which he has RN, nurses on staff, which understand the prognosis of his disease.
GT|gastrostomy tube|GT|291|292|ALLERGIES|3. Recurrent pulmonary infections, most recently growing heavy MRSA in _%#MM#%_ 2004, Aspergillus in _%#MM#%_ 2004, MRSA in _%#MM#%_ 2004, Pseudomonas in 2004. ALLERGIES: Amoxicillin, clindamycin and penicillin. DIET: Regular diet throughout the day, with pancreatic enzyme supplementation, GT feedings at night with Peptamen 1.5 four cans to be run overnight. SOCIAL HISTORY: _%#NAME#%_ is living at home with both his parents.
GT|gastrostomy tube|GT|152|153|DISCHARGE MEDICATIONS|4. Mucomyst 20% 2 mL twice daily with VEST. 5. Pulmozyme 2.5 mg nebulizer q. day. 6. Advair 500/50 one puff twice daily after VEST. 7. Mucomyst 20% per GT 30 mL q. bedtime plus p.r.n. 8. Nasonex AQ 2 sprays each nostril q. day. 9. Prevacid 30 mg p.o. twice daily.
GT|gastrostomy tube|GT|156|157|PAST MEDICAL HISTORY|She is followed by Gastroenterology for this. Her high triglycerides have resolved in the past when off tube feedings. 4. Status post gastric tube. Nightly GT feeds. 5. History of bowel obstruction. 6. History of bowel perforation and some bowel resection. FAMILY HISTORY: Her father has high cholesterol.
GT|gastrostomy tube|GT|162|163|ADMISSION DIAGNOSIS|NUTRITION: Her diet is Nutramigen, Polycose, and microlipids to equal around 30 kcal/oz. She gets bolus feeds of 70 cc over 1 hour x5, and then at night she gets GT feeds 35 cc/h over 2200 to 0600. CHILDHOOD ILLNESS AND EXPOSURE: Hospitalized for pneumonia _%#MM#%_ _%#DD#%_, 2002, discharged on _%#MM#%_ _%#DD#%_, 2002.
GT|gastrostomy tube|GT|118|119|ADMISSION MEDICATIONS|2. Lamictal 50 mg JT q.a.m., 62.5 mg JT q.p.m. 3. Topamax 50 mg JT b.i.d. 4. Carnitine 200 mg JT t.i.d. 5. Sucralfate GT q.a.m. FAMILY HISTORY: There is history of asthma in a maternal grandmother and in an aunt.
GT|gastrostomy tube|GT|193|194|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prevacid 15 mg GT b.i.d. 2. Lamictal 50 mg JT q.a.m., 62.5 mg JT q.p.m. 3. Topamax 50 mg JT q.a.m., 75 mg JT q.p.m. 4. Carnitine 200 mg JT t.i.d. 5. Sucralfate 225 mg GT q.a.m. FOLLOW UP: The patient is to follow up with Dr. _%#NAME#%_ and Dr. _%#NAME#%_ in Metabolism and Neurology Clinic respectively in 2 weeks.
GT|gastrostomy tube|GT|179|180|DISCHARGE MEDICATIONS|7. Multivitamin with iron 1 mL GT q.p.m. 8. Ganciclovir 90 mg GT b.i.d. 9. Bactrim 25 mg GT every 1 week (Friday, Saturday and Sunday at 0700 hours). 10. Magnesium sulfate 400 mg GT q.i.d. DISCHARGE FOLLOWUP PLAN: The patient is to follow up with her regular appointment with the Transplant Team on _%#MMDD2006#%_.
GT|gastrostomy tube|GT|114|115|DISCHARGE MEDICATIONS|11. Metoprolol 75 mg per GT twice a day. 12. Miconazole powder 2% inner thigh twice a day. 13. Prevacid 30 mg per GT daily. DISCHARGE DIAGNOSES: 1. Inclusion body myositis with weakness. 2. Dysphagia with percutaneous G-tube placed this hospitalization.
GT|gastrostomy tube|GT|118|119|MEDICATIONS|5. Guargom 15 cc feeding tube q.6h. 6. Insuline sliding scale. 7. Combivent four puffs inhaled q.4h. 8. Lexapro 20 mg GT q. day. 9. Miconazole topical to labia b.i.d. 10. Multivitamin one tablet p.o. q. day. 11. Pantoprazole 40 mg feeding tube b.i.d. 12. Prednisone 20 mg p.o. q. day.
GT|gastrostomy tube|GT|176|177|DISCHARGE MEDICATIONS|9. Lactobacillus 1 capsule per GT twice a day in 30 mL of water. 10. Losartan 50 mg per GT daily-during this hospitalization was decreased from 75 mg. 11. Metoprolol 75 mg per GT twice a day. 12. Miconazole powder 2% inner thigh twice a day. 13. Prevacid 30 mg per GT daily. DISCHARGE DIAGNOSES: 1. Inclusion body myositis with weakness. 2. Dysphagia with percutaneous G-tube placed this hospitalization.
GT|glutamyl transpeptidase|GT|214|215|LABORATORY AND DIAGNOSTIC DATA/IMAGING|Iron level only 23. Vitamin B-12 level 1100. TSH 3.1. Thyroxin level 1.1. Reticulocyte count was 1.6 which is inappropriately normal. RBC folic acid level was elevated at 1800. Liver function tests including gamma GT on _%#MMDD2007#%_ were normal. CRP 20. ESR 110. Compliment 3 level and compliment 4 level were borderline at 70 and 13 respectively.
GT|gastrostomy tube|GT|172|173|CONSULTATIONS|Follow up with Dr. _%#NAME#%_ of neurosurgery about _%#MMDD2004#%_ for repeat MRI and clinic visit. Discharge medications, treatments and special equipment: 1. Diuril 40mg GT BID 2. Aldactone 4mg po BID 3. Phenobarbital 15 mg GT QD 4. Trivisol 1/2 ml po/GT QD _%#NAME#%_ is a good candidate to continue to receive Synagis during the upcoming RSV season.
GT|gastrostomy tube|GT|110|111|DISCHARGE MEDICATIONS|5. Altace-MT 12 take 6-9 caps p.o. with meals. 6. Prevacid 30 mg by G-tube b.i.d. 7. Vitamin E 400 IU p.o. or GT b.i.d. 8. Vitamin C 500 mg p.o. or GT b.i.d. 9. Vitamin A 50,000 IU p.o. or GT q. day. 10. Vitamin K 5 mg p.o. or GT q. day.
GT|gastrostomy tube|GT|107|108|DISCHARGE MEDICATIONS|7. Vitamin E 400 IU p.o. or GT b.i.d. 8. Vitamin C 500 mg p.o. or GT b.i.d. 9. Vitamin A 50,000 IU p.o. or GT q. day. 10. Vitamin K 5 mg p.o. or GT q. day. 11. Novolog 1 unit prior to breakfast, 3 units prior to lunch, and 5 units subcu prior to dinner.
GT|gastrostomy tube|GT|148|149|DISCHARGE MEDICATIONS|5. Altace-MT 12 take 6-9 caps p.o. with meals. 6. Prevacid 30 mg by G-tube b.i.d. 7. Vitamin E 400 IU p.o. or GT b.i.d. 8. Vitamin C 500 mg p.o. or GT b.i.d. 9. Vitamin A 50,000 IU p.o. or GT q. day. 10. Vitamin K 5 mg p.o. or GT q. day.
GT|gastrostomy tube|GT|145|146|DISCHARGE MEDICATIONS|7. Vitamin E 400 IU p.o. or GT b.i.d. 8. Vitamin C 500 mg p.o. or GT b.i.d. 9. Vitamin A 50,000 IU p.o. or GT q. day. 10. Vitamin K 5 mg p.o. or GT q. day. 11. Novolog 1 unit prior to breakfast, 3 units prior to lunch, and 5 units subcu prior to dinner. 12. Flagyl 375 mg p.o. q.i.d. through _%#MM#%_ _%#DD#%_, 2004, for a 14-day course.
GT|gastrostomy tube|GT|146|147|DISCHARGE MEDICATIONS|13. Actigall 150 mg p.o. b.i.d. 14. Centrum multivitamin 1 tab p.o. q. day. 15. ADEK vitamin 1 tab p.o. q. day. 16. Ciprofloxacin 1000 mg p.o. or GT b. i.d. through _%#MM#%_ _%#DD#%_, 2004, for a 14-day course.
GT|gastrostomy tube|GT|144|145|S|Currently all aspirates from his G tube are replaced through his J tube via a pump. Essentially all po intake comes out of _%#NAME#%_'s J tube. GT outputs have been decreasing on a daily basis over the past week prior to discharge. 6. RENAL - Over the first two days of life _%#NAME#%_ became quite edematous.
GT|gastrostomy tube|GT|161|162|1. FEN|These will need to be monitored intermittently. His current feeds are breastmilk supplemented to 26 kcals run continuously through his JT at 32 ml per hour. All GT output is refed through his J port. _%#NAME#%_ appears to tolerate oral feeds. These are currently only for comfort and not intended to provide nutrition.
GT|gastrostomy tube|GT|166|167|1. FEN|All GT output is refed through his J port. _%#NAME#%_ appears to tolerate oral feeds. These are currently only for comfort and not intended to provide nutrition. The GT output from these feeds is not replaced. Ultimately the goal would be to take full feeds orally. 2. RESP: _%#NAME#%_ has continued pulmonary hypertension. His current therapeutic regimen is Pulmicort, Persantine, Diuril and low flow O2.
GT|gastrostomy tube|GT|355|356|5. CNS|On POD#4, a cloudy, bloody discharge was noted draining from the G-tube incision site and the WBC was 36.5. The pt was placed on Keflex 100mg GT Q6h and the WBC fell to 19.4. However, because she she was still on antibiotics, she was placed on mucostatin one day prior to discharge. Discharge medications, treatments and special equipment: 1) Inderal 8mg GT Q8h 2) Keflex 100mg GT day #5 of 7 day course(ending on _%#MMDD2002#%_) 3) Mycostatin 50,000U PO Discharge measurements: Weight 5570 gms; length 60 cm; OFC 39 cm.
GT|gastrostomy tube|GT|378|379|5. CNS|On POD#4, a cloudy, bloody discharge was noted draining from the G-tube incision site and the WBC was 36.5. The pt was placed on Keflex 100mg GT Q6h and the WBC fell to 19.4. However, because she she was still on antibiotics, she was placed on mucostatin one day prior to discharge. Discharge medications, treatments and special equipment: 1) Inderal 8mg GT Q8h 2) Keflex 100mg GT day #5 of 7 day course(ending on 4-30-02) 3) Mycostatin 50,000U PO Discharge measurements: Weight 5570 gms; length 60 cm; OFC 39 cm.
GT|gastrostomy tube|GT|166|167|* FEN|_%#NAME#%_ will need follow up with Dr. _%#NAME#%_, Pediatric Neurologist, in 4 weeks. Discharge medications, treatments and special equipment: * Phenobarbital 15 mg GT daily * Robinul 0.2mg TID * Prune juice 5 mL BID * Continuous O2 therapy at 1/32 L to keep saturations >90% * Apnea monitoring * Upper airway suctioning as needed Discharge measurements and exam: Weight 2900 gm, length 49 cm, OFC 33.5 cm.
GT|gastrostomy tube|GT|459|460|* FEN|His transition from drip to bolus feeds will need to be managed by the pediatric GI service and will likely take place between one and six months after discharge. * Developmental/Neurological: _%#NAME#%_ will benefit from follow-up to assess his developmental needs in relation to his history of intraventricular hemorrhage and periventricular leukomalacia Discharge medications, treatments and special equipment: * Ursodiol 40mg GT Q12 hours * KCl, 2.5 mEq, GT Q6 hours * NaCl, 2 mEq, GT Q6hours * Diuril, 50 mg, GT Q12 hours * Feeding Pump for administration of Enfacare 24 Kcal as continuous drip at rate of 19ml/hour Discharge measurements and exam: Weight 2978 gm, length 48 cm, OFC 33.5 cm.
GT|gastrostomy tube|GT|486|487|* FEN|His transition from drip to bolus feeds will need to be managed by the pediatric GI service and will likely take place between one and six months after discharge. * Developmental/Neurological: _%#NAME#%_ will benefit from follow-up to assess his developmental needs in relation to his history of intraventricular hemorrhage and periventricular leukomalacia Discharge medications, treatments and special equipment: * Ursodiol 40mg GT Q12 hours * KCl, 2.5 mEq, GT Q6 hours * NaCl, 2 mEq, GT Q6hours * Diuril, 50 mg, GT Q12 hours * Feeding Pump for administration of Enfacare 24 Kcal as continuous drip at rate of 19ml/hour Discharge measurements and exam: Weight 2978 gm, length 48 cm, OFC 33.5 cm.
GT|gastrostomy tube|GT|124|125|DISCHARGE DIAGNOSES|6. Gastroesophageal reflux and aspiration. 7. Oral thrush. DISCHARGE MEDICATIONS: 1. Lasix 5 mg GT b.i.d. 2. Digoxin 13 mcg GT b.i.d. 3. Keflex 40 mg GT t.i.d. through _%#MMDD2003#%_ and then discontinue. 4. Nystatin 1 cc p.o. q.i.d. until _%#MMDD2003#%_ and then discontinue.
GT|gastrostomy tube|GT|170|171|DISCHARGE DIAGNOSES|4. Cellulitis. 5. Status post gastrostomy tube and Nissen for aspiration. 6. Gastroesophageal reflux and aspiration. 7. Oral thrush. DISCHARGE MEDICATIONS: 1. Lasix 5 mg GT b.i.d. 2. Digoxin 13 mcg GT b.i.d. 3. Keflex 40 mg GT t.i.d. through _%#MMDD2003#%_ and then discontinue. 4. Nystatin 1 cc p.o. q.i.d. until _%#MMDD2003#%_ and then discontinue.
GT|gastrostomy tube|GT|160|161|DISCHARGE DIAGNOSES|3. Keflex 40 mg GT t.i.d. through _%#MMDD2003#%_ and then discontinue. 4. Nystatin 1 cc p.o. q.i.d. until _%#MMDD2003#%_ and then discontinue. 5. Tylenol 50 mg GT q. 4h. p.r.n. fever. DISCHARGE INSTRUCTIONS: 1. Follow up with: Dr. _%#NAME#%_ on _%#MMDD2003#%_; Dr. _%#NAME#%_, Pediatric Surgery, _%#MMDD2003#%_, 2:15 PM; Dr. _%#NAME#%_, Cardiology, three weeks after discharge.
GT|glutamyl transpeptidase|GT|268|269|SUMMARY OF HOSPITALIZATION|Liver dysfunction. The patient's INR was initially 1.5. I suspected this was due to malnutrition, however, Vitamin K given twice did not correct the INR. It slightly improved over time, however, I am not exactly sure why that occurred DIC was not confirmed. The gamma GT was also elevated at about 150 or so, and the remainder of liver function tests were unremarkable. She was given one dose of methotrexate but I had to stop this due to the fact she has underlying liver dysfunction.
GT|glutamyl transpeptidase|GT|111|112|PROCEDURES|Sodium 131, potassium 4.2, BUN 13, creatinine 0.6. Liver function tests were unremarkable other than the gamma GT which was grossly elevated. INR was approximately 1.2-1.4. Serum protein electrophoresis revealed hypoalbuminemia. No monoclonal band was seen.
GT|gastrostomy tube|GT|154|155|DISCHARGE MEDICATIONS|During this hospitalization, bilateral myringotomies with pressure equalization tube insertion were performed. DISCHARGE MEDICATIONS: 1. Bosentan 15.6 mg GT q.d. 2. Sildenafil 1 mg GT q.d. 3. Nifedipine 3.5 mg GT five times per day. 4. Lasix 8 mg GT b.i.d. 5. Aldactone 4 mg GT b.i.d. 6. Metolazone 0.5 mg GT b.i.d.
GT|gastrostomy tube|GT|210|211|DISCHARGE MEDICATIONS|During this hospitalization, bilateral myringotomies with pressure equalization tube insertion were performed. DISCHARGE MEDICATIONS: 1. Bosentan 15.6 mg GT q.d. 2. Sildenafil 1 mg GT q.d. 3. Nifedipine 3.5 mg GT five times per day. 4. Lasix 8 mg GT b.i.d. 5. Aldactone 4 mg GT b.i.d. 6. Metolazone 0.5 mg GT b.i.d. 7. Persantine 8 mg GT t.i.d. 8. Digoxin 15 mcg GT q.d.
GT|gastrostomy tube|GT|136|137|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Bosentan 15.6 mg GT q.d. 2. Sildenafil 1 mg GT q.d. 3. Nifedipine 3.5 mg GT five times per day. 4. Lasix 8 mg GT b.i.d. 5. Aldactone 4 mg GT b.i.d. 6. Metolazone 0.5 mg GT b.i.d. 7. Persantine 8 mg GT t.i.d. 8. Digoxin 15 mcg GT q.d.
GT|gastrostomy tube|GT|169|170|DISCHARGE MEDICATIONS|5. Aldactone 4 mg GT b.i.d. 6. Metolazone 0.5 mg GT b.i.d. 7. Persantine 8 mg GT t.i.d. 8. Digoxin 15 mcg GT q.d. 9. Synthroid 37.5 mcg GT q.o.d. alternating with 25 mg GT q.o.d. 10. Potassium chloride 5 mEq GT t.i.d. 11. Erythromycin 13 mg GT q.i.d. 12. Reglan 0.6 GT q.i.d. 13. Carafate 60 mg GT q.i.d.
GT|gastrostomy tube|GT|149|150|DISCHARGE MEDICATIONS|7. Persantine 8 mg GT t.i.d. 8. Digoxin 15 mcg GT q.d. 9. Synthroid 37.5 mcg GT q.o.d. alternating with 25 mg GT q.o.d. 10. Potassium chloride 5 mEq GT t.i.d. 11. Erythromycin 13 mg GT q.i.d. 12. Reglan 0.6 GT q.i.d. 13. Carafate 60 mg GT q.i.d. 14. Prilosec 3 mg GT q.d. 15. Simethicone 20 mg GT q.i.d.
GT|gastrostomy tube|GT|127|128|DISCHARGE MEDICATIONS|9. Synthroid 37.5 mcg GT q.o.d. alternating with 25 mg GT q.o.d. 10. Potassium chloride 5 mEq GT t.i.d. 11. Erythromycin 13 mg GT q.i.d. 12. Reglan 0.6 GT q.i.d. 13. Carafate 60 mg GT q.i.d. 14. Prilosec 3 mg GT q.d. 15. Simethicone 20 mg GT q.i.d.
GT|gastrostomy tube|GT|152|153|DISCHARGE MEDICATIONS|9. Synthroid 37.5 mcg GT q.o.d. alternating with 25 mg GT q.o.d. 10. Potassium chloride 5 mEq GT t.i.d. 11. Erythromycin 13 mg GT q.i.d. 12. Reglan 0.6 GT q.i.d. 13. Carafate 60 mg GT q.i.d. 14. Prilosec 3 mg GT q.d. 15. Simethicone 20 mg GT q.i.d. 16. Lactobacillus one-half packet GT t.i.d. 17. Xopenex 0.63 mg neb q.i.d.
GT|gastrostomy tube|GT|144|145|DISCHARGE MEDICATIONS|10. Potassium chloride 5 mEq GT t.i.d. 11. Erythromycin 13 mg GT q.i.d. 12. Reglan 0.6 GT q.i.d. 13. Carafate 60 mg GT q.i.d. 14. Prilosec 3 mg GT q.d. 15. Simethicone 20 mg GT q.i.d. 16. Lactobacillus one-half packet GT t.i.d. 17. Xopenex 0.63 mg neb q.i.d. 18. Pulmicort 0.25 mg neb b.i.d. 19. Rimantadine 20 mg GT q.d.
GT|gastrostomy tube|GT|116|117|DISCHARGE MEDICATIONS|10. Potassium chloride 5 mEq GT t.i.d. 11. Erythromycin 13 mg GT q.i.d. 12. Reglan 0.6 GT q.i.d. 13. Carafate 60 mg GT q.i.d. 14. Prilosec 3 mg GT q.d. 15. Simethicone 20 mg GT q.i.d. 16. Lactobacillus one-half packet GT t.i.d. 17. Xopenex 0.63 mg neb q.i.d.
GT|gastrostomy tube|GT|219|220|5. ID|9. Genetics: Patient's karyotype showed trisomy 21. Ongoing problems and suggested management: see above Discharge medications, treatments and special equipment: Oximeter, Home oxygen. Meds: 1. Diuril 70 mg q12 hr down GT 2. Lasix 7 mg q12 hr down GT 3. Aldactone 7 mg q12 hr own GT 4. KCl 3 mEq q12 hr down GT 5. NaCl 4.5 mEq q6 hr down GT
GT|gastrostomy tube|GT|248|249|5. ID|9. Genetics: Patient's karyotype showed trisomy 21. Ongoing problems and suggested management: see above Discharge medications, treatments and special equipment: Oximeter, Home oxygen. Meds: 1. Diuril 70 mg q12 hr down GT 2. Lasix 7 mg q12 hr down GT 3. Aldactone 7 mg q12 hr own GT 4. KCl 3 mEq q12 hr down GT 5. NaCl 4.5 mEq q6 hr down GT 6. Atrovent 250 mcg q12 hr down GT 7. Atrovent 250 mcg q6 hr prn
GT|gastrostomy tube|GT|123|124|5. ID|Meds: 1. Diuril 70 mg q12 hr down GT 2. Lasix 7 mg q12 hr down GT 3. Aldactone 7 mg q12 hr own GT 4. KCl 3 mEq q12 hr down GT 5. NaCl 4.5 mEq q6 hr down GT 6. Atrovent 250 mcg q12 hr down GT 7. Atrovent 250 mcg q6 hr prn 8. Nystatin 50000 units oral q6 hr 9. Nifedipine 4.2 mg SL q6 hr, (Teva/Novopharm Brand) withdraw 0.17 ml from capsule, add 0.17ml water, for a total of 0.34 ml.
GT|gastrostomy tube|GT|116|117|5. ID|2. Lasix 7 mg q12 hr down GT 3. Aldactone 7 mg q12 hr own GT 4. KCl 3 mEq q12 hr down GT 5. NaCl 4.5 mEq q6 hr down GT 6. Atrovent 250 mcg q12 hr down GT 7. Atrovent 250 mcg q6 hr prn 8. Nystatin 50000 units oral q6 hr 9. Nifedipine 4.2 mg SL q6 hr, (Teva/Novopharm Brand) withdraw 0.17 ml from capsule, add 0.17ml water, for a total of 0.34 ml.
GT|gastrostomy tube|GT|209|210|* FEN|She should have weekly trach changes. * Ophthalmology: _%#NAME#%_ will require followup examination for ROP in two weeks. Discharge medications, treatments and special equipment: * Medications: * Diuril 75 mg GT q12 hours * KCL 5 mEq GT q6 hours * NaCl 2 mEq GT q6 hours * Reglan 0.75 mg GT q 6 hours * Pear juice 5 ml PO/GT q 12 hours * Flovent 1 puff inhaled q 12 hours * Atrovent 1 puff inhaled q 12 hours * Albuterol 2 puffs inhaled q12 hours * Tamiflu 15 mg GT daily Ventilator: LTV 950 Mode: SIMV/PS Rate 10 Tidal volume 50 PEEP 10 Pressure Support 16 Apnea monitor Pulse oximetry Infinity feeding pump Tracheostomy tube Bivona pediatric 3.0 uncuffed, length 39 mm 24 hour home nursing care Discharge measurements and exam: Weight 4030 g, length 50 cm, OFC 37.5 cm.
GT|gastrostomy tube|GT|234|235|* FEN|She should have weekly trach changes. * Ophthalmology: _%#NAME#%_ will require followup examination for ROP in two weeks. Discharge medications, treatments and special equipment: * Medications: * Diuril 75 mg GT q12 hours * KCL 5 mEq GT q6 hours * NaCl 2 mEq GT q6 hours * Reglan 0.75 mg GT q 6 hours * Pear juice 5 ml PO/GT q 12 hours * Flovent 1 puff inhaled q 12 hours * Atrovent 1 puff inhaled q 12 hours * Albuterol 2 puffs inhaled q12 hours * Tamiflu 15 mg GT daily Ventilator: LTV 950 Mode: SIMV/PS Rate 10 Tidal volume 50 PEEP 10 Pressure Support 16 Apnea monitor Pulse oximetry Infinity feeding pump Tracheostomy tube Bivona pediatric 3.0 uncuffed, length 39 mm 24 hour home nursing care Discharge measurements and exam: Weight 4030 g, length 50 cm, OFC 37.5 cm.
GT|gastrostomy tube|GT|259|260|* FEN|She should have weekly trach changes. * Ophthalmology: _%#NAME#%_ will require followup examination for ROP in two weeks. Discharge medications, treatments and special equipment: * Medications: * Diuril 75 mg GT q12 hours * KCL 5 mEq GT q6 hours * NaCl 2 mEq GT q6 hours * Reglan 0.75 mg GT q 6 hours * Pear juice 5 ml PO/GT q 12 hours * Flovent 1 puff inhaled q 12 hours * Atrovent 1 puff inhaled q 12 hours * Albuterol 2 puffs inhaled q12 hours * Tamiflu 15 mg GT daily Ventilator: LTV 950 Mode: SIMV/PS Rate 10 Tidal volume 50 PEEP 10 Pressure Support 16 Apnea monitor Pulse oximetry Infinity feeding pump Tracheostomy tube Bivona pediatric 3.0 uncuffed, length 39 mm 24 hour home nursing care Discharge measurements and exam: Weight 4030 g, length 50 cm, OFC 37.5 cm.
GT|gastrostomy tube|GT|288|289|* FEN|She should have weekly trach changes. * Ophthalmology: _%#NAME#%_ will require followup examination for ROP in two weeks. Discharge medications, treatments and special equipment: * Medications: * Diuril 75 mg GT q12 hours * KCL 5 mEq GT q6 hours * NaCl 2 mEq GT q6 hours * Reglan 0.75 mg GT q 6 hours * Pear juice 5 ml PO/GT q 12 hours * Flovent 1 puff inhaled q 12 hours * Atrovent 1 puff inhaled q 12 hours * Albuterol 2 puffs inhaled q12 hours * Tamiflu 15 mg GT daily Ventilator: LTV 950 Mode: SIMV/PS Rate 10 Tidal volume 50 PEEP 10 Pressure Support 16 Apnea monitor Pulse oximetry Infinity feeding pump Tracheostomy tube Bivona pediatric 3.0 uncuffed, length 39 mm 24 hour home nursing care Discharge measurements and exam: Weight 4030 g, length 50 cm, OFC 37.5 cm.
GT|gastrostomy tube|GT|463|464|* FEN|She should have weekly trach changes. * Ophthalmology: _%#NAME#%_ will require followup examination for ROP in two weeks. Discharge medications, treatments and special equipment: * Medications: * Diuril 75 mg GT q12 hours * KCL 5 mEq GT q6 hours * NaCl 2 mEq GT q6 hours * Reglan 0.75 mg GT q 6 hours * Pear juice 5 ml PO/GT q 12 hours * Flovent 1 puff inhaled q 12 hours * Atrovent 1 puff inhaled q 12 hours * Albuterol 2 puffs inhaled q12 hours * Tamiflu 15 mg GT daily Ventilator: LTV 950 Mode: SIMV/PS Rate 10 Tidal volume 50 PEEP 10 Pressure Support 16 Apnea monitor Pulse oximetry Infinity feeding pump Tracheostomy tube Bivona pediatric 3.0 uncuffed, length 39 mm 24 hour home nursing care Discharge measurements and exam: Weight 4030 g, length 50 cm, OFC 37.5 cm.
GT|gastrostomy tube|GT|74|75|DISCHARGE MEDICATIONS|2. Acetaminophen 650 mg per GT q.4 h. p.r.n. pain. 3. Naprosyn 250 mg per GT daily. 4. Lasix 20 mg per GT twice a day. 5. Calcium plus D 600/200, 1 per GT twice a day. 6. Amlodipine 10 mg per GT daily-on hold, held this hospitalization.
GT|gastrostomy tube|GT|103|104|DISCHARGE MEDICATIONS|2. Acetaminophen 650 mg per GT q.4 h. p.r.n. pain. 3. Naprosyn 250 mg per GT daily. 4. Lasix 20 mg per GT twice a day. 5. Calcium plus D 600/200, 1 per GT twice a day. 6. Amlodipine 10 mg per GT daily-on hold, held this hospitalization.
GT|gastrostomy tube|GT|152|153|DISCHARGE MEDICATIONS|2. Acetaminophen 650 mg per GT q.4 h. p.r.n. pain. 3. Naprosyn 250 mg per GT daily. 4. Lasix 20 mg per GT twice a day. 5. Calcium plus D 600/200, 1 per GT twice a day. 6. Amlodipine 10 mg per GT daily-on hold, held this hospitalization. 7. Aspirin 81 mg per GT daily. 8. Gabapentin 300 mg per GT twice a day.
GT|gastrostomy tube|GT|141|142|DISCHARGE MEDICATIONS|3. Naprosyn 250 mg per GT daily. 4. Lasix 20 mg per GT twice a day. 5. Calcium plus D 600/200, 1 per GT twice a day. 6. Amlodipine 10 mg per GT daily-on hold, held this hospitalization. 7. Aspirin 81 mg per GT daily. 8. Gabapentin 300 mg per GT twice a day. 9. Lactobacillus 1 capsule per GT twice a day in 30 mL of water.
GT|gastrostomy tube|GT|125|126|DISCHARGE MEDICATIONS|6. Amlodipine 10 mg per GT daily-on hold, held this hospitalization. 7. Aspirin 81 mg per GT daily. 8. Gabapentin 300 mg per GT twice a day. 9. Lactobacillus 1 capsule per GT twice a day in 30 mL of water. 10. Losartan 50 mg per GT daily-during this hospitalization was decreased from 75 mg.
GT|gastrostomy tube|GT|172|173|DISCHARGE MEDICATIONS|6. Amlodipine 10 mg per GT daily-on hold, held this hospitalization. 7. Aspirin 81 mg per GT daily. 8. Gabapentin 300 mg per GT twice a day. 9. Lactobacillus 1 capsule per GT twice a day in 30 mL of water. 10. Losartan 50 mg per GT daily-during this hospitalization was decreased from 75 mg.
GT|gastrostomy tube|GT|160|161|DISCHARGE MEDICATIONS|7. Aspirin 81 mg per GT daily. 8. Gabapentin 300 mg per GT twice a day. 9. Lactobacillus 1 capsule per GT twice a day in 30 mL of water. 10. Losartan 50 mg per GT daily-during this hospitalization was decreased from 75 mg. 11. Metoprolol 75 mg per GT twice a day. 12. Miconazole powder 2% inner thigh twice a day. 13. Prevacid 30 mg per GT daily.
GT|gastrostomy tube|GT|145|146|PAST MEDICAL HISTORY|6. Congestive heart failure. 7. History of Guillain-Barre syndrome. 8. History of urinary tract infection due to candida albicans. 9. History of GT replacement on _%#MMDD2005#%_. 10. History of recurrent C. difficile colitis. 11. Oral thrush. 12. History of decubitus ulcer at coccyx.
GT|gastrostomy tube|GT|246|247|CODE STATUS|Dr. _%#NAME#%_ performed surgery without complications. _%#NAME#%_ remained intubated for a total of 3 days following surgery. His feeds were restarted on _%#MMDD2005#%_ and he tolerated this well. There was a small amount of drainage around his GT site at discharge. His mother was trained and capable of his GT cares and feedings on discharge. _%#NAME#%_ also had a circumcision done on _%#MMDD2005#%_ without complications.
GT|gastrostomy tube|GT|183|184|CODE STATUS|His feeds were restarted on _%#MMDD2005#%_ and he tolerated this well. There was a small amount of drainage around his GT site at discharge. His mother was trained and capable of his GT cares and feedings on discharge. _%#NAME#%_ also had a circumcision done on _%#MMDD2005#%_ without complications.
GT|gastrostomy tube|GT.|141|143|* FEN|Ongoing problems and suggested management: * FEN: _%#NAME#%_ was discharged on Enfacare 24 kcal/oz formula, taking 60 ml every 3 hours PO or GT. * RESPIRATORY DISTRESS SYNDROME: Continue Diuril and Aldactone. No need for home oxygen. * RETINOPATHY OF PREMATURITY: Patient is to follow-up with Ophthalmology in 2 weeks.
GT|gastrostomy tube|GT|345|346|* IMMUNIZATIONS|* SURGERY: He should follow-up wit h Dr. _%#NAME#%_ in Pediatric Surgery in two to three weeks. * IMMUNIZATIONS: _%#NAME#%_ should receive monthly Synagis injections during RSV season. Discharge medications, treatments and special equipment: * Diuril 60 mg GT Q 12 hours * Aldactone 6 mg GT Q 12 hours * NaCl 7 mEq GT Q 6 hours * Ursodiol 30 mg GT BID * Amoxicillin 75 mg GT Daily * Tylenol 40 mg PO Q6 hours PRN fever or discomfort Discharge measurements and exam: Weight 2950 gm, length 43 cm, OFC 34 cm.
GT|gastrostomy tube|GT|205|206|HOSPITAL COURSE|_%#NAME#%_ did have some trouble with his history of gastroparesis during his stay. He was restarted on Reglan. Ultimately, the only thing that relieved _%#NAME#%_'s symptoms of nausea was leaving his his GT open and to drain secondary to his poor mobility. His symptoms resolved after leaving his G-tube open. _%#NAME#%_ is still allowed to have p.o. intake but what he takes in essentially drains out of his G-tube.
GT|glutamyl transpeptidase|GT|213|214|LABS|LABS: White cell count is 6.9, hemoglobin is 12.6. Platelets are 68, MCV is 109, sodium is 132, potassium is 3, chloride is 87, bicarbonate is 39, BUN is 52, creatinine is 1.71, glucose is 155. INR is 2.48, gamma GT 64, alkaline phosphatase 160, ALT 157, AST 326, total bilirubin is 4.2. Ammonia is 494. On _%#MMDD2005#%_ creatinine was 0.71. Alkaline phosphatase was 141, ALT was 91, AST 187 and total bilirubin was 5.6. Peritoneal fluid, gram stain and culture on _%#MMDD2005#%_ was negative.
GT|gastrostomy tube|GT|344|345|* FEN|Further care will be determined at this visit. * Electrolyte supplementation: _%#NAME#%_'s electrolytes should be checked at first office visit and adjusted accordingly Discharge medications, treatments and special equipment: * Oxygen 1/8 LPM as needed to keep oxygen saturations >92%. * KCl 6 mEq NG q12h * NaCl 4.5 mEq GT q12h * Diuril 55 mg GT q12h. Discharge measurements and exam: Weight 3090 gm, length 49 cm, OFC 35 cm.
GT|gastrostomy tube|GT|117|118|DISCHARGE MEDICATIONS|17. Vicodin one to two tablets p.o. q6h p.r.n. 18. Ambien 10 mg p.o. q6h p.r.n. DISCHARGE MEDICATIONS: 1. Aspirin 81 GT q.d. 2. Fluvastatin 20 mg GT q.d. 3. Folate 1 mg g.t. q.d. 4. Lantis 75 U subcu b.i.d. 5. Protonix 40 mg g.t. b.i.d. 6. Paxil 20 mg GT q.d.
GT|gastrostomy tube|GT|146|147|DISCHARGE MEDICATIONS|17. Vicodin one to two tablets p.o. q6h p.r.n. 18. Ambien 10 mg p.o. q6h p.r.n. DISCHARGE MEDICATIONS: 1. Aspirin 81 GT q.d. 2. Fluvastatin 20 mg GT q.d. 3. Folate 1 mg g.t. q.d. 4. Lantis 75 U subcu b.i.d. 5. Protonix 40 mg g.t. b.i.d. 6. Paxil 20 mg GT q.d.
GT|gastrostomy tube|GT|149|150|DISCHARGE MEDICATIONS|1. Aspirin 81 GT q.d. 2. Fluvastatin 20 mg GT q.d. 3. Folate 1 mg g.t. q.d. 4. Lantis 75 U subcu b.i.d. 5. Protonix 40 mg g.t. b.i.d. 6. Paxil 20 mg GT q.d. 7. Midrin 5 mg g.t. b.i.d. being tapered down. 8. Lopressor 25 mg g.t. b.i.d. 9. Ativan 0.5 mg g.t. b.i.d. 10. Albuterol two puffs q4h p.r.n.
GT|gastrostomy tube|GT|154|155|FOLLOW-UP|Mild right atrial and right ventricular enlargement were noted, with normal left atrial and ventricular size and function. He remains on Captopril 0.2 mg GT q8h at discharge. _%#NAME#%_ may need SBE prophylaxis for any further surgical interventions. Problem #4: Hypotension. In order to maintain his systemic blood pressure and improve peripheral perfusion during the first few days of life, _%#NAME#%_ required treatment with dopamine and dobutamine drips.
GT|gastrostomy tube|GT|218|219|* FEN|The G-tube is being clamped between feeds. A 3 hour feeding schedule is recommended for at least 3-4 weeks at the discretion of his outpatient pediatrician. He remains on diuretics, and should continue with 1.5mEq KCl GT q12h and 9mEq NaCl GT q6h. * Bronchopulmonary Dysplasia: _%#NAME#%_ requires _%#MMDD2002#%_, and we have made arrangements for him to receive this at home.
GT|gastrostomy tube|GT|576|577|* BUN (11/22)|* Anemia: _%#NAME#%_ is being discharged on Ferrous Sulfate * Constipation: _%#NAME#%_ was discharged on pear juice And glycerin suppositories prn. Recent Labs: * Sodium (_%#MMDD#%_): 142 * Potassium (_%#MMDD#%_): 5.1 * Chloride (_%#MMDD#%_): 105 * BUN (_%#MMDD#%_): 22 * Glc (_%#MMDD#%_): 90 * Ca (_%#MMDD#%_): 9.5 * Mg (_%#MMDD#%_): 2.4 * Phos (_%#MMDD#%_): 4.7 * TSH: (_%#MMDD#%_)3.20 * Free Thyroxine (_%#MMDD#%_): 1.51 * Hg (_%#MMDD#%_): 12.3 * Platelets (_%#MMDD#%_): 343 * Prealbumin (_%#MMDD#%_): 8 Discharge medications, treatments and special equipment: * Captopril GT 0.2mg q8h * Diuril 40mg GT bid * Spironolactone 4mg GT bid * Potassium Chloride 1.5mEq GT q12h * Sodium Chloride 9 mEq GT q6h * Levothyroxine 12.5mcg GT every other day, 25mcg GT every other day * Acetaminophen 40mg GT q6h prn pain * Glycerin 0.5 PR prn constipation * Ferrous Sulfate 10mg GT qDay * Amoxicillin 125mg GT qDay * Fluticasone 110 micrograms inhaled bid * Atrovent HFA 2puffs inhaled q4h prn respiratory distress Transfer measurements and exam: Weight 4190g (<3%), Length 49.5 (<3%), OFC 36 cm (<3%).
GT|gastrostomy tube|GT|603|604|* BUN (11/22)|* Anemia: _%#NAME#%_ is being discharged on Ferrous Sulfate * Constipation: _%#NAME#%_ was discharged on pear juice And glycerin suppositories prn. Recent Labs: * Sodium (_%#MMDD#%_): 142 * Potassium (_%#MMDD#%_): 5.1 * Chloride (_%#MMDD#%_): 105 * BUN (_%#MMDD#%_): 22 * Glc (_%#MMDD#%_): 90 * Ca (_%#MMDD#%_): 9.5 * Mg (_%#MMDD#%_): 2.4 * Phos (_%#MMDD#%_): 4.7 * TSH: (_%#MMDD#%_)3.20 * Free Thyroxine (_%#MMDD#%_): 1.51 * Hg (_%#MMDD#%_): 12.3 * Platelets (_%#MMDD#%_): 343 * Prealbumin (_%#MMDD#%_): 8 Discharge medications, treatments and special equipment: * Captopril GT 0.2mg q8h * Diuril 40mg GT bid * Spironolactone 4mg GT bid * Potassium Chloride 1.5mEq GT q12h * Sodium Chloride 9 mEq GT q6h * Levothyroxine 12.5mcg GT every other day, 25mcg GT every other day * Acetaminophen 40mg GT q6h prn pain * Glycerin 0.5 PR prn constipation * Ferrous Sulfate 10mg GT qDay * Amoxicillin 125mg GT qDay * Fluticasone 110 micrograms inhaled bid * Atrovent HFA 2puffs inhaled q4h prn respiratory distress Transfer measurements and exam: Weight 4190g (<3%), Length 49.5 (<3%), OFC 36 cm (<3%).
GT|gastrostomy tube|GT|631|632|* BUN (11/22)|* Anemia: _%#NAME#%_ is being discharged on Ferrous Sulfate * Constipation: _%#NAME#%_ was discharged on pear juice And glycerin suppositories prn. Recent Labs: * Sodium (_%#MMDD#%_): 142 * Potassium (_%#MMDD#%_): 5.1 * Chloride (_%#MMDD#%_): 105 * BUN (_%#MMDD#%_): 22 * Glc (_%#MMDD#%_): 90 * Ca (_%#MMDD#%_): 9.5 * Mg (_%#MMDD#%_): 2.4 * Phos (_%#MMDD#%_): 4.7 * TSH: (_%#MMDD#%_)3.20 * Free Thyroxine (_%#MMDD#%_): 1.51 * Hg (_%#MMDD#%_): 12.3 * Platelets (_%#MMDD#%_): 343 * Prealbumin (_%#MMDD#%_): 8 Discharge medications, treatments and special equipment: * Captopril GT 0.2mg q8h * Diuril 40mg GT bid * Spironolactone 4mg GT bid * Potassium Chloride 1.5mEq GT q12h * Sodium Chloride 9 mEq GT q6h * Levothyroxine 12.5mcg GT every other day, 25mcg GT every other day * Acetaminophen 40mg GT q6h prn pain * Glycerin 0.5 PR prn constipation * Ferrous Sulfate 10mg GT qDay * Amoxicillin 125mg GT qDay * Fluticasone 110 micrograms inhaled bid * Atrovent HFA 2puffs inhaled q4h prn respiratory distress Transfer measurements and exam: Weight 4190g (<3%), Length 49.5 (<3%), OFC 36 cm (<3%).
GT|gastrostomy tube|GT|698|699|* BUN (11/22)|* Anemia: _%#NAME#%_ is being discharged on Ferrous Sulfate * Constipation: _%#NAME#%_ was discharged on pear juice And glycerin suppositories prn. Recent Labs: * Sodium (_%#MMDD#%_): 142 * Potassium (_%#MMDD#%_): 5.1 * Chloride (_%#MMDD#%_): 105 * BUN (_%#MMDD#%_): 22 * Glc (_%#MMDD#%_): 90 * Ca (_%#MMDD#%_): 9.5 * Mg (_%#MMDD#%_): 2.4 * Phos (_%#MMDD#%_): 4.7 * TSH: (_%#MMDD#%_)3.20 * Free Thyroxine (_%#MMDD#%_): 1.51 * Hg (_%#MMDD#%_): 12.3 * Platelets (_%#MMDD#%_): 343 * Prealbumin (_%#MMDD#%_): 8 Discharge medications, treatments and special equipment: * Captopril GT 0.2mg q8h * Diuril 40mg GT bid * Spironolactone 4mg GT bid * Potassium Chloride 1.5mEq GT q12h * Sodium Chloride 9 mEq GT q6h * Levothyroxine 12.5mcg GT every other day, 25mcg GT every other day * Acetaminophen 40mg GT q6h prn pain * Glycerin 0.5 PR prn constipation * Ferrous Sulfate 10mg GT qDay * Amoxicillin 125mg GT qDay * Fluticasone 110 micrograms inhaled bid * Atrovent HFA 2puffs inhaled q4h prn respiratory distress Transfer measurements and exam: Weight 4190g (<3%), Length 49.5 (<3%), OFC 36 cm (<3%).
GT|gastrostomy tube|GT|795|796|* BUN (11/22)|* Anemia: _%#NAME#%_ is being discharged on Ferrous Sulfate * Constipation: _%#NAME#%_ was discharged on pear juice And glycerin suppositories prn. Recent Labs: * Sodium (_%#MMDD#%_): 142 * Potassium (_%#MMDD#%_): 5.1 * Chloride (_%#MMDD#%_): 105 * BUN (_%#MMDD#%_): 22 * Glc (_%#MMDD#%_): 90 * Ca (_%#MMDD#%_): 9.5 * Mg (_%#MMDD#%_): 2.4 * Phos (_%#MMDD#%_): 4.7 * TSH: (_%#MMDD#%_)3.20 * Free Thyroxine (_%#MMDD#%_): 1.51 * Hg (_%#MMDD#%_): 12.3 * Platelets (_%#MMDD#%_): 343 * Prealbumin (_%#MMDD#%_): 8 Discharge medications, treatments and special equipment: * Captopril GT 0.2mg q8h * Diuril 40mg GT bid * Spironolactone 4mg GT bid * Potassium Chloride 1.5mEq GT q12h * Sodium Chloride 9 mEq GT q6h * Levothyroxine 12.5mcg GT every other day, 25mcg GT every other day * Acetaminophen 40mg GT q6h prn pain * Glycerin 0.5 PR prn constipation * Ferrous Sulfate 10mg GT qDay * Amoxicillin 125mg GT qDay * Fluticasone 110 micrograms inhaled bid * Atrovent HFA 2puffs inhaled q4h prn respiratory distress Transfer measurements and exam: Weight 4190g (<3%), Length 49.5 (<3%), OFC 36 cm (<3%).
GT|gastrostomy tube|GT|869|870|* BUN (11/22)|* Anemia: _%#NAME#%_ is being discharged on Ferrous Sulfate * Constipation: _%#NAME#%_ was discharged on pear juice And glycerin suppositories prn. Recent Labs: * Sodium (_%#MMDD#%_): 142 * Potassium (_%#MMDD#%_): 5.1 * Chloride (_%#MMDD#%_): 105 * BUN (_%#MMDD#%_): 22 * Glc (_%#MMDD#%_): 90 * Ca (_%#MMDD#%_): 9.5 * Mg (_%#MMDD#%_): 2.4 * Phos (_%#MMDD#%_): 4.7 * TSH: (_%#MMDD#%_)3.20 * Free Thyroxine (_%#MMDD#%_): 1.51 * Hg (_%#MMDD#%_): 12.3 * Platelets (_%#MMDD#%_): 343 * Prealbumin (_%#MMDD#%_): 8 Discharge medications, treatments and special equipment: * Captopril GT 0.2mg q8h * Diuril 40mg GT bid * Spironolactone 4mg GT bid * Potassium Chloride 1.5mEq GT q12h * Sodium Chloride 9 mEq GT q6h * Levothyroxine 12.5mcg GT every other day, 25mcg GT every other day * Acetaminophen 40mg GT q6h prn pain * Glycerin 0.5 PR prn constipation * Ferrous Sulfate 10mg GT qDay * Amoxicillin 125mg GT qDay * Fluticasone 110 micrograms inhaled bid * Atrovent HFA 2puffs inhaled q4h prn respiratory distress Transfer measurements and exam: Weight 4190g (<3%), Length 49.5 (<3%), OFC 36 cm (<3%).
GT|gastrostomy tube|GT|897|898|* BUN (11/22)|* Anemia: _%#NAME#%_ is being discharged on Ferrous Sulfate * Constipation: _%#NAME#%_ was discharged on pear juice And glycerin suppositories prn. Recent Labs: * Sodium (_%#MMDD#%_): 142 * Potassium (_%#MMDD#%_): 5.1 * Chloride (_%#MMDD#%_): 105 * BUN (_%#MMDD#%_): 22 * Glc (_%#MMDD#%_): 90 * Ca (_%#MMDD#%_): 9.5 * Mg (_%#MMDD#%_): 2.4 * Phos (_%#MMDD#%_): 4.7 * TSH: (_%#MMDD#%_)3.20 * Free Thyroxine (_%#MMDD#%_): 1.51 * Hg (_%#MMDD#%_): 12.3 * Platelets (_%#MMDD#%_): 343 * Prealbumin (_%#MMDD#%_): 8 Discharge medications, treatments and special equipment: * Captopril GT 0.2mg q8h * Diuril 40mg GT bid * Spironolactone 4mg GT bid * Potassium Chloride 1.5mEq GT q12h * Sodium Chloride 9 mEq GT q6h * Levothyroxine 12.5mcg GT every other day, 25mcg GT every other day * Acetaminophen 40mg GT q6h prn pain * Glycerin 0.5 PR prn constipation * Ferrous Sulfate 10mg GT qDay * Amoxicillin 125mg GT qDay * Fluticasone 110 micrograms inhaled bid * Atrovent HFA 2puffs inhaled q4h prn respiratory distress Transfer measurements and exam: Weight 4190g (<3%), Length 49.5 (<3%), OFC 36 cm (<3%).
GT|gastrostomy tube|(GT).|145|149|* FEN|_%#NAME#%_ underwent a Nissen fundoplication and gastrostomy tube placement _%#MMDD2003#%_ and was started on feeds through her gastrostomy tube (GT). She tolerated GT feeds well. An attempt was made to allow _%#NAME#%_ to bottle feed as much as she could. Her formula was changed to Enfacare 26 kcal/oz. She was allowed to bottle ad lib demand, with 24-hour minimum feeds of 350cc or110cc/kg/day and a maximum of 420cc or 131cc/kg/day.
GT|gastrostomy tube|GT|172|173|* FEN|A Nissen fundoplication and gastrostomy tube placement were performed by Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2003#%_. Feeds were initiated on POD 2. On _%#MMDD2003#%_, her GT site was erythematous with purulent drainage. A GT site culture was sent and was positive for Staph Aureus and E.Coli. See ID.
GT|gastrostomy tube|GT|105|106|* FEN|Feeds were initiated on POD 2. On _%#MMDD2003#%_, her GT site was erythematous with purulent drainage. A GT site culture was sent and was positive for Staph Aureus and E.Coli. See ID. Her GT site is clean, without erythema since starting antibiotics.
GT|gastrostomy tube|GT|135|136|3. ID|_%#NAME#%_ has been stooling and voiding normally. 3. ID: On _%#MMDD2003#%_ _%#NAME#%_ had a temperature of 100.7 with an erythematous GT site. Both wound cultures and blood cultures were sent, and Cefotaxime and Augmentin started. Cefotaxime and Augmentin were discontinued on _%#MMDD#%_ and Vancomycin started for further coverage.
GT|gastrostomy tube|GT|209|210|3. ID|A follow-up is recommended in 6 months. Ongoing problems and suggested management: 1. Fluids, electrolytes and nutrition: _%#NAME#%_ is unable to meet her minimum caloric needs by bottling alone. She requires GT supplemental feeds, and periodic electrolyte checks. 2. Gastrointestinal: _%#NAME#%_ will require routine G-tube cares 3. Cardiovascular: _%#NAME#%_ will be followed closely by Dr. _%#NAME#%_ _%#NAME#%_ of pediatric cardiology at FUMC.
GT|gastrostomy tube|GT|248|249|* FEN|Ongoing problems and suggested management: * FEN: _%#NAME#%_ was discharged on Enfamil 20 calorie with Iron formula, taking 165 ml every 12 hours approximately 18 ounces a day. Discharge medications, treatments and special equipment: * Zantac 6 mg GT every 12 hours. * Gastric tube supplies Discharge measurements and exam: Weight 3302 gm, length 50.5 cm, OFC 36.5 cm.
GT|gastrostomy tube|GT|235|236|* FEN|Feedings were started on _%#MMDD2005#%_, and he tolerated the increase in volume and strength of breast milk. He was subsequently switched to breastmilk fortified with Enfacare 24kcalories/ounce. At the time of discharge, he was being GT fed his feedings of Breast milk , 100 mL every 3 hours. His weight at the time of discharge was 4606 gm with a head circumference of 36.5 cm and length of 55.5 cm.
GT|gastrostomy tube|GT|215|216|* FEN|Physical exam was normal except for light facial and perianal pinpoint rash noted after unasyn dose post-op, and decreased tone secondary to Down Syndrome. GT site is slightly reddened with serous drainage. Mic-key GT button is 14 Fr, 1.5cm tube. Follow-up appointments: The parents were asked to make an appointment for _%#NAME#%_ to see you within one week.
GT|gastrostomy tube|GT|126|127|HISTORY OF PRESENT ILLNESS|The patient recently was discharged from F-UMC six days ago and was admitted for pneumatosis coli. The patient gets feeds via GT and is only at half-strength right now secondary to volume intolerance. The patient has vomited intermittently when volumes are increased. Calories are also not adequate for the patient to grow and gain weight.
GT|gastrostomy tube|GT|147|148|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Pulmicort 0.5 mg nebulizer q.h.s. 2. Bactrim 20 mg p.o. or GT b.i.d. 3. Mycelex 10 mg p.o. q.i.d . 4. ___ 140 mg p.o. or GT daily. 5. Epogen 750 units IV q. Monday and Thursday. 6. Aspirin 41 mg p.o. or GT daily. 7. Ampicillin 500 mg IV q.6h x 4 days to be discontinued after dose on _%#MMDD#%_.
GT|gastrostomy tube|GT|155|156|DISCHARGE MEDICATIONS|6. Aspirin 41 mg p.o. or GT daily. 7. Ampicillin 500 mg IV q.6h x 4 days to be discontinued after dose on _%#MMDD#%_. 8. CellCept 200 mg/ml 625 mg p.o. or GT q.i.d. 9. Neoral 40 mg p.o. or GT q.a.m. 10. Neoral 35 mg p.o. or GT q.p.m. 11. Triamcinolone topical ointment t.i.d., a small amount to creat a thin film around the GT site.
GT|gastrostomy tube|GT|106|107|DISCHARGE MEDICATIONS|8. CellCept 200 mg/ml 625 mg p.o. or GT q.i.d. 9. Neoral 40 mg p.o. or GT q.a.m. 10. Neoral 35 mg p.o. or GT q.p.m. 11. Triamcinolone topical ointment t.i.d., a small amount to creat a thin film around the GT site. 12. Prednisolone 7.5 mg p.o. or GT daily. 13. Gentamicin 12 mg IV q.12h. x 4 days after discharge, to be discontinued after _%#MMDD#%_ dose.
GT|gastrostomy tube|GT|159|160|DISCHARGE MEDICATIONS|9. Neoral 40 mg p.o. or GT q.a.m. 10. Neoral 35 mg p.o. or GT q.p.m. 11. Triamcinolone topical ointment t.i.d., a small amount to creat a thin film around the GT site. 12. Prednisolone 7.5 mg p.o. or GT daily. 13. Gentamicin 12 mg IV q.12h. x 4 days after discharge, to be discontinued after _%#MMDD#%_ dose.
GT|gastrostomy tube|GT|131|132|DISCHARGE MEDICATIONS|11. Triamcinolone topical ointment t.i.d., a small amount to creat a thin film around the GT site. 12. Prednisolone 7.5 mg p.o. or GT daily. 13. Gentamicin 12 mg IV q.12h. x 4 days after discharge, to be discontinued after _%#MMDD#%_ dose. 14. Lasix 10 mg through GT or p.o. b.i.d.
GT|gastrostomy tube|GT|165|166|DISCHARGE MEDICATIONS|12. Prednisolone 7.5 mg p.o. or GT daily. 13. Gentamicin 12 mg IV q.12h. x 4 days after discharge, to be discontinued after _%#MMDD#%_ dose. 14. Lasix 10 mg through GT or p.o. b.i.d. 15. Protonix 10 mg p.o. GT b.i.d. DISCHARGE INSTRUCTIONS: 1. Diet: Gluten-free diet.
GT|gastrostomy tube|GT|207|208|DISCHARGE MEDICATIONS|12. Prednisolone 7.5 mg p.o. or GT daily. 13. Gentamicin 12 mg IV q.12h. x 4 days after discharge, to be discontinued after _%#MMDD#%_ dose. 14. Lasix 10 mg through GT or p.o. b.i.d. 15. Protonix 10 mg p.o. GT b.i.d. DISCHARGE INSTRUCTIONS: 1. Diet: Gluten-free diet.
GT|gastrostomy tube|GT|134|135|DISCHARGE MEDICATIONS|6. Albuterol 2.5 mg nebulized q.i.d. 7. Cromolyn 20 mg nebulized q.i.d. 8. Mucomyst 10% 2 mL nebulized q.i.d. 9. Cipro 150 mg p.o. or GT b.i.d. 10. Bactrim suspension 50 mg p.o. or GT b.i.d. 11. TOBI neb 300 mg nebulized b.i.d. 12. Lactobacillus GG one capsule p.o. or GT b.i.d.
GT|gastrostomy tube|GT|125|126|DISCHARGE MEDICATIONS|10. Bactrim suspension 50 mg p.o. or GT b.i.d. 11. TOBI neb 300 mg nebulized b.i.d. 12. Lactobacillus GG one capsule p.o. or GT b.i.d. DISCHARGE INSTRUCTIONS: 1. Follow up with Pulmonary Clinic in one to two weeks.
GT|gastrostomy tube|GT|124|125|DISCHARGE INSTRUCTIONS|1. Follow up with Pulmonary Clinic in one to two weeks. 2. BDs four times daily. 3. To give the Pancrecarb MS 4 capsules by GT may suspend two capsules in 10 mL Peptamen Jr and 10 mL appl e juice. 4. GT feeds with Peptamen Jr at 42 mL/hr times 12 hours over night.
GT|gastrostomy tube|GT|144|145|DISCHARGE INSTRUCTIONS|2. BDs four times daily. 3. To give the Pancrecarb MS 4 capsules by GT may suspend two capsules in 10 mL Peptamen Jr and 10 mL appl e juice. 4. GT feeds with Peptamen Jr at 42 mL/hr times 12 hours over night. 5. Return for temperature greater than 101 or worsening symptoms.
GT|glutamyl transpeptidase|GT|134|135|CHIEF COMPLAINT|The following day routine laboratory studies demonstrated ALT of 27.43, ammonia 67, and the following day ALT rose to 6000 with gamma GT 99, and slight increase in total bilirubin. The picture of resolving hepatocellular injury led to the maternal demand of transfer to Fairview-University Medical Center.
GT|guttae:GGT|GT|275|276|BRIEF HOSPITAL COURSE|4. Atrial fibrillation. As mentioned in the H and P, the patient's hospital course at the outside hospital was complicated by multiple episodes of paroxysmal atrial fibrillation. All of these episodes were responded to cardioversion and the patient was started on amiodarone GT T. During the initial hospitalization at UMMC, his hospital course was complicated by an episode of atrial fibrillation which was successfully cardioverted.
GT|gastrostomy tube|GT|195|196|HISTORY OF PRESENT ILLNESS|In addition, he receives Neurontin. His Pain Consultation note from today recommends continuing has Dilaudid PCA at the current setting. They also recommend changing his gabapentin to 800 mg per GT tube q.8h and also to use lidocaine 5% gel around the neck tube site t.i.d. p.r.n. The patient probably had an episode of autonomic dysreflexia.
GT|gastrostomy tube|GT|153|154|MEDICATIONS|11. Pantoprazole 40 mg feeding tube b.i.d. 12. Prednisone 20 mg p.o. q. day. 13. Risperidone 1 mg p.o. q.h.s. and 0.5 mg p.o. q.a.m. 14. Tacrolimus 3 mg GT b.i.d. 15. Tube feeds. 16. Combivent four to six puffs inhaled q.2h p.r.n. ALLERGIES: 1. NSAID. 2. Aspirin. 3. Nitrofurantoin. 4. Flagyl. 5. Codeine.
GT|glutamyl transpeptidase|GT|124|125|PLAN|4. For elevated liver function tests check hepatitis B and hepatitis C, HIV as the patient had blood last year. Check gamma GT for alcoholic liver disease and check a right upper quadrant ultrasound scan as well. Screening ferritin level as well as ceruloplasmin and iron studies as well as serum protein electrophoresis and ANA.
IA|intraarterial|IA|209|210|HISTORY OF PRESENT ILLNESS|ADMISSION DIAGNOSIS: Glioblastoma multiforme. DISCHARGE DIAGNOSIS: Glioblastoma multiforme. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 53-year-old man with GBM who presents for his 8th cycle of IV IA chemotherapy. HOSPITAL COURSE: The patient was admitted to the hospital on _%#MMDD2006#%_ and discharged on _%#MMDD2006#%_.
IA|intraarterial|IA|182|183|PROCEDURE PERFORMED|ADMISSION DIAGNOSIS: Pineal malignant glial neoplasm. DISCHARGE DIAGNOSIS: Pineal malignant glial neoplasm. PROCEDURE PERFORMED: Intra-arterial chemotherapy, this is cycle #5 for IV IA chemotherapy. HOSPITAL COURSE: Uneventful. On _%#MMDD2006#%_ she had a left vertebral artery injection for her chemotherapy.
IA|intraarterial|IA|278|279|DISCHARGE DIAGNOSIS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 36-year-old gentleman with a history of left frontal anaplastic oligodendroglioma, had a resection in 1997, and underwent another resection in _%#MM#%_ 2003. He underwent brain radiation in _%#MM#%_ 2004. The patient presents for IA chemotherapy. HOSPITAL COURSE: The patient was admitted and underwent cycle #9 of left internal carotid artery 800 mg of carboplatin.
IA|(stage) IA|IA|125|126|DISCHARGE DIAGNOSES|ADMIT DIAGNOSES: 1. Postmenopausal bleeding. 2. Grade 1 endometrial cancer. 3. Morbid obesity. DISCHARGE DIAGNOSES: 1. Stage IA endometrial adenocarcinoma, grade 1/3. 2. Postmenopausal bleeding. 3. Morbid obesity. PROCEDURE PERFORMED: 1. Examined under anesthesia.
IA|intraarterial|IA|41|42|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: GBM and status post IA and IV chemotherapy, pneumonia, and urinary tract infection. CHIEF COMPLAINT: Fever, urinary tract infection, pneumonia, and neutropenic thrombocytopenia.
IA|intraarterial|IA|182|183|DISCHARGE DIAGNOSIS|The patient received radiation treatment and blood- brain disruption chemotherapy. The patient is status post left occipital VP shunt in _%#MM#%_ 2004. The patient is now undergoing IA and IV chemotherapy and Cytoxan, etoposide, and carboplatin treatment. Most recently, the patient had a dose on _%#MM#%_ _%#DD#%_, 2005. The patient's mother reports that since that treatment, she has been less interactive with family, especially since the past 4 days prior to admission.
IA|intraarterial|IA|215|216|DISCHARGE DIAGNOSIS|Head CT was unchanged from _%#MM#%_ _%#DD#%_, 2005. Chest x-ray showed left lower lobe infiltrates. HOSPITAL COURSE: Assessment: A 54-year-old woman with GBM status post resection and radiation treatment and recent IA and IV chemotherapy was made. The patient was noted to have a urinary tract infection and pneumonia. The patient was started on antibiotics and was transfused for the hemoglobin of 8.9. The patient improved somewhat, feeling better, and the patient neurologically remained alert with a fluent speech.
IA|intraarterial|IA|41|42|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: GBM and status post IA and IV chemotherapy, pneumonia, and urinary tract infection. Suspect Gram- negative. CHIEF COMPLAINT: Fever, urinary tract infection, pneumonia.
IA|intraarterial|IA|182|183|HISTORY OF PRESENT ILLNESS|The patient received radiation treatment and blood- brain disruption chemotherapy. The patient is status post left occipital VP shunt in _%#MM#%_ 2004. The patient is now undergoing IA and IV chemotherapy and Cytoxan, etoposide, and carboplatin treatment. Most recently, the patient had a dose on _%#MM#%_ _%#DD#%_, 2005. The patient's mother reports that since that treatment, she has been less interactive with family, especially since the past 4 days prior to admission.
IA|intraarterial|IA|215|216|HOSPITAL COURSE|Head CT was unchanged from _%#MM#%_ _%#DD#%_, 2005. Chest x-ray showed left lower lobe infiltrates. HOSPITAL COURSE: Assessment: A 54-year-old woman with GBM status post resection and radiation treatment and recent IA and IV chemotherapy was made. The patient was noted to have a urinary tract infection and pneumonia. The patient was started on antibiotics and was transfused for the hemoglobin of 8.9. The patient improved somewhat, feeling better, and the patient neurologically remained alert with a fluent speech.
IA|intraarterial|IA|162|163|ADMISSION DIAGNOSIS|OPERATIONS/PROCEDURES PERFORMED: On _%#MM#%_ _%#DD#%_, 2005, and _%#MM#%_ _%#DD#%_, 2005, intravenous and intraaortic chemotherapy. IV Cytoxan and etoposide, and IA carboplatin. On _%#MM#%_ _%#DD#%_, 2005, he had a Port-A- Cath system placed. HISTORY OF PRESENT ILLNESS: This is a 51-year-old right handed male with a history of a left temporal lobe lobectomy on _%#MM#%_ _%#DD#%_, 2004, with Dr. _%#NAME#%_, and he is also status post chemo and radiation.
IA|intraarterial|IA|149|150|FOLLOW UP|5. Ativan 1 mg p.o. at bedtime. 6. Dilantin 300 mg p.o. b.i.d. 7. Decadron taper. FOLLOW UP: He will follow up next month with round 2 of his IV and IA chemotherapy program with Dr. _%#NAME#%_. He will have a CT the week of _%#MM#%_ _%#DD#%_, 2005, and he will be readmitted Monday, _%#MM#%_ _%#DD#%_, 2005, at 2:00 p.m. for his next treatment session.
IA|(stage) IA|IA,|100|102|DISCHARGE DIAGNOSES|1. Grade 1 endometrial carcinoma. 2. Hypertension. 3. Hypothyroidism. DISCHARGE DIAGNOSES: 1. Stage IA, grade 1, endometrial adenocarcinoma of the uterus. 2. Hypertension. 3. Hypothyroidism. OPERATIONS/PROCEDURES PERFORMED: Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo- oophorectomy, pelvic and periaortic lymph node dissection, peritoneal washings, IV fluid hydration, PCA narcotics, IV narcotics.
IA|(stage) IA|IA,|167|169|3. FEN|1. Disease: The patient's initial biopsy noted a grade I endometrial carcinoma. Her final pathology at time of discharge was as follows. She was noted to have a stage IA, grade 1 endometrioid adenocarcinoma of the endometrium. Of note, absent was myometrial invasion, absent angiolymphatic invasion, absent cervical involvement, absent serosal and parametrial involvement, absent adnexal or vaginal involvement.
IA|intraarterial|IA|256|257|HISTORY OF PRESENT ILLNESS|Subsequently, the patient developed another drop metastasis to the L2 region which was radiated, along with drop metastasis to the sacral region. The patient was then found to have signs of progressive disease, and a decision was made to treat him with IV IA chemotherapy using a platinum-based agent. The patient is admitted now, on _%#MMDD2005#%_, for his 6th cycle of IV IA chemotherapy. HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted to the University of Minnesota Medical Center, Fairview, to the Neurosurgery Service on _%#MMDD2005#%_.
IA|intraarterial|IA|228|229|HISTORY OF PRESENT ILLNESS|The patient was then found to have signs of progressive disease, and a decision was made to treat him with IV IA chemotherapy using a platinum-based agent. The patient is admitted now, on _%#MMDD2005#%_, for his 6th cycle of IV IA chemotherapy. HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted to the University of Minnesota Medical Center, Fairview, to the Neurosurgery Service on _%#MMDD2005#%_.
IA|intraarterial|IA|340|341|DISCHARGE INSTRUCTIONS|Vital signs are stable. His exam is unchanged from his previous admission with mild right-sided deficits which are not fully documented. DISCHARGE INSTRUCTIONS: Discharge instructions include his regular diet, and he will be rescheduled for admission on Thursday _%#MM#%_ _%#DD#%_, 2006, with an MRI at 1 p.m. and then admission for IV and IA chemotherapy to continue.
IA|(stage) IA|IA|198|199|SUMMARY|He has an excellent pulmonary function test. In _%#MM#%_ of 2001 he underwent coronary artery bypass surgery with a left internal mammary graft and a saphenous vein graft. Clinically this was stage IA lung cancer and left thoracotomy with resection was indicated. On _%#MMDD2002#%_ patient underwent left thoracotomy because of extensive adhesions mainly in the anterior aspect of the left upper lobe of the lung during the dissection the internal mammary graft was transected and had to be ligated without any consequences.
IA|Iowa|IA|124|125||Dr. _%#NAME#%_ Prairie Pediatrics _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_ _%#CITY#%_, IA _%#55100#%_ _%#MM#%_ _%#DD#%_, 2002 Dear Dr. Dr. _%#NAME#%_, Thank you for accepting care of _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ from the Neonatal Intensive Care Unit of Fairview-University Children's Hospital.
IA|intraarterial|IA|145|146|MAJOR PROCEDURE PERFORMED|1. Cytoxan 468.6 mg day one. 2. Etoposide, 284 mg day one. 3. Cytoxan, 468.6 gm day two. 4. Etoposide, 284 mg IV day two. 5. Carboplatin, 568 mg IA on day two. HISTORY OF PRESENT ILLNESS: This is a 45-year-old, right- handed, white female with a history of right parotid carcinoma diagnosed in 1996, status post resection and radiation and subsequently developed difficulty with writing.
IA|(stage) IA|IA|132|133|DISCHARGE DIAGNOSES|Benign Fallopian tubes and ovaries. No evidence of cervical or lower uterine segment involvement. Overall the appearance of a stage IA endometrial adenocarcinoma. BRIEF HISTORY OF THE PRESENT ILLNESS: The patient is a 69- year-old who was admitted on _%#MMDD2002#%_ for total abdominal hysterectomy and bilateral salpingo-oophorectomy.
IA|Iowa|IA|174|175|DISCHARGE INSTRUCTIONS|_%#NAME#%_ _%#NAME#%_, MD _%#NAME#%_ _%#NAME#%_ Children's Hospital Pediatric Hematology/Oncology _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#ADDRESS#%_ _%#CITY#%_ _%#CITY#%_, IA _%#55300#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was just discharged following his unrelated cord blood transplant for AML.
IA|(stage) IA|IA,|299|301|FOLLOW-UP|She was also continuing her home medications of Seroquel 100 mg p.o. q.a.m. and 200 mg p.o. q.p.m. and Remeron 15 mg p.o. q.h.s. FOLLOW-UP: She should return to clinic in six weeks for a postoperative check or as needed. Prior to discharge, the patient's final pathology returned confirming a stage IA, grade 1 endometrial carcinoma.
IA|intraarterial|IA|66|67|MAJOR PROCEDURE PERFORMED|DIAGNOSIS: Glioblastoma multiforme. MAJOR PROCEDURE PERFORMED: IV IA chemotherapy. HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old man with a glioblastoma multiforme.
IA|intraarterial|IA|201|202|HISTORY OF PRESENT ILLNESS|DIAGNOSIS: Glioblastoma multiforme. MAJOR PROCEDURE PERFORMED: IV IA chemotherapy. HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old man with a glioblastoma multiforme. Patient presented for IV IA chemotherapy. The patient tolerated the procedure well without any complications.
IA|intraarterial|IA|196|197|HISTORY OF PRESENT ILLNESS|The patient received partial brain and oral Temodar, and has recently begin the IV/IA chemotherapy program. He presents for cycle #2 of the IV/IA chemotherapy. IV being Cytoxan and etoposide, and IA carboplatin. PAST MEDICAL HISTORY: The past medical history is unremarkable except for a left fibular fracture and a seizure disorder which was presenting symptom of this tumor.
IA|intraarterial|IA|322|323|HOSPITAL COURSE|After admission, the patient received his IV chemotherapy and reported a dizzy feeling upon standing, and it was felt that the patient had orthostatic hypotension after this was documented in his chart with blood pressure recordings. He was started on a dose of Florinef. He tolerated his IV chemotherapy well. He had his IA chemotherapy on _%#MM#%_ _%#DD#%_, 2006. The puncture site was clean, dry, and intact, and he was discharged home in stable condition after tolerating a regular diet, and having good bowel function, and voiding spontaneously, and ambulating independently.
IA|(stage) IA|IA|40|41|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Recurrent stage IA adenocarcinoma of the cervix, diagnosed in 2002. 2. Status post 2 cycles of chemotherapy on the GOG _%#PROTOCOL#%_ protocol. 3. Depression. DISCHARGE DIAGNOSES: 1. History of recurrent stage IA adenocarcinoma of the cervix, diagnosed in 2002.
IA|intraarterial|IA|112|113|ADMISSION DIAGNOSIS|Mr. _%#NAME#%_ is an 18-year-old man with a history of glioblastoma multiforme. He presents for cycle #4 of his IA chemotherapy. HOSPITAL COURSE: Mr. _%#MM#%_ was admitted to the hospital and subsequently underwent right internal carotid intra-arterial chemotherapy receiving 5 g of methotrexate.
IA|intraarterial|IA|134|135|OPERATION AND PROCEDURE PERFORMED DURING THIS HOSPITAL ADMISSION|ADMISSION AND DISCHARGE DIAGNOSIS: Anaplastic oligodendroglioma. OPERATION AND PROCEDURE PERFORMED DURING THIS HOSPITAL ADMISSION: IV IA Chemotherapy. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 39-year-old man with a history of anaplastic oligodendroglioma who had a recurrence of his tumor and is status post 2 resections from this primary tumor site in the right temporal lobe.
IA|intraarterial|IA|216|217|HOSPITAL COURSE|2. Hypertension. 3. History of right occipital oligodendroglioma. HOSPITAL COURSE: The patient was admitted for the above- mentioned procedure which was uneventful. The patient underwent the chemotherapy with IV and IA routes. The patient tolerated the procedure well. He was monitored on the 7C unit of the hospital. The patient was discharged when his right groin site looked normal, with good distal pulses and no evidence of pseudoaneurysm.
IA|(stage) IA|IA|36|37|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Grade 1, stage IA endometrial cancer. DISCHARGE DIAGNOSIS: Grade 1, stage IA endometrial cancer. OPERATIONS/PROCEDURES PERFORMED: 1. TAH. 2. BSO. 3. Lymph node sampling. HISTORY OF PRESENT ILLNESS: This is a 47-year-old who reported one year of pelvic pain intermittently with worsening during menses, especially in the right lower quadrant.
IA|(stage) IA|IA|219|220|SUMMARY OF HOSPITAL COURSE|FINAL DIAGNOSIS: 1. Fever of unclear origin. 2. Pancytopenia following chemotherapy. 3. Hodgkin's disease. SUMMARY OF HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ is a 34-year- old man who has a recent history of a stage IA Hodgkin's disease for which he has been started on chemotherapy using the ABVD regimen. He was admitted on _%#MMDD2003#%_ with symptoms of upper respiratory congestion including nasal congestion and discharge as well as a nonproductive cough and sore throat.
IA|(stage) IA|IA.|172|174|PAST MEDICAL HISTORY|She complains of insomnia and increased anxiety. PAST MEDICAL HISTORY: 1. Non-Hodgkin lymphoma diagnosed in 1994 with a right neck mass; diffuse large cell lymphoma, stage IA. Status post radiation therapy and 6 cycles of CHOP. Recurrence in the right cervical lymph node in the summer of 2002. Biopsy showed low-grade B cell lymphoma. She was treated with observation only.
IA|(stage) IA|IA|24|25|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. IA adenosarcoma of the uterus. 2. Peritoneal vaginal fluid leakage/fistula. 3. Wound separation. DISCHARGE DIAGNOSES: 1. IA adenosarcoma of the uterus. 2. Peritoneal vaginal fistula.
IA|(stage) IA|IA|87|88|DISCHARGE DIAGNOSES|Peritoneal vaginal fluid leakage/fistula. 3. Wound separation. DISCHARGE DIAGNOSES: 1. IA adenosarcoma of the uterus. 2. Peritoneal vaginal fistula. 3. Wound separation. PROCEDURES: 1. CT of the abdomen and pelvis. 2. Abdominal x-ray. 3. Repeat CT of the pelvis. HISTORY OF PRESENT ILLNESS: This is a 76-year-old female with 1A adenosarcoma of the uterus who was operated on _%#MMDD2003#%_ with a TAH/BSO and who had a vaginal nodular reaction.
IA|(stage) IA|IA|250|251|FINAL DIAGNOSES|FINAL DIAGNOSES: 1. Undifferentiated large cell carcinoma, left upper lobe lung, with invasion of the parietal pleura and metastasis to the internal mammary lymph node. Pathology score stage T3, N2, M0. 2. Status post right upper lobectomy for stage IA non-small cell carcinoma, 1996. 3. Hypertension. 4. Status post aortobifemoral bypass. 5. History of cataract surgery. 6. History of smoking. PROCEDURE: _%#MMDD2003#%_ - Left thoracotomy, mediastinal lymph node dissection, left upper lobectomy.
IA|intraarterial|IA.|172|174|HISTORY OF PRESENT ILLNESS|Since her diagnosis of sarcoma, she has been treated with four cycles of ifosfamide and Adriamycin. She had one episode of neutropenic fevers following her first course of IA. She has been feeling well and denies complaints today. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Negative for tobacco or ETOH. FAMILY HISTORY: Significant for maternal aunt and grandmother with non-Hodgkin's lymphoma, and grandfather with prostate cancer.
IA|intraarterial|IA|131|132|DISCHARGE DIAGNOSIS|He presents for cycle #1 of IV/IA chemotherapy. HOSPITAL COURSE: Mr. _%#NAME#%_ presented for cycle #1 of IV Cytoxan and etoposide IA methotrexate chemotherapy. He went on and had IA chemotherapy without blood-brain barrier disruption to the left internal carotid artery on _%#MM#%_ _%#DD#%_, 2006.
IA|intraarterial|IA|180|181|DISCHARGE DIAGNOSIS|He presents for cycle #1 of IV/IA chemotherapy. HOSPITAL COURSE: Mr. _%#NAME#%_ presented for cycle #1 of IV Cytoxan and etoposide IA methotrexate chemotherapy. He went on and had IA chemotherapy without blood-brain barrier disruption to the left internal carotid artery on _%#MM#%_ _%#DD#%_, 2006. He tolerated the procedure well and was returned to the floor where he was able to ambulate, eat, and have good pain control at the time of discharge.
IA|intraarterial|IA|116|117|PROCEDURE|ADMITTING DIAGNOSIS: Anaplastic oligo-astrocytoma. DISCHARGE DIAGNOSIS: Anaplastic oligo-astrocytoma. PROCEDURE: IV IA chemotherapy. HISTORY OF PRESENT ILLNESS: This is a 22-year-old male who has been diagnosed with anaplastic oligo-astrocytoma who presents for his second cycle of intra-arterial chemotherapy.
IA|(stage) IA|IA|25|26|PRIMARY DIAGNOSIS|PRIMARY DIAGNOSIS: Stage IA granulosis cell tumor of the ovary. Secondary diagnoses: Postoperative ileus Tertiary diagnoses: Postoperative anemia. PRIMARY PRINCIPAL PROCEDURE PERFORMED DURING THE HOSPITALIZATION: Total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic and periaortic lymphadenectomy, omentectomy and staging.
IA|intraarterial|IA|189|190|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 40-year-old female with a history of right frontal oligodendroglioma who showed interval growth of this tumor on followup MRI scan. She has had IV and IA chemotherapy for this as well as a prior resection. She presents today for re-resection of this tumor. HOSPITAL COURSE: She was admitted on _%#MMDD2007#%_, underwent the aforementioned procedure.
IA|intraarterial|IA|346|347|HISTORY OF PRESENT ILLNESS|REASON FOR ADMISSION: Continuation of rehab cares. HISTORY OF PRESENT ILLNESS: This is a 20-year-old white woman with a history of primitive neuroectodermal tumor for which she had undergone several resections in 2005 of the left temporal lesions. She has been followed at the University of Minnesota Medical Center, Fairview, for ongoing IV and IA chemotherapy. On _%#MMDD2006#%_ the patient was admitted to the University of Minnesota Medical Center, Fairview for poor mental status, hyponatremia, and thrombocytopenia.
IA|intraarterial|IA|209|210|HOSPITAL COURSE|HOSPITAL COURSE: She was admitted the night before for preparation prior to intra-arterial phase done the following morning. Her port was accessed. There was no difficulty with that. She tolerated both IV and IA chemotherapy quite well throughout her stay. Following afternoon, she was deemed to be stable and was sent home in good condition. She was at her baseline mental status.
IA|intraarterial|IA|190|191|DISCHARGE INSTRUCTIONS|She and continue to care for her dual-lumen port as previously instructed. She will have a CT of the head on _%#MMDD2007#%_ at 4 p.m. and then report to admitting for her next scheduled for IA chemo, which is on _%#MMDD2007#%_ at 8 a.m. She should have a weekly CBC with differential and platelets while receiving chemo.
IA|(grade) IA|IA.|154|156|BRIEF HISTORY OF PRESENT ILLNESS|He was seen by primary cardiologist Dr. _%#NAME#%_ on _%#MMDD#%_ and heart muscle biopsy, which revealed no evidence of rejection with inflammatory grade IA. On _%#MMDD#%_, home health care nurse noticed that the patient has tachycardia around 140s. He denied any symptoms including dyspnea, dizziness, lightheadedness or palpitation.
IA|intraarterial|IA|176|177|PROCEDURES PERFORMED|ADMISSION DIAGNOSIS: Brainstem glioma. DISCHARGE DIAGNOSIS: Same. PROCEDURES PERFORMED: Blood-brain barrier disruption on _%#MMDD2003#%_, with two days of IV chemotherapy, and IA chemotherapy on the day of disruption. HISTORY OF PRESENT ILLNESS: This is a 24-year-old right-handed white female with a past history of brainstem glioma previously treated with radiation who is undergoing the Blood-Brain Barrier Disruption Program.
IA|intraarterial|IA|245|246|HISTORY OF PRESENT ILLNESS|She is status post biopsy on _%#MMDD2003#%_ for an MRI that demonstrated increased signal change in the left posterior limb of the internal capsule in the left periventricular region. The patient presented for blood-brain barrier disruption and IA and IV chemotherapy #11. PAST MEDICAL HISTORY: None. ALLERGIES: No known drug allergies.
IA|(stage) IA|IA|68|69|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old with Stage IA grade 3 endometrial CA with mixed endometrial and clear cell features who is status post laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic and periaortic lymph node dissections on _%#MM2003#%_, who presents with complaint of lower back pain that started shortly after surgery. Her back pain is mostly on the right side. As previously mentioned her back pain started two to three weeks after surgery.
IA|(stage) IA|IA,|121|123|HOSPITAL COURSE|No evidence of disease, and the right tube and lymph nodes, and all biopsies were negative. She was thus staged at stage IA, grade 1. 2. Fluid, electrolytes, and nutrition: She was admitted and aggressively hydrated with lactated Ringer's. She was not nauseous or vomiting at that time and was started on a clear liquid diet with careful observation for possibility of small bowel obstruction.
IA|intraarterial|IA|143|144|ADMISSION DIAGNOSIS|DISCHARGE INSTRUCTIONS: Include a regular diet. Activities as tolerated. She has received instructions to follow up in 1 month to continue the IA chemotherapy program. She will return for any significant drainage, pain, swelling at her groin puncture site or the Port-A-Cath site, or a temperature greater than 100.4.
IA|(stage) IA|IA|41|42|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. History of stage IA non-Hodgkin lymphoma, extranodal marginal zone lymphoma diagnosed in _%#MM#%_ of 2001, and now status post non- myeloablative allogeneic sibling peripheral blood stem cell transplant on _%#MM#%_ _%#DD#%_, 2004. 2. Mild nausea and vomiting post transplant. 3. Bitemporal headaches felt to be cyclosporin related.
IA|intraarterial|IA.|173|175|ADMISSION DIAGNOSIS|HOSPITAL COURSE: Patient was admitted and after informed consent was obtained, she underwent 2 blood-brain barrier disruptions with Cytoxan and etoposide IV and carboplatin IA. Patient tolerated both of these disruptions without any incident, and she was discharge to home in good condition on _%#MM#%_ _%#DD#%_, 2004.
IA|intraarterial|IA|132|133|HOSPITAL COURSE|He presented for his 11 cycle of IVI chemotherapy. HOSPITAL COURSE: On _%#MMDD2006#%_ the patient underwent a left vertebral artery IA chemotherapy. This procedure was uncomplicated. He returned to the floor following this surgery and was monitored for six hours. Following this, he was doing quite well and he was at his neurologic baseline and was therefore discharged.
IA|intraarterial|IA|150|151|PROCEDURE PERFORMED|ADMITTING DIAGNOSIS: Breast cancer with leptomeningeal spread. DISCHARGE DIAGNOSIS: Breast cancer with leptomeningeal spread. PROCEDURE PERFORMED: IV IA chemo. HISTORY OF PRESENT ILLNESS: This is a 39-year-old female with breast cancer and leptomeningeal spread who presents for her next regular scheduled cycle of intravenous and intra-arterial chemotherapy.
IA|intraarterial|IA|137|138|ACTIVITY|Her next appointment is for an MR brain, cervical spine on _%#MMDD2007#%_ at 3:00 p.m. and this should go admitting after that. Her next IA chemo is scheduled for _%#MMDD2007#%_ at 8:00 a.m. She should have a CBC with differential and platelets weekly while receiving chemotherapy.
IA|intraarterial|IA|185|186|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 58-year-old man with a history of anaplastic oligodendroglioma in the right temporal lobe. He presents for his next cycle of intravenous IA chemotherapy. HOSPITAL COURSE: On _%#MMDD2007#%_, the patient underwent right carotid intra-arterial chemotherapy with 800 mg of carboplatin.
IA|intraarterial|IA|114|115|PROCEDURES|SERVICE: Neurology. ATTENDING: Dr. _%#NAME#%_ _%#NAME#%_. RESIDENT: Dr. _%#NAME#%_ _%#NAME#%_. PROCEDURES: IV and IA TPA. CONSULTS: Interventional, PT, OT, speech therapy and PMNR.
IA|intraarterial|IA|293|294|HISTORY OF PRESENT ILLNESS|The patient at that time had improving language, although weakness remained. Given the patient's fluctuating symptoms Dr. _%#NAME#%_ our neural interventionalist recommended giving intravenous TPA and then proceeding with a CT angio and CT perfusion scan of the brain to evaluate the need for IA TPA. Initial head CT on _%#MMDD#%_ revealed the following: No acute hemorrhage, moderate small vessel ischemic disease, lacunar infarcts in the anterior limb of the right internal capsule and in the heads of both caudate nuclei, old left cerebellar infarct.
IA|intraarterial|IA|203|204|ACTIVITY|Her next appointment will be for an MRI on Friday _%#MMDD2006#%_ at 11:00 a.m. at Fairview Lakes. She will go to Dr. _%#NAME#%_'s office on _%#MMDD2007#%_, which is Monday at 4 p.m., clinic 1A. Her next IA chemotherapy is scheduled for Wednesday, _%#MMDD2007#%_, 3:00 p.m. She should have a CBC with differential and platelets weekly while receiving chemotherapy.
IA|(stage) IA|IA,|177|179|IMPRESSION|Last mammogram taken in _%#MM2007#%_ showed Category 2 findings, which are benign. IMPRESSION: 42-year-old female with history of breast cancer, infiltrating ductal type, Stage IA, Grade 3, which was treated with two lumpectomies. She now has acute renal failure with elevated calcium. Her issues are all probably related to metastatic breast cancer.
IA|(stage) IA|IA|82|83|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: 1. Fever, suspecting chemotherapy related. 2. COPD. 3. Stage IA right sided non-small cell lung CA. 4. Essential hypertension. 5. Diabetes. HISTORY OF PRESENT ILLNESS: This is a 66-year-old female with known Stage I-A right sided non-small cell lung CA, status post radiation therapy, status post chemotherapy times three cycles, admitted with fever and shortness of breath.
IA|(stage) IA|IA|173|174|DISCHARGE SUMMARY|She was found to have a 3 cm mass in the right upper lobe of the lung, and biopsy was positive for non- small cell carcinoma. By imaging studies, this is clinically a stage IA lung cancer. She had adequate pulmonary function tests, and as she is very active, based on the findings of the thoracotomy, resection was indicated for treatment.
IA|(stage) IA|IA.|123|125|DISCHARGE DIAGNOSIS|ADMITTING DIAGNOSIS: Pelvic mass suspicious for endometrial cancer. DISCHARGE DIAGNOSIS: Grade 1 endometrial cancer, stage IA. PROCEDURES PERFORMED: 1. Examination under anesthesia with exploratory laparotomy.
IA|intraarterial|IA|207|208|HISTORY|They came to the Emergency Department. Unfortunately, they came to the Emergency Department at five hours after the onset of symptoms. So he was not in the window for IV TPA and probably not a candidate for IA TPA. The patient has no prior history of stroke, transient ischemic attack, amaurosis. He had no weakness of his legs. He had no trouble with headache, confusion or aphasia.
IA|intraarterial|IA|240|241|HOSPITAL COURSE|On _%#MMDD2004#%_, she received left vertebral artery injection #2, and both on _%#MMDD2004#%_ and_%#MMDD2004#%_, she received intravenous chemotherapy. She received Cytoxan and etoposide IV, and then carboplatin was on day 2, which is the IA chemotherapy. PHYSICAL EXAMINATION ON DISCHARGE: She is afebrile. Her vital signs are stable.
IA|(stage) IA|IA,|102|104|DISCHARGE DIAGNOSIS|ADMISSION DIAGNOSIS: 1. Grade 1 endometrial carcinoma. 2. Hypertension. DISCHARGE DIAGNOSIS: 1. Stage IA, grade 1 endometrioid adenocarcinoma of the endometrium. 2. Hypertension. 3. Acute blood loss anemia. OPERATIONS/PROCEDURES PERFORMED: Laparoscopic-assisted vaginal hysterectomy, laparoscopic pelvic and paraaortic lymphadenectomy, pelvic washing, and blood transfusion.
IA|(stage) IA|IA|194|195|POSTOPERATIVE COURSE|There were no complications during the procedure. POSTOPERATIVE COURSE: The patient did follow a routine postoperative course.: 1. Disease. The patient's pathology returned and revealed a stage IA grade 1 endometrioid adenocarcinoma of the endometrium. 2. Cardiovascular. The patient has a history of hypertension and was continued on her hydrochlorothiazide and lisinopril.
IA|(stage) IA|IA,|147|149|DISCHARGE DIAGNOSES|7. Stress incontinence. 8. CNS insufficiency. DISCHARGE DIAGNOSES: 1. Same as above. 2. Afibrillation. 3. Adenocarcinoma of the endometrium, stage IA, grade 1. 4. Wound cellulitis. COMPLICATIONS DURING HOSPITALIZATION: 1. Prolonged intubation requiring stay in Intensive Care Unit.
IA|(stage) IA|IA,|187|189|PROBLEM #9|The patient has an approximately 6 x 3 cm wound on her left flank. ET nursing was consulted and care was assessed. PROBLEM #10: Disease. The patient's final pathology was consistent with IA, grade 1 adenocarcinoma of the endometrium, and she will follow up with Dr. _%#NAME#%_ for her postoperative check on _%#MMDD2005#%_. She will follow up with Cardiology on _%#MMDD2005#%_.
IA|(type) IA|IA|127|128|PAST MEDICAL HISTORY|He denies any joint pain, muscle pain, or sick contacts. PAST MEDICAL HISTORY: 1. Hepatitic C diagnosed in 1988, with genotype IA and a moderate to high viral load. He has had treatment with ribavirin and interferon previously; however, this was discontinued in _%#MM#%_ of 2005 because of side effects.
IA|(grade) IA|IA.|228|230|OPERATIONS/PROCEDURES PERFORMED|Normal global LV systolic function, and there was a small pericardial effusion, most significant valvular disease was identified. 2. Patient underwent endomyocardial biopsy to rule out rejection. Endomyocardial biopsy was grade IA. HISTORY OF PRESENT ILLNESS: Patient is a 61-year-old male status post heart transplant on _%#MM#%_ _%#DD#%_, 2004, with postoperative period complicated with Staphylococcus coagulase negative sepsis, sternal bone infection requiring removal of sternum with multiple surgeries by using flap, and presented at the day of admission with progressive increase in weight over the last 2 weeks, along with shortness of breath and dyspnea on moderate exertion.
IA|intraarterial|IA|58|59|CHIEF COMPLAINT|CHIEF COMPLAINT: The patient is for cycle 11 of 12 for IV IA chemotherapy for gemistocytic astrocytoma. Mr. _%#NAME#%_ is a 25-year-old male with a history of gemistocytic astrocytoma of the left frontal region initially resected in _%#MM2006#%_ after which he received external beam radiation in _%#MM2006#%_ for 6-8 weeks.
IA|intraarterial|IA|252|253|CHIEF COMPLAINT|Mr. _%#NAME#%_ is a 25-year-old male with a history of gemistocytic astrocytoma of the left frontal region initially resected in _%#MM2006#%_ after which he received external beam radiation in _%#MM2006#%_ for 6-8 weeks. Following this, he starting IV IA chemotherapy in _%#MM2006#%_. He is currently here for cycle 11 of 12 of the IV IA chemotherapy. PAST MEDICAL HISTORY: Left front gemistocytic astrocytoma. MEDICATIONS: 1. Keppra 1500 b.i.d.
IA|intraarterial|IA|335|336|CHIEF COMPLAINT|Mr. _%#NAME#%_ is a 25-year-old male with a history of gemistocytic astrocytoma of the left frontal region initially resected in _%#MM2006#%_ after which he received external beam radiation in _%#MM2006#%_ for 6-8 weeks. Following this, he starting IV IA chemotherapy in _%#MM2006#%_. He is currently here for cycle 11 of 12 of the IV IA chemotherapy. PAST MEDICAL HISTORY: Left front gemistocytic astrocytoma. MEDICATIONS: 1. Keppra 1500 b.i.d.
IA|intraarterial|IA|141|142|ASSESSMENT|ASSESSMENT: Mr. _%#NAME#%_ is a 25-year-old male with history of left frontal gemistocytic astrocytoma who was here for cycle 11 of 12 of IV IA chemotherapy. He has consented to and will receive intraarterial chemotherapy.
IA|intraarterial|IA|196|197|ASSESSMENT|Sensory examination is intact to light touch in the upper extremities and lower extremities. He has no dysmetria. ASSESSMENT: Mr. _%#NAME#%_ is a 26-year-old male who is here for cycle 5 of 12 IV IA chemotherapy. 1. He has consent to and will receive chemotherapy. 2. We will follow. I have personally examined the patient, reviewed and edited the resident's note and agree with the plan of care.
IA|intraarterial|IA|79|80|CHIEF COMPLAINT/REASON FOR ADMISSION|CHIEF COMPLAINT/REASON FOR ADMISSION: The patient is here for cycle 3 of 12 IV IA chemotherapy. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_, in brief, is a pleasant 63-year-old female who was here for cycle 3 of 12 of intravenous intraarterial chemotherapy for a GMB mostly on her left parietal-occipital lobe that was diagnosed after an MRI guided needle biopsy on _%#MMDD2006#%_ by Dr. _%#NAME#%_.
IA|intraarterial|IA|180|181|HISTORY OF PRESENT ILLNESS|She subsequently had chemotherapy with oral Temodar and radiation. She also subsequently had gamma knife in _%#MM2006#%_ and she once again currently presents for cycle 3 of 12 IV IA chemotherapy. She states no headaches, nausea, vomiting, lethargy, weakness or paresthesias. She also states that she has not had a seizure since her last IV IA chemotherapy cycle.
IA|intraarterial|IA|126|127|ASSESSMENT|Ms. _%#NAME#%_ is a pleasant 63-year-old female with a history of glioblastoma multiforme who is here for cycle 3 of 12 of IV IA chemotherapy. Our plan is to proceed with chemotherapy and she has been consented. I have personally examined the patient, reviewed and edited the resident's note and agree with the plan of care.
IA|intraarterial|IA|42|43|REASON FOR ADMISSION|REASON FOR ADMISSION: Cycle 7 of 12 of IV IA chemotherapy. HISTORY OF PRESENT ILLNESS: In brief, Mr. _%#NAME#%_ is a 34-year-old male with right temporal GBM resected in _%#MM2006#%_ after which he received radiation therapy and 6 cycles of IV IA chemotherapy.
IA|intraarterial|IA|185|186|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: In brief, Mr. _%#NAME#%_ is a 34-year-old male with right temporal GBM resected in _%#MM2006#%_ after which he received radiation therapy and 6 cycles of IV IA chemotherapy. He currently presents once again for cycle 7 of 12 IV IA chemotherapy. The only change from his last admission is that he currently states slight bilateral hyperacousis.
IA|intraarterial|IA|256|257|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: In brief, Mr. _%#NAME#%_ is a 34-year-old male with right temporal GBM resected in _%#MM2006#%_ after which he received radiation therapy and 6 cycles of IV IA chemotherapy. He currently presents once again for cycle 7 of 12 IV IA chemotherapy. The only change from his last admission is that he currently states slight bilateral hyperacousis. Otherwise, no nausea, vomiting, a slight headache, no change in vision, no weakness or paresthesias.
IA|intraarterial|IA|357|358|ASSESSMENT|ASSESSMENT: Mr. _%#NAME#%_ is a pleasant 34-year-old male with a history of right temporal GBM resection in _%#MM2006#%_ who is here for cycle 7 of 12 IV IA chemotherapy who will be receiving methotrexate at this time for a slight increase in the size of the hyperintensity around the atrium of the right lateral ventricle. He has been consented for the IV IA chemotherapy and he will be receiving the IV IA chemotherapy, which will methotrexate. We will be monitoring methotrexate levels. I have personally examined the patient, reviewed and edited the resident's note and agree with the plan of care.
IA|intraarterial|IA|405|406|ASSESSMENT|ASSESSMENT: Mr. _%#NAME#%_ is a pleasant 34-year-old male with a history of right temporal GBM resection in _%#MM2006#%_ who is here for cycle 7 of 12 IV IA chemotherapy who will be receiving methotrexate at this time for a slight increase in the size of the hyperintensity around the atrium of the right lateral ventricle. He has been consented for the IV IA chemotherapy and he will be receiving the IV IA chemotherapy, which will methotrexate. We will be monitoring methotrexate levels. I have personally examined the patient, reviewed and edited the resident's note and agree with the plan of care.
IA|Iowa|IA|172|173|PAST MEDICAL HISTORY|He has had no prior similar symptoms. He denies any coagulopathy. PAST MEDICAL HISTORY: Crohn's disease which has been in check for awhile. He is visiting from Fort Dodge, IA and had just gotten into the _%#CITY#%_ _%#CITY#%_ area. EMERGENCY DEPARTMENT COURSE: In the ER he did have a workup including abdominal CT which showed some posterior right renal cortical wedge abnormalities which was suspicious for infarct, less likely could be some early pyelonephritis.
IA|intraarterial|IA|118|119|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Right occipital mixed glioma/oligoastrocytoma with anaplastic features. The patient presents for IA and IV chemotherapy. PROCEDURES PERFORMED: On _%#MMDD2002#%_, he had a chemotherapy port placed.
IA|(stage) IA|IA|106|107|DISCHARGE DIAGNOSES|3. Chronic low back pain. 4. History of pulmonary embolus. 5. Fibromyalgia. DISCHARGE DIAGNOSES: 1. Stage IA endometrial cancer. 2. Arthritis. 3. Chronic low back pain. 4. Fibromyalgia. 5. History of pulmonary embolus. PROCEDURES: 1. Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy and washings.
IA|(stage) IA|IA|271|272|HOSPITAL COURSE|EXTREMITIES: Symmetric pulses, no edema. Gynecologic exam is deferred. HOSPITAL COURSE: PROBLEM #1: Disease. The patient is postoperative day #3 from her exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, with frozen pathology showing IA endometrial cancer. She is being discharged home today to _%#CITY#%_. She will follow-up with Dr. _%#NAME#%_ in two to three weeks to discuss further treatment planning.
IA|(stage) IA|IA.|185|187|HISTORY OF PRESENT ILLNESS|Hemoglobin 11.2. HIV negative. PAST MEDICAL HISTORY: 1. Asthma. 2. Restrictive lung disease versus COPD, likely secondary to bleomycin. 3. Embryonal germ cell tumor of the ovary, stage IA. Received chemotherapy with bleomycin/cisplatin/VP-13 and oophorectomy. 4. Known mosaic 47XXX. PAST SURGICAL HISTORY: 1. 1989, exploratory laparotomy with left oophorectomy and salpingectomy.
IA|intraarterial|IA|171|172|OPERATIONS/PROCEDURES PERFORMED|DISCHARGE DIAGNOSIS: Recurrent left temporal anaplastic oligodendroglioma. OPERATIONS/PROCEDURES PERFORMED: Blood brain barrier cycle #4 with IV Cytoxan and etoposide and IA methotrexate. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 33-year-old male with a history anaplastic oligodendroglioma with first resection 1991 and 4 surgeries on the stem, the first in 1991, second in 2000 and 2002.
IA|intraarterial|IA|131|132|HOSPITAL COURSE|HOSPITAL COURSE: The patient was admitted and underwent 2 days of blood brain barrier disruption with IV Cytoxan and etoposide and IA methotrexate. He tolerated the procedures well. He did have seizures for about 30 seconds during the methotrexate that was controlled with pentothal on day #1.
IA|intraarterial|IA|192|193|HOSPITAL COURSE|He tolerated the procedures well. He did have seizures for about 30 seconds during the methotrexate that was controlled with pentothal on day #1. The patient has been having seizures with his IA chemotherapy. At the time of discharge, patient was awake, alert, oriented, pupils reactive, extraocular movements intact, face symmetric, tongue midline.
IA|intraarterial|IA|176|177|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: Left temporal anaplastic oligodendroglioma. OPERATIONS/PROCEDURES PERFORMED: Cycle #5 of blood- brain barrier disruption with IV Cytoxan and etoposide and IA methotrexate. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is a 33-year- old gentleman who had a history of anaplastic oligodendroglioma first resected in 1991 and has had 4 surgeries since then.
IA|(stage) IA|IA,|137|139|HOSPITAL COURSE|Her postoperative recovery was uneventful. Her surgery was uneventful. All of her lymph nodes were negative. Her final stage was a Stage IA, Grade 2 endometrial adenocarcinoma. There was no residual disease left in the abdominal cavity at the end of her surgery. Surgery was slowed by the fact that she was morbidly obese.
IA|intraarterial|IA|288|289|DISCHARGE DIAGNOSIS|His port was accessed without complications. On the morning of _%#MM#%_ _%#DD#%_, 2005, the patient underwent intraarterial chemotherapy with a blood brain barrier disruption via right internal carotid artery injection. The patient was administered carboplatin. This was cycle #12 of his IA chemotherapy. The patient tolerated this procedure well and was transferred to the floor for monitoring after the procedure. He was discharged to home later that evening in stable condition.
IA|(stage) IA|IA|97|98|DIAGNOSES ON ADMISSION|DIAGNOSES ON ADMISSION: History of synchronous stage IC mucinous adenocarcinoma of the ovary and IA endometrial adenocarcinoma, findings suspicious for recurrence. DIAGNOSES ON DISCHARGE: History of synchronous stage IC mucinous adenocarcinoma of the ovary and IA endometrial adenocarcinoma, findings suspicious for recurrence.
IA|(stage) IA|IA|261|262|DIAGNOSES ON DISCHARGE|DIAGNOSES ON ADMISSION: History of synchronous stage IC mucinous adenocarcinoma of the ovary and IA endometrial adenocarcinoma, findings suspicious for recurrence. DIAGNOSES ON DISCHARGE: History of synchronous stage IC mucinous adenocarcinoma of the ovary and IA endometrial adenocarcinoma, findings suspicious for recurrence. PROCEDURES: 1. Exploratory laparotomy, resection of pelvic mass, resection of portion of sigmoid colon, extensive lysis of adhesions, placement of colostomy.
IA|Iowa|IA|148|149|PRIMARY CARE PHYSICIAN|PRIMARY CARE PHYSICIAN: Dr. _%#NAME#%_, _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_, _%#CITY#%_, IA _%#55200#%_ CHIEF COMPLAINT: "Fainted." History is obtained from the patient, her long time male friend named _%#NAME#%_ _%#NAME#%_ and some fax records from her primary physician in _%#CITY#%_, Iowa. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 86-year-old woman who was brought to the Emergency Department by her male friend today after an episode of syncope.
IA|intraarterial|IA.|169|171|HOSPITAL COURSE|HOSPITAL COURSE: The patient was admitted to the neurosurgery service, had a Port-A-Cath placed and subsequently had Cytoxan and etoposide intravenously and carboplatin IA. The patient had unremarkable postoperative course and was discharged in good condition on _%#MM#%_ _%#DD#%_, 2005. DISCHARGE INSTRUCTIONS: Follow up in the outpatient lab every week.
IA|(stage) IA|IA|215|216|ADMISSION DIAGNOSIS|Thus, the patient is being discharged home today in good condition on postoperative day #1. The patient had an excellent postoperative course. PAST MEDICAL HISTORY: The patient's past medical history includes stage IA grade 3 papillary serous adenoma of the ovary and IIA endometrial adenocarcinoma of the uterus. The patient was originally diagnosed in 1996. The patient ended up subsequently having a TAH/BSO and cholecystectomy between the initial diagnoses in _%#MM#%_ 1996 through _%#MM#%_ 1997.
IA|(stage) IA|IA|123|124|ALLERGIES|The patient was placed on pneumatic pump, which he tolerated well. His status on the heart transplant list was elevated to IA status. An organ became available on _%#MM#%_ _%#DD#%_, 2004. His interval time in the hospital was uneventful. Mr. _%#NAME#%_ was subsequently taken to the operating room on _%#MM#%_ _%#DD#%_, 2004, for his heart transplant.
IA|intraarterial|IA|215|216|ADMISSION DIAGNOSIS|She was asymptomatic. DISCHARGE MEDICATIONS: Her discharge medications also include Neulasta, Zofran, Compazine, Lasix, bupropion, Zoloft, and Imitrex. FOLLOW UP: She will follow up next month for her next cycle of IA chemotherapy.
IA|intraarterial|IA|182|183|PROCEDURE PERFORMED|ADMISSION DIAGNOSIS: Pineal malignant glial neoplasm. DISCHARGE DIAGNOSIS: Pineal malignant glial neoplasm. PROCEDURE PERFORMED: Intra-arterial chemotherapy, this is cycle #5 for IV IA chemotherapy. HOSPITAL COURSE: Uneventful. On _%#MMDD2006#%_ she had a left vertebral artery injection for her chemotherapy.
IA|intraarterial|IA|165|166|PROCEDURES|ADMITTING DIAGNOSIS: Breast cancer with central nervous system metastasis. DISCHARGE DIAGNOSIS: Breast cancer with central nervous system metastasis. PROCEDURES: IV IA chemotherapy. HISTORY OF PRESENT ILLNESS: This is a 39-year-old female with a history of breast cancer that now has CNS metastasis who presents for IV IA chemotherapy.
IA|intraarterial|IA|166|167|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ is a 53-year-old man with a history of left temporal GBM initially resected in _%#MM2005#%_. He underwent Gamma knife radiosurgery and 5 cycles of IV, IA chemotherapy. He presented for his sixth cycle of IV, IA chemotherapy. HOSPITAL COURSE: Mr. _%#NAME#%_ underwent an uneventful IV, IA chemotherapy treatment.
IA|intraarterial|IA|117|118|HOSPITAL COURSE|He presented for his sixth cycle of IV, IA chemotherapy. HOSPITAL COURSE: Mr. _%#NAME#%_ underwent an uneventful IV, IA chemotherapy treatment. He was returned to the floor after his treatment where he was feeling quite well. As he was able to ambulate, tolerated p.o. diet and his pain was well controlled on p.o. medications.
IA|(stage) IA|IA.|142|144|HOSPITAL COURSE|There was very little febrile or anemic morbidity. Her final histopathology revealed clear cell adenocarcinoma of the ovary which was a stage IA. All of her lymph nodes, the omentum and the peritoneal biopsies were all negative. She was instructed accordingly. She will need adjuvant chemotherapy with carboplatin and Taxol.
IA|Iowa|IA,|217|219|HISTORY OF PRESENT ILLNESS|Patient had a history of PSAs within normal range for years but an enlarged prostate gland. The PSAs had been 3.4. He had been followed for some 25-30 years. He recently underwent evaluation in _%#CITY#%_ _%#CITY#%_. IA, when PSA rose to 6.3-6.4. This was in _%#MM#%_ 2005. On repeat evaluation, _%#MM2006#%_, PSA was 8.9. Digital rectal exam was reported to be normal.
IA|(stage) IA|IA|87|88|PRIMARY DIAGNOSIS DURING HOSPITALIZATION|PRIMARY DIAGNOSIS DURING HOSPITALIZATION: 1. Stage IC carcinoma of the ovary. 2. Stage IA endometrial carcinoma (grade I). 3. Endometriosis. PRIMARY PRINCIPAL PROCEDURE PERFORMED DURING THE HOSPITALIZATION: Total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic and periaortic lymphadenectomy, omentectomy, staging procedure HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was electively admitted following an outpatient bowel prep on _%#MMDD#%_.
IA|(stage) IA|IA|100|101|ADMISSION DIAGNOSES|DATE OF ADMISSION: _%#MMDD2007#%_. DATE OF DISCHARGE: _%#MMDD2007#%_. ADMISSION DIAGNOSES: 1. Stage IA endometrioid adenocarcinoma of the endometrium. 2. Stage IIIC endometrioid adenocarcinoma of the ovary. 3, Stage IA granulosis cell tumor of the ovary.
IA|(stage) IA|IA|125|126|ADMISSION DIAGNOSES|1. Stage IA endometrioid adenocarcinoma of the endometrium. 2. Stage IIIC endometrioid adenocarcinoma of the ovary. 3, Stage IA granulosis cell tumor of the ovary. 4. Polio as a child. DISCHARGE DIAGNOSES: 1. Stage IA endometrioid adenocarcinoma of the endometrium.
IA|(stage) IA|IA|167|168|DISCHARGE DIAGNOSES|4. Polio as a child. DISCHARGE DIAGNOSES: 1. Stage IA endometrioid adenocarcinoma of the endometrium. 2. Stage IIIC endometrioid adenocarcinoma of the ovary. 3. Stage IA granulosis cell tumor of the ovary. 4. Status post first cycle of intravenous and intraperitoneal chemotherapy with placement of respective ports.
IA|(stage) IA|IA|195|196|HISTORY OF PRESENT ILLNESS|Ms. _%#NAME#%_ _%#NAME#%_ is a 58-year-old woman with concurrent cancers of stage IA endometrioid adenocarcinoma of the endometrium, stage IIIC endometrioid adenocarcinoma of the ovary and stage IA granulosis cell tumor of the ovary. She initially presented with postmenopausal bleeding and biopsy returned with complex atypical hyperplasia.
IA|(stage) IA|IA|98|99|ADMISSION DIAGNOSES|DATE OF ADMISSION: _%#MMDD2007#%_ DATE OF DISCHARGE: _%#MMDD2007#%_ ADMISSION DIAGNOSES: 1. Stage IA endometrioid adenocarcinoma of the endometrium. 2. Stage IIIC endometrioid adenocarcinoma of the ovary. 3. Stage IA granulosa cell tumor of the ovary.
IA|(stage) IA|IA|149|150|DIAGNOSES ON ADMISSION|DIAGNOSES ON ADMISSION: 1. Stage IA endometrioid adenocarcinoma of the endometrium. 2. Stage IIIC endometrioid adenocarcinoma of the ovary. 3. Stage IA granulosis cell tumor of the ovary. DISCHARGE DIAGNOSES: 1. Stage IA endometrioid adenocarcinoma of the endometrium.
IA|intraarterial|IA|377|378|DISCHARGE INSTRUCTIONS|He is instructed to contact us should he notice any increased pain, drainage or swelling at the groin puncture site or temperature greater than 100.4. Next, he should follow up with an MRI on _%#MMDD2007#%_ at 8:00 a.m. followed by a clinic appointment with Dr. _%#NAME#%_ on that same date and his next IV/IA chemotherapy cycle, he will come in on _%#MMDD2007#%_ and have his IA chemotherapy on _%#MMDD2007#%_. Of note, while receiving chemotherapy, the patient should obtain weekly complete blood count with differential and platelets.
IA|(stage) IA|IA|125|126|ADMISSION DIAGNOSES|1. Stage IA endometrioid adenocarcinoma of the endometrium. 2. Stage IIIC endometrioid adenocarcinoma of the ovary. 3. Stage IA granulosa cell tumor of the ovary. 4. Polio as a child. DISCHARGE DIAGNOSES: 1. Stage IA endometrioid adenocarcinoma of the endometrium.
IA|(stage) IA|IA|99|100|DISCHARGE DIAGNOSES|3, Stage IA granulosis cell tumor of the ovary. 4. Polio as a child. DISCHARGE DIAGNOSES: 1. Stage IA endometrioid adenocarcinoma of the endometrium. 2. Stage IIIC endometrioid adenocarcinoma of the ovary. 3. Stage IA granulosis cell tumor of the ovary.
IA|(stage) IA|IA|146|147|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Stage IA endometrioid adenocarcinoma of the endometrium. 2. Stage IIIC endometrioid adenocarcinoma of the ovary. 3. Stage IA granulosis cell tumor of the ovary. 4. Status post 3 cycles of intravenous and intraperitoneal chemotherapy. PROCEDURES: 1. IV Taxol and IP cisplatin. 2. IV fluids.
IA|(stage) IA|IA|212|213|HISTORY OF PRESENT ILLNESS|3. Intravenous Decadron. 4. Intravenous Aloxi for prevention of nausea. COMPLICATIONS: None apparent. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 58-year-old woman with concurrent cancers of stage IA endometrioid adenocarcinoma of the endometrium, stage IIIC endometrioid adenocarcinoma of the ovary and stage IA granulosa cell tumor of the ovary. She initially presented with postmenopausal bleeding and biopsy returned with complex atypical hyperplasia, D&C returned showing grade 1 endometrioid adenocarcinoma.
IA|(stage) IA|IA|99|100|DISCHARGE DIAGNOSES|3, Stage IA granulosis cell tumor of the ovary. 4. Polio as a child. DISCHARGE DIAGNOSES: 1. Stage IA endometrioid adenocarcinoma of the endometrium. 2. Stage IIIC endometrioid adenocarcinoma of the ovary. 3. Stage IA granulosis cell tumor of the ovary.
IA|(stage) IA|IA|164|165|DISCHARGE DIAGNOSES|Polio as a child. DISCHARGE DIAGNOSES: 1. Stage IA endometrioid adenocarcinoma of the endometrium. 2. Stage IIIC endometrioid adenocarcinoma of the ovary. 3. Stage IA granulosa cell tumor of the ovary. 4. Polio as a child. 5. Status post 2 cycles of intravenous and intraperitoneal chemotherapy.
IA|(stage) IA|IA|51|52|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Presumptive clinical stage IA adenocarcinoma of the cervix in situ. 2. Chronic pain syndrome. 3. History of chronic recurrent migraines. 4. Desires definitive surgical management. DISCHARGE DIAGNOSES: 1. Postoperative day #4, status post modified radical hysterectomy, bilateral salpingectomy, bilateral oophoropexy, and extraperitoneal pelvic and periaortic lymph node dissection.
IA|(stage) IA|IA|30|31|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: 1. Stage IA grade I fallopian cancer. 2. Fibromyalgia. 3. Pneumonia. 4. Fever. DISCHARGE DIAGNOSIS: 1. Stage IA grade I fallopian cancer.
IA|(stage) IA|IA|193|194|HISTORY AND PHYSICAL|COMPLICATIONS: 1. Fascial dehiscence. 2. Left upper extremity superficial cephalic vein thrombosis. 3. Colic abscess. HISTORY AND PHYSICAL: The patient is a 48-year-old with a history of stage IA grade I fallopian tube cancer status post exploratory laparotomy, BSO omentectomy, lysis of adhesions, and appendectomy on _%#MM#%_ _%#DD#%_, 2004, status post readmission on _%#MM#%_ _%#DD#%_, 2004, for questionable small bowel obstruction versus ileus left lower lobe pneumonia, readmitted again on _%#MM#%_ _%#DD#%_, 2004, with fever and pneumonia.
IA|(grade) IA|IA,|252|254|PROCEDURES PERFORMED|4. Right heart catheterization dated _%#MMDD2007#%_, severe tricuspid regurgitation, right atrial pressures A/V/mean = 0/17/12, PA pressure 45/23 with a wedge of 20, endomyocardial biopsy performed. 5. Endomyocardial biopsy dated _%#MMDD2007#%_, Grade IA, no evidence of rejection. 6. Transesophageal echocardiogram dated _%#MMDD2007#%_, severe tricuspid regurgitation, RVSP 35 greater than RAP, failure of coaptation of the tricuspid valve.
IA|(stage) IA|IA,|140|142|SECONDARY DIAGNOSIS|2. Likely allergic reaction to an element of her chemotherapy or supportive care. SECONDARY DIAGNOSIS: Diffuse large B-cell lymphoma, stage IA, status post 2 cycles of R-CHOP. IMAGING: Chest x-ray, 2-view, on _%#MMDD2007#%_. Impression: Clear lungs and no other abnormal findings.
IA|(stage) IA|IA|155|156|DISCHARGE DIAGNOSIS|ADMISSION DIAGNOSES: 1. Grade 1 endometrial carcinoma. 2. Family history of factor V Leiden deficiency. 3. Depression. DISCHARGE DIAGNOSIS: Grade 1, stage IA endometrial carcinoma. OPERATIONS/PROCEDURES PERFORMED: 1. Total abdominal hysterectomy. 2. Bilateral salpingo-oophorectomy. 3. Cystoscopy. 4. Epidural placement. 5. IV fluids. COMPLICATIONS: None. HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old para 0, who had postmenopausal bleeding in the end of _%#MM#%_ 2004.
IA|(stage) IA|IA|97|98|DISCHARGE DIAGNOSIS|ADMISSION DIAGNOSIS: Stage IA2 squamous cell carcinoma of the cervix. DISCHARGE DIAGNOSIS: Stage IA grade 2 squamous cell carcinoma of the cervix. OPERATIONS/PROCEDURES PERFORMED: 1. Radical trachelectomy. 2. Pelvic and periaortic lymph node dissection.
IA|intraarterial|IA|300|301|HISTORY OF PRESENT ILLNESS|ADMISSION DIAGNOSIS: Anaplastic oligodendroglioma. DISCHARGE DIAGNOSIS: Anaplastic oligodendroglioma. OPERATIONS/PROCEDURES PERFORMED: IV/IA chemotherapy. HISTORY OF PRESENT ILLNESS: This is a 39-year-old female with an anaplastic oligodendroglioma who presents for her scheduled injection of IV and IA chemotherapy. HOSPITAL COURSE: She was admitted on _%#MM#%_ _%#DD#%_, 2006, and underwent the injection of IA chemotherapy on _%#MM#%_ _%#DD#%_, 2006, without incident.
IA|intraarterial|IA|126|127|PROCEDURE PERFORMED|ADMITTING DIAGNOSIS: Anaplastic oligodendroglioma. DISCHARGE DIAGNOSIS: Anaplastic oligodendroglioma. PROCEDURE PERFORMED: IV IA chemotherapy. HISTORY OF PRESENT ILLNESS: This is a 38-year-old who has been diagnosed with anaplastic oligodendroglioma who presents for his second cycle of intra-arterial chemotherapy.
IA|intraarterial|IA|270|271|HISTORY OF PRESENT ILLNESS|ADMISSION DIAGNOSIS: Anaplastic astrocytoma. DISCHARGE DIAGNOSIS: Anaplastic astrocytoma. PROCEDURE PERFORMED: IV IA chemotherapy. HISTORY OF PRESENT ILLNESS: This is a 39-year-old male with anaplastic astrocytoma who presents for his next regular scheduled cycle of IV IA chemotherapy. HOSPITAL COURSE: The patient was admitted on the evening of _%#MMDD2006#%_.
IA|(stage) IA|IA,|209|211|HOSPITAL COURSE|Her uterine pathology revealed an endometrioid, adenocarcinoma, FIGO grade 1, with no myometrial invasion. The tumor involved the lower uterine segment, but did not extend to the endocervix, making this stage IA, grade 1 endometrioid adenocarcinoma. 2. CV. This patient had a history of hypertension. She was put on a metoprolol p.r.n. protocol, while oral medications were held perioperatively.
IA|(stage) IA|IA|242|243|HOSPITAL COURSE|She was instructed to return to the Women's Health Center on _%#MM#%_ _%#DD#%_, 2002, to have her staples removed and also to follow up with Dr. _%#NAME#%_ in two weeks for postop check. Further treatment is not necessary, based on her stage IA pathology. However, she should continue close follow up at the Women's Health Center, with q.3month exams. She was discharged on the following medications: 1. Prinivil 5 mg p.o. q.d.
IA|intraarterial|IA|138|139|RECOMMENDATIONS|A CBC, BMP and INR/PTT are all pending for today. ASSESSMENT: GBM here for cycle 1 of IV IA chemo. RECOMMENDATIONS: 1. Follow labs. 2. IV IA chemo as planned. I have personally examined the patient, reviewed and edited the resident's note and agree with the plan of care.
IA|(stage) IA|IA.|402|404|COMPLICATIONS|Findings included enlarged uterus measuring 14 x 13 cm, normal- appearing ovaries and fallopian tubes, as well as enlarged and firm pelvic lymph nodes bilaterally with frozen section being benign; no periaortic lymph node dissection was done secondary to the frozen section of the pelvic lymph nodes. Final pathology revealed the patient's final stage of her grade 1 endometrial carcinoma to be staged IA. She was given a followup appointment with Dr. _%#NAME#%_ _%#NAME#%_ in 2 to 3 weeks' time. She was identified for pathology results prior to her discharge.
IA|intraarterial|IA|208|209|HOSPITAL COURSE|His neurological baseline consisted of a left-sided hemiparesis and decreased vision on the left. After informed consent was obtained, the patient was taken to the operating room, where the patient underwent IA carboplatin therapy, as well as well as IV cytoxan and etoposide. He tolerated the procedure well, and remained at his neurologic baseline.
IA|(stage) IA|IA|147|148|SECONDARY DIAGNOSIS|FINAL DIAGNOSIS: Adenocarcinoma, left lower lobe lung, pathological stage T1N0M0. SECONDARY DIAGNOSIS: Status post right upper lobectomy for stage IA squamous cell carcinoma of right upper lobe lung. COMPLICATIONS: Left lower lobe pneumonia with respiratory failure requiring mechanical ventilation.
IA|intraarterial|IA|363|364|PLAN OF CARE|There are no sensory deficits. LABORATORY AND OTHER DATA: Sodium is 141, potassium is 3.9, BUN 23 and creatinine is 1.0. His white blood cell count is 5.3 and his hemoglobin is 13.5 and his INR is 1.0. ASSESSMENT AND PLAN: The patient is stable preprocedure and is back to his baseline in terms of cognitive and overall physical condition. PLAN OF CARE: 1. IV/IV IA chemotherapy commencing this evening. 2. We will follow his postprocedure blood counts and anticipate discharge to home tomorrow. I have personally examined the patient, reviewed and edited the resident's note and agree with the plan of care.
IA|(stage) IA|IA|214|215|FINAL DIAGNOSES|FINAL DIAGNOSES: 1. Poorly differentiated non-small cell carcinoma, left upper lobe lung with metastases to the mediastinal lymph nodes, pathological stage T1, N2, M0. 2. Status post left lower lobectomy for stage IA adenocarcinoma, left lower lobe lung, 1997. 3. ________________. 4. Hypothyroidism. 5. Diverticulosis of colon. 6. Hyperlipidemia. 7. History of smoking. PROCEDURE: _%#MMDD2002#%_ mediastinoscopy with biopsy of right peritracheal and precarinal lymph nodes, left thoracotomy, left completion intrapericardial pneumectomy, and mediastinal lymph node dissection.
IA|(stage) IA|IA|354|355|DISMISSAL SUMMARY|7. History of smoking. PROCEDURE: _%#MMDD2002#%_ mediastinoscopy with biopsy of right peritracheal and precarinal lymph nodes, left thoracotomy, left completion intrapericardial pneumectomy, and mediastinal lymph node dissection. DISMISSAL SUMMARY: Mrs. _%#NAME#%_ _%#NAME#%_ is a 65-year-old woman who underwent in 1997 a left lower lobectomy for stage IA adenocarcinoma. She had a follow-up course and shows a question of nodularity in the left lung. CT scan showed the 2 cm mass in the left upper lobe lung close to the hilum.
IA|(stage) IA|IA|176|177|PAST MEDICAL HISTORY|REVIEW OF SYSTEMS: Negative. PAST MEDICAL HISTORY: 1. Stage IA endometrioid adenocarcinoma of the endometrium. 2. Stage IIIC endometrioid adenocarcinoma of the ovary. 3. Stage IA granulosis cell tumor of the ovary. 4. Polio as a child. PAST SURGICAL HISTORY: 1. The above-mentioned staging procedure.
IA|(stage) IA|IA|183|184|PAST MEDICAL HISTORY|The patient did well postoperatively and elected for chemotherapeutic treatment because of her ovarian cancer stage III C. REVIEW OF SYSTEMS: Negative. PAST MEDICAL HISTORY: 1. Stage IA endometrioid adenocarcinoma of the endometrium. 2. Stage IIIC endometrioid adenocarcinoma of the ovary. 3. Stage IA granulosis cell tumor of the ovary.
IA|(stage) IA|IA|214|215|DISCHARGE DIAGNOSES|2. Stage IA endometrioid adenocarcinoma of the endometrium. 3. Stage IA granulosa cell tumor of the ovary. 4. Polio as a child. DISCHARGE DIAGNOSES: 1. Stage IIIC endometrioid adenocarcinoma of the ovary. 2. Stage IA endometrioid adenocarcinoma of the endometrium. 3. Stage IA granulosa cell tumor of the ovary. 4. Polio as a child. 5. Status post 4 cycles of intravenous and intraperitoneal chemotherapy.
IA|(stage) IA|IA|146|147|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Stage IIIC endometrioid adenocarcinoma of the ovary. 2. Stage IA endometrioid adenocarcinoma of the endometrium. 3. Stage IA granulosa cell tumor of the ovary. 4. Polio as a child. DISCHARGE DIAGNOSES: 1. Stage IIIC endometrioid adenocarcinoma of the ovary.
IA|(stage) IA|IA|86|87|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Stage IIIC endometrioid adenocarcinoma of the ovary. 2. Stage IA endometrioid adenocarcinoma of the endometrium. 3. Stage IA granulosa cell tumor of the ovary. 4. Polio as a child. DISCHARGE DIAGNOSES: 1. Stage IIIC endometrioid adenocarcinoma of the ovary.
IA|(stage) IA|IA|284|285|HISTORY OF PRESENT ILLNESS|COMPLICATIONS: None apparent. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 58-year-old with a diagnosis of stage IIIC endometrioid adenocarcinoma of the ovary with the concurrent stage IA granulosa cell tumor of the ovary. At the same time, she was also diagnosed stage IA endometrioid adenocarcinoma of the uterus. The patient initially presented with a concerned of postmenopausal bleeding diagnosed with complex to atypical hyperplasia and ultimately she underwent a laparoscopic bilateral salpingo-oophorectomy.
IA|(grade) IA|IA|179|180|HOSPITAL COURSE|The patient underwent echo, and biopsy prior to discharge, this was performed on _%#MMDD2007#%_. The results are: LV ejection fraction of approximately 55% and inflammatory grade IA with no evidence of rejection. All other systems were stable during this hospitalization. The patient did have 1, isolated episode of loss of vision in his right eye for which the Neurology Service was consulted.
IA|(grade) IA|IA.|321|323|MAJOR PROCEDURES|Orthotopic cardiac transplantation. Endomyocardial biopsy. The patient's right heart pressures were right atrium 25 mmHg mean, RA 23 mmHg end-diastolic pressure, PA 56/32 with a mean of 40 mmHg and a wedge pressure of 32. Histopathology of the endomyocardial biopsy showed no evidence of ejection with inflammatory grade IA. BRIEF HISTORY OF PRESENTING ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is a 63-year-old gentleman who is status post orthotopic heart transplant in 1994 who presented to the ED with 3 days of fevers and altered mental status.
IA|(stage) IA|IA|25|26|PRIMARY DIAGNOSIS|PRIMARY DIAGNOSIS: Stage IA papillary serous carcinoma of the endometrium. PRIMARY PRINCIPAL PROCEDURE PERFORMED: Total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic and periaortic lymphadenectomy, omentectomy, multiple random biopsies/staging procedure.
IA|(stage) IA|IA|211|212|HOSPITAL  COURSE|The surgery was uneventful. There was no evidence grossly of any metastatic disease. Her diet was slowly advanced and she was discharged home on _%#MMDD2006#%_. Final histopathology revealed a noninvasive stage IA papillary serous carcinoma of the endometrium. I instructed the patient that we would have a pathology review on this for deciding whether or not with regard to follow-up therapy.
IA|(stage) IA|IA|286|287|PAST MEDICAL HISTORY|Prior to this, she has had no history of diarrhea, crampy abdominal pain or inflammatory bowel disease. PAST MEDICAL HISTORY: Surgical: _%#MM2005#%_, Dr. _%#NAME#%_ _%#NAME#%_ performed a total abdominal hysterectomy-bilateral salpingo-oophorectomy-omentectomy-appendectomy for a stage IA endometrial cancer. No adjuvant therapy has been necessary. The patient has done well until onset of problems two days ago. Medical: 1. Endometrial cancer with no evidence of recurrence.
IA|(stage) IA|IA|193|194|HISTORY OF PRESENT ILLNESS|COMPLICATIONS: None. HISTORY OF PRESENT ILLNESS: This patient is a 55-year-old with recurrent cervical cancer, who presents for admission for chemotherapy. The patient was diagnosed with stage IA adenocarcinoma of the cervix in 2002. She had had an abnormal Pap smear in 2002 that led to a LEEP procedure being performed.
IA|intraarterial|IA,|214|216|HOSPITAL COURSE|3. Thyroid nodule removed at age 39. 4. Thyroidectomy at age 69. 5. Hypertension, treated. 6. GERD, treated. HOSPITAL COURSE: PROBLEM #1: leiomyosarcoma: The patient was admitted and was started on chemotherapy of IA, including doxorubicin 18.75 mg days 1- 7, continuous infusion, for a total cycle dose of 130 mg; ifosamide 1.5 g per day, was turned up to 3 grams per day days 1-6, for a total cycle dose of 18 g over 6 days; mesna 1.5 g per day and individual dose of 3 g per day, for a total cycle does of 12 g days 1-7 given over 7 days.
IA|intraarterial|IA|249|250|DISCHARGE INSTRUCTIONS|She has been notified to contact us for any increased pain, drainage, swelling, or anything else at the groin puncture site and is instructed to call _%#NAME#%_ _%#NAME#%_ at _%#TEL#%_ if there are any difficulties. She will follow with her next IV IA chemotherapy cycle with a head CT scheduled for _%#MMDD2007#%_ as an outpatient followed by IV IA chemotherapy _%#MMDD2007#%_. She will also get CBC with differential, and platelets while receiving chemotherapy.
IA|intraarterial|IA|261|262|DISCHARGE INSTRUCTIONS|He should monitor his temperature daily for 3 days. He is instructed to call neurosurgery for any increased pain, drainage, swelling, or temperature 100.4 at the groin puncture site and to call _%#NAME#%_ _%#NAME#%_ at _%#TEL#%_ with any questions. His next IV IA chemotherapy cycle, he is to have head CT on _%#MMDD2007#%_ and to have IV IA chemo on _%#MMDD2007#%_ with admission on _%#MMDD#%_.
IA|intraarterial|IA|339|340|DISCHARGE INSTRUCTIONS|He should monitor his temperature daily for 3 days. He is instructed to call neurosurgery for any increased pain, drainage, swelling, or temperature 100.4 at the groin puncture site and to call _%#NAME#%_ _%#NAME#%_ at _%#TEL#%_ with any questions. His next IV IA chemotherapy cycle, he is to have head CT on _%#MMDD2007#%_ and to have IV IA chemo on _%#MMDD2007#%_ with admission on _%#MMDD#%_. While receiving chemo, he is to have a complete blood count with differential, platelets weekly.
IA|intraarterial|IA|103|104|ADMISSION DIAGNOSIS|His puncture site was clean, dry and intact. His intraarterial chemotherapy was carboplatin at 684 mg. IA chemotherapy on day 1 and day 2, IV chemotherapy with Cytoxan and etoposide 564.3 and 342 mg IV respectively. After the procedure, there were no complications. He was ambulating and having good pain control prior to discharge.
IA|(stage) IA|IA|30|31|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Stage IA grade 1 squamous cell carcinoma of the cervix. 2. Hypertension. 3. Congenital right renal agenesis. 4. Anxiety and depression. 5. Osteopenia. DISCHARGE DIAGNOSES: 1. Stage IA grade 1 squamous cell carcinoma of the cervix.
IA|(stage) IA|IA|125|126|DISCHARGE DIAGNOSES|2. Hypertension. 3. Congenital right renal agenesis. 4. Anxiety and depression. 5. Osteopenia. DISCHARGE DIAGNOSES: 1. Stage IA grade 1 squamous cell carcinoma of the cervix. 2. Hypertension. 3. Congenital right renal agenesis. 4. Anxiety and depression. 5. Osteopenia. 6. Acute blood loss anemia. PROCEDURES: Robot assisted laparoscopy converted to exploratory laparotomy, total abdominal hysterectomy, and bilateral salpingo-oophorectomy with an upper vaginectomy.
IA|(stage) IA|IA|97|98|PROBLEM #2|EBL was 400 mL. Please see the operative report for complete details. PROBLEM #2: Disease: Stage IA grade 1 squamous cell carcinoma of the cervix: Final pathology revealed no residual squamous cell carcinoma with benign leiomyomas and atrophic endometrium.
IA|intraarterial|IA|160|161|PLAN|ASSESSMENT: Right temporal glioblastoma multiforme (GBM) here for cycle 9 of IV/IA chemo with carboplatin; neurologically stable. PLAN: 1. IV chemo tonight. 2. IA chemo in a.m. 3. DC home after IA chemo. I have personally examined the patient, reviewed and edited the resident's note and agree with the plan of care.
IA|intraarterial|IA|148|149|HOSPITAL COURSE|The patient was discharged to home on postoperative day #1. This was following approximately 1.2 g of Cytoxan IV on day 1 and 360 mg of carboplatin IA on day 2. At the time of discharge, the patient was awake, alert and oriented and had no new neurological complaints or deficits.
IA|intraarterial|IA|122|123|OPERATION/PROCEDURES PERFORMED IN THIS HOSPITAL ADMISSION|ADMISSION/DISCHARGE DIAGNOSIS: Anaplastic oligoastrocytoma. OPERATION/PROCEDURES PERFORMED IN THIS HOSPITAL ADMISSION: IV IA chemotherapy without blood-brain barrier disruption. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 37-year-old man with a history of right hemispheric anaplastic oligoastrocytoma who has completed 8 previous cycles of IV IA chemotherapy.
IA|intraarterial|IA|170|171|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 37-year-old man with a history of right hemispheric anaplastic oligoastrocytoma who has completed 8 previous cycles of IV IA chemotherapy. He presented to the hospital on _%#MMDD2006#%_ for cycle #9 of IV IA chemotherapy. HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted on the night of _%#MMDD2006#%_ and he underwent his IV chemotherapy.
IA|intraarterial|IA|253|254|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 37-year-old man with a history of right hemispheric anaplastic oligoastrocytoma who has completed 8 previous cycles of IV IA chemotherapy. He presented to the hospital on _%#MMDD2006#%_ for cycle #9 of IV IA chemotherapy. HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted on the night of _%#MMDD2006#%_ and he underwent his IV chemotherapy.
IA|intraarterial|IA|193|194|HOSPITAL COURSE|HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted on the night of _%#MMDD2006#%_ and he underwent his IV chemotherapy. On the morning of _%#MMDD2006#%_, he underwent his additional carotid cycle #9 IA chemotherapy with 720 mg of carboplatin into his right internal carotid artery. He tolerated the procedure and was returned to the floor where he was observed for a 6 hours period.
IA|intraarterial|IA|150|151|HOSPITAL COURSE|On Wednesday's, he is to have a head CT to evaluate his tumor on _%#MMDD2006#%_ at 12:40 p.m. and he is to have an admission for his next cycle of IV IA chemotherapy on _%#MMDD2006#%_ after his head CT. He is to monitor for any signs of increased drainage, pain, swelling at his groin puncture site as well as a temperature of 100.4 degrees Fahrenheit or higher and to report these to a physician or the chemotherapy nurse as soon as should he see any of these symptoms.
IA|intraarterial|IA|164|165|HISTORY OF PRESENT ILLNESS|Briefly, the patient was first diagnosed in 2002 after complaining of right knee pain. After diagnosis of osteosarcoma by biopsy, the patient underwent 6 cycles of IA chemotherapy followed by 3 cycles of cisplatin. Unfortunately, the patient had recurrence of his cancer in the lungs, which were resected. After his second pulmonary recurrence, he underwent Doxil and Avastin chemotherapy, which he responded to however upon further resection, had severe bleeding complications.
IA|intraarterial|IA|195|196|INSTRUCTIONS|She will have CBC with differential and platelets weekly while seen in chemotherapy. She should have an MRI on _%#MMDD2007#%_ at 12 p.m. at the hospital, report to admission after that. Her next IA is scheduled for _%#MMDD2007#%_ at 9 a.m. She should monitor for increased drainage, pain or swelling at the groin puncture site or temperature greater than 100.4, she should contact _%#TEL#%_ should she notice any of these signs.
IA|intraarterial|IA|176|177|OPERATIONS/PROCEDURES PERFORMED THIS ADMISSION|ADMITTING DIAGNOSIS: Anaplastic oligodendroglioma. DISCHARGE DIAGNOSIS: Anaplastic oligodendroglioma. OPERATIONS/PROCEDURES PERFORMED THIS ADMISSION: IV Cytoxan, etoposide and IA carboplatin therapy per the standard protocol. HISTORY OF PRESENT ILLNESS AND PAST MEDICAL HISTORY: Please see the admission H and P for details.
IA|(stage) IA|IA,|125|127|DIAGNOSES AT THE TIME OF DISCHARGE|2. History of familial adenomatous polyposis. 3. Intra-abdominal desmoid tumor. DIAGNOSES AT THE TIME OF DISCHARGE: 1. Stage IA, grade 1 endometrioid adenocarcinoma of the endometrium. 2. Familial adenomatous polyposis. 3. Resection of desmoid tumor of the small intestine, pathology benign.
IA|(stage) IA|IA|201|202|HOSPITAL COURSE|HOSPITAL COURSE: Prior to the patient's discharge home, her final pathology returned and revealed no evidence of remaining cancer in the specimen, therefore her final diagnosis remained grade 1, stage IA adenocarcinoma of the endometrium. Her postoperative care was managed by both the GYN-Oncology service and the colorectal service. The patient remained n.p.o. with an NG tube to suction until postoperative day #2 when her diet was advanced to ice chips only.
IA|(grade) IA|IA.|156|158|HOSPITAL COURSE|At the time of discharge, she has been returned to her prehospitalization insulin pump regimen. Heart biopsy on the day of discharge was inflammatory grade IA. Pacemaker wires were removed uneventfully and she was ready for discharge. DISCHARGE INSTRUCTIONS: 1. Diet: Diabetic, cardiac. 2. She will check and record her blood sugar q.a.c. and each day at bedtime and more often as needed.
IA|(status) IA|IA.|378|380|HOSPITAL COURSE|It also showed several long clots of blood. She did have a right heart cath the day prior to developing hemoptysis but the balloon was not inflated in the pulmonary artery, which, otherwise, could have been a contributor to developing hemoptysis. In addition, the patient was intubated in the ICU. Pulmonary consult was obtained. The patient's transplant status was upgraded to IA. She remained intubated and was relatively stable until the morning of _%#MMDD2006#%_. She became hypotensive on the morning of _%#MMDD2006#%_ and was profoundly acidotic.
IA|(stage) IA|IA|196|197|ALLERGIES|ALLERGIES : No known drug allergies. MEDICATIONS : She takes Ritalin 5 mg b.i.d. and vitamins. PAST MEDICAL HISTORY : 1. Status post splenectomy. 2. Hysterectomy in 1989. 3. Hodgkin disease stage IA in 1983 treated with radiation. 4. She had a head injury in _%#MM#%_ of 1999 with some chronic brain symptoms. 5. Heart disease. She has left subclavian artery stenosis secondary to radiation.
IA|(stage) IA|IA|199|200|HISTORY OF PRESENT ILLNESS|The patient was seen in consultation on _%#MMDD2007#%_ at which time, decision was made for the patient to undergo wide local excision. Wide local excision pathology results were suggestive of stage IA disease of the vulva. For this reason, she was seen in clinic on _%#MMDD2007#%_. At that time, with the diagnosis of invasive condylomatous carcinoma of the vulva, the decision was made and the patient was consented to return to the operating room for radical excision of the tissue surrounding the area of the previous biopsy.
IA|(stage) IA|IA|172|173|HOSPITAL COURSE|HOSPITAL COURSE: 1. Disease: The patient was taken to the operating room on _%#MMDD2007#%_ where she underwent a radical vulvectomy. Intraoperative findings included stage IA squamous cell vulvar carcinoma. Final pathology is pending. The patient is scheduled to follow up with Dr. _%#NAME#%_ _%#NAME#%_ in 2-3 weeks to discuss final pathology results and future treatment planning.
IA|(grade) IA|IA,|217|219|HOSPITAL COURSE|The patient's chest x-ray was clear and lungs were fully expanded following removal of chest tubes. The patient did have a right heart catheterization and cardiac biopsy on _%#MMDD2007#%_ revealing inflammatory level IA, with no evidence of reduction. The patient also had an echocardiogram on _%#MMDD2007#%_ as a routine procedure related to the transplantation.
IA|(stage) IA|IA,|133|135|HISTORY|CHIEF COMPLAINT: Fever HISTORY: _%#NAME#%_ _%#NAME#%_ is a 34-year-old male who was diagnosed with Hodgkin's disease recently, stage IA, started chemotherapy with ABVD regimen about a week ago. He had right cervical lymph node involvement that was removed and was diagnostic for Hodgkin's.
IA|intraarterial|IA|124|125|PROCEDURE PERFORMED|DISCHARGE DIAGNOSIS: Non-small cell lung cancer with brain metastasis. PROCEDURE PERFORMED: 1. IV Cytoxan and etoposide. 2. IA carboplatin. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 52-year- old female with a history of metastatic non-small cell carcinoma to the lung, diagnosed _%#MM2003#%_.
IA|intraarterial|IA|211|212|HISTORY OF PRESENT ILLNESS|The patient has previously had chemotherapy and radiation. The patient underwent a re-staging imaging which found a new hemorrhagic metastatic mass in the brain in the left frontal area. The patient is here for IA and IV chemotherapy again. The patient was admitted and underwent the chemotherapy treatment. She tolerated the procedure well and did not have any events after the procedure.
IA|(grade) IA|IA,|182|184|ADMISSION LABORATORY|Cyclosporin 129. U/A 1.011, otherwise negative. Cytology path results: On _%#MMDD2004#%_ one sample inflammatory grade 0. On _%#MMDD2004#%_ four samples grade I, three samples grade IA, one sample inflammatory grade 0, one sample with organizing mural thrombus, increased interstitial fibrous tissue. HOSPITAL COURSE: 1. Status post cardiac transplant with symptoms of fatigue and also decreased E.F. on echo.
IA|(stage) IA|IA|115|116|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Fever, suspecting chemotherapy related. 2. Chronic obstructive pulmonary disease. 3. Stage IA right sided non-small cell lung cancer. 4. Essential hypertension. 5. Diabetes. 6. Pulmonary hypertension. 7. Question about diastolic dysfunction.
IA|(stage) IA|IA|170|171|DISCHARGE DICTATIONS|4. Essential hypertension. 5. Diabetes. 6. Pulmonary hypertension. 7. Question about diastolic dysfunction. DISCHARGE DICTATIONS: This is a 66-year-old female with Stage IA right sided non-small cell lung CA status post radiation therapy, status post chemotherapy admitted with fever and shortness of breath.
IA|(grade) IA|IA|154|155|OPERATIONS/PROCEDURES PERFORMED|C. Mild LAE. D. Mild to moderate MR and RV systolic pressure mildly increased about 27 mm above mean right atrial pressure. 4. Heart biopsy showing grade IA rejection performed on _%#MM#%_ _%#DD#%_, 2004. 5. Right heart catheterization was also at this time showing hemodynamics with RA pressure of 12 and RV pressure of 35/12, a PA pressure of 35/20 with a mean of 24, a wedge pressure with a mean of 16, a FIC cardiac output was 6.3 with the index being 3.6. Stroke volume was 68.5. COMPLICATIONS OF THIS HOSPITALIZATION: None.
IA|intraarterial|IA.|244|246|HOSPITAL COURSE|The patient is here for chemotherapy. HOSPITAL COURSE: The patient was admitted on _%#MM#%_ _%#DD#%_, 2004, and had cycle 1 of blood brain barrier disruption with left internal carotid. He had Cytoxan and etoposide IV. He also had methotrexate IA. He had a port placed on day 2 in the right internal carotid. He had methotrexate IA. He also had Cytoxan and etoposide IV.
IA|(stage) IA|IA|142|143|HISTORY OF PRESENT ILLNESS|No washings were obtained during that surgery, but no spread of disease was noted. Based on initial pathology, the patient has at least stage IA adenocarcinoma of the fallopian tube, and was referred to Dr. _%#NAME#%_ for discussion of further staging. The patient is quite healthy, and has no medical problems other than fibromyalgia.
IA|(stage) IA|IA,|126|128|DISCHARGE DIAGNOSES|ADMISSION DIAGNOSES: 1. History of breast cancer. 2. Endometrial cancer. DISCHARGE DIAGNOSES: 1. History of breast cancer. 2. IA, grade-1 endometrial adenocarcinoma. HISTORY OF PRESENT ILLNESS: This is a 42-year-old patient who in 1998 was diagnosed with breast cancer.
IA|(stage) IA|IA,|248|250|PHYSICAL EXAMINATION|Hematologically, the patient remained quite stable, and her discharge hemoglobin was 12.0. On postoperative day #3, the patient was feeling quite well and felt ready for discharge. Her pathology did return, and the final pathology again revealed a IA, grade-1 endometrial cancer with no evidence for myometrial invasion, and the patient was informed of these results. DISCHARGE INSTRUCTIONS: The patient was discharged to home with instructions to call for any fevers greater than 100.4, or any increased drainage, pain, or swelling from her incision.
IA|Iowa|IA.|137|139|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: The patient is to follow up with her primary, Dr. _%#NAME#%_ _%#NAME#%_ at _%#CITY#%_ Iowa Clinic in _%#CITY#%_, IA. The number is _%#TEL#%_ for a BNP and magnesium at that time and for a blood pressure check. The patient is to take no NSAID's. She is to seek medical attention should she develop a recurrent dyspnea.
IA|(stage) IA|IA|88|89|DISCHARGE DIAGNOSES|2. Bipolar disease. 3. Depression. 4. Psychosis. DISCHARGE DIAGNOSES: 1. Grade 1, Stage IA endometrial cancer. 2. Bipolar disease. 3. Depression. 4. Psychosis. 5. Status post appendectomy secondary to fecalith in appendix. PROCEDURES PERFORMED: Total abdominal hysterectomy, bilateral salpingo-oophorectomy, appendectomy, washings. HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old female with a history of bipolar disease admitted with acute depression and psychosis to the Psychiatric Unit at Fairview-University Medical Center, _%#CITY#%_ campus, at the end of _%#MM#%_ 2004.
IA|(stage) IA|IA|179|180|HOSPITAL COURSE|There were no apparent complications. The patient tolerated the procedure well (please see operative report for details). Final pathology came back consistent with grade 1, Stage IA endometrioid adenocarcinoma with no evidence of myometrial invasion. Washings came back showing atypical cells present (a single cluster with atypical but degenerated cells).
IA|intraarterial|IA|237|238|ADMISSION DIAGNOSIS|That was discontinued due to pulmonary fibrosis. The patient's last cycle was in _%#MM#%_, and the patient presents for cycle No. 9. HOSPITAL COURSE: The patient was admitted and underwent blood brain barrier disruption with carboplatin IA and etoposide and Cytoxan IV. On day No. 2, she had Cytoxan and etoposide IV and carboplatin IA. The patient tolerated both days of the chemotherapy well, and had an unremarkable postoperative course.
IA|intraarterial|IA.|203|205|ADMISSION DIAGNOSIS|9. HOSPITAL COURSE: The patient was admitted and underwent blood brain barrier disruption with carboplatin IA and etoposide and Cytoxan IV. On day No. 2, she had Cytoxan and etoposide IV and carboplatin IA. The patient tolerated both days of the chemotherapy well, and had an unremarkable postoperative course. At the time of discharge, she was alert, oriented, and moving all 4 extremities well, and speech was fluent.
IA|intraarterial|IA|176|177|DISCHARGE DIAGNOSIS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 45-year-old gentleman with a history of left frontal anaplastic oligodendroglioma. The patient presents for left ICA cycle 4 of IA chemotherapy. HOSPITAL COURSE: The patient was admitted and underwent the above-mentioned procedure. The patient was admitted and underwent IA chemotherapy. He was given 800 mg carboplatin and 200 mL of normal saline infused over 10 minutes.
IA|intraarterial|IA|188|189|DISCHARGE DIAGNOSIS|The patient presents for left ICA cycle 4 of IA chemotherapy. HOSPITAL COURSE: The patient was admitted and underwent the above-mentioned procedure. The patient was admitted and underwent IA chemotherapy. He was given 800 mg carboplatin and 200 mL of normal saline infused over 10 minutes. He tolerated that procedure well and did not have any procedural events.
IA|intraarterial|IA,|257|259|DISCHARGE DIAGNOSIS|Subsequent biopsy revealed a high-grade chondroblastic osteosarcoma. She received 3 cycles of ifosfamide and Adriamycin, and then underwent surgical resection in _%#MM#%_ 2003. Postoperatively, the patient was to start a postoperative course of 5 cycles of IA, but after the first cycle, developed an infection in the surgical area. This was treated with surgical interventions and an extended course of antibiotic therapy.
IA|(stage) IA|IA,|25|27|PRIMARY DIAGNOSIS|PRIMARY DIAGNOSIS: Stage IA, grade 2 endometrial carcinoma. SECONDARY DIAGNOSES: None. PROCEDURE: Total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic and periaortic lymphadenectomy.
IA|(stage) IA|IA.|89|91|PRIMARY DIAGNOSIS|PRIMARY DIAGNOSIS: Papillary serous tumor of low malignant potential (left ovary), stage IA. PROCEDURE: Left salpingo-oophorectomy, hysterectomy and staging procedure. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 37-year-old woman who presented to my office with an approximately 5-6 cm left adnexal mass.
IA|intraarterial|IA|208|209|HISTORY OF PRESENT ILLNESS|At baseline, he does have a left-sided hemiparesis. His hemiparesis is worse in the arm than the leg. He had noticed that it had gotten worse over the preceding few weeks, and therefore, elected to begin the IA chemotherapy regimen. HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted to the hospital for overnight stay and the following morning, he received both Port-A-Cath placement as well as his first intraarterial chemotherapy treatment.
IA|intraarterial|IA|156|157|HISTORY OF PRESENT ILLNESS|This was diagnosed in _%#MM#%_ 2005. Biopsy was performed in _%#MM#%_ 2005, by orthopedic surgery revealing a malignant tumor. She has received 2 cycles of IA in _%#MM#%_ 2005, and _%#MM#%_ 2005. She has tolerated both of these chemotherapy. Course is with minimal toxicity. She was admitted on _%#MM#%_ _%#DD#%_, 2005, for her third course of ifosfamide, mesna, and doxorubicin.
IA|intraarterial|IA|249|250|ADMISSION DIAGNOSIS|In _%#MM#%_ 2005, he was found to have a recurrent enhancing lesion on MRI, and in _%#MM#%_ 2005 had a PET scan that confirmed active disease. At that point, he was assessed in the Neurooncology Clinic, and the decision was made to proceed with IV, IA chemotherapy. HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted to the University of Minnesota Medical Center, Fairview, on _%#MM#%_ _%#DD#%_, 2005. After admission, he was assessed by the neurosurgery, neurooncology services and then he was started on the standard regimen for chemotherapy administration.
IA|intraarterial|IA|264|265|HISTORY OF PRESENT ILLNESS|1. Metastatic osteosarcoma. 2. Acute hepatitis secondary to high-dose methotrexate. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 28-year-old male who was diagnosed with chondroblastic osteosarcoma of the left forearm in _%#MM#%_ 2004. He had 3 cycles of IA followed by surgical resection of the left radius in _%#MM#%_ 2004. He then received 3 more cycles of IA followed by 3 cycles of Cisplatin.
IA|intraarterial|IA|124|125|HISTORY OF PRESENT ILLNESS|He had 3 cycles of IA followed by surgical resection of the left radius in _%#MM#%_ 2004. He then received 3 more cycles of IA followed by 3 cycles of Cisplatin. He completed his chemotherapy in _%#MM#%_ 2004. He did not have evidence of any local recurrence or metastatic disease until _%#MM#%_ 2005, when a CT imaging revealed multiple bilateral pulmonary nodules.
IA|intraarterial|IA,|156|158|HISTORY OF PRESENT ILLNESS|The patient was then evaluated in the clinic on _%#MM#%_ _%#DD#%_, 2005, by Dr. _%#NAME#%_. Since the patient had improved tolerance of his second cycle of IA, it was decided to proceed with a third cycle. Therefore, the patient was admitted on _%#MM#%_ _%#DD#%_, 2005, for cycle #3. HOSPITAL COURSE: Following admission, the patient was started on a 6-day continuous IV infusion of isophosphamide and a 7-day infusion of mesna.
IA|(stage) IA|IA|48|49|PRIMARY DIAGNOSIS DURING HOSPITALIZATION|PRIMARY DIAGNOSIS DURING HOSPITALIZATION: Stage IA granulosis cell tumor. SECONDARY DIAGNOSES: None. PROCEDURE PERFORMED: Laparoscopic-assisted left salpingo-oophorectomy, pelvic and periaortic lymphadenectomy, staging procedure/exploratory laparotomy.
IA|(grade) IA|IA|180|181|DISCHARGE DIAGNOSIS|4. Problems since transplantation include hypertension, pneumonia, and mild renal insufficiency. 5. Last endomyocardial biopsy showed increase in the level of rejection from grade IA to IB. 6. Repeat endomyocardial biopsy on _%#MM#%_ _%#DD#%_, 2004, showed inflammatory grade IA. HOSPITAL COURSE: CMV infection. During the patient's hospitalization, he had multiple temperature spikes to a maximum of 102.1. He was initially started on gatifloxacin empirically.
IA|(grade) IA|IA.|179|181|DISCHARGE DIAGNOSIS|5. Last endomyocardial biopsy showed increase in the level of rejection from grade IA to IB. 6. Repeat endomyocardial biopsy on _%#MM#%_ _%#DD#%_, 2004, showed inflammatory grade IA. HOSPITAL COURSE: CMV infection. During the patient's hospitalization, he had multiple temperature spikes to a maximum of 102.1. He was initially started on gatifloxacin empirically.
IA|(stage) IA|IA,|173|175|REASON FOR ADMISSION|The patient has a history of follicular lymphoma, status post acyclovir/Rituxan, with the last cycle being on _%#MMDD2004#%_. He was originally diagnosed in 1998 with stage IA, with disease in the left groin. After that he had radiation, and then progression of the disease. In early 2003, he was treated with chlorambucil. The disease once again progressed, and he was treated with Rituxan.
IA|intraarterial|IA|171|172|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: Right frontal glioblastoma multiforme. OPERATIONS/PROCEDURES PERFORMED: Blood-brain barrier disruption chemotherapy with IV Cytoxan and etoposide and IA carboplatin on _%#MM#%_ _%#DD#%_, 2004 and _%#MM#%_ _%#DD#%_, 2004. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 35-year-old white female with a history of GBM with recurrence following resection, chemotherapy with BCNU, and radiation therapy.
IA|intraarterial|IA|136|137|DISCHARGE DIAGNOSIS|HOSPITAL COURSE: The patient was admitted to neurosurgery and taken to the operating room where she underwent her chemotherapy regimen, IA and IV. This is cycle number 4. She had 2 days of this. Carboplatin was administered IA and Cytoxan and etopside given IV.
IA|intraarterial|IA|224|225|DISCHARGE DIAGNOSIS|HOSPITAL COURSE: The patient was admitted to neurosurgery and taken to the operating room where she underwent her chemotherapy regimen, IA and IV. This is cycle number 4. She had 2 days of this. Carboplatin was administered IA and Cytoxan and etopside given IV. DISCHARGE INSTRUCTIONS: 1. Diet regular. 2. Activity as tolerated. 3. Call with temperature greater than 100 over the next 7 days, any pain, swelling of the groin puncture site, mental status changes, weakness, numbness, tingling, speech problems.
IA|UNSURED SENSE|IA|171|172|HOSPITAL COURSE|Right atrium is 13, PA 59/34 with mean of 44, W is 28 with V wave of 34, and Fick cardiac index is 1.3. EKGs showed sinus at 78, no Q waves, poor R wave progression; TWI, IA at VL, V5 through V6. The fellow gave the impression that there was severe ischemic cardiac disease in the young gentleman and elevated filling pressures.
IA|intraarterial|IA,|169|171|HOSPITAL COURSE|This was on the recommendation of the previous infectious disease consult. 3. Leiomyosarcoma: As mentioned, the patient was status post first cycle of chemotherapy with IA, completed on _%#MM#%_ _%#DD#%_, 2005. She received Neulasta and her elevated white counts during the hospital stay were in part attributed to the Neulasta injection.
IA|intraarterial|IA|272|273|HISTORY OF PRESENT ILLNESS|PROCEDURE PERFORMED: Intravenous/intra-arterial chemotherapy with carboplatin. HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old woman with glioblastoma multiforme who has been treated previously with 4 cycles of IV/IA chemotherapy. She presented for cycle 5 of IV IA chemo with carboplatin. For more details, please refer to previously dictated notes in FCIS and Allscripts. HOSPITAL COURSE: The patient was admitted on _%#MMDD2007#%_ and underwent the aforementioned procedure on _%#MMDD2007#%_.
IA|intraarterial|IA|151|152|DISCHARGE INSTRUCTIONS|1. The patient is to follow up for her weekly lab draws. 2. The patient is scheduled for readmission on _%#MM#%_ _%#DD#%_, 2005, for her next round of IA chemotherapy. 3. The patient should review her Port-A-Cath guidelines and chemotherapy discharge booklet. 4. The patient is to return to a carbohydrate-controlled diet.
IA|(stage) IA|IA|163|164|ALLERGIES|Ovaries and fallopian tubes appeared normal. Lymph nodes also appeared normal. There was a 4 x 4-cm umbilical hernia noted. Frozen pathology revealed likely stage IA endometrial cancer. The final pathology results were not available at the time of discharge. The patient is to meet with Dr. _%#NAME#%_ in 2 to 6 weeks to discuss final pathology results and make a plan for future treatments if necessary.
IA|(stage) IA|IA|166|167|PAST SURGICAL HISTORY|HOSPITAL COURSE: 1. Disease: The patient was admitted and underwent an uncomplicated radical vulvectomy with a multilayer closure. Final pathology revealed the stage IA squamous cell carcinoma of the vulva, VAIN 3, and AIN 3. She will follow up with Dr. _%#NAME#%_ in 2 to 3 weeks to discuss the final pathology results and make a plan for future evaluation and treatment.
IA|(stage) IA|IA|138|139|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ is a 46-year-old woman who underwent a right upper lobectomy at an outside hospital for stage IA non-small-cell lung cancer. Her initial postoperative course was unremarkable. In _%#MM#%_ 2005, left supraclavicular and left lower cervical adenopathy was noted on a routine physical examination.
IA|intraarterial|IA|249|250|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: A 32-year-old male with right- sided anaplastic astrocytoma, status post biopsy on _%#MM#%_ _%#DD#%_, 2006, and he is status post radiation and Temodar chemotherapy. On _%#MM#%_ _%#DD#%_, 2006, he received cycle #9 of IV IA chemotherapy. PHYSICAL EXAMINATION: His discharge examination shows him to be afebrile, and his vital signs are stable.
IA|(stage) IA|IA,|39|41|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: 1. At least stage IA, grade 1 mucinous cyst adenocarcinoma of the ovary. 2. Status post exploratory laparotomy, left salpingo-oophorectomy, and abdominoplasty.
IA|(stage) IA|IA,|126|128|DISCHARGE DIAGNOSIS|2. Status post exploratory laparotomy, left salpingo-oophorectomy, and abdominoplasty. DISCHARGE DIAGNOSIS: 1. At least stage IA, grade 1 adenocarcinoma of the ovary. 2. Status post exploratory laparotomy, oophorectomy, and abdominoplasty.
IA|intraarterial|IA|171|172|HISTORY OF PRESENT ILLNESS|He has had 3 previous cycles of IVIA chemotherapy and came to the hospital for cycle #4 of IVIA chemotherapy. His chemotherapy regimen consists of Cytoxan, etoposide, and IA carboplatin. Mr. _%#NAME#%_ came to the hospital and underwent his chemotherapy as planned.
IA|intraarterial|IA|126|127|OPERATIONS/PROCEDURES PERFORMED|ADMISSION/DISCHARGE DIAGNOSIS: Anaplastic oligodendroglioma. OPERATIONS/PROCEDURES PERFORMED: 1. Port-A-Cath placement. 2. IV IA chemotherapy. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 44-year-old woman with a past medical history significant for anaplastic oligodendroglioma diagnosed in 1994.
IA|intraarterial|IA|140|141|HISTORY OF PRESENT ILLNESS|She has had a total of 4 resections as well as chemotherapy. As the patient's MRIs indicate that her tumor is growing, she was seeking a IV IA chemotherapy. HOSPITAL COURSE: Ms. _%#NAME#%_ was admitted to the hospital for her IV IA chemotherapy.
IA|intraarterial|IA|168|169|HOSPITAL COURSE|As the patient's MRIs indicate that her tumor is growing, she was seeking a IV IA chemotherapy. HOSPITAL COURSE: Ms. _%#NAME#%_ was admitted to the hospital for her IV IA chemotherapy. She tolerated this well with no difficulty. She also had a Port-A-Cath placement which she tolerated well. As she has no significant pain, no significant neurologic defects, is eating regular diet, she is to be discharged to home.
IA|intraarterial|IA|152|153|HOSPITAL COURSE|She is also to check in at the admissions department at 4:00 p.m. on _%#MM#%_ _%#DD#%_, 2006, for an admission to the hospital for her next cycle of IV IA chemotherapy. She is to contact a physician for any signs of increased drainage, pain, swelling, or temperature of 100.4 degrees or higher, and any problems with the port incision or groin puncture site.
IA|(stage) IA|IA|101|102|DISCHARGE DIAGNOSES|2. Stage IIB squamous cell carcinoma of the cervix in the remote past. DISCHARGE DIAGNOSES: 1. Stage IA grade 1 endometrioid adenocarcinoma of the endometrium. 2. Stage IIB squamous cell carcinoma of the cervix in the remote past. OPERATIONS/PROCEDURES PERFORMED: 1. Exploratory laparotomy, supracervical hysterectomy, bilateral salpingo-oophorectomy, lysis of adhesions, and conization of the cervix.
IA|(stage) IA|IA|254|255|SECONDARY DIAGNOSIS|FINAL DIAGNOSIS: Poorly differentiated nonsmall cell carcinoma left lower lobe lung, pathological stage T1N0M0. SECONDARY DIAGNOSIS: 1. Atrial fibrillation. 2. History of coronary disease, status post a right thoracotomy, right upper lobectomy for stage IA nonsmall cell carcinoma of the right upper lobe lung. PROCEDURES: On _%#MMDD2005#%_, left video-assisted thoracoscopy with wedge resection of left lower lobe lung nodule, left thoracotomy, left lower lobectomy and mediastinal lymph node dissection.
IA|(stage) IA|IA|219|220|DISMISSAL SUMMARY|DISMISSAL SUMMARY: Mr. _%#NAME#%_ _%#NAME#%_ is a 78-year-old gentleman who was seen for an enlarging indeterminate left lower lobe lung nodule. In 2000 he underwent a right thoracotomy, right upper lobectomy for stage IA adenocarcinoma of the right upper lobe lung. His tolerance to activity has been good. There is no significant shortness of breath.
IA|intraarterial|IA|177|178|FOLLOW UP|2. He is to follow up with an MRI on _%#MM#%_ _%#DD#%_, 2005, at 1 p.m. in the hospital radiology department and then proceed to the admissions department for the next round of IA chemotherapy. 3. Resume a regular diet. 4. Report any increased pain, increased swelling, or increased drainage at the groin puncture site.
IA|(stage) IA|IA|161|162|SECONDARY DIAGNOSES|FINAL DIAGNOSIS: Squamous cell carcinoma, left lower lobe lung, pathological stage T1N0M0. SECONDARY DIAGNOSES: 1. Status post right lower lobectomy for a stage IA nonsmall cell carcinoma, right lower lobe lung. 2. Hypertension. 3. Chronic obstructive pulmonary disease. 4. Esophageal reflux. 5. Hyperlipidemia. 6. Status post hip replacement. 7. Status post knee replacement.
IA|(stage) IA|IA|257|258|DISMISSAL SUMMARY|8. History of depression. PROCEDURE: _%#MMDD2006#%_ - left thoracotomy anatomical superior segmentectomy left lower lobe lung and mediastinal lymph node dissection. DISMISSAL SUMMARY: Ms. _%#NAME#%_ _%#NAME#%_ is a 59-year-old woman with a history of stage IA squamous cell carcinoma of the right lower lobe lung which was resected a year and a half ago with a right lower lobectomy.
IA|(stage) IA|IA|94|95|DISCHARGE DIAGNOSIS|ADMISSION DIAGNOSIS: Grade 3 carcinosarcoma on endometrial biopsy. DISCHARGE DIAGNOSIS: Stage IA grade 3 adenocarcinoma of the endometrium on final pathology. OPERATIONS/PROCEDURES PERFORMED: 1. Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvis and periaortic lymph node dissection.
IA|intraarterial|IA|186|187|PROCEDURES PERFORMED|ADMITTING STAFF: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD. ADMITTING DIAGNOSIS: Anaplastic oligodendroglioma. DISCHARGE DIAGNOSIS: Anaplastic oligodendroglioma. PROCEDURES PERFORMED: IV and IA chemotherapy. HISTORY OF PRESENT ILLNESS: This is a 52-year-old gentleman with anaplastic oligodendroglioma who presents for his next regular cycle of intravenous intra-arterial chemotherapy.
IA|intraarterial|IA|496|497|HISTORY OF PRESENT ILLNESS|ADMISSION DIAGNOSIS: Glioblastoma multiforme. DISCHARGE DIAGNOSIS: Glioblastoma multiforme. OPERATIONS/PROCEDURES PERFORMED: Intra-arterial chemotherapy on _%#MM#%_ _%#DD#%_, 2006. HISTORY OF PRESENT ILLNESS: An 18-year-old male with a history of glioblastoma multiforme status post a resection on _%#MM#%_ _%#DD#%_, 2005, radiation therapy, Temodar, and he had his first cycle on _%#MM#%_ _%#DD#%_, 2006, and presents for his second cycle of IV/IA chemotherapy with IV Cytoxan and etoposide and IA carboplatin. PAST MEDICAL HISTORY: Status post hyperbaric oxygen therapy. HOSPITAL COURSE: Uneventful for neurological, hematological, or infectious complications.
IA|intraarterial|IA|175|176|ADMISSION DIAGNOSIS|She was then followed with sequential MRIs. In _%#MM#%_ 2005, she had an MRI-guided biopsy confirming recurrent anaplastic oligodendroglioma. She was soon after started on IV IA chemotherapy with Cytoxan, etoposide, and IA carboplatin to the right internal carotid artery. She was admitted and discharged at this time for cycle #8 of IV IA chemotherapy.
IA|intraarterial|IA|220|221|ADMISSION DIAGNOSIS|She was then followed with sequential MRIs. In _%#MM#%_ 2005, she had an MRI-guided biopsy confirming recurrent anaplastic oligodendroglioma. She was soon after started on IV IA chemotherapy with Cytoxan, etoposide, and IA carboplatin to the right internal carotid artery. She was admitted and discharged at this time for cycle #8 of IV IA chemotherapy. She was admitted to the hospital and underwent the procedure which was uncomplicated.
IA|intraarterial|IA|195|196|ADMISSION DIAGNOSIS|She was soon after started on IV IA chemotherapy with Cytoxan, etoposide, and IA carboplatin to the right internal carotid artery. She was admitted and discharged at this time for cycle #8 of IV IA chemotherapy. She was admitted to the hospital and underwent the procedure which was uncomplicated. She was doing very well postoperatively and was discharged to home.
IA|(stage) IA|IA|211|212|HOSPITAL COURSE|She will be continued on an outpatient basis on Senokot 1 tablet twice a day, Colace 100 mg b.i.d., and Miralax as needed for constipation. Problem list # 2: Diffused large B-cell lymphoma. The patient is stage IA diffuse large B-cell lymphoma involving her left shoulder. She is currently status post 3 cycles of R-CHOP. She will present to Dr. _%#NAME#%_ _%#NAME#%_ upon followup. She was not neutropenic during the hospital stay.
IA|intraarterial|IA|164|165|CHIEF COMPLAINT|Status post hyperbaric oxygen chamber x6 weeks on _%#MM#%_ _%#DD#%_, 2006, and she presents for cycle 8 of her IV/IA chemotherapy with Cytoxan and etoposide IV and IA carboplatin. HOSPITAL COURSE: The hospital course was uneventful for neurological, hematologic, or infectious complications. After admission and IV chemotherapy, the patient underwent her IA chemotherapy which went well.
IA|intraarterial|IA|175|176|CHIEF COMPLAINT|HOSPITAL COURSE: The hospital course was uneventful for neurological, hematologic, or infectious complications. After admission and IV chemotherapy, the patient underwent her IA chemotherapy which went well. There were no complications. She was tolerating regular diet, having good bowel function, voiding spontaneously, and ambulating with minimal assistance prior to discharge.
IA|intraarterial|IA|207|208|OPERATIONS AND PROCEDURES PERFORMED|DISCHARGE DIAGNOSIS: Left temporal lobe glioblastoma multiform, status post total-to-gross resection with adjuvant therapies. OPERATIONS AND PROCEDURES PERFORMED: The patient presented for cycle V of his IV IA chemotherapy, the intraarterial portion of which was administered through the left internal carotid artery. HISTORY OF PRESENT ILLNESS AND PAST MEDICAL HISTORY: Please see previous admission notes.
IA|intraarterial|IA|176|177|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: The patient will resume his standard outpatient medications, which include Decadron, Keppra and ranitidine. He will follow-up for his fifth cycle of IV IA chemotherapy in one month and will call to confirm his appointment with Dr. _%#NAME#%_'s office.
IA|intraarterial|IA|307|308|HISTORY OF PRESENT ILLNESS|ADMISSION DIAGNOSIS: Breast cancer with CNS metastasis. DISCHARGE DIAGNOSIS: Breast cancer with CNS metastasis. PROCEDURES: IV IA chemotherapy. HISTORY OF PRESENT ILLNESS: This is a 39-year-old female with breast cancer who has had metastasis of central nervous system who presents for her next cycle of IV IA chemotherapy. HOSPITAL COURSE: The patient was admitted on _%#MMDD2006#%_ and on _%#MMDD2006#%_ underwent the uneventful administration of intra-arterial chemotherapy without blood-brain barrier disruption through the vertebral artery.
IA|(stage) IA|IA|159|160|DISCHARGE DIAGNOSES|ADMITTING DIAGNOSES: 1. Endometrial cancer. 2. Hypertension. 3. Patent ductus arteriosus, status post repair at age 18. DISCHARGE DIAGNOSES: 1. Grade 1, stage IA endometrial cancer. 2. Hypertension. 3. Patent ductus arteriosus. PROCEDURE: Exploratory laparotomy, total abdominal hysterectomy and bilateral salpingo-oophorectomy.
IA|intraarterial|IA|180|181|HISTORY OF PRESENT ILLNESS|He completed 3D conformational radiation therapy and subsequently started on intravenous, intra-arterial chemotherapy. He presented on _%#MMDD2007#%_ for his third cycle of IV and IA chemo. HOSPITAL COURSE: The patient was admitted on _%#MMDD2007#%_ and received his intravenous chemotherapy.
IA|(stage) IA|IA,|40|42|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Recurrent stage IA, grade 3 adenocarcinoma of the uterus. 2. Failure to thrive. 3. Intractable pain. DISCHARGE DIAGNOSES: 1. Recurrent stage IA, grade 3 adenocarcinoma of the uterus.
IA|(stage) IA|IA,|83|85|DISCHARGE DIAGNOSES|2. Failure to thrive. 3. Intractable pain. DISCHARGE DIAGNOSES: 1. Recurrent stage IA, grade 3 adenocarcinoma of the uterus. 2. Improved caloric intake and weight gain. 3. Pain, under control. 4. Thrush. HISTORY OF PRESENT ILLNESS: This is a 57-year-old patient who in _%#MM2003#%_ noted some postmenopausal bleeding of six to eight months' duration.
IA|Iowa|IA|175|176|DISCHARGE FOLLOW UP|DISCHARGE MEDICATIONS: 1. Metformin 1000 mg bid, Glyburide 10 mg q day. DISCHARGE FOLLOW UP: The patient should follow up with his primary physician in _%#CITY#%_ _%#CITY#%_, IA in the next 3-4 weeks.
IA|intraarterial|IA|304|305|REVIEW OF SYSTEMS|She is admitted for neutropenic precautions and heavy fluids. REVIEW OF SYSTEMS: She denies any seizures, syncope, change in vision, weakness, change in sensation, or bowel or bladder incontinence. She does have severe mouth ulcers, and it hurts to talk. She otherwise has been feeling rundown since her IA chemotherapy. Other review of systems shows she denies any fever or chills. No nausea, vomiting, constipation, or diarrhea. She denies any chest pain or shortness of breath.
IA|(stage) IA|IA|40|41|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Recurrent Stage IA Grade 3-endometrial cancer with clear cell component. Status post external beam radiation therapy. 2. Urinary tract infection. 3. Infected right ureteral stent. DISCHARGE DIAGNOSES: 1. Stage IA Grade 3 endometrial cancer with clear cell component.
IA|(stage) IA|IA|251|252|HISTORY OF PRESENT ILLNESS|1. Replacement of right ureteral stent. 2. Port placement. 3. Chemotherapy with Adriamycin and cisplatin. 4. Intravenous antibiotics for the urinary tract infection. HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old female with recurrent Stage IA Grade 3 endometrial cancer with an infected ureteral stent with a urinary tract infection. She was admitted for further management. The patient had postmenopausal bleeding in _%#MM2003#%_.
IA|(status) IA|IA|158|159|HOSPITAL COURSE|He was started on dobutamine and this seemed to improve his symptoms with increasing urine output and decreasing shortness of breath. He was placed on status IA heart transplant list. He continued to improve when on _%#MM#%_ _%#DD#%_ a donor heart became available and he was determined to be a suitable recipient.
IA|intraarterial|IA.|155|157|DISCHARGE DIAGNOSIS|HOSPITAL COURSE: Patient was admitted and had blood-brain disruption performed in the left internal carotid. He had Cytoxan, etoposide IV and methotrexate IA. He did have a seizure during the methotrexate infusion which resolved with increased Pentothal. On his second blood-brain barrier day in the right internal carotid, he had Cytoxan and etoposide IV and methotrexate IA.
IA|intraarterial|IA.|264|266|DISCHARGE DIAGNOSIS|He had Cytoxan, etoposide IV and methotrexate IA. He did have a seizure during the methotrexate infusion which resolved with increased Pentothal. On his second blood-brain barrier day in the right internal carotid, he had Cytoxan and etoposide IV and methotrexate IA. He had no complications after that. He did well and at time of discharge was alert, oriented, moving all 4 extremities well with no pronator drift.
IA|intraarterial|IA|133|134|ADMISSION DIAGNOSIS|Patient had blood-brain barrier disruption to her left internal carotid artery with IV injection of Cytoxan and etoposide as well as IA administration of carboplatin. Patient tolerated this procedure well, was transferred back to the progressive care unit on 5D. Patient was neurologically stable overnight. On _%#MM#%_ _%#DD#%_, 2004, patient was brought back to the operating room for a second blood-brain barrier disruption through her right internal carotid artery with injection of Cytoxan and etoposide intravenously and carboplatin intraarterially.
IA|(stage) IA|IA|68|69|ADMISSION DIAGNOSIS|GYNECOLOGY/ONCOLOGY DISCHARGE SUMMARY ADMISSION DIAGNOSIS: 1. Stage IA grade 2 mucinous cystadenocarcinoma of the right ovary. 2. Shortness of breath. 3. Cellulitis. DISCHARGE DIAGNOSES: 1. Stage IA grade 2 mucinous cystadenocarcinoma of the right ovary.
IA|(stage) IA|IA|196|197|DISCHARGE DIAGNOSES|GYNECOLOGY/ONCOLOGY DISCHARGE SUMMARY ADMISSION DIAGNOSIS: 1. Stage IA grade 2 mucinous cystadenocarcinoma of the right ovary. 2. Shortness of breath. 3. Cellulitis. DISCHARGE DIAGNOSES: 1. Stage IA grade 2 mucinous cystadenocarcinoma of the right ovary. 2. Bilateral pleural effusions. 3. Ascites. 4. Cellulitis. PROCEDURES: 1. Spiral CT of the chest. 2. Echocardiogram. 3. Thoracentesis.
IA|(stage) IA|IA|414|415|HISTORY OF PRESENT ILLNESS|She then underwent an exam under anesthesia, exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, intracolic omentectomy, peritoneal biopsies, resection two anterior abdominal wall hernia sacs, bilateral diaphragmatic Pap smears, appendectomy, resection of umbilicus, and bilateral pelvic, and periaortic lymph node dissections on _%#MMDD2004#%_. Final pathology revealed a stage IA grade 2 mucinous cystadenocarcinoma of the right ovary. The patient then presented to her primary-care provider, Dr. _%#NAME#%_ _%#NAME#%_, on _%#MMDD2005#%_ with a complaint of recurrent shortness of breath.
IA|(stage) IA|IA|309|310|PAST MEDICAL HISTORY|HEMATOLOGIC: None. MUSCULOSKELETAL: None. NEUROLOGIC: None. PSYCHOLOGICAL: None. FAMILY HISTORY: Father - cancer at 63, hypertension, and emphysema; mother - diabetes type 2, died of CKD at 75, hypertension; paternal grandfather - esophageal cancer, maternal grandmother - CKD. PAST MEDICAL HISTORY: 1. Stage IA grade 2 right ovarian mucinous cystadenocarcinoma. 2. Hypertension. 3. Obstructive sleep apnea. SOCIAL HISTORY: The patient is single, not sexually active.
IA|(stage) IA|IA,|69|71|DISCHARGE DIAGNOSIS|ADMISSION DIAGNOSIS: Complex pelvic mass. DISCHARGE DIAGNOSIS: Stage IA, grade 3 mucinous adenocarcinoma of the right ovary. OPERATIONS/PROCEDURES PERFORMED: 1. Examination under anesthesia. 2. Exploratory laparotomy.
IA|intraarterial|IA|146|147|HOSPITAL COURSE|This disruption was carried out through the right vertebral artery. Again, Cytoxan and etoposide were infused intravenously. The patient also had IA Methotrexate. The patient tolerated this. However, he did have a seizure after methotrexate infusion. Following his blood- brain barrier disruption, the patient was transferred back to the neurosurgical floor, 5D.
IA|intraarterial|IA|81|82|DIAGNOSIS|DIAGNOSIS: Glioblastoma multiforme. CHIEF COMPLAINT: The patient presents for IV IA chemotherapy. HISTORY OF PRESENT ILLNESS: The patient is a 36-year-old right- handed woman status post left frontal glioblastoma multiforme resection in 1995 and in 1997.
IA|intraarterial|IA|263|264|DIAGNOSIS|HISTORY OF PRESENT ILLNESS: The patient is a 36-year-old right- handed woman status post left frontal glioblastoma multiforme resection in 1995 and in 1997. The patient also received a radiation therapy and chemotherapy. The patient presents for her course of IV IA chemotherapy without blood brain barrier with Cytoxan and cisplatin. PAST MEDICAL HISTORY: The patient has no other significant past medical histories besides the left frontal GBM stated in history of present illness.
IA|intraarterial|IA|183|184|DIAGNOSIS|The patient has normal gait. ASSESSMENT: Assessment of a 36-year-old right-handed woman with a recurrent left frontal glioblastoma multiforme was made. The patient is now here for IV IA chemotherapy with Cytoxan and cisplatin. The patient received the procedure on _%#MM#%_ _%#DD#%_, 2005, without any complications. The patient was discharged home on the same day in a stable condition.
IA|(stage) IA|IA|175|176||The patient is a 76-year-old female who is post-op day #10 from exploratory laparotomy, TAH, bilateral salpingo-oophorectomy, pelvic and para-aortic lymph node dissection for IA grade II adenocarcinoma of endometrium. The plan was for patient to be discharged on _%#MMDD2005#%_. She had dialysis yesterday which did not complete until 10 p.m. As result, transfer to the nursing home that had been arranged for yesterday was not able to be accomplished.
IA|intraarterial|IA|144|145|PROCEDURE PERFORMED|ADMISSION DIAGNOSIS: Right temporal lobe oligodendroglioma. DISCHARGE DIAGNOSIS: Right temporal lobe oligodendroglioma. PROCEDURE PERFORMED: IV IA chemotherapy. HISTORY OF PRESENT ILLNESS: The patient is a 35-year-old gentleman with a history of oligodendroglioma in the right frontal lobe resected at Mercy Hospital by Dr. _%#NAME#%_ in _%#MM1998#%_.
IA|(stage) IA|IA,|126|128|HOSPITAL COURSE|Above procedures were reported as uncomplicated with an estimated blood loss of 350 mL. HOSPITAL COURSE: 1. Disease: A. Stage IA, grade 1 endometrioid carcinoma. B. Infiltrating ductal carcinoma of the right breast with metastasis to axillary lymph nodes. 2. FEN: The patient was tolerating regular diet prior to discharge.
IA|intraarterial|IA|139|140|DIAGNOSIS|HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old man with a diagnosis of glioblastoma multiforme. The patient has undergone IV and IA chemotherapy in _%#MM#%_ 2005. The patient now presents for course #2 of IV and IA chemotherapy. Please refer to previous discharge summaries for his past medical history and medications.
IA|(stage) IA|IA|165|166|PAST MEDICAL HISTORY|She has no recent history of travel. She does not have any tick bites or any mosquito bites recently that she is aware of. PAST MEDICAL HISTORY: 1. History of stage IA low-grade lymphoma, B-cell small lymphocytic lymphoma around her left orbit. Following that she underwent surgery and radiation. 2. History of ITP.
IA|intraarterial|IA|134|135|HOSPITAL COURSE|HOSPITAL COURSE: 1. Malignant fibrous histiocytoma. As indicated above the patient is status post surgical resection and one cycle of IA chemotherapy. At this point, it has been decided not to pursue further treatment. Accordingly, the patient agreed to the recommendation that he be discharged with home hospice in place.
IA|intraarterial|IA|150|151|DIAGNOSIS|A biopsy revealed osteosarcoma compatible with chondroblastic osteosarcoma. A bone scan at that time showed no metastatic disease. He had 3 cycles of IA preoperatively. His tumor was resected on _%#MM#%_ _%#DD#%_, 2004. The osteoblastic areas revealed extensive regressive changes due to treatment.
IA|(stage) IA|IA|52|53||PRIMARY DIAGNOSES DURING The HOSPITALIZATION: Stage IA low malignant potential mucinous ovarian neoplasm. PRIMARY PRINCIPAL PROCEDURE PERFORMED DURING The HOSPITALIZATION: Total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, bilateral pelvic and peritoneum-aortic pelvic lymphadenectomy, appendectomy, and staging procedure.
IA|intraarterial|IA|177|178|ADMISSION DIAGNOSIS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 22-year-old male with anaplastic oligoastrocytoma who presents to the hospital for his ninth blood-brain barrier disruption with IA chemotherapy. HOSPITAL COURSE: The patient was admitted on _%#MM#%_ _%#DD#%_, 2006. He was taken to the operating room subsequently on _%#MM#%_ _%#DD#%_, 2006, and _%#MM#%_ _%#DD#%_, 2006, for blood-brain barrier disruptions and chemotherapy.
IA|intraarterial|IA|163|164|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: A 38-year-old male stockbroker with a history of left frontal anaplastic astrocytoma. He is status post the first and second course of IA and IV chemotherapy for recurrence on _%#MM#%_ _%#DD#%_, 2006, and _%#MM#%_ _%#DD#%_, 2006. He presents for therapy. PAST MEDICAL HISTORY: Tumor-related epilepsy. This anaplastic astrocytoma was originally resected on _%#MM#%_ _%#DD#%_, 2005, in _%#CITY#%_ _%#CITY#%_ _%#CITY#%_ status post radiation therapy and Temodar.
IA|intraarterial|IA|272|273|HOSPITAL COURSE|REVIEW OF SYSTEMS: Decreased energy. He is otherwise negative. HOSPITAL COURSE: His hospital course was uneventful for neurological, hematological, or infectious complications. After admission, he was started on his IV chemotherapy the following morning and underwent his IA chemotherapy. He was discharged after he was tolerating a regular diet, having good bowel function, voiding spontaneously, and ambulating with minimal assistance prior to discharge.
IA|intraarterial|IA|196|197|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: Discharged to home, and he will follow up on Monday, _%#MM#%_ _%#DD#%_, 2006, with a CT scan, and then he will be admitted for his next round of chemotherapy. Of note, the IA chemo was given on _%#MM#%_ _%#DD#%_, 2006; 800 mg carboplatin was administered over 3 minutes. He received Cytoxan and etoposide as his V chemotherapy.
IA|intraarterial|IA|214|215|ADMISSION/DISCHARGE DIAGNOSIS|He had an additional operation for left central craniotomy for tumor resection in _%#MM#%_ 2006. He was admitted through cycle 7 of IVI chemotherapy. His chemotherapy regimen consists of Cytoxan and etoposide. The IA carboplatin was cancelled secondary to severe headaches with the treatment. He was admitted for a cycle of IVI chemotherapy which was not completed.
IA|(stage) IA|IA|165|166|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Postoperative day #3 status post total abdominal hysterectomy and bilateral salpingo-oophorectomy. 2. Postoperative fever. 3. Grade 1, stage IA endometrial, endometrioid adenocarcinoma. HOSPITAL COURSE: _%#NAME#%_ is a 59-year-old, para 1 postmenopausal female who was admitted on _%#MM#%_ _%#DD#%_, 2006, to undergo scheduled total abdominal hysterectomy and bilateral salpingo-oophorectomy.
IA|(type) IA|IA;|170|172|HOSPITAL COURSE|Hematology/Oncology did see the patient, and ordered other labs to further evaluate her von Willebrand's disease. She says that she has von Willebrand's deficiency, type IA; however, on previous records, she has stated that she had IIA. She will need followup with Hematology regarding this. Labs of interest here show a normal platelet level of 259,000, INR 0.99. Surprisingly, her PTT is actually a little bit low at 20.
IA|intraarterial|IA|159|160|OPERATIONS/PROCEDURES PERFORMED|OPERATIONS/PROCEDURES PERFORMED: On _%#MM#%_ _%#DD#%_, 2006, intraarterial carboplatin. He also received IV Cytoxan and etoposide. This is cycle #10 of his IV IA chemotherapy. HISTORY OF PRESENT ILLNESS: A 32-year-old male with a right frontal anaplastic astrocytoma, biopsy diagnosis, _%#MM#%_ _%#DD#%_, 2005.
IA|intraarterial|IA|217|218|HISTORY OF PRESENT ILLNESS|This is cycle #10 of his IV IA chemotherapy. HISTORY OF PRESENT ILLNESS: A 32-year-old male with a right frontal anaplastic astrocytoma, biopsy diagnosis, _%#MM#%_ _%#DD#%_, 2005. He presents for his next cycle of IV IA chemotherapy. He has previously undergone radiation and Temodar therapy. HOSPITAL COURSE: Uneventful for neurological, hematological, or infectious complications.
IA|intraarterial|IA|227|228|DISCHARGE INSTRUCTIONS|There is no pronator drift. DISCHARGE MEDICATIONS: Depakote 500 mg p.o. q.a.m. and 1000 mg q.p.m. DISCHARGE INSTRUCTIONS: Regular diet, no strenuous activity. He will follow up on _%#MM#%_ _%#DD#%_, 2006, for his next cycle of IA chemotherapy, and he will call for any fever or weakness.
IA|(stage) IA|IA|168|169|POSTOPERATIVE COURSE SUMMARY|POSTOPERATIVE COURSE SUMMARY: The patient's postoperative hemoglobin was 12.4. Her postoperative course was complicated by: 1. Postoperative diagnosis of grade 1 stage IA endometrial adenocarcinoma. 2. Postoperative fever. Her maximum temperature was 101 degrees. Her white blood count rose to 11.8. Urinalysis was normal, and no blood cultures or urine culture returned positive.
IA|(stage) IA|IA|184|185|SUMMARY|Left thoracotomy, left lower lobectomy, mediastinal lymph node dissection. SUMMARY: Mr. _%#NAME#%_ is a 70-year-old gentleman with history of right upper lobectomy in 2001 for a stage IA lung cancer. He also has a history of left nephrectomy for renal cell cancer and bladder cancer. He has a history of smoking for 20 years but quit in 2004.
IA|intraarterial|IA|194|195|HISTORY OF PRESENT ILLNESS|DIAGNOSIS: Gemistocytic astrocytoma. MAJOR PROCEDURES AND TREATMENTS: Intra-arterial chemotherapy. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 25-year-old gentleman who has been treated via IA chemotherapy without blood-brain barrier disruption for his known astrocytoma. This is cycle #3 and the left side was injected. Carboplatin was administered. HOSPITAL COURSE: The patient was admitted the night before treatment for accessing of the port and establishing his hospital stay.
IA|intraarterial|IA|157|158|FOLLOWUP CARE|2. The patient's next appointment is for CT scan at 1:40 p.m. on _%#MMDD2006#%_. After this, the patient should proceed to the admissions department for his IA chemotherapy treatment on _%#MMDD2006#%_ at 9:30 in the morning. 3. Follow up with the outpatient lab for CBC with diff and platelets on a weekly basis.
IA|intraarterial|IA|132|133|HOSPITAL COURSE|He presented for his 11 cycle of IVI chemotherapy. HOSPITAL COURSE: On _%#MMDD2006#%_ the patient underwent a left vertebral artery IA chemotherapy. This procedure was uncomplicated. He returned to the floor following this surgery and was monitored for six hours. Following this, he was doing quite well and he was at his neurologic baseline and was therefore discharged.
IA|intraarterial|IA|175|176|DISCHARGE PLAN|DISCHARGE PLAN: On _%#MMDD2007#%_ he is to go to the Gold Waiting Room at 3 p.m. for a CT scan of his head and then he is to go to admitting after his CT first, next cycle of IA chemotherapy. He is to stop his aspirin three days before his next admission. He is to have a CBC with differential and platelets weekly.
IA|intraarterial|IA|205|206|HISTORY OF PRESENT ILLNESS|ADMISSION/DISCHARGE DIAGNOSIS: Left frontal astrocytoma. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 25-year-old man with a history of a left frontal astrocytoma who presents for his next cycle of IV, IA chemotherapy. HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted on _%#MMDD2007#%_ for his 7th cycle of chemotherapy.
IA|(stage) IA|IA,|90|92|FINAL DIAGNOSIS|FINAL DIAGNOSIS: Typical carcinoid, left upper lobe lung, pathological stage T1N0M0 stage IA, status post left video-assisted thoracoscopy and wedge resection. OTHER DIAGNOSES: 1. Status post hip replacement. 2. Status post gastric bypass.
IA|intraarterial|IA|185|186|INDICATIONS AND HOSPITAL COURSE|Due to this respiratory depression, it was determined that the most likely cause was secondary to postoperative ileus and so _%#NAME#%_ was placed on strict bowel rest and a peripheral IA PICC line was placed for total parenteral nutrition. Because of _%#NAME#%_'s intolerance to wean from the vent after his PICC line, he spent approximately 24 hours in the PICU after PICC line placement on ventilator support, but after 1 day in the ventilator, he was weaned from his intubation and transferred back to 5A.
IA|intraarterial|IA|114|115|PROCEDURE PERFORMED|ADMITTING DIAGNOSIS: Glioblastoma multiform. DISCHARGE DIAGNOSIS: Glioblastoma multiform. PROCEDURE PERFORMED: IV IA chemotherapy. HISTORY OF PRESENT ILLNESS: This is a pleasant 34 year male who presents for his next regularly scheduled cycle of intravenous intraarterial chemotherapy.
IA|intraarterial|IA|229|230|MONITORING|DISCHARGE INSTRUCTIONS: Diet regular, activity as tolerated. MONITORING: He is to take his temperature daily for seven days. He should continue the care of his dual lumen port as previously instructed. He should have his next IV IA chemotherapy as scheduled, as follows. He will get an MRI of the brain on _%#MMDD2007#%_ at 4:30 p.m. at the outpatient imaging center.
IA|(stage) IA|IA|210|211|DISCHARGE DIAGNOSIS|MRI of the abdomen was performed on _%#MMDD2002#%_, which showed a large cystic pelvic mass and suspicion of mesenteric and omental involvement. ADMISSION DIAGNOSIS: Adnexal mass. DISCHARGE DIAGNOSIS: Probable IA endodermal sinus tumor of the right ovary. PROCEDURES: Exploratory laparotomy, right salpingo-oophorectomy, right pelvic and periaortic lymph node dissection, omentectomy, peritoneal biopsy, diaphragmatic smears, and cytology.
IA|(stage) IA|IA|34|35|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Recurrent IA ovarian carcinoma with synchronous IA endometrial carcinoma originally diagnosed in 1996. 2. Recurrence in 1997 to the apex of vagina with subsequent radiation and chemotherapy.
IA|(stage) IA|IA|72|73|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Recurrent IA ovarian carcinoma with synchronous IA endometrial carcinoma originally diagnosed in 1996. 2. Recurrence in 1997 to the apex of vagina with subsequent radiation and chemotherapy.
IA|(stage) IA|IA|171|172|DISCHARGE DIAGNOSES|3. Recurrence in 2003 in the pancreas, treatment with Taxol. 4. Recurrent small bowel obstruction. DISCHARGE DIAGNOSES: 1. Recurrent IA ovarian carcinoma with synchronous IA endometrial carcinoma originally diagnosed in 1996. 2. Recurrence in 1997 to the apex of vagina with subsequent radiation and chemotherapy.
IA|(stage) IA|IA|196|197|HISTORY OF PRESENT ILLNESS|5. Placement of PICC line. 6. Nutrition labs. 7. Clostridium difficile toxin and culture. COMPLICATIONS: None. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 55-year-old female with a history of IA ovarian carcinoma and synchronous IA endometrial carcinoma diagnosed in 1996. The patient had recurrences in 1997 to the apex of the vagina with subsequent radiation and chemotherapy as well as recurrence in 2002 in the pancreas with treatment with Taxol.
IA|(stage) IA|IA|143|144|HISTORY OF PRESENT ILLNESS|COMPLICATIONS: None. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 55-year-old female with a history of IA ovarian carcinoma and synchronous IA endometrial carcinoma diagnosed in 1996. The patient had recurrences in 1997 to the apex of the vagina with subsequent radiation and chemotherapy as well as recurrence in 2002 in the pancreas with treatment with Taxol.
IA|intraarterial|IA|175|176|ASSESSMENT|ASSESSMENT: This is a 54-year-old gentleman with recurrent glioblastoma multiforme with progression on MRI, presenting today for cycle 11 of IV/IA chemotherapy. His agent for IA chemotherapy will be changed from carboplatin to methotrexate. RECOMMENDATIONS: 1. Follow his labs. 2. Proceed with intravenous and intra-arterial chemotherapy as planned.
IA|intraarterial|IA|267|268|PROCEDURE PERFORMED|PROCEDURE PERFORMED: On _%#MMDD2003#%_ was intra-arterial and intravenous chemotherapy. On day one and two were the intravenous Cytoxan and etoposide, Cytoxan was 633 mg, etoposide 384 mg. On day two she received again the Cytoxan and etoposide by IV and carboplatin IA 768 mg. HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old right handed white female diagnosed with left parietal GBM diagnosed by MRI guided biopsy.
IA|intraarterial|IA|109|110|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Right occipital mixed glioma oligoastrocytoma with anaplastic features. He presents for IA and IV chemotherapy. HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted to the Neurosurgery Service and underwent intra-arterial chemotherapy treatment on _%#MMDD2002#%_ and received Carboplatin 424 mg.
IA|intraarterial|IA|138|139|HOSPITAL COURSE|He also received Cytoxan 765.6 mg intravenously on two subsequent days and also etoposide 464 mg on two subsequent days. He tolerated the IA and the IV chemotherapy and was subsequently discharged home. DISCHARGE MEDICATIONS: 1. Lipitor 10 mg PO once a day.
IA|(stage) IA|IA,|224|226|PAST MEDICAL HISTORY|Upper GI and small bowel follow-through revealed mild small bowel thickening of the pelvis compatible with previous radiation therapy and a small sliding hiatal hernia. PAST MEDICAL HISTORY: Significant for history of Stage IA, Grade 3 endometrial carcinoma in 1981 which was treated with a total abdominal hysterectomy and bilateral salpingo-oophorectomy followed by radiation.
IA|intraarterial|IA|384|385|PRIMARY PHYSICIAN|PRIMARY PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD, Heart Failure Clinic. DISCHARGE DIAGNOSIS: Congestive heart failure exacerbation. OPERATIONS/PROCEDURES PERFORMED: 1. Right heart catheterization showing high normal left ventricular filling pressure with a wedge pressure of 18 and a prominent V-wave in the pressure tracing, moderately elevated right heart filling pressures with a mean IA pressure of 22, mild pulmonary hypertension, PA pressure of 43 systolic and 20 diastolic, and severely decreased cardiac output of 3.2 liters by the Fick method.
IA|(stage) IA|IA,|68|70|DISCHARGE DIAGNOSIS|ADMISSION DIAGNOSIS: Endometrial cancer. DISCHARGE DIAGNOSIS: Stage IA, grade 1 endometrial cancer. PROCEDURES: Total abdominal hysterectomy, bilateral salpingo- oophorectomy. HISTORY: Ms. _%#NAME#%_ is a 36-year-old female who had increased vaginal bleeding in _%#MM2003#%_.
IA|(stage) IA|IA,|99|101|DISCHARGE DIAGNOSIS|ADMISSION DIAGNOSIS: Grade II/III adenocarcinoma of the endometrium. DISCHARGE DIAGNOSIS: 1. Stage IA, grade III endometrial mixed endometrial and clear-cell carcinoma. 2. Fevers without evidence of infection. PROCEDURES: 1. Examination under anesthesia.
IA|(stage) IA|IA,|262|264|PROBLEM #1|PROBLEM #1: Disease. Final pathology returned as an endometrial carcinoma with mixed endometrioid and clear-cell carcinoma features, grade III. There was no myometrial invasion, no cervical involvement, and no angiolymphatic invasion making this patient a stage IA, grade III. PROBLEM #2: Pain. The patient's pain was initially controlled with a morphine PCA and this was changed to oral pain medications with good control.
IA|(stage) IA|IA|271|272|DISCHARGE DIAGNOSIS|ADMISSION DIAGNOSIS: This is a 56-year-old female with a history of Merkel cell cancer of the right cheek, with a 10 cm complex mass in the pelvis, and a CA-125 of 550. DISCHARGE DIAGNOSIS: 56-year-old female with a history of Merkel cell cancer of the cheek, with stage IA endometrioid adenocarcinoma. PROCEDURES: Examination under anesthesia, exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo- oophorectomy, pelvic and paraaortic lymph node dissection, and staging.
IA|(stage) IA|IA|258|259|ADDENDUM|5. Nothing in the vagina x 6 weeks. 6. She is to call if she has increased drainage, increased pain, increased swelling, or elevated temperature greater than 101 degrees. ADDENDUM: DISCHARGE DIAGNOSIS: Stage IIIC endometrial adenocarcinoma of the ovary, not IA as previously dictated.
IA|(stage) IA|IA|181|182|DISCHARGE DIAGNOSES|1. Patient is 33-year-old with newly diagnosed adenocarcinoma of the cervix, status post modified radical hysterectomy, exploratory laparotomy with preliminary findings of stage I, IA adenocarcinoma of the cervix. 2. Patient is gravida 2, para 2. OPERATIONS/PROCEDURES THIS ADMISSION: 1. Status post exploratory laparotomy. Modified radical hysterectomy, pelvic and periaortic lymph node dissection.
IA|(class) IA|IA|153|154|MANAGEMENT|Very anxious individual. LEG EXAM: As indicated from previous exams with the orthopedic surgeon and with myself. Slowly growing. MANAGEMENT: He is Class IA as a risk. The methotrexate should not be of much concern. We will get liver function tests, CBC, and basic metabolic profile.
IA|(stage) IA|IA|179|180|PE.|The patient does have a history of Hodgkin's disease approximately nine years ago when he presented with left axillary lymphadenopathy. He had a staging laparoscopy and was stage IA and was treated with radiation. He sees Dr. _%#NAME#%_ _%#NAME#%_ one time a year and last saw her in _%#MM#%_ when she did a chest x-ray and blood work.
IA|(type) IA|IA.|131|133|HOSPITAL COURSE|In preparation for her GI visit, we have drawn hepatitis A and B, which are negative, and hepatitis C, which has been genotyped as IA. Her hepatitis C RNA PCR seems to have been canceled, as per the daybook request. This will have to be redrawn. Her liver functions were only mildly elevated, with an ALT of 57 and an AST of 65.
IA|(stage) IA|IA.|129|131|DISCHARGE DIAGNOSES|The procedure was performed under general anesthesia with no apparent complications. Pathology came back as above; her stage was IA. The patient will follow up with Dr. _%#NAME#%_ in 2 to 4 weeks' time to discuss further care. 2. Cardiovascular. The patient has a history of congestive heart failure and atrial fibrillation.
IA|intraarterial|IA|127|128|DISCHARGE DIAGNOSIS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 47-year- old gentleman with a history of thalamic astrocytoma who presents for IA and IV chemotherapy. HOSPITAL COURSE: The patient was admitted and underwent chemotherapy with 360 mg of carboplatin administered IA with catheter at C6 level.
IA|intraarterial|IA|260|261|DISCHARGE DIAGNOSIS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 47-year- old gentleman with a history of thalamic astrocytoma who presents for IA and IV chemotherapy. HOSPITAL COURSE: The patient was admitted and underwent chemotherapy with 360 mg of carboplatin administered IA with catheter at C6 level. He tolerated the procedure well. Intraoperatively and postoperatively, he had an unremarkable course. He remained neurologically stable and was discharged on the day after the procedure.
IA|(stage) IA|IA|256|257|HOSPITAL COURSE|EXTREMITIES: Showed no lower extremity edema. No calf tenderness. MUSCULOSKELETAL: No tenderness to percussion of the shoulders, spine, or pelvis. His gait is normal. HOSPITAL COURSE: This patient with diffuse large B-cell lymphoma, immunoblastic is stage IA or IIA disease presented to the hospital for elective right video-assisted thoracoscopy with conversion to mini- thoracotomy for biopsy of station seven lymph nodes.
IA|Iowa|IA.|352|354|DISPOSITION AT DISCHARGE|25. Diazepam 2 mg p.o. q. vertigo episode. DISPOSITION AT DISCHARGE: _%#NAME#%_ _%#NAME#%_ is to be transferred from the University of Minnesota Transplant Service to Fairview-University Transplant Services for acute rehab services. Patient to follow up with her primary doctor, Dr. _%#NAME#%_ _%#NAME#%_, upon returning home to _%#CITY#%_ _%#CITY#%_, IA. Patient to follow up with a kidney transplant 3-month appointment in Transplant Clinic on _%#MMDD2007#%_ at 2:40 p.m. The patient to have transplant labs, per letter, 3 times a week for 2 weeks and then per protocol.
IA|intraarterial|IA|141|142|PAST MEDICAL HISTORY|5. Hypertension. 6. Peripheral vascular disease. 7. Anemia of chronic renal failure. 8. History of chronic hemodialysis. 9. History of right IA mycotic aneurysm with hemorrhage x 2 in 1995 and 1999. PAST TRANSPLANT HISTORY: 1. Kidney transplant in 1984. Graft failure secondary to chronic rejection.
IA|Iowa|IA|173|174|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ already has a detailed history in the record. He is a young man visiting the _%#CITY#%_ _%#CITY#%_ from the _%#CITY#%_ _%#CITY#%_ IA area. He and his wife drove to visit family in the _%#CITY#%_ _%#CITY#%_ during the day yesterday. He awoke on the morning of _%#MMDD2007#%_ with nagging right flank discomfort which radiated around to the right side of the abdomen.
IA|Iowa|IA,|264|266|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: I was asked to consult on this patient by Dr. _%#NAME#%_ _%#NAME#%_ regarding the patient's deteriorating status secondary to primary pulmonary hypertension. The patient is a very pleasant 31-year-old female from _%#CITY#%_ _%#CITY#%_, IA, and she is married and has a daughter who is 5 years old. She has been diagnosed with primary pulmonary hypertension for about four years, and she has been managed on IV Flolan.
IA|(stage) IA|IA.|161|163|ASSESSMENT|2. COPD. 3. Status post right lower lobectomy dated _%#MMDD2004#%_ for non-small cell lung cancer. 4. Status post left upper lobectomy dated _%#MM1997#%_, stage IA. 5. Anemia - etiology unclear. PLAN: 1. Would give her a full 10-14 day course of antibiotics.
IA|(stage) IA|IA|15|16|PROBLEM|PROBLEM: Stage IA mediastinal large-cell B-cell lymphoma. This patient was seen in the Radiation Oncology Clinic on _%#MM#%_ _%#DD#%_, 2002 by Drs. _%#NAME#%_ _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_ for a reconsultation at the request of Dr. _%#NAME#%_ _%#NAME#%_.
IA|(stage) IA|IA|293|294|HISTORY OF PRESENT ILLNESS|This patient was seen in the Radiation Oncology Clinic on _%#MM#%_ _%#DD#%_, 2002 by Drs. _%#NAME#%_ _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_ for a reconsultation at the request of Dr. _%#NAME#%_ _%#NAME#%_. HISTORY OF PRESENT ILLNESS: This patient is a 41-year-old female with a history of stage IA mediastinal large B-cell lymphoma diagnosed in _%#MM2001#%_. At that time she was complaining of pressure in the anterior chest and difficulty swallowing, but denied fevers, chills, night sweats or loss of weight.
IA|(stage) IA|IA|140|141|PAST MEDICAL HISTORY|The patient's weight and appetite have been stable and she did not experience significant nausea. PAST MEDICAL HISTORY: 1. History of stage IA large cell lymphoma, B-cell lineage of anterior mediastinum as described above. 2. Status post six cycles CHOP chemotherapy having completed her last cycle on _%#MMDD2002#%_.
IA|(stage) IA|IA|228|229|ASSESSMENT|4. PET scan from _%#MMDD2002#%_ showed minimal residual hypermetabolic activity in the mediastinum, similar in appearance to the previous exam dated _%#MMDD2002#%_. ASSESSMENT: Mrs. _%#NAME#%_ is a 41-year-old female with stage IA large cell non-Hodgkin lymphoma, B-cell lineage, who has completed six cycles of CHOP chemotherapy with a near-complete response and appears to be a good candidate for consolidative radiation to an involved field.
IA|(stage) IA|IA)|187|189|IMPRESSION|EXTREMITIES: No clubbing, cyanosis, or edema. IMPRESSION: Mr. _%#NAME#%_ is a 74-year-old male with 2 lung nodules, 1 biopsy-proven non-small cell lung cancer staged as a T1 N0 M0 (stage IA) right upper lobe non-small-cell lung cancer. The left lower lobe lesion has not been biopsied; however, it is likely a synchronous lesion rather than a metastatic lesion secondary to the fact that there is no mediastinal hilar disease on PET.
IA|(stage) IA|IA,|358|360|ASSESSMENT/PLAN|No other neurology problems. LABORATORY: Blood test: CBC, hemoglobin 14.4, hematocrit CBC 14.4, white count 5500, platelet count 314,000, creatinine slightly elevated at 1.36, LD 415, total bilirubin 1.3, AST 26, alkaline phosphatase 71, CA27.29 is within normal limits with 21 units per mL. ASSESSMENT/PLAN: This is an 80-year-old female patient with stage IA, T1 N0 M0 left breast cancer. Patient was recommended radiation treatment to the left breast versus wait-and-see, and the patient elected to be treated with radiation.
IA|(stage) IA|IA|15|16|PROBLEM|PROBLEM: Stage IA Hodgkin disease. Ms. _%#NAME#%_ was seen in the Radiation Oncology clinic by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2002 for consultation at the request of Dr. _%#NAME#%_ _%#NAME#%_.
IA|(stage) IA|IA|140|141|ASSESSMENT AND PLAN|Hemoglobin 11.6, white blood cell count 4.0, platelet count 432,000. ASSESSMENT AND PLAN: Ms. _%#NAME#%_ is a 39-year-old female with stage IA nodular sclerosing Hodgkin disease with a large mediastinal mass. Because of her bulky mediastinal disease, she would fall into the intermediate risk group, and would therefore be a good candidate for combined modality therapy, including chemoradiation.
IA|intraarterial|IA.|225|227|HISTORY OF PRESENT ILLNESS|The family is uncertain of other specific information regarding his treatment. From the hospital chart it appears that the chemotherapy regimens consisted of Taxol, and sometime during his course he completed five courses of IA. PAST MEDICAL HISTORY: The patient has a history of colon cancer in 1989 status post surgery.
IA|(stage) IA|IA.|221|223|ASSESSMENT/PLAN|An extensive pelvic exam was performed by Dr. _%#NAME#%_. EXTREMITIES: 1+ bilateral lower extremity edema. ASSESSMENT/PLAN: The patient is a _%#1914#%_ woman with invasive squamous-cell carcinoma of the vulva, FIGO stage IA. We discussed the options that are available to Ms. _%#NAME#%_ at this time.
IA|(stage) IA|IA,|192|194|ASSESSMENT AND PLAN|The bladder appeared normal. An abdominal ultrasound showed normal liver. No evidence of gallstones or gallbladder wall thickening. ASSESSMENT AND PLAN: This is a 48-year-old woman with stage IA, grade 1 adenocarcinoma of the uterus, who is status post total abdominal hysterectomy and bilateral salpingo-oophorectomy, now postop day #19.
IA|(stage) IA|IA|15|16|PROBLEM|PROBLEM: Stage IA seminoma of the right testicle. The patient was seen in the Radiation Oncology Clinic by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ for an initial consultation on _%#MMDD2003#%_ at the request of Dr. _%#NAME#%_ _%#NAME#%_.
IA|(stage) IA|IA|168|169|IMPRESSION|LABORATORY VALUES: The patient's preoperative serum markers are described above in the history of present illness. IMPRESSION: Mr. _%#NAME#%_ is a young man with stage IA right seminoma, having undergone right radical orchiectomy approximately five weeks ago. He has banked sperm, and is interested in radiation therapy as part of his definitive treatment.
IA|(type) IA|IA,|359|361|RECOMMENDATIONS|All of these conditions are what's called recessive inheritance, which means that both parents need to be a carrier in order to have a child that is affected with these conditions. We reviewed cystic fibrosis, Tay-Sachs disease, Canavan disease, familial dysautonomia, Bloom syndrome, Fanconi anemia, group C, Gaucher's disease, glycogen storage disease type IA, maple syrup urine disease, mucolipidosis type IV, and Niemann-Pick disease (type A). If 1 individual is found to be a carrier, then we can certainly screen the other partner.
IA|(stage) IA|IA|115|116|HISTORY OF PRESENT ILLNESS|There was invasion of the portal vein, and this was felt to be unresectable. Mr. _%#NAME#%_ has a history of stage IA nodular sclerosing Hodgkin's disease. He presented in 1979 with a right cervical node. He was treated with an extended mantle field that included both axillae, para-aortic nodes, and spleen.
IA|(stage) IA|IA|156|157|HPI|The patient underwent an exploratory laparotomy unable to resect because of the invasion of the tumor to the portal vein. Previously, the patient had stage IA nodular sclerosing Hodgkin disease and has previously received radiation to the extended mantle which included the para-aortic and splenic area where the patient's current problem is in 1979.
IA|Iowa|IA|82|83|DOB|DOB: _%#MMDD1931#%_ The patient is a 72 year old who is a farmer from _%#CITY#%_, IA who was fishing yesterday with his kids on a lake up in the _%#CITY#%_ _%#CITY#%_ area. His kids live in this area and his fishing up here is not unusual.
IA|intraarterial|IA|72|73|PROBLEM|PROBLEM: Synovial sarcoma of left upper arm, status post four cycles of IA chemotherapy status post surgical resection with 0.1 cm margins. The patient presents for the possibility of radiation therapy. The patient was seen and examined by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_.
IA|intraarterial|IA|219|220|IMPRESSION|There are no lymph nodes palpable in her left axilla or left supraclavicular area. IMPRESSION: The patient is an 11-year-old female who has a history of a synovial sarcoma of her left upper arm, status post 4 cycles of IA chemotherapy, status post surgical resection on _%#MMDD2004#%_ with the closest margin of 0.1 cm. The patient presents for the possibility of radiation therapy. PLAN: We are requesting the outside MRI scan from CDI in _%#CITY#%_ _%#CITY#%_, Minnesota dated _%#MMDD2004#%_.
IA|(stage) IA|IA|143|144|HISTORY  OF PRESENT ILLNESS|Her history dates back to 2003 when she underwent a TAH, BSO, pelvic and periaortic lymphadenectomy at the University of Minnesota for a stage IA adenosarcoma of the uterus. She did well until approximately _%#MM#%_/_%#MM#%_ of this year when she began experiencing abdominal pain and was cared for during this time at Methodist Hospital at the Park Nicollet Cancer Center.
IA|Iowa|IA.|162|164|SOCIAL HISTORY|FAMILY HISTORY: Cancer: Father had prostate cancer, mother had stomach cancer. SOCIAL HISTORY: The patient lives in an assisted-living environment in _%#CITY#%_, IA. She lives alone. She is estranged from both her husband and her 22-year-old daughter. She does require assistance with her activities of daily living.
IA|Iowa|IA.|137|139|ASSESSMENT/PLAN|She is here without anyone else. The consultation was stopped after the Mini-Mental Examination. Of note the patient is from _%#CITY#%_, IA. She has mentioned that she does not wish to receive radiation therapy in the _%#CITY#%_ _%#CITY#%_. She would prefer to have it performed closer to home.
IA|Iowa|IA.|164|166|ASSESSMENT/PLAN|It is unknown at this time whether or not she will be kept here for further treatment, should her mental status improve, or if she will be sent back to _%#CITY#%_, IA. Should her mental status improve and her living situation be rectified, we would consider radiation for this patient's tumor.
IA|(stage) IA|IA|24|25|PROBLEM|PROBLEM: Clinical stage IA low-grade marginal zone lymphoma of the left parotid. Mrs. _%#NAME#%_ was seen for initial consultation in the Department of Radiation Oncology on _%#MMDD2005#%_ by Drs. _%#NAME#%_ _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_ at the request of Dr. _%#NAME#%_ _%#NAME#%_.
IA|(stage) IA|IA|215|216|ASSESSMENT AND PLAN|The patient states she has had times in the past with ulcerations of her fingertips. Bone marrow from _%#MMDD2005#%_ was negative. ASSESSMENT AND PLAN: In summary, Mrs. _%#NAME#%_ is a 79-year-old female with stage IA low-grade marginal zone lymphoma of the left parotid gland. We discussed the risks, benefits, and alternatives to radiotherapy in this setting.
IA|(stage) IA|IA|15|16|PROBLEM|PROBLEM: Stage IA non-small-cell lung cancer status post resection, recurrent to upper mediastinum and supraclavicular lymph nodes. The patient was seen in consultation by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ in the Radiation Oncology Clinic.
IA|(stage) IA|IA|153|154|IMPRESSION|Positive bowel sounds. No hepatosplenomegaly. EXTREMITIES: Without clubbing, cyanosis, or edema. IMPRESSION: 46-year-old female who has an initial stage IA adenocarcinoma of the right upper lung, treated with surgery alone. The patient did not receive any adjuvant chemotherapy or radiation therapy.
IA|(stage) IA|IA|91|92|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 55-year-old female with a history of stage IA cervical cancer treated surgically. She underwent vaginal hysterectomy and bilateral salpingo-oophorectomy in _%#MM2004#%_ for cervical cancer. Her preoperative biopsy showed microinvasive squamous cell carcinoma of the cervix.
IA|(stage) IA|IA|15|16|PROBLEM|PROBLEM: Stage IA diffuse large B-cell lymphoma of the mediastinum, status post six cycles of R-CHOP chemotherapy with good response. This patient was seen for consultation in the Radiation Oncology Clinic on _%#MMDD2006#%_ by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_.
IA|(stage) IA|IA|136|137|ASSESSMENT/PLAN|Normochromic normocytic anemia. No morphologic evidence of lymphoma. ASSESSMENT/PLAN: Ms. _%#NAME#%_ is a 43-year-old female with stage IA diffuse large B-cell lymphoma, status post six cycles of R-CHOP with excellent response based on CT and PET criteria. The patient would be an excellent candidate for involved field radiation therapy because of the initial bulky size of her tumor.
IA|(stage) IA|IA|158|159|HISTORY OF PRESENT ILLNESS|Within the next year, he had a routine CT scan showing a mediastinal mass. This was biopsied and showed lymphoblastic lymphoma. It was determined to be stage IA disease. He received chemotherapy per a Memorial Sloan-Kettering protocol which included multiple chemotherapeutic agents along with intrathecal Methotrexate.
IA|(stage) IA|IA,|153|155|IMPRESSION|We have also reviewed his recent laboratory studies. IMPRESSION: Mr. _%#NAME#%_ is a 36-year-old male with T-cell lymphoblastic lymphoma/leukemia, stage IA, status post chemotherapy followed by total body irradiation and bone marrow transplant. PLAN: We have recommended consolidative radiation therapy to the mediastinum because of disease in that region at initial diagnosis as well as at relapse.
IA|(stage) IA|IA,|70|72|PROBLEM|PROBLEM: Diffuse large cell lymphoma of the left neck, clinical stage IA, status post chemotherapy. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 58-year-old male patient who is known to have non-Hodgkin lymphoma of the left neck.
IA|(stage) IA|IA|178|179|ASSESSMENT|No other palpable lymphadenopathy in the neck, supraclavicular and axillary area. LUNGS: Essentially clear. HEART: Regular sinus rhythm. ABDOMEN: Unremarkable. ASSESSMENT: Stage IA diffuse large cell lymphoma of the left neck with a large mass, status post chemotherapy with clinical remission.
IA|(stage) IA|IA|15|16|PROBLEM|PROBLEM: Stage IA diffuse large B-cell lymphoma localized to the left neck. The patient was seen in consultation by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_.
IA|(stage) IA|IA|191|192|ASSESSMENT|EXTREMITIES: No clubbing, cyanosis or edema. NEUROLOGIC: Cranial nerves II through XII intact, light touch is symmetric and intact, strength is 5/5 in all four extremities. ASSESSMENT: Stage IA diffuse large B-cell lymphoma localized to the left neck. RECOMMENDATIONS: Mr. _%#NAME#%_ would make an excellent candidate for radiation following his chemotherapy for the treatment of his localized left neck lymphoma.
IA|(stage) IA|IA|130|131|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Stage IA diffuse large cell lymphoma of the left neck. HPI: This is a 58-year-old male patient who presented with a walnut- size neck mass in _%#MM2003#%_.
IA|(stage) IA|IA|144|145|ASSESSMENT AND PLAN|PET scan showed no abnormal uptake. MUGA revealed an ejection fraction of 63%. ASSESSMENT AND PLAN: Diffuse large cell lymphoma, clinical stage IA with right upper neck mass. Status post chemotherapy with 6 cycles of CHOP and rituximab, with which he achieved a complete remission.
IA|(stage) IA|IA|213|214|ASSESSMENT/PLAN|PET CT prior to her chemotherapy showed a right axillary lymphadenopathy with increased metabolic uptake. PATHOLOGY: Diffuse large B-cell lymphoma. ASSESSMENT/PLAN: This is a 42-year-old female patient with stage IA right axillary large B-cell lymphoma status post chemotherapy with good response. Because of the original size of the disease, the patient was recommended to have consolidation radiation.
IA|(stage) IA|IA,|264|266|HISTORY OF PRESENT ILLNESS|She was initially diagnosed on biopsy in _%#MM2002#%_. The biopsy of the left shoulder showed a lesion that was positive for T-cell as well as positivity for CD2, CD3, CD5, CD45, and weakly positive for CD7. She was diagnosed with cutaneous T-cell lymphoma, stage IA, affecting 10% of the body surface area. The patient was seen in the Radiation Oncology Clinic and given radiation to the left shoulder, left upper arm, right buttock and right thigh.
IA|(stage) IA|IA|206|207|ASSESSMENT|PATHOLOGY: Right radical orchiectomy (_%#MMDD2002#%_) was reviewed in clinic, and the findings are described above in History of Present Illness. ASSESSMENT: Mr. _%#NAME#%_ is a 56-year-old male with stage IA (pT1, N0, M0) seminoma of the right testis who appears to be a candidate for external-beam radiation therapy to the abdomen and right pelvis.
IA|(stage) IA|IA,|15|17|PROBLEM|PROBLEM: Stage IA, grade 1, follicular lymphoma, with adenopathy of the right inguinal region. The patient was seen in Radiation Oncology Clinic on _%#MMDD2003#%_ by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ for initial consultation at the request of Dr. _%#NAME#%_ _%#NAME#%_ from the Department of Medical Oncology.
IA|(stage) IA|IA|50|51|PROBLEM|PROBLEM: The patient is a 51-year old female with IA grade 1, endometrial cancer with positive cytology in her peritoneal fluid. The patient was seen in consultation by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_.
IA|(stage) IA|IA|255|256|IMPRESSION|PATHOLOGY: W2003-244: Review of outside pathology showed adenocarcinoma of the endometrium grade 1/3 endometrioid type invading into the myometria superficially with 2 mm invasion of a maximal depth of 12 mm. IMPRESSION: The patient is a 51-year-old with IA grade 1 endometrial adenocarcinoma with positive cytology. The patient is stage IIIA. PLAN: We have discussed with the patient the possibility of radiation therapy as part of GOG protocol _%#PROTOCOL#%_.
IA|(stage) IA|IA,|168|170|IMPRESSION|Cardiac examination is unremarkable. No adenopathy and no cyanosis, clubbing, or edema. IMPRESSION: Endometrial cancer, FIGO IIA and adenocarcinoma of the cervix, FIGO IA, status post simple hysterectomy. RECOMMENDATIONS: Based on the presence of two tumors, one of which was treated with a simple hysterectomy instead of a radical hysterectomy, I would recommend adjuvant postoperative radiation therapy.
IA|intraarterial|IA|169|170|HISTORY OF PRESENT ILLNESS|She underwent 3 cycles of ifosfamide and Adriamycin followed by surgery on _%#MMDD2005#%_. Pathology at that time showed 50% viable tumor. She then had 3 more cycles of IA postoperatively. She also had 4 cycles of HD-MTX and 4 cycles of cisplatinum, with the last one in _%#MM2006#%_. She had a right acetabular recurrence on _%#MMDD2007#%_ which was treated with cement and external beam radiation.
IA|Iowa|IA|137|138||_%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD Spring Medical Park, _%#ADDRESS#%_ _%#ADDRESS#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_, IA _%#52800#%_ Dear Dr. _%#NAME#%_: Please find enclosed copy of my recent evaluation on Mr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_.
IA|(stage) IA|IA|65|66|SUBJECTIVE|SUBJECTIVE: The patient is a 55-year-old with a history of stage IA carcinoma sarcoma of the fallopian tube. She was surgically staged in _%#MM#%_ of 2003 with an initial CA125 of 349 on _%#MMDD2003#%_.
IA|(status) IA|IA|145|146|IMPRESSION|I have discussed his condition after seeing the patient with Dr. _%#NAME#%_ _%#NAME#%_ and I agree with the plan to list the patient as a status IA for transplant evaluation. We will closely follow the patient.
IA|intraarterial|IA|271|272|HISTORY OF PRESENT ILLNESS|She had breast reduction surgery for this pain. She persisted having right shoulder pain, she ultimately was found to have a right scapular lesion. This was biopsied which demonstrated leiomyosarcoma, consistent with uterine primary. The patient received three cycles of IA chemotherapy under the direction of Dr. _%#NAME#%_. On _%#MMDD2004#%_, the patient had a CT scan of her chest, abdomen and pelvis which showed a lytic lesion in her right scapula which persisted.
IA|(type) IA|IA,|298|300|HPI|Both she and her husband are of Ashkenazi Jewish ethnicity. We reviewed the more expanded screening that is available and is offered to Ashkenazi Jewish ethnicity, which includes Canavan disease, familial dysautonomia, Bloom syndrome, Fanconi anemia group C, Gaucher, glycogen storage disease type IA, maple syrup urine disease, leukolipidosis type IV, and Niemann-Pick disease type A. We provided her a pamphlet regarding this screening. We reviewed the recessive nature of these conditions, and the patient stated she needed to think further about the expanded screening and may be interested in this but will let us know or your office know.
IA|(stage) IA|IA|276|277|HPI|Abdomen unremarkable. Extremities unremarkable. No abnormal peripheral palpable lymphadenopathy. There are scratch marks on her skin due to pruritus, most likely due to her Hodgkin disease, although it is not a B-symptom. Assessment and Plan: The patient apparently has stage IA nodular sclerosing Hodgkin disease with a large mediastinal mass. She has significant pruritus, however. The patient is scheduled to receive chemotherapy and we will see her for consolidation radiation treatment after probably 4 cycles of chemotherapy.
IA|(stage) IA|IA.|46|48|PROBLEM|PROBLEM: Follicular lymphoma, grade 3 B stage IA. Mr. _%#NAME#%_ was seen in the Department of Therapeutic Radiology on _%#MMDD2007#%_ by Dr. _%#NAME#%_ and Dr. _%#NAME#%_ at the request of Dr. _%#NAME#%_.
IA|(stage) IA|IA.|214|216|PROBLEM|Mr. _%#NAME#%_ was seen in the Department of Therapeutic Radiology on _%#MMDD2007#%_ by Dr. _%#NAME#%_ and Dr. _%#NAME#%_ at the request of Dr. _%#NAME#%_. PROBLEM: Follicular lymphoma Histologic grade IIIB, stage IA. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 53-year-old gentleman who was diagnosed with follicular lymphoma with large cell component from an excisional biopsy done on _%#MMDD2007#%_.
IA|(stage) IA|IA|248|249|ASSESSMENT AND PLAN|NEUROLOGIC: Cranial nerves II-XII were intact. Normal gait. IMAGING: A PET CT was done on _%#MMDD#%_, which showed no evidence for malignancy. ASSESSMENT AND PLAN: Mr. _%#NAME#%_ is a 53-year-old gentleman with follicular lymphoma grade IIIB stage IA status post 4 cycles of RCHOP. Dr. _%#NAME#%_ personally led a discussion with the patient about the risks and benefits for radiation therapy for his disease.
IA|(stage) IA|IA|21|22|PROBLEM|PROBLEM: Bulky stage IA diffuse large B-cell lymphoma of the right axilla. The patient was seen in the Radiation Oncology Clinic by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_.
IA|(stage) IA|IA|263|264|ASSESSMENT AND PLAN|She presents for evaluation for adjuvant radiation therapy. After examining the patient and the relative studies, we agree that adjuvant therapy is appropriate. It is unfortunate that her peritoneal washings were positive, as otherwise she would have had a stage IA endometrial cancer. Dr. _%#NAME#%_ personally led an extended discussion with the patient and her husband regarding her treatment options, as well as the rationale, risks, benefits, and alternatives to radiation therapy.
IA|(stage) IA|IA|130|131|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Stage IA B-cell lymphoma of the right groin, status post six cycles of CHOP and Rituxan. HPI: This is a 41-year-old male patient who had a renal transplant for IgA nephropathy in _%#MM1996#%_ and again in 1998.
IA|(stage) IA|IA|246|247|INDICATION FOR CONSULTATION|3. recurrent anemia due to the above, 4. improved symptoms of depression and diminished energy with the anemia on thalidomide, 5. depression, 6. anxiety, 7. hyperparathyroidism, remotely, 8. chronic headaches, 9. restless leg syndrome, 10. stage IA endometrial cancer, 11. previous cholecystectomy and total hysterectomy, and 12. polio with chronic dysfunction of her right foot. ALLERGIES: None, but she apparently gets some GI side-effects with aspirin.
IA|(stage) IA|IA|186|187|HISTORY OF PRESENT ILLNESS|Pathology reports were reviewed and Dr. _%#NAME#%_ spoke with Dr. _%#NAME#%_ concerning this patient's care. HISTORY OF PRESENT ILLNESS: The patient was initially diagnosed with a stage IA follicular lymphoma in 1991 in his right axilla which was treated with radiation therapy at what we understand as United Hospital with remission.
IA|(stage) IA|IA|142|143|HPI|The patient is referred to us for evaluation of possible radiation treatment for palliation. HPI: Initially, he was diagnosed as having stage IA disease, presented with right axillary disease in 1991 and had radiation treatment. He recurred in 1996 in the groin area and was treated with radiation again, however, he also developed many peripheral lymphadenopathy which required Chlorambucil until _%#MM2001#%_.
IA|(status) IA|IA|231|232|ASSESSMENT AND PLAN|At this moment the patient's hemodymnamics are stable. His organ functions are within normal range. There is no drive line infection. He is in good physical condition to undergo heart transplantation. We will upgrade him to status IA in the heart transplant waiting list. We hope that he will receive a donor heaert within a month. If he is unable to receive a donor heart in a reasonable period of time we will consider a LVAD exchange procedure to place a HeartMate II LVAD to continue to support him while he is on the transplantation waiting list.
IA|(stage) IA|IA|93|94|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 20-year-old white male with history of stage IA nodular sclerosis Hodgkin disease diagnosed in _%#MM2001#%_. The patient gives a history of two-month history of right lower neck mass which was slowly enlarging and eventually caused some tracheal deviation.
IA|(stage) IA|IA|15|16|PROBLEM|PROBLEM: Stage IA mixed cellularity Hodgkin disease. The patient was seen in consultation by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_. This consultation was requested by Dr. _%#NAME#%_.
IA|(stage) IA|IA|155|156|HISTORY OF PRESENT ILLNESS|The chart was reviewed. The radiological reports were reviewed. HISTORY OF PRESENT ILLNESS: The patient is a 22-year old gentleman with a history of stage IA mixed cellularity Hodgkin disease, status post two cycles of ABVD who presents for the possibility of radiation therapy. This started in _%#MM2002#%_ when the patient noted a left sided neck mass.
IA|(stage) IA|IA|130|131|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Stage IA mixed cellularity Hodgkin disease presented with a large left neck mass. HPI: The patient was seen in consultation earlier, approximately two months ago prior to initiation of his chemotherapy.
IA|(stage) IA|IA|130|131|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Stage IA (T1c N0 M0) infiltrating ductal carcinoma of the right breast, status post lumpectomy. HPI: This is a 38-year-old, premenopausal female patient who presented with a palpable lump in _%#MM2003#%_ and finally was diagnosed to have breast cancer after a few visits to the physicians.
IA|(stage) IA|IA|159|160|REFERRING PHYSICIAN|All margins were negative, and there were proliferative fibrocystic changes located throughout the remainder of the breast. The patient is thus surgical stage IA (T1c, N0, M0). At the same of her surgery, she also had a tissue expander in place by Dr. _%#NAME#%_ _%#NAME#%_ with intention later on having a saline implant.
IA|intraarterial|IA,|239|241|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 69-year-old male with a history of a right thigh mass measuring 12 x 6 cm at the end of 2004. Biopsy showed high-grade MFH. He received neoadjuvant chemotherapy consisting of three cycles of IA, followed by resection in _%#MM#%_ 2004 and adjuvant chemotherapy consisting of two cycles of IA. He also received radiation therapy consisting of 6120 cGy to the posterior thigh between the days of _%#MMDD2005#%_ and _%#MMDD2005#%_.
IA|intraarterial|IA.|194|196|HISTORY OF PRESENT ILLNESS|Biopsy showed high-grade MFH. He received neoadjuvant chemotherapy consisting of three cycles of IA, followed by resection in _%#MM#%_ 2004 and adjuvant chemotherapy consisting of two cycles of IA. He also received radiation therapy consisting of 6120 cGy to the posterior thigh between the days of _%#MMDD2005#%_ and _%#MMDD2005#%_. Most recently, he noticed a lump behind his right knee in the beginning of _%#MM#%_.
IA|(stage) IA|IA.|131|133|HISTORY OF PRESENT ILLNESS|Pathology revealed an endometrioid adenocarcinoma, FIGO grade I to III. The tumor was limited to the endometrium making it a stage IA. The margins were uninvolved by tumor. All dissected lymph nodes were negative, as well as peritoneal washings. She required no adjuvant treatment for this very early stage endometrial cancer.
IA|(stage) IA|IA|188|189|PATHOLOGY|PATHOLOGY: 1. UHR 02-263 (_%#MMDD2002#%_): Revealed 5% slightly atypical plasma cells (lambda light chain restricted). 2. UHH 02- 1083: (_%#MMDD2002#%_) 5% plasma cells. IMPRESSION: Stage IA multiple myeloma with good partial response. RECOMMENDATIONS: Mrs. _%#NAME#%_ was seen and evaluated by Dr. _%#NAME#%_ _%#NAME#%_ and appears to be a suitable candidate for total body irradiation (TBI) prior to an autologous peripheral blood stem-cell transplant per our local protocol _%#PROTOCOL#%_.
IA|(stage) IA|IA|262|263|DOSE|Ms. _%#NAME#%_ was seen on Unit 7B by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2003#%_ at the request of Dr. _%#NAME#%_ _%#NAME#%_. DOSE: The patient received 4500 cGy in 25 fractions to right neck in 1994 for non-Hodgkin lymphoma stage IA at _%#COUNTY#%_ _%#COUNTY#%_ Medical Center. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 67-year-old female with a history of non-Hodgkin lymphoma, stage IA of the right neck diagnosed in 1994.
IA|(stage) IA|IA|266|267|HISTORY OF PRESENT ILLNESS|DOSE: The patient received 4500 cGy in 25 fractions to right neck in 1994 for non-Hodgkin lymphoma stage IA at _%#COUNTY#%_ _%#COUNTY#%_ Medical Center. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 67-year-old female with a history of non-Hodgkin lymphoma, stage IA of the right neck diagnosed in 1994. This was a diffuse large cell lymphoma. She was treated with six cycles of CHOP, followed by consolidative radiation therapy to the right neck with 4500 cGy in 25 fractions using APPA fields.
IA|Iowa|IA|177|178|HISTORY OF PRESENT ILLNESS|Appetite is fair. Bowel and urinary functions are stable. Her cardiac history is positive for: 1. Coronary artery disease, having had a 4-vessel bypass in _%#CITY#%_ _%#CITY#%_ IA 12 years ago. She does not of course know the anatomy. 2. Hypertension. 3. SIADH with hyponatremia. 4. Chronic anemia, cause unclear. An echocardiogram was ordered and was done this morning by our technician.
IA|Iowa|IA.|113|115|PAST MEDICAL HISTORY|It was not until 1998 that the patient started on 6MP. In 1993 the patient had surgery in _%#CITY#%_ _%#CITY#%_, IA. She had bowel perforation that was iatrogenic at the time of laparoscopy which was undertaken as part of the fertility work up at that time.
IA|UNSURED SENSE|IA|270|271|L TIBIAL	54.10	59.95	57.48|2. Pop Fos AH 13.10 2.2 71 7.75 126 15.4 115 17.60 39.4 38 F Wave Nerve Min F Lat Max F Lat Mean FLat ms ms ms L TIBIAL 54.10 59.95 57.48 L PERONEAL 60.50 68.75 63.52 R PERONEAL 54.20 55.60 55.14 R MEDIAN 27.00 30.50 28.90 EMG Summary Table Spontaneous MUAP Recruitment IA Fib/PSW Fasc Other Amp Dur. Poly Pattern L. TIB ANTERIOR Nl 0 0 0 Nl Nl Nl Nl L. GASTROCN (MED) Nl 0 0 0 Nl Nl Nl L.
IA|Iowa|IA|332|333|DISCUSSION|DISCUSSION: Mr. _%#NAME#%_'s history is already well described. The patient has a lengthy history of cardiac issues and is admitted here with a complaint of chest pain. He was last at this hospital in _%#MM2000#%_ and since then has received medical care from a number of sources apparently mainly through physicians in _%#CITY#%_, IA during 2001 and 2002, more recently he has lived in _%#CITY#%_, MN and has been cared for by primary physicians there as well as visiting cardiology consultants from the Abbott Northwestern group.
IA|(stage) IA|IA|224|225|HISTORY OF PRESENT ILLNESS|Biopsy done _%#MMDD2005#%_ (U05-529) showed prostate adenocarcinoma, Gleason 3 + 3 at the left apex involving 5% of the gland. There was no perineural invasion, no angiolymphatic invasion. The patient has a history of stage IA diffuse large B-cell lymphoma which he completed treatment in 2001. He received 6 cycles of R-CHOP chemotherapy. He did not receive consolidative radiation therapy.
IA|(stage) IA|IA|130|131|HISTORY OF PRESENT ILLNESS|PROBLEM: Acute myeloid leukemia. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 59-year-old who was diagnosed in 1999 with stage IA diffuse large B-cell lymphoma involving the left inguinal area. She received 6 cycles of CHOP chemotherapy, followed by radiation to the left inguinal area for a total of 5040 cGy.
IA|(stage) IA|IA|280|281|IMPRESSION|RADIOLOGY STUDIES: MUGA: Scheduled. Chest x-ray: Lungs clear. LABORATORY STUDIES: White blood cell count 9.0, hemoglobin 10.3, platelets 261,000, creatinine 0.93, total bilirubin 0.4, lumbar puncture scheduled. PATHOLOGY: UHH04-? Scheduled for today. IMPRESSION: History of stage IA diffuse large B-cell lymphoma diagnosed in 1999 with recurrence in 2000, treated with chemotherapy and radiation to 2 fields. Subsequently developed myelodysplasia transformed to AML which appears to be in second remission.
IA|(stage) IA|IA|193|194|HPI|Ms. _%#NAME#%_ will be followed by Dr. _%#NAME#%_ _%#NAME#%_ and after transplant by the BMT Clinic. CC: AML. HPI: Ms. _%#NAME#%_ is a 59-year-old female patent who was diagnosed to have stage IA diffuse large B cell lymphoma of the left groin in 1999. The patient received CHOP chemotherapy and groin radiation with a total dose of 5040 cGy.
IA|(stage) IA|IA.|170|172|HISTORY OF PRESENT ILLNESS|She had a TAH/BSO at that time for what sounds like a cyst and unsuspectingly found grade 3 clear cell adenocarcinoma. This was further staged by Dr. _%#NAME#%_ as stage IA. She received 6 cycles of Carbo-Taxol starting in _%#MM2000#%_. After completing this, she had no further therapy and did well until the summer of 2003 when she had a rising CA125, a CT of chest, abdomen and pelvis she revealed a mass in the mediastinum.
IA|(stage) IA|IA|216|217|HPI|Ms. _%#NAME#%_ is a 57-year-old female who I have been asked to see following a recent admission with a left lower extremity deep venous thrombophlebitis. _%#NAME#%_ is known to me with a previous diagnosis of Stage IA left breast cancer status post lumpectomy and sentinel lymph node biopsy done in _%#MM#%_ 2001. She was subsequently treated with adjuvant CMF x 6 ending in _%#MM#%_ 2001 which was followed by local radiation therapy to the left breast completing all of her therapy on _%#MM#%_ _%#DD#%_, 2002.
IA|(stage) IA|IA|215|216|IMPRESSION|No focal deficits. EXTREMITIES: No cyanosis, clubbing, or edema. LABORATORY STUDIES: All of her imaging studies since _%#MMDD2004#%_ have been reviewed. IMPRESSION: Ms. _%#NAME#%_ is a 19-year-old female with stage IA mediastinal diffuse large B-cell lymphoma, status post Rituxan plus CHOP. PLAN: She is scheduled to receive her last cycle of chemotherapy on _%#MMDD2005#%_.
IA|(stage) IA|IA.|190|192|CC|______ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Recurrent follicular small cleaved cell lymphoma, clinical stage IA. HPI: The patient is known to have follicular small cleaved cell lymphoma since 1996.
IA|(class) IA|IA|124|125|ASSESSMENT/RECOMMENDATIONS|There was a torsade rhythm which occurred requiring defibrillation. It is likely this has occurred as a result of the class IA anti-arrhythmic, Quinidine. This is particularly true given the patient's cardiomyopathy. As such, it is recommended that Quinidine be discontinued.
IA|(stage) IA|IA|257|258|IMPRESSION|Chest x-ray from earlier today was felt to show a chest tube in place with no evidence of pneumothorax and no change compared with the previous x-ray from _%#MMDD2006#%_. IMPRESSION: The patient has recent findings of a surgically resected T1, N0, M0 stage IA small cell carcinoma of the left lung. I reviewed the diagnosis of small cell cancer with the patient and with her daughter.
IA|(stage) IA|IA|218|219|ASSESSMENT/PLAN|LUNGS: Essentially clear. HEART: Regular sinus rhythm. EXTREMITIES: Unremarkable, no swelling of the upper extremities. NEUROLOGIC: Cranial nerves II through XII within normal limits. ASSESSMENT/PLAN: Stage IIA versus IA infiltrating ductal carcinoma of the breast with ER, PR positive and HER2 negative, axillary lymph node positive with immunohistochemistry.
IA|UNSURED SENSE|IA|167|168|L MEDIAN - APB|2. Palm Wrist 8 R RADIAL - Snuff 1. Forearm Snuff Yes 12.5 L RADIAL - Snuff 1. Forearm Snuff Yes 12.5 Needle EMG (P)(1) EMG Summary Table Spontaneous MUAP Recruitment IA Fib/PSw Fasc Other Amp Dur. Poly Pattern R. DELTOID Nl 2+ 0 0 L. BICEPS Nl 0 0 0 L. TRICEPS Nl 0 0 0 Nl Nl Nl N
IA|(stage) IA|IA.|138|140|HISTORY  OF PRESENT ILLNESS|The bilateral bone marrow biopsy was performed on _%#MMDD2007#%_ and revealed no evidence of involvement of lymphoma, she was thus staged IA. She was seen by Dr. _%#NAME#%_ and follow-up on _%#MMDD2007#%_ and was recommended to receive R-CHOP chemotherapy to be followed by consolidative radiation.
IA|(stage) IA|IA|158|159|ASSESSMENT|HISTORY OF CHEMOTHERAPY: None. KPS SCORE: Approximately 100. ASSESSMENT: Ms. _%#NAME#%_ is a 51-year-old Caucasian female with diffuse large B cell lymphoma, IA involving the high cervical lymph node chain. She has essentially no medical comorbidities and her performance status is excellent.
IA|(stage) IA|IA|177|178|ADMISSION MEDICATIONS|12. Potassium chloride 20 mEq p.o. daily. 13. Voriconazole 200 mg q.12h. PAST MEDICAL HISTORY: 1. Non-Hodgkin's lymphoma. The patient was diagnosed on _%#MMDD1998#%_ with stage IA follicular small-cleaved cell lymphoma by lymph node biopsy of a left inguinal node. The patient is not known to have any bone marrow involvement.
IA|Iowa|IA|113|114|DISPOSITION|_%#NAME#%_ _%#NAME#%_, MD Pediatric Hematology/Oncology Raymond Blank Children's Hospital _%#CITY#%_ _%#CITY#%_, IA _%#50300#%_ Dear Dr. _%#NAME#%_: _%#NAME#%_ came to clinic on _%#MM#%_ _%#DD#%_, 2002 and was found to have temperatures to 101.1 and 100.7, and thus was admitted.
IA|(stage) IA|IA.|116|118|DISCHARGE DIAGNOSES|2. Depression. 3. Sleep apnea. 4. Obesity. DISCHARGE DIAGNOSES: 1. Grade 1 endometrial adenocarcinoma, likely stage IA. 2. Depression. 3. Sleep apnea. 4. Obesity. OPERATIONS/PROCEDURES PERFORMED: Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo- oophorectomy.
IA|(stage) IA|IA,|284|286|HOSPITAL COURSE|HOSPITAL COURSE: 1. Disease. The patient was taken to the operating room on _%#MM#%_ _%#DD#%_, 2006, and underwent an exploratory laparotomy, bilateral salpingo- oophorectomy, total abdominal hysterectomy without complication. Her final pathology is pending, but this is likely stage IA, grade 1. The patient will follow up for her final pathology with Dr. _%#NAME#%_ in 3 to 4 weeks, but likely no further treatment is necessary.
IA|(stage) IA|IA|149|150|DISCHARGE DIAGNOSES|ADMISSION DIAGNOSES: 1. Grade 1 endometrial cancer. 2. Recently diagnosed breast cancer. 3. Hypertension. 4. Glaucoma. DISCHARGE DIAGNOSES: 1. Stage IA grade 1 endometrial carcinoma of the endometrium. 2. Recently diagnosed breast cancer. 3. Hypertension. 4. Glaucoma. OPERATIONS/PROCEDURES PERFORMED: Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo- oophorectomy, bilateral pelvic and periaortic lymph node dissection, washings, and lysis of adhesions.
IA|(stage) IA|IA,|223|225|PROBLEMS|There was an intramural leiomyoma noted and cervical glandular and squamous epithelium were without evidence of malignancy. The lymph node dissection was negative without evidence of malignancy. Her staging grade was stage IA, grade 1, endometrioid adenocarcinoma. She is to follow up with Dr. _%#NAME#%_ for her postoperative check after her discharge. 2. Fluid, electrolytes, and nutrition: The patient received IV fluids intraoperatively.
IA|(stage) IA|IA,|30|32|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Stage IA, grade 2 recurrent fallopian tube carcinoma. 2. Fibromyalgia. DISCHARGE DIAGNOSES: 1. Stage IA, grade 2 fallopian tube carcinoma, recurrent.
IA|(stage) IA|IA,|290|292|HISTORY OF PRESENT ILLNESS|2. Fibromyalgia. PROCEDURES: Exploratory laparotomy, lysis of adhesions, cystotomy with repair, attempted placement of left ureteral stent, placement of Seprafilm, bladder biopsies. COMPLICATIONS: None. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 51-year-old who has a history of stage IA, grade 2 fallopian tube cancer. The patient was originally diagnosed in _%#MM2004#%_, at which time she underwent exploratory laparotomy, lysis of adhesions, appendectomy, omentectomy, BSO and lymph node dissection for a complex pelvis mass and a strong family history of multiple cancers.
IA|(stage) IA|IA|167|168|PAST MEDICAL HISTORY|The remaining review of systems was negative. PAST MEDICAL HISTORY: 1. Para 2-0-0-2. 2. Otitis media. 3. History of fibromyalgia. 4. BRCA1 mutation positive. 5. Stage IA fallopian tube cancer, now recurrent. PAST SURGICAL HISTORY: 1. Total abdominal hysterectomy for fibroids in 1995.
IA|(stage) IA|IA,|202|204|HISTORY OF PRESENT ILLNESS|2. Placement of rectal stent on _%#MM#%_ _%#DD#%_, 2002. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 56-year-old woman with recurrent ovarian cancer. Her cancer was originally a poorly stage IA, grade III endometrioid cancer of the ovary diagnosed on laparoscopic-assisted vag. hysterectomy and bilateral salpingo- oophorectomy secondary to menorrhagia. Upon findings of malignancy, she underwent carboplatin x3.
IA|(stage) IA|IA|199|200|DIAGNOSES ON DISCHARGE|1. Complex pelvic mass with elevated carcinoembryonic antigen and cancer antigen 125, concerning for malignancy. 2. Hypercholesterolemia. 3. Morbid obesity. DIAGNOSES ON DISCHARGE: 1. Grade 1, stage IA endometrial adenocarcinoma. 2. Hypercholesterolemia. 3. Morbid obesity. OPERATIONS/PROCEDURES PERFORMED: 1. Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, pelvis and paraaortic lymph node dissection.
IA|(stage) IA|IA|125|126|PROBLEMS|The frozen pathology revealed adenocarcinoma. Final pathology results available today indicate that this is a grade 1, stage IA endometrial adenocarcinoma. The patient is to meet with Dr. _%#NAME#%_ in 4-6 weeks to further discuss these pathology results and make a plan for future treatments if necessary.
IA|(stage) IA|IA|118|119|DISCHARGE DIAGNOSES|2. Known fibroid uterus. 3. History of cervical dysplasia. 4. Obesity. 5. Hypertension. DISCHARGE DIAGNOSES: 1. Stage IA grade 1 endometrioid adenocarcinoma of the endometrium. 2. History of cervical dysplasia. 3. Obesity. 4. Hypertension.
IA|(stage) IA|IA,|159|161|HOSPITAL COURSE|There was also adenomyosis noted. All lymph nodes were negative for malignancy. Pelvic washings were also negative for malignancy. Thus, the patient has stage IA, grade 1 endometrioid adenocarcinoma of the endometrium. The patient will meet with Dr. _%#NAME#%_ in 2 to 3 weeks to discuss final pathology and treatment plan.
IA|(stage) IA|IA|164|165|HOSPITAL COURSE|It did not invade past the capsule and was actually 1 mm away from the capsule. All other pathologic specimens were negative for disease, and therefore, a stage of IA was given to the patient. DISCHARGE INSTRUCTIONS: The patient was discharged to home with instructions on a regular diet and activity as tolerated.
IA|intraarterial|IA|166|167|PAST MEDICAL HISTORY|1. Chondroblastic osteosarcoma grade 3, diagnosed in Mayo Clinic in 2004. He is status post right above-the-knee amputation in _%#MM2004#%_ and also post 4 cycles of IA and an additional cycle of CDDP. His last chemotherapy dose was _%#MM2005#%_. He is also status post radiotherapy to his metastatic lesions with most recent treatment in _%#MM2007#%_.
IA|(stage) IA|IA|161|162|DISCHARGE DIAGNOSES|4. Elevated homocystinuria. 5. Hypothyroidism. 6. Hypertension. 7. Right-sided heart failure. 8. Hiatal hernia. 9. Morbid obesity. DISCHARGE DIAGNOSES: 1. Stage IA mucinous cystadenoma, borderline malignant potential. 2. Hypothyroidism. 3. Hypertension. 4. History of bilateral pulmonary emboli. 5. Right-sided heart failure. 6. Hiatal hernia. 7. Morbid obesity.
IA|(stage) IA|IA|344|345|HOSPITAL COURSE|She tolerated the procedure well. However, intraoperatively, she did receive 3 units of packed red blood cells due to a low hemoglobin and 4 units of fresh frozen plasma due to an elevated INR of 1.62. Prior to discharge final pathology did come back on her mass which at the time of operation weighed 27 pounds. Final pathology revealed Stage IA mucinous cystadenoma of borderline malignant potential with no cervix extension. PROBLEM #2: Hematologic. The patient was admitted two days prior to surgery for preoperative reversal of her Coumadin.
IA|(stage) IA|IA|206|207|HOSPITAL COURSE|The patient was taken to the operating room on _%#MMDD2007#%_ at which she underwent a TAH-BSO, pelvic and periaortic lymph node dissection and staging. Final pathology results returned demonstrating stage IA grade 3 endometrioid adenocarcinoma of the right ovary with focal clear cell differentiation. This was consistent with intraop frozen pathology. The patient is scheduled to return to clinic to see Dr. _%#NAME#%_ for discussion of chemotherapy on _%#MMDD2007#%_.
IA|(stage) IA|IA|290|291|PRIMARY CARE CLINIC|REFERRING PHYSICIAN: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD, University of Minnesota Physicians; _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#STREET#%_ _%#STREET#%_ _%#ADDRESS#%_ _%#ADDRESS#%_; _%#CITY#%_, Minnesota _%#55400#%_; phone number _%#TEL#%_. ADMISSION DIAGNOSES: 1. History of stage IA adenocarcinoma of the cervix with recurrent cervical cancer. 2. Undergoing chemotherapy with cisplatin and Taxol on GOG 204. 3. History of depression. DISCHARGE DIAGNOSES: 1. History of stage IA adenocarcinoma of the cervix with recurrent cervical cancer.
IA|(stage) IA|IA|131|132|DISCHARGE DIAGNOSES|2. Undergoing chemotherapy with cisplatin and Taxol on GOG 204. 3. History of depression. DISCHARGE DIAGNOSES: 1. History of stage IA adenocarcinoma of the cervix with recurrent cervical cancer. 2. Undergoing chemotherapy with cisplatin and Taxol on GOG 204. 3. History of depression. OPERATIONS/PROCEDURES PERFORMED: 1. Cisplatin and Taxol chemotherapy as per GOG 204.
IA|(stage) IA|IA|223|224|COMPLICATIONS|5. IV antibiotics with Ancef. 6. Laboratory studies. COMPLICATIONS: None apparent. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 55-year-old with recurrent cervical cancer. The patient was originally diagnosed with stage IA adenocarcinoma of the cervix in 2002. During 2002, the patient had an abnormal Pap smear resulting in a LEEP procedure that showed CIN 2 and 3.
IA|(stage) IA|IA|50|51|DISCHARGE DIAGNOSES|ADDENDUM: DISCHARGE DIAGNOSES: 1. Recurrent Stage IA dysgerminoma, unresectable. Status post etoposide and cisplatin X5 days, readmission with fever. 2. Cystic fibrosis exacerbation with pneumonia from multiple organisms including group D Enterococcus, resistant Alcaligenes xylosoxidans, Pseudomonas aeruginosa, and Aspergillus, on multiple antibiotics.
IA|(stage) IA|IA|123|124|DISCHARGE DIAGNOSES|ADMISSION DIAGNOSES: 1. Pelvic mass. 2. History of renal cell carcinoma in her right kidney. DISCHARGE DIAGNOSES: 1. Stage IA clear cell carcinoma of the ovary. 2. Postoperative day nine, status post exploratory laparotomy, bilateral salpingo-oophorectomy, pelvic and periaortic lymph node dissection, omentectomy and staging.
IA|(stage) IA|IA,|197|199|HOSPITAL COURSE|The surgery went well and had no complications. There is to be returned to the recovery room in stable condition. The pathology did not return prior to the patient's discharge and revealed a stage IA, grade 1 endometrial adenocarcinoma of the endometrium. The patient will probably not require any further treatment as her disease is confined to the uterus.
IA|(stage) IA|IA|223|224|HISTORY OF PRESENT ILLNESS|The patient had a complaint of worsening left lower quadrant pain followed by continued bladder spasms. She was status post total abdominal hysterectomy with pelvic and periaortic lymph node dissection for a presumed Stage IA endometrial stromal sarcoma, later found to be Stage IIIA when peritoneal cytology was found to be positive. There was low-grade evidence of vascular space involvement on final histopathology as well.
IA|(stage) IA|IA.|166|168|PROBLEM #1|The cytopathology from the peritoneal fluid came back as negative for malignant cells, and histopathology was endometrial endometrioid adenocarcinoma, grade 1, stage IA. The patient will follow-up with Dr. _%#NAME#%_ for further follow-up. PROBLEM #2: Fluids, electrolytes, and nutrition. The patient was started on IV fluids during the surgery, and the patient continued to be on IV fluids postoperatively.
IA|(stage) IA|IA|130|131|PROBLEM-ORIENTED HOSPITAL COURSE|The surgery was essentially uncomplicated with an estimated blood loss of 250 cc. The final pathology came back as grade 1, stage IA endometrial cancer. No further treatment was recommended from this point of view. PROBLEM #2: Gastrointestinal. The patient was kept n.p.o. initially postoperatively and was slowly started on her general diet.
IA|(stage) IA|IA,|211|213|DRUG ALLERGIES|She had fallopian tubes and ovaries that looked normal. There was no abnormal fluid. There were no gross lesions in the uterus and no evidence of malignancy was identified. The patient was, thereby, staged as a IA, grade I. The final pathology is still pending at the time of discharge. PROBLEM #2: Pain; the patient was kept on morphine PCA initially postoperatively.
IA|(status) IA|IA.|157|159|HOSPITAL COURSE|His home dose of milrinone was increased to 0.5 mcg/kg per minute from 0.375, and he was initiated on Lasix IV. His transplant status was upgraded to status IA. The patient's milrinone dose was decreased to his home dose of 0.375 mcg/kg per minute due to some discomfort related to tachycardia on _%#MM#%_ _%#DD#%_, 2006.
IA|transient ischemic attack:TIA|IA|472|473|DISCHARGE MEDICATIONS|Given the fact that the patient has a history of migraine headaches and she had a headache at the time of this event, along with several neurologic deficits, which are not localizable to one lesion, it was thought that this was likely an atypical migraine with transient neurologic deficits. The patient had other basic inflammatory markers checked, including a CRP, which was also normal 0.25, as well as a TSH, which was normal at 1.16. The patient was cleared from a T IA and the patient was discharged home with a prescription of Imitrex for symptomatic migraine abortive therapy. The patient has no history of coronary disease, although she does have several coronary risk factors.
IA|intraarterial|IA|199|200|HOSPITAL COURSE|He was therefore directly admitted to the hospital for further evaluation and treatment. HOSPITAL COURSE: 1. Sarcoma: As mentioned above, the patient is now status post 2 cycles of chemotherapy with IA following surgical resection of his left femoral sarcoma. The patient is scheduled to be seen in clinic by Dr. _%#NAME#%_ following discharge to discuss further treatment. 2. Pathological left hip fracture: The patient has been nonweightbearing on his left leg since his surgical resection with allografting in _%#MM#%_ 2005.
IA|(stage) IA|IA|125|126|DISCHARGE DIAGNOSES|2. Diabetes mellitus. 3. Hypertension. 4. Chronic renal failure requiring peritoneal dialysis. DISCHARGE DIAGNOSES: 1. Stage IA endometrioid adenocarcinoma of the uterus, grade 2 to 3. 2. Blood loss anemia. 3. Hypertension. 4. Diabetes mellitus.
IA|(stage) IA|IA|33|34|DIAGNOSES ON ADMISSION|DIAGNOSES ON ADMISSION: 1. Stage IA endometrial cancer. 2. Small bowel obstruction. 3. Urinary tract infection. 4. Hypertension. DIAGNOSES ON DISCHARGE: 1. Stage IA endometrial cancer. 2. Small bowel obstruction. 3. Urinary tract infection.
IA|(stage) IA|IA|106|107|DIAGNOSES ON DISCHARGE|2. Small bowel obstruction. 3. Urinary tract infection. 4. Hypertension. DIAGNOSES ON DISCHARGE: 1. Stage IA endometrial cancer. 2. Small bowel obstruction. 3. Urinary tract infection. 4. Hypertension. PROCEDURES: 1. IV fluids. 2. Abdominal x-ray. 3. Abdomen and pelvis CT scan. 4. Clostridium difficile culture.
IA|(stage) IA|IA|248|249|ASSESSMENT AND PLAN|Upper Extremities appear symmetrical for tone and strength. She has a Port-A-Cath in place in the right chest and it is clean, dry and intact at its insertion. ASSESSMENT AND PLAN: 1. The patient with multiple myeloma originally diagnosed as stage IA day in _%#MM2005#%_ with increased sequelae including protein and anemia changes. She is being referred and followed by the Bone Marrow Transplant Service.
IA|UNSURED SENSE|IA,|176|178|FAMILY HISTORY|The patient was placed on oxygen, as he felt more comfortable with it on. The patient did also undergo a sniff test to evaluate for any possible diaphragmatic dysfunction. The IA, PH, RAG, and ATIC were also normal. With these findings, the pulmonary service did not feel there was a pulmonary etiology which was causing dyspnea.
IA|(stage) IA|IA|153|154|ASSESSMENT|HISTOPATHOLOGY: As per HPI. HISTORY OF RADIATION: None HISTORY OF CHEMOTHERAPY: None. ASSESSMENT: A 72-year-old Caucasian female with a history of stage IA nonsmall cell lung carcinoma, now with solitary brain metastasis, status post surgical excision, postop day #2. PLAN: Dr. _%#NAME#%_ lead a discussion with the patient and her husband brother today in regard to our therapeutic suggestions in the postoperative setting.
IA|(stage) IA|IA|216|217|HISTORY OF PRESENT ILLNESS|We have reviewed pertinent records, including progress notes, pathology reports, operative reports, and radiologic studies. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 22-year old gentleman with a clinical stage IA mixed cellularity Hodgkin disease. His history dates back to some time around mid _%#MM#%_ of 2003, when he noticed a left sided neck mass.
IA|(stage) IA|IA.|221|223|HISTORY OF PRESENT ILLNESS|In conjunction with the patient's CT scan, it was felt that abnormalities visualized in the spleen and in the right iliac region possibly did not represent lymphomatous involvement. Therefore, the patient was staged as a IA. A bone marrow biopsy was performed on _%#MMDD2003#%_ and was normal cellular without any evidence of lymphoma. Mr. _%#NAME#%_ is currently under the care of Dr. _%#NAME#%_ _%#NAME#%_ in _%#CITY#%_, Minnesota.
IA|(stage) IA|IA|132|133|HISTORY OF PRESENT ILLNESS|PROBLEM: Myelodysplastic syndrome. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 59-year-old who was diagnosed in 1999 with stage IA diffuse large B-cell lymphoma involving the left inguinal area. She received 6 cycles of CHOP chemotherapy, followed by radiation consolidation to the left inguinal area.
IA|(stage) IA|IA|145|146|HPI|ADDENDUM BY DR. _%#NAME#%_ (_%#MMDD2004#%_): Problem: Myelodysplastic syndrome. HPI: This is a 59-year-old female patient who was diagnosed with IA diffuse large cell non-Hodgkin's lymphoma in 1999. He received 6 cycles of CHOP chemotherapy and consolidation radiation. Unfortunately he recurred in the L3 vertebral body with nerve root compression.
IA|(stage) IA|IA,|221|223|PAST MEDICAL HISTORY|She also states that she has not had intercourse since her surgery, and again reiterates that she has had no abnormal bleeding since that time. PAST MEDICAL HISTORY: 1. Anxiety. 2. Depression. 3. Hodgkin's disease, stage IA, diagnosed 11 years ago. 4. Complex endometrial hyperplasia with atypia. PAST SURGICAL HISTORY: 1. Status post vestibular nerve resection. 2. Status post biopsy and port placement for Hodgkin's disease.
IA|(stage) IA|IA.|296|298|HISTORY OF PRESENT ILLNESS|On _%#MMDD1997#%_, Mr. _%#NAME#%_ underwent a biopsy of the right axillary lymph node and was found to have follicular predominantly small- cleaved with marginal zone/monocytoid features. REAL classification grade 1 of 3. Abdominal CT, neck CT and bone marrow biopsy were negative. His stage was IA. Mr. _%#NAME#%_ received radiation treatment at the Unity Radiation Center. The right axilla and right supraclavicular regions were treated to 3600 cGy with a boost to 4140 cGy.
IA|(stage) IA|IA|211|212|IMPRESSION|LABORATORY STUDIES: White blood cell count 1.9, hemoglobin 14.0, platelets 149,000, creatinine 1.3, total bilirubin 0.4, LD 732. PATHOLOGY: UHH03-781 (_%#MMDD2003#%_): No evidence of lymphoma. IMPRESSION: Stage IA follicular mixed lymphoma with previous chemotherapy and radiation, and good response to recent fludarabine by patient report. RECOMMENDATIONS: Mr. _%#NAME#%_ was seen and examined by Dr. _%#NAME#%_ _%#NAME#%_ and appears to be a suitable candidate for total body irradiation prior to an allogenic peripheral blood stem cell transplant per our local protocol _%#PROTOCOL#%_.
IA|(stage) IA|IA.|179|181|HISTORY OF PRESENT ILLNESS|Ms. _%#NAME#%_ is a 77-year-old female with grade 3 follicular non-Hodgkin's lymphoma diagnosed in _%#MM1999#%_. She had disease limited to her neck at that time, which was stage IA. She received six cycles of CHOP chemotherapy and then involved field radiation to the supraclavicular area and upper chest to 3060 cGy.
IA|(stage) IA|IA|143|144|ASSESSMENT|Gait is smooth and symmetric. ASSESSMENT: The patient is a 77-year-old female with follicular non- Hodgkin's lymphoma. She was initially stage IA when diagnosed in _%#MM1999#%_ and received six cycles of CHOP and involved field radiation to the supraclavicular and upper chest areas to 3060 cGy.
IA|(stage) IA|IA,|277|279|PROBLEM|Multiple questions were answered with regards to complications. The patient signed a consent dated _%#MMDD2005#%_. _%#NAME#%_ _%#NAME#%_, MD Resident Physician Additional note by Dr. _%#NAME#%_ (_%#MMDD2005#%_): PROBLEM: Left breast cancer, infiltrating ductal carcinoma stage IA, T1 N1 M0, status post lumpectomy and chemotherapy. HPI: This is a 46-year-old female patient who noted lump in her left breast in _%#MM2004#%_ at _%#CITY#%_ _%#CITY#%_ Hospital.
IA|(stage) IA|IA|202|203|HISTORY OF PRESENT ILLNESS|The patient had gene rearrangement, the first was negative, but the second came back positive for monoclonal T-cell lymphoma. The patient at that time was diagnosed with cutaneous T-cell lymphoma stage IA affecting 10% of the body surface area. The patient was started on topical Lidex at treatment. By _%#MMDD2003#%_, the patient began to notice increasing intracutaneous involvement over much of the body surface area.
IA|(stage) IA|IA,|317|319|HISTORY OF PRESENT ILLNESS|Ms. _%#NAME#%_ was seen in the Radiation Oncology clinic by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2002, for consultation at the request of Dr. _%#NAME#%_ _%#NAME#%_. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 66-year-old female with history of non-Hodgkin lymphoma, stage IA, of the right neck diagnosed in 1994. This was a diffuse large-cell lymphoma. At that time she was treated with six cycles of CHOP followed by consolidative radiation therapy to the right neck with 4500 cGy in 25 fractions using AP-PA fields.
IA|(class) IA|IA|142|143|ASSESSMENT|Our choices generally would be Sotalol or amiodarone since she apparently has left ventricular dysfunction. I would be unlikely to use a type IA medication with her. If she develops significant bradycardia with this approach, a permanent pacemaker would be necessary. I would avoid amiodarone for now given her COPD. She does not show evidence of congestive heart failure at this time.
IA|(stage) IA|IA,|185|187|HISTORY OF PRESENT ILLNESS|The chart, radiographic reports/films, and pathology were reviewed. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 65-year-old female with two synchronous primaries, including a Stage IA, grade 1 endometrial adenocarcinoma and a right breast invasive ductal carcinoma. She initially presented in the fall of 2002 with postmenopausal bleeding.
IA|(stage) IA|IA,|141|143|ASSESSMENT|There is also increased uptake in the mid thoracic spine and increased uptake in the right axilla. ASSESSMENT: 65-year-old female with stage IA, grade 1 endometrial adenocarcinoma, status post exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic washings. She also has a stage II (T2 N1 M0) grade 2 invasive ductal carcinoma of the right breast.
IA|(stage) IA|IA,|198|200|RECOMMENDATIONS|One of two sentinel lymph nodes was positive with borderline extracapsular extension, remaining 13 lymph nodes from axillary dissection were negative. RECOMMENDATIONS: Regarding the patient's stage IA, grade 1 endometrial adenocarcinoma, no further therapy is indicated at this time. However, adjuvant radiation therapy is indicated for the patient's right breast invasive ductal carcinoma, status post right modified radical mastectomy.
IA|transient ischemic attack:TIA|IA,|153|155|PAST MEDICAL HISTORY|10. Status post kidney mass removal in 2003. 11. Status post cholecystectomy in 2003. 12. Status post breast reduction in _%#MM2007#%_. 13. History of T IA, patient states she was previously in rehab for this. ALLERGIES: Penicillin, meperidine, sulfa, Vistaril, Ambien and morphine.
IA|(stage) IA|IA|140|141|PLAN|In the meantime, definite staging of the tumor were discussed with the patient clinical stage IA, B, C II and III. If the patient has stage IA disease, then she will probably only need a surgical resection without any further treatment. If the patient has stage IB or stage IC disease mainly involving the uterine muscle or local extension to the local cervix the patient may also need postoperative adjuvant radiation.
IA|(stage) IA|IA|217|218|ASSESSMENT|Also noted is right hydronephrosis and two cystic structures consistent with lymphocele or seroma. ASSESSMENT: Mrs. _%#NAME#%_ is a 57-year old woman with recurrent endometrial mixed carcinoma with a history of stage IA grade 3 primary. She is certainly a candidate for radiotherapy as a means of palliation and local control. We feel that the patient's current pain symptoms will greatly benefit from radiotherapy.
IA|(stage) IA|IA|196|197|HPI|My key findings: CC: Recurrent endometrial adenocarcinoma with clear cell component. HPI: Mrs. _%#NAME#%_ underwent a laparoscopic assisted vaginal hysterectomy on _%#MMDD2003#%_. She had a stage IA grade 2-3 endometrial adenocarcinoma and with a small clear cell component. Nodes were negative. There was no angiolymphatic invasion or adnexal cervical myometrial or parametrial involvement.
IA|(stage) IA|IA.|180|182|ASSESSMENT|EXTREMITIES: No edema. NEUROLOGIC: Cranial nerves II through XII intact. Motor and sensory intact. ASSESSMENT: 62-year-old female with non-small-cell lung cancer, originally stage IA. At the time of surgery it was discovered to be a stage IIIA. The patient underwent 3 cycles of cisplatin and docetaxel, completed in _%#MM2004#%_.
IA|(stage) IA|IA|232|233|HISTORY OF PRESENT ILLNESS|Radiation was tolerated well. Within a year, Mr. _%#NAME#%_ had a mediastinal mass identified on a routine CAT scan. The decision was made to biopsy the mediastinum. The biopsy revealed lymphoblastic lymphoma. Workup revealed stage IA disease. CNS was negative. Bone marrow was negative. No other sites of disease. Mr. _%#NAME#%_ received chemotherapy per a Memorial Sloan-Kettering protocol (L20 regimen) which include multiple chemotherapeutic agents along with intrathecal Methotrexate.
IA|(stage) IA|IA|283|284|IMPRESSION|UHR04-478 (_%#MMDD2004#%_) ALL involving bone marrow (92%) and peripheral blood (84% circulating blasts). UHH04-2251 (_%#MMDD2004#%_) no evidence of lymphoma. IMPRESSION: History of stage I seminoma treated with surgery and radiation, followed a year later with a diagnosis of stage IA lymphoblastic lymphoma involving the mediastinum with good response to chemotherapy and relapse, followed by salvage chemotherapy with apparent complete remission.
IA|(stage) IA|IA|15|16|PROBLEM|PROBLEM: Stage IA diffuse large B-cell lymphoma. The patient was seen in the Radiation Oncology Clinic by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_. The consultation was requested by Dr. _%#NAME#%_ _%#NAME#%_.
IA|(stage) IA|IA|158|159|ASSESSMENT|Strength 5/5 in all four extremities. Light touch is symmetric and intact in all four extremities. Gait is symmetric. ASSESSMENT: 50-year-old male with stage IA diffuse large B-cell lymphoma located in his right axilla. He is status post 6 cycles of R- CHOP chemotherapy with a complete response.
IA|(stage) IA|IA.|189|191|CC|______ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Diffuse large B-cell lymphoma of the right axillary area, stage IA. Post chemotherapy. HPI: This is a 50-year-old male patient who initially had right axillary lymphadenopathy in _%#MM2003#%_.
IA|(stage) IA|IA|136|137|HPI|Lungs essentially clear. Heart regular sinus rhythm. Abdomen with no organomegaly. Extremities unremarkable. Assessment and Plan: Stage IA diffuse large B-cell lymphoma of the right axillary area with a large mass originally. We will review the CT scan and see whether this lesion has broken capsules prior to treatment.
IA|(stage) IA|IA|200|201|HISTORY OF PRESENT ILLNESS|She is referred to Dr. _%#NAME#%_ by Dr. _%#NAME#%_ _%#NAME#%_ to discuss further possible treatment and surveillance options. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 60-year-old with a stage IA carcinosarcoma of the uterus (the carcinosarcoma was limited to an endometrial polyp). She developed postmenopausal bleeding. This was in _%#MM2004#%_. She had endometrial biopsy done and that revealed the pathology of the carcinosarcoma.
IA|(stage) IA|IA|245|246|HISTORY OF PRESENT ILLNESS|There were a total of 31 lymph nodes removed, all of which were negative for any evidence of tumor. Furthermore, the washings were negative for tumor. The patient presents today to discuss further treatment options regarding this diagnosis of a IA carcinosarcoma of the uterus. PAST MEDICAL HISTORY: 1. The patient is a para 3-0-2-3.
IA|(stage) IA|IA|114|115|IMPRESSION|Pathology from this was negative, thus there is no evidence of metastatic disease. IMPRESSION: 60-year-old with a IA carcinosarcoma of the uterus. Her disease was limited to an endometrial polyp. PLAN: After an extensive discussion with the patient of the risks, benefits and alternatives of whole abdominal radiotherapy, pelvic radiotherapy, chemotherapy and observation, the patient ultimately elected to undergo pelvic radiotherapy.
IA|(stage) IA|IA|141|142|ASSESSMENT|She has been diagnosed with synchronous primaries, stage IIA, well-differentiated adenocarcinoma of the left distal fallopian tube and stage IA well-differentiated endometrioid adenocarcinoma of the endometrium. She is status post complete surgical resection and 6 cycles of adjuvant carboplatinum and Taxol chemotherapy.
IA|(stage) IA|IA|15|16|PROBLEM|PROBLEM: Stage IA extranodal mucosa-associated lymphoid tumor of the stomach. HISTORY OF PRESENT ILLNESS: This is an 89-year-old Russian- speaking lady who comes with an interpreter to evaluate for gastric lymphoma.
IA|(stage) IA|IA|108|109|IMPRESSION|Differential shows 67% neutrophils, 24% lymphocytes, 1% eosinophils, and 8% monocytes. IMPRESSION: 1. Stage IA external MALT non-Hodgkin's lymphoma of the stomach, persistent after antibiotic treatment. 2. Recurrent pancreatitis. Discussed with the patient's primary physician, Dr. _%#NAME#%_, who does not feel the patient has active pancreatitis at this time.
IA|(stage) IA|IA.|222|224|ASSESSMENT|Muscle strength 5/5. Gait and stations are normal. ASSESSMENT: 60-year-old, postmenopausal female with a history of CIN 3 status post cold knife cone in 2000, now developed invasive squamous cell carcinoma, clinical stage IA. The patient underwent radical hysterectomy with extraperitoneal para-aortic, pelvic adenectomy. The patient has many indications for adjuvant radiation therapy based on pathology.
IA|intraarterial|IA|195|196|HISTORY OF PRESENT ILLNESS|ADMISSION DIAGNOSIS: Gemistocytic astrocytoma. DISCHARGE DIAGNOSIS: Gemistocytic astrocytoma. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 25-year-old man who presents for his 7th cycle of IV IA chemotherapy. HOSPITAL COURSE: On _%#MMDD2007#%_, the patient underwent an uncomplicated course of intravenous intra-arterial chemotherapy with injections to his left carotid artery of 745 mg of carboplatin.
IA|intraarterial|IA|135|136|HOSPITAL COURSE|HOSPITAL COURSE: The patient was admitted on _%#MMDD2006#%_. She was taken to the operating room on _%#MMDD2006#%_ where she underwent IA chemotherapy treatment. The intraarterial chemotherapy was administered through the left internal carotid artery. Ms. _%#NAME#%_ tolerated the procedure without complications. She was transferred back to the oncology floor for observation.
IA|intraarterial|IA|89|90|ASSESSMENT|A CBC, BMP and INR/PTT are all pending for today. ASSESSMENT: GBM here for cycle 1 of IV IA chemo. RECOMMENDATIONS: 1. Follow labs. 2. IV IA chemo as planned.
IA|(stage) IA|IA|15|16|PROBLEM|PROBLEM: Stage IA nodular sclerosis Hodgkin disease. This patient was seen in the Radiation Oncology Clinic on _%#MM#%_ _%#DD#%_, 2002 for reconsultation by Drs. _%#NAME#%_ _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_ at the request of Dr. _%#NAME#%_ _%#NAME#%_ from the Department of Medical Oncology.
IA|(stage) IA|IA|148|149|HOSPITAL COURSE|The large right ovarian cyst was noted to be a benign cyst. The fallopian tube specimen was unremarkable. Therefore, the patient is a grade 1 stage IA endometrioid cancer of the uterus. Patient also had a Jackson-Pratt drain postoperatively which was discontinued at the time of discharge without difficulty.
IA|(stage) IA|IA.|145|147|DISCHARGE DIAGNOSES|2. Obesity. 3. Hyperlipidemia. 4. Umbilical hernia. DISCHARGE DIAGNOSES: 1. Grade 2 endometrioid adenocarcinoma of the endometrium, likely stage IA. 2. Status post exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic and periaortic lymph node dissection, and umbilical hernia repair.
IA|(stage) IA|IA,|125|127|DISCHARGE DIAGNOSES|ADMISSION DIAGNOSES: 1. Stage IA, grade 2 recurrent fallopian tube carcinoma. 2. Fibromyalgia. DISCHARGE DIAGNOSES: 1. Stage IA, grade 2 fallopian tube carcinoma, recurrent. 2. Fibromyalgia. PROCEDURES: Exploratory laparotomy, lysis of adhesions, cystotomy with repair, attempted placement of left ureteral stent, placement of Seprafilm, bladder biopsies.
IA|(stage) IA|IA|181|182|HOSPITAL COURSE|Estimated blood loss was 350 cc. The procedure was without complication. Please see the operative report for further details. Final pathology was returned and consistent with stage IA grade 1 endometrioid adenocarcinoma of the endometrium arising in the background of complex hyperplasia. There was no myometrial invasion identified. The patient will meet with Dr. _%#NAME#%_ 2 to 3 weeks postoperatively for treatment planning.
IB|(stage) IB|IB|191|192|ADMISSION DIAGNOSIS|ADMISSION DATE: _%#MMDD2007#%_ DISCHARGE DATE: _%#MMDD2007#%_ ADMISSION DIAGNOSIS: Stage IB uterine carcinosarcoma here for IV Taxol and iphosphamide chemotherapy. DISCHARGE DIAGNOSIS: Stage IB uterine carcinosarcoma here for IV Taxol and iphosphamide chemotherapy.
IB|(stage) IB|IB|84|85|PAST MEDICAL HISTORY|The remainder of the review of systems was negative. PAST MEDICAL HISTORY: 1. Stage IB carcinosarcoma of the uterus. 2. Chronic immune demyelinating polyneuropathy. 3. Hypothyroidism. 4. Type 2 diabetes mellitus. 5. Anemia of chronic disease.
IB|(stage) IB|IB,|58|60|PRIMARY PRINCIPAL DIAGNOSIS|PRIMARY PRINCIPAL DIAGNOSIS: Endometrial carcinoma (stage IB, grade 2.) PRIMARY PRINCIPAL PROCEDURE PERFORMED DURING THE HOSPITALIZATION: Total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic and periaortic complete lymphadenectomy. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was electively admitted following an outpatient bowel prep on _%#MMDD2007#%_.
IB|(stage) IB|IB|309|310|HISTORY OF PRESENT ILLNESS|She denied any vaginal bleeding, fevers, chills or nausea or vomiting, but had stated she took a temperature, what she read 101.4 degrees Fahrenheit. Her recent chemotherapeutic regimens have included weekly Taxol and her cervical cancer history is as follows: The patient was originally diagnosed with stage IB squamous cell carcinoma in 1997 and at the time of her surgery did have a lymph node dissection with a positive node that she was treated with external beam radiation as well as cisplatin and paclitaxel chemotherapy.
IB|(stage) IB|IB,|30|32|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Stage IB, grade 3 endometrial adenocarcinoma. 2. Hyponatremia. 3. Elevated liver enzymes. 4. Nausea and vomiting. DISCHARGE DIAGNOSES: 1. Stage IB, grade 3 endometrial adenocarcinoma. 2. Syndrome of inappropriate secretion of antidiuretic hormone. 3. Elevated liver enzymes. 4. Nausea and vomiting. 5. Urinary tract infection.
IB|(stage) IB|IB,|98|100|DISCHARGE DIAGNOSES|2. Hyponatremia. 3. Elevated liver enzymes. 4. Nausea and vomiting. DISCHARGE DIAGNOSES: 1. Stage IB, grade 3 endometrial adenocarcinoma. 2. Syndrome of inappropriate secretion of antidiuretic hormone. 3. Elevated liver enzymes. 4. Nausea and vomiting. 5. Urinary tract infection.
IB|(stage) IB|IB,|193|195|HISTORY OF PRESENT ILLNESS|6. Chest x-rays, flat and upright. 7. Lab workup. COMPLICATIONS: None apparent. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 61-year-old, postoperative day #8, status post TAH-BSO nodes for IB, grade 3 endometrial adenocarcinoma who returns to the ED with persistent nausea, emesis and diarrhea after enema. She also reports a headache. She was discharged on postoperative day #4 and says she has had alternating good and bad days.
IB|(stage) IB|IB,|127|129|PAST MEDICAL AND SURGICAL HISTORY|She also reports significant diarrhea at home after using an enema this afternoon. PAST MEDICAL AND SURGICAL HISTORY: 1. Stage IB, grade 3 endometrial adenocarcinoma, postoperative day #8. 2. Hyperlipidemia. 3. Gastroesophageal reflux disease. 4. Arthritis. 5. Restless legs syndrome.
IB|(stage) IB|IB,|138|140|HOSPITAL COURSE|5. Pain. The patient was treated with Celebrex b.i.d. 6. Prophylaxis. The patient received Lovenox for DVT prophylaxis. 7. Disease. Stage IB, grade 3 endometrioid endometrial cancer. The patient will follow up with Dr. _%#NAME#%_ in two to four weeks for surveillance/treatment planning. DISCHARGE INSTRUCTIONS: The patient was instructed to call us if temperature greater than 100.4, pain not controlled with medications, increased swelling or drainage.
IB|(stage) IB|IB|207|208|HISTORY OF PRESENT ILLNESS|6. Chronic inflammatory demyelinating polyneuropathy. PROCEDURES: 1. Intravenous fluids. 2. Blood cultures and urine cultures. HISTORY OF PRESENT ILLNESS: This patient is a 35-year-old with history of stage IB carcinosarcoma of the endometrium. She is status post TAH, BSO, staging as well as 2 courses of ifosfamide and Taxol. She was sent from clinic where she was undergoing plasma exchange for her demyelinating polyneuropathy.
IB|(stage) IB|IB|226|227|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old female with a complex medical history who is admitted by Dr. _%#NAME#%_ to evaluate hyperbilirubinemia, increased BUN and creatinine. The patient has a history of stage IB endometrial cancer. In 1995 had a THBSO, chemotherapy, and radiation treatment. The patient had post radiation damage to her abdomen, and has had multiple laparotomies for small bowel obstruction.
IB|(stage) IB|IB.|229|231|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: 1. Wound dehiscence. 2. Postoperative from abdominal hysterectomy, bilateral salpingo- oophorectomy and pelvic3. and periaortic lymph node dissection secondary to grade 1 endometrial cancer found to be stage IB. DISCHARGE DIAGNOSIS: 1. Wound dehiscence. 2. Postoperative from abdominal hysterectomy, bilateral salpingo- oophorectomy and pelvic3.
IB|(stage) IB|IB,|290|292|OPERATIONS/PROCEDURES PERFORMED|OPERATIONS/PROCEDURES PERFORMED: Placement of wound VAC. HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old woman who is postoperative day #9 status post total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic and periaortic lymph node dissection secondary to stage IB, grade 1 endometrial carcinoma of the uterus. The patient was seen at the clinic on _%#MM#%_ _%#DD#%_, 2005. At that time, her staples were removed and at that point, her incision completely opened.
IB|(stage) IB|IB|130|131|DISCHARGE DIAGNOSES|DIAGNOSES ON ADMISSION: 1. IB1 squamous cell carcinoma of the cervix. 2. Rectal bleeding. 3. Pelvic pain. DISCHARGE DIAGNOSES: 1. IB squamous cell carcinoma of the cervix. 2. Rectal bleeding. 3. Pelvic pain. OPERATIONS/PROCEDURES PERFORMED: 1. IV fluid hydration.
IB|(stage) IB|IB|27|28|PRINCIPAL DIAGNOSIS|PRINCIPAL DIAGNOSIS: Stage IB poorly differentiated papillary serous carcinoma of the uterus. PRIMARY PRINCIPAL PROCEDURE PERFORMED DURING THE HOSPITALIZATION: Radical hysterectomy, bilateral salpingo-oophorectomy, pelvic and periaortic lymphadenectomy.
IB|(stage) IB|IB,|161|163|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Endometrial adenocarcinoma, grade 1 of 3. DISCHARGE DIAGNOSIS: Endometrial adenocarcinoma, grade 1, final pathology pending. Probable stage IB, grade 1. PROCEDURES: Total abdominal hysterectomy, bilateral salpingo- oophorectomy. HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old patient who presented for her annual exam with pelvic pressure.
IB|(stage) IB|IB,|96|98|DISCHARGE DIAGNOSIS|ADMISSION DIAGNOSIS: Probable endometrial cancer. DISCHARGE DIAGNOSIS: Endometrial cancer stage IB, FIGO stage I. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 76-year-old woman who presents to the Woman's Health Center on _%#MM#%_ _%#DD#%_, 2003, for exploratory laparotomy TAH BSO for suspected endometrial cancer.
IB|(stage) IB|IB,|143|145|HOSPITAL COURSE|The remainder of her postoperative course will be discussed in a system base fashion. Her final pathology was read as endometrial cancer stage IB, grade 1. 1. Fluid, electrolytes, and nutrition. On postoperative number 1, her IV fluids were decreased from her maintenance level of 125 cc per hour.
IB|interferon beta|IB|116|117|DISCHARGE MEDICATIONS|2. Baclofen 10 mg p.o. q.7 am, q. 12 noon, q.5 p.m., and q.10 p.m. 3. Tagamet 300 mg p.o. t.i.d. 4. Interferon beta IB 0.3 mg subcutaneously q.48 h. 5. Synthroid 50 mcg p.o. each day 6. Lisinopril 2.5 mg. p.o. each day. 7. Methylprednisolone 4 mg p.o. t.i.d.
IB|(stage) IB|IB|167|168|HISTORY OF PRESENT ILLNESS|The MRI of the hips was negative for AVN or osteonecrosis. None of the MRI studies demonstrated any evidence of metastasis as the patient did carry a history of stage IB lung cancer, and she is status post pneumonectomy. The patient was also worked up for myeloma as she did have a very mild anemia with bone pain.
IB|(stage) IB|IB|103|104|ADMITTING DIAGNOSIS|ADMITTING DIAGNOSIS: _%#NAME#%_ _%#NAME#%_ with history of IIIC papillary serous ovarian carcinoma and IB endometrial adenocarcinoma of the endometrium, here for cycle #2 or chemotherapy #2 with IV and IP intraperitoneal chemotherapy. DISCHARGE DIAGNOSIS: _%#NAME#%_ _%#NAME#%_ with history of IIIC papillary serous ovarian carcinoma and 1B endometrial adenocarcinoma of the endometrium, here for cycle #2 or chemotherapy #2 with IV and IP intraperitoneal chemotherapy.
IB|(stage) IB|IB|240|241|PAST MEDICAL HISTORY|20.Status post splenectomy. 21.History of multiple esophageal jejunal strictures, status post dilation in 1987 and 1989. 22.Status post total abdominal hysterectomy with bilateral salpingo-oophorectomy and bilateral node sampling for Stage IB Grade I endometrial carcinoma in 1988. 23.History of abnormal gait with extensive workup at the Mayo Clinic in 2001, unrevealing. CURRENT MEDICATIONS: (List obtained from the patient's husband from Transitional Care Unit discharge).
IB|(stage) IB|IB,|87|89|DISCHARGE/DEATH DIAGNOSIS|TIME OF DEATH: Death was _%#MMDD2003#%_ at 12:50 p.m. DISCHARGE/DEATH DIAGNOSIS: Stage IB, grade 1 adenocarcinoma of the endometrium, which was recurrent, with spinal cord and brain metastasis; and a recent bilateral hemiparesis related to the metastasis. HOSPITAL COURSE: In short, the patient was admitted to rehabilitation on _%#MMDD2003#%_ with the hope that she would be able to regain enough strength and mobility to return home.
IB|(stage) IB|IB.|69|71|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Squamous-cell carcinoma of the cervix, probable IB. DISCHARGE DIAGNOSIS: IB2 squamous-cell carcinoma of the cervix. PROCEDURES: 1. Examination under anesthesia. 2. Cystoscopy. 3. Proctoscopy. 4. Extraperitoneal pelvic and periaortic lymphadenectomy. 5. Electrocardiogram. 6. IV fluids.
IB|(stage) IB|IB|129|130|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old man who is status post right upper lobectomy in _%#MM#%_ 2003 for stage IB non- small cell lung cancer. He then had recurrent disease and then underwent a right pneumonectomy. The postoperative course at that time was complicated by a right bronchopleural fistula with associated empyema.
IB|(stage) IB|IB,|110|112|DISCHARGE DIAGNOSES|2. Hypertension. 3. Dyslipidemia. 4. Hypothyroidism. 5. Depression. 6. Obesity. DISCHARGE DIAGNOSES: 1. Stage IB, grade 2 endometrioid adenocarcinoma of the endometrium. 2. Fever of unknown origin. 3. Hypertension. 4. Dyslipidemia. 5. Hypothyroidism. 6. Depression. 7. Obesity. PROCEDURES: 1. Laparoscopic hysterectomy, bilateral salpingo-oophorectomy and pelvic and periaortic lymph node dissection.
IB|(stage) IB|IB,|115|117|HOSPITAL COURSE|There was grade 1 endometrioid adenocarcinoma of the endometrium with depth of invasion of 0.5 of 2 cm for a stage IB, grade 1. There was no lymphovascular space invasion. No cervical serosal, adnexal or vaginal involvement. The tumor did reach down to the endometrial side of the lower uterine segment.
IB|(stage) IB|IB.|144|146|DISCHARGING DIAGNOSES|4. Congenital mitral insufficiency. 5. Aortic stenosis. 6. Meniere's disease. 7. Osteoporosis. DISCHARGING DIAGNOSES: 1. Cervical cancer, stage IB. 2. Hypertension. 3. Rosacea. 4. Congenital mitral insufficiency. 5. Aortic stenosis. 6. Meniere's disease. 7. Osteoporosis. 8. Hypokalemia. 9. Blood loss anemia.
IB|(stage) IB|IB,|225|227|HOSPITAL COURSE|HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was electively admitted on _%#MMDD2007#%_. She underwent a TAH/BSO, pelvic and periaortic lymphadenectomy for a grade 1 endometrial adenocarcinoma. Final histopathology revealed a stage IB, grade 1 adenocarcinoma. Her diet was slowly advanced. She suffered very little if any anemic or febrile morbidity.
IB|(stage) IB|IB.|158|160|DISCHARGE DIAGNOSIS|Her pathology report came back as a 2.7 cm adenocarcinoma with negative lymph nodes, but some pleural involvement. She has been staged as a T2 N0 M0 or stage IB. At the time of her discharge, her wound is clean and dry without any erythema or drainage. DISCHARGE DIET: Regular. DISCHARGE ACTIVITY: She has been instructed not to lift anything greater than 10 pounds for approximately 2 months.
IB|(stage) IB|IB|30|31|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Stage IB grade 3 malignant mixed mullerian tumor of the uterus. 2. Incisional hernia. 3. Hypertension. 4. Hypercholesterolemia. 5. History of diverticulosis.
IB|(stage) IB|IB|124|125|DISCHARGE DIAGNOSES|2. Incisional hernia. 3. Hypertension. 4. Hypercholesterolemia. 5. History of diverticulosis. DISCHARGE DIAGNOSES: 1. Stage IB grade 3 malignant mixed mullerian tumor of the uterus. 2. Incisional hernia. 3. Hypertension. 4. Hypercholesterolemia. 5. History of diverticulosis.
IB|(stage) IB|IB|135|136|HOSPITAL COURSE|HOSPITAL COURSE: Ms. _%#NAME#%_ underwent surgery on _%#MMDD2007#%_ a ventral hernia repair without mesh. 1. Disease. History of stage IB grade 3 MMMT status post high-dose brachytherapy x3. 2. FEN. She received IV fluids immediately postoperatively, which were discontinued once she was able to tolerate p.o. She received electrolyte replacement as needed and was tolerating a regular diet on postoperative day #2.
IB|(stage) IB|IB|264|265|HOSPITAL  COURSE|Her postoperative course was uneventful. Her diet was slowly advanced and she tolerated a regular diet and oral pain medicines prior to discharge. She suffered very little if any anemic or febrile morbidity. Her final stage based on the pathology report was stage IB grade I endometrial adenocarcinoma. The patient would not require any adjuvant therapy.
IB|(stage) IB|IB.|208|210|PAST MEDICAL HISTORY|The date on that is not clear. It has not been evaluated with any imaging studies that are documented. She has had hyperlipidemia. Her last LDL was 120 in _%#MM#%_ 2006. She has osteoporosis and a history of IB. Right ankle arthritis, had a cortisone injection done three days ago. Urinary frequency. Reported gastritis and has been on Prevacid ever since some bowel surgery 25 years ago.
IB|(stage) IB|IB|27|28|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Stage IB squamous cell carcinoma of the cervix. DISCHARGE DIAGNOSES: 1. Postoperative day #3 status post radical hysterectomy, pelvic and para- aortic lymph node dissection, bilateral oophoropexy, cystoscopy and proctoscopy with exam under anesthesia.
IB|UNSURED SENSE|IB|138|139|HOSPITAL COURSE|2. Iron deficiency anemia. The patient was admitted with a hemoglobin of 7.5. Hemoglobin in _%#MM#%_ 2001, was 10.4. MCV 67, MCSC 31, and IB 18. Iron profile showed iron saturation 7, ferratin 230, transferrin 130, TIBC 194 consistent with iron deficiency anemia. Reticulocyte count 3%, red blood cell folate normal. However because the patient had a cousin who died of colon cancer at 30 years old, GI team was consulted who recommended colonoscopy which was postponed because her respiratory status would not allow her to have a colonoscopy when she was in the hospital.
IB|(stage) IB|IB,|207|209|DISCHARGE DIAGNOSES|Date of discharge: _%#MMDD2004#%_. ADMISSION DIAGNOSES: 1. The patient is a 71-year-old para 2-0-0-2 with adenocarcinoma of the uterus. 2. Morbid obesity. 3. Parkinson disease. DISCHARGE DIAGNOSES: 1. Stage IB, grade II adenocarcinoma of the uterus. 2. Morbid obesity. 3. Parkinson disease. 4. Likely chronic hypertension. PROCEDURES DURING HOSPITALIZATION: 1. Chest x-ray for preoperative evaluation.
IB|(stage) IB|IB,|169|171|HOSPITAL COURSE|HOSPITAL COURSE: _%#NAME#%_ was admitted on _%#MMDD2003#%_ and underwent the above procedures. There were no complications, and a final pathology report indicates stage IB, grade II adenocarcinoma of the uterus. Due to _%#NAME#%_'s risk factors for perioperative complications from heart disease, she was placed on the beta blocker protocol per standard policy.
IB|(stage) IB|IB|257|258|BRIEF HISTORY|ADMISSION DIAGNOSES: 1. Hyperbilirubinemia. 2. Cholelithiasis. PROCEDURES PERFORMED: Open cholecystectomy. BRIEF HISTORY: This is a 60-year-old female who underwent an abdominal hysterectomy, chemotherapy, and radiation therapy for endometrial cancer stage IB in 1995. As a result she had chronic radiation changes to her abdomen and had multiple exploratory laparotomies for small bowel obstructions.
IB|(stage) IB|IB|153|154|HISTORY OF PRESENT ILLNESS|4. Head CT. 5. Social work consult. 6. EKG. HISTORY OF PRESENT ILLNESS: In brief, _%#NAME#%_ was a 49-year- old Caucasian female with a history of stage IB metastatic cervical carcinoma, status post to radiation therapy. Please see full dictated discharge summary from _%#MM#%_ _%#DD#%_, 2005, for full details.
IB|(stage) IB|IB|145|146|PAST SURGICAL HISTORY|Abdominal x-rays could not rule out necrotizing enterocolitis. He was subsequently made NPO and started on vancomycin and cefotaxime for a stage IB diagnosis of NEC. He was treated for 1 week of antibiotics before resuming feeds. He experienced no further episodes concerning for NEC. Problem #10: Inguinal Hernia On _%#MMDD2007#%_ _%#NAME#%_ was noted to have a reducible hernia (see problem #9) with concern for bowel ischemia.
IB|(stage) IB|IB|143|144|DISCHARGE DIAGNOSES|ADMISSION DIAGNOSES: 1. Endometrial biopsy consistent with grade 1 endometrioid adenocarcinoma. 2. Hypertension. DISCHARGE DIAGNOSES: 1. Stage IB endometrioid adenocarcinoma. 2. Hypertension. PROCEDURES PERFORMED: On _%#MMDD2007#%_, 1. Exam under anesthesia.
IB|(stage) IB|IB|284|285|PAST MEDICAL HISTORY|Postoperatively, the patient has done well until this hospitalization for which she returned with approximately 4 days of diarrhea with meals, abdominal pain, and vaginal discharge, and noticeable drop in her p.o. intake. PAST MEDICAL HISTORY: Significant for the following: 1. Stage IB adenocarcinoma of the endometrium, status post total abdominal hysterectomy, bilateral salpingo-oophorectomy, and radiation therapy in the 1970s. 2. Vaginal carcinoma in situ, status post neovaginal surgery.
IB|(stage) IB|IB|33|34|DIAGNOSES ON ADMISSION|DIAGNOSES ON ADMISSION: 1. Stage IB squamous cell carcinoma of the cervix. 2. Status post tonsillectomy. 3. Para 0. DIAGNOSES ON DISCHARGE: 1. Stage IB1 squamous cell carcinoma of the cervix with metastases to pelvic lymph nodes.
IB|(stage) IB|IB|37|38|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Recurrent stage IB squamous cell cancer of the cervix status post total pelvic exenteration. DISCHARGE DIAGNOSIS: Recurrent stage IB squamous cell cancer of the cervix status post total pelvic exenteration.
IB|(stage) IB|IB|151|152|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Recurrent stage IB squamous cell cancer of the cervix status post total pelvic exenteration. DISCHARGE DIAGNOSIS: Recurrent stage IB squamous cell cancer of the cervix status post total pelvic exenteration. HISTORY OF PRESENT ILLNESS: This is a 58-year-old female who in _%#MM#%_ 1985 was diagnosed with stage IB squamous cell carcinoma of the cervix.
IB|(stage) IB|IB|217|218|ADMISSION DIAGNOSIS|DISCHARGE DIAGNOSIS: Recurrent stage IB squamous cell cancer of the cervix status post total pelvic exenteration. HISTORY OF PRESENT ILLNESS: This is a 58-year-old female who in _%#MM#%_ 1985 was diagnosed with stage IB squamous cell carcinoma of the cervix. She underwent external beam radiation and cesium implants. In _%#MM#%_ 2002 the patient was noted to have a recurrence of her cancer on a vaginal biopsy.
IB|(stage) IB|IB|33|34|DIAGNOSES ON ADMISSION|DIAGNOSES ON ADMISSION: 1. Stage IB squamous cell carcinoma of the cervix, metastatic to the lymph nodes. 2. Vaginal bleeding. 3. History of arterial clot. 4. Tobacco abuse.
IB|(stage) IB|IB|204|205|DIAGNOSES ON ADMISSION|DIAGNOSES ON ADMISSION: 1. Stage IB squamous cell carcinoma of the cervix, metastatic to the lymph nodes. 2. Vaginal bleeding. 3. History of arterial clot. 4. Tobacco abuse. DISCHARGE DIAGNOSES: 1. Stage IB squamous cell carcinoma of the cervix with metastasis to the lymph nodes. 2. Vaginal bleeding. 3. History of arterial clot. 4. Tobacco abuse.
IB|(cycle) IB|IB|189|190|CHIEF COMPLAINT AND REASON FOR ADMISSION|PLANNED DISCHARGE DATE: _%#MMDD2007#%_ CHIEF COMPLAINT AND REASON FOR ADMISSION: Mr. _%#NAME#%_ _%#NAME#%_ is a 56-year-old man with acute lymphoblastic leukemia. He was admitted for cycle IB of hyperCVAD alternating with methotrexate and Ara-C. HOSPITAL COURSE: His hospital course can be summarized as follows: 1. ALL. He was given cycle IB of hyperCVAD alternating with methotrexate and Ara-C.
IB|(cycle) IB|IB|177|178|HOSPITAL COURSE|He was admitted for cycle IB of hyperCVAD alternating with methotrexate and Ara-C. HOSPITAL COURSE: His hospital course can be summarized as follows: 1. ALL. He was given cycle IB of hyperCVAD alternating with methotrexate and Ara-C. He tolerated the chemotherapy fairly well with exception of nausea. He was given antiemetics for this with excellent control.
IB|(stage) IB|IB|27|28|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Stage IB grade 1 endometrial adenocarcinoma, recurrent and metastatic. DISCHARGE DIAGNOSIS: Stage IB grade 1 endometrial adenocarcinoma, recurrent and metastatic.
IB|(stage) IB|IB|61|62|DISCHARGE DIAGNOSIS|ADMISSION DIAGNOSIS: Pelvic mass. DISCHARGE DIAGNOSIS: Stage IB adenocarcinoma of the endometrium, grade 2. PROCEDURES: 1. LAVH/BPPALND. 2. IV fluids. 3. IV pain medication.
IB|(stage) IB|IB|125|126|PAST MEDICAL HISTORY|There was no cancer seen in those lymph nodes at that time. The patient with that left lower lobectomy was diagnosed with an IB bronchoalveolar carcinoma. Since that time subsequently new pulmonary nodules were found in the patient's lungs, and on _%#MMDD#%_ she underwent a right video-assisted thoracoscopic biopsy.
IB|(stage) IB|IB,|30|32|PREOPERATIVE DIAGNOSIS|PREOPERATIVE DIAGNOSIS: Stage IB, grade I squamous cell carcinoma of the cervix with positive right and left pelvic lymph nodes. DISCHARGE DIAGNOSIS: Stage IB, grade I squamous cell carcinoma of the cervix with positive right and left pelvic lymph nodes.
IB|(stage) IB|IB,|304|306|PREOPERATIVE DIAGNOSIS|Endocervical curettage performed by Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2005, revealed invasive squamous cell carcinoma, FIGO grade II/III. On _%#MM#%_ _%#DD#%_, 2004, Ms. _%#NAME#%_ underwent examination under anesthesia and extraperitoneal lymph node dissection, giving her a final diagnosis of stage IB, grade I squamous cell carcinoma of the cervix with positive bilateral pelvic lymph nodes. Based on loop electrosurgical excision procedure: Specimen with greater than 5 mm invasion.
IB|(stage) IB|IB|186|187|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSIS: Suspected gram negative/anaerobic pneumonia. OPERATIONS/PROCEDURES PERFORMED: None. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 70-year-old gentleman with stage IB nonsmall cell lung cancer of the right upper lobe, who underwent a thoracoscopic right upper lobectomy on _%#MM#%_ _%#DD#%_, 2006.
IB|(stage) IB|IB|161|162|HOSPITAL COURSE|9. Cholelithiasis and also occlusion of the left superficial femoral artery. This is known to be chronic. HOSPITAL COURSE: Disease. The patient had a history of IB squamous cell cancer of the cervix diagnosed in 1991. She also has a history of breast cancer. The patient was admitted with an aggressive bowel regimen.
IB|(stage) IB|IB|82|83|REASON FOR ADMISSION|REASON FOR ADMISSION: Mr. _%#NAME#%_ _%#NAME#%_ is a 67-year-old man with a stage IB nonsmall cell lung cancer, status post surgical resection and four cycles of Taxol and carboplatin. Cycle number four was administered on _%#MMDD2006#%_. Over the weekend, the patient developed nausea and diarrhea with decreased oral intake.
IB|(stage) IB|IB|141|142|EXAMINATION|Bimanual examination is difficult secondary to the fact that I was trying not to disturb the lesion and its bleeding. She either has a large IB in the cervix versus an early IIB with proximal and medial parametrial extension. PLAN: An extensive comprehensive and detailed discussion was held with the patient with the help of an interpreter.
IB|(stage) IB|IB|258|259|HISTORY OF PRESENT ILLNESS|8. Pancytopenia. HISTORY OF PRESENT ILLNESS: This patient is a 68-year-old with history of recurrent squamous cell carcinoma of the cervix with positive left supraclavicular lymph node as well as periaortic lymph nodes. This patient was diagnosed with stage IB squamous cell carcinoma of the cervix in _%#MM1997#%_. At that time, she underwent extraperitoneal lymph node dissection and was involved in WCC_%#PROTOCOL#%_ protocol.
IB|(grade) IB|IB|102|103|DISCHARGE DIAGNOSES|3. Hypertension. 4. Dilated cardiomyopathy with pacemaker implantation. DISCHARGE DIAGNOSES: 1. Grade IB acute T-cell mediated kidney transplant rejection. 2. Status post living donor kidney transplant. 3. Hypertension. 4. Dilated cardiomyopathy with pacemaker implantation. 5. New onset type 2 diabetes.
IB|(stage) IB|IB.|127|129|HISTORY/HOSPITAL COURSE|The patient was found to have an adenocarcinoma of the endometrium that was a FIGO grade 1 with negative nodes. She is a stage IB. The patient did very well postoperatively and was discharged on the fourth postoperative day to home.
IB|(stage) IB|IB|109|110|DISCHARGE DIAGNOSIS|ADMISSION DIAGNOSIS: 1. Cervical versus endometrial cancer. 2. Hypercholesterolemia. DISCHARGE DIAGNOSIS: 1. IB endometrial cancer, frozen, final path pending. 2. Hypercholesterolemia. OPERATIONS/PROCEDURES PERFORMED: 1. Status post total abdominal hysterectomy, bilateral salpingo- oophorectomy, pelvic and periaortic lymph node dissection, omentectomy, and staging procedure.
IB|(stage) IB|IB|299|300|HOSPITAL COURSE|HOSPITAL COURSE: The patient was admitted on _%#MM#%_ _%#DD#%_, 2004, and had surgery including total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic and periaortic lymph node dissection, omentectomy, and staging. 1. Disease: As noted above, the frozen pathology is that of presumed IB endometrioid endometrial carcinoma. The patient was informed today, on the day of discharge that the final pathology is not back. She was instructed that this should become available next week and will be discussed with her by Dr. _%#NAME#%_ at her followup clinic visit which will be in the next 3-6 weeks.
IB|(stage) IB|IB|212|213|PAST MEDICAL HISTORY|17. Total gastrectomy for adenocarcinoma in situ and ulcers with splenectomy 18. Multiple esophageal jejunal strictures dilated in 1989 19. Total abdominal hysterectomy, bilateral salpingo-oophorectomy for stage IB grade I endometrial carcinoma 20. Ataxia, work-up at Mayo _%#MM2001#%_ 21. Osteoporosis 22. Question history of hemochromatosis. FAMILY HISTORY: Father died of coronary artery disease. Mother died of congestive heart failure.
IB|(stage) IB|IB|27|28|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Stage IB squamous cell carcinoma of cervix. DISCHARGE DIAGNOSES: 1. Stage IB squamous cell carcinoma of cervix.
IB|(stage) IB|IB|95|96|DISCHARGE DIAGNOSES|ADMISSION DIAGNOSIS: Stage IB squamous cell carcinoma of cervix. DISCHARGE DIAGNOSES: 1. Stage IB squamous cell carcinoma of cervix. 2. Status post exploratory laparotomy with extraperitoneal lymph node dissection. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 54-year-old woman with squamous cell carcinoma of the cervix who is admitted for exploratory laparotomy and extraperitoneal lymph node dissection.
IB|(stage) IB|IB|263|264|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 54-year-old woman with squamous cell carcinoma of the cervix who is admitted for exploratory laparotomy and extraperitoneal lymph node dissection. Based on physical exam in the operating room, she was found to have IB clinical diagnosis. She had also had a CT scan which showed extensive abdominal and mediastinal lymphadenopathy, worrisome for metastatic disease.
IB|(stage) IB|IB|30|31|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Stage IB carcinosarcoma of the endometrium. 2. Diabetes mellitus. 3. Chronic inflammatory demyelinating polyneuropathy. 4. Hypothyroidism. 5. Morbid obesity. 6. Chronic headaches. DISCHARGE DIAGNOSES: 1. Stage IB carcinosarcoma of the endometrium.
IB|(stage) IB|IB|160|161|HISTORY OF PRESENT ILLNESS|2. IV fluids. 3. Daily urinalysis testing. COMPLICATIONS: None. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 35-year-old female who was diagnosed with stage IB carcinosarcoma of the endometrium after undergoing a staging procedure in _%#MM2006#%_. She was originally diagnosed after having a long history of irregular menses and menorrhagia requiring a blood transfusion, and an MRI at that time revealed an endometrial stripe of 3.4 cm with a cystic area of 1.5 cm.
IB|(stage) IB|IB|30|31|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Stage IB carcinosarcoma of the endometrium. 2. Diabetes mellitus. 3. Chronic inflammatory demyelinating polyneuropathy. 4. Hypothyroidism. 5. Morbid obesity. 6. Chronic headaches. DISCHARGE DIAGNOSES: 1. Stage IB carcinosarcoma of the endometrium.
IB|(stage) IB|IB,|332|334|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old white male who was transferred directly to Fairview University Intensive Care Unit on _%#MM#%_ _%#DD#%_, 2005, from _%#CITY#%_ _%#CITY#%_ Hospital for evaluation and management of hemoptysis. The patient at time of admit was 3 months status post left pneumonectomy for stage IB, T2 N0 M0, nonsmall cell lung cancer, and was currently undergoing adjuvant chemotherapy with Taxol, carboplatin. The patient had been in his normal state of health and had not had postoperative complications (operative procedure was performed at outside hospital), until _%#MM#%_ _%#DD#%_, 2005, while the patient was having a bout of coughing when he suddenly experienced chest pain, shortness of breath, and hemoptysis.
IB|(stage) IB|IB,|282|284|PAST MEDICAL HISTORY|On _%#MM#%_ _%#DD#%_, 2005, the patient was taken to the OR for above stated procedures (see operative notes dated _%#MM#%_ _%#DD#%_, 2005, by Dr. _%#NAME#%_ and Dr. _%#NAME#%_ for specific detail). PAST MEDICAL HISTORY: 1. Above stated nonsmall cell squamous cell carcinoma, stage IB, T2 N0 M0, status post adjuvant chemotherapy and left pneumonectomy (pneumonectomy on _%#MM#%_ _%#DD#%_, 2005, at _%#CITY#%_ _%#CITY#%_ Hospital). 2. Trauma to right arm during Vietnam War, not otherwise specified.
IB|(stage) IB|IB|194|195|DISCHARGE DIAGNOSES|ADMISSION DIAGNOSES: 1. Endometrioid adenocarcinoma of the endometrium. 2. Hypertension. 3. Hyperlipidemia. DISCHARGE DIAGNOSES: 1. Stage IIIC papillary serous carcinoma of the ovary, and stage IB endometrioid adenocarcinoma of the endometrium with clear cell component. 2. Hypertension. 3. Hyperlipidemia. OPERATIONS/PROCEDURES PERFORMED: Exploratory laparotomy, evacuation of the ascites, complete omentectomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, and tumor debulking.
IB|(stage) IB|IB|164|165|HOSPITAL COURSE|Final pathology returned while the patient was still an inpatient and was consistent with 2 primaries, stage IIIC serous papillary carcinoma of the ovary and stage IB grade 3 endometrioid adenocarcinoma of the endometrium with clear cell component. The patient was given chemotherapy teaching before discharge. She will follow up with Dr. _%#NAME#%_ in 2 to 3 weeks for treatment planning.
IB|(stage) IB|IB|99|100|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Stage IIIC papillary serous carcinoma of the ovary and a synchronous stage IB endometrioid adenocarcinoma of the endometrium with clear cell component. 2. Hypertension. 3. Hyperlipidemia. 4. The patient is here for chemotherapy.
IB|(stage) IB|IB|99|100|DISCHARGE DIAGNOSES|ADMISSION DIAGNOSES: 1. Stage IIIC papillary serous carcinoma of the ovary and a synchronous stage IB endometrioid adenocarcinoma of the endometrium with clear cell component. 2. Hypertension. 3. Hyperlipidemia. 4. The patient is here for chemotherapy.
IB|(stage) IB|IB|140|141|BRIEF HISTORY AND PHYSICAL|Pathology returned with a stage IIIC papillary serous carcinoma of the ovary as well as a synchronous tumor of the endometrium with a stage IB endometrioid adenocarcinoma of the endometrium with clear cell component. With further discussion for treatment of her tumors, IV Taxol and IP Taxol/cisplatin were recommended.
IB|(stage) IB|IB|183|184|PAST MEDICAL HISTORY|PSYCHOLOGICAL: Negative. ENDOCRINE: Negative. SKIN: Significant bruising around both port sites. PAST MEDICAL HISTORY: 1. Stage IIIC serous papillary carcinoma of the ovary and stage IB grade 3 endometrioid adenocarcinoma of the endometrium with clear cell component, diagnosed on _%#MM#%_ _%#DD#%_, 2006. 2. Hypertension. 3. Hyperlipidemia. PAST SURGICAL HISTORY: See HPI.
IB|(stage) IB|IB|320|321|ASSESSMENT AND PLAN|SKIN: Significant area of ecchymoses at the port site and the IP port site, probably measuring at the right Port-A-Cath site, approximately 15 x 8 cm and IP site measuring 10 x 10 cm. ASSESSMENT AND PLAN: A 67-year-old female with a new diagnosis of IIIC papillary serous carcinoma of the ovary as well as a synchronous IB endometrioid adenocarcinoma of the endometrium, is admitted for chemotherapy. 1. Chemotherapy: The patient has a standard IP chemotherapy ordered with premedication with dexamethasone, cimetidine, Benadryl, and meloxicam.
IB|(stage) IB|IB,|384|386||The peritoneal washing was negative for malignant cells and microscopic examination of the surgical specimen showed a thecal Grade 1-2 adenocarcinoma, endometrial polyp and adenosis with full course perfusional myometrium invasion, endometrial polyp, leiomyoma, and benign ovaries and fallopian tubes. Therefore her surgical staging of her adenocarcinoma of the endometrium was Stage IB, Grade 1-2. The patient's postoperative course was uncomplicated except for a T- max of 100.7 degrees and UA/UC were negative.
IB|(grade) IB|IB|216|217|ASSESSMENT AND PLAN|There is no physical finding suggestive of that neither. Her echocardiogram at the bedside showed normal ejection fraction and normal cardiac function and morphology. Her last biopsy was in _%#MM#%_ and showed grade IB inflammation. We will continue her Rapamune but will hold Prograf until we check the level. Will continue hydralazine and hold Cozaar for now. 4. Type-1 diabetes: The patient is on insulin.
IB|(stage) IB|IB|108|109|ADMISSION DIAGNOSES|Date of Admission: _%#MMDD2007#%_ Date of Discharge: _%#MMDD2007#%_ ADMISSION DIAGNOSES: 1. Recurrent stage IB grade 3 endometrial carcinoma with brain metastases. 2. Abdominal pain. 3. Nausea and vomiting. 4. Abdominal ascites. 5. Hypertension. 6. Hyperlipidemia. 7. Peptic ulcer disease. 8. Multinodular goiter.
IB|(stage) IB|IB|170|171|HISTORY OF PRESENT ILLNESS|8. Peritoneal fluid analysis and culture. COMPLICATIONS: None apparent. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 63-year-old woman with recurrent stage IB grade 3 endometrial carcinoma with brain metastases and ascites. She is currently receiving whole brain external beam radiation therapy for these brain metastases and she is status post craniotomy for cerebellar bleed.
IB|(stage) IB|IB.|214|216|PAST MEDICAL HISTORY|The patient has been diuretics in the past but has not had any improvement in her edema with those. This has also been complicated by chronic bilateral venous stasis dermatitis. 2. Cutaneous T-cell lymphoma, stage IB. The patient has been undergoing ultraviolet therapy for this but has not had any treatments recently. 3. Morbid obesity with a BMI of 55. 4. Severe degenerative joint disease affecting the bilateral knees.
IB|(status) IB|IB|176|177|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Adriamycin-induced cardiomyopathy status post VentrAssist LVAD implantation in _%#MM2007#%_ as a bridge to transplantation. Currently listed as status IB (patient had used already his 1 month eligibility of status IA). 2. Status post ICD placement. 3. T-cell non-Hodgkin's lymphoma of the oropharynx in childhood, treated with methotrexate and Adriamycin in 1984 with complete resolution.
IB|(stage) IB|IB|160|161|HOSPITAL COURSE|He has been hemodynamically stable otherwise. His CHF has been quiescent. He has had some complaints of sleep, which has been helped by Ambien. He also did get IB iron during his stay here as well as darbepoetin. Dr. _%#NAME#%_ and the resident, Dr. _%#NAME#%_ _%#NAME#%_ did discuss with Dr. _%#NAME#%_ _%#NAME#%_, who will reevaluate the patient during the clinic visit on _%#MM#%_ _%#DD#%_, 2005, as to whether to start him again on Coumadin and/or Plavix.
IB|(stage) IB|IB.|121|123|HISTORY OF PRESENT ILLNESS|Pathologically, it was nodular sclerosing Hodgkin disease with a negative bone marrow biopsy and was designated as stage IB. She received 5 cycles of chemotherapy, ABVE-PC, in consultation with radiotherapy. However, _%#NAME#%_ relapsed abruptly 6 weeks postcompletion of her chemotherapy with disease demonstrated below the diaphragm.
IB|(stage) IB|IB|30|31|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Stage IB carcinoma of the endometrium, status post total abdominal hysterectomy, bilateral salpingo-oophorectomy and staging procedure in _%#MM2006#%_. 2. Chronic inflammatory demyelinating polyneuropathy. 3. Diabetes mellitus. 4. Hypothyroidism.
IB|(stage) IB|IB|128|129|HISTORY OF PRESENT ILLNESS|3. Wound dressing changes. COMPLICATIONS: None apparent. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 35-year-old with stage IB carcinoma of endometrium who presented on _%#MMDD2007#%_ complaining of wound drainage for a period of 1 day. She is status post an exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy and staging surgery on _%#MMDD2006#%_.
IB|(stage) IB|IB|172|173|HOSPITAL COURSE|There was firmness and induration and edema in the area of the erythema. EXTREMITIES: Lower extremity edema bilaterally. HOSPITAL COURSE: 1. Disease: The patient has stage IB endometrial carcinoma and is status post a total abdominal hysterectomy, bilateral salpingo-oophorectomy and staging procedure in _%#MM2006#%_. She has recently undergone 2 courses of chemotherapy with ifosfamide and Taxol.
IB|(stage) IB|IB|106|107|ADMISSION DIAGNOSES|DISCHARGING PHYSICIAN: Dr. _%#NAME#%_. ADMISSION DIAGNOSES: 1. Wound separation with cellulitis. 2. Stage IB grade 2 endometrial cancer status post staging procedure. 3. Hypertension. 4. Anxiety. 5. Chronic sinusitis. 6. Diverticulosis.
IB|(stage) IB|IB|174|175|DISCHARGE DIAGNOSES|3. Hypertension. 4. Anxiety. 5. Chronic sinusitis. 6. Diverticulosis. DISCHARGE DIAGNOSES: 1. Wound separation now with wound VAC placement. 2. Cellulitis resolved. 3. Stage IB grade 2 endometrial cancer. 4. Hypertension. 5. Anxiety. 6. Chronic sinusitis. 7. Diverticulosis. PROCEDURES: On day of admission, the patient was 8 days postoperative from an exam under anesthesia, exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy and bilateral pelvic and periaortic lymph node dissection and washings.
IB|(stage) IB|IB|30|31|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Stage IB grade 2 endometrial adenocarcinoma. 2. Wound infection. 3. Hypertension. 4. Bilateral pulmonary emboli. 5. History of breast cancer in 1990 without recurrence. 6. Cervical dysplasia.
IB|(stage) IB|IB|109|110|DISCHARGE DIAGNOSES|5. History of breast cancer in 1990 without recurrence. 6. Cervical dysplasia. DISCHARGE DIAGNOSES: 1. Stage IB grade 2 endometrial adenocarcinoma. 2. Wound infection. 3. Hypertension. 4. Bilateral pulmonary emboli. 5. History of breast cancer in 1990 without recurrence.
IB|(stage) IB|IB|27|28|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Stage IB squamous cell carcinoma of the cervix. DISCHARGE DIAGNOSIS: Stage IB squamous cell carcinoma of the cervix.
IB|(stage) IB|IB|104|105|DISCHARGE DIAGNOSIS|ADMITTING DIAGNOSIS: 51-year-old with squamous cell carcinoma of the cervix. DISCHARGE DIAGNOSIS: Stage IB squamous cell carcinoma of the cervix. PROCEDURES PERFORMED: Radical examination under anesthesia, hysterectomy, bilateral salpingo-oophorectomy and pelvic and periaortic lymph node dissection.
IB|(stage) IB|IB|210|211|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSIS: Stage IB squamous cell carcinoma of the cervix. OPERATIONS/PROCEDURES PERFORMED: Cesium implant and radiation treatment. HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old with stage IB squamous cell carcinoma of the cervix which is metastatic to lymph nodes. On _%#MM#%_ _%#DD#%_, 2006, the patient underwent EUA, exploratory laparotomy, and extraperitoneal lymph node dissection.
IB|(stage) IB|IB|175|176|CHIEF COMPLAINT|Previous studies have suggested benefit of treatment of both stage 1B and 2A and four to six cycles of adjunctive chemotherapy. However, new data suggest treatment in a stage IB population may provide only limited, if any, survival benefit. Patient was asked to follow up with hematology oncology in three to four weeks.
IB|(stage) IB|IB|155|156|DISCHARGE DIAGNOSES|3. Hyperlipidemia. 4. Gastroesophageal reflux disease. 5. Gout. 6. Arthritis of the knees status post left knee replacement. DISCHARGE DIAGNOSES: 1. Stage IB grade 2 endometrioid adenocarcinoma of the endometrium. 2. Hypertension. 3. Hyperlipidemia. 4. Gastroesophageal reflux disease. 5. Gout. 6. Arthritis of the knees status post left knee replacement.
IB|(stage) IB|IB|158|159|HOSPITAL COURSE|No suspicious lymph nodes, normal appearing omentum, no extrauterine disease noted. HOSPITAL COURSE: PROBLEM #1: Disease. Final pathology returned with stage IB grade 2 endometrioid adenocarcinoma of the endometrium. The patient will plan to follow up with Dr. _%#NAME#%_ in 2-4 weeks for treatment planning and reviewing pathology results.
IB|(stage) IB|IB,|196|198|HISTORY OF PRESENT ILLNESS|It was an uncomplicated procedure and estimated blood loss was 150 cc. The uterus and ovaries were grossly normal. Frozen section was negative for metastatic lesions. She was diagnosed with stage IB, grade 1 endometrioid adenocarcinoma of the endometrium. Unfortunately she had numerous postop complications, including acute blood-loss anemia, hepatobiliary sepsis with coagulopathy, wound dehiscence, acute renal failure, Enterobacter UTI/bacteremia, sacral decubitus ulcer and worsening depression.
IB|(stage) IB|IB,|104|106|ASSESSMENT AND PLAN|She is hemodynamically stable despite being hypotensive. She is also asymptomatic. 1. Gynecology: Stage IB, grade 1 endometrioid adenocarcinoma of the endometrium requiring exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic and periaortic lymph node dissection.
IB|(stage) IB|IB|241|242|HOSPITAL COURSE|On admission, the patient's creatinine was 3.24. The patient's creatinine trended downward and on discharge it was 1.89. The patient's other medical systems remained stable throughout his hospital stay. His biopsy results were read as stage IB rejection. He tolerated p.o. intake, and ambulated independently and participated in his daily routine independently. The patient was discharged with essentially no restrictions. He is to receive an additional Thymoglobulin as an outpatient x1.
IB|(stage) IB|IB|151|152|FINAL DIAGNOSIS|FINAL DIAGNOSIS: Moderately differentiated adenocarcinoma with bronchoalveolar features left upper lobe lung. Final pathological stage T2 N0 M0, stage IB OPERATIVE PROCEDURE: On _%#MMDD2007#%_ diagnostic video flexible bronchoscopy, mediastinoscopy, left thoracotomy, left upper lobectomy and mediastinal lymph node dissection were carried out by Dr. _%#NAME#%_ _%#NAME#%_.
IB|(stage) IB|IB|39|40|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Grade 1, stage IB endometrial carcinoma. 2. Abdominal abscesses. 3. Nausea and vomiting. 4. Dehydration. 5. Menopausal symptoms. DISCHARGE DIAGNOSES: 1. Grade 1, stage IB endometrial carcinoma.
IB|(stage) IB|IB|127|128|DISCHARGE DIAGNOSES|2. Abdominal abscesses. 3. Nausea and vomiting. 4. Dehydration. 5. Menopausal symptoms. DISCHARGE DIAGNOSES: 1. Grade 1, stage IB endometrial carcinoma. 2. Abdominal abscesses. 3. Nausea and vomiting. 4. Dehydration. 5. Menopausal symptoms. 6. Left lower quadrant fluid collection, seroma versus lymphocele.
IB|(stage) IB|IB|319|320|HISTORY OF PRESENT ILLNESS|CT scan of the chest that showed calcified nodules in the right hilum and subcarinal regions that were likely benign sequelae of prior granulomatous disease. _%#MMDD2006#%_. Underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy and bilateral pelvic and periaortic lymph node dissection and was staged IB endometrial carcinoma, grade 1. _%#MMDD2006#%_. The patient underwent a CT of the abdomen and pelvis and presented to her postoperative clinic visit with Dr. _%#NAME#%_.
IB|(stage) IB|IB|184|185|PAST MEDICAL HISTORY|Sexual function, musculoskeletal, skin, neurologic, mental exam and endocrine were all negative on review of systems at her postoperative check. PAST MEDICAL HISTORY: 1. Grade 1 stage IB endometrial carcinoma. 2. Hypertension. 3. Obesity. 4. Right hilar pulmonary nodule. 5. History of keloid formation on bilateral shoulders. 6. History of left upper extremity fracture x5 in 1991 that did not require surgery.
IB|(stage) IB|IB|245|246|HOSPITAL COURSE|The patient received a sinogram to evaluate the fluid collections on the day of discharge, and the determination was made that both drains should remain in place as there was still fluid to be drained from both of those abscesses. Regarding her IB endometrial carcinoma, the patient had no issues. 2. Pathology. Fluid from the right psoas abscess grew out heavy growth of E. coli that was pan-sensitive. 3. Heme. The patient's hemoglobin on admission was 10.7, and her INR was 1.25. This remained stable, and on postop day #2, hemoglobin was 9.7.
IB|(stage) IB|IB|95|96|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. History of IIIC papillary serous adenocarcinoma of the ovary. 2. Stage IB grade 3 endometrioid adenocarcinoma of the endometrium with clear cell component. 3. Hypertension. 4. Hyperlipidemia. 5. Cycle 3/6 of IV Taxol and intraperitoneal cisplatin chemotherapy.
IB|(stage) IB|IB|147|148|HISTORY OF PRESENT ILLNESS|She underwent a staging procedure on _%#MMDD2006#%_, and pathology returned as IIIC papillary serous carcinoma of the ovary as well as synchronous IB endometrioid adenocarcinoma of the endometrium with a clear cell component. The patient tolerated her surgical procedure well and was started on IV Taxol, intraperitoneal cisplatin.
IB|(stage) IB|IB|159|160|HISTORY OF PRESENT ILLNESS|2. Review of PET scan done on _%#MMDD2007#%_. 3. IV fluids. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 57-year-old female with recurrent stage IB grade 2 endometrioid adenocarcinoma of the endometrium who was admitted for new pulmonary embolism. In review, the patient underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy and pelvic and paraaortic lymph node dissection staging procedure for IB grade 2 endometrioid adenocarcinoma of the endometrium.
IB|(stage) IB|IB|167|168|HISTORY OF PRESENT ILLNESS|In review, the patient underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy and pelvic and paraaortic lymph node dissection staging procedure for IB grade 2 endometrioid adenocarcinoma of the endometrium. She did not receive adjuvant therapy at that time. In _%#MM2006#%_, the patient experienced a recurrent to the vaginal cuff for which she received external beam radiation therapy and brachytherapy with needles.
IB|(stage) IB|IB,|223|225|HISTORY OF PRESENT ILLNESS|Pleurx catheter placed in the left chest wall. 2. Paracentesis of abdomen of minimal fluid. COMPLICATIONS: None. HISTORY OF PRESENT ILLNESS: This is a 63-year-old with recurrent endometrial cancer that was originally stage IB, grade III. Her recurrence is cerebellar metastases. Her last chemotherapy was three days prior to admission and was Taxol chemotherapy.
IB|(stage) IB|IB,|178|180|PAST MEDICAL HISTORY|2. Hypertension. 3. History of GI bleed in the past. 4. History of diverticulitis in the past. 5. History of mitral valve prolapse. 6. Now history of endometrial carcinoma stage IB, grade 1. 7. Finally history of paroxysmal atrial fibrillation that was noted in the emergency room at Fairview Southdale in _%#MM2005#%_ and patient states that she has had it at Mayo Clinic before.
IB|(stage) IB|IB.|181|183|HOSPITAL COURSE|Her pathology was notable for poorly differentiated squamous size. Tumor size was 3 cm. All surgical margins were free. Lymph nodes were negative. Therefore, she was T2 N0 M0 stage IB.
IB|(stage) IB|IB|209|210|HISTORY|REFERRING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_, Dr. _%#NAME#%_ _%#NAME#%_, Dr. _%#NAME#%_ _%#NAME#%_, Dr. _%#NAME#%_ _%#NAME#%_ HISTORY: _%#NAME#%_ _%#NAME#%_ is a 53-year-old female with a diagnosis of Stage IB Grade III poorly differentiated adenosquamous carcinoma of the endometrium. The patient has previously undergone a total abdominal hysterectomy and bilateral salpingo-oophorectomy procedure carried out by Dr. _%#NAME#%_ on _%#MMDD2003#%_, poorly differentiated adenosquamous carcinoma was infiltrating into the myometrium in addition to being poorly differentiated.
IB|(stage) IB|IB|99|100|DISCHARGE DIAGNOSES|DATE OF ADMISSION: _%#MMDD2004#%_. DATE OF DISCHARGE: _%#MMDD2004#%_ DISCHARGE DIAGNOSES: 1. Stage IB poorly differentiated adenosquamous carcinoma of the endometrium. 2. Insulin dependent diabetes 3. Hepatitis C. The patient's status at discharge was stable.
IB|(stage) IB|IB|148|149|PROBLEM #1|The procedure went without complications and had an estimated blood loss of 200 cc. PROBLEM #1: Disease. Final pathology came back and showed stage IB Grade 3 endometrioid endometrial adenocarcinoma. PROBLEM #2: Fluids, Electrolytes, and Nutrition. Upon discharge the patient was tolerating a regular diet.
IB|(stage) IB|IB|128|129|DISCHARGE DIAGNOSIS|HISTORY OF PRESENT ILLNESS: This patient is a 27-year-old female status post left lower lobectomy in _%#MM#%_ of 2004 for stage IB bronchioalveolar carcinoma. She was subsequently found to have multiple new pulmonary nodules on CT scan. Attempt at percutaneous biopsy of these nodules was nondiagnostic and she was subsequently referred to Dr. _%#NAME#%_ for a thoracoscopic biopsy.
IB|(stage) IB|IB|289|290|DISCHARGE DIAGNOSES|PRIMARY DIAGNOSIS DURING THE HOSPITALIZATION: Endometrial carcinoma. SECONDARY DIAGNOSIS: Colon cancer. PRIMARY PROCEDURE: Performed during the hospitalization: Total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic and periaortic lymphadenectomy DISCHARGE DIAGNOSES: Stage IB endometrial carcinoma. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was electively admitted on _%#MMDD2007#%_ following an outpatient bowel prep.
IB|(stage) IB|IB|114|115|DISCHARGE DIAGNOSIS|HPRIMARY DIAGNOSIS DURING ADMISSION: Stage IB-I squamous cell carcinoma of the cervix. DISCHARGE DIAGNOSIS: Stage IB squamous cell carcinoma of the cervix with positive pelvic and periaortic lymph nodes. PRIMARY PRINCIPAL PROCEDURE PERFORMED: 1. Radical hysterectomy. 2. Bilateral salpingectomy.
IB|(stage) IB|IB,|189|191|REASON FOR ADMISSION|REASON FOR ADMISSION: Briefly, _%#NAME#%_ _%#NAME#%_ is a 69-year-old female who was discharged from the Mayo Clinic on _%#MMDD2007#%_ after having a total abdominal hysterectomy for stage IB, grade 1 endometrial carcinoma. She reported to the Fairview Southdale Hospital Emergency Department on _%#MMDD2007#%_ with complaints of dizziness, light-headedness, and was found to have significant postural hypotension and also noted to be in atrial fibrillation with a rapid ventricular response.
IB|(stage) IB|IB|96|97|DISCHARGE DIAGNOSIS|ADMISSION DIAGNOSIS: Stage IB squamous cell carcinoma of the cervix. DISCHARGE DIAGNOSIS: Stage IB squamous cell carcinoma of the cervix. OPERATIONS/PROCEDURES PERFORMED: Cesium implant and radiation treatment. HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old with stage IB squamous cell carcinoma of the cervix which is metastatic to lymph nodes.
IB|(stage) IB|IB,|128|130|DISCHARGE DIAGNOSIS|3. Obesity. DISCHARGE DIAGNOSIS: 1. A postoperative patient, status post exploratory laparotomy and staging procedure. 2. Stage IB, grade 1 endometrioid adenocarcinoma on final pathology. 3. History of asthma and obesity. OPERATIONS/PROCEDURES PERFORMED: 1. Exploratory laparotomy.
IB|(stage) IB|IB,|206|208|HOSPITAL COURSE/DISEASE|HOSPITAL COURSE/DISEASE: 1. The patient underwent exploratory laparotomy, TAH-BSO, pelvic and periaortic lymph node dissection with Rad-Onc marker placement. The final pathology came back as grade 1, stage IB, endometrioid adenocarcinoma. The patient will follow up with Dr. _%#NAME#%_ in two weeks' time for further discussion of treatment options.
IB|(stage) IB|IB,|191|193|PAST MEDICAL HISTORY|This is after having a hysterectomy for uterine cancer back in 2004. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Diabetes type 2. 3. Hypertension. 4. Uterine cancer, diagnosed as stage IB, grade 3 serous papillary carcinoma of the endometrium. PAST SURGICAL HISTORY: 1. Hysterectomy in 2004. 2. Tonsillectomy.
IB|(stage) IB|IB,|145|147|ADMISSION DIAGNOSES|DISCHARGE DIAGNOSES: Mucinous cystadenoma and mature cystic teratoma consistent with benign disease of the ovary. Final pathology revealed stage IB, grade 1 mucinous adenocarcinoma of the ovary. OPERATIONS/PROCEDURES PERFORMED: General endotracheal anesthesia, exploratory laparotomy, technically difficult bilateral salpingo-oophorectomy, omentectomy, appendectomy, peritoneal biopsies, placement of Seprafilm, and umbilical hernia repair.
IB|(stage) IB|IB,|66|68|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Squamous cell carcinoma of the cervix, stage IB, grade 2. DISCHARGE DIAGNOSIS: Status post low-dose brachytherapy with cesium via vaginal tandem and ovoids. PROCEDURES PERFORMED: 1. Examination under anesthesia. 2. Tandem and ovoid placement and cesium brachytherapy.
IB|(stage) IB|IB.|125|127|DISCHARGE DIAGNOSIS|ADMISSION DIAGNOSIS: The patient is a 56-year-old woman with grade I endometrial carcinoma. DISCHARGE DIAGNOSIS: Same, stage IB. PROCEDURES: Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, washing, and right pelvic lymph nodes.
IB|(stage) IB|IB|307|308|HOSPITAL COURSE|She began tolerating a regular diet, voiding, and ambulating without difficulty, and was restarted on her outpatient medications for blood pressure control. She is discharged to home on _%#MMDD2003#%_ in stable condition with a postoperative hemoglobin of 10.4. Final pathology indicated that she had stage IB grade I/III endometrial adenocarcinoma with a 1.5 mm invasion (less than 50%) at the maximum depth. Lymph node dissection showed one lymph node and no evidence of malignancy.
IB|(stage) IB|IB|246|247|DISCHARGE DIAGNOSIS|He was ambulating in the hallway without assistance, tolerating a regular diet, and had excellent pain control with oral analgesics. He was sent home later that same day. His final pathology confirmed a 4.2-cm adenocarcinoma, a T2 N0 M0 or stage IB lesion. He is to follow up with Dr. _%#NAME#%_ _%#NAME#%_ in the medical oncology clinic for planned adjuvant chemotherapy.
IB|(stage) IB|IB.|75|77|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Squamous cell carcinoma of the cervix, grade 2, stage IB. DISCHARGE DIAGNOSIS: Status post low-dose brachytherapy. OPERATIONS/PROCEDURES PERFORMED: 1. Examination under anesthesia. 2. Tandem and ovoid placement and cesium brachytherapy. 3. IV fluids.
IB|(stage) IB|IB|351|352|HISTORY OF PRESENT ILLNESS|ADMISSION DIAGNOSIS: Pulmonary nodules. DISCHARGE DIAGNOSIS: Pulmonary nodules. OPERATIONS/PROCEDURES PERFORMED: Principal procedure performed is a left video assisted thoracoscopic surgery with wedge resection of pulmonary nodule x2 and biopsy of pleural nodule. HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old woman with a history of stage IB leiomyosarcoma of the uterus, status post multiple rounds of chemotherapy. She has had a finding of multiple bilateral pulmonary nodules without mediastinal lymphadenopathy, and it is felt that given the patient's multiple nodules, history of cancer, and pleural effusions, it would be of benefit to ascertain whether these nodules were malignant or not.
IB|(grade) IB|IB.|134|136|DISCHARGE DIAGNOSIS|Hemodynamic data showed RA mean of 2, PA of 32/10, with a wedge of 10, cardiac index of 3.2. Biopsy taken revealed inflammatory grade IB. 2. Echocardiogram done on _%#MM#%_ _%#DD#%_, 2004. This showed normal posttransplant anatomy, normal global LV systolic function, mild-to- moderate increase in LV wall thickness, normal AV size and function, no significant valvular disease noted.
IB|(grade) IB|IB.|186|188|DISCHARGE DIAGNOSIS|4. Problems since transplantation include hypertension, pneumonia, and mild renal insufficiency. 5. Last endomyocardial biopsy showed increase in the level of rejection from grade IA to IB. 6. Repeat endomyocardial biopsy on _%#MM#%_ _%#DD#%_, 2004, showed inflammatory grade IA. HOSPITAL COURSE: CMV infection. During the patient's hospitalization, he had multiple temperature spikes to a maximum of 102.1. He was initially started on gatifloxacin empirically.
IB|(stage) IB|IB|178|179|ASSESSMENT AT CLINIC|Cone stitches were intact, and the cervix was small. Uterus small and mobile; no adnexal masses. This was confirmed by rectovaginal examination. ASSESSMENT AT CLINIC: IA2 versus IB cervical carcinoma. HOSPITAL COURSE: PROBLEM #1: Disease. The patient had IB1 squamous cell carcinoma of the cervix, grade 2, with positive lymph-vascular space involvement on cone biopsy prior to admission.
IB|(stage) IB|IB|41|42|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: 1. History of stage IB squamous cell carcinoma of the cervix. 2. Swollen groin lymph nodes. 3. History of bradycardic. 4. Sinus infections. 5. History of hepatitis C, chronic secondary to a blood transfusion in 1980.
IB|(stage) IB|IB|139|140|DISCHARGE DIAGNOSIS|4. Sinus infections. 5. History of hepatitis C, chronic secondary to a blood transfusion in 1980. DISCHARGE DIAGNOSIS: 1. History of stage IB squamous cell carcinoma of the cervix. 2. Swollen groin lymph nodes. 3. History of bradycardic. 4. Sinus infections. 5. History of hepatitis C, chronic secondary to a blood transfusion in 1980.
IB|(stage) IB|IB|152|153|HISTORY OF PRESENT ILLNESS|Right nodal 2 x 1 x 1 cm frozen, also no evidence of malignancy. HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old woman with a history of stage IB squamous cell carcinoma of the cervix. This was done in 1980. The patient then underwent lymph node dissection. All of the lymph nodes were negative. The patient underwent external beam radiation therapy as well as palladium implant.
IB|(stage) IB|IB|201|202|HISTORY OF PRESENT ILLNESS|She does have problems with constipation alternating with diarrhea. PAST MEDICAL HISTORY: 1. Asthma. 2. Severe sinus infections. 3. Chronic hepatitis C secondary to blood transfusion in 1980. 4. Stage IB squamous cell carcinoma of the cervix. 5. Bradycardia. 6. Para 3,0,0,3. PAST SURGICAL HISTORY: 1. Multiple sinus surgeries.
IB|(stage) IB|IB|181|182|HISTORY OF PRESENT ILLNESS|PROCEDURES PERFORMED THIS ADMISSION: Right side Eloesser flap and drainage of empyema on _%#MMDD2005#%_. HISTORY OF PRESENT ILLNESS: This is a 61-year-old male diagnosed with stage IB non-small cell lung cancer in the right upper lobe in 2003, who is status post right upper lobe lobectomy in _%#MM2003#%_.
IB|(stage) IB|IB|179|180|PAST MEDICAL HISTORY|He was sent to University of Minnesota Medical Center as a referral and admitted from clinic for an Eloesser flap. PAST MEDICAL HISTORY: 1. Cardiac arrhythmia by report. 2. Stage IB non-small cell lung cancer right upper quadrant 2003 with recurrence in 2005. 3. Hyperthyroidism. 4. Hyperlipidemia. 5. History of migraine headaches.
IB|(stage) IB|IB|132|133|DISCHARGE DIAGNOSIS|4. Hypothyroidism. 5. Atrial fibrillation. 6. History of grave's disease. Status post radioactive iodide ablation in 1998. 7. Stage IB adenocarcinoma of the ovaries. OPERATIONS/PROCEDURES PERFORMED: Laparoscopic bilateral salpingo-oophorectomy, converted to exploratory laparotomy with total abdominal hysterotomy, complete omentumectomy, appendectomy, peritoneal biopsies, diaphragm Pap smears, pelvic and para-aortic, lymph node dissection.
IB|(stage) IB|IB,|288|290|HISTORY OF PRESENT ILLNESS|The patient did have blood cultures drawn while in the hospital, which were found to be negative for Clostridium difficile. At this time, no results are pending. HISTORY OF PRESENT ILLNESS: The patient is a 40-year-old male with a history of aplastic anemia and nonHodgkin lymphoma stage IB, who is status post allogenic sibling peripheral blood stem cell transplant, approximately day 40, who presented to the clinic and was found to have bacteremia with Serratia 2:57, began to have nausea, vomiting and some diarrhea.
IB|(stage) IB|IB|212|213|DISCHARGE DIAGNOSES|3. Chronic lymphedema. DISCHARGE DIAGNOSES: 1. Status post total abdominal hysterectomy, bilateral salpingo- oophorectomy, bilateral pelvic and periaortic lymph node dissection, pelvic washings for grade 1 stage IB endometrioid adenocarcinoma of the endometrium. 2. Grade 1 endometrial adenocarcinoma. 3. Hypertension. 4. Chronic lymphedema. OPERATIONS/PROCEDURES PERFORMED: Exploratory laparotomy, total abdominal hysterectomy and bilateral salpingo- oophorectomy, pelvic and periaortic lymph node dissection, washings, and opening of the anterior abdominal wall umbilical hernia.
IB|(stage) IB|IB.|179|181|HOSPITAL COURSE|Final pathology did come back as grade 1 endometrioid adenocarcinoma of the endometrium with 3-mm invasion of 18 mm with negative washings and no vascular invasion for a stage of IB. The patient did very well postoperatively. Hemoglobin was 12.8 preoperatively with 11.9 in the evening of her surgery and 11.1 on the morning of postoperative day 1.
IB|(stage) IB|IB|42|43|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. T2, N0, M0, stage IB squamous cell carcinoma of the lung. 2. Persistent air leak with pleural effusions, right hemithorax. 3. Hypertension. 4. Arthritis. 5. Chronic obstructive pulmonary disease. 6. Gastroesophageal reflux disease.
IB|(stage) IB|IB.|189|191|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This patient is a 79-year-old who underwent right middle and lower lobectomy on _%#MM#%_ _%#DD#%_, 2006, for a squamous cell carcinoma, stage postoperatively as IB. Her hospital course was complicated by persistent air leak and she was discharged to home with a single chest tube attached to a mini Pleur-evac.
IB|(stage) IB|IB|173|174|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSIS: Bilateral lower lobe pneumonia. OPERATIONS/PROCEDURES PERFORMED: None. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 70-year-old gentleman with stage IB nonsmall cell lung cancer of the right upper lobe, who underwent a thoracoscopic right upper lobectomy on _%#MM#%_ _%#DD#%_, 2006.
IB|(stage) IB|IB|77|78|PREOPERATIVE DIAGNOSES|REFERRING PHYSICIAN: _%#NAME#%_ _%#NAME#%_. PREOPERATIVE DIAGNOSES: 1. Stage IB squamous cell carcinoma of the cervix. 2. History of a right groin clot. DISCHARGE DIAGNOSES: 1. Stage IB squamous cell carcinoma of the cervix. 2. History of a right groin clot.
IB|(stage) IB|IB|176|177|HISTORY OF PRESENT ILLNESS|3. X-ray of tandem and ovoid placement. 4. Removal of radiation and tandem and ovoids. COMPLICATIONS: None. HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old with stage IB squamous cell carcinoma of the cervix that is metastatic to her lymph nodes. On _%#MM#%_ _%#DD#%_, 2006, she underwent an exam under anesthesia, exploratory laparotomy, and extraperitoneal lymph node dissection.
IB|(status) IB|IB|189|190|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Prerenal azotemia. 2. Congenital cardiomyopathy due to tetralogy of Fallot status post multiple reparative corrections in the 70s and 80s. 3. The patient has status IB on heart transplant list. 4. Hydralazine-induced lupus. 5. Coagulopathy with rising INR due to hydralazine-induced lupus and vitamin K deficiency.
IB|(stage) IB|IB|276|277|HISTORY OF PRESENT ILLNESS|The patient's cardiac output is 5.2, and his cardiac index is 2.4. HISTORY OF PRESENT ILLNESS: The patient is a 35-year-old gentleman with a history of tetralogy of Fallot status post correction in the 1970s and 1980s with multiple surgeries. The patient is currently a stage IB cardiac transplant candidate. He was transferred from St. Joseph Hospital in _%#CITY#%_ where he was admitted for a day. Per the patient, he was in his usual state of health at home until the Monday prior to his admission when he noticed loose stools and fatigue.
IB|(status) IB|IB|342|343|PAST MEDICAL HISTORY|The patient was reportedly hydrated at the outside hospital and that made him produce urine after initial rehydration. PAST MEDICAL HISTORY: Severe pulmonary hypertension, type 2 diabetes mellitus, history of testicular cancer, possible obstructive sleep apnea, right upper extremity superficial thrombus, and the patient is currently status IB on the transplant list. The patient was admitted to this hospital after being treated at _%#CITY#%_ _%#CITY#%_ for dehydration.
IB|(stage) IB|IB|177|178|DISCHARGE DIAGNOSES|REVISION DATE: R/_%#MMDD2006#%_ ADMISSION DIAGNOSES: 1. Grade 1 endometrioid adenocarcinoma of the endometrium. 2. Hypertension. 3. Tobacco abuse. DISCHARGE DIAGNOSES: 1. Stage IB grade 1 endometrioid adenocarcinoma of the endometrium. 2. Hypertension. 3. Tobacco abuse. 4. Hypovolemia, resolved with hydration
IB|(stage) IB|IB|209|210|HOSPITAL COURSE|Please see operative note for further details. Pathology did return while the patient was admitted. Myometrial invasion was 0.2 of 1.3 cm. All lymph nodes were negative. The patient was thus staged at a stage IB grade 1 endometrioid adenocarcinoma of the endometrium. 2. Foods, Electrolytes, and Nutrition: The patient was placed on IV fluids. 3. At the time of surgery, this was decreased as she began tolerating p.o. She was tolerating a regular diet at the time of discharge.
IB|(stage) IB|IB.|250|252|HISTORY OF PRESENT ILLNESS|SERVICE: Thoracic surgery. ATTENDING: Dr. _%#NAME#%_ _%#NAME#%_. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 60-year-old gentleman who underwent a resection for nodular melanoma from his nose in 2006. At that time, his melanoma was staged IB. He had a follow-up PET CT scan on _%#MMDD2007#%_, which demonstrated a new round centrally located 1.9-cm hypermetabolic nodule in the right upper lobe.
IB|(stage) IB|IB|121|122|HOSPITAL COURSE|Final pathology revealed endometrial adenocarcinoma with superficial invasion 2 of 22 mm, grade 1 of 3, making her stage IB grade 1 carcinoma of the endometrium. There was no evidence of lymphvascular invasion. There was a serous adenofibroma of the left ovary (benign).
IB|(stage) IB|IB|224|225|ADMISSION DIAGNOSES|Of note, the patient was discharged originally on _%#MM#%_ _%#DD#%_, 2006, but returned to the emergency room in less than 10 hours following discharge and was re-admitted. ADMISSION DIAGNOSES: 1. Wound cellulitis. 2. Stage IB squamous cell carcinoma of the cervix with metastasis to the lymph nodes. 3. Wound bleeding. DISCHARGE DIAGNOSES: 1. Stage IB squamous cell carcinoma of the cervix.
IB|(stage) IB|IB|177|178|DISCHARGE DIAGNOSES|ADMISSION DIAGNOSES: 1. Wound cellulitis. 2. Stage IB squamous cell carcinoma of the cervix with metastasis to the lymph nodes. 3. Wound bleeding. DISCHARGE DIAGNOSES: 1. Stage IB squamous cell carcinoma of the cervix. 2. Wound cellulitis. OPERATIONS/PROCEDURES PERFORMED: 1. IV antibiotics. 2. Wound cares with dressing changes.
IB|(stage) IB|IB|179|180|HISTORY OF PRESENT ILLNESS|2. Wound cellulitis. OPERATIONS/PROCEDURES PERFORMED: 1. IV antibiotics. 2. Wound cares with dressing changes. HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old with stage IB squamous cell carcinoma of the cervix metastatic to the lymph node who had undergone exam under anesthesia, exploratory laparotomy, and extraperitoneal lymph node dissection on _%#MM#%_ _%#DD#%_, 2006.
IB|(stage) IB|IB|40|41|ADMITTING DIAGNOSES|ADMITTING DIAGNOSES: 1. Recurrent stage IB grade I endometrial adenocarcinoma metastatic to the lung. 2. Hypertension. DISCHARGE DIAGNOSES: 1. Recurrent stage IB grade I endometrial adenocarcinoma metastatic to the lung.
IB|(stage) IB|IB|159|160|DISCHARGE DIAGNOSES|ADMITTING DIAGNOSES: 1. Recurrent stage IB grade I endometrial adenocarcinoma metastatic to the lung. 2. Hypertension. DISCHARGE DIAGNOSES: 1. Recurrent stage IB grade I endometrial adenocarcinoma metastatic to the lung. 2. Hypertension. PROCEDURES: 1. Chemotherapy consisting of doxorubicin given on day 1, cisplatinum given on day 1 drug #2 followed by Taxol given on day #2.
IB|(stage) IB|IB|132|133|HISTORY OF PRESENT ILLNESS|3. Port placement. COMPLICATIONS: None. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is an 89-year-old female with a history of stage IB grade I endometrial cancer. She was diagnosed in _%#MM2002#%_ that was treated with external beam radiation. She had no problems until _%#MM2006#%_ where CT scan was done at her primary care physician and found a large right upper lobe mass, approximately 5 x 5 cm.
IB|(stage) IB|IB|320|321|HISTORY OF PRESENT ILLNESS|3. Head CT on _%#MMDD2008#%_ with findings of new 2.6 x 2.6 cm mass in high left frontal lobe with possible central necrosis with surrounding vasogenic, edema likely representing a met from primary tumor, no acute intracranial hemorrhage. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 47-year-old gentleman with stage IB non-small-cell lung cancer diagnosed in _%#MM2005#%_ status post right-sided pneumonectomy in _%#MM2005#%_, status post postoperative radiation treatment to chest from _%#MM2005#%_ to _%#MM2006#%_.
IB|(stage) IB|IB|178|179|HOSPITAL COURSE|HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a patient with severe rheumatoid arthritis. She is status post right thoracotomy and right upper and right middle bilobectomy for Stage IB lung cancer. The patient was seen in the emergency room on _%#MMDD2006#%_ for increasing dyspnea. At that time the patient was transferred to Abbott Northwestern Hospital due to no beds available at Fairview Southdale.
IB|(stage) IB|IB|33|34|DIAGNOSES ON ADMISSION|DIAGNOSES ON ADMISSION: 1. Stage IB cervical cancer. 2. Status post cesium treatment x1. DISCHARGE DIAGNOSES: 1. Stage IIB cervical cancer.
IB|(stage) IB|IB|146|147|HISTORY OF THE PRESENT ILLNESS|She has a history of a severe rheumatoid arthritis and she is status post right thoracotomy with a right upper and middle bilobectomy for a stage IB adenocarcinoma of the right upper lobe lung. She is a non-smoker. She was seen at Fairview Southdale emergency room on _%#MMDD2006#%_ for increasing shortness of breath.
IB|(stage) IB|IB,|33|35|ADMIT DIAGNOSIS|ADMIT DIAGNOSIS: Recurrent stage IB, grade 1 endometrioid adenocarcinoma with recurrence to the omentum. DISCHARGE DIAGNOSIS: Recurrent stage IB, grade 1 endometrioid adenocarcinoma with recurrence to the omentum.
IB|(stage) IB|IB,|142|144|DISCHARGE DIAGNOSIS|ADMIT DIAGNOSIS: Recurrent stage IB, grade 1 endometrioid adenocarcinoma with recurrence to the omentum. DISCHARGE DIAGNOSIS: Recurrent stage IB, grade 1 endometrioid adenocarcinoma with recurrence to the omentum. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 66-year-old patient with recurrent stage IB, grade 1 endometrial adenocarcinoma.
IB|(stage) IB|IB,|205|207|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSIS: Recurrent stage IB, grade 1 endometrioid adenocarcinoma with recurrence to the omentum. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 66-year-old patient with recurrent stage IB, grade 1 endometrial adenocarcinoma. She was originally diagnosed in _%#MM2004#%_ and at that time underwent complete surgical staging. She received adjuvant chemotherapy followed with surveillance visit and in _%#MM2005#%_ underwent CT scan secondary to abdominal pain.
IB|(stage) IB|IB,|173|175|ASSESSMENT|10. Protonix. 11. Aspirin. 12. Methocarbamol. ALLERGIES: Erythromycin, IV dye, Avelox, Benadryl, Toradol and Tegaderm. ASSESSMENT: A 66-year-old female with recurrent stage IB, grade 1 endometrial adenocarcinoma who was admitted on _%#MMDD2007#%_ and underwent exploratory laparotomy, resection of mass x2, omentectomy, lysis of adhesions and hernia repair on _%#MMDD2007#%_.
IB|(stage) IB|IB|128|129|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Also significant for: 1. Skin cancer 3x in the past. 2. Renal calculi. 3. He had a right upper lobe stage IB bronchioalveolar carcinoma in _%#MM2000#%_ and has been followed closely for this since that time and now is down to yearly chest x-rays and physicals for follow-up.
IB|(stage) IB|IB|119|120|ADMISSION DIAGNOSES|1. 2. Chronic bilateral venous stasis dermatitis. 3. Elephantiasis nostra verrucosa. 4. Cutaneous cell lymphoma, stage IB 5. Morbid obesity with a BMI of 55. 6. Severe degenerative joint disease affecting bilateral knee joints.
IB|(stage) IB|IB,|158|160|HISTORY OF PRESENT ILLNESS|The lady lives in _%#CITY#%_ alone. Her husband died a few years ago and her daughter lives in _%#CITY#%_, Minnesota. For the cutaneous T-cell lymphoma stage IB, the patient had been receiving ultraviolet light (UVB), which was helping her symptoms. Since the last 2 years, she has not been able to receive ultraviolet light as she was not able to stand in the light box because of the degenerative joint disease.
IB|(stage) IB|IB,|198|200|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Cesium implant, endometrial C-A HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 53-year-old Caucasian female with a recent history of endometrial cancer of the uterus, Stage IB, Grade 2. She has undergone TAH/BSO and radiation. At this time, Dr. _%#NAME#%_ plans a cesium implant treatment which would require two days of inpatient care.
IB|(stage) IB|IB|30|31|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: 1. Stage IB grade 2 endometrial adenocarcinoma. 2. Abdominal pain, leukocytosis, and fever, rule out urinary tract infection. DISCHARGE DIAGNOSIS: 1. Stage IB grade 2 endometrial adenocarcinoma. 2. Abdominal pain, likely secondary to fluid collection in pelvis.
IB|(stage) IB|IB|108|109|ADMISSION DIAGNOSIS|2. Abdominal pain, leukocytosis, and fever, rule out urinary tract infection. DISCHARGE DIAGNOSIS: 1. Stage IB grade 2 endometrial adenocarcinoma. 2. Abdominal pain, likely secondary to fluid collection in pelvis. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 68-year-old postmenopausal female who presented to the emergency room on _%#MM#%_ _%#DD#%_, 2003, with complaints of pain in her lower abdomen of 1-day duration.
IB|(stage) IB|IB|192|193|ALLERGIES|PROBLEMS: 1. Primary disease. Ms. _%#NAME#%_ is status post a total abdominal hysterectomy with bilateral salpingo-oophorectomy and lymph node dissection on _%#MM#%_ _%#DD#%_, 2003, for stage IB grade 2 endometrial adenocarcinoma. She has not undergone any further treatment at this time. She was seen by Radiation Oncology on hospital day 4 for a consultation.
IB|(status) IB|IB.|159|161|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. D-transposition of the great vessels status post Mustard procedure in 1972. 2. Congestive heart failure. 3. On transplant list, status IB. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 33-year-old gentleman with a significant history of D-transposition of the great vessels, which was a treated with a Mustard procedure in 1972.
IB|(stage) IB|IB,|30|32|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Stage IB, grade 2 endometrial adenocarcinoma. 2. Fever. 3. Hypokalemia. DISCHARGE DIAGNOSES: 1. Stage IB endometrial adenocarcinoma.
IB|(stage) IB|IB|126|127|DISCHARGE DIAGNOSES|ADMISSION DIAGNOSES: 1. Stage IB, grade 2 endometrial adenocarcinoma. 2. Fever. 3. Hypokalemia. DISCHARGE DIAGNOSES: 1. Stage IB endometrial adenocarcinoma. 2. Fever. 3. Hypokalemia. PROCEDURES/TREATMENTS: 1. IV fluid hydration. 2. IVP. 3. IV antibiotics. 4. Chest x-ray. 5. IV electrolyte replacement.
IB|(stage) IB|IB,|151|153|HISTORY OF PRESENT ILLNESS|2. IVP. 3. IV antibiotics. 4. Chest x-ray. 5. IV electrolyte replacement. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 59-year-old woman with stage IB, grade 2 endometrial adenocarcinoma who underwent total abdominal hysterectomy and bilateral salpingo- oophorectomy and bilateral pelvic and periaortic lymph node dissection on _%#MMDD2003#%_, with pathology revealing grade 2/3 endometrial adenocarcinoma with ductal invasion of 0.2 to cause a 2.6 cm into the myometrium.
IB|(stage) IB|IB,|194|196|ASSESSMENT|11. ANC 5.5. UA revealed moderate leukocyte esterase, negative nitrites, negative blood, and 34 white blood cells. Rapid strep test was negative. ASSESSMENT: This 59-year-old patient with stage IB, grade 2 endometrial adenocarcinoma, postop day #15, was admitted for fevers with presumptive UTI versus pyelonephritis. HOSPITAL COURSE: PROBLEM #1: Stage IB, grade 2 endometrial adenocarcinoma.
IB|(stage) IB|IB,|238|240|HOSPITAL COURSE|Rapid strep test was negative. ASSESSMENT: This 59-year-old patient with stage IB, grade 2 endometrial adenocarcinoma, postop day #15, was admitted for fevers with presumptive UTI versus pyelonephritis. HOSPITAL COURSE: PROBLEM #1: Stage IB, grade 2 endometrial adenocarcinoma. The patient is scheduled to see Dr. _%#NAME#%_ in four months for discussion of her treatment and follow-up.
IB|(stage) IB|IB|69|70|DISCHARGE DIAGNOSIS|DIAGNOSIS: Grade 1 endometrial carcinoma. DISCHARGE DIAGNOSIS: Stage IB endometrial carcinoma with some element of grade 2 cellular change. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 67-year-old multigravida female who was found to have atypical cells on a pap smear done by Dr. _%#NAME#%_ _%#NAME#%_.
IB|(stage) IB|IB,|168|170|HISTORY OF PRESENT ILLNESS|3. Physical therapy and occupational therapy. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 66-year-old female with a history of adenocarcinoma of the endometrium, stage IB, first diagnosed in 1997. She was no evidence of disease until 2001 where a neck mass biopsy was positive for adenocarcinoma.
IB|(grade) IB|IB,|199|201|HOSPITAL COURSE|Echocardiogram was also performed, which showed a decreased global LV systolic function, with an EF estimated at 25. Biopsy was obtained, as well as immunofluorescent staining. Biopsy returned grade IB, and immunofluorescent staining was negative. The patient was initially placed in the ICU with a Swan-Ganz catheter in place and started on IV milrinone.
IB|(grade) IB|IB,|269|271|HOSPITAL COURSE|Please note these changes below, specifically CellCept was increased to 1.5 gm b.i.d., prednisone increased 30 mg p.o. b.i.d., and Prograf continued at 4 mg p.o. b.i.d. Prior to discharge, he had a repeat right heart cath and biopsy. The biopsy returned again at grade IB, and immunofluorescent staining was negative. It was felt safe to discharge the patient home, where he will continue to monitor his weight.
IB|(stage) IB|IB,|36|38|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Presumed stage IB, grade 2, endometrioid adenocarcinoma of the endometrium, status post incomplete surgical staging procedure. DISCHARGE DIAGNOSIS: 1. Presumed stage IB, grade 2, endometrioid adenocarcinoma of the endometrium, status post initial incomplete surgical staging procedure.
IB|(stage) IB|IB,|187|189|DISCHARGE DIAGNOSIS|ADMISSION DIAGNOSIS: Presumed stage IB, grade 2, endometrioid adenocarcinoma of the endometrium, status post incomplete surgical staging procedure. DISCHARGE DIAGNOSIS: 1. Presumed stage IB, grade 2, endometrioid adenocarcinoma of the endometrium, status post initial incomplete surgical staging procedure. 2. Status post laparoscopic lysis of adhesions, peritoneal washings, and right pelvic lymph node dissection with conversion to exploratory laparotomy, technically difficult left salpingo-oophorectomy, left pelvic and periaortic lymph node dissection, and right periaortic lymph node dissection with repair of left external iliac artery and vein injury.
IB|(stage) IB|IB|116|117|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Wound cellulitis, status post Keflex p.o. antibiotics and conservative management. 2. Stage IB grade 1 endometrial adenocarcinoma, postoperative day 27 status post total abdominal hysterectomy, bilateral salpingo- oophorectomy and lymph node dissection.
IB|(stage) IB|IB,|185|187|HISTORY OF PRESENT ILLNESS|Subcutaneous tissue was debrided. Estimated blood loss was 25 mL. 4. Dressing changes b.i.d. were instituted. HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old female with stage IB, grade 1, endometrial adenocarcinoma, endometrioid type. The patient originally underwent diagnosis by ultrasound-guided dilatation and curettage on _%#MM#%_ _%#DD#%_, 2004, which revealed grade 2 adenocarcinoma of the endometrium.
IB|(stage) IB|IB,|238|240|HISTORY OF PRESENT ILLNESS|On _%#MM#%_ _%#DD#%_, 2004,the patient underwent exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy and lymph node dissection for staging. All lymph nodes were negative and her final diagnosis was stage IB, grade 1 endometrioid adenocarcinoma. On _%#MM#%_ _%#DD#%_, 2004, the patient was seen by the nurse at the Women's Health Center with complaints of erythema and warm at the wound with a 1-cm area that was open.
IB|(stage) IB|IB.|94|96|DISCHARGE DIAGNOSIS|ADMISSION DIAGNOSIS: Endometrial carcinoma. DISCHARGE DIAGNOSIS: Endometrial carcinoma, stage IB. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 63-year-old female who on endometrial biopsy was found to have endometrial carcinoma.
IB|(stage) IB|IB|318|319|HISTORY OF PRESENT ILLNESS|2. Abdominal x-ray, _%#MMDD2005#%_: Revealed no free air. 3. Transthoracic echocardiogram for evaluation of murmur: Revealed good left ventricular systolic function with mild MR, trace TR, and no vegetations noted. HISTORY OF PRESENT ILLNESS: The patient is a 45-year-old female with history of cervical cancer, stage IB squamous cell carcinoma with bilateral percutaneous nephrostomy tubes, previously admitted on _%#MMDD2005#%_ with dehydration, upper respiratory infection, and was discharged on _%#MMDD2005#%_ to the Ebenezer nursing home.
IB|(stage) IB|IB|125|126|PAST MEDICAL HISTORY|There was no cancer seen in those lymph nodes at that time. The patient with that left lower lobectomy was diagnosed with an IB bronchoalveolar carcinoma. Since that time subsequently new pulmonary nodules were found in the patient's lungs, and on _%#MMDD#%_ she underwent a right video-assisted thoracoscopic biopsy.
IB|(stage) IB|IB|138|139|ALLERGIES|She had undergone a colonoscopy in _%#MM#%_ 2003. The patient also had a chest x-ray in _%#MM#%_ 2003. HOSPITAL COURSE: 1. Disease. Stage IB endometrioid adenocarcinoma grade 1 of 3. 2. Fluid, electrolytes, and nutrition. The patient did receive IV fluids here well, now tolerating a regular diet, and this was discontinued prior to discharge.
IB|(stage) IB|IB|219|220|COMPLICATIONS|OPERATIONS/PROCEDURES PERFORMED: 1. Intravenous fluid hydration. 2. Intravenous antibiotics. COMPLICATIONS: None. HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old female with recurrent endometrial cancer, stage IB grade 1 diagnosed in _%#MM#%_ 2004. She presents tonight with right lower extremity erythema and swelling. Upon questioning, the patient states that this pain has been present since the day before presentation that has been read for 3 to 4 weeks.
IB|(stage) IB|IB|232|233|HISTORY OF PRESENT ILLNESS|REASON FOR ADMISSION: Left bronchopleural fistula after pneumonectomy. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 56-year-old male transferred here from _%#CITY#%_ _%#CITY#%_ Hospital by Dr. _%#NAME#%_ _%#NAME#%_. He has stage IB non-small cell lung cancer (squamous cell carcinoma) of the left upper lobe, T2, N0, M0 who required a pneumonectomy in _%#MM2004#%_.
IB|(stage) IB|IB|148|149|DISCHARGE DIAGNOSIS|REFERRING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD ADMISSION DIAGNOSIS: 1. Carcinosarcoma of the uterus. 2. Hypertension. DISCHARGE DIAGNOSIS: 1. Stage IB carcinosarcoma of the uterus. 2. Hypertension. OPERATIONS/PROCEDURES PERFORMED: 1. Examination under anesthesia, exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, bilateral pelvic periaortic lymph node dissection and pelvic washings.
IB|(stage) IB|IB|204|205|PAST MEDICAL HISTORY|Labs were drawn at that time as well. The patient is admitted to the Medicine service for further evaluation and treatment. PAST MEDICAL HISTORY: 1. History of squamous cell carcinoma of the cervix Stage IB grade 2, diagnosed in _%#MM1992#%_. The patient is status post hysterectomy and partial colectomy. The patient receives cisplatin, vinblastine, and bleomycin for chemotherapy.
IB|(stage) IB|IB|93|94|DISCHARGE DIAGNOSES|2. Grade 1 stage IB adenocarcinoma of the endometrium. DISCHARGE DIAGNOSES: 1. Grade 1 stage IB adenocarcinoma of the endometrium. 2. Pelvic abscess. 3. Urinary tract infection. OPERATIONS/PROCEDURES PERFORMED: 1. Twice daily wet to dry dressing changes of wound.
IB|(stage) IB|IB|269|270|HOSPITAL COURSE|1. Disease. The patient was admitted and underwent an uncomplicated total abdomen hysterectomy, bilateral salpingo-oophorectomy, and right pelvic lymph node biopsy. Frozen pathology revealed grade 1 endometrial carcinoma with minimal invasion. Final pathology revealed IB grade 1 endometrioid carcinoma. The patient was asked to follow up with Dr. _%#NAME#%_ in 2 to 3 weeks for treatment planning. This will likely consist of observation for a period of 5 years.
IB|(stage) IB|IB|193|194|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSIS: Right lower lobe pneumonia, suspected gram-negative pneumonia. PROCEDURES PERFORMED: None. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 77-year-old gentleman with stage IB non-small-cell lung cancer who underwent a thoracoscopic right upper lobectomy on _%#MMDD2006#%_. His postoperative course was complicated by an air leak, which resolved with conservative management.
IB|(stage) IB|IB|86|87|PAST MEDICAL HISTORY|He denied fevers, chills, rigors, or other complaints. PAST MEDICAL HISTORY: 1. Stage IB non-small-cell lung cancer of the right upper lobe. 2. Hypercalcemia. 3. Hypertension. 4. Major depression. 5. Chronic obstructive pulmonary disease.
IB|(stage) IB|IB|138|139|HISTORY OF PRESENTING ILLNESS|Cervix itself measured 5 cm. There is not felt to be an extension of the mass into the parametrial tissue on exam, then was given a stage IB grade 2 . The patient was scheduled for surgical staging. Then on _%#MM#%_ _%#DD#%_, 2006, surgical staging with examination and an anesthesia cystoscopy, proctoscopy, extraperitoneal lymph node dissection, and left pelvic lymph node dissection as well as excision of the left back scapular raised lesion.
IB|(stage) IB|IB|203|204|IMPRESSION|IMPRESSION: 1. Dehydration secondary to decreased oral intake, following chemotherapy . 2. Weakness which is likely related both to dehydration and also to post-chemotherapy side effect. 3. T2N0M0 stage IB nonsmall cell lung cancer, now status post surgery and three cycles of adjuvant chemotherapy with no evidence of recurrence.
IB|(stage) IB|IB|103|104|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: T4, N2, M0 squamous cell carcinoma of the floor of the mouth with bilateral level IB nodal disease. OPERATIONS/PROCEDURES PERFORMED: 1. Exam under anesthesia. 2. Rigid laryngoscopy.
IB|(stage) IB|IB|199|200|DIAGNOSES ON ADMISSION|3. Status post completion of cycle 4/6 of intravenous Taxol and intraperitoneal cisplatin chemotherapy. DISCHARGE DIAGNOSES: 1. History of IIIC papillary serous adenocarcinoma of the ovary. 2. Stage IB grade 3 endometrioid adenocarcinoma of the endometrium with clear cell component. 3. Status post completion of cycle 4/6 of intravenous Taxol and intraperitoneal cisplatin chemotherapy.
IB|(stage) IB|IB|95|96|DISCHARGE DIAGNOSES|ADMISSION DIAGNOSES: 1. History of IIIC papillary serous adenocarcinoma of the ovary. 2. Stage IB grade 3 endometrioid adenocarcinoma of the endometrium with clear cell component. 3. Hypertension. 4. Hyperlipidemia. 5. Cycle 3/6 of IV Taxol and intraperitoneal cisplatin chemotherapy.
IB|(stage) IB|IB|271|272|HISTORY OF PRESENT ILLNESS|PROCEDURE PERFORMED: Chemotherapy regimen with intravenous Taxol and intraperitoneal cisplatin. COMPLICATIONS: None apparent. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 67-year-old with a history of IIIC papillary serous adenocarcinoma of the ovary as well as stage IB grade 3 endometrioid adenocarcinoma of the endometrium with clear cell component, who is being admitted for intravenous/intraperitoneal chemotherapy.
IB|(stage) IB|IB|81|82|DISCHARGE DIAGNOSES|5. Wound cellulitis. 6. Anemia of chronic disease. DISCHARGE DIAGNOSES: 1. Stage IB carcinosarcoma of the uterus. 2. Chronic inflammatory demyelinating polyneuropathy. 3. Diabetes mellitus. 4. Hypothyroidism. 5. Wound cellulitis. 6. Anemia of chronic disease.
IB|(stage) IB|IB|134|135|PAST MEDICAL HISTORY|She reports no problems with anxiety or depression. She has a history of diabetes and thyroid disease. PAST MEDICAL HISTORY: 1. Stage IB carcinosarcoma of the uterus. 2. Chronic immune demyelinating polyneuropathy. 3. Hypothyroidism. 4. Type 2 diabetes mellitus. 5. Anemia of chronic disease. 6. Morbid obesity. 7. Chronic headaches.
IB|(grade) IB|IB|186|187|ASSESSMENT|RADIOGRAPHS: Radiographs that were taken six days ago showed no evidence of osteomyelitis. ASSESSMENT: Abscess dorsal left foot with associated cellulitis with University of Texas grade IB plantar ulceration third metatarsal head area left. PLAN: Since the infection has worsened and now there appears to be an abscess on the dorsum of the left foot, it was decided after a probe of the abscess the dorsum of the foot to not continue to fully debride it.
IB|(stage) IB|IB|30|31|ADMITTING DIAGNOSES|ADMITTING DIAGNOSES: 1. Stage IB carcinosarcoma of the endometrium. 2. Chronic immunosuppressive demyelinating polyneuropathy exacerbation. 3. Hypothyroidism. 4. Type 2 diabetes mellitus. 5. History of anemia. 6. Obesity. DISCHARGE DIAGNOSES: 1. Stage IB carcinosarcoma of the endometrium.
IB|(stage) IB|IB|184|185|DISCHARGE DIAGNOSES|2. Chronic immunosuppressive demyelinating polyneuropathy exacerbation. 3. Hypothyroidism. 4. Type 2 diabetes mellitus. 5. History of anemia. 6. Obesity. DISCHARGE DIAGNOSES: 1. Stage IB carcinosarcoma of the endometrium. 2. Chronic immunosuppressive demyelinating polyneuropathy exacerbation. 3. Hypothyroidism. 4. Type 2 diabetes mellitus. 5. History of anemia. 6. Obesity. PROCEDURES: 1. IVIG x5 days per Neurology.
IB|(stage) IB|IB|81|82|PAST MEDICAL HISTORY|REVIEW OF SYSTEMS: See HPI is otherwise negative. PAST MEDICAL HISTORY: 1. Stage IB uterine carcinosarcoma diagnosed in _%#MM2006#%_. She has been receiving Taxol and ifosfamide x6 cycles. She is a due for her next cycle on _%#MMDD2007#%_.
IB|(stage) IB|IB|181|182|HISTORY|The patient still has loss of appetite. HISTORY: In _%#MM2007#%_, the patient had total abdominal hysterectomy, bilateral salpingo-oophorectomy with lymph node dissection for stage IB grade III endometrial cancer. She had pelvic radiotherapy done in Texas. In _%#MM2006#%_, the patient had a CT scan of the abdomen and pelvis that showed recurrence with omental thickening and ascites.
IB|(type) IB|IB|217|218|PAST MEDICAL HISTORY|1. Fibromyalgia/chronic fatigue syndrome. She does not participate in an exercise regimen. 2. Sleep disorder including chronic insomnia and ?sleep apnea. 3. History of hepatitis C, biopsy proven, _%#MMDD2002#%_, type IB per the patient. She sees Dr. _%#NAME#%_ _%#NAME#%_ here. She denies high risk activities. She attributes the illness to IV injections and antibiotics that were given to her in the 1980's.
IB|(status) IB|IB|173|174|HOSPITAL COURSE|At the time of discharge, the defibrillator was set in pacing mode of AAIR with a lower rate limit of 75 beats per minute. His status on transplant list was reclassified as IB due to milrinone. DISCHARGE DIAGNOSES: 1. Heart failure. 2. Premature ventricular contractions or ventricular arrhythmia.
IB|(stage) IB|IB|30|31|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: 1. Stage IB T1B-N0-M0 grade III endometrioid adenocarcinoma with endometrium status post hysterectomy with negative resection margins. 2. History of hypertension. 3. History of arthritis. 4. History of herniated lumbar disk.
IB|(stage) IB|IB|128|129|DISCHARGE DIAGNOSIS|ADMISSION DIAGNOSIS: 1. Adenocarcinoma by endometrial biopsy. 2. Depression. 3. Anxiety. DISCHARGE DIAGNOSIS: 1. Grade 1, stage IB endometrial adenocarcinoma. 2. Depression. 3. Anxiety. OPERATIONS/PROCEDURES PERFORMED: 1. Exploratory laparotomy/TAH-BSO/proctoscopy.
IB|(stage) IB|IB|119|120|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Stage IB grade 1 endometrial adenocarcinoma, recurrent and metastatic. DISCHARGE DIAGNOSIS: Stage IB grade 1 endometrial adenocarcinoma, recurrent and metastatic. PROCEDURES PERFORMED: Cisplatin and VP-16 chemotherapy. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 67-year-old Caucasian female with metastatic endometrial adenocarcinoma.
IB|(stage) IB|IB|157|158|HOSPITAL COURSE|BUN 12. Calcium 8.6. Chloride 111. Bicarbonate 23. Creatinine 0.7. Glucose 92. Potassium 4.2. Sodium 143. HOSPITAL COURSE: 1. Disease. The patient had stage IB grade 2 squamous cell carcinoma of the cervix, and no angiolymphatic invasion. She underwent insertion of tandem and ovoids without difficulty, and cesium brachytherapy which was well tolerated.
IB|(stage) IB|IB,|69|71|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old female with IB, stage II squamous cell carcinoma of the cervix. Her history is as follows. She initially presented with post-coital bleeding and vaginal irregular bleeding.
IB|(stage) IB|IB,|40|42|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Recurrent Stage IB, grade 1, endometrial cancer. 2. Lymphedema. DISCHARGE DIAGNOSES: 1. Recurrent Stage IB, grade 1, endometrial cancer.
IB|(stage) IB|IB,|128|130|DISCHARGE DIAGNOSES|ADMISSION DIAGNOSES: 1. Recurrent Stage IB, grade 1, endometrial cancer. 2. Lymphedema. DISCHARGE DIAGNOSES: 1. Recurrent Stage IB, grade 1, endometrial cancer. 2. Lymphedema. OPERATIONS/PROCEDURES PERFORMED: Second course of cisplatinum and ethyol chemotherapy.
IB|(stage) IB|IB|105|106|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Pyelonephritis. 2. Bilateral percutaneous nephrostomy tubes. 3. History of stage IB squamous cell carcinoma of the cervix with no evidence of malignancy at this time. 4. Ureteral radiation fibrosis PROCEDURES: 1. Bilateral percutaneous nephrostomy tube replacement x 2, once on _%#MMDD2003#%_ and once on _%#MMDD2003#%_.
IB|(stage) IB|IB|147|148|HISTORY|2. Triple antibiotic flushes. 3. IV antibiotics. ATTENDING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_. HISTORY: The patient is a 43-year-old female with IB squamous cell carcinoma of the cervix with a vesicovaginal fistula who presented to the clinic with a temperature of 100, back pain, and foul-smelling discharge from her left PNT tube.
IB|(stage) IB|IB|285|286|COURSE TO DATE|HISTORY: The patient is a 43-year-old female with IB squamous cell carcinoma of the cervix with a vesicovaginal fistula who presented to the clinic with a temperature of 100, back pain, and foul-smelling discharge from her left PNT tube. COURSE TO DATE: In 1992 she was diagnosed with IB squamous cell carcinoma of the cervix. She had one positive lymph node of 49. She underwent external beam radiation with cisplatin potentiation, vinblastine, and bleomycin.
IB|(stage) IB|IB|535|536|HOSPITAL COURSE|She has no masses. She was admitted to 7C. She had her PNT changed on admission and then triple antibiotic flushes were initiated and she underwent a CT scan of the abdomen and pelvis, which revealed no significant change in the soft tissue prominence in the perirectal and vaginal cuff region, a small tissue nodule inferior to the left kidney, which is non-specific, and two small hypodense lesions; which again are non-specific, and new bilateral pleural effusions with associated atelectasis. HOSPITAL COURSE: PROBLEM #1: Disease: IB squamous cell carcinoma of the cervix with no evidence of malignancy at this time. PROBLEM #2: Genitourinary: She was noted to have vesicovaginal fistula; however, she has bilateral PNT at this time secondary to ureteral fibrosis from her radiation therapy.
IB|(stage) IB|IB.|235|237|PROBLEM #1|Estimated blood loss was 50 cc. PROBLEM #1: Disease. The patient had an exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, and peritoneal biopsy. The final pathology showed endometrial cancer, stage IB. PROBLEM #2: Pain. The patient was on a Dilaudid PCA for pain control.
IB|(stage) IB|IB|177|178|ADMISSION DIAGNOSES|CONSULTATIONS: Consults obtained during this admission were interventional radiology. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 65-year-old female with a history of stage IB cervical cancer, status post radiation treatment with colostomy placement and bilateral percutaneous nephrostomy tube placement secondary to a vesicovaginal fistula.
IB|(stage) IB|IB|137|138|IMPRESSION|ABDOMEN: Soft and nontender, with a well-healing scar. EXTREMITIES: No inguinal adenopathy. She has mild pitting edema. IMPRESSION: FIGO IB clear-cell carcinoma of the uterus. RECOMMENDATIONS: We would adjuvant postoperative radiation therapy to consist of both external-beam therapy and brachytherapy.
IB|(stage) IB|IB|265|266|ASSESSMENT AND PLAN|Pelvic exam demonstrates a mass in the anterior apex of the vagina which extends from the cuff of the vagina down about 1 cm by about 0.5 cm wide. LABORATORY DATA: CA125 is 10, creatinine 1.3. ASSESSMENT AND PLAN: This is a 77-year-old female with history of stage IB grade 3 endometrial cancer, now with vaginal cuff recurrence. She has a cystic structure in the pelvis, as well, which is indeterminate but could represent cystic neoplasm.
IB|(stage) IB|IB|54|55|PROBLEM|PROBLEM: Adenocarcinoma of the left lower lobe, stage IB (T2 N0 M0). Mr. _%#NAME#%_ was seen for initial consultation in the Department of Therapeutic Radiology on _%#MMDD2007#%_ by Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ at the request of Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_.
IB|(stage) IB|IB|218|219|ASSESSMENT|The patient speaks full sentences. ABDOMEN: Obese, non-tender. EXTREMITIES: Bilateral lower extremity swelling. NEUROLOGIC: Grossly intact. ASSESSMENT: In summary, Mr. _%#NAME#%_ is an 84-year-old gentleman with stage IB (T2 N0 M0) adenocarcinoma of the left lower lobe. The patient has refused surgical resection. We told him that he would be a good candidate for stereotactic body radiation therapy, we expect similar local control rate as compared to surgery.
IB|(stage) IB|IB|174|175|HISTORY OF PRESENT ILLNESS|The chart, radiographic report/films, and pathology were reviewed HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 59-year-old female who was initially diagnosed with a stage IB cervix cancer in 1979. Her initial treatment was radiation therapy. She received pelvic radiation to 3150 cGy and also underwent brachytherapy with tandem and ovoids.
IB|(stage) IB|IB|91|92|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 59-year-old female with a history of stage IB cervical squamous cell carcinoma back in 1979. She was treated with external beam radiation therapy and brachytherapy to a total dose of 80 Gy to point A and 50 Gy to point B.
IB|(stage) IB|IB|129|130|IMPRESSION AND PLAN|Please refer to HPI. PATHOLOGIC SPECIMENS: Sent here for review and these reports were reviewed. IMPRESSION AND PLAN: FIGO stage IB endometrial adenocarcinoma, endometrioid type, grade 2. Her disease appears to have been completely resected. Her peritoneal cytology was negative and there was no evidence of lymph node metastases.
IB|(stage) IB|IB|270|271|HISTORY OF PRESENT ILLNESS|A biopsy of the left mainstem bronchus mass, _%#MMDD2005#%_, showed non-small-cell carcinoma, which did not appear to be adenocarcinoma or squamous cell carcinoma. A PET scan in _%#MM#%_ 2005 showed increased uptake in the left hilum only, and the patient was staged as IB (T2 N0). She was not felt to be a surgical candidate due to her age and poor pulmonary status. She has severe COPD, and the location of the tumor would have required a pneumonectomy.
IB|(type) IB|IB.|177|179|DOB|By history, she has had hepatitis C and had been receiving Interferon therapy. This stopped in _%#NAME#%_ after she had failed to clear the hepatitis C, believed to be genotype IB. She had been doing well but was seen for medication refill.
IB|(stage) IB|IB|358|359|ASSESSMENT AND PLAN|Skin: There is a tiny (4 to 5 mm) subcutaneous nodule palpable on the left buttock which is soft and mobile, and is nontender to palpation. ASSESSMENT AND PLAN: In summary Mrs. _%#NAME#%_ is a 59-year-old female who is status post total abdominal hysterectomy, bilateral salpingo-oophorectomy, as well as pelvic and paraaortic lymph node dissection for FIGO IB grade 2 endometrial adenocarcinoma. We again reviewed the role of postoperative radiation therapy in helping prevent recurrence of the cancer.
IB|(stage) IB|IB|114|115|PROBLEM|*Send cc to: DR. _%#NAME#%_ OR _%#NAME#%_ ?? not spelled St. Joseph's Cancer Center _%#CITY#%_, ND PROBLEM: Stage IB ovarian cancer. Ms. _%#NAME#%_ was seen on _%#MM#%_ _%#DD#%_, 2001 by Drs. _%#NAME#%_ _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_ for consultation at the request of Dr. _%#NAME#%_ for consideration of radiation therapy for the patient's stage IB ovarian cancer.
IB|(stage) IB|IB|220|221|PROBLEM|Ms. _%#NAME#%_ was seen on _%#MM#%_ _%#DD#%_, 2001 by Drs. _%#NAME#%_ _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_ for consultation at the request of Dr. _%#NAME#%_ for consideration of radiation therapy for the patient's stage IB ovarian cancer. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 75-year-old female who had a pelvic mass noted incidentally on an examination by Dr. _%#NAME#%_ on _%#MMDD2002#%_.
IB|(stage) IB|IB|121|122|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a very pleasant 78-year-old woman who was initially diagnosed with a stage IB squamous-cell carcinoma of the cervix in 1984. She underwent radiation therapy at MeritCare in _%#CITY#%_, North Dakota under the direction of Dr. _%#NAME#%_.
IB|(stage) IB|IB|20|21|PROBLEM|PROBLEM: FIGO stage IB grade 3 endometrioid adenocarcinoma. Ms. _%#NAME#%_ was seen in the Department of Therapeutic Radiology on _%#MMDD2006#%_ by Dr. _%#NAME#%_ and Dr. _%#NAME#%_ at the request of Dr. _%#NAME#%_.
IB|(stage) IB|IB|220|221|HISTORY OF PRESENT ILLNESS|In addition, there was a large pelvic mass consistent with an enlarged uterus. On _%#MMDD2006#%_ she underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy by Dr. _%#NAME#%_. Pathology showed stage IB grade 3 endometrioid adenocarcinoma with 8 out of 22 mm myometrial invasion. There was no angiolymphatic invasion or cervical involvement. Thirty-two lymph nodes were uninvolved.
IB|(stage) IB|IB|196|197|PHYSICAL EXAMINATION|NEUROLOGICAL: Cranial nerves II through XII grossly intact with no focal deficits. EXTREMITIES: No cyanosis, clubbing, or edema. IMPRESSION: Ms. _%#NAME#%_ is a 55-year-old female with FIGO stage IB grade 3 endometrioid adenocarcinoma, status post TAH/BSO on _%#MMDD2006#%_. PLAN: We discussed several treatment options including observation alone, in which case we would give radiation if her disease were to recur.
IB|(stage) IB|(IB)|140|143|IMPRESSION|No masses or nodularity present on the right. Left testicle within normal limits. EXTREMITIES: No edema. IMPRESSION: Pathologic stage T3 N0 (IB) seminoma. PLAN: We spoke with Mr. _%#NAME#%_ regarding the clinical, laboratory, radiographic and surgical findings with his disease.
IB|(stage) IB|(IB)|122|125|HPI|Exam: His remaining testicle is unremarkable. There is no palpable lymphadenopathy. Assessment and Plan: FIGO stage T3 N0 (IB) seminoma. Recommendations: Mr. _%#NAME#%_ histopathologic report is somewhat unusual, although it is noteworthy that he had a microscopically involved spermatic cord margin, as well a foci of microscopic disease in the perivascular lymphoid tissue at the resection margin.
IB|(stage) IB|IB|146|147|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Cervical cancer. FIGO IB HPI: Status post retroperitoneal lymph node dissection with 3 positive pelvic nodes.
IB|(stage) IB|IB,|35|37|PROBLEM|PROBLEM: Endometrial cancer, stage IB, grade 2. The patient was seen in the Radiation Oncology Clinic by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ at the request of Dr. _%#NAME#%_.
IB|(stage) IB|IB,|127|129|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 74-year-old female with a recent diagnosis of endometrial adenocarcinoma stage IB, grade 2. She presented in _%#MM2004#%_ with complaints of vaginal bleeding. Her workup included a biopsy done _%#MMDD2004#%_ which showed endometrial adenocarcinoma grade 2 with papillary features.
IB|(stage) IB|IB,|152|154|ASSESSMENT|No focal deficits. LABORATORY STUDIES: We reviewed her records, findings are as mentioned above. ASSESSMENT: Ms. _%#NAME#%_ is a 74-year-old with stage IB, grade 2 endometrial adenocarcinoma, status post total abdominal hysterectomy with bilateral salpingo-oophorectomy. PLAN: We recommend external beam radiation therapy, followed by HDR brachytherapy.
IB|(stage) IB|IB|149|150|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Endometrial cancer, FIGO IB grade 2. HPI: Ms. _%#NAME#%_ underwent a TAH/BSO on _%#MMDD2005#%_ revealing grade 2 endometrial adenocarcinoma with 6 of 14 mm of invasion.
IB|(stage) IB|IB|102|103|IMPRESSION|PELVIC: Not performed, as she just returned from the GYN Clinic earlier today. IMPRESSION: FIGO stage IB adenocarcinoma of the uterus with minimal (1/60 mm of invasion) but high grade. RECOMMENDATIONS: Through an interpreter, I discussed the risks and benefits of adjuvant radiotherapy with Mrs. _%#NAME#%_.
IB|(stage) IB|IB|170|171|HISTORY  OF PRESENT ILLNESS|He has been managed with inhalers in the past but he uses these only sporadically. He has a long-standing ongoing tobacco smoking history. He also has a history of stage IB bronchoalveolar cell carcinoma with apparently right upper lobe resection in the year 2000. He has a history of significant atherosclerosis and coronary artery disease.
IB|(stage) IB|IB|147|148|PAST  MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Skin cancer x3 in the past. 2. Renal calculi. 3. Carotid artery disease as per HPI. 4. Right upper lobe surgery for stage IB bronchoalveolar cell carcinoma in _%#MM#%_ 2000. Patient reportedly followed subsequently since that time. 5. Psoriasis. 6. COPD. 7. PE tube placement in the left ear in the fall 2005.
IB|(stage) IB|IB|140|141|IMPRESSION|2. Probable advanced COPD with exacerbation with a component of bronchitis. 3. History of right upper lobe lung resection in 2000 for stage IB bronchoalveolar cell carcinoma. 4. History of coronary artery disease. 5. History of peripheral vascular disease. 6. Other past medical history as per above. DISCUSSION: This patient has a picture of acute on chronic hypercapnic respiratory failure postop.
IB|(stage) IB|IB|15|16|PROBLEM|PROBLEM: Stage IB carcinosarcoma of the uterus. The patient was evaluated in the Department of Radiation Oncology by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ at the request of Dr. _%#NAME#%_ _%#NAME#%_ from the Women's Health Center.
IB|(stage) IB|IB|102|103|PAST MEDICAL HISTORY|She presents today for evaluation for external beam radiation therapy. PAST MEDICAL HISTORY: 1. Stage IB carcinosarcoma of the uterus. 2. Status post surgery on the left wrist for tendonitis. FAMILY HISTORY OF CANCER: The patient reports that she had 1 sister who died in her 40s from leukemia.
IB|(stage) IB|IB|55|56|SUBJECTIVE|SUBJECTIVE: Ms. _%#NAME#%_ is a 35-year-old with stage IB carcinosarcoma of the uterus who presented to the Emergency Department today with complaints of increased drainage and redness of her wound. Ms. _%#NAME#%_ has a known wound cellulitis with a small superficial wound separation that occurred approximately 2 months after her surgery.
IB|(stage) IB|IB.|215|217|IMPRESSION|No cyanosis, clubbing or edema. PELVIC: Not performed. EXTREMITIES: The right leg has some superficial varicosities without a palpable cord. IMPRESSION: 1. Malignant mixed mesodermal tumor of the uterus, FIGO stage IB. 2. ITP. RECOMMENDATIONS: I spent an hour and ten minutes with Mrs. _%#NAME#%_ and her husband.
IB|(stage) IB|IB,|125|127|IMPRESSION|There is also a T12 lesion measuring 2 cm in greatest dimension. IMPRESSION: The patient is a 68-year-old with initial stage IB, grade 1 endometrial cancer, status post TAH-BSO, with initial recurrence in _%#MM2000#%_. Since that time, she has had a posterior exenteration, radiation therapy to her pelvis to a total dose of 4500 cGy, and a wedge resection of a left lower lobe lesion.
IB|(stage) IB|IB|169|170|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: 66 year old female with MMMT of uterus, FIGO IB HPI: Status post TAH/BSO nodes. Exam: Assessment and Plan: Discussed treatment options at length. Spent over 45 minutes counseling about options including external beam therapy, WAR, vaginal brachytherapy or some combination.
IB|(stage) IB|IB|79|80|IDENTIFICATION|IDENTIFICATION: Ms. _%#NAME#%_ is a 67-year-old female with a history of stage IB carcinosarcoma of the uterus, here for a followup visit. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 67-year-old, P6- 0-1-6 who originally presented with vaginal bleeding.
IB|(stage) IB|IB|281|282|IDENTIFICATION|On _%#MM#%_ _%#DD#%_, 2005, she underwent an exploratory laparotomy, total abdominal hysterectomy, left salpingo- oophorectomy, omentectomy, bilateral pelvic and periaortic lymph node dissection, pelvic washings, and repair of an IVC laceration. Her final pathology returned stage IB carcinosarcoma of the uterus. She then underwent radiation treatments with external beam pelvic radiation, and high-dose brachytherapy. This was completed on _%#MM#%_ _%#DD#%_, 2005. She is here for her 3-month followup.
IB|(stage) IB|IB|221|222|SOCIAL HISTORY|Of note, there is a 3-cm left pelvic side wall cystic structure, most likely postsurgical seroma versus ovarian cyst. Metastatic deposit is a remote consideration. ASSESSMENT: A 67-year-old female with a history of stage IB carcinosarcoma of the uterus status post surgery and pelvic radiation. PLAN: 1. Carcinosarcoma of the uterus. The patient will continue to have pelvic exams and Pap smears every 3 months for a total of 2 years.
IB|(stage) IB|IB|85|86|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 59-year old female with a history of IB cervical cancer grade 2 invasive to a depth of 10 mm diagnosed in 1985. She had initially undergone a TAH/BSO after which invasion was found.
IB|(stage) IB|IB,|20|22|PROBLEM|PROBLEM: FIGO stage IB, grade 3, endometrial cancer, status post TAH/BSO and lymph node sampling. The patient was evaluated in the Department of Radiation Oncology by Dr. _%#NAME#%_ _%#NAME#%_ and the Dr. _%#NAME#%_ _%#NAME#%_ and the request of Dr. _%#NAME#%_ _%#NAME#%_ of OB/GYN.
IB|(stage) IB|IB,|156|158|ASSESSMENT/PLAN|Strength is 5/5 and symmetric. Gait and sensation are grossly intact. ASSESSMENT/PLAN: In summary Ms. _%#NAME#%_ is a 53-year- old female with a FIGO stage IB, grade 3, endometrial carcinoma, status post total abdominal hysterectomy with bilateral salpingo-oophorectomy and lymph node sampling, who presents for evaluation for radiation therapy.
IB|(stage) IB|IB.|138|140|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Cervix Cancer IB. HPI: 48-year-old with postcoital bleeding. Exam: EVA shows 4.5 cm mass in cervix. No extension to parametria.
IB|(stage) IB|IB|15|16|PROBLEM|PROBLEM: Stage IB papillary serous endometrial cancer, grade III. Ms. _%#NAME#%_ was seen by Drs. _%#NAME#%_ _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_ in the Therapeutic Radiation Department on _%#MM#%_ _%#DD#%_, 2002 for consultation at the request of Dr. _%#NAME#%_ _%#NAME#%_.
IB|(stage) IB|IB.|177|179|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Papillary serous adenocarcinoma of uterus FIGO Stage IB. HPI: Recovering well from surgery. Exam: Scar healing well. Assessment and Plan: Risks and benefits of SRT discussed extensively.
IB|(stage) IB|IB,|60|62|PROBLEM|PROBLEM: Recurrent endometrial cancer, initially FIGO stage IB, grade 2 of 3. Ms. _%#NAME#%_ was seen in the Radiation Oncology Department by Drs. _%#NAME#%_ _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2003 for consultation at the request of Dr. _%#NAME#%_ _%#NAME#%_.
IB|(stage) IB|IB,|105|107|PAST MEDICAL HISTORY|He is currently on Dilantin and has had no further seizures. PAST MEDICAL HISTORY: 1. Lung cancer, stage IB, status post left pneumonectomy (_%#MM2002#%_). 2. Colon polyps removed (_%#MM2002#%_). 3. Appendix goblet cell carcinoid with diffuse omental involvement, status post cytoreductive surgery and hypothermic peritoneal chemotherapy.
IB|(stage) IB|IB|124|125|ASSESSMENT AND PLAN|There is a gastrojejunal tube with the tip in the duodenum. ASSESSMENT AND PLAN: 58-year-old male with two primary cancers, IB non-small cell lung cancer, status post pneumonectomy approximately a year ago. He also has an appendiceal adenocarcinoma with peritoneal metastases. He now has on CT scan two foci in the left brain including left frontal and left occipital regions which are consistent with metastases.
IB|(stage) IB|IB|179|180|HPI|_____Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Brain metastases. HPI: S/P left pneumonectomy for stage IB NSC lung cancer. Exam: Patient nauseated. Patient alert and oriented. CN II-XII intact.
IB|(stage) IB|IB,|52|54|PROBLEM|PROBLEM: Early stage endometrial cancer, FIGO stage IB, grade 3. HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ is a very pleasant 56- year-old female who presents to us for an ongoing evaluation and discussion of adjuvant therapy options for her early FIGO stage IB, grade 3, adenocarcinoma of the endometrium.
IB|(stage) IB|IB,|196|198|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ is a very pleasant 56- year-old female who presents to us for an ongoing evaluation and discussion of adjuvant therapy options for her early FIGO stage IB, grade 3, adenocarcinoma of the endometrium. Mrs. _%#NAME#%_ presented in _%#MM2003#%_ with several episodes of postmenopausal bleeding. She presented to her local physician, who performed an endometrial biopsy that revealed a poorly differentiated endometrial adenocarcinoma.
IB|(stage) IB|IB,|168|170|ASSESSMENT AND PLAN|She has good healing of her small laparoscopic surgical scars. ASSESSMENT AND PLAN: The patient is a 56-year-old female with early stage endometrial cancer, FIGO stage IB, grade 3 who is healing nicely from her recent definitive surgery. Dr. _%#NAME#%_ and myself discussed the role of adjuvant radiation therapy in her specific situation.
IB|(stage) IB|IB,|156|158|CC|______ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Endometrial cancer, FIGO stage IB, grade 3. HPI: Status post vaginal hysterectomy, laparoscopic-assisted bilateral salpingo-oophorectomy, and pelvic and para-aortic lymph node dissection on _%#MMDD2003#%_ with pathology showing less than 50% myometrial invasion, but showing lower uterine segment invasion.
IB|(stage) IB|IB|230|231|HPI|Dear Dr. _%#NAME#%_: It was out pleasure to evaluate your patient, Eveline Axness in the Women's Cancer Center at the University of Minnesota on _%#MMDD2004#%_. The patient had been previously seen by you for her history of stage IB 2 squamous cell carcinoma of the cervix with metastatic disease to the paraaortic lymph nodes. This 78-year-old female patient was originally diagnosed in _%#MM2003#%_ when total vaginal hysterectomy for cervical dysplasia revealed evidence of cervical carcinoma.
IB|(stage) IB|IB|235|236|HPI|This appears consistent with the CT scan from _%#MMDD2004#%_. It appears cystic and simple in nature, and is associated with surgical clips, consistent with lymphocele. Our assessment is that this 78-year-old female patient with stage IB 2 squamous cell carcinoma of the cervix has no evidence of recurrent or persistent disease. We will have the CT scan of the abdomen and pelvis from _%#MMDD2004#%_ compared with our previous films here at the University of Minnesota from _%#MM2004#%_ and _%#MM2003#%_.
IB|(stage) IB|IB|15|16|PROBLEM|PROBLEM: Stage IB cervix carcinoma with left parametrial involvement. The patient was seen in radiation Oncology Clinic by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_.
IB|(stage) IB|IB|130|131|CC|______ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: FIGO IB squamous cell carcinoma of the cervix, status post examination under anesthesia, cystoscopy and proctoscopy, with an exploratory laparotomy at which time a grossly positive left parametrium was appreciated, and the radical hysterectomy aborted.
IB|(stage) IB|IB|131|132|CC|Intra-abdominally left parametrial extension, which was hard and suspicious for malignancy, could be appreciated. Impression: FIGO IB carcinoma of the cervix; known parametrial extension and positive pelvic node. Recommendation: Mrs. _%#NAME#%_ is an excellent candidate for definitive radiotherapy and chemotherapy.
IB|(stage) IB|IB|175|176|HISTORY OF PRESENT ILLNESS|She underwent 2 cycles of neoadjuvant chemotherapy followed by resection of her tumor on _%#MM#%_ _%#DD#%_, 2005. Pathology showed that the tumor had been downstaged to Stage IB with no associated adenopathy. The patient then underwent 2 postoperative cycles of carboplatin and gemcitabine, finished in _%#MM#%_ 2005.
IB|(stage) IB|IB|20|21|PROBLEM|PROBLEM: FIGO stage IB carcinosarcoma of the endometrium, status post TAH/BSO followed by external beam radiation. Ms. _%#NAME#%_ was seen in the Department of Therapeutic Radiology on _%#MMDD2006#%_ by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ at the request of Dr. _%#NAME#%_ in the Radiation Oncology Department at North Memorial Medical Center.
IB|(stage) IB|IB|216|217|IMPRESSION|Soft and non-tender. NEUROLOGIC: Cranial nerves II through XII grossly intact, with no focal deficits. EXTREMITIES: No cyanosis, clubbing, or edema. IMPRESSION: Ms. _%#NAME#%_ is a 59-year-old female with FIGO stage IB carcinosarcoma of the endometrium, status post total abdominal hysterectomy and bilateral salpingo-oophorectomy on _%#MMDD2006#%_ followed by 4500 cGy to the pelvis completed on _%#MMDD2006#%_.
IB|(stage) IB|IB|78|79|PROBLEM|NOTE Please fill in the 2 blanks under MEDICATIONS: Thank you. PROBLEM: Stage IB (T1b N0 M0) endometrioid adenocarcinoma. The patient was seen in Radiation Oncology Clinic by Dr. _%#NAME#%_ _%#NAME#%_.
IB|(stage) IB|IB|166|167|ASSESSMENT|GYNECOLOGY: Status post total abdominal hysterectomy, vaginal mucosa is soft and smooth with no palpable masses or nodules. ASSESSMENT: 56-year-old female with stage IB (T1b N0 M0) grade 3?? endometrioid adenocarcinoma, status post total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic and periaortic lymph node dissection _%#MMDD2004#%_.
IB|(stage) IB|IB|239|240|HISTORY OF PRESENT ILLNESS|She presented with post menopausal bleeding in _%#MM2005#%_. At that time endometrial biopsies were done which showed grade 1 endometrial adenocarcinoma. On _%#MMDD2005#%_, she underwent a TAH/BSO by Dr. _%#NAME#%_. Pathology showed stage IB grade 2 endometrial cancer. Lymph nodes were negative and peritoneal washings were negative. On _%#MMDD2006#%_, she had a Pap smear done at an outside location, which showed atypical glandular cells of undetermined origin favoring neoplasia.
IB|(stage) IB|IB|171|172|IMPRESSION|Right periaortic lymph nodes: No evidence of malignancy in 0 of 5 lymph nodes. IMPRESSION: The patient is an 89-year-old female with malignant mixed mullerian tumor, FIGO IB grade 3. PLAN: This patient was seen and examined by Dr. _%#NAME#%_ _%#NAME#%_.
IB|(stage) IB|IB|20|21|PROBLEM|PROBLEM: FIGO stage IB grade 1 endometrial cancer. Ms. _%#NAME#%_ was seen in the Department of Therapeutic Radiology on _%#MMDD2006#%_ by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ at the request of Dr. _%#NAME#%_ _%#NAME#%_.
IB|(stage) IB|IB|252|253|IMPRESSION|Internally there are no palpable masses or abnormalities. NEUROLOGIC: Cranial nerves II through XII grossly intact with no focal deficits. EXTREMITIES: No cyanosis, clubbing, or edema. IMPRESSION: Ms. _%#NAME#%_ is a 77-year-old female with FIGO stage IB grade 1out to 3 endometrioid adenocarcinoma, status post laparoscopic total hysterectomy and bilateral salpingo-oophorectomy on _%#MM2006#%_. PLAN: We discussed treatment options, which include undergoing another surgery to perform a lymph node dissection.
IB|(stage) IB|IB|304|305|REASON FOR CONSULTATION|REASON FOR CONSULTATION: Assist with management of diabetes. _%#NAME#%_ _%#NAME#%_ is a 66-year-old woman with an acute afebrile illness of roughly 48 hours duration with fevers to 103.8 degrees and confusion. She was diagnosed with stage IV, poorly differentiated endometrial carcinoma as well as stage IB clear cell carcinoma of the ovary who underwent extensive GYN surgery approximately five weeks ago. PAST MEDICAL HISTORY: As above. Also, hypertension, diabetes, ovarian cancer and endometrial cancer.
IB|(stage) IB|IB.|111|113|PLAN|Patient seen and examined by me and resident. Agree with resident's note. Dx: Endometrial cancer, grade 3 FIGO IB. HPI: S/P TAH/BSO. Exam: No adenopathy, scar well healed. Recommend: Radiation options discussed at length.
IB|(stage) IB|IB,|207|209|ASSESSMENT AND PLAN|Pelvic exam: No cervix noted on speculum exam. No significant changes at apex of the vagina. No thickening or mass at apex of vagina. ASSESSMENT AND PLAN: This is an 84-year-old female with history of stage IB, grade 1 endometrial cancer status post total abdominal hysterectomy, bilateral salpingo-oophorectomy, now with vaginal-cuff recurrence, biopsy proven one year following surgery.
IB|(stage) IB|IB|182|183|HISTORY OF PRESENT ILLNESS|REASON FOR CONSULTATION: Consideration for gamma knife radiosurgery. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 69-year-old male with past medical history significant for stage IB nonsmall cell lung carcinoma diagnosed in 2005 and treated with surgical resection followed by a single cycle of adjuvant carbo/Taxol.
IB|(stage) IB|IB|195|196|ASSESSMENT|Finger-nose-finger without difficulty. Gait was not tested, as patient is unsteady on his feet from diabetic peripheral neuropathy. ASSESSMENT: This is a 69-year-old male with a history of stage IB nonsmall cell lung cancer, treated in 2005 with lobectomy followed by a single cycle of carbo/Taxol. The patient now presents with left hand spasms with a magnetic resonance imaging on _%#MMDD2007#%_ showing a left-sided central medial inferior brain lesion.
IB|(stage) IB|IB|272|273|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is an 89-year-old female who was originally diagnosed with endometrial cancer in _%#MM#%_, 2001. She underwent a total abdominal hysterectomy, bilateral salpingo- oophorectomy on _%#MMDD2001#%_. Pathology revealed grade 2, stage IB endometrial adenocarcinoma. The tumor invaded .3 cm out of .8 cm total thickness. There was no lymph-vascular involvement, and no cervix or lower uterine segment involvement.
IB|(stage) IB|IB|101|102|REASON FOR CONSULTATION|REASON FOR CONSULTATION: _%#NAME#%_ _%#NAME#%_ is a 72-year-old male with a recently resected, stage IB non-small-cell lung carcinoma who is referred for further management and recommendations regarding his recurrent and progressive deep venous thromboses (DVT) despite ongoing anticoagulation. The patient underwent a right upper lobe resection for a stage IB non- small-cell lung carcinoma in _%#MM#%_ 2002.
IB|(stage) IB|IB|358|359|REASON FOR CONSULTATION|REASON FOR CONSULTATION: _%#NAME#%_ _%#NAME#%_ is a 72-year-old male with a recently resected, stage IB non-small-cell lung carcinoma who is referred for further management and recommendations regarding his recurrent and progressive deep venous thromboses (DVT) despite ongoing anticoagulation. The patient underwent a right upper lobe resection for a stage IB non- small-cell lung carcinoma in _%#NAME#%_ 2002. His preoperative evaluation revealed no definite evidence for metastatic disease, but he had an equivocal PET scan and bone scan done with a small indeterminate nodule in the left lung.
IB|(stage) IB|IB|15|16|PROBLEM|PROBLEM: Stage IB FIGO grade 3 endometrial cancer. HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ is a very pleasant 59- year-old postmenopausal female who presents to us for consideration of adjuvant radiation for her FIGO stage IB, grade 3 adenocarcinoma of the endometrium.
IB|(stage) IB|IB,|148|150|HISTORY OF PRESENT ILLNESS|Mrs. _%#NAME#%_ is a very pleasant 59- year-old postmenopausal female who presents to us for consideration of adjuvant radiation for her FIGO stage IB, grade 3 adenocarcinoma of the endometrium. She is 10 years postmenopausal. Approximately one year ago, she had an episode of postmenopausal bleeding which resolved spontaneously.
IB|(stage) IB|IB,|160|162|IMPRESSION|The patient recently had a pulmonary function test, chest x-ray, and cardiac stress test which results are in electronic medical record. IMPRESSION: FIGO stage IB, grade 3, endometrial adenocarcinoma status post definitive surgery. PLAN: Dr. _%#NAME#%_ and I discussed the risks, benefits, side effects, and alternatives of radiation therapy along with the goals of both external beam radiation therapy and/or intracavitary brachytherapy with Mrs. _%#NAME#%_ and her husband.
IB|(stage) IB|IB,|128|130|CC|_____Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: FIGO IB, grade III adenocarcinoma. HPI: Status post hysterectomy. All nodes negative; cytology negative. Exam: Scar well healed. No adenopathy.
IB|(stage) IB|IB|162|163|HISTORY OF PRESENT ILLNESS|Further workup show that the only area of disease was in the mediastinum. The patient had symptoms of chest tightness and some shortness of breath. His stage was IB small cell lymphoma. The patient then underwent 6 months of chemotherapy of cyclophosphamide, Vincristine and prednisone under the care of Dr. _%#NAME#%_.
IB|(stage) IB|IB|15|16|PROBLEM|PROBLEM: Stage IB grade 2 endometrial carcinoma with incomplete staging. Ms. _%#NAME#%_ was seen in the hospital by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2002 for consultation at the request of Dr. _%#NAME#%_ _%#NAME#%_ for consideration of postoperative radiation therapy.
IB|(stage) IB|IB,|187|189|HISTORY OF PRESENT ILLNESS|The omentum was negative. There was some fibroadipose tissue taken from the left pelvic region which was negative and peritoneal washings showed negative cytology. Therefore, stages FIGO IB, grade 2 with incomplete staging due to lack of lymph node dissection. Her postoperative course has been complicated by atrial fibrillation with rapid response which required cardiac monitor and esmolol drip until today (_%#MMDD2002#%_), when this was discontinued.
IB|(stage) IB|IB|139|140|ASSESSMENT AND PLAN|No inguinal adenopathy noted, no peripheral edema. ASSESSMENT AND PLAN: Ms. _%#NAME#%_ is a 66-year-old female with completely-staged FIGO IB grade 2 adenocarcinoma of the endometrium, status post total abdominal hysterectomy, bilateral salpingo-oophorectomy and partial omentectomy. According to .......................data, her risk for pelvic lymph node involvement would be about 5% and paraaortic involvement of about 4%.
IB|(stage) IB|IB|144|145|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Cervix cancer, FIGO IB HPI: Getting EBT at _%#CITY#%_. Exam: Cervix 4 cm; no pararectal disease noted but patient refused rectal exam.
IB|(stage) IB|IB.|138|140|ASSESSMENT|He also has larger plaques on his legs. LABORATORY STUDIES: We reviewed all his old records. ASSESSMENT: Cutaneous T-cell lymphoma, stage IB. PLAN: We recommend total skin irradiation. We explained the risks and side effects of radiation to Mr. _%#NAME#%_ and his family.
IB|(stage) IB|IB.|177|179|IMPRESSION|Additionally, CT scan of the chest was negative, with no nodules, although I do not have these to review. IMPRESSION: Malignant mixed mesodermal tumor of the uterus. FIGO stage IB. RECOMMENDATIONS: Mrs. _%#NAME#%_ does have a high-grade MMMT of the uterus and is at significant risk for recurrence.
IB|(stage) IB|IB,|385|387|ALLERGIES|Bimanual exam is performed. No masses palpable at the vagina cuff. Vaginal cuff is intact. Rectovaginal confirms this. ASSESSMENT AND PLAN: The patient is a 63-year-old female status post exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, lymph node dissection, and omentectomy on _%#MM#%_ _%#DD#%_, 2005, for mixed malignant mesodermal tumor stage IB, carcinosarcoma invading to a depth of 0.6 cm in 1.9 cm of myometrium. PLAN: Regarding her disease, the patient should repeat CT of the chest, abdomen, and pelvis in 3 months and return to clinic at that time.
IB|(stage) IB|IB|15|16|PROBLEM|PROBLEM: Stage IB adenosarcoma of the uterus. IDENTIFICATION: The patient is a 63-year-old female with a new diagnosis of a stage IB adenosarcoma of the uterus who was referred by Dr. _%#NAME#%_ _%#NAME#%_ to discuss adjuvant radiation treatment. She is seen today in consultation by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_.
IB|(stage) IB|IB|130|131|IDENTIFICATION|PROBLEM: Stage IB adenosarcoma of the uterus. IDENTIFICATION: The patient is a 63-year-old female with a new diagnosis of a stage IB adenosarcoma of the uterus who was referred by Dr. _%#NAME#%_ _%#NAME#%_ to discuss adjuvant radiation treatment. She is seen today in consultation by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_.
IB|(stage) IB|IB.|140|142|HISTORY OF PRESENT ILLNESS|The bilateral ovaries, fallopian tubes, cervix, pelvic washings, and all lymph nodes were negative. Based on this, she was given a stage of IB. Postoperatively, the patient's course was complicated by a wound separation involving only 1 cm of the total length of the incision.
IB|(stage) IB|IB|196|197|ASSESSMENT|There is minimal erythema and induration around the defect. The packing was not removed. A new dressing was placed. ASSESSMENT: The patient is a 63-year-old female with a new diagnosis of a stage IB adenosarcoma of the uterus. She is here for consultation to discuss radiation treatment. PLAN: We did discuss with the patient that we would recommend adjuvant radiation treatment to decrease the risk of recurrence given that the type of cancer she has is aggressive.
IB|(stage) IB|IB|144|145|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: 63 y.o. female with IB adenosarcoma. HPI: Status post TAH/BSO Exam: Scar with small wound separation.
IB|(stage) IB|IB|15|16|PROBLEM|PROBLEM: Stage IB malignant mixed mullerian tumor of the uterus. The patient was seen in the Radiation Oncology Clinic by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ at the request of Dr. _%#NAME#%_.
IB|(stage) IB|IB|209|210|HISTORY OF PRESENT ILLNESS|She was therefore staged as having FIGO IIb grade 2 ovarian cancer and FIGO IIb grade 1 endometrial cancer. She is referred now for consideration of adjuvant therapy. Dr. _%#NAME#%_ does not believe her stage IB ovarian cancer grade 2 requires any adjuvant chemotherapy and he is requesting my opinion regarding the necessity of postoperative radiotherapy.
IB|(stage) IB|IB|15|16|PROBLEM|PROBLEM: Stage IB (T1b N0 M0) endometrial adenocarcinoma. The patient was seen in Radiation Oncology Clinic by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_. The consultation was requested by Dr. _%#NAME#%_.
IB|(stage) IB|IB|268|269|ASSESSMENT|No hepatosplenomegaly palpable. EXTREMITIES: No clubbing, cyanosis or edema. NEUROLOGIC: Cranial nerves II through XII intact, strength is 5/5 in all four extremities, light touch is symmetric and intact in all 4 extremities. ASSESSMENT: 63-year-old female with stage IB (T1b N0 M0) endometrial adenocarcinoma, status post total abdominal hysterectomy and bilateral salpingo-oophorectomy with pelvic and para-aortic lymph node sampling _%#MMDD2004#%_.
IB|(stage) IB|IB.|162|164|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Endometrial adenocarcinoma FIGO stage IB. HPI: Status post total abdominal hysterectomy on _%#MMDD2004#%_ with bilateral salpingo-oophorectomy, pelvic and para-aortic node sampling.
IB|(stage) IB|IB|140|141|HPI|Exam: Her scar is healing well. Abdomen is soft and non-tender. Pelvic examination was not performed today. Assessment and Plan: FIGO stage IB adenocarcinoma of the endometrium grade II. Radiotherapeutic options were discussed with Mrs. _%#NAME#%_. She is at intermediate risk because of the mid-myometrial invasion of the lower uterine segment for a vaginal cuff recurrence and at a minimum I would recommend a vaginal brachytherapy application.
IB|(stage) IB|IB|15|16|PROBLEM|PROBLEM: Stage IB grade 3 endometrioid adenocarcinoma of the endometrium. The patient is status post total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic and periaortic lymph node dissection, and pelvic washings.
IB|(stage) IB|IB|297|298|HISTORY OF PRESENT ILLNESS|The patient was referred to Dr. _%#NAME#%_, and on _%#MMDD2005#%_ had a total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic and periaortic lymph node dissection, resection of prior abdominal scar, and left ureterolysis, with attainment of pelvic washings. Pathology showed stage IB (0.1 mm invasion) grade 3 endometrial adenocarcinoma, with no lymph-vascular invasion and no lower uterine segment involvement. The patient is referred to the Radiation Oncology Clinic for possible adjuvant radiation therapy.
IB|(stage) IB|IB|200|201|ASSESSMENT|Left pelvic lymph nodes 0 of 7 positive. Left periaortic lymph nodes 0 of 4 positive. Omentum resection showed no evidence of malignancy. ASSESSMENT: Ms. _%#NAME#%_ is a 74-year-old female with stage IB grade 3/3 endometrial adenocarcinoma, status post total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic and periaortic lymph node dissection, and pelvic washings, with negative resections.
IB|(stage) IB|IB|185|186|HISTORY OF PRESENT ILLNESS|Her interim medical records, imaging studies, and histopathology have been reviewed. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 56-year-old Caucasian female who was diagnosed with IB grade 1 endometrial cancer in _%#MM2003#%_. At that time she underwent ex-lap for an ovarian cyst as well fibroids. Resultant surgical excision including at TAH and BSO as well as lymph node dissection, revealed grade I adenocarcinoma of the endometrium.
IB|(stage) IB|IB|95|96|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old female. In 1997 she developed a stage IB grade 1 endometrial adenocarcinoma. She underwent a total abdominal hysterectomy, bilateral salpingo- oophorectomy, pelvic and periaortic lymphadenectomy by Dr. _%#NAME#%_.
IB|(stage) IB|IB.|209|211|HISTORY OF PRESENT ILLNESS|I discussed with resident and agree with note. KEY FINDINGS: CHIEF COMPLAINT: Metastatic endometrial carcinoma. HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ was diagnosed in 1997 with endometrial cancer, stage IB. Unfortunately, in 2000 her disease recurred in the neck, and she has undergone chemotherapy and neck dissection. More recently, she was found to have a cerebellar metastasis, at the time of a neck CT scan.
IB|(stage) IB|IB.|182|184|PAST MEDICAL HISTORY|This was complicated by actinomycosis of the jaw with replacement with bone grafting. 2. In _%#MM2003#%_, non-small cell CA of the lung resected, apparently a squamous cell CA stage IB. 3. A few months ago, increasing dyspnea, hemoptysis, finding of recurrent right hilar mass with compression of right main stem bronchus.
IB|(stage) IB|IB|15|16|PROBLEM|PROBLEM: Stage IB serous endometrial carcinoma status post resection for consideration of adjuvant radiation therapy. Ms. _%#NAME#%_ is seen today at the request of Dr. _%#NAME#%_ _%#NAME#%_ in the Department of Gynecologic Oncology.
IB|(stage) IB|IB|97|98|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 53-year-old female with a new diagnosis of stage IB serous carcinoma of the endometrium, status post resection. She experienced vaginal bleeding and has a Pap smear and pelvic exam which was reportedly normal in _%#MM2003#%_.
IB|(stage) IB|IB,|229|231|MEDICATIONS|NEUROLOGICAL: Cranial nerves II through XII intact. Strength 5/5 bilaterally in upper and lower extremities. Gait normal. ASSESSMENT AND PLAN: 53-year old female with new diagnosis of papillary serous endometrial carcinoma stage IB, status post resection and pelvic and paraaortic lymph node dissection and exploratory laparotomy. Adjuvant treatment options were discussed with the patient including whole abdominal radiation therapy alone, chemotherapy with pelvic radiation therapy, or chemotherapy alone.
IB|(stage) IB|IB|209|210|HISTORY OF PRESENT ILLNESS|We have reviewed all the pertinent medical records, including progress notes and pathology reports. HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ is a 62-year-old female recently diagnosed with a recurrent FIGO IB endometrial cancer. Her history dates back to early 1997, at which time she was diagnosed with early endometrial cancer. On _%#MMDD1997#%_, she underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy and revealed a grade I superficially-invasive endometrioid adenocarcinoma with squamous differentiation.
IB|(stage) IB|IB,|45|47|PROBLEM|PROBLEM: Adenocarcinoma of endometrium stage IB, grade 2. Ms. _%#NAME#%_ was seen in the Radiation Oncology Department by Drs. _%#NAME#%_ _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2003 for consultation at the request of Dr. _%#NAME#%_ _%#NAME#%_
IB|(stage) IB|IB,|163|165|ASSESSMENT AND PLAN|RECORDS REVIEW: We reviewed all his old records including her most recent pathology report. ASSESSMENT AND PLAN: Ms. _%#NAME#%_ is a 59-year-old female with stage IB, grade 2 adenocarcinoma of endometrium status post hysterectomy. She has intermediate risk status for pelvic recurrence. We have discussed many options with her including observation, high- dose rate brachytherapy alone versus external-beam radiation therapy to 5040 cGy.
IB|(stage) IB|IB|154|155|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Endometrial cancer. HPI: FIGO IB grade 2. Nodes negative. Exam: Abdomen soft, no adenopathy. Vaginal cuff healing well.
IB|(stage) IB|IB|15|16|PROBLEM|PROBLEM: Stage IB adenocarcinoma of the endometrium. HISTORY OF PRESENT ILLNESS: This is a very pleasant 68-year-old female with adenocarcinoma of the endometrium who presents for discussion of adjuvant therapy. Mrs. _%#NAME#%_ had a one-month history of postmenopausal bleeding, and she presented to her local physician who was unable to obtain an endometrial biopsy at that time.
IB|(stage) IB|IB,|201|203|ASSESSMENT AND PLAN|NEUROLOGIC: Cranial nerves II through XII are intact. PELVIC AND RECTAL EXAM: Deferred. DIAGNOSTICS: Per History of Present Illness. ASSESSMENT AND PLAN: The patient is a 68-year-old female with stage IB, grade 2 adenocarcinoma of the endometrium, currently hospitalized for infection, unknown cause. We discussed the goals, risks, benefits, side effects and alternatives of radiation therapy as an adjuvant treatment for a stage IB grade 2 endometrial adenocarcinoma.
IB|(stage) IB|IB|129|130|ASSESSMENT AND PLAN|We discussed the goals, risks, benefits, side effects and alternatives of radiation therapy as an adjuvant treatment for a stage IB grade 2 endometrial adenocarcinoma. In regards to her current infection, we will defer further evaluation to her primary team with Dr. _%#NAME#%_.
IB|(stage) IB|IB|129|130|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: FIGO IB endometrial cancer. HPI: Status post TAH/BSO/nodes. Exam: Scar healing well. Assessment and Plan: Recommend postop XRT to decrease the risk of vaginal cuff recurrence.
IB|(stage) IB|IB|63|64|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Cranial hemorrhage. 2. Recurrent stage IB endometrial adenocarcinoma. 3. Hypertension. 4. Hyperlipidemia. 5. Peptic ulcer disease. 6. History of a deep vein thrombosis in _%#MM#%_ 2007. 7. Multinodular thyroid goiter. 8. Peripheral neuropathy. 9. Anemia.
IB|(stage) IB|IB|241|242|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|2. IV fluids. 3. CT of the brain. 4. Factor VII and fresh frozen plasma transfusion. COMPLICATIONS: None. HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE: The patient is a 63-year-old female who is known to the Oncology Service to have recurrent IB endometrial adenocarcinoma which was diagnosed in 2005 and has currently been receiving weekly Taxol since _%#MM#%_ 2007. She presented to the emergency room with nausea, vomiting and visual changes, and was found to have a cerebellar hemorrhage, as well as right frontal lobe lesion that was thought to be brain metastasis from her endometrial adenocarcinoma.
IB|(stage) IB|IB|267|268|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a delightful 88-year-old woman in relatively good health who underwent a TAH/BSO and node dissection in 2001 by Dr. _%#NAME#%_ _%#NAME#%_(?) here at the University of Minnesota Medical Center, Fairview for a stage IB squamous cell carcinoma of the cervix. I do not have the histopathology from that surgery, but evidently she had no particular risk factors, was not offered postoperative radiation therapy, and did well until 2002 when ASCUS Pap smear developed, was worked up with colposcopy, and she was put on Premarin cream.
IB|(stage) IB|IB,|45|47|PROBLEM|PROBLEM: Carcinosarcoma of the uterus, stage IB, grade 3. Ms. _%#NAME#%_ was seen in the Radiation Oncology clinic by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2002 for consultation at the request of Dr. _%#NAME#%_ _%#NAME#%_ for consideration of radiation therapy, per Protocol GOG _%#PROTOCOL#%_, for her carcinosarcoma of the uterus.
IB|(stage) IB|IB,|135|137|ASSESSMENT AND PLAN|Normal knee reflexes, normal sensation in the lower extremities. ASSESSMENT AND PLAN: Mr. _%#NAME#%_ is a 53-year-old female with FIGO IB, grade 3 mixed mullerian, status post total abdominal hysterectomy, bilateral salpingo-oophorectomy. She has been randomized to the radiation arm of GOG 150, which involves whole- abdominal radiation at 150 cGy per day, to a total dose of 3000 cGy, followed by pelvic radiation, bringing the total pelvic dose to 4980 cGy in another eleven fractions.
IB|(stage) IB|IB|134|135|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: MMT Stage IB HPI: Doing well status post TAH/BSO. Exam: Scan well-healed. No mass or tenderness. Assessment and Plan: Eligible for GOG #150.
IB|(stage) IB|IB|15|16|PROBLEM|PROBLEM: Stage IB (T2 N0 M0) squamous cell carcinoma of the lung. The patient was seen in the Radiation Oncology Clinic for a consultation by Dr. _%#NAME#%_ _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_.
IB|(stage) IB|IB|125|126|ASSESSMENT|NEUROLOGIC: Cranial nerves II through XII grossly intact. Gait smooth and symmetric. ASSESSMENT: 47-year-old male with stage IB (T2 N0 M0) poorly differentiated squamous cell carcinoma of the right lung. He is status post right pneumectomy _%#MMDD2005#%_ with a 7 mm margin.
IB|(stage) IB|IB|130|131|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Stage IB (T2 N0 M0) poorly differentiated squamous cell carcinoma of the right lung. HPI: Presented in _%#MM2005#%_ with cough and hemoptysis. Status post right pneumonectomy _%#MMDD2005#%_ with 7 mm margin.
IB|(stage) IB|IB|14|15|PROBLEM|PROBLEM: FIGO IB endometrioid adenocarcinoma. The patient was seen in Radiation Oncology Clinic by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_. The consultation was requested by Dr. _%#NAME#%_.
IB|(stage) IB|IB,|156|158|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Endometrial adenocarcinoma FIGO IB, grade 2, status post TAH/BSO and nodes with negative margins, 0.5 cm/2.5 cm myometrial invasion. No lower uterine segment cervix or lymphvascular space involvement, 20 lymph nodes negative.
IB|(stage) IB|IB|142|143|CC|Exaam: Ms. _%#NAME#%_ _%#NAME#%_ abdominal scar is healing well. She has no inguinal or supraclavicular adenopathy. Assessment and Plan: FIGO IB grade 2 endometrioid adenocarcinoma. A discussion regarding the risks and benefits of adjuvant radiotherapy were discussed with Ms. _%#NAME#%_.
IB|(stage) IB|IB|118|119|ASSESSMENT|No other intra-abdominal or pelvic mass or adenopathy was seen. ASSESSMENT: 33-year-old female with preliminary stage IB squamous cell carcinoma of the cervix. She presented with heavy vaginal bleeding and has received 4+ units of packed red blood cells.
IB|(stage) IB|IB|15|16|PROBLEM|PROBLEM: Stage IB (T2A N0 M0) gastric cancer. Mr. _%#NAME#%_ was seen in the Department of Therapeutic Radiology on _%#MMDD2007#%_ by Dr. _%#NAME#%_ and Dr. _%#NAME#%_ at the request of Dr. _%#NAME#%_ for possibility of postop radiation for gastric cancer.
IB|(stage) IB|IB|135|136|ASSESSMENT AND PLAN|Pathologic stage of T2A N0 M0. Preop imaging was reviewed. ASSESSMENT AND PLAN: Mr. _%#NAME#%_ is a 56-year-old gentleman with a stage IB T2A N0 M0 gastric carcinoma, status post gastrectomy, lymphadenectomy, and splenectomy. A significant amount of time was spent in talking with Mr. _%#NAME#%_ about the possibility of adjuvant radiation.
IB|(stage) IB|IB|222|223|ASSESSMENT|HISTORY OF RADIATION: None. HISTORY OF CHEMOTHERAPY: None. KPS SCORE: Approximately 90. ASSESSMENT: Ms. _%#NAME#%_ is a 68-year-old Caucasian female who is postmenopausal. She has been diagnosed with pathologically staged IB endometrial adenocarcinoma, grade 3 with lymphovascular space invasion. All pelvic lymph nodes were negative. She has minimal medical comorbidities and her performance status is excellent.
IB|(stage) IB|IB|147|148|HISTORY OF PRESENT ILLNESS|She then underwent a TAH/BSO on _%#MMDD2004#%_. Intraoperatively, the patient was found to have an exophytic lesion. She was thought to have stage IB disease and lymph node dissection was not performed. The final pathology came back as endometrioid adenocarcinoma grade 1 with myometrial wall invasion limited to the superficial 10%.
IB|(stage) IB|IB|130|131|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Stage IB diffuse large cell lymphoma. HPI: This is a 52-year-old female patient who was diagnosed in _%#MM2005#%_ to have extensive non-Hodgkin's lymphoma involving the left face involving the maxillary ramus and surrounding soft tissue.
IB|(stage) IB|IB|257|258|ASSESSMENT AND PLAN|LABORATORY DATA: Blood tests-CBC: Hemoglobin 15.6, white count 9200, and platelet count 245,000 with a normal differential for white count. Liver function tests within normal limits. ASSESSMENT AND PLAN: Hodgkin's disease, mixed cellularity, clinical stage IB to IIB if prevascular lymph node is of concern. The patient is scheduled to undergo chemotherapy per _%#NAME#%_ _%#NAME#%_, MD.
IB|(stage) IB|IB|15|16|PROBLEM|PROBLEM: Stage IB diffuse large B cell non-Hodgkin's lymphoma. Ms. _%#NAME#%_ was seen for initial consultation in the Department of Therapeutic Radiology on _%#MMDD2007#%_ by Dr. _%#NAME#%_ and Dr. _%#NAME#%_ at the request of Dr. _%#NAME#%_.
IB|(stage) IB|IB|156|157|ASSESSMENT AND PLAN|No hepatosplenomegaly was appreciated. IMAGING: See HPI for pertinent CT PET scan. ASSESSMENT AND PLAN: Mrs. _%#NAME#%_ is a 45-year-old woman with a stage IB diffuse large B cell non-Hodgkin's lymphoma status post 7 cycles of R-CHOP. Dr. _%#NAME#%_ personally led a discussion with the patient about the benefits and risks of radiation therapy for her disease.
IB|(stage) IB|IB|96|97|IMPRESSION|There is no inguinal adenopathy. She has no cyanosis, clubbing or edema. IMPRESSION: FIGO stage IB grade 3 adenocarcinoma of the uterus. RECOMMEDATIONS: Various adjuvant radiotherapeutic options were discussed with Ms. _%#NAME#%_ in detail.
IB|(stage) IB|IB|14|15|PROBLEM|PROBLEM: FIGO IB grade 3 endometrial adenocarcinoma, status post total abdominal hysterectomy/bilateral salpingo-oophorectomy and external-beam radiation therapy. Mrs. _%#NAME#%_ was seen for initial consultation in the Department of Radiation Oncology on _%#MMDD2005#%_ by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ at the request of Dr. _%#NAME#%_.
IB|(stage) IB|IB|184|185|ASSESSMENT/PLAN|A medium dilator was attempted; however, was unable to be passed beyond the introitus without significant tenderness. ASSESSMENT/PLAN: Mrs. _%#NAME#%_ is a 63-year-old woman with FIGO IB grade 3 endometrioid adenocarcinoma, status post total abdominal hysterectomy/bilateral salpingo-oophorectomy and external- beam radiation therapy to the pelvis. We discussed given her lower uterine segment involvement as well as lymph/vascular space invasion that we would generally recommend a boost to the vaginal cuff, as this is most likely the area of recurrence.
IB|(stage) IB|IB,|180|182|HPI|______ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Endometrial CA. HPI: Status post TAH, BSO, nodes. FIGO IB, grade 3. Status post 4500 cGy to the pelvis. Exam: Pelvic exam - slightly narrowed introitus. Cuff well healed.
IB|(stage) IB|IB|14|15|PROBLEM|PROBLEM: FIGO IB grade 3 endometrial endometrioid adenocarcinoma status post TAH who presents for the possibility of radiation therapy. The patient was seen and examined by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_.
IB|(stage) IB|IB|187|188|IMPRESSION|EXTREMITIES: Without clubbing, cyanosis or edema. The patient does have a midline abdominal scar which is well- healed. IMPRESSION: Ms. _%#NAME#%_ is an 81-year-old female who has a FIGO IB grade 3 endometrial endometrioid adenocarcinoma status post total abdominal hysterectomy on _%#MMDD2004#%_ who presents for the possibility of radiation therapy.
IB|(stage) IB|IB|124|125|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: IB adenocarcinoma endometrium, grade 3. HPI: Status post TAH/BSO-grade 3, deep invasion (7/17) with lower uterine segment involvement.
IB|(stage) IB|IB|151|152|IMPRESSION|The edges were clean and dry. She has no inguinal or axillary adenopathy. PELVIC EXAM: Not performed as she is recently postop. IMPRESSION: FIGO stage IB adenocarcinoma of the endometrium, grade 2 in the lower uterine segment; and an occult FIGO stage IB1 squamous cell cancer of the cervix, status post abdominal hysterectomy.
IB|(stage) IB|IB.|192|194|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Endometrioid adenocarcinoma of with clear cell features, FIGO stage IB. HPI: Ms. _%#NAME#%_ underwent a TAH/BSO omental biopsy and bilateral and pelvic para-aortic lymph node dissection on _%#MMDD2004#%_.
IB|(stage) IB|IB|116|117|ASSESSMENT|There is no adenopathy palpable. Her scar is healing well. A pelvic examination was not attempted. ASSESSMENT: FIGO IB endometrioid adenocarcinoma. RECOMMENDATIONS: Because of the large size of the tumor, depth of invasion, and the fact that the tumor was removed in piecemeal I am recommending postoperative adjuvant pelvic radiotherapy.
IB|(stage) IB|IB|129|130|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: FIGO IB cervix cancer. HPI: Post menopausal bleeding. Exam: Lungs clear; no SC nodes. Pelvic exam deferred due to previous EUA by Dr. _%#NAME#%_.
IB|(stage) IB|IB|188|189|ASSESSMENT/PLAN|In summary, Ms. _%#NAME#%_ is a 44-year-old female with a history of liposarcoma of the right buttock treated with surgery and radiation in 1991, now with a diagnosis of presumptive stage IB endometrial cancer, who presents for evaluation for radiation therapy. After evaluating the patient and relevant studies, while she is likely to be a true stage IB, the staging to this point is incomplete.
IB|(stage) IB|IB,|352|354|ASSESSMENT/PLAN|In summary, Ms. _%#NAME#%_ is a 44-year-old female with a history of liposarcoma of the right buttock treated with surgery and radiation in 1991, now with a diagnosis of presumptive stage IB endometrial cancer, who presents for evaluation for radiation therapy. After evaluating the patient and relevant studies, while she is likely to be a true stage IB, the staging to this point is incomplete. The optimal therapy would be very different were she truly stage IB versus a possible stage III with positive peritoneal washings or significant lymphadenopathy.
IB|(stage) IB|IB|200|201|ASSESSMENT/PLAN|After evaluating the patient and relevant studies, while she is likely to be a true stage IB, the staging to this point is incomplete. The optimal therapy would be very different were she truly stage IB versus a possible stage III with positive peritoneal washings or significant lymphadenopathy. Dr. _%#NAME#%_ had an extensive discussion with the patient regarding management options, and our recommendation is that the patient undergo a lymph node dissection and examination of peritoneal washings to formally complete the staging evaluation.
IB|(stage) IB|IB|163|164|ASSESSMENT|ABDOMEN: Soft, nontender, nondistended, bowel sounds positive. Abdominal incision with some erythema, but without drainage. NEUROLOGIC: Nonfocal. ASSESSMENT: FIGO IB grade 2 endometrial cancer, status post surgery. PLAN: The option of proceeding with adjuvant radiation treatment was discussed with the patient.
IB|(stage) IB|IB|81|82|PAST MEDICAL HISTORY|All other systems were reviewed and are negative. PAST MEDICAL HISTORY: 1. Stage IB squamous cell carcinoma of the cervix treated in 1979 with staging lymph node dissection followed by radiation therapy. She received 3325 cGy to the pelvis, as well as two low-dose rate brachytherapy implants.
IB|(stage) IB|IB.|125|127|HPI|In addition, there was no evidence of malignancy in 11 lymph nodes removed. The patient was thus felt to be a surgical stage IB. Following his surgery he did well. He did, however, in early _%#MM#%_ have a gastrointestinal bleed which was worked up and he had intestinal metaplasia.
IB|(stage) IB|IB|140|141||A TLC consultation is requested for this 41-year-old woman by Dr _%#NAME#%_. She was readmitted here on _%#MMDD2004#%_ with recurrent Stage IB of cervical adenocarcinoma. HISTORY OF PRESENT ILLNESS: She was first seen and evaluated and diagnosed with cervical carcinoma made in _%#MM2003#%_.
IB|(stage) IB|IB.|211|213|HISTORY OF PRESENT ILLNESS|The patient saw Dr. _%#NAME#%_ _%#NAME#%_ who on pelvic examination noted a 5 cm cervical mass. This mass was biopsied and it demonstrated grade 3 squamous cell carcinoma. The patient was initial clinical stage IB. The patient sought alternative therapies. The patient is a Jehovah Witness. On Friday of last week, the patient "hemorrhaged". She believes it was approximately 3-4 cups of blood. On Saturday, there were approximately 2 more cups of blood from her vagina.
IB|(stage) IB|IB|117|118|HPI|My key findings: CC: IIIB squamous cell cancer of the cervix. HPI: Mrs. _%#NAME#%_ presented in _%#MM#%_ with a FIGO IB cervical cancer. She sought alternative therapies at that time and now came in with hemorrhage. A CAT scan demonstrated a large pelvic mass and hydronephrosis.
IB|(stage) IB|IB|171|172|IMPRESSION|There is no hepatosplenomegaly. The patient has positive bowel sounds. EXTREMITIES: Without clubbing, cyanosis or edema. IMPRESSION: Mrs. _%#NAME#%_ is a 78-year-old with IB grade 3, mixed mullerian tumor who presents for the possibility of radiation therapy in consideration of GOG _%#PROTOCOL#%_ protocol. PLAN: The risks, benefits, and alternatives to lower pole abdominal and pelvic only radiation were discussed with the patient.
IB|(stage) IB|IB|15|16|PROBLEM|PROBLEM: Stage IB cervical cancer. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a pleasant 28-year- old female who is approximately 1-1/2 months status post radical hysterectomy for a stage IB1 cervical cancer.
IB|(stage) IB|IB|30|31|PREOPERATIVE DIAGNOSIS|PREOPERATIVE DIAGNOSIS: Stage IB squamous cell carcinoma of the cervix with positive pelvic lymph nodes. POSTOPERATIVE DIAGNOSIS: Stage IB2 squamous cell carcinoma of the cervix with positive pelvic lymph nodes.
IB|(stage) IB|IB|135|136|IMPRESSION|The vaginal cuff is well healed. There is only minimal erythema and the mucosa is moist and pink. IMPRESSION: Endometrial cancer stage IB in a 63-year-old female status post hysterectomy. PLAN: I had a detailed and thorough conversation with the patient and her daughter regarding the pathologic findings.
IB|(stage) IB|IB|14|15|PROBLEM|PROBLEM: FIGO IB grade 2 endometrioid endometrial adenocarcinoma who presents for the possibility of postoperative radiation therapy. The patient was seen and examined by Dr. _%#NAME#%_ and she agrees with the above.
IB|(stage) IB|IB|171|172|IMPRESSION|There was no hepatosplenomegaly. The patient has positive bowel sounds. EXTREMITIES: Without clubbing, cyanosis or edema. IMPRESSION: 46-year-old female who has a minimal IB grade 2 endometrial endometrioid adenocarcinoma who presents for the possibility of radiation therapy. PLAN: We discussed with the patient the recent results of GOG 99.
IB|(stage) IB|IB|20|21|PROBLEM|PROBLEM: FIGO Stage IB grade 1 versus grade 2 endometrioid adenocarcinoma status post THBSO lymph node dissection. Patient is referred for discussion of adjuvant radiation therapy.
IB|(stage) IB|IB|131|132|HISTORY OF PRESENT ILLNESS|She had not had a pap smear for approximately 7-8 years. She presented to her primary physicians, who ultimately diagnosed a Stage IB squamous cell carcinoma of the cervix. This was accomplished at United. She did have a pap smear that showed high-grade squamous cell intraepithelial lesion.
IB|(stage) IB|IB|213|214|IMPRESSION|Affect is somewhat emotional, understandably so. Patient denies pelvic exam. Patient denies abdominal exam. Otherwise, no acute respiratory distress. IMPRESSION: This is a 31-year-old female with a clinical stage IB squamous cell carcinoma of the cervix status post radical hysterectomy with positive lymph node. PLAN: I had a detailed and thorough conversation with the patient and her husband regarding the pathologic findings.
IB|(stage) IB|IB,|177|179|PAST MEDICAL HISTORY|An echocardiogram was performed that shows a normal RV and LV function with borderline left atrial enlargement. PAST MEDICAL HISTORY: 1. History of endometrial carcinoma, stage IB, grade 1. Status post abdominal hysterectomy as described above at Mayo Clinic on _%#MMDD#%_. 2. History of paroxysmal atrial fibrillation, no cardioversion. 3. Polymyalgia rheumatica.
IB|(stage) IB|IB,|121|123|HISTORY  OF PRESENT ILLNESS|These records were reviewed. The patient was seen and the situation was discussed. The patient was found to have a stage IB, grade 2 endometrial adenocarcinoma. She had a comprehensive surgical staging, which means that her washings and her lymph nodes were all negative.
IB|(stage) IB|IB|156|157|PAST MEDICAL HISTORY|The patient received her second cycle of chemotherapy today and presents for evaluation for external beam radiation therapy. PAST MEDICAL HISTORY: 1. Stage IB grade III carcinosarcoma of the uterus. 2. Depression. 3. Hypertension. 4. Gravida 4 para 4. 5. History of laparoscopic bilateral tubal ligation. 6. Status post tonsillectomy and adenoidectomy.
IB|(stage) IB|IB|118|119|ASSESSMENT AND PLAN|There are no gross deficits in sensation or gait. ASSESSMENT AND PLAN: Ms. _%#NAME#%_ has been diagnosed with a stage IB grade III carcinosarcoma of the uterus and is currently receiving her second of 3 cycles of chemotherapy prior to radiation. We agree that she would be an appropriate candidate for radiation therapy.
IB|(stage) IB|IB|244|245|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is an 88-year-old man who was self-referred to Radiation Oncology for a second opinion regarding his recurrent non-small cell lung cancer. Mr. _%#NAME#%_ was originally diagnosed with Stage IB (T2N0M0) bronchoalveolar carcinoma of the right lung in _%#MM2005#%_. Due to significant coronary artery disease, surgery was delayed until _%#MM2005#%_ when he underwent a right thoracotomy with mediastinal lymph node sampling and resection of tumor.
IB|(stage) IB|IB|67|68|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Intractable pain. 2. Vaginal recurrence of IB squamous-cell carcinoma of the cervix. 3. Recurrence of IB squamous-cell carcinoma of the cervix to the sacrum. DISCHARGE DIAGNOSES: 1. Intractable pain. 2. Vaginal recurrence of IB squamous-cell carcinoma of the cervix.
IB|(stage) IB|IB|126|127|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Intractable pain. 2. Vaginal recurrence of IB squamous-cell carcinoma of the cervix. 3. Recurrence of IB squamous-cell carcinoma of the cervix to the sacrum. DISCHARGE DIAGNOSES: 1. Intractable pain. 2. Vaginal recurrence of IB squamous-cell carcinoma of the cervix.
IB|(stage) IB|IB|249|250|DISCHARGE DIAGNOSES|ADMISSION DIAGNOSES: 1. Intractable pain. 2. Vaginal recurrence of IB squamous-cell carcinoma of the cervix. 3. Recurrence of IB squamous-cell carcinoma of the cervix to the sacrum. DISCHARGE DIAGNOSES: 1. Intractable pain. 2. Vaginal recurrence of IB squamous-cell carcinoma of the cervix.
IB|(stage) IB|IB|137|138|HISTORY OF PRESENT ILLNESS|5. Wound care by Enterostomal Therapy. HISTORY OF PRESENT ILLNESS: This is a 59-year-old woman with vaginal and sacral recurrence of her IB squamous-cell carcinoma of the cervix, admitted for pain management. The patient was first diagnosed in 1985, after total abdominal hysterectomy; bilateral salpingo- oophorectomy; and partial vaginectomy, with 10 mm of invasion.
IB|(stage) IB|IB|164|165|HOSPITAL COURSE|The colostomy site was intact. EXTREMITIES: No signs of clubbing, cyanosis, or edema. GYNECOLOGIC: Deferred. HOSPITAL COURSE: This 59-year-old woman with recurrent IB squamous-cell carcinoma of the cervix to the right sacrum and vagina was admitted to 7C with complaints of increased pain.
IB|(stage) IB|IB|266|267|PROBLEM #1|She was admitted for pain control, a consultation with the Pain Service, and a consultation with Dr. _%#NAME#%_ for recommendations for further palliative radiation treatment. The patient's hospital course will be discussed by systems. PROBLEM #1: Disease-recurrent IB squamous-cell carcinoma of the cervix. The patient has been in WCCZ 28. She now has metastasis to the sacral area. On hospital day #3, the patient was seen by Radiation Oncology, with recommendations to attend a course of palliative radiation therapy for reduction of pain.
IB|(stage) IB|IB,|161|163|POSTOPERATIVE DIAGNOSES|3. Depression. 4. Hypertension. 5. Sleep apnea. 6. Obesity. POSTOPERATIVE DIAGNOSES: 1. Grade 1 endometrioid adenocarcinoma of the endometrium, at least a stage IB, final pathology is pending. 2. Schatzki ring. 3. Depression. 4. Hypertension. 5. Sleep apnea. 6. Obesity. PROCEDURES: 1. Exploratory laparotomy, bilateral salpingo-oophorectomy, pelvic and periaortic lymph node dissection, lysis of adhesion and peritoneal washings.
IB|(stage) IB|IB|253|254|HOSPITAL COURSE|There was no evidence of angiolymphatic inflammation. In addition, there was acute and chronic inflammation consistent with a tubo-ovarian abscess of the right ovary and fallopian tube. Pelvic washings were negative. This pathology is consistent with a IB endometrial cancer, Grade I. In regards to her cancer, this is a low risk form of endometrial cancer and as will be discussed with her postoperative consultation, no further treatment is required.
IB|(stage) IB|IB|318|319|HOSPITAL COURSE|No specific etiology was ever found for this slightly altered behavior or mentation, but because of its complete resolution, and normalizing laboratory studies, it was still felt that the patient was stable for discharge. Prior to the patient's discharge, her final pathology did return and this was consistent with a IB endometrial cancer that was felt to be a grade I on final pathology. There was no involvement of her lymph nodes or any other pelvic organs, and this was communicated to the patient.
IB|(stage) IB|IB|120|121|DISCHARGE DIAGNOSES|6. Hypercholesterolemia. 7. Chronic low back pain and back neuropathy. 8. Morbid obesity. DISCHARGE DIAGNOSES: 1. Stage IB grade 2/3 endometrioid adenocarcinoma of the uterus. 2. Deconditioned. 3. Wound infection, wound VAC placed. 4. Depression and anxiety. 5. Posttraumatic stress disorder. 6. Type 2 diabetes. 7. Insomnia.
IB|(stage) IB|IB|132|133|DISCHARGE DIAGNOSES|2. Viral-induced macular rash. 3. Hypertension. 4. Hypertriglyceridemia. 5. Type 2 diabetes mellitus. DISCHARGE DIAGNOSES: 1. Stage IB papillary serous adenocarcinoma of the endometrium. 2. Viral-induced macular rash. 3. Hypertension. 4. Hypertriglyceridemia. 5. Type 2 diabetes mellitus.
IB|(stage) IB|IB.|176|178|HOSPITAL COURSE|Additionally, no involvement of the lower uterine segment or cervix was noted. All lymph nodes and omentum were without evidence of malignancy, thus making the patient a stage IB. The patient will follow up with Dr. _%#NAME#%_ in approximately 2-4 weeks to further discuss the results of her pathology and to plan for future treatment.
IB|(stage) IB|IB,|162|164|DISCHARGE DIAGNOSES|ADMISSION DIAGNOSES: 1. Adenosquamous carcinoma of the cervix, stage IBI. 2. Hypothyroidism. DISCHARGE DIAGNOSES: 1. Adenosquamous carcinoma of the cervix, stage IB, status post examination under anesthesia. 2. Hypothyroidism. 3. Anemia secondary to blood loss. OPERATIONS/PROCEDURES PERFORMED: 1. Examination under anesthesia. 2. Cystoscopy. 3. Proctoscopy. 4. Exploratory laparotomy.
IB|(stage) IB|IB|240|241|COMPLICATIONS|During prior examinations, the cervix did appear grossly normal and at the time of the cone biopsy, the cervix was noted to appear grossly normal. On _%#MM#%_ _%#DD#%_, 2004, a discussion was undertaken to the possible management for stage IB cervical carcinoma and the patient gave informed consent at this time to undergo a staging procedure with retroperitoneal lymph node dissection followed by radical hysterectomy and bilateral salpingo oophorectomy.
IB|(stage) IB|IB,|185|187|PAST MEDICAL HISTORY|She has again no recollection of the hospitalization prior to her discharge to the nursing home on _%#MMDD2006#%_. PAST MEDICAL HISTORY: 1. Squamous cell carcinoma of the cervix, stage IB, grade 2 when diagnosed in 1992. The patient had a hysterectomy and partial colectomy. She received Cisplatin, Vinblastine, and bleomycin for chemotherapy, along with radiation therapy.
IB|(stage) IB|IB|74|75|HOSPITAL COURSE|EXTREMITIES: Nontender and without edema. HOSPITAL COURSE: Disease. Stage IB endometrioid adenocarcinoma of the ovary. Final pathology is negative. The patient was taken to the operating room on _%#MMDD2007#%_ where she underwent an exploratory laparotomy, omentectomy, posterior pelvic and lymph node dissection and staging.
IB|(stage) IB|IB,|99|101|FINAL PATHOLOGY|6. History of lung cancer status post right thoracotomy. 7. Hypothyroidism. FINAL PATHOLOGY: Stage IB, grade 1 endometrial adenocarcinoma of the endometrium. OPERATIONS/PROCEDURES PERFORMED: On _%#MM#%_ _%#DD#%_, 2006, she underwent an exam under anesthesia, exploratory laparotomy, total abdominal hysterectomy bilateral salpingooophorectomy, bilateral pelvic lymph node dissections and washings.
IB|(stage) IB|IB,|179|181|DIAGNOSES ON ADMISSION|REFERRING PHYSICIAN: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD DIAGNOSES ON ADMISSION: 1. A 43-year-old with incompletely staged IIC, grade 2 ovarian cancer, with clear cell features, IB, grade 1 endometrial adenocarcinoma diagnosed on _%#MM#%_ _%#DD#%_, 2004. 2. History of hypertension. 3. Status post vaginal hysterectomy converted to abdominal hysterectomy with partial omentectomy, done on _%#NAME#%_ 2004.
IB|(stage) IB|IB|276|277|HISTORY OF PRESENT ILLNESS|A. Urine cultures. B. Chest x-ray done. COMPLICATIONS: Postoperative fever controlled on IV antibiotics. HISTORY OF PRESENT ILLNESS: The patient is a 43-year-old Caucasian female with incompletely staged IIC grade 2 ovarian carcinoma with clear cell features as well as stage IB grade 1 endometrial adenocarcinoma, status post vaginal hysterectomy converted to abdominal hysterectomy, with partial omentectomy done on _%#MM#%_ _%#DD#%_, 2004.
IB|(stage) IB|IB|268|269|HOSPITAL COURSE|3. No evidence for new soft tissue mass. The patient also had a DEXA scan, which showed normal bone density. HOSPITAL COURSE: 1. Disease: As mentioned before, the patient had an incompletely staged IIC grade 2 ovarian cancer with clear cell features, as well as stage IB grade 1 endometrial adenocarcinoma, diagnosed on _%#MM#%_ _%#DD#%_, 2004, during a vaginal hysterectomy converted to an abdominal hysterectomy.
IB|(stage) IB|IB|110|111|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Superficial wound separation with associated cellulitis, possible infection. 2. Stage IB grade II endometrial cancer. 3. Hypertension. 4. Anxiety. 5. Obesity. 6. History of splenectomy. 7. History of chronic sinus infections.
IB|(stage) IB|IB|212|213|DISCHARGE DIAGNOSES|4. Anxiety. 5. Obesity. 6. History of splenectomy. 7. History of chronic sinus infections. DISCHARGE DIAGNOSES: 1. Superficial wound separation with resolved cellulitis. Status post wound VAC placement. 2. Stage IB grade II endometrial cancer. 3. Hypertension. 4. Anxiety. 5. Obesity. 6. History of splenectomy. 7. History of chronic sinus infections.
IB|(stage) IB|IB|151|152|HISTORY OF PRESENT ILLNESS|CONSULTS: 1. ET consult for wound VAC placement. 2. Infectious disease consult. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 63-year-old with stage IB grade II endometrial carcinoma who is status post an exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy and lymph node dissection on _%#MMDD2007#%_.
IB|(stage) IB|IB|58|59|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Small-bowel obstruction. 2. Stage IB grade 1 endometrial cancer. 3. Postoperative day #24 status post exploratory laparotomy total abdominal hysterectomy and bilateral salpingo-oophorectomy and pelvic and periaortic lymph node dissection.
IB|(stage) IB|IB|289|290|DISCHARGE DIAGNOSES|3. Postoperative day #24 status post exploratory laparotomy total abdominal hysterectomy and bilateral salpingo-oophorectomy and pelvic and periaortic lymph node dissection. 4. Hypertension. 5. Mitral valve regurgitation. DISCHARGE DIAGNOSES: 1. Small-bowel obstruction resolved. 2. Stage IB grade 1 endometrial cancer. 3. Postoperative day #24 status post staging exploratory laparotomy total abdominal hysterectomy and bilateral salpingo-oophorectomy and pelvic and periaortic lymph node dissection.
IB|(stage) IB|IB|220|221|BRIEF HISTORY AND PHYSICAL AND REASONS FOR ADMISSION|4. Hypertension. 5. Mitral valve regurgitation. BRIEF HISTORY AND PHYSICAL AND REASONS FOR ADMISSION: The patient is a 61-year-old female, a patient of Dr. _%#NAME#%_ well known to be GYN oncology service, with stage of IB grade 1 endometrial carcinoma, who was admitted on postoperative day #12 on _%#MM#%_ _%#DD#%_, 2006, for left-sided abdominal pain. She had previously been diagnosed with stage IB grade 1 endometrial carcinoma at the end of _%#MM#%_ 2006, and is status post exploratory laparoscopy TAH-BSO lymph node dissection with no complications during the procedure or in the immediate postoperative course and was sent home as usual and had re-presented on _%#MM#%_ _%#DD#%_, 2006, with nausea, vomiting, and abdominal pain.
IB|(stage) IB|IB|181|182|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Postoperative day #18 status post radical hysterectomy with pelvic and periaortic lymph node dissection and repair of umbilical hernia. 2. Presumptive stage IB endometrioid cervical cancer, however, final pathology remains pending on re-review for a potential of endometrioid carcinoma of the uterus.
IB|(stage) IB|IB|181|182|DISCHARGE DIAGNOSES|ADMISSION DIAGNOSES: 1. Postoperative day #18 status post radical hysterectomy with pelvic and periaortic lymph node dissection and repair of umbilical hernia. 2. Presumptive stage IB endometrioid cervical cancer, however, final pathology remains pending on re-review for a potential of endometrioid carcinoma of the uterus.
IB|(stage) IB|IB|27|28|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Stage IB 2 adenocarcinoma of the cervix. DISCHARGE DIAGNOSES: 1. Stage IB 2 adenocarcinoma of the cervix.
IB|(stage) IB|IB|92|93|DISCHARGE DIAGNOSES|ADMISSION DIAGNOSIS: Stage IB 2 adenocarcinoma of the cervix. DISCHARGE DIAGNOSES: 1. Stage IB 2 adenocarcinoma of the cervix. 2. Status post exploratory laparotomy, bilateral salpingo-oophorectomy, bilateral pelvic, paraaortic lymph node dissection, and radical hysterectomy.
IB|(grade) IB|IB|268|269|HOSPITAL COURSE|HOSPITAL COURSE: 1. Cardiovascular: The current working diagnosis is that _%#NAME#%_ is suffering from acute humeral rejection of her heart transplant. Prior to this admission, on _%#MMDD2006#%_, she had a repeat endomyocardial biopsy, which showed inflammatory grade IB rating without evidence of acute re jection. A repeat endomyocardial biopsy on _%#MMDD2006#%_ essentially showed the same findings.
IB|intravenous:IV|IB|105|106|DISCHARGE MEDICATIONS|13. Morphine sulfate 1 to 2 mg IV q.1-2 hours p.r.n. pain. 14. Fentanyl 25 to 50 mg IV. 15. Zofran 48 mg IB q.4 hours p.r.n. nausea. 16. Diphenhydramine 25 mg (_______________) q.4 hours p.r.n. pruritus. OPERATIONS/PROCEDURES PERFORMED: 1. CT of the abdomen which revealed 2 ventral hernias responsible for the patient's small bowel obstruction.
IB|(stage) IB|IB|126|127|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient was originally admitted back in _%#MM#%_ to the University. He had a history of stage IB non-small cell lung cancer for the pneumonectomy he underwent in _%#MM#%_ of 2002. He had no other therapy following this. He had developed abdominal symptoms of nausea, vomiting, constipation, and abdominal discomfort which brought him into the hospital in _%#MM#%_.
IB|(stage) IB|IB|140|141|DISCHARGE DIAGNOSES|2. History of blood clots, status post filter placement _%#MMDD2001#%_ at United Hospital. 3. Morbid obesity. DISCHARGE DIAGNOSES: 1. Stage IB endometrioid adenocarcinoma of the endometrium. 2. Morbid obesity. PROCEDURES: 1. Total abdominal hysterectomy with bilateral salpingo-oophorectomy and bilateral pelvic and periaortic lymph node dissection.
IB|(stage) IB|IB|159|160|HOSPITAL COURSE|Prior to surgery preoperative hemoglobin 14.9. HOSPITAL COURSE: PROBLEM #1: Disease. Final pathology was available at the time of discharge which showed stage IB endometrial carcinoma, grade II. Estimated blood loss of 650 mL. The patient is to follow-up with Dr. _%#NAME#%_ in clinic in about one month to discuss additional treatment planning.
IB|(stage) IB|IB|89|90|DISCHARGE DIAGNOSES|3. Depression. 4. Hypercholesterolemia. 5. Osteoarthritis. DISCHARGE DIAGNOSES: 1. Stage IB endometrial carcinoma graded 3/3. 2. Hypertension. 3. Depression. 4. Hypercholesterolemia. 5. Osteoarthritis. 6. Esophagitis. 7. Gastroesophageal reflux disease. PROCEDURES: 1. Total abdominal hysterectomy.
IB|(stage) IB|IB|331|332|HOSPITAL COURSE|EXTREMITIES: Two plus with bilateral edema. HOSPITAL COURSE: PROBLEM #1: Disease: The patient was taken to the operating room where a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic periaortic lymph node dissection was performed. Pathology did return prior to the patient's discharge and revealed a stage IB endometrial carcinoma. The patient will follow up with Dr. _%#NAME#%_ and Dr. _%#NAME#%_ in 2 to 3 weeks to discuss further treatment.
IB|(stage) IB|IB|192|193|HISTORY OF PRESENT ILLNESS|7. C. difficile culture and toxin - both negative from _%#MMDD2004#%_. COMPLICATIONS: None. HISTORY OF PRESENT ILLNESS: The patient, a 39-year-old female with known history of recurrent stage IB papillary serous adenocarcinoma of the cervix, presented to the Women's Health Clinic at Fairview-University Medical Center for evaluation of green, grainy drainage from her vagina.
IB|(stage) IB|IB|134|135|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1: Disease. As stated in the History of Present Illness, the patient has a known history of recurrent stage IB papillary serous adenocarcinoma of the cervix. She presented to the Women's Health Clinic with the above complaints of diarrhea and constipation, along with a greenish discharge per vagina, status post pelvic exenteration.
IB|(stage) IB|IB|127|128|POSTOPERATIVE DIAGNOSES|ADMISSION DIAGNOSES: 1. Grade 2 endometrial carcinoma. 2. Hypertension. 3. Obesity. POSTOPERATIVE DIAGNOSES: 1. Grade 1, stage IB endometrial carcinoma. 2. Hypertension. 3. Obesity. 4. Right hilum pulmonary nodule. OPERATIONS/PROCEDURES PERFORMED: 1. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, and bilateral pelvic and paraaortic lymph node dissection.
IB|(stage) IB|IB|172|173|HOSPITAL COURSE|None appeared grossly positive for carcinoma. The patient's final pathology of the pelvic washings were negative for malignancy. The histopathology showed a grade 1, stage IB endometrial carcinoma of the endometrioid type. None of the lymph nodes biopsied were positive. Additional findings included endometriosis in the posterior uterine serosa.
IB|(stage) IB|IB|367|368|DISCHARGE DIAGNOSES|4. History of hypertension. DISCHARGE DIAGNOSES: 1. Postoperative day number five status post total abdominal hysterectomy, bilateral salpingo-oophorectomy, optimal debulking, omentectomy, pelvic and periaortic lymph node dissection, Burch procedure, cystoscopy and suprapubic catheter placement. 2. Stage IIIC primary peritoneal serous papillary carcinoma. 3. Stage IB endometrioid adenocarcinoma of the uterus of International Federation of Gynecology and Obstetrics grade 2 out of 3. 4. Increased oxygenation requirements secondary to episodic desaturations from bilateral basilar atelectasis with right pleural effusion with possible mucous plug.
IB|(stage) IB|IB|173|174|FAMILY HISTORY|Final pathology ultimately reviewed a stage 3C primary peritoneal serous papillary tumor with a second primary cancer of an endometrioid adenocarcinoma of the uterus, stage IB FIGO grade 2. PROBLEM #2: Cardiovascular. Given patient's significant past medical history for myocardial infarction, she was given intraoperative beta blockers and continued with postoperative beta blockers throughout her hospitalization.
IB|(stage) IB|IB|210|211|HISTORY OF PRESENT ILLNESS|Ejection fraction is 35% per old record. HISTORY OF PRESENT ILLNESS: This is a 67-year-old white female who has an extensive past medical history including cervical cancer. The patient was diagnosed with stage IB squamous cell carcinoma of the cervix. She was admitted to GYN Oncology on _%#MMDD2003#%_. The patient had cryotherapy approximately 30 years ago, and has had no irregular or abnormal pap smears over the past 20 years.
IB|(stage) IB|IB|364|365|HOSPITAL COURSE|Extremities have no edema. Genitourinary shows the patient had two small superficial ulcers on her buttocks, one on each side. Pelvic exam not performed. DISCHARGE LABORATORY DATA: WBC 9.1; hemoglobin 10.7; platelets 353; 78% neutrophils; 6% lymphocytes; 13% monocytes; magnesium 1.4; potassium 4.3. HOSPITAL COURSE: 67-year-old white female with history of stage IB squamous cell carcinoma of the cervix, status post radical hysterectomy and radiation therapy in the past, admitted to the GYN Oncology Service for sinus symptoms with a small bowel obstruction.
IB|(stage) IB|IB|100|101|ADMISSION DIAGNOSES|DATE OF ADMISSION: _%#MMDD2007#%_. DATE OF DISCHARGE: _%#MMDD2007#%_. ADMISSION DIAGNOSES: 1. Stage IB uterine carcinosarcoma. 2. Cycle #6 Taxol and iphosphamide. 3. Chronic immune demyelinating polyneuropathy. 4. Hypothyroidism. 5. Type 2 diabetes mellitus.
IB|(stage) IB|IB|132|133|DISCHARGE DIAGNOSES|6. Anemia of chronic disease. 7. Morbid obesity. 8. Chronic headaches. 9. History of wound infection. DISCHARGE DIAGNOSES: 1. Stage IB uterine carcinosarcoma. 2. Status post cycle #6 iphosphamide and Taxol. 3. Chronic immune demyelinating polyneuropathy. 4. Hypothyroidism. 5. Type 2 diabetes mellitus. 6. Anemia of chronic disease.
IB|(stage) IB|IB|229|230|HISTORY OF PRESENT ILLNESS|5. Electrolyte replacement protocol. 6. Sliding scale insulin, as needed for coverage of hyperglycemia, status post dexamethasone treatment. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 36-year-old woman with stage IB uterine carcinosarcoma, currently on her 6th cycle of Taxol and iphosphamide chemotherapy. She was initially diagnosed in _%#MM2006#%_ at which time she underwent exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy and pelvic and periaortic lymph node dissection with surgical stating.
IB|(stage) IB|IB|189|190|ADMISSION DIAGNOSES|2. Villous adenoma in right colon. 3. Hypertension. 4. Hypercholesterolemia. 5. History of breast cancer. 6. History of chronic obstructive pulmonary disease. DISCHARGE DIAGNOSES: 1. Stage IB papillary serous endometrial cancer. 2. Status post right hemicolectomy for villous adenoma. 3. Hypertension. 4. Hypercholesterolemia. 5. History of breast cancer. 6. History of chronic obstructive pulmonary disease.
IB|(stage) IB|IB|186|187|HOSPITAL COURSE|The uterus was normal except for the fundus being slightly enlarged and boggy. There was no evidence of extrauterine spread at the time of the procedure. Final pathology confirmed Stage IB papillary serous endometrial cancer. The patient is scheduled for followup with Dr. _%#NAME#%_ in 2 to 3 weeks to discuss these results and make a plan for future treatments, if necessary.
IB|(stage) IB|IB|185|186|DISCHARGE DIAGNOSES|ADMISSION DIAGNOSES: 1. Carcinosarcoma of the uterus diagnosed on endometrial biopsy and endocervical curettings. 2. Hypertension. 3. Atrial fibrillation. DISCHARGE DIAGNOSES: 1. Stage IB carcinosarcoma of the endometrium (17% invasion) with no involvement of the lower uterine segment, no involvement of the cervix, no lymphvascular space invasion.
IB|(stage) IB|IB|189|190|HOSPITAL COURSE|There was no lymphvascular space invasion identified. Ovaries and tubes bilaterally as well as all lymph node tissue were negative for malignancy. Final pathology was consistent with stage IB carcinosarcoma of the endometrium. The patient was informed of this prior to her discharge and will follow up with Dr. _%#NAME#%_ on Monday, _%#MM#%_ _%#DD#%_, 2004, for discussion of further treatment including the possibility of enrollment in GOG-150.
IB|(status) IB|IB,|68|70|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Congenital cardiomyopathy, currently status IB, awaiting orthotopic heart transplant. 2. Pulmonary hypertension. 3. Diabetes mellitus type 2. 4. Anxiety. 5. Atrial fibrillation. OPERATIONS/PROCEDURES PERFORMED: 1. Right antecubital double lumen PICC line placement on _%#MM#%_ _%#DD#%_, 2006.
IB|(status) IB|IB.|166|168|HOSPITAL COURSE|He remained on the same milrinone dose and as a status I-AE. On _%#MM#%_ _%#DD#%_, 2006, his I-AE status was reviewed by UNOS and denied. He was downgraded to status IB. He had a right heart cath to reevaluate his right-sided pressures. Request for appeal was denied. The patient was discharged to home on _%#MM#%_ _%#DD#%_, 2006, as a status IB.
IB|(status) IB|IB.|205|207|HOSPITAL COURSE|He was downgraded to status IB. He had a right heart cath to reevaluate his right-sided pressures. Request for appeal was denied. The patient was discharged to home on _%#MM#%_ _%#DD#%_, 2006, as a status IB. He will remain on his previous milrinone dose of 0.375. At this time, his orthopnea symptoms are well controlled, and he had been active daily with cardiac rehab.
IB|(stage) IB|IB|151|152|HISTORY OF PRESENT ILLNESS|The cervix itself measured 5 cm. There was not felt to be extension of the mass of the parametrial tissue on exam, and she was therefore given a stage IB grade 2 stage. The patient was then scheduled for staging procedure on _%#MM#%_ _%#DD#%_, 2006. On _%#MM#%_ _%#DD#%_, 2006, she underwent an exam under anesthesia, cystoscopy, proctoscopy, extraperitoneal lymph node dissection, and left pelvic lymph node dissection as well as excision of the left back scapulary region.
IB|(stage) IB|IB|119|120|DISCHARGE DIAGNOSES|2. Hyperlipidemia. 3. Gastroesophageal reflux disease. 4. Arthritis. 5. Restless leg syndrome. DISCHARGE DIAGNOSES: 1. IB grade endometrial adenocarcinoma. 2. Hyperlipidemia. 3. Gastroesophageal reflux disease. 4. Arthritis. 5. Restless leg syndrome. 6. Blood loss anemia. PROCEDURE PERFORMED: 1. Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingooophorectomy, and pelvic and periaortic lymph node dissection.
IB|(stage) IB|IB|145|146|HOSPITAL COURSE|Findings included small uterus and cervix, normal bilateral fallopian tubes, ovaries, and upper abdominal survey. Final pathology revealed stage IB grade 3 endometrial adenocarcinoma. Myometrial invasion had a maximum depth of 0.5 out of a total of 1.7 cm myometrial thickness. Angiolymphatic invasion is absent. There were no positive lymph nodes.
IB|(stage) IB|IB,|101|103|DISCHARGE DIAGNOSES|7. Status post inferior vena cava filter placement. 8. Hypothyroidism. DISCHARGE DIAGNOSES: 1. Stage IB, grade 1 adenocarcinoma of the endometrium. 2. Mixed urinary incontinence. 3. Hypertension. 4. Diabetes. 5. Hypercholesterolemia. 6. History of recurrent deep venous thrombosis. 7. Status post inferior vena cava filter placement.
IB|(stage) IB|IB|40|41|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Recurrent stage IB grade III endometrial carcinoma with brain metastasis. 2. Abdominal pain. 3. Ascites. 4. Nausea and vomiting. 5. Hypertension. 6. Hyperlipidemia. 7. Peptic ulcer disease. 8. Multinodular goiter.
IB|(stage) IB|IB,|339|341|DISCHARGE DIAGNOSES|9. Peripheral neuropathy. 10. Obesity. 11. Resolving pyelonephritis. 12. History of deep vein thrombosis and pulmonary emboli, currently off anticoagulation secondary to recent cranial bleed due to metastasis. DISCHARGE DIAGNOSES: 1. Removal of ascites via paracentesis. 2. Resolved abdominal pain, nausea and vomiting. 3. Recurrent stage IB, grade III endometrial carcinoma with brain metastasis currently undergoing external beam radiation therapy to the head. 4. Hypertension. 5. Hyperlipidemia. 6. Peptic ulcer disease. 7. Multinodular goiter.
IB|(stage) IB|IB|188|189|HISTORY OF PRESENT ILLNESS|6. IV pain medication. 7. Electrolyte replacement protocol. COMPLICATIONS: None apparent. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 63-year-old woman with recurrent metastatic stage IB grade III endometrial carcinoma. Ms. _%#NAME#%_ has a past medical history significant for DVT and PE. Consequently, she was on anticoagulation and presented on _%#MMDD2007#%_ with severe nausea, vomiting, dizziness and difficulty focusing her eyes.
IB|international baccalaureate|IB|157|158|DEMOGRAPHICS AND BACKGROUND INFORMATION|As a result, she is concerned about her interaction with her family. This patient is currently in the 11th grade at Patrick Henry High School. She is in the IB program and finds it to be challenging. Right now she tends to get A's and B's and believes that her ranking is somewhere in the top 5-10% of her class.
IB|(stage) IB|IB|140|141|HISTORY OF PRESENT ILLNESS|No angiolymphatic invasion was appreciated. 35 lymph nodes were taken and were found to be negative. She was therefore surgically staged as IB grade 2. Her postoperative course was complicated by this injury to her inferior vena cava requiring prolonged recuperation, and she is currently receiving daily OT and PT at St. Benedict's Senior Community in _%#CITY#%_ _%#CITY#%_, Minnesota.
IB|(stage) IB|IB,|139|141|ASSESSMENT|ASSESSMENT: Ms. _%#NAME#%_ is a 75-year-old Caucasian female who is status post total abdominal hysterectomy for endometrial cancer, stage IB, grade 2. Her treatment course has been complicated by prolonged effort at rehabilitation, for which she is currently receiving daily therapy.
IB|international baccalaureate|IB|183|184|DEMOGRAPHICS AND BACKGROUND INFORMATION|She does not see him very much and she also recalled that she does not confide in very many people. This patient is now in 10th grade at Robbinsdale Cooper High School. She is in the IB program and tends to receive all A's. She would eventually like to become a French language interpreter or photographer.
IB|(stage) IB|IB,|47|49|PROBLEM|PROBLEM: Endometrial adenocarcinoma FIGO stage IB, grade 3. Ms. _%#NAME#%_ was seen for initial consultation in the Department of Therapeutic Radiology on _%#MMDD2005#%_ by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ at the request of Dr. _%#NAME#%_ _%#NAME#%_.
IB|(stage) IB|IB,|91|93|PROBLEM|My key findings: Key elements of the exam repeated. PROBLEM: Endometrial cancer FIGO stage IB, grade 3. HPI: Mrs. _%#NAME#%_ underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and lymph node dissection on _%#MMDD2005#%_. Pathology reveals FIGO grade 3, IB adenocarcinoma with minimal myometrial invasion.
IB|international baccalaureate|IB|220|221|DEMOGRAPHICS AND BACKGROUND INFORMATION|She has 2 sisters (15 and 13), the older with whom she gets along although described the younger as "annoying." This patient currently in the eleventh grade at Central High School in _%#CITY#%_ _%#CITY#%_. She is in the IB program and tends to receive As and Bs. She is involved in swimming, student council and national honor society.
IB|international baccalaureate|IB|252|253|SUMMARY OF CURRENT FINDINGS|This patient also has had a history of kicking her father and "stabbing her mother with a pen to get her out of her room, she was frustrated. Evidently she has not had any problems with her interactions with her peers at school. She is involved in the IB honors program and seems to have few problems with her grades. She would like to go to college but does not know where at this point.
IB|(stage) IB|IB|15|16|PROBLEM|PROBLEM: Stage IB endometrioid adenocarcinoma. Status post total abdominal hysterectomy, bilateral salpingo-oophorectomy, and right pelvic lymph node dissection. The patient was seen in the Radiation Oncology Clinic for consultation by Dr. _%#NAME#%_ _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_ at the request of Dr. _%#NAME#%_ _%#NAME#%_.
IB|(stage) IB|IB|94|95|HPI|A CT scan of the abdomen and pelvis on _%#MMDD2004#%_ was negative. Assessment and Plan: FIGO IB endometrioid adenocarcinoma. Adjuvant postoperative radiation therapy may decrease the chance of a pelvic and vaginal cuff recurrence.
IB|(stage) IB|IB.|168|170|HISTORY OF PRESENT ILLNESS|She underwent an excisional biopsy on _%#MM#%_ _%#DD#%_, 2000 which revealed non-Hodgkin lymphoma-large B cell. There were no other sites of disease. She was staged at IB. Ms. _%#NAME#%_ received 4 cycles of CHOP chemotherapy followed by radiation initiated in _%#MM#%_ 2001 at St. Joseph's Hospital. She reportedly received 3000 cGy in 15 fractions, the last 1000 cGy of which was a boost to the incisional area.
IB|(stage) IB|IB|20|21|PROBLEM|PROBLEM: Stage FIGO IB squamous cell carcinoma of the cervix. The patient was seen in the Radiation Oncology Clinic by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_.
IB|(stage) IB|IB|246|247|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Breast cancer. Hypernephroma which was treated with breast lumpectomy along with lymph node dissection, cholecystectomy for cholelithiasis and right nephrectomy on _%#MMDD1997#%_ at one sitting. 2. Appendectomy. 3. Stage IB endometrioid cancer grade 1/3 which was treated with surgery on _%#MMDD2005#%_. SOCIAL HISTORY: She currently works as a coffee attendant part time at _%#CITY#%_ Hospital, just works two days a week.
IB|(stage) IB|IB,|14|16|PROBLEM|PROBLEM: FIGO IB, grade 2 squamous cell carcinoma of the cervix. The patient was seen in Radiation Oncology Clinic by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_.
IB|(stage) IB|IB,|143|145|ASSESSMENT|MUSCULOSKELETAL: 4 mobile 2 x 2 cm solid masses palpable in lower back, most consistent with lipoma. ASSESSMENT: 65-year-old female with stage IB, grade 2-3, squamous cell carcinoma of the cervix, status post radical hysterectomy and bilateral salpingo-oophorectomy _%#MMDD2004#%_. Margins were negative for invasive or in situ tumor, but significant for low grade squamous epithelial lesion at the vaginal cuff.
IB|(stage) IB|IB.|144|146|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Cervix cancer, FIGO IB. HPI: _%#NAME#%_ _%#NAME#%_ underwent a radical hysterectomy on _%#MMDD2004#%_, revealing a poorly differentiated squamous cell carcinoma with positive pelvic and para-aortic lymph nodes.
IB|(stage) IB|IB.|174|176|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Squamous-cell carcinoma of the cervix, FIGO stage IB. HPI: The patient is a 53-year-old postmenopausal female patient who presented with vaginal discharge and cramping since _%#MM2004#%_ and started having postmenopausal bleeding in _%#MM2005#%_.
IB|(stage) IB|IB|167|168|HPI|Final pathology is pending, however. Overall, the patient noted increasing fatigue and occasional pelvic cramps with discharge. As of now, she is staged at FIGO stage IB squamous-cell carcinoma of the cervix and consulted to us for consideration of radiation treatment. Exam: Physical examination reveals the patient is mentally alert and cooperative.
IB|(stage) IB|IB|157|158|HPI|PELVIC: Deferred. NEUROLOGIC: There are no motor or sensory changes. Cranial nerves II through XII are within normal limits. Assessment and Plan: FIBO stage IB squamous-cell carcinoma of the cervix with bilateral pelvic and paraortic lymph node metastasis pending final pathology. The patient was recommended radiation treatment concurrent with chemotherapy under local protocol WCC_%#PROTOCOL#%_, which includes topotecan and cisplatin with a daily radiation treatment.
IB|(stage) IB|IB,|26|28|PROBLEM|PROBLEM: Pathologic stage IB, poorly-differentiated adenocarcinoma of the endometrium. Ms. _%#NAME#%_ was seen for initial consultation in the Department of Radiation Oncology on _%#MM#%_ _%#DD#%_, 2006, by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ at the request of Dr. _%#NAME#%_ _%#NAME#%_.
IB|(stage) IB|IB|192|193|ASSESSMENT|HISTOPATHOLOGY: As per HPI. HISTORY OF RADIATION: None. HISTORY OF CHEMOTHERAPY: None. ASSESSMENT: This is a 54-year-old Caucasian female status post total laparoscopic hysterectomy for stage IB adenocarcinoma of the endometrium, poorly differentiated with lymphovascular space invasion and 3 of 20 mm myometrial invasion, all nodes negative.
IB|(stage) IB|IB.|164|166|HISTORY OF PRESENT ILLNESS|The pathology revealed nodular sclerosing Hodgkin disease. Workup revealed no other sites of disease. Bone marrow biopsy was negative. Ms. _%#NAME#%_ was staged at IB. Ms. _%#NAME#%_ received six cycles of ABVD chemotherapy which lead to a decrease in the size of the mass on CT scan. She underwent irradiation consolidation at North Memorial Hospital under the direction of Dr. _%#NAME#%_ _%#NAME#%_.
IB|(stage) IB|IB|185|186|IMPRESSION|We specifically reviewed the recent studies presented at the _%#MM#%_, 2004 ESCO meeting demonstrating approximately 15% improvement in disease-free survival for individuals with stage IB or II non-small cell lung cancer treated with chemotherapy alone. Although she has a somewhat higher stage than individuals in these studies, her risk is also higher as well and therefore it is logical to expect she could also benefit from adjuvant therapy.
IB|(stage) IB|IB|222|223|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 68-year-old white female, morbidly obese, approximately 6 weeks post-total abdominal hysterectomy, bilateral salpingo-oophorectomy and lymph node dissection for stage IB endometrial carcinoma. She had multiple postoperative complications causing a prolonged and difficult hospital course and subsequent need for rehab and wound care.
IB|international baccalaureate|IB|125|126|DEMOGRAPHICS AND BACKGROUND INFORMATION|She also stated that when she was going to Warroad, she did not find this be a rigorous program. She is now currently in the IB program at _%#CITY#%_ _%#CITY#%_ _%#CITY#%_ where she tends to receive B grades. During her leisure time she used to play roller hockey and now works at the Mall of America.
IB|(stage) IB|IB,|34|36|PROBLEM|PROBLEM: Endometrial cancer stage IB, grade 2 with positive lymphvascular invasion treated with total abdominal hysterectomy with bilateral salpingooophorectomy and bilateral pelvic and periaortic lymph node dissection on _%#MMDD2003#%_. The patient was seen today by Dr. _%#NAME#%_ _%#NAME#%_, Dr. _%#NAME#%_ _%#NAME#%_ and medical student _%#NAME#%_ _%#NAME#%_ for a consultation at the request of Dr. _%#NAME#%_ _%#NAME#%_ to discuss with the patient the possible adjuvant treatments for her cancer and specifically the role of radiation.
IB|(stage) IB|IB,|165|167|ASSESSMENT|Both ovaries, fallopian tubes and 32 lymph nodes were all negative for malignancy. ASSESSMENT: The patient is a 44-year-old female with endometrial carcinoma, stage IB, grade 2 with positive lymphatic vascular space invasion, status post TAH/BSO performed on _%#MMDD2003#%_. RECOMMENDATIONS: The various methods of treating this patient for the possibility of recurrence were discussed including external beam radiation, brachytherapy, combinations of brachytherapy and external beam radiation and to closely following without treatment.
IB|(stage) IB|IB.|74|76|PROBLEM|PROBLEM: Diffuse large cell lymphoma, right supraclavicular region, stage IB. Ms. _%#NAME#%_ was seen in the Radiation Oncology Department on _%#MMDD2004#%_ by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ for consultation at the request of Dr. _%#NAME#%_.
IB|(stage) IB|IB|141|142|PAST MEDICAL HISTORY|This was scheduled to occur on _%#MMDD2007#%_. A preoperative H&P was performed by Dr. _%#NAME#%_. PAST MEDICAL HISTORY: 1. History of stage IB adenocarcinoma of the endometrium. The patient is status post total abdominal hysterectomy, bilateral salpingo-oophorectomy and radiation therapy with implanted radiotherapy performed in the 1970s.
IB|(stage) IB|IB,|150|152|DISCHARGE DIAGNOSIS|REFERRING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD ADMISSION DIAGNOSIS: Grade 1 endometrial adenocarcinoma of the endometrium. DISCHARGE DIAGNOSIS: Stage IB, grade 1 endometrioid adenocarcinoma of the endometrium. OPERATIONS/PROCEDURES PERFORMED: 1. Exam under anesthesia. 2. Exploratory laparotomy.
IB|(stage) IB|IB|140|141|DISCHARGE DIAGNOSES|3. Recurrence of IB squamous-cell carcinoma of the cervix to the sacrum. DISCHARGE DIAGNOSES: 1. Intractable pain. 2. Vaginal recurrence of IB squamous-cell carcinoma of the cervix. 3. Recurrence of IB squamous-cell carcinoma of the cervix to the sacrum. OPERATIONS/PROCEDURES PERFORMED: 1. Intravenous hydration. 2. Electrolyte replacement. 3. Pain management.
IB|(stage) IB|IB|172|173|ASSESSMENT/PLAN|PELVIC: Exam is deferred at this time. She is less than 1 month postoperative. ASSESSMENT/PLAN: In summary, Ms. _%#NAME#%_ is a 66-year-old very healthy woman with a stage IB carcinosarcoma of the uterus, status post total abdominal hysterectomy, bilateral salpingo-oophorectomy and lymph node dissection. Dr. _%#NAME#%_ personally lead an extended discussion with the patient regarding her options at this time.
IM|intramuscular|IM|122|123|DISCHARGE MEDICATIONS|20. Fosamax 70 mg p.o. every Sunday. 21. Calcarb with vitamin D 1250 mg tablets 1 p.o. b.i.d. 22. B12 injections 1000 mcg IM every month, last given on _%#MMDD2007#%_. DISCHARGE INSTRUCTIONS: No restrictions on her activity or diet.
IM|intramuscular|IM|200|201|DISCHARGE MEDICATIONS|The patient's hyperglycemia is well controlled. DISCHARGE MEDICATIONS: 1. Tenormin 25 mg p.o. daily. 2. Dulcolax 10 mg rectal suppository daily p.r.n. 3. Celexa 20 mg p.o. daily. 4. Vitamin B-12 1 gm IM monthly. 5. Flexeril 10 mg p.o. t.i.d. p.r.n. 6. Colace 100 mg p.o. daily p.r.n. 7. Cosopt one drop each eye b.i.d. for glaucoma.
IM|intramuscular|IM|372|373|HISTORY/HOSPITAL COURSE|Antibiotics were changed, he was put on clindamycin, but the severity of pain in swallowing increased and he presented to the Emergency Room, where his tonsils were touching and starting to cause some difficulty in airway as well as pain on swallowing. It was determined that he had paratonsillar abscess and the large tonsils were obstructing his airway and he was given IM and IV antibiotics, taken to the operating room, where his tonsils were removed. He was found to have bilateral paratonsillar abscesses and these were drained.
IM|intramuscular|IM|202|203|MEDICINES|PAST MEDICAL HISTORY: MEDICINES: 1. Diovan/hydrochlorothiazide 160/12.5, 2 pills daily. 2. Oxybutynin, 5 mg twice daily. 3. Westcort 0.2 percent applied to rash twice daily p.r.n. 4. Risperdal, 37.5 mg IM every 2 weeks (due _%#MMDD2005#%_). 5. Avandamet 2/500, 1 pill twice daily. 6. Nortriptyline, 100 mg daily. 7. Vitamin D, 50,000 units weekly. 8. Trileptal, 600 mg daily.
IM|intramuscular|IM|253|254|HOSPITAL COURSE|The patient denies any intentional weight loss. The patient had a normal low vitamin B12 level in 2005 up to high 200s, repeat vitamin B12 was 387. The methylmalonic acid level is still pending. The patient was started with empiric vitamin B12 1000 mcg IM injection x1 on this admission and needs to continue q. monthly. If Methylmalonic acid result is normal, vitamin B12 injection should discontinued.
IM|intramuscular|IM|304|305|ASSESSMENT AND PLAN|In the setting of lung infection that has not been responding to antibiotics, the differential would include possible relation to the Amoxicillin versus a strep related kidney problem versus IgA related renal dysfunction. In relating to his pneumonia, he is a relatively healthy male that had been given IM Penicillin, Amoxicillin and then Tequin and had failed to respond and had an increasing infiltrate on these medicines. It is very important in this regard to get a specific diagnosis so we are encouraging a sputum be sent and to identify the cystic organism that is causing this infection.
IM|intramuscular|IM|180|181|ADMISSION DIAGNOSIS|On the afternoon of the day of discharge, the patient had not passed flatus and was to pass flatus as a requirement of her discharge. DISCHARGE MEDICATIONS: 1. Depo-Provera 150 mg IM every 3 months. 2. Multivitamin 1 tablet p.o. daily. 3. Tylenol No. 3 elixir 5 to 10 mL p.o. q.4-6 h. p.r.n. FOLLOW UP: The patient was to follow up with her primary care physician in one month.
IM|intramuscular|IM|211|212|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Accupril 10 to 40 mg daily based on the findings of blood pressure scale with her husband. Based on blood pressure readings. 2. Magnesium sulfate 250 mg b.i.d. 3. Vitamin B12 1,000 mcg IM q 3 weeks. 4. Caltrate 600 plus vitamin D, one tab PO b.i.d. Due to the patient's recent hypercalcemia, she is somewhat reluctant to take this initially and therefore, I have told her she can hold this for the next one to two weeks to insure that her calcium levels remain stable.
IM|intramuscular|IM|144|145|MEDICATIONS AT THE TIME OF DISCHARGE|18. Multivite 2 tablets q. day. 19. Flonase 2 sprays b.i.d. 20. Vitamin D 50,000 units q. week. 21. Actigall 600 mg b.i.d. 22. Testosterone 200 IM q.2 weeks, due _%#MM#%_ _%#DD#%_, 2006. 23. Methadone 2 mg b.i.d. at 6 a.m. and 2 p.m. 24. Vitamin E 800 units q. day. 25. Valium 4 mg q.i.d.
IM|intramuscular|IM|199|200|PROBLEM #5|PROBLEM #5: Infectious Disease. The patient had multiple studies done which revealed yet another urinary tract infection with E. coli, this a different strain than previously seen. She was placed on IM ceftriaxone initially and once access was achieved she was converted to IV cefotaxime with the plan of continuing cefotaxime for approximately 10 days and then beginning prophylaxis with oral Gantrisin at 15 mg/kg per day divided twice a day.
IM|intramuscular|IM|179|180|HOSPITAL COURSE|Her postpartum hemoglobin was 10.7. On postpartum day #2, the decision was made to discharge her to home. Routine discharge instructions were reviewed. She was given Depo-Provera IM prior to discharge. DISCHARGE MEDICATIONS: 1. Ibuprofen 600 mg p.o. q.6h p.r.n.
IM|intramuscular|IM|169|170|DISCHARGE MEDICATIONS|7. Lisinopril 20 mg p.o. daily. 8. Toprol XL 100 mg p.o. daily. 9. Keflex 250 mg p.o. t.i.d. for 3 days. 10. Multivitamin one tablet p.o. daily. 11. Vitamin B12 1000 mg IM once a month. 12. TUMS 1-2 tablets p.o. p.r.n. 13. Tylenol 325 mg p.o. q. 4h. p.r.n. 14. Nitroglycerin 0.4 mg sublingual p.r.n. for chest pain, may repeat x 2 q. 5 minutes.
IM|intramuscular|IM|179|180|DISCHARGE MEDICATIONS|7. Prilosec 20 mg bid. 8. Tincture of opium 0.6 cc tid and adjusted accordingly. 9. Kay Ciel 20 mEq tid. 10. Etodolac 300 mg bid. 11. Flomax 0.4 mg daily. 12. Testosterone 200 mg IM weekly. 13. Procrit injection subcutaneously weekly. ALLERGIES: PENICILLIN, CIMETIDINE, POSSIBLY LEVAQUIN, ALTHOUGH, WAS EXPOSED TO LEVAQUIN DURING THIS HOSPITALIZATION WITH NO PROBLEMS.
IM|intramuscular|IM|164|165|DISCHARGE MEDICATIONS|She was felt to be psychiatrically and medically stable and ready for discharge. DISCHARGE MEDICATIONS: 1. Risperdal 1 mg p.o. 1 nightly. 2. Risperdal Consta 25 mg IM q.2 weeks. 3. Timoptic eyedrops 1 drop each eye b.i.d. DISCHARGE PLAN: 1. The patient was discharged to home on safe commitment.
IM|intramuscular|IM|193|194|ASSESSMENT/PLAN|She was discovered to have low normal iron studies and iron IV was ordered by Dr. _%#NAME#%_. She will have 6 doses IV daily continuing as an outpatient. She did receive a dose of Vitamin B-12 IM also in the hospital. At the time of discharge, her electrolytes had returned to essentially normal.
IM|intramuscular|IM|128|129|DISCHARGE MEDICATIONS|3. Nitrostat 0.4 mg p.r.n. 4. OxyContin 80 mg t.i.d. for "chronic back pain." 5. Lisinopril 40 mg daily. 6. Testosterone 300 mg IM every two weeks. 7. Lipitor 40 mg daily. 8. Zoloft 37.5 mg daily. 9. Toprol XL 50 mg daily (new medication). 10. Nexium 20 mg daily.
IM|intramuscular|IM.|247|249|HISTORY OF PRESENT ILLNESS|She does take some baby foods. Mom states her intake is fine, her urine output has been fine, and she has been more irritable and fussy lately. In the Emergency Room, chest x-ray was read as normal. She was given ibuprofen, and 450 mg of Rocephin IM. A cath UA/UC was done. Blood culture, CBC and BMP were done. Her urine looks normal. Her electrolytes are within normal limits.
IM|intramuscular|IM|128|129|HOME MEDICATIONS|HOME MEDICATIONS: Include 1. Aspirin 81 mg daily 2. Furosemide 81 mg daily 3. Potassium 20 mEq. daily 4. Dilaudid 0.2 to 0.4 mg IM every 3-6 hours p.r.n. 5. Senokot two tablets daily p.r.n. 6. Milk of Magnesia one ounce every 12 hours p.r.n. 7. Dulcolax suppositories one daily p.r.n. 8. Lubricate Foley catheter with Neosporin once daily
IM|intramuscular|IM|122|123|DISCHARGE MEDICATIONS|8. Vitamin E 400 units q. day 9. Calcium plus vitamin D 600 mg t.i.d. 10. Multi-vitamin 1 q. day 11. Vitamin B12 1000 mcg IM about the 20th of each month 12. Estrogen vaginal cream one applicator-full weekly on Sundays 13. Roxicet 5/325 1 or 2 tablets q .4-6h. p.r.n. for intense pain
IM|intramuscular|IM|136|137|MEDICATIONS|1. Vitamin E 400 units p.o. q day. 2. Vitamin C 500 mg p.o. q day. 3. Lupron Depo injections 7.5 mg IM monthly. 4. Vitamin B12 1000 mcg IM monthly. 5. Aspirin 81 mg p.o. q day. 6. Nexium 40 mg p.o. q day. 7. Paxil 10 mg p.o. q day. 8. Meclizine 25 mg p.o. q.i.d. prn.
IM|intramuscular|IM|152|153|DISCHARGE MEDICATIONS|20. Tylenol 650 mg p.o. q.4h. p.r.n. 21. Lorazapam 1 mg p.o. q.6h. p.r.n. 22. Percocet tablets 1 to 2 tablets p.o. q.4h. p.r.n. 23. Testosterone 400 mg IM every 4 weeks, the last given on _%#MM#%_ _%#DD#%_, 2002, for a low serum testosterone level. 24. He will also be discharged with home oxygen at 3 L per minute.
IM|intramedullary|IM|169|170|SOCIAL HISTORY|SOCIAL HISTORY: She is living at home with her husband who is blind and has diabetes. They have four children. She was seen by orthopaedics who recommended placing of a IM nail that would allow her to wear a mobile splint. Surgery was done on _%#MMDD2003#%_, and the patient tolerated this well.
IM|intramuscular|IM,|145|147|DISCHARGE MEDICATIONS|2. Ongoing cigarette use. 3. Diarrhea likely secondary to antibiotics. 4. Schizophrenia. DISCHARGE MEDICATIONS: Haldol 100 mg 0.5 cc every month IM, hydroxyzine 25 mg b.i.d., Prozac 20 mg q.d., prednisone 20 mg b.i.d., this will be tapered off after her discharge, Tequin 400 mg q.d. for 5 days, Imodium 2 mg q.i.d. on a p.r.n. basis, Lipitor 10 mg q.d.
IM|intramuscular|IM|303|304|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 23-year-old Ethiopian male who was initially seen in his primary-care clinic on _%#MMDD2003#%_ after reportedly picking at a pimple on his right lateral cheek. The patient was noted to have swelling, pain, and redness over that area, and was treated with an IM injection of ceftriaxone and started on oral Augmentin, with instructions for follow-up. Over the next 24 hours, the patient developed significant pain and swelling at the site, as well as a fever.
IM|intramuscular|I.M.|178|181|DISCHARGE MEDICATIONS|6. Previous degenerative arthrosis right knee with total knee arthroplasty. DISCHARGE MEDICATIONS: 1. Vicodin one to two tablets q3h p.r.n. for pain. 2. Vistaril 50 - 75 mg p.o. I.M. q3-4h p.r.n. for pain. 3. Ascription one tablet p.o. daily. ADDITIONAL MEDICATIONS: Home medications, which include: 1. Amitriptyline 20 mg p.o. q.h.s.
IM|intramuscular|IM,|237|239|REVIEW OF SYSTEMS|He had a temp of 103. He was seen in Fairview Southdale ER at about 7:00 with a temp of about 103.2, pulse 124, respiratory rate 28 and O2 sats of 92% on room air. He had stridor and a barky cough. The patient was given Decadron at 9:15 IM, ibuprofen, one racemic epi neb at 8:15 and one DuoNeb at 9:35. Per the ER MD he was 70% improved after treatment with still slight barky cough and minimal stridor.
IM|intramuscular|IM|168|169||There his chin laceration was closed and he was sent to the Ridges Emergency Room. At that point a CT scan was done with some laboratory work and the patient was given IM morphine and according to his mother a "shot of penicillin". He was told to go home and to see the oral surgeon the next day.
IM|intramuscular|IM|108|109|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Folic acid 1 mg p.o. q. day. 2. Multivitamin one p.o. q. day. 3. B12 100 mcg 1 cc IM or deep subcutaneous injection q. month. 4. Tylenol 650 mg p.o. q. 4 h. p.r.n. pain. 5. Oxycodone 5 mg p.o. q. 4-6 h. p.r.n. pain.
IM|intramuscular|IM|173|174|MEDICATIONS|4. Nexium 40 mg daily. 5. Inderal 160 mg a.m. 80 mg p.m. 6. clonidine 0.1 mg t.i.d. 7. Remeron 30 mg p.r.n. 8. Benicar 20 mg daily., 9. primidone 25 mg h.s. 10. Pamidronate IM q. three month. ALLERGIES: TO GOLD SHOTS, PENICILLAMINE, ACE inhibitors, THIAZIDES, AND CALCIUM BLOCKERS.
IM|intramuscular|IM|204|205|HOSPITAL COURSE|Her fibrinogen returned on _%#MM#%_ _%#DD#%_, 2006, with an INR of 0.92, and a PTT of 29. The patient was immediately started on magnesium sulfate for tocolysis, 2 IV sets were obtained, and she received IM betamethasone x2 with a first dose occurring on _%#MM#%_ _%#DD#%_, 2006, and the next dose on _%#MM#%_ _%#DD#%_, 2006. The patient remained in uterine quiescence. By hospital day #2, bleeding had slowed down.
IM|intramuscular|IM|154|155|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1. Atenolol 50 mg p.o. q.d. 2. Advair 250/50 b.i.d. 3. Diovan/hydrochlorothiazide (unknown dosage). 4. Testosterone, possibly 200 mg IM q. 2 weeks. REVIEW OF SYSTEMS: HEENT: Denies headaches, diplopia, scotomata, decreased visual or auditory acuity, epistaxis, sore throat, dysphagia or change in voice.
IM|intramuscular|IM|136|137|DISCHARGE MEDICATIONS|4. Mental slowing. ALLERGIES: No known drug allergies. PRIMARY TREATMENTS: IV antibiotics. DISCHARGE MEDICATIONS: 1. Ceftriaxone 1 gram IM b.i.d. x 10 more days. 2. Dilantin 200 mg 1 p.o. b.i.d. 3. Keppra 1500 mg 1 p.o. b.i.d. 4. Os-Cal with D 500 mg 1 p.o. t.i.d. 5. Neurontin 800 mg 1 p.o. t.i.d.
IM|intramuscular|IM|113|114|DISCHARGE MEDICATIONS|4. Impaired short term memory, secondary to prior surgeries. DISCHARGE MEDICATIONS: 1. Testosterone Depot 200 mg IM q. 3 weeks. Last dose _%#MMDD2003#%_. 2. Lidoderm patches 5% two to three patches over lumbar spine q. 12h, off for 12 hours, on for 12 hours.
IM|intramuscular|IM|124|125|DISCHARGE  MEDICATIONS|4. Enteric-coated aspirin 81 mg daily. 5. allopurinol 100 mg daily. 6. Clonidine 300 mcg at bedtime 7. vitamin B12 1000 mcg IM q. month 8. Prevacid 30 mg at bedtime 9. Lasix 20 mg daily. 10. Amaryl 4 mg b.i.d. 11. glucosamine, one tablet twice daily 12.
IM|intramuscular|IM|138|139|DISCHARGE MEDICATIONS|10. Calcium with vitamin D and B6, 500 mg p.o. b.i.d. 11. Ciprofloxacin 250 mg p.o. b.i.d. x6 days which is new. 12. Procrit 40,000 units IM every friday. 13. Lactulose 30 mg p.o. t.i.d. DISCHARGE FOLLOW-UP: The patient will follow up with his primary care provider in 1 week after discharge with a Chem-7 before his visit.
IM|intramuscular|IM|175|176|DISCHARGE MEDICATIONS|She may also have solids as desired except for meats. DISCHARGE ACTIVITY : As tolerated. DISCHARGE MEDICATIONS: 1. Carnitine 280 mg G-tube b.i.d. 2. Hydroxocobalamin 1000 mcg IM every Monday and Thursday. 3. Phenobarbital 60 mg G-tube daily. 4. Triamcinolone cream 0.01% to affected area 2 to 3 times a day x5 days.
IM|intramuscular|IM|147|148|SUMMARY OF ADMISSION|The patient did well in the hospital. She was given Tylenol as well as narcotics to control her pain that resulted from Pitocin, Methergine 0.2 mg IM q.6 h. x3 doses as well as Cytotec 800 mcg rectally in the PACU. Bleeding had diminished quite a bit. Hemoglobin prior to procedure on _%#MM#%_ _%#DD#%_, 2006, was 12.7. On _%#MM#%_ _%#DD#%_, 2006, was 10.0. The patient was not orthostatic, not tachycardiac.
IM|intramuscular|IM|123|124|DISCHARGING MEDICATIONS|2. Lovenox 50 mg subcutaneous b.i.d. which can be stopped when the INR is greater than 2 readings. 3. Vitamin B12 1000 mcg IM q.4 weeks due on the _%#MMDD#%_ as it is being given today. 4. Benadryl cream 2% topically apply to the skin b.i.d. p.r.n. itching to the inguinal region and lower back.
IM|intramuscular|IM|188|189|DISCHARGE MEDICATIONS|11. Albuterol 2 puffs inhaled q. 4 hours p.r.n. 12. Nitroglycerin 0.4 mg sublingual p.r.n. 13. Imdur 60 mg p.o. daily (increased dose). 14. Cymbalta 180 mg p.o. daily. 15. Risperdal 50 mg IM q. 2 weeks-last dose _%#MMDD2006#%_. 16. Lamotrigine 400 mg p.o. b.i.d. 17. Topamax 400 mg p.o. q. a.m. and 600 mg p.o. q. p.m. 18. Spiriva 18 mcg inhaler daily.
IM|intramuscular|IM|128|129|MEDICATIONS|3. Ceftin, he completed a course of on _%#MMDD#%_. It was an 8 day course. 4. He takes warfarin 5. he gets vitamin B12 1000 mcg IM monthly 6. Flomax 0.4 mg daily. 7. Fosamax 70 once a week 8. Lasix 20 a day 9. Os-Cal 250/1/25 twice a day.
IM|intramuscular|IM|139|140|CURRENT MEDICATIONS|2. Exelon 4.5 mg b.i.d. 3. Synthroid 0.088 mg PO Q day 4. Glucotrol XL 5 mg PO QD. 5. Lisinopril 10 mg PO QD. 6. Vitamin B. 12, 1,000 mcg. IM Q month 7. Multivitamins one PO QD 8. Caltrate 600 plus D. b.i.d. REVIEW OF SYSTEMS: Head, eyes, ears, nose and throat: Wears glasses.
IM|intramedullary|IM|239|240|SURGICAL PROCEDURES|Primary-care physician with Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ as the orthopedic surgeon. SURGICAL PROCEDURES: Diagnostic tests and invasive procedures: ORIF of the right trimalleolar ankle fracture with seven interfrag screws and right IM tibial roding. BRIEF HISTORY, PERTINENT PHYSICAL EXAMINATION, AND LABORATORY DATA: Ms. _%#NAME#%_ is a 52-year-old African- American female who was admitted to the _%#CITY#%_ ER after falling down five to six stairs on _%#MMDD2003#%_.
IM|intramuscular|IM.|129|131|HISTORY OF PRESENT ILLNESS|He was then taken to the F-UMC ER and then subsequently admitted. In the ER he was given IV fluids as well as a dose of Rocephin IM. He is treated with Folate and penicillin which was stopped five days ago. There are no known sick contacts and review of systems is otherwise unremarkable.
IM|intramuscular|IM|265|266|ADMISSION MEDICATIONS|She denies any shortness of breath or chest pain. She has had similar side effects of increased abdominal girth and fullness status post previous IVF cycles and has had estrogen levels in the past exceeding 5000. ADMISSION MEDICATIONS: 1. Progesterone in oil 50 mg IM q.h.s. 2. Baby aspirin p.o. q.day. 3. Prenatal vitamin 1 tablet p.o. q.day. 4. Levothyroxine 88 mcg p.o. q.day. ALLERGIES: PENICILLIN (swelling).
IM|intramuscular|IM|152|153|MEDICATIONS|ALLERGIES: OPIOIDS LEAD TO NAUSEA, VOMITING, METHOTREXATE. MEDICATIONS: 1. Fosamax (aledronate) 70 mg p.o. weekly on Wednesday. 2. vitamin B12 1000 mcg IM once a month. 3. glucosamine, chondroitin 500/400 mg p.o. daily. 4. Synthroid 0.05 mg p.o. daily. 5. Aspirin 81 mg p.o. daily. 6. Celebrex (COX II inhibitor) 200 mg p.o. daily.
IM|intramuscular|IM|221|222|HISTORY OF PRESENT ILLNESS|It was decided in clinic with Dr. _%#NAME#%_ to proceed with a myomectomy in the expectation that this would decrease or stop the menorrhagia. The patient was placed on Lupron on _%#MMDD2001#%_ and received 11.25 mg dose IM at that time to both shrink the myoma and reduce the blood flow to the myoma. The patient has no significant past medical history except for receiving two units of packed red blood cells in _%#MM#%_ of 2001.
IM|intramuscular|IM|279|280|HISTORY OF PRESENT ILLNESS|The pain persisted for two days and the patient presented to the ER again, again given Rocephin and the patient notes that she was draining blood at that time; it was only a small amount though. On _%#MM#%_ _%#DD#%_, 2002, the patient was seen in the clinic for a second dose of IM Rocephin and at that time she was diagnosed with severe otitis media and sent to a local ear, nose and throat physician.
IM|intramedullary|IM|228|229|HOSPITAL COURSE|Bacteroides Fragilis was found to grow. The patient was initially treated with Flagyl p.o.; however, this was later changed to IV Timentin for improved bone coverage. 2. Ortho: The patient did have removal of his total knee and IM rod. He has a spacer placement. He will be in a hinged knee immobilizer, lock- in extension, until reimplantation can be found.
IM|intramuscular|IM|291|292|DOB|DOB: _%#MMDD1995#%_ _%#NAME#%_ _%#NAME#%_ is an 8-year-old previously healthy female who presented to clinic on the day prior to admission with a two to three day history of ear drainage, puffy eye and sore throat and frontal headache. She also had been having fevers. She received Rocephin IM for periorbital cellulitis, returned the following day, the day of admission, for follow up, and had worsening of the swelling and redness of the eyelid.
IM|intramedullary|IM|196|197|RECOMMENDATIONS|RECOMMENDATIONS: ORIF versus IM rodding. This gentleman may be better off with minimal fixation and casting, given the fact it may split down below but we discussed fibular plating and screws and IM rodding. We will do reduction under anesthesia. He may have some soft tissue juxtaposed in there and that way screw fixation may be best.
IM|intramuscular|IM|199|200|DISCHARGE MEDICATIONS|2 History of CVI, with left hemiparesis. 3 Ovarian cancer 18 years ago, with probable recurrence, with CA 125 elevation to 171. DISCHARGE MEDICATIONS: 1. Morphine 10-30 mg SL q.2h. p.r.n. or 5-10 mg IM q.2h. p.r.n. 2. Tylenol suppository 650 mg PR q.4h. p.r.n. 3. Ativan 1-2 mg IM q.2h. p.r.n. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 65-year-old woman, residing in an assisted living facility, who came in for increasing weakness and lethargy.
IM|intramuscular|IM|191|192|HOSPITAL COURSE|O2 sats remained above 92 percent for 24 hours prior to discharge. He does have intermittent oxygen throughout his hospital stay. He was started on oral steroids, Orapred, and given Rocephin IM for possible pneumonia. X-ray showed no infiltrated subsequently after review by the radiologist. PLAN: He was discharged home on Zithromax, prednisolone, and albuterol nebs q. 4 hours.
IM|intramuscular|IM|135|136|DISCHARGE MEDICATIONS|6. Os-Cal 1000 mg q day. 7. Multivitamin daily. 8. Vitamin E 400 IU daily. 9. Prednisone 5 mg a day. 10. Methotrexate 25 mg/mL, 1.2 mL IM q. Tuesday. 11. Flonase. 12. Macrobid 100 mg b.i.d. for UTI. 13. Tequin 400 mg q.d. x 10 days. DISCHARGE PLAN: She was discharged to a transitional care unit.
IM|intramuscular|IM|160|161|DISCHARGE MEDICATIONS|3. Claritin 10 mg p.o. daily. 4. Senna 2 tabs p.o. b.i.d. 5. Neurontin 600 mg p.o. t.i.d. This is a change from her admission medication. 6. Avonex 30 ________ IM q. Friday. 7. Sorbitol 30 cc p.o. daily. 8. Effexor XR 200 mg p.o. daily. 9. ______________ 50 mg p.o. b.i.d.
IM|intramuscular|IM|247|248|HOSPITAL COURSE|On the day of discharge, it was noted that patient had left bibasilar crackles and was sent for a chest x-ray which revealed a very small consolidation of the left lower lung base which could potentially be an infiltrate. The patient was given an IM of Rocephin 2 g and also was given a prescription of an albuterol inhaler and advised to continue to take deep breaths and use her incentive spirometer.
IM|intramuscular|IM|130|131|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Chronic hepatitis C, genotype 4, status post 22 weeks of Ribavirin. 2. Coinfection with hepatitis B. with IM carrier state followed by Dr. _%#NAME#%_ _%#NAME#%_. 3. History of a duodenal ulcer diagnosed by esophagogastroduodenoscopy status post treatment for Helicobacter pylori, no evidence for varices.
IM|intramuscular|IM|204|205|PAST MEDICAL HISTORY|4. She has a history of a previous DVT, has been on chronic Coumadin, it is indicated that she has an IVC filter. Again, we have no records of this. 5. She has a history of B12 deficiency and has been on IM injections monthly. 6. She has a history of dementia. 7. She is status post a hysterectomy following a tubal pregnancy.
IM|intramuscular|IM|192|193|PLAN|15. Colace 100 mg po daily. 16. Bactroban ointment applied to suprapubic catheter wound site daily for one week. 17. Albuterol meter dose inhaler two puffs qid prn. 18. Vitamin B-12 1,000 mcg IM each month. 19. Senokot 10 milliliters q hs prn constipation. 20. Monitor her sugar daily. Call Dr. _%#NAME#%_ with progress report in approximately one week or earlier if needed.
IM|intramuscular|IM,|139|141||She lives with her mother. She was working at the (_______________) Starbucks. Heroin was her drug of choice; she was using intravenously, IM, and subcutaneous for 6 months. She mentions today that she has had no previous treatment. The patient was detoxed with buprenorphine and did fairly well.
IM|intramuscular|IM|183|184|DISCHARGE MEDICATIONS|The patient is to continue the antibiotics for the next 4 days as an outpatient. 12. Methadone 20 mg p.o. b.i.d. 13. Percocet 5/325 p.o. q.4-6 h. p.r.n. pain. 14. Depo-Provera 150 mg IM q. 3 months. 15. Silvadene cream apply to incision p.r.n. DISCHARGE INSTRUCTIONS: The patient is to follow up in Transplant Clinic on Wednesday, _%#MM#%_ _%#DD#%_, 2005, at 10:30 a.m. The nursing staff on 6B were instructed to schedule that appointment.
IM|intramuscular|IM|239|240|ADMISSION MEDICATIONS|PAST MEDICAL HISTORY: History of substance abuse with methadone being her drug of choice. Treatment completed approximately 1 week prior to admission. ADMISSION MEDICATIONS: None, although she had large doses of Valium and Versed and 2 mg IM of Ativan and 5 mg IM of Haldol prior to admission here. SOCIAL HISTORY: The patient is married, though separated from her husband.
IM|intramuscular|IM|224|225|HISTORY OF PRESENT ILLNESS|On Friday, _%#MMDD2005#%_, the patient went to the Fairview Ridges Emergency Department and was seen by Dr. _%#NAME#%_ _%#NAME#%_, a urologist at Fairview Ridges, and the patient received (per the patient report) 2 doses of IM terbutaline without resolution of the priapism. Per Dr. _%#NAME#%_'s notes, the patient received an intracorporeal injection of terbutaline by the emergency department staff.
IM|intramuscular|IM|180|181|DISCHARGE MEDICATIONS|8. Pancrecarb EC cap MS-8 12 capsules with meals, 6 capsules with snacks. 9. Protonix 40 mg twice daily. 10. Vitamin K 5 mg daily. 11. Depo-Testosterone cypionate 200 mg injection IM q.2 weeks. 12. Ursodiol 300 mg twice daily. 13. Vitamin E 400 units daily. 14. Zithromax 250 mg daily. 15. Imipenem/cilastatin 750 mg IV q.8h. up until _%#MMDD2007#%_ and further therapy to be based the clinic visit.
IM|intramuscular|IM|249|250|PATIENT|No history of trauma. The patient had been diagnosed with superficial vein thrombosis 5 years ago and was treated with Lovenox and warfarin for over 3 months. This is the second episode of superficial phlebitis. The patient was given tramadol 30 mg IM and was stable throughout the day and was discharged home with subcutaneous Lovenox 120 mg daily to follow at Smiley Clinic for evaluation of Lovenox treatment and superficial vein thrombosis.
IM|intramuscular|IM|195|196|ASSESSMENT AND PLAN|I will keep him n.p.o. until she sees him. Likely he will at least need his stitches removed. He may need operative debridement as well. She will be making this call. 2. He did receive a dose of IM ceftriaxone today and also has had p.o. Augmentin. I will, however, go ahead and start him on vancomycin given the potential serious nature of this wound.
IM|intramuscular|IM|221|222|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 132/71, pulse 80, respirations 18, temperature 98.2. GENERAL: The patient currently sleeping. She was very agitated and yelling in the ER so she was given 10 mg of Geodon IM in the ER and currently patient is sleeping. HEENT: Head atraumatic, normocephalic. Eyes, pupils small constricted reactive to light.
IM|intramuscular|IM|197|198|HISTORY OF PRESENT ILLNESS|Similar illness was also seen in other Daycare children. The patient was seen at the Quello Clinic where IM ceftriaxone was administered and the patient was seen yesterday here in the clinic where IM ceftriaxone was re-administered. Evaluation here today showed weight down to 20 pounds 14 ounces with a previous weight of 23 pounds, so a total weight loss of 2 pounds.
IM|intramuscular|IM.|120|122|MEDICATIONS|MEDICATIONS: 1. Celebrex 200 mg one a day. 2. Effexor SR 75 mg a day. 3. Vicodin prn. 4. Methotrexate 35 mg once a week IM. ILLNESSES: 1. History of rheumatoid arthritis, currently followed by Dr. _%#NAME#%_ at Park Nicollet Medical Center.
IM|intramuscular|IM|158|159|MEDICATIONS|OB history: Four term vaginal deliveries including delivery of twins. One prior miscarriage. GYN history: Otherwise unremarkable. MEDICATIONS: Lupron 3.75 mg IM times one on _%#MMDD2002#%_ as well as Synthroid. ALLERGIES: NONE. SOCIAL HISTORY: She is an attorney. She is married.
IM|intramuscular|IM|140|141||She went home and came back again. At that time, was a tight 1 cm but very uncomfortable. She was also exhausted, so she was 15 mg morphine IM in order to be able to have some pain relief and rest. When she awakened, she was having more contractions and at that time, her cervix was 1+ and 60%.
IM|intramuscular|IM|176|177|DATE OF ADMISSION|No known injury either previous or acute, no over-use pattern. He was seen by _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, our physician assistant, and on that day he was given a gram of IM Rocephin and told to elevate and rest and he states that he did. He returned on _%#MMDD2003#%_, again given 1 g IM Rocephin, knee about the same.
IM|intramuscular|IM|162|163|CURRENT MEDICATIONS|8. Cardizem 360 mg PO Q day 9. Fosamax 1 mg PO Q Wednesday 10. Temazepam 15 mg PO two tablets at HS. 11. Glucosamine 750 mg PO b.i.d. 12. B12 injection 1,000 mcg IM Q 8-10 days. 13. Vitamin E unsure of the dose. This is probably 400 International Units. 14. Flonase nasal spray two sprays bilaterally Q day.
IM|intramuscular|IM|147|148|DISCHARGE MEDICATIONS|Also negative for H. pylori and negative for a urine culture. DISCHARGE MEDICATIONS: 1. Ferrous gluconate 325 mg p.o. b.i.d. 2. Vitamin B12 100 mc IM q.d. for the next five days at Smiley's Clinic and then 100 mc monthly IM. 3. Darvocet-N 100 1 tab p.o. q4h p.r.n. #12.
IM|intramuscular|IM.|159|161|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Ferrous gluconate 325 mg p.o. b.i.d. 2. Vitamin B12 100 mc IM q.d. for the next five days at Smiley's Clinic and then 100 mc monthly IM. 3. Darvocet-N 100 1 tab p.o. q4h p.r.n. #12. 4. Protonix 40 mg, take 1 tablet daily. DISCHARGE INSTRUCTIONS: FOLLOW-UP: 1. Smiley's Clinic in two weeks.
IM|intramuscular|IM|127|128|HISTORY OF PRESENT ILLNESS|Additionally, the patient began to have a cough with low-grade fevers to 99.0 five days ago, and three days ago was started on IM Rocephin. Nonetheless, she did not improve. Currently the patient, who is mildly to moderately demented, denies any pain to me, but does complain of a cough.
IM|intramuscular|IM|229|230|IDENTIFICATION|LABORATORY DATA: She had labs drawn on admission. They were essentially within normal limits. HISTORY AND PHYSICAL: Dr. _%#NAME#%_ _%#NAME#%_ did a history and physical. See his dictation. ALLERGIES: 1. IBUPROFEN. 2. LACTOSE. 3. IM IMITREX. DISCHARGE STATUS: She was alert, oriented, and cooperative. Her speech was regular in rhythm and rate and normal in volume and tone.
IM|intramuscular|IM|147|148|DISCHARGE MEDICATIONS|She is to limit her apple juice to 2 ounces. She can mix Pedialyte into 2 ounces of apple juice. She will also need another 0.25 mL of flu vaccine IM x1 in 4 weeks for her second dose. There are no further restrictions. It was a pleasure to be involved in _%#NAME#%_'s medical care.
IM|intramuscular|IM|143|144|IDENTIFICATION|On _%#MM#%_ _%#DD#%_, 2005, later in the shift, the Geodon orders were clarified to 120 mg oral every 2 hours as needed for agitation or 20 mg IM if needed with repeat x1. On _%#MM#%_ _%#DD#%_, 2005, because of her level of agitation and intrusiveness with other clients, she required the use of a Geri-chair for a period of time.
IM|intramuscular|IM|131|132|MEDICATIONS ON DISCHARGE|MEDICATIONS ON DISCHARGE: Includes allopurinol 300 mg p.o. daily, Zofran 4 mg p.o. q.6 h. p.r.n. for nausea, vitamin B12 injection IM 100 mcg q.1 month, Entocort EC 9 mg p.o. q.a.m., Imuran 100 p.o. daily, abd Vicodin 1 to 2 tablets q.6 h. p.r.n., 10 tablets total. FOLLOWUP: 1. With primary physician, Dr. _%#NAME#%_ Smiley's Clinic in 1 week.
IM|intramuscular|IM|154|155|ASSESSMENT AND PLAN|2. Benign prostatic hypertrophy. On Hytrin continue medications via NG tube. 3. Prostate cancer: Due for Lupron injection, the patient will receive 30 mg IM injection this admission. Plan was discussed with his urologist, Dr. _%#NAME#%_. 4. Hypertension: Good control of blood pressure. Continue atenolol 25 mg dose daily via NG tube.
IM|intramuscular|IM|179|180|DISPOSITION|Diet is regular. Activity is as tolerated. A walker is recommended to maintain balance and stability. A prescription is written for one walker for life time use. Pneumovax 0.5 ml IM prior to discharge for pneumonia prophylaxis. The social worker has identified a primary care physician for them to follow-up with.
IM|intramuscular|IM|149|150|DISCHARGE MEDICATIONS|5. Seroquel 25-50 mg p.o. q. 6 h as needed for agitation. 7. Trazodone 50-100 mg p.o. each day at bedtime as needed for sleep. 8. Ceftriaxone 1 gram IM for an additional 3 days. I will be following the patient over on Psychiatry and will come to see him tomorrow to evaluate the condition of his cellulitis.
IM|intramuscular|IM|200|201|MEDICATIONS|ALLERGIES: THE PATIENT IS ALLERGIC TO CODEINE AND PENICILLIN. MEDICATIONS: On presentation included the patient's recent discharge medications as elaborated by Dr. _%#NAME#%_. 1. Vitamin B12 1000 mcg IM q.4h. weeks. 2. Lasix 80 mg p.o. b.i.d. 3. Toprol-XL 12.5 mg p.o. b.i.d. 4. Remeron 30 mg p.o. q.h.s. 5. Multivitamins 1 p.o. q. day.
IM|intramuscular|IM|164|165|DISCHARGE MEDICATIONS|7. Diastat 5 mg PR q. 30 minutes p.r.n. seizures. 8. Ativan 1 mg p.o. p.r.n. seizures. 9. Xopenex 1.25 mg inhale q6 hours p.r.n. dyspnea. 10. EpiPen junior 0.15 mg IM p.r.n. anaphylaxis. 11. Benadryl 25 mg p.o. once p.r.n. anaphylaxis. 12. Zantac 25 mg p.o. twice a day. 13. Zyrtec 5 mg p.o. twice a day.
IM|intramuscular|IM|163|164|MEDICATIONS|She is married, lives with her husband in town. She drinks one glass of wine a day. She does not smoke. MEDICATIONS: Citalopram, Prilosec, trazodone, Enbrel 50 mg IM q. Saturday. She is also on a medication for her heart racing; she cannot remember the name. REVIEW OF SYSTEMS: CARDIOVASCULAR: No chest pain. No known heart disease.
IM|intramedullary|IM|192|193|HISTORY OF PRESENT ILLNESS|He had been doing well up until recently, however, several days ago he had acute onset of left thigh pain. He presented to the Orthopedic Clinic where x-rays were performed and failure of the IM nail was noted on radiograph. The most proximal screw hole of the distal interlock screw holes was noted to fail. The patient was given the option for operative treatment, which he accepted.
IM|intramuscular|IM|350|351|PROBLEM #2|As we know that she could not even tolerate amoxicillin or clarithromycin, we decided to discharge her with 3-day course of ceftriaxone, the first dose being given IV on her last day of hospitalization, and we have arranged for her to come to Masonic Cancer Center on _%#MMDD2007#%_ and also on _%#MMDD2007#%_ to receive her second and third dose of IM ceftriaxone for the completion of UTI treatment. She voiced understanding and she was grateful that we are able to avoid giving her any more oral antibiotics which is most likely playing a role in her gastritis or stomach upset exacerbation.
IM|intramuscular|IM|209|210|DISCHARGE MEDICATIONS|EXTREMITIES: No clubbing, cyanosis or edema. NEUROLOGICAL: Intact. DISPOSITION: To Psychiatry with follow up with the psychiatric physicians. DISCHARGE MEDICATIONS: Include, 1. MSSA protocol. 2. Toradol 15 mg IM q.6 hours p.r.n. pain. 3. Percocet 1-2 tablets p.o. q.4-6 hours p.r.n. pain. 4. Protonix 40 mg p.o. daily. ALLERGIES: Anaphylactic reaction to penicillin.
IM|intramuscular|IM|138|139|MEDICATIONS|8. Diabeta 5 mg one q. day 9. Forteo injection, just started one injection daily. Recently discontinued Fosamax. 10. Vitamin B12 1000 mcg IM once per month 11. Vitamin D 1000 units daily 12. OxyContin 10 mg at h.s. 13. Tramadol 50 mg 1 to 2 every day p.r.n. pain
IM|intramuscular|IM|152|153|DISCHARGE MEDICATIONS|3. Aspirin 325 mg daily. 4. Multivitamin one daily. 5. Azmacort inhaler two puffs q.i.d. 6. Albuterol inhaler two puffs q.i.d. 7. Vitamin B12, 1000 mcg IM monthly. 8. Lantus insulin 25 units q p.m. 9. Prilosec 20 mg daily. 10. Folic acid 1 mg daily. 11. Synthroid 50 mcg daily. 12. Tylenol 1000 mg q six hours p.r.n. for pain.
IM|intramuscular|IM|167|168|REVIEW OF SYSTEMS|No bruising, bleeding or anesthetic complications. No chest pain. He has not had lipid profile ever drawn that he remembers. He did receive Bicillin 1.2 million units IM on _%#MM#%_ _%#DD#%_ and again on _%#MM#%_ _%#DD#%_. This was for a mildly reactive RPR and antibody screen. This was recommended by Infectious Disease consult for possible co- existent gonorrhea and Chlamydia.
IM|intramuscular|IM|251|252|IMPRESSION|Dr. _%#NAME#%_, Neurologist was gracious enough to see the patient in the ICU and she believes that the patient may have had an episode of pseudoseizure which may represent a muscle spasm. As such the patient is given Demerol 75 mg and Vistaril 25 mg IM for control of her muscle spasm. 3. Mild hypokalemia which will be addressed. 4. Mild hypovolemia. Our plan is to give the patient a bolus of normal saline 500 cc followed by 100 cc per hour with 20 mEq of KCL per liter of fluid.
IM|intramuscular|IM|162|163|DISCHARGE MEDICATIONS|2. Levofloxacin 250 mg p.o. daily x7 days. 3. Metoprolol 12.5 mg p.o. daily. 4. Digoxin 62.5 mcg p.o. daily. 5. Aspirin 81 mg p.o. daily. 6. Vitamin B12 1000 mcg IM daily until _%#MMDD#%_, then 1000 mcg IM once a week x4 weeks, then 1000 mcg IM once a month. Of note, the patient was previously on 2.5 mg of lisinopril and 20 mg of Lasix daily.
IM|intramuscular|IM|126|127|DISCHARGE MEDICATIONS|4. Digoxin 62.5 mcg p.o. daily. 5. Aspirin 81 mg p.o. daily. 6. Vitamin B12 1000 mcg IM daily until _%#MMDD#%_, then 1000 mcg IM once a week x4 weeks, then 1000 mcg IM once a month. Of note, the patient was previously on 2.5 mg of lisinopril and 20 mg of Lasix daily.
IM|intramuscular|IM|165|166|DISCHARGE MEDICATIONS|4. Digoxin 62.5 mcg p.o. daily. 5. Aspirin 81 mg p.o. daily. 6. Vitamin B12 1000 mcg IM daily until _%#MMDD#%_, then 1000 mcg IM once a week x4 weeks, then 1000 mcg IM once a month. Of note, the patient was previously on 2.5 mg of lisinopril and 20 mg of Lasix daily.
IM|intramuscular|IM|147|148|DISCHARGE MEDICATIONS|8. Prilosec 20 mg p.o. daily. 9. Atenolol 50 mg p.o. daily. 10. Prednisone 5 mg p.o. daily. 11. Fosamax 70 mg p.o. weekly. 12. Vitamin B12, 1 gram IM monthly. DISCHARGE FOLLOWUP: The patient will have followup with Dr. _%#NAME#%_ at Oxboro Clinic this coming Friday, as previously scheduled.
IM|intramuscular|IM|144|145|DISCHARGE MEDICATIONS|1. E2. nteric-coated aspirin 81 mg daily. 3. Calcium carbonate with vitamin D 1200 mg tablets 1 tablet twice daily. 4. B-12 injections 1000 mcg IM q.3 weeks. 5. Nexium 40 mg p.o. q. day. 6. Synthroid 0.625 mg daily. 7. Ativan 0.5 mg p.o. q.6h. p.r.n. anxiety, vomiting.
IM|intramuscular|IM|179|180|DISCHARGE MEDICATIONS|2. Atenolol 25 mg daily for 14 days for postoperative cardiac protection. 3. Premarin 0.625 mg daily. 4. Soma 350 mg twice daily p.r.n. back or neck pain. 5. Vitamin B12 1000 mcg IM monthly. 6. Hydrocortisone cream 2.5% to rash 3 times daily p.r.n. 7. Advair 500/50 1 inhalation every 12 hours. 8. Effexor XR 450 mg daily.
IM|intramuscular|IM|168|169|HISTORY OF PRESENT ILLNESS|He developed a fever as high as 102.6 with subsequent tachypnea and associated respiratory distress. He was given an albuterol nebulization and had been given Rocephin IM while in the Emergency Department. He was subsequently admitted for further management. At the time of my evaluation he was still having some intermittent respiratory distress-type symptoms with tachypnea and mild flaring.
IM|intramuscular|IM|213|214|LABORATORY AND DIAGNOSTIC EVALUATIONS|LABORATORY AND DIAGNOSTIC EVALUATIONS: Electrolytes were drawn in the office and showed a sodium of 137, potassium 5.0, chloride 107, bicarbonate of 22 and an anion gap of 8. The patient was again given 200 mg of IM Rocephin in the office and was observed while feeding Pedialyte. Despite feeding only small amounts of the Pedialyte frequently _%#NAME#%_ continued to vomit multiple times while he was in the office.
IM|intramuscular|IM|171|172|PAST MEDICAL HISTORY|Her pain slowly continued to improve and her white count also decreased to normal range. The cultures returned positive for gonorrhea and she was given 250 mg of Rocephin IM and was changed to Doxycycline 100 mg p.o. b.i.d. She was discharged home on _%#MMDD2007#%_ with improvement of her pain although it was there slightly still.
IM|intramuscular|IM|95|96|DISCHARGE MEDICATIONS|17. Dextrose 25 mL injection IV q. 15minutes. p.r.n. hypoglycemia. 18. Glucagon 1 mg injection IM subcutaneously q. 15minutes. p.r.n. severe hypoglycemia. 19. Insulin aspart NovoLog 8 units injection subcutaneously before meals for diabetes.
IM|intramuscular|IM|203|204|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Amlodipine 5 mg once daily. 2. Atenolol 50 mg once a day. 2. Miacalcin nasal spray one spray to one nostril daily, alternating nostrils every other day. 3. Vitamin B12 1000 mcg IM every month 4. Remeron 15 mg at bedtime 5. Zegerid 40/1100 once daily (if not available, then okay to substitute formulary alternative)
IM|intramuscular|IM|176|177|PLAN|2. Hypertension, stable. PLAN: 1. Continue Levaquin 500 mg IV daily. 2. Urine culture and blood culture are pending. Antibiotics will be adjusted accordingly. 3. Demerol 25 mg IM x1 for chills. 4. We will schedule a renal ultrasound for the a.m. to rule out hydronephrosis or structural disease.
IM|intramuscular|IM|139|140|OUTPATIENT MEDICATIONS|14. Allegra 60 mg p.r.n. 15. Zelnorm 6 mg p.o. b.i.d. 16. Aspirin 325 mg p.o. daily. 17. Ambien 10 mg p.o. q.h.s. 18. Vitamin B12 1000 mcg IM q. month. HOSPITAL COURSE: The patient underwent an uncomplicated gastric bypass on _%#MMDD2004#%_.
IM|intramuscular|IM|234|235|HISTORY OF PRESENT ILLNESS|Positive nausea and vomiting. She was admitted on _%#CITY#%_ _%#CITY#%_ on _%#MM#%_ _%#DD#%_, 2004, and given the following: A fentanyl patch 100 mcg every 3 days, Phenergan 25 mg p.r. q. 6 h., Zofran 4 mg IV q. 4 h., Vistaril 100 mg IM q. 4 h., morphine 10 mg IM p.r.n. and chronic. She used marijuana 1 to 2 days for the nausea and vomiting.
IM|intramuscular|IM|164|165|DISCHARGE MEDICATIONS|15. Lithium 600 mg p.o. q.p.m. 16. Accolate 20 mg p.o. b.i.d. 17. Flovent two puffs b.i.d. 18. Combivent two puffs inhaled q.i.d. 19. Haloperidol 2 to 5 mg p.o. or IM p.r.n. DISCHARGE INSTRUCTIONS: 1. Complete antibiotics and steroid taper as directed above. 2. The patient should be treated with oxygen as needed.
IM|intramuscular|IM|238|239|DISCHARGE MEDICATIONS|CONDITION ON DISCHARGE: ______ DIET ON DISCHARGE: Regular diet. FUTURE FOLLOW-UP: She should follow with Neurology in 4 weeks for history of tonic clonic seizures and CNS aneurysm as described above. DISCHARGE MEDICATIONS: 1. Haldol 5 mg IM q.6 p.r.n. for shortness of breath or upper airway stridor. 2. ________ 35 mg p.o. q. Saturday. 3. Colace 100 mg p.o. q. daily. 4. Cerocite 5 cc p.o. q. daily. 5. Aspirin 325 mg p.o. q. daily.
IM|intramuscular|IM|140|141|DISCHARGE MEDICATIONS|12. Zoloft 100 mg p.o. daily for her depression. 13. Vicodin 5/100 one to two tabs p.o. q. 4-6h. p.r.n. for pain. 14. Morphine 1-2 mg IV or IM every 4 hours as needed for pain that breaks through the Vicodin. FOLLOW UP: 1. The patient is to follow up in the INR clinic at Fairview Ridgevalley in 3 days for an INR check with the INR nurse.
IM|intramuscular|IM|198|199|IMPRESSION AND PLAN|EXTREMITIES: Without edema. Peripheral pulses are intact. LABORATORY DATA: Pending. IMPRESSION AND PLAN: 1. Worsening cellulitis and possible abscess in the right groin and thigh despite outpatient IM Rocephin and p.o. Augmentin treatment. Whether this is secondary to insufficient antibiotics or if it is MRSA not being covered. 2. Agree with admission. Check blood cultures. Wound culture, CBC, blood sugar.
IM|intramuscular|IM|131|132|FOLLOWUP|FOLLOWUP: _%#NAME#%_ was instructed to follow up in the oncology clinic on _%#MMDD2007#%_. At that day, he will receive his day 20 IM chemotherapy. It was a pleasure to be involved in _%#NAME#%_'s medical care. Please do not hesitate to contact me if you have any questions or concerns.
IM|intramuscular|IM|235|236|HISTORY OF PRESENT ILLNESS|She continued to have difficulty breathing with a barky cough and her symptoms worsened until Friday p.m. when she went to the Fairview Southdale Hospital ER, was diagnosed with croup and treated with racemic epi nebs x 2 and Decadron IM x 1 with minimal response per parents. Per parents, she continued to have difficulty breathing at home, was restless at night and had a barky cough on Saturday, Sunday and Monday.
IM|intramuscular|IM|140|141|DISCHARGE MEDICATIONS|6. Diabetes mellitus. 7. Seizure disorder. The patient will be discharged to Augustana Nursing Home. DISCHARGE MEDICATIONS: 1. Rocephin 1 g IM to be completed after _%#MMDD2007#%_. 2. Senna 1 twice a day. 3. Tylenol on a p.r.n. basis. 4. Insulin Lantus 18 units subcu every morning. Blood sugars to be monitored on a b.i.d. basis.
IM|intramuscular|IM.|150|152|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Norvasc 5 mg daily. 2. Atenolol 25 mg daily. 3. Celexa 20 mg daily. 4. Plavix 75 mg daily. 5. B12 1000 mcg every four weeks IM. 6. Flexeril 10 mg t.i.d. p.r.n. 7. Colace 100 mg b.i.d. p.r.n. 8. Vytorin 10/20 one q. day. 9. Neurontin 300 mg nightly. 10. Lisinopril 40 mg daily.
IM|intramedullary|IM|318|319|ADMISSION DIAGNOSIS|HISTORY OF PRESENT ILLNESS: This is a 44-year-old gentleman with a history of osteogenesis imperfecta who presented to clinic with a broken distal intramedullary femoral nail approximately 1 year after osteotomy at the proximal and distal femur. He was presented with the risks, benefits, and alternatives of revision IM nailing and removal of the broken nail. Additionally, he understood the need for surgery and had significant pain and wished to proceed.
IM|intramuscular|IM|266|267|HOSPITAL COURSE|For most of her hospitalization, the patient continued to oscillate between occasional an angry outburst, that would even be threatening at times, and then returned to a sweeter, less labile mood. The patient improved on risperidone therapy, and agreed to taking an IM Depo injection of Risperidone Consta 25 mg q. 2 weeks. Additionally, Ativan was discontinued from her outpatient drug regimen.
IM|intramuscular|IM|211|212|HISTORY OF PRESENT ILLNESS|Her blood pressure was 70s-80s/40s-50s. Her post-operative hemoglobin was 6.3. She had a fibrinogen of 152 and an INR of 1.38 and a PTT of 33. The patient was given IV Pitocin as well as two doses of Methergine IM and 800 mcg of Cytotec per rectum. However, despite this, the patient continued to bleed and pass clots per vagina. The patient received 6 units of packed red blood cells after the cesarean section in the recovery room.
IM|intramuscular|IM|207|208|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE/SIGNIFICANT FINDINGS|7. Albuterol inhaler 2 puffs q.i.d. 8. Calcium carbonate plus vitamin D 1250 mg p.o. q.d. 9. Xolair injections every 14 days. 10. Quinine 260 mg p.o. q.h.s. p.r.n. for leg cramps. 11. Lupron injection 30 mg IM every 4 months. 12. Levofloxacin 500 mg p.o. q.d. for 14 days; this was added at the time of discharge. 13. Ranitidine 150 mg p.o. q.h.s. 14. Allegra 180 mg p.o. q.d.
IM|intramuscular|IM|156|157|HOME MEDICATIONS|5. Tylenol 1,000 mg q.i.d. 6. Morphine sulfate 2-5 mg IM every 3-6 hours p.r.n. 7. Duonebs 2.5 to 5 mg per nebulizer q.i.d. p.r.n. 8. Haldol 1 mg orally or IM every 6 hours p.r.n. 9. Senokot two tablets daily 10. Milk of Magnesia one ounce every 12 hours p.r.n. 11. Spot oximetry b.i.d. and p.r.n. 12. Septra DS. This treatment was completed on _%#MMDD2006#%_.
IM|intramuscular|IM|170|171|DISCHARGE MEDICATIONS|8. NovoLog insulin. 9. Lantus insulin. 10. Dicloxacillin 500 mg p.o. q. 6 hours. 11. TOBI 300 mg nebs b.i.d. 12. Ciprofloxacin 750 mg nebs b.i.d. 13. Testosterone 200 mg IM q. 2 weeks. 14. An insulin scale.
IM|intramuscular|IM|113|114|MEDICATIONS|8. Detrol 2 mg p.o. b.i.d. 9. Luvox 250 mg p.o. q.h.s. 10. Flonase to each nares q. day. 11. Haldol 5 mg p.o. or IM q.4h. p.r.n. agitation. 12. Triamcinolone cream b.i.d. to affected areas. 13. oxybutynin 5 mg p.o. t.i.d. ALLERGIES: SHE IS REPORTEDLY ALLERGIC TO PENICILLIN, TO QUELL AND OPIOID ANALGESICS.
IM|intramuscular|IM|234|235|PROCEDURES|However, the patient has been complaining of epigastric pain. She was seen at an outside hospital where an upper GI was performed which was negative per the patient. Also, from that hospitalization, the patient was given some Demerol IM which she has required q.laparoscopic. She reports some nausea when the pain is severe. The patient denied any history of fevers, chills, hematochezia or melena.
IM|intramuscular|(IM)|162|165|HOSPITAL COURSE|A small residual suture anchor and suture were removed. Following surgery she had a difficult recovery in terms of postsurgical pain which required intramuscular (IM) pain medication extending to the fourth postoperative day. She was kept in for postsurgical pain control. Arrangements were then made for her return home with a home health aide as she did not have adequate support at home for bathing, home care, etc.
IM|intramuscular|IM|144|145|DISCHARGE MEDICATIONS|4. Norvasc, 5 mg q.d. 5. Spironolactone, 12.5 mg t.i.d. 6. Coreg, 3.125 mg b.i.d. 7. Enteric aspirin, 81 mg p.o. q.d. 8. Vitamin B12, 1,000 mcg IM monthly (on about the 2nd or 3rd of each month). 9. Lasix, 80 mg q.d. 10. Gemfibrozil, 600 mg p.o. b.i.d.
IM|intramuscular|IM|155|156|RECOMMENDATIONS FOR FOLLOW UP|2. Continue to encourage low tyramine and no caffeine in diet. 3. Make appropriate follow up for pain control. 4. Encourage patient that receiving Demerol IM on a as occasion requires basis is not appropriate pain management.
IM|intramuscular|IM|128|129|DISCHARGE MEDICATIONS|18. Flomax 400 mcg tablet p.o. daily. 19. Seroquel 25-50 mg tablet p.o. q.i.d. p.r.n. for agitation. 20. Geodon 20 mg injection IM t.i.d. p.r.n. for agitation. FOLLOWUP: The patient will be transferred to inpatient Psychiatry for further evaluation of his suicidal and homicidal ideation as well as treatment of his schizoaffective disorder and posttraumatic stress disorder.
IM|intramuscular|IM|174|175|MEDICATIONS AT TIME OF DISCHARGE|10. Ferrous sulfate 325 mg p.o. t.i.d. 11. Protonix 40 mg p.o. daily. 12. Lantus insulin 13 units subcutaneous each day at bedtime. 13. Vitamin B12 1000 mcg/mL solution 1 mL IM injection monthly. 14. Suboxone 4 mg p.o. t.i.d. for a total daily dose of 12 mg. Note, maximum dose during this hospitalization was 24 mg in total for the day.
IM|intramuscular|IM|159|160|PLAN|4. Omeprazole 20 mg q. day taken 36 minutes before first meal daily 5. Ambien 5 mg q. day p.r.n. sleep 6. Enalapril 10 mg p.o. q. day 7. Vitamin B12 1,000 mcg IM each month 8. Extra Strength Tylenol 1-2 every 4-6 hours p.r.n. 9. Aspirin 81 mg p.o. q. day with food 10. Plavix 75 mg p.o. q. day
IM|intramuscular|IM|155|156|MEDICATIONS|6. Prilosec 20 mg b.i.d. 7. Tincture of opium 0.6 cc t.i.d. for high output ileostomy 8. KCl 20 mEq daily 9. Etodolac 400 mg b.i.d. 10. Testosterone 10 mg IM weekly 11. Procrit. ALLERGIES: Listed include penicillin, cimetidine, questionable allergy to Levaquin.
IM|intramedullary|IM|113|114||This 56-year-old male suffered a right tib-fib fracture on _%#MMDD2007#%_. He underwent surgical correction with IM tibial nail and screws. HOSPITAL COURSE: The patient had some mild anemia, mild increased temperature.
IM|intramuscular|IM|132|133|HISTORY  OF PRESENT ILLNESS|There is no preceding history of facial laceration. The patient went to Oxboro Urgent Care over the weekend and was given a dose of IM antibiotics and was given a course of Augmentin. He then was referred to a clinic in the physicians building and they sent him over to the emergency room for further evaluation.
IM|intramuscular|IM|138|139|MEDICATIONS|9. Senna 8.6 mg 1 tab twice a day. 10. Compazine 10 mg 1 tab t.i.d. p.r.n. for nausea. 11. Gas-X 80 mg at bedtime. 12. Vitamin B12 0.1 mL IM every month. Her last dose was _%#MMDD2006#%_ so she is due for a dose on _%#MMDD2007#%_. 13. Centrum vitamins. 14. FiberCon. 15. Albuterol nebs every 2 hours as needed.
IM|intramuscular|IM|441|442|MEDICATIONS|She has periods of lesser and greater activity. In the last four weeks, she has had 10 visits to the ER because of pain uncontrolled with her oral medications, and finally last night when she got there, it was clear that she would need ongoing pain control, that oral medications wouldn't be enough. MEDICATIONS: Neurontin 600 mg t.i.d., amitriptyline 25 mg q. hs, Serzone 200 mg p.o. b.i.d., Topamax 25 mg two tablets b.i.d., Avonex 30 mcg IM once a week on Thursdays. ALLERGIES: No known drug allergies. PAST SURGICAL HISTORY: She has had no surgeries.
IM|intramedullary|IM|196|197|ADMISSION DIAGNOSIS|His left lower extremity was approximately 5 cm longer than his right. Treatment options were discussed with him, and the patient wished to proceed with a closed femoral shortening procedure with IM nailing. The risks, benefits, and alternatives were discussed with the patient and he wished to proceed. PAST MEDICAL HISTORY: Status post left nephrectomy secondary to renal stones performed in 1993.
IM|intramuscular|IM|143|144|CLINIC COURSE|Atrovent added in every 6 hours. Oxygen to keep her O2 sats above 90, and because she prefers injectable, I will give her Solu-Medrol at 10 mg IM every 8 hours and have her reevaluated tomorrow. I have discussed the possibility of an aspiration with the mother and the child.
IM|intramuscular|IM|117|118|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. We recommended he continue with his Celexa 30 mg daily. 2. Vitamin B12 1000 mcg injections IM every 4 week. 3. Folic acid 1 mg daily. 4. Guanfacine 600 mg b.i.d. 5. Mevacor 20 mg at night and evening. 6. Lopressor 12.5 mg daily.
IM|intramuscular|IM|159|160|MEDICATIONS|ALLERGIES: No known drug allergies. MEDICATIONS: Betoptic ophthalmic ointment 0.25% daily. Baclofen 20 mg each day at bedtime 15 mg q.i.d. Avonex 30 microgram IM per schedule. Senokot 1 tablet p.o. b.i.d. Mirapex 0.125 mg p.o. q.4 hours p.r.n. Restoril 30 mg p.o. q.6 hours p.r.n. Zanaflex 2 mg p.o. q.i.d. SOCIAL HISTORY: As stated above in HPI.
IM|intramuscular|IM|158|159|DISCHARGE MEDICATIONS|5. Lisinopril 20 mg p.o. daily. 6. Claritin 10 mg daily. 7. Prilosec 20 mg daily. 8. Benadryl 25 mg p.o. each day at bedtime p.r.n. 9. Haldol Decanoate 50 mg IM once every 4 weeks. 10. Aspirin 81 mg p.o. daily. 11. Ibuprofen 600 mg t.i.d. 12. Calcium carbonate 500 mg 1 tablet p.o. b.i.d.
IM|intramuscular|IM|183|184|DISCHARGE MEDICATIONS|2. Haldol 6 mg p.o. or IM nightly. 3. Cogentin 1 mg p.o. or IM nightly with Haldol. 4. Depakote 1000 mg p.o. nightly. Client was discharged with a plan to have Haldol Decanoate 50 mg IM q.2 weeks. Had been refusing IM Decanoate, service hearing was scheduled for _%#MM#%_ _%#DD#%_, 2006.
IM|intramuscular|IM|321|322|HOSPITAL COURSE|This was completed on _%#MM#%_ _%#DD#%_. The source for the E coli septicemia was thought to be from his urine despite the normal urinalysis and urine culture done 1 day after receiving ceftriaxone. 3. A repeat UA/UC done on _%#MM#%_ _%#DD#%_, 2006 was negative. 4. Renal: Given that the urine may have cleared after the IM ceftriaxone in the emergency department on _%#MM#%_ _%#DD#%_, 2006, a renal ultrasound was done during hospitalization which was normal, and a VCUG will be done when antibiotics are complete as an outpatient.
IM|intramuscular|IM|200|201|DISCHARGE MEDICATIONS|The patient's peak and trough levels on this dose were appropriate and are considered therapeutic. 2. Aricept 10 mg p.o. daily. 3. Benefiber 1 scoop p.o. t.i.d. with meals. 4. Cyanocobalamin 1000 mcg IM q/month. 5. Diazepam 5 mg p.o. b.i.d. 6. Docusate liquid 100 mg p.o. b.i.d. 7. Ear otic 6.5% 5 drops both ears on the _%#DD#%_ and _%#DD#%_ of each month.
IM|intramedullary|IM|257|258|ADMISSION DIAGNOSIS|OPERATIONS/PROCEDURES PERFORMED: Left ankle IM rod removal and tibial and fibular open reduction and internal fixation. Ms. _%#NAME#%_ was admitted to University of Minnesota Medical Center, Fairview, on _%#MM#%_ _%#DD#%_, 2006, after undergoing left ankle IM rod removal, tibial open reduction and internal fixation, also fibular open reduction and internal fixation at Minnesota Sports Medicine Center on _%#MM#%_ _%#DD#%_, 2006.
IM|intramedullary|IM|106|107|PROCEDURE|ADMIT DIAGNOSIS: Left femur malunion. POSTOPERATIVE DIAGNOSIS: Left femur malunion. PROCEDURE: Left femur IM nail removal, osteotomy and left femur ORIF with plate on _%#MMDD2007#%_. HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: _%#NAME#%_ is a 45-year-old male who underwent the above-stated procedure on _%#MMDD2007#%_.
IM|intramedullary|IM|133|134||Upon return to the office earlier this week, she was found to have loss of fixation and consequently was admitted for removal of the IM rod and screws and placement of a hemiarthroplasty. This surgery was performed on _%#MMDD#%_. Her postoperative course is documented in the medical record.
IM|intramuscular|IM|224|225|ASSESSMENT/PLAN|The fact that the infection started within 12 hours of the bite is very suggestive of pasteurella multocida infection as most other infections tend to follow within 2 to 3 days. Pasteurella should have responded both to the IM Rocephin as well as the oral Augmentin. It may be, however, because of the depth of the infection, that she either has involvement of deeper structures or needs IV medication.
IM|intramedullary|(IM)|162|165|DISCUSSION|Her choices are to stay in a long leg cast and pursue cast treatment for a period of about 18-20 weeks; the other option would be to go ahead with intermedullary (IM) rodding of the fracture. I had a general discussion with both the patient, her brother, and her somewhat guardian-type person regarding the pros and cons of each and discussed the possibilities of problems of wound healing, infection, neurovascular injury, stiff knee, thrombophlebitis, and future screw and/or rod removal.
IM|intramuscular|IM|162|163|PAST MEDICAL HISTORY|The patient is followed by Dr. _%#NAME#%_. Per Oncology notes, the tumor is unresectable and the patient refused chemotherapy. He is currently being treated with IM octreotide. 2. History of chemical dependency including alcohol abuse as well as a history of heroin dependency. The patient has been on chronic methadone therapy for the last five years.
IM|intramuscular|IM.|178|180|ADMISSION MEDICATIONS|3. History of hepatitis C. ADMISSION MEDICATIONS: 1. Methadone 100 mg p.o. q.d. 2. Trazodone. 3. Lactulose 1-4 tablespoons once a day, per patient. 4. Wellbutrin. 5. Sandostatin IM. HOSPITAL COURSE: PROBLEM #1: Mental Status. On admission the patient was noted to be arousable with stimulation; however, he was often drifting off.
IM|intramuscular|IM|126|127|HISTORY OF PRESENT ILLNESS|The patient was given Mucomyst 7 gm initially in the emergency department followed by Mucomyst 3.5 gm p.o. q. 4h. x 17 doses. IM Tigan was given for nausea. ALLERGIES: No known drug allergies. MEDICATION: No medication on admission.
IM|intramedullary|IM|208|209|IMPRESSION AND PLAN|IMPRESSION AND PLAN: Because the plan would be to perform surgery, if this indeed was a hairline fracture, I have recommended MRI scan to assure that this is fracture. If this is fracture, I have recommended IM rodding. If this is not, I would recommend physical therapy for a torn hamstring.
IM|intramuscular|IM|148|149|PROBLEM #4|The patient was begun on cefazolin IV for post-pacemaker implant prophylaxis. During the night she lost her IV access and cefazolin was switched to IM for a total of one day. Upon discharge her antibiotics were changed to Keflex p.o. for a total of five-day course of antibiotics.
IM|intramuscular|IM|219|220|PLAN|PLAN: This case was discussed with Dr. _%#NAME#%_ _%#NAME#%_ who has accepted transfer of care given early gestation and twin pregnancy. The patient received Nifedipine 30 mg oral load. She received betamethasone 12 mg IM at 04:32. Penicillin prophylaxis was begun. This was discussed in detail with the patient and her husband who express understanding and all questions were answered.
IM|intramuscular|IM|146|147|MEDICATIONS|2. Cardizem-CD 360 mg p.o. q. day. 3. Coumadin per protocol. 4. Glucophage 500 mg p.o. b.i.d. 5. Lasix 20 mg p.o. q. day. 6. Vitamin B12 1000 mcg IM q. month 7. Peri-Colace p.r.n. basis 8. Insulin by sliding scale. REVIEW OF SYSTEMS: The patient admits to frequent loose bowels, two to three times a day over the last several weeks.
IM|intramuscular|IM|138|139|PLAN|ASSESSMENT: Croup. Well-hydrated. Nontoxic. No respiratory distress. PLAN: Will admit for epinephrine nebs. Will administer dexamethasone IM in clinic prior to admission. Close observation of respiratory status and hydration status. Also plan chest x-ray, lateral neck x-ray and NP swab for RSV and for pertussis.
IM|intramuscular|IM|198|199|DISCHARGE MEDICATIONS|She has been considered for a repeat Nissen procedure in surgery and has been worried about that also. DISCHARGE MEDICATIONS: They are as follows, 1. Imuran 150 mg p.o. daily. 2. Methotrexate 25 mg IM every Thursday. 3. Folate 1 pill p.o. every day. 4. Cymbalta 90 mg p.o. daily. 5. Nexium 40 mg p.o. b.i.d. 6. Entocort EG preparation 6 mg p.o. q.a.m. 7. Macrobid 100 mg p.o. b.i.d.
IM|intramuscular|IM|119|120|PROBLEM  LIST|We did treat her with oral replacement of the folate, Thiamine and Pyridoxine. The Vitamin B 12 was given as 1,000 mcg IM injection two days prior to discharge and this should be continued q week times three weeks and then monthly. She received physical therapy and occupational therapy and did demonstrate some improvement prior to discharge.
IM|intramuscular|IM|125|126|MEDICATIONS|He is being discharged to the nursing home to be followed up for comfort measures only. MEDICATIONS: 1. Haldol p.r.n. 1-2 mg IM t.i.d. 2. Ativan 0.5 mg sublingual or IM t.i.d. p.r.n. agitation.
IM|intramuscular|IM|229|230|DISCHARGE MEDICATIONS|Plan is for comfort care. Code status remains DO NOT INTUBATE/DO NOT RESUSCITATE (as previously). DISCHARGE MEDICATIONS: Colace 100 mg twice daily, Senokot two pills daily at bedtime, aspirin 325 mg daily, vitamin B-12 1000 mcgs IM monthly, Depakote 125 mg twice daily, nifedipine XL 60 mg daily, Alphagan one drop in each eye twice daily, albuterol/Atrovent nebs four times daily and every 2 hours p.r.n. dyspnea, oxybutynin 5 mg twice daily, Advair 500/50 one inhalation twice daily, Ibuprofen 400 mg three times daily p.r.n. pain, Effexor XR 37.5 mg twice daily, Tequin 400 mg daily for three days, prednisone 40 mg daily for one more day, and Liquibid 600 mg twice daily.
IM|intramuscular|IM.|138|140|IMPRESSION/PLAN|We will also check a magnesium level. Given the patient's abdominal pain, an order has been written for Demerol 50 mg with Vistaril 25 mg IM. At the present time, however, her abdominal pain is mild-to-moderate in nature. She is gradually becoming more comfortable, especially following treatment with IV Zofran for nausea, which has been prescribed as 4 mg IV q.6h. p.r.n. nausea.
IM|intramuscular|IM|158|159|HISTORY OF PRESENT ILLNESS|Normalization of white count 8400 with hemoglobin of 12.3. Normal BMP. A prealbumin of 24. Mild ALT elevation of 149, thought likely from muscle secondary to IM injections. To be followed up on psychiatry. As of _%#MMDD2007#%_, the patient had improved to the point, where he was felt appropriate for transfer back to inpatient psychiatry.
IM|intramuscular|IM|239|240|HOSPITAL COURSE|The patient's history as well as chest x-ray most suggestive of diagnosis of laryngotracheobronchitis as the cause of his acute onset respiratory distress and cough. The patient had already been given epinephrine nebs as well as 1 dose of IM dexamethasone at the outside hospital, which produced much improvement in his respiratory status. While he remained in the hospital, he had good oxygen saturations on room air.
IM|intramuscular|IM|231|232|EMERGENCY DEPARTMENT COURSE|I am concerned about her pain medicine seeking and the fact that no one is in the room she seems rather comfortable and when we walk in the room she starts moaning as if in severe discomfort. I offered initially some Toradol 30 mg IM and the patient says Toradol will not help and she wants narcotics. I said we would start with 30 of Toradol and when I left the room and went to order, the nurse came out and said the patient had left.
IM|intramuscular|IM|105|106|DISCHARGE MEDICATIONS|6. Diltiazem 60 mg 3 times a day. 7. Nexium 40 mg twice daily. 8. Plavix 75 mg daily. 9. Vitamin B12 1 g IM monthly. 10. Vytorin 10/40 1 tablet oral daily. 11. Percocet 30 tablets dispensed for pain, 1-2 tablets every 4 hours as needed for pain.
IM|intramuscular|IM|138|139|HISTORY OF PRESENT ILLNESS|Dr. _%#NAME#%_ and Dr. _%#NAME#%_ are now considering emergency ECT. Prior to me seeing her, the patient was given a couple milligrams of IM Ativan and, thus, during my visit with her she is somnolent. She will attempt to open her eyes a bit to my voice but otherwise does not follow any commands.
IM|intramuscular|IM.|128|130|MEDICATIONS|3. Potassium chloride 20 mEq. daily 4. Lorazepam 1-2 mg orally or IM Q 2-4 hours prn. 5. Compazine 10 mg Q 4 Hours prn. oral or IM. 6. Tylenol grains 10 Q4 hours prn 7. Vicodin 1-2 tablets Q 4 hours prn. 8. Maalox one ounce daily prn. 9. Peri-Colace one daily prn.
IM|intramuscular|IM|266|267|ALLERGIES|The patient was treated with Robitussin only. No antibiotics. PAST SURGICAL HISTORY: Primary low-segment transverse cesarean section. ALLERGIES: No known drug allergies. Questionable allergy to betamethasone, as her left arm is very red and hot with the rash at the IM site. MEDICATIONS: Ferrous sulfate. SOCIAL HISTORY: The patient is married. He denies use of tobacco, alcohol, or other drugs.
IM|intramuscular|IM|222|223|DISCHARGE MEDICATIONS|The patient was able to tolerate considerable activity while maintaining her O2 sats on room air. She will not be discharged home with any oxygen. DISCHARGE MEDICATIONS: 1. Coumadin 4 mg p.o. q.h.s. 2. Depo-Lupron 2.75 mg IM q. month. Dose given during her hospital stay. 3. Ferrous sulfate 325 p.o. q day. DISCHARGE INSTRUCTIONS: 1. The patient is scheduled to follow up with Dr. _%#NAME#%_, her primary physician, at the HealthPartners _%#CITY#%_ Clinic in the next week.
IM|intramuscular|IM|135|136|HOSPITAL COURSE|He'll be on Levaquin 500 mg a day for 9 additional days for pain control. He'll get Demerol anywhere from 25-75 mg plus Vistaril 25 mg IM or IV every two hours as needed and for anxiety or agitation he can have Ativan .5 to 2 mg IV, IM or po up to every two hours as needed.
IM|intramuscular|IM.|169|171|DISCHARGE MEDICATIONS|DISCHARGE DIAGNOSIS: Intracerebral hemorrhage DISCHARGE MEDICATIONS: 1. Roxanol 20 Smg per cc 10-20 mg sublingual prn. 2. Tylenol. 3. Fosphenytoin 100 mg every 12 hours IM. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was admitted with an intracerebral bleed with intermittently wakeful but mostly lethargic, obtunded.
IM|intramuscular|IM|149|150|HISTORY OF PRESENT ILLNESS|Complains of having some low back pain, otherwise no other concerns. The patient looks mildly distressed in the clinic. She received a Toradol 30 mg IM in the clinic, after that felt a little comfortable. PAST MEDICAL HISTORY: 1. Depression. 2. Fibromyalgia. 3. History of mass in the pubic area in 2002.
IM|intramuscular|IM.|124|126|HOSPITAL COURSE|She was contracting every 2-3 minutes and was 90%, 3, at a minus 2. At 01:50, she received Nubain 15 mg and Phenergan 25 mg IM. At 2:10, she was 90%, 4. The patient received an epidural at 05:50 hours and at 06:15, she was found to be 7 cm.
IM|intramuscular|IM|210|211|PHYSICAL EXAMINATION|She had been discharged about 2 days prior to this admission from Fairview University Medical Center. On admission, Zyprexa 5-10 mg oral or IM was ordered as needed for extreme agitation. Ativan 1-2 mg oral or IM was also ordered for agitation. Trazodone 50 mg at bedtime was ordered if needed for sleep with a repeat x1. The following medications were reordered that she has been on previously: Trazodone 100 mg at bedtime, hydroxyzine 50 mg everyday as needed, NTG 1/150 SL 1 tablet every 10 minutes x3 as needed for chest pain p.r.n., Lexapro 20 mg every a.m., Seroquel 100 mg every a.m., Seroquel 200 mg at bedtime, diltiazem 120 mg every a.m., diltiazem 240 mg at bedtime, Imdur 90 mg at bedtime, Zocor 40 mg at bedtime, lisinopril 2.5 mg every a.m., Florinef 0.1 mg everyday, Nasacort 2 puffs each nostril every evening, Zyrtec 10 mg at bedtime, Depakote ER 1500 mg at bedtime, Abilify 20 mg every a.m., and Lamictal 100 mg every a.m. On _%#MM#%_ _%#DD#%_, 2004, her 72 hour hold was discontinued and she signed- in voluntarily.
IM|intramuscular|IM|137|138|ALLERGIES|2. Lipitor 20 mg p.o. q.d. 3. Levoxyl 0.025 mg p.o. q.d. 4. Prempro 0.625/2.5 mg p.o. q.d. 5. Prilosec 20 mg p.o. q.d. 6. Demerol 100 mg IM with hydroxyzine 50 mg IM p.r.n. migraine. SOCIAL HISTORY: She smokes 1-2 cigarettes per day for the past year.
IM|intramuscular|IM|144|145|DISCHARGE MEDICATIONS|18. Coumadin 0.5 mg on _%#MM#%_ _%#DD#%_. Recheck INR on _%#MMDD2002#%_. 19. Tequin 200 mg qday X 6 days, then discontinue. 20. Compazine 10 mg IM or po q8h as needed for nausea. 21. Zofran 4 mg IM q8h for nausea as well. DISCHARGE FOLLOW-UP: 1. Follow-up with nursing home doctor in _%#CITY#%_ where she will most likely remain.
IM|intramuscular|IM|167|168|ASSESSMENT/PLAN|Will get a CT of his abdomen and pelvis to evaluate for pseudocyst or abscess. Will also get a right upper quadrant ultrasound. The patient will continue with Demerol IM for pain. Will also check amylase and lipase this morning. 1. Alcohol intoxication. Will put the patient on the alcohol withdrawal protocol.
IM|intramuscular|IM|138|139|PLAN|A single nuchal cord was removed with ease. The placenta was delivered intact at 06:12 hours. 3 cord vessels were noted. Pitocin 10 units IM was administered following delivery of the placenta. The cervix, vagina, and perineum were inspected, and a small superficial first degree perineal abrasion was noted.
IM|intramuscular|IM|228|229|PROBLEM #1|She was given hydrocortisone 100 mg IV q.8h. for 24 hours, and then started on oral hydrocortisone 60 mg p.o. x 1 day. She is to be discharged home on her usual dose of 20 mg p.o. q.day of hydrocortisone. She will also be given IM injections in case she has any nausea or vomiting in the future. PROBLEM #2: Viral gastritis. The patient was able to advance her diet.
IM|intramuscular|IM|180|181|DISCHARGE MEDICATIONS|2. Accupril 40 mg p.o. q.a.m. (hypertension). 3. Atenolol 25 mg p.o. q. day (hypertension). 4. Oxybutynin 5 mg p.o. q. day (urinary incontinence). 5. Vitamin B12 1000 mcg/ml, 1 cc IM q. month (B12 deficiency). 6. Nexium 40 mg p.o. q. day (GERD). 7. Celebrex 200 mg p.o. q. day (pain). 8. Percocet 5/325 one to two p.o. q4-6h p.r.n. (pain).
IM|intramuscular|IM.|118|120|MEDICATIONS|7. Iron sulfate, 324 mg b.i.d. 8. Bumex, 0.5 mg p.o. q.d. 9. Ambien, 5 mg q.h.s. p.r.n. 10. B12, 1,000 mcg q. 2 weeks IM. 11. Tramadol, 50 mg p.o. q. 6 hours p.r.n. pain. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: There is no current alcohol.
IM|intramuscular|IM|111|112|MEDICATIONS|8. Proxac100 mg po Q Day. 9. Multiple vitamin 1 po Q Day. 10. Vitamin B6 1 po Q Day. 11. Vitamin B-12 one shot IM q month. 12. Glucophage 1,000 mg po bid. 13. In the evening the patient takes 8 mg. 14. Alprazolam 1 mg at 4 p.m. and 1 mg at hs.
IM|intramuscular|IM|121|122|DISCHARGE MEDICATIONS|8) Folic acid 1 mg daily. 9) Codeine 30 mg three times daily. 10) Coumadin 3 mg daily (resume). 11) Vitamin B12 1000 mcg IM monthly. He was instructed to get his INR checked at our office in four days.
IM|intramuscular|IM|188|189|DISCHARGE MEDICATIONS|8. History of B12 deficiency 9. History of dysphagia, level 3 dysphagia diet recommended per speech therapy 10. History of penicillin allergy DISCHARGE MEDICATIONS: 1. Vitamin B12 1800 mg IM q. month 2. Levaquin 250 mg p.o. on _%#MM#%_ _%#DD#%_, then discontinue 3. Aspirin 81 mg p.o. q.day 4. Ferrous gluconate 325 mg p.o. q.day
IM|intramuscular|IM|191|192|ADMISSION MEDICATIONS|1. Albuterol nebs q4h p.r.n. 2. Ativan 0.5 mg p.o. q8h p.r.n. agitation. 3. Risperdal/Concerta 25 mg IV every two weeks, due this Monday, _%#MM#%_ _%#DD#%_, along with Benadryl 25 mg p.o. or IM every two weeks with the Risperdal for extrapyramidal side effects. 4. Tylenol 325 mg p.o. two tablets t.i.d. 5. Baclofen 10 mg p.o. q.i.d.
IM|intramuscular|IM|231|232|PAST MEDICAL HISTORY|8. History of carotid artery disease. 9. Chronic kidney disease. The patient has endstage kidney disease due to type-2 diabetes. No biopsies were done. He had never been on dialysis. He had no fistula created. He does have a right IM PermCath that was placed recently for the possibility of initiation of dialysis but again, the patient has never been on dialysis in the past.
IM|intramedullary|IM|70|71|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Leg length discrepancy, status post right tibial IM rod for lengthening. PROCEDURE PERFORMED: Exchange IM rod. Mr. _%#NAME#%_ is a 60-year-old man with a leg length discrepancy on the right.
IM|intramuscular|IM|226|227|PAST MEDICAL HISTORY|His exam at two weeks of age was normal. He had a little trouble with an umbilical granuloma which was eventually resolved. He had a febrile illness at two months of age with workup including urine specimen, blood culture and IM Rocephin. The blood culture was coag-negative Staph, and antibiotics were not continued. He also had an episode of gastroenteritis at two months of age.
IM|intramuscular|IM|181|182|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Mesalamine 2400 mg p.o. b.i.d. (new medication). 2. Tylenol 1000 mg p.o. b.i.d. (for osteoarthritis). 3. Aspirin 162 mg p.o. q.d. 4. Vitamin B12, 1000 mcg IM q. month. 5. Protonix 40 mg p.o. q.d. 6. Cardizem CD 240 mg p.o. q.a.m. 7. Remeron 30 mg p.o. q.h.s. 8. Nasonex 1 spray each nostril q.a.m. 9. Relafen 500 mg p.o. b.i.d.
IM|intramuscular|IM|127|128|MEDICATIONS|10. Banana flakes 1 Tbsp. p.o. daily. 11. Acidophilus 1 tablet daily p.r.n. 12. Max EPA 2 g p.o. b.i.d. 13. Sandostatin 80 mcg IM b.i.d. 14. Neurontin 300 mg q.a.m., 600 mg q.p.m. 15. Slo-Mag 2 tablets p.o. q.i.d. 16. Pancrelipase 10,000 mcg 1 to 2 tabs p.o. before each meal.
IM|intramuscular|IM|160|161|ADMISSION MEDICATIONS|On postoperative day 4, the patient was ready for discharge. The patient was instructed on pelvis rest x4 to 6 weeks. The patient was given Depo Provera 150 mg IM x1 for contraception. The patient was instructed on no driving x2 weeks, no driving while taking Percocet. The patient was given prescriptions for Percocet, ibuprofen, Colace, atenolol.
IM|intramuscular|IM|134|135|DISCHARGE MEDICATIONS|10. Prevacid, 30 mg p.o. q. day. 11. Renagel, 800 mg p.o. t.i.d. with meals. 12. Nephrocaps, one cap p.o. q.h.s. 13. Risperdal, 25 mg IM q. two weeks. 14. Senokot, two tablets p.o. q.h.s. 15. Timolol, one drop both eyes q.a.m. 16. _______, 80 mg p.o. q. day. 17. Colace, 100 mg p.o. b.i.d.
IM|intramuscular|IM|358|359|HOSPITAL COURSE|She received relatively high dose of Benadryl 75 mg IV as well as Ativan 1 mg IV on the day of admission at 9 a.m. She received approximately 4 doses of IV Dilaudid as well, but since the initial presentation, she has only needed 4 doses of Dilaudid. She feels that she can manage herself at home. She notes that the high dose of Benadryl IV is helpful, but IM is not and so she deferred on using IM Benadryl at home. She did require a 2 mg bump of lorazepam later in the evening yesterday.
IM|intramuscular|IM|139|140|HISTORY OF THE PRESENT ILLNESS|At that time, room air oxygen saturation was normal. However, the patient continued to have fever and the oral levofloxacin was changed to IM ceftriaxone on _%#MMDD2003#%_. On the date of admission, the patient had a temperature up to 102.7 as well as desaturation with oxygen.
IM|intramuscular|IM|212|213|HOSPITAL COURSE|The patient had been experiencing some palpitations which brought her to the emergency room for evaluation. She was hemodynamically stable, but over the next 48 hours went into a florid withdrawal. This required IM Haldol dosing. The patient was placed on a 72-hour hold. There was no available Intensive Care Unit bed at Fairview Ridges Hospital and therefore, the patient was being transferred to _%#CITY#%_ Hospital for Intensive Care monitoring and IV medications.
IM|intramuscular|IM|182|183|MEDICATIONS|PAST MEDICAL HISTORY: I do not believe the patient has any known medication allergies. MEDICATIONS: 1. Lasix 40 mg daily. 2. Senokot tabs, one at bedtime. 3. Vitamin B-12, 1,000 mcg IM qmonthly. 4. Fosamax 70 mg po qweekly. 5. Centrum silver vitamins daily. 6. Verapamil 180 mg po b.i.d. 7. Ditropan XL 10 mg b.i.d. 8. Calcium carbonate 750 mg b.i.d.
IM|intramuscular|IM|154|155|ASSESSMENT|She does understand that if this progresses that an NG to decompress the stomach would be advised. Pain medications are reviewed and she requests Demerol IM as she has a sensitivity to hydrocodone and prefers IM to IV use. She will be hydrated with IV fluids. Monitor overnight, and if there is no significant improvement we will have Dr. _%#NAME#%_ see her as an inpatient.
IM|intramuscular|IM|179|180|DISCHARGE MEDICATIONS|17. Ciprofloxacin 750 mg p.o. b.i.d. 18. Ferrous sulfate 325 mg p.o. q. day. 19. Amicar 3 mg p.o. b.i.d. 20. Benzoyl peroxide gel for the skin once a day. 21. Testosterone 200 mg IM every month, he got last injection on _%#MM#%_ _%#DD#%_, 2005. 22. Protonix 40 mg p.o. q. day. 23. Tobramycin nebulizers 300 mg b.i.d.
IM|intramuscular|IM|151|152|PLAN|3. Prilosec 20 mg taken 30 to 60 minutes before first meal daily. 4. Reglan 5 mg taken 30 minutes before meals and at bedtime. 5. Vitamin B12 1000 mcg IM each month. 6. Multivitamins, one each day. 7. Ferrous Sulfate 220 mg per 5 ml. The patient had taken 5 ml or one teaspoon daily.
IM|intramuscular|IM|179|180|DISCHARGE MEDICATIONS|3. Lamictal 100 mg p.o. 1 tablets t.i.d. 4. Celexa 20 mg p.o. nightly once a day. 5. Multiple vitamin 1 p.o. daily. 6. Calcium with vitamin D 1 p.o. b.i.d. 7. Depo-Provera 250 mg IM every 3 months for birth control.
IM|intramuscular|IM|138|139|DISCHARGE MEDICATIONS|3. Multivitamins p.o. daily. 4. Neurontin 100 mg p.o. q.a.m. and 300 mg p.o. q.h.s. 5. Nexium 40 mg p.o. daily. 6. Vitamin B12 ingestions IM q. month. 7. Roxicet 5-10 ml p.o. q.6h. p.r.n. given 200 ml without refills. DISCHARGE INSTRUCTIONS: 1. Diet: Clears. 2. Activity: As tolerated.
IM|intramuscular|IM|179|180|HOSPITAL COURSE|He was also monitored for withdrawal from alcohol. He was monitored using the MSSA rating scale with Ativan to cover potential withdrawal symptoms. On _%#MMDD2004#%_ Geodon 20 mg IM up to b.i.d. was ordered for agitation. Trazodone at 50 to 100 mg at bedtime was ordered for sleep. Seroquel 25 to 50 mg q.i.d. was ordered for anxiety.
IM|intramuscular|IM|294|295|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 24-year-old African-American male who is unable to communicate at the time of exam due to pain initially, who complained of bilateral upper extremity pain that started last night, 1 day prior to admission. No fevers or chills. The patient was given IM Dilaudid with some relief. He denies any fevers, chills, or focus of infection. PAST MEDICAL HISTORY: 1. Sickle-cell disease, history of acute chest pain syndrome, and left hip osteomyelitis, status post left total hip replacement.
IM|intramuscular|IM,|250|252|HISTORY|Upon pelvic examination, there were noted to be approximately 550 cc clots coming from the cervix for a total of 1100 cc estimated blood loss at the completion of her surgery. The patient again was treated with fluid resuscitation, Methergine 0.2 mg IM, and Hemabate 250 mcg. There was concern of persistent postpartum hemorrhage, and the discussion was carried out with the patient and her husband regarding returning to the operating room for concerns over bleeding likely to be occurring from the lower uterine segment where the placenta was attached versus proceeding with a uterine artery embolization.
IM|intramuscular|IM|173|174|DISCHARGE MEDICATIONS|She is being discharged to Walker Methodist for ongoing cares. DISCHARGE MEDICATIONS: 1. Chlorthalidone 12.5 mg p.o. q.a.m. 2. Folate 2 mg p.o. q.a.m. 3. Methotrexate 20 mg IM q.Sunday. 4. Aspirin 325 mg p.o. q. day. 5. Calcium and vitamin D 12.5 mg p.o. b.i.d. 6. Celebrex 200 mg p.o. b.i.d. 7. Colace 100 mg p.o. b.i.d.
IM|intramuscular|I.M.|179|182|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Fentanyl patch 50 mcg/hour topical q.72 h. 2. Protonix 40 mg IV daily. 3. Valium 5 mg IV b.i.d./p.r.n. 4. Zofran 32 mg IV q.a.m. 5. Vitamin B12, 100 mcg I.M. every month. 6. Dilaudid 0.5 to 1 mg IV q.2-4 h. p.r.n. 7. Nystatin cream topical to gluteal folds b.i.d./p.r.n. 8. Miconazole powder topical to groin folds b.i.d./p.r.n.
IM|intramuscular|IM|235|236|HISTORY|The child was noted to have moderate respiratory distress with croupiness and he was admitted for steroid therapy and nebulization therapy was given. He was given both racemic epinephrine nebulizations and Albuterol nebulizations, and IM Decadron. His symptoms rapidly resolved and on the day of discharge he did not need any extra oxygen. At the time of discharge, his respirations were 24 with no retractions and no distress.
IM|intramuscular|IM|160|161|HISTORY OF PRESENT ILLNESS|The patient saw his doctor on Tuesday as an outpatient and was given intravenous antibiotics. He was started on oral Augmentin on Wednesday and was again given IM injection of antibiotic. He does not know what antibiotic he received. He continued to take Augmentin up until today. He came in to the emergency department for evaluation today because of this continued problems with swelling.
IM|intramuscular|IM|156|157|DISCHARGE MEDICATIONS|10. Darbepoetin for anemia, 60 mcg subcu every week. 11. Venofer injection, 100 mg IV once a month, 2nd Monday of each month. 12. Lupron injections 22.5 mg IM every three months for prostate cancer. 13. Casodex 50 mg p.o. one time daily at noon. 14. Thalidomide 100 mg p.o. 1 time per day.
IM|intramuscular|IM|179|180|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1. Prozac 20 mg p.o. daily. 2. Trazodone 50 mg p.o. each day at bedtime. 3. Prednisone 5 mg p.o. b.i.d. 4. Omeprazole 20 mg p.o. daily. 5. Methotrexate 10 mg IM q. week. 6. Piroxicam 20 mg p.o. daily. 7. Percocet. The patient only took one today. He got this two days ago from the orthopedic surgeon.
IM|intramuscular|IM|245|246|PLAN|This was addressed and her questions were answered. She is aware that this polyp may not be the cause of her abnormal bleeding. If the abnormal bleeding persists after the surgery, then I may recommend increasing her Depo-Provera dose to 300 mg IM every three months versus discontinuation of the Depo-Provera altogether to see how that affects her bleeding.
IM|intramuscular|IM|133|134|DISCHARGE MEDICATIONS|5. Trazodone 150 mg p.o. nightly. 6. Zoloft 150 mg p.o. q.a.m. 7. Seroquel 50 mg p.o. b.i.d. as needed for psychoses. 8. Ativan 2 mg IM every 15 minutes as needed for seizure. 9. Colace 100 mg p.o. b.i.d. as needed for constipation. 10. Multivitamin daily. DISPOSITION: The patient was to be transferred to the inpatient psychiatry unit to be followed for depression and suicidal ideation.
IM|intramuscular|IM|185|186|MEDICATIONS ON DISCHARGE|3. Supraventricular tachycardia. 4. Hypercholesterolemia. 5. History of gastroesophageal reflux disease. 6. History of asthma. MEDICATIONS ON DISCHARGE: Include 1. Avonex 30 micrograms IM q week on Fridays 2. Celexa 20 mg po q day 3. Ditropan XL 10 mg po bid 4. Maxair 1 to 2 puffs 3 times a day
IM|intramuscular|I.M.|219|222|HISTORY OF PRESENT ILLNESS|The patient's family was also in agreement with this, and this was discussed with the patient's neurologist. The patient was discharged to finish a week course of the azithromycin and a 10-day course of the ceftriaxone I.M. 2. ALS: At the time of admission, the patient's primary neurologist was contacted. Therefore a neurologic consultation was obtained who followed throughout the course of hospitalization.
IM|intramuscular|IM|151|152|MEDICATIONS AT TIME OF DISCHARGE|3. Aricept 10 mg p.o. daily. 4. Depakote ER 1000 mg p.o. daily. 5. Dilantin 100 mg p.o. daily. 6. Actonel 35 mg p.o. weekly. 7. B12 injections 100 mcg IM monthly, last given at the group home, date unknown. 8. MiraLax 1 capful daily p.r.n. constipation. 9. When he returns to the group home he has several eye drops and skin creams that he uses p.r.n. and those can be continued.
IM|intramuscular|IM|195|196|HISTORY OF PRESENT ILLNESS|In the emergency department, the patient's vital signs were notable for blood pressure 160/100, pulse 112. He was afebrile. He was placed on a 72-hour hold in the ER. The patient was given 40 mg IM injection of Geodon in the ER. PAST MEDICAL HISTORY: 1. Significant alcohol abuse with numerous treatments and commitment in the past as detailed above.
IM|intramuscular|IM|214|215|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Include 1. Clindamycin 300 mg p.o. q.i.d. until she is seen back by the oral surgeon in one to two weeks, 2. Iiron 325 mg p.o. q. day., 3. Folic acid 1 mg p.o. q. day. 4. B-12 shots 1000 mcg IM q. month, 5. Synthroid 500 mcg p.o. q. day. 6. Protonix 40 mg p.o. q. day. 7. Toradol 10 mg p.o. t.i.d. p.r.n. to be discontinued on _%#MMDD2005#%_, 8. Mirapex 0.125 mg p.o. q.h.s. for restless leg syndrome.
IM|intramuscular|IM|296|297||Admitted for persistent fevers and gastritis, occasional vomiting in evening since seen in Fairview Ridges emergency room with 24 hour history of fever to 104.8, chills without respiratory symptoms. White count 20,000 with shift to left. Cathed urinalysis showed leukocytosis and sent home after IM Rocephin, on oral Septra with blood culture now no growth at 48 hours. Was later confirmed today greater than 100,000 E.coli sensitive to all antibiotics except the discharge oral antibiotic, Septra.
IM|intramuscular|IM|158|159|DISPOSITION|Normal lochia seen. DISPOSITION: Ms. _%#NAME#%_ is being discharged home in stable condition on postpartum day #2. She received a dose of Depo-Provera 150 mg IM on the day of discharge for contraception. Her partner is planning to undergo vasectomy soon. The patient was advised to follow up in La Clinica Midwife Service in 6 weeks for her postpartum visit.
IM|intramedullary|IM|204|205|HOSPITAL COURSE|HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is an 80-year-old gentleman, admitted for fracture of the right humerus. He underwent ORIF of the comminuted proximal humerus fracture with a Smith & Nephew locking IM nail, along with repair of the rotator cuff. This was done on _%#MMDD2006#%_. His post-op course is documented in the medical record.
IM|intramuscular|IM|117|118|HOSPITAL COURSE|She did receive Venofer for 4 days in the hospital. She was also noted to be B12 deficient. She was given a one time IM injection and will need 1000 mcg q monthly. The next dose would be a _%#MMDD2007#%_. The patient was made aware of this plan.
IM|intramuscular|IM|147|148|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Include: 1. Lexapro 10 mg p.o. q. day. 2. Zyrtec 10 mg p.o. q. day. 3. Multivitamin liquid 1 p.o. q. day. 4. Depo-Provera 1 IM q. 3 months. 5. Ambien 10 mg p.o. each day at bedtime p.r.n. for sleep. 6. Roxicet elixir 5-10 mL p.o. q. 4 hours p.r.n. for pain.
IM|intramuscular|IM|133|134|HISTORY OF PRESENT ILLNESS|Urine analysis in the office was negative. A Wet prep was done that shows presence of clue cells. The patient received betamethasone IM one dose in the office and she was sent to Fairview Southdale Hospital to be admitted for preterm labor evaluation and management.
IM|intramedullary|IM|301|302|SECONDARY DIAGNOSES|DIAGNOSIS: Osteonecrosis ARCO stage IV with degenerative arthritis of the left hip. PROCEDURE: Left total hip arthroplasty. SECONDARY DIAGNOSES: Status post multiple trauma left lower extremity with arthrodesis of left knee, status post cord decompression of left femoral head, status post removal of IM nail. HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old male with a history of long-standing traumatic war injury, post-Vietnam to his left lower extremity, resulting in a fusion of his left knee.
IM|intramedullary|IM|146|147|PAST SURGERIES|The procedure was a right popliteal to dorsalis pedis bypass with translocated, non-reversed saphenous vein. She had bilateral hip pinning and an IM rodding of left femur and a fractured pelvis four weeks ago. PAST MEDICAL HISTORY : Includes 1. Type 1 insulin dependent diabetes.
IM|intramuscular|IM|179|180|HISTORY|The patient was initially placed in the psychiatric room but had to be moved over to the to the critical care bed due to increasing agitation. The patient required about 10 mg of IM Haldol and 1 mg of Cogentin and did not calm down until 5 mg of Versed side. He was given 650 mg of Tylenol and given 1 liter of normal saline and currently has half normal saline with D5 going at 200 cc an hour.
IM|intramuscular|IM|233|234|4.  ID|The patient clinically looked well in terms of his pulmonary status throughout his admission and did not require any treatment. 4. ID: The patient has had a fever x1 day. He was started on antibiotics and received 1 dose of Rocephin IM in the ED. He would be continued on antibiotics until his cultures were negative at 48 hours, awaiting blood culture, urine culture, CSF culture results following his admission, and he was started on vancomycin and cefotaxime.
IM|intramuscular|IM|142|143|ADMISSION HISTORY OF PRESENT ILLNESS|She was seen in the emergency room, where she received 3 duonebs and 1 dose of prednisolone, which she vomited. She then received the dose of IM Decadron and was admitted. Of note, her half-brother had been sick with an upper respiratory infection and her mother said that she thought she was developing cold symptoms as well.
IM|intramuscular|IM|114|115|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Norvasc 5 mg p.o. daily. 2. Lipitor 20 mg p.o. daily. 3. Vitamin B12 injection 1000 mcg IM for next four days, and then once a week x4. (new) 4. Benadryl 50-mg capsule p.o. q.4 hours p.r.n. for pruritus.
IM|intramedullary|IM|157|158|PROCEDURES PERFORMED|PROCEDURES PERFORMED: 1. Wide excision of left thigh sarcoma with proximal femoral excision. 2. Reconstruction with antibiotic-impregnated cement spacer and IM reconstruction nail. REASON FOR ADMISSION AND PROCEDURE: Ms. _%#NAME#%_ is a 44- year-old female with a left thigh mass that has been diagnosed to be an undifferentiated high-grade sarcoma.
IM|intramuscular|IM|148|149|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Ketoconazole to affected areas 2-3 times a day. 2. Bion tears eyedrops one drop to each eye t.i.d. 3. Cyanocobalamin 1 ml IM monthly. 4. Fortical nasal spray one spray daily to alternate nostrils. 3. Omeprazole 20 mg per day. 4. Multivitamin 1 tab per day.
IM|intramuscular|IM|151|152|DISCHARGE MEDICATIONS|5. Obstructive sleep apnea, stable. DISCHARGE MEDICATIONS: 1. Lipitor, 10 mg p.o. daily. 2. Pletal, 100 mg p.o. twice daily. 3. Vitamin B12, 1,000 mcg IM q. monthly. 4. Neurontin, 300 mg p.o. 3 times daily. 5. Guaifenesin, 600 mg tablets p.o. twice daily. (10-day supply)
IM|intramuscular|IM|180|181|CURRENT MEDICATIONS|Hydrochlorothiazide 25 mg p.o. q.d. 7. K-Dur 20 mEq p.o. q.d. 8. Vitamin E 400 units p.o. q.d. 9. Citracal D 500 mg t.i.d. 10. Multivitamin one p.o. q.d. 11. Vitamin B-12 1000 mcg IM q. month. 12. Premarin Vaginal Cream applied twice weekly as needed for dryness. ALLERGIES: Sulfa, Lopid, Floxin, Plavix. HABITS: The patient is not a cigarette smoker and does not drink alcohol.
IM|intramuscular|IM|271|272|ASSESSMENT|ASSESSMENT: Abdominal pain with left-shifted white count. I want to rule out appendicitis so the plan is admit, keep NPO, IV fluids, send urine for UA, CNS, serial CBC with differential, comprehensive metabolic, Hemoccult stools, Protonix 40 mg IV, antiemetic, Phenergan IM as needed, surgical consultation - Dr. _%#NAME#%_ was contacted from my office. I did discuss the case with him and discussed with Dr. _%#NAME#%_, accepting physician, who will consider repeat abdominal and pelvic CT depending on the patient's clinical course.
IM|intramuscular|IM|163|164|LABORATORY DATA|Her electrolytes were unremarkable. BUN 11, creatinine 0.7, glucose 130 mg. The patient was admitted for pain control. She received Vicodin p.o. and Demerol 50 mg IM q 4 hours prn. Also physical therapy and occupational therapy did evaluate her for gait and transfer assessment. It was determined that she was safe to be discharged home under the care of her sister and no further physical therapy needs were recommended.
IM|intramuscular|IM|184|185|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Augmentin 500/125 mg, 1 tab p.o. b.i.d. for UTI, total 14 pills. 2. Vicodin 5/500 mg, 1-2 tabs p.o. q.4-6h. p.r.n. pain, #30 pills. 3. Avonex 30 mcg injected IM once weekly, not dispensed. 4. Oxycodone 5 mg p.o. q.4-6h. p.r.n. pain, #20. 5. Vitamin K 5 mg injected IV/p.o. daily, #20. 6. Lyrica 150 mg p.o. daily., #30.
IM|intramuscular|IM|261|262|* FEN|This will be rechecked at the end of his antibiotic treatment course (_%#MMDD#%_ or _%#MMDD#%_) by the Home Health nurse, as he is at risk for hyperbilirubinemia while on ceftriaxone. Discharge medications, treatments and special equipment: * Ceftriaxone 275mg IM daily, last dose _%#MMDD2007#%_. This will be given by Children's Home Care through _%#MMDD#%_. * Amoxicillin 75 mg PO Daily to start _%#MMDD#%_ and continue until VCUG is done (prescription sent with the parents at the time of discharge).
IM|intramuscular|IM|248|249||After starting antibiotics for his urinary tract infection, _%#NAME#%_ developed vomiting and diarrhea over the 3-4 days prior to admission, and similar gastroenteritis was noted in his daycare contacts. He was evaluated at Quello Clinic and given IM Ceftriaxone on _%#MMDD#%_, then evaluated at Southdale Pediatrics on _%#MMDD#%_ and received a second dose of Ceftriaxone. When he was evaluated on the _%#DD#%_, his weight was found to be down to 20 pounds 14 ounces from 23 pounds, with a total weight loss of 2 pounds, 2 ounces, so he was admitted for IV rehydration for vomiting and diarrhea with dehydration and weight loss.
IM|intramuscular|IM|152|153|DISCHARGE MEDICATIONS|Albuterol MDI two puffs q.i.d. and p.r.n. 7. Zyprexa 15 mg p.o. hs. 8. Atenolol 25 mg p.o. q.d. 9. Prevacid 30 mg p.o. q.d. 10. Haldol Decanoate 150 mg IM q week, it is due on _%#MMDD2002#%_. 11. Colace elixir 100 mg p.o. b.i.d. 12. Tylenol liquid 325 to 650 mg p.o. q4-6h p.r.n. pain.
IM|intramuscular|IM|135|136|IDENTITY|The patient has been followed at our office since 12 weeks gestation. Her pregnancy was complicated by the IVF pregnancy, supported by IM Progesterone injections in the first trimester. She progressed during this pregnancy to term. Level II ultrasound and fetal echo had been normal.
IM|intramuscular|IM|199|200|CHIEF COMPLAINT|She has been having stabbing pain in the lumbar area, radiating into the left lower extremity, more on the posterior aspect of the tibia and the calf. The patient received MS 4 mg and Vistaril 50 mg IM without response and then she required a dose of morphine in order to be able to sleep. PAST MEDICAL HISTORY: Is significant basically for hypothyroidism and depression.
IM|intramuscular|IM|102|103|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Zyprexa 5 mg p.o. q.h.s. 2. Celexa 20 mg p.o. q.d. 3. Haldol 1 to 2 mg p.o. IM q6-8h p.r.n. 4. Cogentin 0.5 to 1.0 mg p.o. IM q4-6h p.r.n. PROCEDURES: 1. Head CT normal. 2. EEG no evidence of seizure-like activity.
IM|intramuscular|IM|448|449|DISCHARGE MEDICATIONS|On the day of discharge, she was ambulating, voiding spontaneously, and tolerating a regular diet, with her pain controlled with the pain medication. DISCHARGE MEDICATIONS: Tylenol No. 3 1-2 tabs q.4h. p.r.n., Valium 5-10 mg q.6h. p.r.n., Colace 100 mg b.i.d. while taking narcotics, Neurontin 400 mg t.i.d., Vioxx 25 mg 1-2 tabs q.d., ranitidine 150 mg b.i.d., Claritin 10 mg q.d., Effexor XR 37.5 mg b.i.d., buspirone 150 mg b.i.d., Depo Provera IM q.10w., Lasix 40 mg q.d. FOLLOW UP: The patient will follow up with Dr. _%#NAME#%_ in 4-6 weeks. The patient will have her staples removed at the postoperative 7- to 10-day point.
IM|UNSURED SENSE|IM|175|176||_%#NAME#%_ _%#NAME#%_ is a 58-year-old female with a history of multiple sclerosis. She has been seen in the Urgent Care at Fairview EdenCenter and previously saw a doctor at IM Oxboro. She came to the Emergency Department with a greater than 1 month history of constipation. Her previous baseline was 2 small bowel movements daily. She feels she has not had a normal bowel movement for about 3 weeks.
IM|intramuscular|IM|182|183|HOSPITAL COURSE|The patient described itching and some "tightness" in the throat, there was some flushing and pruritus; following the vancomycin administration. The patient was given Benadryl 15 mg IM with relief of her symptoms. Because of her history of MRSA, it was decided to continue with the vancomycin and premedicate the patient with Benadryl prior to her treatments.
IM|intramuscular|IM|315|316|ALLERGIES|CURRENT MEDICATIONS: Include Lipitor 10 mg every other day, acebutolol 400 mg daily, Hyzaar 100/25 daily, aspirin 81 mg daily, Loprox p.r.n., Norvasc 5 mg daily, Glucovance 5/500 one b.i.d., cholestyramine one scoop daily, Actos 15 mg daily. ALLERGIES: Sulfa and intravenous morphine. She has been able to tolerate IM morphine. HABITS: She quit smoking in 1963 after a nine year history.
IM|intramuscular|IM|168|169|ADMISSION MEDICATIONS|Cesarean section, 1989. 2. Laparotomy with left salpingo-oophorectomy and lysis of adhesions, 2002. ALLERGIES: Morphine. ADMISSION MEDICATIONS: 1. Depot Lupron 3.75 mg IM on _%#MMDD2003#%_. 2. Norethindrone p.r.n. hot flashes. 3. Toradol p.r.n. 4. Zofran p.r.n. SOCIAL HISTORY: The patient is a nurse in the ICU step-down unit at Fairview-University Medical Center.
IM|intramuscular|IM|136|137|DOB|She was initially seen at a clinic in _%#CITY#%_, Minnesota. She had a positive urinalysis and presumed pyelonephritis and was given an IM injection of Rocephin. However, her fever continued and she was evaluated again with abdominal CT which revealed mesenteric adenitis.
IM|intramuscular|IM|263|264|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 13-year-old male who was skiing on _%#MMDD2003#%_ and sustained a left femur fracture while impacting his left thigh with a tree. He was seen in the Emergency Department at _%#CITY#%_, and had preop for a left femur fracture IM rodding. HOSPITAL COURSE: The patient was taken to the operating room on _%#MMDD2003#%_.
IM|intramuscular|IM|143|144|DISCHARGE MEDICATIONS|Combivent MDI two puffs four times a day. 6. Ferrous sulfate 325 mg p.o. daily. 7. Epogen 10,000 subq Monday, Thursday. 8. Vitamin B12 1000 mg IM q. month. Last received was _%#MMDD2003#%_. 9. Senna two tabs p.o. b.i.d. 10. Gatifloxacin ending on _%#MMDD2003#%_, 200 mg p.o. q.d. 11. Prednisone 60 mg p.o. q. daily to end on _%#MMDD2003#%_.
IM|intramuscular|IM.|189|191|MEDICATIONS|3. History of peptic ulcer disease. 4. History of benign prostate hypertrophy. MEDICATIONS: 1. Coumadin 5 mg a day. 2. Glucosamine chondroitin twice daily. 3. Viagra p.r.n. 4. Testosterone IM. 5. Zantac 150 b.i.d. 6. Atenolol 25 b.i.d. 7. Oxybutynin 5 b.i.d. 8. Rythmol 150 mg t.i.d. ALLERGIES: None. FAMILY HISTORY: Unremarkable. SOCIAL HISTORY: The patient is living with his wife.
IM|intramuscular|IM|263|264|HOSPITAL COURSE|During testing for diphtheria she did have titers drawn for tetanus and diphtheria, which showed that she was, in fact, tetanus immune, however, a non-responder to diphtheria and so Infectious Disease has recommended that she receive a tetanus diphtheria booster IM before her discharge. The patient and her father were reluctant to this prior to her discharge. In fact, she did want to wait about a week until the patient was feeling normal again.
IM|intramuscular|IM|318|319|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Aspirin 81 mg po daily, Docusate 100 mg po daily, Septra DS 1 po bid through _%#MMDD2004#%_, Plavix 75 mg po daily, Xalatan eye drops 1 drop to the left eye q hs. Folate 1 mg po daily, Potassium Chloride 20 mEq po daily, Ferrous Gluconate 325 mg po bid, Vitamin B-12 injections 1,000 micrograms IM monthly, Proscar 5 mg po daily at hs, Dyazide 37.5/25 1 po daily, Betimol 0.5% 1 drop left eye daily. DISCHARGE INSTRUCTIONS AND FOLLOW UP: Patient to follow up with Dr. _%#NAME#%_ in 2-4 weeks.
IM|intramuscular|IM|165|166|PROCEDURES DURING HOSPITALIZATION|3. Preterm contractions. 4. Bacterial vaginosis. 5. Thrush. 6. History of Graves' disease. PROCEDURES DURING HOSPITALIZATION: 1. IV magnesium, 2. IV clindamycin. 3. IM steroids for fetal lung maturity. 4. Renal ultrasound. HISTORY OF PRESENT ILLNESS: The patient is a 28-year-old G2 P- 0-0-1-0 who was admitted on-_%#MMDD2003#%_ at 28+1 weeks by an 8+6 week ultrasound done on _%#MMDD2003#%_.
IM|intramuscular|IM|122|123|HISTORY OF PRESENT ILLNESS|He has a history of laryngomalacia and gastroesophageal reflux. Weaned off Prilosec 3 weeks ago which was tolerated well. IM Decadron was given in clinic prior to admission. Did well overnight with no stridor. O2 sat 93 to 95% asleep in room air. Respiratory rate 20's to 30's with no retractions.
IM|intramuscular|IM|233|234|HOSPITAL COURSE|The fluid was clear. The patient was contracting every 5 minutes, however, this did not advance and therefore IV Pitocin was begun to augment labor at 1440 hours. Intravenous GBS prophylaxis was given. The patient received Phenergan IM and Nubain IV for analgesia. She received additional doses of Penicillin during her labor. She was followed through the evening of _%#MMDD2003#%_.
IM|intramuscular|IM|157|158|HOSPITAL COURSE|She also stated she was feeling increasingly depressed. On admission, Ativan 1 to 2 mg orally or IM every 4 hours as needed was ordered. Also, Zyprexa 10 mg IM q.4 h. as needed, Zyprexa Zydis 10 mg oral every 4 hours as needed, Depakote 500 mg twice daily, Abilify 15 mg daily, and Haldol 5 mg every bedtime was ordered on admission.
IM|intramuscular|IM|151|152|HOSPITAL COURSE|On _%#MMDD2004#%_, Seroquel was ordered at 25 mg twice daily for anxiety, and 100 mg at bedtime. She did require an emergency medication of Zyprexa 10 IM on _%#MMDD2004#%_, as she was very upset and needed a time-out. On _%#MMDD2004#%_, Risperdal at 1 mg q.h.s. was added. She stated that she had been on that previously and it did help.
IM|intramuscular|IM|133|134|IDENTIFICATION|9. Because the patient has a Jarvis order, if she refused any doses of Clozaril or the oral Geodon, she was to be given Geodon 20 mg IM with a limit of 40 mg in 24 hours. On _%#MM#%_ _%#DD#%_, 2004, a call was placed to her residence why the Clozaril dose was at 25 mg.
IM|intramedullary|IM|81|82|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: Left tibia shaft fracture. OPERATIONS/PROCEDURES PERFORMED: IM nail left tibia. HOSPITAL COURSE: Patient is a 23-year-old male who sustained an isolated distal third-middle third junction tib-fib fracture.
IM|intramuscular|IM|176|177|DOB|His mother describes the cough as "barking like a seal." In the emergency room, he was noted to be stridorous and was given three epi nebs, one albuterol and Atrovent neb, and IM Decadron. He continued to have stridorous episodes and was therefore admitted to the Pediatric Floor for continued respiratory observation.
IM|intramuscular|IM|156|157|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Betaine 500 mg (one-half scoop) p.o. t.i.d. 2. Folic acid (500 mcg/mL) 0.1 mL p.o. q.day (50 mcg q.day). 3. Hydroxocobalamin 1 mg IM every other day. 4. Carnitine 250 mg p.o. t.i.d. DISCHARGE FOLLOW-UP: 1. Follow up with primary-care physician within one week. 2. _%#NAME#%_ should be seen in Metabolic Clinic as previously scheduled.
IM|intramuscular|IM|195|196|PLAN|Deep tendon reflexes are 2+/4+. ASSESSMENT: 1. Intrauterine pregnancy at 33 6/7ths weeks with preterm labor PLAN: Admit for magnesium sulfate 4 gram bolus at 2 grams an hour. Betamethasone 12 mg IM repeat in 24 hours. Group B strep culture. The patient will be placed on antibiotics until the cultures are back.
IM|intramuscular|IM|295|296|HISTORY OF PRESENT ILLNESS|DOB: _%#MMDD1995#%_ DISCHARGE DIAGNOSIS: Pyelonephritis. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a previously- healthy, 9-year-old female with a history of urinary tract infections in the past. She presented early in the week and was diagnosed with pyelonephritis. She got Rocephin IM in the clinic; however, her condition deteriorated with recurrent high fever and lethargy. She was admitted on _%#MMDD2004#%_ for pyelonephritis. HOSPITAL COURSE: Problem #1.
IM|intramuscular|IM|273|274|HISTORY OF PRESENT ILLNESS|He apparently lost consciousness at the restaurant. The paramedics were called and when they arrived the patient's blood glucose was in the 30s and there was difficulty in obtaining IV access. The patient needed assistance with his respirations using an Ambu bag. Glucagon IM was given. He was then transported to Fairview Ridges Emergency Department. In the emergency room, they were able to obtain an IV access through the antecubital vein.
IM|intramuscular|IM|186|187|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Ferrous gluconate 324 mg p.o. 3 times a day. 2. Hydrochlorothiazide 25 mg daily. 3. Neurontin 300 mg b.i.d. 4. Lipitor 10 mg q.h.s. 5. Dyanacobalamine 1000 mcg IM qmonth. 6. Ranitidine 150 mg p.o. b.i.d. 7. Ditropan XL 10 mg p.o. daily. 8. OxyContin SA 20 mg p.o. b.i.d. per his outpatient routine.
IM|intramuscular|IM|213|214|DISCHARGE MEDICATIONS|_%#NAME#%_ _%#NAME#%_ in approximately 1-2 weeks. In addition, he has been also therapeutic here with his INR and would recommend an INR check on Friday, _%#MMDD2004#%_. DISCHARGE MEDICATIONS: 1. Ceftriaxone 1 gm IM daily for six days, then discontinue. 2. Protonix 40 mg p.o. q.d. 3. Colace 100 mg p.o. b.i.d. 4. Coumadin 4 mg p.o. q.d. Adjust per INR with goal of INR of 2-3.
IM|intramuscular|IM|165|166|DISCHARGE MEDICATIONS|9. Zyvox 600 mg po bid. Length of treatment to be determined by Infectious Disease, Dr. _%#NAME#%_. 10. Cozaar 50 mg po q day. 11. Glucophage held. 12. Methotrexate IM weekly. 13. Nexium 40 mg po q day. 14. K-Dur 10 mEq po bid. 15. Pravachol 20 mg po q hs. 16. Propranolol 40 mg po bid. 17. Torsemide 20 mg po q pm, 40 mg po q am .
IM|intramuscular|IM|158|159|CURRENT MEDICATIONS|2. Rheumatoid arthritis. 3. Osteoporosis. 4. Gastroesophageal reflux disease (GERD). CURRENT MEDICATIONS: 1. Imuran 50 mg t.i.d. 2. Interferon beta 1a 30-mcg IM q. Friday. 3. Prevacid 30 mg q.d. 4. Reglan 20 mg p.o. with meals. 5. Trazodone 75 mg p.o. q.h.s. 6. Ibuprofen 600 mg p.o. q.d.
IM|intramuscular|IM|315|316|HOSPITAL COURSE|2. Narcotic abuse and dependence: The patient has a history of dependence on narcotics because she is a very difficult patient to obtain IV access on, and because of this, we were able to maintain her on oral narcotics for pain. The pain service was consulted early on in her hospitalization and recommended adding IM Demerol for 3 days to allow her to shower without discomfort. They also recommended starting her on Ultram and to increase the oral Dilaudid dose to 4-8 mg p.o. q.3 hours.
IM|intramuscular|IM|155|156|DISCHARGE INSTRUCTIONS|2. She should follow up with her primary pediatrician, Dr. _%#NAME#%_ in approximately 1 to 2 weeks. 3. The patient has received Synergist RSV prophylaxis IM dose before leaving and will continue to receive these every month. 4. She will also be on ranitidine syrup for RSV prophylaxis during the flu season.
IM|intramuscular|IM|205|206|HOSPITAL COURSE|The patient proceeded to do well with these therapies and was transferred out of the Intensive Care Unit on room air. On admission the patient had a supratherapeutic INR of 8.5. The patient was given 5 mg IM of vitamin K. INR then responded to a decreased level at 4 and drifted down into a therapeutic range before resuming Coumadin prior to discharge.
IM|intramuscular|IM.|161|163|DISCHARGE PLAN|The patient was resumed on his baseline medications. 3. Supratherapeutic INR/coagulopathy. The patient had an initial INR of 8.5. He was given 5 mg of vitamin K IM. INR improved to 4 and drifted into the normal range. Resume Coumadin at 4 mg Monday through Thursday and Saturday at night time.
IM|intramuscular|IM|262|263|DISCHARGE PLAN|HOSPITAL COURSE: _%#NAME#%_ began on the senior treatment program. She received a combination of Depakote, memantine, and Seroquel for her dementia with behavior problems. Acute medical problems were pursued and ruled out by Dr. _%#NAME#%_. She did requite some IM Haldol plus p.r.n. Benadryl for severe agitation not responsive to oral medications. Gradually she became less agitated and was able to accept oral scheduled and p.r.n. medication.
IM|intramuscular|IM|212|213|IDENTIFICATION|On admission, the following medications were re-ordered: Reglan 10 mg q.i.d., Seroquel 100 mg t.i.d., Seroquel 300 mg at bedtime daily, Prozac 60 mg daily, iron sulfate 325 mg b.i.d., Geodon 120 mg oral or 20 mg IM as needed for agitation, may repeat every 2 hours. On _%#MM#%_ _%#DD#%_, 2005, the Prozac was discontinued. On _%#MM#%_ _%#DD#%_, 2005, she had a pain consult ordered, which was done.
IM|intramuscular|IM|142|143|HOSPITAL COURSE|The IV infiltrated as soon as she got the floor. Radiology was called and attempted five tries and could not get IV access. She was given two IM injections of Nafcillin. She refused to accept anymore IM injections and we started on her on p.o. Keflex. The patient remained afebrile with a normal white count on the Keflex.
IM|intramuscular|IM|254|255|HOSPITAL COURSE|Initially, he was put on the opiate withdrawal protocols. Phenobarbital 60 mg 3 times daily was ordered to cover withdrawal symptoms from benzodiazepines. Trazodone 50 to 100 mg at bedtime as needed was ordered, with a repeat x1 as needed. Zyprexa 10 mg IM t.i.d. was ordered for agitation as needed. Zyprexa Zydis 5 to 10 mg up to 4 times daily was ordered also for agitation.
IM|intramuscular|IM|119|120|DISCHARGE MEDICATIONS|Hydrochlorothiazide 25 mg p.o. daily. 3. Pepcid 20 mg p.o. b.i.d. 4. Atenolol 50 mg p.o. b.i.d. 5. Vitamin B12 200 mcg IM q. month. 6. Multivitamin 1 tablet p.o. daily. 7. Potassium chloride 10 mg p.o. daily. The patient was given instructions to eat a pureed diet to be advanced per dietitian instructions.
IM|intramedullary|IM|178|179|HISTORY/HOSPITAL COURSE|The patient requested transfer of care to Dr. _%#NAME#%_ who in turn asked me to do reparative surgery. On _%#MMDD2005#%_ I took her to the operating room and removed the broken IM nail and interlocking screws from the left tibia. I then performed ORIF with a 14 hole Synthes locking plate and also used the INFUSE BMP bone graft product for this difficult nonunion.
IM|intramuscular|IM|238|239|IDENTIFICATION|On admission, the following medications were ordered; Zyprexa 20 mg at bedtime, trazodone 100 mg at bedtime as needed for sleep with a repeat of 50 mg x1, Zyprexa Zydis 10 to 20 mg every 4 hours as needed for agitation, and Zyprexa 10 mg IM every 4 hours as needed for agitation. An albuterol inhaler 2 puffs up to 4 times daily as needed for shortness of breath was also ordered.
IM|intramuscular|IM.|146|148|HOSPITAL COURSE|Emergency medications were ordered because of his agitation on _%#MM#%_ _%#DD#%_, 2005, Zyprexa Zydis 10 mg at bedtime if needed or Zyprexa 10 mg IM. Depakote was increased to 1500 mg at bedtime on _%#MM#%_ _%#DD#%_, 2005. Throughout his stay, Mr. _%#NAME#%_ needed limits set frequently. The Depakote was changed to Depakote Sprinkle because of the possibility that he was cheeking his medication initially.
IM|intramuscular|IM|131|132|MEDICATIONS ON DISCHARGE|MEDICATIONS ON DISCHARGE: 1. Tylenol 500-1000 mg q.4h. p.r.n. 2. Aspirin 81 mg daily. 3. Demadex 20 mg daily. 4. Haldol 0.5-1.0 mg IM q.8h. p.r.n. agitation. 5. MiraLax 1 scoop in 6 ounces H20 daily as tolerated. 6. Norvasc 5 mg daily. 7. Protonix 40 mg daily.
IM|intramuscular|IM|182|183|HISTORY OF PRESENT ILLNESS|Her initial labs done at Myrtle Werth Hospital in _%#CITY#%_ showed a normal electrolyte panel except for a bicarbonate of 19. Blood cultures were drawn, and she was given 1 dose of IM ceftriaxone, and she was then transferred to Fairview University Medical Center for further evaluation and management. She was also started on IV fluids at the time of her transfer.
IM|intramuscular|IM|149|150|HISTORY OF PRESENT ILLNESS|She found _%#NAME#%_ on the floor having tonic movements and unresponsive. He was given some juice, following which his blood sugar was 58. Glucagon IM and glucose gels were administered. Repeat blood sugars were 197. _%#NAME#%_ was taken to _%#CITY#%_, Wisconsin, emergency room for further monitoring.
IM|intramedullary|IM|138|139|PRIMARY DIAGNOSES|_%#NAME#%_, the orthopedic surgeon. PRIMARY DIAGNOSES: 1. Right intertrochanteric subtrochanteric femur fracture. He had procedures done, IM nail on the right femur done on _%#MMDD2005#%_. 2. Fall. 3. Anemia secondary to surgical blood loss. 4. Hyperlipidemia. 5. Postoperative pain. 6. Postoperative temperature, likely secondary to atelectasis and immobility.
IM|intramedullary|IM|168|169|PROCEDURE PERFORMED|DATE OF ADMISSION: _%#MMDD2005#%_. DATE OF DISCHARGE: _%#MMDD2005#%_. ADMITTING DIAGNOSIS: Right intertrochanteric/subtrochanteric femur fracture. PROCEDURE PERFORMED: IM nailing right femur on _%#MMDD2005#%_. HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ was admitted to the inpatient ward on 55 following uneventful surgery.
IM|intramuscular|IM|256|257|HOSPITAL COURSE|She had racemic epinephrine nebulizers for distress and slept through the night following admission without any need for the racemic epinephrine or other cares. Her O2 sats remained in the 90s on room air. She is otherwise stable on feeding. She was given IM steroids. ASSESSMENT: Croup. DISCHARGE INSTRUCTIONS: The child was discharged to home in care of the parents with instructions to give Prelone 15 mg per 5 cc 5 cc p.o. b.i.d. for a total of 3 days.
IM|intramuscular|IM|262|263|MEDICATIONS|He states that 1-2 weeks ago he was treated for urinary tract infection with ciprofloxacin and he believes he was told it was a staphylococcus infection. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Benefiber one tablespoon b.i.d. 2. Vitamin B12 1000 mcg IM monthly. 3. Dexamethasone 2 mg q. 8 h. 4. Iron Sulfate 325 mg b.i.d. with meals. 5. Genasyme chewable 80 mg t.i.d. 6. Metamucil one packet b.i.d.
IM|intramuscular|IM|281|282|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a pleasant 38-year-old white female who is allergic to Macrobid, nitrofurantoin and sulfa, who presented to the clinic yesterday with complaint of right arm and "axillary pain". In the office yesterday _%#MMDD2006#%_, she was given 1 gram IM Rocephin for cellulitis of the right axillary area and asked to follow up today. When seen by me today she has increasing pain, discomfort, she has a large area of erythema and tenderness, induration and redness in the axillary extending over the medial aspect of the right arm, into the elbow.
IM|intramuscular|IM|113|114|DISCHARGE MEDICATIONS|16. Asacol 400 mg p.o. t.i.d. p.r.n. colitis flare. 17. Levaquin 500 mg daily for eight days. 18. B-12 1,000 mcg IM monthly. Please note that the patient was given her first dose at Fairview Southdale Hospital on _%#MM#%_ _%#DD#%_. DISCHARGE INSTRUCTIONS: The patient will follow up with Dr. _%#NAME#%_ _%#NAME#%_ at the Oxboro Clinic in two weeks.
IM|intramuscular|IM|140|141|AXIS II|HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ was admitted to station 20 north adult mental health treatment unit. On admission, Zyprexa 10 mg IM every 2 h. up to 5 injections for 24 hours was ordered to treat any agitation. He was seen by Dr. _%#NAME#%_ and started on Abilify 10 mg daily because of his auditory hallucinations.
IM|intramuscular|IM|189|190|CURRENT MEDICATIONS|ALLERGIES: Epinephrine. CURRENT MEDICATIONS: Current medications are unclear, but appear to be the following: 1. Lasix 20 mg p.o. daily. 2. Toprol XL 50 mg p.o. daily. 3. Vitamin B12 shots IM q. month. 4. Terazosin 2 mg p.o. q.h.s. 5. Synthroid 0.1 mg p.o. daily. 6. Iron 324 mg p.o. daily. 7. Coumadin 3 mg p.o. daily. 8. Digoxin 0.125 mg p.o. daily.
IM|intramuscular|IM|130|131|MEDICATIONS|Prednisone 10 mg alternating with 15 mg daily 5. Zoloft 100 mg daily 6. Synthroid 0.125 mg daily 7. Trazodone 100 mg at hs 8. B12 IM injection monthly PAST SURGICAL HISTORY: 1. Four cesarean sections
IM|intramuscular|IM|128|129|MEDICATIONS|4. Nasonex spray 1 spray ____________ daily. 5. Trazodone 50 mg 1-3 tablets p.o. each day at bedtime p.r.n. 6. Prolixin 18.7 mg IM q. 2 weeks. 7. Klonopin 0.5 mg half tab p.o. t.i.d. 8. Gemfibrozil 600 mg p.o. b.i.d. 9. Detrol LA 2 mg p.o. daily.
IM|intramuscular|IM|191|192|DISCHARGE MEDICATIONS|Her primary care physician needs to address that and to consider decreasing her levothyroxine. DISCHARGE MEDICATIONS: 1. Protonix 40 mg one tablet p.o. daily. 2. Vitamin B12 one thousand mcg IM monthly. 3. Climara 0.05 mg transdermally weekly. 4. Calcium carbonate and vitamin D 1250-mg tablet two tabs daily. 5. Ursodiol 300 mg one tablet p.o. t.i.d. 6. Levothyroxine 125 mcg one tablet p.o. daily.
IM|intramuscular|IM|639|640|DISCHARGE MEDICATIONS|CONDITION ON DISCHARGE: The patient was able to perform activities of daily living without difficulty. He has had symptomatic improvement in his symptoms. DISCHARGE MEDICATIONS: Vitamin K 5 mg p.o. daily, imipenem 750 mg IV q.8 hours, Tylenol 325 to 650 p.o. q.6 hours p.r.n., tobramycin nebulized 150 mg b.i.d., albuterol nebulized 2.5 mg q.i.d., Mucomyst 10% 4 mL per nebulizer dosage 4 times a day, cromolyn 20 mg nebulized 4 times a day, calcium carbonate with vitamin D 1 tablet p.o. t.i.d., azithromycin 250 mg p.o. daily, Bactrim DS 2 tablets p.o. b.i.d., Protonix 40 mg p.o. daily, Actigall 300 mg p.o. b.i.d., testosterone 200 mg IM q.2 weeks, magnesium oxide 400 mg p.o. b.i.d., tobramycin 360 mg IV daily, Pancrecarb MS 8 to 12 tablets p.o. with meals, Ultrase 20 six tablets p.o. with snacks, beta-carotene 50,000 units p.o. b.i.d., vitamin E 400 units p.o. b.i.d., ADEKs 1 tablet p.o. daily, multivitamin 1 tablet p.o. daily, vitamin C 500 mg p.o. daily, and folate 1 mg p.o. daily.
IM|intramuscular|IM|145|146|HISTORY OF PRESENT ILLNESS|2. Claritin 10 mg p.o. daily for allergic reaction. 3. Triamcinolone 0.1% cream applied to the rash on his legs every 12 hours. 4. EpiPen 0.2 mg IM p.r.n. for emergencies was also prescribed, and he was given patient education regarding use to that. FOLLOW UP: 1. Followup appointment with Dr. _%#NAME#%_ _%#NAME#%_ at CUHCC Clinic in 1 week.
IM|intramuscular|IM|176|177|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Haldol 4 mg p.o. b.i.d. 2. Cogentin 1 mg p.o. b.i.d. 3. Depakote ER 1000 mg p.o. nightly. 4. Seroquel 1000 mg p.o. nightly. 5. Risperdal Consta 25 mg IM every 2 weeks. DISCHARGE INSTRUCTIONS: The client was discharged to _%#COUNTY#%_ Regional Treatment Center.
IM|intramuscular|IM|129|130|HOSPITAL COURSE|He was seen by psychiatry and they recommended against any further use of Ativan and they recommended Seroquel orally and Haldol IM if needed for agitation. He did not require that but did have a one-to-one sitter for several days that was finally discontinued 48 hours prior to discharge.
IM|intramuscular|IM|144|145|DISCHARGE MEDICATIONS|11. MiraLax 1.5 packets through the G-tube daily. 12. Tylenol 650 mg q. 6h. p.r.n. through the G-tube. 13. Lorazepam 1 mg through the G-tube or IM p.r.n. seizures. 14. Ducolox suppositories 1 PR daily p.r.n. 15. Maxitrol ophthalmic ointment in the left eye each day at bed-time. 16. Lidocaine 2% gel to the suprapubic catheter site before any changes.
IM|intramuscular|IM|269|270|HOSPITAL COURSE|Finally, with a great deal of coaxing by the staff, the security guards and her own care facility staff, as well as her mother and attendants, she was moved to the preoperative area. Because of her inability to cooperate in readying her for surgery, ketamine was given IM by the anesthesia staff and attendants with excellent response. The patient then complied with necessary cares and moved to the operating room without incidence.
IM|intramuscular|IM|122|123|PHYSICAL EXAMINATION|Reflexes are slightly diminished bilaterally but symmetric. Of note, in the emergency room the patient was given 10 mg of IM morphine and states that she felt better. ASSESSMENT: Low back pain presumed secondary to left lumbar radiculopathy with slight disk disease noted on MRI.
IM|intramuscular|IM,|132|134|HOSPITAL COURSE|The patient did have suffered some uterine atony status post delivery. She did receive 800 mcg of rectal Cytotec, Methergine 0.2 mg IM, and IV Pitocin with resolution of her atony. The patient postpartum course was uncomplicated. Her vital signs remained stable and she was afebrile.
IM|intramuscular|IM|155|156|DISCHARGE MEDICATIONS|9. Lantus 20 units subq daily. 10. Humalog 8 units in the morning, 12 units with supper, and 5 units with lunch. 11. Cardia 240 mg p.o. q h.s. 12. Avastin IM every 6 weeks. 13. Perservision one daily. FOLLOW UP: He will follow up with _%#NAME#%_ in INR Clinic tomorrow and with Dr. _%#NAME#%_ his primary, in the next week to follow up not only his gastroenteritis, but also his breathing as he was noted at times to have saturations in the 89 and 88 range when off oxygen, so they can further evaluate if further needs for his COPD will be needed at home.
IM|intramuscular|IM|204|205|HISTORY OF PRESENT ILLNESS|She reports she went out for Italian and then just before bed she developed nausea with some heartburn. She woke up early this morning with severe vomiting and diarrhea and she could not give herself her IM Solu-Cortef because she could not break the vial, so she took Zofran, vomited her other p.o. medications and came to the emergency department.
IM|intramuscular|IM|170|171|PLAN|X-ray results are pending. Cultures are also pending. PLAN: Until the child is able to take medicine orally and we are certain about the cultures, we will continue to do IM Rocephin. Because he did have a seizure even though he does not appear to have meningitis, no spinal fluid exam was taken, but because of the seizure and the high fever, I will continue to give the 100 mg/kg dosage of Rocephin split into 2 doses a day.
IM|intramedullary|IM|118|119|HISTORY OF PRESENT ILLNESS|He has gone on to a clinical atrophic nonunion. The patient was taken to the operating room on the night for exchange IM nailing and iliac crest bone graft. The patient did well postoperatively. His pain is controlled. He has no nausea or vomiting.
IM|intramuscular|IM|177|178|HISTORY AND HOSPITAL COURSE|It is anticipated that the patient will be released later this evening as she would like to go home. Her discharge medications will include 1. Vitamin B12 injections 1,000 mcg. IM Q month 2. Zetia 10 mg p.o. q. daily 3. Lasix 40 mg every other day 4. Isordil 5 mg every 90 minutes p.r.n.
IM|intramuscular|IM|153|154|DISCHARGE  MEDICATIONS|She was eating well. She was hemodynamically stable. DISCHARGE MEDICATIONS: 1. Allopurinol 100 mg daily. 2. Coreg 6.25 mg b.i.d. 3. Vitamin B12 1000 mcg IM monthly. 4. Aranesp 100 mcg subq weekly at dialysis. 5. Zetia 10 mg daily. 6. Fish oil 1 gram daily. 7. Lopid 600 mg b.i.d. 8. Hydralazine 12.5 mg 3 times a day.
IM|intramuscular|IM|176|177|DISCHARGE MEDICATIONS|9. Levaquin 250 mg qd x 7. 10. Tylenol-#3 liquid q4h per feeding tube prn for pain, maybe given every four hours if routine pain medicines are needed. 11. Solganal 15 mg, 1 cc IM 15th of each month. 12. Sodium Chloride nasal spray bid to nares for epistaxis. 13. Prednisone 5 mg qd for rheumatoid arthritis. 14. Ferrous Sulfate 325 mg liquid once a day.
IM|intramuscular|IM|107|108|DISCHARGE MEDICATION|4. Extra Strength Tylenol 2 tablets p.o. q.d. 5. Ferrous Sulfate 325 mg p.o. q.d. 6. Haldol 1-2 mg p.o. or IM q.d. p.r.n. agitation. HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old female with a history of dementia, who was noted by her assisted living staff to have a fainting episode in the parking lot.
IM|intramuscular|IM|112|113|MEDICATIONS|3. Lasix 40 mg two tab q.a.m. p.r.n. 4. Celebrex 200 mg p.o. q.d. 5. Synthroid 0.2 mg p.o. q.d. 6. Vitamin B-12 IM 1 cc q. monthly. 7. Vicodin two tabs q.4-6h. p.r.n. 8. Coumadin 2.5 mg five times a week. 9. Sodium bicarb up to 12 pills per day p.r.n. ALLERGIES: To Ancef.
IM|intramuscular|IM|257|258|HISTORY OF PRESENT ILLNESS|To strain all urine and reevaluate in 12 hours. HOSPITAL COURSE: The patient this morning was seen at 9:30 a.m. on _%#MM#%_ _%#DD#%_, 2002. She was feeling better; slept some. Pain meds helped. She received a dose of 50 mg of Demerol and 25 mg of Phenergan IM given at 16:50 hours on _%#MM#%_ _%#DD#%_, 2002 and at 22:30 hours no _%#MM#%_ _%#DD#%_, 2002, and today on _%#MM#%_ _%#DD#%_, 2002, at 6 a.m. The patient does complain of a dull left flank pain, is hungry, and is drinking fluids.
IM|intramuscular|IM|155|156|PLAN|7. Dyspepsia/mild gastritis, question aggravated by medicine. 8. Need for placement, at least for short-term. PLAN: 1. Pain control. Will try some Demerol IM p.r.n. and will start her on some Darvocet in the meantime and see if that would help on a scheduled basis. 2. Will continue other medications, particularly the Fosamax, calcium, and Vitamin D.
IM|intramedullary|IM|115|116|COURSE|The patient was seen and evaluated by Dr. _%#NAME#%_ in clinic, and it was decided that an elective removal of the IM rod of his right femur would be done. The risks, benefits, and alternatives of this procedure were explained in clinic, and a consent was obtained.
IM|intramuscular|IM|144|145|PLAN|During the trip he noticed increasing redness and swelling in the forearm. He was seen in Emergency Room in _%#CITY#%_ _%#CITY#%_, was given an IM injection of antibiotic (Rocephin ?) as well as a prescription for Keflex and advised to followup with his physician here on return.
IM|intramuscular|IM|174|175|DOB|Blood culture was drawn. Blood culture has been negative, white count done on admission was 12,600 with 42% PMN's, 29% lymphocytes. The patient was started on Rocephin shots IM 100 mg per kilogram per day as q 12 hour doses as they were unable to start an IV. The patient drank well, fever went down and he has been afebrile now for the past 36 hours before discharge.
IM|intramuscular|IM.|146|148|PLAN|We will follow hemoglobin daily. We will continue with ferrous gluconate 325 mg q. daily. The patient will receive vitamin B12 100 mcg q. monthly IM. Also, we will follow hemoglobin. If hemoglobin drops, we will transfuse (red blood cells) if required. Please see the admit note orders. The patient's hypertension will be treated with Toprol XL 25 mg.
IM|intramuscular|IM|121|122|DISCHARGE MEDICATIONS|9. Doxazosin 1 mg at HS. 10. Clotrimazole cream topically to the left groin bid for two weeks. 11. Vitamin B-12 1000 mcg IM q month. 12. Trazodone 50 mg at HS. 13. Ativan 0.5 mg q4h prn agitation. DISCHARGE FOLLOW-UP: 1. Physical therapy. 2. Electrolytes and white count in one week.
IM|intramuscular|IM,|137|139|HISTORY OF PRESENT ILLNESS|She was slightly dehydrated, and a few petechiae were present where she had been itching in the groin area. She was given Benadryl 25 mg IM, Solu-Medrol 40 mg IM; and was sent home on Atarax 25 mg three times a day, with prednisone 20 mg for a five-day course.
IM|intramuscular|IM|151|152|ADMISSION MEDICATIONS|10. Fosamax 10 mg p.o. q.d. 11. Caltrate + D one tablet p.o. q.d. 12. Prevacid 30 mg p.o. q.d. 13. Bactrim DS one tablet p.o. q.d. 14. Ferrous sulfate IM injections. 15. Erythropoietin q. week. PAST MEDICAL HISTORY: 1. Status post renal transplant in 1985; currently with chronic allograft dysfunction.
IM|intramuscular|IM|152|153|MEDICATIONS|3. Also had a D&C in _%#MM2001S#%_ after a miscarriage. MEDICATIONS: 1. Aciphex. 2. Xanax 0.5 mg as needed. 3. Glucosamine Chondroitin. 4. Vitamin B-12 IM injection. 5. Calcium. 6. Prenatal vitamins. 7. Also Tylenol #3 as needed for her pelvic pain. 8. Vicodin as needed for her pelvic pain. 9. Zoloft 200 mg.
IM|intramuscular|IM|138|139|DISCHARGE PLAN|Medications will be aspirin 81 mg. q.d., Colace 100 mg. q.d., FiberCon 1 tab q.d., Proscar 5 mg. q.d., Flomax 0.4 mg. q.h.s., B12 15 mcg. IM monthly, Plavix 75 mg. q.d., Dyazide one pill daily, potassium chloride mEq. q.d., Xalatan one drop left eye q.h.s., Betimol 0.5% one drop in left eye daily, folic acid 1 mg.
IM|intramuscular|IM|167|168|PROBLEM #2|PROBLEM #2: Back and neck pain from fall exacerbated by polychondritis. The patient received her outpatient pain medications and did well. She did receive one dose of IM Demerol, but otherwise did not require additional medication medications. She was evaluated by Physical Therapy, Occupational Therapy, and will have a home safety physical therapy evaluation with possible recommendations for continuation of physical therapy.
IM|intramuscular|IM|232|233|PRESENT MEDICATIONS|HABITS: She is not a smoker or a drinker. VACCINES: She has had pneumonia vaccine given _%#MMDD#%_. PRESENT MEDICATIONS: MS Contin 15 mg taken two pills b.i.d., morphine oral tablets 10 mg using one pill q.4.h. p.r.n., B12 1000 mcg IM monthly, Lasix 20 mg q.A.M., lorazepam 1 mg t.i.d. p.r.n., Restoril 15 mg q.h.s. p.r.n., ibuprofen 800 mg t.i.d., Amitriptyline a total of 250 mg q.h.s., Skelaxin 400 mg t.i.d., Dulcolax tablets 5 mg taken two pills t.i.d., Colace 100 mg b.i.d., Protonix 40 mg daily, Premarin 0.125 mg daily, Dilantin 100 mg taken two pills q.A.M. and three pills q.h.s., Prinivil 10 mg daily and Prozac 20 mg t.i.d. SOCIAL HISTORY: Shows that she is married, lives at home with her husband and son who help care for her; she attends daycare three times per week at Ebenezer Ridges.
IM|intramuscular|IM|225|226|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Cystic fibrosis. He has had multiple admissions, most recently in _%#MM#%_ of 2003. He has severe lung disease and CF-associated malabsorption. 2. Hypogonadotrophic hypogonadism, treated with monthly IM testosterone. 3. Gynecomastia. 4. History of gastroesophageal reflux. 5. History of multiple port placements. Most recently, a port was removed on _%#MMDD2003#%_, due to a site infection.
IM|intramuscular|IM|229|230|DISCHARGE MEDICATIONS|In addition, due to the compression fractures, I also recommended the patient be started on a phosphonate empirically and we will start Fosamax 70 mg q week. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg PO qd. 2. Vitamin B 12 one mg IM q Monday, Wednesday, Friday times five doses, then q month. 3. Digoxin 0.125 mg PO qd. 4. Diltiazem CD 240 mg PO qd. 5. Lexapro 10 mg PO qd. 6. Metoprolol XL 50 mg PO qd.
IM|intramuscular|IM|201|202|MEDICATIONS|10. Prior psoas abscess. PAST SURGICAL HISTORY: As above. No indication on records of other known serious illness. ALLERGIES: No known drug allergies. MEDICATIONS: At the nursing home. 1. Rocephin 1 g IM q.24 h 2. Hydrocortisone 20 mg via G tube daily 3. Remeron 30 mg q.h.s. 4. Prevacid 30 mg daily 5. Senna-Gen 2 tab via G tube at h.s. 6. Seroquel 25 mg b.i.d.
IM|intramuscular|IM|125|126|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Synthroid 100 mcg daily. 2. Ritalin 10 mg q.i.d. 3. Lisinopril 5 mg b.i.d. 4. Vitamin B12 1000 mcg IM every 3 weeks. 5. Multivitamin daily. 6. Calcium 600 mg b.i.d. 7. Rhinocort AQ two sprays each nostril daily p.r.n.
IM|intramuscular|IM|213|214|REVIEW OF SYSTEMS|He took Prilosec for a couple of days but has not had any recurrence of the pain, so he stopped it. The patient remembers having micturition and syncope at age 15, and then one vasovagal syncopal episode after an IM injection in 1995. He has had syncope in other situations. He denies any seizure disorder. He denies any bleeding disorder. He denies any current bowel or bladder complaints.
IM|intramuscular|IM|213|214|DISCHARGE MEDICATIONS|4. Tobacco use. The patient was counseled against smoking in general, and in particular as she is currently pregnant. DISCHARGE MEDICATIONS: 1. Percocet 1-2 tablets q.6h. p.o. p.r.n. (30 tablets). 2. B12, 200 mcg IM q. month. 3. Prenatal vitamin 1 tablet p.o. q.d. DISPOSITION: 1. The patient is discharged to home. 2. She is to follow up with her primary care physician within one week.
IM|intramuscular|IM.|227|229|COURSE IN EMERGENCY ROOM|There was normal flow to both ovaries. Sodium was 139, potassium 4.7, chloride 104, bicarb 23, glucose 97, BUN 12, creatinine 0.6. Urinalysis was unremarkable. Urine pregnancy test was negative. Patient was given 60 of Toradol IM. Unfortunately, the white blood count was clotted and had to be re-drawn. When it was re-drawn, her white blood count returned at 20,200, 81% neutrophils, 12% lymphocytes, 6% monocytes, hemoglobin was 13.1, SGOT was normal at 30.
IM|intramedullary|IM|173|174|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Cadaveric kidney transplantation _%#MMDD2005#%_ for end-stage renal disease secondary to diabetes mellitus. 2. Status post left femur fracture with IM nailing in 2002. 3. Diabetes mellitus. 4. Hypertension. 5. Ocular surgery x2. 6. Epilepsy. 7. Left AV fistula. 8. Craniotomy secondary to subdural hemorrhage, secondary to motor- vehicle accident 2002.
IM|intramuscular|IM|131|132|DISCHARGE MEDICATIONS|3. Bactrim SS 1 p.o. 3 times weekly. 4. Valcyte 450 mg p.o. daily. 5. Mycelex troche 10 mg p.o. 3 times daily. 6. Octreotide 20 mg IM monthly. 7. Lidoderm patch 5% 1-3 patches transdermal 12 hours on/12 hours off daily. 8. Seroquel 50 mg p.o. each evening. 9. Amitriptyline 50 mg p.o. each evening.
IM|intramuscular|IM|140|141|DISCHARGE MEDICATIONS|4. Bactrim SS 1 p.o. 3 times weekly. 5. Valcyte 450 mg p.o. daily. 6. Mycelex troche 10 mg p.o. 4 times daily. 7. Octreotide LAR Depo 20 mg IM monthly. 8. Flomax 0.4 mg p.o. daily. 9. Metoprolol 25 mg p.o. twice daily. 10. Remeron 15 mg p.o. once daily. 11. Florinef 0.1 mg p.o. daily. 12. Coumadin 4 mg p.o. each afternoon.
IM|intramuscular|IM|187|188|DISCHARGE  MEDICATIONS|11. _____ 24 cap 400 mg p.o. q.a.m. 12. Proventil inhale 2 puffs b.i.d. 13. Spiriva 1 puff inhaled daily (a.m.). 14. Benadryl 25 mg p.o. daily p.r.n. pruritus. 15. Depo testosterone 1 mL IM q. 2-1/2 weeks. 16. Atenolol 25 mg p.o. b.i.d. 17. Zinc sulfate 220 mg p.o. daily. 18. Vitamin C 500 mg p.o. daily. 19. Vitamin A 25,000 international units p.o. daily.
IM|intramuscular|IM|153|154|PLAN|We will allow the 72-hour hold to run. This was placed because of dangerousness to others, secondary to assaultive and paranoid behaviors. We will offer IM Haldol on an emergency basis. The alternative will be oral Seroquel.
IM|intramuscular|IM|121|122|MEDICATIONS|8. Senna tablets. 9. Subcutaneous heparin 5000 units t.i.d. 10. Zofran 4-8 mg IV q.6h. p.r.n. 11. Benadryl 50 mg p.o. or IM q.6h. p.r.n. 12. Prevacid 30 mg per day. 13. Sodium chloride tablets 2 grams by mouth daily for a week, then to be discontinued.
IM|intramuscular|IM,|169|171|IMPRESSION/PLAN|This will require repair, but with her INR of 1.81, we will need to reverse anticoagulation before proceeding. We will keep the patient n.p.o., give her vitamin K 10 mg IM, and recheck her INR early tomorrow, and plan to proceed in the morning. This was discussed with the patient. Hopefully, we will find some time early tomorrow to proceed with this operation.
IM|intramuscular|IM|157|158|PRESENT MEDICATIONS|5. Benadryl 100 mg q.h.s. 6. Trazodone 50 mg q.h.s., may repeat x 1. 7. Tylenol p.r.n. 8. Maalox p.r.n. 9. Milk of magnesia p.r.n. 10. Zyprexa 10 mg p.o. or IM p.r.n. psychotic symptoms or agitation. FAMILY HISTORY: Cancer on father's side. HABITS: Cigarettes 1 1/2 to 2 packs per day smoker.
IM|intramuscular|IM|138|139|CURRENT HOSPITAL MEDICATIONS|3. Benadryl 50 mg p.o. q.h.s. 4. Amantadine 200 mg p.o. q.h.s. CURRENT HOSPITAL MEDICATIONS: 1. Zyprexa 10 mg p.o. q.i.d. 2. Geodon 20 mg IM p.r.n. agitation. 3. Trileptal 300 mg p.o. b.i.d. 4. Tylenol 650 mg p.o. p.r.n. q.4h. ALLERGIES: 1. Sulfa. 2. The patient also states having major side effects and adverse effects from using Haldol.
IM|intramuscular|I.M.|328|331|GYNECOLOGIC HISTORY|The patient gives no history of STDs. I had a long discussion with the patient, stating that treatment for gynecological/pelvic pain of unknown origin usually involves hormonal suppression of the ovaries. This begins usually with continuous low-dose oral contraceptives which stop ovulation; more aggressive therapy can include I.M. Lupron, which is a GNRH agonist, which completely shuts down ovarian estrogen production, putting the patient into chemical menopause.
IM|intramuscular|IM|156|157|MEDICATIONS|MEDICATIONS: 1. Verapamil 120 mg one tablet p.o. daily. 2. Calcium 600 mg plus vitamin D one tablet p.o. daily. 3. Multivitamins. 4. Vitamin B12 1000 units IM q. month. 5. Fosamax one tablet p.o. weekly. 6. Kytril 1 mg p.o. p.r.n. nausea and vomiting. ALLERGIES: Penicillin. Sulfa. Taxol. Tegretol. HEALTH CARE MAINTENANCE: Last Pap smear in _%#MM2002#%_ negative.
IM|intramuscular|IM|139|140|MEDICATIONS|He does not drink alcohol at all. MEDICATIONS: 1. Z-PAK. 2. Imdur 60 mg p.o. q day. 3. Plavix 75 mg p.o. daily. 4. Vitamin B shots 500 mcg IM q.2 weeks. 5. Folic acid 1 mg p.o. daily. 6. KCl 20 mEq p.o. daily. 7. Lisinopril 20 mg p.o. daily. 8. Serevent one puff b.i.d.
IM|intramuscular|IM|112|113|CURRENT MEDICATIONS|3. Avonex (interferon). 4. Tylenol extra-strength 650 mg PO q 4 hours prn. 5. Decadron protocol, currently 8 mg IM q.i.d. X the next two days, with taper. ALLERGIES: No known drug allergies. HABITS: The patient denies tobacco, alcohol, or illicit drug use.
IM|intramedullary|IM|160|161|PHYSICAL EXAMINATION|No active bleeding was noted. No signs of compartment syndrome from this. Tibia itself shows a well-healed proximal incision, presumably the entry point of the IM rod. Distally the ankle though is benign except for some mild edema. Homans' sign appears to be negative. Obvious atrophy is present in the calf muscles compared to the other side.
IM|intramuscular|IM|111|112||I received a call from her husband last night saying that she had visited the ER yesterday. They gave her some IM medication and released her on Percocet. The patient was nauseous and vomited last night. She has not been able to keep things down.
IM|intramuscular|IM|184|185|DISCUSSION|She has a long history of headaches, which are felt to be migraine as well as muscle contraction. She describes extensive past evaluations for this. She says at times she does require IM Dilaudid and this has always worked better than any other analgesic medication for her headache. She sometimes does benefit from Imitrex. She only has received Imitrex this morning without benefit.
IM|intramuscular|IM|153|154|MEDICATIONS|5. Ferrous sulfate 325 mg daily. 6. Multivitamin daily. 7. Protonix 40 mg daily. 8. Seroquel 100 mg at 0800 and 1400 with 200 mg at bedtime. 9. B12 1 mg IM q.4 weeks. 10. Routine p.r.n. meds. FAMILY HISTORY: Father with type 2 diabetes. Mother died from congestive heart failure related to prior chemotherapy.
IM|intramuscular|IM.|182|184|ASSESSMENT/PLAN|5. Anemia, likely secondary to menses versus B12 deficiency due to gastric bypass. Will start ferrous sulfate 324 mg a day. Also will start B12 1000 mcg a week then 1000 mcg a month IM. Also will start multivitamin plus minerals p.o. daily. 6. Tremor, likely secondary to Abilify and not being on her propanolol. Benign finding, but will follow. 7. History of small-bowel obstruction.
IM|intramedullary|IM|218|219|ASSESSMENT|ASSESSMENT: Pathologic fracture right femur in this 69-year-old gentleman with stage IV metastatic lung cancer. I discussed the situation with the patient and his family at length. I think he would be best served with IM rodding of his femur to allow for better mobilization and better pain control. I discussed surgery with them, its risks, benefits, expected postoperative course.
IM|intramuscular|IM|145|146|PRESENT MEDICATIONS|ALLERGIES: No known drug allergies. PRESENT MEDICATIONS: 1. Neurontin 300 mg t.i.d. 2. Seroquel 50 mg b.i.d. with 100 mg q.h.s. 3. Zyprexa 10 mg IM q.4 h. p.r.n. agitation. 4. MSSA withdrawal protocol using Ativan with thiamine 100 mg each day. 5. Tylenol, Maalox, Milk of Magnesia as p.r.n. medications. FAMILY HISTORY: Per old records.
IM|intramuscular|IM|161|162|HISTORY OF PRESENT ILLNESS|Question regarding dyspnea which the patient denies. Was, however, unable to adequately speak. Impression of possible dystonic reaction, for which Cogentin 2 mg IM was administered. The patient indicates prompt relief of symptoms within 15 minutes to the point where she is presently asymptomatic.
IM|intramuscular|IM|152|153|ASSESSMENT|12. Elevated sodium and total protein consistent with probable component of volume depletion. Push fluids for now. 13. Elevated AST possibly related to IM medication injection and/or medication effect. Possible fatty liver with patient's obesity. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Recheck labs including basic metabolic panel, white count, and AST.
IM|intramedullary|IM|139|140|PHYSICAL EXAMINATION|She has a flexion contracture of her left knee, approximately 45 degrees. X-ray examination of the left hip and femur reveals a retrograde IM rod extending from the knee up to the subtrochanteric region and just proximal to the tip of the rod, she has displaced subtrochanteric fracture.
IM|intramuscular|IM|161|162|MEDICATIONS|4. Toprol XL 25 mg q.a.m. 5. Klonopin 25 mg p.o. q.4h. p.r.n. 6. Multivitamin. 7. Calcium. 8. Vitamin D. 9. Estradiol 1 mg every Monday and Thursday. 10. Avonex IM on Saturdays. PAST MEDICAL HISTORY: 1. Multiple sclerosis. 2. Hypertension 3. Hyperlipidemia. SOCIAL HISTORY: Denies tobacco and alcohol.
IM|intramuscular|IM|227|228|HISTORY OF PRESENT ILLNESS|The baby received phenobarbital and then was transported to the NICU at University of Minnesota Medical Center, Fairview. At University of Minnesota Medical Center, Fairview, an LP was successfully done about 4 hours after the IM antibiotics were given the ED. Blood cultures were obtained. Urinalysis was obtained from a bag specimen after unsuccessfully trying a catheter and suprapubic tap, but no urine culture was done.
IM|intramuscular|IM|188|189|MEDICATIONS|3. Allergies. PAST SURGICAL HISTORY: Wisdom teeth extraction. MEDICATIONS: 1. Ativan 0.5 mg to 1 mg t.i.d. p.r.n. 2. Sudafed 30 mg p.o. q.i.d. p.r.n. congestion. 3. Haldol 5-10 mg p.o. or IM q. 4h. p.r.n. 4. Cogentin 1-2 mg p.o. or IM b.i.d. p.r.n. 5. Bactrim DS one tablet p.o. b.i.d., started on _%#MMDD2006#%_.
IM|intramedullary|IM|132|133|DISCUSSION|Mr. _%#NAME#%_ is status post right tibial, and fibular osteotomies as well as bone growth stimulator implantation, and exchange of IM right calcaneal nail procedure by Dr. _%#NAME#%_. This was done because of leg length discrepancy. The patient states he gets short of breath with Percocet.
IM|intramuscular|IM|198|199|ADMISSION MEDICATIONS|ALLERGIES: Mellaril intolerance. ADMISSION MEDICATIONS: 1. Clindamycin solution b.i.d., presumably for facial acne. 2. Tegretol ER 500 mg at h.s. 3. Zyprexa 10 mg at h.s. 4. Haldol Decanoate 100 mg IM q.2 weeks, last administered on _%#MM#%_ _%#DD#%_. 5. Tylenol p.r.n. 6. Presently maintained on Geodon 80 mg p.o. or 20 mg IM q.4h. p.r.n.
IM|intramuscular|IM,|109|111|MMC 185|The child presented with a 1-week history of diarrhea. In the interval time, the child has received Rocephin IM, antibiotics and IV fluids but has also become febrile. The child is known to us in the Genetics and Metabolism service because of the history of a very rare and remarkable condition known as carbohydrate-deficient glycogen protein disease Type Ia.
IM|intramuscular|IM|211|212|DISCUSSION|As per her past dictations, most of her anxiety and pain complaints have centered around to her headaches, which have been thoroughly evaluated in the past. In the past, she has been allowed to receive morphine IM by her primary physician, not to exceed 1 dose per week. I am not certain if this order has been continued at her care center.
IM|intramuscular|IM|143|144|HISTORY OF PRESENT ILLNESS|She states that her headache started on Saturday, which was _%#MMDD2004#%_. The patient states she has tried ibuprofen, Tylenol, Excedrin, and IM Toradol, with no significant improvement. She states that she has slight photophobia; however, there is no noise disturbance. She denies any nausea or vomiting associated with the headache.
IM|intramuscular|IM|154|155|HISTORY|No specific act of self-harm. Taken to Fairview _%#CITY#%_ ER with additional complaint of "migraine headache." Received Toradol 60 mg and Vistaril 50 mg IM with symptom resolution. Presently fairly sedated secondary to medicine regimen, able however, to answer questions appropriately. PAST MEDICAL HISTORY: 1. Psychiatric illness as above.
IM|intramuscular|IM|104|105|MEDICATIONS|3. Detrol LA 4 mg po qd. 4. Zoloft 100 mg po qd. 5. Zocor 40 mg po qd. 6. Vitamin B12 1,000 micro units IM qmonth. 7. Colace 200 mg po b.i.d. 8. Valium prn. 9. Vitamin D with calcium 500 mg po t.i.d. ALLERGIES/SENSITIVITIES: 1. Desipramine (fatigue). 2. Depakote (fatigue). 3. Neurontin, ? reaction. 4. Tegretol (fatigue). 5. Elavil (fatigue).
IM|intramuscular|IM|310|311|MEDICATIONS|ALLERGIES: None known. MEDICATIONS: Medications prior to admission were none except for the possibility of a proton pump inhibitor (?) for "heartburn." She presently is maintained on Risperdal _________tab 1 mg q.a.m. and 2 mg q.h.s., Celexa 20 mg q.h.s., trazodone 100 mg q.h.s. p.r.n. insomnia, Zyprexa 5 mg IM q. 2 h p.r.n. agitation/aggression, with p.r.n. ibuprofen and Colace. FAMILY HISTORY: Without known serious illness. HABITS: She denies smoking or alcohol. She denies other drug use.
IM|intramuscular|IM|142|143|CURRENT MEDICATIONS|ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: 1. Tylenol, Maalox, milk of magnesia p.r.n. 2. Geodon 120 mg p.o. b.i.d. p.r.n. with IM administration if refused. 3. Cogentin 1 mg p.o. q.i.d. p.r.n. 4. Risperdal 3 mg p.o. q.h.s. 5. Lipitor 20 mg q.h.s. 6. Glucotrol XL 10 mg daily.
IM|intramuscular|IM|135|136|MEDICATIONS|3. Norvasc 5 mg daily. 4. Lisinopril 10 mg daily. 5. Zocor 40 mg daily. 6. Aspirin 81 mg daily. 7. Metoprolol 12.5 mg b.i.d. 8. Lupron IM every 4 months. 9. Nitroglycerin p.r.n. 10. Multivitamins. PAST MEDICAL HISTORY: 1. Coronary artery disease with two previous myocardial infarcts and a mildly reduced ejection fraction.
IM|intramuscular|IM.|170|172|MEDICATIONS|7. Cogentin one tablet in the a.m. and one in the p.m. 8. Depakote extended release 500 mg p.o. q.a.m. and 1,000 mg p.o. q.p.m. 9. Risperdal Consta 25 mg every two weeks IM. 10. Zinc 50 mg tablets q.h.s. SOCIAL HISTORY: No tobacco. He quit alcohol in 2006. Last marijuana use was in 1997.
IM|intramuscular|IM|221|222|CURRENT MEDICATIONS|ALLERGIES: SHE IS ALLERGIC TO HALOPERIDOL AND INDERAL. CURRENT MEDICATIONS: Include Reminyl, Isosorbide, Nitrostat, Glucosamine, Zoloft 50 mg q day. Lisinopril, Triamterene/HCTZ, Synthroid, cyanocobalamin 1000 micrograms IM q monthly. Centrum, Vitamin E, K-Lor, aspirin and Detrol LA. EXAMINATION: She is pleasant, alert and cooperative. She has difficulty naming common objects or coming up with the name of the president of the United States.
IM|intramuscular|IM,|144|146|HISTORY|With progressive worsening of her symptoms, she went to North Memorial Medical Center and had some tests. She was treated with medications both IM, Toradol and released to home. The following day she was vomiting and nauseated from her medication and her pain was not improved.
IM|intramuscular|IM|227|228|HISTORY|No nausea. Evaluated in the emergency department at Burnett Medical Center in _%#CITY#%_, Wisconsin. Left lower extremity x-ray demonstrated the tibia/fibula fracture. Chest x-ray was not obtained. The patient was treated with IM Demerol and Vistaril with transfer to Fairview _%#CITY#%_. Since maintained on IV morphine sulfate for pain control. The patient indicates that he has tolerated general anesthesia in the past approximately 15 years ago at time of arthroscopic knee surgery.
IM|intramuscular|IM|154|155|INDICATION FOR PROCEDURE|No recent upper respiratory infectious or flu-like illness. Moderately severe pain presently for which the patient has received 100 mcg of fentanyl 50 mg IM Vistaril and 1 mg IV Dilaudid. Pruritus/skin eruption with tramadol. Mild nausea for which the patient did receive IV Zofran. Hypertension with present blood pressure 188/110 for which the patient has received 10 mg of labetalol with present administration of 5 mg of hydralazine IV.
IM|intramuscular|IM|159|160|ADMISSION MEDICATIONS|ADMISSION MEDICATIONS: He states he has not taken any medications but listed on this admission medications from _%#CITY#%_ _%#CITY#%_ are Benadryl 50 mg PO or IM q 1 to 4 hours as needed; Haldol lactate 5 mg PO or IM q 1 to 4 hours as needed; Lorazepam 1 to 2 mg PO or IM q 1 to 4 hours prn; Risperdal 1 mg PO b.i.d. as needed; Ambien 10 mg PO q.h.s. prn.
IM|intramuscular|IM.|329|331|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old male admitted to station 20 on a 72-hour hold from Fairview Southdale emergency room in 5-point restraint for suicidal ideation and history of depression and bipolar disorder. The patient initially was combative but significantly calmed down after receiving Zyprexa 10 mg IM. Prior to admission, the patient overdose of Gabitril after leaving the doctor's office taking five 4 mg pills. Subsequently, he got into a motor vehicle crash and was taken to the hospital by the police.
IM|intramuscular|IM|116|117|PRESENT MEDICATIONS|2. Cogentin 1 mg q.4 hours p.r.n. 3. Lexapro 10 mg daily 4. Rozerem 8 mg q.h.s. 5. Risperdal 4 mg q.h.s. with 50 mg IM q.2 weeks. FAMILY HISTORY: Without known serious illness. HABITS: One pack per day smoker.
IM|intramuscular|IM|111|112|CURRENT MEDICATIONS|3. Gastroesophageal reflux disease diagnosed 2-4 years ago. CURRENT MEDICATIONS: Per the chart: 1. Haldol 5 mg IM q.4 p.r.n. 2. Ativan 2-4 mg IM q.4 p.r.n. 3. Seroquel 25 mg p.o. b.i.d. 4. Tylenol No. 3 1-2 tablets p.o. q.4 p.r.n.
IM|intramuscular|IM|145|146|MEDICATIONS|He has no known drug allergies. He did develop yeast infections while on Keflex. MEDICATIONS: His medications before admission were testosterone IM every two weeks, glyburide, Flovent 220, 4 puffs b.i.d.; albuterol 2 puffs p.r.n., Allegra p.r.n., Sudafed p.r.n. Current medications include cefotetan.
IM|intramuscular|IM|254|255|HISTORY OF PRESENT ILLNESS|There was some slight discomfort associated with this initially. By the following morning he awakened and his left eye was nearly swollen shut and there was erythema apparently on the cheek and surrounding the eye. He was seen in the clinic and given an IM injection of probably Rocephin, then oral Augmentin. He says that the swelling improved but that he went on to develop a larger, progressing, more painful, and raised area on the left cheek.
IM|intramuscular|IM|140|141|MEDICATIONS|ALLERGIES: None. HEALTH HABITS: No smoking, no alcohol. MEDICATIONS: 1. Norvasc 10 mg once a day. 2. Phoslo p.o. with meals. 3. Vitamin B12 IM x1. 4. Colace 100 mg b.i.d. 5. Duragesic 50 mcg which was placed on admission here. 6. Lidoderm to the left than the right ankle. 7. Lopressor 75 mg every 12 hours.
IM|intramuscular|IM|119|120|MEDICATIONS|13. Lopressor 12.5 mg b.i.d. 14. Paxil 30 mg once a day. 15. Prednisone 5 mg p.o. once a day. 16. Vitamin B12 1000 mcg IM x1 17. Tylenol extra strength 1 tablet q.i.d. 18. Tylenol No. 3, 1 q.i.d., which she is not using. REVIEW OF SYSTEMS: CONSTITUTIONAL: No weight loss, no loss of appetite.
IM|intramuscular|IM|148|149|ASSESSMENT|ASSESSMENT: 1. Major depressive disorder versus borderline personality disorder. Treatment to be followed by Dr. _%#NAME#%_. 2. Depo-Provera 150 mg IM tomorrow, only if urine pregnancy test is negative. If positive, call MD. 3. Hyperglycemia, possibly secondary to diet. No family or past medical history of diabetes. Diabetes doubtful.
IM|intramedullary|IM|248|249|PHYSICAL EXAMINATION|ALLERGIES: Penicillin. MEDICATIONS: Documented in the chart. PHYSICAL EXAMINATION: RIGHT LOWER EXTREMITY: Angulated and shortened. Pain with any motion. X-rays du raise concerns of pathologic fracture but is subtrochanteric in nature. Will need an IM rod. I discussed this with the family. IMPRESSION: We will need to go ahead with rodding of this tonight.
IM|intramedullary|IM|171|172|PLAN|I would recommend surgical stabilization of the injuries. The left side is unstable and will not be held adequately with closed reduction. The need for stabilization with IM rods versus plates and the benefits of each as well as risks were discussed. The nature of the surgery, need for reoperation for hardware removal was discussed.
IM|intramuscular|IM|100|101|MEDICATIONS|10. Pilonidal cystectomy. 11. Vertical banded gastroplasty and takedown. MEDICATIONS: 1. .......lac IM for migraines. 2. Albuterol. 3. EpiPen. 4. Colace b.i.d. 5. Dilantin both 200 mg and 300 mg. 6. Norethindrone 5 mg. 7. Morphine sulfate 45 mg. 8. Detrol LA 4 mg.
IM|intramuscular|IM|108|109|MEDICATIONS|14. EpiPen for beestings. 15. Hydromorphone 2 mg p.o. one to two tablets p.r.n. q. 4 h. 16. Ketorolac 60 mg IM p.r.n., no more than 120 mcg per day. 17. Cipro 500 mg p.o. The patient just finished. 18. Antipyrine/benzocaine otic solution p.r.n. four drops q. 4 h.
IM|intramuscular|IM|141|142|ADMISSION MEDICATIONS|12. Senokot. 13. Trazodone. 14. Dulcolax. 15. Klonopin. 16. Effexor. 17. Levothyroxine. 18. Zanaflex. 19. Calcarb. 20. Prilosec. 21. Demerol IM with Vistaril 2-3 x per month in a clinic. 22. She was also placed on phenobarbital when she came in. NOTE: Of these medications Percocet, ibuprofen, Frova, Phenergan, Tigan, Vicodin, centrum, Klonopin, and Zanaflex were all discontinued.
IM|intramuscular|IM|193|194|PLAN|2. At this time, would recommend therapy with a one-time dose of Depo Lupron of 3.75 mg IM x1. Three weeks postoperatively, I would recommend continued therapy with Depo-Provera every 3 months IM injections. Risks, benefits and alternatives of both medications were counseled with the patient and her husband. The patient is agreeable. The patient was counseled and precautioned that medications, especially the Depo Lupron, given at such a late stage in her menstrual cycle, may increase risk of bleeding and it is likely that onset of her expected menses will resume.
IM|intramuscular|IM|131|132|MEDICATIONS|7. Vistaril 25 mg each day at bedtime, (?)Zydis 15 mg each day at bedtime. 8. Multivitamins 1 tablet daily. 9. Depo-Provera 150 mg IM every 3 months. ALLERGIES: No medication allergies. SOCIAL HISTORY: _%#NAME#%_ has required supervised care for several years secondary to her psychiatric illness.
IM|intramuscular|IM|148|149|MEDICATION|14. Dulcolax suppository 10 mg rectally b.i.d. p.r.n. 15. Zyprexa 2.5 mg p.o. p.r.n. 16. Motrin 600 mg p.o. q.4-6 h. p.r.n. 17. Depo Provera 150 mg IM q.3 months. 18. Cyclobenzaprine 5 mg 1-2 tablets p.o. each day at bedtime as needed for back pain. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Patient is disabled and lives in a group home.
IM|intramuscular|IM|186|187|PLAN|I stated that at least over the weekend, I could give her an IM shot of morphine and also Vistaril. She received that combination in the emergency room a couple weeks ago. I gave her an IM shot of 10 mg of MS and 50 mg of Vistaril. I also gave her fentanyl patch, 25 mcg/hour, total of 10.
IM|intramuscular|IM|152|153|MEDICATIONS ON ADMISSION|5. Aortic stenosis as outlined above. 6. Bilateral DVTs. 7. Peripheral neuropathy. 8. Renal insufficiency. MEDICATIONS ON ADMISSION: 1. Aricept 100 mcg IM once or twice a month. 2. Aspirin 81 mg a day. 3. Bactrim 25 mg twice a week. 4. Cyclosporine 50 mg p.o. b.i.d. 5. Lisinopril 20 mg p.o. q. day.
IM|intramuscular|IM|265|266|HISTORY OF PRESENT ILLNESS|The patient was asked about recent drug use and he replied the only drugs taken within the past few days were his regular Zoloft dose last night and some marijuana use. However, per emergency room record, it was made known that he had a 1-time Haldol dose of 10 mg IM given to him by paramedics at approximately 8:30 a.m. yesterday morning for acute agitation. After consulting with Dr. _%#NAME#%_ and Hosfield and ruling out other explanation for the patient's condition, it was concluded he was having delayed extrapyramidal side effects from Haldol.
IM|intramuscular|IM|198|199|MEDICATIONS|6. Hypertension. ALLERGIES: No known drug allergies. MEDICATIONS: Outpatient medications include: 1. Norvasc 10 mg by mouth once daily. 2. Arimidex 1 mg by mouth once daily. 3. Vitamin B12 1,000 mg IM q. month. 4. Synthroid 112 mcg by mouth once daily. 5. Lopressor 100 mg by mouth twice daily. 6. Glucuronate 325 mg by mouth once daily.
IM|intramuscular|IM|211|212|ASSESSMENT|5. Asthma, well compensated. 6. Pulmonary infiltrate and eosinophilia syndrome on chronic steroids. Stable pulmonary status. 7. Osteoarthritis. 8. Morbid obesity. 9. History of renal insufficiency attributed to IM medication injection. Reduced creatinine clearance per preop note. 10. History of depression, per preoperative note. 11. Preop documentation of Proteus urinary tract infection. 12. Atopic individual with multiple drug allergies as above.
IM|intramuscular|IM|161|162|MEDICATIONS|3. Metoprolol XL 25 mg daily. 4. Senokot S, 2 tablets twice daily. 5. Milk of magnesia 15-30 cc every night. 6. Multivitamin once daily. 7. Vitamin B12 1000 mcg IM once a month. 8. Fentanyl patch 50 mcg per hour, changed every 72 hours. 9. Remeron 30 mg daily at bedtime. 10. Trazodone 25 mg daily at bedtime.
IM|intramedullary|IM|399|400|PLAN|While there is a relative indication for clavicle fixation, his injury is very nondisplaced and I think has excellent healing potential and I do not think the fixation would significantly accelerate his rehabilitation, therefore I have recommended nonsurgical management. With regard to the tibia, we discussed both nonsurgical and surgical management and I have recommended operative fixation with IM nailing. I discussed risks and benefits including bleeding, infection, anesthetic risks, perioperative morbidity, postoperative morbidity, thromboembolic disease, pain, stiffness, nonunion, malunion, compartment syndrome, neurovascular issues, knee pain, etc.
IM|intramuscular|IM|314|315|COMMENT|No intervention or additional diagnostic intervention is necessary unless she has another seizure without awakeing or if she is not arousable within 2 hours after the seizure. If she continues to have a seizure for longer than 5 minutes, then treatment for status epilepticus may be initiated on the CD unit, with IM midazolam 2.5 mg and transfer to a more appropriate setting for continued acute care management. No neurology follow-up on the inpatient unit or as outpatient is needed unless she has another seizure.
IM|intramuscular|IM|257|258|MEDICATIONS|1. MS. 2. Depression/fatigue. 3. Reflux esophagitis. 4. Lower extremity edema. ALLERGIES: The patient has no known drug allergies. MEDICATIONS: Include Synthroid 0.125 mg a day, Aciphex dose unknown, Aldactone 25 mg b.i.d., Celexa 40 mg a day, Avonex 30 mg IM q.week, Ortho Tri-Cyclen and Antivert 25 mg t.i.d. FAMILY HISTORY: Unremarkable. SOCIAL HISTORY: The patient is ordinarily in very good health and cares for herself and is independent.
IM|intramuscular|IM|118|119|PRESENT MEDICATIONS|Carmol cream to toenail fungus and calluses. 8. Clozaril 300 mg q. h.s. and 200 mg b.i.d. 9. Prolixin Decanoate 25 mg IM q. week. 10. Zyprexa 20 mg q. h.s. 11. Depakote ER 1000 mg q. h.s. 12. Synthroid 25 mcg daily. 13. Multivitamin daily.
IM|intramedullary|IM|86|87|IMPRESSION|There is no complication with the nail position or alignment. IMPRESSION: Status post IM nailing, right subtrochanteric femur fracture. PLAN: I think it would be reasonable to obtain ESR/CRP/CBC with differential as a baseline screen to rule out potential infection.
IM|intramuscular|IM|160|161|HISTORY|He was subsequently admitted to the senior treatment unit and initially maintained on Depakote 125 mg q hs with Zyprexa 10 mg q hs and prn Haldol 0.25 mg po or IM up to four times daily. Prior Ativan 0.5 mg po or IM qid was discontinued. Subsequent to admission to the senior treatment unit, the patient has been quite lethargic.
IM|intramuscular|IM|164|165|PHYSICAL EXAMINATION|Romberg is negative. Cerebellar function is intact. There is fine tremor of the distal upper extremities. No rigidity. Of note, the patient did receive Haldol 5 mg IM at Fairview Northland. LABORATORY DATA: Unremarkable urinalysis. Negative urine toxicology screen except for positive THC.
IM|intramedullary|IM|195|196|DISCUSSION|DISCUSSION: _%#NAME#%_ _%#NAME#%_ is a 65-year-old man who I have been asked to see by Dr. _%#NAME#%_ for the assessment of atrial fibrillation. Mr. _%#NAME#%_ underwent a left humerus ORIF with IM rod by Dr. _%#NAME#%_. Mr. _%#NAME#%_ suffered a left shoulder injury 1 month ago while jogging in Florida. Of note is the fact that Mr. _%#NAME#%_ was noted to be in atrial fibrillation at the time of his preoperative assessment here.
IM|intramuscular|IM|198|199|CURRENT MEDICATIONS|2. Aspirin 325 mg p.o. every day. 3. Gatifloxacin 200 mg p.o. every day _%#MMDD#%_ through _%#MMDD#%_. 4. Pantoprazole 20 mg p.o. b.i.d. 5. Zofran 4 mg p.o. q6h p.r.n. nausea. 6. Haldol 0.5 to 1 mg IM or p.o. q8h p.r.n. severe agitation. 7. Ibuprofen p.r.n. 8. Milk of Magnesia and Maalox p.r.n. FAMILY HISTORY: Noncontributory.
IM|intramuscular|IM|119|120|ASSESSMENT AND PLAN|Band-Aid occlusion daily x one week. Z-pac 500 mg p.o. x one day, then 250 mg p.o. x four days. Tetanus booster 0.5 mL IM x one today. 2. Polysubstance dependence. Defer to Dr. _%#NAME#%_ for treatment. 3. Major depressive disorder. Defer to Dr. _%#NAME#%_ for treatment. 4. Hepatitis C. The patient declines all laboratory draws.
IM|intramuscular|IM|131|132|HISTORY OF PRESENT ILLNESS|Allegedly the fantasizing about people she works with. Received parenteral but Dilaudid in the ER (question for lumbar pain). Also IM Haldol. Issue of chronic lumbar pain for which the patient indicates treatment with Vicodin for the last four years. One tablet every 6 hours in the past. Indicates off Vicodin for 2 weeks.
IM|intramuscular|IM.|172|174|CURRENT MEDICATIONS|ALLERGIES: Morphine sulfate (pruritus), urticaria with sulfa. CURRENT MEDICATIONS: 1. Cimetidine 300 mg p.o. three times a day. 2. Celexa 40 mg daily. 3. Decadron protocol IM. 4. Plaquenil 200 mg twice a day. 5. Provigil 200 mg daily. 6. Oxybutynin 5 mg twice a day. 7. Trilafon 2 mg twice a day. 8. Dilantin 100 mg three times a day.
IM|intramuscular|IM|162|163|HISTORY OF PRESENT ILLNESS|The police got involved. When trying to get the patient up, he became violent and was fighting with the police. He was given 2 mg of Versed IM and 5 mg of Haldol IM and brought into the Emergency Department for further evaluation and treatment. He was admitted to the 4A psychiatric unit after the patient admitted to using marijuana and alcohol.
IM|intramuscular|IM|147|148|CURRENT MEDICATIONS|ALLERGIES: No known drug allergies. MEDICATIONS PRIOR TO ADMISSION: None. CURRENT MEDICATIONS: 1. Trazodone 50 mg q.h.s. 2. Vistaril 50 mg p.o. or IM q.2-4 h. p.r.n. anxiety. 3. Tylenol, Maalox, and milk of magnesia p.r.n. FAMILY HISTORY: Without known serious illness. HABITS: Four to five cigarettes daily. Alcohol as above. Occasional marijuana.
IM|intramuscular|IM|136|137|MEDICATIONS|She was mildly acidotic, mildly hyperammonemic, and started on formula. MEDICATIONS: 1. Carnitor 90 mg/kg/day. 2. Hydroxocobalamin 1 mg IM on Mondays and Thursdays. 3. A formula containing Propimex 70 gm in 400 mL of water, mixed 50/50 with breast milk for each feeding.
IM|intramuscular|IM|219|220|HISTORY OF PRESENT ILLNESS|She declined because at that time she was moving from the _%#CITY#%_ _%#CITY#%_ area. Her last endocrine appointment in _%#CITY#%_ _%#CITY#%_ was _%#MMDD2005#%_, and at that time her octreotide was increased from 20 mg IM to 30 mg IM q.3 weeks. Her acromegaly symptoms include sweating, swelling of the hands, and jaw pain. The patient was consulted on by Dr. _%#NAME#%_ on _%#MMDD2005#%_.
IM|intramuscular|IM|115|116|PRESENT MEDICATIONS|ALLERGIES: Rash/urticaria with penicillin and cephalosporin. PRESENT MEDICATIONS: 1. Risperdal, long-acting, 25 mg IM every two weeks with 2 mg q.h.s. 2. Zyprexa Zydis 5-10 mg q.4h. p.r.n. 3. Trazodone 50-100 mg q.h.s. p.r.n., may repeat x 1.
IM|intramuscular|IM|139|140|ADMISSION MEDICATIONS|ALLERGIES: Sulfa. ADMISSION MEDICATIONS: 1. Klonopin 2 mg b.i.d. 2. Prozac 50 mg daily. 3. Claritin daily. 4. Ativan 0.5 mg either p.o. or IM 3 times a day as needed. 5. Tylenol No. 3 p.r.n. 6. Minocycline. 7. Remeron. 8. Zyprexa 5 mg daily, 20 mg h.s. 9. Flomax 0.4 mg daily.
IM|intramuscular|IM|151|152|RECOMMENDATIONS|There was mild mitral insufficiency and mild tricuspid insufficiency noted (final report pending). 5. Neurologic evaluation and treatment. 6. Continue IM amiodarone and nitroglycerin; heparin will be held due to the bleeding noted. 7. IV Zantac.
IM|intramuscular|IM|118|119|REFERRING PHYSICIAN|Presently on 1. Cogentin 1 to 2 mg q. 8 hours p.r.n. 2. Geodon 20 mg IM b.i.d. p.r.n. 3. Haldol 5 mg to 10 mg p.o. or IM q.4 hours p.r.n. 4. NSSA withdrawal protocol for using Ativan. 5. Nicotine gum. 6. Thiamine 100 mg daily for 3 days. 7. Clonidine 0.1 mg p.o. b.i.d. p.r.n.
IM|intramuscular|IM.|190|192|HISTORY OF PRESENT ILLNESS|Mom is unaware of the medication. It was just a trial medication; she does not have prescriptions for these. It did not help. She then went to the clinic and they gave her a shot of Toradol IM. She went home, lay down and continued to have no relief from her headache. Mom felt her later and she felt warm, having a T-max of 101.3 and developed aches all over, feet, back and arms.
IM|intramuscular|IM|209|210|PRESENT MEDICATIONS|ALLERGIES: DHE, Compazine, Halcion, Zoloft, Nubain. PRESENT MEDICATIONS: 1. Methadone 30 mg daily. 2. Lexapro 40 mg q. a.m. 3. Seroquel 100 mg q. h.s. with repeat p.r.n. 4. Demerol 100 mg with Vistaril 100 mg IM p.r.n. once daily with p.r.n. Tylenol, Milk of Magnesia, and Maalox. FAMILY HISTORY: Mother died from lung cancer. Father died in late 70s.
IM|intramuscular|IM|133|134|CURRENT MEDICATIONS|3. Toradol 30 mg IV q.8.h x 2 doses. 4. Os-Cal 250 plus Vitamin D 2 tablets b.i.d. 5. Tylenol p.r.n. 6. Vistaril 25 to 50 mg p.o. or IM q3-4h p.r.n. 7. Coumadin 5 mg, to begin tonight. FAMILY HISTORY: Diabetes. No history of coronary artery disease except for in one grandfather.
IM|intramuscular|IM|259|260|ALLERGIES|4. Surgeries: Left hand surgery approximately 20 years ago. 5. He denies heart disease, asthma, hypertension, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, thyroid disease, seizures, tuberculosis or anemia. ALLERGIES: Allergies include IM penicillin. PRESENT MEDICATIONS: 1. Nicotine gum. 2. Tylenol p.r.n. 3. Maalox p.r.n. 4. Milk of Magnesia p.r.n.
IM|intramuscular|IM|143|144|HISTORY OF PRESENT ILLNESS|She denies any numbness or tingling, but has occasional shooting pains down both legs. She says when pain becomes too severe, she has received IM injections of Demerol. She has seen pain specialists in the past. She says, she was told that no surgery will alleviate her neck, back and scapular pain, and that she "will always have this pain." The patient denies any other complaints at this time.
IM|intramuscular|IM|190|191|DOB|The patient was started on Pitocin per protocol. At 1125 she was having contractions every two to three minutes. She was 70 percent, 1, and minus-2. The patient received Nubain 10 mg IV and IM and Phenergan 25 mg IM. At 1400 she was 80 percent, 2, at a minus-2. At 1640 she was 90 percent, 3, and a minus-2.
IM|intramedullary|IM|178|179|ASSESSMENT|There does not appear to be any pathologic nature of the fracture. ASSESSMENT: Left mid-shaft femur fracture in this 74-year-old female. She would be best served with retrograde IM rod similar to what she had on the opposite side. I discussed surgery with her, its risks, benefits, and expected course.
IM|intramuscular|IM|150|151|MEDICATIONS|10. L-Synthroid 150 mcg p.o. q.d. 11. Zantac 150 mg p.o. b.i.d. 12. Haldol 20 mg p.o. q. AM and 2 mg p.o. q.h.s. 13. Haldol decanoate 100 mg/ml, 2 ml IM q. two weeks. 14. Risperdal 1 mg p.o. q. four hours p.r.n. 15. Abilify 15 mg p.o. q. AM and 1 mg q.h.s.
IM|intramedullary|IM|135|136|IMPRESSION|The articular surface appears to be intact. IMPRESSION: 1. Displaced distal third tibia and fibula fracture of the leg. 2. Status post IM rod right femur. 3. Status post splenectomy. 4. Status post open reduction and internal fixation of right elbow. PLAN: 1. Admission for pain control and elevation. 2. The patient is scheduled for surgical intervention on _%#MMDD2005#%_ with an open reduction and internal fixation.
IM|intramuscular|IM,|141|143|PLAN|Patient will keep this in mind as he contemplates further action. We will give him a pneumococcal vaccine today, a B12 injection of 1000 mcg IM, plan to see him again in 3 to 4 months' time for follow up. We will send a copy of our office notes to his primary care physician, Dr. _%#NAME#%_ _%#NAME#%_ at _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_, Suite #203, _%#CITY#%_ _%#CITY#%_, California _%#55400#%_.
IM|intramedullary|IM|199|200|ASSESSMENT/PLAN|I discussed with the patient the treatment options, one of which could include nonoperative treatment with a coaptation splint now, followed by a Sarmiento brace. The second option would be probable IM rodding versus open reduction and internal fixation. Because of the alignment, which I think overall is quite acceptable, I think there is a good chance that this will heal uneventfully; however, there is a chance that it will displace, despite nonoperative treatment.
IM|intramuscular|IM,|166|168|PLAN|One might try a slightly higher dose of Ultram. For acute treatment, if nothing helps and she insists on something for immediate relief, I recommend Toradol 15-30 mg IM, which could be given every six hours. I would try to avoid that, and certainly not continue it beyond 4-5 days.
IM|intramuscular|IM|189|190|IMPRESSION|She has improved on IV Zosyn and oral Zithromax. She has been afebrile in the hospital. Repeat blood cultures this admission have been negative, but she did receive some interim outpatient IM Rocephin plus oral Erythromycin and Augmentin. Question is whether the strep intermedius is significant. This is a member of the viridans strep group and usually represents oral flora.
IM|intramuscular|IM|116|117|HISTORY OF PRESENT ILLNESS|Please see Dr. _%#NAME#%_ regarding the events leading up to this admission. I was asked by Dr. _%#NAME#%_ to do an IM consult to follow the patient's medical concerns. Apparently, Ms. _%#NAME#%_ experienced an episode of syncope this a.m. on _%#MMDD2005#%_, following a blood draw.
IM|intramuscular|IM|126|127|MEDICATIONS|4. Inderal LAAAA 80 mg daily ...........migraine headaches. 5. Neurontin 600 mg t.i.d. 6. Nardil 30 mg b.i.d. 7. Methotrexate IM every week. 8. Vitamin B12 injections every month. 9. Ambien 10 mg daily. SOCIAL HISTORY: The patient is an RN. She is married and has two children.
IM|intramuscular|IM|166|167|ALLERGIES|ALLERGIES: She is allergic to aspirin, sulfa, and ciprofloxacin. CURRENT MEDICATIONS include: 1. Rocephin IV. 2. Benadryl p.r.n. 3. Zofran p.r.n. 4. Morphine, 5-0 mg IM q. 3 hours p.r.n. or 1-2 mg IV q. 30 minutes p.r.n. pain. 5. Compazine p.r.n. 6. Percocet p.o. p.r.n. 7. Tylenol p.r.n.
IM|intramuscular|IM|162|163|MEDICATIONS|ALLERGIES: No known drug allergies. MEDICATIONS: 1. P.r.n. Tylenol, Maalox, Milk of Magnesia, Colace, Zantac, Robitussin and trazodone. 2. Zyprexa 10 mg Zydis or IM q.4h. p.r.n. 3. Depakote 250 mg t.i.d. 4. Lanoxin 0.5 mg daily. 5. Diltiazem XR 120 mg daily. 6. Lisinopril 5 mg daily.
IM|intramuscular|IM|161|162|MEDICATIONS|1. Dilaudid PCA. 2. Benadryl. 3. D-5 half normal saline with 20 mEq Kcl at 100 mL/hour. 4. Cepacol. 5. Glycerin suppository daily p.r.n. 6. Vistaril 25 to 50 mg IM q.4 h. p.r.n. 7. Mylanta 30 mL suspension p.o. q.4 h. p.r.n. 8. Metoprolol 50 mg p.o. b.i.d. 9. Milk of Magnesia 30 mL suspension p.o. daily.
IM|intramuscular|IM|195|196|MEDICATIONS|7. Zantac 150 mg twice daily as needed. 8. Robitussin DM 10 mL every 4 hours as needed for cough. 9. Trazodone 50 mg as needed for sleep. 10. Haldol 2 mg tablet every 4 hours for agitation, 2 mg IM every 4 hours as needed for agitation. 11. Ativan 1 mg injection every 4 hours as needed for agitation. 12. Benadryl 25 mg every 4 hours as needed.
IM|intramuscular|IM|238|239|MEDICATIONS|14. Chronic obstructive pulmonary disease Recent events documented above MEDICATIONS: List includes Protonix, Zocor, Lopressor, aspirin, insulin, mesalamine, multivitamins, calcium, acidophilus tablets, Lactinex, Methylprednisolone 40 mg IM Q day, Kay Ciel, Flovent and Combivent. The doses are listed on the admitting sheet. ALLERGIES: The patient has no known drug allergies SOCIAL HISTORY: The patient lives with a son and wife.
IM|intramedullary|IM|221|222|PLAN|It has the possibility of going on to nonunion or malunion or developing compartment syndrome no matter how it is treated. I recommended an open reduction, internal fixation. It looks as though it would be amenable to an IM rod locked proximally and distally. I might have to augment the proximal fixation with an interfragmentary screw or two. I drew a picture of this. We talked in detail about the procedure, the risks, the expected results, and the rehabilitation required as well as the possibility for the need to remove the rod and screws in the future.
IM|intramuscular|IM|172|173|OUTPATIENT MEDICATIONS|Just before he was admitted, he had a large bowel movement and felt significantly better. ALLERGIES: Bleeding problems with Naprosyn use. OUTPATIENT MEDICATIONS: 1. Lupron IM q. 3 months: Held by Oncology. 2. Zometa q. 6 months: not currently taing 3. Calcium Citrate 1080 mg 2 tablets p.o. t.i.d. 4. Metformin 500 mg p.o. b.i.d.
IM|intramuscular|IM.|152|154|HISTORY|The patient actually presented to the ER with a migraine headache and severe depression. She received an injection of Demerol 100 mg and Vistaril 50 mg IM. Subsequently transferred to Fairview _%#CITY#%_. No active self-harm. Prior psychiatric hospitalizations at Abbott Northwestern, Mercy, United, and more recently Fairview _%#CITY#%_ in _%#MM#%_ of 2001 and _%#MM#%_ of 2001.
IM|intramuscular|IM|177|178|OUTPATIENT MEDICATIONS|OUTPATIENT MEDICATIONS: 1. Risperdal 1 mg p.o. q.h.s. 2. DDAVP spray 5 mcg p.o. b.i.d. 3. Synthroid 0.125 mg p.o. q.d. 4. Klonopin 0.5 mg p.o. t.i.d. 5. Testosterone injections IM q2weeks. 6. Hydrocortisone. ALLERGIES: Aspirin. SOCIAL HISTORY: The patient is from Somalia.
IM|intramuscular|IM|148|149|MEDICATIONS ON ADMISSION|4. Premarin 0.625 mg every day. 5. Ultram 100 mg every day p.r.n. 6. Lasix 40 mg every day p.r.n. 7. Cimetidine 300 mg t.i.d. 8. Dexamethasone 8 mg IM injections q.i.d. 9. Albuterol inhaler 2 puffs inhaled aerosol q.i.d. p.r.n. 10. Scalexin (sp??) 800 mg p.o. q.6 h. p.r.n. 11. Nitroglycerin.
IM|intramuscular|IM|179|180|HISTORY OF PRESENT ILLNESS|He denies photophobia. He was seen by his primary care doctor on _%#MMDD#%_ and _%#MMDD#%_. On _%#MMDD#%_ he received IM Rocephin and Levaquin, and on _%#MMDD#%_ he also received IM Rocephin. The patient was seen in the Emergency Room where he had an LP done which was cloudy and xanthochromic.
IM|intramuscular|IM|151|152|REQUESTING PHYSICIAN|It was felt that the pain was quite atypical and most consistent with pneumonia and no further workup was performed. His troponins were negative. Some IM amiodarone resulted in resolution of his arrhythmia. His BNP at that time was 163. He was treated with a course of antibiotics which apparently was complicated by some diarrhea.
IM|intramuscular|IM|126|127|DISCUSSION|The patient's only physical complaint at the time of admission was that of back pain, for which he did receive Toradol and MS IM in the emergency room. He was also started on a fentanyl patch 100 mcg, which he stated to the nursing staff he has been taking irregularly.
IM|intramuscular|IM|185|186|ADMISSION MEDICATIONS|3. Chronic low back pain. 4. Bruxism. 5. Myopia. PAST SURGICAL HISTORY: No significant past surgeries. ADMISSION MEDICATIONS: 1. Zyprexa 10 mg IM q. 6h. p.r.n. 2. Ativan 1-2 mg p.o. or IM q. 6h. p.r.n. 3. Wellbutrin 300 mg q.a.m. 4. Protonix 50 mg p.o. daily. 5. Trazodone 25-50 mg p.o. at bedtime. 6. Depakote 500 mg t.i.d.
IM|intramuscular|IM|146|147|PAST MEDICAL HISTORY|2. History of fibromyalgia. The patient was diagnosed with this two to three years ago. She states she uses ibuprofen to control this and Toradol IM if it gets really bad. 3. History of tachycardia. The patient is on Inderal for this. 4. History of right great toe fracture approximately two weeks ago.
IM|intramuscular|IM|193|194|ASSESSMENT|ASSESSMENT: 1. Major depressive disorder, cocaine/crack dependence, suicidal ideation. Details per Dr. _%#NAME#%_. 2. Fibromyalgia. The patient states her pain varies and ibuprofen and Toradol IM help with the pain. Today she states her back, neck, and hips are hurting the most. She states her mattress is making this worse. We will write to change her mattress or provide an egg-crate mattress for the patient.
IM|intramuscular|IM|168|169|PLAN|With elevated alkaline phosphatase. Cannot exclude gallbladder disease. Possible liver function abnormality related to meds. Possible transaminase elevation related to IM injection. Will check serial follow-up LFTs. Consider right upper quadrant abdominal ultrasound if/when clinically appropriate. Thank you for the consultation.
IM|intramuscular|IM|343|344|HISTORY OF PRESENT ILLNESS|After confirming that he had good airflow and his lungs were clear, the patient became more stable and was able to communicate that he felt like his throat seemed like it was tight and that he experienced a similar episode the night before which was just as uncomfortable. Upon reviewing patient's chart, it was revealed that he received15 mg IM of Haldol in the emergency room secondary to aggressive behavior. Upon reviewing this, a stat order for 1 mg IM of Cogentin was placed.
IM|intramuscular|IM|179|180|MEDICATIONS|ALLERGIES: Morphine, sulfate, sulfa, and a penicillin derivative. MEDICATIONS: 1. Geodon 20 mg p.o. b.i.d. 2. Haldol Decanoate 25 mg IM X 1 today, with 125 mg of Haldol Decanoate IM q. two weeks. 3. Cogentin 1 to 2 mg p.o. b.i.d. prn ETSE. Comfort medications including Tylenol, Maalox, Milk of Magnesia, Trazodone. FAMILY HISTORY: Without known serious illness.
IM|intramuscular|IM|241|242|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old woman who is chronically mentally ill with schizophrenia who has an increased paranoia at the nursing home where she resides. She also has had a recent UTI and was treated with a dose IM gentamicin at Methodist Hospital. She denies any other acute medical problems. PAST MEDICAL HISTORY/HABITS: She is a nonsmoker, nondrinker.
IM|intramuscular|IM|185|186|ALLERGIES|7. History of Raynaud's disease. 8. History of pedal edema. OUTPATIENT MEDICATIONS: 1. Celebrex. ALLERGIES: Alphabet soup and orange juice produce urticaria. Patient has intolerance to IM Imitrex. FAMILY HISTORY: Not assessed. SOCIAL HISTORY: Patient smokes approximately 4-5 cigarettes a day. She abused alcohol prior to admission with her intake consisting of 12-24 beers a day.
IM|intramuscular|IM|196|197|ASSESSMENT AND PLAN|We will instruct the nurse to help the patient with this, as he has not used these medications in the past. 3. Possibly sexually transmitted disease. We will treat empirically with gm of Rocephin IM x 1 dose and 1 gm of azithromycin p.o. times one dose. 4. Left great toe pain. We will update the patient's tetanus shot as he is not sure when his last Tetanus shot was.
IM|intramuscular|IM|305|306|HISTORY OF PRESENT ILLNESS|3. Rheumatology to see. 4. Consider abdominal CT scan. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 20-year-old female who was in her usual state of good health until the end of _%#MM#%_ of this year, when she developed illness initially consisting of fever, sore throat and rash. She was given IM minocycline for this and became more ill with joint pains. She was seen in the emergency room where she was found to be in renal failure and was admitted to the hospital.
IM|intramuscular|IM|137|138|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1. Caffeine. 2. Morphine 0.15 mg IV q.6 h. scheduled. 3. Ativan 0.13 mg IV q.6 h. p.r.n. 4. Enalapril. 5. Vitamin A IM q. week. 6. Erythromycin ophthalmic ointment. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Not obtainable. FAMILY HISTORY: No family history of coagulopathy REVIEW OF SYSTEMS: Not obtainable.
IM|intramuscular|IM|195|196|MEDICATIONS|5. PhosLo 667 t.i.d. 6. Minocin 100 b.i.d. 7. Prednisone 15 mg every other day 8. Metoprolol 25 b.i.d. 9. Erythropoietin every other week 10. Sodium bicarbonate 650 t.i.d. 11. Vitamin B12 1 gram IM monthly 12. Synthroid 150 mcg daily 13. Calcitrol 0.25 3 times per week 14. Coumadin as directed. 15. Lasix 20-40 mg daily. 16. Simvastatin 40 mg per day
IM|intramuscular|IM|201|202|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Linezolid 600 mg p.o. b.i.d. (continue until exploratory laparotomy). 2. Piperacillin 5 g IV q. 6 hours (continue until exploratory laparotomy). 3. Octreotide LAR Depot 20 mg IM monthly (next dose due _%#MM#%_ _%#DD#%_, 2006). 4. Flagyl 500 mg p.o. t.i.d. times 10 days and then discontinue. 5. Cellcept 250 mg p.o. b.i.d. 6. Prograf 1 mg p.o. b.i.d.
IM|intramuscular|IM|141|142|* FEN|* Nystatin, 50,000 U po every 6 hours while on Cefzil. * Bactrim, 1 ml po every day, when Cefzil completed. * Testosterone Ciprorate, 25 mg, IM every 3 weeks. Discharge measurements and exam: Weight 3386 gm, length 49.5 cm, OFC 36.25 cm.
IM|intramuscular|IM|148|149|DISCHARGE MEDICATIONS|12. Clarithromycin 500 mg p.o. b.i.d. for prophylaxis. 13. Clotrimazole troche 1 lozenge 5 times daily, dissolved in mouth. 14. Vitamin B12 100 mcg IM shot q. month, due _%#MMDD2006#%_. 15. Dapsone 50 mg p.o. daily as prophylaxis. 16. Pulmozyme 2.5 mg neb daily. 17. Folate 1 mg p.o. daily. 18. Lasix 40 mg p.o. daily.
IM|intramuscular|IM|126|127|HOSPITAL COURSE|The patient was given ceftriaxone for the first 3 days of his hospital stay. It was noted that the patient was actually given IM doses as IV access was extremely hard to obtain and then keep in _%#NAME#%_. By day 4 of his hospital stay, the patient was changed to Cefzil, and he was taking this p.o. quite well.
IM|intramuscular|IM|160|161|HISTORY OF PRESENT ILLNESS|Chest x-ray on _%#MMDD2004#%_ demonstrated apparent bilateral pneumonia with MD notification of report on _%#MMDD2004#%_ prompting treatment with Rocephin 1 gm IM followed by ampicillin 500 mg suspension q.6h. for 10 days. Over this time, however, the patient developed rapid reduction in level of consciousness with decrease in verbal communication.
IM|intramuscular|IM|131|132|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Abilify, 15 mg p.o. daily. 2. Coreg, 12.5 mg p.o. b.i.d. 3. Nexium, 40 mg p.o. daily. 4. Prolixin, 50 mg IM q. 2 weeks. 5. Lasix, 40 mg p.o. b.i.d. 6. Lopid, 600 mg p.o. b.i.d. 7. Cozaar, 100 mg p.o. daily. 8. Pravachol, 40 mg p.o. q.h.s.
IM|intramuscular|IM|175|176|MEDICATIONS|4. Vitamin C 500 mg p.o. t.i.d. 5. Vitamin A 20000 international units p.o. daily. 6. Cranberry tablets 1 tablet p.o. b.i.d. 7. Levaquin 500 mg p.o. daily. 8. Rocephin 1 gram IM daily, appears not to have been administered yet. 9. Arginaid extra 4 ounces p.o. t.i.d. with meals. 10. Clonazepam 0.5 mg p.o. at bedtime. 11. Estrogen 0.3 mg p.o. daily.
IM|intramuscular|IM|114|115|DISCHARGE MEDICATIONS|17. Bactrim double strength 1 tab by mouth daily, this is a new medication for PCP prophylaxis. 18. Glucagon 1 mg IM or subcu every 15 minutes as needed for severe hypoglycemia. 19. Citrucel 1 dose by mouth daily. 20. Imodium 2 mg by mouth daily as needed for diarrhea.
IM|intramuscular|IM|226|227|SPECIAL INSTRUCTIONS|2. The patient was given IM Solu-Cortef to be administered if she was not tolerating p.o. or was extremely ill. The patient was to call the Endocrine fellow at _%#TEL#%_ and ask to have Dr. _%#NAME#%_ paged with questions, if IM Solu-Cortef is given. 3. A digoxin level was to be drawn on _%#MMDD2005#%_, and Dr. _%#NAME#%_ was to be called at _%#TEL#%_ with results.
IM|intramuscular|IM|139|140|HISTORY OF PRESENT ILLNESS|She has been taking Tylenol #3 for her chronic pain issues, though notes this is not controlling her now. She has required 20 mg of IV and IM morphine, and is still uncomfortable. She will be subsequently admitted for pain management. Ms. _%#NAME#%_' last admission to University of Minnesota Medical Center, Fairview, was in _%#MM2005#%_, and I refer you to Dr. _%#NAME#%_ detailed Discharge Summary for further details.
IM|intramuscular|IM|157|158|DISCHARGE MEDICATIONS|1. Duragesic patch 75 mcg per hours, transdermal to be changed every 3 days. 2. Roxanol 20-40 mg sublingual q.1-2h. p.r.n. breakthrough pain. 3. Lasix 20 mg IM p.o. q.2-4h. p.r.n. to be used in limited amounts with hospice for difficulty breathing. 4. Ativan 0.25 mg IM, p.o., or SL q.8h. p.r.n. agitation or insomnia.
IM|intramuscular|IM|257|258|HISTORY OF PRESENT ILLNESS|He indicates a past mental health hospitalization at University of Minnesota Medical Center, Fairview _%#CITY#%_ and St. Joseph's. He is maintained on a medication regimen of Neurontin 500 mg b.i.d., Clozaril 600 mg q.h.s, Depakote 500 mg b.i.d., Risperdal IM every other week, albuterol inhaler (p.r.n.) apparently dispensed in the past during an episode of pneumonia, and Lipitor (?) 40 mg daily for presumed hypercholesterolemia.
IM|intramuscular|IM|144|145|HISTORY OF PRESENT ILLNESS|She was evaluated initially in the ED, _%#CITY#%_, Minnesota. At that time, she was diagnosed with left otitis media and the patient received 1 IM dose of ceftriaxone and sent home with amoxicillin/clavulanic acid. However she was unable to take this discharge medication and she continued to have fever.
IM|intramuscular|IM|186|187|PRESENT MEDICATIONS|ALLERGIES: Multiple including imipenem, ciprofloxacin, Thorazine, ampicillin and cephalosporin drugs. PRESENT MEDICATIONS: 1. Baclofen pump delivering 30 mcg daily. 2. Tobramycin 300 mg IM on the day following suprapubic catheter change. 3. Tylenol 650 mg per G-tube q.4 h. p.r.n. 4. Albuterol by nebulization q.4 h. p.r.n. 5. DuoNeb q.4 h. p.r.n.
IM|intramuscular|IM|511|512|OTHER REVIEW OF SYSTEMS|She states that she has been short of breath. She denies nausea, vomiting, loss of consciousness, chest pain, palpitations or diarrhea. ALLERGIES: PENICILLIN AND FLU VACCINE. MEDICATIONS ON ADMISSION: Albuterol nebs p.r.n., lactulose 15 mL p.o. q.d., Metamucil p.r.n., multivitamin one p.o. q.d., vitamin E 500 international units p.o. q.d., thyroid 50 mg p.o. q.d., prednisone 40 mg p.o. q.d. which was started on _%#MMDD2002#%_, Advair 250 one b.i.d., docusate, calcium 240 mg p.o. q.d., vitamin B12 1000 mcg IM q.month and Os-Cal 500 mg p.o. b.i.d. She is also taking naproxen p.r.n. PAST MEDICAL HISTORY: 1. Asthma/chronic obstructive pulmonary disease, however she has no smoking history.
IM|intramuscular|IM|221|222|HOSPITAL COURSE|At the time of her discharge, the patient said that she had significant improvement of the headaches and felt that the amitriptyline with Percocet for breakthrough was quite sufficient and she was not requiring any other IM or IV narcotics. 6. Ophthalmology. Immediately postoperatively while the patient was in the intensive care unit she began to complain of significant eye pain, redness, and discharge.
IM|intramuscular|IM|199|200|MEDICATIONS|50 mg PO q hs. 5. Haldol 5 mg 1-2 tablets PO or 5 to 10 mg IM every four hours p.r.n. for her aggressive behavior. 6. Benadryl 50 mg 1-2 tablets PO, or 1500 mg IM with Haldol p.r.n. 7. Ativan 1-2 mg IM q four hours p.r.n. for agitation. 8. P.r.n. Tylenol. 9. P.r.n. Bisacodyl suppositories. 10. She was given one gram of Rocephin yesterday and started on Zithromax 500 mg PO daily for three days.
IM|intramuscular|IM|126|127|TRANSFER/ADMISSION MEDICATIONS|16. Mucinex 600 mg b.i.d. p.r.n. upper respiratory congestion. 17. Methadone 40 mg q.i.d. 18. Cyclobenzaprine 1000 mcg per mL IM monthly for B12 deficiency. 19. Adderall 10 mg t.i.d. 20. Advair 1 inhalation daily. 21. Singulair 10 mg daily. 22. Coumadin, current dose 2 mg daily.
IM|intramuscular|IM|157|158|PLAN|The patient consented. 7. Will provide DDAVP nasal spray, 2 sprays each nostril q.h.s. p.r.n. for nocturnal enuresis. 8. Will provide Vistaril 75 mg p.o. or IM q.h.s. on emergency basis p.r.n. 9. Defer to primary team for further medication adjustment in morning.
IM|intramuscular|IM|165|166|HISTORY OF PRESENT ILLNESS|On _%#MMDD2004#%_, she had a temperature of 101 at home. She reported to the emergency department, where her temperature was 102. She did receive a shot of Rocephin IM in the emergency department. Her blood culture was no growth to date. She has had fevers once a day, which are relieved with Tylenol; otherwise, she has no other complaints.
IM|intramuscular|IM|210|211|DISCHARGE/PLANS|DISCHARGE/PLANS: The patient was discharged from the hospital on _%#MM#%_ _%#DD#%_, 2005, in stable condition to her home with the following instructions: Nothing per vagina x6 weeks. She was given a Depo shot IM on the day of admission, _%#MM#%_ _%#DD#%_, 2005, and instructed to follow up with Dr. _%#NAME#%_ regarding an interval tubal ligation after 6 weeks. She would be a good candidate for an Essure procedure or a laparoscopic tubal ligation and is interested in that.
IM|intramuscular|IM|174|175|PROBLEM #3|He will have his next follow-up hemoglobin with his labs, which will be obtained at his follow-up on Monday. PROBLEM #3: Secondary syphilis. The patient was continued on his IM weekly penicillin injections. His last one was given on the day of admission, _%#MMDD2002#%_. PROBLEM #4: Thrush. The patient was continued on his p.o. fluconazole.
IM|intramuscular|IM|145|146|DISCHARGE MEDICATIONS|8. Cipro 750 mg p.o. b.i.d. 9. Kaletra three tablets p.o. b.i.d. 10. Combivir one tablet p.o. b.i.d. 11. Benzathine penicillin 1.2 million units IM q. week. Next dose to be given _%#MMDD2002#%_. DISCHARGE FOLLOW-UP: Dr. _%#NAME#%_ on _%#MMDD2002#%_ at 9:00 a.m.
IM|intramuscular|IM|172|173|MEDICATIONS|13. Albuterol nebs q.6h. p.r.n. 14. DuoNeb q.4h. p.r.n. 15. Compazine 10 mg p.o. q.i.d. p.r.n. nausea. 16. Advair 250/50 b.i.d. 17. Aggrenox 200/25 b.i.d. 18. B12 1000 mcg IM monthly to be given on the _%#DD#%_. 19. Ferrous sulfate 325 mg p.o. b.i.d. 20. Levothyroxine 0.125 mg p.o. daily.
IM|intramuscular|IM|117|118|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Atenolol 75 mg p.o. b.i.d. 2. Calcium carbonate 1.25 g p.o. b.i.d. 3. Vitamin B 12 100 mcg IM q. month, next dose due _%#MMDD2004#%_. 4. Prozac 30 mg p.o. each day. 5. Salt tabs 2 g p.o. b.i.d. 6. Protonix 40 mg p.o. each day. 7. Megace 400 mg p.o. b.i.d.
IM|intramuscular|IM|143|144|DISCHARGE MEDICATIONS|9. Miralax 17 gm p.o. b.i.d. 10. Vitamin D 400 units p.o. t.i.d. 11. Mucomyst 20% 30 ml p.o. four times a day. 12. Insulin Novolog 1 unit/carb IM with meals. 13. Glucagon 0.5 mcg IM q. 15 minutes p.r.n. severe hyperglycemia. 14. Glutose 15-30 gm gel p.o. q. 15 minutes p.r.n. hypoglycemia. 15. Mucomyst 10% neb 5 ml nebulized four times a day.
IM|intramuscular|IM|162|163|SUBJECTIVE|_%#NAME#%_ has tried multiple pain medications and narcotics for pain management without significant relief. She has also been receiving numerous doses of IV and IM narcotics including morphine and Demerol, either during local emergency room visits or local hospitalizations, over the past six weeks. Colonoscopy done _%#MMDD2003#%_ was normal according to mom. Biopsies were also normal.
IM|intramuscular|IM|179|180|ASSESSMENT PLAN|It appears that the pressure on his motor cortex from the blood and edema is etiology of his left-sided symptoms and neurologic deficits on exam. Plan - will start Decadron 10 mg IM q.6h times two days, then titrate down to 6 mg q.6h. We will Dilantin load the patient if he develops recurrent symptoms or seizures.
IM|intramuscular|IM|427|428|* FEN|* ID: _%#NAME#%_ is currently on day 8 of 10 of vancomycin for coagulase negative staphylococcus found from blood cultures on _%#MMDD#%_ and _%#MMDD#%_. Recommend discontinuation of antibiotics on _%#MMDD2007#%_. Discharge medications, treatments and special equipment: * Diuril 25 mg IV q 12 hours * Nystatin 50000 units po q 6 hours * NaCl 1.5 mEq q 6 hours * Vancomycin 20 mg IV q 12 hours (day 8/10) * Vitamin A 5000 units IM three times per week * Tylenol 10mg q 4 hour prn pain, fever * Glycerin suppository 1/4 capsule prn constipation, 24 hours without stool * Hydrocortisone 1% cream prn tid to nares for rash/irritation Of note, per _%#NAME#%_'s health insurance policy (CareAssist Policy), please call Dr. _%#NAME#%_ at _%#TEL#%_ _%#TEL#%_ for weekly discussions on Wednesday afternoons.
IM|intramuscular|IM|156|157|6.  GI|An ultrasound was done early on admission, which revealed peripheral _____, possibly related to fibroids versus adenomyosis. She was given 1 dose of Lupron IM on _%#MMDD2007#%_, which should be continued every 3 months. At the time of discharge, she did not have any complaints of vaginal bleeding and we are keeping her platelets greater than 20,000.
IM|intramuscular|IM|186|187|HOSPITAL COURSE|The patient did have uterine atony after delivery of her infant which responded to IV Pitocin (4 units of Pitocin in 1 liter of IV fluids), IM Methergine x1, IM hemabate x1, 20 units of IM Pitocin into the uterus and 1:1000 mg of Cytotec rectally. She lost a total of 1000 cc of blood. A firm uterus was obtained with the previously mentioned measures.
IM|intramuscular|IM|181|182|HISTORY OF THE PRESENT ILLNESS|Dad brought _%#NAME#%_ to _%#CITY#%_ _%#CITY#%_ Children's ER on Sunday (_%#MM#%_ _%#DD#%_). Chest x-ray at that time showed right upper lobe pneumonia and he was given ceftriaxone IM x1. He was sent home from the ER. Dad brought _%#NAME#%_ back to the ER later on Sunday night with persistent fever and increased work of breathing.
IM|intramuscular|IM|263|264|LABORATORY|We will place the patient on PCA pump for the time being to control his pain, given the fact that he's having significant difficulty with this. Of note, the patient did note to me as I was leaving that he felt that IV narcotic analgesia was more efficacious than IM narcotic analgesia with Demerol, which was undertaken in the Emergency Department due to difficulty placing a line. 2. Anemia. I wonder if this is more nutrition related.
IM|intramuscular|IM|207|208|HISTORY OF PRESENT ILLNESS|Wife reports some jerking of extremities but no bowel or bladder incontinence or tongue biting. On arrival to Fairview-University Medical Center, the emergency personnel, EMS, gave the patient Glucagon 1 mg IM x 2. The patient's blood sugar was 51 on arrival to the emergency department. The patient's vital signs at the emergency department were blood pressure of 147/94, pulse 58, respirations 20, temperature 96.9, 98% saturations on room air.
IM|intramuscular|IM.|125|127|PREOP MEDICATIONS|PREOP MEDICATIONS: 1. 1. Triamterene/hydrochlorothiazide 37.5/25 mg 1/2 tablet daily. 2. and mMonthly B12 injection 1000 mcg IM. FAMILY HISTORY: Denies known serious illness. HABITS: Nonsmoker. Quit in 1998. Alcohol intake twice weekly. Denies drinking to excess.
IM|intramuscular|IM|106|107|MEDICATIONS|10. Aviane birth control pill 1 tablet daily. 11. Proscar 5 mg 1/2 tablet every other day. 12. B12 100 mg IM x1. 13. Phenergan 25 mg q.4 hours p.r.n., nausea. 14. Miconazole powder to anterior chest rash b.i.d. 15. Meclizine 25 mg t.i.d. p.r.n., nausea.
IM|intramuscular|IM|109|110|PRESENT MEDICATIONS|ALLERGIES: None to medications. Notes dust-type allergy. PRESENT MEDICATIONS: 1. Cimetidine 300 mg t.i.d. 2. IM Decadron protocol beginning with 8 mg q.i.d. 3. Restoril 30 mg q. h.s. 4. Lexapro 40 mg daily. 5. Allegra 60 mg daily. 6. Neurontin 300 mg b.i.d.
IM|intramuscular|IM|149|150|PRESENT MEDICATIONS|21. Protonix 40 mg q.h.s. 22. Nasacort 55 mcg q. daily. 23. Multivitamin one p.o. q. daily. 24. Vitamin E 400 IU q. daily. 25. Vitamin B12 1,000 mcg IM q. month. 26. Plaquenil 200 mg b.i.d. 27. Albuterol metered-dose inhaler one to two puffs q4h p.r.n. 28. Premarin 1.25 mg q.a.m. 29. Nystatin swish and swallow 30 cc q.i.d.
IM|intramuscular|IM|186|187|ASSESSMENT AND PLAN|Patient has prior history of vitamin B12 deficiency and on replacement treatment We will obtain methylmalonic acid level methyl malonic acid level. We will start vitamin B12 at 1000 mcg IM q.monthly given the patient's ataxia may be related with not well treated B12 deficiency causing some neuropsychological problems.
IM|intramuscular|IM.|157|159|MEDICATIONS|6. Methylprednisolone 60 mg IV q 12 hours. 7. Protonix 40 mg daily. 8. Paxil 30 mg daily. Pneumococcal vaccine was recorded as given at 10 a.m. this morning IM. ALLERGIES: Zoloft has been associated with a rash. HABITS: Tobacco, generally drinks about 2 times per week and each time drinks approximately 9 alcoholic beverages.
IM|intramuscular|IM|180|181|PRESENT MEDICATIONS|ALLERGIES: Cleocin (rash). Dispensed at time of root canal. Also possibly allergic to some type of foam (correlated with above cough). PRESENT MEDICATIONS: 1. Vistaril 25 to 50 mg IM p.o. q6h p.r.n. 2. Colace 100 mg b.i.d. 3. Zofran 4 mg IV q6h p.r.n. 4. Tylenol 650 mg p.o. q6h p.r.n. 5. Benadryl 25 to 50 mg IV/p.o. q6h p.r.n.
IM|intramuscular|IM|121|122|ADMISSION MEDICATIONS/HOME MEDICATIONS|6. Seroquel 100 mg p.o. t.i.d. p.r.n. anxiety. 7. Maxalt 10 mg p.o. q.2h x2 in 24 hours p.r.n. headache. 8. Geodon 20 mg IM t.i.d. p.r.n. anxiety. 9. Synthroid 0.075 mg p.o. q.a.m. 10.Flovent 110 mcg 2 puffs b.i.d. 11.Spiriva 18 mcg 1 puff in the morning.
IM|intramuscular|IM|177|178|PRESENT MEDICATIONS|2. Trileptal 300 mg b.i.d. beginning _%#MMDD2005#%_. 3. Effexor XR 150 mg q.a.m. 4. Protonix 40 mg b.i.d. in place of Prevacid. 5. Flexeril 5 to 10 mg q.6 h. p.r.n. 6. B12 1 mL IM _%#MMDD2005#%_. 7. Valium 5 mg q.4 h. p.r.n. 8. Puralube eye ointment p.r.n. 9. Phazyme one capsule daily p.r.n. 10. Tums 500 mg t.i.d. p.r.n. 11. MiraLax one capful daily p.r.n.
IM|intramuscular|IM|185|186|MEDICATIONS|2. Ambien has resulted in hallucinations. MEDICATIONS: (Reviewed with the patient and his wife.) 1. Albuterol inhaler 2 puffs q.4 h. p.r.n. 2. Aspirin 81 mg daily. 3. B12 shot 1000 mcg IM monthly. 4. Metoprolol 12.5 mg b.i.d. 5. Percocet 1 tablet b.i.d. 6. Preop spirolactone 25 mg b.i.d. 7. Metolazone 25 mg 4 tablets daily p.r.n. increase in right leg edema (not a major issue subsequent to the above weight loss).
IM|intramuscular|IM|217|218|HOSPITAL COURSE|Persistently normal electrolytes and renal function. Follow- up liver function demonstrated a normal AST of 41, with minimally elevated ALT of 59, the significance of which was unclear. Thought potentially related to IM Haldol injection. Serial stools were negative for occult blood against patient's complaint of "bloody diarrhea." A flat and upright x-ray view of the abdomen on _%#MMDD2002#%_ demonstrated an unremarkable bowel gas pattern; specifically, no evidence for obstruction.
IM|intramuscular|IM|276|277|PRESENT MEDICATIONS|2. No surgeries. ALLERGIES: Sulfa (facial rash and ocular swelling), neuroleptic malignant syndrome with Thorazine, drug reaction to Clozaril, and increased rigidity with Geodon. PRESENT MEDICATIONS: 1. Klonopin 2 mg t.i.d. 2. Abilify 15 mg q.a.m. 3. Ativan 1 to 2 mg p.o. or IM q.i.d. p.r.n. 4. Baclofen 15 mg t.i.d. 5. Protonix 40 mg b.i.d. 6. Depakote sprinkles 750 mg b.i.d. FAMILY HISTORY: Family history is without known serious illness.
IR|interventional radiology|IR|197|198|PROBLEM #2|PROBLEM #2: Left pleural effusion - The patient had worsening shortness of breath and a followup CT showed worsening left pleural effusion throughout most of the left chest. She had initial tap by IR and approximately 1 L drained. However, she continued to have worsening hypoxia and shortness of breath and therefore Cardiothoracic Surgery and Pulmonology were consulted.
IR|interventional radiology|IR|148|149|HOSPITAL COURSE|He was admitted directly and was evaluated by interventional radiology for the possibility of a vertebroplasty. This was considered not possible by IR because the region was "too compressed". MRI showed multiple compression fractures at L2 and L3 and significant spinal canal stenosis L2-L3.
IR|interventional radiology|IR|193|194|HOSPITAL COURSE|HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 32-year-old male status post laparoscopic appendectomy on _%#MMDD2007#%_. He represented with right lower quadrant pain with abscess found on CT and IR placed drain in the right lower quadrant that was confirmed on CT scan to be well placed. His white count and febrile status normalized. He noted to have some diarrhea that was C diff negative and resolving after increasing his p.o. diet.
IR|interventional radiology|IR|201|202|MAJOR PROCEDURES|5. CT chest and abdomen on _%#MMDD2007#%_ - bulky mediastinal adenopathy, large pleural effusions with multiloculated effusion on the left, multiple small pulmonary nodules. 6. Chest tube placement by IR on the left side. 7. Status post talc pleurodesis on the left chest. BRIEF HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old gentleman with metastatic bladder cancer, who was initially diagnosed last week with a DVT and no evidence of PE, who was started on Lovenox and Coumadin therapy and now presents with acute onset of right-sided chest pain and clinical picture consistent with pulmonary embolism.
IR|interventional radiology|IR|203|204|PLAN|5. Current medications - See electronic MAR. Of note, the patient is on heparin, vancomycin and Zosyn. PLAN: 1. Continue to treat the left pleural effusion with continued drainage. We will await further IR and pulmonary recommendations regarding chest tube removal. The patient will continue on heparin for his DVT and PE. 2. Ultimately, we would like to improve the patient's pulmonary status and wean him off oxygen and tends to discharge home.
IR|interventional radiology|(IR)|272|275|ASSESSMENT AND PLAN|a. I will give him Staphylococcus aureus coverage but given the fact that I am still suspicious that this may be a fistula from his bowel I will cover him for gastrointestinal organisms too and therefore I will use IV ertapenem. b. I will consult Interventional Radiology (IR) in the morning to drain the abscess and hopefully now the abscess is big enough such that he can have a drain such as likely a Jackson-Pratt drain to help eliminate the organism.
IR|interventional radiology|IR|224|225|COURSE IN HOSPITAL|3. Hemodialysis catheter flow issue: She was getting her routine dialysis while she is in the hospital and it was noted that her dialysis catheter was not flowing well. They tried TPA infusion initially, which did not work. IR was called and she went to intervention radiology department to have her hemodialysis catheter checked, but apparently there is no evidence of positioning or clot issue and it was deemed to be functional by IR.
IR|interventional radiology|IR.|265|267|COURSE IN HOSPITAL|They tried TPA infusion initially, which did not work. IR was called and she went to intervention radiology department to have her hemodialysis catheter checked, but apparently there is no evidence of positioning or clot issue and it was deemed to be functional by IR. Due to this, she went back to hemodialysis unit and got a full run on _%#MMDD2007#%_ . DISCHARGE MEDICATIONS: There is no new medication during this hospitalization.
IR|interventional radiology|IR|216|217|HOSPITAL COURSE|At this point, she will be sent home with Lovenox bridging, Coumadin effect. According to Interventional Radiology, Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ (pager _%#TEL#%_), this patient does not need to followup with IR unless her symptoms are worsened. IR recommended that she be discharged home today on Coumadin and bridge with Lovenox. She will follow up with Cardiology, Dr. _%#NAME#%_ within 1 month as well.
IR|interventional radiology|IR|176|177|HOSPITAL COURSE|According to Interventional Radiology, Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ (pager _%#TEL#%_), this patient does not need to followup with IR unless her symptoms are worsened. IR recommended that she be discharged home today on Coumadin and bridge with Lovenox. She will follow up with Cardiology, Dr. _%#NAME#%_ within 1 month as well.
IR|immediate-release|IR|132|133|DISCHARGE MEDICATIONS|The patient was ambulatory and able to perform self-cares at that time. DISCHARGE INSTRUCTIONS: DISCHARGE MEDICATIONS: 1. Oxycodone IR 5 mg to be used as directed, #30. 2. Ibuprofen 600 mg p.o. q.6h p.r.n. pain. 3. Estrace 1 mg p.o. daily.
IR|interventional radiology|IR.|270|272|HISTORY OF PRESENT ILLNESS|The patient had previous biliary stents placed in the past and underwent a cholangiogram on _%#MMDD2006#%_ by Interventional Radiology, which showed no evidence of obstruction of his biliary system. His occluded biliary stent were pushed through into his small bowel by IR. He denied any complaints of fever, no chills, no nausea and no vomiting. He was moving his bowels and eating regularly in spite of his symptoms.
IR|immediate-release|IR|124|125|MEDICATIONS|9. Colace 100 mg p.o. b.i.d., number dispensed 40. 10. OxyContin 10 mg p.o. q. 12 hours, number dispensed 20. 13. Oxycodone IR 5 mg p.o. q.4 hours p.r.n. for pain, number dispensed 60. 14. Lasix lisinopril 20 mg p.o. daily. INSTRUCTIONS FOR CONTINUING CARE: 1. Diet is low sodium diet.
IR|interventional radiology|IR|196|197|PLAN|EGD was performed and a bleeding ulcer was noted and the junction of the bulb and 2 nd part of the duodenum. Beta blocker was discontinued and ppi given bid. If bleeding not controlled might need IR embolization.
IR|immediate-release|IR|130|131|CURRENT MEDICATIONS|4. Colace 100 mg p.o. b.i.d. 5. Lasix 40 mg p.o. q.d. 6. Potassium chloride 10 mEq p.o. q.d. 7. MS Contin 30 mg p.o. q.12h. 8. MS IR 10 mg p.o. q.3h. p.r.n. 9. Senokot 2 tablets q.p.m. 10. MiraLax one capful q.p.m. ALLERGIES: The patient is allergic to penicillin.
IR|interventional radiology|IR|167|168|HISTORY OF PRESENT ILLNESS|5. Status post cholecystectomy. 6. Status post vaginal hernia repair in _%#MM#%_ 2003 complicated by colocutaneous fistula formation. 7. Abdominal abscess status post IR percutaneous drainage. ADMISSION MEDICATIONS: 1. Subcutaneous morphine pump 10 mg q.15 minutes. 2. Tobramycin.
IR|interventional radiology|IR|238|239|OPERATIONS/PROCEDURES PERFORMED|His albumin was 2.7, his alkaline phosphatase was 75, AST 43, ALT 33, total bili was 3.8, and conjugated bili was 1.1. PROBLEMS: 1. End stage liver disease. Patient was initially admitted on _%#MM#%_ _%#DD#%_ for a TIPS placement through IR with the help of surgery performing a laparotomy with mesenteric vein cannulation. The procedure was quite prolonged, lasting approximately 6-7 hours and patient was, therefore, admitted to the SICU after procedure.
IR|immediate-release|IR|121|122|DISCHARGE  MEDICATIONS|DISCHARGE MEDICATIONS: 1. MS Contin per previous dose, I believe this is 30 mg b.i.d. 2. Celexa 40 mg daily. 3. Morphine IR 15 mg p.o. q.6h. p.r.n. 4. Xanax 0.5 mg 1-2 tablets daily p.r.n. 5. Atenolol 50 mg daily. 6. Potassium supplementation per previous dose. 7. MiraLax 17 grams p.o. daily.
IR|immediate-release|IR|128|129|DISCHARGE MEDICATIONS|8. Fentanyl patch 150 mcg q.1 h. transdermal q.72 h. 9. MS-Contin 30 mg p.o. b.i.d. 10. Lasix 20 mg p.o. each day. 11. Morphine IR 15 mg p.o. q.6 h. p.r.n. break-through pain. 12. Lactulose 1 bottle 30 mL p.o. b.i.d. 13. Vitamin K 5 mg p.o. each day.
IR|interventional radiology|IR|124|125|FOLLOW UP|DISCHARGE MEDICATIONS: 1. Zosyn 3.375 mg IV q. 6 hours for 2 weeks. 2. Flagyl 500 mg p.o. t.i.d. for 2 weeks. FOLLOW UP: 1. IR Clinic within 2 weeks of discharge. 2. Fairview home infusion for IV antibiotics and PICC line care. 3. Skilled RN initial home safety evaluation. 4. JP drain care.
IR|immediate-release|IR|157|158|DISCHARGE CONDITION|3. Levaquin 500 mg p.o. daily for another 5 days. 4. Multivitamin 1 tablet p.o. daily. 5. K-Dur 20 mEq p.o. t.i.d. 6. Warfarin 5 mg p.o. daily. 7. Diltiazem IR 60 mg p.o. q.i.d. The dose of this could be increased to further control his atrial flutter. He can eventually be placed on a sustained-release Cardizem dose.
IR|immediate-release|IR|441|442|MEDICATIONS|She does have a daughter and grandchildren living in this area. The patient is a nonsmoker and nondrinker. MEDICATIONS: Home medications on admission here include folic acid, Arimidex (an antiestrogen), lorazepam 1 mg at h.s., alprazolam 0.25 mg q.6h., Paxil 40 mg q.d., OxyContin 40 mg b.i.d., Lasix 40 mg b.i.d., metoprolol 50 mg one-half tablet b.i.d., Klor-Con 10 mEq two q.d., Prilosec 40 mg q.d., and aspirin 81 mg q.d. Also oxycodone IR 5 mg one or two on a p.r.n. basis for breakthrough pain. The patient also takes Procrit and Neupogen for 10 days.
IR|immediate-release|IR|149|150|DISCHARGE MEDICATIONS|Do not drive while taking narcotics. Return if there is any neurologic change. DISCHARGE MEDICATIONS: 1. Neurontin 300 mg p.o. nightly. 2. OxyContin IR 5 mg p.o. q.4 h. p.r.n. pain. 3. Senna-S 2 times p.o. nightly.
IR|immediate-release|IR|117|118|DISCHARGE MEDICATIONS|h. Nitropatch 0.6 mg q.h.s. i. Lantus insulin 11 units in the morning. j. Lipitor 80 mg per day. k. Morphine sulfate IR 15 mg 1-1/2 tablet in the morning. l. Norvasc 10 mg per day. m. Plavix 75 mg per day. n. Prevacid 30 mg per day. o. Tylenol No. 3 two tablets q.6h. p.r.n.
IR|immediate-release|IR|184|185|BRIEF HISTORY AND HOSPITAL COURSE|The pain seems reasonably controlled. She was given Dilaudid IV initially for break through pain. She states that the Percocet was not of much help, and this was switched to oxycodone IR 10 mg every 4 hours p.r.n. This seems to have at least controlled her pain to the level where it is tolerable.
IR|immediate-release|IR|213|214|HISTORY & COURSE OF ILLNESS|Pain control was a significant issue as might be expected from the patient taking 160 to 320 mg of OxyContin b.i.d. prior to his admission to the hospital. He was discharged on 320 mg of OxyContin b.i.d. with Oxy IR 5 mg tablets 6-12 3-4 hours p.r.n. breakthrough pain. He was also on Valium 5 mg p.o. q.6h. p.r.n. spasms, multivitamins, vitamin D plus calcium 500 mg t.i.d., iron sulfate.
IR|immediate-release|(IR)|128|131|CURRENT MEDICATIONS|2. MS (morphine sulfate) Contin 30 mg three tablets twice a day (for 90- mg twice a day). 3. Morphine sulfate immediate release (IR) 60 mg two- or four-times a day to relieve pain. 4. Birth control pill (Yasmin). REVIEW OF SYSTEMS: Otherwise negative.
IR|immediate-release|IR|95|96|DISCHARGE MEDICATIONS|1. OxyContin 40 mg b.i.d. and 10 mg b.i.d. 2. Neurontin 300 mg three times a day. 3. OxyContin IR as needed. 4. Bactroban cream to wounds. 5. Lopid 600 mg one daily. 6. Fosamax 70 mg one time per week. 7. Aspirin 81 mg a day. DISCHARGE FOLLOW-UP: Her follow-up visits will be as follows: 1. She should see Dr. _%#NAME#%_ in 2-4 weeks.
IR|interventional radiology|IR|139|140|HOSPITAL COURSE|However, the patient did spike a get fever and a repeat chest x-ray did show pleural effusion on the left. This was subsequently tapped by IR and was sent for analysis. The fluid obtained from the tap was negative for AFB, anaerobic culture, fungal culture.
IR|interventional radiology|IR|192|193|OPERATIONS/PROCEDURES PERFORMED|A 10 cm-segment of jejunum with bright red blood and clots found at the end of the endoscopic range. Two Hemoclips were placed to aid localization angiographically and the patient was sent to IR for embolization. 3. Mesenteric angiogram done on _%#MM#%_ _%#DD#%_, 2006, with the following findings and intervention. Abnormally staining of loop of jejunum adjacent to clips placed endoscopically.
IR|interventional radiology|IR|159|160|HOSPITAL COURSE|An endoscopy was performed on _%#MM#%_ _%#DD#%_, 2006, with localization of area of bleeding jejunum. It was localized with Hemoclips. The patient was sent to IR for embolization which was done on several subsegmental jejunal arteries with resolution of bleed. No evidence of further bleeding or bowel ischemia was noted after this procedure.
IR|interventional radiology|IR|264|265|ASSESSMENT  AND PLAN|She is currently hemodynamically stable. 1. End-stage kidney disease. The patient had a partial run today and had about 2.5 kilos removed per report. Her access is now clotted so she will need that sorted out before we dialyze her again. a Plan declot tomorrow by IR and then dialysis to follow. 2. Anemia. She had significant blood loss at the dialysis unit. She was hypotensive to the 60s but this has resolved after being given fluids and blood.
IR|interventional radiology|IR,|294|296|HOSPITAL COURSE|The patient will continue to follow with Dr. _%#NAME#%_ as an outpatient. 4. Acute intraperitoneal bleed secondary to paracentesis: On _%#MM#%_ _%#DD#%_, 2006, when the patient underwent an unsuccessful paracentesis in the GI clinic followed by a successful 4.5 L of bloody paracentesis in the IR, the patient's hemoglobin dropped from 8.9 to 5.1. The patient was transferred to the ICU and received PRBCs, platelets, and FFPs.
IR|interventional radiology|IR|148|149|ADMISSION DIAGNOSIS|PAST SURGICAL HISTORY: Significant for splenectomy after a gunshot, kidney transplant in _%#MM#%_ 2005, pacemaker placement, wound infection and an IR venoplasty of right upper extremity DVT. He did have a kidney biopsy in _%#MM#%_ with autoimmune signs of rejection, and his lab at the time of admission his potassium was at 6.0 and, therefore, he was admitted to the hospital.
IR|interventional radiology|(IR)|133|136|PERTINENT PROCEDURES AND INVESTIGATIONS|1. Occlusion of hepatic artery to portal vein fistula with a cover stent in the hepatic artery performed by interventional radiology (IR) on _%#MM#%_ _%#DD#%_, 2006. 2. Interventional radiology. HISTORY OF PRESENT ILLNESS: This is a 49-year-old gentleman with a past medical history significant for end-stage liver disease secondary to hepatitis C genotype 5.
IR|interventional radiology|IR.|202|204|HOSPITAL COURSE|The patient denied any abdominal pain, fevers, or chills postprocedure and was noted admitted for further observation overnight. HOSPITAL COURSE: 1. Status post occlusion of hepatic artery performed by IR. After discussion with Dr. _%#NAME#%_ in interventional radiology, it sounded like the procedure went very well. The plan was to have a followup ultrasound the following day to make sure that the shunt was in place and that the fistula was actually cleaned off.
IR|interventional radiology|IR|115|116|PROCEDURES/INVESTIGATIONS|2. Tunneled catheter placement. 3. Thrombocytopenia (transient, probably lab error). PROCEDURES/INVESTIGATIONS: 1. IR placement of tunneled catheter into the left internal jugular vein. 2. Aspiration of left groin seroma. 3. Chest x-ray which showed some small bilateral pleural effusions and acute atelectasis.
IR|interventional radiology|IR|199|200|HISTORY OF PRESENT ILLNESS|The patient presented to the University of Minnesota Medical Center, Fairview, with a reclotted graft. She was recently hospitalized for the same issue and was status post removal of the clot via an IR procedure. The followup ultrasound done on _%#MM#%_ _%#DD#%_, 2006, demonstrated thrombosis of the left upper extremity dialysis graft. The patient was admitted for clot removal and followup dialysis.
IR|interventional radiology|IR|147|148|HOSPITAL COURSE|The patient was admitted for clot removal and followup dialysis. HOSPITAL COURSE: 1. Clotted dialysis graft. The patient did undergo an additional IR procedure with clot removal on _%#MM#%_ _%#DD#%_, 2006. She promptly had dialysis after the clot was removed. Stent was placed to the venous side of the graft anastomosis.
IR|interventional radiology|IR|44|45|HOSPITAL COURSE|He did have a percutaneous G-tube placed by IR on _%#MMDD2006#%_. Nutrition was consulted and he was begun on tube feedings for his nutritional status. The patient's tube feedings were advanced throughout his hospital stay and he tolerated them very well.
IR|interventional radiology|IR,|167|169|HOSPITAL COURSE|He was placed n.p.o. overnight and on _%#MMDD#%_ had a new 14.5 catheter, 19.5 cm dual-lumen tunneled central venous hemodialysis catheter placed by Dr. _%#NAME#%_ in IR, further he had strict I's and O's followed and was discharged on the _%#DD#%_ and told to schedule an appointment with Dr. _%#NAME#%_ _%#NAME#%_ in 1 to 2 weeks.
IR|interventional radiology|IR,|280|282|HOSPITAL COURSE|She grew out mixed flora from her abscess including alpha-hemolytic strep (not Gehrke), moderate growth, coag negative staph and Gram stain showed many Gram negative rods. Blood cultures were negative. She was doing well clinically and on _%#MMDD2006#%_ had a follow procedure in IR, where it was decided that the drain was in an appropriate place and was left alone. However, they do plan to see her back in 4-5 days for followup imaging and possible repositioning of her current drain.
IR|interventional radiology|IR|123|124|HOSPITAL COURSE|The patient was put on, however, Lactulose. The patient also had a great relief of abdominal pain and distention after the IR mediated paracentesis. She was dizzy for a few days but on the day of discharge is pretty awake and back to baseline.
IR|immediate-release|IR|152|153|DISCHARGE MEDICATIONS|6. Multivitamin with minerals 1 tab p.o. q. day. 7. Nexium 40 mg p.o. b.i.d. 8. Prozac 60 mg p.o. q. day. 9. Morphine SR 16 mg p.o. q.12h. and morphine IR 15 mg p.o. q.4h. p.r.n. 10. Advair 500/50 one puff inhaled b.i.d. 11. Spiriva 18 mcg inhaled daily. 12. Xopenex 0.63/3 mL inhaled 3 times daily. 13. Atrovent 0.06% one puff inhaled 4 times daily p.r.n.
IR|interventional radiology|IR|288|289|HOSPITAL COURSE|We did keep platelets greater than 50,000 with checks b.i.d. This was decreased to platelet counts greater than 10,000 with daily checks prior to discharge as he was no longer breathing. 4. Nausea and vomiting: The patient did have a NJ tube, which was out of place in the gastric lumen. IR did advance the tube to the jejunum with excellent results tolerating tube feeds at 60 mL per hour with Isosource 1.5 and this remained his maintenance tube feed rate for the time being.
IR|immediate-release|IR|171|172|PRINCIPAL DIAGNOSIS|4. Coumadin 1 mg orally once daily at 5:00 p.m. 5. Zofran 24 mg orally once daily x2. More doses to take on _%#MM#%_ _%#DD#%_ and _%#DD#%_, 2003, in the a.m. 6. Oxycodone IR 30 mg orally every 4-6 hours as needed for pain. 7. The patient is to take Coumadin (_______________) as ordered until further orders.
IR|interventional radiology|IR|176|177|HISTORY OF PRESENT ILLNESS|He denies any fevers, chills. He has been using a walker for mobility for quite some time. He also had polio as a child when he was nine years old. He is being admitted for an IR procedure of thrombolytics and stenting on his left iliac. ALLERGIES: No known drug allergies. MEDICATION: 1. Prednisone 5 mg t.i.d.
IR|interventional radiology|IR|122|123|ASSESSMENT AND PLAN|Doubt any hemothorax. The patient is currently satting well on room air. We will prep patient for likely thoracentesis by IR in the morning both for therapeutic and diagnostic purposes. 2. Cardiac: Coronary artery disease - status post recent MI. No new chest pains, however, the patient states that she has not had any problems in the past.
IR|interventional radiology|IR|178|179|HISTORY OF HOSPITALIZATION|On the right side, she had radical neck dissection as a teenager. Therefore, the left IJ dialysis access was placed; however, there was a poor flow even after the TPA treatment. IR had to manipulate the catheter several times before obtaining a good flow for adequate hemodialysis. The patient was hemodialyzed on the night of _%#MMDD2006#%_. Both the dialysis the patient did very well.
IR|interventional radiology|IR|122|123|HOSPITAL COURSE|The patient had a few days with a fever, and a CT scan of the abdomen was obtained which showed some pelvic fluid. We had IR place a drain, which drained purulent fluid. She has since remained afebrile. The patient also has been working with Physical Therapy and Occupational Therapy, and we had a Physical Medicine and Rehabilitation consult.
IR|interventional radiology|IR|121|122|HOSPITAL COURSE|This was consulted with Interventional Radiology, and we performed a HIDA scan to rule out bile leak which was negative. IR also went ahead and tapped the fluid collection that was subcapsular in the right lobe and placed a drain. This collection was pure hematoma, and it was partially drained.
IR|interventional radiology|IR|140|141|HOSPITAL COURSE|1. Alveolar rhabdomyosarcoma: The patient was admitted for chemotherapy, this was delayed due to his port being obstructed. He was taken to IR where TPA was administered to his line and then TPA continued to be administered to his line on the floor until the obstruction was removed.
IR|interventional radiology|IR|236|237|PROBLEM #6|PROBLEM #5: GI. Ms. _%#NAME#%_ did complain of significant constipation. She was started on a bowel regimen of Senokot and also discharged with Senokot and a prescription for magnesium citrate. PROBLEM #6: GU. Ms. _%#NAME#%_ will go to IR for replacement of her bilateral JJ stents on the day following admission. The stents were replaced with retrograde catheters, however as her urine cultures remained negative throughout her hospitalization, she was not treated with retrograde antibiotics.
IR|interventional radiology|IR.|169|171|PROBLEM #5|The right percutaneous nephrostomy tube was repositioned and sutured in place. They would like to plan to obtain in 1 month. The patient is instructed to follow up with IR. The patient's urinalysis results demonstrated changes likely secondary to her hydronephrosis and PNTs; however, the presents of bacteria prompted us to treat the patient with a 7-day course of Bactrim.
IR|interventional radiology|IR|224|225|HOSPITAL COURSE|On _%#MMDD2007#%_, Interventional Radiology did place a drain for his bronchopleural fistula with the tip of the chest tube placed in the apical space of the right lung. The patient tolerated this procedure well. Please see IR procedure notes for more details. The patient overall did well following the placement of his chest tube and the output decreased over the proceeding days.
IR|interventional radiology|IR|122|123|BRIEF INITIAL PRESENTATION|Per her (ED note was not available at the time of admit), they saw that she was still on the schedule and sent her to IR. IR placed the line. They knew that _%#NAME#%_ is prone to clotting and that she requires constant anticoagulation in order to keep a line patent.
IR|immediate-release|IR|169|170|OUTPATIENT MEDICATIONS|3. Enteric-coated aspirin 81 mg p.o. q.d. 4. Lipitor 20 mg p.o. q.d. 5. Plavix 75 mg p.o. q.d. 6. FOLTX one tablet p.o. q.d. 7. OxyContin 20 mg p.o. b.i.d. 8. Oxycodone IR 10-15 mg p.o. q.3h. p.r.n. pain. 9. Lasix 20 mg p.o. q.d. 10. Lisinopril 10 mg p.o. q.d. 11. Multi-vitamin one tablet p.o. q.d. 12. Protonix 20 mg p.o. q.d.
IR|immediate-release|IR|168|169|DISCHARGE MEDICATIONS|25. Ambien 10 mg p.o. q.h.s. p.r.n. 26. Benadryl 25 to 50 mg p.o. q.h.s. p.r.n. 27. Combivent two puffs q4-6h p.r.n. 28. Methadone 30 mg p.o. q8h. 29. Morphine sulfate IR 30 mg p.o. q4h x 3 days, then 20 mg p.o. q4h x 3 days, then 10 mg p.o. q4h x 3 days, then discontinue.
IR|immediate-release|IR|312|313|ALLERGIES|14. History of tubal ligation in 1971. ADMISSION MEDICATIONS: Advair, Allegra, calcium, Levoxyl 125 mcg p.o. daily, MS Contin pump 5 mg basal plus 5 mg bumps q.20 minutes, multivitamin, Nicotrol inhaler, omeprazole 40 mg daily, Zofran 48 mg q.7h. p.r.n. and vitamin E. ALLERGIES: Avinza, Carafate, Levaquin, Oxy IR and penicillin. FAMILY HISTORY: Significant for grandmother having pancreatic cancer and son has pancreatitis without alcohol.
IR|interventional radiology|IR|245|246|BRIEF MEDICAL HISTORY|Surgery wise, the patient had an ileostomy and she was constantly on TPN that was discontinued on _%#MMDD2007#%_ when the patient was taking adequate p.o. intake. The patient's postop course was complicated by an intraabdominal abscess that was IR drained. Wound healing was suboptimal and there was evidence of wound infections. The wound was opened and packed with wet and dry for several days and then VAC dressings were started.
IR|interventional radiology|IR|218|219|ASSESSMENT/PLAN|Percussion exacerbates pain EXT: warm, 3+ pitting edema to thighs LABORATORY VALUES: reviewed. See FCIS IMAGING: U/S _%#MMDD2007#%_: Patent tips. Ascites. AXR decub and flat: no free air ASSESSMENT/PLAN 1) PERITONITIS IR came to bedside to do diagnostic paracentesis; amylase negative, ~1600 WBC, appeared serosanguinous. On broad spectrum antibiotics, including gent x 1 dose, pipercillin/tazobactam.
IR|interventional radiology|IR|156|157|COURSE IN THE HOSPITAL|He was then started on 1-1/2 maintenance IV fluid with D5 and half normal saline plus 20 KCl at 40 mL per hour. The patient received a new G-tube after the IR study and he was resumed on G-tube feeding as per home regimen. The patient has been doing very well with his feeding without any difficulty.
IR|immediate-release|IR|139|140|DISCHARGE MEDICATIONS|14. Lipitor 20 mg p.o. each day at bedtime. 15. Glimepiride 4 mg p.o. daily. 16. Sinemet CR 50/200 one tablet p.o. q. 4 hours. 17. Sinemet IR 25/100 one tablet p.o. q. 4 hours as needed. 18. Hyzaar 100/25 one tablet p.o. daily. 19. Melatonin 3 mg p.o. each day at bedtime.
IR|interventional radiology|IR|197|198|HOSPITAL COURSE|Still DIC versus TTP lab had not come back and this had been multiple hours. Vascular Surgery resident came by and thought the patient would not tolerate surgery and thought that we might consider IR and thrombolysis. Given the severity of her illness and florid DIC the family decided to withdraw care.
IR|interventional radiology|IR|204|205|HOSPITAL COURSE|She had quite elevated sugars as well on admission and these have improved with institution of her normal insulin as outlined above. Regarding the hepatocellular carcinoma, she is scheduled to be seen by IR later today. She was seen by Hematology/Oncology as well on the _%#DD#%_ and they essentially agreed with IR evaluation. She will be discharged on her admission medicines and is encouraged to take the Senokot-S and bowel prep regardless as opposed to p.r.n.
IR|interventional radiology|IR|180|181|HOSPITAL COURSE|Regarding the hepatocellular carcinoma, she is scheduled to be seen by IR later today. She was seen by Hematology/Oncology as well on the _%#DD#%_ and they essentially agreed with IR evaluation. She will be discharged on her admission medicines and is encouraged to take the Senokot-S and bowel prep regardless as opposed to p.r.n.
IR|interventional radiology|IR|139|140|PROCEDURE PERFORMED|ADMISSION DIAGNOSIS: Diffuse abdominal pain status post appendectomy. DISCHARGE DIAGNOSIS: Intraabdominal abscess x2. PROCEDURE PERFORMED: IR drainage of the intraabdominal abscess. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 11-year-old female who underwent laparoscopic appendectomy on _%#MMDD#%_.
IR|interventional radiology|IR.|375|377|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 26-year-old female with a history of choledochal cyst possibly associated with biliary atresia status post Kasai as an infant with a history of recurrent strictures, obstructions and cholangitis. The patient was last admitted on _%#MMDD2007#%_ when she underwent a cholangiogram and placement of internal-external biliary stent by IR. The cholangiogram showed significant mucosal irregularities of bile ducts and multiple filling defects and strictures. The roux was noted to be dilated and there was a stricture at the site of prior anastomosis as well as additional stricture distally.
IR|interventional radiology|IR|198|199|HOSPITAL COURSE|Please see admission history and physical by Dr. _%#NAME#%_ from _%#MM#%_ _%#DD#%_, 2006 for details. HOSPITAL COURSE: Ms. _%#NAME#%_ was admitted with extensive clots as noted above. She underwent IR procedure as described above. The patient was discharged on Lovenox and Coumadin. The patient otherwise remained fairly throughout her stay. She did have hypercoagulable studies ordered.
IR|interventional radiology|IR|310|311|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 79-year-old lady with end-stage kidney disease secondary to type 2 diabetes who dialyzes Tuesday, Thursday, Saturdays at the _%#CITY#%_ dialysis unit via right IJ tunneled dialysis catheter. Her nephrologist is Dr. _%#NAME#%_. The patient was sent to IR today for an access declot of her right forearm graft. This was placed about 6 weeks ago by Dr. _%#NAME#%_. The clot was removed, however flow was not established on the venous side.
IR|interventional radiology|IR|223|224|ADDENDUM TO DISCHARGE SUMMARY FOR 04/25/2007|ADDENDUM TO DISCHARGE SUMMARY FOR _%#MMDD2007#%_ The patient had PNT placed per Interventional Radiology on _%#MMDD2007#%_. IR reported that they did not encounter any obstruction and that passing the tube was done easily. IR is going to followup with the patient on Friday to check the PNT placement and the function of the kidney.
IR|interventional radiology|IR.|185|187|COURSE IN THE HOSPITAL|6. Milk of magnesia. 7. Morphine. 8. Zofran COURSE IN THE HOSPITAL: The patient was admitted on _%#MMDD2007#%_ for IV antibiotics and left percutaneous nephrostomy tube to be placed by IR. UA/UC were taken. The patient was started on IV Cipro. The plan was to proceed with a PCNL once infection clears.
IR|immediate-release|IR|383|384|HOSPITAL COURSE|MAJOR PROCEDURES: Surgical implant of a spinal cord stimulator for left lower extremity stimulation. HOSPITAL COURSE: The patient did suffer from significant postoperative nausea and vomiting, and also sensitivity to pain medicine, so I did place her on an IV PCA for two days postoperatively, on morphine 1.5 mg q.8 minutes as needed, and on the final day she was tried on morphine IR 10 mg one to two tablets p.r.n. for pain, and then also was given Pepcid AC, which seemed to help with her reflux and nausea that she gets.
IR|immediate-release|IR|200|201|DISCHARGE MEDICATIONS|The patient is ambulating without difficulty. DISCHARGE MEDICATIONS: 1. There is an intrathecal pump currently infusing morphine sulfate 2 mg every 24 h. plus bupivacaine 8 mg every 24 h. 2. Morphine IR 15 mg to 30 mg every 4 h. as needed for breakthrough pain. 3. Lovenox 40 mg subcutaneous to begin Friday, _%#MM#%_ _%#DD#%_, 2005, through Monday, _%#MM#%_ _%#DD#%_, 2005, then to increase to 80 mg subcutaneous daily.
IR|interventional radiology|IR|156|157|HOSPITAL COURSE|Cultures of these remained negative. Drainage of these continued to decrease and serial CT showed the size of these decreasing. On _%#MM#%_ _%#DD#%_, 2005, IR pulled the midline perihepatic drain. It was flushed with a contrast to confirm this position. It was flushed with TPA. Following this procedure, the drain had some increased output, but much tapered off.
IR|immediate-release|IR|131|132|DISCHARGE INSTRUCTIONS|H. MS Contin 30 mg t.i.d. p.r.n. I. Naloxone 1 mg p.o. t.i.d. J. Torsemide 40 mg p.o. b.i.d. K. Aranesp 40 mcg weekly. L. Morphine IR 10 mg p.o. 6 times a day p.r.n. M. Compazine 10 mg q.i.d. as needed. N. Prograf 1 mg p.o. b.i.d. beginning on _%#MMDD2005#%_.
IR|immediate-release|IR|169|170|DISCHARGE MEDICATIONS|2. Norvasc 10 mg p.o. once a day. 3. Nortriptyline 50 mg p.o. at bedtime. 4. Hydroxyzine 50 mg p.o. every 4 to 6 hours. 5. MS Contin 60 mg p.o. twice a day. 6. Morphine IR 10 mg p.o. every 4 to 6 hours as needed for breakthrough pain. 7. Senna 2 tabs p.o. once a day as needed for constipation.
IR|interventional radiology|IR|210|211|HISTORY OF PRESENT ILLNESS|During this ultrasound they were also unable to visualize line in the axilla, but at that time thought it was due to the child's good musculature. This on the morning of admission, the patient was evaluated in IR by fluoroscopy, which showed the line dislodged and located in the pulmonary artery. For allergies, medications, social history, family history, past medical history and review of systems please see admission H&P.
IR|interventional radiology|IR|221|222|PROBLEM #1|HOSPITAL COURSE: For this 15-year-old with factor V Leiden and a dislodged ex-peripherally inserted midline catheter in the right pulmonary artery. PROBLEM #1: Feeding, electrolytes, nutrition: The patient was n.p.o. for IR procedure to attempt removal of the PICC. He resumed a regular diet after his procedure and had no complaints. PROBLEM #2: Hematology: The patient has heterozygous factor V Leiden.
IR|interventional radiology|IR|206|207|PROBLEM #2|Heme/onc was consulted and Dr. _%#NAME#%_ suggested that if the catheter was able to be removed and there was no evidence of clot there would be no need to anticoagulate him at this time. He did go down to IR and they were able to successfully remove the dislodged piece of the catheter and the hub was also removed. A CT angiogram was done after the procedure and showed no clots as well as a left upper extremity ultrasound, which also showed no clots.
IR|interventional radiology|IR|280|281|PROBLEM #2|The patient had been on atenolol at the time of admission and was continued throughout her hospital stay for prophylaxis against esophageal varices. PROBLEM #2: Ascites: The patient was admitted to our service with complaint of increasing ascites. She did undergo paracentesis by IR and fluid was obtained. On admission concern was for possible spontaneous bacterial peritonitis and she was started on appropriate antibiotics.
IR|interventional radiology|IR.|97|99|PROCEDURES PERFORMED|PRINICIPAL DIAGNOSIS: Abdominal wall abscess. PROCEDURES PERFORMED: Percutaneous drain placed by IR. HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old female who presented to the University of Minnesota Medical Center, Fairview Emergency Department with complaints of abdominal pain and pus draining from a lower abdominal wound.
IR|interventional radiology|IR|140|141|PAST SURGICAL HISTORY|2. Duodenal switch. 3. Ventral hernia repair. 4. Hysterectomy in 1994. 5. Repair of bowel fistula in 1996. 6. Open cholecystectomy 2005. 7. IR drainage of abdominal wall abscess. ADMISSION LABORATORIES: Showed that the patient had a white count of 7.3. EMERGENCY ROOM COURSE: The patient was afebrile while in the emergency department.
IR|interventional radiology|IR|171|172|EMERGENCY ROOM COURSE|The patient was then admitted to the MIS Surgery Department for IR drainage of her fluid collection. While in the hospital the patient was placed on Unasyn 3 gm IV q. 6h. IR placed a percutaneous drain on _%#MMDD2007#%_. The patient had no complications from that procedure. The patient has proceeded to drain approximately 35 cc over the last 24 hours from the drain of serous sanguinous drainage was seen.
IR|interventional radiology|IR|222|223|MEDICATIONS OUTPATIENT PRIOR TO ADMISSION TO HUTCHINSON|Dr. _%#NAME#%_, another member of our service, also weighed in and arranged for us to review the case with Dr. _%#NAME#%_ _%#NAME#%_ from Interventional Radiology to see whether or not there is any vertebroplasty or other IR procedures that may benefit in terms of supporting the area in his thoracic spine that has tumor invasion. According to Dr. _%#NAME#%_ _%#NAME#%_, there is some possibility that a procedure may benefit the patient, but would certainly come with a potential high risk of neurologic sequelae, which depending on the functionality of the patient and ongoing pain management maybe acceptable depending on how successful other interventions are.
IR|interventional radiology|IR|199|200|PROCEDURES PERFORMED DURING HOSPITAL STAY|2. Probable cholangitis. DISCHARGE DIAGNOSES: 1. Probable cholangitis. 2. Biliary tube with slight migration. PROCEDURES PERFORMED DURING HOSPITAL STAY: 1. On _%#MMDD2007#%_ the patient underwent an IR biliary drainage tube study, which showed his biliary tube has migrated out of the anastomosis and is a bit distal in the liver.
IR|interventional radiology|IR|129|130|PROCEDURES|DISCHARGE DIAGNOSES: 1. Adenocarcinoma of unknown primary. 2. Hydronephrosis. 3. Depression/anxiety. PROCEDURES: Antiemetics and IR placement of double-J stent. BRIEF HISTORY AND PHYSICAL AND HOSPITAL COURSE: Ms. _%#NAME#%_ is a 57-year-old, who had been hospitalized initially on _%#MMDD2007#%_ for carcinomatosis on a pelvic mass on a CT scan with biopsy revealing adenocarcinoma of unknown primary, gastrointestinal versus pancreatic versus pulmonary versus GYN malignancy and on _%#MMDD2007#%_, Ms. _%#NAME#%_ represented after her discharge from initial hospitalization from _%#MMDD2007#%_ to _%#MMDD2007#%_, represented to the emergency room on _%#MMDD2007#%_ complaining of nausea, vomiting and abdominal pain.
IR|immediate-release|IR|240|241|DISCHARGE MEDICATIONS|Her condition steadily improved and she was felt ready for discharge to home on _%#MMDD2002#%_ with plans to follow up with Dr. _%#NAME#%_ in one weeks' time. DISCHARGE MEDICATIONS: OxyContin 60 mg in the morning, 80 mg in the evening; Oxy IR 10-30 mg every two to three hours as needed for break-through pain, Senokot one taken twice daily, lorazepam on a p.r.n. basis for sleep.
IR|immediate-release|IR|140|141|HOSPITAL COURSE|10. Mag oxide 400 mg p.o. q.d. 11. Carafate 1 gram p.o. q.8h. 12. Benadryl 25 mg p.o. q.6h. 13. Gatifloxacin 200 mg p.o. q.d. 14. MS Contin IR 10-20 mg p.o.q.6h. p.r.n. 15. Prednisone 80 mg p.o. q.d. x 14 days.
IR|interventional radiology|IR|200|201|HOSPITAL COURSE|After TPA, she only had a small to moderate amount of thrombus remaining in the popliteal vein and superficial femoral. This was broken up with thrombectomy with good result. At the end of _%#MMDD#%_ IR procedure, there was only a very small amount of clot remaining in the mid popliteal vein. DISCHARGE MEDICATIONS: As before, with the addition of 1. Coumadin 5 mg 1/2 tab po q.h.s.
IR|immediate-release|IR|190|191|DISCHARGE MEDICATIONS|The patient agreed with this plan. DISCHARGE MEDICATIONS: 1. Dulcolax 10-mg suppository per rectum q.12 h. p.r.n. constipation. 2. Vistaril 25 to 50 mg p.o. q.4 h. p.r.n. pain. 3. Oxycodone IR 5 to 10 mg p.o. q.3 h. p.r.n. constipation. 4. OxyContin 20 mg p.o. b.i.d. Hold for excess sedation. 5. Protonix 40 mg p.o. b.i.d. 6. Senokot S 1 tab p.o. b.i.d. Hold for loose stools.
IR|interventional radiology|IR|168|169|HISTORY/PHYSICAL EXAM|HISTORY/PHYSICAL EXAM: Mr. _%#NAME#%_ is a 63-year-old man, who is well known to the surgical service, who is admitted to the hospital for an appendiceal abscess under IR drain. On _%#MM#%_ _%#DD#%_, 2005, it was decided to treat this appendicitis as an interval appendicitis and to place a drain tube and drain the fluid in the peritoneum and then to do a primary appendectomy at a later date.
IR|interventional radiology|IR|134|135|PROCEDURES PERFORMED THIS ADMISSION|2. Liver abscess. PROCEDURES PERFORMED THIS ADMISSION: 1. Laparotomy, partial gastrectomy, pelvic mass excision on _%#MMDD2005#%_. 2. IR placement of drain into liver abscess on _%#MMDD2005#%_. 3. Up sizing of drain on _%#MMDD2005#%_. 4. CT abdomen and pelvis x3. HISTORY OF PRESENT ILLNESS: This is a 52-year-old female who was seen at an outside hospital with a chief complaint of persistent vomiting that has occurred intermittently since approximately _%#MM#%_.
IR|interventional radiology|IR|273|274|HISTORY OF PRESENTING ILLNESS|Dr. _%#NAME#%_ _%#NAME#%_ is a 66-year-old gentleman who has a history of infiltrative right liver mass who presented to the University Hospital with fever of 102 at 6 p.m. yesterday. The patient had a therapeutic paracentesis done with removal of 3 liters of fluid in the IR on _%#MMDD2007#%_ and has been complaining of some pain at the site of intervention. No history of nausea, vomiting or diarrhea. No history of change in mental status.
IR|interventional radiology|IR|229|230|DISMISSAL  SUMMARY|The patient's postop care took place on station 33. Her postoperative period was eventful for ongoing air leak with a small basilar pneumothorax which also persisted for quite some time. She had a subphrenic catheter placed by a IR for pneumoperitoneum for reasons of trying to obliterate the ongoing air leak. This was done on postoperative day #8. She made slow improvement, and by postoperative day 17 there was no air leak.
IR|interventional radiology|IR|168|169|DISPOSITION|Standard restrictions and precautions were reviewed with the patient. The patient is to follow up in the Pain Clinic within 1-2 weeks. The patient is to follow up with IR for double-J tube replacement on _%#MMDD2007#%_ at 0800 hours. The patient should followup for exam under anesthesia and check-in at 3-C to undergo OR on Friday _%#MMDD2007#%_.
IR|interventional radiology|IR|134|135|PROCEDURES|2. Hypertension. 3. History of basal cell carcinoma. PROCEDURES: 1. IV and IP chemotherapy with Taxol and cisplatin. 2. IV fluids. 3. IR evaluation of IP ports. COMPLICATIONS: _%#NAME#%_ _%#NAME#%_ did have a difficulty with the IP port, but it was evaluated in Radiology and able to be used.
IR|interventional radiology|IR|183|184|HOSPITAL COURSE|She was transferred to University of Minnesota Medical Center for further care. We consulted general surgery who evaluated the patient and recommended that the patient should undergo IR guided abscess drainage. Therefore, we consulted intervention radiology. The patient underwent CT guided JP drain placement on _%#MMDD2007#%_ by intervention radiology.
IR|interventional radiology|IR|362|363|HOSPITAL COURSE|ADMITTING LABS: Hemoglobin 10.0, wbc 9.1, platelets 451. Sodium 136, potassium 4.4, chloride 100, bicarb 29, BUN 16, creatinine 1.0. HOSPITAL COURSE: PROBLEM #1: As stated above in HPI, the patient was admitted into the Medicine Service, and he subsequently was started on medication for treatment of his TB. His drain was monitored daily with irrigations done. IR Service followed the patient's progress and placed drainage. He continued to drain serous to bloody secretion per his drain. He is going to be discharged to a nursing home facility with drainage in place.
IR|immediate-release|IR|107|108|MEDICATIONS ON ADMISSION|MEDICATIONS ON ADMISSION: Include 1. Tequin 200 mg PO QD. 2. Duragesic patch 50 mcg. Q 3 days 3. Oxycodone IR 5 mg 1-2 Q 4 prn. 4. Prevacid 30 mg QD. 5. Imodium AD one tab up to q.i.d. on a prn. basis. SOCIAL HISTORY: As noted above, was in independent living situation up until the end of _%#MM#%_.
IR|interventional radiology|IR|136|137|ADDENDUM|FOLLOW UP: Patient is discharged to nursing home on _%#MM#%_ _%#DD#%_, 2005. She is going to Benedictine. ADDENDUM: The patient went to IR on _%#MM#%_ _%#DD#%_, 2005, where a red rubber catheter was placed to help divert urine from ureters to the percutaneous nephrostomy tubes.
IR|interventional radiology|IR|173|174|HOSPITAL COURSE|A 16-French Foley catheter was advanced with the tip placed at the distal colon. A 10-French pigtail cathter was advanced into the fistulous cavity. The Foley was placed by IR to decompress the colon adjacent to the fistula, and the 10-French pigtail drain was placed in a subcutaneous collection through the cutaneous fistula to drain that abscess.
IR|immediate-release|IR|300|301|DISCHARGE MEDICATIONS|He required significant replacement early in the hospitalization, but less so on the last 2 days, and was not sent out on extra supplementation, particularly given that his hydrochlorothiazide was discontinued. DISCHARGE MEDICATIONS: 1. Morphine sulfate (MS Contin) CR 200 mg p.o. t.i.d. 2. Morphine IR 60 mg p.o. q.4 h. p.r.n. pain. 3. Amlodipine 5 mg p.o. 4. Paroxetine 20 mg p.o. q. day. 5. Pantoprazole 40 mg p.o. q. day. 6. Synthroid 88 mcg p.o. q. day.
IR|immediate-release|IR|142|143|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Pantoprazole 20 mg b.i.d. 2. Trazodone 50 mg at bedtime. 3. Effexor 75 mg b.i.d. 4. Marinol 5 mg b.i.d. 5. Morphine IR 10 mg q.2 h. as needed for pain. 6. Tincture of opium 5 to 10 mg q.2 h. as needed for diarrhea. 7. Potassium chloride 40 mEq b.i.d.
IR|interventional radiology|IR|100|101|PLAN|In addition, an IVC filter was also felt to be indicated. PLAN: 1. Start alteplase systemically. 2. IR consult for IVC filter placement. 3. Admit to ICU. 4. Will have Pulmonology see tomorrow. 5. Will follow closely in the ICU. If he decompensates, he may need more aggressive intervention.
IR|immediate-release|IR|164|165|MEDICATIONS OF DISCHARGE|6. Xanax 0.5 mg p.o. q. 8 hours p.r.n. anxiety. 7. OxyContin 10 mg p.o. b.i.d. 8. Furosemide 20 mg p.o. daily. 9. Fludrocortisone 100 mcg p.o. daily. 10. Oxycodone IR 5 mg p.o. q. 5 hours p.r.n. pain, this pain medication was given to the patient for approximately 2 days for breakthrough pain post procedure.
IR|interventional radiology|IR|200|201|MAJOR PROCEDURES|2. Renal ultrasound _%#MMDD2007#%_ - no hydronephrosis. 3. Abdominal x-ray _%#MMDD2007#%_ - slightly malpositioned JG tube with tip and first portion of duodenum. 4. Status post G-tube replacement by IR on _%#MMDD2007#%_. 5. CT abdomen and pelvis _%#MMDD2007#%_ - bilateral pleural effusions, no intraabdominal pathology 6. Status post bilateral chest tube removal. HOSPITAL COURSE: PROBLEM #1: Pulmonary - The patient is status post bilateral lung transplant.
IR|interventional radiology|IR|106|107|MAJOR PROCEDURES|ADDITIONAL DIAGNOSIS: Please see dictated H&P dated _%#MMDD2007#%_ for further details. MAJOR PROCEDURES: IR procedure for gastrojejunostomy tube exchange. HISTORY OF PRESENT ILLNESS: Please refer to admission H&P for details.
IR|interventional radiology|IR|238|239|HISTORY OF PRESENT ILLNESS|The patient apparently feels that her GJ tube is not functioning adequately and feels as it did before when it had flipped back into the stomach. She has reported some tenderness around the GJ tube site and she was being sent directly to IR suite in the morning and this procedure demonstrated normal perigastrostomy subcutaneous tissue with no evidence of abscess or fluid collection demonstrated.
IR|interventional radiology|IR|120|121|DISCHARGE DISPOSITION|He will follow up with the interventional radiology RN by phone to assess his abscess and eventually he will go back to IR to have his abscess rechecked and possibly his tube removed. This will not occur until the draining tube stops draining purulent material.
IR|interventional radiology|IR|92|93|ACTIVITY|He will see Dr. _%#NAME#%_ in two weeks. DIET: Diabetic. ACTIVITY: As able. Wound care, the IR RN taught him how to do his abscess drain wound care and for his left armpit dressing. He keep it in for 24 hours, then he will change it by packing with Aquacel AG every other day.
IR|interventional radiology|IR|164|165|PROCEDURE|He had the pericardial window which did grow methicillin sensitive Staph aureus. He had multiple CAT scans of his abdomen which showed the psoas abscess and he had IR drain the psoas abscess with a percutaneous tube and he had the I&D of the left axillary abscess. PENDING TESTS: None. SUMMARY OF HOSPITAL COURSE: 1. Sepsis syndrome with MSSA which involved his pericardium, right retroperitoneal area and psoas muscle area and left axillary area.
IR|interventional radiology|IR|237|238|PLAN|2. Obtain iron studies, although the results may not be accurate given the recent multiple blood transfusions. 3. We will start the patient on levofloxacin. 4. IV fluids. 5. Surgery consult to evaluate for possible surgical treatment vs IR embolectomy vs continued conservative management.
IR|immediate-release|IR|159|160|PROBLEM #3|Dr. _%#NAME#%_ continues to follow and work with this patient. PROBLEM #3: Pain. The patient's home regime of MS Contin 30 mg p.o. b.i.d. and morphine sulfate IR 30 mg p.o. q.3-4h p.r.n. breakthrough pain was continued during this hospitalization, and continued after discharge. DISCHARGE MEDICATIONS: His medications were unchanged from what was previously listed at the time of admission, with the following exceptions: 1. Lactulose must be taken 45 cc b.i.d. to t.i.d., with titration to four to five stools per day.
IR|interventional radiology|IR|182|183|OPERATIONS/PROCEDURES PERFORMED|SOCIAL HISTORY: The patient denies tobacco and occasionally has social alcohol. HOSPITAL COURSE: 1. CV/Pulmonary. The patient was continued on his Flolan for peripheral IV until the IR team was able to place a new Hickman. The patient will be discharged home on his normal dose of Flolan. 2. Heme. The patient is on continuous anticoagulation, however, he required FFP to safely place the Hickman.
IR|interventional radiology|IR|216|217|HOSPITAL COURSE|Surgery was consulted. Interventional Radiology then became involved in the case and placed a drain. Nothing has yet grown out of that drain. It will be capped today per recommendations of the consulting surgery and IR team. She has had no further fevers. She is eating better and she is deemed ready for discharge. LABORATORY DATA: 1. _%#MMDD2005#%_: WBC 6.3, hemoglobin 10.6, and platelet count 219,000.
IR|immediate-release|IR|213|214|CONDITION AT DISCHARGE|DISCHARGE MEDICATIONS: Coumadin 5 mg daily, lisinopril 5 mg daily, multivitamin with minerals daily, Metamucil wafer 1 b.i.d., Levaquin 250 mg daily through _%#MM#%_ _%#DD#%_, 2005, Senokot 1 b.i.d. and oxycodone IR 5 mg to 10 mg q.3h. p.r.n. pain. Patient to apply Desonide topical 0.05% to the groin area b.i.d. for dermatosis.
IR|immediate-release|IR|110|111|DISCHARGE MEDICATIONS|4. Lipitor 20 mg daily. 5. Magnesium oxide 400 mg b.i.d. 6. MiraLax 17 mg daily. 7. MS Contin 60 mg t.i.d. 8. IR morphine 10-20 mg q. 3-4 hours p.r.n. pain. 9. Norvasc 5 mg daily. 10. Roxicet 2 tabs q. 4 hours p.r.n. 11. Senokot. 12. Slow-K, 2 tabs p.o. b.i.d. 13. Vancomycin 1250 mg IV q. 12 hours x10 days.
IR|interventional radiology|IR|212|213|HOSPITAL COURSE|The vancomycin was discontinued after one dose and the patient was maintained on Flagyl and Levaquin. She was seen in consultation by Interventional Radiology, who did not feel that her pathology was amenable to IR drainage. Surgical consultation was obtained by Dr. _%#NAME#%_. The patient was initially treated with IV antibiotics, however, she defervesced and her pain improved.
IR|interventional radiology|IR|108|109|DISCHARGE INSTRUCTIONS|She should have a KUB done prior to this appointment. DISCHARGE INSTRUCTIONS: The patient was instructed by IR on how to do dressing changes for the percutaneous nephrostomy tube site. It has been a pleasure taking care of her.
IR|interventional radiology|IR,|183|185|HISTORY OF PRESENT ILLNESS|He was last seen to be normal by his wife at 11 p.m. the night prior. The patient was actually going to come into the hospital today to get his ureteral stent catheter checked out by IR, however he was found to have this expressive aphasia and immediately taken to the E.D. The patient was able to communicate by nodding yes and no appropriately.
IR|interventional radiology|IR,|198|200|HOSPITAL COURSE|On _%#MMDD2007#%_, the GI physicians at the hospital performed a biliary sphincterotomy and stent placement for a cystic duct stump leak. Following this, percutaneous peritoneal drain was placed by IR, which revealed 1500 cc of bilious fluid. On post intervention day #1, the patient's pain had significantly improved and her vitals signs were more stable.
IR|interventional radiology|IR|144|145|ASSESSMENT|He needs further imaging to assess his weakness if it is a seroma versus abscess versus increased disease. Plan: 1. To obtain repeat images. 2. IR biopsy or drainage of abscess. 3. PICC line placement and IV antibiotics.
IR|interventional radiology|IR|131|132|HISTORY OF PRESENT ILLNESS|The GI physician contacted me to admit the patient after the procedure. I saw the patient in his room on the sixth floor after the IR procedure. The patient presented to _%#CITY#%_ Hospital yesterday evening with some abdominal pain.
IR|interventional radiology|IR|172|173|ASSESSMENT AND PLAN|Because of this I will transfer him to the ICU for closer monitoring. He will be kept n.p.o. He will be put on high dose IV Zosyn. Gastroenterology is already involved and IR plans on working with GI to do a dual procedure on Thursday to romove his stone. 2. Gallstone pancreatitis. I will keep him n.p.o. I will follow his pancreatic enzymes.
IR|interventional radiology|IR.|169|171|HOSPITAL COURSE|We also could try and contact the Intervention Radiology scheduling and informed them about the patient so that the patient can have weekly abdominal paracentesis under IR. If IR does a procedure, they will be able to take out more fluid and therefore give the patient more relief and decrease the frequency of need for further paracentesis procedure.
IR|interventional radiology|IR|176|177|HOSPITAL COURSE|We also could try and contact the Intervention Radiology scheduling and informed them about the patient so that the patient can have weekly abdominal paracentesis under IR. If IR does a procedure, they will be able to take out more fluid and therefore give the patient more relief and decrease the frequency of need for further paracentesis procedure.
IR|interventional radiology|(IR)|171|174|HOSPITAL COURSE|Colorectal consult was ordered and the recommendations were to continue the antibiotics to check the Coreg. We placed a Foley catheter, consulted interventional radiology (IR) for possible drainage of the abscess. Interventional drainage was done on _%#MMDD2007#%_ with a CT of the abdomen and peritoneum. Following the abscess drainage, the patient had 2 more days of spiking temperatures and on _%#MMDD2007#%_ she was afebrile over 24 hours.
IR|interventional radiology|IR|143|144|OPERATIONS AND PROCEDURES PERFORMED|1. Intra-abdominal abscess, status post appendectomy. 2. Urinary tract infection. 3. Pleural effusion. OPERATIONS AND PROCEDURES PERFORMED: 1. IR drainage of abscess. 2. Thoracentesis. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 35-year-old gentleman with a history of mental retardation and referred from an outside hospital for evaluation and drainage of an intra-abdominal abscess.
IR|interventional radiology|IR|173|174|ASSESSMENT/PLAN|ASSESSMENT/PLAN: 1. Diverticular abscess probable. The patient will have to have a CT reviewed by radiologist as CT was sent with no available report. The patient will have IR consult if abscess is present for possible drainage. The patient will be started on Levaquin and metronidazole. I will consult general surgery if patient has no improvement in symptoms.
IR|interventional radiology|IR|159|160|HOSPITAL COURSE|Evaluation by ultrasound showed a nonloculated subcutaneous fluid collection, which subsequently resolved by hospital day #4. Her Port-A-Cath was evaluated by IR on _%#MMDD2007#%_ and was found to be patent. She did receive IP cisplatin between hospital days #3 and #4. She tolerated this procedure well and is scheduled to come to Masonic Cancer Center on _%#MMDD2007#%_ for her day #8 chemotherapy.
IR|interventional radiology|IR|218|219|HOSPITAL COURSE|A neurology consult as well as a psychiatry consult was obtained for mental status changes. A chemical dependency consult was initiated for the patient's cocaine use. On post-admission day #1, the patient underwent an IR guided procedure for drain placement on _%#MMDD2007#%_. A drain was left in place that put out approximately 5 mL of thin red fluid.
IR|interventional radiology|IR|168|169|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Rectal pain. HISTORY OF PRESENT ILLNESS: The patient is a 19-year-old female with Crohn's disease, with severe perianal disease with abscess requiring IR drains, antibiotics, and surgical drains. She presents with perianal pain that started on _%#MMDD2006#%_. She had had a drain placed _%#MMDD2006#%_ that had been pulled out on Monday, _%#MMDD2006#%_.
IR|interventional radiology|IR.|629|631|HOSPITAL COURSE|His bilirubin on admission was 6.5 and during the course of the hospital stay, it went down to 4.3. His amylase and lipase were normal, and his alkaline phosphatase is running around 700 which is hyper for his normal. He was switched from IV Timentin to p.o. Augmentin, and he will be discharged to follow up in 2 weeks for pancreatic duct removal and to make an appointment with _%#NAME#%_ at _%#TEL#%_ and also followup labs Mondays and Thursdays to follow up his bilirubin and alkaline phosphatase and if things are not getting any better in the next couple of weeks, he will be readmitted for a cholangiogram percutaneous by IR.
IR|interventional radiology|IR|172|173|HISTORY OF PRESENT ILLNESS|She was sent for a CT of chest, abdomen, and pelvis, which showed 3 fluid collections in her abdomen. She was sent to University of Minnesota Medical Center, Fairview, for IR drainage of fluid collections. PAST MEDICAL HISTORY: Past medical history includes migraines; history of diabetes mellitus and hypertension, both now resolved.
IR|interventional radiology|IR|200|201|HOSPITAL COURSE|ADMISSION MEDICATIONS: OxyContin, Ambien, Levaquin, vitamins, calcium, amphetamine, and vitamin B12 shots monthly. HOSPITAL COURSE: On _%#MM#%_ _%#DD#%_, 2006, the patient was admitted and set up for IR drainage of her abdominal fluid collections. She was taken to IR to where it was noted that the fluid collections were not large enough to go after at which time they looked for other reasons for increased blood cell count.
IR|interventional radiology|IR|150|151|HOSPITAL COURSE|HOSPITAL COURSE: On _%#MM#%_ _%#DD#%_, 2006, the patient was admitted and set up for IR drainage of her abdominal fluid collections. She was taken to IR to where it was noted that the fluid collections were not large enough to go after at which time they looked for other reasons for increased blood cell count.
IR|interventional radiology|IR|163|164|PROBLEM #1|The pain is slightly relieved with oral pain medications and the patient is denying any IV medications. The patient will be made NPO for planned vertebroplasty by IR tomorrow morning. We will correct INR to goal of around 1 with FFP prior to procedure. PROBLEM #2: Constipation - likely due to increased narcotic use recently.
IR|immediate-release|IR|172|173|DISCHARGE MEDICATIONS|4. Lidocaine patch, 1 patch q. day. 5. N-acetylcysteine 600 mg p.o. t.i.d. 6. Oxycodone CR 60 mg p.o. t.i.d. (refilled by the Pain Team during this admission) 7. Oxycodone IR 5-10 mg p.o. q.4h. p.r.n. (refilled by Pain Team during this admission) please note that oxycodone above was the oxycodone CR.
IR|interventional radiology|IR.|112|114|HOSPITAL COURSE|DR. _%#NAME#%_ agreed to do surgery at united after two weeks of PTU is given. She had a bilary drain placed by IR. 2. Hyperthyroidism. The patient will now need to be on propylthiouracil, as she has signs of hyperthyroidism. She will follow up with Dr. _%#NAME#%_ in 6 weeks to reassess her TSH after being placed on propylthiouracil.
IR|interventional radiology|IR|132|133|HOSPITAL COURSE|She did have poststenotic waveforms as well in the bilateral iliac arteries. HOSPITAL COURSE: The patient was admitted and taken to IR for further evaluation where an aortic angiography was performed. This showed evidence of an apparent acute clot formation within the stent.
IR|interventional radiology|IR|129|130|PROCEDURES|2. Palliative Medicine consult. 3. Speech pathology consult. PROCEDURES: 1. Endotracheal intubation. 2. Chest tube placement. 3. IR thoracentesis. 4. Electromyograph. 5. Plasmapheresis. Please refer for the discharge summary performed by Dr. _%#NAME#%_ on _%#MMDD2007#%_ for details up to and including _%#MMDD2007#%_.
IR|interventional radiology|IR,|193|195|HOSPITAL COURSE|He had a renal ultrasound, which was significant for a new hydronephrosis. The patient subsequently had a nephrostogram and percutaneous nephrostomy tube placed in Interventional Radiology. In IR, he also had renal biopsies. On histopathology, there was no evidence of rejection in the cortef, but there was mild focal interstitial lymphoplasmacytic infiltrate with a rare tubilitis in the medulla.
IR|interventional radiology|IR|246|247|ASSESSMENT AND PLAN|We will order a Doppler ultrasound to re-evaluate the TIPS if it is functioning or not and we will get a GI consult in the morning to evaluate the patient for reconsidering the TIPS procedure if needed. We will also contact IR in the morning for IR guided paracentesis due to patient's abdominal habitus. We will order liver function tests and basic labs to evaluate the patient's hemoglobin, platelets, creatinine.
IR|interventional radiology|IR|283|284|HOSPITAL COURSE|Neurosurgery and intentional radiology were consulted multiple times for shunt revision for the possibility of CSF analysis, however, they felt that this shunt revision would increase the possibility of a CVA. An LP was unsuccessful by IR on _%#MMDD2007#%_ due to patient's anatomy. IR imaged the abdomen and drained about 450 mL of serous fluid earlier in the week, however, cultures were negative at this time.
IR|interventional radiology|IR|168|169|HISTORY OF PRESENT ILLNESS|However, when he went home he subsequently noticed oozing from the site and was unable to stop the bleeding. He went to the ED and underwent evaluation. He was seen by IR service as well as general surgery services. The patient's pressure bandages were applied and currently hemodynamically stable and there is no visible oozing.
IR|interventional radiology|IR|191|192|PLAN|Currently, the patient is hemodynamically stable and his hemoglobin is stable as well. This time we will control patient's pain with p.r.n. pain medications. Will keep the patient n.p.o. The IR is already aware for schedule tomorrow. 2. End-stage renal disease. After replacement of patient's Hickman catheter the patient will be dialyzed by the Nephrology Service for his Monday, Wednesday, Friday run.
IR|interventional radiology|IR.|170|172|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Post TIPS. HISTORY OF PRESENT ILLNESS: A 56-year-old male patient postop from TIPS for his alcohol liver cirrhosis and refractory ascites, admitted from IR. The patient had no complications from that mini laparoscopic TIPS and paracentesis. _____, he does not present with any acute issues. No shortness of breath, orthopnea, chest pain, melena, hematemesis and encephalopathy.
IR|interventional radiology|IR.|197|199|HOSPITAL COURSE|Multiple attempts were made to convince the patient to stay including clear definition of risks to leave. The patient does need Doppler ultrasound in 1 month, 6 months and 1 year as recommended by IR. Additionally, IR recommended that the patient have repeat paracentesis as soon as possible and also have paracentesis 1 to 2 times a week for the next 1-2 months to prevent wound opening.
IR|interventional radiology|IR|215|216|HOSPITAL COURSE|Multiple attempts were made to convince the patient to stay including clear definition of risks to leave. The patient does need Doppler ultrasound in 1 month, 6 months and 1 year as recommended by IR. Additionally, IR recommended that the patient have repeat paracentesis as soon as possible and also have paracentesis 1 to 2 times a week for the next 1-2 months to prevent wound opening.
IR|interventional radiology|IR|178|179|HISTORY OF PRESENT ILLNESS|However, when he went to home he subsequently noticed oozing from the site and was unable to stop the bleeding. He went to the ED and underwent evaluation and he was seen by the IR service as well by General Surgery Service. The patient's pressure bandages were applied and currently hemodynamically stable. There was no visible oozing and the patient will be admitted for overnight observation for scheduled OR placement of the catheter.
IR|interventional radiology|IR|199|200|PROCEDURES PERFORMED|Nodular cirrhotic liver and splenomegaly with large amount of ascites. 2. CT of the head without contrast. No acute intracranial pathology. 3. NG tube placement on _%#MMDD2007#%_. 4. Paracentesis by IR on _%#MMDD2007#%_ and a repeat paracentesis by IR on _%#MMDD2007#%_. HISTORY OF PRESENT ILLNESS: A 73-year-old female with past medical history significant for primary biliary cirrhosis leading to end-stage liver disease.
IR|interventional radiology|IR|387|388|PROBLEM #4|Nutrition was following her for the tube feeds. There was a concern about converting the G-tube to J-tube because of the aspiration and Radiology was consulted but they recommended that due to the recent placement of the G-tube after the stroke they would like the first wound to be healed before they can manipulate it and convert it into GJ-tube. The patient will be scheduled back to IR for conversion of G-tube into GJ-tube in about 3 weeks. The patient will be discharged to a rehab facility for further physical therapy and management of care.
IR|interventional radiology|IR|174|175|DISCHARGE FOLLOWUP|4. The patient can get albuterol neb p.r.n. for shortness of breath. Currently, she is being discharged saturating well on room air. 5. The patient will be following up with IR at Fairview University Medical Center in 3 weeks for changing her G-tube to GJ-tube. 6. The patient is currently getting nutrition through her G-tube at 55 mL per hour and she will continue that for her feedings and for her medications.
IR|interventional radiology|IR.|131|133|HOSPITAL COURSE|On postop day #3, the patient subsequently had the CT scan performed and additional sclerosing of the lymphocyst was performed per IR. The patient tolerated this well and was subsequently discharged home in stable condition. She will follow up in clinic as scheduled. She will also continue her home medications.
IR|interventional radiology|IR|222|223|PROBLEM #2|The patient seemed receptive to the program and services offered and further contact information was given to the patient. PROBLEM #2: Fluids, electrolytes and nutrition: The patient was drinking adequate fluids after her IR procedure on _%#MMDD2007#%_. PROBLEM #3: Cardiovascular: Hyperlipidemia, currently on Lipitor. PROBLEM #4: GI: After her IR procedure paracentesis, she had been tolerating a regular diet without problems.
IR|interventional radiology|IR|217|218|PROBLEM #5|At the time of discharge, she remained stable and was discharged on her home blood pressure medications. PROBLEM #5: GI. Her diet was initially advanced as tolerated; however, she was made n.p.o. on _%#MMDD#%_ for an IR procedure. At the time of discharge, she was tolerating a regular diet. PROBLEM #6: GU: She does have a history of stage III chronic kidney disease with a creatinine of 1.65. Left hydroureter found intraop with renal ultrasound showing a 5-mm cortex of left kidney, likely longstanding.
IR|interventional radiology|IR|223|224|PROBLEM #6|PROBLEM #6: GU: She does have a history of stage III chronic kidney disease with a creatinine of 1.65. Left hydroureter found intraop with renal ultrasound showing a 5-mm cortex of left kidney, likely longstanding. Neither IR nor Renal recommended a stent or PNT placement. Her renal function was stable at the time of discharge. Her Foley catheter was removed on _%#MMDD2007#%_ and she was voiding spontaneously.
IR|interventional radiology|IR|144|145|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|The patient had 1 L of fluid drained and at that time, it was decided that more fluid should be drained by interventional radiology. He went to IR in the morning of _%#MMDD2007#%_ which was the day of admission and when initial labs were drawn it showed his blood sugar to be greater than 600.
IR|interventional radiology|IR|127|128|DISCHARGE FOLLOWUP|4. Propranolol 10 mg p.o. t.i.d. for a month. 5. Prilosec 20 mg p.o. daily. DISCHARGE FOLLOWUP: 1. Patient will follow up with IR for an abdominal ultrasound to evaluate for TIPS followup and to evaluate if TIPS is working well in a week at University of Minnesota Medical Center.
IR|interventional radiology|IR|155|156|DISCHARGE INSTRUCTIONS|H. MiraLax 1 capsule p.o. b.i.d. as needed for constipation. I. Colace 100 mg p.o. b.i.d. J. Morphine sulfate - this is also known as Immediate Release or IR 15 to 30 mg p.o. q.4 h. as needed for pain. K. MS Contin also known as morphine sulfate sustained release (or SR) 15 mg p.o. q.8 h.
IR|interventional radiology|IR.|279|281|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ is a 45-year-old male with end-stage renal disease secondary to polycystic kidney disease who is status post bilateral nephrectomies last month. Postoperative course has been remarkable for intraabdominal fluid collection, which required admission and drainage by IR. The patient complained of diarrhea, nausea and vomiting, and spiking fever started on Friday _%#MM#%_ _%#DD#%_, 2006. He seek medical advise at _%#CITY#%_ _%#CITY#%_ Hospital. He underwent CT scan of his abdomen, which showed multiple abdominal air fluid collections for which he was referred to University of Minnesota Medical Center.
IR|interventional radiology|IR.|165|167|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: 1. End-stage kidney disease. The patient will have a tunneled catheter placed for dialysis in the morning. We have spoken to a nephrologist and IR. Both are aware of patient and will proceed with the above-noted plan in the morning. 2. Diabetes. The patient will be continued on 10 units of Lantus insulin q.p.m. with low-intensity correction dosing.
IR|interventional radiology|IR|199|200|PROBLEM # 3|Interventional Radiology was initially hesitant to change it due to irritation at the site and her condition of neutropenia. Her white counts did increase and her G tube was accidentally pulled out. IR was able to place a new tube, which is now a gastrojejunostomy tube. Their initial instructions were to have the G site set to drain to gravity and not be used for any flushes or medications.
IR|interventional radiology|IR|259|260|HOSPITAL COURSE|GI consults recommended multiple labs and biopsy. The alphafetoprotein was elevated at 15.5, CA 19-9 elevated at 866 and CEA normal 1.1. LFTs remained elevated throughout his admission. His INR was found to be elevated at 2.54 several days into admission. An IR percutaneous liver biopsy was performed on the day of discharge and results are pending. Mr. _%#NAME#%_ is to see his primary care physician for followup of biopsy results and further managements.
IR|interventional radiology|IR.|179|181|HOSPITAL COURSE|Cultures were sent. The patient was made n.p.o. again. A CT scan performed at the time demonstrated a left subfascial collection of fluid which required percutaneous drainage via IR. Also, IV antibiotics were started. For nutritional support, a PICC line was placed, and the patient was begun on TPN. In the first postoperative week, the patient was noted to be anemic.
IR|interventional radiology|IR|206|207|HOSPITAL COURSE|She came to the interventional radiology and the G-tube was removed and a retrograde catheter was placed and we started amphotericin irrigation for 3 days. An UA done after that was negative for infection. IR removed the retrograde catheter and was to replace again her G-tube stent for her urethral stricture. The patient tolerated the procedure and she was stable as she was discharged to home in a stable condition.
IR|interventional radiology|IR|209|210|HOSPITAL COURSE|For further evaluation, they had suggested repeating a CT scan without contrast to evaluate for the position of the chest tube and see if it could be repositioned. Results of the above, this was reviewed with IR who did not feel that they could reposition the chest tube and offered a solution of infusing lidocaine solution into the pleural space before drainage in order to numb the pleural lining to offer some benefit.
IR|interventional radiology|IR|257|258|HOSPITAL COURSE|We changed her antibiotics to Zosyn and vancomycin. The patient's fever resolved but they recommended consulting also the ortho for possible I&D. Ortho saw the patient and recommended doing first angioplasty before the procedure. She had angioplasty by the IR with no significant obstruction and Ortho performed I&D draining the abscess and they sent culture for that fluid. It grew so far gram-positive cocci in chains. For now we will discharge the patient for total of 6 weeks of antibiotics of Zosyn and vancomycin but we will follow up the result of the culture and we will call the nursing home to change the antibiotics when the culture results are available.
IR|interventional radiology|IR|231|232|HOSPITALIZATION COURSE|ADMISSION DIAGNOSIS: Injury to the right femoral artery. DISCHARGE DIAGNOSIS: Status post repair of right femoral artery injury. HOSPITALIZATION COURSE: Mr. _%#NAME#%_ was having a fistula in the left lower limb fixed yesterday by IR when the bleeding from his right femoral artery was not possible to be controlled by the usual measures. Vascular service was consulted and they decided that the right femoral artery needs to be repaired surgically.
IR|interventional radiology|IR|259|260|BRIEF HISTORY OF PRESENT ILLNESS|He has a baseline hemoglobin between 7 and 8, and prior to this admission, the patient was in dialysis and bleeding was noted from his catheter site that was not stopped by moderate pressure. During the prior admission, the tunneled catheter was evaluated by IR for a leak and was found not to have one. During his prior admission, the patient did respond to cryoprecipitate as well as fresh frozen plasma.
IR|interventional radiology|IR|152|153|HISTORY OF PRESENT ILLNESS AND HOSPITALIZATION COURSE|The CT scan came back showing the presence of fluid collection just next to the kidney that looked like an abscess. The fluid collection was drained by IR on _%#MMDD2007#%_. The patient's condition was improving and the fever faded away. The patient was afebrile, tolerating p.o. intake and had no complaints when she was discharged home on _%#MMDD2007#%_.
IR|interventional radiology|IR|215|216|FOLLOWUP|21. TPN per his previous schedule. FOLLOWUP: As noted above, the patient will present to the University of Minnesota Medical Center on Monday _%#MMDD#%_ in the morning for his scheduled admission. He will be on the IR schedule for that afternoon and will be NPO that morning except for his medications. It has been a pleasure to be involved in Mr. _%#NAME#%_'s medical care.
IR|interventional radiology|IR|133|134|PROCEDURES|CONSULT: OB/GYN on _%#MMDD2007#%_. PROCEDURES: 1. CT abdomen, _%#MMDD2007#%_. 2. CT abdomen and pelvis, _%#MMDD2007#%_. 3. Attempted IR drainage of intraabdominal fluid collection, _%#MMDD2007#%_. 4. Transvaginal ultrasound, _%#MMDD2007#%_. 5. Flat plate, _%#MMDD2007#%_. 6. Right upper quadrant ultrasound, _%#MMDD2007#%_.
IR|interventional radiology|IR|168|169|HOSPITAL COURSE|The patient was made n.p.o. and a CT abdomen was performed, which demonstrated mild parastomal hernia as well as 5.3 x 4.6 cm fluid collection in the right mid pelvis. IR attempted to drain this fluid collection and was unsuccessful. They were not able to accomplish the procedure due to possible bladder injury during attempt.
IR|immediate-release|IR|113|114|CURRENT MEDICATIONS|4) Klonopin 1 mg p.o. t.i.d. for anxiety disorder. 5) Ambien 10 mg one p.o. q h.s. for sleep disturbance. 6) Oxy IR 5 mg one p.o. t.i.d.; he was on Darvocet before. 7) Lipitor 80 mg per day. 8) Tricor 160 mg per day. 9) Nexium 40 mg one or two daily. 10) Hyzaar 100/25 one daily.
IR|UNSURED SENSE|IR|166|167|PAST MEDICAL HISTORY|ALLERGIES: Sulfa. PAST MEDICAL HISTORY: 1. Diabetes mellitus type 2. 2. End-stage renal disease. 3. ASCVD status post 2-vessel CABG with LIMA to LAD and saphenous to IR _%#MM#%_ of 2002. 4. Congestive heart failure with an EF of 30% status post MI. On _%#MM#%_ _%#DD#%_, 2002, was EF of 32%. 5. Status post MI with akinesis in the anterior, apical, septal areas.
IR|immediate-release|IR.|140|142|HOSPITAL COURSE|The patient was voiding spontaneously, tolerating a regular diet. She had adequate pain control on morphine PCA as well as Percocet and Oxy IR. The patient was started on Celebrex first on 400 mg p.o. x1 and 200 mg p.o. b.i.d. The patient was discharged to home with a principal diagnosis of 3B cervical cancer.
IR|immediate-release|IR|155|156|DISCHARGE MEDICATIONS|2. Hydrochlorothiazide 25 mg p.o. q.d. 3. Celebrex 200 mg p.o. b.i.d. 4. Fentanyl 50 mcg patch change q.72h. 5. Percocet 1 to 2 p.o. q.4-6h. p.r.n. 6. Oxy IR 5 mg p.o. q.2-4h. p.r.n. 7. Flexeril 10 mg p.o. t.i.d. 3 times a day. FOLLOW UP: Follow-up care is to include a visit with Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2002 and a CT scan on _%#MM#%_ _%#DD#%_, 2003.
IR|interventional radiology|IR|189|190|PROBLEM #1|An ultrasound was obtained in the Emergency Room and showed the patient had a proximal obstruction most likely in the innominate artery or the collateral of the innominate that had formed. IR was consulted to do a venogram, but felt that it was unnecessary, because the previous one had been done in _%#MM2007#%_ showing an occlusion of the innominate vein.
IR|interventional radiology|IR|137|138|PROBLEM #1|Vascular Surgery was then consulted and they felt that this was an obstruction of the collateral vein that could be treated with lytics. IR was later consulted to perform lytic therapy of this DVT, but was concerned because the patient's fistula was located on the left arm and because the clot was previously known to be located near the wires from the patient's ICD.
IR|interventional radiology|IR|232|233|PROBLEM #1|IR was later consulted to perform lytic therapy of this DVT, but was concerned because the patient's fistula was located on the left arm and because the clot was previously known to be located near the wires from the patient's ICD. IR also felt that if lytic therapy was done, the DVT would just return secondary to the wire placement and the difference in flow pressures from the AV fistula.
IR|interventional radiology|IR|161|162|PROBLEM #1|IR also felt that if lytic therapy was done, the DVT would just return secondary to the wire placement and the difference in flow pressures from the AV fistula. IR felt that the only way to remedy this was by placing a stent, but they did not feel comfortable doing that over the ICD guidewires.
IR|interventional radiology|IR|124|125|ASSESSMENT/PLAN|Despite any risks of Greenfield filter placement, the patient wishes to be protected against pulmonary embolism. I will ask IR to place the Greenfield filter. The patient's Lovenox will be held until the Greenfield filter is placed. The patient should have both Lovenox and Greenfield filter. I will start the patient on heparin if he cannot have a Greenfield filter placed today.
IR|interventional radiology|IR|196|197|ASSESSMENT|Will check a chest x-ray tomorrow after dialysis Will also broaden her coverage to add vancomycin to cover for gram positives in particular for IJ dialysis catheter infection. Will plan on having IR remove the dialysis catheter tomorrow. 2. End-stage renal disease. Continue dialysis Monday, Wednesday, Friday or as per Dialysis fellow. 3. End-stage liver disease. She has no evidence of encephalopathy today.
IR|interventional radiology|IR|288|289|ACTIVITY|A followup CBC was performed on the day of discharge which revealed a normal white count. The patient is presently afebrile without any symptoms. ACTIVITY: Continue with original postop discharge orders, no lifting more than 10 pounds for another 4-6 weeks, no manipulating or pulling on IR drain. FOLLOWUP: With Dr. _%#NAME#%_ at clinic in 2 weeks. The patient will continue antibiotic therapy by mouth for another 7 days after discharge (ciprofloxacin).
IR|interventional radiology|IR|266|267|HOSPITAL COURSE|The chest tube was pulled on _%#MMDD2007#%_. The patient was followed with daily chest x-rays, which showed a persistent left hydropneumothorax. At the time of his discharge surgery did not want to address the persistent hydropneumothorax and suggested that perhaps IR could be consulted to place a pigtail drain. Throughout his hospital course the patient remained stable on room air and did not develop any respiratory distress.
IR|interventional radiology|IR,|86|88|DISCHARGE FOLLOWUP|RESTRICTIONS: Refrain from getting her peripheral IV wet. DISCHARGE FOLLOWUP: 1. With IR, PICC placement at 8:30 in the morning on _%#MMDD2007#%_. 2. Dr. _%#NAME#%_ from Rheumatology at 8 a.m. on _%#MMDD2007#%_. 3. Dr. _%#NAME#%_ with GI by phone for followup of sensitivities and antibiotic regimen.
IR|interventional radiology|IR|141|142|ASSESSMENT AND PLAN|The effusion appears minimal and the patient is relatively asymptomatic at this time. However, if it increases, may consider discussing with IR to obtain a thoracentesis. 2. BMT day +20 status post auto transplant. Counts are increasing. She is off GCSF. Platelets are low, however, and we will do frequent platelet checks to keep counts greater than 50,000.
IR|interventional radiology|IR|287|288|PROCEDURES|PROCEDURES: 1. The patient had a CT of her abdomen and pelvis on _%#MMDD2007#%_ which showed a 3 cm irregular shaped fluid collection in the right pelvis with peripheral enhancement, positive free fluid and right hydronephrosis and hydroureter which ends at the pelvic fluid collection. IR was consulted and she was scheduled to have the fluid collection in her pelvis aspirated by IR on _%#MMDD2007#%_. However, repeat CT and interventional radiology showed near complete resolution of the fluid collection and the procedure was canceled.
IR|interventional radiology|IR|158|159|PROBLEM #1|The fluid collection and hydronephrosis was discussed with Dr. _%#NAME#%_ per Dr. _%#NAME#%_. It was decided that the fluid collection should be aspirated by IR under CT guidance if possible. That procedure was scheduled for hospital day #2; however, and she was kept n.p.o. prior to that procedure.
IR|interventional radiology|IR|130|131|PROBLEM #2|PROBLEM #2: Fluids, electrolytes and nutrition: IV fluids were started at the time of her admission to the hospital. Prior to her IR procedure she remained n.p.o. However, she was tolerating a regular diet with some mild nausea. On hospital day #2, her IV fluids were discontinued and she had no electrolyte abnormalities throughout her stay.
IR|interventional radiology|IR|157|158|PROBLEM #1|For further details of this procedure, please see the operative report. She will follow up with Dr. _%#NAME#%_ in the clinic. Her pigtail catheter placed by IR was removed at the patient's bedside with minimal discomfort. The patient tolerated that procedure well. There were no complications and there was no drainage from the catheter site.
IR|interventional radiology|IR|184|185|PROCEDURES|1. Pelvic hematoma with catheter drainage in place. 2. Status post TAH for Symptomatic Myomatous Uterus. 3. Abdominal pain. PROCEDURES: 1. CT guided placement of a catheter drained by IR on _%#MMDD2007#%_ with 30 mL of old blood aspirated sent for culture. The procedure was tolerated well without complications. 2. IV fluids.
IR|interventional radiology|IR|278|279|PROBLEM #1|UA within normal limits. HOSPITAL COURSE: PROBLEM #1: Pelvic fluid collection: The patient was admitted on _%#MMDD2007#%_ and she underwent CT-guided drainage and placement of the drainage into her pelvis to diminish the fluid collection. A 30 mL of old blood were aspirated by IR during the procedure. She tolerated the procedure well without complications. Since that time, her drain had put out approximately 100 mL of serosanguineous and blood over 24 hour period since the placement of her drain minus approximately 20 mL of irrigation.
IR|interventional radiology|IR|264|265|PROBLEM #1|The patient agrees to the plan and was scheduled for a CT abdomen and pelvis with oral contrast for Wednesday, _%#MMDD2007#%_ at 10:00 a.m. and she was also instructed that if her drainage output from the JP drain should decrease considerably, she should call the IR department and arrange to have a CT sooner. Gram stain was negative; however, the fluid culture is still pending. PROBLEM #2: Pain: The patient received oral Percocet for her pain which helped considerably.
IR|interventional radiology|IR|196|197|PROBLEM #1|CT of abdomen and pelvis was performed showing moderate to large ascites consistent with something of higher density than simple fluid and the thought was that this may be blood. She was taken to IR for paracentesis and the fluid was consistent with gross blood and there were no signs of infection. At that point, her anticoagulation was held. Initially on presentation, she had a hemoglobin of 7.5, her last recorded hemoglobin was 13.3 on _%#MMDD2007#%_.
IR|interventional radiology|IR|168|169|PROBLEM #1|At that point, her anticoagulation was held. Initially on presentation, she had a hemoglobin of 7.5, her last recorded hemoglobin was 13.3 on _%#MMDD2007#%_. After her IR paracentesis, her anticoagulation was held in order to prevent further bleeding. Her anticoagulation was held until the following day when she began having recurrent abdominal pain, but a stable hemoglobin.
IR|interventional radiology|IR|211|212|HOSPITAL COURSE|INR was 1.05 and PTT was 27. HOSPITAL COURSE: PROBLEM #1: Right hydronephrosis and hydroureter as well as ureterovaginal fistula. On hospital day #2, the patient's Foley catheter was removed. She was brought to IR where she underwent cystoscopy on double-J stent removal and right sided percutaneous nephrostomy tube placement. The procedure was uncomplicated and the patient tolerated it well.
IR|interventional radiology|IR|226|227|HOSPITAL COURSE|HEALTH MAINTENANCE: The patient's last mammogram was on _%#MMDD2007#%_. She has not had Pap smears other than the most recent one. She has not had a colonoscopy. HOSPITAL COURSE: Infectious disease: The patient was brought to IR on _%#MMDD2007#%_, at which time a JP drain was placed in the abdominal wall abscess. Initially, she did have a straw colored thick fluid that looked purulent.
IR|interventional radiology|IR|152|153|PROBLEM #4|The patient was having discomfort associated with her Port-A-Cath in addition appeared the Port-A-Cath was properly flushing. The area was evaluated by IR and they recommended discontinuing use until further evaluation. The IR physician was unable to access site and he recommended to hold using the Port-A-Cath until _%#MMDD2007#%_.
IR|interventional radiology|IR|224|225|PROBLEM #4|The patient was having discomfort associated with her Port-A-Cath in addition appeared the Port-A-Cath was properly flushing. The area was evaluated by IR and they recommended discontinuing use until further evaluation. The IR physician was unable to access site and he recommended to hold using the Port-A-Cath until _%#MMDD2007#%_. DISCHARGE MEDICATIONS: 1. Atorvastatin 20 mg p.o. daily. 2. Celexa 10 mg p.o. daily.
IR|interventional radiology|IR|208|209|HISTORY OF PRESENT ILLNESS|The patient missed dialysis on the Wednesday before admission and the day before admission was unable to dialyze due to his AV fistula being clotted off. The patient was brought in to the hospital; and under IR guidance, an AV fistulogram was completed and the patient was observed for any complications. Afterwards, the patient complained of arms and leg pain around the area where the fistula was manipulated; otherwise, the patient was asymptomatic upon presentation.
IR|interventional radiology|IR|158|159|OPERATIONS/PROCEDURES PERFORMED|Please do not hesitate to page me with any further questions or concerns at _%#TEL#%_. OPERATIONS/PROCEDURES PERFORMED: Left AV fistulogram with plasty under IR guidance.
IR|interventional radiology|IR|223|224|PROCEDURES PERFORMED|2. Ventricular septal defect closure device seen in an unchanged position compared to previous studies. Mild shunt across the device by carotid Doppler mapping. Moderate pericardial effusion which was evaluated by CVTS and IR and not deemed reasonable to be tapped. 3. Transthoracic echocardiogram performed on _%#MM#%_ _%#DD#%_, 2006, that showed mild left ventricle dilatation with severely decreased left ventricular function with visually estimated ejection fraction of 30%.
IR|interventional radiology|IR|213|214|HISTORY OF PRESENT ILLNESS|She has had similar pain in the past. The first time was in 1998, when she underwent exploratory laparotomy, lysis of adhesions, and left ovarian cystectomy. She also underwent the same procedure in 2004. She had IR drainage of similar benign cyst in 2004 and 2005. The patient states that this pain is similar to those previous episodes.
IR|interventional radiology|IR|198|199|PROBLEM # 2|Perform hemodialysis in the a.m. for fluid removal, and check her ICD for possible arrhythmia triggering her acute shortness of breath event. PROBLEM # 2: Chronic kidney disease-the patient went to IR earlier in the day and it was recommended that she get TPA infusion for 2 hours given the fact that they saw fibrin formation on the access port.
IR|interventional radiology|IR.|185|187|HOSPITAL COURSE|She was admitted to the medicine team following mesenteric angiography for further management. HOSPITAL COURSE: PROBLEM #1: Jejunal bleed: No interventions were able to be performed by IR. Hemoglobin had slowly trended down and upon recheck on admission to the floor, hemoglobin was 8.1. She received 2 units PRBCs without complication.
IR|interventional radiology|IR|375|376|HOSPITAL COURSE|He was evaluated by urology when first admitted and KUB showed PNTs to be in good position; CT scan showed stable nonobstructing stone in left extrarenal pelvis; there was an old retroperitoneal hematoma secondary to recent percutaneous surgery. The percutaneous nephrostomy tubes were irrigated and were functionally draining well. Urology recommended further evaluation by IR with nephrostogram with results as described above. The patient essentially had right nephrostomy tube replaced and left nephrostomy tube was cleaned of thrombus.
IR|interventional radiology|IR|190|191|PROBLEM #1|He was started on diuretics with Lasix and spironolactone, and in addition was started on lactulose. Given his worsening right pleural effusion, he had a thoracentesis performed in the ICU. IR was able to drink 3 liters and given the excessive drainage subsequently put a right-sided pigtail chest tube in place. He continued his hospital course without any significant ascites, but had recurrent problems with the hepatic hydrothorax.
IR|interventional radiology|IR|195|196|MAJOR PROCEDURES|1. Chest x-ray _%#MMDD2007#%_ - left lobe atelectasis versus pneumonia. 2. Ultrasound of the abdomen _%#MMDD2007#%_ - cirrhosis and portal hypertension, moderate ascites. 3. Paracentesis done in IR _%#MMDD2007#%_ - 2300 mL fluid removed. 4. Colorectal surgery, hemorrhoidal repair in the OR on _%#MMDD2007#%_. 5. Echocardiogram on _%#MMDD2007#%_, LV 55%, no wall motion abnormalities, RV normal size and function, unable to estimate RVSP.
IR|interventional radiology|IR|292|293|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1: Chronic kidney disease: As noted the patient with altered mental status and fluid overload (apparently up 18 kg from dry weight) after missing 3 hemodialysis runs. His catheter was clotted at his dialysis earlier in the day. He was therefore admitted and sent to IR for catheter actually removal and replacement. Later that evening he had hemodialysis and was again dialyzed the next day following these are runs he was feeling much better and much more alert.
IR|interventional radiology|IR|215|216|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1: Right lower extremity DVT. IV heparin was started at high intensity protocol. PTT were monitored and heparin rate was adjusted. Coumadin was not started. Initially the patient underwent IR assessment for thrombolytic therapy on _%#MMDD2007#%_; however, the patient had a perforated vein. Therefore, IR directed thrombolytic therapy was postponed until a later time.
IR|interventional radiology|IR|145|146|HOSPITAL COURSE|Initially the patient underwent IR assessment for thrombolytic therapy on _%#MMDD2007#%_; however, the patient had a perforated vein. Therefore, IR directed thrombolytic therapy was postponed until a later time. The patient did not experience any localized bleeding and/or complications from the procedure.
IR|interventional radiology|IR|206|207|HOSPITAL COURSE|The patient did not experience any localized bleeding and/or complications from the procedure. The patient was to be discharged home on Lovenox twice daily subcutaneous dosing and is to follow back up with IR in 2 weeks for a repeat attempt at IR directed thrombolytic therapy. PROBLEM #2: Vasculitis. Continue steroids at the current dose of 30 mg.
IR|interventional radiology|IR|244|245|HOSPITAL COURSE|The patient did not experience any localized bleeding and/or complications from the procedure. The patient was to be discharged home on Lovenox twice daily subcutaneous dosing and is to follow back up with IR in 2 weeks for a repeat attempt at IR directed thrombolytic therapy. PROBLEM #2: Vasculitis. Continue steroids at the current dose of 30 mg.
IR|interventional radiology|IR|377|378|HOSPITAL COURSE AND PLAN|ASSESSMENT AND PLAN: A 59-year-old male patient with a history of chronic right foot osteomyelitis, diabetes, cardiomyopathy, recent discharge from an other North Dakota Hospital, now living in a shelter presented with increased right foot pain and erythema. HOSPITAL COURSE AND PLAN: PROBLEM #1: Right foot cellulitis, osteomyelitis: The patient was initially assessed in the IR and was started on imipenem and vancomycin based on previous microbiological evaluation and the presence of Enterobacter, which was only susceptible to imipenem as well as the presence of MRSA.
IR|interventional radiology|IR|282|283|SOCIAL HISTORY|Plan was set up from her admission to have her renal tumor embolized by Interventional Radiology, however, over the weekend this was not deemed an emergency as she was hemodynamically stable and her hemoglobin was stable as well. Her embolization was performed on _%#MMDD2007#%_ in IR and per report by IR they embolized approximately 80% of the left kidney. Her creatinine function post-procedure was stable at 0.68 and her hemoglobin stayed stable as well.
IR|interventional radiology|IR|303|304|SOCIAL HISTORY|Plan was set up from her admission to have her renal tumor embolized by Interventional Radiology, however, over the weekend this was not deemed an emergency as she was hemodynamically stable and her hemoglobin was stable as well. Her embolization was performed on _%#MMDD2007#%_ in IR and per report by IR they embolized approximately 80% of the left kidney. Her creatinine function post-procedure was stable at 0.68 and her hemoglobin stayed stable as well.
IR|interventional radiology|IR|318|319|HISTORY OF PRESENT ILLNESS|She did well and was discharged on _%#MMDD2007#%_. On _%#MMDD2007#%_, p.m. _%#NAME#%_ began experiencing pain around fistula site as well as a sensation of change in blood flow there. She had ultrasound of the fistula performed at hemodialysis on _%#MMDD2007#%_, which demonstrated thrombus. She has been admitted for IR thrombolysis of the clot. _%#NAME#%_ describes left arm pain in her upper arm 2/10 that is "sore," worse with movement.
IR|interventional radiology|IR|303|304|HOSPITAL COURSE|Sensation and strength dorsally intact. LABORATORY DATA: Labs/diagnostics on admission, bilateral upper extremity ultrasound demonstrating focal near occlusive thrombus in the left cephalic vein at the level of axilla. HOSPITAL COURSE: PROBLEM #1: FEN/GI/renal: _%#NAME#%_ was initially kept n.p.o. for IR intervention to release of thrombus in her fistula. After procedure was performed, she was resumed on renal diet with a fluid restriction of 1 L per day and tolerated this without any difficulties.
IR|interventional radiology|IR|209|210|PROBLEM #2|She was continued on Renagel and Nephrocaps while hospitalized. PROBLEM #2: CV/heme: _%#NAME#%_ was taken to the OR under general anesthesia on _%#MMDD2007#%_ for exploration of her fistula under IR guidance. IR found persistent thrombus and filling defect in left cephalic vein with external compression that was unable to be determined whether there was intra or extravascular.
IR|interventional radiology|IR|133|134|PROBLEM #2|She was given thrombolytics via catheter and was transferred to the PICU to continue heparin and TPA drip. She then went back in for IR for repeat evaluation, which found a fistula be patent with decreased clot in the outflow vein. There was residual compression from an adjacent hematoma that was felt to most likely could be able to resolve gradually on its won.
IR|interventional radiology|IR|208|209|INSTRUCTIONS|8. Oxycodone 5-10 mg p.o. q. 4h. p.r.n. severe pain. DISCHARGE DIET: Renal diet with 1 L per day of fluid restriction. DISCHARGE ACTIVITY: As tolerated. INSTRUCTIONS: Routine dressing change near the fistula IR procedure site. FOLLOWUP: 1. With pediatrics cardiology on _%#MMDD2007#%_ as scheduled to followup pericardial effusion.
IR|interventional radiology|IR|217|218|PLAN|Monitor troponin for and Echo for RV strain. If SBP low start levophed and dobutamine and then dopamine in that order. IVFluid. I will not insert a central or arterial line do not alteplase. If decompensates will ask IR to consult for thrombectomy/embolectomy although this is not standard of care. Obtain doppler legs in am and get IVC placed if needs.
IR|interventional radiology|IR,|268|270|PROCEDURES|3. Pneumonia, coag negative staph bacteremia. 4. Hepatic encephalopathy, acute renal failure secondary to hypervolemia. PROCEDURES: Unsuccessful TIPS revision on _%#MMDD2007#%_ and _%#MMDD2007#%_; successful tips revision _%#MMDD2007#%_, esophageal varices coiling by IR, on _%#MMDD2007#%_ gastric varices coiling by IR, _%#MMDD2007#%_ endoscopy with Derma bonding, on _%#MMDD2007#%_ abdominal ultrasound and _%#MMDD2007#%_ showed patent TIPS.
IR|interventional radiology|IR|223|224|PROBLEM #3|Improvement of oral ulcers was seen. Additionally, the patient had oral thrush and the patient was given Diflucan with oral swish and swallow mouthwash. PROBLEM #3: End-stage liver disease. Continue outpatient medications. IR paracentesis was done on Thursday, _%#MMDD2007#%_, as per the patient's weekly schedule. PROBLEM #4: Cachexia, attributable to end-stage liver disease. HIV ruled out with HIV antibody test.
IR|interventional radiology|IR|137|138|PAST MEDICAL HISTORY|7. Depression. 8. History of alcoholism. 9. Headaches. 10. E. coli & Grp D enterococcal sepsis from ascending cholangitis, - status post IR percutaneous drainage on _%#MMDD#%_ & treatment with Zosyn then Augmentin. - The drain recently repositioned this past hospitalization and needs to be rechecked the first week in _%#MM#%_.
IR|interventional radiology|IR|205|206|HOSPITAL COURSE|HOSPITAL COURSE: Squamous cell carcinoma with nasopharyngeal primary, status post treatment with chemotherapy and radiation. The patient was admitted to the oncology ward. He did have his G-tube placed by IR prior to chemotherapy. He was then treated with high dose cisplatin the evening of admission. He was then treated with radiation per protocol. The patient tolerated this fairly well and was stable at the time of discharge.
IR|interventional radiology|IR|218|219|PAST SURGICAL HISTORY|2. Gastric pacemaker placement in 2003. 3. Ventral hernia repair with AlloDerm mesh and placement of jejunostomy tube on _%#MMDD2007#%_. 4. Dislodgment of jejunostomy tube in mid _%#MM2007#%_ with GJ tube placement in IR on _%#MMDD2007#%_. 5. Below-the-knee amputation secondary to infection in 1997. 6. Coronary angiogram in _%#MM2003#%_. ALLERGIES: Compazine and erythromycin. HOSPITAL COURSE: The patient was admitted to 6B and scheduled for biopsy by IR.
IR|interventional radiology|IR.|215|217|HOSPITAL COURSE|5. Below-the-knee amputation secondary to infection in 1997. 6. Coronary angiogram in _%#MM2003#%_. ALLERGIES: Compazine and erythromycin. HOSPITAL COURSE: The patient was admitted to 6B and scheduled for biopsy by IR. Biopsy results for pancreas graft were positive for acute rejection moderate. Biopsy results for kidney grafts were again acute. T-cell mediated rejection moderate and also moderate interstitial lymphoplasmacytic infiltrate with frequent eosiniphils and scattered tubulitis.
IR|interventional radiology|IR|206|207|PROBLEM #1|The patient's images were reviewed by Interventional Neurology and was agreed to proceed with cerebral angiogram as a diagnostic study. The angiogram showed chronic right M1 occlusion and good collaterals. IR recommended medical management for the avoidance of dehydration and hypertension. They also noted that with any new symptoms that the patient would develop even with an elevated blood pressure or slight hypertension, the patient should be reevaluated for possible bypass sooner.
IR|interventional radiology|IR|178|179|HISTORY OF HOSPITALIZATION|On the right side, she had radical neck dissection as a teenager. Therefore, the left IJ dialysis access was placed; however, there was a poor flow even after the TPA treatment. IR had to manipulate the catheter several times before obtaining a good flow for adequate hemodialysis. The patient was hemodialyzed on the night of _%#MMDD2006#%_. Both the dialysis the patient did very well.
IR|interventional radiology|IR|153|154|HOSPITAL COURSE|The patient was treated empirically with ciprofloxacin for his presumed SBP after which he improved. He had a paracentesis during his hospitalization by IR which drew out 5 liters of fluid. After his paracentesis, he did develop acute renal failure with a creatinine going out to the 4 range with a baseline creatinine of less than 1.
IR|interventional radiology|IR|182|183|PLAN|5. The patient is to strain the stool to find the stent, which we expect will pass through the GI system and be excreted. The stent is to be brought to the University of Minnesota's IR department to be sent to path laboratory for analysis of the tissue, which we expect will be adherent to it. 6. Within 2 weeks, the patient is to return for a downsizing of the biliary drain from 16-French to 10-French.
IR|interventional radiology|IR|216|217|HOSPITAL COURSE|On exam it was clear that the patient had large right pleural effusion likely secondary to her marked ascites and fluid crossing the diaphragm. He did appear extravascularly fluid overloaded. The patient was sent to IR for his thoracentesis and about 1.5 liter of fluid was drained. Gram stain was negative and cell count and differential were consistent with ascitic fluid.
IR|interventional radiology|IR|142|143|BRIEF HOSPITAL COURSE|Later in the day the patient stated that his J tube fell out, thus he was temporarily replaced with an #8 French tube to keep the tract open. IR was consulted and on the _%#DD#%_ they replaced his tube with a #12 French MIC jejunal tube. The patient was made n.p.o. He was taken back to the operating room on _%#MMDD#%_ for an EGD with dilation.
IR|interventional radiology|IR|342|343|DISCHARGE DIAGNOSES|He and his mother will also keep food logs so that when he comes in for general surgery followup, we can ensure that his dietary intake is adequate despite his pancreatitis.2. Left paracolic fluid collection. Urology team was consulted as they were the team that had done his original retroperitoneal lymph node incision. They recommended an IR drainage, which was done on _%#MMDD2007#%_. Jackson-Pratt drain was placed and initial drainage was 250 mL with daily drainages ranging from 100 to 200 mL.
IR|interventional radiology|(IR)|151|154|LABORATORY DATA|LABORATORY DATA: Potassium 4.9, BUN 88, creatinine 10.27, INR 3.81, hemoglobin 10.4, white count 7.7, platelet count 199. Her Interventional Radiology (IR) procedure yesterday showed severe stenosis at the arterial anastomosis and in the venous limb and these both had angioplasty. She had an occluded left subclavian vein.
IR|interventional radiology|IR|368|369|HOSPITAL COURSE|Chest x-ray afterward showed no pneumothorax. On postoperative day #1 from surgery, he had a CT scan, which showed resolution of the renal tumor on the right side 3 weeks after cryo and as well showed several small wisps of calcification in the collecting system, which were thought would pass down his double J stent on the left side. On postoperative day #2, in the IR an antegrade nephrostogram was performed, his UPJ was deemed patent and PN tube was removed with the double J in place. The patient was afebrile, tolerating p.o. and having bowel movements and was discharged to home in sable condition.
IR|interventional radiology|IR|175|176|PROBLEM #2|He was restarted on his feeds at approximately 1700 hours on _%#MMDD2007#%_ status post PICC replacement. PROBLEM #2: Cardiovascular and Respiratory. The PICC was replaced by IR at approximately 1400 hours on _%#MMDD2007#%_. There were no complications or problems and the patient came back to the floor and was doing well.
IR|interventional radiology|IR|244|245|PROBLEM #2|Surgery consult was obtained and upon their recommendation an abdominal pelvic CT was obtained that showed presacral abscess. The patient was started on empiric antibiotics treatment with vancomycin and Zosyn. Abscess drainage was performed by IR and a drain was left in place. However, the patient voluntarily removed the drain due to discomfort and refused replacement of the drain.
IR|interventional radiology|IR|144|145|ADMISSION DIAGNOSES|4. Possible perforation of the Miami pouch with a Foley catheter and hematoma formation within the Miami pouch. 5. The patient presented to the IR today for stent change and nephrostogram. 6. The patient admitted from the IR for aggressive irrigation of the Miami pouch. DISCHARGE DIAGNOSES: 1. A 58-year-old female with a history of stage 2B squamous cell carcinoma of the cervix status post total pelvic exenteration in 1991.
IR|interventional radiology|IR|222|223|ADMISSION DIAGNOSES|4. Possible perforation of the Miami pouch with a Foley catheter and hematoma formation within the Miami pouch. 5. The patient presented to the IR today for stent change and nephrostogram. 6. The patient admitted from the IR for aggressive irrigation of the Miami pouch. DISCHARGE DIAGNOSES: 1. A 58-year-old female with a history of stage 2B squamous cell carcinoma of the cervix status post total pelvic exenteration in 1991.
IR|interventional radiology|IR|144|145|DISCHARGE DIAGNOSES|4. Possible perforation of the Miami pouch with a Foley catheter and hematoma formation within the Miami pouch. 5. The patient presented to the IR today for stent change and nephrostogram. 6. The patient admitted from the IR for aggressive irrigation of the Miami pouch. DISCHARGE DIAGNOSES: 1. A 58-year-old female with a history of stage 2B squamous cell carcinoma of the cervix status post total pelvic exenteration in 1991.
IR|interventional radiology|IR|399|400|HISTORY OF PRESENT ILLNESS|COMPLICATIONS: None. HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old female with a history of stage 2B squamous cell carcinoma of the cervix, status post total pelvic exenteration in 1991, recently admitted from _%#MMDD2007#%_, though _%#MMDD2007#%_ for upper GI bleed and small bowel obstruction. She had the above-noted procedure dictated in the admission diagnosis. She presented to the IR on _%#MMDD2007#%_, for stent change and nephrostogram. Nephrostogram showed flow through the ureters with blockage distally. Pouchogram revealed foul-smelling mucosal debri, which could not be completely cleared.
IR|interventional radiology|IR|139|140|HOSPITAL COURSE|Status post small bowel resection, ileocolic resection and anastomosis with colostomy in _%#MM2007#%_. The patient presents today from the IR secondary to mucosal debri noted in the Miami pouch for flushing. 2. FEN. The patient tolerating regular diet. IV Hep-Lock and discontinued prior to discharge.
IR|interventional radiology|IR|268|269|PLAN|ASSESSMENT: 53-year-old woman with known SMA thrombosis causing abdominal pain, treated with lytic therapy and anticoagulation with enoxaparin requiring follow up angiogram by Interventional Radiology. PLAN: 1. SMA thrombosis: Enoxaparin will be held at this time. If IR procedure is not done today, the team will discuss anticoagulation with heparin with Interventional Radiology. Pancreatitis, which is related to SMA thrombosis on last admission will be considered on this admission.
IR|interventional radiology|IR|177|178|HISTORY OF PRESENT ILLNESS|She was evaluated with a CT scan and discharged on TPN. She was subsequently admitted to Medicine Service for severe fungemia recently with sepsis. Her TPN was discontinued and IR placed feeding tube on _%#MMDD2007#%_. She now presents with acute onset of abdominal pain, nausea and vomiting. She denies any nausea at this time. She rates her pain 10/10 in points to the supraumbilical region.
IR|interventional radiology|IR.|110|112|HOSPITAL COURSE|The cultures did not grow out anything to date. She had her G tube switched out for a button the day prior by IR. Her tube feeds were restarted through this button tube and there was an increased induration at this tube site and a little bit of purulent drainage from the surrounding tube site.
IR|interventional radiology|IR.|163|165|MAJOR PROCEDURES|2. Acute renal failure - postobstructive due to ureteral obstruction. 3. Urinary tract infection. MAJOR PROCEDURES: 1. Bilateral percutaneous nephrostomy tubes by IR. 2. Ultrasound of kidney, _%#MMDD2007#%_ - mild hydro of right kidney and moderate hydro of left kidney. 3. Chest x-ray _%#MMDD2007#%_ - clear lungs. 4. R-CHOP chemotherapy.
IR|interventional radiology|IR|189|190|PROBLEM #2|PROBLEM #2: Renal. _%#NAME#%_ was going to be dialyzed on _%#MMDD2007#%_ per her normal routine, however, she was unable to dialyze due to a clotted dialysis catheter port. She was sent to IR for TPA infusion into the right hemodialysis port. Hemodialysis was again tried the next day and was successful. PROBLEM #3: Cardiovascular. The patient was found to be bradycardic in the PACU postoperatively.
IR|immediate-release|IR|117|118|MEDICATIONS ON ADMISSION|5. Chronic anemia due to chemotherapy, transfusion dependent. 6. Atrial fibrillation MEDICATIONS ON ADMISSION: 1. MS IR 10 mg prn. 2. Vitamin 3. Daily aspirin ALLERGIES: No known drug allergies. SOCIAL HISTORY: Lives locally with her husband, started home hospice program within the last two weeks.
IR|interventional radiology|IR|156|157|PROBLEM #2|A CT was then done that did show extensive subcutaneous and free air, presumably from the new percutaneous gastrojejunostomy tube placed on _%#MMDD2007#%_. IR was consulted and they did pull the tube back slowly to allow the tract to heal. They were not able to remove it completely. At that time the process of pulling back slowly was going to take about 6 weeks.
IR|interventional radiology|IR|175|176|PERTINENT IMAGING PROCEDURES|PERTINENT IMAGING PROCEDURES: 1. Chest x-ray showing bilateral pulmonary edema. 2. Liver ultrasound with Doppler showing no acute changes. 3. TTE negative for vegetations. 4. IR placement of dialysis catheter on _%#MMDD2007#%_ with revision on _%#MMDD2007#%_. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 20-year-old woman on dialysis who presented with abdominal pain, nausea and malaise after skipping to hemodialysis sessions and she was found to have coag negative staph bacteremia.
IR|interventional radiology|IR|145|146|BRIEF HISTORY OF HOSPITALIZATION|Patient received scheduled hemodialysis. It was found that patient has thrombosed fistula during hospitalization. Therefore, she was sent to the IR for thrombolysis. Post IR, ultrasound showed that patient had patent hemodialysis fistula that can be used. The patient was discharged to home in stable condition. DISCHARGE PROBLEMS: Chronic cholecystitis, status post cholecystectomy.
IR|interventional radiology|IR,|171|173|BRIEF HISTORY OF HOSPITALIZATION|Patient received scheduled hemodialysis. It was found that patient has thrombosed fistula during hospitalization. Therefore, she was sent to the IR for thrombolysis. Post IR, ultrasound showed that patient had patent hemodialysis fistula that can be used. The patient was discharged to home in stable condition. DISCHARGE PROBLEMS: Chronic cholecystitis, status post cholecystectomy.
IR|interventional radiology|IR:|185|187|PROCEDURES|2. End-stage renal disease. PROCEDURES: 1. Performed on _%#MMDD2007#%_, by Interventional Radiology: Exchange of double-J stent for retrograde stent. 2. On _%#MMDD2007#%_, performed by IR: Exchange of retrograde stent for double-J stent. TREATMENTS: Continuous bladder irrigation with amphotericin. CONSULTS: 1. Transplant Nephrology.
IR|interventional radiology|IR|96|97|PROCEDURES|3. Small biliary leak. PROCEDURES: 1. Liver biopsy. 2. Kidney biopsy. 3. Abdominal paracentesis IR guided. 4. MRI of abdomen. 5. CT of abdomen and pelvis. 6. Renal ultrasound. 7. Abdominal ultrasound. HISTORY: The patient is a 52-year-old female with status post liver- kidney transplant in _%#MM2003#%_ for treatment of end-stage liver disease secondary to hepatitis C.
IR|immediate-release|IR|177|178|MEDICATIONS|2. Constipation. 3. Portal vein thrombosis. 4. Right hydronephrosis. 5. Progressive abdominal carcinomatosis. DISPOSITION: Hospice. MEDICATIONS: 1. MS Contin 15 mg b.i.d. 2. MS IR 10 mg every 2 hours as needed. 3. Senokot S 2 pills q.d. SUMMARY: Mr. _%#NAME#%_ _%#NAME#%_ is a _%#1914#%_ male with a history of advanced colon and lung cancer.
IR|immediate-release|IR|142|143|SUMMARY|He does open his eyes and turn in response to voice, but he goes right back to sleep. The dose was cut down to 15 mg b.i.d. in addition to MS IR on an as needed basis.
IR|immediate-release|IR|389|390|DISCHARGE DIAGNOSIS|DISCHARGE CONDITION: Terminal. DISCHARGE MEDICATIONS: Acyclovir 400 mg p.o. b.i.d., allopurinol 100 mg p.o. daily, aspirin 81 mg p.o. daily, calcium carbonate plus vitamin D 500 mg p.o. t.i.d., Soma 1 tablet p.o. t.i.d., digoxin 250 mcg p.o. daily, Lasix 40 mg p.o. daily, Tequin 400 mg p.o. daily, insulin NPH 14 units subcutaneous in a.m. and p.m., OxyContin 40 mg p.o. b.i.d., Dilaudid IR 2 mg p.o. q.4 to 6h. p.r.n., Protonix 40 mg p.o. b.i.d., K-Dur 20 mEq p.o. daily, Bactrim DS 1 tablet p.o. b.i.d., voriconazole 200 mg p.o. b.i.d., linezolid 600 mg p.o. b.i.d., Biaxin 500 mg p.o. b.i.d., Senokot-S 2 tablets p.o. at bedtime p.r.n., Ambien 10 mg p.o. at bedtime p.r.n., Zofran 8 mg p.o. t.i.d. p.r.n. DIET: As tolerated.
IR|immediate-release|IR|139|140|DISCHARGE MEDICATIONS|5. KCl 20 mEq 1 p.o. b.i.d. 6. OxyContin 20 mg 1 p.o. b.i.d. 7. Procrit 40,000 subcu q. week. 8. Iron sulfate 325 mg 1 t.i.d. 9. Oxycodone IR 5 mg 1 p.o. q.4h. p.r.n. pain. 10. Morphine sulfate 50 mg 1 p.o. q.12h.
IR|immediate-release|IR|146|147|PROBLEM #3|CONDITION OF PATIENT: Improved. ACTIVITY: As tolerated. DIET: Clear liquids for now. DISCHARGE MEDICATIONS: 1. MS Contin 100 mg p.o. t.i.d. 2. MS IR 30 mg p.o. q. 4h. p.r.n. 3. Lubriderm applied to affected areas. 4. Zofran 8 mg p.o. t.i.d. p.r.n. 5. Compazine 10 mg p.o. q. 6h. p.r.n.
IR|interventional radiology|IR,|229|231|HOSPITAL COURSE BY PROBLEM|HOSPITAL COURSE BY PROBLEM: Pleural effusion. The patient had a left pleural effusion, most likely secondary to CABG, progressively getting worse and symptomatic. The patient, therefore, had an ultrasound-guided thoracentesis by IR, and 1500 mL were drained. The patient's pleural fluid was sent, and it appears to be transudative. The cultures are negative so far, and cytologies are pending at this time.
IR|interventional radiology|IR|309|310|DISCHARGE DIAGNOSES|5. Normal newborn screen. 6. Normal hearing screen. 7. History of murmur with echo performed on _%#MMDD2008#%_ showing mild peripheral pulmonary stenosis and patent foramen ovale with left-to-right shunt. 8. Conjugated hyperbilirubinemia, started on Actigall on _%#MMDD2008#%_. 9. Replacement of PICC line in IR on _%#MMDD2008#%_; 10 day course of Flagyl for possible small bowel bacterial overgrowth on _%#MMDD2008#%_. 10. History of blood transfusion x2. Audra is a 50-day-old infant who is born with known history of gastroschisis.
IR|interventional radiology|IR|149|150|HOSPITAL COURSE|On _%#MMDD#%_, the patient was returned to the ICU for fever and shortness of breath, at which time she developed a right-sided pleural effusion and IR placed a pigtail drain. She was thought to have possible pneumonia at this time as well. She did not, however, require further intubation at this time.
IR|immediate-release|IR|175|176|SUMMARY OF CASE|15. Quetiapine 50 mg daily for anxiety. 16. Glargine 30 units daily at bedtime for his diabetes. 17. Lomotil 1 to 2 tablets 3 times a day as needed for diarrhea. 18. Morphine IR 15 mg every 4 to 6 hours as needed for pain. 19. Phenergan 25 mg orally every 8 hours as needed for nausea.
IR|immediate-release|IR|203|204|DISCHARGE MEDICATIONS|She wants to go home today so we discharged her with a cane, which is fine, and I will see her again next Tuesday, _%#MMDD2004#%_. DISCHARGE MEDICATIONS: 1. Amitriptyline 25 mg p.o. at h.s. 2. Oxycodone IR 5-10 mg every 3 hours p.r.n. pain. 3. Aspirin 325 mg p.o. b.i.d.
IR|immediate-release|IR|133|134|DISCHARGE MEDICATIONS|14. Nicoderm patch 7 mg change daily. 15. Keflex 500 mg every 6 hours - discontinued. 16. MS-Contin 60 mg 1 p.o. t.i.d. 17. Morphine IR 30 to 45 mg every 4-6 hours p.r.n. DISPOSITION: She will go home with the physical therapy to continue with rehabilitation.
IR|interventional radiology|IR|159|160|HOSPITAL COURSE|On _%#MM#%_ _%#DD#%_, 2006, a CT, sonogram showed that there was obvious fistula to efferent limb of the J pouch. At that time, patient was scheduled to go to IR for passing of a wire to train into the distal limb of the ileostomy and into the pouch. Patient had this procedure done and tolerated it without difficulty.
IR|interventional radiology|IR|191|192|BRIEF HISTORY|He was passing stool and flatus without difficulty and tolerated p.o. food prior to discharge. The patient was advised to gently resume his usual diet. The patient was observed by surgery in IR during his hospitalization. It was never felt that he was a surgical case. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. q. day.
IR|interventional radiology|IR|176|177|ADMISSION DIAGNOSIS|5. Multiple episodes of line sepsis. 6. Status post vaginal hernia repair which was complicated with colocutaneous fistula fistula formation. 7. Abdominal abscess, status post IR percutaneous drainage. ALLERGIES: GENTAMICIN, CIPRO, KEFLEX, LINEZOLID, AMOXICILLIN, SULFA, NITROFURANTOIN, VICODIN, DEMEROL, AND CODEINE. HOSPITAL COURSE: This patient was admitted to the hospital for possible debridement of her abdominal wound on _%#MM#%_ _%#DD#%_, 2004.
IR|interventional radiology|IR|216|217|HISTORY OF PRESENT ILLNESS|It was decided to attempt conservative management for her biliopancreatic limb obstruction, and this was to be carried out through a percutaneous gastrostomy tube placed in the gastric remnant. This was attempted by IR in the evening of _%#MM#%_ _%#DD#%_, 2004, but was unsuccessful. Initially, she had tolerated the procedure well; however, on the following morning, she developed peritoneal signs.
IR|immediate-release|IR|179|180|ADDENDUM|ADDENDUM: The patient's primary pain clinic team at Healtheast was spoken to today. They stated that they had given the patient a one time only prescription for an additional Oxy IR #48 tablets on _%#MMDD2005#%_. The patient states that she still has an additional 6 or 8 of these tablets left. Prior to discharge she was very frustrated that she would not receive any more pain medications prior to discharge, stating that her partner would be out of town for the next two days and she would not be able to get into any clinics to get her medication.
IR|interventional radiology|IR|246|247|ASSESSMENT/PLAN|With regard to her pain, we will treat her with intravenous morphine and hold all of her p.o. medications, as she has not been able to tolerate this anyway. She did have a paracentesis last time, which was apparently challenging and performed by IR secondary to loculations. The patient denied whether or not this significantly beneficial, and at this point in time we will hold off on pursuing paracentesis.
IR|interventional radiology|IR.|209|211|HISTORY OF PRESENT ILLNESS|Briefly, this is an 85-year-old female with the past history significant for hypertension, hematuria secondary to renal cell carcinoma, status post ablation who presented for left upper pole embolization from IR. The patient presented for postprocedure. The patient states that upon arrival to the floor, she said she felt quite well but does state that she had some left-sided flank pain.
IR|immediate-release|IR|173|174|DISCHARGE FOLLOWUP|CONSULTS: Oncology, Dr. _%#NAME#%_, who modified her pain medication, and on the day of discharge, her pain medicine was increased to MS Contin 90 p.o. t.i.d. with Morphine IR 30 mg p.o. q.12 h. p.r.n. for breakthrough pain.
IR|interventional radiology|IR|228|229|HOSPITAL COURSE|During the hospital stay, around _%#MM#%_ _%#DD#%_, 2006, she also had an episode of heavy vaginal bleeding which prompted her to be transferred to the ICU because of the hypotension, tachycardia. The patient was later taken to IR and she underwent bilateral internal iliac artery embolization which was able to stop the bleeding within about 1 hour of procedure.
IR|interventional radiology|IR.|119|121|PROCEDURES|6. Depression. 7. Hypertension. 8. Urinary tract infection with enterococcus. PROCEDURES: 1. Double-J stent removal by IR. 2. Placement of retrograde stent by IR. 3. IV antibiotics. 4. IV fluids. 5. Subcutaneous heparin. 6. Stent flushing. 7. Replacement of double-J stent on _%#MM#%_ _%#DD#%_, 2006.
IR|interventional radiology|IR.|159|161|PROCEDURES|6. Depression. 7. Hypertension. 8. Urinary tract infection with enterococcus. PROCEDURES: 1. Double-J stent removal by IR. 2. Placement of retrograde stent by IR. 3. IV antibiotics. 4. IV fluids. 5. Subcutaneous heparin. 6. Stent flushing. 7. Replacement of double-J stent on _%#MM#%_ _%#DD#%_, 2006.
IR|interventional radiology|IR|152|153|BRIEF HISTORY|Left gluteal abscess. Again, as noted the patient will remain on nafcillin for a total of 4 weeks ending on _%#MMDD2006#%_. The abscess was drained via IR and the collected fluid was sent for culture. This remains pending at this time. The patient has remained afebrile with intact counts.
IR|interventional radiology|IR.|122|124|HOSPITAL COURSE|2. Intraabdominal abscesses. The CT scan also revealed intraabdominal abscesses that were drained by Pigtail placement by IR. At the time of discharge, the patient is leaving with his JP drains from his original surgery and also a Pigtail catheter in his right pelvic abscess, which continues to drain.
IR|interventional radiology|IR|116|117|DISCHARGE INSTRUCTIONS|2. The patient has activity as tolerated. No lifting greater than 20 pounds for 6 weeks. 3. Her pigtail care is per IR recommendations to clean daily and p.r.n. or to follow up with interventional radiology in 2 to 3 weeks here at UMMC to replace her G-tube for a G-button and also to follow up with our dietitian and Dr. _%#NAME#%_'s clinic for bolus feeding recommendations on the same day as her G-button is placed.
IR|interventional radiology|IR.|216|218|HOSPITAL COURSE|Her right drain had been replaced until earlier in the week when the output stopped and the drain was pulled because it was thought it was clogged. She was scheduled to undergo ultrasound and possible replacement by IR. I did speak to Dr. _%#NAME#%_ who performed panniculectomy. She came by and saw the patient and was not concerned that there was increasing fluid collection.
IR|interventional radiology|IR.|203|205|PROCEDURES|5. CT chest and abdomen _%#MMDD2007#%_ showing bulky mediastinal adenopathy and large pleural effusions with multiloculated effusion and left multiple small pulmonary nodules. 6. Chest tube placement by IR. 7. Status post talc pleurodesis of the left chest. 8. CT chest, abdomen and pelvis without contrast _%#MMDD2007#%_ showing large pleural effusions bilaterally grossly unchanged on the right with slightly decreased left pleural effusion with new chest tube in place, several new foci of air about the catheter tip, unchanged mediastinal lymphadenopathy and pulmonary nodules and numerous unchanged hepatic cysts.
IR|interventional radiology|IR|185|186|HOSPITAL COURSE|The patient came with a significantly distended abdomen. On the day of discharge, he was sent to an interventional radiology and he had ascitic fluid removed from there. Dictation from IR is still pending, therefore it is unknown for me how much fluid was taken off, however, the patient's abdomen is plain and not distended at this point.
IR|interventional radiology|IR|211|212|HISTORY OF PRESENT ILLNESS AND HOSPITALIZATION COURSE|Around postoperative day #12, the patient started to spike some fever and had some increase in his white blood cell count. Another CT scan was done. It showed fluid collection at the abdomen that was drained by IR on _%#MMDD2007#%_. The patient thereafter started to improve again. He became afebrile, the ostomy started functioning and the patient was tolerating p.o. intake.
IR|interventional radiology|IR,|278|280|SUMMARY OF HOSPITAL COURSE|She was seen by Dr. _%#NAME#%_ from General Surgery who recommended continuing the JP drain but replacing it under IR prior to considering surgery. Family apparently has been fairly resistant to undergoing surgery. In any case, the JP drain was supposed to be replaced today by IR, but inadvertently the 2 JP drains that were present were removed but they were not replaced. As such, the patient now needs to have a new JP drain placed and also given the circumstances of her being on an Adult Medicine Service at this time and being in need of more advanced care, Dr. _%#NAME#%_ felt it would be wise for the patient to be transferred to a facility where she could get more specialized care, and we also feel it is important for her to get Pediatric care given her young age.
IR|interventional radiology|IR|257|258|HOSPITAL COURSE|It appeared as though this was adjacent to one of the surgical anastomoses. However, because the patient had been afebrile, had no pain, and knows how to manage his drain output, it was felt as though he would be able to manage this issue at home until his IR procedure on _%#MM#%_ _%#DD#%_, 2006. DISCHARGE CONDITION: On the day of discharge, the patient was afebrile and his vital signs were all normal.
IR|interventional radiology|IR|205|206|ASSESSMENT|1. Bleeding/oozing at a central venous insertion site with a drop in hemoglobin to 6.9; it had been approximately 8 prior to discharge. Will try and infuse 3 units, give the patient DDAVP and will contact IR for local application of Destat patch around the entry site. If bleeding continues, would consider either cryos or FFP and possibly platelet transfusion as well.
IR|interventional radiology|IR|143|144|DISCHARGE FOLLOWUP|13. Prilosec 30 mg p.o. daily. 14. Bactrim 1 tab p.o. b.i.d. 15. Senna 1 tab p.o. b.i.d. DISCHARGE FOLLOWUP: 1. The patient was scheduled with IR next week on Thursday, _%#MMDD2006#%_ at 10 a.m. to have his double-J removed internal one. 2. The patient has kidney transplant ultrasound to be scheduled at _%#MMDD2006#%_ in the a.m. followed by an appointment in Transplant Surgery Clinic.
IR|interventional radiology|IR|123|124|HISTORY OF PRESENT ILLNESS|The patient also has issues with her G tube. She has had a G tube for many years however her current tube site was done by IR in _%#MM2006#%_. The actual tube itself has been in place for 6 weeks. There is a plan to change the specific tube, however, the patient is currently neutropenic and IR is waiting for her counts to come up.
IR|interventional radiology|IR|149|150|HISTORY OF PRESENT ILLNESS|The actual tube itself has been in place for 6 weeks. There is a plan to change the specific tube, however, the patient is currently neutropenic and IR is waiting for her counts to come up. Her current problem with this G tube is that she can put her tube feedings in, however 30 minutes after this she will experience a significant leakage around the site of the G tube.
IR|interventional radiology|IR|283|284|PLAN|2. G-tube malfunction: The patient is apparently scheduled to have her G tube changed, however due to her neutropenia, Interventional Radiology is waiting for her counts to come up. Overnight tonight we will continue to use her G tube and assess how much is leaking. We will contact IR in the morning and revisit this issue. If we are unable to use her G tube, she may require other means of nutritional support.
IR|immediate-release|IR|130|131|DISCHARGE MEDICATIONS|6. Fentanyl patch 12 mcg per hour apply to skin every 72 hours. 7. Ativan 1-2 mg p.o. q.6h. p.r.n. nausea or anxiety. 8. Morphine IR 5-10 mg p.o. q.4h. p.r.n. pain. 9. Carafate suspension 1 g p.o. q.i.d. p.r.n. throat or upper abdominal pain. 10. Phenergan 12.5-25 mg p.o. q.6h. p.r.n. nausea. 11. Fluconazole 100 mg p.o. q. day.
IR|interventional radiology|IR|136|137|PROCEDURE PERFORMED|ADMISSION DIAGNOSIS: Fevers, nausea and vomiting. DISCHARGE DIAGNOSIS: Intra-abdominal and subcutaneous abscesses. PROCEDURE PERFORMED: IR placement of two drains. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 56-year-old lady who recently underwent exploratory laparotomy with extensive lysis of adhesion, ileostomy take down with small bowel resection, and the rectus abdominus flap repair of colovaginal fistula with colon resection, and transverse colostomy, and intersphincteric proctectomy on _%#MMDD2007#%_.
IR|interventional radiology|IR|161|162|HISTORY OF HOSPITALIZATION|9. Motrin suspension 600 mg p.o. q.i.d. 3 times a day. HISTORY OF HOSPITALIZATION: The patient was admitted on _%#MMDD2007#%_. She was started on Flagyl and the IR was consulted and 2 drains were placed, one into the intra-abdominal cavity and the other subcutaneously. Over the course of several days, the patient's fevers have resolved.
IR|interventional radiology|IR|146|147|HOSPITAL COURSE|The patient did have tap with paracentesis initially with good relief, but this ascites recurred. The patient had a peritoneal catheter placed in IR on the day of discharge for frequent peritoneal fluid drainage for comfort. PROBLEM #2: CLL - advanced: The patient was following with Dr. _%#NAME#%_.
IR|interventional radiology|IR|229|230|PROBLEM #2|She underwent diagnostic tap which showed a relatively bland fluid and no evidence of malignancy. In addition, there was no evidence of infection. After undergoing tap at the bedside, she underwent more thorough drainage with an IR guided paracentesis that removed 4.5 liters. DISCHARGE MEDICATIONS: 1. Creon 5 one tab p.o. with meals.
IR|interventional radiology|IR|177|178|HOSPITAL COURSE|Also Legionella antigen in the urine was negative. After discussion with patient, we indicated we want to be her in treatment for tuberculosis for drugs. We sent the patient to IR for draining of the complete right pleural effusion. Minnesota Public Health Department was informed about these and they were in touch with us and we gave the patient number to call and will call Minnesota Public Health Department.
IR|interventional radiology|IR.|220|222|HOSPITAL COURSE|The patient was transferred to intensive care unit at the time and was given blood again. The patient had been already diagnosed with an aneurysm and the gastroduodenal artery that was then prophylactically embolized by IR. The patient was then transferred again to floor where he had another attack of hematochezia. GI were consulted again, they did an EGD that did not show an active source of bleeding and they also did colonscopy that showed a normal colon with no active source of bleeding.
IR|interventional radiology|IR|285|286|HOSPITAL COURSE|X-ray was performed and found to have a large right sided recurrent pleural effusion seen by Dr. _%#NAME#%_ in pulmonary who then transferred the patient to University with concerns of empyema. CT scan of his chest was obtained on admission, results as above. Chest tube was placed by IR and the patient was started on broad-spectrum antibiotics to cover possible infectious etiologies. Results of the culture of the pleural fluid as described above and the patient was started on Zosyn for coverage of this.
IR|interventional radiology|IR|205|206|HISTORY OF PRESENT ILLNESS|A hepatologist was recommended to be consulted for portal hypertension and management possibility of TIPS procedure. On _%#MMDD#%_, however, the patient had 300 cc hematemesis and the patient was taken to IR for acute GI bleeding and for the splenic artery embolization. On _%#MMDD2007#%_, therefore, the patient was transferred for hematemesis to the medical ICU.
IR|interventional radiology|IR|192|193|HOSPITAL COURSE|At the time of discharge, the patient was in no respiratory distress and breathing comfortably on room air. Lung biopsy for diagnosis of possible infection was discussed with Dr _%#NAME#%_ in IR and _%#NAME#%_ in chest surgery but was considered to be too dangerous because of the high risk of an air leak which would not heal and require subsequent lobectomy.
IR|interventional radiology|IR.|128|130|PROBLEM # 5|The patient's pain likely had a behavioral component to it as he did have anxiety over his line removal and replacement done in IR. At this time there is not a concrete diagnosis for his abdominal pain and vomiting. PROBLEM # 6: Hematology. The patient's anemia was treated with Epogen given during his dialysis runs.
IR|internal rotation|IR,|185|187|WEIGHTBEARING STATUS|Blood pressure and pulse t.i.d. ADVANCE DIRECTIVES: The patient is DNR/DNI. DIET: Low-sodium. WEIGHTBEARING STATUS: Weightbearing as tolerated with walker and assist. Up ad lib. No hip IR, no flexion greater than 90 degrees, no adduction of the hip and abduction pillow at all times in bed. PT and OT evaluation. Fall precautions.
IR|immediate-release|IR|159|160|DISCHARGE MEDICATIONS|2. She is to follow-up with Dr. _%#NAME#%_ in the Women's Health Clinic. DISCHARGE MEDICATIONS: She is sent home with: 1. Duragesic patch 200 mcg q.72h. 2. MS IR 25 mg p.o. p.r.n. breakthrough pain. 3. Senokot. 4. Clinoril. 5. Nystatin. 6. Tylenol with codeine elixir.
IR|immediate-release|IR|186|187|MEDICATIONS ON DISCHARGE|The patient may benefit from celiac access block in the future if pain management at home continues to be difficult. MEDICATIONS ON DISCHARGE: 1. Celebrex 200 mg once daily. 2. Morphine IR 5 mg tablets q. 2-3 hours as needed. 3. Miacalcin spray, one spray to one nostril daily, alternate nostrils. 4. Os-Cal. 5. Vitamin B12 monthly, 1 mg. 6. Multivitamins.
IR|interventional radiology|IR|159|160|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: Were home with a Foley, Foley supplies. Follow up with Dr. _%#NAME#%_, urologist in 1 week and attempt to remove Foley. Follow up with IR Southdale for coiling on Monday. Follow up with cardiologist in one month. Follow up with neurology, Dr. _%#NAME#%_, in one month. Outpatient speech therapy and PT for the shoulder was set up.
IR|immediate-release|IR|181|182|HOSPITAL COURSE|On hospital day number three she was weaned off her PCA and started on a fentanyl patch 75 micrograms along with Percocet for breakthrough pain which was then switched to OxyContin IR as needed for breakthrough pain. She received her Gemzar chemotherapy on _%#MMDD2003#%_ without difficulty. On hospital day number four she is stable and ready to be discharged to home with much improved pain control on her combination of fentanyl patch and oral OxyContin IR.
IR|immediate-release|IR|162|163|DISCHARGE MEDICATIONS|4. Zofran 4-8 mg q. 6 hours p.r.n. 5. Climara 0.01 mg patch, change weekly. 6. Zoloft 50 mg p.o. q. d. 7. Procrit 40,000 units subcutaneous q. week. 8. OxyContin IR 5 mg q. 6 hours p.r.n. 9. Fentanyl patch 75 micrograms to be changed every three days.
IR|immediate-release|IR|131|132|DISCHARGE MEDICATIONS|8. OxyContin 80 mg b.i.d. 9. Senokot two tablets b.i.d. 10. Ciprofloxacin 250 mg b.i.d. 11. Zometa 4 mg IV q. month. 12. Oxycodone IR 15 to 25 mg q2h p.r.n. for pain. PROCEDURE PERFORMED: Palliative radiation to right hip. HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old female who presented initially for admission to the hospital with right hip pain and was found to have an adenocarcinomatous tumor of the acetabulum.
IR|immediate-release|IR|162|163|DISCHARGE MEDICATIONS|3. Zocor 40 mg p.o. q.h.s. 4. Lansoprazole 30 mg p.o. b.i.d. 5. Colace 100 mg p.o. b.i.d. 6. Senokot 1-4 tabs p.o. b.i.d. p.r.n. 7. OxyContin 30 mg p.o. q.8h. 8. IR morphine 15-30 mg p.o. q.4h p.r.n. 9. Trazodone 100-150 mg p.o. q.h.s. STUDIES AND PROCEDURES: 1. Chest x-ray, _%#MMDD2002#%_.
IR|interventional radiology|IR|270|271|IMPRESSION AND PLAN|Her risk factors include recent immobility secondary to asthma/upper respiratory infection, and she is presently being evaluated for endometrial CA. Will check a CT scan and rule out PE, treat with Lovenox (IV heparin if there is evidence of PE); begin Coumadin. Obtain IR consultation from Dr. _%#NAME#%_ regarding the question of lytics; given the extensive nature of this we may be able to decrease the post-phlebitic syndrome.
IR|immediate-release|IR|166|167|DISCHARGE MEDICATIONS|3. Celebrex 200 mg p.o. b.i.d. 4. Colace 100 mg p.o. b.i.d. 5. Senna 2 tablets p.o. b.i.d. 6. Lidoderm patch 5%, 1-3 patches transdermally b.i.d. p.r.n. 7. Oxycodone IR 5 mg p.o. q.6h. p.r.n. 8. Methotrexate 7.5 mg p q.week, next dose due _%#MM#%_ _%#DD#%_, 2003. HISTORY OF PRESENT ILLNESS: This is s a 31-year-old woman with a past history significant for laparoscopic cholecystectomy in 1997.
IR|immediate-release|IR|175|176|DISCHARGE MEDICATIONS|6. MS Contin 60 mg p.o. b.i.d. 7. Claritin D 10 mg p.o. daily. 8. Rosiglitazone 4 mg p.o. daily. 9. Albuterol 2.5 mg nebs t.i.d., q.4-6h p.r.n. (new medication). 10. Morphine IR 15 mg p.o. b.i.d. p.r.n. DISCHARGE FOLLOW-UP: The patient will follow-up with his primary physician, Dr. _%#NAME#%_, in one to two weeks.
IR|interventional radiology|IR|230|231|PROCEDURES|3. On _%#MM#%_ _%#DD#%_, 2004, an arterial ultrasound which revealed a pseudoaneurysm arising from the right external iliac which was approximately 1.3 x 1.7 cm with a diameter of 4 mm. The patient underwent thrombin injection by IR for this with a followup ultrasound confirming resolution of the pseudoaneurysm. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is an 87-year-old female with a history of hypertension and rheumatoid arthritis who presented for shortness of breath.
IR|immediate-release|IR|121|122|DISCHARGE MEDICATIONS|DISCHARGE DIAGNOSIS: Sickle cell crisis. DISCHARGE MEDICATIONS: 1. Methadone 10 to 30 mg p.o. t.i.d. 2. Morphine sulfate IR 15 mg q.4 h. p.r.n. 3. Tylenol 650 mg p.o. q.6 h. p.r.n. 4. Ventolin inhaler 1 to 2 puffs q.4 h. p.r.n.
IR|immediate-release|IR|140|141|DISCHARGE MEDICATIONS|7. Requip 2 mg p.o. b.i.d. 8. Restoril 50 mg at bedtime p.r.n. 9. Trazodone 150 mg p.o. at bedtime. 10. OxyContin 10 mg p.o. b.i.d. 11. Oxy IR 5-10 mg p.o. q. 4-6h. p.r.n. 12. Augmentin 875 mg p.o. b.i.d. 13. Prednisone taper. She will be going home on 20 mg p.o. daily with a taper of 5 mg per week until she gets to zero.
IR|immediate-release|IR|168|169|DIAGNOSIS|The patient is being discharged to home in stable condition. The patient is to follow with Dr. _%#NAME#%_ in 4 weeks at his clinic. DISCHARGE MEDICATIONS: 1. Oxycodone IR 5-mg tabs 1-2 tablets p.o. q.4-6 h. p.r.n. 2. Senna 2 tablets p.o. nightly.
IR|interventional radiology|IR.|125|127|OPERATIONS/PROCEDURES PERFORMED|6. Ultrasound venous extremity of the right upper limb, which showed no deep venous thrombosis. 7. Feeding tube placement by IR. 8. Echocardiogram, which showed normal ejection fraction, left atrial enlargement, abnormal LV function, RV systolic pressure of 25 mmHg. BRIEF HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: Ms. _%#NAME#%_ is a 72-year-old lady who was transferred from Fairview Lakes in _%#CITY#%_ on _%#MM#%_ _%#DD#%_, 2005, with acute renal failure, hypocalcemia and seizures.
IR|interventional radiology|IR|214|215|BRIEF HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|Later on she was transferred to the intensive care unit for observation. She tolerated the thrombolysis very well without complications. Repeat ultrasound showed mild remnant of the nonocclusive thrombus. Later on IR performed angioplasty of the remaining nerve thrombosis. Throughout that time she was continued on heparin intravenous drip. Her right-sided Quinton catheter was removed. Temporary right-sided IJ Quinton was placed.
IR|interventional radiology|IR|159|160|ALLERGIES|ALLERGIES: IV CONTRAST, MORPHINE, WHICH CAUSES A BURNING FEELING AND COMPAZINE, WHICH CAUSES HIVES. HOSPITAL COURSE: The patient was admitted and underwent an IR CT-guided intraperitoneal abscess drainage. The patient tolerated the procedure well and was brought to the floor for postprocedure management.
IR|interventional radiology|IR|206|207|HISTORY OF PRESENT ILLNESS|The patient was admitted on _%#MMDD2005#%_ for pneumonia and has been treated with Levaquin. At that time, he had a CT which demonstrated some loculated lesions; however, thoracentesis was not performed by IR because they could not reach the infiltration. His fever resolved and white count was back to normal. He was sent home on _%#MMDD2005#%_ with Levaquin. According to patient, he has been feeling better since then; however, last night he had a fever of 102, chills, shaking, and some shortness of breath.
IR|interventional radiology|IR|194|195|HOSPITAL COURSE|There are no focal deficits. HOSPITAL COURSE: Problem system #1: GI: The patient was originally admitted due to esophageal varices bleeding, was controlled on admission. The patient was sent to IR for TIPS revision. He had multiple studies done to return flow through the TIPS and anticoagulate the venous system. TIPS is currently functioning. Gastric varices were perforated and embolized.
IR|interventional radiology|IR|158|159|HOSPITAL COURSE|Problem system #3: Anemia: The patient was admitted with esophageal bleed and INR of 1.65 due to chronic liver failure. The patient received FFP prior to all IR procedures. His hemoglobin reached a nadir of 6.3. He was given transfusions where he now has had a hemoglobin of 10.1 and stable.
IR|immediate-release|IR|184|185|DISCHARGE MEDICATIONS|The patient denied having any complaints of palpitations or chest pain. DISCHARGE MEDICATIONS: Additional medications on discharge were: 1. Levaquin 500 mg q. day x1 week. 2. Cardizem IR 90 mg b.i.d. 3. K-Phos 1 sachet b.i.d. FOLLOW UP: He will be followed up by his oncologist, Dr. _%#NAME#%_ at Parker Hughes Clinic for review and lab tests.
IR|interventional radiology|IR|244|245|HISTORY OF PRESENT ILLNESS|She underwent her first dose on Masonic day on _%#MM#%_ _%#DD#%_, 2006, and presents for her day 2 and 3 chemo here on 7 C over the _%#MM#%_ _%#DD#%_, 2006, and _%#MM#%_ _%#DD#%_, 2006. She still retains the drain in the pelvis from her second IR procedure. PAST MEDICAL HISTORY: Para 3-0-0-3. She has no significant past medical history. PAST SURGICAL HISTORY: Exploratory laparotomy as described above in the HPI.
IR|interventional radiology|IR|195|196|HOSPITAL COURSE|On _%#MM#%_ _%#DD#%_, 2006, the patient had a sonogram, which showed a small, less than 1-cm tract that went directly to small bowel. There was no evidence of abscess. No large fluid collection. IR mentioned that it would be possible to put a drain in this tract, but Dr. _%#NAME#%_ felt that this was not necessary, and would allow the wound to spontaneously heal on its own.
IR|immediate-release|IR|120|121|DISCHARGE MEDICATIONS|2. Nexium 40 mg p.o. q. day. 3. Fluconazole 100 mg p.o. q. day. 4. Bactrim DS 1 tablet p.o. b.i.d x14 days. 5. Morphine IR 15 mg p.o. q.3-4 h. p.r.n. pain. 6. Ambien 12.5 mg p.o. nightly. 7. Decadron 4 mg p.o. b.i.d. 8. Albuterol 0.083 one puff q.3-4 h. p.r.n. shortness of breath.
IR|interventional radiology|IR|203|204|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1: Epstein-Barr virus (EBV) lymphoma. The patient was sent to the Interventional Radiology the day after admission for a biopsy of the mass around the left ureter. However, the IR had problems accessing the mass and visualizing it better on ultrasound, though a CT- guided biopsy was ordered. So, she ended up getting a biopsy of the left skin lesion.
IR|interventional radiology|IR|197|198|HOSPITAL COURSE|After the patient was admitted, she received IV fluids and IV antiemetic medications. She was followed up by nephrologist and she underwent dialysis sterile catheter placement on _%#MMDD2006#%_ by IR to start her hemodialysis. Due to the rejection, Rapamune was stopped and the patient was continued on CellCept and rapid prednisone tapered down.
IR|immediate-release|IR|194|195|DISCHARGE MEDICATIONS|She should also follow up with Dr. _%#NAME#%_ _%#NAME#%_ with Plastic Surgery in approximately two weeks to evaluate her wound. DISCHARGE MEDICATIONS: 1. OxyContin 20 mg p.o. b.i.d. 2. Morphine IR 30 mg p.o. q3h as necessary. 3. Senna-S two tabs p.o. b.i.d. 4. Levaquin 750 mg p.o. q day x seven days. 5. Flagyl 500 mg p.o. q.i.d. x seven days.
IR|interventional radiology|IR|202|203|ISSUES|After 1 day, she had increased nausea and vomiting, and a CT scan was repeated as described above on _%#MM#%_ _%#DD#%_, 2006, with no significant increase in the peripancreatic fluid collection. GI and IR team were involved in most of the time, and they thought she could go home and follow with IR and general surgery as an outpatient for a cholecystectomy.
IR|interventional radiology|IR|296|297|ISSUES|After 1 day, she had increased nausea and vomiting, and a CT scan was repeated as described above on _%#MM#%_ _%#DD#%_, 2006, with no significant increase in the peripancreatic fluid collection. GI and IR team were involved in most of the time, and they thought she could go home and follow with IR and general surgery as an outpatient for a cholecystectomy. 2. ID. The patient spiked on the day of admission and blood cultures were drawn which showed gram-positive cocci in clusters.
IR|immediate-release|IR|122|123|DISCHARGE MEDICATIONS|8. Simvastatin 20 mg p.o. nightly. 9. Protonix 20 mg p.o. b.i.d. 10. Sinemet CR 50 mg over 200 mg p.o. b.i.d. 11. Sinemet IR 25/100 one tablet p.o. b.i.d. 12. Comtan 200 mg p.o. 5 times per day. 13. Nitroglycerin 0.4 mg sublingually q.5 minutes x3 p.r.n., chest pain.
IR|interventional radiology|IR|195|196|ASSESSMENT|3. Diabetes: The patient has had several episodes of low blood sugars recently, and it was decided at her clinic visit today that her Lantus will be discontinued. She is currently n.p.o. for her IR procedure, and because of this we will not give any basal insulin. She will be continued on insulin NovoLog sliding scale with q.i.d. blood glucose checks.
IR|interventional radiology|IR|210|211|BRIEF HISTORY OF PRESENT ILLNESS|BRIEF HISTORY OF PRESENT ILLNESS: The patient is a 26-year-old African American male with left groin AV fistula after gunshot wound in _%#MM#%_ 2001. the patient is status post attempts by vascular surgery and IR at outside hospital to close the fistula which all failed. He also had a history of endocarditis for which he is currently on penicillin GK and is in the sixth week of IV antibiotics.
IR|interventional radiology|IR|148|149|ISSUES|However, none of the blood in the urine culture grew anything. She was continued on Levofloxacin for a total of 10 days which was recommended after IR procedure. CONDITION ON DISCHARGE: Stable. ACTIVITY ON DISCHARGE: As tolerated. DIET ON DISCHARGE: Low protein.
IR|interventional radiology|IR|82|83|MAJOR PROCEDURES|2. Pulmonary infiltrates - presumed fungal infection MAJOR PROCEDURES: LP done by IR 1. On _%#MMDD2007#%_ - negative for infection. 2. Bronchoscopy _%#MMDD2007#%_ - light growth coag negative staph. 3. Pulmonary function test on _%#MMDD2007#%_ - within normal limits.
IR|interventional radiology|IR|200|201|ASSESSMENT AND PLAN|4. Possible metastatic cancer. He does want to try to find out whether or not he does have metastatic cancer. I think the easiest way to get some tissue would be a liver biopsy. I will plan on having IR do one on Monday and also check an INR and repeat his CBC tomorrow. Additionally, he may need to get a colonoscopy, especially if he iron deficient, but I think the best way to get a tissue diagnosis would be to start with a liver biopsy.
IR|interventional radiology|IR|184|185|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: Based upon the above findings a diagnosis of a wound abscess was made. Our plan right now is to have him admitted for now, place him on IV antibiotics (Zosyn) and IR do a CT-guided drain placement in the depths of the wound to try and remove the abscess fluid. My plan is to hopefully have this fluid drained in this minimally invasive manner because the next option is to actually open up the entire wound and have it drain that way.
IR|interventional radiology|IR.|191|193|HOSPITAL COURSE|During the following several days, however, she did develop a pleural effusion on the right. She went to Interventional Radiology on _%#MMDD2006#%_ and had a right chest tube placement under IR. This pigtail catheter initially drained 450 cc and, in the following 2 days, 250 cc and 125 cc, respectively, and then became nonfunctional.
IR|interventional radiology|IR|146|147|CONSULTATIONS DURING HOSPITALIZATION|CONSULTATIONS DURING HOSPITALIZATION: 1. Neurology consult for MRI findings. 2. Renal consult for continued hemodialysis. 3. Vascular surgery and IR for AV fistula leak. HISTORY OF PRESENT ILLNESS: Briefly, this is a very pleasant 55-year-old woman with a complicated past medical history significant for MDS status post ablative and nonmyeloablative bone marrow transplantation the last being in 2004, end-stage renal disease on hemodialysis, hypertension, dyslipidemia, hypothyroidism, ovarian cancer status post chemotherapy and surgical resection.
IR|interventional radiology|IR|183|184|PROBLEM #3|PROBLEM #3: AV fistula leak. One day prior to discharge the patient had spontaneous leak of her AV fistula in the left upper arm. The patient's hemoglobin was stable and vascular and IR were consulted. The leak stopped spontaneously and vascular and IR both felt that it was safe to use the AV fistula. The patient did have it accessed that day for hemodialysis with no further sequelae.
IR|interventional radiology|IR|179|180|LABORATORY|Patient had an adenosine sestamibi stress test which showed no evidence of coronary artery disease. LABORATORY: Flow cytometry that showed possible follicular lymphoma. Biopsy by IR of a retroperitoneal lymph node with results pending. He will follow up with Dr. _%#NAME#%_ in clinic. HOSPITAL COURSE/TREATMENT RENDERED: 1. Syncope. The patient's syncopal symptoms had resolved and did not recur while in the hospital.
IR|interventional radiology|IR|209|210|PLAN|PLAN: At this time was to discuss with Dr. _%#NAME#%_ regarding continued care of this patient. He recommends admitting her to interventional radiology for a CT angio possible lysis and we will follow up with IR regarding the findings of the CT angio.
IR|interventional radiology|IR|113|114|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|The patient was then transferred to _%#CITY#%_ and she was started on heparin drip. The patient was then seen by IR and had the thrombus treated by thrombolytic therapy. The patient has pulses in her radial and ulnar artery that show biphasic dopplerable flow.
IR|interventional radiology|IR|160|161|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|The patient was not found to have any other source for this obstruction and the thrombosis was considered to have happened locally. The patient was followed by IR and vascular team during her hospitalization stay and she had improved on the treatments mentioned above. The patient was afebrile. Tolerating her p.o. intake. Had dopplerable pulse in her radial and ulnar arteries when she was discharged home on _%#MMDD2007#%_.
IR|interventional radiology|IR|230|231|PROCEDURES|9. Hypertension. PROCEDURES: 1. Bone marrow biopsy dated _%#MMDD2007#%_ reveals 20% to 40% marrow cellularity with 65% blasts consistent with relapsed AML. 2. Chemotherapy with mitoxantrone/etoposide therapy on _%#MMDD2007#%_. 3. IR thoracentesis for 800 cc bloody fluid, cytology negative. 4. Echocardiogram revealing EF 35% to 40%. 5. Chest CT dated _%#MMDD2007#%_ showed mild improvement of bilateral pneumonia with interval decrease in size and several focal areas of consolidation, also interval resolution of subcutaneous emphysema as well as a new left pleural effusion and pericardial effusion with increased improvement of right-sided pleural effusion.
IR|interventional radiology|IR|249|250|ADDENDUM|2. Upper extremity DVT. As mentioned in the previously dictated summary, the patient was found to have an occlusive thrombus of his left upper extremity that was associated with midline catheter. Today, the patient had a right PICC line replaced in IR and the physician in IR noted that the right upper extremity is nearly clotted off. They think that this will be the last PICC line the patient will be able to have successfully inserted.
IR|interventional radiology|IR|273|274|ADDENDUM|2. Upper extremity DVT. As mentioned in the previously dictated summary, the patient was found to have an occlusive thrombus of his left upper extremity that was associated with midline catheter. Today, the patient had a right PICC line replaced in IR and the physician in IR noted that the right upper extremity is nearly clotted off. They think that this will be the last PICC line the patient will be able to have successfully inserted.
IR|interventional radiology|IR|164|165|IMPRESSION|I will consider some workup including CT scan of the chest which may evaluate a pulmonary process that may also be responsible for this pain, although I will await IR evaluation. MRI of the spine is another consideration especially if IR feels it is necessary, but it may not be with the probable diagnosis.
IR|interventional radiology|IR|235|236|IMPRESSION|I will consider some workup including CT scan of the chest which may evaluate a pulmonary process that may also be responsible for this pain, although I will await IR evaluation. MRI of the spine is another consideration especially if IR feels it is necessary, but it may not be with the probable diagnosis.
IR|interventional radiology|IR,|198|200|PROBLEM #11|PROBLEM #10: Prophylaxis: The patient was started on Lovenox for deep vein thrombosis prophylaxis. PROBLEM #11: Disposition: The patient was clinically improving and had undergone the treatments by IR, she was ready for discharge home and to be followed by IR as an outpatient. DISCHARGE INSTRUCTIONS: 1. Diet as tolerated. 2. Activity as tolerated.
IR|interventional radiology|IR.|201|203|PROBLEM #1|The patient will therefore have a CT of his abdomen followed by IR-guided percutaneous biliary drainage. We will restart his levofloxacin for antibiotic coverage and await further recommendations from IR. PROBLEM #2: Imbalance: Also with some slight confusion, but no focal neurological deficits on exam.
IR|interventional radiology|IR.|119|121|HOSPITAL COURSE|Please see history and physical for further details. HOSPITAL COURSE: 1. Right pleural effusion. This was tapped under IR. Pleural fluid was sent and showed no evidence of malignancy. It was though to be mainly due to decompensated CHF. 2. CHF. Last echocardiogram showed an ejection fraction of 15% most likely due to ischemic cardiomyopathy.
IR|interventional radiology|IR|185|186|HISTORY OF PRESENT ILLNESS|Given his symptoms he was scanned again in the ED and it was noted that his retroperitoneal hematoma was slightly bigger and in addition there was some mild evidence of hydronephrosis. IR was consulted and felt no urgent intervention needed to be done, but that the patient did require close observation and if renal function continued to worsen may need _______ tubes placed.
IR|immediate-release|(IR)|166|169|DISCHARGE MEDICATIONS|3. Paxil 60 mg a day. 4. Clonidine 0.2 mg b.i.d. 5. Klonopin 1 mg t.i.d. for anxiety disorder. 6. Ambien 10 mg h.s. sleep disturbance. 7. OxyContin immediate-release (IR) 5 mg t.i.d. p.r.n. for breakthrough pain. 8. OxyContin 20 mg b.i.d. 9. Lipitor 80 mg a day. 10. Tricor 160 mg a day. 11. Nexium 40 mg a day.
IR|immediate-release|IR|235|236|SOCIAL HISTORY|2. GI. Regular diet throughout hospital stay. DISCHARGE PLAN: Discharge instructions: The patient will be discharged home. Medications: Zoloft 50 mg p.o. q.d., Neurontin 1200 mg p.o. q.i.d., Coumadin 5 mg p.o. q.h.s., morphine sulfate IR 50 mg p.o. t.i.d., MS Contin 50 mg p.o. t.i.d., Megace 400 mg p.o. b.i.d., Senokot one tab p.o. b.i.d., Colace 100 mg p.o. b.i.d., Celebrex 200 mg p.o. b.i.d., Zanaflex 2 mg p.o. b.i.d., intrathecal pump Dilaudid 20 mg per ml plus bupivacaine 25 mg per ml, preservative-free, 20 ml total (all concentrations in mg), infusion rate 0.50 ml per 24 hours, alarm date _%#MM#%_ _%#DD#%_, 2002.
IR|immediate-release|IR|125|126|DISCHARGE MEDICATIONS|2. Zoloft 50 mg orally once a day. 3. Ativan 0.5 mg orally 3 times a day. This was given for a period of 1 week. 4. Morphine IR 45 mg orally every 4-6 hours as needed for pain. 5. Colace 100 mg twice a day. 6. Senna. 7. Compazine 10 mg to be taken before breakfast and as needed for nausea.
IR|immediate-release|IR|225|226|DISCHARGE MEDICATIONS|3. Bacitracin-covered Telfa to frontal wound b.i.d. 4. Cleanse with Clinicare b.i.d. DISCHARGE MEDICATIONS: 1. Neurontin 300 mg p.o. q.h.s. 2. Methadone 5 mg p.o. b.i.d. 3. Lidoderm patch to left ear q12h. 4. Morphine elixir IR 20 mg q4h p.r.n. FOLLOW-UP INSTRUCTIONS: 1. Follow-up with Dr. _%#NAME#%_ in one week. 2. The patient should report signs and symptoms to the ENT Clinic if there is increased drainage, increased pain, increased swelling, or elevated temperature of greater than 101.5 degrees F.
IR|immediate-release|(IR)|176|179|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Atenolol 25 mg daily. 2. Decadron 4 mg twice daily. 3. Glucosamine chondroitin. 4. MS Contin 100 mg three times daily with morphine immediate-release (IR) for breakthrough pain as needed. 5. Multivitamins. 6. MiraLax 17-g daily. 7. Senokot-S. 8. Compazine as needed. 9. Coumadin 1 mg daily. CODE STATUS: The patient's code status is DNR-DNI.
IR|immediate-release|IR|138|139|DISCHARGE MEDICATIONS|5) Advair 250/50 one inhalation b.i.d. 6) Singulair 10 mg per day. 7) Ativan 0.5 mg p.o. q a.m. 8) Lexapro 20 mg p.o. q a.m. 9) OxyContin IR 10 mg q4h p.r.n. 10) Tylenol 1,000 mg q4h p.r.n. (max 4 gm per day). 11) Multivitamin one per day. 12) Vitamin E 400 units per day.
IR|interventional radiology|IR|159|160|HOSPITAL COURSE|Radiology was consulted regarding placement of PNT; however, they were unsuccessful in doing so. Therefore, the patient underwent a CT guided PNT placement by IR Radiology. The patient underwent reimplantation of the transplanted ureter on _%#MMDD2004#%_. The patient's hemodialysis was discontinued around _%#MMDD2004#%_. This was secondary to increasing urine output and incremental drop in the patient's creatinine and BUN.
IR|interventional radiology|IR|145|146|HISTORY OF PRESENT ILLNESS|She has been seen by GI and tried on medicine regimen for her symptoms with limited success. There is no evidence of cancer. G-tube placement by IR was attempted today but aborted due to small bowel inhibiting direct access. The patient was then admitted for surgical placement of a feeding jejunostomy.
IR|immediate-release|IR|119|120|DISCHARGE MEDICATIONS|9. Aldactone 50 mg 2 times a day. 10. Prograf 1 mg 2 times a day. 11. MS Contin 30 mg p.o. 2 times a day. 12. Morphine IR 10 mg p.o. q.4 h. p.r.n. DISCHARGE INSTRUCTIONS: 1. Labs on Monday, Wednesday, Friday. 2. Follow up with Pain Service.
IR|interventional radiology|IR|158|159|PHYSICAL EXAMINATION|The rest of the abdomen was soft. Bowel sounds were audible. There was some rigidity in there. By the time I saw the patient, the patient already had gone to IR and got a drain and therefore the drain was intact and draining pinkish serosanguineous fluid. EXTREMITIES: No pedal edema. LABORATORY: Labs performed this morning showed sodium of 136, potassium 3.38, chloride 96, bicarbonate 930, glucose of 109, creatinine of 0.87. LFTs were within normal limits.
IR|interventional radiology|IR|145|146|ASSESSMENT AND PLAN|We will also consult colorectal surgery on Monday. After colorectal surgery has evaluated, the patient during last admission and had recommended IR guided drainage and the patient improved on that. However, because this is recurrence we will ask colorectal surgery to evaluate the patient again to see if they consider surgical resection of part of the small bowel that is involved in the abscess.
IR|interventional radiology|IR|263|264|SOCIAL HISTORY|Assessment 24 yo with end-stage renal disease, hemodialysis dependent, here for dialysis catheter placement, urgent dialysis, and evaluation of acute and chronic joint pain. Joint pain appears to be non-infectious in origin. Plan Catheter placement - Peformed in IR today ESRD, hemodialysis dependent, no dialysis since 4 days ago - Inform nephrology that cath is in place - Dialysis per their recommendation Joint Pain, Knee films negative - X-rays of hands and feet - ESR, CRP, FANA, DS-DNA, rheumatoid factor - PT/OT to evaluate and treat Recent myocardial ischemia - Stress adenosine-thall when stable Discharge plan as reviewed with the pt - Home when stable on dialysis and work-up complete, likely 24-48 hours.
IR|interventional radiology|IR|157|158|HOSPITAL COURSE|After the patient was admitted, she received IV fluids and IV antiemetic medications. She underwent dialysis sterile catheter placement on _%#MMDD2006#%_ by IR to start her hemodialysis. With the renal allograft no longer functioning, Rapamune was stopped and the patient was continued on CellCept and rapid prednisone tapered down.
IR|interventional radiology|IR|210|211|PAST SURGICAL HISTORY|2. Gastric pacemaker placement 2003. 3. Ventral hernia repair with AlloDerm mesh and placement of jejunostomy tube _%#MMDD2007#%_. 4. Dislodgement of jejunostomy tube in mid _%#MM2007#%_ with GJ tube placed in IR on _%#MMDD2007#%_. 5. Left below-knee amputation secondary to infection in 1997. 6. Coronary angiogram _%#MM2003#%_. ALLERGIES: Compazine, erythromycin, Reglan. HOSPITAL COURSE: The patient was admitted to University of Minnesota Transplant Surgery and was treated for dehydration with IV fluids.
IR|interventional radiology|IR|156|157|PROCEDURES PERFORMED|ADMITTING DIAGNOSIS: Infected perihepatic and intrahepatic biloma. DISCHARGE DIAGNOSIS: Infected perihepatic and intrahepatic biloma. PROCEDURES PERFORMED: IR drainage of fluid as well as tube check x 2. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 48-year-old male status post living related liver transplant _%#MMDD2005#%_.
IR|immediate-release|IR|382|383|DISCHARGE MEDICATIONS|14. Lantus insulin 30 units subcu q.h.s. 15. Humalog insulin 1 u per carbohydrate unit plus correction scale t.i.d. p.r.n.: less than 120, 0; 120 to 170, 1 unit; 171 to 220, 2 units; 221 to 270, 3 units; 271 to 320, 4 units; 321 to 370, 6 units, 371-420, 7 units; greater than 420, 8 units and contact physician 16. Zofran ODT 4 to 8 mg sublingual q.4-6h p.r.n. nausea 17. Morphine IR 15 mg p.o. q.4-6h p.r.n. pain DISPOSITION: The patient was discharged in stable condition.
IR|interventional radiology|IR,|220|222|HOSPITAL COURSE|An ultrasound of her pancreas transplant was obtained which showed a small fluid collection surrounding the transplant pancreas with normal arteriovenous flow. She had a percutaneous biopsy of her pancreas transplant by IR, which was a small sample unable to show evidence of rejection or CMV infection or pancreatitis. Therefore, the patient was treated with 500 mg of Solu- Medrol intravenously X3 doses for clinically diagnosed rejection induced pancreatitis.
IR|interventional radiology|IR|179|180|BRIEF HOSPITAL COURSE|Peds Nephrology was following the patient's Epstein-Barr virus PCRs while in house. The patient did respond well to the plasmapheresis and IV Ig. A Quinton catheter was placed by IR for access that was needed for the plasmapheresis. The patient's creatinine trended downward and was 0.82. When the patient started the plasmapheresis and IV Ig she was kept on Cellcept and Neoral.
IR|immediate-release|IR|241|242|HISTORY OF PRESENT ILLNESS|She had been on Morphine Contin routinely and the last dose according to the EMR is on _%#MMDD#%_ at 2200 when she received 30 mg and has not been given since. The nurse actually held the Morphine Contin because of the high dose of Morphine IR that she has been getting. _%#NAME#%_ is complaining of pain over the right peroneal tendon repair where she has a wound VAC and she has pain that is sharp, stabbing, lightning strike, burning type of pain.
IR|immediate-release|IR|150|151|HISTORY OF PRESENT ILLNESS|With calculating the commonality of oral Morphine, the equianalgesic is 114 mg in a 24-hour period. Today, she has received at 0600 60 mg of Morphine IR and at 0900 30 mg of Morphine Immediate Release for a total of 90 mg thus far of oral Morphine. Much of her pain is the same as yesterday; however, she does state that the wound appears more red today than it did yesterday.
IR|interventional radiology|IR|127|128|A/P|Suspect rejection but could just be all chronic changes. Unable to schedule the procedure with ultrasound so will need to have IR do. Will follow the patient with you. -check UA, urine protein/creatinine ratio -check CMV and BK virus -check renal ultrasound with dopplers I was present and participated in this evaluation and agree with the fellow's note above.--_%#NAME#%_
IR|immediate-release|IR|174|175|RECOMMENDATIONS|We will logroll her q.2h. 4. Pain control is going to be a significant problem given her high doses of OxyContin. We will go ahead and restart the OxyContin and give her Oxy IR q.3h. p.r.n. breakthrough pain. 5. We will have spine radiographs taken at some point when she is comfortable and I am going to order an MRI of the lumbar spine so we have more information about her problems.
IR|interventional radiology|IR|236|237|IMPRESSION AND RECOMMENDATIONS|I did discuss this with the hospitalist on staff tonight regarding correcting his INR with fresh frozen plasma is necessary and potentially even platelets if his platelet count drops below 50. I will go ahead and order a scheduling for IR for tomorrow morning in anticipation that we can accomplish these things prior to that. I will ask that CSF be sent for gram stain and bacterial culture as well as complete blood count with differential protein, glucose and HSVPCR.
IR|interventional radiology|IR|138|139|ASSESSMENT/PLAN|The patient was already started on antibiotics and an extensive workup has been started. The patient will be getting a lumbar puncture by IR today, which will be important. He did have a similar presentation last year with a negative MRI. Recommendations were: a. Await lumbar puncture by IR. b. Continue antibiotics.
IR|interventional radiology|IR.|200|202|ASSESSMENT/PLAN|The patient will be getting a lumbar puncture by IR today, which will be important. He did have a similar presentation last year with a negative MRI. Recommendations were: a. Await lumbar puncture by IR. b. Continue antibiotics. c. If workup is negative, consider obtaining a Neurologic Consultation. 2. Nausea and vomiting likely related to viral infection. It is stable at this time.
IR|interventional radiology|IR|141|142|HISTORY OF PRESENT ILLNESS|He was also put on IV antibiotics. With regards to his drains now they are putting out very little fluid. His Primary Service is waiting for IR input regarding whether the drains can be discontinued soon. The patient will continue to have his central wound vac at discharge from this hospitalization however.
IR|interventional radiology|IR,|190|192|ASSESSMENT/PLAN|This is a complex case with the patient presenting with subjective fevers, right upper quadrant pain suggesting recurrent cholangitis. All of her interventions essentially have been done by IR, requiring percutaneous cholangiography with stent placement. The Roux jejunostomy anastomotic dilation was extremely difficult. At this point would favor continued antibiotic therapy, keeping the patient n.p.o., repeating a CT to better evaluate biliary dilatation since CTs have been consistently done in the past and we have a better reference point for looking for evidence of recurrent stricture and dilatation.
IR|interventional radiology|IR|366|367|ASSESSMENT/PLAN|The Roux jejunostomy anastomotic dilation was extremely difficult. At this point would favor continued antibiotic therapy, keeping the patient n.p.o., repeating a CT to better evaluate biliary dilatation since CTs have been consistently done in the past and we have a better reference point for looking for evidence of recurrent stricture and dilatation. Would call IR and have them him involved in the case to see whether they feel repeat percutaneous cholangiography is required.
IR|interventional radiology|IR|159|160|RECOMMENDATIONS|Would call IR and have them him involved in the case to see whether they feel repeat percutaneous cholangiography is required. RECOMMENDATIONS 1. Discuss with IR the need for possible repeat percutaneous cholangiography. 2. Repeat CT with IV contrast. 3. Keep patient NPO. 4. Continue antibiotics. 5. Further recs will depend on CT findings and our recommendations as well.
IR|immediate-release|IR.|176|178|MEDICATIONS|She has also had splenectomy secondary to ITP. She has had some type of what she reports is stent procedure for a DVT. MEDICATIONS: Current presently include OxyContin and Oxy IR. She is on an estrogen patch, Ambien, and Imitrex. ALLERGIES: SHE IS ALLERGIC TO ASPIRIN, CODEINE, ULTRAM, MORPHINE, NUBAIN, DILAUDID.
IR|immediate-release|IR|115|116|ASSESSMENT AND PLAN|In addition, I will repeat a troponin around noon which will be 8 hours after onset. I will start her on diltiazem IR orally as she is not terribly symptomatic at rest and thus I do not think she needs IV medications to control her rate.
IR|immediate-release|IR|354|355|HISTORY OF PRESENT ILLNESS|She has been seen in the chronic pain clinic at United, saw _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ for seven years. She has been on morphine and then was switched to fentanyl and then was switched to fentanyl and morphine and has been on this combination for 2 to 3 years of 100 mcg fentanyl with 60 mg of morphine, Contin t.i.d. and 15 mg of morphine IR with the total of 24 hour dosing of morphine product of 225 mg a day. For her anesthesia for the total knee replacement, she had spinal analgesia and femoral nerve block, then she had PCA morphine, currently it is bolus only and she has used over the last 12 hours 70.8 mg in a 12 hour time period or 141 mg in a 24 hour time period of IV morphine per PCA.
IR|immediate-release|IR|137|138|HISTORY OF PRESENT ILLNESS|She was switched from methadone 5 mg, I believe it was 4 doses a day and was switched over to morphine contin 15 mg b.i.d. with morphine IR 10 mg elixir and she took 2 doses a day. She states that the pain has been very, very debilitating for her.
IR|interventional radiology|IR|195|196|PLAN|The port will most likely to be out if it is not functioning and obviously is the culprit for the clot formation. I talked to Dr. _%#NAME#%_ regarding this issue. He is going to follow up on the IR dye study today and make a final decision regarding the port removal tomorrow. 3. Thyroid nodules with depressed TSH indicating hyperfunctional thyroid nodules.
IR|interventional radiology|IR|159|160|HISTORY OF PRESENT ILLNESS/IDENTIFICATION|The patient admitted to University of Minnesota Medical Center, Fairview, under Dr. _%#NAME#%_'s service. On _%#MMDD2007#%_, the patient had a paracentesis by IR and patient is planned on being discharged today. Our service was asked to come see the patient to outline our service and opportunities that we may have to help her improve quality of life issues for her.
IR|interventional radiology|IR|80|81|PLAN|3. Peristomal probable abscess in the rectus sheath. Rule out fistula. PLAN: 1. IR to drain the fistula. 2. IV antibiotics started. 3. Further assessment to ascertain if this is a fistula starting will be determined with either fistulogram or small bowel studies.
IR|interventional radiology|(IR|183|185|RECOMMENDATIONS|RECOMMENDATIONS: At this point we recommended that Interventional Radiology be consulted for another attempt at more permanent embolization. I had personally spoken to Dr. _%#NAME#%_ (IR staff) and he is on schedule for angiogram tomorrow morning. It is absolutely critical that the _%#CITY#%_ _%#CITY#%_ records head with him to Interventional Radiology.
IR|interventional radiology|IR.|287|289|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient has a history of two intra-abdominal abscesses and was recently hospitalized from _%#MMDD2005#%_ through _%#MMDD2005#%_. During this hospitalization she had a drain placed in posterior fluid collection and anterior fluid collection was drained in IR. CT scans done at the beginning of her stay and at the end of her stay showed that these fluid collections were decreasing in size.
IR|immediate-release|IR|166|167|SUMMARY|He has had Dilaudid .2 to .4 mg IV every 2-4 hours for pain control. He was seen by the pain team who recommended restarting the Duragesic patch as well as oxycodone IR every 3-4 hours for breakthrough pain. An additional problem is an enlarging thoracic aneurysm. Mr. _%#NAME#%_ needs better pain control and I would suggest that he be placed on a Dilaudid drip for titration and will talk with Dr. _%#NAME#%_ regarding this.
IR|internal rotation|IR|199|200|PHYSICAL EXAMINATION|The pain is exactly reproduced with the impingement maneuver. There is decreased internal rotation on passive and assisted range of motion, forward flexion to 160, abduction to 90, ER at 80 degrees, IR at L4, perhaps L3. Elbows negative. Wrists negative. Hoffman sign negative. Tinel and Phalen negative. X-rays of the left shoulder negative for fracture, no subluxation, no significant arthrosis.
IR|interventional radiology|IR|186|187|ASSESSMENT|She arrested in the Interventional Radiology Suites and 20 minutes of CPR was done with numerous medications being administered. I followed this patient and ran her code as well. In the IR Suites, we were unable to reestablish blood flow. She was extremely hypotensive and asystolic, not responsive to external pacing.
IR|interventional radiology|IR|238|239|ASSESSMENT|It is reasonable to try to document this; even if the HIT ELISA is not initially positive, it may turn positive within a few days and the patient may also have a positive serotonin release assay. We will follow the patient along with the IR and ICU teams, in case this proves to be more complicated than it looks at first blush.
IR|interventional radiology|IR.|245|247|A/P|Recommend: 1)kidney and pancreas US tonight 2)pancreatic enzymes: amylase , lipase 3)UA and urine eosynophiles as well as complement levels We will review above study and she will likely need kidney/pancreas biopsy, which will be discussed with IR. Pancreas transplant service has been notified and will follow the results with us.
IR|interventional radiology|IR|254|255|PAST MEDICAL HISTORY|1. Severe cystic fibrosis pulmonary disease. 2. Cystic fibrosis related cirrhosis with portal hypertension. 3. Possible liver mass seen on MRI in _%#MM2007#%_ without finding on ultrasound, previous AFP and CA 19-9 were negative and on further review by IR apparently there was concern that maybe this was in fact just a confluence of vessels. 4. CF-related diabetes. 5. Status post Port-A-Cath placement _%#MM2006#%_.
IR|interventional radiology|IR|219|220|ASSESSMENT AND PLAN|In terms of question of liver mass, I would recommend repeating the MRI to reevaluate as well as to repeat checking the CA 19-9 and AFP. This again May simply have been an anomaly of vasculature as has been reviewed by IR in the past. Finally given the patient's known history of varices it be reasonable to do an EGD after the weekend to do variceal surveillance.
IR|interventional radiology|IR|217|218|HISTORY OF PRESENT ILLNESS/IDENTIFICATION|The patient did have a GI seizure in which a duodenal ulcer was found to be the likely source. Apparently a vessel n this area was clipped. Following this the patient has had recent jejunostomy tube placement with an IR study later this afternoon to confirmed patency. The patient was successfully extubated. Discussion with primary care, _%#NAME#%_, support staff in the ICU has indicated hope that the patient will be able to be transferred home with hospice support.
IR|immediate-release|IR|110|111|MEDICATIONS PRIOR TO ADMISSION|He denies any black or bloody stools. ALLERGIES: Timoptic. MEDICATIONS PRIOR TO ADMISSION: 1. Morphine, 15 mg IR q. 4 hours p.r.n. 2. Pilocarpine. 3. ________. 4. Senna, 4 tablets daily. 5. Ranitidine, 150 mg q. day. 6. Hydrochlorothiazide, 25 mg p.o. q. day. 7. Doxazosin, 4 mg p.o. q. day.
IR|immediate-release|IR|132|133|MEDICATIONS|MEDICATIONS: 1. Paxil 40 mg. 2. Multivitamin and vitamin E. 3. Calcium with vitamin D. 4. OxyContin 20 mg twice a day. 5. Oxycodone IR 5 mg q.i.d. p.r.n. ALLERGIES: Doxepin and Serzone, which cause her to be groggy. Bextra and Vioxx cause headaches. Wellbutrin causes headaches. She is also allergic to sulfa.
IR|immediate-release|IR|133|134|MEDICATIONS|6. Tylenol extra strength p.r.n. 7. Cyclobenzaprine 10 mg p.r.n. 8. Morphine sulfate 2-4 mg IV q. 4 hours p.r.n. 9. Morphine sulfate IR 60 mg tablet p.o. q. 3 hours p.r.n. 10. Nitrostat p.r.n. 11. Zofran p.r.n. 12. Compazine p.r.n. 13. Restoril 30 mg p.r.n. PAST MEDICAL HISTORY: Shingles on the left side of her face with postherpetic neuralgia, migraine headaches, gastric bypass surgery, left ankle surgery, and cellulitis in the leg.
IR|interventional radiology|IR|316|317|IRP|The gallbladder was contracted. On the MRCP, which was also done on _%#MMDD2007#%_ was unremarkable aside from minimal acidic fluid and gallbladder wall thickening likely secondary to his ascites. IRP: 53 y/o male s/p lung transplant who received Sporonox and Valcycte now presents with cholestatic hepatitis. Plan: IR guided liver biopsy today to further evaluate status and stage of liver. Will follow-up with patient in clinic as an outpatient after liver biospy.
IR|interventional radiology|IR|154|155|HISTORY OF PRESENT ILLNESS|He was started on dopamine and eventually norepinephrine. A right subclavian triple lumen was placed but art lines were not able to be placed. He went to IR and as soon as he was decompressed he pinked up and came off the norepinephrine. He was transferred to the ICU at that point. In the ICU, the patient remained hypotensive and unresponsive.
IR|interventional radiology|IR|97|98|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD Consult was given by Dr. _%#NAME#%_, status post IR procedure for diabetic management. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 81-year-old gentleman with a history of diabetes, peripheral vascular disease and coronary artery disease who presents for procedure today with Interventional Radiology.
IR|immediate-release|IR|199|200|ASSESSMENT/PLAN|2. Left lower tooth pain. This is likely secondary to a tooth abscess. We plan to order a dental consult with Dr. _%#NAME#%_ to evaluate the patient's teeth. We have prescribed the patient oxycodone IR and wrote that the patient not have any Tylenol. We also wrote to have the patient on clindamycin 450 mg t.i.d. x 1 week and Peridex rinse to be swished and spit b.i.d. for one week.
IR|immediate-release|IR|189|190|CURRENT MEDICATIONS|6. Upper endoscopy and colonoscopy in _%#MM2003#%_ was negative. 7. Osteoporosis. 8. Pelvic fracture. 9. Anemia. CURRENT MEDICATIONS: 1. Combivent MDI. 2. Megace. 3. Decadron. 4. Oxycodone IR 5. OxyContin. 6. Zantac. 7. Zithromax. 8. Calcium. 9. Dulcolax suppository p.r.n. 10. Zofran. PHYSICAL EXAMINATION: GENERAL: Mrs. _%#NAME#%_ is an elderly female patient appearing her stated age, lying in bed.
IR|interventional radiology|IR|151|152|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 79-year-old female who was admitted today for a percutaneous kidney stone removal procedure done in concert with IR and Dr. _%#NAME#%_. It looks like this procedure went well without complications. I was asked to see here on the eighth floor in the postoperative period for diabetes.
IR|interventional radiology|IR,|129|131|HISTORY OF PRESENT ILLNESS|She is being worked up for possible TB osteomyelitis of the L2-L3 vertebral bodies, or Pott's disease. She had a biopsy today in IR, the results are pending. She has chronic pain issues. Pain consultation was ordered today.
IR|interventional radiology|IR)|203|205|ADDENDUM|Discussed with Dr. _%#NAME#%_ of Neurology and also informally with Pulmonology. Given probable stroke and recent surgery, it is felt that the patient would be too high risk for lytics (peripheral or by IR) if she becomes unstable. Will just treat with heparin. Fortunately, her blood pressures are stable at this tims. I also discussed the plan with the patient and her family.
IR|interventional radiology|IR|148|149|RECOMMENDATIONS|5. Tagged red blood cell scan given he has bleeding at a rate that he may be able to have identified on a tagged red cell scan.If this is positive, IR angiography and treatment would be optimal. 6. Consider transfer to the ICU. 7. Frequent hemoglobin checks. 8. Obtain IV access. This patient was discussed with Dr. _%#NAME#%_ _%#NAME#%_, who participated in the decision making.
IR|interventional radiology|IR|235|236|HISTORY OF PRESENT ILLNESS|It is not clear to me at this time how long the patient was on IV steroids for but these were not on his medication list on transfer and were not continued on transfer here. On transfer here the patient was evaluated by Surgery and by IR and had repeat imaging. The repeat CT report is not yet available but per the chart the CT was reviewed by Surgery and IR and it was felt that the portal vein thrombosis was likely to be chronic and not acute and therefore lytic therapy was not indicated at this time.
IR|interventional radiology|IR|183|184|HISTORY OF PRESENT ILLNESS|On transfer here the patient was evaluated by Surgery and by IR and had repeat imaging. The repeat CT report is not yet available but per the chart the CT was reviewed by Surgery and IR and it was felt that the portal vein thrombosis was likely to be chronic and not acute and therefore lytic therapy was not indicated at this time.
IR|interventional radiology|IR|290|291||A question of infection/abscess in the thyroid is raised, however from review of CT and U/S neck, there is a low suspicion of this. If from infection stand point, there is no other source and patients condition continue to deteriorate, an U/S guided FNA of the thyroid could be obtained by IR while the pt remains in the ICU. Finally, from hypothyroidism stand point, his TSH remains elevated in the 30s despite getting LT4 supplements @200 mcg/d, suggesting possible LT4 malabsorption.
IR|interventional radiology|IR.|130|132|PROCEDURES|3. CT of the brain. 4. Targeted lytic therapy. 5. Urine cultures. 6. Blood cultures. 7. PICC line placement. 8. PNT stitching per IR. 9. IV antibiotics. COMPLICATIONS: None apparent. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 41-year-old female with stage IVA squamous cell carcinoma of the cervix who was seen in clinic on _%#MMDD2007#%_ for followup of recent admission for neutropenic fever.
IR|interventional radiology|IR|168|169|PROBLEM #3|Albumin was 3.1. PROBLEM #3: Heme: Lovenox was discontinued upon admission, the patient was started on high-dose heparin drip so that this could be manipulated for her IR procedure. After demonstration of completing occlusion of the left common iliac vein by CT of the abdomen and pelvis, directed lytic therapy was performed by Interventional Radiology on _%#MMDD2007#%_.
IR|interventional radiology|IR|161|162|PROBLEM #2|The patient was placed on IV vancomycin and IV Zosyn on hospital day #1 secondary to her history of ___________ UTI in the recent past. The patient was taken to IR for removal of her double J stents and placement of retrograde stents for antibiotic flushes. The patient had daily urine cultures and blood cultures for bacteria and yeast that were negative for growth.
IR|interventional radiology|IR|263|264|PROBLEM #5|She was brought down to Interventional Radiology for a therapeutic thoracentesis of the bilateral pleural effusions on _%#MMDD2007#%_ with significant improvement of her symptoms. However, the pleural effusions reaccumulated on _%#MMDD2007#%_ and she returned to IR for bilateral thoroscopy tubes that were placed on _%#MMDD2007#%_. She initially had a large output of serosanguinous fluid, which dropped over the next 24 hours.
IR|interventional radiology|IR|201|202|PROBLEM #5|She initially had a large output of serosanguinous fluid, which dropped over the next 24 hours. Repeat CAT scan on _%#MMDD2007#%_ again suggested large pleural effusions. The patient went back down to IR to have the pigtails repositioned and had about 600 mL from both sides out on _%#MMDD2007#%_. The fluid from the left chest tube began to look cloudy, so interventional radiology sent cultures.
IR|infrared|IR|142|143|PROCEDURES PERFORMED|Non-contrast sagittal MPRAGE axial T2 weighted, proton density, and diffusion weighted; coronal T2 weighted TIRM proton density TRM, and true IR sequences of the brain were obtained. Impression was that there were no T2 abnormalities seen anywhere in the brain parenchyma.
IR|interventional radiology|IR|207|208|HOSPITAL COURSE|She had been on TPN during her hospitalization and was agreeable to this plan as well. In order to provide TPN as an outpatient, Hickman was placed on _%#MMDD#%_. She tolerated that procedure well; however, IR was unable to place the PEG and PEJ during that procedure due to the multiple dilated loops of bowel overlying the stomach.
IR|interventional radiology|IR|244|245|HOSPITAL COURSE|The patient subsequently refused TPA. He did agree to undergo a sinogram and at that time Interventional Radiology did feel that they could adjust his drain so that it would be able to resolve the abscess. The patient subsequently underwent an IR procedure on _%#MMDD2004#%_ in which he underwent replacement of a 14 French locking pigtail catheter into the subphrenic abscess.
IR|interventional radiology|IR|215|216|PROBLEM #4|An echo was obtained on _%#MM#%_ _%#DD#%_, 2004, after a chest x-ray showed increasing heart size. It was negative for pericardial effusion. When performing a vascular ultrasound to place his hemodialysis catheter, IR noticed a clot in his left innominate artery. _%#NAME#%_ did develop hypertension around _%#MM#%_ _%#DD#%_, 2004. At that time, amlodipine was started.
IR|interventional radiology|IR|432|433|BRIEF HISTORY OF PRESENT ILLNESS|The patient had bronchoscopy done at the day of admission by Thoracic Surgery team and they also did mediastinoscopy because they were not able to do a biopsy with a flexible bronchoscopy and they did a biopsy with mediastinoscopy and they put a stent in the left main bronchus because the anterior mediastinum was causing compression on the left main bronchus and thus causing him shortness of breath and respiratory distress. The IR was consulted for possible stenting in SVC considering that he might be developing SVC syndrome giving distended neck veins and _____.
IR|interventional radiology|IR|212|213|HOSPITAL COURSE|IR was consulted and they placed it through SVC and then they placed 3 stents in the superior vena cava. When we did the PET CT scan, we found that lower stent is getting narrower with a blunt loop. We consulted IR again and they redo the SVC stents. The patient continued on anticoagulation during the course. And we did start the patient on therapeutic dose of Lovenox.
IR|interventional radiology|IR.|153|155|HOSPITAL COURSE|Additionally, on hospital day #2, the patient had a CT scan of the abdomen and pelvis revealing multiple intra-abdominal abscesses which were drained by IR. The cultures of which showed Staphylococcus aureus and group D enterococcus. Because of stabilizing vital signs and that the patient was afebrile on _%#MMDD#%_, she was transferred to the medical surgical floor in satisfactory condition.
IR|interventional radiology|IR.|128|130|HOSPITAL DAY #2|General Medicine was consulted for evaluation and treatment of medical issues. HOSPITAL DAY #2: A soft chest tube was placed in IR. Patient drained greater than 3 liters of transudative pleural effusion over the duration of the chest tube. Echocardiogram was completed. HOSPITAL DAY #3: Cardiology Service was consulted for evaluation.
IR|interventional radiology|IR|180|181|PROBLEM #2|The concern of the biopsy is the patient received cisplatin, doxorubicin, and mitomycin during the chemoembolization and the concern is a build up for possibly cisplatin. This per IR again is concerning for future chemoembolization should the patient undergo further in the future. PROBLEM #3: ID. The patient did have evidence of a urinary tract infection during the hospital course and was treated with a 10 day course of levofloxacin.
IR|interventional radiology|IR|183|184|HOSPITAL COURSE|His sputum culture was positive for moderate growth of group D enterococcus and Candida albicans and Candida glabrata. In addition, on _%#MMDD2006#%_ a pigtail catheter was placed by IR for recurrent mediastinal fluid collection and the fluid collection grew group D enterococcus. In addition it also grew Candida glabrata. So the patient was placed on IV vancomycin 1 g b.i.d. In addition, the patient was placed on caspofungin 50 mg IV daily and Levaquin 750 mg in his feeding tube.
IR|interventional radiology|IR|144|145|HOSPITAL COURSE|However, this amount continued to improve throughout her hospital course and there was a small drop in her hemoglobin. Therefore, at that time, IR was contacted and they did perform a left intercostal artery embolization. After that procedure, the patient's hemoptysis was minimal to none by the time of discharge.
IR|interventional radiology|IR|189|190|PROBLEM #6|A Renal consult was also obtained at that time to ensure proper management of the patient's renal failure and to assist the need for dialysis. Bilateral PNTs were then placed per Renal and IR recommendations and the patient had a post-obstructed diuresis. The patient's creatinine slowly decreased. However, she had multiple problems with recurrent infections and dysfunction in the PNTs throughout her hospital stay necessitating the replacement by IR several times.
IR|interventional radiology|IR|221|222|PROBLEM #6|The patient was taught how to perform the flushes prior to discharge and at the time she left the hospital, the patient was planning to do this at home with help of Fairview Home Infusion. The patient will follow up with IR in 2 weeks after discharge for repeat nephrostogram at which time, the size of the hematoma will be reassessed as well the need for continued TPA flushes.
IR|interventional radiology|IR|247|248|DISCHARGE INSTRUCTIONS|The CT of the chest, abdomen, and pelvis with and without contrast was to be done to further evaluate the fluid collection in the area of her lymphocyst and to evaluate any changes in disease status. The patient is also to call and follow up with IR regarding the lymphocyst drainage. The patient is also instructed to call with any increased drainage, increased pain or pain uncontrolled with medications, any increased temperatures, and for any other symptom that was concerning to her.
IR|interventional radiology|IR|177|178|PROCEDURES|8. Persistent cough. 9. Ascites, status post paracentesis x2. PROCEDURES: 1. Abdominal film. 2. Blood culture. 3. Chest x-ray x3. 4. Urine culture. 5. Paracentesis performed by IR x2 without complications. Paracentesis #1 on _%#MMDD#%_, 1800 mL clear fluid aspirated; paracentesis #2 on _%#MMDD#%_ with 1800 mL fluid drained.
IR|interventional radiology|IR|283|284|DISCHARGE DIAGNOSIS|ADMITTING SURGEON: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, M.D. DISCHARGING SURGEON: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, M.D. ADMITTING DIAGNOSIS: Fever status post colostomy takedown. DISCHARGE DIAGNOSIS: Sepsis with intra-abdominal abscess as the infection source. Status post drainage by IR with communication to jejunum. ADMITTING HISTORY AND PHYSICAL EXAM: _%#NAME#%_ _%#NAME#%_ is a 62-year-old male with recent history significant for perforated diverticulitis, which was treated by exploratory laparotomy and sigmoidectomy along with an end descending colostomy and Hartmann's procedure in _%#MM2007#%_.
IR|interventional radiology|IR.|116|118|HOSPITAL COURSE|He was instructed on wound care for his open abdominal wound as well as care of his drain, which had been placed by IR. He was tolerating regular diet, ambulating well without assistance, and it was determined that he would be ready for discharge. DISPOSITION: To home. DISCHARGE INSTRUCTIONS: The patient was instructed on wound care as well as drain flushes with 10 mL of saline twice daily.
IR|interventional radiology|IR|160|161|PROBLEMS|She was tolerating a regular diet at the time of discharge. 5. GI: Constipation medications were given to prevent constipation. 6. GU: The patient was taken by IR to the OR and bilaterally JJ ureteral stents were placed. A Foley was in and blood-tinged urine was noted at the time of discharge.
IR|interventional radiology|IR|135|136|6. GU|Interventional radiology was called regarding stent change, and she is scheduled for a stent change on _%#MM#%_ _%#DD#%_, 2006, at the IR at 0830. 7. ID: As stated, the patient had pyelonephritis and was on ciprofloxacin for 5 days prior to changing into Levaquin.
IR|interventional radiology|IR|141|142|DISCHARGE INSTRUCTIONS|4. Call _%#TEL#%_ with any questions and concerns. 5. The patient had an indwelling IV catheter which was left per the patient's request for IR procedure. 6. To call for signs and symptoms of increased drainage, increased pain, increased swelling, elevated temperature more than 100.4 degree Fahrenheit.
IR|interventional radiology|IR|156|157|ASSESSMENT/PLAN|PROBLEM #5 - History of E. coli sepsis secondary to cholangitis: Patient has a biliary drainage tube in place. She is scheduled to have a cholangiogram and IR on Monday for drain study and evaluation of any source of obstruction and possible treatment. We will continue her Augmentin and vantin she was discharged with for a total of a 2-week course.
IR|interventional radiology|IR|137|138|PROCEDURES PERFORMED|3. Stage IV A squamous cell carcinoma of the cervix, status post radiation therapy with cisplatin potentiation. PROCEDURES PERFORMED: 1. IR evaluation of bilateral PNTs. PNT is found to be patent. 2. IV fluids, 2 L of normal saline infusion plus 125 mL per hour maintenance fluids.
IR|interventional radiology|IR|133|134|ADMISSION HISTORY|The patient was found to have a left frontal lobe hemorrhage on _%#MMDD#%_ and it was thought possibly related to Integrilin for the IR procedure. This has since stabilized. ASA was discontinued. The hospitalization has been complicated by two falls.
IR|interventional radiology|IR|127|128|BRIEF SUMMARY OF ADMISSION|He presents on the following medications: 1. Lipitor 10 mg q.d. 2. Advair 25/50. 3. Atrovent MDI. 4. Aspirin q.d. 5. OxyContin IR p.r.n. for pain. 6. Lorazepam 2 mg p.o. t.i.d. p.r.n. 7. Multivitamin. 8. Prevacid b.i.d. 9. History of multiple courses of prednisone.
IR|interventional radiology|IR.|236|238|ASSESSMENT|Because the hemoglobin has trended to 8.1 we will transfuse with 2 units of packed red cells with Lasix administered in between. We will let GI know that the patient has been admitted, as the initial plan was to discharge her home from IR. We will follow up a hemoglobin in the morning and in the absence of clinical signs of active bleeding we will plan to discharge her home tomorrow.
IR|interventional radiology|IR|155|156|HOSPITAL COURSE|The patient also had noted acute renal failure likely secondary to hypovolemia which was resolving throughout the hospital stay with IV fluid rehydration. IR will change the PNT after her infection is cleared for 48 hours. 4. FEN: The patient was admitted with significant dehydration and was started on IV fluids.
IR|interventional radiology|IR|182|183|HOSPITAL COURSE|However, at that time, a urinalysis was done, which showed a heavy amount of bacteria and urine cultures were sent, and the double Js were not changed out. The patient returned from IR with bilateral ureteral catheters and a Foley catheter. The urine cultures returned as positive for yeast. The patient began having temperature spikes to 103 degrees Farenheit.
IR|interventional radiology|IR|177|178|HOSPITAL COURSE|She was started on fluconazole for yeast in her urine, but the patient continued to have elevated temperature spikes, and was started on linezolid for a positive blood culture. IR was then willing to place double J while the patient continued to have positive urine cultures and so the patient remained in house while waiting for her urine cultures to clear.
IR|interventional radiology|IR,|372|374|HOSPITAL COURSE|During this time the patient's appetite became significantly decreased, and she was started on Procalamine for an albumin of 1.5. The patient was evaluated for depression, but she refused any psychiatric evaluation or antidepressant therapy. After a few days of antibiotic therapy, the patient's temperatures began to normalize. On _%#MMDD2006#%_, the patient was down to IR, and 28 cm double J stents were placed bilaterally. She tolerated this procedure well. Upon return to the floor the patient did have an elevated temperature to 100.8. Her hemoglobin dropped to 7.4; however, the patient remained stable and said that she was feeling well.
IR|interventional radiology|IR|109|110|HOSPITAL COURSE|A GI consult was obtained and they felt that this is likely secondary to a leak around the PEG tube site and IR was consulted and they did take a look. IR did change out her percutaneous gastrostomy tube without complications an d there was no further complication from the G tube as from the PEG tube after this.
IR|interventional radiology|IR|152|153|HOSPITAL COURSE|A GI consult was obtained and they felt that this is likely secondary to a leak around the PEG tube site and IR was consulted and they did take a look. IR did change out her percutaneous gastrostomy tube without complications an d there was no further complication from the G tube as from the PEG tube after this.
IR|interventional radiology|IR|255|256|HISTORY OF PRESENT ILLNESS|These evaluations yielded evidence of multiple DVTs throughout the left lower extremity venous system, and brain imaging suggestive of a stroke. Lower extremity findings prompted transfer to Fairview-University Medical Center for IVC filter placement per IR to prevent a pulmonary embolism. Transfer was also intended to facilitate a Neurosurgical follow-up. Per the medical records, this patient had a history of hospitalizations multiple times in the past for dehydration secondary to acute psychosis.
IR|interventional radiology|IR|207|208|PROBLEM #5|The patient, subsequently, developed blood in his urine. Heparin was eventually discontinued, given his risk of bleeding. PROBLEM #5: Left lower extremity deep venous thromboses. An IVC filter was placed by IR to prevent a pulmonary embolism. The patient's left lower extremity clots were allowed to resolve without treatment. It was impossible to use direct means to rule out the clot, given the patient's cerebral issues.
IR|immediate-release|IR|155|156|DISCHARGE MEDICATIONS|The patient is also to receive clindamycin 300 mg p.o. q.i.d. for 3 days to complete a 1-week course of treatment for her cellulitis. 11. Morphine sulfate IR 15-30 mg p.o. every 4-6 hours p.r.n. FOLLOW UP: Her followup will be in 1 month with Dr. _%#NAME#%_. She does have home care, who will help with needs at home.
IR|immediate-release|IR|230|231|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|The patient did have some difficulty with pain control and for the majority of his stay he was controlled with Dilaudid PCA pump. He was converted to p.o. morphine yesterday, 200 mg sustained release morphine b.i.d. with 30 mg of IR morphine q.6 hours p.r.n. for breakthrough pain. In summary, this is a 67-year-old Caucasian man with a history of diabetes mellitus and chronic lower extremity ulcers, who presented to the ER with fevers and severe back pain.
IR|interventional radiology|IR.|501|503|HOSPITAL COURSE|Problem #2: Pleural effusion. The patient had respiratory distress on _%#MMDD2006#%_, in the context of lactate 12.6, hco3 14, K 6.3, hypotension, hgb decrease to 6.2 necessitating transfer to ICU and a chest tube was placed with drainage of pleural fluid . The chest tube was pulled on _%#MMDD2006#%_ . Although imaging showed reaccumulation of the effusion, she is comfortable on the floor from the respiratory standpoint and so the curent plan is to have her undergo intermittent thoracentesis per IR. Problem #3: Malnutrition. Admission albumin was 3.3 but prealbumin 20 dropping to 11.
IR|interventional radiology|IR|165|166|HOSPITAL COURSE|The patient also did have moderate growth of Bacteroides fragilis seen in the abscess from _%#MM#%_ _%#DD#%_, 2006. The patient was discharged on Timentin for this. IR was reconsulted as her initial CT showed that the drainage catheter did not seem to be in place. They did replace the drainage catheter; followup CT scan showed a resolution of abscess and fluid collection, and the drainage catheter was discontinued.
IR|interventional radiology|IR|210|211|PROBLEM #4|PROBLEM #4: Hip fracture. There was concern that the fluid seen around his hip on his abdomen and pelvic CT represented joint infection. Therefore, Orthopedic Surgery was consulted and x-rays were obtained and IR performed a CT-guided aspirate of the joint fluid. However, this fluid was cultured and did not grow any organisms. Orthopedics felt that the avulsion fracture of the greater trochanter was not a cause for infection, nor was it a cause for his pain.
IR|interventional radiology|IR|187|188|PROBLEM #3|Post nephrectomy blood cultures were negative. Due to persistent abdominal pain, abdominal CT was obtained on _%#MMDD2007#%_ and revealed a left retroperitoneal abscess. JP was placed by IR via CT guidance. Cultures obtained at placement of left flank, JP drain were positive for Klebsiella and intermediate VRE.
IR|interventional radiology|IR|175|176|PROCEDURES|6. On _%#MMDD2007#%_, right shoulder x-ray, no acute osseous abnormality, acromial spurring with postoperative changes of rotator cuff repair. 7. On _%#MMDD2007#%_, attempted IR CT-guided biopsy of right lower lobe lesion with pneumothorax complication and placement of right-sided chest tube. 8. On _%#MMDD2007#%_, removal of right-sided chest tube. 9. On _%#MMDD2007#%_, chest x-ray demonstrating no pneumothorax, status post removal of chest tube.
IR|interventional radiology|IR|114|115|HOSPITAL COURSE|Initially, it was thought to be touching the superior vena cava. The patient had to receive FFP in order to go to IR to have his hemodialysis catheter replaced. After replacement, the tip of the catheter seems to be pretty deep within the right atrium.
IR|interventional radiology|IR|213|214|HISTORY OF PRESENT ILLNESS|It was noted that she had some black tarry stools and an EGD was done on _%#MMDD2007#%_ that showed an ulcer surrounding her PEG tube, but no signs of active bleeding. The patient was transferred to the floor and IR was called who proceeded to loosen her PEG tube in hopes to help give the ulcer some time to heal. The patient had some mild pulmonary edema while on the floor, but essentially remained stable.
IR|interventional radiology|IR|240|241|HOSPITAL COURSE|The duodenum was normal. In light of these results, the patient's Coumadin was held and her lansoprazole was increased to b.i.d. An IR consultation was obtained to evaluate whether the G-tube was irritating the mucosa and causing bleeding. IR loosened the G-tube and recommended that we just take gastric protective measures with medical management, and if this did not improve, their recommendation then would be to try a G-tube.
IR|interventional radiology|IR|112|113|PROBLEM #3|In regards to her CREST syndrome, the patient can no longer swallow and hence has a G-tube that was loosened by IR during this hospital admission. Her tube feeds were started of Nepro 1.5 at 100 mL per hour, which is to continue when she returns to the nursing home.
IR|interventional radiology|IR|161|162|PROBLEM #5|PROBLEM #5: Gastric ulcer: Upon EGD, it was noted that the patient had an ulcer surrounding her G-tube. This is likely secondary to irritation of her G-tube and IR loosened it with further _____ from IR seen in the above problem list. PROBLEM #6: End-stage renal disease: The patient is hemodialysis dependent, which was started very recently.
IR|interventional radiology|IR|200|201|PROBLEM #5|PROBLEM #5: Gastric ulcer: Upon EGD, it was noted that the patient had an ulcer surrounding her G-tube. This is likely secondary to irritation of her G-tube and IR loosened it with further _____ from IR seen in the above problem list. PROBLEM #6: End-stage renal disease: The patient is hemodialysis dependent, which was started very recently.
IR|interventional radiology|IR|161|162|PROBLEM #7|She had then complaining some shortness of breath as well as a slight cough. She denied any sputum production. On the day of admission, the patient underwent an IR procedure for thoracentesis and had a 175 mL drained from her right lung and a chest tube placed on her left side. Her chest tube continued to put out quite a bit for the first couple of days.
IR|interventional radiology|IR|496|497|PROBLEM #7|She then continued to put out around 950 from her chest tube over 24 hours and then dropped dramatically off to 390 mL; however, we felt that this to may have been kinked or occluded secondary to the extreme decrease in pleural fluid drop out, so a chest x-ray was performed, which showed that she still had a moderate sized left pleural effusion and it appeared that the pigtail catheter was then these kinked. The day prior to her discharge, the patient had her pigtail catheter re-adjusted by IR at the bedside. This was done without complications and she tolerated it well. The chest tube was then removed at the patient's request 24 hours after the readjustment.
IR|interventional radiology|IR|247|248|PROBLEM #11|They both stated that they would recommend a bronchoscopy at this time as that is a very invasive procedure and the patient was really without complaints then maintaining normal oxygen saturation on room air. Therefore it was decided to just have IR drained her pleural effusion. The patient did improve drastically after the chest tube in her left lung was placed and on repeat chest x-ray, it did not show any further mucus or bronchus plugging.
IR|interventional radiology|IR.|157|159|INITIAL PRESENTATION|Over the last several months, he was admitted through the Hematology Oncology Service after having a chemoembolization of the left lobe of the liver done in IR. The symptoms of which we are speaking are flushing, syncope and diarrhea. He had undergone chemoembolization in _%#MM2005#%_ as well. He was on sandostatin to control his symptoms.
IR|interventional radiology|IR|140|141|PLAN|Check CRP. I did discuss the case with GI and conservative management for now until pseudocysts form maybe better. We might need to talk to IR tomortow to see if they recommend drainage once our CT here is obtained. IR is unable to review the scan ay CDI _%#CITY#%_ _%#CITY#%_.
IR|interventional radiology|IR|216|217|PLAN|Check CRP. I did discuss the case with GI and conservative management for now until pseudocysts form maybe better. We might need to talk to IR tomortow to see if they recommend drainage once our CT here is obtained. IR is unable to review the scan ay CDI _%#CITY#%_ _%#CITY#%_. I suspect this fluid explains her bloating. 2. For gentle bloating and distention, we will check a Clostridium difficile and stool studies.
IR|interventional radiology|IR|183|184|HISTORY OF PRESENT ILLNESS|Now there was a new left paraaortic lymph node above the aortic bifurcation on this scan. There was also significant increase in the size off the hilar lymphadenopathy. At this time, IR was consulted to review the scan to determine if the periaortic lymph node was able to be biopsied. Unfortunately, per Interventional Radiology, they were unable to do this due to size and location of the lymph node.
IR|interventional radiology|IR|155|156|HOSPITAL COURSE|The patient also had noted acute renal failure likely secondary to hypovolemia which was resolving throughout the hospital stay with IV fluid rehydration. IR will change the PNT after her infection is cleared for 48 hours. 4. FEN: The patient was admitted with significant dehydration and was started on IV fluids.
IR|interventional radiology|IR|89|90|CODE STATUS|Home PT with front wheeled walker. DIET: Regular diet. CODE STATUS: Full code. CONSULTS. IR and vascular surgery. SUMMARY OF HOSPITALIZATION: _%#NAME#%_ _%#NAME#%_ is a 60-year-old gentleman admitted by myself.
IR|interventional radiology|IR|180|181|PROBLEM #5.  HIV|There were no issues with her dialysis graft and no issues arose. PROBLEM #7. Subclavian Deep venous thrombosis (DVT): On initial presentation to the hospital, the patient went to IR and had her left subclavian angioplasty and thrombectomy with resolution of the subclavian deep venous thrombosis. It was felt at that time she may need revision of her dialysis graft, however, subsequent dialysis runs revealed no difficulty with the graft and therefore, no further evaluation was required.
IR|interventional radiology|IR|283|284|PROBLEM #5.  HIV|It was felt at that time she may need revision of her dialysis graft, however, subsequent dialysis runs revealed no difficulty with the graft and therefore, no further evaluation was required. PROBLEM #8. Hypertension: The patient was initially admitted to the medicine team through IR with a blood pressure of 174/113. Metoprolol and clonidine were started, however, this was considered to be most likely due to volume overload and in need of dialysis.
IR|interventional radiology|IR|128|129|FOLLOW UP|4. The patient will call the clinic should he develop any signs of fever, increased pain, or difficulty with his G-tube. 5. Per IR recommendations, the patient should schedule the removal of his T-tach sutures in 7 to 10 days following the placement of his G-tube, which was on _%#MM#%_ _%#DD#%_, 2005.
IR|immediate-release|IR|139|140|PALLIATIVE SUMMARY|Given the variability of the patient's opioid use, starting with a somewhat lower dose range would be appropriate with continued oxycodone IR for breakthrough and subsequent titration as needed. I would recommend starting at 25 to 37.5 mcg of Duragesic every 72 hours and use 5-10 mg of oxycodone immediate release every 2 hours as needed for breakthrough pain.
IR|immediate-release|IR|189|190|RECOMMENDATIONS|If the patient refuses th e above, would recommend discontinuing IV Dilaudid and starting OxyContin at 500 mg every 8 hours, as per calculated current use as noted. Fifteen mg of oxycodone IR can be used every 2 hours as needed for breakthrough pain. Will attempt to try to find the patient in her room later today or tomorrow and discuss the above with her when she is available.
IR|interventional radiology|IR|211|212|HISTORY OF PRESENT ILLNESS|He has subsequently been admitted and treated for what was thought to be aspiration pneumonia, advancing lung cancer, not thought to be a candidate for any further chemotherapy or radiation. Consults to ENT and IR have occurred in regards to consideration of his trach site, and also possibility of G-tube placement. We were consulted given the overall constellation of his disease and continued decline.
IR|interventional radiology|IR.|154|156|HOSPITAL COURSE|5. BPH. He will continue on oxybutynin. 6. Atrial fibrillation. Patient will continue on Coumadin. 7. Popliteal aneurysm. The patient will follow up with IR. He was felt not to be an appropriate surgical candidate at this time 8. Anemia. The patient has multifactorial anemia. Chronic disease is playing a role, however, he has elevated MCV, so he was started on B12 and will have a B12 level checked by his primary care MD at the next follow-up visit.
IR|immediate-release|IR,|170|172|HOSPITAL COURSE|I had the hospitalist see him for that purpose but he basically did well. We had some problems with pain control. We got that corrected as well with the use of oxycodone IR, and at the time of discharge he was eating, and his wounds were clean and dry. For a list of discharge medications, please see the discharge summary.
IR|immediate-release|IR|121|122|ASSESSMENT AND PLAN|Patient reports that her pain is not controlled on her current dose of Vicodin. The patient will be started on oxycodone IR 10-15 mg p.o. q. 3 hours p.r.n. pain. The patient is medically stable to be discharged to home. The patient is to follow up with her regular MD for any further problems.
IR|immediate-release|IR|258|259|SUMMARY|On examination the right lung is clear. Chest x-ray shows reflection of the mediastinum to the left and the air fluid level is decreasing with increase of left pleural fluid, as expected. OxyContin 20 mg one p.o. q 12 hours, q 8 a.m., 8 p.m., #60, oxycodone IR 5 mg one to two every four hours p.r.n., #80. Motrin 600 mg p.o. q.i.d., #120 was prescribed at the time of dismissal.
IR|immediate-release|IR|208|209|RECOMMENDATIONS|RECOMMENDATIONS: 1. Discontinue Detrol-LA, which may be worsening retention. 2. Trial of urecholine 25 mg p.o. t.i.d. and discontinue if urinary retention does not improve. 3. Use currently ordered oxycodone IR 10-20 mg every 2 hours for shortness of breath p.r.n. as well as for pain. Increase Duragesic dose if he requires frequent dosing for comfort.
IR|immediate-release|IR|167|168|MEDICATIONS|8. Lidoderm, which has not worked. 9. Ativan. 10. Cozaar 100 mg once a day. 11. Lopressor 50 mg once a day. 12. Morphine Contin 25 mg one every 12 hours. 13. Morphine IR 10 mg every 1-2 hours p.r.n. 14. Protonix 40 mg once a day. 15. Dilantin 200 mg once a day. 16. Dilantin 300 mg at bedtime. 17. Restoril 15 mg at bedtime.
IR|immediate-release|IR.|139|141|PLAN|PLAN: 1. Intractable abdominal pain. Again, likely secondary to metastatic disease. Admission for pain control with MS Contin and morphine IR. IV fluids and antiemetics on a p.r.n. basis. 2. Widely spread metastatic breast cancer. At this time, contemplation for palliative chemotherapy per Oncology.
IR|immediate-release|IR|295|296|ADMISSION MEDICATIONS|PAST SURGICAL HISTORY: Surgical history includes a total abdominal hysterectomy (TAH) with bilateral salpingo-oophorectomy (BSO), tonsillectomy, appendectomy, and varicose vein stripping. ADMISSION MEDICATIONS: Medications at the time of admission include: 1. MS Contin 45 mg b.i.d. 2. Morphine IR (immediate-release) 10-20 mg q.12h. as needed for breakthrough pain. 3. Dilantin. 4. Senokot. 5. Colace. 6. Compazine. 7. Multivitamin.
IR|immediate-release|IR|111|112|MEDICATIONS|8. Prostate cancer with prostatectomy and/or radiation implants. ALLERGIES: Timoptic. MEDICATIONS: 1. Morphine IR 15 mg q. 4 hours p.r.n. 2. Pilocarpine eye drops. 3. Senna 4 daily. 4. Ranitidine 150 mg p.o. q. day. 5. Hydrochlorothiazide 25 mg q. day. 6. Doxazosin 4 mg q. day.
IR|immediate-release|IR|191|192|DISCHARGE MEDICATIONS|9. Albuterol MDI 2 puffs q.2 hourly as needed for shortness of breath or wheezing. 10. Allopurinol 300 mg p.o. once daily for 10 more days. 11. MS Contin 15 mg p.o. q.12 hourly. 12. Morphine IR 15 mg p.o. every 4 hours as needed for breakthrough pain. 13. Robitussin with Codeine 5 to 10 mL p.o. every 4 hourly as needed for cough.
IR|immediate-release|IR|164|165|DISCHARGE MEDICATIONS|3. Pantoprazole 40 mg p.o. q. day. 4. Compazine 10 mg p.o. q.6 hours p.r.n. nausea. 5. Senokot 2 tablets p.o. nightly. 6. Morphine ER 15 mg p.o. b.i.d. 7. Morphine IR 15 mg p.o. q.4 hours p.r.n. pain. 8. Albuterol inhaler 2 puffs q.4 hours p.r.n. shortness of breath. 9. Furosemide 40 mg p.o. b.i.d. 10. Potassium chloride 40 mEq p.o. q. day.
IR|immediate-release|IR|153|154|DISCHARGE MEDICATIONS|10. Magnesium oxide 800 mg p.o. t.i.d. 11. Ambien 5 mg p.o. q.h.s. p.r.n. insomnia. 12. Lorazepam 1 mg p.o. a.c. 30 minutes prior to meals. 13. Morphine IR solution 10 mg/ml 0.5-1 cc p.o. q. 2 h p.r.n. pain. 14. Norvasc 2.5 mg p.o. daily. 15. Senna-S one p.o. daily p.r.n. constipation. 16. Reglan 10 mg p.o. t.i.d.
IR|immediate-release|IR.|99|101|MEDICATIONS|PAST MEDICAL HISTORY: 1. Hepatitis C. 2. Appendectomy as a child. MEDICATIONS: 1. MS Contin. 2. MS IR. ALLERGIES: No known drug allergies. FAMILY HISTORY OF CANCER: None. SOCIAL HISTORY: The patient just quit tobacco use this week.
IR|immediate-release|IR|136|137|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Premarin 0.625 mg p.o. q.d. 2. Colace 100 mg p.o. b.i.d. 3. Senokot one to four tabs p.o. b.i.d. p.r.n. 4. MS IR 15 mg p.o. q.4-6h. p.r.n. 5. Tylenol 500 mg p.o. q.4-6. p.r.n. 6. Ciprofloxacin 500 mg p.o. b.i.d. x 2 weeks. 7. Chlorophyll 3 mg tabs one per vagina q.d.
ITP|idiopathic thrombocytopenic purpura|ITP.|164|167|PAST MEDICAL HISTORY AND PAST SURGICAL HISTORY|The patient denies fevers, chills, nausea, vomiting, pain or other bleeding other than his oropharyngeal mucosa. PAST MEDICAL HISTORY AND PAST SURGICAL HISTORY: 1. ITP. 2. Splenectomy. 3. Insulin dependent diabetes. SOCIAL HISTORY: No tobacco. No ethanol. He lives with his wife. No children. FAMILY HISTORY: Mother has a history of ITP.
ITP|idiopathic thrombocytopenic purpura|ITP|307|309|PAST MEDICAL HISTORY|GBS negative. GCT 101. Hemoglobin 13.7. PAST OBSTETRIC HISTORY: Significant for NSVD at 36 weeks, induction secondary to IPT with 7 pounds 15 ounces, this was complicated by postpartum hemorrhage. PAST GYNECOLOGIC HISTORY: Significant for chlamydial infection in 2005. PAST MEDICAL HISTORY: Significant for ITP and history of urinary tract infections. PAST SURGICAL HISTORY: None. SOCIAL HISTORY: She denies any tobacco or alcohol or drug use.
ITP|idiopathic thrombocytopenic purpura|ITP.|192|195|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: 1. She is to follow up with her primary OB for a postpartum visit as well as discussion of contraception. 2. She is to follow up with her hematologist for follow up of ITP. 3. She is instructed nothing in vagina for 6 weeks and to call the clinic for temperature greater than 100.4 degrees, heavy vaginal bleeding, pain not controlled with medications or with other concerns.
ITP|idiopathic thrombocytopenic purpura|ITP.|162|165|IMPRESSION|Troponin less than 0.04. Myoglobin 33. N-terminal proBNP 98. IMPRESSION: 1. AICD discharged. 2. Severe ischemic heart disease. 3. Chronic thrombocytopenia due to ITP. 4. Hypertension. 5. Diabetes mellitus. 6. Mild acute renal failure. PLAN: Will rule out for myocardial infarction with serial troponin.
ITP|idiopathic thrombocytopenic purpura|ITP.|206|209|ASSESSMENT AND PLAN|The patient has received betamethasone on _%#MMDD#%_ and _%#MMDD#%_. 3. Positive group B strep. Penicillin has been started. 4. Fetal status, reassuring tracing. Footling breech presentation. 5. History of ITP. Platelets normal throughout this pregnancy and 218 most recently on _%#MMDD2007#%_. 6. History of HSV. Will need Valtrex suppression if preterm labor does not progress.
ITP|idiopathic thrombocytopenic purpura|ITP|142|144|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 88-year-old man with a history of left nephrectomy in 1986, recent diagnosis of acute ITP in _%#MM2006#%_. His presentation was that he had a platelet count of 41,000 and rapidly progressed with a decline down to 15,000.
ITP|idiopathic thrombocytopenic purpura|ITP,|196|199|COURSE IN THE HOSPITAL|The patient was instructed to stay off Coumadin until further notice. Reinstitution of Coumadin would be based on normalization of the platelet count. Dr. _%#NAME#%_ felt that this was clinically ITP, and that unless there was failure to quickly normalize the platelet count, the bone marrow was not needed at this point, but it could be done as an outpatient.
ITP|idiopathic thrombocytopenic purpura|ITP.|156|159|DISCHARGE DIAGNOSIS|2. Respiratory failure related to altered mental status, in turn secondary to medications. 3. Hematuria related to surgery and thrombocytopenia. 4. Chronic ITP. 5. UTI. 6. Acute renal insufficiency, prerenal. 7. Anemia, multifactorial. 8. Class III CHF. CHRONIC DIAGNOSES: 1. Coronary artery disease.
ITP|idiopathic thrombocytopenic purpura|ITP|216|218|HISTORY OF PRESENT ILLNESS|He had no particular obvious clues on exam and his laboratory tests were most prominent for pancytopenia that included white count going into the 2000 range, platelet count into the 30,000-60,000 range. He has known ITP and prior splenectomy, so this was not surprising in general. He eventually among his workup had a bone marrow exam done which did not show obvious bone marrow disease.
ITP|idiopathic thrombocytopenic purpura|ITP.|174|177|PAST MEDICAL HISTORY|PICC line placed _%#MMDD2006#%_. Previous fall _%#MMDD2006#%_. Penetration with thin and nectar liquids suggest phase II diet. PAST MEDICAL HISTORY: 1. Anaplastic anemia. 2. ITP. 3. UTI. 4. Breast CA type 2. 5. Diabetes. 6. Hypertension. 7. Obesity. 8. Overactive bladder. 9. Depression. 10.CAD. 11.Cognitive changes. 12.Impaired ADLs.
ITP|idiopathic thrombocytopenic purpura|ITP|260|262|BRIEF HISTORY OF PRESENT ILLNESS|RELEVANT TESTS, PROCEDURES AND CONSULTATIONS: The patient received intravenous Ig 30 grams twice as treatment for her thrombocytopenia related to her chronic ITP. BRIEF HISTORY OF PRESENT ILLNESS: The patient is a 37-year- old female with a history of chronic ITP who presented to the emergency room on the day of admission after noticing petechiae on her feet and ankles bilaterally.
ITP|idiopathic thrombocytopenic purpura|ITP.|156|159|ADMISSION DIAGNOSIS|PAST MEDICAL HISTORY: 1. Ischemic cardiomyopathy status post heart transplant in _%#MM#%_ 2003. 2. Lupus x20 years. 3. Status post splenectomy secondary to ITP. 4. Three to four pacemakers have been placed and removed. 5. Status post aortic valve replacement in his native heart secondary to bacterial endocarditis.
ITP|idiopathic thrombocytopenic purpura|ITP|120|122||She had a positive herpes lesion at the time of labor. She also had a history of idiopathic thrombocytopenia purpura or ITP and her platelets were 179,000 on admission. She underwent a primary low segment transverse cesarean section, delivering a viable female infant, weighing 5 pounds 14 ounces, with Apgars of 6 at 1 minute and 9 at 5 minutes.
ITP|idiopathic thrombocytopenic purpura|ITP.|157|160|BRIEF PAST MEDICAL HISTORY|For further details, please see the history and physical dated _%#MM#%_ _%#DD#%_, 2005, by Dr. _%#NAME#%_ _%#NAME#%_. BRIEF PAST MEDICAL HISTORY: History of ITP. Was treated with IgG and has been in remission since 1999. HOSPITAL COURSE: Intermittent gross hematuria with proteinuria. The patient underwent a renal biopsy as stated above without any complications.
ITP|idiopathic thrombocytopenic purpura|ITP.|213|216|HOSPITAL CONSULTATIONS|DOB: ADMISSION DIAGNOSIS: Below the knee amputation, left for chronic non-union, mal-union. HOSPITAL CONSULTATIONS: Physical therapy for gait training, anesthesia for pain management, hematology for management of ITP. HOSPITAL COURSE: There were no postoperative complications. She had an uneventful course, please see hospital chart for details.
ITP|idiopathic thrombocytopenic purpura|(ITP).|105|110|ASSESSMENT/PLAN|Start Rocephin 1 gm q.24h. Close observation with follow-up labs. 2. Idiopathic thrombocytopenic purpura (ITP). Platelet count now is acceptable at 71,000. Will just follow this clinically. No need for steroids or other interventions at this point.
ITP|idiopathic thrombocytopenic purpura|ITP,|189|192|HOSPITAL COURSE|His urine analysis showed 589 white blood cells. HOSPITAL COURSE: He was admitted to the Medicine Service for investigation of thrombocytopenia. Our initial differential diagnosis included ITP, HUS, TTP, sepsis, and malignancy. We obtained hematology consult to help us with the thrombocytopenia.
ITP|idiopathic thrombocytopenic purpura|ITP.|97|100|HOSPITAL COURSE|He received 1 unit of platelets with a minimal response. (_______________) He was diagnosed with ITP. Hematology treated him with steroids with good response. MAINTENANCE BY SYSTEMS: 1. Hematology. He was diagnosed with ITP, immune thrombocytopenic purpura.
ITP|idiopathic thrombocytopenic purpura|ITP,|163|166|MAINTENANCE BY SYSTEMS|(_______________) He was diagnosed with ITP. Hematology treated him with steroids with good response. MAINTENANCE BY SYSTEMS: 1. Hematology. He was diagnosed with ITP, immune thrombocytopenic purpura. This diagnosis came after excluding HUS and TTP as he had no hemolysis on his peripheral smear. Sepsis was excluded as his blood pressures were negative. Malignancy was excluded as the bone marrow biopsy was negative for that.
ITP|idiopathic thrombocytopenic purpura|ITP,|282|285|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Intoxication. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 45-year-old female with a history of suicide attempt in the past, alcoholism, depression, hepatitis C with failed interferon and ribavirin treatment, hypothyroidism, hypertension, splenectomy for ITP, who presents with intoxication. Evidently she was at Applebee's and had 4+ shots of alcohol. She admitted to drinking at least a half a pint of Schnapps prior to even arriving at Applebee's.
ITP|idiopathic thrombocytopenic purpura|ITP,|225|228|PAST MEDICAL HISTORY|She was released from treatment in _%#MM#%_ 2004. It sounds like she has had also recent stay in _%#MM2006#%_. Hepatitis C, failing interferon and ribavirin treatment, hypothyroidism and hypertension, splenectomy in 1980 for ITP, uterine fibroids. She had a hospitalization 2003 to _%#MM#%_ 2004 for left thigh abscess after a stab wound. Then she had another one on _%#MMDD2005#%_ for left thigh stab wound and cellulitis hospitalization on _%#MMDD#%_ through _%#MMDD2005#%_ for erythema and swelling in her left lower leg which is when I saw her at that time.
ITP|idiopathic thrombocytopenic purpura|ITP|205|207|ASSESSMENT|ASSESSMENT: 1. Atrial flutter duration possibly up to a week or so. He is minimally symptomatic from this. 2. Stable coronary disease without active ischemia or angina. 3. Well controlled hypertension. 4. ITP with his most recent platelet count yesterday being 200,000, on steroids. 5. Steroid worsened type II diabetes with less glycemic control.
ITP|idiopathic thrombocytopenic purpura|(ITP)|73|77|CHIEF COMPLAINT|DOB: _%#MMDD1943#%_ CHIEF COMPLAINT: Idiopathic thrombocytopenic purpura (ITP) with inability to wean off steroids. HISTORY: Mrs. _%#NAME#%_ developed idiopathic thrombocytopenic purpura in about _%#MM#%_ when she presented with multiple bruises and a very low platelet count.
ITP|idiopathic thrombocytopenic purpura|ITP|266|268|HISTORY|The patient was noted to have a large uterus and had a CT scan of the abdomen which shows several fibroids in the uterus, the largest measuring approximately 7.3 cm in diameter. The remainder of the abdomen appeared normal. The patient of note also has a history of ITP treated with transfusions and splenectomy resulting in Hepatitis C infection. The patient's menstrual cycles occur monthly, lasting for 6 to 7 days with passage of clots and using pads frequently.
ITP|idiopathic thrombocytopenic purpura|ITP|177|179|HISTORY OF PRESENT ILLNESS|She has no chest pain, no lightheadedness, no cough, no fever or chills. She does feel fatigued, however. PAST MEDICAL HISTORY: 1. Lupus SLE diagnosed in 1988 with a history of ITP and decreased platelets. 2. History of TIAs. 3. Status post left knee arthroscopy. 4. Status post right ankle surgery for fracture. 5. History of osteoporosis/osteopenia secondary to steroids.
ITP|idiopathic thrombocytopenic purpura|ITP.|147|150||Patient had two episodes of sinus tachycardia 20 minutes after the use of Tequin, lasting approximately one hour. Patient has a history of chronic ITP. There were no bleeding complications during the course of his hospitalization. IMPRESSION: 1. Degenerative arthritis with subsequent right total knee replacement.
ITP|idiopathic thrombocytopenic purpura|ITP|163|165|PAST MEDICAL HISTORY|She presented to F-UMC ED for shortness of breath and cough x 2 days, and had been using a friend's albuterol MDI and Tylenol for relief. PAST MEDICAL HISTORY: 1. ITP 1998 diagnosed secondary to bruising. 2. Hyperthyroidism: received radioactive iodide _%#MM#%_ _%#DD#%_, had negative UPT at the time. She has not had further treatment since. 3. Asthma: diagnosed in 1997, two hospitalizations no intubations, multiple ED visits, has no meds currently.
ITP|idiopathic thrombocytopenic purpura|ITP|80|82|PROBLEM #5|May follow up with blood glucose in clinic at Smiley's and with OB. PROBLEM #5: ITP history: No symptoms while in the hospital, no symptoms in months. Follow-up p.r.n. if symptoms develop. PROBLEM #6: OB/GYN: MFM to follow high risk pregnancy.
ITP|idiopathic thrombocytopenic purpura|ITP,|61|64|HISTORY OF PRESENT ILLNESS|She does not use a cane or walker to ambulate. As far as her ITP, she has had no problems with bruising or ease of bleeding. Her platelets chronically run low between 7,000 and 20,000. SOCIAL HISTORY: She is divorced and has two grown children.
ITP|idiopathic thrombocytopenic purpura|ITP|145|147|REVIEW OF SYSTEMS|RESPIRATORY: Negative. GI: Negative. URINARY: History of urge incontinence, which has been chronic. No recent urinary symptoms. HEME: History of ITP without recent bleeding problems. ENDOCRINE: Hypothyroidism, well controlled on medication. MUSCULOSKELETAL: No weakness, numbness of extremities or face which is abrupt in onset.
ITP|idiopathic thrombocytopenic purpura|ITP.|399|402|HISTORY OF PRESENT ILLNESS|The patient was DNR/DNI. At the time of this readmission, this probably constitutes metastatic prostate cancer, with last chemotherapy given about two weeks ago; hypercoagulable state of malignancy; acute embolic stroke on _%#MMDD2002#%_, treated on Coumadin, with INR of 2.64 on _%#MMDD2002#%_; thrombocytopenia; secondary metastatic disease involving bone marrow, chemotherapy, and a component of ITP. Platelet count on _%#MMDD2002#%_ was noted to be 23,000. At this time of presentation, the patient appeared with liver insufficiency with ALT 671, AST 457, alkaline phosphatase 130, creatinine 1.3, and calcium 7.9. HOSPITAL COURSE: Platelet transfusions and FFP were given in the emergency room.
ITP|idiopathic thrombocytopenic purpura|ITP.|169|172|PAST  MEDICAL HISTORY|1. Alcoholism. a. Patient finished treatment in _%#MM2005#%_ but relapsed because she states that she did not get a sponsor. 2. Hypertension. 3. Splenectomy in 1980 for ITP. 4. Hysterectomy for fibroids. 5. History of exploratory laparotomy. 6. Hepatitis C with failed ribavirin and interferon therapy. 7. Appendectomy. 8. Hypothyroidism. 9. Dementia. 10.Depression. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 45-year-old woman who is known to this hospital from previous admission in _%#MM2003#%_ and _%#MM2004#%_ when she was in for left thigh abscess and cellulitis.
ITP|idiopathic thrombocytopenic purpura|ITP|248|250|PAST MEDICAL HISTORY|He was given nitroglycerin and morphine sulfate, a couple of doses, with which his pain did decrease down to 1, but was placed on nitro paste. PAST MEDICAL HISTORY: 1. Coronary artery disease, details as above. 2. Hypertension. 3. Dyslipidemia. 4. ITP with a hemoglobin of 12.9 and platelets of 156,000 on _%#MMDD2006#%_. 5. Polymyalgia, biopsy proven approximately 10 years ago, has been stable on prednisone 5 mg.
ITP|idiopathic thrombocytopenic purpura|ITP,|159|162|IMPRESSION/PLAN|Will go ahead and evaluate this with a CT of the chest and an echo to rule out possible pericarditis, and will also get a sed rate. 3. History of polymyalgia, ITP, hyperlipidemia, hypertension, stable, continue the same medications.
ITP|idiopathic thrombocytopenic purpura|ITP|165|167|FAMILY  HISTORY|MEDICATIONS: She reports uses multivitamins, calcium with vitamin D supplements, vitamin E, fish oil, vitamin C supplements. FAMILY HISTORY: Includes a diagnosis of ITP in the patient's mother who is currently 80. The patient's father was deceased at age 84 from heart disease. She has three sisters and one brother. Of note, all of her sisters and her mother apparently have had problems with rapid heart rates in the past.
ITP|idiopathic thrombocytopenic purpura|ITP|194|196|HISTORY OF PRESENT ILLNESS|ADMITTING DIAGNOSES: 1. Chronic idiopathic thrombocytopenic purpura. 2. Left retinal detachment. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 63-year-old female with a history chronic ITP with a baseline platelet level around 10,000. She was admitted on _%#MM#%_ _%#DD#%_, 2006, for an ophthalmologic procedure due to a left retinal detachment.
ITP|idiopathic thrombocytopenic purpura|ITP.|132|135|HOSPITAL COURSE|She did have significant injection to her left eye, but the pupil was round and reactive to light at that time. HOSPITAL COURSE: 1. ITP. We did administer IVIG on _%#MM#%_ _%#DD#%_, 2006, in the evening. This went without incident. She was premedicated with Tylenol No. 3 and Mirapex 0.25 mg.
ITP|idiopathic thrombocytopenic purpura|ITP.|175|178|PAST MEDICAL HISTORY|He subsequently presented to the Emergency Room and I am seeing him in the Emergency Room at this point in time. PAST MEDICAL HISTORY: 1. CLL, currently stable. 2. History of ITP. 3. Coronary artery disease, status post LAD stent. 4. Total right hip. 5. History of prostate cancer, currently receiving Lupron shots. ALLERGIES: No known drug allergies.
ITP|idiopathic thrombocytopenic purpura|ITP|112|114|ASSESSMENT|Urinalysis negative. Pregnancy test negative. Platelet count 4000. ASSESSMENT: 1. Thrombocytopenia, most likely ITP with a platelet count of 4000. 2. Microcytic hypochromic anemia with iron deficiency, possibility of thalassemia. 3. Hypothyroidism. 4. Polymenorrhea. PLAN: Admit the patient. She already got the loading dose of Solu-Medrol.
ITP|idiopathic thrombocytopenic purpura|ITP.|214|217|PAST MEDICAL HISTORY|1. Chronic prolymphocytic leukemia as in HPI since _%#MM#%_ 2002. 2. History of ascites, responded to treatment with Lasix, Aldactone and chemotherapy. 3. History of heparin-induced thrombocytopenia. 4. History of ITP. 5. History of anemia, leukopenia and transfusions in the past.
ITP|idiopathic thrombocytopenic purpura|(ITP).|164|169|HOSPITAL COURSE|7. Dementia, unchanged during this hospitalization, on Aricept. 8. Asplenia. The patient is asplenic secondary to management of idiopathic thrombocytopenic purpura (ITP). Stable elevated platelet counts as one would expect. No other changes so far to suggest any worsening of ITP. DISCHARGE MEDICATIONS: 1. Norvasc 5 mg q.d. 2. Aspirin 81 mg q.d.
ITP|idiopathic thrombocytopenic purpura|ITP.|201|204|PAST MEDICAL HISTORY|3. Bactrim, GI upset. PAST MEDICAL HISTORY: 1. History of systemic lupus erythematosus, diagnosed at age 21 with CNS and PNS involvement. No renal involvement at this time. 2. Rheumatoid arthritis. 3. ITP. 4. L3-L4 fusion secondary to five herniated disks and DJD. 5. Migraine headaches. 6. Endometriosis. 7. Stroke at age 21.
ITP|idiopathic thrombocytopenic purpura|ITP|173|175|PROBLEM #3|Spontaneous resolution of her thrombocytopenia is expected if it is secondary to drug reaction. A post transfusion purpura is a remote alternative and the onset of ordinary ITP at this point would be a startling coincidence. Although these etiologies are unlikely, she was started on prednisone 45 mg p.o. q day.
ITP|idiopathic thrombocytopenic purpura|ITP|365|367|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: He has chronic dermatitis to the scalp and to the body for the last three years, has seen multiple dermatologists, currently followed at Mayo Clinic along with the chronic right tinea pedis that is being followed there. He denies any significant visual or hearing problems. No significant respiratory or cardiac problems. HEMATOLOGIC: He has had ITP since 1993, has had a splenectomy, has had previous platelet and immunoglobulin transfusions. His platelet count currently is higher than it has been in years, he states.
ITP|idiopathic thrombocytopenic purpura|ITP|256|258|IMPRESSION|Hemoglobin is 16.3. Platelet count is 185,000. Basic metabolic panel was within normal limits except for an elevated blood sugar of 143. IMPRESSION: 1. Right foot cellulitis. 2. Chronic tinea pedis. 3. Chronic scalp dermatitis. 4. Mild GERD. 5. History of ITP with normal platelet count at this time. 6. Severe DJD with mainly left hip and knee symptoms at this time. PLAN: The patient is admitted, started on IV Ancef, IV fluids.
ITP|idiopathic thrombocytopenic purpura|(ITP),|156|161|DISCHARGE DIAGNOSIS|2. Junctional bradycardia. 3. Low platelet, etiology unclear. The patient to have follow-up of low platelet to rule out idiopathic thrombocytopenic purpura (ITP), drug-related or hypersplenism I did not see any drug-causing thrombocytopenia. 4. High INR and PTT secondary to vitamin K deficiency more likely.
ITP|idiopathic thrombocytopenic purpura|ITP.|272|275|HOSPITAL PROCEDURES|The differential is quite broad and anemia of chronic disease and primary bone marrow disorder, this was recommended to be followed up as an outpatient. The differential diagnosis for mild thrombocytopenia could be drug-related thrombocytopenia, hypersplenism, as well as ITP. LABORATORY DATA: TSH 5.03, free-T4 of 1.13, total cholesterol 135, LDL 85, and HDL 39.
ITP|idiopathic thrombocytopenic purpura|ITP.|230|233|HISTORY OF PRESENTATION|She does have a history of TTP that was first diagnosed in _%#MM2000#%_ at which time she had a very complicated course. She was admitted to Mayo Hospital and had seizures and kidney involvement. In 2002, she had a relapse of her ITP. HOSPITAL COURSE: 1. TTP. Patient had a very complicated course. Her platelet counts were low throughout her hospitalization.
ITP|idiopathic thrombocytopenic purpura|ITP|203|205|PAST MEDICAL HISTORY|2. History of GI bleeding times two. 3. History of significant osteoporosis with vertebral compression fracture and history of valvular heart disease with mild to moderate aortic stenosis. 4. History of ITP that has been in complete remission. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: He lives with his wife in the _%#CITY#%_ _%#CITY#%_.
ITP|idiopathic thrombocytopenic purpura|(ITP)|142|146|DIAGNOSES|The left side is normal. There is no umbilical hernia. DIAGNOSES: 1. Right inguinal hernia. 2. History of idiopathic thrombocytopenia purpura (ITP) with thrombocytopenia, although, her most recent platelet count is over 300,000 done in _%#MM2003#%_. Her hemoglobin at that time was 14.4. This will be repeated by Dr. _%#NAME#%_ in her preoperative exam.
ITP|idiopathic thrombocytopenic purpura|ITP.|123|126|SOCIAL HISTORY|She worked at a mortgage company as an office manager while she was in Texas and has been on disability since diagnosis of ITP. She is currently living with one of her daughters. She denies any history of smoking. However, on reviewing her records she does have a 50 pack year history of smoking and quit 2 1/2 years ago.
ITP|idiopathic thrombocytopenic purpura|ITP.|128|131|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Past medical history per last discharge summary on _%#MM#%_ _%#DD#%_, 2004: 1. The patient is above-noted ITP. 2. HIV positive. 3. Hepatitis C positive. 4. Seizure disorder. 5. The patient has a remote history of congestive heart failure with prior ejection fraction of 15% to 20%.
ITP|idiopathic thrombocytopenic purpura|ITP|241|243|PAST MEDICAL HISTORY|6. History of tubal ligation in the past. 7. The patient has a history of chronic substance abuse and history of prostitution. 8. History of depression. 9. Hypothyroidism. 10. The patient had undergone high-dose steroid therapy and IVIG for ITP which was unresponsive to medical therapies. HOSPITAL COURSE: Hospitalizations for low platelet count. Surgery was consulted on the last admission which was _%#MM#%_.
ITP|idiopathic thrombocytopenic purpura|ITP.|211|214|DISCHARGE DIAGNOSIS|A peripheral blood smear was obtained which showed marked thrombocytopenia but no evidence of hemolysis. The patient did receive an intravenous Solu- Medrol dose in the case that her thrombocytopenia was due to ITP. Her platelet count did not respond to either the platelet transfusion or the steroids. On the day of death, the patient had respiratory distress and subsequent respiratory failure.
ITP|idiopathic thrombocytopenic purpura|(ITP).|60|65|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Idiopathic thrombocytopenic purpura (ITP). 2. Anemia. 3. Schizophrenia. HISTORY OF PRESENT ILLNESS: This is a 34-year-old gentleman, well known to the Hematology/Oncology Service, who originally had AML in _%#MM2001#%_ and underwent consolidation therapy, including auto-stem cell transplant.
ITP|idiopathic thrombocytopenic purpura|(ITP)|254|258|PAST MEDICAL HISTORY|Therefore, we have waited on establishing permanent access until dialysis at which point the plan is for her to have a loop graft. PAST MEDICAL HISTORY: 1. Chronic renal disease as discussed above. 2. Hypertension. 3. Idiopathic thrombocytopenic purpura (ITP) in 1991. 4. Glucose intolerance formerly treated with oral hypoglycemics, currently not on any such therapy. 5. Obesity. 6. Status post left total knee replacement in 1994.
ITP|idiopathic thrombocytopenic purpura|ITP|239|241|PROCEDURES PERFORMED|There was no evidence of free retroperitoneal hemorrhage. 4. Peripheral blood smear to evaluate for schistocytes, as the patient had developed acute renal failure and had a hemoglobin drop that was most likely dilutional. However, PTB and ITP were considered and therefore, her peripheral smear, which was unremarkable, was ordered. 5. Packed red blood cell transfusion, _%#MMDD2004#%_. 6. Attempt at dental extraction of her 14th tooth.
ITP|idiopathic thrombocytopenic purpura|ITP.|323|326|HISTORY OF PRESENT ILLNESS|Specifically a platelet count on _%#MMDD2005#%_ was 14,000 with white count at 7400, hemoglobin 14.1. BUN 16 and creatinine 0.9. Previous platelet count from _%#MM#%_ _%#DD#%_, 2004 was 207,000 with a hemoglobin 15.3, creatinine 0.9 at that point. She was initially placed on prednisone due to the presumptive diagnosis of ITP. With further history, however, it was apparent that her diagnosis was that of TTP. A repeat platelet count was then drawn on _%#MMDD2005#%_ which is 22,000.
ITP|idiopathic thrombocytopenic purpura|ITP|201|203|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSES: 1. Idiopathic thrombocytopenic purpura with thrombocytopenia. 2. Parkinson's. 3. Diabetes. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 78-year-old man with a history of ITP who presented from home with a platelet count of 7. The patient has a longstanding history of diabetes, ITP, Parkinson disease as well as multiple medical illnesses.
ITP|idiopathic thrombocytopenic purpura|ITP,|226|229|HISTORY OF PRESENT ILLNESS|2. Parkinson's. 3. Diabetes. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 78-year-old man with a history of ITP who presented from home with a platelet count of 7. The patient has a longstanding history of diabetes, ITP, Parkinson disease as well as multiple medical illnesses. His home health nurse drew blood count and was found to have a platelet count of 7000.
ITP|idiopathic thrombocytopenic purpura|ITP|115|117|IMPRESSION|IMPRESSION: 1. Syncope, questionable etiology. I do not plan to do any further evaluation of this at this time. 2. ITP (idiopathic thrombocytopenic purpura), with decrease in her platelet count. The patient got IVIG during the night, and will be seen by Hematology for further evaluation of this.
ITP|idiopathic thrombocytopenic purpura|ITP|190|192|HOSPITAL COURSE|2. ITP. The patient has been diagnosed with ITP actually in _%#MM2006#%_ and is status post IVIg treatment and is currently on prednisone taper. The patient is to follow with hematology for ITP and his platelets are currently stable. 3. Microscopic hematuria. The patient has been seen by urology for microscopic hematuria and the plan to do cystoscopy in _%#MM2007#%_.
ITP|idiopathic thrombocytopenic purpura|ITP.|165|168|HOSPITAL COURSE|HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ is a 16-year-old young man who has a history of diabetes mellitus as well as colitis and also more recently problems with ITP. He was hospitalized at Fairview Southdale beginning _%#MMDD2007#%_ with gastrointestinal bleeding. Please refer to the admission history and physical for further details.
ITP|idiopathic thrombocytopenic purpura|ITP|210|212|HOSPITAL COURSE|Follow-up was to be in Dr. _%#NAME#%_' office for weekly determination of platelet count. He was instructed to call Dr. _%#NAME#%_ to discuss any other alterations in diabetic management. It is felt likely his ITP will respond to the corticosteroids as well and therefore at present it is felt unlikely he will need additional infusions of intravenous gamma globulin.
ITP|idiopathic thrombocytopenic purpura|(ITP)|194|198|FINAL DIAGNOSES|She has had this in the past. I am not sure if she has had any workup. She certainly requires endoscopies of the colon and possibly esophagus and stomach. 3. Idiopathic thrombocytopenic purpura (ITP) diagnosed _%#MM2002#%_, confirmed by bone marrow biopsy which did not indicate iron deficiency. 4. Chronic obstructive pulmonary disease (COPD); no home oxygen.
ITP|idiopathic thrombocytopenic purpura|ITP.|176|179||_%#NAME#%_ _%#NAME#%_ is a 27-year-old female, gravida 1 para 1 now who has had her entire pregnancy with excellent dates and early ultrasound followed by me. Had a history of ITP. Platelets have been stable for the entire pregnancy with a high of approximately 197. It was approximately in the 130s for the last few weeks of pregnancy.
ITP|idiopathic thrombocytopenic purpura|(ITP).|57|62|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: Idiopathic thrombocytopenic purpura (ITP). OPERATIONS/PROCEDURES PERFORMED: None. HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old male with a history of systemic lupus erythematosus and coronary artery disease.
ITP|idiopathic thrombocytopenic purpura|ITP|160|162|HISTORY OF PRESENT ILLNESS|The kidney is horseshoe shaped. 2. Splenectomy performed by general surgery. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 30-year-old male with a history of ITP diagnosed in 2002. He has been in remission after prednisone and IVIG, with a subsequent 3- to 4-month steroid taper. He has not had petechiae or bleeding symptoms in the interim.
ITP|idiopathic thrombocytopenic purpura|(ITP).|162|167|PLAN|No active bleeding at this time, and his other cell counts appear normal. I wonder if there might be a component of low-grade idiopathic thrombocytopenic purpura (ITP). b. I will check a peripheral smear and consider a Hematology consultation if his counts do deteriorate.
ITP|idiopathic thrombocytopenic purpura|ITP.|192|195|IMPRESSION|Sodium 136, potassium 4.1, chloride 101, CO2 24, glucose 101, BUN 19, creatinine 1.4. IMPRESSION: 1. Postoperative fever and increased left hip pain status post left total hip replacement. 2. ITP. 3. Asplenic. 4. Past history of MRSA. 5. Recurrent staph infections. 6. Anemia. 7. History of gastroesophageal reflux disease.
ITP|idiopathic thrombocytopenic purpura|ITP|162|164|HOSPITAL COURSE|Hematology did not think that this was present, given no renal failure, mental status changes, and negative peripheral smear. There was some concern for possible ITP though this seemed less likely. Antibody studies still pending. CMV, Epstein-Barr virus studies were obtained. Monospot was negative. Abdominal ultrasound was obtained which showed findings possibly suggestive of acalculus cholecystitis.
ITP|idiopathic thrombocytopenic purpura|(ITP),|218|223|DISCHARGE DIAGNOSES|PRIMARY PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD (Southside Medical Clinic - Family Practice; fax _%#TEL#%_) DISCHARGE DIAGNOSES: 1. Recurrent pancreatitis, presumed from gallstones. 2. Idiopathic thrombocytopenic purpura (ITP), discharge platelet count of 39. 3. Chronic obstructive pulmonary disease (COPD). 4. History of heart failure, presumed from diastolic dysfunction.
ITP|idiopathic thrombocytopenic purpura|ITP.|280|283|PROCEDURES AND TESTS|Consultation with Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ (Gastroenterology) who felt approach of either observation, ultrasound (US) or laparoscopic cholecystectomy were all reasonable. Consultation with Dr. _%#NAME#%_ _%#NAME#%_ (Hematology) who felt the clinical diagnosis was of ITP. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 72-year-old woman from Nepal who presents with abdominal pain.
ITP|idiopathic thrombocytopenic purpura|ITP|126|128|PAST MEDICAL HISTORY|Her labor was induced secondary to postdates. PAST GYNECOLOGICAL HISTORY: Negative. PAST MEDICAL HISTORY: Significant for the ITP as mentioned in the history of present illness. This was diagnosed on postpartum in _%#MM#%_ 2003. PAST SURGICAL HISTORY: Splenectomy in _%#MM#%_ 2003.
ITP|idiopathic thrombocytopenic purpura|ITP|420|422|PHYSICAL EXAMINATION|Hematology-Oncology recommended the drawing of multiple lab tests which are resulted above along with a bone marrow biopsy to rule out any abnormal appearance of any cells or any space occupying lesions or any leukemias or any cancers inside the bone marrow which would result in a low platelet count outside in the periphery. However, those were ruled out and her bone marrow came back consistent with the diagnosis of ITP and she was continued on her treatment with Prednisone, 60 mg p.o. q.d. lungs the patient continued to improve and she felt generally well overall with no symptoms of fatigue or shortness of breath.
ITP|idiopathic thrombocytopenic purpura|(ITP),|169|174|PAST MEDICAL HISTORY|2. Intracranial hemorrhage with a right parietal hemorrhage felt secondary to thrombocytopenia and Coumadin use in _%#MM#%_ 1999. 3. Idiopathic thrombocytopenic purpura (ITP), chronic, with relatively stable platelet counts recently. Platelet counts typically have been reported to run between 50,000-100,000. 4. History of seizures due to intracranial hemorrhage. 5. Hypothyroidism on treatment.
ITP|idiopathic thrombocytopenic purpura|ITP|164|166|ADMISSION DIAGNOSIS|She was first evaluated by Dr. _%#NAME#%_ in _%#MM#%_ of 2003 and she has a followup appointment this coming week. PAST MEDICAL HISTORY: 1. Pseudotumor cerebri. 2. ITP and she had a splenectomy in 1992. 3. Hypothyroidism. 4. Gastroesophageal reflux disease. 5. Menorrhagia. 6. Appendectomy. 7. CCE. 8. T and A. 9. Tubal ligation in 1993.
ITP|idiopathic thrombocytopenic purpura|ITP.|247|250|HOSPITAL COURSE|Currently he was admitted for consolidation chemo. During his initial labs, his platelet count was found to be low, and hence he did get a bone marrow biopsy. This showed adequate trilinear hematopoiesis, and hence he was thought to have possibly ITP. We did do a peripheral smear, a HIT panel, and antinuclear panel for evaluation of his thrombocytopenia. The HIT panel and antinuclear panel were negative. He was started on treatment for presumed ITP with IVIG, as well as high-dose dexamethasone, after which his counts have remained stable around 40s.
ITP|idiopathic thrombocytopenic purpura|ITP|197|199|HOSPITAL COURSE|We did do a peripheral smear, a HIT panel, and antinuclear panel for evaluation of his thrombocytopenia. The HIT panel and antinuclear panel were negative. He was started on treatment for presumed ITP with IVIG, as well as high-dose dexamethasone, after which his counts have remained stable around 40s. However, there has been no significant improvement in his platelet count.
ITP|idiopathic thrombocytopenic purpura|ITP|294|296|HOSPITAL COURSE|HOSPITAL COURSE: The patient was admitted to the floor, and after taking the initial history and physical it was decided that her presentation was most consistent with a Mallory-Weiss tear. She has a history of ITP; however, her platelets on admission were 106,000, and it is not felt that her ITP had any role in her presentation. She did spike a fever to 101.9 the evening of admission, and she was kept overnight for observation.
ITP|idiopathic thrombocytopenic purpura|ITP.|138|141|HOSPITAL COURSE|We also asked the patient to have a hemoglobin drawn on Monday as an outpatient with the Hematology Clinic, where she is followed for her ITP. We do note that the day following discharge the patient's urine culture did grow back 50,000 to 100,000 colonies of beta hemolytic Strep as well as 10,000 colonies of Staphylococcus species.
ITP|idiopathic thrombocytopenic purpura|ITP|33|35|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Presumed ITP responding to IV IGN steroids. 2. A 15 week 1 day intrauterine viable pregnancy. 3. Severe thrombocytopenia secondary to presumed ITP. 4. Empiric treatment with Zantac while on Prednisone.
ITP|idiopathic thrombocytopenic purpura|ITP.|167|170|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Presumed ITP responding to IV IGN steroids. 2. A 15 week 1 day intrauterine viable pregnancy. 3. Severe thrombocytopenia secondary to presumed ITP. 4. Empiric treatment with Zantac while on Prednisone. DISCHARGE MEDICATIONS: 1. Prednisone. The patient is currently on 60 mg po qd, however, dosage recommendations are pending from Hematology/Oncology.
ITP|idiopathic thrombocytopenic purpura|ITP|209|211|PAST MEDICAL HISTORY|Hospitalizations have included appendectomy in 1943, TAH-BSOP in 1970, small bowel resection for adhesions in 1970, bilateral cataract surgery. She has had eye strabismus surgery. She did have splenectomy for ITP in 1996. ALLERGIES: None. Rarely uses alcohol. Quit smoking about 8 years ago.
ITP|idiopathic thrombocytopenic purpura|ITP.|148|151|IMPRESSION|3. History of CHF. 4. Mitral valve prolapse and mitral insufficiency. 5. Polymyalgia rheumatica. 6. DJD. 7. Irritable bowel syndrome. 8. History of ITP. PLAN: This patient has very minimal residual symptoms now.
ITP|idiopathic thrombocytopenic purpura|ITP,|194|197|PLAN|Will just place her under usual medications, including her baby aspirin and watch closely. Will obtain neural consult, address questions of any other platelet inhibition in view of her previous ITP, any other suggested workup. I discussed with Dr. _%#NAME#%_ _%#NAME#%_, her primary provider.
ITP|idiopathic thrombocytopenic purpura|ITP.|156|159|ASSESSMENT/PLAN|Tequin was started in the emergency room and will continue for now and add one dose of vancomycin. She is allergic to penicillin. I worry about the DIC and ITP. Will check a peripheral smear, LDH, fibrinogen and a D-dimer. Also lactate, PTT, INR and cortisol. Talked with Dr. _%#NAME#%_ and one of his partners will see the patient in the ICU.
ITP|idiopathic thrombocytopenic purpura|ITP|81|83|PAST MEDICAL HISTORY|For this reason the patient was admitted for IVIg therapy. PAST MEDICAL HISTORY: ITP diagnosed in 2002; hypertension, vasectomy 2003; appendectomy in 1952. He smokes less than 1 pack per day and drinks about 5-6 drinks a week and occasional use of THC.
ITP|idiopathic thrombocytopenic purpura|ITP|231|233|PAST MEDICAL HISTORY|The remainder of his Review of Systems is negative. PAST MEDICAL HISTORY: Remarkable for insulin-dependent diabetes mellitus. He has as history of recurrent urinary tract infections. He has been treated extensively for his CLL and ITP in the past. He also has a history of hypercholesterolemia. MEDICATIONS: At the time of admission included Flomax, Zoloft, insulin, Ativan, and Compazine.
ITP|idiopathic thrombocytopenic purpura|ITP.|124|127|DISCHARGE DIAGNOSIS|4. Thrombocytopenia. 5. Anemia. 6. Rosacea. 7. Type 2 diabetes. 8. Alcohol abuse. DISCHARGE DIAGNOSIS: 1. Alcohol abuse. 2. ITP. 3. Aspiration pneumonia/respiratory failure, resolved. 4. Type 2 diabetes. 5. Deconditioning. 6. Orthostatic hypotension, likely autonomic dysfunction secondary to diabetes.
ITP|idiopathic thrombocytopenic purpura|ITP|208|210|HOSPITAL COURSE|2. ITP. The patient came in with low platelets and initially this was felt secondary to his alcoholism. Hematology/oncology was consulted and a bone marrow biopsy was performed. The patient was found to have ITP and responded well to steroids. 3. Type 2 diabetes. The patient is a known diabetic but had not been taking any medications.
ITP|idiopathic thrombocytopenic purpura|ITP,|246|249|HOSPITAL COURSE|HOSPITAL COURSE: ITP. On admission, her peripheral smear was reviewed which did not show any evidence of TTP/HUS, leukemias, lymphomas, or other hematologic disorder besides thrombocytopenia. It was felt that her presentation was consistent with ITP, and she was started on oral prednisone. She had a very quick response to prednisone, and her platelets increased to 27,000 platelets per microliter over the next 2 days.
ITP|idiopathic thrombocytopenic purpura|ITP.|177|180|HOSPITAL COURSE|The patient's coagulopathy was corrected and the patient was given platelet transfusions. Hematology was consulted for low platelets and it is felt that he had acute on chronic ITP. He was treated with steroids and IVIG. He was also given supportive platelet transfusions. Overall, his platelets improved and his platelet count is 135 on _%#MM#%_ _%#DD#%_, 2007.
ITP|idiopathic thrombocytopenic purpura|ITP,|264|267|HOSPITAL COURSE|The taper will be determined based CBC on follow-up. Some of the patient's medications were held on admission for concern of contribution to thrombocytopenia. However, given that he has known ITP, it is felt that his current presentation with low platelets due to ITP, it is felt that it is okay to restart his medications upon discharge. DISCHARGE MEDICATIONS: 1. Lipitor 20 mg a day. 2. Lisinopril/hydrochlorothiazide 10-12.5 mg q. day.
ITP|idiopathic thrombocytopenic purpura|ITP|177|179|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSES: 1. Idiopathic thrombocytopenic purpura. 2. Menorrhagia. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 39-year-old nurse with a recent diagnosis of ITP previously admitted on _%#MMDD2007#%_ with a platelet count of 2000 with petechiae and mucosal bleeding. She received 2 doses of IVIG, was started on 1 mg/kg/day of prednisone and was discharged from the hospital on _%#MMDD2007#%_.
ITP|idiopathic thrombocytopenic purpura|ITP.|200|203|HOSPITAL COURSE|She was pale and dizzy, and was found to have a hemoglobin of 6.1. Please see original H&P for details of history of present illness, past medical history, medications and allergies. HOSPITAL COURSE: ITP. The patient's hemoglobin dropped to the mid 5's following hydration. She remained hemodynamically stable. She was continued on steroids. She was transfused with RBCs, platelets, and given Amicar.
ITP|idiopathic thrombocytopenic purpura|ITP,|240|243|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 53-year-old woman who was admitted for evaluation of a right knee pain and right knee arthroscopy. She also has a history of longstanding thrombocytopenia of unknown etiology, possible ITP, followed by Dr. _%#NAME#%_. She was treated with prednisone in the past, although did not respond to this. During previous hospitalization, she had arthroscopy with patellar realignment as noted above.
ITP|idiopathic thrombocytopenic purpura|ITP|152|154|REVIEW OF SYSTEMS|PSYCHIATRIC: Negative. NEUROLOGIC: Remarkable for cerebral aneurysm with clipping. HEMATOLOGIC: Remarkable for thrombocytopenia; it sounds like she has ITP or some other antibody associated thrombocytopenia. DERMATOLOGIC: Remarkable for venous stasis disease and changes in the skin related to that PHYSICAL EXAMINATION: VITAL SIGNS: Temperature of 98.6, a pulse of 81, blood pressure of 143/79, respiratory rate of 10 GENERAL: The patient is an obese female resting comfortably in bed in no acute distress.
ITP|idiopathic thrombocytopenic purpura|ITP.|185|188|HOSPITAL COURSE|The patient's creatinine was normal at 0.83. A peripheral smear was without schistocytes. The patient had no history of recent heparin use and was therefore thought most likely to have ITP. The patient was then started on prednisone 80 mg p.o. daily and IVIG 85 grams IV daily x2 doses. The patient tolerated both of these medications well. She was also started on Protonix to take daily while on steroids.
ITP|idiopathic thrombocytopenic purpura|ITP|103|105|DISCHARGE DIAGNOSIS|PRIMARY PHYSICIAN: Fairview Crosstown Clinic DISCHARGE DIAGNOSIS: 1. Profound thrombocytopenia, likely ITP 2. Comfort care option selected. 3. Atrial fibrillation with rapid ventricular response. 4. Congestive heart failure 5. Hyperkalemia 6. DNR/DNI PROCEDURES AND TEST: 1. Admission chemistries remarkable for platelet count of 2, hemoglobin of 13, white count of 6.
ITP|idiopathic thrombocytopenic purpura|(ITP)|30|34|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: Possible (ITP) idiopathic thrombocytopenic purpura. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 26-year-old white male with a previous history of aplastic anemia in 1998 and ITP in 2002, who presented to the ER today with complaints of petechial rash on lower extremities and wrists bilaterally, and appearing in the mouth over the last few days.
ITP|idiopathic thrombocytopenic purpura|ITP|384|386|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ is a 26-year-old white male with a previous history of aplastic anemia in 1998 and ITP in 2002, who presented to the ER today with complaints of petechial rash on lower extremities and wrists bilaterally, and appearing in the mouth over the last few days. He also complained of some mild streaks of blood with coughing. According to the patient, since his diagnosis of ITP about 2-1/2 years ago, the patient has had a few petechiae around his ankles on and off, but this petechial rash was definitively worse.
ITP|idiopathic thrombocytopenic purpura|ITP,|217|220|LABORATORY DATA|Hemoglobin was 16.2, platelet count 6000, INR around 1.07, PTT 33, sodium 145, potassium 4, chloride 106, bicarb 25, BUN 21, creatinine 1.41, glucose 104, normal LFTs. Peripheral smear was consistent with most likely ITP, no evidence of any microangiopathy, dysplasia or other primary marrow disease. HOSPITAL COURSE: The patient was admitted to the hospital with possible diagnosis of ITP.
ITP|idiopathic thrombocytopenic purpura|ITP.|270|273|HISTORY|The patient's comorbid include hypertension, type 2 diabetes, diabetic peripheral neuropathy, asthma, chronic knee pain, hyperlipidemia, and history of kidney stones. The patient was evaluated by her primary-care physician as well as hematology for her known history of ITP. Hematology recommendations have been implemented and she was given IVIG prior to her operation. After a careful preoperative workup the patient was scheduled for the Roux-en-Y gastric bypass surgery on _%#MMDD2005#%_.
ITP|idiopathic thrombocytopenic purpura|ITP|191|193|PAST MEDICAL HISTORY|She denies dizziness but reports she feels tired and weak and has no other complaints. PAST MEDICAL HISTORY: 1. Congestive heart failure, ejection fraction 20% in _%#MM2006#%_. 2. History of ITP in _%#MM2006#%_. 3. Recurrent pleural effusion. This was tapped during her last hospitalization with symptomatic relief. 4. Abdominal aortic aneurysm. 5. Hypertension. 6. Aortic stenosis.
ITP|idiopathic thrombocytopenic purpura|ITP.|185|188|PLAN|6. Elevated INR. I am also concerned about nutritional depletion with this. I will give her a dose of vitamin K and will consider FSP if her hemoglobin continues to drop. 7. History of ITP. Platelet count is not available at this time. I will ask the lab to redraw. 8. Hyponatremia. This appears to be stable from her last hospitalization.
ITP|idiopathic thrombocytopenic purpura|(ITP)|208|212|IMPRESSION|2. Thrombocytopenia appears acute. Etiology unknown. The patient is on Dilantin and Plavix but none of these are new. The only new medication is carvedilol. No evidence of idiopathic thrombocytopenic purpura (ITP) on exam. Other etiologies include infection or other systemic illnesses. 3. Ischemic cardiomyopathy. 4. Hyperlipidemia 5. Seizure disorder. PLAN: 1. The patient will be admitted to the ICU.
ITP|idiopathic thrombocytopenic purpura|ITP|116|118|PAST MEDICAL HISTORY|The patient is also followed by Dr. _%#NAME#%_ at UMMCF who is treating his retinopathy with laser and steroids. 3. ITP - The patient is followed by Dr. _%#NAME#%_ with the Hematology Department; the treatment plan at this point in time is to continue monitoring his platelets with no further treatment, given his complicated past medical history.
ITP|idiopathic thrombocytopenic purpura|ITP,|141|144|ASSESSMENT AND PLAN|IMAGING: Chest x-ray shows clear lungs. ASSESSMENT AND PLAN: Mr. _%#NAME#%_ is a 78-year-old male with a significant past medical history of ITP, Parkinson's disease and diabetes mellitus, who presents with weakness x2 days associated with confusion that is most likely secondary to his urinary tract infection.
ITP|idiopathic thrombocytopenic purpura|ITP|200|202|PAST MEDICAL HISTORY|At this point his father consents to excision of this under local anesthesia. PAST MEDICAL HISTORY: The patient is otherwise healthy. He has had a tonsillectomy in the past and also had a question of ITP in 1993. MEDICATIONS: None. ALLERGIES: None. PHYSICAL EXAMINATION: GENERAL: The patient is well nourished in no distress.
ITP|idiopathic thrombocytopenic purpura|ITP.|162|165|REASON FOR ADMISSION|Haptoglobins were high and total bili was normal. D-dimer was 0.3. He was admitted with the diagnosis of idiopathic thrombocytopenia purpura. HOSPITAL COURSE: 1. ITP. After admission to the hospital a chest x-ray was done to rule out any infection. A chest x-ray showed left lower lobe infiltrate and he was put on gatifloxacin.
ITP|idiopathic thrombocytopenic purpura|ITP,|331|334|DISCHARGE MEDICATIONS|He was able to ambulate without much difficulty. DISCHARGE MEDICATIONS: Norvasc 5 mg p.o. every other day, Protonix 40 mg p.o. q.day, Ambien 5 mg p.o. at bedtime p.r.n. insomnia, and prednisone 250 mg p.o. q.day. He is following up with Dr. _%#NAME#%_ the day after discharge, _%#MM#%_ _%#DD#%_, 2006, for further treatment of his ITP, and he has a followup with Dr. _%#NAME#%_ in neurology on _%#MM#%_ _%#DD#%_, 2006, for further treatment of his CIDP. Question if he will start to receive IV Ig therapy for this again.
ITP|idiopathic thrombocytopenic purpura|ITP.|151|154|HISTORY  OF PRESENT ILLNESS|_%#NAME#%_ was thrombocytopenic at that time and it was felt that he may have either a consumptive thrombocytopenia from splenomegaly versus low-grade ITP. Bone marrow biopsy was not requested at that time and simple recommendations for observation and iron repletion were made. _%#NAME#%_ is now admitted to Fairview Ridges Hospital with symptoms of weakness, shortness of breath, fatigue and upper respiratory tract infection/pneumonia.
ITP|idiopathic thrombocytopenic purpura|ITP.|278|281|PROBLEM #2|PROBLEM #2: Thrombocytopenia. We will continue to transfuse her to keep her count greater than 50, as telangiectasias are frequently found throughout the GI tract and are rarely limited to the gastric antrum. Possible etiologies of her thrombocytopenia include chronic GVHD and ITP. Her primary BMT physician is evaluating. PROBLEM #3: Status post nonmyeloablative allogeneic sibling transplantation for non-Hodgkin lymphoma.
ITP|idiopathic thrombocytopenic purpura|ITP|209|211|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Nosebleed. HISTORY OF PRESENT ILLNESS: This is a 32-year-old male with a history of ITP and diabetes who presents with an acute onset of nosebleed and mouth sores. He was first diagnosed with ITP in 2001 at which time he had symptoms of mouth sores, epistaxis, petechia and hematuria. He was initially treated with prednisone and IVIG and his bleeding resolved.
ITP|idiopathic thrombocytopenic purpura|ITP|105|107|PAST MEDICAL HISTORY|He was admitted to the Hematology Service for further evaluation and treatment. PAST MEDICAL HISTORY: 1. ITP as outlined above. 2. Diabetes, he is unsure if he is type 1 or type 2. Diagnosed in 2001 around the same time as his ITP diagnosis.
ITP|idiopathic thrombocytopenic purpura|ITP|229|231|ASSESSMENT|INR 0.98, PTT 24, sodium 141, potassium 3.7, chloride 104, bicarbonate 26, BUN 12, creatinine 0.98, glucose 277, alk phos 118, ALT 22, AST 20. D-dimer is 0.2. ASSESSMENT: This is a 32-year-old male with a history of diabetes and ITP who presents with acute onset of bleeding and mouth sores. PLAN: PROBLEM #1: ITP. This is the first exacerbation since the time of his splenectomy 2 years ago.
ITP|idiopathic thrombocytopenic purpura|ITP.|152|155|PLAN|At this time we will also give IVIG daily for 2 days and also give a dose of Rituxan. Platelets will no be transfused as this would only exacerbate his ITP. His coags are otherwise normal, such as his INR, PTT and D-dimer. As for his active bleeding, we will ask ENT to come and see the patient and pack his nose as needed.
ITP|idiopathic thrombocytopenic purpura|ITP|169|171|REASON FOR HOSPITAL ADMISSION|REASON FOR HOSPITAL ADMISSION: _%#NAME#%_ _%#NAME#%_ is admitted for further evaluation of progressive weakness and with a known history of thrombocytopenia felt due to ITP or myelodysplastic syndrome. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is a 67-year-old man who has a history of thrombocytopenia dating back several years and with workup showing features consistent with either ITP or early myelodysplastic syndrome.
ITP|idiopathic thrombocytopenic purpura|ITP|245|247|PAST MEDICAL HISTORY|No diarrhea, no dysuria, skin ulcer or infection. He did develop oral sores over the over the last 24-48 hours which are moderately painful. PAST MEDICAL HISTORY: CMML has not required any treatment with borderline neutrophil counts. History of ITP long-standing history, treated with splenectomy and steroids and Imuran, Rituxan and CellCept as well as CHOP chemotherapy. History of splenectomy and erythema nodosum. MEDICATIONS: Vicodin, vitamin B12, multivitamin, Tylenol, completed one course of Levaquin started as an outpatient a week ago.
ITP|idiopathic thrombocytopenic purpura|ITP|208|210|HOSPITAL COURSE|The conclusion of this paper stated splenectomy should be considered safe enough for thrombocytopenia associated with SLA. Again the patient did not require this, but of note may require in the future if her ITP ever becomes refractory to these medications. Please note that the patient has never received immunizations for meningococcemia or pneumonia.
ITP|idiopathic thrombocytopenic purpura|ITP.|147|150|ASSESSMENT AND PLAN|Breast and pelvic exams deferred. Extremities show full range of motion of all joints; there is ecchymosis in the right hand. ASSESSMENT AND PLAN: ITP. I have asked for a consult with Hematology. Her current hemoglobin is 13.4, MCV 81, platelet count 5.0 thousand, white blood count 8.8, lymphs 3.0, granulocytes 5.5. I appreciate the Oncology care.
ITP|idiopathic thrombocytopenic purpura|ITP|186|188|HOSPITAL COURSE|HOSPITAL COURSE: Ms. _%#NAME#%_ is a 29-year-old gravida 1, para 0 presented at 38 weeks gestation for evaluation of preeclampsia. The patient was diagnosed at least a week earlier with ITP when platelets were found to be low in the 80,000 range. She was started on prednisone. The patient continued to have elevated blood pressures and was presented for rule out preeclampsia.
ITP|idiopathic thrombocytopenic purpura|ITP|159|161|PAST MEDICAL HISTORY|6. History of perforated nasal septum. 7. Status post inguinal hernia repair in 1995. 8. Status post orthopedic surgery. 9. History of thrombocytopenia due to ITP status, successful treatment with steroid. 10. Status post right total knee arthroplasty. ADMISSION MEDICATIONS: 1. Potassium chloride 20 mEq p.o. b.i.d. 2. Calcium carbonate 1 gm p.o. daily.
ITP|idiopathic thrombocytopenic purpura|ITP.|154|157|BRIEF HISTORY OF PRESENT ILLNESS|BRIEF HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 39-year-old previously healthy female who has had multiple recent admissions for steroid refractory ITP. On the day of presentation for this admission, Ms. _%#NAME#%_ had onset of menses, which was complicated by severe menorrhagia and thrombocytopenia with platelet count of 2000.
ITP|idiopathic thrombocytopenic purpura|ITP|126|128|PROBLEM #1|She will be discharged on prednisone 1 mg/kg although it is of note that she has been quite steroid refractory throughout her ITP course. Four rituximab infusions are planned. The patient understands that she should be seen in the nearest emergency room should she have any recurrence of bleeding.
ITP|idiopathic thrombocytopenic purpura|ITP|210|212|IMPRESSION/PLAN|Her family understands the significant medical issues involved in her care and they have been apprised of the potential difficulty with this patient. I have also consulted hematology-oncology and discussed the ITP with them and they recommend no further therapy at this time.
ITP|idiopathic thrombocytopenic purpura|ITP|191|193|PAST MEDICAL HISTORY|The patient is currently on chronic prednisone to control her platelet count. 2. Status post thyroidectomy for presumed thyroid cancer. 3. Status post TAH for menorrhagia associated with her ITP with possible BSO. 4. Hyperlipidemia. HOSPITAL COURSE: The patient was admitted to the Thoracic Surgery Service for a possible airway threatening bleed.
ITP|idiopathic thrombocytopenic purpura|ITP|245|247|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1: Idiopathic thrombocytopenic purpura. Ms. _%#NAME#%_ was admitted to the hematology service at which time her platelet count was measured at 14,000. She was initiated on pulse dexamethasone for treatment of suspected ITP versus drug-induced thrombocytopenia as her peripheral smear did not reveal schistocytes to suggest TTP. HIT antibody screen was negative. There was also some concern about her recent clopidogrel load in the setting of her NSTEMI as rare case reports of clopidogrel induced thrombocytopenia have been reported.
ITP|idiopathic thrombocytopenic purpura|ITP.|157|160|BRIEF HISTORY OF PRESENT ILLNESS|She was subsequently admitted to the Hematology Oncology Service for further evaluation and management of both her chronic diarrhea and for treatment of her ITP. Please see my dictated H and P on _%#MMDD2007#%_ for full historical details. HOSPITAL COURSE: PROBLEM #1: ITP. The patient was admitted to the Oncology Service for severe thrombocytopenia.
ITP|idiopathic thrombocytopenic purpura|ITP.|172|175|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Idiopathic thrombocytopenic purpura (ITP), resolved after splenectomy. Platelets currently now around 200,000. 2. Splenectomy, _%#MMDD2004#%_, for ITP. 3. Induced delivery on _%#MMDD2004#%_. This was her second child. The platelets were about 8000 and she had massive bleeding. 4. Migraine headaches since her second child was born, about one time a week.
ITP|idiopathic thrombocytopenic purpura|ITP.|128|131|REVIEW OF SYSTEMS|SOCIAL HISTORY: She lives in _%#CITY#%_ with her husband and two children. REVIEW OF SYSTEMS: Hematologic: She has a history of ITP. No recent history of bleeding. The platelets have been stable. Musculoskeletal: Please see history of present illness. Gynecologic: She had a hysterectomy after her second delivery due to massive bleeding.
ITP|idiopathic thrombocytopenic purpura|ITP.|277|280|HISTORY OF PRESENT ILLNESS|_%#NAME#%_ notes that she has been doing well overall and states she has no history of any coronary artery disease and is having no angina. She notes that she is not having any infections currently, and no history of any bleeding disorders, although she does have a history of ITP. PAST MEDICAL HISTORY: 1. Rheumatoid arthritis. 2. Idiopathic thrombocytopenia purpura (ITP).
ITP|idiopathic thrombocytopenic purpura|ITP,|202|205|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Chronic lymphocytic leukemia, diagnosed sometime between 1991 and 1996 (the patient is very reluctant to discuss events and time course leading to her diagnosis). 2. History of ITP, status post splenectomy in 1991. 3. History of pneumonia, right lower lobe, _%#MM#%_ 2004. 4. History of HSV. 5. Hypothyroidism. 6. History of bilateral avascular necrosis of the hips secondary to high- dose prednisone treatment of ITP 1991.
ITP|idiopathic thrombocytopenic purpura|ITP|199|201|PAST MEDICAL HISTORY|3. History of pneumonia, right lower lobe, _%#MM#%_ 2004. 4. History of HSV. 5. Hypothyroidism. 6. History of bilateral avascular necrosis of the hips secondary to high- dose prednisone treatment of ITP 1991. 7. History of iron-deficiency anemia. 8. History of colon polyps. PHYSICAL EXAMINATION: On admission temperature 100.3, heart rate 103, blood pressure 97/51, respiratory rate 22, oxygen saturation 95% on room air.
ITP|idiopathic thrombocytopenic purpura|ITP,|267|270|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Burkitt lymphoma, diagnosed in late _%#MM#%_ 2004, been treated under protocol CALGB _%#PROTOCOL#%_, cycle #2 was from _%#MM#%_ _%#DD#%_, 2005, through _%#MM#%_ _%#DD#%_, 2005. 2. Normal cardiac function. MUGA scan #5 showed an EF of 58%. 3. ITP, status post splenectomy in 1998. 4. PE in _%#MM#%_ 2005, was on heparin protocol and discharged to home on Lovenox between admissions.
ITP|idiopathic thrombocytopenic purpura|ITP|145|147|CHIEF COMPLAINT|CHIEF COMPLAINT: The patient is a 54-year-old Caucasian female with past medical history significant for auto immune pericarditis, sclerosis and ITP in the past. She states she has poor wound healing due to her auto immune conditions. She got a flu shot in her arm on Tuesday.
ITP|idiopathic thrombocytopenic purpura|ITP|201|203|FOLLOWUP APPOINTMENTS|FOLLOWUP APPOINTMENTS: 1. Dr. _%#NAME#%_ in Gastroenterology, follow up TIPS and variceal bleed in approximately 1 month, _%#MMDD2007#%_, 09:15 a.m. 2. _%#NAME#%_ _%#NAME#%_, PA, Hematology, follow up ITP in one week at the University of Minnesota, _%#MMDD2006#%_, 02:30 p.m. 3. Dr. _%#NAME#%_, primary care, follow up hospitalization and hypertension within 2 weeks.
ITP|idiopathic thrombocytopenic purpura|ITP,|195|198|FOLLOWUP APPOINTMENTS|3. Dr. _%#NAME#%_, primary care, follow up hospitalization and hypertension within 2 weeks. 4. CBC with diff, follow white count as it was elevated at discharge, likely secondary to steroids and ITP, follow up in 1 week. 5. TIPS ultrasound, 1 month. MEDICATIONS: 1. Os-Cal Plus D 1000 mg p.o. daily.
ITP|idiopathic thrombocytopenic purpura|ITP|137|139|HOSPITAL COURSE|Hematology was consulted on _%#MMDD2007#%_ following the cancellation of surgery and their impression was that his platelets were due to ITP and not heparin-induced thrombocytopenia. Consequently, the patient will be discharged to home at this time with the plan for return for surgery at a later date.
ITP|idiopathic thrombocytopenic purpura|ITP|226|228|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 5-year-old girl with cartilage-hair hypoplasia who was diagnosed at birth with her older brother being previously diagnosed. She was doing well until _%#MM2007#%_ when she developed ITP and diminished B and T cell counts. She was treated with steroids, IVIG, packed red blood cells and Decadron, but counts remained low with petechiae persisting.
ITP|idiopathic thrombocytopenic purpura|ITP|179|181|PAST MEDICAL HISTORY|4. Small bowel obstruction. 5. Infiltrating ductal carcinoma of the left breast status post lumpectomy and radiation. 6. Paroxysmal atrial tachycardia. 7. Depression. 8. Possible ITP treated with WinRho. 9. Hypertension. RECENT PROCEDURES DONE DURING HER LAST HOSPITALIZATION: 1. Paracentesis on _%#MMDD2007#%_, _%#MMDD2007#%_, and _%#MMDD2007#%_.
ITP|idiopathic thrombocytopenic purpura|(ITP).|281|286|PAST MEDICAL HISTORY|1. End-stage renal disease due to IgA nephropathy. 2. Status post renal transplant in the year 2000, since failed to chronic allograft nephropathy. 3. Maintained on chronic peritoneal dialysis with a nighttime cycler. 4. Splenectomy in 1994 for idiopathic thrombocytopenic purpura (ITP). 5. History of peritonitis associated with peritoneal dialysis in _%#MM#%_ of 2004. CURRENT MEDICATIONS: 1. Metoprolol 100 mg b.i.d. 2. Lisinopril 20 mg b.i.d.
ITP|idiopathic thrombocytopenic purpura|(ITP).|310|315|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 45-year-old white female with a history of depression, two previous suicide gestures, alcohol abuse status post previous alcohol treatment, hepatitis C, hypothyroidism, hypertension, status post splenectomy in 1980 for idiopathic thrombocytopenic purpura (ITP). She is followed by _%#NAME#%_ _%#NAME#%_, MD at _%#CITY#%_ Sports Health & Wellness, PA. She presents after calling her father while drinking approximately around 4:30 p.m. this afternoon and telling him she was taking Elavil and Prinivil to kill herself.
ITP|idiopathic thrombocytopenic purpura|ITP|117|119|PAST MEDICAL HISTORY|He has no particular complaints aside from a fever that he feels is coming back. PAST MEDICAL HISTORY: 1. History of ITP treated with splenectomy in _%#MM2005#%_. 2. History of obesity treated with a gastric banding procedure in _%#MM2004#%_. Since that time he is he has lost 137 lbs.
ITP|idiopathic thrombocytopenic purpura|(ITP).|175|180|PAST MEDICAL HISTORY|16. Chronic reflux esophagitis. 17. Insomnia. 18. Osteopenia per DEXA scan. 19. Recurrent hemorrhoids. 20. Mild thrombocytopenia, probable idiopathic thrombocytopenic purpura (ITP). 21. Previous episode of shingles in 2001. CURRENT MEDICATIONS: 1. Multivitamin one a day. 2. Potassium chloride 8 mEq once daily.
ITP|idiopathic thrombocytopenic purpura|ITP|278|280|IMPRESSION/PLAN|I anticipate her platelets to increase over the next couple of days and if the platelet count is over 30,000 she could be sent home on prednisone with repeat counts next week on Monday and a follow-up in the office on Wednesday. I discussed the natural history and prognosis of ITP at great length with the patient and her mother who is accompanying her. They asked many questions and I answered them to their satisfaction.
ITP|idiopathic thrombocytopenic purpura|(ITP).|141|146|BRIEF HISTORY|She was admitted to Fairview Southdale Hospital with a platelet count of 3000. The working diagnosis was idiopathic thrombocytopenic purpura (ITP). HOSPITAL COURSE: She was started in IV immunoglobulin and prednisone 60-mg a day.
ITP|idiopathic thrombocytopenic purpura|ITP.|245|248|HISTORY|She presented initially with a platelet count of 18,000. She had investigations including an ANA, which was negative. Direct antiplatelet antibodies of IGG type were positive. Bone marrow aspirate and biopsy was unremarkable and consistent with ITP. She was treated initially as an outpatient with prednisone, a course of about a month. She responded very well and had complete remission; however, shortly after stopping the prednisone she relapsed and her platelets continued to decline steadily.
ITP|idiopathic thrombocytopenic purpura|ITP|163|165|IMPRESSION|PERINEUM: Perineal examination did not show any active bleeding. She has a mild tear; the bleeding has stopped by this time. IMPRESSION: 1) Severe exacerbation of ITP with level of 1,000. The rest of her blood picture is normal. 2) History of hypothyroidism, stable on supplement.
ITP|idiopathic thrombocytopenic purpura|ITP.|170|173|FAMILY HISTORY|SOCIAL HISTORY: Married, lives with his wife and drinks rare alcohol, no tobacco. Exercise is regular. He works as an electrician. FAMILY HISTORY: Includes a sister with ITP. REVIEW OF SYSTEMS: Negative for cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, neurologic symptoms.
ITP|idiopathic thrombocytopenic purpura|ITP.|144|147|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Pulmonary as above. 2. Diabetes. 3. Parkinson's, apparently induced by neuroleptics in the past. 4. Splenectomy due to ITP. He has apparently had a Pneumovax in the past with recently normal platelet counts. 5. Chronic back disease. 6. Hyperlipidemia. 7. Memory loss, felt to be possibly Alzheimer's.
ITP|idiopathic thrombocytopenic purpura|ITP.|147|150|SUMMARY OF HOSPITAL COURSE|Please refer to the admission history and physical for further details. After admission to the hospital, his picture was felt most consistent with ITP. He was initially treated with intravenous gamma- globulin and also platelet transfusions and his platelet count began to rise during the hospitalization.
ITP|idiopathic thrombocytopenic purpura|ITP|250|252|BRIEF HISTORY OF PRESENT ILLNESS|She is known to the Heme-Onc Department here at the University as she was just recently admitted at the end of _%#MM2007#%_ to the PICU with respiratory failure, severe epistaxis resulting in severe anemia. She has carried a presumptive diagnosis of ITP since _%#MM2007#%_ when she first presented with a particular rash, epistaxis and platelet counts in the 30,000 range. Since then, she has been followed periodically with platelet checks and has otherwise been doing well.
ITP|idiopathic thrombocytopenic purpura|ITP.|92|95||_%#NAME#%_ _%#NAME#%_ is currently being admitted for acute appendicitis and relapsed acute ITP. _%#NAME#%_ is well known to me. She is a 25-year-old African-American woman who has been treated for refractory idiopathic thrombocytopenic purpura and was found to be steroid resistant.
ITP|idiopathic thrombocytopenic purpura|ITP.|154|157|HOSPITAL COURSE|IV proton pump inhibitors were started for prophylaxis of her upper GI bleed. Lasix was used for her pulmonary edema. Her steroids were continued for her ITP. On the hospital day #3, the patient's low back pain significantly improved, her respiratory distress significantly resolved and she was transferred back to the Neurosurgery service.
ITP|idiopathic thrombocytopenic purpura|ITP|193|195|FOLLOWUP APPOINTMENT|3. Followup the CBC with platelets for rechecking the platelet count and hemoglobin within 3 days. 4. Hematology/Oncology Clinic for followup thrombocytopenia of unknown etiology, questionable ITP secondary to pulmonary hypertension. The medication and plan of treatment has been discussed with the patient.
ITP|idiopathic thrombocytopenic purpura|ITP.|253|256|HOSPITAL COURSE|Again, no obvious source for the bleeding was found and the patient was able to tolerate p.o. and have normal stools at the time of discharge. 3. Anemia/thrombocytopenia. The patient has a history PNH as well as history of thrombocytopenia secondary to ITP. The patient's hemoglobin did reach a low point of 7.3 during her hospitalization. The patient received a total of 4 units during her hospitalization.
ITP|idiopathic thrombocytopenic purpura|(ITP).|147|152|HOSPITAL COURSE|Megakaryocytes were also felt to be normal as well. The basis for this severe thrombocytopenia was felt related to immune thrombocytopenic purpura (ITP). In addition, it was noted that his MCV was quite low, consistent with possible thalassemia. Laboratory studies were sent for hemoglobin electrophoresis with results still pending at the time of discharge.
ITP|idiopathic thrombocytopenic purpura|ITP|189|191|HOSPITAL COURSE|Briefly, a 36-year-old gentleman with a history of ITP who presented with low grade fever and back pain. HOSPITAL COURSE: The patient was admitted to medicine service. Given his history of ITP and initial fever, he was started on ceftriaxone. The patient was afebrile and subsequently, it was discontinued. The patient also had some lesion on his kidney and liver, and he had an ultrasound to follow up on; the findings are as dictated above.
ITP|idiopathic thrombocytopenic purpura|(ITP).|60|65|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Idiopathic thrombocytopenic purpura (ITP). 2. Chronic lymphocytic leukemia (CLL). 3. Hypertension. PROCEDURES/TREATMENTS: 1. Intravenous immunoglobulin (IVIG) therapy. 2. Transfusion of platelets x1.
ITP|idiopathic thrombocytopenic purpura|(ITP)|142|146|FINAL DIAGNOSIS|FINAL DIAGNOSIS: 1. Chest pain, etiology unknown, noncardiac or pulmonary. 2. Coronary artery disease. 3. Idiopathic thrombocytopenic purpura (ITP) by history. 4. Anxiety. SUMMARY: _%#NAME#%_ _%#NAME#%_ is a 74-year-old male with known coronary disease who had a PTCA and stent which was evidently a somewhat difficult procedure.
ITP|idiopathic thrombocytopenic purpura|ITP|133|135|HISTORY OF PRESENT ILLNESS|She had no bright red blood. She had no melena and this has resolved. No nasal or sinus pain. She was admitted due to her history of ITP and platelet count, observed, and had no more episodes. X-ray of the sinus unremarkable. Being discharged today, she had follow-up with Dr. _%#NAME#%_ on Monday.
ITP|idiopathic thrombocytopenic purpura|ITP,|159|162|ASSESSMENT/PLAN|CBC: Hemoglobin 1.8. Platelet count 47,000. WBC 4000. D-dimer 0.3. TSH 12.7 which is elevated. ASSESSMENT/PLAN: 1. 69-year-old _%#NAME#%_ male with history of ITP, hypertension, distant diagnosis of iron deficiency anemia and recent diagnosis of benign positional vertigo. He is admitted for an episode of possible syncope. The patient's history and physical exam are consistent with vertigo- induced syncope with possible pre and post orthostatic hypotension secondary to medications.
ITP|idiopathic thrombocytopenic purpura|ITP|169|171|FAMILY HISTORY|This pregnancy was conceived with Gonal-F. PRENATAL COURSE: Complicated by subchorionic hemorrhage with bleeding in the first trimester. FAMILY HISTORY: Significant for ITP in her father. MEDICATIONS: Prenatal vitamins, folic acid. HOSPITAL COURSE: The patient was admitted on _%#MMDD2003#%_. Hemoglobin at that time was 10.7 with normal platelets.
ITP|idiopathic thrombocytopenic purpura|ITP|174|176|HOSPITAL COURSE|On day #2, after her first dose of Solu- Medrol, the patient's platelet count jumped to 15,000. On day of discharge her platelet count was up to 31,000. This exacerbation of ITP was felt to be due to her acute sinusitis. PROBLEM #2: Sinus infection. The patient was likely underdosed with her Augmentin at 500 mg b.i.d. The patient was started on 875 mg b.i.d. while in the hospital.
ITP|idiopathic thrombocytopenic purpura|ITP|195|197|PAST MEDICAL HISTORY|2. Stage I infiltrating ductal carcinoma of the right breast, status post radiation and Taxotere, Cytoxan chemotherapy x4 cycles. 3. B12 deficiency with possible pernicious anemia. 4. History of ITP as a child. 5. History of depression. 6. Tobacco abuse. 7. History of carcinoma in situ of the cervix in _%#MM1999#%_, status post LEEP procedure.
ITP|idiopathic thrombocytopenic purpura|ITP|372|374|HOSPITAL COURSE|10. Anxiety disorder. HOSPITAL COURSE: Ms. _%#NAME#%_ _%#NAME#%_ was a 64-year-old woman with a history of breast cancer, coronary artery disease and chronic kidney disease, who was transferred from Fairview Southdale with concerning for her worsening thrombocytopenia as well as end-stage renal disease, recently started on hemodialysis. She did not have any evidence of ITP nor TTP and there was no cause found for her worsening thrombocytopenia. Throughout her hospitalization, she continued to require increasing amounts of platelets and with minimal increased with the platelet transfusions.
ITP|idiopathic thrombocytopenic purpura|ITP.|167|170|IMPRESSION AND PLAN|D. Possibly alcohol abuse and hypersplenism. Agree with admission to oncology floor and as discussed with hematology will start the patient on prednisone for possible ITP. Hold off on any transfusion unless he bleeds acutely. Will work him up with an antiplatelet antibody, peripheral smear, get thyroid function tests, HIV test.
ITP|idiopathic thrombocytopenic purpura|ITP|175|177|HOSPITAL COURSE|Marrow blast counts were slightly increased at 3.3. Cytogenetic testing was also is normal. Therefore, at this time it is still a little bit difficult to tell whether this is ITP that did not respond to steroids versus myelodysplastic syndrome as he did not increase his platelets as expected. The patient did fail the prednisone therapy. Therefore, this continues to be tapered and he did have a trial of IVIG here.
ITP|idiopathic thrombocytopenic purpura|ITP.|310|313|PHYSICIAN FOLLOW-UP|1. Danazol 200 mg p.o. b.i.d. MEDICATIONS DISCONTINUED: Bactrim. NEW MEDICATIONS: Prilosec 20 mg p.o. daily to stop taking when the platelet count is above 20,000. PHYSICIAN FOLLOW-UP: _%#NAME#%_ _%#NAME#%_ will follow up with Dr. _%#NAME#%_ in one week with platelet count prior to visit to address patient's ITP. DIET: Diet as tolerated. ACTIVITIES: As tolerated. CONDITION OF PATIENT ON DISCHARGE: Stable.
ITP|idiopathic thrombocytopenic purpura|ITP.|196|199|HOSPITAL COURSE AND TREATMENT RENDERED|She was put on prophylactic Prilosec until her platelet count is above 20,000 as she has a history of bleeding. She will follow up with Dr. _%#NAME#%_ in one week to reassess the treatment of her ITP. Her danazol dose was increased to 200 mg p.o. b.i.d. 3. Chronic UTI. Patient was treated with Zosyn for a UTI. She will be off antibiotics until she has recurrent UTI if.
ITP|idiopathic thrombocytopenic purpura|ITP|155|157|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Status post hysterectomy with bilateral salpingo-oophorectomy for myomas. Currently on hormone replacement therapy. 2. History of ITP in 1990 cause unknown. No recurrence thus far. 3. Status post cholecystectomy. 4. Status post rectovaginal fistula repair after the birth of her first child.
ITP|idiopathic thrombocytopenic purpura|ITP|203|205|1. ID|We will guaiac her stools times three while here. We will recheck a hemoglobin tonight at 1800, and if it continues to drop consider transfusion. Check another BMP in the morning. She also has a history ITP which has a unknown cause normal the past. We will follower her platelet levels also as certain infections can cause decrease platelets overall.
ITP|idiopathic thrombocytopenic purpura|ITP.|29|32|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: Chronic ITP. HISTORY OF PRESENT ILLNESS: The patient is a 13-year-old male with a long history of chronic ITP status post 2 CNS bleeds. Was admitted twice in the past week, first for low platelets and one round of intravenous IG and secondly for possible third CNS bleed with complaints of headache and neck pain.
ITP|idiopathic thrombocytopenic purpura|ITP.|171|174|DISCHARGE DIAGNOSIS|Platelets at discharge on _%#MM#%_ _%#DD#%_, 2002, was 141,000. REVIEW OF SYSTEMS: Review of systems is only positive for headache and neck pain. PAST MEDICAL HISTORY: 1. ITP. Last IVIG treatment _%#MM#%_ _%#DD#%_, 2002. 2. Splenectomy in 1996. 3. History of migraine headaches. 4. History of CNS bleed in _%#MM#%_ of 2000 and in _%#MM#%_ of 2001.
ITP|idiopathic thrombocytopenic purpura|ITP,|255|258|PROBLEMS DURING PREGNANCY|Secondary to macrosomia, recommendations were made for delivery by primary cesarean section, and also given patient's medical history of ITP. PROBLEMS DURING PREGNANCY: 1. Gestational diabetes. The patient was on insulin and followed by Endocrinology. 2. ITP, which was followed by Hematology, Dr. _%#NAME#%_. The patient was treated with Win Rho D. Platelet levels were followed closely during the pregnancy. 3. The patient also had a subchorionic hemorrhage in the first trimester which resolved.
ITP|idiopathic thrombocytopenic purpura|ITP|224|226|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: _%#NAME#%_ _%#NAME#%_ is being admitted for accelerated phase of her atypical CML and elevated white count. HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ is an 84-year-old woman with a long history of chronic ITP which was complicated by left eye bleeding for which she underwent an enucleation of her left eye in early 2001. At that time she was treated with IVIG ______ high dose steroids and did not respond.
ITP|idiopathic thrombocytopenic purpura|ITP|213|215|PAST MEDICAL HISTORY|She denies chest pain, palpitations, orthopnea or PND. She denies nausea, vomiting, diarrhea, constipation, melena or bright red blood per rectum. She denies any urinary symptoms. PAST MEDICAL HISTORY: 1. Chronic ITP as above. 2. Atypical CML as above. 3. Arteriosclerosis, status post cardiac bypass grafting in 1993. PAST SURGICAL HISTORY: 1. Status post enucleation of left eyeball secondary to bleed.
ITP|idiopathic thrombocytopenic purpura|ITP|188|190|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 30-year-old G2, P 0-0-1-0 38 plus 3 weeks by last menstrual period consistent with a seven- week ultrasound with thrombocytopenia secondary to ITP with positive antiplatelet antibodies and fetus with two-vessel cord who presents for induction of labor. The patient is being induced due to her thrombocytopenia. Platelets on _%#MMDD2003#%_ were 100,000.
ITP|idiopathic thrombocytopenic purpura|ITP,|179|182|ALLERGIES|LABORATORY: On admission, her white count was 11.4, hemoglobin 15, and platelet count was only 1. HOSPITAL COURSE: In summary, she is a 50-year-old female with history of chronic ITP, preceding most likely viral upper respiratory tract infection, admitted because of failure of p.o. steroids. 1. Chronic ITP with thrombocytopenia admitted for IV steroid and she was given 500 mg of IV methyl prednisolone on the day of admission and the next day the platelet count peaked to 21,000 and another dose of 500 mg IV methyl prednisolone was given and on the third day, her platelet count was up to 60,000 and another 500 mg methyl prednisolone IV was given.
ITP|idiopathic thrombocytopenic purpura|ITP,|538|541|PAST SURGICAL HISTORY|He has a history of COPD, bronchiectasis, some fibrosis, history of coronary artery disease with a inferior wall infarct in 1981 and a total right coronary artery occlusion. He does have a history of some diastolic dysfunction and mild to moderate aortic stenosis, history of GI bleed in 2001 and 2003 and history of significant low back pain with sever L3-4 and moderate L4-5 subarticular stenosis PAST SURGICAL HISTORY: Cauterization of his nasal artery for recurrent epistaxis, splenectomy in 1957 for thrombocytopenia felt to be from ITP, total knee replacement on the left side in 1991, on the right side in 1992, TURP in 1992, small bowel obstruction with partial resection due to ischemia in _%#MM#%_ 2003 and a pacemaker inserted in _%#MM#%_ 2003.
ITP|idiopathic thrombocytopenic purpura|ITP,|212|215|HISTORY OF PRESENT ILLNESS ON ADMISSION|4. Large soft probable mass in second portion of duodenum with 2 overlying erosions. HISTORY OF PRESENT ILLNESS ON ADMISSION: The patient is a 54-year-old female with history of esophageal varices, hypertension, ITP, with chronically low platelet count, presenting with weakness and fatigue with symptoms of darkening of her vision when she sits up. The patient denied any symptoms of GI bleeding, nausea or vomiting.
ITP|idiopathic thrombocytopenic purpura|ITP.|206|209|PAST MEDICAL HISTORY|1. Codeine. 2. Sulfa. 3. Penicillin. MEDICATIONS: See orders. PAST MEDICAL HISTORY: 1. Positive for the history of CLL diagnosed in 2002, status post chemotherapy x2, including in 2003 and 2005. 2. Chronic ITP. 3. Hypertension. 4. Chronic diarrhea. 5. History of Clostridium difficile colitis. 6. Meniere's disease. 7. Migraine. 8. Gout. 9. Hypothyroidism. FAMILY HISTORY: Significant for several cancers in the family, including ovarian cancer, colon cancer, gastric cancer.
ITP|idiopathic thrombocytopenic purpura|ITP|239|241|DISPOSITION|She has a past history of a cholecystectomy, appendectomy, total abdominal hysterectomy and tonsillectomy surgeries in the past as well as the lung biopsy. She has known hypertension, hyperlipidemia, prediabetes and significant history of ITP in the past. FAMILY HISTORY: Significant for dad dying in his 70s of colon cancer and coronary artery disease and mother died at 89 of old age.
ITP|idiopathic thrombocytopenic purpura|ITP|103|105|PAST MEDICAL HISTORY|PAST SURGICAL HISTORY: 1. Hernia. 2. Appendectomy. PAST MEDICAL HISTORY: 1. Essential hypertension. 2. ITP as noted. MEDICATIONS: 1. Norvasc 5 mg daily. 2. Has been on a dose of prednisone. 3. Combivent inhaler 2 puffs t.i.d. ALLERGIES: 1. Hydrochlorothiazide.
ITP|idiopathic thrombocytopenic purpura|ITP.|162|165|ALLERGIES|2. Has been on a dose of prednisone. 3. Combivent inhaler 2 puffs t.i.d. ALLERGIES: 1. Hydrochlorothiazide. Patient was on hydrochlorothiazide at the time of his ITP. 2. Penicillin. REVIEW OF SYSTEMS: The patient's appetite has been poor and he thinks he has lost weight, although that has not been documented.
ITP|idiopathic thrombocytopenic purpura|ITP|181|183|HOSPITAL COURSE|Upon repeat lab testing here, his platelet count was confirmed markedly decreased at 4000. However, his ANC was within the normal range at 1600. We elected to treat the patient for ITP with an IV injection of RhoGAM. After the patient received this injection, he did develop some fever, chills and intravascular hemolysis secondary to this medication.
ITP|idiopathic thrombocytopenic purpura|ITP|143|145|HISTORY OF PRESENT ILLNESS|PROCEDURES: On _%#MMDD2007#%_, a laparoscopic splenectomy. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 9-year-old male with chronic ITP first diagnosed in _%#MM2006#%_ due to a suspected Norwalk infection. This patient was initially managed medically in order to keep his platelets in the normal range.
ITP|idiopathic thrombocytopenic purpura|ITP.|187|190|HISTORY OF PRESENT ILLNESS|Platelet closure time at that time was normal. Thrombocytopenia felt potentially secondary to consumption related to the right upper extremity hematoma. Thought not to be consistent with ITP. Potential low-grade DIC secondary to neoplasm could not be excluded. No perioperative bleeding complications. No history of blood clots. Denies recent steroids.
ITP|idiopathic thrombocytopenic purpura|ITP.|137|140|ASSESSMENT AND PLAN|We will check a B12, folate level. He has no other blood count lines down. One could consider an antiplatelet antibody. Possible chronic ITP. He has normal coagulation studies. No evidence for TTP or DIC. He reappears to be no culprit medications.
ITP|idiopathic thrombocytopenic purpura|(ITP)|139|143|HOSPITAL COURSE|He apparently had become increasingly confused and agitated following surgery. He has had a history of idiopathic thrombocytopenic purpura (ITP) and subsequently was admitted with fevers and found to have what seemed to be some mild prostatitis which was treated with Levaquin.
ITP|idiopathic thrombocytopenic purpura|ITP.|121|124|PAST SURGICAL HISTORY|PAST MEDICAL HISTORY: 1. Depression. 2. Reflux. 3. Obesity. PAST SURGICAL HISTORY: 1. Tubal ligation. 2. Splenectomy for ITP. 3. Tonsillectomy. ALLERGIES: No known drug allergies. HOME MEDICATIONS: None. SOCIAL HISTORY: She is a smoker. HOSPITAL COURSE: On _%#MMDD2003#%_, the patient was taken to the operating room where under general anesthesia, an open Roux-en-Y GI bypass was performed.
ITP|idiopathic thrombocytopenic purpura|ITP|145|147|PAST MEDICAL HISTORY|Status post three cycles of consolidation chemotherapy with high-dose Ara-C. 2. Depression. 3. Dental abscess. 4. Degenerative joint disease. 5. ITP - treated with corticosteroids and IV Ig ineffectively. HOSPITAL COURSE: The patient received cycle #4 consolidation with high-dose Ara-C without complication.
ITP|idiopathic thrombocytopenic purpura|ITP|175|177|PLAN|_%#NAME#%_ _%#NAME#%_ is an extremely pleasant, _%#1914#%_ male scheduled for cataract, whom I have been asked to see and clear for surgery by Dr. _%#NAME#%_. The patient has ITP and really otherwise is quite healthy. Because of his visual difficulty he is now scheduled for cataract surgery. The reader is referred to Dr. _%#NAME#%_'s notes for indications and type of procedure.
ITP|idiopathic thrombocytopenic purpura|ITP.|113|116|PAST MEDICAL HISTORY|The reader is referred to Dr. _%#NAME#%_'s notes for indications and type of procedure. PAST MEDICAL HISTORY: 1. ITP. The patient is followed closely for this by Dr. _%#NAME#%_. The patient has previously had treatment with corticosteroids quite some time ago.
ITP|idiopathic thrombocytopenic purpura|ITP|101|103|ASSESSMENT|Left bundle branch block. Compared to his prior EKG the changes are old. ASSESSMENT: 1. Cataract. 2. ITP with platelet count of 51 as noted. He did have slight bleeding difficulty after his tooth extraction. His platelet count I believe is adequate for the anticipated procedure.
ITP|idiopathic thrombocytopenic purpura|ITP|159|161|PAST MEDICAL HISTORY|The patient has also been through an AICD placement due to his cardiomyopathy which was not clearly ischemic in nature. 4. Carcinoma of the prostate, 1994. 5. ITP post splenectomy 1998. 6. Hyperthyroid leading hypothyroid after iodine ablation, presumably for Graves. 7. AV node ablation for atrial fibrillation with pacemaker placement in 1998.
ITP|idiopathic thrombocytopenic purpura|ITP|117|119|PAST MEDICAL HISTORY|The patient has had multiple falls and tripped and sustained pain in the right groin. PAST MEDICAL HISTORY: Included ITP breast cancer, essential hypertension. Status post permanent pacemaker. INITIAL PHYSICAL EXAMINATION: Revealed a tenderness in the right groin and pain with flexion of the right hip.
ITP|idiopathic thrombocytopenic purpura|ITP.|171|174|PAST MEDICAL HISTORY|The appendicolith was measured at 1.1 cm. There was no obvious intra-abdominal pathology. PAST MEDICAL HISTORY: The patient's past medical history is significant only for ITP. Her platelet count on admission was 117. MEDICATIONS: The patient takes prednisone 7.5 mg q.o.d. ALLERGIES: The patient reported a mild allergy to penicillin after which she had hives.
ITP|idiopathic thrombocytopenic purpura|ITP.|107|110|HOSPITAL COURSE|The patient was continued on IV ciprofloxacin in the hospital and has now completed a seven day course. 3. ITP. The patient's platelet count did drop as low as 10, but was 23 on the day of discharge. This is relatively stable for her, and she will follow-up with Hematology as an outpatient.
ITP|idiopathic thrombocytopenic purpura|ITP.|341|344|HOSPITAL COURSE|As part of her evaluation, she was found to be thrombocytopenic, she has a history of ITP and was treated empirically with prednisone and IgG. Her platelet count remained stable but a bone marrow biopsy was obtained prior to discharge to rule out metastatic malignancy to the marrow or other cause of thrombocytopenia aside from her current ITP. At the time of discharge, the patient was eager to go home.
ITP|idiopathic thrombocytopenic purpura|ITP.|166|169|PAST MEDICAL HISTORY|SOCIAL HISTORY: He rarely drinks any alcohol. He stopped smoking in 1970. He retired from banking in 1989. PAST MEDICAL HISTORY: SURGICAL: 1) Splenectomy in 1957 for ITP. 2) Total knee replacement on the left in 1991. 3) Total knee replacement on the right in 1992. 4) TURP in 1997. 5) Small bowel obstruction with partial bowel resection in _%#MM#%_, 2003.
ITP|idiopathic thrombocytopenic purpura|ITP|178|180|DISCHARGE MEDICINE PLAN|The LDH was normal. The reticulocyte count was increased. The direct antiglobulin test was 3+ positive. Diagnosis of additional hemolytic anemia was made or Evans Syndrome, i.e. ITP associated with hemolytic anemia. The patient's hemoglobin ran in the 8 range. She was transfused 2 units and her hemoglobin on the day of discharged is 12.0. At the present time the patient is discharged on Prednisone 60 mg a day, abstaining from Quinidine.
ITP|idiopathic thrombocytopenic purpura|ITP|114|116|DISCHARGE MEDICINE PLAN|She was converted to oral prednisone therapy and is being discharged on Prednisone at 60 mg per day. She had both ITP and hemolytic anemia, both seem to be stable at this time. In addition, she developed an episode of ischemic colitis. This resolved spontaneously and she is discharged on no further therapy.
ITP|idiopathic thrombocytopenic purpura|ITP|205|207|FOLLOW-UP|1. The patient will be followed by the intern on our service as a new primary care physician, Dr. _%#NAME#%_, already scheduled for _%#NAME#%_ _%#DD#%_, 2004. 2. Dr. _%#NAME#%_ _%#NAME#%_, who follows his ITP will see the patient _%#MM#%_ _%#DD#%_. 3. The patient will be followed up with Psychiatry. FOLLOW-UP LABS: The patient will have CBC drawn _%#MM#%_ _%#DD#%_, prior to his appointment with Dr. _%#NAME#%_.
ITP|idiopathic thrombocytopenic purpura|ITP,|187|190|HISTORY OF PRESENT ILLNESS|Vital signs were stable with normal breathing and O2 sats, normal heart exam with no murmur, and abdomen benign. Initial assessment included 34-week premature female infant EGA, maternal ITP, rule-out sepsis. IV fluids were started and CBC and blood cultures were obtained and antibiotics started.
ITP|idiopathic thrombocytopenic purpura|(ITP).|206|211|ASSESSMENT|This may have been complicated by her narcotic usage or her low back pain. 2. Long-standing history of significant hypertension. 3. History of polymyalgia rheumatica and idiopathic thrombocytopenic purpura (ITP). 4. Autoimmune hemolytic anemia. Because of her significant anemia, we are transfusing her and covering her with insulin as needed.
ITP|idiopathic thrombocytopenic purpura|ITP.|211|214|ASSESSMENT|Cardiac echo as noted above. Prior ECG in _%#MM#%_ 2004 shows the right bundle branch block and her ECG has really not significantly changed. ASSESSMENT: 1. Uterine prolapse. 2. Thrombocytopenia which is likely ITP. There is a question of whether she has any rheumatologic disorder and this is currently being evaluated, but certainly she is feeling much better at this point and I do not think this should affect her surgical status.
ITP|idiopathic thrombocytopenic purpura|ITP|138|140|PRIOR SURGERIES|PAST MEDICAL HISTORY: 1. Intermittent depression. 2. Reflux gastritis. 3. Obesity. PRIOR SURGERIES: 1. Tubal ligation. 2. Splenectomy for ITP remotely. 3. Tonsillectomy. 4. She denies any bleeding or anesthetic complications. SOCIAL HISTORY: She continues to smoke one pack daily. MEDICATIONS: Over-the-counter cold medications.
ITP|idiopathic thrombocytopenic purpura|ITP|168|170|PAST MEDICAL HISTORY|Musculoskeletal: No bone pain. No history of arthritis. The rest of the system review is unremarkable. PAST MEDICAL HISTORY: Low grade non-Hodgkin's lymphoma as above. ITP since late 2002. Hx of right-sided lazy eye. MEDICATIONS: Claritin. He received last dose of IV IG two weeks ago.
ITP|idiopathic thrombocytopenic purpura|ITP.|183|186|PAST MEDICAL HISTORY|He was given Pneumovax, H. flu and N. meningitis immunizations on _%#MM#%_ _%#DD#%_, 2004, in anticipation of a splenectomy. PAST MEDICAL HISTORY: 1. Chronic lymphocytic leukemia. 2. ITP. 3. AHA. PAST SURGICAL HISTORY: None. ADMISSION MEDICATIONS: 1. Allopurinol.
ITP|idiopathic thrombocytopenic purpura|ITP.|159|162|PAST SURGICAL HISTORY|He has a history of mild dementia. He has a history of underlying atrial fibrillation with a pacemaker present. PAST SURGICAL HISTORY: Splenectomy in 1957 for ITP. He had bilateral knee replacements with transurethral resection of the prostate in 1997. He had a partial small bowel resection for strangulated small bowel, right inguinal hernia in 2003, pacemaker inserted in _%#MM#%_, 2003 for bradycardia limiting his Coreg usage.
ITP|idiopathic thrombocytopenic purpura|ITP.|238|241|IMPRESSION|INR is 1.02. EKG is pending. IMPRESSION: _%#1914#%_ woman with isolated thrombocytopenia without other lymphadenopathy or splenomegaly on examination. With the abscess of recent infectious symptoms or new medications, this is most likely ITP. Alternate diagnosis would include a hematologic malignancy or conceivably an isolated platelet production disorder. At her age, and dementia status, I favor empiric treatment.
ITP|idiopathic thrombocytopenic purpura|ITP|195|197|PAST MEDICAL HISTORY|2. Prilosec 20 mg p.o. b.i.d. PAST MEDICAL HISTORY: 1. Crohn's disease diagnosed _%#MM2003#%_ with three hospitalizations since _%#MM2003#%_. 2. Chronic anemia with baseline hemoglobin of 10. 3. ITP diagnosed at the age of 12. 4. Hospitalization for mononucleosis at the age of 2. 5. Status post PE tubes x 2 and right TM reconstruction.
ITP|idiopathic thrombocytopenic purpura|ITP,|312|315|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 30-year-old gravida 3, para 1, 0, 1, 1, at 39 weeks' gestation by a 20-week ultrasound giving her an estimated date of delivery of _%#MM#%_ _%#DD#%_, 2004. She has a history of a prior cesarean and desires a repeat cesarean delivery. This pregnancy is complicated by ITP, but her latest platelet level was normal. On admission, she reported good fetal movement without any contractions and no other complaints.
ITP|idiopathic thrombocytopenic purpura|ITP|170|172|DISCHARGE DIAGNOSIS|Blood smear was significant for marked thrombocytopenia, but was otherwise normal. HOSPITAL COURSE: ITP. The patient was admitted and the rest of her labs confirmed that ITP was the most likely diagnosis. She was treated with steroids 40 mg p.o. q. day for 4 days total, and then stopped. Over the course of the 4 days, her bleeding stopped and at the time of discharge, her platelets were up to 10.
ITP|idiopathic thrombocytopenic purpura|ITP|141|143|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 29-year-old male with a recent diagnosis of Burkitt's lymphoma. The patient has a history of ITP with splenectomy approximately 6 years ago. This fall the patient was found to have a few nodes in his left axilla and these were biopsied, and found to be Burkitt's lymphoma.
ITP|idiopathic thrombocytopenic purpura|ITP,|280|283|PRIMARY PHYSICIANS|3. Hypothyroid. PRIMARY PHYSICIANS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD _%#NAME#%_ _%#NAME#%_, MD HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 29-year-old gentleman who was diagnosed with Burkitt's lymphoma in _%#MM#%_ 2005. His past medical history is significant for ITP, which did not respond to conservative medical management, so he underwent splenectomy in 1998. The patient had done well in terms of his ITP following the splenectomy until approximately _%#MM#%_ 2004 when he presented with a recurrence of some petechiae.
ITP|idiopathic thrombocytopenic purpura|ITP|186|188|PRIMARY PHYSICIANS|His past medical history is significant for ITP, which did not respond to conservative medical management, so he underwent splenectomy in 1998. The patient had done well in terms of his ITP following the splenectomy until approximately _%#MM#%_ 2004 when he presented with a recurrence of some petechiae. This finding and some lower platelet counts were associated with recent change in his normal dietary habit, and a decision was made to simply monitor him to see if his condition improved or stabilized.
ITP|idiopathic thrombocytopenic purpura|ITP,|135|138|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Right leg pain. HISTORY OF PRESENT ILLNESS: A 71-year-old _%#NAME#%_ male with a past medical history significant for ITP, hypertension, diabetes mellitus, iron deficiency anemia, and diffuse lytic bone lesions in his pelvis and bilateral lower extremities was admitted last night for right lower extremity pain. The patient stated he was unable to bear weight on his right leg.
ITP|idiopathic thrombocytopenic purpura|ITP.|184|187|PROBLEM #4|The patient is still on iron supplements. He has required frequent transfusions in the past. His hemoglobin has been stable at 11.8. PROBLEM #4: Thrombocytopenia. This is secondary to ITP. The patient's platelet count has been stable. His platelet count this morning is 104,000. PROBLEM #5: Hypertension. Blood pressure is well-controlled on Norvasc of 5 mg p.o. daily which will be continued here.
ITP|idiopathic thrombocytopenic purpura|ITP,|199|202|DISCHARGE DIAGNOSIS|DOB: ADMISSION DIAGNOSIS: Intrauterine pregnancy, 30 weeks gestation, ITP, polyhydramnios, gestational diabetes, failure to progress. DISCHARGE DIAGNOSIS: Intrauterine pregnancy, 30 weeks gestation, ITP, polyhydramnios, gestational diabetes, failure to progress, and primary low segment transverse cesarean section. HOSPITAL COURSE: The patient was submitted to the hospital and on _%#MMDD2005#%_, underwent a primary low segment transverse cesarean section under spinal anesthesia with a blood loss of 700 cc.
ITP|idiopathic thrombocytopenic purpura|ITP|145|147|ASSESSMENT/PLAN|Overall the patient's mortality during the BMT is approximately 35 to 40%. We will check labs per protocol. 3. Hem. The patient has a history of ITP and begins her chemotherapy with a subnormal platelet count. We will need to watch this very closely in addition to monitor closely for any signs of bleeding.
ITP|idiopathic thrombocytopenic purpura|ITP,|206|209|HISTORY|Gestational diabetes was in excellent control. She also had an episode of preterm labor which was stopped by terbutaline. The patient was scheduled for repeat cesarean section at 371/2 weeks because of her ITP, gestational diabetes, and previous cesarean section for a baby who was approximated at almost 81/2 pounds. HOSPITAL COURSE: The patient underwent repeat cesarean section under spinal anesthesia, with husband present.
ITP|idiopathic thrombocytopenic purpura|ITP|328|330|PLAN|I discussed at length the indications for the procedure, the procedure itself including placement of incision, risks including intraoperative and postoperative bleeding and infection as well as the possibility of recurrence, numbness to the area and cosmetic changes. The possibility of significant bleeding with her history of ITP as well as it being a hemangioma were discussed. Benefits and alternatives were discussed and questions were answered. She is interested in proceeding with this and this is scheduled for _%#MMDD2006#%_ at Fairview Southdale Hospital under local anesthesia.
ITP|idiopathic thrombocytopenic purpura|ITP.|150|153|PAST MEDICAL HISTORY|She has no history of similar problem. PAST MEDICAL HISTORY: 1. Diabetes type 2. 2. Hypertension. 3. Atrial fibrillation. 4. Osteoporosis. 5. Chronic ITP. 6. Arthritis. PAST SURGICAL HISTORY: 1. Lumpectomy x3, all benign.
ITP|idiopathic thrombocytopenic purpura|ITP|157|159|HISTORY  OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 50-year-old gentleman with history of non-Hodgkin's lymphoma in remission for over 2 years, IgA nephropathy, ITP and status post splenectomy. He presented to the emergency room with sudden onset of rigors, chills and fever for the past 10 hours.
ITP|idiopathic thrombocytopenic purpura|ITP,|160|163|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Nausea and vomiting for five days. HISTORY OF PRESENT ILLNESS: This is a 71-year-old woman with a past medical history significant for chronic ITP, status post splenectomy, diabetes mellitus, chronic obstructive pulmonary disease, obstructive sleep apnea, with a chronic tracheostomy, diabetes mellitus and hypertension, who presented to the emergency department yesterday with complaints of vomiting for the last five days. The patient denied any hematemesis. She denied any fever or chills.
ITP|idiopathic thrombocytopenic purpura|ITP,|107|110|PAST MEDICAL HISTORY|FAMILY HISTORY: She denies any diabetes mellitus or hypertension. PAST MEDICAL HISTORY: 1. Significant for ITP, status post splenectomy in 1997, and status post acute exacerbation of her ITP in _%#MM2004#%_. 2. Hypertension. 3. COPD. 4. Obstructive sleep apnea. 5. Diabetes mellitus.
ITP|idiopathic thrombocytopenic purpura|ITP.|170|173|IMPRESSION|Blood morphology smeared, look for evidence for hemolysis. 2. Status post mastectomy for inflammatory breast cancer. Will ask her surgeon to see her. 3. Osteoporosis. 4. ITP. 5. Hypertension.
ITP|idiopathic thrombocytopenic purpura|(ITP)|282|286|ASSESSMENT/PLAN|Direct antiglobulin test is negative. ASSESSMENT/PLAN: This is a 21-year-old woman who is otherwise well who presents with a 1 1/2 week history of lower extremity bruising. The differential here is somewhat broad. I would consider causes such as idiopathic thrombocytopenic purpura (ITP) or infection, in particular, parvovirus. I doubt hepatitis in this patient. I also doubt HIV. She and her partner are mutually monogamous. I think in the first instance it may well be worth obtaining hepatitis B and C serologies as well as antiplatelet antibodies.
ITP|idiopathic thrombocytopenic purpura|ITP.|169|172|PLAN|The risks, including but not limited to the risks of anesthesia, infection, hemorrhage, damage to adjacent structures and increased chance of bleeding in a patient with ITP. The patient states she understands the procedure and the risks and benefits of the procedure. The patient's questions have been answered. The patient agrees to the procedure.
ITP|idiopathic thrombocytopenic purpura|ITP|209|211|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSIS: Immune thrombocytopenic purpura with bleeding. MAJOR PROCEDURES/TREATMENTS: Intravenous immunoglobulin infusion. HISTORY OF PRESENT ILLNESS: This is a 74-year-old female with a history of ITP diagnosed in _%#MM#%_ 2002, status post steroid treatment, and after which a splenectomy was done since she did not tolerate a taper, in _%#MM#%_ 2002.
ITP|idiopathic thrombocytopenic purpura|ITP.|208|211|PAST MEDICAL HISTORY|The patient tripped and fell at her home, hitting her face and sustaining contusions and a bloody nose. PAST MEDICAL HISTORY: 1. Recent multiple falls. 2. Carcinoma of the breast. 3. Rheumatoid arthritis. 4. ITP. 5. Essential hypertension. 6. Osteoporosis. 7. Hypothyroidism. 8. Depression. INITIAL PHYSICAL EXAMINATION: Revealed extensive facial ecchymoses and nasal packs in place.
ITP|idiopathic thrombocytopenic purpura|ITP.|156|159|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 77-year-old with ITP admitted to the hospital with a platelet count of 1,000 as a consequence of the ITP. He was admitted to the hospital for intravenous IV IG. His hospitalization was without incident. He did receive 1 gram per kilogram of IV IG daily for two days.
ITP|idiopathic thrombocytopenic purpura|ITP,|233|236|HISTORY OF PRESENTATION|Their assessment was that she had a severe pulmonary hypertension with significantly elevated right-sided pressures. She had had a history of medical noncompliance and was likely a poor candidate for transplant. She also had chronic ITP, which was part of the reason for her transfer to the Hematology Service for ongoing treatment. While on the Hematology Service, she was undergoing plasmapheresis on an every other day schedule.
ITP|idiopathic thrombocytopenic purpura|ITP,|134|137|HISTORY OF PRESENTATION|She had a history of contrast allergy and thus was not able to obtain pulmonary emboli on the CT scan. Regardless, due to her TTP and ITP, she would not have been able to receive anticoagulation therapy as it would be contraindicated. Plan further was to have a VQ scan in the morning to further assess for possible pulmonary embolism.
ITP|idiopathic thrombocytopenic purpura|(ITP),|309|314|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Transferred from Fairview Transitional Care Services to _%#CITY#%_ Campus Intensive Care Unit secondary to tachycardia and hypotension. HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old white female with past medical history significant for chronic idiopathic thrombocytopenic purpura (ITP), status post splenectomy, diabetes mellitus, chronic obstructive pulmonary disease and obstructive sleep apnea on chronic tracheostomy. She was at Fairview Transitional Care Services when she was found to have a heart rate of 150 and systolic blood pressure of 70-80s.
ITP|idiopathic thrombocytopenic purpura|ITP.|140|143|REVIEW OF SYSTEMS|Does complain of weakness of the lower extremities bilaterally, which has been associated with her suprapubic pain. HEMATOLOGIC: History of ITP. ALLERGIES: Reviewed today, as noted above. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 148/54, heart rate 79, respirations 18, temperature 96.8. GENERAL: The patient is a pleasant, elderly woman in no distress, who is alert and oriented.
ITP|idiopathic thrombocytopenic purpura|ITP|259|261|HISTORY OF PRESENTING ILLNESS|3. Dependent IADLs. 4. Subdural hematoma. 5. Aplastic anemia/idiopathic thrombocytopenic purpura requiring frequent platelets transfusions. 6. Dysphasia. 7. Hypertension. HISTORY OF PRESENTING ILLNESS: Ms. _%#NAME#%_ is a 67-year-old female with a history of ITP and aplastic anemia who was admitted status post subdural hematoma after a fall as well as history of seizure disorders. Following admit to the acute rehab, she underwent physical therapy, occupational therapy and speech language pathology b.i.d. She participated in a motivated fashion and showed good progress.
ITP|idiopathic thrombocytopenic purpura|ITP|246|248|PAST MEDICAL HISTORY|3. Polymyalgia rheumatica, on prednisone. 4. Coronary disease, status post coronary artery stent approximately one year ago. 5. Prostate enlargement, status post TUNA surgery. 6. Mild to moderate aortic insufficiency. 7. Dyslipidemia history. 8. ITP history. 9. Chronic renal insufficiency with baseline creatinine 1.5. 10. Hernia surgery. 11. Appendectomy. CURRENT MEDICATIONS: 1. Coumadin, the patient takes 5 mg on all days except Friday when he takes 2.5 mg.
ITP|idiopathic thrombocytopenic purpura|ITP.|180|183|ADDENDUM|The patient is going to be obtaining blood pressure monitoring equipment for home use. Her platelet count today was 42,000. Platelet infusion for today secondary to her underlying ITP. Cross match platelets were requested. Once she receives her 5 pack of platelets the patient will be discharged home with previous discharge instructions.
ITP|idiopathic thrombocytopenic purpura|ITP.|185|188|HISTORY OF PRESENT ILLNESS|DATE OF ADMISSION: _%#MMDD2006#%_ DATE OF DISCHARGE: _%#MMDD2006#%_ HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 78-year-old male with a history of Waldenstrom's disease and chronic ITP. The patient developed severe thrombocytopenia in the weeks prior to admission despite steroid therapy, and he therefore received a single-dose of WinRho 2 days prior to admission.
ITP|idiopathic thrombocytopenic purpura|ITP|136|138|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Autoimmune pericarditis in the past. She states she has poor wound healing due to her autoimmune condition. 2. ITP in the past. 3. Hypertension. 4. Insomnia. MEDICATIONS: 1. Ziac 5 mg once a day for hypertension. 2. Trazodone at bedtime for insomnia.
ITP|idiopathic thrombocytopenic purpura|ITP|156|158|PAST MEDICAL HISTORY|DISCHARGE DIAGNOSIS: 1. Chronic idiopathic thrombocytopenic purpura with low platelet here for intravenous immunoglobulin. PAST MEDICAL HISTORY: 1. Chronic ITP last time this patient received IVIG was in _%#MM2005#%_. 2. Myasthenia gravis. 3. Hypothyroidisms. 4. Osteopenia. 5. Hyperlipidemia.
ITP|idiopathic thrombocytopenic purpura|ITP,|211|214|HISTORY OF PRESENT ILLNESS|She was previously followed by Dr. _%#NAME#%_. She has received 2 cycles of fludarabine for her CLL, once in 2003 and once in 2005. In _%#MM2005#%_ she received prednisone with a long taper for treatment of her ITP, which responded nicely to her steroids. She has not had a problem with this since then. She denies any frank bleeding, gross hematuria, bright red blood per rectum, hemoptysis, etc.
ITP|idiopathic thrombocytopenic purpura|(ITP)|221|225|ASSESSMENT|ASSESSMENT: 1. Right leg cellulitis due to lymphedema: Continue Zosyn, vancomycin and Pharm D to follow. 2. Chronic pain due to osteoarthritis: Consider continuing MS and MS-Contin. 3. Idiopathic thrombocytopenic purpura (ITP) and anemia: Stable 4. Right mouth sores: Will check with clinic what she was using. 5. Check with ortho re: outpatient consultation pending this week regarding severe osteoarthritis of the shoulders and possible surgery.
ITP|idiopathic thrombocytopenic purpura|ITP.|126|129|HOSPITAL COURSE|This was felt likely due to ITP or Evans' syndrome. The patient was treated with one dose of IVIG for a presumed diagnosis of ITP. She was pre-treated with Benadryl and Tylenol and tolerated the IVIG well. The patient was noted to have worsening anemia during her hospital stay with a low hemoglobin of 7.3. This was felt to be due to some blood loss as the patient did have guaiac-positive stools and also dilutional as the 7.3 figure was found after her treatment with IVIG.
ITP|idiopathic thrombocytopenic purpura|ITP|204|206|HOSPITAL COURSE|PAST MEDICAL HISTORY AND OUTPATIENT MEDICATIONS: Please see admission history and physical dated _%#MMDD2007#%_. HOSPITAL COURSE: Ms. _%#NAME#%_ was an 81-year-old female with history of hypertension and ITP on chronic steroids who was noted to be more lethargic and less responsive at her nursing home and became jaundiced on the day of admission.
ITP|idiopathic thrombocytopenic purpura|(ITP)|191|195||She had florid ecchymosis and petechiae on physical exam and her platelet count on admission was 10,000. Therefore, the presumptive diagnosis on admission was immune thrombocytopenic purpura (ITP) secondary to either the recent Bactrim or idiopathic immune causes. During her hospital stay, she was placed on prednisone at a starting dose of 30 mg p.o. b.i.d. Interestingly, she also had significant renal dysfunction on admission with a creatinine level of 7.2. Therefore, she was seen in conjunction with nephrology service (Dr. _%#NAME#%_ _%#NAME#%_) and had various fluid and medication maneuvers to preserve renal function.
ITP|idiopathic thrombocytopenic purpura|(ITP)|310|314|BRIEF HISTORY|4. Left hip pain. BRIEF HISTORY: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ was a _%#1914#%_ man who was admitted to Fairview Southdale Hospital on _%#MMDD2002#%_ with a history of marked thrombocytopenia requiring corticosteroid therapy. Mr. _%#NAME#%_ did have a history of chronic idiopathic thrombocytopenic purpura (ITP) which had been responsive to corticosteroids in the past. HOSPITAL COURSE: He was admitted to Fairview Southdale Hospital on _%#MMDD2002#%_ with thrombocytopenia with a platelet count of 2000.
ITP|idiopathic thrombocytopenic purpura|ITP.|118|121|PAST MEDICAL HISTORY|On further questioning she denied any hematemesis, hematochezia, or melena. PAST MEDICAL HISTORY: 1. Hypertension. 2. ITP. 3. GERD. 4. History of strangulated hernia. 5. History of spinal stenosis, status post surgical repair. 6. History of ischemic colitis five years ago. 7. Osteoarthritis.
ITP|idiopathic thrombocytopenic purpura|ITP|154|156|RECOMMENDATIONS|Other considerations would be splenectomy or use of WinRho although I do not think these are indicated at present. I have reviewed the natural history of ITP with Mr. _%#NAME#%_, including the fact that some individuals can have chronic relapsing courses and that additional treatments are needed.
ITP|idiopathic thrombocytopenic purpura|ITP|115|117|DOB|DOB: _%#MMDD1943#%_ _%#NAME#%_ _%#NAME#%_ is a pleasant 59-year-old white female, a minister, who has a history of ITP diagnosed in _%#MM#%_ of this year, followed by a splenectomy in _%#MM#%_ of this year. She presented to the emergency room this evening with a 24 hour history of nausea, vomiting, and continuous bloody diarrhea since approximately 8:00 last night.
ITP|idiopathic thrombocytopenic purpura|ITP|219|221|PROCEDURES|HOSPITAL COURSE: PROBLEM #1: Thrombopenia. The patient's smear did not reveal any schistocytes and his coagulation studies were normal. Hemolysis studies were normal. He had a negative HIV test. This strongly suggested ITP and the patient was started on prednisone. On day four of his prednisone therapy, his platelets were still less than 10 and so we initiated IVIG therapy.
ITP|idiopathic thrombocytopenic purpura|ITP|175|177|PAST MEDICAL HISTORY|She states she has had chest pain but no in the previous and prior to that point, she had a brief episode which resolved with one nitroglycerin pill. PAST MEDICAL HISTORY: 1. ITP admission _%#MM2002#%_. Confirmed by bone marrow biopsy, responded well to steroid therapy. Currently on steroid therapy secondarily to that. 2. Chronic COPD.
ITP|idiopathic thrombocytopenic purpura|ITP|188|190|IMPRESSION|She did ask about the use of Procrit and this could also be obtained as well although will probably not dramatically affect her strength given her underlying other problems. 5. History of ITP with very mild thrombocytopenia. No active clinical bleeding. PLAN: 1. She will be started on some morphine and if she is able to tolerate this, she will continue this on a regular basis.
ITP|idiopathic thrombocytopenic purpura|ITP|217|219|HISTORY OF PRESENT ILLNESS|His illness has been complicated by two CNS bleeds in _%#MM1996#%_ and _%#MM2001#%_, with no neurologic sequelae. The patient has been admitted several times by F-UMC and _%#CITY#%_ Medical Center for relapses of his ITP and fever. He had been getting IVIG treatments every 4-6 weeks. _%#NAME#%_'s last admission was from _%#MMDD2002#%_ to _%#MMDD2002#%_ for recurrent persistent fevers, nausea, vomiting, and a rash.
ITP|idiopathic thrombocytopenic purpura|ITP.|125|128|PAST SURGICAL HISTORY|2. TURP in 1992. 3. Right total knee replacement in 1992. 4. Left total knee replacement in 1991. 5. Splenectomy in 1957 for ITP. MEDICATIONS: 1. Asacol 400 mg, two tablets q.i.d. 2. Caltrate twice a day.
ITP|idiopathic thrombocytopenic purpura|ITP.|141|144||She does have a history of breast cancer treated 5 years ago with lumpectomy and has a history of left lower extremity DVT. Also, history of ITP. MEDICATIONS: Protonix which was recently started, states something for bowel movement, ibuprofen, Allegra and Os Cal.
ITP|idiopathic thrombocytopenic purpura|ITP|230|232|SUMMARY OF HOSPITAL COURSE|PROCEDURES PERFORMED DURING HOSPITALIZATION: 1. Transfusion of platelets. 2. Administration of intravenous immunoglobulin. SUMMARY OF HOSPITAL COURSE: Ms. _%#NAME#%_ _%#NAME#%_ is a 49- year-old woman who has a known diagnosis of ITP and who was admitted to Fairview Southdale on _%#MMDD2002#%_ with progressive vaginal bleeding. At the time of admission she was found to have a platelet count of 8,000.
ITP|idiopathic thrombocytopenic purpura|ITP|165|167|SUMMARY OF HOSPITAL COURSE|At the time of admission she was found to have a platelet count of 8,000. Her hemoglobin was 13.3 and white count was 7,200. She was felt to have progression of the ITP and was begun on 60 mg of prednisone daily and also was treated with IV Ig given daily for two days. She tolerated this well. After administration of the first dose of IV Ig was at 25,000, the vaginal bleeding seemed to decrease significantly and she was felt ready for discharge on _%#MMDD2002#%_.
ITP|idiopathic thrombocytopenic purpura|ITP|333|335|EVALUATION OF UNDERLYING SYNDROME|A response would lend support to the idea that he has ITP in association with hypogammaglobulinemia, but that will have to be discovered in the outpatient setting. If he does have ITP, it is unclear whether the severity of the thrombocytopenia reflects the influence of his acute inflammatory illness or if it instead means that his ITP will now be an active problem for him. DISCHARGE PLAN: Mr _%#NAME#%_ is a student at UMD, and therefore will receive some of his follow-up care in _%#CITY#%_; I have sent outlines of his case to Dr. _%#NAME#%_ _%#NAME#%_ (St. Luke's Hematology/Oncology) and to Dr. _%#NAME#%_ _%#NAME#%_ (_%#CITY#%_ Clinic).
ITP|idiopathic thrombocytopenic purpura|ITP)|274|277|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSES: 1. Thrombocytopenia possibly due to atypical ITP. 2. Cachexia. 3. Hypokalemia. 4. Metabolic alkalosis. 5. Hyponatremia. HISTORY OF PRESENT ILLNESS: The patient is a 45-year-old female with chronic thrombocytopenia of unknown etiology (possible atypical ITP) who presents to the Heme/Oncology Clinic to have a bone marrow biopsy performed. The patient was found to be severely hypokalemic. The patient had also complained of extreme fatigue, nausea, and a 20-pound weight loss since _%#MM2002#%_.
ITP|idiopathic thrombocytopenic purpura|(ITP),|223|228|PAST MEDICAL HISTORY|3. History of depression, for which he has received ECT treatments x 5 within the last year. 4. History of atrial fibrillation, controlled on digoxin. 5. Bilateral hip osteoarthritis. 6. Idiopathic thrombocytopenic purpura (ITP), treated by splenectomy. 7. Claustrophobia. 8. Seasonal/environmental allergies. 9. Gastroesophageal reflux disease. PAST SURGICAL HISTORY: Splenectomy for ITP. CURRENT MEDICATIONS: 1. Digoxin 0.375 mg p.o. q.d. 2. Allegra 180 mg p.o. q.d.
ITP|idiopathic thrombocytopenic purpura|ITP.|112|115|PAST SURGICAL HISTORY|8. Seasonal/environmental allergies. 9. Gastroesophageal reflux disease. PAST SURGICAL HISTORY: Splenectomy for ITP. CURRENT MEDICATIONS: 1. Digoxin 0.375 mg p.o. q.d. 2. Allegra 180 mg p.o. q.d. 3. Accolate 20 mg p.o. b.i.d. 4. Nasalide 2 puffs b.i.d.
ITP|idiopathic thrombocytopenic purpura|ITP|249|251|PAST MEDICAL HISTORY|1. CLL, diagnosed _%#MM2001#%_. Status post chlorambucil, Rituxan, fludarabine. Last received dose reduced fludarabine on _%#MMDD2003#%_. See HPI for complication following fludarabine. See HPI for complications following fludarabine. 2. History of ITP 1989. Status post IVIG and steroids. 3. C-section x 3. 4. Status post hysterectomy secondary to endometriosis. 5. Cardiomyopathy. Last echo on _%#MMDD2003#%_ showed an EF of approximately 25%.
ITP|idiopathic thrombocytopenic purpura|ITP|103|105|PAST MEDICAL HISTORY|MAINTENANCE MEDICATIONS: Lotrel for hypertension. PAST MEDICAL HISTORY: 1. History of hypertension. 2. ITP status post splenectomy 1997. 3. He states he had a peptic ulcer many years ago. 4. He consumes some alcohol, about one glass of beer or wine per day.
ITP|idiopathic thrombocytopenic purpura|ITP|185|187|SUMMARY OF THE PATIENT'S HOSPITAL COURSE|She agreed to hospice enrollment and this was the plan at the time of discharge. In addition at hospitalization she was noted to have thrombocytopenia. This was felt most likely due to ITP possibly from cancer. She was begun on prednisone at 20 mg twice daily and had a steady improvement in her platelet count, up to 66,000 by the time of discharge.
ITP|idiopathic thrombocytopenic purpura|ITP,|117|120|REVISED REPORT|His atrial fibrillation was still present and was rate controlled. He was on steroids for his low platelet count for ITP, and was placed on a regimen as per the hematologist. He was finally transferred to transitional care on _%#MM#%_ _%#DD#%_.
ITP|idiopathic thrombocytopenic purpura|ITP|179|181|HOSPITAL COURSE|She was born on _%#MMDD2004#%_ at FUMC _%#CITY#%_ and transferred to the NICU on _%#MMDD2004#%_ and discharged on _%#MMDD2004#%_. The mother's pregnancy was complicated by severe ITP requiring steroids, splenectomy, and IVIG. The infant was delivered NSVD with Apgar scores of 8 at one minute and 9 at five minutes. _%#NAME#%_ was a pre-term AGA female infant, 2980 gm at 35 weeks gestation, with a length of 48 cm and head circumference of 32.5 cm.
ITP|idiopathic thrombocytopenic purpura|ITP|241|243|HOSPITAL COURSE|Ongoing problems and suggested management: 1. FEN- _%#NAME#%_ had initial problems with hypoglycemia which resolved with gavage feeds. I recommend checking one glucose level when she is at full feeds. 2. Heme- _%#NAME#%_'s mother had severe ITP and _%#NAME#%_'s platelets were normal. I do not recommend rechecking a platelet count at this time. Discharge measurements: Weight 2940 gms; length 48 cm; OFC 32.5 cm.
ITP|idiopathic thrombocytopenic purpura|ITP|194|196|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ has a 1-1/2-year history of AML and consequent cord blood transfusion. She has done fairly well from a cancer standpoint. She recently developed both ITP and immune hemolysis. She has had treatment with steroids with pretty good success. She presents to the hospital for laparoscopic splenectomy.
ITP|idiopathic thrombocytopenic purpura|ITP,|93|96|PAST MEDICAL HISTORY|He was subsequently sent here for further evaluation and treatment. PAST MEDICAL HISTORY: 1. ITP, first diagnosed in 1996. Previous treatments included 18 months of steroid treatment with unsuccessful tapering attempt. Status post splenectomy, _%#MM#%_ 1998. Has had recurrence since then with last treatments occurring in late 2004.
ITP|idiopathic thrombocytopenic purpura|ITP.|176|179|PHYSICAL EXAMINATION ON ADMISSION|Per routine postchemotherapy cell count monitoring, the patient did receive a transfusion of 2 units of packed cells on the second day of admission for a hemoglobin of 7.6. 4. ITP. As it was time for the patient's regular infusion of IVIG for treatment of ITP, this was administered during the current hospitalization.
ITP|idiopathic thrombocytopenic purpura|ITP,|256|259|PHYSICAL EXAMINATION ON ADMISSION|Per routine postchemotherapy cell count monitoring, the patient did receive a transfusion of 2 units of packed cells on the second day of admission for a hemoglobin of 7.6. 4. ITP. As it was time for the patient's regular infusion of IVIG for treatment of ITP, this was administered during the current hospitalization. 5. Infectious disease. IV antibiotics provided during 48-hour rule out as described above.
ITP|idiopathic thrombocytopenic purpura|ITP,|188|191|HOSPITAL COURSE|Dr. _%#NAME#%_ evaluated the patient and started her on prednisone 40 mg b.i.d. to treat the autoimmune thrombocytopenia. It is unclear if her thrombocytopenia is related to stage IV CLL, ITP, or other etiology. A FANA quantitative immunoglobulin and beta-2 microglobulin along with platelet antibody level have been ordered and are pending on discharge.
ITP|idiopathic thrombocytopenic purpura|ITP.|140|143|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. End stage renal failure with dialysis as noted and failed PTFE grafts _%#MM#%_ 2004. 2. Hypertension 3. History of ITP. 4. Exogenous obesity. 5. Previous surgery bilateral total knee arthroplasty. 6. Hysterectomy 7. Appendectomy ALLERGIES: Cephalosporin antibiotics.
ITP|idiopathic thrombocytopenic purpura|ITP;|291|294|PAST MEDICAL HISTORY|Recent MRI revealed a T7 compression fracture, and since she has had successful vertebroplasty in the past of other vertebra she has elected to proceed with surgery at this time. PAST MEDICAL HISTORY: 1. Osteoarthritis and rheumatoid arthritis; the patient is followed by Dr. _%#NAME#%_. 2. ITP; the patient is followed by Dr. _%#NAME#%_. 3 Hypertension, well controlled. 4. Right breast cancer with mastectomy in _%#MM2004#%_. She also has had Paget disease of the breast.
ITP|idiopathic thrombocytopenic purpura|ITP.|214|217|DISCHARGE DIAGNOSES|After those results it was felt that the GI bleed was related to the severe thrombocytopenia, bone marrow biopsy was done on _%#MMDD2006#%_ and revealed normal megakaryocytes with normal iron storage suggestive of ITP. There was no signs of multiple myeloma or lymphoma present. The patient has had a history of some elevated protein levels so monoclonal gammopathy of insignificance, thus after the bone marrow biopsy results came back the patient was placed on high dose steroids.
ITP|idiopathic thrombocytopenic purpura|ITP|158|160|HISTORY OF PRESENT ILLNESS|Pelvic vein thrombosis could not be entirely excluded. 3. Plasma exchange. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 66-year-old male with a history of ITP and CIDP, who presented with 2 days of chest pain in the right lower chest, especially at the back and to the side.
ITP|idiopathic thrombocytopenic purpura|ITP.|386|389|PAST MEDICAL HISTORY|Past history of treatment for Lyme disease. See admission history and physical for further details. PAST MEDICAL HISTORY: Further remarkable for hypercholesterolemia, osteoarthritis, BPH, bilateral hearing loss, history of CPK elevation without documentation of myositis/underlying rheumatologic condition, family history of colon and prostate cancer, essential tremor, depression, and ITP. PHYSICAL EXAMINATION: Admission exam demonstrated an adult male in no acute distress.
ITP|idiopathic thrombocytopenic purpura|ITP.|201|204|DISCHARGE DIAGNOSES|2. History of lupus, currently quiescent. 3. ITP. 4. History of herniated disk surgery eight years ago by Dr. _%#NAME#%_. 5. History of irritable bowel syndrome. 6. History of splenectomy secondary to ITP. HOSPITAL COURSE: Ms. _%#NAME#%_ _%#NAME#%_ is a 45-year-old, Caucasian female, who presented with vague left groin and anterior pain for the past one week.
ITP|idiopathic thrombocytopenic purpura|ITP|90|92|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ was seen today in follow up for his ITP and was noted to have a creatinine of 9 and a follow-up creatinine in the hospital revealed a creatinine of 10.6. Mr. _%#NAME#%_ _%#NAME#%_ is an 88-year-old gentleman with a history of renal cell carcinoma, status post left nephrectomy in 1988 and a history of prostate cancer for which he underwent prostatectomy several years ago.
ITP|idiopathic thrombocytopenic purpura|ITP.|198|201|HOSPITAL COURSE|The patient was therefore admitted to the general medical floor for transfusions for further workup of his anemia as well as for further treatment of his deep venous thrombosis. HOSPITAL COURSE: 1. ITP. The patient was thrombocytopenic along with his anemia. Bone marrow showed no evidence of malignancy. The patient was started on prednisone and did have response to this measure and his platelet count did improve.
ITP|idiopathic thrombocytopenic purpura|ITP|125|127|HISTORY OF PRESENT ILLNESS|PRIMARY ONCOLOGIST: Dr. _%#NAME#%_ HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 6-year-old female who is newly diagnosed with ITP last month. This past Monday, on _%#MMDD2007#%_, at a routine clinic visit, she was noted to have a platelet count of 22. Follow-up recheck on day of admission was 8. The patient was admitted from clinic for IVIG infusion overnight.
ITP|idiopathic thrombocytopenic purpura|ITP|260|262|MAJOR PROCEDURES|DISCHARGE DIAGNOSES: 1. Immune thrombocytopenia purpura. 2. Acute renal failure, probably secondary to IVIG infusion, now resolved. 3. Hypertension. 4. Microscopic hematuria. MAJOR PROCEDURES: 1. Bone marrow biopsy on _%#MMDD2007#%_, which was consistent with ITP and demonstrated no evidence of hematologic malignancy. 2. Ultrasound of the kidneys on _%#MMDD2007#%_, which demonstrated bilateral small renal cyst, otherwise unremarkable ultrasound.
ITP|idiopathic thrombocytopenic purpura|ITP|325|327|HISTORY OF PRESENT ILLNESS|Once the patient was admitted to the surgical intensive care unit at Fairview University Medical Center, she was delirious and through the medical record it was seen that she had a recent history of sepsis and thrombocytopenia. However, it was unclear of the cause of her sepsis. Her thrombocytopenia workup was treated like ITP and there was no mention of the patient being positive. Therefore, once she came to the ICU, a full workup for sepsis was started.
ITP|idiopathic thrombocytopenic purpura|ITP|187|189|SUMMARY OF HOSPITAL COURSE|FINAL DIAGNOSES: 1. Epistaxis. 2. ITP. 3. Osteoporosis. 4. Coronary artery disease by history. SUMMARY OF HOSPITAL COURSE: Mrs. _%#NAME#%_ is an 82-year-old lady with somewhat refractory ITP who developed upper respiratory infection symptoms, had little bleeding in her right nostril which was successfully cauterized. She had more bleeding in her left nostril which required cauterization and a packing and about five days before she saw me in my office.
ITP|idiopathic thrombocytopenic purpura|ITP.|211|214|PLAN|PLAN: 1. She was initially started on a Protonix drip, which was discontinued this morning and switched to p.o. Protonix. This morning she tolerated diet without any difficulty. 2. Thrombocytopenia secondary to ITP. Platelet is presently current at her baseline and on exam there were no ecchymosis, purpura or petechiae. 3. Type 2 diabetes. She was started on sliding scale since she was NPO.
ITP|idiopathic thrombocytopenic purpura|ITP.|153|156|ASSESSMENT/PLAN|5. Diabetes mellitus, type II. We will perform Accu-Cheks and regular insulin sliding scale. 6. Peptic ulcer disease. Continue proton pump inhibitor. 7. ITP. We will check CBC. If bleed is isolated, then we will consult Hematology immediately.
ITP|idiopathic thrombocytopenic purpura|ITP.|238|241|PAST MEDICAL HISTORY|REVIEW OF SYSTEMS: Included fatigue and hair loss. Also, the patient has a history of idiopathic thrombocytopenic purpura. Review of further systems was negative. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Urinary incontinence. 3. ITP. PAST SURGICAL HISTORY: 1. Splenectomy. 2. Port placement. MEDICATION: 1. Premarin 0.625 mg 1 p.o q.d.
ITP|idiopathic thrombocytopenic purpura|(ITP).|187|192|DISCHARGE DIAGNOSIS|CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSIS: 1. Previous cesarean section, declines vaginal birth after cesarean (VBAC). 2. Term pregnancy. 3. Idiopathic thrombocytopenic purpura (ITP). PROCEDURES PERFORMED: 1. Repeat low transverse cesarean section. 2. Lysis of adhesions. COMPLICATIONS: None.
ITP|idiopathic thrombocytopenic purpura|ITP|276|278|PAST MEDICAL HISTORY|The patient denies any fatigue and states that he has been able to maintain his usual activities of daily living and has not noticed any decrease in his exercise tolerance. PAST MEDICAL HISTORY: 1. Coronary artery disease. He is status post angioplasty in 1989. 2. History of ITP in 1997 secondary to Cardura. He was treated with prednisone and he received blood transfusion at that time. 3. History of diverticulitis in _%#MM2001#%_. The patient had undergone a colonoscopy and an EGD last fall.
ITP|idiopathic thrombocytopenic purpura|ITP|208|210|PAST MEDICAL HISTORY|The patient had a pelvic ultrasound which was interpreted as normal. PAST MEDICAL HISTORY: Usual childhood diseases and idiopathic thrombocytopenia purpura. PAST SURGICAL HISTORY: Splenectomy in 1968 for her ITP and a right mastectomy as noted above. ALLERGIES: Stadol, Darvocet, Cortane. HABITS: Tobacco: None. Alcohol occasionally. FAMILY HISTORY: Mother deceased of colon cancer at age 66 and father is in good health at age 70.
ITP|idiopathic thrombocytopenic purpura|ITP|118|120|PAST MEDICAL HISTORY|She denies any significant incontinence symptoms and denies any intestinal symptoms. PAST MEDICAL HISTORY: History of ITP approximately 20 years ago which was treated with prednisone and has not recurred. PAST SURGICAL HISTORY: Laparoscopy in _%#MM#%_ of 2000 as stated above.
ITP|idiopathic thrombocytopenic purpura|ITP|298|300|HISTORY OF PRESENT ILLNESS|REASON FOR ADMISSION: _%#NAME#%_ _%#NAME#%_ will be admitted on _%#MMDD2003#%_ to initiate treatment with intravenous gamma globulin as part of ongoing treatment for immune thrombocytopenic purpura. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 67-year- old woman who has a history of ITP for last several years in which she has had a variety of different treatments in the past including a course of prednisone as well as previous treatment with IVIG.
ITP|idiopathic thrombocytopenic purpura|ITP|133|135|IMPRESSION|Currently she is taking prednisone at a dose of 60 mg daily and also Protonix at an unknown dose taken daily. IMPRESSION: History of ITP refractory to a number of treatments and with recent onset of epistaxis, now resolved following cauterization. We discussed different options. I have recommended to her that she try repeat dose of IVIG followed by platelet transfusion.
ITP|idiopathic thrombocytopenic purpura|ITP.|246|249|PROBLEM #2|The patient was shown how to use the suction and a home health agency was asked to change the sponges of the vacuum pump as ordered. PROBLEM #2: Idiopathic thrombocytopenic purpura. The patient has had a rather rocky course regarding her chronic ITP. Previous attempts to taper off her steroids have unfortunately failed. The patient does carry significant side effects from the chronic steroids used.
ITP|idiopathic thrombocytopenic purpura|ITP|75|77|PAST MEDICAL HISTORY|Granddaughter with history of one episode of ITP. PAST MEDICAL HISTORY: 1. ITP diagnosed incidentally in 2001, status post treatment with WinRho and Prednisone. He has a history of being responsive to IV Ig. He has not had a splenectomy, although this has been considered.
ITP|idiopathic thrombocytopenic purpura|ITP.|193|196|HOSPITAL COURSE|Although the patient was placed on steroids as an outpatient, this was rapidly tapered and will be discontinued shortly after discharge as he is felt not to respond well with steroids with his ITP. Consideration will be given again in the future to splenectomy should he have more difficulty. He is somewhat a risk for surgery due to his history of myocardial infarction.
ITP|idiopathic thrombocytopenic purpura|(ITP)|56|60|FINAL DIAGNOSES|FINAL DIAGNOSES: 1. Idiopathic thrombocytopenic purpura (ITP) postpartum. 2. Insomnia related to steroids. 3. Moderate headache--resolved. DISCHARGE MEDICATIONS: 1. Prednisone 60 mg q.d. 2. Protonix 20 mg q.d.
ITP|idiopathic thrombocytopenic purpura|ITP.|159|162|PLAN|Other chronic medical problems which the patient is known to have include prostate cancer, with surgery in 1988, with no known recurrence. He has a history of ITP. He has a history of hypertension. The patient's chronic medications include enalapril 20 mg p.o. q.d. and multivitamins.
ITP|idiopathic thrombocytopenic purpura|ITP|227|229|PAST MEDICAL HISTORY|There has been no recurrence since pleurodesis. The exact cause for the effusion is unknown. It is felt that it is possibly tracking up from the abdomen. 5. Hyperlipidemia. 6. Congestive heart failure. 7. Asplenia secondary to ITP and splenic removal. 8. Clostridium difficile diarrhea in _%#MM#%_ 2003. 9. Elevated liver function studies. The exact cause for the elevated LFTs was unknown.
ITP|idiopathic thrombocytopenic purpura|ITP|78|80|PAST MEDICAL HISTORY|The patient is here for elective VP shunt placement. PAST MEDICAL HISTORY: 1. ITP diagnosed in 1989 with resultant splenectomy, in remission. 2. History of Hashimoto's thyroiditis. 3. History of nonspecific arthritis with elevated ANA.
ITP|idiopathic thrombocytopenic purpura|ITP|137|139|HISTORY|She has chronic problems with depression and is on Zoloft. She has hypothyroidism and she takes Synthroid. She had a previous history of ITP that was felt possibly secondary to quinine or nonsteroidals or Tylenol. She has avoided all those and still has persistently low platelet count but hasn't had any further bleeding.
ITP|idiopathic thrombocytopenic purpura|ITP|165|167|SECONDARY DIAGNOSES|FINAL DIAGNOSIS: Acute cholecystitis and pancreatitis, with spontaneous passage of common duct stone suspected. SECONDARY DIAGNOSES: 1. History of thrombocytopenia, ITP severe in 2000, resolved with prednisone. 2. Recent right inguinal hernia repair with mesh, _%#MM#%_ 2003. 3. Hypothyroidism, post I-131 therapy for hyperthyroidism. 4. Hypertension, controlled.
ITP|idiopathic thrombocytopenic purpura|ITP|161|163|PAST MEDICAL HISTORY|He is otherwise healthy with the exception of a history of ITP requiring splenectomy 2 years ago. He takes chronic penicillin prophylaxis. PAST MEDICAL HISTORY: ITP requiring splenectomy. PHYSICAL EXAMINATION: VITAL SIGNS: On admission temperature was 104 in the emergency room.
ITP|idiopathic thrombocytopenic purpura|ITP,|147|150|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 59-year-old woman who has had a long history of chronic back pain. She was to have surgery and found to have ITP, so has been on a prednisone burst and taper. Subsequently, she was found to have a fracture of her left ankle. This was casted on Monday by Dr. _%#NAME#%_ _%#NAME#%_. When she returned home with that cast, she was unable to get around in her apartment and care for herself by using a walker or crutches.
ITP|idiopathic thrombocytopenic purpura|ITP.|176|179|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Bronchoalveolar carcinoma diagnosed via biopsy on _%#MMDD2004#%_. There were bleeding complications associated and she was subsequently diagnosed with ITP. 2. Idiopathic thrombocytopenic purpura. The patient did receive two doses of IVIG on her previous hospitalization for her ITP. 3. Spinal stenosis predominantly in the lumbar spine. 4. Polymyalgia rheumatica for which she is on long-term use of prednisone.
ITP|idiopathic thrombocytopenic purpura|ITP.|38|41|DIAGNOSES|DIAGNOSES: Thrombocytopenia, possibly ITP. HISTORY OF PRESENT ILLNESS: This is a 61-year-old female who is status post a liver transplant on _%#MM#%_ _%#DD#%_, 2004. She was in for her weekly blood draw at the clinic and it showed that her platelets were 30,000.
ITP|idiopathic thrombocytopenic purpura|ITP.|131|134|DISCHARGE INSTRUCTIONS|He was seen by Hematology who dictated a full note. At this point, they do not have a conclusive etiology but do not believe it is ITP. 5. Immunosuppression. He will remain on prednisone, tacrolimus, and MMF. He has had two kidney rejections in the past and this is why he continues to be on prednisone and CellCept.
ITP|idiopathic thrombocytopenic purpura|ITP|207|209|HOSPITAL COURSE|A hematology consultation was obtained given the patient's history of idiopathic thrombocytopenic purpura. Her platelet count nadored at 32,000. The thrombocytopenia was thought to be multifactorial and not ITP related. While she had extensive bruising, there was no active bleeding and she was not transfused with platelets. At the time of discharge she was afebrile and her vital signs were stable.
ITP|idiopathic thrombocytopenic purpura|(ITP).|153|158|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Hypertension. 2. Coronary artery disease. 3. End-stage renal disease secondary to lupus and idiopathic thrombocytopenic purpura (ITP). 4. Coagulopathy (history of DVTs), currently treated with Coumadin. PRIOR TRANSPLANTATION HISTORY: Living-related kidney transplant on _%#MMDD2003#%_ (brother was donor)
ITP|idiopathic thrombocytopenic purpura|ITP|322|324|HISTORY OF PRESENT ILLNESS|The patient's postoperative course has been significant for a postoperative wound infection, nausea, vomiting, acute tubular interstitial rejection (treated with steroids), and C4d positivity with a readmission on _%#MMDD2004#%_ for plasmapheresis and IVIG. The patient is also noted to have had pancytopenia secondary to ITP reaction and multiple attempts(?) of her immunosuppression regimen. The patient presents with an elevated creatinine of 2.94 on a regular weekly check of her laboratory work.
ITP|idiopathic thrombocytopenic purpura|ITP.|248|251|ASSESSMENT|This is also superimposed upon chronic essential tremor. As above, the patient did have unremarkable cerebrovascular evaluation earlier this year. She is not on aspirin because of chronic thrombocytopenia, which likely is medication related versus ITP. At this point, I think the patient definitely would benefit from the institution of aspirin with close monitoring of her platelet count.
ITP|idiopathic thrombocytopenic purpura|ITP,|197|200|HISTORY OF PRESENT ILLNESS|He has been heavily pretreated in the past with chemotherapy, but has had stable disease in terms of his CLL/WDLL, off of treatment for the last several years. Recently, his biggest issue has been ITP, and this has been treated in the past with steroids, IgG, and vincristine, and has been treated by splenectomy as well as accessory splenectomy in 1999.
ITP|idiopathic thrombocytopenic purpura|ITP|217|219|IMPRESSION|IMPRESSION: _%#NAME#%_ _%#NAME#%_ is a very pleasant man with a history of CLL versus low-grade lymphoma, and associated immune thrombocytopenic purpura. His lymphoproliferative process is under good control, and his ITP is also under good control currently. He has responded to Rituxan, and at this point, his platelet count is pretty much as good as it has been in several years.
ITP|idiopathic thrombocytopenic purpura|(ITP)|153|157|DIAGNOSTIC STUDIES|The patient is known to me from consults dating back to _%#MM2000#%_. She, however, carries a diagnosis of long-standing immune thrombocytopenic purpura (ITP) for which she did undergo a splenectomy back in _%#MM1997#%_. Following that, she did well for a long period of time; however, in early 2000 she relapsed with a platelet count of around 30,000.
ITP|idiopathic thrombocytopenic purpura|ITP,|197|200|DIAGNOSTIC STUDIES|Good pulses are noted. Abdomen is obese, with a previous splenectomy scar noted and nontender. She has petechia on her lower extremities. My impression is a patient with a long-standing history of ITP, now with a relapse. This has occurred in the past, and the patient has responded fairly quickly and nicely to pulse doses of Decadron.
ITP|idiopathic thrombocytopenic purpura|ITP|169|171|MEDICAL HISTORY|Please refer to chart for details. In summary, this patient has multiple medical problems that include, but are not limited to, diabetes mellitus, obesity, hypothyroid, ITP for which she requires chronic steroids. Significant hospitalization last year for sepsis, fever of unknown origin. Eventual diagnosis included pancytosis, mastoiditis, bacteremia, some mental status changes that improved over time.
ITP|idiopathic thrombocytopenic purpura|ITP|208|210|PAST MEDICAL HISTORY|He apparently has not had any evidence for a myocardial infarction but his cardiac evaluation is ongoing. PAST MEDICAL HISTORY: Significant for severe Parkinson's disease with associated dementia. He has had ITP and has required a splenectomy. Other problems include hyperlipidemia, chronic low back pain, and recurrent pneumonia. Also, he has a history of a pleural effusion since _%#MM#%_, 2002.
ITP|idiopathic thrombocytopenic purpura|ITP,|129|132|RECOMMENDATIONS|RECOMMENDATIONS: Her epistaxis is currently controlled with nasal packs, and I would leave this in for 3-5 days. With history of ITP, it is important to minimize removing and replacing packs as any gentle abrasions can exacerbate her bleeding. I recommend antibiotic prophylaxis for sinusitis and septic shock. Staph coverage with Keflex should be adequate, although in light of her penicillin allergy, it will be important to watch for a rash.
ITP|idiopathic thrombocytopenic purpura|ITP,|195|198|PAST MEDICAL HISTORY|He subsequently has not had recurrences or major problems with this and he has had no other major infections occurring in the last year. Prior partial left hip replacement, prior splenectomy for ITP, prior MRSA which has not been present for some time. Chronic nonspecific psoriasis/dermatitis problem and recurrent folliculitis; has actually been on some antibiotics for this including Minocin recently, gastroesophageal reflux disease.
ITP|idiopathic thrombocytopenic purpura|ITP,|222|225|PAST MEDICAL HISTORY|Recently a six of six matched donor was identified, and the patient was brought to the University to receive her allogenic bone marrow transplant. PAST MEDICAL HISTORY: 1. Fanconi anemia, as described above. 2. History of ITP, as described above. 3. History of duodenal atresia, treated with three separate surgeries during first two years of life. MEDICATIONS: Please see nursing intake sheet. These medications have been reviewed.
ITP|idiopathic thrombocytopenic purpura|ITP|224|226|DISCUSSION OF ADMISSION|Both can cause thrombocytopenia, although rarely. Other etiology include lupus inhibitor and anticardiolipin antibodies associated with thrombocytopenia. Will check for both conditions. Autoimmune platelet disorders seen in ITP and/or with autoimmune disorders. Will check ANA and platelet-associated antibodies. In view of weight loss anorexia, I would like to rule out primary hematological disorders including dysplasia, lymphoproliferative disorders, and myeloproliferative disorders.
ITP|idiopathic thrombocytopenic purpura|ITP|112|114|IMPRESSION|She has fever and elevated LD. It is unusual that this would respond to steroids. I wonder if she does not have ITP (idiopathic thrombocytopenic purpura) or some other vasculitis like SLE (systemic lupus erythematosus). We are going to check serologies, including hepatitis screens for B and C, ANA, ANCA, C3, C4.
ITP|idiopathic thrombocytopenic purpura|ITP.|115|118|HISTORY|CHIEF COMPLAINT: ITP. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 49-year-old female who was diagnosed late last year with ITP. She had a pre-existing low platelet count in the 100,000 range, presumably due to treatment for left orbital, low grade lymphoma in 1998.
ITP|idiopathic thrombocytopenic purpura|ITP|178|180|IMPRESSION|There is a small umbilical hernia present. LABORATORY DATA: White count of 9.2, hemoglobin 11.6, platelet count of 23,000 (today). Giant platelets are also noted. IMPRESSION: 1. ITP with temporary responses to IVIG. 2. Status post left eye lymphoma. 3. Perimenopausal. PLAN: I discussed the option of splenectomy with the patient, including laparoscopic or open approaches, the possible conversion of laparoscopic to open was also discussed.
ITP|idiopathic thrombocytopenic purpura|ITP.|251|254|HISTORY OF  PRESENT ILLNESS|Previous workup consisted of MRI of the brain showing atypical pontine lesion which was felt to be still representing a stroke in the pons. She also had a cervical MRI which did not show any evidence of spinal stenosis. Mrs. _%#NAME#%_'s suffers from ITP. She has easy bruising with her falls. PAST MEDICAL HISTORY: In addition with hypertension and benign essential tremor, insomnia and depression.
ITP|idiopathic thrombocytopenic purpura|ITP.|183|186|PAST MEDICAL HISTORY|PAST SURGICAL HISTORY: As above. SOCIAL HISTORY: Previous smoker with 22-pack years. Denies current alcohol or IV drug use. PAST MEDICAL HISTORY: 1. Hepatitis C diagnosed in 2002. 2. ITP. 3. Cirrhosis. 4. Diabetes type 2. 5. Cholecystitis. REVIEW OF SYSTEMS: The patient's urologic review of symptoms is negative except as above HPI and 12-point review of symptoms is negative otherwise.
ITP|idiopathic thrombocytopenic purpura|ITP|199|201|IMPRESSION|IMPRESSION: 1. Apparently acute onset of severe thrombocytopenia with essentially cutaneous only bleeding. The severity of the thrombocytopenia makes it most likely that this is immune-mediated, and ITP would be the most likely explanation, either idiopathic or related to a possible viral or medication exposure. She has no evidence of a systemic illness, such as lupus, although this would be difficult to completely exclude.
ITP|idiopathic thrombocytopenic purpura|ITP|153|155|IMPRESSION|3. Restricted/obstructed pulmonary function tests with positive bronchodilator response. Was discharged at last hospitalization with bronchodilators. 4. ITP on prednisone, now is on Solu-Medrol perioperatively and postoperatively. PLAN: 1. Diurese. 2. Weaning trial and hopefully extubate in the next 24 hours.
ITP|idiopathic thrombocytopenic purpura|ITP|146|148|PAST MEDICAL HISTORY|4. Pleural thickening of unclear etiology. This is being followed by Dr. _%#NAME#%_. The possibility of asbestosis has been raised. 5. History of ITP status post splenectomy. 6. Benign prostate nodule. 7. Previous deep venous thrombosis. 8. Thyroid disease. 9. Carotid ultrasound studies showed no significant blockage.
ITP|idiopathic thrombocytopenic purpura|ITP.|144|147|IMPRESSION|2. Thrombocytopenia not associated with bleeding. Once again this could represent medication causes or alternatively could represent developing ITP. ____________ sequestration would not be considered likely given the normal platelet count on admission. 3. Recurring respiratory problems according to aspiration pneumonia and chronic obstructive lung disease.
ITP|idiopathic thrombocytopenic purpura|ITP.|144|147|OTHER PAST MEDICAL HISTORY|OTHER PAST MEDICAL HISTORY: 1. Abdominal aortic aneurysm. 2. Type A thoracic aneurysm which has been managed conservatively. 3. Sleep apnea. 4. ITP. 5. Carcinoma of the prostate. FAMILY HISTORY: There is no history of premature atherosclerotic disease.
ITP|idiopathic thrombocytopenic purpura|ITP,|167|170|HISTORY OF PRESENT ILLNESS|He came in today after a recent hospitalization at Fairview-University Medical Center where he was found to be profoundly thrombocytopenic. It was thought that he had ITP, and he responded very well to pulse prednisone therapy. However, during the course of his evaluation an HIV test was done and proved to be positive.
ITP|idiopathic thrombocytopenic purpura|ITP.|230|233|IMPRESSION|EXTREMITIES: There is no pedal edema. LABORATORY DATA: A current CBC shows a white count of 6.2, hemoglobin 9.9 and platelet count of 27,000. IMPRESSION: _%#NAME#%_ _%#NAME#%_ is a very pleasant 85-year-old gentleman with chronic ITP. His thrombocytopenia is slightly down from his baseline, though not inordinately so. In addition, he is not actively bleeding at present. Unfortunately, the patient is refractory to steroids and did not tolerate WinRho.
ITP|idiopathic thrombocytopenic purpura|ITP.|193|196|ASSESSMENT|She denies any other current symptoms. She has no history of high blood pressure or renal dysfunction. The patient also has a history of low platelets thought to be either due to her SLE or to ITP. She is currently being managed by Dr. _%#NAME#%_ in Hematology for this. Her last platelet count was approximately one week ago and it was found to be 43,000.
ITP|idiopathic thrombocytopenic purpura|(ITP),|173|178|ASSESSMENT|She does have a new sinus tachycardia of unclear etiology. This may be due to acute stress related to her hospitalization. 2. History of idiopathic thrombocytopenic purpura (ITP), status post splenectomy, with normal platelet counts on low-dose prednisone at this time. 3. History of asthma, which appears to be quiescent.
ITP|idiopathic thrombocytopenic purpura|ITP.|100|103|CHRONIC DISEASE/MAJOR ILLNESS|6. Oxycodone p.r.n. for pain. 7. Clonidine 0.2 mg p.o. every day. CHRONIC DISEASE/MAJOR ILLNESS: 1. ITP. 2. Venous insufficiency with chronic lower extremity edema. 3. Hypertension. 4. Asthma which has been quiescent. 5. DJD. 6. Equivocal diagnosis of past rheumatoid arthritis. REVIEW OF SYSTEMS: Other than HPI is essentially negative.
ITP|idiopathic thrombocytopenic purpura|ITP|226|228|REVIEW OF SYSTEMS|No history of gallbladder disease or hepatitis. No history of renal problems or stones, urinary tract infections or sexually transmissible diseases per her report. No history of diabetes. No known clotting disorder other than ITP as reported above. No history of stroke or seizure. PHYSICAL EXAMINATION: GENERAL: She is an alert adult woman who seems nondistressed.
ITP|idiopathic thrombocytopenic purpura|(ITP).|270|275|IMPRESSION/PLAN|IMPRESSION/PLAN: Mr. _%#NAME#%_ is a 35-year-old healthy gentleman who presents with an acute thrombocytopenia without any predisposing factors, including medications, whose acute thrombocytopenia is most likely consistent with acute idiopathic thrombocytopenic purpura (ITP). Other differential includes a possible thrombocytic thrombocytopenic purpura (TTP); however, he does not have splenomegaly or any other microangiopathy to suggest that.
ITP|idiopathic thrombocytopenic purpura|ITP|182|184|IMPRESSION/PLAN|As you know, this is Ms. _%#NAME#%_'s third pregnancy. She has 1 healthy daughter and has had 1 early miscarriage. Ms. _%#NAME#%_'s medical history is significant for a diagnosis of ITP disorder. The patient reports the current pregnancy has been uncomplicated. She reports no alcohol use, tobacco use, chemical exposures, x-rays, fever, bleeding, or other complications.
ITP|idiopathic thrombocytopenic purpura|ITP.|179|182|IMPRESSION|Coagulation battery is normal, including fibrinogen and D-dimer. Other labs, such as platelet antibodies and FANA are currently pending. IMPRESSION: Most likely diagnosis here is ITP. There is a low suspicion for drug-induced thrombocytopenia with a possible exception being amoxicillin, which the patient was taking recently.
ITP|idiopathic thrombocytopenic purpura|ITP,|291|294|IMPRESSION|If this is not happening, we may have to look into the possibility of bone marrow biopsy and possibly other therapy, such as IVIG if the diagnosis still appears to be compatible with ITP. It is of interest the patient had a recent infection by history and one wonders if he may have chronic ITP, that it was acutely exacerbated by intercurrent viral infection. This may become apparent with further examination of the old blood counts.
ITP|idiopathic thrombocytopenic purpura|(ITP),|168|173|IMPRESSION|I doubt a primary marrow disorder or lymphoma, though this remains possible. Autoimmune disease also is obviously possible, such as idiopathic thrombocytopenic purpura (ITP), but we must note she is on good doses of prednisone at 40 mg daily. In order to sort this out, we will check her peripheral blood smear, check antiplatelet antibody tests, LDH and serum protein electrophoresis.
ITP|idiopathic thrombocytopenic purpura|ITP,|107|110|PAST MEDICAL HISTORY|He otherwise feels fairly well with a stable energy level. PAST MEDICAL HISTORY: Significant for childhood ITP, status post splenectomy as well as a history of spinal meningitis as a child as well. He has had no prior other surgical procedures and denies any other chronic medical illnesses.
ITP|idiopathic thrombocytopenic purpura|ITP|209|211|IMPRESSION|He has significant fever likely part of that primary illness, although rule out secondary infection complication. He has no particular localizing symptoms to suggest a source of infection. 2. Prior history of ITP and splenectomy as a child. Had no major infection complications but did have meningitis at one point post-splenectomy. Has had vaccines in the past. 3. Penicillin allergy. PLAN: Agree with imipenem.
ITP|idiopathic thrombocytopenic purpura|ITP|164|166|PAST MEDICAL HISTORY|Today his nurse noted that he had a bit of a facial droop that she did not notice before as well as more weakness on the left side. PAST MEDICAL HISTORY: Childhood ITP , status post splenectomy. History of spinal meningitis at age 3. MEDICATIONS: Currently he is on high dose prednisone as part of his chemotherapy protocol, imipenem, Zyloprim, Protonix and various p.r.n. medications.
ITP|idiopathic thrombocytopenic purpura|ITP)|155|158|ASSESSMENT AND PLAN|This is almost certainly due to splenic sequestration of the transfused platelets. It is also possible that he could have immune thrombocytopenia (chronic ITP) resulting in a lack of response to platelet transfusion. It is going to be very difficult to sort this out definitively as the bone marrow biopsy findings would be expected to be similar (normal to increased numbers of megakaryocytes), were the cause of his thrombocytopenia to be ITP or splenic sequestration.
ITP|idiopathic thrombocytopenic purpura|ITP.|222|225|IMPRESSION|No cyanosis, clubbing or edema. PELVIC: Not performed. EXTREMITIES: The right leg has some superficial varicosities without a palpable cord. IMPRESSION: 1. Malignant mixed mesodermal tumor of the uterus, FIGO stage IB. 2. ITP. RECOMMENDATIONS: I spent an hour and ten minutes with Mrs. _%#NAME#%_ and her husband.
ITP|idiopathic thrombocytopenic purpura|ITP,|209|212|RECOMMENDATIONS|We have retrospectively reviewed our experience here and pelvic radiotherapy seems to be effective at preventing pelvic recurrences, but there are no data available to show that it improves survival. With her ITP, I do not believe she would be a good candidate for whole abdominal radiotherapy and may get into trouble with prolonged pancytopenia.
ITP|idiopathic thrombocytopenic purpura|(ITP).|136|141|PAST MEDICAL HISTORY|No appetite change. Full 12-point review of systems is otherwise negative. PAST MEDICAL HISTORY: 1. Idiopathic thrombocytopenic purpura (ITP). 2. Pyelonephritis in _%#MM2007#%_. 3. History of right bundle branch block on EKG _%#MM2007#%_. MEDICATIONS: None. SOCIAL HISTORY: The patient lives with her significant other.
ITP|idiopathic thrombocytopenic purpura|ITP|233|235|PAST MEDICAL HISTORY|FAMILY HISTORY: Negative for cervix cancer but her grandmother is alive and well after surviving lung cancer and two grandfathers had some type of cancer, possibly lung. PAST SURGICAL HISTORY: Negative. PAST MEDICAL HISTORY: She had ITP during one of her pregnancies, this resolved. Her last Pap and pelvic examination was after the birth of her youngest child 7 years ago, prior to that she may have had one abnormal Pap smear which normalized and this was not followed up.
ITP|idiopathic thrombocytopenic purpura|ITP|130|132|HISTORY OF PRESENT ILLNESS|She had splenectomy in childhood. She was on steroids for many years. She received several regimens based in alkylators. When her ITP became particularly refractory in the 1980s, she received a series of 3rd-line therapies, including attenuated androgens, and the like.
ITP|idiopathic thrombocytopenic purpura|ITP|210|212|HISTORY OF PRESENT ILLNESS|She was found to have a colon cancer, which was resected successfully. Unfortunately, she suffered mesenteric thrombosis in the postoperative period (a thrombotic tendency is reasonably common in patients with ITP who are well compensated and have normal counts); this resulted in an extensive resection and short bowel syndrome. She still has trouble maintaining adequate hydration, electrolytes, and nutrition, but has been off home parenteral nutrition for a couple of years.
ITP|idiopathic thrombocytopenic purpura|ITP|223|225|PAST MEDICAL/SURGICAL HISTORY|He presents to our clinic today at the request of Dr. _%#NAME#%_ _%#NAME#%_ and to review the plan for total body irradiation conditioning assuming that he proceed to transplant at this time. PAST MEDICAL/SURGICAL HISTORY: ITP age 3 and splenectomy age 4. Spinal meningitis age six, causing residual left ear deafness. ALLERGIES: Penicillin causes rash, Levaquin causes rash.
ITP|idiopathic thrombocytopenic purpura|ITP|282|284|HISTORY OF PRESENT ILLNESS|I did a biopsy on her about a month ago which revealed a toxic tubulopathy with ATN and interstitial fibrosis we thought may be due to some of the treatment she had been getting such as rituxan. There was no evidence of glomerulonephritis, vasculitis or lupus. She has a history of ITP and PMR and anemia and has been on chronic steroids at varying doses. She has a history of a PFO and a stroke.
ITP|idiopathic thrombocytopenic purpura|(ITP)|212|216|IMPRESSION|A bone marrow disorder would be unlikely given his recent normal platelet count. Review of his medications does not show an obvious cause such as heparin exposure. Acute onset idiopathic thrombocytopenic purpura (ITP) is possible but seems less likely given the timing following the valve replacement surgery. In addition, he could have sepsis with increased platelet consumption.
ITP|idiopathic thrombocytopenic purpura|ITP|146|148|IMPRESSION AND PLAN|Unfortunately, with her platelet count being significantly low one her ongoing epistaxis, I would recommend starting her treatment for a possible ITP with a high-dose steroid. I would also recommend obtaining platelet antibodies, ANA and rheumatoid factor to rule out any causes for a possible ITP.
ITP|idiopathic thrombocytopenic purpura|ITP.|252|255|DISCUSSION/RECOMMENDATIONS|I discussed with Mr. _%#NAME#%_ the variety of causes of thrombocytopenia, I doubt any med side effect based on the sudden onset, despite being on the same medication for quite a while. I will treat his thrombocytopenia with a presumptive diagnosis of ITP. I will increase his prednisone to 80 mg a day initially and this will be followed by a taper course if his platelet count is significantly improved.
ITP|idiopathic thrombocytopenic purpura|ITP|202|204|HISTORY OF PRESENT ILLNESS|3. Further workup as organism directs as well. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 50-year-old male seen in consultation from Hospitalist Service due to bacteremia. The patient has a history of ITP with splenectomy in 1990. He had 1 episode of unexplained fever about 5 years ago, but has had no major infection complications since that splenectomy.
ITP|idiopathic thrombocytopenic purpura|ITP.|339|342|HISTORY OF PRESENT ILLNESS|The hospitalist service was asked by Dr. _%#NAME#%_ to assist with diabetic management with Mr. _%#NAME#%_ while he is receiving IV steroids for possible ITP versus Evans's syndrome. HISTORY OF PRESENT ILLNESS:. _%#NAME#%_ _%#NAME#%_ is a 66-year-old white male admitted _%#MM#%_ _%#DD#%_, 2005 for thrombocytopenia suspected secondary to ITP. You are referred to Dr. _%#NAME#%_'s admission H&P dated _%#MMDD2005#%_. The patient has a history of CLL diagnosed in _%#MM#%_ 1994, insulin-dependent diabetes mellitus, UTIs and a history of elevated cholesterol.
ITP|idiopathic thrombocytopenic purpura|ITP|149|151|IMPRESSION|There are no chemistries available on the patient. IMPRESSION: 1. Diabetes poorly controlled, secondary to steroids and current therapy for presumed ITP versus Evans's syndrome. Will increase the patient's Ultra-Lente Humulin to 16 units subcu b.i.d. This will need to be followed closely and adjusted as the patient's medications are changed, ie as he is taken off steroids.
ITP|idiopathic thrombocytopenic purpura|ITP.|151|154|RECOMMENDATIONS|This is a 66-year-old male with a history of CLL diagnosed in 1994. He also has been found to have significant thrombocytopenia suspected secondary to ITP. He was admitted on this occasional for IV IG and platelet transfusions as well as Rituxan therapy. The patient has had trouble with ongoing thrombocytopenia. He had improved sufficiently, so that discharge was planned two days ago when he for the first time developed a fever spike to 103.4 degrees with shaking chills.
ITP|idiopathic thrombocytopenic purpura|ITP|246|248|PAST  MEDICAL HISTORY|6. Coronary artery disease, status post coronary bypass surgery. 7. History of ascending aortic aneurysm, aortic root size is 4.2-4.3 cm in _%#MM#%_ 2006, no evidence of aneurysm or dissection. 8. History of left rotator cuff tear. 9. History of ITP in _%#MM#%_ 2003. 10. Hydrocele. 11. Hypertension. 12. Status post bilateral herniorrhaphy. 13. Status post mitral valve prosthesis with St. Jude's valve.
ITP|idiopathic thrombocytopenic purpura|ITP|216|218|IMPRESSION|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_. REASON FOR CONSULTATION: I was asked by Dr. _%#NAME#%_ to provide antibiotic recommendations. IMPRESSION: 1. _%#NAME#%_ _%#NAME#%_ is a 28-year-old male with diagnosis of ITP in 1998. 2. Diagnosis of CMML in _%#MM2006#%_. He is not on any chemotherapy. The patient was seen in the office today where he says his white blood count was around 6,000, though office notes describe "chronic neutropenia".
ITP|idiopathic thrombocytopenic purpura|ITP|193|195|HISTORY OF PRESENT ILLNESS|3. Continue imipenem for the present but if culture is negative, probably stop this soon. 4. Follow fever curve. HISTORY OF PRESENT ILLNESS: This is a 28-year-old male with previous history of ITP in 1998 which he says is quiescent at present. In _%#MM#%_ of this year, he says that he was diagnosed with chronic myelomonocytic leukemia.
ITP|idiopathic thrombocytopenic purpura|ITP.|343|346|IMPRESSION AND PLAN|Creatinine is 1.3. IMPRESSION AND PLAN: Mrs. _%#NAME#%_ is a 75-year-old woman who was treated with cellulitis of the lower extremities with about a month of penicillin who presents with itching and noted to have an acute thrombocytopenia. The clinical picture fits with an allergic reaction to penicillin; however, she may also have an acute ITP. Of concern today, however, is her borderline leukopenia with lymphopenia that may not completely rule out possible myelocystic process.
ITP|idiopathic thrombocytopenic purpura|ITP,|239|242|IMPRESSION|I suspect this cause for her blood suppression is a viral event, culprits to include parvovirus B19, cytomegalovirus and less likely mononucleosis. I doubt this is related to her medications and this certainly does not fit the picture for ITP, TTP or DIC. PLAN: I will order some viral antibody studies, monitor her counts.
ITP|idiopathic thrombocytopenic purpura|ITP.|120|123|IMPRESSION AND PLAN|I would, therefore, recommend that the Protonix be discontinued. I would start him on high dose steroids for a possible ITP. If his count does not improve in the next few days, then I would proceed with a bone marrow biopsy to rule out a myelocystic process.
ITP|idiopathic thrombocytopenic purpura|ITP.|129|132|IMPRESSION|The presence of thrombocytopenia dates back prior to his elbow fracture and infection, and probably represents a chronic form of ITP. His anemia and leukopenia, however, are new from _%#MM2004#%_, and likely related to several processes. Nutritional deficiency however, is present, given the low albumin and lymphocytopenia.
ITP|idiopathic thrombocytopenic purpura|ITP|178|180|PAST SURGICAL HISTORY|PAST SURGICAL HISTORY: 1. Three vessel coronary artery bypass grafting in 1988. 2. History of prostate carcinoma treated with prostatectomy by Dr. _%#NAME#%_. 3. Splenectomy for ITP in approximately 1965. 4. Cholecystectomy between 5-8 years ago. 5. Distant history of appendectomy and tonsillectomy. 6. Colon resection for diverticulitis.
ITP|idiopathic thrombocytopenic purpura|ITP;|139|142|IMPRESSION|I agree with this evaluation to look for lymphadenopathy or hepatosplenomegaly or other pulmonary problems. Assuming the patient does have ITP; there is no obvious infection to implicate. She also denies any new medications she has been on all of her drugs for over ten years.
ITP|idiopathic thrombocytopenic purpura|ITP|145|147|PAST MEDICAL HISTORY|2. History of esophageal varices with endoscopic eradication. 3. Type 2 diabetes. 4. Obesity. 5. Chronic thrombocytopenia, presumed secondary to ITP as well as history of pancytopenia. 6. History of depression. 7. Hypertension. 8. Degenerative joint disease. 9. Status post left total knee replacement. 10. History of VPPV.
ITP|idiopathic thrombocytopenic purpura|ITP.|167|170|IMPRESSION|IMPRESSION: 1. Acute renal failure, presumed secondary to IVIgG or possibly WinRho toxicity. 2. Status post nephrectomy for renal cell carcinoma (distant history). 3. ITP. 4. History of CA prostate with ? history, consider possible obstructive uropathy, though this is less likely. 5. Maybe some element of prerenal azotemia. 6. History of bipolar disorder
ITP|idiopathic thrombocytopenic purpura|ITP|261|263|IMPRESSION|In addition, he could have some element of Heparin-associated thrombocytopenia, although it is unclear what previous exposure he has had to Heparin. There is no obvious medication cause that could account for the thrombocytopenia at present. He also could have ITP on anti-phospholipid antibody responsible for this. At present, he is having relatively little bleeding. RECOMMENDATIONS: 1. Try to avoid any further Heparin and will send blood work for Heparin-induced thrombocytopenia.
ITP|idiopathic thrombocytopenic purpura|ITP|218|220|FAMILY HISTORY|Hemoglobin is 11.1 grams per deciliter. Reticulocyte count is low at 0.4%. PAST MEDICAL HISTORY: Generally uncomplicated and he has had no previous surgeries or dental procedures. FAMILY HISTORY: Includes a history of ITP in a sister also apparently a history of diabetes and transverse myelitis. There is a history of Von Willebrand disease in some additional family members.
ITP|idiopathic thrombocytopenic purpura|ITP,|149|152||Her pain control seems to be reasonably good. She is wearing a TED support garment. She has other identified medical problems including a history of ITP, chronic lung disease and has had gastric bypass procedures. I reviewed her medication list with her today noting that she is on Tessalon, folic acid, Lipitor.
ITP|idiopathic thrombocytopenic purpura|(ITP).|236|241|PAST MEDICAL HISTORY|REVIEW OF SYSTEMS The patient denies any syncope, seizures, change in vision, weakness, new change in sensation. She denies shortness of breath, chest pain. PAST MEDICAL HISTORY: 1. Recent history of idiopathic thrombocytopenic purpura (ITP). 2. Osteoporosis/osteopenia with pathologic fracture. 3. Lumbar stenosis L1-2. 4. Ho alcoholism, status post treatment, sobriety for 15 years. 5. Tobacco abuse. PAST SURGICAL HISTORY: 1. Left total knee arthroplasty at Abbott Northwestern Hospital by Dr. _%#NAME#%_, 1999.
ITP|idiopathic thrombocytopenic purpura|ITP.|186|189|MEDICATIONS|MEDICATIONS: 1. Fosamax 35 mg q. week. 2. MS-Contin 60 mg in morning, 45 mg in evening. 3. Vicodin 2 tabs q.4 h. p.r.n. 4. Gabitril 2 mg p.o. t.i.d. 5. Prednisone 15 mg p.o. per day for ITP. 6. Cyclobenzaprine 10 mg p.o. b.i.d. 7. Fluoxetine 20 mg p.o. per day. 8. Doxepin 25 mg p.o. per day. 9. Ditropan XL 5 mg p.o. per day. 10. Lipitor 10 mg p.o. per day.
ITP|idiopathic thrombocytopenic purpura|ITP,|200|203|REASON FOR CONSULT|2. She has history of severe degenerative arthritis and history of left total knee arthroplasty. 3. She has a past surgical history gastric bypass procedure. 4. History of vulva cancer. 5. History of ITP, had been on steroids in the past. 6. Probable COPD. RECOMMENDATIONS: 1. We will follow up on culture data with you.
ITP|idiopathic thrombocytopenic purpura|ITP|311|313|PROCEDURE NOTE|Several years ago, his platelet count began to dip to levels in the 20,000 to 30,000 range; this was accompanied by a very modest downward drift in his white count and hemoglobin; we elected to try treating him as though he had aplastic anemia rather than pursuing more aggressive immunosuppressive therapy for ITP specifically. He underwent a course of antithymocyte globulin, without very much benefit. He was tested at that time for Fanconi syndrome and was negative; his marrow cytogenetics were normal; he continued to have a marrow that was quite hypocellular for age.
ITP|idiopathic thrombocytopenic purpura|ITP|72|74||I was asked to evaluate Mr. _%#NAME#%_ for his known history of chronic ITP and ongoing bleeding. Mr. _%#NAME#%_ _%#NAME#%_ is a _%#1914#%_ Jehovah's Witness who has a known history of chronic thrombocytopenia felt to be secondary to chronic ITP, for which the patient has never been treated given his religion.
ITP|idiopathic thrombocytopenic purpura|ITP|200|202|RECOMMENDATIONS|Apparently this has been present in the past when he was seen at Abbott and was told a few years ago that he should have a bone marrow, but refused to do this. Thus, I suspect that he has had chronic ITP for a long time. It is my understanding that this gentleman has an upcoming appointment with Dr. _%#NAME#%_ _%#NAME#%_ to have a colonoscopy examination which is very appropriate in a gentleman his age and is iron deficient.
ITP|idiopathic thrombocytopenic purpura|ITP.|226|229|HISTORY OF PRESENT ILLNESS|One year ago the patient was noted to have iron- deficiency anemia with hemoglobin of 10, MCV of 79, and ferritin of 9. He also has a history of thrombocytopenia with platelet count at 75,000 to 85,000 which was attributed to ITP. I do not have all the details of that evaluation. He has prior evaluation for his iron deficiency a couple of months ago, and upper endoscopy showed a small arteriovenous malformation in the stomach, and negative colonoscopy.
ITP|idiopathic thrombocytopenic purpura|ITP|124|126|REASON FOR CONSULTATION|He came to the hospital today for further evaluation. He denies any prior GI bleeding or GI problems. He was diagnosed with ITP one year ago followed at the University of Minnesota. He chronically runs a platelet count between 80 and 90,000 with no treatment.
ITP|idiopathic thrombocytopenic purpura|ITP.|189|192|PAST MEDICAL HISTORY|3. Hypertension. 4. Sleep apnea. 5. Chronic obstructive pulmonary disease. 6. History of atrial fibrillation. 7. Previous transient ischemic attack. 8. Peripheral neuropathy. 9. History of ITP. 10. Previous history of congestive heart failure but apparent echo with a reasonable ejection fraction recently. 11. No history of previous renal disease. 12. Status post cholecystectomy.
ITP|idiopathic thrombocytopenic purpura|ITP|168|170|HISTORY OF PRESENT ILLNESS|REFERRING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_ CHIEF COMPLAINT: Thrombocytopenia. HISTORY OF PRESENT ILLNESS: The patient is a 21-year-old woman with a history of mild ITP who presented with chest pain. She is noted in this admission to have a platelet count a bit lower than her usual 70,000, is down to 30,000.
ITP|idiopathic thrombocytopenic purpura|ITP.|158|161|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. ITP as mentioned above. Extensive evaluation in the past with bone marrow biopsy with no clearcut diagnosis felt to be probable mild ITP. 2. Primary pulmonary hypertension. SOCIAL HISTORY: She has two children at home. Does not smoke or drink. FAMILY HISTORY: Father had skin cancer.
ITP|idiopathic thrombocytopenic purpura|ITP.|180|183|ASSESSMENT/RECOMMENDATION|LABORATORY DATA: Hemoglobin 11.4, hematocrit 5.1, platelet count 30,000. BUN 15, creatinine 0.9. INR normal. ASSESSMENT/RECOMMENDATION: This is a young woman with probable chronic ITP. Her platelet count has dropped some and is probably due to her recent upper respiratory infection. She is not having any problems with excessive bleeding. I do not think any specific action needs to be taken at this time.
ITP|idiopathic thrombocytopenic purpura|(ITP)|341|345|ASSESSMENT AND PLAN|Certainly, observation alone is appropriate at this time, but I have asked that platelet antibody studies be done and if any recent exposure to heparin is uncovered, possibly a heparin-induced platelet antibody a (HIPA) testing. If her platelet count does not improve, a trial of corticosteroids for presumed immune thrombocytopenic purpura (ITP) - prednisone 60 mg p.o. twice daily would be appropriate. This would be all the more appropriate if the platelet antibody studies come back positive.
ITP|idiopathic thrombocytopenic purpura|ITP.|177|180|ASSESSMENT AND PLAN|5. Thrombocytopenia and leukopenia. The patient did have chemo last week, and this is the likely etiology of the low blood counts. Steroids were empirically started to rule out ITP. He has received a couple of platelet transfusions. His white blood cell count was elevated on admission, but it was felt that it would drop, which it is in fact doing.
ITP|idiopathic thrombocytopenic purpura|(ITP)|169|173|IMPRESSION|Increased peripheral destruction is the most likely cause for thrombocytopenia in Mr. _%#NAME#%_'s circumstances. This could include idiopathic thrombocytopenic purpura (ITP) or thrombocytopenia due to antiphospholipid antibody or due to medication effect. Medications are reviewed and there is no obvious potential cause for this.
ITP|idiopathic thrombocytopenic purpura|ITP.|89|92|PAST MEDICAL HISTORY|She had no problems with her surgery at that time. PAST MEDICAL HISTORY: Significant for ITP. She gets WinRho and Prednisone when she has low platelets. She was last checked in _%#MM#%_ and apparently had a platelet count in the 70,000 range.
ITP|idiopathic thrombocytopenic purpura|ITP,|192|195|PLAN|IMPRESSION: Probable perianal or perirectal abscess. PLAN: Exam under anesthesia and drainage, if necessary. The likelihood of needing anything beyond that is unclear at this point. Given her ITP, we will wait and see what her platelet count is prior to proceeding.
ITP|idiopathic thrombocytopenic purpura|ITP|188|190|IMPRESSION|This picture is most consistent with ITP. She has no obvious medication causes and has no obvious underlying inflammatory disorder such as lupus or malignancy. I reviewed the diagnosis of ITP with Ms. _%#NAME#%_ and with her mother and we discussed other diagnostic studies. Specifically I would recommend that she have other diagnostic studies.
ITP|idiopathic thrombocytopenic purpura|ITP|188|190|ASSESSMENT|There is evidence of left lower lobe lung consolidation which may be consistent with pneumonia. Also, the patient has a platelet count of 5. ASSESSMENT: 69-year-old male with a history of ITP and second episode of diverticulitis who is presently being treated with medical therapy. He is off of dopamine and his white count has come down from 19 to 12.
ITP|idiopathic thrombocytopenic purpura|ITP|211|213|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Hypothyroidism, on thyroid replacement. History of failed treatment of hepatitis C. Prior appendectomy. History of fibroids. Exploratory laparotomy in the past. Has splenectomy in 1980 for ITP without major infection problems historically. FAMILY HISTORY: Nothing relevant to the current illness including no major infection history.
ITP|idiopathic thrombocytopenic purpura|ITP.|169|172|HISTORY OF PRESENT ILLNESS|She did have a migraine yesterday, received Imitrex and Naprosyn which was with good relief. She is also on atenolol 25 mg daily for migraine prophylaxis. 6. History of ITP. She underwent a splenectomy. 7. History of an echocardiogram in _%#MM#%_ 2003 with an ejection fraction of 70%. SURGICAL HISTORY: 1. Status post radioactive ablation for Graves disease.
ITP|idiopathic thrombocytopenic purpura|ITP.|158|161|HISTORY OF PRESENT ILLNESS|SURGICAL HISTORY: 1. Status post radioactive ablation for Graves disease. 2. Exploratory laparotomy in 1980s. 3. Splenectomy in 1980 secondary to her history ITP. 4. Appendectomy in 1970s. 5. C-section in 1984. 6. Hysterectomy in 2002 secondary to fibroids and endometriosis. ADMISSION MEDICATIONS: 1. Atenolol 25 mg p.o. q. day.
ITP|idiopathic thrombocytopenic purpura|ITP|149|151|PAST MEDICAL HISTORY|2. Cesarean section in past. 3. Splenectomy and appendectomy in the past. She has had no post- splenectomy related infection problems. She had prior ITP which was completely cured by the splenectomy. MEDICATIONS: Interferon. Has been on Neupogen at one point as well.
ITP|idiopathic thrombocytopenic purpura|ITP.|133|136|PAST MEDICAL HISTORY|4. History of graves disease status post radioablation and currently on replacement with Synthroid. 5. History of splenectomy due to ITP. 6. Migraine headaches for which she is on atenolol for prophylaxis. She does have history of alcohol withdrawal although I am not aware of any history of seizures or DTs.
ITP|idiopathic thrombocytopenic purpura|ITP.|184|187|PAST MEDICAL HISTORY|She developed an upper respiratory tract infection with pharyngitis and a cough about a week prior to her admission. She also has a history of hypothyroidism. PAST MEDICAL HISTORY: 1. ITP. 2. Hypothyroidism. 3. Impetigo. 4. History of prior ovarian cystectomy. ALLERGIES: None known. MEDICATIONS: 1. Iron sulfate 325 mg p.o. b.i.d.
ITP|idiopathic thrombocytopenic purpura|ITP|267|269|REASON FOR CONSULTATION|The hospitalist service was asked by Dr. _%#NAME#%_ to follow _%#NAME#%_ _%#NAME#%_ immediately postop laparoscopic cholecystectomy for diabetes management, and management of her chronic obstructive pulmonary disease. The patient also has a known recent diagnosis of ITP (idiopathic thrombocytopenic purpura). HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 72-year-old female from Nepal who is visiting one of her sons.
ITP|idiopathic thrombocytopenic purpura|ITP.|194|197|HISTORY OF PRESENT ILLNESS|As Dr. _%#NAME#%_ had left, the patient was evaluated by Dr. _%#NAME#%_, and admitted for incisional oozing, felt to be related to the patient's underlying platelet count of 60,000 secondary to ITP. The hospitalist service is asked to follow postoperatively. The patient currently denies any complaints through her son who is translating, with the exception of the oozing when she has changes in position.
ITP|idiopathic thrombocytopenic purpura|ITP.|146|149|PLAN|She was hospitalized at _%#CITY#%_ when she was 16 years old and had low platelets. She had a bone marrow biopsy and I suspect this was childhood ITP. FAMILY HISTORY: Her mother had breast cancer at age 63 and died of metastatic disease at age 66.
ITP|idiopathic thrombocytopenic purpura|ITP|203|205|REVIEW OF SYSTEMS|FAMILY HISTORY: Significant for mother with diabetes and hypertension. Paternal grandmother and grandfather with coronary heart disease. REVIEW OF SYSTEMS: She denies any symptoms that may be related to ITP including epistaxis, melena or rectal bleeding, or menorrhagia. All other review of systems were negative. PHYSICAL EXAMINATION: General: The patient appears to be in no acute distress.
ITP|idiopathic thrombocytopenic purpura|ITP|171|173|PAST MEDICAL HISTORY|She describes a negative past echocardiogram at doctors. She has never had a stress test. 2. Mixed connective tissue syndrome. 3. History of thrombocytopenia secondary to ITP treated with steroids in the past. 4. Epistaxis as noted above. 5. History of cholecystectomy. 6. History of right TKA in _%#MM#%_ of last year. Again, there is no history of postoperative thrombosis.
ITP|idiopathic thrombocytopenic purpura|ITP,|212|215|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 68-year-old female admitted on _%#MMDD2007#%_ to _%#CITY#%_ for rehabilitation from her deconditioning. She carries a past history significant for anaplastic anemia, chronic ITP, diabetes and hypertension and has been hospitalized numerous times over the past 2-3 months with more recent hospitalization being for diarrhea for which she presented to the Fairview Southdale emergency department on _%#MMDD2007#%_ and was subsequently admitted to the University of Minnesota Medical Center, Fairview for further evaluation and treatment.
ITP|idiopathic thrombocytopenic purpura|ITP.|198|201|PAST MEDICAL HISTORY|She denies any sleep difficulties or any depression though she at times gets some occasional low back pain and again no appreciable headaches. PAST MEDICAL HISTORY: 1. Anaplastic anemia. 2. Chronic ITP. 3. History of stage III breast cancer, status post mastectomy and chemotherapy. 4. Diabetes type 2. 5. Hypertension. 6. Obesity. 7. Overactive bladder.
ITP|idiopathic thrombocytopenic purpura|ITP.|280|283|ASSESSMENT AND PLAN|We will place the patient on standing transfusion orders for which she will receive one adult dose (5 packs of platelets) for a platelet count less than 70,000. 2. Hematology: History of pancytopenia secondary to aplastic anemia. Her thrombocytopenia is also secondary to chronic ITP. We will continue the patient's cyclosporin 50 mg p.o. b.i.d. We will transfuse her with packed red blood cells for a hemoglobin less than 8 gm and platelet transfusion if her platelet count is less than 70,000.
ITP|idiopathic thrombocytopenic purpura|ITP.|143|146|PAST MEDICAL HISTORY|She was also having difficulty with remaining alert and was markedly different from her baseline. PAST MEDICAL HISTORY: 1. Aplastic anemia. 2. ITP. 3. Breast cancer on the right side, which was stage III. 4. Urinary tract infection with E. coli sepsis. 5. Generalized encephalopathy.
ITP|idiopathic thrombocytopenic purpura|ITP.|209|212|IMPRESSION|Serum electrolyte studies are normal. Creatinine 0.60. Liver functions studies are normal. IMPRESSION: 1. Marked thrombocytopenia with preservation of other cell lines. The clinical picture is consistent with ITP. She has no obvious associated medical conditions or medication exposures and at present the etiology for the thrombocytopenia is unclear.
ITP|idiopathic thrombocytopenic purpura|ITP|218|220|IMPRESSION|He has no clinical evidence of splenomegaly and has no obvious risk factors for cirrhosis or other conditions that might lead to splenomegaly. Possible explanations for the low platelets could include well-compensated ITP or possibly thrombocytopenia due to antiphospholipid antibody syndrome. This latter syndrome theoretically could also be related to his syncopal spell, particularly if there was thromboembolism present in the posterior circulation.
ITP|idiopathic thrombocytopenic purpura|ITP|175|177|INDICATIONS|She has been okay to ambulate. She denies any chills, nausea or vomiting. She does have a past medical history significant for autoimmune pericarditis which and sclerosis and ITP in the past. Her past surgical history is significant for a TAH and a cystocele excision. Medications: trazodone as well 5 mg. She is a nonsmoker, nondrinker.
ITP|idiopathic thrombocytopenic purpura|ITP.|188|191|ASSESSMENT AND PLAN|3) Check platelet antibodies. 4) Check abdominal ultrasound (to assess spleen size and rule out splenomegaly). 5) Follow platelets daily. 6) Agree with a trial of steroids for presumptive ITP. (This does is usually 1 mg/kg IV q.12 followed by rapid wean). Thank you for the opportunity to see this kind woman in consultation regarding her thrombocytopenia.
ITP|idiopathic thrombocytopenic purpura|ITP.|102|105|PAST MEDICAL HISTORY|2. In 2001, right hip hemiarthroplasty for steroid-induced aseptic necrosis. PAST MEDICAL HISTORY: 1. ITP. This was resolved with surgery, with no further treatment being required. She did have complications from her steroids with aseptic necrosis of her right hip.
ITP|idiopathic thrombocytopenic purpura|ITP.|172|175|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Psoriasis. 2. Gout. 3. Osteoporosis. 4. Pulmonary hypertension. 5. Gastroesophageal reflux disease. 6. Hypotension. 7. Chronic thrombocytopenia or ITP. 10. Depression. 11. History of prostate cancer. PAST SURGICAL HISTORY: 1. Bilateral inguinal hernia surgery. 2. Right shoulder rotator cuff repair in 1987 or 1988.
ITP|idiopathic thrombocytopenic purpura|ITP.|236|239|ADDENDUM TO CONSULTATION|Mr. _%#NAME#%_ was seen and examined by me independently. My clinical findings and plan concur with _%#NAME#%_ _%#NAME#%_. The patient has been taking a significant amount of NSAIDS. He has a low platelet count, secondary likely to his ITP. His INR has also been prolonged, possibly to lupus inhibitor. He had 2 episodes of what was described as significant hematemesis; clot was saved and was viewed by me at time of examining the patient.
ITP|idiopathic thrombocytopenic purpura|ITP|230|232|HISTORY OF PRESENT ILLNESS|Her creatinine now is 1.4. 5. Idiopathic dilated cardiomyopathy, ejection fraction 25% several years ago which resolved completely. 6. Coronary artery disease and angioplasty and stent of the left circumflex as detailed above. 7. ITP with recent exacerbation of problems with low platelets in _%#MM#%_ 2003. When she was seen in the cardiology clinic following that episode, she was still on aspirin and Plavix and I elected to discontinue her Plavix due to concerns regarding bleeding.
ITP|idiopathic thrombocytopenic purpura|ITP|195|197|REASON FOR CONSULTATION|He has been treated with attempts at inhalers and Lasix, but it is hard to know how compliant he was in that regard. Of note, he was treated with high dose prednisone as well as immunoglobin for ITP and has not been on any prednisone recently. He has been treated while in the hospital for a question of heart failure, given pleural effusions.
ITP|idiopathic thrombocytopenic purpura|ITP|212|214|PAST  MEDICAL HISTORY|It also showed emphysematous change and borderline adenopathy. He quit smoking many years ago but has estimated 50-pack-year tobacco smoking history and was on Combivent prior to admission. PAST MEDICAL HISTORY: ITP as above, also hypertension and COPD. MEDICATIONS PRIOR TO ADMISSION: Norvasc, prednisone, Combivent. FAMILY HISTORY: Noncontributory.
ITP|idiopathic thrombocytopenic purpura|ITP|211|213|IMPRESSION|The patient has a diagnosis of chronic relapsing TTP and the question remains whether this is congenital. He has no family history of such. However, he has episodes of petechiae which were formerly diagnosed as ITP (but failed to respond to steroids or IV Ig) going back to childhood. A diagnosis of TTP was made with one of these exacerbations 10 years ago or more, and he was followed at Mercy Hospital at that time for periodic exacerbations.
ITP|idiopathic thrombocytopenic purpura|ITP|207|209|IMPRESSION  AND PLAN|He does not have any evidence of sepsis, however, I would recommend checking a PT, PTT and fibrinogen level as well as review of his smear to rule that out. Furthermore, he does have any previous history of ITP or splenomegaly. However, he does appear to consume alcohol in a moderately with a suspicion for possible hypersplenism. If his count does not recover over the next couple of days, I would recommend obtaining a CT scan of his abdomen and pelvis to evaluate for adenopathy and splenomegaly as well as a bone marrow biopsy to evaluate for possible myelocystic process.
ITP|idiopathic thrombocytopenic purpura|ITP,|147|150|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Notable for breast cancer, status post mastectomy 9 years ago. Status post cholecystectomy 7 years ago. She has a history of ITP, status post splenectomy in her youth. MEDICATIONS: Include Synthroid and Zocor. ALLERGIES: No medical allergies. FAMILY HISTORY: Father deceased at age 62 of heart disease.
ITP|idiopathic thrombocytopenic purpura|ITP.|168|171|DOB|She did have a course of steroids, which she told me lasted for eight months or so without improvement in her platelet count. She had no further symptoms attributed to ITP. The main current problems are: 1. Slurred speech, which almost completely resolved by last night.
ITP|idiopathic thrombocytopenic purpura|ITP.|121|124|IMPRESSION|5. History of deep venous thrombosis in the past. The patient apparently has a Greenfield filter in place. 6. History of ITP. 7. Diabetes. 8. Hypertension. RECOMMENDATIONS; 1. The patient is acceptably awake and responsive. He has tolerated CPAP with pressure support of 10 for several hours, and we will try a short TPS trial.
ITP|idiopathic thrombocytopenic purpura|ITP,|230|233|PAST MEDICAL HISTORY|Early this morning, the patient ran into respiratory distress and had to be mechanically ventilated. PAST MEDICAL HISTORY: 1. Atrial flutter, status post conversion bioprosthetic aortic valve replacement, done in _%#MM2005#%_. 2. ITP, status post splenectomy 25 years ago. 3. Status post radiation and chemotherapy for Hodgkin's lymphoma . 4. On _%#MMDD2006#%_, she had a mammogram of the bilateral breasts, which found that she had mass which was biopsied on the _%#DD#%_.
ITP|idiopathic thrombocytopenic purpura|ITP|133|135|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 16-year-old male who is being admitted for an IV IgG infusion for his thrombocytopenia. He has ITP which was diagnosed about a month ago. This will be his second IV IgG infusion. He typically sees a pediatric endocrinologist regarding his diabetes and I reviewed his at-home regimen with him.
ITP|idiopathic thrombocytopenic purpura|ITP|108|110|HISTORY OF PRESENT ILLNESS|He believes his last hemoglobin A1C value was 7.1%. He was admitted to Fairview last evening because of his ITP and he was started on an IV IgG infusion. His initial blood sugar was immediately postprandial after having a couple ice creams and it was 363.
ITP|idiopathic thrombocytopenic purpura|ITP.|222|225|ASSESSMENT/PLAN|Additionally at bedtime I would give anywhere from 0 to 4 units of insulin depending on his blood sugar result. I will continue to follow along and give further advice regarding his insulin management while he is here. 2. ITP. The IgG infusion is per hematologist. 3. Colitis. Gastroenterology team is involved. 4. Microcytosis with iron studies consistent with iron deficiency.
ITP|idiopathic thrombocytopenic purpura|(ITP)|259|263|PAST MEDICAL HISTORY|She underwent placement of an IVC filter in _%#MM#%_ 2001 because of thrombocytopenia with platelet count of around 24,000 at that time. She says that she has had three deep venous thromboses in her left leg. 4. History of idiopathic thrombocytopenic purpura (ITP) with a history of low platelets, going back to 1994. Recent labs show a platelet count of around 59,000. 5. History of chronic urinary tract infections, for which she has been on chronic Cipro for chronic prophylaxis.
ITP|idiopathic thrombocytopenic purpura|ITP|273|275|IMPRESSION|Despite her abnormal liver enzymes, her findings are inconsistent with HELLP syndrome (hemolysis, elevated liver enzymes and low platelets), which should resolve after delivery. Platelet associated immunoglobulin levels will also be obtained to evaluate the possibility of ITP (idiopathic thrombocytopenic purpura). I would continue to monitor the patient's blood counts and watch for resolution of her thrombocytopenia as her infection improves with supportive management.
ITP|idiopathic thrombocytopenic purpura|ITP.|257|260|PAST MEDICAL HISTORY|She is not sure what therapy she had, but when I mentioned CHOP, she thought that sounded familiar and as also mentioned she had radiation therapy to her neck. 2. Depression 3. Hypothyroid. 4. TAH with BSO. 5. Bilateral eye surgery. 6. Splenectomy done for ITP. MEDICATIONS: Effexor, BuSpar, Wellbutrin dose unclear and levothyroxine 0.88 mg daily.
ITP|idiopathic thrombocytopenic purpura|ITP|169|171|PAST MEDICAL HISTORY AND PAST SURGICAL HISTORY|3. Arterial switch done in _%#MM1989#%_ in _%#CITY#%_. 4. Absence seizures and developmental delay possibly secondary to issues during the arterial switch operation. 5. ITP x 2. The last time was in _%#MM2004#%_, which improved with IVIG. 6. Low factor VII, which was evaluated by Hematology. The last visit was in _%#MM2004#%_.
ITP|idiopathic thrombocytopenic purpura|ITP.|162|165|HISTORY OF PRESENT ILLNESS|She presented about three years ago with spontaneous splenic rupture, at which time her liver disease was discovered. Her spleen was removed. She later developed ITP. Platelet counts have been quite low, and currently are in the 20,000 range. She does experience mucocutaneous hemorrhage, including easy bruising, nosebleeds, and most recently GI bleeding.
ITP|idiopathic thrombocytopenic purpura|ITP,|248|251||In addition to her multiple sclerosis, she has developed what has been called an autoimmune hepatitis and has presented with encephalopathy on occasion. Most recently, her course has been complicated by thrombocytopenia that has been labeled as an ITP, for which she has received immunosuppressive therapy. It is of interest that the patient sustained, again, for reasons that are unclear, alleged spontaneous splenic rupture in the past, at which time she underwent a splenectomy along with a cholecystectomy.
ITP|idiopathic thrombocytopenic purpura|ITP|151|153|ASSESSMENT AND PLAN|Her platelets have been decreased, and this is probably from sequestration from her liver disease. Interestingly, she had been diagnosed possibly with ITP in the past, but in retrospect this is probably from her liver disease. She does not meet any criteria now for evaluation for liver transplantation.
ITP|idiopathic thrombocytopenic purpura|ITP.|120|123|FAMILY HISTORY|4. Status post ankle surgery. ALLERGIES: Augmentin - hives. FAMILY HISTORY: Sister with diabetes mellitus. Brother with ITP. SOCIAL HISTORY: Married and lives at home in _%#CITY#%_ _%#CITY#%_.
ITP|idiopathic thrombocytopenic purpura|(ITP)|193|197|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Dyspnea on exertion, chest pain, atrial flutter. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 69-year-old woman with a history of idiopathic thrombocytopenic purpura (ITP) who presents with atrial flutter. The patient underwent scheduled right cataract removal surgery earlier today. On presentation she was noted to be in atrial flutter with a rate in the 70s range.
ITP|idiopathic thrombocytopenic purpura|ITP.|186|189|DISCHARGE FOLLOW-UP|2. The patient will see Dr. _%#NAME#%_ _%#NAME#%_, a retina specialist, within one week. 3. The patient will be seen by Dr. _%#NAME#%_ _%#NAME#%_ as needed for further management of her ITP. 4. The patient will have a complete blood count with platelets and differential drawn on _%#MMDD2004#%_, with the results faxed to her primary physician.
ITP|idiopathic thrombocytopenic purpura|ITP.|194|197|FOLLOWUP|We suggested that she continue allopurinol at least until uric acid level became normal. FOLLOWUP: 1. Dr. _%#NAME#%_ or his nurse practitioner (_%#NAME#%_ _%#NAME#%_) within two weeks to follow ITP. 2. Because the patient has several significant medical problems and does not have a regular primary physician, we advised that she find a primary internist.
ITP|idiopathic thrombocytopenic purpura|ITP|259|261|DOB|She responded well to steroid therapy with no further issues with bleeding or bruising and no exacerbations of her baseline problems with COPD, GERD, but heme-positive stool was noted. She also showed signs of some iron deficiency suggesting that perhaps her ITP is not th e total explanation for why she has heme-positive stools, but in any event she is not in a situation where aggressive investigation can be done endoscopically because of her low platelet count.
ITP|idiopathic thrombocytopenic purpura|ITP|130|132|PAST MEDICAL HISTORY|4. Metoprolol 25 mg p.o. b.i.d. 5. Coque 10 supplement q. day. 6. Depakote 375 mg p.o. b.i.d. PAST MEDICAL HISTORY: 1. History of ITP at age 4. Diagnosed at Children's Hospital. No treatment was given at that point, but patient was sent home with a helmet and bleeding precaution instructions.
ITP|idiopathic thrombocytopenic purpura|ITP.|261|264|PAST MEDICAL HISTORY|7. Sarcoidosis, diagnosed in 1970s. 8. Hyperlipidemia. 9. Glaucoma. 10. History of Aspergillus niger infection of the lung in _%#MM2006#%_, also with staphylococcus aureus and Branhamella catarrhalis lung infection. 11. Status post splenectomy in the 1980s for ITP. 12. Status post hysterectomy in the 1960s. 13. History of gout. OUTPATIENT MEDICATIONS: It should be noted the patient has not been taking any of these medications for approximately 3 days.
ITP|idiopathic thrombocytopenic purpura|ITP.|194|197|ADMISSION DIAGNOSIS|9. History of nondisplaced zygomatic fracture and subdural hematoma status post MVA _%#MM#%_ 2001. 10. History of syncopal episode _%#MM#%_ 2002 with rule out MI workup. DISCHARGE DIAGNOSIS: 1. ITP. 2. Renal insufficiency, baseline creatinine of 1.4. 3. Hypertension. 4. Iron-deficiency anemia. 5. Hepatitis C. 6. L4-L5 disk herniation. 7. History of gallstone pancreatitis _%#MM#%_ 2001. 8. Positive PPD with stable chest x-ray and sputum negative for AFB, _%#MM#%_ 1999.
ITP|idiopathic thrombocytopenic purpura|ITP|301|303|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|ALLERGIES: The patient lists allergy to codeine with a reaction of hallucinations, sulfa and Cipro, ofloxacin causes nausea, penicillin rash. HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 62-year-old white female with a known history of CLL who had development of chronic ITP and was recently admitted from _%#MMDD2007#%_ to _%#MMDD2007#%_ for IVIG treatment along with platelet transfusions. Unfortunately, the patient developed epistaxis after discharge as well as a skin laceration and was admitted again to an outside hospital Emergency Room and eventually transferred to the University of Minnesota Medical Center, Fairview on _%#MMDD2007#%_ where she did not respond to medical treatment and unfortunately required a splenectomy.
ITP|idiopathic thrombocytopenic purpura|ITP.|198|201|IMAGING|The patient since evaluated by Dr. _%#NAME#%_ _%#NAME#%_ from Hematology with regards to the thrombocytopenia. Numerous laboratory studies have been obtained. Process not felt to be consistent with ITP. Consumption potentially related to the right upper extremity hematoma potentially contributory. Potential low grade DIC secondary to neoplasm cannot be excluded.
ITP|idiopathic thrombocytopenic purpura|ITP.|166|169|2.  FEN|Thus, the patient may benefit in the future from erythropoietin as we are assuming this anemia could be due to bone marrow failure. The patient also has a history of ITP. Platelets checked on _%#MMDD2007#%_ were found to be 244. On postoperative day #1, the platelets were found to be 114. Upon discharge, the patient's platelets were 103. This is a significant decrease for the patient and is likely related to her radiation therapy she is receiving.
ITP|idiopathic thrombocytopenic purpura|ITP.|223|226|HISTORY OF PRESENT ILLNESS|About 2-3 days prior to the admission, the patient has noticed some petechia of her lower extremities. The patient has a history of ITP and has had a splenectomy in 1999 with a history of occasional relapses of her chronic ITP. She has been told that whenever she gets the petechial rash, she is to contact her doctor and if her platelet count is low, she needs to get emergent care.
ITP|idiopathic thrombocytopenic purpura|ITP.|188|191|COMPLICATIONS|NEUROLOGIC: Negative. HEMATOLOGIC/LYMPHATIC: Positive for history of ITP. PAST MEDICAL HISTORY: 1. Patient has had 2 spontaneous vaginal deliveries that were uncomplicated. 2. Patient has ITP. This was diagnosed in 2001 when she had a routine CBC revealing a low platelet count. Bone marrow biopsy confirmed this. She has had 1 platelet transfusion in _%#MM#%_ 2004.
ITP|idiopathic thrombocytopenic purpura|ITP|279|281|PROBLEMS|4. COPD, obstructive sleep apnea status post tracheostomy. The patient requires complex tracheostomy care with frequent suctioning and continued to have requirement for oxygen supplement. She has been receiving 40 FIO2 of 0.40. We were able to decrease it to 0.27. 5. History of ITP status post splenectomy. The patient throughout this admission did not have any signs of mucocutaneous bleeding. Her platelet function was normal. In fact, with this illness she has been demonstrating reactive thrombocytosis of 575 to 604.
ITP|idiopathic thrombocytopenic purpura|(ITP),|215|220|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Increased lower extremity edema and shortness of breath. HISTORY OF PRESENT ILLNESS: 71-year-old white female with a past medical history significant for chronic idiopathic thrombocytopenic purpura (ITP), status post splenectomy, diabetes mellitus, chronic obstructive pulmonary disease and obstructive sleep apnea, on chronic tracheostomy. She presented to the emergency room with the complaint of increased lower extremity edema and a 40-pound weight gain over the past four weeks.
ITP|idiopathic thrombocytopenic purpura|ITP.|175|178|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Hypertension. 2. Previous thyroid dysfunction. 3. Hypercholesterolemia. 4. Diabetes mellitus type 2. 5. History of splenectomy, possibly secondary to ITP. 6. Possible lower extremity DVT with associated pulmonary emboli, status post many months of coumadinization. 7. Tonsillectomy. 8. Appendectomy. 9. Corrective eye surgery. 10. Benign unilateral ovarian tumor removal.
ITP|idiopathic thrombocytopenic purpura|ITP.|175|178|PAST SURGICAL HISTORY|2. Right partial nephrectomy for renal cell in 1996. 3. Resection of right parotid secondary to malt lymphoma in 1996. 4. Appendectomy. 5. Cholecystectomy. 6. Splenectomy for ITP. 7. Bilateral cataracts. 8. Hysterectomy. 9. Left oophorectomy. SOCIAL HISTORY: She is married. She had four children, one child died at age 14 of leukemia.
ITP|idiopathic thrombocytopenic purpura|ITP|207|209|PAST MEDICAL HISTORY|Please refer to the very detailed discharge summary done by Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2007#%_ and also please refer to multiple medical records present on FCIS. PAST MEDICAL HISTORY: 1. History of ITP in 1998, status post splenectomy at the Mayo clinic. 2. Shingles in 2006. 3. Bilateral leg pain and swelling. The likely etiology is erythema nodosum during his hospital stay for peripheral blood stem cell transplant.
ITP|idiopathic thrombocytopenic purpura|ITP.|117|120|DISCHARGE DIAGNOSES|2. ITP refractory to IVIG and steroid treatment. DISCHARGE DIAGNOSES: 1. A 38-year-old G3 P1 0-1-1 at 18+ 3 weeks 2. ITP. 3. Status post splenectomy. OPERATIONS/PROCEDURES PERFORMED: 1. IV stereodisk.
ITP|idiopathic thrombocytopenic purpura|ITP|186|188|ASSESSMENT AND PLAN|Other contributing factors may be a viral process such as Epstein-Barr or cytomegalovirus accounting for her sore throat, although she had a positive Rapid strep. I doubt HELP syndrome, ITP or TTP. She is not anemic. We will check antiplatelet antibody. We will check B12 and folate level, Epstein-Barr and cytomegalovirus IgMs are being checked.
ITP|idiopathic thrombocytopenic purpura|ITP,|163|166|PAST MEDICAL HISTORY|She is now status post double-cord blood transplant on _%#MMDD2003#%_. 2. Chronic graft versus host disease. This presented as autoimmune hemolysis and refractory ITP, which is now resolved after Rituxan. 3. Perineal cellulitis in _%#MM2005#%_. This required I&D and IV antibiotics, and is continuing to heal.
ITP|idiopathic thrombocytopenic purpura|ITP|158|160|PAST MEDICAL HISTORY|12. Adenocarcinoma of the rectum that was resected in _%#MM#%_ of 2001. 13. Crohn's disease. 14. Depression and anxiety. 15. I presume she has a diagnosis of ITP with her description as noted above. MEDICATIONS: 1. Celexa. 2. Diltiazem. 3. Prednisone taper. 4. Inhalers.
ITP|idiopathic thrombocytopenic purpura|ITP.|185|188|PLAN|This recommendation is per Dr. _%#NAME#%_. We will also give platelets today in an attempt to reverse her thrombocytopenia quickly. 3. Melena. Again, I do suspect GI bleed secondary to ITP. We will ask her primary care physician, Dr. _%#NAME#%_, to evaluate her. We will also begin Protonix. 4. History of non-small cell lung cancer with a recent diagnosis.
ITP|idiopathic thrombocytopenic purpura|ITP|133|135|HISTORY OF PRESENT ILLNESS|Given the appearance of her bruising, which progressed to petechia prior to her diagnosis of Fanconi anemia, she was thought to have ITP and did receive a partial dose of IVIG. _%#NAME#%_ and her family were then referred to the University of Minnesota in _%#MM#%_ of 2003 for evaluation for transplant.
ITP|idiopathic thrombocytopenic purpura|ITP.|125|128|PLAN|In the meantime we will continue her diet as tolerated and monitor her stool output. We will continue her cholestyramine. 2. ITP. We will treat her ITT with IV IG 1 gram/kilogram over 1-2 days. She has responded to this well in the past. She received WinRho on _%#MMDD2007#%_.
ITP|idiopathic thrombocytopenic purpura|ITP,|191|194|PAST MEDICAL HISTORY|5. Multiple sclerosis, with onset in 1980s, treated with steroids and interferon in the past. 6. She has a chronic right hemiparesis and neurogenic bladder secondary to her MS. 7. History of ITP, most recently in _%#MM2003#%_, treated with steroids and IVIG. This was complicated by developing ATN. She did get Carimune, which is a certain type of IGIG with sugar content.
ITP|idiopathic thrombocytopenic purpura|ITP,|269|272|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1: Lower extremity deep venous thrombosis. The patient did have a V/Q scan, which showed low probability of pulmonary embolism although lower extremity Dopplers showed bilateral DVT. As the patient is at high risk for anticoagulation with her ITP, liver disease, and multiple other comorbidities and fall risks, a filter was placed. The patient tolerated this procedure well, and she does have a 5% chance of throwing small clots to her lungs per Interventional Radiology.
ITP|idiopathic thrombocytopenic purpura|ITP.|149|152|PAST MEDICAL HISTORY|He was initiated on Prevacid. 5. Thrombocytopenia, chronic. The platelet counts run around 100,000. The primary MD thinks this may be a component of ITP. He has not met criteria for prednisone. 6. History of nonspecific dizziness. SURGICAL HISTORY: 1. Status post cholecystectomy. 2. Status post appendectomy.
ITP|idiopathic thrombocytopenic purpura|ITP.|24|27|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. ITP. 2. Acute chest pain. 3. Systemic lupus erythematosus. 4. History of Graves disease with hypothyroidism. CHIEF COMPLAINT: Chest pain. BRIEF HISTORY OF PRESENT ILLNESS: This is a 21-year-old female with a history of systemic lupus erythematosus, idiopathic thrombocytopenic purpura, as well as a history of Graves disease status post radioactive iodine ablation who presented at approximately 1300 hours to the University of Minnesota Emergency Department with a complaint of "extreme chest pain." She stated that she felt like her chest was "caving in." Her lungs were caving in.
ITP|idiopathic thrombocytopenic purpura|ITP,|163|166|IMPRESSION|Many of the symptoms might be accounted for with this diagnosis, although there are obviously other explanations as well. He could have low platelet counts due to ITP, but that would not fit with his recent onset fever and rigors. 2. Anemia, which is likely multifactorial, including blood loss. His reticulocyte count, however, is inappropriately low, however, may suggest other causes including anemia due to impaired iron mobilization, such as with chronic inflammation or even a primary bone marrow disorder.
ITP|idiopathic thrombocytopenic purpura|(ITP)|210|214|HISTORY OF PRESENT ILLNESS|He has multiple autoimmune conditions and bipolar disorder and presents here with splenomegaly, severe thrombocytopenia and new onset ascites. The patient states that he had idiopathic thrombocytopenic purpura (ITP) as a child and was treated for this on and off with steroids in the past. Typically his platelet count runs between 20,000 and 30,000. After that the patient in his teenage years had an episode of what he describes as acute hepatitis C.
ITP|idiopathic thrombocytopenic purpura|ITP.|152|155|HISTORY OF PRESENT ILLNESS|This is new for her as compared to the past. She also was noted to have a low platelet count in the hospital and was seen by hematologist, who suspects ITP. She has had a platelet transfusion yesterday. PAST MEDICAL HISTORY: 1. Hypertension. 2. History of peripheral vascular disease with left carotid artery stenosis, about 80%, which was treated medically.
ITP|idiopathic thrombocytopenic purpura|ITP.|192|195|ASSESSMENT|Certainly follow-up x-ray after diuresis will be helpful to see if the effusions decreased. 3. Thrombocytopenia. She has been seen by hematologist, and the suspicion is that she may be having ITP. Steroids have been started. 4. Bifascicular block. She has bifascicular block on her EKG.
ITP|idiopathic thrombocytopenic purpura|ITP|263|265|IMPRESSION|She does not have any obvious history of a connective-tissue disorder, but this is difficult to completely exclude on clinical grounds. I believe the picture is most consistent with ITP, and I spent approximately 15 minutes reviewing the presumptive diagnosis of ITP as well as the various treatment options. Treatment options discussed included the use of corticosteroids, IVIG, WinRho, splenectomy and other options in individuals who have refractory disease.
ITP|idiopathic thrombocytopenic purpura|ITP|185|187|IMPRESSION|Splenic sequestration could also explain her mild chronic leukopenia as well. Alternative explanations for the thrombocytopenia could include decreased destruction such as with chronic ITP or thrombocytopenia due to an anti- phospholipid antibody syndrome. A proliferative disorder is possible but considered much less likely given the very long natural history.
ITP|idiopathic thrombocytopenic purpura|ITP.|107|110|SOCIAL HISTORY|He drinks occasionally even now. He is married. He has one son. Of note, both his wife and son suffer from ITP. FAMILY HISTORY: Not contributory. MEDICATIONS: Miconazole, vancomycin, hydromorphone, diltiazem, lorazepam, and metoprolol.
ITP|idiopathic thrombocytopenic purpura|ITP.|208|211|ASSESSMENT|3. Gastroesophageal reflux disease, symptomatically well-controlled on Nexium. 4. Type II diabetes mellitus adequately controlled by diet. 5. History of renal calculus disease. 6. Status post splenectomy for ITP. Residual mild thrombocytopenia. 7. History of atrial fibrillation, presently maintained in a normal sinus rhythm. 8. Status post TURP for recurrent/chronic prostatitis. 9. Status post septoplasty/turbinoplasty.
ITP|idiopathic thrombocytopenic purpura|ITP|177|179|HISTORY OF PRESENT ILLNESS|There is no laboratory evidence of thrombocytopenia during the _%#MM2006#%_ admission at UMCH nor was there a history of blood in stool or urine. The question of whether he had ITP variant as opposed to HSP. Psychiatry saw the patient because of his mood disorder which they attributed to steroid taper, and thought no medication was warranted other than supportive care, and reassurance.
ITP|idiopathic thrombocytopenic purpura|ITP.|174|177|ASSESSMENT/PLAN|Will recheck platelets on _%#MMDD2003#%_. Will also check platelet associated antibody and peripheral smear tomorrow, _%#MMDD2003#%_. This will assess for conditions such as ITP. Call MD if abnormal so that the platelet count and other results may be evaluated. 4. Orthostasis which may be secondary to atenolol or orthostatic blood pressure changes.
ITP|idiopathic thrombocytopenic purpura|ITP|194|196|PAST MEDICAL HISTORY|She denied acute fevers, chills, shortness of breath or syncope. PAST MEDICAL HISTORY: 1. Atrial flutter status post cardioversion. 2. Bioprosthetic aortic valve replacement in _%#MM2005#%_. 3. ITP status post splenectomy 25 years previous. 4. Status post treatment with radiation and chemotherapy for Hodgkin lymphoma.
ITP|idiopathic thrombocytopenic purpura|ITP|178|180|PAST MEDICAL HISTORY|Review of systems was otherwise completely negative. PAST MEDICAL HISTORY: 1. Cirrhosis due to chronic hepatitis-B. 2. Hepatitis B diagnosed in 2000, status post splenectomy. 3. ITP with splenectomy done in 2000. 4. HIV diagnosed in 1987, CD4 nadir of 40. 5. Liver transplant status, with a past history of ascites, but no encephalopathy, occasional itching in hands and feet.
ITP|idiopathic thrombocytopenic purpura|ITP;|211|214|HOSPITAL COURSE|HOSPITAL COURSE: The patient was admitted to the floor, and after taking the initial history and physical it was decided that her presentation was most consistent with a Mallory-Weiss tear. She has a history of ITP; however, her platelets on admission were 106,000, and it is not felt that her ITP had any role in her presentation. She did spike a fever to 101.9 the evening of admission, and she was kept overnight for observation.
ITP|idiopathic thrombocytopenic purpura|(ITP)|307|311|DISCHARGE DIAGNOSES|1. Postpolypectomy bleeding. 2. Anticoagulation for history of deep venous thrombosis (DVT) with life-threatening pulmonary embolus (PE) in 1990 or 1991. 3. Stable conditions include: asthma, hypothyroidism, hypercholesterolemia, chronic fatigue syndrome, and history of idiopathic thrombocytopenic purpura (ITP) secondary to medication reaction. HISTORY OF THE PRESENT ILLNESS AND HOSPITAL COURSE: The patient is a 71-year-old female who was hospitalized on _%#MMDD2004#%_ with a complaint of passing blood clots per rectum.
ITP|idiopathic thrombocytopenic purpura|ITP|199|201|IMPRESSION|Also will do pulmonary function test to try to document the contribution of any obstructive lung disease. Patient is a former smoker. 2. Confusion, no evidence of that at present time. 3. History of ITP with slightly low platelet count. Will follow this for the present time. 4. Anemia, the patient's hemoglobin was 13.7 in _%#MM#%_ of this year so that is a significant drop.
ITP|idiopathic thrombocytopenic purpura|ITP.|190|193|HOSPITALIZATIONS|ALLERGIES: The patient has no known drug allergies. MEDICATIONS: Atenolol 25 mg q.d. PAST MEDICAL HISTORY: Hypertension, ITP. HOSPITALIZATIONS: Secondary to his chest pain. Secondary to the ITP. PAST SURGICAL HISTORY: He is status post splenectomy. He did receive a Pneumovax.
ITP|idiopathic thrombocytopenic purpura|(ITP)|165|169|PHYSICAL EXAMINATION|The remainder of the mouth and oropharynx nasopharyngoscopy and head and neck examination are normal. She does have a history of idiopathic thrombocytopenic purpura (ITP) but her platelet count has been normal. IMPRESSION: Lower lip mass, probable hemangioma. PLAN: I reviewed the findings at length with _%#NAME#%_ _%#NAME#%_.
ITP|idiopathic thrombocytopenic purpura|ITP,|158|161|PAST MEDICAL HISTORY|Normal cytogenetics. No BCR, ABL gene fusion by FISH. A second bone marrow biopsy is scheduled in two months for confirmation of CMML. 2. History of presumed ITP, secondary to CMML, currently on prednisone 80 mg p.o. daily started _%#MM#%_ 2005. 3. History of paroxysmal atrial fibrillation with rapid ventricular response, on amiodarone taper.
ITP|idiopathic thrombocytopenic purpura|ITP|278|280|HISTORY OF PRESENT ILLNESS|He is a 4082 gm, 39 week gestational age male infant born at UMMC to a 21-year-old, gravida 1, para 0-0-0-0, Hispanic female whose LMP was _%#MMDD2006#%_ and whose EDD was _%#MMDD2007#%_. The mother's pregnancy was complicated by a positive PPD with a negative chest X-ray, and ITP (idiopathic thrombocytopenia purpura) treated with IVIG on _%#MMDD#%_, _%#MMDD#%_. Mom was GBS positive and received penicillin, ampicillin and gentamicin while in labor.
ITP|idiopathic thrombocytopenic purpura|ITP|62|64|RECOMMENDATIONS|_%#NAME#%_ _%#NAME#%_ is a 35-year-old male with a history of ITP status post splenectomy about 1997. Since that time his platelet count have been within normal limits. Today he noted the onset of rather generalized abdominal pain, somewhat cramping in nature.
ITP|idiopathic thrombocytopenic purpura|ITP.|123|126|PAST MEDICAL HISTORY|2. History of colon polyps several resected with part of his colon in 2000. 3. Status post 3 hernia repairs. 4. History of ITP. HOSPITAL COURSE: As mentioned above, the patient was admitted to our service for drainage of the left pleural fluid collection.
ITP|idiopathic thrombocytopenic purpura|ITP,|223|226|HOSPITAL COURSE|It was agreed that she certainly is at risk for obstructive sleep apnea and definitely needs a polysomnogram done at Minnesota Lung Sleep Lab. This was arranged by Dr. _%#NAME#%_. In addition, patient had a past history of ITP, and her platelets remained okay both pre and postop and no sign of any autoimmune disorder in the current admission.
ITP|idiopathic thrombocytopenic purpura|ITP.|122|125|PAST MEDICAL HISTORY|ALLERGIES: Penicillin, sulfa. PAST MEDICAL HISTORY: 1. Atrial flutter. 2. Thyroid nodule. 3. Abnormal LFTs. 4. History of ITP. 5. History of right bundle branch block. MEDICATIONS: Multivitamins, fish oil, vitamin C, calcium, glucosamine, Zymar, Pred Forte, SOCIAL HISTORY: She is retired, lives with a significant other, widowed, no alcohol abuse.
ITP|idiopathic thrombocytopenic purpura|ITP|240|242|HOSPITAL COURSE|She is also advised that she can call the hospital and ask for the general surgeon on call if she has any nausea, vomiting, or elevated temperature greater than 101.5. She will also be seen by the Hematology Service as a consultant for her ITP and elevated white count. Her white count on discharge is 18,000. She says her white count normally is 16,000. Hematology will then leave their recommendations with the primary team before she is discharged.
ITP|idiopathic thrombocytopenic purpura|ITP,|167|170|IMPRESSION|Transesophageal echocardiogram as detailed in history of present illness. IMPRESSION: 1) TIA symptoms, resolved. 2) Agammaglobulinemia, on chronic IVIG. 3) History of ITP, normal platelet count at the present time. DISCUSSION/RECOMMENDATION: In view of her TIA at early age, I will rule out hypercoagulable state.
ITP|idiopathic thrombocytopenic purpura|(ITP).|166|171|HISTORY OF PRESENT ILLNESS|I have been asked to see him for further evaluation of his ongoing thrombocytopenia. HISTORY OF PRESENT ILLNESS: The patient has a history of immune thrombocytopenia (ITP). This was apparently diagnosed about 30 months ago at the University of Minnesota under Dr. _%#NAME#%_ _%#NAME#%_'s direction. The patient apparently had a negative bone marrow biopsy, and has been followed with ___,with the platelet count running in the 80,000 to 90,000 range.
ITP|idiopathic thrombocytopenic purpura|ITP.|178|181|IMPRESSION|Urine is positive for blood. Her platelet count in 1999 was normal at 383,000. IMPRESSION: 1. Isolated thrombocytopenia with petechial rash involving soft palate consistent with ITP. Other etiologies include consumptive coagulopathy; ITP; drug-related, although this is unlikely without any recent change in medications; lympho- and myeloproliferative disorders; mild dysplastic syndrome, etc.
ITP|idiopathic thrombocytopenic purpura|ITP.|195|198|ASSESSMENT|I think most likely cause could be: 1. Her Lasix that she has been taking, that can cause thrombocytopenia which has just been stopped. We will see how she does with that. 2. She could also have ITP. The fact that she has an antiplatelet antibody which is positive especially for HLA1, although, in most cases of ITP we have positive antibodies to neglect a protein 2B3A, but again with some large platelets on the smear and normal bone marrow and normal mega-karyocytes, I think ITP is definitely in the differential especially since she also has a history of rheumatoid arthritis and these patients can develop secondary immunological disorders also.
ITP|idiopathic thrombocytopenic purpura|ITP|231|233|REVIEW OF SYSTEMS|History of mild shortness of breath. The patient clearly says that his shortness of breath has not changed over the last 3 weeks, it is mild. No history of abdominal pain, nausea or vomiting. No history of constipation. History of ITP which was treated with splenectomy. No history of rash. No history of musculoskeletal disease. No neurological complaints. PHYSICAL EXAMINATION: GENERAL: A pleasant male in no distress.
ITP|idiopathic thrombocytopenic purpura|ITP.|292|295|CONSULTS|Hopefully these untoward events will not occur and hopefully she will do well throughout the pregnancy that she desires. I did recommend to her that cord platelet count be sent on the infant as it adds to our knowledge base and I have done this over t he years on all of my patients who have ITP. If you should have further questions regarding her care while here at the University of Minnesota Medical Center, Fairview, please do not hesitate to contact me.
IT|information technology|IT|224|225|SOCIAL HISTORY|ALLERGIES: Only allergy is amoxicillin. MEDICATIONS: The patient's current medications include an over-the- counter nasal spray, but otherwise none. SOCIAL HISTORY: The patient is married. He has no children. He works as an IT specialist. He does not smoke and drinks occasional alcohol on the weekends only. He states he has not had any alcohol today. FAMILY HISTORY: Reveals maternal grandmother with cancer.
IT|intertrochanteric|IT|89|90|ADMITTING DIAGNOSIS|ADMISSION DATE: _%#MMDD2004#%_ DISCHARGE DATE: _%#MMDD2004#%_ ADMITTING DIAGNOSIS: Right IT fracture and right elbow abrasion. DISCHARGE DIAGNOSIS: Same and acute blood loss anemia. Surgical procedures include an open reduction internal fixation of a right intertrochanteric hip fracture.
IT|intrathecal|IT|202|203|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 51-year-old woman with advanced metastatic colon cancer with intractable pain, who was admitted following internalization of IT pump. She had an external IT pump placed last week with improvement of pain control. She is currently alert and rates her abdominal pain a 2-3 out of 10 and foot neuropathy a 6 out of 10.
IT|UNSURED SENSE|IT|179|180|DISCHARGE DIET|He's currently being treated for a total of 9 weeks with three, 3-week cycles. Week number 1: Methotrexate infusion. Week number 2: Etoposide and cyclophosphamide. Week number 3: IT triple therapy. He is currently being admitted for week 1 of his third cycle of methotrexate infusion. REVIEW OF SYSTEMS: _%#NAME#%_'s review of systems were negative; however, he did report a left leg "weakness" of unknown duration.
IT|GENERAL ENGLISH|IT|216|217|HOSPITAL COURSE|They made recommendations about dressing changes. CT scan was performed which demonstrated the tube to be in adequate position and not a possible precipitating factor for acute renal failure or abdominal distention. IT should be noted that he had initial urine culture with three different bacteria. Was treated with Levaquin and Vanco. Subsequent follow-up cultures showed just non hemolytic strep.
IT|information technology|IT.|119|121|SOCIAL HISTORY|FAMILY HISTORY: Great-grandmother with diabetes. SOCIAL HISTORY: No known alcohol use or illicit drug use. He works in IT. The patient is divorced. REVIEW OF SYSTEMS: The patient is concerned about his blood pressure, the current headaches and the pupil constriction he is currently having.
IT|information technology|IT|88|89|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 50-year-old, right-hand dominant IT service delivery manger for ACS. She enjoys biking, golfing one to two times a week as well as skiing. She comes in with a history of smashing her right long finger in a car door on _%#MM#%_ _%#DD#%_ while in Hawaii.
IT|GENERAL ENGLISH|IT|105|106|ALLERGIES|7. Lipitor 40 mg daily. 8. Voltaren XR 100 mg daily. ALLERGIES: SULFA, ACE INHIBITOR COUGH. OF INTEREST, IT IS NOTED THAT HE HAS A HISTORY OF ELEVATED LIVER FUNCTION TESTS ON LIPITOR; HE WAS JUST CHANGED TO LIPITOR VIA PHARMACEUTICAL SUBSTITUTION; WE MAY NEED TO REEVALUATE THAT.
IT|intrathecal|IT|243|244|ADMITTING HISTORY AND PHYSICAL|The patient achieved reasonable pain control on this regimen. However, he was requiring high levels of IV Dilaudid and it was felt that it would be in his best interest to switch over to an intrathecal morphine infusion. He, therefore, had an IT test dose with morphine using fluoroscopic guidance to place the needle as several attempts in the patient's room were unsuccessful.
IT|intrathecal|IT|120|121|FAMILY HISTORY|The pain service was consulted as to whether it was okay to give the patient Celebrex and Coumadin while she was on the IT pump and they felt that it was not a problem. PROBLEMS: Number 1: Diffuse end-stage clear cell carcinoma of the ovary.
IT|GENERAL ENGLISH|IT|178|179|PAST MEDICAL HISTORY|She has no personal history of an active cancer, although she has had a hysterectomy for ovarian cancer back in the 1980s. PAST MEDICAL HISTORY: She IS ALLERGIC TO SULFA IN THAT IT CAUSES STOMACH UPSET. NO RASH MEDICINES: Are 1. Atenolol 25 mg Q a.m. 2. Hydralazine probably 50 mg b.i.d. 3. Furosemide 20 mg Q a.m.
IT|information technology|IT|160|161|HISTORY OF PRESENT ILLNESS|PRIMARY PHYSICIAN: Fairview Lakes emergency room CHIEF COMPLAINT: Gallstone pancreatitis HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is a 23-year-old IT worker with an incredibly strong family history of gallstones. He has had intermittent epigastric pain, nausea and vomiting for the past six months.
IT|information technology|IT|130|131|PLAN|They seem to understand all the issues quite well and are anxious to proceed with surgery. The patient, with his employment as an IT professional, requests a copy of his CT scan and these scans were reviewed with him in preinduction.
IT|GENERAL ENGLISH|IT|202|203|ALLERGIES|MEDICATIONS: Prenatal vitamins. ALLERGIES: PENICILLIN. THE PATIENT HAS NEVER HAD AN ALLERGIC REACTION TO PENICILLIN; HOWEVER, SHE HAS NEVER BEEN GIVEN IT SECONDARY TO HER WHOLE FAMILY BEING ALLERGIC TO IT AND PRESUMED ALLERGY. ALSO GIVES AN ALLERGY TO PERCOCET, WHICH CAUSES VOMITING. ADMIT PHYSICAL EXAM GENERAL : She was afebrile. VITAL SIGNS: Stable. Her abdomen was gravid, soft, and nontender.
IT|GENERAL ENGLISH|IT|207|208|ALLERGIES|ALLERGIES: WE NOTE IN HER RECORDS LEVAQUIN IS NOTED, ALTHOUGH THE PATIENT DOES NOT RECALL THIS AND I DO NOT HAVE ANY RECORDS OF WHEN THEY DECIDED LEVAQUIN OR WHY SHE WAS ALLERGIC TO THAT. WE NOTE SHE WAS ON IT AT METHODIST FOR A POSSIBLE PNEUMONIA. THE PATIENT IS PRESUMABLY ALLERGIC TO SULFA. SOCIAL HISTORY: The patient is widowed. She lives by herself in a two-story house in the Deephaven area.
IT|GENERAL ENGLISH|IT|134|135|ALLERGIES|ENDOCRINE: She denies having any history of diabetes or thyroid. PSYCHIATRY: She has a history of depression. ALLERGIES: 1. MORPHINE, IT CAUSES CONFUSION. 2. LISINOPRIL. FAMILY HISTORY: Family history is positive for cardiovascular disease, mother had breast cancer, and diabetes in an aunt.
IT|GENERAL ENGLISH|IT|178|179|PAST MEDICAL HISTORY|Her neck is ok although she says it makes noises which she attributes to " calcium deposits" PAST MEDICAL HISTORY: SHE IS ALLERGIC TO CODEINE SHE DOES NOT REMEMBER WHY. SHE SAYS IT WAS YEARS AGO. She is gravida 3, para 3, all vaginal deliveries. She has had a DVT in the left leg years ago that may or may not have been around at the time of her hysterectomy for benign reasons and incidental appendectomy.
IT|GENERAL ENGLISH|IT|134|135|HOSPITAL COURSE|THE PATIENT HAS HAD A SEVERE REACTION TO COMPAZINE IN THE PAST, SO THIS IS A NOTED ALLERGY FOR HIM. HE PREFERS NOT TO USE ATIVAN INCE IT CAUSES HIM FATIGUE. He was maintained on electrolyte replacement as needed with strict intake and output, and his creatinine remained normal throughout his hospitalization.
IT|GENERAL ENGLISH|IT.|195|197|IDENTIFICATION|He was discharged on Cymbalta to treat depression and also Seroquel. HE STATES, HOWEVER, NOW THAT HE THINKS HE IS ALLERGIC TO THE SEROQUEL. HE FEELS INCREASED ANXIETY AND IRRITATION AFTER TAKING IT. DISCHARGE DIAGNOSES AXIS I: Major depressive disorder, recurrent, moderate, Opioid dependence.
IT|GENERAL ENGLISH|IT|180|181|ALLERGIES|16) Ocean nasal spray. 17) Septra DS, appears to be one daily. ALLERGIES: THE PATIENT REACTED POORLY TO VOLTAREN AND GOLD WHEN SHE PRESENTED WITH THE ILLNESS BACK IN 1986; WHETHER IT WAS A TRUE ALLERGIC REACTION IS UNCLEAR, ALTHOUGH SHE CERTAINLY TOLERATED GOLD VERY POORLY ALONG WITH THE VOLTAREN. PAST MEDICAL HISTORY: 1) Rheumatoid arthritis, which has been reasonably stable on the methotrexate.
IT|intrathecal|(IT)|247|250|BRIEF HISTORY|BRIEF HISTORY: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 45-year-old woman admitted to Fairview Southdale Hospital with progressive weakness in a patient with non-Hodgkin's lymphoma with central nervous system (CNS) involvement and recent intrathecal (IT) methotrexate. She also had probable herpes simplex involving her perineum and is on Acyclovir for that. She had back pain (probably soft tissue injury). She has treated hypothyroidism and depression.
IT|GENERAL ENGLISH|IT|210|211|ALLERGIES|4. History of stress echocardiogram recently normal. CURRENT MEDICATIONS: None with the exception of occasional Tylenol. ALLERGIES: PER PATIENT INCLUDE STEROIDS AND ANTIHISTAMINES FOR WHICH HE BECOMES FLUSHED. IT IS ALSO MENTIONED IN THE NURSING NOTE ABOUT ZITHROMAX, DOXYCYCLINE, TETRACYCLINE, AND QUESTIONABLY FLOXIN. FAMILY HISTORY: Per patient is noncontributory. SOCIAL HISTORY: Patient describes himself as being a nonsmoker.
IT|GENERAL ENGLISH|IT|187|188|ALLERGIES|7) Ferrous sulfate 325 mg p.o. q day. 8) Prilosec 10 mg p.o. b.i.d. 9) Fosamax 70 mg once per week. ALLERGIES: NO KNOWN DRUG ALLERGIES, ALTHOUGH DID HAVE A COUGH WITH LISINOPRIL, CAUSING IT TO BE DISCONTINUED. SOCIAL HISTORY: The patient is a lifelong nonsmoker and does not drink alcohol.
IT|GENERAL ENGLISH|IT|119|120|ALLERGIES|ALLERGIES: SHE DENIES ANY ALLERGY EXCEPT WHEN CONDOM USE CAUSES A RASH, BUT ELASTIC WAIST BANDS DO NOT CAUSE A RASH SO IT IS UNCLEAR HISTORY OF LATEX ALLERGY. NO ALLERGY HISTORY TO ANY MEDICATIONS. PAST MEDICAL HISTORY: Chlamydia or pelvic inflammatory disease in 2001.
IT|GENERAL ENGLISH|IT|145|146|CODE STATUS|She does not smoke. FAMILY HISTORY: Negative for end-stage renal disease. Negative for chronic kidney disease should be noted that. CODE STATUS: IT SHOULD BE NOTED THAT THE PATIENT IS DNR/DNI, ALTHOUGH, THIS WAS NOT COMMUNICATED TO THE EMTs AND SHE WAS INTUBATED AND RESUSCITATED.
IT|UNSURED SENSE|IT,|192|194|HOSPITAL COURSE|ID was called to intervene. She was on her antibiotics and she did seem to respond. Wound care nurse was also seen and please see the number of wounds that she had including a right heel left IT, right trochanteric right IT area. Recommendations were left. ID also did leave a consult on _%#MMDD2006#%_. They were awaiting cultures. She was also hypertensive at 125/92, but seemed to be controlled fairly well.
IT|GENERAL ENGLISH|IT|231|232|ALLERGIES|It is also positive for the mild confusion. ALLERGIES: THE PATIENT HAS AN ALLERGY TO HYDROCODONE, TYLENOL, IT IS NOT COMPLETELY CLEAR WHAT THE REACTION WAS. IT DOES MENTION HIVES IN THE CHART ALTHOUGH THE PATIENT STATES SHE THINKS IT WAS MORE CONFUSION. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 136/66, pulse 70 and regular, the patient is afebrile.
IT|information technology|IT|214|215|SOCIAL HISTORY|MEDICATIONS: Lipitor 20 mg p.o. daily. Synthroid she is not quite sure of the dose, aspirin 1 p.o. daily p.r.n. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Married, she retired as a business manager for an IT company. Exercise is walking and Curves. She does not smoke, no caffeine. She has two glasses of wine most days. REVIEW OF SYSTEMS: HEENT: She complains of a dry mouth.
IT|information technology|IT.|113|115|SOCIAL HISTORY|ALLERGIES: Kutodax and Putidin MEDICATIONS: None. SOCIAL HISTORY: Former electrical engineer, presently works in IT. He is a native of Norway and was scheduled to return to tomorrow. Former smoker, quit 8 years ago. Alcohol one drink per week.
IT|GENERAL ENGLISH|IT|122|123|ALLERGIES|She is also on Vicodin up to 8 every day. ALLERGIES: PATIENT IS ALLERGIC TO CONTRAST DYE. SHE IS ALLERGIC TO PENICILLIN - IT GIVES HER HIVES. ERYTHROMYCIN GIVES HER A RAPID HEART RATE. PATIENT ALSO HAD A PROBLEM WHEN SHE WAS ON A DURAGESIC PATCH WITH CONFUSION FROM THAT.
IT|ischial tuberosity|IT|135|136|PROBLEM #3|We will send out on Imodium p.r.n. PROBLEM #3: Wound care. ET nurse consultation was placed. ET nurses staged his ulcers as; (1) Right IT stage 4 pressure ulcer. (2) Left IT stage 3 pressure ulcer. (3) Left groin wound stage 3 of questionable etiology.
IT|information technology|IT|127|128|SOCIAL HISTORY|He has three children for his first marriage and he has one step child who is age 25. Both he and his wife are employed in the IT field. He presently is not working, however, because he has been disabled by his multiple sclerosis. MENTAL STATUS: Alert and oriented x 3. Speech is clear and productive.
IT|information technology|IT|187|188|SOCIAL HISTORY|PAST MEDICAL HISTORY: 1. Childhood jaundice. 2. Tonsillectomy. ALLERGIES: None. MEDICATIONS: None. FAMILY HISTORY: None. SOCIAL HISTORY: He is a nonsmoker, nondrinker and he works in the IT field. REVIEW OF SYSTEMS: Negative for any bleeding. No angina or anginal equivalent.
IT|(drug) IT|IT|157|158|HISTORY OF PRESENT ILLNESS|We attempted to cross the chronic subtotal OM occlusion with a pilot 50 and cross it with no success. Finally, we were able to cross the lesion with a CROSS IT 150. The total occlusion was then serially dilated with a 1.5 x 18 Maverick followed by a 2.0 x 20 Voyager. We then placed a 2.5 x 28 Cipher stent distally in the OM.
IT|GENERAL ENGLISH|IT|143|144|ALLERGIES|11. Warfarin 12. Actonel 35 mg q. weekly 13. Lantus insulin 10 units at bedtime ALLERGIES: THE PATIENT HAS A LIST OF ALLERGIES TO MEDICATIONS. IT LOOKS LIKE IT IS MOSTLY AN INTOLERANCE TO THESE MEDICATIONS INCLUDING LASIX ALTHOUGH SHE IS TOLERATING LASIX WELL AT THIS TIME, MAINLY LASIX.
IT|GENERAL ENGLISH|IT|157|158|ALLERGIES|11. Warfarin 12. Actonel 35 mg q. weekly 13. Lantus insulin 10 units at bedtime ALLERGIES: THE PATIENT HAS A LIST OF ALLERGIES TO MEDICATIONS. IT LOOKS LIKE IT IS MOSTLY AN INTOLERANCE TO THESE MEDICATIONS INCLUDING LASIX ALTHOUGH SHE IS TOLERATING LASIX WELL AT THIS TIME, MAINLY LASIX.
IT|UNSURED SENSE|IT|133|134|IMPRESSION REPORT AND PLAN|A goal heart rate less than 65. Goal blood pressure less than 125 already. Will increase Lipitor 40 to 80 (consistent with the PROVE IT trial), aspirin 325 mg daily. Will check lipid screen in the morning ECG and follow troponins. We will initiate heparin protocol and continue his Integrilin drip.
IT|intrathecal|(IT)|250|253|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: 1. Follow up in MOHPA-_%#CITY#%_ Clinic on Tuesday, _%#MMDD2006#%_ to receive Neulasta (longacting GCSF) and to meet with our nurse practitioner. 2. Follow up with outpatient interventional radiologist for further intrathecal (IT) methotrexate within the next 2 weeks. 3. Follow up (halfway through chemo) CT scans to be performed in the next 2 weeks to gauge response to treatment thus far.
IT|GENERAL ENGLISH|IT|134|135|BEFORE BY THE PATIENT AND HER FAMILY THAT IF NEEDED,|She continues being admitted to the hospital about twice a year, but overall, she is stable at home. She IS ON A DNR, DNI STATUS, BUT IT HAS BEEN DECIDED BEFORE BY THE PATIENT AND HER FAMILY THAT IF NEEDED, A SHORT TIME INTUBATION, For ACUTE RESPIRATORY DISTRESS IS DESIRED.
IT|intrathecal|IT|182|183|PAST MEDICAL HISTORY|2. History of bacterial infection during induction chemotherapy. 3. Syncopal episodes during initial hospitalization without recurrence. 4. Ommaya reservoir placement and subsequent IT methotrexate. 5. PICC line placement. MEDICATIONS: The patient takes no medications on a scheduled basis.
IT|GENERAL ENGLISH|IT|125|126|ALLERGIES|ALLERGIES: 1. MORPHINE, QUESTIONABLE ALLERGY WITH SOME HISTORY OF NAUSEA. 2. GATIFLOXACIN (I DOUBT THAT THIS WAS A REACTION. IT WAS PROBABLY MORE RELATED TO HER PAIN SYNDROME AND WOULD CONSIDER TAKING THIS ALLERGY OFF HER LIST OF ALLERGIES IF PRIMARY AGREES THAT THIS WAS NOT A TRUE DRUG REACTION).
IT|iliotibial|IT|150|151|REVIEW OF SYSTEMS|MRI was eventually obtained which revealed a medial meniscus tear. She is coming in for arthroscopic surgery. REVIEW OF SYSTEMS: Orthopedic: Possible IT band, running injuries negative otherwise. General, HEENT, pulmonary, cardiovascular, renal, GYN all negative. MEDICATIONS: Prinivil. ALLERGIES: NONE. HABITS: Nonsmoker, nondrinker. Former smoker. FAMILY HISTORY: Negative.
IT|GENERAL ENGLISH|IT|186|187|ALLERGIES|MEDICATIONS: 1. Glipizide, unknown dose. 2. Lipitor unknown dose. 3. Lisinopril, unknown dose. 4. Arimidex 1 mg p.o. daily. ALLERGIES: SULFA, PENICILLIN AND PER PATIENT, ASPIRIN BECAUSE IT CAUSES NOSEBLEEDS. SOCIAL HISTORY: The patient lives alone in an apartment. She originally had five children, however, one was killed in Vietnam.
IT|GENERAL ENGLISH|IT|168|169|HISTORY OF PRESENT ILLNESS|He is having removal of a right shoulder lipoma under local anesthesia with sedation. The patient states that he has had the lipoma in that area for about 10-15 years. IT has been steadily increasing in size. It is becoming uncomfortable. He notes some discomfort and irritation in his shoulder area and he would just like to have this removed.
IT|iliotibial|IT|200|201|OPERATIONS AND PROCEDURES PERFORMED|3. Status post multiple right shoulder surgeries secondary to her accident. 4. Chronic pain secondary to motor vehicle accident. OPERATIONS AND PROCEDURES PERFORMED: Repair of left gluteus medius and IT band on _%#MMDD2002#%_. INDICATIONS: This patient is a 35-year-old woman involved in a motor vehicle crash in 1999 and since that time has had multiple orthopaedic surgeries secondary to chronic pain and difficulties related to her accident.
IT|iliotibial|IT|185|186|INDICATIONS|Most recently, she has had excruciating left hip pain. She has been evaluated by Dr. _%#NAME#%_ and referred over to Dr. _%#NAME#%_, with the thought that it may be related to her left IT band. After evaluation and discussion with the patient, the patient decided to proceed with repair of left gluteus medius and IT band.
IT|iliotibial|IT|120|121|INDICATIONS|After evaluation and discussion with the patient, the patient decided to proceed with repair of left gluteus medius and IT band. HOSPITAL COURSE: The patient was admitted and taken to the operating room on _%#MMDD2002#%_ where under general endotracheal anesthetic, a repair of the left gluteus medius and IT band was performed without apparent complications at the time of surgery.
IT|iliotibial|IT|177|178|HOSPITAL COURSE|HOSPITAL COURSE: The patient was admitted and taken to the operating room on _%#MMDD2002#%_ where under general endotracheal anesthetic, a repair of the left gluteus medius and IT band was performed without apparent complications at the time of surgery. Postoperatively, a Hemovac drain was placed, and the patient was transferred to the ward in stable condition, with an epidural placed for pain control.
IT|intrathecal|IT|209|210|HOSPITAL COURSE|She had a first-degree perineal laceration which was repaired in the usual fashion. EBL was 300 mL. Postpartum the patient did have problems with urinary retention secondary to prolonged time required for the IT narcotic to wear off requiring a Foley catheter. The Foley was essentially discontinued, and the patient was able to void without difficulty prior to discharge.
IT|GENERAL ENGLISH|IT|231|232|SPECIAL NOTE TO THE ANGIOGRAPHER|The risks and benefits of angiogram, possible angioplasty, or bypass surgery including the risk of stroke, heart attack and death were discussed with the patient. SPECIAL NOTE TO THE ANGIOGRAPHER: IF THE PATIENT NEEDS INTERVENTION IT SHOULD PROBABLY BE A BALLOON ANGIOPLASTY WITH ASPIRIN AND PLAVIX FOR TWO WEEKS AND THEN ROTATOR CUFF SURGERY AT THE THIRD TO FOURTH WEEK.
IT|GENERAL ENGLISH|IT|144|145|HOSPITAL COURSE|A surgical consult was placed both thoracic and cardiovascular in terms of what to do with the patient's posterior pericardial loculated fluid. IT was decided by surgery that at this point in time, it would be best to be conservative with this lady's management and follow her based on her symptoms and repeat echocardiogram.
IT|GENERAL ENGLISH|IT|269|270|ASSESSMENT AND PLAN|1. Large ventral hernia which is chronic with recent increased symptoms, per son mainly the diarrhea and decreased PO intake. 2. Elevated white count today, unclear etiology 3. PATIENT REQUESTS TO BE DNR, DNI, NO COMPRESSIONS, NO ELECTRICTY BUT MEDICATIONS ARE OKAY IF IT IS SIMPLE PER HER WORDS. The patient will be admitted to the 8th floor general medicine bed, will be made NPO, will be placed on intravenous fluids overnight.
IT|iliotibial|IT|247|248|HOSPITAL COURSE|The right total knee was performed, and due to her valgus deformity, it was decided to release or sacrifice the posterior cruciate ligament, and she also had release of the posterior lateral capsule and the popliteus. She also had pie-crusting of IT band. Her surgery was uneventful. She was transferred to the PACU after the surgery in satisfactory condition. Her intraoperative blood loss was 150 mL. Her postoperative pain was managed by PCA.
IT|information technology|IT.|156|158|SOCIAL  HISTORY|He quit 3 years ago. He smoked for 20 years up to 2 packs per day. He is married. He has no children. Works as a manager in a printing company. He works in IT. The patient denies any illicit drug use. FAMILY HISTORY: Both parents have hypertension. REVIEW OF SYSTEMS: As noted in the HPI.
IT|GENERAL ENGLISH|IT|132|133|ALLERGIES|CURRENT MEDICATIONS: None. ALLERGIES: THE PATIENT IS INTOLERANT OF ASPIRIN. SHE HAD A GASTROINTESTINAL BLEED WHEN SHE WAS PLACED ON IT 3 YEARS AGO FOR TREMENT OF TIA. ADENOSINE, WHICH SHE REACTS TO WITH DIZZINESS AND VOMITING EMERGENCY DEPARTMENT COURSE: On arrival to the Emergency Department the patient was awake, alert and oriented though noted to be a poor historian.
IT|GENERAL ENGLISH|IT|182|183|ALLERGIES|ALLERGIES: HE HAD A SKIN RASH WITH SULFA AND ALSO WITH PENICILLIN. THERE IS A QUESTION OF ALLERGY TO CIPRO AND ZITHROMAX BUT NOT ABSOLUTELY CLEAR. PATIENT DOES NOT TOLERATE SUDAFED, IT CAUSES URINARY RETENTION. PATIENT ALSO IS TO AVOID ASPIRIN ON ACCOUNT OF HIS RESPIRATORY ALLERGIES. CURRENT MEDICATIONS: 1. Epi-Pen prn. 2. Vitamin 1 daily.
IT|GENERAL ENGLISH|IT|125|126|PRIMARY CARE PHYSICIAN|A chest x-ray did reveal 4 compression fractures of the T3, T5, T6 and T7 levels. It showed T3 20% T5 25% T6 25% and T7 10%. IT was also noted that there was a 7-mm small smooth border calcified nodule on the left lateral lobe consistent with a granuloma that has no change from previous chest x-rays.
IT|GENERAL ENGLISH|IT|143|144|ALLERGIES|He complains only of left forearm pain. PAST MEDICAL HISTORY: Negative. MEDICATIONS: None. ALLERGIES: HE HAD A SKIN REACTION TO MORPHINE WHILE IT WAS GIVEN IN THE EMERGENCY ROOM TODAY. FAMILY HISTORY/REVIEW OF SYSTEMS: Noncontributory. PHYSICAL EXAMINATION: GENERAL: The patient is alert and oriented x 3, in no apparent distress.
IT|information technology|IT|281|282|HOSPITAL COURSE|They felt that since the patient overall felt much better by the time the surgeon got it and felt like everything was improving, would hold off on the OR but any symptoms at all that slightly worsened would cause him to have surgery for further treatment of the diverticulitis. An IT consult was obtained just to maximize the medication given the small perforation. He continued to improve, his vitals remained stable. He was disappointed after a couple days that he could not eat as he felt definitely hungry and felt everything was back to normal, the pain was gone.
IT|GENERAL ENGLISH|IT|369|370|ASSESSMENT AND PLAN|7. Initially, there was a question of DNR, DNI OR NOT, The GRAND DAUGHTER WHO IS HERE With HER HAD SAID YES, The PAPER WORK FROM The NURSING HOME DATED _%#MMDD#%_ AND _%#MMDD#%_ SAID She WAS FULL CODE. THIS HAS BEEN CHANGED RECENTLY BY The FAMILY, THE PATIENT AND The SON WHO IS HER POWER OF ATTORNEY, HE WAS CONTACTED TONIGHT AND DISCUSSED IN DETAIL BY ME AND HE SAYS IT IS DEFINITELY DNR, DNI AND THIS WILL BE MADE SO IN The CHART. Plan pending upcoming treatment, her care will be by Dr. _%#NAME#%_ who is the hospital rounder at Southdale for this week.
IT|GENERAL ENGLISH|IT.|398|400|ALLERGIES|He has a history of COPD, polysubstance abuse, bipolar disorder, and depression. ADMISSION MEDICATIONS: On admission, he was using the following medications: Labetalol 200 mg b.i.d. He was using BuSpar 15 mg t.i.d., loratadine, he was also using minoxidil 10 mg daily, Zyprexa, Viagra, and albuterol nebulizer p.r.n. ALLERGIES: HE HAS A HISTORY OF ALLERGIES TO ASPIRIN, HE GETS SWOLLEN UP BY USING IT. SOCIAL HISTORY: He is a tobacco user. He uses about 3 to 7 cigarettes per day.
IT|GENERAL ENGLISH|IT|140|141|ALLERGIES|Dr. _%#NAME#%_ _%#NAME#%_ did a history and physical. See his dictation. ALLERGIES: MR. _%#NAME#%_ STATED HE DID NOT HAVE ANY ALLERGIES BUT IT IS NOTED THAT THERE WAS AN ALLERGY NOTED TO TETRACYCLINE ON A PREVIOUS CHART. LABORATORY: He had labs drawn on admission. They were essentially within normal limits.
IT|GENERAL ENGLISH|IT|185|186|INCLUDING PENICILLIN, KEFLEX, LEVOFLOXACIN, AND|There was concern that the second strain of staphylococcus found in his ICD site may have spread to his blood. The patient from the time of admission was started on clindamycin IV, and IT IS NOTED HE HAS SEVERAL ANTIBIOTIC ALLERGIES INCLUDING PENICILLIN, KEFLEX, LEVOFLOXACIN, AND SULFAS. He also was started on vancomycin initially but developed an acute reaction significant for respiratory distress and hives.
IT|GENERAL ENGLISH|IT|256|257|ALLERGIES|They have been married 64 years. The patient and her son relates that there have been discussions lately of the couple moving to assisted living but they have been quite resistant to do so. FAMILY HISTORY: Noncontributory. ALLERGIES: THIS IS UNCERTAIN BUT IT APPEARS THAT THE PATIENT MAY HAVE HAD A REACTION OF SOME SORT TO LEVAQUIN EARLIER IN THE WEEK. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 143/68, pulse 80 and regular, patient is afebrile.
IT|GENERAL ENGLISH|IT|158|159|PHYSICAL EXAMINATION|There is no rebound. There are no specific areas of tenderness. Pelvic. NEUROLOGIC: Performed by Dr. _%#NAME#%_. Please see his documentation in this regard. IT is basically a normal exam without cervical motion tenderness. EXTREMITIES: None of the joints are red nor tender. The patient does have pain in the left ankle with active and passive motion.
IT|ischial tuberosity|IT|26|27|PRINCIPAL DIAGNOSIS|PRINCIPAL DIAGNOSIS: Left IT stage IV. SECONDARY DIAGNOSIS: Paraplegia secondary to previous arteriovenous malformation and cerebral aneurysm clipping. PROCEDURES: This occurred prior to admission on the main hospital side.
IT|ischial tuberosity|IT|236|237|PROCEDURES|PRINCIPAL DIAGNOSIS: Left IT stage IV. SECONDARY DIAGNOSIS: Paraplegia secondary to previous arteriovenous malformation and cerebral aneurysm clipping. PROCEDURES: This occurred prior to admission on the main hospital side. Status post IT debridement with bone biopsies and gluteal muscle flap, _%#MMDD2007#%_. REHABILITATION COURSE: Please see the history and physical and consults on the FCIS system for events leading up to the patient's rehab stay.
IT|intrathecal|IT|228|229|HISTORY OF PRESENT ILLNESS|He requires 6 mg per day of morphine sulfate with Dilaudid 6 mg every three to four hours on a p.r.n. basis for breakthrough pain. The patient was seen at the Pain Clinic, the day before admission, and received an extra dose of IT morphine sulfate and developed diaphoresis, agitation, tachypnea, and tachycardia consistent with the diagnosis of anxiety secondary to the injection. O2 saturations were always above 90% on room air. The patient is also on Coumadin for hereditary hypercoagulable state with a goal of keeping INR between 2 and 3.
IT|intrathecal|IT|169|170|HISTORY OF PRESENT ILLNESS|He was admitted for pain control and replacement of the NG tube that was malfunctioning with a leak in the balloon. The patient continued his pain medications including IT morphine sulfate 6 mg a day and Dilaudid solution 6 mg intravenously every three to four hours for breakthrough pain. His pain has been under good control. He continued on his usual medications including (all of them given through the NG tube): 1. Reglan. 2. Ritalin. 3. Zantac. 4. Lexapro. 5. Zofran. 6. Prevacid. 7. Senokot.
IT|iliotibial|IT|96|97|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Recalcitrant trochanteric bursitis. OPERATIONS/PROCEDURES PERFORMED: Right IT band released. COMPLICATIONS: None. HOSPITAL COURSE: On _%#MM#%_ _%#DD#%_, 2003, the patient was admitted, underwent the above procedure, was on IV antibiotics for the first 24 hours, was on IV pain meds the first 24 hours, then oral.
IT|GENERAL ENGLISH|IT.|153|155|ALLERGIES|Patient had a brother who passed away at the age of 36 with pneumonia. ALLERGIES: SHE HAS ALLERGIES TO CODEINE. SHE REPORTS FEELING DIZZY WHILE BEING ON IT. CURRENT MEDICATIONS: Imdur 30 mg 1 po q d, Amaryl 2 mg 1 po q d, Atenolol 50 mg 1 po q day, Lisinopril 30 mg po q d, Phoslo 667 mg 1 po tid, enteric coated aspirin 81 mg 1 po q d.
IT|GENERAL ENGLISH|IT|225|226|ALLERGIES|2) Bunionectomy and fusion of the first metatarsopharyngeal joint in _%#MM#%_, 2004; she thinks she needs another surgery on her other foot and possibly more work on the foot that was operated. ALLERGIES: SULFA. ON HER CHART IT IS LISTED THAT SHE IS INTOLERANT TO LEVAQUIN, BUT FURTHER HISTORY INDICATES THIS MAY IN FACT BE LISINOPRIL WHICH MADE HER COUGH.
IT|GENERAL ENGLISH|IT,|178|180|ASSESSMENT AND PLAN|7. Benign prostatic hypertrophy 8. Mild dehydration 9. DISCUSSED With Patient, HE WOULD LIKE FULL CODE AS FAR AS A VENTILATOR AND SOME INITIAL CPR. HE DOESN'T WANT, AS HE STATES IT, "EXCESSIVE HEROIC MEASURES." The patient will be admitted to a general medicine bed.
IT|information technology|(IT)|255|258|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 69- year-old gentleman from India who is here in the United States for several months visiting his son who resides in _%#MM#%_, Minnesota and works for Carlson Companies in the information technology (IT) department. The patient is married and his wife is also on this trip with him but is not present in the hospital with the patient.
IT|information technology|IT|133|134|SOCIAL HISTORY|FAMILY HISTORY: Is noncontributory SOCIAL HISTORY: Mr. _%#NAME#%_ lives in _%#CITY#%_ _%#CITY#%_. He has two children. He works as a IT manager and is a non-smoker. REVIEW OF SYSTEMS: Head, eyes, ears, nose and throat- no concerns.
IT|GENERAL ENGLISH|IT|137|138|HISTORY OF PRESENT ILLNESS|They were living together. The boyfriend decided to move out. She was packing up his boxes to make his move and she found some Seroquel. IT is unclear as to who the Seroquel belonged to. She took about anywhere between 15 to 20 tablets of Seroquel. Also drank a large amount of alcohol in an attempt to go to sleep.
IT|intrathecal|IT|365|366|HOSPITAL COURSE|HOSPITAL COURSE: A bone marrow biopsy was completed without complications on _%#MMDD2006#%_ along with a lumbar puncture and injection of cytarabine into the intrathecal space without complications. Treatment was begun under protocol AALL_%#PROTOCOL#%_. The induction phase included the administration of vincristine, prednisone, daunorubicin, PEG asparaginase and IT methotrexate. Upon administration of her chemotherapy regimen _%#NAME#%_ began exhibiting unusually high blood sugars. This was presumably a prednisone reaction. Endocrinology was consulted on _%#MMDD2006#%_.
IT|information technology|IT.|151|153|SOCIAL HISTORY|PAST SURGICAL HISTORY: Tubal ligation, cesarean section x2, and tonsillectomy. SOCIAL HISTORY: _%#NAME#%_ travels for a living and works in healthcare IT. She is married and has 2 children, age 26 and 23. She is a nonsmoker and occasionally uses alcohol. PHYSICAL EXAMINATION VITAL SIGNS: Height 5 foot 4, weight 190 pounds, blood pressure 122/80, hemoglobin 13.8. GENERAL: This is a pleasant Caucasian female, alert and oriented in no acute distress.
IT|GENERAL ENGLISH|IT|143|144|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: She HAS NO KNOWN DRUG ALLERGIES, BUT She BECOMES HYPONATREMIC With DIURETICS. She THINKS THAT She IS ALLERGIC TO MILK AS IT GIVES HER DIARRHEA AND She LISTS AS ENVIRONMENTAL ALLERGIES, DUST, CATS AND OTHER ENVIRONMENTAL THINGS. MEDICATIONS: Include 1. Fosamax 70 mg daily. 2. Atenolol 50 mg daily
IT|information technology|IT|181|182|SOCIAL HISTORY|8. Oxycodone 5-10 mg p.o. q.4 hours p.r.n. 9. Ibuprofen 800 mg p.o. t.i.d. ALLERGIES: None known to date. SOCIAL HISTORY: The patient is employed by Target Corporation. He works in IT for their corporate department. He denies any radiation exposure or other chemical exposures. He denies tobacco, alcohol or drug use.
IT|information technology|IT|157|158|SOCIAL HISTORY|PAST MEDICAL/SURGICAL HISTORY: None. FAMILY HISTORY: As dictated in history of present illness. SOCIAL HISTORY: The patient drinks socially. He works in the IT department. No tobacco or recreational drug use or any supplements. ALLERGIES: No known drug allergies. MEDICATIONS: None. REVIEW OF SYSTEMS: GENERAL: Constitutionally, the patient has been complaining of fevers and feeling weak, has not eaten much.
IT|GENERAL ENGLISH|IT|125|126|ASSESSMENT AND PLAN|IN OTHER WORDS, THE FACT THAT HE IS NOT ABLE TO TAKE CARE OF HIMSELF AND NOW HAS LIKELY HAS A SOMEWHAT DEBILITATING MYELOMA. IT MAY MAKE MORE SENSE TO CHANGE HIS CODE STATUS, SHE TELLS ME SHE WILL THINK ABOUT THIS AND DISCUSS THIS WITH HIM TOMORROW.
IT|information technology|IT|159|160|SOCIAL  HISTORY|1. Obesity. 2. Recurrent cellulitis involving the right lower extremity. ALLERGIES: No known drug allergies. MEDICATIONS: None. SOCIAL HISTORY: He works as an IT engineer. Denies smoking or alcohol use. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 109/46, heart rate 111, temperature 105.6 degrees.
IT|GENERAL ENGLISH|IT|289|290|ADMISSION MEDICATIONS|PAST SURGICAL HISTORY: The patient has had a hysterectomy and a tubal abscess many years ago, and the patient is status post right broken arm a few months ago. ADMISSION MEDICATIONS: The patient takes no medications regularly. ALLERGIES: THE PATIENT HAS AN ALLERGY TO PENICILLIN. SHE SAYS IT CAUSES SWELLING OF TONGUE. HOSPITAL COURSE: The patient was taken to the operating room on _%#MM#%_ _%#DD#%_, 2004.
IT|GENERAL ENGLISH|IT|246|247|HOSPITAL COURSE|APPARENTLY HE HAD DECIDED ON A DNR, DNI, BUT AS HIS RESPIRATORY DISTRESS INCREASED AND The EMERGENCY ROOM, The EMERGENCY ROOM PHYSICIAN DISCUSSED THIS With HIM AND TOLD HIM THAT HE MIGHT DIE IF NOT INTUBATED AND APPARENTLY HE WAS FELT TO BE With IT ENOUGH TO MAKE The DECISION TO UNDERGO INTUBATION. This was accomplished in the emergency room and he has been given propofol since that time to relax him on the ventilator.
IT|GENERAL ENGLISH|IT|103|104|ALLERGIES|ALLERGIES: PENICILLIN, SULFA, FOSAMAX, DITROPAN. SHE HAS AN ALLERGY LISTED TO CIPRO, BUT SHE HAS TAKEN IT ORALLY WITHOUT DIFFICULTY. WHEN SHE WAS GIVEN IT IV SHE HAD SOME SLIGHT REDNESS AND BURNING AT THE IV SITE. SOCIAL HISTORY: The patient is divorced and has one son who is currently with her today.
IT|GENERAL ENGLISH|IT|152|153|ALLERGIES|ALLERGIES: PENICILLIN, SULFA, FOSAMAX, DITROPAN. SHE HAS AN ALLERGY LISTED TO CIPRO, BUT SHE HAS TAKEN IT ORALLY WITHOUT DIFFICULTY. WHEN SHE WAS GIVEN IT IV SHE HAD SOME SLIGHT REDNESS AND BURNING AT THE IV SITE. SOCIAL HISTORY: The patient is divorced and has one son who is currently with her today.
IT|GENERAL ENGLISH|IT|237|238|ALLERGIES|TO MY KNOWLEDGE ALLERGIES INCLUDE SULFA, PENICILLIN, CEPHALOSPORINS, IVP DYE, CODEINE, DARVON. THERE WAS AN EPISODE WHERE SHE DEVELOPED A RASH AFTER TAKING VICODIN AND ZITHROMAX AND IT WAS NOT CLEAR WHICH ONE SHE REACTED TO; MORE LIKELY IT WAS VICODIN SINCE SHE HAS HAD ZITHROMAX SINCE THEN WITHOUT PROBLEMS. HABITS: Alcohol as above. Ex-smoker, quitting about five years ago.
IT|ischial tuberosity|IT|185|186|HISTORY OF PRESENT ILLNESS|In addition to the diabetic ulcers on his left lower extremity, he developed 2 ischial tuberosity wounds bilaterally when he sat in the same position in his wheelchair overnight. These IT wounds underwent surgical debridement on the date of his amputation, _%#MMDD2007#%_. Postoperatively he has had anemia. He is also followed by wound care nurses for IT wounds, scrotal wounds, and penile wounds.
IT|ischial tuberosity|IT|174|175|HISTORY OF PRESENT ILLNESS|These IT wounds underwent surgical debridement on the date of his amputation, _%#MMDD2007#%_. Postoperatively he has had anemia. He is also followed by wound care nurses for IT wounds, scrotal wounds, and penile wounds. The patient's therapies while inpatient were limited secondary to a KinAir bed, the patient was concerned with sliding off of it, as well as having pain in the ischial tuberosity when the bed was deflated.
IT|information technology|IT|165|166|SOCIAL HISTORY|Psoriasis. PAST SURGICAL HISTORY: Arthroscopic repair of menisci of both knees many years ago. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is an IT Programmer at North Memorial Hospital. He is married with three kids. He denies current smoking but reportedly quit one year ago.
IT|GENERAL ENGLISH|IT|244|245|CODE STATUS|CODE STATUS: THE PATIENT IS DNR/DNI AND THIS IS WELL DOCUMENTED IN MULTIPLE NOTES INCLUDING THE PATIENT'S CLINIC NOTES AS PER THE PATIENT'S PRIMARY CARE PROVIDER, DR. _%#NAME#%_ _%#NAME#%_, The PATIENT HAS ALSO DECLINED TUBE FEEDS IN THE PAST. IT HAS ALSO BEEN DETERMINED THAT THERE WAS NO NECESSITY FOR THEM TO PURSUE EVALUATION OF The CHRONIC LEFT-SIDED PLEURAL EFFUSION AS THEY WERE NOT GOING TO TREAT IT AGGRESSIVELY UNLESS IT BECAME SYMPTOMATIC.
IT|GENERAL ENGLISH|IT|161|162|CODE STATUS|IT HAS ALSO BEEN DETERMINED THAT THERE WAS NO NECESSITY FOR THEM TO PURSUE EVALUATION OF The CHRONIC LEFT-SIDED PLEURAL EFFUSION AS THEY WERE NOT GOING TO TREAT IT AGGRESSIVELY UNLESS IT BECAME SYMPTOMATIC. SOCIAL HISTORY: The patient lives in the Minnesota Veterans Home.
IT|information technology|IT|190|191|SOCIAL HISTORY|SOCIAL HISTORY: The patient is married. He has only one sexual partner, his wife. He is a nonsmoker, only occasional drinker. He denies illicit drug use. He is employed at Best Buy in their IT department. REVIEW OF SYSTEMS: He denies any change in vision, double vision, ringing in his ears, bleeding nose, bleeding gums, difficulty swallowing, neck or back pain, shortness of breath, chest pain, abdominal pain, pain with urination, burning with urination, difficulty with erections or ejaculation or joint pain.
IT|ischial tuberosity|IT|78|79|PROCEDURES PERFORMED|ADMITTING DIAGNOSIS: Left IT wound. PROCEDURES PERFORMED: Debridement of left IT wound, bone biopsy and inferior gluteal artery rotation flap on _%#MMDD2007#%_. HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old male with a history of T3-T4 paraplegia who has failed medical management of left IT wound.
IT|ischial tuberosity|IT|139|140|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old male with a history of T3-T4 paraplegia who has failed medical management of left IT wound. After a consultation with Dr. _%#NAME#%_ and discussing risks and benefits, the patient elected to go forth with operative intervention.
IT|ischial tuberosity|IT|253|254|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old male with severe multiple sclerosis who presented for an admit 24 hours prior to expected surgical date. The patient was admitted on _%#MMDD2007#%_. The patient has a longstanding history of left IT pressure sore. This has failed medical management and thus the patient was advised of potential therapies including surgery.
IT|ischial tuberosity|IT|134|135|HISTORY OF PRESENT ILLNESS|The patient is being discharged with expectations that he will return on _%#MMDD2007#%_ to undergo a definitive flap therapy for left IT pressure sore. This is a stage IV sore with necrotic tissue at the base. PAST MEDICAL HISTORY: 1. Significant for above-stated multiple sclerosis since 1983.
IT|ischial tuberosity|IT|112|113|DISCHARGE INSTRUCTIONS|ALLERGIES: The patient has no known drug allergies. DISCHARGE INSTRUCTIONS: 1. To minimize pressure to the left IT area. 2. The patient is to utilize KinAir bed. 3. The patient is to be repositioned every 2 hours and monitor heels on mattress.
IT|ischial tuberosity|IT|151|152||_%#NAME#%_ _%#NAME#%_ is a 60-year-old male with severe multiple sclerosis who presented initially on _%#MMDD2007#%_ and underwent debridement of left IT pressure sore and subsequently had a short stay at FUTS followed by return once the wound was clean and underwent a posterior thigh flap to left ischial wound on _%#MMDD2007#%_ (see specific operative notes for details). The patient's hospitalization was without complication. The patient required assistance with the Internal Medicine management for his anticoagulation.
IT|ischial tuberosity|IT|172|173|HISTORY OF PRESENT ILLNESS|This entails creating an lifting the posterior thigh flaps, but then placing them placed back down in their and her original locations and not placing them into e an admit IT woundsonce. This was conducted secondary to worrisome vascular inflow and outflow from the flaps. They appeared very congested. Thus after lifting _____ (01:24) and a plane _____ the flaps, .
IT|ischial tuberosity|IT|146|147|PROCEDURES|CONSULT: Dr. _%#NAME#%_ DIAGNOSIS: Bilateral ischial decubiti stage IV and right gluteal decubitus stage IV. PROCEDURES: Debridement of bilateral IT and right gluteal decubiti with bilateral ischial bone biopsies for culture and bilateral posterior thigh flaps for IT closure and VAC placement to right gluteal wound and the right thigh donor site on _%#MMDD2007#%_.
IT|ischial tuberosity|IT|265|266|PROCEDURES|CONSULT: Dr. _%#NAME#%_ DIAGNOSIS: Bilateral ischial decubiti stage IV and right gluteal decubitus stage IV. PROCEDURES: Debridement of bilateral IT and right gluteal decubiti with bilateral ischial bone biopsies for culture and bilateral posterior thigh flaps for IT closure and VAC placement to right gluteal wound and the right thigh donor site on _%#MMDD2007#%_. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 58-year-old incomplete quadriplegic up to the C6 level who is well known to our service.
IT|ischial tuberosity|IT|213|214|HISTORY OF PRESENT ILLNESS|On _%#MMDD2007#%_, the patient underwent uneventful bilateral ischial decubitus debridement as well as debridement of right gluteal wound. We sent bone biopsies for culture to rule out ischial osteomyelitis. Both IT wounds were closed with posterior thigh flaps. The right flap was advanced from previous surgery and we were unable to close the donor site.
IT|ischial tuberosity|IT|247|248|PENDING DISCHARGE 09/26/2007|The patient was subsequently admitted and transferred to Regency under the care of Dr. _%#NAME#%_ for ongoing care of her wound and she was there for the past month and a half as the wound gradually did granulate in. She still had a massive right IT decubitus but her nutritional status had improved. She had a gastrostomy tube placed while at Regency for feeding purposes and her serum prealbumin had actually improved to more normal levels.
IT|ischial tuberosity|IT|317|318|PENDING DISCHARGE 09/26/2007|She had a pneumonia-like picture at one point during her hospitalization at Regency and was treated vigorously with antibiotics and she gradually overcame that. She was transferred then from Regency back to Fairview Southdale Hospital on _%#MMDD#%_ and underwent extensive debridement and closure of this large right IT decubitus with wound VAC placed superficially over the partially separated incisional area to control the drainage. She has been in the hospital now over the past week with the wound separating some inferiorly but holding intact for the most part.
IT|ischial tuberosity|IT|277|278|PENDING DISCHARGE 09/26/2007|There is a gastrostomy tube in the upper outer quadrant. She has no edema of her lower extremities. She does have a 2 cm by 1.5 cm ulcer on the lateral aspect of her right leg which we are treating with Aquacel Silver and she has the approximately 10 inch wound over the right IT area which has separated inferiorly and is approximately 2 cm in width and about 4-5 cm in length. Wound VAC is placed over the entire incisional area to include not only the separated area but the nearly closed more superficial areas superiorly.
IT|GENERAL ENGLISH|IT|145|146|SOCIAL HISTORY|He mentions that he does smoke marijuana on a regular basis. ALL OF THIS INFORMATION IS CONFIDENTIAL, AND EMPHATICALLY THE PATIENT DOES NOT WANT IT RELEASED TO ANYONE. FAMILY HISTORY: Father was age 81, died of Parkinson's last spring.
IT|GENERAL ENGLISH|IT|161|162|ALLERGIES|7. Dyspepsia. PAST SURGICAL HISTORY: Total abdominal hysterectomy in 1977, secondary to an abnormal pap smear. ALLERGIES: THE PATIENT HAS ALLERGIES TO PERCODAN, IT CAUSES HER PALPITATIONS. BEXTRA CAUSES TINGLING IN THE EARS. MORPHINE CAUSES RASH. DISCHARGE MEDICATIONS: The patient is being discharged home on the following medications: 1. Vitamin C 500 mg p.o. q.24 h.
IT|information technology|IT|204|205|DISCHARGE MEDICATIONS|The patient is discharged on hydrochlorothiazide, lisinopril and labetalol for hypertension. The patient will continue with PT/OT and should undergo detailed psychometric evaluation as he does work as an IT person, before returning to work. In the course of his evaluation carotid ultrasonography would show no significant stenosis.
IT|intertrochanteric|IT|226|227||She fell upon her left hip. She developed the abrupt onset of pain in this area and had immediate difficulty walking. She was therefore brought into the emergency room for further evaluation by her family members where a left IT hip fracture was noted after evaluation by Dr. _%#NAME#%_ of the ER staff. She is therefore being admitted to coordinate operative repair of the above.
IT|GENERAL ENGLISH|IT|241|242|ASSESSMENT|It would appear that the patient is not a candidate for peritoneal dialysis at this time given his dementia and nursing home residence. We have discussed all this with the patient's daughter who confirms his previous DNR, DNI STATUS, WISHES IT TO CONTINUE BUT ALSO WISHES THAT DIALYSIS THERAPY BE CONTINUED IN HER FATHER IF ACCESS CAN BE ACHIEVED. In the meanwhile, we are suspicious that the CBC data from today is erroneous.
IT|information technology|IT|215|216|SOCIAL HISTORY|SOCIAL HISTORY: The patient is from Kuwait. He came here for college and graduate school in 1982. He went back to Kuwait from 1991-2001 and then returned. He works as an executive manager in a management consulting IT firm. He works about 80 hours per week. He has a master's degree in business management. He used to exercise frequently but now cannot due to his long hours on his job.
IT|GENERAL ENGLISH|IT|287|288|HISTORY|He presented to the Fairview-Southdale Hospital Emergency Department. At the time monitors were attached, he was noted to have some PAC's, but they could not document anything further. He does have a history of atrial fibrillation. Initial cardiac enzymes and EKG were normal or stable. IT was elected to admit him overnight for cardiac monitoring. He has remained in a sinus rhythm overnight. Subsequent cardiac enzymes have been negative or normal.
IT|information technology|IT|178|179|SOCIAL HISTORY|MEDICATIONS: (At-home) 1. Prilosec 40 mg daily. 2. Levoxyl. 3. Effexor. 4. Calcium. 5. Multivitamin. SOCIAL HISTORY: She is a nonsmoker and drinks alcohol socially. She works in IT consulting and for the last several months has been working with Blue Cross. FAMILY HISTORY: Negative for vascular disease. Her mother had CHF at the end of life and diabetes and her father had either an atrial septal defect or ventral septal defect.
IT|information technology|IT|158|159|SOCIAL HISTORY|The patient drinks wine on the weekend. Denies any heavy alcohol use. The patient's last alcohol use was about 5 days ago. The patient is married. His job is IT and photographer. REVIEW OF SYSTEMS: All 10-point review of systems was obtained.
IT|GENERAL ENGLISH|IT|173|174|ALLERGIES|Her maternal grandfather has diabetes mellitus. SOCIAL HISTORY: Denies tobacco, alcohol, and drug use. REVIEW OF SYSTEMS: Please see HPI. ALLERGIES: AMOXICILLIN AS A CHILD, IT CAUSED HER RASH. MEDICATIONS: 1. Aldomet 250 p.o. t.i.d. 2. Atenolol 25 p.o. t.i.d.
IT|GENERAL ENGLISH|IT.|237|239|ALLERGIES|ADMISSION MEDICATIONS: 1. Allegra. 2. Multivitamins. 3. Calcium. 4. Vitamin C. 5. Fish Oil. 6. Baby aspirin daily ALLERGIES: NO KNOWN DRUG ALLERGIES, BUT STATES THAT AUGMENTIN CAUSES HER UNTOWARD SIDE EFFECTS AND SHE PREFERS NOT TO TAKE IT. FAMILY HISTORY: Her mother has a history of breast cancer.
IT|GENERAL ENGLISH|IT|663|664|OPERATIONS/PROCEDURES PERFORMED|Diabetic retinopathy with laser treatments and her renal dysfunction was due to diabetic nephropathy. ADMISSION MEDICATIONS: Glipizide and Actos. Dosages include Neoral 125 mg in the morning and 100 mg at night, CellCept 1000 mg p.o. b.i.d., Prevacid 30 mg once in the morning, calcium 500 mg q.a.m., Toprol XL 50 mg p.o. b.i.d., Lipitor 40 mg p.o. nightly, glipizide 10 mg p.o. b.i.d., Bactrim single strength 1 tablet in the morning, (_______________) 1000 mg p.o. nightly, aspirin 81 mg in the morning, torsemide 20 mg q.a.m., Atacand 16 mg p.o. b.i.d., Actos 15 mg p.o. q.p.m. and Mag-Ox 400 mg p.o. t.i.d. ALLERGIES: PENICILLIN OR AT LEAST THAT IS WHAT SHE, IT WAS SOME SORT OF AN ANTIBIOTIC, OUGHT TO BE PENICILLIN, WHICH CAUSED RASH. FAMILY HISTORY: She has a family history for diabetes mellitus, hypertension, and coronary heart disease.
IT|information technology|IT.|283|285|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Alcohol dependence. HISTORY OF PRESENT ILLNESS: This is the first University of Minnesota Medical Center, Fairview admission for _%#NAME#%_ _%#NAME#%_ who is a 44-year-old male from _%#CITY#%_ _%#CITY#%_. The patient is married. He works for Supervalue. He works in IT. He has 13 and 10-year-old children. The patient enters Fairview Recovery Services at this time for his first treatment.
IT|information technology|IT|158|159|SOCIAL HISTORY|ALLERGIES: No known drug allergies SOCIAL HISTORY: The patient is a non-smoker, has not smoked since 1993. No alcohol use. No drug use. He is retired. Former IT employee here at Fairview. Married, three children. FAMILY HISTORY: Father died of coronary artery disease and brother prostate cancer.
IT|GENERAL ENGLISH|IT|266|267|ADDENDUM|CODE STATUS: This was addressed with the patient, and he states he would like to be DNR-DNI, and does have advanced health directives that he will have his wife bring to the hospital with this admission. ADDENDUM: I DISCUSSED CODE STATUS WITH THE PATIENT AT LENGTH. IT WAS CLEAR THAT HIS ACTUAL WISH WAS THAT HE NOT RECEIVE HEROIC TREATMENTS IN THE FACE OF OVERWHELMINGLY ADVERSE ODDS.
IT|GENERAL ENGLISH|IT|148|149|ADDENDUM|HE ACTUALLY WOULD WANT TO BE CARDIOVERTED, AND WOULD WISH TO BE INTUBATED BRIEFLY FOR A PROCEDURE OR FOR TREATMENT OF A PNEUMONIA. I SUGGESTED THAT IT WOULD BE GOOD TO MAKE HIS ADVANCE CARE DIRECTIVE MORE EXPLICIT, AND TO MAKE SURE THAT HIS WIFE (WHO WOULD BE HIS DECISIONAL SURROGATE) KNOWS HIS WISHES IN DETAIL ...
IT|GENERAL ENGLISH|IT|247|248|BRIEF HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSES: 1. Tongue edema following anesthesia. 2. Status post dental reconstruction. BRIEF HISTORY OF PRESENT ILLNESS: The patient is a 42-year-old developmentally disabled gentleman who had a dental re-construction on _%#MMDD2007#%_. IT was noticed that the patient had swelling of his tongue and was given Decadron and Benadryl. The patient was extubated but admitted overnight for observation due to concerns of possible respiratory failure.
IT|information technology|IT|395|396|HISTORY|CHIEF COMPLAINT: Chest pain. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 39-year-old Caucasian male with risk factors of hypercholesterolemia, prior borderline hypertension and family history of early coronary artery disease including her father who has had an MI at the age of 40 as well as tobacco use who presents to Fairview Southdale Hospital with chest pain. The patient works as a consultant for IT and does quite a bit of traveling and had maintaining irregular hours. Today while the patient was standing up making some photocopies the patient experienced substernal and back and chest pain that was squeezing for about 45 minutes to 1 hour.
IT|iliotibial|IT|162|163|ADMISSION DIAGNOSIS|3. Orthopedic. The patient's total hip arthroplasty was removed and an implant with a cement antibiotic spacer was placed. Intraoperative gross purulence deep to IT band was noted. The patient will be kept nonweightbearing and plan is for her to undergo reimplantation after about 6 weeks once the infection has cleared.
IT|ischial tuberosity|IT|194|195|HISTORY OF PRESENT ILLNESS|PROCEDURES PERFORMED: Posterior thigh flaps to bilateral ischium. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 43-year-old paraplegic male, T6 who presents with longstanding bilateral IT pressure sores. The patient had undergone delayed posterior flap elevation and replacement. The patient underwent the delayed posterior thigh flaps on _%#MMDD2007#%_ and on _%#MMDD2007#%_, was brought back to the operative theater for definitive closure of above stated pressure sores.
IT|ischial tuberosity|IT|176|177|PAST MEDICAL HISTORY|We will see the patient at FUTS Plastic Surgery on a regular basis and will be followed by Internal Medicine while there. PAST MEDICAL HISTORY: 1. Significant for above-stated IT ulcers. The patient has had these in the past and has had revision on the right to cover sets above stated pressure sore.
IT|ischial tuberosity|IT|86|87|PROCEDURE|DIAGNOSIS: Left ischial tuberosity decubitus stage IV. PROCEDURE: Debridement of left IT decubitus on _%#MMDD2007#%_. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 80-year-old gentleman with a longstanding history of left ischial decubitus, especially following high-dose steroids for temporal arteritis a number of years ago.
IT|ischial tuberosity|IT|382|383|HISTORY OF PRESENT ILLNESS|Despite _____ daily wound care by his wife, the outer skin was closing quicker than the inner defect and the decision was made to debride the surrounding scar tissue to fill the dressing changes and cover the wound from a chronic wound to an acute wound for healing purposes. The patient was admitted to _%#CITY#%_ hospital on _%#MMDD2007#%_ following an uneventful I&D of the left IT decub under local MAC. During his hospital stay, he had minimal complaints of pain. He did use his CPAP machine overnight and then he was complaining somewhat of some discomfort from the TEDs and SCDs, but otherwise seems to be in good spirits today on postop day #1.
IT|intrathecal|IT|175|176|HISTORY OF PRESENT ILLNESS|Briefly, Ms. _%#NAME#%_ is a 58-year-old with concurrent cancers, as noted above. She underwent her initial staging procedure on _%#MMDD2007#%_. She has been receiving IV and IT chemotherapy for treatment of her stage IIIC endometrioid adenocarcinoma of the ovary. Please see the last discharge summary from _%#MMDD2007#%_ for full details of her past medical and surgical history and her medications.
IT|information technology|IT|132|133|SOCIAL HISTORY|ALLERGIES: Sulfa, which gives her a rash and trouble breathing SOCIAL HISTORY: The patient is married. She works at Fairview in the IT department. She does not smoke, and she does not drink. She has another 7-year-old child. FAMILY HISTORY: Maternal grandfather had MI at the age of 55.
IT|information technology|IT|205|206|SOCIAL HISTORY|He does report some mild frontal headaches recently. Complete review of systems is otherwise negative. SOCIAL HISTORY: He lives with his son. He reports he quit smoking years ago and currently works as an IT consultant. PHYSICAL EXAMINATION: GENERAL: He is very pleasant, talkative and appears in no acute distress.
IT|ischial tuberosity|IT|199|200|HOSPITAL COURSE|They recommended that a wound VAC to be placed for now and that the patient could be discharged home with wound VAC care. Plastic Surgery also recommended a wound VAC in place to the patient's right IT wound. This was debrided at bedside by Plastic Surgery and was noted to be a stage IV wound with some fibrinous slough still present.
IT|ischial tuberosity|IT|124|125|DISCHARGE INSTRUCTIONS|He was instructed to use black foam from the VAC dressing over his sacral wound and Accuzyme then black foam over his right IT wound. He was to bridge these 2 wounds together with a black pad to the front of his abdomen. He can also use Clinical Care Spray for cleansing irrigation of his wounds.
IT|information technology|IT|214|215|SOCIAL HISTORY|ALLERGIES: He has no known drug allergies. FAMILY HISTORY: Significant for AAA, prostate cancer, and TIA. SOCIAL HISTORY: He quit smoking in 1997. He is currently not married. He has has 4 children. He works as an IT tech. He does not use caffeine and denies alcohol and drug use. HOSPITAL COURSE: He had an extensive preoperative counseling and presented to the hospital on _%#MM#%_ _%#DD#%_, 2006, for his laparoscopic Roux-en-Y gastric bypass.
IT|information technology|IT.|165|167|SOCIAL HISTORY|FAMILY HISTORY: Paternal grandmother with colon cancer. Paternal aunt with female cancer, unclear etiology. SOCIAL HISTORY: She works full-time at North Memorial in IT. PHYSICAL EXAMINATION: GENERAL: Pleasant female in no acute distress. VITAL SIGNS: Height 55, weight 165, blood pressure 112/68, hemoglobin is 12.8. HEENT: Pupils are equally correct and accommodate.
IT|GENERAL ENGLISH|IT|344|345|HOSPITAL COURSE|It turns out the patient later revealed that he had been adjusting his furosemide doses on his own as an outpatient, and therefore, his listed doses varied somewhat from what he was actually taking at home. This should be readdressed in future visits. 4. HISTORY OF ALLERGIES: THE PATIENT LISTS MULTIPLE DRUGS TO WHICH HE IS ALLERGIC, HOWEVER, IT TURNS OUT THAT MOST OF THESE ARE NOT ALLERGIES IN THE TRUE SENSE. THE PATIENT REPORTS NOSEBLEED WITH DURICEF, NOSEBLEED WITH SULA DRUGS, ITCHING AND POSSIBLE REDMAN SYNDROME WITH VANCOMYCIN, AND A TRANSIENT RASH WHILE ON AUGMENTIN, ALTHOUGH, THE PATIENT WAS ON AUGMENTIN FOR A TOTAL OF 2 MONTHS AND THE RASH RESOLVED DURING THIS TIME.
IT|iliotibial|IT|178|179|PROCEDURES PERFORMED THIS ADMISSION|PROCEDURES PERFORMED THIS ADMISSION: 1. ACL reconstruction, left knee. 2. PCL reconstruction, left knee. 3. Posterolateral corner reconstruction, left knee. 4. Reconstruction of IT band, left knee. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ suffered a knee dislocation when he caught his knee in a grain auger.
IT|intrathecal|IT|281|282|DISCHARGE FOLLOWUP|His surgery is set for 11:00 a.m. He will check in at 9:00 a.m. The patient received the phone number of the pain clinic nurse line for which she should call for any concerns regarding the pump and/or pain. Fairview Home Infusion will follow the patient and assist in setup of the IT pump. The patient will follow up with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2003, at 10:00 a.m. for further management of hemolytic anemia.
IT|GENERAL ENGLISH|IT|149|150|ALLERGIES|4. Toprol XL 100 mg po q d. 5. Methimazole 10 mg po bid for three days. 6. Lexapro 10 mg a day was discontinued. ALLERGIES: PENICILLIN, SHE BELIEVES IT WAS A RASH A LONG TIME AGO BUT SHE CANNOT REMEMBER. SOCIAL HISTORY: She is a widow. Her husband died a year ago.
IT|GENERAL ENGLISH|IT|183|184|ASSESSMENT AND PLAN|I will have PT, OT and speech see her and I will have social work see her as well. 8. CODE STATUS. GIVEN HER COGNITIVE IMPAIRMENT, I DIDN'T FEEL COMFORTABLE DISCUSSING THIS WITH HER, IT APPEARS THAT SHE HAS BEEN FULL CODE IN THE PAST.
IT|ischial tuberosity|IT|256|257|HOSPITAL COURSE|HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ is a 55-year-old WM with history of T12 incomplete paraplegia secondary to motor vehicle accident long ago who presented to University of Minnesota Medical Center, Fairview on _%#MMDD2007#%_ with severe bilateral IT pressure ulcers. The right ischial pressure wound had 2 openings that communicated and 1 over IT that extended towards right hip oozing a moderate to heavy serosanguineous drainage.
IT|ischial tuberosity|IT|353|354|HOSPITAL COURSE|HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ is a 55-year-old WM with history of T12 incomplete paraplegia secondary to motor vehicle accident long ago who presented to University of Minnesota Medical Center, Fairview on _%#MMDD2007#%_ with severe bilateral IT pressure ulcers. The right ischial pressure wound had 2 openings that communicated and 1 over IT that extended towards right hip oozing a moderate to heavy serosanguineous drainage. This was clearly a stage 4 pressure wound where it extended to the bone.
IT|ischial tuberosity|IT|247|248|HOSPITAL COURSE|The right ischial pressure wound had 2 openings that communicated and 1 over IT that extended towards right hip oozing a moderate to heavy serosanguineous drainage. This was clearly a stage 4 pressure wound where it extended to the bone. The left IT pressure wound was also deeply tunneling with moderate drainage. The patient was evaluated by Wound Ostomy Care, Plastic Surgery and Orthopedic Surgery to treat these wounds as well as Infectious Disease.
IT|GENERAL ENGLISH|IT|175|176|ASSESSMENT/PLAN|The patient's wife _%#NAME#%_ requests more information about home hospice. AT THIS POINT IN TIME THE PATIENT STATES THAT HE WOULD LIKE TO REMAIN FULL CODE UNTIL HE DISCUSSED IT FURTHER WITH HIS WIFE. I will have him review and advanced directive also. This was discussed for greater than 30 minutes with both the patient and his wife.
IT|pravastatin or atorvastatin evaluation and infection therapy|IT|217|218|ASSESSMENT  AND PLAN|He is already on Plavix and aspirin. We will continue the dose of beta blocker and will start him on heparin and Integrilin. He is on Zocor 40 will, we switch him to Lipitor 80 mg a day, in view of results from PROVE IT trial. I will continue his ACE inhibitor. 2. He will be scheduled for angiogram tomorrow. He understands the risks and benefits of angiogram and agrees to proceed and he has signed a consent form.
IT|intertrochanteric|IT|160|161|TEXT OF DOCUMENT|TEXT OF DOCUMENT: _%#NAME#%_ _%#NAME#%_ is an 86-year-old male who was admitted to the 8th floor following surgery with Dr. _%#NAME#%_ _%#NAME#%_. ORIF of left IT femur fracture was completed on _%#MMDD#%_. His hospital stay was relatively uncomplicated. He did have some postoperative anemia, for which he received 2 units of packed red blood cells on _%#MMDD2006#%_.
IT|GENERAL ENGLISH|IT|246|247|IMPRESSION AND PLAN|Her acute renal failure is felt to be related to dehydration in the setting of chronic kidney disease and use of Lasix and lisinopril and these medications will be held for now. The patient has had a few episodes of emesis and it is unclear why. IT is possible it could be from uremia. She has a normal hemoglobin currently. The Gastroccult may just be a red herring. Nonetheless we will check q.8h. hemoglobin levels and follow her clinical course.
IT|GENERAL ENGLISH|IT|199|200|IMPRESSION AND PLAN|Her sister died of either uterine or ovarian cancer but we are not clear on the history. She has no known allergies. She is a nonsmoker. We were unable to obtain an endometrial biopsy in the office. IT showed atypical epithelial fragments and was inadequate so she is scheduled for D&C. She has had a normal mammogram. PAST MEDICAL HISTORY: Hypertension.
IT|information technology|IT|119|120|ALLERGIES|SOCIAL HISTORY: Patient has been married for many years. He is five children. Lives in _%#CITY#%_ in a house. He works IT at Northrup Life. FAMILY HISTORY: Patient has four sisters, one brother, all alive and well. His father died of melanoma. Mother alive and well. ADMISSION PHYSICAL EXAM, ADMISSION LABORATORY DATA: Blood pressure 95/60, pulse 128, respirations 20, temperature 99.5. In GENERAL, patient is alert and oriented, in no apparent distress, interactive.
IT|GENERAL ENGLISH|IT|179|180|ALLERGIES|4. Renal insufficiency. 5. I believe she has some chronic anxiety. ALLERGIES: ASPIRIN AND PROBABLY AMIODARONE WHICH SHE ATTRIBUTES TO GIVING HER INCREASED SHORTNESS OF BREATH AND IT WAS STOPPED ON THE LAST VISIT. CURRENT MEDICATIONS: 1. Xanax 0.25 mg tid. 2. Imdur 30 mg once a day.
IT|GENERAL ENGLISH|IT|177|178|ALLERGIES|15) Multivitamin with iron. 16) Ambien 10 mg one p.o. q h.s. p.r.n. 17) Albuterol two puffs q4h p.r.n. ALLERGIES: NUBAIN, REACTION UNKNOWN. SHE IS INTOLERANT TO NORVASC IN THAT IT CAUSES ANKLE SWELLING. REVIEW OF SYSTEMS: General: Denies any fever, chills or night sweats.
IT|information technology|IT|149|150|PSYCHOSOCIAL|HABITS: No smoking. Alcohol: One to two wines a day. PSYCHOSOCIAL: The patient is married with one 21-year-old son. She is a business manager for an IT consulting firm. She is living with her husband. PHYSICAL EXAMINATION: In general, no acute distress.
IT|intrathecal|IT|261|262|DISCHARGE DIAGNOSIS|She has also had PEG-asparaginase approximately 30 days ago. There was clear reaction at that time, though she have a question that she may have had 4 spots noted. PAST MEDICAL HISTORY: 1. T-ALL diagnosed in _%#MM#%_ 2003 after presentation with adenopathy. 2. IT chemotherapy x6. 3. A history of constipation. 4. History of lymph node biopsy. 5. Last bone marrow biopsy was on _%#MM#%_ _%#DD#%_, 2003.
IT|GENERAL ENGLISH|IT|168|169|SOCIAL HISTORY|ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is a widow. She has two daughters and one son. She lives at Masonic. Her code status is rather unusual. IT STATES, DO CPR BUT DO NOT INTUBATE. The patient quit smoking over 30 years ago. She has occasional glass of wine with dinner.
IT|GENERAL ENGLISH|IT|136|137|PAST MEDICAL HISTORY|She is now being admitted to Fairview Ridges Hospital. PAST MEDICAL HISTORY: 1. ALLERGIES: THE PATIENT REPORTS SHE CANNOT TAKE CODEINE; IT MAKES HER NAUSEOUS. 2. Medications: Atenolol 75 mg a day. Prinivil 40 mg a day. Zocor 20 mg a day. 3. Major diagnoses: Severe aortic stenosis.
IT|GENERAL ENGLISH|IT|218|219|ALLERGIES|He stopped Coumadin one week before surgery. He is advised to reintroduce both ten days after surgery. ALLERGIES: NONE, ALTHOUGH HE HAS MARGINAL RENAL STATUS, SO HE IS UNABLE TO TAKE GLUCOPHAGE, EVEN THOUGH PREVIOUSLY IT HAD DONE A VERY GOOD JOB CONTROLLING HIS DIABETES. VACCINATIONS: He had Pneumovax in 1993 and 1999. He had a hemophilus vaccine.
IT|GENERAL ENGLISH|IT|265|266|SHE HAS KNOWN ALLERGIES INCLUDING DUST AND MOLD|She can smell some things. She also has a history of chronic nasal congestion and post nasal drip, but no sinus headaches or nasal congestion. SHE HAS KNOWN ALLERGIES INCLUDING DUST AND MOLD FOR WHICH SHE HAS BEEN ON IMMUNOTHERAPY For FIVE YEARS AND RECENT STOPPED IT IN _%#MM#%_ OF THIS YEAR. She has also been on antihistamines in the past with some help of her nasal congestion uses saline nose sprays.
IT|UNSURED SENSE|IT|363|364|SURGERIES|PAST MEDICAL HISTORY: C diff diarrhea, gastric ulcer, urinary tract infection, cardiovascular disease, myocardial infarction (recently _%#MMDD#%_), history of congestive heart failure, history of hypertension, history of lower extremity edema, hyperlipidemia, chronic renal failure, history of osteoporosis, history of anemia, history of GI bleed. SURGERIES: Had IT repair, total knee, inguinal hernia repair. DRUG ALLERGIES: None. SOCIAL HISTORY: No smoking, no alcohol. She lives at home with 24 hour care.
IT|GENERAL ENGLISH|IT.|163|165|DISPOSITION|It would cause her carbon dioxide level to rise and would probably killer her. So, if anyone in the nursing staff has a need to increase oxygen they SHOULD NOT DO IT. There are only treating themselves and not helping her. 10. She has received a course of antibiotics appropriate for pneumonia.
IT|GENERAL ENGLISH|IT|144|145|ALLERGIES|He publishes tennis magazines. He does not drink alcohol on a regular basis. He does not smoke. ALLERGIES: PENICILLIN; HE ALSO REPORTS ASPIRIN; IT IS NOT CLEAR WHAT THE ASPIRIN ALLERGY IS OR WHAT THE PENICILLIN ALLERGY IS. MEDICATIONS: 1) Singulair. 2) Lipitor. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 95.2, blood pressure 108/87, respirations 24, heart rate 110 up to the 130's, 93% on three liters nasal cannula.
IT|GENERAL ENGLISH|IT.|181|183|ALLERGIES|She has had bladder dynamics confirming the incontinence and will now have a sling. She will be in the hospital overnight. ALLERGIES: DOES NOT TOLERATE NAPROXEN, HAD DIZZINESS WITH IT. CURRENT MEDICATIONS: Toprol XL 50 mg daily for palpitations, Allegra prn.
IT|GENERAL ENGLISH|IT|161|162|PROCEDURES|2. Status post vasectomy. 3. Depression. CONSULTATIONS: 1. TLC. 2. Hospice. 3. Radiation Oncology. PROCEDURES: 1. CT angiogram of the chest used to rule out PE. IT showed no PE. It did show hilar lymphadenopathy consistent with metastasis, as well as hepatic and sternal metastases. 2. MRI showed metastases in the spine. 3. Pelvis x-ray showed no fracture.
IT|information technology|IT|279|280|SOCIAL HISTORY|He was seen by Dr. _%#NAME#%_ _%#NAME#%_ who performed an MRI which was positive for degenerative changes, and it was recommended that the patient undergo a laparoscopic arthroscopy. MEDICATIONS: None. ALLERGIES: None. SOCIAL HISTORY: Patient works at Children's Hospital in the IT area. He occasionally smokes a cigar. FAMILY HISTORY: Father's history is unknown. Mother is 46 and in good health.
IT|iliotibial|IT|179|180|PAST SURGICAL HISTORY|4. History of anemia. 5. Bilateral shoulder pain with questionable rotator cuff tears. 6. Congestive heart failure. PAST SURGICAL HISTORY: 1. Bilateral total knee replacement. 2. IT band release. 3. Spinal plates placed. ALLERGIES: Penicillin. MEDICATIONS: 1. Combivent metered-dose inhaler 2. Azmacort metered-dose inhaler
IT|GENERAL ENGLISH|IT|278|279|ALLERGIES|2. Status post laparoscopic cholecystectomy. HISTORY OF PRESENT ILLNESS: Please see admission history and physical. PAST MEDICAL HISTORY: Please see admission history and physical. ALLERGIES: PATIENT IS REPORTED TO BE ALLERGIC TO PENICILLIN BUT THERE IS NO DETAILED REACTION TO IT AND PATIENT IS NOT QUITE SURE. HOSPITAL COURSE: 1. Acute cholecystitis, cholelithiasis. _%#NAME#%_ _%#NAME#%_ prior presented to the clinic evaluation.
IT|GENERAL ENGLISH|IT|179|180|ALLERGIES|Her protime is in the therapeutic range. ALLERGIES: CODEINE, CELEBREX, VIOXX, DETROL. ALSO SULFAMIDES WHICH SHE HAS HAD A RASH. SHE IS SENSITIVE TO THE FLU SHOT AND HAS NOT TAKEN IT FOR AWHILE. SHE AVOIDS SOME FOOD PRODUCTS SUCH AS DECAFFEINATED COFFEE AND CRAB MEAT. The patient has many concerns but overall, seems to be quite stable.
IT|ischial tuberosity|IT|197|198|IMPRESSION|The left trochanteric wound is still a quite large pocket that passes beyond the greater trochanter with generalized exposure of the greater trochanter prominence within the wound pocket. The left IT is small but still stage 2 to stage 3. These 2 wounds are in close enough proximity that they could conceivably be VAC'd together.
IT|ischial tuberosity|IT|144|145|IMPRESSION|We would like to be able to VAC this but it is too close to the anus for an adequate seal given the patient's problems with stooling. The right IT is also quite clean now with minimal bone exposed. This could also lend itself easily to VAC. With regards to current dressings we are using Kerlix wrapped in Adaptic for the left gluteal perianal wound to prevent any further bleeding.
IT|information technology|IT|280|281|PRESENT ILLNESS|CHIEF COMPLAINT: Alcohol dependence. PRESENT ILLNESS: This is the first F-UMC admission for _%#NAME#%_ _%#NAME#%_, who is a 35-year-old male from _%#CITY#%_ _%#CITY#%_. The patient is married; he has no children. He is unemployed at the present time, having been laid off from an IT job two months ago. The patient enters for his first treatment. Alcohol is his drug of choice.
IT|(drug) IT|IT|197|198|PLAN|6. Thrombocytopenia, cause unclear. 7. Diabetes mellitus. PLAN: The patient will follow up with urology as they have advised. The patient was given Nitrazine pH paper. He will take Polycitra syrup IT with meals and hs. He will continue on Allopurinol 300 mg daily. Rx for Tequin was given for one week. In addition, the patient will continue on his usual medications, Cardizem, Niaspan, Amaryl, Prinivil and nadolol at usual dosing.
IT|ischial tuberosity|IT|197|198|PHYSICAL EXAMINATION|He self- catheterizes multiple times a day and has been doing this throughout his stay. EXTREMITIES: He is paraplegic secondary to spina bifida and has congenital changes associated with that. The IT flap and incisions are intact. There is no appreciable erythema. There was an area on the medial thigh near the scrotum of the flap that was denuded at one time but this improved over the 96 hours prior to admission.
IT|intrathecal|IT|252|253|PAST MEDICAL HISTORY|She was given IV fluids. Her vital signs on admission included a temperature of 99.9, blood pressure of 90/60, heart rate of 70, respiratory rate of 16. PAST MEDICAL HISTORY: 1. T-ALL diagnosed in _%#MM#%_, 2003, after presentation with adenopathy. 2. IT chemotherapy x 7. 3. A history of constipation. 4. History of lymph node biopsy. 5. Last bone marrow biopsy was on _%#MM#%_ _%#DD#%_, 2003.
IT|GENERAL ENGLISH|IT|390|391|OPERATIONS/PROCEDURES PERFORMED|The patient was supposed to get a renal biopsy to assess for active disease process today which was canceled due to high blood pressure. ADMISSION MEDICATIONS: Norvasc 10 mg p.o. daily, nortriptyline 7 mg p.o. daily, Migranal 4-mg spray, Normodyne 8 sprays per day, metoprolol XL 50 mg p.o. daily, calcitriol 0.25 mcg orally daily, Lasix 80 mg p.o. b.i.d. ALLERGIES: ASPIRIN AND IBUPROFEN; IT DOES NOT HAVE ANY ALLERGIC EFFECT IN IT, BUT IT IS AN ALLERGY FOR HIS NEPHROPATHY. HOSPITAL COURSE: The patient was admitted to the hospital for management of his blood pressure.
IT|GENERAL ENGLISH|IT,|293|295|OPERATIONS/PROCEDURES PERFORMED|ADMISSION MEDICATIONS: Norvasc 10 mg p.o. daily, nortriptyline 7 mg p.o. daily, Migranal 4-mg spray, Normodyne 8 sprays per day, metoprolol XL 50 mg p.o. daily, calcitriol 0.25 mcg orally daily, Lasix 80 mg p.o. b.i.d. ALLERGIES: ASPIRIN AND IBUPROFEN; IT DOES NOT HAVE ANY ALLERGIC EFFECT IN IT, BUT IT IS AN ALLERGY FOR HIS NEPHROPATHY. HOSPITAL COURSE: The patient was admitted to the hospital for management of his blood pressure.
IT|intrathecal|IT|200|201|FOLLOW-UP|5. Colace 20 mg p.o. b.i.d. p.r.n. constipation. 6. Zofran 2 mg p.o. q.6h p.r.n. for nausea. FOLLOW-UP: The patient has a follow-up appointment in Hematology/Oncology Clinic on _%#MMDD#%_ at 1130 for IT chemotherapy. The patient may go to their local clinic on _%#MMDD#%_ and get a CBC with diff and platelets and fax results to the Hematology/Oncology Clinic.
IT|information technology|IT|80|81|SOCIAL HISTORY|He denies any heart disease or diabetes in his family. SOCIAL HISTORY: He is an IT consultant. He was recently in India. He denies any tobacco use. He lives alone, is single, and has no children. ALLERGIES: Codeine apparently causes discomfort for the patient.
IT|information technology|IT|293|294|PRESENT ILLNESS|CHIEF COMPLAINT: Opiate dependence. PRESENT ILLNESS: This is the first University of Minnesota Medical Center, Fairview, admission for _%#NAME#%_ _%#NAME#%_, who is a 31-year-old male from _%#CITY#%_. The patient is married. He has been married for six months. He has no children. He works in IT for Milestone Systems. The patient enters Fairview Recovery Services at this time, with a greater than one-year history of addiction to prescription opiates.
IT|GENERAL ENGLISH|IT|219|220|ALLERGIES|PAST MEDICAL HISTORY: Chronic medical problems as I noted above. PREVIOUS SURGERIES: Remote tonsillectomy. ALLERGIES: HE WAS TOLD SHE IS ALLERGIC TO PENICILLIN WITH HIVES REACTION ALTHOUGH AS A CHILD HE CANNOT REMEMBER IT SPECIFICALLY. SOCIAL HISTORY: The patient is married, he works in computers in computer security I believe, he travels quite a bit around the five state area.
IT|information technology|IT|161|162|SOCIAL HISTORY|FAMILY HISTORY: Father with coronary artery bypass grafting in his sixties. SOCIAL HISTORY: The patient lives in _%#CITY#%_ with his wife and children. He is an IT director. He is married. He is followed by Dr. _%#NAME#%_ _%#NAME#%_ at the _%#CITY#%_ Sports Wellness Clinic. He does not smoke.
IT|intrathecal|IT|167|168|HISTORY OF PRESENT ILLNESS|Etoposide 300 mg per square meter over 1 hour in clinic followed by cyclophosphamide 500 per meters squared over 1 hour for week 2. For week 3 he is to receive triple IT therapy. He denies any new symptoms since his last admission. He has not had any fevers, chills, or fatigue. No oral lesions have been present. He denies any headaches.
IT|information technology|IT|135|136|SOCIAL HISTORY|SOCIAL HISTORY: The patient is married and lives with his wife. Denies tobacco or alcohol use. The patient is employed as a manager in IT Company. FAMILY HISTORY: Hypertension. Alcohol in father. Lung cancer in mother who is a smoker.
IT|information technology|IT|167|168|HISTORY OF PRESENT ILLNESS|He realized in the United States about four days later that he was having progressive difficulties with balance and difficulty answering his password at his job as an IT employee. He began to have worsening headache and noticed some neurologic impairment. After evaluation and radiological workup, a subdural hemorrhage was noticed on the patient's left side.
IT|GENERAL ENGLISH|IT|126|127|ALLERGIES|3. The patient has had radiation therapy secondary to brain metastasis within the past couple of months. ALLERGIES: DILAUDID, IT GIVES HER ITCH. THE PATIENT GETS BLISTERS WITH ADHESIVE TAPE. HOSPITAL COURSE: On initial evaluation, prior to taking her back to the OR, it was noted the patient had muffled heart sounds and lower extremity edema.
IT|GENERAL ENGLISH|IT|121|122|ALLERGIES|SURGICAL: 1) Retinal surgery. 2) Cataract extraction. 3) Repair of anal fissure. ALLERGIES: PENICILLIN REMOTELY; HE SAYS IT HAS BEEN QUITE A NUMBER OF YEARS. CURRENT MEDICATIONS: 1) Z-Pak; he took a dose last night and a first dose today.
IT|GENERAL ENGLISH|IT|150|151|ALLERGIES|3. Lasix 12 mg p.o. b.i.d. 4. Spironolactone 5 mg p.o. b.i.d. 5. Prevacid 5.1 mg p.o. b.i.d. ALLERGIES: ROCEPHIN. THE PATIENT DEVELOPED HIVES, THOUGH IT WAS UNCLEAR THAT THESE MAY ACTUALLY HAVE BEEN DUE TO A VIRAL ILLNESS WHICH SHE HAD AT THE TIME. FAMILY HISTORY: There is no history of bleeding disorders, clotting disorders, immune deficiency, or anesthetic reactions in the family.
IT|iliotibial|IT|233|234|SURGICAL PROCEDURE|FINAL DIAGNOSIS: 1. Patellofemoral failure with arthroplasty with tight lateral retinaculum and malalignment. 2. Possible infection. SURGICAL PROCEDURE: Revision of patellofemoral joint with extensive lateral release with release of IT band. Post-operatively, one colony staph coag negative grew out of it but because of the fact that the gram stain was positive on the intraoperative culture, we will treat it.
IT|intrathecal|IT|160|161|HOSPITAL COURSE/PLAN|If there is any change in antibiotic sensitivity, the patient will be called. 2. Chronic left shoulder pain. No current issues, so patient will continue on the IT pump and oxycodone p.r.n. 3. Posttraumatic stress disorder; no current issues. 4. Depression, stable on Prozac. DISCHARGE FOLLOWUP: 1. Follow up with primary care doctor, Dr. _%#NAME#%_, in 1 week.
IT|GENERAL ENGLISH|IT|134|135|ALLERGIES|Other chronic medical problems none. ALLERGIES: THE PATIENT NOTES PENICILLIN BUT STATES HE WAS TOLD THIS OCCURRED WHEN HE WAS A BABY, IT IS UNCLEAR OF EXACTLY WHAT THE REACTION WAS. HE HAS CARRIED IT With HIM SINCE THEN. WE NOTE HE WAS TREATED DURING HIS HOSPITALIZATION HERE IN 2001 WITH ANCEF AND CEPHALEXIN WITHOUT DIFFICULTY.
IT|GENERAL ENGLISH|IT|197|198|ALLERGIES|Other chronic medical problems none. ALLERGIES: THE PATIENT NOTES PENICILLIN BUT STATES HE WAS TOLD THIS OCCURRED WHEN HE WAS A BABY, IT IS UNCLEAR OF EXACTLY WHAT THE REACTION WAS. HE HAS CARRIED IT With HIM SINCE THEN. WE NOTE HE WAS TREATED DURING HIS HOSPITALIZATION HERE IN 2001 WITH ANCEF AND CEPHALEXIN WITHOUT DIFFICULTY.
IT|information technology|IT.|174|176|SOCIAL HISTORY|2. Depression with history of ingestion. 3. Reflux disease. PAST SURGICAL HISTORY: Inguinal hernia repair. FAMILY HISTORY: Hypertension. SOCIAL HISTORY: The patient works in IT. She lives alone. No IV drug use, alcohol or tobacco use. ALLERGIES: Sulfa causes hives, iodine cause unknown reaction, aspirin causes GI intolerance.
IT|information technology|IT|116|117|SOCIAL HISTORY|1. Strattera, 1 pill q. day. 2. Synthroid. 3. No aspirin. He is not taking aspirin. SOCIAL HISTORY: He works in the IT Department of the Army Corps of Engineers. His children are in school. He is married, lives with his family. He does not smoke or drink alcohol. REVIEW OF SYSTEMS: CARDIOVASCULAR: Negative stress test 7 years ago with his last TIA.
IT|GENERAL ENGLISH|IT|137|138|ALLERGIES|2. She had some inguinal hernia surgery repair, possibly left-sided per mother's report. ALLERGIES: SHE REPORTS BEING ALLERGIC TO SULFA. IT GIVES HER HIVES. MEDICATIONS: She takes Tums for calcium supplement and over-the-counter Tylenol once in a while.
IT|ischial tuberosity|IT|179|180|PROCEDURES|DATE OF DISCHARGE: _%#MMDD2006#%_. ADMISSION DIAGNOSIS: Right iliotibial stage IV decubitus ulcer. PROCEDURES: Debridement, bone biopsy, and posterior thigh flap closure of right IT decubitus ulcer. HISTORY OF PRESENT ILLNESS/DISCHARGE PLAN: This is a 63-year-old male with a history of advanced multiple sclerosis, who developed a right ischial ulcer which is stage IV.
IT|iliotibial|IT|132|133|PHYSICAL EXAMINATION|SKIN: Reveals multiple abrasions in the posterior left shoulder and the left scapula. There are also some abrasions in the anterior IT band bilaterally, mostly on the right. The patient has quite extensive lesions the left lower back which extend from the lower back down to his proximal thigh.
IT|GENERAL ENGLISH|IT|105|106|IMPRESSION|X-rays and MRI are consistent with the gouty tophi lesion. IMPRESSION: Gouty arthritis at the MTP joint. IT is presently resolving. We discussed the triggers for gout, typical symptoms of the hypersensitivity of the light touch and the pins and needles feeling in the skin.
IT|GENERAL ENGLISH|IT|236|237|HISTORY OF PRESENT ILLNESS|HE STATES THAT SHE IS A DNR/DNI AND THAT THE FAMILY DOES NOT WANT ANY WORKUP PERFORMED BECAUSE OF HER ADVANCED AGE AND DEMENTIA. NO FAMILY MEMBERS ARE CURRENTLY PRESENT AT THE TIME OF MY EVALUATION. THE PATIENT WAS SENT UP HERE BECAUSE IT WAS MORE CONVENIENT FOR THE FAMILY TO TAKE HER HERE TO BE TRANSFUSED. Dr. _%#NAME#%_ has no hospital privileges here, therefore, the nurses would not accept his transfusion orders and the hospitalist service was contacted to admit the patient.
IT|GENERAL ENGLISH|IT|136|137|ALLERGIES|Her son is present with her in the emergency room. She quit smoking years ago. ALLERGIES: NO KNOWN DRUG ALLERGIES, HOWEVER, IN THE PAST IT HAS BEEN LISTED THAT SHE HAS BEEN ALLERGIC TO NOVOCAIN. MEDICATIONS: Currently include aspirin 81 mg p.o. daily, but I do not have her official medication list with her currently.
IT|iliotibial|IT|147|148|DISCHARGE EXAMINATION|She has range of motion. She can flex to about 100 degrees bilaterally. She can extend both knees to neutral. Strength was intact. She has a tight IT band. Overs' maneuver is positive. HOSPITAL COURSE: 1. Status post bilateral BKA. The patient's incisions are healing well.
IT|iliotibial|IT|295|296|HOSPITAL COURSE|She underwent a bursal injection on _%#MMDD#%_. She had immediate relief of her pain and fair relief in the next couple of days, however, the release did not last for an extended period of time. At the time of discharge, it was felt that her pain was secondary to a tight tensor fascia lata and IT band, and she has been home with instructions on home stretching and to focus on this. 6. Anxiety. The patient experienced significant anxiety during her recovery period.
IT|GENERAL ENGLISH|IT|177|178|HISTORY OF PRESENT ILLNESS|At that time she was admitted to St. Joseph's Hospital for evaluation of recurrent pancreatitis and remained there until she was transferred here today, for further evaluation. IT should be noted that approximately 5 days prior to admission today, she did have a PEG tube placed for enteral nutrition.
IT|ischial tuberosity|IT|195|196|HOSPITAL COURSE|He is going to follow through with Dr. _%#NAME#%_'s group following there for his ongoing medical issues per the previous orders. He currently is on Zosyn for polymicrobial infection of his left IT wound. Intraoperative cultures were taken by the final conclusions are not back yet at this point and further antibiotic coverage will be dictated by these results.
IT|intrathecal|(IT)|159|162|HISTORY OF PRESENT ILLNESS|She had her Omaya reservoir placed on Monday _%#MMDD2007#%_. She was kept in hospital for 1 day for pain control and ultimately received her first intrathecal (IT) methotrexate (MTX) on the following day _%#MMDD2007#%_. She presented to my clinic today for followup and a discussion of whether a sixth and final cycle of cisplatin-etoposide chemotherapy would be provided systemically in addition to ongoing IT MTX.
IT|intrathecal|IT|188|189|HISTORY OF PRESENT ILLNESS|She presented to my clinic today for followup and a discussion of whether a sixth and final cycle of cisplatin-etoposide chemotherapy would be provided systemically in addition to ongoing IT MTX. Unfortunately on seeing _%#NAME#%_ today she appears notably weak, fatigued, tremulous and in a considerable amount of pain. She was provided semi-urgent intravenous fluids, IV morphine and Ativan anxiolytics in our clinic and stabilized.
IT|intrathecal|IT|153|154|ASSESSMENT AND PLAN|Neurologic consultation will again be obtained during the hospitalization. I will reevaluate her tomorrow for her neuro status and candidacy for ongoing IT MTX. During the course of the hospitalization we will also focus on pain control, anxiolytics and ongoing nutritional supplementation.
IT|iliotibial|IT|210|211|DISCHARGE PHYSICAL EXAMINATION|ABDOMEN: Soft, nontender and nondistended. Present bowel sounds. NEUROLOGIC: Cranial nerve II through XII is intact. Sensory and motor is intact. EXTREMITY: He has pain at the both side of his left knee around IT band. LABORATORY DATA: On the day of discharge, was white count 6.7, hemoglobin 13.7 and platelets 108,000.
IT|GENERAL ENGLISH|IT|204|205|ASSESSMENT|2. Status post CVA x2 from patent foraminal ovale on Coumadin previously. NOTE, THE PATIENT SELF DISCONTINUED HIS COUMADIN 3-4 WEEKS AGO AROUND THE TIME OF HIS LAST ESOPHAGEAL DILATION AND NEVER RESTATED IT BECAUSE HE FELT LIKE HE WOULD NEED TO HAVE ANOTHER DILATION SOMETIME SOON. HE HAS HAD NO STROKE SYMPTOMS APPARENTLY SINCE STOPPING HIS COUMADIN.
IT|GENERAL ENGLISH|IT|146|147|ALLERGIES|5. Calcium supplementation. ALLERGIES: Medicated patches resulting in rash. HEALTH MAINTEANNCE: 1. Last Pap smear was performed in _%#MM#%_ 2002. IT was within normal limits. 2. Last mammogram was status post her bilateral mastectomy. 3. Last colorectal was at age 50. It was within normal limits.
IT|intrathecal|IT|171|172|ALLERGIES|Depo-Provera 150 mg IM every 3 months. Her last dose was _%#MM#%_ _%#DD#%_, 2002. ALLERGIES: ACTH INFUSION. CODE STATUS: Full. HOSPITAL COURSE: 1. Multiple sclerosis with IT Baclofen pump malfunction: The patient was admitted to the floor. IT Baclofen pump was evaluated. The initial plan was for pump revision and anesthesia found that it needed to be replaced.
IT|intrathecal|IT|158|159|ALLERGIES|ALLERGIES: ACTH INFUSION. CODE STATUS: Full. HOSPITAL COURSE: 1. Multiple sclerosis with IT Baclofen pump malfunction: The patient was admitted to the floor. IT Baclofen pump was evaluated. The initial plan was for pump revision and anesthesia found that it needed to be replaced. The patient tolerated the procedure fine. INR was normalized prior to the procedure.
IT|GENERAL ENGLISH|IT|306|307|HISTORY OF PRESENT ILLNESS|ADMISSION DIAGNOSIS: Chest pain with coronary artery disease. OPERATIONS/PROCEDURES PERFORMED: Adenosine thallium stress test which revealed fixed inferior defect and no significant reversible remnants of ischemia. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ was a 51-year-old man who developed chest pain. IT was not improved with nitroglycerin. He was initially taken to Mercy Hospital after calling 911 and subsequently transferred here for further care.
IT|GENERAL ENGLISH|IT|219|220|SOCIAL HISTORY|Her son feels that she is probably now going to go on to an assisted living after she recovers from this. NO ALLERGIES, BUT WHEN She TAKES MEDICATION, ANTIBIOTIC MEDICATION, She GETS GASTROINTESTINAL UPSET IF She TAKES IT FOR MORE THAN 1-2 DAYS. REVIEW OF SYSTEMS: According to the son and the patient, denies cardiac, pulmonary, or renal symptoms.
IT|information technology|IT|155|156|SOCIAL HISTORY|Alcohol - abstained during pregnancy. REVIEW OF SYSTEMS: Unremarkable. SOCIAL HISTORY: The patient is a high school physics teacher. Her husband works for IT at the University of St. Thomas. PHYSICAL EXAMINATION: GENERAL: Well developed, well nourished, moderately obese female in active labor.
IT|GENERAL ENGLISH|IT|143|144|ALLERGIES|His chest pain is apparently located left to the sternum. Doesn't depend on exertion or position of the body and is quite severe in intensity. IT radiates as little bit into his left shoulder. He tells me that it feels exactly like the pain he had in the past with his myocardial infarction.
IT|information technology|IT,|204|206|SOCIAL HISTORY|FAMILY MEDICAL HISTORY: Negative as far as contribution to this issue, with no lung problems in the family noted. SOCIAL HISTORY: The patient is engaged to be married. Works for the City of _%#CITY#%_ in IT, is an avid runner, several times a week, drinks two or three cups of coffee a day, does not smoke, has maybe eight alcoholic beverages a week, usually grouped on the weekends.
IT|iliotibial|IT|275|276|PAST MEDICAL HISTORY|INFECTIOUS DISEASE: Fevers, chills, cough as above. PSYCHIATRIC: Stable. PAST MEDICAL HISTORY: COPD from chemical exposure, hypertension, spinal stenosis with chronic narcotics dependent to pain. Is on home O2 for the COPD. Has a history of anemia. Bilateral TKR status post IT band release. ALLERGY: Penicillin. CURRENT MEDICATIONS: 1. Endocet 2 p.o. q.4-6 h. 2. Hydroxyzine 25 mg q.4-6 h.
IT|iliotibial|IT|223|224|FINAL DIAGNOSIS|She is a very lean if not cachectic person who has had multiple problems healing surgeries, virtually every time she has ever had one, including both feet, the knees, etc. She had an IT band debridement release for chronic IT band pain. She did well for a period of time and then has failed. Cultures were taken. Refer to the chart for medical specific cultures, labs, medications, consultations.
IT|GENERAL ENGLISH|IT|210|211|ALLERGIES|Otherwise, beside intermittent atrial fibrillation, he has no angina or indication of previous cardiac failure. No anesthesia problems, no blood transfusions. ALLERGIES: PENICILLIN AND DEXAMETHASONE; HE CLAIMS IT CAUSED HICCUPS. CURRENT MEDICATIONS: 1) Lanoxin 0.25 mg half tab daily. 2) Pletal 100 mg one-half tab b.i.d. 3) HCTZ 25 mg daily.
IT|intrathecal|IT|183|184|PAST MEDICAL HISTORY|2. History of bacterial infections during induction chemotherapy. 3. Syncopal episodes during initial hospitalization without recurrence. 4. Ommaya reservoir placement and subsequent IT methotrexate. 5. PICC line placement. MEDICATIONS: The patient takes no medications on scheduled basis. ALLERGIES: Sulfa, penicillin, Cefzil.
IT|GENERAL ENGLISH|IT|136|137|ASSESSMENT AND PLAN|7. I discussed CODE STATUS With THE PATIENT AND HER SON, MRS. _%#NAME#%_ APPARENTLY HAS ADVANCED DIRECTIVES. She WISHES TO BE DNR, DNI, IT WILL THEREFORE BE NOTED IN The CHART THAT THE PATIENT IS DNR, DNI.
IT|GENERAL ENGLISH|IT.|194|196|PAST MEDICAL HISTORY|The patient understands the risks and possibilities of surgical complications and is anxious to proceed. PAST MEDICAL HISTORY: ALLERGIES: VALIUM AND POSSIBLY THE FAMILY OF DRUGS ASSOCIATED WITH IT. MEDICATIONS: Vitamins. SURGICAL: The patient has had wisdom teeth removed but no other surgeries. MEDICAL: The patient denies a history of high blood pressure, tuberculosis, heart disease, kidney disease, pulmonary disease, transfusions or hepatitis.
IT|GENERAL ENGLISH|IT|141|142|ALLERGIES|9. Augmentin 875 mg po bid. 10. Colchicine prn. 11. Inspira 25 mg a day. ALLERGIES: ASPIRIN IN THE PAST HAS CAUSED AN ULCER BUT HE HAS TAKEN IT NOW WITHOUT DIFFICULTY. HE HAS HAD A COUGH WITH AN ACE INHIBITOR. PAST MEDICAL HISTORY: 1. Septic syndrome due to subhepatic abscess post cholecystectomy in _%#MM2004#%_.
IT|GENERAL ENGLISH|IT|104|105|ATENOLOL CAUSED AN EXACERBATION OF HER ASTHMA.|13. Metformin 500 mg b.i.d. 14. L-thyroxine 0.1 mg 15. Premarin 0.625 mg She IS INTOLERANT TO DIOVAN AS IT CAUSES PALPITATIONS, ATENOLOL CAUSED AN EXACERBATION OF HER ASTHMA. She HAD PEPTIC ULCER DISEASE IN 1998. She IS ALSO INTOLERANT TO DEMEROL AND THEO-DUR AS IT CAUSED NAUSEA.
IT|GENERAL ENGLISH|IT|263|264|ATENOLOL CAUSED AN EXACERBATION OF HER ASTHMA.|13. Metformin 500 mg b.i.d. 14. L-thyroxine 0.1 mg 15. Premarin 0.625 mg She IS INTOLERANT TO DIOVAN AS IT CAUSES PALPITATIONS, ATENOLOL CAUSED AN EXACERBATION OF HER ASTHMA. She HAD PEPTIC ULCER DISEASE IN 1998. She IS ALSO INTOLERANT TO DEMEROL AND THEO-DUR AS IT CAUSED NAUSEA. In the emergency room, she was given Metoprolol intravenous without any difficulty.
IT|GENERAL ENGLISH|IT|170|171|DRUG ALLERGIES|DRUG ALLERGIES: She IS ALLERGIC TO Amoxicillin, GIVES HER A RASH. She TELLS ME She IS ALLERGIC TO Tylenol #3, MAKES HER SICK, BUT She THINKS THAT MAYBE CODINE PORTION OF IT MAKES IT WORSE AND She hasn't taken any since then. CURRENT MEDICATION LIST: Was reviewed. She is on 1. Accupril 20 mg one a day
IT|GENERAL ENGLISH|IT.|99|101|ALLERGIES|2. Jaw surgery in the 1980s. 3. Foot surgery in the 1980s. ALLERGIES: VICODIN. SHE GETS HIVES FROM IT. MEDICATIONS: None. SOCIAL HISTORY: Noncontributory as is family history. PHYSICAL EXAMINATION VITAL SIGNS: Temperature 97.7. Pulse 90. Blood pressure 120s/60s.
IT|GENERAL ENGLISH|IT|168|169|I TALKED TO THE PATIENT ABOUT RESUSCITATION STATUS.|10. History of tonsillectomy. I TALKED TO THE PATIENT ABOUT RESUSCITATION STATUS. She STATES She HAS A LIVING WILL. HOWEVER, I DON'T HAVE The SPECIFIC DETAILS OF THAT. IT SOUNDED LIKE She DID NOT WANT HEROIC MEASURES AS FAR AS DNR GOES. I DID
IT|intrathecal|IT|231|232|HISTORY OF PRESENT ILLNESS|1. Hematology/oncology. The patient was diagnosed with pre-B-cell ALL. She received chemotherapy via protocol _%#PROTOCOL#%_. Day 0 was _%#MM#%_ _%#DD#%_, 2005. Her chemotherapy included dexamethasone, vincristine, L-asparaginase, IT cytarabine/Ara-C, and IT methotrexate. During this hospitalization, she experienced several side effects from her chemotherapy. From the vincristine, the patient developed jaw pain, ileus, and SIADH.
IT|information technology|IT|114|115|SOCIAL HISTORY|FAMILY HISTORY: Unremarkable although his father has had back problems SOCIAL HISTORY: He is married. He works in IT and has a sedentary job. REVIEW OF SYSTEMS: He has had problems with his weight.
IT|GENERAL ENGLISH|IT|155|156|ALLERGIES|4. Allopurinol 300 mg p.o. q. day. 5. Darvocet as needed. 6. Doxycycline 50 mg p.o. b.i.d. ALLERGIES: HE IS ALLERGIC TO HYDROCHLOROTHIAZIDE AND LASIX, AND IT IS UNCLEAR WHAT REACTION HE HAS.FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: He is married. He does not smoke or drink alcohol.
IT|information technology|IT.|133|135|SOCIAL  HISTORY|Ten system review of systems is otherwise negative or as per HPI. SOCIAL HISTORY: He is married and lives with his wife. He works in IT. A he quit smoking in 1993 and drinks three to four drinks a week. He is working out regularly, sometimes several times a day.
IT|information technology|IT|126|127|SOCIAL HISTORY|Father has hypertension and had coronary artery disease in his 50's and is now in his 70's. SOCIAL HISTORY: The patient is an IT administrator at Metro Printing. He is married and has two children. He denies smoking. He takes alcohol occasionally, denies any street drugs. MEDICATIONS: None ALLERGIES: No known drug allergies.
IT|GENERAL ENGLISH|IT|245|246|HISTORY|Will have her seen by the nurse practitioner at Minnesota Heart Clinic mid next week to review her orthostatic blood pressure and review the Holter monitor. Will schedule her for tilt table study next week after the nurse practitioner sees her. IT IS IMPORTANT THAT SHE BE ON TOPROL AND ON FLORINEF WHEN SHE HAS TILT TABLE. She will then wear a 30 day cardiac event monitor and we will see if she has any break-through episodes of SVT or syncopal events.
IT|GENERAL ENGLISH|IT|117|118|ALLERGIES|2. THE PATIENT IS STATUS POST DESENSITIZATION TO PIPERACILLIN AT THE TIME OF HIS LAST ADMISSION. HE HAS NOT BEEN OFF IT SINCE HIS LAST ADMISSION. HOSPITAL COURSE: 1. Repair of his GJ-tube fistula: The patient as noted above tolerated this surgery well.
IT|information technology|IT|170|171|SOCIAL HISTORY|ALLERGIES: No known drug allergies. MEDICATIONS: None. SOCIAL HISTORY: No tobacco abuse, rare beer on a weekend. No illicit drugs. The patient is married and works as an IT consultant. FAMILY HISTORY: Father had a myocardial infarction in his 70s, and mother had breast cancer.
IT|intrathecal|(IT)|114|117|HISTORY OF PRESENT ILLNESS|He will see Dr. _%#NAME#%_ or our nurse practitioner at that time. Of note, he still needs to arrange intrathecal (IT) methotrexate and cytarabine therapy, which will be arranged within the coming weeks. LABORATORIES: On the day of discharge included a methotrexate level of less than 0.10 micromoles (actual level 0.02 on _%#MMDD2006#%_).
IT|iliotibial|IT|122|123|ASSESSMENT/PLAN|Although x-ray is negative except for some degenerative changes, he still has pain, maybe this is secondary to a bursa or IT band syndrome. We will consult Ortho for further workup. 2. Chronic obstructive pulmonary disease. With history of pneumonitis, this seems to be resolving on x-ray and by symptoms.
IT|GENERAL ENGLISH|IT|281|282|ALLERGIES|I have discussed these findings with the radiologist, and it is felt that this perhaps can be managed with medical care without surgical intervention. PAST MEDICAL HISTORY: No previous hospitalizations, no previous surgeries. ALLERGIES: PROBABLE ALLERGY TO PENICILLIN; WHEN TAKING IT AT AGE FIVE HE DEVELOPED A RASH. FAMILY HISTORY: Negative for serious illness. MEDICATIONS; The patient has been instructed to use Singulair on an as-needed basis for allergies but is not taking any presently.
IT|intrathecal|(IT)|277|280|HISTORY OF PRESENT ILLNESS|_%#NAME#%_ was last seen in clinic on _%#MMDD2007#%_ at which time he was doing well except for some atypical sensations of anterior abdominal pain with rapid movement. He was without any signs of infection at that time and was referred on later that day for a 4th intrathecal (IT) methotrexate treatment. The plan for this hospitalization is to provide him chemotherapy between _%#MMDD2007#%_ and _%#MMDD2007#%_.
IT|intrathecal|IT|191|192|HISTORY OF PRESENT ILLNESS|The plan for this hospitalization is to provide him chemotherapy between _%#MMDD2007#%_ and _%#MMDD2007#%_. He will likely be discharged on Saturday _%#MMDD2007#%_ with plans for yet another IT methotrexate treatment and further Neulasta through our clinic. We will then be scheduled for PET scans to ensure disease response which hopefully will declare him in remission and allow observation from that point forward.
IT|GENERAL ENGLISH|IT|145|146|ASSESSMENT  AND PLAN|7. CODE STATUS. THE PATIENT IS CURRENTLY FULL CODE. PER THE NOTES THERE HAVE BEEN MANY DISCUSSIONS WITH HIS FAMILY ABOUT THIS. I AGAIN DISCUSSED IT WITH HIS SON _%#NAME#%_ JR AND The WOMAN WHO CARES FOR HIM AT A NURSING HOME. HIS SON SEEMS TO UNDERSTAND WHAT THIS MEANS AND SAYS HE WILL TALK TO HIS MOTHER AND BROTHER ABOUT IT.
IT|GENERAL ENGLISH|IT|132|133|PAST MEDICAL HISTORY|I will let the chemical dependency counselors sort that out. PAST MEDICAL HISTORY: She says that She HAS PROBLEMS With MACRODANTIN, IT RAISES HER BLOOD PRESSURE AND HER PULSE. She takes no medicines, but she says she buys human growth hormone someplace.
IT|information technology|IT|130|131|SOCIAL HISTORY|3. Tympanostomy tubes in ears as a child. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: Nonsmoker, social drinker. He is an IT auditor. FAMILY HISTORY: Coronary artery disease with his father having angioplasty in his 50s.
IT|information technology|IT|136|137|SOCIAL HISTORY|MEDICATIONS: Synthroid 0.75 mg p.o. q. day. SOCIAL HISTORY: She does not use tobacco. Only rare occasional alcohol use. She works as an IT consultant. She is not married. No children. FAMILY HISTORY: Significant for diabetes, cardiac disease, and end-stage renal disease in her father.
IT|intrathecal|IT|163|164|ADMISSION 	HISTORY AND PHYSICAL|He was initially maintained on an IV PCA pump. He was subsequently changed to intrathecal analgesia on _%#MMDD2003#%_. He had good pain control after switching to IT pain management until the day of admission. He had some problem with pain through the night and needed increased narcotic administration, including some IV p.r.n. morphine.
IT|intrathecal|IT|153|154|DISCHARGE DIAGNOSES|3. Admitted in _%#MM#%_ 2003, again for fever and neutropenia. 4. Admitted in _%#MM#%_ of 2003 for fever and neutropenia, viral etiology. 5. Status post IT chemotherapy, with at least 4 treatments of methotrexate. ALLERGIES: Tegaderm. SOCIAL HISTORY: He lives in _%#CITY#%_ _%#CITY#%_, Minnesota.
IT|inspiratory time|IT|154|155|DIET|Change pacer batteries q. week. Pacer settings: left 1.5, right 2.0, and a rate of 7. A ventilator at night at SIMV rate of 12, tidal volume 0.5, PEEP 5, IT 0.8. Low alarm 10. High alarm 60. FOLLOW-UP: The patient should follow up with Dr. _%#NAME#%_ _%#NAME#%_ as needed. The patient has extensive follow-up with her as an outpatient.
IT|iliotibial|IT|263|264|SUMMARY OF HOSPITAL COURSE|This request was honored. Due to the significance of his cardiac arrhythmia, according to the anesthesiologist, he wanted us to stop while we were still essentially able to stop without creating avascular necrosis of his hip, so the abductors were closed and the IT band and skin incisions were closed in the usual manner. Please see a copy of the medical consult, specifically his cardiac consult postoperatively, for further medical details.
IT|intrathecal|IT|119|120|PLAN|We will continue with all his medications from the group home. It is verified with his home health care nurse that his IT pump was filled within the last week.
IT|iliotibial|IT|133|134|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Hypertension. 2. Asthma. 3. Depression. 4. Degenerative disk disease. 5. Tobacco abuse. 6. History of right IT band lengthening. 7. Migraine headaches. 8. Abdominal hysterectomy. 9. Cholecystectomy. 10. Anterior spinal fusion from L3 to L4. 11. Appendectomy. ADMISSION MEDICATIONS: 1. Neurontin. 2. Vicodin. 3. Celebrex.
IT|GENERAL ENGLISH|IT|142|143|PERSONALITY CHANGES.|Urine a bit hesitant. He also has a history of prostate cancer. FAMILY HISTORY: Is noncontributory. THE PATIENT HAS ALLERGY TO Amiodarone AND IT LED TO PERSONALITY CHANGES. PHYSICAL EXAMINATION: Slow moving, almost frail looking gentleman who gets up and around slowly.
IT|intrathecal|IT|181|182|PAST MEDICAL HISTORY|2. History of bacterial infection during induction chemotherapy. 3. Syncopal episode during initial hospitalization without recurrence. 4. Ommaya reservoir placement and subsequent IT Methotrexate. 5. PICC line placement. MEDICATIONS: The patient takes no scheduled medications. ALLERGIES: Sulfa, penicillin and Cefzil.
IT|GENERAL ENGLISH|IT|287|288|RAPID ONSET OF THIS NEAR DEATH EXPERIENCE, WE WILL|5. Dementia chronic Initial troponin level and EKG do not suggest any myocardial ischemia due to the acute hemorrhaging. ALSO, THE PATIENT IS A DNR AND DNI AND DUE TO The SECOND EPISODE OF SIGNIFICANT BLEEDING COMPLICATIONS ON Coumadin, WHEN HAVING SEVERAL MONTHLY INRS IN Normal RANGE, IT ELUDES TO THE PATIENT'S INSTABILITY With Coumadin AND With The RAPID ONSET OF THIS NEAR DEATH EXPERIENCE, WE WILL RECOMMEND DISCONTINUATION OF HER Coumadin AT THIS TIME AND TREAT With ASPIRIN ALONE For The INCREASED RISK OF STROKE With The ATRIAL FIBRILLATION.
IT|GENERAL ENGLISH|IT|310|311|ALLERGIES|MEDICATIONS: Toprol XL 50 mg daily, Lisinopril/Hydrochlorothiazide 10/12.5 mg po daily, Zocor 20 mg po daily, Allegra 180 mg po daily, Cimetidine 300 mg po bid, Prednisone 50 mg po bid, Norvasc 10 mg daily, Benadryl as needed. ALLERGIES: NOTED TO SOME SINUS MEDICATION BUT HE IS NOT SURE EXACTLY WHICH ONE AND IT CAUSES A RASH. FAMILY HISTORY: Noncontributory. No history of hives that he recalls.
IT|GENERAL ENGLISH|IT|215|216|HOSPITAL COURSE|However, given patient's history of 5-vessel CABG 8 years prior, it was decided the patient should under a dobutamine stress echocardiogram. The study was within normal limits. An EKG and studies were all negative. IT was decided to continue the patient on aspirin, betablocker, statin and ACE inhibitor. The only new addition was Norvasc 5 mg p.o. every day.
IT|GENERAL ENGLISH|IT|199|200|ALLERGIES|5. Lipitor 10 mg po q hs. ALLERGIES: PENICILLIN, ADHESIVE TAPE. THE PATIENT HAD ADHESIVE TAPE ON HIM FOR THE VARIOUS TUBES THIS HOSPITALIZATION AND HE HAD A VERY EYRHTEMATOUS RASH THAT WAS ITCHY AND IT WAS TREATED WELL WITH BENADRYL. LABORATORY DATA: Lipase was 1,053. Triglycerides 1,915. Amylase of 163.
IT|information technology|(IT)|199|202|SOCIAL HISTORY|PAST MEDICAL HISTORY: Musculoskeletal chest pain on _%#MMDD2004#%_ (see below). CURRENT MEDICATIONS: None. ALLERGIES: Sulfa. SOCIAL HISTORY: He does not smoke. He works in the information technology (IT) field. He is currently married and has a child. REVIEW OF SYSTEMS: ENT: Positive for acute sinusitis. The patient had a history of left anterior chest pain on _%#MMDD2004#%_ and was diagnosed with musculoskeletal chest pain by Dr. _%#NAME#%_.
IT|GENERAL ENGLISH|IT|120|121|IDENTIFICATION|See his dictation. ALLERGIES: 1. TORADOL. 2. HALDOL. 3. TRAZODONE. REGARDING THE USE OF TRAZODONE, UPON TALKING TO HIM, IT WAS DISCOVERED THAT HE WAS NOT ACTUALLY ALLERGIC TO IT AND IT WAS REORDERED DURING HIS STAY. LABORATORY: He had labs drawn on admission. They were essentially within normal limits.
IT|GENERAL ENGLISH|IT|129|130|IDENTIFICATION|3. TRAZODONE. REGARDING THE USE OF TRAZODONE, UPON TALKING TO HIM, IT WAS DISCOVERED THAT HE WAS NOT ACTUALLY ALLERGIC TO IT AND IT WAS REORDERED DURING HIS STAY. LABORATORY: He had labs drawn on admission. They were essentially within normal limits. He did have urine for drug screening and that was positive for cocaine.
IT|information technology|IT|272|273|PRESENTING PROBLEM|Did fairly well when she stayed home raising her daughters, volunteered without social, but generally went to venues that were well known to her and that were structured in a way where she could tolerate them. After the children grew up and left the household, trained in IT for networking but was unable to keep a job in that because she would get very overwhelmed, start feeling restless, worried, and then this would quickly go into feeling overwhelmed, panic, and would shake, sweat, feelings of doom, would actually have to leave the area.
IT|information technology|IT|126|127|PRESENTING PROBLEM|Most recent employment has been with Natural Spaces, a company for which she answers the phones, does reception work and some IT work. She has been able to tolerate that fairly well, but recently has been getting the same sorts of symptoms, feeling restless, overwhelmed, panic, not able to perform at work.
IT|information technology|IT|143|144|SOCIAL HISTORY|FAMILY HISTORY: Remarkable for diabetes. SOCIAL HISTORY: His wife and 2 daughters live in South Carolina. He works full-time recruiting for an IT firm living in Minnesota since 2005. He has also had pain management treatments at _%#CITY#%_ _%#CITY#%_ as well as South Carolina as well as the _%#CITY#%_ area.
IT|GENERAL ENGLISH|IT|212|213|PHYSICAL EXAMINATION|LUNGS: Clear to auscultation bilaterally. CARDIOVASCULAR: Revealed a regular rate and rhythm, normal S1, S2; no S3, S4, or murmurs. ABDOMEN: Positive bowel sounds, nondistended, soft; no organomegaly, no masses. IT was mildly tender in the suprapubic region. EXTREMITIES: Reveal no cyanosis, clubbing, or edema. SKIN: No rashes noted. NEUROLOGIC: The patient was alert and oriented.
IT|GENERAL ENGLISH|IT|154|155|RECOMMENDATIONS|Her diabetes may be playing a role in her susceptibility to an oral infection. At this point, I think Clindamycin intravenous is the best choice for her. IT WOULD BE NICE TO USE UNASYN, BUT IN LIGHT OF HER PENICILLIN ALLERGY, THIS SHOULD BE AVOIDED. Typically, I also like to use a short course of intravenous Decadron for inflammation.
IT|ischial tuberosity|IT|148|149|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Patient is a 57-year-old male who is status post debridement and right posterior flap closure on _%#MMDD#%_ for a right IT decubitus. Dr. _%#NAME#%_ has asked for medical consultation to manage patient's medical issues. PAST MEDICAL HISTORY: 1. C5-6 quadriplegia status post motor vehicle accident in 1980 for which he had a C5-6 fusion (A) Decubitus status post hip fracture for which he has received conservative therapy for one year now (AutoLogel, WoundVAC, prisma) with no evidence of osteomyelitis on x-ray _%#MMDD2006#%_.
IT|GENERAL ENGLISH|IT|156|157|ALLERGIES|1. Insulin dependent diabetes mellitus. 2. Partial amputation, distal right great toe. ALLERGIES: PENICILLIN-DOES NOT KNOW WHAT KIND OF REACTION AS HE SAYS IT HAPPENED WHEN HE WAS A CHILD. SOCIAL HISTORY: Retired and lives at home. Married. FAMILY HISTORY: Noncontributory.
IT|iliotibial|IT|181|182|PHYSICAL EXAMINATION|He has ankle strength with plantar flexion. Dorsiflexion, inversion, and eversion are all 5/5. Trochanteric area and bursa area are nontender. There is a slight tenderness down the IT band about midway down the thigh. IT band testing shows normal flexibility. ASSESSMENT: Low back pain with radiculopathy into the right lower extremity to the lateral thigh.
IT|GENERAL ENGLISH|IT|172|173|ALLERGIES|Others are negative. ALLERGIES: SHE HAS A LISTED ALLERGY TO ASPIRIN, CODEINE, LIPITOR. SHE ALSO STATES THAT SHE HAS NOT HAD AN ALLERGIC REACTION TO ASPIRIN BUT HAS AVOIDED IT BECAUSE She HAD ULCERS BECAUSE OF THAT MEDICATIONS: Those include dexamethasone which she received actually in the emergency room, Versed, morphine and Compazine but the patient continues to have symptoms that she had.
IT|GENERAL ENGLISH|IT.|128|130|ALLERGIES|7. Isordil. 8. Neurontin. 9. Prednisone, question the dose. ALLERGIES: PENICILLIN AND SULFA, NOT CERTAIN OF THE SIDE EFFECTS TO IT. ITI S NOT ANAPHYLACTIC BY HISTORY. SOCIAL HISTORY: Lives alone. Denies smoking or alcohol. FAMILY HISTORY: Family history is reviewed with her.
IT|GENERAL ENGLISH|IT|261|262|ALLERGIES|2) Toprol. 3) Celexa. 4) Lisinopril. ALLERGIES: THE PATIENT IS NOT KNOWN TO HAVE ANY DRUG ALLERGIES, ALTHOUGH THE INITIAL ADMITTING NOTE REFERS TO POSSIBLE ALLERGIES TO ZOCOR AND CELEXA; THIS WOULD HAVE TO BE CONFIRMED. PREVIOUS ER NOTE REFERS TO NO ALLERGIES. IT IS MENTIONED IN THE ER NOTE OF _%#MM#%_ _%#DD#%_, 2002 THAT DUE TO THE PATIENT'S RASH HIS ZOCOR AND CELEXA SHOULD BE DISCONTINUED, SO PRESUMABLY THE PATIENT IS NOT ON THAT MEDICATION AT THE PRESENT TIME.
IT|GENERAL ENGLISH|IT|145|146|ALLERGIES|5) Darvocet as needed for pain. 6) Tylenol as needed for pain. 7) Fiorinal. ALLERGIES: LISTED AS PENICILLIN. SHE RECEIVED ANCEF POSTOPERATIVELY, IT WOULD SEEM WITHOUT DIFFICULTY. FAMILY HISTORY: Father died of lung cancer, no premature ischemic disease.
IT|GENERAL ENGLISH|IT|123|124|IMPRESSION|5. SULFA ALLERGY, PENICILLIN ALLERGY WITH QUINOLONES NOW LISTED AS WELL. SHE HAD AN APPARENT REACTION TO TEQUIN, ALTHOUGH, IT IS QUESTIONABLE. 6. Depression/anxiety/somatization disorder. Obviously makes interpretation of the overall clinical illness difficult currently. PLAN: 1. Check a CT scan of the chest in addition to the abdomen.
IT|GENERAL ENGLISH|IT|219|220|ALLERGIES|MEDICATIONS: Have included Zometa, Aranesp. The patient neither smokes cigarettes nor drinks alcohol on a regular basis. ALLERGIES: THE PATIENT HAVE SOME ALLERGIES TO ANTIBIOTICS, HOWEVER, SHE CANNOT RECALL THE NAME OF IT FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: I MUST NOTE THAT THE PATIENT DOES HAVE A DNR/DNI STATUS.
IT|GENERAL ENGLISH|IT|226|227|IMPRESSION|1. This is a patient with a mechanical mitral valve in whom special precautions are needed prior to his surgery, as I have outlined in detail above. This has been outlined to Dr. _%#NAME#%_ as well, on two occasions by phone. IT is highly unlikely this patient can have surgery tomorrow, as the patient is fully anticoagulated at 2.58 and the INR can not be reversed because of the risk of valve thrombosis.
IT|intertrochanteric|IT|155|156|X-RAYS|Strength in the ankle is 5 out of 5 and equal compared to the contralateral side. X-RAYS: Right hip, AP pelvis, and lateral show a minimally displaced low IT fracture. ASSESSMENT: Right IT fracture with subtrochanteric extension. PLAN: I have discussed with the patient the risks, benefits, the advantages, and the disadvantages and complications regarding the operative treatment versus nonoperative treatment of the right hip pain.
IT|GENERAL ENGLISH|IT|273|274|ALLERGIES|13) Elevated PSA. 14) Edema. ALLERGIES: MULTIPLE, INCLUDING PLETAL, PLAVIX, AMOXICILLIN, LEVAQUIN, MICRONASE, PRINIVIL, GENTAMICIN, PENICILLIN, TETRACYCLINE, SULFA, VANCOMYCIN, CIPRO AND TOBRA. HOWEVER, THE PATIENT HAS BEEN RECENTLY ON CIPRO WITHOUT DIFFICULTY. APPARENTLY IT CAUSED A LOW WHITE COUNT IN THE PAST, AND I WILL BE CHECKING A WHITE COUNT TODAY. MEDICATIONS: 1) Cozaar 100 mg daily. 2) Lasix 40 mg daily.
IT|information technology|IT|206|207|SOCIAL HISTORY|He was seen at the Oxboro Clinic for heart murmur a few months ago and was instructed simply to be sure to get antibiotic prophylaxis with dental work. SOCIAL HISTORY: The patient is single. He is laid off IT professional, trained in computer/accounting/business administration. Presently, he works in a rehabilitation center with physically and mentally challenged patients.
IT|intrathecal|IT|95|96|HPI|Exam: Lethargic, palpable neck node on right diplopia. Assessment and Plan: Patient will start IT chemotherapy. Palliative radiation will be started to brain and Waldeyer's ring and nasopharynx. Neck CT is recommended.
IT|information technology|IT|237|238|SOCIAL HISTORY|MEDICATIONS: 1. Diflucan. 2. Bactrim. 3. Insulin. SOCIAL HISTORY: The patient smoked one pack per day for 30 years and quit smoking one year ago. The patient does not drink alcohol. He lives with his wife and children. The patient is an IT specialist. FAMILY HISTORY: Significant for diabetes mellitus and heart disease.
IT|GENERAL ENGLISH|IT|152|153|ASSESSMENT  AND PLAN|6. CODE STATUS. I BELIEVE THE PATIENT IS CURRENTLY FULL CODE AT PRESENT. HE MAY HAVE A LIVING WILL AND THE SOCIAL WORKER IS CALLING HIS FAMILY TO BRING IT IN IF THAT IS THE CASE. 7. Right lower lobe pneumonia. The patient is afebrile and on azithromycin already. His white count is fine. a. Continue azithromycin.
IT|GENERAL ENGLISH|IT|195|196|MEDICATION ALLERGIES|4) Trazodone 75 mg q h.s. 5) Alprazolam 0.25 mg q h.s. or q4-6h p.r.n. MEDICATION ALLERGIES: 1) CODEINE (THE PATIENT REPORTS BECOMING NAUSEATED WITH HYPEREMESIS FOLLOWING THE USE OF CODEINE). 2) IT IS ALSO IMPORTANT TO NOTE THAT THE PATIENT HAS A HISTORY OF ALLERGIC REACTION TO NICKEL (METAL). FAMILY HISTORY: The patient's biological parents are still alive and well.
IT|information technology|IT|111|112|SOCIAL HISTORY|PAST MEDICAL HISTORY: 1) Glaucoma. 2) Multiple surgeries. Allergies: None. Alcohol: He denies. SOCIAL HISTORY: IT consultant. Three children. Divorced. Lives in an apartment in _%#CITY#%_ _%#CITY#%_. EXAM: T-max: 100.3. BP: 149/97. P: 87. Room air saturation 97%. Skin without rash. Cranial nerves intact.
IT|intrathecal|IT|224|225|HISTORY OF PRESENT ILLNESS|Her chemotherapy per CLGB protocol ended in _%#MM2000#%_. Unfortunately, the patient recurred in her bone marrow in _%#MM2002#%_. At that time she had no evidence of CNS disease. The patient was treated with hyper-CVAD with IT methotrexate, and again achieved clinical remission. The patient has been on maintenance chemotherapy, which has been discontinued, with a plan for further treatment with bone marrow transplantation at that time.
IT|information technology|IT|151|152|RECOMMENDATION|We thoroughly updated her family history during our genetic counseling session. _%#NAME#%_ works as an engineer and her husband _%#NAME#%_ works as an IT project manager. There were no updates from the family history, or nothing overtly significant that was reviewed before. _%#NAME#%_ has had her blood drawn for cystic fibrosis carrier screening, which was negative, which reduces her chance to have a baby with cystic fibrosis.
IT|GENERAL ENGLISH|IT|174|175|ALLERGIES|5. Hypertension, newly diagnosed on this admission. 6. cholesterol unknown. 7. BPH. MEDICATIONS: He is not sure. He thinks he was on Hytrin or Flomax on admission ALLERGIES: IT SOUNDS LIKE HE HAS ALLERGIES TO NONSTEROIDAL ANTI-INFLAMMATORY AGENTS BUT HE WAS NOT CERTAIN. SOCIAL HISTORY: He is married. He works selling John-Deere Equipment.
IT|information technology|IT|286|287|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Dysarthria. HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old male with no significant past medical history, although his wife tells me he has probably had a long history of untreated hypertension who presents today with dysarthria. He was working at his job in IT and became confused. He had no history of hypertension per records but his wife says that he has often been hypertensive and that he was even hypertensive when they met 20 years ago.
IT|information technology|IT,|283|285|SOCIAL HISTORY|The patient is slow and somnolent. PAST MEDICAL HISTORY: Right eye, he had a bee-bee gunshot into his eye and he has been essentially blind in the right eye since he was a child. MEDICATIONS none. ALLERGIES: NONE. SOCIAL HISTORY: He is a nonsmoker, no alcohol, no drugs. He works in IT, he is married. He has a son. FAMILY HISTORY: Noncontributory REVIEW OF SYSTEMS: Unable to really obtain secondary to his depressed mental status and some dysarthria/aphasia.
IT|information technology|IT|231|232|SOCIAL HISTORY|FAMILY HISTORY: No history of malignancy in immediate relatives. SOCIAL HISTORY: The patient is married and lives with her husband. She has never been pregnant. Onset of menses at age 12. Currently, she works at Wells Fargo in the IT Department. She does not use tobacco. She drinks an occasional glass of wine. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Cyclosporin. 2. Imuran.
IT|intrathecal|IT|137|138|HISTORY OF PRESENT ILLNESS|The patient developed new severe pain to his back, which was determined to be secondary to multiple vertebral replacement with tumor. An IT pump was placed yesterday for chronic pain control as he was suffering significant side effects of the high-dose narcotic therapy he had been previously taking, including extreme sedation and constipation.
IT|intrathecal|IT|141|142|ASSESSMENT AND PLAN|They were stable compared to the last exam. ASSESSMENT AND PLAN: 1. Metastatic lung cancer with intractable pain secondary to metastases. An IT pump has been placed by Dr. _%#NAME#%_. Pain management will be managed by Dr. _%#NAME#%_. 2. Urinary retention. Likely related to anesthesia and IT pump. The patient will again attempt to void his bladder today.
IT|ischial tuberosity|IT|159|160|HISTORY OF PRESENT ILLNESS|I was asked by Dr. _%#NAME#%_ to see the patient for internal medicine consult. Currently the patient was scheduled for debridement and flap revision of right IT decubitus ulcer but the surgery was postponed secondary to hypotension in the preop area. Apparently the blood pressure was approximately in the 80 range over 50.
IT|GENERAL ENGLISH|IT|134|135|ALLERGIES|9) Zyprexa 2.5 mg p.o. q h.s. 10) Paxil 20 mg daily. 11) Ambien 5 mg h.s. ALLERGIES: PENICILLIN. SHE HAS MULTIPLE DRUG SENSITIVITIES; IT IS UNCLEAR TO ME WHICH SHE IS ALLERGIC TO, LISTED AS PENICILLIN, DARVOCET, OXYCONTIN, ERYTHROMYCIN, TERRAMYCIN, NEURONTIN, AMITRIPTYLINE, DILANTIN, TEGRETOL, TRILEPTIL, IMIPRAMINE, SINEMET, KLONOPIN AND MIRAPEX.
IT|GENERAL ENGLISH|IT|99|100|ALLERGIES|5. Right bundle branch block. 6. Asthma. 7. Hyperlipidemia. ALLERGIES: LISTED AS CONTRAST DYE, BUT IT HAS BEEN GIVEN WITHOUT REACTION SINCE THEN. NO ANTIBIOTIC ALLERGIES LISTED. SOCIAL HISTORY: He is married. His wife is here with him currently.
IT|intrathecal|IT|172|173|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: ALL CSF+ HPI: Multiple prior chemo regimens and IT chemo Exam: No focal deficits. Assessment and Plan: Recommend XRT to spine to try to resolve area of abnormality by MRI.
IT|iliotibial|IT|123|124|ASSESSMENT|There is no allodynia to that area, but there is hyperalgesia there. ASSESSMENT: 1. Myofascial pain in particular over the IT band on the right. 2. This is in the context of chronic pain from fibromyalgia and degenerative disk disease with spondylosis and osteoarthritis.
IT|iliotibial|IT|238|239|ASSESSMENT/PLAN|Given his relatively minimal trauma history which seems to have preceded this event to suspect soft tissue injury above bone injury. Pending negative x-ray findings, would recommend heat therapy as well as PT for gentle stretching of the IT band. The patient understands that we will follow up following x-ray reading. We will be happy to follow this patient for his right hip concerns.
IT|intrathecal|IT|240|241|ASSESSMENT/PLAN|2. Thoracolumbar spine x-ray showed the pump present within the right anterior abdominal wall, severe degenerative change within the left hip joint, and grade I anterolisthesis within the lower lumbar spine. ASSESSMENT/PLAN: 1. Status post IT pump placement per Dr. _%#NAME#%_. 2. MS per Dr. _%#NAME#%_. 3. Tachycardia probably secondary to MS verus medications. The patient is asymptomatic. We will continue to monitor.
IT|GENERAL ENGLISH|IT|157|158|PAST MEDICAL HISTORY|ALLERGIES: MULTIPLE MEDICATION ALLERGIES INCLUDING ANTIBIOTICS. HAS HAD SULFA RASH. PENICILLIN CAUSED ANAPHYLACTIC TYPE REACTION ALTHOUGH BY HER DESCRIPTION IT IS SOMEWHAT QUESTIONABLE SOUNDING. SHE HAS TOLERATED CEPHALOSPORIN SINCE THAT TIME. LEVAQUIN HAS CAUSED RASH AND THROAT RELATED PROBLEMS AS WELL.
IT|GENERAL ENGLISH|IT|206|207|ALLERGIES|5. Combivent two puffs qid prn for asthma. 6. Provera q day for amenorrhea. ALLERGIES: 1. PATIENT DOES HAVE A LATEX SENSITIVITY/ALLERGY (CAUSES RASH). 2. CLEOCIN (CAUSES RASH). 3. CEPHALEXIN (CAUSES RASH). IT SHOULD BE NOTED THAT PATIENT HAS NOT HAD OTHER CEPHALOSPORINS AND IS UNSURE WHETHER OR NOT SHE HAS AN ALLERGIC REACTION TO ANY OTHER GENERATION OF CEPHALOSPORINS.
IT|GENERAL ENGLISH|IT|132|133|ALLERGIES|No significant travel or recent exposures. ALLERGIES: LISTED AS PENICILLIN, BUT DETAILS NOT AVAILABLE. ON TALKING WITH THE PATIENT, IT APPEARS TO HAVE BEEN AN AMOXICILLIN REACTION IN THE PAST. FAMILY HISTORY: Noncontributory to the current illness. MEDICATIONS PRIOR TO ADMISSION: 1) Baclofen.
IT|immature-to-total neutrophil|IT|134|135|MEDICATIONS|I will get the details from our office as far as his basals, but typically basals are around 1 unit per hour and 1 per 7 grams on his IT ratio and around 1 per 40 above 140 on his correction. In addition, he was on hydrochlorothiazide, Lisinopril, Lasix, metoprolol, Lumigan eye drops, aspirin, Plavix, ____ and Protonix.
IT|GENERAL ENGLISH|IT|146|147|LABORATORY DATA|Well-healed surgical scars and no evidence for any hernias today. LABORATORY DATA: Include a white count of 8.7. Her bilirubin was initially 3.5; IT IS 2.9 today. LFTs were also elevated. Please refer to those in the chart. Ultrasound as noted above. ERCP was completed. No actual stones were found, but sphincterotomy was done.
IT|GENERAL ENGLISH|IT|212|213|ADVANCE DIRECTIVES|14. P.r.n. Zofran, which has not been used. ADVANCE DIRECTIVES: DO NOT RESUCITATE, DO NOT ATTEMPT RESUCITATION. SHE DOES HAVE A LIVING WILL WHICH IS ON THE CHART, WHICH INDICATES HER SON IS HER HEALTHCARE PROXY. IT ALSO INDICATES ON THE CHART THAT HER VALUE AT THE TIME OF THE HEALTHCARE DIRECTIVE WAS THAT SHE WANTED TO NOT TAKE FOOD ANY OTHER WAY THAN BY MOUTH.
IT|information technology|IT|132|133|SOCIAL HISTORY|SOCIAL HISTORY: The patient is a 40-year-old Caucasian female who is currently married and has one child. She works full-time as an IT manager in an accounting firm. She is a former smoker who quit back in 1986 and has rare alcohol use, no other drug use is noted.
IT|information technology|IT|251|252|SOCIAL HISTORY|5. Tylenol q.4-6 h. p.r.n. ALLERGIES: Vicodin, which makes him itchy; Percocet also makes him itchy; Dyazide makes him tachycardic and flushed. SOCIAL HISTORY: He is currently married. He does have 2 children. He lives in _%#CITY#%_ and works for the IT department at a law firm. He currently does not smoke tobacco, drinks alcohol occasionally, and does not use any street drugs.
IT|GENERAL ENGLISH|IT|100|101|ALLERGIES|There is no family history significant for cancer, diabetes, or hypertension. ALLERGIES: CODEINE AS IT CAUSES GI UPSET. REVIEW OF SYSTEMS: Negative for constitutional symptoms, HENT, cardiovascular, pulmonary, GI, GU, psychiatric, neurologic, endocrine, skin, and musculoskeletal, except as otherwise noted above.
IT|GENERAL ENGLISH|IT|304|305|ALLERGIES|ALLERGIES: LISTED AS AUGMENTIN, PERCOCET, AND MORPHINE BUT ACTUALLY ALL OF THEM ARE GI INTOLERANCE TYPE ISSUES RATHER THAN TRUE DRUG RASHES. OBVIOUSLY SHE HAS SOME TYPE OF ALLERGIC REACTION OCCURRING CURRENTLY AND MOST LIKELY IS ANTIBIOTIC RELATED, DIFFICULT TO TELL BY TEMPORAL OR OTHER FACTORS WHETHER IT IS VANCOMYCIN, CLINDAMYCIN OR CIPRO. FAMILY HISTORY: Significant for coronary artery disease. No history of tuberculosis in the family.
IT|GENERAL ENGLISH|IT|395|396|ALLERGIES|The injury to the knee was on _%#MM#%_ 10. CHRONIC MEDICAL PROBLEMS: 1) History of hyperlipidemia. 2) Of course, the atherosclerotic coronary disease. 3) Depression. ALLERGIES: HE STATES TO CT SCAN DYE, ALTHOUGH, INTERESTINGLY ENOUGH, HE TOOK THE TWO ANGIOGRAMS AND MAY HAVE BEEN TREATED WITH BENADRYL; HE IS NOT AWARE OF ANYTHING ELSE, ALTHOUGH CERTAINLY HE MAY HAVE ALSO USED CORTICOSTEROIDS; IT IS IMPOSSIBLE TO TELL IN DISCUSSION WITH HIM. SOCIAL HISTORY: Reviewed by Dr. _%#NAME#%_. FAMILY HISTORY: Reviewed and is unremarkable for premature ischemic disease.
IT|information technology|IT|143|144|SOCIAL HISTORY|MEDICATIONS: None. ALLERGIES: Penicillin. SOCIAL HISTORY: This gentleman is married, living with his wife. Unfortunately he lost his job as an IT professional recently. He smokes 2-3 cigarettes daily. He denies use of alcohol or other substances. FAMILY HISTORY: Not obtained. REVIEW OF SYSTEMS: Negative for headaches, fevers, chills, dyspnea, chest pain, abdominal pain, nausea, vomiting, constipation, diarrhea, or urinary complaints.
IT|information technology|IT.|251|253|SOCIAL HISTORY|His symptoms have not worsened it was weaned off. The patient denies chronic medical problems or previous hospitalizations other than for kidney stones as a fifth grader. MEDICATIONS: None currently. SOCIAL HISTORY: The patient is single. He works at IT. He denies chemical use. FAMILY HISTORY: _________________ is unremarkable. PHYSICAL EXAMINATION: On examination, he is a pleasant, tall, very anxious-appearing male whose clothes are quite baggy.
IT|iliotibial|IT|153|154|PHYSICAL EXAMINATION|EXTREMITIES: No cyanosis, clubbing or edema. Right knee - upon extension there is some clicking/popping felt and heard. This is presumed to be along the IT band. SKIN: No rashes are noted. NEUROLOGIC: Alert and oriented. Cranial nerves II through XII are grossly intact. Sensation is intact to light touch. Strength 5/5 bilaterally. Gait is within normal limits.
IT|iliotibial|IT|165|166|ASSESSMENT AND PLAN|Will observe blood pressure on a daily basis. 4. Right lateral knee pain, most likely secondary to overuse versus osteoarthritis. It is most likely secondary to the IT band being tightened causing the bursa to become inflamed. However, the patient denies any need for treatment at this time. She denies she uses anything at home to help treat this.
IT|GENERAL ENGLISH|IT|90|91|ALLERGIES|The remainder of social history is unobtainable. FAMILY HISTORY: Unobtainable. ALLERGIES: IT DOES NOT APPEAR THAT THE PATIENT HAS ANY KNOWN DRUG ALLERGIES. CURRENT MEDICATIONS: 1) Pantoprazole 40 mg IV q day. 2) Zosyn 3.75 gm IV q8h.
IT|GENERAL ENGLISH|IT|167|168|SUMMARY OF CASE|She has not noticed any articular problems with rashes nor has she had any significant edema. ALLERGIES: SHE HAS NO SPECIFIC MEDICATION ALLERGIES IDENTIFIED, ALTHOUGH IT DOES SOUND LIKE SHE HAS SOME GASTROINTESTINAL UPSET WHEN TAKING NUMEROUS MEDICATIONS. SOCIAL HISTORY: She is not a smoker, not a drinker.
IT|GENERAL ENGLISH|IT|232|233|DRUG SENSITIVITIES|3. Paxil at bedtime. 4. He is diagnosed with Autism and pervasive developmental delay. FAMILY HISTORY: Known at this time. DRUG SENSITIVITIES: HE IS ALLERGIC TO PEANUTS WHICH GIVE HIM HIVES, BENADRYL IS NOT AN ALLERGIC REACTION BUT IT MAKES HIM HYPERACTIVE. REVIEW OF SYSTEMS: Essentially normal except for history of allergy and hayfever and use of albuterol inhaler prn for hayfever.
IT|information technology|IT|159|160|HISTORY OF PRESENT ILLNESS|I was requested by Dr. _%#NAME#%_ for pre-operative clearance on patient with kidney stone. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 39-year-old IT director with a history of kidney stones. He describes having ESWL four years ago with Dr. _%#NAME#%_. He does not recall the exact chemical composition of his stone, but has not been on any specific treatment, either diet or medicinal since that time.
IT|information technology|IT|168|169|SOCIAL HISTORY|5. Prazosin 1 mg daily for nightmares. ALLERGIES: Lithium. SOCIAL HISTORY: _%#NAME#%_ lives with her partner. She denies chemical use in general. She is a director for IT for United Way. PHYSICAL EXAMINATION: GENERAL: She is a pleasant female in no distress.
IT|information technology|IT.|235|237|SOCIAL HISTORY|16. Cyclosporin. 17. Methylprednisone. SOCIAL HISTORY: Quit smoking about a 1-1/2 years ago and no history of alcohol abuse. The patient is married and lives in _%#CITY#%_, Michigan with his wife _%#NAME#%_ and 2 children. He works in IT. FAMILY HISTORY: Daughter diagnosed with CMML and underwent match unrelated donor transplant about 2 years ago.
IT|information technology|IT|187|188|PATIENT NARRATIVE|His parents are deceased. No significant family nearby. The patient lives alone but has been able to function up until the hospitalization. PATIENT NARRATIVE: The patient is a manager of IT at Target Corporation a job which he enjoys. He when asked what he is Most proud of he said that what he is most proud of are at that people he was helped in the careers he has helped develop and he did not realize this until he became ill and people began to send him cards and talk to him about you know what his support and mentoring meant to them.
IT|GENERAL ENGLISH|IT|183|184|ALLERGIES|ALLERGIES: LISTED AS NITROFURANTOIN, FOSAMAX, LEVAQUIN AND SULFA. NOT CLEAR WHAT THE EXACT HISTORY IS ON THESE. I THINK AT LEAST ONE OF THEM WAS CAUSING C. DIFF WHICH OBVIOUSLY MAKES IT NOT AN ALLERGY. SOCIAL HISTORY: Lives in _%#CITY#%_. No recent travel exposures. No one else she has been around has been ill.
IT|intrathecal|IT|119|120|HISTORY OF PRESENT ILLNESS|An extraventricular drain was placed. The cerebrospinal fluid cultures were positive, and he was placed on both IV and IT antibiotics. Postoperatively, he was noted to have right gaze preference. He moved his right upper extremity, but was not noted to have movement in the bilateral lower extremities.
IT|information technology|IT|139|140|SOCIAL HISTORY|MEDICATIONS: None. ALLERGIES: None, however Vicodin makes him sick to his stomach. SOCIAL HISTORY: The patient is a nonsmoker. He works in IT doing computer work. He is married and has two young children. REVIEW OF SYSTEMS: GENERAL: No loss of consciousness.
IT|information technology|IT.|160|162|FAMILY/SOCIAL HISTORY|The patient has a 50 pack year smoking history. He states that he quit smoking in _%#MM#%_ of this year. He is divorced and works for Blue Cross/Blue Shield on IT. REVIEW OF SYSTEMS: HEENT: Negative. Pulmonary: History of pneumonia in the past.
IT|information technology|IT|133|134|HABITS|ALLERGIES: Sulfa. MEDICATIONS: Insulin pump. HABITS: She admits to tobacco use. She denies alcohol or drug abuse. This patient works IT at the hospital. REVIEW OF SYSTEMS: She denies bleeding diathesis. She denies recent steroid use.
IT|information technology|IT,|121|123|SOCIAL HISTORY|Says he has not drank in a couple of weeks. He also smokes marijuana. The patient has a degree in accounting and also in IT, and is currently doing temporary work. The patient is not married and has no children. REVIEW OF SYSTEMS: As noted in the HPI.
IT|GENERAL ENGLISH|IT.|351|353|ALLERGIES|MEDICATIONS: Prior to admission include Lipitor, Robaxin, Ambien and amitriptyline, Imuran and prednisone, Atacand, Diltiazem, I believe she is on some oral antibiotic as well, probably Levaquin by description Imodium for diarrhea which just has just started as well. ALLERGIES: CEFAZOLIN HAS CAUSED A RASH IN THE PAST, HAS NOT BEEN RECHALLENGED WITH IT. SOCIAL/FAMILY HISTORY: No recent travel or exposures. No history of tuberculosis in the family.
IT|iliotibial|IT|142|143|PHYSICAL EXAMINATION|Full range of motion. He has mild pain with patellar groin test on right knee. Right knee was painful to palpation on lateral aspect over the IT band close to the joint line space. He has bruising on the lateral aspect of the patellar area. He has increased anterior translocation of tibia compared to the contralateral side.
IT|intrathecal|IT|161|162|HISTORY OF PRESENT ILLNESS|He was treated per CCG Protocol _%#PROTOCOL#%_ with induction with IdaDCTER. On day 14 there were 3.6 % blasts. His consolidation regimen included IdaDCTER with IT ara-C for 5 doses ending on _%#MMDD2002#%_. In _%#MM#%_, 2002 a bone marrow biopsy and lumbar puncture were obtained prior to going to the next phase of chemotherapy.
IT|intertrochanteric|IT|213|214|X-RAYS|SOCIAL HISTORY: The patient is a nursing home resident. PHYSICAL EXAMINATION: On exam the right lower extremity is shortened and externally rotated. No other signs of orthopaedic trauma. X-RAYS: X-rays show a mid IT fracture. IMPRESSION/PLAN: He will need ORIF. The risks and benefits were discussed with his family, and we will proceed.
IT|information technology|IT|206|207|SOCIAL  HISTORY|9. Cozaar 100 mg p.o. q. day. REVIEW OF SYSTEMS: Negative except what is noted above in history of present illness. SOCIAL HISTORY: He rarely drinks alcohol but is still smoking cigarettes. He works in the IT department of a music company. FAMILY HISTORY: Significant for cardiac disease. He believes some of his grandparents had heart attacks.
IT|information technology|IT|155|156|SOCIAL  HISTORY|ALLERGIES: No known drug allergies. FAMILY HISTORY: Unknown as the patient is adopted. SOCIAL HISTORY: The patient previously worked in computer repair in IT and is retired. He is married and is seen with his wife. He has been living independently. He is a nonsmoker with only a social alcohol history.
IT|intrathecal|IT|80|81|CR.|The patient presented at that time with headaches. The patient was treated with IT chemotherapy through the Ommaya shunt with a good response. He also received a systemic chemotherapy and again achieved CR. On _%#MMDD2003#%_, the patient was seen at Fairview- University Medical Center for a bone marrow transplantation.
IT|intertrochanteric|IT|179|180|IMAGING|PHYSICAL EXAMINATION: On examination, she is comfortable. The left lower extremity is externally rotated and shortened. Neurologically, she is intact. IMAGING: X-rays show a left IT fracture. IMPRESSION/PLAN: We will go ahead with ORIF. Risks and benefits are discussed.
IT|GENERAL ENGLISH|IT|163|164|ALLERGIES|5. Status post ganglion cyst surgery. 6. Appendectomy. 7. Hernia surgery. 8. History of ulcers. ALLERGIES: LISTED AS TEQUIN ON THE HISTORY AND PHYSICAL, ALTHOUGH, IT IS UNCLEAR IF HE TRULY HAS THIS. SOCIAL HISTORY: He works as a cook. He is engaged to be married.
IT|GENERAL ENGLISH|IT,|260|262|ALLERGIES|PAST MEDICAL HISTORY: CHRONIC MEDICAL PROBLEMS: None. SURGERIES: As listed above, except for drainage of a perirectal abscess in 1984. ALLERGIES: HE IS FELT TO BE ALLERGIC TO PENICILLIN. HE WAS IN AFRICA AND THEY SKIN TESTED HIM, AND HE HAD A RASH REACTION TO IT, AND HE HAS CONSIDERED HIMSELF ALLERGIC TO PENICILLIN SINCE. FAMILY HISTORY: Mother died in her 70's. No family history of other premature morbidity or mortality.
IT|GENERAL ENGLISH|IT|187|188|PHYSICAL EXAMINATION|In addition to his tremor, Mr. _%#NAME#%_ has striking generalized weakness which strikes me as being much more pronounced than would be anticipated on the basis of deconditioning alone. IT is conceivable that the recent addition of prednisone in the context of an Intensive Care Unit stay and relative immobility has caused a mild critical care myopathy or steroid myopathy.
IT|GENERAL ENGLISH|IT|221|222|ALLERGIES|4) Hypertension. MEDICATIONS PRIOR TO ADMISSION: 1) Tetracycline. 2) Hydrochlorothiazide. 3) Avapro. 4) Aspirin. ALLERGIES: LISINOPRIL AND AMOXICILLIN CAUSED PRINCIPALLY GASTROINTESTINAL SYMPTOMS IN THE PAST WHEN HE TOOK IT FOR PROPHYLAXIS FOR HIS VALVES. HE HAS BEEN TAKING CLINDAMYCIN ALTERNATIVELY SINCE THEN. SOCIAL HISTORY: Prior cigarette smoker, quit about ten years ago, one or two alcoholic drinks per day.
IT|iliotibial|IT|160|161|ASSESSMENT AND PLAN|Lithium level less than 0.2. ASSESSMENT AND PLAN: 1. Bipolar affective disorder. Treatment per Dr. _%#NAME#%_. 2. Knee pain. The patient was told that this was IT band syndrome by his doctor. The patient only has pain when he is physically active, and he has not been physically active for some time, so he has had no pain for some time.
IT|information technology|IT.|170|172|SOCIAL HISTORY|SOCIAL HISTORY: She lives with her husband in a house in _%#CITY#%_, Minnesota. Her husband works outside of the home but is able to sometimes work in the home. He is in IT. Patient was previously independent with ADLs and mobility. The husband is her primary caregiver. He was assisting her with her medications and did all of the housework and cooking.
IT|intrathecal|IT|198|199|HPI|My key findings: CC: CNS relapse. HPI: Responded to IT therapy 1st relapse, now recurrent with TIA symptoms. Exam: No focal defects. Assessment and Plan: Await BM, if clear, would try to clear with IT chemo then consolidate with craniospinal XRT. Risks, benefits discussed.
IT|information technology|IT|144|145|SOCIAL HISTORY|He has 2 children. One daughter lives locally and a son lives in South Dakota. He denies alcohol or tobacco use. The patient is a supervisor of IT professionals. FAMILY HISTORY: Hypertension. Alcoholism with father. Lung cancer in mother who was a smoker.
IT|information technology|IT|182|183|SOCIAL HISTORY|HABITS: The patient denies alcohol, tobacco, or drug use. SOCIAL HISTORY: The patient is married and lives with her husband _%#NAME#%_ in _%#CITY#%_. Both are employed by the Family IT Consulting Company as managers. FAMILY HISTORY: A three-generation pedigree was taken and was unremarkable for additional factors, which would place a pregnancy at increased risk.
IT|GENERAL ENGLISH|IT|100|101|ALLERGIES|We know of no other significant medical history but no historian is presently available. ALLERGIES: IT APPEARS THE PATIENT HAS NO KNOWN ALLERGIES, ALTHOUGH SHE HAS APPARENTLY HAD AN ADVERSE REACTION TO PERCOCET. She apparently consumes some alcohol although we have no history to help us with this either.
IT|GENERAL ENGLISH|IT|123|124|ALLERGIES|ALLERGIES: PENICILLIN WHICH CAUSES A RASH. MOTRIN, CAUSES SOME GI UPSET. SULFA, POSSIBLY A RASH, SHE IS UNCLEAR AS TO WHAT IT CAUSES. FAMILY HISTORY: Dad had diabetes Type 2, myocardial infarction at age 62 for which he died at age 62.
IT|GENERAL ENGLISH|IT|140|141|ALLERGIES|5. Joint pains. MEDICATIONS: 1. Lipitor 10 mg. 2. Citalopram 20 mg 3. baby aspirin q daily ALLERGIES: THE PATIENT IS ALLERGIC TO PENICILLIN IT CAUSES HIVES. PAST SURGICAL HISTORY: The patient had a testicular mass and a ventral wall hernia repair done in 1999.
IT|GENERAL ENGLISH|IT|187|188|SUMMARY OF RECOMMENDATIONS|We can follow this and see if this offers her any benefit and if well tolerated can be titrated slowly. 3. Code status. The patient is still stating she would like to be full code, "GIVE IT A SHOT" if her heart was to suddenly stop. 4. Proxy identification. The patient identifies her daughter _%#NAME#%_ as her health care proxy should she be in a circumstance where she is not able to make her own health care decisions.
IT|intrathecal|IT|176|177|PLAN|5. This is a very difficult and unfortunate situation. meningeal involvement with nerve root involvement require RT with suboptinmal response. I agree with Dr. _%#NAME#%_ that IT chemo or systemic chemo have limited role in this situation. Total time spent with the patient was about 40 minutes.
IT|intertrochanteric|IT|179|180|HISTORY OF PRESENT ILLNESS|He was weightbearing on the right lower extremity, just not on the left. The patient denies any numbness or shooting pains. Of note, the patient is also status post ORIF of right IT fracture in _%#MM2004#%_, which was also treated with sliding screw and compression plate. The patient expresses no symptoms of the right lower extremity.
IT|intertrochanteric|IT|183|184|PAST SURGICAL HISTORY|8. Depression. 9. Chronic obstructive pulmonary disease. 10. Benign prostatic hypertrophy. 11. Diabetes mellitus insulin dependent. PAST SURGICAL HISTORY: 1. Status post ORIF of left IT fracture in _%#MM2006#%_. 2. Status post ORIF of right IT fracture in _%#MM2005#%_. 3. Status post coronary artery bypass graft in 1997.
IT|intertrochanteric|IT|259|260|ASSESSMENT AND PLAN|These are on hard copy. The sliding cannula is at the level of threads on the screw, however, the hip apex distance is completely unchanged. ASSESSMENT AND PLAN: This is an 82-year-old male with ORIF of left intertochanteric fracture and collapse of his left IT fracture and sliding screw. There is no advanced fracture or progression since _%#MMDD2006#%_. PLAN: My recommendation is that this patient follow up with Dr. _%#NAME#%_ in 10-14 days with new x-rays of his left hip, continued pain management, and the patient should be nonweightbearing on the left lower extremity.
IT|ischial tuberosity|IT|124|125|HISTORY OF PRESENT ILLNESS|Postoperatively, he has had postop anemia and has otherwise been stable. He has been followed by a Wound Care nurse for his IT wound, scrotal wound, and penile wound. The patient has been seen by PT and OT and has found his KinAir bed to be the main barrier limiting his bed mobility.
IT|ischial tuberosity|IT|204|205|HISTORY OF PRESENT ILLNESS|The patient has been seen by PT and OT and has found his KinAir bed to be the main barrier limiting his bed mobility. He has been reluctant to do some bed exercises due to the bad situation affecting his IT sores with sliding movement. He has been found to be minimal assist for bed mobility and max assist of two for supine to sit.
IT|ischial tuberosity|IT|127|128|IMPRESSION/RECOMMENDATIONS|IMPRESSION/RECOMMENDATIONS: This is a 72-year-old male, status post left AKA with a history of recently diagnosed diabetes and IT ulceration. He has significantly impaired mobility and ADLs, and functionally he is significantly impaired. His significant barrier at this stage appears to be as he reports his mattress which limits his mobility.
IT|GENERAL ENGLISH|IT|273|274|DISCUSSION|Please see Dr. _%#NAME#%_'s notes in the charting for details regarding the patient's chemical use and psychiatric history and the circumstances leading up to admission. The patient was transferred here from the _%#CITY#%_ Hospital where he was admitted on _%#MMDD2007#%_. IT was felt initially that he had ingested Coricidin, although the patient actually ingested a generic diphenhydramine. He had no significant medical sequelae from his ingestion. He is transferred here for further chemical use assessment.
IT|GENERAL ENGLISH|IT|181|182|ALLERGIES|ALLERGIES: SEPTRA, PENICILLIN, NONSTEROIDALS, ERYTHROMYCIN, TOBRA, CIPRO, ULTRAM, VICODIN, DARVOCET, NEOSPORIN. DETAILS OF THE ANTIBIOTIC ALLERGIES ARE NOT CLEAR. AS STATED BEFORE, IT APPEARS SHE HAS TOLERATED CEPHALOSPORINS AT ONE POINT OR ANOTHER BUT AT ANOTHER POINT THERE WAS CONSIDERATION SHE MIGHT BE ALLERGIC TO THEM AS WELL.
IT|intrathecal|IT|265|266|HISTORY OF PRESENT ILLNESS|He received 2 induction chemotherapy courses with daunorubicin and Ara-C as well as etoposide, followed by a third course, all at Stanford University. He also received an AML protocol with Mylotarg. At the end of this he still had 15% blasts. Chemotherapy included IT prophylaxis with chemotherapy, but no cranial radiation. His chemotherapy ended in _%#MM2005#%_. The patient was transferred to the University of Minnesota Medical Center, Fairview, in _%#MM2005#%_ for an NK study, but he was not considered a candidate because of active infection.
IT|GENERAL ENGLISH|IT,|175|177|ALLERGIES|5. Xalatan eye drops. 6. MS Contin 30 mg q.8h. 7. Nephrocaps one daily. 8. Prednisone 5 mg day. ALLERGIES: ASPIRIN, COMPAZINE, FOSAMAX, MORPHINE IS ALSO LISTED, BUT SHE IS ON IT, LOZOL, MILK PRODUCTS. IT IS UNCLEAR WHAT THE REACTIONS ARE WITH THESE MEDICATIONS. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She is married and lives with her husband.
IT|GENERAL ENGLISH|IT|138|139|ALLERGIES|2) Lexapro. 3) Tamoxifen. 4) Norvasc. 5) Toprol. 6) Lopid. 7) I do not have the exact doses. ALLERGIES: NO KNOWN DRUG ALLERGIES, ALTHOUGH IT APPERED THE CODEINE MADE HER SICK; UNSURE WHETHER THIS WAS THE CODEINE YESTERDAY OR HER INFARCT CAUSING THE NAUSEA AND VOMITING.
IT|intrathecal|IT|83|84|PLAN|Fund of knowledge is good. ASSESSMENT: CNS breast carcinoma. PLAN: The plan is for IT chemotherapy requiring Ommaya reservoir placement. We did review risks of Ommaya reservoir placement, which include infection, bleeding, hematoma, device malfunction and toxicity.
IT|GENERAL ENGLISH|IT|99|100|ALLERGIES|MEDICATIONS: Prior to this admission 1. Flomax 2. Lipitor 3. Percocet 4. Fiber ALLERGIES: CODEINE, IT IS UNCLEAR IF She HAS A PENICILLIN ALLERGY SOCIAL HISTORY: The patient was living at home until her fracture and most recently was at a care facility.
IT|ischial tuberosity|IT|195|196|PLAN|No antibiotics indicated for now. Likely will need surgical intervention for the valve. Await findings before deciding on any more extended antibiotics, but likely they are not needed. The right IT joint area is still problematic, but does not appear to be actively infected either. She is now several weeks off antibiotics and has been culture negative to date.
IT|ischial tuberosity|IT|155|156|HISTORY|She was found to have septic emboli, probably right-sided endocarditis, most likely a tricuspid valve, and also had presumptive ongoing infection of right IT joint. She also had a left shoulder component to the infection, which required an I&D. There was consideration of I&D of her right hip area, but eventually this began to clear up with improvement in her symptoms.
IT|GENERAL ENGLISH|IT.|147|149|ALLERGIES|10) Elavil 25 mg p.o. q h.s. 11) Albuterol inhaler two puffs q.i.d. ALLERGIES: THE PATIENT STATES AS A CHILD SHE HAD PENICILLIN AND GOT HIVES FROM IT. BIAXIN CAUSES NAUSEA AND VOMITING. CODEINE CAUSES NAUSEA. SULFA CAUSES NAUSEA. SHE HAS A LATEX ALLERGY. FAMILY HISTORY: She is a retired CRNA who is active and travels.
IT|GENERAL ENGLISH|IT,|200|202|ALLERGIES|She was stable throughout the emergency room evaluation. She is able to give a relatively good history. ALLERGIES: ASPIRIN AND AUGMENTIN, NOT PENICILLIN, She HAD DIARRHEA AND HAS HAD A MILD RASH FROM IT, She HAS HAD NO RECURRENCES OF IT. MEDICATIONS: 1) Glucotrol. 2) Metformin. 3) Coumadin for atrial fibrillation 4) Lisinopril.
IT|intertrochanteric|IT|156|157|IMPRESSION AND PLAN|PHYSICAL EXAMINATION: Extremity is shortened and externally rotated on her left side. Pulses are intact. Neurologically she is intact. IMPRESSION AND PLAN: IT fracture. Once she is medically cleared, we will go ahead with ORIF. This was discussed with the family.
IT|intertrochanteric|IT|141|142|EXAMINATION|EXAMINATION: Her right lower extremity is externally rotated and shortened. Neurologically she is intact. Pulses are intact. X-rays: Show an IT fracture on the right. IMPRESSION/PLAN: Will need ORIF. INR needs to come down under 1.5. I would not reverse this at this time.
IT|information technology|IT|89|90|SOCIAL HISTORY|5. Zofran. 6. Reglan. 7. Prednisone. 8. Trazodone. 9. Coumadin. SOCIAL HISTORY: He is an IT project manager. He is married. He does not have any children. He does not drink. He does not smoke. FAMILY HISTORY: Paternal grandmother had lung cancer and eye cancer.
IT|GENERAL ENGLISH|IT|116|117|ALLERGIES|6. Aspirin 81 mg daily 7. Amitriptyline 10 mg q.h.s. 8. multivitamin ALLERGIES: VASOTEC, IT CAUSES FACIAL SWELLING, IT SOUNDS LIKE AN ANGIOEDEMA TYPE PICTURE. SOCIAL HISTORY: Nonsmoker, he does drink alcohol occasionally. No drugs.
IT|information technology|IT|109|110|SOCIAL HISTORY|ALLERGIES: The patient states he has no known allergies. SOCIAL HISTORY: The patient is retired, had been an IT consultant. He is married and has children. The patient continues to smoke, approximately half a pack of cigarettes each day and also has 1-2 drinks per day.
IT|GENERAL ENGLISH|IT|202|203|ALLERGIES|2) Appendectomy in 1947. 3) Childhood tonsillectomy. 4) Also in 1963 she underwent removal of a vulvar tumor; no recurrences. ALLERGIES: NONE KNOWN, BUT SHE IS AFRAID TO TAKE MORPHINE BECAUSE SHE FEELS IT WAS RELATED TO HER HUSBAND'S DEATH WHILE AT THE VA. MEDICATIONS ON ADMISSION: 1) Coumadin 4 mg alternating with 3 mg.
IT|GENERAL ENGLISH|IT|182|183|ALLERGIES|1. PATIENT REPORTS SIGNIFICANT ALLERGIES TO LATEX. 2. PENICILLIN CAUSES SWELLING AND SYSTEMIC RASH. 3. SULFA AND IBUPROFEN CAUSED DRY MOUTH, NASOPHARYNX SWELLING, FULL BODY RASH. 4. IT IS ALSO NOTED THAT PATIENT HAS A SEVERE ALLERGY TO SEAFOODS (SHELLFISH)-EVEN IF PATIENT IS EXPOSED TO DROPLETS OR VAPORS IN THE AIR THE PATIENT HAS SIGNIFICANT REACTIONS.
IT|GENERAL ENGLISH|IT|212|213|PHYSICAL EXAMINATION|No previous history of urinary retention. PHYSICAL EXAMINATION: Reveals bladder to be slightly distended. The Foley catheter is in the penis, however, the balloon is right out in the submeatal fossa navicularis. IT is quite tender and there is some bleeding at the meatus. Testicles are unremarkable. A 25 gauge needle was carefully advanced into the urethra alongside the catheter until the balloon was encountered.
IT|iliotibial|IT|126|127|PAST SURGICAL HISTORY|No sign of recurrence. 7. GERD controlled. 8. History of benign colon poly removed on _%#MM2006#%_. PAST SURGICAL HISTORY: 1. IT band release on right side in _%#MM2009#%_. 2. CABG in 1994 and 2 stent placements. 3. Exploratory laparotomy in 1993.
IT|iliotibial|IT|153|154|ASSESSMENT/PLAN|Remainder of BMP was within normal limits. EKG showed a normal sinus rhythm with left axis deviation. No acute findings. ASSESSMENT/PLAN: 1. Status post IT band release. Plan per Dr. _%#NAME#%_. 2. Hypertension controlled. We will continue current medications. 3. Type II diabetes fairly well controlled. We will have glucose checks q.i.d. before meals and cover these with Regular insulin using an insulin sliding scale.
IT|information technology|IT|117|118|ALLERGIES|2. Occasionally Advil. ALLERGIES: No known drug allergies. Denies alcohol, tobacco or drug abuse. This patient is an IT worker here at Fairview. He lives in the area. REVIEW OF SYSTEMS: Negative for bleeding problems. No recent steroid use.
IT|GENERAL ENGLISH|IT|254|255|ALLERGIES|She moved back to Minnesota from _%#CITY#%_ where she been living with her boyfriend with whom she is just very recently broken up. ALLERGIES: TO SULFA, COMPAZINE, IMITREX, ALEVE, CODEINE, MORPHINE AND TRAMADOL. SHE WAS GIVEN DARVOCET BUT DOES NOT THINK IT HELPS HER AT ALL. REVIEW OF SYSTEMS: She has had chronic difference in the feeling on her left body compared to the right since her previous surgeries.
IT|information technology|IT|146|147|SOCIAL HISTORY|He drinks one-and-a-half pints of alcohol a day. He is currently laid off from work. Prior to that he worked for _______ Food Distribution in the IT Department. No chemical exposures. FAMILY HISTORY: Father died at age 40 with esophageal cancer.
IT|information technology|IT|158|159|SOCIAL HISTORY|MEDICATIONS: None. ALLERGIES: Penicillin. SOCIAL HISTORY: He is a 1 1/2 pack per day smoker for 40 years. He works in a in Nash-Finch food distributor in the IT department. No chemical exposures. No high risk sexual behavior to include prostitutes or sex with males. He drinks daily one drink a day, some times two.
IT|information technology|IT|262|263|SOCIAL HISTORY|2. Tonsillectomy 3. Adenoidectomy. REVIEW OF SYSTEMS: Negative for pneumonia, tuberculosis, bronchitis, asthma ALLERGIES: Penicillin SOCIAL HISTORY: Smokes 1 1/2 packs per day times 40 years. Alcohol - 1-2 drinks per day. Works at Nash-Finch food distributor in IT department. FAMILY HISTORY: Father died at age 40 of esophageal carcinoma.
IT|ischial tuberosity|IT|196|197|PHYSICAL EXAMINATION|LUNGS: Clear bilaterally. ABDOMEN: Soft, nontender, no particular flank tenderness. EXTREMITIES/NEUROLOGIC: Multiple sclerosis changes neurologically and some mental status changes occurring. The IT ulcers as described by ET nurse. LABORATORY: White count currently in the 3000s. She has been as low as 1500-1700 previously, with a bone marrow being negative.
IT|GENERAL ENGLISH|IT|127|128|ALLERGIES|The patient doesn't smoke or drink, but quit smoking ten years ago. ALLERGIES: SHE DOES HAVE A SENSITIVITY WITH HYDRALAZINE AS IT CAUSED TO DRUG INDUCED LUPUS. PHYSICAL EXAMINATION: Today shows a lethargic elderly woman who is in no acute distress.
IT|GENERAL ENGLISH|IT|130|131|ALLERGIES|InnoPran XL 120 mg daily (a medication I'm not actually familiar with). ALLERGIES: INTOLERANCE TO ACE INHIBITORS IS NOTED IN THAT IT INDUCED WEAKNESS. INTOLERANCE TO THE WATER PILL IS NOTED I THINK FOR WEAKNESS AS WELL AND INTOLERANCE TO TOPROL FOR FATIGUE HAS BEEN IDENTIFIED.
IT|information technology|IT|188|189|SOCIAL HISTORY|ALLERGIES: None He takes no medications, does not smoke regularly although has about one cigar a month and drinks alcohol infrequently. SOCIAL HISTORY: He is married and is employed doing IT work which is primarily a desk type position. REVIEW OF SYSTEMS: Otherwise negative PHYSICAL EXAMINATION: He lists his height as 5'10" and weight at 260 pounds.
IT|information technology|IT|247|248|SOCIAL HISTORY|Ultimately made his way to _%#CITY#%_ _%#CITY#%_, South Dakota where he was on dialysis for one dialysis for a short time pre-kidney transplant. He has been married 7 several years feels uses no tobacco or alcohol. He is currently employed in the IT industry. FAMILY HISTORY: No diabetes or renal failure. REVIEW OF SYSTEMS: Primarily related to his acute illness and includes constitutional symptoms in the form of fever, chills, some decreased appetite and general myalgias, arthralgias.
IT|iliotibial|IT|141|142|PHYSICAL EXAMINATION|Motor 5/5 all areas. Left knee surprisingly nontender over the fibula. Tenderness over the tibial plateau mild but no effusion. No bruising. IT bands negative. Collateral and cruciate stable. No false motion or crepitus to suggest fracture. X-rays were reviewed showing possible fracture of the proximal fibula.
IT|iliotibial|IT|190|191|PHYSICAL EXAMINATION|She holds the right knee at about 5-10 degrees of flexion and external rotation of the hip. She has a very tender medial joint and exquisitely tender lateral joint. Careful palpation, _____ IT band. Range of motion is virtually impossible due to the pain. The general body habitus is moderately over weight. The x-rays were again reviewed here, taken in the hospital, AP and lateral, corresponding with some taken by orthopedic medicine service showing no fractures.
IT|iliotibial|IT|169|170|IMPRESSION|MRI from orthopedic surgery medicine was reviewed with no evidence for dislocation, obvious meniscus tear laterally or, for that matter, stress fracture. IMPRESSION: 1. IT band, severe. 2. Medial joint line arthrosis. RECOMMENDATIONS: Injection. Rule out hemarthrosis. Because she is on Coumadin; her INR has really been doing fine here.
IT|iliotibial|IT|290|291|IMPRESSION|Hemoglobin 12.9, white blood count 6. Crystals not done nor is it necessary. IMPRESSION: 1. End-stage arthrosis, right knee. 2. IT band, by history, more than likely she has been walking and hobbling for two to three weeks as she has circumducted her gait, given the external stress on the IT band as a result. PROCEDURE: The patient was prepped and draped under informed consent.
IT|iliotibial|IT|147|148|PROCEDURE|I waited 15-20 minutes and no true degree or relief was noted laterally. A second injection was done under informed consent and sterile technique, IT band, bursa and lateral aspect of the right iliotibial band was injected first with 5-10 cc of 1% lidocaine and then we placed 40 mg or 1 cc of Kenalog in there without difficulty.
IT|GENERAL ENGLISH|IT|105|106|IMPRESSION|X-rays and MRI are consistent with the gouty tophi lesion. IMPRESSION: Gouty arthritis at the MTP joint. IT is presently resolving. We discussed the triggers for gout, typical symptoms of the hypersensitivity of the light touch and the pins and needles feeling in the skin.
IT|GENERAL ENGLISH|IT|129|130|ALLERGIES|ALLERGIES: 1) THE PATIENT REPORTS AN ALLERGIC REACTION TO PENICILLIN BUT NOTES SHE HAS GOTTEN A SIGNIFICANT YEAST INFECTION FROM IT WHICH DOES NOT OFFICIALLY SUGGEST AN ALLERGIC REACTION. 2) SULFA (CAUSES FEVER AND RASH). 3) CODEINE (CAUSES VISUAL HALLUCINATIONS).
IT|intrathecal|IT|141|142|HISTORY OF PRESENT ILLNESS|The patient was sent back to have further treatment with chemotherapy, which was denied by the patient. She is also not going to receive any IT methotrexate. Under the circumstances the patient was asked to see us again for possible further radiation therapy to the remaining residual lesion after whole brain radiation treatment.
IT|information technology|IT|140|141|SOCIAL HISTORY|PAST MEDICAL HISTORY: Left knee problems recently. SURGICAL: None. ALLERGIES: NONE. SOCIAL HISTORY: The patient is divorced. He works as an IT professional. He does not drink alcohol, does not smoke. FAMILY HISTORY: Biological father's history is unknown.
IT|GENERAL ENGLISH|IT|351|352|HISTORY OF PRESENT ILLNESS|New medications which have been added since she came to University of Minnesota Medical Center, Fairview, include Nicotrol Inhaler one puff per hour p.r.n. not to exceed 12 in 24 hours, trazodone 50 to 100 mg nightly p.r.n. may repeat 50 to 100 mg p.o. x1 nightly and Seroquel 25 to 50 mg p.o. q.i.d. p.r.n. ALLERGIES: SHE IS ALLERGIC TO ERYTHROMYCIN IT CAUSES STOMACH ACHE. SOCIAL HISTORY: The patient smokes one pack of cigarette every 2 to 3 days. She does not drink alcohol as of _%#MM#%_ 2006. The patient denies using drugs.
IT|information technology|IT|145|146|SOCIAL HISTORY|4. Seasonal rhinitis. MEDICATIONS: Celexa and Rhinocort. ALLERGIES: None. SOCIAL HISTORY: The patient had been out of work. He is now working in IT Department. He has never been a smoker. He has one alcoholic beverage per week. He has up to six caffeinated products per day.
IT|GENERAL ENGLISH|IT|136|137|ALLERGIES|They have no recent travel or exposures. ALLERGIES: HAD PROBABLE ALLERGIC REACTION PREVIOUSLY TO ZOSYN DURING THE RECENT HOSPITAL STAY. IT IS STILL UNCLEAR TO ME WHETHER THAT WAS THE CAUSE BUT LISTED AS SUCH CURRENTLY. MEDICATIONS: 1. OxyContin. 2. Zofran. 3. Celexa. 4. Cellcept.
IT|GENERAL ENGLISH|IT|371|372|ALLERGIES|She had initial visit with my partner Dr. _%#NAME#%_ approximately a month ago in the office and workup was begun at that time for possible inflammatory bowel disease again. She comes in now with worsening symptoms. PAST MEDICAL HISTORY: Otherwise, negative except for the rectocele, cystocele repair, 1997 No medications except Xanax ALLERGIES: TO SULFA She STATES THAT IT WENT THROUGH HER FAMILY HISTORY: Sister with Crohn's disease in an aunt with diverticulitis versus chronic the ulcerative colitis.
IT|intrathecal|IT|182|183|HPI|__x___ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: CNS lymphoma. HPI: Status post RGOG-10 chemotherapy with IT methotrexate. Exam: No neurologic deficits seen. Assessment and Plan: CT still shows edema in brain.
IT|GENERAL ENGLISH|IT|203|204|HISTORY OF PRESENT ILLNESS|However, when he was admitted, a lumbar puncture showed that he had hydrocephalus and subsequent culture have shown gram-positive cocci growth which has been identified as MSSA. He is being treated with IT antibiotics, 10 days of intrathecal vancomycin and nafcillin. His right ventricular shunt has been removed. The left ventricular externalized shunt is still in place.
IT|GENERAL ENGLISH|IT.|181|183|ALLERGIES|10. Chronic anemia related to renal insufficiency and infection. 11. Hypogonadism. 12. TURP. 13. Orchiectomy. ALLERGIES: MORPHINE, ERYTHROMYCIN, ZOLOFT, ALTHOUGH HE IS CURRENTLY ON IT. IV DYE, IODINE, LISINOPRIL AND TOPROL. SOCIAL HISTORY: Smoke: None. Alcohol: None. The patient currently resides in a nursing home.
IT|information technology|IT|104|105|SOCIAL HISTORY|FAMILY HISTORY: Significant for coronary disease in the mother. SOCIAL HISTORY: The patient works as an IT consultant. She is pursuing a doctorate in psychology and computer science. She is single. MEDICATIONS: 1. Aspirin 162 mg p.o. given today.
IT|GENERAL ENGLISH|IT|148|149|ALLERGIES|MEDICATIONS: 1) Diltiazem XR 180 mg per day. 2) Effexor XR 75 mg p.o. daily. 3) Aspirin 81 mg p.o. q day. ALLERGIES: PENICILLI, WHICH INDUCES RASH; IT HAS BEEN 40 YEARS OR MORE. HABITS: Smokes one-plus packs per day, down from two packs per day.
IT|GENERAL ENGLISH|IT|103|104|ALLERGIES|11.Tylenol. 12.Intrathecal baclofen. 13.Ibuprofen. ALLERGIES: MORPHINE, AMPICILLIN, CEPHALEXIN, SULFA. IT IS HARD TO SAY WHAT WE ARE DEALING WITH. THEY ARE PROBABLY RELATED TO THE PENICILLIN REACTION. ALSO CIPROFLOXACIN AND TRIMETHOPRIM.
IT|intrathecal|IT|222|223|HISTORY OF PRESENT ILLNESS|His pain slowly and was persistent and progressive. He was seen in the Pain Clinic and an intrathecal pump was attempted which unfortunately was complicated with by infection. Cellulitis and meningitis associated with the IT catheter. He is referred now for discussion regarding radiotherapy. He was seen earlier today by Dr. _%#NAME#%_ who is considering re-resection with postoperative radiotherapy.
IT|UNSURED SENSE|IT|171|172|SUMMARY AND RECOMMENDATIONS|SUMMARY AND RECOMMENDATIONS: Current testing suggests hearing levels through the cochlear implant at a level which will allow _%#NAME#%_ access to speech information. The IT maze is indicating good initial benefit from the cochlear implant. Early intervention and educational programming, in addition to parent and family support, continue to be critical to _%#NAME#%_'s progress as he is in a critical language development.
IT|GENERAL ENGLISH|IT|121|122|HISTORY  OF PRESENT ILLNESS|She described this as a pressure extending from shoulder to shoulder across the top of her chest and up into her throat. IT formed a tight knot in her throat. She was not initially short of breath with it but when she walked in from the parking ramp to the emergency room she did notice more shortness of breath.
IT|intrathecal|IT|131|132|ADDENDUM|Mr. _%#NAME#%_ will be followed by Dr. _%#NAME#%_ _%#NAME#%_ and after transplant by the BMT Clinic ADDENDUM: Patinet will receive IT chemotherapy to clear the CSF followed by whole brain radiation over 5 days and then the transplant conditioning regimen which includes 1320 cGy TBI in 8 treatments.
IT|information technology|IT|144|145|PLAN|Testing for this can be done through cultured amniotic cells. We thoroughly reviewed the remainder of their family history. _%#NAME#%_ works in IT and _%#NAME#%_ is a stay at home mom. _%#NAME#%_ reported having 2 sisters both having issues with their eyes, one of them having a cataract, another having some other eye issues.
IT|iliotibial|IT|188|189|HISTORY OF PRESENT ILLNESS|There was no blood present in the diarrhea. The patient denies having any GI symptoms at all. The left leg revealed some ecchymotic changes on the left lateral (_______________) along the IT band area. He had a swollen left knee that was erythematous and definitely tender. There was some blistering in the posterior and medial aspect of the left upper leg with tenderness.
IT|GENERAL ENGLISH|IT|366|367|REFERRING PHYSICIANS|She has no other cancer diagnosis. MEDICATIONS: On admission included Levoxyl 0.075 mg daily, isosorbide 30 mg twice daily, Os-Cal with vitamin D b.i.d., Paxil 20 mg twice daily, Valium 5 mg at bedtime or as necessary, 81 mg enteric- coated aspirin per day, Lipitor 10 mg per day, Dyazide 37.5/25 daily, Protonix 40 mg daily, and oxybutynin 5 mg per day. ALLERGIES: IT SHOULD BE NOTED THAT THE PATIENT IS ALLERGIC TO AMOXICILLIN, SULFA, ERYTHROMYCIN, CODEINE, AND CELEBREX. SOCIAL HISTORY: She does live in assisted-living facility. FAMILY HISTORY: Noncontributory.
IT|information technology|IT.|146|148|SOCIAL HISTORY|2. Lovenox 40 mg subcutaneously daily. SOCIAL HISTORY: He lives in the _%#CITY#%_ _%#CITY#%_ and is single. He has 2 daughters. He is employed in IT. His primary care giver is his former girlfriend. PHYSICAL EXAMINATION UPON ADMISSION: GENERAL: _%#NAME#%_ is a robust, middle-aged male.
IT|GENERAL ENGLISH|IT.|214|216|ALLERGIES|14. MiraLax p.r.n. 15. ADEK vitamin 1 tablet q. day. 16. Vitamin K 2.5 mg every Sundays. ALLERGIES: 1. INHALED COLY-MYCIN: THIS IS A SENSITIVITY NOT A TRUE ALLERGY, AUGMENTIN WHERE HE HAS SEVERE DIARRHEA CAUSED BY IT. PHYSICAL EXAMINATION GENERAL: On exam, the patient appeared to be well nourished in no apparent distress.
IT|ischial tuberosity|IT|203|204|HISTORY OF PRESENT ILLNESS|He developed postradiation fibrous dysplasia and chronic lymphedema. He also has a diagnosis of diabetes. In addition to his recent amputation, he has wounds on his bilateral ischial tuberosities. These IT wounds underwent surgical debridement on the date of his amputation, which was _%#MMDD2007#%_. Postoperatively, he has had anemia. He has been followed by wound care nurses for his IT wounds.
IT|ischial tuberosity|IT|190|191|HISTORY OF PRESENT ILLNESS|These IT wounds underwent surgical debridement on the date of his amputation, which was _%#MMDD2007#%_. Postoperatively, he has had anemia. He has been followed by wound care nurses for his IT wounds. The patient has been maintained throughout his rehabilitation on a First Step pressure relief mattress. During his rehabilitation stay, he developed a fever. This was worked up with a chest x-ray, which was negative for infiltrate.
IT|ischial tuberosity|IT|177|178|PROBLEM #7|These include to the ischial wounds Accuzyme, calcium alginate packing, and then covering the wound with Mepilex and then cover that with 3M foam dressing. This is for the left IT wound. For the right IT wound, cover with 3M foam dressing. For the right lateral malleolus change three days. Cleanse with Clinical Care spray and cover with Mepilex dressing.
IT|ischial tuberosity|IT|201|202|PROBLEM #7|These include to the ischial wounds Accuzyme, calcium alginate packing, and then covering the wound with Mepilex and then cover that with 3M foam dressing. This is for the left IT wound. For the right IT wound, cover with 3M foam dressing. For the right lateral malleolus change three days. Cleanse with Clinical Care spray and cover with Mepilex dressing.
IT|intrathecal|IT|187|188|HISTORY OF PRESENT ILLNESS|_%#NAME#%_ was scheduled to receive chemotherapy as an inpatient with a three-week regimen of methotrexate during week 1, etoposide during week 2, and cyclophosphamide followed by triple IT therapy in clinic during week 3. At clinic on _%#MMDD2004#%_, however, his labs showed neutropenia of 0.9 with 82% neutrophils, and platelets of 19.
IT|GENERAL ENGLISH|IT|187|188|ALLERGIES|7. Questionable history of hypoglycemia. The patient did have a glucose tolerance test on _%#MM#%_ _%#DD#%_, 2006, which was unremarkable. ALLERGIES: THE PATIENT HAS AN ALLERGY TO SULFA. IT CAUSES RASH AND RESPIRATORY DISTRESS. FAMILY HISTORY: There is a grandmother with thyroid disease. There is diabetes mellitus on the father's side.
IT|UNSURED SENSE|IT|104|105|BRIEF HISTORY OF PRESENT ILLNESS|Moreover, he complained of severe pain in the right big toe. He was seen for his right foot pain at the IT Clinic, in which it was not felt that he had frank cellulitis. HOSPITAL COURSE: EMERGENCY ROOM COURSE: In the emergency room, his vitals were stable.
IT|ischial tuberosity|IT|146|147|HOSPITAL COURSE|He was treated with 6 days of IV Unasyn. 8. Decubitus ulcers: The patient had multiple pressure ulcers including a 1.2 black eschar over the left IT area, purple non-blanchable scrotum with 3.52 area of full-thickness skin loss from pressure between (stage 3 with red base). Purple blanchable skin blanchable skin all along the lower buttocks.
IT|GENERAL ENGLISH|IT|242|243|ASSESSMENT|The plan at this time is for conservative care with hydration. Surgery was alerted to her case. She IS DNR, DNI BECAUSE OF HER RECENT DIAGNOSIS OF BRONCHOGENIC CARCINOMA For WHICH She EXPRESSES NO DESIRE For TREATMENT OR FURTHER WORK-UP, BUT IT IS ENTIRELY POSSIBLE She WILL DECLINE ANY INTERVENTION For HER SMALL BOWEL OBSTRUCTION. She is under hospice care in her home. DNR, DNI order was written in the chart and her wishes will be respected here in regards to treatment of the bowel obstruction should intervention be necessary.
IT|GENERAL ENGLISH|IT|177|178|DOXYCYCLINE CAUSING YEAST AND HAS COMPLAINED OF|She HAS ALLERGIES TO PENICILLIN CAUSING HIVES AND SULFA CAUSING ERYTHEMA. She COMPLAINS OF DOXYCYCLINE CAUSING YEAST AND HAS COMPLAINED OF CIPRO CAUSING FATIGUE IN The PAST AND IT IS FELT THAT MS CAUSED URINARY RETENTION AND SOME LETHARGY. FAMILY HISTORY: Her father had colon cancer in his 40's, mother is alive and well.
IT|GENERAL ENGLISH|IT|180|181|HISTORY OF PRESENT ILLNESS, HOSPITAL COURSE, AND SIGNIFICANT FINDINGS|Following this, she was transferred to the MICU at University Hospital and thereafter was admitted to the inpatient floor. The patient's past medical history is extremely complex. IT COMPRISES OF MULTIPLE ALLERGIES, INCLUDING ULTRAM, LIDOCAINE, NARCAN, ASPIRIN, KLONOPIN, MELLARIL, HALDOL, DESYREL, ELAVIL, COGENTIN, DEPO-MEDROL, LITHIUM, NARDIL, CECLOR, KEFLEX, SULFA, PENICILLIN, TRAZODONE, SCOPOLAMINE.
IT|GENERAL ENGLISH|IT|190|191|4. CODE STATUS.  I DISCUSSED THIS WITH HER DAUGHTER|We will check an ultrasound of her lower extremity. We will place her on Lovenox prophylaxis as she will not likely be very ambulatory 4. CODE STATUS. I DISCUSSED THIS WITH HER DAUGHTER AND IT IS VERY CLEAR THAT THE PATIENT WOULD LIKE TO BE DNR, DNI. SHE HAS HAD THAT STATED IN THE PAST AS WELL AND I WOULD AGREE WITH THIS DECISION.
IT|intrathecal|IT|163|164|HISTORY OF PRESENT ILLNESS|She received the regimen described by the CCG 1191 regimen OS with the exclusion of cyclophosphamide and anthracycline. Cerebrospinal fluid treatment consisted of IT methotrexate only. After 1 dose of IT methotrexate, the CSF was negative. Bone marrow on day #10 revealed 2.2% blasts after a vincristine, dexamethasone and PEG asparaginase.
IT|intrathecal|IT|201|202|HISTORY OF PRESENT ILLNESS|She received the regimen described by the CCG 1191 regimen OS with the exclusion of cyclophosphamide and anthracycline. Cerebrospinal fluid treatment consisted of IT methotrexate only. After 1 dose of IT methotrexate, the CSF was negative. Bone marrow on day #10 revealed 2.2% blasts after a vincristine, dexamethasone and PEG asparaginase.
IT|GENERAL ENGLISH|IT|289|290|ALLERGIES OR SIDE EFFECTS INCLUDE THE FOLLOWING|8. Pilocarpine 0.5 mg ophthalmic drops to left eye 1 drop b.i.d. THE PATIENT HAS BEEN DNR/DNI PER HER REQUEST AND DAUGHTER'S REQUEST . ALLERGIES OR SIDE EFFECTS INCLUDE THE FOLLOWING: TALWIN, CODEINE, DARVON, EQUAGESIC, METOPROLOL, ERYTHROMYCIN, PENICILLIN CAUSES DIARRHEA, Spironolactone IT CAUSED GENERALIZED WEAKNESS, LORAZEPAM MAKES HER TOO CONFUSED. FAMILY HISTORY: Mother deceased of breast cancer in her 70s.
IT|information technology|IT|274|275|SOCIAL HISTORY|3. Chronic lower back pain 4. Hypercholesterolemia. ALLERGIES: He does have an allergy to contrast dye and did need a special regimen including mucomyst and Benadryl prior to having his CT scan. SOCIAL HISTORY: He is employed by the Target Corporation where he works in the IT department. He does not use tobacco, alcohol or drugs. FAMILY HISTORY: Apparently, there is Alzheimer's disease in his family, rheumatoid arthritis, CVAs, and he thinks his mother has coronary artery disease.
IT|GENERAL ENGLISH|IT|170|171|ALLERGIES|12. Centrum 1 p.o. q day. 13. temazepam, she takes at night either one or two tablets I believe at 7.5-15 mg at night. ALLERGIES: SHE TELLS ME NO, BUT IN HER OLD RECORDS IT IS INDICATED SHE IS PROBABLY ALLERGIC TO CODEINE AND SULFONAMIDES. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: ENDOCRINE: No history of diabetes.
IT|information technology|IT|132|133|SOCIAL HISTORY|FAMILY HISTORY: Mother died of heart disease in her 80s. SOCIAL HISTORY: The patient is divorced. He has five children. He works in IT for Blue Cross Blue Shield. HABITS: He quit smoking in _%#CITY#%_. Prior to that, he has a 50-year smoking history of an average of one pack per day.
IT|intrathecal|IT|134|135|HISTORY OF PRESENT ILLNESS|PAST MEDICAL HISTORY: The patient is nulliparous. Her history is significant for a recent DVT in _%#CITY#%_ of 2002, and placement of IT pain pump. Also, as noted above, a history of ovarian cancer. PAST SURGICAL HISTORY: Past surgical history, as noted above, consists of surgery in 1993 of a TAH-BSO, with exploratory laparotomies in 1994 and 1996.
IT|ischial tuberosity|IT|173|174|ADMISSION MEDICATIONS|3. Lovenox 40 mg daily. 4. Omeprazole 20 mg daily. 5. Tricor 145 mg daily. 6. Lyrica 100 mg twice daily. 7. Pulmozyme 1 vial nebulized twice daily. 8. Solosite to bilateral IT wounds, changed daily. 9. Pros source 1 ounce by mouth twice daily. 10. Arginaid one packet three times daily. 11. Xopenex 1.25 mg nebulizer b.i.d. to t.i.d.
IT|GENERAL ENGLISH|IT|188|189|HOSPITAL COURSE|Of note, upon admission, her albumin level was 2.4, and total protein was 6.1. 5. PROBLEM #5: MACULOPAPULAR RASH. THE PATIENT DID DEVELOP A MACULOPAPULAR RASH PRIOR TO ADMISSION, AND THEN IT DID SEEM TO GET WORSE DURING HER HOSPITAL STAY. THIS WAS BOTH ON HER ARMS AND HER LOWER EXTREMITIES BILATERALLY.
IT|GENERAL ENGLISH|IT|222|223|HOSPITAL COURSE|PROBLEM #5: MACULOPAPULAR RASH. THE PATIENT DID DEVELOP A MACULOPAPULAR RASH PRIOR TO ADMISSION, AND THEN IT DID SEEM TO GET WORSE DURING HER HOSPITAL STAY. THIS WAS BOTH ON HER ARMS AND HER LOWER EXTREMITIES BILATERALLY. IT WAS PALPABLE, AND IT WAS QUITE ITCHY FOR THE PATIENT, THIS WAS THOUGHT TO BE DUE TO THE TIMENTIN, AND THIS WAS ACTUALLY DISCONTINUED DURING HER HOSPITALIZATION, AND ADDITIONAL LEVAQUIN AND FLAGYL WAS ADDED.
IT|idiopathic thrombocytopenic purpura:ITP|IT|182|183|ASSESSMENT|9. Thrombocytopenia probably related to problem #1. We will review peripheral smear. 10. History of CPK elevation. The etiology of which was unclear. 11. Status post splenectomy for IT P. 12. Mild exogenous obesity. 13. Hyponatremia potentially dilutional in origin. I cannot exclude SIDH.
IT|iliotibial|IT|209|210|CHIEF COMPLAINT|5. Left tibia fibula fracture. 6. Left anterior collateral ligament injury, status post ACL reconstruction. Left medial meniscus tear, repair of left posterior lateral corner, including biceps femoris, LC and IT band. 7. Right knee tibial plateau fracture. 8. Right knee medial collateral ligament sprain. 9. Status post right lower lung collapse. Right upper lobe pulmonary contusion.
IT|GENERAL ENGLISH|IT|203|204|ALLERGIES|ADMISSION MEDICATIONS: Current medications include Lopressor 50 mg p.o. q. day, lisinopril 40 mg p.o. q. day, triamterene/hydrochlorothiazide 37.5/25 p.o. q. day. ALLERGIES: SHE IS ALLERGIC TO ROCEPHIN, IT CAUSES A RASH. FAMILY HISTORY: Significant for hypertension, diabetes, and coronary artery disease.
IT|intrathecal|IT|304|305|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1: Bone marrow transplant: _%#NAME#%_ _%#NAME#%_ is status post myeloablative Allosib related donor peripheral blood stem cell transplant in first complete remission on _%#MMDD2007#%_. She had no history of CNS involvement at the time of diagnosis and also received prophylatic IT methotrexate prior to transplant. She now presents with disease relapse in the bone marrow as well as CNS. Lumbar puncture on the day of admission revealed 361 white blood cells (91% blasts, 9% lymphocytes) and cytology revealed numerous leukemic blasts.
IT|intrathecal|IT|201|202|HISTORY OF PRESENT ILLNESS|He had no increase in blasts at that time. A lumbar puncture was performed to obtain CSF on _%#MMDD2007#%_. This revealed leukemic myeloid blast and white blood cell count of 16. The patient underwent IT chemotherapy with methotrexate, ARA-C and dexamethasone on _%#MMDD2007#%_, _%#MMDD2007#%_, _%#MMDD2007#%_, _%#MMDD2007#%_ and _%#MMDD2007#%_. His 6th dose on _%#MMDD2007#%_ consisted of DepoCyt 50 mg.
IT|GENERAL ENGLISH|IT|149|150|HOSPITAL COURSE|HOSPITAL COURSE: Please see dictated history and physical for the patient's initial presentation. The patient was admitted with acute renal failure. IT also appeared that she had pancreatitis. Her initial creatinine was 7.58, with a BUN of 80, and her initial lipase was 13,739. She die have a normal troponin and normal TSH. The patient was hydrated with IV fluids with bicarbonate due to the fact that her bicarbonate was only 11.
IT|iliotibial|(IT)|167|170|ASSESSMENT AND PLAN|3. Asthma. Plan to continue on her Advair at current dosing. Will order albuterol nebulizer on a p.r.n. basis. 4. Right hip pain with bursitis and probable iliotibial (IT) band syndrome. Will ask PT and OT to see her for this as well as her ataxia. Will try lidoderm patches tonight, Tylenol p.r.n. 5. Hyperlipidemia. Continue on her current Lipitor dose.
IT|information technology|IT|175|176|SOCIAL HISTORY|There is also a cousin and 2 of her mother's sisters with Crohn disease. SOCIAL HISTORY: She denies tobacco, alcohol or drug use. She has never been a smoker. She works as an IT analyst at 3M. She is married. REVIEW OF SYSTEMS: A complete 12-point review of systems was performed in her preoperative evaluation.
IT|information technology|IT.|241|243|DEMOGRAPHICS AND BACKGROUND INFORMATION|His mother remarried and divorced. He has 3 sisters (14, 8, and 2) on his mother's side, as well a 24-year-old step sister. This patient is currently in the 12th grade at _%#CITY#%_ High School. He would eventually like to go to college for IT. He may start at Century College and then transfer to Brown or Dunwoody Institute. He tends to receive B's and C's, although in the past he has received D's and F's.
IT|GENERAL ENGLISH|IT|172|173|SUMMARY OF CURRENT FINDINGS|Conversely he has continued to use all the way up until 3 months, when he was abusing opiates. He also has had a history of passive-aggressive and forceful type behaviors. IT should be noted though that his father has a history of alcoholism and continues to drink on a daily basis. Overall, he feels that he was emotionally abused by his father.
IT|information technology|IT|292|293|REASON FOR REFERRAL AND BACKGROUND INFORMATION|His older brother, _%#NAME#%_, is age 12, younger sister _%#NAME#%_ is age 6, and younger sister, _%#NAME#%_, is age 3. Ms. _%#NAME#%_, who was interviewed by phone, reported that she is a stay-at-home mother and her husband, _%#NAME#%_ _%#NAME#%_, is a self-described "computer geek" for an IT and security company, Cross Telecom. _%#NAME#%_ _%#NAME#%_, his mother, was interviewed over the phone on _%#MMDD2007#%_.
IT|information technology|IT|134|135|SUMMARY OF CURRENT FINDINGS|This individual was in a gifted and talented program at his high school and is currently in sophomore year at University of Minnesota IT Program. Prior to this he was at Ohio Wesleyan, but did not like the program there as well. In fact, according to documentation in consultation with staff he had been living in a dormitory with older college students.
IT|GENERAL ENGLISH|IT|138|139|HISTORY OF PRESENT ILLNESS|This was assumed to be an idiopathic cardiomyopathy, however, THE PATIENT HAS NOT BEEN TRUTHFUL. I HAVE NOW TALKED TO HER IN DEPTH AND AS IT TURNS OUT SHE IS A VERY, VERY HEAVY METHAMPHETAMINE USER. The patient never told any of her doctors about this. As it turns out, she started using methamphetamines several months before she was diagnosed with her cardiomyopathy.
IT|GENERAL ENGLISH|IT|333|334|6.   GI|Bacteria: Cultures have been negative to date. His ceftazidime, tobramycin and vancomycin were continued for a 10-day course and were finishing on _%#MMDD#%_ due to fevers of 101-102 and again, no infectious etiology was noted. Fungal: The patient is on Micafungen. His voriconazole was stopped in mid _%#MM#%_ due to LFT elevation. IT should also be noted that the patient was EBV negative on _%#MMDD#%_, _%#MMDD#%_ and _%#MMDD#%_. His sputum culture on _%#MMDD#%_ was negative today and showed normal flora.
IT|information technology|IT|88|89|SOCIAL HISTORY|ALLERGIES: None. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: He just retired as an IT consultant. He is married and has kids. HABITS: He smokes half pack a day, drinks 1 Scotch a day, but no drugs.
IT|information technology|IT.|148|150|SOCIAL HISTORY|SOCIAL HISTORY: The patient is married. She is a college graduate and intends to work. She has 1 child who is 3-1/2 years old. Her husband works in IT. Per prior medicine report she does have a past medical history of marijuana and opiate use. REVIEW OF SYSTEMS: Please see HPI. Otherwise feeling anxious about her pain and alcohol drinking.
IT|GENERAL ENGLISH|IT|231|232|ALLERGIES|NORVASC WHICH CAUSED SWELLING. CIPRO, CEFUROXIME AND MACROBID, ALL WHICH CAUSED UNKNOWN REACTIONS. SHE HAD A REACTION ALSO TO VAGINAL PREMARIN. SHE HAS HAD SOME KIND OF REACTION TO HYDROCHLOROTHIAZIDE POSSIBLY THE HYPONATREMIA BUT IT IS NOT SPECIFIED IN THE CHART. CURRENT MEDICATIONS: Tylenol, Maalox, Milk Of Magnesia, Restoril p.r.n. MiraLax, morphine p.r.n., aspirin, potassium, Zofran, Reglan, both p.r.n., artificial tears, diltiazem, Zocor, Prinivil, Zantac, trandate ciprofloxacin 250 mg p.o. b.i.d. Ocean Nasal Spray, prednisone was decreased from 10-5 mg yesterday, Zithromax 250 mg IV daily.
IT|GENERAL ENGLISH|IT|235|236|HISTORY OF PRESENT ILLNESS|I should comment that I am reading from the report and it is a bit hard to follow and I am reading it as best I can. The mean gradient across the aortic valve was 14-mmHg again consistent with mild to at most moderate aortic stenosis. IT was recommended that the patient have medical therapy. The coronary anatomy was stable. An echocardiogram dated _%#MM#%_ 2005 shows left ventricle dilated, ejection fraction 30%, anterior and inferior wall motion abnormalities.
IT|GENERAL ENGLISH|IT|250|251|ALLERGIES|ALLERGIES: PATIENT RELATES INTOLERANCE TO ASPIRIN, MOTRIN, VOLTAREN, TYLENOL, CODEINE, ALL CHOLESTEROL LOWERING MEDICATIONS, NORVASC, MONOPRIL, NOVOCAINE-THE LATTER OF WHICH CAUSED SKIN REDDENING. SHE ALSO RELATES DIFFICULTY WITH PENICILLIN-ALTHOUGH IT IS UNCLEAR TO ME WHETHER THAT REPRESENTED A TRUE ALLERGY. SOCIAL HISTORY: Is largely covered above. The patient and her husband live together in the _%#CITY#%_ _%#CITY#%_ area.
IT|ischial tuberosity|IT|193|194|PAST SURGICAL HISTORY|2. Status post colostomy placement 2004 to help facilitate bowel evacuation. 3. Right posterior thigh flap closure of right ischial ulcer _%#MMDD2005#%_. 4. Debridement and flap revision right IT decubitus ulcer _%#MMDD2007#%_. FAMILY HISTORY: The patient's mother died in her 60s secondary to multiple myeloma.
IT|information technology|IT|108|109|SOCIAL  HISTORY|FAMILY HISTORY: Multiple family members with cancer. SOCIAL HISTORY: The patient is divorced. He works as a IT guy. HABITS: No tobacco or drugs. Occasional alcohol. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 96.1, blood pressure 80s-90s/40s, heart rate in 80s-90s, respiratory rate 20, sats 99% on room air.
IT|GENERAL ENGLISH|IT.|208|210|ALLERGIES|THE PATIENT HAS A REACTION OF FATIGUE AND BRADYCARDIA WITH METOPROLOL AND THE DETAILS CONCERNING THIS ARE UNKNOWN, IN TERMS OF THE DOSE THAT HE WAS TAKING AS WELL AS THE DEGREE OF BRADYCARDIA ASSOCIATED WITH IT. DILTIAZEM CAUSES FATIGUE. OMEPRAZOLE CAUSES NAUSEA. THE PATIENT'S METOPROLOL, SOTALOL AND DILTIAZEM AS WELL AS OMEPRAZOLE ALLERGIES ARE MORE LIKELY INTOLERANCES.
IT|iliotibial|IT|155|156|ASSESSMENT/PLAN|Last hemoglobin is 10.7. Last INR is 1.39. Last white blood cell count is 3.9. ASSESSMENT/PLAN: 68-year-old male with right hip pain, suspect secondary to IT band shortening. This may well be a result of his loss of adductor and medial rotational stability secondary to his CVA.
IT|information technology|IT|172|173|SOCIAL HISTORY|The patient's son suffers bipolar disorder and autism. SOCIAL HISTORY: The patient is nonsmoker, nondrinker. She is married, she has two children, and the patient works as IT developer. REVIEW OF SYSTEMS: All ten systems was reviewed completely. Please see History of Present Illness, and most of the review of systems negative, except those discussed with History of Present Illness.
IT|GENERAL ENGLISH|IT.|197|199|ASSESSMENT  AND PLAN|I AGAIN DISCUSSED IT WITH HIS SON _%#NAME#%_ JR AND The WOMAN WHO CARES FOR HIM AT A NURSING HOME. HIS SON SEEMS TO UNDERSTAND WHAT THIS MEANS AND SAYS HE WILL TALK TO HIS MOTHER AND BROTHER ABOUT IT.
IT|intrathecal|IT|225|226|ASSESSMENT AND PLAN|1. Metastatic lung cancer with intractable pain secondary to metastases. An IT pump has been placed by Dr. _%#NAME#%_. Pain management will be managed by Dr. _%#NAME#%_. 2. Urinary retention. Likely related to anesthesia and IT pump. The patient will again attempt to void his bladder today. We will monitor his urine output, continue straight catheter p.r.n.
IT|intrathecal|IT|203|204|HPI|MRI showed enhancing leptomeningeal carcinomatosis with a prominence in the basilar cisterns in the brain. The patient had Ommaya shunt placement on _%#MMDD2004#%_ for intrathecal chemotherapy receiving IT methotrexate, as well as Xeloda per Dr. _%#NAME#%_. The patient's symptoms have improved. The patient is being seen by us for possible radiation to the brain.
IT|iliotibial|IT|245|246|ASSESSMENT|I was impressed with the flexibility of her hamstring. Negative piriformis and this is bilateral. ASSESSMENT: 1. Left osteoarthritic knee pain. 2. Left greater trochanteric bursa pain and then pain on the lateral thigh on the left, possibly the IT band. PLAN: 1. We will apply ketoprofen gel to the left knee joint entirely around the knee and then extend the ketoprofen gel up the lateral portion of the left thigh and then over the left greater trochanteric bursa.
IT|intertrochanteric|IT|139|140|LABORATORY DATA|LABORATORY DATA: Hemoglobin of 11.3, normal electrolytes with a potassium of 3.6, creatinine 1.0. X-ray showed a minimally displaced right IT fracture of the hip. EKG showed sinus bradycardia, otherwise quite unremarkable, perhaps some LVH. ASSESSMENT: 1. Elderly male with advanced Parkinson's disease with frequent falls who now has fractured his right hip.
IT|information technology|IT|121|122|SOCIAL HISTORY|Aunt also had colon cancer, metastasizing to the liver. SOCIAL HISTORY: The patient does not smoke or drink. He works in IT as an administrator. He takes no illicit drugs. REVIEW OF SYSTEMS: Obtained and unremarkable. All symptoms are as already mentioned.
IT|intrathecal|IT|133|134|HPI|No other neurologic signs or symptoms. Assessment and Plan: Meningeal carcinomatosis of breast cancer. The patient will have further IT Methotrexate and have a re-evaluation of CSF after 4 cycles and we will decide whether she should have whole brain irradiation or not.
IT|intertrochanteric|IT|78|79|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old female with a right IT fracture. She is admitted at this time for ORIF. She is very active and did not complain of pain previously. PAST MEDICAL HISTORY: 1. Osteoporosis. 2. See "History of Present Illness."
IT|GENERAL ENGLISH|IT|162|163|ALLERGIES|CHRONIC MEDICATIONS: Triamterene hydrochlorothiazide. ALLERGIES: PENICILLIN AS LISTED AS YEARS AGO. SHE DOES NOT KNOW WHAT THE REACTION WAS. SHE DOES NOT BELIEVE IT WAS VERY SERIOUS. HEALTH HABITS: Smoking history as outlined above, probably 80- pack-years.
IT|GENERAL ENGLISH|IT.|189|191|ALLERGIES|7. Centrum daily. 8. He gets Gamma-guard 30 g IV every 3 weeks. ALLERGIES: QUESTIONABLE ALLERGY TO SOME FORM OF PAIN MEDICATION THAT GAVE HIM AN ELEVATED PULSE-HE DOES NOT KNOW THE NAME OF IT. ANESTHESIA REACTIONS NONE. FAMILY HISTORY OF ANESTHESIA REACTIONS OR BLEEDING PROBLEMS: None.
IT|GENERAL ENGLISH|IT.|256|258|ALLERGIES|6. Above-mentioned history of left ischemic stroke. 7. Bilateral moyamoya syndrome. PRE-HOSPITAL MEDICATIONS: Include aspirin 81 mg p.o. q. day. ALLERGIES: THE PATIENT HAS AN ALLERGY TO MORPHINE DURING WHICH HE HAD A RESPIRATORY ARREST WHILE HE WAS TAKING IT. HOSPITAL COURSE: The patient was brought to the operating room on _%#MM#%_ _%#DD#%_, 2006, with the above named procedure.
IT|GENERAL ENGLISH|IT|180|181|ALLERGIES|PAST MEDICAL HISTORY: Negative. PAST SURGICAL HISTORY: Ovarian cystectomy and also laparoscopic cholecystectomy in _%#MM2002#%_. ALLERGIES: SHE STATES SHE IS ALLERGIC TO INAPSINE, IT SUSTAINED AN ANXIETY STATE. EXAMINATION: She is a well developed, well nourished patient not in any acute distress.
IT|GENERAL ENGLISH|IT.|104|106|ALLERGIES|SOCIAL HISTORY: She is a nonsmoker who uses no alcohol. ALLERGIES: NIACIN, OR AT LEAST DID NOT TOLERATE IT. REVIEW OF SYSTEMS: On review of systems now she indicates that she had another episode around an hour ago and had some slurring of speech and facial numbness which is now improving again.
IT|GENERAL ENGLISH|IT|155|156|ALLERGIES|She has a mature cataract. She will now have surgery on _%#MMDD2005#%_ by Dr. _%#NAME#%_. ALLERGIES: HAS HAD SOME PROBLEMS WITH MACROBID BUT HAS TOLERATED IT OTHER TIMES. HEALTH HABITS: Tobacco: None. Did have past exposure. Alcohol: None.
IT|GENERAL ENGLISH|IT|83|84|CODE STATUS|ALLERGIES: She is allergic to Prilosec that causes her rash. CODE STATUS: DNR, BUT IT IS OKAY TO INTUBATE HER. SOCIAL HISTORY: She is widowed and lives in an apartment.
IT|GENERAL ENGLISH|IT|174|175|ALLERGIES|9) Cataract extraction in the left eye. 10) Pneumonia in the past. SURGICAL: 1) Hysterectomy. 2) Cholecystectomy. 3) Cataract extraction. ALLERGIES: PENICILLIN, UNCLEAR WHAT IT CAUSES. SOCIAL HISTORY: The patient lives alone in assisted living. She quit smoking about 20 years ago, smoked for 30 years.
IT|GENERAL ENGLISH|IT|202|203|ALLERGIES|ALLERGIES: ASPIRIN CAUSES HER STOMACH UPSET. SHE LISTS AS ALLERGIES TO VALIUM, NOVOCAINE, SEPTRA, KEFLEX, CIPRO, CLINDAMYCIN, AZITHROMYCIN, VANCOMYCIN. SHE REPORTS THAT WHEN SHE TAKES THESE ANTIBIOTICS IT CAUSES HER THROAT TO CLOSE UP. SHE ALSO REPORTS INTOLERANCE TO COMPAZINE, DROPERIDOL, AND REGLAN-SHE REPORTS THOSE CAUSE A DYSTONIC REACTION.
IT|GENERAL ENGLISH|IT|165|166|ALLERGIES|2. Protonix 40 mg daily. 3. Coreg 3.125 mg b.i.d. 4. Multiple vitamin, iron, calcium. ALLERGIES: SHELL FISH AND SEAFOOD. QUESTION OF IVP DYE, ALTHOUGH, WE HAVE DONE IT IN THE PAST WITH PRETREATMENT SUFLA DRUGS. HEALTH HABITS: Smoking history none. Alcohol use none. SOCIAL HISTORY: The patient is married.
IT|GENERAL ENGLISH|IT|137|138|ALLERGIES|ADMISSION MEDICATIONS: Include prenatal vitamins only throughout the entire pregnancy. ALLERGIES: THE PATIENT IS ALLERGIC TO PENICILLIN. IT CAUSES HIVES. SOCIAL HISTORY: The patient is married. She is a member of the Air Force ROTC, as is her husband.
IT|GENERAL ENGLISH|IT|192|193|ALLERGIES|2) Diabetes mellitus, under good control. 3) Hypertension. 4) Restless leg syndrome. 5) Hypogonadism, on replacement. ALLERGIES: LISTED AS PENICILLIN, BUT HE HAS ACTUALLY BEEN CHALLENGED WITH IT SINCE THEN AND DID NOT HAVE A REACTION. MEDICATIONS: 1) Sinemet. 2) Lipitor. 3) Mirapex. 4) Testosterone injections.
IT|GENERAL ENGLISH|IT|154|155|ALLERGIES|7. Nephrocaps one daily. 8. Prednisone 5 mg day. ALLERGIES: ASPIRIN, COMPAZINE, FOSAMAX, MORPHINE IS ALSO LISTED, BUT SHE IS ON IT, LOZOL, MILK PRODUCTS. IT IS UNCLEAR WHAT THE REACTIONS ARE WITH THESE MEDICATIONS. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She is married and lives with her husband.
IT|GENERAL ENGLISH|IT|261|262|ALLERGIES|REVIEW OF SYSTEMS: The patient is tired, without fever, but otherwise denies any conjunctival irritation, sore throat, runny nose, cough, diarrhea, abdominal pain, dysuria, rashes, lymphadenopathy, or neurological deficits. ALLERGIES: 1. ZITHROMAX: CANNOT TAKE IT WHILE SHE IS ON TACROLIMUS. 2. CHLOROHYDRATE: CAUSES HYPERACTIVITY. FAMILY HISTORY: The patient has an older sister with intrahepatic cholestasis type 3, but otherwise there is no history of autoimmune disease, diabetes, renal or metabolic endocrine disorders.
IT|GENERAL ENGLISH|IT|264|265|CODE STATUS|CODE STATUS: THE PATIENT STATES HER DAUGHTER _%#NAME#%_ IS HER POWER OF ATTORNEY, SHE WAS NOT AWARE OF ANY ADVANCED DIRECTIVE OR LIVING WILL. SHE STATES THAT SHE WILL LOOK THIS OVER DURING HER HOSPITAL STAY, FOR NOW SHE WILL REMAIN FULL CODE UNTIL SHE CAN DISCUSS IT WITH HER DAUGHTER. ALLERGIES: PENICILLIN. MEDICATIONS: 1. Aleve 2. Aspirin 3. Calcium.
IT|GENERAL ENGLISH|IT|114|115|ALLERGIES|PAST SURGICAL HISTORY: 1. Duodenal ulcer repair. 2. Debridement of her cellulitis. ALLERGIES: PENICILLIN TO WHICH IT IS BELIEVED THAT SHE HAD A RASH. ADMISSION MEDICATIONS: 1. Gabapentin 300 mg, 2 t.i.d. and 3 at bed-time.
IT|GENERAL ENGLISH|IT|121|122|ALLERGIES|12. Atrovent inhaled p.r.n. 13. Advair 250/50 listed p.r.n. ALLERGIES: PENICILLIN ALTHOUGH SPECIFIC REACTION IS UNCLEAR. IT MAY HAVE BEEN A REACTION. SOCIAL HISTORY: The patient is disabled secondary to his severe cardiac and renal disease.
IT|GENERAL ENGLISH|IT|173|174|ALLERGIES|6. Panhypopituitarism in 1983. Resection of the pituitary cranial angioma and is on chronic hormone replacement. ALLERGIES: PENICILLIN AND LEVAQUIN. THE LEVAQUIN LOOKS LIKE IT IS PRIMARILY GI SYMPTOMS AND MAY NOT BE A TRUE ALLERGY. FAMILY HISTORY/SOCIAL HISTORY: No recent travel or exposures. No significant tobacco use, he did use in the past.
IT|GENERAL ENGLISH|IT|124|125|ALLERGIES|Most of her hospitalizations have been in _%#CITY#%_ _%#CITY#%_. ALLERGIES: PENICILLIN, WHICH CAUSED A RASH MANY YEARS AGO. IT SOUNDS LIKE SHE HAS HAD CEPHALOSPORINS SINCE THAT TIME. MEDICATIONS: See admit medication list. Since then she has been on Tequin and vancomycin in appropriate dosing schedules.
IT|GENERAL ENGLISH|IT|151|152|ALLERGIES|2) A statin. 3) Flonase. 4) Loratadine. 5) Lexapro. ALLERGIES: NO KNOWN DRUG ALLERGIES, ALTHOUGH SHE STATES SHE HAS A DRUG INTOLERANCE TO MORPHINE AND IT CAUSES HER TO VOMIT. SOCIAL HISTORY: She does not smoke, does not drink alcohol.
IT|GENERAL ENGLISH|IT.|131|133|IMPRESSION|THE VANCOMYCIN ALLERGY IN PARTICULAR, I BELIEVE IN THE AND WE TREATED HER WITH THIS DESPITE THE ALLERGY WERE ABLE TO TREAT THROUGH IT. 7. Coronary artery disease. 8. Prior GI bleeding 9. New atrial flutter and apparent reason for this admission. PLANS: 1. Daptomycin 4 mg/kg q.48h., may be able to get away with doing this at dialysis three times a week.
IT|GENERAL ENGLISH|IT|153|154|ALLERGIES|She has no known other serious medical issues. ALLERGIES: CIPRO AND PENICILLIN, THE PENICILLING HER MOTHER TOLD HER SINCE CHILDHOOD, SHE WAS ALLERGIC TO IT BY GETTING A RASH. CIPRO LOOKS LIKE ALMOST AN ANAPHYLACTIC-LIKE REACTION FROM HER DESCRIPTION. SOCIAL HISTORY: The patient does not drink, does not smoke.
IT|information technology|IT|209|210|HISTORY OF PRESENT ILLNESS|PRIMARY PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_ Fairview _%#CITY#%_ Clinic CHIEF COMPLAINT: Pain and paresthesias in the legs and confusion. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 51-year-old IT manager without significant medical diseases. She has been troubled by mild dizziness for the past several years and sought neurological consultation without a specific diagnosis clearly evident.
IT|ischial tuberosity|IT|398|399|DIAGNOSIS|HISTORY OF PRESENT ILLNESS: This is a 49-year-old white male with advanced multiple sclerosis and with paraplegia and dementia, who was transferred originally from Park Nicollet _%#CITY#%_ Rehab Facility for evaluation and treatment of the right ischial decubitus which is nonhealing with conservative therapy. The patient was admitted on _%#MM#%_ _%#DD#%_, 2005, and underwent an uneventful right IT wound debridement with bone biopsies for culture as well as posterior thigh flap closure. The patient was admitted postoperatively for bedrest. His hospital stay has been relatively uneventful.
IT|information technology|IT|163|164|SOCIAL HISTORY|2. Mesalamine 2,000 mg p.o. b.i.d. 3. Mercaptopurine 25 mg p.o. q day. 4. Nexium 40 mg p.o. q day. SOCIAL HISTORY: The patient currently lives with her son, is an IT specialist. She denies any recent travel. She denies any recent sexual activity. She smokes approximately a quarter pack of tobacco per day and recently decreased this approximately two months ago from a half pack of cigarettes per day.
IT|intertrochanteric|IT|136|137|PHYSICAL EXAMINATION|There is tenderness to palpation of the left hip. Chest x-ray reveals pacer in place, cardiomegaly, no effusion. Hip x-ray reveals left IT fracture. EKG reveals a right bundle branch block, left anterior fascicular block. Basic metabolic panel is within normal limits. CBC is within normal limits with the exception of white blood cell count of 11.9.
IT|GENERAL ENGLISH|IT|148|149|ASSESSMENT AND PLAN|She is a delightful 76-year-old female with known history of coronary artery disease failed attempts at angioplasty in the past and bypass surgery. IT sounds as if she has small vessel disease consistent with diabetes. My recommendation at this point in time would be to try and treat her medically symptomatic wise.
IT|GENERAL ENGLISH|IT|232|233|HISTORY|She underwent cardioversion apparently over a year ago at the Mayo Clinic and states a visit two months ago as far as she was aware, she was still in sinus rhythm. Since cardioversion she generally thinks she feels slightly better. IT is not really affected her exertional intolerance but she just feels somewhat overall more functional. She has noted over the last week that she has generally been feeling weaker.
IT|iliotibial|IT|115|116|PLAN|We anticipate probably IV for a few weeks. We are not going to move the knee until it has healed. The split of the IT band had ruptured as well. She has plain Prolene sutures in and nothing else. We are going to go slow with the movement.
IT|GENERAL ENGLISH|IT|188|189|HOSPITAL COURSE|He also continued on medications through his feeding tube. 3. Type 2 diabetes: Mr. _%#NAME#%_ had elevated blood sugars, which was covered with a sliding scale insulin. 4. Deconditioning: IT became clear during this hospitalization that Mr. _%#NAME#%_ became very deconditioned. PT and OT were consulted and recommended further rehabilitation in the nursing home setting.
IT|intrathecal|IT|141|142|DISCHARGE MEDICATIONS|10. Morphine elixir 10 mg q. 4-6h. p.r.n. 11. Zofran 8 mg p.o. b.i.d. p.r.n. nausea and vomiting. 12. Keflex 500 mg q.i.d. for one week. 13. IT pump and manipulated by the Pain Team. 14. Check sugars q.i.d., with sliding scale per patient. DISPOSITION: The patient will be following up with her primary care physician, Dr. _%#NAME#%_, in on week to follow up on diabetes and with Dr. _%#NAME#%_ _%#NAME#%_ for a CBC, SMA-10, platelets, and liver function tests in one week, on _%#MMDD2003#%_.
IT|GENERAL ENGLISH|IT|288|289|PLAN|5. Social Service evaluation 6. Continue current medications. We will continue her aspirin at this time until we get more data. Certainly no indication for Coumadin at this point. 7. DNR, DNI WHICH WAS MADE QUITE CLEAR BY HER CONSERVATOR DURING The LAST HOSPITAL STAY AND I WILL CONTINUE IT AT THIS TIME.
IT|GENERAL ENGLISH|IT|163|164|ALLERGIES|It is positive for the neck pain radiating to the head. It is also positive for the mild confusion. ALLERGIES: THE PATIENT HAS AN ALLERGY TO HYDROCODONE, TYLENOL, IT IS NOT COMPLETELY CLEAR WHAT THE REACTION WAS. IT DOES MENTION HIVES IN THE CHART ALTHOUGH THE PATIENT STATES SHE THINKS IT WAS MORE CONFUSION.
IVF|intravenous fluid|IVF|207|209|PROBLEM #2|However, no fracture was present. _%#NAME#%_ was placed in a left long leg cast to be on for a 3-week period. PROBLEM #2: Fluid, electrolytes, and nutrition/Gastrointestinal. _%#NAME#%_ was prehydrated with IVF before beginning chemotherapy. He had significant difficulties with nausea and vomiting during the chemotherapy. This was controlled with IV Zofran drip and dexamethasone and lorazepam.
IVF|intravenous fluid|IVF.|172|175|PLAN|We will continue his Celexa, Doxepin and amitriptyline. I will hold Campral and Neurontin. I will start him on Protonix 40 mg IV daily for his gastritis and treat him with IVF. I will consult with chemical dependency for possible transfer to inpatient psychiatry in the a.m. Overall, he is hemodynamically stable.
IVF|intravenous fluid|IVF|283|285|IMPRESSION AND PLAN|We will reevaluate the patient at that point and either discharge later today if the patient is feeling better or perhaps tomorrow morning. 2. Hypokalemia: We will place the patient on potassium protocol. 3. Hypotension: Suspect related to dehydration and infection. Will administer IVF and monitor.
IVF|intravenous fluid|IVF|263|265|HOSPITAL COURSE|With regard to her kidney function; Her baseline creatinine is 2.0. This is probably secondary to hypertensive nephrosclerosis versus diabetic nephropathy. She went into ARF 2nd to prerenal azotemia. Peak cr 2.54 during this hospital course. She was treated with IVF and cr came down to 2.2 on the day of this discharge. She will follow-up with her primary care physician in clinic for further monitoring.
IVF|intravenous fluid|IVF|160|162|4.  FEN|She does have chronic anemia and her hemoglobin on discharge was 9.1. 3. Pain: The patient's pain was controlled with Percocet. 4. FEN: The patient did receive IVF at the time of admission, but on the day of discharge, was tolerating p.o. well. 5. Infectious Disease: The patient did have fever of unknown etiology but was no infectious source identified, was not treated with antibiotics.
IVF|intravenous fluid|IVF.|154|157|IMPRESSION|There is no palpable hepatosplenomegaly and no masses. IMPRESSION: 1. Suspicious ultrasound for a polyp. 2. Past history of polyps. 3. Patient undergoing IVF. PLAN: Proceed to hysteroscopy with polypectomy, and possible D&C.
IVF|intravenous fluid|IVF.|171|174|PATIENT IDENTIFICATION|She is now being evaluated for IVF. In preparation for the IVF, Dr. _%#NAME#%_ has recommended bilateral proximal tubal occlusion to improve the chances of the success of IVF. It was felt that a laparotomy was necessary to accomplish this. On _%#MMDD2004#%_, the patient underwent laparotomy, lysis of pelvic and intraabdominal adhesions, bilateral proximal tubal ligation, oversewing of sigmoid bowel serosa.
IVF|intravenous fluid|IVF|261|263|4. GI|He was transferred to the NICU for prematurity. The admission physical examination was normal except for moderate bruising of the scalp. Problems during the hospitalization included the following: 1. Fluids, Electrolytes, & Nutrition: _%#NAME#%_ was started on IVF fluids on admission and started 10mL feeds of breast mil of Enfamil preterm formula every three hours the following day, which he tolerated well with only small amounts of infrequent emesis.
IVF|intravenous fluid|IVF|108|110|1. FEN|Problems during the hospitalization included the following: 1. FEN: _%#NAME#%_ was initially made NPO, with IVF of D10W at 60 mL/kg/day. He was quickly transitioned to breast feeding ad-lib, on demand when it became apparent he was exhibiting no respiratory difficulties.
IVF|intravenous fluid|IVF,|203|206||The patient was counseled about this extensively at that time and now wants pregnancy. She understands the risk of ectopic. She also understands the fact that she may not be able to get pregnant without IVF, but after all of this counseling the patient still wanted to try for pregnancy without IVF. She wanted to be reevaluated at this point and if reevaluation proved that there was damage that that might convince her to do another strategy.
IVF|intravenous fluid|IVF|171|173|ASSESSMENT AND PLAN|Continue medications as previous. 5. Cellulitis, treated on IV antibiotics. 6. Patient does not appear to be dehydrated and if taking p.o.fluids well, we will Heplock his IVF or reduce the rate. 7. Degenerative joint disease and pain, control with pain medications. 8. Medications p.r.n. to help sleep and decrease anxiety as needed.
IVF|in vitro fertilization|IVF,|226|229|HISTORY|The patient has known congenital absence of the left adnexa and had a hematosalpinx on her right adnexa which was removed in the past in hopes of improving her changes for IVF. The patient did in fact conceive with the use of IVF, and went on to have a normal spontaneous vaginal delivery. Following this, the patient again had problems with right lower quadrant pain and a repeat laparoscopy was performed which showed significant adhesions, recurrent right ovarian cyst, and endometriosis.
IVF|intravenous fluid|IVF.|182|185|1. FEN|Problems during the hospitalization included the following: 1. FEN: Glucose on admission was within the normal range, so she was allowed to breast feed on demand without needing any IVF. Prior to discharge, she was taking adequate volume breastfeeding to maintain hydration. 2. Heme: An initial CBC was obtained in the new-born nursery because of maternal fever, it showed a platelet count of 56,000.
IVF|in vitro fertilization|IVF|247|249|HISTORY OF PRESENT ILLNESS|3. Tocolysis with nifedipine 10 mg p.o. q.8h. 4. Cervical length ultrasound on _%#MM#%_ _%#DD#%_, 2005, at 3.2 cm. CONSULTATIONS: Maternal fetal medicine, Dr. _%#NAME#%_. HISTORY OF PRESENT ILLNESS: This is a 30-year-old G1, P0 who conceived with IVF di-di twin gestation, who presents at 26 plus 4 weeks' gestation on _%#MM#%_ _%#DD#%_, 2005. The patient conceived with embryo transfer. Her presentation included contractions greater than 2 days and vaginal bleeding in a.m. of presentation.
IVF|in vitro fertilization|IVF|101|103||_%#NAME#%_ _%#NAME#%_ is a 26-year-old gravida 2, para 1 presents with a twin pregnancy with a known IVF cycle. The patient did have history of preterm labor and the last pregnancy had been a cesarean section at approximately 36 weeks.
IVF|in vitro fertilization|IVF,|202|205|DISCHARGE MEDICATIONS|He was born on _%#MMDD2002#%_ at Fairview Southdale and transferred to the NICU on _%#MMDD2002#%_ and transferred back to Fairview Southdale on _%#MMDD2002#%_. The mother's pregnancy was complicated by IVF, gestational diabetes, PROM 15 hours prior to delivery and twin discordancy. The infant was delivered as twin B by C-section with Apgar scores of 7 at one minute and 8 at five minutes.
IVF|in vitro fertilization|IVF|183|185|HISTORY OF PRESENT ILLNESS|DOB: HISTORY OF PRESENT ILLNESS: Patient is a 38-year-old white female, gravida 3, para 1011, with an EDC of _%#MMDD2005#%_, blood group A, RH positive, rubella status immune who has IVF with IXI twins, presently at 32 2/7 weeks gestation. There are dichorionic diamniotic twins. The patient denies any known contractions.
IVF|in vitro fertilization|IVF|247|249|HISTORY OF PRESENT ILLNESS|COMPLICATIONS: None. HISTORY OF PRESENT ILLNESS: This is a 28-year-old P0 at 37 plus 5 weeks who was admitted for assessment, induction, and delivery. Pregnancy complicated by class B diabetes, hypothyroidism, and mild preeclampsia. Pregnancy was IVF pregnancy with transfer on _%#MM#%_ _%#DD#%_, 2004. The patient has been followed for prenatal care from _%#MM#%_ _%#DD#%_, 2004, at 7 weeks by Dr. _%#NAME#%_.
IVF|intravenous fluid|IVF|199|201|HOSPITAL COURSE|Therefore, upon discharge on _%#MM#%_ _%#DD#%_, 2005, as the patient was afebrile and stable, her clindamycin was discontinued before discharge. 3. Fluids, electrolytes, and nutrition - Liz received IVF per chemotherapy protocol. Her electrolytes were followed, and she did not develop new complications. She also tolerated a regular diet very well during her stay.
IVF|in vitro fertilization|IVF|195|197|HISTORY OF PRESENT ILLNESS|In light of her previous ectopic gestation, the patient does not desire conservative therapy and instead desires salpingectomy. The patient understands that future pregnancies will have to be by IVF and she said that she does not want to run the risk of another ectopic gestation. We told her that removing the tube would minimize that, but not necessarily completely eliminate that risk.
IVF|in vitro fertilization|IVF|296|298|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 37-year-old white female gravida 2, para 1-0-0-1, EDC of _%#MMDD2006#%_, blood group B, Rh positive, rubella status immune, VDRL nonreactive, hepatitis B surface antigen negative, HIV negative, Pap normal, 1 hour glucose screen 139, who has IVF twin pregnancy with a persistent complete placenta previa. The twins are dichorionic diamniotic twins. First trimester screening was performed and was within normal limits patient.
IVF|in vitro fertilization|IVF|161|163|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 33-year-old white female gravida 1 para 0-0-0-0, blood group B rh positive, rubella status immune with an IVF dichorionic diamniotic twin gestation with a previous myomectomy who had an EDC of _%#MMDD2005#%_. After reviewing the findings and discussing the risks, benefits and alternative forms of therapy, the decision was made that the patient is not a candidate for trial of labor.
IVF|intravenous fluid|IVF|187|189|DISCHARGE MEDICATIONS|Problems during his hospitalization included the following: Problem #1: Fluids/Electrolytes/Nutrition. _%#NAME#%_ had the following lines placed: peripheral IV. _%#NAME#%_ was started on IVF in an attempt to correct his hypernatremia and dehydration. He was also allowed to breast feed ad lib. He had difficulty with weight gain during his hospitalization, and this problem was thought to be due to water loss and renal tubular acidosis rather than an increased metabolic demand.
IVF|intravenous fluid|IVF.|167|170|DISCHARGE MEDICATIONS|Repeat renal US showed bilateral increased renal echogenicity and hydronephrosis. VCUG was negative. _%#NAME#%_ was begun on supplemental free water and maintained on IVF. He was transitioned to oral free water supplementation, but was able to maintain hydration without this at the time of discharge.
IVF|intravenous fluid|IVF|171|173|1. FEN|The physical examination was significant for jaundice and sluggish reflexes. Problems during the hospitalization included the following: 1. FEN: _%#NAME#%_ was started on IVF and gavage feeds at 30ml every 3 hours of breast milk. He tolerated feeds well and was gradually increased to 160 ml/kg/day.
IVF|intravenous fluid|IVF|351|353|2. GU|A basic metabolic in the evening showed a sodium of 124, a potassium of 5.8, a chloride of 92, a bicarbonate of 27, a glucose of 71, and a BUN/creatinine of 12/0.6. Aggressive rehydration was initiated; _%#NAME#%_ received boluses of NS at 10mg/kg, and was started on D5 NS IVF. Urine output improved, with rising sodium and falling potassium levels. IVF was titrated downwards as his PO and gavage feeds were increased. Please refer to F/E/N section for additional information regarding feeds.
IVF|intravenous fluid|IVF|224|226|5. F/E/N|_%#NAME#%_ was afebrile throughout the entire NICU stay. 5. F/E/N: _%#NAME#%_ was advanced slowly on his feeds, starting at 15cc q3hrs via PO and gavage and later increasing to 60cc q3 hrs. He required additional fluids via IVF when poor urine output was noted. Although he did not tolerate our attempt to advance his feeds at first, repeat attempts were successful, and he was able to feed ADL at the time of discharge.
IVF|intravenous fluid|IVF|227|229|1. FEN|The admission physical examination was significant for tachypnea (respiratory rate 80- 100/min) without retractions, grunting, or flaring. Problems during the hospitalization included the following: 1. FEN: Logan was placed on IVF and ultimately titrated on breast milk via OG/breast. He tolerated these feeds well and crystalloid fluids were subsequently reduced to prevent fluid overload.
IVF|in vitro fertilization|IVF.|195|198|HISTORY OF PRESENT ILLNESS|Prenatal labs include B positive, antibody negative, rubella immune, HIV negative, hepatitis B negative, VDRL negative. Pregnancy was complicated by infertility. This pregnancy was the result of IVF. Past OB history is negative. Past GYN history is negative.
IVF|intravenous fluid|IVF.|193|196|HISTORY|_%#NAME#%_ was subsequently diagnosed with Down syndrome. Problems during the hospitalization included the following: 1. FEN. Upon admission, _%#NAME#%_ was made NPO and started on maintenance IVF. _%#NAME#%_ required multiple 5% albumin colloid flushes on day two of life for hypotension. He got TPN from DOL _%#MMDD#%_. MBM gavage feeds were started on DOL 6 and advanced to full volumes on day 10, at which time we started working on breast and bottle-feeds.
IVF|intravenous fluid|IVF,|183|186|1. FEN|The admission physical examination was significant for few crackles at lung bases. Problems during the hospitalization included the following: 1. FEN: She was made NPO and started on IVF, which was changed to TPN after a few hours. TPN was given until DOL 3. She started gavage feeds on DOL 1 and reached full feeds on DOL 4.
IVF|intravenous fluid|IVF.|193|196|1. FEN|Also, it was noted that the umbilical cord was short at only 27 cm (normal > 45). Problems during the hospitalization included the following: 1. FEN: Pt was initially held NPO with maintenance IVF. Blood glucose was normal on admission to the NICU at 97. Cord blood gas and initial ABG were suggestive of a mild metabolic acidosis, consistent with intrauterine stress.
IVF|intravenous fluid|IVF.|164|167|1. FEN|Problems during the hospitalization included the following: 1. FEN: Initially the baby was made NPO secondary to the respiratory distress and placed on maintenance IVF. Once her respiratory status was stable she given gavage feeds and the IVF was titrated down. Later she attempted breastfeeding. The admission glucose was 68.
IVF|in vitro fertilization|IVF|179|181|HISTORY OF PRESENT ILLNESS|She does have some mild edema of the lower extremities which has been stable. The remainder of _%#NAME#%_'s prenatal course has been significant only for the fact that this is an IVF pregnancy in an AMA mother. She had a normal level II and amniocentesis. PAST OBSTETRICAL HISTORY: VIP times two.
IVF|in vitro fertilization|IVF|127|129||_%#NAME#%_ _%#NAME#%_ is a 40-year-old white female, gravida 2, para 0-0-1-0, who had a successful pregnancy on first cycle of IVF (secondary to infertility), and she had twin gestation in this pregnancy, diamniotic, dichorionic, and she had serial level II ultrasounds that showed adequate fetal growth, with Twin A at the 76th percentile, and Twin B at the 48th percentile. The first baby was presenting as breech, and the second as transverse lie.
IVF|in vitro fertilization|IVF|155|157|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Menometrorrhagia, unresponsive to medical management. HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old white female para 1,0,4,2, IVF twins at 37 weeks' gestation with a long-standing history of infertility who we have been following for menometrorrhagia that has been unresponsive to medical management. The patient underwent a fractional D&C and failed attempt at NovaSure endometrial ablation on _%#MMDD2006#%_.
IVF|intravenous fluid|IVF|138|140|PLAN|Problems during his hospitalization included the following: Problem #1: Fluids/Electrolytes/Nutrition. _%#NAME#%_ was initially placed on IVF and breast feeding ad lib was started on _%#MMDD2006#%_. Gavage feedings of Enfamil 20 were initiated on _%#MMDD2006#%_ to supplement breast feeding and were discontinued at time of transfer.
IVF|intravenous fluid|IVF|249|251|HOSPITAL COURSE|3. Pain: The patient's pain was controlled with a PCA. On postoperative day #1, she was transitioned to Roxicet elixir with good pain control. 4. FEN: The patient received IVF at the time of surgery. She began to tolerate increased p.o. intake. Her IVF rate was decreased. IV was heplocked on postoperative day #2. 5. GI: No issues. 6. GU: The patient's Foley catheter was removed on postoperative day #1.
IVF|in vitro fertilization|IVF|197|199|PATIENT IDENTIFICATION|Cesarean section is scheduled for _%#MM#%_ _%#DD#%_ along with a tubal ligation should she not begin spontaneous labor by that time. It should also be mentioned that her first two pregnancies were IVF pregnancies; the current pregnancies was spontaneous. Her first pregnancy resulted in an early pregnancy loss, a trisomy-20. PAST MEDICAL HISTORY: The patient has no significant chronic or acute medical illnesses.
IVF|intravenous fluid|IVF|200|202|1. FEN|The admission physical examination was significant for subcostal retractions and increased work of breathing. Problems during the hospitalization included the following: 1. FEN: NPO on admission with IVF at 60cc/kg/day. By DOL 1 he was taking oral feedings of breast milk and Enfamil with iron 20 kcal/oz. He has bottled very well and at discharge was on ad lib demand feeds.
IVF|intravenous fluid|IVF|139|141|1. CV|He was NPO initially secondary to his respiratory distress. He was able to begin breastfeeding ad lib on _%#MMDD2004#%_, at which time his IVF were discontinued. Lactation consult was obtained to assist _%#NAME#%_ and his mother with breastfeeding. He was able to breastfeed every two to three hours with no difficulties.
IVF|in vitro fertilization|IVF.|149|152|HISTORY/HOSPITAL COURSE|HISTORY/HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 32 5/7 week primigravid who has a known placenta previa. The patient's pregnancy was achieved by IVF. She presented to the office with concerns of decreased fetal movement. Fetal heart tones were obtained and patient was placed on the nonstress test monitor.
IVF|in vitro fertilization|IVF.|132|135|HOSPITAL COURSE|HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 28-year-old, gravida 2, para 0-0-1-0, who was followed in clinic for twin gestation via IVF. She had an ultrasound in clinic on the day of admission, which showed a total amniotic fluid index of 5, and Baby A had a 2 cm pocket consistent with oligohydramnios.
IVF|in vitro fertilization|IVF.|168|171|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 41-year-old gravida 3, para 0-0-2-0 at 26 plus 3 weeks by an EDC of _%#MM#%_ _%#DD#%_, 2006, by date of conception from IVF. The patient currently has a di-di twin pregnancy, and she was transferred from Southdale Hospital due to pre-term labor symptoms.
IVF|intravenous fluid|IVF|153|155|DISCHARGE INSTRUCTIONS|He bottles Breastmilk fortified to 28kcal/oz with Neosure, in addition to breastfeeding. He was made NPO briefly prior to surgery, and was maintained on IVF during that time. There was some concern that he was not gaining weight well during his stay, and he was briefly put on a cue-based schedule.
IVF|intravenous fluid|IVF|150|152|HOSPITAL COURSE|ABDOMEN: Benign. EXTREMITIES: She was warm, well perfused in her extremities. HOSPITAL COURSE: Post-dental procedure - Sheena was observed overnight. IVF were administered. She did well and woke up, began eating and looked clinically well in the morning except for a fever to 103.2 and cough.
IVF|intravenous fluid|IVF|211|213|STAFF ADDENDUM|Unclear etiology of vomiting. Early gastroenteritis vs gastric outlet obstruction, vs other. Plan Slowly restart feeds to see if vomiting returns. If returns, consider evaluation for gastric outlet obstruction. IVF rehydration.
IVF|in vitro fertilization|IVF,|253|256|HISTORY OF PRESENT ILLNESS|4. Removal of uterine packing with cystoscopy, _%#MM#%_ _%#DD#%_, 2003. HISTORY OF PRESENT ILLNESS: Patient is a 34-year-old G4, P1-1- 1-2 with an intrauterine pregnancy at 24 plus 0 weeks gestational age by EDC of _%#MM#%_ _%#DD#%_, 2003, conceived on IVF, who presented initially with vaginal bleeding and back pain for 4 days duration. Patient also had vaginal discharge that was clear and yellow.
IVF|intravenous fluid|IVF|206|208|1. FEN|The admission physical examination was significant for coarse breath sounds bilaterally. Problems during the hospitalization included the following: 1. FEN: _%#NAME#%_ was initially made NPO and started on IVF and TPN. Gavage feeds were started at one day of age, and were advanced quickly to full feeds. TPN was stopped at 3 days of age. _%#NAME#%_ then began breastfeeding.
IVF|in vitro fertilization|IVF|208|210|HISTORY OF PRESENT ILLNESS|The patient denies any change in her bowel or bladder habits. She denies any shortness of breath or chest pain. She has had similar side effects of increased abdominal girth and fullness status post previous IVF cycles and has had estrogen levels in the past exceeding 5000. ADMISSION MEDICATIONS: 1. Progesterone in oil 50 mg IM q.h.s.
IVF|in vitro fertilization|IVF|110|112|ASSESSMENT|Endometrial stripe is 7 mm. Several liters of fluid are apparent in the cul-de-sac. ASSESSMENT: A 36-year-old IVF patient with ovarian hyperstimulation syndrome. PLAN: Plan at the time was to admit patient to 10A for strict fluid resuscitation, subcutaneous heparin, intake and output, DVT prophylaxis, and plan for paracentesis in the a.m. on _%#MM#%_ _%#DD#%_, 2004, in the reproductive endocrinology clinic.
IVF|intravenous fluid|IVF|91|93|ASSESSMENT/PLAN|Will need reversal of coagulopathy and platelets should he need surgery 2) ESLD - minimize IVF (currently at TKO of 30 ml/hour into PICC). Minimize transfusions as he is a transplant candidate 3) CKD - at baseline, monitor 4) CHRONIC HYPOTENSION - monitor, will bolus only if becomes more hypotensive than baseline and/or symptomatic 5) CODE STATUS: FULL CODE
IVF|intravenous fluid|IVF:|189|192|HOSPITAL COURSE|As she began to tolerate increased p.o. intake, she was transitioned to oral pain medications. At the time of discharge, the patient's pain was well controlled on oral pain medications. 4. IVF: The patient received intravenous fluids at the time of surgery. On postop day #1, her IV was Hep-Locked and she was tolerating regular diet at the time of discharge.
IVF|intravenous fluid|IVF|284|286|HOSPITAL COURSE|3. Pain. Initially, the patient's pain was well controlled with the PCA which was discontinued on postoperative day #1 when the patient was tolerating p.o. intake. At the time of discharge, the patient's pain was well controlled on oral pain medications. 4. FEN: The patient received IVF at the time of surgery. As she tolerated increased p.o. intake, her IV fluids were Hep-Locked on postoperative day #1.
IVF|in vitro fertilization|IVF|140|142|HISTORY OF PRESENT ILLNESS|She was treated with Glucophage b.i.d. x6 months plus 4 cycles of Clomid, one combined with gonadotropins. She recently completed her first IVF attempt on a low dose protocol of Follistim. She had a total of 15 oocytes retrieved on _%#MMDD2007#%_ and had 2 embryos transferred on _%#MMDD2005#%_.
IVF|in vitro fertilization|IVF|170|172|HISTORY OF PRESENT ILLNESS|2. Preterm labor with cervical dilation of 3 cm. PROCEDURES: None. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 32-year-old G2, P 1-0-0-1 at 34 plus 4 weeks by IVF dating with di-di twin IUP presented to _%#CITY#%_ _%#CITY#%_ with regular painful contractions, cervix 2-3. The patient was given Terbutaline x2 and transferred via helicopter to Fairview _%#CITY#%_ as contractions stopped while in transition.
IVF|intravenous fluid|IVF|170|172|1. FEN|The physical examination was significant only for fussiness. Problems during the hospitalization included the following: 1. FEN: _%#NAME#%_ was initially rehydrated with IVF and continued to receive IVF through her first hospital day. Her oral intake improved after the first day and she was bottling well (about 50-60 cc q3 hours) at discharge.
IVF|intravenous fluid|IVF|199|201|1. FEN|The physical examination was significant only for fussiness. Problems during the hospitalization included the following: 1. FEN: _%#NAME#%_ was initially rehydrated with IVF and continued to receive IVF through her first hospital day. Her oral intake improved after the first day and she was bottling well (about 50-60 cc q3 hours) at discharge.
IVF|intravenous fluid|IVF|196|198|FEN|The physical examination was significant for intubation, subcostal retractions and coarse breath sounds. Problems during the hospitalization included the following: FEN: _%#NAME#%_ was started on IVF on arrival to the NICU. She was started and remains on TPN while her feedings advance. The day of transfer, she attempted breastfeeding and was started on gavage feeds of breast milk.
IVF|in vitro fertilization|IVF|150|152||She had presented to the office with no fetal movement this morning. The patient's pregnancy has been complicated by known placenta previa. She is an IVF pregnancy and has been watched with biophysical profiles and is scheduled for a planned cesarean section. When the patient presented to Labor and Delivery, fetal heart tones were heard.
IVF|intravenous fluid|IVF|221|223|RDS.|The admission physical examination was unremarkable except for decreased air entry and tachypnea and a 2 vessel umbilical cord. Problems during the hospitalization included the following: 1. FEN-_%#NAME#%_ was started on IVF in first day of life and continued for 2 days. TPN was started _%#MMDD2004#%_ and discontinued after 2 days. We began EPF 20 kcal/oz formula on _%#MMDD2004#%_, but _%#NAME#%_ didn't tolerate feeding initially.
IVF|in vitro fertilization|IVF|176|178|PATIENT IDENTIFICATION|_%#NAME#%_ underwent a sonohysterogram on _%#MM#%_ _%#DD#%_, 2004, that resulted in a suspected pelvic infection which required hospitalization. She is now being evaluated for IVF cycles. However, prior to proceeding with IVF given her history of bilateral hydrosalpinges related to her pelvic endometriosis and pelvic inflammation, Dr. _%#NAME#%_ has recommended bilateral proximal tubal occlusion to improve the chances of in vitro fertilization success.
IVF|in vitro fertilization|IVF|222|224|PATIENT IDENTIFICATION|_%#NAME#%_ underwent a sonohysterogram on _%#MM#%_ _%#DD#%_, 2004, that resulted in a suspected pelvic infection which required hospitalization. She is now being evaluated for IVF cycles. However, prior to proceeding with IVF given her history of bilateral hydrosalpinges related to her pelvic endometriosis and pelvic inflammation, Dr. _%#NAME#%_ has recommended bilateral proximal tubal occlusion to improve the chances of in vitro fertilization success.
IVF|in vitro fertilization|IVF|119|121|HISTORY OF THE PRESENT ILLNESS|HISTORY OF THE PRESENT ILLNESS: The patient is a 35-year-old G2, P0-1-0-1 at 21 plus 0 weeks by date of conception for IVF pregnancy. The patient has a diamniotic dichorionic twin gestation. The patient was transferred from Fairview-_%#CITY#%_ _%#CITY#%_ with preterm cervical changes.
IVF|in vitro fertilization|IVF|101|103|PRENATAL COURSE|She felt rare, mild tightening, although no significant contractions. PRENATAL COURSE: 1. This is an IVF pregnancy with the conception date being _%#MMDD2003#%_ and a frozen transfer date of _%#MMDD2003#%_. 2. Twin gestation. 3. History of preterm delivery. PRENATAL LABS: The patient is A-positive, antibody screen negative, GC/Chlamydia negative, HIV negative, rubella immune, and RPR negative.
IVF|intravenous fluid|IVF|99|101|1. FEN|Problems during the hospitalization included the following: 1. Nutrition: _%#NAME#%_ was given D10 IVF at 100mL/kg/d. By _%#MMDD#%_, he was tolerating bottle feeds well, and this IVF was stopped. He breastfed and bottled the remainder of his stay on an ad lib demand schedule and gained weight well.
IVF|intravenous fluid|IVF|179|181|1. FEN|Problems during the hospitalization included the following: 1. Nutrition: _%#NAME#%_ was given D10 IVF at 100mL/kg/d. By _%#MMDD#%_, he was tolerating bottle feeds well, and this IVF was stopped. He breastfed and bottled the remainder of his stay on an ad lib demand schedule and gained weight well.
IVF|intravenous fluid|IVF|181|183|LABORATORY DATA|The creatinine was 3.1, BUN 58 (baseline creatinine about 2.0 mg/dl), sodium 153, potassium 5.9 mEq/l, CO2 102, chloride 23, calcium 9.8, initial troponin 0.07, myoglobin 86. After IVF and insulin and a dose of Kayexalate, his repeat potassium was down to 4.8. Initial blood sugar in the Emergency Room was 377.
IVF|UNSURED SENSE|IVF|215|217|OPERATIONS/PROCEDURES PERFORMED|2. Echocardiogram dated _%#MM#%_ _%#DD#%_, 2005. Technically difficult examination. Normal global systolic function. Biatrial enlargement. Normal pericardium. RV systolic pressure 34, greater than RAP. LVIDD 53 mm. IVF 15 mm. 3. Cardiac catheterization dated _%#MM#%_ _%#DD#%_, 2005: Right dominant coronary system with normal left main. LAD with diffuse disease 50% in the mid-LAD. First diagonal normal caliber and mild disease at the ostium.
IVF|in vitro fertilization|IVF.|177|180|OBSTETRIC HISTORY|5. In 1998, oral terbutaline starting at 19-20 weeks with a successful 36 weeks vaginal birth after cesarean was complicated by preeclampsia. 6. Current di-di twin gestation by IVF. GYNECOLOGIC HISTORY: Negative. PAST MEDICAL HISTORY: Headaches, depression, GERD and allergic rhinitis. PAST SURGICAL HISTORY: 1. C-section x1.
IVF|intravenous fluid|IVF|307|309|PROBLEM #4|As she began to tolerate increased p.o. intake, she was transitioned to oral pain medications and at the time of discharge, the patient's pain was well controlled on oral pain medications. PROBLEM #4: FEN. The patient received IVF at the time of surgery. As she began to tolerate increased p.o. intake, her IVF rate was decreased. Her IV was hep locked on postoperative day #1 and at the time of discharge, she was tolerating a regular diet.
IVF|in vitro fertilization|IVF.|238|241|HISTORY|She is scheduled next week for this, but given the rupture of membranes and labor, plans are made to proceed with a cesarean section immediately. Prenatal care was at Southdale OB/GYN. Care was excellent. This pregnancy was the result of IVF. Prenatal labs were within normal limits including blood type O positive, antibody negative, hemoglobin 13, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, HIV negative, urine culture negative, quad screen negative, 1-hour GCT 132, group B strep positive.
IVF|intravenous fluid|IVF|133|135|PROBLEM #4|PROBLEM #4: FEN: The patient received intravenous fluids at the time of surgery. As she began to tolerate increased p.o. intake, her IVF rate was decreased and then stopped. Her IV was hep-locked on postop day #1. At the time of discharge, the patient was tolerating a regular diet.
IVF|intravenous fluid|IVF|263|265|1. FEN|The admission physical examination was significant for hematoma on the forehead, grade 2/6 SEM along the LSB, and decreased movement of the left arm. Problems during the hospitalization included the following: 1. FEN: Initially Shaneese was placed on maintenance IVF which was titrated down once she was able to take ad lib po with Enfamil 20 kcal/oz. She had great po intake so the IV was heplocked.
IVF|intravenous fluid|IVF|195|197|1. FEN|Eyes were fused. Remainder of exam was consistent with an AGA extremely preterm female infant. Her hospital course, summarized by system, is as follows: 1. FEN: _%#NAME#%_ was NPO and started on IVF at 80 cc/kg/d. A UAC was placed. A UVC was unable to be placed in a high position, so a low UVC was used temporarily for medications, until a right IJ line was placed by Peds Surgery later that day.
IVF|in vitro fertilization|IVF|128|130|HISTORY|PRIMARY PHYSICIAN: Dr. _%#MM#%_ _%#DD#%_ HISTORY: _%#NAME#%_ _%#NAME#%_ is a 35-year-old gravida 2, para 1 who is in her second IVF pregnancy that has been complicated by central location placenta previa. Her last menstrual period was _%#MM#%_ _%#DD#%_, her estimated date of confinement which would be exact because for IVF is _%#MMDD#%_.
IVF|in vitro fertilization|IVF|325|327|HISTORY|PRIMARY PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_ HISTORY: _%#NAME#%_ _%#NAME#%_ is a 35-year-old gravida 2, para 1 who is in her second IVF pregnancy that has been complicated by central location placenta previa. Her last menstrual period was _%#MM#%_ _%#DD#%_, her estimated date of confinement which would be exact because for IVF is _%#MMDD#%_. She is admitted at 32 5/7ths weeks gestation because of her second episode of bleeding. Her initial placenta previa had bleeding at 26 weeks gestation.
IVF|in vitro fertilization|IVF|162|164|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ presented to labor and delivery as a 35-year-old, G11, P1, 091 at 26 plus 5 weeks' estimated gestational age by IVF transfer on _%#MM#%_ _%#DD#%_, 2004, for an EDC of _%#MM#%_ _%#DD#%_, 2004. Patient had originally presented with right lower quadrant pain, and an ultrasound showed cervical shortening (0.8 to 0.9 cm).
IVF|in vitro fertilization|IVF|121|123|HISTORY OF THE PRESENT ILLNESS|REASON FOR ADMISSION: Abdominal pain HISTORY OF THE PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 31- year-old G5, P1 with IVF and embryo transfer done on _%#MMDD2004#%_ by _%#NAME#%_ _%#NAME#%_. Two embryos were transferred. She had hyperstimulation of the ovary and removal by culdocentesis of fluid on _%#MMDD#%_ and _%#MMDD#%_ of 2004.
IVF|in vitro fertilization|IVF|201|203|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Probable incomplete AB. HISTORY OF PRESENT ILLNESS: The patient is a 39-year-old white female gravida 1, para 0-0-0-0, blood group O, Rh positive, who, on _%#MMDD2005#%_, underwent an IVF cycle at Reproductive Medicine Associates. It was a transfer of 4 embryos into the uterine cavity. She had an initial positive pregnancy test at RMIA on _%#MMDD#%_.
IVF|in vitro fertilization|IVF|147|149|ADMISSION DIAGNOSIS|Fetal fibronectin negative on _%#MM#%_ _%#DD#%_, 2005. PAST OBSTETRICAL HISTORY: Spontaneous abortion x1 on the first trimester. This pregnancy is IVF in _%#CITY#%_. PAST GYNECOLOGICAL HISTORY: 1. PCOS previously on Glucophage. 2. Endometriosis diagnosed by laparoscopy in 2004. PAST MEDICAL HISTORY: PCOS and endometriosis. PAST SURGICAL HISTORY: PCO repair and laparoscopy.
IVF|in vitro fertilization|IVF|179|181|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old white female para 0-0-0-0 with a long-standing history of primary infertility. She has recently been scheduled to undergo IVF beginning approximately _%#MMDD2006#%_ with Dr. _%#NAME#%_ _%#NAME#%_ at the Center For Reproductive Medicine. Dr. _%#NAME#%_ performed a pre-IVF ultrasound examination, and the examination in his office suggested small endometrial polyp in the anterior uterine wall.
IVF|in vitro fertilization|IVF|185|187|HISTORY OF PRESENT ILLNESS|I reviewed these findings with Dr. _%#NAME#%_ _%#NAME#%_, and I discussed the endometrioma with him and whether it would have an impact on her ability to conceive and retrieve eggs for IVF cycles. At this point, he feels that it should not have an effect on the pregnancy outcome, but it could potentially make retrieval of the egg more challenging.
IVF|in vitro fertilization|IVF|200|202|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 28-year-old gravida 1, para 0, with a twin gestation at 33 and 5/7th weeks' gestation and an estimated date of delivery of _%#MMDD2006#%_. That is exact because of IVF technologies. She is presenting with frequent regular contractions that are not controlled by taking terbutaline 5 mg every two hours. She has previously had some preterm contractions but has not changed her cervix, and was actually able to continue working up until four days prior to this admission.
IVF|in vitro fertilization|IVF.|206|209|OB HISTORY|FD ratio of twin B also was abnormal with increased resistance in the end-diastolic flow at the umbilical artery. OB HISTORY: SAB x1. The patient does have 1 adopted child. This pregnancy was conceived via IVF. GYN HISTORY: The patient denies any history of sexually transmitted infections or abnormal Pap smear.
IVF|in vitro fertilization|IVF|271|273|HISTORY|DATE OF SURGERY: _%#MMDD2007#%_ PROCEDURE: Cesarean section. HISTORY: The patient is a 30-year-old gravida 4, para 1, EDC _%#MMDD2007#%_, who is to be admitted on _%#MMDD#%_ for primary C-section due to twin gestation with twin A vertex and twin B transverse. This is an IVF pregnancy complication by diamniotic dichorionic twins. Growth has been concordant with twin A slightly smaller. She has had no evidence of preterm labor.
IVF|intravenous fluid|IVF|143|145|4. ID|Problems during the hospitalization included the following: 1. FEN. _%#NAME#%_ was allowed to breast feed ad lib upon his arrival in the NICU. IVF were started as maintenance, electrolytes were monitored, and urine output was within normal limits. By day 3 of life, _%#NAME#%_ had a V-P shunt placed per neurosurgery, and he began taking small enteral feeds by day 4 of life.
IVF|in vitro fertilization|IVF|173|175|ISSUES|HIV: negative. Hepatitis surface antigen: negative. Rubella: immune. RPR: negative. GBS: pending. GCT: not available. ISSUES: The patient has advanced chronological age, an IVF pregnancy, and labile blood pressures, with an elevated GCT. PAST OBSTECTRICAL HISTORY: In 2002, she had a 5- to 6-week spontaneous AB.
IVF|in vitro fertilization|IVF,|348|351|OPERATIONS/PROCEDURES PERFORMED|HISTORY OF PRESENT ILLNESS: The patient is a 34-year-old gravida 4, para 1-1-1-2, with a 16-week intrauterine pregnancy by last menstrual period of _%#MM#%_ _%#DD#%_, 2003, consistent with a 7+ 4-week ultrasound with an EDC of _%#MM#%_ _%#DD#%_, 2004. The patient presents on _%#MM#%_ _%#DD#%_, 2003, for cerclage. This pregnancy was the result of IVF, which was initially a twin pregnancy; one intrauterine pregnancy and one intracervical. The intracervical pregnancy has resulted in demise, with a resolving gestational sac.
IVF|in vitro fertilization|IVF;|191|194|OPERATIONS/PROCEDURES PERFORMED|Her cervix was noted to shorten over the past 2 weeks from 4.6 cm to 2.4 cm with funneling. A cervical gestational sac appears to be resolving in size. PRENATAL CARE: This was the product of IVF; twin pregnancy, now singleton, with demise of cervical pregnancy. Prenatal care was with Dr. _%#NAME#%_, total of 5 visits. PRENATAL LABS: O positive, antibody negative, RPR nonreactive, rubella immune, HIV nonreactive, hepatitis surface antigen negative.
IVF|in vitro fertilization|IVF|148|150|OPERATIONS/PROCEDURES PERFORMED|In 2000, she had a 2-pound 3-ounce baby delivered at 27 weeks with preterm premature rupture of membranes and subsequent delivery; this was also an IVF pregnancy. In 2002, she had an ectopic pregnancy on her right tube. PAST MEDICAL HISTORY: Unremarkable. ADMISSION MEDICATIONS: Prenatal vitamins. ALLERGIES: Include BETADINE, IV DYE, AND IODINE.
IVF|in vitro fertilization|IVF|149|151|OPERATIONS/PROCEDURES PERFORMED|GYN HISTORY: At the age of 12, she experienced menarche with irregular cycles. These last for 5-7 days. She has a history of an ectopic. She has had IVF for 2 pregnancies, this one with a frozen embryo, and this was a second-cycle pregnancy. SURGERIES: She has had 5 laparoscopies, one included for the right ectopic pregnancy.
IVF|intravenous fluid|IVF|140|142|PATIENT IDENTIFICATION|She had typical premature features. Problems during the hospitalization included the following: 1. Fluids, electrolytes and nutrition & GI: IVF were started on admission. These were changed to TPN during the first 24 hours of life. Trophic enteral feeds were started by gavage consisting of breast milk and Enfamil premature 20 Kcal formula on DOL#2.
IVF|UNSURED SENSE|IVF.|132|135|1. FEN|Trophic feeds were begun on DOL #7. Feeds were advanced slowly and he was taking 22cc breast milk Q3 hours at the time of discharge IVF. TPN was discontinued on the day of transfer secondary to accidental removal of the UVC. TPN will likely need to be continued for 1-2 more days.
IVF|intravenous fluid|IVF.|113|116|ASSESSMENT AND PLAN|He is to be NPO in a.m. He may have some clear to thick liquids p.o. tonight for dinner x 1. I will start him on IVF. I will call in those orders. His other medications will be Paxil 20 mg p.o. q. day, Accupril 7.5 mg p.o. q. day, Zantac 50 mg IV q8h, and Albuterol inhaler two puffs q.i.d. p.r.n. Check abdominal girth.
IVF|in vitro fertilization|IVF|433|435|HISTORY OF PRESENT ILLNESS|She had been followed for prenatal care since 10 weeks gestation on _%#MMDD2004#%_ and the pregnancy was complicated by genital herpes with the last outbreak approximately one month prior to admission and she was treated with Acyclovir for suppression. She was thought to have a macrosomic fetus by ultrasound examination at 39 weeks, indicating an estimated fetal weight of 39 to 48 grams and in view of the elderly gravida with an IVF pregnancy and an assumed macrosomic fetus, it had been elected to proceed with scheduled primary cesarean section, which had been scheduled for _%#MMDD2005#%_.
IVF|intravenous fluid|IVF|231|233|1. FEN|Maternal screening labs done after deliver were remarkable for a negative HIV screen and negative Hepatitis B surface antigen. Problems during the hospitalization included the following: 1. FEN: _%#NAME#%_ was initially started on IVF for borderline hypoglycemia, which has stabilized with better oral intake. At the time of discharge, he was taking close to full volumes of Neosure 22 by bottle on an ad lib demand schedule.
IVF|in vitro fertilization|IVF|259|261|FOLLOW UP|She was the 1580 gm, 32 + 1 week gestational age female infant born at Fairview Ridges to a 31-year-old, O positive, gravida 1, para 0-0-0-0, Asian female whose LMP was _%#MMDD2005#%_ and whose EDC was _%#MMDD2006#%_. The mother's pregnancy was the result of IVF and was complicated by twin gestation. She presented to Fairview Ridges after spontaneous rupture of membranes and in active labor.
IVF|in vitro fertilization|IVF|170|172|PAST MEDICAL HISTORY|The indications and decision to proceed with a Burch procedure will be further evaluated. PAST MEDICAL HISTORY: 1. The patient has a history of infertility with multiple IVF attempts. 2. Hypertension. 3. History of pituitary adenoma. ALLERGIES: None. MEDICATIONS: 1. Hydrochlorothiazide. 2. Fluoxetine. 3. Cozaar. 4. Detrol. 5. Loestrin _%#MMDD#%_ (discontinued).
IVF|in vitro fertilization|IVF|227|229|GYN HISTORY|Of note is that her HCG was negative. REVIEW OF SYSTEMS: She also states that she has had shortness of breath, is light-headed and fatigued. GYN HISTORY: In 1999, she underwent Cesarean section for triplets. She conceived with IVF and had twins but then one embryo split and she developed triplets with two of them identical. She also has a history of abnormal Pap smears and in the past biopsies have been normal and no treatment has been needed.
IVF|intravenous fluid|(IVF,|186|190|FOLLOWUP|Problem #2: Fluids/Electrolytes/Nutrition. _%#NAME#%_ had the following lines placed: umbilical arterial catheter (cardiopulmonary monitoring, _%#MMDD2006#%_); umbilical venous catheter (IVF, TPN, medication administration, _%#MMDD2006#%_); and peripheral IV. _%#NAME#%_ was initially started on a parenteral glucose infusion. Feedings were started on _%#MMDD2006#%_, and he tolerated the increase in volume and strength of breastmilk and Enfamil 20.
IVF|intravenous fluid|IVF|214|216|PROBLEM #4|The patient's pain was controlled with PCA. On postop day 1 she was transitioned to oral pain medications and pain was well controlled on ibuprofen. PROBLEM #4: Fluid, electrolytes, nutrition. The patient received IVF at the time of surgery. As she began to tolerate increased p.o. intake her IVF was decreased. Her IV was hep-locked on postop day 1. PROBLEM #5: Gastrointestinal.
IVF|intravenous fluid|IVF|159|161|5.  FEN|4. Pain: The pain was controlled with a PCA. On postoperative day #1, the patient's pain was controlled with p.o. pain medicines. 5. FEN: The patient received IVF at the time of surgery. As she began to tolerate p.o. intake her IVF rate was decreased and her IV followed on postoperative day #2 and was not replaced as the patient's p.o. intake was adequate.
IVF|in vitro fertilization|IVF.|168|171|DISCHARGE PLANS|DISCHARGE PLANS: Include follow up with Dr. _%#NAME#%_ for 6-week postpartum visit. Birth control was declined at this point in time as the pregnancy was achieved with IVF. DISCHARGE MEDICATIONS: Include Percocet, ibuprofen and stool softeners. DISCHARGE INSTRUCTIONS: Include 6 weeks of pelvic rest.
IVF|in vitro fertilization|IVF|324|326|HISTORY OF PRESENT ILLNESS|The endometrial curetting showed inactive weak secretory endometrium with the stromal glandular dyssynchrony showing areas of early deciduate change suggestive of exogenous progestational effect, but there was no evidence of any hyperplasia or atypia. The patient most recently has been undergoing infertility treatment and IVF cycles with Dr. _%#NAME#%_ _%#NAME#%_. Most recently the patient's ultrasound has suggested again endometrial filling defects. Because of her past history and potential issues with endometrial filling defects and infertility, a decision was made to repeat an exam under anesthesia, fractional D&C hysteroscopy.
IVF|in vitro fertilization|IVF|171|173|HISTORY|She was given precautions and was sent home on Percocet for pain, Cleocin and Tequin. She will follow up in the office with Dr. _%#NAME#%_ and also had been going through IVF cycle with Dr. _%#NAME#%_ _%#NAME#%_ and will continue to do so. She was currently on Lupron and will begin the IVF cycle in the near future.
IVF|in vitro fertilization|IVF|201|203|HISTORY|She will follow up in the office with Dr. _%#NAME#%_ and also had been going through IVF cycle with Dr. _%#NAME#%_ _%#NAME#%_ and will continue to do so. She was currently on Lupron and will begin the IVF cycle in the near future.
IVF|intravenous fluid|IVF|147|149|1. FEN|The admission physical examination was unremarkable. Problems during the hospitalization included the following: 1. FEN: _%#NAME#%_ was started on IVF initially, but quickly started breastfeeding on an ad lib demand schedule and IVF were discontinued on _%#MMDD2004#%_. He was breast feedings well at discharge. 2. Respiratory / Cardiovascular: No issues.
IVF|intravenous fluid|(IVF)|253|257|ASSESSMENT  AND PLAN|It is unclear whether or not his symptoms are in any way related to his Xeloda therapy given the absence of hand-foot-mouth syndrome and clear liver dysfunction. However, I will do the following things during his admission: 1. Provide intravenous fluid (IVF) rehydration. 2. Undergo infectious workup (culture blood, urine and stools). 3. Perform chest x-ray and abdominal films to rule out pneumonia and bowel obstruction/perforation, respectively.
IVF|in vitro fertilization|IVF.|233|236|HISTORY|PROCEDURE: Repeat low transverse Cesarean birth under spinal anesthesia. HISTORY: _%#NAME#%_ _%#NAME#%_ is a patient of Dr. _%#NAME#%_ _%#NAME#%_ who has been followed regularly throughout her pregnancy. She did have conception with IVF. Her first Cesarean was performed for fetal distress. She was at a playground with her four-year-old daughter, was sitting on a park bench and had spontaneous rupture of membranes.
IVF|in vitro fertilization|IVF|192|194|MEDICATIONS|6. The patient has a vasovagal disorder, which was only a problem for her during delivery of her daughter. MEDICATIONS: The patient is currently on: 1. Progesterone. 2. Estrogen shots per the IVF protocol. ALLERGIES: The patient has no known drug allergies. She does have an allergy to shellfish.
IVF|intravenous fluid|IVF|155|157|ASSESSMENT AND PLAN|10. Intensive Care Unit: Pneuma boots, Ted stockings, seizure precautions. Will start Lovenox tomorrow if patient not willing to get up and move. 11. PPI: IVF 1/2 normal saline 150 mL/hr.
IVF|intravenous fluid|IVF|167|169|ASSESSMENT AND PLAN|8. Due to social issues will have social worker discuss options. She has a history of cocaine abuse. Will consult chem dep. 9. ICU: A PPI, pneumoboots, TED stockings, IVF is D5 half-normal saline with KCl at 125 mL/hr.
IVF|intravenous fluid|IVF|187|189|ASSESSMENT AND PLAN|_%#NAME#%_ also had some moulding, but the remainder of her exam was unremarkable. Problems during the hospitalization included the following: 1. FEN- _%#NAME#%_ was initially started on IVF with glucose, but was rapidly transitioned to gavage feeds and breastfeeding. 2. Respiratory- Her respiratory status continued to stabilize over the NICU stay and she did not require further intervention or intubation.
IVF|intravenous fluid|IVF|172|174|HISTORY OF PRESENT ILLNESS|However, if she has extensive pelvic adhesive disease, I would not try to repair it, as it could cause more damage than I could repair and instead would recommend she have IVF treatments. She is in agreement with this plan. All of _%#NAME#%_'s questions were answered prior to the surgery and she does wish to proceed with the expressed understanding of the risks.
IVF|in vitro fertilization|IVF|136|138|PAST MEDICAL HISTORY|Otherwise review of systems is negative. PAST MEDICAL HISTORY: 1. Prematurity at 30-5/7 weeks. He was 1900 grams. He was the product of IVF and fraternal twins. His brother is fine. 2. Dilated cardiomyopathy. 3. Necrotizing enterocolitis. 4. Seizures in _%#MM#%_ 2004 followed by hydrocephalus. 5. Strabismus.
IVF|intravenous fluid|IVF|206|208|PLAN|The NICU admitted _%#NAME#%_ to rule out sepsis. Problems during his hospitalization included the following: Problem #1: Fluids/Electrolytes/Nutrition. On initial admission to the NICU, _%#NAME#%_ required IVF for a short time until he was talking enteral feeds. He was then transferred to an ad lib demand feeding schedule.
IVF|in vitro fertilization|IVF|215|217|IMPRESSION|BRIEF PHYSICAL EXAMINATION PRIOR TO SURGERY: Normal. The patient is felt to be a satisfactory candidate for the surgery planned. IMPRESSION: 1. Intrauterine pregnancy, twin gestation, 37 and 5/7 weeks gestation. 2. IVF pregnancy with ICSI. 3. Arrest of cervical dilatation in labor. PLAN: Primary low segment transverse cesarean section, under regional anesthesia.
IVF|in vitro fertilization|IVF.|170|173|ALLERGIES|PAST SURGICAL HISTORY: Is negative ALLERGIES: She ACKNOWLEDGES NO ALLERGIES. She does acknowledge a history of infertility with her first two pregnancies, conceived with IVF. The patient's other two pregnancies were delivered in 2003 and 2005. OB/GYN HISTORY: Menarche age 23, periods Q 30 days, lasting three to five days.
IVF|in vitro fertilization|IVF|166|168|HISTORY OF PRESENT ILLNESS|We discussed questions that had arisen on previous ultrasound dating back to _%#MMDD2007#%_. The patient and her husband had given thought extensively about going to IVF and at this point, would prefer not to go there. The distal end of the right fallopian tube was not identified from the hysterosalpingogram of _%#MMDD2006#%_.
IVF|intravenous fluid|IVF,|225|228|HOSPITAL COURSE|Hemoglobin stabilized at 10.9 at the time of discharge. HOSPITAL COURSE: The patient was admitted for possible pyelonephritis given her significant morbidity status post right nephrectomy. Empirically started on Cipro IV and IVF, given reported p.o. intolerance. Cipro was discontinued after the patient was observed to remain afebrile, have an initial negative urine culture and have resolution of her left flank and suprapubic pain overnight.
IVF|in vitro fertilization|IVF|111|113|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 33-year-old gravida 2, para 1 who has had one miscarriage presents with an IVF pregnancy and an estimated date of confinement of _%#MM#%_ _%#DD#%_. The patient has had a good pregnancy but because of her slight stature and the suspicion that the baby is on the smaller side, serial ultrasound were performed just to confirm appropriate growth and amniotic fluid levels and these have been confirmed.
IVF|intravenous fluid|IVF|269|271|FEN|_%#NAME#%_ was a pre-term AGA female infant, 2360 gm at 34+4 weeks gestation, with a length of 47 cm and head circumference of 30 cm. The physical examination was insignificant. Problems during the hospitalization included the following: FEN: _%#NAME#%_ was started on IVF and some breastfeeding on admit. She was gavage fed what she was not taking by breast to maintain caloric intake, and her feedings were advanced as tolerated.
IVF|intravenous fluid|IVF.|154|157|ASSESSMENT AND PLAN|Infection possible, although patient denies fevers, chills, sick contacts. Will however check blood cultures. Will start aggressive volume repletion with IVF. Follow Hgb and recheck WBC in the am. 4. Substance abuse problem. The patient has history of alcohol abuse and is currently using marijuana daily and tested positive for cocaine.
IVF|intravenous fluid|IVF.|235|238|HOSPITAL COURSE|Right upper quadrant ultrasound at admission demonstrated multiple gallstones. Amylase and lipase were markedly elevated. Bilirubin was also higher than usual baseline. Mr. _%#NAME#%_ was made NPO and was given IV pain medications and IVF. There was no evidence for cholangitis, therefore antibiotics were not started. Gastroenterology was involved and did not want to perform urgent EUS or ERCP due to thrombocytopenia, coagulopathy, and recent banding of esophageal varices.
IVF|intravenous fluid|IVF|192|194|A/P|Will f/u on cultures. 3. Weakness: Likely multifactorial: hypothyroidism, dehydration, UTI, depression, deconditioning. We have increased synthroid and are treating UTI. Will also cont gentle IVF until oral intake improves. PT/OT consulted. May benefit from appetite stimulant and antidepressant. 4. Bladder cancer: Locally advanced, although extent and prognosis unclear. Will obtain outside records to clarify.
IVF|in vitro fertilization|IVF|239|241|HISTORY|PROCEDURE: Cesarean section. HISTORY: The patient is a 30-year-old gravida 4, para 1, EDC _%#MMDD2007#%_, who is to be admitted on _%#MMDD#%_ for primary C-section due to twin gestation with twin A vertex and twin B transverse. This is an IVF pregnancy complication by diamniotic dichorionic twins. Growth has been concordant with twin A slightly smaller. She has had no evidence of preterm labor.
IVF|in vitro fertilization|IVF|159|161|HISTORY OF PRESENT ILLNESS|The patient's gynecological history is also significant for secondary infertility which she states was treated with multiple D&C's. She also attempted several IVF cycles without success. Her past OB history is significant for normal spontaneous vaginal delivery followed by retained placenta and a postpartum hemorrhage necessitating emergent D&C.
IVF|intravenous fluid|IVF|165|167|HOSPITAL COURSE|She was transitioned to p.o. pain medications and was tolerating these p.o. medications as adequate pain control on date of discharge. 4. FEN: The patient was given IVF at the time of surgery. Fluids were decreased as the patient started to tolerated increased p.o. intake. She was tolerating a regular diet at the time of discharge.
IVF|intravenous fluid|IVF|225|227|FOLLOW UP|Problem# 3: Polycythemia. Initial labs on _%#MMDD2006#%_ demonstrated a hemoglobin of 21.3 and a hematocrit of 61.6%. Several fluid flushed were given and a peak hemoglobin/hematocrit 23.4/66.4% were drawn on _%#MMDD2006#%_. IVF were started in addition to feeds. During _%#NAME#%_'s hospital course he remained asymptomatic while polycythemic. Upon discharge his hemoglobin was 20.0 and his hematocrit was 59.1%. Problem #4: Screening Examinations/Immunizations.
IVF|intravenous fluid|IVF.|283|286|PROBLEM LIST|2. Renal: The patient was admitted with acute renal failure. Her baseline creatinine is 0.8. FENa was checked during this hospital course, and was elevated at 3.3. This is consistent with acute tubular necrosis, possibly related to ongoing diarrhea. She was aggressively hydrated w/ IVF. We also held her metformin, Micardis/hydrochlorothiazide, Norvasc, and torsemide. Her creatinine on the day of discharge is down to 1.57. The patient was encouraged to drink fluids, and to hold all the aforementioned medications for a couple of more days.
IVF|intravenous fluid|IVF|123|125|ASSESSMENT AND PLAN|We will also be consulting the GI Service for possible endoscopy. We will also have blood type and cross matched. NPO with IVF in anticipation of possible EGD in AM. CODE STATUS: The patient wishes to be a full code.
IVF|intravenous fluid|IVF|208|210|HOSPITAL COURSE|At the time of discharge, the patient's pain was well controlled using only oral pain medications. 4. FEN. The patient received IVF at the time of surgery. As she began to tolerate increased p.o. intake, her IVF rate was decreased and it was actually heparin locked on postoperative day #0. At the time of discharge, the patient was tolerating a regular diet.
IVF|intravenous fluid|IVF|125|127|HISTORY OF PRESENT ILLNESS|She also complained of loss of appetite and back pain. At the emergency room, her blood pressure was 98/53 and she was given IVF bolus. Her urine culture from _%#MMDD2007#%_ showed group D Enterococcus which was susceptible to Ampicillin. Her urinalysis from today showed yellow cloudy urine with trace nitrites and leukocyte esterase and small amount of white blood cells.
IVF|intravenous fluid|IVF|261|263|1. GU|She was transferred to the NICU for respiratory distress. The admission physical examination was significant for bibasilar crackles and oxygen requirement. Problems during the hospitalization included the following: 1. FEN - _%#NAME#%_ was initially started on IVF and TPN for nutrition. On day of life 2, when her respiratory status had improved, she was allowed to take oral feeds.
IVF|intravenous fluid|IVF|124|126|ASSESSMENT AND PLAN|We will keep her on clears for now and advance her diet as tolerated. Will recheck her CBC in AM to monitor her response to IVF and antibiotics. 2. Hyperglycemia likely secondary to patient's diabetes and current infection. At present we will treat her with insulin sliding scale, check her blood sugars frequently and depending on how she does, she may require oral antiglycemic agents at the time of discharge.
IVF|in vitro fertilization|IVF|378|380|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Left ovarian endometrioma. HISTORY OF PRESENT ILLNESS: The patient is a 32-year-old white woman gravida 0 whose last menstrual period was _%#MM2007#%_ who has a history of infertility and has actually had to go all the way to one cycle of in vitro fertilization with ICSI with a reproductive endocrinology and fertility subspecialist. During her workup for the IVF cycle though, she was found to have a probable left ovarian endometrioma that was 2 to 3 cm in diameter. The rest of her ultrasound was reportedly normal by the infertility specialist.
IVF|in vitro fertilization|IVF|276|278|HISTORY OF PRESENT ILLNESS|2. Breech presentation. 3. Fetal macrosomia. 4. In vitro fertilization pregnancy. OPERATIONS/PROCEDURES PERFORMED: Primary low transverse cesarean section. HISTORY OF PRESENT ILLNESS: This is a 37-year-old gravida2, para 0-0-1-0 at 40 plus 0 weeks by early ultrasounds in the IVF clinic, who presented for a primary low transverse cesarean section for breech presentation and suspected fetal macrosomia. At the time of admission, the patient denied vaginal bleeding, loss of fluid, and has occasional contractions, and good fetal movement.
IVF|in vitro fertilization|IVF|330|332|HISTORY OF PRESENT ILLNESS|COMPLICATIONS: Fetal bradycardia. HISTORY OF PRESENT ILLNESS: The patient is a 42-year-old G1, para 0, with EDC of _%#MM#%_ _%#DD#%_, 2006, admitted at 38 weeks with spontaneous rupture of membranes at 0800 hours with clear fluids. The patient was admitted secondary to spontaneous rupture of membranes. Pregnancy was a result of IVF with donor sperm. Ultrasound showed a live intrauterine pregnancy. PAST MEDICAL HISTORY: No significant past medical history.
IVF|in vitro fertilization|IVF|219|221|PAST OB HISTORY|This has been discussed again at length throughout this pregnancy, including the increased risk of C-section and the increased recovery and she continues to express a desire for primary C-section. This pregnancy was an IVF pregnancy. It was otherwise uncomplicated. Quad test was normal. Glucose screen was normal. She is Rh negative and received RhoGAM on _%#MMDD2006#%_.
IVF|intravenous fluid|IVF|254|256|FEN|She was transferred to the newborn nursery but developed an increased oxygen requirement and an evolving systolic heart murmur, and was then transferred to the NICU. Problems during the hospitalization included the following: FEN: Destiny was started on IVF upon admission, and supplemented with total parenteral nutrition (TPN) until oral feeds were initiated on DOL 2, which she has tolerated without difficulty.
IVF|in vitro fertilization|IVF|139|141|FINAL DIAGNOSIS|FINAL DIAGNOSIS: 1. 32 weeks gestation 2. Twins 3. Preterm labor and premature rupture of membranes 4. Gestational diabetes 5. Age 42 with IVF 6. Caesarian section with delivery of twins
IVF|intravenous fluid|(IVF),|126|131|ASSESSMENT AND PLAN|We will check a chem 6 and treat as needed. Also I will add Compazine 10 mg IV q.8, and she will need to be on some IV fluids (IVF), D5 half-normal saline at 125 cc per hour, with 20 mEq of potassium, and then change to 100 cc an hour after the first bag.
IVF|intravenous fluid|IVF.|213|216|ASSESSMENT AND PLAN|The admission physical examination was significant for resp rate of 58, good air entry with no crackles bilaterally. Problems during the hospitalization included the following: 1. FEN - _%#NAME#%_ was admitted on IVF. He started gavage feeds on DOL 2 with breast milk and Enfamil 20kcal/oz. He was allowed to breastfeed ad lib. He initially had episodes of hypoglycemia for the first 3 days of life, with glucoses as low as 36 (post feeding).
IVF|intravenous fluid|IVF|191|193|1. FEN|Enteral feeds were started on DOL # 0. He was treated with IV Lasix to assist with minimizing pulmonary congestion. Hyponatremia of 128 on DOL# 5 resolved without sequela after adjustment of IVF and decreasing the Lasix dose. He was started on enteral feeding on _%#MM#%_ 2 including breast milk and Enfamil 20 Kcal formula which was tolerated well.
IVF|UNSURED SENSE|IVF|135|137|ASSESSMENT/PLAN|10. Nicotine with continued use: Patient is trying to quit. Will add nicotine patch. 11. Dyslipidemia: Will restart Lipitor. 12. Dispo IVF Lovenox PPI: PT/OT pain control. Will change to a PCA.
IVF|intravenous fluid|(IVF)|295|299|PLAN|Unfortunately, on admission, _%#NAME#%_ was quite symptomatic and had hemoglobin of 6.9. He had recently been transfused 3 times over a 1-month period with hemoglobins below 8; therefore, during his hospital course, he was admitted to the ICU with large-bore IVs for initially intravenous fluid (IVF) rehydration and later PRBC transfusion. During his hospital stay, he ultimately received a total of 4 units of PRBCs (2 units on _%#MMDD2007#%_ and 2 units _%#MMDD2007#%_).
IVF|in vitro fertilization|IVF|121|123|DIAGNOSES ON ADMISSION|DIAGNOSES ON ADMISSION: 1. _%#NAME#%_ _%#NAME#%_ is a 36-year-old G1, P0 at 28 plus 1 week by date of conception through IVF with a dichorionic-triamniotic triplet IUP. 2. Preterm contractions. 3. No other complaints. 4. Advanced maternal age. 5. Baby A with history of polyhydramnios and pregnancy.
IVF|intravenous fluid|IVF)|280|283|ASSESSMENT AND PLAN|- Presently being - Monitoring with her with the usual tranplant lab schedule - Nephrology will reassess in 1-2 weeks. 5. PULMONARY HYPERTENSION: Continue Viagra, prn Ventolin. 6. FLUID OVERLOAD (multifactorial: right-sided heart failure, hypoalbuminemia, proteinuria, and recent IVF) - Okay per Nephrology to gently diurese with oral Lasix and monitoring of creatinine, weight, and Is and O's carefully. 7. TYPE 2 DM, diet-controlled. 8. Cardiovascular: a. HYPERTENSION well controlled with present meds.
IVF|in vitro fertilization|IVF.|114|117|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. This 36-year-old G2 P 0-0-1-0 at 29+ 1 weeks. 2. History of di-di IUP with donor eggs and IVF. 3. Known pleural effusion and polyhydramnios in baby A of unknown origin. 4. Hydrops of unknown origin of infant A.
IVF|in vitro fertilization|IVF|272|274|OBSTETRIC HISTORY|She denied nausea and vomiting. The pain worsened with deep breaths and movement, located mostly in the pelvis extending to right lower quadrant and radiating to the neck. Lying in the fetal position provides some relief. OBSTETRIC HISTORY: Nulliparous; this is her third IVF cycle. GYNECOLOGIC HISTORY: History of cone biopsy x2. PAST MEDICAL HISTORY: Primary infertility, otherwise healthy (husband also had testicular microsurgery).
IVF|in vitro fertilization|IVF|237|239|FOLLOWUP APPOINTMENTS|Her repeat hemoglobin was stable at 11.5. DISCHARGE MEDICATIONS: Progesterone, Medrol, doxycycline, Colace, prenatal vitamins and Tylenol No. 3 with doses described above. FOLLOWUP APPOINTMENTS: The patient will follow up for her normal IVF procedure on _%#MMDD2007#%_.
IVF|in vitro fertilization|IVF|180|182|HISTORY OF PRESENT ILLNESS|Ms. _%#NAME#%_ is a 40-year-old G1, P0 who presented to Fairview _%#CITY#%_ who presented for induction of labor on _%#MMDD2007#%_ for IUGR and a low AFI at 7 cm. Pregnancy was an IVF pregnancy. PRENATAL CARE: At Fairview _%#CITY#%_ Women's Clinic.
IVF|intravenous fluid|IVF|86|88|ASSESSMENT AND PLAN|BUN and Cre are not elevated, but BP did respond well to fluid flush in ER. Will cont IVF and monitor overnight. No evidence of sepsis, but will go ahead and pan culture to be on the safe side.
IVF|in vitro fertilization|IVF|261|263||_%#NAME#%_ _%#NAME#%_ is a 37-year-old white female, gravida 2, para 1 whose has had previous cesarean section for complete placenta previa and had complications of uterine atony and excessive blood loss. Her prenatal care was under Dr. _%#NAME#%_. This was an IVF pregnancy and due date was _%#MMDD2006#%_. She was scheduled to undergo C-section repeat at 39 weeks gestation. However, two days prior to scheduled C-section, she came in with history of spontaneous rupture of membranes and she was unclear if she had been leaking for previous day or so.
IVF|in vitro fertilization|IVF|77|79|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This 37-year-old individual para 1-0-0-1 with an IVF transfer on _%#MMDD2006#%_ and an estimated date of delivery of _%#MMDD2007#%_ was followed for an intrauterine pregnancy from _%#MMDD2006#%_ at 9 weeks' gestation. Her prenatal laboratory studies and screening tests were negative, normal, or within normal limits.
IVF|in vitro fertilization|IVF|171|173|HISTORY OF THE PRESENT ILLNESS|The patient states that her prenatal care had been complicated by what was an initial previa which became a marginal previa at 34 weeks. Additionally the pregnancy was an IVF conception. Initial evaluation by Dr. _%#NAME#%_ revealed a decrease in bleeding, findings consistent with probable rupture of membranes and stable fetal heart tones in the 130's with positive accels.
IVF|in vitro fertilization|IVF|151|153|IMPRESSION|There is no S3 and no murmurs. ABDOMEN: Negative. There is no palpable hepatosplenomegaly and no masses. PELVIC: Negative. IMPRESSION: Term pregnancy, IVF cycle. Previous myomectomy. PLAN: Proceed to primary cesarean section. The patient understands the surgery and asks that we proceed.
IVF|in vitro fertilization|IVF.|138|141|HOSPITAL COURSE|3. Pregnancy-induced hypertension. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 38-year-old gravida 1 para 0 female pregnant with twins by IVF. She come in with increasing worse PIH. On _%#MMDD2003#%_, the patient underwent a low segment transverse cesarean section with delivery of twins.
IVF|intravenous fluid|IVF|138|140|HOSPITAL COURSE|The admission physical examination was unremarkable. Problems during the hospitalization included the following: 1. Feedings - Baby given IVF for first 48 hours in addition to breastfeeding. Patient breastfeeding well at time of transfer to newborn nursery and IVF discontinued at that time.
IVF|intravenous fluid|IVF|148|150|HOSPITAL COURSE|1. Feedings - Baby given IVF for first 48 hours in addition to breastfeeding. Patient breastfeeding well at time of transfer to newborn nursery and IVF discontinued at that time. 2. Temperature Instability - Mother with prolonged rupture of membranes and unknown GBS status and baby initially lethargic and not feeding well with temperatures of 96 and 97 degrees.
IVF|intravenous fluid|IVF|226|228|ASSESSMENT|Problems during the hospitalization included the following: 1. FEN-_%#NAME#%_ was started on IVF which were continued until the time of transfer. TPN was started on day of life 1 and continued for a total until day of life 5. IVF is still being given at the time of transfer. Enteral feedings were initiated using EPF 20 on day of life 2 and feedings have been advanced.
IVF|intravenous fluid|IVF|141|143|ASSESSMENT|2. FEN-continue Enfamil Premature Formula 20 calorie. 15cc q3h,increase if tolerated. Encourage mom to continue trial of the breast feeding. IVF - D12 1/3NS at 4.5 cc/hr. 3. ID-follow up for TORCH screen, result is pending. Discharge medications, treatments and special equipment: 1. IVF D12.5 1/2 NS with 40 mEq KCL/l at 6.2 cc/hr.
IVF|in vitro fertilization|IVF|163|165|HISTORY|We discussed increased risk for ectopic pregnancy should she get pregnant and the need to notify us immediately if she becomes pregnant. I recommended she discuss IVF with a reproductive endocrinologist prior to the tubal reversal and she has done that. The price for one cycle of invitro was about the same as for the tubal reversal surgery.
IVF|in vitro fertilization|IVF|171|173||_%#NAME#%_ _%#NAME#%_ is a 36-year-old female, gravida 1, with a due date of _%#MMDD2007#%_ who has been followed throughout her prenatal course in our office. This is an IVF pregnancy and the pregnancy was complicated by gestational diabetes which was diet-controlled. She came into Labor and Delivery with spontaneously ruptured membranes at 3:00 a.m. today and this was confirmed at about 9 a.m. in the Labor and Delivery suite.
IVF|in vitro fertilization|IVF|330|332|DISPOSITION|She is a 1650 gm, 31 5/7 week gestational age female infant born at University of Minnesota, Fairview _%#CITY#%_ to a 36-year-old, gravida 2, para 0-0-1-0, blood type A+, Caucasian female whose LMP was _%#MMDD2007#%_ and whose EDC was _%#MMDD2008#%_. The mother's pregnancy was complicated by a previous spontaneous abortion from IVF with donor eggs. This pregnancy was also the product of IVF with donor eggs. Multiple ultrasounds were performed, but the earliest ones (_%#MMDD#%_, _%#MMDD#%_, _%#MMDD#%_) showed a "pericardial effusion" in twin A.
IVF|in vitro fertilization|IVF|289|291|PLAN|At the time of discharge, the infant's postmenstrual age was 35 weeks. She is a 1205 gm, 30+5 week gestational age female infant, twin A, born at University of Minnesota Hospital, Fairview _%#CITY#%_ to a 32-year-old, gravida 1, para 0-0-0-0, blood type O positive, Caucasian female whose IVF retrieval date was _%#MMDD2006#%_ and whose EDC was _%#MMDD2007#%_. The mother's pregnancy was complicated by preeclampsia and HELLP syndrome.
IVF|in vitro fertilization|IVF|176|178|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 39-year-old, gravida 1 para 0 female, with an estimated date of confinement of _%#MMDD2007#%_, whose pregnancy initially was an infertility IVF pregnancy, now has a known placenta previa which she has had no bleeding with to date, also complicated with some insulin-dependent gestational diabetes and serial ultrasounds that showed the fetal head approximately two weeks ahead of the body, who on _%#MMDD#%_ had a biophysical profile that scored a 6/10 with an absence of fetal movement and fetal tone. This was repeated on _%#MMDD#%_, which again showed no fetal tone and absence of fetal breathing movements.
IVF|in vitro fertilization|IVF|247|249|PAST GYN HISTORY|The patient's pregnancy was complicated by preterm contractions, breech presentation, and bilateral choroid plexus cysts on her infant. PAST OB HISTORY: None. PAST GYN HISTORY: None; however, she did have hyperstimulation syndrome after her first IVF cycle. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: None. FAMILY HISTORY: Non-contributory.
IVF|intravenous fluid|IVF|140|142|1. FEN|6. ENDO: Concern large for gestational age. Mother has no history of diabetes. Glucose on infant at admission 74. Recheck prefeed level off IVF 57. Ongoing problems and suggested management: 1. FEN: Work on breast feeding.
IVF|intravenous fluid|IVF|77|79|1. FEN|Problems during the hospitalization included the following: 1. FEN: NPO with IVF D10 W at 60cc/kg/day. Feedings of breast milk by gavage were started on DOL 2, slowly reaching feeds of 11 cc q 3 hours, plus TPN for a total fluid goal of 100cc/kg/day.
IVF|intravenous fluid|IVF|236|238|1. GI|The admission physical examination was significant for a II/IV systolic ejection murmur consistent with a known ASD. Problems during the hospitalization included the following: 1. GI: _%#NAME#%_ was initially made NPO and was placed on IVF until a gastrostomy tube could be placed. This was successfully completed on _%#MMDD2004#%_. TPN was initiated as tube feeds were slowly advanced from a Pedialyte drip and subsequently to feeds of Enfamil 22kcal 75ml over 30 min every 3 hours.
IVF|intravenous fluid|IVF|226|228|1. FEN|The admission physical examination was significant for crackles at both lung bases, "ruddy" skin color and poor tone. Problems during the hospitalization included the following: 1. FEN: The infant was initially supported with IVF at 60 ml/kg/day and was advanced to TPN on DOL 2 after adequate urine output was observed. Enteral feedings were started this morning at 5 cc q 3hours by gavage.
IVF|intravenous fluid|IVF.|275|278|1. FEN|PO intake for breast and bottle slowly increased during his stay, and _%#NAME#%_ was discharged on MBM with 22 kcal fortification (Enfacare powder) and breastfeeding. 6. 6. Heme- patient was polycythemic on arrival, was given fluid flush times two and started on maintenance IVF. Initial Hgb/Hct was 21.4/62.2. Initial bilirubin of 18.4 and _%#NAME#%_ was started on phototherapy for 24 hours. The bilirubin decreased to 12.4 and follow-up bilirubin levels were 14.2, 13.5, and 14.2. There was no ABO incompatibility.
IVF|in vitro fertilization|IVF|230|232|OPERATIONS/PROCEDURES PERFORMED|COMPLICATIONS: None. HISTORY OF PRESENT ILLNESS: This is a 30-year-old G1 P0 who presents at 34 plus 4 weeks by an 9 plus 3 week ultrasound on _%#MM#%_ _%#DD#%_, 2004 with diamniotic-dichorionic twin gestation. The patient was an IVF patient of Dr. _%#NAME#%_ and is status post 3 cycles of IVF successful after the 3rd cycle. The patient reports that she had rupture of membranes with clear fluid at 2330 on _%#MM#%_ _%#DD#%_, 2004.
IVF|in vitro fertilization|IVF|212|214|OPERATIONS/PROCEDURES PERFORMED|2. Ultrasound on _%#MM#%_ _%#DD#%_, 2004, at 17 plus weeks concordant growth twin B having an echogenic bowel. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY : None. PAST GYN HISTORY : Status post 3 cycles of IVF via Dr. _%#NAME#%_. No diagnosis of etiology of infertility. ADMISSION MEDICATIONS: Prenatal vitamins. ALLERGIES: None. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She is married.
IVF|in vitro fertilization|IVF|122|124|TET|The mother's pregnancy was complicated by a previous SAB from IVF with donor eggs. This pregnancy was also the product of IVF with donor eggs. Multiple ultrasounds were performed, but the earliest ones (_%#MMDD#%_, _%#MMDD#%_, _%#MMDD#%_) showed a "pericardial effusion" in twin A.
IVF|in vitro fertilization|IVF|207|209|PRENATAL CARE|PROCEDURE: 1. Primary low-transverse cesarean section. 2. Amnio reduction x1. 3. Multiple ultrasounds. PRENATAL CARE: At OB-GYN Infertility with Dr. _%#NAME#%_. Known di-di twins. Pregnancy was achieved via IVF with donor oocytes. Prenatal labs were A positive, antibody negative, hemoglobin was 12.1, rubella was immune, RPR and hepatitis B were negative.
IVF|in vitro fertilization|IVF.|139|142|DIAGNOSES ON ADMISSION|DIAGNOSES ON ADMISSION: 1. A 31-year-old, gravida 1, para 0 at 31 plus 6 weeks. 2. Premature preterm rupture of membranes. 3. Pregnancy by IVF. 4. Complicated by significant fetal anomalies of twin A with selective reduction at 21 weeks. DIAGNOSES AT DISCHARGE: 1. A 31-year-old, gravida 1, para 0 at 31 plus 6 weeks.
IVF|in vitro fertilization|IVF|194|196|OB HISTORY|PRENATAL LABS: Labs are O positive, gonorrhea and chlamydia negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative and GCT was 121. OB HISTORY: Nulliparous infertility, IVF pregnancy with selective reduction. GYN HISTORY: No STDs or abnormal Pap smears. MEDICAL HISTORY: None. SURGICAL HISTORY: D&C secondary to endometrial polyps.
IVF|intravenous fluid|IVF.|202|205|FEN|The physical examination on admission was significant for a left-sided hydrocele. Problems during the hospitalization included the following: FEN: He was made NPO for surgery and started on maintenance IVF. When he was awake and alert, enteral feeds were restarted without difficulty. PULM: Given his history of BPD his fluid status was followed closely.
IVF|intravenous fluid|IVF|95|97|HEME|Problems during the hospitalization included the following: 1. FEN - _%#NAME#%_ was started on IVF on admission, she was then started on TPN while ventilated. Off the ventilator, she advanced quickly on Enfamil preterm 20 kcals by bottle.
IVF|in vitro fertilization|IVF.|153|156|HISTORY OF PRESENT ILLNESS|If there are any peritubal adhesions we will lyse those. If she does have clearly- significant hydrosalpinx we would ligate the tubes to prepare her for IVF. She had a consultation with the reproductive endocrinologist also, who had recommended if there was hydrosalpinx present we would ligate the tubes to prepare her for IVF.
IVF|in vitro fertilization|IVF.|166|169|HISTORY OF PRESENT ILLNESS|She had a consultation with the reproductive endocrinologist also, who had recommended if there was hydrosalpinx present we would ligate the tubes to prepare her for IVF. The patient is aware of her medical condition and she is also aware of the minor cardiopulmonary and neurological risks from anesthesia, and also the risks of gastrointestinal injury, genitourinary injury, blood loss.
IVF|intravenous fluid|IVF|232|234|1. FEN/GI|In addition, he was given intermittent doses of Lasix at the time of admission and was then placed on scheduled Lasix q8 hours. His edema had improved at the time of discharge. _%#NAME#%_ had intermittent hypokalemia corrected with IVF and was continued on his potassium and sodium supplementations orally after extubation. Today's labs: Na 138, K 3.9, Glucose 92. 2. RESP: _%#NAME#%_ was continued on supplemental O2 per nasal canula at the time of admission.
IVF|in vitro fertilization|IVF.|173|176|HISTORY OF PRESENT ILLNESS|The patient had a sonohysterogram performed no _%#MMDD2003#%_ by Dr. _%#NAME#%_ _%#NAME#%_, a community reproductive endocrinologist, as part of an evaluation leading up to IVF. The polyp is described as arising from the anterior wall of the uterus, measuring approximate 14 x 7 mm. It is thought to be located on the anterior uterine wall and slightly to the right of the midline.
IVF|intravenous fluid|IVF|168|170|PLAN|The admission physical examination was unremarkable. There was no evidence of respiratory distress. Problems during the hospitalization included the following: 1. FEN- IVF was started on the day of admission and enteral feeds were subsequently initiated and infant feeding improve with time. By the time of discharge he has taking breast milk on ad lib very well.
IVF|in vitro fertilization|IVF|137|139||_%#NAME#%_ _%#NAME#%_ is a 33-year-old female now gravida 1, para 0, AB1 with a diagnosis of a blighted ovum. The patient had her fourth IVF cycle which resulted in pregnancy but unfortunately, there was no heart beat and this was basically a blighted ovum versus an early fetal demise.
IVF|in vitro fertilization|IVF|273|275||The patient had her fourth IVF cycle which resulted in pregnancy but unfortunately, there was no heart beat and this was basically a blighted ovum versus an early fetal demise. The patient was counseled about this by both her reproductive endocrinologist who performed the IVF cycles and by me and wanted a suction dilatation and curettage at this time. I agreed with the plan. This patient has a history of rheumatoid arthritis that has been fairly difficult to manage and has been on prednisone 20 mg a day.
IVF|in vitro fertilization|IVF|128|130|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Shows a normal female upset because of her situation as she has had 15 attempts at pregnancy both by four IVF cycles and by superovulation cycles. Her height is 5 feet 7 inches, weight is 212 pounds. Blood pressure is 120/70. Hemoglobin 14.1, urinalysis is clear. HEAD, EYES, EARS, NOSE AND THROAT: Clear with no thyromegaly, but has a short neck and would be difficult to intubate.
IVF|in vitro fertilization|(IVF),|216|221|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 39-year- old Japanese female, gravida 2 para 0-0-1-0, with an estimated date of confinement (EDC) of _%#MMDD2005#%_, who had conceived by in vitro fertilization (IVF), blood group A Rh positive, rubella status immune, glucose screen 103. She had an elevated quad test and had been noted to an have intracardiac echogenic foci noted.
IVF|in vitro fertilization|IVF|206|208|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 34-year-old gravida 2, para 1-0-0-1 female who presents to Labor and Delivery with spontaneous rupture of membranes at home. Her care was initiated at nine weeks with an IVF pregnancy. Her pregnancy has been healthy. Her weight gain was approximately 25 pounds. Her blood pressures have remained stable. Hemoglobin has remained stable.
IVF|intravenous fluid|IVF|125|127|1. FEN|Problems during the hospitalization included the following: 1. FEN: Upon admission to the NICU, BB Ali was given maintenance IVF and made NPO in preparation for surgery. After postoperative recovery, the baby was allowed to breastfeed ad lib and was able to maintain his fluid status on an ad lib on demand schedule.
IVF|intravenous fluid|IVF|231|233|1. FEN|He was transferred to the NICU for respiratory distress. The admission physical examination was significant for grunting and tachypnea. Problems during the hospitalization included the following: 1. FEN: BG was initially placed on IVF at 60 ml/kg/day and kept NPO due to her respiratory status. With feedings started, she experienced reflux and was started on reflux precautions and ranitidine.
IVF|intravenous fluid|IVF|185|187|1. FEN|Problems during the hospitalization included the following: 1. FEN: _%#NAME#%_ had a UAC and UVC placed prior to transfer to the NICU. On admission _%#NAME#%_ was placed on maintenance IVF and then started on TPN support. He was started on trophic gavage feeds with Enfamil 20 kcal/oz on DOL 3 (_%#MMDD2003#%_) and slowly increased.
IVF|intravenous fluid|IVF|195|197|1. FEN|The admission physical examination was normal except for 2 small hemangiomas on the back. Problems during the hospitalization included the following: 1. F/E/N - An initial glucose was 8 prior to IVF administration and was treated with a 4 cc/kg bolus of D10W. All repeat glucose values were normal. IVF hydration at 60 cc/kg was continued for the first day of life along with a trial enteral feed via gavage of 5 cc every 3 hours.
IVF|in vitro fertilization|IVF|203|205|PATIENT IDENTIFICATION|PROPOSED PROCEDURE: Primary low segment transverse cesarean section. PATIENT IDENTIFICATION: _%#NAME#%_ _%#NAME#%_ is a 39-year-old married woman, gravida 1, para 0 with an EDC of _%#MMDD2003#%_ with an IVF donor egg pregnancy, which was facilitated through Dr. _%#NAME#%_'s office. The patient is well known to our office. She conceived with an IVF donor egg cycle with transfer on _%#MMDD2002#%_, which calculated to a due date of _%#MMDD2003#%_.
IVF|in vitro fertilization|IVF|346|348|PATIENT IDENTIFICATION|PROPOSED PROCEDURE: Primary low segment transverse cesarean section. PATIENT IDENTIFICATION: _%#NAME#%_ _%#NAME#%_ is a 39-year-old married woman, gravida 1, para 0 with an EDC of _%#MMDD2003#%_ with an IVF donor egg pregnancy, which was facilitated through Dr. _%#NAME#%_'s office. The patient is well known to our office. She conceived with an IVF donor egg cycle with transfer on _%#MMDD2002#%_, which calculated to a due date of _%#MMDD2003#%_. The patient was followed during this pregnancy with normal testing.
IVF|intravenous fluid|IVF|126|128|PLAN|TPN was gradually reduced as gavage feeds were added starting on DOL# 5. Change to full PO feeding occurred on DOL#14. Due to IVF and pulmonary inflammation secondary to meconium aspiration, he gained 260 grams in the first 2-3 days. He was treated with IV lasix with good diuresis and improved cardiopulmonary status.
IVF|intravenous fluid|IVF|172|174|DISCHARGE INSTRUCTIONS|Problems during the hospitalization included the following: 1. FEN - Serum glucose at birth was 58. Electrolytes values were normal on admission to the NICU. She was given IVF initially and then started on oral feeds by gavage while learning to breastfeed. She is currently bottle-feeding well, but having difficulty breast-feeding. At the time of discharge, Irene was being supplemented by bottle after every breastfeeding attempt.
IVF|intravenous fluid|IVF|190|192|1. FEN|The admission physical examination was significant for a right auricular tag, but was otherwise normal. Problems during the hospitalization included the following: 1. FEN: He was started on IVF at admission, but as his respiratory status rapidly improved, he was able to start breastfeeding. Prior to transfer to the newborn nursery he was breastfeeding easily on an ad lib demand schedule with stable glucoses.
IVF|intravenous fluid|IVF|209|211|1. FEN|He was transferred to the NICU for atrial flutter. The admission physical examination was significant for tachycardia. Problems during the hospitalization included the following: 1. FEN: Landen was started on IVF using D10 at first, then eventually being switched to TPN peripherally on DOL #1. By DOL #2, he began taking po feeds via gavage as well as breastfeeding ad lib demand.
IVF|intravenous fluid|IVF|147|149|1. FEN|His sugar improved rapidly after oral glucose and a gavage feed. On admission to the NICU he was initially placed on IVF and ad lib breastfeeding. IVF were discontinued by day 2 and _%#NAME#%_ continued to do well with breastfeeding. 2. Respiratory: In the newborn nursery, _%#NAME#%_ was tachypneic into the 70s with occasional desaturations into the 80s.
IVF|intravenous fluid|IVF.|221|224|ASSESSMENT AND PLAN|4. Hypokalemia: Will be corrected with potassium supplements. 5. Agitation: She will be given morphine 1 to 2 mg q.2-3 h. p.r.n. agitation and pain control. 6. Hypernatremic: Secondary to dehydration, should correct with IVF. I discussed this patient's case in detail with the Smiley's resident, Dr. _%#NAME#%_ _%#NAME#%_.
IVF|in vitro fertilization|IVF,|147|150|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 39-year- old, Japanese female, gravida 2, para 0-0-1-0, EDC of _%#MMDD2005#%_, conceived by IVF, blood group A Rh-positive, rubella status immune, glucose screen negative, whose pregnancy had been complicated by an elevated quad test with an ultrasound intracardiac echogenic foci, and also had concerns with elevated and decreased amounts of amniotic fluid, who on the day of admission was admitted for cesarean section for breech presentation. Informed consent had been obtained preoperatively. HOSPITAL COURSE: On the day of admission, the patient underwent a low segment transverse cesarean section under a regional anesthetic with the birth of a 7 pound, 9 ounce male, infant Apgars 8 and 9 at one and five minutes respectively.
IVF|intravenous fluid|IVF,|288|291|1. FEN|The admission physical examination was significant for tachypnea, grunting, and fine crackles bilaterally, hypotonia that resolved by 45 minutes of life, and an II/VI systolic murmur. Problems during the hospitalization included the following: 1. FEN: _%#NAME#%_ was initially started on IVF, but was able to start feeds by day of life 2 when her respiratory status improved. She was able to advance to feeds of Enfamil 20 at 55ml every three hours, and was breastfeeding as well.
IVF|in vitro fertilization|IVF|143|145|* FEN|This pregnancy is the result of in vitro fertilization due to significant male factor infertility. The patient during sonohysterogram prior to IVF was noted to have cervical funneling. This pregnancy is a confirmed Singleton intrauterine pregnancy and most recent ultrasound on _%#MMDD#%_ revealed a viable intrauterine pregnancy with a cervical length of 3.1 cm with no funneling noted.
IVF|in vitro fertilization|IVF|135|137||Her blood type is A positive. Group B strep status was unknown. Mom's OB history was complicated by a previous spontaneous abortion of IVF and donor pregnancy. This pregnancy was also the product of IVF with donor eggs. This pregnancy was further complicated by pericardial effusion in twin A and subsequent neonatal demise of twin A on day of life #1.
IVF|intravenous fluid|IVF|166|168|PLAN|Blood sugars ranged from 40 to 80 during the first 11 days of life at _%#CITY#%_ Memorial Hospital. She remained asymptomatic throughout these hypoglycemic episodes. IVF were gradually decreased as feeds were introduced, and were discontinued on DOL #8. Because of persistent hypoglycemia, _%#NAME#%_ was transferred for further evaluation.
IVF|in vitro fertilization|IVF|78|80|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This 37-year-old individual, para 0, 000, with an IVF transfer on _%#MM#%_ _%#DD#%_, 2004, was followed for an intrauterine pregnancy from _%#MM#%_ _%#DD#%_, 2004, at 9-weeks' gestation. Her twin gestation was essentially unremarkable. Because of her advanced maternal age, the risks of chromosomally abnormal pregnancy compounded by the multifetal gestation were discussed.
IVF|in vitro fertilization|IVF|182|184|HISTORY OF PRESENT ILLNESS|Her questions have been answered and informed consent has been obtained. She has a longstanding history of infertility. One-hour glucose screen was 138. GBS was negative. This is an IVF donor egg pregnancy. PAST MEDICAL HISTORY: ALLERGIES: NO TRUE MEDICATION ALLERGIES. She says she does not think that amoxicillin works quite as well for her as it used to.
IVF|intravenous fluid|IVF|197|199|PLAN|Skin exam reveals a large mongolian spot over the sacrum, and the remainder of the exam was normal. Problems during the hospitalization included the following: 1. FEN- She was initially started on IVF overnight _%#MMDD#%_, but was able to begin breast feeding with bottle supplements ad lib demand on _%#MMDD#%_. She has tolerated feeds well. 2. CV/Resp- She did not have any further episodes of apnea or choking.
IVF|in vitro fertilization|IVF.|203|206|PAST OBSTETRICAL HISTORY|PAST MEDICAL HISTORY: Significant for depression. PAST SURGICAL HISTORY: She has had her wisdom teeth removed. PAST OBSTETRICAL HISTORY: She does have a history of PCOF and the pregnancy was a result of IVF. Prenatal care with _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD. Most recent ultrasound on _%#MM#%_ _%#DD#%_, 2005, showed twin A vertex, maternal right, with a 2- vessel cord.
IVF|intravenous fluid|IVF|171|173|FOLLOW UP|By transfer, his glucose was 108. While at the NICU, _%#NAME#%_'s glucose remained stable, and IVF were given overnight. He began to take bottle and breast feeds, and his IVF was stopped. The last glucose was 74 on _%#MMDD2005#%_. He transitioned to oral feeds quickly and without difficulties. 2. Rule-out sepsis: Because of the earlier temperature instability, decreased tone and hypoglycemia, _%#NAME#%_ was given 48 hours of ampicillin and gentamicin.
IVF|intravenous fluid|IVF|247|249|HOSPITAL COURSE|3. Pain: The patient's pain was initially well controlled via use of a PCA and when tolerating p.o. intake, the patient was changed to p.o. pain medications, and the pain was well controlled at the time of discharge. 4. FEN: The patient was given IVF at the time of surgery, fluids were decreased with the patient started to tolerate and increased p.o. intake and she is tolerating regular diet at the time of her discharge.
IVF|intravenous fluid|IVF.|168|171|DISCHARGE MEDICATIONS|Mom brought _%#NAME#%_ to her primary care physician who found her urine glucose to be greater than 1,000 and a serum pH of 6.9. At this time _%#NAME#%_ was started on IVF. Serial glucose were followed and found to be 440, then 342. She was then intubated and transported to University of Minnesota Children's Hospital, _%#CITY#%_ for further management.
IVF|intravenous fluid|IVF.|162|165|DISCHARGE MEDICATIONS|Problems during the hospitalization included the following: 1. Problem #1: Fluids, Electrolytes, and Nutrition. Upon _%#NAME#%_'s admission she was maintained on IVF. She was kept NPO and glucose were checked on an hourly basis. She was maintained on her IVF until _%#MMDD2006#%_ when her blood glucose was found to be 150.
IVF|in vitro fertilization|IVF|127|129|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 49-year-old gravida 3, para 1-0-2-1 with a 5 week missed AB. The patient just went through IVF with Dr. _%#NAME#%_ who confirmed with ultrasound on _%#MMDD#%_ a small gestational sac that was consistent with 5 weeks. Repeat ultrasound a week later showed no growth. The patient has had a previous D&C for a missed AB similar to this and wants to proceed with another one.
IVF|in vitro fertilization|IVF.|197|200|PRENATAL CARE|PRENATAL CARE: Forwick Clinic with Dr. _%#NAME#%_, total weight gain was 43 pounds. Pregnancy complication included advanced maternal age which declined genetic testing and twin IUP as a result of IVF. PAST MEDICAL HISTORY: Significant for hypothyroidism. PAST SURGICAL HISTORY: Significant for appendectomy, hysteroscopy, tonsillectomy, diagnostic laparoscopy, and breast aspiration.
IVF|in vitro fertilization|IVF|270|272|COMPLICATIONS|HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old gravida 3, para 1-0-1-1, at 20 plus 1 week by stated EDD of _%#MM#%_ _%#DD#%_, 2004, admitted on _%#MM#%_ _%#DD#%_, 2006, with diamnionic-dichorionic twins and cervical funneling. This pregnancy was the result of IVF with date of conception of _%#MM#%_ _%#DD#%_, 2006. The patient has had recurrent bleeding episodes through this pregnancy with the most recent occurring on _%#MM#%_ _%#DD#%_, 2006, requiring hospitalization.
IVF|in vitro fertilization|IVF|155|157|HISTORY OF PRESENT ILLNESS|The patient did undergo her first IVF cycle in _%#MM#%_ of 2006, which did not result in pregnancy. Follow up ultrasound exam was performed following that IVF cycle, which did show her right ovary to contain a 4.3 x 35 mm cystic area with low levels of echos within it.
IVF|in vitro fertilization|IVF|218|220|HISTORY OF PRESENT ILLNESS|As a result of these findings, the patient is scheduled again to undergo a diagnostic laparoscopy with ovarian cystectomy on _%#MMDD2006#%_. This is being done in preparation for the patient planning to start a second IVF cycle in _%#MM#%_. Of note, the patient did undergo a diagnostic laparoscopy in _%#MM#%_ of 2005, as well and at that time endometrioma was found in the left ovary.
IVF|in vitro fertilization|IVF|139|141|HISTORY OF PRESENT ILLNESS|She has had 5 previous laparoscopies, the most recent of which was in _%#MM2003#%_. Since that time she has had a pregnancy resulting from IVF and delivered twins in _%#MM2004#%_. Over the last 6 months she has had increasingly severe pelvic pain and increasing abnormal bleeding over the last 3-4 months.
IVF|intravenous fluid|IVF|148|150|1. FEN|The UVC was removed on _%#MMDD2006#%_. _%#NAME#%_ had hypoglycemia initially that responded appropriately to 5 mL of D10W. Pre-prandial glucose off IVF prior to transfer to the newborn nursery was 71. 2. Sepsis Evaluation: Ampicillin and Gentamicin was given for one dose each upon admission to the NICU.
IVF|in vitro fertilization|IVF.|166|169|PAST OB HISTORY|She had fetal echos showing no abnormalities for babies A and C but a complex cardiac defect for baby B. PAST OB HISTORY: 1. AB x1. 2. Current pregnancy is result of IVF. PAST GYN HISTORY: No abnormal Pap smears or STDs. PAST MEDICAL HISTORY: 1. PCOS. 2. Mild preeclampsia.
IVF|in vitro fertilization|IVF|89|91||_%#NAME#%_ _%#NAME#%_ is a 35-year-old white female, gravida 1, para 0, who underwent an IVF with a twin pregnancy at 36+ weeks gestation. The patient has moderate pregnancy-induced hypertension. On _%#MMDD2006#%_ she underwent a primary low segment transverse cesarean section and excision of nevus under the left breast.
IVF|intravenous fluid|IVF|213|215|* FEN|Primary diagnosis on admission was fever, rule out sepsis. Problems during her hospitalization included the following: Problem #1: Fluids/Electrolytes/Nutrition. Siri was breast fed ad lib from birth. Maintenance IVF were started _%#MMDD2006#%_ to treat mild dehydration and hypernatremia. They were weaned the following day. At the time of discharge, she was breastfeeding all of her feedings of every 3-4 hours.
IVF|in vitro fertilization|IVF|120|122|HOSPITAL COURSE|Rubella status immune, VDRL nonreactive, hepatitis B negative. Group B strep was not done during pregnancy. This was an IVF pregnancy complicated by twin gestation. Mother was admitted on _%#MMDD2007#%_ with spontaneous rupture of membranes. Infant was delivered by C-section secondary to breech presentation. Apgar scores were 8 at 1 minute and 9 at 5 minutes.
IVF|in vitro fertilization|IVF.|172|175|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Indicates that she has had history of depression after the adoption of her last child, but was not on any treatment at present. Both pregnancies with IVF. ALLERGIES: She has allergy to penicillin, sulfa and erythromycin .
IVF|in vitro fertilization|IVF|160|162|HISTORY OF PRESENT ILLNESS|She has hepatitis B surface antigen, RPR, HIV negative. Urine culture with 50,000 to 100,000 enterococcus in _%#MM2006#%_. Pregnancy is complicated by AMA with IVF with donor egg. The patient was on progesterone shots, which were discontinued on _%#MMDD2006#%_. She had a subchorionic placental bleed, which resolved on _%#MMDD2006#%_, and had scant vaginal bleeding prior to this resolving.
IVF|in vitro fertilization|IVF|141|143||She has had four ____otropin cycles and no pregnancies. Fibers have been noted on ultrasound. We are proceeding onto myomectomy prior to her IVF consult. Patient otherwise is well. Functional inquiry shows the patient to be taking Paxil 20 mg a day.
IVF|intravenous fluid|IVF|205|207|FEN|The initial physical examination was significant for poor respiratory effort and decreased air entry bilaterally. Problems during the hospitalization included the following: FEN: _%#NAME#%_ was started on IVF and total parenteral nutrition (TPN). Gavage feeds were initiated and poorly tolerated, thought to be secondary to both his prematurity and his mother's antepartum magnesium course.
IVF|in vitro fertilization|IVF|369|371|HISTORY OF PRESENT ILLNESS|However, she was maintained on Synthroid through her pregnancy. Past OB history is significant for a low-transverse cesarean section in _%#MM2003#%_ of a 7-pound 7-ounce female for arrest of descent. The infant was found to be in OP position. Past medical history is significant for the above-noted Hashimoto's thyroiditis and a history of infertility with above-noted IVF this pregnancy. Past surgical history was significant for appendicitis at age 15.
IVF|intravenous fluid|IVF.|142|145|HOSPITAL COURSE|Problem #1. Alcohol intoxication: The patient came in with an ethanol level of 0.40 so she was started on MSSA protocol, thiamine, folate and IVF. The patient reported that she had a history of alcohol withdrawal seizures so we took precaution against seizures and fall precautions.
IVF|in vitro fertilization|IVF|158|160||_%#NAME#%_ _%#NAME#%_ is a 33-year-old married gravida 2, para 0-0-1-0 female who is being admitted for vacuum curettage and D&C for a missed AB following an IVF pregnancy. The patient's IVF pregnancy was performed through Dr. _%#NAME#%_'s office at Abbott Northwestern Hospital. She had transfer done on _%#MMDD2004#%_ and ultrasound done on _%#MMDD2007#%_ at approximately 8 weeks gestation showed a 6 week 1 day fetus with positive fetal heart tones.
IVF|in vitro fertilization|IVF|187|189||_%#NAME#%_ _%#NAME#%_ is a 33-year-old married gravida 2, para 0-0-1-0 female who is being admitted for vacuum curettage and D&C for a missed AB following an IVF pregnancy. The patient's IVF pregnancy was performed through Dr. _%#NAME#%_'s office at Abbott Northwestern Hospital. She had transfer done on _%#MMDD2004#%_ and ultrasound done on _%#MMDD2007#%_ at approximately 8 weeks gestation showed a 6 week 1 day fetus with positive fetal heart tones.
IVF|in vitro fertilization|(IVF)|212|216|IMPRESSION|ABDOMEN: Nontender, no masses. PELVIC: Shows the uterus to be anteflexed, 7 weeks size and no palpable adnexal masses. Pelvis is nontender. IMPRESSION: 1. Missed abortion 9 weeks by dates, in vitro fertilization (IVF) pregnancy, 6 weeks by recent ultrasound. 2. Probable Rh negative patient. PLAN: 1. Patient is going to have vacuum curettage and D&C.
IVF|intravenous fluid|IVF|207|209|HOSPITAL COURSE|Good pulses. Abdomen is soft, nontender and nondistended with no hepatosplenomegaly, normal bowel sounds. The rest of the exam is within normal limits. HOSPITAL COURSE: PROBLEM #1: FEN. The patient received IVF hydration per chemo protocol. She was on a regular diet, but due to nausea, did not eat much during most of her admission.
IVF|in vitro fertilization|IVF|198|200|IDENTITY|IDENTITY: _%#NAME#%_ _%#NAME#%_ is a 32-year-old married woman gravida 2, para 0-0-1-3, with a history of a triplet delivery by cesarean section in 2000 who is currently 39+ weeks gestation with an IVF pregnancy who is to undergo repeat cesarean section at term. The patient has been followed at our office since 12 weeks gestation.
IVF|in vitro fertilization|IVF|370|372|IDENTITY|IDENTITY: _%#NAME#%_ _%#NAME#%_ is a 32-year-old married woman gravida 2, para 0-0-1-3, with a history of a triplet delivery by cesarean section in 2000 who is currently 39+ weeks gestation with an IVF pregnancy who is to undergo repeat cesarean section at term. The patient has been followed at our office since 12 weeks gestation. Her pregnancy was complicated by the IVF pregnancy, supported by IM Progesterone injections in the first trimester. She progressed during this pregnancy to term. Level II ultrasound and fetal echo had been normal.
IVF|intravenous fluid|IVF|219|221|1. FEN|The physical examination was remarkable for tachypnea with retractions and grunting prior to intubation. Problems during the hospitalization included the following: 1. FEN: Initially, the patient was made NPO and given IVF resuscitation with D10NS at 60cc/kg/day. On her second day in the NICU, she was started on TPN. She tolerated the TPN well, and as her respiratory status improved, she was started on low volume gavage feeds.
IVF|intravenous fluid|IVF|94|96|1. FEN|Problems during the hospitalization included the following: 1. FEN: _%#NAME#%_ was started on IVF at admission and on total parental nutrition (TPN) on DOL 1. Gavage feeds were introduced on DOL 3 and she was quickly able to be maintained on gavage feeds alone.
IVF|in vitro fertilization|IVF.|190|193|HISTORY OF PRESENT ILLNESS|The patient denies any leakage of fluid or bleeding. She has been having occasional contractions in the morning for the last month. Of particular note is that this pregnancy is secondary to IVF. The pregnancy originally started with twins the eventual demise of one of the twins. PRENATAL CARE: She is seen by Dr. _%#NAME#%_ at the Fairview _%#CITY#%_ Women's Clinic.
IVF|intravenous fluid|IVF|206|208|1. FEN|The admission physical examination was significant for the infant being sedated and intubated. Problems during the hospitalization included the following: 1. FEN: Initially _%#NAME#%_ placed on maintenance IVF (60 cc/kg/d) while he was intubated then he was started on TPN support on day one in the NICU. Once his respiratory status improved, post-intubation, he was started on trophic feeds with Enfamil 20 kcal/oz at 5 cc every 3 hours.
IVF|intravenous fluid|IVF|225|227|3. CV|A CR scan was equivocal. 3. CV: _%#NAME#%_ had two episodes of decreased blood pressures to MAP's in the mid 30's after two separated lasix doses on days #1 and 2 of hospitalization. Each episode responded well to a 20 cc/kg IVF flush. He subsequently maintained his heart rate and pressures well. Because of his unexplained oxygen desats mentioned above, _%#NAME#%_ received a cardiac echo, which was normal.
IVF|intravenous fluid|IVF|180|182|1. FEN|The admission physical examination was significant for an irregular-breathing pattern. Problems during the hospitalization included the following: 1. FEN: _%#NAME#%_ was placed on IVF with oral formula feeds advanced on day two of life. He tolerated these well and was discharged home on Enfamil 20 with iron ALD 2.
IVF|intravenous fluid|IVF.|167|170|1. FEN|Problems during the hospitalization included the following: 1. FEN: _%#NAME#%_ was unable to breast feed post-partum while monitored in NICU and thus he was placed on IVF. He subsequently began breast feeding. 2. Pulmonary: _%#NAME#%_ was intubated in delivery room and transferred to NICU. Shortly after transfer he was extubated and placed on O2 via nasal canula and was weaned overnight.
IVF|intravenous fluid|IVF|209|211|1. FEN|He was transferred to the NICU for prematurity. The admission physical examination was significant for prematurity. Problems during the hospitalization included the following: 1. FEN: _%#NAME#%_ was placed on IVF and received Enfamil feeds via nasogastric tube in increasing amounts and IVF were subsequently decreased. He was started on bottle feeds as tolerated until he was able to sustain himself without nasogastric gavage.
IVF|intravenous fluid|IVF|171|173|1. FEN|Problems during the hospitalization included the following: 1. FEN: _%#NAME#%_ was placed on IVF and received Enfamil feeds via nasogastric tube in increasing amounts and IVF were subsequently decreased. He was started on bottle feeds as tolerated until he was able to sustain himself without nasogastric gavage.
IVF|intravenous fluid|IVF.|149|152|1. FEN|Admission neurological exam was normal. Problems during the hospitalization included the following: 1. FEN: He was initially made NPO and started on IVF. TPN was given from DOL 2 to 7. Trophic feeds were started on DOL 5, and were maximized by DOL 8. He tolerated gavage feeds well. He started breastfeeds on DOL 7, with initial poor effort and latch.
IVF|intravenous fluid|IVF|135|137|1. RESP|He remained on nasal cannula O2and was weaned to room air after 24hrs. He has been stable on room air since. 2. FEN: He was started on IVF and later TPN on DOL 2. He was initially fluid restricted due to increasing weight and pulmonary edema. He initially had poor urine output, and needed a urinary catheter to drain urine.
IVF|intravenous fluid|IVF|207|209|1. FEN|The admission physical examination was significant for decreased breath sounds in LUL and jaundice. Problems during the hospitalization included the following: 1. FEN: _%#NAME#%_ was initially hydrated with IVF and scheduled feeds initiated. By hospital day 2 he was on ad-lid demand feeds with a 12 hour minimum. 2. RESP: Upon admission pt. was not tachypnic and required small amounts of oxygen by nasal cannula.
IVF|intravenous fluid|IVF|238|240|1. FEN|Problems during the hospitalization included the following: 1. FEN: On admission a peripheral IV was placed and D10W was started at 60cc/kg/d. TPN was later started that night at 80cc/kg/day. Glucose on admission was 42 then 88 after the IVF were started. A UVC was placed on admission and was discontinued. Enteral feeds were started on DOL #1 and slowly advanced as parenteral nutrition weaned.
IVF|intravenous fluid|IVF|235|237|PLAN|The admission physical examination was significant for tachypnea, acrocyanosis, and bilateral crackles on auscultation of the lungs. Problems during the hospitalization included the following: 1. FEN- Patient was placed on maintenance IVF and transitioned early on to parenteral nutrition. Enteral nutrition was held until he demonstrated respiratory stability. On _%#MMDD2004#%_, he was started on enteral feeds.
IVF|intravenous fluid|IVF.|168|171|1. FEN|Problems during the hospitalization included the following: 1. FEN: _%#NAME#%_ was made NPO upon admission because of his history of hematemesis. He was started on D10 IVF. After malrotation and volvulus were ruled out, he was started back on breast milk with a presumptive diagnosis of swallowed maternal blood- possibly from a fissure at his mother's breast.
IVF|intravenous fluid|IVF|261|263|4. GI|He was transferred to the NICU for prematurity. The admission physical examination was normal except for moderate bruising of the scalp. Problems during the hospitalization included the following: 1. Fluids, Electrolytes, & Nutrition: _%#NAME#%_ was started on IVF fluids on admission and started 10mL feeds every three hours the following day, which he tolerated well. He had no problems advancing to full feeds of 40mL of breast milk and Enfamil premature formula fortified to 24kcal/ounce every three hours.
IVF|intravenous fluid|IVF|118|120|1. FEN|Problems during the hospitalization included the following: 1. FEN: On admission to NICU she was placed NPO and given IVF overnight. She was started on TPN on her second day in NICU, and transitioned to breast feeding ALD by day 3. She took in good volumes by breast feeding ad lib on demand.
IVF|intravenous fluid|IVF|150|152|1. FEN|The patient was also clinically dehydrated on admission with approximately 10% dehydration and mild hypernatremia, Na 150. This quickly improved with IVF and gavage/breast feedings. IV fluids were weaned off by 24 hours, and _%#NAME#%_ was allowed to breast feed ad lib demand for the duration of his admission.
IVF|in vitro fertilization|IVF.|177|180|IMPRESSION|Fetal heart tones were excellent. Cervix was 7 cm and very puffy. IMPRESSION: Term pregnancy age 41, two vessel cord, fever, arrest of dilatation, first trimester bleeding, and IVF. PLAN: The patient will undergo cesarean section. She understands the risks of surgery including anesthesia, blood loss, infection, and injury to adjacent organs including the bladder and ureters.
IVF|in vitro fertilization|IVF|109|111|REASON FOR ADMISSION|DOB: _%#MMDD1969#%_ REASON FOR ADMISSION: The patient is a 35-year-old white female, gravida 1, para 0, with IVF conception date of _%#MMDD2004#%_ and calculated EDC _%#MMDD2004#%_, who was admitted for cesarean section at term with persistent breech lie. Please refer to HPI regarding details of the patient's antepartum course and counselling for surgery.
IVF|in vitro fertilization|IVF|362|364|* FEN|She was born on _%#MM#%_ _%#DD#%_, 2005, at 2320 hours, transferred to the NICU on the same evening and discharged on _%#MM#%_ _%#DD#%_, 2005. She was the 1675 gm, 32 + 6 week gestational age female infant born at Fairview University - _%#CITY#%_ to a 36-year-old, O positive, gravida 1, para 0, married black female whose pregnancy began on _%#MMDD2004#%_ with IVF and whose EDC was _%#MMDD2005#%_. The mother's pregnancy was complicated only by subchorionic hemorrhage in the first trimester.
IVF|intravenous fluid|IVF.|147|150|1. FEN|Problems during the hospitalization included the following: 1. FEN: Due to concern for her respiratory status, _%#NAME#%_ was initially started on IVF. By the following morning she was able to bottle easily without any respiratory compromise. Prior to transfer she was breastfeeding ad lib demand and had started Tri-vi-sol- with iron.
IVF|in vitro fertilization|IVF|270|272|HISTORY OF PRESENT ILLNESS|3. Status post right chest tube. 4. Possible pneumonia. HISTORY OF PRESENT ILLNESS: This is a 25-year-old who presented to the emergency department with acute onset of shortness of breath and right-sided chest pain. She is 6 days status post egg retrieval after planned IVF cycle and injectable ovarian stimulation. She had received 2 L of fluid, one Friday and one Saturday, in the REI Clinic, because of dehydration secondary to ovarian hyperstimulation.
IVF|in vitro fertilization|IVF|156|158|HISTORY OF PRESENT ILLNESS|Both were discontinued at 34 weeks gestation. PAST MEDICAL HISTORY: She is gluten-sensitive and had infertility. This pregnancy was the result of her third IVF cycle. PAST SURGICAL HISTORY: Negative. MEDICATIONS: Terbutaline, prenatal vitamins, and stool softeners. ALLERGIES: She has no allergies. HOSPITAL COURSE: The patient is admitted to the hospital where she underwent a vacuum-assisted delivery of Twin A for prolonged bradycardia x6 minutes.
IVF|intravenous fluid|IVF|141|143|HISTORY OF PRESENT ILLNESS|Problems during the hospitalization included the following: 1. Nutrition: _%#NAME#%_'s glucose level was 50 on admission, and we started D10 IVF at 60mL/kg. The glucose level normalized, and feeds were started on the night of _%#MMDD2005#%_. She tolerated advancements of enteral feeds with Enfamil Premature formula, and the TPN was stopped on _%#MMDD2005#%_.
IVF|in vitro fertilization|IVF|151|153|PAST SURGICAL HISTORY|PAST MEDICAL HISTORY: 1) Endometriosis. 2) Primary infertility. PAST SURGICAL HISTORY: In 1999, laparoscopy and fulguration of endometriosis. In 2000, IVF transfer of two embryos. Later in 2000, primary cesarean section at 30+ weeks for preterm labor and premature rupture of membranes.
IVF|in vitro fertilization|IVF|221|223|PAST SURGICAL HISTORY|In 2000, IVF transfer of two embryos. Later in 2000, primary cesarean section at 30+ weeks for preterm labor and premature rupture of membranes. In _%#MM#%_ 2004, D&C hysteroscopy for possible endometrial polyp. In 2004, IVF transfer of one embryo. PAST OB HISTORY: As noted above. TPROM preterm labor with twin delivery at 30-1/2-weeks in _%#MM#%_ 2000 - two female infants, both doing well.
IVF|in vitro fertilization|IVF.|164|167|PROCEDURES|The mother's pregnancy was complicated by GDDM treated with Glyburide, preeclampsia which was treated with Mg, and premature labor on _%#MMDD#%_ that resolved with IVF. The mother was found to be GBS positive at 29 weeks. No antibiotics were given upon delivery. Two doses of Betamethasone were given at 28 weeks (_%#MMDD#%_-_%#MMDD#%_).
IVF|in vitro fertilization|IVF|370|372|HISTORY|The patient is scheduled for a repeat cesarean section at Fairview Southdale on _%#MMDD2006#%_ at 10:30 a.m. HISTORY: The patient's previous pregnancy was significant for postpartum hypertension, and she underwent a cesarean section for fetal intolerance of labor and failure to descend. The patient declines trial of labor after cesarean section. Last pregnancy was an IVF pregnancy. This pregnancy is spontaneous. The patient had a one-hour GCT that was elevated, and a three-hour GTT that was normal.
IVF|in vitro fertilization|IVF|132|134|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 39-year-old primigravida with an estimated date of delivery of _%#MMDD2006#%_. Pregnancy was an IVF pregnancy. She was first seen at nine weeks gestation. She had a normal CVS, normal Level II ultrasound, and normal fetal echocardiogram.
IVF|intravenous fluid|IVF|208|210|(C14|Problem # 2: Musculoskeletal: Given the risk of rhabdomyolysis with VLCAD, a creatine kinase was checked at admission. It was elevated at 1403. It peaked at 1478 on _%#MMDD2006#%_ and gradually declined with IVF hydration and improving PO intake. At the time of discharge it had been within normal limits for several days. The last level obtained was 93 on _%#MMDD2006#%_ and 101 on _%#MMDD2006#%_.
IVF|in vitro fertilization|IVF|145|147||_%#NAME#%_ _%#NAME#%_ is a 29-year-old, gravida 4, para 0, presents with an estimated date of confinement of _%#MMDD#%_. The patient did undergo IVF and developed a twin pregnancy. She has been followed closely throughout the pregnancy and has done well, now presents at 38 weeks gestation with baby A having been breech until the last week or so.
IVF|in vitro fertilization|IVF|243|245|PATIENT IDENTIFICATION|SURGEON: _%#NAME#%_ _%#NAME#%_, M.D. ANESTHESIA: General. PATIENT IDENTIFICATION: _%#NAME#%_ _%#NAME#%_ is a 36-year-old gravida 1, para 0-0-1-0, with an LMP in _%#MM#%_ 2007, who is now on continuous birth control pills in preparation for an IVF cycle. She sees Dr. _%#NAME#%_ _%#NAME#%_ for evaluation of secondary infertility. The patient is currently on OCPs in preparation for an IVF cycle.
IVF|in vitro fertilization|IVF|385|387|PATIENT IDENTIFICATION|SURGEON: _%#NAME#%_ _%#NAME#%_, M.D. ANESTHESIA: General. PATIENT IDENTIFICATION: _%#NAME#%_ _%#NAME#%_ is a 36-year-old gravida 1, para 0-0-1-0, with an LMP in _%#MM#%_ 2007, who is now on continuous birth control pills in preparation for an IVF cycle. She sees Dr. _%#NAME#%_ _%#NAME#%_ for evaluation of secondary infertility. The patient is currently on OCPs in preparation for an IVF cycle. During this evaluation the patient had a sonohysterogram which suggested an endometrial polyp in the lower uterine segment. Dr. _%#NAME#%_ notified me of this finding and requested removal of the endometrial polyp.
IVF|in vitro fertilization|IVF|85|87|IMPRESSION|PELVIC: Deferred until under anesthesia. EXTREMITIES: Normal. IMPRESSION: 1. Current IVF cycle planned for _%#MMDD#%_. 2. Endometrial polyp identified in the lower uterine segment on a sonohysterogram. PLAN: Examination under anesthesia, diagnostic hysteroscopy, removal/excision of endometrial polyp, D&C.
IVF|intravenous fluid|IVF,|174|177|ASSESSMENT|Of note also is that Mr. _%#NAME#%_'s creatinine was found to be significantly elevated at 2.14. This may be secondary to poor perfusion of kidneys pt is currently receiving IVF, his serum creatinine will be rechecked later on today. Mr. _%#NAME#%_'s care will be assumed by the Oxboro rounding physician.
IVF|intravenous fluid|IVF|271|273|ASSESSMENT|Primary diagnosis during hospitalization included: 1. Rule out sepsis secondary to suspected maternal chorioamnionitis Problems during his hospitalization included the following: Problem #1: Fluids/Electrolytes/Nutrition. Baby Boy _%#NAME#%_ was initially started on D10 IVF and formula. IVF was stopped on _%#MMDD2007#%_. Breastfeeding started on _%#MMDD2007#%_. At the time of transfer, he was breastfeeding all of his feedings on an ad lib schedule.
IVF|in vitro fertilization|IVF|149|151|* FEN|The patient knows that a laparotomy may be necessary. The patient strongly wants to save at least some of her ovary so that either superovulation or IVF could still be possible. The patient is now admitted for this problem. ALLERGIES: NONE. MEDICATIONS: Pain medication along with Alavert and Flonase. PAST MEDICAL HISTORY: SURGICAL: As per history of present illness.
IVF|intravenous fluid|IVF|80|82|ADDENDUM|Hemoglobin slightly low. CXR poor inspiration. EKG pending. So will d/c NSAID's IVF bolus check PO4 recheck BMP in am. Continue with previous insulin order. Check iron studies and ferritin. Myeloma UPEP and SPEP already ordered.
IVF|in vitro fertilization|IVF|129|131|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ is a 38-year-old G2 para 0-0-1-0 at 30 plus one weeks by an EDC of _%#MMDD2001#%_ by IVF with di-di twin intrauterine pregnancy. She was being ruled out for labor at Ridges overnight and had a final cervical exam of 1 cm.
IVF|in vitro fertilization|IVF|147|149|HOSPITAL COURSE|The patient chose to breast feed her babies and was doing so with pumping at the time of discharge. She declined birth control due to her need for IVF and donor eggs. She is aware of the recommendation, not to get pregnant for at least one year given the increased risk of uterine rupture following cesarean section.
IVF|intravenous fluid|IVF|209|211|PLAN|Biopsy done and result is pending. Patient's symptoms probably related to ibuprofen use chronically. PLAN: Patient to undergo colonoscopy in a.m. Will check hemoglobin q. 6 hours. I will also place patient on IVF and Prilosec 20mg po daily since no active bleeding is noted. He appears to be hemodynamically stable.
IVF|intravenous fluid|IVF|165|167|ASSESSMENT AND PLAN|9. ARF. She had postoperative dehydration and pre-renal azotemia. with creatinine of 2.1 the day after the surgery. We gave her 1 liter of IV bolus and maintainance IVF due to poor oral intake, and the day after that her creatinine was back to normal at the level of 1. 10. PT/OT. PT/OT was consulted to increase her mobilization and to help her get back to her normal basis.
IVF|intravenous fluid|IVF|158|160|PLAN|6. Congestive heart failure secondary to diastolic dysfunction, compensated at this time. PLAN: Will admit the patient to the medical ward and treat her with IVF and IV morphine for pain. Will continue rest of her home medications. Will strain her urine. Urology consult was requested by the ED physician last night, and I am awaiting their recommendations.
IVF|intravenous fluid|IVF|194|196|1. FEN|The physical examination was normal. Problems during the hospitalization included the following: 1. FEN: On admit, _%#NAME#%_ was approximately 10% dehydrated, based on his weight. He was given IVF and allowed to continue to feed ad lib. 2. Fever: A sepsis work up was done. CXR was without focal findings.
IVF|intravenous fluid|IVF|123|125|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1: FEN and GI: _%#NAME#%_ has been maintained on a regular diet. She was started on large volume IVF _%#MMDD2007#%_ per chemo protocol prior to her chemotherapy. We were concerned about constipation in _%#NAME#%_ secondary to location of her lesion and the effects of vincristine.
IVF|in vitro fertilization|IVF|255|257|OBSTETRIC HISTORY|She was placed on bedrest since that time. The patient was scheduled on _%#MMDD2007#%_ for C-section for breech presentation. OBSTETRIC HISTORY: 1. 2002, salpingostomy for ectopic. 2. _%#MM2006#%_, bilateral salpingectomy for bilateral hydrosalpinges. 3. IVF x3. GYNECOLOGIC HISTORY: History of abnormal Pap smear x1, history of gonorrhea in college that was treated.
IVF|intravenous fluid|IVF|300|302|FEN|The physical examination was significant for acrocyanosis, subcostal retractions, grunting and decreased air entry as well as the following signs of prematurity: absent breast buds and prominent labia minora. Problems during the hospitalization included the following: FEN: _%#NAME#%_ was started on IVF on admission then advanced to TPN. She was gradually weaned to gavage feeds of Enfamil 20 kcal PT formula. We recommended using formula for _%#NAME#%_'s feeds because of the high level of metabolite from Effexor found in breast milk.
IVF|intravenous fluid|IVF|191|193|ID|The physical examination was positive for grunting and retractions, with good breath sounds bilaterally. Problems during the hospitalization included the following: 1. FEN - Pt was placed on IVF on admission, NPO, then advanced to gavage feeds. These were well tolerated, breastfeeding was initiated and well tolerated. 2. Respiratory -Respiratory distress and increased oxygen need - she was intubated and placed on the ventilator until am of _%#MMDD2002#%_.
IVF|intravenous fluid|IVF|375|377|INTRODUCTION|The physical examination was remarkable for pale skin with cool lower extremities, decorticate posturing with 9 beat bilateral ankle clonus, decreased left hand grasp, generalized hyperreflexia, and a large vacuum extraction bruise over the R anterior fontanelle.. Problems during the hospitalization included the following: 1. FEN - _%#NAME#%_ was placed NPO with a UVC and IVF started. Hyperalimentation was started on _%#MMDD#%_ and continued with gavage feeds which were started on _%#MMDD#%_. Feeds were increased slowly to goal of 52 cc of Enfacare 20kcal every three hours.
IVF|intravenous fluid|IVF.|145|148|HOSPITAL COURSE|The patient did well postoperatively, and on postoperative day #2 she was weaned from her IV pain medicines and tolerated p.o. intake. _________ IVF. She was seen by Physical Therapy. The patient was also seen by Dr. _%#NAME#%_ in-house. She will require postoperative radiation therapy. In addition to physical therapy, the patient was seen by Occupational Therapy.
IVF|in vitro fertilization|IVF|507|509|PATIENT IDENTIFICATION|2. Group B strep positive. PLAN: Repeat low segment transverse Cesarean section _%#MM#%_ _%#DD#%_, 2002 at Fairview Southdale Hospital PATIENT IDENTIFICATION: _%#NAME#%_ _%#NAME#%_ is a 32-year-old married woman, gravida 2, para 0-1-0-3 (history of a triplet delivery by Cesarean section in 2000) who currently is 39+ weeks gestation with an IVF pregnancy who is to undergo repeat Cesarean section at term. The patient is followed at our office since 12 weeks gestation. Her pregnancy was complicated by an IVF pregnancy, supported by IM Progesterone injections in the first trimester. The patient progressed during this pregnancy. She did have a level II ultrasound and a fetal echo due to the fact that one of her daughters has had an aortic arch abnormality.
IVF|intravenous fluid|IVF|251|253|PLAN|Problems during the hospitalization included the following: 1. FEN- _%#NAME#%_'s magnesium level the morning after admission was elevated at 4.3 (Mother's level near delivery was 6). The level was decreased to 2.9 by _%#MMDD2002#%_. He was started on IVF on the day of admission, and parenteral fluids were started on _%#MMDD2002#%_. He was started on gavage feeds of Enfamil on _%#MMDD2002#%_ and these were gradually advanced.
IVF|intravenous fluid|IVF|195|197|1. FEN|She was then switched to TPN and intravenous lipids and kept NPO for 2 days. Feeds were started on day of life #3. _%#NAME#%_ had problems with hypoglycemia and required increased glucose in her IVF for the first two days of life; however, her hypoglycemia resolved by day three of life. An UVC had been placed upon admission; this was discontinued by day 5 of life.
IVF|intravenous fluid|IVF|233|235|1. FEN|He was transferred to the NICU for prematurity. The admission physical examination was significant for a normal AGA premature infant. Problems during the hospitalization included the following: 1. FEN: Ethan was initially started on IVF until TPN was initiated on DOL 1. He was started on gavage feeds on DOL 1 and advanced to full volume feeds without problems.
IVF|intravenous fluid|IVF|278|280|1. FEN|The admission physical examination was normal. During the first two hours after admission, the infant had several episodes of apnea with desaturation requiring moderate stimulation to resolve. Problems during the hospitalization included the following: 1. FEN: Victor was given IVF until Mom was available for breastfeeding. He did well with breastfeeds and was maintained on an ad lib schedule. 2. ID: Empiric antibiotics were started and blood cultures were sent which remain negative to date.
IVF|intravenous fluid|IVF,|180|183|2. ID|Antibiotics were discontinues after the afternoon doses on _%#MMDD2003#%_. 3. Hematopoetic: Hgb was 13.8 and WBC was 11 on admission. 4. FEN: The infant was started on maintenance IVF, by the afternoon of DOL#1 she was stable, and enteral feeds were started. She breast fed x3 overnight with good effort and suck, and also took 10cc by gavage.
IVF|intravenous fluid|IVF|274|276|1. FEN|A mottled appearance and transitory rash was described on physical exam at the outside hospital, but these findings were not replicated on exam on admission. Problems during the hospitalization included the following: 1. FEN: _%#NAME#%_ was maintained NPO with supplemental IVF on admission due to intubation and sedation. TPN was started on _%#MMDD2003#%_ (DOL 1). Lasix was provided to aid diuresis on DOL 2-3.
IVF|intravenous fluid|IVF,|180|183|1. FEN|3. CARDIOVASCULAR: Pressor support was initiated with dopamine on _%#MMDD2003#%_ secondary to low mean blood pressures (30-40) and minimal urine output. In addition to maintenance IVF, _%#NAME#%_ received both albumin solution and PRBC to maintain intravascular volume. Perfusion improved dramatically over the first days of life, and dopamine was discontinued on _%#MMDD2003#%_ (DOL 4).
IVF|intravenous fluid|IVF|159|161|1. FEN|The babe was in no distress and was stable on room air. Problems during the hospitalization included the following: 1. FEN: _%#NAME#%_ was maintained NPO with IVF to provide maintenance needs on admission. She remained stable for several hours, and enteral feeds were initiated several hours after presentation.
IVF|intravenous fluid|IVF.|176|179|1. FEN|Subsequently, _%#NAME#%_ was placed on D12.5W IVF with gavage feedings advancing to 55 cc per 3 hours. Glucose level became normal overnight and feeding advanced while weaning IVF. Breast feeding was initiated on day #1 and advanced throughout admission while decreasing scheduled feedings. Hypoglycemia was probably due to hyperinsulinemia secondary to the mother's diabetes.
IVF|in vitro fertilization|IVF|213|215|DOB|She also has noted severe cramping with her episodes of bleeding also deep pain with intercourse. She states that she has had a diagnosis of endometriosis in the past. She had undergone infertility workup and had IVF to conceive her first child. She may consider adding the laparoscopy to the D&C. PAST MEDICAL HISTORY: Migraines and endometriosis, infertility, mitral valve prolapse, spinal meningitis in 1995.
IVF|intravenous fluid|IVF|222|224|DISPOSITION|The admission physical examination was significant for acrocyanosis, decreased breath sounds, grunting and nasal flaring. Problems during the hospitalization included the following: 1. FEN- She was initially was placed on IVF and TPN for total fluids of 60cc/kg/day. On day one of life, she was started on feeds. The feeds were started at 5cc every three hours. She was increased to 80cckg/day on day one of life.
IVF|intravenous fluid|IVF.|208|211|1. ID|The admission physical examination was significant for mild respiratory distress manifested by grunting in room air. Problems during the hospitalization included the following: 1. FEN- Patient was started on IVF. Initial serum glucose level was low on admission. Subsequent serum glucose level increased to within normal ranges after a dextrose bolus.
IVF|in vitro fertilization|IVF|143|145|HISTORY OF PRESENT ILLNESS|She and her husband are no longer interested in achieving a pregnancy. They are beginning the adoption process. They have thought about trying IVF again extensively, but they feel they do not want to undergo the emotional and/or financial burden that it does entail.
IVF|in vitro fertilization|IVF|388|390|PAST MEDICAL HISTORY|Total weight gain 63 pounds. Prenatal labs, blood type A+, antibody negative, hemoglobin range from 13.7 to 12.5, rubella immune, RPR nonreactive, urine culture negative, hepatitis B surface antigen negative, HIV negative, Chlamydia and gonorrhea negative/negative, one hour GCT 85, GBS positive. GBS was performed on _%#MM#%_ _%#DD#%_, 2004. PAST MEDICAL HISTORY: Infertility, underwent IVF cycles, became pregnant on her second IVF cycle. PAST SURGICAL HISTORY: None. ADMISSION MEDICATIONS: Prenatal vitamins and calcium supplementation.
IVF|intravenous fluid|IVF|201|203|ASSESSMENT|Problems during his hospitalization included the following: Problem #1: Fluids/Electrolytes/Nutrition: _%#NAME#%_ received maintenance IV fluids of D10W during his first 48 hours in the NICU, then the IVF was titrated down as feedings increased. Breastfeedings ad lib were started prior to NICU admission on _%#MMDD#%_ and were well tolerated.
IVF|in vitro fertilization|IVF.|271|274|1. F/E/N|She was the 2240 gm, 34+5 week gestational age female twin A infant born at Fairview _%#CITY#%_ to a 30- year-old, O positive, gravida 1, para 0000, married caucasian female whose EDC was _%#MMDD2004#%_. The mother's pregnancy was complicated by twin gestation following IVF. The infant was delivered by cesarean section with Apgar scores of 7 at one minute and 8 at five minutes. _%#NAME#%_ required blow by oxygen and tactile stimulation in the delivery room.
IVF|in vitro fertilization|IVF|216|218|SOCIAL HISTORY|Following that, he thinks that Lupron would be the most appropriate option; however, he is recommended a follow up in the infertility clinic immediately postoperative so that they can manage the Lupron and follow up IVF cycles with the couple. He agrees that at this point Lupron alone would not be a good option given the patient's pain and the size of the endometrioma.
IVF|intravenous fluid|IVF|145|147|PLAN|Problems during his hospitalization included the following: Problem #1: Fluids/Electrolytes/Nutrition. _%#NAME#%_ had a peripheral IV placed and IVF were given. His initial blood glucose was 25 and so he was given a bolus of dextrose. Subsequent assessments of his blood glucose were all normal. _%#NAME#%_ began feeding on _%#MM#%_ _%#DD#%_, taking Enfamil Premature 20 kcal/oz formula, and has tolerated the increase in volume and strength of formula.
IVF|intravenous fluid|IVF|719|721|CXR|Uncooperative with neurologic exam, moves all 4 extremeties, good tone and strength CXR: Right pleural effusion, moderate size, continue RML infiltrate Assessment: right parapneumonic effusion with fever and sepsis, RML bacterial pneumonia with S. pneumoniae, acute and chronic feeding intolerance. Plan: Right parapneumonic effusion with RML bacterial pneumonia - Thoracentesis for inspection, cell count, gram stain, culture, protein, LDH, and glucose - Chest tube if empyema - Continue ceftriaxone - Start azithromycin for atypical coverage - Given history of MRSA, start vanco if condition worsens - Consider CT scan if condition worsens FEN, feeding intolerance - Hold feeds now in anticipation of thoracentesis - IVF for maintenance - Restart GT feeds when procedure completed
IVF|intravenous fluid|IVF,|187|190|CV|The extent of verterbral involvement is unclear -- we may have to pursue an MRI to assess this. His hypercalcemia is likely either from boney destruction of PTHrP. Either way, will begin IVF, start bisphosphanate and control his pain.
IVF|in vitro fertilization|IVF|178|180|CV|She reported no smoking, alcohol use, medications other than Synthroid during her pregnancy. This pregnancy was achieved through IVF, specifically using ICSI. This was the third IVF try for this couple. This couple stated that there was an unknown reason for their infertility issues and they had subsequently tried using intrauterine insemination prior to this IVF.
IVF|in vitro fertilization|IVF.|338|341|CV|Features of Down syndrome was discussed. In addition, I also reviewed other types of chromosome abnormalities including trisomy 13, trisomy 18, and sex chromosome abnormalities. I discussed that this pregnancy would be at approximately 1% increased risk for sex chromosome abnormalities based on the fact that ICSI was performed with the IVF. We discussed further testing and diagnostic options such as limitations of Level II ultrasound as well as amniocentesis which is diagnostic for Down syndrome and other chromosome abnormalities with greater than 99% accuracy.
IVF|in vitro fertilization|IVF|192|194|G 4   P	0030				LMP|She came to clinic with her husband, _%#NAME#%_, for genetic consultation and level II ultrasound due to a history of Down syndrome in a previous pregnancy. Pregnancy History: G 4 P 0030 LMP: IVF pregnancy Age: 42 EDC (LMP): _%#MMDD2008#%_ Age at Delivery: 43 EDC (U/S): Gestational Age: 19+2 weeks * No significant complications or exposures were reported in the current pregnancy.
IVF|in vitro fertilization|IVF|223|225|G 4   P	0030				LMP|I spent approximately 45-minutes with this patient today. _%#NAME#%_ is a 30-year-old gravida 1, para 0-0-0-0 who is currently 12 weeks' gestation based on an estimated date of delivery of _%#MMDD2008#%_. She had undergone IVF due to endometriosis and the fact that she was diagnosed with multiple sclerosis 2 years ago. She currently is not on any medications. We reviewed first trimester screening and its limitations.
IVF|in vitro fertilization|IVF|243|245|OB-GYN|We spent 45 minutes with the patient. _%#NAME#%_ is a gravida 2, para 1-0-0-1, and she will be 39 years of age at the time of delivery. _%#NAME#%_ was 12.3 weeks' pregnant at the appointment. This is a twin pregnancy that was achieved through IVF using _%#NAME#%_'s sperm and _%#NAME#%_'s egg. The couple experienced infertility for 15 months, possibly due to radiation that _%#NAME#%_ received for treatment of a brain tumor.
IVF|in vitro fertilization|IVF|152|154|OB-GYN|One of his half- brothers through his mother had Hodgkin disease at age 28, but is currently doing well at age 45. His brother and hs wife went through IVF because of the cancer treatments, and have healthy triplets. _%#NAME#%_'s half-sister through his mother has 2 healthy children, and also experienced an early miscarriage.
IVF|in vitro fertilization|IVF|242|244|LACEY BENOIT|As you know, she was referred for first-trimester screening. I spent approximately 30 minutes with this patient reviewing the following information. _%#NAME#%_ is a 36-year-old gravida 2 para 0-0-1-0 whose current pregnancy was the result of IVF using a donor egg, age 29. She has endometriosis. Her gestational age at the time of the visit was 12 weeks and 2 days' gestation, giving her an estimated date of delivery of _%#MM#%_ _%#DD#%_, 2005.
IVF|in vitro fertilization|IVF,|148|151|LACEY BENOIT|I spent approximately 45 minutes with this patient today. _%#NAME#%_ is a 35-year-old, gravida 2, para 1-0-0-1. This pregnancy was achieved through IVF, and the specific reason for their infertility was unknown. Her first pregnancy was delivered at 29 weeks and currently, they have a 6-year-old son who is doing quite well, despite his prematurity.
IVF|in vitro fertilization|IVF|167|169|LACEY BENOIT|Her first pregnancy was delivered at 29 weeks and currently, they have a 6-year-old son who is doing quite well, despite his prematurity. ICSI was not used during the IVF for these embryos that were implanted. I reviewed the results of their triple screen, which were as follows: 0.45 MoM AFP, 1.42 MoM hCG, 1.34 MoM estriol, which increases her chance to have a baby with Down syndrome from 1 in 250 to 1 in 90.
IVF|in vitro fertilization|IVF.|138|141|LACEY BENOIT|She is taking Zyrtec. This pregnancy took them a while to achieve, and they had previous tries with intrauterine insemination, as well as IVF. This pregnancy was conceived naturally and, thus, they are very excited. They had been ready to start the adoption process. I reviewed that at the age of 40, her chance to have a baby with any type of chromosome abnormality is approximately 1 in 66.
IVF|in vitro fertilization|IVF|165|167|MMC 276|The focus of our discussion was the patient's diagnosis of cystic fibrosis and possible risk to a future pregnancy. As stated earlier, the patient is considering an IVF pregnancy using her eggs and _%#NAME#%_'s sperm but with a surrogate carrier (_%#NAME#%_'s sister). The autosomal recessive pattern of inheritance of cystic fibrosis was reviewed with the patient.
IVF|in vitro fertilization|IVF|217|219|HISTORY OF PRESENT ILLNESS|She has noted intermittent tightness which is nonpainful today. She notes positive fetal movement. She denies rupture of membranes or vaginal bleeding. The prenatal course has been otherwise uncomplicated. This is an IVF pregnancy. PAST MEDICAL HISTORY: Significant for 1 ectopic pregnancy, status post neosalpingostomy on the left side, as well as umbilical hernia repair.
IVF|in vitro fertilization|IVF|214|216|PLAN|As you know, Ms. _%#NAME#%_ is a 35-year-old, gravida 1, para 0, whose pregnancy was 18 weeks 6 days based on an estimated date of delivery of _%#MM#%_ _%#DD#%_, 2008. As you know the pregnancy was conceived using IVF with ICSI with donor sperm. The patient reports the current pregnancy has been uncomplicated. She reports no alcohol use, tobacco use, chemical exposures, x-rays, fever, bleeding or other complications.
IVF|in vitro fertilization|IVF.|186|189|MMC 276|Risk of miscarriage is 1:200. We thoroughly reviewed her family history during our genetic counseling session. As stated earlier this is their first pregnancy, which is achieved through IVF. _%#NAME#%_ has 3 brothers, one of which is 40 and is an autism spectrum, however, did graduate high school and college.
IVF|in vitro fertilization|IVF|182|184|G  2 P	1001				LMP|She came to clinic with her husband, _%#NAME#%_ _%#NAME#%_, for genetic consultation due to a diagnosis of fetal spina bifida in a twin pregnancy. Pregnancy History: G 2 P 1001 LMP: IVF pregnancy Age: 31 EDC (LMP): Age at Delivery: 31 EDC (U/S): _%#MMDD2006#%_ Gestational Age: 19+3 weeks * _%#NAME#%_ reported no significant exposures, illnesses, or complications in the current pregnancy.
IVF|in vitro fertilization|IVF.|287|290|G  3 P	3003				LMP|Pregnancy History: G 3 P 3003 LMP: _%#MMDD2005#%_ (uncertain) Age: 39 EDC (LMP): _%#MMDD2006#%_ Age at Delivery: 40 EDC (U/S): c/w EDC Gestational Age: 16+4 * _%#NAME#%_ and her husband reported a long-standing history of infertility. Each of their prior two pregnancies was achieved by IVF. The current pregnancy is a spontaneous pregnancy. * _%#NAME#%_ was recently diagnosed with multiple sclerosis and takes copaxone. She had some questions about the safety of this medication during pregnancy.
IVF|in vitro fertilization|IVF.|309|312|G  3 P	3003				LMP|She had declined quad screen. We reviewed the limitations of level II ultrasound, as well as the diagnostic capabilities of amniocentesis along with its less than 1:200 risk of miscarriage. We thoroughly updated her family history during our genetic counseling session. Her previous pregnancy was a result of IVF. _%#NAME#%_ is currently 14 months old and is doing quite well. He has been walking since 10 months of age and is quite active.
IVF|in vitro fertilization|IVF|266|268|G  3 P	3003				LMP|_%#NAME#%_ stated that her first pregnancy was the result of in vitro fertilization in which she has twin sons who are 21 years of age and are currently healthy. This pregnancy was achieved naturally without any assistance. _%#NAME#%_ stated that the reason for the IVF initially was due to _%#NAME#%_'s sperm morphology. _%#NAME#%_ reported a nephew diagnosed at the age of 19 with _%#NAME#%_'s disease. _%#NAME#%_ also reported her brother having several surgeries on his ear, and becoming deaf in 1 ear.
IVF|in vitro fertilization|IVF|156|158|G  3 P	3003				LMP|As you know this patient has a history of infertility and this pregnancy was the result of treatment using artificial insemination and was achieved through IVF without the use of ICSI. I reviewed that at the age of 41 her chance to have a baby with any type of chromosome abnormality is approximately 2%.
IVF|in vitro fertilization|IVF|173|175|G  3 P	3003				LMP|_%#NAME#%_ is a 41-year-old gravida 2, para 0-0-1-0, who is currently 11 weeks' gestation based on an estimated date of delivery of _%#MMDD2007#%_. This is the result of an IVF pregnancy. Her previous pregnancy was also the result of an IVF pregnancy and first trimester screening during that pregnancy had shown increased nuchal translucency of 4.0 mm.
IVF|in vitro fertilization|IVF|165|167|G  3 P	3003				LMP|As you know this pregnancy was the result of invitro fertilization and was initially a twin pregnancy but unfortunately one of the twins passed away at 6 weeks. Her IVF was performed at Reproductive Medicine Clinic. As you know, her first pregnancy a couple of years ago had revealed a thickened nuchal translucency 4.0 mm and first trimester screen had showed increased risk for Down syndrome.
IVF|in vitro fertilization|IVF|252|254|PLAN|We discussed prenatal testing is available once an individual achieves a pregnancy, which can include chorionic villous sampling, amniocentesis, first trimester screening quad screen or a level 2 ultrasound. The patient had several questions regarding IVF and preimplantation genetic diagnosis. We stated that there may be some centers doing preimplantation genetic diagnosis for aneuploidy given this patient's age.
IVF|intravenous fluid|IVF|219|221|RECOMMENDATIONS|3. Hypertension and proteinuria secondary to #1. 4. Possible aspiration during surgery. RECOMMENDATIONS: 1. Continue p.r.n. IV hydralazine. 2. Monitor renal hepatic function, platelets and magnesium levels. 3. Continue IVF and magnesium sulfate per OB Service. Can add additional calcium. 4. Observe for possible nutritional needs. Would assume she can start eating within the next 24 hours.
IVF|in vitro fertilization|IVF.|142|145|IN SUMMARY|_%#NAME#%_ has a sister whose son has a diagnosis of ADD. Two of _%#NAME#%_'s sisters had issues with infertility and one sister conceived by IVF. _%#NAME#%_'s sister and father both have history of anxiety. Ethnic Background: _%#NAME#%_'s ethnic background is Irish and German.
IVF|in vitro fertilization|IVF|209|211|G  1  P	0000				LMP|She came to clinic for genetic consultation and first trimester screening in a twin pregnancy. Today's ultrasound revealed an abnormal nuchal translucency in twin A (2.5mm). Pregnancy History: G 1 P 0000 LMP: IVF transfer date _%#MMDD2007#%_ Age: 34 EDC (LMP): Age at Delivery: 34 EDC (U/S): _%#MMDD2008#%_ Gestational Age: 11+6 weeks * The current pregnancy is a monochorionic diamniotic twin pregnancy.
IVF|in vitro fertilization|IVF|222|224|G  1  P	0000				LMP|She reported no smoking, alcohol use, medications, or problems with this pregnancy. They did not have specific reasons for the infertility issues, but certainly were excited with this pregnancy being achieved on the first IVF cycle. I reviewed that at the age of 39 her chance to have a baby with any type of chromosome abnormality is approximately 1 in 83.
IVF|in vitro fertilization|IVF.|263|266|ADDENDUM|As you know her reproductive history is significant for the fact their first pregnancy was achieved through IVF using ICSI which produced identical twin boys who are now 10 months of age. This most recent pregnancy was a spontaneous conception without the aid of IVF. _%#NAME#%_ also reported having a miscarriage when she was 19. _%#NAME#%_ reported that the reason for the infertility was low sperm count and motility issues, and by report he has had a normal karyotype which was performed at the Center for Reproductive Medicine in _%#CITY#%_ _%#CITY#%_.
IVF|in vitro fertilization|IVF.|170|173|ADDENDUM|Her pregnancy loss with trisomy 18 was in _%#MM#%_ of 2005. She has a set of twin boys who are 2 years of age and are healthy. They were conceived with the assistance of IVF. Her subsequent pregnancies, including this one, have been spontaneous without the assistance of IVF. We reviewed that at the age of 39 her chance to have a baby with any type of chromosome abnormality is approximately 1 in 82.
IVF|in vitro fertilization|IVF|315|317|ADDENDUM|I spent approximately 45 minutes with this patient today. _%#NAME#%_ is a 36-year-old who will be 37 at the time of delivery and is a gravida 1, para 0-0-0-0, who is currently at 12 weeks' gestation, based on an estimated date of delivery of _%#MM#%_ _%#DD#%_, 2006. A you know, this pregnancy was achieved through IVF without the use of ICSI. The cause of the infertility was quoted to be, from the patient, "bad eggs." I reviewed that at the age of 37, her chance of having a baby with any type of chromosome abnormality is approximately 1 in 129.
IVF|intravenous fluid|IVF|146|148|LABORATORY DATA|One episode of transient hypoxia after suctioning likely due to laryngeal irritation. Plan Post-operative pain - Acetaminophen PRN Poor feeding - IVF fluids until feeding well - Start oral feedings when more awake Post-operative care - Tobi-drops per ophtho - Follow-up care per ophtho Discharge planning - Home when pain well controlled and taking adequate oral intake, likley tomorrow AM
IVF|in vitro fertilization|IVF|216|218|LABORATORY DATA|We spent approximately 60 minutes with this patient today. _%#NAME#%_ is a 44-year-old gravida 3, para 0-0-2-0, who is currently 7 weeks' gestation, based an estimated date of delivery of _%#MMDD2008#%_. This was an IVF pregnancy with an embryo transfer on _%#MMDD2007#%_. She has had a normal MCV based on the fact that her husband is Italian.
IVF|in vitro fertilization|IVF|141|143|LABORATORY DATA|Examples of Down syndrome, trisomy 13, trisomy 18 and sex-chromosome abnormalities were reviewed. We also reviewed the fact that this was an IVF pregnancy and the slightly increased risk for sex-chromosome abnormalities. We reviewed the differences between screening and diagnostic testing. We reviewed CVS, which is diagnostic for chromosome abnormalities with greater than 99% accuracy.
IVF|in vitro fertilization|IVF|120|122|PLAN|This pregnancy was the result of IVF. _%#NAME#%_ stated that they have had 6 years of infertility. This was their first IVF attempt which was performed through Dr. _%#NAME#%_'s office. We reviewed that at the age of 35 her chance to have a baby with any type of chromosome abnormality is approximately 1 in 200.
IVF|in vitro fertilization|IVF|212|214|PLAN|There is no additional history of recurrent miscarriages, mental retardation, birth defects, or consanguinity. This current pregnancy is desired, confirmed and uncomplicated. This pregnancy was conceived through IVF along with ICSI The patient reported early ultrasound revealed she was carrying twins which spontaneously reduced to a singleton pregnancy.
IVF|in vitro fertilization|IVF|353|355|ICSI.|At age 37, she has a mid- trimester risk of carrying a baby with any type of chromosome abnormality of 1:82, and a mid-trimester risk of carrying a baby with Down syndrome of 1:150. Because this pregnancy was conceived along with ICSI procedure, we also discussed the 1% risk for sex chromosome abnormality associated with pregnancies conceived through IVF with ICSI. In light of this increased risk, we discussed available prenatal testing either through chorionic villi sampling or through amniocentesis.
IVF|in vitro fertilization|IVF|110|112|G  1  P	0000				LMP|She came to clinic for genetic consultation and first trimester screening. Pregnancy History: G 1 P 0000 LMP: IVF retrieval date _%#MMDD2007#%_ Age: 39 EDC (LMP): _%#MMDD2008#%_ Age at Delivery: 40 EDC (U/S): Gestational Age: 11+6 weeks * No significant complications or exposures were reported in the current pregnancy.
IVF|in vitro fertilization|IVF|286|288|G  1  P	0000				LMP|Pregnancy History: G 1 P 0000 LMP: IVF retrieval date _%#MMDD2007#%_ Age: 39 EDC (LMP): _%#MMDD2008#%_ Age at Delivery: 40 EDC (U/S): Gestational Age: 11+6 weeks * No significant complications or exposures were reported in the current pregnancy. * The current pregnancy was achieved by IVF and ICSI using a donor egg from a 24-year-old donor. Risk assessment for chromosome conditions: * We discussed the association between maternal age and an increasing risk for chromosome conditions, such as Down syndrome.
IVF|in vitro fertilization|IVF|267|269|G  1  P	0000				LMP|_%#NAME#%_ is a 37-year-old who will be 38 at the time of delivery and is a gravida 2, para 0-0-1-0 who is currently 19 weeks and 6 days gestation based on an estimated date of delivery of _%#MM#%_ _%#DD#%_, 2005. The patient stated that after two failed attempts of IVF and years of infertility they got pregnant on their own. She reported no smoking, alcohol use, and medications just related to her asthma during her pregnancy.
IVF|in vitro fertilization|IVF|300|302|PLAN|This letter will summarize our 30 minute discussion. Ms. _%#NAME#%_ will be 47 years old at the time of delivery and is a gravida 2, para 1-0-0-1 who is currently 13 and 2/7 weeks gestation based on an estimated date of delivery of _%#MM#%_ _%#DD#%_, 2006. Of note, the pregnancy was conceived using IVF with donor egg. The age of the donor was 25 years. This is Ms. _%#NAME#%_'s second pregnancy. As you know she has a healthy 3-year-old daughter.
IVF|intravenous fluid|IVF|212|214|RECOMMENDATIONS|If this does not give enough information, may need to convert this to a Swan-Ganz catheter 2. He responded to intravenous bolus of fluid, suggesting that he is slightly volume depleted. We will continue cautious IVF using CVP as a monitor. 3. Check urine and sodium, creatinine and calculate fractional excretion of sodium. 4. ON Zosyn and Azithromycin per pulmonary , continue with these.
IVF|intravenous fluid|IVF|194|196||1. CHF stage C, functional class unknown, etiology unknown, LVEF in the 30% range. 2. Minimal fluid overload. 3. Acute on chronic renal failure, now improving. 4. Recommendations: - Discontinue IVF - Lasix 20 mg IV BID today, will change to 40 mg PO QD tomorrow - Continue treatment with lisinopril and metoprol - EC ASA 81 mg QD 5.
IVF|in vitro fertilization|IVF.|118|121|SOCIAL HISTORY|3. Clonodine. 4. Seroquel. ALLERGIES: Penicillin and amoxicillin (hives). SOCIAL HISTORY: The patient is a product of IVF. His parents are divorced and they have equal custody. The patient does not smoke cigarettes or use drugs. FAMILY HISTORY: Not obtained. REVIEW OF SYSTEMS: Unremarkable. PHYSICAL EXAMINATION: GENERAL: Cooperative yet extremely distractable young male in no acute distress.
IVF|in vitro fertilization|IVF.|265|268|RE|This letter will summarize our 40-minute discussion. As you know, _%#NAME#%_ is a 30-year-old gravida 4, para 1-0-2-1, whose pregnancy was 16 weeks, 2 days on an estimated date of delivery of _%#MM#%_ _%#DD#%_, 2007. This is currently a twin pregnancy conceived by IVF. _%#NAME#%_ has a history of 2 prior ectopic pregnancies. Her previous pregnancy with her daughter was also conceived by IVF. We began our discussion by reviewing the purpose of maternal serum screen.
IVF|in vitro fertilization|(IVF)|259|263|RE|I spent approximately 45 minutes with this patient today. _%#NAME#%_ is a 32-year-old gravida 2, para 0-0-1-0 who is currently 12 weeks gestation with an estimated date of delivery of _%#MMDD2006#%_. This pregnancy was achieved through in-vitro fertilization (IVF) using ISCI. This was performed at Reproductive Medicine Center. During her previous pregnancy, she had an abnormal triple screen which gave her an increased risk of 1:150 for Down syndrome.
IVF|in vitro fertilization|IVF|266|268|RE|We reiterated that there was nothing either of them did to cause their prior pregnancy to have Down syndrome, as these things can just happen. We also discussed the slightly increased risk for sex-chromosome abnormality given the fact that they used ICSI during the IVF procedure. Literature states there is approximately a 0.8% risk for sex-chromosome abnormality such as Klinefelter syndrome. We discussed the procedure of CVS, which is diagnostic for chromosome abnormality with greater than 99% accuracy.
IVF|in vitro fertilization|IVF|132|134|ADDENDUM|This pregnancy was terminated. They have a 17-month-old son who was healthy. Both of these were IVF. This current pregnancy is also IVF as well as ICSI. We reviewed that her risk to have a baby with Down syndrome based on her age and history is approximately 1%.
IVF|in vitro fertilization|IVF|152|154|G  3  P 0112				LMP|She came to clinic for genetic consultation and first trimester screening due to advanced maternal age in pregnancy. Pregnancy History: G 3 P 0112 LMP: IVF transfer date _%#MMDD2007#%_ Age: 39 EDC (IVF): _%#MMDD2008#%_ Age at Delivery: 39 EDC (U/S): c/w EDC Gestational Age: 12+1 weeks * No significant complications or exposures were reported in the current pregnancy.
IVF|in vitro fertilization|IVF.|171|174|G 3   P	0020				LMP|She reports no concerns in her medical history. The current pregnancy was conceived with in vitro fertilization. Day 5 embryos were transferred during this fresh cycle of IVF. ICSI was not done. _%#NAME#%_ reports no complications with the current pregnancy and she is taking prenatal vitamins and progesterone.
IVF|in vitro fertilization|IVF|269|271|IN SUMMARY|This letter will summarize our 30 minute discussion. As you know, _%#NAME#%_ is a 35-year-old, gravida 2, para 1-0-0-1, whose pregnancy is 18 weeks and 2 days gestation based on an estimated date of delivery of _%#MM#%_ _%#DD#%_, 2006. This pregnancy was the result of IVF with possible ICSI. The specific cause of their secondary infertility was unknown. They have a 3-year-old son who is healthy. We reviewed features of Down syndrome, trisomy 18 and 13 and sex chromosomes.
IVF|in vitro fertilization|IVF|264|266|IN SUMMARY|As you know, Ms. _%#NAME#%_ is a 36-year-old, gravida 3, para 2-0-0-2, whose pregnancy was 13 weeks 1 days based on an estimated date of delivery of _%#MM#%_ _%#DD#%_, 2008. As you know this is Ms. _%#NAME#%_'s third pregnancy. She has 2 healthy children. She had IVF with her second pregnancy, however, this pregnancy was conceived spontaneously. She patient reports the current pregnancy has been uncomplicated. She reports no alcohol use, tobacco use, chemical exposures, x-rays, fever, bleeding or other complications.
IVF|inferior vena cava:IVC|IVF|408|410|PLAN|4. Bilateral effusions plus lower extremity edema plus pericardial effusion raises concern for constrictive pericarditis which could be causing his profound dyspnea, leading to a sedentary lifestyle or at least contributing to it that will not get better with diuresis or even dialysis. PLAN: 1. Formal sleep study. 2. Empiric CPAP (10-cm of water). 3. Ultrasound thoracentesis on the right (diagnostic). 4. IVF filter placement. 5. Consider right heart catheterization to look waveform analysis to rule out constrictive pericarditis. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 74-year-old male who was admitted to Fairview Southdale Hospital on _%#MMDD2003#%_ with recurrent syncopal episodes.
IVF|in vitro fertilization|IVF|220|222|IN SUMMARY|The couple has had one pregnancy, which resulted in a miscarriage around 12 weeks. The patient reports that chromosome studies were unable to be performed following this miscarriage. That pregnancy was conceived through IVF with ICSI performed at Center for Reproductive Medicine. At the time of her visit, a family history was obtained.
IVF|in vitro fertilization|IVF|327|329|IN SUMMARY|In addition, the availability of preimplantation genetic diagnosis was briefly discussed as an available means to test an embryo for a chromosome abnormality prior to implantation with an IVF cycle. We discussed that should the patient wish to discuss these prenatal testing options in more detail should they consider another IVF cycle, we would be happy to do that. At the conclusion of our discussion, the patient's husband had his blood drawn for chromosome studies, Y-microdeletion studies, as well as a hemoglobin electrophoresis.
IVF|in vitro fertilization|IVF|198|200|G  3  P 1011				LMP|As you know, Ms. _%#NAME#%_ is a 37-year-old, gravida 2, para 1-0-01, whose pregnancy was 13 weeks 2 days based on an estimated date of delivery of _%#MMDD2008#%_. The pregnancy was conceived using IVF with ICSI and assisted hatching. The patient was seen through the Reproductive Medicine Center and Dr. _%#NAME#%_ _%#NAME#%_. The patient reports the current pregnancy is uncomplicated.
IVF|in vitro fertilization|IVF|180|182|G 1  P	0000				LMP|She came to clinic with her husband, _%#NAME#%_, for genetic consultation and level II ultrasound due to ultrasound markers in a twin pregnancy. Pregnancy History: G 1 P 0000 LMP: IVF pregnancy with ICSI Age: 31 EDD (LMP): _%#MMDD2007#%_ (by IVF dates) Age at Delivery: 31 EDD (U/S): Gestational Age: 26+1 weeks * _%#NAME#%_ reported a history of infertility, which has been attributed to endometriosis.
IVF|in vitro fertilization|IVF|290|292|PLAN|I spent approximately 45 minutes with this patient today. _%#NAME#%_ is a 32-year-old gravida 2, para 1-0-0-1, who is currently 12 weeks' gestation based on estimated date of delivery of _%#MMDD2008#%_. She has a 3-year-old daughter, who is healthy, and this pregnancy was achieved through IVF due to morphology issues of her husband, _%#NAME#%_. We reviewed 1st trimester screening as well as its limitations and false-positives and false-negatives.
IVF|in vitro fertilization|IVF|285|287|PLAN|As you know, _%#NAME#%_ is a 36-year-old prima gravida who is currently 8 weeks 1 day gestation by date of conception of _%#MM#%_ _%#DD#%_, 2006, giving an estimated date of confinement of _%#MMDD2007#%_. Her prenatal course has been as follows: She conceived with her second cycle of IVF with ICSI. Of note, the father of this pregnancy had low sperm count presumably due to a varicocele which was repaired without much improvement in his sperm count.
IVF|in vitro fertilization|IVF.|181|184|G 1   P	0000				LMP|She was diagnosed with hypothyroidism approximately 4 years ago . She has one sister who has polycystic ovarian syndrome and is overweight and has a son, which was assisted through IVF. Her mother died of lung cancer at the age of 52 and did smoke. _%#NAME#%_ is trying to cut back on her smoking and we encouraged her to do so.
IVF|in vitro fertilization|IVF|259|261|IN SUMMARY|We discussed the options if in the event there was an abnormality found during this pregnancy, including continuation of the pregnancy or termination of the pregnancy up to 22 weeks in the State of Minnesota. You stated that ICSI was not performed during the IVF procedure. However, we did review that if this was performed, studies indicate that there may be an increased risk for sex chromosome abnormalities because of this procedure.
IVF|intravenous fluid|IVF|207|209|RECOMMENDATIONS|6. Hypertension. 7. Benign prostatic hypertrophy. 8. 4 cm abdominal aortic aneurysm and 2.5 right common iliac aneurysm. RECOMMENDATIONS: 1. Continue hydration with IV fluids. 2. Add some bicarbonate to his IVF which should help correct the metabolic acidosis. 3. Check urine indices including urine sodium, creatinine, and calculate a fractional excretion of sodium.
IVF|in vitro fertilization|IVF|254|256|IN SUMMARY|As you know _%#NAME#%_ is a 34-year-old who will be 35 at the time of delivery and is a gravida 3, para 0-0-2-0 who is currently 18 weeks and 3 days gestation based on an estimated date of delivery of _%#MM#%_ _%#DD#%_, 2005. This pregnancy was achieved IVF using ICSI. She has had two previous miscarriages and had multiple workups regarding infertility with no known reason. According to Reproductive Medicine Center records, both her and her husband had chromosomes performed at (DNYa Gene) which were normal.
IVF|in vitro fertilization|IVF|154|156|IN SUMMARY|We thoroughly reviewed their family history during our genetic counseling session. _%#NAME#%_ reported that both her brother and sister have gone through IVF due to their spouse's infertility issues. _%#NAME#%_ also reported a significant family history of adult onset muscular dystrophy. Specifically she reported two paternal aunts and one paternal uncle who began having symptoms in their 20s and were wheelchair bound in their 30s.
IVF|in vitro fertilization|IVF|234|236|LABORATORY DATA|_%#NAME#%_ is a 39-year-old who will be 40 at the time of delivery, gravida 4, para 1-0-2-1, who is currently 17 weeks and 1 day gestation, based on an estimated date of delivery of _%#MMDD2004#%_. This pregnancy was the result of an IVF procedure using ICSI. She reported no smoking, alcohol use, chemical exposures or x-rays, medication, fevers, or problems during this pregnancy.
IVF|in vitro fertilization|IVF|166|168|G 1   P	0000				LMP|She came to clinic with her husband, _%#NAME#%_ _%#NAME#%_, for genetic consultation regarding advanced maternal age in pregnancy. Pregnancy History: G 1 P 0000 LMP: IVF pregnancy Age: 37 EDC (LMP): Age at Delivery: 37 EDC (U/S): _%#MMDD2006#%_ (9+6 on _%#MMDD2005#%_) Gestational Age: 20+1 weeks * No significant complications or exposures were reported in the current pregnancy.
IVF|in vitro fertilization|IVF|264|266|G 2  P	1001				LMP|She came to clinic with her husband, _%#NAME#%_ _%#NAME#%_, for genetic consultation and level II ultrasound due to advanced maternal age in pregnancy. Pregnancy History: G 2 P 1001 LMP: in-vitro Age: 39 EDD (LMP): Age at Delivery: 39 EDD (U/S): _%#MMDD2006#%_ by IVF dates Gestational Age: 20+4 weeks * The embryo used for this IVF pregnancy was conceived when _%#NAME#%_ was 35 years old.
IVF|in vitro fertilization|IVF|153|155|G 2  P	1001				LMP|* As discussed above, _%#NAME#%_'s age related risks in this pregnancy would be the same as the risks quoted for a 35-year-old (due to the fact that the IVF embryos were fertilized when _%#NAME#%_ was 35 years old). o Age mid trimester Down syndrome risk= 1:250 o Age mid trimester risk for any chromosome condition= 1:120 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
IVF|in vitro fertilization|IVF.|159|162|G 2   P 0010				LMP|As you know Ms. _%#NAME#%_'s past pregnancy history is significant for a quad pregnancy that was lost at 21 weeks. The current pregnancy was conceived through IVF. The patient reports that there was no ICSI or assisted hatching. She reports the current pregnancy is unremarkable. There is no known alcohol use, tobacco use, chemical exposures, x-rays, medications, fever, bleeding, or other complications.
IVF|in vitro fertilization|IVF|175|177|HISTORY OF PRESENT ILLNESS|She is paying attention to her temperatures as her partner has been ill, and two weeks ago she underwent in vitro fertilization. Based on hormonal levels, it appears that the IVF is successful so far. She has no unusual exposures. She was moved into a newly remodeled area at Fairview _%#CITY#%_ for work, she is a psychologist who does counseling at Fairview _%#CITY#%_.
IVF|in vitro fertilization|IVF|231|233|ASSESSMENT/PLAN|I spent approximately 60 minutes with this pleasant couple. _%#NAME#%_ is a 42-year-old gravida 1, para 0-0-0-0 whose current pregnancy was achieved through IFV using donor egg from her partner, _%#NAME#%_, who is 36 years of age. IVF was performed at Midwest Reproductive Center in _%#CITY#%_ _%#CITY#%_. They used donor sperm from California Cryobank. Currently _%#NAME#%_ is approximately 12 weeks gestation based on an estimated date of delivery of _%#MM#%_ _%#DD#%_, 2006.
IVF|in vitro fertilization|IVF|159|161|G  5  P 2022				LMP|She came to clinic for genetic consultation and first trimester screening due to advanced maternal age in a twin pregnancy. Pregnancy History: G 5 P 2022 LMP: IVF pregnancy Age: 38 EDC (LMP): _%#MMDD2007#%_ Age at Delivery: 38 EDC (U/S): Gestational Age: 13 2 weeks * The current pregnancy is an IVF pregnancy.
IVF|in vitro fertilization|IVF|172|174|G  5  P 2022				LMP|Pregnancy History: G 5 P 2022 LMP: IVF pregnancy Age: 38 EDC (LMP): _%#MMDD2007#%_ Age at Delivery: 38 EDC (U/S): Gestational Age: 13 2 weeks * The current pregnancy is an IVF pregnancy. _%#NAME#%_ and _%#NAME#%_ pursued IVF due to a prior tubal ligation (i.e. no underlying medical infertility diagnosis).
IVF|in vitro fertilization|IVF|221|223|G  5  P 2022				LMP|Pregnancy History: G 5 P 2022 LMP: IVF pregnancy Age: 38 EDC (LMP): _%#MMDD2007#%_ Age at Delivery: 38 EDC (U/S): Gestational Age: 13 2 weeks * The current pregnancy is an IVF pregnancy. _%#NAME#%_ and _%#NAME#%_ pursued IVF due to a prior tubal ligation (i.e. no underlying medical infertility diagnosis). The oocytes for the IVF were retrieved in _%#MM#%_ 2006.
IVF|in vitro fertilization|IVF|152|154|G  3  P 0020				LMP|She came to clinic for genetic consultation and first trimester screening due to advanced maternal age in pregnancy. Pregnancy History: G 3 P 0020 LMP: IVF pregnancy Age: 40 EDC (LMP): _%#MMDD2006#%_ Age at Delivery: 41 EDC (U/S): Gestational Age: 12+6 weeks * The current pregnancy is a twin pregnancy.
IVF|in vitro fertilization|IVF|223|225|REASON FOR CONSULT|_%#NAME#%_ was born at approximately 31 weeks gestation through a pregnancy complicated by antiphospholipid antibodies in the mother with a significant cough and fever 2 weeks prior to delivery. _%#NAME#%_ was conceived by IVF and was a twin. His birth weight was 1900 grams with Apgars of 7 and 8. Because of respiratory distress he was evaluated with echo, which showed 22% ejection fraction, dilated cardiomyopathy, and moved to the Fairview PICU after birth, where I initially saw him.
IVF|in vitro fertilization|IVF.|213|216|INDICATION|Please evaluate for current function and follow. Information provided by chart, interview with mother and father, and staff. _%#NAME#%_ is a 5-week-old male infant born at 30 +5 weeks after pregnancy conceived by IVF. Pregnancy was complicated by being a twin in mother with a history of antiphospholipid antibody and positive APL, and pretreatment with prednisone before conception, as well as IVIG x 2 with chronic heparin use during the pregnancy.
IVF|in vitro fertilization|IVF|201|203|IMPRESSION|He has flaccid hypotonia diffusely. Cranial ultrasound was reviewed and shows no bleed and normal ventricular size. There is no periventricular leukomalacia. IMPRESSION: 1. Status post prematurity. 2. IVF pregnancy. 3. Congestive cardiomyopathy, etiology unknown, with current normal cranial ultrasound. 4. Clinical examination ablated by treatment. PLAN: 1. I spoke with the family and told them that there are no causes for additional concern, based on my review of history and findings.
IVF|intravenous fluid|IVF|145|147|PHYSICAL EXAMINATION|The actual report is not available at this dictation. Hemoglobin 16, white count 12,800. Sodium 140, K 3.7, chloride 107, cO2 24, glucose 122, ? IVF running. Clavicle x-ray apparently shows a mid-shaft fracture. Thanks for the consultation.
IVF|in vitro fertilization|IVF|240|242|PHYSICAL EXAMINATION|I spent approximately 60 minutes with this patient. _%#NAME#%_ is a 44-year-old, gravida 4, para 2-0-1-2, who is currently 12weeks 4 days' gestation based on an estimated date of delivery of _%#MMDD2007#%_. This pregnancy was the result of IVF using her egg and her husband's sperm. I reviewed that at the age of 44, her chance to have a baby with any type of chromosome abnormality is approximately 1 in 25 or 4%.
IVF|in vitro fertilization|(IVF|161|164|G 1  P	0000				LMP|She came to clinic for genetic consultation and level II ultrasound due to advanced maternal age in pregnancy. Pregnancy History: G 1 P 0000 LMP: _%#MMDD2007#%_ (IVF dates) Age: 36 EDD (LMP): _%#MMDD2008#%_ Age at Delivery: 36 EDD (U/S): c/w EDC Gestational Age: 18+1 weeks * No significant complications or exposures were reported in the current pregnancy.
IVF|in vitro fertilization|IVF|147|149|G 1  P	0000				LMP|Examples of Down syndrome, trisomy 13, trisomy 18, or sex chromosome abnormalities were reviewed. Individuals who perform Icsi in conjunction with IVF might be at slightly increased risk for the sex chromosome abnormalities. We reviewed the limitations of 1st trimester screening as it can assess one's risk for Down syndrome, trisomy 13 and 18, and congenital heart defects.
IVF|in vitro fertilization|(IVF)|198|202|PLAN|3. I would recommend that she see a lipid specialist for control of her triglycerides before she would do any attempts at pregnancy. She should consider either injectables or in vitro fertilization (IVF) in order to speed up the process. Time spent in today's consultation was 20 minutes.
IVF|in vitro fertilization|IVF.|301|304|G  4  P	1021				LMP|Pregnancy History: G 4 P 1021 LMP: IVF pregnancy-due date _%#MMDD2006#%_ Age: 42 EDC (LMP): Age at Delivery: 42 EDC (U/S): Gestational Age: 11+2 weeks * No significant complications or exposures were reported in the current pregnancy. * The current pregnancy is a twin pregnancy and was achieved with IVF. Donor eggs were used and the age of the donor was 25 years. I explained that the age related risks for chromosome conditions would thus be comparable to the risks for a 25-year-old.
IVF|in vitro fertilization|IVF|172|174|G  3 P	2002				LMP|Her husband is still back in Missouri. She stated that they tried to get pregnant for approximately 10 months and then tried 3 cycles of IUI, and then this was their first IVF attempt. _%#NAME#%_ has 1 sister who is healthy, who has a son that is healthy. Her fiance, _%#NAME#%_, is 33 and is also healthy. Otherwise, there was nothing remarkable about the family history such as mental retardation, birth defects or early-onset cancer.
IVF|in vitro fertilization|IVF|277|279|G  3 P	2002				LMP|I spent approximately 60 minutes with this patient today. _%#NAME#%_ is a 41-year-old gravida 2 para 0-0-1-0 who is currently 12 weeks' gestation based on an estimated date of delivery of _%#MMDD2008#%_. This pregnancy was the result of a donor egg whose age is 32, along with IVF using ISCI. _%#NAME#%_ herself has had 1 early ectopic pregnancy previously. We reviewed first trimester screen as a way to obtain risk assessment information regarding Down syndrome, trisomy 13, trisomy 18, and congenital heart defects.
IVF|in vitro fertilization|IVF|171|173|G  3 P	2002				LMP|They have a 4-year-old daughter who is healthy. They have been trying for over 2 years to get pregnant including artificial insemination and are planning to start with an IVF cycle. The cause for their secondary infertility is unknown, although _%#NAME#%_ did have some endometriosis. _%#NAME#%_ has 1 brother who is 36 years of age and does have some elevated cholesterol and high blood pressure.
IVF|in vitro fertilization|IVF|337|339|G  1  P 0000				LMP|Pregnancy History: G 1 P 0000 LMP: In vitro Age: 38 EDC (LMP): Age at Delivery: 39 EDC (U/S): _%#MMDD2007#%_ Gestational Age: 12+4 weeks * No significant complications or exposures were reported in the current pregnancy. * _%#NAME#%_ and her husband reported a history of unexplained infertility. The current pregnancy was achieved with IVF and ICSI. We briefly spent some time discussing the fact that there is some data to suggest a modest increase in risk for some chromosome conditions associated with the ICSI procedure.
IVF|in vitro fertilization|IVF|188|190|ALLERGIES|If she would choose to do this treatment prior to pregnancy there is some concern that she may lose ovarian function permanently. We discussed that assisted reproductive technologies with IVF could be performed and embryos could be stored with plans to replace those embryos after her treatment with mitoxantrone.
IVF|in vitro fertilization|IVF.|357|360|G  5  P 2022				LMP|Pregnancy History: G 5 P 2022 LMP: IVF retrieval _%#MMDD2007#%_ Age: 37 EDC (IVF): _%#MMDD2007#%_ Age at Delivery: 38 EDC (U/S): Gestational Age: 13+3 weeks * No significant complications or exposures were reported in the current pregnancy. * _%#NAME#%_ and _%#NAME#%_ reported a history of unexplained infertility. The current pregnancy was achieved using IVF. * _%#NAME#%_ reported a history of two unexplained first trimester miscarriages. One of these miscarriages was with a former husband. Risk assessment for chromosome conditions: * We discussed the association between maternal age and an increasing risk for chromosome conditions, such as Down syndrome.
IVF|in vitro fertilization|IVF|168|170|G  6  P 1041				LMP|She came to clinic for genetic consultation and first trimester screening due to a history of four first trimester pregnancy losses. Pregnancy History: G 6 P 1041 LMP: IVF pregnancy Age: 41 EDC (IVF): _%#MMDD2005-2006#%_ Age at Delivery: 42 EDC (U/S): Gestational Age: 12+2 weeks * No significant complications or exposures were reported in the current pregnancy.
IVF|in vitro fertilization|IVF|144|146|G  6  P 1041				LMP|This finding would not be expected to significantly alter the age related risk for chromosome conditions in the current pregnancy. * This is an IVF pregnancy and a donor egg was used. The age of the egg donor is 29. Risk assessment for chromosome conditions: * We discussed the association between maternal age and an increasing risk for chromosome conditions, such as Down syndrome.
IVF|in vitro fertilization|IVF|201|203|G  6  P 1041				LMP|He also has developed diabetes. To _%#NAME#%_'s knowledge, she is uncertain whether he has undergone genetic testing, however, she did share that he and an ex-wife had gone through several attempts of IVF to achieve a pregnancy, which unfortunately failed. Her brother's name is _%#NAME#%_ _%#NAME#%_, born on _%#MMDD1974#%_. _%#NAME#%_ always knew that she could be a carrier because of her family history of her brother having cystic fibrosis, however, it was just until recently when she met with you did she have the blood test, which revealed that she is a carrier of delta F508.
IVF|in vitro fertilization|IVF|423|425|ASSESSMENT AND PLAN|We discussed that with future pregnancies, it would seem likely that her risk for preeclampsia, would be relatively lower, if she were carrying an unaffected fetus, and probably somewhat higher if she were carrying an effected fetus. We discussed the options for prenatal diagnosis with chorionic villi sampling at 10 to 12 weeks, or amniocentesis at 15 to 18 weeks, or the option of preimplantation genetic diagnosis with IVF and embryo biopsy to test and then eventually replace only embryos that were unaffected. We discussed the pros and cons of each of these options.
IVF|in vitro fertilization|IVF|144|146|ASSESSMENT AND PLAN|We specifically discussed Down syndrome, trisomies 13 and 18, and the sex chromosome abnormalities. Based on information provided regarding the IVF pregnancy, the patient has a term risk of carrying a baby with Down syndrome of 1:1429 and a term risk of carrying a baby with any of the aforementioned chromosome abnormalities of 1:500.
IVF|in vitro fertilization|IVF|140|142|ASSESSMENT AND PLAN|They feel reassured that this pregnancy is now in the second trimester, and their worries have dissipated somewhat. Given that they pursued IVF to conceive this pregnancy they do not wish to risk any miscarriage with invasive diagnostic testing. I assured them that we would have a discussion if any abnormalities were found on the level II ultrasound today.
IVF|in vitro fertilization|(IVF|181|184|G 4   P	1021				LMP|She came to clinic with her husband, _%#NAME#%_ _%#NAME#%_, for genetic consultation regarding advanced maternal age in pregnancy. Pregnancy History: G 4 P 1021 LMP: _%#MMDD2006#%_ (IVF pregnancy) Age: 37 EDC (LMP): _%#MMDD2007#%_ Age at Delivery: 37 EDC (U/S): Gestational Age: 20+4 weeks * No significant complications or exposures were reported in the current pregnancy.
IVF|in vitro fertilization|IVF|303|305|LABORATORY DATA|This letter will summarize our 45 minute discussion. Ms. _%#NAME#%_ will be 45 years old at the time of delivery and is a gravida 6, para 3-0-2-3 who is currently 18 and 1/7 weeks gestation based on an estimated date of delivery of _%#MM#%_ _%#DD#%_, 2006. As you know the pregnancy was conceived using IVF with donor eggs. The patient reports that the donor was approximately 31 years of age. She also reports that the egg that was used was frozen.
IVF|in vitro fertilization|IVF|306|308|LABORATORY DATA|This letter will summarize our 45 minute discussion. Ms. _%#NAME#%_ will be 37-years-old at the time of delivery and is a gravida 2, para 1-0-0-1 who is currently 13 and 6/7 weeks gestation based on an estimated date of delivery of _%#MM#%_ _%#DD#%_, 2005. Ms. _%#NAME#%_'s pregnancy was conceived through IVF with ICSI and is significant for a twin demise. The patient reports no complications currently with the pregnancy. There is no known history of alcohol use, tobacco use, chemical exposures, x-rays, medications, fever, bleeding, or other complications.
IVF|in vitro fertilization|IVF|182|184|G  2  P 0100				LMP|She came to clinic with her husband, _%#NAME#%_, for genetic consultation and first trimester screening due to advanced maternal age in pregnancy. Pregnancy History: G 2 P 0100 LMP: IVF pregnancy Age: 39 EDC (LMP): _%#MMDD2007#%_ (by IVF dates) Age at Delivery: 40 EDC (U/S): c/w EDC (8+2 on _%#MMDD2007#%_) Gestational Age: 12+3 weeks * No significant complications or exposures were reported in the current pregnancy.
IVF|in vitro fertilization|IVF|234|236|G  2  P 0100				LMP|She came to clinic with her husband, _%#NAME#%_, for genetic consultation and first trimester screening due to advanced maternal age in pregnancy. Pregnancy History: G 2 P 0100 LMP: IVF pregnancy Age: 39 EDC (LMP): _%#MMDD2007#%_ (by IVF dates) Age at Delivery: 40 EDC (U/S): c/w EDC (8+2 on _%#MMDD2007#%_) Gestational Age: 12+3 weeks * No significant complications or exposures were reported in the current pregnancy.
IVF|in vitro fertilization|IVF|363|365|G  2  P 0100				LMP|This letter will summarize our 45 minute discussion. Ms. _%#NAME#%_ will be 35 years old at the time of delivery and is a gravida 3, para 2-0-0-2, who is currently 12 2/7 weeks gestation, based on an estimated date of delivery of _%#MM#%_ _%#DD#%_, 2006. As you know, Ms. _%#NAME#%_ has a medical history of Asherman's syndrome. The pregnancy was conceived using IVF with ICSI. The patient reports the current pregnancy has been uncomplicated. She reports no alcohol use, tobacco use, chemical exposures, x-rays, medications, fever, bleeding or other complications.
IVF|in vitro fertilization|IVF|253|255|ADMISSION MEDICATIONS|She is status post appendectomy a few years ago. She has had two laparoscopies apparently to investigate the endometriosis. She is otherwise fairly healthy. ADMISSION MEDICATIONS: Estrace, ibuprofen, Estradiol and Estrace combination for an anticipated IVF cycle. REVIEW OF SYSTEMS: Constitutional: The patient denies fevers or chills.
IVF|in vitro fertilization|IVF|166|168|PLAN|We thoroughly reviewed her family history during our genetic counseling session. _%#NAME#%_ stated that she has two brothers. One of her brother's wives went through IVF treatment and they have a set of triplets. One of these triplets was born with a clubbed foot.
IVF|in vitro fertilization|IVF|176|178|G 2  P	0010				LMP|She came to clinic with her husband, _%#NAME#%_, for genetic consultation and level II ultrasound due to advanced maternal age in pregnancy. Pregnancy History: G 2 P 0010 LMP: IVF pregnancy (retrieval _%#MM2006#%_) Age: 34 EDD (LMP): _%#MMDD2007#%_ Age at Delivery: 35 EDD (U/S): Gestational Age: 19+4 weeks * _%#NAME#%_ had an ectopic pregnancy.
IVF|in vitro fertilization|IVF|289|291|G 2  P	0010				LMP|Pregnancy History: G 2 P 0010 LMP: IVF pregnancy (retrieval _%#MM2006#%_) Age: 34 EDD (LMP): _%#MMDD2007#%_ Age at Delivery: 35 EDD (U/S): Gestational Age: 19+4 weeks * _%#NAME#%_ had an ectopic pregnancy. This, in addition to fallopian tube scarring from a childhood surgery necessitated IVF for the current pregnancy. Risk assessment for chromosome conditions: * We discussed the association between maternal age and an increasing risk for chromosome conditions, such as Down syndrome.
IVF|in vitro fertilization|IVF|140|142|G  4  P	0030				LMP|She came to clinic with her husband, _%#NAME#%_, for genetic consultation and first trimester screening. Pregnancy History: G 4 P 0030 LMP: IVF retrieval _%#MMDD2007#%_ Age: 28 EDC (IVF): _%#MMDD2007#%_ Age at Delivery: 28 EDC (U/S): Gestational Age: 12+2 weeks * The current pregnancy is a twin pregnancy.
IVF|in vitro fertilization|IVF|182|184|G  3  P 0020				LMP|She came to clinic with her husband, _%#NAME#%_, for genetic consultation and first trimester screening due to advanced maternal age in pregnancy. Pregnancy History: G 3 P 0020 LMP: IVF retrieval date _%#MMDD2007#%_ Age: 36 EDC (LMP): _%#MMDD2008#%_ by IVF dates Age at Delivery: 36 EDC (U/S): Gestational Age: 12+0 weeks * No significant complications or exposures were reported in the current pregnancy.
IVF|in vitro fertilization|IVF.|211|214|G  3  P 0020				LMP|Both _%#NAME#%_ and _%#NAME#%_ reported that they had a normal blood chromosome study following the second miscarriage. I did not have records of this testing to review. They achieved the current pregnancy with IVF. Risk assessment for chromosome conditions: * We discussed the association between maternal age and an increasing risk for chromosome conditions, such as Down syndrome.
IVF|in vitro fertilization|IVF|202|204|G  3  P 0020				LMP|This letter will summarize the information that was discussed. _%#NAME#%_ is a 36-year-old gravida 4, para 3-0-0-3 who is currently 18 weeks and four days gestation. This pregnancy was achieved through IVF due to a previous tubal ligation. Her insemination date was _%#MM#%_ _%#DD#%_, 2002 and her estimated date of delivery is _%#MM#%_ _%#DD#%_, 2003.
IVF|in vitro fertilization|IVF|156|158|G  3  P 0020				LMP|I would not agree with that course. You are familiar with the specific fertility issues, including both male factor and female tubal factor considerations. IVF has been recommended as a means of circumventing the problem. Her medications include Nexium, Zantac, Pentasa, Lipram, a generic antihistamine, antidiarrheal medication, trazodone, Vicodin, extra- strength acetaminophen, Sinemet, Compazine, prenatal vitamins, folic acid, Carafate, and I-flora.
IVF|in vitro fertilization|IVF.|234|237|PLAN|Today's visit was primarily to review the consent form for amniocentesis as well as to obtain a thorough family history. Time spent was 30 minutes. _%#NAME#%_ is a 42-year-old Gravida 2, para 0-1-0-1 whose pregnancy was the result of IVF. Her current date of delivery is _%#MMDD2008#%_. She has a history of having previous twins, one of which was stillborn at 35 weeks which revealed a normal 46,X karyotype.
IVF|in vitro fertilization|IVF|205|207|IN SUMMARY|This letter will summarize the information we discussed. _%#NAME#%_ is a 39-year-old gravida 4, para 2-0-1-0, who is currently 12 weeks gestation, based on a conception date through IVF of _%#MMDD2003#%_. IVF was performed due to some problems with _%#NAME#%_'s fallopian tubes and ICSI was not performed for this procedure. _%#NAME#%_ reported being on progesterone oil and had some concerns regarding the potential teratogenics during her pregnancy.
IVF|in vitro fertilization|IVF,|240|243|IN SUMMARY|Her family history was updated from that appointment. _%#NAME#%_ has an 18-year-old son (with a different partner) who is apparently healthy. _%#NAME#%_ and _%#NAME#%_ have a 2-year-old son from her initial pregnancy, also obtained through IVF, who is currently healthy. _%#NAME#%_ reported a cousin with cleft lip and also has some infertility issues. _%#NAME#%_ reported several family members, including an aunt and uncle with breast and colon cancers, as well as ovarian cancer in their 50's, 60's and 70's, respectively.
IVF|in vitro fertilization|IVF|258|260|IN SUMMARY|A level two ultrasound is typically performed between 18 to 20weeks gestation, and can assess physical features of a developing baby, however is not diagnostic for chromosomal abnormalities. _%#NAME#%_ stated that because this pregnancy was achieved through IVF and her concern regarding the risk of miscarriage associated with an amniocentesis, she decided to begin with first trimester screening.
IVF|in vitro fertilization|IVF|193|195|IN SUMMARY|It would be important for the center to be very familiar with the specific translocation in order to be able to have the pre-implantation genetic diagnosis available. This as you know involves IVF and can be quite costly as well as emotionally investment as well as may require physical travel. We also discussed other options such as egg donation, adoption, as well as prenatal testing for future pregnancies.
IVF|in vitro fertilization|IVF|182|184|G  1  P 0000				LMP|She came to clinic with her husband, _%#NAME#%_, for genetic consultation and first trimester screening due to advanced maternal age in pregnancy. Pregnancy History: G 1 P 0000 LMP: IVF pregnancy Age: 36 EDC (LMP): Age at Delivery: 37 EDC (U/S): _%#MMDD2007#%_ Gestational Age: 13+1 weeks * No significant complications or exposures were reported in the current pregnancy.
IVF|in vitro fertilization|IVF|195|197|G  1  P 0000				LMP|She reported a maternal uncle also with infertility problems, and he and his wife adopted 2 children. _%#NAME#%_ reported his sister had infertility due to endometriosis and conceived twins with IVF using ICSI. There was no report of mental retardation, early onset cancers, or other birth defects. Both of them are of northern European ethnic background. I reviewed that congenital hip dislocation is the result of both genetic and environmental factors and the risk for this pregnancy is approximately 12%.
IVF|in vitro fertilization|IVF|218|220|G  1  P 0000				LMP|_%#NAME#%_ is a 39-year-old who will be 40 at the time of delivery, gravida 2, para 0-1-0-1, who is currently 12 weeks' and 3 days' gestation, based on an estimated date of delivery of _%#MM#%_ _%#DD#%_, 2007. She had IVF performed, and implantation date was _%#MM#%_ _%#DD#%_, 2007. The cause of their infertility was unknown. It had taken them 4 IVF cycles for their first daughter, who is doing well and is 18 months old.
IVF|in vitro fertilization|IVF|138|140|G  1  P 0000				LMP|She had IVF performed, and implantation date was _%#MM#%_ _%#DD#%_, 2007. The cause of their infertility was unknown. It had taken them 4 IVF cycles for their first daughter, who is doing well and is 18 months old. She was born premature at 34 weeks and did spent 2 weeks in NICU working on feeding.
IVF|in vitro fertilization|IVF|242|244|G  1  P 0000				LMP|The cause of their infertility was unknown. It had taken them 4 IVF cycles for their first daughter, who is doing well and is 18 months old. She was born premature at 34 weeks and did spent 2 weeks in NICU working on feeding. This pregnancy, IVF cycle was achieved with 1 time. These were new embryos than the previous cycle. We reviewed that at the age of 40, her chance to have a baby with any type of chromosome abnormality is approximately 1:65.
IVF|in vitro fertilization|IVF|289|291|G  1  P 0000				LMP|This letter will summarize our 45 minute discussion. Ms. _%#NAME#%_ will be 42-years-old at the time of delivery and is a gravida 5, para 0-0-4-0, who is currently 12 and 1/7 weeks gestation based on an estimated date of delivery of _%#MM#%_ _%#DD#%_, 2005. The patient was conceived with IVF and donor sperm. The patient was a twin gestation that spontaneously reduced to a singleton. This is the patient's fifth pregnancy. She has a history of 3 early miscarriage and tubal pregnancy.
IVF|in vitro fertilization|IVF|224|226|G  1  P 0000				LMP|She had artificial insemination by donor due to her husband's poor sperm motility in the U.S. on two occasions, both of which were unsuccessful. The couple then moved to Ecuador for mission work that they do. In Ecuador had IVF with ICSI with one cycle. Three fresh embryos were transferred without success. They had a frozen cycle in which three embryos were transferred again without success.
IVF|in vitro fertilization|IVF|174|176|G  1  P 0000				LMP|They had a frozen cycle in which three embryos were transferred again without success. Her past surgical history is remarkable for a D and C in _%#MM#%_ 2004 between the two IVF cycles. Cataract removal in 1998. Wisdom tooth extraction. Her current medications include Ditropan XL 10 mg p.o. q. day, vitamin C 400 mg p.o. q. day, calcium 500 mg q. day, vitamin E the patient is unsure of the dose, folic acid 1200 mg p.o. q. day, and several herbal medications including cod liver oil, flaxseed oil, omega 3 and 6 fatty acids, teamiss, and spring green.
IVF|in vitro fertilization|IVF|306|308|G  1  P 0000				LMP|They had discussed options in the event that the baby did have Down syndrome such as possibly placing this child up for adoption or in the case of a more severe abnormality possible termination of her pregnancy. We also discussed the increased risk for sex chromosome abnormalities due to ICSI use and the IVF procedure. Literature states that there is an approximate 0.8% increased risk for sex chromosome abnormalities such as Klinefelter's syndrome in which individuals are usually of normal intelligence, but can have fertility problems.
IVF|in vitro fertilization|IVF.|282|285|G  1  P 0000				LMP|This letter will summarize our 45-minute discussion. Ms. _%#NAME#%_ will be 35 years old at the time of delivery and is a gravida 2 para 0-0-1-0, who is currently 13-0/7 weeks' gestation, based on an estimated date of delivery of _%#MMDD2006#%_. The pregnancy was conceived through IVF. The patient's past pregnancy history is significant for one early miscarriage. The current pregnancy is reportedly unremarkable. The patient reports no alcohol use, tobacco use, smoke exposures, x-rays, fever, bleeding or other complications.
IVF|in vitro fertilization|IVF|180|182|G  1  P 0000				LMP|_%#NAME#%_ is a 34-year-old gravida 1, para 0-0-0-0 who will be 35 at the time of delivery and is carrying a twin pregnancy which was achieved through IVF. The specific reason for IVF and infertility was not known. We had reviewed that her risk to have one or both babies to have a chromosome abnormality is approximately 1% and we briefly reviewed examples of Down syndrome, trisomy 13, trisomy 18, and sex chromosome abnormalities.
IVF|in vitro fertilization|IVF|238|240|A/P|This is a procedure where they can preferentially select sperm that would make it higher chance to have a female thus would lower her chance to have an affected male. This can be done through MicroSort which is located in both Genetics & IVF Institute in Virginia and California. Their phone number for further information is _%#TEL#%_. To my knowledge nobody in the _%#CITY#%_ _%#CITY#%_ including Reproductive Medicine Center is able to do MicroSort procedure and it appears that this couple would physically need to go to that center to have that procedure done in conjunction with intrauterine insemination.
IVF|in vitro fertilization|IVF|187|189|G 4  P	0030				LMP|She came to clinic with her husband, _%#NAME#%_ _%#NAME#%_, for genetic consultation and level II ultrasound due to advanced maternal age in pregnancy. Pregnancy History: G 4 P 0030 LMP: IVF Age: 35 EDD (LMP): _%#MMDD2007#%_ Age at Delivery: 36 EDD (U/S): c/w EDC Gestational Age: 19+1 weeks * This pregnancy was originally a twin pregnancy with a loss of one twin prior to 9 weeks gestation.
IVF|in vitro fertilization|IVF|178|180|G 4  P	0030				LMP|They then had an infertility workup that included both normal blood chromosomes and normal CF carrier screening (for both _%#NAME#%_ and _%#NAME#%_). The current pregnancy is an IVF pregnancy. Risk assessment for chromosome conditions: * We discussed the association between maternal age and an increasing risk for chromosome conditions, such as Down syndrome.
IVF|in vitro fertilization|IVF|173|175|G  2  P 0010				LMP|She came to clinic with her husband, _%#NAME#%_ _%#NAME#%_, for genetic consultation regarding advanced maternal age in a twin pregnancy. Pregnancy History: G 2 P 0010 LMP: IVF pregnancy Age: 36 EDC (LMP): Age at Delivery: 37 EDC (U/S): _%#MMDD2006#%_ Gestational Age: 20+6 weeks * The current pregnancy is a twin pregnancy.
IVF|in vitro fertilization|IVF|225|227|G  6 P	2032				LMP|Her 8th pregnancy was initially a twin pregnancy; one of them was lost early and subsequently the second one was lost at 7 to 8 weeks' gestation. Her 9th pregnancy was achieved through preimplantation genetic diagnosis using IVF in Washington. Apparently, a supposedly unaffective embryo was implanted. However, the baby was discovered to be affected, having an additional piece of chromosome 1 and miscarried at 7 weeks' gestation.
IVF|in vitro fertilization|IVF.|323|326|G  6 P	2032				LMP|I spent approximately 60 minutes with them today. As you know, _%#NAME#%_ is a 41-year-old gravida 3, para 1-0-1-1, who is currently 20 weeks' gestation based on estimated date of delivery of _%#MMDD2007#%_. I had seen her and _%#NAME#%_ earlier in pregnancy for first trimester screening. This pregnancy was the result of IVF. As you know, first trimester screening revealed Twin B had a 3.0 nuchal translucency, which is greater than the 95th percentile.
IVF|in vitro fertilization|IVF.|183|186|G  6 P	2032				LMP|The infertility was primarily just due to the fact that she was older, as they had tried 4 attempts of insemination previously. Their daughter, _%#NAME#%_, also was conceived through IVF. I reviewed that at the age of 42 the chance of one or both babies to have any type of chromosome abnormality is approximately 1 in 20 or 5%.
IVF|in vitro fertilization|IVF|239|241|PRENATAL CARE|PRENATAL CARE: _%#NAME#%_ _%#NAME#%_ is a 38-year-old gravida 1, para 0 at 18 + 3 weeks who is dated by __________________________ from an IVF cycle. Prenatal care is with Dr. _%#NAME#%_ _%#NAME#%_. This pregnancy is a result of her first IVF cycle. HOSPITAL COURSE: The patient presented to the emergency room today with complaint of bleeding.
IVF|in vitro fertilization|IVF.|287|290|PLAN|This letter will summarize our 60-minute discussion. As you know, _%#NAME#%_ is a 39-year-old, gravida 6, para 0-0-5-0, whose pregnancy was 10 weeks 5 days based on an estimated date of delivery of _%#MMDD2007#%_. This is currently a twin pregnancy. This pregnancy was conceived through IVF. The focus of our discussion was the increasing risk for a fetal chromosomal trisomy with advancing maternal age.
IVF|intravenous fluid|IVF|185|187|REASON FOR CONSULTATION|She seems to be stable. Urinary production appropriate. I reviewed the films together with the radiologist, and there is currently no abscess that can be drained. I suggest appropriate IVF resuscitation, intravenous antibiotics, and consult with infectious disease regarding optimal antibiotics. If the patient gets more pain, please get back to us for urgent reassessment.
IVF|in vitro fertilization|IVF.|197|200|PAST MEDICAL HISTORY|She is scheduled to be evaluated in Colorectal Surgery regarding the presence of any obstructive lesions. The patient has a longstanding history of infertility. Her last pregnancy was realized via IVF. She had 1 first trimester spontaneous abortion when 35 years of age. The patient has undergone 2 cycles of IVF since her last pregnancy with no resultant pregnancy.
IVF|in vitro fertilization|IVF|209|211|PAST MEDICAL HISTORY|The patient has undergone 2 cycles of IVF since her last pregnancy with no resultant pregnancy. She is currently being evaluated for possible left hydrosalpinx. She is currently considering the possibility of IVF with donor eggs and her husband's sperm. PAST MEDICAL HISTORY: Ulcerative colitis and depression.
IVF|in vitro fertilization|IVF.|165|168|ASSESSMENT|Abdominal ultrasound twin pregnancy is noted. Both measured at 10 weeks. Ovaries are normal. ASSESSMENT: 36-year-old female with a 9+2 weeks' pregnancy, status post IVF. She is admitted with acute onset of fever, chills and right upper extremity pain and swelling 1. Basilic vein thrombus: This is consistent with a superficial venous clot with the possibility of septic thrombophlebitis secondary to PICC line.
IVF|in vitro fertilization|IVF|93|95|IMPRESSION|The _%#MMDD2007#%_, labs were done prior to the patient starting her Lovenox. IMPRESSION: 1. IVF with twin pregnancies with hyperemesis gravidarum. 2. Estrogen patch to be continued until the end of _%#MM#%_. 3. PICC line with PICC line thrombus with extensive clot present.
IVF|in vitro fertilization|IVF|165|167|ASSESSMENT AND PLAN|I recommend using Zantac 150 mg p.o. b.i.d. for the above. (Zantac is class B). 3. Pregnancy management per OB. Definitely a high risk patient, especially following IVF and other previous complications. Hospitalist service would like to thank Dr. _%#NAME#%_ for her consultation. We will be happy to follow with you.
IVF|in vitro fertilization|IVF|152|154|G  2  P 0010				LMP|She came to clinic for genetic consultation and first trimester screening due to advanced maternal age in pregnancy. Pregnancy History: G 2 P 0010 LMP: IVF pregnancy Age: 35 EDC (LMP): _%#MMDD2006#%_ Age at Delivery: 35 EDC (U/S): Gestational Age: 12+0 weeks * No significant complications or exposures were reported in the current pregnancy.
IVF|in vitro fertilization|IVF|296|298|PLAN|At age 40, the patient has a mid trimester chance of carrying a baby with Down syndrome of 1:74 and a chance of carrying a baby with any of the aforementioned chromosome abnormalities of 1:40. This risk is doubled given the patient is carrier a twin pregnancy. In addition, given the patient had IVF with ICSI, there is an associated 1% risk for a sex chromosome abnormality. This is in addition to the 3-4% risk for birth defects that is present for all couples, regardless of age.
IVF|in vitro fertilization|IVF|140|142|G  6 P	2032				LMP|She came to clinic for genetic consultation and amniocentesis due to advanced maternal age in pregnancy. Pregnancy History: G 6 P 2032 LMP: IVF pregnancy Age: 36 EDC (LMP): Age at Delivery: 36 EDC (U/S): _%#MMDD2007#%_ Gestational Age: 16+2 * No significant complications or exposures were reported in the current pregnancy.
IVF|in vitro fertilization|IVF|257|259|G  2  P 0010				LMP|As you know, Ms. _%#NAME#%_ is a 34-year-old gravida 1, para 0 who is currently 19 and 0/7 weeks' gestation based on an estimated date of delivery of _%#MMDD2008#%_. As you know, Ms. _%#NAME#%_ is carrying a twin pregnancy. The pregnancy was conceived with IVF with ICSI through Dr. _%#NAME#%_'s group, Reproductive Medicine Institute in _%#CITY#%_, Minnesota. The patient reports the pregnancy has been uncomplicated.
IVF|in vitro fertilization|IVF|160|162|G  2  P 0010				LMP|_%#NAME#%_ is a 30-year-old gravida 1 para 0-0-0-0 whose current estimated date of delivery is _%#MMDD2008#%_. As you know, this twin pregnancy was a result of IVF and using PGD specifically to screen for cystic fibrosis as both her and her husband are carriers of cystic fibrosis. Unfortunately, last week at the Maternal-Fetal Medicine Center one of the developing babies, Twin A, has a severe skeletal dysplasia which one possible skeletal dysplasia could be thanatophoric dysplasia, which is a lethal skeletal dysplasia.
IVF|in vitro fertilization|IVF|275|277|G  2  P 0010				LMP|_%#NAME#%_ as you know herself had also had infertility issues and had cystic fibrosis carrier screening, which revealed and she is a carrier. Her husband _%#NAME#%_ then also was found to be a carrier, too, and thus they had embarked on preimplantation genetic diagnosis in IVF for this pregnancy, specifically for cystic fibrosis. _%#NAME#%_ stated that neither her nor her husband have ever had their chromosomes analyzed and the cause of their infertility was unknown.
IVF|in vitro fertilization|IVF|165|167|PLAN|This pregnancy was conceived by in vitro fertilization. Eggs were retrieved on _%#MM#%_ _%#DD#%_, 2007 and embryos were transferred on _%#MM#%_ _%#DD#%_, 2007. This IVF was completed at RMIA in _%#CITY#%_, Minnesota. _%#NAME#%_ and _%#NAME#%_ report that the reason for their pursuing IVF was that _%#NAME#%_ had a previous vasectomy and after surgical reversal, his sperm counts were low.
IVF|in vitro fertilization|IVF|179|181|FEN|_%#NAME#%_ has a 5-year-old daughter who is healthy, thus this pregnancy had complications of secondary infertility. _%#NAME#%_ had several rounds of IUI and this was their first IVF pregnancy which she was not certain whether or not ICSI was used. Two embryos were implanted. The remainder of her family history is unremarkable for mental retardation, birth defects, multiple miscarriages, or early onset cancers.
IVF|in vitro fertilization|IVF|236|238|ETHNIC BACKGROUND|In reference to ICSI used to conceive this pregnancy, we discussed the implications of potentially having an increased risk of genetic birth defects due to the ICSI procedure. Some studies have suggested that using ICSI and potentially IVF might increase the risk of birth defects in the pregnancy. There is a potential increase in sex chromosome abnormalities with children born from IVF with ICSI.
IVF|in vitro fertilization|IVF|209|211|ETHNIC BACKGROUND|Some studies have suggested that using ICSI and potentially IVF might increase the risk of birth defects in the pregnancy. There is a potential increase in sex chromosome abnormalities with children born from IVF with ICSI. I shared with the couple if they were interested in further clarifying this risk, amnio or CVS would be informative.
IVF|in vitro fertilization|IVF|222|224|HOSPITAL COURSE|On postoperative day #5, when the NG tube was removed, the patient was eagerly transitioned to p.o. pain medications and her pain was controlled on these medications at the time of discharge. 4. FEN. The patient was given IVF at the time of surgery. Fluids were continued at maintenance rate until removal of her NG tube, at which time her diet was easily advanced to a regular diet.
IVF|in vitro fertilization|IVF.|205|208|HOSPITAL COURSE|Patient has been placed on Septra 3. Double Strength as an agent to prevent her UTIs. 3. Acute on chronic renal failure, prerenal azotemia. We attempted to improve her situation with gentle hydration with IVF. Currently, patient's prerenal azotemia and creatinine level have improved. Her discharge BUN and creatinine were; BUN was 26 and creatinine was 1.20.
IVF|in vitro fertilization|IVF|141|143|HOSPITAL COURSE|He will continue with his home vitamin supplements and pancreatic enzymes with meals. He was made n.p.o. prior to surgery and continued with IVF at maintenance after surgery. He was subsequently advanced to a soft diet following surgery which he had tolerated with minimal success initially but was taking some soft and reasonable p.o. liquid at the time of discharge.
IVF|in vitro fertilization|IVF|219|221|HOSPITAL COURSE|She was given initially a PCA immediately postoperatively and then transitioned to p.o. pain medications during the rest of her hospitalization. 5. Fluids, Electrolytes, and Nutrition. The patient was given crystalloid IVF at the time of surgery. These were decreased as the patient began to increase her p.o. intake. She was tolerating a regular diet at the time discharge.
IVF|in vitro fertilization|IVF,|208|211|DISCHARGE MEDICATIONS|He was born on _%#MMDD2002#%_ at Fairview _%#CITY#%_ Hospital, transferred to the NICU immediately after birth, and transferred to Fairview Ridges on _%#MMDD2002#%_. The mother's pregnancy was complicated by IVF, twin pregnancy with approximately 20% discordance and preterm labor. The infant was delivered as twin B in a double footling breech position by spontaneous vaginal delivery with Apgar scores of 5 at one minute and 9 at five minutes.
IVF|intravenous fluid|IVF|128|130|PROBLEMS|On the day of discharge, the patient's pain was well controlled with these p.o. pain medications. 4. FEN: The patient was given IVF at the time of surgery. Fluids were decreased as the patient started to tolerate increased p.o. intake. She had no nutritional concerns, and the patient was tolerating a regular diet at the time of discharge.
IVF|in vitro fertilization|IVF|99|101|DOB|DOB: _%#MMDD1968#%_ The patient is a 34-year-old white female, gravida 2, para 1-0-0-1, with known IVF twins who was admitted with spontaneous rupture of membranes at 35-5/7. The patient's pregnancy had been complicated by gestational diabetes, and she ha d an emergency cesarean section with her first pregnancy.
IVF|intravenous fluid|IVF|106|108|1. FEN|Problems during the hospitalization included the following: 1. FEN: _%#NAME#%_ was started on maintenance IVF while NPO due to respiratory distress. Gavage feedings were started on day 1 when his respiratory distress had resolved. He tolerated increased feeds- maximum feeds by day 5. While he was able to feed well, he was unable to protect his airway without an OG holding down his tongue and was unable to breathe through his mouth and therefore was taken to OR by ENT for repair of presumed choanal atresia.
IVF|in vitro fertilization|IVF|342|344|ID|She was a 1271 gm, 31 5/7 week gestational age female infant born at Fairview Southdale to a 42-year-old, gravida 1, para 0-2-0-0, blood type B+, Caucasian female whose LMP was _%#MMDD2007#%_ and whose EDC was _%#MMDD2008#%_. The mother's pregnancy was complicated by pregnancy induced hypertension, diet controlled gestational diabetes, and IVF conception and a twin gestation. The mother received magnesium sulfate and antibiotics prior to delivery. The infant was delivered by cesarean section with Apgar scores of 7 at one minute and 9 at five minutes.
IVF|in vitro fertilization|IVF|142|144|PAST OBSTETRICAL/GYNECOLOGICAL HISTORY|NSVD x1 twelve years ago. 2. Ectopic pregnancy x1, requiring salpingectomy. 3. SAB x2. 4. Salpingo-oophorectomy for ruptured ovarian cyst. 5. IVF Di-Di twins. 6. Ultrasound _%#MM#%_ _%#DD#%_, 2006, A: Vertex, AFI normal, 136 beats per minute. B: Vertex, AFI normal, 130 beats per minute. Cervix 4.0 cm.
IVF|intravenous fluid|IVF|236|238|HOSPITAL COURSE|TPN was started after each of _%#NAME#%_'s surgeries, but she was quickly started on enteral feeds again on post-op day 1. Electrolytes remained within the range of normal except for an episode of hypocalcemia. Calcium was replaced via IVF and a parathyroid hormone level was checked and returned normal. There were no further problems. She is now at full PO feed with breast milk or Enfamil 20.
IVF|intravenous fluid|IVF|137|139|3. CV|She was given a bolus of D10 after this her glucose improved to 92. She was then allowed to bottle feed ad lib demand and continued with IVF of D10 with monitoring of her preprandial glucoses which remained within a normal range and she was able to be weaned of the D10 after a day.
IVF|intravenous fluid|IVF.|227|230|ATTENDING ADDENDUM|Likely needs better afterload reduction. Aim SBP approximately 100 with nitrate and hydralazine in setting of elevated creatinine. Will consult Cardiology after TEE. 2. Third spacing with decreased intravascular volume. Gentle IVF. Await renal consult recommendations. B. Hepatorenal syndrome. Renal consult with ? renal biopsy. C. Obstructive uropathy. Renal ultrasound. II. Anasarca. Likely secondary to progressive third spacing versus acute heart failure: see above.
IVF|intravenous fluid|IVF|212|214|PROBLEM # 4|He is also on amiodarone and could be some concern for toxicity given his slight bumps in his LFTs as well as prolonged QT. Will recheck EKG in the a.m. Based on most recent documented EF of 50%, will administer IVF cautiously and follow pulmonary sx/exam closely for signs of pulmonary edema. PROBLEM # 5: Right-sided pleural effusion c/w exudate. Cirrhosis versus pancreatic CA vs. lung cancer are possible etiologies.
IVF|intravenous fluid|IVF|122|124|HOSPITAL COURSE|The patient's pain was well controlled with p.o. pain medications at the time of discharge. 4. FEN: The patient was given IVF at the time of surgery. Fluids were continued throughout her postoperative course until postoperative day #4 when her NG tube was discontinued, and she was able to advance her diet to include p.o. intake.
IVF|intravenous fluid|IVF|244|246|PROBLEM #3|She was transitioned to oral pain medications and at the time of discharge, her pain was well controlled on oral medications. PROBLEM #3: FEN: The patient received IVF at the time of surgery. As she began to tolerate increased p.o. intake, her IVF rate was decreased. Her IV was hep-locked on postoperative day #1 and at the time of discharge, she was tolerating a regular diet.
IVF|intravenous fluid|IVF|233|235|1. FEN|On DOL 28 (_%#MMDD2003#%_) his gavage feeds were increased to 40 cc every 3 hours (total volume of 160 cc/kg/d) to promote better weight gain. 2. CV: On admission, _%#NAME#%_ had mildly low MAPs, for which he received IV calcium and IVF boluses to increase the intravascular volume. On DOL 19 (_%#MMDD2003#%_) he had increased systolic BP and there was a concern about renal perfusion so a Cr checked on _%#MMDD2003#%_ was 0.4. However, for the rest of admission his HR and bp remained stable.
IVF|intravenous fluid|IVF.|166|169|3. RESP|_%#NAME#%_'s last apneic spell was _%#MMDD2003#%_ and he is not currently on theophylline. 4. ENDO: His initial low glucose on admission normalized after he received IVF. There were no problems with glucose levels during the rest of the hospital stay. 5. ID: On admission empiric IV antibiotics were given for 4 days until initial blood cultures were negative.
IVF|intravenous fluid|IVF|294|296|1. FEN|On admission electrolytes were normal except for phosphorus high at 7.7, magnesium low at 1.3, ionized calcium slightly low at 3.9 and total calcium low at 7.2. She was given a multiple doses of calcium gluconate to correct her calcium. In addition she received magnesium. She was kept NPO and IVF of D10W were started at 150cc/kg/day. By day two she began enteral feeds of EPF 20 kcal/oz formula via gavage feeds and tolerated this well; however she was not alert enough to bottle until DOL # 13 when she started to feed orally much better.
IVF|intravenous fluid|IVF|168|170|4. PULM|A portable cranial ultrasound on _%#MMDD2004#%_ was negative for intraventricular hemorrhage. Follow-up cranial ultrasound on _%#MMDD2004#%_ revealed bilateral grade 1 IVF and increased ventricle size. A third cranial ultrasound was done on _%#MMDD2004#%_. Results showed "1. persistent enlargement of atrial appendage of lateral ventricles, left greater than right, unchanged from previous, 2. Resolving hemorrhage of right germinal matrix."
IVF|intravenous fluid|IVF|175|177|1. FEN|Admission exam was limited by the critical nature of the patient. Problems during the hospitalization included the following: 1. FEN: Anna was NPO on admission and started on IVF and TPN. A right-sided IJ as well as a UAC were placed. She required several fluid flushes in the first 24 hours of life to maintain adequate blood pressures.
IVF|intravenous fluid|IVF|157|159|PAST OBSTETRICAL HISTORY|Given nifedipine and terbutaline. She was not hospitalized. 4. Gestational diabetes mellitus (GDM A-1), diet-controlled. PAST OBSTETRICAL HISTORY: 1. Second IVF cycle, chemical pregnancy only, not seen on the ultrasound, _%#MMDD2003#%_. 2. History of infertility. This pregnancy is cycle #4 with donor oocytes.
IVF|intravenous fluid|IVF|178|180|ADMISSION DIAGNOSIS|Once her pain medication was changed to p.o. Dilaudid, her pain was well-controlled without GI distress, and she was discharged with p.o. Dilaudid. 4. FEN: The patient was given IVF at the time of surgery. Fluids were decreased as the patient started to tolerate increased p.o. intake. She was tolerating a regular diet at the time of discharge.
IVF|in vitro fertilization|IVF,|194|197|FOLLOW-UP|He was born on _%#MMDD2002#%_ at Fairview _%#CITY#%_ Hospital and transferred to the NICU immediately after birth. He was discharged on _%#MMDD2002#%_. The mother's pregnancy was complicated by IVF, twin pregnancy, with approximately 20% discordance and preterm labor. The infant was delivered as twin B in a double footling breech position by spontaneous vaginal delivery with Apgar scores of 5 at one minute and 9 at five minutes.
IVF|intravenous fluid|IVF|92|94|DISCHARGE MEDICATIONS|Problems during the hospitalization included the following: FEN - _%#NAME#%_ was started on IVF initially with change to TPN when available. He received additional fluid for hypotension and diminished urine output. His urine output remained diminished despite pressor support and, therefore, a foley catheter was placed and diuretics were started.
IVF|in vitro fertilization|IVF.|155|158|IN SUMMARY|This involved the transfer of two, fresh, day 5 embryos on _%#MM#%_ _%#DD#%_, 2007. _%#NAME#%_ and _%#NAME#%_ indicated that this was their third round of IVF. This pregnancy was conceived using a donor egg and _%#NAME#%_'s sperm. The egg donor is 22 years old. _%#NAME#%_'s pregnancy history is significant for a miscarriage in _%#MM#%_ of 2006.
IVF|in vitro fertilization|IVF|171|173|IN SUMMARY|The egg donor is 22 years old. _%#NAME#%_'s pregnancy history is significant for a miscarriage in _%#MM#%_ of 2006. That pregnancy was conceived with their first cycle of IVF with a donor egg. _%#NAME#%_ and _%#NAME#%_ report a history of infertility and unsuccessful intrauterine inseminations and IVF with _%#NAME#%_'s own eggs.
IVF|in vitro fertilization|IVF.|164|167|RE|Family History: A detailed family history was obtained during the visit. _%#NAME#%_ and her partner have a healthy 14-month-old daughter that was also conceived by IVF. _%#NAME#%_ has a history of endometriosis and a tubal ligation in 2005. IVS was used due to her history of endometriosis and her tubal ligation.
IVF|in vitro fertilization|IVF.|395|398|RE|On review of _%#NAME#%_ and her husband's family history, _%#NAME#%_ reports that in addition to the first pregnancy where she had 1 twin that was lost at 8 weeks of pregnancy, and the other twin lost at 13 weeks of pregnancy which was affected with trisomy 21, she reports another pregnancy that resulted in demise at around 6 weeks. She reports that these pregnancies were all conceived using IVF. However, her first pregnancy was conceived without using assisted reproduction. She reports no problems with this first pregnancy.
IVF|in vitro fertilization|IVF.|182|185|RE|She had 1 miscarriage with her current partner. She has a 3-year-old daughter conceived through IVF with her current partner. She is currently pregnant with twins, conceived through IVF. _%#NAME#%_ has a history of anxiety, for which she takes Zoloft. _%#NAME#%_'s brother, who is currently age 19 and in college had a learning disability earlier in his school days.
IVF|in vitro fertilization|IVF.|136|139|IN SUMMARY|This was due to that _%#NAME#%_ had a vasectomy and a subsequent reversal vasectomy was not successful, and this was the reason for the IVF. _%#NAME#%_ reported having a son with a previous partner who has mental retardation of unknown cause. _%#NAME#%_ reported that his son has been extensively evaluated by a neurologist, which to his knowledge performed normal chromosome analysis on the son.
IVF|in vitro fertilization|IVF,|267|270|RECOMMENDATIONS|This letter will summarize our 75-minute discussion. As you know, _%#NAME#%_ is a 43-year-old, gravida 2, para 0-0-1-0 whose pregnancy was 12 weeks' gestation based on an estimated date of delivery of _%#MMDD2007#%_. _%#NAME#%_ and her husband had undergone previous IVF, but this current pregnancy was spontaneous. The focus of our discussion was the increasing chance of a fetal chromosomal trisomy with advancing maternal age.
IVF|intravenous fluid|IVF|92|94|1. FEN|Problems during the hospitalization included the following: FEN - _%#NAME#%_ was started on IVF with a change to TPN when available. _%#NAME#%_ had poor urine output in conjunction with hypotension. She was placed on a Foley catheter and had good urine output after dobutamine was started.
IVF|intravenous fluid|IVF.|174|177|PROCEDURES DURING STAY|1. Social Work. 2. Physical and Occupational Therapy. 3. Hematology-Oncology-Dr. _%#NAME#%_. 4. Nutrition. 5. Transitions and Life Choices. PROCEDURES DURING STAY: None, but IVF. PAST MEDICAL HISTORY: 1. Metastatic colon cancer, diagnosed _%#MM2004#%_, Stage III, following up with Dr. _%#NAME#%_.
IVF|in vitro fertilization|IVF.|229|232|HISTORY OF PRESENT ILLNESS|INFORMANT: Mother, medical records. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 3-year-old male with complicated medical history including multiple previous consultations by me. Born at 38 + 5 weeks with a pregnancy conceived by IVF. Pregnancy complication by being a twin and maternal anti-phospholipid antibody, prednisone pretreatment and IVIG and chronic Heparin use during the pregnancy.
IVF|intravenous fluid|IVF|258|260|2.  GI|As stated above, GI consult requested. 4. Renal: The patient has a history of chronic renal insufficiency with baseline creatinine of 1.4-1.7 possibly 2nd to hepatorenal syndrome. His creatinine today is 1.9. This is probably due to dehydration. I will hold IVF hydration since patient has moderate ascites and bilateral lower extremity edema. 5. Hematology: The patient just returned to the United States from a trip that took over 30 days.
IVF|in vitro fertilization|IVF|365|367|LABORATORY DATA|_%#NAME#%_ _%#NAME#%_, MD Fairview _%#CITY#%_ Clinic _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_, MN _%#55400#%_ Dear _%#NAME#%_: _%#NAME#%_ _%#NAME#%_ came to the Perinatal Diagnostic Center, Fairview University Medical Center, on _%#MMDD2003#%_ as a 41-year-old individual, para 0-0-1-0. She is currently at 27 weeks gestation in a pregnancy resulting from IVF with donor eggs. The ovum donor is reported to be 23 years old. This lady's medical history is complicated, and includes rheumatoid arthritis, asthma, and, recently, a strong likelihood of hyperthyroidism.
IVF|intravenous fluid|IVF.|280|283|1. FEN|The admission physical examination was significant for a distended and firm abdomen without bowel sounds, a small umbilical hernia, and an absent left forearm (congenital.) Problems during the hospitalization included the following: 1. FEN: _%#NAME#%_ was made NPO and started on IVF. He was maintained on TPN while NPO and restarted on clears on post-op day 3. He was started on drip feeds on post-op day 5, and advanced to bolus feeds on post-op day 6.
LA|UNSURED SENSE|LA|200|201|PAST PSYCHIATRIC HISTORY|Please review the detailed note by LSW _%#NAME#%_ _%#NAME#%_ on _%#MMDD2007#%_ for details of the past times that he was in treatment. He was never on any psychiatric medications. Basically he was in LA inpatient program, Kansas, _%#NAME#%_. PAST MEDICAL HISTORY: The patient denied any. It was reviewed and it is negative.
LA|long-acting|LA|156|157|DISCHARGE MEDICATIONS|She is ambulating with the use of a walker. She is considering a nursing home in the future. DISCHARGE MEDICATIONS: 1. Inderal 100 mg p.o. t.i.d. 2. Detrol LA 4 mg p.o. daily. 3. Combivent 1-2 puffs inhaled twice daily. 4. Calcitonin spray 1 spray to each nostril daily. 5. Tylenol 325-650 mg p.o. every 4-6 hours as needed for pain or fever.
LA|long-acting|LA|179|180|REVIEW OF SYSTEMS|No dark tarry stools or bloody stools. GU: She is post-menopausal. She denies any history of hematuria. She does have a history of bladder incontinence for which she takes Detrol LA for incontinence. She denies any history of bleeding diathesis. MUSCULOSKELETAL: She denies any weakness. Denies any decrease in sensation. As noted above, she does have a lesion that was biopsied by dermatology two weeks ago and found to have squamous cell cancer to the left leg.
LA|Los Angeles|LA|188|189|LABORATORY AND DIAGNOSTIC DATA|The patient was stable. After her CT scan she had normal electrolytes, BUN, and creatinine. She underwent an EGD on _%#MMDD2007#%_ by Dr. _%#NAME#%_. This revealed the following findings: LA grade A one or more mucosal breaks less than 5 mm, not extending between tops of two mucosal folds, esophagitis with nonbleeding was found 38 cm from the incisors localized, moderately erythematous mucosa with no bleeding was found in the prepyloric region of the stomach.
LA|long-acting|LA|137|138|DISCHARGE MEDICATIONS|12. Isopto tears 0.5% one to two drops both eyes q.i.d. 13. Prozac 20 mg q.a.m. 14. Lasix 40 mg p.o. b.i.d., start in 3 days. 15. Detrol LA 4 mg p.o. daily. 16. Deltasone 5 mg q.a.m. 17. Nexium 400 mg q.a.m. 18. Senokot 1 p.o. daily p.r.n. 19. Aldactone 100 mg p.o. b.i.d. starting in 2 days.
LA|long-acting|LA|119|120|MEDICATIONS|MEDICATIONS: Have included: 1. Levothyroxine 100 mcg daily 2. Estropipate 0.75 mg daily 3. Zocor 40 mg q day 4. Detrol LA 4 mg daily 5. Zyrtec 10 mg daily 6. Diclofenac 75 mg twice a day for her osteoarthritis and this actually has been well tolerated.
LA|long-acting|LA|296|297|ADDITIONAL DISCHARGE MEDICATIONS|She was to take buprenorphine 10 mg a day for 3 days, then 8 mg a day for 4 days and then follow up with me in my office. Slow taper will be planned versus maintenance. ADDITIONAL DISCHARGE MEDICATIONS: Include Wellbutrin SR 150 mg b.i.d., trazodone 100-200 mg each day at bedtime p.r.n., Detrol LA 4 mg daily and Colace 100 mg daily. DISCHARGE DIAGNOSIS: Opiate dependence.
LA|left atrial|LA|177|178|HOSPITAL COURSE|The fluid overload was probably from IV fluids in the setting of atrial fibrillation. He had an echocardiogram on _%#MM2007#%_ which showed moderate concentric LVH and moderate LA enlargement. The EF was noted to be normal. The left ventricle wall motion was also noted to be normal. Pulmonology was consulted for hypercapneic respiratory failure.
LA|long-acting|LA|143|144|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Amitriptyline 100 mg at h.s. 2. Neurontin 300 mg t.i.d. 3. Lisinopril 20 daily. 4. Remeron 15 mg h.s. 5. Propranolol LA 160 mg daily. 6. Triamterene/hydrochlorothiazide 75/50 one daily. She will be following up with Dr. _%#NAME#%_ next week and states that she will be seeing her psychiatrist then as well.
LA|long-acting|LA|82|83|DISCHARGE MEDICATIONS|2. Simvastatin 20 mg p.o. daily. 3. Lactobacillus pack at 1 p.o. t.i.d. 4. Detrol LA 4 mg p.o. daily. 5. Prenatal vitamin 1 p.o. daily. 6. Protonix 40 mg p.o. daily. 7. Actose 45 mg p.o. daily. 8. Zonisamide 100 mg p.o. daily. 9. Keppra 1 g p.o. b.i.d.
LA|left atrial|LA|165|166|HISTORY OF PRESENT ILLNESS|Avastin is known to inhibit neoangiogenesis and can cause bleeding as one of its complications. The upper GI endoscopy was done on _%#MMDD2006#%_. It demonstrated a LA grade A reflux esophagitis. There were 1 or more mucosal breaks, less than 5 mm, not extending between 2 mucosal folds.
LA|long-acting|LA|191|192|ADMISSION MEDICATIONS|6. Dipivefrin 0.1% ophthalmic solution to both eyes b.i.d. 7. Keppra 1 gm p.o. b.i.d. 8. Voltaren 0.1% one drop in the right eye q.i.d. 9. Alphagan 0.15% in the left eye b.i.d. 10. Diltiazem LA 120 mg daily. 11. Lexapro 20 mg daily. 12. Azithromycin 250 mg every other day. 13. Magnesium oxide 650 mg t.i.d. 14. Voriconazole 200 mg b.i.d.
LA|long-acting|LA|180|181|DISCHARGE MEDICATIONS|Her target INR is between 2 and 3. 3. Coumadin 5 mg p.o. daily on Monday, Tuesday, Thursday, Friday, and Saturday. 4. Coumadin 7.5 mp p.o. daily on Wednesday and Sunday. 5. Detrol LA 4 mg p.o. daily. 6. Celebrex 200 mg p.o. daily. 7. Enalapril 100 mg p.o. daily. 8. Senokot 2 to 4 mg p.o. daily.
LA|long-acting|LA|123|124|MEDICATIONS|13. Potassium chloride 10 mEq. p.o. daily 14. Compazine 25 mg p.r. p.r.n. nausea 15. Lipitor 10 mg p.o. nightly 16. Detrol LA 4 mg p.o. daily 17. Aciphex 20 mg p.o. daily 18. Ranitidine 150 mg p.o. daily 19. Nitrofurantoin 100 mg p.o. daily for ten days.
LA|long-acting|LA|152|153|DISCHARGE MEDICATIONS|5. Levothyroxine 100 mcg p.o. daily. 6. Nasonex 2 sprays to each nostril daily. 7. Prilosec 40 mg p.o. daily. 8. Paroxetine 20 mg p.o. daily. 9. Detrol LA 2 mg p.o. daily. 10. Lipitor 10 mg p.o. daily. 11. Neurontin 300 mg 2 tablets p.o. three times daily. FOLLOW-UP: The patient will be set up for a cardionet outpatient monitor prior to her discharge.
LA|long-acting|LA|390|391|HISTORY OF PRESENT ILLNESS|She has cognitive issues, and her fluctuating capabilities make it difficult to measure our success. DISCHARGE MEDICATIONS: She is discharged at this time on Imdur 30 mg, Nexium 40 mg a day, Plavix 75 mg a day, Xanax 2 mg at bedtime, baclofen 10 mg 4 times a day, Colace 100 mg a day, folic acid 1 mg a day, glipizide XL 10 mg a day, Zocor 40 mg a day, calcium carbonate, Betaseron, Detrol LA 4 mg a day, Effexor, tapering up on the Effexor slowly to 150 mg a day, Lopressor 25 mg day, risedronate, Cymbalta 60 mg twice a day, and she will be seen in the office in 6 weeks.
LA|long-acting|LA|124|125|DISCHARGE MEDICATIONS|3. Fosamax 70 mg a week 4. Effexor XR 225 mg p.o. q day 5. Valtrex 500 mg p.o. q day 6. Topamax 50 mg p.o. b.i.d. 7. Detrol LA 4 mg p.o. q day 8. Zoloft 50 mg p.o. q h.s. 9. Multivitamin one p.o. q day 10. Ritalin 20 mg p.o. q. day
LA|long-acting|LA|219|220|DISCHARGE MEDICATION|DISCHARGE MEDICATION: Cardizem 360 mg p.o. q.d., Premarin 0.625 mg p.o. q.d. which patient was advised not to take until after two weeks after her operation and she is resumed to normal activity. Stool softener. Detrol LA 4 mg p.o. b.i.d. Naprosyn p.r.n., Calcium 500 daily, Lipitor 80 mg p.o. every night at bedtime, Isosorbide 30 mg p.o. daily, Augmentin 400 mg p.o. q.h.s., Klor-Con 8 mEq p.o. t.i.d., niacin a gram p.o. b.i.d., aspirin 325 mg p.o. q.d., dicloxacillin 500 mg p.o. q.i.d. for 14 days, Percocet p.r.n. for pain.
LA|long-acting|LA|126|127|IMPRESSION|However, her followup has not been always optimal by history. 2. Nocturia. She has significant nocturia. We will start Detrol LA and see if that helps. 3. Knee pain, likely some DJD and patellofemoral syndrome. We will treat with some ibuprofen.
LA|long-acting|LA,|186|188|AXIS I|HOSPITAL COURSE: As stated, Ms. _%#NAME#%_ was admitted from 3A to station 10 North because of her volatile and out-of-control behaviors. She was restarted on albuterol inhaler, Inderal LA, Lipitor daily, lisinopril daily, multivitamin daily, Protonix daily, and prednisone 10 mg twice daily x2 days and then discontinue after the ADM dose on _%#MM#%_ _%#DD#%_, 2005.
LA|Los Angeles|LA|223|224|KEY INTERVENTIONS/STUDIES/PROCEDURES|Small ascites, new since previous. Right lower lobe atelectasis. Radiation fibrosis in the lungs. Left adrenal nodule, right adrenal hypoattenuating lesion unchanged. 2. Upper GI endoscopy dated _%#MMDD2006#%_. Impression: LA grade G monilial esophagitis, biopsied. Normal stomach, normal ampulla, duodenal bulb and second part of the duodenum. 3. Whole body bone scan _%#MMDD2006#%_. Impression: No evidence of metastasis to bones.
LA|long-acting|LA|142|143|DISCHARGE MEDICATIONS|He will also use Xanax as needed for anxiety. DISCHARGE MEDICATIONS: 1. Aspirin 81 to 325 mg once daily 2. Lipitor 20 mg daily 3. Propranolol LA 60 mg one tablet daily 4. Neurontin 400 mg three times daily and 800 mg at bedtime. 5. Ambien 5 mg 1/2 to 1 tablet at bedtime as needed for insomnia
LA|long-acting|LA|135|136|HOME MEDICATION LIST|5. Protonix 40 mg orally once daily. 6. Paxil 40 mg orally once daily. 7. Spiriva 18 mcg inhaled as needed for bronchospasm. 8. Detrol LA 4 mg capsule once daily. 9. Trazodone 50 mg orally once daily.
LA|long-acting|LA|175|176|DISCHARGE MEDICATIONS|I have encouraged her to continue to check blood sugars twice a day and bring these results to Dr. _%#NAME#%_ when she sees him in follow-up. DISCHARGE MEDICATIONS: 1. Detrol LA 4 mg p.o. q.d. 2. Alprazolam 0.5 mg p.o. q.d. p.r.n. anxiety. 3. Tamoxifen 10 mg p.o. b.i.d. 4. Accupril 40 mg p.o. q.d.
LA|long-acting|LA|149|150|CURRENT MEDICATIONS|3. Left ankle fracture in 1973. 4. Status post tonsillectomy and adenoidectomy. 5. Status post pilonidal cyst removal. CURRENT MEDICATIONS: 1. Entex LA 1 tab p.o. b.i.d. 2. Flonase two sprays each naris q.d. ALLERGIES: Sulfa (rash). SOCIAL HISTORY: Nonsmoker.
LA|long-acting|LA|371|372|MEDICATIONS ON DISCHARGE|INR was adjusted accordingly and his Coumadin dose was reduced to achieve an INR of approximately 1.5 to 2.5. DISCHARGE PLAN: The patient was discharged to Jones-Harrison for rehab prior to returning home. MEDICATIONS ON DISCHARGE: Lasix 80 mg b.i.d., Imdur 30 mg daily, lisinopril 5 mg daily, potassium supplement 40 mEq p.o. q day, Lactulose 15 cc p.o. q a.m., Inderal LA 60 mg p.o. q day and Coumadin 2.5 mg daily. The patient is DNR/DNI. He will follow up with his primary care physician after discharge from _%#NAME#%_.
LA|left atrial|LA|164|165|HOSPITAL COURSE|Cardiology saw the patient and felt that this was lone afib. The patient will be discharged home on Toprol XL. His cardiac echo showed ejection fraction of 65% and LA size of 43 mm. He has borderline LVH. No evidence of valvular disease. His TSH is pending at this point. DISCHARGE MEDICATIONS: Aspirin 325 mg p.o. q.d., Toprol XL 50 mg p.o. q.d. DISCHARGE INSTRUCTIONS: The patient will follow-up with Minnesota Heart in three months.
LA|long-acting|LA|180|181|DISCHARGE MEDICATIONS|As noted above, the patient is code status DNR/DNI with instructions also from the family to do not hospitalize in the future. DISCHARGE MEDICATIONS: Celexa 5 mg p.o. q.d., Detrol LA 4 mg p.o. q.d., vitamin B-12 injections q four weeks. DISPOSITION: The patient will be discharged back to her assisted living dementia care unit.
LA|long-acting|LA|157|158|MEDICATIONS|ALLERGIES: Sulfa, Tegretol, Valium, Seldane, Motrin, Desyrel, niacin, Sinequan, codeine. MEDICATIONS: 1. Dilantin 400 mg qd. 2. Prilosec 20 mg qd. 3. Detrol LA 4 mg qd. PHYSICAL EXAMINATION: The patient is awake and alert and appears oriented at this time.
LA|long-acting|LA|113|114|MEDICATIONS|1. Aspirin. 2. Metamucil. 3. Crestor 5 mg a day. 4. Niaspan 1000 mg a day. 5. Lisinopril 10 mg a day. 6. Inderal LA 80 mg a day. 7. Inderal 20 mg p.r.n. 8. Prevacid. ALLERGIES: Verapamil. SMOKE: None since 1985, 70 pack year history.
LA|long-acting|LA|113|114|MEDICATIONS|9. Regular insulin sliding scale. 10. Hydralazine 50 mg p.o. b.i.d. 11. Protonix 1 tablet p.o. daily. 12. Detrol LA 4 mg p.o. daily. 13. Lasix 40 mg p.o. b.i.d. 14. Potassium chloride 20 mEq daily. 15. Metoprolol 100 mg twice daily. FAMILY HISTORY: Unable. SOCIAL HISTORY: She does continue to report smoking cigarettes although, she does have a history of drug dependence.
LA|long-acting|LA,|323|325|DISCHARGE MEDICATIONS|7. Sliding scale insulin per protocol. If glucose less than 150, 0 units, glucose 151-200 three units, glucose 201-250 five units, glucose 251-300 seven units, glucose 301-350 nine units, glucose 351-400 eleven units, if greater than 400 call PMD. 8. Lisinopril 10 mg p.o. daily. 9. Metoprolol 50 mg p.o. b.i.d. 10. Detrol LA, 4 mg p.o. daily. 11 Coumadin 4 mg p.o. until INR checked Monday, _%#MMDD2005#%_, further dosing per PMD. HOSPITAL COURSE: Please see dictated history and physical for patient's initial presentation.
LA|long-acting|LA|251|252|DISCHARGE DIAGNOSES|She worked full-time in the church and had not imparted to her employer that she had any medical illness at all. The balance of her neurological, medical review of systems on admission were not contributory. Her medications included Betaseron, Detrol LA and Femhrt. She had no medication allergies. Her physical examination revealed bilateral optic atrophy and intranuclear ophthalmoplegia on upward gaze, bilateral horizontal nystagmus on lateral gaze.
LA|long-acting|LA|138|139|CURRENT MEDICATIONS|She lives with her husband. She reports using no alcohol and being a nonsmoker. CURRENT MEDICATIONS: 1. Lisinopril 10 mg daily. 2. Detrol LA 2 mg daily. 3. Lipitor 20 mg daily. 4. Ambien 5 mg at bed time. 5. Dilantin 200 mg daily. 6. Synthroid 0.05 mg daily.
LA|long-acting|LA|127|128|DISCHARGE MEDICATIONS|16. Rocephin 2 g IV q. day x10 days. 17. Clonidine patches TT1 once a day. 18. Aranesp 100 mg subcutaneous q. week. 19. Detrol LA 4 mg p.o. nightly. 20. Colace 100 mg p.o. b.i.d. In discussion with his wife, he will get feedings at home.
LA|long-acting|LA|108|109|DISCHARGE MEDICATIONS|7. Carbidopa and levodopa 25-100 mg p.o. q. 1.5 h. p.r.n. 8. CoQ10 supplement 100 mg p.o. q. day. 9. Detrol LA CP24 one tab p.o. q. day. 10. Fish oil 1000 mg p.o. q. day. 11. Flomax CP24 one tab p.o. q. day. 12. Folic acid 1 tab p.o. q. day.
LA|long-acting|LA|163|164|DISCHARGE MEDICATIONS|PROBLEM #9: Hypokalemia. The patient was continued on K-Dur, and her potassium was 3.7, within normal limits, while she was here. DISCHARGE MEDICATIONS: 1. Detrol LA 4 mg capsules p.o. daily. 2. Restoril 15 mg p.o. q.h.s. for insomnia. 3. Lactaid 1 tab p.o. with meals. 4. Flexeril 10 mg tablets p.o. t.i.d. 5. Cozaar 50 mg p.o. daily.
LA|long-acting|LA|112|113|MEDICATIONS AT THE TIME OF DISCHARGE|MEDICATIONS AT THE TIME OF DISCHARGE: 1. Protonix 20 mg tablets 1 tablet daily. 2. Paxil 30 mg daily. 3. Detrol LA 1 tablet b.i.d. 4. Extra Strength Tylenol 500 mg tablets, 1 or 2 tablets every 4-6 hours p.r.n. pain (total Tylenol dose less than 4 g daily).
LA|long-acting|LA|199|200|MEDICATIONS|There has been no weight loss. She has had no fevers, night sweats, bone pain and no cardiovascular, genitourinary or gastrointestinal issues. MEDICATIONS: 1. Allegra. 2. Lyrica 150 b.i.d. 3. Detrol LA daily. 4. Zoloft 100 mg. 5. Lisinopril. 6. Hydrochlorothiazide 20/25 once per day. 7. Lipitor 40 mg at h.s. 8. Multivitamins. 9. Calcium with vitamin D.
LA|long-acting|LA|130|131|DISCHARGE MEDICATIONS|2. Senokot S 1-2 tablets p.o. b.i.d. and hold for loose stools. 3. Zonegran 100 mg p.o. nightly for seizure prevention. 4. Detrol LA 4 mg p.o. daily. 5. Zocor 20 mg p.o. q.p.m. 6. Protonix 40 mg p.o. daily. 7. Compazine 2.5 mg p.o. q.6h. p.r.n. nausea and vomiting.
LA|long-acting|LA|135|136|DISCHARGE MEDICATIONS|1. Aspirin 81 mg daily. 2. Klonopin 1 mg q.h.s. 3. Neurontin 100 mg q.h.s. 4. Prevacid 30 mg q.d. 5. Nephrocaps, one daily. 6. Inderal LA 80 mg q.d. 7. Renagel 1600 mg p.o. t.i.d. with meals. 8. Keflex 500 mg b.i.d. x 10 days. 9. Combivent inhaler, two puffs q.i.d. 10. Vicodin, one or two every six hours p.r.n.
LA|long-acting|LA|96|97|DISCHARGE MEDICATIONS|Physical therapy and occupational therapy have been consulted. DISCHARGE MEDICATIONS: 1. Detrol LA 4 mg p.o. q.d. 2. Colace 100 mg p.o. b.i.d. 3. Ferrous sulfate 325 mg p.o. b.i.d. 4. Lasix 20 mg p.o. q.d.
LA|long-acting|LA|144|145|DISCHARGE MEDICATIONS|7. Glucophage 850 mg b.i.d. 8. Insulin NPH 16 units subcu b.i.d. 9. Insulin regular 14 units subcu b.i.d. 10. Insulin sliding scale. 11. Detrol LA 4 mg q a.m. 12. Protonic 40 mg per day. 13. Macrobid 100 mg p.o. b.i.d. through _%#MM#%_ _%#DD#%_. 14. Multiple vitamins one per day. 15. Fosamax 70 mg p.o. q Wednesday as directed.
LA|long-acting|LA|102|103|HOSPITAL COURSE|She was also to get a new hearing aid mold. She was discharged on her admission medications of Detrol LA 2 mg po q.a.m., Dyazide 37.5/25 po qd, in addition to Tequin 200 mg po q.a.m. through _%#MM2004#%_ and Floxin otic two drops b.i.d. for a week.
LA|long-acting|LA|163|164|DISCHARGE MEDICATIONS|The patient will also be given simethicone for gas. DISCHARGE MEDICATIONS: 1. Docusate 100 mg p.o. b.i.d. 2. Diazepam 2.5 mg one-half tablet p.o. b.i.d. 3. Detrol LA 4 mg p.o. q. day. 4. Senna 2 tablets p.o. b.i.d. as needed. 5. Simethicone 40 mg p.o. q.i.d. p.r.n. 6. Dulcolax suppositories 1 suppository b.i.d. p.r.n.
LA|long-acting|LA.|166|168|REVIEW OF SYSTEMS|No known history of COPD or emphysema in the past. Gastrointestinal - mild nausea today, no BM times two days. Urinary stress and urge urinary incontinence on Detrol LA. Bleeding tendencies, integumentary, endocrine reviews are all negative. Musculoskeletal - review reveals osteoporosis with a history of osteoarthritis and degenerative vertebral disease.
LA|long-acting|LA|116|117|HOSPITAL COURSE|Modafinil 200 mg a day. Carbamazepine 150 mg twice a day. She will be on Trilafon 2 mg twice a day, as well. Detrol LA 4 mg twice a day. She will have home PT continued. FOLLOW UP: She will be seen in the office in 2 weeks and in 6 weeks.
LA|long-acting|LA|128|129|DISCHARGE MEDICATIONS|4. Zocor 20 mg p.o. nightly. 5. Zantac 150 mg p.o. b.i.d. 6. Provigil 100 mg p.o. daily. 7. Zanaflex 4 mg p.o. daily. 8. Detrol LA 4 mg p.o. daily. 9. Bupropion SR 200 mg p.o. daily. 10. Avonex 30 mcg IM q. Sunday. 11. Hydrochlorothiazide 25 mg p.o. daily.
LA|long-acting|LA|172|173|DISCHARGE MEDICATIONS|At this time, they are not interested in any further home physical therapy. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. q. day. 2. Clonazepam 0.5 mg p.o. b.i.d. 3. Detrol LA 4 mg p.o. q. day. 4. TriCor 160 mg p.o. q. day. 5. Insulin 70/30, 22 units subcut q.a.m. and 13 units subcut q.p.m.
LA|long-acting|LA|150|151|CURRENT MEDICATIONS|ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: 1. Multivitamin with minerals 1 tablet p.o. daily. 2. Effexor XR 75 mg p.o. daily. 3. Detrol LA 4 mg p.o. daily. 4. Florinef 100 mcg tablets p.o. nightly. 5. Keppra 500 mg p.o. daily. 6. Clonazepam 0.5 mg p.o. q.h.s. 7. Midodrine 2.5 mg p.o. at noon, 5 mg p.o. at a.m.
LA|long-acting|LA|1032|1033|DISCHARGE MEDICATIONS|She will make a call at _%#TEL#%_. She is told to call UMMC or 911 if she has any increased drainage, increased pain, increasing swelling, elevated temperature greater than 100.5, nausea, vomiting, constipation, diarrhea and any other medical condition. DISCHARGE MEDICATIONS: Include Zinc 2 tablets 30 mg p.o. daily, vitamin D 400 international units p.o. daily, vitamin A 8000 international units p.o. daily, vitamin C 1000 mg p.o. daily, Vesicare 5 mg p.o. at night, Lyrica 150 mg p.o. b.i.d., phytonadione 2 tabs 5 mg p.o. daily, ketoconazole apply topical cream to affected area daily, Enulose 5 g/30 mL p.o. t.i.d., Vicodin 5/500 mg 1 tablet p.o. up to 4 times per day, ferrous sulfate 325 mg p.o. daily, Lunesta 3 mg p.o. nightly, thiamine 100 mg p.o. daily, quinine 260 mg p.o. daily, ammonium lactate 12% topical cream b.i.d., furosemide 40 mg p.o. b.i.d., spironolactone 200 mg p.o. daily, Lexapro 20 mg p.o. daily, Nexium 40 mg p.o. daily, Allegra 180 mg p.o. daily, zolpidem 10 mg p.o. every day at bedtime, tolterodine LA 2 mg p.o. q.p.m. and oxycodone elixir 5/5, 5-10 mg p.o. q.4-6h. p.r.n. pain. DISCHARGE DISPOSITION: The patient is discharged in stable condition. ADDENDUM Please see discharge summary on _%#MMDD2006#%_ for full HPI and past medical history.
LA|long-acting|LA|132|133|MEDICATIONS|MEDICATIONS: 1. Vytorin 10/40. 2. Aspirin 325 mg q d. 3. Estrace 0.5 mg q d. 4. Niaspan 1000 mg q d. 5. Zoloft 50 mg q d. 6. Detrol LA 4 mg q d.
LA|long-acting|LA|152|153|CURRENT MEDICATIONS|Denies any active tobacco use. FAMILY HISTORY: Unremarkable. CURRENT MEDICATIONS: 1. Nexium 40 mg p.o. daily. 2. Lisinopril 40 mg p.o. daily. 3. Detrol LA 4 mg p.o. daily. 4. Pilocarpine 5 mg p.o. t.i.d. 5. Lamictal 50 mg p.o. at bedtime. 6. Metamucil 1 tsp p.o. daily.
LA|long-acting|LA|171|172|DISCHARGE MEDICATIONS|14. Klonopin 0.5 mg p.o. b.i.d. 15. Gabapentin 600 mg p.o. t.i.d. 16. Dilantin 300 mg p.o. at bedtime. 17. Seroquel 50 mg p.o. a.m. and 100 mg p.o. at bedtime. 18. Detrol LA 2 mg p.o. daily. The patient's discharge planning including followup and discharge medications were discussed with the patient who was in agreement with the plan.
LA|long-acting|LA|179|180|MEDICATIONS|HABITS: The patient is a nonsmoker and nondrinker. ALLERGIES: Sensitive to codeine. MEDICATIONS: 1. Insulin. 2. Flagyl. 3. OxyFast for pain. 4. Enalapril 2.5 mg b.i.d. 5. Inderal LA 80 mg every day. 6. Seroquel 50 mg h.s. 7. Timolol 0.5% eye drops, one drop each eye every day for glaucoma.
LA|long-acting|LA|112|113|MEDICATIONS|MEDICATIONS: The patient's medications prior to admission included: 1. Glucotrol XL 5 mg p.o. b.i.d. 2. Inderal LA 60 mg p.o. q. daily. 3. Protonix 40 mg p.o. b.i.d. 4. Lactulose q. 6h. routinely although apparently they have been giving it to her every four hours up until the last day or so when they are not certain that she took it.
LA|left atrial|LA,|271|273|PROCEDURES PERFORMED|3. Acute renal insufficiency, likely prerenal. PROCEDURES PERFORMED: 1. On _%#MMDD2004#%_, placement of a VVI pacer without major complications. 2. Transthoracic echocardiogram on _%#MMDD2004#%_ revealing ejection fraction 55%, mildly dilated LV, and mildly elevated RV, LA, and RA pressures. Mild to moderate MR and AI. Moderate tricuspid regurgitation. 3. On _%#MMDD2004#%_, repeat CT of the chest without contrast showed no change in a right upper lobe, well demarcated infiltrate that was present on _%#MMDD2004#%_.
LA|long-acting|LA|174|175|DISCHARGE MEDICATIONS|4. Ferrous gluconate 324 mg p.o. t.i.d. with meals. 5. Senokot two p.o. q.h.s. 6. Meclizine 25 mg 1-2 tabs p.o. q.d. p.r.n. dizziness. 7. Effexor 37.5 mg p.o. q.d. 8. Detrol LA 1 p.o. q.h.s. 9. Prempro (we are holding that for now). DISPOSITION: The patient will be in a transitional care unit (TCU).
LA|long-acting|LA|143|144|ADMISSION MEDICATIONS|3. Urinary incontinence. 4. Hypothyroidism. ALLERGIES: No known drug allergies. ADMISSION MEDICATIONS: 1. Levoxyl 0.1 mg p.o. daily. 2. Detrol LA 4 mg daily. 3. Actinal q.week. 4. Calcium, vitamin D, and iron supplements. HOSPITAL COURSE: After informed consent was obtained, the patient was taken to the operating room and underwent posterior approach for a C5-C6 foraminotomy and removal of Harrington rods.
LA|long-acting|LA|196|197|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Lasix 40 mg p.o. b.i.d. 2. Aldactone 100 mg p.o. b.i.d. 3. Vitamin K 10 mg p.o. every day. 4. Lithium 300 mg p.o. q.h.s. 5. Protonix 40 mg p.o. every day. 6. Venlafaxine LA 75 mg p.o. q.a.m. 7. Ursodiol 300 mg p.o. t.i.d. 8. Quetiapine (Seroquel) 25 mg p.o. q.h.s. 9. Lactulose 30 cc p.o. t.i.d. FOLLOWUP: 1. Patient to follow up with Psychiatry.
LA|long-acting|LA|160|161|DISCHARGE MEDICATION|23. Prednisolone acetate 1% ophthalmic drops 1 drop to the left eye Monday and Thursday. 24. Klor-Con 20 mEq p.o. q. day. 25. ASA 81 mg p.o. q. day. 26. Detrol LA 4 mg p.o. q.a.m. 27. Norvasc 10 mg p.o. q. day. 28. FESO4 325 mg p.o. b.i.d. with orange juice. ALLERGIES: Demerol and Macrobid. SPECIAL TREATMENTS: Oxygen 2 liters by nasal cannula continuously.
LA|long-acting|LA|173|174|DISCHARGE MEDICATIONS|6. NPH insulin 47 units q.a.m. 7. Synthroid 0.075 mg 1 tablet daily. 8. Multivitamin 1 tablet daily. 9. Zoloft 75 mg at night. 10. Zocor 20 mg 1 tablet at night. 11. Detrol LA 1 capsule daily. 12. Tylenol Extra Strength 500 mg 1 tablet twice per day. 13. Keflex 500 mg 1 tablet 4 times a day x 14 days.
LA|left atrial|LA|263|264|HISTORY OF PRESENT ILLNESS|_%#MM#%_ _%#DD#%_, 2004: She was readmitted for increased INR 8.8, given FFP, vitamin K, and was discharged home on Coumadin. Echo ejection fraction was 45%. _%#MM#%_ _%#DD#%_, 2004: Echo ejection fraction was 34%, moderate mitral regurgitation, RVSP was 47, RA, LA 4.8, LVD 5.6/4.7. _%#MM#%_ _%#DD#%_, 2004: Admitted for catheterization with PA 71/31, after having been seen for physical exam by primary care physician with a murmur and "extra heart beats." This is a scheduled admission to continue transplant workup and to start milrinone and heparin.
LA|long-acting|LA|126|127|MEDICATIONS|5. Consultation for physical therapy, occupational therapy, and speech therapy to evaluate, and treat. MEDICATIONS: 1. Detrol LA 4 mg p.o. daily for her bladder. 2. Lasix 40 mg p.o. daily for her hypertension. 3. Prozac 10 mg p.o. daily for depression. 4. Lopressor 50 mg p.o. daily for hypertension.
LA|long-acting|LA|180|181|MEDICATIONS|8. Breast cancer. 9. Hypothyroidism. FAMILY HISTORY: Unobtainable. ALLERGIES: None. All the information was obtained from the chart. MEDICATIONS: 1. Coumadin 3 mg a day. 2. Detrol LA 4 mg Q day. 3. Potassium 20 mEq a day. 4. Synthroid 0.088 mg a day. 5. Toprol XL 25 mg Q day. 6. Lanoxin 0.125 Q day.
LA|long-acting|LA|148|149|MEDICATIONS|3. Fentanyl patch transdermal, 100 mcg q. 72 hours, last dose _%#MM2001#%_ 2 p.m. 4. OxyContin 2 mg twice daily 5. Omeprazole 20 mg daily 6. Detrol LA 4 mg 10 a.m. 7. Nitrofuran 20 mg every morning 8. Abilify 10 mg 10 p.m. 9. Pyridium 200 mg 10 a.m., 4 p.m. and 10 p.m.
LA|left atrial|LA|165|166|PROCEDURE PERFORMED|EF 45-50%. Nodular calcification of the aortic valve. Bicuspid valve cannot be excluded. Moderate eccentric aortic insufficiency. RV normal size. _____ IVSD 1.9 cm. LA route 3.6 cm, LA 5 cm. 3. Blood cultures performed _%#MMDD2007#%_, no growth. 4. Blood cultures _%#MMDD2007#%_: No growth after one day. HISTORY OF PRESENT ILLNESS: For complete details see H and P dated _%#MMDD2007#%_.
LA|long-acting|LA.|194|196|MEDICATIONS|10. Renal insufficiency, chronic. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Decadron. 2. Insulin. 3. Keppra. 4. Protonix. 5. Actos. 6. Compazine. 7. Senokot. 8. Simethicone. 9. Detrol LA. 10. Ambien. 11. Zonegran. SOCIAL HISTORY: She is from Wisconsin, lives by herself in a ground floor apartment that is handicap accessible.
LA|left atrial|(LA)|210|213|HISTORY OF PRESENT ILLNESS|Echocardiogram results from _%#MMDD2002#%_ revealed mild aortic sclerosis, good valvular opening, partially flailed posterior mitral valve leaflet with moderate-to-severe mitral regurgitation; both left atrium (LA) and left ventricle (LV) have enlarged. The patient should be considered for mitral valve surgery. The patient is here today for a History and Physical for a transesophageal echocardiography (TEE) scheduled tomorrow with Dr. _%#NAME#%_ at Fairview Southdale Hospital.
LA|long-acting|LA|156|157|MEDICATIONS|4. In her 20's a gallbladder. 5. She has hyperlipidemia 6. Known allergic rhinitis with multiple allergies. MEDICATIONS: 1. Allegra 60 mg a day 2. Guiaphen LA 600 mg b.i.d. 3. Nasacort two Q ala Q day 4. Sulindac for arthritis 200 mg b.i.d. 5. Zestril 20 mg b.i.d.
LA|long-acting|LA|109|110|ADMISSION MEDICATIONS|2. Humalog 9 units q.a.m. and 3 units q.p.m. 3. Glucophage 1000 mg b.i.d. 4. Diovan 320 mg q. day. 5. Detrol LA 4 mg q. day. 6. Neurontin 300 mg t.i.d. ALLERGIES: She has no known drug allergies. FAMILY HISTORY: Mother is alive at 81 years old. She has had diabetes mellitus and a stroke.
LA|long-acting|LA|138|139|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1) Coumadin 2. 5 mg daily. 2) Synthroid 0.125 mg daily. 3) Lasix 40 mg b.i.d. 4) Allopurinol 300 mg daily. 5) Detrol LA 4 mg h.s. 6) Toprol XL 50 mg daily. ALLERGIES: NONE KNOWN. REVIEW OF SYSTEMS: Otherwise negative. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 124/70, pulse 80 and regular.
LA|long-acting|LA|158|159|PLAN|PLAN: Will admit to the floor. She received a dose of Unasyn 3 grams IV in the ER. Will continue with this q. 6h. Continue with her home medications, Inderal LA 120 mg a day, Captopril we will increase to 50 mg t.i.d., Synthroid 0.125 mg q.day; Coumadin, continue same dose; Lasix 40 mg daily.
LA|long-acting|LA|182|183|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Isordil 30 mg p.o. q.d. 3. Synthroid 100 mcg p.o. q.d. 4. Exelon 3 mg p.o. q.d. 5. Senokot-S, two tablets p.o. q.h.s. 6. Detrol LA 4 mg p.o. q.d. 7. Calan SR 120 mg p.o. q.d. 8. OxyContin 5 mg p.o. q.i.d. p.r.n. FOLLOW-UP: The patient will have a CBC in one week's time.
LA|long-acting|LA|132|133|DISCHARGE MEDICATIONS|4. Entacapone 200 mg p.o. q.3h. 0600 hour to 2100 hours daily. 5. Clozapine 2 mg p.o. q.h.s. 6. Donepezil 10 mg p.o. q.d. 7. Detrol LA 4 mg daily. 8. MiraLax one packet in water in the morning with breakfast. 9. Sorbitol 15 mL after lunch for bowel program. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_.
LA|long-acting|LA|220|221|MEDICATIONS|ALLERGIES: SULFA. MEDICATIONS: Cipro 500 mg p.o. b.i.d. p.r.n. for recurrent infection, not taking now. Patanol 0.1% ophthalmic eye drops one to two drops per eye per day for allergies, Fosamax 70 mg p.o. weekly, Detrol LA 4 mg one tablet p.o. daily to every other day, Tizanidine (Zanaflex) 4 mg one-half to two tablets p.o. every 6-8 hours p.r.n. spasticity, Diazepam 5 mg one-half to three tablets p.o. at h.s. p.r.n. sleep - the patient takes this one out of every 10 nights or so, Synthroid 88 mcg p.o. daily.
LA|long-acting|LA|135|136|MEDICATIONS PRIOR TO ADMISSION|MEDICATIONS PRIOR TO ADMISSION: 1. Aspirin 81 mg p.o. every day. 2. Pletal 1 tablet b.i.d. 3. Lipitor 10 mg p.o. every day. 4. Inderal LA 160 mg every day. 5. Diazepam 5 mg p.o. p.r.n. 6. Terazosin 5 mg p.o. every day. ALLERGIES: No known drug allergies.
LA|long-acting|LA|126|127|CURRENT MEDICATIONS|9. History of contractures and spasticity. ALLERGIES: None. CURRENT MEDICATIONS: 1. Duragesic patch 75 mcg an hour. 2. Detrol LA 4 mg PO daily. 3. Aspirin 325 mg PO daily. 4. Flomax 0.4 mg PO daily. 5. Multivitamin one PO daily. 6. Nasonex one spray each nostril daily.
LA|long-acting|LA|452|453|HOSPITAL COURSE|He was transferred on postoperative day number seven. At that time of the transfer his hemoglobin was stable at a level of approximately 11.0. He was taking OxyContin 40 mg p.o. q.12h. with oxycodone 5-10 mg p.o. q.6h. p.r.n. for breakthrough pain. Additional meds included ferrous sulfate 325 mg p.o. each day for his postoperative anemia, levofloxacin 500 mg p.o. each day for 8 days, Inderal LA 80-mg tablets three tablets each morning, and Inderal LA 80-mg tablets two tablets each evening. He will follow up in my clinic four weeks from the time of discharge.
LA|long-acting|LA|161|162|DISCHARGE MEDICATIONS|10. Prednisone 40 mg p.o. daily for 4 days, then 20 mg p.o. daily for 3 days, then 10 mg p.o. daily for 3 days. 11. Flomax 400 micrograms p.o. daily. 12. Detrol LA 4 mg p.o. every night. 13. Maxzide 37.5/25 mg p.o. daily. 14. Percocet 1 or 2 tabs p.o. q. 4 to 6 hours p.r.n. 15. Clarinex 1 tab p.o. daily.
LA|long-acting|LA|145|146|MEDICATIONS|9. Hydrochlorothiazide 25 mg PO q.d. 10. Metoprolol XL 200 mg PO q.d. 11. Pyridoxine 50 mg PO q.d. 12. Simvastatin 40 mg PO q.d. 13. Tolterodine LA 4 mg PO q.d. 14. Ranitidine 150 mg PO b.i.d. 15. Ezetimibe 10 mg PO q.d. 16. Dexamethasone 4 mg PO t.i.d. x1 month only.
LA|long-acting|LA|151|152|MEDICATIONS|MEDICATIONS: 1. Allopurinol 100 mg p.o. daily. 2. Aricept 5 mg p.o. daily at bedtime. 3. Hydrochlorothiazide 12.5 mg daily. 4. Multivitamin. 5. Detrol LA 2 mg p.o. daily. 6. Septra/Bactrim 800/160 p.o. b.i.d. 7. Coumadin. PHYSICAL EXAMINATION: The patient has a large hematoma over his right chest.
LA|Los Angeles|LA|186|187|FINDINGS|The patient's esophagogastroduodenoscopy on _%#MMDD2007#%_, which showed esophagitis with gaping of lower esophagus sphincter. PROCEDURE: Upper GI endoscopy on _%#MMDD2007#%_. FINDINGS: LA grade A esophagitis, gaping lower esophagus sphincter was found. The stomach was normal. The examined duodenum was normal. A small hiatal hernia was found.
LA|long-acting|LA|142|143|MEDICATIONS|4. Aquaphor topical 3 times a day. 5. Aspirin 81 mg daily. 6. Atenolol 50 mg daily. 7. Celexa 20 mg daily. 8. Claritin 10 mg daily. 9. Detrol LA 4 mg daily for urinary incontinence. 10. Metamucil 1 dose daily. 11. Milk of magnesia 1 dose daily. 12. Neurontin 400 mg p.o. t.i.d. for neuropathy. 13. Nystatin powder b.i.d. under the breast for chronic recurrent dermatomycosis.
LA|long-acting|LA|123|124|MEDICATIONS|MEDICATIONS: 1. Lotensin 10 mg q.d. 2. Miacalcin spray. 3. Aspirin 81 mg q.d. 4. Lexapro 10 mg q.d. 5. Celebrex. 6. Detrol LA 4 mg q.d. 7. Prevacid 30 mg q.d. 8. Colace. 9. Synthroid 0.05 q.d. 10. Multivitamin. 11. Aricept 5 mg q.d.
LA|long-acting|LA|180|181|DISCHARGE MEDICATIONS|4. Hypertension. 5. Hyperglycemia. DISCHARGE MEDICATIONS: 1. Enteric-coated aspirin 81 mg p.o. q.d. 2. Atenolol 12.5 mg p.o. q.d. 3. Antivert 25 mg p.o. q.i.d. x 2 days. 4. Detrol LA 4 mg p.o. q.h.s. DISCHARGE PLANS: The patient will be discharged to a rehab center, either the _%#CITY#%_ Care Center or FUTC.
LA|long-acting|LA|217|218|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Coumadin 3 mg p.o. q.today. Recheck INR in a.m. on _%#MMDD2004#%_ prior to discharge and ......for further medication dose. 2. Aricept 10 mg p.o. q.a.m. 3. Hytrin 10 mg p.o. q.a.m. 4. Detrol LA 4 mg p.o. q.a.m. 5. Multivitamin 1 mg p.o. daily. FOLLOW-UP: Follow up with primary care provider next week. Check INR at the clinic.
LA|long-acting|LA|155|156|ADMISSION MEDICATIONS|4. Lipitor 10 mg p.o. q.d. 5. Labetalol 100 mg p.o. b.i.d. 6. Lisinopril 40 mg p.o. q.d. 7. Celexa 20 mg p.o. q.d. 8. Potassium 20 mEq p.o. q.d. 9. Detrol LA 4 mg p.o. q.d. 10. Fentanyl patch 25 mcg topically q.3d. 11. Senna 2 tablets p.o. b.i.d. 12. Ritalin 5 mg p.o. b.i.d. 13. Travertine 0.04% one drop both eyes at h.s. ALLERGIES: Penicillin.
LA|long-acting|LA,|168|170|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Ferrous gluconate, 324 mg p.o. t.i.d. 2. Combivent, 2 puffs b.i.d. 3. Lactulose, 30 cc p.o. t.i.d. 4. Protonix, 40 mg p.o. q. day. 5. Inderal LA, 60 mg p.o. q. day. 6. Aldactone, 100 mg p.o. q. day. 7. Demadex, 40 mg p.o. q. day. 8. Thiamine, 100 mg p.o. q. day. 9. Oxycodone, 5 mg p.o. t.i.d. p.r.n. The patient will follow up with his primary care physician, Dr. _%#NAME#%_ or Dr. _%#NAME#%_, within two weeks time.
LA|long-acting|LA|124|125|DISCHARGE MEDICATIONS|His affect on discharge was congruent. His insight and judgment impaired, his mood stable. DISCHARGE MEDICATIONS: 1. Detrol LA 4 mg daily. 2. Lipitor 20 mg daily. 3. Nexium 20 mg daily. 4. Fluoxetine 20 mg daily. 5. Geodon 120 mg twice daily. DISCHARGE INSTRUCTIONS: 1. He is to continue his prescribed medications.
LA|long-acting|LA,|144|146|CURRENT MEDICATIONS|7. Synthroid 0.075 mg p.o. q. day. 8. Multivitamin, one tablet p.o. q. day. 9. Zoloft 100 mg p.o. q.h.s. 10. Zocor 20 mg p.o. q.h.s. 11. Detrol LA, one tablet p.o. q.h.s. 12. Tylenol Extra Strength 500 mg, one tablet p.o. b.i.d. ALLERGIES: None reported. SOCIAL HISTORY: Patient lives with her granddaughter, _%#NAME#%_. She does not drink or smoke.
LA|long-acting|LA|243|244|HOSPITAL COURSE|He will be seen by Dr. _%#NAME#%_ or his partner in about three weeks to repeat upper GI endoscopy and recheck the varices. He was discharged on Rifampin 300 mg daily, spironolactone 25 mg daily, Hytrin 2 mg q.h.s., Lasix 20 mg daily, Inderal LA 60 mg daily, Cipro 500 mg once daily for one week and then once weekly on an ongoing basis for subacute bacterial peritonitis prophylaxis, Protonix 40 mg daily, Lactulose syrup 15 cc b.i.d.
LA|long-acting|LA,|121|123|REVIEW OF SYSTEMS|2. Spironolactone, 25 mg daily, which I recognize as half the dose that he was on upon admission in _%#MM#%_. 3. Inderal LA, 60 mg daily. 4. Ciprofloxacin, 500 mg weekly on Mondays. 5. Protonix, 40 mg daily. 6. Lactulose, 15 cc p.o. b.i.d.
LA|long-acting|LA|165|166|MEDICATIONS|He is very inactive physically and walks with walker. MEDICATIONS: 1. NPH Insulin 35 units each morning and he uses a sliding scale of NPH in the evening. 2. Detrol LA 4 mg daily. 3. Elmiron 100 mg t.i.d. 4. Hydrochlorothiazide 25 mg daily. 5. Lisinopril 20 mg daily. 6. Atenolol 50 mg daily. 7. Prilosec 40 mg daily.
LA|long-acting|LA|125|126|DISCHARGE MEDICATIONS|2. Percocet 5/325 mg 1 to 2 p.o. q.6 h. p.r.n. 3. Atorvastatin 10 mg p.o. daily. 4. Rosiglitazone 2 mg p.o. daily. 5. Detrol LA 4 mg p.o. daily. 6. Nitroglycerin 0.4 mg sublingual p.r.n. chest pain. 7. Metoprolol 25 mg p.o. b.i.d. 8. Furosemide 20 mg p.o. daily.
LA|long-acting|LA|113|114|MEDICATIONS ON ADMISSION|CODE STATUS: Full code. MEDICATIONS ON ADMISSION: 1. BuSpar 5 mg t.i.d. 2. Lotrel 5/20 mg p.o. q. day. 3. Detrol LA 4 mg q. day. 4. Pepcid one tablet daily. 5. Aspirin 81 mg daily. 6. Citracal 1 tablespoon daily. 7. Mineral Oil 1-2 tablespoons each day at bed time on a daily basis.
LA|long-acting|LA|262|263|DISCHARGE MEDICATIONS|Because of that, he is being discharged on a double Medrol Dose-Pak rather than a 1-month taper of steroids. DISCHARGE MEDICATIONS: Other discharge medications include baclofen 10 mg 4 times a day, Celexa 20 mg a day, betaseron, Provigil 200 mg a day and Detrol LA 4 mg a day. FOLLOW UP: He will be seen in the office in 2 weeks and at 6 weeks.
LA|long-acting|LA|147|148|DISCHARGE MEDICATIONS|Her hemoglobin postoperatively was stable at 11.4. DISCHARGE MEDICATIONS: 1. Coreg 3.125 mg p.o. b.i.d. 2. Gabapentin 300 mg p.o. t.i.d. 3. Detrol LA 4 mg p.o. daily. 4. Fosamax 70 mg p.o. q. week. 5. Percocet 5/325 one to two tablets p.o. q.4-6 h. p.r.n. pain. 6. Colace 100 mg p.o. b.i.d. 7. Ibuprofen 600 mg p.o. q.6 h. p.r.n. pain.
LA|long-acting|LA|147|148|MEDICATIONS|5. Norvasc 5 mg daily. 6. Neurontin 600 mg q. evening 7. Ambien 5 mg p.r.n. sleep. 8. Nitroglycerin spray p.r.n. 9. Tricor 54 mg daily. 10. Detrol LA 2 mg daily. ALLERGIES: No known drug allergies. SYSTEM REVIEW: GENERAL: Weight has been stable.
LA|long-acting|LA|138|139|CURRENT MEDICATIONS|4. Coumadin 2 mg daily. 5. Digoxin 0.125 mg daily. 6. Actonel 35 mg daily. 7. Os-Cal 500 mg b.i.d. 8. Vitamin B-12 every month. 9. Detrol LA 4 mg daily. 10. Milk of Mag 1 Tbsp daily as needed. 11. _____________ suppository daily. 12. Metamucil daily. 13. Docusate 1 tablet twice daily.
LA|Los Angeles|LA|277|278|HOSPITAL COURSE|Lipase was within normal limits, INR was 1.02, the patient had a negative UA. By the evening of admission, the patient's hemoglobin had dropped to 9.1 and by midnight that evening was at 9.2. HOSPITAL COURSE: Postoperative day 1, the patient underwent an EGD which revealed an LA grade A reflux esophagitis with normal jejunum with no evidence of bleeding. The patient did not receive any packed red blood cells as her hemoglobin stabilized through her hospitalization ending up with hemoglobin on the day of discharge of 10.1. Additionally on the second day after discharge, the patient underwent colonoscopy to evaluate for source of bleeding.
LA|long-acting|LA|123|124|MEDICATIONS|12. Metoprolol 25 mg 1 daily. 13. Avandia 4 mg daily. 14. Furosemide 40 mg 1 daily. 15. Percocet 5/325 two h.s. 16. Detrol LA 4 mg one daily ALLERGIES: NO KNOWN DRUG ALLERGIES SOCIAL HISTORY: The patient has 3 children.
LA|long-acting|LA|230|231|DISCHARGE MEDICATIONS|DISCHARGE CONDITION: Stable. DISPOSITION: The patient will be discharged to home with recommendations of using a wheelchair and an orthotic shoe for his right foot. DISCHARGE MEDICATIONS: 1. Effexor XR one po q am. 2. Propranolol LA 60 mg one po q day. 3. Ambien 10 mg one po q hs. 4. Adderall 15 mg on po q day. 5. Zithromax 250 mg one po q two remaining days.
LA|long-acting|LA|200|201|PLAN|2. Hypertension, variable. 3. Hypothyroidism. 4. Depression. PLAN: Discharge on aspirin 325 mg q day, Celexa 20 mg q day, Colace p.r.n., Synthroid 0.175 q day, Cozaar 50 mg q day and will hold Detrol LA and follow up in a week. Adjust Cozaar if blood pressure stays high.
LA|long-acting|LA|110|111|MEDICATIONS|MEDICATIONS: 1. Enulose 30 cc p.o. q.i.d. 2. Glucotrol XL 5 mg two to three times daily as needed. 3. Inderal LA 60 mg p.o. daily as needed. 4. Protonix 40 mg p.o. b.i.d. 5. Zofran 4-8 mg p.o. b.i.d. as needed. 6. Lasix and spironolactone as needed for ankle swelling. ALLERGIES: Morphine (causes a rash).
LA|long-acting|LA|195|196|PLAN/DISCHARGE MEDICATIONS|2. We will add vitamin K 5 mg orally to her current medication regimen that was used following a _%#MM#%_ release. 3. We will continue Protonix at 40 mg orally b.i.d. 4. We will continue Inderal LA 60 mg once daily. 5. She takes Glucotrol and prefers a 5 mg orally 3 times per day dose before meals so that she may withhold doses if need be.
LA|long-acting|LA|156|157|DISCHARGE PRESCRIPTIONS|DISCHARGE PRESCRIPTIONS: 1. Dilaudid 4 mg p.o. q.4h. p.r.n., dispense 60. 2. Ativan 1 mg p.o. b.i.d. p.r.n., #30. 3. Septra SS one p.o. q.d. x20. 4. Detrol LA 4 mg p.o. q.d. x20. Will have her follow up in clinic in _%#CITY#%_ on _%#MMDD2004#%_ for removal of her stent in the office.
LA|long-acting|LA|199|200|MEDICATIONS|Subdural hematoma that required neurosurgical evacuation, pernicious anemia for which she takes B12 shots. A chronically elevated serum iron level. MEDICATIONS: 1. Risperdal 0.25 mg daily. 2. Detrol LA 4 mg a day. 3. Dilantin 500 mg a day. 4. Effexor XR 37 1/2 mg daily. 5. Lisinopril10 mg a day. 6. Coumadin 7 mg a day. 7. She has been on oral Vancomycin.
LA|long-acting|LA|163|164|DISCHARGE MEDICATIONS|5) Avalide 300/12.5 strength tablets, one tablet p.o. q.A.M. 6) Xanax 0.25 mg p.o. at bedtime. 7) Zyprexa 2.5 mg p.o. q.A.M. 8) Nexium 40 mg p.o. q day. 9) Detral LA 4 mg p.o. q.P.M. for history of urinary retention. 10) Neurontin 600 mg p.o. b.i.d. 11) Coreg 12.5 mg p.o. b.i.d. 12) Norvasc 10 mg p.o. q.A.M. 13) Folgard two tablets p.o. q.A.M. with food.
LA|long-acting|LA|162|163|MEDICATIONS|4. Lantus insulin 35 units subcutaneous at bedtime. 5. Novolog insulin on a sliding scale. 6. Amitriptyline 50 mg at bedtime. 7. TriCor 145 mg per day. 8. Detrol LA 4 mg per day. 9. Premarin. 10. Hydrochlorothiazide 50 mg per day. 11. Benicar 40 mg per day. 12. Flexeril 10 mg at bedtime. REVIEW OF SYSTEMS: Cardiovascular: She denies any chest pain.
LA|long-acting|LA|166|167|DISCHARGE MEDICATIONS|5. Allegra 60 mg daily. 6. Lamivudine 50 mg daily. 7. Metoprolol 100 mg b.i.d. 8. Minoxidil 5 mg daily. 9. Nephrocaps one daily. 10. Kaletra 0.5 mg daily. 11. Detrol LA 2 mg daily 12. Percocet p.r.n. DISCHARGE PLAN: 1. Continue vancomycin 1-g weekly x 6 weeks as an outpatient in the dialysis center.
LA|long-acting|LA|163|164|PLAN|2. Amoxicillin 500 mg t.i.d. for one week 3. Nitroglycerin sublingual p.r.n. angina 4. Caltrate 600 plus D. b.i.d. 5. Lipitor 10 mg each day at bed-time 6. Detrol LA 4 mg p.o. q. daily. 7. Aspirin 81 mg p.o. q. daily 8. Glipizide 10 mg p.o. q. daily Over 30 minutes spent with this patient in discharge planning.
LA|Los Angeles|LA|165|166|PROCEDURES|b. Pyloric channel ulcer with partial outlet obstruction. c. Significant amount of retained fluid. d. Arteriovenous malformations. e. Very large dilated stomach. f. LA grade D monilial esophagitis. Cytology specimen sent. This could also be from gastric outlet obstruction. Multiple gastric angioectasias. Partially obstructing gastric ulcer with clean base.
LA|long-acting|LA|195|196|DISCHARGE MEDICATIONS|6. Remeron 15 mg p.o. q.h.s. 7. Multi-vitamin one tablet p.o. q.day 8. Propranolol as ordered, to be DCd on _%#MMDD2007#%_. 9. Saccharomyces boulardii one capsule by mouth twice daily 10. Detrol LA 4 mg capsule p.o. daily 11. Extra Strength Tylenol 1 gram p.o. q8 hours as needed. 12. Aspirin 81 mg p.o. q.day 13. TobraDex eye drops one drop to left eye 4 times daily
LA|long-acting|LA|195|196|HOME MEDICATIONS|The patient's D-dimer was elevated at 0.9. She was admitted for severe shortness of breath and presumed acute asthma exacerbation. Chest x-ray was essentially normal. HOME MEDICATIONS: 1. Detrol LA 4 mg capsule q. day. 2. Ranitidine HCL 150 mg capsule p.o. b.i.d. SOCIAL HISTORY: The patient denies any tobacco, alcohol or other drug use.
LA|long-acting|LA|81|82|PROBLEM #5|She also requested to have BOOST at Ebenezer Luther Hall. PROBLEM #5: GU: Detrol LA for control for urge incontinence. PROBLEM #6: ID: No issues. PROBLEM #7: Cardiology: Hypertension moderately well controlled on Vasotec 10 mg p.o. q.a.m., her usual home dose.
LA|long-acting|LA|205|206|DISCHARGE MEDICATIONS|4. History of shoulder replacement. 5. Rotator cuff repair. 6. Remote history of asthma, not active. 7. History of ulcer with subsequent surgery. DISCHARGE MEDICATIONS: 1. Synthroid 175 mcg q.d. 2. Detrol LA 2 mg daily. 3. Warfarin. If INR is greater than 1.8, will hold. If INR is between 0 and 1.29, will give 5 mg.
LA|long-acting|LA|150|151|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1. Metamucil 1 tsp p.o. b.i.d. 2. Lexapro 10 mg p.o. q.d. 3. Tylenol 1000 mg p.o. q.a.m. 4. Ecotrin 325 mg p.o. q.a.m. 5. Detrol LA 4 mg p.o. q.d. 6. Hydrochlorothiazide 12.5 mg p.o. q.d. 7. Prilosec 20 mg p.o. q.d. 8. Multivitamin with iron 1 tab p.o. q.d.
LA|long-acting|LA|110|111|DISCHARGE MEDICINES|He had decreased movement of his left upper extremity but no other complaints. DISCHARGE MEDICINES: 1. Detrol LA 4 mg p.o. daily. 2. Allegra D 60-120 mg p.o. b.i.d. 3. Singulair 10 mg p.o. q.h.s. 4. Nasonex 50 mcg 2 sprays in each nostril daily.
LA|long-acting|LA|125|126|MEDICATIONS AT DISCHARGE|3) Glucovance 1.25/250 mg one daily. 4) Hydrochlorothiazide 25 mg daily. 5) Lipitor 40 mg h.s. 6) Zetia 10 mg h.s. 7) Detrol LA 4 mg daily. 8) Mediglip one-half tab with supper. 9) Norvasc 10 mg daily. 10) Colace 100 mg b.i.d. p.r.n. 11) Dulcolax suppository p.r.n.
LA|long-acting|LA|114|115|DISCHARGE MEDICATIONS|If she has worsening symptoms, it is recommended to continue treatment of that. DISCHARGE MEDICATIONS: 1. Inderal LA 60 mg p.o. each day. 2. Metformin 1000 mg p.o. b.i.d. 3. Lantus insulin 65 units subcutaneously q.h.s. 4. Novolog insulin 17 units subcutaneously q.a.m. 5. Novolog insulin 20 units subcutaneous q.p.m.
LA|long-acting|LA|156|157|ADMISSION MEDICATIONS|3. Gastroesophageal reflux disease. 4. Detrusor instability. ADMISSION MEDICATIONS: 1. Klor-con 20 meq p.o. b.i.d. 2. Trazodone 50 mg p.o. q.h.s. 3. Detrol LA 4 mg p.o. p.r.n. 4. Plendil 5 mg p.o. q.a.m. 5. Ambien 5 mg p.o. q.h.s. p.r.n. 6. Imodium p.o. p.r.n. 7. Lactate chewables p.o. p.r.n. 8. Jantoven 4.5 mg p.o. daily.
LA|long-acting|LA|119|120|CURRENT MEDICATIONS|9. Pericardial tamponade _%#MM#%_ 2004 completely resolved CURRENT MEDICATIONS: 1. Lyrica 75 mg t.i.d. 2. Detrol 4 mg. LA version 3. Provigil 400 mg daily 4. Cymbalta 60 mg daily 5. Pulmicort Turbuhaler one puff b.i.d. 6. Spiriva one puff daily 7. Lipitor 20 mg daily
LA|long-acting|LA|239|240|ALLERGIES|She is married. However, her husband is "locked up in the VA where he can't do any harm because of his schizophrenia and bipolar disorder." ALLERGIES: Ditropan causes dry mouth, NSAIDS cause pruritus, celecoxib causes palpitations. Detrol LA causes itching. PHYSICAL EXAMINATION: Ventricular rate was 130, blood pressure was 144/94.
LA|long-acting|LA|138|139|HISTORY AND HOSPITAL COURSE|10. Nitroglycerin sublingual p.r.n. 11. Metamucil 2 capsules q. day. 12. Exelon 6 mg twice a day. 13. Zocor 40 mg p.o. q. day. 14. Detrol LA 4 mg p.o. q. day. 15. Coumadin 1 mg p.o. q. day. 16. Aspirin 81 mg p.o. q. day. 17. Celebrex 200 mg p.o. q. day. 18. Potassium chloride 20 mEq p.o. q. day.
LA|Los Angeles|LA|124|125|PROCEDURES AT THE TIME OF HOSPITALIZATION|There was no evidence of cholecystitis. There was no focal hepatic mass. 2. Upper GI endoscopy on _%#MMDD2007#%_: There was LA grade A esophagitis. There was portal hypertensive gastropathy. The exam of the duodenum was normal. BRIEF SUMMARY OF HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 26-year-old male with a past medical history of alcohol, tobacco and methamphetamine abuse who presented to _____ Hospital on _%#MMDD2007#%_ with abdominal pain and was found to have transaminitis.
LA|long-acting|LA|170|171|MEDICATIONS|6. Remicade IV every 6 weeks. 7. Multivitamin one tablet p.o. daily. 8. Prednisone 3 mg p.o. daily. 9. Crestor 200 mg p.o. daily. 10. Viagra 25 mg p.o. t.i.d. 11. Detrol LA 4 mg p.o. daily. 12. Dilaudid 1-2 mg every 4 hours as needed. 13. Plaquenil 200 mg p.o. b.i.d. 14. Zetia 10 mg p.o. daily.
LA|long-acting|LA|156|157|DISCHARGE MEDICATIONS|9. Zantac 75 mg p.o. daily. 10. Benicar 40 mg p.o. daily. 11. Zofran 4 mg p.o. q.6h. p.r.n. nausea. 12. Vicodin 1-2 tabs p.o. q.6h. p.r.n. pain. 13. Detrol LA 2 mg p.o. daily. 14. Dexamethasone 4 mg p.o. daily. EXAMINATION AT DISCHARGE: GENERAL: The patient is alert, awake and oriented to person, place and time.
LA|long-acting|LA|144|145|DISCHARGE MEDICATIONS|4. Advair 500/50 mcg 1 puff b.i.d. followed by rinse. 5. Pyridium 200 mg twice daily. 6. Zantac 150 mg b.i.d. 7. Senokot 1 tab b.i.d. 8. Detrol LA 8 mg daily. 9. Coumadin adjusted based on INR. 10. Oxycodone 5 mg at bedtime with q.4-6h. p.r.n. throughout the day.
LA|long-acting|LA|195|196|MEDICATIONS|6. Bladder repair in 1999. MEDICATIONS: 1. Coumadin, dosed through anti-coagulation clinic at Oxboro. 2. Rythmol 150 mg t.i.d. 3. Crestor 10 mg every other day. 4. Fosamax 70 mg qweek. 5. Detrol LA 4 mg qday. 6. Caltrate 600 mg b.i.d. 7. Multi-vitamin one a day. ALLERGIES: Aspirin, Zocor, Pravachol, Zetia, Vioxx, and PENICILLIN. HEALTH HABITS: The patient does not smoke.
LA|left atrial|LA|299|300|HOSPITAL COURSE|He had an ablation procedure performed after which he had his pacer turned off secondary to a pacer-induced (_______________) atrial arrhythmia after he had ablation burns after cardiomapping of the RA to a large area in the right septal area. He had a transseptal puncture and cardiomapping of the LA with burns in the root of the LA appendage. The patient also had continued RA mapping and a burn in the high anterior atrial septum as well.
LA|long-acting|LA|148|149|MEDICATIONS|3. Avodart 0.5 mg daily. 4. Ketoconazole 2% topical cream b.i.d. to effected area. 5. Prilosec 20 mg daily. 6. Lantus 25 units subcu qhs. 7. Detrol LA 40 mg daily. 8. Levothyroxine 50 mg daily. 9. Niacin XL 500 mg daily. 10. Glyburide 10 mg q.a.m. and at 14:00 hours daily.
LA|left atrial|LA|443|444|HOSPITAL COURSE|PROBLEM #1. Nonischemic cardiomyopathy, status post ICD placement, _%#MMDD2005#%_: The patient underwent echocardiogram on the day of admission which showed severely decreased LV function with left ventricular ejection fraction of 10%, followed by transesophageal echocardiogram revealing mild to moderate LV dilatation with severely decreased LV function and ejection fraction of 10%. No thrombus or continuous echo contrast was noted in the LA appendage. Right ventricular systolic pressure was mildly to moderately increased (approximately 34 mmHg above mean right arterial pressure). The patient had an ICD placement with DFT testing on _%#MMDD2005#%_.
LA|long-acting|LA|143|144|MEDICATIONS|No previous strokes. ALLERGIES: Include penicillin, cephalosporins and codeine. MEDICATIONS: At home 1. Premarin 0.625 mg daily 2. Propranolol LA 80 mg one daily 3. Hydrochlorothiazide 25 mg daily 4. Norvasc 10 mg daily 5. K-Dur 20 mEq daily 6. Lorazepam 0.5 mg at hs and t.i.d. p.r.n.
LA|long-acting|LA|291|292|HOSPITAL COURSE|Her stools improved, and after monitoring for a few more days and us getting her off the digoxin and onto the beta blocker, etc., she remained very stable and after a long discussion with patient and Dr. _%#NAME#%_ of Cardiology, it was felt that patient is best served by using the Inderal LA and not by further interventions at this point, given the normal echo. She was doing well from a respiratory standpoint and at this point was felt stable and ready for discharge.
LA|long-acting|LA|221|222|PLAN|4. Hypertension: Continue hydrochlorothiazide and propranolol for optimal control of hypertension. Check vitals q. shift. 5. Hypercholesterolemia: Continue simvastatin. 6. History of urinary incontinence: Continue Detrol LA for now. Estimated length of stay is about 7-10 days with discharge home.
LA|long-acting|LA|152|153|DISCHARGE MEDICATIONS|3. Aricept one p.o. daily. 4. Coumadin 1 mg p.o. every Sunday, Tuesday, and Friday. 5. Detrol LA 4 mg p.o. daily. 6. Zocor 20 mg p.o. daily. 7. Inderal LA 125 mg p.o. daily. 8. Glucosamine 500 mg p.o. daily. 9. Senokot-S 1 to 3 p.o. daily to b.i.d. p.r.n. 10. Hydrochlorothiazide 12.5 mg p.o. daily. FOLLOW UP: PM and R followup will be on an as needed as basis.
LA|Los Angeles|LA|129|130|HISTORY OF PRESENT ILLNESS|Her band was deflated and treated medically with proton pump inhibitor. She was rescoped and found to be improved. She went from LA grade C to an LA grade A and her band was reinitiated on the _%#MMDD2006#%_. She now presents to the emergency department with 5-day history of pain, vomiting, seen in the University of Minnesota ED on Thursday.
LA|long-acting|LA,|124|126|PROBLEMS ADDRESSED DURING TRANSITIONAL CARE STAY|Urology consultation was obtained. A Foley catheter was replaced and is currently in place at the time of discharge. Detrol LA, which had been started during acute hospitalization was discontinued at their request. Urology followup in 2-3 weeks is planned. The catheter is to remain in place for 1 more week, at which time, discontinuation and postvoid residual evaluation is to be undertaken.
LA|long-acting|LA|122|123|TRANSFERRING MEDICATIONS|1. Decadron 1 mg p.o. q. 8 h, which will continue until follow up and then be tapered by the Neurosurgery team. 2. Detrol LA 4 mg p.o. daily. 3. Zocor 20 mg p.o. q.p.m. 4. Protonix 40 mg p.o. daily. 5. Compazine 2.5 mg p.o. q. 6 h p.r.n. 6. Senokot one to two tablets p.o. b.i.d. for constipation.
LA|long-acting|LA|163|164|DISCHARGE  INSTRUCTIONS|DISCHARGE INSTRUCTIONS: The patient will be discharged to home on the following medications: 1. Lisinopril 2.5 mg b.i.d. 2. Digoxin 0.125 mg daily. 3. Propranolol LA 150 mg daily. 4. Tapazole 20 mg b.i.d. 5. Furosemide 10 mg p.o. b.i.d. The patient's next follow-up will be Wednesday, _%#MM#%_ _%#DD#%_ at Minnesota Heart Clinic for INR check.
LA|left atrial|LA|236|237|PAST MEDICAL HISTORY|Echo also showed mild annular calcification of mitral valve with mild mitral regurgitation and mitral prolapse. He has normal RV function and normal RV size. He had severe hypokinetic inferior wall and inferior lateral hypokinesis. His LA size was moderately dilated. He had mild tricuspid regurgitation. His RA size was moderately dilated. His overall EF was 40% to 45%.
LA|long-acting|LA|114|115|CURRENT MEDICATIONS|ALLERGIES/SENSITIVITIES: Ciprofloxacin and morphine. CURRENT MEDICATIONS: 1. Imuran 50 mg p.o. b.i.d. 2. Mestinon LA 180 mg p.o. at bedtime. 3. Mestinon 120 mg p.o. q.i.d. 4. Cymbalta 60 mg p.o. daily. 5. Percocet up to 4 per day.
LA|long-acting|LA|158|159|CHRONIC MEDICATIONS|CHRONIC MEDICATIONS: 1. Lipitor 10 mg p.o. daily. 2. Singulair 10 mg p.o. daily. 3. Allegra 180 mg p.o. daily. 4. Phenytoin 300 mg p.o. at bedtime. 5. Detrol LA 4 mg p.o. daily. 6. Nexium 40 mg p.o. b.i.d. 7. Oral contraceptive 1 tab p.o. daily. 8. Albuterol inhaler 1-2 puffs every 4-6 hours p.r.n.
LA|long-acting|LA.|167|169|HOSPITAL COURSE|The thing that makes most sense is that she has had this since starting the Detrol LA which she has been using for urinary incontinence. We took her off of the Detrol LA. She did not seem to have the dizziness at that point. She seemed to do actually quite well and physical therapy even signed off as she was ambulating without any difficulty.
LA|long-acting|LA|121|122|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1. Atenolol 25 mg p.o. q.a.m. 2. Lisinopril 5 mg p.o. q.a.m. 3. Aciphex 20 mg p.o. q.p.m. 4. Detrol LA 4 mg p.o. every day. 5. Lipitor 40 mg p.o. every day. 6. Terazosin 5 mg p.o. at bedtime. 7. Enteric-coated aspirin 325 mg p.o. every day. 8. Sublingual nitroglycerin 0.4 mg tablets used as directed five minutes apart for onset of chest pain.
LA|long-acting|LA|384|385|HISTORY OF PRESENT ILLNESS|Her medications were readjusted and she actually did surprisingly well. Her pain diminished and her function improved, and she is discharged at this time, doing much better on amantadine 100 mg b.i.d., BuSpar 15 mg t.i.d., Hygroton 12.5 mg a day, clonazepam 1 mg b.i.d., a Medrol taper, birth control pills, Lamictal 25 mg q.i.d., Trilafon 2 mg b.i.d., Zocor 20 mg at bedtime, Detrol LA 4 mg b.i.d., trazodone 300 mg at bedtime, and Effexor 150 mg b.i.d. She will be seen in the office in 2 weeks and in 6 weeks.
LA|long-acting|LA|128|129|DISCHARGE MEDICATIONS|She will continue on a phenobarbital taper to cover withdrawal symptoms from benzodiazepines. DISCHARGE MEDICATIONS: 1. Inderal LA 120 mg daily. 2. Advair 100/50 one puff twice daily. 3. Amlodipine 10 mg daily. 4. Lisinopril 20 mg daily. 5. Lipitor 20 mg daily. 6. Protonix 40 mg daily.
LA|long-acting|LA|193|194|DISCHARGE MEDICATIONS|13. Nitroglycerin p.r.n. 14. Protonix 40 mg daily. 15. Risperdal 2 mg q.p.m. 16. Serevent 1 puff b.i.d. 17. Zoloft 25 mg daily. 18. Zocor 80 mg daily. 19. Restoril 30 mg q.p.m. 20. Tolterodine LA 2 mg daily. 21. Zinc sulfate 220 mg daily. PHYSICIAN FOLLOWUP: Follow up with primary care physician in 1-2 weeks.
LA|Los Angeles|LA|164|165|HOSPITAL COURSE|They recommended a helicobacter pylori antibody screen which is pending. Upper GI endoscopy was recommended and performed on _%#MM#%_ _%#DD#%_, and demonstrated an LA grade B esophagitis with nonbleeding, bilious fluid within the gastric body and diffuse mildly erythematous gastric mucosa without bleeding.
LA|long-acting|LA|161|162|MEDICATIONS|MEDICATIONS: Vioxx 25 mg p.o. q. day, Vanceril 2 puffs b.i.d., Prinivil 10 mg p.o. q. day, Fosamax 70 mg p.o. q. week (Fridays), Zoloft 50 mg p.o. q. day, Q-Bid LA 600 mg p.o. b.i.d., Atrovent nebs q. 4 hours p.r.n., albuterol nebs q. 4 hours and p.r.n., Premphase, calcium with vitamin D 2 per day, Claritin-D 1 per day.
LA|long-acting|LA|274|275|HISTORY OF PRESENT ILLNESS|Because of his need for continued therapy with transfer to FUTS, he will be followed over there by Dr. _%#NAME#%_. He is being transferred on Metformin 1000 mg q.a.m., 500 mg q.p.m., Copaxone 1 cc subcu q.d., Avandia 4 mg q.d., Lipitor 10 mg q.d., Celexa 40 mg q.d., Detrol LA 4 mg q.d., Glucotrol 10 q.a.m. and 5 in afternoon and Dr. _%#NAME#%_'s group will outline the insulin coverage. He will be seen in our office in follow-up eval.
LA|left atrial|LA.|359|361|SOCIAL HISTORY|Retired business owner. Heart catheter study in _%#MM2002#%_. LAD was stented with minimal stenosis, RCA and left circumflex without significant stenosis. Echo _%#MM2002#%_ showed severe decline in left ventricular function. EF 25% global hypokinesis, severe hypokinetic septum, akinetic apex, moderate to severe left ventricular dilatation, mild to moderate LA. PHYSICAL EXAMINATION: 97.5, 80s, blood pressure 90s-100/50s, respiratory rate 16.
LA|long-acting|LA|125|126|MEDICATIONS|6. Paxil 40 mg p.o. q. day. 7. BuSpar 30 mg p.o. q. day. 8. Norvasc 5 mg p.o. q day. 9. Evista 60 mg p.o. q day. 10. Inderal LA 160 mg p.o. q day. 11. Multivitamin 1 p.o. q. day. 12. Albuterol inhaler p.r.n. 13. Seroquel 25 mg p.o. q.h.s. p.r.n.
LA|long-acting|LA|200|201|PROBLEM #7|No platelet transfusions as needed. His low platelets is related to his liver failure. PROBLEM #7: Sinus bradycardia with heart rate of about 55, secondary to beta blocker inderal. The was on Inderal LA 60 mg daily. The dose was decreased to Inderal 10 mg p.o. t.i.d. We will continue Inderal to prevent recurrence of esophageal varices rebleed.
LA|long-acting|LA|136|137|HISTORY OF PRESENT ILLNESS|This subsequently has reduced today. He tells me that he does not like to drink too much water otherwise he pees more. He was on Detrol LA in the past but was switched to Flomax by Dr. _%#NAME#%_ to help prevent urinary tract infections and to minimize any prostate symptoms.
LA|long-acting|LA|277|278|SUMMARY OF CASE|His current schedule calls for 2 units of NovoLog for blood sugars of 120-149, 3 units for blood sugars of 150-199, 5 units for blood sugars of 200-249, 7 units for blood sugars of 250-299 and 8 units for blood sugars of 300-349. Other meds include Demadex 20 mg daily, Detrol LA 4 mg every evening, Senokot-S 2 tablets daily, sotalol 80 mg once a day, Neurontin 600 mg 3 times per day, ferrous gluconate 325 mg twice a day, Zocor 20 mg every evening and Protonix 40 mg daily.
LA|long-acting|LA|135|136|DISCHARGE MEDICATIONS|11. Prednisone 50 mg p.o. daily. 12. Metamucil. 13. Mestinon 60 mg p.o. q.6 a.m., 9 a.m., noon, 3 p.m., 6 p.m. and 9 p.m. 14. Mestinon LA 180 mg p.o. daily. 15. Ritalin 5 mg p.o. q.a.m. 16. Tylenol 650 mg p.o. q.4 h. p.r.n. 17. Zosyn 3.375 gm IV q.6 h., stop date _%#MMDD2007#%_.
LA|Los Angeles|LA|158|159|PROCEDURES|4. Depression. 5. PTSD. 6. Iron deficiency anemia. 7. History of seizures. PROCEDURES: 1. Lumbar puncture on _%#MMDD2007#%_. 2. EGD on _%#MMDD2007#%_ showing LA grade A esophagitis in the lower esophagus with normal stomach and duodenum. BRIEF SUMMARY OF HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 36-year-old female with a known past medical history of AIDS who presents with the chief complaint of abdominal pain and odynophagia.
LA|long-acting|LA|145|146|DISCHARGE MEDICATIONS|8. Lidocaine 5% patch topically p.r.n. 9. Metoprolol 100 mg p.o. b.i.d. 10. OxyContin 10 mg p.o. b.i.d. 11. Norvasc 10 mg p.o. b.i.d. 12. Detrol LA 4 mg p.o. daily. 13. Trazodone 100 mg p.o. q.h.s. 14. Protonix 40 mg p.o. daily. 15. 15. Pregabalin 25 mg p.o. daily.
LA|long-acting|LA|103|104|MEDICATIONS|PAST SURGICAL HISTORY: Includes chest/mediastinal mass biopsy in _%#MM2006#%_. MEDICATIONS: 1. Inderal LA 60 mg daily. 2. Allopurinol 300 mg daily. 3. DuoNebs q.4h. as needed. 4. Advair 250/50 one puff twice daily. 5. Fentanyl 100 mcg per hour in the form of a patch changed every 3 days.
LA|long-acting|LA|268|269|DISCHARGE MEDICATIONS|1. OxyContin 10 mg per tube b.i.d. 2. Tegretol 200 mg per tube q.i.d., which may taper to 100 mg per tube q.i.d. for a week if her pain is decreased, and then she can go down to 100 mg per tube b.i.d. for a week, then off. 3. Her Celexa is 60 mg p.o. daily. 4. Detrol LA 4 mg p.o. daily. 5. Copaxone 20 mg/mL subcu daily. 6. Baclofen 10 mg per tube q.i.d. 7. Oxycodone 5 mg p.o. q3-4h. p.r.n. for pain. 8. She is also on Fosamax weekly.
LA|Los Angeles|LA|251|252|PROCEDURE|They were small-mouth diverticula found at the splenic flexure, transverse colon, hepatic flexure, ascending colon, sigmoid colon and descending colon. Upper GI endoscopy done on _%#MMDD2006#%_ showed gastric polyps, non-bleeding erosive gastropathy, LA Grade A reflux esophagitis. A biopsy was taken. LABORATORY DATA: Hemoglobin on _%#MMDD2006#%_ was 11.4. The patient's blood sugars were running in the range of 145.
LA|long-acting|LA|162|163|DISCHARGE MEDICATIONS|3. Losartan 50 mg p.o. every 12 hours. 4. Isosorbide mononitrate 60 mg p.o. daily. 5. Furosemide 80 mg p.o. daily. 6. Citalopram 20 mg p.o. daily. 7. Tolterodine LA 4 mg p.o. daily. 8. Simvastatin 20 mg p.o. daily. 9. Zolpidem 5 mg p.o. at night for insomnia. 10. Ranitidine 150 mg p.o. daily. 11. Augmentin 875 mg p.o. every 12 hours for 10 days.
LA|long-acting|LA|179|180|MEDICATIONS|No prior history of arrhythmias. She has had no surgical history. ALLERGIES: None known. MEDICATIONS: Regular medications include: 1. Hydrochlorothiazide 12.5 mg daily, 2. Detrol LA 4 mg daily. 3. Prempro .625/2.5 daily. 4. Aspirin 325 mg daily. 5. Evista 60 mg daily. 6. Cozaar 50 mg daily. 7. Vitamin D. 8. Centrum.
LA|long-acting|LA|205|206|MEDICATIONS|2. Percocet 1 tab q 6 hours p.r.n. 3. Ibuprofen 800 mg PO t.i.d. times five days, started on _%#MMDD2002#%_. 4. Albuterol metered-dose inhaler 2 puffs q 3 hours p.r.n. 5. Zoloft 100 mg PO q AM. 6. Inderal LA 120 mg PO b.i.d. 7. Oral contraceptives 1 q day. 8. Lithium 600 mg q AM, 900 mg q HS. 9. Trazodone 150 mg q HS. 10. Meclizine. 11. Fiber laxatives.
LA|long-acting|LA,|199|201|CURRENT MEDICATIONS|02 sats noted to be 81% on room air. The patient is therefore being admitted for further management. CURRENT MEDICATIONS: 1. Methotrexate, 10 mg per week. 2. Prednisone, dose unknown. 3. Guaifenesin LA, 600 mg b.i.d. started one week ago. 4. Ranitidine 300 mg q hs. 5. Evista 60 mg daily, unclear if the patient is taking as last prescription refilled in _%#MM#%_.
LA|long-acting|LA.|176|178|DISCHARGE MEDICATIONS|12. Flovent (110 mcg) 1 puff b.i.d. 13. Albuterol 2 puffs p.r.n. 14. Advair 1 puff q.d. 15. BuSpar 15 mg t.i.d. 16. Meclizine 25 mg t.i.d. p.r.n. 17. Scopace p.r.n. 18. Detrol LA. 19. Estrogen patch. 20. Hydroxychloroquine 200 mg b.i.d. (arthritis). HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 41-year-old female who presented to the Fairview Southdale Hospital emergency room with symptoms of dizziness.
LA|long-acting|LA|138|139|DISCHARGE MEDICATIONS|CONDITION: Good. DISCHARGE MEDICATIONS: 1. Metoprolol 50 mg p.o. b.i.d. 2. Celexa 40 mg p.o. q.d. 3. Baclofen 10 mg p.o. t.i.d. 4. Detrol LA 2 mg q.d. 5. Colace 100 mg p.o. b.i.d. 6. Multivitamins 1 tablet p.o. q.d. 7. Folic acid 1 mg p.o. q.d. 8. Aspirin 325 mg p.o. q.d. 9. Keflex 500 mg p.o. t.i.d. x 7 days.
LA|long-acting|LA|201|202|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Protonix 40 mg p.o. q.d. 2. Metronidazole 50 mg p.o. b.i.d. for five more days. Step date is _%#MMDD2003#%_. 3. Tylenol 650 mg p.o. q. 4-6h. p.r.n. fever/pain. 4. Guaifenesin LA 600 mg p.o. q.d. 5. Celexa 20 mg p.o. q.d. 6. Vioxx 25 mg p.o. q.d. 7. Hydrochlorothiazide 25 mg p.o. q.d. 8. Kay-Ciel 20 mEq p.o. q.d.
LA|long-acting|LA|145|146|MEDICATIONS DISCONTINUED|5. Lidocaine patch as directed. 6. Baby aspirin. 7. Z-PAK as directed x5 days for sinus infection. MEDICATIONS DISCONTINUED: Lanoxin and Inderal LA 160 mg daily. FOLLOW-UP APPOINTMENTS: 1. In seven to ten days with _%#NAME#%_ _%#NAME#%_, CNP to reassess for palpitations and hypertension.
LA|long-acting|LA|195|196|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Fosamax 70 mg weekly. 2. Flexeril 10 mg 3 times daily as needed. 3. Lexapro 20 mg daily. 4. Milk of magnesia as needed for constipation. 5. Senna twice daily. 6. Detrol LA 4 mg daily. 7. Percocet 1-2 tabs every 4-6 hours as needed for pain. 8. Ampicillin continuous infusion 6 g, infused over 24 hours.
LA|long-acting|LA|151|152|REHAB DISCHARGE RECOMMENDATIONS|6. Protonix 40 mg p.o. b.i.d. 7. Metamucil 1 tablespoon p.o. everyday. 8. Senokot-S 2 tablets p.o. b.i.d. 9. Simvastatin 20 mg p.o. q. p.m. 10. Detrol LA 4 mg p.o. each day at bedtime for baseline urgency. 11. Vitamin B plus C complex 1 tablet p.o. everyday. 12. Hydroxyzine 25 mg p.o. q. 4h. p.r.n. pain.
LA|long-acting|LA|88|89|DISCHARGE MEDICATIONS|Subsequently her hydrochlorothiazide was discontinued. DISCHARGE MEDICATIONS: 1. Detrol LA 2 mg daily p.r.n. 2. Pyridium 200 mg 3 times daily p.r.n. 3. Lisinopril 20 mg daily. 4. Polycitra 1 packet after each meal and at bedtime.
LA|long-acting|LA|162|163|DISCHARGE MEDICATIONS|DISPOSITION: Discharge to home. DISCHARGE MEDICATIONS: 1. Norvasc 5 mg p.o. b.i.d. 2. Zetia 10 mg p.o. q.a.m. 3. Pravachol 80 mg p.o. daily at bedtime. 4. Detrol LA 4 mg p.o. b.i.d. 5. Isosorbide 60 mg p.o. q.a.m. 6. Metoprolol 100 mg p.o. b.i.d. 7. Aspirin 81 mg p.o. daily. 8. Multivitamin 1 tab p.o. daily. 9. Premarin 0.625 mg 2-3 times a week.
LA|long-acting|LA|179|180|HOSPITAL COURSE|Also some decreased sensation of bowel movement. This was not a new finding, just that the patient had not reported this previously. Urology consult was obtained suggested Detrol LA 4 mg per day. Follow up with Urology after discharge. Patient had some improvement with Detrol still however has some leakage with standing, coughing, moving.
LA|long-acting|LA|268|269|DISCHARGE MEDICATIONS|Social services worked on placement for this gentleman until time of discharge. 2. Multiple sclerosis. This was stable during his stay. DISCHARGE MEDICATIONS: Baclofen 10 mg p.o. q.6h p.r.n.; Prozac 40 mg p.o. q.d.; fluocinonide ointment topically q.d. p.r.n.; Detrol LA 2 mg p.o. q.d.; amantadine 100 mg p.o. b.i.d.; Citrucel 1 tsp p.o. q.d.; Percocet one q.4-6h p.r.n. pain; Tylenol 650 mg p.o. q.6h p.r.n.
LA|long-acting|LA|367|368|DISCHARGE MEDICATIONS|This will be for long term care but also for some initial rehab. DISCHARGE MEDICATIONS: Calcium 500 mg t.i.d., Protonix 40 mg daily, Tylenol 325 one to two every six hours p.r.n., Ultram 50 mg one every eight hours p.r.n. but to try and use the Tylenol first, guaifenesin 600 mg daily, Synthroid 0.025 mg daily, Levaquin 250 mg daily for five additional days, Detrol LA 4 mg daily, Paxil 40 mg daily, Miacalcin one spray alternating nostrils daily, Nasacort AQ one spray each nostril daily, Lasix 40 mg daily, Kay Ciel 20 mEq b.i.d. Oxygen to titrate to keep O2 sats greater than or equal to 94%.
LA|long-acting|LA,|220|222|PROBLEM #2|In addition, the patient was receiving low molecular Heparin with Fragmin, 10,000 units twice daily subcu. PROBLEM #2: Labile severe hypertension, difficult to control. The patient was to continue treatment with Inderal LA, 80 mg daily, Hydrochlorothiazide 25 mg/daily. The patient was difficult and refusing new medications, so the patient's wife and patient were explained the risks including severe stroke because of the marked blood pressure elevations.
LA|long-acting|LA|243|244|HOSPITAL COURSE|She is going to follow up with Dr. _%#NAME#%_ _%#NAME#%_ at the end of this time period. Otherwise, her other discharge medications will include Klor-Con 20 mEq a day, Inderal 80 mg b.i.d., ranitidine 150 mg b.i.d., Zoloft 25 mg daily, Detrol LA 4 mg a day, Lomotil 2.5 mg one to two tabs every six hours as needed for diarrhea, Restoril 7.5 mg q.h.s. as needed, aspirin 81 mg a day, FiberCon one tablet b.i.d., digoxin 0.125 mg daily, Lasix 20 mg a day, Neurontin 300 mg t.i.d., Synthroid 0.15 mg daily, lisinopril 5 mg a day, multivitamin daily, OxyContin 10 mg b.i.d., and trazodone 50 mg q.h.s. Hopefully you can wean her off this home oxygen fairly quickly.
LA|long-acting|LA|132|133|MEDICATIONS|4. Clonazepam 2 mg PO each day at bedtime. 5. Colace 1 tablet PO in the morning and at night. 6. Reglan 5-10 mg PO t.i.d. 7. Detrol LA 4 mg PO each day at bedtime. 8. Requip 1 mg PO each day at bedtime. 9. Zofran 8 mg PO t.i.d. p.r.n. nausea. 10. Estroven ES 1 tablet PO each day at bedtime.
LA|long-acting|LA|120|121|DISCHARGE MEDICATIONS|9. Coumadin 5 mg daily on Monday, Tuesday, Thursday, Friday and Sunday and 7.5 mg on Wednesday and Saturday. 10. Detrol LA 4 mg p.o. daily. 11. Doxycycline 200 mg p.o. daily. 12. Fosamax 70 mg p.o. q. Monday. 13. Furosemide 40 mg p.o. q.a.m.
LA|long-acting|LA|153|154|DISCHARGE MEDICATIONS|14. Protonix 40 mg p.o. b.i.d. 15. Propranolol 120 mg p.o. daily. 16. Rifaximin 400 mg p.o. t.i.d. 17. Sodium bicarbonate 1300 mg p.o. t.i.d. 18. Detrol LA 2 mg p.o. daily. 19. Witch hazel pads (Tucks) apply to hemorrhoids b.i.d. DISCHARGE FOLLOWUP: The patient should follow up with the GI Clinic in a week for followup of acute blood loss anemia with CBC.
LA|long-acting|LA|118|119||The patient will be sent home on Percocet and Darvocet N100 for pain control. The patient will be sent home on Detrol LA for bladder spasms. The patient will be seen in my office in a week by one of my partners to discuss extracorporeal shock wave lithotripsy therapy versus a percutaneous nephrostolithotomy.
LA|Los Angeles|LA|211|212|IMAGING AND STUDIES|Impression, partial small bowel obstruction at proximal to mid small bowel with prominence of bowel wall involving some of the loops of small bowel as well as colon. 2. Endoscopy dated _%#MMDD2007#%_. Findings, LA grade A esophagitis, nonbleeding found at the GE junction. There was a Billroth I anastomosis found in the gastric body.
LA|long-acting|LA|106|107|DISCHARGE MEDICATIONS|14. Flomax 0.4 mg q. day for his BPH. 15. Timolol 0.5% one drop both eyes q. day for glaucoma. 16. Detrol LA 2 mg b.i.d. 17. Trazodone 50 mg q. day for depression. 18. Sanctura 20 mg daily for overactive bladder. 19. Coumadin 5 mg daily with an INR done in three days.
LA|long-acting|LA|178|179|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Include 1. Aspirin 2. Premarin 0.625 mg one table daily 3. Prozac 20 mg daily 4. Plaquenil 200 mg daily 5. Pamelor 20 mg two tablets at bedtime 6. Inderal LA 80 mg daily 7. Lisinopril 5 mg daily The patient was discharged on a stage IV diet.
LA|long-acting|LA|406|407|MEDICATIONS|PAST SURGICAL HISTORY: Small bowel obstruction; cholecystectomy laparoscopically. FAMILY HISTORY: Noncontributory. ALLERGIES: IV dye. MEDICATIONS: Oxygen at 2-4 liters per nasal cannula; Nexium 40 mg qd; Rhinocort 2 sprays each nostril qd; amiodarone 200 mg po qd; aspirin 81 mg qd; Furosemide 40 mg qd; Lisinopril 10 mg qd; Astelin nasal spray 1 puff each nostril bid; Advair 50/500 1 puff bid; Guaifenex LA 600 mg tablets, 2 tablets bid; albuterol nebulizations; Atrovent nebulizations; quinine sulfate 260 mg tablets 1 po qhs for muscle spasm; doxazosin 4 mg po qhs; Xalatan 0.005% ophthalmic drops to the right eye at that time; Combivent inhaler prn as well as the albuterol and Atrovent nebs prn.
LA|long-acting|LA|138|139|ADMISSION MEDICATIONS|6. Irritable bowel syndrome. ADMISSION MEDICATIONS: Effexor XR 300 mg p.o. q.d., multivitamin 1 tablet p.o. q.d., Imodium p.r.n., Inderal LA 80 mg p.o. q.d, fluvoxamine 300 mg p.o. q.d. ALLERGIES: None. HOSPITAL COURSE: The patient was taken to the operating room on the day of admission for breast reduction surgery.
LA|long-acting|LA|138|139|DISCHARGE MEDICATIONS|3. Tranxene 3.75 mg p.o. t.i.d. (anxiety). 4. Prinivil 20 mg p.o. q.d. 5. Klor-Con 10 mEq p.o. q.d. 6. Prilosec 20 mg p.o. q.d. 7. Detrol LA 2 mg p.o. q.d. 8. Ultram 50 mg p.o. q.d. 9. Vicodin 1-2 p.o. q.8h. p.r.n. x 7 days. 10. Senokot 2 tabs p.o. b.i.d.
LA|left atrial|LA|150|151|PAST MEDICAL HISTORY|Echo in _%#MM#%_ of 2004 showed decreased LV function of 25%, with a mild LV dilatation, inferoposterior akinesis, mild MR/trace MR, mild to moderate LA enlargement, and RVP of 38/right atrial pressure. 3. Hyperlipidemia. 4. Gout. 5. Status post bilateral inguinal hernia repair. There has been a question of a failure of this repair, and this will be likely fixed during surgery for his cancer.
LA|long-acting|LA|212|213|CURRENT MEDICATIONS|6. Cataract extractions. 7. Hysterectomy for unknown diagnosis. CURRENT MEDICATIONS: 1. Hydroxyurea 1000 mg in the morning and 500 mg in the evening. 2. Hydrochlorothiazide 25 mg p.r.n. (bottle empty). 3. Detrol LA 4 mg per day (bottle empty). ALLERGIES: None. HEALTH HABITS: No alcohol or tobacco. REVIEW OF SYSTEMS: Review of systems was obtained from the niece who sees her frequently.
LA|long-acting|LA|203|204|REVIEW OF SYSTEMS|RESPIRATORY: Negative. No shortness of breath, chest pain, cough or wheezing. GASTROINTESTINAL: Negative. No constipation, diarrhea, nausea, or vomiting of blood. GENITOURINARY: He was started on Detrol LA four weeks ago. Bladder spasms have improved. SKIN: Negative. MUSCULOSKELETAL: He is weak in the upper and lower extremities. LYMPHATIC: Negative. No enlarged lymph nodes. ENDOCRINE: He is diabetic x 20 years, under good control at the present time with glyburide.
LA|long-acting|LA|120|121|CURRENT MEDICATIONS|2. Lisinopril 10 mg PO Q a.m. 3. Digoxin 0.25 mg PO daily 4. Centrum one PO daily 5. Ocuvite one tab PO daily 6. Detrol LA 4 mg PO daily 7. Glyburide 10 mg PO b.i.d. 8. Flutamide 125 mg PO daily 9. E supplements 10. Rosiglitazone 8 mg PO daily
LA|long-acting|LA|150|151|DISCHARGE MEDICATIONS|4. Albuterol nebulizer 2.5 mg in 3 mL inhaled t.i.d. 5. Mestinon 60 mg p.o. 6 times daily at 0600, 0900, 1200, 1500, 1800 and 2100 hours. 6. Mestinon LA 180 mg p.o. daily. 7. Metamucil 1 packet p.o. daily. 8. Amlodipine 5 mg p.o. daily. 9. Multivitamin 1 p.o. daily. 10. Ritalin 5 mg p.o. every 0800 hours and every 1200 hours.
LA|long-acting|LA|304|305|HOSPITAL COURSE|She was put on Skelaxin and fentanyl patch for pain control and muscle tightness. She is discharged in stable condition on Skelaxin 400 mg two tablets q.8.h. times seven days and p.r.n., prednisone 10 mg for two days, then continue taper, Vicodin p.r.n. pain as well as her Liquibid 600 mg b.i.d., Entex LA 600 mg b.i.d., Singulair 10 mg a day, Advair one dose b.i.d., Rhinocort two sprays each nostril b.i.d., Wellbutrin 200 mg b.i.d., Effexor 200 mg q.d., Protonix 20 mg a day, and Ortho-Cyclen daily.
LA|long-acting|LA|304|305|ADMISSION MEDICATIONS|6. Removal of mediastinal mass in 1980s. ADMISSION MEDICATIONS: Premarin 0.625 mg daily, Diovan HCT 160/12.5 mg p.o. q.d., folic acid 1 mg daily, multivitamin daily, furosemide 40 mg p.r.n. for pedal edema, trazodone 50 mg q.h.s., Norvasc 5 mg p.o. q.d., Zoloft 50 mg p.o. q.d., Vioxx 25 mg q.d., Detrol LA 40 mg q.d. ALLERGIES: NO KNOWN DRUG ALLERGIES. PHYSICAL EXAMINATION: Blood pressure 130/82, respiratory rate 18, pulse 68, temp 96.6, weight 261 lbs.
LA|long-acting|LA.|242|244|HOSPITAL COURSE|However, two days after her heart rate had been normalized by discontinuing the digoxin and switching to low-dose beta blockers, she continued to exhibit confusion and disorientation. At this point, I stopped her Wellbutrin SR and her Detrol LA. By the next day, her mental status had improved, and today on the day of discharge, it remains improved. Her family has noted a marked improvement, and she is much closer to her baseline.
LA|long-acting|LA|161|162|ALLERGIES|5. Ditropan XL 15 mg p.o. q. d. 6. Colace 200 mg q. h.s. 7. Fibercon 2 tablets b.i.d. 8. Flomax 0.4 mg capsule b.i.d. 9. Furosemide 40 mg b.i.d. 10. Guaifenesin LA 600 mg half tablet b.i.d. 11. K-Tab 20 mEq b.i.d. 12. Lisinopril 20 mg p.o. q. d. 13. Miralax 17 g b.i.d. 14. Multivitamin q. d.
LA|long-acting|L.A.|148|151|MEDICATIONS|He was then admitted to the hospital for further evaluation. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Tequin 400 mg p.o. q.d. 2. Humibid L.A. 600 mg p.o. b.i.d. 3. Paxil 40 mg p.o. q.d. FAMILY HISTORY: His father died at the age of 85 of unknown cause.
LA|long-acting|LA|185|186|DISCHARGE MEDICATIONS|It was felt by all involved that he was ready for discharge to home on _%#MMDD2003#%_. DISCHARGE MEDICATIONS: 1. Hydrochlorothiazide 25 mg p.o. q.d. 2. Hytrin 2 mg p.o. q.d. 3. Inderal LA 120 mg p.o. q.d. 4. Ranitidine 150 mg p.o. b.i.d. 5. Combivent inhaler with a spacer, two puffs q 6 hours. FINAL DIAGNOSIS: 1. Acute cholecystitis with cholelithiasis and gallbladder empyema.
LA|long-acting|LA|148|149|DISCHARGE MEDICATIONS|4. Altace 5 mg p.o. q.d. 5. Lanoxin 0.125 mg p.o. q.d. 6. Protonix 40 mg p.o. q.d. 7. Zoloft 25 mg p.o. q.d. 8. Coumadin 2.5 mg p.o. q.d. 9. Detrol LA 4 mg p.o. q.d. 10. Tylenol 325 mg p.o. q.i.d. p.r.n. 11. Prednisone, the patient ongoing and tapered, 30 mg p.o. x1 more day, 20 mg p.o. q.d. x3 days, 10 mg p.o. q.d. x3 days, 5 mg p.o. q.d. x3 days, and then off.
LA|long-acting|LA|154|155|DISCHARGE MEDICATIONS|8. K-Dur 20 mEq p.o. b.i.d. 9. Lasix 40 mg p.o. q.d. (to start on _%#MMDD2004#%_). 10. Imdur 180 mg p.o. q.a.m. 11. Multivitamin one p.o. q.d. 12. Detrol LA 4 mg p.o. q.d. 13. Metamucil p.r.n. DISCHARGE FOLLOW-UP: The patient is to follow up in 5-7 days with Dr. _%#NAME#%_ _%#NAME#%_.
LA|long-acting|LA,|120|122|ADMIT MEDICATIONS|ADMIT MEDICATIONS: 1. Coreg, 3.125 mg p.o. b.i.d. 2. Lasix, 40 mg p.o. q. day. 3. Flomax, 0.4 mg p.o. q. day. 4. Detrol LA, 4 mg p.o. q. day. 5. Pravachol, 40 mg p.o. q. day. 6. Lisinopril, 10 mg p.o. q. day. 7. Aspirin, 325 mg p.o. q. day.
LA|long-acting|LA|149|150|MEDICATIONS|6. History of pneumonia per patient. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Atenolol 50 mg po daily. 2. Paxil 20 mg po daily. 3. Detrol LA 4 mg po daily. 4. Motrin three tablets po q4h. 5. Tylenol PM two tabs po daily. 6. Multi-vitamins one tablet po daily.
LA|long-acting|LA|168|169|DISCHARGE MEDICATIONS|She was discharged to home with three weeks of home health care on _%#MMDD2003#%_, normoglycemic in the absence of exogenous insulin. DISCHARGE MEDICATIONS: 1. Inderal LA 120 mg p.o. q.d. 2. Aciphex 20 mg p.o. q.d. 3. Wellbutrin 150 mg p.o. b.i.d. 4. Multivitamin p.o. q.d. 5. Pancrease two tablets p.o. t.i.d. with meals.
LA|long-acting|LA|301|302|MEDICATIONS|She also is taking Zoloft 50 mg qd for possible depression. She presently is on Glucovance 2.5/500 2 orally bid. The patient is on synthroid 125 mcg qd for hypothyroidism, B12 injections monthly for B12 deficiency and multivitamins, as well as potassium chloride 8 mEq qd, aspirin 81 mg daily, Detrol LA 4 mg daily and glucosamine 500 mg daily for arthritis. PAST MEDICAL HISTORY: Obtained from the family and the chart.
LA|long-acting|LA|769|770|HOSPITAL COURSE|Otherwise, the medicines were the same as prior to admission. Discharge medications were Duragesic 75 mcg per hour patch, change every three days, diazepam 5 mg three times daily, Percocet one pill every four hours p.r.n. break through pain, Serevent one inhalation every 12 hours, acetaminophen 1000 mg three times daily, spironolactone 25 mg three times daily, Artificial Tears one drop in each eye four times daily, Milk of Magnesia 30 mg at bedtime, Bisacodyl 10 mg suppository every other day, Depo-Provera 300 mg IM every three months - due again in _%#MM#%_ 2004, multiple vitamin one pill daily, omeprazole 20 mg daily, disopyramide 300 mg twice daily and 150 mg at noon, Warfarin 3.5 mg daily, furosemide 80 mg daily, metoprolol 50 mg twice daily, guaifenesin LA 600 mg twice daily, Xalatan 0.005% one drop in the right eye at bedtime, Fibercate one pill daily, Arginaid one serving twice daily mix with gingerale, sliding scale regular insulin, Novolin N 18 units every morning and 8 units every evening before supper, Novolin R 8 units every morning and 10 units every evening before supper.
LA|long-acting|LA|126|127|DISCHARGE MEDICATIONS|3. Aspirin 81 mg p.o. q.d. 4. Avapro 150 mg q.d. 5. Colchicine 0.6 mg q.d. 6. Cosopt, one drop to the left eye q.d. 7. Detrol LA 4 mg q.d. 8. Imdur 30 mg p.o. q.d. 9. Lasix 80 mg p.o. q.d. 10. Norvasc 5 mg p.o. q.d. 11. Prednisone 7.5 mg p.o. q.d. 12. Senna, one or two p.o. q.a.m.
LA|long-acting|LA|182|183|MEDICATIONS|5. TURP. ALLERGIES: None known. MEDICATIONS: 1. Singulair 10 mg h.s. 2. Klonopin 0.5 mg daily. 3. Cardizem 180 mg daily. 4. Dilantin 400 mg daily. 5. Prevacid 30 mg daily. 6. Detrol LA 4 gm daily. 7. Flovent two puffs b.i.d. 8. Medrol 2 mg daily. 9. Synthroid 0.225 mg daily. REVIEW OF SYSTEMS: Otherwise negative, although somewhat unreliable as the patient's memory is not the best.
LA|long-acting|LA.|235|237|PAST MEDICAL HISTORY|He evidently received about 2.5 liters of intravenous fluids in the emergency department and is just now this evening, several hours after admission, had a need to urinate. PAST MEDICAL HISTORY: Hypertension, on lisinopril and Inderal LA. History of migraine and cluster headaches. Sleep apnea, on CPAP. Hyperlipidemia. History of depression and anxiety. Gastroesophageal reflux disorder. PAST SURGICAL HISTORY: Left palm Dupuytren's surgery.
LA|Los Angeles|LA|284|285|REVIEW OF SYSTEMS|FAMILY HISTORY: Mom mitral valve replacement and partial thyroidectomy. Maternal grandfather did apparently have a history of blood clots but died at a very advanced age. Maternal grandmother with osteoporosis. REVIEW OF SYSTEMS: Also does note that she flew to an uncle's funeral in LA on Labor Day, which was about three weeks ago, and it was about a four hour flight. She states she is up to date on her mammogram.
LA|long-acting|LA|395|396|DISCHARGE MEDICATIONS|Follow-up was arranged for Dr. _%#NAME#%_ in two weeks and Dr. _%#NAME#%_ in three weeks. DISCHARGE MEDICATIONS: Zithromax 250 mg once a day to end on _%#MMDD2003#%_, Ceftin 500 mg p.o. b.i.d. to add on _%#MMDD2003#%_, Doxazosin 4 mg one half tablet in the morning and one half in the evening, Nexium 40 mg a day, aspirin 81 mg a day, Lasix 40 mg a day, Amiodarone 200 mg p.o. q.d., Guaifenesin LA 600 mg p.o. b.i.d., Astelin nasal spray one each nostril b.i.d., and Quinine Sulfate 260 mg p.o. q.h.s.
LA|long-acting|LA|152|153|MEDICATIONS|History of anxiety. History of orthostatic hypertension. History of hiatal hernia. MEDICATIONS: Include Celexa 20 mg a day, Flomax 0.4 mg a day, Detrol LA 4 mg daily, Plavix 75 mg every other day, Florinef 0.1 mg daily, Prevacid 30 mg daily, vitamins, Celebrex 200 mg daily, amiodarone 200 mg daily, atenolol 25 mg daily.
LA|long-acting|LA|152|153|DISCHARGE MEDICATIONS|1. Coumadin 5 mg a day. 2. Cardizem 180 mg q.d. 3. Tequin 200 mg a day for two days. 4. Protonix 40 mg q.d. 5. Zantac 150 mg, two at bedtime. 6. Detrol LA 4 mg. 7. Restoril p.r.n. FOLLOW-UP APPOINTMENTS: 1. Follow up with me in one week after chemotherapy, on the _%#DD#%_.
LA|long-acting|LA|119|120|DISCHARGE PLAN|2. He is to drink large amounts of fluids. 3. He is to resume all of his medications. 4. I have also put him on Detrol LA 4 mg once a day for the next four weeks. 5. I have advised him to continue on Proscar 5 mg once a day for the next four weeks until all bleeding has subsided.
LA|long-acting|LA|184|185|REVIEW OF SYSTEMS|Her medications include: Lipitor 20 mg daily. Aspirin 81 mg a day. Imdur 60 mg daily. Plavix 75 mg a day. Norvasc 2.5 mg daily. Lisinopril 2.5 mg daily. Synthroid 0.1 mg daily. Detrol LA 4 mg daily. FAMILY HISTORY: Negative for any definite cancers. There is heart disease in her mother.
LA|Los Angeles|LA|110|111|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: GENERAL: Sweats. She has hot flashes that are mild. Appetite - she is losing weight on the LA Weight loss. She is down about 12 pounds. EYES: Negative, no blurred or double vision EARS: Negative. NOSE: Negative. THROAT: Negative. No sore throat or hoarseness. CARDIOVASCULAR: Occasional palpitations.
LA|long-acting|LA|125|126|MEDICATIONS|13. History of degenerative joint disease MEDICATIONS: 1. Beconase 42 micrograms, one spray in each nostril b.i.d. 2. Detrol LA 4 mg p.o. q.h.s. 3. Lanoxin 0.125 mg p.o. four times a week 4. Lanoxin 0.25 mg p.o. three times a week 5. Ferrous gluconate 324 mg p.o. b.i.d.
LA|long-acting|LA|167|168|DISCHARGE MEDICATIONS|He is instructed to follow with primary MD within 1 to 2 weeks after discharge. DISCHARGE MEDICATIONS: Cipro 500 mg twice a day for 6 days, Aricept 5 mg daily, Detrol LA 4 mg daily, and Hytrin 10 mg 2 tablets p.o. nightly.
LA|long-acting|LA|137|138|MEDICATIONS|5. Norethindrone 5 mg daily. 6. Zyrtec 10 mg daily. 7. Seroquel 1200 mg q.h.s. 8. Ativan 4 mg q.h.s. 9. Norvasc 2.5 mg daily. 10. Detrol LA 4 mg p.o. daily. ALLERGIES: 1. Zonegran. 2. Topamax. 3. Lamictal. 4. Nardil.
LA|left atrial|LA.|317|319|HOSPITAL COURSE|He remained asymptomatic for the remainder of the hospital stay and was chest pain free without any other symptoms or EKG changes. His follow-up EKG was unchanged. He also had a follow-up echocardiogram revealing an ejection fraction of 65% with mild LVH, normal LV chamber size, normal LV function, and mild dilated LA. DISCHARGE MEDICATIONS: 1. Lipitor 80 mg p.o. daily. 2. Toprol XL 25 mg p.o. daily.
LA|long-acting|LA|117|118|HOSPITAL COURSE|4. Verapamil 180 mg daily. 5. Singulair 10 mg daily. 6. Protonix 40 mg b.i.d. 7. Synthroid 0.175 mg daily. 8. Detrol LA 4 mg daily. 9. Estradiol 2 mg every day. 10. Flonase 2 sprays each nostril daily. 11. Advair 500/50 one puff b.i.d. The medical staff followed her throughout her stay for her Coumadin orders.
LA|long-acting|LA|121|122|DISCHARGE MEDICATIONS|9. Verapamil 180 mg daily. 10. Singulair 10 mg daily. 11. Protonix 40 mg b.i.d. 12. Synthroid 0.175 mg daily. 13. Detrol LA 4 mg daily. 14. Coumadin 5 mg daily. 15. Estradiol 2 mg daily. 16. Flonase nasal spray 2 sniffs each nostril daily.
LA|long-acting|LA|151|152|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: The patient was discharged on the following medications. 1. Protonix 40 mg p.o. q. day. 2. Flomax 0.4 mg p.o. q. day. 3. Detrol LA 2 mg p.o. q. day. 4. Tylenol 325 mg 1 to 2 tablets p.o. every 4 to 6 hours as needed for pain.
LA|long-acting|LA|159|160|DISCHARGE MEDICATIONS|7. Isordil 10 mg p.o. t.i.d. 8. Xalatan eye drops 0.005% both eyes one drop q.h.s. 9. Lisinopril 5 mg p.o. daily. 10. Primidone 200 mg p.o. q.h.s. 11. Inderal LA 120 mg p.o. b.i.d. Patient to follow up with Dr. _%#NAME#%_ in approximately 2 weeks and to follow up with Dr. _%#NAME#%_ in approximately 2 months.
LA|long-acting|LA|133|134|CURRENT MEDICATIONS|ALLERGIES: Penicillin that flares her psoriasis. CURRENT MEDICATIONS: 1. Altace 10 mg once a day. 2. Lexapro 20 mg daily. 3. Inderal LA 80 mg. 4. Multivitamin. 5. Enbrel which has been on hold. 6. Wellbutrin XL 150 mg. SOCIAL HISTORY: The patient is a recent ex-smoker.
LA|long-acting|LA|200|201|HOSPITAL COURSE|The urine culture was negative, hence levofloxacin was discontinued upon discharge. Problem #4. History of atrial fibrillation: The patient was getting treatment for atrial fibrillation with Cardizem LA for rate control. Cardizem was continued. Since the patient is going to be anticoagulated for her multiple myeloma and hip fracture, this would benefit her atrial fibrillation to prevent further strokes.
LA|long-acting|LA,|164|166|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Plavix 75 mg p.o. daily, lifelong due to an aspirin allergy. 2. Crestor 10 mg p.o. nightly. 3. Wellbutrin XL 300 mg p.o. daily. 4. Detrol LA, the patient reports, she takes 10 mg daily, but I suspect she only takes between 1 mg to 4 mg a day. 5. Lasix 20 mg p.o. daily x5 days. 6. Remicade IV injection every 6 weeks in rheumatology clinic, next injection on _%#MM#%_ _%#DD#%_, 2006.
LA|long-acting|LA|178|179|CURRENT MEDICATIONS|NEUROLOGIC: Her cranial nerves II-XII are intact. She is answering questions appropriately, but during her response has severe flight of thoughts. CURRENT MEDICATIONS: 1. Detrol LA 4 mg daily. 2. Lactate 1 tablet with meals. 3. Flexeril 10 mg t.i.d. 4. Synthroid 100 mcg daily. 5. Cozaar 15 mg daily. 6. Neurontin 900 mg t.i.d.
LA|long-acting|LA|148|149|MEDICATIONS|6. OxyContin 10 mg p.o. b.i.d. 7. Protonix 40 mg daily. 8. Macrobid 50 mg p.o. b.i.d. 9. Senokot p.o. b.i.d. 10. Zocor 20 mg p.o. daily. 11. Detrol LA 2 mg p.o. daily. 12. Vicodin 5/500 1-2 p.o. q 4-6 hours p.r.n., maximum 6 tabs per day. 13. Restoril 7.5 mg p.o. at bedtime p.r.n. 14. Oxygen 2-1/2 liters per nasal cannula chronically.
LA|long-acting|LA,|173|175|DISCHARGE MEDICATIONS|5. Cevimeline, 30 mg p.o. t.i.d. 6. Lisinopril, 5 mg p.o. daily. 7. Protonix, 40 mg p.o. daily. 8. Prednisone, 5 mg p.o. daily. 9. Senokot, 2 tablets p.o. b.i.d. 10. Detrol LA, 4 mg p.o. q.h.s. 11. Citrucel, one packet p.o. b.i.d. p.r.n. The patient is to follow up with Dr. _%#NAME#%_ in two weeks. He is to have an INR on Thursday, results called to office of Dr. _%#NAME#%_.
LA|long-acting|LA|115|116|MEDICATIONS|6) Gastroesophageal reflux disease. 7) Essential hypertension. ALELRGIES: CARDIZEM, SULFA. MEDICATIONS: 1) Inderal LA 120 mg daily. 2) Protonix 40 mg daily. 3) Hydrochlorothiazide 25 mg daily 4) Synthroid 0.125 mg daily. 5) Norvasc 5 mg daily. 6) Amiodarone 200 mg daily.
LA|long-acting|LA|160|161|CURRENT MEDICATIONS|ALLERGIES: SHE CARRIES ALLERGIES TO PENICILLIN, DEMEROL, DEPAKOTE, PHENOBARBITAL, MACROBID, LINCOCIN. CURRENT MEDICATIONS: 1. Lotrel 5/20 once daily. 2. Detrol LA 4 mg daily. 3. Glyburide/metformin 1.25/250 one daily. 4. Ranitidine 150 mg h.s. 5. Centrum Silver. 6. Metamucil. 7. Calcium supplement. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 66-year-old woman now scheduled for elective left knee replacement.
LA|long-acting|LA|147|148|DISCHARGE MEDICATIONS|8. Metoprolol 100 mg p.o. every day. 9. K-Dur 10 mEq p.o. every day. 10. Senna 2 tabs p.o. every day. 11. Flomax 400 mg p.o. every day. 12. Detrol LA 2 mg p.o. every day. 13. NovoLog 8 units subcu at breakfast, 8 units subcu at lunch, 10 units subcu at supper.
LA|long-acting|LA|168|169|MEDICATIONS ON DISCHARGE|9. Nystatin swish and swallow q.i.d. 10. Protonix 20 mg p.o. daily. 11. Avandia 2 mg p.o. daily. 12. Simvastatin 20 mg p.o. daily. 13. Spiriva 18 mcg daily. 14. Detrol LA 4 mg daily. 15. Ativan 1 mg t.i.d. p.r.n. 16. Percocet 5/325 one to two q.4-6 h. p.r.n. pain. 17. Tylenol 500 to 1000 mg q.6 h. p.r.n. pain.
LA|left atrial|LA|269|270|BRIEF HISTORY|The patient prior to the outpatient evaluation had a thallium test performed which was suggestive of inferolateral ischemia. An EKG performed demonstrated an inferior wall infarct. The patient subsequently underwent a coronary angiography which revealed a 95% proximal LA deviation and a totally occluded right coronary artery with minimal disease of circumflex system. After evaluation, therapeutic options were discussed with the patient. After indications, risks, benefits, the potential complications were discussed, the patient decided to proceed with a coronary artery bypass graft.
LA|long-acting|LA|129|130|DISCHARGE MEDICATIONS|3. Levaquin 250 mg for 3 days. 4. Lisinopril 10 mg daily. 5. Toprol XL 50 mg twice daily. 6. K-Dur 20 mEq twice daily. 7. Detrol LA 2 mg daily. 8. Hydralazine 10 mg every 6 hours p.r.n. itching. It should be noted that there is chronic renal insufficiency.
LA|long-acting|LA|180|181|DISCHARGE MEDICATIONS|6. Imdur 30 mg daily. 7. Xalatan 0.005% 1 drop each eye nightly. 8. Lopressor 25 mg b.i.d. 9. Ativan 1 mg every evening as needed for anxiety. 10. Prevacid 30 mg daily. 11. Detrol LA 4 mg oral daily. 12. Triamcinolone topical to the skin daily at 0.1%. 13. Coumadin 4 mg on Mondays, 2 mg Tuesday through Sunday.
LA|long-acting|LA|297|298|ADMISSION DIAGNOSIS|She is on a tapering course of Medrol. She is discharge to _%#CITY#%_ with no cellulitis. She is on baclofen 10 mg three times a day and then once p.r.n., cimetidine 300 mg three times a day, Betaseron 0.3 mg subcutaneous every other day, lactulose 15 mg a day, levothyroxine 50 mcg a day, Detrol LA 4 mg twice a day, Provigil 200 mg twice a day, senna twice a day, Tylenol as necessary, Maalox, and a tapering dose of Medrol.
LA|long-acting|LA|141|142|DISCHARGE MEDICATIONS|10. Metformin 1000 mg a day every morning. 11. Trilafon 2 mg at bedtime. 12. Zantac as necessary. 13. Zocor 40 mg in the evening, 14. Detrol LA 2 mg a day. Her residual urines, unfortunately are 300 mL or so, and that is a product of her disease and Detrol, but by lowering the Detrol, I think we will get in more trouble, and there is very little way to manage the bladder without a tube that would be appropriate for her.
LA|long-acting|LA|86|87|DISCHARGE MEDICATIONS|She is to be discharged to skilled nursing facility. DISCHARGE MEDICATIONS: 1. Detrol LA 2 mg daily. 2. Lisinopril 10 mg daily. 3. Lasix 40 mg b.i.d. 4. Prozac 20 mg daily. 5. Toprol XL 50 mg daily. 6. Erythromycin 400 mg daily.
LA|Los Angeles|LA|328|329|HOSPITAL COURSE|She was kept n.p.o. after midnight, her oral antihypertensives were held, IV fluids with normal saline were begun, Flagyl was begun, Protonix IV begun, stool cultures gotten, Accu-Cheks followed closely. She was seen by Dr. _%#NAME#%_ _%#NAME#%_, Minnesota Gastroenterology. She had an upper endoscopy on _%#MMDD2006#%_, noting LA grade A reflux esophagitis, hiatus hernia, gastric ulcer with clean base, erythematous gastropathy, normal duodenum. She was advised to be on life-long proton pump inhibitors and discontinue all nonsteroidal anti-inflammatories.
LA|long-acting|LA|145|146|DISCHARGE MEDICATIONS|2. Diovan HCT 160/12.5 p.o. daily. 3. Toprol XL 100 mg p.o. daily. 4. Prilosec OTC 20 mg p.o. daily. 5. Hydroxyurea 500 mg p.o. b.i.d. 6. Detrol LA 4 mg p.o. q.48 h. 7. Plavix 75 mg p.o. daily. 8. Aspirin 81 mg p.o. daily. 9. Levaquin 250 mg 1 p.o. daily, to be stopped on _%#MMDD2007#%_ for UTI and bronchitis.
LA|long-acting|LA|189|190|CURRENT MEDICATIONS|8. Hydrochlorothiazide 12.5 mg daily. 9. Xalatan 0.005% one drop to both eyes every evening. 10. Timolol 0.5% drops twice a day to each eye. 11. Restoril 30 mg q.h.s. if needed. 12. Detrol LA 4 mg daily. 13. Aldactone 50 mg one tablet daily. 14. Omeprazole 20 mg one tablet daily. 15. Metoprolol 100 mg, one tablet twice a day.
LA|long-acting|LA|180|181|MEDICATIONS|ALLERGIES: Penicillin, Sulfa, Erythromycin. PAST MEDICAL HISTORY: Irritable bowel, osteopenia. PAST SURGICAL HISTORY: Cholecystectomy and urethral dilatations. MEDICATIONS: Detrol LA 4 mg daily, Allegra 180 mg daily, Flonase 1 spray daily, Buspar 10 mg one-half tablet in the morning, Prempro 0.45 mg daily.
LA|long-acting|LA|126|127|MEDICATIONS|3. Potassium chloride 10 mEq b.i.d. 4. Propranolol 40 mg b.i.d. 5. Captopril 50 mg b.i.d. 6. Guanfacine 1 mg b.i.d. 7. Detrol LA 4 mg daily. 8. Calcium 1 pill b.i.d. 9. Ecotrin 325 mg daily. ALLERGIES: She has no known drug allergies.
LA|long-acting|LA|101|102|DISCHARGE MEDICATIONS|DISPOSITION: The patient was discharged to home on _%#MMDD2006#%_. DISCHARGE MEDICATIONS: 1. Inderal LA 60 mg p.o. daily. 2. Phenobarbital 100 mg p.o. b.i.d. 3. Soma 350 mg p.o. t.i.d. p.r.n. (#20, no refills). 4. Folic acid 1 mg p.o. daily. 5. Flonase two sprays each nostril daily.
LA|long-acting|LA|169|170|DISCHARGE INSTRUCTIONS|11. Lasix 60 mg p.o. daily, the patient was instructed to abstain from Lasix until the next follow-up appointment. 12. Potassium chloride 20 mEq p.o. daily. 13. Ritalin LA 20 mg p.o. daily, the patient was instructed not to take Ritalin LA, in its place Ritalin 10 mg p.o. twice daily was prescribed because it can be crushed.
LA|long-acting|LA|140|141|DISCHARGE MEDICATIONS|4. Patanol 0.1% ophthalmic solution one drop left eye daily 5. Lyrica 150 mg one p.o. b.i.d. 6. Actonel 35 mg tab one p.o. q week 7. Detrol LA 4 mg one p.o. daily 8. Percocet 5/325 mg one to two p.o. q 4-6 hours p.r.n. pain, #30 dispensed
LA|Los Angeles|LA|204|205|IMAGING STUDIES AND PROCEDURE PERFORMED DURING THIS HOSPITALIZATION|Also noted was that there was diffuse thickening in the adrenal glands bilaterally. There was no abdominal or pelvic lymph node enlargement. 5. Upper GI endoscopy performed on _%#MMDD2007#%_. Impression: LA grade B reflux esophagitis. Hiatus hernia. Multiple gastric polyps. Normal duodenal bulb and second part of the duodenum. Unclear that mild esophagitis is primary or secondary event. Also was noted on the ultrasound.
LA|long-acting|LA|457|458|MEDICATIONS|Past illnesses: Pneumonia, last in _%#MM#%_ of 2002 when she was hospitalized at Fairview Southdale Hospital. Arthritis, osteoarthritis, osteoporosis, hypertension and stress incontinence. ALLERGIES: NONE. MEDICATIONS: Aspirin, one p.o. q day, Prinivil 10 mg p.o. q day, amitriptyline 10 mg p.o. q h.s., temazepam 15 mg p.o. q h.s. p.r.n. insomnia, Percocet 5/325 one p.o. q.i.d. p.r.n. She uses one before bed and maybe once during the day if pain; Detrol LA 10 mg, one p.o. q h.s., p.r.n. incontinence; Prilosec 40 mg p.o. q h.s. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She lives with her daughter. She is a nonsmoker.
LA|long-acting|LA|123|124|OUTPATIENT MEDICATIONS|ALLERGY: NKDA. OUTPATIENT MEDICATIONS: 1. Triamcinolone cream 0.1% to face b.i.d. 2. Prevacid 30 mg p.o. b.i.d. 3. Dietrol LA mg p.o. b.i.d. 4. Reglan 5 mg p.o. q. h.s. 5. Florinef 0.1 mg 1/2 tab p.o. b.i.d. 6. Klor-Con 20 mg p.o. b.i.d. 7. Senokot 1 tab p.o. b.i.d.
LA|Los Angeles|LA|172|173|HISTORY|He took a trip to LA and last Friday started to develop more significant pain, which he rated somewhere in the neighborhood of 3 out of 10. By Sunday on his trip back from LA he had pain which he rated 5 to 6 out of 10 and on Monday when he woke up he had severe disabling pain and numbness in his leg which by today was 7 to 10 out of 10.
LA|left atrial|LA|194|195|PROCEDURE|DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. b.i.d. 2. Diltiazem SR 180 mg p.o. q.day. 3. Coumadin 3 mg p.o. q.day. 4. Lisinopril 2.5 mg p.o. q.day. PROCEDURE: Transthoracic echo shows a moderate LA enlargement at 47 mm, mild mitral regurgitation, and normal global left ventricular function. No mention of diastolic dysfunction. HISTORY OF PRESENT ILLNESS: This is a 73-year-old female with a history of sick sinus syndrome status post pacemaker placement for bradycardia and a history of atrial fibrillation on flecainide.
LA|long-acting|LA|134|135|MEDICATIONS|3. Hormone replacement. 4. Aspirin 1 q.d. 5. Dilantin 300 alternating with 200 q.d. 6. Florinef for orthostasis 0.1 mg q.d. 7. Detrol LA 4 mg q.d. for urinary urgency. ALLERGIES: Sulfa and penicillin. HABITS: Nonsmoker. Alcohol is minimal. SOCIAL HISTORY: She is widowed.
LA|long-acting|LA|147|148|DISCHARGE MEDICATIONS|Discharge diet is a qualitative diabetic diet. Discharge activity is without restrictions. DISCHARGE MEDICATIONS: 1. Demadex 20 mg q.d. 2. Inderal LA 160 mg q.d. 3. Monopril 10 mg q.d. 4. Detrol LA 4 mg q.d. 5. Estradiol 2 mg q.d. 6. Avandia 4 mg q.d.
LA|long-acting|LA|130|131|DISCHARGE MEDICATIONS|DISCHARGE ACTIVITY: Without restriction. DISCHARGE MEDICATIONS: 1. Rocephin 1 gm IV q.24h. 2. Demadex 100 mg p.o. q.d. 3. Inderal LA 80 mg p.o. q.d. 4. Monopril 5 mg p.o. q.d. 5. Detrol LA 4 mg p.o. b.i.d. 6. Estradiol 2 mg p.o. q.d. 7. Avandia 4 mg p.o. q.d.
LA|long-acting|LA|186|187|DISCHARGE MEDICATIONS|DISCHARGE ACTIVITY: Without restriction. DISCHARGE MEDICATIONS: 1. Rocephin 1 gm IV q.24h. 2. Demadex 100 mg p.o. q.d. 3. Inderal LA 80 mg p.o. q.d. 4. Monopril 5 mg p.o. q.d. 5. Detrol LA 4 mg p.o. b.i.d. 6. Estradiol 2 mg p.o. q.d. 7. Avandia 4 mg p.o. q.d. 8. Gemfibrozil 600 mg p.o. b.i.d. 9. Vioxx 25 mg p.o. q.d.
LA|long-acting|LA|111|112|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1. Wellbutrin SR 200 mg b.i.d. 2. Serzone 150 mg b.i.d. 3. Ambien 10 mg at h.s. 4. Detrol LA 4 mg q.d. 5. Tylenol 1000 mg p.r.n. She denies any recent use of aspirin, Motrin, Nuprin, Advil, or Aleve.
LA|long-acting|LA|346|347|DISCHARGE MEDICATIONS|Discharge diet: Regular, as tolerated. Discharge activity: Without restrictions. Physical therapy and occupational therapy will be initiated. DISCHARGE MEDICATIONS: Lasix 20 mg q.d., Plendil 10 mg q.d., Toprol XL 100 mg p.o. q.d., Tequin 200 mg p.o. q.d. through _%#MM#%_ _%#DD#%_, 2003; Tylenol 650 mg q 4 hours p.r.n. for pain or fever, Detrol LA 4 mg q.d., Synthroid 0.05 mg p.o. q.d., Imdur 30 mg p.o. q.d. Beconase AQ two sprays to each nostril q.d., enteric aspirin 81 mg p.o. q.d., Zocor 40 mg p.o. q.d., Plavix 75 mg p.o. q.d., guaifenesin 600 mg p.o. b.i.d., multivitamin one p.o. q.d., Nitrostat 0.4 mg sublingual q five minutes p.r.n. for chest pain, Meclizine 12.5 mg q 4 hours p.r.n. dizziness, Tussionex elixir 1 tsp q 12 hours p.r.n. for cough.
LA|long-acting|LA|156|157|DISCHARGE MEDICATIONS|9. History of hypertension. 10. History of osteoporosis. 11. Has a present femoral hernia and varicose veins of her legs. DISCHARGE MEDICATIONS: 1. Inderal LA one p.o. daily. 2. Norvasc 2.5 mg p.o. daily. 3. Spironolactone 12.5 mg 1/2 tablet daily. 4. Calcium carbonate 500 mg two times daily for her osteoporosis.
LA|long-acting|LA|124|125|PLAN|3. Percocet 5 mg 1-2 four times daily. 4. Aceon one daily 8 mg. 5. Toprol XL 25 mg daily. 6. Lipitor 10 mg daily. 7. Detrol LA 4 mg daily. 8. Caltrate with D, 600 mg, one twice a day. 9. Glucosamine chondroitin 500/500 one three times a day.
LA|long-acting|LA|133|134|MEDICATIONS|ALLERGIES: None. MEDICATIONS: 1. Diabeta 2.5 q.d. 2. Lanoxin 0.125. 3. Coumadin 2 mg alternating with 2.5. 4. Altace 5 mg. 5. Detrol LA 4 mg. 6. Synthroid 0.05 mg. 7. Dyazide one a day. 8. Protonix 40 mg a day. HABITS: She stopped smoking in the 1980s. She is a widow with two children.
LA|long-acting|LA|132|133|DISCHARGE MEDICATIONS|2. Miconazole powder one spray dermally to affected area b.i.d. 3. Aspirin 81 mg p.o. q.d. 4. Depakote 1.5 gm p.o. q.h.s. 5. Detrol LA 4 mg p.o. q.d. 6. __________ 10 mg p.o. q.d. 7. Pantoprazole 40 mg p.o. q.d. 8. Certagen one tab p.o. q.d. 9. Fluconazole 150 mg p.o. q.d. x 3 days. FOLLOW-UP: The patient is to follow up with his primary physician, Dr. _%#NAME#%_, in three to four days.
LA|long-acting|LA|135|136|CURRENT MEDICATIONS|8. Nexium 40 mg p.o. q.d. 9. Calcium 500 mg p.o. q.d. 10. Senokot S, one tablet b.i.d. 11. Effexor XR (75) two tablets q.d. 12. Detrol LA 4 mg q.d. 13. Metamucil 1 Tbsp q.d. p.r.n. to prevent constipation. 14. Meprobamate 400 mg p.o. t.i.d. p.r.n. for anxiety.
LA|long-acting|LA|176|177|CURRENT MEDICATION|No other complaints. PAST MEDICAL HISTORY: 1) Hypertension. 2) Hypothyroidism. 3) Bilateral cataract extraction. ALLERGIES: PENICILLIN AND CODEINE. CURRENT MEDICATION: Inderal LA 80 mg once a day, Avapro 150 mg once a day, hydrochlorothiazide/triamterene, Synthroid 100 mcg q.d., Claritin-D 24 hour q.d., Zithromax which was started two days ago, aspirin 325 mg q.d. SOCIAL HISTORY: Lives at home.
LA|long-acting|LA|155|156|DISCHARGE MEDICATIONS|CODE STATUS: Full. DISCHARGE MEDICATIONS: 1. Lipitor 10 mg p.o. q.h.s. 2. Macrobid 10 mg p.o. q.day for 3 more days. 3. Avandia 2 mg p.o. q.day. 4. Detrol LA 4 mg p.o. q.day. 5. Tylenol p.r.n. pain. 6. Aspirin 325 mg p.o. q.day. 7. Benicar 20 mg p.o. q.day.
LA|long-acting|LA|157|158|MEDICATIONS|5. Genital herpes. 6. History of suffering kidney failure during hospitalization 1996. MEDICATIONS: 1. Atenolol 50 mg q day. 2. Imitrex 50 mg prn. 3. Detrol LA q day. ALLERGIES: Morphine. PLAN: The patient will be admitted to station 33 for hydration and to check her labs.
LA|long-acting|LA|144|145|DISCHARGE MEDICATIONS|6. Nitroglycerin 0.4 mg p.r.n. 7. Isosorbide mononitrate 150 mg p.o. q.day. 8. Crestor 10 mg p.o. q.day. 9. Diovan 80 mg p.o. q.day. 10. Detrol LA 4 mg p.o. q.day. 11. Metoprolol 50 mg p.o. b.i.d. COMPLICATIONS: No complications.
LA|long-acting|LA|458|459|MEDICATIONS|She has some nausea with Tequin and Levaquin in the past. MEDICATIONS: Lantus 15 units q.h.s., Humalog per scale, Bextra 10 mg a day, albuterol inhaler p.r.n., Astelin nasal spray p.r.n., Avapro 450 b.i.d., Actonel 35 q.weeks, calcium 500 a day, multivitamin daily, aspirin 81 mg one tablet daily, Synthroid 175 mcg daily, Alphagan eye drops, Dyazide one daily, Reglan 5 mg q.i.d., Protonix one daily, estradiol 1 mg daily, vitamin E 400 units daily, Detrol LA 4 mg at h.s., and the meds per urgent care as above. REVIEW OF SYSTEMS: General, the chills as stated above, otherwise negative.
LA|long-acting|LA|396|397|HISTORY OF PRESENT ILLNESS|She will continue her usual medications, which consist of sliding scale insulin, clonazepam 1 mg p.o. q. h.s., Toprol XL 200 mg p.o. h.s., doxazosin 1 mg p.o. q. day, lisinopril 40 mg p.o. q. day, triamterene/hydrochlorothiazide 37.5/25 mg daily, verapamil SR 120 mg p.o. daily, Lantus insulin 50 units q. h.s., her usual sliding scale Lispro insulin, Carafate 1 gram q.i.d. before meals, Detrol LA 2 mg p.o. b.i.d. and Bextra 10 mg p.o. q. day as well as aspirin 81 mg p.o. q. day and she also now has some Percocet to take p.r.n. for pain.
LA|long-acting|LA|152|153|ADMISSION MEDICATIONS|13. Amaryl 1 mg daily. 14. Zoloft 100 mg daily. 15. Advair Diskus 1 puff b.i.d. 16. Aspirin 81 mg p.o. daily. 17. Atenolol 50 mg p.o. daily. 18. Detrol LA 1 daily. 19. Mirapex 0.125 mg p.o. daily. 20. Combivent 2 puffs q.i.d. 21. OxyContin 10 mg q.8 hours. 22. Aricept 5 mg p.o. daily.
LA|left atrial|LA|316|317|HISTORY|On _%#MM#%_ _%#DD#%_, 2005, her INR was 2.6; on _%#MMDD2005#%_ it was 9.8, and on _%#MMDD2005#%_, 1.3. Echocardiogram performed recently at Minnesota Heart Clinic revealed normal LV function with mild concentric left ventricular hypertrophy. Her LV diastolic dimension is 3.4 cm. Her septal dimension is 1.2 cm. Her LA dimension is 4.1 cm. She has moderate aortic regurgitation, moderate mitral regurgitation, with moderate tricuspid regurgitation and moderate pulmonary hypertension with right ventricular systolic pressure elevated to 40-50 mmHg plus right atrial pressure.
LA|long-acting|LA|220|221|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Lantus insulin 30 units daily. 2. Regular insulin per sliding scale. 3. Coumadin, averaging 3 mg daily, for chronic atrial fibrillation. 4. Clonidine as Catapres-TTS-3 once weekly. 5. Diltiazem LA 360 daily. 6. Lopressor (metoprolol) 12.5 b.i.d. 7. PhosLo 667, one with each meal. 8. Nephrocaps, one daily. Primary care will be resumed by his primary physician, _%#NAME#%_ _%#NAME#%_, at Fairview EdenCenter Clinic.
LA|long-acting|LA|114|115|DISCHARGE MEDICATIONS|8. Paxil 40 mg p.o. q. day. 9. Atarax 25 mg p.o. q. day. 10. Enteric coated aspirin 81 mg p.o. q. day. 11. Detrol LA 4 mg p.o. q. day. 12. Albuterol inhaler as needed. 13. Lantus insulin 60 units subcu twice a day. 14. Humalog insulin sliding scale as prescribed. 15. Roxicet elixir 5-10 mL p.o. q.4-6 h. p.r.n. for pain.
LA|long-acting|LA|210|211|CURRENT MEDICATIONS|5. Presumed urge incontinence on medication. 6. Hypertension. 7. Depression and anxiety on Celexa daily. CURRENT MEDICATIONS: 1. Glipizide extended release 5 mg once daily. 2. Digoxin 0.125 mg daily. 3. Detrol LA 2 mg daily. 4. Premarin 0.625 mg daily. 5. Lasix 20 mg daily. 6. Protonix 40 mg daily. 7. Potassium supplement 10 mEq daily.
LA|long-acting|LA|182|183|MEDICATIONS|He takes Coumadin anticoagulation since his CVA. He has gout and takes allopurinol and colchicine. MEDICATIONS: Existing medications include: 1. Lipitor, 20 mg once daily. 2. Detrol LA for bladder control, 4 mg once daily. 3. Effexor XR, 150 mg, one daily with Effexor XR, 75 mg, once daily. 4. Coumadin, 5 mg alternating in a rotation with 7.5 mg with recent increases in his INR.
LA|long-acting|LA|387|388|HISTORY OF PRESENT ILLNESS|_%#NAME#%_ is discharged at this time on bowel medicines including Dulcolax tablets 10 mg and rectal suppositories as necessary, Klonopin 0.5 mg at bedtime, Colace 200 mg twice a day, Lexapro 10 mg a day, Premarin 0.625 mg a day, Neurontin 300 mg 3 time a day. There is ibuprofen 400 mg 3 times a day, betaseron every other day, Provigil 200 mg twice a day, Protonix 40 mg a day, Detrol LA 4 mg a day, and Coumadin. FOLLOW UP: She will follow with me for her intrathecal Baclofen pump and she will need continued followup with Medicine as well for these other medical problems.
LA|long-acting|LA|202|203|PLANS FOR DISCHARGE|She has been able to take soft foods now in the hospital and she will persist with advancing her diet. 2. Asacol 400 mg tablets 2 p.o. t.i.d., K-dur 10 mEq 2 daily, Wellbutrin 150 mg SR 1 daily, Detrol LA 4 mg 1 daily. She will not resume any aspirin or Advil for three days because of a small polyp that was removed at the time of her colonoscopy.
LA|long-acting|LA|153|154|DISCHARGE MEDICATIONS|23) Nystatin topical cream to the corners of the lips twice a day. 24) Lactose bacillus take one capsule 2-3 times a day when on antibiotics. 25) Detrol LA 4 mg p.o. q day. 26) Prilosec 20 mg p.o. q day. 27) Aspirin one p.o. q day. The patient received OT and PT services this admission and those services should continue as an outpatient basis.
LA|long-acting|LA|162|163|PAST MEDICAL HISTORY|He has had surgery on his left knee. He had an appendectomy and herniorrhaphy in the past. Past medical illnesses include hypertension for which he takes Inderal LA and Norvasc. He was also prescribed the Inderal for tremor and he is not sure if this is helping. He has been on Lipitor for hypercholesterolemia, but has not been much in favor of taking it and has been relatively poorly compliant.
LA|long-acting|LA|139|140|MEDICATIONS|ALLERGIES: To codeine. MEDICATIONS: 1. Lipitor 20 mg PO q. day. 2. Lisinopril 20 mg PO q. day. 3. HydroDIURIL 25 mg PO q. day. 4. Cardizem LA 240 mg PO q. day. 5. Allopurinol 100 mg PO b.i.d. PHYSICAL EXAMINATION: On arrival her temperature is 96.7, her BP is 132/64, heart rate 74, respirations 20, 99% sats on room air.
LA|long-acting|LA|150|151|MEDICATIONS|14. Carotid endarterectomy in 1989. MEDICATIONS: 1. Singulair 10 mg daily. 2. Multivitamin. 3. Aciphex 20 mg daily. 4. Flomax 0.4 mg daily. 5. Detrol LA 4 mg daily. 6. Clarinex 5 mg daily. 7. Advair 250/50 one puff b.i.d. 8. Levaquin as above. 9. Xopenex p.r.n. ALLERGIES: CAPOTEN, PENICILLIN, TETRACYCLINE. SOCIAL HISTORY: Smoke: None.
LA|long-acting|LA|247|248|BRIEF HISTORY|BRIEF HISTORY: This is a 67-year-old male with a history of adenocarcinoma of the prostate and is status post radical retropubic prostatectomy. The patient has post-prostatectomy incontinence with a component of urge incontinence. He takes Detrol LA and has an artificial urinary sphincter. In addition, the patient has a 3-piece penile prosthesis placement, with which he is satisfied, after previously having a malleable, which was removed.
LA|long-acting|LA|177|178|HOSPITAL COURSE|She was monitored using the MSFA rating scale with Ativan to cover withdrawal symptoms. On admission, the following medications were reordered: Cymbalta 60 mg daily and Inderal LA 80 mg 1 time daily. She was seen by medical staff and given a dose of potassium as her admission potassium level was low.
LA|long-acting|LA|90|91|OUTPATIENT MEDICATIONS|The patient will contact this office for appointments. OUTPATIENT MEDICATIONS: 1. Inderal LA 80 mg p.o. q. day. 2. Lexapro 10 mg p.o. q. day. 3. Migranal 4 mcg per mL nasal spray as needed for headache.
LA|long-acting|LA|110|111|DISCHARGE MEDICATIONS|4. Spironolactone 50 mg p.o. b.i.d. 5. Protonix 40 mg p.o. q. day. 6. Toprol XL 100 mg p.o. q. day. 7. Detrol LA 2 mg p.o. q. day. 8. Cozaar 50 mg p.o. q. day. 9. Questran 4 gm one packet oral q.i.d. 10. Levofloxacin 250 mg p.o. q. day x14 days. 11. Flagyl 500 mg p.o. t.i.d. x7 days.
LA|long-acting|LA|179|180|DISCHARGE MEDICATIONS|8. Coumadin 7.5 mg today or as adjusted. 9. Prevacid 30 mg per day. 10. Calcium with vitamin D 500 mg b.i.d. 11. Forteo injections 3-cc = 750 mcg subcu every other day 12. Detrol LA 4 mg per day. 13. Colace 100 mg per day. 14. Nitroglycerin 0.4 mg sublingual p.r.n. 15. Claritin 10 mg per day.
LA|long-acting|LA|192|193||Due to the quinolones, his Coumadin will be switched from 5 mg a day to 5 mg alternating with 2.5 mg daily with a re-check in approximately 6-7 days. His other medications such as Propranolol LA 120 mg daily, Ranitidine 150 mg b.i.d., Nasonex 2 sprays in each nostril daily, Metformin 1,000 mg P.O. daily with dinner, lisinopril 20 mg daily, Isordil 10 mg b.i.d., Levothyroxine 0.05 mg daily, Neurontin 300 mg daily will be continued.
LA|long-acting|LA|119|120|MEDICATIONS|6. Prolixin 18.7 mg IM q. 2 weeks. 7. Klonopin 0.5 mg half tab p.o. t.i.d. 8. Gemfibrozil 600 mg p.o. b.i.d. 9. Detrol LA 2 mg p.o. daily. SOCIAL HISTORY: She smokes about a pack a day for "a long time." Denies any alcohol.
LA|long-acting|LA|177|178|HOSPITAL COURSE|His bladder spasms eventually resolved or became minimal on postoperative day #4. The patient was off of his PCA, just taking Tylenol for pain medication. He remained on Detrol LA p.o. for bladder spasms. His 3-way catheter was off of irrigation and remained pink to peach-colored on postoperative day #4.
LA|long-acting|LA|128|129|DISCHARGE MEDICATIONS|4. Spironolactone 100 mg p.o. daily, decreased from previous dose of 200 mg daily. 5. Pantoprazole 40 mg p.o. b.i.d. 6. Inderal LA 60 mg p.o. daily. 7. Hydromorphone 2 mg p.o. q.4-6 h. as needed for pain. FOLLOW UP: With his primary care as needed and with Dr. _%#NAME#%_ as needed.
LA|Los Angeles|L.A.|133|136|SOCIAL HISTORY|SOCIAL HISTORY: The patient is married, does not smoke. May have two or three alcoholic drinks per day. She has recently been on the L.A. Weight Loss Diet and has had a weight loss of perhaps as much as ten pounds in the past three months or so.
LA|long-acting|LA|183|184|HOSPITAL COURSE|During her stay, she complained of urgency and pain. A bladder scan was done as well as having a urology consult. The consult was done by Dr. _%#NAME#%_ _%#NAME#%_. He ordered Detrol LA 4 mg daily to help alleviate any bladder spasms. She was started on Cipro 250 mg twice daily for 7 days. There was a note stating, per Dr. _%#NAME#%_, that the patient had exhibited drug-seeking behaviors before, and he suspected her abdominal pain may be psychiatric in nature.
LA|long-acting|LA|137|138|MEDICATIONS|MEDICATIONS: 1. Atenolol 50 mg p.o. 2. Quinine sulfate 260 mg p.o. daily. 3. Fosamax once a week. 4. Calcium. 5. Multivitamin. 6. Detrol LA 4 mg p.o. q. day. SOCIAL HISTORY: She is a nonsmoker and nondrinker.
LA|long-acting|LA|167|168|DISCHARGING AND TRANSFERRING MEDICATIONS|9. Zofran 4-8 mg p.o. q. 6h. p.r.n. nausea and vomiting. 10. Keppra 250 mg p.o. b.i.d. 11. Zonegran 100 mg p.o. daily. 12. Prenatal vitamin 1 tablet daily. 13. Detrol LA 4 mg daily. 14. Zocor 20 mg p.o. q. p.m. 15. Benadryl 12.5 mg p.o. q. 6h. p.r.n. 16. Percocet 5/325 mg 1-2 tablets p.o. q. 4-6h. p.r.n. pain.
LA|long-acting|LA|159|160|DISCHARGE MEDICATIONS|4. Levaquin 250 mg daily through _%#MMDD2006#%_. 5. Prednisone 20 mg p.o. b.i.d. 6. Lorazepam 1 mg q.i.d. p.r.n. for anxiety. 7. Zoloft 50 mg daily. 8. Detrol LA 4 mg daily for bladder control. 9. Albuterol by neb 2.5 mg q.i.d. p.r.n. for wheezing. 10. Tylenol 350 mg 1-2 tablets q 4 hours p.r.n. for mild pain or fever.
LA|long-acting|LA|166|167|MEDICATIONS|She has been requiring a walker for ambulation. She does have a past history of syncope and then none since being admitted to assisted living. MEDICATIONS: 1. Detrol LA 4 mg at h.s. 2. Tylenol p.r.n. 3. Kay Ciel 20 mEq t.i.d. 4. Prednisone 5 mg daily. 5. Aricept 10 mg daily. 6. Lasix 40 mg once daily.
LA|long-acting|LA|110|111|MEDICATIONS|7. Toprol 25 mg twice a day. 8. Lipitor 10 mg daily. 9. Norvasc 5 mg daily. 10. Lasix 20 mg daily. 11. Detrol LA 4 mg daily. 12. Aspirin 325 mg. 13. Avandia 2 mg. 14. Nitroglycerine as needed. REVIEW OF SYSTEMS: Complete review of systems other than stated in the History of Present Illness is negative.
LA|long-acting|LA|191|192|CURRENT MEDICATIONS|He has no bleeding tendencies. CURRENT MEDICATIONS: 1. Toprol-XL 100 mg daily. 2. Digitek 0.125 mg daily. 3. Coumadin. 4. Multivitamin daily. 5. Folic acid. 6. Crestor 10 mg daily. 7. Detrol LA daily. ALLERGIES: No allergies. FAMILY HISTORY: Brother with diabetes. Another brother with unknown cancer.
LA|long-acting|LA|149|150|MEDICATIONS|2. Atenolol 50 mg daily. 3. Macrodantin 50 mg q.h.s. for urinary tract suppression. 4. Ferrous sulfate one daily. 5. Protonix 40 mg daily. 6. Detrol LA 4 mg at h.s. HABITS: Nonsmoker. No alcohol. SOCIAL HISTORY: Widow. Lives alone in _%#CITY#%_, Minnesota. SYMPTOM REVIEW: At present she denies facial pain subsequent to the above trauma.
LA|long-acting|LA|177|178|DISCHARGE MEDICATIONS|4. Home PT and home RN evaluation. DISCHARGE MEDICATIONS: Home medications: 1. Fosamax 70 mg weekly. 2. Lipitor 10mg nightly. 3. Glucosamine two capsules p.o. q. day. 4. Detrol LA 4 mg p.o. q. day. 5. Sublingual nitroglycerin p.r.n. for chest pain. 6. Tylenol 650 mg q.i.d. p.r.n. 7. Aspirin 81 mg. 8. Glipizide 5 mg p.o. b.i.d.
LA|left atrial|LA|173|174|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Congestive heart failure, thought secondary to chemotherapy. The patient's last echocardiogram, _%#MMDD2006#%_, showed an ejection fraction of 10%, LA size 4.7 cm, severe mitral regurgitation, moderate to severe tricuspid regurgitation, small pericardial effusion and normal pulmonary systolic pressure.
LA|long-acting|LA|124|125|DISCHARGE MEDICATIONS|She is to receive physical and occupational therapy at rehab. DISCHARGE MEDICATIONS: 1. Zocor 20 mg p.o. nightly. 2. Detrol LA 4 mg p.o. daily. 3. Multivitamin 1 tab p.o. daily. 4. Protonix 40 mg p.o. daily. 5. Actos 45 mg p.o. daily. 6. NovoLog 6 units subcutaneously t.i.d.
LA|long-acting|LA|79|80|MEDICATIONS|Patient offers no complaints. ALLERGIES: Penicillin. MEDICATIONS: 1. Glipizide LA 15 mg daily. 2. Metformin 1000 twice daily. 3. Prednisone 10 mg daily. 4. Omeprazole 20 mg each day at bedtime. 5. Senna S 1 tablet daily.
LA|long-acting|LA|171|172|DISCHARGE MEDICATIONS|6. Protonix 40 mg daily. 7. Paxil 50 mg at bedtime. 8. Mirapex 0.25 mg 5 times daily. 9. Seroquel 25 mg every 6 hours as needed for agitation or hallucination. 10. Detrol LA 4 mg daily. 11. Naprosyn 250 mg twice daily. 12. Aztreonam 1 g IV every 12 hours until _%#MMDD2007#%_. 13. Nystatin swish and swallow 5 cc 4 times daily for 5 days.
LA|long-acting|LA|131|132|DISCHARGE MEDICATIONS|6. Namenda 10 mg p.o. b.i.d. 7. Prilosec 20 mg p.o. q. day. 8. Zoloft 50 mg p.o. q. day. 9. Aldactone 25 mg p.o. q.h.s. 10. Detrol LA 4 mg p.o. q. day. 11. Aspirin 81 mg p.o. q. day. DISCHARGE DIET: Dysphagia level 1 diet.
LA|long-acting|LA|149|150|PLAN|For general lab testing, will obtain a sed rate, TSH, B12 level, hemoglobin A1c, and get a fasting lipid profile. For meds, will continue her Detrol LA at 4 mg/day, aspirin 325, Plavix 75, atenolol 25, but add Cozaar 50 mg q. day, and then use the insulin. Will use lotion to her legs and treat the left knee with Keflex 500 mg t.i.d. and also irrigate out the right ear.
LA|long-acting|LA|105|106|MEDICATIONS|2. C-section times one. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Zoloft 50 mg a day. 2. Entex LA one per day. 3. Meclizine 12.5 mg one per day. SOCIAL HISTORY: She occasionally smokes cigarettes, especially if she goes out socially.
LA|long-acting|LA|102|103|MEDICATIONS|She has also had a complete hysterectomy, appendectomy and a right hernia repair. MEDICATIONS: Detrol LA 4 mg daily, Celebrex 200 mg daily, Furosemide 80 mg q.a.m., Lipitor 40 mg q hs, Lopid 600 mg bid, Reglan 5 mg before evening meal, Prevacid 30 mg bid.
LA|long-acting|LA|242|243|DISCHARGE MEDICATIONS|The patient will come back to Emergency Medicine if she has a temperature of 101.5 F or higher, has increased drainage, pain, or swelling around her incision site, or has numbness or weakness in her legs. DISCHARGE MEDICATIONS: 1. Propanolol LA 80 mg p.o. q.d. 2. Allegra one tablet q.a.m. 3. Aspirin 325 mg p.o. q.d. 4. Dyazide 25/37.5 mg p.o. q.d. 5. Fosamax 70 mg p.o. q. week.
LA|long-acting|LA.|216|218|ADMISSION MEDICATIONS|7. History of depression. 8. History of moderate Alzheimer dementia. ADMISSION MEDICATIONS: 1. Prozac. 2. Capoten. 3. Vicodin. 4. Hytrin. 5. Celebrex. 6. Extra-strength Tylenol. 7. Vitamin E. 8. Vitamin C. 9. Detrol LA. 10. (_______________) ALLERGIES: PENICILLIN AND CODEINE. FAMILY HISTORY: Negative for heart disease, stroke, anesthesia reactions.
LA|long-acting|LA|164|165|CURRENT MEDICATIONS|4. Hydrochlorothiazide 50 mg p.o. q.d. p.r.n. 5. Estradiol 2 mg p.o. q.d. 6. Vioxx 25 mg p.o. q.d. 7. Prevacid 30 mg p.o. q.d. 8. Clarinex 5 mg p.o. q.d. 9. Detrol LA 4 mg p.o. q.d. 10. K-Dur 20 mEq p.o. q.d. 11. Calcium + vitamin D (600/200) 1 p.o. t.i.d. 12. Vitamin E 200 units p.o. b.i.d. 13. Centrum one tablet p.o. q.d.
LA|long-acting|LA|138|139|CURRENT MEDICATIONS|5. Albuterol metered dose inhaler two puffs q.i.d. prn. 6. Lisinopril 20 mg daily 7. Atenolol 25 mg daily 8. Multivitamin daily 9. Detrol LA 2 mg daily ALLERGIES: The patient has an allergy to theophylline which causes a rash and shortness of breath.
LA|long-acting|LA|408|409|CURRENT MEDICATIONS|16) Status post dual-chamber pacemaker placement (_%#MM#%_, 2002). 17) Hypothyroidism. 18) Renal insufficiency. CURRENT MEDICATIONS: 1) Avapro 150 mg p.o. q.d. 2) Toprol XL 50 mg p.o. q.d. 3) Lasix 40 mg p.o. q.d. 4) Imdur 30 mg p.o. q.d. 5) Enteric aspirin 81 mg p.o. q.d. 6) Beconase AQ nasal spray one spray to each nostril b.i.d. 7) Guaifenesin 600 mg b.i.d. 8) Multivitamin with iron one q.d. 9) Detrol LA 4 mg q.d. 10) Synthroid 0.05 mg q.d. 11) Zocor 40 mg q h.s. 12) Plavix 75 mg q.d. 13) Nitrostat 0.4 mg sublingual q5 minutes p.r.n. angina.
LA|long-acting|LA|312|313|MEDICATIONS|He has maintained a vigorous lifestyle as a part-time ballroom dance teacher, a business which he and his wife have maintained together. MEDICATIONS: His medication list in addition to the above mentioned recently completed prednisone and melphalan include the following: torsemide 20 mg once a day, propranolol LA 160 mg once a day, amLodipine 10 mg once a day, Protonix 40 mg once a day. PAST MEDICAL HISTORY: The patient's other distant medical history as previously noted includes benign essential tremor for which the beta blocker therapy was primarily prescribed and also longstanding mild hypertension with recent exacerbation.
LA|long-acting|LA|170|171|CURRENT MEDICATIONS|PAST MEDICAL HISTORY: 1. Diabetes mellitus type II. 2. Hypertension. 3. Obesity. CURRENT MEDICATIONS: 1. Glucophage XR 2000 mg q.a.m. 2. Glyburide 9 mg q.a.m. 3. Inderal LA 80 mg q.a.m. 4. Avandia 8 mg q.a.m. 5. Diovan 80 mg with hydrochlorothiazide 12.5 mg q.a.m. 6. Lasix 20 mg q.a.m. 7. Elavil 50 mg q.h.s.
LA|long-acting|LA|139|140|DISCHARGE MEDICATIONS|As he is clinically stable, felt reasonable to discharge the patient back to Trevilla. DISCHARGE MEDICATIONS: Atenolol 50 mg q.d., Humibid LA 1 p.o. b.i.d., Synthroid 0.075 mg q.d., Nizoral cream 2% b.i.d. to facial rash p.r.n. erythema and scaling, Baclofen pump as before, Trileptal 150 mg q.d., prednisone taper beginning with 20 mg daily for 3 days and reducing by 5 mg every 3 days until off, fluid flush of the PEG q.4h. with 250 cc alternating between water and normal saline, gentamicin 420 mg IV through the PICC line on _%#MM#%_ _%#DD#%_, 2003, followed by discontinuation.
LA|long-acting|LA|188|189|MEDICATIONS|10. Aortic sclerosis. 11. Bilateral carpal tunnel MEDICATIONS: Currently 1. Lasix 20 mg PO Q day 2. Plendil 10 mg PO Q day 3. Toprol XL 100 mg PO Q day 4. Tequin 200 mg PO Q day 5. Detrol LA four Q day 6. Synthroid 50 mcg. PO Q day 7. Imdur 30 mg PO Q day 8. Beconase AQ two sprays Q day 9. Aspirin enteric coated 81 mg PO Q day
LA|long-acting|LA|257|258|ASSESSMENT AND PLAN|He has a history of chronic renal insufficiency, some mild hyperlipidemia, status post right carotid endarterectomy in 1999, and some chronic anemia first noted in the spring of 2002. The patient's PRESENT MEDICATIONS ARE: 1. Aspirin 81 mg a day 2. Inderal LA 120 mg a day which he takes for tremor as well as hypertension 3. Avapro 300 mg a day 4. Norvasc 10 mg a day
LA|long-acting|LA|166|167|MEDICATIONS|MEDICATIONS: 1. Estrogen 0.625 mg Q day 2. Pilocarpine eye drops 3. Prednisone 5 mg daily 4. Bactrim single strength one daily 5. Timoptic eye drops b.i.d. 6. Detrol LA 4 mg daily PHYSICAL EXAMINATION: The patient is sitting upright in bed, awake and alert, up and walking about the emergency room without difficulty having just returned from the bathroom.
LA|long-acting|LA|192|193|DISCHARGE DISPOSITION|Will have her receive physical therapy, occupational therapy, and speech therapy. 2. Medications include Celebrex 200 mg daily for hip pain, Lasix 20 mg daily for fluid retention, propranolol LA 60 mg daily for hypertension, Darvocet N-100 one p.o. q.4.h. p.r.n. pain, and aspirin 325 mg daily. Of note, discussion was held with her daughter introducing the idea of resuscitation status.
LA|long-acting|LA,|146|148|DISCHARGE DIAGNOSES|The aortic valve replacement may have been a porcine valve as she was not on anticoagulants. Also, at the time of admission she was taking Detrol LA, and that was stopped in case it was contributing to confusion. Her hospital course was unremarkable. Speech was appropriate at times and inappropriate at other times.
LA|long-acting|LA|153|154|DISCHARGE MEDICATIONS|DISCHARGE DIAGNOSES: 1. Multiple sclerosis. 2. Urge incontinence. 3. Near vision problems. DISCHARGE MEDICATIONS: 1. Medrol taper as directed. 2. Detrol LA 4 mg daily. HISTORY OF PRESENT ILLNESS: This is a 50-year-old black male with a history of multiple sclerosis.
LA|long-acting|LA|182|183|DISCHARGE MEDICATIONS|Abdomen was benign, and lung fields clear. Thought reasonable for discharge back to Trevilla Nursing Home. DISCHARGE MEDICATIONS: 1. Atenolol 50 mg q.day with parameters. 2. Humibid LA per G-tube q12h. 3. Synthroid 0.075 mg q.day. 4. Trileptal 150 mg daily. 5. Nizoral cream 2% to facial rash b.i.d. (seborrheic dermatitis).
LA|Los Angeles|LA|223|224|OPERATIONS/PROCEDURES PERFORMED|No clear portal gastropathy. C) Localized inflammation characterized by congestion (edema) was found in the duodenal bulb. D) Inflammation characterized by erythema was found in the second part of the duodenum. Impression: LA grade D esophagitis. Non-bleeding grade 1 esophageal varices. HISTORY OF PRESENT ILLNESS: This is a 47-year-old gentleman with past medical history significant only for bilateral knee and bilateral shoulder injury secondary to sports, history of kidney stones, and chronic low back pain, who presents to FUMC after leaving Unity Hospital AMA.
LA|long-acting|LA|150|151|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Darvocet for pain. 2. Coumadin as anticoagulant for a couple more weeks. 3. Continue on atenolol 25 mg one b.i.d. 4. Detrol LA 4 mg one q.d. 5. Senokot two tabs po q.h.s. 6. Quinine sulfate 260 mg one or two q.h.s. p.r.n. cramps. 7. Lorazepam 0.5 mg one or two q8 hours p.r.n. tension.
LA|long-acting|LA|153|154|CURRENT MEDICATIONS|3. History of anxiety. 4. History of insomnia. 5. History of diverticulitis, status post partial colon resection (1994). CURRENT MEDICATIONS: 1. Inderal LA 80 mg p.o. q.d. 2. Effexor XR 150 mg p.o. q.d. 3. Zomig 2.5 mg, 1-2 p.o. q.12h. p.r.n. migraine. ALLERGIES: None known. HABITS: The patient is a cigarette smoker, and enjoys lots of caffeine in the form of Mountain Dew.
LA|Los Angeles|LA|202|203|SOCIAL HISTORY|He has two half brothers who have passed away as well as two half sisters who have passed away. SOCIAL HISTORY: The patient is widowed. He lives in an apartment in _%#CITY#%_, Iowa. He was traveling to LA to visit his two daughters and also his grandson and their family. All of his descendants live in California and he was traveling with his two half sisters who live in Iowa.
LA|long-acting|LA|120|121|MEDICATIONS|3. Norvasc 5 mg p.o. q.d. 4. Accupril 20 mg p.o. q.d. 5. Klor-Con 20 mEq p.o. q.d. 6. Aspirin 81 mg p.o. q.d. 7. Detrol LA 4 mg p.o. q.d. 8. Synthroid .05 mg p.o. q.d. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 95.9, blood pressure 172/86, pulse 99, respirations 18, oxygen saturation 95% on room air.
LA|long-acting|LA|130|131|CURRENT MEDICATIONS|8. Cataracts. 9. Lesions to face. CURRENT MEDICATIONS: 1. Anusol topically p.r.n. 2. Bactroban topically to face p.r.n. 3. Detrol LA 2 mg q.d. CURRENT DRUG ALLERGIES: Cortisone, penicillin, erythromycin, flour.
LA|long-acting|LA.|148|150|ASSESSMENT/PLAN|4. History of gastroesophageal reflux disease. Will continue the patient on Protonix. 5. History of migraines. Will keep the patient on her Inderal LA.
LA|long-acting|LA|196|197|DISCHARGE MEDICATIONS|2. Telemetry. 3. Cardiac catheterization. DISCHARGE MEDICATIONS: 1. Enteric coated aspirin 81 mg PO Q day. 2. Metoprolol 50 mg PO b.i.d. 3. Zocor 20 mg PO q hs. 4. Celexa 10 mg PO q hs. 5. Detrol LA 4 mg PO Q day. 6. Hydrochlorothiazide 25 mg PO Q day. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 63-year-old woman whose cardiac risk factors are age, post-menopausal state, hypertension, hyperlipidemia and a family history of coronary artery disease.
LA|long-acting|LA|223|224||A decision was made that a more intensive approach toward her circumstance was necessary and admission was scheduled. She was admitted to the hospital having taken baclofen 20 mg three times a day at home along with Detrol LA 4 mg b.i.d., Tenormin 25 mg a day, and Betaseron. Neurologically she appears alert, oriented, and cooperative. Examination of the cranial nerves reveal the fields to be full.
LA|long-acting|LA|126|127|MEDICATIONS|MEDICATIONS: 1. Prednisone 5 mg p.o. daily. 2. Bactrim SS 1 tablet p.o. daily. 3. Spironolactone 50 mg p.o. b.i.d. 4. Inderal LA 60 mg p.o. daily. 5. Sodium bicarbonate 1.3 gm p.o. b.i.d. 6. Prilosec 20 mg p.o. daily. 7. Oxycodone 5-10 mg p.o. q. 4-6h. p.r.n. for pain.
LA|Los Angeles|LA|145|146|HOSPITAL COURSE|The patient also had issues with fullness, belching, and epigastric pain with eating. An esophageal gastroduodenoscopy was obtained which showed LA grace C reflux esophagitis with normal stomach and duodenum. She was therefore started on Protonix to help with her gastroesophageal reflux disease.
LA|long-acting|LA.|184|186|REQUESTING PHYSICIAN|She did improve in the emergency room and was admitted for further observation. The patient is on multiple medications for her medical problems including: 1. Spironolactone. 2. Detrol LA. 3. Aricept. 4. Baclofen. 5. Furosemide. 6. Relafen. 7. Lanoxin. 8. Lisinopril. 9. Coreg. 10. Fosamax. 11. Coumadin. 12. Calcium. 13. Multivitamins. She lives with her husband in her _%#CITY#%_ home.
LA|long-acting|LA|148|149|MEDICATIONS|PAST MEDICAL HISTORY: The patient has a history of diabetes mellitus, trochanteric bursitis, and a left leg fracture. MEDICATIONS: She is on Detrol LA for 4 mg q.d., Vioxx one tablet q.d. p.r.n., Fosamax, Glucotrol XL, Glucophage, Roxicet. ALLERGIES: There are no known drug allergies. PERSONAL HISTORY: No significant history of smoking or drinking.
LA|long-acting|LA|113|114|MEDICATIONS ON ADMISSION|5. Lisinopril 10 mg daily. 6. She was supposed to be on Lexapro for depression but does not take this. 7. Detrol LA 4 mg daily. PAST MEDICAL HISTORY: 1. Status post cholecystectomy. 2. Status post hysterectomy. 3. History of Paget's disease.
LA|long-acting|LA|139|140|PLAN|Decreased ADL. Pain control. Equipment needs and safety of gait. PLAN: Admit to acute rehab for PT and OT evaluation and treatment. Detrol LA 4 mg per day. Check hemoglobin. Hematocrit was 9.4/27.1 on _%#MMDD2006#%_ with transfusion below 9 hemoglobin, check UC. Likely stay 1 to 2 weeks. PROGNOSIS: Good.
LA|Los Angeles|LA|248|249|HISTORY OF PRESENT ILLNESS|Her primary care provider is _%#NAME#%_ _%#NAME#%_, PA-C She describes a lifelong struggle with her weight, where she has had multiple attempts for weight loss including working with a dietitian, doing exercise programs, long time history of using LA weight loss and even trying medications in the past. All of her attempts for weight loss have failed.
LA|long-acting|LA|173|174|MEDICATIONS|Recurrent urinary tract infections, Parkinson's, osteoporosis, abnormal chest x-ray and GERD. MEDICATIONS: 1. Carbidopa/levodopa 25/100. 2. Mirapex 0.25 mg t.i.d. 3. Detrol LA 4 mg daily. PAST SURGICAL HISTORY: Vaginal hysterectomy, breast biopsies, left eye surgery.
LA|long-acting|LA,|232|234|MEDICATIONS|She is status post a hip fracture with open reduction and internal fixation, and as stated above, bladder surgery and a hysterectomy. MEDICATIONS: On transfer from the nursing home, her medications included Amaryl, atenolol, Detrol LA, Paxil, Premarin, ferrous sulfate, Tylenol, Os-Cal + vitamin D (1 tablet t.i.d.), Remeron, Zyprexa, Coumadin. ALLERGIES: Penicillin, tetracycline, Haldol. FAMILY HISTORY: There is no family history of end-stage renal disease.
LA|long-acting|LA,|250|252|MEDICATIONS ON ADMISSION|9. Mitral valve prolapse. 10. Chest pain of variable frequency, but unclear to the patient whether this represents GI or cardiac trouble. 11. Dyspnea on exertion at about one-half block. MEDICATIONS ON ADMISSION: Synthroid, Lanoxin, aspirin, Inderal LA, Combivent, albuterol, Atrovent. REVIEW OF SYSTEMS: As above. PHYSICAL EXAMINATION: GENERAL: The patient is a thin, elderly, somewhat uncomfortable- appearing woman, lethargic presumably from morphine, but conversant and oriented.
LA|long-acting|LA|214|215|CURRENT MEDICATIONS|His generalized dermatitis is as severe as ever. He has been admitted for further evaluation of these various problems. CURRENT MEDICATIONS: His current medication list includes: 1. Allegra 180 mg daily. 2. Detrol LA 4 mg daily. 3. Furosemide 40 mg daily. 4. Folic acid 1 mg daily. 5. Prevacid 30 mg daily. 6. Norvasc 5 mg daily. 7. Hydroxyzine 25 mg daily.
LA|long-acting|LA|135|136|MEDICATIONS|She quit smoking six to seven years ago. She drinks one shot of whiskey with a manhattan every night. No drugs. MEDICATIONS: 1. Detrol LA 4 mg every night. 2. Fosamax 70 mg a week. 3. Prinivil 5 mg a day. 4. Amitriptyline 2.5 mg every night. 5. Nexium 40 mg po every day.
LA|long-acting|LA|120|121|HISTORY OF PRESENT ILLNESS|She will often have a sudden urge to void and be unable to make to the bathroom in time. She has been started on Detrol LA 4 mg a day in the past, but unfortunately could not tolerate that due to severely dry mouth. She denies having any loss of control of urine associated with coughing, sneezing, or lifting.
LA|left atrial|LA|188|189|PHYSICAL EXAMINATION|EKG shows sinus rhythm, low voltage, right axis deviation and also QRS morphology consistent with RVH. Chest x-ray showed very generous cardiomegaly and both RV and LV enlargement, RA and LA enlargement and also interstitial marker was increased. Her echo showed mild LV enlargement with ejection fraction 40% with a diffuse hypokinesis.
LA|long-acting|LA|116|117|MEDICATIONS|1. History of asthma which is primarily exercise-induced. 2. History of migraine headaches. MEDICATIONS: 1. Inderal LA 80 mg b.i.d. 2. Prednisone 60 mg daily. 3. Zithromax which she is completing today. 4. Vistaril p.r.n. 5. Fluocinonide ointment to the hands and feet. ALLERGIES: No known drug allergies.
LA|long-acting|LA|146|147|OUTPATIENT MEDICATIONS|2. Metoprolol 100 mg p.o. b.i.d. 3. Lexapro. 4. Lisinopril 20 mg p.o. daily. 5. Glyburide 5 mg p.o. b.i.d. 6. Norvasc 10 mg p.o. daily. 7. Detrol LA 4 mg p.o. daily. 8. Potchor (?) 10 mEq CR 2 tablets p.o. daily. 9. Lasix 80 mg 2 tabs p.o. b.i.d. 10. FOLTX 1 tab p.o. q.a.m.
LA|Los Angeles|LA|118|119|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: The patient has experienced a 97- pound weight loss over the last 10 months, which she did through LA Weight Loss. The patient complains of bilateral ear pain for the last several days. The patient also complains of mild nasal congestion for the past several days.
LA|long-acting|LA|182|183|CURRENT MEDICATIONS|2. Sleep apnea. 3. Hysterectomy secondary to endometriosis. 4. Migraine headaches. 5. Rosacea. 6. Hypercholesterolemia. CURRENT MEDICATIONS: 1. Lipitor 10 mg p.o. q. day. 2. Inderal LA 160 mg p.o. q. day. 3. Asacol 800 mg p.o. b.i.d. 4. Prilosec 20 mg p.o. q. day. 5. Zoloft 200 mg p.o. q.h.s. 6. Lutimel 325 mg p.o. q.h.s. for depression.
LA|long-acting|LA|289|290|CURRENT MEDICATIONS|She is tolerating PT and OT quite well. PAST HISTORY: Significant for hypertension, DJD and osteoporosis. ALLERGIES: PENICILLIN, AMOXICILLIN AND SULFA. CURRENT MEDICATIONS: Lovenox subcu q 12 hours, Estrace .5 mg po q d, Hydrochlorothiazide 25 mg po q day, Lisinopril 10 mg po bid, Detrol LA 4 mg po q p.m., Vanco prophylactically. SOCIAL HISTORY: She lives with her husband. She denies any tobacco or alcohol use.
LA|long-acting|LA|296|297|REFERRING PHYSICIAN|It was 1.96 on _%#MMDD#%_ and on _%#MMDD#%_ was 2.95. Her exact discharge dose of Coumadin was not stated but the patient does recall that she is very sensitive to Coumadin and her usual dose is approximately 1.5 mg per day. In addition, I did find of note that the patient was started on Detrol LA for irritable bladder. She had not previously been on this medication before and this can increase the INR value. Also, she was given an orthopedic brace for her back and she indicated that this was quite uncomfortable, causing a large bruise on her abdominal wall and that it was digging into her groin area.
LA|long-acting|LA|362|363|IMPRESSION|Urine culture showed greater than 10 of the 5th colonies of mixed gram positive flora, probable contaminant, white count 4.3, hemoglobin 12.3, hematocrit 36.3. Electrolytes were normal, BUN 11, creatinine 0.67. IMPRESSION: Overactive bladder with neurogenic bladder causing symptoms of urgency, frequency, and nocturia. She is unresponsive to Oxytrol and Detrol LA and possibly even Ditropan. PLAN: I would recommend switching her from Oxytrol to Vesicare 5 mg p.o. every day for the next 2 weeks and then increasing the dose to 10 mg a day.
LA|Los Angeles|LA|184|185|HISTORY OF PRESENT ILLNESS|The patient describes a lifelong struggle with her weight. She has had attempts for weight loss including structured programs such as Weight Watchers and Jenny Craig and most recently LA Weight Loss. She has tried Nutri-Systems in the past. She has done over-the-counter diets. She has tried medications such as Meridia and Xenical and phentermine.
LA|long-acting|LA|243|244|MEDICATIONS|She denies abdominal pain and change in bowel habits. MEDICAL HISTORY: Primarily remarkable for psychiatric concerns. MEDICATIONS: Medications are supposed to be Prozac 60 mg a day, Abilify 50 mg twice a day, Depakote 1250 mg at h.s., Inderal LA 160 mg a day, Seroquel 100 mg twice a day on a p.r.n. basis. ALLERGIES: Haldol causes dystonia. SOCIAL HISTORY: _%#NAME#%_ lives with her mother and brother.
LA|long-acting|LA|233|234|CURRENT MEDICATIONS|The nature of this disorder is not known. He does have a past history of alcoholism with incarceration for a DWI. CURRENT MEDICATIONS: Mr. _%#NAME#%_ is on Abilify, pyridium, Pregabalin, p.r.n. Compazine and Zofran, Protonix, Detrol LA 4 mg capsules, Cymbalta and MiraLax for constipation. In addition he is on a variety of pain medications including Oxycodone CR, fentanyl patch, ketoprofen topical, tramadol, as well as antibiotics, at the present time Zosyn, combination of piperacillin and tazobactam.
LA|long-acting|LA|218|219|RECOMMENDATIONS|Additionally we will use an indwelling Foley catheter for the first 2-3 days after surgery removing the catheter and attempting to have the patient empty her bladder on her own. The patient also has a supply of Detrol LA and will utilize this should she experience significant urgency after discharge from the hospital. Dry mouth and dry eyes have been discussed with her.
LA|Los Angeles|LA|150|151|HISTORY OF PRESENT ILLNESS|The balance of her health history is unremarkable. As indicated, she has had a 90-pound weight loss intentionally over the past seven months with the LA Weight Loss system, which is basically dietary. She is not having any other systemic complaints in any other systems reviewed.
LA|Los Angeles|LA|251|252|HISTORY OF PRESENT ILLNESS|She describes a lifelong struggle with her weight where she has had multiple attempts for weight loss including exercise, low carb diets, and over-the-counter supplements. She has also tried structured weight loss programs such as Weight Watchers and LA Weight Loss. All of her personal attempts for weight loss have failed. PAST MEDICAL HISTORY: 1. Back and knee pain. 2. Shortness of breath with activity attributed to her weight.
LA|long-acting|LA|114|115|MEDICATIONS|4. Prozac 40 mg a day. 5. Levoxyl 0.025 mg a day. 6. Zantac 150 mg twice a day. 7. Prazosin 2 mg a day. 8. Detrol LA 4 mg a day. 9. Lasix 40 mg twice a day. 10. Keppra 250 mg at h.s. 11. Lactulose 2 teaspoons twice a day.
LA|long-acting|LA|285|286|RECOMMENDATIONS|In addition, her renal ultrasound does show some mild dilatation of the left collecting system which may or may not be significant and perhaps later this can be followed up with an IVP. If her bladder spasm has become problematic then bladder antispasmodic using Ditropan XL or Detrol LA could be utilized. I discussed this with the patient and she seems to be in agreement. If Sister _%#NAME#%_ is not available, then urodynamics could be scheduled at our office.
LA|long-acting|LA|151|152|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1) Lasix 40 mg p.o. q.d. 2) Aspirin 81 mg p.o. q.d. 3) Avapro 150 mg p.o. q.d. 4) Ativan. 5) Synthroid 0.1 mg p.o. q.d. 6) Detrol LA 4 mg p.o. q.d. 7) Lomotil 2.5 mg p.o. q.i.d. 8) Zoloft 50 mg p.o. q h.s. SOCIAL HISTORY: The patient lives in a senior housing condominium.
LA|long-acting|LA|320|321|MEDICATIONS|MEDICATIONS: On admission, the patient's medications were N insulin 50 units q.a.m. and 46 units q. evening (the patient says the evening dose is 14 units), R insulin 14 units b.i.d., metformin 850 mg b.i.d., hydrochlorothiazide 25 mg q.d., Zoloft probably 50 mg q.d., Fosamax 70 mg q. week, Protonix 40 mg q.d., Detrol LA 4 mg q.d. Since admission, the patient has been receiving Celebrex, regular insulin, hydrochlorothiazide, Lasix, ceftriaxone, aspirin, metoprolol, Protonix, isosorbide, metformin, Tylenol #3.
LA|long-acting|LA|135|136|MEDICATIONS|6. Geodon 80 mg p.o. b.i.d. 7. Synthroid 0.075 mg p.o. q.a.m. 8. Claritin 10 mg p.o. q.a.m. 9. Trazodone 300 mg p.o. q.h.s. 10. Detrol LA 4 mg p.o. q.a.m. 11. Protonix 40 mg p.o. q.a.m. 12. Nicotine patch 21 mg q.a.m. ALLERGIES: Penicillin, sulfa, morphine, and codeine.
LA|long-acting|LA|265|266|MEDICATIONS|9. The patient denies history of myocardial infarction, CVA, asthma, emphysema, kidney stones, pulmonary embolus or deep venous thrombosis. MEDICATIONS: Synthroid, Miacalcin, Prevacid, Lotensin, Neurontin, erythromycin, Lexapro, Celebrex, Colace, vitamin E, Detrol LA 4 mg q.d., HypoTears, Prilosec, lisinopril, Aricept 5 mg p.o. q.h.s., calcium, MVI, one baby aspirin q.d. ALLERGIES: None. PAST SURGICAL HISTORY: 1. Bilateral cataract extraction. 2. Spinal stenosis surgery.
LA|long-acting|LA,|186|188|MEDICATIONS|5. Status post tonsillectomy and adenoidectomy. 6. Status post left carpal tunnel release. MEDICATIONS: Requip. Rimantadine. Sinemet. Stalevo. Clonazepam. Methocarbamol. Effexor. Detrol LA, discontinued on _%#MMDD2005#%_. TUMS. Clarinex. Senna. Colace. Ibuprofen. Junel (estrogen). Levaquin. ALLERGIES: No known drug allergies. LABORATORY DATA: Urine culture on _%#MMDD2005#%_ showed a pansensitive E coli 10-50,000 colonies.
LA|long-acting|LA|186|187|MEDICATIONS|1. Warfarin. 2. Propranolol 40 mg. 3. Celexa 40 mg. 4. Clonazepam 0.5 mg q.p.m. for restless legs. 5. Testosterone 2 percent ointment. 6. Premarin. 7. Lovastatin. 8. Nasonex. 9. Inderal LA 100 mg. 10. Migranal 4 mg. 11. Trazodone. 12. Clarinex. 13. Imitrex 25 mg. 14. Celexa 40 mg. 15. Nystatin. 16. Albuterol. REVIEW OF SYSTEMS: Notable for the patient feeling that her migraines are usually well controlled with a current regimen as she has been using less than 10 Imitrex a month.
LA|long-acting|LA|167|168|MEDICATIONS|6. Stress incontinence. MEDICATIONS: 1. Tylenol Arthritis 650 mg b.i.d. 2. Ecotrin aspirin 325 mg Q day. 3. Multi vitamin Q day. 4. Triamterene 75 mg Q day. 5. Detrol LA 4 MG Q day. 6. Paroxetine 20 mg for depression. 7. Zocor 10 mg Q day for cholesterol. 8. Indomethacin 25 mg Q day (anti-inflammatory). 9. Fosinopril 10 mg Q day blood pressure prophylaxis.
LA|long-acting|LA|125|126|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1. Folic acid 1 mg once a day. 2. Phenobarbital 100 mg b.i.d. 3. Dilantin 300 mg p.o. b.i.d. 4. Inderal LA 60 mg once a day. 5. Vitamin B2 400 mg p.o. once a day. 6. Vicodin 5/500 - two tablets that were given at 0400 today and at 1400 today so she uses about 4-6 Vicodin per day, usually about 4, and yesterday had some at 1900.
LA|long-acting|LA|175|176|PLAN|3. Folate 1 mg q day. 4. Thiamine 100 mg q day X3, with MSSA withdrawal protocol. 5. Push fluids. 6. Z-pack for bronchitis. 7. Atrovent metered-dose inhaler p.r.n. 8. Humibid LA one b.i.d. to help loosen/promote secretion clearance. 9. Recommendation to patient on smoking reduction/cessation. 10. Clinical observation. Thank you for the consultation.
LA|Los Angeles|L.A.|358|361|HISTORY OF PRESENTING PROBLEM|HISTORY OF PRESENTING PROBLEM: _%#NAME#%_ _%#NAME#%_ is a 31-year-old Caucasian female who has been referred to our program from her primary care _%#NAME#%_ _%#NAME#%_, Nurse practitioner. The patient describes a 25 year struggle with obesity where she has had multiple attempts for weight loss including Weight Watcher's twice, New Day Weight Loss Program, L.A. Weight Loss Program, prescription medications such as Xenical and exercise programs to try to loose weight. She has even met with a dietician over a year's time to aid in her weight loss attempts, however, all of her attempts for permanent weight loss have failed.
LA|long-acting|LA|147|148|MEDICATIONS PRIOR TO ADMISSION|MEDICATIONS PRIOR TO ADMISSION: 1. Plavix 75 mg daily 2. Aspirin 81 mg daily 3. The patient had been on Bactrim for a bladder infection and Detrol LA to help with urinary urgency and incontinence. REVIEW OF SYSTEMS: Now the patient denies headache. She states that she has some chronic backache from arthritis.
LA|long-acting|LA|259|260|CURRENT MEDICATIONS|Mr. _%#NAME#%_ is an accountant working for an accounting firm. _%#NAME#%_ is on maternity leave at this time, but works in the retirement division of Wells Fargo. CURRENT MEDICATIONS: Mr. _%#NAME#%_ is on copaxone, which he takes daily. He also is on Detrol LA 4 mg at night. NEUROLOGIC EXAMINATION: HEENT/NECK: No masses or tenderness. Carotids were equal bilaterally without bruits.
LA|long-acting|LA|169|170|MEDICATIONS|She has never had a formal coronary artery assessment. Per the chart, there is a history of chronic incomplete right bundle branch block by EKG. MEDICATIONS: 1. Ritalin LA 20 mg each morning and 5 mg q.i.d. on a p.r.n. basis. 2. Provigil 200 mg t.i.d. 3. Effexor XR 225 mg once a day.
LA|long-acting|LA|124|125|MEDICATIONS|6. Miacalcin nasal spray 200 units daily. 7. Atenolol 50 mg a day. 8. Lipitor 40 mg a day. 9. Imdur 30 mg a day. 10. Detrol LA 5 mg a day. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Diabetes mellitus type 2. 4. Neuropathy, likely secondary to diabetes.
LA|long-acting|LA|129|130|PLAN|4. Increased urinary urgency with occasional secondary incontinence, most likely secondary to urge incontinence. PLAN: 1. Detrol LA 4 mg p.o. daily. 2. Claritin 10 mg p.o. daily. 3. Ibuprofen 600 mg p.o. q.6 h. p.r.n. pain. 4. Topical Nizoral 2% shampoo to be applied to scalp with every shower as needed.
LA|long-acting|LA|154|155|MEDICATIONS|She also has had a previous upper GI endoscopy. MEDICATIONS: Her medications at the time of admission included: 1. Premarin 0.625 mg daily 2. Propranolol LA 80 mg daily 3. Hydrochlorothiazide 25 mg daily 4. Norvasc 10 mg daily 5. K-Dur 20 mEq daily 6. Lorazepam 0.5 mg at bed-time and q 8 hours p.r.n.
LA|long-acting|LA|166|167|MEDICATIONS|8. .......psoriasis affecting the right upper extremity. MEDICATIONS: 1. Gamma globulin infusions. 2. Betaseron 0.3 IM q.o.d. 3. Baclofen 10 mg p.o. q.i.d. 4. Detrol LA 4 mg p.o. b.i.d. 5. Ecotrin 325 mg daily. 6. Lisinopril 2.5 mg daily. 7. Provigil 200 mg p.o. b.i.d. 8. Synthroid 50 mcg daily. 9. Senokot p.r.n. 10. Solu-Medrol 500 mg IV daily over 1 hour.
LA|long-acting|LA|185|186|PLAN|If not, then we would wait on that and start Cipro once he has finished the linezolid. He should continue the Flomax 0.4 mg p.o. every day. In addition, I would recommend adding Detrol LA 4 mg a day for the urinary frequency. I have also ordered a helical CT scan of the abdomen and pelvis to get a better look at the stone, as well as a KUB x-ray.
LA|long-acting|LA|164|165|OUTPATIENT MEDICATIONS|4. Lipitor 40 mg p.o. daily. 5. Colace 100 gm p.o. daily. 6. Aspirin 325 mg p.o. daily. 7. Synthroid 0.125 mg p.o. daily. 8. Seroquel 400 mg p.o. q.h.s. 9. Inderal LA 80 mg p.o. daily. 10. Celexa 120 mg p.o. daily. 11. Benadryl 25-50 mg p.o. t.i.d. p.r.n. 12. Carafate 1 tablet p.o. q.i.d. p.r.n. 13. Zyban 150 mg p.o. b.i.d. ALLERGIES: Amoxicillin.
LA|Los Angeles|LA|216|217|HISTORY OF PRESENT ILLNESS|The patient recently fractured her ankle and had pins and plates placed and recently had then removed on _%#MMDD2006#%_. Because of her injury, she was unable to work. She usually works as a weight loss counselor at LA Weight Loss. Prior to that, she was a nutrition counselor. Because of her ankle, she was not able to work out as much and, therefore, has gained a significant amount of weight.
LA|long-acting|LA|165|166|MEDICATIONS|2. History of post herpetic neuralgia in the right thorax. 3. Urinary incontinence 4. Osteoporosis MEDICATIONS: On admission 1. Fosamax 70 mg p.o. weekly. 2. Detrol LA 4 mg p.o. daily 3. Mestinon 60 mg in the morning, 30 mg in the afternoon and bedtime 4. Primidone 25 mg daily Since the patient has been hospitalized, she has been on aspirin suppository as well as various eye drops as she was taking for her glaucoma which include Alphagan and Cosopt.
LA|long-acting|LA|167|168|MEDICATIONS|MEDICATIONS: Present medications include: 1. Seroquel 50 mg p.o. t.i.d. p.r.n. 2. Effexor 225 mg q.h.s. 3. Combivent two puffs t.i.d. 4. DDAVP 0.1 mg q.h.s. 5. Detrol LA 4 mg daily. 6. Seroquel 200 mg p.o. b.i.d. 7. Lamictal 25 mg q.h.s. 8. Senna S up to two tablets daily. 9. Piroxicam 20 mg q.h.s.
LA|Louisiana|LA|179|180|PLAN|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, MD Our Lady of the Lakes Regional Center _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_ _%#CITY#%_, LA _%#70800#%_ Dear Dr. _%#NAME#%_ and Dr. _%#NAME#%_: I am pleased to report that _%#NAME#%_ _%#NAME#%_ is doing much better.
LA|long-acting|LA|120|121|MEDICATIONS|8. Protonix 40 mg once a day. 9. Deltasone 60 mg once a day. 10. Senokot 1 b.i.d. 11. Zocor 20 mg every p.m. 12. Detrol LA 2 mg once a day. 13. Vancomycin 1200 mg IV every 24 hours. ALLERGIES: Penicillin and sulfa. REVIEW OF SYSTEMS: CONSTITUTIONAL: No weight loss and he has been eating well.
LA|long-acting|LA.|266|268|REVIEW OF SYSTEMS|States that she had a low-grade fever yesterday. She states that prior to admission yesterday she presented in the emergency room and had a Rapid Strep test done. Denies knowing the result. Nonetheless states that she was given a one-time only injection of Bicillin LA. The patient also admits to developing a rash on her abdomen as well as in her thighs, prior to receiving the antibiotic yesterday.
LA|long-acting|LA|188|189|PAST MEDICAL HISTORY|She has had diverticulosis. She has a paralyzed right hemidiaphragm and is status post right shoulder arthroscopy. She takes Lipitor for hypercholesterolemia, Avandia for diabetes, Detrol LA for overactive bladder and severe urinary frequency. FAMILY AND SOCIAL HISTORY: Please see dictated history and physical.
LA|Los Angeles|LA|170|171|HISTORY OF PRESENT ILLNESS|She describes a 15 year struggle with her weight which began after thyroid cancer. She has attempted many programs for weight loss including Weight Watchers three times, LA Weight Loss. She has been prescribed medications and many over the counter diets. All of these have failed for her to lose permanent weight.
LA|long-acting|LA|275|276|ADMISSION MEDICATIONS|Along with that he was placed on cimetidine 300 mg p.o. t.i.d., temazepam 30 mg p.o. q.h.s., and Maalox Plus oral suspension 30 mg p.o. p.r.n. for dyspepsia. These are all per Dr. _%#NAME#%_ to deal with the side affects of the dexamethasone. In addition, he has Tolterodine LA 4 mg p.o. daily. ALLERGIES: Avonex gives him a very high fever and allergy to chocolate.
LA|long-acting|LA|118|119|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1. Lisinopril 10 mg a day. 2. Hydrochlorothiazide 25 mg a day. 3. Flomax 0.4 mg a day. 4. Detrol LA 1 a day. 5. It is not clear to me if the patient received Lisinopril or hydrochlorothiazide on the morning of surgery.
LA|long-acting|LA|184|185|PRESENT MEDICATIONS|4. Maalox p.r.n. 5. Trilafon 2 mg b.i.d. 6. Baclofen 10 mg q.i.d. 7. Bupropion SR 150 mg b.i.d. apparently started for smoking cessation. 8. Divalproex EC 500 mg daily. 9. Tolterodine LA 4 mg daily. 10. Atacand 2 mg daily. 11. Macrobid 100 mg b.i.d. x 10 days started at home on _%#MMDD2003#%_ presumably for urinary tract infection.
LA|long-acting|LA,|176|178|MEDICATIONS|PAST MEDICAL HISTORY: Status post hysterectomy, status post total knee replacement, status post ankle replacement and status post hip replacement. MEDICATIONS: Lipitor, Detrol LA, Prilosec, carbidopa/levodopa, Synthroid, hydrochlorothiazide and Humulin insulin, also metformin. ALLERGIES: None FAMILY HISTORY: Parents both deceased of old age in their 80s.
LA|long-acting|LA,|121|123||I discussed her current symptoms. She has not had a trial of Detrol or Ditropan. For this reason I started her on Detrol LA, one daily. Bladder scan and postvoid residual can be done on a p.r.n. basis.
LA|long-acting|LA|195|196|CURRENT MEDICATIONS|4. Urinary incontinence. PAST SURGICAL HISTORY: Significant for a vein stripping in 1973. CURRENT MEDICATIONS: 1. Aspirin 81 mg a day. 2. Atenolol 25 mg. 3. Calcium. 4. Centrum Silver. 5. Detrol LA 4 mg daily. 6. Furosemide 20 mg a day. 7. Lovastatin 20 mg at dinner. 8. Norvasc 5 mg daily. 9. Plavix 75 mg daily.
LA|long-acting|LA|138|139|MEDICATIONS|2. Methotrexate 25 mg weekly. 3. Sulindac. 4. Protonix. 5. Premarin. 6. Fluoxetine. 7. Norflex. 8. Imitrex. 9. Vistaril p.r.n. 10. Detrol LA 2 mg daily. 11. Atenolol daily. 12. Toradol p.r.n. 13. Clindamycin 300 mg every 6 hours. 14. Midrin p.r.n. 15. Oxycodone for pain control recently. 16. Lasix 20 mg daily.
LA|long-acting|LA.|197|199|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: 1. Status post left total knee arthroplasty, postop day #1. Plan per Dr. _%#NAME#%_. 2. Hypertension; will restart Cartia XT. 3. Urinary urge incontinence; will restart Detrol LA. 4. Hypercholesterolemia; will restart Vytorin. 5. The patient will be followed by the hospitalist in the morning and further recommendations made as per the clinical situation.
LA|long-acting|LA|120|121|MEDICATIONS|10. Compazine 10 mg t.i.d. 11. Singulair 10 mg daily. 12. Aciphex 20 mg b.i.d. 13. Synthroid 0.175 mg daily. 14. Detrol LA 4 mg daily. 15. Seroquel 400 mg in the morning and 800 mg in the evening. 16. Cogentin 1 mg t.i.d. 17. Flonase nasal spray.
LA|long-acting|LA|188|189|OUTPATIENT MEDICATIONS|4. The patient denies sexually transmitted diseases, hypertension, seizures, heart disease, or other significant medical problems. OUTPATIENT MEDICATIONS: 1. Ativan. 2. Cylert. 3. Inderal LA 60 mg p.o. q.a.m. 4. Birth control pills 1 tablet p.o. q.a.m. ALLERGIES: No known drug allergies. FAMILY HISTORY: Remarkable for diabetes in the patient's father and paternal grandfather.
LA|long-acting|LA|114|115|MEDICATIONS|2. Sinemet 25/100 two tabs every two hours during the day 3. Parlodel 5 mg two tablets four times a day 4. Detrol LA 4 mg daily 5. Seroquel 25 mg two tablets at HS. ALLERGIES: None Smoke - none. Alcohol - none. SOCIAL HISTORY: He is married, retired from IBM.
LA|left atrial|LA|187|188|HISTORY OF PRESENT ILLNESS|REQUESTING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_. CHIEF COMPLAINT: Diarrhea. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 82-year-old white female who underwent closure of PFO, LA appendage, mitral valve repair and repair of mid ventricular rupture on _%#MMDD#%_. The post-a course was complicated by a transient thrombocytopenia. The patient did receive Cephalosporin intravenously perioperatively.
LA|long-acting|LA.|139|141|PLAN|I think by that time, hopefully, her bladder symptoms should be settled down. If not, you could try an antispasmodic agent, such as Detrol LA. I would recommend continuing the antibiotics, however, for a full 7 days. If urinary urgency and frequency symptoms continue to be unmanageable, then I think certainly an indwelling Foley catheter would be the best option.
LA|Los Angeles|LA|194|195|HISTORY OF PRESENTING PROBLEM|She describes a life-long struggle with her weight where she has had multiple attempts for weight loss including seeing dietitians, over-the-counter weight loss guidelines. She has also been to LA Weight Loss Structured Program to try to lose weight. All of her attempts for weight loss have failed.
LA|long-acting|LA|186|187|PLAN|2. Encourage p.o. fluids. 3. To ensure no ill effect from the above overdose will recheck liver profile on _%#MMDD#%_ in addition to a follow-up serum sodium. 4. Adjust Inderal to 60 mg LA daily. 5. Excedrin Migraine 1 to 2 tabs q.6 hours p.r.n. 6. Clinical observation. Thank you for the consultation. Will follow along as indicated.
LA|long-acting|LA.|207|209|CURRENT ADMISSION MEDICATIONS|The patient's admission history and physical by Dr. _%#NAME#%_ _%#NAME#%_ was reviewed and I also did discuss this case with Dr. _%#NAME#%_ last evening. CURRENT ADMISSION MEDICATIONS: 1. Humalog. 2. Lantus LA. 3. Prozac 20 daily. 4. Levaquin 500 mg daily. 5. OxyContin extended-release 60 mg every 12 hours and Dilaudid 4 mg on a p.r.n. basis.
LA|long-acting|LA|197|198|IMPRESSION|I will recommend discontinuing the alcohol withdrawal protocol and start her on Ativan 1 mg p.o. q. 8 hours and use Ativan 1 mg IV q. 4 hours p.r.n. for agitation. I will also start her on Inderal LA 60 mg p.o. q.d. for essential tremors. She does not want to take Celexa, and I will put her back on Lexapro 2 mg p.o. q.d.
LA|long-acting|LA.|173|175|MEDICATIONS ON ADMISSION|15. Chronic cough. 16. Chronic allergic rhinitis. MEDICATIONS ON ADMISSION: 1. Avapro. 2. Toprol XL 50 mg daily. 3. Isosorbide SR 6. 4. Aspirin. 5. Beconase. 6. Guaifenesin LA. 7. Multivitamin with iron. 8. Ditropan. 9. Synthroid. 10. Nitrostat p.r.n. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient was in the emergency room with her youngest daughter.
LA|Los Angeles|LA|172|173|REVIEW OF SYSTEMS|A maternal aunt had diabetes mellitus. There are no other diseases in the family. REVIEW OF SYSTEMS: GENERAL: She has some hot flashes. She has some weight loss. She is on LA Weight Loss. She lost 20 pounds before joining LA Weight Loss and now has lost another 22 pounds so she is very pleased with herself with the diet and exercise.
LA|long-acting|LA|102|103|MEDICATIONS|2. Atenolol 25 mg p.o. q. day. 3. Celebrex 100 mg p.o. q. day. 4. Celexa 20 mg p.o. q. day. 5. Detrol LA 4 mg p.o. q. day. 6. Flomax 0.4 mg p.o. q. day. 7. Florinef 0.1 mg p.o. q. day. 8. Plavix 75 mg p.o. q. day. 9. Protonix 40 mg p.o. q. day.
LA|long-acting|LA|147|148|MEDICATIONS|5. Neurontin 600 mg t.i.d. 6. DDAVP nasal spray, 2 sprays at h.s. into her nostrils. 7. Trazodone 400 mg daily. Vitamin B6 400 mg a day. 8. Detrol LA 4 mg daily. 9. Remeron 30 mg at h.s. 10. Seroquel 25 mg in the a.m. and 100 mg at h.s. 11. Geodon 60 mg twice a day. 12. Klonopin 0.5 mg in the a.m. and once a day on a p.r.n. basis.
LA|long-acting|LA|147|148|MEDICATIONS|PAST MEDICAL HISTORY: 1. Hypertension. 2. History of tobacco use. 3. Barrett's esophagus. 4. Gastroesophageal reflux disease. MEDICATIONS: Inderal LA 60 mg po daily, Prevacid 50 mg po daily and Trazodone 50 mg po q hs. FAMILY HISTORY: Unknown, the patient is adopted. ALLERGIES: None known.
LA|long-acting|LA|114|115|OUTPATIENT  MEDICATIONS|3. Doxycycline 100 mg p.o. b.i.d. X7 days. 4. Prednisone 40 mg p.o. q.a.m. 5. Tricor 145 mg p.o. q.a.m. 6. Detrol LA 4 mg p.o. q.a.m. 7. Trazodone. 8. Cymbalta. 9. Seroquel. 10. Multivitamin with calcium 200 mg p.o. q.a.m. 11. Aspirin 81 mg p.o. daily. This is extended release.
LA|Los Angeles|LA|253|254|HISTORY OF PRESENT ILLNESS|Her primary care provider is the _%#CITY#%_ Big Lake Clinic. The patient describes a lifelong struggle with her weight. She has had multiple attempts at weight loss including structured weight loss programs such as Weight Watchers at least eight times, LA Weight Loss programs at least twice the recent one a year ago, over-the-counter diets and supplements. All of her attempts for weight loss have failed.
LA|Los Angeles|LA|253|254|HISTORY OF PRESENT ILLNESS|Her primary care provider is _%#NAME#%_ _%#NAME#%_, MD. The patient describes a 35 year plus struggle with her weight. She has had multiple attempts for weight loss including Weight Watchers structured programs at least six times, NutriSystems program, LA Weight Loss. She has tried working with her doctor on over-the-counter diets. She has tried medications such as Meridia and Xenical. She has tried other over-the-counter diets and supplements.
LA|long-acting|LA|156|157|ASSESSMENT AND PLAN|Therefore we will initiate treatment with Norvasc 5 mg p.o. q. day to be held for systolic blood pressure of less than 100. We will also treat with inderal LA 80 mg p.o. q. day and will hold for systolic blood pressure less than 100 and pulse less than 55. Will treat with a beta blocker to help with the hypertension but also to assist with her social anxiety symptoms.
LA|left atrial|LA|222|223|LABORATORY DATA|There is concentric left ventricular hypertrophy, and the LV is mildly dilated. Ejection fraction 25-35%. Mild mitral regurgitation. Trace tricuspid regurgitation. I reviewed her coronary angiogram which shows 90% diffuse LA disease, prox circumflex 95% stenosis, 100% occlusion of the right coronary artery. ASSESSMENT/PLAN: 67-year-old female with past history of hypertension, hyperlipidemia and diabetes with severe ischemic cardiomyopathy with severe three vessel coronary artery disease.
LA|Los Angeles|LA,|119|121|TREATMENT HISTORY|The client reports being in AA at the present time on a weekly basis. The client has also been in treatment in 2000 in LA, inpatient 90 days and then to a sober house and was sober two years. The client in 2005 was in _%#CITY#%_ outpatient, completed, sober a year, and in _%#MM2007#%_ he was in Pride inpatient for 50 days, completed, sober two months.
LA|long-acting|LA|415|416|IMPRESSION|Basic metabolic panel showed sodium of 138, potassium 3.8, BUN of 15 and a creatinine of 0.8. Her blood glucoses have ranged from 117-196 with a hemoglobin A1c of 6.4. IMPRESSION: This is a 35-year-old woman with a longstanding history of multiple sclerosis with recurrent exacerbation with complaints of urge and urge incontinence over the last year to 18 months. She trialed what sounds like a low dose of Detrol LA in the past up to 4 mg once a day. This had a good response initially but however did not produce long lasting stable relief of her symptoms.
LA|Los Angeles|LA|151|152|HISTORY OF PRESENT ILLNESS|The patient describes a lifelong struggle with her weight. She has had attempts for weight loss including structured programs like Weight Watchers and LA Weight Loss. She has tried over-the-counter diets and supplements as well as exercise. All of her attempts for weight loss have failed her.
LA|long-acting|LA|172|173|HISTORY OF PRESENT ILLNESS|She still has residual blurring of vision. Her symptoms of hyperthyroidism have resolved as well. The patient had been treated ________ 10 mg 3 times a day and propranolol LA 60 mg a day along with SSKI prior to her surgery. PAST MEDICAL HISTORY: 1. Graves disease, status post subtotal thyroidectomy as mentioned above.
LA|long-acting|LA|128|129|ADMISSION DIAGNOSES|She had bilateral hip surgery in 1995 and then in 2000. She has also had an open tubal ligation. ADMISSION MEDICATIONS: Inderal LA 60 mg p.o. daily, Paxil CR 25 mg p.o. daily, Lasix 20 mg p.o. daily, Fiorinal as needed for migraines, Vicodin as needed for neck pain, Neurontin 100 mg once daily, Prinivil 20 mg once daily, Prevacid 30 mg once daily, Entocort EC 3 mg b.i.d., Allegra 180 mg once daily, Levbid 0.375 mg as needed twice weekly.
LA|long-acting|LA|144|145|MEDICATIONS ON THIS ADMISSION|MEDICATIONS ON THIS ADMISSION: 1. OxyContin 40 mg p.o. t.i.d., as per patient. 2. Effexor 25 mg q.d. 3. Climara patch 0.1 mg topical. 4. Detrol LA 1 tablet q.d. 5. Percocet 1-2 tablets daily p.r.n. 6. Singulair 4 mg p.o. q.d. 7. Albuterol inhaler 2 puffs t.i.d. p.r.n. FAMILY HISTORY: The patient's mother suffered with endometriosis and underwent a hysterectomy.
LA|long-acting|LA|153|154|CURRENT MEDICATIONS|8. Ferrous sulfate 325 mg p.o. q. day. 9. Fosamax 70 mg p.o. q. week. 10. Hexavitamin 1 p.o. q. day. 11. Imitrex 50 mg p.o. p.r.n. migraine. 12. Inderal LA 160 mg p.o. q. day. 13. Loperamide p.r.n. 14. Magnesium oxide 800 mg p.o. q. day. 15. Neutra-Phos-K 1 packet in water p.o. q. day.
LA|long-acting|LA|196|197|CURRENT MEDICATIONS|I spoke with Dr. _%#NAME#%_ of the emergency room and requested the patient be given a dose of aspirin 81 mg in the emergency room. CURRENT MEDICATIONS: 1. Nifedipine CR30 mg daily 2. Propranolol LA 160 mg PO b.i.d. 3. Clonidine 0.1 mg QHS 4. Sinemet CR50/200 mg one tab PO b.i.d. 5. Fosamax 70 mg PO weekly on Sundays 6. Coumadin on Mondays and Fridays and 2.5 mg on other days of the week 7.
LA|long-acting|LA|314|315|DISCHARGE MEDICATIONS|Cerebellum: Finger-to-nose is slow, but no dysmetria. She cannot perform heel-to- shin and cannot stand or walk secondary to weakness. DISCHARGE MEDICATIONS: Baclofen 5 mg p.o. t.i.d., Singulair 10 mg p.o. nightly, cyclobenzaprine 5 mg p.o. b.i.d., Pulmicort 0.5 mg nebulizer b.i.d., DuoNeb 4 times a day, Inderal LA 80 mg p.o. daily, Lexapro 10 mg p.o. daily, trazodone 25 mg p.o. nightly p.r.n. for sleep, bacitracin ointment apply to spinal pressure points b.i.d., and Valium 0.5 mg p.o. b.i.d. x4 days and 0.5 mg p.o. nightly x3 days and stop.
LA|long-acting|LA|178|179|ADMISSION MEDICATIONS|COMPLICATIONS: 1. Tertiary wound dehiscence. 2. Colocutaneous/enterocutaneous fistula. 3. Neutropenia. 4. Sepsis. ADMISSION MEDICATIONS: 1. Celebrex 200 mg p.o. daily. 2. Detrol LA 4 mg p.o. daily. 3. Prevacid 30 mg p.o. daily. 4. Oxycodone 1-2 tabs p.o. q.4-6h. p.r.n. 5. Iron sulfate t.i.d.
LA|left atrial|LA|200|201|1. FEN|She had hyperdynamic systole, and significant diastolic dysfunction. She had mild RVSP = 38 + CVP. No PDA was noted. Her preliminary cardiac measurements were as follows LVIDd 15, LVIDs 8, LVPWd 6-8, LA 12, aorta 12. Because of her hemodynamic instability, she was initially on dobutamine and Nipride. A trial of Esmolol was initiated, but quickly discontinued due to worsening respiratory status.
LA|long-acting|LA|107|108|ADMISSION MEDICATIONS|3. Norvasc 2.5 mg daily. 4. Atenolol 100 mg daily. 5. Zocor 10 mg daily. 6. Avapro 300 mg daily. 7. Detrol LA 4 mg daily. 8. Terazosin 1 mg at bedtime. 9. Glipizide XL 15 mg q.a.m. 10. Lantus 12 units at bedtime. 11. Plavix 75 mg daily. 12. Enteric-coated aspirin 81 mg daily.
LA|long-acting|LA.|219|221|HOSPITAL COURSE|Dr _%#NAME#%_ did see him during his hospital admission. There were no changes made to his current treatment regimen for his bladder spasms which include scheduled MS Contin, oxycodone on an as needed basis, and Detrol LA. His bladder spasms were controlled well on this regiment throughout his entire hospitalization. PROBLEM #4 Persistent microscopic and gross hematuria: _%#NAME#%_ has a known history of persistent gross and microscopic hematuria.
LA|long-acting|LA|172|173|DISCHARGE MEDICATIONS|7. Multivitamin 1 p.o. daily. 8. Omeprazole 20 mg p.o. daily. 9. Rifaximin 400 mg p.o. t.i.d. for end-stage liver disease. 10. Spironolactone 100 mg p.o. daily. 11. Detrol LA 4 mg p.o. daily. 12. Triamcinolone lotion 0.1% topically b.i.d. to abdomen. 13. Ambien 5 mg p.o. daily at bedtime. 14. Oxycodone 5-10 mL p.o. q.4h. p.r.n. 15. Clotrimazole 1% topical b.i.d. to glans penis.
LA|long-acting|LA|436|437|HOSPITAL COURSE|Other significant findings this admission included a leukocytosis and hyperglycemia which were felt secondary to the Decadron injections, although he did have a cough which was thought to be related to either congestive heart failure related to the atrial fibrillation versus bronchitis in a smoker versus ACE-inhibitor cough. He will therefore be discharged on an ARB instead of lisinopril, a short course of azithromycin, and Humibid LA 600 mg b.i.d., with recommendations to stop smoking. Chest x-rays were negative x 2 this admission. He does have an end- expiratory wheeze, and probably has some tobacco-induced chronic obstructive pulmonary disease, and would benefit from pulmonary function testing some time after recovery from this current illness; however, I would avoid pulmonary function tests for now due to the necessity for Valsalva-like maneuver, which may have been possibly linked to the onset of the current intracranial hemorrhage.
LA|left atrial|LA|197|198|PERTINENT PROCEDURES|2. Transthoracic echocardiogram on _%#MMDD2003#%_ showed normal LV systolic function, moderate RV dilatation and hypertrophy with flattening of the intraventricular septum in diastole. a. Moderate LA enlargement. b. Severe right atrial dilation. c. Mild aortic regurgitation. d. Severe tricuspid regurgitation. e. RV systolic pressure moderately/severely increased approximately 67 mmHg above the mean right atrial pressure.
LA|long-acting|LA|166|167|CURRENT MEDICATIONS|3. Prevacid 30 mg daily. 4. Vicodin p.r.n. pain. 5. Lisinopril 10 mg daily. 6. Norvasc 10 mg daily. 7. Hydrochlorothiazide 25 mg daily. 8. Meclizine p.r.n. 9. Detrol LA 4 mg daily. 10. Magnesium oxide 400 mg daily. 11. Tylenol Extra Strength p.r.n. pain. 12. Multivitamin daily. 13. Calcium and Vitamin D supplements daily.
LA|long-acting|LA|171|172|REVIEW OF SYSTEMS|Respiratory: No cough, purulent sputum, hemoptysis, or dyspnea. Cardiovascular and gastrointestinal as above. Genitourinary: Chronic urinary incontinence for which Detrol LA has been tried. Otherwise negative. Musculoskeletal negative except for the above. Neurologic: Occasional headaches that are diffuse, sometimes with some nausea, otherwise no acute neurologic symptoms.
LA|long-acting|LA|133|134|DISCHARGE MEDICATIONS|5. Clonazepam 3 mg p.o. q.h.s. 6. Methocarbamol 750 mg p.o. q.i.d. p.r.n. muscle soreness. 7. Effexor XR 75 mg p.o. q.a.m. 8. Detrol LA 4 mg p.o. q.a.m. 9. Clarinex 5 mg p.o. q.a.m. 10. Senna 2 tabs p.o. q.a.m. 11. Colace 300 mg p.o. q.h.s. 12. Ibuprofen 800 mg p.o. q.h.s.
LA|left atrial|LA|178|179|OTHER LABORATORY|A baseline INR was 1.06. Urine culture is in progress. Echocardiogram revealed only aortic sclerosis with mild left ventricular enlargement and ejection fraction as noted above. LA was 4 cm in size. ASSESSMENT/PLAN: 1. Atrial fibrillation. The patient has symptoms of shortness of breath, which appears to be due to congestive heart failure related to atrial fibrillation and fast ventricular rate and mild cardiomyopathy.
LA|long-acting|LA|161|162|MEDICATIONS|2. Atenolol 50 mg twice daily. 3. Betoptic 0.25 mg 1 drop to both eyes twice daily. 4. Centrum Silver 1 daily. 5. Cytotec 100 mcg, 1 p.o. twice daily. 6. Detrol LA 4 mg 1 p.o. daily. 7. Levothyroxine 0.25 mg 1 p.o. daily. 8. Miacalcin Nasal Spray 1 spray daily. 9. MiraLax 17 gm 1 capsule chew daily p.r.n. constipation.
LA|long-acting|LA|122|123|CURRENT MEDICATIONS|8. Neurontin 600 mg p.o. t.i.d. 9. Diltiazem CR 180 mg 1 capsule twice daily. 10. Nitrofurantoin 100 mg daily. 11. Detrol LA 4 mg daily. 12. Mucinex 600 mg p.o. daily as needed. 13. Prochlorperazine 5 mg p.o. t.i.d. as needed. 14. Humalog sliding scale. 15. Spironolactone 25 mg q.a.m.
LA|long-acting|LA|221|222|PROBLEM #3|We did talk about the possibility that she would not be able to return to an independent living situation. PROBLEM #3: Urinary incontinence. A mix of urge and stress symptoms. The patient is currently treated with Detrol LA and had no urinary retention while she was in the hospital. This should be continued. PROBLEM #4: Vision loss. The patient has macular degeneration and cataracts bilaterally.
LA|left atrial|LA|174|175|PROCEDURES|Moderate pulmonary hypertension with no significant response to Flolan. Moderately elevated pulmonary vascular resistance. ASD large left to right shunt. 9. Left heart cath, LA angio, FICE eval: RULPV and LA angio showed large secundum ASD. ICE shows the defect to be up to 17 mm. HISTORY OF PRESENT ILLNESS: Please refer to the dictated History and Physical Examination performed _%#MMDD2006#%_.
LA|long-acting|LA|125|126|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. q.d. 2. Calcium carbonate 1600 mg p.o. q.d. 3. Plavix 75 mg p.o. q.d. 4. Detrol LA 4 mg p.o. q.d. 5. Imdur 30 mg p.o. q.d. 6. Prevacid 60 mg p.o. b.i.d. 7. Prinivil 10 mg p.o. q.d. 8. Lopressor 25 mg p.o. b.i.d.
LA|long-acting|LA|177|178|MEDICATIONS|2. Aspart 5 units t.i.d. with meals. 3. Norvasc 5 mg p.o. q.h.s. 4. Warfarin 2 mg p.o. daily. 5. Aspirin 81 mg p.o. daily. 6. Os-Cal with vitamin D 500 mg p.o. t.i.d. 7. Detrol LA 4 mg p.o. daily. 8. Colace 100 mg p.o. b.i.d. 9. Lexapro 20 mg p.o. daily. 10. Nortriptyline 75 mg p.o. daily.
LA|long-acting|LA|195|196|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Oxycodone 20 mg p.o. q. 2 hour p.r.n. for breakthrough pain. 2. Fentanyl transdermal patch 50 mcg to be changed every 72 hours. 3. Prednisone 5 mg p.o. daily. 4. Detrol LA 4 mg p.o. q. 24 hours. 5. Vitamin D 400 international units p.o. daily. 6. Lantus 10 units subq q.a.m. 7. Aspirin 325 mg p.o. daily.
LA|long-acting|LA|331|332|MEDICATIONS AT ADMISSION|Records from Dr. _%#NAME#%_'s office suggest she was supposed to be on furosemide, but she states all medications make her sick after awhile so she usually does not keep taking them, but does not have any specific symptoms she was willing to share. It is unclear how she has been taking her medications. Listed also are: 1. Detrol LA 4 mg daily. 2. Aspirin 81 mg daily. 3. Lisinopril 2.5 b.i.d. 4. Darvocet-N 100 p.r.n. 5. Vitamin B12 100 mcg daily. 6. Multivitamins one daily. ALLERGIES: Chart lists intolerances to penicillin because of nausea, sulfa drugs due to headache, alendronate due to dizziness, Actonel also GI upset, Lipitor nausea and Evista nausea.
LA|long-acting|LA|97|98|CURRENT MEDICATIONS|She follows with Dr. _%#NAME#%_ at Fairview Cedar Ridges Clinic. CURRENT MEDICATIONS: 1. Inderal LA 60 mg each day at bed time. 2. DuoNeb p.r.n. 3. Advair Diskus 50/100 mcg 1 puff every day. 4. Advil p.r.n. 5. Medrol Dosepak. 6. Z-PAK one dose left.
LA|long-acting|LA|143|144|MEDICATIONS|4. Folic acid 1 mg q.d. 5. Furosemide 40 mg 1 p.o. q.d. 6. Hydroxyzine 25 mg 1 p.o. q.d. p.r.n. itching. 7. Prevacid 30 mg p.o. q.d. 8. Detrol LA 4 mg 1 p.o. q.d. 9. Zocor (dose not known). 10. Diovan 80 mg 1 p.o. q.d. 11. Vicodin 1 to 2 p.o. q.4-6 h p.r.n. back pain.
LA|long-acting|LA|118|119|MEDICATIONS|MEDICATIONS: 1. Lisinopril 5 mg p.o. daily. 2. Ranitidine 150 mg p.o. daily. 3. Aldactone 50 mg p.o. b.i.d. 4. Detrol LA 2 mg p.o. daily. 5. Tylenol 1000 mg p.o. t.i.d. 6. Robitussin DM 5 to 10 cc p.o. q.4-6 h. p.r.n. 7. Imodium AD 2 mg p.o. p.r.n. with each loose stool.
LA|long-acting|LA|149|150|CURRENT MEDICATIONS|ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: 1. Triamcinolone cream 0.1% b.i.d. to the face 2. Prevacid 30 mg p.o. b.i.d. 3. Detrol 4 mg LA p.o. b.i.d. 4. Reglan 5 mg p.o. q.i.d. one half hour AC and h.s. 5. Florinef 0.1 mg one half tab p.o. b.i.d. 6. Klor-Con 20 mEq p.o. b.i.d. for tendency toward hypokalemia (presumably related to Florinef)
LA|Louisiana|LA|174|175|SUGGESTIONS|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_ Our Lady of the Lakes Regional Center _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_ _%#CITY#%_, LA _%#70800#%_ Dear Drs. _%#NAME#%_ and _%#NAME#%_: I had the pleasure of seeing _%#NAME#%_ accompanied by her mother on Thursday, _%#MM#%_ _%#DD#%_, 2007 for a consultation on our bone marrow transplant unit.
LA|Los Angeles|LA|220|221|SOCIAL HISTORY|She just moved into a handicap accessible apartment. It is on the first floor with flat access. She has normal toilet with grab bars, tub-shower transfer bench, hand- held shower, grab bars. She is employed full-time at LA Weight Loss and American Cancer Society. FUNCTIONAL HISTORY: She has a lightweight manual wheelchair which she obtained after rehabilitation in 2001.
LA|antinuclear antibody:ANA|LA|149|150|IMAGING STUDIES|Total cholesterol 131, LDL 56, triglycerides 147, HDL 46, blood cultures no growth to date. Lupus inhibitor battery is negative. IGG was normal. SSB LA antibody, IGG normal. DNA double stranded negative at 4 international units per ml, C3 and C4 levels 136 and 15 respectively and both normal.
LA|long-acting|LA|136|137|HOSPITAL COURSE|By the next morning, the patient's condition was stable, and he was sent home. He did have some urinary urgency, so I prescribed Detrol LA 4 mg a day, as well as Peridium 200 mg p.o. t.i.d. p.r.n. dysuria, Bactrim single-strength one a day as prophylaxis for infection from his stent, as well as Vicodin for pain.
LA|left atrial|LA|196|197|REVIEW OF SYSTEMS|His previous evaluation including an echocardiography, which showed a mild dysfunction with septal hypokinesis, markedly increased LA size. An exercise Cardiolite Test was reported as normal. The LA size measured approximately 5.2 cm. PAST MEDICAL HISTORY: 1. SIC sinus syndrome, paroxysmal atrial fibrillation.
LA|long-acting|LA|136|137|DISCHARGE MEDICATIONS|13. Rozerem (ramelteon) 8 mg p.o. each day at bed-time p.r.n. for insomnia 14. Senokot 2 tablets p.o. q day for constipation 15. Detrol LA has been discontinued. She should not need this as she has a suprapubic catheter. 16. Coumadin 4 mg p.o. q p.m. until her next INR which should be on _%#MMDD2007#%_; this is for blood thinning
LA|long-acting|LA|169|170|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: She is discharged at this time to finish her Cipro. She will continue on Betaseron 1 cc every other day along with Zoloft 100 mg a day and Detrol LA 4 mg a day. She will be on a tapering dose of Medrol. FOLLOW UP: She will be seen in the office in 2 weeks and in 6 weeks.
LA|long-acting|LA|134|135|HOSPITAL COURSE STAY|The patient has a history of hyperlipidemia. She is on Zocor 20 mg 1 tablet at night. For her bladder incontinence and spasms, Detrol LA 4 mg 1 tablet daily. DISCHARGE MEDICATIONS: 1. Allopurinol 100 mg 1 tablet daily.
LA|left atrial|LA,|224|226|HOSPITAL COURSE|This would be consistent by the less than rebuffed response noted to large platelet transfusion. 4. Cardiomegaly. Mr. _%#NAME#%_ received an echocardiogram while he was inpatient which noted mild LVH, moderately dilated LV, LA, and RA, mild MR, a mildly stenotic aortic valve that was bicuspid without any sort of vegetation. No AI was detected. He also had mild TR and overall normal LV function with an estimated EF of approximately 60%.
LA|Los Angeles|LA|153|154|PAST  MEDICAL HISTORY|4. Left bundle branch block. 5. Paroxysmal atrial fibrillation. 6. B12 deficiency. 7. Anemia _%#MM#%_ 2006 a. EGD _%#MM#%_ 2006 by Dr. _%#NAME#%_ showed LA grade A esophagitis, bleeding erosive gastropathy normal duodenum. b. EGD and colonoscopy on _%#MMDD2007#%_ showed normal EGD and diverticulosis in the sigmoid colon.
LA|long-acting|LA|507|508|MEDICATIONS|Hypercholesterolemia. Normal pressure hydrocephalus. Mild organic brain syndrome. History of the TIAs as well as history of frequent syncopal episodes. Vertebral fractures secondary to osteoporosis. MEDICATIONS: She currently is taking a calcium supplement with 200 mg of vitamin D two b.i.d., hydrochlorothiazide 25 mg daily, Lescol XL 80 mg daily, Plavix 35 mg daily, metoprolol 25 mg daily, potassium chloride 10 mEq b.i.d., Extra Strength Tylenol two tablets t.i.d., amitriptyline 10 mg at h.s., Detrol LA 4 mg q.h.s., and Fosamax 70 mg weekly on Sundays. ALLERGIES: None known. SOCIAL HISTORY: She lives with her daughter.
LA|long-acting|LA|270|271|HOSPITAL COURSE|His blood pressure has nonetheless remained well controlled. The patient had urinary frequency and urgency throughout this hospital course despite unremarkable urinalysis with microscopic exam. Although consideration was given to an anticholinergic agent such as Detrol LA or Ditropan XL, in view of his fluctuating mental status, it was felt more prudent to withhold this medication and he found his symptoms to be tolerable.
LA|left atrial|LA|215|216|HOSPITAL COURSE|He underwent a follow up ablative procedure at Mayo Clinic by Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2007#%_ and per Dr. _%#NAME#%_'s summary notes it appeared to run around his right pulmonary veins using the lateral LA isthmus as the superior to inferior component of that circuit. The retrograde component likely went in and out of the wide area of the circumferential ablating ring from the last procedure.
LA|long-acting|LA|199|200|MEDICAL DECISION-MAKING AND EMERGENCY DEPARTMENT COURSE|Rapid strep is positive. I spoke with the child's father about the option of using oral antibiotics or IM injection of LA Bicillin. He opted for the LA Bicillin. The child was given 900,000 units of LA Bicillin IM. She was observed for 20 minutes afterward with no untoward effect. The child is to stay out of school for 24 hours and may then return to school.
LA|left atrial|LA|142|143|HOSPITAL COURSE|TEE prior to the procedure shows a slight reduction in EF at 35-40%, although this was performed during tachycardia. There was no evidence of LA thrombus. A limited echo performed with Defnity as it was technically difficult to visualize the LV, appears to show of approximately 45-50%.
LA|Los Angeles|LA|386|387|HOSPITAL COURSE|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 57-year-old Somali female who was admitted through Fairview Southdale Hospital Emergency Department on _%#MMDD2006#%_ with a history of vomiting, hematemesis and some bright red blood per rectum. Please refer to admitting history for full details. HOSPITAL COURSE: The patient had an EGD done the evening of admission which showed LA grade B reflux esophagitis, erosive gastropathy and a single gastric angiodysplastic lesion with a normal duodenum. The patient was prepared for colonoscopy given the history of bright red blood per rectum and the only finding on _%#MMDD#%_ was some internal hemorrhoids, otherwise unremarkable.
LA|left atrial|LA|157|158|PAST MEDICAL HISTORY|On _%#MM#%_ _%#DD#%_, 2002, was EF of 32%. 5. Status post MI with akinesis in the anterior, apical, septal areas. 6. Moderate LV dilation, mild MR, moderate LA enlargement. 7. History of ITP status post splenectomy. 8. History of hysterectomy for possible cervical CA. 9. Gout. 10. Glaucoma. 11. History of PE.
LA|long-acting|LA|155|156|ASSESSMENT AND PLAN|She is on Bactrim, I believe DS one a day as prevention, Prednisone, I will check the dose and continue that unchanged. Premarin 0.625 mg once day, Detrol LA 4 mg daily.
LA|Los Angeles|LA|178|179|HOSPITAL COURSE|She underwent unsucessful DC cardioversions on _%#MMDD2007#%_ and _%#MMDD2007#%_. She was placed on amiodarone, diltiazem and Coumadin. She had a GI bleed with an EEG showing an LA grade C Candida esophagitis and was placed on fluconazole and Protonix. She was seen by psychiatry and she was treated with p.r.n. Seroquel, but had some tardive dyskinesia-type movements, so it was discontinued and she was placed on Benadryl.
LA|long-acting|LA|150|151|DISCHARGE MEDICATIONS|Resolution of alcohol withdrawal and above noted diarrhea. DISCHARGE MEDICATIONS: Included Flovent 220 mcg 2 puffs b.i.d., followed by rinse. Humibid LA one p.o. b.i.d. Vent metered dose inhaler 2 puffs q.i.d. Zestril 2.5 mg q.d. to be held p.r.n. systolic blood pressure less than 130.
LA|long-acting|LA|195|196|HOSPITAL COURSE|She was also having some bladder spasms after removal of her Foley, causing incontinence. She has had a little bit of incontinence actually prior to this hospitalization so was given some Detrol LA 4 mg daily to see if that helps. DISCHARGE MEDICATIONS: 1. Lantus 40 mg each morning. 2. Potassium chloride 20 mEq daily.
LA|long-acting|LA|135|136|DISCHARGE DIAGNOSIS|She is on Neurontin 300 mg every 2 hours for this. She is discharged on betaseron, Fosamax 70 mg a week, Provigil 200 mg a day, Detrol LA 4 mg a day, doxycycline 100 mg a day, Neurontin, Diovan 80 mg a day, and Inderal long-acting 160 mg a day. She was seen in internal medicine consultation by Dr. _%#NAME#%_ and his group.
LA|long-acting|LA|173|174|LABORATORY|Her affect is handled quite well. She is discharged at this time on a tapering dose of Medrol. She will continue on baclofen 10 mg every 6 hours along with Copaxone, Detrol LA 4 mg a day, and Flonase. She will finish off the Cipro. She is on ascorbic acid, and she will be seen in the office in 6 weeks.
LA|Los Angeles|LA|306|307|CURRENT MEDICATIONS|PAST MEDICAL HISTORY: Elevated cholesterol, otherwise negative. FAMILY HISTORY: Negative for coronary artery disease, positive for hypertension in her dad, positive for diabetes in her mother, positive for lung cancer in her mom who is a heavy smoker. Drug sensitivity is none. CURRENT MEDICATIONS: Taking LA weight loss pills which includes calcium, vitamins, questionable ephedra I do not know all ingredients and we will need to find out.
LA|left atrial|LA|214|215|PROCEDURE PERFORMED|2. Dilated left atrium on a 2D echo. 3. Previous history of coronary artery disease with a 3-vessel coronary artery bypass graft in 1995 and 1996. 4. Achondroplasia left arm. PROCEDURE PERFORMED: A 2D echo showing LA measurements of 6.7 cm, inferior and posterior wall motion abnormality with a preserved EF at 45%. No valve motion abnormalities were noted.
LA|long-acting|LA|114|115|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Tequin 400 mg p.o. q.d. x 9 days. 2. Medrol dose pack, take as directed. 3. Guaifenesin LA 600 mg p.o. b.i.d. 4. Combivent 2 puffs q.i.d. 5. Flovent (110 mcg) 2 puffs b.i.d. (rinse mouth after use). 6. Aspirin 81 mg, or 1/2 of a 325 mg tablet, p.o. q.d.
LA|long-acting|LA|598|599|MEDICATIONS|MEDICATIONS: Her meds in the assisted living facility include Zantac 150 mg p.o. twice a day, lisinopril 10 mg a day, FiberCon one tablet twice a day, Lomotil one tablet every day as needed for diarrhea; Tylenol 500 mg, she takes one to two tablets every 4 to 6 hours as needed for pain; triamcinolone 0.1% cream to be applied to skin rashes as needed; Fiorinal with codeine, she takes one tablet every 4 to 6 hours as needed for pain; Restoril 7.5 mg, she takes one to two tablets q. h.s. as needed for sleep and rarely uses these above two medications. She takes a multivitamin every day, Detrol LA 4 mg p.o. each day, propranolol 80 mg one tablet twice a day, trazodone 50 mg q. h.s., OxyContin 10 mg p.o. twice a day, Zoloft 50 mg one-half a tablet p.o. q.day, Neurontin 300 mg three times a day, Synthroid 0.15 mg p.o. q.day, Lasix 20 mg p.o. q.day, aspirin 80 mg each day, Lanoxin 0.125 mg p.o. each day.
LA|Los Angeles|LA|245|246|HOSPITAL COURSE|Results included positive urine culture for group D. enterococcus, and the patient was started on Vancomycin and discharged on Zyvox. Due to epigastric abdominal pain, dyspepsia, and nausea and vomiting, the patient had an EDG done which showed LA grade B esophagitis and gastritis. Biopsies were taken of both the esophagus and stomach. At the time of discharge, biopsy was still pending.
LA|long-acting|LA|236|237|PHYSICIAN|3. IV fluids were changed to D5 normal saline plus 20 mEq potassium chloride at 75 mL per hour. Saline lock when taking adequate p.o. Morning laboratories to include hemoglobin and electrolytes. 4. Urinary incontinence. Continue Detrol LA 4 mg p.o. at bedtime. 5. Von Recklinghausen disease, stable with numerous neurofibromas. 6. Deep venous thrombosis prophylaxis.
LA|long-acting|LA|204|205|MEDICATIONS|12. Chest pain, not otherwise specified. MEDICATIONS: 1. Zantac 150 b.i.d. 2. Nystatin powder. 3. Hydrocortisone cream b.i.d. 4. Accu-Checks with sliding scale insulin. 5. Zoloft. 6. Seroquel. 7. Inderal LA 60 mg q day. 8. Multivitamin. 9. Haldol. 10. Clonazepam 0.5 mg t.i.d. 11. Calcium carbonate 500 mg b.i.d. 12. Acetaminophen 500 mg q4h p.r.n.
LA|long-acting|LA|337|338|RECOMMENDATIONS|This letter will summarize the information we discussed. _%#NAME#%_ is a 33-year-old gravida 3, para 1-0-1-1, who is currently 22 weeks and 3 days gestation, based on an estimated date of delivery of _%#MMDD2004#%_. She reported no smoking, alcohol use, chemical exposures, x- rays, or fevers during her pregnancy. She is taking Inderal LA for her elevated blood pressure, during this pregnancy. Her triple-screen blood test results were as follows: 0.75 MoM AFP, 0.86 MoM estriol, and 1.60 MoM hCG.
LA|long-acting|LA.|210|212|ASSESSMENT|May account for low-normal potassium. 3. Self-injurious behavior with prior self-cutting and self-inflicted chemical burns (requiring skin grafting, as above). 4. Migraine headaches, well controlled on Inderal LA. 5. Viral URI with bronchitis, aggravated with ongoing smoking. No clear indication for antibiotics at this time. 6. Gastroesophageal reflux disease, symptomatically well controlled on Protonix.
LA|long-acting|LA|144|145|MEDICATIONS|2. Remote history of tonsillectomy and PE tube placement. 3. Acne vulgaris. 4. No other known chronic medical ailments. MEDICATIONS: 1. Inderal LA 120 mg daily for uncontrolled anger. 2. Depakote 500 mg daily, 1000 mg q.h.s. for a mood stabilizer. 3. Minocycline 100 mg daily for acne. 4. Strattera 40 mg four tabs daily for attention.
LA|long-acting|LA|125|126|CURRENT MEDICATIONS|3. Zanaflex 4 mg q.i.d. 4. Imipramine 25 mg 3 times a day. 5. Prozac 20 mg 2 times a day. 6. Prilosec 20 mg daily. 7. Detrol LA 4 mg 2 times per day. 8. Lipitor 10 mg p.o. daily. 9. P.r.n. Lasix. FAMILY HISTORY: In terms of family history, there is no family history of progressive neurologic problems.
LA|long-acting|LA|126|127|DISCHARGE DIAGNOSES|3. Ranitidine 150 mg p.o. q.a.c. 4. Remeron 30 mg p.o. q.d. 5. Provigil 200 mg p.o. q.d. 6. Lexapro 10 mg p.o. q.d. 7. Detrol LA 4 mg p.o. q.d. 8. ACA 81 mg p.o. q.d. 9. Ambien 5 mg p.o. p.r.n. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 55-year-old white man who is transferred from the nursing home because he had a decreased level of consciousness.
LA|long-acting|LA|147|148|DISCHARGE MEDICATIONS|15. Seroquel 12.5 mg p.o. t.i.d. p.r.n. anxiety. 16. Senna 2 tablets p.o. q. 48 hours for constipation. 17. Aldactone 25 mg p.o. b.i.d. 18. Detrol LA 10 mg p.o. daily. 19. Tylenol 500 mg p.o. q.i.d. p.r.n. pain or fever. 20. Glucotrol XL 2.5 mg p.o. q.a.m. 21. Calcium plus vitamin D 2 tablets p.o. daily.
LA|long-acting|LA|129|130|MEDICATIONS ON ADMISSION|7. Essential tremor. 8. Bicuspid aortic valve which the patient was not aware of MEDICATIONS ON ADMISSION: 1. Aspirin 2. Inderal LA 80 mg a day 3. Mysoline 50 mg a day (tremor) 4. Avandamet 2/500 b.i.d. 5. Avapro 150 mg daily 6. Lipitor 10 mg daily
LA|long-acting|LA|166|167|CURRENT MEDICATIONS|1. Amiodarone 200 mg p.o. daily. 2. Lisinopril 5 mg p.o. daily. 3. Plavix 75 mg p.o. daily. 4. Atenolol 25 mg p.o. daily. 5. Flomax 0.4 mg p.o. at bedtime. 6. Detrol LA 4 mg p.o. at bedtime. 7. Lovastatin 40 mg p.o. at bedtime. 8. Triamcinolone cream 0.4% topical at bedtime. 9. Enteric coated aspirin 81 mg p.o. q a.m. In addition, he takes vitamin C 500 mg p.o. daily, vitamin E 400 IU p.o. daily, multivitamin p.o. daily, zinc p.o. daily, B complex 2 daily and Herbalax 3 tabs p.o. at bedtime.
LA|long-acting|LA|202|203|DISCHARGE MEDICATIONS|In addition she should follow up with Dr. _%#NAME#%_ her primary care provider following her gastric bypass surgery on an as needed basis. DISCHARGE MEDICATIONS: 1. Lexapro 20 mg p.o. daily. 2. Ritalin LA 10 mg p.o. daily. 3. Vitamin B12 1000 mg p.o. daily. 4. Ativan 0.5 mg p.o. q.6 hours. 5. Tegretol solution 200 mg p.o. q.i.d. 6. Dilaudid 8 mg p.o. q.4 hours p.r.n. pain.
LA|long-acting|LA|124|125|PRESENT MEDICATIONS|3. Macrodantin 50 mg q.h.s. for urinary tract/...??... 4. Ferrous sulfate daily. 5. Protonix 40 mg daily with p.r.n. Detrol LA 4 mg q.h.s. HABITS: Nonsmoker. No alcohol. SOCIAL HISTORY: A widow. Lives alone in _%#CITY#%_, Minnesota.
LA|long-acting|LA|181|182|DISCHARGE MEDICATIONS|2. Aspirin 81 mg p.o. daily. 3. Calcium carbonate 1 tab p.o. daily. 4. Metoprolol 12.5 mg p.o. b.i.d. 5. Ranitidine 150 mg p.o. daily. 6. Terazosin 10 mg p.o. daily. 7. Tolterodine LA 4 mg p.o. q.p.m. 8. Vitamin E 1 tab p.o. daily. 9. Percocet 5/325 1-2 tabs every 4-6 hours as needed for pain.
LA|long-acting|LA|171|172|MEDICATIONS|3. Hydrochlorothiazide 25 mg a day. 4. Norvasc 10 mg a day. 5. Lisinopril 10 mg a day. 6. She is supposed to be on Lexapro for depression, she does not take it. 7. Detrol LA 4 mg since she has been on this for a period of time. SOCIAL HISTORY: She lives alone, although she does have family involvement.
LA|long-acting|LA|115|116|DISCHARGE MEDICATIONS|2. Glatiramer 20 mg subcutaneous daily. 3. Modafinil 200 mg daily. 4. Temazepam 30 mg p.r.n. at bedtime. 5. Detrol LA 4 mg daily at bedtime.
LA|long-acting|LA|119|120|DISCHARGE MEDICATIONS|4. Metoprolol XL 100 mg p.o. q. day. 5. Levaquin 500 mg p.o. day x12 days. 6. Glucotrol-XL 5 mg p.o. q. day. 7. Detrol LA one tablet p.o. q. day, dispense #21. 8. Pyridium 200 mg 1 tablet p.o. q.8h. Dispense #36 per Dr. _%#NAME#%_. DISCHARGE FOLLOW-UP 1. He is supposed to be seen in three months' time by Dr. _%#NAME#%_.
LA|long-acting|LA|82|83|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1. Demadex 100 mg PO QD. 2. Zaroxolyn 5 mg PO QD. 3. Inderal LA 160 mg PO QD. 4. Monopril 20 mg PO QD. 5. Detrol LA 2 mg b.i.d. 6. Estradial 2 mg QD 7. Avandia 4 mg PO QD.
LA|long-acting|LA|132|133|DISCHARGE MEDICATIONS|5. Advair 500/50 one puff inhaled b.i.d. 6. Singulair 10 mg daily. 7. Zofran 4 mg t.i.d. p.r.n. 8. Seroquel 800 mg daily. 9. Detrol LA 4 mg oral daily. 10. Effexor XR 375 mg daily. 11. Vicodin 5/500 one p.o. q.i.d. p.r.n., #30. 12. Mylanta and Maalox 2 tablespoons p.r.n. q. 2 hours.
LA|long-acting|LA|157|158|MEDICATIONS|8. Serevent two puffs b.i.d. 9. Albuterol nebulizers t.i.d. to q.i.d. 10. Atrovent nebulizer t.i.d. to q.i.d. 11. Coumadin 5 mg as directed. 12. Guaifenesin LA 600 mg one b.i.d. 13. Prinivil 10 mg 1 1/2 po q.d. 14. Fosamax 70 mg q. week. 15. She also has been taking over-the-counter sleep aids and has had lorazepam and Flonase in the past.
LA|long-acting|LA|165|166|DISCHARGE MEDICATIONS|12. Xalatan eyedrops 0.005% one drop to each eye q.h.s. 13. Cozaar 50 mg p.o. q. daily. 14. Lopressor 25 mg p.o. b.i.d. 15. Prevacid 30 mg p.o. q. daily. 16. Detrol LA 4 mg p.o. q. daily. 17. Triamcinolone 0.1% cream topically to back and arms daily. 18. Coumadin 2 mg p.o. q. daily or as directed.
LA|long-acting|LA|114|115|MEDICATIONS|6. Cozaar 100 mg p.o. q. day. 7. Medroxyprogesterone 20 mg p.o. t.i.d. 8. Prednisone 50 mg p.o. q. day. 9. Detrol LA 2 mg p.o. q. day. 10. MiraLax 5 mg p.o. q. day. 11. Geodon. 12. Synthroid 0.1 mg p.o. q. day. 13. Aspirin 5 grains p.o. q. day.
LA|long-acting|LA|115|116|OTHER MEDICATIONS INCLUDE|3. Plavix 75 mg daily. 4. Lisinopril 5 mg daily. 5. Lovastatin 40 mg at bedtime. 6. Flomax 0.4 mg daily. 7. Detrol LA 4 mg at bedtime. 8. Amiodarone 200 mg daily.
LE|leukocyte esterase|LE,|186|188|HOSPITAL COURSE|She had some guarding with palpation. Blood were drawn and showed WBC 22.7, hemoglobin 12.9, platelets 323,000. Electrolytes were within normal limits. UA was sent which showed positive LE, positive nitrites, positive ketones, positive rbc's, positive wbc's, positive bacteria. Wet prep was also positive for Trichomonas, clue cells and yeast.
LE|leukocyte esterase|LE|211|212|HOSPITAL COURSE|The patient was admitted as an outpatient to evaluate possibly viral versus pyelo versus chorioamnionitis workup. A UA, UC and UT were obtained. The urine tox screen was negative. The UA revealed only small and LE and 3 white blood cells effectively ruling out pyelonephritis. Abdominal exam was quite reassuring. Chorioamnionitis was unlikely as well.
LE|leukocyte esterase|LE.|252|254|LABORATORY DATA|This is a nonfocal exam. LABORATORY DATA: CBC revealed a hemoglobin of 12.7, white count 8.6, platelet count 226, INR 1.02, and PTT 31. BMP normal except for a sodium of 128, potassium is 4.5, BUN 17, creatinine 0.87, glucose 109. UA 30 protein, small LE. Hip and pelvis x-ray per the emergency department showed right intertrochanteric and femoral neck fracture.
LE|leukocyte esterase|LE.|257|259|LABORATORY|Otherwise, his exam was unchanged from previous admissions. LABORATORY: His admit labs showed a white count of 7.1, hemoglobin 12.2, and lymphocytes of 287. Electrolytes were normal. UA showed trace nitrites with 100 white blood cells and a large amount of LE. Abdominal x-ray showed no free air. Normal bowel gas pattern and a lot of stool. HOSPITAL COURSE: 1. Constipation. The patient was brought in to the hospital and on the evening of the admission, he was offered regimen including soap suds enema and tap water enemas.
LE|lower extremity|LE|158|159|IMPRESSION|Also puffiness of the feet. 4/4+ DP pulses. The nails are cornified. Negative CCOA nodes, thyroid, inguinal nodes. IMPRESSION: 1. Small bowel obstruction. 2. LE edema for several years. 3. Abdominal aortic aneurysm 3.3 cm per CAT scan. 4. SPO "three" herniorrhaphies and an appy per a large right vertical lateral incision.
LE|leukocyte esterase|LE.|216|218|LABORATORY|Extremities: Without edema. LABORATORY: Sodium 139, potassium 4.4, chloride 105, bicarbonate 29, glucose 105, BUN 10, creatinine 0.8, calcium 9.4, and hemoglobin 12.6. UA showed large blood and 30 protein with trace LE. Urine culture eventually showed no growth. HOSPITAL COURSE: 1. FEN: The patient was maintained on IV fluids throughout admission but at the time of discharge, he was taking good p.o.
LE|leukocyte esterase|LE.|161|163|LABORATORY DATA|EXTREMITIES: No edema. Full range of motion. GENITAL: Deferred. NEUROLOGIC: Alert and oriented x 3. No focal deficit appreciated. LABORATORY DATA: UA with small LE. WBC 2-5. Urine pregnancy test is positive. Potassium 2.5, sodium 137, glucose 173, repeat glucose 93, calcium 7.9. BUN and creatinine within normal limits.
LE|leukocyte esterase|LE|211|212|PROBLEM #4|Was very alert and conversant at discharge. PROBLEM #4: Infectious disease: With chronic indwelling Foley catheter secondary to urinary retention. Did collect a UA and UC and continued the Foley. Did show small LE and white cells. Grew out group D enterococcus. Did not treat other than to continue course of levofloxacin. Did also receive clindamycin postoperatively x3. DISPOSITION PLANNING: Plan is to return to walker on the day of this discharge summary.
LE|leukocyte esterase|LE|311|312|PROBLEM #5|His discharge creatinine was 1.38. PROBLEM #4: Anemia: His admitting hemoglobin was 12.6 and discharge hemoglobin 12.1, this was felt to be consistent with anemia of chronic disease and remained stable throughout the hospitalization. PROBLEM #5: ID: The patient was initially thought to have a UTI due to large LE and greater than 182 wbc's in his urine, however, urine culture did not grow anything. The patient was initially started on ceftriaxone and this was discontinued when urine culture was negative.
LE|UNSURED SENSE|LE,|174|176|HISTORY OF PRESENT ILLNESS|She complains of intermittent, atypical, right-sided chest pain. An echocardiogram on _%#MM2002#%_ showed normal LV function, mild to moderate LVH, mild MR, mild to moderate LE, normal RV size and function. 5. Stroke with right-sided hemophoresis and the patient with aphasia approximately 5 years. The patient took approximately 1 year to recuperative. CT of the head _%#MM2002#%_ showed SCID, no ischemic strokes.
LE|leukocyte esterase|LE|139|140|HISTORY OF PRESENT ILLNESS|Electrolytes including BUN, creatinine and blood sugar were normal. A catheterized urine sample was done with a specific gravity of 1.010, LE negative and nitrate negative. No bacteria were in this urine sample. A urine culture and blood culture were done. Baby was discharged to home from the emergency room with followup with me on Tuesday, _%#MMDD#%_.
LE|leukocyte esterase|LE,|220|222|LABORATORY DATA|Hemoglobin, the day prior to transfer was 10.8 and stable postoperatively. EKG on the day prior to transfer showed sinus tachycardia with non-specific ST-T changes. Urinalysis on _%#MMDD2006#%_ showed small blood, trace LE, 0-2 red cells. Urine culture had revealed no growth. HOSPITAL COURSE/PLAN: 1. Status post left total knee arthroplasty.
LE|leukocyte esterase|LE,|210|212|LABS ON ADMISSION|Electrolytes were as follows: Sodium 135, potassium 3.9, chloride 98, CO2 29, BUN 19, creatinine 0.78, glucose 237, and calcium 8.6. INR was 1.30. UA showed 500 of glucose, trace ketones, positive blood, trace LE, and negative nitrites. Micro showed 21 white blood cell counts, 9 red blood cell counts, few bacteria, 3 hyaline casts, and squamous epithelial cells were present.
LE|leukocyte esterase|LE|191|192|LABORATORY|Hepatic panel: ALT 104, AST 71, albumin 4.1, bilirubin 4.1, alkaline phosphatase 98. Lactic acid 0.9, INR 1.15, PTT 25. Urinalysis is significant for ketones 5, protein 10, nitrite positive, LE large, wbc greater than 182. Urine culture pending. IMAGING: X-ray of the abdomen revealed no air-fluid levels.
LE|leukocyte esterase|LE,|212|214|LABORATORY|Sodium 136, potassium 4.0, chloride 100, bicarb 25, BUN 24 with a creatinine of 1.10 with a glucose of 114. Calcium was 10.0. Troponin was less than 0.04. INR was normal at 1.05. U/A was significant for positive LE, a lot of white cells 154, small red cells of 3, few bacteria, few squamous epithelials, but there are positive clue cells.
LE|leukocyte esterase|LE.|128|130|HOSPITAL COURSE|Pain was controlled with p.o. medications. The patient did note some dysuria. UA showed positive white blood cells and moderate LE. It was decided to treat the patient with Cipro at discharge. Hemoglobin at discharge 11.3. Blood glucose 130. DISPOSITION: The patient was discharged on postoperative day #4 in stable condition.
LE|leukocyte esterase|LE,|257|259|DISCHARGE DIAGNOSIS|BUN/creatinine 11/0.8. Glucose 121, calcium 8.5, lipase 11, total protein 7.6, albumen 3.8, alkaline-phosphatase 135, ALT 21, AST 23, total bilirubin 0.2. CT of the abdomen showed no hydronephrosis, mild pyelonephritis. UA: Ketones 40+, proteins 100, trace LE, negative nitrates, moderate blood. Urobilinogen 1.0. This was a 40-year-old Hmong female with no significantly past medical history who comes with pyelonephritis.
LE|leukocyte esterase|LE.|194|196|PROBLEM #2|The patient underwent an hepatobiliary scan while inpatient that showed normal biliary excretion. The patient had a urinalysis during her stay, which showed large blood and trace protein, small LE. It was found, however, that the patient was menstruating at the time of this collection. An orotic acid from urine is pending at the time of discharge.
LE|left ventricle:LV|LE|256|257|HOSPITAL COURSE|Echocardiogram on _%#MMDD2003#%_ showed an EF of 35% and a large region of akinesis involving the apical anterior and septal and lateral segments. EKG performed shortly prior to discharge, showed an EF of 40 to 45% with mild to moderately decreased global LE dysfunction and a hypo to akinetic mid distal septal and apical region; hypokinetic lateral region as well. PROBLEM #1: Coronary artery disease with anterolateral MI. The patient should remain on Plavix for one month and pursue aggressive risk factor modification.
LE|leukocyte esterase|LE,|194|196|LABORATORY|Total protein 6.3. Alkaline-phosphatase 333. Total bilirubin 0.5. Lipase 1263, ammonia level 126. UA done in the emergency room showing a specific gravity of 1.022, pH 5.5, no glucose, ketones, LE, nitrates or white blood cells. There are 5 red blood cells per high-powered field as well as some calcium oxylate crystals.
LE|leukocyte esterase|LE|277|278|LABS ON ADMISSION|Hemoglobin 14.7, platelets 248. Sodium 138, potassium 4.2, chloride 101, bicarb 29, BUN 13, creatinine 0.8. Calcium was 9.1. INR 0.93. Lipase less than 10, amylase 40, PTT 25. Urinalysis was done showing 250 of glucose. Specific gravity was 1.014, moderate blood, negative for LE or nitrates. There are 5 white cells/hpf, 10 red cells/hpf. Liver enzymes: total bilirubin was 0.4, AST 20, ALT 21, alk. phos. 135, albumin 4.2, total protein 7.5. There is an MRI of the abdomen from _%#MM#%_ _%#DD#%_, 2003, which shows some packed cirrhosis and portal hypertension.
LE|leukocyte esterase|LE|181|182|PROBLEM #3|We recommended that she continue to take her oral medication, Amaryl, for her diabetes. PROBLEM #3: Genitourinary. The patient had positive ketones, positive bacteria, and positive LE and nitrites in her urine. We started the Cipro for this reason, and the patient had no complaints. We discharged her with the recommendation to continue the Cipro for seven more days, and we will recheck her urine culture and U/A three to four weeks after treatment.
LE|leukocyte esterase|LE|249|250|LABORATORY|LABORATORY: Notable for a creatinine of 1.7, white count of 34.8, and a troponin of 6.11. Electrocardiogram revealed flipped T-waves in leads V1 through V3, but no ST or T changes. Urinalysis was turbid red and reported to be milky. There was large LE and over 3700 white blood cells. HOSPITAL COURSE: PROBLEM #1: Non-Q-wave myocardial infarction. The patient was started on aspirin and metoprolol and remained stable.
LE|leukocyte esterase|LE.|337|339|LABS ON ADMISSION|LUNGS: Clear to auscultation. NEURO: Grossly within normal limits. LABS ON ADMISSION: White blood count 4.8. Hemoglobin 14.3, hematocrit 41.3, platelets 284, sodium 133, potassium 2.8, chloride 96, CO2 21, BUN 6, creatinine 0.6, glucose 81. A U/A showed greater than 80 ketones, specific gravity 1.024 with 30 of protein; albumin, small LE. Few amorphous crystals, few squamous epithelial cells. HOSPITAL COURSE: The patient was admitted and continued with IV hydration.
LE|leukocyte esterase|LE,|226|228|LABS ON ADMISSION|SKIN: Clear. NEUROLOGIC: With cranial nerves intact, sensation intact to touch and strength intact in her upper and lower extremities. LABS ON ADMISSION: Reveal urinalysis with 40 ketones, spec. grav. 1.025, 30 protein, trace LE, 3 WBCs and 4 RBCs. Urine HCG was negative. Lipase elevated at 1007, amylase elevated at 202. Basic metabolic was sodium 140, potassium 3.4, chloride 100, bicarb 29, BUN 7, creatinine 0.7, glucose 103, calcium 9.7. Hepatic panel was normal other than mildly elevated albumin and protein.
LE|lower extremity|LE|181|182||My key portions: 51 yo male with h/o retroperitoneal fibrosis for which he is currently on 5mg per day of prednisone presents with 3 d h/o L leg swelling. 2 years ago had extensive LE DVT involving the IVC trx with stents. Was on chronic coumadin. INR last week was 1.4. In clinic today INR was 2.5. Denies CP, SOB.
LE|lower extremity|LE|135|136|ASSESSMENT AND PLAN|Other medical conditions are currently stable. He will continue current treatment. He will be started on Keflex 500 mg twice daily for LE cellulitis.
LE|lower extremity|LE,|152|154|PHYSICAL EXAMINATION|No hepatosplenomegaly. CNS: Grossly intact. Reflexes are normal. Muscular strength is normal sensation is intact. MUSCULOSKELETAL: There is no edema of LE, no calf tenderness. PSYCHIATRIC: Mentation is intact. Normal mood and affect. SKIN: Lesion noted on right lower extremity which has been biopsied and evaluated by the dermatologist.
LE|leukocyte esterase|LE|200|201|PHYSICAL EXAMINATION|Sterile speculum exam reveals cervix parous, visually approximately 0.5 cm. There is no pool, fern or Nitrazine. Fetal fibronectin performed at _%#CITY#%_ _%#CITY#%_ was negative. UA reveals negative LE or negative nitrites. Wet prep reveals negative clue, yeast or Trich. IMPRESSION: A 23-year-old G3 P1-0-1-1 at 23 plus 5 weeks by stated EDC of _%#MMDD2007#%_ with dizygotic twin intrauterine pregnancy with preterm contractions, possible preterm labor.
LE|leukocyte esterase|LE,|208|210|DISCHARGE DIAGNOSES|He was urinating and stooling well, his normal enteral hydration was started as well as an oral diet. While he was in the hospital, some of his pertinent labs were a CSA level of 162, a urinalysis with small LE, 3 white blood cells and 1 red blood cell. He had few bacteria, some mucus and 9 Hyaline cast. White blood cell count was 8.2, hemoglobin 12, platelets 461,000.
LE|leukocyte esterase|LE,|203|205|ADMISSION LABORATORY DATA|ADMISSION LABORATORY DATA: White count 10.8, hemoglobin 12.6, platelets 263. Sodium 139, potassium 3.9, chloride 109, bicarbonate 24, BUN 16, creatinine 1.0, glucose 91. Urinalysis: trace protein, small LE, many bacteria, 2-5 white cells, no red cells. It was later found to have greater than 100,000 colonies of vancomycin- resistant Enterococci sensitive only to nitrofurantoin.
LE|leukocyte esterase|LE,|221|223|PAST GYN HISTORY|Cervix was 4.33 cm and appears closed, slight increased resistance in end- diastolic flow in umbilical artery. Urinalysis revealed 250 glucose, greater than 80 ketones, moderate blood. Specific gravity of 1.010, negative LE, negative nitrites, no white blood cells, 5-10 red blood cells. PHYSICAL EXAMINATION: Vital signs were blood pressure of 100/57, 98, 4 86.
LE|left ventricle:LV|LE|193|194|PROCEDURES PERFORMED|None of the lesions were flow limiting. However, flow down the coronary arteries was slow probably secondary to endothelial dysfunction. Left ventriculogram was suboptimal with multiple PVC's. LE function appeared normal. HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old male who developed substernal chest pressure approximately 10:30 a.m. the day of admission while walking down the street.
LE|leukocyte esterase|LE,|135|137|LABORATORY DATA|Carotid pulses were symmetrical with no bruits heard. LABORATORY DATA: Hemoglobin 12.3. White cell count 12.8. Urinalysis showed large LE, white cells, clumps and many bacteria. BUN and creatinine 20/1.7 respectively. Blood sugar 169. Liver function is normal. Platelet count 249,000. IMPRESSION: 1. This is an adult woman with clinical history and urinalysis evidence of urinary tract infection, probably right pyelonephritis.
LE|lower extremity|LE|168|169|IMPRESSION|3. Psychosis versus Wernicke's encephalopathy. 4. HTN. 5. New onset diabetes type 1. 6. Tachycardia secondary to above. 7. Recent weight loss secondary to diabetes. 8. LE venous stasis, some dermatitis. 9. Subcu skin coloration deposits lower extremities. PLAN: Per Neurology and alcohol withdrawal protocol.
LE|leukocyte esterase|LE|256|257|LABORATORY|Skin exam showed no rashes. Neuro exam was alert and orientated, full sensation and strength, reflexes were symmetric; otherwise, it was nonfocal. LABORATORY: On her admitting labs, urinalysis showed no white cells, no red cells, negative for nitrites and LE with a specific gravity of 1.010. Urine culture was negative. Sodium was 138, potassium 4.5, chloride 110, bicarb 22, BUN was 14, creatinine 0.9, glucose was 140, calcium was 9.2. White count was 5.8, hemoglobin 12.5, platelets were 385.
LE|leukocyte esterase|LE,|197|199|LABORATORY|No focal neurologic deficits. LABORATORY: CBC white count 15.8 with 82 neutrophils, 11 lymphocytes, hemoglobin 11.4, platelets 165. Troponin is less than 0.7 x2. UA large blood, 100 protein, large LE, many bacteria. BMP sodium 125, potassium 3.5, chloride 93, CO2 25, BUN 9, creatinine 0.63, glucose 124, calcium 8. EKG per my interpretation normal sinus rhythm at 75 with no ST, T abnormalities.
LE|leukocyte esterase|LE|513|514|LABORATORY DATA ON ADMISSION|No edema of left leg. SKIN: No rashes. NEUROLOGIC: Alert and cooperative. Facies symmetric, grossly intact. Motor 4-5/5 throughout. LABORATORY DATA ON ADMISSION: White count 0.3, hemoglobin 9.8, platelets 5, sodium 133, potassium 3.2, chloride 107, bicarbonate 22, BUN 13, creatinine 0.95, glucose 95, magnesium 1.5, phosphorus 2.4, calcium 8.9, INR 1.14, PTT 36, fibrinogen 359, anti 10A 0.1. Urinalysis 500 glucose, pH 7.5, small amount of blood, specific gravity 1.009, trace albumin, negative for nitrites or LE HOSPITAL COURSE: PROBLEM #1: FEN/GI. Amy was given a fluid bolus of 500 cc normal saline upon admission and was started on maintenance IV fluids.
LE|leukocyte esterase|LE.|159|161|LABORATORY DATA|Abdominal x-ray shows air-fluid levels with no obvious dilated loops of bowel, may be left upper extremity Doppler shows no DVT. UA shows nitrite and positive LE. PLAN: The patient was transferred to the hospital for further closer monitoring and to have IV parenteral nutrition and monitor respiratory status closely and because of renal insufficiency.
LE|lower extremity|LE|704|705|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY 1) ESLD secondary to ETOH. Sober since last year. Refractory ascites. 2) CKD baseline fluctuating but between 1.5-2.2, felt to have intermittent worsening secondary to hepatorenal syndrome 3) Purulent Group B strep pericarditis s/p subxiphoid pericardial window, drainage, partial pericardectomy, and placement of irrigation/drainage system into the pericardium _%#MMDD2004#%_ 4) esophageal varices 5) h/o UGI bleed with hematemesis (presentation of cirrhosis diagnosis about 1 year ago) 6) chronic hyponatremia, hypocalcemia, hypokalemia 7) chronic hypotension, baseline systolic 80-90, on fludrocortisone and midodrine 8) h/o hepatic encephalopathy 9) s/p appendectomy 10) chronic LE edema CURRENT MEDICATIONS include one dose of gentimicin today, imipenem, rocaltrol, phoslo, lactulose, cipro qweek, diphenhydramine, fludrocortisone, folate, prednisone, NaHCO3 tabs, lasix, metronidazole (stopped today), oxycontin, oxycodone prn, ursodiol, rifaxamin, pipercillin/tazobactam since _%#MMDD#%_.
LE|lower extremity|LE|138|139|ROS|Has chronically draining RLQ peritoneal-cutaneous fistula resulting from paracentesis, and problems with infections if foleys are placed. LE edema unchanged from baseline. PHYSICAL EXAM Vitals reviewed. BP's chronically in the 80's systolic, asymptomatic.
LE|leukocyte esterase|LE|130|131|HOSPITAL COURSE|3. Urinary tract infection: The patient had some urinary frequency and prior to discharge she had a UA done. This showed positive LE and white cells, however, she became asymptomatic at the time of discharge. We sent in a prescription for ciprofloxacin to be filled if her symptoms returned or her culture comes back positive.
LE|leukocyte esterase|LE|189|190|ADMISSION PHYSICAL EXAMINATION|Her RSV was negative. Blood cultures remained negative to day at time of discharge. A urine was also sent and urinalysis appeared negative, but was positive for ketones, had no WBC and was LE trace positive. Her urine culture did come back less than 1,000 colonies of beta-hemolytic strep. This was thought to be contaminate and was not treated.
LE|UNSURED SENSE|LE.|130|132|HOSPITAL COURSE|Laboratory studies during this hospitalization included an electrolyte panel at admission which was unremarkable except for a low LE. LFTs also unremarkable except for a slightly low albumin of 3.1. A hemogram was notable for slight leukopenia of 3.4. Hepatitis screen was negative for hep B surface antigen and hepatitis C antibody.
LE|leukocyte esterase|LE|196|197|LABORATORY|LABORATORY: Labs on admission included a white count of 7.5, hemoglobin 10, platelets 287,000. Electrolyte panel was normal. Liver and pancreatic enzymes normal. Urine HCG negative. UA with large LE and 5 white cells. No red cells or casts appreciated. HOSPITAL COURSE: The patient is a 26-year-old female with insulin- dependent diabetes mellitus since age 16 years old who presented with intractable nausea and vomiting for 8 or 9 days, dysuria, left flank pain.
LE|leukocyte esterase|LE,|213|215|ADMISSION LABS|ADMISSION LABS: White blood cell count of 5.5. Hemoglobin of 10.0, platelets of 97, sodium 146, potassium 4.9, chloride 122, bicarb 18, BUN 97, creatinine 3.1, glucose of 85. Urinalysis was negative for nitrites, LE, and white blood cells but did show a small amount of blood. BNP was 2140, INR 2.91, calcium 8.7, albumin 2.8, total protein 5.7, troponins less that 0.07. Chest x-ray showed bilateral pleural effusions.
LE|leukocyte esterase|LE.|130|132|LABORATORY DATA|NEUROLOGIC: Nonfocal. The patient is alert and oriented. LOWER EXTREMITIES: No edema. LABORATORY DATA: U/A showed trace blood and LE. Troponin less than 0.7. Basic metabolic profile: sodium 143, potassium 4.2, chloride 100, CO2 29, BUN 51, creatinine 2.6, glucose 124, total protein elevated at 8.6, LFTs stable.
LE|leukocyte esterase|LE.|143|145|HISTORY OF PRESENT ILLNESS|Creatinine is 1.09. Her UA showed 40 ketones, moderate blood, white blood cells 338, red blood cells of 8; she has positive nitrites and large LE. HOSPITAL COURSE: The patient was admitted to 7C for IV antibiotics which consisted of ciprofloxacin 400 mg b.i.d., for IV hydration, and to follow her labs.
LE|leukocyte esterase|LE|385|386|LABORATORY DATA|There is no right upper quadrant tenderness. Bowel sounds are normoactive. EXTREMITIES demonstrate 1+ edema with multiple varicose veins. LABORATORY DATA: CK is elevated at 912, normal CKMV with a myoglobin of greater than 500, troponin is less than 0.05. CBC with a white count of 7.1, hemoglobin 13.7, electrolytes demonstrate sodium of 130, creatinine is 1.0. Urinalysis: 3+ blood, LE and nitrite negative but he does have 1 to 3 WBC's as well as 10 to 15 RBC's. Liver function tests demonstrate some elevated alkaline phosphatase of 224, total bilirubin of 2.08 and AST of 54.
LE|leukocyte esterase|LE,|143|145|SIGNIFICANT LABORATORY AND STUDIES|This was decreased to 13,000 on the day of discharge. UA at the time of admission revealed significant ketones, protein, moderate blood, large LE, negative nitrites, many bacteria and bacterial clumps with 23 squamous cells. Urine culture from _%#MMDD#%_ was negative at the time of discharge.
LE|leukocyte esterase|LE|275|276|LABORATORY DATA ON ADMISSION|Irritation but does not appear to be frank cellulitis. LABORATORY DATA ON ADMISSION: White count 14.4, 82% neutrophils, 7% lymphocytes, hemoglobin 16.8, platelets 250. Blood culture is pending. Urine shows moderate bacteria with less than 1 white cell and 0 red cells. Micro LE and nitrates are negative. BMP is pending. Stool studies, including C. diff antigen, C. diff culture, bacterial pathogens and ova and parasites are pending.
LE|lower extremity|LE|212|213|PAST MEDICAL HISTORY|SPO corrective surgery at three months old, but has had life long LVP without radiculopathy and lack of urethral tone with urgency. She has also _____ and _____. Laparoscopic cholecystectomy in 1997. She has had LE edema for about 20 years, but has been worse lately, especially acute yesterday, left greater than right. Known hyperlipidemia treated with Lipitor. She has known morbid obesity.
LE|leukocyte esterase|LE,|220|222|LABS|SKIN: Warm and dry. MUSCULOSKELETAL: Extremities: No edema. NOSE, MOUTH And THROAT: Oral mucosa moist. NEURO: No focal deficits at baseline. LABS: White blood cell count 6.3, hemoglobin 12.4, platelets 103, U/A positive LE, white blood cells 15, RBC 22. Sodium 137. Potassium 3.5. Chloride 111. CO2 23. BUN 3. Creatinine .8, glucose 121, BUN 3, creatinine .8, glucose 121, mag 1.7, phos.
LE|leukocyte esterase|LE,|159|161|PRENATAL LABS|PRENATAL LABS: She is A positive, antibody negative, rubella immune. No GCT done. No GBS done. Urinalysis shows greater than 80 ketones, moderate blood, trace LE, 5 to 15 white blood cells and 4-10 RBCs. An ultrasound on _%#MM#%_ _%#DD#%_, 2004, at 30 plus 5 showed an estimated date of confinement of _%#MM#%_ _%#DD#%_, 2004, questionable amniotic (_______________) around lower extremities with femur leg significantly discrepant from abdominal circumference and BPD for dating.
LE|leukocyte esterase|LE|286|287|LABORATORY DATA|Right-sided spastic paresis of the lower and upper extremities. LABORATORY DATA: Sodium 137, potassium 3.2, chloride 101, bicarb 23, BUN 17, creatinine 0.95, glucose 148, calcium 9.4. White blood count 13, hemoglobin 13.1, platelets 437, ANC 9.3, INR 1.03, PTT 34. UA nitrite positive, LE large, wbc's 25 to 50; many bacteria. AST 31, ALT 15, alkaline phosphatase 103, bilirubin 0.4, protein 1.9, albumin 4.1. IMAGING: CT of head showed old CVA on left side.
LE|leukocyte esterase|LE,|292|294|LABORATORY|Bimanual exam was deferred as the patient was menstruating. She did not have CVA tenderness with percussion. LABORATORY: White blood cell count 9.5, hemoglobin 14.5, platelets 327,000, 58% neutrophils, 35% lymphocytes, 6% monocytes, UA had a specific gravity of 1.016 with large blood, small LE, 37 white blood cells, and 27 RBCs, which is improved from an initial CBC with 878 white blood cells and 66 red blood cells and many bacteria.
LE|leukocyte esterase|LE,|158|160|LABORATORY|Chest x-ray: Retrocardiac infiltrate in the right middle lobe, suspicious for pneumonia. Urinalysis: Ketones 15, specific gravity 1.023, trace albumin, small LE, and no nitrites. Microscopic, 2 to 5 whites and moderate bacteria. Urine culture and blood culture obtained on admission.
LE|leukocyte esterase|LE,|219|221|LABORATORY DATA|BMP shows sodium 135, potassium 4.3, chloride 98, bicarbonate 28, BUN 18, creatinine 0.9. Glucose is 139. Troponin is less than 0.07. Blood cultures are pending. Urinalysis shows some moderate amount of blood, moderate LE, WBC clumps present, many bacteria seen. Urine culture is pending. Chest x-ray reviewed by me, I did not see a definite infiltrate.
LE|leukocyte esterase|LE|217|218|LABORATORY TESTS|EXTREMITIES: No edema. NEUROLOGIC: Alert and oriented x3. There is fine tremors of her hands, otherwise no focal deficit. LABORATORY TESTS: Shows pregnancy test negative and urine drug screen is negative. Urine shows LE positive WBC 34, phosphorus 1.2. LDH 799, GGT 1019. INR 1.13. Lipase and amylase are within normal limits. ALT 53, AST 287, bilirubin 7.8. Repeat LFTs are still pending.
LE|leukocyte esterase|LE,|230|232|LAB ON ADMISSION|Basic metabolic profile sodium 137, potassium 4.3, chloride 96, bicarbonate 21, BUN 17, creatinine 1.2, glucose 410. AST 169, ALT 136, alk phos 165. UA showed 500 glucose, positive ketones x2, small blood, negative protein, small LE, negative nitrite. EKG showed sinus tachycardia but was otherwise normal sinus rhythm. HOSPITAL COURSE: There was consult with endocrinology and their recommendations were to check peptide C, glucose and GAD antibody.
LE|leukocyte esterase|LE,|134|136|PHYSICAL EXAMINATION ON ADMISSION|PHYSICAL EXAMINATION ON ADMISSION: See physical exam. Pertinent positives include left flank pain. WBC of 27.5. UA positive nitrites, LE, wbc's, and moderate bacteria. Beta HCG negative. COURSE IN HOSPITAL: The patient was started on IV ceftriaxone and improved over the course of two to three days.
LE|lower extremity|LE|380|381|IMPRESSION|RECTAL/GENITALIA: Deferred. IMPRESSION: 1. Chest pain, rule out angina, rule out MI in a patient with history of coronary artery disease, status post 1988 coronary artery bypass graft and four PTCAs since, with history of frequent hospitalizations for chest pain always with negative cardiac markers and EKGs. 2. Diabetes type 1. 3. Hyperlipidemia. 4. Hypertension. 5. History of LE edema. 6. GERD. 7. Minimal CHF. 8. Hypothyroidism. 9. 60+ year pack history of nicotine addition, smoking from 1945-1971 and ten two packs per day.
LE|lower extremity|LE|246|247|PROCEDURES PERFORMED|The patient has, over the past several days, had critical improvement after receiving a tracheostomy and able to tolerate trach dome trials rather frequently. PROCEDURES PERFORMED: 1. Renal ultrasound showing normal sized kidneys bilaterally. 2. LE ultrasound showing no sort of deep venous clot. 3. Multiple chest x-rays that showed no infiltrate or effusion
LE|leukocyte esterase|LE|211|212|LABS ON ADMISSION|She had positive dependent edema. LABS ON ADMISSION: Hemoglobin 9.6, white count 15.1, platelets 301, BMP 1050, digoxin level 1.0, troponins less than 0.07, creatinine 3.7, BUN 82. UA showed ____ at 1010, large LE 10-50 white blood cells, 10-25 RBCs. This was a Foley specimen. Chest x-ray showed bilateral pleural effusions without any overt ___.
LE|leukocyte esterase|LE,|271|273|LABORATORY DATA|Sodium 127, potassium 3.8, chloride 86, bicarbonate 33, BUN 18, creatinine 0.68, glucose 128, calcium 8.9, ALT 14, AST 25, alkaline phosphatase 87, total protein 7.3, total bilirubin 0.6. INR 0.98, PTT is 27. Troponin is negative. UA showed ketones 15, protein 30, trace LE, white blood cell 2 to 5, hyaline casts 5 to 10. IMAGING: Chest x-ray: Hyperinflated, no infiltrate, positive fluid in the fissure.
LE|leukocyte esterase|LE,|150|152|LABS|ABDOMEN: Soft and nontender. Bowel sounds present. EXTREMITIES: No edema. Pulses present. LABS: Urinalysis shows trace ketones, moderate blood, large LE, more than 100 WBCs, 5-10 RBCs, moderate bacteria. Hemoglobin is 15.7, hematocrit 49.1, white count 33.1, platelets 181, BNP shows sodium 168, potassium 3.7, chloride 119, bicarb 28, BUN 85, creatinine 3.8, glucose 164, BNP is 877.
LE|lower extremity|LE|334|335|HEENT|Pt mood is at baseline. PMH, FH, SH, ROS as per resident note. Exam: Gen: lying in bed, tired appearing, alopecia HEENT: EOMI, PERRLA, A&Ox3 Pulm:CTABL CV:nl s1s2 no m/r/g Abd:soft nt/nd nl bs Neuro: 3/5 strength with eye closure, 4/5 shoulder shrug, cranial nerves otherwise intact, 3/5 proximal UE strength, 3/5 proximal and distal LE strength, 1+ left patellar refelx, no reflex on right, no ankle jerks,no clonus Labs, radiology studies, and medications reviewed.
LE|leukocyte esterase|LE,|157|159|LABORATORY DATA|NEUROLOGIC: Notable cogwheeling. LABORATORY DATA: CBC: White count 9.2. Hemoglobin 10.3. Platelets 211. Urinalysis small blood, 5 ketones, 10 protein, trace LE, few bacteria. BMP is normal with BUN of 19, creatinine 1.3. ASSESSMENT AND PLAN: _%#1914#%_ male with generalized weakness and urinary retention likely related to his Parkinson's.
LE|leukocyte esterase|LE.|408|410|LABORATORY DATA|Note differential - 82% neutrophils, 12% lymphocytes. Sodium is 140, potassium 3.8, chloride 109, bicarb 24, BUN 11, creatinine 0.7, glucose 91, calcium 8.4, total bilirubin 0.2, alkaline phosphatase 76, ALT 18, AST 14, albumin 3.7, total protein 7, amylase 47, lipase 61. Urine tox positive for amphetamines, cannabinoids, opiates. HCG negative. Urinalysis positive for ketones. Negative nitrates, negative LE. Imaging: Cholelithiasis on ultrasound without wall thickening, plus sonographic Murphy sign.
LE|leukocyte esterase|LE,|159|161|LABORATORY DATA|Calcium 9.6. Blood cultures pending. Influenza A and B antigens negative. Rapid strep is negative. Culture is pending. Urine is clear. Protein 30 mg/dL, large LE, negative nitrites, WBC 21, red blood cell 10. Urine culture is pending. IMAGING: Chest x-ray shows mild bibasilar atelectasis or possibly small infiltrates.
LE|leukocyte esterase|LE,|156|158|HOSPITAL COURSE|A GI consult felt that with normal imaging and no fever, an infection was unlikely. A UA showed specific gravity of 1.038, 10 protein, negative nitrite and LE, 3 wbc, 2 rbc. Urine culture grew less than 10,000 colonies of Gram positive cocci. GI felt like noninvasive imaging with EGD and colonoscopy should be pursued as an outpatient.
LE|leukocyte esterase|LE,|154|156|LABORATORY DATA|LABORATORY DATA: Her labs include white count of 20.3 with a left shift. Her blood culture was negative initially. Beta hCG was negative. UA showed large LE, greater than 102 white blood cells and negative nitrates. Rapid Strep was negative. Wet prep included rare yeast and GC and chlamydia cultures were pending.
LE|lower extremity|LE|169|170|HPI|He has a chronic cough w/ occ clear sputum production that has not increased. He denies hemoptysis, Fever/chills. No PND/orthopnea, no CP/diaphoresis/nausea. He has occ LE edema and compression stockings help sx. He does not that combivent inhaler helps symptoms but he uses it as needed. . ROS positive for increasing fatigue and anorexia in the past 2 weeks w/ 10 lb. weight loss in the past 2 weeks.
LE|leukocyte esterase|LE,|203|205|HOSPITAL COURSE|Her symptoms did continue, although she had been on linezolid for approximately 2 weeks p.o. and IV therapy prior to that that was begun on _%#MMDD2007#%_. Her urinalysis showed positive nitrates, large LE, large blood, and many bacteria. She was symptomatic with back pain that was most likely related to pyelonephritis. Secondary to those findings, she was admitted and given IV hydration and pain control.
LE|leukocyte esterase|LE,|150|152|HISTORY OF PRESENT ILLNESS|She is also DNR/DNI and has started to consider hospice care and is not interested in dialysis treatment. A UA/UC was also done which showed negative LE, negative nitrites; mixed culture, likely perineal contamination, but that reports says it is final. 3. Constipation. The patient was given Senna-S and did well with this bowel regimen and had relief.
LE|leukocyte esterase|LE,|123|125|LABORATORY DATA|Skin is otherwise dry with significant excoriations. LABORATORY DATA: Labs including urinalysis with positive blood, trace LE, 10-25 white cells and red cells. Culture will be ordered. Myoglobin is slightly elevated at 336, previously elevated in the 600-700 range at past hospitalizations.
LE|leukocyte esterase|LE,|210|212|LABORATORY|No hepatosplenomegaly. GYNECOLOGY: Deferred. EXTREMITIES: Showed trace edema bilaterally. ASSESSMENT: A 65-year-old with recurrent ovarian cancer, now febrile with urinary tract infection. LABORATORY: UA large LE, 23 red cells, 69 white cells and negative nitrites. Hemoglobin 11.9, A1c 2.5, white blood cell count 2.9 and platelets 199,000.
LE|leukocyte esterase|LE,|268|270|LABORATORY DATA|LABORATORY DATA: Hemoglobin 10.6, white count 11.7, platelets 679,000. Sodium 134, potassium 3.5, chloride 96, bicarb 28, BUN 21, creatinine 0.82, glucose 94, INR 3.91, troponin negative, AST 25, ALT 15, amylase less than 30, lipase 28. UA shows small blood, moderate LE, greater than 182 white blood cells, 12 red blood cells, many bacteria, white blood cell clumping, 33 hyaline cast. IMAGING: CT scan shows, 1. Large ascites. 2. Small left pleural effusion with associated atelectasis and consolidation.
LE|leukocyte esterase|LE,|325|327|LABS ON ADMISSION|No cerebellar deficits. LABS ON ADMISSION: White count 6.5. 79% neutrophils, 11% lymphocytes, hemoglobin 12.8, platelets 128, sodium 139, potassium 5.1, BUN 50, creatinine 2.31, glucose 101, calcium 8.7, magnesium 2.2. INR 1.55. TSH 2.04, digoxin slightly elevated at 2.1 and U-tox positive for opiates and THC. UA: moderate LE, 2 white cells and 3 red cells, negative nitrites. Urine culture pending. CT scan of head shows mild cerebral atrophy without evidence for acute injury.
LE|leukocyte esterase|LE,|228|230|LABS ON ADMISSION|LABS ON ADMISSION: White count 6.9, hemoglobin 11.8. INR 2.79. Sodium 134, potassium 4.7, BUN 28, creatinine 1.51, glucose 91, calcium 9.2. N-terminal proBNP 4400, troponin less than 0.04. UA: 3 white cells, no red cells, trace LE, negative blood. Urine culture are pending. Spinal x-ray initial read shows a compression fracture at L1 as described above, with new compression fracture at T12.
LE|lower extremity|LE|193|194|KEY IMAGING STUDIES AND PROCEDURE PERFORMED DURING THIS HOSPITALIZATION|The right ventricle was mild to moderately dilated. Mild decreased right ventricular systolic function. 3. Renal ultrasound on _%#MMDD2007#%_. Impression: Normal renal ultrasound. 4. Bilateral LE doppler US on _%#MMDD2007#%_. No DVT. ADMISSION HISTORY: Please see the H&P by Dr. _%#NAME#%_ on _%#MMDD2007#%_ for complete details. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was admitted with tachycardia.
LE|leukocyte esterase|LE|461|462|LABORATORY|Sodium 132, potassium 3.2, chloride 100, bicarbonate 32, BUN 7, creatinine 0.39, glucose 96, calcium 7.5, magnesium 1.8, and phosphorus 6.1. Blood culture and urine culture eventually showed no growth. CRP is 2.20. TSH 6.17, normal range 0.4 to 0.5. Free thyroxin 0.59, normal range 0.7 to 1.85. Albumin 1.7, normal range 3.3 to 4.6. Total protein 4.9, normal range is 5.7 to 7.9. UA showed over 80 ketones, small blood, over 300 protein, negative nitrites and LE 0 to 2, white cells 10 to 25, red blood cells 0 to 2 hyaline casts. The specific gravity was 1.034 and pH of 6.0. Total urine protein was 25, protein-to-creatinine ratio was 15.63, normal is up to 0.2. HOSPITAL COURSE: PROBLEM #1.
LE|leukocyte esterase|LE.|297|299|HISTORY OF PRESENT ILLNESS|Sodium of 139, potassium of 3.5, chloride of 106, bicarb 25, BUN of 8, creatinine of 0.62, blood glucose of 100, and calcium of 9.6. A chest x-ray was read to be normal. An AP lateral of this lumbar spine was shown to be normal. Urinalysis was normal without ketones, blood, protein, nitrites, or LE. White blood cells were less than 1 and red blood cells were less than 1. An abdominal and pelvic CT showed no definite abnormalities in his abdomen.
LE|leukocyte esterase|LE,|287|289|LABORATORY|PHYSICAL EXAMINATION: Vital signs within normal limits. No fevers notable for postoperative changes on the right thoracic area and rib cage, but good air movement bilaterally without crackles or wheezes. LABORATORY: White count 7.9, hemoglobin 11.9, platelets 577, negative UA, negative LE, negative nitrite, 2 white blood cells, 3 rbc's, BMP within normal limit, creatinine 1.18, BUN 17. HOSPITAL COURSE: _%#NAME#%_ underwent treatment with ifosfamide, etoposide, and mesna.
LE|leukocyte esterase|LE,|146|148|LABORATORY STUDIES|LABORATORY STUDIES: Laboratories drawn at the time of presentation included an AST of 21, ALT 22, uric acid 5.6, BUN 10. UA 1+ protein with trace LE, platelets 183, hemoglobin 13.4, white count 9.1. The patient was consented for primary C-section after discussion of the risks, benefits, and alternatives, and was taken to the operating room on _%#MMDD2006#%_.
LE|leukocyte esterase|LE|196|197|LABORATORY DATA|Calcium is 8. ALT and AST are 92/85. Otherwise bilirubin, albumin, total protein and alkaline phosphatase are all normal. Urinalysis is significant for 5 white cells and 3 red cells, but negative LE and negative nitrites. Urine culture and blood culture are both pending. ASSESSMENT AND PLAN: 1. History of recurrent febrile illness, this with pancytopenia. Will start Solu-Medrol 125 mg initially and 60 mg q.8 h., and consider change to p.o. prednisone.
LE|leukocyte esterase|LE,|170|172|ADMITTING LABS|ADMITTING LABS: Include white count of 9.7, hemoglobin of 11.5 and platelets of 275. ANC is 7.6. Electrolyte panel is within normal limits. UA shows large ketones, large LE, positive nitrites, greater than 182 white blood cells with clumps, moderate bacteria, blood and protein. HOSPITAL COURSE: The patient was admitted to the hospital. Her diagnosis was pyelonephritis.
LE|leukocyte esterase|LE,|233|235|LABORATORY DATA ON ADMISSION|LABORATORY DATA ON ADMISSION: White blood cell count 6.3, hemoglobin 9.5, platelet count 115, MCV 79, lipase 222, lactic acid 1.2, alkaline phosphatase 182, albumin 2.7, calcium 7.7. UA showed 30 of protein, positive nitrites, large LE, 148 white blood cells, and many bacteria. BMP was normal. HOSPITAL COURSE: PROBLEM #1: UTI/urosepsis. The patient was started empirically on Levaquin IV in the emergency department.
LE|leukocyte esterase|LE,|166|168|LABORATORY DATA|Sodium 133, potassium 4.0, BUN 21, creatinine 1.0, glucose 119, total bilirubin was 2.1, troponin was 0.5. Urinalysis notable for trace ketones, trace albumin, trace LE, and few bacteria. Head CT revealed opacification of ethmoid sinuses and some diffuse calcifications. EKG showed normal sinus rhythm. No acute changes. Chest x-ray per Emergency Room report showed bilateral infiltrates, left greater than right.
LE|leukocyte esterase|LE.|180|182|PROBLEM#9|Her ferritin this admission was 81. We have increased her ferrous gluconate to twice daily. PROBLEM#9: UTI: Pt had low fever on hospital night two. UA showed 18 WBCs with positive LE. Culture grew >100K beta-hemolytic strep, sensitivities not done. She was started on a 5-day course of bactrim. WBC count remained normal.
LE|leukocyte esterase|LE|346|347|LABORATORY DATA|SKIN: Appears pale. NEUROLOGIC: The patient is oriented to self, is unable to move her left side at all. LABORATORY DATA: White blood count 18.4, hemoglobin 8, platelet count 511, sodium 132, potassium 4.4, chloride 97, bicarbonate 18, BUN 152, creatinine 1.9, calcium 9.4, INR 1.1. Troponin less than 0.7. Urinalysis revealed large blood, large LE 14, 329 white blood cells, 1200 red blood cells, many bacteria and many white blood cell clumps. Reticulocyte count 2.3%. ASSESSMENT AND PLAN: _%#NAME#%_ _%#NAME#%_ is a 69-year-old female status post CVA who presented to the Emergency Department from the nursing home with altered mental status and decreasing hemoglobin, with increasing white blood count, hematuria, and possible GI bleed.
LE|leukocyte esterase|LE|168|169|LABORATORY|LABORATORY: On admission demonstrated a white count of 12.6, hemoglobin 14.1, and platelets 539 with normal electrolytes. UA was particularly demonstrative of moderate LE with 7 wbc's and 5 rbc's. Chest x-ray demonstrates no infiltrates. HOSPITAL COURSE: 1. Influenza A infection: The patient did remarkably well throughout the course of her hospitalization with influenza A.
LE|leukocyte esterase|LE,|138|140|LABORATORY ON ADMISSION|TSH 1.63, FANA negative, BUN and creatinine within normal limits. Admission labs include UA that is significant for 300 of protein, small LE, negative nitrites, 43 WBCs, 3 RBCs and moderate bacteria. Urine toxicity drug screen is negative. White blood cell count 6.9, hemoglobin 13.0 and platelet count 118,000.
LE|leukocyte esterase|LE|264|265|LABORATORY DATA|CARDIOVASCULAR: Heart regular rate and rhythm. No murmurs. LABORATORY DATA: White blood cell count 9.5. Hemoglobin 11.1. Platelets 243. BUN and creatinine 32 and 1.29 respectively. Liver function tests are within normal limits. Negative troponin evaluation. UA Lg LE and WBC IMAGING: Chest x-ray LLL Pneumonia ASSESSMENT AND PLAN: _%#1914#%_ male with a history of Parkinson disease is admitted for increased cough shortness of breath and fever PROBLEM # 1: LLL Pneumonia - NH acquired pneumonia.
LE|leukocyte esterase|LE,|121|123|LABORATORY VALUES AND IMAGING|There was no fluid wave noted. EXTREMITIES: Nontender without edema. LABORATORY VALUES AND IMAGING: UA 40 ketones, trace LE, 30 protein, 5 WBC and 1 RBC. WBC is 8.5, hemoglobin 11.1, platelets 375,000, INR 1.0, PTT 35, sodium 139, potassium 3.5, chloride 100 and bicarbonate 28, BUN 14, creatinine 0.88, glucose 163, calcium 9.2, total bilirubin 0.4, alkaline phosphatase 69, ALT 27, AST 40, amylase 58, lipase 85 and lactic acid 0.9. On imaging, CT, abdomen and pelvis showed multiple new hypodense lesions including liver lesions and increased ascites.
LE|leukocyte esterase|LE|164|165|PHYSICAL EXAMINATION|Liver function tests are normal. Amylase is normal at 92, lipase elevated at 582. Urinalysis notable for granular casts, protein 30, glucose 100, negative nitrate. LE chest xray reported per the ED, left basilar infiltrate. ASSESSMENT/PLAN: 85-year-old female with acute onset of nausea, vomiting, fall and found to have elevated lipase.
LE|lower extremity|LE|184|185|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Stage III lymphedema, treated with daily lymph drainage. 2. Epilepsy. 3. Atrial fibrillation since 1995. 4. Vertigo. 5. Anal fistula. 6. Left knee surgery. 7. LE cellulitis. ADMISSION MEDICATIONS: 1. Dilantin 300 mg p.o. q.d. 2. Lanoxin 0.125 mg p.o. q.d.
LE|leukocyte esterase|LE,|191|193|LABS|An EKG showed borderline LVH with some left axis deviation and a prolonged QT corrected at 556. The patient's UA was completely normal with 10 red blood cells, no white blood cells, negative LE, negative nitrites, but with 30 mg of protein and small blood. The patient was admitted for the workup of her cellulitis.
LE|leukocyte esterase|LE,|267|269|LABORATORY DATA|Cranial nerves were intact. Mental Status: Intact. RADIOGRAPHIC STUDIES: Abdominal CT scan revealed gallstone with dilated gallbladder with thickness of the wall. LABORATORY DATA: White blood cell count 11.1, hemoglobin 13.1. Urinalysis revealed trace albumin, small LE, negative nitrate. WBC 14, RBC 1, ........., potassium 3.2, sodium 141, sodium 103, BUN 39, creatinine 1.4, glucose 94. .... ..............PSA 4.6, alkaline phosphatase 19. ELECTROCARDIOGRAM: Revealed sinus rhythm with left bundle branch block, left axis deviation.
LE|leukocyte esterase|LE.|130|132|PHYSICAL EXAMINATION|Urea nitrogen is 9. Creatinine is 0.3, calcium is 8.5. Urine 80, greater than 80 ketones. Trace blood. Positive nitrate, moderate LE. 10-25 WBCs, moderate bacteria. White count is 17.4, hemoglobin is 11.7. Platelets are 437. IMPRESSION: A 67-year-old male with post polio syndrome and pneumonia and what appears to be urinary tract infection, elevated white count, hypotension, possibly urosepsis versus sepsis.
LE|lower extremity|LE|173|174|HOSPITAL COURSE|On postoperative day #1, however, he responded appropriately to diuretic therapy and strong pulmonary toilet which included overnight BiPAP. MI was ruled out. Dupelx U/S of LE was negative and there was low clinical suspicion of PE. By postoperative day #2, the patient's respiratory status had stabilized greatly and he was tolerating nasal cannula oxygen.
LE|lower extremity|LE|106|107|ASSESSMENT AND PLAN|LABORATORY DATA: No laboratory studies have been drawn at this point. ASSESSMENT AND PLAN: 1. PROGRESSIVE LE EDEMA. We will go ahead and give Lasix 20 mg IV tonight and then Torsemide 10 mg p.o. q.a.m., monitoring daily weights and I's and O's.
LE|lower extremity|LE|185|186|ASSESSMENT AND PLAN|We will check his liver function tests, albumin and urinalysis to screen for both liver disease and nephrotic syndrome. PT and OT will be consulted to help him with ambulation, etc. 2. LE CELLULITIS, nondiabetic & not allergic to any medication. Try cefazolin 1 gram IV q.8h. since it is not too bad of a cellulitis and certainly he does not think it is worse than it has been in the past several years.
LE|leukocyte esterase|LE,|232|234|HOSPITAL COURSE|Comprehensive OB ultrasound was performed, which she showed an estimated fetal weight of 888 g, 46th percentile, breech presentation, normal AFI and normal anatomy. Urinalysis was performed, which showed negative nitrites, negative LE, 19 red blood cells and no white cells. Urine culture was negative. On _%#MMDD2007#%_, the patient reported significant improvement of her pain and desired discharge home.
LE|leukocyte esterase|LE,|216|218|ADMISSION LABORATORY|NEUROLOGICAL: Cranial nerves II through XII intact. Pedal pulses +2 bilaterally. ADMISSION LABORATORY: White count 5.8. Hemoglobin 12.2. Platelet count 143,000. Hematocrit 38. Urinalysis with trace protein, moderate LE, 5 to 10 whites, red blood cells 2 to 5, moderate bacteria. Electrolytes: Sodium 136, potassium 4.4, BUN 28, creatinine 0.92, glucose 122, GFR 63.
LE|leukocyte esterase|LE,|126|128|LABORATORY|NEUROLOGIC: Cranial nerves 2 through 12 grossly intact. LABORATORY: Urinalysis: Specific gravity 1.016, moderate blood, trace LE, negative nitrites, many amorphous crystals, HCG was negative. Urine culture ultimately grew out 10 to 15 mixed Gram positive flora, suspect contamination.
LE|leukocyte esterase|LE,|198|200|LABORATORY DATA|LUNGS: Clear to auscultation. ABDOMEN: Benign. EXTREMITIES: He has no lower extremity swelling or edema. SKIN: No worrisome lesions. NEUROLOGIC: No focal deficits. LABORATORY DATA: UA with moderate LE, large blood, specific gravity greater than 1.030. Microscopic does show many bacteria; culture is pending at this time. White count elevated at 15.1, hemoglobin 13.0. INR slightly elevated at 1.24. His metabolic panel, electrolytes are normal.
LE|left ventricle:LV|LE|159|160|DISCHARGE DIAGNOSES|CT of the head revealed prior basal ganglia injury, otherwise no acute changes. Bilateral carotid ultrasounds were less than 50%. Echocardiogram revealed mild LE with a normal ejection fraction, grade II diastolic dysfunction. MRI/MRA one week ago apparently noted atrophy only. Dr. _%#NAME#%_ noted that her MRI, 2-D echo and carotids were essentially normal and did note that she had benign positional vertigo versus a questionable TIA type symptoms and she would be well covered on a combination of one baby aspirin per day.
LE|leukocyte esterase|LE|186|187|LABORATORY DATA ON ADMISSION|Lab is 45. INR 1.43, AST 160, ALT of 37, alkaline phosphatase of 387, albumin 3.1, calcium 8.6. Electrolytes within normal limits on admission but now potassium is 3.3. Urinalysis shows LE positive, WBC is 22, RBC of 3. Hemoglobin is down to 11.4. INR is down to 1.27. Magnesium is 1.6.
LE|leukocyte esterase|LE|164|165|LABORATORY DATA|Electrolytes within normal limits except glucose 132, BUN 15, creatinine 1.30. LFT is within normal limits. Calcium 9.2. Urinalysis shows blood, which is moderate. LE is negative. Urine WBC is 5, RBCs 11. Urine culture pending. CT scan of abdomen and pelvis with contrast shows there is a 2-mm distal right ureter stone with obstruction, consistent with right hydroureteronephrosis
LE|leukocyte esterase|LE,|156|158|HOSPITAL COURSE|While in-house, she did undergo a chest x-ray which showed bilateral lower lobe atelectasis with no evidence of pneumonia. Urinalysis is positive for trace LE, otherwise within the normal limits and urine culture is pending. Blood cultures are no growth to date. The patient will be continued on her subcu Lovenox and her Coumadin until therapeutic.
LE|lower extremity|LE|292|293|HOSPITAL COURSE|Her ventilator was adjusted to give her pCO2 around the 70s and 80s which gave her a pH around 7.35. Echocardiogram was obtained which had a poor acoustical window because of hyperinflation, but showed only mild right ventricular pressure overload. This along with the normal BNP and minimal LE edema suggested her volume status was near-normal. Her tube feedings were increased. She became hyperglycemic because of critical illness and steroids and therefore she was started on insulin drip.
LE|leukocyte esterase|LE|271|272|LABORATORIES AND STUDIES ON ADMISSION|LABORATORIES AND STUDIES ON ADMISSION: White blood cell count 10.4, hemoglobin 13.3, platelet count 339,000, troponin less than 0.04, sodium 135, potassium 3.3, chloride 99, CO2 27, BUN of 8, creatinine of 0.8, glucose of 114. UA showed ketones of 10, protein of 30 with LE and nitrite negative. Liver function tests were all within normal limits. Head CT was negative for any acute event and EKG showed a regular rate and rhythm with first-degree AV block.
LE|leukocyte esterase|LE,|137|139|SIGNIFICANT LABORATORY STUDIES DURING THE HOSPITAL STAY|INR is 0.99. Electrolytes were all within normal limits. Creatinine 1.10. Troponin was negative. Again, a UA revealed large blood, trace LE, negative nitrites with 53 white cells and 182 red cells. Urine culture returned with 10 to 50,000 colonies of the staph species and 50-100,000 colonies of second species of staph.
LE|leukocyte esterase|LE|164|165|LABORATORY DATA|Her cervix was then checked and was closed, long and high. LABORATORY DATA: A urinalysis was obtained, as were patient's new OB labs. The patient's UA showed trace LE with 7 white cells and 3 red cells per high-powered field, negative for nitrites. The wet prep revealed trichomonas, no clue cells or yeast.
LE|leukocyte esterase|LE,|175|177|LABORATORY|No focal deficits. No neck stiffness. LABORATORY: White count 25.5, hemoglobin 11.2, neutrophils 36%, lymphocytes 63%, MCV 91, RDW 14. UA shows 40 ketones, 100 protein, trace LE, 6 white blood cells, 43 red cells, 12 hyaline casts. Blood culture growth of Streptococcus pneumoniae type 3 susceptible to ceftriaxone less than 0.015 and vancomycin 0.25. CSF culture no growth.
LE|lower extremity|LE|133|134|PAST MEDICAL HISTORY|During her childhood she recurrent AOM. She has had almost continual postnasal drip and rhinitis since _%#MM#%_ of 2000. She has had LE edema with her pregnancies right greater than left, 1938 and every since. Recurrent with some stasis ulcers and pretib distally the right leg and severe stasis dermatitis bilaterally.
LE|leukocyte esterase|LE|147|148|ADMISSION HISTORY AND PHYSICAL EXAM|She has had 2 loose stools, but resolved with Imodium. Otherwise, the patient has felt well in general state of health. The patient's UA has large LE and white blood cell count of 182 and was sent directly to interventional radiology for double-J stent removal and placement of retrograde stent on her left side.
LE|leukocyte esterase|LE|219|220|HOSPITAL COURSE|In addition, the patient has also postoperative fever most likely secondary to atelectasis. The patient used incentive spirometry during her stay. Urinary tract infection was suspected. Urine analysis was positive with LE and WBC was 8. The patient was started with empiric Macrobid 100 mg p.o. b.i.d. Later this was discontinued when urine culture turned to be negative.
LE|leukocyte esterase|LE,|224|226|LABORATORY DATA|She also has a dry, irritative, almost fungal-like rash on her buttocks that is also old. LABORATORY DATA: Glycosylated hemoglobin 9.3. Creatinine is 0.6. Urine microalbumin area high at 440. Urinalysis _%#MMDD2007#%_ trace LE, 3 WBC, and we treated her with a 3-day course of Levaquin that she will complete on _%#MMDD2007#%_. Rest of labs unremarkable. ASSESSMENT AND PLAN: 1. Status post left foot open reduction and internal fixation.
LE|NAME|L.E.|146|149|DISCHARGE PLAN/RECOMMENDATIONS|DISCHARGE PLAN/RECOMMENDATIONS: Client was discharged to the care of his mother on _%#MMDD2002#%_. Client was referred for inpatient treatment at L.E. Phillips Chemical Dependency Treatment program in Wisconsin/_%#CITY#%_. Concerning academic pursuits client is encouraged to return at a time when behavior and/or chemical issues seem affectively addressed.
LE|leukocyte esterase|LE,|336|338|LABS ON ADMISSION|LABS ON ADMISSION: White count 6.3, hemoglobin 14.6, platelets 392, neutrophils 66%, lymphocytes 23%, monocytes 10%, eosinophils 1%, ALT 39, AST was noted to be elevated at 68, sodium 135, potassium 4.5, chloride 99, bicarb 18, BUN 9, creatinine 0.8, glucose 90, anion gap 18. Urinalysis: Greater than 80 ketones, moderate blood, small LE, 4 red blood cells, 3 red blood cells. Urine culture grew less than 10,000 colonies of gram-negative rods. Blood cultures were drawn and did not have any growth.
LE|lower extremity|LE|223|224|IMPRESSION|4. Arteriosclerotic heart disease. 5. Renal insufficiency on dialysis. 6. HTN since 1974. 7. Smoking history of 120-pack-year-history of nicotine addiction at three-packs-per-day stopping in 1965. 8. LE dependent edema. 9. LE severe distal third stasis dermatitis. 10. Pelvic inflammatory disease. 11. Hypothyroidism controlled with medications. 12. Anemia of chronic disease. 13. GOUT. 14. Renal insufficiency on dialysis with #15 below.
LE|leukocyte esterase|LE,|368|370|LABORATORY DATA|LABORATORY DATA: White count is 10/6, hemoglobin is 13.0, platelets 215; Electrolytes: Sodium is 136, potassium is 3.4, chloride 101, cO2 is 24, BUN 16, creatinine 1.3, glucose 109, total bilirubin 0.4, albumin is 4.0, total protein is 1.6, alkaline phosphatase is elevated at 230, ALT is 34, AST is 28. UA has 15 ketones, moderate blood , 100 protein, no nitrates or LE, with 10 to 25 RBCs, 2 to 5 white blood cells. HOSPITAL COURSE: PROBLEM #1: Pulmonary. The patient is a 77-year-old white female who was admitted for respiratory distress.
LE|leukocyte esterase|LE.|130|132|LABORATORY|Total protein, albumin, alk phos, AST, ALT were all normal. Acetaminophen and salicylate levels were less than 1. UA showed small LE. UPT was negative. U tox was positive for cannabinoids and benzodiazepines. EKG was grossly normal. ASSESSMENT/PLAN: 1. Overdose. Per Poison Control, Valium and Seroquel is mostly supportive care after charcoal that she did receive in the ER.
LE|lupus erythematosus|LE|246|247|PAST MEDICAL HISTORY|She remained afebrile. The patient was determined to require cesarean section for better management of her infant and this is scheduled for the next couple of hours on _%#MMDD2002#%_. PAST MEDICAL HISTORY: Includes B+ blood type, history of anti LE antibody with initial antibody screen early in pregnancy but negative antibody screen during this hospitalization. The patient had a previous vaginal delivery of a 9 lb. female in 1991 in her native land of Sierra Leone.
LE|leukocyte esterase|LE,|215|217|LABORATORY DATA|SKIN: Negative. LABORATORY DATA: CBC is normal. BMP notable for a potassium of 3.3, otherwise normal. Calcium of 7.9, albumin 2.6, LFT's are normal. Troponin less than 0.7. UA - large blood, positive nitrite, large LE, 30 protein. EKG - atrial fibrillation, flutter, 73. Chest x-ray - extensive bilateral infiltrates, status post bilateral humeral head resection; unclear if this is old.
LE|NAME|L.E.|132|135|SIGNIFICANT EVENTS|Mother reports 2 previous interventions, with one at Miller-Dwan Hospital and the other through the chemical dependency services of L.E. Phillips. Mother also reports an active court order, partly influencing the present STOP admission. Concerning family history, mother reports divorce in 1999 significantly impacting _%#NAME#%_.
LE|leukocyte esterase|LE,|302|304|PHYSICAL EXAMINATION|EXTREMITIES: Reveal no edema. Basic metabolic panel shows a sodium of 129, potassium 4.2, bicarbonate of 27, BUN of 16, creatinine of 0.76. White count of 8.6, hemoglobin of 12.4, platelets of 210. Lipase of 79. Total bilirubin of 1.4. AST of 80, ALT of 49, alkaline phosphatase is 75. UA has negative LE, positive nitrates, white blood cells 0-2. ECG reveals sinus rhythm, however, has frequent PACs. Chest x-ray shows some chronic changes, otherwise there is no acute infiltrates.
LE|leukocyte esterase|LE.|120|122|LABORATORY|PELVIC: Negative per the emergency room. NEUROLOGIC: Nonfocal. DERMATOLOGY: Negative. LABORATORY: UA large blood, trace LE. UPT negative. INR 1.54. Comprehensive metabolic panel notable for a glucose of 155, CBC white count 11 with 77% neutrophils, hemoglobin 14.5, platelets 265.
LE|leukocyte esterase|LE,|186|188|PHYSICAL EXAMINATION|Tocometry showed no contractions. Extremities were nontender. White count 17.7, hemoglobin 11.3, platelets 582, and PMN of 81%. UA cath showed 2 to 5 white cells, rbc's of 0 to 2, large LE, and negative nitrite. Sodium 136, potassium 3.4, chloride 104, CO2 18, BUN 10, creatinine 1.2, glucose 82, calcium 9.1. Renal ultrasound, single left kidney, with compensatory hypertrophy and moderate hydronephrosis.
LE|leukocyte esterase|LE.|130|132|PHYSICAL EXAMINATION|NEURO: Cranial nerves II-XII are grossly intact. SKIN: Without suspicious lesions. UA negative for protein, glucose and blood, 1+ LE. WBC 3-5 and only occasional bacteria. White count 15,100. The patient's hemoglobin 13.7, platelets 412,000. IMPRESSION: 1. CHF, left ventricular diastolic dysfunction, gentle diuresis, continue with TED hose and telemetry.
LE|leukocyte esterase|LE,|106|108|LABORATORY|EXTREMITIES: Trace edema. Arthritis. NEUROLOGIC: Power appears 5/5. LABORATORY: Urinalysis shows moderate LE, WBC clumps, moderate bacteria. Blood culture is pending. BNP is 1070. BMP shows sodium 127, potassium 3.9, chloride 103, bicarb 18, BUN 40, creatinine 2.1, glucose 224.
LE|leukocyte esterase|LE,|153|155|LABORATORY|CNS: Alert, oriented x3. Power is 5/5. Deep tendon reflexes intact. Sensation grossly normal. LABORATORY: UA shows large blood, positive nitrites, large LE, more than 182 WBCs per urine, more than 182 RBCs. WBC clumps and bacteria present. CT scan of the abdomen was done.
LE|lower extremity|LE|184|185|DIAGNOSIS|2. Hyperlipidemia. 3. History of gastrointestinal bleed in _%#MM#%_ 2006 secondary to a Dieulafoy lesion. 4. Barrett esophagus, diagnosed in _%#MM#%_ 2006. 5. Anemia. DIAGNOSIS: Right LE cellulitis with ulcers of lower leg. HOSPITAL COURSE: Right lower extremity cellulitis. The patient was started on nafcillin IV.
LE|lymphedema|LE.|161|163|PHYSICAL EXAMINATION|Lungs were clear to auscultation bilaterally. Abdomen was soft, nontender, nondistended with some mild epigastric tenderness. Extremities were normal with trace LE. She did not have any rashes, and her neurologic exam was grossly intact. LABORATORY: On admission, white count was 11,000, hemoglobin 14.3, platelets 390,000.
LE|leukocyte esterase|LE|173|174|LABORATORY DATA|EXTREMITIES: Lower extremities no edema. Dorsalis pedis positive. Dorsi and plantar flexion intact bilaterally. NEUROLOGIC: Exam is unremarkable. LABORATORY DATA: UA, large LE otherwise negative. BMP notable for a potassium 2.7, CBC normal. CT of the abdomen and pelvis a couple of days ago was negative.
LE|leukocyte esterase|LE|151|152|PHYSICAL EXAMINATION|Alkaline phosphatase was 147. Lipase 406; amylase 103; LDH 1,010. BUN was 45; creatinine 1.6. His UA showed large blood, was positive for nitrates and LE and bacteria. HOSPITAL COURSE: PROBLEM #1: E. Coli bacteremia. Blood cultures drawn on the day of admission subsequently grew Escherichia Coli.
LE|leukocyte esterase|LE,|241|243|LABORATORY EVALUATION|Currently on admission her hemoglobin was 7.8. With transfusing two units, she did jump up to 10.2, white count decreased from 22.8 thousand down to 22.1 thousand. Stool is guaiac positive. Her UA shows large blood, positive nitrates, large LE, many bacteria and white cells. Urine culture and blood culture are both pending. Her electrolytes - Sodium is 131 with potassium 3.8, creatinine is 0.88 with a BUN of 20.
LE|leukocyte esterase|LE,|207|209|PHYSICAL EXAMINATION|Chest x-ray is negative by emergency room report. White count is 8.1, hemoglobin 12.8, platelets 164, sodium 141, potassium 4.2, BUN 32, creatinine 1.3, glucose 144. Urinalysis is significant only for small LE, 5 white blood cells per high power field and a few bacteria. A urine culture is pending. ASSESSMENT AND PLAN: 1. Weakness: Multiple possible etiologies include bradycardia.
LE|leukocyte esterase|LE,|166|168|LABORATORY DATA|BUN 9, creatinine 0.62, glucose 109. Albumin elevated at 4.8. LFTs negative. Lipase mildly elevated at 288. Amylase is 70. Urinalysis, 15 ketones, small blood, large LE, 100 albumin. Abdominal x-rays per the ER is negative. EKG, per my interpretation, normal sinus rhythm at 80 with nonspecific ST-T waves in lead III.
LE|leukocyte esterase|LE;|206|208|LABORATORY|Weakness and paraplegia in lower extremities. NEUROLOGIC: Alert and oriented x 3. Paraplegic. LABORATORY: On admission, WBC 11.7, hemoglobin 15.9, platelet count 177. U/A is positive for nitrites, positive LE; wbc 5200. Urine culture is pending. Electrolytes were within normal limits; glucose 179, BUN 5, creatinine 0.60, calcium 8.6, INR 1.13.
LE|leukocyte esterase|LE,|178|180|HOSPITAL COURSE|Problem #2. Leukocytosis. This was believed to be secondary to the shot of Neulasta given. However, other causes of infection were ruled out as well. A UA was done showing trace LE, negative nitrites, few bacteria, and 6 white blood cells, as well as 184 RBCs. The patient was currently having her menses. A urine culture showed less than 10,000 colonies of lactose-fermenting organisms.
LE|leukocyte esterase|LE,|200|202|LABORATORY DATA|Electrolytes all normal. Potassium 4.0, creatinine 0.7, INR 3.1 on _%#MMDD2006#%_. BNP elevated at 448, dig level 0.5, troponin negative at less than 0.7, myoglobin 44. Urinalysis: Small blood, trace LE, 0-2 white cells and red cells, a few epithelial cells. Chest x-ray negative for acute process. EKG: Atrial fibrillation with rapid ventricular response, rate in 150s.
LE|leukocyte esterase|LE,|211|213|LABORATORY|BMP: Sodium 142, potassium 3.2, chloride 104, bicarbonate 28, BUN and creatinine 25 and 1.1, respectively with glucose of 131. GFR 63, protein 7.4, albumin 3.8, ALP 88, ALT 19, and AST 21. Urinalysis with small LE, no nitrates, 10 white cells, few bacteria, few squamous cells, likely contaminant. Urine cultures again ultimately showing likely contamination.
LE|leukocyte esterase|LE,|144|146|LABORATORY|LABORATORY: EKG shows a left bundle branch block which is old. Lab tests show a troponin of 0.04. Blood cultures are pending. UA shows moderate LE, 3 WBCs. BNP is 186. Myoglobin is 45. BMP shows sodium 143, potassium 4.1, chloride 107, bicarb 26, BUN 48, creatinine 1.2, calcium level 8.2. CBC shows hemoglobin 11.6, hematocrit 35.8, white count 17.2, platelets 219.
LE|leukocyte esterase|LE,|269|271|ADMISSION LABORATORY|No skin rashes. ADMISSION LABORATORY: WBC on admission was 3.4 with 56% neutrophils, 36% lymphocytes. Hemoglobin 11.2 with an MCV of 88, platelets 100. Sodium 141, potassium 4.1, chloride 106, CO2 29, BUN 15, creatinine 0.66. U/A had large blood, 300 protein, moderate LE, negative nitrite, WBC greater than 182, RBC greater than 182, few bacteria, wbc clumps present. Urine hCG was negative. HOSPITAL COURSE: PROBLEM #1: Pyelonephritis. The patient was started on IV Levaquin 500 mg daily.
LE|leukocyte esterase|LE.|172|174|LABORATORY ON ADMISSION|BMP: Sodium 136, potassium 4.1, chloride 104, bicarbonate 22, BUN 9, creatinine 0.6, and blood glucose 82. Wet prep: No clue, trichomonas, or yeast. UA without nitrites or LE. HCG was positive. Chlamydia collected, ultimately negative. Gonorrhea collected, ultimately negative. HCG quantitative 128,000. ABO is A+. HOSPITAL COURSE: 1. Abdominal pain: The patient was admitted for serial abdominal exams.
LE|lower extremity|LE|246|247|DISPOSITION PLANNING|_%#NAME#%_ was a term AGA male infant, 4000 gm at 38 weeks gestation, with a length of 55 cm and head circumference of 36 cm. He was transferred to the NICU for evaluation for CHD. The admission physical examination was significant for decreased LE pulses, dusky LEs. Problems during the hospitalization included the following: * Respiratory distress: intubated for resp acidosis, that improved to 7.37 37 37 21.
LE|lower extremity|LE|173|174|* CHD|* Treatments: vibratory BDs to RUL q 6 hours as tolerated. Discharge measurements: same as admit, see above. Physical exam was significant for grade II/VI murmur, decreased LE pulses. PKU/galactosemia/hypothyroidism/hemoglobinopathy/adrenal hyperplasia screens were sent and the results are NOT DONE at transfer.
LE|leukocyte esterase|LE|507|508|LABORATORY|He has good pulses distally. LABORATORY: Admission laboratory studies showed serum Na 143, Cl 107, K 3.6, CO2 27, glucose 97, BUN 9, creatinine 0.63, Ca 9.2, P 4.3, and albumin 4.3. Plasma cortisol (p.m.) was 9.0 (normal 1.4-14.0), TSH 2.78 (normal 0.4-5.0), plasma aldosterone 2.6 (normal 4.0-31), plasma renin 1.3 (normal 0.5-3.3), plasma epinephrine 47 (normal 18- 460) and plasma norepinephrine 409 (normal 85-1250). Urinalysis showed sp. Gr. 1001, pH 6.5, and was negative for blood, albumin, glucose, LE and nitrates. Renal ultrasound was unremarkable with normal Doppler examination. Echocardiogram showed upper limits of normal left ventricular thickness with otherwise normal findings.
LE|leukocyte esterase|LE,|197|199|HOSPITAL COURSE|She denied dysuria on this admission but also has limited sensation below the umbilical level. An infectious disease consult was obtained after the patient's urinalysis revealed 39 wbc's, moderate LE, and bacteruria. The patient was initiated on gentamicin based on sensitivities from previous urine cultures. Infectious disease recommendations were for stopping the antibiotics and to not use an oral antibiotic for prophylaxis as this was felt to lead to selection of antibiotic resistance in the future.
LE|leukocyte esterase|LE|119|120|PROBLEM #6|CT scan from 2 weeks ago looked okay per urologist. She was started empirically on Cipro due to abnormal UA with small LE and blood. DISCHARGE PLAN: The patient is to follow up in 4-5 days for electrolyte recheck.
LE|leukocyte esterase|LE,|191|193|HOSPITAL COURSE|HOSPITAL COURSE: The patient was admitted on _%#MMDD2006#%_ at 32+1 weeks with pyelonephritis. Her white count on admission was 13.2. UA was cloudy with large blood, positive nitrites, trace LE, 10-25 white cells and large RBCs. There were many bacteria identified also. Urine culture was pending on admission. The patient had received 1 gram of IV ceftriaxone in _%#CITY#%_, which was continued on admission to Fairview _%#CITY#%_.
LE|lower extremity|LE|241|242|PLAN|Will consider consulting with Hematology in a.m. His urinalysis also shows hemoglobinuria but he does not appear to have rhabdomyolysis. I am awaiting results of the imaging studies. Will treat his fever with Tylenol p.r.n but will consider LE u/s to eval for DVT and LP to eval for infection. Will hydrate him with IV fluid. Will start DuoNeb and albuterol inhaler because of history of chronic tobacco abuse.
LE|leukocyte esterase|LE|157|158|LABORATORY DATA|Lipase 21, ketone whole blood 1.1, pH 7.34. Pregnancy test is negative. Urine is slightly cloudy. Protein 30 mg per dL, glucose negative, nitrites negative, LE moderate. WBC 18, RBC 2. Urine culture is pending. Blood culture is pending. IMPRESSION: 1. Acute urinary tract infection. 2. Type-1 diabetes mellitus with complications including retinopathy and neuropathy.
LE|leukocyte esterase|LE.|185|187|LABORATORY DATA|White count upon admission 8.5, 84% neutrophils, 7 lymphs and 8 monos, hemoglobin 8.6, platelets 39, ANC 7100, electrolytes were within normal limits. UA was negative nitrite, negative LE. HOSPITAL COURSE: 1. FEN/GI: The patient was able to be maintained on a regular diet.
LE|leukocyte esterase|LE|149|150|LABS ON ADMISSION|BUN 9. Creatinine 0.9. Glucose was 603. No serum ketones. UA pH of 6, negative protein, glucose greater than 1000. Ketones negative. Blood negative. LE negative. Bilirubin negative. Nitrites negative. Specific gravity 1.034. White count 5.4. Hemoglobin 14.3. Platelets 205. Hematocrit 43.8. MCV 87. RDW 15.7. EKG did show some bradycardia with occasional ectopy.
LE|leukocyte esterase|LE|196|197|PROBLEM #5|If the modified barium swallow does show a paraesophageal hernia which was a question from the EGD, we will start her on Reglan 10 mg p.o. q.i.d. PROBLEM #5: GU. She did have some blood and trace LE in the urine. A urine culture was sent. Urine culture showed no growth at the time of discharge. PROBLEM #6: Fluid, electrolytes and nutrition. The patient's nutrition is quite poor.
LE|lower extremity|LE.|260|262|DISCHARGE PLAN|The physical examination was significant for sighing on exhalation with shallow air movement, as well as hypospadias. Femoral pulses were present but weak, and both feet had decreased capillary refill of 4 seconds and were blue to pink and cooler than rest of LE. Problems during the hospitalization included the following: Ongoing problems and suggested management: 1. FEN - Mom is breastfeeding ALD every 3 hours.
LE|left ventricle:LV|LE|132|133|DISCHARGE DIAGNOSIS|Maximum cardiac index achieved was approximately 2.1. The patient also had an echocardiogram which showed an EF of 10% and probable LE thrombus. The initial plan was to discharge the patient with an LVAD. However, partially due to patient preference for only 1 procedure, a continuous Milrinone drip was decided upon.
LE|left ventricle:LV|LE|260|261|PROCEDURES PERFORMED|3. Shortness of breath. PROCEDURES PERFORMED: 1. Pulmonary function test, FEVC of 2.4, 61% predicted; FEV1 of 2.12, 63% predicted; a ratio of 88 with a DLCO of 18.43 showing a restrictive pattern. 2. Transthoracic echocardiogram showing normal systolic global LE function. 3. Chest CT showing a small right pleural effusion, no air space disease. Improvement in interstitial nodularity seen on previous CT. HISTORY OF PRESENT ILLNESS: This is a 25-year-old woman with sickle-cell disease who also has hypereosinophilia of unclear etiology (findings consistent with eosinophilic pneumonitis, but not confirmed on biopsy).
LE|leukocyte esterase|LE.|199|201|LABORATORY DATA|White count 9.8, hemoglobin 14.8. 82 neutrophils, 8 lymphocytes, platelet count 259. Urine analysis - specific gravity greater than 1.030 with trace ketones, blood and protein. Negative nitrates and LE. There are 2-5 white blood cells. Chest x-ray report as per the Emergency Room. C-diff cultures, stool cultures and urine culture were drawn in the ER and are pending.
LE|leukocyte esterase|LE,|196|198|LABORATORY|Hemoglobin 10.1, sodium 140, potassium 3.8, chloride 105, bicarb 25. BUN 11, creatinine 0.91, glucose 96, calcium 8.7. UA, clean catch specimen: Trace protein and albumin, 2.0 urobilinogen, large LE, 10-25 white cells, 0-2 red cells, few squamous epithelial cells. Catheterized specimen shows negative for nitrates and LE, 30 protein, 0- 2 white cells, negative red cells.
LE|leukocyte esterase|LE,|250|252|LABORATORY|BUN 11, creatinine 0.91, glucose 96, calcium 8.7. UA, clean catch specimen: Trace protein and albumin, 2.0 urobilinogen, large LE, 10-25 white cells, 0-2 red cells, few squamous epithelial cells. Catheterized specimen shows negative for nitrates and LE, 30 protein, 0- 2 white cells, negative red cells. Mucous present. Negative hCG. CT of abdomen and pelvis: No stones, no hydronephrosis.
LE|leukocyte esterase|LE,|279|281|LABORATORY|ABDOMEN: Bowel sounds are positive, soft, nontender, nondistended, obese. LOWER EXTREMITIES: There is no edema. NEUROLOGIC: Examination is nonfocal, good motor strength. LABORATORY: BMP notable for a glucose of 180, albumin 3.1, LFTs are normal, troponin less than 0.7, UA trace LE, BMP slightly elevated at 119, CBC notable for a hemoglobin of 11, white count of 11.6, platelets 149. EKG per my interpretation normal sinus rhythm, LAD no acute changes.
LE|leukocyte esterase|LE|235|236|LABORATORY DATA|Sodium 138, potassium 5.2, chloride 104, bicarbonate 24, BUN 30, creatinine 1.2, glucose 91, calcium 8.7, magnesium 1.7. White count 5000, hemoglobin 10, platelets 348 with a normal differential. Urinalysis Negative nitrites, negative LE with trace protein. HOSPITAL COURSE: PROBLEM #1: Fluid, electrolytes and nutrition.
LE|lupus erythematosus|LE|153|154|REVIEW OF SYSTEMS|CV: Negative. Respiratory: Negative. Digestive: Negative. Urinary: Negative. Muscle, bone, and concomitant joint pain and myofacial pain associated with LE flares. Skin: The patient has been experiencing increasing episodes of hives, although not in the most recent exacerbation that led to her admission.
LE|leukocyte esterase|LE|187|188|HOSPITAL COURSE|Urinalysis was completed on the day of admission which did demonstrate evidence of infection with the results as follows: Glucose being greater than 1000, protein being greater than 300, LE was large. White blood cell count was 131. Many bacteria were noted, and culture eventually grew out greater than 100,000 colonies of Escherichia coli.
LE|leukocyte esterase|LE|181|182|LABORATORY ON ADMISSION|Sodium low at 128, potassium 4.4. BUN 8, creatinine 0.58. Total albumin 3.7, total protein 7.4, alkaline phosphatase elevated at 158, ALT 13, AST 16. UA shows positive nitrites and LE 50 to 100 wbc's with a few bacteria. Urine culture drawn at that time grew greater than 100,000 colonies of two strains of Pseudomonas, both sensitive to ciprofloxacin and both resistant to Bactrim and tetracycline.
LE|leukocyte esterase|LE,|242|244|ADMISSION LABORATORY DATA|ADMISSION LABORATORY DATA: White count 8.5, 90% neutrophils, hemoglobin 13.3, platelets 65, INR 1.43, PTT 31, troponin less than 0.07. Urine pregnancy test is negative. UA revealed protein of 100, 5 to 10 white cells, 2 to 5 red cells, trace LE, and positive nitrites. LFTs included total bili 2.2, albumin 3.4, total protein 7.6, AST 99, ALT 71, lipase 635, alkaline phosphatase within normal limits.
LE|leukocyte esterase|LE.|144|146|ADMISSION LABS|Sodium 142, potassium 4.0, chloride 108, bicarb 24, BUN 7, creatinine 0.6, glucose 90, calcium 8.5. Her beta hCG was negative. U/A showed trace LE. Lipase 272, amylase 90, T-bili 0.5, albumin 3.6, protein 6.8, AST 36, ALT 24, alkaline phosphatase 114. PAST MEDICAL HISTORY: 1. Tubal ligation years ago. 2. Status post appendectomy.
LE|leukocyte esterase|LE|200|201|LABS ON ADMISSION|Calcium 9.1, mag 1.5, phosphorus 4.6, total protein 6.4 with an albumin of 3.6. AST 46, ALT 47, alk phos 156. A U/A at the time of admission showed a specific gravity 1.009, pH 7.5, nitrite negative, LE negative. Urine culture was negative. HOSPITAL COURSE: PROBLEM #1: Fluids, electrolytes, and nutrition.
LE|leukocyte esterase|LE,|98|100|LABORATORY DATA|CNS: Alert and oriented times three. Power is 5 out of 5. LABORATORY DATA: Urinalysis shows trace LE, 2 to 5 WBC's. Blood cultures times two pending. Beta type natriuretic peptide is 130. Phenytoin is 19.9. Troponin is less than 0.07. A basic metabolic panel shows sodium 127, potassium 4.3, chloride 94, bicarb 24, BUN 13, creatinine 0.8, glucose 110.
LE|leukocyte esterase|LE|164|165|ASSESSMENT/PLAN|2. Hyponatremia. Check his serum osmolality, urine, electrolytes, monitor the beta type natriuretic peptide since he will be on Lasix. 3. Urinalysis did show trace LE and 2 to 5 WBC's. He has a urinary catheter in place continuously, so it is hard to say whether this is a real infection or just contaminant.
LE|leukocyte esterase|LE,|173|175|LABORATORY|Extremities are nontender with no edema. External fetal monitoring is in the 120s with accelerations to 150 and reactive. Toco: No contraction. LABORATORY: UA reveals large LE, greater than 100 white blood cells per high power field, and many bacteria. It is cloudy. ASSESSMENT AND PLAN: Intrauterine pregnancy at 29 weeks with pyelonephritis.
LE|leukocyte esterase|LE.|343|345|STUDIES|It shows some chronic change. Laboratories showed a hemoglobin A1c of 6.2, D- dimer 1.9, BMP is 707, troponin I 0.07, electrolytes within normal limits, glucose 164, BUN 25, potassium 1.08, albumin 3, liver function tests were within normal limits, calcium 9, hemoglobin 11, WBC 12.8 with a left shift. UA shows positive nitrates and positive LE. WBC urine 25 to 50. Urine culture is pending. ASSESSMENT/PLAN: 1. Severe hypoglycemia secondary to glyburide and Avandia and hypoglycemia unawareness attributed to a metoprolol or beta blocker.
LE|leukocyte esterase|LE,|132|134|ASSESSMENT AND PLAN|Fetal well-being reactive tracing noted. Also, we will obtain an NICU consult. MSM staff aware of admit. LABORATORY: UA shows small LE, many squamous cells, 5 blood cells 0 to 2. PRENATAL LABS: A positive. Rubella immune. RPR negative. Hepatitis B surface antigen negative.
LE|leukocyte esterase|LE,|181|183|LABORATORY EVALUATION|His CBC, hemoglobin 12.2. His BMP electrolytes are normal, creatinine 1.6, glucose is 188, C02 is 36. Catheterized urinalysis did show a few bacteria on catheterization, however no LE, and trace blood. IMPRESSION: 1) This is a 71-year-old male with left hip fracture.
LE|leukocyte esterase|LE.|186|188|PHYSICAL EXAMINATION|Electrolytes within normal limits. Glucose 112, BUN 29, creatinine 1.34. Liver function tests were within normal limits. UA positive with moderate blood, positive for nitrites, negative LE. WBC 2, RBC 12. ____________________ is negative. IMPRESSION: 1. Facial injury and left nasal fracture secondary to fall.
LE|leukocyte esterase|LE.|140|142|LABORATORY|Electrolytes within normal limits, except sodium 128. Lipase normal. Troponin #1 less than 0.07. Urinalysis showed positive nitrates, large LE. Micro showed 10-25 white blood cells, 2-5 red blood cells. Chest x-ray was negative. Electrocardiogram was normal sinus rhythm with some left ventricular hypertrophy.
LE|leukocyte esterase|LE.|189|191|LABORATORY DATA|LABORATORY DATA: _%#MMDD#%_ Hemoglobin 14, white count left shift, electrolytes 141/3.4/98/33/10 and 2.7 consistent with recent dialysis. Albumin 3.4. Negative influenza swab. UA with mild LE. CSF, protein and glucose are okay. There are 800 red cells, 3 white cells, gram stain negative.
LE|leukocyte esterase|LE.|157|159|1. FEN|Urine was observed to be "brick red" with a visible sediment. Urinalysis was significant for ketones, small bilirubin, 30 protein, no blood, no nitrites, no LE. Micro was significant for no WBC's, no RBC's, few bacteria, few squam's and many uric acid crystals, which explained the brick red appearance.
LE|leukocyte esterase|LE,|137|139|LABORATORIES ON DISCHARGE|He was discharged in stable condition. LABORATORIES ON DISCHARGE: Blood cultures showed no growth. Urinalysis showed 5-10 WBCs, moderate LE, moderate blood, a few bacteria. Imaging done in the hospital was a chest x-ray that showed retrocardiac opacity which could be either atelectasis or a pneumonia and __________ scoliosis of the thoracic spine.
LE|leukocyte esterase|LE|238|239|HOSPITAL COURSE|The patient had multiple blood cultures drawn which had no growth to date. The patient had a hemogram done showing an elevated white blood cell count on admission of 28.0. Additionally, the patient had a UA/UC sent which was negative for LE and nitrites, and the initial UC showed less than 10,000 colonies of Staphylococcus aureus. However, on the day of discharge, we were notified of a urine culture on the _%#MM#%_ _%#DD#%_, 2005, which showed MRSA 10,000 to 50,000 colonies.
LE|leukocyte esterase|LE|97|98|LABORATORY TESTS|Full range of motion in lower extremities. There is no focal deficit. LABORATORY TESTS: UA trace LE and WBC 5-10, RBC 2-5. WBC 12.3 with normal differential sed count, hemoglobin 11.8, __________count 596, electrolytes within normal limits, glucose 141, liver function tests were within normal limits, albumin 3.4, INR 1.03, TSH and T4 was within normal limits on _%#MM#%_ _%#DD#%_, 2005.
LE|leukocyte esterase|LE,|188|190|LABORATORY DATA|Glucose 143, calcium 7.7. Liver function tests within normal limits. Albumin 4. Troponin less than 0.07. CBC within normal limits. Urine tox screen positive for cocaine. Urinalysis: small LE, otherwise negative. Pregnancy test is negative. Ionized calcium 4.1, phosphorus 2.2, CK 71. EKG on admission: sinus tachycardia, otherwise normal. IMPRESSION: 1. Acute cocaine intoxication and abuse.
LE|leukocyte esterase|LE,|153|155|LABORATORY DATA|NEUROLOGIC: The patient is awake, disoriented x3. She is moving all extremities. LABORATORY DATA: Her UA shows <____________________> positive nitrites, LE, WBC more than 100, and RBC 50-100. A urine culture shows more than 100,000 colonies of staph <____________________> and a WBC of 12.5 with a left shift.
LE|leukocyte esterase|LE,|242|244|LABORATORY DATA|CHEST: There are bibasilar rales. ABDOMEN: Bowel sounds are positive, soft, nontender, nondistended, no HSM or masses. EXTREMITIES: 1 plus edema with palpable pulses. NEUROLOGIC: Nonfocal. LABORATORY DATA: UA 5 ketones, moderate blood, large LE, 100 protein, greater than 182 white blood cells, 160 red cells, positive transitional cells, and renal tubular cells. CBC white count 8.2, hemoglobin 10.4, MCV of 88, BMP notable for a BUN of 24, creatinine 1.35. LFTs including albumin are normal.
LE|leukocyte esterase|LE,|167|169|LABORATORY|ABDOMEN: Obese, nontender. No organomegaly. Bowel sounds present. EXTREMITIES: Minimal edema. Dermatitis changes from long-standing stasis. LABORATORY: UA shows trace LE, few bacteria. CT scan of the head shows mild cortical atrophy, no significant from _%#MM2006#%_. Chest x-ray: Two chest x-rays were done in the emergency room.
LE|leukocyte esterase|LE.|167|169|ADMISSION LABORATORY DATA|Wet prep: Many PMNs seen. No yeast. No trichomonas. No clue cells seen. Pregnancy test was negative. Chlamydia and gonorrhea PCR testing is pending. Urinalysis: Trace LE. WBC: 3. Few bacteria. Lactic acid level is 1.4. Phosphorus 1.5, magnesium 1.6. PHYSICAL EXAMINATION: The patient is a 27-year-old female in no acute distress.
LE|lower extremity|LE.|150|152|VSS|Tenderness is mild, no tenderness with dorsiflexion or plantar-flexion against resistance, no edema or blistering. Pulses are normal and symmetric in LE. Labs, radiology studies, and medications reviewed.
LE|leukocyte esterase|LE|191|192|LABORATORY|Hepatic panel: ALT 104, AST 71, albumin 4.1, bilirubin 4.1, alkaline phosphatase 98. Lactic acid 0.9, INR 1.15, PTT 25. Urinalysis is significant for ketones 5, protein 10, nitrite positive, LE large, wbc greater than 182. Urine culture pending. IMAGING: X-ray of the abdomen revealed no air-fluid levels.
LE|leukocyte esterase|LE|234|235|LABORATORY|BMP revealed sodium 140, potassium 3.6, chloride 105, CO2 28, glucose 97 and creatinine 0.71. ALT 21, AST 25, protein total 9.8, albumin 4.3, bilirubin 0.2. Blood cultures were no growth after 1 day. HCG was negative. UA showed trace LE but only 1 white blood cell. Urine culture showed contamination. Wet prep was negative. Chlamydia and gonorrhea were negative.
LE|leukocyte esterase|LE.|256|258|HISTORY OF PRESENT ILLNESS|On admission, WBC 14.2, hemoglobin 15, platelet count 237,000, neutrophils 75%, lymphocytes 13%. Electrolytes were within normal limits with a creatinine of 0.96. A urinalysis was positive for ketones and large blood, 1 WBC, 69 RBCs, negative nitrites and LE. HOSPITAL COURSE: PROBLEM #1: Diverticulitis. The patient was treated with IV Levaquin and metronidazole.
LE|lower extremity|LE|522|523|PE|PMH: 1. alcoholic cirrhosis - (+)h/o varices - no prior SBP 2. withdrawal seizures 3. obstructive sleep apnea 4. Raynaud's ROS/Meds/All/Fam/Soc: see resident H&P; pertinently, last drink in _%#MMDD#%_ PE: 99.6, 118, 121/88, 16, 99% Gen: cachectic 53yo male, appears chronically ill HEENT: MMM, anicteric Neck: no JVD Chest: clear bilat, small lung volumes CV: tachy, 2/6 flow murmur RUSB Abd: moderately distended abdomen with few bowel sounds, tenderness in epigastrium - no RUQ tenderness, liver not palpable Ext: trace LE edema, 1+ pedal pulses Skin: faint jaundice Pertinent labs and imaging: reviewed. WBC mildly elevated. Hgb stable. Bili 3.2 and alk phos 260.
LE|leukocyte esterase|LE|220|221|ID|She subsequently underwent blood cultures and urine cultures. Her blood cultures remained negative to date and her urine culture was not yet back by the time of hospital discharge. However, her UA revealed only moderate LE with negative nitrites. After that initial temperature of 102.2, she was then started on ampicillin by the attending and this was discontinued 24 hours later after she remained afebrile.
LE|leukocyte esterase|LE,|138|140|LABORATORY ON ADMISSION|TSH 1.63, FANA negative, BUN and creatinine within normal limits. Admission labs include UA that is significant for 300 of protein, small LE, negative nitrites, 43 WBCs, 3 RBCs and moderate bacteria. Urine toxicity drug screen is negative. White blood cell count 6.9, hemoglobin 13.0 and platelet count 118,000.
LE|leukocyte esterase|LE.|297|299|HISTORY OF PRESENT ILLNESS|Sodium of 139, potassium of 3.5, chloride of 106, bicarb 25, BUN of 8, creatinine of 0.62, blood glucose of 100, and calcium of 9.6. A chest x-ray was read to be normal. An AP lateral of this lumbar spine was shown to be normal. Urinalysis was normal without ketones, blood, protein, nitrites, or LE. White blood cells were less than 1 and red blood cells were less than 1. An abdominal and pelvic CT showed no definite abnormalities in his abdomen.
LE|leukocyte esterase|LE,|283|285|LABORATORY DATA|EXTREMITIES: The patient had no calf tenderness bilaterally. LABORATORY DATA: The patient's albumin was 3.2. Creatinine was 1.1 on admission and 1.0 on discharge. White cell count 11.4, hemoglobin 12.7, and platelets 356,000. INR was 1.28. UA on the date of admission revealed large LE, negative nitrites, 37 white blood cells, and 122 red blood cells. IMAGING: 1. The patient's chest x-ray revealed improved left basilar atelectasis, as well as left subclavian chest port with a tip in the left subclavian vein.
LE|lower extremity|LE|171|172|HOSPITAL COURSE|She was instructed to return in 6 weeks' time for a post-partum check and institution of birth control. She and her mother at the bedside were reassured that he bilateral LE edema will resolve post-partum.
LE|lower extremity|LE|213|214|HOSPITAL COURSE|The patient responded very slowly to treatement, and toward the end of her hospitalization she requested that no further aggressive therapy be done. She refused a feeding tube and placement of an IVC filter for a LE DVT associated with a drop in hemoglobin when anticoagulated. On _%#MMDD#%_ we discontinued antibiotics and put her on comfort cares.
LE|leukocyte esterase|LE,|153|155|ADMIT LABORATORY DATA|LFT's were all within normal limits. Calcium 8.2. He had a U/A showing specific gravity 1.032, large blood, pH 5.5, 309 red cells, 12 white cells, small LE, positive nitrites, 100 mg per dl of protein. Urine culture subsequently grew greater than 100K colonies of coag negative staph.
LE|lower extremity|LE,|259|261|PHYSICAL EXAMINATION|ABDOMEN: Is soft, nontender, nondistended. Normoactive bowel sounds. No masses, No HSM EXTREMITIES: Without clubbing, without cyanosis or edema. The joints without inflammatory arthropathy. SKIN: Without rash. NEUROLOGICAL: motor 5/5 bilaterally equal UE and LE, DTR 1+ bilat equal UE and LE. REVIEWED OBJECTIVE DATA: This includes her last culture result from _%#MMDD2007#%_.
LE|UNSURED SENSE|LE:|235|237|PHYSICAL EXAMINATION|Chest: Diminished breath sounds bilaterally, right more than left. Scattered rhonchi and wheezes. Cardiovascular: Normal S1. Increased S2 without murmur, rub or click. Abdomen: Supple. Nontender. Nondistended. Extremities: Clubbing +. LE: 0. LABORATORY DATA: Chest x-ray: Thoracic distention with front and back films bilaterally.
LE|leukocyte esterase|LE,|207|209|OBJECTIVE|Lungs were clear to auscultation bilaterally, without wheezes, crackles, rales, or rhonchi. Abdomen: Gravid, right flank pain, positive bowel sounds. On admission a AU showed protein greater than 100, small LE, nitrates negative, 15 white blood cells, and 267 red blood cells. A cervical examination revealed external os to be open, internal os closed, greater than 2 cm long, high in vertex.
LE|leukocyte esterase|LE|160|161|LABORATORY DATA|Platelets 271. Differential: Neutrophils 71, lymphocytes 82, and monocytes 6. Urinalysis: Many phosphorus crystals, wbc's 2 to 8, rbc's 2 to 8, protein 30, and LE small. ALT 19. AST 31. ANA negative. Sodium 144. Calcium 9.2. Potassium 3.5. Chloride 103. BUN 10. Creatinine 0.6. Glucose 145. OTHER DIAGNOSTIC STUDIES: Head CT was normal, without any change.
LE|leukocyte esterase|LE,|165|167|LABORATORY EVALUATIONS|ABG shows a pH of 7.08 initially, PCO2 of 55, PO2 of 126, bicarb 17. Repeat at 1741 showed a pH of 7.13, PCO2 of 50, PO2 115, bicarb 17 again. Urine does show small LE, D-dimers elevated at greater than 20. White count is elevated at 41.5, hemoglobin is 16.2 with a normal differential. Platelets are 272. Chest x-ray is pending review at this time.
LE|lower extremity|LE|311|312|DISCHARGE PLAN|She tolerated feeds well. 2. Neuro-The paraspinal mass was evaluated by x-ray, followed by an abdominal CT which showed invasion of the contrast-enhancing retroperitoneal mass into the T12-L2 foramina; a spinal and brain MRI and ultrasound were done on _%#MMDD2004#%_ to further delineate the anatomy. Her left LE paraparesis persisted ,with some spontaneous flexion- extension of the right LE noted at time, consistent with compression of the motor tracts of lumbar cord.
LE|leukocyte esterase|LE|311|312|LABORATORY DATA|Neurologically, oriented x3, no focal deficit appreciated. LABORATORY DATA: Laboratory tests are obtained and show lytes normal, glucose 122, BUN 11, creatinine 0.45, calcium 8.9. WBC is 18.9 with neutrophils of 81%, lymphocytes 15%, monocytes 4%. Hemoglobin is 11, hematocrit 31.8. Urinalysis is positive with LE and nitrates. WBC is 50 to 100, RBCs negative. Bacteria are moderate. Pregnancy test is negative. Urine culture is pending. Influenza A antigen and influenza B antigen negative.
LE|lower extremity|LE|138|139||No cough. She has occasional CP and tightness, relieved by rest. She had CABG in 1996 and 5 stents placed in _%#MM#%_. Pt also has 3 left LE ulcers which are being followed by podiatry -- she saw her podiatrist two days ago. No drainage, warmth, redness or tenderness. Lastly, pt has had occasional 20 minute episodes of confusion, or facial droop.
LE|lower extremity|LE,|207|209|CV|These resolve spontaneously. She does not recall these episodes. Her family reports them. Exam: Gen:NAD, pleasant, sitting upright CV:nl s1s2 no m/r/g Pulm: CTABL Abd: obese, NT, ND Ext: 1+ pitting edema bl LE, three shallow ulcers on left foot, one on heel with black eschar, one shallow ulver over 1st MTP joint on right Labs, radiology studies, and medications reviewed.
LE|leukocyte esterase|LE|119|120|LABORATORY|As mentioned above, the patient also underwent a CT of the abdomen, which showed 4 x 5 x 4 cm abscess. UA showed trace LE and trace blood in urine. There was 1 wbc and 1 rbc. ASSESSMENT AND PLAN: Mr. _%#NAME#%_ _%#NAME#%_ is a 51-year-old male with previous history of Crohn disease and recent discharged from hospital after recent admission for pelvic abscess who now comes in with recurrence of the same pelvic abscess.
LE|leukocyte esterase|LE|180|181|LABORATORY	DATA|Deep tendon reflexes reveal negative Babinski, and 1+ patellar deep tendon reflexes, and unable to get the ankles. LABORATORY DATA: Urinalysis shows small glucose, blood, moderate LE and urine culture is pending. Electrocardiogram is pending. No other laboratories were drawn. ASSESSMENT AND PLAN: 1. Tremors. This could be related to her dementia or there possibly could be other causes.
LE|leukocyte esterase|LE|198|199|LABORATORY DATA|White blood count 2.9. Hemoglobin 10.5. Admission liver functions within normal limits. Admission electrolytes, BUN, and creatinine within normal limits. Repeat potassium 3.1. Urine clear. There is LE large, WBC 4, RBC 2, and bacteria a few. Urine culture pending. ASSESSMENT AND PLAN: 1. This is a 22-year-old female, gravida 2, para 1 pregnant at 13 weeks and 4 days intrauterine pregnancy, presenting with lower abdominal pain, positive urine with suspected infection and dysuria.
LE|lower extremity|LE|232|233|HISTORY OF PRESENT ILLNESS|The patient was transferred from _%#COUNTY#%_ _%#COUNTY#%_ Medical Center with fevers of unknown etiology. However, she was diagnosed with pneumonia at that hospital previously. She initially was hospitalized on _%#MMDD2006#%_ with LE erythema what was presumably cellulitis and chills for which she has been treated with Levaquin and vancomycin. She was later started on Meropenem and Levaquin. Antibiotics were stopped on the fourth day of hospitalization since the cellulitis was improving.
LE|lower extremity|LE|165|166||Pt is s/p liver transplant in 1998 for Hep C who had a CABGx3 with mitral valve replacement in _%#MM#%_ 2006. Her post-operative course has been complicated by left LE wound dehiscence and drainage. She was initially treated with outpatient PO antibiotics with improvement of redness and purulent drainage, but the wounds continue to heal poorly.
LE|lower extremity|LE|255|256|HEENT|No fevers, chills. Pt has chronic pain that is unchanged. She does have orthopnea. Exam: Gen:NAD HEENT:EOMI, PERRLA, elevated JVP to ~10cm Pulm:crackles at bases, poor air entry CV: S1 click, nl s2 no m/r/g Abd:soft, mildly distended, nl bs, nt Ext: 2-3+ LE edema bl, left leg with three areas of poor wound healing, most distal one is clean and weeping clear fluid, no erythema, tenderness or warmth, the middle wound has some yellow drainage but no frank purulence, her proximal wound is deeper, clean, no erythema and draining clear fluid.
LE|lower extremity|LE|246|247|HEENT|Patient seen and examined by me with the resident, Dr. _%#NAME#%_ and discussed with the admitting resident, Dr. _%#NAME#%_. I agree with their notes and plan of care. My key findings are: 7 yo male with history of spina bifida with VP shunt and LE paraplegia presents with new onset tonic-clonic seizure. Occured on day of admission after returning home. Patient appeared distant and non-verbal, did not answer to name, and then began to have arm and hand extension.
LE|lower extremity|LE|171|172|CC|She has some RUQ pain related to her fall, worse with motion, better with rest (in fact, she has no pain at rest). It is sharp, non-radiating. She also has had increasing LE edema, L>R over the last 2 days. Exam: NAD Left sided bulbar conjunctival hemorrhage Lungs: crackles at bases bilaterally CV:nl s1 s2 no m/r/g Abd: soft, ND, nl bs, mild RUQ tenderness, exquisite point tenderness over right anterior 12th rib.
LE|lower extremity|LE|226|227|NAD|Exam: NAD Left sided bulbar conjunctival hemorrhage Lungs: crackles at bases bilaterally CV:nl s1 s2 no m/r/g Abd: soft, ND, nl bs, mild RUQ tenderness, exquisite point tenderness over right anterior 12th rib. Ext: massive 4+ LE edema up to knees, L>R, some redness on left Labs, radiology studies, and medications reviewed. Assessment and Plan: 58 yo man with cirrhosis, confusion, fall and LE edema.
LE|lower extremity|LE|182|183|NAD|Ext: massive 4+ LE edema up to knees, L>R, some redness on left Labs, radiology studies, and medications reviewed. Assessment and Plan: 58 yo man with cirrhosis, confusion, fall and LE edema. 1)Confusion -- likely hepatic encephalopathy from not taking lactulose, why she was vomitting the lactulose is not as clear -- she says it might be related to her phlegm from her sinus infection.
LE|leukocyte esterase|LE.|211|213|PROBLEM|Labs of interest is a TSH less than 0.02, although she did not appear to be thyroid toxic by exam. Hemoglobin is 12.0, white count is 6.2 with 74% neutrophils, 70% differential. UA shows 30 of albumin, moderate LE. Urine culture is pending. AST is 27, ALT 47. Lipase is normal at 95. Albumin is 3.7. Alkaline phosphatase 87. Sodium is 137. Potassium 3.4. Chloride 103.
LE|lower extremity|LE|249|250|HPI|Briefly he was admitted for a kidney biopsy. Over this past summer he had a baseline creatinine of 0.8-1.0 but has steadily increased to 1.5-1.6 since. No biopsies have been done. He is without new complaints today. He continues to report bilateral LE swelling that has been ruled out for DVT with a doppler. PMH (as taken from most recent discharge summary) 1. Chronic pancreatitis.
LE|lower extremity|LE|303|304|PE|13. Narcan 1 mg p.o. t.i.d. 14. Tap water enema per rectum every day p.r.n. constipation. Allergies: compazine and Thymoglobulin FH/SH non-contributory to this admission PE: vitals reviewed alert, in NAD thin, chronically ill-appearing NCAT, no conj, no icterus neck supple non-labored breath +edema in LE most recent labs and imaging studies reviewed in FCIS A/P: 57 year old male s/p DDKT 2004 admitted for kidney biopsy to eval steadily rising creatinine over the past few months.
LE|lower extremity|LE|115|116|HPI|My key findings: CC: Stage IV non-small cell lung cancer HPI: Painful bone mets right hip Exam: Muscle strength in LE 5/5. Pain in right hip. Assessment and Plan: Because of difficulties transporting patient we are planning palliation with a single shot of 800 cGy.
LE|leukocyte esterase|LE.|143|145|LABORATORY|SKIN: Negative. NEUROLOGIC: Cranial nerves are intact, nonfocal exam. LABORATORY: TSH is slightly low at 0.16. GGT is elevated at 73. UA small LE. Chest x-ray was negative. ASSESSMENT/PLAN: A 33-year-old female admitted with depression.
LE|lower extremity|LE|503|504|PE|He denies any tobacco or alcohol use. FAMILY HISTORY: noncontributory. PE: vitals reviewed I/O's reviewed - patient has been borderline oliguric since hospitalization alert, thin, evidence of malnutrition with bilateraly temporal wasting, chronicially ill appearing, in NAD non-toxic NCAT, no conj, no icterus OP clear neck supple and NT without LAD RRR +murmur no JVD appreciated CTAB +bowel sounds, distended abdomen but soft and NT, no rebound, no guarding, did not appreciate splenomegaly +edema in LE R>L neuro non-focal labs reviewed, including his admission HCT and most recent CXR on _%#MMDD#%_ renal biopsy from _%#MM#%_ _%#DD#%_, 2006 reviewed (creatinine was 2.7 at that time) - no rejection but has FSGS path from the bilateral native nephrectomy reviewed, and it appears that only the right adrenal gland was removed as the left adrenal gland was not noted on the report A/P: 62 year old male with a very complicated medical history, who is s/p LDKT 1996.
LE|leukocyte esterase|LE.|266|268|PHYSICAL EXAMINATION|A CT of the abdomen with contrast shows multiple retroperitoneal and periaortic lymph nodes. Without contrast shows a left-sided mass in the bladder. Her creatinine is 0.8. Her INR is 0.87. Her urinalysis shows large blood, 1313 RBC, and negative nitrates, negative LE. ASSESSMENT/PLAN: This patient is a 55-year-old woman with a history of non-Hodgkin's lymphoma and new gross hematuria.
LE|lower extremity|LE|244|245|REVIEW OF SYSTEMS|1. Coumadin. 2. Aspirin. REVIEW OF SYSTEMS: CONSTITUTIONAL: Occasional fatigue. Denies fever, chills, respiratory, decreasing shortness of breath. CARDIOVASCULAR: Status post LVAD. GU: None. GI: None. ENDOCRINE: None. MUSCULOSKELETAL: Resolved LE blisters NEUROLOGICAL: None. PSYCHIATRIC: None. INTEGUMENT: None. PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile, blood pressure 90/74, mean 80, heart rate 86.
LE|lower extremity|LE|193|194|PHYSICAL EXAMINATION|LUNGS: Clear without wheezes, rales or rhonchi. ABDOMEN: Soft, nontender EXTREMITIES: Without edema. He does have palpable dorsalis pedis pulses. HEENT: Normal. NEUROLOGIC: MS as above. Normal LE and UE strength, non-focal exam. LABORATORY DATA: White count 7.2, hemoglobin 12.8, hematocrit 38.4, platelet count 360,000.
LE|lower extremity|LE,|132|134||He appears comfortable. He is hemodynamically stable. There are no issues with alarms of the LVAD. The patient continues to have 2+ LE, as well as upper extremeties edema. Both have significantly improved. A/P: 1. CHF stage D, NYHA class IV, LVEF 20%, ischemic etiology.
LE|lower extremity|LE,|132|134||He appears comfortable. He is hemodynamically stable. There are no issues with alarms of the LVAD. The patient continues to have 2+ LE, as well as upper extremeties edema. Both have significantly improved. A/P: 1. CHF stage D, NYHA class IV, LVEF 20%, ischemic etiology.
LE|lower extremity|LE|252|253||2. S/P LVAD placement. 3. Outstanding issues: - Rehabilitation, needs more aggressive work; - Nutrition; - Teaching regarding the LVAD. - Recommend to decrease the diuretic regimen as the patient is getting pre-renal. His volume status, especially his LE edema will improve when he gets more mobile.
LE|lower extremity|LE,|132|134||He appears comfortable. He is hemodynamically stable. There are no issues with alarms of the LVAD. The patient continues to have 2+ LE, as well as upper extremeties edema. Both have significantly improved. A/P: 1. CHF stage D, NYHA class IV, LVEF 20%, ischemic etiology.
LE|lower extremity|LE|178|179|HPI|She has no sick contacts, no occupational exposures, no recent travel. She denies CP, fevers, N/V. She does have loose stools. She was recently on a 1 wk course of Augmentin for LE cellulitis. She also has OSA, that is treated with CPAP set at 13. PMH: DM type 2, HTN, metabolic syndrome, lymphedema with chronic bilat cellulitis, OSA, presumed BOOP/COP with chronic steroid use tapered in _%#MM2007#%_ PSH: hemorroidectomy, cholecystecomy, bilat salpingoophrectomy Family hx: father - metastatic penile CA; mother - HTN Social hx: negative tobacco hx, rare ETHOH, no illicit drug use.
LE|lower extremity|LE|427|428|PE|Current inpatient medication list reviewed Allergies Adhesive Tape TAPE Codeine Derivatives Protamine; Allergy; Angina,Tachycardia. SH/FH both non-contributory to this admission PE: alert, non-toxic, appears chronically ill oriented x3 alert, non-toxic, in NAD NCAT, no conj, no icterus OP clear neck supple and NT RRR CTAB non-labored +bowel sounds, tender to deep palpation in RLQ and LLQ, no rebound or guarding no edema in LE neuro grossly non-focal labs reviewed, including her CSA level and urine culture results renal ultrasound reviewed A/P: 46 year old female admitted with elevated creatinine likely due to acute illness with UTI/dehydration.
LE|lymphedema|LE.|223|225||He clearly has profound cognitive and functional deficits. He marginally responds to verbal interactions. His vital signs are stable. His JVD is midway to the angle of the jaw, there is minimal bi-basilar crackles, RRR, no LE. His CT has now minimal output. His laboratory profile is notable for an elevated WBC. His Cr has improved compared to admission. His ECG shows NSR, old antero-septal infaction.
LE|lymphedema|LE.|223|225||He clearly has profound cognitive and functional deficits. He marginally responds to verbal interactions. His vital signs are stable. His JVD is midway to the angle of the jaw, there is minimal bi-basilar crackles, RRR, no LE. His CT has now minimal output. His laboratory profile is notable for an elevated WBC. His Cr/BUN have increased today. His ECG shows NSR, old antero-septal infaction.
LE|lower extremity|LE|401|402|PE|1. ASA 81 mg qday 2. nephrocaps 3. PhosLo 667mg tid 4. lisinopril 40mg qday 5. metoprolol 150mg bid 6. EPO 18000 units 3x/wk Allergies: PCN, iron dextrose, vancomycin, nifedipine, ciprofloxacin SH/FH: non-contributory for this admission PE: vital reviewed oxygen saturation in the upper 90's on 2-3 L NC alert, non-toxic, in NAD NCAT, no conj, no icterus RRR CTAB anteriorly and laterally no edema in LE labs reviewed, K was 4.1 this morning A/P: 26 year old female POD #0 s/p transplant nephrectomy, no acute indications for dialysis today.
LE|long-acting:LA|LE|132|133||Mr. _%#NAME#%_ came in for follow-up of his positive RPR titre. In the interval since I had last seen him, he has been treated with LE Bicillin 2.4 million units IM every week. He is not having any problems with the injections other than local pain for about 48 hours after each time.
LE|lower extremity|LE|2013|2014|PE|Current Medications: Calcitriol 0.25 MCG Capsule;TAKE 1 CAPSULE DAILY.; RPT Levothyroxine Sodium 125 MCG Tablet;TAKE 1 TABLET DAILY.; RPT Zetia 10 MG Tablet;TAKE 1 TABLET DAILY.; RPT Norvasc 10 MG Tablet;TAKE 1 TABLET DAILY.; RPT Aranesp (Albumin Free) SOLN;125mcg s.q. once weekly for correction of anemia; RPT Cortef TABS;take 20mg po every am and 10mg po every evening; RPT Metoprolol Tartrate 50 MG Tablet;TAKE 1 TABLET EVERY 12 HOURS DAILY.; RPT CellCept CAPS 1 GM BID Senokot S TABS;take one tab po twice daily; RPT Flomax 0.4 MG CPCR;TAKE 2 CAPSULE DAILY; RPT Magnesium Oxide 400 MG Tablet;TAKE 1 TABLET 4 TIMES DAILY; RPT Ritalin 5 MG Tablet;TAKE 1 TABLET DAILY.; RPT Dapsone 25 MG Tablet;TAKE 2 TABLET DAILY; RPT Milk of Magnesia SUSP;take 30ml po every night prn for constipation; RPT Zofran 4 MG Tablet;take one tablet every 6hrs prn n/v; RPT NovoLog 100 UNIT/ML Solution;Inject 2 units 3 times daily with each meal BS < 250: 0 units 215-300: 2 units, 301-350: 3 units, 351-400: 4 units, 401 higher call doctor; RPT BuPROPion HCl 300 MG Tablet Extended Release 24 Hour;TAKE 1 TABLET DAILY.; RPT Tylenol Arthritis Ext Relief 650 MG TBCR;take as needed; RPT Lisinopril 5 MG Tablet;TAKE 1 TABLET DAILY.; RPT Loperamide HCl 2 MG Tablet;TAKE 2 TABLET EVERY 8 HOURS as needed for diarrhea; RPT Protonix 40 MG Tablet Delayed Release;TAKE 1 TABLET DAILY.; RPT Prograf 1 MG Capsule;1 cap in pm; RPT Prograf 1.5 MG Capsule;1 cap in am; RPT Metoclopramide HCl 10 MG Tablet;TAKE 1 TABLET 4 TIMES DAILY, BEFORE MEALS AND AT BEDTIME.; RPT Reglan 10 MG Tablet;TAKE 1 TABLET 4 TIMES DAILY, BEFORE MEALS AND AT BEDTIME.; RPT Hydrocortisone 20 MG Tablet;TAKE AS DIRECTED.; RPT Nitrofurantoin 50 MG CAPS;TAKE 1 CAPSULE 4 TIMES DAILY.; RPT. FH/SH: non-contributory for this admission PE: vitals reviewed alert, in NAD fraile, chronically ill-appearing NCAT, no conj, no icterus OP clear neck supple and NT without LAD RRR CTA, non-labored +bowel sounds, soft, ND, allograft non-tender, no rebound, no guarding no edema in LE neuro non-focal labs reviewed ECG reviewed - unchanged when compared to previous CXR reviewed - no focal infiltrates A/P: 61 year old female s/p kidney transplant admitted with hypoglycemic episode.
LE|lower extremity|LE|240|241|PE|FAMILY HISTORY: Significant for hypertension as well as cardiovascular disease. PE: vitals reviewed asleep, easily arousable, in NAD NCAT no conj, no icterus neck supple RRR CTAB, non-labored abdomen soft and NT, PNT site C/D/I no edema in LE labs and x-rays reviewed A/P: 56 year old male admitted with elevated creatinine and right leg pain.
LE|leukocyte esterase|LE,|174|176|LABORATORY|LABORATORY: White count 7.3, hemoglobin 11.4, platelet 231, INR is 1.5, potassium is 6.3, creatinine is 2.44, ammonia is 30. Urinalysis is negative for nitrates, shows trace LE, 15 white blood cells, and moderate bacteria on the _%#MMDD2004#%_. Urine culture grew group D enterococcus and E. coli, both are pan sensitive to all antibiotics.
LE|lower extremity|LE|86|87|HPI|My key findings: CC: Chest pain. HPI: R/O CAVD and shunt. Exam: Heart RRR. No murmur. LE 1+ pitting edema. Assessment and Plan: We have consented patient for possible endovascular brachytherapy.
LE|leukocyte esterase|LE,|195|197|LABORATORY DATA|CT scan yesterday without contrast showed two kidneys. There was some nephrocalcinosis. There was no stones or hydronephrosis. Yesterday, his urinalysis showed large blood, 100 protein, moderate LE, 45 white cells with clumps and some red cells. IMPRESSION: He has end-stage renal disease. He has been on dialysis in the past.
LE|lower extremity|LE|113|114|HPI|My key findings: CC: Small cell lung cancer. HPI: S/P chemotherapy, chest RT, and PCI now with brain mets. Exam: LE 1+ edema bilat. Assessment and Plan: Recommend stereotactic surgery
LE|long-acting:LA|LE|142|143|MEDICATIONS PRIOR TO ADMISSION|MEDICATION ALLERGIES: None known. MEDICATIONS PRIOR TO ADMISSION: 1. Depakote ER 500 mg two q.h.s. 2. Metamucil one teaspoon daily. 3. Datril LE 2 mg daily. 4. Provera 10 mg two tablets t.i.d. 5. Oxygen 2 L per nasal cannula while sleeping. 6. Premarin 0.625 mg daily. 7. Synthroid 0.05 mg daily for presumed hypothyroidism.
LE|lower extremity|LE|187|188|O|Participating in PT well. O: VS and data/labs reviewed; see appropriate sections of FCIS for full details. Comfortably lying in bed. MMM, o/p clear. CTA b/l. RRR, nl S1/S2, no murmur, no LE edema. Strength in UE 4/5 b/l. A/P: 1. Fungal pneumonia - awaiting final ID on organism.
LE|leukocyte esterase|LE,|198|200|ALLERGIES|LABORATORY DATA: Urine hCG negative. Urine tox screen negative; however, this is being rechecked because of a possible interfering substance. Urinalysis positive for 5 ketones, 30 of protein, trace LE, 6 white blood cells, and a few bacteria. ASSESSMENT AND PLAN: 1. Psychiatric diagnosis of schizoaffective borderline personality disorder, MDD per Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_.
LE|lower extremity|LE|227|228|PE|Eyes: Non-icteric, non-injected ENT: Mucous membranes pink, moist. Neck: No palpable LAD Lungs: Slightly diminished posterior bases. Easy effort, no wheezes. CV: RRR. I/VI SEM LLSB. No rubs. Abd: No BS. Soft, NT, ND. Lymph: No LE edema Neuro: Alert and oriented. Skin: Warm, dry. Cap refill <2 sec. Labs: WBC 14.1 Hgb 11.9 Plt 382 Creat 0.73 Last tacrolimus levels were 14.6 on _%#MMDD#%_, and 7.8 on _%#MMDD#%_.
LE|lower extremity|LE.|126|128|PAST MEDICAL/SURGICAL HISTORY|5. Hypertension. 6. History of syncope. 7. History of arthritis. 8. History of pneumonia. 9. Small MI. 10. DVT with bilateral LE. 11. History of GI bleed. 12. Ectopic pregnancy at age 24. REVIEW OF SYSTEMS: Negative for constitutional, allergic, ENT, eyes, neurologic, lymphatic, endocrine, skin, breasts, musculoskeletal.
LE|lower extremity|LE|2594|2595|PE|9. Past history of MRSA. Current Medications: Zoloft 100 MG Tablet;TAKE 2 TABLET DAILY; RPT Mirtazapine 45 MG Tablet Dispersible;DISSOLVE ONE TABLET ON TONGUE AND SWALLOW WITH OR WITHOUT WATER ONCE DAILY AT BEDTIME.; RPT Loperamide HCl 2 MG Tablet;TAKE 2 TABLET 4 TIMES DAILY; Rx Advair Diskus 250-50 MCG/DOSE Miscellaneous;INHALE 1 PUFFS TWICE DAILY; Rx Calcium 600 + D 600-200 MG-UNIT Tablet;TAKE 1 TABLET 3 TIMES DAILY; Rx Nasonex 50 MCG/ACT Suspension;one spray each nostriol once daily; Rx Clonazepam 0.5 MG Tablet;TAKE TABLET TWICE DAILY; Rx Aspirin 81 MG Tablet;TAKE 1 TABLET DAILY enteric coated; Rx CellCept 500 MG BID Gemfibrozil 600 MG Tablet;TAKE TABLET TWICE DAILY; Rx Ranitidine TABS;TAKE 1 TABLET DAILY.; RPT Claritin 10 MG Tablet;TAKE 1 TABLET DAILY.; Rx Vitamin C 500 MG Tablet;TAKE 1 TABLET DAILY.; Rx GlipiZIDE 2.5 MG Tablet Extended Release 24 Hour;TAKE 1 TABLET DAILY.; RPT Ambien CR 12.5 MG Tablet Extended Release;TAKE TABLET TAKE 1 TAB QHS; RPT Benadryl 25 MG Capsule;TAKE 3 CAPSULE DAILY; RPT Diphenoxylate-Atropine 2.5-0.025 MG Tablet;TAKE 2 TABLETS 4 TIMES DAILY AS NEEDED.; Rx Rapamune 2 MG BID Albuterol 90 MCG/ACT Aerosol Solution;INHALE 2 PUFFS EVERY 4-6 HOURS PRN wheezing; Rx wheezing Nexium 40 MG Capsule Delayed Release;TAKE 1 CAPSULE DAILY.; Rx Ferrous Sulfate 325 (65 Fe) MG Tablet;TAKE 1 TABLET DAILY; Rx CombiPatch 0.05-0.25 MG/DAY Patch Biweekly;USE AS DIRECTED.; Rx Trazodone HCl 100 MG Tablet;TAKE 1 TABLET DAILY AS DIRECTED.; RPT Lidoderm 5 % Patch;apply on patch to Left shoulder, 12 hours on 12 hours off.; Rx Opium 10 % Tincture;USE AS DIRECTED.; RPT Ritalin 10 MG Tablet;TAKE 1 TABLET 3 TIMES DAILY; RPT Cyanocobalamin 1000 MCG/ML Solution;INJECT 1 ML AS DIRECTED monthly; Rx Gabapentin 300 MG Capsule;TAKE 1 CAPSULE 4 TIMES DAILY; Rx Magnesium Oxide 400 MG Tablet;TAKE 1 TABLET 3 TIMES DAILY; Rx Levaquin 250 MG Tablet;TAKE 2 TABLET OTHER on _%#MMDD2007#%_ and then 1 tablet a day x 6 days; Rx Novolin N 100 UNIT/ML Suspension;SLIDING SCALE 180 2 UNITS; 181-250 3 UNITS; 251-300 4 UNITS; 301+ 5 UNITS.; RPT Hydrocodone-Acetaminophen 5-500 MG Tablet;TAKE 2 TABLET 3 TIMES DAILY; Rx Mephyton 5 MG Tablet;TAKE 2 TABLET DAILY; Rx Multivitamins Tablet;TAKE 1 TABLET DAILY.; Rx. FH/SH: both non-contributory for this admission PE: vitals reviewed she has been afebrile since admission from the clinic alert, appears chronically ill NCAT, no conj, no icterus neck supple and NT without LAD RRR CTAB no crackles abdomen soft and NT, ostomy site C/D/I dog bit wound looks much improved from last hospitalization blanching macular rash on back no edema in LE labs reviewed CXR reviewed cultures pending A/P: 60 year old female s/p kideny transplant admitted with fever.
LE|leukocyte esterase|LE,|226|228|LABORATORY DATA|No loose bodies are identified. No evidence for osteomyelitis is seen. LABORATORY DATA: Labs from the outside institution demonstrate a sed rate of 90 and a white blood cell count of 17.7. Her urinalysis demonstrates positive LE, positive nitrites, positive protein, 10 white blood cells and positive bacteria. ASSESSMENT: 1. Urinary tract infection. 2. Mild focal swelling right distal ulnar, possibly consistent with unrecognized trauma or other soft tissue irritation.
LE|leukocyte esterase|LE|142|143|LABORATORY DATA|White blood count 14.7, hemoglobin 10.1, hematocrit 29.8. Sodium 135, potassium 4.1. BUN 12, creatinine 1, UA as previously noted was benign, LE positive and evidence of white cells. Cholesterol 156. Chest x-ray was reviewed and demonstrates what appear to be bilateral infiltrates, worse on the left with evidence of chronic lung disease appearing evident as well.
LE|lower extremity|LE.|161|163|RECOMMENDATIONS|Unhappy with diet - no meat? Continues on high dose decadron for cord mets/compression. T 100 max, 85 102/66. Very slight movement of toes. Otherwise no movt of LE. Current insulin regimen Lantus 25 am, Novlolg 1u/cho with meals + low correction schedule.
LE|lower extremity|LE.|135|137|T 97, 103 92/69.|Endocrine consult Patient eating well. No N/V. Continues on high dose decadron for cord mets/compression. T 97, 103 92/69. No vol movt LE. Current insulin regimen Lantus 25 am, Novlolg 1u/cho with meals + low correction schedule.
LE|lower extremity|LE|132|133|MUSCULOSKELETAL|RESPIRATORY: SOB. GI: Pancreas transplant. GU: Chronic renal insufficiency. ENDOCRINE: Diabetes mellitus. MUSCULOSKELETAL: Tremors, LE weakness. NEUROLOGIC: Intracranial hemorrhages, subdural hematoma. PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile, blood pressure 130/60, heart rate 86.
LE|lower extremity|LE|124|125||No JVD. Lungs are mostly clear to auscultation with fine crackles bilaterally. RRR, normal S1, S2. Abdomen is soft. Mild 1+ LE edema. Upon further review of the initial TTE, the LVEF perfectly normal and there are no wall motion abnormalities. the RVSP is severely increased and the the IVC is dilated.
LE|lower extremity|LE|124|125||No JVD. Lungs are mostly clear to auscultation with fine crackles bilaterally. RRR, normal S1, S2. Abdomen is soft. Mild 1+ LE edema. Upon further review of the initial TTE, the LVEF perfectly normal and there are no wall motion abnormalities. the RVSP is severely increased and the the IVC is dilated.
LE|lower extremity|LE|414|415|PE|No tuberculosis. 2 sons, both healthy, ages 15 & 10. SH: no EtOH PE: vitals reviewed I/O's reviewed - patient oliguric since admission although urine output appears to be increasing alert, appears dyspnic, somewhat toxic NCAT, no conjunctivitis, jaundiced OP clear neck supple and NT without LAD RRR diminished breath sounds at the bases, otherwise clear decreased bowel sounds, incision site C/D/I trace edema in LE neuro exam non-focal labs, imaging studies, cultures since admission reviewed A/P: 48 year old male with acute kidney injury likely multifactorial - elevated Prograf level, suspect hypotensive/septic episode at home given ERCP findings, and dehydration.
LE|lower extremity|LE|149|150|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Urinary incontinence and LE weakness. HPI: Gastric cancer with extensive spine metastasis.
LE|leukocyte esterase|LE,|226|228|UA|LE without any edema CN 2-12 intact. No rash Labs: Cr 1.96 (2.2 on admit), HCO 17 (13 on admit), K 5.1 (5.4 on admit), Na 138, Hg 9.7 (7.6 on admit-transfused) Phos 3.6, Mg 2.1, Ca 7.6 UA: SG1.011, pH6.5, 10alb, +nitrite/lrge LE, mod bld. 122 WBC/17RBC. WBC clumps kidney fluid: GPC, GNR PTH (_%#MM2007#%_') 622; Ur protcr 1.04g/gCr (_%#MM2007#%_') TTE (_%#MM2007#%_'): LVEF 30%.
LE|lower extremity|LE.|248|250|ROS|Trace pedal edema. NABS, ND/NT/S without HSM or masses. FROM in all joints without tenderness or swelling; mild erythema and tenderness at base or large L great toe. Strength of all extremities: 5/5 and symmetric. Unable to elicit reflexes in both LE. Normal sensation throughout. No skin rash, unusual lesions. A/P: Elderly male with new embolic CVI s/p thrombolysis with resolution of neurologic sx and 2 month h/o back pain, anorexia/weight loss and night sweats.
LE|lower extremity|LE|169|170|PE|Clear anterior and lateral. Easy effort, no wheezes. CV: RRR. Distant. No obvious murmurs. Abd: No BS. Dressings from lap trochars w/no drainage. Soft, ND. Lymph: Trace LE edema. Skin: Warm, dry Neuro: Somnolent, but arousable and appropriate. Labs reviewed in FCIS. Creat 0.96 Mg 1.6 Fingerstick glc 167 @ 1700 Pre-op Hgb 15.3 WBC 7.7 on _%#MMDD#%_ Last tacrolimus level _%#MMDD#%_ = 7.4 (13.5 hour trough) A/Recs: 33 y/o M with bilat SLT for DIP, POD#0 lap chole and umbilical hernia repair.
LE|leukocyte esterase|LE.|192|194|LABORATORY DATA|Complete metabolic profile within normal limits except for mild hypokalemia with potassium of 3.3. Beta human chorionic gonadotropin 2,790. Blood type A+. Urinalysis was large blood and trace LE. Otherwise within normal limits. IMAGING: Pelvic ultrasound performed and revealed no intrauterine pregnancy, a thickened 18 mm heterogenous endometrial strip that could represent blood or retained products in the endometrial cavity.
LE|lower extremity|LE|190|191||A/P: 1. S/p permanent bivad placement 2. S/p bivad Levitronix explant 3. Cardiogenic shock following MVR 4. Continue supportive measures. 5. Long term prognosis: heart/kidney transplant. 6. LE bilateral wounds adrressed by vascular surgery.
LE|lower extremity|LE|959|960|PE|PMH: 1. ESKD secondary to congenital renal agenesis, this was discovered when he had an accident in 2004 and was found to have an elevated creatinine, he apparently had only his right kidney, s/p LDKT _%#MM2007#%_ without a complicated post-operative course, no rejection episodes, but for the past few months has been running a low Prograf level 2. history of HD from _%#MM2006#%_-_%#MM2007#%_ 3. history of MVA in 2004 Current Medications: Prograf 2.5 mg bid MMF 500 mg bid sodium bicarbonate amlodipine 5 mg bid metoprolol 50 mg bid Protonix Calcium with vitamin D Bactrim Allergies: IVP dye needs prophylaxis SH: he is college student at UND denies smoking, EtOH abuse, and recreational drug use FH: non-contributory to this admission PE: vitals reviewed alert, pleasant, non-toxic, in NAD NCAT, no conj, no icterus OP clear neck supple and NT RRR no murmurs CTAB no crackles abdomen soft and NT, no rebound, no guarding, allograft non-tender no edema in LE neuro grossly non-focal today's labs reviewed, including CBC and coags creatinine 2.5 (per patient was 2.6 yesterday) A/P: 18 year old male s/p LDKT _%#MM2007#%_ with evidence of rejection on biopsy _%#MMDD#%_.
LE|lower extremity|LE|130|131|HPI|Just came back from a month long trip to Europe. Has had a 30 Lb weight loss over the last 6 months. has noticed increasing Bilat LE edema PMH: Hep C, esophageal varieces, ascites s/p paracenthesis today, CKD, cocaine and heroin abuse sober x 15 years.
LE|lower extremity|LE|147|148||2. Status post HeartMate-II LVAD placed as a bridge to transplantation. 3. Continue current measures. Would recommend lasix to prevent significant LE edema. LVAD flows are stable.
LE|lower extremity|LE|174|175||There were no new events overnight. The only issue is an increased WBC. However, in the absence of clinical correlate, it is reasonable to discharge the patient to home. Her LE edema will likely improve as she becomes more ambulatory. She should continue to take lasix at her current dose of 40 mg PO BID.
LE|leukocyte esterase|LE|249|250|ADMISSION LABORATORY DATA|Lipase, amylase were within normal limits as were all his other liver function tests except for a slightly increased alkaline phosphatase of 145. A UA was initially read out as having ketones, blood, greater than 300 albumin, urobilinogen and small LE with 12 white cells, hyalin casts, granular casts and some urine oxylate crystals. However, these results were removed from the computer since the specimen was not properly labeled; it was unclear whether or not this was the patient's urine.
LE|leukocyte esterase|LE,|282|284|LABORATORY|LABORATORY: CBC: While blood count 7.3 with an ANC 6.6, hemoglobin 10.8 and platelets 613,000. BMP: Sodium 135, potassium 3.7, chloride 100, CO2 28, BUN 21, creatinine 0.72, glucose 215, calcium 9.2, magnesium 2.1 and phosphorus 2.3. URINALYSIS: A 30 protein, moderate blood, large LE, 21 wbc's and 11 hyaline casts. HOSPITAL COURSE: PROBLEM #1: Disease: As previously stated, the patient has recurrent ovarian cancer with metastases to the lungs, liver and brain.
LE|leukocyte esterase|LE.|195|197|PROBLEM #6|Two days prior to discharge, the patient's urine was noted to be cloudy, therefore was sent for UA which did appear to be positive with marked wbc's and bacteria as well as positive nitrites and LE. She was started on Cipro p.o. for a total of a 10-day course of treatment. Culture returned greater than 10,000 colonies of E. coli. This is a preliminary reading prior to discharge.
LE|leukocyte esterase|LE|163|164|LABORATORY DATA|Basic metabolic panel: Sodium 138, potassium 3.9, chloride 104, CO2 25, BUN 12, creatinine 1.04, glucose 98 and calcium 9. INR 1.04. CA-125 15. UA showed moderate LE with 64 wbc's and few bacteria. Urine culture show a probable contamination. IMAGING: Chest x-ray: Two nodular densities in the right mid lung likely representing calcified granulomas.
LE|leukocyte esterase|LE.|465|467|LABORATORY DATA|EXTREMITIES: Nontender. LABORATORY DATA: White blood cell count 21.3, hemoglobin 13.8, platelets of 657, sodium 136, potassium 3.5, chloride 105, CO2 18, BUN 19, creatinine 1.43, glucose of 196, INR of 1.28, PTT 25, troponin less than 0.04, BNP 304, fingerstick blood glucose 182, amylase 36, lipase 26, lactate 2.2, AST 40, ALT 44, alkaline phosphatase 97, protein 6.7, albumin 3, total bilirubin 0.3. Cath UA, moderate blood, 12 WBCs, negative nitrites, negative LE. C. diff is pending. IMAGING: Chest x-ray clear. CT abdomen and pelvis was pending.
LE|leukocyte esterase|LE,|325|327|LABORATORY|Extremities: Nontender. Brief bedside ultrasound revealed a singleton in a frank breech presentation with an anterior placenta, weight 1317 g with an AFI of 3.1. LABORATORY: TSH was less than 0.03, INR 0.94, fibrinogen 436. BUN 5, creatinine 0.4, and uric acid 4.0. Urine toxicology is negative. UA has moderate blood, trace LE, negative protein, and negative nitrites. HOSPITAL COURSE: The patient was transferred to maternal fetal medicine service and the family practice service on the hospital day #1.
LE|leukocyte esterase|LE|158|159|LABORATORY DATA|Sodium is 133, potassium 4.3, chloride 104, CO2 19, BUN 7, creatinine 0.6, glucose 136. UPT negative, UA specific gravity 1.020 with moderate blood, negative LE and nitrites. CT exam demonstrated 7.2 x 7.7 cm mass in the left adnexa that is cystic with multiple septations.
LE|leukocyte esterase|LE|155|156|LABORATORY TESTS ON ADMISSION|There is ST-T wave abnormality in lateral leads compared with prior EKG there is no new change. Urine shows blood in urine negative, urine protein 30, and LE in urine is moderately positive, wbc's 5 to 10. Urine culture and blood cultures are pending. Stool cultures still pending.
LE|leukocyte esterase|LE|170|171|LABORATORY DATA|BUN 55, creatinine 2.50 from 2.40 yesterday. One month ago, her baseline creatinine was 1.2. Calcium 7.8. Magnesium and phosphorus within normal limits. Urine is cloudy, LE positive, nitrates negative, WBC 182, RBC 23. Hemoglobin 9.6, MCV 96. Hemoglobin on admission was 11.5. ALT 35, AST 49, alkaline phosphatase 244, albumin 4.
LE|leukocyte esterase|LE|139|140|LABORATORY STUDIES ON ADMISSION|A UA showed dark brown urine with a cloudy appearance, large amount of bilirubin was present. Specific gravity was 1.014. Large amounts of LE were present along with 114 white cells, many bacteria and white blood cell clumps. UPT was negative. Drug screen was positive for opiates. Amylase 54, lipase 138, ammonia was 76.
LE|leukocyte esterase|LE.|120|122|PROBLEM #2|UA and culture were sent, and the Foley was pulled. The UA was positive for large blood, 100 mg/dl of protein and trace LE. The culture showed greater than 100,000 colonies of E. coli. She was treated empirically on _%#MM#%_ _%#DD#%_, 2002, with one dose of IV Rocephin shortly after this specimen of urine was obtained, and then she was placed on oral Bactrim double strength one p.o. b.i.d. x 10 days.
LE|leukocyte esterase|LE,|279|281|LABORATORY DATA|LABORATORY DATA: Labs on admission; hemoglobin 6.7, platelets 410, and white count 10.3. Basic metabolic panel significant for creatinine of 1.84, BUN 74, initial troponin was negative, albumin 2.3, alkaline phosphatase 398, ALT 71, AST 199. UA; cloudy, moderate blood, moderate LE, 107 white blood cells, moderate bacteria, and 9 granular casts. HOSPITAL COURSE: 1. Disease: As noted above, the patient has platinum resistant recurrent progressive papillary serous carcinoma of the ovary, despite multiple chemotherapeutic regimens, most recently on 825A study protocol.
LE|leukocyte esterase|LE,|122|124|PAIN ASSESSMENT|Alkaline phosphatase 76. ALT 16, AST 16, INR was 2.99, GTT 55. Amylase 35, lipase 23. UA was negative for nitrites, small LE, 9 white blood cells, greater than 182 red cells. IMAGING STUDIES: Chest x-ray within normal limits. Abdominal x- ray was within normal limits.
LE|lower extremity|LE|138|139|STUDIES PERFORMED|She was asked to continue her medications, as prescribed. STUDIES PERFORMED: 1. Echocardiogram. 2. Stress echocardiogram. 3. V/Q scan. 4. LE Doppler. ADMISSION HISTORY: The patient is a 30-year-old female with a past medical history of bipolar disorder who came to the ER with a chief complaint of right-sided chest pain for three days on deep inspiration.
LE|lower extremity|LE|178|179|PROBLEM #1|PROBLEM #1: Right-sided chest pain. During her stay in the hospital, the patient remained afebrile, and vital signs were stable. The patient was ruled out for PE by V/Q scan and LE Doppler, and clinically the patient was improved with Vicodin. The patient rated her pain on admission as 7/10, which was decreased to 4/10 on discharge.
LE|lower extremity|(LE)|250|253|HISTORY OF PRESENT ILLNESS|She denies respiratory distress, she says it is just that was so noisy. At any rate she came into the emergency room and she was found to have bilateral rales and rhonchi with some wheezing, increased jugular venous distention (JVD), lower extremity (LE) edema, and an increased blood pressure of around 200/100 with a pulse of 110. She was treated with IV Lasix, labetalol and nitroglycerin drip plus mask O2 bringing her O2 saturations from 86% to 99% and her comfort level became much better.
LE|leukocyte esterase|LE|211|212|ADMISSION LABORATORY DATA|SKIN: There is a large tattoo on the left arm as well as the right back which were placed two years ago. ADMISSION LABORATORY DATA: U/A: ketone greater than 18 mg/dL, ______ 1.02, blood was trace, pH was 5, and LE and nitrate were negative. CBC: WBC was elevated, at 16.2; hemoglobin 15.6; with platelets of 261; and 82% neutrophils. ABG: He was acidotic, with a pCO2 of 13, bicarbonate of 5, and pO2 of 59.
LE|leukocyte esterase|LE,|190|192|LABORATORY|NEUROLOGIC: The patient is alert and oriented x3. Cranial nerves are intact otherwise no exam beyond that done. LABORATORY: Include a urinalysis in the clinic yesterday morning showed small LE, positive nitrates, 10 to 20 white blood cells and 0 to 3 red blood cells. Urine culture from ER is pending, unfortunately after she has received a few doses of Keflex.
LE|leukocyte esterase|LE,|198|200|ADMISSION LABORATORY DATA|On _%#MMDD2002#%_, there was a hemoglobin drop from 10.6 to 9.2. The patient was transfused. On _%#MMDD2002#%_, she had a hemoglobin of 12.2. Urinalysis showed large blood, negative nitrites, trace LE, gross blood and rare bacteria. HOSPITAL COURSE: The patient was admitted with review of outside pathology and scheduled for possible exploratory laparotomy/staging.
LE|leukocyte esterase|LE.|167|169|LABORATORY DATA|The patient has history of splenectomy and his platelet of 534 is therefore expected. His blood ketone value was elevated ...... UA was positive for ketones and trace LE. The urine toxicology screen was negative. Basic metabolic panel showed a sodium 145, potassium 4.3, chloride 101, bicarb 7, glucose 131, creatinine 1.03 and calcium of 8.9. His total bilirubin was 0.6, albumin was 4.0, total protein was 8.6, alkaline phosphatase was 192, ALT was 126 and AST was 258.
LE|leukocyte esterase|LE|137|138|LABORATORY|Hemoglobin 13.6, platelets 407, troponin less than 0.3. Urinalysis reveals a specific gravity of 1.019, 15 ketones, 30 protein, negative LE and nitrite, 4 WBC, 3 RBC. Albumin 3.7. Abdominal x-ray revealed approximately an 8 mm left ureteral stone at the inferior margin of the left sacroiliac joint.
LE|lower extremity|LE|251|252|LABORATORY DATA ON ADMISSION|LABORATORY DATA ON ADMISSION: WBC 5.9, hemoglobin 11.3, platelets 393, neutrophils 62%, lymphs 24%, sodium141, potassium 4.7, chloride 100, bicarb 27, BUN 34, creatinine 3.08, glucose 62, calcium 8.6, BNP 136. UA showed small blood, 10 protein, large LE greater than 100, 82 WBCs, 94RBCs, many bacteria, and mucous. Blood and urine cultures were pending at the time of admission.
LE|leukocyte esterase|LE,|270|272|LABS UPON ADMISSION|_%#NAME#%_'s LFTs were within normal limits. Her electrolyte panel was remarkable for a Sodium of 129, Potassium 3.5, Chloride 90, bicarbonate 33, BUN 31, creatinine 0.84, calcium was 8. Her urinalysis from the emergency department demonstrated 300 of protein, negative LE, negative nitrite. Rapid influenza A and B was found which was negative along with the rapid strep which was negative. Laboratories 2 weeks prior to admission had demonstrated normal complement level C3 being 94 and C4 is 16 respectively, and CRP of 0.40. _%#NAME#%_'s CRP upon admission was 145 mg/L.
LE|leukocyte esterase|LE,|113|115|LABORATORY DATA|LABORATORY DATA: Hemoglobin 12.1 with a white cell count of 8.5, and platelet of 331, UA shows trace large small LE, white cell 8, negative nitrate and a few bacteria. Electrolytes were within normal limits with creatinine of 0.72, and BUN of 13.
LE|lower extremity|LE|169|170|3.  ARF|On exam, BP slightly below baseline (90s/50s), others vitals WNL. She is comfortable appearing. Large pannus, several erythematous streaks, warm and tender to touch. No LE edema. U/S pending A/P: 55 yo female with ESLD secondary to NASH, s/p gastric bypass surgery complicated by malnutrition, admitted with worsening ascites and ARF.
LE|leukocyte esterase|LE|150|151|LABORATORY DATA|NEUROLOGIC: The patient is awake, alert, oriented X2. Motor of lower extremities is 3/5. Gait not tested. LABORATORY DATA: In the ER shows urinalysis LE moderate, WBC 99, RBC 2, WBC clumps present. WBC 10.4, hemoglobin 10.8, MCV 93, neutrophils 81%, lymphocytes 12%, monocytes 5%.
LE|leukocyte esterase|LE|189|190|LABORATORY ON ADMISSION|LABORATORY ON ADMISSION: 1. White blood count 3.0, hemoglobin 11, platelet 225, MCV 98, neutrophils 58, lymphocytes 29, monocytes 9. U/A white blood count 25, rbc's 0 to 2, a few bacteria. LE moderate. Urine culture showed E. coli and Klebsiella. Micro-organisms sensitive to ciprofloxacin, gentamicin, and tobramycin. 2. EKG shows abnormal T in V2 and V3.
LE|lower extremity|LE|164|165|PHYSICAL EXAMINATION ON ADMISSION|No fasciculations. Strength/RL: Deltoid 5/5, biceps 4/4+, triceps 5/4+, wrist extension 5/2, finger extension 5/2. Hip flexion 5/3, hip extension 5/3, abduction of LE 5/1, abduction LE 5/1, quad 4/2, hamstrings 4/2. Flexion of the foot 4+/2, extension 5/4. Sensory: Normal to light touch.
LE|leukocyte esterase|LE|243|244|PROBLEM #7|PROBLEM #7: GU: The patient had a Foley placed preoperatively and this was discontinued on postop day #1. She was voiding spontaneously at the time of discharge. Due to a mild fever on _%#MMDD2007#%_, UA was performed which demonstrated large LE and elevated wbc's and therefore she was started on Cipro and received a total of 3 days of treatment for presumed UTI. Urine culture was pending at the time of discharge. PROBLEM #8: ID: The patient was started on nystatin powder for candidiasis below the breasts and pannus.
LE|leukocyte esterase|LE|204|205|PROBLEM #8|She spiked a T-max of 101.7 at 8:00 p.m. on _%#MMDD2007#%_ and therefore blood and urine cultures were done given that she was greater than 24 hours postop. White count was 20.2 and UA demonstrated large LE with 156 wbc's and a few bacteria. Therefore, she was started on ciprofloxacin p.o. and continued this for a total of 3 days of therapy.
LE|leukocyte esterase|LE|135|136|LABS AND IMAGING ON ADMISSION|LABS AND IMAGING ON ADMISSION: White blood cell count 7.2, hemoglobin 12.4, platelet count 139. UA shows 40 of ketones, 10 of protein, LE and nitrite negative, 1 white blood cell and 3 red blood cells. Basic metabolic panel was within normal limits. Chest x-ray shows compression fractures severe at T11 and minor at T9 with subsequent T-spine series showing osteopenia and the compression fractures as above.
LE|leukocyte esterase|LE,|157|159|PROBLEM #3|Her urinary tract infection was managed with ceftriaxone and fluconazole, and her follow-up U/A upon discharge is a specific gravity of 1.007, pH 5.0, trace LE, and a few bacteria. She should continue on gram-negative and fluconazole coverage for a total of 7 days, and have a sterile urine retested at that point in time.
LE|leukocyte esterase|LE|246|247|PROBLEM #6|PROBLEM #5: Genitourinary. The patient has a left double J stent in place for whic h Interventional Radiology was called for possible revision of this stent, however, they said that it was not necessary at this time. She had UA that showed small LE and urine culture that was pending at the time of discharge. PROBLEM #6: Infectious Disease. The patient remained afebrile throughout her hospitalization.
LE|leukocyte esterase|LE.|155|157|PHYSICAL EXAMINATION|Electrolytes were within normal limits. Creatinine was 1.24, glucose 89. Comprehensive metabolic panel was within normal limits. A urinalysis showed trace LE. HOSPITAL COURSE: 1. Infectious Disease. This is a 67-year-old with chronic MRSA infection, recently had a manipulation of her Hickman catheter, and so increased dose of vancomycin was started and the patient's blood cultures were positive for methicillin-resistant Staphylococcus aureus from the blood drawn from the Hickman.
LE|lower extremity|LE|141|142|HOSPITAL COURSE|Sodium 140, potassium 4, chloride 100, CO2 28, BUN 20, creatinine 1.09, calcium 9.4, bilirubin 0.4. HOSPITAL COURSE:. PROBLEM #1. Asymmetric LE weakness, proximal greater than distal We involved the neurology team in the evaluation of this lady and an EMG was done. The overall picture was that of diabetic amyotrophy. Therefore the patient was started on IVIG infusion, and she received a total of 210 g.
LE|lower extremity|LE|192|193|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Prostate cancer s/p partial irradiation (45 Gy) with urethritis and LE weakness causing discontinuation. HPI: Now PSA rising. Resumed Lupron. Exam: Prostate smooth, no nodule appreciated.
LE|lower extremity|LE|120|121|HPI|HPI: New weakness both legs with CT shows progressive disease at prior decompression. Also mets at L1, L3 and L5. Exam: LE weakness. Assessment and Plan: Risks and benefits of XRT explained to patient and wife.
LE|lower extremity|LE|129|130|HPI|R/O radiation neuropathy. HPI: Patient is s/p sigmoid resection and post op pelvic RT of 4900 cGy in 175 cGy fx. Exam: Decreased LE strength Assessment and Plan: At this dose, with these low fraction sizes, the patient appears to be the generally accepted dose for peripheral nerve tolerance.
LE|lower extremity|LE|162|163|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Cord compression. HPI: Rapid onset of LE weakness/paralysis. Exam: No strength LE. Sensory level at T7. MRI shows huge mass destroying vertebral body and compressing cord.
LE|leukocyte esterase|LE|158|159|LABORATORY DATA|Platelet count is normal at 199,000. U-tox was positive for cocaine. Urinalysis shows greater than 1000 glucose, positive for nitrates, moderate blood, large LE with white and red cells in the urine. The patient denies any urinary symptoms currently, however. IMPRESSION: This is a 54-year-old woman admitted with worsening depression/bipolar illness and recent substance abuse with a chaotic home situation.
LE|leukocyte esterase|LE,|299|301|LABORATORY DATA|Sensation grossly intact. LABORATORY DATA: White count 17.5, hemoglobin 14.9, platelets 462, sodium 144, potassium 3.8, chloride 105, bicarbonate 28, BUN 20, creatinine 0.75, calcium 9.7, total bilirubin 2.2, ALT 64, AST 53, alkaline phosphatase 844, lipase 3067. Urinalysis positive nitrite, trace LE, 30 protein, 2-5 white blood cells, 10-25 red blood cells, moderate bacteria. ASSESSMENT AND PLAN: 66-year-old female with history of chronic abdominal pain who recently underwent ERCP, now with pancreatitis.
LE|leukocyte esterase|LE,|451|453|LABORATORY DATA|EXTREMITIES: Trace edema bilaterally. LABORATORY DATA: On day of admission, CBC revealed WBC 5.8, hemoglobin 9.1 and platelets 262, INR was 1.02, ionized calcium 4.6, magnesium 2.0. BMP: Sodium 140, potassium 3.4, chloride 105, CO2 26, BUN 8 and creatinine 0.51. The patient did have elevated blood sugars from 123 to 252. Urinary analysis revealed a specific gravity of 1.009, negative for ketones, glucose or protein. Negative nitrates and negative LE, 1 white blood cell, less than 1 red blood cell. Urine culture less than 10,000 colonies of Gram negative rods two kinds.
LE|leukocyte esterase|LE|185|186|LABORATORY TESTS|EXTREMITIES: No edema. Full range of motion. NEUROLOGICAL: Alert and oriented x3, no focal deficits appreciated. LABORATORY TESTS: On admission, urine is cloudy with nitrates positive, LE positive, WBC more than 182, RBC 7, bacteria moderate. Urine culture pending. Pregnancy test negative. ?? is 55. Electrolytes within normal limits.
LE|leukocyte esterase|LE|122|123|LABORATORY|Urinalysis which showed 0 white blood cells, 0 red blood cells, specific gravity of 1.012, pH of 6.5, and a few bacteria. LE and nitrites were negative. ALT was mildly elevated at 98, AST at 47, total bilirubin was 0.4, alkaline phosphatase was 70, and albumin 4.0. A recent CMV antigenemia result from _%#MM#%_ _%#DD#%_, 2004, was known to be negative at that time.
LE|leukocyte esterase|LE|110|111|LABORATORY TESTS|Stool cultures pending. Stool occult blood negative. Vitamin B12 of 387, folate level 7.1, TSH 3.25. UA shows LE positive, 11 wbc but urine culture negative. Phosphorus 3.4, MCV 103, platelet counts 131,000, ferritin 306 and iron 128. DISCHARGE MEDICATIONS: 1. Prozac 20 mg p.o. q. daily.
LE|leukocyte esterase|LE|215|216|LABORATORY DATA|Psychiatric evaluation: .............. ..................patient is ..........and crying during examination. LABORATORY DATA: Urine tox screen positive for benzodiazepine, opiates, cannabinoids and urinalysis shows LE small, WBC 10, RBC 99, bacteria many, cultures pending. Basic metabolic panel and CBC normal. IMPRESSION: This patient is 51-year-old female with history of chronic lower back pain and with history of septic left-hip arthroscopy, obesity and schizoaffective disorder, and history of ................substance abuse and is homeless.
LE|leukocyte esterase|LE,|160|162|FAMILY HISTORY|Creatinine 1.5. Glucose 135. Protein 9.2. Lipase 109. INR 1.12. LFTs were normal. U tox revealed positive cocaine and positive benzos. UA revealed ketones 1 gm LE, 5-10 WBC. UPT negative. EKG showed biphasic Ps, tachycardic to 103. Chest x-ray normal. COURSE IN THE HOSPITAL: PROBLEM #1: Polysubstance abuse/withdrawal.
LE|leukocyte esterase|LE,|142|144|PHYSICAL EXAMINATION|White count was 4.8 with a normal differential and hemoglobin 10.9 with a MCV of 115, platelets 283. Urinalysis showed red blood cells, trace LE, and few bacteria. Urine pregnancy test was negative. SUMMARY OF PROBLEMS: 1. Renal/Urologic: Pyelonephritis and left nephrolithiasis.
LE|leukocyte esterase|LE|270|271|LABORATORY DATA|Extremities: without cyanosis, clubbing, or edema. LABORATORY DATA: A urine culture from _%#MMDD2002#%_ showed greater than 10,000 E. coli, which is only marginally sensitive to gentamicin. A wet prep showed many clue cells, and her urinalysis showed nitrates and large LE consistent with a UTI which had not been treated. HOSPITAL COURSE: The patient received a bedside ultrasound which is consistent with her dates.
LE|leukocyte esterase|LE,|308|310|LABS ON ADMISSION|Hemoglobin 12.5 and platelets 328. Sodium 139, potassium 3.5, chloride 100, bicarbonate 28, BUN 27, creatinine 1.12, glucose 106, GFR 54, calcium 8.8, bilirubin 0.3, alkaline phosphatase 136, ALT 30, AST 30, and TSH 1.20. Troponin negative x1. Blood culture, urine culture, and CRP pending. UA cloudy, small LE, otherwise, within normal limits. Urine micro; 5 to 10 white blood cells, 5 to 10 hyaline casts, and many uric acid crystals.
LE|leukocyte esterase|LE,|261|263|LABORATORY|Red cell indices, MCV low at 72, MCH low at 23, MCHC 32 normal, RDW is increased, INR 1.03, PTT is 31, D-dimer is 0.3, CMP all within normal limits, amylase 45, lipase 30, troponin x1 is negative, BNP was 35, magnesium 2.1, urine HCG was negative, UA was trace LE, negative microscopic evaluation, negative microscopic urine. Utox was negative for all, interesting noting that benzodiazepines were negative, supposedly had taken Ativan.
LE|leukocyte esterase|LE,|206|208|ADMISSION LABS|INR 1.15, PTT 33, BUN 142, potassium 3.2, chloride 104, CO2 29, AG 10, glucose 112, BUN 12, creatinine 0.47, GFR greater than 90, calcium 8.7. Troponin I 0.12. 4. U/A with 15 ketones, negative nitrites for LE, 100 protein, 100 albumin. Micro with moderate bacteria and mucous present. Also, though, with squamous cells. HOSPITAL COURSE: PROBLEM #1: Infectious disease. The patient was treated as if she had community-acquired pneumonia, on azithromycin and ceftriaxone.
LE|leukocyte esterase|LE|125|126|LABORATORY DATA|LABORATORY DATA: Chest x-ray shows no infiltrates nor effusion, no sign of congestive heart failure. UA shows trace positive LE with 2-5 white blood cells and bacteria, however, there are squamous cells well, white blood cell count 6.2, hemoglobin 12.4, electrolytes are all within normal limits other than a glucose 158.
LE|leukocyte esterase|LE|246|247|LABORATORY EVALUATIONS|RECTAL: Stool guaiac is negative in the ER. LABORATORY EVALUATIONS: Show a CBC of 5.9 with hemoglobin of 8.0, platelet count 358,000. INR 1.08. Electrolytes are essentially normal. Her lipase is 129, troponins negative, BNP 95. Urine shows trace LE with positive nitrite. 10-20 WBCs in the urine with many bacteria. IMPRESSION: This is an 80-year-old female with urinary tract infection and anemia.
LE|leukocyte esterase|LE,|246|248|LABORATORY DATA ON ADMISSION|BMP sodium 142, potassium 3.9, BUN 54, creatinine 1.11, calcium 9.0. Hepatic panel: Unable to obtain conjugated and delta bili. Total bili 0.4, albumin 3, ALP 72, ALT 17, AST 21, amylase 38, lipase 24, troponin initial is negative. UA with large LE, moderate blood, white cells - note indwelling Foley. Urine culture ultimately grew 10,000 to 50,000 non- lactose fermenting gram negative rods.
LE|leukocyte esterase|LE.|153|155|LABORATORY|Chest x-ray of abdomen as above. Wet prep: Moderate yeast, no trichomonas, no clue cells or PMNs. Beta HCG was negative. UA was negative for nitrites or LE. Urine culture obtained. Ultrasounds as above. EKG was normal sinus rhythm, normal EKG. HOSPITAL COURSE: 1. Abdominal pain. Given antiemetics and 6 mg Dilaudid, 30 mg Toradol and 1 g of Rocephin in the emergency department.
LE|leukocyte esterase|LE,|192|194|HOSPITAL COURSE BY PROBLEM|He was tolerating clears by second night and a full diet by the third with normal bowel movements. 2. Urinary tract infection: The patient had a fever of 100.9 and had a UA which showed large LE, negative nitrites, moderate bacteria, and 182 wbc's. GIVEN THE PATIENT'S ALLERGIES TO PENICILLIN AND SULFA, the patient was given a course of levofloxacin 250 mg p.o. q. day.
LE|leukocyte esterase|LE|166|167|LABORATORY DATA|Liver function tests are normal. Lipase, TSH, troponin and myoglobin are all within normal limits. Her troponin was 0.07. Urine, UA is positive nitrates and moderate LE with many bacteria noted on mid stream urine. A straight Cath UA and UC is pending also. IMPRESSION: 1. Urinary tract infection, possible pyelo. 2. Dehydration 3. Anemia.
LE|leukocyte esterase|LE|181|182|LABORATORY DATA|BACK: Nontender to palpation. His pain was located along the spine, more or less, from the lower lumbar radiating up through the shoulders. LABORATORY DATA: Urinalysis showed trace LE with moderate bacteria and mucus present. He is ketotic, 10 mg per deciliter ketones with a specific gravity 1.030. His electrolytes are within normal limits with chloride being 96 which is slightly low, albumin slightly raised at 4.8, protein is 8.4. His white count is not elevated at 8.2 thousand, hemoglobin 14.9. Neutrophils 76% with lymphocytes 18%.
LE|leukocyte esterase|LE.|118|120|LABORATORY DATA|SKIN: Unremarkable. NEUROLOGIC: Alert and oriented x 3, nonfocal exam. LABORATORY DATA: Urinalysis: 10 ketones, trace LE. Comprehensive metabolic panel: Lipase normal. CBC normal. H. pylori negative. Abdominal x-ray from _%#MMDD2006#%_ consistent with constipation. CT of the abdomen from last: Small amount of free fluid in the pelvis.
LE|lower extremity|LE|158|159|IMPRESSION|10. Morbid obesity, now much decreased secondary to dieting efforts for the last year. 11. Leukopenia in _%#MM#%_ 2002. 12. Anxiety/depression, lifelong. 13. LE edema minimal pretib, _%#MM#%_ 2002. 14. Minimal ________ dermatitis distal LE. 15. SPO 1986 cholecystectomy. PLAN: Admit to the hospital. Do routine rule out chest pain orders.
LE|leukocyte esterase|LE,|204|206|ADMISSION LABORATORY DATA|NEUROLOGIC: completely normal. Extraocular movements: intact. ADMISSION LABORATORY DATA: Hemoglobin 11.6, hematocrit 34.7, and platelets 305. Urinalysis: some ketones, positive for nitrites, positive for LE, white blood count 2-5, many bacteria. Electrolytes: potassium 2.6, sodium 140, chloride 106, CO2 27, creatinine 0.9, glucose 41, lipase 84, AST 18, ALT 5, bilirubin 0.3. Clostridium difficile: pending.
LE|leukocyte esterase|LE,|315|317|LABORATORY|Neurologic: Awakens with exam. Patella reflexes 2+ bilaterally. LABORATORY: At the time of admission are significant for a white count of 8, hemoglobin 12.8, platelets 32, with a differential of 83% neutrophils, 10% lymphocytes, 4% monocytes, and 3% eosinophils. ESR 8. UA with a moderate amount of blood, moderate LE, protein 100, large bilirubin, 80 white blood cells, and 12 red blood cells. Rapid strep negative. Electrolytes with sodium 138, potassium 3.8, chloride 101, bicarbonate 20, BUN 15, creatinine 0.3, glucose 114, calcium 9.3.
LE|leukocyte esterase|LE,|113|115|LABORATORY EVALUATION|Protein is 7.6. Albumin is 4.0. ALT is 28. Alkaline p'tase is 57, bili total is .5. Urine was trace blood, small LE, moderate epithelial cells, a few bacteria. Hemoglobin originally on admission was 6.3. After one unit was 6.2, white count is slightly decreased at 3.9. Platelets are normal at 337,000.
LE|leukocyte esterase|LE.|214|216|LABORATORY|Hemoglobin was 11.3, and platelets were 327. Her chemistries is remarkable for a BUN of 24 and creatinine of 2.83. The last creatinine on _%#MM#%_ _%#DD#%_, 2004, was 0.3. UA showed 145 white blood cells and small LE. Abdominal film showed some air fluid level. No free air. Chest x-ray showed a left lower lobe infiltrate versus atelectasis.
LE|leukocyte esterase|LE|243|244|LABORATORY DATA|SKIN: Shows no breakdown. NEUROLOGICAL: He can move all extremities and respond appropriately to simple questions, but otherwise non-verbal. LABORATORY DATA: Noted for a room air O2 saturation of 88%. Urinalysis has a small amount of positive LE . White blood cell count is quite elevated, 21.8 with a left shift. Electrolytes are all within normal limits other than a glucose of 260.
LE|leukocyte esterase|LE|186|187|LABORATORY DATA|NEUROLOGIC: The patient is alert and oriented x2. There is no focal deficit appreciated. Gait not tested. LABORATORY DATA: Obtained on admission shows urine clear and nitrates negative. LE negative. WBC 3, RBC 1. INR 0.99, sodium 135, potassium 2.7. Other electrolytes within normal limits. Liver function tests within normal limits. Calcium normal. WBC 5, hemoglobin 12.1, MCV 98, platelet count 155.
LE|lower extremity|LE|133|134|PHYSICAL EXAMINATION|All skin seems to be quite intact. RECTAL/GENITAL: Deferred. EXTREMITIES: DP pulses are 4/4+ bilaterally as are PT pulses. No distal LE edema. LABORATORY DATA: Electrolytes: CBC is normal. Glucose 118. IMPRESSION: 1. Chronic partial bowel ileus with recent acute exacerbation last p.m.
LE|leukocyte esterase|LE,|186|188|PHYSICAL EXAMINATION|Glucose 213, calcium 7.8, liver function tests normal, WBC 4, hemoglobin 15.3, hematocrit 45.6, platelet count 135, MCV 90. Calcium not collected. Urinalysis positive for glucose, trace LE, but negative WBC and red blood cell. Rapid strep A screens negative, cultures pending. Chest xray shows mild cardiomegaly, bibasilar opacity consistent with consolidation versus atelectasis.
LE|leukocyte esterase|LE|104|105|LABORATORY DATA|The patient moving all extremities. Patient has short-term memory loss. LABORATORY DATA: Urine shows an LE positive, WBC 6, RBC 1. Urine culture pending. CBC within normal limits, hemoglobin 15.8, MCV 45.9, MCV 90, WBC 10.5 with left shift.
LE|lower extremity|LE|132|133|IMPRESSION|Life long LVP without radiculopathy, plus lack of urethral tone and strength. 6. HTN since 1998. 7. SPO cholecystectomy in 1997. 8. LE edema, left greater than right. Worse more acute for a few days. Has been present for about 20 years. 9. Hyperlipidemia, treated with Lipitor.
LE|leukocyte esterase|LE,|162|164|HOSPITAL COURSE|She denied any symptoms of dysuria or painful urination. Of note however she did have a white blood cell count of 20.3 and the UA showed moderate blood, moderate LE, negative nitrites, 8 white blood cells, and few bacteria. The urine culture is pending. This will be followed up as an outpatient and if the urine culture is positive, will be treated appropriately.
LE|lower extremity|LE|207|208||_%#NAME#%_ _%#NAME#%_ is an 86-year-old female who comes in complaining of right sided chest pain as well as ongoing nausea and vomiting. The chest pain panned out to be bilateral pulmonary emboli. Anterior LE venous doppler showed bilateral deep venous thrombosis to the superficial femoral. The PE's on CAT scan were RLL and LLL. She had bibasilar atelectasis, possible bronchiectasis at the left lung base.
LE|leukocyte esterase|LE.|160|162|LABORATORY DATA|Total bilirubin is normal. Magnesium and phosphorus are normal, as well as albumin. Urinalysis did not show any obvious signs of infection. She does have small LE. HOSPITAL COURSE: The patient was admitted for observation. She remained afebrile throughout her hospitalization and had no localizing symptoms.
LE|leukocyte esterase|LE.|164|166|LABORATORY|Sodium 136, potassium 4.4, chloride 99, bicarbonate 29, BUN 17, creatinine 0.94, and glucose 99. ALT 79, AST 65. UA was positive for ketones and protein with trace LE. Urine micro was normal. Tox screen was positive for opiates, otherwise negative. Note, the patient's mother did mention that she had given him cough syrup with codeine.
LE|leukocyte esterase|LE,|162|164|REASON FOR ADMISSION|NEUROLOGIC: Nonfocal. LABORATORY: CMP normal LFT's, creatine 1.19, BUN 27, potassium 5.0, sodium 141, chloride 113, CO2 23, glucose 101, calcium 8.7. UA positive LE, a few bacteria, as well as squamous epithelial cells. ASSESSMENT/PLAN: 1. A 75-year-old female with type 2 diabetes admitted for hyperkalemia from an ACE, now resolved.
LE|leukocyte esterase|LE.|246|248|HISTORY OF PRESENT ILLNESS|The patient had recently been seen at the University of Minnesota Medical Center, Fairview _%#CITY#%_ Emergency Department where she was found to have a normal white blood cell count, normal CMP, lipase of 22, UA with ketones, trace blood, trace LE. Other tests that had been done prior to admission were wet prep, which was negative. GC and chlamydia were both negative, and CT of the abdomen performed in the emergency department had showed minimal retrouterine fluid otherwise normal CT.
LE|leukocyte esterase|LE,|405|407|COMPLICATIONS|No organomegaly or masses are demonstrable. Abdomen is nontender to palpation. GYNECOLOGIC: Deferred. LABORATORY: INR 2.39, PTT 53, white count 4.8, hemoglobin 11.9, platelets 829, sodium 112, potassium 4.9, chloride 78, bicarbonate 18, BUN 83, creatinine 2.51, calcium 9.2, glucose 109, albumin 4.5, total bilirubin 0.5, ALT 26, AST 23, alkaline phosphatase 108, magnesium 2.0, phosphorus 4.6. UA: Trace LE, negative ketones, moderate blood, negative nitrites, many bacteria, one white blood cell, blood osmolality 273, sodium urine less than 5, urine osmolality 411.
LE|leukocyte esterase|LE|95|96|LABORATORY DATA|The remainder of abdominal ultrasound was also unremarkable. LABORATORY DATA: Urinalysis shows LE small, WBC 12, others normal. CBC within normal limits except elevated cell differential with neutrophils of 83%, lymphocytes of 11%.
LE|leukocyte esterase|LE|181|182|LABORATORY DATA|No hepatosplenomegaly or masses. EXTREMITIES: No edema. SKIN: No rashes. NEURO: within normal limits LABORATORY DATA: Hemoglobin 7.4. White count 7.3. Urinalysis SG 1.030 with UN & LE negative, trace ketones. Sodium 137, potassium 3.8, chloride 104, CO2 27, BUN 9, creatinine 0.68, calcium 8.7. Liver functions normal.
LE|lower extremity|LE|237|238|ASSESSMENT AND PLAN|Alert, cooperative, NAD Sclera clear, oralphayrnx clear Neck supple, no LAD Lungs clear, no crackles or wheezes. Heart regular, no murmur. Abdomen obese, soft, mild tenderness in RUQ and epigastric regions. Good pulses and perfusion, 1+ LE edema. Skin clear, mucous membranes moist. Assessment 64 yo obese woman with acute pancreatitis, most consistent with gallstone pancreatitis.
LE|leukocyte esterase|LE|299|300|LABORATORY DATA ON ADMISSION|BMP, sodium 135, potassium 3.3, chloride 99, bicarbonate 25, BUN 14, creatinine 1, glucose 319. Islet cell antibody, less than 1.4. Hemoglobin A1c 14.5. UA, glucose more than 1000, bilirubin negative, ketone more than 150, protein albumin 10, urobilinogen normal, nitrites negative, blood negative, LE moderate, WBC 8, RBC 4, bacteria few, squamous epithelial 3, transitional epithelial cell less than 1, mucus present. Microalbumin, less than 2, creatinine urine 56, urine culture pending, glucose 301.
LE|leukocyte esterase|LE,|180|182|LABORATORY DATA|Cervical exam was fingertip long and high posterior. EXTREMITIES: Nontender without edema. LABORATORY DATA: On admission, UA negative, nitrite greater than 82 red cells, and trace LE, Utox negative, hemoglobin 11.9, platelets 204, INR 1.0, PTT 25, fibrinogen 427, and KUB negative. HOSPITAL COURSE: The patient was monitored overnight and noted a decrease in her spotting as contractions as spaced to approximately every 5 minutes and the patient was able to tolerate them and not feeling most of them.
LE|lower extremity|LE|312|313|CV|Over the last 4-5 days she has had increasing difficulty standing up from a chair, walking, and sitting up. PMH: In addition to above, DM, PAH, CMV. Exam: VSS as per EMR Gen:NAD, some difficulty recalling history Pulm: CTABL CV: nl s1 s2 no m/r/g Neuro: CN II-XII intact , str 4/5 prox, distal 4/5, 3/5 proximal LE strength, 4/5 distal, nl DTR UE/LE, no dysmetria, nl rapid alternating movements Labs, radiology studies, and medications reviewed.
LE|lower extremity|LE|413|414|CV|PMH: In addition to above, DM, PAH, CMV. Exam: VSS as per EMR Gen:NAD, some difficulty recalling history Pulm: CTABL CV: nl s1 s2 no m/r/g Neuro: CN II-XII intact , str 4/5 prox, distal 4/5, 3/5 proximal LE strength, 4/5 distal, nl DTR UE/LE, no dysmetria, nl rapid alternating movements Labs, radiology studies, and medications reviewed. Assessment and Plan: 51 yo woman with multiple medical problems here with LE weakness and CK elevation. 1)Weakness --Her weakness might be related to rhabdomyolysis, although CK is not markedly elevated. Causes include statin, CSA, CMV infection. Pt may have weakness from deconditioning as well.
LE|leukocyte esterase|LE,|271|273|HISTORY OF PRESENT ILLNESS|_%#NAME#%_ was taken to Dr. _%#NAME#%_'s office, where CBC was done that showed a white count of 15.5, platelet count 222,000 and hemoglobin of 12.2. A rapid strep was negative. A UA was also completed that showed specific gravity of 1.015, 30 of protein, moderate small LE, 10-25 white cells, moderate bacteria. Blood cultures were obtained at this time also. She was given a dose of Rocephin at that time.
LE|leukocyte esterase|LE,|166|168|HOSPITAL COURSE|Fundal height was 28 centimeters. A sterile speculum exam confirmed rupture of membranes. Cervix was visually closed. Urinalysis revealed negative nitrites, moderate LE, 50-100 white cells, few bacteria, and trichomonads present. Urine toxicology screen was positive for amphetamines, THC, and cocaine. The patient was admitted to the antepartum service at that time.
LE|leukocyte esterase|LE,|136|138|LAB DATA|Creatinine 6.5. Chest x-ray is negative. EKG sinus brady 60 with LAD of lateral inverted T-waves. UA, large blood, 30 of protein, large LE, positive bacteria. ASSESSMENT AND PLAN: 1. Eighty-nine-year-old female with decreased mental status secondary to uremia of acute renal failure.
LE|leukocyte esterase|LE|198|199|LABORATORIES ON ADMISSION|Cranial nerves II through XII grossly intact. LABORATORIES ON ADMISSION: CBC, WBC 11.8, hemoglobin 13.8, hematocrit 42.5, platelets 232,000, 57% N and 25% L. Utox negative. UA, pH 7.5, blood small, LE trace and rbc 17. CMP, sodium 140, potassium 4.4, chloride 109, bicarbonate 27, BUN 15, creatine 1.3, glucose 93, alkaline phosphatase 63, ALT 58, AST 28.
LE|lower extremity|LE|188|189|FOLLOWUP|She appears fatigued but in NAD. MMM. JVP elevated to just below the jawline. Lungs with diffuse wet crackles bilaterally. Heart irreg irreg. Abd nondistended, soft, nontender, no masses. LE with pitting edema to lower shins bilaterally. Labs reviewed: Cr up to 2.54; last Cr on record hear from 2006 at which time it was 1.32. NT proBNP >14,000.
LE|lower extremity|LE|147|148|A/P|On exam, vitals stable. He is a frail, pleasant elderly male in NAD. Lungs clear, heart RRR, abd thin, nondistended, +BS, no tenderness or masses, LE without edema. Foley catheter is in place. Labs remarkable for TSH>10, Na 131, Cr 1.07, and WBC ~12,000.
LE|leukocyte esterase|LE,|175|177|PROBLEM #4|The patient will be discharged on these medications. PROBLEM #4: Urinary tract infection. Upon admission, the patient's UA showed a mild urinary tract infection with moderate LE, but the patient was not complaining of any urinary symptoms. The patient was initially started on ciprofloxacin and then switched to Levaquin and the urine culture subsequently grew less than 10,000 colonies of group B strep.
LE|leukocyte esterase|LE|119|120|HISTORY OF PRESENT ILLNESS|She is not currently denying any hematuria or dysuria. Her urinalysis was found to have 3 white blood cells with trace LE and moderate bacteria. Her urine culture grew coag- negative Staph, which was sensitive to nitrofurantoin and vancomycin. HOSPITAL COURSE: 1. Pyelonephritis. Given the patient's back pain and the positive urine culture, she was treated for pyelonephritis.
LE|lower extremity|LE|153|154|PHYSICAL EXAMINATION|CARDIOVASCULAR: Regular rate and rhythm, no S3. ABDOMEN: Soft, nontender, positive bowel sounds. No hepatosplenomegaly or masses. EXTREMITIES: No edema; LE underdeveloped due to the spina bifida. Head CT and shunt series unremarkable. CBC, BMP unremarkable
LE|leukocyte esterase|LE,|192|194|LAB DATA|LAB DATA: CBC: WBC 8.4, hemoglobin 11.9, platelets 230, BMP is sodium 143, potassium 3.4, chloride 109, CO2 24, BUN 23, creatinine 1.1, glucose 140. Urinalysis reveals positive nitrate, large LE, positive protein, and many bacteria. Electrocardiogram normal sinus rhythm with sinus arrhythmia, nonspecific ST T abnormalities that are unchanged from _%#MM#%_ 2001.
LE|leukocyte esterase|LE|117|118|LABORATORY DATA|NEURO: No focal neurologic deficits at this time. LABORATORY DATA: Troponin today is negative. Urine does show small LE and 2 to 5 white blood cells. Also there are a few squamous cells. Hemoglobin is 10.7, hematocrit 13.1, white count 4.5, sodium 135, potassium 4.2, chloride 103, C02 is 25, glucose 116, nitrogen is 37, creatinine 1.3, calcium 7.9 and BNP is 363 with normal being less than 100.
LE|lower extremity|LE|375|376|CV|He comes here for further evaluation of his weakness. Pt had evaluation for his weakness including LP, eval for GBS, myasthenia gravis, he had several cervical spine MRI's to eval for spinal stenosis but there was too much motion artifact. Exam: Gen:on non-rebreather mask, NAD Pulm:diminished BS, poor air entry, no crackles CV: nl s1s2 no m/r/g Abd:soft NT/ND nl bs Ext:3+ LE pitting edema Neuro: CN II-XII intact, 4/5 proximal UE str, 4/5 distal str on right, 3/5 distal str on left, 4/5 LE str, DTR 1+ throughout.
LE|lower extremity|LE|251|252|CV|Exam: Gen:on non-rebreather mask, NAD Pulm:diminished BS, poor air entry, no crackles CV: nl s1s2 no m/r/g Abd:soft NT/ND nl bs Ext:3+ LE pitting edema Neuro: CN II-XII intact, 4/5 proximal UE str, 4/5 distal str on right, 3/5 distal str on left, 4/5 LE str, DTR 1+ throughout. Labs, radiology studies, and medications reviewed. Assessment and Plan: 74 yo man with progressive weakness and difficulty breathing.
LE|lower extremity|LE.|158|160|CV|Pt had a thorough evluation at regions which did not yield any etiology. The patient, on exam, does have significant proximal muscle weakness, expecially the LE. Will check a NIF to evaluate diaphragmatic function, check lead level and possibly a heavy metal screen. Consider EMG and/or muscle biopsy, will get neuro consult and MRI of the C-spine.
LE|leukocyte esterase|LE,|215|217|PRENATAL LABS|Cervix 2 cm long, 2 cm open. No discharge. PRENATAL LABS: Blood type A+, antibody negative, rubella normal, RPR negative. Hep-B serum antigen negative. Hemoglobin 11.3 at last check. GC/Chlamydia negative. UA/UC 2+ LE, otherwise negative. Recent Pap normal, HIV negative. Vag KOH/wet prep 8/3 negative. PRENATAL EXAMS: Normal blood pressure, normal glucose, hemoglobin, UA, weight gain.
LE|leukocyte esterase|LE,|124|126|LABORATORY DATA ON ADMISSION|Twins currently equal in size, presenting twin is vertex. LABORATORY DATA ON ADMISSION: GBF swab negative. Urinalysis trace LE, otherwise normal. Urine culture negative. HOSPITAL COURSE: The patient was admitted to monitor and stop progression of labor.
LE|leukocyte esterase|LE,|190|192|LABS ON ADMISSION|Neurologically, she was alert and oriented. Cranial nerves appeared grossly intact. Motor exam grossly normal. LABS ON ADMISSION: 1. Rapid strep. 2. UA with 15 ketones, trace protein, trace LE, 3 white cells, no bacteria. 3. CBC with white count of 7.3, 82 neutrophils, 9 lymphs, hemoglobin 12.6. 4. Chest x-ray normal. 5. Electrolytes normal. HOSPITAL COURSE: PROBLEM #1: Fluids, electrolytes and nutrition.
LE|leukocyte esterase|LE|151|152|ADMISSION LABS REPORTS|INR is 1.28, PT is 33. UA is significant for specific gravity of 1.026, large amount of blood, pH is 6.5, protein greater than 300, nitrites positive, LE negative, WBC negative, RBC 40, and bacteria moderate. Calcium is 9.1, magnesium is 1.0, phosphorus of 1.0. The patient underwent chest x-ray on _%#MMDD2002#%_.
LE|lower extremity|LE|249|250|IMPRESSION|5. Bilateral pleural effusions, left greater than right, chronic, of unknown etiology, though probably secondary to the mediastinal tumor radiation. See below. 6. Congestive heart failure with an excellent ejection fraction of 65% some time ago. 7. LE edema. 8. Superficial varicosities. 9. HT under control. 10. Status post 1978, mediastinal cancer, radiation treatment only by Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, U of M.
LE|leukocyte esterase|LE|297|298|LABS ON ADMISSION|The patient also had ulcer on right heel which looked improved compared to two weeks ago and which was approximately 3 cm. wide with a 1 cm. deeper ulceration which is somewhat healed from previous. LABS ON ADMISSION: White count was 18.8, hemoglobin was 10.7, platelets 287. Urinalysis positive. LE positive nitrates, 10-20 white blood cells. BNP within normal limits. Wound culture is pending, urine culture is pending. Blood culture is pending.
LE|leukocyte esterase|LE,|195|197|DISCHARGE DIAGNOSES|LABORATORY: White count 18.2, hemoglobin initially 14.5, platelets 461. 92% polys, 6% lymphs. Lipase and amylase were normal, as were liver function tests. A urinalysis showed trace blood, small LE, 50-10 wbc's and 2-5 rbc's. Sodium was 139, potassium 3.9, chloride 104, bicarb 26, BUN 10, creatinine 1.0. Sugar 101. An ultrasound did not show an appendix, did not show gallstones or an inflamed gallbladder.
LE|leukocyte esterase|LE,|148|150|LABORATORY DATA|Motor intact. Deep tendon reflexes normoactive throughout. LABORATORY DATA: Urinalysis negative protein, negative glucose, positive nitrites, small LE, urine culture pending. WBC 9500, hemoglobin 15.0, platelets 259,000. EKG shows normal sinus rhythm with a rate of 62. ASSESSMENT: 1. Preanesthesia consult. Suitable candidate for surgery and anesthesia.
LE|leukocyte esterase|LE|165|166|HOSPITAL COURSE|She had had a sore throat and had gotten a rapid Strep last week which was negative. A second swab for group A Strep was checked which was negative. UA showed trace LE with negative nitrites, 7 white blood cells, and squamous. The patient then was afebrile and feeling well on postoperative day #4.
LE|leukocyte esterase|LE.|249|251|LABORATORY DATA|LABORATORY DATA: Hemoglobin 12.3, hematocrit 37.4, white blood cell count 8.1, platelets 106, INR 2.85, sodium 142, potassium 4.0, chloride 98, bicarbonate 36, BUN 43, creatinine 1.2 with a glucose of 119. The urinalysis did show small blood, large LE. Nitrites were negative. White blood cells were 112, red blood cells 7. EKG was entirely paced. X-ray final results are pending. ASSESSMENT AND PLAN: 1. Left ankle fracture.
LE|lower extremity|LE|146|147|PMH|Thick neck and poor visualization of posterior pharynx. Increased JVP. Decreased BS throughout with poor air movement. RR with systolic murmur. 1 LE edema. Feet slightly cool. CXR: upper lobe nodular opacities, blunting of left CPA.
LE|leukocyte esterase|LE|297|298|LABORATORY DATA|Last sodium was 155. Admission potassium was 3.1, down to 2.9, BUN 54, creatinine 1.30. Repeat BUN is a 43 and creatinine 0.90, calcium 8.9. WBC is 15.3 with left shift, hemoglobin 14.2, MCV 94, platelet count is 41. Urine osmolality 618 and urine sodium 16. The urinalysis shows WBC less than 1, LE and nitrates negative. CT scan of head without contrast shows a moderate ?? and no acute bleed nor other abnormality findings.
LE|leukocyte esterase|LE,|195|197|LABORATORY|Hemoglobin 14.1, platelets 401,000, MCV 87. Sodium 136, potassium 3.5, chloride 103, bicarbonate 24, BUN 7, creatinine 0.7, glucose 130. Urinalysis revealed 30 proteins, positive nitrites, large LE, greater than 182 white blood cells in clumps, 136 red blood cells and moderate bacteria. Urinalysis done on _%#MMDD2006#%_ was essentially the same. Amylase less then 30, lipase 33, remainder of complete metabolic panel was unremarkable.
LE|leukocyte esterase|LE|149|150|LABORATORY|Her sodium was 143, potassium 4.4, chloride 105, bicarb 29, BUN and creatinine were 28 and 0.8, glucose was 115. UA showed trace blood, nitrates and LE negative. Chest x-ray showed no clear infiltrates but the patient was rotated and kyphotic.
LE|leukocyte esterase|LE.|131|133|LABORATORY|Electrolytes: Sodium 140, potassium 3.3, chloride 109, CO2 24, BUN 10, creatinine 0.8, glucose 109, calcium 8.9. UA shows moderate LE. Urine culture was negative. HOSPITAL COURSE: A 53-year-old, white female with a history of drug use in the past and a ureteral stone on the right with most of her pain on the left.
LE|lower extremity|LE|148|149|IMPRESSION|12. Bilateral recurrent AOM lanced for an abscess of the mastoid in childhood. 13. Continuous post nasal drip and rhinitis since _%#MM#%_ 2000. 14. LE edema, 1938 onset with IUP right greater than left. 15. Recurrent stasis ulcers in 2001, pretib. 16. Right greater than left leg stasis dermatitis.
LE|leukocyte esterase|LE|154|155|LABORATORY DATA ON ADMISSION|Left upper quadrant with air and stool seen within the colon or rectum. Urine cultures are still pending. Urinalysis shows clear urine, pH of 7.65, small LE in urine, nitrates negative, WBC 8, RBC 1. ASSESSMENT/PLAN: 1. The patient is a 15-year-old boy with history of gunshot wound with residual paraplegia and neurogenic bladder with frequent urinary catheterizations, history of urinary tract infection and kidney stones.
LE|leukocyte esterase|LE,|166|168|LABORATORY AND DIAGNOSTICS|Sodium 144, potassium 3.8, chloride 110, CO2 28, BUN 30 and creatinine 1.0 and glucose 117. UA with a specific gravity of 1.024, protein 10, negative nitrates, small LE, white blood cells 21, rbc's 6. Influenza A and B negative. Gonorrhea and chlamydia PCR negative. Chest x-ray with a large hernia in the small bowel or stomach behind the left lung and heart, otherwise no focal infiltrates.
LE|leukocyte esterase|LE.|243|245|ADMISSION LABORATORY DATA|INR 0.94. PTT 30. Electrolytes - sodium 143, potassium 3.7, chloride107, bicarb 29, BUN 11, creatinine 0.6, glucose 93. Urinalysis, performed the morning of the procedure, was yellow clear, and negative for glucose, bili, ketones, nitride and LE. She, again, had trace blood with 3 red blood cells per high powered field. A repeat hemoglobin after the biopsy was 11.3. HOSPITAL COURSE: This 25-year old woman, who underwent a non- complicated native kidney biopsy, did quite well in the hospital after the biopsy.
LE|leukocyte esterase|LE|324|325|LABORATORY DATA|No obvious rashes otherwise. LABORATORY DATA: Sodium is 136, potassium 3.9, chloride 101, bicarb 27, glucose 97, BUN 18, creatinine 1.3, calcium 8.8, white count 11.6, hemoglobin 14.7, platelets 290, 75% PMNs, 13% lymphocytes, 9% monos, 2% eosinophils. Urinalysis is clear. A small amount of blood with 0 to 2 red cells. No LE or nitrates noted. There were a few uric acid crystals. CT scan of the abdomen showed a 4-mm stone right UVJ, also a 9-mm stone left renal pelvis.
LE|leukocyte esterase|LE,|169|171|LABORATORY|Bicarb was 29. BUN was 12. Creatinine was 0.67. Glucose was 88. Calcium was 8.7. Dilantin level was 19.8. Urinalysis is remarkable mostly for 5 to 10 white cells, small LE, negative nitrates. Lumbar, pelvis, and hip x-ray final results were all pending. ASSESSMENT/PLAN: PROBLEM #1: Lumbar and buttocks pain. Will continue with pain medications and have PT, OT evaluate the patient and treat.
LE|leukocyte esterase|LE.|179|181|LABORATORY|EXTREMITIES: No edema. NEUROLOGIC: Non-focal. LABORATORY: Urine culture from the _%#DD#%_ reveals E. coli sensitive to Cipro. UA yesterday with small blood, 100 protein, positive LE. White count on the _%#DD#%_ was 26.8 with 88 neutrophils. Yesterday it was 16.8 with 80 neutrophils. Normal hemoglobin and platelets.
LE|leukocyte esterase|LE,|199|201|OPERATIONS/PROCEDURES PERFORMED|Nitrazine-positive and fern-positive. Fetal fibronectin was positive and GBS was pending which ultimately became positive. Her urine showed 2+ blood, 10 to 15 red cells, 0 to 2 white cells, negative LE, negative nitrates, negative bacteria. She was given betamethasone, IV ampicillin, and magnesium sulfate because of contractions 2 to 3 times in an hour.
LE|leukocyte esterase|LE|269|270|HISTORY OF PRESENT ILLNESS|No blood was seen in the urine. She was started on Amoxicillin for group B Strep grown out of a _%#MMDD2003#%_ urine culture. Subsequent urine cultures have been negative. Today, on the day of admission, in clinic, she did have some white blood cells in her urine, but LE was negative and for the last one to two days prior to admission, her UTI symptoms have resolved. REVIEW OF SYSTEMS: Other than above, negative. She has had no fever, no nausea, no vomiting, or diarrhea.
LE|leukocyte esterase|LE,|251|253|LABORATORY|LABORATORY: Labs on admission, white count 8.9, hemoglobin 12.2, and platelets 261. BMP with sodium 132, potassium 3.7, chloride 99, bicarbonate 25, BUN 9, creatinine 0.83, glucose 316, calcium 8.7. UA: glycosuria, ketonuria, negative nitrates, small LE, white cells 0 to 2. HOSPITAL COURSE: 1. Pyelonephritis. The patient did grow out E. coli sensitive to ciprofloxacin on her urine.
LE|leukocyte esterase|LE,|364|366|LABORATORY|Sodium 140, potassium 4.4, chloride 109, bicarbonate 23, BUN 26, creatinine 1.08, glucose 133, calcium 9.4, bilirubin 0.3, albumin 3.9, protein 8.1, alkaline phosphatase 101, AST 232, ALT 1239, INR 0.99, PTT 30, and troponin less than 0.07. EKG, normal sinus rhythm. Normal Q waves in 2, 3, and aVF. UA: Glucose 100, trace ketones, large blood, 100 protein, small LE, 2 to 5 red blood cells, and many amorphous crystals. CK 60,750. HOSPITAL COURSE: 1. Rhabdomyolysis. The patient's elevated CK was thought to be secondary to her lengthy stay on the floor after a fall out of bed.
LE|leukocyte esterase|LE.|209|211|LABORATORY|His abdomen was soft, nontender, nondistended with good bowel sounds and no organomegaly. Neurologically, he was without any deficits. LABORATORY: Admission labs showed a UA that was negative for nitrites and LE. His rapid strep was negative. His white count was 1.9. Hemoglobin 9.6 and platelets of 532. His BUN was 4 and creatinine 0.25. His ANC was 100.
LE|leukocyte esterase|LE,|219|221|LABORATORY|Sodium 141, potassium 2.7, chloride 105, CO2 21, anion gap of 16, glucose 91, BUN of 12, creatinine 0.61, albumin of 3.9, ALP 198, ALT 26, AST 37. EKG was sinus tachycardia. HCG was negative. Urine with large blood and LE, greater than 100 white cells, 5 to 10 reds. CXR with heart at upper limits of normal. Chest otherwise was negative.
LE|UNSURED SENSE|LE|218|219|BRIEF HISTORY OF PRESENT ILLNESS|He has experienced increasing shortness of breath and fluid retention and had been on prednisone for treatment of gout in his left foot. He had undergone right heart cath with biopsy, which showed a RA pressure of 17, LE of 32/5 and an end of 15. Pulmonary wedge pressure of 26, biopsy was pending, but had experienced rejection in the past.
LE|leukocyte esterase|LE,|168|170|LABS UPON ADMISSION|SKIN: Clear without rashes. LABS UPON ADMISSION: White count 9.8, hemoglobin 10.3, and platelets 406. INR 1.11 and PTT 27. A UA demonstrated negative glucose, negative LE, negative nitrites, and 100 protein. Urine protein- to-creatinine ratio 1.31. Electrolytes were within normal limits with a BUN of 12 and a creatinine 0.35. HOSPITAL COURSE: _%#NAME#%_ tolerated the renal biopsy well.
LE|leukocyte esterase|LE.|144|146|LABORATORY DATA|Soft, non-tender and non-distended. LOWER EXTREMITIES: No edema. SKIN: Clear. LABORATORY DATA: Urinalysis: 30 protein, positive nitrites, large LE. BMP: BUN 42, creatinine 1.5, calcium elevated at 10.8, sedimentation rate 26, CBC normal. The spine MRI reveals metastatic replacement of the L4 vertebral body with bulging on the right resulting in right foraminal stenosis.
LE|leukocyte esterase|LE,|135|137|LABORATORY|LABORATORY : Initial labs includes lipase and amylase normal. CBC normal including 8.2 white cell count. UA shows 225 wbc's with large LE, negative nitrite. Urine culture and blood culture are pending. CT of the abdomen revealed no abscess, no renal stone, diverticulitis, or appendicitis.
LE|leukocyte esterase|LE|208|209|HISTORY OF PRESENT ILLNESS|He had initially been seen in Fairview Lakes Clinic with temperature of 101.6, pulse of 172, respirations 26, with good saturation in room air. Influenza and RSV were negative. His urinalysis showed negative LE and negative nitrites, but 25 to 50 white blood cells, and 5 to 10 red blood cells. His CBC was normal. His chest x-ray was normal. He was given Rocephin there and transferred to the University of Minnesota Children's Hospital for further observation and management.
LE|leukocyte esterase|LE,|229|231|ADMISSION LABORATORY|Comprehensive metabolic panel -- sodium 135, potassium 3.2, BUN 28, creatinine 0.76, GFR 76, otherwise, within normal limits. Influenza A and B were ultimately negative, and Group B Strep was negative. U/A was negative nitrites, LE, moderate blood. HOSPITAL COURSE: PROBLEM #1: Pneumonia/viral upper respiratory infection.
LE|leukocyte esterase|LE,|120|122|LABORATORY DATA|ALT/AST 16 and 20 respectively. Amylase 82, lipase 127. Troponin initial is negative. UA: Specific gravity 1.005, small LE, negative nitrite, hyaline casts 5, few bacteria, 8 white cells, present mucus. EKG on admit showing atrial fibrillation with rate of 93.
LE|leukocyte esterase|LE,|212|214|HISTORY OF PRESENT ILLNESS|Sodium 141, potassium 4.3, chloride 111, CO2 24, BUN 12, creatinine 0.73. ALT 29, AST 55, alk phos 217, albumin 2.4, total bili 2.8, lipase 152 and total protein 7.0. INR 1.91 and negative troponin. UA had trace LE, negative nitrites, 1 wbc and 1 rbc. HOSPITAL COURSE: 1. Hypertension. The differential diagnosis on admission was dehydration versus sepsis.
LE|leukocyte esterase|LE|316|317|LABORATORY DATA|Differential reveals 81% neutrophils and 12% lymphocytes. Electrolytes, sodium 140, potassium 4.3, chloride 105, bicarbonate 22, BUN 11, creatinine 1.1, glucose 106 and calcium 10.3. Hepatic panel, bili 0.4, albumin 5.2, protein 9.5, alk phos 120, ALT 17 and AST 26. Urinalysis: Ketones 40, blood trace, protein 10, LE and nitrite negative, RBCs 17, squamous cells 2, otherwise normal/negative. Pregnancy test was negative. Urine culture pending. IMAGING: CT of abdomen and pelvis revealed 3 to 4 mm stone at the left ureterovesicular junction, positive hydronephrosis and positive perinephric stranding.
LE|leukocyte esterase|LE,|202|204|LABS ON ADMISSION|This morning BMP was repeated which showed high potassium at 5.6, this was taken with a fingerstick check. Bicarb has continued to be low and is currently 15. Glucose has been normal. UA shows moderate LE, negative nitrites, 2-5 white cells, less than 1 red cell, this was a bag catch. Urine culture is pending. ASSESSMENT AND PLAN: 1. Viral gastroenteritis.
LE|lower extremity|LE|114|115|ASSESSMENT AND PLAN|4. History of right leg pain. That has resolved. There is no Homan's sign on exam or edema today. We will perform LE dopplers while we are getting him ready for a possible angiogram tomorrow. 5. He is being admitted to my service, the Pulmonary firm service, where he will undergo his current studies.
LE|leukocyte esterase|LE,|267|269|COURSE IN HOSPITAL|Upon discharge, Rocephin was changed to cefuroxime 250 mg p.o. b.i.d. x 10 days. Blood cultures were negative x 48 hours upon discharge. Urinalysis revealed positive glucose (50), plus ascorbic acid, white blood cells 4, red blood cells 6, negative nitrite, negative LE, negative protein, specific gravity 1.026. After 24 hours of IV antibiotics, the patient was afebrile and felt significantly better.
LE|leukocyte esterase|LE|159|160|ADMISSION LABORATORY DATA|ABG: 7.40, pCO2 18, pO2 265, calculated bicarbonate of 11. Urinalysis significant for specific gravity of 1.009, moderate blood, pH of 5, urobilinogen of 0.2, LE and nitrite negative. Microscopic for white cells per high power field had 4 red cells per high power field. Electrolytes on admission: Sodium 131, potassium 5.3, chloride 107, bicarbonate 15, BUN 83, creatinine 2.1, glucose 115, calcium 7.7, magnesium 2.7, phosphorus 4.7. Albumin 2.5, alkaline phosphatase 152, ALT 58, AST 82, total bilirubin 8.8, conjugated bilirubin 2.5, total protein 6.4. Troponin I 0.4. Salicylate level less than 1.
LE|leukocyte esterase|LE,|344|346|ADMISSION LABORATORY DATA|INR 0.9. PTT 26. Troponin less than 0.3. TSH 0.14. Sodium 137, potassium 4.4, chloride 103, bicarbonate 17, BUN 8, creatinine 0.6, glucose 78, AST 37, ALT 18, albumin 4.3, alkaline phosphatase 81, bilirubin 0.6. Urine pregnancy test was negative. EKG showed multiple PVCs. No ischemic changes. Urinalysis: 0-2 white cells, negative RBCs, trace LE, moderate blood, trace protein. HOSPITAL COURSE: PROBLEM #1: Alcohol dependency. The patient has severe alcohol dependence and has failed treatment multiple times.
LE|leukocyte esterase|LE,|219|221|HISTORY OF PRESENT ILLNESS|A repeat urinalysis was initially brought in on _%#MMDD#%_ that had negative nitrates and 5 to 10 WBCs with a negative urine culture. Another urine specimen was brought in on the _%#DD#%_ because of persistent positive LE, and this one again had negative nitrates but 50 to 100 WBCs, and the preliminary cultures showed 40,000 colonies enterococcus, 30,000 colonies gram-positive cocci, and another 10,000 colonies of gram- negative rods, all from a catheterized specimen.
LE|sinemet-levodopa|LE|118|119|DISCHARGE MEDICATIONS|She was discharged on postoperative day 1 after her pulse generator was programmed. DISCHARGE MEDICATIONS: 1. Sinemet LE 25/100 1/4 tablet at 0700 and 1100. 2. Sinemet LE 25/100 1/2 tablet at 1900. 3. Sinemet CR 50/200 1/2 tablet at 0700, 1100, 1900, and 2300.
LE|leukocyte esterase|LE,|149|151|LABORATORY EVALUATIONS|Troponin-I is less than 0.07. Myoglobin 106. Electrolytes show a creatinine of 1.9; otherwise normal. The urine shows large blood, 30 protein, small LE, specific gravity 1.025 with the clumps of wbc's. This is a catheterized urine specimen. Doppler ultrasound is pending at this time of the lower extremities.
LE|leukocyte esterase|LE,|144|146|LABORATORY DATA|Differential: 78% neutrophils, 15% lymphocytes, and 5% monocytes. BMP was normal. UA showed moderate blood, 30+ proteins and nitrates, moderate LE, 10 to 25 WBCs, and moderate bacteria. Urine culture was sent. UPT was negative. Wet prep showed clue cells. GC and chlamydia were pending. In summary, this is a 20-year-old female with pyelonephritis and UTI.
LE|leukocyte esterase|LE,|207|209|LABORATORY EVALUATION|LABORATORY EVALUATION: Chest x-ray did show an increasing pleural effusions bilaterally right greater than left. White count was elevated at 21.6. 84% neutrophils. Platelets are 627. Urinalysis showed small LE, many bacteria , albumin is decreased to 2.6, alkaline phosphatase is 175, ALT is 23. Protein is 6.4, magnesium is 2.2. Lytes are normal. Calcium is slightly low, however at 8.4. IMPRESSION: This is a 63-year-old male with severe dementia and history of aspiration likely recurrent aspiration.
LE|leukocyte esterase|LE|160|161|ADMISSION STUDIES|ABDOMEN: Multiple ecchymoses, non- distended, positive bowel sounds. EXTREMITIES: Generalized muscle wasting. ADMISSION STUDIES: UA with 22 rbc's and no wbc's, LE negative, and moderate amorphous crystals. WBC 21.9, hemoglobin 14.4, platelets 304. ALT 71, AST 24, alkaline phosphatase 136, calcium 9. Sodium 138, potassium 4.3, chloride 105, bicarb 22. BUN 35, creatinine 0, glucose 110.
LE|leukocyte esterase|LE,|132|134|LABORATORY|UA showed greater than 1000 protein, greater than 80 ketones, pH of 5.5, large amount of blood, negative for nitrites, negative for LE, no cells. ABG showed a pH of 7.32, PCO2 of 28, PO2 of 94, and bicarb of 14. Chest x-ray did not show any abnormalities. HOSPITAL COURSE: The patient was admitted to the hospital, and her insulin pump was stopped and she was put on a sliding scale and was rehydrated overnight.
LE|leukocyte esterase|LE,|132|134|SOCIAL HISTORY|EKG was sinus bradycardia, otherwise normal. CT of head was negative. Chest x-ray negative as above. UA: Positive nitrate, moderate LE, 5-10 whites, few clues, and many bacteria. HOSPITAL COURSE: 1. Neuro. Approached the patient initially as if had probable stroke. MRI scheduled for the following day as above was negative.
LE|leukocyte esterase|LE,|159|161|ADMITTING LABORATORY|ADMITTING LABORATORY: White blood count 10.9, with 85% neutrophils, 8% lymphocytes; hemoglobin 13, platelets 202. UA had large blood, positive nitrites, small LE, 2 to 5 wbc's, 10 to 25 rbc's, many bacteria. Urine culture was pending at that time. Electrolytes were within normal limits with a BUN of 34 and creatinine of 1.26, lipase 322, coags were normal, LFT within normal limits.
LE|leukocyte esterase|LE,|146|148|DISCHARGE DIAGNOSIS|LABORATORY: Hemoglobin 10.7, white count 10.4, platelets 281, 83% PMNs, 8.6 ANC. Clean-catch UA: Moderate blood, pH 7.5, negative nitrites, trace LE, few bacteria, and amorphous phosphate crystals. The patient was admitted for recheck of her cervix. One hour later, it was unchanged. The patient was admitted, however, for overnight observation secondary to her vaginal bleeding.
LE|leukocyte esterase|LE,|371|373|SOCIAL HISTORY|She has a facial droop from central paralysis. LABORATORY: On admission, white count 10,000, hemoglobin 11.7, hematocrit 35.5, platelets 373,000. Phenytoin decreased at 2.8 with normal range of 10-20. Sodium 138 potassium 4.9, BUN 13, creatinine 1.36, glucose 81, AST 67, ALT 23, alkaline phosphatase 323, total protein 8.6. A urinalysis shows a positive nitrates, large LE, 18 white cells, many bacteria, white blood cell clumps, and 30 protein. HOSPITAL COURSE: 1. The patient was admitted and had 1 course of IV gatifloxacin 400 mg in the Emergency Department.
LE|leukocyte esterase|LE,|224|226|PHYSICAL EXAMINATION|White count 8.8, hemoglobin 9.9, platelets 287, BMP 672, troponins 0.6, INR 1.29. LFTs: Within normal limits. Sodium 137, potassium 5, chloride 97, bicarb 32, BUN 27, creatinine 0.66, glucose 216. UA, slightly cloudy, large LE, large blood, white blood cells, 31. Chest x-ray was difficult to interpret, but unchanged since comparison chest x-ray. HOSPITAL COURSE: PROBLEM #1: Respiratory distress. The patient was admitted on an ED vent, usually is on an LP-10, is a chronically ventilated patient.
LE|leukocyte esterase|LE|106|107|LABS|Chest x-ray reveals cardiomegaly but is otherwise unremarkable. LABS: Labs have UA 0-2 white blood cells, LE is negative. Lipase is 119. INR is 2.6. Troponin is less than 0.07. White count of 12.9, hemoglobin 11.2, platelets 378.
LE|leukocyte esterase|LE,|227|229|STUDIES|Potassium 4.9, chloride 118, CO2 24, BUN 36, creatinine 1.62; repeat creatinine 1.40. Calcium 9.2, hemoglobin on admission 14.3. Repeat hemoglobin 12.2. MCV 111. Platelet count 219, WBC 5.8. Urine shows lots of blood, positive LE, moderate wbc in urine 10-25, rbc urine 50 to 100; there was few bacteria. 2. IMAGING: Chest x-ray shows COPD with upper lobe volume loss and calcified granulomata of left upper lobe.
LE|leukocyte esterase|LE,|197|199|LABORATORY DATA|Cardiac echocardiogram as mentioned above showed an ejection fraction of 25% with a global hypokinesis in the lower part of the heart. Troponin was 3.57, and myoglobin 338. Urinalysis showed trace LE, 5 to 10 white cells with a large number of epithelial cells as well. Electrolytes were within normal limits with a BUN of 0.8, creatinine of 19, and white blood cells 16.7. The patient is on steroids.
LE|leukocyte esterase|LE,|214|216|ADMISSION LABS|UPT was negative. Electrolytes were within normal limits. Amylase and lipase were normal. INR was 1.19. PTT 31. Blood culture is negative. UA showed 40 ketones, large blood, 100 of protein, positive nitrite, large LE, 25 to 50 wbc's, and 2-5 rbc's. LABORATORY: CT of the abdomen and pelvis done in the ER with the results as above, was consistent with pyelonephritis.
LE|leukocyte esterase|LE|242|243|REPORTS|Other findings include on _%#MMDD2004#%_ a normal LFT, ALT, AST, AT and ALT9, alk phos 61, total bili 0.3, and normal chemistries. CBC with a white count of 5.2, hemoglobin 10.6, platelets 237, MCV 73. Small UTI from _%#MMDD2004#%_ UA, small LE and 4 WBCs. DISCHARGE MEDICATIONS: 1. Keppra 750 mg p.o. twice a day.
LE|leukocyte esterase|LE,|143|145|LABORATORY DATA|She has a white count of 3.6 with an absolute lymphocyte count of 0.3. Hemoglobin 13.2. MCV 85. Platelet count 193,000. Urinalysis shows trace LE, 0-2 white and 0-2 red cells. She has moderate squamous epi and moderate bacteria, 100 glucose, large bili and greater than 80 ketones.
LE|leukocyte esterase|LE.|173|175|LABORATORY DATA|Chest x-ray appears to have some fluid in the right fissure. BNP 3510 and from _%#MM#%_ of 2006, a BNP was 2290. Her urinalysis is positive with 57 white cells and moderate LE. EKG shows a paced rhythm and also some T-wave inversion in the inferior leads, which is new compared to the old EKG.
LE|leukocyte esterase|LE,|191|193|LABORATORY & DIAGNOSTIC DATA|On telemetry on the floor, the patient has returned to normal sinus rhythm. Urinalysis reveals trace ketones, specific gravity greater than 1.030, blood in the urine, trace protein, negative LE, 2-5 hyaline casts, moderate amorphous urate crystals, 0-2 white cells and red cells. Basic metabolic panel is within normal limits with the exception of the fact that her anion gap is 18 and her glucose level is 160, her myoglobin level is 975, her troponin is less than 0.04. White count is 15.9, hemoglobin and hematocrit are within normal limits, 75% neutrophils, 338,000 platelets.
LE|leukocyte esterase|LE,|173|175|LABORATORY DATA|SKIN: Without any known rash or suspicious lesions. LABORATORY DATA: Sodium is 141, potassium 5.6, creatinine is 10.21, BUN 144, glucose 112. UA positive nitrates, moderate LE, 50-100 WBCs. INR 1.23. White count elevated at 16, hemoglobin low at 10.3. EKG consistent sinus tachycardia. IMPRESSION: 1. Confusion, history of strokes, uncertain baseline, trying to obtain further information from the wife and family.
LE|leukocyte esterase|LE|137|138|LABORATORY DATA|LABORATORY DATA: CBC is negative. Metabolic panel is negative. Ethanol level is negative. HCG is negative. Urine shows some blood, small LE with some mucus and epithelial cells present, U-tox does show cannabinoids. IMPRESSION: 26-year-old female with history of bipolar disorder, tobacco use and apparent cannabis use who had apparently stopped her meds for approximately 3 days with what appears to be worsening bipolar or schizophrenia.
LE|leukocyte esterase|LE|152|153|RECENT ADMISSIONS|Musculoskeletal normal. No rash. Physical exam for neurologic, grossly intact. LABORATORY: On admission, x-ray chest negative per ER. Urinalysis: Small LE positive, otherwise negative. White count 10.2, hemoglobin 14.1, platelets 258. Blood culture and urine culture were drawn at the time of admission.
LE|lower extremity|LE|125|126|HISTORY OF PRESENT ILLNESS|At that point, she was sent to clinic for follow up. She was seen in clinic three days ago, had a TEE arranged. She also had LE Dopplers done at the time, which were negative. She was feeling a little better, went away with some friends for the weekend, and on the way home, started feeling a little weak and dizzy and not herself again.
LE|leukocyte esterase|LE,|195|197|LABORATORY DATA|No masses or hepatosplenomegaly. EXTREMITIES: Without pedal edema. NEUROLOGICAL: Deep tendon reflexes normal active. Cranial nerves II-XII were intact. LABORATORY DATA: Hemoglobin 12.5, UA trace LE, 0-3 white blood cells, negative red blood cells, moderate bacteria. ASSESSMENT: 1. Suitable candidate for anesthesia and surgery. 2. Urinary tract infection.
LE|leukocyte esterase|LE|218|219|LABORATORY DATA ON ADMISSION|LABORATORY DATA ON ADMISSION: White count 36.6, hemoglobin 15.6, platelets 475, neutrophils 86%, lymphocytes 6%, monocytes 7%. UA: Greater than 1000 glucose, greater than 80 ketones, large blood, trace protein, no LA, LE or nitrates. 2 to 5 white blood cells. 5 to 10 red blood cells. Amylase 45, albumin 5.3, alkaline phosphatase 163, ALT 36, AST 38, total bilirubin less than 0.3, INR 1.5, moderate serum ketones, lipase 75, serum osmolality 354, troponin negative x 1, magnesium 3.5, phosphorus 7.4, sodium 126, potassium 5.8, chloride 86, bicarbonate 6, BUN 50, creatinine 2.2, glucose 979, anion gap 34, calcium 11.
LE|leukocyte esterase|LE,|209|211|PHYSICAL EXAMINATION|Sodium 142, potassium 4.1, chloride 105, bicarb 29, BUN 23, creatinine 1.2, glucose of 82, calcium 9.0. Her LFT's were within normal limits. UA showed a specific gravity of 1.013, was positive for nitrite and LE, and microscopic exam showed 26 wbc's, 47% rbc's, 5 hyaline casts, and many bacteria. Upon review of past urine cultures, at our facility, she has grown Klebsiella pneumoniae, sensitive to ciprofloxacin from her urine.
LE|leukocyte esterase|LE,|221|223|ALLERGIES|Hemoglobin is 12.9, platelets were 196. His sodium was 126, potassium 4.0, chloride 9.8, bicarbonate 32, BUN 12, creatinine 1.0, glucose 94, calcium 9.3, UA showed a moderate amount of blood, specific gravity 1.01, large LE, 50- 100 white blood cells, 5-10 red blood cells. Urine culture was pending at the time discharge.
LE|leukocyte esterase|LE,|157|159|LABORATORY|AST and ALT within normal limits. EKG has a normal axis with normal sinus rhythm, rate of 72. UA is cloudy with a trace of ketones, trace of blood, moderate LE, 5-10 white blood cells with many bacteria. HOSPITAL COURSE: 1. Right ankle sprain. The patient was treated conservatively with ice, elevation, Tylenol, and Dilaudid for pain.
LE|leukocyte esterase|LE|391|392|DISCHARGE PLAN|She tolerated feeds well. 2. Neuro-The paraspinal mass was evaluated by x-ray, followed by an abdominal CT which showed invasion of the contrast-enhancing retroperitoneal mass into the T12-L2 foramina; a spinal and brain MRI and ultrasound were done on _%#MMDD2004#%_ to further delineate the anatomy. Her left LE paraparesis persisted ,with some spontaneous flexion- extension of the right LE noted at time, consistent with compression of the motor tracts of lumbar cord. _%#MMDD2004#%_ paraspinal mass biopsy was done which showed neonatal fibrosarcoma.
LE|leukocyte esterase|LE,|174|176|LABORATORY DATA|LABORATORY DATA: (Today) Sodium 140, potassium 3.7, urea nitrogen 30, glucose 246, creatinine 1.45, BNP 2060, calcium 8.9. Urine does show moderate blood, 100 protein, large LE, moderate bacteria. White count is elevated at 24,900, 92% neutrophils, platelet count 263,000. IMPRESSION: 1. CHF. 2. UTI. 3. Possible pneumonia, difficult to assess in the setting of CHF.
LE|leukocyte esterase|LE|253|254|HOSPITAL COURSE|Mr. _%#NAME#%_ underwent a pancreas allograft biopsy on _%#MM#%_ _%#DD#%_, 2005 which revealed acute mild rejection superimposed on chronic rejection. In addition, Mr. _%#NAME#%_'s urinalysis revealed several white blood cells, although he had negative LE and nitrates. He was started on antibiotics for this, but he cells may be pancreaticoduodenal. Mr. _%#NAME#%_ received Campath 30 mg IV and Solu-Medrol 500 mg IV on _%#MMDD2005#%_ after the pancreas biopsy results were obtained.
LE|leukocyte esterase|LE|125|126|LABS|Albumin 3.2. AST 102. Other liver function studies normal. Urinalysis showed 2-5 red cells, 0-2 white cells, and nitrite and LE negative. Hemoglobin 12.5, white cell count 2500, platelet count 316,000. Sedimentation rate 65 mm/hr, compared to 46 mm/hr on _%#MMDD2005#%_. IMPRESSION: 1. This is an adult gentleman, here with exacerbation of systemic lupus erythematosus symptoms, possibly on the basis of a concurrent upper respiratory infection.
LE|lower extremity|LE|198|199|PLAN|Skin clear, mucous membranes moist. Poor tone, unable to assess strength or sensation. Chest CT: Pulmonary embolism Assessment 37 you with ALS and new pulmonary embolism. Unclear etiology. Possibly LE DVT and/or thrombus affecting renal veins due to increased creatinine. Likely dehydration. Plan Pulmonary Embolism - High intensity heparin - Initiate warfarin therapy - Lower extremity and abdominal US for DVT Elevated creatinine, dehdyration vs renal vein thrombosis vs (less likely) other - IV fluid flushes - Increase free water by G-tube - Renal ultrasound to evaluate kidneys ALS - Contact primary ALS physician, Dr, _%#NAME#%_ - Continue current cares Nutrition - poor feeding - Restart GT feeds Code status (per group home records and confirmed by mother): DNR/DNI
LE|lower extremity|2)LE|187|190|NAD|Will continue lactulose, follow her MS. Her ct showed area of hypodensity, will f/u with MRI. Currently no diffuse abdominal pain, wil check for SBP if she develops this, spikes a fever. 2)LE Edema -- evaluate with US for DVT, o/w will treat with diuretics, although this is likely related to her pulm HTN and cirrhosis.
LE|lower extremity|LE|147|148||There is evidence for mild JVD, scattered bilateral crackles, tachycardia without significant rubs or gallops. There is mild RUD tenderness and no LE edema. She is oliguric. I have personally reviewed her CXR, TTEs, right heart catheterization data. Her CXR is mortly clear. Her TTE shows hyperdynamic and small LV, enlarged RV and mild PHT (RVSP in the 30-35 cmmHg + RAP).
LE|lower extremity|LE|134|135|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: New onset LE weakness x 12 hours. HPI: MRI shows cord compression at T9, T10. Exam: Sensory level at T10.
LE|lower extremity|LE,|132|134|OBJECTIVE|Patient also exhibited opisthoclonus and back extension but is able to answer questions during this. Rapid, single and both, UE and LE, convulsive-like, limb shaking observed. ASSESSMENT/PLAN: This is a 22-year-old male with a long history of paroxysmal dystonia diagnosed back in approximately 2001.
LE|lower extremity|LE,|132|134||He appears comfortable. He is hemodynamically stable. There are no issues with alarms of the LVAD. The patient continues to have 2+ LE, as well as upper extremeties edema. Both have significantly improved. A/P: 1. CHF stage D, NYHA class IV, LVEF 20%, ischemic etiology.
LE|lower extremity|LE|531|532|HEENT|Otherwise complete ROS reviewed and negative. Vitals: reviewed and as per FCIS Physical exam: General: morbidly obese, nasal canula in place, in NAD. HEENT: EOMFI, PERRL; moist mucous membranes; could not visualize pharynx d/t tongue size Neck: no LAD, trachea midline, no masses Heart: distant heart sounds secondary to body habitus, RRR, no murmurs appreciated Lungs: mild expiratory wheezes, diffuse crackles; poor respiratory effort Abdomen: obese abdomen, no tenderness to palpation, distant but present BS Extremities: bilat LE skin ulcerations, lymphedema; pulses not palpable. Labs _%#MMDD#%_: WBC 10.2, Hg 9.9, Plt 306 Na 143, K 3.1, Cl 107, HCO3 28, BUN 12, Cr 0.93, Ca 8.4 Other labs reviewed as per FCIS CXR OSH: increased pacity/density in RLL; no effusions per chart, but CXR not avail to review.
LE|lower extremity|LE|167|168|PHYSICAL EXAMINATION|LUNGS: Lungs are clear without wheezes, rales, or rhonchi. ABDOMEN: Abdomen is soft, nontender. EXTREMITIES: Extremities reveal trace edema. NEUROLOGIC: Intact UE and LE strength, non-localizing. HEENT: Clear throat and sclera. No cyanosis or pallor. LABORATORY DATA: Sodium 139, potassium 4.6, chloride 105.
LE|lower extremity|LE|176|177|HPI|My key findings: CC: Recurrent low grade oligodendroglioma HPI: Status post partial resection and 5960 cGy in 1997. Exam: Right eye blindness and unresponsiveness, left UE and LE 3/5, right 4/5 Assessment and Plan: We have offered the patient fractionated stereotactic radiation.
LE|lower extremity|LE|489|490|PE|SOCIAL HISTORY: The patient is married. He has 2 children. He denies tobacco or alcohol use. PE: vitals reviewed he has been afebrile since being transferred here overnight he is making good amounts of urine in general, he appears chronically ill and weak however he was in no acute distress NCAT, no conj, no icterus OP clear neck supple and NT RRR no murmurs slight bibasilar crackles but non-labored breathing, no wheezing +bowel sounds, soft, NT, ND, no rebound, no guarding +edema in LE but much improved since his last admission CXR and CT scans reviewed stool studies all sent and are pending at this time UA was not suggestive of UTI, although UC pending sodium 132, potassium 5.7, chloride 112, bicarb 14, BUN 53, creatinine 2.95 (baseline before rejection episode was 2.5) calcium 7.7, magnesium 1.6, phosphorus 6.0 WBC 7.3, Hgb 9.6, Plt 111 tacrolimus 15 CMV pending A/P: 60 year old male s/p kidney transplant with recent IIB rejection that has responded with Thymo.
LE|lower extremity|LE|176|177|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Back pain. HPI: Metastatic cancer to the spine with LE weakness and back pain. Currently under radiotherapy. Exam: Back pain. Lower extremity weakness 3/5 LLE, 2/5 RLE.
LE|leukocyte esterase|LE,|203|205|LABORATORIES|NEUROLOGICAL: Oriented x 3, no focal deficit. LABORATORIES: Hemoglobin 10.8, sodium 134, potassium 4.3, chloride 103, CO2 28. Creatinine on _%#MM#%_ _%#DD#%_ was 1.4. Urinalysis shows small blood, small LE, rbc's 5, wbc's 5. Chest x-ray done on _%#MM#%_ _%#DD#%_ shows cardiomegaly, otherwise clear. IMPRESSION: 1. Severe degenerative joint disease of left hip, status post left total hip arthroplasty.
LE|lower extremity|LE|361|362|T|9. Dapsone 10.Rocaltrol 0.25mcg po qd 11.Protonix 12.Zoloft 13.Vit D Currently, while Inpt, changes are: Started Imipenem not on Prograf or Cellcept Physical Examination: T: 97.8, HR 70bpm, BP 111/71, RR 16, 95%-r/a, Wt:44/5kg 8hr i/o: 905/800uo; yest: 1400/410uo A/O x3 PERRL CTA. No wheezes/ronchi/crackles BS present. Nontender to palpation No elevated JVP. LE without any edema CN 2-12 intact. No rash Labs: Cr 1.96 (2.2 on admit), HCO 17 (13 on admit), K 5.1 (5.4 on admit), Na 138, Hg 9.7 (7.6 on admit-transfused) Phos 3.6, Mg 2.1, Ca 7.6 UA: SG1.011, pH6.5, 10alb, +nitrite/lrge LE, mod bld.
LE|lower extremity|LE|181|182|HPI|He stabilized overnight with improvement in neurologic sx. Patient first developed low back pain about 2 months ago that initially was very debilitating but not associated with any LE neurolgic sx or fecal/urine incontinence. His sx improved somewhat with regular use of ibuprofen. Over the next several weeks, the patient and his wife both noted an appreciable decrease in appetite and food intake with an associated 10 lb. unintentional weight loss.
LE|lower extremity|LE|421|422|HPI|He denies any HA, dizziness, vertigo, tinnitus, hearing loss, sinus pain/pressure, recent dental work or any dental abnormalities, neck pain/stiffness, LAN, CP/pressure, unusual SOB/DOE, orthopnea, PND, SOB, cough, wheezing, N/V, changes in bowel habits, melena or hematochezia, abd pain, focal joint pain/swelling, rash or other skin changes. He did not measure any temperatures at home. He has had some progressive b/l LE swelling that is worse during the day and improved at night with elevation. He has been disproportionately fatigued, falling asleep as early as 8PM.
LE|lower extremity|LE|161|162|S|Persistent high fevers throughout day yesterday. Tolerated TEE well. No CP/pressure, unusual SOB. Some pain at the base of the L great toe. Back pain stable. No LE neurologic sx. O: VS/labs confirmed; see appropriate sections of FCIS for full details.
LE|lower extremity|LE|234|235|IMPRESSION/PLAN|C. Medication Compliance- Increase Rifaximin to 400mg po tid. I had a long discussion with the patient regarding her lactulose and the necessity of taking the drug. The patient should titrate her lactulose to 5 BM/day. 2. Ascites and LE edema Plan: Continue current medications, there is some room to move with her diuretics, especially the Spironolactone. However, the patient would like to defer this decision to her Mayo Hepatologist, Dr. _%#NAME#%_.
LE|lower extremity|LE.|139|141|HPI|My key findings: CC: History of bladder cancer. HPI: MRI shows spinal and encasement T5-T10. Exam: Patient has no movement or sensation in LE. No DTR in LE. Assessment and Plan: We will institute emergent RT. Procedure and side effects explained to patient.
LE|leukocyte esterase|LE|181|182|LABORATORY DATA|GENITALIA: Exam deferred. Patient states she does have a female circumcision. LABORATORY DATA: Beta HCG 1232, blood type B positive, antibody negative. Urine notable only for trace LE 125 RBCs and moderate amorphic crystals. Potassium 3.1, hemoglobin 8.1. White count 9.5, platelets 261. The patient did undergo a CT of the abdomen and pelvis that was notable for an enlarged uterus containing few fibroids, dominant being 7 cm in the left side of the uterine body.
LE|leukocyte esterase|LE,|138|140|ADMITTING LABS|EOM is intact. DTR two, brisk, symmetrical upper and lower extremities. ADMITTING LABS: WBC 3.5, hemoglobin 15.1, platelets 203. MUGA 47% LE, LVEF _%#MM#%_ 2002. Last bone marrow biopsy _%#MMDD2002#%_, no evidence of acute leukemia. COURSE OF HOSPITALIZATION: PROBLEM #1: Bone marrow transplant. The patient had myeloablative preoperative regime with Cytoxan, fludarabin, and total body irradiation, On _%#MMDD2002#%_, he had double umbilical cord infusion.
LE|leukocyte esterase|LE,|368|370|LABORATORY DATA|LABORATORY DATA: White blood cell count 21. 9, hemoglobin 12, platelets 240, hematocrit 26.2, sodium 135, potassium 3.1, chloride 99, bicarbonate 27, BUN 20, creatinine 0.91, glucose 101, calcium 9.9, bilirubin 1.3, albumin 3.4, protein 7, alkaline phosphatase 78, ALT 23, AST 21, lipase 29. Urinalysis of the nephrostomy tube shows moderate blood, 100 protein, large LE, negative nitrites, 51 white blood cells, and 84 white blood cells. Urinalysis of midstream urine reveals .....protein negative, leukocyte esterase and nitrites, 1 white blood cell, positive mucous, and granular casts.
LE|leukocyte esterase|LE;|255|257|LABORATORY DATA|Distal pulses are full. Peripheral perfusion is intact with capillary refill less than 2 seconds. The extremities are warm. LABORATORY DATA: Urinalysis in the emergency department shows a specific gravity of 1.011, protein 30, negative nitrite, blood and LE; 2 WBCs and 2 RBCs. The white blood cell count was 13.7 with 92% neutrophils, hemoglobin 10.1 and platelets 252.
LE|leukocyte esterase|LE,|162|164|EMERGENCY ROOM LABORATORY DATA|ALT was 554 and AST 1174, albumin 3.1; electrolytes were within normal limits, except for creatinine 2.8 and BUN of 77. UA shows moderate blood and protein trace LE, white cell 2 to 5 and RBCs 2 to 5. Blood cultures were sent and pending. CHEST X-RAY: Chest x-ray shows left lower lobe consolidation.
LE|lower extremity|LE|153|154|DISPOSITION|56 y/o W with hx of post-lumbar fusion epidural MSSA abscess in _%#MM2007#%_, now presented with intractable low back pain, fever, rigors, and bilateral LE pain. Bld ctx + for GPCs in clusters. MRI shows epidural abscess from L3-L4, and right psoas muscle abscess. Diastolic murmur noted on exam of heart. Overall, concerning for seeding of a native heart valve -- though initial TTE negative for vegetaions.
LE|lower extremity|LE|185|186|PHYSICAL EXAMINATION|He is afebrile. Respiratory rate 22 per minute. Pulse ox 96% on 3 liters nasal cannula. SKIN: Reveals a rash over the abdominal wall with scratch marks. There is no pedal edema. Distal LE pulses were 2+. Skin bruises were noted. HEENT: Oral cavity was clear. NECK: Supple. JVD was difficult to evaluate. CARDIAC: Distant S1, S2 with no S3 or S4.
LE|leukocyte esterase|LE|150|151|HOSPITAL COURSE|On postoperative day #0, the patient was noted to have a temperature 100.1 degrees Fahrenheit. Urinalysis was obtained at that time that showed small LE and subsequent urine culture was negative. The patient continued to be febrile through postoperative day #2 at which time her temperate was 101.1. At that time white blood cell count was obtained as well as repeat UA and UC, chest x-ray and blood cultures.
LE|leukocyte esterase|LE|278|279|HOSPITAL COURSE|The patient continued to be febrile through postoperative day #2 at which time her temperate was 101.1. At that time white blood cell count was obtained as well as repeat UA and UC, chest x-ray and blood cultures. White blood cell count was found to be 2.7. UA was negative for LE or nitrites. Urine culture, however, showed multiple species including greater than 100,000 gram-negative rods. A chest x-ray at that time showed atelectasis. The final urine culture results were obtained on postoperative day #4 and the patient was prescribed ciprofloxacin 500 mg p.o. b.i.d. to begin at home for presumed UTI.
LE|leukocyte esterase|LE.|170|172|LABORATORY|Initial troponin was less than 0.07. Urinalysis was significant for red color with cloudy appearance, ......of 1.028. Trace ketones, large blood proteinuria of 30, small LE. Blood cultures were drawn, and a CT of the head was performed, which revealed a right parietal occipital infarct consistent with his previous insult.
LE|lower extremity|LE|254|255|PROBLEM #1|Since the patient has a strong family history of coronary artery disease and she is a smoker, we ruled out MI with serial EKGs and troponins x 3. The patient in the meantime was treated with IV heparin, and she was put on a high-intensity protocol. Once LE Doppler was negative, we stopped her heparin, and she was put on telemetry. Her chest x-ray showed bilateral pleural effusions and cardiomegaly. The patient had undergone echocardiography which showed trace pericardial effusion.
LE|leukocyte esterase|LE|167|168|ASSESSMENT AND PLAN|We will discuss with surgery team to reschedule surgery when the patient is stable later on. 3. Suspected urinary tract infection with urinalysis which shows positive LE and positive nitrates and white blood count of 33 and the patient complaining of dysuria. We will start her on Levaquin 250 mg p.o. daily this morning before surgery and we will await urine culture report.
LE|leukocyte esterase|LE|136|137|PROBLEM #4|The patient had been started on Levofloxacin 250 mg p.o. q.d. She had no symptoms throughout. Repeat urinalysis still revealed positive LE and WBCs. She was afebrile throughout. We will discharge the patient home on a 10-day course of levofloxacin and have her repeat urinalysis on follow-up.
LE|leukocyte esterase|LE,|118|120|LABS ON ADMISSION|AST and ALT within normal limits. EKG: Normal axis with NSR rate of 72. U/A with trace ketones, trace blood, moderate LE, 5 to 10 white cells, and many bacteria. HOSPITAL COURSE: PROBLEM #1: Rectal prolapse. The patient had surgery on _%#MMDD2004#%_ with Dr. _%#NAME#%_ of colorectal surgery for perineal rectosigmoidectomy.
LE|leukocyte esterase|LE,|238|240|PROBLEM #8|Continued on Lasix for diuresis. Otherwise course was uneventful. PROBLEM #8: Due to weakness and incontinence a Foley was placed during the course. On discharge she did have a urine culture pending for a UA with positive nitrates, large LE, and moderate blood and bacteria. Was started on Bactrim DS for a 3 day course with recognition that most likely asymptomatic bacteria.
LE|leukocyte esterase|LE.|135|137|LABORATORY DATA|INR is 2.84. She has normal LFTs, amylase and lipase. A troponin is less than 0.04. Urinalysis shows small blood, negative nitrate and LE. There is less than 1 WBC and 8 RBCs. Chest x-ray is clear without any focal consolidation.
LE|lower extremity|LE|155|156|IMPRESSION|6. Diabetes type I, poor control, present since 1973. 7. Hypermagnesemia has been recurrent with him and normal on admission, but low during the night. 8. LE dermatitis secondary to Agent Orange with signs of excoriation. 9. Incredible history of nicotine addiction at least a 60-70 year pack history.
LE|leukocyte esterase|LE,|224|226|LABORATORY|3. Head CT was performed because of dementia, which revealed moderate to marked brain atrophy, consistent with previous films done in _%#MM#%_. LABORATORY: Urinalysis at the time of admission was remarkable only for a trace LE, but no nitrites, and urine culture revealed organisms. BMP was entirely within normal limits with creatinine of 0.81, and GFR of 71.
LE|leukocyte esterase|LE,|280|282|LABORATORY DATA|UPT negative. Sodium 135, potassium 4.1, chloride 101, CO2 29, BUN 5, creatinine 0.7, glucose 99, amylase 59, lipase 49, calcium 8.7, total protein 6.4, albumin 3.4, total bilirubin 0.2, alkaline phosphatase 91, ALT 14, AST 29. UA 10 ketones with specific gravity 1.018, negative LE, nitrites with few bacteria. Chest x-ray and abdominal x-ray were done. Chest x-ray was negative. Abdominal x-ray showed slight scoliosis with stool in the right colon but otherwise unremarkable.
LE|leukocyte esterase|LE|235|236|LABORATORY DATA|Glucose 378. Sed rate 57. White blood count 20,300 with left shift, neutrophils 91%, lymphocytes 4%, monocytes 5%, hemoglobin 12.9, MCV 96, platelet count 364. Lactic acid was 2.3. Urine shows nitrates negative. Urine, blood positive, LE positive, white blood cells 76, red blood cell 1. Urine culture pending. Repeat electrolytes today, potassium is down to 3.2, creatinine is 1.40, glucose 120.
LE|leukocyte esterase|LE|137|138|LABORATORY DATA ON ADMISSION|UA had been collected on _%#MMDD2007#%_ as well showing 30 mg of protein, otherwise, few bacteria, mucus and hyaline casts, negative for LE or nitrites. Urine culture had been obtained and showing no growth. Chest x-ray from _%#MMDD2007#%_ showed a suspect worsening infiltrate in the right lung apex, new infiltrate in the left midlung zone.
LE|lower extremity|LE|139|140|ASSESSMENT AND PLAN|Lungs with decreased BS at bases R>L, no crackles. Heart RRR, no murmurs. Abd soft, nontender. Erythema at site of right CT site resolved. LE with marked edema, stable since d/c. Labs reviewed; WBC increased since d/c. UA with LE and few bacteria. A/P: 60 yo woman with amyloidosis (AL) s/p one cycle melphalan/prednisone, d/ced on _%#MMDD#%_, readmitted for evaluation of SOB.
LE|leukocyte esterase|LE|153|154|ASSESSMENT AND PLAN|Abd soft, nontender. Erythema at site of right CT site resolved. LE with marked edema, stable since d/c. Labs reviewed; WBC increased since d/c. UA with LE and few bacteria. A/P: 60 yo woman with amyloidosis (AL) s/p one cycle melphalan/prednisone, d/ced on _%#MMDD#%_, readmitted for evaluation of SOB.
LE|leukocyte esterase|LE|187|188|LABORATORY|His CK was 166. Urinalysis showed greater than 1000 glucose, a small amount of blood, specific gravity of 1.026. Ketones were negative. There was a trace albumin, nitrites were negative, LE was moderate, with 78 white blood cells, 19 red blood cells, and many bacteria were seen on microscopic. His urine culture eventually grew Escherichia coli that was pansensitive.
LE|leukocyte esterase|LE,|168|170|LABORATORY|ALT was 10, AST 10. Uric acid 4.1. All of these values are within normal limits except for an elevated white count. UA showed a large blood, negative nitrite, negative LE, 20-30 red blood cells per high power field. Monitoring on admission revealed reactive NST. Toco monitoring revealed no contractions.
LE|lower extremity|LE|222|223|PAST MEDICAL HISTORY|She did not feel any shortness of breath. No deep venous thrombosis or pulmonary embolism history. PAST MEDICAL HISTORY: 1. Severe multiple sclerosis as detailed above. Nonambulatory, with marked weakness of the bilateral LE and RUE. She is able to move the LUE. 2. Hypertension. 3. Osteoporosis. 4. Pyelonephritis. 5. Seizure disorder diagnosed 2 weeks ago.
LE|lower extremity|LE|150|151|CC|__x___ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Patient with symptoms of LE weakness and numbness. R/O radiation neuropathy. HPI: Patient is s/p sigmoid resection and post op pelvic RT of 4900 cGy in 175 cGy fx.
LE|UNSURED SENSE|LE|168|169|DEMOGRAPHICS AND BACKGROUND INFORMATION|He also has engaged in self-injurious behaviors using an eraser and rubbing a pen on his skin to the point where he wrote "pimp" on his arm. He also wrote the initials LE because he has called "Little E. This patient has been experiencing depressive symptoms such as loss of motivation, difficulty concentrating, difficulty falling asleep, decreased appetite, irritability and suicidal ideation.
LE|lower extremity|LE|237|238|REVIEW OF SYSTEMS|He is on an intermittent straight catheterization program. Some incontinence is seen between his caths. He is not on a regular bowel program. He reports persistent abdominal pain. He wears upper extremity splints at night and alternates LE splint/boot q2h. He denies limb pain. He is on ventilator support at night, trach dome during the day. Recent abdominal x-ray showed stool throughout the colon. PHYSICAL EXAMINATION: VITAL SIGNS: T-max 98.7, blood pressure 111/56-116/56, pulse 50-64, respiratory rate 11-14, O2 sats 98% on trach dome.
LE|lupus erythematosus|(LE).|221|225|BRIEF HISTORY|She had a past medical history of some kind of bladder surgery and hysterectomy, also chronic recurrent cystitis, chronic obstructive lung disease (COLD) in a nonsmoker, rheumatoid arthritis (RA) with lupus erythematosus (LE). She stated she had been ill for at least a month prior to admission. No nausea, vomiting, or constipation. She denies any past medical history of hypertension (HTN) or phlebitis.
LE|leukocyte esterase|LE,|184|186|LABS ON ADMISSION|LYMPHATICS: No cervical or supraclavicular lymphadenopathy. LABS ON ADMISSION: CBC: White count 9.5, hemoglobin 13.1, platelets 148, 71% neutrophils, 15% lymphocytes. U/A has moderate LE, small blood, negative albumin and nitrites with 2-5 white blood cells, 2-5 red blood cells, and positive Trichomonas. LFTs were normal with an ALT of 18, AST 24, alk phos 79, total bili 0.2, total protein 7.6, albumin 3.6. Electrolytes: Sodium 133, K 3.6, chloride 97, CO2 26, BUN 17, creatinine 1.6, glucose 149, calcium 8.6, lipase 54.
LE|lower extremity|LE,|132|134||He appears comfortable. He is hemodynamically stable. There are no issues with alarms of the LVAD. The patient continues to have 2+ LE, as well as upper extremeties edema. Both have significantly improved. A/P: 1. CHF stage D, NYHA class IV, LVEF 20%, ischemic etiology.
LE|lower extremity|LE|722|723|PE|8. Left total knee arthroplasty. 9. Ovarian cyst removal, age 16. 10. s/p CABG _%#MMDD2007#%_ Reviewed in chart: current inpatient med list outpatient med list - Nexium, Vicodin, Sensipar 30mg qday, PhosLo 667mg tid, Renagel 800mg tid, hydroxyzine, Allegra, gemfibrozil, ASA, dialyvite, Lexapro, Seroquel, Flexeril SH - no smoking, EtOH abuse, drugs FH non-contributory PE: vitals reviewed I/O's reviewed - essentially anuric alert, very pleasant, non-toxic, in NAD NCAT, no conj, no icterus OP clear neck supple and NT no cervical LAD RRR left PermCath site C/D/I CTA non-labored abdomens soft, incision site C/D/I has right AV fistula (per patient had an aneurysm resected and repaired intra-operatively) trace edema in LE neuro non-focal today's labs reviewed A/P: 65 year old female who is now POD #1 s/p DDKT with DGFx likely due to ATN from prolonged cold ischemia time.
LE|lower extremity|LE|182|183|PHYSICAL EXAMINATION ON ADMISSION|No fasciculations. Strength/RL: Deltoid 5/5, biceps 4/4+, triceps 5/4+, wrist extension 5/2, finger extension 5/2. Hip flexion 5/3, hip extension 5/3, abduction of LE 5/1, abduction LE 5/1, quad 4/2, hamstrings 4/2. Flexion of the foot 4+/2, extension 5/4. Sensory: Normal to light touch. Proprioception normal x 4. Reflex: Overall brisk left more so than right.
LE|leukocyte esterase|LE,|242|244|ADMISSION LABORATORY DATA|ADMISSION LABORATORY DATA: White count 8.5, 90% neutrophils, hemoglobin 13.3, platelets 65, INR 1.43, PTT 31, troponin less than 0.07. Urine pregnancy test is negative. UA revealed protein of 100, 5 to 10 white cells, 2 to 5 red cells, trace LE, and positive nitrites. LFTs included total bili 2.2, albumin 3.4, total protein 7.6, AST 99, ALT 71, lipase 635, alkaline phosphatase within normal limits.
LE|lower extremity|LE|171|172|ENT|Crackles left (transplant) lung, scattered. Easy effort. No wheezing. CV: RRR. II/VI SEM. No rubs. Abd: Normal BS. Soft, NT, ND. Ext: No edema. Skin: Warm, dry. Lymph: No LE edema Neuro: Alert and oriented Psych: Slightly restricted affect. Labs reviewed in EMR: WBC normal. Hgb 14.9 INR 1.27 Na/K normal Chest x-ray personally reviewed: No new infiltrate.
LE|lower extremity|LE|599|600|PE|No nausea, no shortness of breath, no chest pain, pain well-controlled. PMH: ESKD secondary to interstitial nephritis -history of DDKT 1984 -has been on HD since 1998 -dialyzes via a left upper extremity AV fistula, with EDW of 95 kg history of hepatitis C treated with interferon in 2005 secondary hyperparathyroidism s/p subtotal hyperparathyroidism history of duodenal ulcer Medications, Allergies reviewed in chart PE: asleep, arousable, in NAD NCAT, no conj, no icterus RRR CTAB, non-labored abdomen soft, incision site C/D/I left upper extremity fistula with good thrill and bruit no edema in LE patient has had minimal urine output since surgery CXR reviewed and showed no acute airspace disease labs from ealier today reviewedl K was 5.4 post-op A/P: 45 year old male with ESKD s/p DDKT.
MOM|milk of magnesia|MOM|125|127|MEDICATIONS|7. Detrol 1 mg b.i.d. 8. Darvon plain 65 mg or Tylenol gr 10 every 4 hours prn. 9. Ex-Lax with Senna, 1-2 tablets daily. 10. MOM 1-2 ounces every 12 hours prn. 11. Coumadin 4 mg daily. 5 mg Tuesday and Friday. 12. Fosamax was prescribed but she never filled the prescription.
MOM|milk of magnesia|MOM|120|122|DISCHARGE MEDICATIONS|2. Amaryl 1 mg qd. 3. Prinivil 10 mg qd. 4. Lasix 40 mg qd. 5. Neurontin 100 mg h.s. 6. Prn Endocet, Darvocet, Tylenol, MOM and acidophilus. Social Services arranged a ride home. Hospice will take over his last two days of care.
MOM|milk of magnesia|MOM|212|214|CURRENT MEDICATION|CODE STATUS: Her code status is Do Not Resuscitate but if dyspneic, she would allow usage of a ventilator. CURRENT MEDICATION: 1. Percocet 5/325, 1 or 2 q.i.d. 2. Colace 200 mg orally daily, taken with water. 3. MOM 15 mL p.o. daily. 4. Hydrochlorothiazide at 12.5 mg p.o. daily. 5. Lisinopril 20 mg p.o. daily. 6. Potassium chloride 10 mEq p.o. daily. 7. Coated ASA 81 mg p.o. daily with dipyridamole 75 mg p.o. daily.
MOM|milk of magnesia|MOM|124|126|DISCHARGE MEDICATIONS|5. Periactin 4 mg q.i.d. 6. Vitamin E 400 units daily. 7. Guaifenesin 600 mg b.i.d. 8. Senokot two tablets daily in h.s. 9. MOM 1 ounce every 12 hours p.r.n. 10. Afrin nasal spray once daily p.r.n. 11. Zofran 4 mg q.i.d. p.r.n. orally. 12. Citrucel 1 Tbsp daily with 12 ounces of water.
MOM|milk of magnesia|MOM,|158|161|SOCIAL HISTORY|PROBLEM #4: Constipation. The patient has a chronic history of constipation. During her hospital stay, constipation was treated with combination of Dulcolax, MOM, Fleet Enemas and Colace. Constipation resolved with a bowel movement the day prior to discharge. PROBLEM #5: Seizure disorder. Seizures stable with therapeutic dilantin level of 14.
MOM|milk of magnesia|MOM,|179|182|OPERATIONS/PROCEDURES PERFORMED|Review of other systems in their entirety were negative. PAST MEDICAL HISTORY: Only significant for pyelonephritis as a child. ADMISSION MEDICATIONS: Wellbutrin, Megace, Senokot, MOM, Zofran, Celebrex. PAST OB HISTORY: The patient is a P3,1,0,3. PAST SURGICAL HISTORY: Had an appendectomy at the age of 16. ALLERGIES: No known drug allergies. FAMILY HISTORY: Mother died at the age of 78 of lung cancer.
MOM|milk of magnesia|MOM|363|365|OPERATIONS/PROCEDURES PERFORMED|Ms. _%#NAME#%_ was discharged in satisfactory condition on hospital day #4. Her exam was within normal limits. She was afebrile. DISCHARGE MEDICATIONS: Amoxicillin 500 mg 1 tablet p.o. t.i.d. for 14 days, clindamycin 400 mg 1 tablet po q.i.d. for 14 days, Wellbutrin 100 mg 1 tablet p.o. b.i.d., Megace 400 mg p.o. b.i.d., Senokot 1-4 tablets p.o. b.i.d. p.r.n., MOM 13 ml p.o. t.i.d. p.r.n., Zofran 8 mg p.o. b.i.d. p.r.n., Celebrex 100 mg p.o. b.i.d., Ambien 5 mg p.o. q.h.s. p.r.n., Percocet 1-2 tablets p.o. q.4-6h. p.r.n. FOLLOW UP: She will follow up with CV Radiology for PNT changes as needed.
MOM|milk of magnesia|MOM|129|131|MEDICATIONS|3. Miacalcin nasal spray 1 puff daily. 4. Senna S 2 tablets daily. 5. Calcium with vitamin D t.i.d. 6. Tylenol 1000 mg t.i.d. 7. MOM 30 cc p.o. p.r.n. 8. Sorbitol solution 15 mL p.o. p.r.n. 9. Hydrocortisone acid 0.1 mg p.o. daily. 9. O10. meprazole 20 mg daily.
MOM|milk of magnesia|MOM|368|370|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Her medications at discharge were Pulmicort nebs b.i.d. after her albuterol and Atrovent nebs which she is taking q.i.d. She is tapering her prednisone from 20 mg to 0 over the next four days. She is taking Zantac 150 mg b.i.d., Xanax p.r.n., Ambien at h.s. p.r.n., diltiazem 30 mg q.i.d., flecainide 50 mg b.i.d., guaifenesin SA 600 mg b.i.d., MOM 10 cc daily, Dulcolax p.r.n., nortriptyline 10 mg at h.s., Zostrix Cream to her area of involvement of shingles.
MOM|milk of magnesia|MOM|126|128|MEDICATIONS|8. Valium 5 mg t.i.d. 9. Betadine 0.5% one drop left eye b.i.d. 10. Pilocarpine 2% one drop left eye b.i.d. 11. Prunes and/or MOM one ounce q.12h. p.r.n. Comments after her last hospitalization he was discharged on _%#MMDD2007#%_. The patient did develop significant hyperkalemia with potassium of 6.1, so her KCl was discontinued and with this it came back to normal.
MOM|milk of magnesia|MOM|159|161|MEDICATIONS ON DISCHARGE|6. Ferrous sulfate 300 mg solution by mouth everyday for iron supplementation. 7. Synthroid 25 mcg suspension by mouth everyday. 8. Metoprolol 25 mg b.i.d. 9. MOM 30 mL suspension p.o. p.r.n. for constipation. 10. Multivitamin 1 tablet daily. 11. Protonix 40 mg suspension daily. 12. Senna 1 tablet by mouth twice a day for constipation.
MOM|Mall of America:MOA|MOM|148|150|SOCIAL HISTORY|SOCIAL HISTORY: The patient has graduated. She is currently working two part-time jobs, one at a pediatric urgent care as a receptionist and one at MOM Express in the clothing store. She is planning to start at Northwest College in _%#MM#%_ to become a massage therapist.
MOM|milk of magnesia|MOM|112|114|DISCHARGE MEDICATIONS|5. Darvon 65 mg one or two capsule q 4 hours prn. 6. Reglan 10 mg q.i.d. prn. 7. Celebrex 100 mg b.i.d. prn. 8. MOM one ounce q 12 hours prn. 9. Senokot two tablets daily at h.s. 10. Imodium one capsule q.i.d. prn. 11. Multiple vitamin supplement one daily.
MOM|milk of magnesia|MOM|129|131|DISCHARGE MEDICATIONS|3. Spiriva daily. 4. PhosLo 667 p.o. b.i.d. 5. Augmentin 500 mg p.o. b.i.d. for 13 more days. 6. Mycostatin 10 mL p.o. q.i.d. 7. MOM 30 p.r.n. constipation. 8. Nitroglycerin patch 0.6 mcg/hour, apply daily to skin. 9. Zocor 10 mg p.o. each day at bed time.
MOM|milk of magnesia|MOM,|188|191|PROBLEM #6|The patient was continued with Lasix. PROBLEM #6: Diarrhea, most likely secondary to stool softeners. The patient was constipated at the beginning of the week and patient was treated with MOM, Senokot, and Fleet enema; the last 2 days the patient had diarrhea. Senokot was discontinued today. The patient has a prior history of C. difficile colitis treated.
MOM|milk of magnesia|MOM|183|185|DISCHARGE PLANS|d. Prednisone 20 b.i.d. times seven, then 40 mg single daily dose times seven, followed by 5 mg per day decrease weekly until she gets to 25 mg daily. e. L-thyroxine 0.1 mg daily. f. MOM 30 cc h.s. prn. g. Amitriptyline 50 mg h.s. for neuropathy. 4. Followup. a. Social Services informs me that Dr. _%#NAME#%_ at the _%#CITY#%_ Care Center will manage her day to day needs.
MOM|milk of magnesia|MOM|218|220|MEDICATIONS|FAMILY HISTORY: Positive for diabetes. Per patient also positive for lupus in very distant relatives, dating back to 3 generations ago. ALLERGIES: Amoxicillin, rash. MEDICATIONS: 1. Dulcolax p.r.n. 2. Atarax p.r.n. 3. MOM p.r.n. 4. ProAir inhaler 2 puffs per q.4 h. p.r.n. 5. Prednisone 10 mg q. day. 6. Senokot p.r.n. 7. Coumadin daily. 8. Oxycodone 5/325 1-2 tablets q.4 h. p.r.n.
MOM|milk of magnesia|MOM|142|144|MEDICATIONS|PAST MEDICAL HISTORY: 1. Depression. 2. Aggressive behavior. 3. Huntington's chorea. MEDICATIONS: 1. Tylenol prn. 2. Prevacid 15 mg Q Day. 3. MOM 30 cc po Q Day. 4. Maalox 30 cc q4 hours po prn. 5. Cogentin 1 mg po q hs. 6. Luvox 100 mg po q hs.
MOM|GENERAL ENGLISH|MOM|148|150|DRUG SENSITIVITIES AND ALLERGIES|The CHILD ALSO HAS A FOOD ALLERGY TO EGGS WHICH SHOWED UP IN ALLERGY TESTING, BUT HE HAS NEVER HAD A REACTION TO EGGS. AS FAR AS AVOIDANCE OF EGGS, MOM COOKS With EGGS, BUT DOES NOT GIVE THEM PLAIN TO The CHILD. NO KNOWN DRUG ALLERGIES. CURRENT MEDICATIONS: The child takes a vitamin and had the Albuterol as stated earlier at 8 o'clock this morning.
MOM|milk of magnesia|MOM|181|183|DISCHARGE MEDICATIONS|4. Miconazole cream 2% periarea b.i.d. 5. Dilantin 300 mg p.o. daily. 6. Senokot S 1 tab p.o. b.i.d. 7. Oxycodone 5 mg p.o. q.4h. p.r.n. 8. Ambien 5 mg p.o. q.h.s. p.r.n. sleep. 9. MOM 30 cc p.o. daily p.r.n. ALLERGIES: No known drug allergies. CODE STATUS: DNR/DNI. FURTHER INSTRUCTIONS: 1. Accu-Cheks q.i.d. 2. Keep pin site from gamma knife treatment that was performed _%#MMDD2006#%_ clean.
MOM|milk of magnesia|MOM|135|137|DISCHARGE MEDICATIONS|9. Detrol 1 mg b.i.d. p.r.n. 10. Darvon 65 mg or Tylenol grains 10 q.4h. p.r.n. 11. Ex-Lax with senna 1-2 tablets daily as needed. 12. MOM 1-2 ounces q.12h. p.r.n. 13. Coumadin 4 mg q.d. and 5 mg Tuesday and Friday. PLAN: : Office follow up next week. Continue with glucose monitoring q.i.d.
MOM|milk of magnesia|MOM|113|115|MEDICATIONS|MEDICATIONS: 1. Lexapro 15 mg daily. 2. Lorazepam 0.5-1 mg p.o. each day at bed-time p.r.n. 3. Tylenol p.r.n. 4. MOM p.r.n. 5. Maalox p.r.n. 6. Trazodone 50-100 mg each day at bed-time p.r.n. PHYSICAL EXAMINATION: GENERAL: She is alert, awake, oriented x3 and not in acute distress.
MOM|milk of magnesia|MOM|179|181|MEDICATIONS|MEDICATIONS: 1. Ranitidine 150 mg daily 2. Compazine 10 mg q.6h. p.r.n. 3. K-Dur 30 mEq daily. 4. Furosemide 20 mg daily. 5. Premarin 0.625 daily. 6. Lomotil one q.i.d. p.r.n. 7. MOM 1 ounce q.12h. p.r.n. 8 . Senokot 2 tablets daily. 9. Percocet 7.5-325 1 q.4h. p.r.n. versus Tylenol 650 q.4h. p.r.n.
MOM|milk of magnesia|MOM|212|214|MEDICATIONS|MEDICATIONS: 1. Lanoxin 0.125 mg daily. 2. Isosorbide 30 mg tablets, to take 1/2 a tablet daily. 3. Spironolactone 25 mg daily. 4. Demadex 20 mg daily. 5. Synthroid 112 mcg daily. 6. Senokot one tablet daily. 7. MOM one ounce daily prn. 8. Paxil 10 mg daily. 9. Ferrous gluconate 325 mg daily. 10. ____ one daily. The patient was on Amaryl at one time, although this was discontinued due to relatively well-controlled diabetes.
MOM|milk of magnesia|MOM|285|287|DISPOSITION|These will include dexamethasone 4 mg p.o. b.i.d., Reglan 10 mg p.o. q.i.d., Ambien 10 mg p.o. q.h.s. p.r.n. insomnia, Marinol 5 mg p.o. b.i.d., Zofran ODT 8 mg sublingual q. 8h. p.r.n. nausea and vomiting, Bumex 1 mg p.o. q. 12h., Prevacid 30 mg p.o. q.d., Colace 100 mg p.o. b.i.d., MOM 30 cc p.o. t.i.d., Diflucan 200 mg p.o. q.d., morphine sulfate PCA 2 mg per hour plus 2 mg q. 10 minute PCA with a 14 mg per hour limit, Dulcolax suppository 1 PR q.d. p.r.n. and TPN.
MOM|milk of magnesia|MOM|187|189|MEDICATIONS ON DISCHARGE|9. Niacin 2000 mg daily. 10. Neomycin, polymyxin, and dexamethasone 1 drop right eye t.i.d. 11. Avandia 4 mg daily. 12. Senokot-S 2 tablets nightly. 13. Metamucil 1 tablespoon daily. 14. MOM 30 mL daily as needed. 15. Dulcolax suppository p.r.n. REHAB COURSE: Rehab stay was uncomplicated. He was admitted for further physical and occupational therapy due to worsening falls from his Alzheimer dementia.
MOM|milk of magnesia|MOM|142|144|DISCHARGE MEDICATIONS|8) B-12 1,000 mcg I.M. once monthly. 9) Nitroglycerine patch 0.2 mg one patch daily in a.m., remove at h.s. 10) Zantac 150 mg once daily. 11) MOM one ounce p.r.n. 12) ___________ 0.375 mg q12h p.r.n. PRINCIPAL DIAGNOSES: 1) Severe osteoarthritis of the right knee.
MOM|GENERAL ENGLISH|MOM|129|131|HISTORY OF PRESENT ILLNESS|He also has a history of a unilateral, undescended testicle as an infant which has been resolved for quite some time. ALLERGIES: MOM STATES THAT HE DID HAVE A HIVE-LIKE REACTION WHEN GIVEN MOTRIN. SOCIAL HISTORY: He does live at home and with both of his parents and his 7-year-old sister.
MOM|milk of magnesia|MOM|164|166|PAST MEDICAL HISTORY|6. Liquibid 600 mg b.i.d. 7. Imdur 30 mg one tablet daily 8. Albuterol two puffs Q 4 prn. 9. Serevent two puffs daily at HS 10. Percocet one tablet q.i.d. prn. 11. MOM one ounce every 12 hours prn. FAMILY HISTORY: Mother died at age 72 of myocardial infarction.
MOM|milk of magnesia|MOM|146|148|DISCHARGE MEDICATIONS|5. Lovenox 40 mg subcu daily. 6. Prozac 40 mg p.o. daily. 7. Neurontin 300 mg p.o. b.i.d. 8. Lactobacillus 1 capsule daily. 9. Mylanta p.r.n. 10. MOM 30 mL p.r.n. for constipation. 11. Multivitamin 1 tablet daily. 12. Zofran 4-8 mg p.o. q.6 hour's p.r.n. 13. Protonix 40 mg daily. 14. Phosphate enema p.r.n. 15. Senokot 1-2 tablets p.o. daily.
MOM|milk of magnesia|MOM|103|105|DISCHARGE  MEDICATIONS|6. Ambien 5 mg daily at bedtime p.r.n. 7. Senokot 2 tablets daily at bedtime, hold if loose stools. 8. MOM one ounce q.12h. p.r.n. 9. Fleet's or tap water enema rectally, one daily p.r.n. only. 10. Blistex to sore on lower lip t.i.d. leave on that side.
MOM|milk of magnesia|MOM|151|153|DISCHARGE MEDICATIONS|11. Pantoprazole 40 mg p.o. q.d. 12. Accu-Cheks b.i.d. 13. Vistaril 25 to 50 mg IM/p.o. q.3-4h. p.r.n. 14. Compazine 10 mg IV/IM/p.o. q.6h. p.r.n. 15. MOM 30 cc p.o. p.r.n. 16. Dulcolax 10 mg suppository p.r.n. 17. Fleets enema p.r.n. 18. Maalox 30 cc p.o. p.r.n. 19. Benadryl 25 mg p.o. q.4h. p.r.n.
MOM|milk of magnesia|MOM|163|165|MEDICATIONS|She has been on tamoxifen for several years and this was recently discontinued by Dr. _%#NAME#%_. MEDICATIONS: 1. Albuterol Nebs q.i.d. 2. Atrovent Nebs q.i.d. 3. MOM 30 cc twice a day. 4. Norvasc 5 mg twice a day. 5. Paxil 40 mg. 6. Prevacid 30 mg a day.
MOM|milk of magnesia|MOM|125|127|MEDICATIONS|5. Zyprexa 2.5 mg per day. 6. Accupril 20 mg bid. 7. Metoprolol 15 mg bid. 8. Alprazolam 0.25 mg po tid. 9. Tylenol prn. 10. MOM prn. 11. Loratadine prn. 12. Ipratropium nose drops 0.03% two drops q4 hours. 13. Single dose of ceftriaxone and azithromycin.
MOM|milk of magnesia|MOM|394|396|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: Discharged home on her usual medications which included aspirin 81 mg a day, Protonix 40 mg a day, prednisone 5 mg a day, Darvocet, Reglan 5 mg t.i.d., Ambien 5 mg q.h.s., Renagel 1600 mg t.i.d. with meals, Norvasc 10 mg a day, Nephrocaps one tablet a day, Avapro again was increased to 225 mg a day, Allopurinol 100 mg a day, Lasix 20 mg a day, vitamin E 400 IU a day, MOM 15-30 cc p.o. p.r.n., Paxil 20 mg a day, Miacalcin spray, hydroxychloroquine 200 mg b.i.d., and there is another nutritional supplement - I believe it is called Nepro or something of that sort, 120 cc t.i.d. and she was to continue with her dialysis as before.
MOM|milk of magnesia|MOM.|141|144|ADMISSION MEDICATIONS|6. MVI. 7. Calcium and vitamin D. 8. Zinc. 9. Colace. 10. Senna. 11. L-lysine. 12. Fish oil. 13. Beta complex. 14. Zofran. 15. Sorbitol. 16. MOM. 17. Depo. 18. Celexa. 19. Lamictal. 20. Ambien. 21. Neurontin. 22. Nexium. 23. MiraLax as needed. 24. Lipitor. 25. Aspirin. 26. Vitamin B12. ALLERGIES: Protonix. Dilaudid.
MOM|milk of magnesia|MOM|151|153|CURRENT MEDICATIONS|11. Prilosec 20 mg p.o. daily. 12. Aricept 10 mg p.o. each day at bedtime. 13. Zocor 40 mg p.o. each day at bedtime. 14. Namenda 10 mg p.o. b.i.d. 15. MOM 30 cc p.o. daily. DRUG ALLERGIES: Penicillin, morphine, atenolol and labetalol. Penicillin gives a rash, morphine causes confusion and hallucinations.
MOM|milk of magnesia|MOM|173|175|CURRENT MEDICATIONS|11. Lantus 30 units q.a.m. 12. Lisinopril 20 mg p.o. b.i.d. 13. Magnesium oxide 200 mg p.o. b.i.d. 14. MiraLax 8.5 217 grams p.o. daily. 15. Mirtazapine 15 mg p.o. h.s. 16. MOM 30 cc p.o. daily, 17. Nifedipine ER 90 mg p.o. daily, 18. Oyster shell calcium vitamin D 500 mg p.o. b.i.d.
MOM|milk of magnesia|MOM|115|117|MEDICATION|He has had no recent cardiac arrest by symptoms. MEDICATION: 1. Cogentin .5 mg at h.s. 2. Diazepam 2 mg at h.s. 3. MOM 30 cc a day. 4. Risperdal .5 mg at h.s. 5. Zoloft 25 mg at h.s. 6. Tylenol on a p.r.n. basis. 7. The patient was started on Ferrous Gluconate, as well as Prilosec just prior to admission when he initially had refused workup.
MOM|milk of magnesia|MOM|150|152|PLAN|3) Vitamin C one tablet G-tube q day. 4) Ditropan 10 mg G-tube q.i.d. 5) Colace 100 mg G-tube b.i.d. 6) Multivitamin with iron 15 mg G-tube daily. 7) MOM 30 cc G-tube at bedtime. 8) Dilantin 300 mg G-tube q day. 9) Desyrel 100 mg G-tube at bedtime. 10) Xanax 0.5 mg G-tube at bedtime.
MOM|milk of magnesia|MOM|150|152|MEDICATIONS ON DISCHARGE|3. Imipramine HCl 50 mg p.o. every day. 4. Levothyroxine 75 mcg p.o. daily. 5. Mylanta 30 mL suspension every 4 hours p.r.n. for gastric distress. 6. MOM 30 mL suspension twice a day p.r.n. for constipation. 7. Multivitamin 1 tablet p.o. daily. 8. Zofran 4 mg p.o. every 6 hours p.r.n. for nausea.
MOM|milk of magnesia|MOM|168|170|MEDICATIONS|8. History of left bundle branch block. MEDICATIONS: 1. Pravachol 40 mg po q d. 2. Metoprolol 12.5 mg po bid. 3. Miconazole powder to feet bid. 4. ASA 81 mg po q d. 5. MOM 30 cc po q d prn. 6. Dulcolax suppository pr q d prn. 7. Tylenol 650 mg po q 4 hours prn. 8. Maalox 30 cc po tid prn. ALLERGIES: NKDA. CODE STATUS: DNR/DNI.
MOM|milk of magnesia|MOM|184|186|DISCHARGE MEDICATIONS|1. Darvocet-N 100 1-2 q.4h. p.r.n. 2. Her old products remain Senokot 1 tablet p.o. q. day. 3. Florinef 100 mcg q. day. 4. Vitamin B12 1000 mcg IM q. month. 5. Lodosyn 25 mg b.i.d. 6. MOM 30 cc p.o. q. day p.r.n. 7. Midodrine 15 mg in the morning and 10 units at noon. 8. Sinemet 25/100 1 whole tablet 3x a day and 1/2 tablet twice a day.
MOM|milk of magnesia|MOM|123|125|DISCHARGE MEDICATIONS|12. Ativan 0.5 mg qid prn, and 0.5 mg daily at hs. 13. Colace 200 mg daily. 14. Senokot 2 tablets daily and at hs prn. 15. MOM 1 ounce q 12 hours prn. 16. Coumadin 5 mg daily or as directed. Daily protime and INR, results to Dr. _%#NAME#%_.
MOM|multiples of median|MOM|143|145|G 4   P	0030				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.4 weeks gestation. The screen was within normal limits. o AFP=1.26 MOM o Estriol= 1.49 MOM o HCG= 1.85 MOM o DIA= 1.54 MOM * Adjusted risk for Down syndrome=1:3134 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * We discussed the fact that a history of a pregnancy with the sporadic form of Down syndrome would generally translate into higher risks in future pregnancies.
MOM|multiples of median|MOM|163|165|G 4   P	0030				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.4 weeks gestation. The screen was within normal limits. o AFP=1.26 MOM o Estriol= 1.49 MOM o HCG= 1.85 MOM o DIA= 1.54 MOM * Adjusted risk for Down syndrome=1:3134 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * We discussed the fact that a history of a pregnancy with the sporadic form of Down syndrome would generally translate into higher risks in future pregnancies.
MOM|multiples of median|MOM|179|181|G 4   P	0030				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.4 weeks gestation. The screen was within normal limits. o AFP=1.26 MOM o Estriol= 1.49 MOM o HCG= 1.85 MOM o DIA= 1.54 MOM * Adjusted risk for Down syndrome=1:3134 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * We discussed the fact that a history of a pregnancy with the sporadic form of Down syndrome would generally translate into higher risks in future pregnancies.
MOM|multiples of median|MOM|195|197|G 4   P	0030				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.4 weeks gestation. The screen was within normal limits. o AFP=1.26 MOM o Estriol= 1.49 MOM o HCG= 1.85 MOM o DIA= 1.54 MOM * Adjusted risk for Down syndrome=1:3134 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * We discussed the fact that a history of a pregnancy with the sporadic form of Down syndrome would generally translate into higher risks in future pregnancies.
MOM|multiples of median|MOM|163|165|G 2   P 0010				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.7 weeks gestation. The screen was within normal limits. o AFP=1.64 MOM o Estriol= 1.28 MOM o HCG= 0.50 MOM o DIA= 0.40 MOM * Adjusted risk for Down syndrome=1:5000 * Adjusted risk for Trisomy 18=1:5000 * Adjusted risk for ONTD=1:1895 * We discussed the significance of the intracardiac echogenic focus.
MOM|multiples of median|MOM|179|181|G 2   P 0010				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.7 weeks gestation. The screen was within normal limits. o AFP=1.64 MOM o Estriol= 1.28 MOM o HCG= 0.50 MOM o DIA= 0.40 MOM * Adjusted risk for Down syndrome=1:5000 * Adjusted risk for Trisomy 18=1:5000 * Adjusted risk for ONTD=1:1895 * We discussed the significance of the intracardiac echogenic focus.
MOM|multiples of median|MOM|195|197|G 2   P 0010				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.7 weeks gestation. The screen was within normal limits. o AFP=1.64 MOM o Estriol= 1.28 MOM o HCG= 0.50 MOM o DIA= 0.40 MOM * Adjusted risk for Down syndrome=1:5000 * Adjusted risk for Trisomy 18=1:5000 * Adjusted risk for ONTD=1:1895 * We discussed the significance of the intracardiac echogenic focus.
MOM|multiples of median|MOM|191|193|G 2   P 0010				LMP|o Age mid trimester Down syndrome risk= 1:412 * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 17.9 weeks gestation. o AFP=1.21 MOM o Estriol= 1.15 MOM o HCG= 0.90 MOM o DIA= 1.40 MOM * Adjusted risk for Down syndrome=1:3238 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=not calculated (normal screen) * The screen was originally calculated without inclusion of the family history of spina bifida.
MOM|multiples of median|MOM|158|160|G 2   P 0010				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 17.9 weeks gestation. o AFP=1.21 MOM o Estriol= 1.15 MOM o HCG= 0.90 MOM o DIA= 1.40 MOM * Adjusted risk for Down syndrome=1:3238 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=not calculated (normal screen) * The screen was originally calculated without inclusion of the family history of spina bifida.
MOM|multiples of median|MOM|258|260|G 2   P 0010				LMP|I spent approximately 45 minutes with this patient today. _%#NAME#%_ is a 19-year-old gravida 1, para 0-0-0-0, who is currently 21 weeks gestation based on an estimated date of delivery _%#MMDD2007#%_. We reviewed her quad screen, which was as follows: 0.61 MOM AFP, 0.51 MOM Estriol, 2.31 MOM hCG, and 0.86 MOM inhibin. Thus this increased her chance to have a baby with Down syndrome for a more age-related risk of 1:1535 to 1:334.
MOM|multiples of median|MOM|143|145|G 4   P	3003				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.6 weeks gestation. The screen was within normal limits. o AFP=0.79 MOM o Estriol= 0.85 MOM o HCG= 0.94 MOM o DIA= 1.07 MOM * Adjusted risk for Down syndrome=1:845 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 4   P	3003				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.6 weeks gestation. The screen was within normal limits. o AFP=0.79 MOM o Estriol= 0.85 MOM o HCG= 0.94 MOM o DIA= 1.07 MOM * Adjusted risk for Down syndrome=1:845 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 4   P	3003				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.6 weeks gestation. The screen was within normal limits. o AFP=0.79 MOM o Estriol= 0.85 MOM o HCG= 0.94 MOM o DIA= 1.07 MOM * Adjusted risk for Down syndrome=1:845 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.7 weeks gestation. The screen was within normal limits. o AFP=1.77 MOM o Estriol= 1.03 MOM o HCG= 1.04 MOM o DIA= 1.20 MOM * Adjusted risk for Down syndrome=1:716 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=1:1373 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 4   P	2012				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.3 weeks gestation. The screen was within normal limits. o AFP=1.11 MOM o Estriol= 1.24 MOM o HCG= 0.65 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|milk of magnesia|MOM|114|116|MEDICATIONS|MEDICATIONS: 1. Fentanyl patch 75 mcg/hour. 2. Vicodin ES for break-through pain. 3. Zofran 4 mg p.o. q 6 prn. 4. MOM prn. 5. Fleet's prn. 6. Peri-Colace prn. 7. Trazodone 200 mg q h.s. 8. Effexor 100 mg q a.m. 9. Paxil 30 mg q a.m.
MOM|multiples of median|MOM).|134|138|G  3  P	1021				LMP|* _%#NAME#%_'s first pregnancy was a twin pregnancy. I met with her during that pregnancy due to an elevated maternal serum AFP (4.05 MOM). As you are aware, there was a loss of one twin in the pregnancy. _%#NAME#%_ subsequently delivered a healthy male infant. Since that pregnancy, _%#NAME#%_ also had a first trimester miscarriage of a singleton pregnancy (_%#MM#%_ 2006).
MOM|multiples of median|MOM).|430|434|RE|Test results: Revised Down syndrome risk: 1:109 (abnormal) Revised Trisomy 13/18 risk: 1:7641 (normal) I explained that the screen had increased the risk for Down syndrome in the current pregnancy from _%#NAME#%_'s age-related risk of 1:219 to a new risk of 1:109. To state another way, the risk for Down syndrome increased from 0.5% to 0.9%. This increase in risk was largely attributed to a significant elevation of B-HCG (5.93 MOM). We discussed follow-up options including amniocentesis and additional screening options.
MOM|multiples of median|MOM,|242|245|ASSESSMENT AND PLAN|We discussed that increased nuchal fold as well as EIFs are associated with risks for chromosome abnormalities, specifically trisomy 21 or Down syndrome. The patient had a quad screen drawn through your clinic that resulted in an AFP of 1.05 MOM, an HCG of 0.79 MOM, an estril of 0.61 MOM, and an inhibin of 0.63 MOM. This result, which was normal, decreased the patient's age-related risk to have a baby with Down syndrome to 1:3600.
MOM|multiples of median|MOM,|108|111|ASSESSMENT AND PLAN|The patient had a quad screen drawn through your clinic that resulted in an AFP of 1.05 MOM, an HCG of 0.79 MOM, an estril of 0.61 MOM, and an inhibin of 0.63 MOM. This result, which was normal, decreased the patient's age-related risk to have a baby with Down syndrome to 1:3600.
MOM|multiples of median|M.O.M.,|246|252|ASSESSMENT AND PLAN|We then reviewed the results of the maternal serum screen that _%#NAME#%_ had on _%#MMDD2006#%_ at 16 weeks and 5 days' gestation. Specifically, the resultant chemical values were as follows: an AFP value of 1.14 M.O.M., an estriol value of 0.76 M.O.M., an inhibin value of 1.48 M.O.M., and an hCG value of 2.03 M.O.M. This decreased her age-related risk of fetal Down syndrome to a screen positive newly adjusted chance of 1:58.
MOM|multiples of median|M.O.M.|312|317|ASSESSMENT AND PLAN|We then reviewed the results of the maternal serum screen that _%#NAME#%_ had on _%#MMDD2006#%_ at 16 weeks and 5 days' gestation. Specifically, the resultant chemical values were as follows: an AFP value of 1.14 M.O.M., an estriol value of 0.76 M.O.M., an inhibin value of 1.48 M.O.M., and an hCG value of 2.03 M.O.M. This decreased her age-related risk of fetal Down syndrome to a screen positive newly adjusted chance of 1:58. The amniocentesis procedure was reviewed and explained as the only procedure available at this gestational age that is able to diagnose Down syndrome, as well as other numerical chromosome abnormalities in a pregnancy.
MOM|multiples of median|MOM|179|181|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.3 weeks gestation. The screen was within normal limits. o AFP=1.05 MOM o Estriol= 0.97 MOM o HCG= 1.03 MOM o DIA= 1.25 MOM * Adjusted risk for Down syndrome=1:826 * Adjusted risk for Trisomy 18=Not increased * Adjusted risk for ONTD=1:10,000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|178|180|G 2   P	1001				LMP|This was performed at Ob/Gyn Specialists. The first trimester screening was performed on _%#MMDD2007#%_. The screen indicated an increased risk for Down syndrome. o PAPP-A= 0.74 MOM o Free Beta= 1.71 MOM o NT=2.2mm * Adjusted risk for Down syndrome= 1:110 (abnormal) * Adjusted risk for Trisomy 18= 1:4473 (normal) Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|143|145|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.3 weeks gestation. The screen was within normal limits. o AFP=1.36 MOM o Estriol= 1.19 MOM o HCG= 1.36 MOM o DIA= 1.79 MOM * Adjusted risk for Down syndrome=1:1088 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=1:4033 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.3 weeks gestation. The screen was within normal limits. o AFP=1.36 MOM o Estriol= 1.19 MOM o HCG= 1.36 MOM o DIA= 1.79 MOM * Adjusted risk for Down syndrome=1:1088 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=1:4033 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.3 weeks gestation. The screen was within normal limits. o AFP=1.36 MOM o Estriol= 1.19 MOM o HCG= 1.36 MOM o DIA= 1.79 MOM * Adjusted risk for Down syndrome=1:1088 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=1:4033 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM.|189|192|G 2   P	1001				LMP|Your patient indicated that she did not wish to know the gender of her child and this information was withheld. The alpha-fetoprotein in the amniotic fluid was within normal limits at 1.02 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|multiples of median|MOM|163|165|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.9 weeks gestation. The screen was within normal limits. o AFP=1.25 MOM o Estriol= 1.70 MOM o HCG= 1.77 MOM o DIA= 1.24 MOM * Adjusted risk for Down syndrome=1:3648 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.9 weeks gestation. The screen was within normal limits. o AFP=1.25 MOM o Estriol= 1.70 MOM o HCG= 1.77 MOM o DIA= 1.24 MOM * Adjusted risk for Down syndrome=1:3648 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.9 weeks gestation. The screen was within normal limits. o AFP=1.25 MOM o Estriol= 1.70 MOM o HCG= 1.77 MOM o DIA= 1.24 MOM * Adjusted risk for Down syndrome=1:3648 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|143|145|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2005#%_. At the time, your patient was 15.7 weeks gestation. The screen was within normal limits. o AFP=1.24 MOM o Estriol= 0.90 MOM o HCG= 2.12 MOM o DIA= 1.12 MOM * Adjusted risk for Down syndrome=1:1742 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * _%#NAME#%_'s quad screen was calculated as if she did not have a personal or family history of spina bifida.
MOM|multiples of median|MOM|179|181|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2005#%_. At the time, your patient was 15.7 weeks gestation. The screen was within normal limits. o AFP=1.24 MOM o Estriol= 0.90 MOM o HCG= 2.12 MOM o DIA= 1.12 MOM * Adjusted risk for Down syndrome=1:1742 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * _%#NAME#%_'s quad screen was calculated as if she did not have a personal or family history of spina bifida.
MOM|multiples of median|MOM|164|166|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.14 weeks gestation. The screen was within normal limits. o AFP=0.94 MOM o Estriol= 1.26 MOM o HCG= 1.03 MOM o DIA= 0.93 MOM * Adjusted risk for Down syndrome=1:1400 * Adjusted risk for Trisomy 18=<1:10,000 * Adjusted risk for ONTD=<1:10,000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|180|182|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.14 weeks gestation. The screen was within normal limits. o AFP=0.94 MOM o Estriol= 1.26 MOM o HCG= 1.03 MOM o DIA= 0.93 MOM * Adjusted risk for Down syndrome=1:1400 * Adjusted risk for Trisomy 18=<1:10,000 * Adjusted risk for ONTD=<1:10,000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|196|198|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.14 weeks gestation. The screen was within normal limits. o AFP=0.94 MOM o Estriol= 1.26 MOM o HCG= 1.03 MOM o DIA= 0.93 MOM * Adjusted risk for Down syndrome=1:1400 * Adjusted risk for Trisomy 18=<1:10,000 * Adjusted risk for ONTD=<1:10,000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|164|166|G 1   P 0000				LMP|The serum screen was drawn _%#MMDD2006#%_. The results below are from the recalculated quad screen (using an EDC of _%#MMDD2006#%_). o AFP=2.72 MOM o Estriol= 0.71 MOM o HCG= 3.07 MOM o DIA= 2.11 MOM * Adjusted risk for Down syndrome=1:2600 * Adjusted risk for Trisomy 18=<1:10,000 * Adjusted risk for ONTD=1:170 Screen positive * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of open neural tube defects.
MOM|multiples of median|MOM|180|182|G 1   P 0000				LMP|The serum screen was drawn _%#MMDD2006#%_. The results below are from the recalculated quad screen (using an EDC of _%#MMDD2006#%_). o AFP=2.72 MOM o Estriol= 0.71 MOM o HCG= 3.07 MOM o DIA= 2.11 MOM * Adjusted risk for Down syndrome=1:2600 * Adjusted risk for Trisomy 18=<1:10,000 * Adjusted risk for ONTD=1:170 Screen positive * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of open neural tube defects.
MOM|multiples of median|MOM|196|198|G 1   P 0000				LMP|The serum screen was drawn _%#MMDD2006#%_. The results below are from the recalculated quad screen (using an EDC of _%#MMDD2006#%_). o AFP=2.72 MOM o Estriol= 0.71 MOM o HCG= 3.07 MOM o DIA= 2.11 MOM * Adjusted risk for Down syndrome=1:2600 * Adjusted risk for Trisomy 18=<1:10,000 * Adjusted risk for ONTD=1:170 Screen positive * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of open neural tube defects.
MOM|multiples of median|MOM).|201|205|G  3  P	1011				LMP|Your office provided results of this quad screen, which was positive for Down syndrome with a 1:102 risk. This risk was likely attributable to elevation of two serum markers (HCG=2.24 MOM and DIA=2.07 MOM). Evangeline reported that the night the quad screen was drawn, she became very ill and developed a fever of 103 degrees. This fever persisted, on and off, for approximately 1 week.
MOM|multiples of median|MOM,|362|365|G  3  P	1011				LMP|The history of the current pregnancy is reportedly unremarkable. There is no reported history of alcohol use, tobacco use, chemical exposure, x- rays, fevers, or other complications. The patient is currently taking prenatal vitamins. _%#NAME#%_'s maternal serum sample was obtained on _%#MMDD2006#%_ at 16.3 weeks' gestation and resulted in an AFP value of 5.79 MOM, an hCG value of 0.85 MOM, an estriol value of 0.37 MOM and a dimeric inhibin A value of 0.49 MOM. This adjusted the chance of Down syndrome in the pregnancy from an age-related risk of 1 in 1105 to a newly adjusted risk of 1 in 1255.
MOM|multiples of median|MOM|263|265|G 1   P	0000				LMP|o PAPP-A= 0.49 MOM o Free Beta= 0.83 MOM o NT=3.1 mm * Adjusted risk for Down syndrome= 1:433 * Adjusted risk for Trisomy 18= 1:2427 * A maternal serum AFP was drawn in your clinic on _%#MMDD2006#%_. At the time, your patient was 15.9 weeks gestation. o AFP=0.74 MOM * Adjusted risk for neural tube defects=<1:5000 We spent a great deal of time reviewing screening results to date.
MOM|multiples of median|MOM|126|128|G 3   P	2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15+5 weeks gestation. o AFP=0.63 MOM o Estriol= 0.77 MOM o HCG= 1.42 MOM o DIA= 1.43 MOM * Adjusted risk for Down syndrome=1:50 Screen Positive * Adjusted risk for Trisomy 18=<1:100 (normal) * Adjusted risk for ONTD=Screen negative * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|142|144|G 3   P	2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15+5 weeks gestation. o AFP=0.63 MOM o Estriol= 0.77 MOM o HCG= 1.42 MOM o DIA= 1.43 MOM * Adjusted risk for Down syndrome=1:50 Screen Positive * Adjusted risk for Trisomy 18=<1:100 (normal) * Adjusted risk for ONTD=Screen negative * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|158|160|G 3   P	2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15+5 weeks gestation. o AFP=0.63 MOM o Estriol= 0.77 MOM o HCG= 1.42 MOM o DIA= 1.43 MOM * Adjusted risk for Down syndrome=1:50 Screen Positive * Adjusted risk for Trisomy 18=<1:100 (normal) * Adjusted risk for ONTD=Screen negative * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM).|308|312|G 3   P	2002				LMP|Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2007. She came to clinic with her significant other, _%#NAME#%_ _%#NAME#%_, for genetic consultation regarding an elevated maternal serum alpha fetoprotein (2.58 MOM). Pregnancy History: G 1 P 0000 LMP: _%#MMDD2006#%_ Age: 27 EDC (LMP): _%#MMDD2007#%_ Age at Delivery: 27 EDC (U/S): Gestational Age: 19+5 weeks * No significant complications or exposures were reported that would clearly explain the elevated serum AFP.
MOM|multiples of median|MOM|232|234|G 1   P 0000				LMP|o Age mid trimester Down syndrome risk= 1:915 o Population risk for spina bifida=1:900 * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 18.4 weeks gestation. o AFP=2.58 MOM o Estriol= 0.96 MOM o HCG= 2.30 MOM o DIA= 0.54 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=1:247 Screen positive * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of open neural tube defects.
MOM|multiples of median|MOM|158|160|G 1   P 0000				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 18.4 weeks gestation. o AFP=2.58 MOM o Estriol= 0.96 MOM o HCG= 2.30 MOM o DIA= 0.54 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=1:247 Screen positive * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of open neural tube defects.
MOM|multiples of median|MOM|160|162|G 1   P 0000				LMP|She had stated that she thought she was not able to get pregnant, thus this pregnancy was an unexpected surprise. Her quad screen results were as follows: 1.54 MOM AFP, 0.52 MOM Estriol, 120.39 MOM HCG, and 10.29 MOM inhibin. Thus, this increased her chance for Down syndrome from her age-related risk of 1:35 to 3/4 or 75%.
MOM|multiples of median|MOM|251|253|G 2   P 1001				LMP|o Age mid trimester Down syndrome risk= 1:322 o Age mid trimester risk for any chromosome condition=1:160 * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.3 weeks gestation. o AFP=0.86 MOM o Estriol= 0.18 MOM o HCG= 2.05 MOM o DIA= 0.92 MOM * Adjusted risk for Down syndrome=1:69 Screen positive * Adjusted risk for Trisomy 18=1:657 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|158|160|G 2   P 1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.3 weeks gestation. o AFP=0.86 MOM o Estriol= 0.18 MOM o HCG= 2.05 MOM o DIA= 0.92 MOM * Adjusted risk for Down syndrome=1:69 Screen positive * Adjusted risk for Trisomy 18=1:657 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|144|146|G 3   P	1011				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.86 weeks gestation. The screen was within normal limits. o AFP=1.31 MOM o Estriol= 0.86 MOM o HCG= 1.69 MOM o DIA= 2.23 MOM * Adjusted risk for Down syndrome=1:820 * Adjusted risk for Trisomy 18=<1:10,000 * Adjusted risk for ONTD=1:6000 * We discussed the significance of the ultrasound findings of fetal intracardiac echogenic focus and bilateral pyelectasis.
MOM|multiples of median|MOM|196|198|G 3   P	1011				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.86 weeks gestation. The screen was within normal limits. o AFP=1.31 MOM o Estriol= 0.86 MOM o HCG= 1.69 MOM o DIA= 2.23 MOM * Adjusted risk for Down syndrome=1:820 * Adjusted risk for Trisomy 18=<1:10,000 * Adjusted risk for ONTD=1:6000 * We discussed the significance of the ultrasound findings of fetal intracardiac echogenic focus and bilateral pyelectasis.
MOM|multiples of median|MOM|143|145|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.1 weeks gestation. The screen was within normal limits. o AFP=0.58 MOM o Estriol= 0.59 MOM o HCG= 0.47 MOM o DIA= 0.51 MOM * Adjusted risk for Down syndrome=1:2549 * Adjusted risk for Trisomy 18=1:219 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.1 weeks gestation. The screen was within normal limits. o AFP=0.58 MOM o Estriol= 0.59 MOM o HCG= 0.47 MOM o DIA= 0.51 MOM * Adjusted risk for Down syndrome=1:2549 * Adjusted risk for Trisomy 18=1:219 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.1 weeks gestation. The screen was within normal limits. o AFP=0.58 MOM o Estriol= 0.59 MOM o HCG= 0.47 MOM o DIA= 0.51 MOM * Adjusted risk for Down syndrome=1:2549 * Adjusted risk for Trisomy 18=1:219 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|143|145|G 3   P	1011				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.0 weeks gestation. The screen was within normal limits. o AFP=1.58 MOM o Estriol= 1.34 MOM o HCG= 1.61 MOM o DIA= 1.11 MOM * Adjusted risk for Down syndrome=1:2212 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 3   P	1011				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.0 weeks gestation. The screen was within normal limits. o AFP=1.58 MOM o Estriol= 1.34 MOM o HCG= 1.61 MOM o DIA= 1.11 MOM * Adjusted risk for Down syndrome=1:2212 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|143|145|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.6 weeks gestation. The screen was within normal limits. o AFP=1.13 MOM o Estriol= 1.36 MOM o HCG= 0.90 MOM o DIA= 1.10 MOM * Adjusted risk for Down syndrome=1:1741 * Adjusted risk for Trisomy 18=Not increased * Adjusted risk for ONTD=1:8106 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.6 weeks gestation. The screen was within normal limits. o AFP=1.13 MOM o Estriol= 1.36 MOM o HCG= 0.90 MOM o DIA= 1.10 MOM * Adjusted risk for Down syndrome=1:1741 * Adjusted risk for Trisomy 18=Not increased * Adjusted risk for ONTD=1:8106 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 3   P	2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.9 weeks gestation. The screen was within normal limits. o AFP=0.89 MOM o Estriol= 1.00 MOM o HCG= 1.17 MOM o DIA= 1.32 MOM * Adjusted risk for Down syndrome=1:549 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 3   P	2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.9 weeks gestation. The screen was within normal limits. o AFP=0.89 MOM o Estriol= 1.00 MOM o HCG= 1.17 MOM o DIA= 1.32 MOM * Adjusted risk for Down syndrome=1:549 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 3   P	2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.9 weeks gestation. The screen was within normal limits. o AFP=0.89 MOM o Estriol= 1.00 MOM o HCG= 1.17 MOM o DIA= 1.32 MOM * Adjusted risk for Down syndrome=1:549 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|133|135|RE|She has not had an ultrasound yet with this pregnancy. We reviewed her abnormal quad screen which was as follows. 1.19 MOM AFP, 1.18 MOM HCG, 0.64 MOM estriol, and 2.43 MOM inhibin. Thus, this did not change her age-related risk of 1 in 110 and this risk after the screen was also 1 in 110 for Down's syndrome.
MOM|multiples of median|MOM|143|145|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.7 weeks gestation. The screen was within normal limits. o AFP=1.19 MOM o Estriol= 0.45 MOM o HCG= 0.98 MOM o DIA= 0.81 MOM * Adjusted risk for Down syndrome=1:318 * Adjusted risk for Trisomy 18=1:512 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.7 weeks gestation. The screen was within normal limits. o AFP=1.19 MOM o Estriol= 0.45 MOM o HCG= 0.98 MOM o DIA= 0.81 MOM * Adjusted risk for Down syndrome=1:318 * Adjusted risk for Trisomy 18=1:512 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.7 weeks gestation. The screen was within normal limits. o AFP=1.19 MOM o Estriol= 0.45 MOM o HCG= 0.98 MOM o DIA= 0.81 MOM * Adjusted risk for Down syndrome=1:318 * Adjusted risk for Trisomy 18=1:512 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|123|125|RE|She reports having some depression, and is currently on Zoloft. As you know, her quad screen results were as follows: 1.12 MOM AFP, 1.55 hCG MOM, 0.53 MOM estriol, and 2.27 MOM inhibin, which increased her chance to have a baby with Down syndrome from 1 in 857 to 1 in 162.
MOM|multiples of median|MOM.|180|183|RE|Your patient indicated that she wished to know the gender of her child and was given this information. The alpha-fetoprotein in the amniotic fluid was within normal limits at 0.70 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|multiples of median|MOM|192|194|G 2   P 0010				LMP|o Age mid trimester Down syndrome risk= 1:1169 * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.4 weeks gestation. o AFP=0.66 MOM o Estriol= 1.44 MOM o HCG= 2.76 MOM o DIA= 2.23 MOM * Adjusted risk for Down syndrome=1:123 Screen positive * Adjusted risk for Trisomy 18=not increased * Adjusted risk for ONTD=1:10,000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|126|128|G 2   P 0010				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.4 weeks gestation. o AFP=0.66 MOM o Estriol= 1.44 MOM o HCG= 2.76 MOM o DIA= 2.23 MOM * Adjusted risk for Down syndrome=1:123 Screen positive * Adjusted risk for Trisomy 18=not increased * Adjusted risk for ONTD=1:10,000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|142|144|G 2   P 0010				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.4 weeks gestation. o AFP=0.66 MOM o Estriol= 1.44 MOM o HCG= 2.76 MOM o DIA= 2.23 MOM * Adjusted risk for Down syndrome=1:123 Screen positive * Adjusted risk for Trisomy 18=not increased * Adjusted risk for ONTD=1:10,000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|158|160|G 2   P 0010				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.4 weeks gestation. o AFP=0.66 MOM o Estriol= 1.44 MOM o HCG= 2.76 MOM o DIA= 2.23 MOM * Adjusted risk for Down syndrome=1:123 Screen positive * Adjusted risk for Trisomy 18=not increased * Adjusted risk for ONTD=1:10,000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM.|180|183|G 2   P 0010				LMP|Your patient indicated that she wished to know the gender of her child and was given this information. The alpha-fetoprotein in the amniotic fluid was within normal limits at 0.79 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|multiples of median|MOM|143|145|G 4   P	1021				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.6 weeks gestation. The screen was within normal limits. o AFP=0.98 MOM o Estriol= 1.02 MOM o HCG= 1.15 MOM o DIA= 0.27 MOM * Adjusted risk for Down syndrome=1:2360 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 4   P	1021				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.6 weeks gestation. The screen was within normal limits. o AFP=0.98 MOM o Estriol= 1.02 MOM o HCG= 1.15 MOM o DIA= 0.27 MOM * Adjusted risk for Down syndrome=1:2360 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 4   P	1021				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.6 weeks gestation. The screen was within normal limits. o AFP=0.98 MOM o Estriol= 1.02 MOM o HCG= 1.15 MOM o DIA= 0.27 MOM * Adjusted risk for Down syndrome=1:2360 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 4   P	1021				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.6 weeks gestation. The screen was within normal limits. o AFP=0.98 MOM o Estriol= 1.02 MOM o HCG= 1.15 MOM o DIA= 0.27 MOM * Adjusted risk for Down syndrome=1:2360 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|251|253|G 3   P 2002				LMP|o Age mid trimester Down syndrome risk= 1:320 o Age mid trimester risk for any chromosome condition=1:160 * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.4 weeks gestation. o AFP=0.61 MOM o Estriol= 0.34 MOM o HCG= 0.81 MOM o DIA= 0.83 MOM * Adjusted risk for Down syndrome=1:503 * Adjusted risk for Trisomy 18=1:87 Screen positive * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of trisomy 18 in the current pregnancy.
MOM|multiples of median|MOM|126|128|G 3   P 2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.4 weeks gestation. o AFP=0.61 MOM o Estriol= 0.34 MOM o HCG= 0.81 MOM o DIA= 0.83 MOM * Adjusted risk for Down syndrome=1:503 * Adjusted risk for Trisomy 18=1:87 Screen positive * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of trisomy 18 in the current pregnancy.
MOM|multiples of median|MOM.|257|260|G 3   P 2002				LMP|We discussed that based on empiric studies, the recurrence risk for a second-degree relative to have spina bifida is thought to be approximately 1%. In addition, the patient had a maternal serum AFP drawn through your clinic that resulted in an AFP of 0.49 MOM. This reduced the patient's risk to have a baby with a neural tube defect to less than 1 in 5,000. We discussed the availability of a level II ultrasound to screen for spina bifida as well as other birth defects.
MOM|multiples of median|MOM|142|144|G 3   P 0020				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.1 weeks gestation. o AFP=0.95 MOM o Estriol= 1.00 MOM o HCG= 0.96 MOM o DIA= 1.53 MOM * Adjusted risk for Down syndrome=1:156 Screen positive * Adjusted risk for Trisomy 18=1:4382 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|158|160|G 3   P 0020				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.1 weeks gestation. o AFP=0.95 MOM o Estriol= 1.00 MOM o HCG= 0.96 MOM o DIA= 1.53 MOM * Adjusted risk for Down syndrome=1:156 Screen positive * Adjusted risk for Trisomy 18=1:4382 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM.|130|133|G 3   P 0020				LMP|Amniotic fluid AFP and Acetylcholinesterase results: The alpha-fetoprotein in the amniotic fluid was within normal limits at 0.69 MOM. This assay excludes approximately 98% of open neural tube defects. Acetylcholinesterase testing was performed due to _%#NAME#%_'s history of insulin dependent diabetes and _%#NAME#%_'s family history of spina bifida.
MOM|multiples of median|MOM,|180|183|IMPRESSION|We also discussed _%#NAME#%_'s maternal serum screen that was obtained on _%#MMDD2007#%_, at 15.7 weeks. This screen resulted in an AFP value of 1.28 MOM, an estriol value of 1.18 MOM, and inhibin value of 1.10 MOM and an hCG value of 0.38 MOM. This decreased the patient's chance of having a child with Down's syndrome from her age related chance to a newly adjusted chance of less than 1 in 5000.
MOM|multiples of median|MOM|211|213|IMPRESSION|We also discussed _%#NAME#%_'s maternal serum screen that was obtained on _%#MMDD2007#%_, at 15.7 weeks. This screen resulted in an AFP value of 1.28 MOM, an estriol value of 1.18 MOM, and inhibin value of 1.10 MOM and an hCG value of 0.38 MOM. This decreased the patient's chance of having a child with Down's syndrome from her age related chance to a newly adjusted chance of less than 1 in 5000.
MOM|multiples of median|MOM,|287|290|IMPRESSION|It was explained that low maternal AFP and estradiol levels, together with elevated hCG levels, indicate an increased risk of Down syndrome in a pregnancy. _%#NAME#%_'s' maternal serum sample was obtained on _%#MMDD2005#%_ at 15.57 weeks' gestation, and resulted in an AFP value of 0.79 MOM, an estriol value of 0.65 MOM, and a hCG value of 1.74 MOM. This increased the patient's chance of having a child with Down syndrome from her age-related risk of 1 in 470 (0.2%) to a newly adjusted chance of 1 in 120 (0.8%). The clinical features and genetics of Down syndrome were briefly reviewed with the couple.
MOM|multiples of median|MOM,|161|164|IMPRESSION|_%#NAME#%_'s' maternal serum sample was obtained on _%#MMDD2005#%_ at 15.57 weeks' gestation, and resulted in an AFP value of 0.79 MOM, an estriol value of 0.65 MOM, and a hCG value of 1.74 MOM. This increased the patient's chance of having a child with Down syndrome from her age-related risk of 1 in 470 (0.2%) to a newly adjusted chance of 1 in 120 (0.8%). The clinical features and genetics of Down syndrome were briefly reviewed with the couple.
MOM|multiples of median|MOM.|190|193|IMPRESSION|_%#NAME#%_'s' maternal serum sample was obtained on _%#MMDD2005#%_ at 15.57 weeks' gestation, and resulted in an AFP value of 0.79 MOM, an estriol value of 0.65 MOM, and a hCG value of 1.74 MOM. This increased the patient's chance of having a child with Down syndrome from her age-related risk of 1 in 470 (0.2%) to a newly adjusted chance of 1 in 120 (0.8%). The clinical features and genetics of Down syndrome were briefly reviewed with the couple.
MOM|multiples of median|MOM|143|145|G 4   P	2012				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.6 weeks gestation. The screen was within normal limits. o AFP=0.80 MOM o Estriol= 0.85 MOM o HCG= 1.23 MOM o DIA= 1.12 MOM * Adjusted risk for Down syndrome=1:610 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 4   P	2012				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.6 weeks gestation. The screen was within normal limits. o AFP=0.80 MOM o Estriol= 0.85 MOM o HCG= 1.23 MOM o DIA= 1.12 MOM * Adjusted risk for Down syndrome=1:610 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 4   P	2012				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.6 weeks gestation. The screen was within normal limits. o AFP=0.80 MOM o Estriol= 0.85 MOM o HCG= 1.23 MOM o DIA= 1.12 MOM * Adjusted risk for Down syndrome=1:610 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|143|145|G 3   P	2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.9 weeks gestation. The screen was within normal limits. o AFP=1.19 MOM o Estriol= 1.08 MOM o HCG= 0.94 MOM o DIA= 0.64 MOM * Adjusted risk for Down syndrome=1:3207 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 3   P	2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.9 weeks gestation. The screen was within normal limits. o AFP=1.19 MOM o Estriol= 1.08 MOM o HCG= 0.94 MOM o DIA= 0.64 MOM * Adjusted risk for Down syndrome=1:3207 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 3   P	2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.9 weeks gestation. The screen was within normal limits. o AFP=1.19 MOM o Estriol= 1.08 MOM o HCG= 0.94 MOM o DIA= 0.64 MOM * Adjusted risk for Down syndrome=1:3207 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|191|193|G 3   P 2002				LMP|o Age mid trimester Down syndrome risk= 1:668 * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.3 weeks gestation. o AFP=0.41 MOM o Estriol= 0.49 MOM o HCG= 2.22 MOM o DIA= 0.76 MOM * Adjusted risk for Down syndrome=1:74 Screen positive * Adjusted risk for Trisomy 18=1:2351 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|126|128|G 3   P 2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.3 weeks gestation. o AFP=0.41 MOM o Estriol= 0.49 MOM o HCG= 2.22 MOM o DIA= 0.76 MOM * Adjusted risk for Down syndrome=1:74 Screen positive * Adjusted risk for Trisomy 18=1:2351 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|142|144|G 3   P 2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.3 weeks gestation. o AFP=0.41 MOM o Estriol= 0.49 MOM o HCG= 2.22 MOM o DIA= 0.76 MOM * Adjusted risk for Down syndrome=1:74 Screen positive * Adjusted risk for Trisomy 18=1:2351 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|158|160|G 3   P 2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.3 weeks gestation. o AFP=0.41 MOM o Estriol= 0.49 MOM o HCG= 2.22 MOM o DIA= 0.76 MOM * Adjusted risk for Down syndrome=1:74 Screen positive * Adjusted risk for Trisomy 18=1:2351 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|124|126|G 2   P 1001				LMP|The serum screen was drawn _%#MMDD2005#%_. At the time, your patient was 15 weeks gestation. o AFP=0.79 MOM o Estriol= 1.48 MOM o HCG= 1.20 MOM o DIA= 1.27 MOM * Adjusted risk for Down syndrome=1:202 Screen positive * Adjusted risk for Trisomy 18=1:4614 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|140|142|G 2   P 1001				LMP|The serum screen was drawn _%#MMDD2005#%_. At the time, your patient was 15 weeks gestation. o AFP=0.79 MOM o Estriol= 1.48 MOM o HCG= 1.20 MOM o DIA= 1.27 MOM * Adjusted risk for Down syndrome=1:202 Screen positive * Adjusted risk for Trisomy 18=1:4614 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|156|158|G 2   P 1001				LMP|The serum screen was drawn _%#MMDD2005#%_. At the time, your patient was 15 weeks gestation. o AFP=0.79 MOM o Estriol= 1.48 MOM o HCG= 1.20 MOM o DIA= 1.27 MOM * Adjusted risk for Down syndrome=1:202 Screen positive * Adjusted risk for Trisomy 18=1:4614 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM,|244|247|RE|It was explained that high AFP indicates an increased risk of neural tube defects in the pregnancy. _%#NAME#%_'s maternal serum screen sample was obtained on _%#MM#%_ _%#DD#%_, 2007, at 15.4 weeks gestation and resulted in an AFP value of 4.68 MOM, estriol value of 1.65 MOM, and inhibin value of 2.95 MOM and an HCG value of 4.63 MOM. This increased the patient's chance of having a child with neural tube defects; however, the actual risk was not calculated.
MOM|multiples of median|MOM,|271|274|RE|It was explained that high AFP indicates an increased risk of neural tube defects in the pregnancy. _%#NAME#%_'s maternal serum screen sample was obtained on _%#MM#%_ _%#DD#%_, 2007, at 15.4 weeks gestation and resulted in an AFP value of 4.68 MOM, estriol value of 1.65 MOM, and inhibin value of 2.95 MOM and an HCG value of 4.63 MOM. This increased the patient's chance of having a child with neural tube defects; however, the actual risk was not calculated.
MOM|multiples of median|MOM|202|204|RE|_%#NAME#%_'s maternal serum screen sample was obtained on _%#MM#%_ _%#DD#%_, 2007, at 15.4 weeks gestation and resulted in an AFP value of 4.68 MOM, estriol value of 1.65 MOM, and inhibin value of 2.95 MOM and an HCG value of 4.63 MOM. This increased the patient's chance of having a child with neural tube defects; however, the actual risk was not calculated.
MOM|milk of magnesia|MOM|173|175|CURRENT MEDICATIONS|HABITS: She is a half pack-per-day smoker. She denies alcohol or drug use. ALLERGIES: None. CURRENT MEDICATIONS: Comfort medications only including nicotine patch, Tylenol, MOM and Maalox . After admission, the patient was started on Nortriptyline q.h.s. She also takes diltiazem CD 180 mg q.d.
MOM|multiples of median|MOM|143|145|G 4  P	1021				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.3 weeks gestation. The screen was within normal limits. o AFP=1.10 MOM * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 3   P	0020				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.3 weeks gestation. The screen was within normal limits. o AFP=1.51 MOM o Estriol= 1.11 MOM o HCG= 0.80 MOM o DIA= 0.98 MOM * Adjusted risk for Down syndrome=1:3812 * Adjusted risk for Trisomy 18=not increased * Adjusted risk for ONTD=1:2661 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 3   P	0020				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.3 weeks gestation. The screen was within normal limits. o AFP=1.51 MOM o Estriol= 1.11 MOM o HCG= 0.80 MOM o DIA= 0.98 MOM * Adjusted risk for Down syndrome=1:3812 * Adjusted risk for Trisomy 18=not increased * Adjusted risk for ONTD=1:2661 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|151|153|G 3   P	0020				LMP|The serum screen was drawn _%#MM#%_ _%#DD2007#%_. At the time, your patient was 15.86 weeks gestation. The screen was within normal limits. o AFP=0.67 MOM o Estriol= 0.79 MOM o HCG= 1.09 MOM o DIA= 0.94 MOM * Adjusted risk for Down syndrome=1:850 * Adjusted risk for Trisomy 18=<1:10,000 * Adjusted risk for ONTD=<1:10,000 * We discussed the significance of the EIF, which was verified by today's ultrasound.
MOM|multiples of median|MOM|143|145|G 1   P 0000				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.86 weeks gestation. o AFP=0.73 MOM o Estriol= 0.77 MOM o HCG= 2.39 MOM o DIA= 1.67 MOM * Adjusted risk for Down syndrome=1:90 Screen positive * Adjusted risk for Trisomy 18=<1:10,000 * Adjusted risk for ONTD=<1:10,000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|143|145|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.9 weeks gestation. The screen was within normal limits. o AFP=1.50 MOM o Estriol= 0.74 MOM o HCG= 1.33 MOM o DIA= 0.73 MOM * Adjusted risk for Down syndrome=1:542 * Adjusted risk for Trisomy 18=1:4268 * Adjusted risk for ONTD=1:2733 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.9 weeks gestation. The screen was within normal limits. o AFP=1.50 MOM o Estriol= 0.74 MOM o HCG= 1.33 MOM o DIA= 0.73 MOM * Adjusted risk for Down syndrome=1:542 * Adjusted risk for Trisomy 18=1:4268 * Adjusted risk for ONTD=1:2733 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.9 weeks gestation. The screen was within normal limits. o AFP=1.50 MOM o Estriol= 0.74 MOM o HCG= 1.33 MOM o DIA= 0.73 MOM * Adjusted risk for Down syndrome=1:542 * Adjusted risk for Trisomy 18=1:4268 * Adjusted risk for ONTD=1:2733 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM.|189|192|PLAN|Your patient indicated that she did not wish to know the gender of her child and this information was withheld. The alpha-fetoprotein in the amniotic fluid was within normal limits at 1.34 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|multiples of median|MOM|195|197|PLAN|Your patient indicated that she wished to know the gender of her child and was given this information. The alpha-fetoprotein in the amniotic fluid was within normal limits for both twins at 0.90 MOM and 1.00 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|multiples of median|MOM|163|165|G 4   P	2012				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.3 weeks gestation. The screen was within normal limits. o AFP=0.83 MOM o Estriol= 0.96 MOM o HCG= 0.88 MOM o DIA= 0.79 MOM * Adjusted risk for Down syndrome=1:3019 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 4   P	2012				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.3 weeks gestation. The screen was within normal limits. o AFP=0.83 MOM o Estriol= 0.96 MOM o HCG= 0.88 MOM o DIA= 0.79 MOM * Adjusted risk for Down syndrome=1:3019 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 4   P	2012				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.3 weeks gestation. The screen was within normal limits. o AFP=0.83 MOM o Estriol= 0.96 MOM o HCG= 0.88 MOM o DIA= 0.79 MOM * Adjusted risk for Down syndrome=1:3019 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM.|164|167|G 4   P	2012				LMP|The focus of our discussion was the patient's AFP result. As you know, the patient had a maternal serum AFP drawn on _%#MMDD2006#%_ that resulted in an AFP of 3.81 MOM. Based on this the patient was placed at increased risk for fetal neural tube defects. This risk was estimated as 1 in 34 as reported by Lab One Laboratories.
MOM|multiples of median|MOM.|180|183|IN SUMMARY|Your patient indicated that she wished to know the gender of her child and was given this information. The alpha-fetoprotein in the amniotic fluid was within normal limits at 1.03 MOM. This assay excludes approximately 98% of open neural tube defects. At _%#NAME#%_'s request, a copy of her amniocentesis results was forwarded to the Reproductive Medicine Institute in New Jersey.
MOM|multiples of median|MOM|143|145|G 3   P	1011				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 18.4 weeks gestation. The screen was within normal limits. o AFP=1.09 MOM o Estriol= 1.15 MOM o HCG= 0.95 MOM o DIA= 0.81 MOM * Adjusted risk for Down syndrome=1:4021 * Adjusted risk for Trisomy 18=1:24854 * Adjusted risk for ONTD=1:9300 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 3   P	1011				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 18.4 weeks gestation. The screen was within normal limits. o AFP=1.09 MOM o Estriol= 1.15 MOM o HCG= 0.95 MOM o DIA= 0.81 MOM * Adjusted risk for Down syndrome=1:4021 * Adjusted risk for Trisomy 18=1:24854 * Adjusted risk for ONTD=1:9300 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 3   P	1011				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 18.4 weeks gestation. The screen was within normal limits. o AFP=1.09 MOM o Estriol= 1.15 MOM o HCG= 0.95 MOM o DIA= 0.81 MOM * Adjusted risk for Down syndrome=1:4021 * Adjusted risk for Trisomy 18=1:24854 * Adjusted risk for ONTD=1:9300 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|191|193|G 2   P 1001				LMP|o Age mid trimester Down syndrome risk= 1:311 * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.1 weeks gestation. o AFP=0.72 MOM o Estriol= 0.29 MOM o HCG= 1.61 MOM o DIA= 1.82 MOM * Adjusted risk for Down syndrome=1:28 Screen positive * Adjusted risk for Trisomy 18=1:419 * Adjusted risk for ONTD=<1:5000 * _%#NAME#%_ subsequently had a normal amniocentesis through your office and we reviewed these results today.
MOM|multiples of median|MOM|126|128|G 2   P 1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.1 weeks gestation. o AFP=0.72 MOM o Estriol= 0.29 MOM o HCG= 1.61 MOM o DIA= 1.82 MOM * Adjusted risk for Down syndrome=1:28 Screen positive * Adjusted risk for Trisomy 18=1:419 * Adjusted risk for ONTD=<1:5000 * _%#NAME#%_ subsequently had a normal amniocentesis through your office and we reviewed these results today.
MOM|multiples of median|MOM|142|144|G 2   P 1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.1 weeks gestation. o AFP=0.72 MOM o Estriol= 0.29 MOM o HCG= 1.61 MOM o DIA= 1.82 MOM * Adjusted risk for Down syndrome=1:28 Screen positive * Adjusted risk for Trisomy 18=1:419 * Adjusted risk for ONTD=<1:5000 * _%#NAME#%_ subsequently had a normal amniocentesis through your office and we reviewed these results today.
MOM|multiples of median|MOM|143|145|G 2   P	0010				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.6 weeks gestation. The screen was within normal limits. o AFP=0.95 MOM o Estriol= 0.78 MOM o HCG= 0.57 MOM o DIA= 0.46 MOM * Adjusted risk for Down syndrome=1:3234 * Adjusted risk for Trisomy 18=1:2591 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 2   P	0010				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.6 weeks gestation. The screen was within normal limits. o AFP=0.95 MOM o Estriol= 0.78 MOM o HCG= 0.57 MOM o DIA= 0.46 MOM * Adjusted risk for Down syndrome=1:3234 * Adjusted risk for Trisomy 18=1:2591 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 2   P	0010				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.6 weeks gestation. The screen was within normal limits. o AFP=0.95 MOM o Estriol= 0.78 MOM o HCG= 0.57 MOM o DIA= 0.46 MOM * Adjusted risk for Down syndrome=1:3234 * Adjusted risk for Trisomy 18=1:2591 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM,|242|245|G 2   P	0010				LMP|As stated earlier, the patient had an ultrasound performed at your Altru Health Clinic, given an abnormal quad screen. Specifically, the patient had a quad screen drawn through your clinic on _%#MM#%_ _%#DD#%_ that resulted in an AFP of 0.90 MOM, an HCG of 3.23 MOM, an estriol of 0.64 MOM, and an inhibin of 5.19 MOM. This increased her risk to have a baby with Down's syndrome to 1 in 4.
MOM|multiples of median|MOM,|143|146|G 2   P	0010				LMP|Specifically, the patient had a quad screen drawn through your clinic on _%#MM#%_ _%#DD#%_ that resulted in an AFP of 0.90 MOM, an HCG of 3.23 MOM, an estriol of 0.64 MOM, and an inhibin of 5.19 MOM. This increased her risk to have a baby with Down's syndrome to 1 in 4.
MOM|multiples of median|MOM,|167|170|G 2   P	0010				LMP|Specifically, the patient had a quad screen drawn through your clinic on _%#MM#%_ _%#DD#%_ that resulted in an AFP of 0.90 MOM, an HCG of 3.23 MOM, an estriol of 0.64 MOM, and an inhibin of 5.19 MOM. This increased her risk to have a baby with Down's syndrome to 1 in 4. Based on this information, the patient had an ultrasound performed at Altru clinic.
MOM|multiples of median|MOM.|180|183|G 2   P	0010				LMP|Your patient indicated that she wished to know the gender of her child and was given this information. The alpha-fetoprotein in the amniotic fluid was within normal limits at 1.17 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|multiples of median|MOM|249|251|G 3   P 1011				LMP|o Age mid trimester Down syndrome risk= 1:65 o Age mid trimester risk for any chromosome condition=1:31 * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.4 weeks gestation. o AFP=1.04 MOM o Estriol= 0.74 MOM o HCG= 1.59 MOM o DIA= 1.10 MOM * Adjusted risk for Down syndrome=1:133 Screen positive * Adjusted risk for Trisomy 18=1:3528 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|126|128|G 3   P 1011				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.4 weeks gestation. o AFP=1.04 MOM o Estriol= 0.74 MOM o HCG= 1.59 MOM o DIA= 1.10 MOM * Adjusted risk for Down syndrome=1:133 Screen positive * Adjusted risk for Trisomy 18=1:3528 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|142|144|G 3   P 1011				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.4 weeks gestation. o AFP=1.04 MOM o Estriol= 0.74 MOM o HCG= 1.59 MOM o DIA= 1.10 MOM * Adjusted risk for Down syndrome=1:133 Screen positive * Adjusted risk for Trisomy 18=1:3528 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|158|160|G 3   P 1011				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.4 weeks gestation. o AFP=1.04 MOM o Estriol= 0.74 MOM o HCG= 1.59 MOM o DIA= 1.10 MOM * Adjusted risk for Down syndrome=1:133 Screen positive * Adjusted risk for Trisomy 18=1:3528 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|milk of magnesia|MOM|153|155|MEDICATIONS|11. Glyburide. 12. Niacin. 13. Multivitamin. 14. Senokot. 15. Phenergan p.r.n. 16. Zofran p.r.n. 17. Fish oil b.i.d. 18. Dulcolax suppository p.r.n. 19. MOM p.r.n. SOCIAL HISTORY: Ms. _%#NAME#%_ lives with her significant other of 20 years, _%#NAME#%_.
MOM|multiples of median|MOM.|228|231|TIME FOR CONSULTATION|I have left messages indicating that the results are normal and that I would like them to contact me to confirm that they have received these results. The alpha-fetoprotein in the amniotic fluid was within normal limits at 0.79 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|multiples of median|MOM|143|145|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.3 weeks gestation. The screen was within normal limits. o AFP=0.85 MOM o Estriol= 1.69 MOM o HCG= 1.28 MOM o DIA= 1.30 MOM * Adjusted risk for Down syndrome=1:519 * Adjusted risk for Trisomy 18=not increased * Adjusted risk for ONTD=<1:10,000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.3 weeks gestation. The screen was within normal limits. o AFP=0.85 MOM o Estriol= 1.69 MOM o HCG= 1.28 MOM o DIA= 1.30 MOM * Adjusted risk for Down syndrome=1:519 * Adjusted risk for Trisomy 18=not increased * Adjusted risk for ONTD=<1:10,000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.3 weeks gestation. The screen was within normal limits. o AFP=0.85 MOM o Estriol= 1.69 MOM o HCG= 1.28 MOM o DIA= 1.30 MOM * Adjusted risk for Down syndrome=1:519 * Adjusted risk for Trisomy 18=not increased * Adjusted risk for ONTD=<1:10,000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|191|193|G 2   P 0010				LMP|o Age mid trimester Down syndrome risk= 1:399 * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15+3 weeks gestation. o AFP=0.58 MOM o Estriol= 0.58 MOM o HCG= 1.83 MOM o DIA= 1.06 MOM * Adjusted risk for Down syndrome=1:102 Screen positive * Adjusted risk for Trisomy 18=1:4743 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|126|128|G 2   P 0010				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15+3 weeks gestation. o AFP=0.58 MOM o Estriol= 0.58 MOM o HCG= 1.83 MOM o DIA= 1.06 MOM * Adjusted risk for Down syndrome=1:102 Screen positive * Adjusted risk for Trisomy 18=1:4743 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|142|144|G 2   P 0010				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15+3 weeks gestation. o AFP=0.58 MOM o Estriol= 0.58 MOM o HCG= 1.83 MOM o DIA= 1.06 MOM * Adjusted risk for Down syndrome=1:102 Screen positive * Adjusted risk for Trisomy 18=1:4743 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|158|160|G 2   P 0010				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15+3 weeks gestation. o AFP=0.58 MOM o Estriol= 0.58 MOM o HCG= 1.83 MOM o DIA= 1.06 MOM * Adjusted risk for Down syndrome=1:102 Screen positive * Adjusted risk for Trisomy 18=1:4743 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|195|197|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 14.9 weeks gestation. The screen was within normal limits. o AFP=0.71 MOM o Estriol= 0.68 MOM o HCG= 0.49 MOM o DIA= 0.37 MOM * Adjusted risk for Down syndrome=1:3029 * Adjusted risk for Trisomy 18=1:522 * Adjusted risk for ONTD=not calculated o We discussed the fact that the risk for open spina bifida was not provided as the laboratory indicated that _%#NAME#%_ was less than 15 weeks gestation at the time of the screen.
MOM|multiples of median|MOM|194|196|G 3   P 2002				LMP|o Age mid trimester Down syndrome risk= <1:1000 * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.3 week's gestation. o AFP=3.02 MOM o Estriol= 2.68 MOM o HCG= 0.6 MOM o DIA= 0.8 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=1:114 Screen positive * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of open neural tube defects.
MOM|multiples of median|MOM|142|144|G 3   P 2002				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.3 week's gestation. o AFP=3.02 MOM o Estriol= 2.68 MOM o HCG= 0.6 MOM o DIA= 0.8 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=1:114 Screen positive * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of open neural tube defects.
MOM|multiples of median|MOM|157|159|G 3   P 2002				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.3 week's gestation. o AFP=3.02 MOM o Estriol= 2.68 MOM o HCG= 0.6 MOM o DIA= 0.8 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=1:114 Screen positive * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of open neural tube defects.
MOM|multiples of median|MOM|141|143|G 6   P 5005				LMP|The quad screen results were calculated using _%#NAME#%_'s legal birthdate in order to determine her a priori Down syndrome risk. o AFP=1.02 MOM o Estriol= 0.86 MOM o HCG= 1.75 MOM o DIA= 1.11 MOM * Adjusted risk for Down syndrome=1:270 Screen positive * Adjusted risk for Trisomy 18=<1:100 * Adjusted risk for ONTD=screen normal * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|161|163|G 6   P 5005				LMP|The quad screen results were calculated using _%#NAME#%_'s legal birthdate in order to determine her a priori Down syndrome risk. o AFP=1.02 MOM o Estriol= 0.86 MOM o HCG= 1.75 MOM o DIA= 1.11 MOM * Adjusted risk for Down syndrome=1:270 Screen positive * Adjusted risk for Trisomy 18=<1:100 * Adjusted risk for ONTD=screen normal * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|193|195|G 6   P 5005				LMP|The quad screen results were calculated using _%#NAME#%_'s legal birthdate in order to determine her a priori Down syndrome risk. o AFP=1.02 MOM o Estriol= 0.86 MOM o HCG= 1.75 MOM o DIA= 1.11 MOM * Adjusted risk for Down syndrome=1:270 Screen positive * Adjusted risk for Trisomy 18=<1:100 * Adjusted risk for ONTD=screen normal * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|161|163|G 2   P	0010				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16 weeks gestation. The screen was within normal limits. o AFP=0.85 MOM o Estriol= 1.98 MOM o HCG= 0.67 MOM o DIA= 1.07 MOM * Adjusted risk for Down syndrome=1:4866 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|177|179|G 2   P	0010				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16 weeks gestation. The screen was within normal limits. o AFP=0.85 MOM o Estriol= 1.98 MOM o HCG= 0.67 MOM o DIA= 1.07 MOM * Adjusted risk for Down syndrome=1:4866 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|193|195|G 2   P	0010				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16 weeks gestation. The screen was within normal limits. o AFP=0.85 MOM o Estriol= 1.98 MOM o HCG= 0.67 MOM o DIA= 1.07 MOM * Adjusted risk for Down syndrome=1:4866 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|155|157|G 2   P	0010				LMP|She has not had an ultrasound as of yet. We reviewed her quad screen results, which were as follows: 1.13 MoM AFP, 3.04 MoM hCG, 1.47 MoM estriol and 4.44 MOM inhibin. This increased her chance to have a baby with Down syndrome from 1 in 639 to 1 in 150. Examples and features of Down syndrome were reviewed, as well as other possible reasons for this abnormal screen including normal variation, incorrect gestation date twins, or a baby with Down syndrome.
MOM|multiples of median|MOM|191|193|G 2   P 1001				LMP|o Age mid trimester Down syndrome risk= 1:504 * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.1 weeks gestation. o AFP=0.79 MOM o Estriol= 0.34 MOM o HCG= 1.52 MOM o DIA= 1.11 MOM * Adjusted risk for Down syndrome=1:114 Screen positive * Adjusted risk for Trisomy 18=1:658 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|142|144|G 2   P 1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.1 weeks gestation. o AFP=0.79 MOM o Estriol= 0.34 MOM o HCG= 1.52 MOM o DIA= 1.11 MOM * Adjusted risk for Down syndrome=1:114 Screen positive * Adjusted risk for Trisomy 18=1:658 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM.|180|183|ADDENDUM 7-6-2007-FISH RESULTS|Your patient indicated that she wished to know the gender of her child and was given this information. The alpha-fetoprotein in the amniotic fluid was within normal limits at 0.70 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|multiples of median|MOM|143|145|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.4 weeks gestation. The screen was within normal limits. o AFP=0.75 MOM o Estriol= 0.74 MOM o HCG= 0.88 MOM o DIA= 0.41 MOM * Adjusted risk for Down syndrome=1:4265 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * The screen incorrectly indicated that there was no family history of spina bifida, which may have resulted in an under-estimation of risk for spina bifida by the serum screen.
MOM|multiples of median|MOM|163|165|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.4 weeks gestation. The screen was within normal limits. o AFP=0.75 MOM o Estriol= 0.74 MOM o HCG= 0.88 MOM o DIA= 0.41 MOM * Adjusted risk for Down syndrome=1:4265 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * The screen incorrectly indicated that there was no family history of spina bifida, which may have resulted in an under-estimation of risk for spina bifida by the serum screen.
MOM|multiples of median|MOM|179|181|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.4 weeks gestation. The screen was within normal limits. o AFP=0.75 MOM o Estriol= 0.74 MOM o HCG= 0.88 MOM o DIA= 0.41 MOM * Adjusted risk for Down syndrome=1:4265 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * The screen incorrectly indicated that there was no family history of spina bifida, which may have resulted in an under-estimation of risk for spina bifida by the serum screen.
MOM|multiples of median|MOM|195|197|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.4 weeks gestation. The screen was within normal limits. o AFP=0.75 MOM o Estriol= 0.74 MOM o HCG= 0.88 MOM o DIA= 0.41 MOM * Adjusted risk for Down syndrome=1:4265 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * The screen incorrectly indicated that there was no family history of spina bifida, which may have resulted in an under-estimation of risk for spina bifida by the serum screen.
MOM|multiples of median|MOM|177|179|PLAN|The focus of our discussion was the patient's triple screen results. The patient had a triple screen drawn through your clinic on _%#MMDD2006#%_ that resulted in an AFP of 0.67 MOM and hCG of 1.71 MOM and an estriol of 0.39 MOM. This increased her risk to have a baby with Down syndrome from 1:1130 to 1:128.
MOM|multiples of median|MOM.|180|183|IMPRESSION|Your patient indicated that she wished to know the gender of her child and was given this information. The alpha-fetoprotein in the amniotic fluid was within normal limits at 0.97 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|multiples of median|M.O.M.,|202|208|IMPRESSION|We then went on to review the results of the quad screen that _%#NAME#%_ _%#NAME#%_ had on _%#MMDD2006#%_ at 16 weeks' gestation. Specifically, the chemical values were as follows: an AFP value of 1.21 M.O.M., an hCG value of 0.6 M.O.M., an estriol value of 1.02 M.O.M., and a dimeric inhibin A value of 0.76 M.O.M. These results reduced her age-related chance of Down syndrome of 1:150 to a newly adjusted risk of 1:4956.
MOM|multiples of median|M.O.M.,|230|236|IMPRESSION|We then went on to review the results of the quad screen that _%#NAME#%_ _%#NAME#%_ had on _%#MMDD2006#%_ at 16 weeks' gestation. Specifically, the chemical values were as follows: an AFP value of 1.21 M.O.M., an hCG value of 0.6 M.O.M., an estriol value of 1.02 M.O.M., and a dimeric inhibin A value of 0.76 M.O.M. These results reduced her age-related chance of Down syndrome of 1:150 to a newly adjusted risk of 1:4956.
MOM|multiples of median|MOM|143|145|G 2   P	2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.1 weeks gestation. The screen was within normal limits. o AFP=0.97 MOM o Estriol= 1.12 MOM o HCG= 0.40 MOM o DIA= 0.48 MOM * Adjusted risk for Down syndrome=1:5000 * Adjusted risk for Trisomy 18=1:2862 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 2   P	2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.1 weeks gestation. The screen was within normal limits. o AFP=0.97 MOM o Estriol= 1.12 MOM o HCG= 0.40 MOM o DIA= 0.48 MOM * Adjusted risk for Down syndrome=1:5000 * Adjusted risk for Trisomy 18=1:2862 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 2   P	2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.1 weeks gestation. The screen was within normal limits. o AFP=0.97 MOM o Estriol= 1.12 MOM o HCG= 0.40 MOM o DIA= 0.48 MOM * Adjusted risk for Down syndrome=1:5000 * Adjusted risk for Trisomy 18=1:2862 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.9 weeks gestation. The screen was within normal limits. o AFP=1.27 MOM o Estriol= 2.33 MOM o HCG= 0.84 MOM o DIA= 0.38 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|178|180|G 3   P	1011				LMP|I contacted Quest Diagnostics and had them recalculate the quad screen using the correct EDC of _%#MMDD2007#%_. Results of the recalculated screen are reported below. o AFP=1.32 MOM o Estriol= 1.35MOM o HCG= 1.21 MOM o DIA= 0.98 MOM * Adjusted risk for Down syndrome=1:1640 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:4528 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|229|231|G 3   P	1011				LMP|I contacted Quest Diagnostics and had them recalculate the quad screen using the correct EDC of _%#MMDD2007#%_. Results of the recalculated screen are reported below. o AFP=1.32 MOM o Estriol= 1.35MOM o HCG= 1.21 MOM o DIA= 0.98 MOM * Adjusted risk for Down syndrome=1:1640 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:4528 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM,|306|309|G 3   P	1011				LMP|It was explained that low maternal AFP and estriol levels, together with elevated hCG and dimeric inhibin A values, indicate an increased risk of Down syndrome in a pregnancy. _%#NAME#%_'s maternal serum sample was obtained on _%#MMDD2005#%_ at 16.57 weeks' gestation, and resulted in an AFP value of 0.55 MOM, an estriol value of 0.95 MOM, an hCG value of 2.73 MOM, and an inhibin value of 2.69 MOM. This increased the patient's risk of having a child with Down syndrome from her age-related risk of 1 in 790 to a newly adjusted risk of 1 in 10.
MOM|multiples of median|MOM,|336|339|G 3   P	1011				LMP|It was explained that low maternal AFP and estriol levels, together with elevated hCG and dimeric inhibin A values, indicate an increased risk of Down syndrome in a pregnancy. _%#NAME#%_'s maternal serum sample was obtained on _%#MMDD2005#%_ at 16.57 weeks' gestation, and resulted in an AFP value of 0.55 MOM, an estriol value of 0.95 MOM, an hCG value of 2.73 MOM, and an inhibin value of 2.69 MOM. This increased the patient's risk of having a child with Down syndrome from her age-related risk of 1 in 790 to a newly adjusted risk of 1 in 10.
MOM|multiples of median|MOM,|186|189|G 3   P	1011				LMP|_%#NAME#%_'s maternal serum sample was obtained on _%#MMDD2005#%_ at 16.57 weeks' gestation, and resulted in an AFP value of 0.55 MOM, an estriol value of 0.95 MOM, an hCG value of 2.73 MOM, and an inhibin value of 2.69 MOM. This increased the patient's risk of having a child with Down syndrome from her age-related risk of 1 in 790 to a newly adjusted risk of 1 in 10.
MOM|multiples of median|MOM|124|126|G 2   P 0010				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16 weeks gestation. o AFP=0.78 MOM o Estriol= 0.12 MOM o HCG= 2.13 MOM o DIA= 0.89 MOM * Adjusted risk for Down syndrome=1:110 Screen positive * Adjusted risk for Trisomy 18=1:630 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|140|142|G 2   P 0010				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16 weeks gestation. o AFP=0.78 MOM o Estriol= 0.12 MOM o HCG= 2.13 MOM o DIA= 0.89 MOM * Adjusted risk for Down syndrome=1:110 Screen positive * Adjusted risk for Trisomy 18=1:630 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM,|207|210|G 2   P 0010				LMP|Based on this new due date her quad screen was recalculated by your clinic and again came back at increased risk for neural tube defects. Specifically, the patient had an elevated maternal serum AFP of 2.64 MOM, which increased her risk to 1:190 for neural tube defects. The patient was referred for genetic counseling to discuss the following abnormal maternal serum AFP results as well as in conjunction with her normal level 2 ultrasound.
MOM|milk of magnesia|MOM.|181|184|MEDICATIONS|6. Status post TIPS in _%#MM2002#%_. 7. History of pancytopenia. ALLERGIES: She has allergies to Phenergan, Imitrex, spironolactone, contrast, Rocephin, and versed. MEDICATIONS: 1. MOM. 2. Reglan. 3. Senokot. 4. Robitussin. 5. Zofran. 6. Tylenol. 7. Vicodin p.r.n. 8. Dapsone. 9. Levaquin. 10. Lantus insulin sliding scale. 11. Albuterol. FUNCTIONAL SOCIAL HISTORY: This has been covered in the HPI.
MOM|multiples of median|MOM|143|145|G  1  P 0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.9 weeks gestation. The screen was within normal limits. o AFP=1.26 MOM o Estriol= 0.89 MOM o HCG= 0.89 MOM o DIA= 0.53 MOM * Adjusted risk for Down syndrome=1:3925 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G  1  P 0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.9 weeks gestation. The screen was within normal limits. o AFP=1.26 MOM o Estriol= 0.89 MOM o HCG= 0.89 MOM o DIA= 0.53 MOM * Adjusted risk for Down syndrome=1:3925 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G  1  P 0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.9 weeks gestation. The screen was within normal limits. o AFP=1.26 MOM o Estriol= 0.89 MOM o HCG= 0.89 MOM o DIA= 0.53 MOM * Adjusted risk for Down syndrome=1:3925 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|143|145|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.7 weeks gestation. The screen was within normal limits. o AFP=1.14 MOM o Estriol= 1.75 MOM o HCG= 0.72 MOM o DIA= 1.12 MOM * Adjusted risk for Down syndrome=1:2570 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.7 weeks gestation. The screen was within normal limits. o AFP=1.14 MOM o Estriol= 1.75 MOM o HCG= 0.72 MOM o DIA= 1.12 MOM * Adjusted risk for Down syndrome=1:2570 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.7 weeks gestation. The screen was within normal limits. o AFP=1.14 MOM o Estriol= 1.75 MOM o HCG= 0.72 MOM o DIA= 1.12 MOM * Adjusted risk for Down syndrome=1:2570 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|135|137|G 2   P	1001				LMP|At the time, your patient was 19.14 weeks gestation. The screen was reported as abnormal for Down syndrome with a 1:5 risk. o AFP=0.56 MOM o Estriol= 0.59 MOM o HCG= 2.50 MOM o DIA= 1.60 MOM * Adjusted risk for Down syndrome=1:5 (abnormal) * Adjusted risk for Trisomy 18=1:1300 (normal) * Adjusted risk for ONTD=<1:10,000 I spoke with _%#NAME#%_ about these results and she indicated that she had an amniocentesis scheduled at your office on _%#MM#%_ _%#DD#%_.
MOM|multiples of median|MOM|155|157|G 2   P	1001				LMP|At the time, your patient was 19.14 weeks gestation. The screen was reported as abnormal for Down syndrome with a 1:5 risk. o AFP=0.56 MOM o Estriol= 0.59 MOM o HCG= 2.50 MOM o DIA= 1.60 MOM * Adjusted risk for Down syndrome=1:5 (abnormal) * Adjusted risk for Trisomy 18=1:1300 (normal) * Adjusted risk for ONTD=<1:10,000 I spoke with _%#NAME#%_ about these results and she indicated that she had an amniocentesis scheduled at your office on _%#MM#%_ _%#DD#%_.
MOM|multiples of median|MOM|171|173|G 2   P	1001				LMP|At the time, your patient was 19.14 weeks gestation. The screen was reported as abnormal for Down syndrome with a 1:5 risk. o AFP=0.56 MOM o Estriol= 0.59 MOM o HCG= 2.50 MOM o DIA= 1.60 MOM * Adjusted risk for Down syndrome=1:5 (abnormal) * Adjusted risk for Trisomy 18=1:1300 (normal) * Adjusted risk for ONTD=<1:10,000 I spoke with _%#NAME#%_ about these results and she indicated that she had an amniocentesis scheduled at your office on _%#MM#%_ _%#DD#%_.
MOM|multiples of median|MOM|143|145|G 3   P	2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.3 weeks gestation. The screen was within normal limits. o AFP=0.82 MOM o Estriol= 1.11 MOM o HCG= 0.78 MOM o DIA= 1.50 MOM * Adjusted risk for Down syndrome=1:625 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 3   P	2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.3 weeks gestation. The screen was within normal limits. o AFP=0.82 MOM o Estriol= 1.11 MOM o HCG= 0.78 MOM o DIA= 1.50 MOM * Adjusted risk for Down syndrome=1:625 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM.|180|183|PLAN|Your patient indicated that she wished to know the gender of her child and was given this information. The alpha-fetoprotein in the amniotic fluid was within normal limits at 1.31 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|multiples of median|M.O.M.,|314|320|PLAN|It was explained that low maternal AFP and estriol levels, together with elevated hCG and dimeric inhibin A values, indicate an increased risk of Down syndrome in a pregnancy. _%#NAME#%_'s maternal serum sample was obtained on _%#MM#%_ _%#DD#%_, 2005, at 16.5 weeks gestation, and resulted in an AFP value of 0.79 M.O.M., an estriol value of 0.45 M.O.M., an inhibin value of 1.75 M.O.M., and an hCG value of 1.59 M.O.M. This increased the patient's risk of having a child with Down syndrome from her age-related risk of 1 in 860, to a newly adjusted risk of 1in 150 (0.7%). The clinical features and genetics of Down syndrome were reviewed with the patient.
MOM|multiples of median|M.O.M.,|380|386|PLAN|It was explained that low maternal AFP and estriol levels, together with elevated hCG and dimeric inhibin A values, indicate an increased risk of Down syndrome in a pregnancy. _%#NAME#%_'s maternal serum sample was obtained on _%#MM#%_ _%#DD#%_, 2005, at 16.5 weeks gestation, and resulted in an AFP value of 0.79 M.O.M., an estriol value of 0.45 M.O.M., an inhibin value of 1.75 M.O.M., and an hCG value of 1.59 M.O.M. This increased the patient's risk of having a child with Down syndrome from her age-related risk of 1 in 860, to a newly adjusted risk of 1in 150 (0.7%). The clinical features and genetics of Down syndrome were reviewed with the patient.
MOM|multiples of median|M.O.M.|413|418|PLAN|It was explained that low maternal AFP and estriol levels, together with elevated hCG and dimeric inhibin A values, indicate an increased risk of Down syndrome in a pregnancy. _%#NAME#%_'s maternal serum sample was obtained on _%#MM#%_ _%#DD#%_, 2005, at 16.5 weeks gestation, and resulted in an AFP value of 0.79 M.O.M., an estriol value of 0.45 M.O.M., an inhibin value of 1.75 M.O.M., and an hCG value of 1.59 M.O.M. This increased the patient's risk of having a child with Down syndrome from her age-related risk of 1 in 860, to a newly adjusted risk of 1in 150 (0.7%). The clinical features and genetics of Down syndrome were reviewed with the patient.
MOM|multiples of median|MOM|214|216|PLAN|_%#NAME#%_ _%#NAME#%_ is a 29-year-old, gravida 2, para 1-1-0-1, who is currently 21 weeks and 3 days' gestation, based on estimated date of delivery of _%#MMDD2006#%_. Her quad screen levels were as follows: 1.12 MOM AFP, 3.10 MOM hCG, 0.83 MOM estriol, and 1.67 MOM inhibin. Her quad screen increased her chance of a baby with Down syndrome from her age-related risk of 1 in 790 to 1 in 140.
MOM|multiples of median|MOM|264|266|PLAN|_%#NAME#%_ _%#NAME#%_ is a 29-year-old, gravida 2, para 1-1-0-1, who is currently 21 weeks and 3 days' gestation, based on estimated date of delivery of _%#MMDD2006#%_. Her quad screen levels were as follows: 1.12 MOM AFP, 3.10 MOM hCG, 0.83 MOM estriol, and 1.67 MOM inhibin. Her quad screen increased her chance of a baby with Down syndrome from her age-related risk of 1 in 790 to 1 in 140.
MOM|multiples of median|MOM|142|144|G 3   P	0020				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.4 weeks gestation. The screen was within normal limits. o AFP=0.8 MOM o Estriol= 0.8 MOM o HCG= 1.63 MOM o DIA= 0.70 MOM * Adjusted risk for Down syndrome=1:2440 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=Not provided due to family history.
MOM|multiples of median|MOM|161|163|G 3   P	0020				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.4 weeks gestation. The screen was within normal limits. o AFP=0.8 MOM o Estriol= 0.8 MOM o HCG= 1.63 MOM o DIA= 0.70 MOM * Adjusted risk for Down syndrome=1:2440 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=Not provided due to family history.
MOM|multiples of median|MOM|177|179|G 3   P	0020				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.4 weeks gestation. The screen was within normal limits. o AFP=0.8 MOM o Estriol= 0.8 MOM o HCG= 1.63 MOM o DIA= 0.70 MOM * Adjusted risk for Down syndrome=1:2440 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=Not provided due to family history.
MOM|multiples of median|MOM|193|195|G 3   P	0020				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.4 weeks gestation. The screen was within normal limits. o AFP=0.8 MOM o Estriol= 0.8 MOM o HCG= 1.63 MOM o DIA= 0.70 MOM * Adjusted risk for Down syndrome=1:2440 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=Not provided due to family history.
MOM|multiples of median|MOM|124|126|G 2   P 1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15 weeks gestation. o AFP=0.58 MOM o Estriol= 1.10 MOM o HCG= 1.44 MOM * Adjusted risk for Down syndrome=1:191 Screen positive * Adjusted risk for Trisomy 18=not increased * Adjusted risk for ONTD=1:10,000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|140|142|G 2   P 1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15 weeks gestation. o AFP=0.58 MOM o Estriol= 1.10 MOM o HCG= 1.44 MOM * Adjusted risk for Down syndrome=1:191 Screen positive * Adjusted risk for Trisomy 18=not increased * Adjusted risk for ONTD=1:10,000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM.|180|183|G 2   P 1001				LMP|Your patient indicated that she wished to know the gender of her child and was given this information. The alpha-fetoprotein in the amniotic fluid was within normal limits at 1.63 MOM. This assay excludes approximately 98% of open neural tube defects. We had previously recommended a comprehensive ultrasound at 18-20 weeks gestation and fetal echocardiogram due to the fact that _%#NAME#%_'s first trimester nuchal translucency measurement exceeded the 95%tile.
MOM|multiples of median|MOM.|243|246|G 2   P 1001				LMP|The screen was still reported as "normal" for Down syndrome because this particular lab uses a risk cutoff of 1:150 (rather than the usual 1:270). The risk for spina bifida was reported as "abnormal" (1:20 risk) due to an elevated AFP of 3.82 MOM. Given that _%#NAME#%_ already had a normal comprehensive ultrasound, the possibility of fetal spina bifida had previously been almost completely excluded.
MOM|multiples of median|MOM.|180|183|G 2   P 1001				LMP|Your patient indicated that she wished to know the gender of her child and was given this information. The alpha-fetoprotein in the amniotic fluid was within normal limits at 0.74 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|multiples of median|MOM|179|181|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.7 weeks gestation. The screen was within normal limits. o AFP=1.43 MOM o Estriol= 1.35 MOM o HCG= 1.10 MOM o DIA= 1.47 MOM * Adjusted risk for Down syndrome=1:7363 * Adjusted risk for Trisomy 18=Not increased * Adjusted risk for ONTD=1:3311 Plan: * Given the lack of certainty about the diagnosis in the family, I gave _%#NAME#%_ several questions to ask family members in order to clarify the nature of the familial bleeding condition.
MOM|multiples of median|MOM|250|252|G 3   P	2002				LMP|o Age mid trimester Down syndrome risk= 1:92 o Age mid trimester risk for any chromosome condition= 1:50 * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.3 weeks gestation. o AFP=1.00 MOM o Estriol= 1.37 MOM o HCG= 1.30 MOM o DIA= 1.68 MOM * Adjusted risk for Down syndrome=1:166 Screen Positive * Adjusted risk for Trisomy 18=not increased * Adjusted risk for ONTD=1:10,000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|126|128|G 3   P	2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.3 weeks gestation. o AFP=1.00 MOM o Estriol= 1.37 MOM o HCG= 1.30 MOM o DIA= 1.68 MOM * Adjusted risk for Down syndrome=1:166 Screen Positive * Adjusted risk for Trisomy 18=not increased * Adjusted risk for ONTD=1:10,000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|142|144|G 3   P	2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.3 weeks gestation. o AFP=1.00 MOM o Estriol= 1.37 MOM o HCG= 1.30 MOM o DIA= 1.68 MOM * Adjusted risk for Down syndrome=1:166 Screen Positive * Adjusted risk for Trisomy 18=not increased * Adjusted risk for ONTD=1:10,000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|158|160|G 3   P	2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.3 weeks gestation. o AFP=1.00 MOM o Estriol= 1.37 MOM o HCG= 1.30 MOM o DIA= 1.68 MOM * Adjusted risk for Down syndrome=1:166 Screen Positive * Adjusted risk for Trisomy 18=not increased * Adjusted risk for ONTD=1:10,000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|milk of magnesia|MOM|191|193|PLAN|6. Mildly abnormal lung exam without pulmonary pathology. 7. Type 2 diabetes mellitus under uncertain control. PLAN: 1. We will treat her constipation with combination of Senna scheduled and MOM tonight. 2. Check chest x-ray. 3. Obtain old laboratory results contributing to renal function studies and hemoglobin. 4. Accu chek will be done on b.i.d. basis.
MOM|multiples of median|MOM,|245|248|PLAN|It was explained how low values tested for in the quad screen indicate an increased risk of trisomy 18 in a pregnancy. _%#NAME#%_'s maternal serum screen was obtained on _%#MMDD2006#%_ at 16 weeks' gestation and resulted in an AFP value of 0.49 MOM, an estriol value of 0.34 MOM, and an hCG value of 0.55 MOM. This increased the patient's chance of having a child with trisomy 18 from her age-related chance of 1 in 4629 to a newly adjusted chance of 1 in 81.
MOM|multiples of median|MOM,|156|159|PLAN|_%#NAME#%_'s maternal serum screen was obtained on _%#MMDD2006#%_ at 16 weeks' gestation and resulted in an AFP value of 0.49 MOM, an estriol value of 0.34 MOM, and an hCG value of 0.55 MOM. This increased the patient's chance of having a child with trisomy 18 from her age-related chance of 1 in 4629 to a newly adjusted chance of 1 in 81.
MOM|multiples of median|MOM|143|145|G 5   P	2022				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.7 weeks gestation. The screen was within normal limits. o AFP=0.67 MOM o Estriol= 0.91 MOM o HCG= 1.09 MOM o DIA= 0.54 MOM * Adjusted risk for Down syndrome=1:1781 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 5   P	2022				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.7 weeks gestation. The screen was within normal limits. o AFP=0.67 MOM o Estriol= 0.91 MOM o HCG= 1.09 MOM o DIA= 0.54 MOM * Adjusted risk for Down syndrome=1:1781 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 5   P	2022				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.7 weeks gestation. The screen was within normal limits. o AFP=0.67 MOM o Estriol= 0.91 MOM o HCG= 1.09 MOM o DIA= 0.54 MOM * Adjusted risk for Down syndrome=1:1781 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 5   P	2022				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.7 weeks gestation. The screen was within normal limits. o AFP=0.67 MOM o Estriol= 0.91 MOM o HCG= 1.09 MOM o DIA= 0.54 MOM * Adjusted risk for Down syndrome=1:1781 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|143|145|G 4   P	3003				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.1 weeks gestation. The screen was within normal limits. o AFP=0.80 MOM o Estriol= 1.00 MOM o HCG= 0.25 MOM o DIA= 0.68 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=1:592 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 4   P	3003				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.1 weeks gestation. The screen was within normal limits. o AFP=0.80 MOM o Estriol= 1.00 MOM o HCG= 0.25 MOM o DIA= 0.68 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=1:592 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM.|189|192|G 4   P	3003				LMP|Your patient indicated that she did not wish to know the gender of her child and this information was withheld. The alpha-fetoprotein in the amniotic fluid was within normal limits at 0.86 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|multiples of median|MOM|126|128|G 2   P 2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.4 weeks gestation. o AFP=0.67 MOM o Estriol= 0.41 MOM o HCG= 0.55 MOM * Adjusted risk for Down syndrome=1:1055 * Adjusted risk for Trisomy 18=1:19 Screen positive * Adjusted risk for ONTD=1:10,000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of trisomy 18 in the current pregnancy.
MOM|multiples of median|MOM|142|144|G 2   P 2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.4 weeks gestation. o AFP=0.67 MOM o Estriol= 0.41 MOM o HCG= 0.55 MOM * Adjusted risk for Down syndrome=1:1055 * Adjusted risk for Trisomy 18=1:19 Screen positive * Adjusted risk for ONTD=1:10,000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of trisomy 18 in the current pregnancy.
MOM|multiples of median|MOM|142|144|G 1   P 0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.9 weeks gestation. o AFP=0.60 MOM o Estriol= 0.97 MOM o HCG= 1.83 MOM o DIA= 2.14 MOM * Adjusted risk for Down syndrome=1:65 Screen positive * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|195|197|G 5   P	2022				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.4 weeks gestation. The screen was within normal limits. o AFP=1.16 MOM o Estriol= 0.62 MOM o HCG= 0.58 MOM o DIA= 1.63 MOM * Adjusted risk for Down syndrome=1:843 * Adjusted risk for Trisomy 18=<1:316 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM,|194|197|G 5   P	2022				LMP|We next reviewed screening results. The quad screen was drawn on _%#MMDD2007#%_, at that time Dawn was 16.1 weeks gestation. The results are as follows: AFP=0.87 MOM, estriol=0.53 MOM, hCG=1.16 MOM, DIA=1.57 MOM. The adjusted risks for Down syndrome provided by the screen was 1:49. This new risk for Down syndr5ome exceeded the screening threshold of 1:270 and was therefore reported as positive for Down syndrome.
MOM|multiples of median|MOM.|208|211|G 5   P	2022				LMP|We next reviewed screening results. The quad screen was drawn on _%#MMDD2007#%_, at that time Dawn was 16.1 weeks gestation. The results are as follows: AFP=0.87 MOM, estriol=0.53 MOM, hCG=1.16 MOM, DIA=1.57 MOM. The adjusted risks for Down syndrome provided by the screen was 1:49. This new risk for Down syndr5ome exceeded the screening threshold of 1:270 and was therefore reported as positive for Down syndrome.
MOM|multiples of median|MOM|126|128|G 3   P 1011				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.3 weeks gestation. o AFP=0.98 MOM o Estriol= 0.28 MOM o HCG= 2.14 MOM o DIA= 0.85 MOM * Adjusted risk for Down syndrome=1:60 Screen positive * Adjusted risk for Trisomy 18=1:456 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|191|193|G 3   P 2002				LMP|o Age mid trimester Down syndrome risk= 1:522 * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.1 weeks gestation. o AFP=0.51 MOM o Estriol= 0.59 MOM o HCG= 1.21 MOM o DIA= 1.03 MOM * Adjusted risk for Down syndrome=1:262 Screen positive * Adjusted risk for Trisomy 18=1:3777 * Adjusted risk for ONTD=1:10,000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|142|144|G 3   P 2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.1 weeks gestation. o AFP=0.51 MOM o Estriol= 0.59 MOM o HCG= 1.21 MOM o DIA= 1.03 MOM * Adjusted risk for Down syndrome=1:262 Screen positive * Adjusted risk for Trisomy 18=1:3777 * Adjusted risk for ONTD=1:10,000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM.|402|405|ASSESSMENT/PLAN|_%#NAME#%_ _%#NAME#%_, PA-C Fairview _%#CITY#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_, MN _%#55300#%_ Dear _%#NAME#%_ _%#NAME#%_: Thank you for the referral of your patient, _%#NAME#%_ _%#NAME#%_, who was seen on _%#MMDD2006#%_, at the Maternal Fetal Medicine Center at the University of Minnesota Medical Center, Fairview. As you know, she was referred to discuss her elevated AFP of 2.85 MOM. I spent approximately 45 minutes with this patient today. _%#NAME#%_ is a 25-year-old gravida 1, para 0-0-0-0, who is currently 18 weeks' gestation based on estimated date of delivery of _%#MMDD2007#%_.
MOM|multiples of median|MOM,|265|268|RE|At age 41, the patient has a mid trimester risk of carrying a baby with any chromosome abnormality of 1:31. In addition, the patient had a quad screen drawn through your clinic on _%#MM#%_ 15 at 16.3 weeks gestation that resulted in an AFP of 1.20 MOM, hCG of 0.71 MOM, and an estriol of 1.26 MOM, and an inhibin of 0.91 MOM. This decreased the patient's age-related risk to have a baby with Down syndrome from 1:54 to 1:1707.
MOM|multiples of median|MOM|251|253|G 4   P 3003				LMP|o Age mid trimester Down syndrome risk= 1:289 o Age mid trimester risk for any chromosome condition=1:120 * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.1 weeks gestation. o AFP=0.59 MOM o Estriol= 0.36 MOM o HCG= 1.26 MOM o DIA= 0.49 MOM * Adjusted risk for Down syndrome=1:180 Screen positive * Adjusted risk for Trisomy 18=1:220 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|126|128|G 4   P 3003				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.1 weeks gestation. o AFP=0.59 MOM o Estriol= 0.36 MOM o HCG= 1.26 MOM o DIA= 0.49 MOM * Adjusted risk for Down syndrome=1:180 Screen positive * Adjusted risk for Trisomy 18=1:220 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|142|144|G 4   P 3003				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.1 weeks gestation. o AFP=0.59 MOM o Estriol= 0.36 MOM o HCG= 1.26 MOM o DIA= 0.49 MOM * Adjusted risk for Down syndrome=1:180 Screen positive * Adjusted risk for Trisomy 18=1:220 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|158|160|G 4   P 3003				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.1 weeks gestation. o AFP=0.59 MOM o Estriol= 0.36 MOM o HCG= 1.26 MOM o DIA= 0.49 MOM * Adjusted risk for Down syndrome=1:180 Screen positive * Adjusted risk for Trisomy 18=1:220 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM.|189|192|G 4   P 3003				LMP|Your patient indicated that she did not wish to know the gender of her child and this information was withheld. The alpha-fetoprotein in the amniotic fluid was within normal limits at 0.91 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|multiples of median|MOM|143|145|G 4   P	1021				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.9 weeks gestation. The screen was within normal limits. o AFP=0.91 MOM o Estriol= 0.77 MOM o HCG= 1.70 MOM o DIA= 1.02 MOM * Adjusted risk for Down syndrome=1:479 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 4   P	1021				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.9 weeks gestation. The screen was within normal limits. o AFP=0.91 MOM o Estriol= 0.77 MOM o HCG= 1.70 MOM o DIA= 1.02 MOM * Adjusted risk for Down syndrome=1:479 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 4   P	1021				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.9 weeks gestation. The screen was within normal limits. o AFP=0.91 MOM o Estriol= 0.77 MOM o HCG= 1.70 MOM o DIA= 1.02 MOM * Adjusted risk for Down syndrome=1:479 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|143|145|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.7 weeks gestation. The screen was within normal limits. o AFP=1.17 MOM o Estriol= 0.94 MOM o HCG= 0.88 MOM o DIA= 1.04 MOM * Adjusted risk for Down syndrome=1:705 * Adjusted risk for Trisomy 18= Not increased * Adjusted risk for ONTD=1:7137 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.7 weeks gestation. The screen was within normal limits. o AFP=1.17 MOM o Estriol= 0.94 MOM o HCG= 0.88 MOM o DIA= 1.04 MOM * Adjusted risk for Down syndrome=1:705 * Adjusted risk for Trisomy 18= Not increased * Adjusted risk for ONTD=1:7137 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.7 weeks gestation. The screen was within normal limits. o AFP=1.17 MOM o Estriol= 0.94 MOM o HCG= 0.88 MOM o DIA= 1.04 MOM * Adjusted risk for Down syndrome=1:705 * Adjusted risk for Trisomy 18= Not increased * Adjusted risk for ONTD=1:7137 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|milk of magnesia|MOM|164|166|CURRENT MEDICATIONS|2) Solu-Medrol 75 mg IV piggyback x 1. 3) Atacand 60 mg p.o. q.d. 4) Pravachol 60 mg p.o. q h.s. 5) Zetia 10 mg p.o. q.d. 6) Percocet one to two p.o. q4h p.r.n. 7) MOM 30 cc p.o. q.d. 8) Metamucil one scoop daily. 9) Flexeril 10 mg p.o. q8h. PAST MEDICAL HISTORY: 1) Hypercholesterolemia.
MOM|multiples of median|MOM.|180|183|RECOMMENDATIONS|Your patient indicated that she wished to know the gender of her child and was given this information. The alpha-fetoprotein in the amniotic fluid was within normal limits at 1.01 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|multiples of median|MOM|143|145|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.6 weeks gestation. The screen was within normal limits. o AFP=0.99 MOM o Estriol= 1.20 MOM o HCG= 0.67 MOM o DIA= 0.54 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.6 weeks gestation. The screen was within normal limits. o AFP=0.99 MOM o Estriol= 1.20 MOM o HCG= 0.67 MOM o DIA= 0.54 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.6 weeks gestation. The screen was within normal limits. o AFP=0.99 MOM o Estriol= 1.20 MOM o HCG= 0.67 MOM o DIA= 0.54 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|252|254|G 3   P	1011				LMP|o Age mid trimester Down syndrome risk= 1:279 o Age mid trimester risk for any chromosome condition= 1:110 * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.6 weeks gestation. o AFP=0.99 MOM o Estriol= 1.08 MOM o HCG= 2.03 MOM o DIA= 1.98 MOM * Adjusted risk for Down syndrome=1:219 Screen Positive * Adjusted risk for Trisomy 18=1:22,114 * Adjusted risk for ONTD=1:13,000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|143|145|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.1 weeks gestation. The screen was within normal limits. o AFP=0.86 MOM o Estriol= 0.92 MOM o HCG= 1.05 MOM o DIA= 1.08 MOM * Adjusted risk for Down syndrome=1:917 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.1 weeks gestation. The screen was within normal limits. o AFP=0.86 MOM o Estriol= 0.92 MOM o HCG= 1.05 MOM o DIA= 1.08 MOM * Adjusted risk for Down syndrome=1:917 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.1 weeks gestation. The screen was within normal limits. o AFP=0.86 MOM o Estriol= 0.92 MOM o HCG= 1.05 MOM o DIA= 1.08 MOM * Adjusted risk for Down syndrome=1:917 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.1 weeks gestation. The screen was within normal limits. o AFP=0.86 MOM o Estriol= 0.92 MOM o HCG= 1.05 MOM o DIA= 1.08 MOM * Adjusted risk for Down syndrome=1:917 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|143|145|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.4 weeks gestation. The screen was within normal limits. o AFP=0.83 MOM o Estriol= 1.34 MOM o HCG= 0.77 MOM o DIA= 0.91 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.4 weeks gestation. The screen was within normal limits. o AFP=0.83 MOM o Estriol= 1.34 MOM o HCG= 0.77 MOM o DIA= 0.91 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|143|145|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.6 weeks gestation. The screen was within normal limits. o AFP=0.67 MOM o Estriol= 0.95 MOM o HCG= 1.09 MOM o DIA= 0.78 MOM * Adjusted risk for Down syndrome=1:994 * Adjusted risk for Trisomy 18=not increased * Adjusted risk for ONTD=<1:10,000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.6 weeks gestation. The screen was within normal limits. o AFP=0.67 MOM o Estriol= 0.95 MOM o HCG= 1.09 MOM o DIA= 0.78 MOM * Adjusted risk for Down syndrome=1:994 * Adjusted risk for Trisomy 18=not increased * Adjusted risk for ONTD=<1:10,000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.6 weeks gestation. The screen was within normal limits. o AFP=0.67 MOM o Estriol= 0.95 MOM o HCG= 1.09 MOM o DIA= 0.78 MOM * Adjusted risk for Down syndrome=1:994 * Adjusted risk for Trisomy 18=not increased * Adjusted risk for ONTD=<1:10,000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.6 weeks gestation. The screen was within normal limits. o AFP=0.67 MOM o Estriol= 0.95 MOM o HCG= 1.09 MOM o DIA= 0.78 MOM * Adjusted risk for Down syndrome=1:994 * Adjusted risk for Trisomy 18=not increased * Adjusted risk for ONTD=<1:10,000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|126|128|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.0 weeks gestation. o AFP=0.96 MOM o Estriol= 0.68 MOM o HCG= 1.14 MOM o DIA= 1.58 MOM * Adjusted risk for Down syndrome=1:190 Screen Positive * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|142|144|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.0 weeks gestation. o AFP=0.96 MOM o Estriol= 0.68 MOM o HCG= 1.14 MOM o DIA= 1.58 MOM * Adjusted risk for Down syndrome=1:190 Screen Positive * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|158|160|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.0 weeks gestation. o AFP=0.96 MOM o Estriol= 0.68 MOM o HCG= 1.14 MOM o DIA= 1.58 MOM * Adjusted risk for Down syndrome=1:190 Screen Positive * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|142|144|G 4   P	1021				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.4 weeks gestation. The screen was within normal limits. o AFP=1.2 MOM o Estriol= 0.85 MOM o HCG= 0.92 MOM o DIA= 0.76 MOM * Adjusted risk for Down syndrome=1:1600 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM,|274|277|G 4   P	1021				LMP|As you recall, _%#NAME#%_ had an amniocentesis on _%#MM#%_ _%#DD#%_, 2006, due to an abnormal first trimester screen (1:24 risk for Downs). This elevated risk was due to ultrasound and biochemical patterns that are very consistent with Down syndrome (NT=2.3 mm, PAPP-A=0.72 MOM, HCG=2.65 MOM). While the pattern was suggestive of Down syndrome, none of the individual markers was strikingly abnormal (i.e. the NT was still below 95%tile).
MOM|multiples of median|MOM|179|181|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.3 weeks gestation. The screen was within normal limits. o AFP=0.86 MOM o Estriol= 0.81 MOM o HCG= 1.21 MOM o DIA= 0.89 MOM * Adjusted risk for Down syndrome=1:3422 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|143|145|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.6 weeks gestation. The screen was within normal limits. o AFP=1.27 MOM o Estriol= 0.88 MOM o HCG= 2.51 MOM o DIA= 1.70 MOM * Adjusted risk for Down syndrome=1:383 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.6 weeks gestation. The screen was within normal limits. o AFP=1.27 MOM o Estriol= 0.88 MOM o HCG= 2.51 MOM o DIA= 1.70 MOM * Adjusted risk for Down syndrome=1:383 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.6 weeks gestation. The screen was within normal limits. o AFP=1.27 MOM o Estriol= 0.88 MOM o HCG= 2.51 MOM o DIA= 1.70 MOM * Adjusted risk for Down syndrome=1:383 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|180|182|G 4   P	1021				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.43 weeks gestation. The screen was within normal limits. o AFP=1.14 MOM o Estriol= 1.33 MOM o HCG= 0.37 MOM o DIA= 0.36 MOM * Adjusted risk for Down syndrome=<1:10,000 * Adjusted risk for Trisomy 18=1:4800 * Adjusted risk for ONTD=<1:10,000 * _%#NAME#%_'s records indicated that she had a nuchal translucency measurement in the first trimester of 2.3mm (CRL=66mm).
MOM|multiples of median|MOM|196|198|G 4   P	1021				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.43 weeks gestation. The screen was within normal limits. o AFP=1.14 MOM o Estriol= 1.33 MOM o HCG= 0.37 MOM o DIA= 0.36 MOM * Adjusted risk for Down syndrome=<1:10,000 * Adjusted risk for Trisomy 18=1:4800 * Adjusted risk for ONTD=<1:10,000 * _%#NAME#%_'s records indicated that she had a nuchal translucency measurement in the first trimester of 2.3mm (CRL=66mm).
MOM|multiples of median|MOM.|189|192|ASSESSMENT|Your patient indicated that she did not wish to know the gender of her child and this information was withheld. The alpha-fetoprotein in the amniotic fluid was within normal limits at 0.90 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|multiples of median|MOM|161|163|G 2   P	0010				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17 weeks gestation. The screen was within normal limits. o AFP=1.34 MOM o Estriol= 0.84 MOM o HCG= 0.96 MOM * Adjusted risk for Down syndrome=1:683 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=1:4272 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|177|179|G 2   P	0010				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17 weeks gestation. The screen was within normal limits. o AFP=1.34 MOM o Estriol= 0.84 MOM o HCG= 0.96 MOM * Adjusted risk for Down syndrome=1:683 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=1:4272 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM.|130|133|G 2   P	0010				LMP|Specifically, the resultant chemical values were as follows: an AFP value of 0.64 MOM, an hCG of 1.41 MOM, and an estriol of 0.61 MOM. This increased the chance for fetal Down syndrome to a newly-adjusted chance of 1:3. The amniocentesis procedure was reviewed and explained as the only procedure available at this gestational age that is able to diagnose Down syndrome, as well as other numerical chromosome abnormalities in a pregnancy.
MOM|multiples of median|MOM.|189|192|IN SUMMARY|Your patient indicated that she did not wish to know the gender of her child and this information was withheld. The alpha-fetoprotein in the amniotic fluid was within normal limits at 0.72 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|multiples of median|MOM.|180|183|IN SUMMARY|Your patient indicated that she wished to know the gender of her child and was given this information. The alpha-fetoprotein in the amniotic fluid was within normal limits at 0.70 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|multiples of median|MOM|196|198|RE|We reviewed the results of the maternal serum screen that _%#NAME#%_ had on _%#MMDD2007#%_ on 15.71 weeks gestation. Specifically, the resultant chemical values were as follows: AFP value of 0.61 MOM and estriol value of 0.92 MOM and inhibin value of 1.24 MOM and an HCV value of 0.69 MOM. This indicated a decreased chance of Down syndrome from 1:1100 to 1:4,600.
MOM|multiples of median|MOM|139|141|RE|Specifically, the resultant chemical values were as follows: AFP value of 0.61 MOM and estriol value of 0.92 MOM and inhibin value of 1.24 MOM and an HCV value of 0.69 MOM. This indicated a decreased chance of Down syndrome from 1:1100 to 1:4,600. It also reduced _%#NAME#%_'s risk of having a baby with trisomy 18 to less than 1:10,000.
MOM|multiples of median|MOM.|168|171|RE|Specifically, the resultant chemical values were as follows: AFP value of 0.61 MOM and estriol value of 0.92 MOM and inhibin value of 1.24 MOM and an HCV value of 0.69 MOM. This indicated a decreased chance of Down syndrome from 1:1100 to 1:4,600. It also reduced _%#NAME#%_'s risk of having a baby with trisomy 18 to less than 1:10,000.
MOM|multiples of median|MOM|143|145|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.0 weeks gestation. The screen was within normal limits. o AFP=1.08 MOM o Estriol= 1.19 MOM o HCG= 0.66 MOM o DIA= 0.94 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * We discussed the significance of the ultrasound finding of echogenic bowel.
MOM|multiples of median|MOM|179|181|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.0 weeks gestation. The screen was within normal limits. o AFP=1.08 MOM o Estriol= 1.19 MOM o HCG= 0.66 MOM o DIA= 0.94 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * We discussed the significance of the ultrasound finding of echogenic bowel.
MOM|multiples of median|MOM|195|197|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.0 weeks gestation. The screen was within normal limits. o AFP=1.08 MOM o Estriol= 1.19 MOM o HCG= 0.66 MOM o DIA= 0.94 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * We discussed the significance of the ultrasound finding of echogenic bowel.
MOM|multiples of median|MOM|143|145|G 3   P	0020				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.4 weeks gestation. The screen was within normal limits. o AFP=1.11 MOM o Estriol= 1.07 MOM o HCG= 0.73 MOM o DIA= 0.71 MOM * Adjusted risk for Down syndrome=1:3912 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 3   P	0020				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.4 weeks gestation. The screen was within normal limits. o AFP=1.11 MOM o Estriol= 1.07 MOM o HCG= 0.73 MOM o DIA= 0.71 MOM * Adjusted risk for Down syndrome=1:3912 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 3   P	0020				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.4 weeks gestation. The screen was within normal limits. o AFP=1.11 MOM o Estriol= 1.07 MOM o HCG= 0.73 MOM o DIA= 0.71 MOM * Adjusted risk for Down syndrome=1:3912 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|164|166|G 3   P	0020				LMP|The patient also had a quad screen drawn through your clinic on _%#MM#%_ _%#DD#%_, 2006 that resulted in an AFP of 0.52 MOM and HCG of 0.95 MOM and estriol of 1.30 MOM and inhibin of 0.59 MOM. This decreased the patient's age-related risk to have a baby with Down syndrome from 1 in 265 to 1 in 1,993.
MOM|multiples of median|M.O.M.,|202|208|G 3   P	0020				LMP|We then went on to review the results of the quad screen that _%#NAME#%_ had on _%#MM#%_ _%#DD#%_, 2005, at 15.9 weeks gestation. Specifically, the chemical values were as follows: an AFP value of 1.14 M.O.M., an hCG value of 2.16 M.O.M., an estriol value of 1.05 M.O.M., and a dimeric inhibin A value of 0.89 M.O.M. These results reduced her aged-related risk of Down syndrome of 1:259 to a newly adjusted risk of 1:2714.
MOM|multiples of median|M.O.M.,|231|237|G 3   P	0020				LMP|We then went on to review the results of the quad screen that _%#NAME#%_ had on _%#MM#%_ _%#DD#%_, 2005, at 15.9 weeks gestation. Specifically, the chemical values were as follows: an AFP value of 1.14 M.O.M., an hCG value of 2.16 M.O.M., an estriol value of 1.05 M.O.M., and a dimeric inhibin A value of 0.89 M.O.M. These results reduced her aged-related risk of Down syndrome of 1:259 to a newly adjusted risk of 1:2714.
MOM|multiples of median|M.O.M.,|264|270|G 3   P	0020				LMP|We then went on to review the results of the quad screen that _%#NAME#%_ had on _%#MM#%_ _%#DD#%_, 2005, at 15.9 weeks gestation. Specifically, the chemical values were as follows: an AFP value of 1.14 M.O.M., an hCG value of 2.16 M.O.M., an estriol value of 1.05 M.O.M., and a dimeric inhibin A value of 0.89 M.O.M. These results reduced her aged-related risk of Down syndrome of 1:259 to a newly adjusted risk of 1:2714.
MOM|multiples of median|M.O.M.|310|315|G 3   P	0020				LMP|We then went on to review the results of the quad screen that _%#NAME#%_ had on _%#MM#%_ _%#DD#%_, 2005, at 15.9 weeks gestation. Specifically, the chemical values were as follows: an AFP value of 1.14 M.O.M., an hCG value of 2.16 M.O.M., an estriol value of 1.05 M.O.M., and a dimeric inhibin A value of 0.89 M.O.M. These results reduced her aged-related risk of Down syndrome of 1:259 to a newly adjusted risk of 1:2714. The screen also indicated that the risk of an open neural tube defect in this pregnancy is less than 1:5000 and the risk of trisomy 18 is less than 1:5000.
MOM|multiples of median|MOM|143|145|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.3 weeks gestation. The screen was within normal limits. o AFP=0.62 MOM o Estriol= 1.25 MOM o HCG= 0.90 MOM o DIA= 1.11 MOM * Adjusted risk for Down syndrome=1:793 * Adjusted risk for Trisomy 18=1:7,822 * Adjusted risk for ONTD=1:55,000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.3 weeks gestation. The screen was within normal limits. o AFP=0.62 MOM o Estriol= 1.25 MOM o HCG= 0.90 MOM o DIA= 1.11 MOM * Adjusted risk for Down syndrome=1:793 * Adjusted risk for Trisomy 18=1:7,822 * Adjusted risk for ONTD=1:55,000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.3 weeks gestation. The screen was within normal limits. o AFP=0.62 MOM o Estriol= 1.25 MOM o HCG= 0.90 MOM o DIA= 1.11 MOM * Adjusted risk for Down syndrome=1:793 * Adjusted risk for Trisomy 18=1:7,822 * Adjusted risk for ONTD=1:55,000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|M.O.M.,|264|270|G 1   P	0000				LMP|We then went on to review the results of the quad screen that _%#NAME#%_ had on _%#MM#%_ _%#DD#%_, 2006, at 16.9 weeks gestation. Specifically, the chemical values were as follows: an AFP value of 0.81 M.O.M., an hCG value of 1.86 M.O.M., an estriol value of 1.64 M.O.M., and a dimeric inhibin A value of 0.96 M.O.M. These results reduced her aged-related risk of Down syndrome of 1:129 to a newly adjusted risk of 1:1161.
MOM|multiples of median|M.O.M.|310|315|G 1   P	0000				LMP|We then went on to review the results of the quad screen that _%#NAME#%_ had on _%#MM#%_ _%#DD#%_, 2006, at 16.9 weeks gestation. Specifically, the chemical values were as follows: an AFP value of 0.81 M.O.M., an hCG value of 1.86 M.O.M., an estriol value of 1.64 M.O.M., and a dimeric inhibin A value of 0.96 M.O.M. These results reduced her aged-related risk of Down syndrome of 1:129 to a newly adjusted risk of 1:1161. The screen also indicated that the risk of an open neural tube defect in this pregnancy is less than 1:5000, and the risk of trisomy 18 is less than 1:5000.
MOM|multiples of median|MOM.|323|326|RECOMMENDATIONS|Dear Dr. _%#NAME#%_: Thank you for the referral of your patient, _%#NAME#%_ _%#NAME#%_, who was seen along with her mother, _%#NAME#%_, on _%#MMDD2007#%_ at the Maternal Fetal Medicine Center at the University of Minnesota Medical Center, Fairview. As you know, she was referred to discuss her slightly elevated AFP of 2.6 MOM. We met with her briefly for genetic counseling prior to her level 2 ultrasound today, which was unremarkable. _%#NAME#%_ is a 22-year-old gravida 2, para 0-0-1-0 who is currently 18 weeks' gestation based on estimated date of delivery of _%#MMDD2007#%_.
MOM|multiples of median|MOM|121|123|RECOMMENDATIONS|At the time, your patient was 21.14 weeks gestation. The screen was within normal limits. o AFP=0.75 MOM o Estriol= 1.19 MOM o HCG= 1.11 MOM o DIA= 1.24 MOM * Adjusted risk for Down syndrome=1:2000 * Adjusted risk for Trisomy 18=<1:10,000 * Adjusted risk for ONTD=1:9900 This screen makes the possibility of Down syndrome in the current pregnancy unlikely, though it does not definitively exclude this possibility.
MOM|multiples of median|MOM|153|155|RECOMMENDATIONS|At the time, your patient was 21.14 weeks gestation. The screen was within normal limits. o AFP=0.75 MOM o Estriol= 1.19 MOM o HCG= 1.11 MOM o DIA= 1.24 MOM * Adjusted risk for Down syndrome=1:2000 * Adjusted risk for Trisomy 18=<1:10,000 * Adjusted risk for ONTD=1:9900 This screen makes the possibility of Down syndrome in the current pregnancy unlikely, though it does not definitively exclude this possibility.
MOM|multiples of median|MOM|172|174|G 1   P 0000				LMP|The serum screen was drawn _%#MMDD2007-2007#%_. At the time, your patient was 16.0 weeks gestation (dates based upon EDC of _%#MMDD2007#%_ from 11+2 week scan). o AFP=0.89 MOM o Estriol= 0.43 MOM o HCG= 1.07 MOM o DIA= 1.02 MOM * Adjusted risk for Down syndrome=1:200 Screen positive * Adjusted risk for Trisomy 18=1:384 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|208|210|G 1   P 0000				LMP|The serum screen was drawn _%#MMDD2007-2007#%_. At the time, your patient was 16.0 weeks gestation (dates based upon EDC of _%#MMDD2007#%_ from 11+2 week scan). o AFP=0.89 MOM o Estriol= 0.43 MOM o HCG= 1.07 MOM o DIA= 1.02 MOM * Adjusted risk for Down syndrome=1:200 Screen positive * Adjusted risk for Trisomy 18=1:384 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM,|197|200|G 1   P 0000				LMP|The triple screen looks for specific birth defects, including those with chromosome abnormalities and neural tube defects. As you know, _%#NAME#%_ had a triple screen which indicated an AFP of 0.9 MOM, an hCG of 1.3 MOM, and an estriol of 0.63 MOM, which adjusted her age- related risk from 1 in 370 for Down's syndrome to 1 in 300, or 0.8%. She had no elevated risk for trisomy 18 (1 in 3700) or neural tube defects (was < 1 in 10,000).
MOM|multiples of median|MOM|163|165|G 3   P	2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.4 weeks gestation. The screen was within normal limits. o AFP=1.15 MOM o Estriol= 0.76 MOM o HCG= 0.68 MOM o DIA= 0.58 MOM * Adjusted risk for Down syndrome=1:2988 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 3   P	2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.4 weeks gestation. The screen was within normal limits. o AFP=1.15 MOM o Estriol= 0.76 MOM o HCG= 0.68 MOM o DIA= 0.58 MOM * Adjusted risk for Down syndrome=1:2988 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 3   P	2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.4 weeks gestation. The screen was within normal limits. o AFP=1.15 MOM o Estriol= 0.76 MOM o HCG= 0.68 MOM o DIA= 0.58 MOM * Adjusted risk for Down syndrome=1:2988 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|143|145|G 2   P 0010				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.7 weeks gestation. The screen was within normal limits. o AFP=1.12 MOM o Estriol= 0.82 MOM o HCG= 1.74 MOM o DIA= 1.74 MOM * Adjusted risk for Down syndrome=1:282 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 2   P 0010				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.7 weeks gestation. The screen was within normal limits. o AFP=1.12 MOM o Estriol= 0.82 MOM o HCG= 1.74 MOM o DIA= 1.74 MOM * Adjusted risk for Down syndrome=1:282 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|191|193|G 1   P 0000				LMP|o Age mid trimester Down syndrome risk= 1:958 * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15+1 weeks gestation. o AFP=0.57 MOM o Estriol= 0.62 MOM o HCG= 1.58 MOM o DIA= 1.52 MOM * Adjusted risk for Down syndrome=1:145 Screen positive * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|126|128|G 1   P 0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15+1 weeks gestation. o AFP=0.57 MOM o Estriol= 0.62 MOM o HCG= 1.58 MOM o DIA= 1.52 MOM * Adjusted risk for Down syndrome=1:145 Screen positive * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|142|144|G 1   P 0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15+1 weeks gestation. o AFP=0.57 MOM o Estriol= 0.62 MOM o HCG= 1.58 MOM o DIA= 1.52 MOM * Adjusted risk for Down syndrome=1:145 Screen positive * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|253|255|G 4   P	1021				LMP|o Age mid trimester Down syndrome risk= 1:201 o Age mid trimester risk for any chromosome condition= 1:110 * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 17.4 week's gestation. o AFP=1.25 MOM o Estriol= 0.56 MOM o HCG= 2.11 MOM o DIA= 1.64 MOM * Adjusted risk for Down syndrome=1:80 Screen Positive * Adjusted risk for Trisomy 18=1:4561 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|127|129|G 4   P	1021				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 17.4 week's gestation. o AFP=1.25 MOM o Estriol= 0.56 MOM o HCG= 2.11 MOM o DIA= 1.64 MOM * Adjusted risk for Down syndrome=1:80 Screen Positive * Adjusted risk for Trisomy 18=1:4561 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|159|161|G 4   P	1021				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 17.4 week's gestation. o AFP=1.25 MOM o Estriol= 0.56 MOM o HCG= 2.11 MOM o DIA= 1.64 MOM * Adjusted risk for Down syndrome=1:80 Screen Positive * Adjusted risk for Trisomy 18=1:4561 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|325|327|G 4   P	1021				LMP|At age 35 the patient has a mid-trimester risk of carrying a baby with Down's syndrome of 1:274 and a mid-trimester risk of carrying a baby with any chromosome abnormality of 1:135. In addition, the patient had a quad screen drawn through your clinic on _%#MMDD2006#%_, at 16 weeks gestation which resulted in an AFP of 2.61 MOM and HCG 0.8 MOM, and SGO of 0.8 MOM and inhibin of 1.40 MOM. This decreased her risk to have a baby with Down's syndrome to 1:1200 and her trisomy 18 risk was estimated at 1:10,000.
MOM|multiples of median|MOM.|203|206|G 4   P	1021				LMP|In addition, the patient had a quad screen drawn through your clinic on _%#MMDD2006#%_, at 16 weeks gestation which resulted in an AFP of 2.61 MOM and HCG 0.8 MOM, and SGO of 0.8 MOM and inhibin of 1.40 MOM. This decreased her risk to have a baby with Down's syndrome to 1:1200 and her trisomy 18 risk was estimated at 1:10,000.
MOM|multiples of median|MOM|143|145|G 4   P	2012				LMP|The information below is from the recalculation using an EDC of _%#MMDD2007#%_. o AFP=1.37 MOM o Estriol= 0.67 MOM o HCG= 0.95 MOM o DIA= 0.73 MOM * Adjusted risk for Down syndrome=1:1303 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=not calculated o We discussed the fact that a revised risk for open neural tube defects was not provided because a family history of spina bifida was reported.
MOM|multiples of median|MOM|141|143|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 14 weeks gestation. The screen was within normal limits. o AFP=1.43 MOM o Estriol= 0.31 MOM o HCG= 0.86 MOM o DIA= 0.85 MOM * Adjusted risk for Down syndrome=1:1200 * Adjusted risk for Trisomy 18=1:5400 * Adjusted risk for ONTD=1:4300 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|161|163|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 14 weeks gestation. The screen was within normal limits. o AFP=1.43 MOM o Estriol= 0.31 MOM o HCG= 0.86 MOM o DIA= 0.85 MOM * Adjusted risk for Down syndrome=1:1200 * Adjusted risk for Trisomy 18=1:5400 * Adjusted risk for ONTD=1:4300 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|193|195|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 14 weeks gestation. The screen was within normal limits. o AFP=1.43 MOM o Estriol= 0.31 MOM o HCG= 0.86 MOM o DIA= 0.85 MOM * Adjusted risk for Down syndrome=1:1200 * Adjusted risk for Trisomy 18=1:5400 * Adjusted risk for ONTD=1:4300 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|180|182|G  1  P 0000				LMP|At the time, _%#NAME#%_ was 16.3 weeks gestation. The quad screen was within normal limits. The results are as follows: o AFP=2.84 MOM o Estriol=2.25 MOM o HCG=1.83 MOM o DIA=2.51 MOM * Pseudorisk for Down syndrome=1:4798 * Trisomy 18 risk= not calculated due to twins * Open neural tube defects=normal screen (<4.0 MOM) Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|milk of magnesia|MOM.|137|140|P.R.N. INCLUDES|4. Ciprofloxacin. 5. Aspirin. 6. Plavix. 7. Protonix. 8. Combivent. 9. Lopressor. P.R.N. INCLUDES: 1. Lopressor. 2. Morphine sulfate. 3. MOM. 4. Magnesium sulfate. 5. Haldol. 6. Nitroglycerin. 7. Potassium chloride. 8. Sodium phosphate. SOCIAL HISTORY: The patient is a retired community college teacher in _%#NAME#%_, Wisconsin.
MOM|multiples of median|MOM|235|237|G 4   P 2012				LMP|o Age mid trimester Down syndrome risk= 1:346 o Age mid trimester trisomy 18 risk= 1:1400 * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.6 weeks gestation. o AFP=1.06 MOM o Estriol= 0.75 MOM o HCG= 0.15 MOM o DIA= 0.36 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=1:42 Screen positive * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of trisomy 18 in the current pregnancy.
MOM|multiples of median|MOM|126|128|G 4   P 2012				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.6 weeks gestation. o AFP=1.06 MOM o Estriol= 0.75 MOM o HCG= 0.15 MOM o DIA= 0.36 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=1:42 Screen positive * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of trisomy 18 in the current pregnancy.
MOM|multiples of median|MOM|142|144|G 4   P 2012				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.6 weeks gestation. o AFP=1.06 MOM o Estriol= 0.75 MOM o HCG= 0.15 MOM o DIA= 0.36 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=1:42 Screen positive * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of trisomy 18 in the current pregnancy.
MOM|multiples of median|MOM|158|160|G 4   P 2012				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.6 weeks gestation. o AFP=1.06 MOM o Estriol= 0.75 MOM o HCG= 0.15 MOM o DIA= 0.36 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=1:42 Screen positive * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of trisomy 18 in the current pregnancy.
MOM|multiples of median|MOM|143|145|G 4  P	0030				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.7 weeks gestation. The screen was within normal limits. o AFP=0.85 MOM o Estriol= 1.34 MOM o HCG= 1.81 MOM o DIA= 0.91 MOM * Adjusted risk for Down syndrome=1:2547 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 4  P	0030				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.7 weeks gestation. The screen was within normal limits. o AFP=0.85 MOM o Estriol= 1.34 MOM o HCG= 1.81 MOM o DIA= 0.91 MOM * Adjusted risk for Down syndrome=1:2547 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 4  P	0030				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.7 weeks gestation. The screen was within normal limits. o AFP=0.85 MOM o Estriol= 1.34 MOM o HCG= 1.81 MOM o DIA= 0.91 MOM * Adjusted risk for Down syndrome=1:2547 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|154|156|LABORATORY ON ADMISSION|She reported having one dental x-ray during her pregnancy. Her quad screen levels were as follows: 1.41 MOM AFP, 0.67 MOM estriol, 1.77 MOM HCG, and 3.27 MOM inhibin. This quad screen increased her risk to have a baby with Down syndrome from her age-related risk of 1 in 491 to 1 in 217.
MOM|multiples of median|MOM|143|145|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.6 weeks gestation. The screen was within normal limits. o AFP=1.06 MOM o Estriol= 1.14 MOM o HCG= 1.48 MOM o DIA= 1.00 MOM * Adjusted risk for Down syndrome=1:3410 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.6 weeks gestation. The screen was within normal limits. o AFP=1.06 MOM o Estriol= 1.14 MOM o HCG= 1.48 MOM o DIA= 1.00 MOM * Adjusted risk for Down syndrome=1:3410 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM.|180|183|G 2   P	1001				LMP|Your patient indicated that she wished to know the gender of her child and was given this information. The alpha-fetoprotein in the amniotic fluid was within normal limits at 1.33 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|multiples of median|MOM|118|120|G 2   P	1001				LMP|At the time, your patient was 20 weeks gestation. The screen was within normal limits. o AFP=1.05 MOM o Estriol= 0.66 MOM o HCG= 1.47 MOM o DIA= 2.16 MOM * Adjusted risk for Down syndrome=1:170 * Adjusted risk for Trisomy 18=<1:10,000 * Adjusted risk for ONTD=1:5200 Please note that while the screen increased the Down syndrome approximately 2-3 fold above _%#NAME#%_'s age related risk (which is 1:470), this new risk still did not exceed the screening threshold of 1:150.
MOM|multiples of median|MOM|134|136|G 2   P	1001				LMP|At the time, your patient was 20 weeks gestation. The screen was within normal limits. o AFP=1.05 MOM o Estriol= 0.66 MOM o HCG= 1.47 MOM o DIA= 2.16 MOM * Adjusted risk for Down syndrome=1:170 * Adjusted risk for Trisomy 18=<1:10,000 * Adjusted risk for ONTD=1:5200 Please note that while the screen increased the Down syndrome approximately 2-3 fold above _%#NAME#%_'s age related risk (which is 1:470), this new risk still did not exceed the screening threshold of 1:150.
MOM|multiples of median|MOM|150|152|G 2   P	1001				LMP|At the time, your patient was 20 weeks gestation. The screen was within normal limits. o AFP=1.05 MOM o Estriol= 0.66 MOM o HCG= 1.47 MOM o DIA= 2.16 MOM * Adjusted risk for Down syndrome=1:170 * Adjusted risk for Trisomy 18=<1:10,000 * Adjusted risk for ONTD=1:5200 Please note that while the screen increased the Down syndrome approximately 2-3 fold above _%#NAME#%_'s age related risk (which is 1:470), this new risk still did not exceed the screening threshold of 1:150.
MOM|multiples of median|MOM|212|214|G 1   P 0000				LMP|o Age mid trimester Down syndrome risk= 1:897 Quad screen results: * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 18.4 weeks gestation. o AFP=5.36 MOM o Estriol= 0.32 MOM o HCG= 0.47 MOM o DIA= 0.66 MOM * Adjusted risk for Down syndrome=1:1570 * Adjusted risk for Trisomy 18=1:31 Screen positive * Adjusted risk for ONTD=>1:10 Screen positive * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of open neural tube defects.
MOM|multiples of median|MOM|126|128|G 1   P 0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 18.4 weeks gestation. o AFP=5.36 MOM o Estriol= 0.32 MOM o HCG= 0.47 MOM o DIA= 0.66 MOM * Adjusted risk for Down syndrome=1:1570 * Adjusted risk for Trisomy 18=1:31 Screen positive * Adjusted risk for ONTD=>1:10 Screen positive * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of open neural tube defects.
MOM|multiples of median|MOM|158|160|G 1   P 0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 18.4 weeks gestation. o AFP=5.36 MOM o Estriol= 0.32 MOM o HCG= 0.47 MOM o DIA= 0.66 MOM * Adjusted risk for Down syndrome=1:1570 * Adjusted risk for Trisomy 18=1:31 Screen positive * Adjusted risk for ONTD=>1:10 Screen positive * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of open neural tube defects.
MOM|multiples of median|MOM|142|144|G 2   P 0010				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.1 weeks gestation. o AFP=0.92 MOM o Estriol= 0.46 MOM o HCG= 1.99 MOM o DIA= 1.72 MOM * Adjusted risk for Down syndrome=1:44 Screen positive * Adjusted risk for Trisomy 18=1:1830 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|179|181|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.0 weeks gestation. The screen was within normal limits. o AFP=0.78 MOM o Estriol= 1.36 MOM o HCG= 0.94 MOM o DIA= 1.03 MOM * Adjusted risk for Down syndrome=1:3634 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.0 weeks gestation. The screen was within normal limits. o AFP=0.78 MOM o Estriol= 1.36 MOM o HCG= 0.94 MOM o DIA= 1.03 MOM * Adjusted risk for Down syndrome=1:3634 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|191|193|G 4   P 2012				LMP|o Age mid trimester Down syndrome risk= 1:794 * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.3 weeks gestation. o AFP=0.53 MOM o Estriol= 0.35 MOM o HCG= 1.08 MOM o DIA= 1.21 MOM * Adjusted risk for Down syndrome=1:177 Screen positive * Adjusted risk for Trisomy 18=1:397 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|126|128|G 4   P 2012				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.3 weeks gestation. o AFP=0.53 MOM o Estriol= 0.35 MOM o HCG= 1.08 MOM o DIA= 1.21 MOM * Adjusted risk for Down syndrome=1:177 Screen positive * Adjusted risk for Trisomy 18=1:397 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|158|160|G 4   P 2012				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.3 weeks gestation. o AFP=0.53 MOM o Estriol= 0.35 MOM o HCG= 1.08 MOM o DIA= 1.21 MOM * Adjusted risk for Down syndrome=1:177 Screen positive * Adjusted risk for Trisomy 18=1:397 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|143|145|G 5   P	3013				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.1 weeks gestation. The screen was within normal limits. o AFP=1.01 MOM o Estriol= 1.25 MOM o HCG= 0.61 MOM o DIA= 1.09 MOM * Adjusted risk for Down syndrome=1:2302 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * We discussed the fact that an increased nuchal thickness was seen on today's ultrasound.
MOM|multiples of median|MOM|163|165|G 5   P	3013				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.1 weeks gestation. The screen was within normal limits. o AFP=1.01 MOM o Estriol= 1.25 MOM o HCG= 0.61 MOM o DIA= 1.09 MOM * Adjusted risk for Down syndrome=1:2302 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * We discussed the fact that an increased nuchal thickness was seen on today's ultrasound.
MOM|multiples of median|MOM|179|181|G 5   P	3013				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.1 weeks gestation. The screen was within normal limits. o AFP=1.01 MOM o Estriol= 1.25 MOM o HCG= 0.61 MOM o DIA= 1.09 MOM * Adjusted risk for Down syndrome=1:2302 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * We discussed the fact that an increased nuchal thickness was seen on today's ultrasound.
MOM|multiples of median|MOM|120|122|G 5   P	3013				LMP|This delivery date was consistent with a 9-week ultrasound. Her quad screen results were as follows: 1.21 MOM AFP, 4.55 MOM HCG, 0.63 MOM Estriol, 3.84 MOM inhibit. Thus, this increased her risks for Down syndrome from her age-related risks of 1 in 920 to 1 in 90.
MOM|multiples of median|MOM|120|122|G 5   P	3013				LMP|This delivery date was consistent with a 9-week ultrasound. Her quad screen results were as follows: 1.21 MOM AFP, 4.55 MOM HCG, 0.63 MOM Estriol, 3.84 MOM inhibit. Thus, this increased her risks for Down syndrome from her age-related risks of 1 in 920 to 1 in 90.
MOM|multiples of median|MOM|134|136|G 5   P	3013				LMP|This delivery date was consistent with a 9-week ultrasound. Her quad screen results were as follows: 1.21 MOM AFP, 4.55 MOM HCG, 0.63 MOM Estriol, 3.84 MOM inhibit. Thus, this increased her risks for Down syndrome from her age-related risks of 1 in 920 to 1 in 90.
MOM|multiples of median|MOM|152|154|G 5   P	3013				LMP|This delivery date was consistent with a 9-week ultrasound. Her quad screen results were as follows: 1.21 MOM AFP, 4.55 MOM HCG, 0.63 MOM Estriol, 3.84 MOM inhibit. Thus, this increased her risks for Down syndrome from her age-related risks of 1 in 920 to 1 in 90. We reviewed possible explanations for this abnormal quad screen including normal variation, baby with Down syndrome, increased risk for pregnancy complications such as low birth weight, maternal hypertension, or per-term labor.
MOM|multiples of median|MOM|191|193|G 4   P 3003				LMP|o Age mid trimester Down syndrome risk= 1:933 * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.1 weeks gestation. o AFP=2.73 MOM o Estriol= 1.54 MOM o HCG= 1.24 MOM o DIA= 2.44 MOM * Adjusted risk for Down syndrome=1:4394 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=1:188 Screen positive * Prior to _%#NAME#%_'s ultrasound, we discussed possible explanations for an elevated AFP.
MOM|multiples of median|MOM|126|128|G 4   P 3003				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.1 weeks gestation. o AFP=2.73 MOM o Estriol= 1.54 MOM o HCG= 1.24 MOM o DIA= 2.44 MOM * Adjusted risk for Down syndrome=1:4394 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=1:188 Screen positive * Prior to _%#NAME#%_'s ultrasound, we discussed possible explanations for an elevated AFP.
MOM|multiples of median|MOM|158|160|G 4   P 3003				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.1 weeks gestation. o AFP=2.73 MOM o Estriol= 1.54 MOM o HCG= 1.24 MOM o DIA= 2.44 MOM * Adjusted risk for Down syndrome=1:4394 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=1:188 Screen positive * Prior to _%#NAME#%_'s ultrasound, we discussed possible explanations for an elevated AFP.
MOM|multiples of median|MOM,|159|162|G 4   P 3003				LMP|This letter will summarize these test results. As you know, Ms. _%#NAME#%_'s quad screen came back normal, specifically her AFP was 1.14 MOM, her hCG was 1.67 MOM, her estriol was 0.89 MOM, and inhibin was 1.60 MOM. This reduces the patient's risk to have a baby with Down syndrome from 1 in 120 to 1 in 210, her trisomy 18 risk was 1 in 480, reduced to less than 1 in 10,000 and her neural tube defect risk was reduced from 1 in 900 to 1 in 4200.
MOM|multiples of median|MOM.|198|201|HISTORY|Therefore, an amniocentesis was undertaken both for chromosome analysis and amniotic fluid alpha fetoprotein analysis. Results from twin A include a normal amniotic fluid, alpha fetoprotein of 1.04 MOM. In addition, acetylcholinesterase was absent, excluding 99.5% of open neural tube defects. Twin A's chromosome results were 46, XY (a normal male karyotype).
MOM|multiples of median|MOM,|302|305|HISTORY|It is explained that low maternal AFP and estriol levels, together with elevated hCG and dimeric inhibin A values, indicate an increased risk of Down syndrome in a pregnancy. _%#NAME#%_'s maternal serum sample was obtained on _%#MMDD2005#%_ at 16 weeks' gestation, and resulted in an AFP value of 0.91 MOM, an estriol value of 0.50 MOM, an inhibin value of 1.42 MOM, and an hCG value of 2.11 MOM. This increased the patient's risk of having a child with Down syndrome from her age-related risk of 1 in 890 to a newly adjusted risk of 1 in 120.
MOM|multiples of median|MOM,|187|190|HISTORY|_%#NAME#%_'s maternal serum sample was obtained on _%#MMDD2005#%_ at 16 weeks' gestation, and resulted in an AFP value of 0.91 MOM, an estriol value of 0.50 MOM, an inhibin value of 1.42 MOM, and an hCG value of 2.11 MOM. This increased the patient's risk of having a child with Down syndrome from her age-related risk of 1 in 890 to a newly adjusted risk of 1 in 120.
MOM|multiples of median|MOM.|217|220|HISTORY|_%#NAME#%_'s maternal serum sample was obtained on _%#MMDD2005#%_ at 16 weeks' gestation, and resulted in an AFP value of 0.91 MOM, an estriol value of 0.50 MOM, an inhibin value of 1.42 MOM, and an hCG value of 2.11 MOM. This increased the patient's risk of having a child with Down syndrome from her age-related risk of 1 in 890 to a newly adjusted risk of 1 in 120.
MOM|multiples of median|MOM|143|145|G 3   P	2002				LMP|The serum screen was drawn _%#MMDD2005#%_. At the time, your patient was 18.9 weeks gestation. The screen was within normal limits. o AFP=0.97 MOM o Estriol= 1.12 MOM o HCG= 1.28 MOM o DIA= 0.88 MOM * Adjusted risk for Down syndrome=1:3580 * Adjusted risk for Trisomy 18=1:99,494 * Adjusted risk for ONTD=1:14,000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 3   P	2002				LMP|The serum screen was drawn _%#MMDD2005#%_. At the time, your patient was 18.9 weeks gestation. The screen was within normal limits. o AFP=0.97 MOM o Estriol= 1.12 MOM o HCG= 1.28 MOM o DIA= 0.88 MOM * Adjusted risk for Down syndrome=1:3580 * Adjusted risk for Trisomy 18=1:99,494 * Adjusted risk for ONTD=1:14,000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 3   P	2002				LMP|The serum screen was drawn _%#MMDD2005#%_. At the time, your patient was 18.9 weeks gestation. The screen was within normal limits. o AFP=0.97 MOM o Estriol= 1.12 MOM o HCG= 1.28 MOM o DIA= 0.88 MOM * Adjusted risk for Down syndrome=1:3580 * Adjusted risk for Trisomy 18=1:99,494 * Adjusted risk for ONTD=1:14,000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 3   P	2002				LMP|The serum screen was drawn _%#MMDD2005#%_. At the time, your patient was 18.9 weeks gestation. The screen was within normal limits. o AFP=0.97 MOM o Estriol= 1.12 MOM o HCG= 1.28 MOM o DIA= 0.88 MOM * Adjusted risk for Down syndrome=1:3580 * Adjusted risk for Trisomy 18=1:99,494 * Adjusted risk for ONTD=1:14,000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM.|362|365|G 1   P	0000				LMP|Pregnancy History: G 1 P 0000 LMP: _%#MMDD2006#%_ Age: 36 EDC (LMP): _%#MMDD2006#%_ Age at Delivery: 36 EDC (U/S): c/w EDC (9+3 on _%#MMDD2006#%_) Gestational Age: 20+2 weeks * As mentioned above, _%#NAME#%_ had a normal amniocentesis through your office due to an abnormal serum screen (elevated Down syndrome risk). The AF-AFP was within normal limits at 1.00 MOM. Chromosomes were normal (46,XX). * No other significant complications or exposures were reported in the current pregnancy. Risk assessment for chromosome conditions: * We discussed the association between maternal age and an increasing risk for chromosome conditions, such as Down syndrome.
MOM|multiples of median|MOM|252|254|G 1   P	0000				LMP|o Age mid trimester Down syndrome risk= 1:210 o Age mid trimester risk for any chromosome condition= 1:110 * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 14+6 weeks gestation. o AFP=1.13 MOM o Estriol= 0.72 MOM o HCG= 1.41 MOM o DIA= 2.22 MOM * Adjusted risk for Down syndrome=1:107 Screen Positive * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=not calculated due to gestational age * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|126|128|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 14+6 weeks gestation. o AFP=1.13 MOM o Estriol= 0.72 MOM o HCG= 1.41 MOM o DIA= 2.22 MOM * Adjusted risk for Down syndrome=1:107 Screen Positive * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=not calculated due to gestational age * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|142|144|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 14+6 weeks gestation. o AFP=1.13 MOM o Estriol= 0.72 MOM o HCG= 1.41 MOM o DIA= 2.22 MOM * Adjusted risk for Down syndrome=1:107 Screen Positive * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=not calculated due to gestational age * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM.|189|192|G  2  P 0010				LMP|Your patient indicated that she did not wish to know the gender of her child and this information was withheld. The alpha-fetoprotein in the amniotic fluid was within normal limits at 0.96 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|multiples of median|MOM|143|145|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 17.0 weeks gestation. The screen was within normal limits. o AFP=1.10 MOM o Estriol= 1.17 MOM o HCG= 1.43 MOM o DIA= _%#MMDD#%_ MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 17.0 weeks gestation. The screen was within normal limits. o AFP=1.10 MOM o Estriol= 1.17 MOM o HCG= 1.43 MOM o DIA= _%#MMDD#%_ MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 17.0 weeks gestation. The screen was within normal limits. o AFP=1.10 MOM o Estriol= 1.17 MOM o HCG= 1.43 MOM o DIA= _%#MMDD#%_ MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 17.0 weeks gestation. The screen was within normal limits. o AFP=1.10 MOM o Estriol= 1.17 MOM o HCG= 1.43 MOM o DIA= 1/19 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.1 weeks gestation. The screen was within normal limits. o AFP=1.31 MOM o Estriol= 0.80 MOM o HCG= 1.97 MOM o DIA= 0.93 MOM * Adjusted risk for Down syndrome=1:4257 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=1:4662 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 16.1 weeks gestation. The screen was within normal limits. o AFP=1.31 MOM o Estriol= 0.80 MOM o HCG= 1.97 MOM o DIA= 0.93 MOM * Adjusted risk for Down syndrome=1:4257 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=1:4662 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM.|180|183|G 1   P	0000				LMP|Your patient indicated that she wished to know the gender of her child and was given this information. The alpha-fetoprotein in the amniotic fluid was within normal limits at 1.85 MOM. This assay excludes approximately 98% of open neural tube defects. _%#NAME#%_ also had a normal cystic fibrosis carrier test through Genzyme Genetics, reducing her cystic fibrosis carrier risk to 1:343.
MOM|multiples of median|MOM,|194|197|G 1   P	0000				LMP|Her due date was consistent using an ultrasound. She reported no smoking, no alcohol use, medications or drugs during her pregnancy. Her triple-screen levels were as follows: AFP 0.86 MOM, 0.71 MOM, Estriol and 2.29 MOM HCG. Thus, this increased her chance to have a baby with Down syndrome from her age-related risk of 1 in 385 to 1 in 106.
MOM|multiples of median|MOM|143|145|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.7 weeks gestation. The screen was within normal limits. o AFP=0.79 MOM o Estriol= 0.63 MOM o HCG= 1.22 MOM o DIA= 0.81 MOM * Adjusted risk for Down syndrome=1:280 * Adjusted risk for Trisomy 18=<1:3461 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.7 weeks gestation. The screen was within normal limits. o AFP=0.79 MOM o Estriol= 0.63 MOM o HCG= 1.22 MOM o DIA= 0.81 MOM * Adjusted risk for Down syndrome=1:280 * Adjusted risk for Trisomy 18=<1:3461 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 5   P	0040				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.4 weeks gestation. The screen was within normal limits. o AFP=0.87 MOM o Estriol= 1.34 MOM o HCG= 0.29 MOM o DIA= 1.33 MOM * Adjusted risk for Down syndrome=1:2022 * Adjusted risk for Trisomy 18=Not increased * Adjusted risk for ONTD=<1:10,000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 5   P	0040				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.4 weeks gestation. The screen was within normal limits. o AFP=0.87 MOM o Estriol= 1.34 MOM o HCG= 0.29 MOM o DIA= 1.33 MOM * Adjusted risk for Down syndrome=1:2022 * Adjusted risk for Trisomy 18=Not increased * Adjusted risk for ONTD=<1:10,000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|milk of magnesia|MOM|124|126|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1. Depakote ER 1,500 mg p.o. h.s. 2. Ativan 1-2 mg IM q.6 p.r.n. 3. Maalox 30 cc p.o. q.i.d. p.r.n. 4. MOM 30 cc p.o. daily p.r.n. 5. Zyprexa 10 mg p.o. h.s. 6. Zyprexa 5-10 mg tablets p.o. q.6 p.r.n. for agitation.
MOM|multiples of median|MOM|194|196|PLAN|The patient also had a quad screen which was reviewed at the time of our visit. The patient's quad screen was drawn through your clinic on _%#MM#%_ _%#DD#%_, 2006 and resulted in an AFP of 1.62 MOM and HCG of 0.5 MOM and estriol of 1.61 MOM. This resulted in a decrease in the patient's age-related risk to have a baby with Down syndrome from 1 in 452 to 1 in 9,190.
MOM|multiples of median|MOM,|167|170|PLAN|The patient had a quad screen drawn on _%#MM#%_ _%#DD#%_, 2005, at 17 1/7 weeks gestation. This resulted in an AFP of 0.76 MOM, an hCG of 1.76 MOM, an estriol of 0.72 MOM, and an inhibin of 2.16 MOM. This increased the patient's age related risk to have a baby with Down syndrome from 1 in 1100 to 1 in 130.
MOM|multiples of median|MOM|126|128|G 1   P 0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.4 weeks gestation. o AFP=1.18 MOM o Estriol= 0.67 MOM o HCG= 2.90 MOM o DIA= 2.55 MOM * Adjusted risk for Down syndrome=1:194 Screen positive * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|158|160|G 1   P 0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.4 weeks gestation. o AFP=1.18 MOM o Estriol= 0.67 MOM o HCG= 2.90 MOM o DIA= 2.55 MOM * Adjusted risk for Down syndrome=1:194 Screen positive * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM.|384|387|G  2  P 1001				LMP|o PAPP-A= 2.4 MOM o Free Beta= 1.06 MOM o NT (twin A)=1.3 mm o NT (twin B)=1.6 mm * Adjusted risk for Down syndrome= 1:4261 (for each twin) * Adjusted risk for Trisomy 18 or 13= 1:7761 (for each twin) * _%#NAME#%_ had a maternal serum AFP drawn in your office on _%#MMDD2006#%_. At the time, she was 16.6 weeks gestation. The AFP was within normal limits for a twin pregnancy at 1.76 MOM. Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|143|145|G 2   P 1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.9 weeks gestation. The screen was within normal limits. o AFP=0.82 MOM o Estriol= 1.03 MOM o HCG= 2.19 MOM o DIA= 0.92 MOM * Adjusted risk for Down syndrome=1:3060 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 2   P 1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.9 weeks gestation. The screen was within normal limits. o AFP=0.82 MOM o Estriol= 1.03 MOM o HCG= 2.19 MOM o DIA= 0.92 MOM * Adjusted risk for Down syndrome=1:3060 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 2   P 1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.9 weeks gestation. The screen was within normal limits. o AFP=0.82 MOM o Estriol= 1.03 MOM o HCG= 2.19 MOM o DIA= 0.92 MOM * Adjusted risk for Down syndrome=1:3060 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|126|128|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.7 weeks gestation. o AFP=1.13 MOM o Estriol= 0.70 MOM o HCG= 1.95 MOM o DIA= 1.27 MOM * Adjusted risk for Down syndrome=1:195 Screen Positive * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * We discussed the fact that the quad screen had reduced the risk for Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|158|160|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.7 weeks gestation. o AFP=1.13 MOM o Estriol= 0.70 MOM o HCG= 1.95 MOM o DIA= 1.27 MOM * Adjusted risk for Down syndrome=1:195 Screen Positive * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 * We discussed the fact that the quad screen had reduced the risk for Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|163|165|G 3  P	2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.7 weeks gestation. The screen was within normal limits. o AFP=1.05 MOM o Estriol= 1.11 MOM o HCG= 1.57 MOM o DIA= 1.24 MOM * Adjusted risk for Down syndrome=1:547 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 3  P	2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.7 weeks gestation. The screen was within normal limits. o AFP=1.05 MOM o Estriol= 1.11 MOM o HCG= 1.57 MOM o DIA= 1.24 MOM * Adjusted risk for Down syndrome=1:547 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 3  P	2002				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 15.7 weeks gestation. The screen was within normal limits. o AFP=1.05 MOM o Estriol= 1.11 MOM o HCG= 1.57 MOM o DIA= 1.24 MOM * Adjusted risk for Down syndrome=1:547 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|143|145|G 1  P	0000				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 17.4 weeks gestation. The screen was within normal limits. o AFP=0.89 MOM o Estriol= 0.98 MOM o HCG= 1.80 MOM o DIA= 1.10 MOM * Adjusted risk for Down syndrome=1:2399 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 1  P	0000				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 17.4 weeks gestation. The screen was within normal limits. o AFP=0.89 MOM o Estriol= 0.98 MOM o HCG= 1.80 MOM o DIA= 1.10 MOM * Adjusted risk for Down syndrome=1:2399 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 1  P	0000				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 17.4 weeks gestation. The screen was within normal limits. o AFP=0.89 MOM o Estriol= 0.98 MOM o HCG= 1.80 MOM o DIA= 1.10 MOM * Adjusted risk for Down syndrome=1:2399 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 1  P	0000				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 17.4 weeks gestation. The screen was within normal limits. o AFP=0.89 MOM o Estriol= 0.98 MOM o HCG= 1.80 MOM o DIA= 1.10 MOM * Adjusted risk for Down syndrome=1:2399 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM.|189|192|G 4   P	0030				LMP|Your patient indicated that she did not wish to know the gender of her child and this information was withheld. The alpha-fetoprotein in the amniotic fluid was within normal limits at 0.92 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|multiples of median|MOM|144|146|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.29 weeks gestation. The screen was within normal limits. o AFP=0.98 MOM o Estriol= 0.42 MOM o HCG= 0.96 MOM o DIA= 0.94 MOM * Adjusted risk for Down syndrome=1:10,000 * Adjusted risk for Trisomy 18=1:10,000 * Adjusted risk for ONTD=1:10,000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|164|166|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.29 weeks gestation. The screen was within normal limits. o AFP=0.98 MOM o Estriol= 0.42 MOM o HCG= 0.96 MOM o DIA= 0.94 MOM * Adjusted risk for Down syndrome=1:10,000 * Adjusted risk for Trisomy 18=1:10,000 * Adjusted risk for ONTD=1:10,000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|219|221|G 2   P	0010				LMP|The screen was within normal limits. * The original screen was calculated using an EDC of _%#MMDD2008#%_. I contacted Quest Diagnostics to have the screen recalculated and the recalculated results are below: o AFP=1.19 MOM o Estriol= 0.85 MOM o HCG= 0.52 MOM o DIA= 0.48 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=1:3821 * Adjusted risk for ONTD=1:2218 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|255|257|G 2   P	0010				LMP|The screen was within normal limits. * The original screen was calculated using an EDC of _%#MMDD2008#%_. I contacted Quest Diagnostics to have the screen recalculated and the recalculated results are below: o AFP=1.19 MOM o Estriol= 0.85 MOM o HCG= 0.52 MOM o DIA= 0.48 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=1:3821 * Adjusted risk for ONTD=1:2218 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 4   P	2012				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.2 weeks gestation. The screen was within normal limits. o AFP=1.38 MOM o Estriol= 1.23 MOM o HCG= 0.93 MOM o DIA= 0.80 MOM * Adjusted risk for Down syndrome=1:6400 * Adjusted risk for Trisomy 18=<1:100 * Adjusted risk for ONTD=Normal screen Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|142|144|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.4 weeks gestation. The screen was within normal limits. o AFP=1.0 MOM o Estriol= 0.84 MOM o HCG= 0.39 MOM o DIA= 0.78 MOM * Adjusted risk for Down syndrome=1:3150 * Adjusted risk for Trisomy 18=not increased * Adjusted risk for ONTD=<1:10,000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|178|180|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.4 weeks gestation. The screen was within normal limits. o AFP=1.0 MOM o Estriol= 0.84 MOM o HCG= 0.39 MOM o DIA= 0.78 MOM * Adjusted risk for Down syndrome=1:3150 * Adjusted risk for Trisomy 18=not increased * Adjusted risk for ONTD=<1:10,000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|194|196|G 1   P	0000				LMP|The serum screen was drawn _%#MMDD2006#%_. At the time, your patient was 17.4 weeks gestation. The screen was within normal limits. o AFP=1.0 MOM o Estriol= 0.84 MOM o HCG= 0.39 MOM o DIA= 0.78 MOM * Adjusted risk for Down syndrome=1:3150 * Adjusted risk for Trisomy 18=not increased * Adjusted risk for ONTD=<1:10,000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|192|194|G 1   P 0000				LMP|o Age mid trimester Down syndrome risk= 1:1187 * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.3 weeks gestation. o AFP=0.57 MOM o Estriol= 0.34 MOM o HCG= 1.87 MOM o DIA= 1.52 MOM * Adjusted risk for Down syndrome=1:68 Screen positive * Adjusted risk for Trisomy 18=1:1575 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|126|128|G 1   P 0000				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.3 weeks gestation. o AFP=0.57 MOM o Estriol= 0.34 MOM o HCG= 1.87 MOM o DIA= 1.52 MOM * Adjusted risk for Down syndrome=1:68 Screen positive * Adjusted risk for Trisomy 18=1:1575 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|142|144|G 1   P 0000				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.3 weeks gestation. o AFP=0.57 MOM o Estriol= 0.34 MOM o HCG= 1.87 MOM o DIA= 1.52 MOM * Adjusted risk for Down syndrome=1:68 Screen positive * Adjusted risk for Trisomy 18=1:1575 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|158|160|G 1   P 0000				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.3 weeks gestation. o AFP=0.57 MOM o Estriol= 0.34 MOM o HCG= 1.87 MOM o DIA= 1.52 MOM * Adjusted risk for Down syndrome=1:68 Screen positive * Adjusted risk for Trisomy 18=1:1575 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|163|165|G 3   P	2002				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 17.1 weeks gestation. The screen was within normal limits. o AFP=1.54 MOM o Estriol= 0.48 MOM o HCG= 0.65 MOM o DIA= 0.83 MOM * Adjusted risk for Down syndrome=1:604 * Adjusted risk for Trisomy 18=1:232 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 3   P	2002				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 17.1 weeks gestation. The screen was within normal limits. o AFP=1.54 MOM o Estriol= 0.48 MOM o HCG= 0.65 MOM o DIA= 0.83 MOM * Adjusted risk for Down syndrome=1:604 * Adjusted risk for Trisomy 18=1:232 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|253|255|G 3   P	2002				LMP|I spent approximately 45 minutes with this patient today. Letitia is a 34-year-old Gravida 5, para 4-0-0-4 who is currently 19 weeks gestation based on estimated date of delivery of _%#MM#%_ _%#DD#%_, 2007. Her quad screen results were as follows: 0.74 MOM AFP, 1.15 MOM HCG, 1.22 MOM Estriol, and 2.42 MOM inhibin. This, this increases her chances to have a baby with Down's syndrome with her age-related risk of 1 in 310 to 1 in 80.
MOM|multiples of median|MOM|284|286|G 3   P	2002				LMP|I spent approximately 45 minutes with this patient today. _%#NAME#%_ is a 34-year-old Gravida 5, para 4-0-0-4 who is currently 19 weeks gestation based on estimated date of delivery of _%#MM#%_ _%#DD#%_, 2007. Her quad screen results were as follows: 0.74 MOM AFP, 1.15 MOM HCG, 1.22 MOM Estriol, and 2.42 MOM inhibin. This, this increases her chances to have a baby with Down's syndrome with her age-related risk of 1 in 310 to 1 in 80.
MOM|multiples of median|MOM|152|154|G 1   P	0000				LMP|I had the screen re-calculated for _%#NAME#%_'s actual weight at the time, which was 103 pounds. The recalculated values are reported below: o AFP=1.37 MOM o Estriol= 1.72 MOM o HCG= 0.38 MOM o DIA= 0.99 MOM * Adjusted risk for Down syndrome=<1:10,000 * Adjusted risk for Trisomy 18=<1:10,000 * Adjusted risk for ONTD=1:7000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|172|174|G 1   P	0000				LMP|I had the screen re-calculated for _%#NAME#%_'s actual weight at the time, which was 103 pounds. The recalculated values are reported below: o AFP=1.37 MOM o Estriol= 1.72 MOM o HCG= 0.38 MOM o DIA= 0.99 MOM * Adjusted risk for Down syndrome=<1:10,000 * Adjusted risk for Trisomy 18=<1:10,000 * Adjusted risk for ONTD=1:7000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|171|173|G 2   P 1001				LMP|The results below are the results of the recalculated quad screen. The original quad screen was abnormal with 1:122 risk for Down syndrome. o AFP=0.61 MOM o Estriol= 1.22 MOM o HCG= 1.28 MOM o DIA= 1.05 MOM * Adjusted risk for Down syndrome=1:2892 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=Not calculated (GA<15 weeks) * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|120|122|G 2   P 1001				LMP|The original quad screen was abnormal with 1:122 risk for Down syndrome. o AFP=0.61 MOM o Estriol= 1.22 MOM o HCG= 1.28 MOM o DIA= 1.05 MOM * Adjusted risk for Down syndrome=1:2892 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=Not calculated (GA<15 weeks) * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM.|161|164|G 2   P 1001				LMP|_%#NAME#%_'s quad screen was drawn on _%#MM#%_ _%#DD#%_, 2007. At the time she was 17.57 weeks gestation. Her results are as follows: AFP = 0.55 MOM. HCG = 0.31 MOM. Estriol = 1.16 MOM. DIA = 0.53 MOM. This screen significantly reduced the risk for Down's syndrome to less than 1:10,000.
MOM|multiples of median|MOM.|181|184|G 2   P 1001				LMP|_%#NAME#%_'s quad screen was drawn on _%#MM#%_ _%#DD#%_, 2007. At the time she was 17.57 weeks gestation. Her results are as follows: AFP = 0.55 MOM. HCG = 0.31 MOM. Estriol = 1.16 MOM. DIA = 0.53 MOM. This screen significantly reduced the risk for Down's syndrome to less than 1:10,000. The risk for spina bifida was also reduced to less than 1:10,000.
MOM|multiples of median|MOM.|180|183|G 2   P	1001				LMP|Your patient indicated that she wished to know the gender of her child and was given this information. The alpha-fetoprotein in the amniotic fluid was within normal limits at 0.80 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|milk of magnesia|MOM|170|172|CURRENT MEDICATIONS|2. Compazine 5 mg IV q.6 hours p.r.n. 3. Zofran 1 mg IV q.6h. 4. Dulcolax 10 mg suppository every day p.r.n. for constipation. 5. Senokot 1-2 tablet p.o. daily p.r.n. 6. MOM 30 cc daily p.r.n. 7. Zantac 75-150 mg p.o. b.i.d. 8. Flexeril 10 mg p.o. t.i.d. p.r.n. 9. Vistaril 50 mg IV q.4 hours p.r.n. 10. Ambien 5 mg p.o. each day at bedtime p.r.n.
MOM|multiples of median|MOM.|180|183|G 2   P	1001				LMP|Your patient indicated that she wished to know the gender of her child and was given this information. The alpha-fetoprotein in the amniotic fluid was within normal limits at 1.10 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|multiples of median|MOM|251|253|G 3   P 2002				LMP|o Age mid trimester Down syndrome risk= 1:232 o Age mid trimester risk for any chromosome condition=1:110 * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 19.6 weeks gestation. o AFP=1.56 MOM o Estriol= 0.49 MOM o HCG= 1.56 MOM o DIA= 1.19 MOM * Adjusted risk for Down syndrome=1:155 Screen positive * Adjusted risk for Trisomy 18=1:1673 * Adjusted risk for ONTD=1:970 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|158|160|G 3   P 2002				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 19.6 weeks gestation. o AFP=1.56 MOM o Estriol= 0.49 MOM o HCG= 1.56 MOM o DIA= 1.19 MOM * Adjusted risk for Down syndrome=1:155 Screen positive * Adjusted risk for Trisomy 18=1:1673 * Adjusted risk for ONTD=1:970 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM.|180|183|G 3   P 0020				LMP|Your patient indicated that she wished to know the gender of her child and was given this information. The alpha-fetoprotein in the amniotic fluid was within normal limits at 0.85 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|multiples of median|MOM|189|191|G 1   P 0000				LMP|o Age mid trimester Down syndrome risk= 1:710 * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 20 weeks gestation. o AFP=0.97 MOM o Estriol= 0.42 MOM o HCG= 5.06 MOM o DIA= 1.42 MOM * Adjusted risk for Down syndrome=1:90 Screen positive * Adjusted risk for Trisomy 18=1:2600 * Adjusted risk for ONTD=1:6200 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|140|142|G 1   P 0000				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 20 weeks gestation. o AFP=0.97 MOM o Estriol= 0.42 MOM o HCG= 5.06 MOM o DIA= 1.42 MOM * Adjusted risk for Down syndrome=1:90 Screen positive * Adjusted risk for Trisomy 18=1:2600 * Adjusted risk for ONTD=1:6200 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM.|492|495|G 1   P 0000				LMP|o AFP=0.97 MOM o Estriol= 0.42 MOM o HCG= 5.06 MOM o DIA= 1.42 MOM * Adjusted risk for Down syndrome=1:90 Screen positive * Adjusted risk for Trisomy 18=1:2600 * Adjusted risk for ONTD=1:6200 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy. * We discussed the fact that the HCG was significantly elevated at 5.06 MOM. I explained that there previously was discussion about whether elevated HCG is associated with an increased risk for abnormal pregnancy outcomes.
MOM|multiples of median|MOM.|180|183|G 1   P 0000				LMP|Your patient indicated that she wished to know the gender of her child and was given this information. The alpha-fetoprotein in the amniotic fluid was within normal limits at 0.97 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|multiples of median|MOM|143|145|G 7   P	1051				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.3 week's gestation. o AFP=1.12 MOM o Estriol= 0.78 MOM o HCG= 0.67 MOM o DIA= 2.14 MOM * Adjusted risk for Down syndrome=1:231 Screen Positive * Adjusted risk for Trisomy 18=1:1636 * Adjusted risk for ONTD=<1:5000 * We discussed the fact that the screen had actually reduced the risk for Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|150|152|G 3  P	2002				LMP|This was performed at your clinic. The first trimester screening was performed on _%#MMDD2007#%_. The screen was within normal limits. o PAPP-A= 1.04 MOM o Free Beta= 0.83 MOM o NT=1.09 mm * Adjusted risk for Down syndrome= <1:5000 * Adjusted risk for Trisomy 18= <1:5000 * AFP was drawn at your clinic to screen for open neural tube defects.
MOM|multiples of median|MOM|143|145|G 3   P	1011				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.7 weeks gestation. The screen was within normal limits. o AFP=0.98 MOM o Estriol= 0.97 MOM o HCG= 0.68 MOM o DIA= 0.53 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|163|165|G 3   P	1011				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.7 weeks gestation. The screen was within normal limits. o AFP=0.98 MOM o Estriol= 0.97 MOM o HCG= 0.68 MOM o DIA= 0.53 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 3   P	1011				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.7 weeks gestation. The screen was within normal limits. o AFP=0.98 MOM o Estriol= 0.97 MOM o HCG= 0.68 MOM o DIA= 0.53 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 3   P	1011				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 15.7 weeks gestation. The screen was within normal limits. o AFP=0.98 MOM o Estriol= 0.97 MOM o HCG= 0.68 MOM o DIA= 0.53 MOM * Adjusted risk for Down syndrome=<1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|143|145|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 17.3 weeks gestation. The screen was within normal limits. o AFP=1.06 MOM o Estriol= 1.42 MOM o HCG= 0.69 MOM o DIA= 0.71 MOM * Adjusted risk for Down syndrome=1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|179|181|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 17.3 weeks gestation. The screen was within normal limits. o AFP=1.06 MOM o Estriol= 1.42 MOM o HCG= 0.69 MOM o DIA= 0.71 MOM * Adjusted risk for Down syndrome=1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM|195|197|G 2   P	1001				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 17.3 weeks gestation. The screen was within normal limits. o AFP=1.06 MOM o Estriol= 1.42 MOM o HCG= 0.69 MOM o DIA= 0.71 MOM * Adjusted risk for Down syndrome=1:5000 * Adjusted risk for Trisomy 18=<1:5000 * Adjusted risk for ONTD=<1:5000 Testing Options: * Amniocentesis is an invasive test that can diagnose numerical chromosome abnormalities with greater than 99% accuracy.
MOM|multiples of median|MOM.|189|192|IMPRESSION|Your patient indicated that she did not wish to know the gender of her child and this information was withheld. The alpha-fetoprotein in the amniotic fluid was within normal limits at 1.20 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|milk of magnesia|MOM|122|124|DISCHARGE MEDICATIONS|10. Tylenol 325 to 650 mg p.o. q.6-8 h. p.r.n. 11. Artificial Tears p.r.n. 12. Vicodin 1 tab p.o. q.4 h. p.r.n. pain. 13. MOM 30 mL p.o. daily p.r.n. 14. Oxycodone 5 mg p.o. 6 h. p.r.n. extreme pain. 15. MiraLax 17 gm p.o. daily p.r.n. 16. Phenergan 12.5 mg p.o. q.12 h. p.r.n.
MOM|GENERAL ENGLISH|MOM|140|142|ALLERGIES|ALLERGIES: PATIENT IS ALLERGIC TO IODINE, ALTHOUGH SHE REPORTS THAT SHE IS UNSURE IF SHE IS TRULY ALLERGIC OR NOT. SHE JUST STATES THAT HER MOM TOLD HER AT ONE POINT THAT SHE WAS ALLERGIC. SHE HAS NOT HAD ANY REACTIONS THAT SHE KNOWS OF. PHYSICAL EXAMINATION: On exam, patient was afebrile, pulse was 100, respirations were 20, BP was 131/66, sats were 100% on room air.
MOM|milk of magnesia|MOM|128|130|MEDICATIONS ON TRANSFER|14. Ativan 0.5 mg IV q.4 h. p.r.n. anxiety. 15. Ativan 1 mg p.o. q.4 h. p.r.n. for anxiety. 16. Lopressor 50 mg p.o. b.i.d. 17. MOM 30 mL suspension p.o. p.r.n. for constipation. 18. Nasonex 2 sprays for both nostrils daily. 19. Protonix EC 40 mg p.o. daily.
MOM|milk of magnesia|MOM|145|147|DISCHARGE MEDICATIONS|9. Lexapro 10 mg p.o. q. 48h. alternating with 20 mg. 10. Mylanta 30 mL p.o. q.4h. p.r.n. gastric distress. 11. Metoprolol 25 mg p.o. b.i.d. 12. MOM 30 mL p.o. b.i.d. p.r.n. constipation. 13. Multivitamin one tablet daily. 14. Zofran 4 mg p.o. q.6h. p.r.n. nausea. 15. Protonix 40 mg p.o. daily. 16. Phosphate enema PR daily p.r.n. constipation.
MOM|multiples of median|MOM|251|253|G 4   P	0030				LMP|o Age mid trimester Down syndrome risk= 1:113 o Age mid trimester risk for any chromosome condition= 1:89 * We reviewed serum-screening results. The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.7 weeks gestation. o AFP=1.09 MOM o Estriol= 0.58 MOM o HCG= 0.82 MOM o DIA= 1.65 MOM * Adjusted risk for Down syndrome=1:151 Screen Positive * Adjusted risk for Trisomy 18=1:698 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|multiples of median|MOM|126|128|G 4   P	0030				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 16.7 weeks gestation. o AFP=1.09 MOM o Estriol= 0.58 MOM o HCG= 0.82 MOM o DIA= 1.65 MOM * Adjusted risk for Down syndrome=1:151 Screen Positive * Adjusted risk for Trisomy 18=1:698 * Adjusted risk for ONTD=<1:5000 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MOM|milk of magnesia|MOM|218|220|RECOMMENDATIONS|RECOMMENDATIONS: 1. TLC social work to see the patient early next week for interventions as noted above. 2. TLC chaplains to continue spiritual support. 3. Senokot-S 1 p.o. b.i.d. scheduled and Dulcolax suppository or MOM p.r.n. no bowel movement after 2 days. Laxatives should be continued as long as the patient is on opioid treatment. Can be made p.r.n. after that. 4. Give Percocet 2 tabs 30 minutes prior to anticipated physical therapy sessions as long as pain continues to be significant.
MOM|milk of magnesia|MOM|179|181|MEDICATIONS|All siblings have passed away, mostly from various cancers. MEDICATIONS: 1. Aspirin 81 mg daily. 2. Synthroid 0.088 mg daily. 3. Xalatan eye drops. 4. Colace one tablet daily. 5. MOM daily. 6. Lisinopril 5 mg daily. ALLERGIES: NONE. REVIEW OF SYSTEMS: He has continued to have problems with chronic constipation.
MOM|milk of magnesia|MOM,|223|226|MEDICATIONS|3. History of depression. 4. History of hypercholesterolemia. 5. Current history of reflux esophagitis. ALLERGIES: No known drug allergies. MEDICATIONS: The patient is on Klonopin, Lovenox, Prozac, Levaquin, levothyroxine, MOM, Protonix, lisinopril, hydralazine, labetolol, Lasix, and metoprolol. P.r.n. medications are albuterol, Zofran, morphine sulfate, and Tylenol. LABORATORY DATA: On _%#MMDD2006#%_, he had hemoglobin of 12.5, with a white count of 9.6, hematocrit 37.7, platelets 342.
MOM|milk of magnesia|MOM|176|178|HOSPITAL MEDICATIONS|6. Azithromycin 600 mg p.o. every day. 7. Fuzeon 90 mg subcu q.12 h. 8. Ethambutol 1200 mg p.o. every day. 9. Dulcolax suppository per rectum every other day as scheduled. 10. MOM every other day scheduled. 11. Effexor XR 150 mg p.o. every day. 12. Seroquel 50 mg p.o. q.h.s. 13. Gabapentin 900 mg p.o. three times a day.
MOM|multiples of median|MOM.|189|192|ASSESSMENT/PLAN|Your patient indicated that she did not wish to know the gender of her child and this information was withheld. The alpha-fetoprotein in the amniotic fluid was within normal limits at 1.37 MOM. This assay excludes approximately 98% of open neural tube defects. If you have any questions concerning this report, please do not hesitate to call me.
MOM|multiples of median|MOM.|147|150|HISTORY|Twin A's chromosome results were 46, XY (a normal male karyotype). Twin B's amniotic fluid alpha fetoprotein was also within normal limits at 1.68 MOM. Acetylcholinesterase was absent from the amniotic fluid. Fetal chromosomes showed a normal female karyotype (46, XX). This was consistent with the ultrasound findings, but discrepant from the initial CVS chromosome results.
MOM|multiples of median|MOM|242|244|PLAN|_%#NAME#%_ _%#NAME#%_ is a 29-year-old, gravida 2, para 1-1-0-1, who is currently 21 weeks and 3 days' gestation, based on estimated date of delivery of _%#MMDD2006#%_. Her quad screen levels were as follows: 1.12 MOM AFP, 3.10 MOM hCG, 0.83 MOM estriol, and 1.67 MOM inhibin. Her quad screen increased her chance of a baby with Down syndrome from her age-related risk of 1 in 790 to 1 in 140.
MOM|multiples of median|MOM|126|128|G 3   P 2002				LMP|The serum screen was drawn _%#MMDD2007#%_. At the time, your patient was 19.6 weeks gestation. o AFP=1.56 MOM o Estriol= 0.49 MOM o HCG= 1.56 MOM o DIA= 1.19 MOM * Adjusted risk for Down syndrome=1:155 Screen positive * Adjusted risk for Trisomy 18=1:1673 * Adjusted risk for ONTD=1:970 * We discussed possible explanations for an abnormal serum screen including inconsistencies in pregnancy dating, normal variations in the levels of these chemicals, and the possibility of Down syndrome in the current pregnancy.
MP|mercaptopurine|MP,|175|177|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is an 18-year-old male who was diagnosed with ALL in _%#MM2002#%_. He underwent induction chemotherapy and is currently receiving daily MP, weekly methotrexate, and monthly vincristine and prednisone therapy. He is now postoperative day #2, status post right femoral head resurfacing hemiarthroplasty secondary to avascular necrosis related to the prednisone therapy with postoperative course complicated by a fever and neutropenia, without swelling and erythema at the incision site.
MP|(device) MP|MP|229|230|DISCHARGE MEDICATIONS|The patient was taking 5 tabs with each meal, and had improvement with her diarrhea, having approximately an average of 1 bowel movement after a meal, 4 to 5 bowel movements per day. DISCHARGE MEDICATIONS: 1. Pancrease (Ultrase) MP 20 - 5 tabs orally before meals. The tablets consist of 20,000 units of lipase, 65,000 units of amylase, and 65,000 units of protease with each meal.
MP|mercaptopurine|MP|108|109|MEDICATIONS|HABITS: Occasional smoker. Occasional alcohol, occasional caffeine. No regular exercise. MEDICATIONS: 1. 6. MP 75 mg q. daily 2. HCTZ 12.5 mg q. daily 3. prochlorperazine 10 mg q.6h. p.r.n. nausea. 4. Atenolol 100 mg daily
MP|metatarsophalangeal/metacarpophalangeal|MP|180|181|PHYSICAL EXAMINATION|She has a tender painful nodule at the MP joint, likely the remnant of her flexor profundus. She is stable to radial and ulnar deviation at the DIP and PIP joint as well as at the MP joint. She has full active extension at therapy MP, PIP and DIP joint. IMPRESSION: Flexor tendon laceration that is only retracted to the MP joint level.
MP|metatarsophalangeal/metacarpophalangeal|MP,|138|140|PHYSICAL EXAMINATION|She is stable to radial and ulnar deviation at the DIP and PIP joint as well as at the MP joint. She has full active extension at therapy MP, PIP and DIP joint. IMPRESSION: Flexor tendon laceration that is only retracted to the MP joint level.
MP|metatarsophalangeal/metacarpophalangeal|MP|131|132|IMPRESSION|She has full active extension at therapy MP, PIP and DIP joint. IMPRESSION: Flexor tendon laceration that is only retracted to the MP joint level. PLAN: Is to proceed with a flexor tendon repair. Her surgery is being scheduled for _%#MMDD#%_.
MP|mercaptopurine|MP.|222|224|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is an 11-year-old male with pre-B cell Acute lymphocytic leukemia (ALL) diagnosed in _%#MM2005#%_, admitted for interim maintenance chemotherapy with vincristine, methotrexate, and 6 MP. He was admitted through the clinic, where he had an lumbar puncture and intrathecal methotrexate. He denied recent illness including cough, nausea, vomiting, fevers, chills, night sweats, no sore throat, diarrhea, dysuria.
MP|mercaptopurine|MP,|202|204|HOSPITAL COURSE|CSF labs at time of admission were pending. HOSPITAL COURSE: PROBLEM #1. Pre-B cell acute lymphocytic leukemia: As previously mentioned, _%#NAME#%_ was admitted for interim maintenance including oral 6 MP, IV vincristine and IV methotrexate. At the time of admission, elevated LFTs were noted, and thought secondary to dapsone, which was subsequently discontinued.
MP|mercaptopurine|MP|188|189|HOSPITAL COURSE|_%#NAME#%_ tolerated his chemotherapy well with minimal nausea and no emesis. At the time of discharge, he was in no apparent distress and was afebrile. He went home with daily doses of 6 MP which they plan to crush, at home, to help swallowing. Also at the time of his discharge he was switched from dapsone to Bactrim, which was also to be crushed and mixed in with his food for PCP prophylaxis.
MP|metacarpophalangeal|MP|296|297|PHYSICAL EXAMINATION|HEART: Is regular rate and rhythm EXAMINATION OF HIS LEFT UPPER EXTREMITY: Reveals a laceration on the ulnar side of his finger more towards the dorsal aspect along the PIP joint and then a large volar laceration extending from the DIP crease on the radial side just to about 1 cm. distal to the MP crease of the finger. He does have a positive Tinel's proximally at the finger. His profundus and superficialis are intact. His two point discrimination on that side is greater than 15 mm.
MP|metacarpophalangeal|MP|200|201|PHYSICAL EXAMINATION|HEENT : Normocephalic, atraumatic CHEST: Lungs are clear HEART: Regular rate and rhythm EXTREMITIES: Examination of her left upper extremity reveals a small 5 mm wound at the base of her thumb on the MP crease, located more towards the radial side. She has full FPL pull-through as well as full extension. Her two point discrimination on the radial side, however, is greater than 14 mm.
MP|metatarsophalangeal|MP|116|117|DOB|The problem started approximately 20 years ago when he developed pain in a "corn" on the medial aspect of his first MP joint of his right foot. He was given shoe inserts, which helped. The corn ultimately resolved, and he did fine for a time, but then pain became more prominent in the bottom of his first MP joint on the right foot.
MP|metatarsophalangeal|MP|162|163|DOB|He was given shoe inserts, which helped. The corn ultimately resolved, and he did fine for a time, but then pain became more prominent in the bottom of his first MP joint on the right foot. The pain spread across his metatarsal heads in the same foot. He did have a surgical procedure in the past, which involved his metatarsal heads.
MP|metatarsophalangeal|MP|129|130|PHYSICAL EXAM|GENITORECTAL: Deferred. UPPER EXTREMITIES: Negative. LOWER EXTREMITIES: Large callus present on the plantar surface of his first MP joint, right foot. Complete findings of his right foot are deferred to his operating surgeon. IMPRESSION AT THIS TIME: Chronic right foot pain. LABORATORY FINDINGS: Hemoglobin 15.2 gm percent, WBC 6,300 with 64 neutrophils, 27 lymphs, 6 monos, 2 eosinophils, 1 basophil.
MP|metacarpophalangeal|MP|183|184|PHYSICAL EXAMINATION|He has got swelling on the ulnar border of his hand with gentle range of motion of his fingers, his small finger completely rotates underneath his ring finger when flexed down at the MP joint. He has full profundus and superficialis pull through. He also has full extension. Review of his x-rays show a oblique spiral fracture to the fifth metacarpal neck with it shifted ulnarly.
MP|metacarpophalangeal|(MP)|208|211|PHYSICAL EXAMINATION|HEENT: Normocephalic, atraumatic. LUNGS: Clear at both bases. HEART: Regular rate and rhythm. LEFT THUMB: There is a laceration along the ulnar border extending about 1.0-cm distal to the metacarpophalangeal (MP) crease and then carried distally. There is loss of two-point discrimination greater than 12.0-mm on that ulnar border. IMPRESSION: Ulnar digital nerve laceration to the thumb. PLAN: The plan is to do an ulnar digital nerve repair.
MP|metacarpophalangeal|MP|118|119|PHYSICAL EXAMINATION|Examination of his left upper extremity revealed a laceration proximal to the IP joint of the thumb and distal to the MP joint. He was unable to fully extend the thumb at the IP joint. Extensor pollicis longus tendon has retracted. His APL and EPB are intact.
MP|metatarsophalangeal|MP|141|142|PHYSICAL EXAMINATION|Bowel sounds are normoactive. Examination of the EXTREMITIES: No edema is noted. There is some localized tenderness in the right foot at the MP joint region. IMPRESSION: 1. Chronic foot pain. 2. Well-adult exam. Preoperative labs include a hemoglobin of 15.4 g%.
MP|metatarsophalangeal/metacarpophalangeal|MP|287|288|PHYSICAL EXAMINATION|It is beneath the extensor mechanism. He has pain to palpation of the ACRL and ACRB and pain with wrist extension and pain with elbow extension, wrist flexion and digital flexion. The patient has fluid profundus and superficialis pull through. He has full extension of each digit at the MP joint. IMPRESSION: Dorsal ganglion with associated extensor tendinitis, likely aggravated by the type of repetitive activity he does at work, cutting vegetables and slicing meat.
MP|metabolic panel|MP|214|215|SUMMARY OF ADMISSION|The back had no CVA tenderness. The extremities showed no cyanosis, clubbing, or edema. LABORATORY: On admission, white blood count 15 with 79% neutrophils, 12% lymphocytes, hemoglobin 15.5, platelets 277,000. The MP sodium was 135, potassium 3.8, chloride 99, bicarbonate 23, BUN 12, creatinine 1.2, and glucose 137. The abdominal CT in the emergency room showed a 3-mm stone at the ureter vesicular junction with right hydronephrosis and extravasation of fluid around the right kidney.
MP|metacarpophalangeal|MP|139|140|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: General - the patient has multiple deformities from her arthritis, especially her hands with ulnar deviations at the MP joints. Her ABDOMEN is obese. There is a midline surgical incision from the umbilicus to the pubis. There is no palpable hernia because of the amount of subcutaneous tissue.
MP|metacarpophalangeal|MP|152|153|PHYSICAL EXAMINATION|SKIN: No unusual identified lesions are seen, at this point. EXTREMITIES: Some subpatellar crepitation at the knees. She has effusion of both wrists in MP joints of both hands, some mild ulnar deformity. The fingers appear relatively normal. She has symmetrical, but slightly reduced grasp.
MP|mercaptopurine|MP|143|144|CHIEF COMPLAINT|On exam, done by Dr. _%#NAME#%_, he was found to have severe ulcerative colitis with ulcerations through the entire colon. He was started on 6 MP and prednisone 40 mg a day but since then, there has been no change in his symptoms. In the last two days the prednisone was increased to 60 mg a day but he developed nausea, retching and was unable to keep food or liquids down.
MP|metatarsophalangeal|MP|189|190|PHYSICAL EXAMINATION|She has maceration between the 4th and 5th toe and between the 3rd and 4th toe. She has some cracking and in fact even a small open laceration over her the pad of her 1st metatarsal at the MP joint. She also has another little area on the plantar aspect of her foot that looks suspicious for a possible entry place for bacteria.
MP|mercaptopurine|MP|327|328|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 3-year-old male with myelodysplastic syndrome and monosomy 7 who was admitted to the pediatric bone marrow transplant unit at University of Minnesota Medical Center, Fairview, for observation following a line replacement. _%#NAME#%_ was transplanted on _%#MMDD2006#%_ under protocol MP _%#PROTOCOL#%_ with a 6 out of 6 HLA-matched unrelated donor. On day of admission he was day #31. His parents noted some bleeding last night from his Hickman line site and again in the morning.
MP|mercaptopurine|MP|149|150|PAST MEDICAL HISTORY|7. Myelodysplastic syndrome with monosomy 7. 8. Unrelated single-cord blood transplant with 6 out of 6 matched donor on _%#MMDD2006#%_, per protocol MP _%#PROTOCOL#%_. Preparatory regimen included fludarabine, Cytoxan and 4 days of total body irradiation. 9. Hickman central line. SOCIAL HISTORY: _%#NAME#%_ lives with his mother and father and 2 sisters.
MP|metacarpophalangeal|MP|146|147|PHYSICAL EXAMINATION|EXTREMITIES: Warm and well perfused with no lower extremity edema or injury noted. His left hand does have some mild ecchymoses around the fourth MP joint. He has normal range of motion in this joint except for mild decrease in flexion. There is some associated mild tenderness in this area. Otherwise the joint appears stable.
MP|metatarsophalangeal|MP|213|214|DOB|DOB: _%#MMDD1946#%_ This 56-year-old white male has had problems with his big toe joints for several years, perhaps even for a decade. Initially this was rather mild and he simply noticed some aching in his first MP joint of his left toe when he would be on his feet too much or walk a great deal. There was mild swelling in the joint. However, this would promptly resolve.
MP|metatarsophalangeal/metacarpophalangeal|MP|182|183|DOB|There was mild swelling in the joint. However, this would promptly resolve. Gradually, this increased in severity over the years and he developed some involvement in his right first MP joint. In the last six months he has had rather marked increase in symptoms, however. He finds that he simply cannot step off as normally as he did in the past.
MP|metacarpophalangeal|MP|384|385|HISTORY|5. Hypercholesterolemia. 6. Prostatic hypertrophy. PROCEDURES: Spinal canal exploration and drainage of abscess as well as surgical drainage of pyogenic arthritis and tenosynovitis, right hand. HISTORY: This gentleman had gradual onset of increasing low back pain and shortly before hospitalization, some weakness in his legs along with redness and swelling of the right thumb at the MP joint and then spreading into more diffuse inflammation and swelling on the dorsum of the hand. MRI scan done of the low back demonstrated epidural abscess in the lumbar region.
MP|mercaptopurine|MP|174|175|LABORATORY DATA|She felt much better by the next day. Her vomiting went away. She had an upper GI/small bowel follow-through, which came back as normal so she is going to be discharged on 6 MP 25 mg a day, prednisone starting at 40 mg a day and then tapering down over six weeks to 0, ___________ 750 mg three tablets 3x a day, folic acid, Fosamax, and I am not going to restart her Pravachol until I see her liver chemistries normalized.
MP|metatarsophalangeal/metacarpophalangeal|MP|259|260|PHYSICAL EXAMINATION|X-rays of the left hand (multiple views) taken in the Emergency Room earlier today reveal an absolutely shattered proximal phalanx in its mid portion. It almost has the appearance of a gun shot wound. There does not appear to be any extension into either the MP or PIP joints, however. IMPRESSION: Crush injury, left V, with probable neurovascular compromise. _%#NAME#%_ will be taken to the operating room for exploration of his wound.
MP|metatarsophalangeal|MP|313|314|PHYSICAL EXAMINATION|Sensation intact, 2+ pulses, normal reflexes and motor tone. On the contralateral side hip, knee and ankle motion are good, however, when I dorsiflex his ankle he has increased pain radiating to the right great toe. When I attempt to move his toe at the IP joint he has minimal symptoms until I try to extend his MP joint. He has increase in plantar pain at the MP joint. There is a small poke hole on the plantar central aspect of the first MTP joint.
MP|metatarsophalangeal|MP|146|147|PHYSICAL EXAMINATION|When I attempt to move his toe at the IP joint he has minimal symptoms until I try to extend his MP joint. He has increase in plantar pain at the MP joint. There is a small poke hole on the plantar central aspect of the first MTP joint. There is no purulence there but the entire right great toe is swollen and reddened and very tender to touch.
MP|metacarpophalangeal|MP|202|203|PHYSICAL EXAMINATION|HEART: Regular rate and rhythm without audible murmur. ABDOMEN: Soft, nontender, no hepatosplenomegaly. EXTREMITIES: The left thumb has moderate swelling. There is an ulnarly directed angulation of the MP joint. Tenderness is located over the proximal phalanx. Neurovascular exam is intact. X-rays of the left thumb (three views) taken at the Oxboro Clinic on _%#MMDD2006#%_ reveal the transverse fracture of the proximal metaphysis of the thumb proximal phalanx.
MP|metacarpophalangeal|MP|93|94|ADMITTING DIAGNOSIS|ADMITTING DATE: _%#MMDD2007#%_ DISCHARGE DATE: _%#MMDD2007#%_. ADMITTING DIAGNOSIS: Infected MP joint at ring finger. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 42-year-old male who had an I&D of his long and ring finger MP joints, and an I&D of his long finger flexor sheath.
MP|metacarpophalangeal|MP|222|223|HOSPITAL COURSE|ADMITTING DATE: _%#MMDD2007#%_ DISCHARGE DATE: _%#MMDD2007#%_. ADMITTING DIAGNOSIS: Infected MP joint at ring finger. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 42-year-old male who had an I&D of his long and ring finger MP joints, and an I&D of his long finger flexor sheath. He did grow out Pseudomonas. He was placed on IV medication by Dr. _%#NAME#%_.
MP|mercaptopurine|MP,|103|105|HISTORY OF PRESENT ILLNESS|His disease has been difficult to control per the patient with 6-7 courses of steroids. He was given 6 MP, but then he developed leukopenia. He had been on steroids for less than a couple of months. However, tried to taper and developed cramps and diarrhea. Several days prior to discharge, he reports that he had tapered himself down to 5 mg a day, developed cramps, nonbloody diarrhea of at least approximately 5 stools a day.
MP|metacarpophalangeal|MP|135|136|PHYSICAL EXAMINATION|Good strength. Normal muscle tone, coordination, deep tendon reflexes throughout. Spine normal. She has typical ulnar deviation in the MP joints both hands, but no acutely inflamed joints, no increased temperature and no tenderness in any joints with fairly normal range of motion throughout.
MP|metacarpophalangeal|MP|189|190|PHYSICAL EXAMINATION|No skin lesions appreciated. NEUROLOGIC: Cranial nerves II through XII are intact with +2 deep tendon reflexes in all extremities. MUSCULOSKELETAL: Deformities are noted in the right first MP joint from arthritic changes. There are also changes noted in the right third toe which is swollen from gouty change. ADMISSION LABORATORY DATA: White count 14.9. Hemoglobin 15.7. Hematocrit 49.4. Platelets 205.
MP|mercaptopurine|MP|117|118|DISCHARGE MEDICATIONS|The patient is being discharged to be seen in the office by myself in about two weeks time. DISCHARGE MEDICATIONS: 6 MP as before plus Keflex 500 mg tid for 7 days for the wound infection and Percocet for pain. DISCHARGE DIAGNOSIS: 1. Stricture of the terminal ileum secondary to Crohn's status post ileocolostomy.
MP|mercaptopurine|MP,|86|88|BRIEF HISTORY OF PRESENT ILLNESS|She was on multiple immunosuppressive medication in the past, including prednisone, 6 MP, Remicade, Rifaximin and methotrexate. Her current immunosuppression medication is Humira 40 mg every 2 weeks. She admitted to Internal Medicine Service for pain control and evacuation of diarrhea.
MP|metacarpophalangeal|MP|172|173|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Status post wrist left effusion and . Endograft fracture repair , rheumatoid arthritis, . reflux esophagitis, sleep apnea - on CPAP, right thumb from MP fusion , asthma -- allergy induced and bladder spasms. SOCIAL HISTORY: Socially, She is married, lives with her spouse in _%#CITY#%_ .
MP|metacarpophalangeal|MP|192|193|PHYSICAL EXAMINATION|RECTAL: Exam negative. Hemoccult negative. EXTREMITIES: Normal with no edema. She has good peripheral pulses. There is a synovial cyst on third and fourth extensor tendons at the level of the MP joints of right hand. LABORATORY DATA: Normal electrocardiogram. Hemoglobin 13.2, potassium 4.2. Urine analysis shows 3+ blood, INR 1.0. DIAGNOSTIC IMPRESSION: 1. Complex left ovarian cyst.
MP|metatarsophalangeal/metacarpophalangeal|MP|145|146|HISTORY|Salient features of her examination: On examination in the hospital, she had sausage-like swelling of her left index finger that was tender. The MP joint seemed a little tender, but wasn't really that swollen. She also had some sausage-like swelling of her right thumb which was also very tender.
MP|metacarpophalangeal|MP|122|123|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a delightful 53-year-old female who has had chronic pain in her left MP joint and thumb. She has been under the care of Dr. _%#NAME#%_ who recommended tendon repair. She has decided to move forward with this and have it repaired.
MP|mercaptopurine|MP|133|134|ALLERGIES|He really can't tell me why but he thinks it was a good idea too. ALLERGIES: He doesn't have any true allergies but allegedly had 6- MP in the past and it sounded like he was immunosuppressed and he says he "had to have 13 antibiotics to survive." MEDICATIONS: The only medicine he knows that he takes for sure is a proton pump inhibitor but he is not sure of the name.
MP|metatarsophalangeal/metacarpophalangeal|MP|131|132|PHYSICAL EXAMINATION|He is able to actively extend the finger as a portion of the extensor mechanism is still intact. He has good motion in his PIP and MP joint. His defect measures about 1 cm wide and about 16 to mm in length. He has full profundus superficialis pulsar is normal two point discrimination.
MP|mercaptopurine|MP.|115|117|CURRENT MEDICATION REGIMEN|4. He then had the recent fistula surgery as noted above. CURRENT MEDICATION REGIMEN: 1. Remicade q.6 weeks plus 6 MP. 2. Simethicone. 3. Percocet p.r.n. for pain. PHYSICAL EXAMINATION: GENERAL: Shows a young man who is chronically ill appearing.
MP|mercaptopurine|MP,|99|101|MEDICATIONS|PAST MEDICAL HISTORY: 1. Crohn's disease. 2. Rectovaginal fistula and incontinence. MEDICATIONS: 6 MP, Ultram, zinc, monthly vitamin B12 injections and an inhaler. ALLERGIES: Prednisone intolerance, Remicade, penicillin leads to hives. HOSPITAL COURSE: The patient was admitted to the hospital.
MP|metacarpophalangeal|MP|286|287|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: He is a tall well-developed, well- nourished gentleman who is alert and oriented x three in no acute distress. Examination of his left upper extremity when compared wit the right upper extremity reveals a laceration beginning proximal about 2.0 cm proximal to the MP joint level and then carried from the ulnar to the radial side longitudinally. His FDL is intact. His ulnar digital nerve is intact with two-point discrimination measuring 4.0 mm.
MP|mercaptopurine|MP|237|238|PROBLEM #2|PROBLEM #2: Oncology. Daniel has a history of pre-B-cell acute lymphocytic leukemia and was originally treated with chemotherapy in 2001. He has done quite well since then and is currently in his fifth maintenance cycle. He is getting 6 MP on a daily basis and methotrexate weekly; as well as vincristine once a month. He is getting methotrexate intrathecally once every three months. He is also getting dexamethasone x 5 days per month.
MP|mercaptopurine|MP|141|142|PROBLEM #2|Since _%#NAME#%_'s absolute neutrophil count remained below 1000 at the time of his discharge, he was discharged home on a reduced dose of 6 MP 25 mg per day. This is down from his usual 25 and 50 on alternating days. This dose can be adjusted up after he has his blood counts drawn in follow up if revealing a recovering white count.
MP|metacarpophalangeal|MP|182|183|PHYSICAL EXAMINATION|ABDOMEN: Flat, normal bowel sounds, soft, nontender, no organomegaly or abnormal masses. Normal male genitalia. Spine and extremities are unremarkable. Complaint of some pain in the MP joints of both thumbs but aside from that no pain on movement of joints and with normal stability in the spine.
MP|(device) MP|MP|167|168|HISTORY|He had electrolytes, which showed a bicarb of 15, potassium of 134, glucose of 177. His white count yesterday was 12,700 with 35 lymphs, 19 monos, 45 neutrophils. His MP swab was negative for influenza A and influenza B. His urine was normal, it was obtained by catheter with 3 whites and 1 red cell.
MP|mercaptopurine|MP|214|215|PROBLEM # 2|She did have a capsule study done during her previous hospitalization, which showed significant small bowel involvement per report, although I have not yet seen the official results. _%#NAME#%_ was discharged on 6 MP for treatment, but upon on readmission we switched her over to IV Imuran for faster efficacy. She has also received her second dose of Remicade on _%#MMDD2006#%_.
MP|metatarsophalangeal/metacarpophalangeal|MP|289|290|PHYSICAL EXAMINATION|There is some associated bone debris along the distal portion of the proximal phalanx, but this is fairly mild. The index finger reveals a "divot" taken out of the radial base of the proximal phalanx but there does not appear to be a complete transverse fracture and no extension into the MP joint. IMPRESSION: Saw injury to the left hand with underlying nerve and tendon injuries, probably the flexor pollicis longus and the digital nerves involving the radial aspect of the index and ulnar aspect of the thumb.
MP|metacarpophalangeal|MP|126|127|REVIEW OF SYSTEMS|Neuropsychiatry: No headaches or double vision. Back: No chronic back pain. Musculoskeletal: She does have joint pains in her MP joints of the hands and the PIP joints of the fingers, shoulders, feet and ankles. She really has no significant problem with her left knee and has had a recent right total knee arthroplasty.
MP|metacarpophalangeal|MP|204|205|PHYSICAL EXAMINATION|There is an extended puncture wound in the palm along the third ray which appears clean without drainage; this is about 5.0-mm in length. There is tenderness around this area and some extending up to the MP joint. There is no tenderness extending up into the finger, however. There is no circumferential swelling of the digit and no pain with passive motion.
MP|metacarpophalangeal|MP|182|183|PHYSICAL EXAMINATION|EXTREMITIES: Examination of her left upper extremity reveals a laceration over the dorsum at the base of the ring and small finger. She can definitely extend the small finger at the MP joint. She has a little trouble initiating full PIP and DIP extension. On the palmar side, she has significant ecchymosis and bruising.
MP|nurse practitioner:NP|MP|234|235|ASSESSMENT/PLAN|Questions regarding her brief stay on the subacute unit may be directed to the hospitalist at Fairview- University Medical Center, _%#CITY#%_. The reader is further directed to previous discharge summaries from _%#NAME#%_ _%#NAME#%_, MP dated _%#MMDD2005#%_ and Dr. _%#NAME#%_ _%#NAME#%_ dated _%#MMDD2005#%_.
MP|mercaptopurine|MP|170|171|CHIEF COMPLAINT|He was having one to two stools a day without any blood in the stool. The plan was to taper him a little more slowly and then to add an immunosuppressant drug such as 6- MP or azathioprine. By _%#MMDD2005#%_ the patient had tapered down to 5 mg of prednisone. On _%#MMDD2005#%_ he noted the onset of blood in his stools and on the _%#MMDD2005#%_ he called our office and was told to increase to 10 mg of prednisone.
MP|metatarsophalangeal|MP|114|115|PHYSICAL EXAMINATION|No guarding or rebound. EXTREMITIES: Shows swelling, redness and erythema of her right ankle as well as the first MP joint. The patient does have pain with motion about the ankle. She has dystrophic nails. The left ankle though not red, is warm and she does have some mild discomfort with movement of the ankle.
MP|metabolic panel|MP|127|128|ASSESSMENT/PLAN|4. Fluids, electrolytes, nutrition. NPO currently. Change fluids to D5 normal saline with 20 KCL at 70 cc per hour. Repeat the MP as scheduled for 1800 today, _%#MMDD2006#%_. 5. Presurgical clearance. The patient's activity level and general health suggests acceptable risk.
MP|metatarsophalangeal|MP|196|197|HOSPITAL COURSE|On after admission, he was started on Zosyn and Podiatry was consulted to evaluate the ulcer. An x-ray was obtained which showed soft tissue swelling over the lateral foot at the level of the 5th MP joint. No evidence of osteomyelitis was seen; however, the ulcer base looked necrotic and there was serosanguineous discharge.
MP|metatarsophalangeal/metacarpophalangeal|MP|120|121|HISTORY OF PRESENT ILLNESS|During his last hospitalization in late _%#MM#%_ he underwent I&D of the area for which staph aureus was grown from the MP joint with a significant surgical wound infection occurring. The patient was treated with clindamycin initially and then vancomycin. He tolerated these well and the area gradually improved. He was discharged from the hospital on _%#MMDD2002#%_ with IV vancomycin as an outpatient.
MP|metatarsophalangeal|MP|175|176|LABORATORY DATA|Hemoglobin 11.6 and WBC 9.0 with normal differential. Culture of the wound shows ________ coagulase negative staph. X-ray of the left foot shows probable osteomyelitis of the MP joint of the left great toe. Chest x-ray - lung fields are clear. MRI of the left foot - edema around the head of the first metatarsal, amputation of the great left toe, and changes suspicious for osteomyelitis.
MP|mercaptopurine|MP|170|171|HISTORY|The patient has had two prior resections for Crohn's disease in 1993 and 1999 respectively. The patient had been placed on 6-MP in _%#CIT#%_, but she discontinued the 6- MP of her own accord in the spring of 2003. EXAMINATION: Vital signs are normal. There is no icterus. Cardiopulmonary exam was normal.
MP|metacarpophalangeal|MP|248|249|HISTORY OF THE PRESENT ILLNESS|Two days ago and on _%#MMDD2004#%_, this patient was cutting up some vegetables at home, holding the knife in her dominant right hand. Unfortunately, the knife slipped and she essentially stabbed the medial aspect of her left index finger near the MP joint. This patient did not seek medical treatment. Over the course of the last two days, she has noted increasing pain and swelling in the joint and difficulty moving her finger.
MP|metatarsophalangeal/metacarpophalangeal|MP|170|171|HISTORY OF THE PRESENT ILLNESS|No abnormalities were seen. She was however, advised to follow up with me immediately. I saw this patient in my office early this afternoon. I felt that she had a septic MP joint and therefore she is admitted for surgical drainage. This patient denies prior history of left hand problems. This is an isolated injury.
MP|metatarsophalangeal/metacarpophalangeal|MP|189|190|PHYSICAL EXAMINATION|Reveals a 4 mm. puncture wound/laceration along the radial aspect of the MP joint, dorsal to the course of the radial digital nerve. There is moderate swelling and mild erythema around the MP joint. There is pain with any MP joint motion. There is no tenderness over the flexor tendon sheath and no pain with passive motion of the DIP or PIP joints.
MP|metacarpophalangeal|(MP|150|152|IMPRESSION|The opposite right hand and wrist have no swelling, tenderness or limitation of motion. IMPRESSION: 1. Septic arthritis left II metacarpal phalangeal (MP joint) I believe that this patient has a septic joint which requires immediate surgical drainage.
MP|mercaptopurine|MP|200|201|HISTORY OF PRESENT ILLNESS|The 6-MP was then discontinued shortly secondary to concerns about adverse effects on the liver. The patient was maintained on prednisone 40 mg p.o. daily, and then on _%#MM#%_ _%#DD#%_, 2005, the 6- MP was resumed at a lower dose, 50 mg per day, as the patient had previously been on 75 mg Saturday, Sunday, Tuesday, Thursday, and 50 mg Monday, Wednesday, Friday.
MP|mercaptopurine|MP|214|215|HOSPITAL COURSE|1. BMT. Again, the patient is status post allogeneic sibling stem cell transplantation from his brother, day 0 was _%#MM#%_ _%#DD#%_, 2006. His initial miniprep consisted of Cytoxan, fludarabine, allopurinol, ABG, MP along with TBI. 2. Hyperbilirubinemia. The patient did have mild elevation of bilirubin likely secondary to his prep. He is on estradiol which provided good results with decrease of bilirubin levels.
MP|metacarpophalangeal|MP|165|166|PAST MEDICAL HISTORY|8. History of depression and anxiety. 9. Osteoarthritis. 10. Adhesive capsulitis of the shoulder. 11. Status post tonsillectomy. 12. Status post arthroplasty of the MP joints of the right hand. 13. Status post right shoulder hanger arthroplasty. MEDICATIONS: 1. Paroxetine 20 mg p.o. q.a.m. 2. Vasotec 20 mg p.o. daily. 3. Prilosec 20 mg p.o. daily.
MP|mercaptopurine|MP.|196|198|MEDICATIONS|PAST HISTORY: Significant for a knee surgery and tonsils, history of depression FAMILY HISTORY: His father has had ulcerative colitis. MEDICATIONS: On admission included prednisone, Fluoxetine, 6 MP. SOCIAL HISTORY: He does not smoke. ALLERGIES: NONE. PHYSICAL EXAMINATION: GENERAL: This is a healthy appearing male in no distress.
MP|mercaptopurine|MP|121|122|IMPRESSION|IMPRESSION: Erythema nodosum. The differential would be erythema nodosum from the ulcerative colitis or from the 6-MP. 6 MP can do this and his other symptoms with the aches and chills and the sweats are suspicious for 6-MP since he just started it and he never had these symptoms on initial diagnosis and at that time his GI symptoms were much worse.
MP|mercaptopurine|MP|196|197|MEDICATIONS|PAST MEDICAL HISTORY: Also, significant for a lung nodule which was biopsied significant for history of histoplasmosis . MEDICATIONS: Current medicines included his 1. Remicade twice a month 2. 6 MP 100 mg 3. occasional Tylenol. He denies frequent use of aspirin or nonsteroidal anti-inflammatory agents. 4. He is also maintained on Coumadin for persistent diarrhea.
MP|metabolic panel|MP|234|235|FOLLOWUP|8. Marinol 2.5 mg q.a.m. 9. 6-MP 100 mg p.o. Monday to Friday and 75 mg p.o. Saturday and Sunday through day 41, which is _%#MMDD2007#%_. FOLLOWUP: Follow up in Oncology Clinic on _%#MMDD#%_ with Dr. _%#NAME#%_ for CBC, differential, MP and nurse visit for chemotherapy on day 42. Chemotherapy consolidation per protocol CCG-_%#PROTOCOL#%_. Thank you, it was a pleasure taking care of the patient during this hospitalization.
MP|metacarpophalangeal|MP|79|80|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Polyarticular gout involving left wrist and left third MP and PIP joints requiring initiation of colchicine therapy and steroid injection by Dr. _%#NAME#%_ of Orthopedic Surgery. 2. Known coronary artery disease maintained on medical management.
MP|metacarpophalangeal|MP|210|211|HOSPITAL COURSE|While patient was placed on antibiotics, Orthopedics evaluated the patient and felt that this was consistent with gout rather than septic joint. The patient underwent injection of the left wrist and left third MP and PIP joints with marked improvement of her symptoms. Additionally, patient had an elevated creatinine upon admission which resolved with appropriate treatment.
MP|metacarpophalangeal|MP|254|255|PHYSICAL EXAMINATION|HEART: Is regular rate and rhythm EXAMINATION OF HIS RIGHT UPPER EXTREMITY: Reveals a laceration over the right ring finger at the metacarpal phalangeal joint. He has a 45-50 degree extensor lag to his ring finger. He can do some slight extension at his MP joint through his intrinsics, but he can not elevate the finger at the metacarpal phalangeal joint. He is also able to fire slightly through the juncture of tendinea.
MP|metacarpophalangeal|MP|205|206|PHYSICAL EXAMINATION|HEENT: Normocephalic, atraumatic. CHEST: Lungs are clear HEART: Regular rate and rhythm EXTREMITIES: Examination of his right upper extremity reveals significant ecchymosis and bruising extending from the MP joint proximally towards the wrist. He does have palpable Stener lesions over the MP joint and with deviation stress, he opens up to 90 degrees without any pain.
MP|metacarpophalangeal|MP|290|291|PHYSICAL EXAMINATION|HEENT: Normocephalic, atraumatic. CHEST: Lungs are clear HEART: Regular rate and rhythm EXTREMITIES: Examination of his right upper extremity reveals significant ecchymosis and bruising extending from the MP joint proximally towards the wrist. He does have palpable Stener lesions over the MP joint and with deviation stress, he opens up to 90 degrees without any pain. IMPRESSION: Ulnar collateral ligament complete tear with a Stener lesion PLAN: Proceed with ulnar collateral ligament repair with Mitek anchor.
MP|mercaptopurine|MP.|144|146|MEDICATIONS|He does not smoke. He quit about four years ago. FAMILY HISTORY: Negative for GI problems. MEDICATIONS: 1. Avapro. 2. Hydrochlorothiazide. 3. 6 MP. 4. Nexium. 5. Dilantin. 6. Aspirin. 7. Rhinocort. 8. Multivitamin. 9. B6. 10. B12. 11. Vitamin C. 12. Tolmetin. PHYSICAL EXAMINATION: Reveals an adult male in no distress.
MP|mercaptopurine|MP|128|129|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: MS Contin 100 mg bid, Zantac 150 mg bid, Prinivil 20 mg q day. New medications upon discharge include 6- MP 125 mg po beginning today _%#MMDD#%_ and continuing through _%#MMDD#%_, Compazine 10 mg po q4-6h prn nausea. Peri-Colace one tab bid, Ibuprofen 600 mg po qid times eight doses and then qid prn pain, Hickman flushes 200 units per Hickman lumen q 24 hours.
MP|metacarpophalangeal|MP|125|126|PHYSICAL EXAMINATION|This measures about 2 by 2 cm and is mildly tender. He also has a 5 mm cyst on the dorsal aspect of the thumb, distal to the MP joint. IMPRESSION: 1. Lipoma, right palm. 2. Extensor tendon cyst, right EPL.
MP|mercaptopurine|MP.|130|132|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Sensitivity to Fentanyl which has dropped her heart rate and blood pressure. She also has sensitivity to 6- MP. Her last blood transfusion was 1985. She has had no significant medical illnesses except for the Crohn's disease. The rest of her past history and physical examination aside from the rectovaginal fistula and the presence of anal and rectal Crohn's disease is normal.
MP|metatarsophalangeal|MP|162|163|HOSPITAL COURSE|She had had increased doses of Glargine insuline, and while in the hospital she actually had some low blood sugars. She was found to have a red and swollen first MP joint of the left foot and an elevated uric acid of 8.7. She was treated with colchicine, and at discharge this was discontinued.
MP|metabolic panel|MP|156|157|LABORATORY|LABORATORY: White count 13.5 with 84% neutrophils. Hemoglobin 14.4. Platelet counts 242. Coags and D-dimer, troponin, and BMP all within normal limits. The MP is within normal limits with exception of glucose elevated at 184. Head CT is within normal limits. Chest CT is within normal limits.
MP|mercaptopurine|MP|183|184|DISCHARGE MEDICATIONS|At this time, endocrine did not feel that she was appropriate for insulin therapy. DISCHARGE MEDICATIONS: 1. Gatifloxacin 400 mg p.o. daily through _%#MM#%_ _%#DD#%_, 2005. 2. Altace MP 6-7 tablets with meals 3 to 4 with snacks. 3. Azithromycin 250 mg 1 p.o. q. day. 4. Betacarotene 25,000 units 1 p.o. q. day.
MP|metacarpophalangeal|MP|201|202|HOSPITAL COURSE|CT of the cervical spine demonstrated no fracture. There were degenerative changes at multiple levels, greater at C5-C6. Left wrist x-ray demonstrated marked degenerative arthritis at first and second MP joint. X-ray of the facial bones were negative. Lumbar spine x-ray demonstrated grade 1 to 2 spondylolisthesis at L4 and L5, unchanged since _%#MM#%_ _%#DD#%_, 2005.
MP|metacarpophalangeal|MP|130|131|HISTORY|Any attempts to grip give him sharp pain. At rest he has dull pain. He has no numbness or tingling. The pain is mostly around the MP joint. He also suffered some bruising to the arm and forearm, but no other significant injuries. PAST MEDICAL HISTORY: Remarkable for appendectomy. He has had a greater tuberosity fracture of the shoulder.
MP|metatarsophalangeal/metacarpophalangeal|MP|136|137|PHYSICAL  EXAMINATION|ABDOMEN: Benign. NEUROLOGIC: He is neurologically intact. EXTREMITIES: Left thumb is grossly swollen, and he is quite tender around the MP joint. The digit is well perfused and sensate, but he is unstable to varus and valgus stress. I ordered and interpreted AP and lateral radiographs of the thumb.
MP|metarsophalangeal|MP|285|286|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a nulligravid female who has a significant problem with scleroderma and associated with that has inflammatory arthritis associated with significant malformation of her left foot with dislocation and varus angulation on the left toe MP joints and destructive arthritis. Patient did have surgery done on her right foot in _%#MM#%_ and now is in for repair of her left foot.
MP|metacarpophalangeal|MP|147|148|PHYSICAL EXAMINATION|EXTREMITIES: There was no edema. She has good peripheral pulses. There is a synovial cyst on third and fourth extensor tendons at the level of the MP joints on the right hand. LABORATORY DATA: EKG done in _%#MM#%_ is normal. Hemoglobin today is 13.6, potassium 5.2. Urinalysis is negative.
MP|metacarpophalangeal|MP|244|245|HISTORY OF THE PRESENT ILLNESS|When this patient was two years old, he apparently grabbed a hot curling iron and sustained a rather severe burn to his left palm. As such, he developed some palmar scar tissue which eventually resulted in some contracture of his central three MP joints. This has caused some functional problem for him and he therefore presents for surgical release. PAST MEDICAL HISTORY : This patient is quite healthy. He has no medical problems.
MP|metacarpophalangeal|MP|116|117|PHYSICAL EXAMINATION HEAD, EYES, EARS, NOSE AND THROAT|No hepatosplenomegaly. EXAM OF THE LEFT HAND: Reveals full flexion of all digits. There is a transverse scar at the MP crease involving the central three fingers. As such, he has a 10 degree lack of extension of two of the digits. Scar itself is non-tender. NEUROVASCULAR EXAM: Is entirely intact. IMPRESSION: Scar contracture left central three fingers at the metacarpal phalangeal joint.
MP|metacarpophalangeal|MP|161|162|DOB|This causes pain. As a result she walks with her foot somewhat to the side. She sought medical attention, was diagnosed with right hallucis rigidus of the first MP joint. She is in for surgical correction. PAST MEDICAL HISTORY: FAMILY HISTORY: Father died of ruptured aortic aneurysm age 69.
MP|metatarsophalangeal|MP|195|196|PHYSICAL EXAM|GENITORECTAL: Deferred. Upper extremities negative. Lower extremities: Prominent. Hard bony lump present at the dorsum of her first MP joint right foot. Complete findings are dorsum of her first MP joint right foot, obvious limitation of dorsi flexion of her right first toe. Complete findings are deferred to her operating surgeon.
MP|metacarpophalangeal|MP|149|150|PHYSICAL  EXAMINATION|It is well perfused and sensate, but it definitely has a different shape than the contralateral little finger. He is unable to meaningfully flex the MP and PIP joints, although he can wiggle the DIP joint. I reviewed Park Nicollet x-rays which show an oblique or spiral fracture through the mid portion of the proximal phalanx.
MP|metacarpophalangeal|MP|125|126|PHYSICAL EXAMINATION|He is hard-of-hearing. Cardiac: regular rate and rhythm. Lungs: Clear. Examination of his hands: On the left side, he has an MP contracture of 60 degrees of the both the long and ring finger. He does not have a PIP contracture. His small finger has independent range of motion.
MP|metacarpophalangeal|MP|124|125|PHYSICAL EXAMINATION|He does not have a PIP contracture. His small finger has independent range of motion. On the right hand, he has a 60 degree MP contracture of the ring with a 70 degree contracture of the PIP and he also has some involvement of the small finger.
MP|metacarpophalangeal|MP|166|167|PHYSICAL EXAMINATION|ABDOMEN: Soft, nontender. No hepatosplenomegaly. EXTREMITIES: Examination of the right hand reveals a 2.0 cm oblique laceration almost directly over the index finger MP joint. He has a 20 degree extensor tendon lag. There does not appear to be any infection in the wound. Neurovascular exam is intact. IMPRESSION: Laceration, right dorsal hand with underlying tendon injury.
MP|metacarpophalangeal|MP.|145|147|PHYSICAL EXAMINATION|Nontender. No masses. Femoral pulses are normal. EXTREMITIES: There is a 3-mm, mobile cyst on the ulnar side of his left middle finger, near the MP. joint. LABORATORY DATA: Hemoglobin 15.5. White count 5,900. Platelet count 171,000.
MP|metacarpophalangeal|MP|136|137|PHYSICAL EXAM|EXTREMITIES: Reveal no pedal edema. She has decreased pedal pulses. She has some slight redness and minimal swelling to the right first MP joint with tenderness locally there into the proximal phalanx of the right great toe, no deformity. Skin is clear. Electrolytes were within normal limits with a BUN of 31, creatinine of 1.1. Electrocardiogram shows normal sinus rhythm with a rare PVC.
MP|mercaptopurine|MP|178|179|HOSPITAL COURSE|She is to follow-up in two weeks and at six weeks for Remicade and taper her prednisone by 5 mg per week, initially from 60 mg down to zero. In addition, she was sent home on 6- MP 75 mg a day and will follow-up for labs.
MP|mercaptopurine|MP|185|186|HOSPITAL COURSE|The patient was started on prednisone therapy and had some improvement but continued with symptoms. She was seen in consultation by Dr. _%#NAME#%_ (Gastroenterology) who recommended 6- MP which was started. She had undergone previous flexible sigmoidoscopy with biopsy which revealed changes typical of ulcerative colitis.
MP|mercaptopurine|MP.|172|174|ALLERGIES|2. Status post terminal ileal resection 15 years ago. 3. "Stricture plasty" in 1999, approximately 30 cm involved. 4. Hyperlipidemia. ALLERGIES: Penicillin, Remicade and 6 MP. CURRENT MEDICATIONS: 1. Pentasa 1,000 mg q.i.d. 2. Calcium plus vitamin D two tablets daily.
MP|metacarpophalangeal|MP|318|319|PHYSICAL EXAMINATION|There is no erythema on the other aspects of the hand or the forearm; however, there is cellulitis about 15 x 6 cm over the biceps of the upper extremity which is very tender to palpation and slightly warm, and he also has tenderness in the left armpit. The patient is able to flex and extend the DIP, the PIP and the MP of all digits on the left hand. His range of motion is normal in the wrist as well. His sensation is intact. He has positive radial pulses. There does seem to be a fluctuance under the volar and radial aspect of the distal phalanx.
MP|nurse practitioner:NP|MP|166|167|HISTORY OF PRESENT ILLNESS|He does have a small amount of sputum production daily, which is his baseline. Additional history can be obtained from the recent clinic note dictated by _%#NAME#%_, MP _%#MMDD2007#%_. PAST MEDICAL HISTORY: 1. History of cystic fibrosis and CF lung disease and sinusitis.
MP|metatarsophalangeal/metacarpophalangeal|MP|142|143|HISTORY|There is a small area that is draining like a puncture site and another small area proximally. She does not complain of pain at motion of the MP joint. IMPRESSION: Likely strep fascitis even given her denial of intravenous drug abuse.
MP|metacarpophalangeal|MP|193|194|PROCEDURES PERFORMED|6. _______ syndrome. 7. Anemic of chronic renal disease. PROCEDURES PERFORMED: 1. Inpatient hemodialysis _%#MMDD2002#%_ and _%#MMDD2002#%_. 2. Left hand plane films. 3. Combination right index MP amputation and right thumb P-I amputation performed on _%#MMDD2002#%_ without apparent complication. HOSPITAL COURSE: 1. End stage renal disease. Patient known chronic renal failure patient who undergoes three times per week maintenance hemodialysis.
MP|mercaptopurine|MP|109|110|MEDICATIONS|PAST MEDICAL HISTORY: Crohn's colitis, history of DVT. MEDICATIONS: Prednisone 40 mg a day, Flagyl t.i.d., 6 MP and Coumadin. He did receive Remicade a month ago when he was hospitalized. ALLERGIES: Pentasa and Asacol. His physical examination was largely unremarkable other than the presence of erythema and swelling in his perianal region.
MP|metacarpophalangeal|MP|169|170|DOB|DOB: _%#MMDD1967#%_ _%#NAME#%_ _%#NAME#%_ is a 35-year-old white female has had problems with bunions for several years. She essentially has a bunion of her right first MP joint, which has not caused particular alarm, though is obviously enlarged visibly. She also has bunions on her left feet, but the first MP joint and the fifth MP joint.
MP|metacarpophalangeal|MP|188|189|DOB|She essentially has a bunion of her right first MP joint, which has not caused particular alarm, though is obviously enlarged visibly. She also has bunions on her left feet, but the first MP joint and the fifth MP joint. At this particular time, the bunion deformity causing the most deformity is the outer aspect of her left foot, that is her fifth metatarsophalangeal joint.
MP|metarsophalangeal|MP|211|212|DOB|She essentially has a bunion of her right first MP joint, which has not caused particular alarm, though is obviously enlarged visibly. She also has bunions on her left feet, but the first MP joint and the fifth MP joint. At this particular time, the bunion deformity causing the most deformity is the outer aspect of her left foot, that is her fifth metatarsophalangeal joint.
MP|metarsophalangeal|MP|253|254|IMPRESSION AT THIS TIME|GENITORECTAL: Deferred. EXTREMITIES: Upper extremities negative. Lower extremities: Bilateral bunion deformities as noted in the present illness. Complete findings are deferred to her operating surgeon. IMPRESSION AT THIS TIME: Bunion, left foot, fifth MP joint. LABORATORY FINDINGS: Hemoglobin 12.6 gm percent. WBC was 9,400 with 50 neutrophils, 40 lymphs, 8 monos, 1 eosinophil, 1 basophil.
MP|metacarpophalangeal|MP|218|219|BRIEF CLINICAL HISTORY|BRIEF CLINICAL HISTORY: This is a 27-year-old male who presented to the Fairview-University Medical Center Emergency Department on _%#MMDD2004#%_. One week prior to presentation, he cut his hand over the dorsum of the MP joint area of the right small finger while working on his car. He presented to _%#COUNTY#%_ _%#COUNTY#%_ Medical Center and was treated.
MP|mercaptopurine|MP|136|137|DISCHARGE PLAN|At this time since the patient is improving _%#NAME#%_ has opted for medical treatment. This will consist of prednisone 30 mg a day, 6- MP 50 mg per day, Cipro and Flagyl for one week. He will have a follow-up abdominal and pelvic CT scan and the patient will be seen again by Dr. _%#NAME#%_ on _%#MMDD2002#%_.
MP|metarsophalangeal|MP|144|145|PHYSICAL EXAMINATION|PELVIC AND RECTAL: Deferred not indicated. EXTREMITIES: Normal pedal pulses, no edema. Severe rheumatoid arthritis with marked abnormalities at MP joints both hands and feet. Left first toe is markedly deviated, almost at 90 degree angle to the joint. Left foot is not as severely affected. Both hands have severe MP joint involvement, less involvement of phalangeal joints.
MP|metarsophalangeal|MP|139|140|PHYSICAL EXAMINATION|Left first toe is markedly deviated, almost at 90 degree angle to the joint. Left foot is not as severely affected. Both hands have severe MP joint involvement, less involvement of phalangeal joints. Verbal report, head CT scan shows no evidence of hemorrhage or bleeding.
MP|metacarpophalangeal|MP|152|153|PHYSICAL EXAMINATION|EXTREMITIES: Exam of the right hand reveals no abnormalities other than the thumb. There is moderate swelling, tenderness and ecchymosis based upon the MP joint. There is also a mild adduction angular deformity of the thumb. Neurovascular exam is intact. X-rays of the left thumb (multiple views) taken at the Oxboro Clinic on _%#MMDD2004#%_ reveal an intracondylar T fracture of the proximal phalanx into the MP joint.
MP|metatarsophalangeal/metacarpophalangeal|MP|185|186|PHYSICAL EXAMINATION|Neurovascular exam is intact. X-rays of the left thumb (multiple views) taken at the Oxboro Clinic on _%#MMDD2004#%_ reveal an intracondylar T fracture of the proximal phalanx into the MP joint. There does not appear to be any articular stepoff, but there is an angular deformity of the diaphysis. IMPRESSION: Right thumb proximal phalangeal fracture. This patient presents at this time for closed reduction and pinning of her fracture.
MP|menstrual period|MP|237|238|HISTORY OF PRESENT ILLNESS|3. GBS negative. 4. Fetal fibronectin positive. OPERATIONS/PROCEDURES PERFORMED: 1. Magnesium sulfate tocolysis. 2. Bedrest. 3. Betamethasone administration x2. HISTORY OF PRESENT ILLNESS: Patient is a 29-year-old G1, P0, with an unsure MP and dating by an 8 week ultrasound, who presents at 32 weeks and 0 days, transferred from Fairview Northland after an admission on _%#MM#%_ _%#DD#%_, 2004, for contractions and an ultrasound showing a cervix less than 1 cm long with greater than 3 cm of funneling.
MP|metacarpophalangeal|MP|144|145|PHYSICAL EXAMINATION|EXTREMITIES: Examination of his left upper extremity reveals a thenar laceration. He is unable to flex at the I-P joint. He has a little bit of MP motion through his intrinsics. His two-point discrimination is 4 mm. So pressing to the left FTL laceration as well as a thenar laceration, the plan is to do a FTL tendon repair.
MP|metatarsophalangeal/metacarpophalangeal|MP|26|27|ADMISSION DIAGNOSIS|DOB: ADMISSION DIAGNOSIS: MP joint septic arthritis, left second MPT joint. CONSULTATIONS: Cardiology for murmur, Family Practice for medical management, and Infectious Disease for antibiotic recommendations.
MP|mercaptopurine|MP|169|170|REVIEW OF SYSTEMS|INR 0.93, PTT less than 20. Total protein 6.3, uric acid 2.6, phosphorus 2.7, magnesium 2.5. HOSPITAL COURSE: PROBLEM #1: Prep: Cytoxan x1, fludarabine x5, ATG x3 days, MP x4 days, allopurinol x6 days. PROBLEM #2: BMT: Transplant _%#MM#%_ _%#DD#%_, 2004. CD-34 dose: 5.08 x10 to the _%#DD#%_. GCSF was started on _%#MM#%_ _%#DD#%_, 2004. PROBLEM #3: GVHD: Patient on CsA while hospitalized.
MP|metatarsophalangeal|MP|269|270|PHYSICAL EXAMINATION|No apparent cardiomegaly. ABDOMEN: Soft, flat and easily palpable, without palpable liver, kidney, spleen or other abdominal masses. GENITORECTAL: Deferred. UPPER EXTREMITIES: Negative. LOWER EXTREMITIES: Some generalized swelling and significant loss of motion, first MP joint, right foot. Complete findings are deferred to his operating surgeon. IMPRESSION: Hallux rigidus, right foot first metatarsophalangeal joint.
MP|mercaptopurine|MP|135|136|HISTORY|It was felt that the patient had a flare-up of her ulcerative colitis. She will be maintained on her same maintenance treatment with 6 MP 75 mg a day, along with her Rowasa enema and Canasa suppository and her Asacol 4800 mg a day divided in three doses at 1600 mg three times a day.
MP|UNSURED SENSE|MP|207|208|PHYSICAL EXAMINATION|He is alert and oriented in no acute distress. HEENT: Head is atraumatic and normocephalic. Pupils are equally round, reactive to light and accommodation. TMs are clear. Oropharynx and nasopharynx is clear. MP 2 to 3. NECK: Supple, no adenopathy, no thyromegaly, no carotid bruits noted, no JVD. HEART: Regular today with no murmurs noted. LUNGS: Clear to auscultation.
MP|metatarsophalangeal/metacarpophalangeal|MP|226|227|PHYSICAL EXAMINATION|ABDOMEN: Abdomen is soft and nontender. No hepatosplenomegaly. EXTREMITIES: Examination of the left hand reveals a 1.5 cm transverse laceration in line with the middle finger, just proximal to the MP joint. He has a 20 degree MP joint extensor lag. There is full flexion of the digit, however. Neurovascular exam is intact. IMPRESSION: Left III extensor tendon laceration, dorsal hand.
MP|metatarsophalangeal/metacarpophalangeal|MP|156|157|PHYSICAL EXAMINATION|Bunion deformity is remarkable in both feet. The hands are remarkable for early destructive changes of rheumatoid arthritis with synovial thickening at the MP and PIP joints bilaterally. No hot, red joints are appreciated. IMPRESSION: 1. Appropriate surgical candidate. 2. History of rheumatoid arthritis on immunosuppressive medications. PLAN: The patient has held her last dose of Humira and took her last injection on _%#MMDD2005#%_.
MP|metatarsophalangeal|(MP)|166|169|PHYSICAL EXAMINATION|Somewhat diminished pulses but they are palpable. MUSCULOSKELETAL: Hands and feet have stigmata of rheumatoid arthritis, especially affecting the metatarsophalangeal (MP) joints. NEUROLOGIC: He is somewhat tired appearing but alert and oriented. LABORATORY DATA: White count on admission was 17,200, hemoglobin 14.5. This morning the white count is 14,700.
MP|metatarsophalangeal/metacarpophalangeal|MP|119|120|PHYSICAL EXAMINATION|HEART: Regular rate and rhythm. RIGHT UPPER EXTREMITY: Reveals a laceration of the thumb along the volar aspect at the MP crease and carried into the first web space. He has full flexion of his SPL tendon. He has normal two-point discrimination along the radial border to 4 mm on the ulnar border to greater than 14 mm.
MP|metacarpophalangeal|MP|160|161|IMPRESSION|He has normal radial and ulnar pulses and a good brachial radialis reflex. IMPRESSION: A radial digital nerve laceration to the ring finger at the level of the MP joint. Given that the patient is a chef and will be using a knife, the concern about developing a neuroma at that area is a concern, so we did discuss surgical repair versus not repairing it and given his utility of hand tools for his chef work, he decided to proceed with the surgery.
MP|mercaptopurine|MP,|294|296|HISTORY OF PRESENT ILLNESS|She has required steroids twice to help increase her hemoglobin and has been receiving prophylactic anticoagulation with Coumadin prior to her admission. She is being treated under study UMN BMT 2001-10 which includes reduced intensity conditioning chemotherapy with Cytoxan, fludarabine, ATG, MP, and total body irradiation. Further details can be found in the history and physical form detailed in her chart. HOSPITAL COURSE: PROBLEM #1: Fluids, Electrolytes, and Nutrition. After starting chemotherapy _%#NAME#%_ rapidly lost her appetite and was placed on TPN on _%#MMDD2005#%_.
MP|mercaptopurine|MP|139|140|HOSPITAL COURSE|See history and physical regarding other details. The patient was seen by GI and started on IV steroids. In addition to his Asacol added 6 MP empiric Flagyl. His bowel movements did decrease in frequency down to about 4 or 5. The patient felt better ____________. The cardiologist held his Cardura, suggested Florinef, to increase the IV volume if symptoms do not continue to stabilize after discharge.
MP|metacarpophalangeal|MP|198|199|PHYSICAL EXAMINATION|HEAD, EYES, EARS, NOSE AND THROAT: Is normocephalic, atraumatic LUNGS: Are clear HEART: Is regular rate and rhythm EXAMINATION OF HIS RIGHT UPPER EXTREMITY: Reveals a large laceration at the thenar MP crease. He does have a normal radial and ulnar sensation to 4 mm. His profundus is completely intact. He has full active extension.
MP|mercaptopurine|(MP),|282|286|HOSPITAL COURSE|The patient tolerated his initial chemotherapy quite well and also received prophylactic intrathecal methotrexate. Prior to discharge he was continuing to tolerate chemotherapy well and the plan was to discharge him and have him continue the chemotherapy with oral 6-mercaptopurine (MP), cytarabine and Cytoxan as an outpatient. The patient was instructed to follow up with Dr. _%#NAME#%_ _%#NAME#%_ for prophylactic intrathecal methotrexate weekly and to follow up in my office on Monday to repeat laboratory tests and to resume chemotherapy.
MP|(device) MP|MP|255|256|HISTORY OF PRESENT ILLNESS|Her cough is reportedly improved considerably. The chest x-ray was subsequently read from the Emergency Department was possible early pneumonia, but as stated she did complete a course of azithromycin. At that time, her sodium was 132 and she also had an MP swab done which was negative for influenza. A BNP was 111 and a CBC was unremarkable with a hemoglobin of 11.2, platelet count of 156,000 with a TSH of 0.53 from previously in _%#MM#%_.
MP|mercaptopurine|MP.|154|156|MEDICATIONS|She also had no clear resection of her Crohn's disease. 4. Hypertension. 5. Breast reduction in 1998. MEDICATIONS: At the time of admission include: 1. 6 MP. 2. Lisinopril. 3. Birth control pill. 4. Hydrochlorothiazide. 5. B-12. 6. Percocet. 7. Dilaudid. ALLERGIES: She has an allergy to morphine, sulfa and an adverse reaction to Remicade.
MP|metacarpophalangeal|MP|157|158|PHYSICAL EXAMINATION|EXTREMITIES: Examination of his left upper extremity being compared with right upper extremity reveals an oblique laceration on the index finger between the MP and PIP crease. He has full profundus and superficialis pull-through. He has diminished 2 point discrimination which is greater than a centimeter on the radial side and 3-4 mm on the ulnar side.
MP|mercaptopurine|MP|156|157|PAST MEDICAL HISTORY|At that time, she was prescribed cortisone, corticosteroids, and weaned successfully. According to old records, she has good compliance with her current 6- MP and Pentasa. Her last flexible sigmoidoscopy was in _%#MM#%_ 2004 which showed minimally active Crohn's disease. No flares since _%#MM#%_ 2003. 2. History of low albumin per Dr. _%#NAME#%_.
MP|metatarsophalangeal/metacarpophalangeal|MP|149|150|PHYSICAL EXAMINATION|Her two point discrimination measures 4 mm on both sides. She cannot fire her IP joint. She has no flexion there. She has tenderness proximal to the MP joint. IMPRESSION: Left thumb flexor tendon injury. PLAN: Is to do a left thumb flexor tendon repair.
MP|mercaptopurine|MP,|208|210|PAST MEDICAL HISTORY|The patient is status post induction chemotherapy with vincristine, dexamethasone, daunorubicin, and intrathecal ARA-C, and intrathecal methotrexate. He is also status post consolidation chemotherapy with 6- MP, ARA-C, vincristine, cyclophosphamide, and multiple intrathecal methotrexate doses. Last chemotherapy was vincristine 2 weeks ago in _%#CITY#%_ _%#CITY#%_. Last bone marrow biopsy was _%#MM#%_ _%#DD#%_, 2005, which showed only 2% blasts and erythroid predominance with left shifted myeloid cell.
MP|mercaptopurine|MP|120|121|HISTORY|The patient has been off of treatment for Crohn's disease over the last year. Treatment at that time had consisted of 6 MP and prednisone. She apparently had a herpes zoster flare and for this reason was taken off the 6MP. The patient had had problems with a small bowel to colon fistula, but was told that her fistula had closed.
MP|mercaptopurine|MP|178|179|DISCHARGE DIAGNOSES|11. Acute respiratory failure, requiring intubation. 12. Anemia. 13. Hypernatremia. 14. Depression. 15. Deconditioning. 16. Aspiration pneumonia. 17. Arthrosis of the left index MP joint, inflammatory versus infectious. HISTORY OF PRESENT ILLNESS: Please see the admission history and physical.
MP|mercaptopurine|MP|239|240|PHYSICAL EXAMINATION|It starts at about the mid-portion of the back of the hand, and emanates towards but just proximal to the little finger MCP joint. He has good intrinsic muscle function in that he can extend his IP joints but he cannot actively extend the MP joints of the ring and little fingers. The rest of the fingers have normal motion and extension. He does not have any sensory loss and all digits are well perfused.
MP|(device) MP|MP|116|117|HISTORY OF PRESENT ILLNESS|Prior to septal cannulation right femoral vein access was also obtained. Radi wire was placed in the LV cavity over MP catheter. The gradient was measured at baseline and post PVC. Cardiac echo was also performed. At 2.0 x 8 mm over the wire Maverick was used initially; however, the largest balloon was 2.5 x 13 mm.
MP|mercaptopurine|MP|338|339|HISTORY OF PRESENT ILLNESS|He has undergone a small bowel resection for small-bowel obstruction secondary to Crohn's in 1990 and underwent partial right-sided colon resection in 1990 following obstructive symptoms secondary to his Crohn's disease at that time. He is followed by Dr. _%#NAME#%_ _%#NAME#%_ Minnesota GI _%#CITY#%_ Clinic. He has been stable on her 6 MP along with Colestid for diarrhea. He occasionally has a flare as described above which is thought to be related to his Crohn's disease or possible intermittent resolving diverticulitis.
MP|mercaptopurine|MP|228|229|MEDICATIONS|He does not smoke, he drinks alcohol occasionally, is followed by Dr. _%#NAME#%_ at _%#CITY#%_ _%#CITY#%_ Medical Center and Dr. _%#CITY#%_ Minnesota GI Clinic, _%#CITY#%_, Minnesota. MEDICATIONS: 1. Lisinopril 5 mg daily. 2. 6 MP I believe exact dose unknown. He thinks it is 50 mg a day. 3. Colestid 2 tablets b.i.d. 4. Sudafed p.r.n. takes this approximately daily. He took 2 tablets yesterday.
MP|metatarsophalangeal|MP|207|208|PHYSICAL EXAMINATION|Femoral pulses normal, posterior tibialis is very weak on the left, no dorsalis pedis on the left. Venous stasis dermatitis changes the left foot is edematous, the distal 50% is erythematous, over the first MP joint left foot is a fluctuant 2 cm mass with a black 6 mm eschar on it. She has some tinea pedis. Joints without inflammation. NEUROLOGIC: Patellar reflexes unobtainable.
MP|metacarpophalangeal|MP|126|127|PHYSICAL EXAMINATION|RIGHT UPPER EXTREMITY: Reveals significant ecchymosis and bruising in the thumb. He has a palpable Stener lesion at the thumb MP joint and he opens up about 80 to 90 degrees at the MP joint with deviation stress. IMPRESSION: Acute ulnar collateral ligament tear. PLAN: Ulnar collateral ligament repair under Bier block anesthesia.
MP|metatarsophalangeal/metacarpophalangeal|MP|181|182|PHYSICAL EXAMINATION|RIGHT UPPER EXTREMITY: Reveals significant ecchymosis and bruising in the thumb. He has a palpable Stener lesion at the thumb MP joint and he opens up about 80 to 90 degrees at the MP joint with deviation stress. IMPRESSION: Acute ulnar collateral ligament tear. PLAN: Ulnar collateral ligament repair under Bier block anesthesia.
MP|metacarpophalangeal|MP|170|171|PHYSICAL EXAMINATION|EXTREMITIES: Her left upper extremity has four puncture wound sites, one with exposed subcutaneous fat and draining some serous fluid. She has erythema outlined from her MP joints to about four fingerbreadths proximal to her radial styloid. She does have swelling on the dorsum of her hand. She has no pain with resisted digital extension of the index.
MP|UNSURED SENSE|MP|219|220|HISTORY|4. Aortocoronary bypass. 5. Hypertension. 6. Iatrogenic hypertension. PRINCIPAL PROCEDURE: Left radical nephrectomy. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 56-year-old white male who was seen because of microhematuria. An MP 22 urine test was negative. Urinalysis showed 0-1 red blood cell per high power field. Flexible cystoscopy was performed. CT scan of the abdomen revealed renal tumors bilaterally, no adenopathy and no venous thrombus.
MP|mercaptopurine|MP|214|215|PAST MEDICAL HISTORY|His colon biopsy showed active chronic ulcerative colitis with areas indefinite for dysplasia. 3. History of bilateral rotator cuff repair surgeries. 4. A previous history of pancreatitis with patient being on six MP which was thought to cause this. 5. History of hypertension for the last three years PAST SURGICAL HISTORY: 1. Multiple colon surgeries 2. Cholecystectomy. 3. Mesh hernia repair.
MP|metatarsophalangeal/metacarpophalangeal|MP|146|147|PHYSICAL EXAMINATION|The left foot and toes 2 through 4 are clear of any redness or lesions. The left great toe has significant swelling and erythema extending to the MP joint. There is a small 1 x 1-cm break in the skin over the medial aspect of the left great toe with associated purulent drainage.
MP|mercaptopurine|(MP)|77|80|PRINCIPAL DISCHARGE DIAGNOSIS|PRINCIPAL DISCHARGE DIAGNOSIS: 1. Pancytopenia secondary to 6-mercaptopurine (MP) versus myelodysplastic syndrome. 2. Crohn's disease. 3. Fever of unknown origin. 4. Gastroesophageal reflux disease (GERD). CONSULTATIONS: 1. Hematology Oncology (Dr. _%#NAME#%_ _%#NAME#%_). 2. Infectious Disease (Dr. _%#NAME#%_ _%#NAME#%_).
MP|mercaptopurine|MP|164|165|HISTORY OF PRESENT ILLNESS|He was initially diagnosed after presenting for short stature, and CBC revealed pancytopenia. He presents for a double umbilical cord blood transplant per protocol MP _%#PROTOCOL#%_ and currently feels well. PAST MEDICAL HISTORY: 1. Fanconi anemia. 2. ADHD diagnosed at age 9, and currently not being on treatment.
MP|metatarsophalangeal/metacarpophalangeal|MP|165|166|PHYSICAL EXAMINATION|There is mild abrasion on the lateral edge of the right foot but no erythema. There may be a bit of generalized swelling. There is no tenderness to the first ray or MP joint. LABORATORY DATA: Creatinine this morning is 2.6, white count is steady at 13,700.
MP|metatarsophalangeal|MP|231|232|PHYSICAL EXAMINATION|ABDOMEN: Soft, flat and easily palpable without palpable liver, kidney, spleen or other abdominal masses. GENITORECTAL: Deferred. EXTREMITIES: Upper extremities are negative. Lower extremities reveal typical bunion deformity first MP joint, left foot, and also typical hammertoe type deformity with considerable callus on the dorsal aspect of her second toe. Complete foot findings are deferred to the operating surgeon. IMPRESSION: Left foot, first MP bunion, second toe hammertoe deformity.
MP|metacarpophalangeal|MP|180|181|PAST MEDICAL HISTORY|Tylenol #3 CAUSES UPSET STOMACH. DOXYCYCLINE CAUSES NAUSEA AND VOMITING. NO TRUE MEDICINE ALLERGIES PAST MEDICAL HISTORY: HOSPITALIZATIONS: 1. Right wrist ganglion and right first MP joint repair in _%#MM#%_, 2006. 2. Left cataract in _%#MM#%_ of 2006 3. Tonsillectomy age 16. 4. Appendectomy 1970 5. Childbirth x 2 in the past
MP|mercaptopurine|MP|142|143|HOME MEDICATIONS|This was done in 2002 he did have a fistula in the anal area sometime before the surgery. 2. Anemia of chronic disease HOME MEDICATIONS: 1. 6 MP 125 mg a day 2. Recently has been placed on Cipro. ALLERGIES: Possibly iron but also iodine. SOCIAL HISTORY: He is a nonsmoker, nondrinker. FAMILY HISTORY: Positive for hypertension.
MP|metatarsophalangeal/metacarpophalangeal|MP|149|150|CHIEF COMPLAINT|About two weeks ago on _%#MMDD2006#%_, this patient was playing soccer when he landed on his right hand and jammed it. He noted onset of pain in the MP joint. This was initially self-managed but eventually he found his way to his family physician who got some x-rays. These revealed a fracture. I saw this patient the following day.
MP|mercaptopurine|MP,|219|221|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Crohn's disease; this was diagnosed in 1996, approximately 1 year post-partum. She has had an extensive work-up for this. She has been treated at different times with prednisone and Remicade, 6 MP, Pentasa. Her colonoscopy from _%#MMDD2006#%_ was negative for Giardia, Clostridium, and ova and parasites. Her stool cultures are negative as well. She did have changes on biopsy consistent with the diagnosis of Crohn's.
MP|metatarsophalangeal/metacarpophalangeal|MP|181|182|PHYSICAL EXAMINATION|He then has a red lower leg which is confluent with sharp demarcation just below the knee. Negative Homans'. He has 1+ edema. He has a small blister on the medial side of the first MP joint. NEUROLOGIC: He is intact grossly, has the right foot drop as mentioned. LABORATORY DATA: His white count has been normal x2. Hemoglobin 11.8. Creatinine was 1.18 on admission, 1.82 this morning, glucose 99 and 117.
MP|mercaptopurine|MP|147|148|HOSPITAL COURSE|The plan with medications was to continue oral prednisone at 30 mg q.d. on discharge. Do not restart Luvsin or asacol at discharge. To continue 6- MP and consider Remicade treatment after 6-MP for a couple of months (6-MP decreases the risk of anaphylactic reaction to Remicade).
MP|metatarsophalangeal|MP|198|199|HISTORY OF PRESENT ILLNESS|She has difficulty with shoe wear because of it. On examination, there is no dorsiflexion to the left great toe at all. She has marginal spur formation that is both visible and palpable so that the MP joint of the left great toe is much larger than the right. X-rays demonstrate some narrowing of the MP joint space together with marginal spurs.
MP|metatarsophalangeal/metacarpophalangeal|MP|181|182|HISTORY OF PRESENT ILLNESS|She has marginal spur formation that is both visible and palpable so that the MP joint of the left great toe is much larger than the right. X-rays demonstrate some narrowing of the MP joint space together with marginal spurs. Her diagnosis is hallux rigidus. _%#NAME#%_ is now admitted for a cheilectomy of the left great toe.
MP|metatarsophalangeal/metacarpophalangeal|MP|127|128|PHYSICAL EXAMINATION|LUNGS: Clear. HEART: Regular rate and rhythm. LEFT UPPER EXTREMITY: Reveals a laceration along the dorsal radial aspect of the MP joint. She is unable to fully extend the IP joint. IMPRESSION: EPL extensor tendon injury. PLAN: Direct repair under Bier block anesthesia. The risks and benefits of the surgery were described to the patient and she fully consented.
MP|metacarpophalangeal|MP|284|285|PHYSICAL EXAMINATION|He is not married. REVIEW OF SYSTEMS AND FAMILY HISTORY: Are noncontributory PHYSICAL EXAMINATION: HEAD, EYES, EARS, NOSE AND THROAT: Normocephalic, atraumatic. LUNGS: Are clear. HEART: Regular rate and rhythm EXAMINATION OF HIS INDEX FINGER: Reveals a small radial laceration at the MP crease level of his index finger. He has about 2 1/2 stitches in it. He has two point discrimination on the radial border of his index finger measures 12 mm, on the ulnar side of the digit, it measures 3-4 mm.
MP|metacarpophalangeal|MP|282|283|PHYSICAL EXAMINATION|She is in no acute distress. HEENT: Normocephalic atraumatic. LUNGS: Clear. HEART: Regular rate and rhythm. EXTREMITIES: Examination of right upper extremity when compared to left upper extremity reveals three lacerations, one is on the volar aspect of the thumb just distal to the MP crease and then there are two in the thenar area with nylon sutures. She has full FDL ______ to the thumb. She has good capillary refill.
MP|metacarpophalangeal|MP|134|135|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: 1. Left pubic rami fracture, the patient will be treated conservatively. 2. Volar dislocation, right 2 through 5 MP joints, old. The patient will be treated conservatively. The patient did not want surgery. 3. Left elbow contusion. 4. Anemia, B12 deficiency.
MP|nurse practitioner:NP|MP|123|124|HISTORY OF PRESENT ILLNESS|He states it came back again and lasted approximately 45 minutes and that is when he called 911. His initial rhythm by the MP showed a short P-R interval, junctional tachycardia, and a left bundle branch block. The patient was given aspirin, oxygen, and two Nitroglycerin in route to the Fairview Southdale Emergency Room.
MP|metacarpophalangeal|MP|228|229|PHYSICAL EXAMINATION|Examination of his right upper extremity reveals a well healed surgical scar on the posterior aspect of his elbow. At the thumb, he has a tenderness at the ulnar collateral ligament. He does open up with deviation stress at the MP joint and MRI demonstrates he had complete tear of the ulnar collateral ligament. HEART: Is regular rate and rhythm. LUNGS: Are clear.
MP|mercaptopurine|MP|164|165|HOSPITAL COURSE|5. Lovenox 60 mg subq p.o. b.i.d. 6. Potassium chloride 10 mEq p.o. q.d. HOSPITAL COURSE: 1. Stem cell transplant. _%#NAME#%_ underwent conditioning, with protocol MP _%#PROTOCOL#%_, which included two doses of Cytoxan and four days of TBI. She tolerated this with some nausea and vomiting, but no other complications.
MP|metacarpophalangeal|MP|57|58|DIAGNOSIS|DOB: _%#MMDD1974#%_ DIAGNOSIS: 1. Left hand septic index MP joint. PROCEDURE THIS ADMISSION: 1. I&D of left index MP joint.
MP|metacarpophalangeal|MP|114|115|PROCEDURE THIS ADMISSION|DOB: _%#MMDD1974#%_ DIAGNOSIS: 1. Left hand septic index MP joint. PROCEDURE THIS ADMISSION: 1. I&D of left index MP joint. 2. I&D and closure of left index MP joint. HISTORY AND HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 27-year- old male who presented to the hospital with left hand cellulitis.
MP|metacarpophalangeal|MP|120|121|HISTORY AND HOSPITAL COURSE|In follow up, examination in the hospital it became more apparent there was a likelihood of an involvement of his index MP joint. For that reason he underwent I&D. Appropriate antibiotics initially were started and were appropriately addressed based on the cultures positive for beta hemolytic Strep.
MP|metacarpophalangeal|MP|122|123|PLAN|Distant appendectomy age 20. He had excision of a squamous cell carcinoma on the dorsum of the right hand over the second MP area in _%#MM2001#%_ for squamous cell carcinoma. That was done at North Memorial Medical Center. Other health problems include hypertension since age 43 and hypercholesterolemia.
MP|metacarpophalangeal|MP|208|209|PHYSICAL EXAMINATION|HEENT: he has a cataract in his left eye, prior lens implant on the right, remainder of the head and neck area is normal. Skin: he has a skin graft well healed over the dorsum of the right hand at the second MP area. He has several actinic keratoses on the hands and wrists which are treated with liquid nitrogen on _%#MM#%_ _%#DD#%_. Actinic change is minimal elsewhere. Lungs clear. Heart: regular rhythm, no murmurs.
MP|mercaptopurine|MP|119|120|DISCHARGE PLAN|She will follow up probably with _%#NAME#%_ _%#NAME#%_ this week and with me the following week. Will plan to start 6- MP at that time. Diet will be slowly increased. Activity as tolerated.
MP|mercaptopurine|MP|159|160|SUMMARY|As noted Dr. _%#NAME#%_ did colonoscopy which on biopsy proved to show Crohn's disease. The patient was treated with steroid and also we added Remicade and 6- MP to her regimen. Within a few more days her bowel pattern started to improve and at the time of discharge bowels are still a little bit more frequent but are formed.
MP|military police|MP.|174|176|HISTORY OF PRESENT ILLNESS|He presents electively to our clinic to consider surgical resection of the cyst so he could discontinue his antiepileptic medication and so he could enlist in the army as an MP. The MRI reveals close proximity of the medial wall of the cyst to the lateral ventricle. The plan is for the patient to come for elective decompression and fenestration of the cyst.
MP|mercaptopurine|MP|264|265|DISCHARGE PLANS|She was able to be discharged on _%#MMDD2003#%_. DISCHARGE PLANS: The patient is discharged on _%#MMDD2003#%_ with Remicade, per protocol, after 2 weeks and 6 weeks, prednisone tapering (schedule provided by Dr. _%#NAME#%_), Asacol (400 mg tabs) 4 tabs t.i.d., 6- MP 50 mg q.a.m., with CBC in two weeks, and follow up per Minnesota Gastroenterology in one month's time.
MP|metarsophalangeal|MP|260|261|DOB|She has difficulty walking forward and taking a stride with her left foot because of pain when she strides forward with the left leg because of pain and stiffness in the right great toe. On examination, she has visible and palpable marginal spurring about the MP joint of the right great toe. The right great toe is actually in a plantarflexed position and does not even extend to a neutral position.
MP|metatarsophalangeal/metacarpophalangeal|MP|187|188|PHYSICAL EXAMINATION|HEART: Regular rate and rhythm. LEFT UPPER EXTREMITY: No pain or tenderness over the radial, ulnar, or collateral ligaments and stable to deviation stress at the interphalangeal (IP) and MP joint. He does not have pain at the volar aspect of the MP joint. No crepitus there with range of motion. Large bony osteophytes prominent at the carpometacarpal (CMC) joint.
MP|metatarsophalangeal/metacarpophalangeal|MP|246|247|PHYSICAL EXAMINATION|HEART: Regular rate and rhythm. LEFT UPPER EXTREMITY: No pain or tenderness over the radial, ulnar, or collateral ligaments and stable to deviation stress at the interphalangeal (IP) and MP joint. He does not have pain at the volar aspect of the MP joint. No crepitus there with range of motion. Large bony osteophytes prominent at the carpometacarpal (CMC) joint. Positive grind maneuver. He has pain with pressure over the volar and radial aspect of his CMC joint.
MP|metatarsophalangeal|MP|89|90|HISTORY OF PRESENT ILLNESS|The patient has had a recurrent ulceration on the bottom of his right foot under the 1st MP for the past several months. The patient states that this heals and then becomes sore and ulcerated off and on and the surgeon has decided it is time to surgically correct this.
MP|metacarpophalangeal|MP|255|256|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 64-year-old gentleman who was in good state of health until today when at 09:30 hours he was working with his table saw cutting a piece of wood when it "kicked back" and cut off his 4th finger to the MP on his left hand. He was transported to the emergency department at Fairview Southdale Hospital for further evaluation.
MP|metacarpophalangeal|MP|122|123|PHYSICAL EXAMINATION|EXTREMITIES: Negative for any cyanosis, clubbing or edema. There is however on the left hand 4th finger amputation to the MP joint with good hemostasis. Pulses were 2+ at wrists with sensation intact. Two other digits of his hand skin was pink. NEUROLOGIC: Cranial nerves II-XII are intact. LABORATORY DATA: Currently hemoglobin is 16, INR 2.67, potassium of 5.
MP|metacarpophalangeal|MP|52|53|HISTORY OF PRESENT ILLNESS|This patient has pain along the right little finger MP joint. She has swelling and limitation of motion. She denies numbness, however. There is no prior history of right hand problems. _%#NAME#%_ denies pain in her wrist.
MP|metacarpophalangeal|MP|166|167|PHYSICAL EXAMINATION|ABDOMEN: Soft and nontender. No hepatosplenomegaly. RIGHT HAND: Examination reveals mild swelling. There is tenderness and ecchymosis centered over the little finger MP joint. There is no rotational malalignment however. NEUROLOGICAL EXAM: Intact. X-rays of the right hand (three views) taken in my office on _%#MMDD2003#%_ reveal an oblique fracture of the fifth metacarpal head.
MP|metacarpophalangeal|MP|182|183|HISTORY OF PRESENT ILLNESS|3. Pneumonia. HISTORY OF PRESENT ILLNESS: This 77-year-old man with known myelodysplastic syndrome since _%#MM2004#%_ presents with complaints of pain and swelling in the left third MP joint, with associated redness of the surrounding skin for three days. He was seen at a local urgent care two days ago and was advised to start Augmentin; however, he has had worsening of symptoms, with persistent fevers up to a temperature of 101.6. He is now admitted for further management.
MP|metacarpophalangeal|MP|162|163|ADMISSION PHYSICAL EXAMINATION|EYES: Pupils equal, round, and reactive to light and accommodation. Extraocular movements intact. MOUTH: Moist, without oral lesions. EXTREMITIES: The left third MP joint and surrounding skin was erythematous and warm. His right knee was without tenderness or effusions. ADMISSION LABORATORY WORK: White count 1.0, hemoglobin 6.5, platelets 111, ANC 200.
MP|metacarpophalangeal|MP|217|218|HISTORY OF PRESENT ILLNESS|Her exam and x- rays were consistent with overload of the first ray consistent with a plantarflexed first metatarsal resulting in dorsiflexion of the proximal phalanx. She was unable to fully passively flex the first MP joint down to a neutral position. She was also developing second toe overload. Because of her persistent symptoms and radiographic findings, it was felt she may benefit from an attempted dorsiflexion osteotomy of the first metatarsal to elevate the metatarsal head and unload this area.
MP|metatarsophalangeal|MP|283|284|PHYSICAL EXAMINATION|ABDOMEN: Soft, nontender, nondistended, good bowel sounds. EXTREMITY exam: The left extremities, second, third, fourth and fifth toes are normally aligned and benign. The wound on the plantar aspect of the foot is completely healed. The great toe is erythematous to the level of the MP joint. Tenderness to the skin palpation diffusely around the great toe. The tip of the great toe has a callus on the distal aspect and this callus was sharply debrided in the clinic and purulent material was expressed.
MP|milligram:mg|MP|181|182|HISTORY OF PRESENT ILLNESS|His medications on admission were said to be antabuse as well as fluoxetine 40 mg p.o. daily. The fluoxetine is continued. He has also been placed by psychiatry on Seroquel at a 50 MP oral daily dosage taken at bedtime.
MP|metatarsophalangeal|MP|157|158|HISTORY OF PRESENT ILLNESS|In the Emergency Department at Fairview Southdale Hospital, he was found to have the infected tophi that was actively draining in his left foot, the big toe MP joint. He was also found to have some skin breakdown in his groin and lower abdomen. He was also found to have significant venostasis disease of both lower legs and he was felt to have gout in his knees as well as his feet, and being unable to bear any weight.
MP|metatarsophalangeal|MP|120|121|PHYSICAL EXAMINATION|He has good strong pulses and his edema is non-pitting and is at the 2+ level, but is chronic and old. His left big toe MP joint has an open wound approximately 2 cm long, draining what appears to be uric acid crystals, and is purulent as well.
MP|metatarsophalangeal/metacarpophalangeal|MP|183|184|LEFT UPPER EXTREMITY|LUNGS: Clear. HEART: Regular rate and rhythm. LEFT UPPER EXTREMITY: Examination reveals a thumb hyperextended at the MP joint of the thumb. She has no passive range of flexion at the MP joint, has no numbness in the tip, and is able to fire her flexor pollicis longus (FPL) tendon. X-RAYS: Review is suggestive of a complex dislocation of the MP joint and, give her lack of motion there, it is my impression that is what she has.
MP|metatarsophalangeal/metacarpophalangeal|MP|203|204|X-RAYS|She has no passive range of flexion at the MP joint, has no numbness in the tip, and is able to fire her flexor pollicis longus (FPL) tendon. X-RAYS: Review is suggestive of a complex dislocation of the MP joint and, give her lack of motion there, it is my impression that is what she has. IMPRESSION: Complex dislocation of MP joint. PLAN: Open reduction, MP dislocation, and Dr. _%#NAME#%_ got her scheduled for Friday at the _%#CITY#%_ Campus, so I am dictating the preoperative history and physical.
MP|metatarsophalangeal/metacarpophalangeal|MP|183|184|IMPRESSION|X-RAYS: Review is suggestive of a complex dislocation of the MP joint and, give her lack of motion there, it is my impression that is what she has. IMPRESSION: Complex dislocation of MP joint. PLAN: Open reduction, MP dislocation, and Dr. _%#NAME#%_ got her scheduled for Friday at the _%#CITY#%_ Campus, so I am dictating the preoperative history and physical.
MP|metatarsophalangeal/metacarpophalangeal|MP|215|216|PLAN|X-RAYS: Review is suggestive of a complex dislocation of the MP joint and, give her lack of motion there, it is my impression that is what she has. IMPRESSION: Complex dislocation of MP joint. PLAN: Open reduction, MP dislocation, and Dr. _%#NAME#%_ got her scheduled for Friday at the _%#CITY#%_ Campus, so I am dictating the preoperative history and physical.
MP|metacarpophalangeal|MP|144|145|PHYSICAL EXAMINATION|The skin has been brought up. It has some open granulation tissue. He does have motion at the DIP crease, as well as at the PIP crease and good MP motion. At the long finger, his nail is in place, but you can significantly move the distal tip and there is no stability to any pinch.
MP|UNSURED SENSE|MP|120|121|HISTORY OF PRESENT ILLNESS|Initially, she could not initiate micturition for uroflow testing, and 160 cc were drained from the bladder. She had an MP urethral pressure profile, revealing a maximum closure pressure of 48 cm water. During filling cystometry, she had the following low threshold sensations.
MP|metacarpophalangeal|MP|141|142|PHYSICAL EXAMINATION|With later examination, he has bullae developing in the dorsal aspect of the finger and a fluctuant area extending from the PIP joint to the MP joint. He can activate range of motion minimally secondary to swelling. He has no evidence of wrist or more proximal process.
MP|nurse practitioner:NP|M.P.|390|393|DISCHARGE FOLLOW-UP|GENITALIA: Her right groin is without hematoma or bruit. LABORATORY AND DIAGNOSTIC DATA: Labs today show that her troponin increase slightly to 1.56, hemoglobin 12.2, potassium 3.8, creatinine 1.53. DISCHARGE MEDICATIONS: She will be discharged on all of her admission medications with the addition of Plavix which she will take daily for six months. DISCHARGE FOLLOW-UP: 1. A visit with a M.P. or P.A. at Minnesota Heart Clinic in two to three weeks. 2. She will have a lipid profile in six months. 3. A thallium stress test in six months. 4. Office visit with Dr. _%#NAME#%_ in six months.
MP|metacarpophalangeal|MP|162|163|PHYSICAL EXAMINATION ON ADMISSION|Bowel sounds are normal. SPINE: Patient has severe tenderness in the right flank. SKIN: Patient has multiple tattoos as well as scars over bilateral dorsal first MP joints, right greater than left. NEURO: Cranial nerves II-XII intact. MUSCULOSKELETAL EXAMINATION: Patient has some tenderness in the right trapezius muscular area.
MP|mercaptopurine|MP|189|190|HISTORY|It is noted the patient has had a previous respiratory arrest after Remicade and thus she is not a candidate for future Remicade use. She will be discharged on Prednisone 40 mg daily and 6 MP 100 mg daily in addition to her usual medications. She will follow-up with Dr. _%#NAME#%_ in two weeks.
MP|UNSURED SENSE|MP|413|414|HISTORY OF PRESENT ILLNESS|Official results pending, including sections. RFLP results pending. HISTORY OF PRESENT ILLNESS: This is a 54-year-old, male patient with a history of acute myelogenous leukemia, status post myeloablative allogeneic sibling peripheral blood stem cell transplant on _%#MM#%_ _%#DD#%_, 2005, with recent hospitalization in _%#MM#%_, complicated by bacteremia with development of acute GVHD. He was admitted from the MP clinic today for an un-resolving rash, likely from GVHD. The patient was recently admitted in _%#MM#%_ of 2005 with coag-negative Staphylococcus bacteremia and line infection.
MP|metacarpophalangeal|MP|196|197|PHYSICAL EXAMINATION|GENERAL: Color is good. She is alert and fully oriented and appears quite comfortable. MUSCULOSKELETAL: There are obvious deformities particularly in the PIP joints of both hands, but also in the MP joints. The spine is somewhat tender in the lumbar region with limited range of motion. HEENT: Unremarkable. The right eye is very well healed after her cataract extraction recently.
MP|metatarsophalangeal/metacarpophalangeal|MP|133|134|PHYSICAL EXAMINATION|She has a flexion posture to her I-P joint of about 40 degrees. Passively we can extend the I-P joint maybe 10 degrees. She has good MP motion and CMC motion. She does not show any sign of nailbed deformity. Her ______ is intact. Review of her x-rays show a displaced condylar fracture of her proximal phalanx to the thumb.
MP|(device) MP|MP|185|186|LABORATORY DATA|No high-pitched wheezes were heard. There were no retractions and respirations were easy. LABORATORY DATA: White count 7.1, hemoglobin 12.5 and platelets 153. Chest x-ray was negative. MP swab for RSV and influenza A&B were both negative. HOSPITAL COURSE: _%#NAME#%_ was admitted and started on frequent nebulizations and IV steroids.
MP|metacarpophalangeal|MP|296|297|PHYSICAL EXAMINATION|LUNGS: Clear. HEART: Regular rate and rhythm. EXTREMITIES: Examination of his right upper extremity reveals significant ecchymosis and bruising in the thenar area of the thumb at the IP joint. He has no tenderness over the radioulnar collateral ligament. He is stable to deviation stress. At the MP joint, he is significantly tender over the ulnar collateral ligament, but no Steiner's lesion is palpable. He does begin to open up with deviation stress. He has pain at that joint level.
MP|metacarpophalangeal|MP|62|63|PREOPERATIVE DIAGNOSIS|PREOPERATIVE DIAGNOSIS: Left thumb complex dislocation of the MP joint. PROPOSED PROCEDURE: Left thumb open reduction of the thumb MP dislocation HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 14-year-old right-hand dominant ninth grader who plays football, basketball and lacrosse for school.
MP|metacarpophalangeal|MP|131|132|PROPOSED PROCEDURE|PREOPERATIVE DIAGNOSIS: Left thumb complex dislocation of the MP joint. PROPOSED PROCEDURE: Left thumb open reduction of the thumb MP dislocation HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 14-year-old right-hand dominant ninth grader who plays football, basketball and lacrosse for school.
MP|metacarpophalangeal|MP|138|139|PHYSICAL EXAMINATION|HEART: Regular rate and rhythm. LUNGS: Clear. NOSE: Without coryza. Throat is without erythema. LEFT THUMB; Reveals hyperextension at the MP joint. He is unable to flex at the MP joint at all. He can fire his FDL. He has normal two-point discrimination.
MP|metacarpophalangeal|MP|172|173|PHYSICAL EXAMINATION|He can fire his FDL. He has normal two-point discrimination. Review of his preoperative picture as well as the x-rays demonstrate a complex dislocation of the thumb at the MP joint with volar plate interposition. PLAN: Open reduction. I did try to see if he could get on today with Dr. _%#NAME#%_ since he has not eaten breakfast, however there was no surgical time available.
MP|metacarpophalangeal|MP|139|140|PAST MEDICAL HISTORY|3. Obstructive sleep apnea. 4. Stressed-induced hives occasionally treated with prednisone. 5. Left wrist fusion and graft. 6. Right thumb MP fusion. 7. Tenosynovectomy in _%#MM2006#%_. ALLERGIES: Penicillin; Ceftin. SOCIAL HISTORY: She lives in _%#CITY#%_ with her husband.
MP|metacarpophalangeal|MP|184|185|HISTORY OF PRESENT ILLNESS|Apparently she was pulling a blanket from right to left while she was making her bed. She felt a "pop" in her hand and after that she immediately had trouble extending her long finger MP joint. This patient noted minimal swelling in the area and really only a mild amount of pain.
MP|metatarsophalangeal/metacarpophalangeal|MP|207|208|HISTORY OF PRESENT ILLNESS|He was concerned about a possible dislocation and therefore referred this patient to me. I saw this patient in my office on _%#MMDD2002#%_. After examining her, I felt that she had somehow sustained a volar MP joint dislocation, which was locked. She therefore presents at this time for surgical intervention. Of note is that in the office I reviewed this patient's x-rays.
MP|metacarpophalangeal|MP|121|122|HISTORY OF PRESENT ILLNESS|This patient denies prior history of problems with her right hand. She was always able to fully extend the middle finger MP joint. PAST MEDICAL HISTORY: Significant for osteoarthritis, hypercholesterolemia, hiatal hernia, water retention, and depression.
MP|metacarpophalangeal|MP|168|169|EXAMINATION|She is married with three grown children. She enjoys reading, music, and shopping. EXAMINATION: Examination of the right hand reveals ulnar drift of the fingers at the MP joints. She has full flexion of all digits and full extension of all fingers but for the middle digit. The middle finger MP joint lacks 45 degrees of full extension.
MP|metacarpophalangeal|MP|209|210|EXAMINATION|EXAMINATION: Examination of the right hand reveals ulnar drift of the fingers at the MP joints. She has full flexion of all digits and full extension of all fingers but for the middle digit. The middle finger MP joint lacks 45 degrees of full extension. There is no swelling. She does not have any tenderness over the extensor hood of the MP joint, which would lead me to believe she has a ruptured sagittal band.
MP|metatarsophalangeal/metacarpophalangeal|MP|148|149|EXAMINATION|The middle finger MP joint lacks 45 degrees of full extension. There is no swelling. She does not have any tenderness over the extensor hood of the MP joint, which would lead me to believe she has a ruptured sagittal band. Neurovascular exam is intact. X-rays of the right hand (three views) taken at Suburban Imagining on _%#MMDD2002#%_ reveal volar subluxation of the long finger MP joint.
MP|metacarpophalangeal|MP|159|160|EXAMINATION|Neurovascular exam is intact. X-rays of the right hand (three views) taken at Suburban Imagining on _%#MMDD2002#%_ reveal volar subluxation of the long finger MP joint. Subluxation appears much greater than that noted on the adjacent MP joints. IMPRESSION: Volar dislocation, probably complex, MP joint grade III. As I was unable to reduce this patient's injury in a closed fashion in the office, she therefore presents at this time for possible surgical management by my partner, Dr. _%#NAME#%_.
MP|metatarsophalangeal/metacarpophalangeal|MP|125|126|IMPRESSION|Subluxation appears much greater than that noted on the adjacent MP joints. IMPRESSION: Volar dislocation, probably complex, MP joint grade III. As I was unable to reduce this patient's injury in a closed fashion in the office, she therefore presents at this time for possible surgical management by my partner, Dr. _%#NAME#%_.
MP|metatarsophalangeal|MP|171|172|PHYSICAL EXAMINATION|The erythema extends pretty much up to the calf. The leg is warm. He has tenderness over toe, but it is not particularly exquisite. He is able to move the toe through the MP joint, but not through the IP joint. The IP joint simply seems to be very stiff rather than severely painful. He has good pulses in the foot. The toe is sensate and well perfused.
MP|metacarpophalangeal|MP|257|258|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_, MD is a right-hand dominant orthopedic hand surgeon who was working in her garage this weekend when she was opening some boxes and the knifeblade to cut open the box basically stabbed her left thumb at the MP joint level. PHYSICAL EXAMINATION: She has a small 1.0-cm laceration directly over the extensor pollicis longus (EPL).
MP|UNSURED SENSE|MP|179|180|DIET|The patient prefers Fairview Ridges. He was noted to have a moderate dilated descending aorta and will need an echocardiogram around 2-3 months to assess this. He will need to be MP drawn at nurse practitioner office visit in 1-2 weeks.
MP|metacarpophalangeal|MP|163|164|PHYSICAL EXAMINATION|Examination of the right hand: Reveals significant swelling of the right thumb with moderate redness as well and warmth. The patient keeps the thumb flexed at the MP and IP joints, and is unwilling to move it much at all due to pain. Redness extends up her arm to just below the elbow, and measures at its widest diameter at 2.5 to 3 cm.
MP|metacarpophalangeal|MP|155|156|PHYSICAL EXAMINATION|This was removed for the examination. She has obvious swelling and ecchymosis about the thumb. The area of greatest tenderness is around the IP joint. The MP joint is minimally tender. The thumb is sensate and well-perfused. Outside radiographs of the thumb show a neck of phalanx fracture.
MP|metacarpophalangeal|MP|102|103|IMPRESSION|ADMITTING DIAGNOSIS: Infected thumb, status post removal of a pin IMPRESSION: Cellulitis and infected MP joint of his right thumb _%#NAME#%_ _%#NAME#%_ had surgical removal of the pin ten days prior to admission. Developed swelling, redness and drainage. He was admitted after an I&D, was found to have gross pus in the joint.
MP|metacarpophalangeal|MP|217|218|PHYSICAL EXAMINATION|HEART: Regular rate and rhythm without audible murmur. ABDOMEN: Soft, nontender, no hepatosplenomegaly. LEFT HAND: There is a healed puncture wound in the interspace volarly between the index and long finger near the MP joint. This is associated with mild swelling and low-grade tenderness. Digital motion is normal. There is no evidence of infection. Neurovascular exam is intact.
MP|metabolic panel|MP,|207|209|PROBLEM #3|He will follow up with Dr. _%#NAME#%_ _%#NAME#%_ at Fairview Milaca Clinic in one week. He is to follow up in Transplant Clinic with Dr. _%#NAME#%_ in two weeks. Follow-up laboratories: Hemoglobin A1C, ANC, MP, magnesium, CBC with platelets in 1-2 weeks. The patient's surgical wound is to be kept clean and dry. Accu-Cheks q.i.d. with coverage of Regular insulin with sliding scale.
MP|metacarpophalangeal|MP|198|199|COURSE IN THE HOSPITAL|He underwent open reduction internal fixation of the ulnar styloid fracture, carpal tunnel release, and closed reduction internal fixation of the right thumb ulnar collateral ligament rupturing the MP joint. His postoperative course was benign. He had no complications. It was characterized by the expected paresthesias and discomforts following surgery of this type.
MP|metacarpophalangeal|MP|130|131|PHYSICAL EXAM|Straight leg raising is negative. EXTREMITIES: Remarkable for nodularity in PIP and DIP joints throughout both hands. None in the MP joints however. Has fairly good range of motion throughout these joints. The remaining joints throughout the body unremarkable aside from some crepitus in both knees.
MP|metatarsophalangeal/metacarpophalangeal|MP|128|129|PHYSICAL EXAMINATION|He has tenderness with a palpable ____ lesion. He does deviate about 45 degrees in full extension and he can hyperextend at his MP joint as well. On the opposite side, he does hyperextend at his MP joint but he has good stability to radial and ulnar deviation.
MP|metacarpophalangeal|MP|195|196|PHYSICAL EXAMINATION|He has tenderness with a palpable ____ lesion. He does deviate about 45 degrees in full extension and he can hyperextend at his MP joint as well. On the opposite side, he does hyperextend at his MP joint but he has good stability to radial and ulnar deviation. IMPRESSION: Grade 3 AC joint separation and a right thumb ulnar collateral ligament rupture.
MP|metacarpophalangeal|MP|155|156|PHYSICAL EXAMINATION|There is a laceration over the long finger. He has full active extension of that long finger. He does not have any tenderness over the volar aspect of the MP joint of the long finger. On the ring finger, he has a bite mark that measures about 12 mm in the fourth dorsal webspace, not directly over the extensor tendon, but he does have significant tenderness over the MP joint on the volar aspect.
MP|metatarsophalangeal/metacarpophalangeal|MP|184|185|PHYSICAL EXAMINATION|On the ring finger, he has a bite mark that measures about 12 mm in the fourth dorsal webspace, not directly over the extensor tendon, but he does have significant tenderness over the MP joint on the volar aspect. He has swelling extending to the volar aspect with warmth and erythema. ASSESSMENT: The question is whether he has a dorsal webspace infection versus an MCP joint infection.
MP|mercaptopurine|MP|180|181|DISCHARGE INSTRUCTIONS|3. Repeat upper gastrointestinal with small bowel follow through at F- UMC in one months' time. 4. Follow-up with Dr. _%#NAME#%_ in _%#CITY#%_ _%#CITY#%_ in two to three weeks. 6- MP may be rechecked at that time.
MP|metacarpophalangeal|MP|144|145|OBJECTIVE|Femoral, DP, PT pulses normal. ______ normal. Normal patellar reflexes, 2+. SKIN: Normal. Well-healed scar right knee. Some inflammation of the MP joints of the hands. LABORATORY DATA: INR 0.97, hemoglobin 15.7, white count 11,900 and dropped to 6800.
MP|metacarpophalangeal|MP|179|180|PHYSICAL EXAMINATION|HEENT: Normocephalic atraumatic. LUNGS: Clear. HEART: Regular rate and rhythm. EXTREMITIES: Examination of her right upper extremity reveals a palpable Stener lesion at the thumb MP joint. When you deviate or stress her at that MP joint she opens up to 90 degrees. IMPRESSION: Right thumb ulnar collateral ligament acute rupture. PLAN: Repair.
MP|metacarpophalangeal|MP|149|150|PHYSICAL EXAMINATION|EXTREMITIES: Examination of her right upper extremity reveals a palpable Stener lesion at the thumb MP joint. When you deviate or stress her at that MP joint she opens up to 90 degrees. IMPRESSION: Right thumb ulnar collateral ligament acute rupture. PLAN: Repair.
MP|mercaptopurine|MP,|199|201|HOSPITAL COURSE|Neutropenia was identified after hospitalization, and it was felt that these fevers stemmed from her neutropenia. There were no signs of meningitis, pneumonia or bacteremia. With cessation of the 6- MP, her infection fighting counts returned to normal, her temperature returned to normal, and her mentation improved. She was seen by three consultants, and concurrence was that this was from 6-MP.
MP|metacarpophalangeal|MP|145|146|PHYSICAL EXAMINATION|LUNGS: Clear to auscultation. EXTREMITIES: The patient has multiple lacerations. He has one on the dorsal aspect of the thumb just distal to the MP joint. He has intact extensor pollicis longus function but pain with resist at extension. He also has two lacerations at the level of the mid shaft of the index metacarpal.
MP|nurse practitioner:NP|MP|231|232|PAST MEDICAL HISTORY|5. Observation for hypertension with most recent elevated pressure of 148/82 on _%#MMDD2003#%_, presently 110/70. 6. Diabetes mellitus diagnosed _%#MMDD2004#%_ on routine screening. Subsequently evaluated by _%#NAME#%_ _%#NAME#%_, MP for type 2 diabetic counseling presenting doing accu chek, and on Actos 15 mg daily, with most recent glycosylated hemoglobin at 7.6 on _%#MMDD2004#%_.
MP|(drug) MP|MP|154|155|MEDICATIONS|5. Misoprostol 100 mg 3 times daily. 6. Pancrecarb MS 8 CPAP 12 with meals 6 with snacks. 7. Protonix 40 mg delayed release 1 tab twice daily. 8. Ultrase MP 20 CPAP 12 with meals 6 with snacks. 9. Alternates between coli and TOBI. He has not been doing either 1. ALLERGIES: No known drug allergies. REVIEW OF SYSTEMS: Aside from the HPI the complete review of systems is negative.
MP|metacarpophalangeal|MP|154|155|PHYSICAL EXAMINATION|She indicates that her left shoulder is much improved over the status that she noted yesterday. EXTREMITIES: Examination of the upper extremities reveals MP joint synovitis of both of her hands. She has some mild ulnar drift to her fingers. Examination of the left shoulder reveals marked swelling about the shoulder joint.
MP|metacarpophalangeal|MP|251|252|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished female who is alert and oriented times 3, in no acute distress. EXTREMITIES: Examination of her upper extremity reveals an eschar over the dorsum of her long finger at the MP joint with necrotic superficial tissue. She has a 13 mm wide eschar. She has a permanent marker that is probably about 4 cm out from that initial eschar without any erythema at this time.
MP|metacarpophalangeal|MP|172|173|IMPRESSION|She has normal capillary refill. Normal sensation above the volar and dorsal aspect. IMPRESSION: Left hand cellulitis without involvement of the extensor mechanisms or the MP joint. My plan of action would be to have her do warm soaks twice per day in a mild antibacterial. Apply bacitracin and Adaptic to the dorsum of the wound and will keep her in a resting splint.
MP|metacarpophalangeal|MP|145|146|PHYSICAL EXAMINATION|He does have some deltoid atrophy. This is problem bilaterally. On his right hand, he does have dorsal swelling from the wrist level down to the MP joints of his hand. He does have some associated erythema. It is tender to light touch dorsally. He has wrist joint swelling on the volar aspect, as well, and he is painful with range of motion at the volar aspect of the wrist.
MP|metatarsophalangeal/metacarpophalangeal|MP|287|288|LABS PRIOR TO SURGERY|Slight increased warmth is also noted. Examination of her right hand shows evidence of fusiform swelling from her fingernail extending down to the wrist of her right thumb in the first ray. She has exquisite pain with motion of the IP joint and lesser degrees of pain with motion of the MP and CMC joints. I am not able to elucidate any neurologic deficits in her lower extremities. Lymphatic examination is notable for absence of any regional adenopathy or extremity edema.
MP|metacarpophalangeal|MP|220|221|PHYSICAL EXAMINATION|Sensation is intact in radial nerve distribution, but slightly decreased, absent in the ulnar and median nerve distribution. She has no ability to fire intrinsic muscles of her hand, but has the ability to extend at the MP joints and at the wrist so that extension is weak at 4 out of 5. Triceps function is good. Wrist extension is 5- out of 5.
MP|metacarpophalangeal|MP|176|177|HISTORY|She has a good radial pulse. She demonstrates normal sensory function in the median and ulnar nerves. She demonstrates a sensation over the axillary nerve distribution. If her MP joints are extended for her, she can abduct and adduct the fingers. She can make a fist. She can palmar flex the wrist, but she cannot extend the wrist.
MP|metabolic panel|MP|189|190|PLAN|If her creatinine is significantly above her baseline value of 1.3 then we may wish to postpone the idea of angiography until this acute renal dysfunction is sorted out. PLAN: 1. Check the MP today. If creatinine is less than 1.5 proceed with renal angiography tomorrow. 2. If creatinine is greater than 1.5 then we will have to hold further angiography and evaluate further what this acute decline in renal function may be related to.
MP|metabolic panel|MP|114|115|ASSESSMENT|2. Oliguria of unclear etiology. Will check basic metabolic panel stat and increase IV fluids to 100 mL until the MP results are available. 3. Anemia secondary to surgical blood loss. PLAN: The patient will remain in the ICU. We will change the IV rate as per above and check a stat basic metabolic panel.
MP|metacarpophalangeal|MP|218|219|PHYSICAL EXAMINATION|He does have swelling and ecchymosis along the dorsal aspect of the hand as well as on the proximal phalanx of the ring finger. The ring finger demonstrates good active flexion of FDS and FDP. Some tenderness over the MP joint. X-rays of the left hand demonstrate a nondisplaced fracture of the proximal phalanx of the left ring finger.
MP|metacarpophalangeal|MP|135|136|PLAN|PLAN: 1. The patient's right-upper extremity was placed in a short-arm cast allowing for free movement of her thumb and fingers at the MP joints. 2. The patient will see Dr. _%#NAME#%_ in orthopaedic clinic next week. 3. Please contact orthopaedic surgery for any further questions or concerns.
MP|metatarsophalangeal|MP|178|179||She has a history of chronic venous stasis and probably has some vascular insufficiency to that foot, although, she is not a diabetic. She developed an ulcer under the great toe MP joint which probably got infected and caused a severe infection in her foot, the cellulitis, and the sepsis. On examination today, she has an open draining wound under the first metatarsal in the sesamoid area and at the base of the great toe.
MP|metatarsophalangeal|MP|153|154|HISTORY OF PRESENT ILLNESS|The joint was not tapped but was treated successfully with indomethacin. Since that time, he has had several other episodes, usually involving the first MP but occasionally involving the ankle and knee. He has stored up some Indocin and usually aborts attacks by treating with a few Indocins.
MP|metacarpophalangeal|MP|156|157|PHYSICAL EXAMINATION|X-rays of the right hand and thumb (multiple views) taken in the Emergency Department earlier today appear unremarkable. He has mild arthritis of the thumb MP joint. There are no fractures or dislocations. IMPRESSION: Right thumb contusion with nail avulsion. I believe that this patient had all the treatment that he really requires in regard to his thumb while he was in the Emergency Department.
MP|metatarsophalangeal/metacarpophalangeal|MP|133|134|PHYSICAL EXAMINATION|Range of motion: The patient is not able to flex at the IP joints of the right fourth and fifth digits. Flexion and extension of the MP joints is intact, however, bilaterally. ASSESSMENT: 47-year-old female status post tendon repair of the fourth and fifth digits of the right hand following a knife wound and status post partial amputation of the right fourth digit just to the IP joint now with a 2-week history of ulcerations on the palmar aspect of the right fourth and fifth digits at the IP joints with exposed suture noted over the fifth digit.
MP|mercaptopurine|MP|191|192|PLAN|3. We need to get the records from our office to see exactly how active her Crohn's is. 4. She might need a small bowel follow-through when this is cleared. 5. She could be a candidate for 6 MP or even budesonide.
MP|mercaptopurine|MP.|145|147|LABORATORY STUDIES|Her hemoglobin has come up from 8.2 to 11.4 with transfusion. White blood cell count has improved from 1.5 to 8.1 after discontinuation of the 6 MP. IMPRESSIONS: Ms. _%#NAME#%_ _%#NAME#%_ is a 73-year-old woman with an episode of fevers, chills and acute shortness of breath probably due to development of acute congestive heart failure.
MP|mercaptopurine|MP|157|158|DISCUSSION|Meanwhile, the patient has a longstanding history of Crohn's disease. She has had previous bowel resection. She has been on previous extended therapy with 6 MP although this has not been used since her transplantation. A recent bout of increasing diarrhea led to a colonoscopy in early _%#MM2006#%_ which showed changes consistent with active Crohn's disease.
MP|mercaptopurine|MP,|257|259|IMPRESSION|IMPRESSION: 1. _%#NAME#%_ is a 51-year-old woman presenting with massive left leg deep venous thrombosis and bilateral pulmonary emboli concerning for hypercoagulable status II 2. Macrocytic anemia. Possible etiologies include hemolysis, drug effect of six MP, primary bone marrow disorders, hypothyroidism 3. Thrombocytosis; could be reactive to acute thrombosis or primary marrow disorder or secondary to other etiologies including inflammatory and neoplastic conditions
MP|metatarsophalangeal/metacarpophalangeal|MP|203|204|PHYSICAL  EXAMINATION|She does have in her left hand ecchymosis and swelling over the ulnar border of the hand including between the third between the fourth and fifth metacarpals. This is mildly restricts the flexion in the MP joint, but not substantially. There is no diminished sensation. Color and circulation is good in the fingers and hand other than the ecchymotic sites.
MP|mercaptopurine|(MP)|247|250|PAST MEDICAL HISTORY|The patient was seen in the emergency room. PAST MEDICAL HISTORY: The patient's past medical history is significant in that he has Crohn's disease. The patient also had elevation of pancreatic enzymes thought to be secondary to a 6-mercaptopurine (MP) drug. CURRENT MEDICATIONS: None. ALLERGIES: None. CT scan and KUB were done.
MP|metacarpophalangeal|MP|159|160|PHYSICAL EXAMINATION|He states that the nailer double fired and a nail was projected into his left thumb. The entry wound is on the dorsal radial side of the thumb and entered the MP joint, according to the emergency room personnel. The emergency room physician did remove the nail after taking x-rays showing the nail tip in the joint.
MP|metatarsophalangeal/metacarpophalangeal|MP|121|122|PHYSICAL  EXAMINATION|Examination of the left hand there is a small 2-3 mm puncture wound and entry wound over the dorsal radial aspect of the MP joint. There is no gross contamination. The skin is clean about the site. There is some diminished sensation in the area but he has received a local block by the emergency room personnel and presumably that numbness is due to that or regional block.
MP|metacarpophalangeal|MP|139|140|PHYSICAL  EXAMINATION|I have recommended the patient go to the operating room tonight for irrigation and debridement of this wound that penetrates down into the MP joint of the thumb. We have given him 1 gram of Ancef IV and updated his tetanus immunization. The patient understands the indications, risks, benefits and time involved for recovery.
MP|metacarpophalangeal|MP|182|183|PHYSICAL EXAM|PHYSICAL EXAM: Pleasant healthy appearing gentleman. He has noted swelling, erythema, induration of his right hand overlying the dorsal ulnar aspect of the hand just proximal to the MP joint. He has good range of motion of the MP joint with only minimal discomfort and no evidence of joint involvement.
MP|metatarsophalangeal|MP|186|187|PHYSICAL EXAMINATION|On the dorsum of the interphalangeal joint, there appears to be an ulcer or wound with surrounding erythema and signs of infection and redness that are also proximal to the level of the MP joint on the dorsolateral aspect of the foot. He is unable to flex his DIP joint. He flexes his MP and PIP joint.
MP|metatarsophalangeal/metacarpophalangeal|MP|285|286|PHYSICAL EXAMINATION|On the dorsum of the interphalangeal joint, there appears to be an ulcer or wound with surrounding erythema and signs of infection and redness that are also proximal to the level of the MP joint on the dorsolateral aspect of the foot. He is unable to flex his DIP joint. He flexes his MP and PIP joint. The areas are nontender. They are firm, indurated, distal of this toe. The others toes on this foot are not infected, nor is there swelling of the rest of the foot.
MP|metacarpophalangeal|MP|132|133|PHYSICAL EXAMINATION|The skin remains intact. There is some surrounding erythema and dorsal hand swelling. He has no pain with flexion, extension of the MP joints or distally. There is mild ascending cellulitis. IMPRESSION: Left hand cellulitis. PLAN: Discussed with the patient I would recommend IV antibiotics and observation at this point, there is no fluctuance or need for surgical drainage and likely this will not be required.
MP|metacarpophalangeal|MP|198|199|PHYSICAL  EXAMINATION|He is alert and oriented x3. Blood pressure 129/79, pulse 120, respiratory rate 12, temperature is 98.3, O2 sats 97% on room air. SKIN: About the left upper extremity reveals some erythema over the MP joint and PIP joint of the left index finger. Skin is otherwise intact and unremarkable around his left elbow with the exception of a mildly prominent olecranon bursa.
MP|metacarpophalangeal|MP|121|122|PHYSICAL  EXAMINATION|He has a lot of tenderness over the olecranon bursa. Examination of his left hand reveals he has got tenderness over the MP joint and PIP joint where the area is erythematous. However, passive range of motion of the MP joint and PIP joint are unremarkable.
MP|metatarsophalangeal/metacarpophalangeal|MP|163|164|PHYSICAL  EXAMINATION|Examination of his left hand reveals he has got tenderness over the MP joint and PIP joint where the area is erythematous. However, passive range of motion of the MP joint and PIP joint are unremarkable. He has no tenderness over the flexor tendon sheaths themselves. I should say that over the PIP joint, he has some mild tenderness to range of motion but nothing that appears restrictive.
MP|mercaptopurine|MP|207|208|HISTORY OF PRESENT ILLNESS|His CNS and testicles were negative at diagnosis and he was thought to have standard risk ALL and was started on COCG protocol _%#PROTOCOL#%_. This was complicated by a mild VOD and the 6TG was changed to 6 MP therapy was completed in _%#MM2001#%_. One month later, he developed bilateral testicular enlargement and was found to have testicular relapse.
MP|metatarsophalangeal/metacarpophalangeal|MP|122|123|RECOMMENDATIONS|She is unable to actively extend her DIP joint but she has full passive extension at the DIP joint as well as the PIP and MP joints. Her finger is somewhat stiff in flexion because of being in the splint but she is able to flex her finger without too much discomfort.
MP|metacarpophalangeal|MP|159|160|PHYSICAL EXAMINATION|He has full range of motion of the right hand, no rotational or angular deformity. Right small finger is without tenderness or instability. PIP joint, DIP and MP joints all have full range of motion. No tenderness along the distal radius or forearm. The right lower extremity demonstrates multiple abrasions along the lateral aspect of the calf and mid tibia region.
MP|metatarsophalangeal/metacarpophalangeal|MP|184|185|PHYSICAL EXAMINATION|The right is obviously swollen. A soft dressing is removed and he has an L-shaped incision over the MCP joint where there is abundant purulence draining. He has difficulty flexing the MP joint beyond 45 degrees. This is likely a joint infection secondary to human hand bite, a common organism would be Eikenella corrodens.
MP|mercaptopurine|MP|208|209|HISTORY OF PRESENT ILLNESS|Because of the stricture at the ileocecal area, she underwent a resection of this area five years ago by Dr. _%#NAME#%_. She has been followed by Dr. _%#NAME#%_ since that time and has been taking 75 mg of 6 MP daily. She is due to see a Dr. _%#NAME#%_ on _%#MMDD2004#%_ for pre- scheduled appointment. In the interim, the patient was doing well and occasional diarrhea.
MP|mercaptopurine|MP|73|74|MEDICATIONS|3. Status post C-section. 4. Status post appendectomy. MEDICATIONS: 1. 6 MP 75 mg daily. 2. Birth control pills. 3. Cholestyramine one scoop daily. 4. Multivitamin. ALLERGIES: None known. HABITS: Rare alcohol.
MP|mercaptopurine|MP|62|63|ADDENDUM|Further discussions can then ensue regarding increasing the 6 MP dose as a possible preventative maintenance therapy and considering the addition of Remicade.
MP|metatarsophalangeal/metacarpophalangeal|MP|158|159|IMPRESSION|He is status post I&D of the finger yesterday with second tendon repair after it was found to be ruptured. Dr. _%#NAME#%_'s note describes clear fluid at the MP joint with fibrinous tissue around the sinus tract. Gram stain from the surgical specimen showed few gram-positive rods and few gram-positive cocci.
MP|metacarpophalangeal|MP|187|188|HISTORY|DOB: _%#MMDD1979#%_ HISTORY: A 24-year-old otherwise healthy young man sustained an injury at work with a saw as the saw blade went in through the nondominant left index finger along the MP joint. He had acute onset pain; also abrasion and a small laceration to the dorsal aspect of the thumb. He was brought to the emergency room where there was evidence of ______ saw injury down to the bone along the proximal phalanx with neurovascular injury.
MP|metatarsophalangeal/metacarpophalangeal|MP|238|239|PHYSICAL EXAMINATION|He is employed at Lenox Frame and Finishing. PHYSICAL EXAMINATION: A healthy-appearing gentleman with obvious injury to the left index finger with a 4- to 5-cm oblique laceration extending along the dorsal aspect and radial aspect of the MP joint extending down volarly. Active flexion with the FDP is intact. The collateral ligament appears to have some laxity, although difficult to assess secondary to pain and guarding.
MP|metacarpophalangeal|MP|181|182|PHYSICAL EXAMINATION|He has diminished 2-point sensation in the radial digital nerve distribution with the laceration extending just along the palmar radial aspect of the index finger. Extension of the MP joint appears intact. X-rays demonstrate bony injury to the proximal phalanx at the site of the insertion and site of the collateral ligament.
MP|mercaptopurine|MP|110|111|ALLERGIES|2. Positive PPD treated with INH. 3. History of rectovaginal fistula related to Crohn's disease. ALLERGIES: 6 MP and contrast dye. MEDICATIONS: 1. Omeprazole 20 mg daily. 2. Tylenol 325 mg daily. HEALTH HABITS: Smokes five cigarettes daily, used to smoke more.
MP|metatarsophalangeal|MP|165|166|PHYSICAL EXAMINATION|X-rays were reviewed, showed a severe destructive and lytic process throughout the proximal and distal phalanx of the great toe. Does not appear to be involving the MP joint. LAB WORK: White count 5.4, sed rate 48. IMPRESSION: A 62-year-old with acute on chronic draining and erythematous left great toe with x-rays consistent with osteomyelitis.
MP|metatarsophalangeal/metacarpophalangeal|MP|155|156|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: On examination, the patient has a violaceous appearing ring finger. The erythema demarcates quite significantly just proximal to the MP joint, both dorsally and volarly. The patient has no evidence of flexor tendon signs, with full range of motion of the digit and no digital swelling.
MP|metatarsophalangeal|MP|164|165||He is status post right first metatarsal osteotomy, right phalangeal osteotomy, right second toe proximal interphalangeal resection and extensor lengthening at the MP joint of the right second toe. The operation was performed without complication per report and he currently feels relatively well.
MP|metacarpophalangeal|MP|128|129|PHYSICAL EXAMINATION|She is in a splint and I have been instructed to leave the splint on. She has good finger and thumb motion at the DIP, PIP, and MP joints. There is no evidence of distal instability. Strength is 5 out of 5 in all finger flexors, deep and superficial, both sides, as well as finger extensors and all extrinsics.
MP|metacarpophalangeal|MP|174|175|HISTORY OF PRESENT ILLNESS|He was in his usual state of health until about a month ago when he developed fairly sudden onset of pain, swelling and erythema in his right hand, localized about the first MP joint. It was thought that this may represent an infection. He has been on antibiotics without any resolution of his symptoms.
MP|metacarpophalangeal|MP|138|139|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: On examination, the patient appears of stated age of 82. EXTREMITIES: He has mild erythema about the first MP joint. He has pitting edema over the entire dorsum of his hand. He has only mild tenderness over the MP joint. He has no pain with gentle range of motion at the index MP joint except at the extremes of motion.
MP|metacarpophalangeal|MP|154|155|PHYSICAL EXAMINATION|EXTREMITIES: He has mild erythema about the first MP joint. He has pitting edema over the entire dorsum of his hand. He has only mild tenderness over the MP joint. He has no pain with gentle range of motion at the index MP joint except at the extremes of motion. DIAGNOSTIC DATA: X-ray examination of the right hand revealed demineralization throughout the bones of the entire hand.
MP|metatarsophalangeal/metacarpophalangeal|MP|160|161|PHYSICAL EXAMINATION|He has pitting edema over the entire dorsum of his hand. He has only mild tenderness over the MP joint. He has no pain with gentle range of motion at the index MP joint except at the extremes of motion. DIAGNOSTIC DATA: X-ray examination of the right hand revealed demineralization throughout the bones of the entire hand.
MP|metacarpophalangeal|MP|247|248|DIAGNOSTIC DATA|DIAGNOSTIC DATA: X-ray examination of the right hand revealed demineralization throughout the bones of the entire hand. ____________ degenerative changes particularly in the thumb. There is chondrocalcinosis in multiple joints including the first MP joint. There is no definite evidence of osteomyelitis on the plain x-ray. ASSESSMENT: Right hand pain, swelling and mild erythema which appears to be an inflammatory arthritis of the first metacarpophalangeal joint.
MP|metatarsophalangeal/metacarpophalangeal|MP|170|171|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Patient has TM incision on the dorsal base of the digit. He has evidence of extrinsic tightness with positive extrinsic tightness test. He has mild MP joint stiffness with passive range of motion. He has adequate PIP joint extension. He has normal sensation distally. The remainder of his hand examination is unremarkable. X-rays have been ordered and are not yet available.
MP|metacarpophalangeal|MP|217|218|PHYSICAL EXAMINATION|No tremors noted on my examination, though the resident had noticed some tremor in the right lower extremity. MUSCULOSKELETAL: Benign with functional range of motion in all joints, but there is ulnar deviation at the MP joint in both the hands, more prominent on the left side. NEUROLOGIC: Tone in the left upper extremity with limitation of range of motion of the left elbow.
MP|mercaptopurine|MP,|131|133|MEDICATIONS|PAST MEDICAL HISTORY: Lymphocytic leukemia, Ommaya reservoir and previously prior meningitis and prior splenectomy. MEDICATIONS: 6 MP, Ativan, hydromorphone. ALLERGIES: PENICILLIN ALLERGIC. HE HAS TOLERATED THE OTHER ANTIBIOTICS HE HAS RECEIVED TO DATE.
MP|metacarpophalangeal|MP|113|114|PHYSICAL EXAMINATION|He has no significant rotation or malalignment. He has tenderness at the base of the thumb, no tenderness at the MP or IP joint. He has no wrist tenderness or other findings. RADIOGRAPHIC STUDIES: X-rays were reviewed demonstrating a Bennett's fracture.
MP|metatarsophalangeal/metacarpophalangeal|MP|240|241|IMPRESSION|3. Recent development of swelling, redness and drainage from the right thumb at the previous incision site with development of erythema across the dorsum of the hand. 4. Status post I&D yesterday with finding of infected fluid in the first MP joint. Surgical culture is growing staph (2B speciated) and perhaps a second gram positive organism. 5. PENICILLIN ALLERGY-ANAPHYLAXIS. RECOMMENDATIONS: 1. Continue intravenous Clindamycin pending further culture data.
MP|metatarsophalangeal/metacarpophalangeal|MP|183|184|RECOMMENDATIONS|He denies any fevers or chills. He was seen by Dr. _%#NAME#%_ and admitted to the hospital where yesterday she performed open reduction and internal fixation with finding of infected MP Joint fluid which was sent for culture. That culture is now growing staph and perhaps a second gram positive organism.
MP|mercaptopurine|MP.|126|128|MEDICATIONS|3. Crohn's disease, for surgery done in 1981. 4. Status post cholecystectomy and hysterectomy. MEDICATIONS: 1. Entocort. 2. 6 MP. 3. Altace 5 mg p.o. q day. 4. Hydrochlorothiazide 25 mg p.o. q day. 5. Toprol XL 50 mg p.o. q day. 6. Kay Ciel 20 mEq p.o. q day. 7. Protonix 40 mg p.o. q day.
MP|metatarsophalangeal|MP|69|70|REASON FOR CONSULTATION|DOB: _%#MMDD1984#%_ REASON FOR CONSULTATION: Cellulitis, right foot, MP joint to the hallux. HISTORY: This is an 18-year-old male who approximately five days ago sustained a puncture wound from a nail through the medial border of the foot in the region of the MP joint and the hallux.
MP|metatarsophalangeal|MP|167|168|HISTORY|HISTORY: This is an 18-year-old male who approximately five days ago sustained a puncture wound from a nail through the medial border of the foot in the region of the MP joint and the hallux. He was initially treated with irrigation and debridement and closure of a small dorsal wound. He also had a plantar exit wound. He was admitted to the hospital yesterday, _%#MMDD2002#%_, for advancing pain and swelling around the foot.
MP|metatarsophalangeal/metacarpophalangeal|MP|234|235|MEDICATIONS|He suggested there has been a retreat of the erythema and swelling from the marked margins even over the past 12 hours. Clinical examination demonstrates no evidence of subcutaneous abscess formation. Passive and active motion of the MP joint does not demonstrate extreme synovial irritability suggestive of a septic arthritis. There is no evidence of abscess formation. Active flexor hallucis longus and active extensor hallucis longus are intact without signs of tenosynovitis.
MP|metatarsophalangeal/metacarpophalangeal|MP,|152|154|PHYSICAL EXAMINATION|She has good pulses. She has good sensation. She is exceedingly tender on one side of the fingertip, but not on the other. She has normal motion of the MP, PIP, and DIP joints. The nail appears normal. This patient's platelet count is only 15,000 and her white count is only 300.
MP|metatarsophalangeal/metacarpophalangeal|MP|136|137|PHYSICAL EXAMINATION|This extends through the middle phalanx of the long finger. The index finger appears spared. Arthritic changes are noted in the PIP and MP joints but no injury proximal to this site. X-rays, AP, lateral and oblique were reviewed and confirm the traumatic amputations through the levels of the DIP joints.
MP|metacarpophalangeal|MP|156|157|LEFT UPPER EXTREMITY|LEFT UPPER EXTREMITY: Exam reveals full motion of the left wrist and all digits of the left hand. He has several abrasions on the dorsal hand, one over the MP joint of the little finger, and several small ones over the PIP joints of the index, long and ring fingers. There is mild associated erythema and low-grade swelling extending into the dorsal hand.
MP|metatarsophalangeal|MP|148|149|EXAMINATION|Previous surgery is compliant to wisdom teeth. ALLERGIES: Noted on his chart. EXAMINATION: The right great toe is erythematous and swollen from the MP joint distally. He has diminished sensation to his feet. No pulses are palpable about the right foot. He has active flexion and dorsi flexion of the right great toe.
MP|metacarpophalangeal|MP|184|185|PHYSICAL EXAMINATION|He is very pleasant with his mother and answering questions appropriately. EXTREMITIES: Examination of his left upper extremity reveals a crescent-shaped laceration just distal to the MP joint of his left index finger. There is significant bleeding in this area. _%#NAME#%_ would not voluntarily extend the finger for me today.
MP|metatarsophalangeal/metacarpophalangeal|MP|123|124|PROCEDURE NOTE|I was able to visualize basically that he had a full thickness and complete tear of the extensor tendon just distal to the MP joint. I repaired this with 3 figure-of-eight 5-0 Prolene sutures and this was able to bring the tendon back nicely. I did some further debridement and irrigation of the wound.
MP|metatarsophalangeal|MP|136|137|PHYSICAL EXAM|On the left side, there is redness and erythema with induration extending to mid calf. On the plantar surface of the left foot over the MP joints, there is a large ischemic, soft, black ulcer. This extends laterally over the MP joint and comes to about the midfoot dorsally.
MP|metatarsophalangeal|MP|138|139|PHYSICAL EXAM|On the plantar surface of the left foot over the MP joints, there is a large ischemic, soft, black ulcer. This extends laterally over the MP joint and comes to about the midfoot dorsally. In the right foot, there is a 4 x 4 cm ischemic ulcer over the lateral aspect of the 5th MP joint and there is a small nearly healed ulcer over the great toe on the medial aspect.
MP|metatarsophalangeal/metacarpophalangeal|MP|171|172|PHYSICAL EXAM|This extends laterally over the MP joint and comes to about the midfoot dorsally. In the right foot, there is a 4 x 4 cm ischemic ulcer over the lateral aspect of the 5th MP joint and there is a small nearly healed ulcer over the great toe on the medial aspect. There is no cellulitis on the right side. IMPRESSION: Diabetic with severe peripheral vascular disease as well as diabetic neuropathy, now with threatened left foot.
MP|metatarsophalangeal/metacarpophalangeal|MP|160|161|PHYSICAL EXAMINATION|The splint was removed. He has mild swelling along the area of the index metacarpal and proximal phalanx, a minimum amount of erythema and induration along the MP joint. He has a small abrasion, which he reports as old over the dorsal metacarpal, and an acute injury with a 3-mm puncture wound along the radial aspect of the proximal phalanx, based on the trajectory reports extending towards the flexor tendon sheath.
MP|metatarsophalangeal/metacarpophalangeal|MP|158|159|PHYSICAL EXAMINATION|He does have some discomfort with flexion and extension of the digit, but no obvious Kanavel sign. He is able to fully extend the digit. He has motion at the MP joint resulting in some mild discomfort, but no evidence of septic joint or septic synovitis. The neurovascular status is intact. No fluctuance. No purulence from the wound.
MP|metatarsophalangeal/metacarpophalangeal|MP|214|215|PHYSICAL EXAMINATION|His profundus is intact. His superficialis is intact. He has no tenderness over the A-2 or the A-4 pulley. He does not have significant swelling. There is no sign of any cellulitis. There is no tenderness over the MP joint. IMPRESSION: Superficial laceration without nerve or tendon involvement.
MP|metatarsophalangeal|MP|188|189|PHYSICAL EXAM|PAST MEDICAL HISTORY: Insulin dependent diabetes, obesity. PHYSICAL EXAM: Morbidly obese woman, pleasant and cooperative, complaining of left foot pain and swelling. Her right foot at the MP joint also has some mild swelling and erythema with some mild tenderness but no fluctuance and no significant pain with motion at the IP and MP joint.
MP|metatarsophalangeal|MP|166|167|PHYSICAL EXAM|Her right foot at the MP joint also has some mild swelling and erythema with some mild tenderness but no fluctuance and no significant pain with motion at the IP and MP joint. The right calf has a 3 cm in diameter ulcerative lesion with multiple pustules along the skin with purulent drainage expressed from within the subcutaneous space with some areas of very dusky and necrotic appearing skin in this region, mild periphery having erythema but no significant ascending lymphangitis or cellulitis.
MP|metatarsophalangeal|MP|497|498|PHYSICAL EXAM|The right calf has a 3 cm in diameter ulcerative lesion with multiple pustules along the skin with purulent drainage expressed from within the subcutaneous space with some areas of very dusky and necrotic appearing skin in this region, mild periphery having erythema but no significant ascending lymphangitis or cellulitis. Her ankle has good range of motion without pain. The left foot demonstrates some moderate swelling and edema with erythema and induration along the foot at the level of the MP joint of the great toe extending to the IP of the great toe and to the mid metatarsal region along the great toe.
MP|metatarsophalangeal|MP|193|194|PHYSICAL EXAM|She has tenderness, two ulcerative lesions with some dry eschar over this with some purulent drainage expressed from within the subcutaneous spaces. She has pain with any movement of the IP or MP joint of the great toe. The lesser toes have benign appearance and no significant ascending cellulitis or lymphangitis.
MP|metatarsophalangeal|MP|149|150|PHYSICAL EXAM|She has good palpable bounding pulses and sensibility to her distal digits was intact as well. X-rays of the left foot demonstrate erosion along the MP joint of the metatarsal and IP joint of the distal phalanx with underlying arthritic changes of the MP joint noted with joint space narrowing sclerotic changes and osteophytes.
MP|metatarsophalangeal/metacarpophalangeal|MP|252|253|PHYSICAL EXAM|She has good palpable bounding pulses and sensibility to her distal digits was intact as well. X-rays of the left foot demonstrate erosion along the MP joint of the metatarsal and IP joint of the distal phalanx with underlying arthritic changes of the MP joint noted with joint space narrowing sclerotic changes and osteophytes. X-rays of the right foot demonstrates some arthritic change of the first MP joint, no obvious osteomyelitis or erosions.
MP|metatarsophalangeal|MP|307|308|PHYSICAL EXAM|X-rays of the left foot demonstrate erosion along the MP joint of the metatarsal and IP joint of the distal phalanx with underlying arthritic changes of the MP joint noted with joint space narrowing sclerotic changes and osteophytes. X-rays of the right foot demonstrates some arthritic change of the first MP joint, no obvious osteomyelitis or erosions. IMPRESSION: 1. Left foot great toe osteomyelitis and abscess formation.
MP|metatarsophalangeal|MP|189|190|PLAN|2. Right calf abscess and infection. 3. Right foot cellulitis. PLAN: I recommended surgical debridement of the right calf wound and left foot including debridement of the osteomyelitis and MP joint and IP joints. Following the excisional debridement and irrigation, I have recommended dressing changes, obtain surgical cultures and tissue cultures during surgery.
MP|mercaptopurine|MP|205|206|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: HEENT is negative. Cardiorespiratory is negative. GI - see history of present illness. Last fall the patient had been on prednisone for approximately six to eight weeks. At that time 6- MP was started and the patient was subsequently stable. GU unremarkable. The patient has apparently missed her last one or two periods, but otherwise there has been no problems.
MP|mercaptopurine|MP|160|161|HISTORY OF PRESENT ILLNESS|Ms. _%#NAME#%_ was able to achieve a remission as determined by a bone marrow biopsy 4 weeks after induction. Ms. _%#NAME#%_ received a second induction with 6 MP Cytoxan, cytarabine, Vincristine, and intrathecal Methotrexate. This was completed at the end of _%#MM2004#%_. Chemotherapy was complicated with coagulopathy.
MP|metatarsophalangeal/metacarpophalangeal|MP|160|161|PROBLEM|He is right-hand dominant. PHYSICAL EXAMINATION: On examination, the patient is a healthy- appearing 30-year-old male. He has a 1-cm laceration over his fourth MP joint. There is some purulent material in the wound and there is swelling and it is quite tender. He also has some mild erythema radiating up into the fourth finger, proximal phalanx, and also an area of redness on his palm below the fourth finger.
MP|metacarpophalangeal|(MP)|220|223|PHYSICAL EXAM|Some ecchymosis and a stellate laceration along the radial condyle of the proximal phalanx. Attempts at flexion and extension demonstrates some tendon function but quite painful and unable to flex. Metacarpal phalangeal (MP) joint has no tenderness. Neurovascular status demonstrates some venous congestion. There is capillary refill. Sensibility is slightly diminished maybe secondary to the previous block performed.
MP|metatarsophalangeal/metacarpophalangeal|MP|217|218|PHYSICAL EXAMINATION|Careful neurologic examination was performed. The patient had intact sensation of the radial and ulnar digital nerves. He had intact FPL as well as APB function. He also demonstrated flexion against resistance at the MP joint. X-RAYS: Unremarkable. IMPRESSION: Laceration right thenar eminence. PLAN: I discussed with patient that I would favor exploration and thorough debridement.
MP|metacarpophalangeal|MP|180|181|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: The patient's left hand has some moderate swelling. There is a small incision which was made in the emergency room over the palmar aspect of the index finger MP joint. There is no active drainage at this time. There is swelling in this area. There is also swelling generally over the dorsum of the hand in this area.
MP|mercaptopurine|MP|261|262|INDICATION|She has tried multiple medications which include Remicade which she thought worked for awhile, and then she thinks she had a reaction to it where she had electric worms going up and down her body. In addition, she was on Asacol which did not work. She tried 6- MP which gave her elevations of liver enzymes. Azulfidine gave her hemolytic anemia. Flagyl made her nauseated. She does not know whether she was ever on Cipro.
MP|metatarsophalangeal/metacarpophalangeal|MP|117|118|PHYSICAL EXAMINATION|There is swelling present over the distal forefoot and into the great toe. She has motion at the IP joint and at the MP joint without guarding today. IMPRESSION: 1. Newly diagnosed diabetic as of yesterday. 2. Osteomyelitis proximal phalanx right great toe with a small adjacent soft tissue abscess.
MP|metatarsophalangeal/metacarpophalangeal|MP|183|184|PHYSICAL EXAMINATION|Neurovascular status is intact. There is a complex 3 cm laceration with avulsion along the skin with some partial thickness and full thickness skin loss over the dorsal aspect of the MP joint. This communicates directly with the fracture. X-RAYS: Three views of the left hand were reviewed, which demonstrate a comminuted fracture of the metacarpal neck, the index finger with flexion deformity and shortening.
MP|metacarpophalangeal|MP,|169|171|PHYSICAL EXAMINATION|Skin is warm and dry. She is in no apparent distress. Exam of the right hand and wrist reveals no abnormalities other than the index finger. There is full motion of the MP, PIP, and DIP joints, all without tenderness or swelling. She has no tenderness over the flexor tendon sheath. The tip of the finger, however, has an area of epidermolysis and swelling along the radial paronychial fold.
MP|metacarpophalangeal|MP|197|198|PHYSICAL  EXAMINATION|There is blistering of the skin distally. There is flexion deformity of the distal phalanx and substantial role granulation and mounding of tissue at the base of the nail. The skin proximal to the MP joint is intact. There is faint erythema over the dorsum of the foot that seems to be receding based on his descriptions.
MP|mercaptopurine|MP|150|151|RECOMMENDATIONS|I doubt it is related to her new blood pressure pill even though the timing was right. RECOMMENDATIONS: At this point I would like to increase her 6- MP as she has a very aggressive Crohn's disease and have her follow up with Dr. _%#NAME#%_ likely for a repeat colonoscopy. I wonder whether she might benefit from Remicade at some point.
MP|metatarsophalangeal/metacarpophalangeal|MP|256|257|SURGERY|There is superficial skin cracking running in a transverse fashion across the flexion crease at the DIP joint but no full thickness skin break. There is no drainage. There is mild surrounding cellulitis and stiffness in the DIP joint. She has full PIP and MP joint motion and there is no extension of tenderness or swelling down along the finger into the palm. I have recommended that Mrs. _%#NAME#%_ undergo open incision and drainage and debridement of this area.
MP|metabolic panel|MP,|186|188|LABORATORY DATA|Her uterus was very difficult to examine secondary to the procedures felt small with no masses. LABORATORY DATA: Hemoglobin 17.3. She does have an ethanol level today that was 0.04. The MP, LFTs, and coags were for the most part normal. ASSESSMENT: This is a 46-year-old P0 patient of Dr. _%#NAME#%_ with heavy vaginal bleeding.
MP|mercaptopurine|(MP)|249|252|IMPRESSIONS/PLAN|2. Leukocytosis likely related to recent systemic steroids. a. I agree with discontinuing the steroids and can follow up on this blood test. 3. Ulcerative colitis. a. Diagnosed approximately three years ago. b. Treated with routine 6-mercaptopurine (MP) and intermittent systemic steroids. (Last course of oral prednisone was approximately one year ago prior to _%#MMDD2003#%_.) 4. Bout of diarrhea in _%#MM#%_ 2003 at a time when her family was also ill.
MP|metatarsophalangeal/metacarpophalangeal|MP|154|155|PHYSICAL EXAMINATION|He has sutures but the wound is healed. He has tenderness along the volar aspect of the joint from the PIP joint extending proximally to the level of the MP flexion crease. Distally, he has no pain with range of motion or palpation about the DIP joint. He does have pain with motion of the PIP joint.
MP|metatarsophalangeal|MP|154|155|HISTORY OF THE PRESENT ILLNESS|This is from the knee down. Bone scan was ordered by Dr. _%#NAME#%_ and reviewed. It showed significant up take in the right great toe and the left first MP joint which correlates very well with the areas of his ulcers and infection. IMPRESSION: 1. Diabetic ulcers with osteomyelitis right great toe and first metatarsal phalangeal joint, possibly second.
MP|military police|MP,|157|159|REVIEW OF SYSTEMS|He is retired. Worked at 3M in chemicals and fiberglass. He may have had a rare asbestos exposure but he does not believe it was significant. He was an army MP, had no exposures there. ALLERGIES: No known drug allergies. He has had a chest x-ray which I have not been able to view.
MP|metatarsophalangeal/metacarpophalangeal|MP|157|158|PHYSICAL EXAMINATION|He does have motion at the DIP and PIP joint without pain. He has 2+ swelling of the entire digit. He does not have tenderness over the flexor sheath at the MP joint or at the index at the proximal phalanx level. He is stable the radial ulnar deviation stress. IMPRESSION: Cellulitis.
MP|nurse practitioner:NP|MP|83|84|TRANSITION & LIFE CHOICES CONSULTATION|TRANSITION & LIFE CHOICES CONSULTATION Consult requested by _%#NAME#%_ _%#NAME#%_, MP with Minnesota Heart Clinic to clarify discharge goals. IMPRESSION: 1. _%#NAME#%_ _%#NAME#%_ is an 80-year-old white married male admitted on _%#MMDD2004#%_ after being discharged from Fairview Southdale on _%#MMDD2004#%_ where he was treated for CHF.
MP|metatarsophalangeal/metacarpophalangeal|MP|192|193|EXAMINATION|He works in the cleaning department at Northwest Airlines. He is right-hand dominant. EXAMINATION: The patient is a healthy appearing 41-year-old male. He has a small abrasion over the fourth MP joint and a puncture wound over the shaft of the fifth metacarpal, it appears clean. His hand is swollen but there is no obvious deformity.
MP|metabolic panel|MP|143|144|LABORATORY DATA|Sensation intact to light touch Strength 5/5 bilaterally. Gait within normal limits. Reflexes +2/4 bilaterally. LABORATORY DATA: CBC, UA, AST, MP and GGT are all pending. Results from _%#MMDD#%_ include a urine drug screen which is positive for cocaine and alcohol, and a breathalyzer test done in the Emergency Room with the results at .164.
MP|metacarpophalangeal|MP|183|184|PHYSICAL EXAMINATION|There is also significant shortening. The end of the small fingertip only comes to the distal aspect of the PIP joint of the ring finger. There is pain over the proximal phalanx. The MP joint now appears to be reduced. HEART: Regular rate and rhythm. LUNGS: Clear. X-RAYS: Review of x-rays show the previous MP fracture-dislocation with the proximal phalanx fracture as well.
MP|metatarsophalangeal/metacarpophalangeal|MP|170|171|X-RAYS|There is pain over the proximal phalanx. The MP joint now appears to be reduced. HEART: Regular rate and rhythm. LUNGS: Clear. X-RAYS: Review of x-rays show the previous MP fracture-dislocation with the proximal phalanx fracture as well. The plan is to do a closed reduction and percutaneous pinning at Minnesota Orthopaedic Specialists, PA (_%#CITY#%_ Lakes office) on Tuesday, _%#MMDD2003#%_, due to the fact that she has a significant rotational deformity.
MP|metacarpophalangeal|MP|247|248|IMPRESSION|The plan is to do a closed reduction and percutaneous pinning at Minnesota Orthopaedic Specialists, PA (_%#CITY#%_ Lakes office) on Tuesday, _%#MMDD2003#%_, due to the fact that she has a significant rotational deformity. IMPRESSION: Small finger MP dislocation and proximal phalanx fracture. PLAN: The decision was made to proceed with surgery.
MP|metacarpophalangeal|MP|142|143|PHYSICAL EXAMINATION|Around the ring finger, he has tenderness and swelling in the flexor tendon sheath. He has some swelling around the dorsum of the hand at the MP joint, but that is not very tender, and most of the problem is really in the proximal portion of the finger, the flexor tendon side.
MP|metacarpophalangeal|MP|120|121|HISTORY OF PRESENT ILLNESS|He has been followed by a rheumatologist in Washington state, where he lives. On _%#MMDD2002#%_, this patient underwent MP arthroplasties of his left hand. His daughter informs me that prior to surgery, he did have a period of time when he had some swelling in his wrist; however, his treating physicians thought it was just a "bug bite," and this was treated with oral antibiotics, and that condition resolved.
MP|metatarsophalangeal/metacarpophalangeal|MP|333|334|HISTORY OF PRESENT ILLNESS|His daughter informs me that prior to surgery, he did have a period of time when he had some swelling in his wrist; however, his treating physicians thought it was just a "bug bite," and this was treated with oral antibiotics, and that condition resolved. On _%#MMDD2002#%_, he was taken to the operating room for the surgery on his MP joints. Initially, this patient did well; however, during the last several days, he has had increasing pain and swelling in his wrist and fingers.
MP|metacarpophalangeal|MP|145|146|HISTORY OF PRESENT ILLNESS|He was given some Keflex but, unfortunately, this caused a rash. He was therefore readmitted. An aspirate of this patient's hand (presumably the MP joints) revealed MRSA. He has been admitted to this hospital under the care of Dr. _%#NAME#%_ _%#NAME#%_, who has recommended that I see the patient.
MP|metacarpophalangeal|MP|235|236|PHYSICAL EXAMINATION|The left wrist, however, has moderate swelling. He has diffuse tenderness over the carpus and over the distal radioulnar joint. There is no tenderness in the thumb. More distal exam of the hand reveals low-grade swelling; however, the MP joints, the site of presumed infection, have absolutely no tenderness whatsoever. He has no pain in the digits, including the MP joints, on passive motion.
MP|metacarpophalangeal|MP|236|237|PHYSICAL EXAMINATION|There is no tenderness in the thumb. More distal exam of the hand reveals low-grade swelling; however, the MP joints, the site of presumed infection, have absolutely no tenderness whatsoever. He has no pain in the digits, including the MP joints, on passive motion. There is slight ulnar drift of the fingers. He can almost fully make a fist without pain. Neurovascular exam is intact. The opposite right hand and wrist have typical rheumatoid changes and mild limitation of motion.
MP|metacarpophalangeal|MP|135|136|IMPRESSION|He has MP arthroplasties in the long, ring and small fingers. IMPRESSION: 1. Probable septic arthritis, left wrist. 2. Possible septic MP arthroplasties, left third, fourth and fifth fingers. 3. Rheumatoid arthritis. RECOMMENDATIONS: I believe that Mr. _%#NAME#%_ would benefit, at the very least, from incision and drainage of his wrist.
MP|metacarpophalangeal|MP|191|192|RECOMMENDATIONS|3. Rheumatoid arthritis. RECOMMENDATIONS: I believe that Mr. _%#NAME#%_ would benefit, at the very least, from incision and drainage of his wrist. Concern exists, however, about draining the MP joints if they are not infected, as this might contaminate them, done at the same setting. Clinically, his problem appears to center more around the wrist.
MP|nurse practitioner:NP|MP,|202|204|PLAN|She has attended informational session and has an interest in attending a support group as well for additional information. She has discussed this with her primary care provider, _%#NAME#%_ _%#NAME#%_, MP, as well. She is very highly educated about the surgery and would make an excellent candidate. She is already scheduled to have her psych evaluation done, and her laboratory studies have already been completed and are in the normal range.
MP|metatarsophalangeal/metacarpophalangeal|MP|166|167|PHYSICAL EXAMINATION|She has no rotational deformity. She has no flexion contractures. She has full profundus and superficialis pulses. She has slow active extension at the DIP, PIP, and MP joints. X-RAYS: Review of her x-rays show a small impacted fracture to the proximal phalanx of the small finger.
MP|metatarsophalangeal/metacarpophalangeal|MP|153|154|HISTORY OF PRESENT ILLNESS|This patient noted deformity of his index finger and severe pain. He was brought to the emergency room where x-rays revealed a dorsal dislocation of the MP joint without associated fracture. Dr. _%#NAME#%_ attempted to do a digital block, but he was unable to reduce this.
MP|metacarpophalangeal|MP|139|140|PHYSICAL EXAMINATION|However, he voluntarily holds his wrist in flexion to keep tension off his index finger. The hand reveals a dorsal angulation of the index MP joint. Metacarpal head is prominent volarly. He is unable to move the finger without pain. There is tenderness over the MP joint and no where else.
MP|metacarpophalangeal|MP|173|174|PHYSICAL EXAMINATION|The hand reveals a dorsal angulation of the index MP joint. Metacarpal head is prominent volarly. He is unable to move the finger without pain. There is tenderness over the MP joint and no where else. Skin is intact. Neurovascular exam is normal. The opposite left hand and wrist have no swelling, tenderness or limitation of motion.
MP|metacarpophalangeal|MP|258|259|PHYSICAL EXAMINATION|Skin is intact. Neurovascular exam is normal. The opposite left hand and wrist have no swelling, tenderness or limitation of motion. X-rays of the right hand (three views) taken in the emergency room this evening reveal a complex dislocation of index finger MP joint. There is no associated fracture. The dislocation is dorsal. IMPRESSION: Dorsal dislocation, MP joint right II.
MP|metatarsophalangeal/metacarpophalangeal|MP|227|228|IMPRESSION|X-rays of the right hand (three views) taken in the emergency room this evening reveal a complex dislocation of index finger MP joint. There is no associated fracture. The dislocation is dorsal. IMPRESSION: Dorsal dislocation, MP joint right II. This patient's dislocation was reduced as outlined in a separate procedure note.
MP|metacarpophalangeal|MP|143|144|PHYSICAL EXAMINATION|He does have tenderness over the distal radius, but no ecchymosis or bruising there. He has a left ring and small finger hyperextension at the MP joint, but he does not have any clawing. He can make a fist. He has normal capillary refill and gross motor is intact.
MP|metacarpophalangeal|MP|251|252|IMPRESSION|Will also place a volar wrist splint today for the hand and radius in case he has a nondisplaced radius fracture. If he does not have a radius fracture, I am going to write an order for the hand therapist to make him a lumbrical _____ splint with the MP joints flexed 20 degrees at the low profile splint that prevents those ring and small finger MP joints from hyperextending.
MP|metacarpophalangeal|MP|347|348|IMPRESSION|Will also place a volar wrist splint today for the hand and radius in case he has a nondisplaced radius fracture. If he does not have a radius fracture, I am going to write an order for the hand therapist to make him a lumbrical _____ splint with the MP joints flexed 20 degrees at the low profile splint that prevents those ring and small finger MP joints from hyperextending. So at this point we will do the sling and Ace wrap for the shoulder.
MP|metatarsophalangeal/metacarpophalangeal|MP|271|272|PHYSICAL EXAMINATION|He has normal tone otherwise, reflexes, sensation, rapid alternating movements and pulses. SKIN: No evidence of tenting. X-ray examinations of the left right finger, AP, lateral and oblique that were ordered and obtained in the emergency room and I reviewed show a fifth MP dislocation with a sesamoid present within the joint. ASSESSMENT: Left probable complex MP dislocation. PLAN: I attempted a closed reduction using the classic technique of hypertension dorsally directed pressure and closing reduction maneuver which was unsuccessful in the emergency room, had been unsuccessful previously by the ER physician.
MP|metatarsophalangeal/metacarpophalangeal|MP|271|272|ASSESSMENT|SKIN: No evidence of tenting. X-ray examinations of the left right finger, AP, lateral and oblique that were ordered and obtained in the emergency room and I reviewed show a fifth MP dislocation with a sesamoid present within the joint. ASSESSMENT: Left probable complex MP dislocation. PLAN: I attempted a closed reduction using the classic technique of hypertension dorsally directed pressure and closing reduction maneuver which was unsuccessful in the emergency room, had been unsuccessful previously by the ER physician.
MP|mercaptopurine|MP,|199|201|HISTORY OF PRESENT ILLNESS|He has minimal residual neurological deficit is manifested by slow processing of information and balance irregularity. Mr. _%#NAME#%_ continued on a maintenance chemotherapy including Vesanoid and 6 MP, apparently he was intolerant of the Methotrexate. By _%#MM2003#%_, he was considered to be in a morphologic remission. In _%#MM2004#%_, his original diagnostic slides were reviewed here. He was felt to have microgranular variant of APL.
MP|metacarpophalangeal|MP|109|110|PHYSICAL EXAMINATION|He is also able to extend the thumb with pain. He is unable to extend the long, ring and small finger at the MP joints. The intrinsic hand function of the DIP and PIP joints are intact. Flexor tendon function intact. IMPRESSION: Right forearm complex laceration from hockey skate blade.
MP|metacarpophalangeal|MP|190|191|PHYSICAL EXAMINATION|EXTREMITIES: Her right arm is in a long arm splint with the elbow fairly straight. CMS is intact in the hand. Specifically radial nerve function is good with good extension at the wrist and MP joints as well as the IP joint of the thumb. There are no other apparent injuries to her other upper extremity or lower extremities.
MP|mercaptopurine|MP|168|169|PHYSICAL EXAMINATION|Ms. _%#NAME#%_ suffered from acute myeloid leukemia and was 36 years old. She had been diagnosed in _%#MM2002#%_ and treated with Anthra-adarubicin, methotrexate and 6 MP for 2-1/2 years achieving cytogenic remission. In _%#MM2006#%_, the patient developed pancytopenia. Workup revealed treatment related AML. On _%#MMDD2006#%_ the patient was referred to the University of Minnesota Medical Center, Fairview and saw _%#NAME#%_ _%#NAME#%_, MD.
MP|mercaptopurine|MP|179|180|PHYSICAL EXAMINATION|LUNGS: Clear to auscultation, no labored breathing. ABDOMEN: Benign. EXTREMITIES: Left hand sensation is intact in radial, ulnar, and median distributions. He is able to move his MP joints on all five digits. Radial pulse is intact. Capillary refill in all five digits is less than 2 seconds. He is unable to move the PIP and DIP joints of the small left finger and there is an obvious deformity laterally and dorsally displaced.
MP|UNSURED SENSE|MP|286|287|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Reveals no fevers. While she was extubated no stridor or gulf were noted. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 36.7, pulse 142, respiratory rate 40, blood pressure 72/42, oxygen saturations 97% being on 50% O2 and SIMB 30.begins with ?????? Pressure 33 and MP of 5. GENERAL: She looks sedation and not showing signs of discomfort.
MP|metatarsophalangeal|MP|203|204|PHYSICAL EXAMINATION|He is examined lying in his bed. His right lower extremity is twisted and externally rotated at the level of the ankle. He has large three cm. wide blisters on the dorsum of his foot at the level of the MP joints. There is no signs of infection around these blisters. They are clear. They are sterilely prepped and lanced and this partial thickness skin was debrided and sterilely dressed.
MP|metatarsophalangeal/metacarpophalangeal|MP|158|159|PHYSICAL EXAMINATION|It is nice and warm. The infection is obviously under control. There is a minimal amount of opening of the wound. There is no pus or sign of infection at his MP joint. His ulcer on the lateral aspect is superficial. It has good blood supply at the base and looks like it will heal with proper treatment.
MP|mercaptopurine|MP|167|168|ASSESSMENT|3) Recent fistula problems, although now improved on Flagyl. 4) Undocumented loss of 20 pounds. 5) Lack of response to Remicade, 6-MP, although not clear about the 6- MP compliance. PLAN: 1) Colonoscopy will be checked tomorrow. 2) IV steroids started.
MP|metatarsophalangeal/metacarpophalangeal|MP|238|239|PHYSICAL EXAMINATION|He is unemployed currently; he normally works in construction. He is right-hand- dominant. PHYSICAL EXAMINATION: On examination, the patient has swelling and tenderness localized primarily over the dorsum of his left hand, over the third MP joint; he is exquisitely tender over this area, and there is mild swelling over the entire dorsum of the hand, but his fingers are not swollen, and although he does have some tenderness in his palm, there does not appear to be much swelling in his palm.
MP|metacarpophalangeal|MP|168|169|PHYSICAL EXAMINATION|He denies any fever, chills, or sweats and otherwise has been feeling satisfactory. PHYSICAL EXAMINATION: On the left hand, there is an abrasion over the dorsum of his MP joint, index finger left hand. There is also an abrasion on the dorsum of the hand itself. There is generalized mild to moderate swelling and erythema on the dorsum of his hand.
MP|metacarpophalangeal|MP|134|135|EXAMINATION|She has mild pain with passive extension of the digit. The remainder of her hand exam is unremarkable. She has no tenderness over the MP joint on the ulnar aspect of the hand, and no tenderness at the wrist. Proximally, she has no pain at the elbow or shoulder.
MP|metacarpophalangeal|MP|280|281|HISTORY OF THE PRESENT ILLNESS|Since that time she has undergone an extensive evaluation. About 5-7 days ago, this patient states that she was using her walker whereby she stumbled and fell forward, her right fist hitting the wall. As such, she noted pain and swelling of the dorsal aspect of the middle finger MP joint. In addition, since this patient's injury, she has noted ability to make a full fist, but inability to actively fully extend her middle finger.
MP|metacarpophalangeal|MP|149|150|IMPRESSION|X-rays of the right hand (multiple views) recently taken demonstrate no obvious fractures. IMPRESSION: 1. Sagittal band rupture, right middle finger MP joint. I reviewed the anatomic nature of the patient's problem with her.
MP|metacarpophalangeal|MP|201|202|IMPRESSION|Therefore, I wrote an order for one of the hand therapists from the Fairview Hand Center to come up and fashion a forearm based wrist splint with a digital extension into the middle finger to keep the MP joint from flexing no more than 20 degrees. The remainder of the finger may be free. As patient will need to wear this splint full time for the next eight weeks.
MP|metatarsophalangeal|MP|186|187|HISTORY OF THE PRESENT ILLNESS|HISTORY OF THE PRESENT ILLNESS: The patient was at his lake cabin on _%#MMDD2005#%_ and stepped on a nail. It went through the sole of his shoe and entered the sole of his foot near the MP flexion crease of the great toe. He did receive a tetanus shot at urgent care site and also received some antibiotics.
MP|mercaptopurine|MP|119|120|MEDICATIONS|1. Otitis media with P-E tubes. 2. Asthma. 3. Seasonal allergies. ALLERGIES: E. coli L-asparaginase. MEDICATIONS: 1. 6 MP 2. Septra. SOCIAL HISTORY: He lives with his parents and 7-year-old brother in Wisconsin.
MP|metatarsophalangeal/metacarpophalangeal|MP|192|193|HISTORY OF PRESENT ILLNESS|She sustained an injury just over 24 hours ago with trauma sustained to the right index finger. Puncture wounds are distal to the MPJ on the dorsal aspect of the digit and at the level of the MP joint volarly. She has developed ascending lymphangitis to the level of the axilla. She is admitted for IV antibiotics and is splinted. Initial examination demonstrated some cellulitis extending proximally.
MP|metatarsophalangeal/metacarpophalangeal|MP|115|116|PLAN|In brief, however, patient was admitted to the hospital with back pain as well as a history of swelling of his 1st MP joint. I reviewed all imaging studies and examined him. Pertinent findings on examination are the presence of swelling of his great toe.
MP|mercaptopurine|MP|357|358|IMPRESSION|Consider C. diff, would recommend checking stools. Would hold on colonoscopy at this time, especially in light of pancytopenia and platelets of 16,000 if the C. diff is negative consider continuing the Imodium versus adding Questran p.r.n. The other issue is this patient is already immunosuppressed therefore would not be a candidate for prednisone or six MP or Remicade which are the mainstay of treatment for active Crohn's disease. Currently would recommend treating the diarrhea symptomatically, rule out infection, monitor, further recommendations to follow.
MP|mercaptopurine|MP.|346|348|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD _%#NAME#%_ _%#NAME#%_ is a 65-year-old man with a history of Crohn's disease diagnosed in 2000 treated with prednisone with some improvement, tapered off prednisone several times over the last year but always relapses, on prednisone in varying doses for 6-7 months of this year. Also on 75 mg of 6 MP. Apparently had epistaxis in higher doses. Also takes calcium for osteoporosis. He was on Remicade this year and took at least two courses, but developed some type of itching.
MP|mercaptopurine|MP|144|145|MEDICATIONS|Also history of esophageal stricture and hiatal hernia dilated in the past. History of umbilical hernia. MEDICATIONS: 1. Prednisone 40 mg. 2. 6 MP 75 mg. 3. Calcium. 4. Currently on Prevacid, although he takes ranitidine at home. ALLERGIES: Allergic to Pentasa, which gave him C. difficile colitis he says.
MP|mercaptopurine|MP,|135|137|REQUESTING PHYSICIANS|He indicates that he has used prednisone most of the last two years. The patient currently is on 40 mg of prednisone a day, 75 mg of 6 MP, Flagyl 250 mg 3x a day. The patient is also on Coumadin and calcium tabs. The patient was hospitalized here in _%#MM#%_ with some degree of rectal bleeding, a hemoglobin of 7.4, and a DVT.
MP|mercaptopurine|MP,|236|238|IMPRESSION|Peripheral pulses are normal. AVAILABLE LABORATORY DATA: Includes a potassium of 4.2. INR yesterday was 1.66. Hemoglobin is 11.1, white count 10,700 with 89% polys. IMPRESSION: 1. Crohn's colitis currently on therapy with prednisone, 6 MP, and Flagyl. 2. Perianal abscess likely related to anorectal Crohn's disease. The above has been reviewed with Mr. _%#NAME#%_. Hopefully will have the opportunity to talk with Dr. _%#NAME#%_ and Dr. _%#NAME#%_.
MP|metatarsophalangeal/metacarpophalangeal|MP|198|199|PHYSICAL EXAMINATION|Motor exam reveals normal painless function at the NP joint with some decreased flexion at the PIP joint and markedly decreased flexion at the DIP joint. The patient does have full extension at the MP joint but is unable to fully extend at either the PIP or DIP joint. Both flexion and extension of the finger appear to be painless.
MP|metatarsophalangeal/metacarpophalangeal|MP,|182|184|EXAMINATION|The incisions are well healed. The hand appears normal. There is no focal area of tenderness. There is no obvious swelling in any of the joints. She does have reduced flexion at the MP, PIP, and DIP joints. Her neurologic exam disclosed hypesthesia to light touch and pinprick predominantly in the ulnar two innervated digits but across the hand in general.
MP|UNSURED SENSE|MP|166|167|ACTION AND PLAN|Letter on the chart also indicates the patient wanted no artificial measures but wanted to be comfortable. 5) Wife appreciated hearing comfort measures only options. MP feels that the patient's wife and family are leaning toward comfort care, but unsure where that would be provided. 6) TLC will continue to follow for psychosocial and spiritual concerns and support.
MP|metatarsophalangeal/metacarpophalangeal|MP|204|205|PHYSICAL EXAMINATION|She does have some fluctuance distally. She has a radial sided incision with a white tissue. The question of that tissue is the vascularity. She has no tenderness over her flexor sheath proximally at the MP or the proximal phalanx level. IMPRESSION: Gross infection at risk for amputation given her diabetes and the extent of the infection.
MP|mercaptopurine|MP.|173|175|MEDICATIONS|9. ARDS. 10. Hypertension. 11. History of pericarditis. 12. History of pancreatitis. 13. History of depression. MEDICATIONS: 1. Micafungen. 2. Levofloxacin. 3. Nystatin. 4. MP. 5. Nicardipine 6. Ceftazidime. 7. G-CSF. 8. Dilaudid drip. 9. Ativan drip. 10. Albuterol. 11. Protonix. 12. Carafate. 13. Zoloft. 14. Urso. 15. Platelet drip. 16. Insulin drip.
MP|metacarpophalangeal|MP|161|162|PHYSICAL  EXAMINATION|There is a 15 x 15 mm area of fluctuance, swelling and tenderness along the radial volar base of the index finger. The erythema extends only to the level of the MP joint. There does not appear to be significant tenderness over the flexor tendon sheath and there is no significant increase of pain with passive motion of the flexor tendons.
MP|metatarsophalangeal/metacarpophalangeal|MP|134|135|REQUESTING PHYSICIAN|He has the Charcot changes on his plain films, along the spur off the shaft of the second metatarsal. He has a dislocated left second MP joint. He has, on MRI scan, soft tissue edema on the plantar surface. I am not as impressed by any osteomyelitic changes in the second metatarsal head, however.
MP|military police|MP|122|123|SOCIAL HISTORY|SOCIAL HISTORY: He was born in Indiana, not certain the extent of his education, may have finished high school. He was an MP during World War II, serving in both European and Pacific theaters. He has been married three times, has six children, one by his first marriage, three by second and two by his third.
MP|mercaptopurine|MP,|130|132|INDICATION|This demonstrated Crohn's of the colon in the distal ileum The patient was treated with prednisone and initially with 6-MP. On 6- MP, she was unable to wean herself off the prednisone. She subsequently went to the Mayo Clinic, where she was placed on 250 mg of Imuran.
MP|metacarpophalangeal|(MP)|181|184|HISTORY OF PRESENT ILLNESS|She has been able to continue writing and attending to most of her personal issues. In the emergency room yesterday an x-ray of the right hand revealed multiple metatarsophalangeal (MP) joint dislocations. The emergency room physician attempted a closed reduction but this was unsuccessful. PAST MEDICAL HISTORY: Glaucoma. She uses eye drops twice a day but she does not recall the name.
MP|metacarpophalangeal|MP|157|158|PHYSICAL EXAMINATION|The thumb reveals osteoarthritic changes as do the other fingers. The thumb has normal motion. The ulnar forefingers, however, have volar dislocation of the MP joints. There is no swelling and no significant tenderness. I am unable to extend the ulnar three MP joints at all. The index finger MP joint can almost be completely extended but it does not stay in place.
MP|metacarpophalangeal|MP|192|193|PHYSICAL EXAMINATION|The thumb has normal motion. The ulnar forefingers, however, have volar dislocation of the MP joints. There is no swelling and no significant tenderness. I am unable to extend the ulnar three MP joints at all. The index finger MP joint can almost be completely extended but it does not stay in place. The left hand has no swelling, tenderness, or limitation of motion.
MP|metacarpophalangeal|MP|125|126|PHYSICAL EXAMINATION|There is no swelling and no significant tenderness. I am unable to extend the ulnar three MP joints at all. The index finger MP joint can almost be completely extended but it does not stay in place. The left hand has no swelling, tenderness, or limitation of motion.
MP|metacarpophalangeal|MP|199|200|X-RAYS|X-RAYS: X-rays of the right hand (multiple views) taken in the emergency room yesterday reveal diffuse osteopenia. There are no fractures. She does, however, have volar dislocation of the ulnar four MP joints. X-rays of the pelvis and the left hip reveal a superior pubic ramus fracture.
MP|metacarpophalangeal|MP|201|202|IMPRESSION|X-rays of the pelvis and the left hip reveal a superior pubic ramus fracture. There is no fracture of the proximal femur. IMPRESSION: 1. Left elbow contusion/abrasion. 2. Volar dislocations, right 2-5 MP joints, old. 3. Stable left superior pubic ramus fracture. RECOMMENDATIONS: 1. In regard to this patient's left elbow, I would recommend continued sterile dressing.
MP|metacarpophalangeal|MP|275|276|HISTORY|DOB: HISTORY: _%#NAME#%_ _%#NAME#%_ is a 14-year-old, right-hand dominant, otherwise healthy young man, who sustained an injury when he struck a saxophone along a sharp edge of the instrument. He had acute onset laceration, inability to extend the finger, and pain along the MP joint. He was seen in the emergency room. PAST MEDICAL HISTORY: Status post herniorrhaphy and adenoidectomy.
MP|metatarsophalangeal/metacarpophalangeal|MP|208|209|PHYSICAL EXAMINATION|HEENT is unremarkable. LUNGS: Clear to auscultation. HEART: Regular rate and rhythm. No audible murmurs. ABDOMEN is benign. Left upper extremity demonstrates a 2 cm transverse laceration just proximal to the MP joint with obvious distal ends of the tendons. Trajectory is distal with evidence of possible laceration into the MP joint with traumatic arthrotomy.
MP|metatarsophalangeal/metacarpophalangeal|MP|240|241|PHYSICAL EXAMINATION|No audible murmurs. ABDOMEN is benign. Left upper extremity demonstrates a 2 cm transverse laceration just proximal to the MP joint with obvious distal ends of the tendons. Trajectory is distal with evidence of possible laceration into the MP joint with traumatic arthrotomy. He is unable to extend the small finger. The ring, long, and index finger have normal extension and flexion.
MP|metacarpophalangeal|MP|173|174|PHYSICAL EXAMINATION|He has a near-complete amputation of the left thumb, an oblique complex laceration extending distally from distal to the IP joint in an oblique fashion extending beyond the MP joint into the thenar muscles and first web space. The thumb remains attached by a dorsal and ulnar skin bridge along the first web space.
MP|metacarpophalangeal|MP|490|491|X-RAYS|Both flexor and extensor tendons have also been lacerated. Small abrasions to the superficial ulnar aspect of the digits of the index and ring finger also are noted, but active flexion and extension of all digits - index, long, ring, and small - are all intact. X-RAYS: AP and lateral demonstrate an oblique laceration and fracture with segmental wick of the saw blade through the length of the proximal phalanx extending from the radial aspect of the IP joint past the ulnar aspect of the MP joint; some dorsal comminution as well. IMPRESSION: Complex table saw injury to the left thumb with (1) near-complete amputation, (2) open fracture, (3) flexor and extensor tendon lacerations, and (4) both radial and ulnar neurovascular bundles lacerated with devitalized distal thumb tip.
MP|metacarpophalangeal|MP|163|164|PHYSICAL EXAMINATION|She is cooperative on the exam and answering all questions appropriately. Examination of her left upper extremity reveals ulnar drift to all of her fingers at her MP joint. She does have some healed surgical scars in her palm. She has inability to pinch significantly on the left side, in terms of thumb-index pinch.
MP|metatarsophalangeal/metacarpophalangeal|MP|237|238|PHYSICAL  EXAMINATION|The entire finger is not generally ischemic. This appears to be a localized area of ecchymosis and perhaps bleed that spontaneous. There is limitation of motion, stiffness in the DIP joint. The PIP joint is only mildly stiffened and the MP joint is entirely normal. There is no tenderness to palpation in the finger proximal to the area of demarcation of the ecchymosis.
MP|metacarpophalangeal|MP|196|197|HISTORY OF PRESENT ILLNESS|She has limited finger flexion and extension but only because of the mass effect dorsally. She has no significant pain with flexion or extension of the finger including the PIP and DIP as well as MP joints. Plain x-rays were obtained through the emergency department. (_______________) index finger contraction with a gross purulence dorsally. At this point, because of the amount of purulence noted, I believe it would be most reasonable to perform an I and D of this.
MP|metatarsophalangeal|MP|243|244|RECOMMENDATIONS|The x-rays I will have to look at. I could not find them on the PAX viewer on the 6th floor so I will look at those and then I will see her in the morning. Certainly, from an expeditious standpoint to amputate the right third toe at the third MP joint would be reasonable since she has ongoing troubles with this. I think her vascular support is adequate so this would work.
MP|nurse practitioner:NP|MP,|167|169|ACTION AND PLAN|EXTREMITIES: She moves her left arm, left leg and right toes. ACTION AND PLAN: 1. Call return to daughter _%#NAME#%_ regarding family meeting and message left to call MP, Dr. _%#NAME#%_ available on _%#MMDD2004#%_ at 1 p.m. Call out to Dr. _%#NAME#%_ regarding attendance and waiting to hear of his availability.
MP|metatarsophalangeal/metacarpophalangeal|MP|138|139|HISTORY OF PRESENT ILLNESS|Examination demonstrates a mallet deformity of 30 degrees. The remainder of his hand exam is unremarkable. He has no pain over the PIP or MP joints. He has full digital flexion. He has intact flexor digitorum, profundus, and superficialis function. He is neurovascularly intact, with intact two point discrimination in his radial and ulnar digital nerves.
MP|metatarsophalangeal/metacarpophalangeal|MP|117|118|PHYSICAL EXAMINATION|I can palpate pieces of bone of the medial condyle of the proximal phalanx. This redness extends to the level of his MP joint and then abruptly stops. He has apparently swelling in the past there and the swelling has since resolved. He has very brisk capillary refill. He has palpable pulses dorsally.
MP|metatarsophalangeal/metacarpophalangeal|MP|169|170|PHYSICAL EXAMINATION|On the volar aspect she is fluctuant. There is a small laceration along the radial edge. She has no tenderness over her flexor sheath at the middle, proximal, or at the MP crease and she has good range of motion there. She has delayed capillary refill in the tip. IMPRESSION: An infected index finger.
MP|metatarsophalangeal/metacarpophalangeal|MP,|196|198|ASSESSMENT AND PLAN|4. The Medicine Service should see her for preoperative clearance. 5. Occupational therapy will be consulted for a wrist extension block splint, as well as passive inactive range of motion of the MP, PIP, DIP joints.
MP|mercaptopurine|MP.|145|147|MEDICATIONS|ALLERGIES: PEG-asparaginase causes rash or shortness of breath. Dapsone causes cyanosis. MEDICATIONS: 1. Foscarnet. 2. Levaquin. 3. Meprin. 4. 6 MP. 5. Neurontin. 6. Phenergan. 7. Vfend. 8. Zoloft. 9. Zofran. GROWTH AND DEVELOPMENT: _%#NAME#%_ is the product of a full-term pregnancy.
MP|metatarsophalangeal|MP|216|217|PAST MEDICAL HISTORY|His glucose control has been somewhat more difficult because of the infection but typically it is in good control with metformin. He has no surgical history on his feet, but of note has had this chronic ulcer on the MP joint of the great toe. MEDICATIONS: He is on Lipitor, lisinopril, metformin, and Maxzide. HABITS: He smokes occasionally.
MP|metatarsophalangeal|MP|138|139|PHYSICAL EXAMINATION|The MP joint has significant callus with a small ulcer that does not seem to track very deeply. On probing on the lateral aspect over the MP joint of the foot though, he has a greater ulcer and some skin necrosis overlying it. I am unable to express any purulence with some effort and the packing that was removed from that ulcer was relatively clean.
MP|metabolic panel|MP,|88|90|LABORATORY DATA|Sensation is intact to light touch. Gait is within normal limits. LABORATORY DATA: UAC, MP, and CBC are within normal limits. ASSESSMENT/PLAN: 1. Depression. History and diagnosis is per Dr. _%#NAME#%_.
MP|metatarsophalangeal/metacarpophalangeal|MP|156|157|PHYSICAL EXAMINATION|There was an oblique laceration at the level of the DIP joint with a longer radial flap. This is clean without any residual foreign material. Motion of the MP and PIP joints is full. The skin margins are intact in regard to neurovascular function. The opposite right index has no swelling, tenderness or limitation of motion.
MP|nurse practitioner:NP|MP|179|180|REHABILITATION|REHABILITATION: Speech is working with his dysphagia at this point. He is at risk of aspiration. Physical and Occupational Therapy are to see him today and message left to update MP regarding his status. REVIEW OF SYSTEMS: Denies pain. Family unsure of his last bowel movement, last documented was _%#MM#%_ _%#DD#%_.
MP|metacarpophalangeal|MP|216|217|PHYSICAL EXAMINATION|He is otherwise healthy. He is right hand dominant. PHYSICAL EXAMINATION: The patient is a healthy appearing 15- year-old male. He has multiple lacerations over the ulnar aspect of his hand at the level of the fifth MP joint and then extending distally into the fifth digit. It is difficult to test sensation in his finger, as he has recently had local anesthetic.
MP|metacarpophalangeal|MP|256|257|PHYSICAL EXAM|With pressure I am unable to express purulence from this but he appears to have some significant boggy edema or fluctuance along the length of the thumb. Sensibility is intact. He has pain with movement of the IP joint. He tolerates gentle movement in the MP joint. He has swelling and erythema that extend down into the thenar aspect of the hand. No pain along the palmar surface of the hand or along the carpal tunnel.
MP|metatarsophalangeal/metacarpophalangeal|MP|123|124|REASON FOR CONSULTATION|All fingers are well-perfused. She has obvious degenerative changes of the DIP joints. The splint goes a bit distal to the MP joints. I am therefore not able to evaluate the more proximal joints. She reports sensation on each of the fingertips. I reviewed the Emergency Department notes.
MP|metatarsophalangeal/metacarpophalangeal|MP|164|165|PHYSICAL EXAMINATION|Palpated this and am unable to feel bone deep beneath with a cotton tip. There is thickened callus surrounding it. The IP joint is not painful to motion nor is the MP joint but it is painful to grab his toe. The toe is stable to Drawer. His strength is 5 out of 5 in his toe flexors and extensors but he does get some pain proximally behind his ankle with flexion.
MP|nurse practitioner:NP|MP|161|162|ASSESSMENT|The date of admission was _%#MMDD2004#%_. The family is most upset about apparent respiratory distress and discomfort of patient when they arrived this morning. MP was called by staff to assist with comfort care issues urgently. CODE: Comfort care. ALLERGIES: Please see list as delineated by Dr. _%#NAME#%_ on _%#MMDD2004#%_.
MP|metacarpophalangeal|MP|141|142|X-RAY|It is friable measuring 8 x 8 mm. X-RAY: AP and lateral x-ray of the left thumb were reviewed and demonstrated dislocation of the left thumb MP joints. Sesamoids were non-visible. IMPRESSION: Left thumb MP dislocation, left long finger mass.
MP|metacarpophalangeal|MP|203|204|IMPRESSION|It is friable measuring 8 x 8 mm. X-RAY: AP and lateral x-ray of the left thumb were reviewed and demonstrated dislocation of the left thumb MP joints. Sesamoids were non-visible. IMPRESSION: Left thumb MP dislocation, left long finger mass. PLAN: Discussed options for treatment with the patient and the patient's mother through an interpreter.
MP|metacarpophalangeal|MP|175|176|PLAN|I have discussed with the family a repeat reduction maneuver, and they agree to this. With the current ulnar nerve block, I have performed a reduction maneuver flexing at the MP joint and adducting at the fracture site. A repeat splint is applied with the ring and small fingers in an intrinsic plus position.
MP|metatarsophalangeal|MP|272|273|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: On physical examination, he has a good femoral pulse, very weak popliteal pulse, and absent dorsalis pedis and posterior tibial pulses on the right. The left side is unremarkable. The toe itself is gangrenous and a bit malodorous. The skin below the MP joint looks healthy. IMPRESSION: Ischemic right leg with gangrenous right great toe.
MP|metacarpophalangeal|MP|191|192|PHYSICAL EXAMINATION|Sling is on the left upper extremity. There is some mild to moderate swelling about the left proximal humerus. Skin is otherwise intact. On the left hand, there is a splint which goes to the MP joints. There is some moderate swelling of the fingers. Sensation is grossly intact although somewhat limited examination limited by the splint.
MP|metatarsophalangeal|MP|174|175|HISTORY OF THE PRESENT ILLNESS|There is a white eschar covering this and it does not appear infected. On his right foot he has an ulcer measuring 3 to 4 cm in diameter over the plantar aspect of his first MP joint. This has been present for a year, according to the patient's wife. There is some fibrinous exudate within the wound and a necrotic base, but there is no exposed bone.
MP|metatarsophalangeal/metacarpophalangeal|MP|177|178|EXAMINATION|She is a healthy-appearing 69-year-old female. She is afebrile. Her right foot dressing was taken down. She has two open wounds. One is over the dorsomedial aspect of her first MP joint. It measures approximately 3 cm long. There is fibrinous base. There is no evidence of any purulence. There is another smaller wound in the first web space, which appears deeper.
MP|metacarpophalangeal|MP|185|186|PHYSICAL EXAMINATION|X-rays of the left hand (multiple views) taken in the emergency room and interpreted by me reveal a comminuted fracture of the little finger proximal phalanx as it articulates with the MP joint. The metacarpal appears unremarkable. This fracture was associated with a dislocation. X-rays of the left tibia/fibula (two views) also taken in the ER and interpreted by me appear normal.
MP|metacarpophalangeal|MP|136|137|HISTORY OF PRESENT ILLNESS|I have been asked to see him because of a left hand problem. About 24 hours ago, his nurse noted pain and swelling along his left index MP joint. There is certainly no history of trauma either from a fall or from local venous access. At this time, the patient complains of pain isolated to the index MP joint.
MP|metacarpophalangeal|MP|154|155|HISTORY OF PRESENT ILLNESS|There is certainly no history of trauma either from a fall or from local venous access. At this time, the patient complains of pain isolated to the index MP joint. He has a redness in the area and discomfort with motion. PAST MEDICAL HISTORY: Significant for: 1. Diverticulosis. 2. Prostate cancer.
MP|metatarsophalangeal/metacarpophalangeal|MP|180|181|PHYSICAL EXAMINATION|EXTREMITIES: The left wrist demonstrates no swelling, tenderness or limitation of motion. The hand demonstrates swelling and tenderness, isolated to the dorsal aspect of the index MP joint. Maximal tenderness is directly over the joint itself. There does not appear to be any erythema or swelling extending out into the digit.
MP|metatarsophalangeal/metacarpophalangeal|MP|150|151|PHYSICAL EXAMINATION|Maximal tenderness is directly over the joint itself. There does not appear to be any erythema or swelling extending out into the digit. He holds the MP joint in about 30 degrees of flexion and there is pain with any passive motion of it. None of the other digits have tenderness but there does appear to be chronic changes consistent with osteoarthritis throughout.
MP|metatarsophalangeal/metacarpophalangeal|MP|122|123|IMPRESSION|The opposite right index finger has no swelling, tenderness or limitation of motion. IMPRESSION: 1. Arthrosis, left index MP joint, inflammatory versus infectious. This appears to be of acute onset. 2. Pancreatitis with cholecystitis and pancreatic pseudocyst.
MP|metatarsophalangeal/metacarpophalangeal|MP|95|96|IMPRESSION|I, therefore, have taken the liberty of ordering them. Developing an isolated infection of the MP joint would be rather unusual. Considering this patient's poor medical status, including renal failure and with an elevated creatinine of 2.78 today, I would be more likely to believe that this is possibly a crystallin arthropathy.
MP|metatarsophalangeal/metacarpophalangeal|MP|195|196|PHYSICAL EXAM|Some mild calf edema with no erythema, no distant tenderness on the left. No clubbing and no cyanosis. Bilateral hand changes of rheumatoid arthritis and some synovial swelling over the proximal MP joints. LABORATORY DATA: Chest x-ray initial film unavailable. Perhaps shallow inspiratory effort, mild bilateral atelectasis further than normal size.
MP|metatarsophalangeal/metacarpophalangeal|MP|160|161|PHYSICAL EXAMINATION|There is a 3 cm area of erythema and tenderness along the volar aspect of the middle phalanx. No tenderness extending proximally over the flexor tendon sheath. MP motion is painless, either active or passive. The skin over the middle phalanx has an area of a small draining puncture wound in the center of the erythematous region measuring about 4 mm.
MP|metacarpophalangeal|MP|141|142|PHYSICAL EXAMINATION|The swelling does, however, involve in his right hand. Skin and subcutaneous tissues show no signs of laceration. He has ability to flex his MP joint at that finger, equal compared to the contralateral side, but he cannot flex his PIP or DIP without pain. He is stable at his MP joint. Strength is 5/5 in finger flexion and extension.
MP|metacarpophalangeal|MP|162|163|PHYSICAL EXAMINATION|He has ability to flex his MP joint at that finger, equal compared to the contralateral side, but he cannot flex his PIP or DIP without pain. He is stable at his MP joint. Strength is 5/5 in finger flexion and extension. He has normal tone, normal rapid alternating movements bilaterally, normal sensation, but significantly painful right ring finger.
MP|nurse practitioner:NP|MP,|128|130|SOCIAL HISTORY|SOCIAL HISTORY: She lives at _%#CITY#%_ _%#CITY#%_ Care Center for the past couple of years and is fairly active over there per MP, _%#NAME#%_. She does not smoke and does not consume any alcohol or other drugs. MEDICATIONS: She is currently on include: 1. Aspirin 162 mg daily.
MP|metatarsophalangeal|MP|133|134|HISTORY OF PRESENT ILLNESS|He has recently, as of 2 weeks ago, healed an ulcer in the IP region with nonsurgical treatment. He previously also had a second toe MP joint level amputation. This ulcer once closed within a few days became swollen, red and began to drain to the previous ulcer hole on the plantar surface.
MP|metatarsophalangeal/metacarpophalangeal|MP|147|148|PHYSICAL EXAMINATION|No sensation is noted in this area. No areas of pain. He has crepitation with examination of his IP joint, which appears to have increased motion. MP joint has stable and normal motion. FHL and EHL function are fairly well. He has normal tone and reflexes. LABORATORY DATA: Laboratory values show he has got an increased hemoglobin A1c at 9.9. Other labs documented his hemoglobin A1c on _%#MMDD2005#%_ is 7.5 and glucose is 255.
MP|metatarsophalangeal|MP|144|145|HISTORY OF PRESENT ILLNESS|There is no evidence of metatarsal head involvement. I discussed with the patient the probable need for amputation of the great toe through the MP joint. He understood the surgical plan. I have appraised him the risks, benefits, advantages, disadvantages and complications.
MP|mercaptopurine|MP|185|186|HISTORY OF PRESENT ILLNESS|This demonstrated active disease in left side of the colon, with quiescence disease elsewhere. She has been on a prednisone taper her, which ended last week. She subsequently began six MP on _%#MMDD#%_. However, during the steroid taper, she was still noticing rectal bleeding, and once the taper ended, she began actually having very heavy bleeding.
MP|mercaptopurine|MP|90|91|MEDICATIONS|This ultimately required decortication of the lung and pericardial window. MEDICATIONS: 6 MP 75 mg daily, Effexor, Prilosec, mesalamine suppositories q.h.s. ALLERGIES: None known. HABITS: Nonsmoker, occasional alcohol. FAMILY HISTORY: Negative for irritable bowel disease, colon CA or polyps.
MP|mercaptopurine|MP|192|193|ASSESSMENT|Liver profile normal. ASSESSMENT: 1. Ulcerative colitis, predominantly left-sided inactivity now. 2. Rectal bleeding secondary to above, following steroid taper. 3. Recent commencement of six MP immuno modulated therapy. 4. Anemia secondary to blood loss. PLAN: 1. The patient will be discharged today with outpatient follow-up.
MP|mercaptopurine|MP|161|162|PLAN|PLAN: 1. The patient will be discharged today with outpatient follow-up. 2. She will be restarted on a prednisone taper beginning at 40 mg. 3. Will continue six MP with regular lab protocol, weekly for 4 weeks to start. 4. The patient will be following up with Dr. _%#NAME#%_ _%#NAME#%_ in our clinic.
MP|metacarpophalangeal|MP|195|196|PHYSICAL EXAMINATION|Within normal limits. EXTREMITIES: Lower extremities are without injuries. Right upper extremity has an obvious injury with a longitudinal laceration extending along the thenar muscles up to the MP joint. The MP joint has a subluxed posture. Distal aspect of the digit appears preserved with active flexion and extension intact and sensibility intact.
MP|metacarpophalangeal|MP|209|210|PHYSICAL EXAMINATION|Within normal limits. EXTREMITIES: Lower extremities are without injuries. Right upper extremity has an obvious injury with a longitudinal laceration extending along the thenar muscles up to the MP joint. The MP joint has a subluxed posture. Distal aspect of the digit appears preserved with active flexion and extension intact and sensibility intact.
MP|UNSURED SENSE|MP,|243|245|HOSPITAL COURSE|The patient was seen in consultation by Dr. _%#NAME#%_, who recommended therapy including high-dose Solu-Medrol, cyclophosphamide to be given oral bases after infectious disease issues were resolving. Further studies, which included SSA, SSB, MP, anti-Smith, serine protease 3, MPO, SCL 70, anticentromere antibody, all which have been drawn at this time. Plasmapheresis is also considered and will be performed starting tomorrow under the direction of Nephrology and the blood bank.
MP|UNSURED SENSE|MP:|164|166|LABORATORY DATA|LABORATORY DATA: 1. CBC: Hemoglobin 11.8, white blood count 7.9, neutrophils 59%, lymphocytes 28%, platelets 415, MCV 85. 2. INR 1.20. 3. Troponin 0.08. 4. NT prob MP: 35,300. 5. Urine examination yellow color, slightly cloudy, specific gravity 1.021, PS 5.5, protein 30, urobilinogen 2.0, negative nitrate, negative blood, trace leukocyte esterase, white blood count 3 per high power field, many bacteria.
MP|mercaptopurine|MP,|232|234|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1 . Bone marrow transplantation: Patient received a nonmyeloablative double-cord transplant on _%#MMDD2005#%_. Both double cords were 4 out of 6 HLA matches. Myeloablative preparatory regimen included ATG, MP, fludarabine, TBI. Day #21 biopsy showed cellularity of less than 5% with evidence of erythroid and myeloid hematopoiesis. Pancytopenic. Marrow biopsy dated _%#MM#%_ _%#DD#%_, 2005 showed variable marrow cellularity overall 10% with good evidence of erythroid and myeloid hematopoiesis and scant evidence of megakaryocytopoiesis.
MP|mercaptopurine|MP,|145|147|HISTORY OF PRESENT ILLNESS|Bone marrow biopsy had 70% cellularity. Fish was negative for BCR ......and normal cytogenetics. The second induction of chemotherapy included 6 MP, Cytoxan, cytarabine, vincristine, and intrathecal methotrexate, which was completed on _%#MMDD2004#%_. Two days later, she had a fever of 101.5 and a large right IJ clot associated with her Hickman.
MP|metatarsophalangeal|MP|223|224|-CHIEF COMPLAINT|-CHIEF COMPLAINT: Scheduled for right wrist surgery. -HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 72-year-old female who on _%#MMDD2007#%_ will undergo anesthesia and right wrist CMC excisional arthroplasty with MP fusion by Dr. _%#NAME#%_ _%#NAME#%_ at Fairview Southdale Hospital. -PAST MEDICAL HISTORY: 1. Osteopenia. 2. Reactive airway disease. 3. Borderline hypercholesterolemia with normal LDL cholesterol.
MP|metatarsophalangeal|MP|179|180|ADMISSION PHYSICAL EXAMINATION|There was nodularity and scarring. The foot in general was quite swollen and deformed. In addition, there was a 5 x 5 mm ulceration on the plantar surface of the left foot at the MP joint of the third toe. ADMISSION LABORATORY DATA: Admission labs were remarkable for: White count 10.3. Hemoglobin 7.5. Platelets 501.
MP|mercaptopurine|MP.|323|325|HOSPITAL COURSE|LABORATORY: White count 2.0, hemoglobin 11.4, platelets of 86. Chem panel significant for creatinine of 0.95. SPEP showed a beta 2 peak of 6.0. Total protein was 7.3. HOSPITAL COURSE: 1. Bone marrow transplant: The patient was started on protocol MT _%#PROTOCOL#%_ with preparation including Cytoxan, fludarabine, ATG, and MP. He also received one dose of total body radiation. Transplantation was performed on _%#MM#%_ _%#DD#%_, 2005 with HLA matched allogeneic sibling donor which was actually the cousins with a 6/6 match.
MP|metabolic panel|MP|68|69|LABORATORY|No tenderness to palpation along the spinal column. LABORATORY: The MP was within normal limits except for an elevated glucose of 539. LFTs are within normal limits. Lipase was less than 10.
MP|mercaptopurine|MP|384|385|HOSPITAL COURSE|Sodium 141, potassium 4.2, chloride 107, CO2 25, BUN 11, creatinine 0.64, calcium 8.7. ALT 143, ALT 74, total bilirubin 0.3, alkaline phosphatase 94, albumin 4.1 and protein 7.2. INR 1.11. PTT 31, ferritin of 6002. HOSPITAL COURSE: PROBLEM #1: Preoperative regimen: Mr. _%#NAME#%_ received a prep with fludarabine x4 doses on _%#MMDD2007#%_ through _%#MMDD2007#%_, thymoglobulin with MP x3 doses on _%#MMDD#%_ to _%#MMDD#%_ followed by one fraction of TBI on _%#MMDD#%_. He received allopurinol few days ago _____ to prevent tumor lysis syndrome.
MP|UNSURED SENSE|MP|181|182|PHYSICAL EXAMINATION|SOCIAL HISTORY: No use of alcohol, tobacco, or drugs. She does live with her husband. PHYSICAL EXAMINATION: Of note was colostomy on patient's abdomen with a slight erythema at the MP site. Abdomen was tender to palpation as well. The plan was to admit patient to rule out lower extremity deep vein thromboses, as well as evaluate her abdomen via CT scan.
MP|mercaptopurine|MP,|209|211|HISTORY OF PRESENT ILLNESS|In the past, _%#NAME#%_ has received chemotherapy with vincristine, ara-C, L-asparaginase, prednisone, methotrexate, and 6-TG. Recently, _%#NAME#%_ had begun a maintenance course of chemotherapy, including 6- MP, methotrexate, and prednisone. On _%#MMDD#%_, 24% blasts were noted on a peripheral blood specimen during a routine clinic follow-up.
MP|UNSURED SENSE|MP|220|221|PERTINENT LABORATORY TESTS|2. _%#MMDD2007#%_: WBC 6.8, hemoglobin 9.6, platelet count 143,000. 3. _%#MMDD2007#%_: INR 1.13. 4. _%#MMDD2007#%_: Phosphorus 3.7, magnesium 1.7. 5. _%#MMDD2007#%_: Tacrolimus level 11.6. Mycophenolate acid level 0.62. MP flucloronide greater than 200. 6. _%#MMDD2007#%_: Sodium 136, potassium 4, chloride 98, CO2 27, glucose 90, BUN 79, creatinine 2.95, calcium 7.9.
MP|(drug) MP|MP|157|158|MEDICATION PROFILE ON ADMISSION|3. Tobramycin 300 mg b.i.d., again on a 28 day on and 28 day off cycle, alternating with the colistin. 4. Mucomyst 10%, 8 to 10 cc nebulized t.i.d. 5. Creon MP 10's, 12 with meals and snacks. 6. Pancrease 15 caplets with meals and snacks. 7. Actigall 300 mg b.i.d. 8. Advair 550, 1 puff b.i.d. with vest treatments.
MP|mercaptopurine|MP|170|171|HOSPITAL COURSE|EXTREMITIES: +2 pedal pulses and upper extremity pulses were normal. HOSPITAL COURSE: PROBLEM #1: Prep. _%#NAME#%_ received ATG x2 _%#MMDD2007#%_ through _%#MMDD2007#%_, MP x2 on _%#MMDD2007#%_ through _%#MMDD2007#%_. He had 1 dose of Cytoxan on _%#MMDD2007#%_. _%#NAME#%_ was given on _%#MMDD2007#%_ through _%#MMDD2007#%_.
MP|mesangial proliferative|MP|176|177|HISTORY OF PRESENT ILLNESS|The patient is followed closely by _%#NAME#%_ as an outpatient and has been noted to have been developing and elevated creatinine and proteinuria. The patient has a history of MP glomerulonephritis secondary to the cryoglobulinemia with consistently elevated cryoglobulin. The patient had been on plasmapheresis in the past and had his last plasmapheresis in _%#MM2005#%_.
MP|metatarsophalangeal|MP|184|185|REVIEW OF SYSTEMS|ALLERGIES: Aspirin, no tobacco use, rare and very slight alcohol intake. REVIEW OF SYSTEMS: General, remarkable for painful arthritis in hands and feet, major deformity over the first MP joint of both feet requiring particularly wide shoes, otherwise has not had any help for this. She has most of her own teeth, wears partial upper denture.
MP|metacarpophalangeal|MP|149|150|PHYSICAL EXAMINATION|SPINE - with increased thoracic kyphosis and some compensatory cervical lordosis. EXTREMITIES - remarkable for extreme deformity particularly in the MP joints. This is very obvious in the hands but extremely prominent in the feet particularly on the right side of the first MP joint.
MP|metatarsophalangeal|MP|192|193|PHYSICAL EXAMINATION|EXTREMITIES - remarkable for extreme deformity particularly in the MP joints. This is very obvious in the hands but extremely prominent in the feet particularly on the right side of the first MP joint. There is some overlying inflammation and callous at what amounts to an extreme bunion on that side. Aside from that, she has CN II-XII intact and formal testing of visual fields and hearing.
MP|mercaptopurine|MP|400|401|HPI|Unfortunately, the patient had some residual mediastinal lymphadenopathy a small pulmonary nodule continuously and eventually grew in size, as well as developed a right neck lymph adenopathy which was biopsied in _%#MM2003#%_ which showed nodular sclerosing Hodgkin disease. The patient has been treated with ICE chemotherapy and is being evaluated for autologous peripheral stem cell transplant for MP protocol _%#PROTOCOL#%_. Physical examination: The patient is mentally alert and cooperative. The patient has no abnormal palpable peripheral lymphadenopathy.
MP|mercaptopurine|MP|251|252|HISTORY OF PRESENT ILLNESS|4. History of factor V Leiden mutation (homozygous). 5. History of bilateral PE and DVT diagnosed _%#MM2006#%_. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a pleasant 52-year-old lady with history of ulcerative colitis, being maintained on 6 MP recently and steroids. History of DVT, PE, homozygous factor V Leiden, plus ET as diagnosed on bone marrow biopsy. She was seen by my colleague, Dr. _%#NAME#%_ in the clinic, where she is monitored regularly for INR and also her other blood work while on hydroxyurea.
MP|mercaptopurine|MP,|122|124|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Ulcerative colitis diagnosed in summer of 2002. She is seen by Dr. _%#NAME#%_. She had been on 6 MP, Pentasa, and Colestid. Her last colonoscopy was in 2006 when she was hospitalized. She has recently increased her dose of steroids and is maintained on 6 MP.
MP|mercaptopurine|MP.|131|133|PAST MEDICAL HISTORY|Her last colonoscopy was in 2006 when she was hospitalized. She has recently increased her dose of steroids and is maintained on 6 MP. 2. History of admission _%#MM2006#%_ with complaints of lower extremity edema, and was found to have a DVT in left lower extremity and bilateral PE.
MP|mercaptopurine|MP|204|205|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: Diffuse large cell lymphoma residual mass density in the spleen after R-CHOP and ICE chemotherapy treatment. The patient is scheduled to have bone marrow transplantation on the local MP protocol _%#PROTOCOL#%_, which requires total body irradiation 1320 cGy in 8 treatments over 4 days. The patient has no contraindication for the TBI and will plan to schedule.
MP|metabolic panel|MP|159|160|HISTORY|Flexible cystoscopy showed some increased blood vessels at the bladder neck. There is a questionable this small hyperemic area in the floor of the bladder. An MP 22 was negative. I ordered up a CT scan of the abdomen and pelvis to evaluate the upper tracts. That CT scan was done late last week and showed no evidence of any mass lesions but in fact he had a nonobstructive left upper ureteral stone about 4 mm in size.
MP|metatarsophalangeal/metacarpophalangeal|MP|119|120|PHYSICAL EXAMINATION|She has full superficialis pull through, but she had no profundus pull through. She has a tender painful nodule at the MP joint, likely the remnant of her flexor profundus. She is stable to radial and ulnar deviation at the DIP and PIP joint as well as at the MP joint.
MP|military police|MP|217|218|SOCIAL HISTORY|Hemoglobin was 17.4 gm %. FAMILY HISTORY: The patient's sister, _%#NAME#%_ _%#NAME#%_, had a cerebrovascular accident in her 40s. SOCIAL HISTORY: The patient has 100% disability, as he is a Vietnam veteran. He was an MP in Vietnam. His family is unsure as to what happened, but he had some kind of skin cancer of the right leg, but now has a "disease in the right leg" and cannot balance on it, occasionally almost falling.
MP|mercaptopurine|MP|147|148|MEDICATIONS|MEDICATIONS: 1. Zyrtec. 2. Singulair. 3. Prednisone as an outpatient. Since being in the hospital, he has been treated with steroids as well as 6- MP and was recently started on Remicade. He additionally is on metronidazole and ceftazidime. He reports no allergies. FAMILY HISTORY: Inflammatory bowel disease in a maternal great aunt, otherwise unremarkable.
MP|metatarsophalangeal|(MP)|211|214|PHYSICAL EXAMINATION|There is no crepitus with range of motion. He has no pain with resisted digital extension. He has normal two-point discrimination in the tip and good capillary refill. No tenderness over the metatarsophalangeal (MP) joint. IMPRESSION: Resolving hand cellulitis with abscess which was lanced.
MP|mercaptopurine|MP|149|150|ASSESSMENT/PLAN|At this time I will discontinue her present medicines since she feels so much better since admission here to the hospital. We have kept her on the 6 MP and her hypertension medicines, and we will add ciprofloxacin. We will keep her on clear liquids. She reports she does not get any response at all from steroids and until I get some of her old reports I will not add this medication.
MR|magnetic resonance|MR|146|147|PLAN|5. Osteopenia/porosis. 6. Hyperlipidemia. 7. COPD/asthma. PLAN: We will discharge after ultrasound of the carotids. I do not believe she needs an MR at this point. I do believe that she should start taking Plavix and stop her aspirin. She should follow up with Dr. _%#NAME#%_ in 2 weeks.
MR|mitral regurgitation|MR.|257|259|INDICATION FOR ADMISSION|_%#NAME#%_ _%#NAME#%_ will have admission within the next week. INDICATION FOR ADMISSION: Right and left heart catheterization with assessment of coronary anatomy, right heart pressures, aortic valve assessment, and LV function assessment with attention to MR. _%#NAME#%_ _%#NAME#%_ is a 78-year-old man who is admitted in anticipation of having aortic valve replacement because of progressive deterioration in exertional abilities with dyspnea on exertion increasing the ease of dyspnea.
MR|mitral regurgitation|MR.|169|171|PLANNED DISCHARGE DATE|An echocardiogram dated _%#MMDD2007#%_ showed diminished EF of 35-40%, akinetic inferoseptal wall, mild LV dilation, moderate biatrial enlargement and moderately severe MR. There was aortic leaflet sclerosis, trace TR and the right heart pressures could not be assessed. There was trace to mild PR. There was mild LVH.
MR|magnetic resonance|MR|176|177||She was subsequently seen in our clinic on _%#MM#%_ _%#DD#%_. At that time, her examination was completely unremarkable but because of these symptoms, she was scheduled for an MR angiogram. She subsequently had the MR angiogram done that showed that left subclavian was normal. However, there was a question of a clot in the right subclavian, the possibility was intimal tear.
MR|magnetic resonance|MR|278|279|PHYSICAL EXAMINATION|We will evaluate the patient for anemia. The ferritin level may be misleading due to the patient's acute inflammatory response with tumor/thrombus. Further imaging studies will be determined once the contrast studies are completed and reviewed, including evaluation of possible MR angiographies of the kidney system, PET scans will be evaluated with urology and radiology department.
MR|mitral regurgitation|MR|243|244|HOSPITAL COURSE|Further stroke work-up was done including carotid ultrasound which showed minimal plaque disease at both carotid bifurcations. She also underwent an echocardiogram which showed left ventricular systolic function which was normal. She had mild MR and mild TR. She had some early diastolic dysfunction as well as biatrial enlargement. The patient was seen by physical therapy and had slow improvement and strength in her right lower extremity.
MR|magnetic resonance|MR|307|308|PLAN|ASSESSMENT: Abdominal pain, nausea, vomiting, multiple stools. Must rule out graft occlusion or stenosis related to his pervious procedure, but this may be something relatively simple, such as gastroenteritis or cholecystitis. PLAN: We will check a serum lactate level and repeat his labs. We will check an MR angiogram. Discussed in detail with the patient. Discussed with Dr. _%#NAME#%_, who will follow up with him in the morning.
MR|mitral regurgitation|MR,|308|310|HISTORY OF PRESENT ILLNESS|The patient's initial echo showed an EF of 15% to 20%, anterior septal hypokinesis to akinesis, apical akinesis, mild MR, moderate TR, estimated PA systolic function was 36, LVIDD was 4.8 cm. Subsequent echoes on _%#MM#%_ _%#DD#%_, 2005, showed an EF of 20% to 25%, anterior septal and apical akinesis, mild MR, only contractile portion was the left base. Normal LV size. Tissue Doppler on _%#MM#%_ _%#DD#%_, 2005, showed mild LV desynchrony of the QRS in the 70s.
MR|mitral regurgitation|MR,|298|300|DISCHARGE DIAGNOSES|2. Chemical dependence. OPERATIONS/PROCEDURES PERFORMED: Procedures performed during this hospitalization: Echocardiogram performed on _%#MM#%_ _%#DD#%_, 2005, showing ejection fraction of 15%, severely diffuse global left ventricular function, mild LV dilation, mildly thickened LV, mild AI, mild MR, mild LAE, and RV systolic pressure mildly elevated. HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old male with a history of idiopathic cardiomyopathy, ejection fraction 10% to 15%, and a history of ICD placement in 1993 who was admitted as he presented with increased abdominal distention, lower extremity edema, and dyspnea on exertion with nocturnal cough.
MR|mitral regurgitation|MR.|162|164|OPERATIONS/PROCEDURES PERFORMED|Mild increase in LV valve thickness. Moderately severe by gradient, 39 mmHg, to severe aortic valve stenosis by aortic valve area (0.63 cm sq). Mild AI. Moderate MR. Moderate TR. RV systolic pressure at 46 greater than RAP. No effusion. Findings similar to echo dated _%#MM#%_ _%#DD#%_, 2005. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 78-year-old female with a past medical history of coronary artery disease, AICD placement for bradycardia, diastolic dysfunction, aortic stenosis, diabetes, hypertension, rheumatoid arthritis, and paroxysmal atrial fibrillation who presents with chest pressure.
MR|magnetic resonance|MR|149|150|PAST MEDICAL HISTORY|3. Smoking. 4. Cerebrovascular infarction (CVI). The patient had an extensive workup in _%#MM#%_ 2004 for neurovascular disease at which time he had MR angiogram of the circle of Willis with no large vessel occlusions. Carotid ultrasound did not show any significant disease. CURRENT MEDICATIONS: At this time he is taking no medications.
MR|magnetic resonance|MR|142|143|HOSPITAL  COURSE|HOSPITAL COURSE: Upon admission a CT scan of the brain was unremarkable. A lumbar puncture was likewise negative. An MRI of the brain with an MR angiogram of circle of Willis and great vessels of the neck was unremarkable. The patient had an EEG performed which was normal. In addition, she developed a severe headache which was treated with Dilaudid.
MR|magnetic resonance|MR|192|193|BRIEF HISTORY|Her initial CT scan was negative for acute infarction; did not seem to be a condition that required t-PA. Her symptoms were improving. She was started on heparin nonetheless. She had a repeat MR which showed no significant vascular stenosis and the CT again was as above. It was felt that she would require increasing therapy from aspirin to Plavix and if she had further symptoms then to Coumadin.
MR|magnetic resonance|MR|288|289|ASSESSMENT|MRI of the brain with and without contrast demonstrated a 2 x 1.3 x 1 cm left frontal periventricular white matter focus consistent with the patient's known multiple sclerosis. MRI of the thoracic cord demonstrated a left T10 nerve root sheath cyst, but no other evidence of abnormality. MR of the lumbar spine demonstrated no significant abnormalities. The patient was treated with intravenous Solu-Medrol with marked improvement of her presenting symptoms and was discharged in significantly improved status.
MR|magnetic resonance|MR|112|113|OPERATIONS AND PROCEDURES|PRIMARY DIAGNOSIS: Cystic craniopharyngioma. OPERATIONS AND PROCEDURES: P32 instillation and cyst drainage with MR guidance performed on _%#MMDD2002#%_. HISTORY OF PRESENT ILLNESS: This is a 45-year-old right-handed gentleman with a history of a cystic craniopharyngioma.
MR|mitral regurgitation|MR|314|315|LABORATORY STUDIES ON ADMISSION|Electrolytes: Sodium 141, potassium 3.6, chloride 106, CO2 23, BUN of 6, creatinine 0.9, and glucose of 156 with magnesium 1.8, phosphorus of 3.4. INR was 1.14. PT 24. CK 69. LFTs and ALT of 50, AST of 40, alkaline phosphatase of 83, and total bilirubin 0.6. HOSPITAL COURSE: This is a 50-year-old white male with MR and morbid obesity, here with 3 admissions for worsening left lower extremity cellulitis and fevers. PROBLEM #1: Infectious disease. The patient has worsening cellulitis with fevers on p.o. Augmentin.
MR|GENERAL ENGLISH|MR.|203|205|PLAN|3. Proceed with MRI scan of the brain to help exclude central nervous system metastases. 4. Continue Coumadin for treatment of hypercoagulable stable. 5. Continue TPN. 6. Continue DNR, DNI STATUS AS PER MR. _%#NAME#%_'S PREVIOUSLY STATED WISH. This plan was reviewed with Mr. _%#NAME#%_ and his wife and they are in agreement.
MR|mitral regurgitation|MR.|146|148|HISTORY OF PRESENT ILLNESS|3. LV gram with moderate degree of LV dysfunction with an EF of 30%. 4. End diastolic pressures substantially elevated at 27. 5. Mild to moderate MR. The patient has had chest pain for 18 years. He says this occurs about one time a week to one time every four weeks.
MR|mitral regurgitation|MR.|184|186|PROCEDURES PERFORMED DURING THIS ADMISSION|Cannot exclude a basal inferior and posterior wall motion abnormality. The global left ventricular function is at the lower limits of normal with EF 55%. Mitral valve normal with mild MR. No pericardial effusion. 7. Stress thallium dated _%#MM#%_ _%#DD#%_, 2005 preliminary report shows normal EKG portion of test. Perfusion portion of study shows possible old non- transmural infarct, but negative for any acute ischemia with EF of approximately 50%.
MR|mitral regurgitation|MR,|170|172|PROCEDURES PERFORMED THIS HOSPITALIZATION|Echocardiogram obtained _%#MMDD1950#%_ demonstrated sinus rhythm with diastolic dysfunction and aortic sclerosis with mild stenosis and AVA of 1.5 cm2. Trace TRRRR, mild MR, and mild increase in left ventricular wall thickness was identified. His ejection fraction was estimated at 35%. 2. Initial video swallow examination during hospitalization indicated some risk for aspiration.
MR|mitral regurgitation|MR|382|383|REASON FOR ADMISSION|Not surprisingly there was biatrial enlargement that was severe. The interventricular septum was flattened, supporting pressure and volume overload of the right ventricle. He has never been eager to reconsider another cardiac surgery, but I feel forced to proceed down this path because of his progressive left ventricular dilation, diminished left ventricular function, and severe MR is also progressing. He is short of breath if he climbs any kind of stairs or goes up hills.
MR|magnetic resonance|MR|138|139|DISCHARGE PLANS|2. Hyperlipidemia. 3. Acid reflux disease. 4. Status post right total knee arthroplasty in 2001. DISCHARGE PLANS: 1. Repeat MRI brain and MR angiogram of circle of Willis on _%#MMDD2005#%_ at Fairview Southdale Hospital. 2. Follow up with Dr. _%#NAME#%_ _%#MMDD2005#%_. 3. Follow up at primary-care clinic in about two weeks
MR|magnetic resonance|MR|122|123|SUMMARY OF HOSPITAL COURSE|She drove in to see me the next day and my neuro exam was unremarkable. In the course of setting up an outpatient EEG and MR scan of her brain, she had another episode. I witnessed the episode and found that she had a regular pulse and her blood pressure was a bit elevated in the range of 180/90, and her blood sugar was 161.
MR|mitral regurgitation|MR,|281|283|DIAGNOSES|He was admitted to the hospital with left heart failure and cardiomegaly on his chest x-ray. It was mild left heart failure but real. Echocardiogram was done and showed that the left ventricle was not dilated, EF was 25-30, visually he had mild LVH, left atrial dilation, moderate MR, moderate TR, mild pulmonary hypertension with an RVSP of 32 mmHg plus right atrial pressure. In the hospital, he was quickly asymptomatic with initial IV Lasix diuresis and he felt better.
MR|mitral regurgitation|MR|221|222|IMPRESSION|IMPRESSION: 1. Recurrent cardiomyopathy. 2. Nonischemic cardiomyopathy with a thallium study showing no scars, no ischemia and ejection fraction of 20%, 25-30% by echo. 3. Obesity. 4. Obstructive sleep apnea. 5. Moderate MR and moderate TR with mild pulmonary hypertension. PLAN: 1500 calorie day diet, outpatient cardiac rehabilitation, relentless gentle exercise and gradually working up to a 45-60 minutes a day with diet, weight loss and exercise.
MR|mitral regurgitation|MR.|241|243|PROCEDURES PERFORMED DURING THIS ADMISSION|4. Transthoracic echocardiogram showing mildly decreased left ventricular function with an EF of 50%, mild AS with mean gradient of 19.4, mild aortic dilatation with ________________ dimension 3.7 cm, mild mitral annular calcification, mild MR. Negative for any vegetations. 5. Transesophageal echocardiogram negative for vegetations. No evidence of any left atrial thrombi. Showing an aneurysmal atrial septum with right-to-left shunt by carotid Doppler mapping _____________ saline contrast study.
MR|magnetic resonance|MR|554|555|HOSPITAL COURSE|_%#NAME#%_ _%#NAME#%_ is a 28-year-old female, presenting with a history suggestive of possible complex migraine, possible seizure. HOSPITAL COURSE: Evaluation in hospital included appropriate imaging study inclusive of CT of the head demonstrating a small lipoma in the corpus collosum, MRA of the circle of Willis demonstrating no abnormalities, MR angiogram of the neck with and without contrast demonstrating no abnormalities, MR of the brain with and without contrast entirely normal, aside from the incidental finding of the aforementioned lipoma, MR of the cervical spine demonstrating no evidence of abnormality in the cord or surrounding structures. EKG was found to have normal sinus rhythm. Laboratory studies otherwise inclusive of essentially normal chemistry panel and negative urine drug screen, negative hCG, normal spinal fluid, including normal glucose and protein with no pleocytosis.
MR|mitral regurgitation|MR.|157|159|OPERATIONS/PROCEDURES PERFORMED|Findings: Technically difficult study. There was moderate-to-severe left atrial enlargement. EF estimated at 60%. There is some severe concentric LVH. Trace MR. Moderate pulmonary hypertension with PA pressures of 42 mmHg above CVP. 2. MRI of L spine date _%#MMDD2006#%_. Findings: At the L5-S1, there is severe right-sided foraminal stenosis as well as moderate-to-severe left foraminal stenosis as the result of an asymmetric disk bulge.
MR|mitral regurgitation|MR,|184|186|PROCEDURES|Moderate diffuse cerebral volume loss in excess of expected for age. No evidence of recent hemorrhage or infarction. 5. Echocardiogram this admission revealed normal LV function, mild MR, AI, and TR, poor acoustic windows, aortic stenosis, with AO, V2, max 2.6 cc/second, mean gradient 66 mm/Hg, aortic valve area 2.8 cm2.
MR|magnetic resonance|MR|164|165|PAST MEDICAL HISTORY|3. Cerebrovascular accident in _%#MM#%_ 2001, with MRI changes compatible with a new infarct in the region of the right posterior paramedian and frontal region. An MR angiogram demonstrated a noncritical stenosis of the carotid vessels. 4. Chronically abnormal liver function studies, felt to be related to the use of Tegretol for his seizure disorder.
MR|mitral regurgitation|MR|204|205|HISTORY OF PRESENT ILLNESS|She is slowed more by some arthritis of her knees, osteoarthritis, and this has been a more dominant issue. She is having a TEE in follow up of her previous study to accurately assess the severity of her MR and to look at her mitral anatomy. She may wish to consider mitral valve repair or replacement at this time, more likely the latter.
MR|mitral regurgitation|MR,|214|216|DISCHARGE MEDICATIONS|His children are in Michigan, and he is very adamant about not going to the nursing home like his wife has been. While he was here, he had an echo done with severe diffuse hypokinesis, several walls involved, mild MR, TR, AI, and PI. RV septum severely hypokinetic. Estimated LV ejection fraction was 20-25%. HOSPITAL COURSE: The patient had come in after calling 911, and he was noted to have increasing troponins.
MR|mitral regurgitation|MR|138|139||_%#NAME#%_ _%#NAME#%_, age 40, was admitted with a history of moderately severe mitral insufficiency, EF of 45-50% and concerned that his MR was causing worsening symptoms of shortness of breath on exertion. He was assessed and evaluated by Dr. _%#NAME#%_ who recommended mitral valve repair.
MR|mitral regurgitation|MR.|201|203|OPERATIONS/PROCEDURES|ADMISSION DIAGNOSIS: Chest pain. DISCHARGE DIAGNOSIS: Same. OPERATIONS/PROCEDURES: _%#MMDD2002#%_ transthoracic echocardiogram. 1. Cardiac echo revealed hypokinetic basilar mid septal segment. 2. Mild MR. 3. Normal RSVP. 4. Normal global systolic left ventricular function with ejection fraction estimated at 55%. HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old white female who returns to Fairview University Medical Center after approximately two weeks time for an episode of chest pain the previous evening.
MR|mitral regurgitation|MR|237|238|PAST MEDICAL HISTORY|Status post CAB in 1979 and 1993 three vessel. 2. History of CHF. 3. Ischemic cardiomyopathy on transplant list. Last echo _%#MM2001#%_ showed EF of 20%, severe diffuse hypokinesis with moderate to severe LV dilatation, mild to moderate MR and mild RV dilatation with mild to moderate decrease in RV function. 4. Diabetes diagnosed 1985. 5. AICD secondary to CAD treated with pacemaker.
MR|magnetic resonance|MR|163|164|DISCHARGE MEDICATIONS|A carotid ultrasound was performed showing less than 40% stenosis in both carotid artery distributions. The MR angiogram of the neck was essentially unremarkable. MR angiography of the head was also normal. However an MRI scan of the cervical spine showed a recent infarct o the right side of the pons as well as a nonenhancing mass lesion on the right side of the cervical spinal cord at the C2-3 level, etiology indeterminate.
MR|magnetic resonance|MR|159|160|PLAN|The patient obviously has hypertension that also needs to be treated although at this stage I would not treat it very aggressively. PLAN: 1. MRI of brain with MR angiogram of the circle of Willis and of the great vessels of the neck. 2. Echocardiogram. 3. Because of the risk of possible basilar artery thrombosis or cardiac embolism, the patient should be started on heparin.
MR|mitral regurgitation|MR|166|167|HOSPITAL COURSE|The elevation in troponin was thought secondary to the pneumonia process. Also, a 2D echocardiogram was obtained which showed a normal ejection fraction of 60%, mild MR and mild TR. On the second day of hospitalization, he started having melenic stool. His hemoglobin dropped to 6 from 11. A GI consultation was obtained and patient underwent an upper GI endoscopy in the Intensive Care Unit.
MR|magnetic resonance|MR|192|193|ASSESSMENT AND PLAN|We will also get MR angiogram of the neck and head vessels, as well as do an MRI of the brain. Pending this workup, a decision will be made as to whether to add Plavix to this regimen. If the MR angiogram shows significant narrowing of the carotid arteries, then we will have Vascular Surgery consultation. I think in the differential at this time is also a peripheral nerve problem, namely some type of entrapment syndrome from the elbow distally.
MR|magnetic resonance|MR|218|219|PHYSICAL EXAMINATION|He was able to walk without difficulty, there was no Romberg sign, and in fact no focal or lateralizing neurologic findings. Subsequent MR studies included an MRI of the brain, MR angiogram of the circle of Willis and MR angiogram of the carotids in the neck. His brain MRI was normal with a normal diffusion scan, vessels in the circle of Willis and carotids were widely patent, with no evidence of stenotic disease or changes.
MR|mitral regurgitation|MR,|233|235|OPERATIONS/PROCEDURES PERFORMED|DISCHARGE DIAGNOSIS: Myocarditis. OPERATIONS/PROCEDURES PERFORMED: Procedures performed while the patient was in the hospital: 1. Echocardiogram showing mildly decreased left ventricular function, hypokinetic inferior segment, trace MR, normal right side, and negative bubble study with mild left ventricular dilatation. This was done on _%#MM#%_ _%#DD#%_, 2006. 2. The patient also had a coronary angiogram performed on _%#MM#%_ _%#DD#%_, 2006, for chest pain and positive troponin and elevated CK-MB.
MR|magnetic resonance|MR|125|126|FINAL DISCHARGE DIAGNOSES|FINAL DISCHARGE DIAGNOSES: 1. Two small strokes in right cerebellum, one measuring 1.5 cm and the other measuring 8.0 mm. A. MR angiogram shows short segment high-grade stenosis over a 7 mm length with maximum stenosis in the 80% range. All other blood vessels in the circle of Willis and in the extracranial circulation were normal on MRA scanning.
MR|magnetic resonance|MR|129|130|ADMISSION LABS|No evidence of infarct was noted. MRA of the head showed a widely patent superior sagittal sinus with no evidence of thrombosis. MR venogram was therefore normal. The patient was seen in consultation by neurosurgery and thought to have a right falcine subdural hematoma versus apparent parenchymal bleed which may have been traumatic in nature.
MR|magnetic resonance|MR|153|154|ASSESSMENT AND PLAN|She has actually had a similar presentation before. She was worked up extensively in _%#MM2005#%_. MRI of the brain showed old infarct and some atrophy. MR angiogram of the head and neck vessels showed minimal atherosclerosis. Echocardiogram at that time showed normal ejection fraction, with no evidence of atrial septal defect or intracardiac clot.
MR|mitral regurgitation|MR,|148|150|PROCEDURES PERFORMED|ADMISSION/DISCHARGE DIAGNOSIS: Congestive heart failure. PROCEDURES PERFORMED: 1. Cardiac echo, which showed EF of 55%, diastolic dysfunction, mild MR, moderate TR, mildly dilated left ventricular and left atrium, unchanged from previous echos. 2. Upper extremity doppler ultrasound, which did not show any evidence for deep venous thrombosis or any arterial flow impairment.
MR|mitral regurgitation|MR.|160|162|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Mitral valve replacement, _%#MM#%_ 2002, secondary to endocarditis. 2. Coronary artery disease. Angiogram in _%#MM#%_ 2002 revealed 3+ MR. Inferior basal hypokinesis. EF 50-55%. Mild to moderate LAD and left circumflex disease. Moderate to severe RCA. 100% occlusion of PL branch of distal RCA.
MR|mitral regurgitation|MR,|270|272|HOSPITAL COURSE|HOSPITAL COURSE: Ultimately he was admitted to the hospital where he had a CT of the chest showing no evidence of pulmonary emboli, large pleural effusions and cardiomegaly. Echocardiography showed a decreased ejection fraction visually approximated at 20-25% with mild MR, mild TR and diastolic dysfunction of the LV. There was mild LVH. There was mild left atrial enlargement. His diagnosis of heart failure led to initiation of a heart failure program, including transient Lasix and then Spironolactone 12.5 mg a day.
MR|magnetic resonance|MR|160|161|PAST MEDICAL/SURGICAL HISTORY|Dr. _%#NAME#%_ from Colorectal Surgery thought that the ischemic colitis is due to decreased blood flow from high IMA ligation. Dr. _%#NAME#%_ will consider an MR angiogram in the future if his symptoms worsen. REVIEW OF SYSTEMS: He complained of orthopnea, paroxysmal nocturnal dyspnea, and dyspnea on exertion.
MR|magnetic resonance|MR|252|253|HOSPITAL COURSE|Minnesota Gastroenterology was consulted early on as well. His initial CT scan showed what looked like a cecal mass but noninflamed appendix. Colonoscopy demonstrated ulceration in the ascending colon and pathology suggested this was ischemic colitis. MR angiogram, however, demonstrated some slight narrowing at the origin of the celiac artery but otherwise everything was widely patent.
MR|magnetic resonance|MR|179|180|HISTORY OF PRESENT ILLNESS|Over the course of the last few months she has had extensive workup at outside hospitals including upper endoscopy, CT abdomen, chest, pelvis with contrast, abdominal ultrasound, MR of her brain and all of these studies were normal. She also had cholecystectomy in _%#MM#%_. Her appetite has been good however it has been difficult eat secondary to nausea and she has had 20-pound weight loss since _%#MM#%_ of 2006.
MR|magnetic resonance|MR|132|133|ADDENDUM|ADDENDUM: The patient was held in the hospital one additional day for headache and Neurology consultation. The patient underwent an MR venous circulation, which was negative for any clot or venous obstruction on _%#MMDD2007#%_. She underwent an MRI of her cervical spine on _%#MMDD2007#%_, which showed some very mild/minimal annular disk bulges at C4-5, C5-6, C6-7 as well as T3-4 and T4-5.
MR|magnetic resonance|MR|186|187|DIAGNOSTIC STUDIES|2. Brain MRI done _%#MMDD2007#%_. Formal reading is pending. Preliminary review by me revealed small T2 white matter hyperintensities, but no diffusion abnormality and no abnormality by MR angiography of the carotid, vertebral, or Circle of Willis vessels. 3. Transthoracic echocardiogram performed. Results are pending. 43. Chest x-ray on _%#MMDD2007#%_: Negative.
MR|mitral regurgitation|MR,|223|225|HOSPITAL COURSE|She will be changed to oral antibiotics on _%#MMDD2003#%_, assuming she continues to improve. Blood cultures are negative to date. Ms. _%#NAME#%_ had a cardiac echo in _%#MM2003#%_, showing a normal ejection fraction, mild MR, mild pulmonary hypertension, and left atrial enlargement. Consideration could be given to a CT of the abdomen and pelvis, should she have recurrent issues with edema and cellulitis.
MR|magnetic resonance|MR|146|147|PAST MEDICAL HISTORY|He was diagnosed by Dr. _%#NAME#%_ when an MRI of his brain showed acute nonhemorrhagic infarct in the left cerebellar hemisphere. He also had an MR angiography of the circle of Willis done at the same time, which showed an anatomic variant of a hypoplastic A-1 segment but no evidence for vertebral basilar stenosis or thrombosis.
MR|magnetic resonance|MR|218|219|FOLLOW UP|He was seen locally at the _%#CITY#%_ Hospital. CT of the head was obtained demonstrating no abnormalities. Spinal tap was obtained demonstrating no abnormalities (two red cells). Subsequently an MRI of the brain with MR angiography was also obtained. This study has been read as normal. The patient still feels some numbness and tingling on the left side.
MR|magnetic resonance|MR|146|147|SUMMARY OF HOSPITAL COURSE|She had a history of fairly significant alprazolam use. This medication was stopped. She had a single non-focal seizure. Neurology was consulted. MR on CT scanning was really unremarkable. EEG was also obtained. Results are pending. She seemed to be having difficulty orienting to reality and was noted to have hallucinations.
MR|mitral regurgitation|MR,|152|154|DIAGNOSES|DIAGNOSES: 1. Left lower lobe pneumonia. 2. Severe ischemic cardiomyopathy with ejection fraction of 30%. 3. Moderate to severe aortic stenosis, severe MR, severe TR, severe PR. Ms. _%#NAME#%_ was an 81-year-old female who was admitted with increased shortness of breath and orthopnea.
MR|magnetic resonance|MR|120|121|HISTORY OF PRESENT ILLNESS|He apparently was felt to have left vertebral artery dissection diagnosed by MR angiography and was started on heparin. MR angiography of the neck was suggestive of either left vertebral dissection vs artifact, therefore a formal angiogram was obtained and no evidence of dissection was found.
MR|magnetic resonance|MR|338|339|HOSPITAL COURSE|The patient was admitted for further evaluation and treatment. HOSPITAL COURSE: The patient was paced placed on Plavix and his symptoms subsided with only mild residual left upper and lower extremity dysmetria, mild left pronator drift, and mild left facial droop. He also had a slight problem with gait ataxia. He already had previously MR angiograms of the brain and neck at the _%#CITY#%_ Hospital which were unremarkable, thus, the only additional test in addition to the repeat MRI at this point was a transesophageal echocardiogram which revealed left ventricular hypertrophy but normal valves intact atrial septum with negative bubble study.
MR|magnetic resonance|MR|149|150|HISTORY OF PRESENT ILLNESS|During this hospitalization, he had an MR angiogram of the head and neck which was negative. He had normal renal ultrasound, the abnormal CT, had an MR of the head which showed recent infarct of left central pons area. He had an echocardiogram which showed no source of embolism.
MR|magnetic resonance|MR|271|272|HISTORY OF PRESENT ILLNESS|The details of that visit are not known but the patient was sent for an MRI which showed a recent infarct in the periventricular white matter and superior occipital horn of the left lateral ventricle, and old infarct in the right frontal periventricular white matter. An MR from _%#MMDD2001#%_ had shown right basal ganglia infarcts and periventricular infarcts. Dr. _%#NAME#%_ told the daughter to bring the patient to the Emergency Room to admit him to further evaluate his multiple problems.
MR|mitral regurgitation|MR.|127|129||She has had aortic gradient recheck by ultrasound that was 12.5 mm mean gradient with thus mild AS. Also had mild AI, and mild MR. She has had a previous cardiac echocardiogram which did not show abnormalities other than LVH and RVH. In the hospital present visit she underwent carotid ultrasound which showed minimal plaque at the bifurcation of the arteries.
MR|magnetic resonance|MR|246|247|IMAGING STUDIES|IMAGING STUDIES: 1. Chest x-ray obtained _%#MMDD2002#%_ results: Mildly elevated cardiac silhouette unchanged from previous study. Questionable cephalization consistent with early heart failure, poor inspiratory effort, no infiltrate. 2. Cardiac MR results: No evidence of infiltration. Ejection fraction estimated at 43%. Possible wall motion abnormality in the anterior lateral wall. HOSPITAL COURSE: Briefly, this is a 24-year-old male with a past medical history of tuberous sclerosis who presents with several day history of chest pain.
MR|magnetic resonance|MR|141|142|RADIOGRAPHIC STUDIES|CONSULTATIONS: Surgery and Neurology. RADIOGRAPHIC STUDIES: MRI/MRA of head - normal appearing brain with no focal white matter lesions. The MR angiogram is negative. No vasculitis was identified. DISCHARGE LABS: ESR discharge of 22, rheumatoid factor less than 20, TSH 0.45, electrolytes are normal.
MR|mitral regurgitation|MR|203|204|HISTORY/HOSPITAL COURSE|This was done with some anxiety as she had a history of diabetes and renal insufficiency. Cardiac catheterization was performed on _%#MMDD2004#%_. Ejection fraction was approximately 45%. No significant MR was noted. During the procedure, the patient developed worsening respiratory distress, pulmonary edema, and needed to be intubated. Patient received an extensive coronary intervention with a total of 550 cc of dye.
MR|magnetic resonance|MR|252|253|PLAN|PLAN: Will admit her, hydrate her, correct her hypokalemia, get a flat and upright of the abdomen and chest x-ray today and then get a pelvic ultrasound tomorrow. I would like to hold on using any IV contrast; in fact, we may have to go with abdominal MR scan to look at this further. The other thing is to probably set her up for a formal pelvic exam, as I have just done a bimanual through the rectum; however, that may not be necessary on the basis of what the ultrasound shows.
MR|magnetic resonance|MR|125|126|IMPRESSION|For now, we will proceed as follows: 1. Start Plavix in addition to aspirin 2. Hold hormone replacement therapy 3. Obtain an MR angiogram with the great vessels of the neck. 4. Obtain an echocardiogram. If this is negative then obtain a transesophageal echocardiogram.
MR|magnetic resonance|MR|152|153|HOSPITAL COURSE|His initial CT scan was unremarkable with the exception of a large amount of fecal matter in the colon. He received Fleet's enemas and underwent an MRI MR angiogram of his abdomen to rule out bowel ischemia. Lactic acid level was normal and the MRI scans were normal as well.
MR|magnetic resonance|MR|144|145|ASSESSMENT AND PLAN|We will also add intravenous Ativan and Benadryl for nausea as needed. We will place on deep venous thrombosis prophylaxis. We will arrange for MR CT to further evaluate and obtain general consult. We will also start on empiric intravenous proton pump inhibitors and antibiotic therapy for now.
MR|magnetic resonance|MR|134|135|PLAN|He will continue on aspirin but we will add Plavix and continue his blood pressure management. I am going to get MRI of the brain and MR angiography of the circle of Willis as well as a carotid ultrasound and transthoracic echocardiogram to evaluate this fully.
MR|mitral regurgitation|MR.|196|198|DIAGNOSTIC STUDIES|ReoPro given. Cypher stent placed in LAD. 6. Echocardiogram dated _%#MM#%_ _%#DD#%_, 2005: Mildly decreased LVEF 50%. Moderate region of hypokinesis involving the apical and septal segments. Mild MR. Mild LAE. Mild TR. RV systolic pressure 36, greater than RAP. 7. Echo dated _%#MM#%_ _%#DD#%_, 2005: Normal global systolic LV function.
MR|magnetic resonance|MR|143|144|HISTORY OF PRESENT ILLNESS|Lupus inhibitor was negative. Protein C and protein S were normal. ANCA is pending. ENA was negative. Lyme's screen was negative in the serum. MR angiogram of the head and neck were unremarkable. Chest x-ray was negative. Cerebral spinal fluid angiotensin converting enzyme was normal. White cell count was 1, red cell count was 0.
MR|mitral regurgitation|MR.|124|126|FOLLOWUP|2. He was followed up with cardiology as per arranged. His last echo had been on _%#MMDD2007#%_ and showed mild AI and mild MR. It has been a pleasure to be involved in the care of this patient.
MR|magnetic resonance|MR|139|140|CONSULTATIONS|2. MRA of the head which was limited secondary to the patient's motion and therefore difficult to exclude intracranial stenosis but normal MR angiogram. 3. CT of the chest showed marked elevation of the right diaphragm with bibasilar atelectasis, greater on the right than the left.
MR|magnetic resonance|MR|210|211|HOSPITAL COURSE|MRI scanning of the brain was subsequently performed disclosing evidence of a moderate to large nonhemorrhagic infarct, both in the left posterior frontal and left parietal lobe. His left carotid artery on the MR angiogram revealed either very proximal high-grade stenosis or more likely occlusion. 80-90% stenosis of the right internal carotid artery was also identified.
MR|magnetic resonance|MR|231|232|PAST HISTORY|By the time she got to the emergency room, she developed left-sided facial drooping and had some slurring of speech but no alteration of consciousness or inappropriate behavior. At the emergency room, she got CT scan, MRI and MRA, MR diffuse of the head and head, all of which were reported by radiology as normal. All of her blood work including basic metabolic panel, INR, sed rate, D-dimer evaluation, white count, hemoglobin, urinalysis were normal.
MR|magnetic resonance|MR|122|123|HOSPITAL COURSE|Duplex carotid ultrasound showed mild to moderate disease with a 50 to 69% stenosis of the right internal carotid artery. MR angiography did not show any significant flow- limiting lesions. Cardiac disease risk factor modification was discussed. The patient was not previously on an aspirin tablet and therefore was discontinued on aspirin.
MR|mitral regurgitation|MR|229|230|HOSPITAL COURSE|The patient is a 63- year-old male admitted by Dr. _%#NAME#%_ after being seen in _%#CITY#%_ _%#CITY#%_ with new-onset chronic heart failure with an EF of 20% to 25% on echo, and global dysfunction. The patient also had moderate MR and pulmonary hypertension, as noted above. He has no previous coronary artery disease history, however had a history of hypertension.
MR|mitral regurgitation|MR|323|324|HISTORY OF PRESENT ILLNESS|Electrocardiogram showed sinus rhythm with a rightward axis, low voltage QRS, and decreased PR segment in II, III and AVF. The patient had cardiac echo done which showed chamber sizes within normal limits, trileaflet aortic valve, LV systolic function within normal limits with an estimated ejection fraction of 60%, trace MR and a small to moderate pericardial circumferential effusion with some respiratory variation, estimated size 1.3 cm to 1.5 cm. The patient does report that she had taken a little ibuprofen at home and did have some improvement of her symptoms.
MR|mitral regurgitation|MR,|274|276|PROCEDURES PERFORMED|DIAGNOSIS: Coronary artery disease. PROCEDURES PERFORMED: 1. Transthoracic echocardiogram on _%#MMDD2003#%_, showing diffuse hypokinesis with ejection fraction of 10 to 15%, pulmonary artery pressure of 52, plus right atrial pressure, mild left ventricular dilatation, mild MR, mild left atrial enlargement, mild right atrial enlargement, and trace tricuspid regurgitation. 2. Coronary angiography on _%#MMDD2003#%_, showing a left main with 25% stenosis lesion of circumflex, which was occluded, and right coronary artery that showed in-stent restenosis with a lesion of 75% to 90%.
MR|magnetic resonance|MR|202|203|ASSESSMENT AND PLAN|The scan was normal except for irregular protrusions into the lateral ventricles bilaterally. An MRI scan was reviewed. The study showed multiple excrescences into the ventricular system. These had the MR characteristics of gray matter. There was also an area of T2 hyperintensity in the right frontoparietal cortex, as well as thickening of the pachymeninges over the same area.
MR|magnetic resonance|MR|155|156|IMAGING STUDIES|Subsequent MRA of the brain shows large nonhemorrhagic right middle cerebral artery territory infarct, cerebral atrophy, and old right cerebellar infarct. MR angiogram of the neck. Chest x-ray shows infiltrate in the mid and lower lung fields on the left with leftward shift mediastinum.
MR|magnetic resonance|MR|151|152|SUMMARY|SUMMARY: We have a woman who may have had a TIA or seizure last night causing decreased level of consciousness. We will get an MRI of her brain and an MR angiogram of the circle of Willis. Will check an EEG. We will follow up with her after she has had a chance to have these tests performed.
MR|mitral regurgitation|MR,|199|201|PROCEDURES|7. Hyponatremia secondary to fluid overload. PROCEDURES: 1. Echocardiogram which showed ejection fraction of 50%, ascending artery also mildly enlarged measuring around 4 cm, there is trace and mild MR, trace TR. 2. Chest x-ray which was consistent with congestive heart failure with probable left pleural effusion. CONSULTATIONS: None. HISTORY: _%#NAME#%_ _%#NAME#%_ is an 83-year-old, white female with past medical history significant for coronary artery disease, history of congestive heart failure, history of chronic obstructive pulmonary disease, who presented to the Emergency Room complaining of increasing shortness of breath, orthopnea and differential walking secondary to dyspnea on exertion.
MR|magnetic resonance|MR|111|112|FOLLOW UP|She was given Dilaudid in the Emergency Room, MRI scanning of the brain including a diffusion scan was normal, MR angiography of the cervical vessels was normal and MRI scanning of the circle of Willis was normal. Because her symptoms were persistent, Dr. _%#NAME#%_ suggested she be transferred to a hospital with a neurologist and she was transferred to Fairview Southdale Hospital the morning of _%#MMDD2006#%_.
MR|mitral regurgitation|MR,|263|265|HISTORY|I do see that he had a follow-up echocardiogram in 2004 that showed ejection fraction now down to 30-35% left ventricle was severely enlarged to 75 mm. The RV was enlarged RV systolic function was mildly reduced. There is biatrial enlargement. There was moderate MR, mild to moderate TR, mild aortic regurgitation. The patient apparently has been having chest pain on and off for a week, he did not initially tell family then last night at 11:00 p.m. it became much worse.
MR|mitral regurgitation|MR|176|177|HISTORY|Preliminary cardiac echo has been done which shows an EF that is normal at 55%, with akinetic inferior base and LVH. He has AS and 1+ AI with valve area preliminary of 0.8. 2+ MR is noted with some pulmonary hypertension as well. It was felt likely diastolic dysfunction was the cause of his symptoms.
MR|magnetic resonance|MR|222|223||Symptomatology includes nausea and vomiting, dysphagia, dizziness, left arm abnormal sensation, right arm ataxia, and diplopia. He had an MRI done prior to admission, which confirmed a right lateral medullary infarct. His MR of his brain also showed more chronic infarcts located in the basal ganglia region. Video swallow study had aspiration even on honey thick liquid and was made NPO.
MR|medical record|MR|157|158|HISTORY OF PRESENT ILLNESS|The history was obtained primarily from wife and from the medical record as the patient was not able to give history at the time of admission. Review of the MR indicated at the time of admission that the patient had chronic kidney disease and since _%#MM2006#%_ the renal function had been getting worse.
MR|magnetic resonance|MR|209|210|HISTORY OF PRESENT ILLNESS/SUMMARY OF ACUTE REHABILITATION STAY|LP tap at that time revealed what appeared to be a subarachnoid hemorrhage. She was transferred to the University Hospitals for further evaluation. Extensive evaluation by neurosurgery including CT angiogram, MR venogram, MR angiogram and digital subtraction angiogram were undertaken. There were no significant findings except for 2 areas in the bifrontal region that was thought to have imaging findings representative of small hemangiomas.
MR|magnetic resonance|MR|220|221|HOSPITAL COURSE|She was admitted for further evaluation. HOSPITAL COURSE: The patient was stable throughout her hospitalization. She showed no dramatic increase or decrease in her weakness. Neurology was consulted and suggested further MR imaging of the brain and C-spine. This disclosed a pontine infarct, which was apparent explanation for her increased weakness according to Dr. _%#NAME#%_.
MR|mitral regurgitation|MR,|297|299|HOSPITAL COURSE|She also had bilateral carotid Dopplers which showed less than 50% diameter stenosis of both internal carotid arteries and an echocardiogram done during this admission was also within normal limits with a normal ejection fraction of 60-65%, trace to mild AI with minimally sclerotic valves, trace MR, trace TR and trace PR. No clots were noted within the atrial chamber. The right ventricular systolic pressure was slightly elevated consistent with mild pulmonary hypertension.
MR|mitral regurgitation|MR,|343|345|PAST MEDICAL HISTORY|MEDICATIONS ON ADMISSION: 1. Combivent 2 puffs daily. 2. Spiriva 1 capsule inhalation daily. 3. Medrol 60 mg p.o. daily. PAST MEDICAL HISTORY: High blood pressure, allergic rhinitis, question asthma, episode of bronchitis, _%#MM2007#%_, CHF with moderate left ventricular dysfunction, EF of 40% in _%#MM2007#%_ with diffuse hypokinesis, trace MR, trace TR. REVIEW OF SYSTEMS: Review of systems on admission positive for chest pain as described above.
MR|magnetic resonance|MR|135|136|FOLLOW-UP|I will ask her to see Dr. _%#NAME#%_ after that to determine if any additional changes are made. Again, we will be doing an outpatient MR angiogram, and she will need a follow-up with Dr. _%#NAME#%_ regarding thyroid, blood pressure, cholesterol, etc.
MR|magnetic resonance|MR|136|137|ASSESSMENT AND PLAN|She should be making sure she is getting her mammograms yearly. If she has a lot of density in the breast, she should have at least one MR to make sure that there is not something that is unusual there. I will see her again on a p.r.n. basis.
MR|mitral regurgitation|MR|332|333|HOSPITAL COURSE|While hospitalized, he underwent EGD and small bowel follow-through, both negative. No specific reason for his melena was found. With regard to episode of ventricular tachycardia, the patient's echocardiogram demonstrated a low normal ejection fraction of 50% with biatrial enlargement, myxomatous changes in mitral valve with mild MR and TR and mild aortic stenosis. Outpatient stress thallium test was scheduled on discharge. The patient also reported having some blood from the tip of his penis.
MR|mitral regurgitation|MR.|203|205|DISCHARGE DIAGNOSIS|OPERATIONS/PROCEDURES PERFORMED: 1. Transthoracic echo was performed on _%#MM#%_ _%#DD#%_, 2005, which showed severely decreased LV function with visually estimated EF of 10%. Severe LV dilation. Severe MR. RV systolic pressure was 41 above right atrial pressure. Severe TR. Moderate pulmonary regurgitation. Small pericardial effusion. 2. Right heart catheterization performed on the _%#MM#%_ _%#DD#%_, 2005, showed elevated RA, RV, PA, and pulmonary capillary wedge pressure.
MR|magnetic resonance|MR|117|118|IMPRESSION|He does not have a history of hypertension, though he does have diabetes. I would like to do an MRI of the brain and MR angiography to make sure that there is no underlying lesion here. We will also check an echocardiogram. We will check a urine culture given his abnormal UA.
MR|mitral regurgitation|MR.|254|256|MAJOR IMAGING AND PROCEDURES|1. Chest x-ray shows small area of radiolucency in the apical region of the left lung, likely due to a cyst, otherwise clear lungs. 2. Dobutamine echo shows no resting or stress infarct or ischemia at inadequate heart rate, mitral valve prolapse without MR. BRIEF HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 49-year-old female with no previous cardiac history and risk factors of smoking and family history who presents with a very atypical right-sided rib pain for the past 3 weeks.
MR|magnetic resonance|MR|154|155|NEUROLOGY IMPRESSION|Neurology also saw him today and felt that patient was doing well as he is now walking to the bathroom with his IV and pole. No back pain. They felt that MR of his brain showed old ischemic changes only. His carotids had stenosis right greater than left but not likely related to yesterday's symptoms.
MR|magnetic resonance|MR|185|186|PLAN|Probably the sequelae of arteriosclerotic disease. He has arthrosclerotic disease of the right carotid bifurcation with 50% stenosis of the right internal carotid artery at its origin. MR angiography of the Circle of Willis showed 50% stenosis at the right posterior cerebral artery, estimated portion. Echocardiogram did not show any evidence for embolism or source of emboli.
MR|magnetic resonance|MR|147|148|HISTORY OF THE PRESENT ILLNESS|Mrs. _%#NAME#%_ _%#NAME#%_ is a 58-year-old right-handed white female with a diagnosis of left frontal glioblastoma, status post brain biopsy with MR guidance on _%#MM#%_ _%#DD#%_, 2002. Patient was transferred from Fairview-University Medical Center to Fairview Transitional Care for rehabilitation.
MR|magnetic resonance|MR|239|240|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. AV node ablation/DDDR pacemaker _%#MM2002#%_ due to supraventricular arrhythmias associated with near syncope. 2. Right carotid endarterectomy _%#MM2002#%_. 3. Left carotid artery disease with a 70-80% stenosis by MR angiogram _%#MM2002#%_. 4. Supraventricular tachycardias including atrial fibrillation. 5. Mild memory impairment. 6. Elevated PSA. He recently was in the 7.75 range.
MR|magnetic resonance|MR|189|190|HOSPITAL COURSE|Subsequent workup included MRI imaging of the brain which confirmed acute ischemic injury in the left middle cerebral territory with mild mass effect consistent with incomplete infarction. MR angiography revealed a 99% critical stenosis of the proximal left internal carotid artery with otherwise unremarkable vessels elsewhere and intracranially.
MR|mitral regurgitation|MR.|258|260|DISCHARGE DIAGNOSES|7. Hyperlipidemia. 8. Cytomegalovirus infection. 9. Right pleural effusion. 10. Atrial fibrillation, on chronic anticoagulation. Last echocardiogram, TEE, _%#MM2007#%_, moderately dilated LV, normal ejection fraction (55-60%), RV structure normal and severe MR. Last right heart catheterization in _%#MM2007#%_, right atrium _____, PA 45, wedge 18, cardiac output 5.5 and cardiac index 2.8. Left heart catheterization in _%#MM2007#%_, normal coronaries.
MR|mitral regurgitation|MR,|144|146|PAST MEDICAL HISTORY|This was diagnosed in _%#MM#%_ with an echocardiogram at the University. He presented with mild CHF. He was also found to have mild to moderate MR, moderate left atrial enlargement, mildly dilated right ventricle with right ventricle systolic pressure of 38+ RA and a mildly to moderately dilated left ventricle.
MR|magnetic resonance|MR|137|138|HISTORY OF PRESENT ILLNESS|In addition to antibiotic therapy, twice a day dressing changes with new gauze and Bactroban were recommended. Scanning of the foot with MR modality did not suggest any deep abscess and no evidence of retained foreign body was noted. The patient underwent ultrasound evaluation of the peripheral arterial supply in the left leg demonstrating narrowing at the femoral and popliteal sites in both legs with reduction in flow at the trifurcation level as well on the left.
MR|mitral regurgitation|MR,|273|275|ECHOCARDIOGRAM|HEART CATHETERIZATION: Not done this hospitalization as not indicated. ECHOCARDIOGRAM: Done on _%#MMDD2005#%_, which showed normal LV size and systolic function. No wall motion abnormalities. No mild increase in LV wall thickness. It did show severe TR, moderate to severe MR, and some mitral valve prolapse in the exterior leaflet. Moderate RV enlargement, severe biatrial enlargement, small posterior loculated pericardial effusion, small right pleural effusion, and estimated LV ejection fraction of 65-70%.
MR|magnetic resonance|MR|180|181|PHYSICAL  EXAMINATION|LUNGS are clear to auscultation. HEART: Sounds were unrevealing. No cervical bruits are heard. ABDOMEN is nontender. Admission labs reveal a normal CBC and chemistry panel. He had MR scans of his brain, cervical, thoracic and lumbar spine and all felt to be unrevealing. IMPRESSION: I suspect that this may not be a neurogenic issue in terms of his left-sided weakness.
MR|magnetic resonance|MR|152|153|DISCHARGE  MEDICATIONS|It is important to note that the patient has been worked up for causes of secondary hypertension as he has a nearly 15-year history of hypertension. An MR angiogram that was performed after discharge from his last hospitalization did not show evidence of renal artery stenosis. He does not have any evidence of aldosterone or renin-producing endocrinopathies.
MR|magnetic resonance|MR|334|335|HOSPITAL COURSE|She had carotid ultrasound which was normal. She had an MRI/MRA of her brain which showed one 5 mm potential abnormal focus of contrast enhancement in the inferior medial right temporal lobe seen only on a single image. Incidental small venous angioma in the right posterior frontal region. Remainder of the brain is negative. Normal MR angiogram of the intracranial vessel. The patient had follow-up thin sliced, pre and post contrast coronal and post contrast axial images for the area of possible abnormal enhancement in the right inferior frontal medial temporal region.
MR|mitral regurgitation|MR,|179|181|PHYSICAL EXAMINATION|NECK: Supple without lymphadenopathy LUNGS: Clear. BACK: Is straight and non-tender. HEART: Reveals a regular rate and rhythm with a III/VI apical systolic murmur consistent with MR, (no change). ABDOMEN: Soft, nondistended, and diffusely mildly tender. Her cholecystectomy scars are clean. NO rebound or tenderness. Bowel sounds are present. EXTREMITIES: Reveal no edema.
MR|mental retardation|MR|146|147|REVIEW OF SYSTEMS|She obviously has respiratory troubles. She has been coughing somewhat. She has chronically had severe contractures of her musculature and severe MR complicating assessment of her neurological and cognitive states since birth. No known abnormalities from ER evaluation of fluids and metabolites besides glucose metabolism and acid base status.
MR|mitral regurgitation|MR|197|198|OPERATIONS/PROCEDURES PERFORMED|The patient also had a transesophageal echo of her heart that showed normal left ventricular function, moderate to severe left atrial enlargement, moderate to severe right atrial enlargement, mild MR left pleural effusion. There was no valvular vegetation identified. The patient also had a chest x-ray done on _%#MM#%_ _%#DD#%_, 2002, that showed a small left pleural effusion by humeral head prosthesis.
MR|mitral regurgitation|MR|157|158|PROBLEMS|He did undergo a cardiac echo on _%#MMDD2007#%_ which showed severe 4+ MR with a mildly dilated LV, and an EF of 60-65% with pulmonary hypertension present. MR was worse compared with 1999. He was seen in consultation by Dr. _%#NAME#%_ and Dr. _%#NAME#%_ and Lasix was initiated this admission.
MR|magnetic resonance|MR|146|147|FOLLOWUP APPOINTMENTS AND REFERRALS|We will discuss means for imaging the vascular system with the Vascular Neurology and Neuroradiology services. The patient is not a candidate for MR angiography because of his pacemaker and CT angiography would require a larger dye load than selective angiography.
MR|magnetic resonance|MR|146|147|HISTORY OF PRESENT ILLNESS|There was also some language disturbance at that time. It resolved after 30 minutes. Her workup included an MRI of the head, which was normal. An MR angiogram showed paraglenoid aneurysm. She was referred for additional workup with cerebral angiogram revealing a small left ICA median paraclinoid aneurysm, another small right ICA median paraclinoid aneurysm and a bulge of the right PCA P1.
MR|magnetic resonance|MR|165|166|HISTORY OF PRESENT ILLNESS|He had a flaccid hemiplegia and anesthesia over his left arm, face, trunk and leg. CT scanning of the brain was done which was normal. MRI scanning of the brain and MR angiography was done which I reviewed and also appears normal. Lumbar puncture was performed reflecting evidence of normal CSF with 4 white cells, no red cells, gram stain negative, protein 51, glucose 60.
MR|mitral regurgitation|MR.|172|174|PROCEDURES|There was severe tenting of the mitral valve which restricted motion of the posterior mitral leaflet. This was associated with severe eccentric posteriorly directed jet of MR. 4. Transthoracic echocardiography dated _%#MM#%_ _%#DD#%_, 2006. This study was consistent with the findings from previous echocardiograms including severe MR, mild AI, and moderate TR.
MR|magnetic resonance|MR|200|201|OPERATIONS/PROCEDURES PERFORMED|ADMISSION DIAGNOSIS: Renal artery stenosis. DISCHARGE DIAGNOSIS: Renal artery stenosis. OPERATIONS/PROCEDURES PERFORMED: The patient had a study of a Captopril renogram, also abdominal ultrasound and MR angiogram of renal arteries. BRIEF HISTORY: The patient is a 27-year-old male status post a cadaveric kidney transplant on _%#MM#%_ _%#DD#%_, 2001, for end-stage renal disease secondary to membranous glomerulonephritis.
MR|magnetic resonance|MR|127|128|DISCHARGE SUMMARY|He had a bilateral carotid ultrasound which was found to be normal. His initial CT without contrast was negative. He underwent MR scan of his brain and circle of Willis MR angiogram which showed a normal brain, normal circle of Willis, MRA, mild nonspecific signal intensity in the tip of the right mastoid air cells.
MR|magnetic resonance|MR|218|219||Her gallbladder was without stones as well, and she just had a lot of scarring over the gallbladder and the gallbladder was removed. The patient had gone to surgery at that time for these indications found just on the MR cholangiogram, despite the fact that it was strongly recommended by everyone seeing her including her surgeon that she have an ERCP previously, but she refused it, and in view of that, her demands for surgery, and the fact that she did have a finding on her MR cholangiogram, we decided to proceed.
MR|mitral regurgitation|MR,|315|317|HOSPITAL COURSE|They did not find this very concerning and recommended consideration of an outpatient stress test and outpatient Holter monitor. Additionally, they recommended starting digoxin to control symptoms. Cardiac echo obtained during the hospital course showed a normal ejection fraction, mild LVH, moderate LAE, moderate MR, moderate RVE, moderate RAE, moderate TR, moderate increased right ventricular systolic pressure. PROBLEM #3: Chronic change right lung base on CT scan.
MR|mitral regurgitation|MR|149|150|LABORATORY DATA|EKG demonstrating RVH with right axis deviation. TEE _%#MMDD2006#%_, no vegetations. Patent foramen ovale. RV pressure 70-80. Normal EF. Significant MR and TR. Lower extremity Doppler _%#MMDD2006#%_, nonocclusive thrombus left lower extremity involving the common femoral, superficial, popliteal and one branch of the posterior tibial vein.
MR|magnetic resonance|MR|298|299|HOSPITAL COURSE|His workup included a MRI scan of the head. Although the MRI scan revealed no significant areas of ischemia, it was assumed based on the clinical symptoms that the patient presented with acutely that he undoubtedly did have a left brainstem stroke best localized to the dorsal lateral medulla. His MR angiogram did reveal 50% stenosis of the right RCA and left vertebral artery moderate stenosis. This was reviewed with the radiologist. There do not appear to be any characteristics to indicate other pathology, such as dissection.
MR|magnetic resonance|MR|158|159|STROKE RISK FACTOR WORKUP|Magnetic resonance imaging of the brain confirmed a stroke in the left MCA territory as well as a distal MCA artery occlusion consistent with these findings. MR angiography also showed an ulcerated moderate to sever stenosis of the left internal carotid artery. This was felt to be the cause of her stroke with an artery to artery embolization.
MR|magnetic resonance|MR|162|163|PLAN|Follow lipase. He may need an endoscopic retrograde cholangiopancreatography at some point to make sure he does not have a duplicated duct. He has had a previous MR cholangiogram and a CT scan showing the early pseudocyst formation. This may need to be followed also. Dr. _%#NAME#%_ will follow in the hospital.
MR|magnetic resonance|MR|189|190|ASSESSMENT|I do not think this is a malignant process or fracture as it does have a tendency to hurt all the time but Dr. _%#NAME#%_ has done a CT scan and is planning on doing another CT, I think an MR just to be sure there is no infiltrative process. Will also pick up a serum protein electrophoresis and sedimentation rate would be worthwhile.
MR|magnetic resonance|MR|135|136|HOSPITAL COURSE|This also showed mucosal thickening in the frontal sinus, ethmoid sinus, and left maxillary sinus. He also had a negative intracranial MR angiogram. The patient will follow up with his Parkinson's clinic, where he has been seen in the past, and his dizziness can be more fully evaluated at that time.
MR|mitral regurgitation|MR.|270|272|PROCEDURES PERFORMED|2. Echocardiogram performed _%#MMDD2003#%_ reveals mildly decreased LV function with an EF of 50%, moderate region of akinesis in the inferior posterior segments, mild left atrial enlargement at 5.6 cm, mild aortic dilation with maximal dimension of 4.1 cm, mild AR and MR. Compared to the previous echocardiogram in 1999, his chamber sizes have enlarged mildly, but other valvular and LV functions have been maintained as previous.
MR|mitral regurgitation|MR,|242|244|CHIEF COMPLAINT|There was a wide saphenous vein graft to the two OM vessels and the saphenous vein graft was occluded at its origin with no significant lesions previously noted in the RCA, although moderate disease is present. It was felt that he had severe MR, moderate pulmonary hypertension with recurrent heart failure due to the MR, and that the inferior wall was well perfused by the native RCA and the other territories well perfused by patent bypass grafts.
MR|magnetic resonance|MR|366|367|HISTORY OF PRESENT ILLNESS|PROCEDURES PERFORMED: Endoscopic resection of pituitary adenoma. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 44-year-old female with Cushing's disease who is status post transnasal hypophysectomy in the fall of 2006 who had continued Cushing's symptoms and an MRI suggestive of residual disease. She presents for endoscopic resection using intraoperative MR guidance. HOSPITAL COURSE: The patient was admitted on _%#MMDD2007#%_ and underwent the aforementioned procedure.
MR|mitral regurgitation|MR.|129|131|HOSPITAL COURSE|He also had a cardiac echo done which had normal LVF of an estimated EF of 55% but was noted to have moderate LVH and a trace of MR. It was a technically difficult study. The patient had labs done here with a sodium of 138. Potassium 4.1. Chloride 98. Bicarb 35. BUN 17. Creatinine 0.9. His TSH was also slightly low at 0.24. Reviewed sleep apnea symptoms with the patient and his wife.
MR|magnetic resonance|MR|195|196|HOSPITAL COURSE|He has had cardiograms which have shown sinus rhythm with first- degree AV blocks, and prolonged QT interval, with some lengthening of that, but no rhythm disturbance whatsoever. We have done an MR of the brain, and that shows moderate chronic white matter disease. There is a single tiny punctate area of diminished signal in the left posterior temporal lobe which could represent some white matter shearing injury.
MR|mitral regurgitation|MR,|358|360|HOSPITAL COURSE|HOSPITAL COURSE: The patient's laboratory studies revealed no evidence of a myocardial infarction, no evidence of pulmonary emboli, no evidence of pneumonia or pleural effusion, no evidence of mass in the chest and no evidence of constrictive pericarditis. Significant laboratory values on _%#MMDD2003#%_, a 2-D echo revealed ejection fraction of 60%, trace MR, TR, no shunts, no clots. _%#MMDD2003#%_ a chest x-ray revealed no PE, left deviation of left ventricle, lungs clear, no pleural effusion.
MR|mitral regurgitation|MR|195|196|HISTORY OF PRESENT ILLNESS|Chest x-ray revealed minimal ________ation and bilateral pleural effusions. She was seen by Cardiology consultation. The patient underwent an echocardiogram which revealed enlarged LV and severe MR with posterior leaflet that was flail and mild AS. The patient was subsequently transferred to Fairview-University Medical Center to undergo right and left heart catheterization.
MR|mitral regurgitation|MR|178|179|HISTORY OF PRESENT ILLNESS|These subsequently came down and currently she is not requiring any medication. The patient has a loud cardiac murmur and a cardiac echo shows IHSS. Transthoracic echo showed 2+ MR with an EF of 60% with LVH. Metoprolol was added this admission. As above a transesophageal echo was done which showed no evidence of endocarditis.
MR|magnetic resonance|MR|366|367|HISTORY OF PRESENT ILLNESS|MRI of the brain, several areas found of high-signal intensity in the right hemisphere; one 2-cm area of this sort in the right posterior frontal cortex, a second lesion in the right parietal area 3 cm, extending into the occipital region. There was also high-signal in the white matter of the right hemisphere. There were no other abnormalities identified, and the MR angiogram was unremarkable for the intracerebral arteries. Carotid ultrasound showed 50% to 69% stenosis of the left internal carotid artery and greater than 70% stenosis of the right internal carotid artery.
MR|magnetic resonance|MR|253|254||She had been hospitalized in _%#MM#%_ of 2004 for a similar concern, but the past few days prior to admission have gotten progressively worse. Workup was done, which showed that she had a right carotid bruit. She had those investigated. She then had an MR angiogram, which showed over 90% diameter stenosis of both right and left internal and external carotid arteries. Irregular tight stenosis of the distal left common carotid artery as well.
MR|magnetic resonance|MR|184|185|PLAN|5. Osteoporosis, on Fosamax. 6. Smoker. PLAN: 1. IV hydration. 2. The patient is to be n.p.o. except for ice chips. 3. GI consultation regarding possible flexible sigmoidoscopy versus MR angiogram. 4. Check liver function tests and lipase. 5. Pain and nausea control. 6. Levaquin and Flagyl empirically for now. 7. Stool culture and Clostridium difficile toxin.
MR|magnetic resonance|MR|176|177|HOSPITAL COURSE|Evaluation revealed a critical stenosis of the right anterior carotid artery with a moderate stenosis of the left. HOSPITAL COURSE: The patient was admitted on _%#MMDD2002#%_. MR angiogram confirmed a critical stenosis on the right with a moderate stenosis on the left. The patient was taken to the operating room and underwent a right carotid endarterectomy with external jugular vein-angioplasty.
MR|mitral regurgitation|MR,|257|259|HOSPITAL COURSE|This also could be an anginal equivalent, so she was started on Imdur 30 mg p.o. q.d. Cardiology did see her and she did obtain an Echocardiogram which on discharge, a preliminary revealed normal global left ventricular systolic function, moderate AI, mild MR, mild bilateral atrial enlargement and mild TR. An estimated RVSP was 31. They recommended that eventually attempting to stop the Nitroglycerin patches and increase the Metoprolol as her blood pressure and pulse tolerates.
MR|mitral regurgitation|MR|199|200|PROCEDURES PERFORMED|ADMITTING DIAGNOSIS: Chest palpitations. DISCHARGE DIAGNOSIS: AV nodal reentrant tachycardia. PROCEDURES PERFORMED: Transthoracic echocardiogram showing normal global left ventricular function, mild MR and an ejection fraction of 55%, with an estimated pulmonary artery pressure of 27 mmHg above mean right atrial pressure. HISTORY OF PRESENT ILLNESS: Fifty-two-year-old female with a history of hypertension and recurrent atrial fibrillation, who awoke on the morning of admission with nausea and palpitations.
MR|mitral regurgitation|MR|196|197|IMPRESSION|We will reverse her anticoagulation with 4 units of FFP and IV vitamin K, which was given in the Emergency Room. The patient will be monitored in the ICU because of her critical AS and her severe MR to help monitor her volume status very closely. I suspect her bleeding source is likely upper considering her previous EGDs.
MR|magnetic resonance|MR|178|179|PAST MEDICAL HISTORY|She has chronic mid to upper back discomfort. PAST MEDICAL HISTORY: 1. Syncope, _%#MM2003#%_. Evaluation included, I believe, a negative stress test, unremarkable event monitor, MR angiogram of the brain showing some small vessel changes and a negative carotid ultrasound. She did not have electrophysiologic study at that time.
MR|mitral regurgitation|MR.|297|299|3) MAC.|The patient also had an echocardiogram done; the official results are still pending at the time of this dictation, but the preliminary results are as follows: 1) Normal left ventricular ejection fraction with an estimated ejection fraction of 80%. 2) Left ventricular hypertrophy. 3) MAC. 4) Mild MR. 5) Biatrial enlargement. 6) Aortic valve sclerotic with mild AI 7) Trace PI. 8) Mild TR with an RVSP of 31 mmHg plus right atrial pressure.
MR|GENERAL ENGLISH|MR.|192|194|PLAN|2. Laboratory studies when the patient allows, to help assist renal and hepatic function. 3. CONTINUE DNR/DNI STATUS AS DISCUSSED DURING PREVIOUS HOSPITALIZATIONS. THIS PLAN IS DISCUSSED WITH MR. _%#NAME#%_ AND WITH HIS FAMILY.
MR|magnetic resonance|MR|174|175|PROCEDURE|ADMITTING DIAGNOSES: 1. Stroke. 2. Dementia. 3. Hypertension. DISCHARGE DIAGNOSES: 1. Mild stroke. 2. Dementia. 3. Hypertension. PROCEDURE: 1. Duplex carotid ultrasounds. 2. MR angiography. 3. MRI of brain. 4. CT scan of the head. PAST MEDICAL HISTORY/HISTORY OF PRESENT ILLNESS: Please see dictated H&P.
MR|mitral regurgitation|MR|319|320|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1: Non Q-wave MI/Coronary vasospasm. The patient was admitted with a bump in her troponin, and there was concern for an ongoing .....type of angina. She was placed on a heparin/nitro drip. She underwent an echocardiogram which demonstrated normal left ventricular systolic function with trace MR and TR with an estimated ejection fraction of 60 to 65%. On hospital day #1 she continued to complain of persistent ongoing chest pain despite the heparin/nitro drip.
MR|mitral regurgitation|MR,|215|217|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Essential thrombocytosis, the patient is presently taking hydroxyurea 1 gm p.o. q.d. 2. Paroxysmal atrial fibrillation. Recent echocardiogram showed a normal global systolic function, trace MR, and mild to moderate mitral valve calcifications. 3. Hypertension. 4. Questionable history of TIAs, small vessel ischemic disease on MRI _%#MMDD2003#%_.
MR|mitral regurgitation|MR,|230|232|PROCEDURES|PROCEDURES: 1. Cardiac echocardiogram. The results of this showed mild LV dilatation and mild increase in the LV wall thickness, normal systolic function, no regional wall abnormality, trace AR, mild left atrial enlargement, mild MR, and a normal right ventricular size and systolic function. 2. Right heart cardiac catheterization, which showed central venous pressure of 7, PA pressures of 22/2, pulmonary artery rest pressure of 6, with cardiac output of 5.1 with a cardiac index of 2.0. BRIEF HISTORY OF PRESENT ILLNESS: The patient is a 57-year- old male, with a past medical history significant for permanent pacemaker for complete heart block, hypertension, diabetes, obstructive sleep apnea, sarcoidosis, and questionable history of chronic obstructive pulmonary disease.
MR|mitral regurgitation|MR.|193|195|HOSPITAL COURSE|TSH was borderline low. Free T4 and Free T3's are pending at the time of dictation. The patient underwent a cardiac echo which showed a mild sclerotic aortic valve and borderline LVH and trace MR. This was otherwise unremarkable with an ejection fraction of 55-60%. No shunts or clots were seen. The patient was initially rate controlled with Cardizem drip and was given digoxin 0.5 mg.
MR|mitral regurgitation|MR|570|571|HOSPITAL COURSE|_%#NAME#%_'s cardiac ECHO during this hospital course showed moderate LV dilatations, severe decreased LV function with an ejection fraction of 25%, severe left atrial enlargement, severe mitral regurg, trace aortic regurg, mild right ventricular dilatation, mildly decreased right ventricular function, moderate right atrial dilation, severe tricuspid regurg, right ventricular systolic pressure moderately increased at 46 mmHg, small pericardial effusion compared to the previous study of _%#MM#%_ 2001, the right ventricular size is increased, function is decreased. MR on TR have worsened. We should consider repeating this ECHO after about 6-9 months. Creatinine was 1.42 on the day of discharge. Appropriate nutrition was strongly advised for the patient.
MR|magnetic resonance|MR|144|145|HISTORY OF PRESENT ILLNESS|She was then found to be complaining of left leg pain and was unwilling to move her left leg. Plane films were not felt to be remarkable but an MR is consistent with a nondisplaced left pubic ramus fracture. Orthopedic consultation was obtained. He recommended simply deep venous thrombosis prophylaxis of some kind and physical therapy.
MR|mitral regurgitation|MR|313|314|PROCEDURES PERFORMED|1. Coronary arteriography performed on _%#MMDD2004#%_, which revealed focal coronary artery disease with no hemodynamically significant lesions. 2. Transesophageal echocardiography performed on _%#MMDD2004#%_, which revealed mild to moderate LVH, normal LV size and function, normal valvular function, with trace MR and TRR, with an EF estimated at 60%. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 58-year-old African-American female with a history of type 2 diabetes and reported AV nodal reentrant tachycardia who initially presented to the _%#CITY#%_ Emergency Department on _%#MMDD2004#%_ with an odd sensation in her chest.
MR|mitral regurgitation|MR,|218|220|IMAGING STUDIES|Bilateral lower extremity Dopplers: No evidence of DVT. Echocardiogram to rule out thrombus showed normal LV function, ejection fraction of 60 percent, no regional wall motion abnormalities, mild concentric LVH, trace MR, trace AI. No stenosis. Trace TR. Trace TI. No pericardial effusion or thrombi. There was a mildly positive bubble study. PERTINENT LABORATORY STUDIES ON ADMISSION: Urinalysis negative.
MR|magnetic resonance|MR|130|131|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 65-year-old diabetic who has developed a nonhealing ulceration of his left 4th-5th web space. MR angiogram revealed occlusion of the trifurcation vessels with a probable reconstituted distal anterior tibial and posterior tibial artery. It was felt that revascularization was indicated. HOSPITAL COURSE: The patient was admitted on _%#MMDD2005#%_ where, under a spinal anesthetic, a left above-knee popliteal to distal anterior tibial nonreversed vein bypass graft was performed.
MR|mitral regurgitation|MR;|178|180|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: Atrial fibrillation; new onset. OPERATIONS/PROCEDURES PERFORMED: 1. Echocardiogram performed on _%#MM#%_ _%#DD#%_, 2005. Preliminary findings: Mild TR; mild MR; mild PI; no AI; mild aortic stenosis with AVA of 4.7 cm2; no wall motion abnormalities. EF is estimated at 65%. Official report is pending. HISTORY OF PRESENT ILLNESS: This is a _%#1914#%_ lady with a history of hypertension, and hyperlipidemia, and "borderline" diabetes who presented to the ED, after having complaints of chest tightness which started in the afternoon.
MR|magnetic resonance|MR|225|226|LABORATORY DATA|MRI of the brain with intracranial angiogram showed an area of high signal intensity in the region of the left internal capsule measuring about 2 cm in diameter and compatible with a recent lacunar type infarct. Intracranial MR angiogram was unremarkable. Carotid ultrasound scan showed no significant stenosis at either carotid bifurcation.
MR|magnetic resonance|MR|136|137|HOSPITAL COURSE|West Nile was also pending. HOSPITAL COURSE: PROBLEM #1: Intractable headaches. A Neurology consult was obtained, and they performed an MR venogram, which did not show any clot in the venous sinuses of the brain. She was treated with anti-emetics and narcotics with very little improvement in her pain.
MR|mitral regurgitation|MR|233|234|INDICATION FOR TRANSFER|In particular, she had severe hypo-akinesia of the anteroseptal apical, apical inferior and apical lateral walls with moderate hypokinesia other wall segments and the RV was mildly to moderately diminished. She had moderately severe MR and mild TR with right heart pressures at the upper limits of normal at 24 mmHg plus right atrial pressure. She had mild LVH and she had mild to moderate LA dilation.
MR|mitral regurgitation|(MR)|325|328|IMPRESSION|I have told her she may well get stenting or bypass surgery as needed or as directed by our best judgment from a cardiology standpoint in view of her MR and her diminished LV function. IMPRESSION: 1. Newly appreciated cardiomyopathy, likely rather gradual and progressive in nature. 2. Moderately severe mitral regurgitation (MR) by echo. 3. Left ventricular ejection fraction (LVEF) of 25-30% with wall motion abnormalities, as noted above involving the anteroseptal apical left ventricle.
MR|mitral regurgitation|MR|225|226|DOB|It is less than an ideal combination with the patient's severe aortic stenosis as outlined by her echocardiogram showing an aortic valve area of 0.5 cm squared, moderate TR, moderate pulmonary hypertension, moderately severe MR and an LVEF of 45 percent. At age _%#1914#%_ she was certainly not eager to consider anything like cardiac surgery.
MR|mitral regurgitation|MR,|146|148|HOSPITAL COURSE|The patient had ultrasound and it showed ejection fraction 45-50%, no obvious clots, hypokinetic base in mid inferior. Chamber size is normal, 2+ MR, trace TR, LVH. Angiogram was done which showed 95% occlusion of the RCA, 50% stenosis at the left circumflex, ejection fraction 40-45%.
MR|mitral regurgitation|MR|256|257|HISTORY OF PRESENT ILLNESS|This was declining by the time of discharge. The significance is unclear given the patient's severe cardiac disease and renal failure. Given his increasing troponins, we did obtain a cardiac echo, which showed severe global hypokinesis, moderate-to-severe MR and TR, and mild AI and PI. He had 4-chamber enlargement and estimated LVEF of 20% on his echo during this admission.
MR|magnetic resonance|MR|203|204|HOSPITAL COURSE|He was seen by Dr. _%#NAME#%_ _%#NAME#%_ (Orthopedics) and was to follow up with him in his office for further treatment. He also had an elevated lipase which was rather persistent. He did go through an MR of the abdomen which showed no evidence of bilary tract disease or pancreatic inflammation. He is not a user of alcohol. His lipase eventually did return to normal.
MR|mitral regurgitation|MR.|156|158|PAST MEDICAL HISTORY|There was a small region of akinesis involving the apical segment. The lateral segment had hypokinesis. There was mild left ventricular dilatation and mild MR. 2. Type II Mobitz heart block, status post biventricular pacemaker placement at the VA in _%#MM2004#%_. 3. Coronary artery disease status post three-vessel coronary artery bypass graft x two in 1980, and 1992.
MR|magnetic resonance|MR|164|165|PLAN|I am not convinced that she has a serious degree of dementia but rather this could be primarily psychiatric disease. PLAN: Will do a neurological work-up including MR of the brain, B12, TSH, folate and calcium levels and EEG. Will get a neurology consult. At this point we will stop her Lasix which can cause tinnitus and begin Seroquel 25 mg b.i.d. as an antianxiety agent.
MR|mitral regurgitation|MR|140|141|ALLERGIES|Her BNP was 435. A transthoracic echo which was performed on _%#MM#%_ _%#DD#%_, 2005, showed an LVEF of 60%, postoperative. She had 2 to 3+ MR and TR. Her RV systolic pressure was 61+ RA. She had bilateral atrial enlargement. Results of the right heart catheterization have been dictated above.
MR|mitral regurgitation|MR,|335|337|PAST MEDICAL HISTORY|2. Congestive type heart failure _%#MM2005#%_ due to high output. 3. Severe AS. Cardiac echo done _%#MM2005#%_ showed the following, mild biatrial enlargement, RV mildly dilated and mildly dysfunctional, RV mild concentric LVH with moderate global hypokinesis with the apex having worse contractility with an EF of 40%, trace TR, mild MR, aortic valve heavily calcified with aortic valve area 0.7 cm2, with a maximum gradient of 61 mmHg and a mean gradient of 42.
MR|magnetic resonance|MR|165|166|FINAL DISCHARGE DIAGNOSES|11. Peripheral vascular disease with healing ischemic right great toe ulcer. 12. Carotid artery disease with previous ultrasounds showing severe disease; definitive MR angiogram studies are pending. 13. History of recurrent deep vein thrombosis. 14. History of chronic atrial fibrillation. 15. Chronic Coumadin therapy for deep venous thrombosis history and chronic atrial fibrillation.
MR|magnetic resonance|MR|197|198|HOSPITAL COURSE|He developed hypertension and worse headache which necessitated a repeat MRI of the brain and MR angiogram to rule out possibility of a stroke or of extension of the dissection. The repeat MRI and MR angiogram were unremarkable. Because of the hypertension internal medicine was consulted and they recommended treatment with lisinopril. This did control his blood pressure much better. His pain was treated as mentioned above with Percocet but that only offered 50% relief.
MR|mitral regurgitation|MR,|185|187|IMAGING|IMAGING: Cardiac echo shows prominent right pulmonary artery flow with very mild increased velocities, prominent pulmonary artery size, left and right. No clots were seen. She has mild MR, mild TR and trivial PR. Aortic valve is sclerotic with very small mobile echoes seen - strands. She has a normal LV and mild hypo right ventricular function.
MR|magnetic resonance|MR|207|208|PLAN|She is extremely claustrophobic, therefore, will attempt with 2 mg of IV Ativan prior to the procedure. If unsuccessful, will consider right upper quadrant ultrasound instead. 7. Depending on the results of MR CP, will consult Gastroenterology. If MR CP is negative, she may be discharged to home with follow up with GI clinic for possible ER CP to rule out splinter of Oddi dysfunction.
MR|mitral regurgitation|MR.|237|239|HOSPITAL COURSE|As part of her evaluation, she was seen by Dr. _%#NAME#%_ from Cardiology who recommended echocardiogram, which revealed ejection fraction of 45- 50%, regional wall motion abnormalities and severe hypokinetic basilar inferior wall. Mild MR. It was recommended that the patient take scheduled nitrates and other cardiac medications as prescribed. The patient was also seen by Dr. _%#NAME#%_ of Oxboro Internal Medicine.
MR|magnetic resonance|MR|162|163|HOSPITAL COURSE|CT head scan revealed extensive small vessel ischemic change. Echocardiogram revealed no intracardiac cause for a stroke. Sedimentation rate was mildly elevated. MR angiogram of the circle of Willis revealed normal flow through anterior middle and posterior cerebral arteries with no residual occluded vessels.
MR|magnetic resonance|MR|352|353|HISTORY OF PRESENT ILLNESS|The findings were nonspecific, but consistent with various diagnoses, i.e., sequelae of old head injury which the patient has suffered in the past, but also the possibility of demyelinating disease, Lyme disease, etc., was raised. The patient also underwent an MR angiogram of the circle of Willis which ruled out the possibility of an aneurysm and an MR angiogram of the neck which ruled out the possibility of a vertebral artery dissection. He had additional workup which included the following: A CBC with differential was read as unremarkable with relative neutrophilia.
MR|magnetic resonance|MR|136|137|HISTORY OF PRESENT ILLNESS|Troponin was normal. TSH was 1.64 (normal). Erythrocyte sedimentation rate was 2. Urinalysis was unremarkable. MRI of the brain with an MR angiogram was as described above. A chest x-ray was obtained to rule out sarcoidosis and was negative. An antinuclear antibody screen was negative. Hemoglobin A1c was 5.2% (normal).
MR|magnetic resonance|MR|208|209|RECOMMENDATIONS|If such episodes continue to occur and there is no particular cause for forthcoming then I would recommend obtaining imaging of the cervical spine as well. RECOMMENDATIONS: 1. For now, I will proceed with an MR angiogram of the Circle of Willis and the great vessels of the neck. 2. I would also recommend obtaining a transesophageal echocardiogram looking for a patent foramen ovale.
MR|magnetic resonance|MR|167|168|LABORATORY|LABORATORY: Reveal elevated hemoglobin at 16.3. Electrolytes - Creatinine, glucose, urea-nitrogen are normal. MRI brain scan is reviewed - Small left thalamic stroke. MR angiogram of the circle of Willis negative. MRA of the extracranial carotids revealed no significant blockages. She has a dominant right vertebral artery. ELECTROCARDIOGRAM: Normal sinus rhythm.
MR|magnetic resonance|MR|171|172|HOSPITAL COURSE|She was not a TPA candidate. A CT scan of the brain did not reveal any abnormalities. An MRI of the brain showed evidence of a left small cortical cerebral infarction. An MR angiogram of the brain did not reveal any intracranial vasculitic lesions and carotid ultrasound revealed no hemodynamically significant stenosis.
MR|mitral regurgitation|MR.|162|164|DISCHARGE DIAGNOSES|2. 40-mm apical LAD stenosis of up to 99% with severe apical hypokinesis with hyperdynamic basilar portion of the heart and an ejection fraction of 50% with mild MR. 3. History of migraine. 4. History of seizure in _%#MM2004#%_ with no subsequent findings. 5. Hypertension in the past year. 6. Positive family history for coronary artery disease.
MR|magnetic resonance|MR|179|180|PLAN|4. Discontinue the phentermine and do not use phentermine again ever, as it can precipitate migraines and it can contribute to strokes, as well as to cardiac valvular disease. 5. MR angiogram of the neck to look for evidence of vasculitis. 6. Transesophageal echocardiogram to rule out endocarditis or vascular disease or patent foraminal valve.
MR|mitral regurgitation|MR,|257|259|PROCEDURES AND INVESTIGATIONS|3. Hypertension. 4. Gastroesophageal reflux disease. 5. Depression. 6. Osteoporosis. 7. Hyperlipidemia. PROCEDURES AND INVESTIGATIONS: 1. Transthoracic echocardiogram which showed abnormal ejection fraction, severe left atrial enlargement, mild-to-moderate MR, moderate mitral annular calcification, mild-to-moderate right atrial dilatation, moderate TR and RV systolic pressure 44 mmHg above right atrial pressure.
MR|mitral regurgitation|MR,|112|114|HOSPITAL COURSE|He had 60% EF with wall motion within normal limits. The atria were at the upper limits of normal. He had trace MR, trace TR, trace PR and pulmonary pressure of 33 mmHg plus right atrial pressure. The patient had normal diastolic function. LABORATORY DATA: On the day of discharge revealed a urinalysis that was negative, white count 5.1, hemoglobin 13.7, platelet count 187,000, sodium 139, potassium 3.9, chloride 103, bicarb 31 and creatinine 1.08. Chest x-ray done on admission was negative as was a head CT.
MR|mitral regurgitation|MR.|200|202|MAJOR IMAGING|Lungs are clear. 2. Transthoracic echocardiogram done on _%#MMDD2007#%_, shows an LV function of 20%, severely reduced. LV is mildly dilated. Mild aortic root dilatation. Trace AR. Moderate-to-severe MR. RV systolic function is mildly reduced. Severe left atrial enlargement. Right atrium moderate-to-severely dilated. RV systolic pressure of 23 plus right atrial pressure.
MR|magnetic resonance|MR|160|161|HISTORY|His family and social history were remarkable for intracerebral hemorrhage, otherwise unremarkable. His workup has been rather extensive in the past, including MR studies showing no evidence for aneurysm or vascular pathology. He has allergies to caffeine. His past history also includes colon cancer, macular degeneration, gastroesophageal reflux, hypertension, hypothyroidism.
MR|magnetic resonance|MR|221|222|HISTORY OF PRESENT ILLNESS AND SUMMARY OF TRANSITIONAL CARE STAY|She was significantly hypertensive at the time of emergency room evaluation with blood pressures of 230/160. She was treated urgently and admitted to the Intensive Care Unit. CT scan demonstrated no active hemorrhage. An MR scan revealed posterior reversible leukoencephalopathy syndrome (PRES). This was thought to be related to tacrolimus toxicity. Further, the patient was noted to go into acute renal failure secondary to her tacrolimus toxicity.
MR|mitral regurgitation|MR|167|168|PROBLEM #1|PROBLEM #1: Cardiology consulted regarding cardiomyopathy. Echocardiogram showed a 30% left ventricular ejection fraction with severe diffuse global hypokinesis, mild MR left ventricular enlargement. The patient was stabilized on aforementioned medications. Blood pressure returned to normal levels, as did tachycardia resolve.
MR|mitral regurgitation|MR,|317|319|PROBLEM-ORIENTED HOSPITAL COURSE|Given the history of severe MI, we decided to perform a transthoracic echocardiogram to further evaluate the mitral valve. This echo showed severely decreased LV function with officially estimated ejection fraction of 17%, severe LV dilatation with mild mitral annular calcifications and fibrosis, moderate to severe MR, moderate left atrial enlargement and mild AR and no evidence of right or left shunt on echo contrast study. We have consulted cardiothoracic surgery to consider patient for bypass.
MR|mitral regurgitation|MR|186|187|HOSPITAL COURSE|The left ventricular function showed an ejection fraction of approximately 60-65% with normal response to dobutamine infusion with increased in EF of approximately 80%. Mild to moderate MR was noted on routine screening carotid Doppler. Pulmonary artery systolic pressure was 33 mm of Mercury right radial pressure. The patient was in addition evaluated by the EP Study and since the patient had had a prolonged QT on admission and the patient had a history of near syncope; however, the patient's QTC corrected with replacement of Potassium and it was felt that the patient did not need EP Study at this point.
MR|magnetic resonance|MR|206|207|HISTORY OF PRESENT ILLNESS|PROCEDURE PERFORMED: Right carotid endarterectomy. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 63-year-old female who was referred to Dr. _%#NAME#%_ _%#NAME#%_ after she had a carotid stenosis noted on MR angiography during evaluation for a neurologic workup. She had apparently had symptoms suggestive of a TIA in _%#MM2006#%_. She had not had any recurrences of that TIA, which was evaluated by Dr. _%#NAME#%_, but in discussion with her it was felt that she had significant enough risk of stroke that she did warrant carotid endarterectomy.
MR|magnetic resonance|MR|178|179|CONSULTATIONS|4. An MR of the neck: No significant stenosis identified in either carotid system. Apparent stenosis at the origin of the right vertebral artery, probably due to an artifact. 5. MR angiogram of the head negative. 6. MRI of the head: No acute pathology, no bleed or mass or acute infarct seen.
MR|magnetic resonance|MR|193|194|ADMISSION DIAGNOSIS|The patient was started on heparin. The decision was made to defer lysis of the thrombosis because of the mild symptoms, partial nature of the thrombosis, and relatively good appearance of the MR scan. A urine pregnancy test was confirmed as negative. The oral contraceptive agents were stopped. The patient was started on Coumadin. A Hematology consultation was obtained which agreed with the anticoagulation and recommended Coumadin for 6 months.
MR|magnetic resonance|MR|157|158|HOSPITAL COURSE|Patient has been seen in the emergency room on several occasions for headache. CT scan was unremarkable. Spinal tap was also unremarkable. She has completed MR angiogram which showed some basilar artery changes which are felt to be nonspecific. MR of the cervical spine shows minimal small disk protrusion centrally at C5-6 causing no cord changes.
MR|magnetic resonance|MR|182|183|DISCHARGE MEDICATIONS|We suspect that an infarct to the cerebellum, rather than just labyrinthitis as there was definitely ongoing confusion. We did obtain an MRI, which was not revealing. We also got an MR angiogram of the carotid arteries and of the circle of Willis. Again, there was no definite significant pathology seen in the cerebellar circulation.
MR|magnetic resonance|MR|112|113|MAJOR PROCEDURES AND TREATMENTS|DISCHARGE DIAGNOSES: 1. Multiple enhancing brain lesions. 2. Renal failure. MAJOR PROCEDURES AND TREATMENTS: 1. MR scan. 2. Dialysis. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 54-year-old female who was evaluated with a history of diabetes mellitus type 1 who has had previous pancreatic and kidney transplants.
MR|mitral regurgitation|MR|295|296|DISCHARGE INSTRUCTIONS|PROBLEM #7: Unstable angina. The patient had developed some chest pain on his third hospital day with some EKG changes, consistent with some anterior ischemia. An echocardiogram was performed which showed a normal left ventricular ejection fraction of 70-75%, no wall motion abnormalities, mild MR and a sclerotic aortic valve, without significant stenosis. The patient was initially started on heparin, his troponins were followed and were normal.
MR|magnetic resonance|MR|225|226|PAST MEDICAL HISTORY|She has a mild cough which is occasionally productive of phlegm, but she is not short of breath. PAST MEDICAL HISTORY: 1. Subarachnoid hemorrhage in _%#MM#%_ 2002. She had numerous tests done, including a cerebral angiogram, MR venography and angiography of the circle of Willis, and no cause for a bleed was found. She did have a moderate interventricular and subarachnoid hemorrhage, but no evidence of underlying mass.
MR|mitral regurgitation|MR|184|185|DISCHARGE DIAGNOSES|Her low extremity Dopplers were negative. D-dimer was negative. Chest x-ray showed some cardiomegaly but no acute CHF or(_______________). Echo showed a mild diffuse hypokinesis, mild MR and AI and a trace TR, and on tele she remained in paced rhythm with normal rate. 3. As for her hypertension, it was pretty labile. She had systolic going up to 198, but after we increased her clonidine to 0.2 mg b.i.d., blood pressure did normalize.
MR|mental retardation|MR,|235|237|HISTORY|Was sent over to the hospital and had a venous Doppler which was consistent with extensive left lower extremity venous clot. She was admitted for Heparin. She has an extensive past medical history. She has cerebral palsy, has moderate MR, has organic personality disorder and suffers with GERD. PAST SURGICAL HISTORY: Includes cholecystectomy and appendectomy which was removed here at Fairview-Southdale Hospital.
MR|magnetic resonance|MR|120|121|NEUROLOGICAL EXAMINATION|4. She also needs to follow up with Dr. _%#NAME#%_ in one month. 5. She needs prior to that visit MRI of the brain with MR angiogram of circle of Willis to follow up on hemorrhage. That has to be done before her appointment with Dr. _%#NAME#%_. I reviewed with patient and her son all the discharge medications and recommendations.
MR|mitral regurgitation|MR|267|268|HOSPITAL COURSE|Total triglyceride level of 124. The patient underwent a transthoracic echocardiogram, which demonstrated normal left ventricular function with an ejection fraction of approximately 60%. There was no obvious wall motion abnormality. No obvious clots with noted trace MR and TR and nonspecific thickening of the aortic valve with mild LVH. No other focal changes have been noted. Duplex carotid ultrasound per dictated report showed no significant hemodynamic flow limiting lesions.
MR|mitral regurgitation|MR|276|277|HOSPITAL COURSE|The patient cleared her neurological symptoms in the Emergency Department and was felt to have normal neurological examination by Dr. _%#NAME#%_. He ordered MRI/MRA, carotid ultrasound, echocardiogram. Echocardiogram preliminary report showed normal EF estimated at 55%, 1-2+ MR otherwise unremarkable. Of note, a formal cardiology read has not been performed. She had carotid ultrasound which was performed earlier, but is not officially red by radiology.
MR|mitral regurgitation|MR|201|202|PROCEDURES PERFORMED THIS ADMISSION|Findings demonstrates a previous ASD which had been repaired. Status post VSD repair. There is a repair of the left cleft of the mitral valve. There is no residual shunt appreciated. There is moderate MR with mild MS. The mean gradient across the mitral valve is 4 mm of mercury. RV systolic pressures estimated at 25 plus RA. There is no thrombus appreciated.
MR|mitral regurgitation|MR.|353|355|OPERATIONS/PROCEDURES PERFORMED|CONSULTATIONS: Heart failure team. STUDIES: Transthoracic echocardiogram in _%#MM#%_ 2003 showed severe left ventricular dilation with an ejection fraction of approximately 15%, possible small left ventricular thrombus, mild decrease in right ventricular function with right ventricular systolic pressure of 44 plus right atrial pressures, and moderate MR. HISTORY OF PRESENT ILLNESS: This is a 67-year-old female with severe dilated cardiomyopathy which is idiopathic who is status post ICD and biventricular pacer first placed in the summer of 2002 who also underwent a mitral valve and tricuspid valve repair in _%#MM#%_ of 2003.
MR|mitral regurgitation|MR.|219|221|PAST MEDICAL HISTORY|Dr. _%#NAME#%_ _%#NAME#%_ did the initial removal and said that it was a superficial melanoma, and he feels he got it all. 3. History of cardiac murmur. The patient had a cardiac echo done recently that showed moderate MR. 4. History of hyperlipidemia. PAST SURGICAL HISTORY: 1. Tonsillectomy, age 5. 2. Hernia repair, age 5. 3. Vasectomy, age 37.
MR|magnetic resonance|MR|177|178|IMAGING STUDIES|Ejection fraction at 60%. 2. Right bundle branch block, normal study, good quality. 3. Head CT scan without contrast, negative. 4. Chest x-ray on admission, negative. 4. Normal MR angiogram of the head, including internal vertebral arteries. No stenoses. 5. MRI of the brain showing small vessel ischemic disease, otherwise normal.
MR|mitral regurgitation|MR,|146|148|PAST MEDICAL HISTORY|He was placed on Coumadin therapy. However, a short while after discharge decided to discontinue this medication on his own. 2. History of severe MR, status post mitral valve annuloplasty in _%#MM#%_ 2002. He was placed on medical management after this but again discontinued these medications on his own.
MR|magnetic resonance|MR|153|154|OPERATIONS/PROCEDURES PERFORMED|A bit of visual blurring had occurred during part of the illness. The patient due to the spinal tap findings and headache history underwent MRI scan and MR angiogram of the intracranial vessels. There was no aneurysm evident. The vessels were widely patent. No abnormality was found. Pain control has been reached as of _%#MM#%_ _%#DD#%_, 2004, and the patient is released home.
MR|magnetic resonance|MR|186|187|ASSESSMENT AND PLAN|NEUROLOGIC: Cranial nerves II-XII are intact. ASSESSMENT AND PLAN: The patient had a negative MR in _%#MM#%_ with her having problems with the lymphedema on the breast. Will get another MR in _%#MM#%_ of next year and will not do mammograms on that breast until it is less tender. I have discussed with her massage technique. I will see her again in three months with labs.
MR|mitral regurgitation|MR,|169|171|OPERATIONS/PROCEDURES PERFORMED|It was felt that the etiology of her shortness of breath was multifactorial, including restrictive obstructive lung disease, pulmonary hypertension, moderate- to-severe MR, and moderate aortic regurgitation, and also ventricular dysynchrony. DISCHARGE PLAN: She should follow up with her primary care physician, Dr. _%#NAME#%_ _%#NAME#%_, in 1 to 2 weeks. She will also follow up with electrophysiology in 1 month, and she is to undergo a repeat echocardiogram at Fairview in 4 months with cardiology to evaluate left ventricular dimensions and ejection fraction, and for her mitral regurgitation and aortic regurgitation.
MR|magnetic resonance|MR|120|121|HOSPITAL COURSE|No evidence for any acute infarcts or intracranial mass lesions. The patient had a MRA of her head which was a negative MR angiogram of the circle of Willis. She had an ultrasound of her carotids which showed mild to moderate atherosclerotic disease involving the carotid bifurcation.
MR|magnetic resonance|MR|241|242|PROCEDURE LIST|(Pneumonia versus atelectasis) 5. MRI of the lumbar spine which revealed multilevel degenerative disc and facet joint disease. No focal herniation, moderate to severe left neural foraminal stenosis at L4-L5. 6. MRI, MRA of the brain. Normal MR angiogram of the head. MRI of the brain reveals generalized atrophy of the brain, scattered white matter lesions consistent with small vessel ischemia.
MR|mitral regurgitation|MR,|143|145|PERTINENT LABORATORY STUDIES|Echocardiogram showed severely decreased LV function with the ejection fraction of 15-20 percent. There is severe global hypokinesis, moderate MR, trace AI. No pericardial effusion shunts or thrombi noted. HOSPITAL COURSE: Multiple likely embolic brain infarcts. _%#NAME#%_ _%#NAME#%_ is a _%#1914#%_ gentleman with a history of type 2 diabetes, coronary artery disease, who was found unresponsive today by family members in his apartment.
MR|magnetic resonance|MR|246|247|HOSPITAL COURSE|Troponins and ECG were nonischemic. Flat and upright of the abdomen were unremarkable, and she was felt to have a stress gastritis which was responding nicely with antacids. She also had negative MR scan of her head, actually a very good looking MR scan. The patient was treated with antacids and chest x-ray resolved. Neurology saw her and had nothing else to add, felt that this possibly could be related to medicine, she was on some Levaquin for her venous stasis ulcer and that was subsequently stopped.
MR|mitral regurgitation|MR.|231|233|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Ischemic cardiomyopathy. Echocardiogram in 2003 showed moderate to severe left ventricular enlargement, ejection fraction of 20%, severe global hypokinesis, moderate right ventricular enlargement, moderate MR. 2. Coronary artery bypass graft in _%#MM2000#%_. 3. Atrial arrhythmias with permanent pacemaker and ICD implantation. The patient is on chronic Coumadin. 4. DM2. 5. Gastroesophageal reflux disease.
MR|magnetic resonance|MR|190|191|HOSPITAL COURSE|There was also a tiny infarct in the left dentate nucleus and a stroke also noted on the right cerebellar peduncle, the left dentate nucleus stroke had been new on the _%#MMDD2005#%_ study. MR angiogram revealed 60% diameter stenosis of the left internal carotid artery. The patient was seen in consultation by Dr. _%#NAME#%_ from the vascular surgery service.
MR|mitral regurgitation|MR.|234|236|IMPRESSION|He was discharged with the following impressions. IMPRESSION: 1. Progressive left heart failure improved within 48 hours. 2. Underlying ischemic cardiomyopathy. 3. No evidence of myocardial infarction. 4. LVEF around 30%. 5. Moderate MR. 6. Moderate TR with mild pulmonary hypertension. 7. Orthostatic hypotension. Complex combination of deconditioning, diminished LV function and heart failure - vasodilator therapy.
MR|mitral regurgitation|MR,|266|268|HOSPITAL COURSE|Her anoxic encephalopathy resolved fairly rapidly, and she was studied with echocardiography, revealing severe aortic stenosis with a mean gradient of 37 mm and a peak gradient of 64 mm, and an estimated aortic valve area of 0.64 cm. She had mild-to-moderate TR and MR, and trace AI. Ejection fraction was judged to be 45-50%. She underwent coronary angiography, revealing mild-to-moderate left main disease, an ostial 90% circumflex stenosis, and mild LAD disease, but with an aneurysm at the junction of the LAD and intermediate branch.
MR|magnetic resonance|MR|138|139|IMPRESSION|We will keep his blood pressure under 180 on Nipride. I will consult neurosurgeon, Dr. _%#NAME#%_ and his colleagues today. I will pursue MR of the brain with MR angiogram to rule out an underlying aneurysm. The patient may need a formal 4-vessel angiogram later. At this point, I do not see any need in loading him with fosphenytoin.
MR|magnetic resonance|MR|234|235|HOSPITAL SUMMARY|When he presented to the hospital, he underwent MR imaging which revealed evidence of an acute infarct in the right posterior inferior cerebellar artery distribution. There were chronic appearing infarctions in both cerebellum areas. MR angiography revealed a small right vertebral artery with an apparent stenosis at the origin of the right vertebral artery. It was felt this was most consistent with atherosclerosis. Also noted was about 50%-60% stenosis of the left internal carotid artery and a possible ulceration of the plaque was seen in the proximal left internal carotid artery.
MR|magnetic resonance|MR|146|147|PROCEDURES PERFORMED DURING ADMISSION|1. MRI of the brain from _%#MMDD2005#%_ was normal with normal circle of Willis MRA. 2. MRA of the neck performed on _%#MMDD2005#%_ showed normal MR angiogram of the carotid bifurcations and vertebral arteries in the neck. 3. MRI of the chest performed on _%#MMDD2005#%_ showed ascending aortic aneurysm, 46 mm wide in the mid-ascending aorta.
MR|magnetic resonance|MR|113|114|HOSPITAL COURSE|HOSPITAL COURSE: Upon admission, an MRI of the brain did not disclose any new areas of ischemia in the brain. An MR venogram was also obtained which did not show any evidence of venous sinus thrombosis. The patient's chest x-ray was normal without any evidence of sarcoidosis.
MR|mitral regurgitation|MR|168|169|DISCUSSION|I believe she may need a TEE, but if they just do mitral valve replacement, it should not be necessary. She may need another transthoracic echocardiogram to see if her MR has worsened, but I believe cardiac catheterization is the place to start. I have reviewed the risks and benefits, including death, myocardial infarction, stroke, bleeding, dye reaction, urgent surgery, etc., she understands and agrees to proceed.
MR|myocardial infarction:MI|MR.|122|124|HOSPITAL COURSE|On the day of admission he had severe chest pressure which quite frightened him and brought him here. He ruled out for an MR. His initial cardiac echo was normal and his EKG was normal. He did have a couple of very mild episodes of his chest pressure.
MR|mitral regurgitation|(MR)|188|191|ASSESSMENT AND PLAN|1. Dyspnea/increasing lower extremity swelling. At this time suspect worsening of pulmonary hypertension with history of severe valvular disease including both severe mitral regurgitation (MR) and tricuspid regurgitation (TR). She does have a component of biventricular heart failure with crackles in her lungs as well as increasing lower extremity edema and an elevated jugular venous pressure.
MR|mitral regurgitation|MR|192|193|DIAGNOSES|2. Hypotension, unable to titrate on an ACE inhibitor or angiotensin receptor blocker secondary to hypotension. 3. Mitral valve disease noted on echo with a partial flail and severe eccentric MR with pulmonary vein reversal 4. Elevated digoxin level on admission; the patient likely needs to be on digoxin at a decreased dose of every other day in a very elderly patient.
MR|magnetic resonance|MR|458|459|COURSE OF STAY IN THE HOSPITAL|On the time of stay, a CT scan of the head was done, and it was not suggestive of a hemorrhagic stroke. An MRA and MRI were done. The impression on the MRA is moderate-sized area of recent infarction in inferior-posterior left occipital lobe and a small second area of recent infarct in the anteromedial portion of the left occipital lobe; high-grade short-segment stenosis, left posterior cerebral artery P1 segment; and the last one is marginal quality of MR angiogram of the neck vessels due to the patient motion but no evidence for high-grade stenosis of either carotid bifurcation.
MR|magnetic resonance|MR|199|200|HOSPITAL COURSE|There was mild diastolic dysfunction. An MRA of the head was done which showed occluded left posterior inferior cerebellar artery and mild stenosis of the carotid siphons. Otherwise, it was a normal MR angiogram. Clinically, he continued to do very well and was feeling much better. At this time, he was last seen by the neurologist on _%#MMDD2006#%_ in the morning and given his excellent clinical course.
MR|magnetic resonance|MR|477|478|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Oligodendrogliomas. DISCHARGE DIAGNOSIS: Oligodendrogliomas. OPERATIONS/PROCEDURES PERFORMED: MRI-guided biopsy of the right parietal lesion. HISTORY OF PRESENT ILLNESS: Briefly, this is a 52-year-old female with a history of oligodendroglioma diagnosed several years ago demonstrated some minor growth on MR scan and as such she had a treatment with radiation and Temodar, but there was some question of increased change in this lesion on her most recent MR which was possibly suggestive of ongoing treatment effect, but the increase in size of the tissue itself caused difficulty with seizure management.
MR|magnetic resonance|MR|246|247|HISTORY OF PRESENT ILLNESS|Previous workup for multiple sclerosis was unremarkable and due to the fact that she does not have a diagnosis for the lesion she was referred to Dr. _%#NAME#%_. Following a meeting with Dr. _%#NAME#%_ she was scheduled for elective biopsy using MR guidance. HOSPITAL COURSE: The patient was admitted on _%#MMDD2006#%_ and underwent the aforementioned procedure.
MR|magnetic resonance|MR|202|203|DISCHARGE DIAGNOSES|In the course of his hospitalization, he did undergo MR imaging of the brain. This did reveal the hematoma in the left globus pallidus rupturing into the ventricular system. There was no hydrocephalus. MR angiography disclosed significant vertebral artery stenosis particularly on the right as well as some proximal basilar artery stenosis. Blood sugars were slightly elevated during the hospitalization though his hemoglobin A1c came back at 6.0. He was seen by the hospitalist service in terms of blood pressure management.
MR|GENERAL ENGLISH|MR.|168|170|PLAN|4. Interventional radiology consultation for possible vertebral plasty. 5. Radiation oncology consultation. 6. Dexamethasone. I ALSO DISCUSSED ADVANCED DIRECTIVES WITH MR. _%#NAME#%_ AND HE AGREES TO DNR/DNI STATUS.
MR|GENERAL ENGLISH|MR|167|168|RECOMMENDATIONS|2. She will be asked to follow up with my nurse practitioner in a week. 3. She will continue cardiac rehab at Fairview Ridges Hospital. 4. We should consider doing an MR lipoprotein profile to assess for LDL particle number as well as size. I would also consider doing a lipoprotein (a) and evaluated, her LDL should be less than 60.
MR|magnetic resonance|MR|175|176|SURGICAL INDICATIONS|SURGICAL INDICATIONS: _%#NAME#%_ _%#NAME#%_ is a 52-year-old female who recently was admitted with a bout of right upper quadrant pain. She was found to have abnormal LFT and MR cholangiogram showed a large stone in the common duct. She did have ERCP and sphincterotomy with extraction of a large stone.
MR|magnetic resonance|MR|207|208|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 87-year-old man with recent diagnosis of small cell lung CA with multiple falls. Seen first in the clinic at that time and evaluated for falls with an MR head showing no evidence for metastatic disease to the brain, however, there has been metastatic disease found in the liver on previous evaluation prior to hospitalization.
MR|magnetic resonance|MR.|282|284|HISTORY OF PRESENT ILLNESS|She was also been seen in by the cardiologist during her hospitalization and had new cardioechogram done at the University, which showed ejection fraction of 65%, mild aortic stenosis, mild MR, moderate atrial enlargement and RV systolic pressure mild to moderately increased, mild MR. She was started on Coumadin also as well as receiving Lovenox shots daily to keep her INR at the range of 2-3. At the day of discharge, she had not had any arrhythmia and denies having any chest pain.
MR|mitral regurgitation|MR,|155|157|PLAN|His INR was greater than 10, and he spent about a week in the hospital. He had been seen in Florida, and had an angiogram in _%#MM2005#%_ showing moderate MR, and he had a PTCA of his native LAD via the LIMA. He also had an obtuse marginal with 90% stenosis, and numerous 80% lesions in the RCA, with 100% distally.
MR|magnetic resonance|MR|116|117|PRINCIPAL PROCEDURES|4. History of left retinal artery occlusion (1995, Dr. _%#NAME#%_). PRINCIPAL PROCEDURES: 1. Upper GI endoscopy. 2. MR pancreatography. 3. GI consultation (Dr. Feldshon). 4. Psychiatry consultation (Dr. _%#NAME#%_). 5. Physiatry consultation (Dr. _%#NAME#%_). HOSPITAL COURSE: Mrs. _%#NAME#%_ _%#NAME#%_ is a 74-year-old woman who has been having problems over the past four months with left upper quadrant abdominal and flank pain.
MR|magnetic resonance|MR|196|197|PAST MEDICAL HISTORY|6. Lasix allergy. The patient was on IV Lasix last admission and developed hives. 7. Carotid stenosis. Ultrasound sound done last admission showed severe stenosis in left internal carotid artery. MR angiography showed an 80-99% stenosis in the left internal carotid and a 70-80% on right internal carotid artery. She had a left carotid endarterectomy on _%#MMDD#%_ with Dr. _%#NAME#%_.
MR|magnetic resonance|MR|155|156|SUMMARY|She was admitted to the hospital for suspected TIA and placed on heparin as an anticoagulant. Subsequent neurologic workup was entirely negative including MR angiogram, MRI scan, ultrasound of the carotids, and ultrasound of the heart, including the bubble study. Our conclusion is this was probably a microembolic phenomenon that has resolved entirely and may have been provoked in part by the procoagulant effect of her hormone therapy plus her smoking.
MR|magnetic resonance|MR|202|203|PAST MEDICAL HISTORY|6. Left total knee arthroplasty. 7. History of TIA: The patient had an MRI/MRA on _%#MMDD2002#%_ which showed mild small vessel ischemic-type changes with no evidence of stroke. The patient also had an MR of the spine which showed mild diffuse degenerative changes. FAMILY HISTORY: The patient's mother had a stroke at 62 years old, and the patient's sister had a stroke as well.
MR|mitral regurgitation|MR.|115|117|PROCEDURES AND STUDIES|Right ventricular pressure was mildly elevated at 38 millimeters of mercury above the mean RAP, mild LAE, and mild MR. 4. On _%#MMDD2002#%_, cardiac MRI: No perfusion defect during rest. No evidence of irreversible damage to left ventricular myocardium.
MR|magnetic resonance|MR|112|113|BRIEF HISTORY|She has had bilateral arthroscopic surgery and has been on Naprosyn for this. She had been scheduled to have an MR scan the next morning but the headache became so severe that all she did was sit and moan. Her housemaid brought her to the emergency room where an attempt at a lumbar puncture (LP) was aborted because of inability to find the spaces due to her significant body size.
MR|magnetic resonance|MR|265|266|HOSPITAL COURSE|He was seen by orthopedics and they did an open reduction and internal fixation and casted him and he is now nonweightbearing for a while. He was also seen by Dr. _%#NAME#%_ _%#NAME#%_ from neurology for consultation regarding the radiculopathy. Of note, he had an MR scan to clear him of any disc, metastases or osteomyelitis or other disc space- occupying lesions before this. She agreed that this was a motor involvement with zoster and agreed with steroids.
MR|magnetic resonance|MR|131|132|HOSPITAL COURSE|However, there was suggestion of stenosis of the iliac artery near the renal artery anastomosis. The stenosis was confirmed by the MR angiography. Interventional Radiology was consulted for angioplasty and stenting of the lesion. However, when the stent was deployed it migrated in the iliac artery.
MR|magnetic resonance|MR,|340|342||She gave a history of severe back pain, which she had had for three or four days prior to admission, the pain passed down the left buttock region to the knee, and she was also complaining of difficulty controlling her urination. She was admitted to the hospital and seen in consultation by Dr. _%#NAME#%_ _%#NAME#%_. The patient did have a MR, which revealed a left-sided pericentral disc herniation with slight compression of the S1 nerve root. His recommendation at that time was for a short period of bedrest followed by increasing activity with oral analgesics.
MR|magnetic resonance|MR|262|263|PLAN|2. Cigarette smoker. 3. Hypertension. 4. Hypokalemia. 5. Type II diabetes mellitus, diet controlled, however, under the stress of this her blood sugar now is 269. PLAN: Will admit her, replete her potassium, monitor her. She will need a carotis ultrasound and a MR scan of her head later today. Will also get a neurology consultation. She has been loaded with Fosphenytoin and we will do an EEG and ask neurology whether or not they want to continue the Dilantin.
MR|magnetic resonance|MR|165|166|IMPRESSION|Amyloid angiopathy can look like this, but I think her age is really too young. To evaluate things further, we will do an MRI of the brain with contrast, as well as MR angiography. Because of her significant neurologic deficits and the mass effect, I will give her some Decadron to see if we can help with those.
MR|magnetic resonance|MR|152|153|HISTORY OF PRESENT ILLNESS|Neurologically, she had, however, worsened. The neurologist at the Fairview Ridges hospital evaluated her for stroke and an MRI of the brain as well as MR angiogram of the brain were completed on _%#MMDD2004#%_. The MRI revealed no acute infarct and the bilateral subdural hematomas were again unchanged.
MR|mitral regurgitation|MR|139|140|BRIEF SUMMARY OF THE HISTORY OF PRESENT ILLNESS|Echo on _%#MM#%_ _%#DD#%_, 2004, revealed severe mitral regurgitation and an EF of 35%. Previous echos were noted to have mild to moderate MR and normal EF. The patient was admitted for heart failure management and evaluation for mitral valve replacement. PAST MEDICAL HISTORY: 1. Mitral valve regurgitation diagnosed 2 years ago.
MR|magnetic resonance|MR|179|180|PROCEDURES|1. Percutaneous drainage of intra-abdominal fluid collections under CT guidance. 2. Percutaneous biopsy of pancreas allograft X2. 3. Intravenous antibiotics. 4. Thymoglobulin. 5. MR angiography of pancreas allograft. HISTORY OF PRESENT ILLNESS: The patient is a 23-year-old Caucasian female with an 11-year history of type 1 diabetes mellitus complicated by severe hypoglycemic unawareness.
MR|magnetic resonance|MR|197|198|MAJOR  PROCEDURES AND TREATMENTS|1. Simultaneous living donor kidney (brother) and deceased donor pancreas transplant with bladder drainage on _%#MMDD2007#%_. 2. Packed red blood cell transfusion. 3. Ultrasound of the abdomen. 4. MR angiogram of abdomen. 5. Total parenteral nutrition. HISTORY OF PRESENT ILLNESS: This is a 27-year-old female with a history of diabetes mellitus type 1 complicated by end-stage renal disease.
MR|magnetic resonance|MR|174|175|SUMMARY|At the present time, I would recommend continuing him on aspirin. Workup will include MRI of the brain to document the distribution of the stroke as well as the extent. Also MR angiography of the circle of Willis will be checked. Duplex carotid ultrasound will be checked as well. Further management depends on the outcome of the above studies.
MR|magnetic resonance|MR|127|128|IMPRESSION|IMPRESSION: This is a 36-year-old male with neutropenia and probable left lower extremity cellulitis. I do not see evidence by MR or physical examination of any osteomyelitis, any septic joint or fasciitis. PLAN: We recommend aggressive IV antibiotics and ID consultation for resolution of left lower extremity cellulitis.
MR|mitral regurgitation|MR,|187|189|CHIEF COMPLAINT|White count 12,000. Hemoglobin 10.9. Since admission, an echocardiogram was done. This showed mild pulmonary hypertension with an RVSP of 37 mmHg plus right atrial pressure. She had mild MR, well-preserved LVR and systolic function, mild LVH, mild left atrial dilation, moderate TR with normal RV systolic function. The past medical history includes: 1. Remote history of skin grafting.
MR|mitral regurgitation|MR.|143|145|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Atrial fibrillation as above. 2. Hysterectomy. 3. Negative stress test and relatively normal echocardiogram with mild MR. 4. Hypertension. 5. Restless leg. 6. Negative sleep apnea workup. MEDICATIONS: 1. Labetalol, I am not clear of the dose.
MR|magnetic resonance|MR|184|185|PHYSICAL EXAMINATION|She also has evidence of old strokes in the cerebellum bilaterally, more prominent on the right. She has notable subcortical white matter ischemic change in the right parietal region. MR angiography shows a right dominant vertebral artery, but otherwise no abnormalities. Chest x-ray shows resolution of the left lower lobe infiltrate that was seen a week ago.
MR|magnetic resonance|MR|239|240|DOB|Ms. _%#NAME#%_ went to the Emergency Room at Fairview Ridges Hospital where her exam showed a left hemiparesis involving the left face as well as the left upper extremity and lower extremity. An MRI of the brain was obtained as well as an MR angiogram of the head and the neck. All of these studies were entirely normal. Over the ensuing 16-18 hours Ms. _%#NAME#%_ states the pain in her neck has continued.
MR|mitral regurgitation|(MR)|212|215|IMPRESSION|She does have a II/VI ejection systolic murmur and an echocardiogram from last year documented aortic sclerosis which is probably the cause for this murmur. Other possibilities include trace mitral regurgitation (MR) and trace tricuspid regurgitation (TR) which are not hemodynamically significant. I will also request repeat carotid ultrasound as it has been more than two years from old records that she has had one.
MR|magnetic resonance|MR|159|160|RECOMMENDATION|All of these are small. The lesions are present not only in the watershed areas, but within the distributions of the major arteries. Cervical and intracranial MR angiography is unremarkable. The lesions are most suggestive of an embolic process.
MR|magnetic resonance|MR|187|188|HISTORY OF PRESENT ILLNESS|Her Hhospital course was pertinent for heparin induced thrombocytopenia, duodenal ulcer bleed treated nonsurgically, blurred vision and left-sided weakness with negative CT and unable to MR oobtain MRI, pulmonary hypertension. Her antibiotics are due to be discontinued on the _%#DD#%_ and her fifteen thinner antifungal medications on the _%#DD#%_ and today is the last day of sternal preVersed dermal precautions.
MR|magnetic resonance|MR|271|272|IMPRESSION/PLAN|SKIN: Negative. ULTRASOUND: She did undergo ultrasound of the carotid arteries that showed a 50-80% stenosis of the left internal carotid artery. IMPRESSION/PLAN: While I think her cerebrovascular event was likely secondary to her heart catheterization, I would consider MR angiogram of her carotid stenosis to more fully document and assess it. Certainly if there is significant ulceration present or it is in the 80% range endarterectomy would be considered.
MR|mitral regurgitation|MR|216|217|PHYSICAL EXAMINATION|SKIN: Otherwise benign. NEUROLOGIC: Alert and oriented x 3, cranial nerves II through XII are grossly intact. Echocardiogram shows fairly-normal ejection fraction of 60%; there is left ventricular hypertrophy, trace MR and TR with right ventricular systolic pressure of 41 mmHg plus right atrial pressure. Left atrial enlargement is seen. LABORATORY DATA: Hemoglobin yesterday was 5.9 with albumin 2.5. This has increased considerably since _%#MM#%_ _%#DD#%_, when albumin was 1.9, protein 4.9. Creatinine was 3.5 yesterday, compared to 3.9 on _%#MM#%_ _%#DD#%_ and 4.1 on _%#MM#%_ _%#DD#%_.
MR|magnetic resonance|MR|260|261|RECOMMENDATIONS|He did come to Fairview Southdale Hospital, did undergo MRI scanning of the brain and MR angiography, which I reviewed with the patient and his daughter this afternoon. The MRI of the brain does show a new deep thalamic infarction in the right hemisphere. His MR angiography shows complete occlusion of his right carotid artery. Mr. _%#NAME#%_ has not had additional evaluation other than his labs, performed by Dr. _%#NAME#%_ on an outpatient basis revealing a normal white count, red count, hemoglobin, platelet count, differential.
MR|magnetic resonance|MR|116|117|RADIOLOGY|For further details of the physical examination please see the fellow's note in the chart. RADIOLOGY: I reviewed an MR scan of his brain showing a diffuse lesion in the pons. This has spectroscopy characteristics felt consistent with a tumor. He has a PET scan that apparently does not show increased metabolic activity in this region.
MR|mitral regurgitation|MR|211|212|PHYSICAL EXAMINATION|I cannot hear carotid bruits although he should have some bruits transmitted from his heart. LUNGS: Quite clear listened supine. HEART: Shows a musical systolic ejection murmur in the aortic distribution and an MR murmur that I think at the axilla. Both are fairly high pitched, not harsh, not late peaking. ABDOMEN: He has no hepatomegaly or abdominal aortic prominence, but it does have a full abdomen.
MR|magnetic resonance|MR|272|273|LABORATORY VALUES|I request that we complete the necessary preoperative evaluations including hospitalist consult for history and physical examination as well as anesthesia consult for the planned surgery. We will go ahead and obtain an MRI of the brain with contrast tomorrow morning with MR angiography to clearly delineate the anatomy as well as the vascular supply of this mass. We will then proceed with a stealth guided craniotomy for resection this Wednesday morning.
MR|mitral regurgitation|MR|153|154|INDICATIONS FOR CONSULTATION|I reviewed this study. It showed an ejection fraction around 50-55%, rather than 25%. She had diastolic dysfunction of the left ventricle. She had trace MR and mild aortic and mitral leaflet sclerosis. She had mitral annular calcification. Her chest x-ray on admission shows borderline cardiomegaly but does not show signs of heart failure.
MR|magnetic resonance|MR|125|126|HISTORY OF PRESENT ILLNESS|He was seen in clinic. The wound was cultured and he was admitted for IV antibiotics and further evaluation. He underwent an MR angiogram today and it shows good inflow down to the popliteal with poor runoff below, but he does have trifurcation demonstrated but has segmental blockage of the posterior tibial and peroneal branch of the anterior tibial, his dominant branch of the three.
MR|magnetic resonance|MR|220|221|HISTORY OF PRESENT ILLNESS|For this reason, a neurology consultation was obtained. He did have a couple falls during his hospitalization and a CT scan of the brain without contrast was unremarkable and yesterday he had an MRI of the brain with an MR angiogram of the brain which were also unremarkable. In the meanwhile, he has been found to have dysphagia and therefore he is being fed with a feeding tube.
MR|mitral regurgitation|MR,|208|210|PAST  MEDICAL HISTORY|He is pacing through the epicardial pacing wire. Otherwise, the patient has been convalescing well. The chest tube is still in place. PAST MEDICAL HISTORY: 1. Severe mitral valve prolapse resulting in severe MR, status post mitral valve repair. 2. PFO, status post closure. 3. Crohn disease. 4. Hypertension. 5. Hyperlipidemia. 6. Depression. CURRENT MEDICATIONS: 1. Azathioprine 200 mg.
MR|magnetic resonance|MR|266|267|IMPRESSION|2. Autism. 3. Abnormal liver function tests, etiology undetermined. There is a possibility that this could be drug related, although I doubt this is caused by the 6-MP. The Serzone has been discontinued as discussed with Dr. _%#NAME#%_. We will proceed Tuesday with MR cholangiogram to assess for the possibility of primary sclerosing cholangitis. The patient's hepatitis A and hepatitis C antibodies will also be checked.
MR|magnetic resonance|MR|144|145|DOB|This young woman does have a history of migraine headaches. These have been evaluated in the past at Mayo Clinic and she previously had MRI and MR angiography done. Her current MRA is unremarkable except for an area of cephalomalacia in one segment. She is a cigarette smoker of a half a pack of cigarettes a day.
MR|magnetic resonance|MR|168|169|HISTORY OF PRESENT ILLNESS|The study shows areas of restricted diffusion in the watershed zone between the superficial distributions of the left middle anterior, and posterior cerebral arteries. MR angiogram demonstrated a highly stenotic or occluded left internal carotid artery as well as irregular narrowing of the right internal carotid artery at the origin.
MR|magnetic resonance|MR|266|267|EXAMINATION|With both evidence of infarcts being on the posterior circulation, I do feel that further assessment is indicated to rule out the possibility of a high grade intracranial or extracranial stenosis of the vertebral basilar system. As such, MRI of the brain as well as MR angiogram of circle of Willis and the cervical vessels will need to be evaluated. Further management depends on outcome of the above measures. Thank you very much for allowing me to participate in the care and evaluation of this very interesting pleasant lady.
MR|magnetic resonance|MR|116|117|PLAN|She is tolerating a diet without pain in spite of the abnormalities identified. PLAN: She has been scheduled for an MR cholangiogram to better define the anatomy. She may continue her diet as she tolerates. Would consider laparoscopic cholecystectomy after the acute episode.
MR|magnetic resonance|MR|179|180|IMPRESSION|This was followed up with an MR angiogram and MRI of the brain. The brain appeared normal on diffusion, flare and T2 images. No cortical lesions were identified. The intracranial MR angiogram was normal with the exception of a tiny anterior communicating artery aneurysm (1mm). The MR angiogram of the neck revealed an 80-90% right internal carotid artery stenosis, severe disease of the origin of the right external carotid and 40-50% of the proximal left internal carotid artery stenosis.
MR|magnetic resonance|MR|121|122|SOCIAL HISTORY|SOCIAL HISTORY: He uses no alcohol but he is a smoker. We note that preop serum creatinine is stable at approximately 2. MR scanning of the renal arteries demonstrates a minimal right renal artery stenosis and a more moderate, though perhaps only as much as 50% stenosis of the main left renal artery.
MR|magnetic resonance|MR|122|123|PLAN|She seems to understand the issues involved quite well as well as the alternatives of immediate surgery or observation or MR scanning and she wishes to proceed with surgery. We will also notify GYN of the procedures so they can be available to assess the ovaries if clear appendicitis is not identified.
MR|magnetic resonance|MR|154|155|ASSESSMENT|I do not believe that the symptoms are related to vertebrobasilar insufficiency and do not believe that vascular imaging is necessary, particularly since MR angiography is not possible. Our bet can be hedged in this regard in that the patient is already taking aspirin.
MR|magnetic resonance|MR|148|149|LABORATORY & DIAGNOSTIC DATA|The remainder of the organs and systems review is really negative. LABORATORY & DIAGNOSTIC DATA: Labs are reviewed, and again MRI of the brain with MR angiogram of circle of Willis is negative, it is personally reviewed, and carotid ultrasound is consistent with 50% left ICA stenosis.
MR|mitral regurgitation|MR|165|166|LABS|LABS: Echocardiogram showed normal left ventricular systolic function with an ejection fraction of 60%. There was mild LVH, mild pulmonary hypertension, mild TR and MR noted as well. Myoglobin 52, initial troponin was less than 0.07, next 0.09 and next is 0.09, sodium 143, potassium 4.1, chloride 113, CO2 24, BUN 16, creatinine 1.20. CBC revealed a hemoglobin of 10.1, white blood cell count of 4.6, hematocrit 32.7, platelets at 78.
MR|mitral regurgitation|MR,|158|160|HISTORY OF PRESENT ILLNESS|An echocardiogram shows mild LVH and a nondilated left ventricle with an ejection fraction of 20-25% without segmental wall motion abnormality. He has severe MR, mild biatrial enlargement and rapid atrial fibrillation. He was an alcoholic at one point, but has been dry for 20 years.
MR|mitral regurgitation|MR|197|198|REVIEW OF SYSTEMS|13. Spironolactone, 12.5 mg/day. 14. Levothyroxine, 0.1 mg/day. 15. Metamucil, 1.7 gm, 1 tsp twice per day. It is noted that the most recent echo showed an EF of 40 percent with moderate to severe MR and moderate to severe TR with a right ventricular systolic pressure of 22 mm plus right atrial pressure with right atrial pressure no doubt quite high.
MR|magnetic resonance|MR|337|338|HISTORY OF PRESENT ILLNESS|This involved burning and numbness and tingling in her hands and feet for a couple of months, and a phenomenon where when she flexes her head there is an electrical sensation traveling down her spine. Apparently, Dr. _%#NAME#%_ was concerned about possible demyelinating disease and wished to have her undergo further testing, including MR scans. The testing was postponed due to insurance reasons, but scheduled finally to take place tomorrow. She presented to the hospital today because over the last couple of days she developed a very severe headache.
MR|magnetic resonance|MR.|142|144|LABORATORY DATA|No vertebral lesions are identified. Incidental finding of pelvic soft tissue mass. The findings are better described with a dedicated pelvic MR. ASSESSMENT AND PLAN: This patient was seen and examined by Dr. _%#NAME#%_ _%#NAME#%_.
MR|magnetic resonance|MR|113|114|LABORATORY AND DIAGNOSTIC DATA|Normoactive bowel sounds. EXTREMITIES: Unremarkable. NEUROLOGIC: Grossly intact. LABORATORY AND DIAGNOSTIC DATA: MR angiogram of the abdomen negative. CT scan of the abdomen demonstrates distal small bowel obstruction, etiology uncertain. This may be on the basis of adhesions. ER reading suggested paralytic ileus.
MR|magnetic resonance|MR|262|263|ASSESSMENT|Skeletal system: He has high arches. ASSESSMENT: I think the MR finding represents a benign, incidental finding, which may simply represent a prominent perivascular space. PLAN: I do not think that he needs any further neurologic assessment or evaluation of the MR finding. His headache I think is a benign headache. He may be predisposed to it by somewhat the increased muscle tone.
MR|magnetic resonance|MR|218|219|ASSESSMENT|Wound culture shows heavy-growth Strep, many gram-positive cocci, many gram-negative rods, heavy-growth anaerobes. ASSESSMENT: Probable, at least some, contribution of ischemia. Discussed the options of Doppler study, MR angiography. If abnormal these would lead to angiography. Given his young age, low risk for angiography and high risk of limb loss I think we should proceed directly to angiography in an effort to assess for revascularization.
MR|magnetic resonance|MR|181|182|RECOMMENDATIONS|2. I did review the MRI of the brain. There does not appear to be any acute ischemia to my eye. Will await the formal report. 3. I would cancel the carotid ultrasound and obtain an MR angiogram of the great vessels of the neck so that we can take a better look at the posterior circulation as well as an MRI of the circle of Willis.
MR|magnetic resonance|MR|176|177|HISTORY OF PRESENT ILLNESS|Dr. _%#NAME#%_ ordered an MRI of the brain with an MR angiogram of the circle of Willis. I did review the MRI of the brain and I do not see any evidence of any acute ischemia. MR angiogram has also some normal variants of the circle of Willis, but I do not see any major branch artery occlusion or any aneurysms.
MR|magnetic resonance|MR|286|287|LABORATORY STUDIES|LABORATORY STUDIES: Laboratory studies from _%#MMDD2007#%_ show a white count of 7000, hemoglobin 13.3, platelet count 394,000 with normal serum electrolytes. Creatinine 0.9. Liver function studies on this date are normal including ALT 37, AST 16 and normal total bilirubin at 0.5. The MR scan of the brain demonstrates an enhancing intraaxial lobulated mass in the left cerebellum measuring 1.8 x 1.2 x 1.8 cm with a small amount of surrounding edema, but no shift at midline structures.
MR|magnetic resonance|MR|138|139|RECOMMENDATIONS|I discussed my impressions with the family and they are in agreement with heparinization for now. We will also obtain an MRI of brain and MR angiogram and circle of Willis in the morning to assess the size and location of the infarct or multiple infarcts and to rule out any high-grade stenotic disease in the vertebral basilar system in view of the fluctuating symptoms she manifests.
MR|magnetic resonance|MR|97|98|PLAN|2. Hypertension. 3. Status post radical prostatectomy for cancer in situ. PLAN: 1. MRI brain and MR angiography. 2. Just on Thursday, _%#MMDD2005#%_, he had bilateral carotid ultrasound study, and we will try to get those results. 3. Other studies, as per CVI admission orders, and depending on the results of the initial evaluation and his clinical course.
MR|mitral regurgitation|MR.|153|155|LAB  DATA|Sigmoid diverticulosis was also noted. Echo preliminary shows LV size mildly increased. There is probable hypokinesis of the inferior wall with moderate MR. Ejection fraction is at least 40%. EKG demonstrates a sinus rhythm, tall R wave in V1 and V2, possibly consistent with previous posterior infarct, mild nonspecific ST-T wave changes from lead V2 to V6, probably consistent with global ischemia, mild ST depression was noted on lead II.
MR|magnetic resonance|MR|263|264|RECOMMENDATIONS|Multiple other problems noted as outlined above. He has a very large common bile duct on CT scan, but the minimal liver function tests changes would suggest that this is not the cause of his current problems. RECOMMENDATIONS: 1. Agree with current management. 2. MR angiogram at some point in the near future to look at his celiac and SMA and evaluate for any critical stenosis.
MR|mental retardation|MR,|180|182|DISCUSSION|The patient was admitted for the evaluation of escalating behavior concerns. She has a significant psychiatric history, which includes pervasive developmental disorder, ADHD, mild MR, fetal alcohol spectrum. She has been hospitalized here on several occasions for similar concerns. The patient denies acute physical concerns. She does have a history of pulmonary stenosis and recently had an echocardiogram done to evaluate this, in view of history of intermittent left lower extremity edema.
MR|mitral regurgitation|MR.|196|198|INDICATION FOR CONSULTATION|White count was 21,000, hemoglobin 14.3 grams. There was trace elevation of the troponin. This led to an echocardiogram being done which showed well preserved LV systolic function. No significant MR. The left atrium was difficult to see. The right ventricle was hypokinetic and dilated and the right atrium was dilated with mild TR.
MR|magnetic resonance|MR|150|151|RECOMMENDATIONS|RECOMMENDATIONS: Proceed with near-term IV anticoagulation with Heparin rather than antiplatelet therapy, which has been initiated by Dr. _%#NAME#%_. MR angiography of both the cervical and cranial blood vessels is a good place to start, although conventional angiography may be required to look at all the branches of the left middle cerebral and posterior cerebral distributions.
MR|magnetic resonance|MR|116|117|REQUESTING PHYSICIAN|He has been additionally identified as having a lesion at the L5 vertebral body and possible lesion at L3 on recent MR scan. He is starting Decadron and thalidomide treatment for his myeloma and he is started on Decadron at 20 mg q.d. He is seen for consideration of radiation therapy to his multiple level areas of disease involvement.
MR|mitral regurgitation|MR|315|316|IMPRESSION/RECOMMENDATIONS|IMPRESSION/RECOMMENDATIONS: The patient is a pleasant 44-year-old lady who presented with decreased exercise tolerance, along with palpitations and symptoms of thyrotoxicosis. She is noted to have atrial fibrillation with a rapid ventricular response. The patient does have severe valvular disease including severe MR and TR with subvalvular restriction likely from rheumatic valvular disease. It is likely the atrial fibrillation is from the MR and thyrotoxicosis and appeared to be chronic.
MR|magnetic resonance|MR|188|189|NEUROLOGY CONSULTATION|The question as to whether or not this gentleman has had a TIA or perhaps a mild stroke needs to be evaluated further. MRI scan to be done with diffusion imaging will help in this regard. MR angiogram of both the circle of Willis and the carotid vasculature in the neck will be obtained. We will also obtain his medical records from his past admission to review that workup as well.
MR|magnetic resonance|MR|187|188|PHYSICAL EXAMINATION|An MRI scan of the head done _%#MMDD2004#%_ revealed an old right frontal cerebrovascular infarct with encephalomalacia and there was significant high signal changes in both hemispheres. MR angiogram was negative for any significant carotid, vertebral, or basilar artery stenosis. Glucose 118 and creatinine 1.63. IMPRESSION: 1. Syncopal episode yesterday.
MR|mitral regurgitation|MR,|205|207|INDICATION FOR CONSULTATION|An echocardiogram was done in the hospital today showing a technetium approximated EF of 20 percent to 25 percent, anteroseptal apical akinesia, severe inferoseptal and posterior hyperkinesia. He has mild MR, mild TR, mild aortic and mitral leaflet sclerosis, and mild mitral annular calcification. Left atrial dilation was noted. Since admission, he has been asymptomatic.
MR|mitral regurgitation|MR,|137|139|HISTORY OF PRESENT ILLNESS|Remarkably the LV was not dilated, but all the other chambers were. There was no LV aneurysm or LV thrombus. There was moderately severe MR, moderately severe TR and mild pulmonary hypertension, RVSP of 29 mmHg plus right atrial pressure. There was sclerosis of the aortic and mitral leaflet, but really nothing clinically significant.
MR|magnetic resonance|MR|107|108|RECOMMENDATIONS|3. Myalgia, rule out polymyalgia rheumatica versus osteoarthritis. RECOMMENDATIONS: 1. MRI of the head. 2. MR angiogram of the aortic arch and subclavian vessel. 3. Check sedimentation rate. 4. Will follow his course with you.
MR|mitral regurgitation|MR,|213|215|ASSESSMENT|The patient is hemodynamically stable. 2. Alpha hemolytic strep detected per right knee aspirate _%#MMDD2007#%_. 3. History of chronic heart murmur with an echocardiogram several years ago revealing mild AI, mild MR, and no aortic stenosis. 4. No known coronary artery disease. 5. Hyperlipidemia. RECOMMENDATIONS: Routine postoperative labs will be obtained.
MR|magnetic resonance|MR|343|344|ASSESSMENT|At this point, we would pursue some additional non-invasive studies including semi-quantitative evaluation of proteinuria, a broad battery of blood chemistries tomorrow including muscle enzymes and uric acid as well as indicators of hemolysis. Additional imaging studies of the kidneys and urinary tract might be warranted. This might include MR scanning. At this point, we will hold this in reserve, but certainly a percutaneous renal biopsy might very well be entertained by about _%#MM#%_ the _%#DD#%_ in the event that diagnosis has not already been established.
MR|magnetic resonance|MR|279|280|ASSESSMENT/PLAN|At this point, I would like to recheck a right upper quadrant ultrasound to be sure she has not developed any obvious gallbladder wall thickening or common duct dilatation. If that is negative and liver function tests reveal any abnormality, then consideration might be given to MR cholangiogram, but hopefully during the work-up the patient's pain will get back to her baseline. I think we will have significantly more options if she can get at least to her second trimester.
MR|mitral regurgitation|MR.|186|188|PAST  MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Hyperlipidemia with hypertriglyceridemia. 2. Hypertension 3. atrial fibrillation and flutter with previous cardioversion as above. 4. Mitral valve prolapse with MR. 5. Cataract surgery SOCIAL HISTORY: She lives alone but her daughter is here with here.
MR|mitral regurgitation|MR|350|351|PAST  MEDICAL HISTORY|1. Aortic valve disease with known aortic insufficiency. She has had variable ejection fractions, but her last echo a year ago showed nearly normal ejection fraction, however the fact that her ejection fraction of 55-60% last year with significant AI suggests that there was already LV dysfunction. 2. Mild aortic enlargement 3. She has had moderate MR in the past but only trace to mild more recently. She had moderate to severe pulmonary hypertension in the past which also improved with medical therapy.
MR|magnetic resonance|MR|241|242|HISTORY OF PRESENT ILLNESS|The patient states that she has seen an acupuncturist who has given her Siberian Ginseng and claims her headaches have decreased. On _%#MMDD2002#%_ the patient had a seizure with aphasia lasting approximately 8 minutes. On _%#MMDD2002#%_ an MR scan was performed showing two new metastases, one in the right medial frontal lobe and one in the right medial occipital lobe.
MR|mitral regurgitation|MR.|185|187|LABORATORY DATA|CT of the chest shows a left infiltrate, right atelectasis with a very small left effusion. Echocardiogram shows decreased RV function and increased RV pressure, normal LV function, 1+ MR. Pleural fluid LD 572, pleural fluid protein 2.1. No cell count available. Serum bicarbonate 30. BNP is 159. PHYSICAL EXAMINATION: VITALS: She is currently afebrile with a pulse of 124, respiratory rate of 24 to 28, blood pressure 129/64, sp02 is 91% on 10 liter Oxymizer.
MR|magnetic resonance|MR|171|172|ASSESSMENT/RECOMMENDATIONS|In that case, she may require permanent pacing. It is recommended that thyroid function studies be obtained. She may require further work-up for hypertension including an MR angiogram of the abdomen. Given that the patient has "ruled out" for myocardial infarction, enoxaparin could be discontinued.
MR|magnetic resonance|MR|192|193|IMPRESSION|I would not do a bolus because I see signs of attenuation on the CT scan, and I am afraid of hemorrhagic transformation of this ischemic CVI. I will plan to proceed with MRI of the brain with MR angiogram, and review records from her primary MD. I will also plan to ask for consultation from Vascular Surgery to make a decision about the time of the carotid endarterectomy.
MR|magnetic resonance|MR|199|200|IMPRESSION|MRI does not show any evidence of diffusion weighted abnormalities to suggest stroke or TIA. 2. Evidence of high-grade ICA stenosis, versus near occlusion, versus occlusion. The patient needs formal MR angiogram of neck and circle of Willis for further assessment. RECOMMENDATIONS: Proceed with MR angiogram of neck and circle of Willis while patient in the Emergency Room and make further decision about treatment.
MR|magnetic resonance|MR|126|127|SUMMARY OF HOSPITAL COURSE|He probably has multiple old strokes as noted in the past MRI's which can explain his mental status. We will check an MRI and MR angiogram. We will check an ultrasound to see if there has been any progression, even though this is probably a posterior circulation stroke.
MR|magnetic resonance|MR|182|183|SUMMARY|Most likely, Mr. _%#NAME#%_ had a focal seizure resulting from a right hemispheric stroke. I will proceed with a full stroke workup, including an MRI scan of the brain as well as an MR angiogram. A duplex carotid ultrasound will be checked as well. In the interim, he has already been started on Plavix. Further, we will proceed with an oral Dilantin load. He will placed on venous Dilantin as well.
MR|magnetic resonance|MR|172|173|SUMMARY|I would recommend checking the cholesterol, as well as hemoglobin A1c. Carotid ultrasound is a reasonable improvement test, but I would actually be interested in seeing an MR of the brain and brain stem to insure that the localization is consistent with small vessel involvement. If that is the case, aspirin (or Plavix) should be sufficient therapy.
MR|magnetic resonance|MR|316|317|HISTORY OF PRESENT ILLNESS|This was followed up with an MRI of the brain, which on diffusion-weighted imaging revealed lesions in the right frontal lobe and right temporal lobe in the distribution of the right middle cerebral artery. These were felt to be compatible with acute infarct and distribution of the right middle cerebral artery. An MR angiogram demonstrated occlusion of the right middle cerebral artery as well, but decreased flow to the anterior branch of the middle cerebral artery and stenosis at the genu of the right middle cerebral artery.
MR|magnetic resonance|MR|153|154|RECOMMENDATIONS|I would consider her for an MR angiogram again if she consents to this. RECOMMENDATIONS: 1. Await dialysis. 2. Consider repeat upper endoscopy, consider MR angiogram, consider small bowel follow-through and consider lower GI evaluation with either barium enema vs colonoscopy if her clinical status improves post dialysis.
MR|magnetic resonance|MR|208|209|IMPRESSION|IMPRESSION: This lady presents with most likely brain stem stroke due to small vessel ischemic disease related to underlying cardiovascular disease. At this point, I would like to obtain MRI of the brain and MR angiogram to assess for the type of stroke and possibility of intracranial stenosis which may change anticoagulation therapy.
MR|magnetic resonance|MR|214|215|IMPRESSION|IMPRESSION: 1. Persistent vascular headache on the right 2. Right partial internal ophthalmoplegia. 3. Increased RBC in the spinal fluid without clearing of the fourth tube. Suspect for subarachnoid hemorrhage. 4. MR angiogram performed elsewhere suggestive of possible fibromuscular dysplasia of the large vessels. DISCUSSION: It is entirely possible that this patient is suffering from a bad migraine.
MR|magnetic resonance|MR|273|274|HISTORY OF PRESENT ILLNESS|She received postoperative CyberKnife radiotherapy to that site (L1-L2 intradural mass) between _%#MMDD2005#%_ and _%#MMDD2005#%_, a total dose of 300 cGy was delivered to the 85% isodose line. We have now been asked to see Ms. _%#NAME#%_ in consultation because follow-up MR scans of her brain have demonstrated some progression with new contrast enhancement in the medial right occipital lobe, as well as increasing associated edema.
MR|mitral regurgitation|MR.|279|281|EXAMINATION|Review of the report includes a thallium scan which reveals no evidence of viability in the region of the right coronary insertion of this artery. However, there was viability demonstrated in the anterior wall in the distribution of the LAD. Echocardiogram also reveals moderate MR. IMPRESSION: This is a 62-year-old gentleman with a past medical history of coronary artery disease, congestive heart failure, dilated cardiomyopathy, diabetes mellitus, hypertension, hypercholesterolemia with significant triple vessel coronary artery disease.
MR|magnetic resonance|MR|222|223|IMPRESSION|The denseness of involvement seems to be pretty much more consistent perhaps with deeper involvement such as the internal capsule and I presume there may be some thalamic involvement as well. We will do an MRI. We will do MR angiography. We will do an echocardiogram. He has been started on a baby aspirin for now although obviously will need to keep a close eye on bleeding related issues.
MR|magnetic resonance|MR|199|200|HISTORY OF PRESENT ILLNESS|He has never had similar symptoms in the past. He did undergo MRI of the brain in the Emergency Room revealing a recent stroke in the left internal capsule corona radiata region. He also did undergo MR angiography and I believe no significant large vessel stenosis was identified. PAST MEDICAL HISTORY: His medical history is fairly benign. No prior history of hypertension, diabetes, cancer.
MR|magnetic resonance|MR|135|136|ASSESSMENT|However, with a question of vasculitis, further assessment would be appropriate. MRI of the brain with and without contrast as well as MR angiogram of the circle of Willis will be carried out. She will be started on a full course of myofascial therapy to her neck and shoulders.
MR|magnetic resonance|MR|203|204|SUMMARY|We will check an ultrasound, MRI, MR angiogram and an echo. Her risk factors are hypertension and hyperlipidemia with her two old infarcts on CT scan in the left hemisphere, I suspect her ultrasound and MR angiogram will probably show something in the left carotid distribution. We will keep her on aspirin for now. Internal medicine will manage her acute renal failure.
MR|magnetic resonance|MR|216|217|HISTORY OF PRESENT ILLNESS|Since admission, she has had head CT and MRI of the brain which I personally reviewed, none of which showed any evidence of intracranial pathology such as bleed or stroke. She has mild small vessel ischemic disease. MR angiogram of the neck and the circle of Willis were also done, reviewed by me, and were unremarkable. She had a metabolic workup which did not show any evidence of a urinary tract infection.
MR|magnetic resonance|MR|262|263|IMPRESSION|No evidence of intracranial hemorrhage is noted. IMPRESSION: This gentleman presents with left internal capsule stroke due to possibly left internal carotid artery stenosis. At this point, I would like him to have MRI of the brain to rule out embolic stroke and MR angiogram of neck and circle of Willis to estimate stenosis. I would like to start him on Coumadin tonight per protocol and keep his Plavix to Wednesday and discontinue that.
MR|magnetic resonance|MR|232|233|HISTORY OF PRESENT ILLNESS|She is seen at this time for consideration of radiation therapy to the brain region. She is also being considered for stereotactic radiosurgery treatment to the lesion, which is felt to be consistent with metastatic tumor, based on MR scan. PAST MEDICAL HISTORY: 1. Right mastectomy in 1988. 2. Left hip replacement in _%#MM#%_ 2001.
MR|mitral regurgitation|MR.|201|203|PAST MEDICAL HISTORY|Internal medicine consultation was requested to follow this patient regarding his history of asthma. PAST MEDICAL HISTORY: 1. Bipolar affective disorder. 2. Mild persistent asthma. 3. Mild to moderate MR. 4. History of suicide attempt x 1 by hanging. SURGICAL HISTORY: None. ADMISSION MEDICATIONS: 1. Depakote. 2. Concerta.
MR|mitral regurgitation|MR|230|231|ASSESSMENT|He has had congestive heart failure in the past and is admitted now with worsening orthopnea, PND and fatigue along with peripheral edema. He is clearly in biventricular heart failure. His echocardiogram demonstrates worsening of MR and TR as well as possible or likely worsening of his LV function. He is in class III to IV heart failure at the time of my visit today.
MR|mitral regurgitation|MR|307|308|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is a 70-year-old gentleman who was recently discharged from the hospital after having suffered a left posterior temporal occipital infarct. He was hospitalized at that time at our institution and he underwent a rather extensive workup. This included an MR of the brain which revealed a stroke as described above. A carotid ultrasound revealed a less than 50% narrowing of the carotid artery and an echocardiogram which did not show any significant cardiac source of embolus.
MR|mitral regurgitation|MR|277|278|REASON FOR CONSULTATION|She has had a cardiac catheterization in _%#MM2005#%_ at North Memorial and was found to have normal coronary arteries, and her LV function has been normal with diastolic dysfunction suggested in the past by pseudonormalization of the mitral inflow pattern. Moderate to severe MR has been noted in the past, although on the current echocardiogram, the MR appears to be mild to moderate, rather than moderate to severe.
MR|magnetic resonance|MR|309|310|IMPRESSION|IMPRESSION: This gentleman presents with acute stroke in the distribution of left middle cerebral artery, it is possible that he does have carotid stenosis because he did presents with amaurosis Fugax. At this point, I think it most reasonable to put him on heparin until we will obtain MRI of the brain with MR angiogram of neck and circle of Willis and evaluate him for carotid stenosis. At this point I will hold his aspirin. We also will proceed with echocardiogram and the rest of the admission orders for be done per stroke protocol.
MR|mitral regurgitation|MR,|155|157|LABORATORY DATA|Troponin was 4.64, 7.34 and now 9.08. Echocardiogram reveals an ejection fraction of 45-50%. Global hypokinesis, moderate basal inferior hypokinesis, mild MR, moderate AS with aortic valve area of 1.0 cm squared. Admission EKG reveals atrial fibrillation with Q waves in II, III and aVF.
MR|magnetic resonance|MR|328|329|RECOMMENDATIONS|I suspect we are dealing with more problems over her baseline and I would be suspicious that her dehydration, urinary tract infection and cellulitis are the source of her recent decline, having an antecedent frail central nervous system. RECOMMENDATIONS: At this point in time I do not believe that MRI scanning of the brain or MR angiography is going to make much difference and would cancel that. I believe that antiplatelet therapy remains appropriate for her in any circumstance.
MR|magnetic resonance|MR|232|233|HISTORY OF PRESENT ILLNESS|The following day she noted intermittent left arm tingling as well as facial numbness which apparently slit the midline. These symptoms have completely resolved, and she is not certain when they began. She was evaluated by MRI with MR angiogram of the neck. There is no evidence for stroke and no evidence of vascular abnormality. She was ready for discharge yesterday, but complained of leg weakness so she was help further.
MR|magnetic resonance|MR|115|116|RECOMMENDATIONS|Alternatively, this stroke could be related to embolization from cardiac source. RECOMMENDATIONS: 1. MRI brain and MR angiogram of the carotid arteries in the neck to evaluate further. 2. Continue Heparin and aspirin therapy for now. 3. Speech therapy to evaluate and treat.
MR|mitral regurgitation|MR|159|160|LABORATORIES|Echocardiogram revealed decreased ejection fraction of 20% with severe left ventricular dysfunction. There is mild right ventricular dysfunction with moderate MR and mild TR. ASSESSMENT AND PLAN: 66-year-old gentleman admitted with severe ischemic cardiomyopathy and dependent inotropes.
MR|magnetic resonance|MR|231|232|RECOMMENDATIONS|Some type of external brace maybe an option because of the worse case scenario if this culture grows out nothing will be a stress fracture. Therefore, if we just keep it conservative and follow with serial x-rays, I don't think an MR is going to be needed and I don't see her sitting still for an MRI scan. Bone scan would be nice, but right now it would be superfluous as her only bone pain seems to be the obvious, the right knee.
MR|magnetic resonance|MR|217|218|IMPRESSION|Somewhat concerned about possible ascending fasciitis here if it gets in the leg but right now there is no signs of that at all. Some times this becomes urgent for surgical debridement therefore I would recommend get MR today rather than tomorrow and may see more early gas shadows or problems and/or deep pockets of fluid, particularly to see if it is following a fascial plane.
MR|mitral regurgitation|MR,|224|226|LABORATORY DATA|His only sister died from a malignancy. LABORATORY DATA: Chest x-ray shows minimal left atelectasis. Troponins 1.66, 1.37, 1.28, white blood count 8.1. Echocardiography shows depressed left ventricular function of 35%, mild MR, left atrial enlargement, right ventricular and atrium within normal limits, mild pulmonary hypertension. PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile, pulse 80, respiratory rate 18, blood pressure 118/47, SpO2 96% on room air.
MR|mitral regurgitation|MR|197|198|HISTORY OF PRESENT ILLNESS|His echocardiogram which was also done recently showed an ejection fraction of 35-40% with inferior akinesis. His RV was normal in size, his mitral valve was mildly thickened with mild to moderate MR . He also had mild tricuspid regurgitation. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Secondary heart block with permanent pacemaker.
MR|magnetic resonance|MR|124|125|PLAN|We will use haloperidol for sedation as needed. We will allow the patient a liquid po diet with her improved mental status. MR scanning is appropriate. We will plan on that later today as we are able. DISCUSSION: Ms. _%#NAME#%_'s history is already well described. This unfortunate young woman has a history of adenocarcinoma of the breath, with diagnosis made apparently in 1999.
MR|magnetic resonance|MR|129|130|RECOMMENDATIONS|RECOMMENDATIONS: MRI to further characterize the size and location of the stroke to assist with prognosis. Ultrasound of carotid MR angiogram of the intracranial circulation, swallow evaluation and Cardiology consultation is already being arranged with Dr. _%#NAME#%_. Apparently previous conversations have determined that the patient would not want to be aggressive with his care of this condition, but this needs to be confirmed.
MR|mitral regurgitation|MR|305|306|HISTORY|HISTORY: Mr. _%#NAME#%_ _%#NAME#%_ is an 83-year-old with a history of diabetes and coronary artery disease, status post angiogram and PCI three years ago who presented with sudden onset of dyspnea on exertion and heart failure. Transthoracic echocardiogram revealed a normal EF with a moderate to severe MR and question if there is a flail cord or leaflet. He was then transferred here for further management from Lakes Hospital.
MR|magnetic resonance|MR|245|246|HISTORY OF PRESENT ILLNESS|His foot ulcer developed over the last few weeks, at which time he had noted painless eschar on the bottom of the lateral left foot. He apparently saw a couple physicians in Florida, and ultimately was admitted for further evaluation. He had an MR angiogram, and I have reviewed this. It shows no proximal inflow disease. The left proximal superficial femoral and profunda femoris are patent.
MR|magnetic resonance|MR|238|239|HISTORY OF PRESENT ILLNESS|His gait is changed after the stroke. Since admission, the patient had MRI of the brain with MR angiogram of neck and circle of Willis which I personally reviewed. There is no evidence of acute stroke. There is old right thalamic stroke. MR angiogram of neck and circle of Willis do not show any intracranial stenosis. The patient did have echocardiogram which showed hypokinetic left ventricle and ejection fraction of 45% with no evidence of clots or shunt.
MR|magnetic resonance|MR|181|182|RECOMMENDATIONS|I did see him recently on neurologic consultation. He did have low normal vitamin B12 of 289. He also had a low normal zoster of 248. MRI of the brain shows age-related change, but MR angiogram did demonstrate an incidental 8.5-mm aneurysm arising from the right middle cerebral artery trifurcation. I last saw him on _%#MMDD2006#%_. Plan atrial fibrillation that time was to refer him for interventional radiology consultation for coiling.
MR|magnetic resonance|MR|189|190|REASON FOR CONSULTATION|At this point he does not have any symptoms of angina or of congestive heart failure. He also has had a stent placed in the left external iliac artery. He has a small left kidney. He had a MR angiogram of the abdomen done on _%#MMDD2004#%_ and this shows the superior mesenteric artery wide open. The patient has been on a proton pump inhibitor for quite awhile.
MR|magnetic resonance|MR|385|386|LABORATORY DATA|His imaging studies including a CT of the head on admission and again this morning reveal a subacute right occipital hemorrhagic infarct with mild localized mass effect as well as a subtle low density in the left occipital lobe, possibly reflecting a subacute left occipital infarct. There are no other hemorrhagic areas. LABORATORY DATA: In _%#MM#%_, just a few weeks ago he did have MR imaging of the carotids, he did have an echocardiogram that did not reveal an embolic sources or severe stenoses. IMPRESSION: Elderly man with colon cancer and multiple embolic infarcts now one hemorrhagic probably due to anticoagulant therapy which was slightly supratherapeutic.
MR|magnetic resonance|MR|180|181|RECOMMENDATIONS|RECOMMENDATIONS: Obtain a thorough metabolic workup for electrolytes, liver function tests, drug levels, sed rates, CM and B12. I will also obtain urine analysis and I will pursue MR images of the brain at this point with and without contrast to rule out brain tumor and EEG to rule out encephalopathy.
MR|magnetic resonance|MR|175|176|RECOMMENDATIONS|RECOMMENDATIONS: Proceed with MRI of the brain with and without contract and diffusion-weighted imaging to identify any evidence of a new left hemisphere stroke. In addition, MR angiogram of both the circle of Willis and the cervical vessels will be obtained to assess any evidence of high-grade large vessel occlusion.
MR|magnetic resonance|MR|201|202|SHE IS ALLERGIC OR INTOLERANT OF PENICILLIN.|Her white count on admission was 6700, hemoglobin 12.7. The CAT scan did show a dilated biliary system with a question of air in the biliary tree as well. I did speak with Dr. _%#NAME#%_, radiologist. MR does not show evidence of stones. IMPRESSION: This patient is admitted with acute abdominal pain that is now resolved.
MR|magnetic resonance|MR|157|158|REASON FOR CONSULTATION/HISTORY OF PRESENT ILLNESS|It was noted that her BUN had crept up to 33 with her BUN of 1.5. Her troponins have been normal, but her B-type natriuretic peptide has crept up to 924. An MR angiogram of her aorta was performed demonstrating severe diffuse atheromatous disease in the aorta, particularly around the posterior aspect of the peri renal aorta.
MR|magnetic resonance|MR|250|251|HISTORY OF PRESENT ILLNESS|Because of an MRI showing evidence for a CVA, and the patient's somewhat confusing presentation, he was transferred to Fairview Southdale Hospital for evaluation where an MR angiogram was performed. Please see Dr. _%#NAME#%_'s dictated notes for the MR angiogram details. PAST SURGICAL HISTORY: The patient has had an appendectomy, tonsillectomy, and nasal septal repair, all in the remote past.
MR|magnetic resonance|MR|123|124|HISTORY OF PRESENT ILLNESS|The patient reports being admitted because of seeing things, which is no longer, the case. He was evaluated with a MRI and MR angiogram at _%#CITY#%_ _%#CITY#%_ Radiology. on _%#MM#%_ _%#DD#%_, 2002, with ventricular enlargement consistent with atrophy. However, normal pressure hydrocephalus could not be ruled out. Moderate small vessel ischemic changes were present bilaterally with no mass, hemorrhage, or recent infarct.
MR|magnetic resonance|MR|150|151|PLAN|I am going to ask in he morning to have Women's Imaging specialist review her _%#MM#%_ pelvic CT. I think it might be reasonable to consider a pelvic MR scan to clarify if she still has extensive clot in pelvic veins, which would be the likely source of her embolisms.
MR|GENERAL ENGLISH|MR.|113|115|CURRENT MEDICATIONS|MEDICATION ALLERGIES: HE REPORTED AN ALLERGY TO SULFA. HE WAS UNABLE TO TOLERATE CARVEDILOL DUE TO SIDE EFFECTS. MR. _%#NAME#%_ INSISTS HE IS UNABLE TO TAKE TOPROL XL SINCE HIS DIABETES MELLITUS WAS UNCONTROLLABLE WHILE HE WAS ON THIS FORM OF METOPROLOL AS A RESULT HE HAS BEEN TAKING LOPRESSOR AT 100 MG P.O. T.I.D. FAMILY HISTORY: He did not report a family history of premature coronary artery disease or sudden cardiac death.
MR|magnetic resonance|MR|225|226|DOB|Vascular status is intact. The MRI scan was reviewed of the thoracic spine which shows severe central canal stenosis and cord deformity at T11-12 secondary to broad- based disk bulging and facet degeneration. He does have an MR scan of the cervical spine which shows moderate degenerative disk disease at C3-4 with moderate stenosis at C3-4 and C4-5 levels.
MR|magnetic resonance|MR|83|84|REVIEW OF SYSTEMS|He does not smoke. He is a social drinker. REVIEW OF SYSTEMS: Unremarkable. X-ray: MR scan of the lumbar spine dated _%#MMDD2005#%_ was personally reviewed. He does have a Grade 1 L5 on S1 spondylolisthesis due to bilateral pars defect.
MR|magnetic resonance|MR|124|125|RECOMMENDATIONS|3. MRI of the cervical spine with and without contrast. 4. MR angiogram of circle of Willis 5. MR angiogram of the neck. 6. MR venogram of the brain. 7. Psychiatric consultation. 8. Will continue to follow the patient with you.
MR|magnetic resonance|MR|240|241|PHYSICAL EXAMINATION|COR: S1, S2 regular, no pedal edema. Her workup includes a CT of the head which reveals chronic age-related changes with no mass effect. MRI scan of the head reveals ossification of the posterior falx, otherwise no significant abnormality. MR angiogram of the circle of Willis was normal. Ultrasound of the carotid artery was unremarkable. Labs thus far included a TSH, glucose, urinalysis and sed rate which are unremarkable.
MR|magnetic resonance|MR|223|224|REASON FOR CONSULTATION|Recently she has had increasing difficulty with lower extremity pain and pain and discomfort in the low back region. The patient was hospitalized and has subsequently developed bladder incontinence. Evaluation has included MR scan of the spine which shows no evidence of epidural or leptomeningeal involvement. The patient has also undergone a spinal fluid tap carried out late last week.
MR|magnetic resonance|MR|126|127|HISTORY  OF PRESENT ILLNESS|She had a repeat colonoscopy today, and again, there were changes consistent with acute ischemic colitis. Of note, she had an MR angiogram in _%#MM#%_ 2007, and there was no evidence for arterial atherosclerosis or acute thrombosis. For workup of ischemic colitis, she had a number of studies in _%#MM2007#%_.
MR|magnetic resonance|MR|135|136|HISTORY OF PRESENT ILLNESS|She had been admitted to the hospital and since yesterday had developed urinary retention. Since admission to the hospital, she had an MR of the brain which I personally reviewed. It did not show any evidence of metastasis. MRI of the cervical, thoracic and lumbar spine were done without contrast.
MR|mitral regurgitation|MR|183|184|PHYSICAL EXAMINATION|The aortic valve has been approximated at 0.8 cm squared down to 0.66 cm squared on the current echo with a mean gradient of 32 and a peak gradient of 53 mmHg. LV function is normal. MR is +2, TR +1, and he has moderate pulmonary hypertension. The cause of his syncope is unclear and certainly could be multifactorial including orthostatic and vasovagal mechanisms with standing and lying down associated with weakness, nausea, and queasiness before passing out.
MR|magnetic resonance|MR|256|257||The patient was taken as quickly as possible to radiology where she underwent a cervical CT scan because the MRI scan was not available. The CT showed a narrow canal at the cervical level. She was taken emergently across the river to the University campus MR scanner where suboptimal images were obtained because of patient movement. Cervical, thoracic and lumbosacral segments were imaged again with poor quality films.
MR|magnetic resonance|MR|212|213|RECOMMENDATIONS|These are ischemic infarcts, most likely due to atherosclerotic cerebrovascular disease. RECOMMENDATIONS: 1. Agree with aspirin therapy. 2. Continue to monitor for blood pressure elevations. 3. Lipid profile. 4. MR angiography of the intracranial vasculature to see if he has an area of high grade stenosis or occlusion. 5. Smoking cessation. 6. Rehab. All of this was discussed with the patient and his wife.
MR|magnetic resonance|MR|248|249|IMPRESSION|She does have some abnormalities on EKG and I think it would be worthwhile to do echocardiogram to rule out obvious significant embolic source. At this point Plavix has been added to her aspirin which seems entirely appropriate. I would like to do MR angiography as opposed to carotid ultrasound as I believe this will give us better views of her posterior circulation. We will do an MRI brain just to see if there is any obvious acute ischemia.
MR|magnetic resonance|MR|284|285|RECOMMENDATIONS|The patient has appropriately undergone urgent right carotid endarterectomy for management of carotid artery disease, which was likely the cause of the stroke. RECOMMENDATIONS: Initiate stroke protocol for nursing purposes. Continued aspirin/persantine/Aggrenox. MRI of the head with MR angiography to further workup the anatomy and further characterize the stroke and echocardiogram. Will follow her course with you.
MR|magnetic resonance|MR|197|198|RECOMMENDATION|RECOMMENDATION: At this time, from a neurologic standpoint we have to proceed with EEG. MRI of the brain will be carried out and look for any structure that correlates to this episode. In addition MR angiography of circle of Willis as well as cervical vessels would be checked. During his hospitalization here, I recommend cardiac monitoring and telemetry.
MR|magnetic resonance|MR|222|223|REQUESTING PHYSICIAN|This biopsy demonstrates metastatic adenocarcinoma of the prostate. The patient has had elevated prostate specific antigen value of 14,364 on _%#MMDD2005#%_. The patient has had right leg weakness. This was evaluated with MR scan of the spine being carried out earlier today. This demonstrates spinal cord impingement at the T6 vertebral body level with additional lesion at T8.
MR|magnetic resonance|MR|134|135|HISTORY OF PRESENT ILLNESS|He did have an MRI scan of the brain which demonstrated nonspecific small vessel changes but no evidence of acute or subacute stroke. MR angiogram of the circle of Willis and the neck vessels was normal. He states that shortly after admission to the hospital, his symptoms did resolve.
MR|magnetic resonance|MR|197|198|DISCUSSION|He is admitted after recent laboratory studies were obtained in the clinic after he presented with symptoms of a two week history of left hip pain. Apparently a plane film was negative and further MR scan may have been done on an outpatient basis, results of which we are not clear on. In the meantime, he had blood work done at the clinic and was told to come for hospitalization because of a potassium of about 6 and an elevated creatinine.
MR|magnetic resonance|MR|250|251|REQUESTING PHYSICIANS|His symptoms basically persisted and I believe later in the same year, 2002, he had further episodes of left-sided weakness, numbness, and tingling. He underwent further evaluation including transesophageal echocardiography showing no abnormalities, MR angiography showing no abnormalities, and MRI scanning of the brain showing small vessel white matter ischemic changes. He was seen in neurological consultation by my associate, Dr. _%#NAME#%_ _%#NAME#%_, who felt that it would be most appropriate to manage him with aspirin and Plavix for small vessel ischemic cerebrovascular disease and continue to manage him for migraine.
MR|magnetic resonance|MR|108|109|RECOMMENDATIONS|3. Same thing holds true about the word finding difficulties. RECOMMENDATIONS: 1. MRI of cervical spine. 2. MR angiogram of the great vessels of the neck, the aortic arch and the circle of Willis. 3. We will continue to follow the patient with you.
MR|magnetic resonance|MR|134|135|ASSESSMENT/RECOMMENDATIONS|If he were not leaving town so quickly, I would prefer a stress nuclear study. His symptoms are not suspicious for aortic disease. An MR angiogram has been ordered of the neck as well as the aortic arch which will be beneficial. As such, it is recommended that lisinopril be initiated. Basic metabolic panel can be performed tomorrow.
MR|magnetic resonance|MR|178|179|RECOMMENDATIONS|He may require low dose neuroleptic, but this should be deferred to Psychiatry. If there is evidence of a new cerebral infarct, I would recommend adding aspirin to the Coumadin. MR angiogram should be followed up, with the MRA previously suggesting stenosis of the right carotid. Thank you for asking me to see this pleasant gentleman in consultation.
MR|magnetic resonance|MR|137|138|PHYSICAL EXAMINATION|Whether or not she can have an MRI scan will depend on the type of valve. Radiology will be contacted about the ability to perceive with MR imaging. She states that she has already had MRI scan since the valve was replaced. MR angiogram of circle of Willis will be carried out as well.
MR|mitral regurgitation|MR,|235|237|REASON FOR CONSULTATION|Today the patient underwent transesophageal echocardiography to assess the diameter of the aortic annulus, and this was measured at 22 mL. Left ventricular ejection fraction was judged to be about 30% and there was trivial AI, trivial MR, and trivial TR noted. Intra-aortic balloon pump was inserted yesterday. PAST MEDICAL HISTORY: Inferior wall myocardial infarction and stent in the right coronary artery in _%#MM#%_ of 2001, type 2 diabetes mellitus diagnosed in 2004, morbid obesity, hypertension, gastroesophageal reflux disease.
MR|magnetic resonance|MR|206|207|ASSESSMENT/RECOMMENDATIONS|In addition, fasting lipids will be obtained and lipid-lowering therapy initiated as indicated. Aspirin will be added to the patient's medical regimen. If the patient has difficult to control hypertension, MR angiography may be of benefit to assess possibility of renal artery stenosis.
MR|magnetic resonance|MR|119|120|PHYSICAL  EXAMINATION|The appearance could be one of an embolic infarct rather than of a lacunar infarct. I have also reviewed the patient's MR angiogram of the brain which shows an approximately 50% proximal internal carotid artery stenosis on the left and approximately 60-70% proximal internal carotid artery stenosis on the right.
MR|magnetic resonance|MR|186|187|HISTORY OF PRESENT ILLNESS|He was seen by my associate, Dr. _%#NAME#%_, who evaluated him for syncope. He had an MRI scan which revealed an old cerebellar stroke, but no evidence of acute infarcts. He did have an MR angiogram which showed greater than 90% stenosis of his right carotid, and a carotid ultrasound revealed evidence of about a 70% stenosis of the right carotid.
MR|magnetic resonance|MR|183|184|SUGGESTIONS|2. If the patient is not alert, at least back to her baseline by tomorrow a.m., I think we should repeat an MRI of the brain with contrast to evaluate further and compare to previous MR studies and rule out carcinomatous meningitis. Radiation necrosis could explain a deteriorating neurologic status as well, however. I spoke with the patient's husband at length. Neurology will follow with you for now.
MR|magnetic resonance|MR|168|169|PLAN|At any rate, I would proceed as follows. PLAN: 1. I agree with obtaining an EEG and an echocardiogram. 2. Rather than obtaining a carotid ultrasound, I would obtain an MR angiogram of the neck and the great vessels of the neck which will give us a better idea of the condition of the posterior circulation as well as of the intracranial vessels.
MR|magnetic resonance|MR|158|159|X-RAYS|PAST MEDICAL HISTORY: Unremarkable. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Nonsmoker, rare alcohol intake. REVIEW OF SYSTEMS: Unremarkable. X-RAYS: MR scan of the lumbosacral spine was reviewed, and this shows a focal moderate-sized central disc herniation at L4-5. PHYSICAL EXAMINATION: The patient is a somewhat heavyset woman who was resting on the bed.
MR|magnetic resonance|MR|212|213|IMPRESSION|However, if this is bioccipital infarcts she might be a candidate for intra-arterial TPA particularly if there is evidence of basilar artery thrombosis. Will proceed expeditiously with an MRI of the brain and an MR angiogram of the circle of Willis. Depending on the results we may need to involve Interventional Neuroradiology. If the results are negative we may need to proceed with intravenous heparin and further workup with an echocardiogram to look for evidence of cardiac source of emboli.
MR|magnetic resonance|MR|135|136|RECOMMENDATIONS|Maintain on intravenous fluids in the meantime. 4. Continue oxygen by nasal cannula. 5. Will start gentle therapies at the bedside. 6. MR angiograms will be obtained of the neck and brain. 7. Will hold the Coumadin for now. 8. Will continue to monitor the patient's condition along with primary service.
MR|magnetic resonance|MR|199|200|HISTORY|He could speak. He had some trouble walking. He came promptly to the emergency room. A CT of the head was unremarkable and subsequently about three to four hours after onset, an MRI of the brain and MR angio of the circle of Willis and of the vessels in the neck were all entirely unremarkable. He has no history of previous such episodes. PAST MEDICAL HISTORY: Diabetes mellitus controlled with metformin low dose.
MR|magnetic resonance|MR|461|462|REASON FOR CONSULTATION|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD (Fairview Cedar Ridge Clinic) REASON FOR CONSULTATION: _%#NAME#%_ _%#NAME#%_ was seen earlier today for evaluation of post coronary angiography symptoms of a right third nerve palsy and left facial twitching. Given his history of hypertension and his hypertension during his acute evaluation today as well as his history of hyperlipidemia, he was evaluated on an emergent basis with MRI scanning of the brain and MR angiography. I reviewed the MR angiography and MRI scan of the brain tonight at 6:00 p.m. with Dr. _%#NAME#%_ _%#NAME#%_ (Radiology).
MR|magnetic resonance|MR|108|109|PHYSICAL EXAMINATION|There is not a great deal of edema surrounding it. It appears to indent the brain An incidental note on the MR angiogram was made of a 6 mm. bifurcation middle cerebral artery aneurysm. A CT of the chest was obtained today which shows a small nodule in the left lower lobe of the lung.
MR|magnetic resonance|MR|132|133|HISTORY OF  PRESENT ILLNESS|Apparently on Friday afternoon she had seen Dr. _%#NAME#%_ as an outpatient in the office who referred her to the MRI of the brain, MR angiogram and sed rate. The dictation from Dr. _%#NAME#%_'s note is not available. It is not clear whether or not patient did have fevers at that time or not.
MR|magnetic resonance|MR|370|371|RECOMMENDATIONS|RECOMMENDATIONS: The patient has been loaded with fosphenytoin. I agree with that and will also recommend continuing with maintenance Dilantin which the care continued at 300 mg per day. Both free and bound phenytoin levels will be checked. As to further evaluation of the infarct, an MRI of the brain with and without contrast and diffusion-weighted imaging as well as MR angiogram of the circle of Willis and cervical vessels will be checked. In addition, an echocardiogram will be checked. He will be maintained on aspirin at the present time.
MR|magnetic resonance|MR|124|125|EXAM|Certainly, he could have had a small infarct which is no clearly identifiable on his MRI scan. I would like to proceed with MR angiogram of the circle of Willis as well as the carotids. I feel that he probably should be maintained on his Coumadin for INRs in the 2.5- 3.0 range.
MR|magnetic resonance|MR|157|158|LABORATORY DATA|If his Inderal could be reduced and amitriptyline eliminated, this would probably help. The patient will be scheduled for MRI of the brain but specifically, MR angiogram of the posterior circulation, including the vertebral arteries from their origins through the basilar artery. Further recommendations can be made once the results of the imaging is available.
MR|magnetic resonance|MR|229|230|RECOMMENDATIONS|IMPRESSION: 1. Ischemic colitis, clinically improving. 2. Heart murmur, question if previously evaluated, question of aortic stenosis. 3. Abdominal bruit. RECOMMENDATIONS: 1. Colonoscopy in a.m. to confirm diagnosis. 2. Consider MR cholangiogram. 3. Consider echocardiogram.
MR|mitral regurgitation|MR.|287|289|IMPRESSION/REPORT/PLAN|2. Mitral regurgitation. This seems moderate to severe by echocardiogram tonight and also by exam. The mechanism is unclear. I think once we have her chest pain sorted out and she has been evaluated by angiography, I would lean towards a transesophageal echo to find a mechanism for the MR. I would like to thank Dr. _%#NAME#%_ for asking me to see Mrs. _%#NAME#%_ who will follow closely.
MR|magnetic resonance|MR|175|176|RECOMMENDATIONS|4. Gait _________________ due to the neuropathy. RECOMMENDATIONS: 1. Maintain the INR above 2. 2. Check a MRI of the brain to look for evidence of recent ischemia. 3. Check a MR angiogram of the circle of Willis to exclude the possibility of basilar artery thrombosis. 4. Check a carotid ultrasound to look for evidence of carotid artery stenosis that would predispose him to transient ischemic attacks.
MR|magnetic resonance|MR|278|279|SUMMARY|I believe that she should stay on aspirin. MRI scan of the brain has been scheduled and will hopefully provide some additional information as to the nature of her left frontal slowing on the EEG, as well as the questionable subdural hematoma in the frontal region. In addition, MR angiogram of the circle of Willis will be obtained looking for evidence of intracranial occlusion. Further management depends on the outcome of the above studies.
MR|mitral regurgitation|MR|170|171|PHYSICAL EXAMINATION|SKIN: Warm and dry. HEENT: Negative. NECK: No carotid bruits. LUNGS: Clear bilaterally. HEART: Grade III/VI systolic ejection murmur heard over the entire precordium. No MR murmur heard. ABDOMEN: No organomegaly, masses or tenderness. EXTREMITIES: No pretibial edema or varicosities. Posterior tibial and dorsalis pedis pulses are faintly palpable bilaterally.
MR|magnetic resonance|MR|256|257|RECOMMENDATIONS|It is conceivable she may have had a brain stem stroke; even if she did, we would not utilize tissue plasminogen activator (t-PA) given her marked reduced platelets and diffuse metastatic disease and so forth. Once medically stable, I would like to pursue MR imaging of the brain to look into that possibility further. The medical doctors will be looking into primary cardiopulmonary-related issues.
MR|magnetic resonance|MR|155|156|RECOMMENDATIONS|IMPRESSION: Right adductor eye movement weakness, either partial third nerve palsy versus medial longitudinal fasciculus (MLF) lesion. RECOMMENDATIONS: 1. MR angiography of intracranial circulation. 2. Repeat diffusion-weighted image. 3. Continue aspirin daily. 4. Continue to optimize any stroke risk factors. 5. Physical Therapy to assess home safety.
MR|mitral regurgitation|MR,|132|134|CARDIAC RISK FACTORS|She does not have hypertension or diabetes mellitus or a family history for early coronary disease. Echocardiography revealed trace MR, trace TR and inferior and lateral akinesia with an ejection fraction of about 30 to 35%. She underwent coronary angiography today, revealing about 40 to 50% left main stenosis, about a 90% proximal LAD stenosis involving the first diagonal branch, an 80% mid right coronary artery stenosis and about a 90% obtuse marginal branch stenosis.
MR|magnetic resonance|MR|182|183|PHYSICAL EXAMINATION|No carotid bruits. CT head scan was normal. MRI scan did reveal nonspecific, subcortical small vessel changes and some question of myeloproliferative changes in the skull structure. MR angiogram showed a mild segment arrowing at 81. LABORATORY STUDIES: Included a CBC which was unremarkable.
MR|magnetic resonance|MR|374|375|IMPRESSION|I do not see any obvious hemiparesis. Due to the fact that this is only involving speech without other definite motor or new neurologic abnormalities as well as the history of trauma and mild uncertainty as to timing of the event, I would prefer not to use TPA at this time, She will be admitted for closer observation and neuro checks. She will be on telemetry. We will do MR imaging of the brain and MRA of her neck and check echocardiogram for possible stroke source. For now she will be treated with aspirin. She will be n.p.o, until that can be further analyzed as well.
MR|magnetic resonance|MR|217|218|RECOMMENDATIONS|I very much doubt that the PFO has anything to do with this but I was unable to obtain the formal report to look at the specifics regarding this PFO. RECOMMENDATIONS: 1. MRI of the brain with and without contrast. 2. MR angiogram of the neck and circle of Willis. 3. Echocardiogram. 4. EEG. 5. Target INR should be 2.5. Until the patient's INR is above 2 she should remain on heparin.
MR|magnetic resonance|MR|174|175|NEUROLOGY CONSULTATION|I agree with the diagnosis of polymyalgia rheumatica. I will look at other possible causes such as a bilateral L4 radiculopathy. I doubt that is the case, however, given her MR scan findings. In addition, the possibility of a more diffuse myositis will be evaluated. The recommendations at this time will be to proceed with CK, aldolase, and thyroid functions.
MR|magnetic resonance|MR|142|143|REQUESTING PHYSICIAN|She has no known history of stroke, TIA, amaurosis. She did have an MRI last night which showed a negative MRI scan, negative diffusion scan. MR angiogram of the circle of Willis was normal. PAST MEDICAL HISTORY: Remarkable for type II diabetes, hypertension, atrial fibrillation.
MR|magnetic resonance|MR|163|164|RECOMMENDATIONS|RECOMMENDATIONS: This is a situation where an MRI of the brain would be helpful to confirm an infarct, and give us an idea about the nature of it. In addition, an MR angiogram of the carotids extracranially will help us more precisely define the degree of stenosis, and we can subsequently decide whether this patient may be a surgical candidate.
MR|magnetic resonance|MR|170|171|ASSESSMENT/RECOMMENDATIONS|Given that she has a single kidney, she would be particularly prone to development of hypertension if she has a single renal artery. This could be evaluated further with MR angiography.
MR|magnetic resonance|MR|236|237|RECOMMENDATIONS|PVC and lytes are reviewed. IMPRESSION: Truncal ataxia, vertigo, visual disturbance, suspicious for her posterior circulation, stroke syndrome. DIFFERENTIAL DIAGNOSIS: Labyrinthitis. RECOMMENDATIONS: MRI/MRA angiogram. I would also add MR angiogram of the extracranial circulation to rule out vertebral artery disease. I would continue the aspirin and dyslipidemia management. If the MRI scan does confirm a stroke, then we will need to initiate the stroke protocol/pathway.
MR|mitral regurgitation|MR|201|202|SOCIAL HISTORY|EXAM: Afebrile since _%#MMDD2004#%_ when he had a temp to 100.4, blood pressure 118/70, respiration 24, pulse 87, no cervical adenopathy. NECK: Supple. LUNGS: Clear. Regular rate and rhythm with II/VI MR murmur. ABDOMEN: Soft, nontender. LABORATORY DATA: One AFB smear negative from _%#MMDD2004#%_.
MR|magnetic resonance|MR|82|83|IMAGING|She has normal finger tapping. Her pain is worse with axial loading. IMAGING: Her MR of the C-spine did not show any acute cord or nerve root impingement at this time. There is some disk bulging at C4-5. LABORATORY STUDIES: Sodium was 132, platelets are 299, INR is 0.96. ASSESSMENT: This is a 60-year-old female with neck pain and some radicular symptoms as well as bilateral pulmonary emboli.
MR|magnetic resonance|MR|237|238|LABORATORY DATA|His brain imaging studies included the unremarkable CT scan, but the MRI of the brain showed an acute ischemic injury in the left pons. He also has more diffuse and nonspecific white matter changes, likely small vessel ischemic changes. MR angiography of the head and MR angiography of the vessels in the neck is really quite unremarkable. IMPRESSION: Left pontine infarct. We cannot determine whether this is due to small vessel disease or ischemic infarct but with the suspected left ventricular thrombus, this could also represent an embolic infarct.
MR|magnetic resonance|MR|252|253|FAMILY HISTORY|I reviewed the recent neurological evaluation and note that a standard treadmill has been considered and recommended, and a tilt table has additionally been considered and recommended. I note that an ultrasound of the abdomen is essentially normal. An MR angio with contrast of the abdomen has been positive in producing a right renal artery stenosis of about 50 percent with essentially normal kidney sizes.
MR|magnetic resonance|MR|108|109|SUMMARY|No evidence of lateral medullary involvement is seen. Further short-term anticoagulation seems prudent. The MR angiogram of the posterior circulation is also reasonable. I would be very reluctant to alter the patient's blood pressure unless there is a compelling need to do so.
MR|magnetic resonance|MR|404|405|IMPRESSION|From neurological standpoint as far as the management of her stroke, she needs to be on heparin or Lovenox at this point and then she needs to be on Coumadin for at least three months after the event and then if no other cardiac embolic risk factors are found, she could be on Plavix. Again, at this point I have discussed with patient and her son that I would like to proceed with MRI of the brain with MR angiogram and after that have a discussion with Cardiology as far as safety of cardiac procedure. Dr. _%#NAME#%_, my colleague, will be rounding tomorrow and will most likely participate in that discussion.
MR|magnetic resonance|MR|211|212|IMPRESSION|The thickening of the wall as well as the pericholecystic fluid would likely be due to his liver disease. If the question needs further clarification of whether he would be jaundiced from choledocholithiasis an MR cholangiogram would be a good idea. I will follow Mr. _%#NAME#%_ along with you. Thanks for the consultation
MR|magnetic resonance|MR|222|223|HISTORY|The patient denies a previous myocardial infarction. He did suffer a stroke at the time of his bilateral total knee arthroplasties in _%#MM#%_ of 1999. Carotid ultrasound at that time showed a 10-15% stenosis bilaterally. MR angiogram, however, showed a recent infarct in the right medial temporal and medial and inferior occipital lobe in the distribution of the right posterior cerebral artery.
MR|mitral regurgitation|MR.|149|151|LABORATORY|The posterolateral walls appear increased hypokinetic. Left ventricular hypertrophy. Left ventricular enlargement. Left atrial enlargement. Trace of MR. Moderate AI. Very mild aortic valve sclerosis. Trace of TR. Trace of PI. No evidence for pericardial effusion or clots. IMPRESSION/PLAN: 1. History of idiopathic cardiomyopathy with slightly elevated B-type natriuretic peptide with an improved ejection fraction when compared to an echocardiogram in _%#MM#%_ 2004.
MR|magnetic resonance|MR|240|241|RECOMMENDATIONS|RECOMMENDATIONS: 1. Course of antibiotics for 7-10 days until symptoms resolve, and then a period of observation, perhaps two weeks, to be sure there is no recurrence of his diverticulitis. 2. We will have a CT reformatted or repeat for an MR angiogram. I suspect that he is a suitable candidate for an endovascular repair, and I have discussed the alternatives of open and endovascular repair in detail with the patient.
MR|mitral regurgitation|MR|76|77||She was admitted recently with volume overload and was found to have severe MR and TR in addition to her LVEF of ~25%. The decision has been made to proceed with LVAD placement as a BTT.
MR|mitral regurgitation|MR|143|144|PHYSICAL EXAMINATION|The aortic valve area is approximately at 1.0 cm2. Mean gradient of 19 and peak gradient of 31 mm. There is LVH biatrial enlargement. Moderate MR and TR pressures, however, were seen lower, which is likely related to the fact that if you add her right atrial pressure on top of the RVSP of 22 mmHg, there still would at least moderate pulmonary hypertension.
MR|magnetic resonance|MR|171|172|RECOMMENDATIONS|2. I will obtain an MRI of the brain to look for evidence of a more recent stroke. If such is present a discussion should be initiated about Coumadin. 3. I will obtain an MR angiogram of the aortic arch to rule out ascending aortic dissection which might be the cause of the recent strokes or proximal carotid artery stenosis.
MR|magnetic resonance|MR|127|128|RECOMMENDATIONS|We will make a decision about a needle biopsy after the PET scan is done. I agree with the neurologist that she should have an MR of the brain and cervical spine to rule out the presence of metastatic disease. We will follow the patient during her hospitalization.
MR|magnetic resonance|MR.|337|339|IMPRESSION, REPORT AND PLAN|He understands the risks associated with antiarrhythmic drug therapy. I reviewed his echocardiogram which was done during his last hospital admission for atrial fibrillation which shows preserved left ventricular systolic function, borderline RV enlargement and mild right atrial and left atrial enlargement with only trace TR and trace MR. He also has trace AR. Mr. _%#NAME#%_ is actually even more interested in considering an atrial fibrillation ablation (a pulmonary vein isolation procedure).
MR|magnetic resonance|MR|158|159|NEUROLOGICAL EXAM|These would be highly unusual for an embolic event but remains a possibility as well. The plan is to rule out pathology requiring anticoagulation. Therefore, MR angiogram of the vertebral arteries and basilar artery should be done. Specifically, right vertebral artery occlusion or dissection should be ruled out.
MR|mitral regurgitation|MR.|129|131|PAST MEDICAL HISTORY|1. Hypertension. 2. Migraine headache. 3. Arthritis. 4. Osteoporosis. 5. Anxiety. 6. History of gastric ulcer. 7. Falls. 8. Mild MR. 9. Diastolic dysfunction. 10. Atrial fibrillation. PAST SURGICAL HISTORY: 1. Back surgery 1995. 2. Femoral surgery 2006. FAMILY HISTORY: Father had CVA and hypercholesterolemia.
MR|magnetic resonance|MR|269|270|IMPRESSION|In addition, I would further evaluate Ms. _%#NAME#%_ for any surgically accessible causes of impaired cerebrovascular blood flow. This can easily be done with carotid ultrasounds. Should the carotid ultrasounds reveal very significant stenosis, I would proceed with an MR angiogram to be sure that there was not any more distal significant stenosis which would obviate the need for surgery in her neck.
MR|mitral regurgitation|MR|220|221|PHYSICAL EXAMINATION|We have recommended for her the following steps: She should be placed in Keppra for seizure prophylaxis at a dose of 500 mg per mouth every 12 hours. We are going to proceed with obtaining an MRI/MR angiogram as well as MR venogram of the brain to evaluate for venous thrombosis, possible vascular malformation. If this study is negative, she will need to have a repeat head CT in the morning to evaluate the stability of her falcine hematoma, her chronic medical issues will then need to be stabilized and addressed and possible discharge with a follow up one month with a head CT.
MR|magnetic resonance|MR|288|289|PHYSICAL EXAMINATION|If this study is negative, she will need to have a repeat head CT in the morning to evaluate the stability of her falcine hematoma, her chronic medical issues will then need to be stabilized and addressed and possible discharge with a follow up one month with a head CT. If, however, the MR venogram is positive for a possible cortical venous thrombosis, I would treat her with a more conservative course of therapy using mild hydration, elevating the head of the bed 30-45 degrees to optimize venous outflow.
MR|magnetic resonance|MR|175|176|LABORATORY & DIAGNOSTIC DATA|INR today 1.98. Echocardiogram was done showing ejection fraction of 60%, right to left shunt and changes in the bowels consistent with Marfan syndrome. MRI of the brain with MR angiogram were done and personally reviewed showing old right MCA stroke, evidence of multiple stenosis of carotid and vertebral arteries and left subclavian artery aneurysm measuring 2 cm.
MR|magnetic resonance|MR|150|151|DOB|His workup has included initial CT scan of the head which was unremarkable. MRI scan of the brain performed last night demonstrated no acute changes. MR angiogram of the circle of Willis was described as being normal. Laboratory studies include a CBC, sedimentation rate, electrolytes, glucose, BUN, creatinine, troponin I, and myoglobin, all of which were normal.
MR|magnetic resonance|MR|206|207|PAST NEUROLOGIC HISTORY|He was admitted to Fairview Ridges Hospital on _%#MMDD2000#%_ after he experienced a similar episode. That lasted for about 48 hours. Again, workup at that time was unremarkable including MRI of the brain, MR angiography, and coagulation studies. He was seen by associated, Dr. _%#NAME#%_. Initially, it was felt he may have had an ischemic event however his workup was unremarkable.
MR|magnetic resonance|MR|141|142|IMPRESSION|IMPRESSION: Likely benign vertigo related to labyrinth dysfunction. There is a possibility of transient ischemic attack and I agree with the MR with MR angiogram of the carotids, etc. Blood pressure she is may be problematic to manage given the wide range of the systolic reading in particular.
MR|magnetic resonance|MR|217|218|RECOMMENDATIONS|If the patient has progression of her symptoms during her hospitalization, I would consider a repeat CT scan and if there is no hemorrhagic conversion, I would consider heparinizing her. 2. I agree with an MRI and an MR angiogram of the brain and the great vessels of the neck. 3. I agree with the stroke protocol orders. 4. I agree with rehabilitation.
MR|magnetic resonance|MR|215|216|IMPRESSION|IMPRESSION: This gentleman presents with seizure and severe headache. MRI of the brain is negative for stroke or structural lesions. I think he presents with complex migraine. I certainly would like to see what the MR angiogram results are. I discussed the case with the patient's family members and emergency room physician. I would recommend if the MR angiogram is normal, to proceed with the treatment of the headache and see if patient would improve.
MR|magnetic resonance|MR|156|157|HISTORY OF PRESENT ILLNESS|Prior to admission he did not have any significant headaches, nausea or vomiting, no other complaints of motor or sensory changes. In the Emergency Room an MR scan showed areas suggestive of acute, subacute and chronic ischemic changes and on MRA, there was a suggestion for possible vasculitis.
MR|mitral regurgitation|MR,|180|182|PAST MEDICAL HISTORY|7. Vitamin C. 8. Vitamin B. PAST MEDICAL HISTORY: Echocardiogram per hand written preop H & P from her outpatient clinic reported normal LV function with mild to moderate PR, mild MR, with large atria. The patient has been labeled as having atrial fibrillation on her preoperative evaluation, based on a _%#MMDD2004#%_ EKG.
MR|magnetic resonance|MR|357|358|IMPRESSION|IMPRESSION: This gentleman presents with new onset of neurological deficits with some progression over the course of 24 hours, most likely given the risk factors for cardiovascular disease, his presentation is consistent with lacunar stroke in the right deep hemisphere or right brain stem. At this point, he is going for MRI of the brain, I also would add MR angiogram of neck and circle of Willis. I would like also to see echocardiogram which was also ordered by Dr. _%#NAME#%_. I think we also should proceed with stroke workup in a young adult, given his young age, which would include coagulopathy workup and homocysteine level.
MR|magnetic resonance|MR|127|128|IMPRESSION|I did speak with Dr. _%#NAME#%_ _%#NAME#%_ of Interventional Radiology. He wants us to pursue an emergent MRI of the brain and MR angiogram both of the neck and intracranial vessels. If she does have a large vessel occlusion, he discussed intra-atrial TPA.
MR|magnetic resonance|MR|139|140|REQUESTING PHYSICIAN|In _%#MM#%_ she returned to the hospital for some similar symptoms and was told that it was a TIA. She had numerous studies done including MR imaging and was told to take a baby aspirin daily. She denies a history of hypertension or diabetes. She is being watched for possible early diabetes, however.
MR|magnetic resonance|MR|187|188|PHYSICAL EXAMINATION|She has bilateral cerebellar infarctions and she has a new area of stroke with some vasogenic edema in the left parietal lobe which appears to light up on diffusion weighted imaging. The MR angiography of the neck and intracranial vessels does not show any occlusive disease of note. The echocardiogram done with bubbles shows a normal ejection fraction and no shunts or clots.
MR|magnetic resonance|MR|151|152|HISTORY OF PRESENT ILLNESS|Since he had been in the emergency room, his blood pressure is 126/76, pulse 70 and regular. He is afebrile. He did have an MRI scan of the brain with MR angiogram of circle of Willis. I personally reviewed the films and discussed them with Dr. _%#NAME#%_. They do not show any evidence of stroke. On diffusion weighted image there is no evidence of abnormalities on the T2 signal images.
MR|magnetic resonance|MR|215|216|HISTORY OF PRESENT ILLNESS|Further imaging on _%#MM#%_ _%#DD#%_, 2002, at Fairview Southdale Hospital showed osteopenia of the thoracic spine with compression fractures at T12 and T7, age undetermined. She also had an MRI of the brain and an MR angiogram that showed (1) several tiny focal areas of recent infarct in the right periventricular frontal and periparietal lobes; (2) moderate nonspecific white matter changes, most likely small vessel ischemic disease in both hemispheres; (3) atrophy; (4) a normal circle of Willis per MRA.
MR|magnetic resonance|MR|240|241|PAST MEDICAL HISTORY|At present, she is feeling well other than weak. She is not nauseated and denies any headache, shortness of breath, chest pain, palpitations, diarrhea, or bladder symptoms. PAST MEDICAL HISTORY: 1. Left carotid endarterectomy _%#MM2000#%_. MR angiogram showed an 80% stenosis prior to surgery. 2. Cerebrovascular accident _%#MM1998#%_, resulting in right sided weakness and aphasia. A CT scan showed a large left frontal/parietal infarct. She was treated with Coumadin.
MR|mitral regurgitation|MR,|359|361|HISTORY OF PRESENT ILLNESS|The patient has critical aortic stenosis diagnosed since 2004. An echo obtained in 2004 showed normal global left ventricular function, left ventricular hypertrophy, critical aortic stenosis with a mean gradient 65 mmHg and a calculated valve area of 0.4 cm square. There is descending aortic aneurysm of 3.3 x 3.3 cm, mild aortic dilatation 3.3 cm, moderate MR, and moderate TR. The patient refused surgical intervention on multiple occasions. TLC was consulted and the patient was advised to have hospice care and a consultation was obtained.
MR|mitral regurgitation|MR.|158|160|PHYSICAL EXAMINATION|She was in no acute distress, alert and oriented to time and person. Cardiovascular: Regular rate and rhythm, S1, S2, 2/6 systolic murmur likely secondary to MR. Lungs clear to auscultation bilaterally. Abdomen soft, nontender, nondistended. Presence of ascites positive. Skin: No new lesions but presence of spider angiomata. Neuro nonfocal.
MR|magnetic resonance|MR|158|159|HOSPITAL COURSE|Because of her continuing confusion, A MRI and MRA was done. This showed no acute pathology identified, no hydrocephalus, pineal region tumor, and a negative MR angiogram with no aneurysm or AV malformation identified. The patient also had a cardiac echocardiogram which showed normal left atrial and left ventricular size with normal left ventricular systolic contractility.
MR|mitral regurgitation|MR|170|171|ASSESSMENT/PLAN|His symptoms have now become somewhat more progressive occurring at rest, associated with atypical back pain. At the present time I do think it is appropriate to perform MR of his chest as a potential dissection, although low on the list of concern, is of grave consequence if positive. With his mild anemia and slightly positive stool hemoccults, I am going to hold anticoagulation at this point and continue with an aspirin.
MR|mitral regurgitation|MR,|240|242|HOSPITAL COURSE|7. Elevated blood sugar. She did have some elevated blood sugars, but with her tapering prednisone, her blood sugars by the time of discharge were noted to be in the 120-140 range. 8. Mitral regurgitation on TEE. She was noted to have 2-3+ MR, and she will need antibiotic prophylaxis per American Heart Association's recommendations. She will need to have endocarditis prophylaxis for certain procedures.
MR|mitral regurgitation|MR,|191|193|HISTORY  OF PRESENT ILLNESS|Eventually her atrial fibrillation was controlled well and her diarrhea ceased. An echo at that time was performed which revealed any ejection fraction of 65% with mild aortic stenosis, mild MR, mild atrial enlargement, and a right ventricular systolic pressure that was mild to moderately increased. She was started on Coumadin at that time and received Lovenox to ramp her Coumadin level up to a therapeutic range.
MR|mitral regurgitation|MR,|416|418|OPERATIONS/PROCEDURES PERFORMED|Mild decreased right ventricular systolic function with mild to moderate dilatation of the pulmonary arteries, significant biatrial enlargement with mild to moderate insufficiency, very large right pleural effusion, and small pericardial effusion. No sign for pericardial constriction. 4. Echocardiogram showing an ejection fraction of 70% to 75%, good systolic function, LVH, left ventricular enlargement, moderate MR, large pleural effusion, and no pericardial thickening. HISTORY OF PRESENT ILLNESS: This is a 51-year-old female who has presumed restrictive cardiomyopathy who presented to Fairview- University Medical Center from the Iowa University Medical Center.
MR|mitral regurgitation|MR.|207|209|PROCEDURES PERFORMED DURING HOSPITALIZATION|The left circumflex had 30% proximal narrowing. 2. Echocardiogram dated _%#MMDD2007#%_, which showed normal LV size and function. No regional wall motion abnormalities noted. Mild aortic regurgitation. Mild MR. Right ventricular systolic pressure was mildly increased to 30 plus RAP. Mild left atrial enlargement. 3. CT abdomen without contrast dated _%#MMDD2007#%_, which showed large hematoma involving the right groin, however, no evidence for intraperitoneal or retroperitoneal hemorrhage.
MR|magnetic resonance|MR|156|157|HOSPITAL COURSE|AFP came back elevated, and it was most consistent with probable hepatocellular carcinoma, based on liver masses seen on both abdominal ultrasound, CT, and MR venogram. Hepatitis B surface antigen and antibody came back negative, so the patient will likely need to be vaccinated against hepatitis B in the future.
MR|mitral regurgitation|MR.|155|157|PAST MEDICAL HISTORY|His most recently echocardiogram previous to this admission was 1997 showing normal LV systolic function, ejection fraction of 70% with moderate to severe MR. 2. Macular degeneration. 3. Prostate cancer. He requires a permanent Foley catheter. He has had numerous UTIs and traumatic Foley removal, usually self-removal.
MR|magnetic resonance|MR|298|299|HISTORY OF PRESENT ILLNESS|In order to confirm this, the cardiology staff on-call performed a transesophageal echocardiogram, which revealed similar findings. The cardiology staff, however, could not exclude a small intramural hematoma in the descending aorta and hence advised that once her blood pressure was stabilized an MR angiogram would be appropriate. The patient was started on an esmolol drip along with nitroprusside and admitted to the intensive care unit.
MR|magnetic resonance|MR|271|272|KEY IMAGING STUDIES AND PROCEDURES PERFORMED DURING THIS HOSPITALIZATION|These findings suggest a global episode of hypoperfusion possibly from a cardiac etiology superimposed on the absence or hypoplasia the left A1 segment. Perfusion abnormality also suggest a stenosis in the right carotid circulation, although none was seen on ultrasound. MR angiogram of the head and neck is suggested for further evaluation. 3. MRA of the head with and without contrast on _%#MM2005#%_.
MR|mitral regurgitation|MR,|278|280|PROCEDURES DONE DURING PRESENT ADMISSION|Pancreas is normal. Normal sized kidneys. 5. Echocardiogram (_%#MMDD2002#%_). Indications were that the patient had known coronary artery disease, status post for amylase. Results were moderately decreased LV function (LVEF 35%), ______ segment, _______ posterior segment, mild MR, mild RV dilatation. HISTORY OF PRESENT ILLNESS: The patient is a 43-year-old Caucasian woman with longstanding history of peripheral vascular disease and hypercoagulable state.
MR|mitral regurgitation|MR|207|208|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|He did have an evaluation by Cardiology who consulted on his case and through Cardiology recommendations the patient had a bedside TTE on _%#MMDD2007#%_, which showed LV function that was hyperdynamic, mild MR and AI. The patient was then started on metoprolol, statin and aspirin. He was also evaluated for possible PE with a lower extremity Doppler, which was negative for DVT.
MR|mitral regurgitation|MR.|284|286|LABORATORY STUDIES|LABORATORY STUDIES: Troponin negative x 2, myoglobin 138, potassium 145, bicarb 26, chloride 123, sodium 145, BUN and creatinine 23 and 2.0. Anion gap 9, calcium 8.4, BNP 1020, hemoglobin 11.9, platelet count 148, white blood cell count 6.8, blood cultures pending. Echo shows severe MR. Trivial TR. Regular rhythm. Apex akinetic, septum akinetic, anterior inferior wall akinetic. Lateral mid apex akinetic. EKG shows normal sinus rhythm. No ischemic changes.
MR|mitral regurgitation|MR|206|207|LUNGS|CARDIOVASCULAR: The apex lies in the 6th intercostal space outside the midclavicular line. It is a dyskinetic apex. There is a pa nsystolic murmur in the mitral area and in the tricuspid area suggestive of MR and TR. There is moderate pulmonary hypertension as noted by a diastolic shock. The P2 is loud. LUNGS: The air entry is diminished bilaterally in the bases.
MR|mitral regurgitation|MR|212|213|ADMISSION LABORATORY DATA|Liver function tests within normal limits. Albumin 3, urinalysis negative. Echocardiogram obtained today shows left ventricular ejection fraction of 55%, norm left ventricular ejection fraction, mild to moderate MR on the prolapse of the anterior mitral valve leaflet. IMPRESSION: 1. Possible congestive heart failure with pulmonary edema.
MR|mitral regurgitation|MR,|170|172|PROBLEM #3|A cardiology consult was obtained after an echocardiogram was performed. The echo showed preservation of the LV function with an ejection fraction of 60%. There was mild MR, left atrial enlargement and mild increase in right ventricular systolic pressure. The cardiology service recommended that the patient obviously would continue his anticoagulation for his hypercoagulable state.
MR|magnetic resonance|MR|265|266|IMPRESSION/PLAN|IMPRESSION/PLAN: 1. Metastatic breast cancer apparently progressive. Chemotherapy decision will need to be made after we have established the extent of this progression and the patient has had the symptomatic relief. 2. Potential biliary dilatation. We will get an MR cholangiogram, interventional radiology will plan on stenting her if she has distal obstruction on the basis of the MR cholangiogram probably tomorrow.
MR|magnetic resonance|MR|178|179|PROCEDURES PERFORMED|a. Probable perisinusitis. b. Multiple nonspecific punctate T2 hyperintensities in the cerebral white matter which may be present chronic small vessel ischemic change. c. Normal MR angiography of Circle of Willis. 2. Spinal tap, _%#MMDD2002#%_, did not show any evidence of malignancy. 3. CT maxillofacial without contrast, _%#MMDD2002#%_, findings consistent with acute pansinusitis.
MR|magnetic resonance|MR|256|257|HISTORY OF PRESENT ILLNESS|She did need the PCA treatment, but eventually was able to take oral medications to control her pain and was discharged after several days of being in the hospital. It was thought that perhaps her pain was related to a paraneoplastic phenomenon, given the MR results could not seem to adequately explain her symptoms she was having. The patient did followup with Oncology. She was supposed to get chemotherapy, but apparently this was put on hold because of thrombocytopenia.
MR|magnetic resonance|MR|185|186|HISTORY OF THE PRESENT ILLNESS|He arrived approximately six hours after the alleged onset of his symptoms, although as far as we know the symptoms may have started in the middle of the night. An MRI of the brain and MR angiogram of the circle of Willis were obtained emergently. This showed a area of ischemia in the entire distribution of the right middle cerebral artery.
MR|magnetic resonance|MR|333|334|CONCLUSION|This patient also has severe carotid disease, although, he apparently has been argumentative with me about that whether the severe carotid disease is exacerbating his d ecreased cerebral perfusion from his orthostasis is probable. I am going to have him talk to Dr. _%#NAME#%_ about that to determine if further such studies such as MR angiogram or vascular surgery consult might be appropriate. I will keep all of his other medications just as they are. While it is possible he may have a different component of orthostasis from a primary neurologic problem, there is no clear history of Parkinson's disease or other movement disorder that might be associated with Shy-Drager.
MR|mitral regurgitation|MR.|185|187|IMPRESSION|3. Cor pulmonale due to emphysema, COPD, left heart failure. 4. Left heart failure due to diminished LV function, diastolic dysfunction of the LV, aortic stenosis and moderately severe MR. 5. Chronic paced in the VVI mode and mode with chronic atrial fibrillation. 6. Chronic renal insufficiency, creatinines have been 1.4 up to now 2.1. This is a really a conflict.
MR|magnetic resonance|MR|108|109|LABORATORY DATA|Gram stain is negative. Electrolytes are within normal limits. White blood cell count is 6.1 with no shift. MR of the brain performed with and without contrast shows no evidence of intraparenchymal structural lesions. Contrast does not reveal any areas of abnormal enhancement. There is no dural enhancement.
MR|mitral regurgitation|MR,|241|243|HISTORY|However, a follow-up echo dated _%#MMDD2006#%_ shows left ventricle dilated 57 mm, EF of 20-25%, global hypokinesis, inferior wall akinetic, anterior wall hypokinetic. Right ventricle was normal size and function. There was mild to moderate MR, aortic sclerosis, but no stenosis. They could not estimate right heart pressures. The patient denies any type of chest pain, in fact, his main problem is low back pain and leg problems for which he has a history of spinal stenosis and spinal surgery, including microdiskectomy and redo in 2005.
MR|mitral regurgitation|MR,|128|130|PHYSICAL EXAMINATION|She has also severe aortic stenosis and moderate pulmonary hypertension with an RVSP going from 39 up to 47 mmHg. She has trace MR, moderate TR and severe aortic stenosis with an aortic valve area 0.6 cm2. This is more difficult to evaluate because now the deterioration and decrease in LV function.
MR|mitral regurgitation|MR.|218|220|LABORATORY DATA|It clearly shows LV enlargement with moderate LV systolic dysfunction with ejection fraction of 35-40%. There is severe mitral regurgitation noted with pulmonary vein reversal on systolic Doppler. It is mainly central MR. There is no evidence of mitral valve prolapse or flail leaflets. The mitral valve per se appears to be known coaptatic and is mildly thickened, particularly at the tips.
MR|mitral regurgitation|MR|111|112|IMPRESSION|Similarly, one would have expected to hear the murmur on previous exams, and doubt it is new to have this much MR and TR; to be acute would be unusual. One wonders about chronic atrial fibrillation leading to atrial enlargement, annular dilatation and progressive MR and TR in the setting of what was no doubt lung disease and cor pulmonale in a patient with previous sarcoid and who is a heavy smoker; that would also account for why the right bundle branch block pattern is seen.
MR|mitral regurgitation|MR,|232|234|HISTORY OF PRESENT ILLNESS|During that admission, it was noted that he had a visually approximated EF by echo of 25-30% with borderline left ventricle at the upper limits of normal, mild LVH, moderate biatrial enlargement, normal right heart pressures. Trace MR, trace TR, and an RVSP was not available as it could not be accurately approximated. He went home on a relatively extensive program, including: 1. Coreg 6.25 mg b.i.d. 2. Lasix 40 mg a day.
MR|mitral regurgitation|MR|167|168|OBJECTIVE|There was an occlusion of the right but a widely patent saphenous vein to the distal right and a 75% stenosis of the PDA. A ventriculogram showed an EF of 55% with 1+ MR and elevated left ventricular end-diastolic pressure. He was admitted in _%#MM2003#%_ with renal failure and had transient dialysis. I believe at that time. He has had a TIA and a carotid endarterectomy on the right and was told that his left carotid was totally occluded.
MR|magnetic resonance|MR|167|168|ASSESSMENT|I doubt pheochromocytoma or carcinoid tumor or coarctation of the aorta based on exam and history. There is no renal artery bruits heard. I would, however, suggest an MR angiogram of the renal arteries. I would then treated with vasodilator, diuretics and beta-blockers as well as diuretics. This can be manipulated overtime. I would avoid over-the-counter supplements.
MR|magnetic resonance|MR|276|277|HISTORY OF PRESENT ILLNESS|There was evidence of precordial and azygoesophageal lymphadenopathy. Surgical pathology report (UHC 02-00813) revealed no evidence of malignancy. CT scan of the head was performed on _%#MMDD2002#%_ and it showed mild small-vessel ischemic disease. No evidence of metastases. MR scan performed the following day on _%#MMDD2002#%_ revealed no evidence of metastases. PET scan performed on _%#MMDD2002#%_ showed nodular focus of increased tracer uptake within the right lower lobe correlating with a nodule seen on prior CT.
MR|magnetic resonance|MR|129|130|RECOMMENDATIONS|4. The patient will be under seizure precautions. 5. An MRI will be obtained to evaluate the possibility of a new infarct. 6. An MR angiogram of the great vessels of the neck will be obtained to assess the patency of the right internal carotid artery following stenting which took place last spring.
MR|mitral regurgitation|MR,|244|246|CHIEF COMPLAINT|In the last 6 months he has had 7 echocardiograms, the last of which was done today _%#MMDD2006#%_. This study showed a visually approximated EF of 50%, question of inferior hypokinesia, aortic leaflet sclerosis, mitral leaflet sclerosis, mild MR, trace TR and right heart pressures were elevated at 37 mmHg plus right atrial pressure. A week ago he had an echocardiogram in our office.
MR|mitral regurgitation|MR|157|158|ASSESSMENT|She has moderate biatrial enlargement, mild LVH and left ventricular ejection fracture of 68% and RV systolic function diminished. There was a trace to mild MR and a trace pulmonic insufficiency. This combination of findings I think supports significant pulmonary hypertension and signs of right heart failure.
MR|magnetic resonance|MR|103|104|SENSORY EXAM|However if there is very small restricted cortical area involved, it may have been missed on the scan. MR angiogram shows the stenoses as indicated in the history of present illness. His white count was slightly reduced on admission at 3.6 with H&H normal at 14 and 42, and platelets of 219,000.
MR|mitral regurgitation|MR,|344|346|LABORATORY|NT BNP 2650. Troponin #1 was negative. Troponin #2 was 0.93 and the next one was 3.08. Echocardiogram reports moderate to severe decreased ejection fraction, actual number is not listed with anterior apical and septal severe hypokinesis, right ventricle mildly dilated with moderate reduced RV systolic function, biatrial enlargement, moderate MR, mild to moderate TR, moderate pulmonary hypertension, no pericardial effusion. Blood gas 7.38, pCO2 26/PO2 314/bicarbonate 15. Blood cultures are pending.
MR|mitral regurgitation|MR,|120|122|PHYSICAL EXAMINATION|Prednisone has also been ramped up. Her echocardiogram shows persistent severe global hypokinesia with mild-to-moderate MR, moderate TR and moderately severe pulmonary hypertension. She has pulmonary hypertension due to a complex combination of left heart failure and her severe COPD.
MR|mitral regurgitation|MR,|297|299|INDICATION FOR CONSULTATION|That EKG looks similar to today's EKG with a somewhat shorter QTC of 474 milliseconds and a QT of 520 milliseconds. An echocardiogram was done today and I have not had a chance to review it, but the preliminary report states without a measurement that she does have aortic root dilation, moderate MR, moderately severe AR, moderately severe TR, well-preserved LV function, mild RV and RA dilation, left atrial dilation, LV was not dilated.
MR|mitral regurgitation|MR,|272|274|SOCIAL HISTORY|She had five children. She is retired. She does not currently drink or smoke, although she does certainly have emphysema. An echocardiogram done about six months ago in _%#MM2006#%_ showed normal LV and RV systolic function, EF of 65%, diastolic dysfunction of the LV, +2 MR, moderately severe pulmonary hypertension, RVSP greater than 50 mmHg, moderate biatrial dilation and aortic leaflet sclerosis. PHYSICAL EXAMINATION: GENERAL: Elderly, frail, poorly sluggishly responsive female. VITAL SIGNS: Heart rate 80-90 beats per minute in atrial fibrillation, blood pressure 130/70, O2 sats 100% on nasal oxygen.
MR|magnetic resonance|MR|207|208|HISTORY OF PRESENT ILLNESS|Neurologic consultation demonstrated a non-focal exam. The episodes were not felt to be typical for amaurosis; thought likely to be psychogenic in origin. He was evaluated with an unremarkable brain MRI and MR angiogram. Subsequent to his last hospitalization at Fairview _%#CITY#%_ the patient was admitted to St. Joseph's, undergoing nine electroconvulsive therapy treatments. He indicates worsening of his condition with increase in flashbacks and forgetfulness.
MR|mitral regurgitation|MR,|241|243|LABORATORY & DIAGNOSTIC DATA|An echocardiogram was done after admission and noted a visually approximated ejection fraction of 20% with multiple wall motion abnormalities with severe akinesia in the inferoseptal LV with global hyperkinesia otherwise. There was +1 to +2 MR, trace to mild TR, mild pulmonary hypertension with an RVSP of 35 mmHg plus right atrial pressure. There was LVH. PHYSICAL EXAMINATION: GENERAL: Elderly, frail-looking gentleman. He looks older than his stated age.
MR|mitral regurgitation|MR,|237|239|PHYSICAL EXAMINATION|She has severe hypothyroidism-akinesia of the posterior walls, severe hyperkinesia of the lateral wall, moderate hyperkinesia of the septum. The anterior and apical walls have fairly decent function. She has severe LVH, mild to moderate MR, aortic and mitral leaf sclerosis. She has moderate TR and severe pulmonary hypertension with an RVSP of 67 mmHg plus right atrial pressure.
MR|magnetic resonance|MR|166|167|PLAN|She has been given Zosyn downstairs. We will continue that here, place a PPD, put her on mini dose heparin, x-ray the leg. If the leg x-ray is negative we will do an MR scan also have speech to do a swallowing evaluation. We will continue the triamcinolone cream for her bottom and Xalatan and Timoptic
MR|magnetic resonance|MR|206|207|PAST MEDICAL HISTORY|She took this but did stop it about two weeks ago and since that time has had trouble maintaining her INR in the 2-3 range. PAST MEDICAL HISTORY: 1. CVI in _%#MM#%_ 2006. The patient had a workup including MR angiography which suggested of a developmentally small right vertebral artery without any dissection and a possible occlusion of the right posterior cerebral artery at the P1 level as well as findings consistent with acute infarct in the right posterior cerebral artery distribution.
MR|magnetic resonance|MR|282|283|HOSPITAL COURSE|Denies any other drug use. HOSPITAL COURSE: PROBLEM #1: Left lower abdominal pain: The patient was admitted for alcohol abuse and left lower abdominal pain. Abdominal CT scan in the emergency room showed an indeterminate 1.7 cm left adrenal nodule with recommendation for follow-up MR scan to better characterize the findings. There was no definite renal or ureteral calculi identified. There were no secondary signs of obstruction seen.
MR|magnetic resonance|MR|297|298|RECOMMENDATIONS|For this reason at this point some additional work-up is necessary and the patient will be best served by being admitted to the special neurology care unit for subsequent follow- up, observation and work-up. RECOMMENDATIONS: 1. Admit to special neurology care. 2. MRI of the brain tonight with an MR angiogram of the brain and the neck. 3. Seizure precautions. 4. EEG first thing in the morning. 5. If not already done, a urine toxicology screen should be obtained.
MSSA|modified selective severity assessment|MSSA|151|154|HOSPITAL COURSE|HOSPITAL COURSE: The patient was admitted and he was detoxed to using buprenorphine off the opioids and he has used to detox off the alcohol using the MSSA protocol on valium because of a prior history of seizures. He had an uneventful detox. Over the course of his hospitalization, his mental status improved.
MSSA|modified selective severity assessment|MSSA|107|110|PLAN|Axis IV: Psychosocial stressors: Moderate. Axis V: GAF = 30. PLAN: Ms. _%#NAME#%_ may be detoxed using the MSSA protocol with Valium because there was a previous history of questionable seizures. Ms. _%#NAME#%_ will be started on citalopram 20 mg to target her symptoms of post-traumatic stress disorder and also depression.
MSSA|modified selective severity assessment|MSSA|184|187|ASSESSMENT AND PLAN|5. Abnormal LFTs. This is also likely alcohol related. These will be monitored. 6. Hyponatremia. The patient will be put on normal saline. 7. Alcohol abuse. The patient will be put on MSSA protocol and CD counseling will be obtained in the morning.
MSSA|modified selective severity assessment|MSSA|149|152|PROBLEM LIST|He is now hemodynamically stable and cooperative. PROBLEM LIST: 1. Psychiatry: History of alcohol dependency, depression and PTSD. Will place him on MSSA protocol and request Chemical Dependency consult in a.m. Patient is willing to go to inpatient chemical dependency treatment. He is currently on 72-hour hold because he was agitated at the emergency room and reports Vietnam War flashback.
MSSA|modified selective severity assessment|MSSA|131|134|PLAN|DISPOSITION: To Psychiatry. PLAN: 1. Psychiatric meds as per the psychiatrist. 2. Anxiety and ETOH withdrawal. She has been on the MSSA protocol and will leave her on that overnight until this can be assessed by the psychiatrist. Of note, she does not show any symptoms of acute alcohol withdrawal.
MSSA|modified selective severity assessment|MSSA|138|141|PLAN|PLAN: 1. The patient is admitted to the intensive care unit for close monitoring. 2. The patient was begun on alcohol withdrawal protocol MSSA with Valium. 3. Given IV fluids with D5W with normal saline with multivitamin and thiamine and folic acid 1 mg and magnesium sulfate 2 g, 125 cc/hr.
MSSA|modified selective severity assessment|MSSA|169|172|HOSPITAL COURSE|HOSPITAL COURSE: Ms. _%#NAME#%_ was admitted to station 3A adult chemical dependency detox unit to be monitored for withdrawal from alcohol. She was monitored using the MSSA rating scale with Ativan to cover withdrawal symptoms. On admission, Lexapro 20 mg daily was re-ordered, Crestor 10 mg one time daily was also re-ordered.
MSSA|modified selective severity assessment|MSSA|234|237|HOSPITAL COURSE|On hospital day 2, her pancreatic enzymes increased to amylase of 188 and lipase of 1412, so her n.p.o. status was continued. However, her pain did improve over the course of that day. 2. Alcohol withdrawal. The patient was placed on MSSA protocol with scores generally ranging from 7-12 during the course of her admission. She did on some occasions refuse the Ativan when nursing offered it based on the MSSA scale.
MSSA|modified selective severity assessment|MSSA|151|154|HOSPITAL COURSE|Mr. _%#NAME#%_ was admitted to station 3A adult chemical dependency detox unit to be monitored for withdrawal from alcohol. He was monitored using the MSSA rating scale with Valium to cover withdrawal symptoms. On admission, Nexium 40 mg daily, multivitamin 1 daily, and folic acid 1 tablet daily were reordered.
MSSA|modified selective severity assessment|MSSA|247|250|ASSESSMENT/PLAN|1. Alcohol abuse. Recommend psychiatric consultation. At the present time the patient does not appear to be experiencing hemodynamic instability secondary to alcohol withdrawal. However, I would recommend continuing to monitor vital signs and use MSSA protocol if indicated. We will request psychiatric consultation. The patient should be transferred to 3A as soon as possible. 2. Seizure disorder. We will plan to resume her Tegretol.
MSSA|modified selective severity assessment|MSSA|238|241|HOSPITAL COURSE|HOSPITAL COURSE: 1. Alcohol withdrawal: The patient did develop fairly severe withdrawal including disorientation, hallucinations, and severe tremors. He did not develop not any cardiovascular instability or seizures. He was managed on a MSSA protocol and required large doses of both oral and eventually IV benzodiazepines. The patient did require transfer to the intensive care unit for closer monitoring and intravenous benzodiazepines.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA.|176|180|HOSPITAL COURSE|The patient was continued on his outpatient medications. He was given IV fluids and vancomycin on hospital day #2. On day of discharge, cultures and sensitivities came back as MSSA. The patient was discharged with home health care with continuation of his peripheral IV and for outpatient Ancef. Followup with Dr. _%#NAME#%_ of Intermed Consultants in Clinic on _%#MMDD2006#%_ to determine whether he needs ongoing IV antibiotics versus changing to oral antibiotics.
MSSA|modified selective severity assessment|MSSA|156|159|PLAN|May have carpal tunnel syndrome based on positive Tinel's sign. No demonstrated weakness. 4. Nicotine addiction. PLAN: 1. Admit ICU. 2. Detoxification with MSSA withdrawal protocol using Valium in light of seizure history. 3. Seizure precautions. 4. Check CBC, CMP, serial troponin, and EKG. 5. Thiamine. 6. Multivitamin. 7. Staff to call p.r.n. progressive chest discomfort or dyspnea.
MSSA|modified selective severity assessment|MSSA|82|85|ASSESSMENT|2. Chronic alcohol abuse with current intoxication. He is being maintained on the MSSA protocol. I will recommend a stat recheck of his potassium as well as magnesium and phosphorus. He will be continued on IV fluids. 3. Alcoholic hepatitis and cirrhosis, with history of hepatic encephalopathy.
MSSA|modified selective severity assessment|MSSA|177|180|HOSPITAL COURSE|HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted to station 3A adult chemical dependency detoxification unit to be monitored for withdrawal from alcohol. He was monitored using the MSSA rating scale with Valium to cover withdrawal symptoms. On admission, the following medications were reordered: Depakote 1000 mg daily at bedtime, Lexapro 20 mg daily a.m., folic acid 1 mg daily a.m., and cephalexin 500 mg 3 times daily.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA,|187|191|HOSPITAL COURSE|PROBLEM #2. Infectious disease: _%#NAME#%_ is maintained on IV antibiotics via PICC line. He was given 1 week's worth of Timentin and tobramycin. At the time of discharge, because of his MSSA, he was sent home on oral clindamycin to finish a 14-day course. At the time of this dictation, results of his BAL cultures are staphylococcus aureus, MSSA, acid-fast bacilli not yet identified and Aspergillus fumigatus.
MSSA|modified selective severity assessment|MSSA|271|274|HISTORY OF PRESENT ILLNESS|When the patient was evaluated by psychiatry in the emergency room, he was both intoxicated and sedated by Ativan and gave a limited history; however, he did describe hearing voices telling him to harm himself. HOSPITAL COURSE: The patient was admitted and placed on the MSSA protocol. He went through moderate alcohol withdrawal with some tremors and minor sweats, no hallucinations or tachycardia. His peak MSSA score was 15 on the day after admission.
MSSA|modified selective severity assessment|MSSA.|195|199|HOSPITAL COURSE|HOSPITAL COURSE: The patient was originally admitted back in _%#MM#%_ from a _%#CITY#%_ hospital. She was found at that time to have lumbar spinal epidural abscesses. Blood cultures did grow out MSSA. She was found also to have a diskitis. She was worked up and followed closely by Neurosurgery and Dr. _%#NAME#%_. She was originally here until _%#MMDD#%_ when she was transferred back to the University for surgery.
MSSA|modified selective severity assessment|MSSA|168|171|IDENTIFICATION|HOSPITAL COURSE: Ms. _%#NAME#%_ is admitted to station 3A Adult Chemical Dependency Detox Unit to be monitored for withdrawal from alcohol. She was monitored using the MSSA rating scale with Ativan to cover withdrawal symptoms. On admission, the following medications were reordered: Norvasc 5 mg daily, vitamin C 500 mg daily, vitamin B12 one tablet daily, folic acid one tablet daily, and calcium D 600 mg 2 tablets daily.
MSSA|modified selective severity assessment|MSSA|152|155|HOSPITAL COURSE|Mr. _%#NAME#%_ was admitted to station 3A, adult chemical dependency detox unit to be monitored for withdrawal from alcohol. He was monitored using the MSSA rating scale with Valium to cover withdrawal symptoms. On admission, the following medications were reordered: 1. Paxil 20 mg daily at bedtime.
MSSA|modified selective severity assessment|MSSA|165|168|HOSPITAL COURSE|He has been through alcohol treatment before and has relapsed. HOSPITAL COURSE: PROBLEM #1: Chemical dependency/alcohol abuse/psychiatric. The patient was placed on MSSA protocol, and was started on thiamine and folate as well as hydration. He was placed on seizure withdrawal precaution, and a chemical dependency consultation was obtained.
MSSA|modified selective severity assessment|MSSA|144|147|HOSPITAL COURSE|He was admitted on a 72-hour hold for his safety which was discontinued. He was signed in on a voluntary basis. On _%#MM#%_ _%#DD#%_, 2006, his MSSA protocol was discontinued as he was out of detoxification. He was started on Neurontin 300 mg b.i.d. for chronic pain per Dr. _%#NAME#%_.
MSSA|modified selective severity assessment|MSSA|203|206|IDENTIFICATION|Her blood alcohol level was 0.36. HOSPITAL COURSE: Ms. _%#NAME#%_ was admitted to station 3A adult chemical dependency detox unit to be monitored for withdrawal from alcohol. She was monitored using the MSSA rating scale with Ativan to cover withdrawal symptoms. On admission, Zoloft 100 mg daily was reordered. She was seen by Dr. _%#NAME#%_ who started her on Effexor XR 37.5 mg daily times 3 days and titrated everyday by 37.5 mg up to 150 mg daily thereafter to treat symptoms of depression.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|86|89|HOSPITAL COURSE|8. Levofloxacin 250 mg p.o. q. 24 hours x5 days. ALLERGIES: NONE. HOSPITAL COURSE: 1. MSSA bacteremia. The patient initially presented to Fairview Lakes with a fever and chills. Blood cultures were positive for Staph aureus and sensitivities showed that it was pansensitive except to penicillin.
MSSA|modified selective severity assessment|MSSA|167|170|HOSPITAL COURSE|HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted to station 3A Adult Chemical Dependency Treatment to be monitored for withdrawal from alcohol. He was monitored using the MSSA rating scale with Ativan to cover withdrawal symptoms. On admission the following medications were re-ordered; Effexor XR 150 mg daily, Seroquel 50 mg b.i.d., and Seroquel 200 mg q.p.m. By _%#MMDD2004#%_ it was determined that he was out of detoxification, physically stable, and ready to be discharged to the community.
MSSA|modified selective severity assessment|MSSA|147|150|IDENTIFICATION|On admission to the unit, he stated that, although he felt depressed, he was no longer suicidal. He was monitored for alcohol withdrawal using the MSSA rating scale with Valium to cover withdrawal symptoms. Lexapro 20 mg daily and Campral 666 mg t.i.d. were restarted. By _%#MM#%_ _%#DD#%_, 2006, it was determined that he could safely be discharged; he was out of detox.
MSSA|modified selective severity assessment|MSSA|190|193|IDENTIFICATION|ALLERGIES: PENICILLIN. HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted to station 3A adult chemical dependency detox unit to be monitored for withdrawal from alcohol. He is monitored using the MSSA rating scale with Ativan to cover withdrawal symptoms. On admission, he was restarted on Topamax 200 mg daily at bedtime, Risperdal 4 mg daily at bedtime and lithium 1200 mg daily at bedtime.
MSSA|modified selective severity assessment|MSSA|324|327|HOSPITAL COURSE|NEUROLOGIC: No tremor. Nonfocal. LABORATORY DATA: Remarkable for serum sodium of 150, low normal potassium of 3.6, BUN of 50, creatinine of 1.0. Normal liver profile. Ethanol level 0.34. HOSPITAL COURSE: The patient was admitted to the intensive care unit where he was maintained on intravenous fluid support in addition to MSSA withdrawal protocol using Ativan, thiamine 100 mg daily for three days, and atenolol p.r.n. heart rate greater than 100. Developed moderate alcohol withdrawal. Depressed with regard to bipolar illness and no sequela with regard to above closed head injury.
MSSA|modified selective severity assessment|MSSA|192|195|PLAN|6. Upper abdominal tenderness on exam. May be related to gastritis. Rule out pancreatitis (doubt). PLAN: 1. Admit to Intensive Care Unit (ICU). 2. Intravenous fluids. 3. Diet as tolerated. 4. MSSA withdrawal protocol using Valium. 5. Thiamine and multi-vitamins. 6. Seizure precautions. 7. Resume Prozac and Neurontin. 8. Psychiatry consultation. 9. 72-hour-hold. 10. Check amylase and lipase.
MSSA|modified selective severity assessment|MSSA|144|147|PLAN|Rule out low magnesium. PLAN: 1. Admit ICU. 2. Replace potassium. 3. Check magnesium. 4. Intravenous fluid support. 5. Prevacid 30 mg b.i.d. 6. MSSA withdrawal protocol using Ativan. 7. Seizure precautions. 8. Follow-up laboratory studies. Obtain x-ray of facial bones. 9. Psychiatric consultation with Dr. _%#NAME#%_ with transfer to Detox Unit when clinically stable.
MSSA|modified selective severity assessment|MSSA|128|131|HOSPITAL COURSE|It was presumed that she had aspirated. HOSPITAL COURSE: The patient was started on IV antibiotics. given IV fluids, and put on MSSA protocol for alcohol withdrawal. She had a lot of hallucinosis during her first 24 to 48 hours, and Haldol was added to her regimen, with significant improvement.
MSSA|modified selective severity assessment|MSSA|159|162|HOSPITAL COURSE|HOSPITAL COURSE: Acute alcohol intoxication. As previously stated, the patient's alcohol level was 0.28 at the time of admission. The patient was placed on an MSSA protocol. A lengthy discussion was held with the patient regarding her alcohol use, and she realizes that she is drinking too much.
MSSA|modified selective severity assessment|MSSA|140|143|PLAN|She has already received charcoal in the emergency department. We will get a repeat chemistry and BMP in the morning. She will be placed on MSSA protocol, and a monitor will be applied accordingly. She will be placed on aspiration precautions. Zofran and Xanax have been ordered for her as well, and albuterol nebs for asthma.
MSSA|modified selective severity assessment|MSSA|200|203|ASSESSMENT AND PLAN|We will start the patient on intravenous fluid hydration. We will continue to monitor the patient's enzymes. We will keep the patient n.p.o. We will control pain as well. We will place the patient on MSSA protocol for his alcohol abuse. At this point in time, given that the patient has had no fever, chills, or rigors, it does not seem that has any infectious present.
MSSA|modified selective severity assessment|MSSA|228|231|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: 1. Acute alcohol withdrawal with history of chronic alcohol abuse and intoxication and dependence. The patient was admitted to medical floor for treatment of alcohol withdrawal. The patient was started with MSSA with Ativan, thiamin, folic acid, and atenolol for blood pressure. CD consultation still pending. Also, psych was consulted and the patient will be admitted to the detox unit for further treatment.
MSSA|modified selective severity assessment|MSSA|160|163|SUMMARY OF HOSPITAL COURSE|He therefore came to Fairview _%#CITY#%_ and because we did not have any detox beds available, the patient stayed on our service until he was finished with his MSSA protocol. During the course of hospitalization, he did not require any Ativan for withdrawal. He did not have any signs of tremors or hallucinations or other signs of obvious withdrawal.
MSSA|modified selective severity assessment|MSSA|190|193|PLAN|2. Intravenous fluid support based on follow-up basic metabolic profile. For now we will go with D5 normal saline at 125 per hour. Serial follow-up sodium, potassium, and renal function. 3. MSSA withdrawal protocol using Ativan. 4. Thiamine. 5. Atenolol for hypertension. Avoid further use of hydrochlorothiazide. 6. Accu-Cheks with sliding scale insulin coverage. 7. Zantac IV, switched to oral Protonix when adequately tolerating p.o.
MSSA|modified selective severity assessment|MSSA|188|191|PLAN|6. Sinus tachycardia secondary to alcohol withdrawal. 7. Nicotine addiction. 8. Hypokalemia. PLAN: 1. Continue intravenous fluid support. 2. Diet as tolerated. 3. Recheck CMP. 4. Continue MSSA withdrawal protocol using Ativan with thiamin and p.r.n. atenolol. 5. Seizure precautions. 6. Resume Celexa 40 mg daily. 7. Consult Dr. _%#NAME#%_ from Psychiatry. 8. Continue telemetry monitoring for now.
MSSA|modified selective severity assessment|MSSA|136|139|DISCHARGE DIAGNOSES|Old antral septal MI could not be excluded. HOSPITAL COURSE: Patient was admitted to the intensive care unit where he was maintained on MSSA alcohol withdrawal protocol using Ativan. Initially placed on IV Lopressor followed by nadolol 40 mg daily for blood pressure control. Thiamine 100 mg daily for 3 days in addition to folate, multivitamins, and Protonix for symptoms of acid reflux.
MSSA|modified selective severity assessment|MSSA|155|158|IDENTIFICATION|HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted to station 3A adult chemical dependency treatment unit to be detoxed from alcohol. He was monitored using the MSSA rating scale with Valium to cover withdrawal symptoms. Dr. _%#NAME#%_ _%#NAME#%_ saw him for history and physical as well as to evaluate his high blood pressure.
MSSA|modified selective severity assessment|MSSA|302|305|HOSPITAL COURSE|On admission, the following medications were reordered: trazodone 150 mg at bedtime, Effexor XR 300 mg every a.m., Seroquel 100 mg 2 times daily, and a multivitamin 1 time daily. On _%#MMDD2004#%_, chemical dependency evaluation was ordered. Antabuse at 250 mg daily was started on _%#MMDD2004#%_. The MSSA protocol was discontinued on _%#MMDD2004#%_ as he was out of detox. A plan was initially made for him to complete the Chemical Dependency Treatment Program in the Outpatient Department.
MSSA|modified selective severity assessment|MSSA|142|145|PLAN|We will have PT and OT evaluate him and follow him. 3. Alcohol abuse. It is unclear how much he is currently drinking. We will put him on the MSSA protocol and monitor for signs and symptoms of withdrawal.
MSSA|modified selective severity assessment|MSSA|199|202|HISTORY OF PRESENT ILLNESS|Please see history and physical dictated from Dr. _%#NAME#%_ dictated on _%#MMDD2006#%_ for full details. At the time of admission, the patient's alcohol level was 0.47 and the patient was placed on MSSA protocol. HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted and placed on a 72-hour hold secondary to the patient's continued alcohol intake and was subsequently a danger to himself due to the continued alcohol intake.
MSSA|modified selective severity assessment|MSSA|217|220|HISTORY|5. Gait instability secondary to #1, improved. HISTORY: A 46-year-old male with history of alcohol dependency admitted through the emergency department with acute intoxication. Monitored in the intensive care unit on MSSA withdrawal protocol using IV Valium, thiamine and multivitamins administered. Intravenous fluid support. Seizure precautions. Elevated liver function consistent with alcoholic hepatitis.
MSSA|modified selective severity assessment|MSSA|155|158|PLAN|Later we will switch to D5 half-normal saline with 20 mEq potassium chloride at 150 cc per hour. The patient was given thiamine, folic acid. The patient's MSSA will be Valium, given as needed, depending on his course of MSSA, and scheduled Valium 10mg q 6hours. Current care, diagnoses and prognosis was discussed with patient and his .mother There is questionable history of GI bleed.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA.|147|151|DISCHARGE DIAGNOSES|PLANNED DISCHARGE DATE: _%#MMDD2007#%_ DISCHARGE DIAGNOSES: 1. Infected right total knee arthroplasty with sepsis and bacteremia. The organism was MSSA. Status post removal of total knee arthroplasty. 2. Postoperative myocardial infarction. 3. Right MCA distribution CVI. 4. Upper GI bleed secondary to bleeding duodenal ulcers. 5. Multiple vessel atherosclerosis relating to stroke, including an occluded right internal carotid artery and 70% stenosis in the left ICA.
MSSA|modified selective severity assessment|MSSA|140|143|DISCHARGE MEDICATIONS|3. Multivitamin 1 tablet p.o. q.d. 4. Albuterol MDI 2 puffs q.i.d. and q.2h p.r.n. 5. Atrovent MDI 2 puffs p.o. q.i.d. 6. Ativan p.r.n. per MSSA protocol. The patient was discharged in stable condition to the _%#COUNTY#%_ _%#COUNTY#%_ Medical Center Detox Center.
MSSA|modified selective severity assessment|MSSA|233|236|HOSPITAL COURSE|Medically, the patient was stable throughout his hospital stay. Admission laboratory values were all within normal limits, with the exception of a urine tox screen that showed positive cocaine and alcohol. The patient was started on MSSA protocol, but did not require any benzodiazepine treatment, and had no withdrawal symptoms during his hospital stay. DISCHARGE MENTAL STATUS EXAMINATION: Slightly disheveled with long ungroomed hair, appropriate dress and good eye contact.
MSSA|modified selective severity assessment|MSSA|250|253|HOSPITAL COURSE|1. Hepatitis C. 2. Hypertension. 3. Depression. HOSPITAL COURSE: Please see the history and physical on the chart for events leading up to the patient's hospitalization. The patient was admitted to Intensive Care Unit. He was treated with the Valium MSSA protocol. His liver function tests were followed. They improved after several days. In addition, the patient's platelet count improved. The patient was seen by Psychiatry, who recommended continuing the patient on Celexa.
MSSA|modified selective severity assessment|MSSA|137|140|DISCHARGE DIAGNOSIS|They are essentially within normal limits. See chart for labs. HOSPITAL COURSE: She came to Station 22 North. She was monitored with the MSSA Rating Scale with Ativan to cover for any withdrawal symptoms from the alcohol. Trazodone 50 mg was ordered initially at bedtime if needed for sleep.
MSSA|modified selective severity assessment|MSSA|173|176|HOSPITAL COURSE|HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted to station 3A, Adult Chemical Dependency Treatment Unit to be monitored for withdrawal from alcohol. He was monitored using the MSSA rating scale with Ativan to cover withdrawal symptoms. On admission the following medications were reordered. Avandia 4 mg daily. Lithium ER 400 mg twice daily. Glyburide/metformin 5/500 1 daily.
MSSA|modified selective severity assessment|MSSA|159|162|DISCHARGE DIAGNOSES AXIS I|HOSPITAL COURSE: Ms. _%#NAME#%_ was admitted to station 3A adult chemical dependency treatment unit to be detoxified from alcohol. She was monitored using the MSSA rating scale with Ativan to cover withdrawal symptoms and MSSA. On _%#MM#%_ _%#DD#%_, 2004, Effexor XR was added at 37.5 mg titrated every 3 days by 37.5 mg up to 150 mg daily.
MSSA|modified selective severity assessment|MSSA|259|262|HOSPITAL COURSE|Adequate pain control with p.r.n. Vicodin. A history of depression/anxiety, for which the patient was seen in consultation by Dr. _%#NAME#%_ from psychiatry. He agreed to accept patient when medically stable for transfer to station 30 (inpatient psychiatry). MSSA scores of 11 and 9 on _%#MM#%_ _%#DD#%_, 2005. No tremor clinically. Clinically doing well with stable vital signs, O2 saturation 97% room air.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|91|94|IMPRESSIONS/PLANS|DOB: IMPRESSIONS/PLANS: 1. Right hip infected arthroplasty. Recent admission with positive MSSA bacteremia requiring significant incision and drainage, as well as partial total hip arthroplasty. She was treated with vancomycin and Zosyn initially then switched over to Ancef and rifampin.
MSSA|modified selective severity assessment|MSSA|117|120|PLAN|2. Alcohol abuse. 3. Tobacco abuse. PLAN: We are admitting the patient to 11A with telemetry. We will keep him on an MSSA protocol in attempt to prevent him from having any further withdrawal seizures. We will consult Chemical Dependency regarding his alcohol abuse. We will also provide the patient with a nicotine patch for tobacco withdrawal and monitor him for signs of instability.
MSSA|modified selective severity assessment|MSSA|197|200|HOSPITAL COURSE|For further details, please follow up with the admission note dictated by Dr. _%#NAME#%_ on _%#MMDD2007#%_. HOSPITAL COURSE: The patient was placed on alcohol withdrawal protocol tapered off using MSSA protocol and Ativan and the patient was initially started on phenobarbital taper, but it was found that the patient has been only using Ativan for 2 mg for the past 2 weeks, so phenobarbital taper was stopped and she was continued on B12 another vitamins.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|334|337|LABORATORY DATA|Sodium is 140, potassium 4.0, chloride 103, carbon dioxide 23, anion gap 15, glucose 110, BUN 12, creatinine 0.94, calcium 9.2, magnesium 2.2, phosphorus 3.0, AST 26, ALT or alkaline phosphatase 129, bilirubin 0.6, albumin 4.2, prealbumin 12, INR 1.21, blood culture and sputum cultures are pending. His sputum on _%#MMDD2004#%_ grew MSSA and also burkholderia cepacia, which showed sensitive to ciprofloxacin, ceftazidime and piperacillin and intermedium resistant to Timentin. Also from the note of Dr. _%#NAME#%_ _%#NAME#%_ who saw the patient on _%#MMDD2004#%_ he reviewed his record and showed that his sputum also grew sometime an Aspergillus Candida lusitaniae and also Pseudomonas aeruginosa and Alcaligenes xylosoxidans.
MSSA|modified selective severity assessment|MSSA|128|131|BRIEF HOSPITAL COURSE|During the hospitalization, the patient did not have a seizure. He was admitted to the general medical floor. He was started on MSSA protocol with Valium. Since the patient had 8 seizures in the last 1 year, Neurology was consulted on the phone and their recommendation was to get an EEG done which was performed.
MSSA|modified selective severity assessment|MSSA.|149|153|BRIEF HISTORY OF PRESENT ILLNESS|The patient underwent revision for previous sepsis of a hip hemiarthroplasty with a history of sepsis with Clostridium perfringens, Enterococcus and MSSA. The patient was treated with a course of IV antibiotics as well as resection arthroplasty and placement of an antibiotic spacer.
MSSA|modified selective severity assessment|MSSA|175|178|DIAGNOSIS|AxisII:DEF Axis III:as per Dr _%#NAME#%_s TEAM Axis IV:MODERATE Axis V:35 PLAN: The patient will be continued on his psychiatric medications. The patient will be continued on MSSA protocol. The patient at the time of the interview denied any suicidal/homicidal ideation plan or intent.
MSSA|modified selective severity assessment|MSSA|233|236|HOSPITAL COURSE|Histroy of present illness: Pt reports he relapsed after 10 months of sobriety ,is homeless.For further details plase review admission note on him by Dr _%#NAME#%_ on _%#MMDD2007#%_. HOSPITAL COURSE:The patient was detoxed using the MSSA protocol. He had an uneventful detox. He was restarted on his medication Seroquel 200 mg each day at bed, Neurontin 600 mg in the morning and 900 mg at bedtime.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA.|166|170|7. GERD|5. _%#MMDD2002#%_ Stool was sent for clostridium difficile which was negative. IMPRESSION And PLAN: 1. Lumbar spinal epidural abscess: Nafcillin and Rifampin for the MSSA. We will consult with Infectious Disease (Dr. _%#NAME#%_) to follow the antibiotic therapy and adjust as necessary. This was discussed with Dr. _%#NAME#%_ at the University upon receiving report on this patient, and he agreed with this.
MSSA|modified selective severity assessment|MSSA|175|178|HOSPITAL COURSE|Patient required about 10 mg of Ativan during hospital day #1. On hospital day #2 the patient only required 2 mg of Ativan, and by the day of discharge patient required none. MSSA scores turned it down during the hospital to around 3 at the time of discharge. PROBLEM #2: Alcohol abuse. Patient didn't have any insurance so Rule 25 assessment was obtained.
MSSA|modified selective severity assessment|MSSA|123|126|HOSPITAL COURSE|Urinalysis was negative. HOSPITAL COURSE: PROBLEM #1: Alcohol withdrawal and alcohol abuse. The patient was started on the MSSA protocol with p.o. Valium. She required significant amounts of p.o. Valium, especially on days #1 through #3. By day #4 and #5, she was tapering herself off of the Valium and was requiring only small doses in the evenings.
MSSA|modified selective severity assessment|MSSA|172|175|HOSPITAL COURSE|HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted to station 3A adult chemical dependency treatment unit to be monitored for withdrawal from alcohol. He was monitored using the MSSA Rating Scale with Ativan to cover withdrawal symptoms. He was started on Zoloft on _%#MMDD2004#%_. The Zoloft was started at 50 mg every a.m. x 3 days, then to be increased to 100 mg thereafter.
MSSA|modified selective severity assessment|MSSA|161|164|HOSPITAL COURSE|Ms. _%#NAME#%_ was admitted to station 3A adult chemical dependency detoxification unit to be monitored for withdrawal from alcohol. She was monitored using the MSSA Rating Scale with Ativan to cover withdrawal symptoms. On admission, Campral 333 mg 2 tablets 3 times daily, Paxil 40 mg every a.m., and trazodone 100 mg every p.m. were reordered.
MSSA|modified selective severity assessment|MSSA|200|203|HISTORY OF PRESENT ILLNESS|The Effexor was continued. Dr. _%#NAME#%_ wrote additional buprenorphine orders on _%#MM#%_ _%#DD#%_, 2004, and _%#MM#%_ _%#DD#%_, 2004. On _%#MM#%_ _%#DD#%_, 2004, the Zanaflex was discontinued. The MSSA rating scale was also discontinued. On _%#MM#%_ _%#DD#%_, 2004, a CD consult was ordered and done. By _%#MM#%_ _%#DD#%_, 2004, it was determined that he was able to be discharged home.
MSSA|modified selective severity assessment|MSSA|169|172|HOSPITAL COURSE|HOSPITAL COURSE: Ms. _%#NAME#%_ was admitted to station 3A adult chemical dependency detox unit to be monitored for withdrawal from alcohol. She was monitored using the MSSA rating scale with Ativan to cover withdrawal symptoms. On admission, Zantac, Seroquel, folic acid, spironolactone, and fluoxetine were reordered.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|184|187|HOSPITAL COURSE|2. PROBLEM #2: Cystic fibrosis of pulmonary exacerbation. The patient was treated with ceftazidime, tobramycin, and azithromycin as above. Cystic fibrosis culture grew out 1 strain of MSSA and 2 strains of pseudomonas with susceptibilities to prescribed medications. PFTs performed on the day of discharge showed FEV1 48% of predicted FVC 85% of predicted which was modestly improved from admission.
MSSA|modified selective severity assessment|MSSA|258|261|ASSESSMENT AND PLAN|We will check erythrocytes, sedimentation rate and c-reactive protein. We will await for Dermatology Service recommendations prior to embarking on autoimmune work-up. The patient probably needs a skin biopsy. Alcohol dependency. We will place the patient on MSSA protocol for alcohol withdrawal. We will consider getting a chemical dependency evaluation once his dermatologic condition work-up is complete.
MSSA|modified selective severity assessment|MSSA|148|151|ASSESSMENT/PLAN|The patient will be continued on D5 normal saline at 200 cc per hour. We will repeat the sodium level in the morning. The patient will be placed on MSSA alcohol withdrawal prevention protocol with Ativan, as per protocol. The patient was given thiamine and folic acid. Chemical dependency consultation is still pending.
MSSA|modified selective severity assessment|MSSA|243|246|PLAN|At the present time, the patient will be monitored. There is a vague history of seizures but patient when I interview denied any history of seizures, so will monitor the patient and if patient develops any complicated are increasing scores on MSSA will switch the patient over to Valium. Also, the patient will be restarted back on his hypothyroidism medications and levothyroxine.
MSSA|modified selective severity assessment|MSSA|138|141|HOSPITAL COURSE|She was on Effexor 150 mg in the morning and 75 mg at bedtime and trazodone 100 mg at bedtime. HOSPITAL COURSE: The patient was placed on MSSA protocol. She was initially unstable on her feet and she needed to be placed on 1:1, which was later discontinued. She was continued on the Valium on MSSA protocol and detox, restarted on Effexor 150 mg in the morning and 75 mg at bedtime and trazodone 100 mg at bedtime.
MSSA|modified selective severity assessment|MSSA|198|201|HOSPITAL COURSE|HOSPITAL COURSE: The patient was placed on MSSA protocol. She was initially unstable on her feet and she needed to be placed on 1:1, which was later discontinued. She was continued on the Valium on MSSA protocol and detox, restarted on Effexor 150 mg in the morning and 75 mg at bedtime and trazodone 100 mg at bedtime.
MSSA|modified selective severity assessment|MSSA|173|176|ASSESSMENT AND PLAN|2. Hypertension, continue the patient's Norvasc, Lopressor and HCTZ. 3. Hyperlipidemia. Continue the Lipitor. 4. Questionable alcohol abuse. The patient should be put on an MSSA protocol with Ativan if needed and he should be started on thiamine and folic acid. The patient himself denies any history of withdrawal seizures or DTs.
MSSA|modified selective severity assessment|MSSA|185|188|HOSPITAL COURSE|AXIS V: GAF-45. HOSPITAL COURSE: Initially, _%#NAME#%_ was angry about admission. However, he did remain generally cooperative. Due to reported benzodiazepine and heavy alcohol use, an MSSA protocol was instituted for withdrawal risks but no meds were given. Thiamine and folate were given for possible nutritional deficiencies. He presented with slurred speech, droopy eyelids, poor eye contact and sluggish, blunted affect with poor concentration.
MSSA|modified selective severity assessment|MSSA|299|302|MEDICATIONS|She denies a history of chronic medical ailments and specifically denies hypertension, heart disease, asthma, history of hepatitis or pancreatitis, diabetes, or other chronic medical ailments. MEDICATIONS: Medications at home include Prempro, Seroquel, and trazodone. She is currently utilizing the MSSA protocol with Ativan and has had 14 mg over the past eight hours. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient resides in her own home and works as a labor representative for the union at Honeywell.
MSSA|modified selective severity assessment|MSSA|133|136|ASSESSMENT|3. History of alcohol use daily, although the patient denies any prior history of alcohol withdrawal or seizure. Will keep her on an MSSA protocol to avoid any alcohol withdrawal postoperatively. Will give the patient thiamine 100 mg q day, folic acid 1 mg q day. Will obtain liver function tests to evaluate any alcoholic liver disease.
MSSA|modified selective severity assessment|MSSA|170|173|IDENTIFICATION|HOSPITAL COURSE: Miss _%#NAME#%_ was admitted to station 3A adult chemical dependency detox unit to be monitored for withdrawal from alcohol. She was monitored using the MSSA Rating Scale with Ativan to cover withdrawal symptoms. On _%#MM#%_ _%#DD#%_, 2005, Zoloft 150 mg one time daily was reordered. An order was also written for the case manager to call child protection regarding a petition.
MSSA|modified selective severity assessment|MSSA|169|172|HOSPITAL COURSE|HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted to station 3-A Adult Chemical Dependency Detox Unit to be monitored for withdrawal from alcohol. He was monitored using the MSSA rating scale with Valium to cover withdrawal symptoms. On admission, Zocor, Tenormin, and hydrochlorothiazide were ordered. Neurontin was reordered at 600 mg 2 times daily.
MSSA|modified selective severity assessment|MSSA|146|149|HOSPITAL COURSE|The patient was monitored closely, but at no time throughout his hospitalization that he exhibits signs or symptoms of alcohol withdrawal and the MSSA protocol was not needed. 4. Infectious disease. The patient did have an elevated temperature the day after surgery, and therefore urine culture, blood culture, and a chest x-ray were obtained.
MSSA|modified selective severity assessment|MSSA|171|174|HOSPITAL COURSE|HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted to station 3-A Adult Chemical Dependency Detox Center to be monitored for withdrawal from alcohol. He was monitored using the MSSA rating scale with Valium to cover withdrawal symptoms. An orthopedic consult was done. His left wrist had been x-rayed in the emergency room.
MSSA|modified selective severity assessment|MSSA|159|162|HOSPITAL COURSE|He was initially admitted by Dr. _%#NAME#%_ _%#NAME#%_ and then transferred to Dr. _%#NAME#%_ _%#NAME#%_. He was monitored for an alcohol withdrawal using the MSSA rating scale with Valium to cover withdrawal symptoms. Dr. _%#NAME#%_ started Campral 666 mg t.i.d. to deter cravings for alcohol. By _%#MM#%_ _%#DD#%_, 2006, it was determined that he could be discharged to lodging plus chemical dependency treatment program.
MSSA|modified selective severity assessment|MSSA|109|112|HOSPITAL COURSE|PROBLEM #4. Alcohol abuse: Mr. _%#NAME#%_ admits that he is drinking 10-12 cans of beer daily. We put him on MSSA protocol to treat his alcohol withdrawal, but he was stable. Most of the time his MSSA score was in between 4 and 6. We have also offered CD treatment, but the patient does not want to pursue it.
MSSA|modified selective severity assessment|MSSA|144|147|ASSESSMENT AND PLAN|Her last alcohol intake was 2 days prior to admission, and her ethanol level was less than 0.01. We will place her on a telemetry bed and start MSSA protocol for alcohol withdrawal treatment. We will also consult with chemical dependency service in the morning. The patient is agreeable to talk to the chemical dependency service.
MSSA|modified selective severity assessment|MSSA|336|339|SUMMARY OF HOSPITAL COURSE|Overall, the patient's hospital course was one of improvement. His oxygenation improved and as such at the time of my exam, he was able to saturate well without any supplemental oxygen at a saturation of 92%-93%. Additionally, he showed improvements in terms of his cognitive status after sustaining his withdrawal from alcohol. On the MSSA protocol, the patient eventually stabilized and is very committed to the idea of cessation of alcohol consumption at the time of discharge.
MSSA|modified selective severity assessment|MSSA|179|182|ASSESSMENT/PLAN|2. Injection drug use of heroin and cocaine: The patient is open to chemical-dependency treatment and will be seen by CD tomorrow if possible. In the interim we started him on an MSSA protocol, and we will be giving him some intermittent IV morphine, again, if a line can be started for the purposes of preventing any withdrawal symptoms that might take place.
MSSA|modified selective severity assessment|MSSA|136|139|HOSPITAL COURSE|Collateral information from wife was also obtained. The patient was on a 72-hour hold which was discontinued. The patient was placed on MSSA protocol and patient had an uneventful detox. During the hospitalization, he was also seen by Dr. _%#NAME#%_. Please review the detailed note on _%#MMDD2007#%_ for details regarding that.
MSSA|modified selective severity assessment|MSSA|178|181|HOSPITAL COURSE|No clonus. Mild resting tremor. DIAGNOSTIC STUDIES: Head CT negative for acute intracranial pathology. Troponin negative x2. HOSPITAL COURSE: The patient was put at least on the MSSA Protocol for alcohol withdrawal and withdrawal symptoms were treated with benzodiazepines, IV fluids and the patient was monitored on Telemetry.
MSSA|modified selective severity assessment|MSSA|157|160|ASSESSMENT|Will also put him on a very low insulin sliding scale. 4. History of psoriasis. He will continue with Enbrel. 5. History of alcohol abuse. Will place him on MSSA protocol and watch for possible withdrawal. 10. History of hyperlipidemia. We will resume Zocor at 20 mg daily. Also for his alcohol use will give him thiamine, folic acid and multivitamin.
MSSA|modified selective severity assessment|MSSA|138|141|PROBLEM #4|His blood sugars may be also elevated after hospital stay as he will be on a Medrol pack. PROBLEM #4: Alcohol abuse: He was placed on the MSSA protocol and did receive some Ativan for this. He was also started on thiamine and folate. Regarding his alcohol intake, he usually does 5 hard drinks a day but has been drinking more since his brother died a month ago from colon cancer and having a "black heart." He has had DUIs in the past and does not drive.
MSSA|modified selective severity assessment|MSSA|169|172|PROBLEM#1|HOSPITAL COURSE: On admission, PROBLEM#1: Alcohol intoxication and dependency: The patient since the time of admission was on MSSA protocol and throughout his stay, his MSSA protocol was 2-3. The patient does not show any withdrawal symptoms and he also has a history of DT in the past. The patient requested to be discharged and since his admission is also voluntary, the patient's request was granted and he will be discharged.
MSSA|modified selective severity assessment|MSSA|146|149|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: 1. Alcohol intoxication/abuse: We will have chemical dependency see the patient when he is more stable. We will continue the MSSA protocol for now. 2. Hypernatremia: This is likely secondary to profound dehydration likely secondary to subsisting on alcohol. We will give him normal saline at this time. He does have some slight hypokalemia as well.
MSSA|modified selective severity assessment|MSSA|135|138|PLAN|2. Major depression. 3. Low magnesium. 4. Scalp eczema. PLAN: The patient as admitted to the medical floor. The patient was started on MSSA protocol with Ativan p.r.n. The patient's MSSA scores were 4 and 5, and she did not require any Ativan since admission.
MSSA|modified selective severity assessment|MSSA|146|149|HOSPITAL COURSE|He was asked to leave the halfway house that he was living at because of his alcohol use. On Station 3A he was monitored for withdrawal using the MSSA rating scale with Ativan to cover withdrawal symptoms. On _%#MM#%_ _%#DD#%_, 2004, Effexor XR 37.5 mg was started, increasing by 37.5 mg titration every 3 days up to 150 mg daily.
MSSA|modified selective severity assessment|MSSA|162|165|IDENTIFICATION|HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted to station 3A adult chemical dependency treatment unit to be monitored for withdrawal from alcohol. He was monitored MSSA rating scale with Valium to cover withdrawal symptoms. On admission the following medications were reordered: Zoloft 100 mg daily, Pemoline 75 mg twice daily, nortriptyline 75 mg every h.s., BuSpar 15 mg 3 times daily, and Vistaril 25 to 50 mg every 4 hours as needed for anxiety.
MSSA|modified selective severity assessment|MSSA|237|240|HOSPITAL COURSE|2. Alcohol abuse and dependence. Patient did not receive a CD consult but was apparently committed to abstinence and was going to follow up with his sponsor and AA upon discharge. Patient required approximately 2 days of Ativan while on MSSA protocol. 3. Patient also with multiple financial and social concerns and later in course was able to negotiate (_______________) financial coverage through friends during course and was also able to receive advance on paycheck.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|179|182|HOSPITAL COURSE|He did end up decompensating during his hospitalization and was intubated. He had a left atrial appendage clot. He also was found to have vegetation on his mitral valve which was MSSA and also a candida pneumonia. He furthermore due to his poor hemodynamic status did have a balloon pump for a period of time as well.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|198|201|HOSPITAL COURSE|Following that the patient was admitted to the ICU where he has been having chronic ventilatory problems. A percutaneous tracheostomy was placed on _%#MM#%_ _%#DD#%_, 2005. He was diagnosed with an MSSA pneumonia on _%#MM#%_ _%#DD#%_, 2005, and then he was diagnosed with an MRSA pneumonia on _%#MM#%_ _%#DD#%_, 2005. The patient went into respiratory failure and ARDS during his SICU stay.
MSSA|modified selective severity assessment|MSSA|152|155|HOSPITAL COURSE|Ms. _%#NAME#%_ was admitted to station 3A adult chemical dependency detox unit to be monitored for withdrawal from alcohol. She was monitored using the MSSA rating scale with Ativan to cover withdrawal symptoms. She was seen by Dr. _%#NAME#%_ and started on Protonix 40 mg daily, Claritin 10 mg daily, and Estratest 1.25/2.5 mg daily.
MSSA|modified selective severity assessment|MSSA|125|128|HOSPITAL COURSE|His blood alcohol level was 0.43. Initially, we gave him IV fluid, thiamin, folic acid and multivitamins. We also put him on MSSA protocol along with seizure precautions. CD was consulted and the patient was evaluated during his stay in the hospital. During his stay in our service, the patient improved gradually and at the time of his discharge, he was stable, alert and oriented and willing to go home.
MSSA|modified selective severity assessment|MSSA|158|161|HOSPITAL COURSE|HOSPITAL COURSE: The patient was observed initially in the intensive care unit and was hemodynamically stable and put on the usual protocol with vitamins and MSSA protocol. He did fairly well with tapering doses of Ativan, was alert and oriented at the time of his discharge. He was willing, at least in conversation, to pursue chemical dependency treatment, and it was a strong request of his family that he go directly to a chemical dependency treatment program because he has already tried 4 treatment programs in the past 5 years and relapsed rather quickly.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|134|137|HOSPITAL COURSE|The patient also had numerous excoriations secondary to self-inflected damage. The patient was started on Unasyn given her history of MSSA infections. On _%#MMDD2007#%_ vancomycin was added to cover MRSA as well. ACT done on _%#MMDD2007#%_ did not show any evidence of abscess or osteomyelitis.
MSSA|modified selective severity assessment|MSSA|135|138|PLAN|1. Alcohol intoxication and dependency with continuous use. 2. Headache. Not an issue at this time. PLAN: We will start the patient on MSSA protocol. I will also treate him with thiamine, folate, and atenolol p.r.n. for systolic blood pressure greater than 150. I will check his electrolytes, and CBC with differential. Chemical Dependency Consult requested.
MSSA|modified selective severity assessment|MSSA|246|249|PLAN|5. Prolonged Q-T interview, likely secondary to Seroquel overdose. PLAN: Will monitor the patient in the Intensive Care Unit overnight. Will check magnesium and phosphorus levels tonight. Awaiting for urine drug screen results. Will place him on MSSA protocol. Will also hydrate him overnight with D5 normal saline with 20 mEq potassium chloride and 150 mL/hr. Chemical dependency consult will be requested. The patient may also benefit from Psychiatry consult too, which will be requested.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA.|206|210|PROBLEM #5|His platelet count on the day prior to admission was trending down at 1112. PROBLEM #5: Infectious disease: _%#NAME#%_ was noted to have purulent drainage during intubation. Sputum culture was positive for MSSA. He was initially started on vancomycin and clindamycin, but transitioned to Zosyn for coverage of suspected ventilator associated pneumonia.
MSSA|modified selective severity assessment|MSSA|188|191|PROBLEM #2|PROBLEM #2: Chemical dependency with ongoing use. CD consult for the possible rehab transfer. CD evaluation input is pending at the time of this dictation. The patient was also started on MSSA protocol, although she scored between 4-17. On the first day of admission she received 2 g of Ativan. No withdrawal symptoms were noted during her hospital stay. PROBLEM #3: Elevated WBCs with the pruritic chest pain and cough at the time of admission suspected early community-acquired pneumonia and pneumonitis versus aspiration pneumonia and no fever.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|152|155|PROBLEM LIST|3. Infectious Disease. _%#NAME#%_ has not been febrile during this exacerbation. He appears well now and not septic. His recent cultures have grown out MSSA and Hemophilus influenza. For this reason, we will start Augmentin in an attempt to give him antibiotics orally. He does have a distant history of Pseudomonas aeruginosa and Klebsiella pneumoniae culture positivity and this will be borne in mind when considering antibiotics by the primary team in the morning.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|210|213|DISCHARGE DIAGNOSIS|She, therefore, attended clinic and was admitted to the hospital. Her last appointment that she attended was with Dr. _%#NAME#%_ 2 months previously. PAST MEDICAL HISTORY: Remarkable for Staphylococcus aureus, MSSA and MRSA in 2002. She has also had previous Pseudomonas infection, a diagnosis of asthma, and CF-related glucose dysregulation which has been controlled with diet.
MSSA|modified selective severity assessment|MSSA|179|182|IDENTIFICATION|HOSPITAL COURSE: Initially Ms. _%#NAME#%_ was admitted to station 3A adult chemical dependency detox unit to be monitored for withdrawal from alcohol. She was monitored using the MSSA rating scale with Ativan to cover withdrawal symptoms. On admission, the following medications were reordered. Zoloft 200 mg daily, trazodone 100 mg daily at bedtime, Lipitor 10 mg daily, Seroquel 25 mg twice daily, Seroquel 50 mg daily at bedtime, and atenolol 25 mg daily.
MSSA|modified selective severity assessment|MSSA|137|140|HOSPITAL COURSE|He was transferred to the ICU on hospital day #2 for that reason. Eventually these symptoms improved and he was able to be taken off the MSSA protocol and transferred back to the floor. 2. Altered mental status. The patient became agitated and confused on hospital day #2.
MSSA|modified selective severity assessment|MSSA|260|263|ADMISSION LABORATORY DATA|A chest tube was inserted for the patient on _%#MMDD2007#%_ and was followed by multiple chest x-rays every day for monitoring. His hyponatremia during admission started to improve the second day of his admission and the patient was put on Valium protocol for MSSA and series of troponin was done for the patient, which was no significant change, and chest tube was removed on _%#MMDD2007#%_, and chest x-ray showed complete resolution of the pneumothorax.
MSSA|modified selective severity assessment|MSSA|166|169|PLAN|3. Intravenous fluid support. 4. NPO until fully alert. 5. Chest x-ray. 6. Urine tox. 7. In the event that the patient has been abusing alcohol, we will place him on MSSA withdrawal protocol using Ativan. 8. Clonidine with issue of potential opiate withdrawal. 9. Psychiatry consultation to assist with withdrawal measures and underlying mental health issues.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|50|53|PRINCIPAL FINAL DIAGNOSES|DOB: _%#MMDD1951#%_ PRINCIPAL FINAL DIAGNOSES: 1) MSSA (methicillin-sensitive Staphylococcus aureus) bacteremia secondary to line infection. 2) Metastatic colon cancer. 3) Congestive heart failure. 4) Obstructive sleep apnea.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|173|176|MEDICATIONS|Compazine 5-10 mg p.o./IV q. 6h. p.r.n. nausea and vomiting. Albuterol metered dose inhaler 2 puffs inhaled q. 4h. p.r.n. shortness of breath. Vancomycin 125 mg p.o. b.i.d. MSSA protocol. PAST MEDICAL HISTORY: 1. Clostridium difficile originally diagnosed on _%#MMDD2005#%_ after a course of ciprofloxacin.
MSSA|modified selective severity assessment|MSSA|151|154|LABORATORY|HOSPITAL COURSE: Ms. _%#NAME#%_ was admitted to station 30 north adult mental health treatment unit. She is monitored for alcohol withdrawal using the MSSA rating scale with Ativan to cover withdrawal symptoms. The Ativan to cover withdrawal symptoms was changed to Valium. She was seen by Dr. _%#NAME#%_ and started on Effexor-XR 37.5 mg daily x3 days, then increased to every 3 days by 37.5 mg upto 150 mg daily to treat symptoms of depression, Seroquel was added at 25 mg twice daily for anxiety with 50 mg daily at bedtime to ease sleep.
MSSA|modified selective severity assessment|MSSA|164|167|HOSPITAL COURSE|A Dobutamine stress echo was unremarkable. His pain is significantly diminished. At this time his electrolyte abnormalities were corrected and he was maintained on MSSA protocol for withdrawal and most recent score was down to 4. I have discussed the need for the patient to abstain from alcohol use and he agrees to pursue outpatient chemical dependency treatment.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA.|130|134|DISCHARGE DIAGNOSES|DATE OF ADMISSION: _%#MMDD2007#%_ DATE OF DISCHARGE: _%#MMDD2007#%_ DISCHARGE DIAGNOSES: 1. Right forearm abscess and cellulitis, MSSA. 2. IV cocaine use. 3. Tobacco use. CONSULTS: Orthopedic surgery with Dr. _%#NAME#%_, Orthopedic Consultants, social work given chemical dependency issues, chemical dependency consult.
MSSA|modified selective severity assessment|MSSA|266|269|PLAN|4. Alcohol-related gastritis. PLAN: The patient was admitted to the medical floor for IV hydration with D5 half normal saline with 20 mEq potassium chloride at 125 cc/hour, and pain control with morphine sulfate. Will add Zantac 150 mg p.o. b.i.d. The patient is on MSSA protocol for prophylaxis of alcohol withdrawal and DTs. His MSSA score was 11. He received 2 mg of Ativan. The patient desires CD treatment as an outpatient, and will obtain CD treatment and psychiatric treatment for possible anxiety and underlying depression.
MSSA|modified selective severity assessment|MSSA|251|254|HOSPITAL COURSE|After much encouragement, the patient did agree to transfer to the detoxification center, and initially has agreed to admission to the Lodging Plus program for long-term treatment. He will be transferred to the detox center with Ativan p.r.n. per the MSSA protocol. Problem #2: Hypertension. Medications were initially held, given elevated blood pressures due to alcohol withdrawal.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|309|312|HISTORY OF PRESENT ILLNESS|At that time, she was being treated for MSSA sepsis stemming from a septic right knee, ruptured Baker cyst, and an infected calf with the complications of acute renal failure and possible endocarditis. She has history of steroid injection in her right knee for this ruptured Baker cyst and presented with the MSSA sepsis a few weeks later. She was being treated with Ancef and rifampin on admission and presents for definitive evaluation of this spinal epidural abscess and discitis.
MSSA|modified selective severity assessment|MSSA|190|193|LABORATORY DATA|LABORATORY DATA: White blood cell count 8.7, hemoglobin 16.2, hematocrit is 46.8, platelet count 376, sodium 148, potassium 3.8, chloride 110, CO2 19, BUN 10, creatinine 0.9, glucose of 70. MSSA score recently was 7 at 7:00 a.m. ASSESSMENT AND PLAN: 1. This is a 26 year old with alcohol dependence and continued use.
MSSA|modified selective severity assessment|MSSA|147|150|HOSPITAL COURSE|The patient continued to have suicidal ideation with plan. He had no intent to act on it, his depression continued. The patient was tapered of the MSSA using Valium and had an uneventful detox. The patient was seen by the internist. Please review the detailed note on _%#MMDD2007#%_ for details about it.
MSSA|modified selective severity assessment|MSSA|250|253|HOSPITAL COURSE|He remained there through _%#MMDD2007#%_ when he was transferred out to the floor and care was assumed by the Hospitalist Department. The patient did require supplemental nutrition and time on the ventilator. While on the floor the patient developed MSSA sepsis and bacteremia of unclear source. He was on multiple antibiotics and ultimately consolidated to nafcillin. During this same time he was felt to have developed an aspiration pneumonia for which he was placed on IV Invanz.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA.|214|218|PROBLEM #3|He remained afebrile during his hospitalization and had 4 more blood cultures that were negative after this one. Towards the end of his hospital course, he did have another positive blood culture with another with MSSA. He was given 1 dose of nafcillin and he will be discharged with 7-day course of Bactrim double strength b.i.d. to treat this.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA.|217|221|PROCEDURE|DIET: Diabetic. ACTIVITY: She should minimize weightbearing on the right foot but she can use weightbearing on the heel as needed on the right side. CODE STATUS: Full. PROCEDURE: She had a wound culture that did grow MSSA. Her blood cultures were negative. CONSULTATIONS: Orthopedics. PENDING TESTS: None. SUMMARY OF HOSPITAL COURSE: 1. Neuropathic diabetic foot ulcer with right toe cellulitis; A culture was obtained from secretions from the wound.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|152|155|HOSPITAL COURSE|He was started on antibiotics orally as an outpatient in the form of dicloxacillin with no improvement. The sputum culture during this admission showed MSSA and pseudomonas. On admission, he was started on nafcillin every 4 hours 2 g and when the sputum showed non-lactose fermenter, we expected it is pseudomonas.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA.|229|233|HOSPITAL COURSE|After this was accomplished, the patient began to improve. She had been empirically started on IV antibiotics including Zosyn and Levaquin. Ultimately E. Coli was cultured from the blood. The patient also had positive sputum for MSSA. Aggressive antibiotic treatment was later in the course complicated by both C. difficile and development of fungus infection. Throughout the hospitalization, the patient was episodically in atrial fibrillation.
MSSA|modified selective severity assessment|MSSA|228|231|HOSPITAL COURSE|CHIEF COMPLAINT: "I came for detox." HISTORY OF PRESENT ILLNESS: The patient relapsed after 2 months of sobriety and he was kicked out of his house. HOSPITAL COURSE: During the hospital course, the patient was detoxed using the MSSA protocol using Ativan. During the hospital course, the patient was restarted back on Lexapro 20 mg. The patient had an uneventful detox. During his hospital course, his energy, motivation, sleep and interest improved.
MSSA|modified selective severity assessment|MSSA|326|329|HOSPITAL COURSE|Urine toxicology only was positive for alcohol. Otherwise, salicylate level less than 1, acetaminophen level 4, troponin less than 0.07. HOSPITAL COURSE: Poison control was contacted regarding Seroquel overdose, and at this point, the patient was just monitored in the ICU overnight. She was given IV hydration and started on MSSA alcohol withdrawal protocol with Ativan or Valium as needed. The patient remained very stable and did not require any further intervention.
MSSA|modified selective severity assessment|MSSA|130|133|HISTORY OF PRESENT ILLNESS|Normal liver profile except for a minimally elevated AFC of 57. Magnesium 2.2. Admitted to the Intensive Care Unit. Maintained on MSSA withdrawal protocol using oral Ativan. MSSA scores of 7-8 without required medication intervention. Also intravenous fluid support. Tolerating a diet well without nausea or vomiting. No dyspepsia or abdominal pain.
MSSA|modified selective severity assessment|MSSA|134|137|ASSESSMENT/PLAN|The patient is now more alert and oriented. The patient's alcohol level was markedly elevated to 0.41 g/dL. The patient was placed on MSSA and Ativan protocol. In addition he was given thiamine 100 mg p.o. daily and folic acid 1 mg p.o. daily. Will obtain Chemical Dependency consultation today. The patient is to admitted to the Adolescent Detox Unit today.
MSSA|modified selective severity assessment|MSSA|131|134|PLAN|8. Hypernatremia consistent with volume depletion. PLAN: 1. Admit to intensive care unit. 2. Seizure precautions. 3. IV fluids. 4. MSSA withdrawal protocol. 5. Psychiatric consult. 6. Monitor with regard to left lower quadrant abdominal pain. Again, proceed with abdominal CT if tenderness persists. 7. Psychiatry consultation.
MSSA|modified selective severity assessment|MSSA|207|210|HOSPITAL COURSE|Chest x-ray revealed questionable left lower lobe infiltrate. HOSPITAL COURSE: PROBLEM #1: Psychiatric/social issues: 1. Alcoholism with acute alcohol withdrawal. On admission, the patient was placed on the MSSA protocol with Ativan. During his withdrawal process, he was tachycardic and slightly agitated. Haldol was added prn secondary to needing large doses of Ativan.
MSSA|modified selective severity assessment|MSSA|143|146|PLAN|2. We will review her labs and x-ray of her pelvis and hips. 3. Observe for alcohol withdrawal. Treat with thiamine and benzodiazepines on the MSSA protocol. 4. We will do a CD evaluation and consult. 5. We will provide her Tylenol and Motrin for her pain.
MSSA|modified selective severity assessment|MSSA|269|272|PLAN|ASSESSMENT: 63-year-old male with long history of alcohol abuse and dependence, now with cirrhosis, alcoholic hepatitis, probable ascites, and liver failure. PLAN: 1. Alcohol abuse. We will get CD and Psychiatry involved. He may need commitment. We will put him on the MSSA withdrawal protocol, as I am not entirely convinced his last drink was a full six days ago. 2. Cirrhosis/liver disease, with acute alcoholic hepatitis, hepatosplenomegaly and ascites.
MSSA|modified selective severity assessment|MSSA|234|237|HOSPITAL COURSE|Please review the detailed admission note on _%#MMDD2007#%_. Please review the detailed admission note on _%#MMDD2007#%_ for further history of admission. HOSPITAL COURSE: During the hospital course, the patient was detoxed using the MSSA protocol on Ativan. She had an uneventful detox. Her sleep, energy, interest and motivation improved. DISCHARGE DISPOSITION: The patient is going to Lodging Plus. DISCHARGE MEDICATIONS: None.
MSSA|modified selective severity assessment|MSSA|133|136|PLAN|6. History of previous CVA. PLAN: At this point will place patient on telemetry. Will give him IV fluid rehydration and place him on MSSA protocol. Will monitor him for signs of withdrawal. His initial plan was to go to detox once he is stable; however, he sounds less than motivated to go to detox at this time.
MSSA|modified selective severity assessment|MSSA|141|144|HOSPITAL COURSE|He was placed on CPAP and spent the next 2 nights in the SICU for close observation. The patient was placed on adequate pain medication. The MSSA protocol was started for ETOH withdrawal. Aggressive pulmonary toilet was started as well as a CPAP. p.r.n. for presumed COPD. Hematology was consulted for the patient's chronic anemia.
MSSA|modified selective severity assessment|MSSA|165|168|ASSESSMENT AND PLAN|Ketones are positive at 1.3, ALT 9, AST 24, hemoglobin 13.5, platelets 206,000, white count 10.6. ASSESSMENT AND PLAN: 1. Crack cocaine abuse: I will put her on the MSSA protocol and hopefully she will get over to Psychiatry in the next day or so. 2. Diabetic ketoacidosis secondary to lack of insulin and lack of eating.
MSSA|modified selective severity assessment|MSSA|154|157|PLAN|2. Will get Chemical Dependency and GI consults. 3. Put on MSSA protocol. 4. The patient received banana bag in the emergency room. 5. Will continue with MSSA protocol on the floor. 6. Follow serial hemoglobins.
MSSA|modified selective severity assessment|MSSA|220|223|ASSESSMENT AND PLAN|2. Long-standing alcohol abuse. This relates to the patient's first problem and although she came in with a fairly unremarkable alcohol level she could still go into withdrawal. We will, therefore, keep the patient on a MSSA protocol and as the patient becomes more alert a chemical dependency consult will be pursued. An ammonia will be checked to see if this could be related to more of a hepatic encephalopathy picture in terms of causes for the patient's confusion.
MSSA|modified selective severity assessment|MSSA|251|254|PLAN|Rehydrate him properly with IV fluids and correct his electrolyte disturbances, checking a magnesium and phosphorus level and replacing as necessary, as well. We will also redo his EKG once his electrolytes have been balanced. We will place him on an MSSA protocol, do a urine and blood tox screen and plan to have psych and CD evaluation as he is detoxified and stabilized.
MSSA|modified selective severity assessment|MSSA|154|157|HOSPITAL COURSE|The next a.m., lipase was obtained and was found to be 398. Ethanol 0.42 on admission. HOSPITAL COURSE: 1. Alcohol withdrawal. The patient was put on the MSSA protocol. Did develop some tremors, however. These were well managed by day 2 of admission. He was also having intermittent high blood pressure. Was initially started on a clonidine patch, but then was changed over to atenolol 25 mg p.o. q.d.; however, his blood pressure subsequently improved and the atenolol was no longer necessary.
MSSA|modified selective severity assessment|MSSA|132|135|ASSESSMENT/PLAN|5. Depression. Celexa 20 mg p.o. q. daily. 6. Suicidal ideation. Try to keep the patient safe on a 72-hour hold. He is intoxicated. MSSA protocol. 7. Analgesics for chest wall pain. I did call for an emergent psychiatric consultation. That was called in to _%#NAME#%_ at _%#TEL#%_.
MSSA|modified selective severity assessment|MSSA|239|242|HOSPITAL COURSE|The patient was admitted to the medical bed due to findings consistent with alcoholic hepatitis on admission and for the purpose of alcohol withdrawal. HOSPITAL COURSE: The patient was treated with alcohol abstinence, nutritional support, MSSA protocol, and close monitoring of laboratory work. The patient gradually showed improvement with control of alcohol withdrawal tremulousness, stabilization of liver enzymes, and stable thrombocytopenia.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|199|202|TESTS|He is to remain no weight bearing on that foot, he will receive wound care and assistance through home nursing and has a follow-up also with Ortho for two weeks. TESTS: He grew Staph aureus that was MSSA or pansensitive. He also grew some Strep anginosus. His hemoglobin was stable here. He had no major white count. Platelets were normal. Creatinine on admission was mildly elevated at 1.5 but decreased to 1.3. Later on he was up walking with the help of a walker and physical therapy and felt stable to be discharged home with the assistance of home nursing for wound changes and home antibiotic treatments.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA.|146|150|HISTORY OF PRESENT ILLNESS|He is now hemodialysis dependent. He has a history of multiple line infections. The most recent one being in _%#MM2007#%_, which turned out to be MSSA. Per the patient and his mother, he reported that 5-6 days prior to admission, he started feeling ill with chills, decreased oral intake, nausea, vomiting, fatigue and headache.
MSSA|modified selective severity assessment|MSSA|160|163|HOSPITAL COURSE|Please review the detailed admission note on _%#MMDD2007#%_ for further details. HOSPITAL COURSE: During the hospital course, the patient was detoxed using the MSSA protocol on Ativan. The patient did not want to take Celexa. His Celexa was discontinued. During the hospitalization the patient was seen by Dr. _%#NAME#%_.
MSSA|modified selective severity assessment|MSSA|136|139|HOSPITAL COURSE|Please review the detailed admission note on _%#MMDD2007#%_. HOSPITAL COURSE: During the hospital course, the patient was detoxed using MSSA protocol and Ativan. The patient had an uneventful detox. While the patient was in the hospital, he was seen by Dr. _%#NAME#%_. Please review the detailed note by Dr. _%#NAME#%_ on _%#MMDD2007#%_.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA,|232|236|HOSPITAL COURSE|HOSPITAL COURSE: 1. Pneumonia. The patient was found to have right lower lobe infiltrate, increased right lower lobe opacity with possible parapneumonic effusion. He was started on antibiotics to cover his past positive cultures of MSSA, pan sensitive pseudomonas and multidrug resistant Stenotrophomonas, also taking into account his decompensation while on Bactrim and Cipro. Initial antibiotics were tobramycin, ceftazidime, levofloxacin and Bactrim. On _%#MMDD#%_ his antibiotics were changed by discontinuing Cipro and Bactrim and starting dicloxacillin which was subsequently changed to nafcillin the next day.
MSSA|modified selective severity assessment|MSSA|171|174|PLAN|Axis II: Deferred. Axis III: Hashimoto's disease, diabetes mellitus and gastric bypass. Axis IV: Moderate. Axis V: GAF: 30. PLAN: 1. The patient will be detoxed off using MSSA protocol on Ativan. 2. The patient will have Internal Medicine consultation. 3. Patient will continue on Paxil 50 mg at bedtime and trazodone 50-100 mg.
MSSA|modified selective severity assessment|MSSA|225|228|HOSPITAL COURSE|Please review the detailed admission note dictated by Dr. _%#NAME#%_ on _%#MMDD2007#%_ for further details. HOSPITAL COURSE: During the hospital course, the patient was initially very uncooperative. She was detoxed using the MSSA protocol on Valium. The patient was restarted back on Celexa 20 mg at bedtime and she was also given Zyprexa 2.5 mg t.i.d. for agitation.
MSSA|modified selective severity assessment|MSSA|261|264|HOSPITAL COURSE|Chemical dependency consult was done. The patient refused lodging treatment as an inpatient and he wants to continue outpatient treatment after being discharged. Instruction for contact and treatment was given for the patient. Alcohol withdrawal, he was put on MSSA protocol and on this protocol he was treated accordingly and on discharge he had been on the lower score of the MSSA protocol, 3 to 6 for over 12 hours.
MSSA|modified selective severity assessment|MSSA|215|218|ASSESSMENT AND PLAN|He needs vaccination. Lactic acid 1.9. Drug screen, urine toxicity is positive for marijuana and alcohol. Alcohol level was 0.42. ASSESSMENT AND PLAN: A 46-year-old admitted for alcohol abuse. 1. Alcohol abuse. His MSSA score on the day of discharge was 8 and he received 2 mg Valium in the last 24 hours prior to discharge.
MSSA|modified selective severity assessment|MSSA|180|183|HOSPITAL COURSE|Alcohol or 1 liter of vodka per day for the past 2 weeks. FAMILY HISTORY: Father has hypertension. HOSPITAL COURSE: 1. Alcohol intoxication: The patient was admitted and placed on MSSA protocol with thiamine, folate and multivitamins. MSSA score was 8 upon discharge. The patient's status was stable upon discharge. 2. Alcohol hepatitis: With findings on the CT and ultrasound, it may be secondary to alcohol chronic use.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|167|170|WORKING DIAGNOSIS|He did quite well over time. He felt better and his white count normalized. His pulmonary function test was 1.9 at the time of discharge. His sputum culture came back MSSA sensitive to fluoroquinolones. The patient was sent home in stable condition with levofloxacin. He will continue the p.o. levofloxacin until he sees his primary care provider in few days.
MSSA|modified selective severity assessment|MSSA|117|120|PROBLEM #2|An alcohol level was obtained and showed some presence of alcohol, with a level of less than 0.01. He was put on the MSSA protocol with Ativan, not to exceed 3 mg a day. Episodes of agitation continued to occur. Urinalysis was obtained, which showed possible urinary tract infection.
MSSA|modified selective severity assessment|MSSA|138|141|DISCHARGE MEDICATIONS|3. Percocet 5 mg/325 mg one to two p.o. q.4-6h p.r.n. pain. 4. Vistaril 25-50 mg p.o. q.4-6h p.r.n. pain. 5. Zantac 150 mg p.o. b.i.d. 6. MSSA protocol with Ativan 0.25 mg p.o., maximum q.i.d., for MSSA scores greater than or equal to 8. 7. Ciprofloxacin 250 mg p.o. b.i.d. x 7 days.
MSSA|modified selective severity assessment|MSSA|113|116|PROBLEM #2|He was discharged on augmentin 875 mg for one week. PROBLEM #2: Alcohol intoxication: The patient was started on MSSA protocol. CD was involved and recommended to continue. His withdrawal well controlled on MSSA. There are minimal cues for Ativan. Continue to follow alcohol levels and continue what appears to be declining in 24 hours of admission.
MSSA|modified selective severity assessment|MSSA|217|220|PROBLEM #3|Subsequently, this was discontinued, as her p.o. intake improved. I's and O's were followed to insure kidney function, and the patient did have good urine output. PROBLEM #3: Alcoholism. The patient was placed on the MSSA protocol, given her history of apparent alcohol dependence. She did not require any Valium while in the hospital. Alcohol levels were found to be mildly elevated on admission.
MSSA|modified selective severity assessment|MSSA|209|212|ADMISSION HISTORY AND PHYSICAL EXAMINATION|Also, the patient was started on Dilantin, once transferred to the ICU secondary to the patient having a history of a seizure disorder from alcohol withdrawal and the patient seeming to score very high on the MSSA scores and believed to be in very severe alcohol withdrawal. Also, CK levels were obtained upon admission, which were elevated around 537.
MSSA|modified selective severity assessment|MSSA|167|170|PLAN|1. Alcohol abuse. 2. Tachycardia secondary to anxiety and possible beta blocker withdrawal. 3. Anxiety. PLAN: The patient will be admitted to the ICU and be placed on MSSA protocol. I will consult psychiatry in the morning and re-check his basic metabolic panel in the morning. If the patient attempts to leave, we will place a 72-hour-hold on him.
MSSA|modified selective severity assessment|MSSA|161|164|PLAN|4. Mild coagulopathy. 5. Possible early withdrawal symptoms. PLAN: 1. The patient will be placed at bedrest and under close observation, and we will initiate an MSSA protocol. 2. Check other liver function studies to evaluate for hepatitis A, B, C, and also other hepatic conditions. We will also obtain a CT scan of his abdomen.
MSSA|modified selective severity assessment|MSSA|156|159|HOSPITAL COURSE|He was admitted to the unit on a 72-hour hold. Initially, Effexor XR 150 mg daily and Seroquel 25 mg at bedtime were re-ordered. He was monitored using the MSSA rating scale with Ativan to cover withdrawal symptoms. On _%#MMDD2004#%_, a chemical-dependency assessment was ordered, with a recommendation for treatment.
MSSA|modified selective severity assessment|MSSA|212|215|HOSPITAL COURSE|He was monitored using the MSSA rating scale with Ativan to cover withdrawal symptoms. On _%#MMDD2004#%_, a chemical-dependency assessment was ordered, with a recommendation for treatment. By _%#MMDD2004#%_, the MSSA rating scale was discontinued, as he was not showing withdrawal symptoms. By _%#MMDD2004#%_, it was determined that he could be discharged to the Lodging Plus Chemical Dependency Program when a bed was available.
MSSA|modified selective severity assessment|MSSA|179|182|PLAN|4. Possible substance abuse. 5. History of depression. 6. Hypokalemia. PLAN: We will admit the patient to the medical floor for observation and one-to-one nursing. We will follow MSSA protocol. The patient seems somnolent and seemed to have drugs in her system but the patient refused urine drug screen at this time.
MSSA|modified selective severity assessment|MSSA|136|139|PLAN|2. We will obtain serial chemistries and LFTs. 3. Due to her elevation of lipase, we will place on clear liquid diet. 4. She will be on MSSA protocol for withdrawal. 5. Dr. _%#NAME#%_ will be re-consulted, who has managed her depression and alcoholism in the past.
MSSA|modified selective severity assessment|MSSA|158|161|ALLERGIES|Glucose 131, BUN 8, creatinine 0.6. AST 163, ALT 36, alkaline phosphatase 95. Albumin 3.1. HOSPITAL COURSE: 1. Alcohol intoxication. Admitted to the floor on MSSA protocol with Ativan. She was started on folic acid 1 mg daily and thiamine 100 mg daily. Her maximum MSSA score was 9. Scores fell to 2 or below by hospital day 5.
MSSA|modified selective severity assessment|MSSA|206|209|PLAN|Patient was advised to stop using alcohol. The patient states that his wife also died of cirrhosis of the liver. The patient today is clinically stable. Will transfer to a medical floor for continuation of MSSA Ativan protocol. If clinically stable, will transfer to chemical dependency treatment inpatient.
MSSA|modified selective severity assessment|MSSA|224|227|HOSPITAL COURSE|Fever evaluated, with negative chest x- ray and urinalysis. She did have cough productive of purulent sputum, for which she was initially placed on Rocephin 1 gm IV q.24h., with subsequent change to Zithromax. Maintained on MSSA withdrawal protocol using Valium. Placed on seizure precautions. Thiamine 100 mg p.o./IV q.d. x 3 days. Clinical stability, with transfer to the medical ward with a sitter.
MSSA|modified selective severity assessment|MSSA|205|208|HOSPITAL COURSE|1. Alcohol intoxication/withdrawal. In the ER the patient received Valium and folate and a multivitamin. He was started on IV fluids and given Ativan. He was transferred to the ICU where was placed on the MSSA protocol with Valium. He required large amounts of Valium, up to 200 mg per night. He denied any hallucinations and there was no evidence of seizure activity.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|115|118|DIAGNOSES|3. Pseudomonas pneumonia. 4. Pseudomonas urinary tract infection, resolved. 5. Group D enterococcus bacteremia. 6. MSSA septic arthritis and bacteremia. 7. Pain. 8. Right hemidiaphragm elevation. 9. Elevated liver function tests. PROCEDURES PERFORMED: 1. Transesophageal echocardiogram on _%#MMDD2003#%_. This showed no valvular vegetations.
MSSA|modified selective severity assessment|MSSA|136|139|IDENTIFICATION|HOSPITAL COURSE: He was admitted to station 3A adult chemical dependency unit for detoxification of alcohol. He was monitored using the MSSA rating scale with Ativan to cover withdrawal symptoms. On _%#MM#%_ _%#DD#%_, 2004, the Ativan was discontinued as he did not tolerate the Ativan.
MSSA|modified selective severity assessment|MSSA|167|170|HOSPITAL COURSE|He continued not to make any progress as far as improvement in his delirium. We therefore consulted neurology who recommended an EEG as well as discontinuation of the MSSA protocol, discontinuation of the Haldol, and starting a low dose of Risperdal at 0.5 mg p.o. q.h.s. We completed these recommendations and the patient over the course of the next 1 to 2 days made significant improvement in his delirium.
MSSA|modified selective severity assessment|MSSA|143|146|LABORATORY|Urine toxicology screen was positive for cocaine. HOSPITAL COURSE: Ms. _%#NAME#%_ was admitted to adult chemical dependency. She was placed on MSSA withdrawal protocol using Ativan. Ms. _%#NAME#%_ was pregnant and was in need of treatment secondary to using cocaine while pregnant.
MSSA|modified selective severity assessment|MSSA|150|153|ASSESSMENT/PLAN|LABORATORY: As noted in the computer. ASSESSMENT/PLAN: 1. Alcohol abuse and dependence. We will place the patient on observation and place her on the MSSA protocol. 2. Gastritis. Start antacids and IV and have GI consult. 3. Headaches. Take Tylenol Extra Strength for pain.
MSSA|modified selective severity assessment|MSSA|206|209|IDENTIFICATION|ALLERGIES: NO KNOWN DRUG ALLERGIES. HOSPITAL COURSE: Ms. _%#NAME#%_ was admitted to station 3A, adult chemical dependency detox unit to be monitored for withdrawal from alcohol. She was monitored using the MSSA rating scale with Ativan to cover withdrawal symptoms. On admission, Effexor XR 75 mg daily, Seroquel 100 mg 1/2 to 1 tablet daily at bedtime were reordered.
MSSA|modified selective severity assessment|MSSA|178|181|PLAN|4. Hypernatremia probably related to mild dehydration related to diuretic effects of alcohol. PLAN: The patient will be admitted to the hospital for IV hydration, institution of MSSA protocol, and psychiatric consultation. We will defer to psychiatry for recommendations on chemical-dependency treatment. We will continue with his Atenolol and mycelian and allopurinol therapy.
MSSA|modified selective severity assessment|MSSA|249|252|HOSPITAL COURSE|He was noted to have hypokalemia felt secondary to emesis, ethanol use, as well as mild elevation of his liver function tests consistent with alcoholic hepatitis. His hospital course was characterized by mild alcohol withdrawal. He was treated with MSSA protocol and eventually transferred to the medical unit. He was seen by psychiatry who did recommend discharge to lodging plus unit.
MSSA|modified selective severity assessment|MSSA|140|143|HOSPITAL COURSE|On _%#MMDD2003#%_ the patient woke up stating that she just didn't feel well at all, denied hallucinations, was scoring from 4 to 12 on the MSSA protocol. She did receive a small amount of Valium. She complained of a headache, which was helped some by ibuprofen. She did complain significantly of diarrhea, and had numerous small bowel movements.
MSSA|modified selective severity assessment|MSSA|162|165|HOSPITAL COURSE|The patient states that he has had seizures from alcohol withdrawal a couple of times. HOSPITAL COURSE: PROBLEM #1: Alcohol withdrawal. The patient was placed on MSSA protocol for alcohol withdrawal. Over a period of four days the patient did not experience any seizures or other adverse effects.
MSSA|modified selective severity assessment|MSSA|206|209|HOSPITAL COURSE|She has a history of depression. HOSPITAL COURSE: Ms. _%#NAME#%_ was admitted to station 3A adult chemical dependency treatment unit to be monitored for withdrawal from alcohol. She was monitored using the MSSA rating scale with Ativan to cover withdrawal symptoms. On admission Trazodone at 25 mg at bedtime was started, and her Prozac was ordered at 20 mg daily.
MSSA|modified selective severity assessment|MSSA|133|136|IDENTIFICATION|Keflex 500 mg 4 times daily x7 days was ordered to prevent any infection on the arm that he had cut. On _%#MM#%_ _%#DD#%_, 2005, the MSSA protocol for withdrawal was discontinued. By _%#MM#%_ _%#DD#%_, 2005, it was determined that he could be discharged. He had declined any additional electroconvulsive therapies, but he did complete 7 treatments.
MSSA|modified selective severity assessment|MSSA|155|158|IDENTIFICATION|Mr. _%#NAME#%_ was admitted to station 3A Adult Chemical Dependency Treatment Unit, to be monitored for withdrawal from alcohol. He is monitored using the MSSA rating scale with Valium to cover withdrawal symptoms. On admission, folate 1 mg daily x 7 days was ordered as well as Lamictal 25 mg every a.m., Protonix 40 mg twice daily, tenazosin 5 mg every evening (spelled by Ms. _%#NAME#%_.), Azmacort 1 to 2 puffs up to twice daily, and thiamine 100 mg every day x 2 days.
MSSA|modified selective severity assessment|MSSA|196|199|DISCHARGE DIAGNOSIS|They were essentially within normal limits. HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted to Station 3A adult chemical dependency treatment to be withdrawn from alcohol. He was monitored using the MSSA rating scale without event to cover for withdrawal symptoms. By _%#MM#%_ _%#DD#%_, 2004, it was determined that he was physically stable and through withdrawal.
MSSA|modified selective severity assessment|MSSA|152|155|HOSPITAL COURSE|Secondary to emesis the patient was placed on all IV medications for 2 days. His ketoacidosis was self-corrected. On the day of discharge the patient's MSSA score was 3. He was medically stable. He declined chemical dependency treatment as he has gone through it 4 times before. He will return to his AA meetings, and feels that he has the plan to stay sober.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA.|143|147|SUMMARY|CT of the neck revealed some edema and inflammation, but no drainable fluid. Urine culture revealed Klebsiella and blood cultures positive for MSSA. The patient will be discharged on cefazolin IV for two weeks, and clindamycin for two weeks, and five more days of acyclovir.
MSSA|modified selective severity assessment|MSSA|193|196|HOSPITAL COURSE|HOSPITAL COURSE: Ms. _%#NAME#%_ was initially admitted to station 3A adult chemical dependency treatment unit to be monitored for withdrawal from alcohol. She was monitored initially using the MSSA rating scale with Ativan to cover withdrawal symptoms. Because of her increasing agitation, destructive behaviors on the chemical dependency unit, she was transferred to station 32 adult mental health treatment unit on _%#MM#%_ _%#DD#%_, 2005.
MSSA|modified selective severity assessment|MSSA|168|171|HOSPITAL COURSE|HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted to station 3A adult chemical dependency detox unit to be monitored for withdrawal from alcohol. He was monitored using the MSSA rating scale with Valium to cover withdrawal symptoms. He was seen by Dr. _%#NAME#%_ regarding history and physical. On _%#MM#%_ _%#DD#%_, 2006, it was determined that he was out of detox and could be discharged.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|215|218|HISTORY OF PRESENT ILLNESS|The patient had an extensive history of opportunistic infections in the past for which she was treated and is currently on prophylaxis. These infections included candidiasis, HSV infection, cryptococcal meningitis, MSSA sepsis, and pneumonia. She has an ongoing disseminated MAI infection which was diagnosed from blood cultures drawn on _%#MM#%_ 2005.
MSSA|modified selective severity assessment|MSSA|151|154|HOSPITAL COURSE|Ms. _%#NAME#%_ was admitted to Station 3A Adult Chemical Dependency Detox Unit to be monitored for withdrawal from alcohol. She is monitored using the MSSA rating scale with Ativan to cover withdrawal symptoms. On admission, the following medications were re-ordered, Norvasc 5 mg daily, Lithobid 600 mg daily in the a.m., Lithobid 900 mg daily in the p.m., Synthroid 150 mcg daily, Seroquel 200 mg at bedtime, and Effexor 150 mg daily.
MSSA|modified selective severity assessment|MSSA|508|511|PROBLEM #1|White blood count 5.5. Hemoglobin 16.4. Platelet counts 260. ASSESSMENT AND PLAN: 43-year-old man with history of chronic alcohol abuse and dependence, and with acute alcoholic intoxification, major depression with suicidal ideation who was transferred to University of Minnesota Medical Center, Fairview for treatment and alcohol detoxification. PROBLEM #1: Acute alcohol intoxification. The patient was admitted to medical floor 11A and IV fluids with D5 half-normal saline with 20 mg KCl at 125 cc q 1 h, MSSA protocol started with diazepam, Valium, and the patient was also given thiamine 100 mg daily. The patient also is receiving chemical dependency consultation after depression is treated.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|323|326|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 41-year-old obese male with history of recurrent left lower extremity cellulitis, last admitted to Fairview Southdale Hospital for IV antibiotics in _%#MM#%_ of 2005. The patient was at that time treated with Zosyn IV, switched to Augmentin. He does have a history of MSSA in the past, however, the majority of his blood cultures have been negative in the past. He now states that he was in his usual state of health until earlier this morning when he noticed acute onset of redness and pain in his left lower extremity in his usual area of cellulitis.
MSSA|modified selective severity assessment|MSSA|165|168|ASSESSMENT AND PLAN|The patient was admitted Intensive Care Unit for close monitoring. After admission the patient had a period of agitation and confusion. The patient was treated with MSSA protocol with Ativan. The patient was continued with intravenous fluids with D5/.05 normal saline at 200 cc/hr. The patient was continued with thiamine, folic acid, and treated for pain control and Toradol 15/30 mg.
MSSA|modified selective severity assessment|MSSA|202|205|HOSPITAL COURSE|Total bilirubin 0.6, alkaline phosphatase 123, ALT 129, AST 124, lipase 90, amylase 30, troponin less than 0.04. HOSPITAL COURSE: PROBLEM #1: Alcohol withdrawal. Initially the patient was placed on the MSSA protocol using Ativan IV due to vomiting and inability to take medications p.o. He did not have any hematemesis at any point during his hospital course.
MSSA|modified selective severity assessment|MSSA|157|160|ASSESSMENT AND PLAN|The patient was placed on MSSA protocol for preventing alcohol withdrawal. The patient was continued with thiamine 100 mg daily for 3 days and Ativan as per MSSA protocol. The patient is still refusing any alcohol detoxification at this time. Will obtain Chemical Dependency Consultation if the patient changes his mind and possibly alcohol treatment, and inpatient admission.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|176|179|PROBLEM #5|PROBLEM #2: Hypertension remained stable during hospital stay. PROBLEM #3: Diastolic dysfunction/congestive heart failure. Stable. PROBLEM #4: Osteoporosis stable. PROBLEM #5: MSSA Pseudomonas colonization no issues. PROBLEM #6: Diverticulosis. Stable. No issues. PROBLEM #7: Chronic disease/anemia with baseline of hemoglobin 9.5 gm/dL remained stable.
MSSA|modified selective severity assessment|MSSA|188|191|IDENTIFICATION|See his dictation. HOSPITAL COURSE: Ms. _%#NAME#%_ was admitted to station 3A adult chemical dependency detox unit to be monitored for withdrawal from alcohol. She was monitored using the MSSA rating scale with Ativan to cover withdrawal symptoms as there was a question of potential allergy to Valium. On admission, Prozac 40 mg daily was reordered. She was started on Effexor XR 37.5 mg daily x3 days and increased every 3 days by 37.5 mg up to 150 mg daily to treat symptoms of depressions.
MSSA|modified selective severity assessment|MSSA|258|261|HOSPITAL COURSE|Amylase was 55 and lipase was 170. Blood alcohol level was 0.42. Albumin was 4.5, total protein 8.5, alkaline phosphate 199, ALT 480, AST 804. UA was within normal limits. HOSPITAL COURSE: The patient was admitted to the floor in stable condition and placed MSSA protocol for an alcohol withdrawal. She was offered CD treatment, declined throughout her hospital stay. Workup of her left lower quadrant, pain was undertaken including pelvic exam which was within normal limits.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|100|103|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. MSSA sepsis with bacteremia of unclear source. (a) Urine culture did grow a MSSA but it is not clear whether this was secondary to the bacteremia or primary UTI. (b) Consultation by Dr. _%#NAME#%_ and Dr. _%#NAME#%_ of infectious disease for which patient was treated inpatient with IV nafcillin and was consolidated to IV Ancef for four weeks as an outpatient.
MSSA|modified selective severity assessment|MSSA|151|154|ASSESSMENT AND PLAN|1. Admit initially to the ICU for alcohol detox and MSSA protocol and neurologic observation after alleged assault. Usual IV fluids and multivitamins, MSSA protocol, 72-hour hold, and usual seizure withdrawal precautions. 2. History of seizure disorder. Monitor clinically. Will have to encourage patient to follow up with Neurology after discharge.
MSSA|modified selective severity assessment|MSSA|174|177|PROBLEM #3|PROBLEM #3: Alcohol intoxication. The patient was placed on multivitamins, which included thiamine, folic acid supplementation and also magnesium. He was also started on the MSSA protocol in order to prevent from alcohol withdrawal and also encouraged him to quit alcohol. PROBLEM #4: Smoking. The patient is a chronic smoker and is very highly motivated to quit and did not ask for any nicotine patch.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|152|155|ASSESSMENT AND PLAN|Considering her recent MSSA infection, I think it is appropriate to treat her slightly more broadly. We will give her Zosyn and Levofloxin to cover her MSSA and community-acquired pneumonia. We will await the results of the blood cultures as well as obtain sputum culture. PROBLEM #2: Recent pulmonary embolism. We will recheck the patient's INR.
MSSA|modified selective severity assessment|MSSA|194|197|HOSPITAL COURSE|HOSPITAL COURSE: The patient was withdrawing from alcohol on admission and was placed on MSSA protocol and did receive some Ativan for stabilization. After approximately 48 hours, the patient's MSSA was discontinued as he was stable. Medications were re- instituted. Seroquel 200 mg at hour of sleep. Depakote 500 mg extended release 1 q.p.m. was added to prior medications of Effexor 150 mg which was originally ordered as XR, but on discharge, it was changed to Prozac because his insurance coverage would not cover Effexor in any form.
MSSA|modified selective severity assessment|MSSA|162|165|ASSESSMENT/PLAN|He is hemodynamically stable at this time. 1. Alcohol intoxication: At this time the patient's vital signs are within normal limits. We will place the patient on MSSA protocol and consult with the Chemical Dependency team in the morning for possible inpatient detoxification treatment. We will place a sitter with the patient for one-to-one monitoring.
MSSA|modified selective severity assessment|MSSA|152|155|HOSPITAL COURSE|ALLERGIES: Please refer to the record. CHEMICAL USE: History of alcohol dependency. This admission is for alcohol detox. HOSPITAL COURSE: Started on an MSSA protocol, but the patient essentially was detoxified after about 48 hours of observation. Medications were restarted. His Cymbalta was increased to 60 mg a day.
MSSA|modified selective severity assessment|MSSA|107|110|DISCHARGE MEDICATIONS|15. Chronic alcohol abuse. ALLERGIES: Ciprofloxacin. DISCHARGE MEDICATIONS: 1. Norvasc 5 mg p.o. daily. 2. MSSA protocol. 3. Lopressor 75 mg p.o. b.i.d. 4. Remeron 30 mg p.o. q. h.s. 5. Protonix 40 mg p.o. daily. 6. Thiamine 100 mg p.o. daily. 7. Trazodone 50 mg p.o. daily.
MSSA|modified selective severity assessment|MSSA|151|154|PLAN|We will discontinue the fentanyl patch and Effexor, with frequent neurologic checks. Also, because of a history of alcohol abuse, we will place him on MSSA protocol. 2. Hypertension: We will continue with lisinopril 20 mg once a day. Sinus tachycardia did resolve. We will give him some IV fluid D5 half normal saline at 100 cc per hour.
MSSA|modified selective severity assessment|MSSA|282|285|ASSESSMENT|Urine toxicity screen only positive for ethanol. ASSESSMENT: 48-year-old male with history of bipolar disorder and alcohol abuse presenting with alcohol intoxication, nausea, vomiting and acute pancreatitis: 1. Alcohol intoxication: The patient is admitted to the medical ward with MSSA protocol, seizure and withdrawal precaution. He will have a chemical dependency evaluation in the morning. 2. Acute pancreatitis: Will keep the patient n.p.o. Protonix IV 40 mg daily.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA.|191|195|HOSPITAL COURSE|He should followup with his primary care physician to this level rechecked in the future. 4. Pneumonia: The patient was found to have pneumonia during his admission. Sputum cultures grew out MSSA. The patient was treated with Zosyn. This was eventually converted to Augmentin. This patient responded well to antibiotic therapy.
MSSA|modified selective severity assessment|MSSA|180|183|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|She was started on Remeron at bedtime. She also had her Topral XL increased secondary to hypertension. Of note, she had no seizures or DTs during her withdrawal and she was on the MSSA protocol. She felt, as did the family, that the patient would not go through further alcohol treatment and she did refuse chemical dependency evaluation.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|165|168|HISTORY OF PRESENT ILLNESS|SERVICE: Pediatric Hematology/Oncology. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 19-year-old male with osteosarcoma of the right mid humerus. He has a history of MSSA bacteremia, status post port removal and completion of antibiotic treatment with Levaquin. He was last hospitalized for treatment with methotrexate and leucovorin rescue on _%#MMDD2007#%_ through _%#MMDD2007#%_.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|161|164|HOSPITAL COURSE|For further details of the past medical history and exam, please see the history and physical dated _%#MMDD2007#%_. HOSPITAL COURSE: PROBLEM #1: Bacteremia with MSSA from culture _%#MMDD2007#%_ at outside hospital with possible vegetation on valve. The patient was continued on the antibiotic regimen that she arrived on the nafcillin, rifampin and gentamicin.
MSSA|modified selective severity assessment|MSSA|246|249|HOSPITAL COURSE|Once on the floor medication adjustments were initially tried. His Wellbutrin SR was increased to 200 mg PO b.i.d., Celexa increased to 60 mg PO q AM. On hospital day #3 the patient was not showing any signs or symptoms of alcohol withdrawal and MSSA protocol was discontinued. On hospital day #5 Trileptal 150 mg b.i.d. was added to his medication regimen. The following day Trileptal was increased 300 mg b.i.d. On hospital day #8 the patient was found to have conjunctivitis and was given Garamycin 0.3% eye drops per medicine consult.
MSSA|modified selective severity assessment|MSSA|172|175|PROBLEM #2|Culture was negative after 24 hours, but the final report is pending. PROBLEM #2: Acute alcohol intoxication with chronic abuse and dependence. The patient was placed with MSSA Ativan protocol. There were no signs of withdrawal or delirium tremens during admission. Chemical-dependency consultation was obtained, but the patient was not eligible for inpatient treatment at this time.
MSSA|modified selective severity assessment|MSSA|138|141|TREATMENTS/THERAPIES|7. Iron 325 mg p.o. b.i.d. TREATMENTS/THERAPIES: 1. IV fluids. 2. Multivitamins, including thiamine and folate. 3. Valium, as part of the MSSA Protocol. HISTORY OF PRESENT ILLNESS: This is a 38-year-old gentleman who was brought in by the police to the emergency department.
MSSA|modified selective severity assessment|MSSA|196|199|HOSPITAL COURSE|He has a past history of alcohol dependence. HOSPITAL COURSE: The patient was admitted to station 3A, Adult Chemical Dependency Treatment Unit, to detoxify from opiates. He was monitored with the MSSA rating scale with buprenorphine to cover withdrawal symptoms. Seroquel 25-50 mg was ordered as needed for anxiety; Neurontin was added at 600 mg 3 times per day for back pain.
MSSA|modified selective severity assessment|MSSA|145|148|AXIS II|HOSPITAL COURSE: _%#NAME#%_ was admitted to Station 3A adult chemical dependency unit to be detoxified from Klonopin. She was monitored with the MSSA scale. She was started on phenobarbital 30 mg t.i.d. on _%#MM#%_ _%#DD#%_, 2004, to cover withdrawal symptoms from the Klonopin.
MSSA|modified selective severity assessment|MSSA|193|196|PLAN|4. Dehydration. 5. Elevated amylase which could be related to alcoholic pancreatitis. PLAN: The patient was admitted to the Intensive Care Unit for close monitoring. The patient was started on MSSA Ativan protocol. The patient is receiving IV fluids. The patient was also given thiamine 100 mg daily and will continue with thiamine 100 mg daily and folic acid 1 mg daily.
MSSA|modified selective severity assessment|MSSA|174|177|HOSPITAL COURSE|HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted to station 3A, Adult Chemical Dependency Treatment Unit, to be monitored for withdrawal from alcohol. He was monitored using the MSSA rating scale, with Valium to cover withdrawal symptoms. On _%#MMDD2004#%_ Lipitor 10 mg at bedtime and Trazodone 50 to 100 mg at bedtime were ordered.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA.|149|153|HOSPITAL COURSE|She was extubated on _%#MMDD2005#%_, and aggressive pulmonary cares with Xopenex and tiotropium was instituted. She was started on nafcillin for her MSSA. Pulmonary toilet was encouraged. She has had a rather slow improvement during her hospitalization here and was kept in the unit for the most part of her stay.
MSSA|modified selective severity assessment|MSSA|142|145|HOSPITAL COURSE|The patient was put on MSSA protocol including thiamine and folate. He had very minimal withdrawal symptoms and required no p.r.n. Ativan per MSSA protocol. Chemical dependency treatment was recommended. 3. Pancreatitis. The patient's lipase elevated mildly to 266. The patient remained asymptomatic. 4. Accelerated hypertension. The patient likely has an essential hypertension, which was exacerbated by alcohol withdrawal and anxiety.
MSSA|modified selective severity assessment|MSSA|156|159|DISCHARGE STATUS|HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted to station 3A adult chemical dependency detoxification unit. He was monitored for alcohol withdrawal using the MSSA rating scale with Ativan to cover withdrawal symptoms. Wellbutrin XL 150 mg daily x3 days and then increased to 300 mg daily was ordered to treat symptoms of depression.
MSSA|modified selective severity assessment|MSSA|189|192|PROBLEM #1|She is agreeable for transfer to Psychiatric inpatient treatment service. PROBLEM #1: Alcohol intoxication. No blackout or withdrawal seizures. Her vitals are very stable this morning. Her MSSA score is very low. The patient was evaluated by Chemical Dependency/Psychiatry Service this morning. She will be transferred to Psychiatric inpatient treatment service for her alcohol abuse and anorexia nervosa.
MSSA|modified selective severity assessment|MSSA|226|229|ASSESSMENT AND PLAN|His vital signs are stable. He was evaluated chemical dependency without cleared him for transfer to chemical detoxification inpatient facility. The patient is medically stable to be transferred at this time. He was placed on MSSA protocol earlier this morning. He will be continued on thiamine and folate. 2. Hypernatremia. His sodium level was 145 (upper normal 144), which could be secondary to mild dehydration.
MSSA|modified selective severity assessment|MSSA|155|158|IDENTIFICATION|On admission he was monitored for alcohol withdrawal using the MSSA rating scale with Ativan to cover withdrawal symptoms. On _%#MM#%_ _%#DD#%_, 2004, the MSSA rating scale and Ativan protocol were discontinued as he no longer showed any withdrawal symptoms. On _%#MM#%_ _%#DD#%_, 2004, Zoloft was started at 25 mg every a.m. x3 days and increased every 3 days up to 100 mg daily to treat symptoms of depression.
MSSA|modified selective severity assessment|MSSA|156|159|ASSESSMENT AND PLAN|EKG showed normal sinus rhythm with left axis deviation. ASSESSMENT AND PLAN: 1. Depression. Alcohol. The patient will be treated through withdrawal on the MSSA protocol. We will continue to monitor him clinically. 2. Alcoholic gastritis which is slowly improving.
MSSA|modified selective severity assessment|MSSA.|165|169|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: 73-year-old Mr. _%#NAME#%_ was admitted to our service. 1. Worsening groin rash. Groin cultures which were drawn from the outside hospital grew MSSA. He was seen by Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ in the outpatient clinic setting and was advised for hospitalization.
MSSA|modified selective severity assessment|MSSA|206|209|PROBLEM #1|PROBLEM #1: Alcohol withdrawal. The patient reports his last drink as being at 11 p.m. tonight and does have a history of DT. We will need to be closely monitored tonight and tomorrow. We will start him on MSSA protocol. We will also get a CD consultation, the patient is interested in returning to CD treatment for his alcohol abuse.
MSSA|modified selective severity assessment|MSSA|126|129|PLAN|Patient will be on bed rest with ............ and TEDs for deep venous thrombosis (DVT) prophylaxis. He will be placed on the MSSA protocol. This case was discussed with the patient's orthopaedic team, and I will discuss with his wife, if he consents.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA,|173|177|HOSPITAL COURSE|In the emergency room, Ceftazidime, Vanco, and Bactrim were administered. HOSPITAL COURSE: PROBLEM #1. Polymicrobial pneumonia. Sputum sample on admission grew out e. coli, MSSA, non-group A strep, and pseudomonas. The patient was managed on Ceftazidime, Vanco, and Bactrim and these antibiotics were eventually changed to Ceftaz and Levofloxacin.
MSSA|modified selective severity assessment|MSSA|232|235|HOSPITAL COURSE|The patient was able to repeat these risks and was adamant that he was not going to start drinking again and actually has set up an appointment for a rule 25. For the patient's alcohol withdrawal initially the patient was placed on MSSA protocol for withdrawal with Ativan. He did receive several doses, particularly in the evenings. However, at the time of discharge he was stable.
MSSA|modified selective severity assessment|MSSA|261|264|IDENTIFICATION|See his dictation. HOSPITAL COURSE: Ms. _%#NAME#%_ was admitted to station 3A adult chemical dependency detox unit to be monitored for withdrawal from alcohol. On admission Dilantin 300 mg daily was reordered. She was monitored for alcohol withdrawal using the MSSA rating scale with Valium to cover withdrawal symptoms. Her admission liver function tests were elevated. Dr. _%#NAME#%_ noted and ordered a repeat of the liver function tests.
MSSA|modified selective severity assessment|MSSA|169|172|IDENTIFICATION|HOSPITAL COURSE: Ms. _%#NAME#%_ was admitted to station 3A adult chemical dependency detox unit to be monitored for withdrawal from alcohol. She was monitored using the MSSA rating scale with Valium to cover withdrawal symptoms. She was seen by Dr. _%#NAME#%_ and started on Cymbalta 30 mg daily x3 days and then to be increased to 60 mg daily thereafter to treat symptoms of depression.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA,|175|179|HOSPITAL COURSE|The patient resumed his outpatient cystic fibrosis regimen including his Pneumovax therapy which he tolerated well. Of note, the patient did have a throat swab which grew out MSSA, and for this reason, the pulmonologist started the patient on Ancef. The patient will be discharged to home with a 2-week course of Keflex.
MSSA|modified selective severity assessment|MSSA|156|159|IDENTIFICATION|HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted to station 3A adult chemical dependency detoxification unit. He was monitored for alcohol withdrawal using the MSSA rating scale with Ativan to cover withdrawal symptoms. He was seen by Dr. _%#NAME#%_ _%#NAME#%_; see his dictation. The Ativan was changed to Valium on _%#MM#%_ _%#DD#%_, 2005, to cover withdrawal symptoms.
MSSA|modified selective severity assessment|MSSA|147|150|HOSPITAL COURSE|HOSPITAL COURSE: The patient was admitted to the hospital for treatment of alcohol intoxication and impending withdrawal. She was treated with the MSSA protocol and intoxication resolved. MSSA protocol was used with success to control her withdrawal tremulousness. She had electrolyte imbalance that was treated with IV re-hydration as well as electrolyte replacement therapy, both IV and oral.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA.|154|158|CULTURES|5. Aspirin 81 mg p.o. q. day. 6. Multiple vitamin 1 p.o. q. day. CULTURES: All blood cultures were negative. Right lateral nasal superficial abscess grew MSSA. Urine culture grew E. coli sensitive to Cipro. C. diff studies negative. CONSULTATIONS: 1. ENT Dr. _%#NAME#%_ who recommended ongoing antibiotics. He did not feel that further debridement was indicated.
MSSA|modified selective severity assessment|MSSA|199|202|IDENTIFICATION|ALLERGIES: NO KNOWN DRUG ALLERGIES. HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted to Station 3A adult chemical dependency detox unit, monitored for withdrawal from alcohol. He was monitored using the MSSA rating scale with Valium to cover withdrawal symptoms. He is followed medically by Dr. _%#NAME#%_ _%#NAME#%_, Zoloft 50 mg daily t.i.d and then increase to 100 mg daily thereafter was ordered for depression, Seroquel was ordered for anxiety and sleep with adjustments made because of an episode with apparent confusion.
MSSA|modified selective severity assessment|MSSA|224|227|PLAN|Will defer resumption for now so as to reduce risk of potential seizure in the setting of alcohol withdrawal. 7. Nicotine addiction. PLAN: 1. Admit to Intensive Care Unit. 2. Intravenous fluid support. 3. Follow up labs. 4. MSSA withdrawal protocol using Ativan. 5. Atenolol p.r.n. heart rate greater than 100. 6. Thiamine and multivitamin. 7. Psychiatry consultation. The patient is presently on a 72-hour hold.
MSSA|modified selective severity assessment|MSSA|156|159|MEDICATIONS|I am not aware of other chronic medical ailments. MEDICATIONS: Her medications include: 1. Zoloft 100 mg daily. 2. Multivitamin. 3. Currently she is on the MSSA protocol with Ativan. 4. She was receiving Campral 333-mg tablets - 2 t.i.d. but discontinued these, apparently. ALLERGIES: There are no known drug allergies. SOCIAL HISTORY: The patient lives alone and works as a letter carrier.
MSSA|modified selective severity assessment|MSSA|150|153|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: The patient is a 48-year-old Caucasian man admitted with alcohol intoxication. 1. Alcohol intoxication. The patient was put on a MSSA protocol and we will get chemical dependency to evaluate and possibly transfer the patient. 2. The patient was also given a banana bag with normal saline.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA.|128|132|HOSPITAL COURSE|The culture shows first Staphylococcus aureus. The patient was continued on vancomycin and today the results are back and shows MSSA. IV vancomycin was discontinued. The patient was started with IV Ancef 2 g IV q 8 hours. Continuation of the antibiotic for around 6 weeks. The patient to follow-up with Infectious Disease Clinic.
MSSA|modified selective severity assessment|MSSA|209|212|HOSPITAL COURSE|ALLERGIES: No known drug allergies. HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted to station 3A adult chemical dependency detox unit to continue monitoring of alcohol detoxification. He was monitored using the MSSA rating scale with Valium to cover withdrawal symptoms. He was continued on lithium, spironolactone, quinine sulfate, Protonix, Noroxin, nadolol, and loratadine.
MSSA|modified selective severity assessment|MSSA|205|208|HOSPITAL COURSE|ALLERGIES: NO KNOWN DRUG ALLERGIES. HOSPITAL COURSE: Ms. _%#NAME#%_ was admitted to station 3A adult chemical dependency detox unit to be monitored for withdrawal from alcohol. She was monitored using the MSSA rating scale with Valium to cover withdrawal symptoms. A petition for commitment was initiated because of her unwillingness to consider treatment and wanting to go home.
MSSA|modified selective severity assessment|MSSA|145|148||This occurred in the setting of relapsed and heavy alcohol use. The patient did develop moderate alcohol withdrawal for which he was treated per MSSA protocol. He was seen by the chemical dependency counselor who noted the patient was not interested as inpatient receiving treatment.
MSSA|modified selective severity assessment|MSSA|140|143|HOSPITAL COURSE|She was treated with sliding scale insulin and responded well. 3. Alcohol and cocaine intoxication/withdrawal. The patient was placed on an MSSA protocol for possible alcohol withdrawal. The patient declined a chemical dependency evaluation. The patient was showing no signs of alcohol withdrawal at the time of discharge, and had not required any medication in over 24 hours.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|58|61|DIAGNOSES|DATE OF DISCHARGE: _%#MM#%_ _%#DD#%_, 2006. DIAGNOSES: 1. MSSA bacteremia. 2. Isaac Syndrome. 3. Hypothyroidism. 4. Hypertension. 5. Folliculitis. 6. Bilateral feet scald burns. MAJOR PROCEDURES: 1. Chest x-ray.
MSSA|modified selective severity assessment|MSSA|137|140|ASSESSMENT AND PLAN|Hemoglobin 13.1. ASSESSMENT AND PLAN: The patient is a 54-year-old with alcohol intoxication. 1. Alcohol intoxication. He was started on MSSA protocol and on the day of discharge, his score was 6. He was off the Ativan for 24 hours. He also consulted his a CD treatment and he has a plan for outpatient CD treatment and he has his Sponsor Program for that.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|200|203|HISTORY OF PRESENT ILLNESS|REVISION DATE: R/_%#MMDD2006#%_ HISTORY OF PRESENT ILLNESS: The patient is a 14-year-old boy with pervasive developmental disorder and recent left ankle osteomyelitis with blood cultures positive for MSSA and recent Clostridium difficile colitis, presents to the emergency room with one- day history of fever and low back pain. The patient was treated with vancomycin and clindamycin orally for his left ankle osteomyelitis that ended on _%#MM#%_ _%#DD#%_, 2006.
MSSA|modified selective severity assessment|MSSA|206|209|HOSPITAL COURSE|The patient's family history was reportedly negative for chronic conditions such as coronary artery disease, malignancy, diabetes or hypertension. HOSPITAL COURSE: The patient was admitted and placed on an MSSA protocol and kept under close medical and neurologic supervision. He remained stable throughout the duration of his stay with no evidence of overt withdrawal symptoms.
MSSA|modified selective severity assessment|MSSA|206|209|ASSESSMENT/PLAN|1. ASSESSMENT/PLAN: 1. Alcohol withdrawal with history of alcoholism. We will give the patient thiamin, folic acid and a multivitamin. The patient will be placed on the MSSA protocol. The patient's current MSSA scores have been 10 and 9. He will be given Ativan as needed. 2. Hypokalemia. The patient is currently being placed on potassium replacement protocol.
MSSA|modified selective severity assessment|MSSA|219|222|PLAN|5. Congestive heart failure. 6. Hearing impairment, 7. Possible alcoholic liver disease with elevated AST. 8. Suspected dysphagia. PLAN: The patient is admitted to the medical floor for alcohol withdrawal protocol with MSSA with Ativan and Valium. The patient was given thiamine 100 mg daily, folic acid 1 mg p.o. daily, multivitamin 1 tab daily, IV fluid for hydration with D5 half normal saline at 125 cc per hour later decreased to 50 cc per hour.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA.|204|208|DISCHARGE INFORMATION|He was started on Protonix for this, which did help relieve his symptoms. DISCHARGE INFORMATION: DISCHARGE DATE: _%#MMDD2007#%_. DISCHARGE DIAGNOSIS: Right osteosarcoma of the humerus and bacteremia with MSSA. DISCHARGE MEDICATIONS: 1. Bactrim Double-Strength 1 tab p.o. every Monday and Tuesday. 2. Fluconazole 100 mg p.o. daily. 3. Peridex Rinse 10 mL swish and spit b.i.d.
MSSA|modified selective severity assessment|MSSA|169|172|SOCIAL HISTORY|PROBLEM #3: Acute alcohol intoxication. The patient stated that she had had a few drinks with her friend that night and was not a chronic drinker. She was placed on the MSSA protocol, but did not require significant amounts of Ativan. Psychiatry and chemical dependency was consulted and they felt she needed a follow-up psychiatric care, but no recommendations for substance abuse because patient is not admitting to any problems with substances at the time of the interview.
MSSA|modified selective severity assessment|MSSA|128|131|PLAN|2. The patient has a history of alcohol abuse. We will start thiamine at 100 mg q. daily x 3 days and folic acid 1 mg q. daily. MSSA precaution for alcohol withdrawal and DTs. The patient needs alcohol detox. The patient was explained this and he is not ready at this point.
MSSA|modified selective severity assessment|MSSA|130|133|HISTORY|HOSPITAL COURSE: The patient was admitted to the medical ward where she was treated with intravenous fluid support in addition to MSSA withdrawal protocol using Valium. The seizure precautions were implemented in light of history of withdrawal related seizures. The patient was placed on telemetry with the issue of tachycardia and a history of rapid palpitations.
MSSA|modified selective severity assessment|MSSA|174|177|HOSPITAL COURSE|During hospitalization she was noted to be mildly hypokalemic, and was given 40 meq of KDUR. After that her potassium did come back to a normal level of 3.8. She did well on MSSA protocol, and was discharged in stable condition. Her follow up and discharge plans are that she is to see me, Dr. _%#NAME#%_, in Smiley's Clinic this week, and she is going to follow up at 1800 _%#CITY#%_ for Rule 25 to assess for chemical dependency.
MSSA|modified selective severity assessment|MSSA|306|309|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is an 81-year-old male who comes into the Fairview-University Transitional Service seven days postoperatively from a left total hip arthroplasty secondary to degenerative joint disease with subsequent episodes of delirium vs. alcohol withdrawal, treated with Ativan by the MSSA protocol with 3 mg q day. Since his surgery he was treated for a possible urinary tract infection and also was tapered off of a very small Ativan dose for the MSSA for episodes.
MSSA|modified selective severity assessment|MSSA|133|136|ADMISSION MEDICATIONS|1. Lovenox 40 mg subcu q.24h 2. Percocet 1-2 p.o. q.4-6h 3. Vistaril 25-50 mg p.o. q.4-6h p.r.n. 4. MSSA protocol 0.25 mg q.i.d. for MSSA greater or equal to eight 5. Ranitidine 150 mg p.o. b.i.d. 6. Ciprofloxacin 250 mg p.o. b.i.d. X7 days 7. Dulcolax 10 mg pr p.r.n. 8. Folate 1 mg p.o. q day
MSSA|modified selective severity assessment|MSSA|166|169|PLAN|4. Apparently no known coronary artery disease based on recent cardiac evaluation. PLAN: The plan will be to monitor the patient on telemetry. He has been started on MSSA alcoholic withdrawal protocol. Liver function tests will be monitored. His swallowing function and bowel and bladder will be monitored. CD and psychiatric consultation will be requested, as the patient's status dictates.
MSSA|modified selective severity assessment|MSSA|202|205|ASSESSMENT AND PLAN|I doubt pulmonary embolism. We will order nadolol 80 mg p.o. daily and continue with telemetry. We will also order a fasting lipid panel for _%#MMDD2004#%_. 2. Alcohol withdrawal. We will continue with MSSA protocol with p.o. Ativan. We will request a CD consult and a Psych consult with Dr. _%#NAME#%_ or one of his associates. 3. Left arm weakness and loss of consciousness.
MSSA|modified selective severity assessment|MSSA|115|118|PLAN|The patient at this point will have all routine labs done with him. He will restart Risperdal. I will start him on MSSA protocol and detoxify him. Start him on trazodone 50 mg at bedtime to help him sleep and Risperdal 3 mg at bedtime and Prozac 40 mg p.o. daily.
MSSA|modified selective severity assessment|MSSA|141|144|IDENTIFICATION|Mr. _%#NAME#%_ was admitted to Station 3A Adult Chemical Dependency Treatment Unit to be detoxified from alcohol. He was monitored using the MSSA Rating Scale with Ativan to cover withdrawal symptoms. On admission, medications that were reordered include Colace 100 mg twice daily, Protonix 40 mg daily, Remeron 15 mg at h.s., Zyprexa 20 mg twice daily, Celexa 20 mg daily, and aspirin 81 mg daily.
MSSA|modified selective severity assessment|MSSA|125|128|HOSPITAL COURSE|On _%#MMDD2004#%_ Effexor XR at 150 mg was ordered, as well as Ambien 20 mg every night and Seroquel 100 mg every night. The MSSA rating scale to monitor for withdrawal was discontinued as he was not showing any withdrawal effects. On _%#MMDD2004#%_ he was given a list of sober houses that he could call for residential placement.
MSSA|modified selective severity assessment|MSSA|172|175|IDENTIFICATION|HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted to station 3A adult chemical dependency treatment unit to be monitored for withdrawal from alcohol. He was monitored using the MSSA rating scale with Ativan to cover withdrawal symptoms. On admission the following medications were ordered: Dyazide 37.5/25 mg daily, Protonix 40 mg daily, Flonase nasal spray p.r.n., Zyrtec 10 mg as needed, Seroquel 50 to 100 mg at bedtime if needed for sleep with a repeat x1.
MSSA|modified selective severity assessment|MSSA|179|182|PLAN|AXIS IV. Psychosocial stressors: Severe - his child is moving away and recent death of friend. AXIS V. GAF: 30. PLAN: 1. Hospitalize patient for safety and treatment. 2. Place on MSSA protocol for alcohol withdrawal. 3. Patient is mainly trouble by anxiety symptoms and states that Neurontin has worked in the past and will therefore begin treatment with Neurontin 100 mg po tid.
MSSA|modified selective severity assessment|MSSA|160|163|PRESENTING PROBLEM|PRESENTING PROBLEM: Patient requires detox from alcohol. He has been drinking up to 2 pints a day. He was at the time of admission shaky, tremors, diaphoretic. MSSA score was 11. The patient does have a history of DTs in the past and was placed on Ativan protocol. The patient also has post-traumatic stress disorder. He is a Vietnam veteran.
MSSA|modified selective severity assessment|MSSA|260|263|PLAN|We will resume his home medications of Depakote and Wellbutrin as well as Benadryl 50 mg p.o. q.h.s. p.r.n. for sleep. 2. The patient will be made code 1 and put on suicide/withdrawal/seizure precautions. 3. Due to the patient's history of alcohol dependence, MSSA protocol will be started and maintained as needed. 4. Medicine consultation for health maintenance issues. 5. Plan for chemical dependency treatment as well as possible outpatient day treatment will be considered in the future.
MSSA|modified selective severity assessment|MSSA|151|154|PLAN|He continues on a 72-hour hold. He will be placed on the University of Minnesota Medical Center, Fairview, alcohol withdrawal protocol. We will pursue MSSA scale scores which will be treated with lorazepam per protocol. He will receive atenolol and thymin as well. PRN Seroquel will be ordered for anxiety or agitation.
MSSA|modified selective severity assessment|MSSA|77|80|PLAN|Axis IV: Moderate. Axis V: GAF = 30. PLAN: The patient will be detoxed using MSSA protocol. The patient is presently on no psychiatric medications . We will consider an SSRI for this patient. Patient will placed on the Valium protocol for her probable history of complicated withdrawal.
MSSA|modified selective severity assessment|MSSA|175|178|PLAN|The patient will be educated about medication side effects including nausea, vomiting, sedation, headache, history of pancreatitis. The patient will also be detoxed using the MSSA protocol on Ativan. The patient will also be monitored and given symptomatic management for withdrawal from cocaine. At the time of interview the patient denied any suicidal, homicidal ideation, plan or intent.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|236|239|PLAN|My key findings are: Patient well known to our service, see discharge summary dated _%#MMDD2007#%_ for details of recent hospitalization with our team. Briefly, 24 yo female with history of medullary cystic kidney disease was here with MSSA line sepsis, and non-ST eleveation myocardial ischemia. The new dialysis cath placed last week was dysfunctional and she returned today for new line placement.
MSSA|modified selective severity assessment|MSSA|229|232|ASSESSMENT AND PLAN|2. Polysubstance abuse with use of alcohol and crack. It is not clear to me how chronically she has been abusing alcohol. Certainly at the present time her Seroquel is masking any withdrawal symptoms. I recommend instituting the MSSA protocol for scoring only and no addition of Ativan at this time. I will continue to follow her during the hospitalization.
MSSA|modified selective severity assessment|MSSA|158|161|PLAN|Axis IV: Relationship problems, primary support group problems. Axis V: GAF = 30. PLAN: The patient will continue Celexa 80 mg. The patient will be placed on MSSA protocol for recent alcohol use. At the time of interview, patient denied any suicidal, homicidal ideation, plan or intent.
MSSA|modified selective severity assessment|MSSA|218|221|PLAN|Axis V: 30. PLAN: The patient will need inpatient detoxification as the patient has a history of DTs. At the time of interview, the patient denied any suicidal, homicidal ideation, plan or intent. He will be placed on MSSA protocol on Valium. The patient is not on any psychiatric medication. Would consider starting him on Lexapro.
MSSA|modified selective severity assessment|MSSA|270|273|PLAN|Axis II: Deferred. Axis III: According to medical team. Axis IV: Psychosocial stressors: Financial, primary support group, grief, occupational stressors. Axis V: GAF = 30. PLAN: The patient will be detoxed off Valium using phenobarbital. The patient will be detoxed off MSSA protocol using Valium because of history of seizures. At the time of interview, the patient denied any suicidal, homicidal ideation, plan or intent.
MSSA|modified selective severity assessment|MSSA|145|148|PLAN|Axis IV Severe: Major mental illness and alcohol dependency. Axis V Global Assessment of Functioning: 35. PLAN: Detoxification from alcohol with MSSA protocol using Valium. After the patient is stabilized, chemical dependency assessment for possibility of follow-up care. We will need disposition. As the patient was living in a hotel, we will probably need some sort of sober housing or group home placement.
MSSA|modified selective severity assessment|MSSA|188|191|PLAN|DIAGNOSES: Axis I: Alcohol dependence, continuous. Axis II: Deferred. Axis III: According to medical team. Axis IV: Moderate. Axis V: GAF = 30. PLAN: The patient will be detoxed using the MSSA protocol. The patient will be evaluated by Medicine for pain. At the time of interview, patient denied any suicidal, homicidal ideation, plan or intent.
MSSA|modified selective severity assessment|MSSA|243|246|PLAN|Encourage p.o. fluids. 7. Vicodin and Percocet excess without elevation in acetaminophen level or evidence for hepatic toxicity. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Encourage p.o. fluids. 3. Nicotine patch. 4. Complete MSSA withdrawal protocol. Thiamine 100 mg daily for 3 days. 5. Copy of labs to patient at discharge for primary MD follow-up.
MSSA|modified selective severity assessment|MSSA|84|87|PRESENT MEDICATIONS|ALLERGIES: Penicillin (?reaction) and Dilantin (urticaria). PRESENT MEDICATIONS: 1. MSSA withdrawal protocol which was discontinued. 2. Lexapro 10 mg q. day. 3. Thiamine 100 mg q. day x 3. 4. Trileptal 150 mg b.i.d. 5. Tylenol p.r.n.
MSSA|modified selective severity assessment|MSSA|309|312|MEDICATIONS|SURGERY: None. OTHER KNOWN SERIOUS ILLNESS: None. Denies other heart disease, hypertension, diabetes, asthma, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, thyroid disease, seizure, tuberculosis or anemia. ALLERGY: None. MEDICATIONS: 1. Multivitamin q day. 2. Thiamine 100 mg q day. 3. MSSA withdrawal protocol using Ativan, Zyprexa 10 mg q 4 hours p.r.n. 4. Prozac 20 mg q day. 5. Zyprexa 20 mg q HS.
MSSA|modified selective severity assessment|MSSA|169|172|PLAN|Recheck TSH in 6 weeks. 3. Boost for nutritional support. 4. Prevacid 30 mg q.d. for 2 weeks for possibility of alcoholic gastritis. 5. Replace KCl. Check magnesium. 6. MSSA withdrawal protocol as ordered. 7. Clinical observation. Thank you for the consultation. I will follow along as clinically indicated.
MSSA|modified selective severity assessment|MSSA|175|178|CURRENT MEDICATIONS|ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: 1. Sertraline (Zoloft) 200 mg daily. 2. Kay Ciel 40 mEq p.o. x1 earlier today. 3. Nicorette gum 4 mg q.4 h. p.r.n. 4. MSSA withdrawal protocol using Ativan. 5. Atenolol p.r.n. 6. Thymin 100 mg daily for 3 days. 7. Neurontin 400 mg three times a day. 8. Campral 333, 2 tabs three times a day.
MSSA|modified selective severity assessment|MSSA|134|137|RECOMMENDATIONS|2. I would obtain an x-ray of her left elbow to rule out fracture or other post-traumatic abnormality. 3. Will keep the patient on an MSSA protocol. 4. Will get a CD evaluation and consultation. 5. Will transfer her to the medical floor to continue close neurologic observation.
MSSA|modified selective severity assessment|MSSA|138|141|PLAN|5. Chronic diarrhea secondary to intestinal bypass. 6. Hypertension, under satisfactory control at this time. PLAN: The patient is on the MSSA protocol. It does not appear that she needs any intervention for withdrawal at this time. Electrolyte replacement has ben ordered orally which is appropriate. I will follow her for management of intercurrent medical issues during her stay.
MSSA|modified selective severity assessment|MSSA|107|110|MEDICATIONS|It is unclear if he has chemical dependency treatment in the past. MEDICATIONS: 1. Seroquel. 2. Geodon. 3. MSSA protocol. 4. Tricor 160 mg each day. 5. Lisinopril 12.5 mg each day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is married, works as a painter.
MSSA|modified selective severity assessment|MSSA|93|96|MEDICATIONS|He has had a history of elevated blood pressures felt to be related to alcohol. MEDICATIONS: MSSA protocol utilizing Ativan and Zofran on a p.r.n. basis. ALLERGIES: No known drug allergies. SOCIAL HISTORY: This gentleman lives in an apartment on his own and is a student at the University of Minnesota.
MSSA|modified selective severity assessment|MSSA|116|119|PLAN|8. Hearing loss. 9. Depression, deferred to psychiatry. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. MSSA withdrawal protocol as ordered. 3. Follow-up liver profile. 4. Add maintenance dose of KCl on hydrochlorothiazide. 5. Head CT without contrast. 6. PT to evaluate and treat gait.
MSSA|modified selective severity assessment|MSSA|175|178|PAST MEDICAL HISTORY|7. Questionable history of hepatitis B and C. She describes seeing another specialist many years ago. She is unsure if she had a biopsy. Her medications presently include the MSSA protocol, using Ativan. Lice treatment has been ordered for her. In the past, she has taken Effexor and Risperdal, but has been off of these for some time.
MSSA|modified selective severity assessment|MSSA|184|187|ASSESSMENT/PLAN|Hemogram was within normal limits. GGT was 39. ASSESSMENT/PLAN: 1. Attention-deficit/hyperactivity disorder versus major depressive disorder versus alcohol abuse. Continue with Ativan MSSA protocol and treatment is to be followed by Dr. _%#NAME#%_. 2. Gastroesophageal reflux disease. Start on Protonix 40 mg p.o. b.i.d. scheduled.
MSSA|modified selective severity assessment|MSSA|294|297|MEDICATIONS|Denies other surgery or known serious illness. Specifically without heart disease, murmur, diabetes, renal disease, peptic ulcer disease, hepatitis/gallbladder disease, thyroid disease, seizure, tuberculosis, or anemia. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Paxil 20 mg q.a.m. 2. MSSA alcohol withdrawal protocol using Ativan 3. Thiamine 100 mg q day X3 4. P.r.n. atenolol for heart rate greater than 100 5. Trazodone 50 mg 1 q.h.s. p.r.n. sleep, may repeat X1
MSSA|modified selective severity assessment|MSSA|180|183|PRESENT MEDICATIONS|PRESENT MEDICATIONS: 1. Nortriptyline 25 mg q. h.s. 2. Ibuprofen 400 mg q4h p.r.n. (which the patient tolerates) 3. Tylenol, Maalox, Milk of Magnesia p.r.n. 4. Trazodone p.r.n. 5. MSSA withdrawal protocol as above with p.r.n. atenolol and thiamine 100 mg q. day X3 days. FAMILY HISTORY: Cancer. HABITS: Non-smoker. Alcohol as above.
MSSA|modified selective severity assessment|MSSA|118|121|CURRENT MEDICATIONS|2. Seroquel 50 mg b.i.d. with 100 mg at h.s. 3. Methadone taper beginning today with 30 mg tapering by 10 mg daily 4. MSSA withdrawal protocol using Ativan 5. Zyprexa 10mg IM q.4 h p.r.n. with Zyprexa/Zydis form 10 mg p.o. q.h.s. p.r.n. 6. Ativan 1 to 2 mg p.o./IM q.4 h p.r.n.
MSSA|modified selective severity assessment|MSSA|242|245|PLAN|3. Aspirin. 4. Cardiology consultation U of M. 5. Clinical observation, presently asymptomatic. Check a.m. lipid profile. 6. Consider trial of sublingual nitroglycerin, however, again, symptoms seem atypical for cardiac ischemia. 7. Continue MSSA protocol for alcohol withdrawal using Ativan. Thank you for the consultation. Will follow patient on the medical unit.
MSSA|modified selective severity assessment|MSSA|182|185|MEDICATION|ALLERGIES: None. MEDICATION: Medication prior to admission included multivitamins. Since, started on Effexor XR 37.5 mg q.d. by Dr. _%#NAME#%_, with plan to gradually increase dose. MSSA withdrawal protocol using Valium, thiamine 100 mg q.d. x 3, p.r.n. Tylenol, Maalox, Milk of Magnesia, and multivitamins q.d. FAMILY HISTORY: Mother died from cancer.
MSSA|modified selective severity assessment|MSSA|175|178|CURRENT MEDICATIONS|Past trauma significant for two rib fractures, knee hyperextension, all associated with sporting activities. No sequelae to these injuries. CURRENT MEDICATIONS: 1. Ativan per MSSA schedule. 2. Tenormin for hypertension per alcohol withdrawal 3. Thiamine 100 mg q day 4. Multivitamin q day ALLERGIES: No known drug allergies. Patient is allergic to bees.
MSSA|modified selective severity assessment|MSSA|139|142|PLAN|PLAN: 1. We will request a CD consult and Psychiatry consult. 2. The patient appears medically stable to transfer to the floor on the oral MSSA protocol. I do not feel he needs a one-to-one sitter at this time. 3. When he is medically stable, we will plan on transferring him to detox.
MSSA|modified selective severity assessment|MSSA|205|208|ASSESSMENT AND PLAN|1. Alcohol dependence with withdrawal. We will check and follow up with labs to determine liver involvement. Chemical dependency - counselor to evaluate. Psychiatric consult ordered. The patient placed on MSSA protocol. Compazine ordered for nausea. 2. Left-sided pneumonia probably community-acquired pneumonia, doubt PCP - Dr. _%#NAME#%_ to determine follow-up chest x-ray. Zithromax and Rocephin were ordered.
MSSA|modified selective severity assessment|MSSA|125|128|MEDICATIONS|5. Ambien on a p.r.n. basis. 6. Vistaril on a p.r.n. basis. 7. Midrin on a p.r.n. basis. 8. She is also receiving Valium per MSSA protocol. SOCIAL HISTORY: The patient lives alone. She smokes cigarettes, 1/2 pack per day.
MSSA|modified selective severity assessment|MSSA|145|148|PRESENT MEDICATIONS|ALLERGIES: Include cats, molds, dust, trees (question allergic rhinitis). PRESENT MEDICATIONS: Include p.r.n. Tylenol, Maalox, Milk of Magnesia. MSSA withdrawal protocol using Ativan and thiamine 100 mg q.d. x 3. FAMILY HISTORY: Without known serious illness. HABITS: Indicates alcohol on an occasional basis, i.e., twice weekly.
MSSA|modified selective severity assessment|MSSA|117|120|PRESENT MEDICATIONS|ALLERGIES: No known drug allergies. Medication prior to admission included Prozac, as above. PRESENT MEDICATIONS: 1. MSSA withdrawal protocol using Ativan. 2. Thiamine 100 mg daily for three days. 3. Atenolol p.r.n. 4. Nicotine gum. 5. Milk of Magnesia, Tylenol, Maalox p.r.n.
MSSA|modified selective severity assessment|MSSA|151|154|PLAN|4. Pulmonary nodules followed by pulmonary physician. 5. Recurrent cellulitis over the past year. No active cellulitis at this time. PLAN: 1. Continue MSSA protocol. We will investigate for infection if she has persistent fevers. 2. No other medical intervention appears indicated at this time.
MSSA|modified selective severity assessment|MSSA|213|216|PLAN|5. Rhinophyma with question regarding acne rosacea. 6. Status post cholecystectomy, appendectomy, and cataract extraction. 7. Presumed BPH, on Prostata. PLAN: 1. CD intervention as per Dr. _%#NAME#%_. 2. Continue MSSA withdrawal protocol with Ativan. 3. Thiamine 100 mg daily x 3 with multivitamin daily. 4. Scheduled Combivent, two puffs q.i.d. with DuoNebs q4h p.r.n.
MSSA|modified selective severity assessment|MSSA|94|97|PLAN|4. Moderate alcohol withdrawal tremulousness. 5. Chronic cough secondary to smoking. PLAN: 1. MSSA protocol. 2. Will evaluate more extensively his laboratory profiles to rule out metabolic abnormalities or anemia related to his alcohol abuse.
MSSA|modified selective severity assessment|MSSA|133|136|HISTORY OF PRESENT ILLNESS|He is admitted to the CD Unit for treatment of alcohol abuse. He has a history of alcohol withdrawal seizures in the past. He was on MSSA withdrawal protocol overnight, with Valium. HABITS: Two pack per day smoker. ALLERGIES: None. MEDICATIONS: None. PRIOR HOSPITALIZATIONS: The patient had a motor vehicle accident in 1981, with multiple trauma, lacerated liver, and pneumothorax, for which he required surgery.
MSSA|modified selective severity assessment|MSSA|119|122|PLAN|5. Mildly elevated lipase and AST level secondary to recent alcohol abuse. PLAN: 1. Will discontinue atenolol from the MSSA protocol and start atenolol 50 mg p.o. daily with parameters. 2. We will get repeat liver panel on Tuesday _%#MMDD2007#%_.
MSSA|modified selective severity assessment|MSSA|168|171|ASSESSMENT AND PLAN|3. Tremulous tongue. It is questionable whether or not the patient is going through alcohol withdrawal. He minimizes his drinking. We will consider starting him on the MSSA protocol although at this time this is the only symptom of withdrawal. We appreciate the consultation.
MSSA|modified selective severity assessment|MSSA|294|297|CURRENT MEDICATIONS|5. Other known serious illness: None. 6. Denies known heart disease, diabetes, asthma, renal disease, hypertension, peptic ulcer disease, hepatitis, gallbladder disease, thyroid disease, seizure, tuberculosis or anemia. ALLERGIES: Topamax. CURRENT MEDICATIONS: 1. Atenolol 75 mg p.o. b.i.d. 2. MSSA withdrawal protocol using Valium, thiamine 100 mg q.d. x 3, p.r.n. Milk of Magnesia, Tylenol, and Maalox, and multivitamin q.day. FAMILY HISTORY: Mother with COPD and alcoholism.
MSSA|modified selective severity assessment|MSSA|210|213|PRESENT MEDICATIONS|3. Appendectomy. ALLERGIES: Bee stings. PRESENT MEDICATIONS: 1. Effexor XR 37.5 mg daily for 3 days, then increase to 75 mg XR daily. 2. Methocarbamol 750 mg t.i.d. with salicylate 500 mg two tablets t.i.d. 3. MSSA withdrawal protocol using Lorazepam. 4. Atenolol 50 mg p.r.n. elevated heart rate. 5. Thiamine 100 mg daily for 3 days. 6. Nicotine patch 21 mg daily.
MSSA|modified selective severity assessment|MSSA|178|181|MEDICATIONS|ALLERGIES: No known drug allergies. MEDICATIONS: 1. Seroquel 25 mg b.i.d. with 100 mg at h.s. 2. Effexor 37.5 mg daily for 3 days with gradual increased dose to 150 mg daily. 3. MSSA withdrawal protocol using Ativan, < > 100 mg daily for 3 days, p.r.n. atenolol. FAMILY HISTORY: Remarkable for heart disease and asthma. HABITS: A 2- to 3-pack-per-day smoker particularly when high.
MSSA|modified selective severity assessment|MSSA|234|237|ASSESSMENT|Urinalysis was significant for ketones of 80, protein albumin qualitative urine of 30, urobilinogen of 4.0, and mucus being present; all other lab values are within normal limits. ASSESSMENT: 1. Alcohol abuse and chemical dependency. MSSA protocol enacted per Dr. _%#NAME#%_. 2. Severe psoriasis. We will treat this with Lidex 0.05% cream which will be applied to the affected area every day.
MSSA|modified selective severity assessment|MSSA|205|208|PLAN|7. Osteopenia, on Fosamax. 8. Abnormal Pap smear, treated with cryosurgery and colposcopy, as described above. 9. Nicotine addiction. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Agree with MSSA withdrawal protocol, thiamine. 3. Monitor temperature. Staff to call p.r.n. persistent fever. 4. Urinalysis and urine culture. 5. Reduced nicotine patch. 6. Empiric Protonix 40 mg daily.
MSSA|modified selective severity assessment|MSSA|213|216|MEDICATIONS|PAST MEDICAL HISTORY: 1. Exercise-induced asthma. 2. History of ovarian cyst, which was self-limited. 3. No other chronic ailments are known. MEDICATIONS: 1. Prilosec. 2. Albuterol. 3. She has been started on the MSSA protocol and has received 1 booster dose of potassium for a slightly low potassium noted in the Emergency Department. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient resides in the care of her parents and has a number of extended family members residing in the home as well.
MSSA|modified selective severity assessment|MSSA|246|249||She wanted to get into detox or into treatment here, so she had 1 pint of straight tequila and smoked crack at 5 p.m. on _%#MMDD2006#%_. She drinks 4-5 times a week, about a fifth to a liter of booze, usually hard liquor and usually tequila. Her MSSA was 4 on admission. PAST MEDICAL HISTORY: 1. Alcohol dependency. 2. Chemical dependency. 3. Drug dependency. 4. Depression.
MSSA|modified selective severity assessment|MSSA,|222|226|IMPRESSION|IMPRESSION: 1. Right calcaneal osteomyelitis and calcaneal intramedullary abscess. Gram stain is negative though the Gram stain is negative for PMNS, seems somewhat unusual. Primary organisms implicated here would include MSSA, MRSA, beta hemolytic streptococci, aerobic gram negative rods and anaerobes. I anticipate she will need IV antibiotic treatment for at least 4 weeks followed by a prolonged course of enteral treatment.
MSSA|modified selective severity assessment|MSSA|181|184|PLAN|6. Status post cervical decompression. 7. Amoxicillin allergy. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Resume Atenolol 50 mg q day, with parameters. 3. Continue MSSA withdrawal protocol using Ativan, thiamine 100 mg q day X3. 4. Multivitamin q day. 5. Staff to call p.r.n. nausea, vomiting, or abdominal pain.
MSSA|modified selective severity assessment|MSSA.|238|242|HISTORY|Given his age and solidness of his fusion, and the length of his rods, it was felt that full explantation would be quite difficult and may not be in his best interest. Today, he was changed to Ancef 2 grams Q 12 hours when culture showed MSSA. Vancomycin was stopped. PAST MEDICAL HISTORY: 1. Prostate carcinoma 2. Hypothyroidism 3. Avascular necrosis of the right patella secondary to fracture
MSSA|modified selective severity assessment|MSSA|309|312|ASSESSMENT/PLAN|ASSESSMENT/PLAN: 1. I agree that the patient likely has an element of alcohol withdrawal given her history of heavy alcohol abuse, the timing 48 hours after surgery, and the previous history of chronic elevations in her transaminases. She will need to be monitored closely, kept well hydrated, and put on the MSSA protocol. We will follow her basic metabolic panel in the morning. 2. Given the slight increase in temperature, we would monitor for other signs of infection.
MSSA|modified selective severity assessment|MSSA|199|202|PRESENT MEDICATIONS|7. Denies known heart disease, diabetes, asthma, renal disease, peptic ulcer disease, gallbladder disease, thyroid disease, tuberculosis, anemia, or seizure. ALLERGIES: None. PRESENT MEDICATIONS: 1. MSSA withdrawal protocol using Ativan, thiamin 100 mg q.d. x 3. 2. Atenolol 50 mg q.d. 3. Lisinopril 20 mg q.d. 4. Tylenol p.r.n. 5. Mylanta p.r.n. FAMILY HISTORY: Without known serious illness.
MSSA|modified selective severity assessment|MSSA|136|139|CURRENT MEDICATIONS|She describes 1 hospitalization for depression at United. She denies any hospitalizations for medical ailments. CURRENT MEDICATIONS: 1. MSSA protocol. 2. Birth control patch which she changes each Sunday. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient just graduated from high school 2 weeks ago.
MSSA|modified selective severity assessment|MSSA.|162|166|RECOMMENDATIONS|3. Sickle cell crisis, fairly significant hemolysis with very high LDH and bilirubin. RECOMMENDATIONS: 1. DC ceftriaxone. 2. Cephalexin 500 mg p.o. q.i.d. versus MSSA. 3. Lemon drops or lemon glycerin swabs to help increase drainage through Stensen's duct, if he does have a left parotitis.
MSSA|modified selective severity assessment|MSSA|105|108|PLAN|2. Status post unilateral oophorectomy for ovarian cyst (benign). 3. Gravida 0 para 0. PLAN: 1. Continue MSSA withdrawal protocol using Ativan. 2. Multivitamin q.d. 3. Encourage p.o. fluids. 4. Prevacid 30 mg q.d. x 2 weeks for possibility of alcoholic gastritis.
MSSA|modified selective severity assessment|MSSA|143|146|RECOMMENDATIONS|RECOMMENDATIONS: The patient will be monitored for alcohol withdrawal. Atenolol has been added to his antihypertensive medication regimen, per MSSA alcohol withdrawal protocol. A short course of Celebrex will be given for right ankle sprain - I would prefer to avoid NSAID in view of history of GI bleeding.
MSSA|modified selective severity assessment|MSSA|93|96|MEDICATIONS|Denies any history of myocardial infarction or other known coronary disease. MEDICATIONS: 1. MSSA protocol. 2. Paxil. 3. Zestril. ALLERGY: NKDA. SOCIAL HISTORY: This gentleman lives alone and runs his own fence company.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|143|146|PAST  MEDICAL HISTORY|She is lethargic but can communicate. PAST MEDICAL HISTORY: 1. ALL with recent relapse and initiation of reinduction chemotherapy. 2. Previous MSSA and coagulase negative staph bacteremias, likely line associated. 3. Depression. 4. Seasonal allergies. ALLERGIES: Zyrtec, codeine. SOCIAL HISTORY: Single and lives at home.
MSSA|modified selective severity assessment|MSSA|163|166|MEDICATIONS|2. Vistaril 50 mg q.a.m., 2 q.h.s. 3. Geodon 80 mg 2 q.h.s. 4. Risperdal 2 mg b.i.d. and 1 q.h.s. for two days then discontinue 5. Risperdal 3 mg t.i.d. p.r.n. 6. MSSA withdrawal protocol using Ativan, thiamine 100 mg daily X3 days 7. Benadryl 50 mg t.i.d. 8. Neurontin 1200 mg t.i.d. 9. Tylenol p.r.n. 10. Maalox p.r.n. 11. Milk of Magnesia p.r.n. FAMILY HISTORY: Mother with mental illness.
MSSA|modified selective severity assessment|MSSA|274|277|CURRENT MEDICATIONS|The patient denies other surgery or known serious illness. Denies known heart disease, diabetes, asthma, renal disease, peptic ulcer disease, gallbladder disease, thyroid disease, seizure, tuberculosis or anemia. ALLERGIES: Apparent Zoloft intolerance. CURRENT MEDICATIONS: MSSA withdrawal protocol using Ativan, thiamine 100 mg q.d. x 3, comfort medications in addition to multivitamin 1 p.o. q.d. FAMILY HISTORY: Without known serious illness.
MSSA|modified selective severity assessment|MSSA.|123|127|ADMISSION MEDICATIONS|As per Dr. _%#NAME#%_. 2. Gastroesophageal reflux disease. ADMISSION MEDICATIONS: 1. Seroquel. 2. Trazodone. 3. Ativan per MSSA. 4. Zithromax with last dose on _%#MM#%_ _%#DD#%_, 2003. 5. Tylenol 650 mg p.o. q4-6h p.r.n. pain. 6. Maalox 30 mL p.o. q.i.d. p.r.n. indigestion.
MSSA|modified selective severity assessment|MSSA|189|192|MEDICATIONS PRIOR TO ADMISSION|Presently maintained on Celexa 20 mg two q am. Zyprexa 10 mg q bedtime. Trazodone 50 mg q bedtime, may repeat times one. As occasion requires Tylenol, Maalox, and milk of magnesia. Also on MSSA which are all protocol using Ativan with thiamine 100 mg q day times three. FAMILY HISTORY: Remarkable for father with hypertension and heart disease.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|171|174|RECOMMENDATIONS|3. History of polycystic ovaries. 4. History of anxiety and depression. RECOMMENDATIONS: 1. Her previous cultures from _%#MM#%_ _%#DD#%_ showed Staph aureus, which was an MSSA strain and Enterobacter species sensitive to sulfa, Levaquin, and ceftriaxone. She has had recent outpatient treatment with dicloxacillin orally and topical antifungal (miconazole) and antibacterial (mupirocin) creams.
MSSA|modified selective severity assessment|MSSA|89|92|PRESENT MEDICATIONS|PAST SURGICAL HISTORY: None. ALLERGIES: No known drug allergies. PRESENT MEDICATIONS: 1. MSSA withdrawal protocol using Ativan. 2. Thiamine 100 mg daily for 3 days. 3. P.r.n. atenolol for heart rate greater than 100.
MSSA|modified selective severity assessment|MSSA|182|185|PLAN|6. History of "HELLP" syndrome with prior pregnancy. 7. Headache discomfort, likely tension/muscle contraction in origin. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. MSSA withdrawal protocol as ordered. 3. Start Protonix 40 mg daily for two weeks for possibility of gastritis. 4. Zithromax for bronchitis. Advair 250/50 one puff b.i.d. followed by rinse with p.r.n. albuterol.
MSSA|modified selective severity assessment|MSSA|158|161|PRESENT MEDICATIONS|ALLERGIES: No known drug allergies. She has GI upset with codeine. PRESENT MEDICATIONS: 1. Tylenol, Maalox, milk of magnesia p.r.n. 2. Multivitamin daily. 3. MSSA withdrawal protocol using Lorazepam. 4. Thiamine 100 mg daily x 3 days. 5. Atenolol p.r.n. 6. Effexor XR 150 mg q.a.m. FAMILY HISTORY: Without known serious illness.
MSSA|modified selective severity assessment|MSSA|193|196|MEDICATION|5. Tubal ligation. MEDICATION: Includes Zyprexa, Paxil, Advair 250/50 mcg preparation 1 puff b.i.d., Albuterol p.r.n., trazodone, Cepacol lozenges p.r.n., Colace daily. She is currently on the MSSA protocol utilizing Valium. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Chemical issues as described earlier. She also smokes one pack of cigarettes daily.
MSSA|modified selective severity assessment|MSSA|126|129|PRESENT MEDICATIONS|ALLERGIES: Penicillin (urticaria at injection site and more recently urticaria with oral penicillin). PRESENT MEDICATIONS: 1. MSSA withdrawal protocol using Valium, thiamine 100 mg daily x 3 days. 2. Atenolol p.r.n. 3. Nicotine gum. 4. Seroquel 100 mg q.h.s. with 50 mg daily.
MSSA|modified selective severity assessment|MSSA|134|137|ASSESSMENT AND PLAN|Well treated at present. 4. Alcohol abuse. The patient does not appear to be in any alcohol withdrawal. I recommend discontinuing the MSSA protocol. I will be happy to follow up should new arise during the hospitalization.
MSSA|modified selective severity assessment|MSSA|144|147|MEDICATIONS|ALLERGIES: No known drug allergies. MEDICATIONS: 1. Lisinopril 20 mg daily. 2. Seroquel 100 mg daily at bedtime. . 3. Thiamine 100 mg daily. 4. MSSA withdrawal protocol using Valium. 5. Routine p.r.n. medications. FAMILY HISTORY: Remarkable for diabetes. Both parents with alcohol abuse.
MSSA|modified selective severity assessment|MSSA|187|190|MEDICATIONS|6. Hypothyroidism. 7. Chronic headaches. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Protonix 40 mg p.o. daily. 2. Synthroid 0.05 mg p.o. daily. 3. Clonazepam 2 mg p.o. b.i.d. 4. MSSA protocol. 5. Thiamine 100 mg p.o. daily x 3 days. 6. Lexapro 10 mg p.o. q.a.m. Medications which are taken on a p.r.n. basis are: 1. Motrin 800 mg p.o. b.i.d.
MSSA|modified selective severity assessment|MSSA|127|130|IMPRESSION|2. He has residual decubitus ulcer right buttock and pressure lesions on the second digits of each foot with colonization with MSSA and with pseudomonas. The patient was advised to continue attentive wound care through the home health agency and with his family's assistance.
MSSA|modified selective severity assessment|MSSA|264|267|PRESENT MEDICATIONS|Specifically without known coronary artery disease, diabetes, asthma, hypertension, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, thyroid disease, seizure, tuberculosis or anemia.. ALLERGIES: No known drug allergies. PRESENT MEDICATIONS: 1. MSSA withdrawal protocol using Ativan. 2. Thiamine 100 mg q.d. x 3. 3. P.r.n. Tylenol for heart rate greater than 100. 4. Multivitamin q. day. 5. P.r.n. Maalox, acetaminophen and Milk of Magnesia.
MSSA|modified selective severity assessment|MSSA|132|135|ASSESSMENT AND PLAN|In the meantime, I will plan to check vital signs q. shift for the next 2 days to rule out tachycardia. I do not think placement of MSSA protocol is necessary at this time as I do not think the patient is at risk for development alcohol withdrawal-related seizures or other complications.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA,|165|169|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Right lung transplant in _%#MM#%_ complicated by PE of right lung with hemothorax following this. Has had an IVC placed. Also with empyema, MSSA, decortication x2. 2. Chronic anticoagulation. 3. Coronary artery disease, status post PCI. 4. Diabetes secondary to steroid use. 5. Anxiety. 6. PTSD.
MSSA|modified selective severity assessment|MSSA|224|227|PLAN|PLAN: 1. The patient will return to see his primary care physician for follow up of TSH level and thyroid adjustment if necessary. 2. Encourage the patient to see an optometrist for evaluation of eye correction. 3. Continue MSSA protocol. I anticipate blood pressure normalization with resolution of mild alcohol withdrawal syndrome. 4. Patient to have recheck of LFTs in approximately two weeks to confirm normalization.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|145|148|HISTORY|She was found to have acute myocardial infarction. During this hospitalization she was found also to have pneumonia with sputum culture yielding MSSA and Strep pneumoniae. This was treated with appropriate intravenous antibiotic. Later on _%#MM#%_ _%#DD#%_ she cultured MRSA from the sputum. She was at that time placed on IV vancomycin, which she has continued to the present.
MSSA|modified selective severity assessment|MSSA|242|245|PLAN|2. Major depressive disorder. Details per Dr. _%#NAME#%_. 3. Right flank discomfort likely musculoskeletal in origin in light of reproduction of discomfort with direct palpation. 4. Mild hypokalemia. Rule out low magnesium. PLAN: 1. Continue MSSA withdrawal protocol using Ativan, thiamine 100 mg q.d. x 3, multivitamin q.d. 2. KCl 30 mEq p.o. x 1. 3. Recheck potassium along with magnesium.
MSSA|modified selective severity assessment|MSSA|236|239|CURRENT MEDICATIONS|Aside from alcohol, denies other chemical use. ALLERGIES: None. MEDICATIONS PRIOR TO ADMISSION: None. CURRENT MEDICATIONS: 1) Tylenol p.r.n. 2) Milk of Magnesia p.r.n. 3) Maalox p.r.n. 4) Zantac 150 mg b.i.d. 5) Remeron 30 mg q.h.s. 6) MSSA alcohol withdrawal protocol using Ativan with thiamine 100 mg q.d. times 3. 7) Atenolol 50 mg this morning for heart rate in the 130 range.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA,|225|229|HOSPITAL COURSE|T-max on the day of transfer was 103.7 degrees. The patient has had numerous blood cultures and urine cultures which are all no growth to date. He had sputum cultures performed on the ventilator which were positive for light MSSA, light Klebsiella and light Candida. The MSSA and Klebsiella are being treated with vancomycin and ceftriaxone. The patient also had wound ulcers on his right lower extremity which were positive for MRSA as described below.
MSSA|modified selective severity assessment|MSSA|340|343|MEDICATIONS|5. The patient states that he was fairly recently diagnosed with H. pylori while at HCMC and did, in fact, start approximately three days of antibiotic treatment, but then was discharged, began drinking, and failed to continue with this treatment. He does note ongoing difficulties with reflux. MEDICATIONS: 1. The patient was initially on MSSA protocol, using Valium. Since then ______ was clear. 2. Motrin 400 mg p.o. q. 4h. p.r.n. 3. Penn VK 500 mg p.o. q.i.d. x 5 days.
MSSA|modified selective severity assessment|MSSA|182|185|RECOMMENDATIONS|2. Overall apparent good medical health. RECOMMENDATIONS: Routine labs including liver function tests ordered and pending. Her vital signs will be monitored. She has been started on MSSA alcohol withdrawal protocol. I will be happy to see her during her hospitalization for these and any other medical concerns.
MSSA|modified selective severity assessment|MSSA|124|127|RECOMMENDATIONS|4. History of migraine headaches. RECOMMENDATIONS: The patient's blood pressure will be monitored. HE will be started on an MSSA alcohol withdrawal protocol on the Mental Health Unit and after anticipated transfer to the Inpatient CD Unit. Electrolytes and renal function are ordered and will be followed if abnormal.
MSSA|modified selective severity assessment|MSSA|149|152|MEDICATION PRIOR TO ADMISSION|ALLERGIES: No known drug allergies. MEDICATION PRIOR TO ADMISSION: 1. Atenolol 50 mg daily (per old record) in addition to Effexor and trazodone, on MSSA protocol with Ativan. 2. Imitrex 200 mg p.r.n. acute onset of migraine headache with repeat of 100 mg dose in two hours if no relief.
MSSA|modified selective severity assessment|MSSA|185|188|PLAN|She was advised this should be followed up with her primary care provider. 6. Status post total abdominal hysterectomy. PLAN: 1. Resume atenolol 50 mg q.d. with parameters. 2. Continue MSSA withdrawal protocol using Ativan. Multivitamin q.d. Thiamin 100 mg q.d. x 3. 3. Imitrex p.r.n. migraine headache. Reduce dose as 300 mg is in excess of that recommended.
MSSA|modified selective severity assessment|MSSA|120|123|ASSESSMENT|White count 5.5, hemoglobin 12.9, and platelets 235. ASSESSMENT: 1. Alcohol abuse. The patient will be continued on the MSSA protocol and needs to be followed by Dr. _%#NAME#%_. 2. History of seizures, in the past felt to be secondary to withdrawal, now with apparent increased frequency.
MSSA|modified selective severity assessment|MSSA|147|150|HISTORY OF PRESENT ILLNESS|The patient indicates that she underwent head CT (report not indicated on record) which was allegedly unremarkable. She is presently maintained on MSSA withdrawal protocol using Ativan and thiamine 100 mg q.d. x 3. She does indicate a prior history of withdrawal; shakes and sweats presently.
MSSA|modified selective severity assessment|MSSA|193|196|MEDICATIONS|No history of cardiopulmonary disease, no history of hepatitis, pancreatitis, GI bleed, or other ongoing ailment. MEDICATIONS: 1. Clomipramine. 2. Vitamin B. 3. Multivitamin. 4. Naltrexone. 5. MSSA protocol. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Patient lives in a rooming house and does piecework.
MSSA|methicillin-susceptible Staphylococcus aureus|(MSSA)|183|188|IMPRESSION|His maximal temperature in the past 24 hours has been 101.7 degrees last night. I suspect that this is most likely secondary to his leukemia but he has Staph aureus on sputum culture (MSSA) and atelectasis on chest CT, so staph bronchitis could be contributing as well. RECOMMENDATIONS: 1. Would continue vancomycin and Zosyn for the present.
MSSA|modified selective severity assessment|MSSA|305|308|ASSESSMENT AND PLAN|Blood alcohol level was 0.16. ASSESSMENT AND PLAN: A 17-year-old female with past medical history significant for alcohol abuse, polysubstance abuse, and bipolar disorder who comes in with acute alcohol intoxication. 1. The patient was admitted to the adolescent psychiatric unit. 2. She will be put on a MSSA protocol. 3. For the patient's hypernatremia which is secondary to dehydration the patient has been given 2 liters of normal saline.
MSSA|modified selective severity assessment|MSSA|141|144|PRESENT MEDICATION|PRESENT MEDICATION: 1. Ibuprofen 600 mg q.i.d. p.r.n. 2. Albuterol inhaler two puffs q. 4 h. p.r.n. 3. Lexapro 10 mg daily. 4. Nicotine gum, MSSA withdrawal protocol using Valium, requiring fairly large doses. 5. Thiamine 100 mg daily for three days with p.r.n. Milk of Magnesia.
MSSA|modified selective severity assessment|MSSA|122|125|RECOMMENDATIONS|RECOMMENDATIONS: Liver function tests will be repeated in a few days to assure stability. The patient has been started on MSSA per alcohol withdrawal protocol. T4 is ordered. Thank you for having me see this patient. DISCUSSION: _%#NAME#%_ _%#NAME#%_ is a 52-year-old female with history of chemical abuse involving alcohol who currently is hospitalized on station 3A under the care of Dr. _%#NAME#%_ for the evaluation of ethanol abuse.
MSSA|modified selective severity assessment|MSSA|226|229|ASSESSMENT AND PLAN|This is to be followed by Dr. _%#NAME#%_. 2. Laryngitis, likely representing viral upper respiratory infection. Recommend supportive treatment. 3. Alcohol abuse with possible risk for withdrawal. She will be maintained on the MSSA protocol. 4. Menorrhagia of uncertain significance, following elective abortion. We will request a consultation with OB-GYN, at which time she should under go STD testing, if pelvic exam is felt to be indicated.
MSSA|modified selective severity assessment|MSSA|138|141|PRESENT MEDICATIONS|3. Toprol XL 50 mg q.a.m. 4. Milk of Magnesia p.r.n. 5. Tylenol p.r.n. 6. Maalox p.r.n. 7. Multivitamin 1 p.o. daily. 8. Nicotine gum. 9. MSSA withdrawal protocol using Valium with thiamine 100 mg daily for 3 days. FAMILY HISTORY: Family history is remarkable for lung cancer. HABITS: Two pack-per-day smoker.
MSSA|modified selective severity assessment|MSSA|208|211|RECOMMENDATIONS|3. Chronic low back pain status post surgery for Sherman's disease several years ago. RECOMMENDATIONS: The patient will be monitored for symptoms and signs of alcohol withdrawal. He will receive atenolol per MSSA protocol. I will be able to review his blood pressure at the time of discharge to determine the need for longer term antihypertensive therapy.
MSSA|modified selective severity assessment|MSSA|178|181|PRESENT MEDICATIONS|ALLERGIES: None known. PRESENT MEDICATIONS: 1. Magnesium gluconate 500 mg b.i.d. 2. Zoloft 50 mg daily. 3. Protonix 40 mg daily. 4. Asacol 1200 mg b.i.d. 5. KCl 20 mEq daily. 6. MSSA withdrawal protocol using Ativan, with p.r.n. Atenolol. 7. Thiamine 100 mg daily for three days. 8. Multivitamin daily. 9. Tylenol p.r.n. 10. Maalox p.r.n.
MSSA|modified selective severity assessment|MSSA|139|142|MEDICATIONS|1. Premarin. 2. Multivitamin q. day. 3. Thiamine 100 mg p.o. q. day x3 days. 4. Phenobarbital 30 mg p.o. t.i.d. 5. Celexa. 6. Seroquel, 7. MSSA Valium protocol. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives with her husband and 3 children in south _%#CITY#%_.
MSSA|modified selective severity assessment|MSSA|164|167|PRESENT MEDICATIONS|ALLERGIES: Sulfa (rash). PRESENT MEDICATIONS: 1. Lexapro 10 mg daily. 2. Allegra 180 mg daily. 3. Albuterol inhaler 2 puffs q.i.d. p.r.n. 4. Multivitamin daily. 5. MSSA withdrawal protocol using Ativan, p.r.n. atenolol for heart rate greater than 100, thiamine 100 mg daily for 3 days, and p.r.n. Tylenol, Maalox, and Milk of Magnesia.
MSSA|modified selective severity assessment|MSSA|85|88|MEDICATIONS|No other known cardiac ailments. 4. Gastroesophageal reflux disease. MEDICATIONS: 1. MSSA protocol using Ativan. 2. Neurontin. 3. Seroquel. 4. Effexor. 5. Robitussin. 6. Hydrocortisone cream. ALLERGIES: No known drug allergies.
MSSA|modified selective severity assessment|MSSA|154|157|MEDICATIONS|1. Depression. 2. Previous chemical dependency treatment. 3. He is not aware of chronic medical ailments. MEDICATIONS: Normally none. Presently, he is on MSSA protocol. ALLERGIES: Penicillin and erythromycin. SOCIAL HISTORY: The gentleman works construction and is homeless at present.
MSSA|modified selective severity assessment|MSSA|279|282|MEDICATIONS|2. Cleft palate repair. 3. He denies heart disease, diabetes, asthma, hypertension, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, thyroid disease, seizure, tuberculosis, or anemia. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Nicotine gum p.r.n. 2. MSSA withdrawal protocol using Ativan with p.r.n. 3. Atenolol. 4. Thiamine 100 mg daily for 3 days. 5. Risperdal 1 mg p.o. q.6h. p.r.n. agitation
MSSA|modified selective severity assessment|MSSA|131|134|ASSESSMENT/PLAN|Absolute lymphocytes are low at 0.7. GGT high at 43. ASSESSMENT/PLAN: 1. Alcohol dependence in acute withdrawal as per Psychiatry. MSSA protocol. Multivitamin, thiamin, magnesium sulfate. 2. Mild liver enzyme elevation. We will give the patient a copy of labs on discharge to follow up with her primary-care provider.
MSSA|modified selective severity assessment|MSSA|146|149|PRESENT MEDICATIONS|ALLERGIES: No known drug allergies. PRESENT MEDICATIONS: 1. Multivitamin daily. 2. Protonix 20 mg daily. 3. Thiamine 100 mg daily for 3 days with MSSA withdrawal protocol using. Lorazepam. FAMILY HISTORY: Without known serious illness. HABITS: Nonsmoker. Polysubstance use/abuse as above.
MSSA|modified selective severity assessment|MSSA)|197|201|ASSESSMENT|ASSESSMENT: A 26-year-old male admitted with the following: 1. CD intervention for polysubstance abuse/dependence. The drug of choice is alcohol. No overt signs of alcohol withdrawal presently (on MSSA) except for elevated blood pressure and heart rate. Normal liver profile. 2. Lower chest/upper abdominal discomfort intermittently, possibly related to alcoholic gastritis or frank peptic ulcer disease.
MSSA|modified selective severity assessment|MSSA|184|187|PLAN|Rule out substance-induced mood disorder. Deferred to Psychiatry. 4. Thrombocytopenia secondary to alcohol effect. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Complete MSSA withdrawal protocol. 3. Thiamine 100 mg daily. 4. Replace potassium. Check magnesium. 5. Seizure precautions with withdrawal seizure history. 6. Clinical observation.
MSSA|modified selective severity assessment|MSSA|234|237|PRESENT MEDICATIONS|SURGERIES: 1. Tubal ligation. 2. Breast augmentation. Denies heart disease, asthma, hepatitis, gallbladder disease, thyroid disease, or tuberculosis. ALLERGIES: Wellbutrin (urticaria). PRESENT MEDICATIONS: 1. Protonix 40 mg daily. 2. MSSA withdrawal protocol using Valium, thiamine 1 mg daily for 3 days, p.r.n. atenolol, phenobarbital 30 mg 3 times daily. 3. Nicotine gum. 4. P.r.n. Tylenol. 5. Multivitamin daily. FAMILY HISTORY: Depression and alcohol abuse.
MSSA|methicillin-susceptible Staphylococcus aureus|(MSSA),|288|294|IMPRESSION|Asked by Dr. _%#NAME#%_ to provide antibiotic recommendations. IMPRESSION: 1. _%#NAME#%_ _%#NAME#%_ is a 72-year-old female admitted with necrotizing fasciitis of the left leg with sepsis syndrome. She is status post left above the knee amputation. Culture revealed Staphylococcus aureus (MSSA), Pseudomonas, group B Strep and Diphtheroids. One blood culture bottle grew Diphtheroids. She has received a course of vancomycin and is now on Zosyn and is clinically improved without fever.
MSSA|modified selective severity assessment|MSSA|169|172|PLAN|7. Tubal ligation. 8. Nicotine addiction. 9. Low normal blood pressure with mildly elevated hemoglobin consistent with possible mild volume depletion. PLAN: 1. Complete MSSA withdrawal protocol with thiamin as ordered. 2. Multivitamin daily. 3. Recheck TSH in 1 week. 4. Primary care follow-up with Dr. _%#NAME#%_ regarding thyroid function and workup regarding seizure episode (as above).
MSSA|modified selective severity assessment|MSSA|311|314|HISTORY OF PRESENT ILLNESS|The patient had been using alcohol, he says beer and vodka for the past several days and when he presented to the emergency room yesterday, his blood alcohol level was 0.24. His general neurologic examination failed to disclose any other major abnormalities. He was admitted for detoxification and placed on an MSSA protocol. Please refer to other hospitalization notes including psychiatric consultation from less than a month ago. At the current time the patient is awake, alert, oriented and interactive.
MSSA|modified selective severity assessment|MSSA|203|206|PLAN|3. ___________ cream b.i.d. to the plantar aspect of the feet for issue of xerosis. Will cleanse the area of superficial ulceration with soap and water, apply bacitracin and sterile bandage. 4. Continue MSSA protocol; however, doubt the patient will develop significant signs of alcohol withdrawal. 5. Multivitamin qday. 6. Review of screening labs as ordered.
MSSA|modified selective severity assessment|MSSA|189|192|MEDICATIONS|2. History of withdrawal seizure several years ago. 3. History of alcoholic hepatitis. 4. History of pancreatitis presumably associated with alcoholism. No recent recurrences. MEDICATIONS: MSSA protocol. ALLERGIES: Penicillin and Sulfa. SOCIAL HISTORY: The patient lives independently. She smokes two packs of cigarettes daily. She states she has been drinking a half of a quart to a quart of alcohol daily.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|474|477|HISTORY OF THE PRESENT ILLNESS|8. Depression maintained on Zoloft 9. Left lower extremity ischemia related to peripheral arterial disease HISTORY OF THE PRESENT ILLNESS: A 54-year-old man well known to the hospitalist department from his hospitalization _%#MM#%_ _%#DD#%_, to _%#MM#%_ _%#DD#%_, 2005 when he was hospitalized for acute renal failure related to significant over diuresis in the outpatient setting. He had a prolonged hospital course requiring initiation of brief hemodialysis. He developed MSSA pneumonia with Methicillin resistant staphylococcus aureus colonization. He had blood loss anemia related to significant epistaxis and he developed worsening left lower extremity ischemia.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA.|194|198|LABORATORY DATA|_%#MMDD#%_ sputum has heavy Methicillin resistant staphylococcus aureus. Urine culture is no growth to date. Stool from _%#MMDD#%_, positive C-Difficile toxin. _%#MMDD#%_ sputum is heavy growth MSSA. IMPRESSION: Mr. _%#NAME#%_ is a 54-year-old gentleman with multiple medical problems outlined above.
MSSA|modified selective severity assessment|MSSA|234|237|PRESENT MEDICATIONS|She is without heart disease, asthma, hypertension, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, seizure, tuberculosis or recent anemia. ALLERGY: NKDA. PRESENT MEDICATIONS: 1. Peri-Colace 1 tab p.o. q. day. 2. MSSA withdrawal protocol using Ativan. 3. Thiamine 100 mg q. day times three. 4. Trazodone 150 mg q.h.s. 5. Levothyroxine 0.112 mg q. a.m.
MSSA|methicillin-susceptible Staphylococcus aureus|(MSSA|203|207|RECOMMENDATIONS|3. I would agree with your use of intravenous Zosyn for now. If the most recent cultures are positive, then modify the antibiotics appropriately for coverage. If he has coagulase positive Staphylococcus (MSSA or MRSA) then he will need intravenous antibiotics for a minimum of two weeks. 4. He should probably have further assessment of his hepatitis C, looking at a genotype, hepatitis C viral load, and a right upper quadrant ultrasound as you are doing.
MSSA|modified selective severity assessment|MSSA|180|183|HISTORY OF PRESENT ILLNESS|She had a right frontal headache and significant shakes and sweats. She has a prior history of DTs. She had a withdrawal seizure when in _%#CITY#%_. She is presently maintained on MSSA withdrawal protocol using Ativan. I discussed the use of Valium, but patient indicated Ativan has been more effective. I am unaware of alcohol-related liver disease. She has had a history of pancreatitis with an episode over one year ago.
MSSA|modified selective severity assessment|MSSA|158|161|PLAN|PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Clinical observation. 3. Tylenol p.r.n. for headache discomfort. 4. Agree with discontinuation of MSSA as no features of alcohol withdrawal. Thanks for the consultation. We will follow along as indicated.
MSSA|modified selective severity assessment|MSSA|164|167|PRESENT MEDICATIONS|Has resulted in asystole (?) and brady-arrhythmia requiring adrenalin. PRESENT MEDICATIONS: 1. Fluoxetine 20 mg q.a.m. 2. Trazodone 50 mg q.h.s. 3. Ativan based on MSSA withdrawal protocol with p.r.n. atenolol. 4. Thiamine 100 mg daily for 3 days, with p.r.n. Maalox, Tylenol and Milk of Magnesia.
MSSA|modified selective severity assessment|MSSA|205|208|PLAN|7. Nicotine addiction (recurrent). PLAN: 1. Psychiatric intervention, as per Dr. _%#NAME#%_. 2. Resume home meds. 3. Protonix 40 mg daily, for possibility of alcoholic gastritis and/or reflux. 4. Continue MSSA withdrawal protocol using Ativan. 5. Thiamine 100 mg daily for 3 days. 6. The patient advised to notify RN p.r.n. recurrent chest discomfort or dyspnea pf concern.
MSSA|modified selective severity assessment|MSSA|190|193|HISTORY OF PRESENT ILLNESS|On physical examination, he is a mesomorphic adult gentleman who appears to be non-distressed, oriented. He is non-tremulous but has been given Valium every two hours since admission on the MSSA protocol. His vital signs are stable and he is afebrile. The skin shows some acneform lesions on the upper back. No other abnormalities. HEENT: normal extraocular muscle activity and pupillary response.
MSSA|modified selective severity assessment|MSSA|133|136|MEDICATIONS|2. Depakote 500 mg q.h.s. 3. Seroquel 100 mg q.4 hours p.r.n. 4. Wellbutrin SR 100 mg daily with 100 mg at noon. 5. Nicotine gum. 6. MSSA withdrawal protocol using Ativan. 7. Thiamine 100 mg daily for 3 days. 8. Tylenol p.r.n. 9. Milk of magnesia. 10. Colace. 11. Zantac. 12. Trazodone. FAMILY HISTORY: Grandfather with alcohol dependency.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA.|196|200|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Spondylolisthesis status post posterior fusion in _%#MM2006#%_ at an unclear level. Then a subsequent L2-L3 fusion in _%#MM2007#%_, at which the course was complicated by MSSA. The patient states that she had a spine infection after the surgery in _%#MM2006#%_. 2. Hypertension(?). 3. Hyperlipidemia, under treatment. 4. Hypothyroidism, treated with Synthroid.
MSSA|modified selective severity assessment|MSSA|147|150|ASSESSMENT|1. Alcohol abuse (question dependency) with the following: a. Alcohol withdrawal. The patient has received Valium 10 mg on two occasions, based on MSSA protocol. b. Elevated lipase, consistent with possible mild alcoholic pancreatitis (asymptomatic per patient). c. Elevated liver function, consistent with alcoholic hepatitis, and/or fatty change.
MSSA|modified selective severity assessment|MSSA|158|161|HISTORY OF PRESENT ILLNESS|He has also had increased alcohol intake recently. At baseline he drinks 3 liters of gin 2-3 days. The patient was admitted on _%#MMDD2007#%_ and has been on MSSA protocol. He had a liver ultrasound that was normal. CT of his head showed small vessel ischemic changes, and an echocardiogram was done to follow up known mitral regurgitation.
MSSA|modified selective severity assessment|MSSA|210|213|PRESENT MEDICATIONS|Specifically without history of DT, alcohol withdrawal seizures, known alcohol-related liver disease, pancreatitis, or upper GI hemorrhage. 5. Surgeries: none. ALLERGIES: None. PRESENT MEDICATIONS: Include: 1. MSSA withdrawal protocol using Ativan. Thiamine 100 mg q.d. x 3. 2. Neomycin ointment p.r.n. 3. Zithromax 150 mg q.d. for 4 days beginning _%#MMDD2002#%_.
MSSA|modified selective severity assessment|MSSA|93|96|CURRENT MEDICATIONS|6. Without other known serious illness. ALLERGIES: Haldol and Sulfa. CURRENT MEDICATIONS: 1. MSSA withdrawal protocol as above. 2. Zyprexa 10 mg q.4h. PRN agitation. 3. Bacitracin daily to the stump ulcer PRN. 4. Multivitamins.
MSSA|modified selective severity assessment|MSSA|136|139|PRESENT MEDICATIONS|5. Hepatitis C carrier. 6. Hyperlipidemia. He is without other known serious illness. ALLERGIES: Haldol and Sulfa. PRESENT MEDICATIONS: MSSA withdrawal protocol using Ativan, thiamine 100 mg q.d. x 3, p.r.n. atenolol, Zyprexa 10 mg q.h.s., amitriptyline 50 mg q.h.s., Atarax 50 mg 2 tablets up to q.i.d. p.r.n. FAMILY HISTORY: Per old records.
MSSA|modified selective severity assessment|MSSA|127|130|MEDICATIONS|Presently maintained on Seroquel 50 mg at noon, 100 mg at 1600 and 300 mg at h.s. Effexor XR 75 mg daily, Lexapro 10 mg daily. MSSA withdrawal protocol using Ativan. Tenormin 50 mg p.r.n. heart rate greater than 100. Thiamine 100 mg daily for 3 days. FAMILY HISTORY: Without known serious illness.
MSSA|modified selective severity assessment|MSSA|120|123|MEDICATIONS|5. Remote history of appendectomy and tonsillectomy. MEDICATIONS: 1. Synthroid 100 mcg p.o. qod. 2. She is currently on MSSA protocol utilizing Valium as well as thiamine and folate. ALLERGIES: Penicillin. SOCIAL HISTORY: Patient currently resides in her own apartment.
MSSA|modified selective severity assessment|MSSA|141|144|MEDICATIONS|MEDICATIONS: Her current medications on admission were: 1. Lexapro. 2. Lotrel. 3. Remeron. 4. Trazodone. 5. Seroquel. 6. She is currently on MSSA protocol. CHRONIC DISEASE/MAJOR ILLNESSES: 1. Hospitalization this past month at Regions for renal insufficiency, as mentioned above.
MSSA|modified selective severity assessment|MSSA|452|455|MEDICATIONS|Surgeries: None. Other known serious illness: None. He denies heart disease, diabetes, asthma, renal disease, peptic ulcer disease, gallbladder disease, thyroid disease, seizure, tuberculosis, or anemia. ALLERGIES: None. MEDICATIONS: Present medications include Seroquel 100 mg t.i.d. p.r.n.; Darvocet-N 100 t.i.d. p.r.n. pain; p.r.n. Tylenol, Maalox, and milk of magnesia; Prozac 20 mg q.a.m.; Seroquel 100 mg q.h.s.; and Celebrex 200 mg b.i.d.; with MSSA withdrawal protocol using Ativan and thiamine 100 mg daily for three days. FAMILY HISTORY: Without known serious illness. HABITS: Occasional cigarette use.
MSSA|modified selective severity assessment|MSSA|177|180|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: 1. Depression per Dr. _%#NAME#%_. 2. Alcohol abuse. No clinical sign of withdrawal at present. Continue to monitor her. I do not think she will require the MSSA protocol much longer. 3. Hypertension. She seems to be well-controlled with use of lisinopril. 4. Asthma, mild, intermittent. Continue use of Albuterol p.r.n.
MSSA|modified selective severity assessment|MSSA|212|215|RECOMMENDATIONS|3. Diarrhea. Likely, secondary to ethanol use. 4. Mild hypokalemia secondary to ethanol use and diarrhea. RECOMMENDATIONS: Liver function tests will be repeated in a few days. The patient has been started on the MSSA alcohol withdrawal protocol. I will be able to see her during her hospitalization for these and any other medical concerns.
MSSA|modified selective severity assessment|MSSA|126|129|MEDICATIONS|MEDICATIONS: 1. Topamax 75 mg q.h.s. 2. Neurontin 900 mg p.o. q.i.d. 3. Wellbutrin XL 450 mg daily. 4. Zoloft 50 mg daily. 5. MSSA protocol. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives alone.
MSSA|modified selective severity assessment|MSSA|214|217|MEDICATIONS|4. Abdominal wall abscess excision. Denies heart disease, asthma, hypertension, renal disease, hepatitis, gallbladder disease, thyroid disease, tuberculosis or anemia. ALLERGIES: Penicillin (rash). MEDICATIONS: 1. MSSA withdrawal protocol using lorazepam. 2. Folic acid 1 mg daily. 3. Routine hypoglycemic protocol. 4. Regular insulin by sliding scale. 5. Multivitamin 1 daily.
MSSA|modified selective severity assessment|MSSA|123|126|PRESENT MEDICATIONS|ALLERGIES: No known drug allergies. MEDICATIONS PRIOR TO ADMISSION: Celexa as above. PRESENT MEDICATIONS: 1. Maintained on MSSA protocol using Ativan. 2. Thiamine 100 mg q. day x 3 with p.r.n. Atenolol. 3. Effexor XR 37.5 mg q.a.m. for three days with gradual increased dose to 150 mg daily.
MSSA|modified selective severity assessment|MSSA|143|146|MEDICATIONS|The patient did have a normal echocardiogram in _%#MM#%_ of this year. MEDICATIONS: 1. Seroquel 1500 mg q6h p.r.n. 2. Cymbalta 30 mg a day. 3. MSSA alcohol withdrawal protocol with Valium. 4. Imodium 4 mg q6h p.r.n. 5. Trazodone 200 mg at h.s. 6. Claritin 10 mg a day.
MSSA|modified selective severity assessment|MSSA|122|125|CURRENT MEDICATIONS|CURRENT MEDICATIONS: . 1. Parnate 40 mg p.o. t.i.d. 2. Trazodone. 3. Lamictal. 4. Seroquel. 5. Synthroid 25 mcg daily. 6. MSSA protocol with Valium. ALLERGIES: No known drug allergies. SOCIAL AND FAMILY HISTORY: Available in old records. He is a half-pack per day cigarette smoker.
MSSA|modified selective severity assessment|MSSA|152|155|MEDICATIONS|MEDICATIONS: (prior to admission) 1. Zyrtec. 2. Maalox p.r.n. 3. Milk of Magnesia p.r.n. 4. Tylenol p.r.n. 5. Kaopectate p.r.n. 6. Multivitamin q.d. 7. MSSA withdrawal protocol using Ativan, thiamin 100 mg q.d. X3, and p.r.n. atenolol. FAMILY HISTORY: Grandmother with heart disease. Father's side with diabetes.
MSSA|modified selective severity assessment|MSSA|224|227|PRESENT MEDICATIONS|6. Surgeries: None. 7. Other known serious illness: None. Without heart disease, asthma, renal disease, gallbladder disease, thyroid disease, tuberculosis or anemia. MEDICATION ALLERGIES: None known. PRESENT MEDICATIONS: 1. MSSA withdrawal protocol using Ativan. 2. Tenormin p.r.n. for heart rate greater than 100. 3. Thiamine 100 mg daily for 3 days. 4. Lithium 1350 mg q.h.s.
MSSA|modified selective severity assessment|MSSA|227|230|PLAN|9. Hypernatremia, likely related to volume depletion on presentation with normalization (as above). PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_ (in place of Dr. _%#NAME#%_). 2. Encourage good nutrition. 3. Complete MSSA withdrawal protocol using Ativan. Continue thiamine and multivitamin. 4. Dental consult. 5. Clinical observation. Further medical intervention at this point does not appear required.
MSSA|modified selective severity assessment|MSSA|124|127|PLAN|2. If not done, we will check CBC and repeat CMP to assess electrolytes, renal function, and liver function. 3. Continue on MSSA withdrawal protocol using Ativan. Multi-vitamin q.d. 4. We will follow up on laboratory studies. We will otherwise observe clinically.
MSSA|modified selective severity assessment|MSSA|215|218|PLAN|8. History of renal calculus disease, clinically quiescent. 9. History of PID secondary to chlamydia. 10. Alleged history of withdrawal seizures. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Continue MSSA withdrawal protocol using Valium. 3. PRN atenolol. Thymin 100 mg daily for 3 days. We will start multivitamin 1 p.o. daily. 4. With regard to fever this may relate to withdrawal.
MSSA|modified selective severity assessment|MSSA|148|151|PRESENT MEDICATIONS|1. Imodium two p.o. p.r.n. loose stools. 2. Claritin 10 mg q.a.m. 3. Celexa 20 mg q.h.s., 40 mg q.a.m. 4. Seroquel 300 mg q.h.s. May repeat x 1. 5. MSSA withdrawal protocol, using Ativan with p.r.n. Tylenol and Mylanta. FAMILY HISTORY: His father died from alcoholism. HABITS: Three to four cigarettes daily.
MSSA|modified selective severity assessment|MSSA|91|94|PRESENT MEDICATIONS|5. He is not aware of any history of heart disease or other ailments. PRESENT MEDICATIONS: MSSA protocol with the use of Ativan. He has been placed on Tenormin 50 mg b.i.d. with parameters to hold due to elevated blood pressures since the time of admission.
MSSA|modified selective severity assessment|MSSA|117|120|MEDICATIONS|2. Right hand surgery. ALLERGIES: No known drug allergies. Nausea and vomiting with codeine in 1997. MEDICATIONS: 1. MSSA withdrawal protocol using Valium. 2. Lexapro 10 mg daily. 3. Multivitamin daily. 4. Thiamine 100 mg daily for 3 days. 5. Routine p.r.n. meds. FAMILY HISTORY: Remarkable for cancer. HABITS: One-half pack per day smoker.
MSSA|modified selective severity assessment|MSSA|97|100|PLAN|4. Left foot drop, probably secondary to peroneal nerve palsy from leg crossing. PLAN: 1. Switch MSSA protocol to Valium. I think it will give her better coverage for her withdrawal. The patient is instructed not to cross her legs to allow healing of the peroneal nerve to treat her foot drop.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|189|192|PAST MEDICAL HISTORY|She reports no history of recent seizures. PAST MEDICAL HISTORY: 1. In addition to the seizure disorder she has chronic illnesses such as severe rheumatoid arthritis, a history of MRSA and MSSA She also has a history of hepatitis C. Those factors are also felt to be contributing to her anemia. 2. Multiple joint surgeries 3. C1-C2 fusion 4. Bilateral hip replacements
MSSA|modified selective severity assessment|MSSA|289|292|RECOMMENDATIONS|I will have follow-up laboratories, including lipase. Should he have further emesis then he should be admitted to the Medical Service, although I think he will be very difficult to manage on medicine because of his propensity for severe agitation. In any event, he should be maintained on MSSA alcohol withdrawal protocol. As above should have follow-up liver function tests, as well as lipase will be obtained in the morning. If the patient is admitted to the mental health unit I will be contact with the nursing staff to monitor his status after admission.
MSSA|modified selective severity assessment|MSSA|127|130|MEDICATIONS PRIOR TO ADMISSION|1. Seroquel 50 mg b.i.d. and 100 mg q.h.s. 2. Wellbutrin SR 100 mg q.a.m. x 3 days, increasing to 200 mg q.a.m. thereafter. 3. MSSA withdrawal protocol using Ativan, thiamine 100 mg q. day x 3 p.r.n. 4. Multivitamin q. day. 5. Tylenol p.r.n. 6. Maalox p.r.n. 7. Milk of Magnesia p.r.n. FAMILY HISTORY: Father died age 62 from malignant melanoma.
MSSA|modified selective severity assessment|MSSA|110|113|PRESENT MEDICATIONS|ALLERGIES: None to medication. Does have environmental allergies to grass, cats, etc. PRESENT MEDICATIONS: 1. MSSA withdrawal protocol, switched to Valium 5 mg daily x 3 days. 2. Atenolol p.r.n. for a heart rate greater than 100.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|211|214|IMPRESSION|IMPRESSION: 1. _%#NAME#%_ _%#NAME#%_ is a 46-year-old male, status post right total hip arthroplasty complicated by a fall and periprosthetic fracture requiring open reduction and internal fixation. 2. Previous MSSA infection of the right leg, _%#MM2006#%_, treated with incision and drainage and exchange of hardware. He was given an eight-week course of intravenous Ancef.
MSSA|modified selective severity assessment|MSSA|287|290|CURRENT MEDICATIONS|PAST SURGICAL HISTORY: None. OTHER KNOWN SERIOUS ILLNESS: None. Denies heart disease or asthma, hypertension, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, thyroid disease, seizure, tuberculosis, or anemia. ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: MSSA withdrawal protocol using Ativan with routine p.r.n. meds. FAMILY HISTORY: Denies known serious illness. HABITS: A 1-pack per day smoker.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|228|231|PAST  MEDICAL HISTORY|He has chronic renal failure and was dialyzed today. He has a history of coronary artery disease and a heart murmur. He has had a previous craniotomy with some bone grafts from his ribs. He has a history of hypertension. He had MSSA right arm abscess with bacteremia which he survived. He was hospitalized with sepsis and Clostridium difficile colitis at Fairview Ridges _%#MMDD2007#%_, the same admission in which he had the duodenal bleed and the DVT.
MSSA|modified selective severity assessment|MSSA|151|154|HISTORY OF PRESENT ILLNESS|She denies a history of chemical dependency; however, she was drinking up to four glasses of wine nightly with dinner. She initially was maintained on MSSA alcohol withdrawal protocol using Ativan, which has since been discontinued. An ER evaluation included a breathalyzer of 0.09.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|175|178|RECOMMENDATIONS|RECOMMENDATIONS: 1. Continue with your attentive intensive care management. 2. If he remains febrile, then blood, urine and sputum samples should be sent off for cultures. 3. MSSA protocol per your plans. 4. Track liver functions and renal functions. 5. He is at risk for a variety of .......infections, but he is in a good environmental to identify them and treat in a timely manner.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|203|206|IMPRESSION|Urinalysis negative. 0-2 white blood cells, white blood count 8.2, creatinine is 1.79, up from 1.6. Chest x-ray is clear. IMPRESSION: 1. Staph aureus bacteremia, MICs are pending, but needs coverage for MSSA and Methicillin resistant staphylococcus aureus. This is likely his presenting problems and the result of his respiratory failure. Sources would include an infected abdominal aortic aneurysm graft, endocarditis, infected pacemaker, septic right wrist.
MSSA|modified selective severity assessment|MSSA|378|381|MEDICATIONS PRIOR TO THIS ADMISSION|3. Status post tubal ligation. 4. Denies known heart disease, diabetes, asthma, hypertension, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, thyroid disease, seizure, tuberculosis, or anemia. ALLERGIES: None known. MEDICATIONS PRIOR TO THIS ADMISSION: None. Presently, maintained on p.r.n. Milk of Magnesia, Tylenol Maalox, Kaopectate, multivitamin q day, MSSA withdrawal protocol using Ativan with thiamine, 100 mg q day x3. FAMILY HISTORY: Without serious illness. HABITS 1 to 1-1/2 pack per day smoker.
MSSA|modified selective severity assessment|MSSA|252|255|MEDICATIONS|PAST SURGICAL HISTORY: None. Denies heart disease, diabetes, asthma, hypertension, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, thyroid disease, seizure, tuberculosis, or anemia. ALLERGIES: No known drug allergies. MEDICATIONS: MSSA withdrawal protocol using Ativan, thiamine 100 mg daily for 3 days, p.r.n. atenolol for heart rate greater than 100. FAMILY HISTORY: Without known serious illness. HABITS: One-half to 1 pack per day smoker.
MSSA|modified selective severity assessment|MSSA|146|149|MEDICATIONS|4. History of pelvic inflammatory disease diagnosed outpatient and treated on an outpatient basis one year ago. 5. Childbirth X2. MEDICATIONS: 1. MSSA protocol using Ativan. 2. She states she was prescribed Celexa but took only one dose of this which she started a week ago.
MSSA|modified selective severity assessment|MSSA|139|142|CURRENT MEDICATIONS|ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: 1. Zoloft 50 mg q.a.m. for 2 days then 100 mg q.a.m. 2. Methadone 30 mg today. 3. MSSA withdrawal protocol using Ativan with p.r.n. atenolol. 4. Thiamine 100 mg daily for 3 days. 5. Ibuprofen 800 mg q. 6h. p.r.n. pain. 6. Bacitracin ophthalmic ointment to the lower lids b.i.d.
MSSA|modified selective severity assessment|MSSA|149|152|HISTORY OF PRESENT ILLNESS|She denies any other acute medical problems. She is feeling quite unsteady. During the day today, she has received about 2 mg of Ativan according to MSSA protocol. HABITS: She is a half-pack per day smoker. ALLERGIES: No known drug allergies.
MSSA|modified selective severity assessment|MSSA|122|125|MEDICATIONS|4. History of removal of pre-cancerous vulvar lesions. 5. Status post cholecystectomy. 6. Osteoarthritis. MEDICATIONS: 1. MSSA protocol. 2. Prempro. 3. Maxzide. 4. Albuterol. 5. Norvasc 2.5 mg p.o. q.d. 6. Fosamax. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is currently living with her elderly mother whom she is caring for.
MSSA|modified selective severity assessment|MSSA|122|125|PLAN|5. Nicotine addiction. 6. Question of sulfa allergy. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Continue MSSA protocol with Ativan. 3. Agree with discontinuation of atenolol. 4. Cardizem 30 mg p.o. q.6h p.r.n. heart rate greater than 100. Hold p.r.n. systolic blood pressure less than 120. 5. Albuterol metered-dose inhaler two puffs q.i.d. p.r.n.
MSSA|modified selective severity assessment|MSSA|139|142|RECOMMENDATIONS|2. Continue intravenous Ancef 1 gram q.8h. and plan a 4-week course of antibiotics depending on the culture data and clinical progress. 3. MSSA protocol will be implemented. 4. Place a PICC line for durable intravenous access, if possible. 5. Ask the discharge planner to see this patient regarding outpatient antibiotic options.
MSSA|modified selective severity assessment|MSSA|94|97|MEDICATIONS|She has since discontinued them. There are no known chronic medical ailments. MEDICATIONS: 1. MSSA protocol. 2. Vistaril. 3. Trileptal 150 mg b.i.d. ALLERGIES: No known drug allergies, although ibuprofen causes severe nausea and vomiting.
MSSA|modified selective severity assessment|MSSA|253|256|MEDICATIONS|She denies any acute physical complaints at present. PAST MEDICAL HISTORY: Is significant for several chemical dependency treatments in the past. She has a history of bipolar disorder. MEDICATIONS: Depakote, Prozac, and Effexor. She is currently on the MSSA protocol. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient with chemical use history as described earlier.
MSSA|modified selective severity assessment|MSSA|145|148|HISTORY OF PRESENT ILLNESS|12. Bitemporal headache, likely tension/muscle contraction in origin. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_ or so. 2. Continue MSSA withdrawal protocol for now, however, no overt signs of alcohol withdrawal presently. 3. Protonix 40 mg daily for symptoms of acid reflux.
MSSA|modified selective severity assessment|MSSA|222|225|ASSESSMENT AND PLAN|The patient drinks alcohol 2 times weekly. Denies any alcohol symptoms, alcohol withdrawal, and denies that he has a problem with alcohol. If the patient has symptoms of alcohol withdrawal symptoms, we will start him with MSSA alcohol prophylaxis treatment, but at this point the patient denies any alcohol problems. We will follow up closely. We will follow up hemoglobin in the morning.
MSSA|modified selective severity assessment|MSSA|192|195|RECOMMENDATIONS|3. Slight elevation of pancreatic enzymes consistent with mild pancreatitis. The patient is minimally symptomatic, however, in this regard. RECOMMENDATIONS 1. The patient will be continued on MSSA protocol. 2. I will be in to see him later on today to reassess his status, in particular with regard to the possible need for transfer to the medical unit.
MSSA|modified selective severity assessment|MSSA|121|124|MEDICATIONS|Without renal disease, hepatitis, gallbladder disease or thyroid disease. ALLERGIES: None to medication. MEDICATIONS: 1. MSSA withdrawal protocol using Ativan, Folic acid 1 mg daily. 2. Glucophage 1000 mg b.i.d. 6. Multivitamin daily. 3. Dilantin 300 mg administered last evening.
MSSA|modified selective severity assessment|MSSA|101|104|MEDICATIONS|2. No history of hospitalization for other medical or surgical issues. MEDICATIONS: 1. Albuterol. 2. MSSA protocol. ALLERGY: Codeine. SOCIAL HISTORY: The patient lives with her parents, drinking a quart of alcohol daily for about a year.
MSSA|modified selective severity assessment|MSSA|159|162|PLAN|2. Review headache issue with Neurology. Either consultation and/or proceed with brain imaging. 3. Request outside labs from St. Francis Hospital. 4. Complete MSSA withdrawal protocol with multivitamin and thiamine. 5. Patient notify staff if diarrhea persists. 6. Clinical observation. Thank you for the consultation. Will follow along as indicated.
MSSA|modified selective severity assessment|MSSA|252|255|MEDICATIONS|The patient denies heart disease, diabetes, asthma, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, thyroid disease, seizure, tuberculosis, or anemia. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Effexor XL 225 mg daily. 2. MSSA withdrawal protocol, using Valium. 3. Thiamine 100 mg daily for 3 days. 4. Atenolol p.r.n. 5. Nicotine lozenge or gum. 6. Milk of magnesia p.r.n.
MSSA|modified selective severity assessment|MSSA|126|129|RECOMMENDATIONS|3. Possible history of alcohol withdrawal seizure, though this is not clear. RECOMMENDATIONS: The patient will be treated per MSSA protocol. No further medical evaluation seems necessary. I will be able to see him during his hospitalization for concurrent medical issues.
MSSA|modified selective severity assessment|MSSA|160|163|MEDICATIONS|ALLERGIES: No known drug allergies. MEDICATIONS: Present medications include: 1. Folic acid 1 mg daily. 2. Multivitamin 1 daily. 3. Thiamine 100 mg daily, with MSSA withdrawal protocol using Ativan. FAMILY HISTORY: Father with anemia (?). HABITS: One-half pack pack-per-day smoker.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|180|183|HOSPITAL COURSE|7. MSSA urinary-tract infection; the patient started on IV antibiotic therapy, was afebrile throughout her stay with normal white count. She was relatively asymptomatic. As 1/3 of MSSA positive urine cultures will also have positive blood cultures, blood cultures were obtained to ensure no evidence of bacteremia. Blood cultures were obtained and are negative to date in the past 24 hours; however, the 48-hour results are still pending at the time of discharge dictation, but the patient and family are anxious for discharge and wish to follow this up with her primary-care physician.
MSSA|modified selective severity assessment|MSSA|137|140|PROBLEM #2|Throughout his stay at the hospital, Mr. _%#NAME#%_ required less and less of p.o. Ativan for his symptoms withdrawal. His course on the MSSA protocol was uneventful. PROBLEM #3: Mr. _%#NAME#%_'s psychiatric condition was in question as well due to his history of a previous withdrawal seizure.
MSSA|modified selective severity assessment|MSSA|165|168|HOSPITAL COURSE|He was placed on Telemetry. Protonix and Phenergan were continued. He was, initially, NPO for medications with bed rest and bathroom privileges. He was placed on an MSSA protocol with folate and thiamine. Atenolol, Lisinopril, and clonidine were continued for his hypertension. Percocet was continued. PROBLEM #1: Legal. The patient was placed on a 72-hour hold initially for suicidal ideation and run risk.
MSSA|modified selective severity assessment|MSSA|566|569|PROBLEM #9|The patient was started on vancomycin and the sepsis gradually resolved during his stay at the hospital and at the time of discharge, the patient was afebrile for the past few days and his WBC count was 5.5. A culture from the PICC line tip grew more than 100 colonies of coagulase negative Staphylococcus that was resistant to oxacillin and penicillin and susceptible to ciprofloxacin, clindamycin, erythromycin, gentamicin, levofloxacin, trimethoprim/sulfa and vancomycin. PROBLEM #9: Alcohol abuse/dependence. At the time of admission, the patient was started on MSSA protocol. Psychiatry and CD were consulted and as per their recommendations, the patient would benefit from sober house and lodging plus.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|152|155|DISCHARGE PLAN|Cefotaxime was continued Vanco was discontinued and Clinda was started 4 days into the treatment. A follow up tracheal culture revealed light growth of MSSA and her respiratory status remained tenuous prompting us to extend her treatment with Cefotaxime and Clinda to 14 days. A CRP was checked prior to discontinuing these antibiotics and found to be negligible consistent with her clinical recover from the infection.
MSSA|modified selective severity assessment|MSSA|162|165|PLAN|She will be placed on routine precautions with special attention to withdrawal symptoms, suicideality, and the possibility of seizures. She will be placed on the MSSA protocol for benzodiazepine withdrawal using Valium although we may consider putting her on a Valium taper if we can get a better idea of what her Ativan use has been.
MSSA|modified selective severity assessment|MSSA|80|83|PROBLEM # 2|She denies history of seizures or severe alcohol detox in the p ast. Will start MSSA protocol and vitamins as a precaution. PROBLEM # 3: Crack/cocaine abuse: The patient reports 6-7 hours of crack/cocaine abuse yesterday.
MSSA|modified selective severity assessment|MSSA.|129|133|HOSPITAL COURSE|The patient was on MSSA protocol, and continued to score between 8 and 14 throughout course. She received Valium as indicated by MSSA. The patient did also experience elevated temperatures, T-max of 100. 4 on day of discharge. PROBLEM #2: Alcoholic hepatitis, cholelithiasis, and right upper quadrant pain.
MSSA|modified selective severity assessment|MSSA|139|142|PLAN|1. Admit the patient to station 20 under the care of Dr. _%#NAME#%_. 2. Will obtain routine orders and labs. 3. Will put the patient on an MSSA protocol with Ativan. 4. Will add a pregnancy test and sexually transmitted diseases to the patient's labs per her request. 5. Will not restart her psychotropic medications at this time out of concern the patient may be pregnant, as well as not sure the patient is tolerating these medications and would be compliant with it as an outpatient.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA.|199|203|HISTORY OF PRESENT ILLNESS|The patient had intensive workup. The patient was found to have positive blood cultures from the central line with methicillin sensitive staphylococcus aureus and also urine cultures showed the same MSSA. The patient was started on IV antibiotics in combination with Nafcillin and gentamycin. Chest x-ray workup also showed right middle lobe infiltrate consistent with hospital-acquired pneumonia.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|172|175|HISTORY OF PRESENTING ILLNESS|He did not follow up as recommended and was seen in the clinic in _%#MM2006#%_ with PFTs significantly decreased. He underwent bronchoscopy at that time, which just showed MSSA (Staph aureus) and light growth of pseudomonas with transbronchial biopsy of A0 B2. He was given a Solu-Medrol bolus and treated with antibiotics and sent home on azithromycin.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|367|370|HISTORY OF PRESENT ILLNESS|6. Physical therapy/occupational therapy/cardiac rehabilitation. 7. PM and R. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 64-year-old woman with history of type 2 diabetes mellitus and peripheral vascular disease, who was transferred to the Fairview University Medical Center from _%#CITY#%_ in cardiogenic shock secondary to NSTEMI and septic shock secondary to MSSA infected gangrenous wound status post recent BKA with a balloon pump, arterial line, Swan-Ganz catheter and chest tube in place, not on pressors.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|198|201|ASSESSMENT AND PLAN|Left ventricular assist device coordinators will be involved with monitoring his heart failure as well. He has a scheduled follow-up with Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2007#%_ at 8:20 a.m. 2. MSSA sepsis. The patient is on clindamycin and will continue for the recommendation duration. We will have Infectious Disease follow with us in this regard.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA.|223|227|PROCEDURES PERFORMED|The patient was also given oral Coumadin with a goal of INR reaching 2.5 to 3.5. His hospital course was complicated by the fact that the patient developed fever and blood cultures showed positive for Staphylococcus aureus MSSA. Therefore, the patient's right IJ hemodialysis catheter was removed and the patient had a temporary hemodialysis Quinton put in for dialysis access.
MSSA|modified selective severity assessment|MSSA|180|183|ASSESSMENT|The patient's most likely diagnosis was alcohol withdrawal. The patient was admitted to the Intensive Care Unit. The patient was treated per MSSA-Valium protocol and the patient's MSSA score is about 28 to 30 at this time, requiring high doses of Valium. The patient was to continue with IV fluids, D5- half normal saline, with 20 mEq of potassium chloride, at 125 cc per hour.
MSSA|modified selective severity assessment|MSSA|141|144|PROBLEM #2|It was noted that the patient had tremors at baseline consistent with his psychiatric medications, and this factor was not to be used in the MSSA protocol. A consult with the Psychiatric Department was made for this patient. PROBLEM #3: FEN/GI: The patient was given a course of thiamine, folate, and multivitamins.
MSSA|modified selective severity assessment|MSSA|136|139|PROBLEM #2|PROBLEM #2: Ethanol intoxication: The patient was observed for withdrawal given thiamine and folate in the emergency room followed with MSSA protocol, administered Valium and Ativan p.r.n. over the following 24 hours. MSSA protocol was discontinued after 24 hours inpatient, was stable at the time of discharge.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|155|158|DISCHARGE DIAGNOSES|2. GI bleed secondary to Cameron erosions of the hiatal hernia. 3. C. difficile colitis. 4. Dysphagia . 5. Left upper extremity deep venous thrombosis. 6. MSSA pneumonia and respiratory failure. 7. Status post trach placement. 8. Status post G-tube placement. 9. Hypernatremia.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|185|188|HOSPITAL COURSE|3. Respiratory failure. The patient was placed on a ventilator postop, mostly for sedation. However, he did develop a fever and a left lower lobe infiltrate. Sputum eventually revealed MSSA and he now has completed antibiotics. The patient has actually been weaned from the ventilator and he has a 6 cuffless Shiley trach that is capped.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|178|181|HOSPITAL COURSE|Liver enzymes normal. HOSPITAL COURSE: 1. CF pulmonary exacerbation secondary to methicillin-sensitive Staphylococcus aureus: The patient was started on IV Timentin for presumed MSSA infection. Her vest and nebulizer therapies were increased in frequency to q.i.d. to help with pulmonary toilet. Despite this aggressive therapy, _%#NAME#%_'s pulmonary function tests showed minimal improvement.
MSSA|modified selective severity assessment|MSSA|73|76|PLAN|14. Intertrigo and seborrheic dermatitis of the scalp. PLAN: 1. Continue MSSA withdrawal protocol using Ativan, thiamine 100 mg q. day times three. Multivitamin q. day. 2. Adjustment of intravenous fluids with regard to hyponatremia.
MSSA|modified selective severity assessment|MSSA|271|274|ASSESSMENT  AND PLAN|In any case, the cardiology service would like to perform cardiac catheterization the following day and will be in contact with our service to make arrangements for that. 2. Alcohol withdrawal. The patient appears to be going through withdrawal and he will be kept on an MSSA protocol and given thiamine, folate, IV rehydration with seizure precautions. 3. Multiple electrolyte abnormalities including low magnesium and borderline low potassium.
MSSA|modified selective severity assessment|MSSA|250|253|PLAN|ASSESSMENT: A 62-year-old African-American male with a significant history of seizure disorder and alcoholism, with acute alcohol intoxication and acute onset of seizure activity, admitted for observation. PLAN: The plan is to put the patient in the MSSA protocol with Ativan and to watch for alcohol withdrawal seizures to rule out for a myocardial infarction with serial troponins and EKGs and to give him thiamine and fluids and also to try to get more medical records on him.
MSSA|modified selective severity assessment|MSSA|219|222|PROBLEM #2|We did not give him Percocet secondary to the Tylenol in the Percocet and not wanting to harm the liver with his hepatitis C. So we kept him mostly on IV morphine. PROBLEM #2: Chemical-dependency. He was started on the MSSA protocol and put on seizure precautions secondary to his alcohol level of 0.3. He said that he was extremely interested and very serious about detox and rehab, and so we thought that he might be eligible for a Rule 25.
MSSA|modified selective severity assessment|MSSA|212|215|PLAN|The patient needs empiric antibiotic with imipenem 500 mg IV q.6h. and pending blood cultures times two because the patient looks to have severe pancreatitis, with peripancreatic necrosis. The patient will be on MSSA protocol with Ativan for alcohol withdrawal prevention and seizure precautions. The patient will be given thiamine 100 mg q.d. and folic acid 1 mg q.d. We will obtain a chemical dependency consultation on Monday.
MSSA|modified selective severity assessment|MSSA.|159|163|HOSPITAL COURSE|Workup included microbiology and the patient did have blood cultures positive for gram negative rods which were unable to be identified further in addition to MSSA. Infectious Disease was consulted. The patient did have a line in place which was removed. It was felt that the patient may have had a line infection.
MSSA|modified selective severity assessment|MSSA|133|136|HOSPITAL COURSE|The patient was protecting his airway. Social worker Rule 25 was consulted at the time of the admission. The patient remained on the MSSA protocol and continued to be monitored in the Intensive Care Unit. The patient did not have any withdrawal seizures. PROBLEM #2: Noncardiac region musculoskeletal chest pain of the left side.
MSSA|modified selective severity assessment|MSSA|229|232|HOSPITAL COURSE|ELECTROCARDIOGRAM: Sinus tachycardia, Q wave in lead 3 and aVF, which was present in _%#MMDD2006#%_ EKG as well. No interval ST segment changes. HOSPITAL COURSE: PROBLEM #1. Acute alcohol intoxication: The patient was started on MSSA protocol and was also started on D5 half-normal saline with 20 KCl at 150 cc/h. He was getting thiamine, multivitamin and folic acid through his MSSA.
MSSA|modified selective severity assessment|MSSA.|266|270|HOSPITAL COURSE|No interval ST segment changes. HOSPITAL COURSE: PROBLEM #1. Acute alcohol intoxication: The patient was started on MSSA protocol and was also started on D5 half-normal saline with 20 KCl at 150 cc/h. He was getting thiamine, multivitamin and folic acid through his MSSA. His MSSA of 8-11 while he was on the floor and he was getting Valium for his agitation. On _%#MMDD2006#%_ he was stable, not requiring much medications. His ALT and AST on the day after admission were 106 and 94, respectively.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|236|239|PROBLEM #3|The patient was transferred up to the floor, aspirated, and developed a pneumonia in her right lower and middle lobes. This was treated with a course of Timentin and started on a course of vancomycin. Sputum cultures did come back with MSSA and MRSA. The patient did complete a course of Timentin. This was discontinued. The patient had a positive sputum culture for MRSA on _%#MMDD2006#%_, and the vancomycin was continued.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|257|260|HOSPITAL COURSE|The patient was on vancomycin until it was shown that a swab of the right lower extremity did not grow out MRSA. Of note, the right lower extremity swab for wound culture eventually grew out methicillin-sensitive Staphylococcus aureus. Again, this grew out MSSA and not MRSA. With the antibiotics, the patient's cellulitis gradually improved as did her pain. Congestive heart failure: Shortly after admission, the patient developed some difficulty breathing.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|151|154|HOSPITAL COURSE|On admission, the patient was noted to have temperature of 102.8, blood pressure 150/80, pulse 91, and saturation 94% on room air. HOSPITAL COURSE: 1. MSSA bacteremia/febrile illness. On the day of admission, blood cultures were obtained. There was a concern for a possible CNS infection with the patient's symptoms of increasing headache, febrile illness, and elevated white count; however, there was a concern with the findings on the CT scan previously with any type of mass effect.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA.|204|208|HOSPITAL COURSE|Chest CT showed left lower lobe pneumonia and possible right middle lobe pneumonia. She was placed on broad spectrum antibiotics, Zosyn and a dose of vancomycin. Her cultures grew out oxacillin-sensitive MSSA. She was transitioned to nafcillin, and Zosyn and vancomycin were discontinued. Nafcillin was continued for approximately one week. However, the patient began developing some low-grade temperatures with ultimately fever spikes.
MSSA|modified selective severity assessment|MSSA|183|186|HISTORY OF PRESENT ILLNESS|Gradual improvement with incomplete blood pressure control with IV Ativan and Lopressor 5 mg with drop in blood pressure to 150/112 and heart rate of 102. He has since been placed on MSSA withdrawal protocol with IV Valium, having received one dose of Lopressor 5 mg IV this morning at 0715, with persistent significant hypertension.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA.|267|271|PAST MEDICAL HISTORY|Later the patient left leg pain with pain, and he underwent a second surgery at the Mayo Clinic, apparently with a frature at periprosthetic joint. He had a third knee replacement done 2 years ago again at Mayo Clinic. Now patient suffers left knee septic joint with MSSA. See above. Also, the patient underwent a right knee replacement in 2006 by Dr. _%#NAME#%_ 3. Diabetes mellitus type 2. 4. Hypertension. 5. Chronic kidney disease with baseline creatinine of 1.8, most likely secondary to diabetic nephropathy.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|188|191|HOSPITAL COURSE|Hematemesis resolved and had no further evidence of hematemesis. She continued on Protonix as an outpatient. PROBLEM #3. MSSA bacteremia: Prior to admission the patient was diagnosed with MSSA bacteremia and had been initiated on vancomycin. Her tunneled catheter was removed and a temporary Quinton catheter was placed for dialysis.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|178|181|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: End-stage renal disease secondary to diabetic nephropathy, type 2 diabetes with nephropathy and neuropathy in all 4 extremities. History of line infection, MSSA bacteremia in _%#MM#%_ and _%#MM2006#%_ and _%#MM2006#%_. Hypertension, coronary artery disease with ischemic cardiomyopathy on medical management and stress nuclear study in summer of 2005 showed small amount of anterior ischemia, ejection fraction of 41%, dyslipidemia.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|393|396|MEDICATIONS|PAST SURGICAL HISTORY: 1. As above. 2. Rhinoplasty. OTHER KNOWN SERIOUS ILLNESSES: None; specifically, he denies heart disease, hypertension, diabetes, asthma, renal disease, gallbladder disease, thyroid disease, seizures, tuberculosis, or anemia. ALLERGIES: No known drug allergies. MEDICATIONS: Remeron 15 mg q.h.s., Naltrexone 50 mg q.h.s. (on hold), prn Maalox, milk of magnesia, Tylenol, MSSA withdrawal protocol using Ativan and thiamine 100 mg q day X3. FAMILY HISTORY: Without known serious illness. HABITS: Nonsmoker. Binge-style alcohol intake as above with 12 to 24 mixed drinks per time.
MSSA|modified selective severity assessment|MSSA|170|173|HISTORY OF PRESENT ILLNESS|He was relatively stable hemodynamically with blood pressure 98/58, respirations unlabored, and normal temperature. He was admitted to 3A where he has been maintained on MSSA alcohol withdrawal protocol by using Ativan. He does indicate mild withdrawal symptoms manifested by mild tremor. No appreciable sweats. He denies ongoing chest discomfort or dyspnea presently.
MSSA|modified selective severity assessment|MSSA|256|259|MEDICATIONS|PAST SURGICAL HISTORY: None. Without heart disease, diabetes, asthma, hypertension, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, thyroid disease, seizure, tuberculosis, or anemia. ALLERGIES: No known drug allergies. MEDICATIONS: 1. MSSA withdrawal protocol using Ativan. 2. Campral 666 mg t.i.d. 3. Zoloft 25 mg daily. 4. Thiamine 100 mg daily for 3 days. FAMILY HISTORY: Without known serious illness.
MSSA|modified selective severity assessment|MSSA|135|138|PLAN|10. Concern regarding "gang rape," desire to be checked for STDs. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Continue MSSA withdrawal protocol using Valium and thiamine. 3. Seizure precautions. 4. Attempt to contact the patient's primary MD, Dr. _%#NAME#%_, _%#CITY#%_ Medical Center, regarding details regarding rheumatic fever.
MSSA|modified selective severity assessment|MSSA|173|176|MEDICATIONS|ALLERGIES: Multiple, including Haldol, Compazine, Thorazine, and Depakote (?). MEDICATIONS: Present medications include: 1. Celexa 20 mg daily. 2. Klonopin 0.5 mg t.i.d. 3. MSSA withdrawal protocol using Ativan. 4. Methadone 120 mg daily. 5. Nicotine patch 21 mg daily. 6. Seroquel 25 mg t.i.d. p.r.n. 7. Thiamine 100 mg daily for three days. 8. Geodon 10 mg IM q. 4 h p.r.n.
MSSA|modified selective severity assessment|MSSA|293|296|MEDICATIONS|ALLERGIES: Cortisone (?) with possible rash. MEDICATIONS: Prior to admission he was on p.r.n. Advil for musculoskeletal complaints. The patient is presently maintained on trazodone 100 mg q.h.s. p.r.n. sleep, may repeat x 1; nifedipine 30 mg q.a.m.; olanzapine 20 mg q.h.s.; nicotine lozenge; MSSA withdrawal protocol using Ativan, with thiamin 100 mg daily x 3; and p.r.n. Tylenol, Maalox, and milk of magnesia. FAMILY HISTORY: Without known serious illness, except for the patient's father age 78 with possible colon cancer.
MSSA|modified selective severity assessment|MSSA|105|108|MEDICATIONS|2. Tapazole 5 mg daily. 3. Dilantin 100 mg q.i.d. 4. Thymin 100 mg daily. 5. Effexor XR 225 mg daily. 6. MSSA withdrawal protocol using Valium and trazodone 300 mg q.h.s. Also requesting use of a nicotrol inhalers and conjunction with nicotine patch, which he indicates he has used in conjunction in the past and tolerated well.
MSSA|modified selective severity assessment|MSSA|103|106|PRESENT MEDICATIONS|ALLERGIES: Penicillin (in infancy, question reaction). Sulfa (airway closure). PRESENT MEDICATIONS: 1. MSSA withdrawal protocol using Ativan, which has since been discontinued. 2. Thiamine 100 mg q.d. times three. 3. Tylenol p.r.n. 4. Maalox p.r.n. 5. Milk of Magnesia p.r.n. 6. Paxil, increased to 40 mg q.a.m. for three days, then 60 mg q.a.m.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|211|214|HISTORY|HISTORY: Please see multiple previously dictated history and physicals. Briefly, this is a 51 -year-old female, known alcoholic, with recent IV cocaine use who was admitted _%#MMDD#%_ through _%#MMDD#%_ with an MSSA right arm abscess requiring surgical debridement. She was evaluated thoroughly by Infectious Disease and there was found to be no evidence of bacterial endocarditis.
MSSA|modified selective severity assessment|MSSA|203|206|ASSESSMENT|Possible bacteremia with rigor and fever. 2. Polysubstance abuse with drugs of choice cocaine and alcohol. Abstention since _%#MMDD#%_. No signs of cocaine or alcohol withdrawal presently. Will place on MSSA withdrawal protocol. Check urine toxicology screen. Administer thiamine and multivitamin. 3. Asthma, well compensated. 4. Depression with unclear degree of compensation.
MSSA|modified selective severity assessment|MSSA|262|265|PRESENT MEDICATIONS|2. Hysterectomy for fibroids. 3. Appendectomy. Denies heart disease, asthma, diabetes, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, seizure, tuberculosis, or anemia. ALLERGIES: None known. PRESENT MEDICATIONS: 1. Campral 666 mg t.i.d. 2. MSSA withdrawal protocol using Ativan, thiamine 100 mg daily for 3 days, p.r.n. Tylenol, Milk of Magnesia, Imodium, Dulcolax, Colace, Zantac, and Trazodone.
MSSA|modified selective severity assessment|MSSA|90|93|HISTORY OF PRESENT ILLNESS|He also gets the shakes, cold and hot sweats, and his blood pressure will go up at times. MSSA have ranged between 2 and 7, notable for tremors, sleepiness and some diaphoresis. PAST PSYCHIATRIC HISTORY: Largely summarized above. The patient denies any history of psychiatric hospitalizations.
MSSA|modified selective severity assessment|MSSA|172|175|MEDICATIONS|9. Metformin 500 mg daily. 10. Bactrim-DS two tablets b.i.d. 11. Multivitamin 1 daily. 12. Protonix 40 mg daily. 13. Thiamine 100 mg daily. 14. Trazodone 100 mg q.h.s. 15. MSSA withdrawal protocol using lorazepam. FAMILY HISTORY: Remarkable for alcoholism involving multiple members. HABITS: Nonsmoker.
MSSA|modified selective severity assessment|MSSA|196|199|MEDICATIONS|She presently is on losartan, as above; Effexor XR 37.5 mg q. daily for three days, with plan of a gradual increase to 150 XR daily; Claritin 10 mg daily, as above; multivitamin one q. daily; and MSSA withdrawal protocol using Ativan, which has since been discontinued. FAMILY HISTORY: Her father had diabetes. HABITS: She quit smoking 11 years ago.
MSSA|modified selective severity assessment|MSSA|202|205|PLAN|I did suggest an appointment with Dr. _%#NAME#%_ _%#NAME#%_ from Hand Surgery, on Wednesday, _%#MMDD2006#%_. 6. Nicotine addiction. PLAN: 1. Psychiatric intervention, as per Dr. _%#NAME#%_. 2. Continue MSSA withdrawal protocol. 3. Thiamine; add multivitamin 1 daily. 4. Protonix 40 mg daily for symptoms of acid reflux. 5. Z-PAK for bronchitis. Check chest x-ray. 6. Hydrogen peroxide cleanse followed by bacitracin ointment and gauze dressing daily to left wrist wounds.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|188|191|HOSPITAL COURSE/DIAGNOSES|Is currently on levofloxacin for UTI treatment; however, as of _%#MMDD2007#%_ there is no growth on urine culture. The patient is afebrile without an increasing white count. 8. History of MSSA pneumonia. The patient completed nafcillin/vancomycin course. 9. Coag negative staph bacteremia secondary to line infection. Line was DC'd and treated with a complete course of vancomycin.
MSSA|modified selective severity assessment|MSSA|199|202|HISTORY|Twelve years of sobriety until five days prior to admission, when the patient relapsed with up a quart of whiskey daily. Denies other chemical use. Subsequent to admission, the patient maintained on MSSA withdrawal protocol using Ativan in conjunction with thiamine. Presently denies overt symptoms of alcohol withdrawal. Unaware of withdrawal related seizures, DTs, pancreatitis, or known alcohol related liver disease.
MSSA|methicillin-susceptible Staphylococcus aureus|MSSA|153|156|PAST MEDICAL HISTORY|6. Status post subdural hematoma with evacuation in 2000. 7. Status post cholecystectomy in 2000. 8. History of transient ischemic attack. 9. History of MSSA bacteremia in 2003. 10. Bilateral nephrectomy in 1999 secondary to hypertension. Planned kidney transplant later this year. MEDICATIONS: Patient states he is on: 1. Dilantin 200 mg b.i.d.
MS|multiple sclerosis|MS|356|357|HISTORY OF PRESENT ILLNESS|REASON FOR ADMISSION: Weakness. HISTORY OF PRESENT ILLNESS: This 48-year-old male was admitted to the emergency room last night four days after he was discharged from the hospital complaining of being too weak to get out of bed for the past three days. Four days ago he was discharged after spending 8-days in the hospital on the rehabilitation center for MS exacerbation likely due to severe gastroesophageal reflux disease at night, with corresponding insomnia, and then marked fatigue during the day.
MS|morphine sulfate|MS|245|246|DISCHARGE MEDICATIONS|6. Prednisone 60 mg p.o. daily x2 days, then 40 mg p.o. daily x2 days, then 20 mg p.o. daily x4 days, then 10 mg p.o. daily x4 days, then stop. 7. Seroquel 100 mg p.o. at bedtime. 8. Carafate 1 gram p.o. q.i.d. 9. Effexor 225 mg p.o. daily. 10. MS Contin 45 mg p.o. b.i.d. 11. Oxycodone 5-10 mg p.o. .q.4h. p.r.n. 12. Tylenol p.r.n. 13. Ketoprofen 10% gel t.i.d. to left shoulder as needed.
MS|morphine sulfate|MS|149|150|PROBLEM #2|The patient is not being discharged on that medication as it most likely caused the rhabdomyolysis. PROBLEM #2: Altered mental status. The patient's MS Contin had been recently increased from 15 mg b.i.d to 100 mg b.i.d. The patient apparently had started to feel lethargic right after the increase in the dose.
MS|multiple sclerosis|MS,|195|197|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 46-year-old gentleman with progressive multiple sclerosis who is a patient of Dr. _%#NAME#%_'s. _%#NAME#%_ is significantly affected by his MS, which is both cerebral and cerebellar affecting his gait. _%#NAME#%_ was at his neurological baseline until last week when he began noticing an increase in ataxia and upper extremity weakness, as well as weakness in his legs.
MS|morphine sulfate|MS|191|192|MEDICATIONS|2. Ascorbic acid. 3. Atenolol. 4. Colace. 5. Effexor. 6. Iron. 7. Geodon. 8. Haldol. 9. Lisinopril. 10. Multivitamin. 11. Seroquel. 12. Xanax. 13. Trazodone. 14. Metformin. 15. Protonix. 16. MS Contin. 17. Lamictal. 18. Artane. 19. Nicotine patch. HOSPITAL COURSE: This gentleman was brought to the hospital and went to the operating room suite where he underwent debridement of his perineal wound with exposing of all pockets and undergoing packing.
MS|multiple sclerosis|MS|215|216|HISTORY|The patient was felt to be suitable based on the above for a DD3 diet with thin liquids. Improved chest congestion by time of dictation. Dyspnea in part thought likely related to possible restrictive deficit due to MS associated weakness. The patient was seen in consultation by Dr. _%#NAME#%_ _%#NAME#%_, her neurologist, elected to treat patient with parental Decadron protocol.
MS|multiple sclerosis|MS.|182|184|FAMILY HISTORY|2. Prior splenectomy. 3. Erythema nodosum involving the left lower extremity in _%#MM#%_ 2005, treated with amoxicillin. FAMILY HISTORY: Significant for the patient's father who had MS. He also had chronic myelomonocytic leukemia, which transformed to acute myelomonocytic leukemia, resulting in his death. The patient also has a family history of heart disease.
MS|multiple sclerosis|MS.|173|175|IMPRESSION|IMPRESSION: This is a lady with MS who presents with recent urinary tract infection, increased confusion and inability to care for herself. She probably has dementia due to MS. As well, she may have metabolic encephalopathy due to multiple medications that she is on. My plan is to admit her for physical therapy, occupational therapy and speech therapy evaluation and will plan to do EEG to rule out encephalopathy.
MS|multiple sclerosis|MS|181|182|DISCHARGE DIAGNOSES|This 53- year-old has known progressive MS, comes from _%#CITY#%_, Minnesota, and has been followed for many years. She has significant problems with depression associated with her MS and that has a direct effect on her maintaining her strength and her function. The MS has been relatively stable on betaseron but over the past few months she has been having increasing weakness in her legs and arms and decreasing function.
MS|morphine sulfate|MS|230|231|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Will be his same home medications, which are Nexium 40 mg a day, Effexor 150 mg a day, Celebrex 100 mg b.i.d., Actos 30 mg daily, Glipizide 10 mg daily, Milk of Magnesia as needed, multiple vitamins. He has MS Contin 30 mg b.i.d. as well. He is going to follow-up with Dr. _%#NAME#%_ _%#NAME#%_ to discuss possibility of further chemotherapy for salvage.
MS|morphine sulfate|MS|233|234|SUMMARY OF HOSPITAL COURSE|The patient's other major medical problems this hospitalization were managed appropriately including his gastroesophageal reflux disease which was managed by Protonix. The patient's pain control was achieved with Percocet as well as MS Contin as it was felt that the morphine PCA did not really benefit the patient in any case. At the time of discharge, he feels his pain is reasonably controlled on the current regimen, and he is given scripts for pain management in the intermediate time period until he is seen again by Orthopedic Surgery.
MS|multiple sclerosis|MS.|143|145|MAJOR PROCEDURES, TREATMENTS AND DIAGNOSTIC TESTS|MAJOR PROCEDURES, TREATMENTS AND DIAGNOSTIC TESTS: 1. CT of the head, _%#MMDD2006#%_, showing diffuse atrophy, patchy disease, consistent with MS. 2. Brain MRI without contrast, _%#MMDD2006#%_, showing multiple periventricular and supraventricular foci consistent with MS, diffuse cerebral atrophy, no acute intracranial pathology.
MS|multiple sclerosis|MS|165|166|HISTORY OF PRESENT ILLNESS|They were of varying ages and 6 of the lesions were enhancing. Based on that, she was referred over the university for methylprednisolone therapy and evaluation for MS versus other acute demyelinating syndromes. See full admission history and physical for other details. HOSPITAL COURSE: The patient was admitted and received a 3-day course of IV methylprednisolone per protocol.
MS|morphine sulfate|MS|295|296|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a _%#1914#%_ female, admitted with frequent falls and frequent inappropriate sleeping spells and persistent low back and leg pain. The patient has a long standing spinal stenosis with poor pain control despite pain medications, epidural injections. Had been on MS Contin on a regular basis with relatively good pain control, but she was cutting back on this according to the patient.
MS|multiple sclerosis|MS.|186|188|PAST MEDICAL HISTORY|HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old Caucasian female with MS who presented for a left PCNL for a large left staghorn calculus. PAST MEDICAL HISTORY: Significant for MS. She also had a CVA (in _%#MM#%_ 2002) and history of a T&A. MEDICATIONS: 1. Baclofen. 2. Avonex. 3. Detrol. 4. Two supplements with vitamin C.
MS|morphine sulfate|MS|131|132|MEDICATIONS|7. Methotrexate 10 mg q. week. 8. Zaroxolyn 2.5 mg q.d. 9. Demadex 20 mg b.i.d. 10. Combivent. 11. Nystatin Swish and Swallow. 12. MS Contin q.h.s. for chronic pain. 13. Pilocarpine eye drops. ALLERGIES: Penicillin, codeine. HABITS: Unfortunately, the patient continues to be a cigarette smoker.
MS|multiple sclerosis|MS|171|172|FAMILY HISTORY|1. Hip fracture 2. Shoulder surgery 3. Appendectomy 4. Tonsillectomy FAMILY HISTORY: Mother died 83 of unknown cancer. The patient did not know her father. Her sister had MS and brother had Alzheimer's disease. SOCIAL HISTORY: The patient quit smoking over 30 years ago.
MS|morphine sulfate|MS|153|154|ASSESSMENT AND PLAN|3. Chronic headache dating back to CVA _%#MMDD2001#%_. Unclear etiology. Using Vicodin almost daily. Consider management for chronic pain syndrome (i.e. MS Contin). Continue Vicodin for now. 4. Tobacco use. I stressed the importance of quitting given the patient's history of coronary disease and hypertension.
MS|morphine sulfate|MS|187|188|PLAN|Despite a significant ultrasound finding [sic], the patient has continued to have escalating pain in her right shoulder and neck. The pain is exacerbated by activity. She is currently on MS Contin 15 mg b.i.d. with no significant relief. She does not feel short of breath. She is experiencing low grade temperatures in the range of 100.5. Her PICC line in the right antecubital fossa appears unremarkable.
MS|multiple sclerosis|MS.|176|178|REVIEW OF SYSTEMS|Musculoskeletal - positive for MS signs. Neurologic - positive MS signs. Depression he describes as negative. Cognitive - has had mental cognitive problems associated with his MS. PHYSICAL EXAM: Blood pressure 126/56, pulse 65, respirations 16, temp.
MS|morphine sulfate|MS|90|91|PAST SURGICAL HISTORY|The patient also has been taking some alprazolam crushed and she has also been given some MS extended release morphine 15 mg. Her last dose of this was reportedly on Saturday. She had an oral dose of alprazolam at 1 p.m. today.
MS|multiple sclerosis|MS.|153|155||_%#NAME#%_ _%#NAME#%_ is a 50-year-old female admitted for evaluation of possible MS exacerbation. She has been followed for quite a number of years for MS. She is followed in our offices by Dr. _%#NAME#%_ who feels that she has probably secondary progressive disease. She has been on Betaseron for the past eight years.
MS|multiple sclerosis|MS,|216|218|IMPRESSION|Her electrolytes are normal. Her BUN is 12, creatinine is 0.6, her CBC is normal with a normal white count, slightly left shift with 90% polys. IMPRESSION: History and findings compatible with an exacerbation of her MS, probably involving her cervical cord accounting for significant spasms. Coincident with this she has probable urinary tract infection. She is admitted at this time for inpatient management.
MS|multiple sclerosis|MS.|209|211|PROCEDURES|3. TLC at University of Minnesota. PROCEDURES: 1. CT of the head on _%#MMDD2006#%_ which showed no acute abnormality, ventriculomegaly which may be related to central loss of green volume from patient's known MS. 2. CT of the abdomen and pelvis without contrast on _%#MMDD2006#%_. This was done in follow-up for a pancreatic mass seen on CT in _%#MM2005#%_.
MS|morphine sulfate|MS|152|153|DISCHARGE MEDICATIONS|11. Valsartan 80 mg p.o. q.h.s. and 160 mg p.o. q.a.m. 12. Lasix 40 mg p.o. b.i.d. 13. Neurontin 300 mg p.o. t.i.d. 14. Meclizine 25 mg p.o. t.i.d. 15. MS Contin 30 mg p.o. b.i.d. 16. Vicodin 1-2 p.o. q.4-6h. p.r.n. severe pain. 17. Metamucil 1 tablespoon p.o. b.i.d. 18. Colace 100 mg p.o. b.i.d. DISCHARGE DIET: ADA diabetic. DISCHARGE ACTIVITY: The patient should be in her TLSO brace whenever greater than 30 degrees in bed or whenever out of bed.
MS|morphine sulfate|MS|217|218|HOSPITAL COURSE|Thereafter, he continued to require a PCA, Dilaudid, and oral MS Contin, with gradual resolution of his pain back to baseline. Prior to his discharge, he was placed back on his normal regimen of 240 mg twice daily of MS Contin. Chest x-ray demonstrating a question of right humeral head sclerosis versus avascular necrosis.
MS|morphine sulfate|MS|71|72|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Levaquin 500 mg q.d. for three more days. 2. MS Contin 50 mg q. 12 h. as before. 3. Senokot-S one b.i.d. PLAN: Follow-up appointment with Dr. _%#NAME#%_ in one week with a CBC and to discuss further cancer treatment..
MS|morphine sulfate|MS|111|112|PLAN|Her catheter has been replaced and appears to be draining well at this time. PLAN: 1. She will be continued on MS Contin, using intravenous morphine for breakthrough pain over the next 24 hours. 2. If her pain does not improve, a repeat abdominal CT scan will be considered to evaluate her liver disease and to look for other possible causes for her increasing abdominal symptoms.
MS|morphine sulfate|MS|195|196|HISTORY OF PRESENT ILLNESS|He is also known to have pain management issues currently following by interventional pain clinic, by Dr. _%#NAME#%_ who haw been managing his medications in this regard which apparently include MS Contin in addition to Percocet for break-through pain. _%#NAME#%_ as usual rambles a bit. He is unable to provide real detailed history but he does answer questions, what appears to be appropriately.
MS|morphine sulfate|MS|195|196|PLAN|5. Pain control issues. PLAN: 1. Update INR, hemoglobin and potassium from laboratory standpoint. 2. Hemodialysis today. 3. Stump film and evaluation by orthopedic surgery. 4. Pain control using MS Contin and IV morphine for break-through pain.
MS|morphine sulfate|MS|223|224|DISCHARGE MEDICATIONS|After extensive discussion with the patient, his wife and children, we opted for comfort measures, and he was discharged home to continue with hospice care to try to maintain some quality of life. DISCHARGE MEDICATIONS: 1. MS Contin 50 mg in the evening and morphine immediate as needed for breakthrough pain. 2. Celexa 40 mg daily. 3. Lasix 40 mg daily.
MS|morphine sulfate|MS|143|144|DISCHARGE MEDICATIONS|2. History of chronic lymphocytic leukemia (CLL). 3. Hypertension. DISCHARGE MEDICATIONS: 1. Decadron 4 mg q.i.d. 2. Dilantin 300 mg q. day 3. MS Contin 60 mg b.i.d. 4. Celexa 20 mg q. day 5. Clonidine patch 6. Lactulose 7. Senokot S Follow-up appointment with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_; with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_.
MS|morphine sulfate|MS|218|219|CURRENT MEDICATIONS|She has been told that if she continues to have pain that she would be a candidate for a fusion of her back but she wants to hold off until she has more children. CURRENT MEDICATIONS: 1. Diazepam 10 mg twice a day. 2. MS (morphine sulfate) Contin 30 mg three tablets twice a day (for 90- mg twice a day). 3. Morphine sulfate immediate release (IR) 60 mg two- or four-times a day to relieve pain.
MS|morphine sulfate|MS|293|294|HOSPITAL COURSE|Abdominal x-ray just showed some nonspecific air fluid levels. She was admitted then with diagnosis of recurrent hemorrhagic colitis, UTI, and her known underlying schizophrenia. Dr. _%#NAME#%_ _%#NAME#%_ admitted her, checked for C. difficile, placed her on Ultram, trazodone, Neurontin, and MS sulfate for pain, Zofran for nausea, and gave her Solu-Medrol IV t.i.d. along with Cipro and Flagyl. GI consultation was obtained. Dr. _%#NAME#%_ saw her and did endoscopy of the colostomy site.
MS|multiple sclerosis|MS|143|144|HISTORY OF PRESENT ILLNESS|He has been treated with copaxone for 1-2 years in the past and may restart this to stabilize his condition. The patient has a history of some MS in the family, apparently in uncle. The patient is disabled and on disability. He does have depression and takes Prozac for this.
MS|morphine sulfate|MS|247|248|PLAN|A semi-conservative course is going to be undertaken until we can get formal Transitions And Life Choices (TLC) involvement in this case. I am going to give her some fluid aggressively and transfuse her with 2 units of packed cells. We will start MS Contin for pain control and continue her routine medicines as tolerated. I am hopeful with some normal saline and a repeat of her blood work overnight that her sodium will correct and her hemoglobin will come upwards to the point where she starts to feel better.
MS|morphine sulfate|MS|84|85|MEDICATIONS|10. Fluoxetine 10 mg every day 11. Potassium chloride 12. Ritalin 2.5 mg b.i.d. 13. MS Contin 15 mg b.i.d. ALLERGIES: None. SOCIAL HISTORY: She currently resides at a nursing home with plans to eventually go home, however, she has declined in performance status further.
MS|morphine sulfate|MS|172|173|ADMISSION MEDICATIONS|3. Lovenox 40 mcg subcutaneously daily for deep venous thrombosis prophylaxis (this may be discontinued as his activity level increases). 4. Flexeril 10 mg p.o. q. 6 h. 5. MS Contin 30 mg p.o. q. 12 h. 6. Percocet 5/325 one or two tablets p.o. q. 4 h. p.r.n. breakthrough pain. 7. Ceftriaxone 2 gm IV q. 24 h. x 4 weeks.
MS|morphine sulfate|(MS|133|135|ASSESSMENT AND PLAN|He will be wearing his TLSO brace. 2. Chronic back pain with exacerbation secondary to recent infection. He is on long-acting agents (MS Contin) as well as medications for rescue purposes (Percocet). We will continue to monitor his bowel pattern and his pain management with these agents.
MS|multiple sclerosis|MS|143|144|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Multiple sclerosis diagnosed 44 years ago. The patient is nonambulatory at baseline. 2. Neurogenic bladder related to MS with chronic Foley catheter. 3. Frequent urinary tract infections. 3. Bed sore on patient's coccyx. 4. Hysterectomy. 5. Tonsillectomy. 6. Status post tubal ligation.
MS|multiple sclerosis|MS|209|210||She is having problems with bowel activity as well. It became apparent that she was in need of going over from head to foot. Steroids are difficult for her tolerate and thus they are not contemplated, but the MS in combination with everything else has impaired her ability to function. Thus a short admission was contemplated and she is admitted to the hospital with difficulties in the above mentioned spheres.
MS|multiple sclerosis|MS,|120|122|HISTORY OF PRESENT ILLNESS|They are having difficulty waking her in the morning because she is so sleepy. She does have profound weakness from her MS, but over the past few days has been even more weak and tired. She receives total cares because of her MS. She has minimal use of her arms and no use of her legs.
MS|morphine sulfate|MS|159|160|CURRENT MEDICATIONS|14. Vicodin as needed. 15. DuoNeb q.i.d. 16. Two dry dressings on his left knee scab and right knee scab area. 17. Bactrim DS 1 tablet b.i.d. for 2 weeks. 18. MS Contin 30 mg orally once daily. 19. Levaquin 500 mg orally once daily for another 2 days. PAST MEDICAL HISTORY: Is significant for COPD, osteomyelitis, anxiety, insomnia, tuberculosis in the past, right hemiparesis from an old CVA, atrial fibrillation, hypertension, depression, recent MI, peripheral vascular disease.
MS|morphine sulfate|MS|128|129|HOSPITAL COURSE|At the time of admission, the patient did not complain of any radicular symptoms. HOSPITAL COURSE: He was admitted and begun on MS Contin 15 mg. q8. He was also given Valium 10 mg Q8 for spasm. He had on two occasions, break through pain of intravenous morphine, however, by the time of discharge, he was able to ambulate fairly comfortably.
MS|multiple sclerosis|MS|108|109|HISTORY OF PRESENT ILLNESS|She has had this blurred vision for about a week. She states that whenever she does get exacerbation of her MS it usually presents with blurred vision as well as weakness. However, she states that no new weakness is noted. Initially admitted for diarrhea, however, she has not had a bowel movement for the last 6 days and has complaints of abdominal pain.
MS|morphine sulfate|MS|139|140|DISCHARGE  MEDICATIONS|She is being transferred to N C Little. DISCHARGE MEDICATIONS: Their standing orders plus Synthroid 0.125 mg daily, while taking p.o., and MS Contin 90 mg one q. 8 hours with Roxanol 1/2 to 1 mL q. 2 hours p.r.n. pain.
MS|multiple sclerosis|MS|178|179|MEDICATIONS|DISCHARGE CONDITION: Stable. DISCHARGE DISPOSITION: Discharged to home. MEDICATIONS: 1. Prilosec 40 mg p.o. b.i.d. for 2 weeks. 2. Prilosec 40 mg p.o. daily indefinitely. 3. Her MS drugs per prescribing physician. INSTRUCTIONS: The patient is to continue her soft puree diet.
MS|morphine sulfate|MS|224|225|HISTORY OF PRESENT ILLNESS|Benzodiazepines, barbiturates, and opiates were her drugs of choice. Patient has had multiple treatments in the past. She has had difficulty finding long-term sobriety. Lately, she has been using Fiorinal No. 3, Valium, and MS Contin. PAST MEDICAL HISTORY: She had a past history of sarcoidosis, depression, and a gastrectomy. HOSPITAL COURSE: Patient was started on Catapres for her opiate withdrawal and phenobarbital for benzodiazepine withdrawal.
MS|morphine sulfate|MS|153|154|PLAN|We will continue with pain control and follow with left arm and shoulder pain, which is probably a post herpetic neuropathy. We will continue Neurontin, MS Contin, and morphine sulfate acting for breakthrough pain. We will continue with current immunosuppressive medications, with above medications.
MS|morphine sulfate|MS|119|120|MEDICATIONS|She does remain on MS Contin as well as Dilaudid p.r.n. for breakthrough pain. Neurologic is negative. MEDICATIONS: 1. MS Contin. 2. Prozac. 3. Colace. 4. Prevacid. 5. Senokot. 6. Prempro. 7. Hydromorphone. SOCIAL HISTORY: She is divorced. She has no children. She smoked approximately two packs of cigarettes a day; however, she did discontinue this several years ago.
MS|morphine sulfate|MS|156|157|PLAN|Also, in the future she is definitely a candidate for Forteo since she had the recent fractures despite minimal trauma and regular use of Fosamax. Will use MS Contin here in the hospital for pain control. Will have Social Services see her since she will likely need transitional care.
MS|morphine sulfate|MS|89|90|MEDICATIONS|3. Osteoporosis. 4. Status post tonsillectomy. 5. Status post appendectomy. MEDICATIONS: MS Contin 30 mg p.o. b.i.d., Prozac, Senokot, Milk of Magnesia, Aredia. ALLERGIES: Fosamax, Evista, Prempro. HABITS: The patient smoked two packs of cigarettes per day for 50 years, for a 100 pack year smoking history, but quit smoking in 1996.
MS|morphine sulfate|MS|139|140|MEDICATIONS|5. Ambien 10 mg h.s. 6. Renal Softgel Vitamin. 7. Lantus insulin, dose unknown. 8. Humalog insulin, according to his own sliding scale. 9. MS Contin 30 mg tabs 5 per day for chronic total body pain. FAMILY HISTORY: His mother and his father are deceased, causes unknown.
MS|morphine sulfate|MS|131|132|DISCHARGE MEDICATIONS|3. Lopressor 50 mg twice a day for blood pressure. 4. ___________ for constipation. 5. Zantac twice a day for stomach problems. 6. MS Contin 30 mg p.o. t.i.d. 7. Liquid morphine 10-15 mg q 2 p.r.n. 8. Levaquin 250, one p.o. b.i.d. x7 days. The patient is being discharged to _%#CITY#%_ _%#CITY#%_ Nursing Home.
MS|morphine sulfate|MS|137|138|DISCHARGE MEDICATIONS|4. Synthroid 112 mcg p.o. daily. 5. Lisinopril 10 mg p.o. daily. 6. Milk of Magnesia 30 cc p.o. each day at bed-time for constipation 7. MS Contin 30 mg p.o. q.12h. 8. Multivitamin 1 p.o. daily. 9. Potassium 10 mEq p.o. b.i.d. 10. Maxzide 37.5/25 1 p.o. daily.
MS|multiple sclerosis|MS|132|133|HISTORY OF PRESENT ILLNESS|She had broken her ankle in _%#MM#%_ at MS camp and had worsening of her previous symptoms in _%#MM#%_. Her current regimen for her MS is Rebif Monday, Wednesday, and Friday and 1 gram of methylprednisolone p.o. every month. This had been working previously; however, she feels that her symptoms return before her next dose of methylprednisolone is due.
MS|multiple sclerosis|MS.|148|150|FAMILY HISTORY|FAMILY HISTORY: Father died at 86, had questionable coronary artery disease and questionable prostate cancer. Mother died at 71 of complications of MS. She has no siblings. REVIEW OF SYSTEMS: GENERAL: Her weight has actually gone up since her surgery in 1995.
MS|musculoskeletal|MS|187|188|PHYSICAL EXAMINATION|LUNGS: Clear to auscultation bilaterally. ABDOMEN: Right subcostal old incision, supple, non- tender, non-distended, no organomegaly. SKIN: No rashes. NEUROLOGIC: Alert and oriented x 3, MS 5/5 distal proximal left and right upper and lower. Deep tendon reflexes are positive throughout. CTR 0, indifferent. LABORATORY DATA: EKG: negative T-waves in leads 3 and aVF, none significant.
MS|morphine sulfate|MS|174|175|CURRENT MEDICATIONS|5. Dilantin has been 125 p.o. b.i.d. 6. She has been changing from Wellbutrin to Effexor, the specific dose I do not have. 7. Duragesic patch 450 micrograms every 3 days. 8. MS Contin 15 mg twice a day. 9. Prevacid 30 mg a day. 10. Kytril for nausea, once or twice a day. 11. Leucovorin 25 mg four times per day. ALLERGIES: None are listed, and the patient reports none Other chronic medical problems - the patient denies anything, but she is a little slow in her answers.
MS|multiple sclerosis|MS|142|143|FOLLOW UP|He notes the major stressors as being a contentious divorce situation with his wife. _%#NAME#%_ 's past medical history is remarkable for: 1. MS diagnosed approximately four years ago for which he is followed by Dr. _%#NAME#%_. He notes primarily having generalized fatigued as well as lower extremity spasticity.
MS|morphine sulfate|MS|314|315|HOSPITAL COURSE|The Pain Management service thought the patient possibly could be having nausea, vomiting and pain related to withdrawal of his narcotic medications; he had apparently been transferred from the VA on 100 mg b.i.d. of MS Contin and this had not been continued at the nursing home. He was therefore restarted on his MS Contin 100 mg p.o. b.i.d. The patient's stool C. diff cultures and routine cultures came back negative. He was initially placed, because of his high white count, on Tequin and Flagyl.
MS|morphine sulfate|MS|190|191|HISTORY OF PRESENT ILLNESS|Temperature normal. After Narcan 0.4 mg IV, the patient became alert with subsequent withdrawal symptoms manifested by recurrent nausea and vomiting. This subsided following Zofran 4 mg and MS 4 mg IV. She has subsequently been somnolent but arousable. Stable hemodynamics and pulmonary status. She arouses with ability to appropriately answer questions. She indicates prior history of depression without prior hospitalization.
MS|multiple sclerosis|MS.|159|161|FAMILY HISTORY|She has two sisters who are twins, 10 years older, alive and well. One brother who is 15 years older, alive and well. One brother who is 8 years older who has MS. HABITS: No tobacco of late, no significant alcohol intake. SOCIAL HISTORY: Single mother of two children.
MS|morphine sulfate|MS|317|318|DISCHARGE MEDICATIONS|8. Vioxx 25 mg daily. 9. Senokot tablets one to three b.i.d. and hold for loose stools. 10. The patient has MS Contin and it will be tapered as follows: On _%#MMDD2004#%_, MS Contin 15 mg p.o. q.8h. This will continue until _%#MMDD2004#%_, when MS Contin will be decreased to 15 mg p.o. q.12h. On _%#MMDD2004#%_, the MS Contin will be decreased to 15 mg p.o. q.a.m. x 2 days, then will be discontinued. 11. Codeine 90 mg p.o. q.4h p.r.n. for pain.
MS|multiple sclerosis|MS.|144|146|FAMILY HISTORY|8. Genfiber q. day. 9. Senna two tablets q. day p.r.n. 10. Sorbitol solution b.i.d. FAMILY HISTORY: Father died of bladder cancer; brother with MS. SOCIAL HISTORY: Occasional alcohol use; lives with a cat in assisted living.
MS|morphine sulfate|MS|242|243|CURRENT MEDICATIONS|She takes MS Contin for this. 5. Recent diagnosis on _%#2004#%_ of glucose intolerance. 6. Status post hysterectomy. CURRENT MEDICATIONS: Celexa, 20 mg/day for recent diagnosis of depression; lisinopril/ hydrochlorothiazide 20/25 once a day; MS Contin, 30 mg, 1 p.o. b.i.d.; Ultram, 50 mg, 2 q.i.d. p.r.n.; Feldene, 10 mg p.o. b.i.d.; Premarin, 1.25 mg once a day, and Zocor, 20 mg once a day.
MS|morphine sulfate|MS|140|141|DISCHARGE MEDICATIONS|3. Xalatan eyedrops 0.005% one drop in both eyes q. day. 4. ______ 2 tabs q. day. 5. Nephrocaps 1 tab q. day. 6. Prednisone 5 mg q. day. 7. MS Contin 60 mg t.i.d. 8. Phoslo one tablet q. with meals. 9. Actonel q. week. 10. Heparin 5,000 units subq q. 8 hours until ambulating well.
MS|morphine sulfate|MS|139|140|DISCHARGE MEDICATIONS|3. Protonix 20 mg a day. 4. Senna 1 tablet b.i.d. 5. Colace 100 mg b.i.d. 6. Lexapro 5 mg at bedtime. 7. Zofran 8 mg p.o. q. 8h. p.r.n. 8. MS Contin 45 mg b.i.d. 9. Compazine 10 mg q. 6h. p.r.n. 10. Sutent 50 mg each day at bedtime with a plan 30 day course.
MS|multiple sclerosis|MS.|125|127|FAMILY HISTORY|Father deceased at 82 of emphysema. There are no brothers. She has four sisters. One of them is diabetic and another one has MS. Her other sisters have problems with depression. There is a family history of heart trouble on both sides of her ancestry. PHYSICAL EXAMINATION: The patient is a pleasant, almost 56- year-old female.
MS|morphine sulfate|MS|163|164|DISCHARGE MEDICATIONS|4. Colace 100 mg p.o. twice a day. 5. Prevacid 30 mg p.o. once a day. 6. Multivitamin 1 p.o. q.d. 7. Zonegran 100 mg p.o. q.d. 8. Citrucel 1 packet p.o. t.i.d. 9. MS Contin 15 mg p.o. twice a day. 10. Baclofen 15 mg p.o. 4 times a day. 11. Therevac mini-enema 1 p.r. q.o.d. 12. Valium 2 mg p.o. 4 times a day.
MS|morphine sulfate|MS|171|172|DISCHARGE MEDICATIONS|His mucous membranes hurt in his mouth. Denies anything with the urinary tract. No dysuria, hematuria, and so forth. He was admitted to the ER here. Since 1850 he has had MS 5 mg IV three times and states he still has horrible pain in the legs. He had Benadryl 25 mg IV and was started on clindamycin 900 mg IV.
MS|multiple sclerosis|MS,|115|117|PAST MEDICAL HISTORY|The patient was admitted for the Neurology Service for further workup for his complaints. PAST MEDICAL HISTORY: 1. MS, diagnosed 7 years ago. 2. Status post appendectomy. 3. Hyperlipidemia. 4. Syncopal episode. 5. Depression. 6. History of polysubstance abuse. ALLERGIES: No known drug allergies.
MS|morphine sulfate|MS|115|116|DISCHARGE INSTRUCTIONS|1. Aspirin 81 mg daily. 2. Carvedilol 25 mg b.i.d. 3. Lanoxin 125 mcg p.o. daily. 4. Diltiazem ER 180 mg daily. 5. MS Contin 60 mg q.12h. 6. Protonix 20 mg p.o. daily. 7. Zocor 5 mg p.o. q.h.s. 8. Colace 100 mg p.o. b.i.d. 9. Senokot 1 tab p.o. b.i.d. 10. Albuterol inhaler 2 puffs inhaled q.4h. p.r.n.
MS|morphine sulfate|MS,|117|119|ALLERGIES|11. Levemir 10 units at bedtime. 12. Potassium chloride 20 mEq twice daily. ALLERGIES: Codeine, penicillin, Vicodin, MS, Naprosyn, Lisinopril. FAMILY HISTORY: Significant for father died of MI at 60.
MS|morphine sulfate|MS|246|247|MEDICATIONS ON ADMISSION|5. Temazepam 15 mg q.h.s. 6. Multivitamin 7. Oxycodone 5 mg two to four tablets every three hours, which the patient last took on Friday morning 8. Lorazepam 0.5 to 1 mg q.8h. p.r.n. 9. Compazine 10 mg p.o. p.r.n. 10. Zofran 4 mg p.o. p.r.n. 11. MS Contin 60 mg p.o. t.i.d. This was last taken on _%#MMDD#%_ at night. 12. Ibuprofen 400 mg p.o. p.r.n. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 130/90, heart rate 80, temperature 98.7. GENERAL: Middle-aged woman looking chronically ill and comfortable.
MS|morphine sulfate|MS|242|243|HOSPITAL COURSE|3. Chronic shoulder and other pain and respiratory distress. The patient was maintained on his usual long-acting morphine and we played around a little bit going up on the dose but he did not like it, so we ended up with him back on 45 mg of MS Contin. Vicodin added with fairly good control. 4. Bipolar disorder. Patient was relatively stable throughout this stay. He was seen in consultation by psych who elected to go down on his Klonopin from 2 down to 1 1/2 and to start him on a good dose of Seroquel at bedtime to help with sleep.
MS|multiple sclerosis|MS|172|173|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 42-year-old woman with relapsing/remitting multiple sclerosis admitted for an acute exacerbation. _%#NAME#%_ has had MS since 1990 with particularly aggressive disease. More recently she developed an acute cerebellar syndrome with multiple falls at home. Previous exacerbations have shown incomplete recovery and a poor response to corticosteroids.
MS|morphine sulfate|MS|138|139|HOSPITAL COURSE|The patient is willing and receptive to psychiatric care and does agree that this may be a large based component to his chronic pain. His MS Contin was increased to 30 mg p.o. q.12h. per the pain consultant and the patient will be using Tylenol on a p.r.n. basis for pain control.
MS|morphine sulfate|MS|162|163|MEDICATIONS|9. Celexa 10 mg p.o. daily. 10. Vicodin 1-2 tabs every 4 hours p.r.n. 11. Compazine 5 mg every 4-6 hours p.r.n. nausea. 12. Lovastatin 20 mg p.o. at bedtime. 13. MS Contin 15 mg p.o. q. 12 hours. 14. Simethicone 80 mg p.o. 4 times daily. p.r.n. 15. Tylenol p.r.n. SOCIAL HISTORY: He is a retired military officer.
MS|multiple sclerosis|MS|173|174|HOSPITAL COURSE|An extensive neurologic workup was negative except as I previously mentioned with the MRI. She was transferred then to the University from an outside hospital with possible MS versus acute demyelinating encephalomyelitis. During her stay in the hospital, she was seen by Neurology, Cardiology and Psychiatry. Depression was ruled out. She had an echocardiogram which was normal.
MS|morphine sulfate|MS|134|135|HOSPITAL COURSE|HOSPITAL COURSE: The patient was admitted for IV fluids and received several liters. He received cipro 400 and Flagyl IV. He received MS for pain. He developed no nausea or vomiting and was passing gas. He was maintained on clear liquids. He was seen in consultation by Dr. _%#NAME#%_ and recommended continuing medical therapy with workup as outpatient to determine the extent of his diverticular disease.
MS|morphine sulfate|MS|214|215|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|She was brought to the Emergency Department and admitted for what seems to have been a seizure and further management. Her hospital course included a neurology consult and MRI was done which showed no flare ups of MS or evidence of acute stroke. It was felt that she had most likely had a seizure and postictal _%#NAME#%_'s paralysis.
MS|morphine sulfate|MS.|194|196|FAMILY HISTORY|7. Urinary retention 8. Fall with compression fracture _%#MMDD2002#%_. 9. Chronic obstructive pulmonary disease unknown baseline pulmonary functions. FAMILY HISTORY: Father died of TB, also had MS. SOCIAL HISTORY: No alcohol, no tobacco, married. ALLERGIES: No known drug allergies.
MS|morphine sulfate|MS|64|65|HOSPITAL COURSE|15. Lomotil 1 tablet p.o. q.h.s. 16. Zoloft 50 mg p.o. q.d. 17. MS Contin 15 mg p.o. q.d. 18. Morphine sulfate liquid 1 to 2 ml q.1 to 2h p.r.n., max dose t.i.d.
MS|multiple sclerosis|MS.|199|201|REVIEW OF SYSTEMS|Cardiac- no palpitation, no chest pain. Gastrointestinal -no diarrhea, constipation- melena or hematochezia. Genitourinary - no hematuria, frequency of urination, nocturia. Neurological - history of MS. No recent problems or symptoms related to the disease. Musculoskeletal - some occasional pain in the intercostal muscles due to cough.
MS|multiple sclerosis|MS|280|281|HOSPITAL COURSE|LABORATORY STUDIES: On admission, notable for a sodium of 150, otherwise unremarkable. A lumbar puncture from _%#MM2002#%_ had positive oligoclonal bands, and serum IgG of 1280, and CSF IgG of 4.1. HOSPITAL COURSE: The patient was admitted, and felt to have what was possibly and MS flare, although her main complaints were headache and eye pain, as well as recent diplopia. She was started on IV Solu- Medrol as well as pain medications, which during this hospitalization included Ultram, ibuprofen, Dilaudid, and Vicodin.
MS|multiple sclerosis|MS|183|184|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: 1. Vertigo and Bell's palsy. Unclear etiology. Will check MRI and MRA of brain and brain stem to rule out cerebellar infarct and to further evaluate for possible MS or underlying neurologic disease as well as to rule out possible mass lesion. Will consult neurology for further evaluation and treatment. We will treat the patient symptomatically with scheduled Zofran and prn.
MS|multiple sclerosis|MS.|98|100|HOSPITAL COURSE|She was started on Maxzide 37.5/25 mg po q d in addition to her Cozaar and Norvasc. 3. History of MS. Tobacco decreased, she was counseled to quit. She was interested in nicotine patches. She will be discharged to home on a nicotine patch taper.
MS|morphine sulfate|MS|139|140|ASSESSMENT AND PLAN|Will obtain a baseline EKG. 4. Deconditioning: The patient will be evaluated by PT and OT. 5. Pain control: This seems to be adequate with MS Contin of 30 mg b.i.d. and Neurontin 300 mg b.i.d. 6. Gastroesophageal reflux disease prophylaxis: Continue the Protonix 40 mg t.i.d.
MS|morphine sulfate|MS|202|203|HOSPITAL COURSE|The patient also has a significant history of seizure activity secondary to radiation therapy and brain metastasis, and has been maintained on Topamax and Dilantin for that. For pain, he had been using MS Contin 15 mg in the morning, 30 mg in the evening, and Percocet as needed with the occasional methocarbamol.
MS|morphine sulfate|MS|264|265|ADMISSION DIAGNOSIS|She was hemodynamically stable, her pain was well controlled, and she passed physical therapy to go home on _%#MM#%_ _%#DD#%_, 2004. DISCHARGE MEDICATIONS: She should continue her normal medications and add Vicodin 1-2 p.o. q.4-6 hours p.r.n. pain, 80 were given; MS Contin 75 mg p.o. t.i.d. for 1 week and then she will resume her normal 60 mg p.o. t.i.d. at that time.
MS|morphine sulfate|MS|108|109|DISCHARGE MEDICATIONS|2. Constipation due to analgesia, resolved 3. Fever, resolved. Cultures negative. DISCHARGE MEDICATIONS: 1. MS Contin increased to 60 mg q.8h. 2. Decadron 4 mg b.i.d. 3. Zofran as needed in addition to his preadmission medications.
MS|multiple sclerosis|MS|264|265|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 27-year-old female with 3-1/2 year history of multiple sclerosis admitted to Fairview Ridges on _%#MMDD2007#%_ with a 48-hour feeling of nausea, illness and felt to have a viral syndrome, mild dehydration and MS exacerbation. MRI of her head revealed no change, negative UA, negative pregnancy test. Neurology consult obtained who felt she may have labyrinthitis or complicated migraines, but not consistent with MS exacerbation.
MS|multiple sclerosis|MS.|388|390|SOCIAL HISTORY|PAST MEDICAL HISTORY: Pertinent for MS, major depression, gastroesophageal reflux, status post right radial head fracture treated with reduction and fixation in 2005. SOCIAL HISTORY: Socially, the patient is married, on disability. Has 2 children, ages 1 and 3, was ambulating independently, performing ADLs independently, does have a cane and a walker, she would use for flareups of her MS. HOSPITAL COURSE: The patient was seen by Psychiatry during this hospital stay.
MS|multiple sclerosis|MS,|84|86|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 49-year-old patient with extensive history of MS, who has been followed by the _%#CITY#%_ Clinic of Neurology. Has been unable to get his recommended beta serone for 3 months due to insurance refusal to cover it.
MS|multiple sclerosis|MS|176|177|HISTORY OF PRESENT ILLNESS|He has again the _%#CITY#%_ Clinic of Neurology and he was strongly recommended to be on this medication. His partner _%#NAME#%_ and he have noted gradual deterioration of his MS including increasing incoordination, i.e. recurrent falls and mental status changes, i.e. worsening confusion for the past several weeks to the point where he cannot be taken care of at home or take care of himself even with assistance.
MS|morphine sulfate|MS|134|135|DISCHARGE MEDICATIONS|8. Calmoseptine ointment to skin, applied to burn sites q.i.d. p.r.n. pain and to _____ b.i.d. scheduled. 9. Zanaflex 8 mg t.i.d. 10. MS Contin 60 mg p.o. q. 5h. a.m., q. 1300, q. 2100. 11. Oxycodone 15-30 mg p.o. q. 4h. p.r.n. breakthrough pain. 12. Ventolin 2 puffs q. 4h. p.r.n.
MS|morphine sulfate|MS|110|111|DISCHARGE MEDICATIONS|3. Albuterol 2.5 mg neb q. 4h. p.r.n. 4. Vistaril 25 to 50 mg p.o. q. 6h. p.r.n. 5. Sliding scale insulin. 6. MS Contin 15 mg p.o. b.i.d. 7. Vicodin one to tabs p.o. q. 4-6h. p.r.n. breakthrough pain. 8. FE S04 325 mg p.o. t.i.d. 9. Colace 100 mg p.o. b.i.d. DISCHARGE FOLLOW-UP: 1. The patient will be discharged to a transitional care unit for rehab.
MS|morphine sulfate|MS|152|153|ASSESSMENT, PLAN|ASSESSMENT, PLAN: 1. Narcotic toxicity. Patient gradually clearing per comparison from the ERs report as to how she was initially. Will discontinue the MS Contin, start regular scheduled Tylenol. Give the patient Vicodin p.r.n. pain as well, but will have to exercise caution regarding how much of this we use.
MS|UNSURED SENSE|MS|342|343|OPERATIONS/PROCEDURES PERFORMED|The patient was admitted to primary low transverse cesarean section via Pfannenstiel on _%#MM#%_ _%#DD#%_, 2005, at 8:15 p.m. PREOPERATIVE DIAGNOSES: Nonreassuring fetal heart tracing, false date, and failure to progress. SURGEON: Dr. _%#NAME#%_ _%#NAME#%_. ASSISTANT: Dr. _%#NAME#%_. SECOND ASSISTANT : Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MS III. ANESTHESIA: Epidural. EBL: 1000 mL. URINE OUTPUT: 75 mL of clear at the end of the procedure. FINDINGS: Viable male infant in OP position, presence of meconium.
MS|morphine sulfate|MS|283|284|ADMISSION DIAGNOSIS|The patient tolerated the chemotherapy well and was discharged home on _%#MM#%_ _%#DD#%_, 2006, evening after the cisplatin flush was done, in good condition. INSTRUCTIONS AT DISCHARGE: He will continue with a regular diet and with activities as tolerated. DISCHARGE MEDICATIONS: 1. MS Contin 60 mg p.o. twice daily. 2. Senna 1 tablet p.o. 1 to 2 tablets daily as needed for constipation. 3. Compazine 10 mg p.o. q.6 hourly p.r.n. for nausea and vomiting.
MS|morphine sulfate|MS|233|234|HOSPITAL COURSE|2. Fluids, electrolytes, and nutrition. The patient was initially n.p.o. on admission but was slowly advanced after her nausea and vomiting improved. 3. Pain. She was on a PCA during this admission and will be discharged home on the MS Contin, with Celebrex and morphine elixir for breakthrough pain. 4. Cardiovascular. No issues. 5. Pulmonary. Some shortness of breath that was felt to be likely secondary to the ascites.
MS|multiple sclerosis|MS|245|246|PLAN|It is not clear exactly what that medicine was yet. PLAN: I think she needs a swallowing evaluation. Then we need to see if she has any further rehabilitation needs (she has been in a rehabilitation), and if she does want to be evaluated in the MS clinic here, we can arrange for her to get an appointment there after her medical records have been assembled for their review.
MS|morphine sulfate|MS|138|139|DISCHARGE MEDICATIONS|FINAL DIAGNOSIS: Advanced metastatic colon cancer, anorexia, malnutrition and lower extremity edema. DISCHARGE MEDICATIONS: 1. Nexium. 2. MS Contin. 3. Senokot. 4. Hytrin. 5. Tylenol with codeine. 6. Magic mouthwash. 7. Reglan. 8. Morphine instant release. 9. Compazine and Restoril. DISPOSITION: Hospice to Our Lady of Good Counsel.
MS|multiple sclerosis|MS.|161|163|HISTOR OF PRESENT ILLNESS|The medical aspects of the patient's fever spike was being managed by Medicine and felt to be either due to the UTI versus bronchial congestion secondary to his MS. The patient was also seen by ID for their recommendations. The patient was finally discharged and transferred to _%#COUNTY#%_ by stretcher on _%#MMDD2006#%_.
MS|UNSURED SENSE|MS|165|166|PLAN|Patient will have follow up appointments with his primary care physician and Psychiatry as noted. Suggest continued PT if possible. Also place patient in touch with MS Achievement Center.
MS|multiple sclerosis|MS,|197|199|FAMILY HISTORY|SOCIAL HISTORY: He is divorced. He does not smoke. He does continue to drink about five to six beers per day. FAMILY HISTORY: Reviewed; his mother may have had some hypertension and she had severe MS, and his father apparently had schizophrenia. The patient is presently unemployed but was involved in the design of medical devices. PHYSICAL EXAMINATION: VITAL SIGNS : Initial blood pressure 156/100, though diastolic is now down to about 85, pulse 77 and regular, respiratory rate 20, temperature 96.5. He is 6 feet tall, 265 pounds.
MS|morphine sulfate|MS|236|237|ONCOLOGY HISTORY|He had two cycles of ifosfamide, MESNA, and VP-16 and three cycles of Cytoxan, doxorubicin, and vincristine. Currently he is getting palliative radiation therapy. Cisplatin will be given concurrently with radiation therapy. He requires MS Contin 200 mg b.i.d. for his leg pain. PAST MEDICAL HISTORY: 1. Hypertension. 2. History of right popliteal deep venous thrombosis with extension to the superficial femoral vein.
MS|multiple sclerosis|MS,|273|275|ASSESSMENT|LABORATORY DATA: Electrolytes normal, calcium slightly low at 8.4, CPK 303, hemoglobin 12.6, white count 10,900 with left shift, glucose 114. ASSESSMENT: 1) Generalized weakness with falls, etiology unknown. Could be secondary to barbiturates, reasons for anxiety could be MS, arrhythmia. 2) Diabetes. 3) Anemia. PLAN: Will work up MRI, consider weaning off Mebaral
MS|multiple sclerosis|MS|170|171|PAST MEDICAL HISTORY|7. Right knee arthroscopy 2000 as well as left knee arthroscopy 8. Colonoscopy normal 2003 9. Eye surgery due to cross eyed as a child. 10. Hysterectomy in the 1970s 11. MS diagnosed in 1982. MEDICATIONS: 1. Prednisone, 16 mg a day, she has been on chronic steroids for some time.
MS|morphine sulfate|MS|144|145|CURRENT MEDICATIONS|3. Levsin sublingually q.i.d. prn. 4. Lomotil prn. 5. Morphine 10 mg per 5 milliliters 5-10 milliliters Q 4-6 hours prn. break through pain. 6. MS contin 60 mg Q 12 hours. 7. Protonix 40 mg PO Q day 8. Neurontin 300 mg t.i.d. 9. Topamax 25 mg b.i.d. 10. Imodium prn. 11. Vivelle dot 0.075 mg patch change twice each week.
MS|multiple sclerosis|MS.|183|185|PAST MEDICAL HISTORY|He is asymptomatic today. PAST MEDICAL HISTORY: 1. Multiple sclerosis, wheelchair bound. He has a chronic indwelling suprapubic catheter secondary to neurogenic bladder problems with MS. The multiple sclerosis was diagnosed when he was in his 20s. 2. Hypertension. 3. Depression. 4. Inflatable penile prosthesis placement in 1998.
MS|morphine sulfate|MS|183|184|CURRENT MEDICATIONS|History of heart disease, history of aortic stenosis, history of anemia. CURRENT MEDICATIONS: Ativan, Trazodone, Levaquin IV 250 mg a day, Theo-Dur 200 mg b.i.d., potassium, Imodium, MS Contin, Celexa, Allegra. She also has several p.r.n. medications. SOCIAL HISTORY: She takes one wine cooler a day. She does not smoke. She lives alone with the help of her family and visiting health care workers.
MS|morphine sulfate|MS|185|186|MEDICATIONS|He reports no fevers or sweating spells. PAST MEDICAL HISTORY: Really dominated by the history of renal cell carcinoma with treatment as outlined. MEDICATIONS: On admission included 1. MS Contin at 145 mg twice daily along with morphine sulfate for breakthrough pain. 2. Dexamethasone 4 mg three times daily. 3. Zantac 150 mg daily.
MS|multiple sclerosis|MS|149|150|HISTORY OF PRESENT ILLNESS|DOB: _%#MMDD1961#%_ CHIEF COMPLAINT: Left upper extremity weakness. HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old gentleman with advanced MS who presents with increased weakness in the left upper extremity. The patient found this alarming, which precipitated a 911 call and him being brought in to the Fairview Ridges ER for further evaluation.
MS|medical student|MS|200|201|PROCEDURE|3. Desires repeat cesarean section. 4. Delivered. PROCEDURE: Repeat low transverse cesarean section. SURGEON: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD ASSISTANTS: 1. Dr. _%#NAME#%_ _%#NAME#%_. 2. Student MS III, _%#NAME#%_. FINDINGS: Viable female infant with Apgars of 9 at 1 minute and 9 at 5 minutes, weighing 7 pounds 9 ounces, normal appearing uterus, tubes and ovaries bilaterally with dense bladder adhesions to the anterior uterine wall.
MS|morphine sulfate|MS|142|143|DISCHARGE MEDICATIONS|2. Lasix 20 mg p.o. every day. 3. Spironolactone 25 mg p.o. every day. 4. Vitamin K 5 mg p.o. every day. 5. Atenolol 50 mg p.o. every day. 6. MS Contin 15 mg p.o. twice a day. 7. Oxycodone 5 mg p.o. q.4 h. p.r.n. breakthrough pain. 8. Tylenol 325 to 650 mg p.o. q.4-6 h. p.r.n. pain.
MS|multiple sclerosis|MS.|175|177|SOCIAL HISTORY|18. Senna 1 twice daily. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient has required nursing home placement the last couple of years secondary to progressive MS. She is married. REVIEW OF SYSTEMS: Remarkable for chronic spasticity.
MS|multiple sclerosis|MS|313|314|HOSPITAL COURSE|4. We will check with orthopedics, Dr. _%#NAME#%_ as to whether he would like to see the patient postoperatively for her fibular fracture or this has healed significantly enough that follow up is not needed by orthopedics. HOSPITAL COURSE: This is an unfortunately lady who started to have more problems with her MS this past spring. Initially went to the Abbott Northwestern Hospital, where she did have steroids as well as Cytoxan and mesna without any relief or improvement.
MS|morphine sulfate|MS|118|119|DISCHARGE MEDICATIONS ARE|3. Colace 100 mg p.o. b.i.d. 4. Senna 1 p.o. b.i.d. 5. Dilantin 200 mg p.o. b.i.d. 6. Dexamethasone 4 mg p.o. q.6. 7. MS Contin 160 mg p.o. b.i.d. 8. Sorbitol 70% 30 cc p.o. t.i.d. p.r.n. constipation. 9. MS elixir 5-10 mg p.o. q.2h. p.r.n. The patient will follow up with Dr. _%#NAME#%_ in one month and will also follow up with radiation therapy for his radiation treatments.
MS|morphine sulfate|MS|182|183|DISCHARGE MEDICATIONS|She may resume a regular home diet. She will follow up with the pain team consult in the near future, she will give them a call to set this appointment up. DISCHARGE MEDICATIONS: 1. MS Contin 90 mg p.o. b.i.d., #40, no refills. 2. Percocet 1-2 tabs p.o. q.4-6h. p.r.n. pain, #40, no refills. 3. Coumadin 5 mg p.o. q.d., one month's supply, no refills, and will have the Coumadin Clinic follow her INRs for a goal range of 1.8 to 2.5 and adjust as necessary.
MS|musculoskeletal|MS|177|178|REVIEW OF SYSTEMS ON ADMISSION|Abdomen: Soft, NTND. No organomegaly. Normoactive bowel sounds. Extremities: No lower extremity edema. Lower extremity venous insufficiency. Neurologic: Alert and oriented x 3. MS 5/5. Cranial nerves II-XII intact. HOSPITAL COURSE: PROBLEM #1: Pulmonary embolism; the patient was anticoagulated with heparin. He was hemodynamically stable. The patient was started on Coumadin and was refractory to the usual dose and the dose was increased to 10 mg p.o. q.d. He is to have a follow-up INR three days after discharge.
MS|multiple sclerosis|MS|116|117|ASSESSMENT ON ADMISSION|Her lungs are clear. Her heart is in a normal sinus rhythm. Her abdomen shows a colostomy. ASSESSMENT ON ADMISSION: MS with cerebral palsy and the above-mentioned complications. HOSPITAL COURSE: The patient was admitted to the hospital for further rehabilitation, evaluation, and management.
MS|multiple sclerosis|MS|184|185|PAST MEDICAL HISTORY|She was admitted for orthopedic evaluation and treatment. PAST MEDICAL HISTORY: 1. Multiple sclerosis. Her symptoms have been stable for some time now. She sees Dr. _%#NAME#%_ for her MS cares. She does have a Baclofen pump as well as a suprapubic catheter. 2. Hypertension. 3. History of superficial phlebitis. She denies other surgeries.
MS|morphine sulfate|MS|163|164|SUMMARY|Previously she received 5 mg doses as loading few doses. Her medications were refilled. She has adequate supply of all preadmission medication. A prescription for MS Contin was given, 1-month supply.
MS|multiple sclerosis|MS|267|268|FAMILY HISTORY|Does state she has been able to quit smoking in the past, however, does not wish to have any smoking cessation aid during hospital stay as she believes she can quit on her own. FAMILY HISTORY: The patient does not know of any heart disease, diabetes, cancer or other MS in the family. On her grandfather's side, there is a history of Huntington's chorea. REVIEW OF SYSTEMS: The patient denies fevers, chills, night sweats, has not had a sore throat.
MS|morphine sulfate|MS|183|184|ASSESSMENT AND PLAN|She was discharged home to continue on outpatient therapy including Coumadin. On discharge her INR was 2.38. The patient will be discharged home on Paxil, Seroquel, Zantac, Coumadin, MS Contin 15 mg twice daily and magnesium oxide. She was instructed to follow up this Friday to have an INR rechecked, and again the following week.
MS|multiple sclerosis|MS|146|147|IMPRESSION AND PLAN|Blood culture is pending. EKG sinus tachycardia without ST-T-wave changes. IMPRESSION AND PLAN: This is a 54-year-old gentleman with a history of MS who is wheelchair bound who is admitted with chest discomfort, also with a history of urinary tract infection. 1. I will rule out myocardial infarction with serial troponins.
MS|morphine sulfate|MS.|126|128|ALLERGIES|23. Glycolax for bowels. 24. Liquibid, stopped. 25. Florinef 0.5 mg daily, had been as high as 0.5. ALLERGIES: 1. Aspirin. 2. MS. 3. EES. 4. Penicillin. 5. Tetracycline. 6. Betadine. 7. IVP dye. 8. Toradol. 9. NSAIDs. 10. Ultram. 11. Imitrex. 12. Vioxx. 13. Celebrex. 14. Suprax. 15. Keflex.
MS|multiple sclerosis|MS|235|236|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 45-year-old woman with end-stage MS who was admitted to the hospital for a deteriorating condition thought to be related possibly to sepsis. The patient, on admission, was ill with advanced MS with quadriplegia and minimal verbalization. Her neurologic condition was poor at the time of admission. HOSPITAL COURSE: The patient showed no improvement during her hospital stay.
MS|multiple sclerosis|MS|260|261|HISTORY OF PRESENT ILLNESS|2. MS. TREATMENTS: Debridement of right ischial decubitus with re-advancement of posterior thigh flap and VAC placement to donor posterior right thigh. This was done on _%#MMDD2007#%_. HISTORY OF PRESENT ILLNESS: This is as 63-year-old gentleman with advanced MS who originally presented with a persistent right ischial decubitus. This had been previously debrided and closed with a small local flap, which recurred.
MS|morphine sulfate|MS|162|163|DISCHARGE MEDICATIONS|6. Colace 100 mg by mouth twice daily. 7. Celebrex 100 mg by mouth twice daily. 8. Cymbalta 60 mg by mouth daily. 9. Neurontin 100 mg by mouth 3 times daily. 10. MS Contin, take 30 mg by mouth every morning and 60 mg by mouth every evening. 11. Zofran 8 mg by mouth every 6 hours as needed for nausea.
MS|morphine sulfate|MS|128|129|DISCHARGE MEDICATIONS|15. Humibid 800 mg p.o. t.i.d. 16. Effexor 225 mg p.o. q d. 17. Nexium 40 mg p.o. b.i.d. 18. Fluconazole 100 mg p.o. daily. 19. MS Contin 45 mg p.o. b.i.d. (new prescription was written for 180 15 mg tablets). FOLLOW UP INSTRUCTIONS: 1. He should follow up with Dr. _%#NAME#%_ in 1-2 weeks for recheck of his symptoms.
MS|multiple sclerosis|MS|200|201|LABORATORY DATA|LABORATORY DATA: Blood type is B negative, antibody screen negative, Pap smear negative, rubella immunity present, serology nonreactive, urine and hepatitis B screening negative. She declined HIV and MS AFP screening. Screening for gestational diabetes showed an elevated screen of 149 on _%#MMDD2002#%_. Ultrasound _%#MMDD2002#%_, demonstrated twin pregnancies compatible with 22 weeks 5 days and 22 weeks 6 days, both compatible with EDC of _%#MMDD2002#%_.
MS|morphine sulfate|MS|177|178|OUTPATIENT MEDICATIONS|10. History of lung cancer, status post chemotherapy. 11. Recurrent ataxia. 12. Migraine. ALLERGIES: Penicillin. OUTPATIENT MEDICATIONS: 1. Baclofen. 2. Lasix. 3. Neurontin. 4. MS Contin. 5. Protonix. 6. Dilaudid. 7. Potassium. SOCIAL HISTORY: Quit tobacco in 2007. FAMILY HISTORY: Noncontributory.
MS|morphine sulfate|MS|162|163|MEDICATIONS|3. Dulcolax 10 mg p.o. daily p.r.n. constipation. 4. Ativan 2 mg p.o. daily and 2 mg p.o. each day at bedtime p.r.n. insomnia. 5. Megestrol 400 mg p.o. b.i.d. 6. MS Contin 100 mg p.o. t.i.d. (recently increased). 7. Morphine 20 mg p.o. q. 2h. p.r.n. pain. 8. Pantoprazole 40 mg p.o. daily. 9. Senna-S 1 tab p.o. b.i.d. p.r.n. constipation.
MS|morphine sulfate|MS|130|131|MEDICATIONS|11. Zetia 10 mg daily. 12. Synthroid 0.1 mg daily. 13. KCl 40 mEq t.i.d. 14. Colace 200 mg daily. 15. MiraLax 17 grams daily. 16. MS Contin 75 mg t.i.d. 17. Slow Fe 47.5 mg daily. 18. Vancomycin 1000 mg q.48h. FAMILY HISTORY: Not really contributory.
MS|morphine sulfate|MS|165|166|PLAN|4. History of depression. Will resume her current antidepressants, which include Effexor, Lexapro, Remeron, lorazepam. 5. Chronic pain. The patient is on Neurontin, MS Contin and Oxycodone 20 mg q.4-6h. added for breakthrough pain. The patient also is requesting pain management team to see her while she is in the hospital.
MS|multiple sclerosis|MS|181|182|ASSESSMENT|He has had a CT scan which was negative for vascular disease, but he has had a partial MRI scan which shows some white matter changes that are consistent with but not diagnostic of MS or vascular disease. That MRI is not good enough to make any diagnosis with. I believe that he needs to have a workup for multifocal central nervous system disease with appropriate blood work looking for demyelination with appropriate blood work, looking for other causes that may mimic demyelination such as CADASIL, sarcoid Sjogren's, etc.
MS|morphine sulfate|MS|215|216|IMPRESSION AND PLAN|3. Hyponatremia: Will rehydrate gently with normal saline 75 an hour but will need to watch for signs of a failure. Will give him Lasix 20 mg IV daily. 4. Dementia: Refusing to eat. Discussed with daughter, use the MS p.r.n. pain, keep him DNR/DNI and comfortable. 5. Cirrhosis/ascites: Will use IV Lasix. Hold spironolactone for now. Resume lactulose when able and recheck his ammonia in the morning.
MS|multiple sclerosis|MS.|218|220|DISCHARGE MENTAL STATUS EXAMINATION|3. Multivitamin 1 tablet a day. DISCHARGE MENTAL STATUS EXAMINATION: The patient is alert, oriented, cooperative, has good grooming, good hygiene, good eye contact. The patient has bilateral hand tremor secondary from MS. The patient has euthymic mood, congruent affect. Speech was linear. Thought process is logical. Speech is normal in rate, rhythm, volume, clear and coherent and spontaneous.
MS|morphine sulfate|MS|196|197|HOSPITAL COURSE|The patient also was seen in pain consultation by _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, nurse practitioner. She has had significantly improved pain control with initiation of Neurontin 100 mg t.i.d., MS Contin 30 mg b.i.d., and Lidoderm patches, 3 to the abdominal wall incision site daily. The patient will be discharged home on these medications. She was started empirically on vancomycin orally for possible C.
MS|morphine sulfate|MS|108|109|HISTORY OF PRESENT ILLNESS|He has only been taking a stool softener daily at this time. The patient is reasonably comfortable with his MS Contin 15 mg b.i.d. He does have some supplemental oxycodone to use q. 4 hours p.r.n. for pain. According to his wife, who is a reliable informant, he has not needed these on a significant basis.
MS|morphine sulfate|MS|94|95|MEDICATIONS|He does have allergic rhinitis. ALLERGIES: He is not allergic to medications. MEDICATIONS: 1. MS Contin 15 mg orally q. 12 hours. 2. Seroquel 25 mg at bedtime. 3. Talopram 20 mg orally q.a.m. 4. Myadec vitamins 1 daily. 5. Calcium with D 500 mg daily.
MS|morphine sulfate|MS|187|188|HOSPITAL COURSE|The TLC service was consulted, _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ MD. The patient had significant improvement in his pain control with the addition of Vistaril. He will continue Oxycodone, MS Contin and Neurontin at discharge. His pain was adequately controlled at discharge. DISCHARGE PLAN: The patient was discharged home. DISCHARGE MEDICATIONS: 1. Vistaril 25 mg p.o. three times daily.
MS|morphine sulfate|MS|139|140|DISCHARGE MEDICATIONS|5. Combivent 1 to 2 puffs inhaled t.i.d. 6. Aspirin 81 mg p.o. q. day. 7. Citalopram 40 mg p.o. q. day. 8. Neurontin 600 mg p.o. t.i.d. 9. MS Contin extended release 100 mg p.o. q.8 h. 10. Feldene 20 mg p.o. q. day. 11. Ranitidine 150 mg p.o. b.i.d.
MS|morphine sulfate|MS|230|231|HOSPITAL COURSE|The patient was monitored for bradycardia and hypertension. The patient did not experience any significant side effects. Precedex was subsequently terminated. The patient's pain for scleroderma was then controlled with the use of MS Contin as well as p.r.n. ketamine. These were some what effective; however, the patient still continued complaining of some pain.
MS|morphine sulfate|MS|187|188|HOSPITAL COURSE|These were some what effective; however, the patient still continued complaining of some pain. He was evaluated by the pain consult service who recommended the patient be discharged with MS Contin 100 mg p.o. q.8 , Morphine 45 mg p. o. q.2 hours p.r.n., and Effexor 150 mg p.o. q. day. Additionally, pain service recommended regular follow up with pain clinic.
MS|morphine sulfate|MS|124|125|DISCHARGE MEDICATIONS|2. Diovan 40 mg daily. 3. Gabapentin 600 mg q.i.d. 4. Furosemide 20 mg daily. 5. Senokot 2 tablets each day at bed-time. 6. MS Contin 15 mg b.i.d. 7. Docusate 1-2 tablets p.o. q.i.d. p.r.n. 8. Synthroid 75 mcg p.o. daily. 9. Valium 10 mg p.o. p.r.n. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 59-year-old woman with history of diabetes mellitus and neuropathy who was admitted on _%#MMDD2006#%_.
MS|morphine sulfate|MS,|121|123|ASSESSMENT/PLAN|ASSESSMENT/PLAN: 1. Recurrent small bowel obstruction with an exacerbation today. Will make him NPO, give him IV fluids, MS, and Zofran as needed. I do not think he needs an NG if he is not vomiting. Follow labs. 2. Hypertension. He may take his Cozaar with sips of water.
MS|morphine sulfate|MS|111|112|DISCHARGE MEDICATIONS|11. Coumadin 10 mg p.o. each day at bedtime. 12. Ambien 5 mg p.o. each day at bedtime p.r.n. for insomnia. 13. MS Contin 500 mg p.o. b.i.d. chronically for pain. 14. Short-acting morphine 10 mg p.o. q. 4 hours p.r.n. for breakthrough pain. 15. Lantus 14 units subcu b.i.d. 16. Hydralazine 50 mg p.o. t.i.d.
MS|morphine sulfate|MS|117|118|MEDICATIONS|5. Levoxyl 0.075 mg daily. 6. Multivitamin one daily. 7. Senokot 2 tabs daily. 8. Neurontin 600 mg 3 times a day. 9. MS Contin 60 mg twice daily. 10. Tylenol ES 2 tabs q.3-4h. as needed. 11. Tylenol PM, 2 tablets p.o. every h.s. as needed.
MS|morphine sulfate|MS|131|132|MEDICATIONS|5. Ultram 50 mg p.o. q.4-6h p.r.n. 6. Effexor 225 mg daily. 7. Xopenex nebulizer q.i.d. and q.3h p.r.n. 8. Cromolyn nebs q.i.d. 9. MS Contin 30 mg p.o. q.12h p.r.n. 10. Percocet 5 mg 1-2 q.4-6h p.r.n. 11. Potassium 20 mEq p.o. b.i.d. 12. Fosamax 70 mg p.o. weekly.
MS|morphine sulfate|MS|206|207|DISCHARGE FOLLOW-UP|DISCHARGE FOLLOW-UP: The patient will follow up with Dr. _%#NAME#%_ in 10 days, on _%#MMDD2002#%_ at 3 p.m. The patient will be evaluated for pain control, with consideration toward decreasing needs in her MS Contin as the radiotherapy takes effect. Additionally, the patient will be seen by Dr. _%#NAME#%_ on _%#MMDD2002#%_ at 10:30 a.m. The patient is scheduled to receive her monthly Zometa infusion on _%#MMDD2002#%_ at 2:30.
MS|morphine sulfate|MS|198|199||She works as an RN. She has a previous history of alcohol dependence but has been sober for nine years. She has a history of chronic low back pain. She has had three back surgeries. She had been on MS Contin 360 mg per day for a year. Her Pain Clinic doctor was refusing to prescribe more. There were some episodes of missed appointments and chaotic use of prescriptions.
MS|morphine sulfate|MS|165|166|DISCHARGE MEDICATIONS|14. Silver sulfadiazine cream, apply to affected area p.r.n. 15. Lidocaine jelly 2% affected area p.r.n. 16. Proshield Plus cream, apply to affected area p.r.n. 17. MS Contin 15 mg p.o. q.i.d. 18. Colace 100 mg p.o. b.i.d. 19. Senna one to two tabs p.o. b.i.d. 20. Lactulose 15 cc p.o. q.d., 2 t.i.d. 21. Morphine gel apply to affected area p.r.n.
MS|morphine sulfate|MS|191|192|PAST MEDICAL HISTORY|He has had some chronic type of pain in the abdomen as well as chronic migraine headache disease. He is has been taking Prilosec and Tylenol as well as Percocet and ibuprofen. He has been on MS Contin for chronic pain as well in the past. He is allergic to Dilaudid, gets hives from that. He also gets hives from morphine sulfate.
MS|morphine sulfate|MS|220|221|IMPRESSION|She has multiple reasons for her back pain, including osteoporosis, compression fractures and scoliosis. At this point, I suspect the patient needs IV morphine for control, and likely will require transition to possibly MS Contin with morphine elixir for breakthrough regimen. We will arrange for physical therapy/occupational therapy. We will ambulate her and see how she does.
MS|morphine sulfate|MS|114|115|MEDICATIONS|2. Flexeril 10 mg 3 times daily. 3. Meropenem 500 mg changed to every 8 hours. 4. Morphine sulfate in the form of MS Contin 15 mg extended release twice daily. 5. Protonix 40 mg b.i.d. 6. Risperdal 2 mg tablets 3 times daily. 7. Senokot S 2 tablets daily for constipation. 8. Vancomycin 1 gram q.24 h.
MS|morphine sulfate|MS|184|185|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 72-year-old patient with history of metastatic breast cancer, came to the ER with worsening right knee pain, not controlled with MS Contin or oxycodone. She "couldn't lift her leg." She has a past history of pathologic fracture of the right hip due to metastatic breast cancer.
MS|morphine sulfate|MS|169|170|DISCHARGE PLANS|She was transferred to Masonic Nursing Home with the above orders. DISCHARGE PLANS: 1. Discharged to Masonic Nursing Home, comfort care only. 2. Medications: Ativan and MS IV as needed. Valproate IV. 3. Suctioning on a regular basis. 4. Skin care, turning over in bed. 5. Follow-up with house officer.
MS|multiple sclerosis|MS|170|171|HOSPITAL COURSE|She is new to the nursing home. We have purposely stopped the Relafen and Lexapro. She will continue on Remeron but increased to 15 mg daily, iron sulfate 325 mg b.i.d., MS Contin 30 mg b.i.d., Percocet one tablet q. 4hours p.r.n., Salagen 5 mg q.i.d., prednisone 5 mg q.a.m., folic acid, Colace, and Senokot.
MS|multiple sclerosis|MS.|193|195|FAMILY HISTORY|No drugs. FAMILY HISTORY: Both parents died of heart disease in their upper 70s. One sister with "unusual cancer" of the neck recently diagnosed. One brother with severe arthritis and one with MS. Remainder of siblings and five children are healthy. REVIEW OF SYSTEMS: The patient denies constitutional complaints, HEENT or endocrine symptoms.
MS|multiple sclerosis|MS|168|169|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Multiple sclerosis diagnosed in _%#MM#%_ 2001 without a significant deficient, currently well controlled on Betaseron. 2. Seizure secondary to MS lesion. Patient had one general tonic/clonic seizure and two episodes of partial complex seizure. 3. Urinary tract infection. ADMISSION MEDICATIONS: 1. Betaseron 0.3 mg subcu.
MS|multiple sclerosis|MS.|145|147|ASSESSMENT|Lungs are clear. Heart rate is regular. Abdomen is benign. ASSESSMENT: Chronic pain of right shoulder, unclear etiology, possibly related to her MS. PLAN: Will start on a PCA pump. Hopefully, this will resolve her pain in the next few days.
MS|morphine sulfate|MS|155|156|DISCHARGE DIAGNOSES|Had severe PVD status post right femoral endarterectomy and right femoral patch angioplasty _%#MM#%_ 2002. On narcotics at home for pain control including MS Contin and morphine elixir. Patient developed confusion and visual hallucination at home. HOSPITAL COURSE: Problem #1: Mental status change.
MS|morphine sulfate|MS|179|180|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: HEENT: On examination, the patient is hard of hearing. His pupils are mid size, reactive. He did indicate that he took his morning medications including his MS Contin. Tongue moist. NECK: No bruits over his carotids. His thyroid is not enlarged or nodular. No cervical adenopathy noted. LUNGS: Clear. HEART: Rate is regular at this time as he is converted back to normal sinus rhythm.
MS|multiple sclerosis|MS|175|176|HISTORY OF PRESENT ILLNESS|ADMISSION DIAGNOSIS: Multiple sclerosis. DISCHARGE DIAGNOSIS: Multiple sclerosis. HISTORY OF PRESENT ILLNESS: The patient is a 35-year-old white female who was diagnosed with MS in _%#MM#%_ 2002. She has had a long history of balance problems, for more than two years. In the last year, in the fall, she had a tingling and numbness in her hands and her _______.
MS|morphine sulfate|MS|237|238|MEDICAITONS ON ADMISSION|3. Positive MRSA. 4. Diabetes, Type II. 5. Hypertension. 6. Post left BKA in _%#MM#%_ 2002. 7. Anemia. 8. Gastritis. MEDICAITONS ON ADMISSION: Include Zestril, Prevacid, Tylenol, Ativan, Haldol, Endocet, Duragesic patch, Metoclopramide, MS Contin, Dilaudid, insulin, Tearisol, multivitamin, vitamin C, and iron. SOCIAL HISTORY: The patient resides in Colonial Place. He has a history of extreme agitation and yelling out with ________ dementia.
MS|multiple sclerosis|MS.|174|176|PHYSICAL EXAMINATION|Extremities: no edema noted. Musculoskeletal examination: muscle strength +5/5 upper extremities. The patient has very limited movement in the lower extremities secondary to MS. Sensory is intact. LABS: White count 7.5, hemoglobin 11.2, sodium 138, potassium 3.8, BUN 13, creatinine 0.8, alkaline phosphatase 187, total bili 0.2. Free valproic acid 17.
MS|multiple sclerosis|MS.|227|229|IMPRESSION|EXTREMITIES: Without calf tenderness, Homans' sign or edema. Peripheral pulses are 1+ symmetric without bruits. IMPRESSION: 1. Mild confusion from ?dehydration and/or Vicodin 2. Several decubitus ulcerations. 3. Dehydration 4. MS. 5. Chylosis. 6. Undifferentiated anemia with increased MCV. PLAN: The patient will be treated with intravenous fluids, her urine output will be monitored.
MS|morphine sulfate|MS|103|104|DISCHARGE MEDICATIONS|He will have sitting PA and lateral x- rays of the full spine at that visit. DISCHARGE MEDICATIONS: 1. MS Contin 15 mg p.o. b.i.d. x 10 days. 2. Vicodin 1 tablet p.o. t.i.d. to q.i.d. p.r.n. after discontinuation of the MS Contin.
MS|morphine sulfate|MS|180|181|IMPRESSION|The patient is going to be started on IV Dilaudid 1 to 2 mg every three to four hours. The patient will be continued on fentanyl patch 100 mcg every 72 hours. We will start her on MS Contin 75 mg p.o. b.i.d. The patient will also be started on Zofran 8 mg IV every eight hours for p.r.n. nausea.
MS|morphine sulfate|MS|202|203|ASSESSMENT AND PLAN|I suspect that the summation of the Remeron and morphine was too much to clear, and with his somewhat compromised liver function he is not clearly medications appropriately. At this point will stop the MS Contin, use morphine elixir to prevent withdrawal if required. Halve the Remeron to 15 mg at h.s. and follow, also stop the Lexapro at this time.
MS|morphine sulfate|MS|108|109|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Coumadin 4 mg p.o. q. day taken for 2 days, then 2 mg for 2 days, alternating. 2. MS Contin 15 mg p.o. q. a.m. 3. Morphine fast-acting 10 mg q. 4 to 6 hours p.r.n. 4. Zoloft 50 mg p.o. q. h.s.
MS|multiple sclerosis|MS|212|213|ASSESSMENT AND PLAN|She has no obvious medical contraindications for proceeding with the surgical repair. However, the patient will need to be observed closely postoperatively and anesthesia will need to be given carefully with her MS in mind. It is possible that she may take a while longer to come out from the effects of the anesthesia given her MS.
MS|multiple sclerosis|MS.|144|146|FAMILY HISTORY|8. Genfiber q. day. 9. Senna two tablets q. day p.r.n. 10. Sorbitol solution b.i.d. FAMILY HISTORY: Father died of bladder cancer; brother with MS. SOCIAL HISTORY: Occasional alcohol use; lives with a cat in assisted living.
MS|morphine sulfate|MS|156|157|MEDICATIONS|She is currently unemployed and lives in Litchfield. MEDICATIONS: 1. Prevacid 30 mg 1 p.o. q.d. 2. Insulin Humalog 75/25. 3. Coumadin 0.5 mg 1 p.o. q.d. 4. MS 15 mg 1 p.o. t.i.d. 5. Celebrex 200 mg 1 p.o. q.d. 6. Magnesium and potassium supplements. 7. Nexium 1 p.o. q. day. 8. Macrobid. 9. Vitamins.
MS|morphine sulfate|MS|124|125|HISTORY OF PRESENT ILLNESS|She has been using narcotic analgesics. She was on a pain contract with her family physician and violated it. She was using MS Contin. She was obtaining it from emergency rooms. She was using more than prescribed. She was using it to get high. She admits to withdrawal symptoms when she tries to stop.
MS|multiple sclerosis|MS|170|171|HISTORY OF THE PRESENT ILLNESS|She denies alcohol. The patient used Cephalexin one month ago and has been using for the last five days due to a laceration of the hand. The patient complains of current MS attack. In the emergency room, she was given Imitrex, intravenous Solu-Medrol 125 mg, Tequin 400 mg and Albuterol nebs. SOCIAL HISTORY: The patient lives in _%#CITY#%_ _%#CITY#%_ in an apartment, disabled, watches TV all day long.
MS|morphine sulfate|MS|181|182|MEDICATIONS|3. Previous history of seizure disorder related to alcohol withdrawal in the past, also without recurrence. MEDICATIONS: From admission include: Neurontin 300 mg three times daily, MS Contin 490 mg three times daily, ibuprofen 800 mg three times daily, Senokot three pills, twice daily. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He is married and lives in _%#CITY#%_, Minnesota.
MS|morphine sulfate|MS|197|198|HOSPITAL COURSE|She mobilized on an ongoing basis and this improved over her postoperative course also. Her pain regimen at the time of discharge was modified from just Percocet and Motrin to scheduled Motrin and MS Contin was added. At the time of discharge the patient was afebrile, tolerating a regular diet, had good pain control, and was moving around the ward well.
MS|morphine sulfate|MS|284|285|PROBLEM #6|The patient's last liver function tests were running about ALT of 35, AST of 50, alkaline phosphatase of 214, and albumin of 2.4. Anemia was stable at 11.6. PROBLEM #6: Pain control. The patient had a pain in the wound area of the lower abdomen and legs. The patient was treated with MS contin 15 mg p.o. b.i.d. and breakthrough pain control with Percocet one to two tablets p.o. q6h p.r.n. The patient is clinically stable and will be discharged to home.
MS|morphine sulfate|MS|143|144|DISCHARGE MEDICATIONS|She was discharged in stable condition and was to follow-up with her primary physician. DISCHARGE MEDICATIONS: Vicodin one q.4.h. p.r.n. pain. MS Contin 15 mg p.o. q.8.h. Zofran 4 mg q.8.h. p.r.n. nausea. Ambien 10 mg at h.s. p.r.n. Valtrex 1 gm t.i.d. x5 days.
MS|morphine sulfate|MS|184|185|DISCHARGE MEDICATIONS|1. Procrit 40,000 units subq q. week. 2. Ferrous gluconate 324 mg p.o. q.d. 3. Tambocor 100 mg b.i.d. 4. Diflucan 100 mg p.o. q.d. (through _%#MMDD2003#%_). 5. Toprol XL 50 mg q.d. 6. MS Contin 60 mg b.i.d. 7. Protonix 40 mg q.d. 8. Aldactone 25 mg q.d. 9. Demadex 20 mg p.o. q.d. 10. Morphine sulfate 30-50 mg p.o. q.3h. p.r.n.
MS|multiple sclerosis|MS.|128|130|IDENTIFICATION|He does not always use a cane or walker as has been strongly suggested to him. He does have lower extremity weakness related to MS. In any event, the patient fell against a door jam, striking the left side of his head earlier today. He was noted to have profuse bleeding. In the ER, he initially was seen ...........stable. He did have significant bleeding at the time his incision was explored.
MS|multiple sclerosis|MS|148|149|HISTORY OF THE PRESENT ILLNESS|DOB: _%#MMDD2006#%_ CHIEF COMPLAINT: Status post fall and weakness. HISTORY OF THE PRESENT ILLNESS: A 76-year-old white female who has a history of MS with secondary global weakness and also polyarthritis which has not been adequately treated with Vioxx in recent weeks. She is accompanied by a care attendant that is with her six hours a week and a neighbor who calls her every morning.
MS|master of science|MS,|236|238|ASSESSMENT/PLAN|Both Drs. _%#NAME#%_ and _%#NAME#%_ have reviewed the surgery in detail with _%#NAME#%_ on several occasions. Model surgery has been done and splint constructed. Presurgical orthodontics has been done by Dr. _%#NAME#%_ _%#NAME#%_, DDS, MS, orthodontist who aligned and leveled the teeth in the maxillary and mandibular skeletal structures. Visual aids used to describe the patient to the family have included the model surgery, the Epker drawings, the plastic skull and the AAOMS booklet.
MS|morphine sulfate|MS|166|167|MEDICATIONS|He has not used narcotics chronically. MEDICATIONS: 1. Lisinopril/HCTZ, 10/12.5 q.d. 2. Aspirin, 81 mg q.d. held preoperatively. 3. Multivitamins. 4. Glucosamine. 5. MS Contin, 15 mg b.i.d. 6. Flexeril, 10 mg at h.s. p.r.n. 7. Senokot, 1 b.i.d. 8. Colace, 100 mg b.i.d. ALLERGIES: No known allergies.
MS|morphine sulfate|MS|193|194|PLAN|5. She will be started on Tequin to treat her urinary tract infection and may consider switching IV Morphine again to MS Contin, although, she may be having nausea secondary to the pain or the MS Contin. 6. If she does not tolerate oral Morphine, Duragesic patch will be reasonable based on her multiple allergies to other narcotic analgesics.
MS|morphine sulfate|MS|117|118|MEDICATIONS|5. Prednisone 15 mg daily 6. Ativan 2 mg one or two times per day 7. Folic acid 1 mg daily 8. Zoloft 100 mg daily 9. MS Contin 200 mg t.i.d. 10. Percocet 325/5 mg one to four per day 11. She also takes Neurontin 200 mg three times per day REVIEW OF SYSTEMS: HEENT - no visual problems.
MS|morphine sulfate|MS|101|102|MEDICATIONS|5. Aspirin 81 mg a day 6. Gabapentin 300 mg t.i.d. 7. Glipizide 5 mg b.i.d. 8. Lasix 40 mg Q day. 9. MS one tablet 30 mg one tablet b.i.d. 10. Lithium carbonate 300 mg b.i.d. 11. Nitroglycerin prn. 12. Prevacid 20 mg b.i.d.
MS|morphine sulfate|MS|218|219|CURRENT MEDICATIONS|5. Fusion of C4-5 in 1974 6. Status post TURP in _%#MM#%_ 2005 ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: 1. Iron supplement 2. Temazepam 3. Methocarbamol 4. Salsalate 5. Zocor 6. Propacet 7. Morphine 8. MS Contin 15 mg twice a day 9. Tylenol 10. Ibuprofen 11. Zofran 12. Lactulose 13. Dulcolax SOCIAL HISTORY: He is widowed and lives in a motor home most of the time in Arizona.
MS|multiple sclerosis|MS|181|182|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: Diagnosis at the time of discharge is that of management of progressive multiple sclerosis. This 73-year-old is a new patient to me and has primary progressive MS and has a 10-year history of spasms in the legs and pressure in her head and difficulty walking with weakness in her arms as well.
MS|morphine sulfate|MS|112|113|DISCHARGE MEDICATION|5. Advair 1 puff p.o. b.i.d. 6. Inderal 10 mg p.o. t.i.d. 7. Albuterol 1 to 2 puffs p.o. q. 4 to 6 h. p.r.n. 8. MS Contin 15 mg p.o. b.i.d. The patient will be discharged to home in stable condition.
MS|morphine sulfate|MS|188|189|MEDICATIONS|MEDICATIONS: See home medication list. 1. Vicodin p.r.n. 2. Imodium p.r.n. 3. Coumadin. 4. Multivitamin. 5. Protonix. 6. Toprol. 7. Zocor. 8. Imdur. 9. Lisinopril. 10. Fentanyl patch. 11. MS Contin. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.8, pulse 67, respiratory rate 22, blood pressure 107/67, oxygen saturation 98% on room air.
MS|morphine sulfate|MS|148|149|ASSESSMENT/PLAN|We will get him home with hospice care and try to keep him as comfortable as possible. Currently, he is on a tapering Decadron schedule, as well as MS Contin 30 mg twice daily with immediate-release morphine for breakthrough pain. Additional medications include MiraLax, Senokot, Zantac, and Compazine as needed.
MS|morphine sulfate|MS|197|198|HOSPITAL COURSE|She felt generally better over the next few days, although she developed some abdominal discomfort from constipation. The patient was also started on ibuprofen and her IV morphine was converted to MS Contin again a few days after admission. The patient's pain remained adequately controlled and she was felt ready for discharge on _%#MMDD2005#%_ with plans to follow-up with Dr. _%#NAME#%_ a few days after discharge for initiation of her chemotherapy with Alinta.
MS|morphine sulfate|MS|109|110|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Dexamethasone 10 mg p.o. three times a day. 2. Protonix 40 mg p.o. twice a day. 3. MS Contin 60 mg p.o. twice a day. 4. Casodex 50 mg p.o. every day. 5. Senokot S 2 tabs p.o. twice a day. 6. Citrucel powder 1 Tbs with 8 ounces of water three times a day.
MS|multiple sclerosis|MS|160|161||She was seen in the office and a decision was made that it had reached the stage that it required more aggressive therapy with rehabilitation and steroids. Her MS is complicated by the fact that she is also diabetic and this creates a problem with management. She has been taking over the this period of time baclofen, Zanaflex, Zoloft, Wellbutrin, glipizide, Actos, Avapro, Zyrtec, Lipitor, Pepcid, Betaseron, Mucinex, calcium citrate, and some p.r.n. Vicodin at times for pain.
MS|multiple sclerosis|MS,|98|100|IMPRESSION|Will need to get her home medication list and renew as able and as appropriate. In regards to her MS, we will ask Dr. _%#NAME#%_ to see the patient for further neurological cares. The patient does appear to have chronic kidney disease. She likely has an acute component of renal failure now likely related to prerenal causes.
MS|multiple sclerosis|MS|259|260|PLAN|PLAN: Our plan is to review her EMG and nerve conduction studies and obtain formal pulmonary function studies and a sniff test to evaluate her diaphragm function, along with a swallowing study. We will also consider whether trying to confirm the diagnoses of MS with the help of an MRI is likely to help with the current complaint (dysphagia and shortness of breath), and, if so, it may have to be done with Anesthesia's help.
MS|multiple sclerosis|MS|250|251|OPERATIONS/PROCEDURES PERFORMED|Otherwise negative. ADMISSION MEDICATIONS: None. ALLERGIES: NKDA. FAMILY HISTORY: The patient's mother passed away at age 64 of thrombophlebitis. The patient's father passed away at age 56 with an myocardial infarction. The patient has 1 sister with MS and 1 sister has emphysema. The patient also has a brother who is alive and well. A maternal grandmother had breast disease. No history of colon, uterine, or ovarian cancer.
MS|morphine sulfate|MS|177|178|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Compazine 10 mg p.o. t.i.d. 2. Colace 100 mg p.o. b.i.d. while taking opiates. 3. Protonix 40 mg p.o. b.i.d. 4. Dulcolax 1 tablet per rectum daily. 5. MS Contin 75 mg p.o. b.i.d. 6. Neurontin 600 mg p.o. t.i.d. 7. Naloxone 1 mg p.o. t.i.d. for constipation; hold for diarrhea.
MS|morphine sulfate|MS|279|280|OPERATIONS/PROCEDURES PERFORMED|The patient was then restarted on her dexamethasone and with the platelet transfusion and the resumption of the dexamethasone, the patient did not have anymore hemoptysis. DISCHARGE MEDICATIONS: 1. The patient is to have dexamethasone 4 mg p.o. t.i.d. x5 days and then b.i.d. 2. MS Contin 50 mg p.o. b.i.d. 3. Vancomycin 1 g IV q.12 h. 4. Tylenol 650 mg p.o. q.6 h. p.r.n. 5. Robitussin with codeine 10 mL p.o. q.6 h. p.r.n. for cough.
MS|morphine sulfate|MS|142|143|ADMISSION MEDICATIONS|The patient denied any fevers. She denied any chest pain or any respiratory symptoms. ADMISSION MEDICATIONS: 1. Azathioprine. 2. Remicade. 3. MS Contin. 4. Reglan. 5. Lexapro. 6. Zofran. 7. Ativan. 8. Compazine. 9. Roxanol. 10. Benadryl. 11. Miconazole. 12. Protonix. 13. Asacol. When the patient was seen in the ......Department, she was noticed to have stable vital signs.
MS|morphine sulfate|MS|155|156|MEDICATIONS|Patient denies any alcohol issues. ALLERGIES: Sulfa. MEDICATIONS: 1. Lasix 40 mg p.o. daily which she has discontinued. 2. Neurontin 600 mg p.o. q.i.d. 3. MS Contin 15 mg p.o. b.i.d. 4. Oxycodone 5 mg p.o. q.i.d. 5. Synthroid 0.025 mg p.o. daily. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.3, pulse 98, respiratory rate 16, blood pressure 134/81, sats 99% on room air.
MS|multiple sclerosis|MS,|210|212|DISCHARGE MEDICATIONS|5. Warfarin 2.5 mg p.o. daily. 6. Metoprolol 12.5 mg p.o. b.i.d. 7. Levaquin 500 mg p.o. daily for additional eight days. The patient to have followup of anemia, the patient to have followup with Neurology for MS, the patient to have followup bladder studies, IVP, urodynamic studies with Urology. The patient to have followup of microcytic, hypochromic anemia with stool studies and colonoscopy.
MS|morphine sulfate|MS|279|280|PLAN|For the open wound of the skin at the right upper chest wall, place Tegaderm over the area and watch for any changes such as purulent drainage or increasing pain. As patient has chronic pain secondary to his previous trauma and he is on multiple narcotics, will use Percocet and MS Contin for pain management and use IV morphine for breakthrough pain.
MS|morphine sulfate|MS|200|201|HOSPITAL COURSE|3. Plavix 75 mg p.o. daily, which the patient should take for 1 year after her recent stent placement. 4. Lisinopril 5 mg p.o. daily. 5. Metoprolol 25 mg p.o. b.i.d. 6. Prednisone 5 mg p.o. daily. 7. MS Contin 15 mg p.o. b.i.d. x5 days. 8. Percocet 5/325, 1 to 2 tablets p.o. q.6 h. p.r.n. for pain. FOLLOW UP: 1. The patient is to have a followup visit with her primary care physician, Dr. _%#NAME#%_ _%#NAME#%_, within 1 week of this hospitalization.
MS|multiple sclerosis|MS|223|224|HOSPITAL COURSE|Those results are described above. There is no evidence of renal stones and no evidence of hip fracture or avascular necrosis of the hip. The patient was admitted for pain control. The patient did report previous flares of MS resolving nicely with IV steroid treatment. We did decide to go ahead and give her 125 mg of Solu-Medrol IV on her night of admission.
MS|morphine sulfate|MS|182|183|HOSPITAL COURSE|This was after her pain medications had been adjusted. She apparently fell on _%#MMDD2005#%_ with new compression fractures at T6-T7, and T9 and T10. She had been given two doses of MS Contin the Thursday and Friday before admission. We had readjusted her pain medications and now she is on Dilaudid 2 mg Q 4 hours with a greater frequency than before.
MS|multiple sclerosis|MS|149|150||He denies chest or stomach pain or in the bowels. He has a suprapubic catheter, gets muscle spasms. He is paraplegic with paralysis of his legs from MS and weakness of his hands and some blurring of vision. He has had MS since 1989. PAST MEDICAL HISTORY: He does not know why he is on Naproxen, hydroxyzine or gabapentin.
MS|morphine sulfate|MS|175|176|HOSPITAL COURSE|Due to the fact the patient wants to follow up closure to home. Their serviced will not be needed at this time. On _%#MMDD2006#%_, the patient had his pain well controlled on MS Contin 30 mg p.o. q. 12hours and hydrocodone and acetaminophen 10/325 one q. 4hours p.r.n. and was to receive his third dose of radiation therapy.
MS|morphine sulfate|MS|146|147|DISCHARGE MEDICATIONS|4. Morphine sulfate immediate release 10 mg tablets p.o. q.2h. p.r.n. pain. 5. Atarax/Vistaril 25-50 mg tablets p.o. q. 4-6 hours p.r.n. pain. 6. MS Contin 15 mg extended release 1 tablet p.o. q.12h. 7. Bactrim DS 1 tablet p.o. b.i.d. total duration of 7 days. 8. Zocor 40 mg p.o. q.p.m. 9. Effexor XR 75 mg p.o. q. day.
MS|morphine sulfate|MS|136|137|MEDICATIONS|2. Fish oil 2 grams q. day. 3. Xalatan eye drops q. day. 4. Limbitrol 2 tabs q. day. 5. Nephrocaps q. day. 6. Prednisone 5 mg a day. 7. MS Contin 60 mg t.i.d. 8. Oxycodone 7.5 mg q.4h. p.r.n. 9. Aspirin 162 mg a day. 10. PhosLo one tablet with meals. SOCIAL HISTORY: The patient does not smoke or drink.
MS|master of science|MS|221|222|HISTORY|The patient is currently on antihypertensives. Surgeons will be _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, DDS MD, assisted by _%#NAME#%_ _%#NAME#%_ DDS. Pre-surgical orthodontics have been done by Dr. _%#NAME#%_ _%#NAME#%_, DDS, MS orthodontist to align and level the teeth in the mandibular and maxillary skeletal structures.
MS|multiple sclerosis|MS|60|61||_%#NAME#%_ _%#NAME#%_ is a 51-year-old female with advanced MS with a significant history of recurrent aspiration pneumonia as well as infected decubitus ulcer who was admitted through the ER to the ICU for evaluation of fever, cough, and myalgias. The patient was just discharged from this facility approximately 10 days ago after she was treated for an aspiration pneumonia and sacral decubitus ulcer.
MS|morphine sulfate|MS|199|200|CURRENT MEDICATIONS|ALLERGIES AND SENSITIVITIES: These include Compazine, Stadol, Nubain, codeine, Toradol, Imitrex, Flexeril, Robaxin, and tetracycline. CURRENT MEDICATIONS: Klonopin 1 mg, one-half to 1 mg p.o. q.h.s. MS Contin 15 mg b.i.d. Prozac 60 mg p.o. q.d. Ambien 10 mg p.o. q.d. Protonix one per day. Combivent MDI two puffs q.i.d. OBJECTIVE: Weight 84.5 pounds. Blood pressure 98/68.
MS|(drug) MS|MS|126|127|DISCHARGE MEDICATIONS|7. Albuterol 2.5-mg nebs q.i.d. 8. Nasacort 2 puffs q.d. 9. Pulmozyme 2.5-mg nebs. 10. Vitamins A, D, E and K. 11. Pancrecarb MS 7-8 tabs with meals and 4-5 tabs with snacks. 12. Tums ES 2 tabs p.o. with meals. 13. Ranitidine 150 mg p.o. b.i.d.
MS|morphine sulfate|MS|111|112|DISCHARGE MEDICATIONS|3. Neurontin 900 mg t.i.d. 4. MDI, one tablet daily. 5. Reglan 10 mg a.c. and h.s. 6. Prevacid 30 mg b.i.d. 7. MS Contin 30 mg q.12h. 8. Zofran 8 mg q.8h. as needed. 9. Senna, 1-2 tablets b.i.d. 10. Colace 100 mg b.i.d.
MS|morphine sulfate|MS|264|265|DISCHARGE MEDICATIONS|She gradually improved to the point where she was able to be discharged to follow up with her primary care doctor and rheumatology on an outpatient basis. DISCHARGE MEDICATIONS: 1. Procardia XL 60 mg daily. 2. Prednisone 30 mg daily. 3. Plaquenil 200 mg daily. 4. MS Contin 30 mg b.i.d. 5. Neurontin 300 mg t.i.d. 6. Synthroid .125 mg daily. 7. Clonidine 2 mg at bedtime. 8. Insulin NPH 17 units in the morning and sliding scale Regular insulin.
MS|morphine sulfate|MS|212|213|ASSESSMENT/PLAN|2. Pain secondary to gout and healing fractures. It is unclear if he actually had an allergy to oxycodone. However, we will continue colchicine p.r.n. for gout. Hold off on steroids secondary to infection. Start MS Contin 15 mg p.o. b.i.d. and Roxanol 10 mg p.r.n. We will titrate up if necessary. His foot does not look like it has an infection.
MS|multiple sclerosis|MS|203|204|HISTORY OF PRESENT ILLNESS|The patient had identical admission approximately one year ago in _%#MM#%_ 2006. The patient denies any recent infectious signs or symptoms, denies any recent bowel troubles. The patient states that his MS will typically have an exacerbation in response to "major stress." The patient reports that the recent holiday season was extremely difficult and bad for him, creating a lot of stress.
MS|morphine sulfate|MS|163|164|MEDICATIONS|5. Lasix 40 mg q.a.m. 6. Metoprolol 25 mg b.i.d. 7. Lopid 600 mg b.i.d. 8. Prilosec 40 mg q.a.m. 9. Senna. 10. Slo-K. 11. Neurontin 600 mg t.i.d. 12. She receives MS Contin 100 mg b.i.d. 13. Occasional Percocet. 14. Lidocaine patches. She is to follow up with her primary care provider _%#NAME#%_ _%#NAME#%_ at Health Partners _%#CITY#%_ _%#CITY#%_.
MS|morphine sulfate|MS|230|231|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|The patient was continued on a morphine drip at 2 mg/hour with 1 mg boluses for pain; with that her respiratory status is normal, however there is a considerable amount of reduction in her pain. The patient usually is on 15 mg of MS Contin at home with 5 mg Roxanol p.r.n. every two hours. It seems the patient will need more medications when she goes home.
MS|morphine sulfate|MS|156|157|DISCHARGE MEDICATIONS|2. She is to follow-up with Dr. _%#NAME#%_ in the Women's Health Clinic. DISCHARGE MEDICATIONS: She is sent home with: 1. Duragesic patch 200 mcg q.72h. 2. MS IR 25 mg p.o. p.r.n. breakthrough pain. 3. Senokot. 4. Clinoril. 5. Nystatin. 6. Tylenol with codeine elixir.
MS|multiple sclerosis|MS|132|133|HOSPITAL COURSE|Baclofen and Zanaflex were resumed once the patient was able to take p.o., and she had improvement in her spasticity. The patient's MS has been managed with azathioprine. There was some concern with regard to the immunosuppressant effects of azathioprine. The patient has been on this medication for some time and has not seen Dr. _%#NAME#%_ in neurology recently for evaluation.
MS|morphine sulfate|MS|153|154|HOSPITAL COURSE|On discharge, her creatinine had normalized to approximately 1.1. Her pain was managed with Vicodin, morphine, and morphine sulfate extended release, or MS Contin. She had difficulty sleeping. We managed this by giving her Restoril p.r.n. In terms of her heme, she was restarted on Coumadin 5 mg q.d., and her INR was checked daily until therapeutic.
MS|morphine sulfate|MS|114|115|DISCHARGE MEDICATIONS|Of note, the Percocet has worked well for her without any nausea or vomiting. 7. Of note also, she was given oral MS solution and that also seemed to work well without any nausea or vomiting, although, she has had trouble with Vicodin, codeine, and Duragesic.
MS|morphine sulfate|MS|241|242|ADDENDUM|She never got rid of the need for it. She has been on Neurontin since _%#MM#%_ because of peripheral pain. Current medications included Lanoxin 0.125 mg per day, Klor-Con 10 mEq per day, Prevacid 30 mg po b.i.d., Vicodin had been changed to MS Contin 15 mg po b.i.d., Norvasc 5 mg per day, Lasix 40 mg per day, Celexa 10 mg per day, Neurontin 300 mg q.i.d., amitriptyline 10 mg po qhs, aspirin-coated 81 mg daily - stopped, Advair 250/50 one puff b.i.d. This is a very small, elderly lady wanting to not be examined, very confused.
MS|morphine sulfate|MS|215|216|ADMISSION MEDICATIONS|PAST MEDICAL HISTORY: 1. Sickle cell disease. 2. History of left hip osteomyelitis status post total hip arthroscopy in _%#MM#%_ 2002. 3. Status post cholecystectomy. ADMISSION MEDICATIONS: Hydroxyurea, folate, and MS Contin. ALLERGIES: Demerol is oversedating. SOCIAL HISTORY: He is a student at Southwest State at _%#CITY#%_ studying marketing.
MS|morphine sulfate|MS|245|246|DOB|The patient's most recent hospitalization was _%#MMDD2003#%_, at which time with back pain that was felt to be secondary to her compression fractures and osteoarthritis of her spine. At that point she was started on chronic pain medication with MS Contin and Neurontin. The patient at present does not complain of back discomfort. She is taking the following medications: Darvocet-N 100 mg q.4-6 h. p.r.n. for pain.
MS|multiple sclerosis|MS.|181|183|REVIEW OF SYSTEMS|Cardiovascular - no chest pain, palpitations. Genitourinary - she does have neurogenic bladder noted and does do self catheterization at home. Neurological review of systems - with MS. The rest of her review of systems is unremarkable. PHYSICAL EXAMINATION: Temperature is 98.7, other vital signs are stable.
MS|morphine sulfate|MS|119|120|ALLERGIES|History of orchiopexy at 3 years of age. MEDICATIONS: Currently on Zoloft, Reglan, and Atarax. ALLERGIES: Allergies to MS resulting in nausea. FAMILY HISTORY: Negative family history. Please see prior charts for extensive workup here and at Mayo in the past.
MS|morphine sulfate|MS|155|156|REASON FOR ADMISSION|He was on Dilantin for his history of seizure. The Dilantin dose was subtherapeutic so the dose was increased. The patient also received pain medications, MS Contin with oxycodone as needed for his headache. An eye patch helped with his symptoms of double vision. The patient was evaluated by physical therapy and occupational therapy who recommended possible home physical therapy versus rehabilitation placement.
MS|mitral stenosis|MS.|128|130|PROCEDURES PERFORMED THIS ADMISSION|There is a repair of the left cleft of the mitral valve. There is no residual shunt appreciated. There is moderate MR with mild MS. The mean gradient across the mitral valve is 4 mm of mercury. RV systolic pressures estimated at 25 plus RA. There is no thrombus appreciated.
MS|morphine sulfate|MS|259|260|DISCHARGE PLANNING|DISCHARGE PLANNING: The patient was discharged to Ebenezer Luther Hall, where she probably will be switched ultimately to a palliative bed, although initially there were none of those available. Hospice care will be following her. They recommended her taking MS Contin 15 mg b.i.d., Robitussin AC as needed if she had a cough, also Benadryl as needed, Lotrimin cream for the pubic area, where she was experiencing significant itching, and they will continue to follow for palliative cares as needed.
MS|morphine sulfate|MS|95|96|DISCHARGE MEDICATIONS|There was never any focal neurologic signs. No known drug allergies. DISCHARGE MEDICATIONS: 1. MS Contin 15 mg po q8, #30. 2. Valium 10 mg tablet po q8 prn spasm, #15. 3. Prednisone 60 mg po q.a.m. X 2days and then decrease by 10 mg per day until gone.
MS|morphine sulfate|MS|135|136|PROBLEM #2|She did have a recent MRI, showing no evidence of spinal stenosis, and no metastases. She was treated conservatively for her pain with MS Contin as needed, which she takes on an infrequent basis. PROBLEM #3: Deconditioning. The patient did have a PT/OT consult, and recommendations for a TLC consult was preferred.
MS|morphine sulfate|MS|176|177|HISTORY OF PRESENT ILLNESS|The patient is going to be admitted for management of pain, nausea and vomiting. The patient states that her pain has increased in the last couple of days. She has been taking MS Contin 75 mg twice a day, as well as fentanyl patch 200 mcg. The patient has used enemas x 4 in the last 12 hours without any results.
MS|morphine sulfate|MS|250|251|HOSPITAL COURSE|Currently, the patient really cannot ambulate due to severe low back pain as well as spinal stenosis, and the family understands that he probably will not walk again. With respect to his back pain, this has markedly improved. He was initially put on MS Contin, but changed yesterday to methadone because of persistent nausea which was felt likely due to the MS Contin. The nausea has improved. He was also seen in consultation by Dr. _%#NAME#%_ _%#NAME#%_ of Oncology, and Decadron was started.
MS|morphine sulfate|MS|207|208|ASSESSMENT AND PLAN|ABDOMINAL X-RAY: Per Emergency Department revealed no free air or small bowel obstruction. Significant amount of stool. ASSESSMENT AND PLAN: The patient is a 74-year-old female with obstipation secondary to MS leading to nausea, vomiting, and mild dehydration. 1. Obstipation and mild dehydration. Will give Fleet enema, IV fluids, clear liquids overnight.
MS|morphine sulfate|MS|178|179|ASSESSMENT|ASSESSMENT: 1. Evaluation of compression fracture in lumbar area. Intractable pain. The patient has a low tolerance to metoprolol medications and so far had been in control with MS Contin. Also consult to see the patient and consider any procedures that can help to improve this fracture and consequence results which are severe pain.
MS|morphine sulfate|MS|159|160|PHYSICAL EXAMINATION|HOSPITAL COURSE: 1. Discussing with the patient and the patient's husband, we found that she had been taking quite a few narcotics at home. She had been using MS Contin and p.r.n. morphine and than was placed on methadone, as well as having multiple prescriptions for codeine, Vicodin, and Percocet at home which the husband says he is not sure if she has been taking, but has noticed that she has had these around and gone to other appointments and received further pain medications when he has not been along with these appointments.
MS|morphine sulfate|MS|151|152|ADMISSION MEDICATIONS|She also has a history of chronic back pain for which she is on chronic narcotics and a cholecystectomy. ADMISSION MEDICATIONS: Amitriptyline, Ambien, MS Contin, vitamin B12, and hyperalimentation. ALLERGIES: PENICILLIN, CODEINE, AND IBUPROFEN. HOSPITAL COURSE: On _%#MM#%_ _%#DD#%_, 2004, the patient was taken to the operating room where under general anesthesia her long-limb Roux- en-Y gastric bypass was revised to a standard Roux-en-Y gastric bypass.
MS|morphine sulfate|MS|209|210|PROCEDURES, OTHER STUDIES DONE|Likely surgery would not provide any benefit. He was then started on pain medicines, a Dilaudid PCA. He was comfortable at the time of discharge. We discharged him with Roxanol as well as Ativan and morphine, MS Contin per hospice. His code status has changed to DNR-DNI. We discussed his grave condition per the TLC note. He was made a Comfort Care patient. TLC will follow him and we appreciate their input.
MS|morphine sulfate|MS|134|135|DISCHARGE MEDICATIONS|6. Humulin 35 units subcutaneous q.a.m. and 30 units subcutaneous q.p.m. 7. MS Contin 75 mg p.o. q.8h. 8. Paxil 60 mg p.o. q. day. 9. MS morphine elixir 10 mg/5 mL to be taken p.r.n. FOLLOW UP: The patient will need to follow up with Dr. _%#NAME#%_, her primary MD in 1 week to discuss regular hospital followup.
MS|morphine sulfate|MS|131|132|MEDICATIONS ON TRANSFER|Patient was transferred on _%#MMDD2004#%_, for further evaluation and treatment at the VA Medical Center. MEDICATIONS ON TRANSFER: MS Contin 60 mg p.o. t.i.d. Toradol 30 mg I.V. q.6h p.r.n. Tylenol p.r.n. DISCHARGE DIET: Regular. DISCHARGE ACTIVITY: As tolerated.
MS|morphine sulfate|MS|131|132|CURRENT MEDICATIONS|CURRENT MEDICATIONS: See home medication sheet. They include: 1. Prilosec 20 mg p.o. q.d. 2. Docusate 100 mg p.o. b.i.d. p.r.n. 3. MS Contin 30 mg p.o. q.d. 4. Evista 60 mg p.o. q.d. 5. Ativan 0.5 mg p.o. b.i.d. p.r.n. 6. Klonopin 1 mg p.o. q.h.s. 7. Klonopin 0.25 mg p.o. q.a.m.
MS|multiple sclerosis|MS|113|114|IMPRESSION|Urinalysis today has blood, leukocyte esterase positive, 10-25 white cells. IMPRESSION: A 67-year-old woman with MS presents with myalgias and urinary tract infection. I suspect this is all urinary tract infection without sepsis and likely follows her self catheterization.
MS|multiple sclerosis|MS|196|197|HISTORY OF PRESENT ILLNESS|She has had no laboratory tests done. She is being admitted because she essentially declined to go home secondary to these severe vertiginous symptoms. When questioned about the management of her MS she states that she does it homeopathically, however, she is willing to see a neurologist if it is felt necessary during this admission.
MS|multiple sclerosis|MS,|158|160|HOSPITAL COURSE|Urine culture is still pending at time of dictation. 2. Blood cultures x2 negative, _%#MMDD2004#%_. HOSPITAL COURSE: 1. _%#NAME#%_ _%#NAME#%_ is 44-year-old, MS, wheelchair-bound patient with a chronic wound on her right foot ever since removal of a cyst approximately two years ago. The patient has had difficulty with healing in this area.
MS|morphine sulfate|MS|356|357|MEDICATIONS AT THE TIME OF DISCHARGE|5. Chronic pain. MEDICATIONS AT THE TIME OF DISCHARGE: 1) Prednisone 40 mg p.o. daily for three days beginning _%#MMDD2005#%_; then prednisone 30 mg p.o. daily times three days; then prednisone 20 mg p.o. daily times three days; then prednisone 10 mg p.o. daily times three days; then stop. 2) Guaifenesin 1200 mg p.o. b.i.d. 3) Lasix 40 mg p.o. q.A.M. 4) MS Contin 30 mg p.o. b.i.d. for a combined dose of 45 mg p.o. b.i.d. 5) MS Contin 15 mg p.o. b.i.d. for a total dose of 45 mg p.o. b.i.d. 6) Plain morphine 10 mg p.o. b.i.d. p.r.n. for break through pain.
MS|morphine sulfate|MS|428|429|MEDICATIONS AT THE TIME OF DISCHARGE|5. Chronic pain. MEDICATIONS AT THE TIME OF DISCHARGE: 1) Prednisone 40 mg p.o. daily for three days beginning _%#MMDD2005#%_; then prednisone 30 mg p.o. daily times three days; then prednisone 20 mg p.o. daily times three days; then prednisone 10 mg p.o. daily times three days; then stop. 2) Guaifenesin 1200 mg p.o. b.i.d. 3) Lasix 40 mg p.o. q.A.M. 4) MS Contin 30 mg p.o. b.i.d. for a combined dose of 45 mg p.o. b.i.d. 5) MS Contin 15 mg p.o. b.i.d. for a total dose of 45 mg p.o. b.i.d. 6) Plain morphine 10 mg p.o. b.i.d. p.r.n. for break through pain.
MS|morphine sulfate|MS|296|297||He was hoping to be able to be treated as outpatient with OxyContin and breakthrough Percocet until he had his lithotripsy which is scheduled for Monday, but the pain got so severe today with increasing nausea, that he needed to come in for pain management and possible dehydration. He was given MS and Dilaudid as well as Zofran and Toradol in the emergency room. He is a lot better now. Pain is about 3 out of 10, but he knows the pain will soon come back.
MS|multiple sclerosis|MS.|92|94|FAMILY HISTORY|There is no smoking, alcohol, or drug use. FAMILY HISTORY: Daughter has primary progressive MS. He is not aware of any other family members of amyotrophic lateral sclerosis. HOSPITAL COURSE: PROBLEM #1: Diarrhea. Gastroenterology Consultation was obtained at the time of admission and it was recommended that the patient have flexible sigmoidoscopy revealing colitis and he had a normal gastric emptying study.
MS|multiple sclerosis|MS.|185|187|FAMILY HISTORY|FAMILY HISTORY: Shows that both her parents died of myocardial infarctions. She has two brothers that have passed away with the same. She has a couple sisters. One of her daughters has MS. REVIEW OF SYSTEMS: The patient has had a mildly abnormal stress thallium in _%#MM2004#%_ .
MS|master of science|MS,|186|188||_%#NAME#%_ _%#NAME#%_ is a 19-year-old trisomy 21 woman with pre-operative diagnosis of maxillary vertical excess. She has been under the orthodontic care of _%#NAME#%_ _%#NAME#%_, DDS, MS, orthodontist, for more than a year. He has aligned and leveled the arches nicely and we have met with _%#NAME#%_ and her family on multiple occasions, discussing her skeletal imbalance and treatment options.
MS|morphine sulfate|MS|106|107|DISCHARGE MEDICATIONS|3. Allegra 180 mg q.day. 4. Lasix 20 mg q.day. 5. Neurontin 400 mg q.h.s. 6. Ativan 0.5 mg p.o. t.i.d. 7. MS Contin 30 mg p.o. q.a.m., 15 mg p.o. q.p.m. 8. Protonix 40 mg q.a.m. 9. Senokot. 10. Percocet 1-2 q.4-6 hours p.r.n. pain.
MS|multiple sclerosis|MS:|204|206|HOSPITAL COURSE|Urine culture showed E. coli sensitive to ciprofloxacin. He was treated with ciprofloxacin 500 mg p.o. b.i.d. On day 3, the patient is afebrile and clinically improved. 4. Neurogenic bladder secondary to MS: The patient had a condom catheter in place. 5. Constipation: The patient was given stool softeners with some good results.
MS|multiple sclerosis|MS|197|198|HISTORY OF PRESENT ILLNESS|He is managed with regular trips to the chiropractor for muscle and lower extremity treatments which are partially effective for him. When asked about what recent treatments may have been done for MS or whether or not steroids have been effective, the patient is disinterested in providing an answer. He is clearly angry about the lack of availability of a new experimental MS drug that was apparently not released to the market.
MS|UNSURED SENSE|MS|135|136|ASSESSMENT, PLAN|2. Hyponatremia. Suspect SIADH in nature given her high urine osmolality. Free water restriction to less than 1 liter. Continue gentle MS at 75 cc/hour for maintenance. Monitor b.i.d. 3. Status post mitral valve replacement back in 1995 and 2003.
MS|morphine sulfate|MS|166|167|HOSPITAL COURSE BY PROBLEM|At the time of discharge, the patient had been afebrile for greater than 48 hours. 3. Unremitting pain secondary to esophageal cancer: The patient was placed on oral MS Contin as well as morphine solution for break through pain. This resulted in reasonable pain control. In addition, because of his increasing nutritional needs as well as for chronic pain management, he will be referred to the Fairview Home Care TLC Program to help with home management.
MS|morphine sulfate|MS|68|69|HISTORY OF PRESENT ILLNESS|Past medical history is quite complicated in that the patient is on MS Contin, Lidoderm patch as an outpatient for left-sided chest pain and knee pain. She has a history of craniotomy x2 with shunt placement, secondary to cerebral aneurysms and seizures, also secondary to this.
MS|multiple sclerosis|MS,|206|208|FINAL DIAGNOSES|2. Chronic indwelling suprapubic catheter needs change, follow-up plan per Dr. _%#NAME#%_. 3. Urinary tract infection with MRSA. 4. Severe multiple sclerosis. 5. Severe pulmonary disease largely related to MS, see above discussion. Chest x-ray demonstrated some fibrosis left upper lobe and base, slight blunting of the left costophrenic angle with mild pleural thickening of effusion.
MS|UNSURED SENSE|MS|197|198|DISCHARGE RECOMMENDATIONS|As a general rule, all members of the team are somewhat concerned about the plan that she has in place. We also recommended and offered our assistance in following through with the referral to the MS Treatent Center and she seemed open to that.
MS|morphine sulfate|MS|385|386|PHYSICAL EXAM AT THE TIME OF DISCHARGE|We spent a couple of days titrating his dosage but by the time of discharge, a successful dose of MS Contin 45 mg q.8 hours and immediate-release morphine 3 mg q.4 hours p.r.n. pain proved to be acceptable pain management for the patient, and he was discharged home. DISCHARGE CONDITION: Good. DISPOSITION: Discharged to home. DISCHARGE MEDICATIONS: 1. Methadone 120 mg p.o. daily. 2. MS Contin 45 mg p.o. q.8 h. for pain, dispensed 30, no refills. 3. Immediate-release morphine 20 mg p.o. q.4 h. p.r.n. for pain, dispensed 80. 4. Senna/docusate 1 tablet p.o. b.i.d. p.r.n. for constipation.
MS|morphine sulfate|MS|132|133|HOSPITAL COURSE|She did have some pain with movement from side to side and was treated with initially IV Dilaudid and then p.o. Dilaudid as well as MS Contin. It was felt that the patient would likely benefit from intensive rehabilitation and will therefore be discharged to a transitional care unit with the goal of a short-term stay and then home.
MS|morphine sulfate|MS|196|197|HOSPITAL COURSE|They recommended that the patient be started on Neurontin and the dose increased to a goal of 800 mg p.o. t.i.d., and at the same time, the patient's morphine should be tapered off. The patient's MS Contin has been decreased to 30 mg p.o. b.i.d., and the patient has been put on Neurontin which is going to be increased as per schedule.
MS|morphine sulfate|MS|153|154|PROBLEM #3|In addition to addressing multiple end-of-life issues, the TLC Service also made recommendations regarding a more stable pain control regimen to include MS Contin, as well as continuing on the liquid form of Vicodin. This may be adjusted further at subsequent hospice follow-ups. PROBLEM #4: Aspiration: _%#NAME#%_ underwent evaluation by the Speech Pathology Service, who felt that he continued to be at high risk for aspiration despite being fed entirely through a gastrojejunostomy tube.
MS|morphine sulfate|MS|162|163|DISCHARGE MEDICATIONS|9. Lisinopril 5 mg p.o. daily. 10. Dilantin 400 mg p.o. daily. 11. Viagra 75 mg p.o. t.i.d. 12. Zelnorm 12 mg p.o. b.i.d. 13. Citrucel 1 teaspoon p.o. daily. 14. MS Contin 100 mg p.o. t.i.d. 15. Morphine immediate release 45 mg p.o. q.2h. p.r.n. pain. 16. Tylenol 500 mg p.o. q.6h. p.r.n. pain. 17. Ambien 10 mg p.o. nightly p.r.n. insomnia.
MS|multiple sclerosis|MS|231|232|PAST MEDICAL HISTORY|She is also on Dilantin. 2. History of a Trache with recurrent pneumonias thought to be due to aspiration. 3. History of frequent urosepsis. She last had urosepsis in _%#MM2006#%_ when she had enterococcus. 4. History of end-stage MS with severe dysarthria and a Trache in 2001 using feeding tubes and also has quadriplegia. 5. History of SIADH. ALLERGIES: None per old records. CURRENT MEDICATIONS: Unknown doses.
MS|morphine sulfate|MS|113|114|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Vistaril. 2. Colace. 3. Vicodin. 4. Premarin. 5. Vitamin B12. 6. Prenatal vitamins. 7. MS Contin. 8. Valium. 9. Neurontin.
MS|multiple sclerosis|MS|97|98|PAST MEDICAL HISTORY|He also has poor endurance and fatigue and poor attention. PAST MEDICAL HISTORY: 1. Positive for MS secondary progressive. 2. He has optic neuritis, legally blind. 3. Asthma. 4. Recurrent nasal polyps, status post multiple removals.
MS|multiple sclerosis|MS|176|177|ASSESSMENT AND PLANNING|His deep tendon reflexes are 2 bilaterally. Hoffman sign is negative bilaterally. Sensations intact to light touch. ASSESSMENT AND PLANNING: A 57-year-old male with history of MS with secondary progressive disease with recent influenza A significantly impairing his functional capacity, limiting his mobility and ADLs. He also had associated spasticity, possibly chronic, and a neurogenic bladder.
MS|GENERAL ENGLISH|MS|111|112|HOSPITAL COURSE|She and her parents elected to undergo the procedure for repair as offered by Dr. _%#NAME#%_. HOSPITAL COURSE: MS _%#NAME#%_ was admitted on the day of the operation and underwent the above procedure without complication. Orthotics was consulted to fashion a brace intraoperatively. The patient was brought to the operating room with her brace in place.
MS|morphine sulfate|MS|140|141|DISCHARGE MEDICATIONS|14. Trazodone 100 mg tablets, 1 tablet daily at bedtime. 15. Morphine sulfate immediate release tablets, 20 mg q. 2h. p.r.n. bone pain. 16. MS Contin 90 mg p.o. daily at 0600 and 2200 hours, 60 mg at 1400 hours. 17. Motrin 600 mg 1 tablet p.o. t.i.d. with food.
MS|multiple sclerosis|MS.|207|209|FAMILY HISTORY|She has 3 grown children and she is single. She states that father takes care of her guardianship. FAMILY HISTORY: No history of MI, hypertension, diabetes. She have mother with eczema. No family history of MS. REVIEW OF SYSTEMS: Positive for fever, chills, muscle weakness, muscle spasm.
MS|morphine sulfate|MS|213|214|PROBLEM #4|The patient was continued on her MS contin of 45 mg t.i.d. and Celebrex 200 mg b.i.d. for breakthrough pain. She took Motrin 600 mg q.d. She does appear stable on this pain medication. Also, at home she does have MS elixir which she states she takes for breakthrough pain. The patient was discharged home on _%#MM#%_ _%#DD#%_, 2002.
MS|morphine sulfate|MS|130|131|COURSE IN THE HOSPITAL|His main problems in the hospital were his pain control and that was initially done with PCA Dilaudid and then he was switched to MS Contin with good control of his pain. Physical therapy helped his walking, but continued to have some weakness in his left leg.
MS|multiple sclerosis|MS.|180|182|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: CONSTITUTIONAL: Fatigue and low grade subjective fevers, otherwise negative. HEAD and EYES: Intermittent headache and visual changes which she attributes to the MS. ENT: Sore throat some time ago now resolved. PULMONARY: Negative. GI: As per history of present illness, plus the addition of occasional heart burns/indigestion, mild.
MS|multiple sclerosis|MS.|138|140|PAST SURGICAL HISTORY|The patient had been working as a nursing assistant at Fairview Ridges. The patient's mother has been invalid for many years secondary to MS. The patient's father has history of obesity. MEDICATIONS: On admission include Serevent 2 puffs bid, Combivent 2 puffs q 6 prn, Ortho-Tri-Cyclen and the pain medication, the Oxycodone and the Phenergan suppositories as noted as well as monthly B-12 shots.
MS|morphine sulfate|MS|111|112|DISCHARGE MEDICATIONS|3. Plavix 75 mg q day times six months. 4. Folgard one p.o. q day times six months. 5. Prinivil 5 mg q day. 6. MS Contin 60 mg q day. 7. Nexium 20 mg q day. 8. Lexapro 20 mg q day. 9. Lipitor 20 mg q day. 10. Niaspan ER 500 mg q h.s. I am arranging for _%#NAME#%_ to have a followup office visit with me in about four months.
MS|morphine sulfate|MS|147|148|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg po qd to try to maintain sinus rhythm. 2. Haloperidol 0.25 mg po bid on schedule for any agitation. 3. MS Contin 50 mg po bid for pain and dyspnea. 4. Potassium 10 mEq po qd. 5. Furosemide 20 po bid. 6. Senna and _____ 2 po bid for bowels.
MS|morphine sulfate|MS|206|207||She was admitted on _%#MM#%_ _%#DD#%_, 2002, for her third cycle and close observation. PAST MEDICAL HISTORY: She has no other past medical history except for this current cancer. ADMISSION MEDICATIONS: 1. MS Contin. 2. Morphine elixir p.r.n. pain. 3. Zantac. 4. Zofran. 5. Ativan p.r.n. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION ON ADMISSION : GENERAL: She is a thin female, sleepy but in no acute distress.
MS|morphine sulfate|MS|197|198|HOSPITAL COURSE|The patient continued to have some tenderness in his right upper quadrant, but this improved. He was continued on Darvocet, however, continued to complain of pain, so his medication was changed to MS Contin. PROBLEM #2. Hydronephrosis. This was secondary to his recurrent lymphoma.
MS|morphine sulfate|MS|217|218|DISCHARGE MEDICATIONS|Therefore TLC consultation was obtained and plans were made for the patient to be transferred to the _%#CITY#%_ Care Center for hospice comfort care status. DISCHARGE MEDICATIONS: 1. Fosphenytoin 100 mg IV q. 8 h. 2. MS Contin 15 mg per rectum q. 12 hours. 3. Valproic acid 500 mg IV q. 6 h. 4. Tylenol 650 mg per rectum q. 6 h. p.r.n. pain/fever.
MS|morphine sulfate|MS|172|173|CURRENT MEDICATIONS|4. Anemia of unclear origin. Work up has previously shown no evidence of a hemoglobinopathy and the cause of anemia is, therefore, unclear. CURRENT MEDICATIONS: Oxycodone, MS Contin and Questran. ALLERGIES: There are no reported medication allergies.
MS|morphine sulfate|MS|183|184|IMPRESSION|The plan is for stereotactic radiosurgery due to be completed on _%#MMDD2003#%_ under the direction of Dr. _%#NAME#%_. 4. Pain. At this time her pain is well controlled on the use of MS Contin. We will also provide Percocet for break-through pain as needed. 5. At this time the patient does remain a full code status.
MS|morphine sulfate|MS|195|196|HISTORY OF PRESENT ILLNESS|Her pain is mostly in the right upper quadrant and left lower quadrant, but also present in other areas of the abdomen. She has distention. There is no radiation of the pain. Minimal response to MS Contin recently. She had CT scan about a week ago at North Memorial Hospital. The results are not available to us at this point.
MS|multiple sclerosis|MS,|137|139|HOSPITAL COURSE|1. Pneumonia bilaterally. 2. Hypoxia. 3. Failure to thrive. HOSPITAL COURSE: The patient is a 66-year-old white female with a history of MS, paraplegic, resident of Erickson Cottages Assisted Living. The patient was brought to Fairview Ridges Hospital complaining of hypoxia, at which time she was diagnosed with pneumonia.
MS|morphine sulfate|MS|101|102|DISCHARGE MEDICATIONS|However, he will be discharged to a nursing home in _%#CITY#%_ _%#CITY#%_. DISCHARGE MEDICATIONS: 1. MS Contin 75 mg p.o. b.i.d. 2. Neurontin 300 mg p.o. b.i.d. 3. OxyFAST 2 to 4 drops p.o. b.i.d. p.r.n. 4. Oxycodone 15 to 30 mg p.o. q.4h. p.r.n. pain.
MS|multiple sclerosis|MS|231|232|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old who has known multiple sclerosis of a multiple nature. _%#NAME#%_ has had every immunosuppressive agent that one can imagine over the past several years. This is because his MS has progressed significantly. This has included cladribine and Novantrone, as well as the standard interferons. He has continued to progress, nonetheless. He is able to live fairly independently with the aid of his helping dog.
MS|morphine sulfate|MS|176|177|HISTORY OF PRESENT ILLNESS|She states similar to a previous spinal headache. She also is continuing to have nausea and vomiting and has been unable to keep down her meds except an occasional dose of her MS Contin. She has been unable to keep down even water or other liquids for 36 hours. She did have some rectal Compazine at home and tried that last night but again was unable to tolerate any po despite that.
MS|multiple sclerosis|MS|105|106|RECOMMENDATIONS|Diagnosis at the time of discharge is that of management of multiple sclerosis. This 71-year-old has had MS of a progressive nature which has gotten in the way of her gait, transferring and general functioning. She was admitted to the hospital with 2/5 strength in the left leg, a fairly strong right leg and good upper extremity strength but inability to ambulate.
MS|morphine sulfate|MS|212|213|DISCHARGE MEDICATIONS|By postoperative day #4, he had passed physical therapy. He was tolerating his pain control quite well, and he had no drainage evidence from his wound. DISPOSITION: Home. DIET: Regular. DISCHARGE MEDICATIONS: 1. MS Contin 90 mg p.o. b.i.d. 2. Vioxx 25 mg p.o. q.d. 3. Coumadin 5 mg p.o. q.d. 4. Colace 100 mg p.o. b.i.d. ACTIVITY: The patient was instructed that he may be weight bearing, as tolerated, on his right lower extremity, with a knee immobilizer in place, using crutches or a walker.
MS|morphine sulfate|MS|92|93|DISCHARGE MEDICATIONS|FOLLOW-UP: Follow-up appointment in one week with Dr. _%#NAME#%_. DISCHARGE MEDICATIONS: 1. MS Contin 200 mg q. 8 h. 2. Morphine sulfate 10-20 mg as needed every 2-3 hours. 3. Wellbutrin. 4. Senokot. 5. Paxil. 6. Levaquin 500 mg q.d. x 5 days.
MS|morphine sulfate|MS|218|219|FINAL DISCHARGE DIAGNOSES|Later on in the hospital course, she mentioned alternating constipation and diarrhea, and said that she had been diagnosed with irritable bowel syndrome. At the time of admission, she had been taking Oramorph (same as MS Contin) 30 mg every 12 hours. It is unclear if she took this consistently. Sometimes took Darvocet and Percocet in addition.
MS|multiple sclerosis|MS|144|145|REVIEW OF SYSTEMS|Recently the TSH was 16 so her Synthroid was increased from 150 mcg to 175 mcg daily. Diabetes has shown itself when she is on Decadron for her MS flares. PSYCHIATRIC: She feels depressed. She attempted suicide once in 1999. She denied any intent to hurt herself recently. She is on Effexor.
MS|multiple sclerosis|MS|173|174||_%#NAME#%_ has had throughout the years significant issues with bipolar disease as well. Both have been very bothersome to him and have caused great stress in his life. His MS has been progressive and quite disabling. He has been treated aggressively with rehabilitation, high-dose steroids, and he has even had one dose of Novantrone.
MS|morphine sulfate|MS|207|208|DISCHARGE MEDICATIONS|Pain medicine. Physical therapy, occupational therapy. DISCHARGE MEDICATIONS: 1. Norvasc 5 mg daily 2. Celebrex 200 mg b.i.d. 3. Folic acid one tablet daily 4. Arava 20 mg daily 5. Lisinopril 40 mg daily 6. MS Contin SR 200 mg t.i.d. 7. Zoloft 100 mg daily 8. Prednisone 15 mg a day 9. Neurontin 100 mg t.i.d. P.r.n. medications include Tylenol 325 q4 hours p.r.n., Maalox Plus, Dulcolax suppository, Ativan 2 mg q4-6 hours p.r.n., Percocet 5/325 one or two q4-6 hours p.r.n. DISPOSITION: Transitional care at _%#CITY#%_.
MS|morphine sulfate|MS|244|245|DISCHARGE MEDICATIONS|He had no further nausea and no further lightheadedness. He was instructed to follow up in the office as planned for serial lab work and to see me in 1-2 weeks for reevaluation prior to a second cycle of chemotherapy. DISCHARGE MEDICATIONS: 1. MS Contin 60 mg b.i.d. 2. Baby aspirin, one q.d. 3. Folate. 4. Glucosamine. 5. Multivitamins. 6. Vioxx 25 mg.
MS|multiple sclerosis|MS|173|174|CHIEF COMPLAINT|2. Knee arthroplasty, _%#MMDD2004#%_, without problems. 3. Pneumonia. 4. Longstanding problems with urinary incontinence status post _%#NAME#%_- _%#NAME#%_. 5. Longstanding MS with minimal disability. 6. Status post appendectomy. 7. Remote hysterectomy with left salpingectomy and oophorectomy. 8. Clinical depression.
MS|morphine sulfate|MS|127|128|DISCHARGE MEDICATIONS|4. Tequin 200 mg p.o. daily. 5. Prednisone 45 mg p.o. on even days, and 20 mg p.o. on odd days. 6. Bactrim DS 1 p.o. b.i.d. 7. MS Contin 30 mg p.o. b.i.d. 8. .......Flintstone vitamins, 1 p.o. daily. 9. Simethicone 80 mg p.o. q.i.d. 10. Clonazepam 1 mg p.o. q.h.s. 11. Zyprexa 5 mg p.o. daily.
MS|morphine sulfate|MS|218|219|SIDE EFFECTS FROM MEDICATIONS|In other words there is some abnormality on the scan but not proven it is due to metastatic disease. This could change in the future. SIDE EFFECTS FROM MEDICATIONS: 1. OxyContin and Fentanyl cause profuse sweating. 2. MS Contin causes extensive numbness on legs and feet. 3. Other side effects from medications include: ______, Neurontin, Lipitor, doxepin, Norflex.
MS|morphine sulfate|MS|159|160|HISTORY OF PRESENT ILLNESS|The patient denies any particular complaints other than being intoxicated and weak. She denies any pain. When I asked her why she was taking the OxyContin and MS Contin, she said it was to get high and she had not been prescribed this for any particular pain syndrome.
MS|morphine sulfate|MS|146|147|IDENTIFICATION|IDENTIFICATION: Mr. _%#NAME#%_ is a 30-year-old Caucasian male. He is married. He currently lives in _%#CITY#%_, Minnesota. His drug of choice is MS Contin. He has not had any previous chemical dependency treatment. He has been treated for depression as an outpatient. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ states he is here to get detoxed so he can have infusion pump implanted in his back.
MS|multiple sclerosis|MS|238|239|SUBJECTIVE|SUBJECTIVE: The patient is 57 years old and has known multiple sclerosis with psychiatric overlay of significant depression and neuropathic pain. Pain is her main issue, and that has caused her severe disability despite the fact that her MS has, in fact, been somewhat progressive over the years. She has been through every pain approach that one can imagine, and every pain program that has been offered here in the region without any success.
MS|morphine sulfate|MS|240|241|ASSESSMENT|Continue Zofran and IV fluids. 3. Chronic pain. It seems that the patient is manipulating her prescribed narcotics at home, and this may have possibly led to a withdrawal. Will consult Pain Clinic. Continue her Duragesic patch for now. Add MS overnight as needed. Plan to have them follow her pain medications in the future.
MS|multiple sclerosis|MS|322|323|SUBJECTIVE|Superimposed upon the multiple sclerosis is a significant functional disturbance, but complicating it all is the fact that she apparently has significant arthrosclerotic heart disease, has had myocardial infarct, has had 2 stents placed, has diabetes mellitus, depression, and some chemical dependency. Over the years her MS has been relatively stable and she has been able to get along with occasional symptomatic management, but she has received large amounts of medicines from many different doctors that I have not really approved of.
MS|multiple sclerosis|MS|177|178|SUBJECTIVE|These have involved such things as amphetamines combos, Adderall, hydrocodone, and other chemically dependent treatments. She was seen in the office in _%#MM#%_ of 2005 and her MS was stable, but there were a lot of other problems. Her examination was functional and we discussed the amphetamine abuse.
MS|multiple sclerosis|MS|194|195|HISTORY OF PRESENT ILLNESS|The patient is being seen by Internal Medicine with Dr. _%#NAME#%_, writing diabetes orders. She is admitted to the hospital for further evaluation, rehabilitation, and management of increasing MS symptoms. Our estimated length of stay is one week.
MS|multiple sclerosis|MS|125|126||She is scheduled to visit the pain clinic in _%#CITY#%_ _%#CITY#%_. In the meantime she has become weaker and feels that her MS is becoming activated. She is verbalizing to me that all of this discussion about her pain medicine sound relatively new and that she is a little surprised by it when I have had this conversation with her at every single visit over the past 10 years.
MS|morphine sulfate|MS|151|152|CURRENT MEDICATIONS|PAST MEDICAL HISTORY: Otherwise notable for rotator cuff problems. She has had a pulmonary embolism. CURRENT MEDICATIONS: 1. Oxycodone 2. OxyContin 3. MS Contin 4. Colace 5. Ibuprofen 6. Metoclopramide ALLERGIES: Simvastatin. HABITS: She is a nonsmoker and does not consume alcoholic beverages.
MS|morphine sulfate|MS|150|151|HISTORY OF THE PRESENT ILLNESS|He is on intravenous Dilaudid 0.1 mg q ten minutes although this was just recently increased to 0.2 mg. intravenous Q 10 minutes. Typically, he takes MS Contin 30 mg t.i.d. and has only taken 30 mg today and thus this may also be why he is in more pain now, although normally, he doesn't have this lancinating pain.
MS|multiple sclerosis|MS,|140|142|RECOMMENDATIONS|RECOMMENDATIONS: The patient has failed gamma knife therapy, which was chosen because it was the least invasive. Given that concern and her MS, it may be prudent to proceed percutaneous radiofrequencyt rhizotomy. These actions were discussed with the patient, and she will decide what she would like to do.
MS|multiple sclerosis|MS|159|160|HPI|__x___ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Meningioma. HPI: Sudden change of MS episode. Exam: No neurologic deficit seen. Assessment and Plan: We have offered the patient Gamma Knife SRS.
MS|multiple sclerosis|MS|222|223|DISCUSSION|His international normalized ratio has been monitored, particularly as he has been placed on antibiotics. Thank you for having me see this patient. DISCUSSION: _%#NAME#%_ _%#NAME#%_ is a 61-year-old male with a history of MS who currently is hospitalized on Acute Rehab Unit for evaluation of weakness. I have been asked to see him by Dr. _%#NAME#%_ for assessment of positive urine culture and blood culture.
MS|morphine sulfate|MS|191|192|MEDICATIONS|PAST MEDICAL HISTORY: The patient has history of chronic pain and reflex sympathetic dystrophy. MEDICATIONS: She is on Vicodin, Neurontin 12 mg three times a day, Zanaflex, Klonopin, Ambien, MS Contin, and Estrace. ALLERGIES: There are no known drug allergies. PERSONAL HISTORY: She denies any histor of smoking or drinking.
MS|multiple sclerosis|MS,|270|272|DISCUSSION|Records will be requested pertaining to a recent hospitalization in _%#CITY#%_ for her abdominal symptoms as well as recent cardiac evaluation. Thank you for having me see this patient. DISCUSSION: _%#NAME#%_ _%#NAME#%_ is a 60-year-old white female with a longstanding MS, who currently is hospitalized for evaluation, with a one month history of low-grade temperature, abdominal pain, nausea, vomiting.
MS|multiple sclerosis|MS|186|187|HISTORY OF PRESENT ILLNESS|NEUROLOGICAL CONSULTATION NOTE: HISTORY OF PRESENT ILLNESS: The patient is 50-year-old who I have followed for a very long time for significant cerebral multiple sclerosis. Actually her MS has been relatively stable, despite the fact that it has significant disabling prognosis. _%#NAME#%_ has been severely disabled for many years and has no capability in terms of judgment, planning, or foresight.
MS|multiple sclerosis|MS|299|300|ASSESSMENT|Functional exam is deferred. ASSESSMENT: This is a 71-year-old right-handed woman who has right lower extremity weakness secondary to spinal cord injury postoperatively from L3-4 laminectomy. She has normal bowel and bladder function. She also has a history of right-sided weakness secondary to her MS of 15 years. She has impaired mobility and ADLs because of this new right lower extremity weakness superimposed on her old right-sided weakness, and would benefit from acute rehab.
MS|morphine sulfate|MS|182|183|PLAN|2. Check hemoglobin and electrolytes in the a.m. 3. Mobilize per Dr. _%#NAME#%_'s request. 4. The patient will likely need to be transitioned from her combination of PCA morphine to MS Contin, and breakthrough short-acting morphine as she was preoperatively to facilitate her mobilization after surgery. 5. Will hold antihypertensive therapy due to her low blood pressure at this time.
MS|multiple sclerosis|MS|154|155|MEDICATIONS|12. trazodone 100 h.s. 13. Prempro 0.625/2.5 daily 13. Darvocet. 14. Some type of injection that she administers to herself once monthly in her thigh for MS REVIEW OF SYSTEMS: No fever or chilling. Respiratory: no cough or wheezing recently has had some asthmatic symptoms.
MS|multiple sclerosis|MS|182|183|REVIEW OF SYSTEMS|Otherwise, negative. REVIEW OF SYSTEMS: The patient has had a 15-pound weight loss in the last 5-6 weeks secondary to decreased appetite because of his depression and because of his MS exacerbation. He denies fevers or chills. HEENT positive for double vision that has been going on the last month, which the patient feels is related to his MS exacerbation.
MS|morphine sulfate|MS|205|206|PROBLEM #2|The patient was also seen by Dr. _%#NAME#%_ from palliative care service. The patient complained left upper chest pain and lumbar spinal pain, those from metastatic lung carcinoma. Current medications are MS Contin 90 mg at 6 a.m., 60 mg at 2 p.m. and 90 mg at 10 p.m. He will continue to use Pregabalin 50 mg t.i.d. for neuropathic pain and may use original morphine sulfate 20 mg p.o. every 2 hours for breakthrough pain.
MS|multiple sclerosis|MS|400|401|SUBJECTIVE|REFERRING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD SUBJECTIVE: Ms. _%#NAME#%_ is a 58-year-old female who was recently admitted because of progressive multiple sclerosis and for whom I have been asked that to consider administration of novantrone for her multiple sclerosis. Please see Dr. _%#NAME#%_'s admission note for details surrounding this patient's disease. According to the patient, she has had MS for over 30 years and has been a gradual decline, but more recently she has been having problems with balance as well as some increase cognitive loss.
MS|morphine sulfate|MS|207|208|ASSESSMENT AND PLAN|4. Prophylaxis against DVT (with SCDs and ted hose at present and possibly Heparin prior to surgery). 5. Liberal use of opioids for pain control (IV Morphine as a short acting agent and possibly long acting MS Contin or Oxycontin). 6. Close observation for progression of symptoms consistent with partial or full small bowel obstruction (i.e. consider NG tube or NPO status if vomiting returns).
MS|multiple sclerosis|MS|113|114|ASSESSMENT|NEUROLOGIC: Per Dr. _%#NAME#%_. LABORATORY DATA: CBC and chemistry panel were essentially normal. ASSESSMENT: 1. MS exacerbation with consideration of Novantrone therapy. 2. Diabetes mellitus type 2 with mild hyperglycemia at this time. 3. Hypertension under satisfactory control. 4. History of nocturnal snoring without daytime sleepiness makes her low risk for obstructive sleep apnea but this would be a consideration.
MS|multiple sclerosis|MS|243|244|ASSESSMENT|ASSESSMENT: Multiple sclerosis with the above mentioned complicating issues. She has spasticity, which is under better control on regular dose of Baclofen around the clock. I will follow her on a semi- regular basis here to make sure that her MS is not more of a complication. Obviously, there has to be the healing process that needs to occur and continue.
MS|multiple sclerosis|MS|149|150|FAMILY HISTORY|ALLERGIES: There are no known drug allergies. PERSONAL HISTORY: She denies any history of smoking or drinking. FAMILY HISTORY: There is a history of MS in her family. REVIEW OF SYSTEMS: The patient also gives a history of intermittent vertigo for which she takes Antivert on a regular basis.
MS|morphine sulfate|MS|89|90|MEDICATIONS|The patient does have allergies to adhesive tape. MEDICATIONS: 1. BuSpar 30 mg b.i.d. 2. MS Contin 60 mg t.i.d. 3. Morphine 5-10 mg q.4 hours p.r.n. 4. Lantus 30 Units subq each day at bedtime. 5. Insulin Regular sliding scale before meals. 6. Sennalax three tabs q. day.
MS|multiple sclerosis|MS,|162|164|SOCIAL HISTORY|6. Aspirin 81 mg p.o. daily. 7. Vicodin 5/500, 1 tablet daily p.r.n. (used infrequently). ALLERGIES: None known. SOCIAL HISTORY: The patient is disabled from his MS, and lives with his sister. He requires assistance for ambulation and activities of daily living. He quit smoking about 3 years ago, and drinks alcohol infrequently.
MS|multiple sclerosis|MS,|299|301|DISCUSSION|Thank you for asking me to see this patient. I will be able to follow her during hospitalization for concurrent medical concerns. DISCUSSION: _%#NAME#%_ _%#NAME#%_ is a 55-year-old woman with history of multiple sclerosis, currently hospitalized on station 10A for evaluation of exacerbation of her MS, exacerbated by worsening bilateral leg discomfort and spasticity in her hands. I was asked by Dr. _%#NAME#%_ to see this patient to assess medical problems including a probable UTI.
MS|morphine sulfate|MS|100|101|MEDICATIONS|4. Hepatitis C positive. 5. History of chronic pain/phantom limb pain. MEDICATIONS: 1. Dilantin. 2. MS Contin. 3. Morphine. 4. Trazodone. ALLERGIES: No known drug allergies. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: He has smoked cigarettes since age 17.
MS|multiple sclerosis|MS|173|174|RECOMMENDATIONS|2. Pain consultation. 3. KinAir bed and frequent positional changes to prevent skin breakdown. 4. PT and OT for passive range of motion as tolerated. 5. Given her end-stage MS disease and severe stroke end-of-life issues, TLC/hospice should be considered. Palliative care consult should be initiated after some discussion with family members.
MS|morphine sulfate|MS|133|134|PLAN|4. Weight loss. There is an unclear etiology, but may be secondary to multiple sclerosis versus diet. PLAN: 1. Nutrition consult. 2. MS will be per Dr. _%#NAME#%_. 3. Cipro for the urinary tract infection. 4. We will follow the patient.
MS|multiple sclerosis|MS|145|146|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: The patient denies any episodes of choking or aspiration prior to the onset of this illness. No bladder difficulties from his MS and no diarrhea or constipation. PHYSICAL EXAMINATION: VITALS: Temperature 98, blood pressure 126/81, heart rate 63 and regular, respiratory rate 18.
MS|multiple sclerosis|MS|143|144|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: This is a 49-year-old woman here for treatment of multiple sclerosis exacerbation. 1. Neurologic. The patient is here for MS exacerbation. She is being cared for by Dr. _%#NAME#%_ of the Neurology Service. She is scheduled for high-dose dexamethasone taper.
MS|multiple sclerosis|MS|150|151|ASSESSMENT/PLAN|The treatments were associated with a couple of days of fatigue following treatment but it is not persistent. Overall, he and his wife think that his MS has gotten a bit better, but certainly not a major benefit. Fortunately, there have been no hospitalizations over the past year.
MS|multiple sclerosis|MS|213|214|ASSESSMENT AND PLAN|1. Severe depression. 2. New multiple sclerosis lesions on the brain MRI without any focal neurological deficits. Patient has history of severe depression that is being worsened by situational stress of increased MS activity in the brain. She does not have any significant neurological deficits clinically. She would need I.V. Solu-Medrol for the enhancing lesions on the brain MRI.
MS|morphine sulfate|MS|189|190|MEDICATIONS|5. Allegra 180 mg p.o. daily. 6. Lasix 10 mg x1 dose has been given by surgery this morning 7. She is on sliding scale insulin and TPN. 8. Morphine sulfate with dressing changes and was on MS Contin 15 mg p.o. q.12h. for pain. However, I have held this. 9. Zosyn 3.375 grams IV q.8h. 10. Travatan is 0.004% 1 drop both eyes q.h.s. PAST MEDICAL HISTORY: Remarkable for 1. Severe rheumatoid arthritis, details are unknown.
MS|morphine sulfate|MS|249|250|REVIEW OF SYSTEMS|FAMILY HISTORY: Negative for malignancy. REVIEW OF SYSTEMS: The patient reports an approximately 8-pound weight loss in the recent past. In addition, he experiences nocturia 4 to 5 times per night, and experiences some constipation secondary to his MS Contin use. Otherwise, the patient has no complaints, and a 10-point review of systems is within normal limits. PHYSICAL EXAMINATION: The patient appears relaxed and in no acute distress.
MS|multiple sclerosis|"MS|162|164|HISTORY|I do not have any of those records but I understand his work up was quite extensive including ENT assessment and multiple MRI imaging. They said that he also had "MS test done". Apparently no definitive diagnosis was obtained. He was seen most recently at the Mayo Clinic a year ago. He was admitted at this time because of the transient episodes that he has been experiencing.
MS|multiple sclerosis|MS|176|177|ASSESSMENT|It is not clear if the patient has a proper type of cushion for her wheelchair where she spends most of her time. 4. Chronic urinary and stool incontinence likely secondary to MS aggravated by immobility. A Foley catheter has been placed. It may be that a Foley catheter is in fact a good option for her to assist in the resolution of her open areas and from a comfort standpoint.
MS|multiple sclerosis|MS|106|107|HISTORY OF PRESENT ILLNESS|INTERNAL MEDICINE CONSULT: HISTORY OF PRESENT ILLNESS: This patient is a 60-year-old female with cerebral MS admitted to the hospital to start dexamethasone and copaxone. I was asked by Dr. _%#NAME#%_ to do an internal medicine consult on this patient.
MS|multiple sclerosis|MS|123|124|ASSESSMENT AND PLAN|Complete metabolic panel is within normal limits. UA shows a trace of leukocyte esterase. ASSESSMENT AND PLAN: 1. Cerebral MS per Dr. _%#NAME#%_. 2. Hypertension (may be due to anxiety). We will monitor. Recommend low-salt diet, which is already in place per Dr. _%#NAME#%_.
MS|multiple sclerosis|MS.|192|194|DISCUSSION|Please see Dr. _%#NAME#%_'s notes in the charting for details regarding the patient's neurologic history and the circumstances leading up to admission. _%#NAME#%_ has a 10-year-old history of MS. She has noted slow progression of lower extremity weakness. She denies acute medical concerns otherwise. She does have occasional urinary incontinence.
MS|multiple sclerosis|MS.|245|247|PAST MEDICAL HISTORY|He is admitted to the hospital at this time after discussion with the family with their interest of going ahead with ORIF to facilitate continued ambulation. PAST MEDICAL HISTORY: 1. History of right sided paraplegia secondary to hemorrhage. 2. MS. 3. Hypertension. 4. GERD. 5. Prominent heart murmur. MEDICATIONS AND ALLERGIES: Reviewed and documented on the chart. SOCIAL HISTORY: The patient is a nursing home resident.
MS|morphine sulfate|MS|162|163|MEDICATIONS|6. Fosamax 70 mg weekly, on Mondays. 7. Lorazepam 0.5 mg b.i.d. 8. Multivitamin 1 daily. 9. Calcium with vitamin D 600 mg b.i.d. 10. Vitamin C 1000 mg daily. 11. MS Contin 15 mg b.i.d. 12. Oxycodone 5 mg q.4-6 hours (as above). FAMILY HISTORY: Mother died age 74 from myocardial infarction.
MS|multiple sclerosis|MS|225|226|LOCATION|We started treatment on _%#MMDD2006#%_ and concluded today. She received 24 mg each 12 weeks and, with today's treatment, she will have total of 96 mg. Thus far, the patient indicates that she has noted no improvement in her MS and actually thinks she may be getting worse. There is a significant amount of psychosocial things going on in her life, and she mentioned how depressed and worthless she is feeling.
MS|multiple sclerosis|MS|148|149|REFERRING PHYSICIAN|REFERRING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 64-year-old gentleman seen for episode of diplopia. He has a past medical history of MS diagnosed by Dr. _%#NAME#%_ _%#NAME#%_ in the mid 1970's. Over the years, this has provided him with difficulty with gait, balance, coordination and double vision.
MS|morphine sulfate|MS|225|226|MEDICATIONS|MEDICATIONS: Her medications include: 1. ........... 2. sodium bicarbonate to treat chronic metabolic acidosis. 3. She is also on Metoprolol. 4. She had been on Protonix. 5. She has been on long-term narcotic usage including MS Contin and oxycodone. 6. She takes amitriptyline q.h.s. 7. She has been on Proventil, Advair and Albuterol nebulization treatments for chronic respiratory symptoms including reactive airway disease and recurrent bronchitis.
MS|NAME|_%#NAME#%_|151|160|PLAN|6. History of vocal cord polyps. PLAN: 1. I will not order addictive substance due to her history of chemical abuse. I suggest to her that she see Dr. _%#NAME#%_ while she is here. She is refusing to do that at this time. 2. Physical therapy evaluation for gait assistive devise or general therapy to improve her gait.
MS|multiple sclerosis|MS|161|162||The patient was scheduled to start mitoxantrone on _%#MMDD2003#%_, but he decided to delay it for a while and try alternative medicine. Since that decision, his MS has had a couple of flares, with an episode of left lower leg numbness, and the patient is now ready to take the proposed mitoxantrone treatment.
MS|multiple sclerosis|MS.|163|165|SOCIAL HISTORY|History of depression and history of anxiety disorder. SOCIAL HISTORY: She is married and lives with her husband who suffers from severe visual impairment and has MS. Her son is about to be stationed in Iraq. She is under some stress. MEDICATIONS: 1. Prednisone 15 mg daily. 2. Cleocin IV 900 mg q.8h.
MS|multiple sclerosis|MS|126|127|PAST MEDICAL HISTORY|She did have a fair amount of white cells in her urine, but had a normal CBC and white count. PAST MEDICAL HISTORY: 1. Severe MS with quadriparesis. She has a baclofen pump in place. 2. History of aspiration pneumonia. 3. Chronic urinary catheterization.
MS|multiple sclerosis|MS.|149|151|PAST MEDICAL HISTORY|2. History of herpes zoster involving the left trigeminal dermatome. 3. Chronic pain syndrome on chronic methadone. 4. Chronic vertigo attributed to MS. 5. History of anemia (remote). PAST SURGICAL HISTORY: 1. Gravida III, para 0. 2. Arthroscopic shoulder surgery bilaterally for adhesive capsulitis/impingement.
MS|multiple sclerosis|MS|304|305|HISTORY OF PRESENT ILLNESS|4. Hypertension. 5. Depression. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 57-year-old man with the above past medical history who was in his usual state of health until Monday, when he developed increasing fatigue. This progressed to the point where he has become progressively weak and his MS has become exacerbated. The patient presented to Fairview Southdale Hospital emergency room where he was evaluated by Dr. _%#NAME#%_. The patient has been admitted to Dr. _%#NAME#%_, who has requested consultation.
MS|multiple sclerosis|MS.|373|375|HISTORY OF PRESENT ILLNESS|Her feedings consist of Pulmocare 120 cc of water plus 237 cc of the Pulmocare plus 120 cc of water after the Pulmocare q.i.d. The parents deny any fever, chills, vomiting, diarrhea, change in color of the urine, decrease in output of the urine, any chills, chest pain, or cough. Her last bowel movement was on _%#MMDD2003#%_. She also has a baclofen pump in place for her MS. PAST MEDICAL HISTORY: 1. She is a multiple sclerosis patient.
MS|morphine sulfate|MS|131|132|CURRENT MEDICATIONS|2. Protonix 40 mg q.d. 3. Murelax 17 mg q.d. 4. Amiodarone 400 mg p.o. b.i.d. 5. Wellbutrin 150 mg b.i.d. 6. Lasix 80 mg b.i.d. 7. MS Contin 15 mg b.i.d. 8. Coreg 50 mg b.i.d. 9. Amaryl 8 mg q.d. 10. Zofran, Ativan, MS p.r.n. CHRONIC DISEASE/MAJOR ILLNESSES: 1. Lower extremity paraparesis with chronic dysfunction of bowel and bladder with indwelling suprapubic cystotomy catheter.
MS|multiple sclerosis|MS|200|201|DISCUSSION|As above, further GI evaluation will be indicated if she has persistent diarrhea. Thank you for having me see this patient. DISCUSSION: _%#NAME#%_ _%#NAME#%_ is a 41-year-old female with a history of MS whom I have been asked to see on the acute rehabilitation unit by Dr. _%#NAME#%_. Ms. _%#NAME#%_ underwent gastric bypass surgery one week ago and has been transferred from the medical/surgical unit to the acute rehabilitation setting for the treatment of exacerbation of her MS in this setting.
MS|morphine sulfate|MS|161|162|MEDICATIONS|2. Hysterectomy. 3. Likely cholecystectomy with common bile duct exploration in 2004. MEDICATIONS: On admission include Levaquin, Arimidex, Percocet, potassium, MS Contin, Compazine and Anzemet. She also is receiving Navelbine weekly for chemotherapy, however, she has not received this in the past 2 weeks.
MS|morphine sulfate|MS,|285|287|MEDICATIONS|ALLERGIES: Antiphylactic penicillin allergy previously and also Codeine allergy. PAST MEDICAL HISTORY: Diabetes that has been under good control. MEDICATIONS: Glucophage, insulin, Neurontin, Vioxx, Flexeril, Pamelor, started on vancomycin after being on clindamycin earlier, Prinivil, MS, and Decadron. FAMILY HISTORY: Little in the family history suggests problems. No significant history of prior infections or abscesses.
MS|multiple sclerosis|MS.|218|220|HISTORY|The patient was seen by the Emergency Department physician. Weakness approximately 4/5 was documented. The patient was sent along for CT of the head which shows some white matter changes consistent with possibility of MS. No other change such as hemorrhage or evidence of acute stroke, etc. I was asked to see the patient. FAMILY HISTORY/SOCIAL HISTORY: Detailed elsewhere.
MS|multiple sclerosis|MS|139|140|ASSESSMENT|ASSESSMENT: 1. Multiple sclerosis exacerbation, probably related to urosepsis. 2. History of some urinary retention in the past. 3. Severe MS with quadriparesis and paraplegia essentially in the lower extremities. PLAN: 1. The patient was started on IV ceftriaxone for urinary tract infection, pending further sensitivities.
MS|morphine sulfate|MS|163|164|HISTORY OF PRESENT ILLNESS|He does have a history of prostatism and takes Doxazosin for this. No other acute complaints. He has not required any pain medication today. He was receiving 5 of MS in the Recovery Room. PAST MEDICAL HISTORY/HABITS: He is a nonsmoker, nondrinker.
MS|multiple sclerosis|MS.|164|166|FAMILY HISTORY|ALLERGIES: None. SOCIAL HISTORY: Lives independently in York Apartments. Prior to this, no significant recent travel or exposures. FAMILY HISTORY: Daughter died of MS. No major infections in the family. REVIEW OF SYSTEMS: Somewhat difficult. Currently she is fairly lethargic and sleepy.
MS|morphine sulfate|MS|408|409|HISTORY OF PRESENT ILLNESS|The patient apparently had endoscopy that did not varices but did show ....gastropathy. The etiology of the gastrointestinal bleed was thought multifactorial in origin resulting from alcohol abuse as well as coagulopathy. It was recommended that the patient avoid NSAIDs indefinitely. The patient did well after the chest tube was removed, and it was recommended that she be discharged on a tapering dose of MS Contin, and that NSAIDs should be avoided as well as minimal Tylenol use. The patient acquired pneumonia that apparently resolved, but the patient was continued on levofloxacin to end on _%#MMDD2003#%_.
MS|morphine sulfate|MS|168|169|LABORATORY DATA|He seems to be in quite a severe amount of distress due to his hallucinations right now. I would suggest that we treat the urinary tract infection and that we stop his MS Contin. His mental status should clear with time. Thank you for the consultation.
MS|morphine sulfate|MS|211|212|CURRENT MEDICATIONS|He denies any particular acute medical problems. HABITS: He is a nonsmoker, nondrinker. ALLERGIES: None. CURRENT MEDICATIONS: Current medications are listed in the medication reconciliation list. He had been on MS Contin up until 2 weeks ago which he stopped. CHRONIC DISEASE/MAJOR ILLNESS: 1. Long history of depression. 2. Status post left elbow open reduction internal fixation for an accident in 2000.
MS|morphine sulfate|MS|149|150|ASSESSMENT|The patient does describe a sensitivity to many medicines in the past and needed to take lower doses of medicines. He has actually received 16 mg of MS this morning, and the range on the PCA was 1 to 2 every six minutes p.r.n. No other etiology is apparent at this time, and in fact, as the dose was decreased in the first hour, he has already improved symptomatically.
MS|multiple sclerosis|MS.|215|217|ASSESSMENT|7. Dizziness characterized as a dysequilibrium sensation with occasional true vertigo. Potentially vestibular in origin. Doubt vertebral basilar insufficiency. Cannot exclude early presentation of something such as MS. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Additional labs to include serum iron studies, B12 level, RPR, sed rate, C. reactive protein and FANA.
MS|morphine sulfate|MS|222|223|HOME MEDICINES|10. She had an upper endoscopy in _%#MM2001#%_ for abdominal pain and that was negative. HOME MEDICINES: 1. Prednisone. 2. Percocet. 3. Glucophage. 4. Singulair. 5. Verapamil. 6. Amitriptyline. 7. Neurontin. 8. Advair. 9. MS Contin. She denies frequent use of aspirin and nonsteroidal anti-inflammatory agents.
MS|multiple sclerosis|MS|139|140|IN SUMMARY|Family history is noncontributory. She has no children. She has never been pregnant. Her husband is deceased approximately nine years from MS complications. She does not smoke. She has an occasional glass of wine. The patient's insurance is through HealthPartners. She has been a _%#CITY#%_ HealthPartners patient for many years.
MS|multiple sclerosis|MS.|163|165|FAMILY HISTORY|MEDICATIONS: No medications. ALLERGIES: No known drug allergies. PAST SURGICAL HISTORY: Left hip replacement surgery in 2005. FAMILY HISTORY: His father died from MS. His mother has had high blood pressure and his grandparents have had heart disease, strokes and high blood pressure. SOCIAL HISTORY: The patient is a 47-year-old Caucasian male who is married and has three children, all boys.
MS|multiple sclerosis|MS.|162|164|IMPRESSION|Per Dr. _%#NAME#%_, she has not been treated in an aggressive fashion and he is recommending that she receive Novantrone. Novantrone is approved for treatment of MS. Most of the experience has been in the relapse and remitting form, but there is a chance that she might benefit from this approach.
MS|multiple sclerosis|MS,|203|205|PAST MEDICAL HISTORY|Apparently he had a difficulty time with irritation and cough when the trach was initially placed and finally they were able to get him comfortable with the cuffless #4 metal tube. PAST MEDICAL HISTORY: MS, depression, urosepsis. He has a G.-tube in, suprapubic catheter. FAMILY HISTORY: Reviewed on the admit H&P. SOCIAL HISTORY: Reviewed on the admit H&P.
MS|multiple sclerosis|MS.|47|49|RECOMMENDATIONS|The patient is a poor historian related to her MS. The fever apparently was noted early on the morning of admission. Maximum temperature was 103 degrees. There has been no associated nausea or vomiting.
MS|morphine sulfate|MS|146|147|MEDICATIONS|He has had no nausea or vomiting, fevers or chills. PAST MEDICAL HISTORY: Depression, tonsillectomy and shoulder surgery. MEDICATIONS: Oxycodone, MS Contin, Cymbalta and Zanaflex. ALLERGIES: None. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished male, lying in bed, uncomfortable, writhing or clutching at his abdomen.
MS|morphine sulfate|MS|138|139|ASSESSMENT/PLAN|Wife wants to see how her husband does after the transfer to 88. 6. Continue to discuss hospice options on _%#MMDD#%_. 7. Continue p.r.n. MS and Ativan and O2. 8. May call NP for comfort concerns, 24/7. Gave wife the books "Hard Choices" and the other book is "Journey Through the Dying Process".
MS|multiple sclerosis|MS.|222|224|DISCUSSION|Oral intake will be encouraged. I will be able to follow up with _%#NAME#%_ during her hospitalization for these and any other medical concerns. DISCUSSION: _%#NAME#%_ _%#NAME#%_ is a 44-year-old patient with longstanding MS. She is hospitalized on Station 11A for a malfunctioning Baclofen pump. She did undergo pump pocket revision with pump refill by Dr. _%#NAME#%_ on _%#MMDD2004#%_.
MS|multiple sclerosis|MS|155|156|HISTORY OF THE PRESENT ILLNESS|The patient's past medical history and review of systems were reviewed. She is otherwise reasonably healthy. She is on multiple medications because of her MS as listed in the hospital record. On examination, the patient appears her stated age of 47.
MS|multiple sclerosis|MS.|240|242|FAMILY HISTORY|20. Lorazepam p.r.n. for seizures. SOCIAL HISTORY: The patient currently lives in a group home. She does not smoke, drink or use recreational drugs. FAMILY HISTORY: Positive for an uncle who recently died of colon cancer and a brother with MS. REVIEW OF SYSTEMS: The patient denies any fevers, sweats or chills or weight loss.
MS|multiple sclerosis|MS|225|226|PHYSICAL EXAMINATION|Toes were equivocal. Finger-to-nose and heel-to-shin were intact. Her gait was slightly stiff. She had trouble tandem walking. In summary, we have a woman with a history of a neurologic syndrome that could be either lupus or MS and this needs to be clarified as the findings would be identical on clinical examination, MRI and even the spinal tap.
MS|multiple sclerosis|MS|148|149|PHYSICAL EXAMINATION|She does have peripheral edema in both legs with some erythema and a cellulitis on the right leg. Ms. _%#NAME#%_ suffers from secondary progressive MS with this last flare going on for the last 3-4 weeks with increasing left upper extremity weakness, increasing spasticity and bladder symptoms.
MS|multiple sclerosis|MS|164|165|SURGICAL HISTORY|He is currently single with no children. Lives with his mother. FAMILY HISTORY: Maternal side with hypertension, alcoholism, and hyperlipidemia. Paternal side with MS and alcoholism. REVIEW OF SYSTEMS: General: The patient denies fevers, chills, or significant weight change. HEENT: Negative. Cardiovascular: Negative. Pulmonary: Negative. GI: Positive for intermittent heartburn with spicy foods.
MS|multiple sclerosis|MS.|145|147|FAMILY/SOCIAL HISTORY|Review of systems other than HPI essentially unremarkable. FAMILY/SOCIAL HISTORY: The patient is divorced. Resident of a nursing home due to her MS. She has two sons. PHYSICAL EXAMINATION: VITAL SIGNS: Normal; patient afebrile. GENERAL: She is alert and oriented x3. HEENT: Negative. NECK: Shows no masses or thyroid enlargement. LUNGS: Clear with good air movement.
MS|multiple sclerosis|MS|153|154|REASON FOR CONSULTATION|The family states that she really began to change around the Christmas season. She was admitted to the hospital under the care of Dr. _%#NAME#%_ for her MS and given high dose steroids. There was very little improvement and the impression was that her MS had progressed and was not going to improve.
MS|multiple sclerosis|MS.|125|127|REASON FOR CONSULTATION|The patient does live in a group home setting, and the staff has been treating her fever with Tylenol. The patient does have MS. Ms. _%#NAME#%_ does deny any trauma or falls. Ms. _%#NAME#%_ states that her leg is feeling much better at this time. She state 2 days ago a nurse came to her room when she was going to give her an injection.
MS|multiple sclerosis|MS|124|125||Dr. _%#NAME#%_ believes at this point that perhaps this should be reinstituted and he is also making further changes in her MS drugs. Her neurocognitive function has been good. She lives at home with her two young children. Current medications include Tagamet 300 mg orally t.i.d., dexamethasone pulse therapy, Restoril 30 mg at h.s., and Detrol 4 mg daily.
MS|multiple sclerosis|MS|110|111|HISTORY OF PRESENT ILLNESS|She was admitted to Fairview-_%#CITY#%_ Hospital because of some shortness of breath and chest tightness. Her MS history started a little over a year ago with transient right optic neuritis with some residual visual difficulties. Since that time, she has had progressive deterioration of motor strength, first affecting her lower extremities than her upper extremities.
MS|morphine sulfate|MS|148|149|MEDICATION|3. Hypertension. 4. Chronic renal insufficiency. 5. History of microhematuria with negative workup. MEDICATION: 1. Vicodin 1 to 2 q. 4 h. p.r.n. 2. MS 1 to 3 mg IV q. 1 to 2 h. 3. Loped 600 mg twice a day. 4. Lisinopril 20 mg a day. 5. Dyazide 37.5/25 mg one twice a day. 6. Tequin 400 mg a day.
MS|multiple sclerosis|MS|131|132|RE|He has responded well to steroids whenever we have needed them, although this is not one of those situations. He is on no specific MS related drug at this time. He is on Trileptal, which he takes for seizures, and that tends to exacerbate the hyponatremia to some degree.
MS|multiple sclerosis|MS|121|122|RE|The reflexes are present with bilateral toe signs. Cerebellar function reveals a moderate to marked ataxia. _%#NAME#%_'s MS is stable. I will follow him along to watch over that, but at this point I would not recommend any steroids.
MS|morphine sulfate|MS|230|231|RECOMMENDATIONS|5. Obtain sputum gram stain and CF culture. 6. Vest therapy q.i.d. along with her baseline bronchodilators. 7. Pulmozyme nebs 2.5 mg b.i.d. 8. Would continue patient on her baseline ciprofloxacin until sensitivities come back. 9. MS Contin 45 mg p.o. b.i.d. based on her most recent dosings. 10. Additional morphine IV on a p.r.n. basis.
MS|multiple sclerosis|MS|193|194|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Generalized weakness with history of right hemiparesis secondary to multiple sclerosis. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 55-year-old female with long history of MS and is status post cardiac transplant. She evidently has had labile hypertension. Her blood pressure medications were adjusted recently and she had some orthostasis.
MS|multiple sclerosis|MS.|111|113|FAMILY HISTORY|His wife does the cares during the evenings. Nonsmoker. Denies any illicit drugs. FAMILY HISTORY: Negative for MS. REVIEW OF SYSTEMS: CONSTITUTIONAL: Fevers, generalized malaise.
MS|multiple sclerosis|MS|151|152|RECOMMENDATIONS|As she has been seen in that system before I would recommend acute rehab at Sister Kenney Institute. Her new weaknesses are not due to exacerbation of MS she probably will be able to recondition and return to her baseline. She has identified a need for adaptive equipment. She probably could benefit from having a more intensive rehabilitation evaluation to allow her to return to independent living more safely.
MS|morphine sulfate|MS|154|155|IMPRESSION|The patient/wife requesting comfort care. 2. Patient on BiPAP moaning and wife feels he is not comfortable. Has received the equivalent of 5.5 mg an hour MS since midnight with Ativan 4 mg. 3. Past medical history - admit _%#MMDD2004#%_ with pneumonia a. NSCLC with mets to chest wall b. Status post radiation, chemo and surgery
MS|morphine sulfate|MS|172|173|MEDICATIONS|She thus is seen for consideration of emergency radiation treatment on the left hilar lung region. PAST MEDICAL HISTORY: History of hypothyroidism. MEDICATIONS: Synthroid, MS Contin for pain. ALLERGIES: Percocet. HABITS: Tobacco. The patient smoked for 35 years, discontinued five years ago.
MS|morphine sulfate|MS|293|294|REQUESTING PHYSICIAN|This study demonstrates diffuse bony metastasis with tumor involvement of the C2, C6 and C7 vertebrae, and also T1 and T2 vertebral bodies with some evidence of tumor along the right neural foramen at C2-C3. The patient's pain and discomfort has been quite pronounced. She has been started on MS Contin 30 mg t.i.d. She is seen at this time for consideration of palliative radiation treatment to the cervical spine region.
MS|morphine sulfate|MS|124|125|ASSESSMENT, EVALUATION, AND RECOMMENDATION|We will continue to manage fluids and maximize her fluid intake. 3. Pain. We recommend pain palliation. She is currently on MS Contin 50 mg b.i.d. and IV morphine p.r.n. We recommend a Duragesic patch, likely start with a 25 mg transdermal patch.
MS|multiple sclerosis|MS|15|16|ASSESSMENT|ASSESSMENT: 1. MS exacerbation. 2. Positive urine culture. The patient is not clearly symptomatic in view of his MS exacerbation and current corticosteroid treatment. This probably should be treated. 3. No known coronary artery disease.
MS|morphine sulfate|MS|154|155|PLAN|2. We will decrease IV TKO. 3. Offer oral care and moisture. 4. No K protocol. 5. Turn only for comfort. 6. Atropine for congestion. 7. No suctioning. 8. MS for dyspnea. 9. Continue mask 02 until family members from out-of-town are present. ALLERGIES: Sulfa. CODE: Comfort care. REVIEW OF SYSTEMS: The patient is unable.
MS|multiple sclerosis|MS|110|111|PLAN|4. History of cervical dysplasia with follow-up negative Pap smears. 5. History of anxiety disorder. PLAN: 1. MS management per Dr. _%#NAME#%_. 2. No other medical intervention appears indicated at this time. I will be happy to see her during her stay for any intercurrent medical issues.
MS|multiple sclerosis|MS.|69|71|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old female with MS. She was admitted earlier this week with left knee pain and swelling. Previous to this, she had been able to stand for transfers.
MS|multiple sclerosis|MS|231|232|LABORATORY DATA|Since his initiation on _%#MM#%_ _%#DD#%_, 2003, with today's treatment, _%#NAME#%_ will have received a total of 96 mg of mitoxantrone. Overall, he has tolerated the treatment quite well. He feels that since starting therapy, his MS has been stable. He does have occasional setbacks when he develops urinary tract infections, but he knows to contact you and get started on antibiotics quickly.
MS|multiple sclerosis|MS.|161|163|HISTORY OF PRESENT ILLNESS|She lives alone in her own apartment; that is an independent living apartment. She has been doing self-catheterization due to bladder dysfunction related to her MS. She denies any urinary symptoms or other infectious symptoms. No other acute complaints. HABITS: She is a nonsmoker and nondrinker. ALLERGIES: Penicillin. ADMISSION MEDICATIONS: Listed in the medicine reconciliation list.
MS|multiple sclerosis|MS.|106|108|MEDICAL PROBLEM LIST|5. MiraLax and Senna. 6. Neurontin. 7. Lunesta. 8. Dilantin. 9. Compazine p.r.n. MEDICAL PROBLEM LIST: 1. MS. She is described as end-stage with quadriplegia. 2. Depression. 3. Status post suprapubic catheter with occasional bowel incontinence as well.
MS|multiple sclerosis|MS|109|110|PAST MEDICAL HISTORY|No other sickness at home. No recent travel. No anorexia. No dysuria. PAST MEDICAL HISTORY: This patient has MS as well as Meniere's disease. History of urinary retention, anxiety, and depression. He has had some orthopaedic surgery in the past. No abdominal surgeries. No history of inguinal hernias.
MS|morphine sulfate|MS|219|220|PAIN AND SYMPTOM MANAGEMENT|The board and care facility there will take her on hospice and also too Fairview Hospice will follow her and work with the care team there. PAIN AND SYMPTOM MANAGEMENT: The pain and symptoms are being well managed. The MS Contin, since the patient is unable to swallow, will be given rectally and also too there will be morphine, Roxanol backup for breakthrough pain and also too for dyspnea.
MS|morphine sulfate|MS|138|139|RECOMMENDATIONS|She currently is undergoing appropriate treatment with the MS Contin and Neurontin. Hopefully, she will find some better effects with the MS Contin, which has just been started. I did explain to the patient that there are other medications that may help, especially if she is primarily having muscle spasms as a result of her arachnoiditis.
MS|morphine sulfate|MS|310|311|MEDICATIONS|History of osteoporosis. PAST SURGICAL HISTORY: Includes an open cholecystectomy. She has had an appendectomy and a hysterectomy. MEDICATIONS: Multiple and include multivitamins, Flonase, Albuterol, Advair, Prilosec, Zyrtec, Quinine, Avapro, Plaquenil, Premarin, Sinemet, Lidoderm, Neurontin, Norvasc, Vicodin MS Contin and Prednisone. ALLERGIES: METHADONE, CODEINE, PHENOTHIAZINE, SULFA DRUGS, CONTRAST DYE, ____________, CELEBREX, PROCHLORPERAZINE AND CEPHALOSPORINES.
MS|morphine sulfate|MS|144|145|CURRENT MEDICATIONS|7. Lasix 20 mg p.o. 8. Lisinopril 2.5 mg p.o. daily. 9. Nicotine patch q.24h. 10. Megace 200 mg p.o. b.i.d. 11. Lopressor 25 mg p.o. b.i.d. 12. MS Contin 15 mg extended release p.o. q.12h. 13. Zyprexa 5 mg p.o. each day at bedtime. 14. Protonix 20 mg p.o. daily.
MS|morphine sulfate|MS|136|137|IMPRESSION AND PLAN|He will be provided information on the clinical trial tomorrow and we will aim to begin his chemotherapy within the next 1-2 weeks. His MS Contin dose will be adjusted to control his abdominal pain over the next couple of days. His situation was reviewed at length with the patient and his family and we will follow along with you while he remains hospitalized.
MS|multiple sclerosis|MS.|274|276|DISCUSSION|Mr. _%#NAME#%_ was noted to have urine culture that was positive for less than 10,000 colonies of MRSA, sensitive to Sulfamethoxazole. Urinalysis did reveal a trace leukocyte esterase. Mr. _%#NAME#%_ does describe long-standing bladder dysfunction presumably related to his MS. He does have chronic urgency with incontinence. He does take Ditropan XL, which has been somewhat helpful. He does do self catheterizations on a q.i.d. basis, so has recently has had a more difficult time with this as he believes he did develop some sort of a stricture in his urethra a couple of months ago.
MS|multiple sclerosis|MS|193|194||These have been felt to be related to urinary-tract infections. However, review of the chart indicates that prior to her last admission in _%#MM2003#%_, she had not had an admission related to MS or UTI for about a year. The patient had questions regarding a suprapubic catheter. The patient denies any problems with her current urethral catheter.
MS|multiple sclerosis|MS|209|210|DISCUSSION|Thank you for having me see this patient. My assessment was discussed with the patient's daughter who is in attendance to day. DISCUSSION: _%#NAME#%_ _%#NAME#%_ is a 47-year-old white female with longstanding MS who is currently hospitalized on station 8A for evaluation of a change in mental status. I have been asked to see her by Dr. _%#NAME#%_ to assess her medical causes for mental status changes and also to assess hypertension and hyponatremia.
MS|multiple sclerosis|MS.|131|133|PAST MEDICAL HISTORY|_%#NAME#%_ denies cough, shortness of breath, abdominal pain, or diarrhea. PAST MEDICAL HISTORY: Well described in old records. 1. MS. 2. History of recurrent UTIs. She has an indwelling Foley catheter. 3. History of peptic ulcer disease. 4. History of borderline elevated blood sugars in the setting of steroids.
MS|morphine sulfate|MS|73|74|ASSESSMENT/PLAN|The Pain Service then saw her again on _%#MMDD#%_ here and suggested the MS Contin be given 60 mg q.12 h., that she receive IV Dilaudid 0.5 to 1 mg q.2 h. p.r.n. for incisional pain, that she be given the lidoderm patch around her incision site, that the Neurontin 200 mg t.i.d. be continued and increased after 1 or 2 days for neuropathic foot pain, that she receive ketoprofen 10% in PLO gel b.i.d. to t.i.d., and that she receive psych consult.
MS|morphine sulfate|MS|142|143|MEDICATIONS|She is status post neck fusion and two prior cesarean sections. She also has a history of migraines and hypothyroidism. MEDICATIONS: Vicodin, MS Contin, atenolol, Aciphex, and Synthroid. SOCIAL HISTORY: The patient is the caregiver for a 26-year-old disabled son with severe CP and blindness.
MS|multiple sclerosis|MS|147|148|PAST MEDICAL HISTORY|The patient generally has constipation, although today she had one loose stool. She has been passing gas. PAST MEDICAL HISTORY: 1. Hypertension 2. MS 3. Diabetes mellitus type II 4. Diabetic gastroparesis. 5. Hypertension 6. Status post Cesarean section ALLERGIES: None known HABITS: Non-smoker, no alcohol.
MS|multiple sclerosis|MS.|206|208|PAST MEDICAL HISTORY|She has not yet had the chance to see her doctor to review her management in this regard. PAST MEDICAL HISTORY: _%#NAME#%_'s past medical history is well- described in old records and is remarkable for: 1. MS. 2. Hypertension. 3. Asthma. 4. Diabetes mellitus. 5. Hyperlipidemia. MEDICATIONS: Her medication list is quite extensive and includes: 1. Baclofen 30 mg five times a day.
MS|morphine sulfate|MS|139|140|ASSESSMENT AND PLAN|5) Functional abilities are very limited due to the patient's severe chronic obstructive pulmonary disease. Would look to establish a base MS Contin dose so that the patient might be more comfortable and perhaps more functional. Hope the patient would be able to eat better if dyspnea is controlled.
MS|multiple sclerosis|MS|162|163|REPORT|REASON FOR CONSULTATION: Multiple sclerosis. DATE OF CONSULTATION: _%#MMDD2006#%_ REPORT: Ms. _%#NAME#%_ _%#NAME#%_ is a 54-year-old woman who has chronic severe MS and is followed by Dr. _%#NAME#%_ _%#NAME#%_. She presented to the hospital at this time relative to severe abdominal pain and was subsequently found to have acute pancreatitis.
MS|morphine sulfate|MS|201|202|ASSESSMENT|Abduction and adduction is unremarkable. ASSESSMENT: 1. Pain in the hips secondary to metastatic process, right greater than the left. 2. Sedated and experiencing pain, while on pain medications here, MS Contin 30 mg twice a day. PLAN: The nurses state that he gets the most relief from the Percocet so I would like to work with the oxycodone product to see how he would do.
MS|morphine sulfate|MS|127|128|HISTORY|She currently is on prednisone which she varies from day to day depending on her symptoms, 10 to 15 mg per day. She is also on MS Contin as well as immediate-release morphine. Recently she has been having fever up to 102, by the patient's report.
MS|morphine sulfate|MS|423|424|ADMISSION MEDICATIONS|She has had also history of deep venous thrombosis, gastroesophageal reflux disease, osteoarthritis, hypertension, depression, renal failure, left ankle fracture and recurrent cellulitis. ADMISSION MEDICATIONS: Lasix 60 mg b.i.d., 40 at noon, K-Dur 20 mEq daily, Isosorbide 30 mg daily, Coumadin insulin, Zoloft 200 mg daily, Colace 100 b.i.d., quinine sulfate at night p.r.n., Valtrex 500 mg b.i.d., Protonix 40 mg a day, MS Contin 40 mg t.i.d. SOCIAL HISTORY: Quit smoking in 1980. Lives in a nursing home. REVIEW OF SYSTEMS: Pertinent for snoring, apnea, hypersomnia.
MS|morphine sulfate|MS|202|203|MEDICATIONS|ALLERGIES: Allergies to ampicillin and Keflex; both caused significant rashes in the past. MEDICATIONS: Medications on admission included Coumadin, Lasix, aldactone, Protonix, Reglan, Carafate, Zoloft, MS Contin in high doses, prednisone in high doses, Toprol, Imdur, and Advair. She has been on Levaquin earlier in the hospital stay.
MS|morphine sulfate|MS|140|141|MEDICATIONS|He is status post cholecystectomy and appendectomy. ALLERGIES: He is allergic or intolerant to penicillin. MEDICATIONS: His medications are MS Contin 15 mg p.o. b.i.d., Compazine, Eulexin, captopril, Zantac, Motrin, Septra DS 1 p.o. b.i.d., vancomycin 500 mg IV q. 12 hours, prednisone 40 mg today, tomorrow, and then tapering to 30 mg thereafter.
MS|multiple sclerosis|MS|98|99|REQUESTING PHYSICIAN|She sees my partner, Dr. _%#NAME#%_, in this regard. My understanding is that the patient has had MS for quite a number of years. She is not on any prophylactic medication per se at this time (interferons, etc.).
MS|multiple sclerosis|MS|245|246|ASSESSMENT|Long term adhesive capsulitis is difficult to manage and often times requires surgical manipulation under anesthesia. A year out from the time the problem begins adhesive capsulitis is certainly a problem seen in quadriplegics and especially in MS patients or patient who have decreased active movements because of neurologic or muscular weakness. If the patient develops pain that is intractable and would like to try a steroid injection this can certainly be arranged on an outpatient basis when he is in clinic for his hematology oncology follow up and neurologic appointment.
MS|multiple sclerosis|MS,|159|161|HISTORY OF PRESENT ILLNESS|She has, however, had some neurologic complaints that have led to a very complex workup at the Mayo Clinic and elsewhere for what was previously thought to be MS, but apparently this remains debated at this time. Depression and anxiety are also very big problems for her. ALLERGIES: Demerol and Percocet. OUTPATIENT MEDICATIONS: 1. Prozac 60 mg p.o. daily.
MS|morphine sulfate|MS|175|176|MEDICATIONS|PAST MEDICAL HISTORY: Surgery, 70% total body surface area second and third degree burns. Medical problems, diabetes, bipolar disorder. MEDICATIONS: Actos, Neurontin, Ativan, MS Contin, Percocet, trazodone, Levemir, Novolog, Colace, Celebrex, baclofen, Geodon, Zyprexa, tizanidine, atenolol, Prilosec, Depakote, magnesium, multivitamins. ALLERGIES: Reported to Ambien and penicillin. FAMILY HISTORY: Remarkable for diabetes and coronary artery disease.
MS|morphine sulfate|MS|167|168|PROBLEM|The patient came through the ER in the middle of _%#MM#%_ with worsening of the right leg and knee pain, which was not able to be controlled with the pain medication, MS Contin and oxycodone. She also has had lower back pain. When she came to the emergency room she could not lift her leg.
MS|multiple sclerosis|MS.|134|136|HISTORY OF PRESENT ILLNESS|She in general has been feeling progressively weaker over the past one month. She has a history of frequent falls associated with her MS. She normally uses a walker or cane for ambulation. She is followed by Dr. _%#NAME#%_ and believes her last visit with him was approximately one month ago.
MS|multiple sclerosis|MS.|125|127|ADMISSION MEDICATIONS|3. Neurontin 300 mg q.i.d. 4. Nortriptyline 25 mg q.h.s. 5. Glucovance 25/500 mg b.i.d. 6. Copaxone 1 mL subq q.h.s. for her MS. 7. Lipitor q.h.s. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient denies tobacco, alcohol, and illicit drug use.
MS|multiple sclerosis|MS:|130|132|REVIEW OF SYSTEMS|GU: The patient has a history of occasional emptying problems and incontinence, but she has not had this happen to her for years. MS: She has muscle weakness, and she uses a cane to walk. GYN: She has had a hysterectomy. Therefore, she is not having her menstrual cycle anymore.
MS|multiple sclerosis|MS|255|256|HISTORY OF PRESENT ILLNESS|5. Hypertension. 6. Cholecystectomy. 7. Probable osteoarthritis. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 57-year-old woman, with the above past medical history, was admitted this morning by Dr. _%#NAME#%_ after patient has had flare of her MS with increasing leg and arm spasms. The patient does have a Baclofen pump. The patient was started on 1 gm of IV Solu-Medrol q. day and baseline labs have been ordered, urinalysis and urine culture has been ordered.
MS|multiple sclerosis|MS,|134|136|HISTORY OF PRESENT ILLNESS|DOB: _%#MMDD1942#%_ CHIEF COMPLAINT: Right leg injury. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 60-year-old female with MS, who sustained a fall from a short height, resulting in an isolated right leg injury. She describes no other complaints or problems. She has been in a splint overnight.
MS|morphine sulfate|MS|201|202|MEDICATIONS|He has been seen at the Mayo Clinic by Dr. _%#NAME#%_ and Dr. _%#NAME#%_ and per his report, they are recommending surgery with radiotherapy either intraoperatively or postoperatively. MEDICATIONS: 1. MS Contin 360 q6hr. 2. Dilaudid 12 mg p.o. p.r.n. He says his pain is a 7/10 most of the time. He finds it difficult sleeping in particular. PAST MEDICAL HISTORY: Otherwise unremarkable.
MS|multiple sclerosis|MS|149|150|SUMMARY OF CASE|SUMMARY OF CASE: This is a 51-year-old male patient of Dr. _%#NAME#%_ who has long term history of multiple sclerosis. He reports intensification of MS symptoms and associated fevers. This resulted in his hospitalization on _%#MMDD2002#%_. The patient has sense of malaise and has been diaphoretic at times, but denies significant localized pain other than the chronic arthritic symptoms in his hips.
MS|morphine sulfate|MS,|101|103|ALLERGIES|CURRENT MEDICATIONS: Listed in the hospital record. Refer to them for specifics. ALLERGIES: Quinine, MS, atorvastatin, and Percocet. REVIEW OF SYSTEMS: Constitutional - negative. Pulmonary, GI, GU, neuro, psychiatric, GYN, cardiovascular - negative by history.
MS|morphine sulfate|MS|230|231|ASSESSMENT|If Ritalin ineffective in the next three to five days would increase the dose to 10 mg in the morning and at noon. 3. Headache and ongoing dyspnea. Would strongly consider low dose long acting opioid to help manage both symptoms. MS Contin 15 mg p.o. b.i.d. would be the most appropriate dose at this time. 4. Care planning. The patient wishes to do everything possible to prolong his life, but if he does die or code he does not wish attempts at resuscitation and does not wish to be intubated and that was again discussed with him today and remains his plan.
MS|multiple sclerosis|MS,|166|168|ASSESSMENT|Lower extremity impaired sensation at the foot on the left. Gait not tested. ASSESSMENT: 54-year-old status post below-knee amputation on the right, known history of MS, wheel-chair bound. Admit to Acute Rehabilitation. PT/OT evaluation and treatment. On regular diet. Denies bowel or bladder difficulties. Stump pain management on current medications.
MS|morphine sulfate|MS|163|164|HISTORY OF PRESENT ILLNESS|On _%#MMDD2002#%_ she had a TAH/BSO and debulking procedure. The patient has had back pain since surgery. She claims that it is not worsening. The patient is on a MS Contin and Percocet. On further questioning, the patient claims that she has always had back pain. The patient's last chemotherapy was approximately one month ago. The patient has received six cycles of Taxol carboplatin.
MS|multiple sclerosis|MS|177|178||Ms. _%#NAME#%_ _%#NAME#%_ is a 68-year-old female admitted for decline in her MS function. She has been followed in our offices for quite a few years for exacerbating remitting MS which over the last few years has seemed to evolve into a secondary progressive disorder. She was in the distant past on Betaseron, but I believe has not taken it since 2004 when she discontinued it following progressive decline with the thought that this was more of a treatment for exacerbating remitting disorder.
MS|multiple sclerosis|MS.|192|194|FAMILY HISTORY|However, she denies any intravenous drug use. FAMILY HISTORY: She states that her father does have diabetes and is currently being treated with insulin. Patient stated that her mother died of MS. REVIEW OF SYSTEMS: This is otherwise negative except for items mentioned in the history of present illness.
MS|morphine sulfate|MS|174|175|MEDICATIONS|SOCIAL HISTORY: The patient is a carpenter, married. Wife and a son are by the bedside. MEDICATIONS: At home have included Coumadin, Decadron taper, morphine, nitroglycerin, MS Contin, Vytorin, Imdur, lisinopril, levothyroxine, multivitamins, Senokot, Neurontin, and artificial tears. REVIEW OF SYSTEMS: GI as noted, otherwise noncontributory. PHYSICAL EXAMINATION: GENERAL: Thin, cachectic appearing white male with cough.
MS|multiple sclerosis|MS.|171|173|DISCUSSION|DISCUSSION: _%#NAME#%_ _%#NAME#%_ is a 37-year-old female with a history of MS who is admitted through the ER to the 1 North unit for the treatment of exacerbation of her MS. I have been asked to see her by Dr. _%#NAME#%_ for the evaluation of hypokalemia, diabetes, hypertension and asthma.
MS|multiple sclerosis|MS.|216|218|DISCUSSION|Thank you for having me see this patient. DISCUSSION: This is a 42-year-old male with progressive MS who is currently hospitalized on station 11A under the care of Dr. _%#NAME#%_ for treatment of exacerbation of his MS. I have been asked to see him by Dr. _%#NAME#%_ to assess medical problems including hypertension and abdominal pain.
MS|morphine sulfate|MS|189|190|OUTPATIENT MEDICATIONS|3. History of tobacco use. 4. Alleged history of polysubstance abuse per documentation on chart but the patient is currently sober. OUTPATIENT MEDICATIONS: 1. Decadron 40 mg p.o. b.i.d. 2. MS Contin 100 mg p.o. b.i.d. 3. Percocet p.r.n. 4. Proton pump inhibitor. ALLERGIES: Contrast dye. FAMILY HISTORY/SOCIAL HISTORY: Reviewed and per documentation on chart.
MS|morphine sulfate|MS|110|111|MEDICATIONS|1. Actos 30 mg p.o. daily. 2. Neurontin 800 mg tablets 3 times per day. 3. Ativan 1 b.i.d. p.r.n. anxiety. 4. MS Contin 15 mg 3 tablets p.o. b.i.d. 5. Percocet 5/325 mg 2 p.o. q.p.m. 6. Trazodone 100 mg 4 tablets p.o. q.h.s.
MS|morphine sulfate|MS|164|165|DISCHARGE MEDICATIONS|8. Lantis Insulin 8 units subcutaneous q.p.m. 9. Novalog 2 units subcutaneous q.a.c. 10. Lidocaine two patches transdermal b.i.d. 11. Remeron 60 mg p.o. q.h.s. 12. MS Contin 45 mg p.o. t.i.d. 13. Zantac 150 mg p.o. b.i.d. 14. Ambien 5 mg p.o. q.h.s. 15. Tylenol 225 mg p.o. or p.r. q. 4-6 h. p.r.n.
MS|morphine sulfate|MS|208|209|PAST MEDICAL HISTORY|He was at North Memorial Hospital and did not have immediate access to her clinic records but did have access to her most recent hospital records from _%#MM#%_ of 2004. At that time, her medications included MS Contin 15 mg p.o. q. 12 hours and morphine sulfate elixir 5 to 10 mg q. 4 hours p.r.n. for break-through pain. PAST MEDICAL HISTORY: Non small cell carcinoma of the left lung, presenting with a malignant left pleural effusion in _%#MM#%_ of 2004 to Ridges Hospital.
MS|multiple sclerosis|MS|154|155|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Hypothermia and lethargy. HISTORY OF PRESENT ILLNESS: This is a 43-year-old female with past medical history significant for very severe MS who was brought into the emergency department by her caregiver because of some hypothermia, as well as a change in mental status. Since she woke up she has been lethargic and has had very poor motor skills and has been dropping things.
MS|morphine sulfate|MS|201|202|DISCHARGE MEDICATIONS|(The plan will be to eventually wean this down as much as we are able to over the next several weeks.) 2. Cozaar 100 mg daily. 3. Hold Lipitor until further notice. 4. Synthroid 88 mcg p.o. q. day. 5. MS Contin 45 mg p.o. b.i.d. 6. Atenolol 25 mg b.i.d. (hold for heart rate less than 52, or systolic blood pressure less than 100).
MS|morphine sulfate|MS|151|152|HOSPITAL COURSE|I went down on her MS Contin to 15 mg a day b.i.d., which seemed to still provide adequate pain control. She was given approximately a week's worth of MS Contin and Percocet p.r.n. and to follow-up with her primary M.D. and Pain Clinic regarding her chronic pain issues. At time of discharge, her blood pressure was 107/67. Patient was no longer feeling dizzy with ambulation.
MS|morphine sulfate|MS|155|156|TRANSFERRING MEDICATIONS|2. Os-Cal with D 500 mg p.o. t.i.d. 3. Gabapentin 300 mg p.o. t.i.d. for pain. 4. Lidoderm patch 5% one to the left shoulder at 2200 and off at 10 a.m. 5. MS Contin 90 mg p.o. q8h. 6. MMF 500 mg p.o. b.i.d. for immunosuppression. 7. Protonix 40 mg p.o. q.d. for reflux. 8. Prednisone 5 mg p.o. b.i.d. for immunosuppression.
MS|morphine sulfate|MS|232|233|HISTORY OF PRESENT ILLNESS|She has been healthy preoperatively. The patient underwent Achilles tendon repair and a bone spur removal 2 days ago, on _%#MMDD2006#%_ at _%#CITY#%_ Lakes Health South, patient's surgical center. She was sent home with a scheduled MS Contin and p.r.n. oxycodone for break-through pain. She has felt constipated over the last few days, has not had a bowel movement. She has felt overly sedated from the narcotics and has been feeling intermittently dizzy.
MS|morphine sulfate|MS|175|176|DISCHARGE MEDICATION|10. Vistaril 25 mg p.o. q.i.d. p.r.n. 11. Albuterol inhaler q.i.d. p.r.n. 12. Urispas 100 mg p.o. t.i.d. p.r.n. 13. Lidoderm patch q.h.s. p.r.n. 14. Senokot 1 to 2 b.i.d. 15. MS Contin 15 mg p.o. b.i.d. 16. Dilaudid 4 mg p.o. 2 to 3 tablets q. 4 to 6 h. p.r.n. for breakthrough pain. The patient's hospital course was conveyed to Dr. _%#NAME#%_, and he was actively involved in several of the decisions made during this hospitalization.
MS|multiple sclerosis|MS.|272|274|HISTORY OF PRESENT ILLNESS|She was seen by neurologist, Dr. _%#NAME#%_, on _%#MMDD2005#%_ who commented on incomplete bilateral I and O's and slight right facial weakness. They did an MRI of the brain, which revealed pericallosal demyelination. The differential was Wernicke's encephalopathy versus MS. She was given a three-day trial with IV Solu-Medrol, 500 mg daily, without any improvement neurologically. She was transferred to our service for further workup and management.
MS|morphine sulfate|MS|164|165|HOSPITAL COURSE|It is felt to be most likely a neuropathic type pain. The patient was then see by Dr. _%#NAME#%_. At that time a number of recommendations were made. The patient's MS Contin was stopped. He was switched to methadone. In addition, he was started on Neurontin. EMLA lidocaine cream was prescribed to help with the pain locally.
MS|morphine sulfate|MS|278|279|HISTORY OF PRESENT ILLNESS|He had no further vomiting. Family contacted the patient's primary oncology service, and they recommended that he present to Fairview Ridges Hospital for treatment for possible dehydration. The patient denies any alcohol use and has had no abdominal surgery. He is on scheduled MS Contin and p.r.n. morphine for breakthrough pain, and I do not believe he is on a bowel regimen at this time. He has no history of pancreatitis. In the Emergency Department he was given Ativan shortly into his Emergency Department course and has had subsequent delirium and confusion with this.
MS|morphine sulfate|MS|127|128|DISCHARGE MEDICATIONS|3. She is placed on no restrictions at the time of discharge. DISCHARGE MEDICATIONS: Macrobid 1 tablet p.o. b.i.d. for 3 days; MS Contin 30 mg p.o. q.12 h.; Compazine 10 mg p.o. q.6 h. p.r.n. nausea; Senna 1 to 2 tablets p.o. b.i.d. p.r.n. constipation; oxycodone 5 mg p.o. q.4 h. p.r.n. breakthrough pain; Colace 100 mg p.o. b.i.d. p.r.n. constipation; Ativan 0.5 to 1 mg p.o. q.6 h. p.r.n. anxiety; and Emend 125 mg p.o. days #2, #3, and #4 for nausea.
MS|multiple sclerosis|MS.|168|170|ALLERGIES|Last colorectal: The patient has never had a colorectal examination. Last chest x-ray was done _%#MM#%_ _%#DD#%_, 2003. FAMILY HISTORY: Her mother is 66 years old with MS. Her father died at age 65 with lung cancer. She has 3 sisters and 7 brothers who are all alive and well.
MS|multiple sclerosis|(MS)|236|239|PAST MEDICAL HISTORY|At this time the patient elects to proceed with definitive surgical therapy in the form of laparoscopic-assisted vaginal hysterectomy. She does want to preserve the ovaries. PAST MEDICAL HISTORY: The patient has mild multiple sclerosis (MS) for which she sees Dr. _%#NAME#%_. She does experience intermittent fatigue, however, her MS is usually quiescent. PAST SURGICAL HISTORY: 1. Diagnostic laparoscopy. 2. Cone biopsy of the cervix.
MS|multiple sclerosis|MS|138|139|FAMILY HISTORY|PAST SURGICAL HISTORY: Notable for prior thyroidectomy in 1987 and appendectomy in 2002. FAMILY HISTORY: Notable for a mother who died of MS at age 76. Father died recently at age 88 of Alzheimer. She denies any breast, ovarian, colon, or pancreatic cancer in her family.
MS|morphine sulfate|MS|194|195|HOSPITAL COURSE|The patient was admitted to the floor for pain control. He was doing fair for the first few days after admission, however, developed decreased level of responsiveness thought to be secondary to MS Contin he had received for pain control. EBD revealed hypercarbia, and he was transferred to the unit for management and was subsequently intubated.
MS|morphine sulfate|MS|131|132|HOSPITAL COURSE|On _%#MM#%_ _%#DD#%_, 2006, her PCA was weaned and she was started on oral Vicodin. On _%#MM#%_ _%#DD#%_, 2006, she was started on MS Contin 45 mg PO 3. q.4-12 hours and morphine immediate acting tablets. On _%#MM#%_ _%#DD#%_, 2006, her pain was well controlled on this regimen.
MS|morphine sulfate|MS|132|133|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|The patient improved with the Tequin and holding of her MS Contin. I tried to give her a dose of Tylenol #3 at night in lieu of the MS Contin, but she did not tolerate that. She became agitated and suspicious and paranoid that night. At the time of discharge, I am discontinuing all narcotic pain medications and prescribing only Extra Strength Tylenol for pain.
MS|morphine sulfate|MS|121|122|PLAN|2. Will plan on offering him narcotics in the hospital on a p.r.n. basis at a much decreased dose. He will remain on the MS Contin 45 mg b.i.d. but only 2 mg every 4 hours p.r.n. of Dilaudid. Other medications will be maintained, except for Trazodone, that I would like to have reduced to 200 mg at bedtime as well.
MS|morphine sulfate|MS|119|120|HOSPITAL COURSE|On the day of her discharge, the patient was still on morphine PCA for pain control. That day, she was transitioned to MS Contin, extended release morphine tablets with p.r.n. morphine sulfate tablets. The patient was encouraged to stay in the hospital overnight to see if this pain regimen would effectively treat her pain; however, the patient was anxious to get home and request to be discharged that same day.
MS|morphine sulfate|MS|349|350|ASSESSMENT/PLAN|I believe that some of his renal insufficiency is prerenal secondary to decreased oral intake and thus acute on chronic renal insufficiency and thus hydration will be give overnight and we will recheck a BUN and creatinine in the morning. We will keep him NPO for potential stent placement and empirically give him 1 gm of Rocephin and use morphine MS 04 for pain control as needed. I have been in contact with Dr. _%#NAME#%_'s partner, Dr. _%#NAME#%_, who informed me that they will see the patient in the morning.
MS|morphine sulfate|MS|140|141|MEDICATIONS|10. Motor vehicle crash with subsequent C-spine and L spine fusion. 11. Appendectomy. MEDICATIONS: (Unclear if this is a complete list). 1. MS Contin 30 mg b.i.d. 2. Celexa 40 mg per day. 3. Morphine immediate release 15 mg q6h p.r.n. 4. Neurontin 300 mg t.i.d.
MS|morphine sulfate|MS|142|143|HOSPITAL COURSE|The patient's back pain is chronic and secondary to a car accident. The patient had at least 8 to 9 back surgeries. The patient is on chronic MS Contin. The patient continued to have the back pain during the hospital stay which was well managed with pain medication.
MS|morphine sulfate|MS|472|473|MEDICATIONS|PAST HISTORY: The patient does have past history of chronic recurring skin breakdown of her legs due to edema and recurrent wound infections requiring recurring hospitalizations with I.V. antibiotics and diuretics and elevation. MEDICATIONS: The patient is presently on Lasix 60 mg orally b.i.d., Zaroxolyn 2.5 mg daily, potassium chloride 30 mEq orally b.i.d., Atenolol 25 mg daily, Lisinopril 5 mg daily, Protonix 40 mg daily, Imdur 30 mg daily, prednisone 10 mg daily, MS Contin 60 mg three orally q.i.d., Zoloft 150 mg daily, Neurontin 300 mg orally b.i.d., Skelaxin 400 mg orally q.i.d., Coumadin 7.5 mg q.o.d. alternating with 5 mg q.o.d. Additionally, she is using her albuterol inhaler, she is checking her blood sugars at least q.i.d. She has antacids to use at home as needed.
MS|morphine sulfate|MS|197|198|HOSPITAL COURSE|5. Hypertension: This was likely secondary to cyclosporin and is well controlled on nifedipine XL 30 mg. 6. Hip pain: Mr. _%#NAME#%_ has bilateral ossification of the femoral heads. He had been on MS Contin 60 mg b.i.d. for an extended period of time prior to this hospitalization, however, he was refusing his pain medication because he didn't feel it was helping.
MS|multiple sclerosis|MS|158|159|ASSESSMENT|8. Degenerative arthrit is, left knee with a history of right elbow tendinitis/bursitis. 9. Remote nicotine addiction. 10. Issue of fatigue likely related to MS exacerbation. Rule out anemia. Rule out suboptimal Synthroid replacement. 11. Possible Novantrone therapy. I will discuss the clinical issues with Dr. _%#NAME#%_ from hematology.
MS|multiple sclerosis|MS|195|196|HISTORY OF PRESENT ILLNESS|REASON FOR CONSULTATION: Second opinion regarding multiple sclerosis diagnosis and treatment. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 49-year-old right- handed female who presents to the MS Clinic for a second opinion regarding her diagnosis of multiple sclerosis and her current treatment plan. She was initially diagnosed in _%#MM2003#%_ with multiple sclerosis after an attack of blurred vision, as well as gait disturbance and numbness and tingling in her feet.
MS|morphine sulfate|MS.|188|190|PHYSICAL EXAMINATION|Since I have been here she has received 15 mg of intravenous adenosine, 40 mg of Lasix on top of 20 mg this morning. She received 100 mg of oral metoprolol this morning, and 15 mg of oral MS. Nitroglycerin drip has been initiated. VITAL SIGNS: Blood pressure has come from 170 down to 120 systolic and currently it is 120/80, heart rate is 99 beats per minute, O2 sat 93%, up from 87% to 89%.
MS|multiple sclerosis|MS|203|204|OBJECTIVE|There is no posterior calf tenderness to suggest DVT. There is no erythema or increased warmth. Genitalia and rectal exam deferred. Condom catheter in place. Neurologic demonstrates quadriparesis due to MS with lower extremity greater than upper extremity weakness. Further details per Dr. _%#NAME#%_. LABORATORY DATA: Pending. ASSESSMENT: This is a 58-year-old male with the following: 1. Advanced multiple sclerosis with progressive decline in functional status.
MS|multiple sclerosis|MS|260|261|RE|Women with multiple sclerosis do not have an increased risk for miscarriage, premature delivery, pregnancy complications or pre-eclampsia. Dawn was primarily concerned with the high likelihood of relapsing immediately postpartum. We discussed the treatment of MS during pregnancy as well. _%#NAME#%_'s current medication, Rebif, is a category C for pregnancy risk. This indicates that no teratogenic effects have been seen in humans thus far.
MS|multiple sclerosis|MS|266|267|ALLERGIES|3. Appendectomy. 4. Left ankle procedures, as above. She is without heart disease, diabetes, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, thyroid disease, seizure, tuberculosis, or anemia. ALLERGIES: Codeine intolerance (nausea.) She has had MS in the past apparently resulting in some pruritus. PREOPERATIVE MEDICATIONS: 1. Zoloft. 2. Armour thyroid, as above.
MS|multiple sclerosis|MS|172|173|SOCIAL HISTORY|SOCIAL HISTORY: The patient has been rendered essentially homeless. His daughter who has MS is in a difficult situation with what I understand to be an exacerbation of her MS and not able to care for him. He also has a sister. PALLIATIVE MEDICINE REVIEW: CODE STATUS: The patient previously stated to me that he wanted to be full code.
MS|morphine sulfate|MS|93|94|MEDICATIONS|3. Von Willebrand disease. 4. History of migraines. 5. Depression. MEDICATIONS: 1. Taxol. 2. MS Contin. 3. Vicodin. 4. Xanax. 5. Penicillin V. 6. Benadryl. 7. Senokot. ALLERGIES: Codeine, sulfa, Halcion, Levaquin. FAMILY HISTORY OF CANCER: None. SOCIAL HISTORY: She lives with her husband and has 5 grown children.
MS|multiple sclerosis|MS|130|131|HISTORY OF PRESENT ILLNESS|I was asked to see this patient by Dr. _%#NAME#%_ for an internal medicine consult. The patient states that he was diagnosed with MS approximately 3 years ago, and he is followed by Dr. _%#NAME#%_. He states his last MS exacerbation was approximately 1 year ago which he received steroids for as an outpatient.
MS|multiple sclerosis|MS|173|174|ASSESSMENT AND PLAN|We will recheck sodium tomorrow. 6. Hypoglycemia. This is likely the result of a nonfasting test or could be due to the Decadron that the patient has been receiving for his MS exacerbation. No further workup at this time. 7. Thrombocytopenia, likely an adverse reaction of the Rebif which he takes for his multiple sclerosis.
MS|multiple sclerosis|MS.|189|191|REVIEW OF SYSTEMS|PSYCHIATRIC: Negative. NEUROLOGIC: Remarkable for reports of previous strokes, although she was not symptomatic for that. Also, she has a neurogenic bladder. She has double vision from her MS. She has decreased use of her lower extremities. PSYCHIATRIC: Remarkable for some depression. HEMATOLOGIC: Negative. MUSCULOSKELETAL: Negative. PHYSICAL EXAMINATION: The patient's vital signs currently show the patient has a temperature of 98.8, pulse 74, blood pressure 126/71, respiratory rate of 20.
MS|morphine sulfate|MS|182|183|MEDICATIONS|PAST RADIATION HISTORY: None. MEDICATIONS: 1. Compazine 10 mg tabs p.o. q. 6 hours p.r.n. 2. Coumadin 7.5 mg tablets p.o. daily. 3. Eucerin cream. 4. Lisinopril 10 mg p.o. daily. 5. MS Contin 30 mg p.o. b.i.d. 6. Oxycodone 5 mg p.o. q. 4-6 hours p.r.n. 7. Senna tabs. 8. Tylenol p.r.n. 9. Ibuprofen p.r.n. ALLERGIES: No known drug allergies FAMILY HISTORY: Father died of leukemia.
MS|morphine sulfate|MS|440|441|ADMISSION MEDICATIONS|PAST MEDICAL HISTORY: Significant for rheumatoid arthritis, an episode of pneumonia treated 10 years ago, a diagnosis of asthma made based on cough and "wheezing" a month ago, chronic back pain requiring pain medication followed by MAPS Clinic, history of nicotine dependence - recently started smoking again, tentative diagnosis of fibromyalgia by her primary physician, history of left saphenous vein surgery 2005. ADMISSION MEDICATIONS: MS Contin as above, prednisone 60 mg a day having come down from 60 mg b.i.d., Ativan, a steroid inhaler type and dose unknown, Humira injections the last one _%#MMDD#%_, Restoril, Arava, Excedrin, Minocin.
MS|morphine sulfate|MS|150|151|HISTORY OF PRESENT ILLNESS|She was referred to our pain clinic by our OB-GYN doctor at that time, _%#NAME#%_ _%#NAME#%_, in _%#MM#%_ of 2003. At that time the patient was taken MS Contin and the pain clinic evaluation confirmed the diagnosis of chronic pelvic pain. We switched her to Methadone which she took for approximately one week and then discontinued on her own.
MS|morphine sulfate|MS|374|375|PLAN|PLAN: She is refusing any interventions that I am trying to offer her between ketoprofen gel for anti-inflammatory or any type of physical therapy, TENS unit for her back; any of those things she has decided and told me that she has tried everything and she is not able to tolerate anything other than her huge doses of morphine. She reports at home that she takes 90 mg of MS Contin t.i.d. as well as 15 mg of immediate release morphine and she is up to 6 per day on that. So her total amount that she takes according to her report is 360 mg of morphine every day.
MS|multiple sclerosis|MS.|106|108|FAMILY HISTORY|2. Ativan p.r.n. 3. Benadryl. 4. Solu-Medrol. 5. Zantac. 6. Aspirin. FAMILY HISTORY: He has a sister with MS. Family history positive for CAD, hypertension and type-2 diabetes. He also has a sister with brain tumor. SOCIAL HISTORY: The patient lives with his wife and 15-year-old daughter in a multilevel home I believe in _%#CITY#%_.
MS|morphine sulfate|MS|178|179|REASON FOR CONSULTATION|He reports radicular pain down the upper part of the left arm and a deep boring type of pain into the shoulder and surrounding soft tissue areas. Since admission, he has been on MS Contin 30 mg q.12 h. with morphine sulfate IV at 2-mg boluses via nurse every 2 hours. Over the last 17 hours, he has used 8 mg of break-through medication equating to 11 mg of IV morphine over the last 24 hours.
MS|morphine sulfate|MS|104|105|DISCHARGE MEDICATIONS|She was discharged to home in good condition on _%#MM#%_ _%#DD#%_, 2004. DISCHARGE MEDICATIONS: Keflex, MS Contin and Percocet. She is to resume her usual outpatient medications. FOLLOW UP: Will Dr. _%#NAME#%_ in 1-2 weeks. Discharge instructions written.
MS|morphine sulfate|MS|235|236|HOSPITAL COURSE|HOSPITAL COURSE: 1. Suicide attempt and opioid overdose. The patient was admitted to Telemetry with monitoring. The patient also had a sitter for suicide precautions. The patient was continued on home medications with the exception of MS Contin. Patient did not develop significant withdrawal without MS Contin during his hospital stay. Overnight was uneventful. The patient was interested in inpatient treatment to get the diabetic neuropathy pain under control.
MS|multiple sclerosis|MS,|157|159|REVIEW OF SYSTEMS|He has had episodes of dysphagia, but none in the last 5 years. He has lost about 14 pounds in the last 3 months. He suffers from chronic imbalance from his MS, chronic left lower extremity paresthesias and numbness, left upper extremity numbness, and occasional right lower extremity numbness. Remainder of the review of systems is negative. FAMILY HISTORY/SOCIAL HISTORY: He is married for 12 years to his third wife.
NAD|nothing abnormal detected|NAD.|151|154|PHYSICAL EXAMINATION|VITAL SIGNS: Afebrile, blood pressure 154/70, 95 degrees Fahrenheit, temperature 98%, O2 saturations are normal, heart rate 54, respirations 12. SKIN: NAD. Normal color and temperature. HEENT: Lips appear dry; tongue appears dry. CHEST: Clear to auscultation. HEART: Regular rate and rhythm. ABDOMEN: Soft; really non-tender on exam.
NAD|no acute distress|NAD.|134|137|PHYSICAL EXAMINATION|VITAL SIGNS: Temperature 97.6, pulse in the 70s. GENERAL: The patient is slightly over ideal body weight but appears fit and healthy, NAD. HEENT: NC/AT; PERRL; fundoscopic exam shows some arterial narrowing, only one episode of slight AV nicking and some milder AV crossing change is noted.
NAD|no acute distress|NAD.|155|158|OBJECTIVE|ALLERGIES: No known drug allergies. OBJECTIVE: Afebrile. Blood pressure 113/64, heart rate 75, respiratory rate 20. General, alert young female tired, but NAD. HEENT, EOMI, OP clear. Neck supple without adenopathy or thyromegaly. Mucous membranes are most. Cardiovascular regular rate and rhythm, no murmurs, rubs, or gallops.
NAD|no acute distress|NAD.|172|175|PHYSICAL EXAMINATION|19. Clotrimazole 1% cream to yeast type rash t.i.d. ALLERGIES: Penicillin, sulfa, Lexapro and Paxil. PHYSICAL EXAMINATION: GENERAL: Pleasant lady very calm now, completely NAD. She does not look at all uncomfortable at this point. Her legs are no longer cramping. She states that she has only "faint chest pressure" at this point.
NAD|no acute distress|NAD|130|132|PHYSICAL EXAMINATION|6. Calcium 500 b.i.d. 7. Centrum 1 daily. ALLERGIES: Penicillin and erythromycin. PHYSICAL EXAMINATION: GENERAL: A pleasant lady, NAD now, breathing easily on room air. She does have a wet-sounding cough. HEENT: TMs look normal. Tonsils and pharynx not injected. NECK: No significant anterior nodes or masses.
NAD|no acute distress|NAD.|164|167|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: On admission, temperature 96, pulse 84, blood pressure 82/40, respirations 28, and O2 saturation 96% on room air. Disheveled and disoriented. NAD. Head: Normocephalic, atraumatic. Eyes: PERRLA. EOMI x2. Ears and TMs normal. Mouth: Mucous membranes are dry, white exudate on oropharynx.
NAD|no acute distress|NAD,|211|214|HISTORY OF PRESENT ILLNESS|The patient was referred for followup and treatment. PHYSICAL EXAMINATION ON ADMISSION: Vital Signs: Temperature 97.9, blood pressure 185/90, heart rate 80, RR 20, SPO2 97% on room air. General: Pleasant woman, NAD, comfortable. HEENT: Eyes injected sclerae, PERRL. Oropharynx moist. One small benign appearing submandibular lymph node. Neck: Supple. Cardiovascular: RRR, split S2 normal. Lungs: CTA bilaterally. Abdomen: Soft, active, high pitched bowel sounds.
NAD|no acute distress|NAD,|176|179|PHYSICAL EXAMINATION|6. Prozac, 20 mg - apparently since just _%#MM#%_ 2001. ALLERGIES: Sulfa. PHYSICAL EXAMINATION: GENERAL: The patient is a stocky, very moderately overweight, large, older male NAD, A&O times 3. He does tend to hold the suprasternal notch a little bit. He has no evident burping while I am in the exam room with him.
NAD|no acute distress|NAD.|160|163|REVIEW OF SYSTEMS|It lasted until 5:00 p.m. Was relieved in the ER with Maalox given p.o. GU - History of prostate CA. No adjuvant radiotherapy, radical resection. Extremities - NAD. PHYSICAL EXAMINATION: VITAL SIGNS: Heart rate 70, O2 saturations 100% on 2 liters of oxygen, blood pressure 178/92, respirations 12.
NAD|no acute distress|NAD|200|202|STAFF ADDENDUM|She reports desiring chemical dependency treatment. We spent several minutes discussing possible short and long term consequences of EtOH and withdrawal. Vitals and Labs reviewed. Alert, cooperative, NAD Oriented X 3, showed insight and judgement into her illness. Heart regular, no murmur. Lungs clear, no crackles. Abd soft, non-tender.
NAD|no acute distress|NAD.|141|144|STAFF ADDENDUM|Previously vomiting stopped but restarted on day of admission. Multiple, non-bilious. No diarrhea. VS and labs reviewed. Alert, cooperative, NAD. Abdomen soft, non-tender, no HSM, no masses in the area of the stomach. Dry mucous membranes. Extremeties warm, good perfusion. Projectile vomiting with moderate dehyration.
NAD|nothing abnormal detected|NAD.|207|210|LABORATORY|Her blood pressure was 137/57. She was alert and oriented and pleasant, although she seemed to be having a declining memory. Skin: No color or temperature changes. HEENT: NAD. Heart, lungs, and abdomen were NAD. No peripheral edema was noted. Thus, she was stable enough and feeling well enough to be discharged to home. DISCHARGE MEDICATIONS: 1. Amlodipine 7.5 mg p.o. q.d. for hypertension.
NAD|nothing abnormal detected|NAD.|233|236|PHYSICAL EXAMINATION|Bowel sounds are present. Difficult to examine for organomegaly because of distended belly from being overweight. EXTREMITIES: No peripheral edema, peripheral pulses are intact. NEUROLOGIC: Grossly within normal limits. PSYCHIATRIC: NAD. LABORATORY DATA: Urinalysis with nitrite positive, leukocyte esterase large positive.
NAD|nothing abnormal detected|NAD.|127|130|PHYSICAL EXAMINATION|Blood pressure 192/107, pulse 98, respirations 18, temperature normal, O2 sats normal at 95%. HEENT: NAD. HEART: NAD. ABDOMEN: NAD. CHEST: NAD. MUSCULOSKELETAL: NAD. SKIN: Multiple back lesions status post liquid nitrogen treatment. PSYCHIATRIC: NAD. NEUROLOGIC: Please review the Neurology consult and is concurrent with that.
NAD|nothing abnormal detected|NAD.|152|155|PHYSICAL EXAMINATION|HEENT: NAD. HEART: NAD. ABDOMEN: NAD. CHEST: NAD. MUSCULOSKELETAL: NAD. SKIN: Multiple back lesions status post liquid nitrogen treatment. PSYCHIATRIC: NAD. NEUROLOGIC: Please review the Neurology consult and is concurrent with that. Peripheral pulses intact. EXTREMITIES: Nails of the left hand .......and appear to have a fungal infection.
NAD|no acute distress|NAD.|252|255|OBJECTIVE|Uses a walker. FAMILY HISTORY: Noncontributory. OBJECTIVE: VITAL SIGNS: Afebrile; heart rate 60s to 70s; blood pressure 130s to 140s over 60s; oxygen saturation at 99% on room air; respiratory rate 16 to 20. GENERAL: Alert and oriented x3 older female NAD. HEENT: PERRLA, EOMI. NECK: Supple without adenopathy or thyromegaly. OP is dry mucous membranes. CARDIOVASCULAR: Regular rate and rhythm with 2/6 systolic ejection murmur.
NAD|nothing abnormal detected|NAD,|142|145|HOSPITAL COURSE|Her respirations were 16, blood pressure 112/65. Her O2 sats were 97% on room air. She was alert and oriented, seemed a little anxious. SKIN: NAD, normal temperature, normal color. HEENT: Except for some feeling of congestion or runny nose, otherwise, negative. CHEST: Clear to auscultation bilaterally. HEART: No murmurs are noted.
NAD|no acute distress|NAD|157|159|OBJECTIVE|98% on 2 liters by nasal cannula. In general, a 70-year-old male appears quite concentrated on his supper. Overall, appears slightly dry clinically. HEENT - NAD except his ears have hearing aid, noted that right ear has hearing aid, left ear hearing aid is absent. Nares clear. Throat clear. No dentures present. NECK - supple, no lymphadenopathy.
NAD|no acute distress|NAD.|163|166|PHYSICAL EXAMINATION ON ADMISSION|PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.6. Blood pressure 197/85. Heart rate 90. Respirations 20. Oxygen saturation 97% on room air. Alert and oriented, NAD. Sclerae are clear. PERRL and EOMI. OP clear. No rhinorrhea. Thyroid normal. No JVD. There is a 3/6 systolic ejection murmur at the apex.
NAD|no acute distress|NAD.|194|197|PHYSICAL EXAMINATION ON ADMISSION|PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: Temperature 101.3, heart rate 90, blood pressure 120/76, respiratory rate 16, oxygen saturation 95% on room air, weight 74.7 kg. GENERAL: A+ x 4, NAD. HEENT: Normocephalic, atraumatic. Tenderness over the sinuses, particularly maxillary. EOM I. PERRLA. Anicteric. MMM. Thick white layer on the tongue. NECK: JVP 0. CARDIOVASCULAR: RRR. S1, S2 normal. Distant heart sounds.
NAD|nothing abnormal detected|NAD.|171|174|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: As noted. GENERAL: The patient is alert and oriented. She is able to give moderately good history. SKIN: No acute changes noted. HEENT: NAD. CHEST: NAD. CARDIOVASCULAR: NAD. ABDOMEN: Soft, nontender; bowel sounds are heard. EXTREMITIES: No peripheral edema is noted. The patient does not have any increased amount of weakness.
NAD|nothing abnormal detected|NAD.|204|207|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: As noted. GENERAL: The patient is alert and oriented. She is able to give moderately good history. SKIN: No acute changes noted. HEENT: NAD. CHEST: NAD. CARDIOVASCULAR: NAD. ABDOMEN: Soft, nontender; bowel sounds are heard. EXTREMITIES: No peripheral edema is noted. The patient does not have any increased amount of weakness.
NAD|no acute distress|NAD.|138|141|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Temperature 97.6, pulse 84, respiratory rate 18, blood pressure 104/63, and weight 25 kilos. General: Alert, quiet, NAD. Head is normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Nose is clear. Oropharynx is clear. Neck is supple with no lymphadenopathy.
NAD|no acute distress|NAD.|195|198|PHYSICAL EXAMINATION|He is an avid artist who enjoys drawing. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.8, pulse 94, blood pressure 123/77, respiratory rate 24, weight 57 kilos, height 150 cm. GENERAL: Thin, NAD. HEENT: Alopecia; pupils, equal, round, and reactive to light; 1 to 2 mm bilaterally. Extraocular movements intact anicteric sclerae; nose, no congestion; oropharynx is negative for ulcers or lesions; mucous membranes moist.
NAD|no acute distress|NAD.|152|155|PHYSICAL EXAMINATION|No cardiac, other respiratory, GI, GU, neurological or orthopedic problems. PHYSICAL EXAMINATION: GENERAL: A pleasant gentleman, seems comfortable now, NAD. Certainly not short of breath at this time and no coughing during our exam. HEENT: His TMs look normal. Tonsils and pharynx are not injected.
NAD|no acute distress|NAD.|167|170|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.6; pulse 85; blood pressure 121/82; respiratory rate 19; oxygen saturations at 100% on room air. Alert, oriented x3, NAD. HEENT: Head was normocephalic and atraumatic. PERRLA, EOMI. Oropharynx was without erythema and good dentition. NECK: Supple without lymphadenopathy.
NAD|no acute distress|NAD.|191|194|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: On admission, temperature 98.6, pulse 126, blood pressure 122/61, respirations 24, and O2 saturation is 92% on room air. GENERAL: He is alert, oriented x3, NAD. Sitting and eating dinner. HEENT: Head: Normocephalic and atraumatic. Eyes: PERRLA. Ears: TMs are clear. Oropharynx: No posterior pharyngeal injection or exudate. NECK: Without JVD or LAD.
NAD|no acute distress|NAD|234|236|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Negative for any other eye symptoms, ear symptoms, lymphatic symptoms, psychiatric symptoms, no cardiac, respiratory, GI, GU, neurologic, orthopedic problems. PHYSICAL EXAMINATION: GENERAL: Very pleasant gentleman, NAD now. States he feels fine, no chest pain, no shortness of breath, does not even feel particularly weak at this point.
NAD|no acute distress|NAD.|180|183|OBJECTIVE|No cardiac, respiratory, GI, GU, neurologic, or orthopedic problems. FAMILY HISTORY: Noncontributory. OBJECTIVE: A very pleasant lady who seems comfortable now without an NG tube. NAD. The HEENT exam is benign. The CHEST is clear. CARDIOVASCULAR has a regular rate and rhythm; S1 and S2, no murmurs. The ABDOMEN is soft, very mildly tender in the low midline, otherwise nontender.
NAD|nothing abnormal detected|NAD.|229|232|PHYSICAL EXAMINATION ON THE DAY OF DISCHARGE|PHYSICAL EXAMINATION ON THE DAY OF DISCHARGE: VITAL SIGNS: Afebrile, pulse 82, respirations 22, blood pressure 114/59, O2 sat 97% on CPAP. GENERAL: Alert and oriented, sitting up in chair, cooperative, talkative, friendly. SKIN: NAD. HEENT: NAD. HEART: NAD. LUNGS: Wheezing positive, but much improved than before. ABDOMEN: Soft, nontender, trace pedal edema. ASSESSMENT AND PLAN: As above.
NAD|nothing abnormal detected|NAD.|182|185|DISCHARGE EXAMINATION|VITAL SIGNS: Blood pressure 160/83; oxygen saturation at 96% on room air; she is afebrile; heart rate is 87; respiratory rate 16. Alert and oriented. She is sitting up in bed. SKIN: NAD. HEENT: NAD. HEART/LUNG: NAD. ABDOMEN: Slight epigastric tenderness, otherwise bowel sounds are normal and audible. EXTREMITIES: No palpable edema. Thus the patient was well enough to be discharged and to do the follow up as suggested above.
NAD|no acute distress|NAD.|167|170|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: On admission, temperature 96.7, pulse 81, respiratory rate 16, blood pressure 145/88, O2 saturation is 98%. He is awake, alert, and oriented x3, NAD. Eyes with clear sclerae. EOMI. Head is normocephalic and atraumatic. Neck: Supple with tracheal scar. Cardiovascular: Normal S1 and S2, no murmurs. Abdomen: Soft and nontender.
NAD|no acute distress|NAD;|111|114|PHYSICAL EXAMINATION|She denies any chest pain or shortness of breath. PHYSICAL EXAMINATION: GENERAL: She is alert and oriented, in NAD; lovely affect & good attitude. Does not appear to be depressed or anxious in any way. VITAL SIGNS: Blood pressure is 116/73, heart rate in 80s, respirations normal.
NAD|no acute distress|NAD|125|127|ASSESSMENT AND PLAN|No fevers or chills overnight. Nausea and vomiting resolved. VS, medications, and labs reviewed in FCIS. Alert, cooperative, NAD Sclera clear, oralphayrnx clear Neck supple, no LAD Lungs clear, no crackles or wheezes. Heart regular, no murmur. Abdomen obese, soft, mild tenderness in RUQ and epigastric regions.
NAD|nothing abnormal detected|NAD.|140|143|PHYSICAL EXAMINATION ON DISCHARGE|Alert and oriented, cooperative, afebrile; pulse 60; respirations 20, blood pressure 138/802. SKIN: No positive findings were noted. HEENT: NAD. CHEST: CT. HEART: Bilaterally no murmurs. ABDOMEN: Soft; nontender. Bowel sounds present. EXTREMITIES: His left upper extremity continues to be slightly weaker than his right.
NAD|no acute distress|NAD.|135|138|OBJECTIVE|Heart rate 60. Blood pressure 130/57. Respiratory rate 16. Saturation 93% on room air. GENERAL: Alert older female, appears tired, but NAD. HEENT: PERRL. EOM I. OP is clear. Mucous membranes are moist. NECK: Supple without adenopathy, thyromegaly, or carotid bruits.
NAD|no acute distress|NAD.|159|162|REVIEW OF SYSTEMS|18. He is also on a fentanyl patch which is not on his home med list but he does have a patch on, I am not clear about the dosage. REVIEW OF SYSTEMS: GENERAL: NAD. Reviewed and negative for fevers or chills. Has been positive for weight loss and his torsemide is being adjusted. CARDIOVASCULAR: He denies any chest pain, palpitations. CHEST: Reviewed and negative.
NAD|no acute distress|NAD.|226|229|PHYSICAL EXAMINATION ON ADMISSION|Lower extremity edema bilaterally without claudication. PHYSICAL EXAMINATION ON ADMISSION: Vital Signs: Blood pressure 135/72, heart rate 84, respiratory rate 22, SiO2 97 percent on 2 L, temperature 98.6. Appearance: A/O x 3, NAD. No use of accessory muscles. Head: AT/NC. Eyes: EOMI, PERRL, conjunctivae anicteric. HEENT: Normal mucosa, moist. Neck: Supple, no thyromegaly. Respiratory: Diminished breath sounds bilaterally without crackles or wheezes.
NAD|no acute distress|NAD.|192|195|IMPRESSION AND PLAN|Meds, allergies, family/social history, and ROS reviewed. Agree with documentation in resident?s admission H&P. On exam, she has a temp of 100.1 and BP of ~120/70. She appears fatigued but in NAD. MMM. JVP elevated to just below the jawline. Lungs with diffuse wet crackles bilaterally. Heart irreg irreg. Abd nondistended, soft, nontender, no masses.
NAD|no acute distress|NAD.|165|168|A/P|Meds, allergies, family/social history, and ROS reviewed; agree with documentation in resident note. On exam, vitals stable. He is a frail, pleasant elderly male in NAD. Lungs clear, heart RRR, abd thin, nondistended, +BS, no tenderness or masses, LE without edema. Foley catheter is in place. Labs remarkable for TSH>10, Na 131, Cr 1.07, and WBC ~12,000.
NAD|no acute distress|NAD.|165|168|OBJECTIVE|GI: As above. GU: Has been going frequently. No dysuria or hematuria. The rest negative. OBJECTIVE: GENERAL: Slim, tall, very well-built, young, Afro-American male. NAD. A&O times 3. Moves about the room well. Does look a little tired. Weight 187 pounds VITAL SIGNS: BP yesterday was about 120/80.
NAD|no acute distress|NAD|167|169|OBJECTIVE|PSYCHOLOGICAL: Negative. OBJECTIVE: VITAL SIGNS: Afebrile. Heart rate in the 100's. Blood pressure stable. Respiratory rate 20, 89% on room air. GENERAL: Alert female NAD and CNT. TM's are clear. NECK: Supple without adenopathy or thyromegaly. CARDIOVASCULAR; Regular rate and rhythm. CHEST: Lungs are tight with diffuse extensive inspiratory and expiratory wheezes.
NAD|no acute distress|NAD.|156|159|PHYSICAL EXAMINATION|No drug use. Works at McDonalds. PHYSICAL EXAMINATION: VITALS: Blood pressure 123/78, heart rate 97, temperature 98.9, respirations 14. GENERAL APPEARANCE: NAD. HEENT: Within normal limits. CARDIOVASCULAR: Regular rate and rhythm, no murmurs, gallops, or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft; non-tender; negative for guarding or rebound.
NAD|no acute distress|NAD.|139|142|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: He may have a tiny bit of protuberant abdomen. He says he has had this all along. He is a middle-aged male. NAD. A&O X 3. He walks with ease. He gets upon the table. He, however, uses his hand to push himself up and shows pain in his eyes when sitting up from lying down supine.
NAD|no acute distress|NAD.|128|131|PHYSICAL EXAMINATION|She is admittedly a very anxious person. PHYSICAL EXAMINATION: GENERAL: This is a pleasant lady, very anxious now but otherwise NAD. No chest pain at present. She does have intermittent fluttering sensation in her chest that corresponds with her bouts of tachycardia.
NAD|no acute distress|NAD.|208|211|HOSPITAL COURSE|His pulse was 78, his respirations were 20. His blood pressure was 139/74, his O2 sats were 90% on 2 liters of O2. He appeared alert and oriented. He seemed to have tolerated the procedure well. Skin, HEENT, NAD. Chest: CTA bilateral but decreased airflow on the left. CV: No murmurs. Abdomen: Soft, nontender. No peripheral edema was noted.
NAD|no acute distress|NAD.|249|252|OBJECTIVE|OBJECTIVE: Pulse 70, respiration is 15, temperature afebrile. Blood pressure is 150/90, O2 sats are 96-97% on 1-2 liter of Oxygen by nasal cannula. GENERAL: The patient is alert and oriented and not in acute distress. HEENT: Wears glasses otherwise NAD. NECK supple, no lymphadenopathy. LUNGS clear. HEART regular rate and rhythm. Bilateral breast exam, no palpable mass or lumps noted. ABDOMEN is obese. There is some old scar in the lower mid abdomen and also in the suprapubic area.
NAD|no acute distress|NAD,|205|208|PHYSICAL EXAMINATION|4. Hyperlipidemia. 5. GERD. 6. Hypertension. PHYSICAL EXAMINATION: VITAL SIGNS: temperature 97.1, blood pressure 150/109, respiratory rate 16, 97% on room air, heart rate 114. GENERAL: Alert older female, NAD, alert and oriented x 3. Speech is difficult to understand because of tremor. HEENT: PERRL, EOMI. OP is clear. NECK: supple without adenopathy or carotid bruits, no thyromegaly.
NAD|nothing abnormal detected|NAD.|170|173|HOSPITAL COURSE|On the day of discharge, his exam was as follows: Afebrile, pulse 57, respirations 14, blood pressure 115/63, and 94% O2 saturation on room air. Alert and oriented. Skin NAD. HEENT NAD. Heart, lungs, abdomen, and extremities NAD. The patient was well enough to be discharged to home. DISCHARGE MEDICATIONS: Percocet 1-2 p.o. q.6h. p.r.n. pain, a 7- day supply.
NAD|nothing abnormal detected|NAD.|225|228|HOSPITAL COURSE|On the day of discharge, his exam was as follows: Afebrile, pulse 57, respirations 14, blood pressure 115/63, and 94% O2 saturation on room air. Alert and oriented. Skin NAD. HEENT NAD. Heart, lungs, abdomen, and extremities NAD. The patient was well enough to be discharged to home. DISCHARGE MEDICATIONS: Percocet 1-2 p.o. q.6h. p.r.n. pain, a 7- day supply.
NAD|no acute distress|NAD|115|117|PHYSICAL EXAMINATION|We will need to clarify them. REVIEW OF SYSTEMS: Otherwise negative. PHYSICAL EXAMINATION: GENERAL: Pleasant lady. NAD now. She is quite pale. She is quite hard of hearing. Her sense of humor is still intact. HEENT: Benign. No significant anterior nodes or masses. Neck is supple.
NAD|no acute distress|NAD.|239|242|REVIEW OF SYSTEMS|Mother died of ovarian CA at age 73. REVIEW OF SYSTEMS: Constitutional - The patient has fever and chills as described above. Extremities - Right leg redness and some discomfort as described above. No history of any injury or trauma. Else NAD. EXAMINATION: The patient's vital signs are 140/87 blood pressure, heart rate 126, respirations 12, temp 101.6( Fahrenheit.
NAD|no acute distress|NAD.|218|221|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature is afebrile, pulse 77 regular, respiratory rate not recorded, blood pressure 105/63, weight 209 pounds, height is 65 inches. GENERAL: Pleasant, obese 49-year-old woman in NAD. HEENT: PERRLA; EOMI; oropharynx is clear without erythema or exudate; TMs are clear; external auditory canals and pinnae are normal.
NAD|nothing abnormal detected|NAD.|173|176|DISCHARGE PHYSICAL EXAMINATION|DISCHARGE PHYSICAL EXAMINATION: GENERAL: Subjectively, he reports he has had bowel movements yesterday and feels better. VITAL SIGNS: On exam vital signs were stable. SKIN: NAD. No color temperature changes noted. HEENT: No acute changes noted. CHEST: Clear to auscultation. HEART: Murmur is positive. ABDOMEN: Soft, nontender, difficult to palpate for organomegaly.
NAD|no acute distress|NAD.|197|200|OBJECTIVE|He does not smoke, uses occasional alcohol, no drugs. OBJECTIVE: Temperature 99.8, respiratory 26, 95% on room air, heart rate in the 90's, blood pressure 111/53. General: Alert older male, obese, NAD. HEENT: TM obscured by cerumen. OP is clear although the hard/soft palate and dorsal tongue reveal multiple aphthous ulcers.
NAD|no acute distress|NAD,|82|85|PAST MEDICAL HISTORY|3. SPO cholecystectomy. 4. Pleurodesis for the mesothelioma. On admission she was NAD, A&O x 3, interactive. Blood pressure 151/76. Pulse oximeter percent O2 92 on room air. WBC elevated at 17,100 with a left shift. Hemoglobin 11.4. Patient was dehydrated after not having eaten for several days.
NAD|nothing abnormal detected|NAD.|194|197|PHYSICAL EXAMINATION ON DISCHARGE|She has NAD. VITAL SIGNS: Afebrile, pulse 82, respirations 16, blood pressure 112/71, oxygen saturation 96%. SKIN: NAD, especially with reference to the left lower extremity. HEENT: NAD. HEART: NAD. LUNGS: NAD. ABDOMEN: NAD. No peripheral edema was noted. The left lower extremity was less tender, more equal in size and diameter to the right.
NAD|no acute distress|NAD.|200|203|OBJECTIVE|OBJECTIVE: VITAL SIGNS: T max 100.8, T AM 98.4, heart rate 80's, respiratory rate 18, 92 to 96% on room air, blood pressure 137 to 196/70s to 80s. GENERAL: Alert elderly female on the edge of the bed NAD. NEUROLOGIC: She is oriented to self, but not to place or date. HEENT: PERRL, EOMI, OP is clear. Mucous membranes are moist.
NAD|nothing abnormal detected|NAD.|140|143|PHYSICAL EXAMINATION ON DISCHARGE|Alert and oriented, cooperative, afebrile; pulse 60; respirations 20, blood pressure 138/802. SKIN: No positive findings were noted. HEENT: NAD. CHEST: CT. HEART: Bilaterally no murmurs. ABDOMEN: Soft; nontender. Bowel sounds present. EXTREMITIES: His left upper extremity continues to be slightly weaker than his right.
NAD|no acute distress|NAD.|183|186|PHYSICAL EXAMINATION|SKIN: She has a rash on the upper extremities and it seems like a highly raised reddish rash. HEENT: Decreased hearing, bilateral hearing aids. Minimal tongue tremor is noted. CHEST: NAD. HEART: No murmurs. ABDOMEN: Soft, epigastric tenderness, no organomegaly. Bowel sounds are heard. NEUROLOGIC: Grossly intact. EXTREMITIES: No peripheral edema.
NAD|no acute distress|NAD.|194|197|PHYSICAL EXAMINATION|He does not smoke or use alcohol or drugs. PHYSICAL EXAMINATION: VITAL SIGNS: Stable with temperature 97.8, respiratory rate 20, heart rate 76, blood pressure 112/86. GENERAL: Alert young male, NAD. HEENT: TMs clear bilaterally. OP clear. NECK: Supple without adenopathy or thyromegaly. CV: Regular rate and rhythm. No murmurs, rubs, or gallops. CHEST: Clear to auscultation bilaterally, no wheezes, rhonchi, or crackles.
NAD|nothing abnormal detected|NAD.|179|182|OBJECTIVE|REVIEW OF SYSTEMS: See history of present illness, past medical history. The rest is negative. OBJECTIVE: His vital signs were reviewed while he was in the emergency room. HEENT: NAD. Glasses present. Mouth: Has some dentures. NECK: Supple. No lymphadenopathy, no thyromegaly. LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm.
NAD|no acute distress|NAD|121|123|HISTORY OF PRESENT ILLNESS|His stool is black, but he is taking iron supplements now. In the clinic, he does look very pale and weak, but otherwise NAD still very pleasant. We checked the hemoglobin and it was down to 7.3. The decision was made that he will be admitted for packed red cell transfusion and also for repeated GI examination.
NAD|nothing abnormal detected|NAD.|200|203|EXAM|EXAM: VITAL SIGNS: T-max 99, respirations 16, blood pressure 149/73, 96% on room air O2 sats, and her heart rate was 79. GENERAL: She was alert and oriented. SKIN: No acute changes were noted. HEENT: NAD. CHEST: NAD. HEART: NAD. ABDOMEN: NAD. EXTREMITIES: No peripheral edema was noted. ASSESSMENT & PLAN: The patient was noted to be well enough to be discharged to home with the above diagnoses and discharge medications and discharge follow-up.
NAD|nothing abnormal detected|NAD.|212|215|EXAM|EXAM: VITAL SIGNS: T-max 99, respirations 16, blood pressure 149/73, 96% on room air O2 sats, and her heart rate was 79. GENERAL: She was alert and oriented. SKIN: No acute changes were noted. HEENT: NAD. CHEST: NAD. HEART: NAD. ABDOMEN: NAD. EXTREMITIES: No peripheral edema was noted. ASSESSMENT & PLAN: The patient was noted to be well enough to be discharged to home with the above diagnoses and discharge medications and discharge follow-up.
NAD|nothing abnormal detected|NAD.|224|227|EXAM|EXAM: VITAL SIGNS: T-max 99, respirations 16, blood pressure 149/73, 96% on room air O2 sats, and her heart rate was 79. GENERAL: She was alert and oriented. SKIN: No acute changes were noted. HEENT: NAD. CHEST: NAD. HEART: NAD. ABDOMEN: NAD. EXTREMITIES: No peripheral edema was noted. ASSESSMENT & PLAN: The patient was noted to be well enough to be discharged to home with the above diagnoses and discharge medications and discharge follow-up.
NAD|nothing abnormal detected|NAD.|143|146|OBJECTIVE|PAST MEDICAL HISTORY: Otherwise negative. OBJECTIVE: Pulse 74 per minute, respirations 18, temperature afebrile, blood pressure 130/65. HEENT: NAD. NECK: Supple, no lymphadenopathy, no thyromegaly. LUNGS: Clear. HEART: Regular rate and rhythm. ABDOMEN: Soft. There is palpable tenderness in the left mid and lower abdominal quadrant area although there is no rebound, no guarding.
NAD|nothing abnormal detected|NAD.|157|160|PHYSICAL EXAMINATION|She was alert and oriented on exam, and her vitals were stable. Skin: Some ecchymosis was noted. Redness noted at the site of the peripheral IV line. HEENT: NAD. Heart/lung: NAD. Abdomen: Soft, non- tender. Extremities: No peripheral edema. We did spend more than 45 minutes going over the details and answering many questions, and the patient was ready and able to be discharged as that was done.
NAD|nothing abnormal detected|NAD.|174|177|PHYSICAL EXAMINATION|She was alert and oriented on exam, and her vitals were stable. Skin: Some ecchymosis was noted. Redness noted at the site of the peripheral IV line. HEENT: NAD. Heart/lung: NAD. Abdomen: Soft, non- tender. Extremities: No peripheral edema. We did spend more than 45 minutes going over the details and answering many questions, and the patient was ready and able to be discharged as that was done.
NAD|no acute distress|NAD.|173|176|OBJECTIVE|OBJECTIVE: VITAL SIGNS: Afebrile. Heart rate 108 to 114, respiratory rate 16, 95% on room air, blood pressure 144 to 163/70s to 80s. GENERAL: Alert, thin, disheveled female NAD. Oriented times person and place, off by day for the date. HEENT: PERRL. EOMI no nystagmus. OP is clear. Mucous membranes are slightly dry.
NAD|no acute distress|NAD.|183|186|PHYSICAL EXAMINATION|SOCIAL HISTORY: The patient is married. PHYSICAL EXAMINATION: Afebrile. Heart rate 65, respiratory rate 18, blood pressure 111/72, 100% on room air. GENERAL: Alert, cachectic female, NAD. CV: Regular rate and rhythm with 1/6 systolic ejection murmur at the apex. CHEST: Clear to auscultation bilaterally. Tender to palpation over the left anterior chest wall.
NAD|no acute distress|NAD.|153|156|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.4, heart rate 170, respiratory rate 68, blood pressure 98/57, satting 99% on room air. GENERAL: Alert, NAD. HEENT: Normocephalic atraumatic. Anterior fontanele soft and flat. Pupils equal, round, and reactive to light; extraocular movements intact; mucous membranes moist; oropharynx clear.
NAD|no acute distress|NAD.|228|231|OBJECTIVE|No cardiac, respiratory, GI, GU, neurologic or orthopedic problems. FAMILY HISTORY: Positive for a brother with coronary artery disease. No cancer, no diabetes. OBJECTIVE: A very pleasant lady, she looks a bit pale and weak but NAD. HEENT - benign. NECK - no significant anterior nodes or masses. Neck is supple. CHEST - has rales in the left base, otherwise fairly clear.
NAD|no acute distress|NAD|158|160|OBJECTIVE|No cardiac, respiratory, GI, GU, neurological, or orthopedic problems. OBJECTIVE: A pleasant lady. She does not look as pale as her hemoglobin would suggest. NAD now. Actually has a very good appetite at present. The HEENT exam is benign. TMs normal. Tonsils and pharynx not injected.
NAD|no acute distress|NAD.|165|168|PHYSICAL EXAMINATION|(These are postop vitals). Heart rate 71, blood pressure 89/59, respiratory rate 16, oxygen saturation 99% on 2 liters. GENERAL: An alert, thin female eating Jello, NAD. HEENT: PERRL. Sclerae are non-icteric. EOMI. NECK: Neck is supple without adenopathy. Oropharynx is clear. CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs or gallops.
NAD|nothing abnormal detected|NAD.|146|149|DISCHARGE PHYSICAL EXAMINATION|She appeared to be comfortable. VITAL SIGNS: She was afebrile. Her blood pressure was 161/89. Her O2 sats were 97% on room air. SKIN: NAD. HEENT: NAD. CHEST: NAD. HEART: Cardiac murmur present. ABDOMEN: Soft, nontender. EXTREMITIES: No peripheral edema. Peripheral vasculature intact. Peripheral pulses intact. NEUROLOGIC: Grossly intact. PSYCHIATRIC: NAD. The patient is fit enough to be discharged to home.
NAD|nothing abnormal detected|NAD.|188|191|PHYSICAL EXAMINATION ON THE DAY OF DISCHARGE|SKIN: Superior part of face on the right side of the forehead close to the yearly exam bruising which is healing, superificial laceration which is healing, no sutures were applied. HEENT: NAD. CHEST: Clear to auscultation. HEART: No new findings. No murmurs are noted. ABDOMEN: Soft; negative to date. EXTREMITIES: No peripheral edema is noted.
NAD|nothing abnormal detected|NAD.|163|166|DISCHARGE EXAMINATION|She has more energy. VITAL SIGNS: Afebrile; pulse 20; blood pressure 124/62; oxygen saturations at 97% on room air. Alert, oriented, and sitting up in bed. HEENT: NAD. SKIN: NAD. CHEST: Clear to auscultation. HEART: Regular rate and rhythm. ABDOMEN: Soft, nontender. No peripheral edema. This patient feels she is strong enough to be going home.
NAD|nothing abnormal detected|NAD.|174|177|DISCHARGE EXAMINATION|She has more energy. VITAL SIGNS: Afebrile; pulse 20; blood pressure 124/62; oxygen saturations at 97% on room air. Alert, oriented, and sitting up in bed. HEENT: NAD. SKIN: NAD. CHEST: Clear to auscultation. HEART: Regular rate and rhythm. ABDOMEN: Soft, nontender. No peripheral edema. This patient feels she is strong enough to be going home.
NAD|no acute distress|NAD.|110|113|PHYSICAL EXAMINATION|Blood pressure 98/60, temperature 98. GENERAL: The patient is at an ideal body weight. He is fit and healthy. NAD. HEENT: NC/AT; PERRL; TM clear; funduscopic exam is normal; oral exam is normal. NECK: Supple without adenopathy. CHEST: Clear to auscultation. HEART: Regular rate and rhythm without murmur.
NAD|no acute distress|NAD.|205|208|OBJECTIVE|4. HCTZ 25 mg daily. 5. Metformin 500 mg p.o. b.i.d. OBJECTIVE: VITAL SIGNS: Afebrile, blood pressure 117/61, heart rate 70, respiratory rate 20, 97% on room air. GENERAL: Alert female with a flat affect, NAD. HEENT: NC/NT, EOMI, PERRL, cranial nerves II-XII intact bilaterally, OP is clear, mucous membranes are moist. NECK: Supple without adenopathy or thyromegaly. CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; no carotid bruits.
NAD|no acute distress|NAD.|200|203|PHYSICAL EXAMINATION  VITAL SIGNS|PHYSICAL EXAMINATION VITAL SIGNS: Orthostatics, lying blood pressure 115/77, pulse 72 to seated, blood pressure of 108/73 with pulse of 93. Respirations 18. GENERAL: Pleasant, alert, and oriented x3. NAD. Requesting to go home. HEAD: NC/AT. EYES: PERRLA. EOMI. NECK: No LAD. NEUROLOGIC: Cranial nerves 2 through 12 intact. Gait not assessed. Fully oriented. Speech is clear. Tongue midline.
NAD|no acute distress|NAD|155|157|ASSESSMENT AND PLAN|Otherwise acting as a normal baby with appropriate sleep-wake cycles. No fevers. VS, medications, and labs reviewed in FCIS. Alert, cooperative with exam, NAD Sclera clear, oralphayrnx clear Observed breast feeding with appropriate technique by mother and latching and feeding by patient. Neck supple, no LAD Lungs clear, no crackles or wheezes.
NAD|no acute distress|NAD|179|181|PHYSICAL EXAMINATION ON ADMISSION|Maternal grandmother died of a CVA at age 87. PHYSICAL EXAMINATION ON ADMISSION: Temperature 100.1. Blood pressure 104/67. Heart rate 125. Weight 46.5 kg. This is a thin woman in NAD and able to speak in full sentences. Head is AT/NC. Sclerae are slightly injected but nonicteric. Oral mucosa is moist.
NAD|no acute distress|NAD.|192|195|PHYSICAL EXAMINATION ON ADMISSION|PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Blood pressure 143/76, heart rate 92, temperature 98.9, respiratory rate 24, oxygen saturation 94% on room air. Appearance: Alert and oriented, NAD. Eyes: PERRL, EOMI, without icterus. ENT: Oral mucosa moist and pink. Neck: LAD-0. Supple. Possible fullness of the thyroid. Chest: CTA bilaterally. Cardiovascular: RRR, S1, S2 normal. Abdomen: Bowel sounds positive, moderate distention with some right upper quadrant tenderness to palpation and involuntary guarding.
NAD|no acute distress|NAD.|233|236|PHYSICAL EXAMINATION|She uses Lomotil prn if she is going to be out and about and needs to control her loose stools, as she sometimes has no warning. PHYSICAL EXAMINATION: This is a pleasant, alert, elderly, non- toxic and indeed well-appearing woman in NAD. HEENT: Unremarkable. Lungs are clear to auscultation and percussion X 2. No jugular venous distention or carotid bruits. Cor: 1/6 soft, systolic aortic murmur, 1 to 2/6 mitral systolic murmur.
NAD|no acute distress|NAD|111|113|STAFF ADMIT NOTE|Fever to > 103. Eating well, still interactive. No rash, URI, or GI symptoms. VS reviewed. Alert, cooperative, NAD Clear sclera, OP clear, TMs clear. Neck supple, no LAD. Lungs clear, no crackles. Heart regular, no murmur. Abdomen soft, NT. No rash or bruises. No muscle or joint pain.
NAD|no acute distress|NAD,|198|201|PHYSICAL EXAMINATION|Eyes: Pupils are regular secondary to surgery. Ears: Nothing abnormal detected. Nose and throat: Nothing abnormal detected. No loose teeth are noted. Neck: No abnormalities noted. Lymphatics: Again NAD, chest clear to auscultation. No wheezing is noted. Lungs are clear to auscultation. No wheezing is noted. Breast exam: Deferred. Heart: Regular rate and rhythm. Abdomen is soft and nontender.
NAD|no acute distress|NAD.|144|147|REVIEW OF SYSTEMS|EXAM: VITAL SIGNS: Blood pressure 140's to 150's/70's to 80's. Pulse 60's to 74, respiratory rate 14, temperature 98.0. O2 sat 97% on room air. NAD. The patient did receive an aspirin and a dose of Labetalol for a systolic pressure of 170/70. PHYSICAL EXAM: GENERAL: Patient alert, oriented, pleasant, cooperative. HEENT: Normal sclera.
NAD|nothing abnormal detected|NAD.|233|236|DISCHARGE EXAMINATION|Chest x-ray showed chronic obstructive pulmonary disease findings. DISCHARGE EXAMINATION: VITAL SIGNS: Afebrile. Pulse 78. Respirations 18. Blood pressure 125/72. Oxygen saturation on room air 91%. GENERAL: Alert and oriented. SKIN: NAD. ABDOMEN: NAD. EXTREMITIES: No peripheral edema. ASSESSMENT AND PLAN: As above. The patient is ready to be discharged.
NAD|nothing abnormal detected|NAD.|134|137|DISCHARGE EXAMINATION|Pulse 78. Respirations 18. Blood pressure 125/72. Oxygen saturation on room air 91%. GENERAL: Alert and oriented. SKIN: NAD. ABDOMEN: NAD. EXTREMITIES: No peripheral edema. ASSESSMENT AND PLAN: As above. The patient is ready to be discharged.
NAD|nothing abnormal detected|NAD|125|127|PHYSICAL EXAMINATION|Pulse is 62, respirations 20, blood pressure 179/71, 95% O2 sats on room air. SKIN: normal temperature, normal color. HEENT: NAD of acute nature. He does have facial weakness secondary to a stroke. NECK: supple. CHEST: clear to auscultation. HEART: no murmurs are noted. CHEST: clear to auscultation, no wheezing or rhonchi.
NAD|nothing abnormal detected|NAD.|196|199|DISCHARGE EXAMINATION|VITAL SIGNS: Afebrile; pulse 83; respiratory rate 16; blood pressure 129/68; O2 saturations at 94% on room air. SKIN: No acute changes are noted. No color or temperature changes are noted. HEENT: NAD. HEART: No murmurs are noted. LUNGS: No crackles or wheezing is noted. ABDOMEN: Soft, non-tender, there is no peripheral edema noted. Thus the patient was thought well enough to be discharged to the nursing home.
NAD|no acute distress|NAD.|172|175|OBJECTIVE|He does not smoke or use alcohol. OBJECTIVE: VITAL SIGNS: Afebrile. Heart rate 70s, respiratory rate 16, 99% on room air, blood pressure 137/67. GENERAL: Alert, pale male, NAD. HEENT: Conjunctivae are pale. EOMI, no nystagmus. NECK: Supple without adenopathy or thyromegaly. CARDIOVASCULAR: Regular rate and rhythm with a harsh 3/6 holosystolic murmur with radiation to the bilateral carotids.
NAD|nothing abnormal detected|NAD.|209|212|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: As noted, afebrile, pulse 89, respirations 22, blood pressure 148/78, sat 97% on three liters of O2, weight 264.5 pounds, obese. Obvious wheezing is noted. SKIN: NAD. HEENT: NAD. CHEST: Positive wheezing. CVS: No murmurs are noted. ABDOMEN: Soft, nontender. No peripheral edema is noted. NEURO: Grossly within normal limits. PERIPHEROVASCULAR: Peripheral pulses are intact.
NAD|no acute distress|NAD,|129|132|OBJECTIVE|Coffee: May be less than a cup a day. No street drugs. ALLERGIES: Codeine, Omniflex. OBJECTIVE: GENERAL: She is a pleasant lady. NAD, lying in bed supine, alert and oriented times three, moderately over weight. HEENT: Negative. NECK: Negative CCOA nodes and thyroid; requires a refraction.
NAD|nothing abnormal detected|NAD.|138|141|PHYSICAL EXAMINATION|She was alert and oriented. Skin: The left anterior shin rash had improved even more. There were no new acute findings were noted. HEENT: NAD. Heart: NAD. Chest clear to auscultation. Abdomen soft, nontender. Extremities: Right hip pain continues. (_______________)04:58 left lower extremity infection improving on the anterior shin area.
NAD|nothing abnormal detected|NAD.|161|164|DISCHARGE EXAMINATION|SKIN: No acute changes except for the ones present on the left pictorial which seems to be improving in redness and temperature wise. Alert and oriented. HEENT: NAD. CHEST: NAD. CVS: NAD. ABDOMEN: Soft and non-tender. Bowel sounds present. EXTREMITIES: Decreased sensation below the knees. Decreased pin prick and soft touch.
NAD|no acute distress|NAD.|240|243|OBJECTIVE|She does not smoke. Uses significant alcohol, as above. OBJECTIVE: VITAL SIGNS: Afebrile, heart rate 100 to 115; respiratory rate 16 to 18 and 98% on room air; blood pressure 140 to 162 over 80's to 90's. GENERAL: An alert, flushed female, NAD. HEENT: PERRLA, EOMI. NECK: Supple, without adenopathy or thyromegaly. OP is clear. Mucous membranes are moist. CARDIOVASCULAR: Tachycardiac; regular rate and rhythm; no murmurs, rubs, or gallops.
NAD|no acute distress|NAD.|181|184|OBJECTIVE|OBJECTIVE: Afebrile. VITAL SIGNS: Heart rate 60s to 70s; respiratory rate 16 to 18; oxygen saturation at 97% on room air; blood pressure 118 to 140 over 50s to 60s. GENERAL: Alert, NAD. Oriented times self. HEENT: PERRLA, EOMI. NECK: Supple without adenopathy, thyromegaly, or carotid bruits. Mucous membranes are moist. OP is clear. CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops.
NAD|nothing abnormal detected|NAD.|231|234|DISCHARGE PHYSICAL EXAMINATION|DISCHARGE PHYSICAL EXAMINATION: Subjectively, she had no concerns or questions, and she was feeling much better. On exam she was afebrile, pulse was 59, respirations 20, blood pressure 137/59, O2 saturation 96% on room air. HEENT: NAD. Skin: NAD. Chest clear to auscultation. Heart: Regular rate and rhythm. Abdomen soft, non- tender. Extremities: Trace peripheral edema. Peripheral pulses are present.
NAD|no acute distress|NAD|136|138|PHYSICAL EXAMINATION|Heart rate 72, blood pressure 111/63, respiratory rate 16, 96% on room air, weight 160.2. GENERAL: Alert, tearful female; cries easily. NAD and CNT. There is point tenderness to palpation in the right occipital region. There is a slight TMJ click on the right. OP is clear.
NAD|no acute distress|NAD|162|164|110/70, 100, 98 F, RR 14.|On _%#MMDD2007#%_, AST of 107, ALT of 71, alkaline phosphatase of 169, total bilirubin of 26.4, hemoglobin of 10.4. Physical Exam on Discharge : Alert oriented , NAD 110/70, 100, 98 F, RR 14. PERRL, left 6th nerve weakness. Icterus postive. Neck : supple. Chest : clear B/L. CVS : RRR ABD : Non tender, Bowelsound present.
NAD|no acute distress|NAD.|133|136|PHYSICAL EXAM|NAD. Vital signs: The temperature is 97.3. Blood pressure 166/78. Heart rate 98. Respiratory rate 22. SPO2 93% on room air. General: NAD. HEENT: Pharyngeal erythema. Nares are normal. Lungs: Palpable crepitus, rhonchi and scattered crackles on the left field. CV: RRR, S1 and S2 normal. JVD 0. Carotid bruits 0.
NAD|no acute distress|NAD,|135|138|HISTORY OF PRESENT ILLNESS|PHYSICAL EXAM ON ADMISSION: Blood pressure 138/62, heart rate 72, temperature 97.9, SPO2 99% on room air. Appearance: Alert, oriented, NAD, brown skin. Head: ATNC. No sinus tenderness. Eyes: PERL, EOMI. Icterus 0. ENT/Mouth: OP moist, pink. No petechiae over the palate.
NAD|no acute distress|NAD.|207|210||In the ER he got activated charcoal. He has been resting, I would not say he is somnolent or drowsy, very easily arousable, awakeable. He wakes and talks with just soft voice questions. He is lucid A&O x 3, NAD. His only complaint is of a two-month history of right eye pus in the morning. He states this has been green and yellow. REVIEW OF SYSTEMS: Is very difficult to obtain.
NAD|nothing abnormal detected|NAD.|174|177|HOSPITAL COURSE|I spoke to the patient via an interpreter, _%#NAME#%_(?). She was asleep but did awake and was alert and oriented, able to communicate via the interpreter. HEENT: NAD. Skin: NAD. The webbed spaces are healing better. Chest: clear to auscultation. Heart: no murmurs. Abdomen: soft, nontender. Extremities: no peripheral edema is noted. Her hemoglobin was 13.4 today probably because of hemodilution but it had been 12.4, 12.6, and was stable.
NAD|no acute distress|NAD,|172|175|PHYSICAL EXAMINATION|There is no tobacco abuse. She did smoke up until six months ago. There is no caffeine or alcohol abuse. PHYSICAL EXAMINATION: GENERAL: Alert, shaky, oriented times three, NAD, complaining of shortness of breath although her 02 sats with oxygen are currently 98%. VITAL SIGNS: Blood pressure 135/72, pulse 119, respiratory rate 24, temperature 100.5. HEENT: Grossly within normal limits.
NAD|no acute distress|NAD.|254|257|PHYSICAL EXAMINATION|CURRENT MEDICATIONS: None. PAST MEDICAL HISTORY: Negative. PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile; heart rate in the 100's, respiratory rate 26; O2 saturations at 97% on room air; blood pressure 90's/60's. GENERAL: An alert good colored young male. NAD. HEENT: Negative. CV: Regular rate and rhythm, no murmurs, rubs, or gallops. CHEST: Clear to auscultation bilaterally. ABDOMEN: Bowel sounds are positive, soft, non-tender, non- distended, no masses.
NAD|nothing abnormal detected|NAD.|393|396|DISCHARGE PHYSICAL EXAMINATION|DISCHARGE PHYSICAL EXAMINATION: SUBJECTIVE: Doing better. "Will you write the prescriptions for me, I have some of the medications but I will need the pain medications." VITAL SIGNS: Afebrile, pulse 68, respirations 14, blood pressure 118/50, 98% O2 saturations on room air. GENERAL: Alert and oriented. SKIN: No acute changes. HEENT: NAD. HEART/LUNG: NAD. ABDOMEN: Some flank pain, otherwise NAD. EXTREMITIES: No peripheral edema noted and the patient was stable enough to go back home.
NAD|nothing abnormal detected|NAD.|173|176|DISCHARGE PHYSICAL EXAMINATION|Her temperature has stayed at this in the last few days, and her white count has been normal. GENERAL: She is alert and oriented. SKIN: No acute changes. HEENT: NAD. CHEST: NAD. No costochondral or vertebral tenderness noted. HEART: No murmurs noted. ABDOMEN: Soft, nontender. Bowel sounds are heard. EXTREMITIES: No peripheral edema. The patient was deemed fit enough to be transferred.
NAD|no acute distress|NAD|146|148|ASSESSMENT/PLAN|This morning more like self without fussiness with handling. No fevers overnight. VS, medications, and labs reviewed in FCIS. Alert, cooperative, NAD Sclera clear, oralphayrnx clear Neck supple, no LAD Lungs clear, no crackles or wheezes. Heart regular, no murmur. Abdomen soft, non-tender. Good pulses and perfusion.
NAD|no acute distress|NAD|149|151|CV|Attends special education program. No allergies. I have reviewed all labs, medications, vital signs, and imaging. Sleepy but arousable, cooperative, NAD Sclera clear, oralphayrnx clear Neck supple, no LAD, no palpable thyroid. Lungs clear, no crackles or wheezes. Heart regular, no murmur.
NAD|no acute distress|NAD|273|275|FEN|Had a long discussion regarding the pathophysiology of diabetes, the reasons to take insulin, and the need to eat consistent regular meals during the day while on insulin. He appeared to understand and agree. VS, medications, and labs reviewed in FCIS. Alert, cooperative, NAD Sclera clear, oralphayrnx clear Neck supple, no LAD Lungs clear, no crackles or wheezes. Heart regular, no murmur. Abdomen soft, non-tender. Good pulses and perfusion.
NAD|no acute distress|NAD|124|126|FEN|A small cephalohematoma was noted at birth but is now gone. VS, medications, and labs reviewed in FCIS. Alert, cooperative, NAD Sclera clear, oralphayrnx clear, normal suck Neck supple, no LAD Lungs clear, no crackles or wheezes. Heart regular, no murmur. Abdomen soft, non-tender. Good pulses and perfusion.
NAD|no acute distress|NAD|214|216|A/P|Orthostatic hypotension noted with greatly decreased blood pressure when going to a sitting position from a supine (unable to stand due to leg pain). VS, medications, and labs reviewed in FCIS. Alert, cooperative, NAD Sclera clear, oralphayrnx clear Neck supple, no LAD Lungs clear, no crackles or wheezes. Heart regular, no murmur. Abdomen soft, non-tender. Good pulses and perfusion.
NAD|no acute distress|NAD|115|117|CXR|No fevers or chills. Eating and sleeping normally. VS, medications, and labs reviewed in FCIS. Alert, cooperative, NAD Sclera clear, oralphayrnx clear Neck supple, no LAD Lungs clear, no crackles or wheezes. Heart regular, no murmur. Abdomen soft, non-tender. Good pulses and perfusion.
NAD|no acute distress|NAD|225|227|A/P|Continues to have mild nausea and headache. History of oral aversion, gets TPN 2 X per week. Feelilng better this am. No fevers overnight. VS, medications, and labs reviewed in FCIS. Sleepy but easily arousable, cooperative, NAD Sclera clear, oralphayrnx clear Neck supple, no LAD Lungs clear, no crackles or wheezes. Heart regular, no murmur. Abdomen soft, non-tender. Good pulses and perfusion.
NAD|no acute distress|NAD|160|162|A/P|CXR in ED showed right pleural effusion. VS, medications, and labs reviewed in FCIS. Sleepy but easily arousable, irritable only with exam (fears port change), NAD Sclera clear, oralphayrnx clear Neck supple, no LAD Lungs course with decreased breath sounds on the right, otherwise good air movement.
NAD|no acute distress|NAD|181|183|IMPRESSION/RECOMMENDATIONS|We were unable to get much review of systems or any family history. He denies any pain or shortness of breath on O2. VS, medications, and labs reviewed in FCIS. Alert, cooperative, NAD Sclera clear, oralphayrnx clear Neck supple, no LAD Lungs clear, slightly prolonged expiratory phase, good air movement, no crackles or wheezes.
NAD|nothing abnormal detected|NAD.|120|123|IDENTIFICATION|HEENT: Right eye ectropion which is slightly red. Matted material noted at the bases of the eyelashes. Other HEENT exam NAD. Neck supple. Full range of motion. Chest: CTA bilaterally. Heart: No murmurs are noted. Abdomen: Soft, nontender. Extremities as follows: Right lower extremity has slight bruising on the lateral aspect noted.
NAD|no acute distress|NAD|119|121|CV|No chest pains, nauseas or vomiting, fevers or chills. VS, medications, and labs reviewed in FCIS. Alert, cooperative, NAD Sclera clear, oralphayrnx clear Neck supple, no LAD Lungs clear, no crackles or wheezes, decreased size of lung fields, shallow breaths.
NAD|no acute distress|NAD|205|207|PLAN|Feels comfortable giving self insulin injections. We discussed and she appeared to understand the pathphysiology and rational for treatment. VS, medications, and labs reviewed in FCIS. Alert, cooperative, NAD Sclera clear, oralphayrnx clear Neck supple, no LAD Lungs clear, no crackles or wheezes. Heart regular, no murmur. Abdomen soft, non-tender. Good pulses and perfusion.
NAD|no acute distress|NAD|228|230|HEENT|My key findings are: 87 yo with a history of bladder cancer and chronic hematuria comes with 3 weeks of left leg swelling now diagnosed with DVT by leg ultrasound. VS, medications, and labs reviewed in FCIS. Alert, cooperative, NAD Sclera clear, oralphayrnx clear Neck supple, no LAD Lungs clear, no crackles or wheezes. Heart regular, no murmur. Abdomen soft, non-tender. Good pulses and perfusion.
NAD|no acute distress|NAD|224|226|PLAN|She denies any neck stiffness, increased confusion, or photophobia. History of a rash on her right leg 2 months ago. Recent travel to Montana, no other travel. VS, medications, and labs reviewed in FCIS. Alert, cooperative, NAD Sclera clear, oralphayrnx clear Kernig and Brudzinkis were negative, no LAD Lungs clear, no crackles or wheezes. Heart regular, no murmur. Abdomen soft, non-tender. Good pulses and perfusion.
NAD|no acute distress|NAD|200|202|PE|13. Narcan 1 mg p.o. t.i.d. 14. Tap water enema per rectum every day p.r.n. constipation. Allergies: compazine and Thymoglobulin FH/SH non-contributory to this admission PE: vitals reviewed alert, in NAD thin, chronically ill-appearing NCAT, no conj, no icterus neck supple non-labored breath +edema in LE most recent labs and imaging studies reviewed in FCIS A/P: 57 year old male s/p DDKT 2004 admitted for kidney biopsy to eval steadily rising creatinine over the past few months.
NAD|no acute distress|NAD|188|190|BS|Stool pattern typically daily with small hard stools that frequently he strains to expel. Last BM yesterday. VS, medications, and labs reviewed in FCIS. Sleepy but arousable, cooperative, NAD Sclera clear, no red light reflex on right, normal on left, oralphayrnx clear Neck supple, no LAD Lungs course but good air movement, no crackles or wheezes.
NAD|no acute distress|NAD,|1328|1331|RRR|8. Hypertension. 9. Hyperlipidemia. 10. History of gallstones status post cholecystectomy Current Medications: PredniSONE 5 MG Tablet;TAKE 1 TABLET DAILY.; RPT Ambien 5 MG Tablet;TAKE 1 TABLET DAILY AT BEDTIME.; Rx Nexium 40 MG Capsule Delayed Release;TAKE 1 CAPSULE DAILY.; Rx Oxycodone-Acetaminophen 10-325 MG Tablet;TAKE 1 TABLET EVERY 4-6 HOURS PRN pt takes about 1-2 times per week; Rx Calcium 500 MG Tablet;TAKE 1 TABLET TWICE DAILY; RPT NIFEdipine 30 MG Tablet Extended Release 24 Hour;TAKE 1 TABLET EVERY 12 HOURS; Rx Furosemide 40 MG Tablet;TAKE 1 TABLET TWICE DAILY.; Rx Vytorin 10-40 MG Tablet;TAKE 1 TABLET DAILY.; Rx Sodium Bicarbonate 650 MG Tablet;TAKE 2 TABLET TWICE DAILY; Rx Metoprolol Tartrate 100 MG Tablet;Take 1 1/2 tablets by mouth twice daily; RPT Aspirin 81 MG Tablet;TAKE 1 TABLET DAILY.; Rx Calcitriol 0.25 MCG Capsule;TAKE 2 CAPSULE DAILY; Rx Sulfamethoxazole-Trimethoprim 400-80 MG Tablet;TAKE 1 TABLET DAILY; Rx Aranesp (Albumin Free) 100 MCG/0.5ML Solution;Inject 100 mcg SQ WEEKLY; Rx CellCept 500 MG Tablet;TAKE 2 TABLET TWICE DAILY; RPT. Allergies Ancef SOLR; Allergy; Rash. SH/FH: non-contributory to this hosptialization PE: vitals reviewed she is afebrile she is on 3L oximizer with sats in the upper 90's I/O: 4636.5/1955 with urine output of 1655 alert, oriented, appears uncomfortable in NAD, non-toxic NCAT, no conj, no icterus neck supple RRR very limited lung exam but all fields clear to ausultation anteriorly, non-labored abdomen soft and NT no edema in LE labs and CXR reviewed A/P: 35 year old female POD #1 s/p mitral valve surgery - removal of fibroelastoma.
NAD|no acute distress|NAD|257|259|PE|Current inpatient medication list reviewed Allergies Adhesive Tape TAPE Codeine Derivatives Protamine; Allergy; Angina,Tachycardia. SH/FH both non-contributory to this admission PE: alert, non-toxic, appears chronically ill oriented x3 alert, non-toxic, in NAD NCAT, no conj, no icterus OP clear neck supple and NT RRR CTAB non-labored +bowel sounds, tender to deep palpation in RLQ and LLQ, no rebound or guarding no edema in LE neuro grossly non-focal labs reviewed, including her CSA level and urine culture results renal ultrasound reviewed A/P: 46 year old female admitted with elevated creatinine likely due to acute illness with UTI/dehydration.
NAD|no acute distress|NAD|325|327|PE|1. ASA 81 mg qday 2. nephrocaps 3. PhosLo 667mg tid 4. lisinopril 40mg qday 5. metoprolol 150mg bid 6. EPO 18000 units 3x/wk Allergies: PCN, iron dextrose, vancomycin, nifedipine, ciprofloxacin SH/FH: non-contributory for this admission PE: vital reviewed oxygen saturation in the upper 90's on 2-3 L NC alert, non-toxic, in NAD NCAT, no conj, no icterus RRR CTAB anteriorly and laterally no edema in LE labs reviewed, K was 4.1 this morning A/P: 26 year old female POD #0 s/p transplant nephrectomy, no acute indications for dialysis today.
NAD|no acute distress|NAD|1805|1807|PE|Current Medications: Calcitriol 0.25 MCG Capsule;TAKE 1 CAPSULE DAILY.; RPT Levothyroxine Sodium 125 MCG Tablet;TAKE 1 TABLET DAILY.; RPT Zetia 10 MG Tablet;TAKE 1 TABLET DAILY.; RPT Norvasc 10 MG Tablet;TAKE 1 TABLET DAILY.; RPT Aranesp (Albumin Free) SOLN;125mcg s.q. once weekly for correction of anemia; RPT Cortef TABS;take 20mg po every am and 10mg po every evening; RPT Metoprolol Tartrate 50 MG Tablet;TAKE 1 TABLET EVERY 12 HOURS DAILY.; RPT CellCept CAPS 1 GM BID Senokot S TABS;take one tab po twice daily; RPT Flomax 0.4 MG CPCR;TAKE 2 CAPSULE DAILY; RPT Magnesium Oxide 400 MG Tablet;TAKE 1 TABLET 4 TIMES DAILY; RPT Ritalin 5 MG Tablet;TAKE 1 TABLET DAILY.; RPT Dapsone 25 MG Tablet;TAKE 2 TABLET DAILY; RPT Milk of Magnesia SUSP;take 30ml po every night prn for constipation; RPT Zofran 4 MG Tablet;take one tablet every 6hrs prn n/v; RPT NovoLog 100 UNIT/ML Solution;Inject 2 units 3 times daily with each meal BS < 250: 0 units 215-300: 2 units, 301-350: 3 units, 351-400: 4 units, 401 higher call doctor; RPT BuPROPion HCl 300 MG Tablet Extended Release 24 Hour;TAKE 1 TABLET DAILY.; RPT Tylenol Arthritis Ext Relief 650 MG TBCR;take as needed; RPT Lisinopril 5 MG Tablet;TAKE 1 TABLET DAILY.; RPT Loperamide HCl 2 MG Tablet;TAKE 2 TABLET EVERY 8 HOURS as needed for diarrhea; RPT Protonix 40 MG Tablet Delayed Release;TAKE 1 TABLET DAILY.; RPT Prograf 1 MG Capsule;1 cap in pm; RPT Prograf 1.5 MG Capsule;1 cap in am; RPT Metoclopramide HCl 10 MG Tablet;TAKE 1 TABLET 4 TIMES DAILY, BEFORE MEALS AND AT BEDTIME.; RPT Reglan 10 MG Tablet;TAKE 1 TABLET 4 TIMES DAILY, BEFORE MEALS AND AT BEDTIME.; RPT Hydrocortisone 20 MG Tablet;TAKE AS DIRECTED.; RPT Nitrofurantoin 50 MG CAPS;TAKE 1 CAPSULE 4 TIMES DAILY.; RPT. FH/SH: non-contributory for this admission PE: vitals reviewed alert, in NAD fraile, chronically ill-appearing NCAT, no conj, no icterus OP clear neck supple and NT without LAD RRR CTA, non-labored +bowel sounds, soft, ND, allograft non-tender, no rebound, no guarding no edema in LE neuro non-focal labs reviewed ECG reviewed - unchanged when compared to previous CXR reviewed - no focal infiltrates A/P: 61 year old female s/p kidney transplant admitted with hypoglycemic episode.
NAD|no acute distress|NAD.|166|169|PHYSICAL EXAMINATION|She has missed 4 days of work over the last year due to her symptoms. PHYSICAL EXAMINATION: Vital signs are stable. She is pleasant and cooperative with the exam and NAD. She is able to stand and rise from the bed and is able to walk with a limp on the right side. Able to heel and toe walk with some increased discomfort.
NAD|no acute distress|NAD,|128|131|GENERAL|Acting like normal self. Eating and sleeping well. Interactive. VS, medications, and labs reviewed in FCIS. Alert, cooperative, NAD, happy. Head bandaged and exam deferred to neurosurgery. Tracking, EOM intact, PERRL. Sclera clear, oralphayrnx clear Neck supple, no LAD Lungs clear, no crackles or wheezes.
NAD|no acute distress|NAD.|158|161|OBJECTIVE|PAST SURGICAL HISTORY: None. SOCIAL HISTORY: Denies smoking. OBJECTIVE: VITAL SIGNS: Blood pressure 109/71; temperature 97.0; heart rate 80; Caucasian female NAD. NST is reactive to no contractions. ABDOMEN: Soft, nontender. Transabdominal ultrasound confirms a single viable intrauterine gestation and frank breech presentation with anterior placenta.
NAD|no acute distress|NAD|445|447|PE|No nausea, no shortness of breath, no chest pain, pain well-controlled. PMH: ESKD secondary to interstitial nephritis -history of DDKT 1984 -has been on HD since 1998 -dialyzes via a left upper extremity AV fistula, with EDW of 95 kg history of hepatitis C treated with interferon in 2005 secondary hyperparathyroidism s/p subtotal hyperparathyroidism history of duodenal ulcer Medications, Allergies reviewed in chart PE: asleep, arousable, in NAD NCAT, no conj, no icterus RRR CTAB, non-labored abdomen soft, incision site C/D/I left upper extremity fistula with good thrill and bruit no edema in LE patient has had minimal urine output since surgery CXR reviewed and showed no acute airspace disease labs from ealier today reviewedl K was 5.4 post-op A/P: 45 year old male with ESKD s/p DDKT.
NAD|no acute distress|NAD|157|159|PLAN|Pain appears well controled without medications. No fevers or chills. No recent URI symptoms VS, medications, and labs reviewed in FCIS. Alert, cooperative, NAD Left eye patched, right eye ERRL, sclera clear Neck supple, no LAD Lungs clear, no crackles or wheezes. Heart regular, no murmur. Abdomen soft, non-tender. Good pulses and perfusion.
NAD|no acute distress|NAD.|134|137|OBJECTIVE|OBJECTIVE: VITAL SIGNS: Blood pressure 113/76; heart rate in the 90s; respiratory rate 16; afebrile. GENERAL: Alert, depressed female NAD. EOMI. NECK: Supple without adenopathy, thyromegaly, or carotid bruits. CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops. CHEST: Clear to auscultation bilaterally. ABDOMEN: Bowel sounds are positive, soft, nontender, nondistended, no masses or HSM.
NAD|no acute distress|NAD|447|449|PE|Currently she is without complaints. 10 point ROS done and was unremarkable. PMH: DM1 s/p pancreas and LDKT transplants - pancreas in 2001 - kidney in 2000 (brother) without rejection HTN GERD CAD history sz depression HUS/TTP from Prograf Allergies: sulfa, Cipro Meds: MMF 1gm bid dapsone Keppra Reglan carafate Prevacid Effexor metoprolol amlodipine 10 qday SH: lives at nursing home FH: non contributory PE: vitals reviewed alert, pleasant, in NAD NCAT no conj, no icteurs OP clear neck supple and without LAD RRR CTAB abdomen soft and NT no edema no obvious joint swelllings neuro exam grossly non-foca imaging and labs reviewed A/P: 49 year old female admitted for kidney biospy for elevated creatinine.
NAD|no acute distress|NAD|790|792|PE|PMH: 1. ESKD secondary to congenital renal agenesis, this was discovered when he had an accident in 2004 and was found to have an elevated creatinine, he apparently had only his right kidney, s/p LDKT _%#MM2007#%_ without a complicated post-operative course, no rejection episodes, but for the past few months has been running a low Prograf level 2. history of HD from _%#MM2006#%_-_%#MM2007#%_ 3. history of MVA in 2004 Current Medications: Prograf 2.5 mg bid MMF 500 mg bid sodium bicarbonate amlodipine 5 mg bid metoprolol 50 mg bid Protonix Calcium with vitamin D Bactrim Allergies: IVP dye needs prophylaxis SH: he is college student at UND denies smoking, EtOH abuse, and recreational drug use FH: non-contributory to this admission PE: vitals reviewed alert, pleasant, non-toxic, in NAD NCAT, no conj, no icterus OP clear neck supple and NT RRR no murmurs CTAB no crackles abdomen soft and NT, no rebound, no guarding, allograft non-tender no edema in LE neuro grossly non-focal today's labs reviewed, including CBC and coags creatinine 2.5 (per patient was 2.6 yesterday) A/P: 18 year old male s/p LDKT _%#MM2007#%_ with evidence of rejection on biopsy _%#MMDD#%_.
NAD|no acute distress|NAD|96|98|STAFF ADDENDUM|History of asthma, poorly controlled, and depression. VS and labs reviewed. Alert, cooperative, NAD Thin but not ematiated. Poor dentition, no acute oral lesions. Abdomen soft and non-tender, no hepatosplenomegaly. Skin with psoriatic lesions on trunk.
NAD|no acute distress|NAD.|177|180|COMPLICATIONS|HOSPITAL COURSE: Hospital Day #1: The patient feels well. Pain is controlled, receiving sips, no nausea and vomiting. Vital signs were stable, the patient is afebrile. General: NAD. Pulmonary: Lungs are clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, no murmurs. Abdomen: Soft, nondistended, bowel sounds present. Incision, clean, dry, and intact.
NAD|nothing abnormal detected|NAD|137|139|PAST MEDICAL HISTORY|NEUROLOGIC: Negative. MENTAL HEALTH: Positive for anxiety. ENDOCRINE: Negative. PAST MEDICAL HISTORY: 1. Breast cancer diagnosed in 2003 NAD since that time. 2. Hypothyroidism in 2004. Initially, she was hypothyroid and was treated with radioactive iodine. 3. Diverticulitis, 5 bouts or so of diverticulitis over the last 18 months.
NAD|no acute distress|NAD.|380|383|FOLLOW UP RECOMMENDATIONS AND APPOINTMENTS|* Immunizations: none given Discharge medications, treatments and special equipment: * Lasix 3 mg IV q 24 hours * Ativan 0.5 mg IV q 8 hours * Nystatin 50,000 units PO q 6 hours * Phenobarbital 20 mg IV q 24 hours * Fentanyl 3 mcg/kg/hour * Fentanyl 12 mcg IV q 1 hour prn pain Discharge measurements and exam: Weight 3620 gm. Physical exam was notable for an intubated infant in NAD. The remained of the physical exam was within normal limits. Thank you again for allowing us to share in the care of your patient.
NAD|no acute distress|NAD.|145|148|STAFF ADDENDUM NOTE|Now very sleepy. Patient has not received any vaccinations or had any well child checks. VS and labs reviewed. Listless and difficult to arouse, NAD. Neck supple, no LAD. Heart regular, no murmur. Lungs clear, no crackles. Abdomen soft, mild diffuse tenderness, no HSM. MS exam showed no joint or muscle pain.
NAD|no acute distress|NAD.|163|166|DISCHARGE DIAGNOSIS|Endocrine: Negative. Hematologic/lymphatic: Negative. PHYSICAL EXAMINATION: Blood pressure 128/78. Weight is 178 pounds. Generally, she is alert and oriented x 3. NAD. Cardiovascular is RRR. No murmurs, rubs, or gallops. Lungs: CTAB. Abdomen: Soft, nontender. No palpable masses. Pelvic exam deferred as this was performed in _%#MM#%_.
NAD|no acute distress|NAD.|210|213|PHYSICAL EXAMINATION ON ADMISSION|She also has chronic chest wall pain. PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: Temperature 98.0; heart rate 68; blood pressure 164/84, respiratory rate 15, weight 56.8. In general the patient is in bed, NAD. HEENT: ACMT, PERRLA, EOMI, oropharynx is clear. NECK: Supple. LAD was 9. JVP was 0. CV: RRR; S1, S2 are normal. LUNGS: CTA bilaterally.
NAD|no acute distress|NAD.|170|173|STAFF NOTE|Agree with residents note. Patient has COPD & CAD. COPD worse x 2 weeks. Could not ambulate this AM without assistance due to increased dyspnea. Exam confirms patient in NAD. Bilateral expiratory wheezes and rhonchi, few inspiratory roles. Prolonged expiratory phase. H&P discussed and developed with the resident. Agree with steroids, nebs, and antibiotics.
NAD|nothing abnormal detected|NAD|144|146|FAMILY HISTORY|The patient's mother is alive at age of 65 and was diagnosed with breast cancer at age 60. She underwent mastectomy and hormonal therapy and is NAD at this time. The patient also relates that she has a great aunt who was also diagnosed with breast cancer in her 60s.
NAD|nothing abnormal detected|NAD|352|354|OBJECTIVE|No cardiac, respiratory, other GI, GU, neurologic, orthopedic problems. MEDICATIONS: Her current medications include Neurontin 100 mg q.h.s., Lipitor 40 mg daily, Diovan 160 mg daily, isosorbide 30 mg daily, Toprol XL 50 mg daily, Lasix 20 mg daily, Nexium 40 mg daily, potassium 20 mEq daily, and Miralax as needed. OBJECTIVE: A pleasant lady, fairly NAD now. She is not actively retching at this point without an NG tube. HEENT EXAM: TMs normal. Pharynx not injected. NECK: No significant nodes or masses.
NAD|nothing abnormal detected|NAD.|146|149|OBJECTIVE|I believe her mom is a stay-home mom. REVIEW OF SYSTEMS: Completely negative per mom. OBJECTIVE: She is slightly irritable, but very cooperative. NAD. She does not look overtly dehydrated now after 12 hours of IV fluids. HEENT exam: The TMs look normal. Tonsils and pharynx not injected.
NAD|no acute distress|NAD.|176|179|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile. Blood pressure 132/92, heart rate 106, respiratory rate 16, 96% on room air. GENERAL: Alert, very depressed-appearing thin female, NAD. HEENT: PERRL, EOMI. Mucous membranes are moist, clear. NECK: Supple without thyromegaly or adenopathy. CV: Regular rate and rhythm. CHEST: There is good air movement, coarse rhonchi throughout.
NAD|nothing abnormal detected|NAD.|132|135|PHYSICAL EXAMINATION|PSYCHIATRIC: History of depression. PHYSICAL EXAMINATION: GENERAL: Pleasant elderly WM sitting in a semi upright position in bed in NAD. Alert and oriented x3 and able to provide a decent history. VITAL SIGNS: Blood pressure 96/59, respiratory rate 20, O2 saturation 96%, O2 per nasal cannula at 2 liters per minute.
NAD|no acute distress|NAD.|235|238|PHYSICAL EXAMINATION ON ADMISSION|16. Pancytopenia. 17. Malnutrition, TPN dependent. PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: Temperature 99.3, pulse 122, blood pressure 88/54, respiratory rate 16, O2 saturation 99% on room air and weight 38 kilograms. GENERAL: NAD. HEENT: NCAT, no scleral injection. TMs clear bilaterally. Oropharynx without lesions, nonerythematous. Positive for nasal congestion. NECK: Supple, no LAD.
NAD|nothing abnormal detected|NAD|210|212|EXAM|He has had intermittent headaches and some complaints of fatigue recently. Otherwise the patient denies any major complaints. EXAM: Vitals Temp=37 HR=65 BP=144/99 RR=20 O2sat=94% on RA GEN: pleasant conversant NAD HEAD: normal cephalic EENMT: Pupils equally round and reactive to light bilaterally, oropharynx clear without lesions, tongue midline, NECK: supple without masses RESP: CTA B CV: RRR S1,S2 no murmurs ABD: soft nontender, non-distended good bowel sounds EXT: weak pedal pulses, no edema, no calf tenderness SKIN: no jaundice NEURO: patient visibly dizzy and nauscious when seated, unable to complete cranial nerve exam secondary to nausea, discomfort Deep tendon reflexes and strength exam appears symmetric and intact PSYCH: affect slightly flat, ALLERGIES: None known to date.
NAD|no acute distress|NAD,|530|533|VS 36.3, 82, 111/58, 18|HEENT: no dysphagia, odonophagia, diplopia, neck pain or tenderness, dry/scratch eyes, URI, cough, sinus drainage, tinittus, sinus pressure CV: no chest pain, pressure, palpitations, skipped beats, LOC LUNGS: no SOB, DOE, cough, sputum production, wheezing ABDOMEN: no diarrhea, constipation, + abdominal pain EXTREMITIES: no rashes, ulcers, edema NEUROLOGY: no changes in vision, tingling or numbness in hands or feet. MSK: no muscle aches or pains, weakness Physical Exam VS 36.3, 82, 111/58, 18 GENERAL: Alert and oriented X3, NAD, well dressed, answering questions appropriately, appears stated age. HEENT: OP clear, no LAD, no TM, non-tender, no exopthalmous, no proptosis, EOMI, no lig lag, no retraction CV: RRR, no rubs, gallops, no murmurs LUNGS: CTAB, no wheezes, rales, or ronchi ABDOMEN: soft, Nontender, nondistended, +BS, no organomegaly EXTREMITIES: no edema, +pulses, no rashes, no lesions NEUROLOGY: CN grossly intact, + pinprick, + DTR upper and lower extremity MSK: grossly intact LABS Na 134, K 4.4, Cl 109 HCO3 25, BUN 21, Creat 0.84, G 132 WBC 11.2, Hgb 10.4, Hct 131, Plts 223 BS 150-200
NAD|no acute distress|NAD,|191|194|PHYSICAL EXAMINATION|-Married. -4 children -Work as a Sales Rep in Baline REVIEW OF SYSTEMS: as per HPI. Full 13 pt ROS performed. PHYSICAL EXAMINATION: VS- 36.1, 105, 18, 147/85 GENERAL: Alert and Oriented X 3, NAD, agitated, appears stated age. HEENT: EOMI, no exopthalmous, no lid lag, no retraction. No nystagmus. Sclerae nonicteric. Neck: Thyroid 50 g with 2 cm nodule left lobe and 1 cm nodule nodule right lobe.
NAD|nothing abnormal detected|NAD.|507|510|PE|Allergies: Sulfa Meds: Levaquin Acyclovir Caspafungin Pentamidine Ceftazidime Synthroid Celexa Protonix Ursodiol GCSF Immodium Carafate Ativan Granisetron Fentanyl PCA Benadryl FH: Dad --> Lung cancer, CHF, MI Mom -->CVA, uterine and breast cancers, Other MI, CHF SH: Married, lives in _%#CITY#%_ _%#CITY#%_, Recovering alcoholic-->quit 1980, h/o cocaine and THC use ROS: Per HPI other systems reviewed and negative except for some diarrhea PE: BP:100/64 HR:82 RR:16 T:36.7 98% on 3LPM N/C Gen: A and O x 3 NAD. Speaks in complete sentences. Very pleasant female HEENT: PERRLA, MMM and pink, EOMI, no scleral icterus, allopecia Neck: Supple, no JVD, +calcified/firm node left side at the angle of the jaw CV: RRR no M/R/G.
NAD|nothing abnormal detected|NAD.|220|223|DISCHARGE PHYSICAL EXAMINATION|VITAL SIGNS: Afebrile, blood pressure 120/67, respiratory rate 18, oxygen saturation 98% on room air, heart rate 77. SKIN: She has a bruise on the left forearm which seems to be healing. No lacerations are noted. HEENT: NAD. CHEST: NAD. HEART: NAD. LUNGS: NAD. ABDOMEN: Soft and nontender. Bowel sounds are heard. No epigastric tenderness noted now. No peripheral edema is noted.
NAD|nothing abnormal detected|NAD.|232|235|DISCHARGE PHYSICAL EXAMINATION|VITAL SIGNS: Afebrile, blood pressure 120/67, respiratory rate 18, oxygen saturation 98% on room air, heart rate 77. SKIN: She has a bruise on the left forearm which seems to be healing. No lacerations are noted. HEENT: NAD. CHEST: NAD. HEART: NAD. LUNGS: NAD. ABDOMEN: Soft and nontender. Bowel sounds are heard. No epigastric tenderness noted now. No peripheral edema is noted.
NAD|nothing abnormal detected|NAD.|127|130|DISCHARGE PHYSICAL EXAMINATION|SKIN: She has a bruise on the left forearm which seems to be healing. No lacerations are noted. HEENT: NAD. CHEST: NAD. HEART: NAD. LUNGS: NAD. ABDOMEN: Soft and nontender. Bowel sounds are heard. No epigastric tenderness noted now. No peripheral edema is noted.
NAD|no acute distress|(NAD)|142|146|OBJECTIVE|No cardiac, respiratory, gastrointestinal, genitourinary, neurologic, or orthopedic problems. OBJECTIVE: A pleasant lady in no acute distress (NAD) now. No cramping at present. The HEAD, EYES, EARS, NOSE, and THROAT exam is benign. NECK: No significant anterior nodes or masses. The NECK is supple.
NAD|no acute distress|NAD.|153|156|ALLERGIES|PHYSICAL EXAMINATION: On admission: Temperature 97, pulse 63, blood pressure 111/72, respiratory rate 20, O2 saturation 99% with 2 L of oxygen. GENERAL: NAD. Speaks in full sentences. Dyspneic with minimum exertion. NECK: JVP with 11-10 dilated. CARDIOVASCULAR: Irregularly irregular soft systolic murmur, 3/6, split S2, no S3 or rubs.
NAD|no acute distress|NAD,|104|107|PHYSICAL EXAM|No cardiac, respiratory, GI, GU, neurological or orthopedic problems. PHYSICAL EXAM: Very pleasant lady NAD, now no symptoms whatsoever. HEENT EXAM: Benign. NECK: No significant masses. No JVD is noted. NECK is supple. CHEST is clear. CARDIOVASCULAR: Irregular rhythm with a rate around 100.
NAD|no acute distress|NAD,|183|186|REVIEW OF SYSTEMS|NEUROLOGICAL EXAM: Negative. BACK: Negative. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 102/66, pulse 81, respirations 18, temperature 97.4, pulse ox 95% on room air. GENERAL: NAD, somewhat cushingoid on appearance. He is alert, pleasant. HEENT: No scleral icterus. Oral mucosa is moist without lesions. NECK: Supple. No LA or bruit. CHEST: Clear to auscultation bilaterally.
NAD|no acute distress|NAD.|141|144|PHYSICAL EXAMINATION|Blood pressure 150s to 180s/70s. Heart rate 80. Respiratory rate 18. Afebrile. Oxygen saturation 96% on room air. GENERAL: Alert older male, NAD. HEENT: N/C, N/T. EOM I wearing glasses. OP is clear. Mucous membranes are moist. NECK: Supple without adenopathy, thyromegaly, or carotid bruits.
NAD|no acute distress|NAD|215|217|EXAM ON ADMISSION   GENERAL|There was some thought certainly given on continuing others and thought certainly given to conversion disorder, unable to identify the precipitating factors other than history of anxiety. EXAM ON ADMISSION GENERAL: NAD and pleasant. VITAL SIGNS: Afebrile, pulse 65, blood pressure 117/96, saturating 100% in room air, and respiratory rate 38. HEENT: Eyes: EOMI, PERLA without nystagmus. Head: NCAT. Ears: TMs normal.
NAD|no acute distress|NAD,|291|294|PHYSICAL EXAMINATION|NEURO: Negative. PSYCH: Negative. ENDOCRINE: Negative. MUSCULOSKELETAL: Some "flat feet" with some foot pain when she walks, and some osteoarthritis of the hands, and otherwise negative. PHYSICAL EXAMINATION: VITALS: Blood pressure 185/89, pulse ox 96%, temperature 98.2, pulse 61. GENERAL: NAD, alert and pleasant, cooperative. SKIN: Petechial rash, non-blanched, affecting patch on both shoulders, as well as the interior lower legs. HEENT: She has a resolving ecchymosis over the right temple.
NAD|no acute distress|NAD|100|102|OBJECTIVE|No other cardiac, respiratory, GI, GU, neurologic, orthopedic problems. OBJECTIVE: A pleasant lady, NAD now. Heart rate in the 80s to 140s, fluctuating. HEENT EXAM: NC/AT, PERRLA, full EOMs, full fields. Vision intact per patient. TMs normal. Tonsils and pharynx not injected.
NAD|no acute distress|NAD.|171|174|PHYSICAL EXAMINATION|Blood pressure is 120/67. He is afebrile. Pulse is 84 and regular, respiratory rate 16 and unlabored, 97% on room air. GENERAL: Pleasant, non-toxic, well-appearing man in NAD. SKIN: Warm and dry. No lymphadenopathy. LUNGS: Clear to auscultation and percussion X 2. COR: Normal S1, S2. RRR. No M/G/R. ABDOMEN: Non-distended. Normoactive bowel sounds.
NAD|no acute distress|NAD|356|358|OBJECTIVE|SOCIAL HISTORY: She is married, has two children. She is moderately active physically, in fact she goes for a walk every morning at 5:00 a.m. She states that two days ago she felt extremely fatigued/exhausted after her walk which is not at all her usual norm after going for these walks. REVIEW OF SYSTEMS: Completely negative. OBJECTIVE: A pleasant lady, NAD now. HEENT - benign. NECK - no significant anterior nodes or masses. Neck is supple. CHEST - clear. CARDIOVASCULAR - regular rate and rhythm, S1, S2 normal.
NAD|no acute distress|NAD,|81|84|OBJECTIVE|The does of her furosemide is unclear at this point. OBJECTIVE: A pleasant lady, NAD, now at rest. She is extremely unstable, needs, max assist of two just to stand up. HEENT EXAM: NCAT, PERRLA, full EOMs, full field of vision intact per patient.
NAD|no acute distress|NAD.|207|210|PHYSICAL EXAMINATION  VITAL SIGNS|PHYSICAL EXAMINATION VITAL SIGNS: On her admit exam, vitals afebrile, pulse 68, blood pressure 137/99, respirations of 16, O2 saturation 95% on room air. GENERAL: She was alert, oriented, well appearing, in NAD. HEENT: Head: NCAT. Eyes: PERRLA. EOMI. Nose and Throat: Oropharynx is without erythema. Mucous membranes are moist. NECK: Supple without TM, or LA.
NAD|no acute distress|NAD|122|124|PHYSICAL EXAMINATION|He occasionally drinks alcohol, has a few cups of coffee a day. PHYSICAL EXAMINATION: GENERAL: A very pleasant gentleman, NAD now. HEENT: Normocephalic, atraumatic. PERRLA. Full field of vision intact per patient. TMs normal. Tonsils and pharynx not injected. NECK: No significant nodes or masses.
NAD|no acute distress|NAD.|162|165|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: GENERAL: She was fast asleep and I had to wake her up for the exam. History is given by the patient. She denies any further suicidal ideation. NAD. CVS, respiratory, GI, extremities and neurologic negative. VITAL SIGNS: Include a temperature of 36.2 with a heart rate of 102, blood pressure 130/80, respirations 18, 02 saturation 99% on room air.
NAD|no acute distress|NAD|122|124|PHYSICAL EXAMINATION|No cardiac, respiratory, GI, GU, neurologic, orthopedic problems. PHYSICAL EXAMINATION: GENERAL: Very pleasant gentleman, NAD now after Toradol. HEENT: Benign. NECK: No significant nodes or masses. Neck is supple. CHEST: Clear. CARDIOVASCULAR: Regular rate and rhythm. S1, S2, no murmurs.
NAD|no acute distress|NAD|130|132|PHYSICAL EXAMINATION|No cardiac, respiratory, GI, other GU, neurologic or orthopedic problems. PHYSICAL EXAMINATION: GENERAL: Pleasant lady. She seems NAD now. HEENT: Benign. NECK: No significant nodes or masses. Neck is supple. CHEST: Clear. CARDIOVASCULAR: Regular rate and rhythm. S1, S2, no murmurs. ABDOMEN: Soft, mild diffuse tenderness in the low abdomen without any focality.
NAD|no acute distress|NAD|303|305|PHYSICAL EXAMINATION|He is minimally active physically. ALLERGIES: None. MEDICATIONS: None. REVIEW OF SYSTEMS: Negative for any new eye symptoms, ear symptoms, lymphatic symptoms, psychiatric symptoms, no cardiac, respiratory, GI, GU, neurologic, orthopedic problems. PHYSICAL EXAMINATION: GENERAL: Very pleasant gentleman, NAD now. Only mildly short of breath on nasal cannula O2. HEENT: Benign. NECK: No significant nodes or masses. Neck is supple.
NAD|no acute distress|NAD.|245|248|VITAL SIGNS|VITAL SIGNS: Stable: T-max 36.8, pulse 77 to 91, blood pressure 144 to 158 systolic over 71 to 82 diastolic, respiratory rate 18, O2 saturation 96% to 98% on room air. GENERAL: A pleasant female, alert, awake, and oriented, and conversing well, NAD. CARDIOVASCULAR: Grade 1/6 systolic murmur. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Obese, soft, no masses or tenderness, absence of CVA tenderness.
NAD|no acute distress|NAD.|184|187|OBJECTIVE|OBJECTIVE: VITAL SIGNS: Afebrile. Heart rate 100, blood pressure 157/83, respiratory rate 18, 94% on room air. Weight 126 pounds. GENERAL: Alert female, appears older than stated age. NAD. HEENT: NCNT. Pupils are pinpoint. EOMI. OP clear. Mucous membranes are moist. NECK: Supple without adenopathy, thyromegaly or carotid bruits. CARDIOVASCULAR: Regular rate and rhythm.
NAD|no acute distress|NAD.|275|278|PHYSICAL EXAMINATION ON ADMISSION|PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: Temperature 98.4, pulse 76, blood pressure 130/76, respiratory rate is 16, O2 saturation 98% on room air. Orthostatics were not done due to the patient's discomfort with sitting up and standing. GENERAL: Alert and oriented x3, NAD. HEAD: Atraumatic, normocephalic. HEENT: Pupils equal, round and reactive to light. Extraocular eye movements intact. No nystagmus appreciated. TMs clear bilaterally.
NAD|no acute distress|NAD|138|140|OBJECTIVE|No cardiac, respiratory, GI, GU, neurologic, or orthopedic problems other than that noted above. OBJECTIVE: GENERAL: A very pleasant man, NAD now. He has not had pain for 6 hours. HEENT exam is benign. NECK: No significant anterior nodes or masses.
NAD|no acute distress|NAD,|156|159|OBJECTIVE|OBJECTIVE: VITAL SIGNS: Blood pressure 119/78, pulse 89, respiratory rate 16, temperature 97.4. GENERAL: This is a pleasant fairly well appearing woman in, NAD, lying comfortable in bed. HEENT: Unremarkable. LUNGS are clear to auscultation times two. COR: Normal sinus rhythm, S1, S2, regular rate and rhythm/G/R.
NAD|no acute distress|NAD,|122|125|OBJECTIVE|No cardiac or respiratory, GI, GU, neurologic, or orthopedic problems. OBJECTIVE: This is a very pleasant lady, who looks NAD, but is complaining of weakness even after arrival here. HEENT: Benign. NECK: No significant nodes or masses, no JVD noted. Neck is supple. CHEST: Clear. CARDIOVASCULAR: Regular rate and rhythm, S1 and S2 normal.
NAD|no acute distress|NAD,|192|195|CHIEF COMPLAINT|At that time, his pulse was 68 to 102, blood pressure was 96 to 103 over 55 to 65, respiratory rate 18 to 20, saturating 92% to 99% on room air. He was afebrile with a T-max of 98.8. General: NAD, thin, and pleasant. Head: Atrophic, normocephalic. Neck: Supple, no lymphadenopathy. Cardiovascular: Regular rate and rhythm. Holosystolic murmur, heard best at the apex, prominent PMI, murmur heard 3/6, ejection, at the right upper sternal border.
NAD|no acute distress|NAD|178|180|CV|No BRBPR, no hematemesis. No N/V, no abdominal pain. He had mild SOB, no CP. The patient actually feels well. PMH, FH, SH and ROS as per resident note. Exam: VSS as per EMR Gen: NAD Pulm:CTABL CV:nl s1s2 no m/r/g Abd:soft NT/ND nl bs Labs, radiology studies, and medications reviewed. Assessment and Plan: 72 yo man with a h/o of GI bleeds from AVM here for anemia.
NAD|no acute distress|NAD.|290|293|PHYSICAL EXAMINATION|FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Negative for any new eye symptoms, ear symptoms, lymphatic symptoms, psychiatric symptoms, no cardiac, respiratory, gastrointestinal, genitourinary, neurologic, orthopedic problems. PHYSICAL EXAMINATION: GENERAL: Very pleasant gentleman, NAD. HEENT: NC/AT. PERRLA, full EOMs, full field vision intact per patient. TMs normal. Tonsils and pharynx not injected. NECK: No significant lymph nodes or JVD, no carotid bruits.
NAD|no acute distress|NAD.|119|122|PHYSICAL EXAMINATION|No cardiac, respiratory, GI, GU, neurologic or orthopedic problems. PHYSICAL EXAMINATION: GENERAL: Very pleasant lady, NAD. HEENT: NC/AT, PERRLA, full EOMs, field of vision intact per patient. TMs normal. Tonsils and pharynx not injected. NECK: No significant anterior nodes or masses.
NAD|no acute distress|NAD|155|157|ENT|Mother diagnosed with cancer and a brother with COPD as well. Physical Exam: Afebile, P78, BP168/96, RR18, Sats 95% on 3L NC 42.2 kg Gen: Alert, pleasant, NAD Eyes: Non-icteric, non-injected ENT: TMs obscured by cerumen. Tender to percussion over bilateral frontal and maxillary sinuses. Pulm: Very little air movement right (native) lung.
NAD|no acute distress|NAD|99|101|OBJECTIVE|No cardiac, respiratory, GI, GU, neurologic, orthopedic problems. OBJECTIVE: A very pleasant lady, NAD now. HEENT exam is benign. NECK: No significant extra nodes or masses. Neck is supple. CHEST is clear. CARDIOVASCULAR: Regular rate and rhythm.
NAD|nothing abnormal detected|NAD.|172|175|PHYSICAL EXAMINATION|GENERAL: Alert, oriented as always, very pleasant. SKIN: Chronic scleroderma changes noted on the right lower extremity. No acute ecchymosis or other changes noted. HEENT: NAD. LUNGS: NAD. HEART: NAD. ABDOMEN: NAD. EXTREMITIES: Some trace edema. Some discoloration which is chronic because of poor circulation, her weight issues, and scleroderma positive.
NAD|nothing abnormal detected|NAD.|196|199|PHYSICAL EXAMINATION|GENERAL: Alert, oriented as always, very pleasant. SKIN: Chronic scleroderma changes noted on the right lower extremity. No acute ecchymosis or other changes noted. HEENT: NAD. LUNGS: NAD. HEART: NAD. ABDOMEN: NAD. EXTREMITIES: Some trace edema. Some discoloration which is chronic because of poor circulation, her weight issues, and scleroderma positive.
NAD|nothing abnormal detected|NAD.|210|213|PHYSICAL EXAMINATION|GENERAL: Alert, oriented as always, very pleasant. SKIN: Chronic scleroderma changes noted on the right lower extremity. No acute ecchymosis or other changes noted. HEENT: NAD. LUNGS: NAD. HEART: NAD. ABDOMEN: NAD. EXTREMITIES: Some trace edema. Some discoloration which is chronic because of poor circulation, her weight issues, and scleroderma positive.
NAD|no acute distress|NAD.|178|181|OBJECTIVE|FAMILY HISTORY: Positive for father with diabetes and a stroke and also cancer, origin unknown. REVIEW OF SYSTEMS: Otherwise is negative. OBJECTIVE: Pleasant man morbidly obese, NAD. HEENT EXAM: Benign. NECK: No significant anterior nodes or masses. NECK is supple. CHEST is clear. CARDIOVASCULAR: Regular rate and rhythm, S1 and S2.
NAD|nothing abnormal detected|NAD.|171|174|LABORATORY|Her blood pressure was 137/57. She was alert and oriented and pleasant, although she seemed to be having a declining memory. Skin: No color or temperature changes. HEENT: NAD. Heart, lungs, and abdomen were NAD. No peripheral edema was noted. Thus, she was stable enough and feeling well enough to be discharged to home.
NAD|nothing abnormal detected|NAD.|223|226|PHYSICAL EXAMINATION ON DISCHARGE|VITAL SIGNS: Blood pressure 148/68, 90% O2 saturations on room air, pulse 88, respirations 18, she was afebrile. She was alert and oriented lying in bed. SKIN: Wound site as per ortho, otherwise nothing acute noted. HEENT: NAD. CHEST: CT bilateral. CV: No murmurs. ABDOMEN: Soft; nontender. EXTREMITIES: Not edematous in pneumoboots. ASSESSMENT AND PLAN: As above and ready to be discharge.
NAD|nothing abnormal detected|NAD.|184|187|PHYSICAL EXAMINATION|On examination, vitals were stable, afebrile. Pulse 76, respirations 18, blood pressure 131/63, O2 saturations 95% on room air. Alert, oriented, very pleasant, decreased hearing. Skin NAD. HEENT: Decreased hearing. Chest: NAD. Heart: NAD. Abdomen: Soft and nontender Extremities: No peripheral edema and grossly neurologically intact.
NAD|no acute distress|NAD.|149|152|PHYSICAL EXAMINATION|He occasionally drinks alcohol. No other drug use. REVIEW OF SYSTEMS: Negative other than that noted above. PHYSICAL EXAMINATION: Very pleasant man, NAD. Of note, his blood pressure has been running quite low in the 70's and 80's systolic. He does not feel lightheaded or have any symptoms now.
NAD|nothing abnormal detected|NAD.|185|188|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Vitals as documented in the e-chart. Blood pressure 192/107, pulse 98, respirations 18, temperature normal, O2 sats normal at 95%. HEENT: NAD. HEART: NAD. ABDOMEN: NAD. CHEST: NAD. MUSCULOSKELETAL: NAD. SKIN: Multiple back lesions status post liquid nitrogen treatment. PSYCHIATRIC: NAD. NEUROLOGIC: Please review the Neurology consult and is concurrent with that.
NAD|no acute distress|NAD.|177|180|PHYSICAL EXAMINATION|No cardiac, respiratory, GI, GU, neurologic or orthopedic problems. PHYSICAL EXAMINATION: GENERAL: The patient is a pleasant man. He does have a mild facial droop but otherwise NAD. He is complaining of a headache at present. HEENT: He does have a mild residual, right facial droop involving the right eyelid.
NAD|no acute distress|NAD.|172|175|PHYSICAL  EXAMINATION|She was recently transferred to the ICU, however, for hypotension. Her blood pressure currently is stable. GENERAL: She is pleasant and cooperative with examination and in NAD. Temperature at midnight was 96.3, pulse currently 125, blood pressure 102/68, pulse oximeter at 91% with O2 per nasal cannula. She is pleasant and cooperative with exam and in no apparent distress.
NAD|no acute distress|NAD|216|218|OBJECTIVE|He is quite inactive physically, although he still drives a car and does his own cooking and most of his cleaning. REVIEW OF SYSTEMS: Negative otherwise. OBJECTIVE: A very pleasant man cordial, oriented times three, NAD now. The HEENT exam is benign. NECK: No significant anterior nodes or masses. The NECK is supple. The CHEST is clear. CARDIOVASCULAR: Regular rate and rhythm.
NAD|no acute distress|NAD.|151|154|OBJECTIVE|She is very inactive physically. REVIEW OF SYSTEMS: Negative other than the extensive history noted above. OBJECTIVE: A pleasant lady, actually fairly NAD. Now she is complaining of significant pain in her hands and fingers at this time. HEENT EXAM: NC/AT. PERRLA. Full fields of vision grossly intact.
NAD|no acute distress|NAD,|133|136|PHYSICAL EXAMINATION|Neuro: Negative. Musculoskeletal: Negative except for mild arthritis in the fingers. Psych: Negative. PHYSICAL EXAMINATION: GENERAL: NAD, alert, pleasant, comfortable. VITAL SIGNS: Blood pressure 123/64, pulse 86, respiratory rate 20, pulse ox 99% on two liters. HEENT: Normocephalic and atraumatic. No icterus. ENT: OMM without lesions.
NAD|no acute distress|NAD.|135|138|OBJECTIVE|Oxygen saturation 94 to 97% on room air. Blood pressure in the 1 teens over 70s. General: The patient is sleeping, arousable to voice, NAD. HEENT: Neck is supple without adenopathy or bruits. Mucous membranes are moist. Cranial nerves are grossly intact. CV: Regular rate and rhythm with a I/VI systolic ejection murmur at the left upper sternal border (no radiation).
NAD|nothing abnormal detected|NAD.|115|118|PHYSICAL EXAMINATION|SKIN: Skin appears cooler on his lower extremities. There are large pores present on his nose and his face. HEENT: NAD. CHEST: NAD. HEART: NAD. ABDOMEN: Soft, nontender, obese. BACK: No obvious deformities noted when he sits up in bed. EXTREMITIES: Peripheral pulses are present, though they seem to be weak.
NAD|nothing abnormal detected|NAD.|139|142|PHYSICAL EXAMINATION|SKIN: Skin appears cooler on his lower extremities. There are large pores present on his nose and his face. HEENT: NAD. CHEST: NAD. HEART: NAD. ABDOMEN: Soft, nontender, obese. BACK: No obvious deformities noted when he sits up in bed. EXTREMITIES: Peripheral pulses are present, though they seem to be weak.
NAD|nothing abnormal detected|NAD.|127|130|PHYSICAL EXAMINATION|SKIN: Skin appears cooler on his lower extremities. There are large pores present on his nose and his face. HEENT: NAD. CHEST: NAD. HEART: NAD. ABDOMEN: Soft, nontender, obese. BACK: No obvious deformities noted when he sits up in bed. EXTREMITIES: Peripheral pulses are present, though they seem to be weak.
NAD|no acute distress|NAD.|137|140|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITALS: Temp 97.6, pulse 142, blood pressure 92/42, respirations 36, weight 11.3 kg, height 78 cm. GENERAL: WN/WD, NAD. HEAD: NC/AT, soft anterior fontanel. EYES: Small conjunctival hemorrhage in both eyes. EARS: Patent, clear TMs bilaterally. NOSE: Patent. MOUTH/THROAT: OP is clear.
NAD|no acute distress|NAD,|144|147|PHYSICAL EXAM|No psychiatric symptoms. No cardiac, respiratory, GI, GU, neurologic, or orthopedic problems. PHYSICAL EXAM: This is a very pleasant young man, NAD, seems energetic and talkative now. HEENT - TMs look normal. Tonsils are moderately enlarged although I think this is likely his baseline.
NAD|no acute distress|NAD|136|138|OBJECTIVE|REVIEW OF SYSTEMS: Negative for any other cardiac, respiratory, GI, GU, neurologic, or orthopedic problems. OBJECTIVE: A pleasant lady, NAD now. Please see HPI. HEENT EXAM: Benign. NECK: No significant anterior nodes or masses. Neck is supple. CHEST is clear. CARDIOVASCULAR: Regular rate and rhythm. S1, S2, no murmurs.
NAD|no acute distress|NAD|233|235|REVIEW OF SYSTEMS|He denies any other drug use. REVIEW OF SYSTEMS: Negative for eye symptoms, ear symptoms, lymphatic symptoms, psychiatric symptoms. No cardiac, respiratory, GI, GU, neurological, or orthopedic problems. OBJECTIVE: Very pleasant man, NAD now. HEENT exam is benign. NECK: No significant anterior nodes or JVD. NECK: Supple. CHEST is clear. CARDIOVASCULAR: Regular rate and rhythm, S1, S2.
NAD|no acute distress|NAD.|256|259|REVIEW OF SYSTEMS|He is married. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Negative for eye symptoms, ear symptoms, lymphatic symptoms, psychiatric symptoms, no other cardiac, respiratory, GI, GU, neurological or orthopedic problems. OBJECTIVE: Very pleasant man, NAD. HEENT exam is benign. Of note is his blood pressure is slightly low in the 90 to 110 range systolic. NECK: No significant extra nodes or carotid bruits. Neck is supple.
NAD|no acute distress|NAD,|114|117|PHYSICAL EXAMINATION|Cardiovascular: Negative. No chest pain or lower extremity swelling. GI: Negative. PHYSICAL EXAMINATION: GENERAL: NAD, alert, pleasant. VITAL SIGNS: Initially the systolic blood pressure was in the 70's during the event, noted on the nurses report.
NAD|no acute distress|NAD,|124|127|OBJECTIVE|There is no diabetes or breast cancer. Father died of colon cancer at 76 years old. OBJECTIVE: GENERAL: Very pleasant lady, NAD, A&O times 3. HEENT: Negative. Wears a refraction. Negative CCOA, inguinal nodes and thyroid. No carotid or abdominal bruits. No JVD. CHEST: Normal configuration. PELVIC/BREAST/RECTAL: Deferred. CHEST: Clear to auscultation with excellent inspiratory effort, anterior/posterior.
NAD|no acute distress|NAD.|235|238|OBJECTIVE|No cardiac, respiratory, GI, GU, neurologic, orthopedic problems. MEDICATIONS: Avapro 150 mg daily, Niaspan 500 mg daily, Lopid 600 mg bid, aspirin daily. ALLERGIES: ZITHROMAX. OBJECTIVE: A pleasant man somewhat fatigued but otherwise NAD. HEENT EXAM: TM's look normal. Tonsils and pharynx not injected. NECK: No significant nodes or masses. NECK is supple. CHEST: He has some rhonchi and faint wheezes in the right lung fields.
NAD|no acute distress|NAD,|119|122|PHYSICAL EXAMINATION|No other cardiac, respiratory, GI, GU, neurologic or orthopedic problems. PHYSICAL EXAMINATION: GENERAL: Pleasant lady NAD, now pain-free at this point. HEENT: Benign. NECK: No significant nodes or masses. Neck is supple. CHEST: Clear. CARDIOVASCULAR: Regular rate and rhythm, S1 and S2.
NAD|no acute distress|NAD,|162|165|SOCIAL HISTORY|The patient is married. PHYSICAL EXAMINATION: On admission: VITAL SIGNS: Temperature 98, blood pressure 119/75, heart rate 105, and respiratory rate 18. GENERAL: NAD, pleasant, and cooperative. Alert and oriented x3. CARDIOVASCULAR: Regular rate and rhythm with a 2/6 systolic ejection murmur at the left intercostal space.
NAD|no acute distress|NAD.|173|176|PHYSICAL EXAMINATION|No cardiac, respiratory, GI, GU, neurologic or orthopedic problems. PHYSICAL EXAMINATION: GENERAL: Very pleasant lady, obviously embarrassed somewhat achy now but otherwise NAD. HEENT: Benign. NECK: No significant nodes or masses. Neck is supple. CHEST: Clear. CARDIOVASCULAR: Regular rate and rhythm, S1, S2, no murmurs.
NAD|no acute distress|NAD.|280|283|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: A 10-point review of systems was completed and significant positives include epigastric pain radiating toward the back with recurrent abdominal pain and some dysuria. PHYSICAL EXAMINATION: GENERAL: The patient was seen by me a few hours after she was admitted. NAD. VITAL SIGNS: Temperature 97.3, blood pressure 102/61, respirations 10. HEAD: Without any sign of trauma. EARS, NOSE AND THROAT: Normal. EYES: PERRLA. Extraocular muscles intact. NECK: Supple without any adenopathy.
NAD|no acute distress|NAD|95|97|OBJECTIVE|REVIEW OF SYSTEMS: Otherwise negative other than that noted above. OBJECTIVE: A pleasant lady, NAD while at rest. She states her ankle is painful with motion, but does not hurt if she does not move it. HEENT exam is benign. NECK: No significant anterior nodes or carotid bruits heard.
NAD|nothing abnormal detected|NAD|158|160|PHYSICAL EXAMINATION|She does tell me the time and the date. However, she has decreasing memory. SKIN: Normal temperature. Normal color. No signs of dehydration are noted. HEENT: NAD except maybe dry tongue. NECK: Supple. Good range of motion. CHEST: CTA bilateral. CVS: RRR, no murmurs. ABDOMEN: Soft, non-tender.
NAD|no acute distress|NAD|115|117|PHYSICAL EXAMINATION|No cardiac, respiratory, GI, GU, neurologic, or orthopaedic problems. PHYSICAL EXAMINATION: A very pleasant woman, NAD now. She seems quite comfortable at this point. HEENT exam: Normocephalic, atraumatic. PERRLA. Full extraocular movements. Significant to moderate jaundice which is chronic for her.
NAD|no acute distress|NAD.|203|206|PHYSICAL EXAMINATION|PAST MEDICAL HISTORY: He has been healthy. He has received all his immunizations for age. FAMILY HISTORY: Non-contributory. PHYSICAL EXAMINATION: GENERAL: Alert and oriented, cooperative, 4-year-old boy NAD. HEENT: Normocephalic. Eyes are clear. Tympanic membranes are dull with normal landmarks bilaterally. Nose is without drainage. Oropharynx is clear. Moist mucous membranes.
NAD|no acute distress|NAD.|290|293|PHYSICAL EXAMINATION|She walks unassisted. She has been very inactive physically. REVIEW OF SYSTEMS: Negative for any new eye symptoms, ear symptoms, lymphatic symptoms, psychiatric symptoms, no cardiac, respiratory, GI, GU, neurologic or orthopedic problems. PHYSICAL EXAMINATION: GENERAL: Very pleasant lady, NAD. HEENT: TMs look normal. Tonsils and pharynx not injected. NECK: No significant nodes or masses. Neck is supple. CHEST: She does have some scattered rales in the bases, right side more than the left.
NAD|no acute distress|NAD.|187|190|PHYSICAL EXAMINATION|No cardiac, respiratory, GI, GU, neurologic, orthopedic problems MEDICATIONS: Only multivitamin. ALLERGIES: NKDA line. PHYSICAL EXAMINATION: GENERAL: A very pleasant lady, pain-free now, NAD. HEENT: Benign. NECK: No significant nodes or JVD is noted. Neck is supple. CHEST: Clear. CARDIOVASCULAR: Regular rate and rhythm.
NAD|no acute distress|NAD.|153|156|PHYSICAL EXAMINATION|No cardiac, respiratory, GI, GU, neurologic, or orthopedic problems. PHYSICAL EXAMINATION: GENERAL: Very pleasant lady. Appropriate affect, very cordial NAD. HEENT: Benign. NECK: No significant nodes or masses. No JVD. CHEST: Clear. CARDIOVASCULAR: Regular rate and rhythm. S1, S2. No murmurs. ABDOMEN: Soft, nontender. Bowel sounds present throughout. No masses.
NAD|no acute distress|NAD.|207|210|OBJECTIVE|Has been admitted numerous times, 4 hospitalizations in the last 6 months. OBJECTIVE: VITAL SIGNS: Blood pressure 111/75, afebrile, respiratory rate 16-20. GENERAL: Alert, tired female who is morbidly obese NAD. HEENT: EOMI. NECK: Supple without adenopathy or thyromegaly. CARDIOVASCULAR: Regular rate and rhythm. Chest is clear to auscultation bilaterally. No wheezes, rhonchi or crackles.
NAD|no acute distress|NAD.|244|247|ADMISSION PHYSICAL EXAMINATION|ADMISSION PHYSICAL EXAMINATION: VITAL SIGNS: Respiratory rate 16, O2 sats 99% of room air, temp 99.3, pulse 74, blood pressure 128/97. GENERAL: Alert, awake and oriented x3 in mild acute distress. HEAD: Atraumatic. EYES: EOMI x2. NECK: Supple. NAD. NOSE MOUTH THROAT: Mucous membranes moist. CARDIOVASCULAR: Regular rate and rhythm. No murmurs, rubs or gallops. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Bowel sounds positive, soft, left lower quadrant pain.
NAD|no acute distress|NAD,|330|333|PE|Mr. _%#NAME#%_ lives with his wife in _%#CITY#%_. They have two sons _%#NAME#%_ and _%#NAME#%_, all present at hospital today. No sick contacts FH: Mother- stroke in 70's; HTN Father: Died of MI at 92 Sister: Mi at 83 Brother: Died of asthma attack at 74 PE: Vitals: T- 98.9, P- 88, BP- 147/79, RR- 24, 02 sat: 94% on RA General: NAD, mild resp distress Head: NT/NC Eyes: PERRL, EOMI OP: no erythema/exudate Neck: w/o LAD or thryomegaly CV: RRR; exam comp. by lung sounds. DP/PD 2/2 Lungs: inc. A-P diameter, + use of accessory muscles, decr air mvmt throughout, +scattered exp wheezes, symmetic tactile fremitus, slight hyperresonance to percussion Abdominal: mild distention, soft, NT, +BS, no HSM Extremities: muscle strength 5/5 all extremities, reflexes 2/2 Skin: mild ecchymosis on dorsal surfaces of hands and distal upper arms MMSE: 27/30 Neuro: CN III-XII intact; sensation preserved in extremities, no focal deficits Labs: Na 141 K 4.4 Cl 94 PCO2 39 BUN 29 Creatitine 1.89, Glucose 98, ISTAT(venous): pH 7.35 pO2 74 Bicarb 41 Hg 12.6 Hct 37 CXR: bibasilar incr markings but unchanged since previous CXR A/P 74 yo M w/ COPD exacerbation and 10 lb weight loss 1) SOB: likely COPD exac given wheezing, decr air mvmt w/ unclear precipitating factor.
NAD|nothing abnormal detected|NAD.|208|211|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Vital signs - as above. General - healthy-appearing 73-year-old male who appears comfortable, not in acute distress. Appears appropriate for his age and conversing appropriately. HEENT: NAD. NECK: Supple, no lymphadenopathy, no thyromegaly. CHEST: Lungs - bilateral lung bases with rales and decreased air entry on both sides, right more compared to left side.
NAD|nothing abnormal detected|NAD.|211|214|DISCHARGE EXAMINATION|VITAL SIGNS: Blood pressure 160/83; oxygen saturation at 96% on room air; she is afebrile; heart rate is 87; respiratory rate 16. Alert and oriented. She is sitting up in bed. SKIN: NAD. HEENT: NAD. HEART/LUNG: NAD. ABDOMEN: Slight epigastric tenderness, otherwise bowel sounds are normal and audible. EXTREMITIES: No palpable edema. Thus the patient was well enough to be discharged and to do the follow up as suggested above.
NAD|nothing abnormal detected|NAD.|194|197|DISCHARGE EXAMINATION|VITAL SIGNS: Blood pressure 160/83; oxygen saturation at 96% on room air; she is afebrile; heart rate is 87; respiratory rate 16. Alert and oriented. She is sitting up in bed. SKIN: NAD. HEENT: NAD. HEART/LUNG: NAD. ABDOMEN: Slight epigastric tenderness, otherwise bowel sounds are normal and audible. EXTREMITIES: No palpable edema. Thus the patient was well enough to be discharged and to do the follow up as suggested above.
NAD|no acute distress|NAD.|134|137|PHYSICAL EXAMINATION|No cardiac, respiratory, GI, GU, neurologic or orthopedic problems. PHYSICAL EXAMINATION: GENERAL: This is a very pleasant gentleman, NAD. HEENT: Normocephalic and atraumatic. PERRLA. Full EOMs. Full field vision intact per the patient. TMs are normal. Tonsils and pharynx are not injected. NECK: No significant anterior nodes or masses.
NAD|no acute distress|NAD.|236|239|ADMISSION PHYSICAL EXAMINATION|ADMISSION PHYSICAL EXAMINATION: VITAL SIGNS: On arrival, the patient's temperature was 97.9 degrees Fahrenheit, 02 saturation was 93%, respiratory rate was 16, pulse 85, blood pressure 119/75, weight was 52.6 kg. GENERAL: Awake, alert, NAD. HEAD: Atraumatic, normocephalic. EYES: EOMI, PERRL. ENT: MMM. NECK: Supple, trachea midline, posterior oropharynx with thick green drainage, no erythema, positive anterior cervical lymphadenopathy, nontender and mobile.
NAD|no acute distress|NAD.|212|215|PHYSICAL EXAMINATION|Retired from Mesaba Airlines, does part-time work. REVIEW OF SYSTEMS: No chest pain, shortness of breath, polyuria, polydipsia abdominal pain, currently not bleeding. PHYSICAL EXAMINATION: GENERAL: Appears well, NAD. VITAL SIGNS: Height 5 feet 4 inches, weight 159 pounds, blood pressure 104/66, Pulse 71 regular, T 97.6. HEENT: TMs and canals normal.
NAD|nothing abnormal detected|NAD.|135|138|PHYSICAL EXAMINATION|His is drinking his Ensure. He is alert oriented, pleasant. He does not appear short of breath. He can speak complete sentences. SKIN: NAD. HEENT: Mild pharyngeal erythema. Cough which is productive. Tongue and lips are dry. CHEST: Clear to auscultation. HEART: No murmur noted.
NAD|no acute distress|NAD|175|177|OBJECTIVE|No cardiac, respiratory, GI, GU, neurologic, orthopedic problems. HABITS: She is not a smoker, does not drink alcohol, occasional drinks caffeine. OBJECTIVE: A pleasant lady, NAD now. HEENT EXAM: The TMs are normal. Tonsils and pharynx not injected. NECK: No significant anterior nodes or masses. Neck is supple. CHEST is clear. CARDIOVASCULAR: Regular rate and rhythm, S1, S2.
NAD|no acute distress|NAD|232|234|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Negative for any new eye symptoms, ear symptoms, lymphatic symptoms, psychiatric symptoms, no cardiac, respiratory, GI, GU, neurologic, orthopedic problems. PHYSICAL EXAMINATION: GENERAL: Very pleasant gentleman, NAD now. HEENT: Benign. NECK: No significant nodes or masses. Neck is supple. CHEST: Clear. CARDIOVASCULAR: Irregular rhythm with a rate in the 70s, S1, S2, 1/6 systolic murmur heard.
NAD|no acute distress|NAD.|128|131|PHYSICAL EXAMINATION|No cardiac, respiratory, GI, other GU, neurologic, orthopedic problems. PHYSICAL EXAMINATION: GENERAL: Very pleasant gentleman, NAD. HEENT: PERRLA, full field, vision intact. TMs normal. Tonsils and pharynx not injected. NECK: No significant nodes or masses. Neck is supple. CHEST: Clear.
NAD|no acute distress|NAD,|176|179|OBJECTIVE|Some type of complex q.d. A.S.A. 81 mg q.d. M.V.I. Vitamin E 400 IU. Vitamin C, assumed 500 mg q.d. OBJECTIVE: A very frail, small-appearing white female quite chipper, alert, NAD, A&O times three. She has a rapid respiratory rate of around 28 per minute. Temperature 99.8 degrees F. Pulse 105. Blood pressure 134/70. Weight 55.4 kg.
NAD|no acute distress|NAD|147|149|PHYSICAL EXAMINATION|There is no diabetes or cancer in the family. REVIEW OF SYSTEMS: Review of systems is otherwise negative. PHYSICAL EXAMINATION: Very pleasant man, NAD now. He states he has no pain whatsoever at this point as he had a small bowel movement and passed some gas just 30 minutes earlier.
NAD|no acute distress|NAD.|167|170|OBJECTIVE|Denies history of tobacco or alcohol use. OBJECTIVE: Afebrile, blood pressure 166/77, heart rate 76, respiratory rate 16, 98% on room air. General: Alert older female NAD. Neurologic Exam: Alert and oriented x person, place, month, and date, but says the year is 1999. She spells world frontwards okay but backwards is unable to spell it.
NAD|no acute distress|NAD,|182|185|PHYSICAL EXAMINATION|On _%#MMDD2001#%_ he had an EKG which was read as abnormal; consider anteroseptal infarct. PHYSICAL EXAMINATION: GENERAL: The patient is a slim, fairly healthy appearing older male, NAD, alert and oriented times three. HEENT: Negative. He wears refraction. NEUROLOGICAL: He moves all four extremities well. Normal neurologic grossly, normal gait. Negative CCOA, inguinal nodes, thyroid, CVA.
NAD|no acute distress|NAD.|163|166|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Afebrile, heart rate in the 60's, respiratory rate 18, 100% on room air, blood pressure 130's/70's. General: Alert, slightly disheveled male NAD. HEENT: PERRL, EOMI. No nystagmus. Neck: Supple without adenopathy, thyromegaly or carotid bruits. OP: Clear. CV: Regular rate and rhythm, no murmurs, gallops or rubs.
NAD|nothing abnormal detected|NAD,|116|119|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITALS: Blood pressure 90/50, pulse 60 to 70, afebrile. Pulse ox is 100% on two liters. NECK: NAD, alert, pleasant, mildly confused regarding some details of her past history. HEENT: Neck supple without jugular venous distention or bruit. CHEST: Clear to auscultation bilaterally.
NAD|no acute distress|NAD.|143|146|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 36.1 with a heart rate of 74, respirations 20, blood pressure 150/77, 96% on room air. GENERAL: NAD. HEENT: Examined and negative. CHEST: Clear to auscultation, no rales, rhonchi. CARDIOVASCULAR: S1, S2, regular. No murmur or gallops. ABDOMEN: Soft, bowel sounds present, nontender, no organomegaly.
NAD|no acute distress|NAD.|186|189|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Her blood pressure upon admission 116/71, heart rate of 99, respirations 24, temperature 97.6, respirations 94% on 2 liters of nasal cannula. GENERAL: NAD. HEENT: Examined and negative. She has some pursing of lips with breathing but is able to speak in complete sentences, has an oxygen cannula on currently at 2 liters and she is sitting upright.
NAD|no acute distress|NAD.|135|138|PHYSICAL EXAMINATION AT ADMISSION|The patient was seen with an interpreter. GENERAL: The patient appears much younger than 65 years old. She is alert and oriented x3 in NAD. HEAD: NC/AT. EYES: EOMI, PERRLA, positive arcus senilis. EARS: Normal tympanic membranes. Minimal cerumen. NOSE, MOUTH, THROAT: Moist pink oral mucosa. Teeth moderately healthy.
NAD|no acute distress|NAD.|214|217|PHYSICAL EXAMINATION|Maternal aunt watches the children. No known ill exposures, either at home or from extended family members. FAMILY HISTORY: Diabetes and hypertension. PHYSICAL EXAMINATION: GENERAL: The patient is an alert, active NAD. Does not appear toxic. HEENT: Anterior fontanel soft and flat. PERL. EOMI. Conjunctivae clear. TMs clear bilaterally. Nose clear without exudate.
NAD|no acute distress|NAD.|198|201|PHYSICAL EXAMINATION|Drinks alcohol socially, perhaps when he goes out on Friday night after a football game. PHYSICAL EXAMINATION: GENERAL: Well appearing very pleasant fair skinned young man with a Mohawk haircut and NAD. VITAL SIGNS: Temperature 37.1, blood pressure 120/80 to 140/91, heart rate 70 to 80, respiratory rate 16, oxygen saturation 99% on room air.
NAD|no acute distress|NAD,|204|207|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 36.9, heart rate 73 with normal sinus rhythm and monitor, blood pressure 185/92, respiratory rate 18, on 2 L/m of O2 via nasal cannula. GENERAL: Lying down, NAD, pleasant. HEENT: MMM. NECK: Supple, no LAD. RESPIRATORY: Decreased air entry bilateral lung bases, no crackles or wheeze heard, good air entry in the upper zones.
NAD|no acute distress|NAD.|158|161|EXAM|LFT normal, CBC normal, hemoglobin 15.4, hematocrit of 45.8. Troponin negative x1 at 1341. 12-lead EKG shows sinus rhythm. EXAM: GENERAL: Well appearance and NAD. EYES: PERL, EOMI, white sclera. NECK: Supple, no thyroid enlargement, no mass. RESPIRATORY: Clear to auscultation, no rales. CARDIOVASCULAR: JVP normal. No carotid bruit, normal chest palpitation.
NAD|no acute distress|NAD.|240|243|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Respirations 18, pulse ox 98% on room air, temperature 98.1, pulse 94, blood pressure 157/70 in ER and admission highest currently 155/84 ranging from 130-140/80-100 in average. GENERAL: Well-appearing in NAD. EYES: PERL, EOMI, white sclerae. NECK: Supple, no thyroid enlargement, no mass. RESPIRATIONS: Clear to auscultation, no rales. CV: JVP normal, no carotid bruits, normal chest palpitation.
NAD|no acute distress|NAD,|228|231|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Negative for any new eye symptoms, ear symptoms, lymphatic symptoms, psychiatric symptoms, and no cardiac, respiratory, GI, GU, neurologic or orthopedic problems. PHYSICAL EXAMINATION: GENERAL: Pleasant lady, NAD, pale and weak in the gurney. HEENT: NC/AT, PERRLA, full extraocular motions. Vision is intact per patient. Tympanic membranes look normal. Tonsils and pharynx are not injected.
NAD|no acute distress|NAD|118|120|OBJECTIVE|No cardiac, respiratory, GI, GU, neurologic or orthopedic problems. OBJECTIVE: GENERAL: This is a very pleasant lady, NAD now. Does not seem short of breath, on oxygen. VITAL SIGNS: Sats are in 95-96% range on 2L. HEENT: Benign. NECK: No significant anterior nodes. No JVD. Neck is supple.
NAD|no acute distress|NAD|163|165|PHYSICAL EXAMINATION|No cardiac, respiratory, GI, GU, neurologic or orthopedic problems. PHYSICAL EXAMINATION: GENERAL: Pleasant lady, much less short of breath by the time I saw her, NAD and now on low lose-dose O2. HEENT: Benign. NECK: No significant nodes or masses. Neck is supple. CHEST: Have some rales on both bases, slightly decreased air movement in the bases as well as no wheezes or rhonchi.
NAD|nothing abnormal detected|NAD.|244|247|PHYSICAL EXAMINATION|No murmur or gallops. While I was listening to his heart, he again said go away and he did refuse to sit up for his lung exam. His family does stay he has been coughing up some significant sputum. His breathing has improved on antibiotics. GI: NAD. Bowel sounds are present. LABORATORY DATA: I had no labs from the ER. He was initially only admitted as ____________ for NG tube placement but upon finding that he has had fever here I am going to order blood cultures, CBC, electrolytes, glucose, UA and urine culture.
NAD|no acute distress|NAD.|126|129|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: BP 128/88, pulse 83, respirations 19, pulse ox 96% on BiPAP with 15 liters of O2. GENERAL: NAD. Extremely hard of hearing. Awake. HEENT: No scleral icterus. Oral mucosa is moist. NECK: JVD to the angle of the jaw. CHEST: Bibasilar crackles, left greater than right. CARDIAC: Regular S1, S2 with a 2/6 systolic murmur at the apex.
NAD|no acute distress|NAD.|178|181|EXAMINATION|Orthostatics lying - blood pressure 187/92 with pulse 92. Standing - blood pressure 162/88 with pulse 105. Temperature 97.8, pulse ox 96% on room air. Peak flow of 200. GENERAL: NAD. Alert, pleasant. No dysarthria. Speech is clear. HEENT: She has a large forehead ecchymosis with bilateral periorbital ecchymoses.
NAD|no acute distress|NAD.|212|215|PHYSICAL EXAMINATION|PSYCHIATRIC: Negative. ENDOCRINE: Negative. ALLERGIC/IMMUNOLOGIC: Negative. She is on Allegra for vertigo and not for allergies. PHYSICAL EXAMINATION: GENERAL: Well-appearing, very pleasant middle-aged female in NAD. VITAL SIGNS: Blood pressure 110/70, pulse rate 50s, respiratory rate 16, O2 saturation 96-98% on room air. HEENT: NC/AT, PERRLA, EOMI. No conjunctivitis; sclerae anicteric. Hearing is intact bilaterally.
NAD|no acute distress|NAD.|199|202|PHYSICAL EXAMINATION|2. Transthoracic echocardiogram on _%#MMDD2007#%_ with no intracardiac thrombus. 3. Pacemaker placement on _%#MMDD2007#%_. PHYSICAL EXAMINATION: GENERAL: The patient is well appearing elderly man in NAD. HEENT: Head is normocephalic. NECK: Supple. LUNGS: Decreased breath sounds throughout; no rales or ronchi. CARDIOVASCULAR: Heart rate regular, S1 and S2. No murmur, strong bilateral pedal pulses.
NAD|no acute distress|NAD.|187|190|PHYSICAL EXAMINATION|Radionuclide stress test _%#MMDD2007#%_: normal with no perfusion abnormality. PHYSICAL EXAMINATION: VITAL SIGNS: Stable, blood pressure 120-140s/80s. GENERAL: A well-appearing female in NAD. LUNGS: Clear, no rales. HEART: Rate regular, S1, S2, no murmur. EXTREMITIES: Moves all extremities, gait normal. NEUROLOGIC: Deaf; otherwise normal. HOSPITAL COURSE: PROBLEM #1: HTN, accelerated BP of 178/98 to 211/116, without medications at home, significant LVH and history of drug abuse.
NAD|no acute distress|NAD.|281|284|PHYSICAL EXAMINATION|The patient had adenosine stress nuclear imaging done instead. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature of 97.8 Fahrenheit, pulse of 65, blood pressure 104/66, EKG returned normal sinus rhythm, respiration rate of 16, pulse ox of 95% on room air. GENERAL: Well appearing, in NAD. LUNGS: Clear to auscultation. CARDIAC: Heart rate regular S1, S2, no murmur plus strong bilateral pedal pulses, no pedal edema.
NAD|no acute distress|NAD,|167|170|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 36.5, heart rate 88, blood pressure 161/115, respiratory rate 16, O2 saturations 100% on room air. GENERAL: Lying down, NAD, cooperative. HEAD: NTNC. EYES: PERRLA, EOMI. ENT: MMM. NECK: Supple, no LAD. EXTREMITIES: Good pulses, no pedal edema. CARDIOVASCULAR: S1 and S2, RRR, no MDR. LUNGS: Clear to auscultation in breathing, no wheeze/crackles/creps.
NAD|nothing abnormal detected|NAD.|152|155|EXAMINATION ON ADMISSION|NECK: Supple. CARDIOVASCULAR: Regular rate and rhythm. No murmur. No gallop. LUNGS: Clear to auscultation. ABDOMINAL: Lax, soft, no organomegaly. SKIN: NAD. EXTREMITIES: No edema. Power 0/5. Sensations 2/2. NEURO: No movement in lower limbs, power is 0, sensations are good, left hand has power 2/4, sensation good.
NAD|no acute distress|NAD.|188|191|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Respirations 22, O2 sat 96% on room air, temperature 96.5, pulse 60, blood pressure 139/89, weight 151.5 pounds, and 68.9 kilo. GENERAL: Well appearing, NAD. HEAD: Normocephalic. NECK: Supple. CARDIOVASCULAR: JVP normal, no carotid bruit, heart rate regular, S1, S2, no murmur, positive strong bilateral pedal pulses, negative pedal edema.
NAD|no acute distress|NAD.|122|125|PHYSICAL EXAMINATION|No cardiac, respiratory, GI, GU, neurologic, orthopedic problems. PHYSICAL EXAMINATION: GENERAL: Very pleasant gentleman, NAD. HEENT: Normocephalic, atraumatic. PERRLA. Full EOMs. Full fields. Vision intact per patient. TMs normal. Tonsils and pharynx are not injected. NECK: No significant nodes or masses.
NAD|no acute distress|NAD.|258|261|PHYSICAL EXAMINATION|5. OxyContin 40 mg t.i.d. REVIEW OF SYSTEMS: Negative for any new eye symptoms, ear symptoms, lymphatic symptoms, psychiatric symptoms, no cardiac, respiratory, GI, GU, neurologic, orthopedic problems. PHYSICAL EXAMINATION: GENERAL: Very pleasant gentleman, NAD. _%#NAME#%_ seems a little shaky. HEENT: PERRLA, full field vision intact. Pupils fully reactive. TMs normal. Tonsils and pharynx not injected. NECK: No significant anterior nodes or masses.
NAD|no acute distress|NAD.|251|254|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Review of systems is negative for any new eye symptoms, ear symptoms, psychiatric symptoms, no cardiac, respiratory, gastrointestinal, genitourinary, neurologic, or orthopedic problems. PHYSICAL EXAMINATION: GENERAL: Pleasant lady, NAD. HEENT: Benign. NECK: No significant elevated JVD. CHEST: Clear. CARDIOVASCULAR: Regular rate and rhythm, S1, S2, no murmurs. ABDOMEN: Soft and nontender. Bowel sounds are present throughout without masses or HSM.
NAD|no acute distress|NAD|274|276|CV|He comes here for further evaluation of his weakness. Pt had evaluation for his weakness including LP, eval for GBS, myasthenia gravis, he had several cervical spine MRI's to eval for spinal stenosis but there was too much motion artifact. Exam: Gen:on non-rebreather mask, NAD Pulm:diminished BS, poor air entry, no crackles CV: nl s1s2 no m/r/g Abd:soft NT/ND nl bs Ext:3+ LE pitting edema Neuro: CN II-XII intact, 4/5 proximal UE str, 4/5 distal str on right, 3/5 distal str on left, 4/5 LE str, DTR 1+ throughout.
NAD|no acute distress|NAD|229|231|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Negative for any new eye symptoms, ear symptoms, lymphatic symptoms, psychiatric symptoms, no cardiac, respiratory, GI, GU, neurologic or orthopedic problems. PHYSICAL EXAMINATION: GENERAL: Pleasant gentleman, NAD now. He states his leg pain is much less after Tylenol. HEENT: Benign. NECK: No significant nodes or masses. Neck is supple.
NAD|no acute distress|NAD.|142|145|PHYSICAL EXAMINATION ON ADMISSION|PHYSICAL EXAMINATION ON ADMISSION: Blood pressure 123/56, heart rate 114, temperature 99.5, respiratory rate 18. Appearance: A young woman in NAD. Head: NC/AT. Eyes: Left conjunctival injection. HEENT: White pharyngeal lesions. Neck: Supple, no thyromegaly: 0. Respiratory: CTA AUSCULTATION bilaterally.
NAD|no acute distress|NAD.|227|230|PHYSICAL EXAMINATION|MUSCULOSKELETAL: Negative. GENITOURINARY: No urinary complaints. See history of present illness. PSYCH: Negative. DERM: Negative. PHYSICAL EXAMINATION: On physical examination this is a well- developed, well-nourished woman in NAD. Weight: 144, temperature 98.3, blood pressure 118/52. NECK: Supple. Thyroid is not enlarged. BRESTS: No masses, no skin changes, or retractions. Axilla are negative.
NAD|no acute distress|NAD.|162|165|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Very pale, translucent skin, elderly female, small, lying in bed with left leg propped and pain in the right hip. She is coherent. NAD. A&O X 3. She is very pleasant. HEENT: Negative. Eyes okay. She wears a refraction. She has thin hair. She has false teeth. Negative CCOA, inguinal nodes, thyroid, CVA's.
NAD|nothing abnormal detected|NAD.|247|250|DISCHARGE PHYSICAL EXAMINATION|VITAL SIGNS: Afebrile, pulse 73, respiratory rate 20, blood pressure 116/72, 100% O2 saturations on room air. He is alert and oriented. SKIN: The rash has cleared. HEENT: Normocephalic and atraumatic. CHEST: Clear to auscultation. CARDIOVASCULAR: NAD. ABDOMEN: Soft, non-tender. There is no peripheral edema. BACK: The area of the puncture wound made for the collection of CSF is healing well.
NAD|no acute distress|NAD.|146|149|PHYSICAL EXAMINATION|SOCIAL HISTORY: She denies smoking. PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile, vital signs stable. GENERAL: This is an African-American female, NAD. ABDOMEN: Soft. Questionable fetal positioning on abdominal exam. External fetal monitoring shows reactive tracing with no contractions. The patient noted positive fetal movement.
NAD|no acute distress|NAD.|257|260|PHYSICAL EXAM|Works as a secretary FAMILY HISTORY: unable to obtain-pt intubated and sedated ROS: Unable to obtain other than above and in documentation from Fairview Southdale PHYSICAL EXAM Temp 100.2 BP 112/55 HR 117 RR 25 O2 100% on 40% FIO2 GEN: opens eyes to voice. NAD. Obese. MAE spontaneously. HEENT: NC/AT, PERRL, ictetric, no injection, unable to formally assess EOM, but appear intact. No nystagmus NECK: R IJ in place, cannot assess JVP, no bruits BACK: no obvious deformities LUNGS: CTAB CV: tachycardic, regular, no m/r/g ABD: soft, obese, NT/ND, NABS, no masses, liver percusses to 1 cm below costal margin, spleen not percussable.
NAD|no acute distress|NAD.|238|241|PHYSICAL EXAMINATION|PAST MEDICAL HISTORY: ALLERGIES: None. MEDICATIONS: Prenatal vitamins. Ultrasounds performed initially at _%#MMDD#%_ and then 4 and 8 weeks after the initial ultrasound. PHYSICAL EXAMINATION: Well-developed, well-nourished Asian woman in NAD. Weight 136, blood pressure 100/60. HEENT: normocephalic, extraocular movements intact. Lungs: clear to A and P. Heart: normal sinus rhythm, no murmurs or gallops. Abdomen: vertex presentation, fundal height 37 centimeters, no organomegaly.
NAD|no acute distress|NAD|134|136|OBJECTIVE|She does drive. She walks with a wheeled walker. REVIEW OF SYSTEMS: Negative other than noted above. OBJECTIVE: A very pleasant lady. NAD now. No complaints at this time other than hunger. The HEENT exam is benign. She does have an obviously opaque right cornea.
NAD|nothing abnormal detected|NAD.|127|130|DISCHARGE PHYSICAL EXAMINATION|On examination, vital signs were stable. She was alert and oriented, sitting up in the wheelchair but able to ambulate. HEENT: NAD. SKIN: NAD. CHEST: NAD. HEART: No murmurs. ABDOMEN: Soft and non-tender. No peripheral edema. ASSESSMENT/PLAN: As above.
NAD|nothing abnormal detected|NAD.|138|141|DISCHARGE PHYSICAL EXAMINATION|On examination, vital signs were stable. She was alert and oriented, sitting up in the wheelchair but able to ambulate. HEENT: NAD. SKIN: NAD. CHEST: NAD. HEART: No murmurs. ABDOMEN: Soft and non-tender. No peripheral edema. ASSESSMENT/PLAN: As above.
NAD|nothing abnormal detected|NAD.|150|153|DISCHARGE PHYSICAL EXAMINATION|On examination, vital signs were stable. She was alert and oriented, sitting up in the wheelchair but able to ambulate. HEENT: NAD. SKIN: NAD. CHEST: NAD. HEART: No murmurs. ABDOMEN: Soft and non-tender. No peripheral edema. ASSESSMENT/PLAN: As above.
NAD|nothing abnormal detected|NAD.|149|152|PHYSICAL EXAMINATION ON DISCHARGE|He is alert, slow to respond. SKIN: Dry skin anterior ankle area. Ecchymosis noted. Cellulitis, redness, and temperature and edema improving. HEENT: NAD. HEART: No murmurs are noted. LUNGS: Clear to auscultation. ABDOMEN: Soft; non-tender. EXTREMITIES: Please see the skin exam above. The patient is stable enough to be transferred.
NAD|no acute distress|NAD.|187|190|OBJECTIVE|REVIEW OF SYSTEMS: Difficult because he is a vague historian, but he denies any GI, GU, neurologic, orthopedic, psychiatric type symptoms. OBJECTIVE: A very pleasant man, weak but alert, NAD. HEENT exam is benign. NECK: No significant nodes or masses. Neck is supple. CHEST is clear. CARDIOVASCULAR: Regular rate and rhythm. S1, S2. No murmurs. ABDOMEN is soft, nontender throughout.
NAD|no acute distress|NAD,|166|169|DISCHARGE EXAMINATION|DISCHARGE EXAMINATION: VITAL SIGNS: Temperature max 37, heart rate 90-128, respiratory rate 28 to 32, weight 8.18 kilos/18 pounds. GENERAL: He is alert, cooperative, NAD, smiling and playful. ABDOMEN: Soft, nondistended, nontender with no organomegaly or mass. GENITOURINARY: He has normal uncircumcised male genitalia. The foreskin is retractable to expose 1/2 of the surface of the head of the penis and the urethra appears normal.
NAD|no acute distress|NAD,|146|149|PHYSICAL EXAMINATION|She does not have presyncopal feelings. Menopausal for many years. PHYSICAL EXAMINATION: Pleasant, older female appears a little drowsy or tired. NAD, A&O X 3. Skin: Tense. Severely dry dorsum of hands. Negative HEENT. She wears a refraction. Fundi: Very difficult to see secondary to some change in the iris and pupil.
NAD|no acute distress|NAD|99|101|OBJECTIVE|No cardiac, respiratory, GI, GU, neurologic or orthopedic problems. OBJECTIVE: Very pleasant lady, NAD now. HEENT - there is no sign of any facial weakness on the right side. No eye droop. PERRLA, full EOMs, full fields, vision intact per patient.
NAD|no acute distress|NAD,|128|131|OBJECTIVE|No cardiac, respiratory, GI, GU, neurological or other orthopedic problems. ALLERGIES: Ibuprofen. OBJECTIVE: Very pleasant man, NAD, pain controlled now. HEENT - benign. NECK - no significant anterior nodes or masses. Neck is supple. CHEST - clear. CARDIOVASCULAR -regular rate and rhythm, S1, S2, no murmurs.
NAD|nothing abnormal detected|NAD.|181|184|HOSPITAL COURSE|On the day of discharge, his exam was as follows: Afebrile, pulse 57, respirations 14, blood pressure 115/63, and 94% O2 saturation on room air. Alert and oriented. Skin NAD. HEENT NAD. Heart, lungs, abdomen, and extremities NAD. The patient was well enough to be discharged to home. DISCHARGE MEDICATIONS: Percocet 1-2 p.o. q.6h. p.r.n. pain, a 7- day supply.
NAD|no acute distress|NAD.|100|103|OBJECTIVE|No cardiac and respiratory, GI, GU, neurologic, orthopedic problems. OBJECTIVE: Very pleasant male, NAD. No pain at this time. HEENT exam is benign. NECK: No significant anterior nodes or masses. NECK is supple. CHEST is clear. CARDIOVASCULAR: Regular rate and rhythm, S1, S2.
NAD|no acute distress|NAD.|164|167|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 96.3, pulse 81, respiratory rate 18, blood pressure 128/57. Weight 160.8, Pulse oximeter 98% on two liters. GENERAL: NAD. Alert, pleasant, speaks in full sentences. Diminished eye contact secondary to blindness. HEENT: Oral mucosa moist without lesions. Poor dentition. No scleral icterus.
NAD|no acute distress|NAD.|126|129|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: I did not perform because of the language barrier. PHYSICAL EXAMINATION: In general, a very pleasant lady. NAD. Speaking through the interpreter. HEENT: Normocephalic, atraumatic. PERRLA. Full field of vision is grossly intact. TMs normal. TONSILS AND PHARYNX - not injected. NECK - no significant anterior nodes or carotid bruits.
NAD|no acute distress|NAD.|171|174|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Some generalized subjective fevers and hand pain as before. No pulmonary symptoms. PHYSICAL EXAMINATION: VITAL SIGNS: Pending. We will review. GENERAL: NAD. Alert and pleasant. HEENT: No scleral icterus. CHEST: Clear to auscultation bilaterally. CARDIAC: Regular S1, S2 without added. EXTREMITIES: Left wrist anterior aspect with two visible puncture wounds, nondraining, one puncture wound with a golden crust on the posterior aspect of the wrist over the head of the radius.
NAD|no acute distress|NAD,|169|172|OBJECTIVE|SOCIAL: He is divorced. He is fairly sedentary. He does not smoke, occasionally drinks alcohol, no other drug use. REVIEW OF SYSTEMS: Negative. OBJECTIVE: Pleasant man, NAD, this is after Demerol however. HEENT - benign. NECK -no significant anterior nodes or masses. NECK - supple. CHEST - clear. CARDIOVASCULAR - regular rate and rhythm, S1, S2, no murmurs.
NAD|nothing abnormal detected|NAD.|174|177|PHYSICAL EXAMINATION|VITALS: She was afebrile, pulse 84, respirations 16, blood pressure 111/72. O2 sat was 97% on room air. SKIN: Normal color and normal temperature. NECK: Supple, soft. HEENT: NAD. HEART: NAD. CHEST: NAD. BACK: Back pain much improved. ABDOMEN: Soft and nontender. EXTREMITIES: No peripheral edema or positive findings noted.
NAD|nothing abnormal detected|NAD.|186|189|PHYSICAL EXAMINATION|VITALS: She was afebrile, pulse 84, respirations 16, blood pressure 111/72. O2 sat was 97% on room air. SKIN: Normal color and normal temperature. NECK: Supple, soft. HEENT: NAD. HEART: NAD. CHEST: NAD. BACK: Back pain much improved. ABDOMEN: Soft and nontender. EXTREMITIES: No peripheral edema or positive findings noted. HOSPITAL COURSE: When the patient was admitted, she had pain and we treated her with pain medications.
NAD|nothing abnormal detected|NAD.|198|201|PHYSICAL EXAMINATION|VITALS: She was afebrile, pulse 84, respirations 16, blood pressure 111/72. O2 sat was 97% on room air. SKIN: Normal color and normal temperature. NECK: Supple, soft. HEENT: NAD. HEART: NAD. CHEST: NAD. BACK: Back pain much improved. ABDOMEN: Soft and nontender. EXTREMITIES: No peripheral edema or positive findings noted. HOSPITAL COURSE: When the patient was admitted, she had pain and we treated her with pain medications.
NAD|no acute distress|NAD|145|147|PHYSICAL EXAMINATION|She has remained quite independent. REVIEW OF SYSTEMS: Negative other than for the issues noted above. PHYSICAL EXAMINATION: Very pleasant lady, NAD now on mask O2. HEENT exam is benign. NECK - no significant anterior nodes or JVD. NECK is supple. CHEST - some rales in the bases.
NAD|nothing abnormal detected|NAD.|151|154|DISCHARGE PHYSICAL EXAMINATION, 12/10/03|GENERAL: Up in chair, alert, and oriented. His wife was visiting and he is pleasantly conversing with her. SKIN: No acute changes. HEENT, HEART, LUNG: NAD. ABDOMEN: Soft and non-tender. EXTREMITIES: No peripheral edema. ASSESSMENT AND PLAN: 1. Pancreatitis, resolving. 2. Abdominal pain, resolving. 3. History of arthritis. PLAN: Discussed with the patient to avoid Aleve which he takes on a regular basis, one to two q. day.
NAD|nothing abnormal detected|NAD,|133|136|DISCHARGE PHYSICAL EXAMINATION|SKIN: Calluses are noted on the plantar surfaces of the feet bilaterally. Left knee ecchymosis is healing well. NECK: Supple. HEENT: NAD, acute in nature. HEART: No murmurs are noted. LUNGS: Clear to auscultation. ABDOMEN: Soft, non-tender. EXTREMITIES: No edema noted. The patient continues to be feeling well and is able to ambulate with a walker thus she is being discharged to home with home PT and OT to follow and home care to follow.
NAD|no acute distress|NAD.|152|155|PHYSICAL EXAMINATION ON DISCHARGE|This can be further discussed with her primary physician, as well. PHYSICAL EXAMINATION ON DISCHARGE: She is very pleasant, alert and oriented. She has NAD. VITAL SIGNS: Afebrile, pulse 82, respirations 16, blood pressure 112/71, oxygen saturation 96%. SKIN: NAD, especially with reference to the left lower extremity.
NAD|nothing abnormal detected|NAD.|220|223|PHYSICAL EXAMINATION ON DISCHARGE|She has NAD. VITAL SIGNS: Afebrile, pulse 82, respirations 16, blood pressure 112/71, oxygen saturation 96%. SKIN: NAD, especially with reference to the left lower extremity. HEENT: NAD. HEART: NAD. LUNGS: NAD. ABDOMEN: NAD. No peripheral edema was noted. The left lower extremity was less tender, more equal in size and diameter to the right. The patient is deemed well enough to be discharged to home, and that is being done.
NAD|nothing abnormal detected|NAD.|182|185|PHYSICAL EXAMINATION ON DISCHARGE|She has NAD. VITAL SIGNS: Afebrile, pulse 82, respirations 16, blood pressure 112/71, oxygen saturation 96%. SKIN: NAD, especially with reference to the left lower extremity. HEENT: NAD. HEART: NAD. LUNGS: NAD. ABDOMEN: NAD. No peripheral edema was noted. The left lower extremity was less tender, more equal in size and diameter to the right.
NAD|nothing abnormal detected|NAD.|206|209|PHYSICAL EXAMINATION ON DISCHARGE|She has NAD. VITAL SIGNS: Afebrile, pulse 82, respirations 16, blood pressure 112/71, oxygen saturation 96%. SKIN: NAD, especially with reference to the left lower extremity. HEENT: NAD. HEART: NAD. LUNGS: NAD. ABDOMEN: NAD. No peripheral edema was noted. The left lower extremity was less tender, more equal in size and diameter to the right.
NAD|nothing abnormal detected|NAD.|146|149|DISCHARGE PHYSICAL EXAMINATION|Blood pressure 105/60. 92% oxygen saturations on room air. She appeared alert and oriented. SKIN: No acute changes were noted. HEENT: NAD. HEART: NAD. LUNGS: Wheezing was still present, but the patient was not requiring oxygen and her oxygen saturations were 92% as mentioned above.
NAD|nothing abnormal detected|NAD.|134|137|DISCHARGE PHYSICAL EXAMINATION|Blood pressure 105/60. 92% oxygen saturations on room air. She appeared alert and oriented. SKIN: No acute changes were noted. HEENT: NAD. HEART: NAD. LUNGS: Wheezing was still present, but the patient was not requiring oxygen and her oxygen saturations were 92% as mentioned above.
NAD|no acute distress|NAD.|219|222|OBJECTIVE|Due to nonresponse to outpatient therapy, admitted for I.V. antibiotics and further evaluation. MEDICATIONS: Augmentin b.i.d. ALLERGIES: None. OBJECTIVE: Weight 19.8, heart rate 110, respiratory rate 24, alert, active, NAD. Sclerae clear, red reflex positive bilaterally. EAC, TMs normal. OROPHARYNX - unremarkable, no erythema or tonsillar hypertrophy. Right mandible/submandibular area with a 4 x 4 cm firm mass overlying the mandible but moderately mobile.
NAD|no acute distress|NAD|175|177|OBJECTIVE|MEDICINES: Included diuretic name unknown, Cardizem 360 mg daily, Lipitor 40 mg daily and aspirin daily. REVIEW OF SYSTEMS: Completely negative. OBJECTIVE: Very pleasant man, NAD now. No symptoms of any kind. No pain, no dizziness or weakness. HEENT EXAM: Benign. No carotid bruits. NECK is supple. CHEST is clear.
NAD|nothing abnormal detected|NAD.|198|201|PHYSICAL EXAMINATION|Her father has diabetes mellitus and hypertension. PHYSICAL EXAMINATION: On exam, her pulse is 72; respirations 20; blood pressure 122/63; 97% O2 sats on room air. She is alert, lying in bed. Skin: NAD. HEENT: NAD, except for dry lips. Chest: Clear to auscultation bilaterally. CVS: No murmurs. Abdomen: Soft, non-tender, and is gravid.
NAD|nothing abnormal detected|NAD.|223|226|PHYSICAL EXAMINATION|VITAL SIGNS: Afebrile. Pulse 92, respirations 24, blood pressure 143/79, oxygen saturations 100% on room air. GENERAL: Alert and oriented, lying in bed. SKIN: Normal color and temperature. Wound site is healing well. HENT: NAD. CHEST: Clear to auscultation. HEART: Regular rate and rhythm. ABDOMEN: Soft. Incisional tenderness. Bowel sounds are present. EXTREMITIES: No peripheral edema is noted.
NAD|no acute distress|NAD|70|72|OBJECTIVE|FAMILY HISTORY: Benign for any childhood illnesses. OBJECTIVE: She is NAD now. She is asleep. HEENT exam is benign. TMs look normal. ____________ pharynx are not injected. NECK: No significant anterior nodes or masses.
NAD|nothing abnormal detected|NAD|185|187|PHYSICAL EXAMINATION|The patient is alert and oriented, pleasant lady in no distress. Normal appearing cranial nerves, normal heart sounds, normal lung sounds. ABDOMEN: Is soft and non-tender. EXTREMITIES: NAD EKG reveals sinus bradycardia with a rate of 59, slight ST elevation in V1, otherwise no other relative abnormality and normal EKG.
NAD|nothing abnormal detected|NAD.|217|220|EXAMINATION|Otherwise normal cranial nerves. PRECORDIUM: No heave or thrill. S1, S2 both present. LUNGS: Clear and resonant bilaterally. ABDOMEN: Soft. Tenderness only with deep palpation of the left lower quadrant. EXTREMITIES: NAD. IMPRESSION: 1. Hyperglycemia. Will place on insulin drip until stabilized and then will continue her current medications.
NAD|no acute distress|NAD|129|131|PHYSICAL EXAMINATION|No cardiac, respiratory, GI, GU, neurologic or orthopedic problems. PHYSICAL EXAMINATION: GENERAL: This is a very pleasant lady, NAD now. No symptoms at present. HEENT: Benign. TMs normal. Tonsils and pharynx not injected. NECK: No significant anterior nodes or masses. Neck is supple.
NAD|no acute distress|NAD.|201|204|PHYSICAL EXAMINATION|No dysuria or problems with urination. No rash. No lower extremity edema or swelling. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.3, pulse 56, blood pressure 134/69, pulse oximetry 99%. GENERAL: NAD. Alert, anxious, pleasant, oriented. HEENT: Oral mucosa moist. She has dentures above and below. NECK: Supple. No bruit or JVD. CHEST: Clear to auscultation bilaterally. BACK: Kyphotic. CARDIAC: Regular S1, S2 with a 1/6 systolic murmur at the left upper sternal border.
NAD|no acute distress|NAD|105|107|OBJECTIVE|No cardiac, respiratory, GI, GU, other neurologic or orthopedic problems. OBJECTIVE: Very pleasant lady, NAD now. No dizziness at rest. HEENT - benign. PERRLA, full EOMs, full fields, no nystagmus noted. NECK - no significant anterior nodes or thyroid palpated. No carotid bruits felt.
NAD|no acute distress|NAD|146|148|PHYSICAL EXAMINATION|No cardiac, respiratory, GI, GU, neurologic, or orthopaedic problems. PHYSICAL EXAMINATION: A very pleasant young lady, open mouth breathing, but NAD now. HEENT exam: TMs look normal. TONSILS and PHARYNX are hugely swollen with copious yellowish discharge. TONSILS are almost kissing posteriorly. NECK - she has a very large left anterior cervical node which is firm and slightly tender to the touch.
NAD|no acute distress|NAD|281|283|PHYSICAL EXAMINATION|He is minimally active physically. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Negative for eye symptoms or symptoms of the lymphatic system, psychiatric symptoms, no cardiac, hemological, GI, GU, neurologic, or orthopedic problems. PHYSICAL EXAMINATION: Very pleasant man NAD now. HEENT exam is benign. NECK: No significant cancer nodes or masses. Supple. CHEST: Clear. CARDIOVASCULAR: Regular rate and rhythm, S1 and S2, no murmurs.
NAD|nothing abnormal detected|NAD.|183|186|PHYSICAL EXAMINATION ON ADMISSION|Heart rate 73. Blood pressure 117/70, 97% O2 saturatoins on room air. SKIN: Redness is much more localized, less much decreased swelling of the left ankle. Alert and oriented. HEENT: NAD. CHEST: CT bilateral. CV: No murmurs. ABDOMEN: Soft; nontender. EXTREMITIES: Left ankle swelling is much more down. Redness is much more down. The patient can weight bear on heels and toes.
NAD|nothing abnormal detected|NAD.|138|141|OBJECTIVE|GENERAL: A 76-year-old male who appears to be comfortable, appears to be in mild respiratory distress. HEAD, EYES, EARS, NOSE AND THROAT: NAD. NECK: Supple, no lymphadenopathy or thyromegaly LUNGS: Have diffuse wheezing throughout the both lungs and slightly decreased air entry bilateral lung bases.
NAD|no acute distress|NAD.|150|153|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Vital signs: Blood pressure 110/74, pulse 107, respiratory rate 18, temperature 97.9, O2 saturation 96. General: The patient in NAD. He is AAOx3. HEENT: AT/NC. No tonsillar exudates. PERLA. EOMx2. Neck: Supple. No LAD. No JVD. Heart: RRR. S1, S2 heard. No murmurs, rubs or gallops heard.
NAD|nothing abnormal detected|NAD.|219|222|CODE STATUS|Subjectively "I can't run around the block yet." On examination, pulse 48, respirations 16, blood pressure 111/87, oxygen saturation 95% on room air. Alert, oriented, pleasant. Skin normal temperature and color. HEENT: NAD. Heart, lungs, abdomen NAD. Extremities: Right extremity in a brace. Some weakness noted. Other exam was unremarkable. The patient continues to be well and stable enough to be transferred to rehab while she awaits her surgery.
NAD|no acute distress|NAD|264|266|OBJECTIVE|No other drug use. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Negative for eye symptoms, ear symptoms, lymphatic symptoms, psychiatric symptoms, no other cardiac, respiratory, GI, GU, new neurologic or orthopedic problems. OBJECTIVE: A very pleasant man, NAD now. Seems to be quite alert and cordial. HEENT -benign other than the two occipital scalp lacerations which were closed nicely with sutures in the emergency department.
NAD|nothing abnormal detected|NAD.|127|130|PAST MEDICAL HISTORY|SKIN: No lacerations or discolorations noted. Difficult to assess for ecchymosis because of the dark color of her skin. HEENT: NAD. No Battle dor sign. No raccoon eyes. No discharge is noted from the ear, nose, or throat. Other HEENT exam NAD. NECK: Supple. Full range of motion noted.
NAD|no acute distress|NAD.|119|122|PAST MEDICAL HISTORY|HEENT: NAD. No Battle dor sign. No raccoon eyes. No discharge is noted from the ear, nose, or throat. Other HEENT exam NAD. NECK: Supple. Full range of motion noted. CHEST: CTA bilateral. HEART: No murmurs are noted. ABDOMEN: Appears distended secondary to her pregnancy.
NAD|no acute distress|NAD.|253|256|OBJECTIVE|MUSCULOSKELETAL: Negative. DERMATOLOGY: Negative. PSYCHIATRIC: Is stressed, frustrated that no one believes him, but does not feel that there is anything wrong with him. OBJECTIVE: VITAL SIGNS: Afebrile. Vitals are stable. GENERAL: An alert young male, NAD. Mood and affect are depressed and angry. Thought processes are coherent. Content is focused on the fact that nobody believes him on this episode of having raped a girl.
NAD|no acute distress|NAD.|152|155|OBJECTIVE|SOCIAL HISTORY: She does not smoke, rarely drinks alcohol, no other drug use. OBJECTIVE: Very pleasant lady complaining of some headache now, otherwise NAD. HEENT - benign. NECK - no significant anterior nodes or masses. Neck is supple. CHEST - clear. CARDIOVASCULAR - regular rate and rhythm, S1, S2, no murmurs.
NAD|no acute distress|NAD.|227|230|PHYSICAL EXAMINATION|Leg movement is limited. CENTRAL NERVOUS SYSTEM: Deep tendon reflexes normal in upper limbs, depressed in lower limbs. Power in the upper limbs is good. Significant leg weakness. Cranial nerves II through XII are intact; fundi NAD. NEUROPSYCHIATRIC: Affect is normal; speech pattern is normal; she responds appropriately to questions. INVESTIGATIONS: Hemoglobin 14.6, hematocrit 44.6, platelets 262, white count 12.7. INR 1.0, PTT 26.
NAD|nothing abnormal detected|NAD.|309|312|PHYSICAL EXAMINATION|GU: Negative. NEURO: Negative. EXTREMITIES: Chronic pain. NEUROVASCULAR: Negative. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 135/79, respirations 16, pulse 100, temperature 98.1, O2sats 99%, O2 on room air. GENERAL: Obesity positive, pleasant, alert. Boyfriend actually in the room at present. HEENT: NAD. CHEST: NAD. HEART: NAD. ABDOMEN: NAD. SKIN: Foul smelling area in the groin area, pitting scarring, some local discharge moisture noted in the inguinal pole area and the medial thigh area in the surrounding area.
NAD|no acute distress|NAD.|175|178|OBJECTIVE|Rare alcohol. OBJECTIVE: VITAL SIGNS: Afebrile; respiratory rate 18; oxygen saturations at 98% on room air; heart rate 80; blood pressure 126/82. GENERAL: Alert young female, NAD. HEENT: PERRLA, EOMI. NECK: Supple without adenopathy or thyromegaly. OROPHARYNX: Clear. Mucous membranes are moist. CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops.
NAD|nothing abnormal detected|NAD.|180|183|DISCHARGE EXAMINATION|Blood pressure 115/69. 94% oxygen saturations on room air. She is alert and oriented. Knows it is cloudy outside, 2 plus 2 is equal 4 (when asked gives the correct answer). HEENT: NAD. CHEST: Clear to auscultation. HEART: No murmurs or noted. ABDOMEN: Soft, non-tender. Bowel sounds are heard. No organomegaly is noted.
NAD|no acute distress|NAD.|124|127|OBJECTIVE|No cardiac, respiratory, GI, GU, neurologic or orthopedic problems. OBJECTIVE: GENERAL: Very pleasant lady, poor memory but NAD. RESPIRATORY: Benign. HEENT: Benign. I do not see any scalp trauma signs. NECK: No significant nodes. Neck is supple. CHEST: Clear. CARDIOVASCULAR: Irregular rhythm with a rate around 110.
NAD|no acute distress|NAD.|113|116|OBJECTIVE|No cardiac, respiratory, GI, GU, neurologic or orthopedic problems. OBJECTIVE: GENERAL: Very pleasant gentleman, NAD. He is comfortable now after getting morphine. HEENT: Benign. NECK: No significant anterior nodes or masses. Neck is supple. CHEST: Clear. CARDIOVASCULAR: Regular rate and rhythm, S1 and S2.
NAD|no acute distress|NAD.|138|141|PHYSICAL EXAMINATION|No New GI, GU, neurologic, orthopedic problems. PHYSICAL EXAMINATION: A pleasant gentleman having some mild abdominal pain at present but NAD. He does look somewhat pale. HEENT: Benign. TMs normal. Tonsils and pharynx not injected. NECK: No significant nodes or masses. Neck is supple. CHEST: Clear.
NAD|nothing abnormal detected|NAD.|134|137|DISCHARGE PHYSICAL EXAMINATION|She appeared to be comfortable. VITAL SIGNS: She was afebrile. Her blood pressure was 161/89. Her O2 sats were 97% on room air. SKIN: NAD. HEENT: NAD. CHEST: NAD. HEART: Cardiac murmur present. ABDOMEN: Soft, nontender. EXTREMITIES: No peripheral edema. Peripheral vasculature intact.
NAD|nothing abnormal detected|NAD.|224|227|DISCHARGE PHYSICAL EXAMINATION|SKIN: NAD. HEENT: NAD. CHEST: NAD. HEART: Cardiac murmur present. ABDOMEN: Soft, nontender. EXTREMITIES: No peripheral edema. Peripheral vasculature intact. Peripheral pulses intact. NEUROLOGIC: Grossly intact. PSYCHIATRIC: NAD. The patient is fit enough to be discharged to home. Her niece is a home care nurse also, so she can help in addition to the home health care we can arrange.
NAD|nothing abnormal detected|NAD.|176|179|PHYSICAL EXAMINATION|On exam, she is afebrile. Her O2 saturations are 95% on room air. Her pulse is 97, her respirations 20, blood pressure 150/107. Alert, oriented. Skin: No acute changes. HEENT: NAD. Heart: NAD. Lungs: NAD. Abdomen is soft, nontender. Extremities: No peripheral edema. ASSESSMENT AND PLAN: All of the above except hypertension, and I will change the Norvasc to 5 mg p.o. q.day. She does have hypoalbuminemia, and we will try to correct that and help obtain help from Nutrition.
NAD|nothing abnormal detected|NAD.|134|137|PHYSICAL EXAMINATION|Her pulse is 97, her respirations 20, blood pressure 150/107. Alert, oriented. Skin: No acute changes. HEENT: NAD. Heart: NAD. Lungs: NAD. Abdomen is soft, nontender. Extremities: No peripheral edema. ASSESSMENT AND PLAN: All of the above except hypertension, and I will change the Norvasc to 5 mg p.o. q.day. She does have hypoalbuminemia, and we will try to correct that and help obtain help from Nutrition.
NAD|nothing abnormal detected|NAD.|291|294|DISCHARGE EXAMINATION|DISCHARGE EXAMINATION: SUBJECTIVE: Doing better, breathing better. VITAL SIGNS: She is afebrile; blood pressure 147/73; pulse 59; respiratory rate 20; oxygen saturation at 97% on 2 liters of oxygen. GENERAL: She was alert, oriented, and sitting up in a chair. SKIN: No acute changes. HEENT: NAD. HEART: NAD. CHEST: No wheezing or crackles noted. Moderately good air flow is noted. ABDOMEN: Soft, nontender. EXTREMITIES: No peripheral edema is noted and the patient is doing well.
NAD|nothing abnormal detected|NAD.|303|306|DISCHARGE EXAMINATION|DISCHARGE EXAMINATION: SUBJECTIVE: Doing better, breathing better. VITAL SIGNS: She is afebrile; blood pressure 147/73; pulse 59; respiratory rate 20; oxygen saturation at 97% on 2 liters of oxygen. GENERAL: She was alert, oriented, and sitting up in a chair. SKIN: No acute changes. HEENT: NAD. HEART: NAD. CHEST: No wheezing or crackles noted. Moderately good air flow is noted. ABDOMEN: Soft, nontender. EXTREMITIES: No peripheral edema is noted and the patient is doing well.
NAD|no acute distress|NAD|113|115|OBJECTIVE|No cardiac, respiratory, GI, GU, neurologic, orthopedic problems. OBJECTIVE: A pleasant very pleasant gentleman, NAD now, eating voraciously. HEENT EXAM: NC/AT, PERRLA. Full EOMs, full fields. Vision is intact per patient. NECK: No significant anterior notes or masses. Neck is supple.
NAD|no acute distress|NAD|200|202|OBJECTIVE|OBJECTIVE: VITAL SIGNS: Stable. The patient is afebrile. Blood pressure 113/53, heart rate 79, respiratory rate 18, 985 on room air. GENERAL: Alert, older female frustrated to be in the hospital, but NAD sitting up on the edge of her bed. HEENT: Ophthalmologic unremarkable. EOMI, OP mucous membranes are dry. NECK: Supple without adenopathy or thyromegaly.
NAD|no acute distress|NAD,|119|122|PHYSICAL EXAMINATION|No other cardiac, respiratory, GI, GU, neurologic or orthopedic problems. PHYSICAL EXAMINATION: GENERAL: Pleasant lady NAD, now pain-free at this point. HEENT: Benign. NECK: No significant nodes or masses. Neck is supple. CHEST: Clear. CARDIOVASCULAR: Regular rate and rhythm, S1 and S2.
NAD|no acute distress|NAD|250|252|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Negative for any new eye symptoms, ear symptoms, lymphatic symptoms, psychiatric symptoms, no other cardiac, respiratory, GI, other GU, neurological or orthopedic problems. PHYSICAL EXAMINATION: GENERAL: A very pleasant gentleman, NAD now. VITAL SIGNS: His heart rate is in the 110s. HEENT: Benign. NECK: No significant nodes or carotid bruits. Neck is supple.
NAD|no acute distress|NAD.|143|146|PHYSICAL EXAMINATION|SOCIAL HISTORY: He lives with both parents. REVIEW OF SYSTEMS: Completely benign. PHYSICAL EXAMINATION: GENERAL: A pleasant little boy, alert. NAD. HEENT: Benign. His sclerae are mildly icteric now, although improved from yesterday. Nailbeds are not jaundiced at all. Skin color is only mildly jaundiced.
NAD|no acute distress|NAD.|124|127|PHYSICAL EXAMINATION|No alcohol for 9 years. Retired grocer, as above. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: Alert, cachectic male NAD. HEENT: Mucous membranes are slightly dry. OP is clear. NECK: Supple without adenopathy. Cranial nerves are intact CARDIOVASCULAR: Regular in rhythm.
NAD|no acute distress|NAD,|163|166|PHYSICAL EXAMINATION    VITAL SIGNS|She states she does still have custody overall of her children. She has history of arrest for illicit drug use. PHYSICAL EXAMINATION VITAL SIGNS: Stable. GENERAL: NAD, conversing well, and cognition appropriate. Appears somewhat irritable. Affect slightly flat. CARDIOVASCULAR: RRR. No murmur. LUNGS: CTA. ABDOMEN: Soft, no mass, and mild lower abdominal tenderness.
NAD|no acute distress|NAD,|237|240|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Negative for any new eye symptoms, ear symptoms, lymphatic symptoms, psychiatric symptoms, no cardiac, respiratory, GI, GU, neurologic, orthopedic problems. PHYSICAL EXAMINATION: GENERAL: This is a very pleasant lady, NAD, no symptoms of any kind at this point. HEENT: NC/AT, PERRLA, full EOMs, full fields, vision intact per patient. NECK: No significant anterior nodes or masses. Neck is supple.
NAD|no acute distress|NAD.|259|262|OBJECTIVE|She does not smoke, drink alcohol, use any drugs. REVIEW OF SYSTEMS: Negative for any new eye symptoms, ear symptoms, olfactory symptoms, psychiatric symptoms, no cardiac, respiratory, GI, GU, neurologic or orthopedic problems. OBJECTIVE: Very pleasant lady, NAD. HEENT: NC/NT, PERRLA full, EOMs full, vision intact per patient. TMs normal. Tonsils and pharynx not injected. NECK: No significant nodes, no obvious JVD.
NAD|no acute distress|NAD|167|169|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Otherwise, benign. Difficult because of the language barrier. PHYSICAL EXAMINATION: GENERAL: Very pleasant lady, very few words to her answers, but NAD now. No respiratory distress. No coughing. HEENT: Benign. NECK: She does have some positive JVD bilaterally. No other masses or abnormalities noted. CHEST: She has some rales in both bases, fairly good aeration, still no wheezes or rhonchi.
NAD|no acute distress|NAD|129|131|PHYSICAL EXAMINATION|No cardiac, respiratory, GI, GU, neurologic or orthopedic problems. PHYSICAL EXAMINATION: GENERAL: This is a very pleasant lady, NAD now, no pain at this point. HEENT: Benign. NECK: No significant anterior nodes or carotid bruits. Neck is supple. CHEST: Clear. CARDIOVASCULAR: Regular rate and rhythm, S1, S2, no murmurs.
NAD|no acute distress|NAD|138|140|PHYSICAL EXAMINATION|No cardiac, respiratory, other GI, GU, neurologic or orthopedic problems. PHYSICAL EXAMINATION: A pleasant lady who has a sad affect, but NAD now. HEENT: Benign. NECK: No significant nodes or masses. Neck is supple. CHEST: Clear. CARDIOVASCULAR: Irregular rhythm with a rate in the 60s.
NAD|no acute distress|NAD|104|106|OBJECTIVE|He does not smoke or drink any alcohol or use any drugs. OBJECTIVE: GENERAL: A very pleasant gentleman, NAD now, smiling today. HEENT: TMs are normal. Tonsils and pharynx are not injected. NECK: No significant nodes or masses. Neck is supple. CHEST: Clear.
NAD|no acute distress|NAD|129|131|PHYSICAL EXAMINATION|No cardiac, respiratory, GI, GU, neurologic or orthopedic problems. PHYSICAL EXAMINATION: GENERAL: This is a very pleasant lady, NAD now at rest. She is pain free at present. HEENT: Normocephalic and atraumatic. PERRLA. Full field vision intact per the patient. TMs are normal.
NAD|no acute distress|NAD.|162|165|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile, pulse 77, blood pressure 163/71, respirations 20, O2 sats 96% on 2 liters. GENERAL: She was alert, oriented, chatty, NAD. HEAD: Normocephalic, atraumatic. EYES: PERRLA, EOMI. OROPHARYNX: Some erythema. Mucous membranes were moist. NECK: LAD. CARDIOVASCULAR: Regular rate and rhythm. No murmurs, rubs, or gallops.
NAD|no acute distress|NAD|137|139|PHYSICAL EXAMINATION|No cardiac, respiratory, GI, GU, neurologic or orthopedic problems. PHYSICAL EXAMINATION: GENERAL: Very pleasant man, mildly overweight, NAD now, pain-free. HEENT: Benign. NECK: No significant nodes or JVD. NECK: Supple. CHEST: Clear. CHEST WALL: Nontender to AP and lateral stress.
NAD|no acute distress|NAD.|119|122|PHYSICAL EXAMINATION|No cardiac, respiratory, GI, GU, neurologic, orthopedic problems. PHYSICAL EXAMINATION: GENERAL: A very pleasant lady, NAD. VITAL SIGNS: Stable now. HEENT: Benign. NECK: No significant anterior nodes or thyroid palpated. Neck is supple. CHEST: Clear. CARDIOVASCULAR: Regular rate and rhythm.
NAD|no acute distress|NAD|162|164|OBJECTIVE|She walks with a walker and even this has been very difficult for her. OBJECTIVE: GENERAL: In general, a pleasant lady, alert, very appropriate with her answers, NAD now. No nausea or vomiting after the Zofran. Denies any pain. HEENT: NC/NT. PERRLA. Full EOMs. Full field vision intact per patient.
NAD|no acute distress|NAD.|303|306|PHYSICAL EXAMINATION|FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Negative for any new eye symptoms, ear symptoms, lymphatic symptoms, psychiatric symptoms, no cardiac, respiratory, GI, GU, neurologic, orthopedic problems. ALLERGIES: Sulfa. PHYSICAL EXAMINATION: GENERAL: Very feisty gentleman today but cooperative. NAD. HEENT: Benign. NECK: No significant nodes or masses. Neck is supple. CHEST: Clear. CARDIOVASCULAR: Regular rate and rhythm. S1, S2, no murmurs.
NAD|no acute distress|NAD|304|306|PHYSICAL EXAMINATION|ALLERGIES: Unknown. MEDICATIONS: Hydrochlorothiazide, eye drops and calcium. REVIEW OF SYSTEMS: Negative for any new eye symptoms, ear symptoms, lymphatic symptoms, psychiatric symptoms, no cardiac, respiratory, GI, GU, neurologic, orthopedic problems. PHYSICAL EXAMINATION: GENERAL: Very pleasant lady, NAD now, slightly weak. HEENT: Benign. NECK: No significant nodes or carotid bruits. Neck is supple. CHEST: Clear. CARDIOVASCULAR: Regular rate and rhythm. S1, S2, no murmurs.
NAD|no acute distress|NAD|127|129|PHYSICAL EXAMINATION|No cardiac, respiratory, GI, GU, neurologic, orthopedic problems. PHYSICAL EXAMINATION: GENERAL: This is a very pleasant lady, NAD now. HEENT: Benign. NECK: No significant nodes or masses. Neck is supple. CHEST: Clear. CARDIOVASCULAR: Regular rate and rhythm. S1, S2, no murmurs.
NAD|no acute distress|NAD.|100|103|OBJECTIVE|No cardiac or respiratory, GI, GU, neurologic, orthopedic problems. OBJECTIVE: A very pleasant lady NAD. HEENT - NC/AT, PERRLA, full EOMs, full field of vision is intact per patient. Cranial nerves II-XII seem grossly intact. NECK - no significant anterior nodes or masses.
NAD|nothing abnormal detected|NAD.|256|259|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 65-year-old woman with a massive ventral hernia status post bowel resection here for repair. PAST MEDICAL HISTORY: Significant for CAD, CABG, reflux, Crohn's. REVIEW OF SYMPTOMS: noncontributory. PHYSICAL EXAMINATION: NAD. RRR. CTAB. ASSESSMENT AND PLAN: A 65-year-old woman with a ventral hernia. The plan was to do a laparoscopic ventral herniorrhaphy. HOSPITAL COURSE: The above procedure was performed in the OR on _%#MM#%_ _%#DD#%_, 2002, without complication.
NAD|no acute distress|NAD|189|191|PHYSICAL EXAMINATION|No _____________ or psychiatric symptoms. No cardiac or respiratory. No GI, GU, neurologic or orthopaedic symptoms. PHYSICAL EXAMINATION: A very pleasant lady, obviously somewhat tired but NAD now. She is actually eating. She was nauseated earlier, vomited, but got Phenergan for this. HEENT exam is benign. NECK - no significant anterior nodes or masses.
NAD|no acute distress|NAD.|199|202|PHYSICAL EXAMINATION|Immune: No fevers or chills. Respiratory: Negative. CV: Negative. GI: Negative. Urinary: Negative. Endocrine: Negative. PHYSICAL EXAMINATION: General: Well-developed, well- nourished white female in NAD. HEENT: Negative. Neck: No thyromegaly. Back: Without CVAT. Chest: Clear. CV: RRR without murmur. Abdomen: S, NT, without masses or hepatosplenomegaly.
NAD|no acute distress|NAD.|145|148|PHYSICAL EXAMINATION|ETOH: Rare. Exercise: Walks 1-2 times per week plus yoga q. week. PHYSICAL EXAMINATION: General: Well-developed, well- nourished white female in NAD. HEENT: Negative. Neck: Without thyromegaly. Back: Without CVAT. Chest: Clear. CV: RRR without murmur. Pelvic: EG normal, BUS negative. Vagina: No lesions or discharge.
NAD|no acute distress|NAD.|114|117|PHYSICAL EXAMINATION|2. Hydrocortisone cream p.r.n. 3. Lamisil cream in the past. PHYSICAL EXAMINATION: GENERAL: A very pleasant lady. NAD. A&O x 3. VITAL SIGNS: Blood pressure 128/66, temperature 97.8, and O2 sat 98%. HEENT: Negative. Wears refraction. CHEST: Chest is not barreled. Clear with excellent excursion.
NAD|no acute distress|NAD,|196|199|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: See history of the present illness. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature is 97.8, pulse 79, blood pressure 122/81, respirations 20, pulse ox 97% on room air. GENERAL: NAD, alert, pleasant. Speech clear. HEENT: He has a several centimeter laceration in the left posterior occipital area. He has tenderness surrounding this, but no fluctuance. NEUROLOGICAL: Pupils are equal and reactive to light bilaterally.
NAD|no acute distress|NAD.|140|143|OBJECTIVE|No cardiac and respiratory, GI, GU, other neurologic or orthopedic problems. OBJECTIVE: Very pleasant man, oriented x 3 now, very alert and NAD. HEENT EXAM is benign. He has no sign of any facial droop or focal impairment. NECK: No significant mass, no carotid bruits heard. CHEST is clear.
NAD|no acute distress|NAD|104|106|OBJECTIVE|There is no cancer or heart attacks. REVIEW OF SYSTEMS: Otherwise negative. OBJECTIVE: A pleasant lady, NAD now after getting morphine. HEENT EXAM is benign. NECK: No significant nodes or masses. Neck is supple. CHEST is actually quite clear.
NAD|no acute distress|NAD,|88|91|PHYSICAL EXAMINATION|Endocrine: Negative except for the recent thyroid check. PHYSICAL EXAMINATION: GENERAL: NAD, alert, pleasant. VITAL SIGNS: Blood pressure 126/69, pulse 64, temperature 98.2, respirations 18. HEENT: Within normal limits. NECK: Neck is supple. No bruit or thyromegaly.
NAD|no acute distress|NAD,|149|152|OBJECTIVE|He does not smoke or drink alcohol. REVIEW OF SYSTEMS: Negative other than that noted above. OBJECTIVE: GENERAL: The patient is a very pleasant man, NAD, a bit forgetful. HEENT: Benign. NECK: No significant notes or carotid bruits noted. Neck is supple. CHEST: Chest is clear. HEART: Regular rate and rhythm.
NAD|no acute distress|NAD|146|148|PHYSICAL EXAMINATION|No cardiac, respiratory, GI, GU, neurologic, or orthopaedic problems. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: A very pleasant man, NAD now. Very talkative. HEENT exam is benign. Normocephalic, atraumatic. PERRLA, full field vision intact per patient. TMs - normal. TONSILS and PHARYNX - not injected. No facial droop is noted.
NAD|no acute distress|NAD,|173|176|PHYSICAL EXAMINATION|He has eight children altogether, 18 grandchildren, and two great-grandchildren. PHYSICAL EXAMINATION: GENERAL: Cheerful, very obese, white male, well-tanned, lying in bed, NAD, A&O X 3. Actually, he is lying absolutely flat, supine. HEART: S1 and S2 within normal limits. Regular rhythm. No extra sounds heard. CHEST: The chest is extremely barreled.
NAD|no acute distress|NAD.|217|220|ADMISSION PHYSICAL EXAMINATION|Skin: No ecchymosis. Myalgias: zero. Tenderness: zero. ADMISSION PHYSICAL EXAMINATION: VITAL SIGNS: temperature 97.2 F, heart rate 82, blood pressure 139/51, RR 20, SpO2 98% on RA. GENERAL: pleasant, elderly woman in NAD. HEENT: ATNC, PERRL, small pupils, EOMI. Conjunctivae: normal. Oropharynx: clear, upper and lower dentures. Neck: supple. Carotid artery x 2: zero. DJV, with an estimated CVP 15 cm of water.
NAD|no acute distress|NAD.|174|177|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile. Blood pressure 120/65, not orthostatic. Respiratory rate 20, 97% on room air. Heart rate in the 80s. GENERAL: Alert, young male, NAD. HEENT: PERRL, EOMI, OP clear. NECK: Supple without adenopathy. NEURO: Alert and oriented x 3. Affect is full range. Cranial nerves II- XII are intact.
NAD|no acute distress|NAD.|221|224|PHYSICAL EXAMINATION ON ADMISSION|Severe, diffuse arthralgias involving the large and small joints. PHYSICAL EXAMINATION ON ADMISSION: Temperature 99.4, heart rate 95, blood pressure 145/65, respiratory rate 18, weight 76.8 Kg. General: A+ x 3. Pleasant. NAD. HEENT: Normocephalic. Tenderness to palpation of the right zygomatic arch, as well as to percussion over the right maxillary sinus. EOMI. Conjunctivae pink. PERRL. Sclerae anicteric. Nares patent. Erythema of the posterior pharynx.
NAD|no acute distress|NAD.|146|149|PHYSICAL EXAMINATION|SOCIAL HISTORY: She denies smoking. PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile, vital signs stable. GENERAL: This is an African-American female, NAD. ABDOMEN: Soft. Questionable fetal positioning on abdominal exam. External fetal monitoring shows reactive tracing with no contractions. The patient noted positive fetal movement.
NAD|no acute distress|NAD,|193|196|DISCHARGE DIAGNOSES|Drinks socially. She lives with her daughter. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.2, heart rate 90, BP 138/88, RR 26, and SO2 94% on 2 L. GENERAL: Slightly anxious elderly woman, NAD, comfortable. HEENT: NC/AT, conjunctivae x2 normal, PERRL, EOMI. No oral lesions. NECK: LAD zero, thyromegaly zero, JVP not elevated. Carotid bruit x2. CARDIOVASCULAR: RR: S1 and S2 normal, MRG zero.
NAD|no acute distress|NAD,|255|258|PHYSICAL EXAMINATION|SKIN: Negative. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 160/86 initially, presently 145/94, pulse 112, pulse ox 90% on room air, raising to 97% on three liters, temperature 96.3, respirations initially 38 and presently 18. GENERAL: Thin female, NAD, alert, pleasant. HEENT: Bilateral hearing aids. No scleral icterus or injection. NECK: JVD, mild to moderate. CHEST: Bibasilar inspiratory crackles. No wheezing. CARDIAC: Regular S1, S2 with a 2/6 systolic murmur.
NAD|no acute distress|NAD,|132|135|PHYSICAL EXAMINATION|GENERAL: She is a very pleasant, stocky, elderly white female whom I awakened on coming into the room at this hour. Still she is in NAD, alert and oriented times three and a very good historian. HEENT: Negative. She does wear refraction. Negative CCOA, inguinal nodes and thyroid.
NAD|no acute distress|(NAD)|142|146|OBJECTIVE|No cardiac, respiratory, other gastrointestinal, other genitourinary, or neurologic problems. OBJECTIVE: A pleasant lady in no acute distress (NAD) now. She is very slightly confused but appropriate and cooperative. Her memory is good. The HEENT exam is benign. NECK: No significant anterior nodes or masses.
NAD|nothing abnormal detected|NAD.|296|299|PHYSICAL EXAMINATION|Continue Advil for back pain off and on. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 99.2 Tmax, heart rate 86, respirations 20, blood pressure 149/79, 92% O2 saturations on room air. GENERAL: Alert and oriented. SKIN: No ecchymosis or discolor changes or temperature changes are noted. HEENT: NAD. HEART, LUNGS: NAD. No CARDIOVASCULAR: No CV tenderness. ABDOMEN: Flank area pain. Bowel sounds are heard. Some degree of bladder area pain.
NAD|nothing abnormal detected|NAD.|315|318|PHYSICAL EXAMINATION|Continue Advil for back pain off and on. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 99.2 Tmax, heart rate 86, respirations 20, blood pressure 149/79, 92% O2 saturations on room air. GENERAL: Alert and oriented. SKIN: No ecchymosis or discolor changes or temperature changes are noted. HEENT: NAD. HEART, LUNGS: NAD. No CARDIOVASCULAR: No CV tenderness. ABDOMEN: Flank area pain. Bowel sounds are heard. Some degree of bladder area pain. No organomegaly is noted. EXTREMITIES: Good pulses are noted. Normal reflexes are noted.
NAD|no acute distress|NAD|363|365|OBJECTIVE|REVIEW OF SYSTEMS: Negative. MEDICATIONS: Include Coumadin alternating 4 and 6 mg every other day, tamoxifen 10 mg/day, Lasix 40 mg/day, which we are going to hold, lisinopril 20 mg/day, multivitamin daily, Colace 100 mg b.i.d. ALLERGIES: NKDA. REVIEW OF SYSTEMS: Otherwise is negative. OBJECTIVE: A very pleasant, extremely hard of hearing and a poor historian. NAD now. She is oriented. HEENT exam shows the 5 cm left posterior scalp laceration, which is nicely closed with staples.
NAD|nothing abnormal detected|NAD.|159|162|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: On exam, vitals are as noted. GENERAL: She is alert and oriented, pleasant except for complaining of pain and nausea. SKIN: NAD. HEENT: NAD. CHEST: No wheezes or crackles. HEART: Regular rate and rhythm, no murmurs noted. ABDOMEN: Soft, nontender, no CV tenderness. BACK: Positive for pain.
NAD|nothing abnormal detected|NAD.|171|174|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: On exam, vitals are as noted. GENERAL: She is alert and oriented, pleasant except for complaining of pain and nausea. SKIN: NAD. HEENT: NAD. CHEST: No wheezes or crackles. HEART: Regular rate and rhythm, no murmurs noted. ABDOMEN: Soft, nontender, no CV tenderness. BACK: Positive for pain.
NAD|nothing abnormal detected|NAD.|150|153|PHYSICAL EXAMINATION|She was alert and oriented. Skin: The left anterior shin rash had improved even more. There were no new acute findings were noted. HEENT: NAD. Heart: NAD. Chest clear to auscultation. Abdomen soft, nontender. Extremities: Right hip pain continues. (_______________)04:58 left lower extremity infection improving on the anterior shin area.
NAD|nothing abnormal detected|NAD.|202|205|PHYSICAL EXAMINATION|Otherwise the remainder is negative. PHYSICAL EXAMINATION: VITAL SIGNS: Pulse 65, respiratory rate 18, blood pressure 139/61. Weight is 61.7 kilos. T max 100.2 since she is up here on the floor. HEENT: NAD. Mouth: There is some upper lateral jaw teeth missing. The patient is wearing hearing aids. NECK: Supple. No lymphadenopathy.
NAD|nothing abnormal detected|NAD.|129|132|PHYSICAL EXAMINATION|GENERAL: Healthy-appearing 81-year-old female who appears very young for her age. Otherwise, she maintains a good affect. HEENT: NAD. Nothing abnormal detected. Neck supple without lymphadenopathy. No hepatomegaly. LUNGS: Clear bilaterally. HEART: Regular rate and rhythm. ABDOMEN: Soft and nontender, non-distended. EXTREMITIES: Within normal limits. BREASTS: No palpable masses or lumps noted.
NAD|no acute distress|NAD|209|211|OBJECTIVE|No cardiac respiratory, GI, GU, neurologic, orthopedic problems. He has been depressed of late and admits to this. His wife concurs. OBJECTIVE: Pleasant man bronzed in color from his hemochromatosis otherwise NAD at rest. He does have increased pain when he is standing up such as when he went to the bathroom. HEENT EXAM: Benign. NECK: No significant nodes or masses. Neck is supple.
NAD|no acute distress|NAD.|131|134|OBJECTIVE|No cardiac, respiratory, gastrointestinal, genitourinary, neurological, or orthopedic problems. OBJECTIVE: A very pleasant lady in NAD. The H&P exam is benign. NECK: No significant anterior nodes or masses. The NECK is supple. The CHEST is clear. CARDIOVASCULAR: There is a regular rhythm, S1 and S2.
NAD|nothing abnormal detected|NAD.|173|176|DISCHARGE EXAMINATION|SKIN: No acute changes except for the ones present on the left pictorial which seems to be improving in redness and temperature wise. Alert and oriented. HEENT: NAD. CHEST: NAD. CVS: NAD. ABDOMEN: Soft and non-tender. Bowel sounds present. EXTREMITIES: Decreased sensation below the knees. Decreased pin prick and soft touch.
NAD|nothing abnormal detected|NAD.|183|186|DISCHARGE EXAMINATION|SKIN: No acute changes except for the ones present on the left pictorial which seems to be improving in redness and temperature wise. Alert and oriented. HEENT: NAD. CHEST: NAD. CVS: NAD. ABDOMEN: Soft and non-tender. Bowel sounds present. EXTREMITIES: Decreased sensation below the knees. Decreased pin prick and soft touch. Local examination of the left great toe showed decreased warmth, decreased swelling, decreased redness noted.
NAD|no acute distress|NAD,|211|214|DISCHARGE EXAMINATION|She will have Fairview Home Health Care, RN, PT, OT, and home-health aide to help her. DISCHARGE EXAMINATION: She was afebrile. Pulse was 92. Respirations 18. Blood pressure 137/70. O2 saturations 91%. General: NAD, alert, decreased hearing, decreased vision, decreased memory. HEENT: No new changes noted. Chest: CTA bilateral. CVS: No new changes. Abdomen: Soft, non-tender. Extremities: No peripheral edema. ASSESSMENT/PLAN: Vioxx seems to be helping the patient.
NAD|no acute distress|NAD,|166|169|OBJECTIVE|SOCIAL HISTORY: He is living at nursing home. He does not smoke, use alcohol, use any drugs. REVIEW OF SYSTEMS: Unable to cooperate. OBJECTIVE: A pleasant man, seems NAD, but unable to give any meaningful conversation. HEENT - benign. NECK - no significant anterior nodes or JVD. Neck is supple. CHEST - clear. CARDIOVASCULAR - regular rhythm, S1, S2, no obvious murmurs.
NAD|no acute distress|NAD|99|101|OBJECTIVE|She is eating table foods exclusively now. REVIEW OF SYSTEMS: Completely benign. OBJECTIVE: She is NAD now. She is "crabby" per her mother, no respiratory distress whatsoever. She has not had any further vomiting since being on the floor or any bowel movements.
NAD|no acute distress|NAD.|156|159|PHYSICAL EXAMINATION|HEALTH HABITS: She is smoking one-half of one cigarette per day. She denies any alcohol use. PHYSICAL EXAMINATION: GENERAL: She is a morbidly obese female, NAD. VITALS: Blood pressure is up slightly today, 122/100. She states she is nervous. Last blood pressures have been normal. Weight is 267. HEENT: Tympanic membranes and canals are normal bilaterally.
NAD|no acute distress|NAD|103|105|OBJECTIVE|No cardiac, respiratory, GI, GU, neurologic, or orthopedic problems. OBJECTIVE: A very pleasant man in NAD now. He states his headache is 2 out of 10 after Vicodin. HEENT EXAM: He does have a mild lid lag on the right side, although he can fully open it if he makes an effort.
NAD|no acute distress|NAD.|194|197|OBJECTIVE|OBJECTIVE: VITAL SIGNS: Temperature maximum 100.8; heart rate 80's; blood pressure 90's over 50's; respiratory rate 12 to 16; oxygen saturations at 99% on room air. GENERAL: Alert young female, NAD. HEENT: PERRLA, EOMI. NECK: Supple without adenopathy. OP: Clear. Mucous membranes are moist. CARDIOVASCULAR: Regular rate and rhythm; no murmurs, rubs or gallops.
NAD|no acute distress|NAD.|206|209|OBJECTIVE|FAMILY HISTORY: Noncontributory. OBJECTIVE: VITAL SIGNS: Afebrile, heart rate 78, blood pressure 163/76, respiratory rate 24, 95% on room air. GENERAL: Alert older female, dressed, sitting up in her chair, NAD. HEENT: PERRL, EOMI. NECK: Supple without adenopathy, thyromegaly, or carotid bruits. CARDIOVASCULAR:: Regular rate and rhythm. CHEST: Clear to auscultation bilaterally.
NAD|no acute distress|NAD|108|110|OBJECTIVE|No cardiac, respiratory, GI, GU, neurologic, or orthopedic problems. OBJECTIVE: GENERAL: Very pleasant man, NAD now. He has been pain free for 6 hours at this point. HEENT exam is benign. NECK: No significant anterior nodes or carotid bruits.
NAD|nothing abnormal detected|NAD.|213|216|PHYSICAL EXAMINATION|GENERAL: In no acute distress. CHEST: Clear to auscultation. CARDIOVASCULAR: S1 and S2 regular. No murmur or gallops. ABDOMEN: Soft but some distention present. Tenderness in the left lower quadrant. EXTREMITIES: NAD. LABORATORY DATA: White count is elevated at 14.6, hemoglobin at 10.
NAD|no acute distress|NAD.|173|176|PHYSICAL EXAMINATION  VITAL SIGNS|PHYSICAL EXAMINATION VITAL SIGNS: On admission, temperature 99, pulse 107, blood pressure 90/49, respirations 16, and O2 saturations 95% on room air. GENERAL: Awake, alert, NAD. HEENT: Head: NCAT. Eyes: EOMI, PERRLA. Ears: TMs normal bilaterally. Nose, Mouth, Throat: Poor dentition with multiple deep caries.
NAD|no acute distress|NAD.|198|201|OBJECTIVE|NEUROLOGICAL: Negative. PSYCHIATRIC: Negative. OBJECTIVE: VITAL SIGNS: Stable. Blood pressure 144/74. Pulse 72. Respiratory rate 16. Saturation 98% on room air. Afebrile. GENERAL: Alert older male, NAD. HEENT: PERRL. EOM I. NECK: Supple without adenopathy or thyromegaly. There is a prominent right carotid bruit. Mucous membranes are moist. CARDIOVASCULAR: Regular rate and rhythm with a 2/6 systolic ejection murmur.
NAD|no acute distress|NAD|135|137|PHYSICAL EXAMINATION|No cardiac, respiratory, GI, GU, neurologic or other orthopedic problems. PHYSICAL EXAMINATION: GENERAL: This is a very pleasant lady, NAD now at rest in bed. HEENT: Benign. NECK: No significant nodes or carotid bruits. Neck is supple. CHEST: Clear. CARDIOVASCULAR: Regular rate and rhythm, S1, S2 with a 1/6 systolic heart murmur noted.
NAD|no acute distress|NAD.|179|182|PHYSICAL EXAMINATION|No cardiac, respiratory, GI, GU, neurologic or orthopedic problems. PHYSICAL EXAMINATION: GENERAL: Pleasant lady, complaining of back pain now in the left SI region but otherwise NAD. She is alert and oriented. HEENT: Benign. NECK: No significant nodes or masses. Neck is supple. CHEST: Clear. CARDIOVASCULAR: Regular rate and rhythm, S1, S2, no murmurs.
NAD|no acute distress|NAD.|194|197|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 132/83, heart rate 84, respirations 16, temperature 96.9, sats 99% on room air. The patient says at home his Accu-Cheks have been 510. GENERAL: NAD. CHEST: Clear to auscultation, minimal basilar rales. CV: S1 and S2, regular, no murmurs or gallops. ABDOMEN: Soft, bowel sounds present, obese. EXTREMITIES: He has a small callous on the left foot, on the left big toe, but no open sores or ulcers.
NAD|no acute distress|NAD,|122|125|PHYSICAL EXAMINATION|No cardiac, respiratory, GI, GU, neurologic, orthopedic problems. PHYSICAL EXAMINATION: GENERAL: Very pleasant gentleman, NAD, no respiratory distress at all now. VITAL SIGNS: O2 sats 98% on room air. HEENT: Benign. NECK: No significant nodes or carotid bruits. Neck is supple.
NAD|no acute distress|NAD|197|199|PHYSICAL EXAMINATION|SOCIAL HISTORY: She has been living at Friendship House assisted living needing maximal cares there. REVIEW OF SYSTEMS: Unable to be completed. PHYSICAL EXAMINATION: GENERAL: A very pleasant lady, NAD now, fairly alert, quite confused. HEENT: Benign. NECK: No significant nodes or JVD. NECK: Supple. CHEST: Clear. CARDIOVASCULAR: Irregular rhythm with a rate in the 80s, S1, S2, 1/6 systolic murmur.
NAD|no acute distress|NAD.|241|244|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Negative for any new eye symptoms, ear symptoms, lymphatic symptoms, psychiatric symptoms, no other cardiac or respiratory, GI, other GU, neurologic, orthopedic problems. PHYSICAL EXAMINATION: GENERAL: Very pleasant lady, NAD. HEENT: Normocephalic and atraumatic. PERRLA. EOMs are intact. Field of vision is intact per patient. TMs are normal. Tonsils and pharynx not injected. NECK: No significant nodes or masses.
NAD|no acute distress|NAD|146|148|PHYSICAL EXAMINATION|No cardiac or respiratory, GI, GU, other orthopaedic or other neurologic problems. PHYSICAL EXAMINATION: Very pleasant man, obviously frustrated. NAD now. HEENT: benign. NECK - no significant anterior nodes or carotid bruits. Neck is supple. Chest is clear. CARDIOVASCULAR - regular rate and rhythm, S1, S2, I/VI systolic murmur.
NAD|no acute distress|NAD.|146|149|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Afebrile, heart rate 60's to 80's, respiratory rate 16-20, 95% room air, blood pressure 104-116/60's. General: Alert female NAD. Skin: Negative. HEENT/Neck: Supple without adenopathy. No thyromegaly or carotid bruits. OP: Clear. Lower partial dentures. Nose: Clear. EOMI. Ears normal. CV: Regular rate and rhythm, no murmurs, gallops or rubs.
NAD|no acute distress|NAD.|88|91|PHYSICAL EXAM|No fevers or chills. Minimal sore throat and insomnia. PHYSICAL EXAM: Cushingoid woman. NAD. Vital signs: The temperature is 97.3. Blood pressure 166/78. Heart rate 98. Respiratory rate 22. SPO2 93% on room air. General: NAD. HEENT: Pharyngeal erythema. Nares are normal. Lungs: Palpable crepitus, rhonchi and scattered crackles on the left field.
NAD|no acute distress|NAD,|149|152|PHYSICAL EXAMINATION|He has an aunt with diabetes mellitus. Sister has hypertension. Father cholelithiasis. PHYSICAL EXAMINATION: Temperature 98.4, blood pressure 144/78 NAD, improved to 128/68, heart rate 79, respirations 16, 97% on room air. Weight 200 pounds NAD. Head AT/NC. Sclerae white. PERRL and extraocular movements intact.
NAD|no acute distress|NAD.|160|163|PHYSICAL EXAMINATION|MEDICATIONS: Currently are confined to Keflex 500 mg p.o. q.i.d.. ALLERGIES: She has no known allergies. PHYSICAL EXAMINATION: Reveals an alert, young woman in NAD. Blood pressure 102/68, weight 153 pounds, height 5'6" and temperature 97.7 degrees tympanic. PERRL, the TMs are gray, shiny. Pharynx is normal. Neck: Supple and without adenopathy, thyromegaly.
NAD|no acute distress|NAD,|170|173|ALLERGIES|PHYSICAL EXAMINATION ON ADMISSION: Weight: 55.4 kg. Temperature: 97.1. Blood pressure: 113/74. Heart rate: 85. Respiratory rate: 20. SpO2: 99% on room air. General: A/O, NAD, pleasant, thin male. HEENT: PERRL, EOMI, without icterus. No maxillary or frontal sinus tenderness. Oral mucosa moist and pink, without ulcers or lesions.
NAD|no acute distress|NAD,|239|242|OBJECTIVE|She drinks as noted above. No significant exercise. REVIEW OF SYSTEMS: Negative for ear symptoms, lymphatic symptomatic, psychiatric symptoms, no cardiac risk or GI, GU, neurologic or other orthopedic problems. OBJECTIVE: A pleasant lady, NAD, mildly confused, a minimizer. She is obviously cross-eyed in the exam room. HEENT: NC/AT. She does not have conjugate gaze with lateral movement.
NAD|no acute distress|NAD.|143|146|PHYSICAL EXAMINATION|Chronic constipation. PHYSICAL EXAMINATION: VITAL SIGNS: BP 111/79, pulse 101, respirations 18, temperature 97.1, pulse oximetry 94%. GENERAL: NAD. Alert. Unusual affect. Tangential speech. She has an obvious tremor of the upper extremities, left greater than right. HEENT: No scleral icterus. OMM without lesions. NECK: Supple. No JVD or bruit.
NAD|no acute distress|NAD,|132|135|OBJECTIVE|No cardiac, respiratory, GI, GU, neurologic or orthopedic problems. OBJECTIVE: GENERAL: The patient is a very pleasant, young lady, NAD, somewhat cheerful and afraid. HEENT: Benign. NECK: No significant ___________ or masses. Neck is supple. CHEST: Clear. CARDIOVASCULAR: Regular rate and rhythm. S1, S2. No murmurs.
NAD|no acute distress|NAD.|133|136|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 100.7, pulse 93, BP 166/76, respirations 16, pulse oximetry 95% on room air. GENERAL: NAD. Alert. Pleasant. HEENT: Partial upper denture. No scleral icterus. Oral mucosa moist without lesions. NECK: Supple. He has bilateral carotid bruits with 1+ upstrokes.
NAD|nothing abnormal detected|NAD.|163|166|HOSPITAL COURSE|I spoke to the patient via an interpreter, _%#NAME#%_(?). She was asleep but did awake and was alert and oriented, able to communicate via the interpreter. HEENT: NAD. Skin: NAD. The webbed spaces are healing better. Chest: clear to auscultation. Heart: no murmurs. Abdomen: soft, nontender. Extremities: no peripheral edema is noted. Her hemoglobin was 13.4 today probably because of hemodilution but it had been 12.4, 12.6, and was stable.
NAD|no acute distress|NAD.|134|137|HISTORY OF PRESENT ILLNESS|PAST MEDICAL HISTORY: Ulcerative colitis. ADMISSION MEDICATIONS: Prednisone. ALLERGIES: NKDA. PHYSICAL EXAMINATION: Physical exam was NAD. Lungs clear bilaterally. Regular rate and rhythm. ASSESSMENT AND PLAN: A 32-year-old female with ulcerative colitis for total proctocolectomy.
NAD|no acute distress|NAD|73|75|OBJECTIVE|REVIEW OF SYSTEMS: Otherwise completely negative. OBJECTIVE: A pleasant, NAD now. He is quite pale. HEENT EXAM is benign. NECK: No significant anterior nodes or masses. Neck is supple. CHEST is clear. CARDIOVASCULAR is regular rate and rhythm.
NAD|no acute distress|NAD,|198|201|PHYSICAL EXAMINATION|GI: Negative. GU: Negative. Skin: Negative. Musculoskeletal: Negative. Endocrine: Sugars are running in the 100's and are much better since the initiation of insulin. PHYSICAL EXAMINATION: GENERAL: NAD, alert, pleasant. VITAL SIGNS: Blood pressure initially 162/91, presently 149/82, pulse 81, respirations 16. Temperature 97, pulse ox 99% on room air. HEENT: Within normal limits.
NAD|no acute distress|NAD,|170|173|PHYSICAL EXAMINATION|GI: Negative. GU: Some intermittent dysuria. Musculoskeletal: Some chronic right knee and hand pain. Skin: Negative. Neurologic: Negative. PHYSICAL EXAMINATION: GENERAL: NAD, alert, her speech is clear, incoherent. VITAL SIGNS: Blood pressure 163/90, pulse 83, respirations 16, pulse ox 97% on room air. Orthostatics were not done in the Emergency Department. HEENT: She has a right forehead laceration which is sutured.
NAD|no acute distress|NAD.|164|167|PHYSICAL EXAMINATION|1. History of PID at age 13. 2. No history of hypertension or diabetes. PAST SURGICAL HISTORY: Negative. PHYSICAL EXAMINATION: GENERAL: This is an Hispanic female, NAD. VITALS: Afebrile. Vital signs stable. ABDOMEN: Soft, negative guarding, negative rebound, but moderate tenderness to palpation in the left lower quadrant compared to the right.
NAD|no acute distress|NAD.|148|151|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.1, pulse oximeter 98% on room air. Pulse 90, blood pressure 154/91. Respiratory rate 20. GENERAL: NAD. Alert, somewhat tearful. Pleasant. HEENT: Within normal limits. No scleral icterus. Mucosa moist without lesions. CHEST: Clear to auscultation bilaterally. CARDIAC: Regular, S1, S2, without added.
NAD|no acute distress|NAD,|130|133|EKG|Spine: No tenderness. Skin: Warm and dry. Neuro: No gross focal deficits. LABS ON ADMISSION: See above. EKG: Normal sinus rhythm, NAD, normal EKG. HOSPITAL COURSE: PROBLEM #1: Relapse of C. diff diarrhea after completion of a 14 day course of oral vancomycin.
NAD|no acute distress|NAD.|159|162|ADMISSION PHYSICAL EXAMINATION|ADMISSION PHYSICAL EXAMINATION: VITAL SIGNS: temperature 97.3 F, blood pressure 136/64, heart rate 74, O2 saturation 97%, RR 18. GENERAL: A + O x 4, pleasant, NAD. HEENT: NCAT, EOMI, PERRLA. Oropharynx: No lesions. Neck: supple, JVD: 0. CARDIOVASCULAR: Heart: RRR; S1, S2 normal; MRG: 0. LUNGS: bilateral crackles, left greater than right. Otherwise, clear. ABDOMEN: soft, positive for guarding, diffuse tenderness to palpation.
NAD|no acute distress|NAD|154|156|OBJECTIVE|REVIEW OF SYSTEMS: At this time negative for HEENT, GI, GU, neurologic, orthopedic, psychiatric. OBJECTIVE: GENERAL: The patient is a very pleasant lady, NAD now. She is pain- free at this time. HEENT: Benign. NECK: No significant nodes or masses. Her neck and jaw are nontender to palpation. Neck is supple.
NAD|nothing abnormal detected|NAD.|215|218|OBJECTIVE|OBJECTIVE: VITAL SIGNS: Pulse 73, respiratory rate 20, temperature 99.8, blood pressure 136/70. GENERAL: A healthy- appearing 34-year-old male, who appears comfortable, conversational, not in acute distress. HEENT: NAD. NECK: Supple. LUNGS: Clear. HEART: Regular rate and rhythm. ABDOMEN is soft, nontender, nondistended. No rebound, no guarding, no masses felt.
NAD|nothing abnormal detected|NAD.|215|218|DISCHARGE PHYSICAL EXAMINATION|Blood pressure 130/58. She was satting at 96% on 2 liters of oxygen. She was alert and oriented. SKIN: Much improved. EXTREMITIES: Lower extremities have normal color and decreased redness noted bilaterally. HEENT: NAD. HEART: NAD. LUNGS: No wheezing or crackles noted. ABDOMEN: Soft, non-tender. EXTREMITIES: Trace peripheral edema was noted today also. The patient was fit enough to be transferred and the necessary paperwork is being done.
NAD|no acute distress|NAD|98|100|OBJECTIVE|No cardiac, respiratory, GI, GU, neurologic or orthopedic problems. OBJECTIVE: Very pleasant man, NAD now. He is slightly dizzy even at rest. He does not have any chest pain or shortness of breath current. HEENT - benign. NECK - no significant anterior nodes or carotid bruits.
NAD|no acute distress|NAD|106|108|OBJECTIVE|MEDICINES: Synthroid .112 mg a day, multivitamin. ALLERGIES: VICODIN. OBJECTIVE: This is a pleasant lady, NAD now. No symptoms at present. HEENT EXAM: Benign. NECK: No significant anterior nodes are palpable. Neck is supple. CHEST is clear. CARDIOVASCULAR: Irregular rhythm with heart rate in the 150's.
NAD|no acute distress|NAD.|137|140|PHYSICAL EXAMINATION|IV fluids at KVO for 12 hours, urine output within normal limits. Only one stool yesterday. PHYSICAL EXAMINATION: Alert and cooperative, NAD. Chest clear to auscultation bilaterally. Minimal upper airway congestion. Heart regular without a murmur. Skin turgor is normal. Abdomen is soft, nondistended, nontender with no hepatosplenomegaly or mass.
NAD|nothing abnormal detected|NAD|196|198|PHYSICAL EXAMINATION|Temperature has been afebrile. Weight 106 pounds. GENERAL: Healthy appearing 80-year-old female who appears comfortable, conversational and not in acute distress. She looks slightly tired. HEENT: NAD (nothing abnormal detected) except patient wears glasses. NECK: Supple. No lymphadenopathy, no hepatomegaly. LUNGS: Clear to auscultation bilaterally.
NAD|no acute distress|NAD.|208|211|OBJECTIVE|He smokes 1 pack per day. He denies alcohol use or any other street drug use. FAMILY HISTORY: Noncontributory. OBJECTIVE: VITAL SIGNS: Afebrile. Vitals stable, as above. GENERAL: Alert male, confrontational, NAD. HEENT: EOMI. NECK: Supple without adenopathy. CV: Regular rate and rhythm without murmurs, rubs, or gallops. CHEST: Clear to auscultation bilaterally. ABDOMEN: Benign. Liver is not palpable.
NAD|nothing abnormal detected|NAD.|196|199|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Heart rate 57, afebrile, respirations 16, blood pressure 122/75, 96% oxygen saturations on room air. GENERAL: Alert and oriented. SKIN: No acute changes. HEENT: NAD. HEART/LUNG: NAD. No CVA tenderness. No flank area or bladder area tenderness noted. Heart had no murmurs. ABDOMEN: As above. EXTREMITIES: No peripheral edema.
NAD|nothing abnormal detected|NAD.|213|216|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Heart rate 57, afebrile, respirations 16, blood pressure 122/75, 96% oxygen saturations on room air. GENERAL: Alert and oriented. SKIN: No acute changes. HEENT: NAD. HEART/LUNG: NAD. No CVA tenderness. No flank area or bladder area tenderness noted. Heart had no murmurs. ABDOMEN: As above. EXTREMITIES: No peripheral edema.
NAD|nothing abnormal detected|NAD.|232|235|PHYSICAL EXAMINATION|HEART/LUNG: NAD. No CVA tenderness. No flank area or bladder area tenderness noted. Heart had no murmurs. ABDOMEN: As above. EXTREMITIES: No peripheral edema. Peripheral pulses are intact. NEUROLOGICAL: Grossly intact. PSYCHIATRIC: NAD. VASCULAR: NAD. ASSESSMENT AND PLAN: 1. History of pain secondary to renal stone.
NAD|no acute distress|NAD|110|112|OBJECTIVE|MEDICATIONS: Only ibuprofen p.r.n. ALLERGIES: No known drug allergies. OBJECTIVE: A pleasant, morbidly obese. NAD now. HEENT: NC/AT. PERRLA. Full EOMs. Full field of vision intact. The patient's funduscopic exam is benign. TMs normal. Tonsils and pharynx not injected.
NAD|no acute distress|NAD.|235|238|PHYSICAL EXAMINATION|He is an avid artist who enjoys drawing. PHYSICAL EXAMINATION: Vitals: Temperature 97.7, pulse 92, respiratory rate 16, saturating 98% on room air, blood pressure 110/68, weight 57 kg, height 177 cm. General: Shy, limited eye contact, NAD. HEENT: Normocephalic, atraumatic. Mucous membranes moist. Bright sclerae. Pupils equal, round, and reactive to light. Intact extraocular muscles. Moderate cerumen. No erythema. Good light reflex on tympanic membranes.
NAD|no acute distress|NAD.|196|199|OBJECTIVE|OBJECTIVE: VITAL SIGNS: Afebrile; heart rate in the 60s, respiratory rate 18 to 20; oxygen saturation at 97% on room air; blood pressure 120s to 140s over 60s to 70s. GENERAL: Alert, older female NAD. HEENT: Bilateral cataracts. EOMI bilaterally. NECK: Supple without adenopathy, thyromegaly, or bruits. CV: Regular rate and rhythm heard better on the right side as paced.
NAD|nothing abnormal detected|NAD.|200|203|PHYSICAL EXAMINATION|GU: Negative. Heart, lungs: Negative. Neurovascular: Negative. PHYSICAL EXAMINATION: On exam, alert, oriented, sitting up in the bed. She is not sleepy. She is arousable, cooperative, pleasant. Skin: NAD. HEENT: NAD. Chest: NAD. Heart: NAD. Abdomen: NAD. No CV tenderness noted. Extremities: No peripheral edema. Pulses intact. LABORATORY: White count 13.5; hemoglobin 13.9; 87 neutrophils.
NAD|nothing abnormal detected|NAD.|224|227|PHYSICAL EXAMINATION|GU: Negative. Heart, lungs: Negative. Neurovascular: Negative. PHYSICAL EXAMINATION: On exam, alert, oriented, sitting up in the bed. She is not sleepy. She is arousable, cooperative, pleasant. Skin: NAD. HEENT: NAD. Chest: NAD. Heart: NAD. Abdomen: NAD. No CV tenderness noted. Extremities: No peripheral edema. Pulses intact. LABORATORY: White count 13.5; hemoglobin 13.9; 87 neutrophils.
NAD|nothing abnormal detected|NAD.|236|239|PHYSICAL EXAMINATION|GU: Negative. Heart, lungs: Negative. Neurovascular: Negative. PHYSICAL EXAMINATION: On exam, alert, oriented, sitting up in the bed. She is not sleepy. She is arousable, cooperative, pleasant. Skin: NAD. HEENT: NAD. Chest: NAD. Heart: NAD. Abdomen: NAD. No CV tenderness noted. Extremities: No peripheral edema. Pulses intact. LABORATORY: White count 13.5; hemoglobin 13.9; 87 neutrophils.
NAD|nothing abnormal detected|NAD.|146|149|PHYSICAL EXAMINATION|S1 and S2 are both present. No added heart sounds. LUNGS: Clear. No added lung sounds. ABDOMEN: Convex, adipose, soft and nontender. EXTREMITIES: NAD. No pulse deficits noted. No cyanosis. LABORATORY DATA: Electrocardiogram shows normal sinus rhythm with a rate of 49, left bundle branch block, none for comparison.
NAD|no acute distress|(NAD)|89|93|OBJECTIVE|ALLERGIES TO SULFA AND PENICILLIN. OBJECTIVE: A very pleasant lady, in no acute distress (NAD) now. No pain at rest. The HEENT exam is benign. NECK: No significant anterior nodes or masses. The neck is supple. The CHEST is clear. CARDIOVASCULAR has a regular rate and rhythm and S1 and S2.
NAD|no acute distress|NAD.|104|107|PHYSICAL EXAMINATION|PAST SURGICAL HISTORY: none. SOCIAL HISTORY: No smoking. PHYSICAL EXAMINATION: African American female, NAD. Afebrile. Vital signs stable. ABDOMEN: Soft, mild tenderness in the right inguinal area. BACK: No CVA tenderness. PELVIC: Cervix is closed, long, and high.
NAD|no acute distress|Gen:NAD|124|130|CV|RUQ US showed dilated common bile duct. No fevers, chills, N/V. PMH, FH, SH, ROS as per resident note. Exam: VSS as per EMR Gen:NAD Pulm:CTABL CV:nl s1s2 no m/r/g brady Abd:soft nt/nd nl bs Labs, radiology studies, and medications reviewed.
NAD|no acute distress|NAD|164|166|CV|Ct scan shows a large mass in his left lung apex with abuttment of his vertebral body as well as erosion into the rib. FH, SH, ROS as per resident note. Exam: Gen: NAD Pulm: diminished BS throughout left lung field, scattered rhonci, crackles at base, right lung has scattered rhonchi CV: nl s1 s2 no m/r/g Abd:soft NT/ND nl bs Labs, radiology studies, and medications reviewed.
NAD|no acute distress|NAD.|94|97|PHYSICAL EXAMINATION|SOCIAL HISTORY: Denies smoking. She has an office job. PHYSICAL EXAMINATION: Caucasian female NAD. VITAL SIGNS: Initial blood pressure was 141/93, repeat on her side was 110/70; temperature 98.3; heart rate 100; respiratory rate 18.
NAD|no acute distress|NAD.|154|157|PHYSICAL EXAMINATION|GI: As above, no diarrhea, constipation. Urinary: No frequency or urgency. PHYSICAL EXAMINATION: General: Well-developed, well- nourished white female in NAD. There is no significant pallor or flushing to the skin. Vital signs are stable. The patient is afebrile. Abdomen: There is tenderness to palpation in the right lower quadrant, without rebound or guarding.
NAD|no acute distress|NAD,|157|160|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VS: 38.6, 111, 152/76, 16, 95% RA GENERAL: Sleeping, appears stated age, most of the information came from husband, daughter, and son, NAD, resting comfortably. HEENT: OP dry, eyes closed, does not follow commands, nontender thyroid, non palpable, no LAD CHEST: + decrease BS at bases, + coarse crackles at bases.
NAD|no acute distress|NAD,|971|974|VS|MSK: no muscle aches or pains, weakness PMH/PSH 1) Tongue - Squamous cell -s/p Chemo therapy (TAF) X 1 (_%#MMDD#%_?_%#MMDD#%_) -with Dexamethasone 2) Orthostatic Hypotension (dehydration and BB) 3) Gout 4) Nephrolithiasis 5) DM 6) Hlipids 7) Gout 8) Colon Ca s/p resection with chemotherapy Family Hx CAD: + mother HTN: + mother Cancer: no Thyroid disease: no DM2: + Social Hx Smoke: +pipe (quit years ago) OH: occ Other drugs: no Married: + Kids: + Job: stage actor Meds at home: 1) Allopurinol 2) Actos 3) TCF 4) Prandin 5) Mydradin 6) Lipitor 7) Byetta 8) Prevacid Meds at the Hospital 1) Valtrex 2) Tylenol 3) ASA 4) Allopurinol 5) Reglan 6) Midodrine 7) MVI 8) Protonix 9) Simvasiatin 10) Byetta 11) Actos 12) Prandin ALL: NKDA Labs: CBC: 7.7, 10.2, 30, 158 BMP: 133, 3.9, 101, 26, 13, 1.66, 127, 8.1 TSH: 2.73 Cortisol 6pm: 13.9 Cortisol 7pm: 32.8 HbA1c: 6.9 Physical Exam VS: 36.3, 94, 20, 100% Orthostatic: 124/66 *85)m 94/54 (67) GENERAL: Alert and oriented X3, NAD, well dressed, answering questions appropriately, appears stated age. HEENT: OP clear, no LAD, no TM, non-tender, no exopthalmous, no proptosis, EOMI, no lig lag, no retraction CV: RRR, no rubs, gallops, no murmurs LUNGS: CTAB, no wheezes, rales, or ronchi ABDOMEN: soft, Nontender, nondistended, +BS, no organomegaly EXTREMITIES: no edema, +pulses, no rashes, no lesions NEUROLOGY: CN grossly intact, + pinprick, + DTR upper and lower extremity MSK: grossly intact A/P: 69yo male with orthostatic hypotension, ? adrenal insufficiency.
NAD|no acute distress|NAD|318|320|PE|Lives in an apt with a dog and a cat. Smokes 1 ppd x 12 years. No alcohol. Meds: Reviewed and per FCIS Allergies: gluten, adhesive tape FH: Lupus, arthritis, autoimmune ROS: as per HPI, other systems reviewed and were negative PE: BP: 119/78 HR: 119 RR: 18 97% on 30% venti mask T: 35.8 Gen: A and O x3 very pleasant, NAD HEENT: EOMI, PERRLA, MMM and pink Neck: Supple, left IJ TLC site looks good. No LAD, No bruits CV: Sinus tach, No M/R/G Normal S1/S2 Lungs: Diffuse crackles.
NAD|no acute distress|NAD,|192|195|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: A 10-point review was completed. Pertinant + as above. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 36.6, 84, (148/88) 97% on RA, RR ? 20 GENERAL: Alert and Oriented X 3, NAD, appears stated age HEENT: OP clean, poor dentition, no TM, no LAD LUNGS: decrease BS at bases, + ronchi CARDIOVASCULAR: RRR, no rubs, no gallops ABDOMEN: Soft NT/ND, +BS, + scars consistent with surgeries EXTREMITIES: no cyanosis/clubbing, edema NEUROLOGIC: grossly intact.
NAD|no acute distress|NAD,|442|445|PHYSICAL EXAMINATION|1. Diabetes mellitus. 2. Hypertension. 3. Depression. MEDICATIONS: Norvasc ASA Wellbutrin Enalapril Enozaparin Prozac Aspart SSI (24 hours - 58 Units) Lantus 20Units qpm Metformin 1000mg po bid D5, 1/2 NS (d/c yesterday) SOCIAL HISTORY: +occasional drinker no smoke + married carpentar, recently retired FAMILY HEALTH HISTORY: +DM2 +HTN no Cancer PHYSICAL EXAMINATION: VS: 90s, 110-120s/70s-80s, 14-17, 98% RA GENERAL: Alert and oriented X3, NAD, well dressed, answering questions appropriately, appears stated age. HEENT: OP clear, no LAD, no TM, non-tender, no exopthalmous, no proptosis, EOMI, no lig lag, no retraction CV: RRR, no rubs, gallops, no murmurs LUNGS: CTAB, no wheezes, rales, or ronchi ABDOMEN: soft, Nontender, nondistended, +BS, no organomegaly EXTREMITIES: no edema, +pulses, no rashes, no lesions, bandanges consistent with surgeries NEUROLOGY: CN grossly intact, + pinprick, + DTR upper and lower extremity MSK: grossly intact Labs: BS: 250-400s
NAD|no acute distress|NAD.|216|219|PHYSICAL EXAMINATION|SOCIAL HISTORY: Denies smoking. PHYSICAL EXAMINATION: Temperature 98.4, blood pressure 124/79, heart rate 97, respiratory rate 20, protein negative for ketones or proteinuria. GENERAL APPEARANCE: Caucasian female in NAD. ABDOMEN: Soft, gravid, non-tender. Negative guarding or rebound. NST is reactive showing occasional contractions. Infant is vertex per _%#NAME#%_'s. Cervix is closed, long, and high.
NAD|no acute distress|NAD.|145|148|HEENT|Otherwise complete ROS reviewed and negative. Vitals: reviewed and as per FCIS Physical exam: General: morbidly obese, nasal canula in place, in NAD. HEENT: EOMFI, PERRL; moist mucous membranes; could not visualize pharynx d/t tongue size Neck: no LAD, trachea midline, no masses Heart: distant heart sounds secondary to body habitus, RRR, no murmurs appreciated Lungs: mild expiratory wheezes, diffuse crackles; poor respiratory effort Abdomen: obese abdomen, no tenderness to palpation, distant but present BS Extremities: bilat LE skin ulcerations, lymphedema; pulses not palpable.
NAD|no acute distress|NAD,|147|150|OBJECTIVE|2. Her past medical history is, otherwise, not significant. SOCIAL HISTORY: She denies smoking. She works as a nurse. OBJECTIVE: Caucasian female, NAD, afebrile. Initial blood pressure was 134/84. Subsequent repeat blood pressures were 110s over 60s. Trace protein on urine dipstick. NST is reactive. Abdomen is soft, nontender.
NAD|no acute distress|NAD.|173|176|OBJECTIVE|DERMATOLOGY: Ulcers as per past medical history. OBJECTIVE: Afebrile. Blood pressure 120s/62, heart rate 70s, respiratory rate 20, weight 210. GENERAL: Alert, obese female, NAD. HEENT: NC/NT, EOMI. NECK: Supple without adenopathy, thyromegaly, or carotid bruits. CV: Regular rate and rhythm. CHEST: Clear to auscultation bilaterally.
NAD|no acute distress|NAD,|203|206|PHYSICAL EXAMINATION|GI: Some mild chronic constipation, otherwise negative. Psychiatric: Negative. PHYSICAL EXAMINATION: VITAL SIGNS: T-max of 100.4, current 98.8, blood pressure 118/54, pulse 98, respirations 24. GENERAL: NAD, alert, pleasant. HEENT: Oral mucosa moist without lesions. Pupils are equal. No icterus. NECK: Neck is supple. Carotids are without bruit.
NAD|no acute distress|NAD.|244|247|PHYSICAL EXAMINATION|PAST MEDICAL HISTORY: As above. Osteoarthritis, right hip. MEDICATIONS: Vicodin p.r.n. SOCIAL HISTORY: Nonsmoker. Desk job. FAMILY HISTORY: No history of clots. PHYSICAL EXAMINATION: VITAL SIGNS: Vitals reviewed as per chart - stable. GENERAL: NAD. Alert, pleasant. CHEST: Clear to auscultation bilaterally. CARDIAC: Regular S1, S2 without added. EXTREMITIES: Right hip incision healing well. No significant erythema, swelling, or cord at the right calf.
NAD|no acute distress|NAD,|128|131|PHYSICAL EXAMINATION|SOCIAL HISTORY: -No smoke, no OH -married, 8 children PHYSICAL EXAMINATION: VITAL SIGNS: 97.2, 77, 123/68. GENERAL: A and O X3, NAD, answering questions appropriately. HEENT: Head: NC/AT, PERRLA, no TM, nontender, noLAD LUNGS: CTAB, no wheezes, rales, ronchi. CARDIOVASCULAR: + heart sounds, RRR, no rubs ABDOMEN: + bowel sounds, minimal distention, nontender.
NAD|no acute distress|NAD|1142|1144|EXAMINATION|ALLERGIES: NKDA MEDICATIONS: aspart medium dose correction scale aspart 2 units /meal Lantus as per the HPI L-T4 200 mcg/day Lipitor 80 mg/day, Benadryl 25 mg q HS, Compazine 5-10 mg q 6 hours prn, sevelamer 800 mg po q day SOCIAL HISTORY: lives in Florida; nonsmoker FAMILY HISTORY: father MI; + DM; + HTN REVIEW OF SYSTEMS: eating more since admission compared to what she was seating before 10 system ROS as per the HPI or negative ALLERGIES: NKDA REVIEW OF SYSTEMS: Recent 20# gain of water weight which has now also been dialyzed off, otherwise weight is stable Chronic cold intolerance Legally blind; can read with lighted magnifier Lifelong constipation followed by a period of diarrhea a few months ago (had to take Lomotil then). Now more recently she as regular BM – at least once/day “not myself” Difficulty walking, not stable on feet - requires stabilitizing assistance to walk; + weakness Has been on HD Mon, Wed, Fri in _%#CITY#%_ _%#CITY#%_ Florida 10 system ROS as per the HPI or negative EXAMINATION: VITALS Tmax this hospitalization 37.6, HR 65, BP 162/67 GENERAL: very thin middle aged woman lying flat in bed ; she is in NAD SKIN: normal color, temperature, texture without hirsutism, alopecia or purple striae HEENT: EOMI, no scleral icterus, eyelid retraction, stare, lid lag, proptosis or conjunctival injection.
NAD|no acute distress|NAD|139|141|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 36.3, heart rate 103, blood pressure 120/68, 18. GENERAL: Oronary male, appears stated age, NAD HEENT: NC/AT, PEERL, EOMI, OP clear, dry MM RESPIRATORY: CTAB, no wheezes. HEART: + tachycardic, no rubs, no gallops. ABDOMEN: +soft, NT/ND + BS, no masses.
NAD|no acute distress|NAD.|166|169|CV|Physical: Vss Blood sugars: 08:00 12:00 13:00 14:00 17:00 21:00 _%#MMDD#%_ 4 units/hr gtt 2 units/hr 3 units/hr BGs 162 163 11/17 BGs 454 309 370 11/18 BGs 338 Alert NAD. Lungs: CTA, CV: RRR Skin: No rash. Abdomen: benign Recomendations: 1- Type 2 diabetes. This is likely to have been ongoing for some time, supported also by her A1C% of >10.
NAD|no acute distress|NAD.|140|143|PHYSICAL EXAMINATION|PAST MEDICAL HISTORY: Negative for hypertension, diabetes, or asthma. SOCIAL HISTORY: Denies smoking. PHYSICAL EXAMINATION: A Somali female NAD. VITAL SIGNS: Blood pressure initially was 145/101, however, lateral on her side was 122/83; temperature 98; heart rate 90, protein is 1 plus unchanged from previous evaluation 1 week ago.
NAD|no acute distress|NAD.|183|186|PHYSICAL EXAMINATION|She has otherwise been feeling reasonably well except for some mild bronchitic symptoms over the last month. PHYSICAL EXAMINATION: VITALS: Afebrile. Other vitals are stable. GENERAL: NAD. Alert, pleasant, no wheezing. HEENT: Within normal limits. Neck is supple. CHEST: Clear to auscultation bilaterally. No wheezes. COR: Regular S1, S2 with a soft, mid-systolic click.
NAD|no acute distress|NAD,|360|363|GENERAL|14. Ibuprofen 600mg QID PRN Allergies: NKDA LABS: _%#MMDD2007#%_ Ca 16.5 Phs 2.5 PTH 261 TSH 0.66 Free T4 1.25 _%#MMDD2007#%_ Ca 14.6 _%#MMDD2007#%_ Ca 13.8 _%#MMDD2007#%_ Ca 13.7 Sestamibi scan reviewed personally by me and discussed with radiologist. +inferior left adenoma. PExam: Vitals: T 98.4 P 67 BP 120/67 RR 20 Sats 95 GENERAL: Alert and oriented X3, NAD, dressed in hospital gown, answering questions appropriately, appears stated age. HEENT: OP clear, dry MMM, no exopthalmous, no proptosis, EOMI grossly, no lig lag, no retraction LUNGS: no wheezes, rales, or ronchi ABDOMEN: Obese GU: foley intact and draining EXTREMITIES: no edema, +pulses, no rashes, no lesions MSK: grossly intact A/Plan: 66 y/o male with elevated calcium, low phosphorus suggestive of primary hyperparathyroidism.
NAD|no acute distress|NAD|167|169|NCAT|Had been to the dentist about 2 wks prior for routine cleaning and was given prophylactic antibiotics. VS, medications, and labs reviewed in FCIS. Alert, cooperative, NAD NCAT Sclera clear, oralphayrnx clear Neck supple, no LAD Lungs clear, no crackles or wheezes. Heart regular, 3/6 holosystolic flow murmur hear best at RUSB.
NAD|no acute distress|NAD.|231|234|OBJECTIVE|DERM: Negative. NEURO: Has been getting tension headaches. MUSCULOSKELETAL: Complains of right wrist pain worse when writing or using a keyboard. OBJECTIVE: VITAL SIGNS: Stabile, afebrile. GENERAL: Alert, slightly disheveled male. NAD. HEENT: NC/NT. OP clear. NECK: Supple without adenopathy or thyromegaly. CV: Regular rate and rhythm. CHEST: Clear to auscultation bilaterally.
NAD|no acute distress|NAD.|257|260|PHYSICAL EXAMINATION|GU: No difficulty urinating, no hesitancy or frequency. States that her menstrual periods are regular and she had menses when she was first admitted. PHYSICAL EXAMINATION: GENERAL: Relatively well appearing, very pleasant, sweet, cooperative young woman in NAD. MOUTH: Gaping open and she is drooling. However, the surgical sites on right neck and chin appear clean, dry and intact.
NAD|no acute distress|NAD.|223|226|PHYSICAL EXAMINATION|They use condoms consistently. She previously was taking oral contraceptive pill and plans to start the patch with her next cycle. The patient currently has her period. PHYSICAL EXAMINATION: GENERAL: Pleasant young female, NAD. VITAL SIGNS: Normal. She is afebrile. HEENT: Head normocephalic, atraumatic. Eyes, pupils equal, round, and reactive. Lids and sclera normal.
NAD|no acute distress|NAD,|702|705|VS 72, 145/114, 14, 100% GENERAL|MSK: no muscle aches or pains, weakness PMH: 1) Anemia 2) steroid induced DM2 3) Lung transplant secondary to COPD h/o RAPA induced BOOP 4) ESRD 5) CMV 6) HTN 7) GERD 8) Hypothyroidism FHx no CAD no HTN + Cancer (colon, prostate) no Thyriod disease no DM2 SHx: Smoke +, quit in 1999 OH no Other drugs no no Married 2 Kids Job - retired transit driver Medications: 1) Dapsone 2) Prednisone 25mg po qam (_%#MMDD#%_) 3) Prograf 4) Lantus 10Units qday (_%#MMDD#%_) 5) Azithromycin 6) Flonase 7) Synthroid 25mcg po qday 8) Metoprolol 50mg po qday 9) Protonix 10) Tobra/Dexamethasone optho sup 11) Aranesp qweek 12) Albuterol 13) Elavil 14) Stadol NS VS 72, 145/114, 14, 100% GENERAL: Alert and oriented X3, NAD, well dressed, answering questions appropriately, appears stated age. HEENT: OP clear, no LAD, no TM, non-tender, no exopthalmous, no proptosis, EOMI, no lig lag, no retraction CV: RRR, no rubs, gallops, no murmurs LUNGS: + mild expiratory wheeze lower lung fields, no rales, or ronchi ABDOMEN: soft, Nontender, nondistended, +BS, no organomegaly EXTREMITIES: no edema, +pulses, no rashes, no lesions NEUROLOGY: CN grossly intact, + pinprick, + DTR upper and lower extremity MSK: grossly intact Labs: BS 136-218 TSH 3.0 A1c 5.3 A/Plan: Ms _%#NAME#%_ is a 68yo female with steroid induced DM2.
NAD|no acute distress|NAD.|109|112|PHYSICAL EXAMINATION|History of an appendectomy. SOCIAL HISTORY: Denies smoking. PHYSICAL EXAMINATION: GENERAL: Caucasian female, NAD. VITAL SIGNS: Blood pressure is 131/75, heart rate 100, temperature 99. NST shows reactive tracing. Tocometer shows no contractions. ABDOMEN: Shows no contractions.
NAD|nothing abnormal detected|NAD.|129|132|PHYSICAL EXAMINATION|She is alert and oriented, not very talkative, however. SKIN: Acne marks noted on the face, in various stages of healing. HEENT: NAD. CHEST: Clear to auscultation bilaterally. CVS: No murmurs; regular rate and rhythm. ABDOMEN: Soft, nontender; bowel sounds are positive. EXTERMITIES: No peripheral edema is noted.
NAD|no acute distress|NAD,|218|221|SUBJECTIVE|FAMILY MEDICAL HISTORY: Noncontributory. SUBJECTIVE: VITAL SIGNS: Stable. Blood pressure 120s over 80s. Heart rate 90s to 100s. Respiratory rate 18, 97% on room air, afebrile. GENERAL: Alert male, limited eye contact, NAD, NC/NT, pupils equal, round, slightly constricted. EOMI. NECK: Supple without adenopathy or thyromegaly. CV: Regular rate and rhythm, no murmurs, rubs, or gallops.
NAD|no acute distress|NAD,|220|223|PHYSICAL EXAMINATION|He is a non-smoker. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: As per history of present illness. PHYSICAL EXAMINATION: VITALS: Fingerstick 130, blood pressure 110/60, pulse 60. GENERAL: Healthy-appearing male, NAD, alert, pleasant. HEENT: No scleral icterus, and essentially negative. CHEST: Previous sternotomy scar, well-healed. Clear to auscultation bilaterally. COR: Regular S1 with mechanical S2.
NAD|no acute distress|NAD.|73|76|OBJECTIVE|SOCIAL HISTORY: No smoking. Works as a pastry chef. OBJECTIVE: Caucasian NAD. VITAL SIGNS: Stable. ABDOMEN: Soft, nontender. NST is reactive. Ultrasound demonstrates a breech presentation with amniotic fluid volume of approximately 7, 1 fluid packet was noted to be 4.0 cm.
NAD|no acute distress|NAD.|341|344|PHYSICAL EXAMINATION|Prenatal course has been otherwise uncomplicated. PAST MEDICAL HISTORY: Significant for a history of depression, stable on Celexa, as well as a history of asthma, which is controlled with Advair and albuterol p.r.n. Otherwise significant for one prior cesarean section. SOCIAL HISTORY: Denies smoking. PHYSICAL EXAMINATION: Caucasian female NAD. VITAL SIGNS: Temperature 98.2, blood pressure 121/62, heart rate 78. ABDOMEN: Soft; non-tender, vertex per _%#NAME#%_'s. NST is reactive. Tocometer shows no contractions.
NAD|no acute distress|NAD.|235|238|OBJECTIVE|OBJECTIVE: VITAL SIGNS: Afebrile. Heart rate in the 50s. Blood pressure 110 to 120 over 60s to 70s. Respiratory rate 18 to 20. 96% on 1 liter, nasal cannula. I&Os: 1213/1400 2:40 p.o. this morning. GENERAL: Alert male. Cervical brace, NAD. CV: Regular rate and rhythm; no murmurs, rubs, or gallops. CHEST: Clear to auscultation bilaterally. ABDOMEN: Bowel sounds positive, soft, nontender, nondistended, no HSM or masses.
NAD|no acute distress|NAD.|168|171|HISTORY OF PRESENT ILLNESS|Endocrine negative. Respiratory negative. CV negative. GI negative. Urinary negative. PHYSICAL EXAMINATION: General: A well-developed, well- nourished Hispanic female, NAD. Abdomen: No significant tenderness, S, no palpable masses or hepatosplenomegaly. Pelvic: EG normal, BUS negative. Vagina: A small amount of blood in vault.
NAD|no acute distress|NAD.|1091|1094|EXAMINATION|Recent relevant labs are as noted: _%#MMDD2007#%_: Na 131, K 4.5, Cl 103, Co2 23, BUN 22, creatinine 0.83, glucose 379 _%#MMDD2007#%_: TSH 0.19, free T4 1.53 _%#MMDD2007#%_ at 0755: Na 131, K 5, Cl 101, Co2 23, BUN 23, careatinine 0.8, glucose 375 PAST MEDICAL HISTORY: Hypothyroid diagnosed 5 yrs ago, on L-T4 DM diagnosed 1992 ? age 35, RA ?diagnosed 1995 She last had humira 3 weeks ago Asthma Sinusitis Chronic cough Osteoporosis Anemia for which she has had blood transfustions in the past MEDICATIONS: Albuterol nebs, ASA, budosinide inhalers, ca, vitamin D, ergocalciferol, folate, High intensity insulin correction Lantus 40 units /day ALLERGIES: as per Dr _%#NAME#%_ note SOCIAL HISTORY: from _%#CITY#%_ _%#CITY#%_, Music teacher in elementary school; nonsmoker FAMILY HISTORY: RA mother and sister REVIEW OF SYSTEMS: Reduced appetite + thirst Some SOB early satiety I did not ask about her periods denies neuropathy denies retinopathy 10 system ROS otherwise as per the HPI or negative EXAMINATION: VITALS: 147/89, 107, afebrile GENERAL: pleasant middle aged woman lying in bed in NAD. Her 2 sisters are present. She has O2 per NC SKIN: normal color, temperature, texture without hirsutism, alopecia HEENT: PER, EOMI,no scleral icterus, eyelid retraction, stare, lid lag, proptosis or conjunctival injection.
NAD|no acute distress|NAD;|1172|1175|EXAMINATION|The lasix, diovan and sotalol have not been given. Review of the Flowsheet shows that she had oxygen saturation of 86% on RA on _%#MMDD#%_ and after this she was started on supplemental oxygen. _%#MMDD#%_ 278 _%#MMDD#%_ 1737 214 _%#MMDD#%_ 2338 184 _%#MMDD#%_ 0802 152 _%#MMDD#%_1352 186 _%#MMDD#%_ 1730 149 _%#MMDD#%_2349 180 _%#MMDD#%_ 1706 158 _%#MMDD2007#%_ aldolase 9.1 (1.5-8.1), CK < 20 _%#MMDD2007#%_: Na 139, K 3.2, Cl 108, Co2 28, BUN 14, creatinien 1.17, glucose 214 PAST MEDICAL HISTORY (incomplete list) metastatic neuroendocrine tumor A Fib pacemaker MEDICATIONS: mucomyst 600 bid x 4 doses ASA 81 mg/day Atenolol 50 mg/day Fe glucoonate 324 mg /day Motrin 600 mg every 6 hours Ketoconazole 100 mb bid Mgoxide 400 mg/day ranitidine 150 mg bid Ativan 0.5 mg po every 4 hours prn Reglan prn KCl replacement other prn meds REVIEW OF SYSTEMS reduced appetite + some nausea since yesterday some SOB during the night has been out of bed walking to the bathroom aware of the fact she can't take care of herself, willing to go to living situation that works EXAMINATION vitals: 35.5, HR 62/minute, BP 179/92, RR 18 with 93% o2 sat elderly woman lying flat in bed in NAD; she has on O2 per NC SKIN: pale; ecchymosis on forearmes; normal temperature HEENT: PET, no scleral icterus NECK prominent fat distribution; I am unable to see neck veins LUNGS: clear bilaterally CARDIAC: RRR S2 S2 1/6 systolic murmur ABDOMEN: rounded; + BS, soft/ nontender NEURO: awake, responds appropriately to questions, moves all extremities; unable to sit up from raise HOB without assistance EXTREMITIES: no foot ulcers or deformities; 2+ pitting malleolus but otherwise improved edema in feet compared to her last clinic visit with me Assessment/Plan 1.
NAD|no acute distress|NAD,|561|564|HEENT|She is currently doing well without troubles with pain. Has nursed multiple times since the procedure. PCP: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD - Northern Lights Peds PMHx: born at 38 weeks, spontaneous vaginal delivery, no complications healthy, no hospitalization, surgeries, medical problems except as above Allergies: NKDA Meds: none SocHx: lives with parents, 2 sisters in _%#CITY#%_ _%#CITY#%_, MN 1 cat in the home, no smoking FHx: paternal great-grandmother with lung cancer and glaucoma wt 4.8 kg T 97.7 P 132 BP 119/68 RR 38 O2 sat 98% (RA) General: NAD, WD/WN Caucasian female HEENT: NC/AT, MMM, L eye coverred in patch Chest: CTAB, RRR Abdomen: soft, NT/ND, NABS Extremities: WWP, cap refill < 2 sec Neuro: MAE, CN III-XII grossly normal 2 mo female with congenital cataract on the left s/p removal today -encourage oral intake now that awake -for pain, tylenol 75 mg PO Q4-6 PRN or if needing something stronger, could consider tylenol #3 1 cc Q4-6 PRN -will follow with you Thank you for the consult.
NAD|no acute distress|NAD|249|251|PE|H/O cocaine use and currently uses THC. No ETOH. Lives at home with family. ROS: Per HPI other systems reviewed completely and were negative PE: BP: 140/47 HR: 63 RR:20 T: 97.8 O2 sats: 97% on RA Gen: Awake but drowsy, speaks in complete sentences, NAD HEENT: Mild scleral icterus, EOMI, PERRL, MMM and pink, no thrush NECK; Trachea midline, no bruits, No JVD, no LAD CV: RRR without M/R/G Normal S1/S2 Lungs: Coarse BS bilat.
NAD|no acute distress|NAD.|128|131|PE|Complete ROS otherwise reviewed and negative. PE: BP: 102/71 HR: 72 RR: 16 T: 36.5, O2 sat 93% on 3 LPM of N/C GEN: A and O x 3 NAD. Speaks in complete sentences. Looks pinkish. HEENT: EOMI, PERRL, No scleral icterus, MMM and pink. NECK: No LAD, some JVD seen CV: RRR sof SEM 2/6 no S3/S4 heard Lungs: Diffuse crckles, mild expiratory wheezing, prolonged expiratory phase Abd: Soft, NT, ND, +BS x4 Ext: Stasis changes, 2+ pitting edema Neuro: CN II-XII grossly intact.
NAD|no acute distress|NAD.|175|178|OBJECTIVE|It feels worse today. Has pain which shoots down from her lower back and down the side of her right leg. OBJECTIVE: GENERAL: This is a pleasant, very tired appearing woman in NAD. VITAL SIGNS: Blood pressure 135/61, pulse 84, respirations 16, temperature 97.8. HEENT: Remarkable for conjunctival injection and ptosis on the left.
NAD|no acute distress|NAD.|160|163|ALLERGIES|ADMISSION HISTORY AND PHYSICAL VITAL SIGNS: Blood pressure is a 102/64. Pulse is 100. Weight is 106.6 kg. Height is 165.5 cm. BMI 38.8. GENERAL: The patient is NAD. HEENT: Sclerae are anicteric. Conjunctivae are pink. Moist mucous membranes. NECK: Supple. CARDIOVASCULAR: Regular rate and rhythm. PULMONARY: Clear to auscultation bilaterally. BACK: No CVA tenderness. ABDOMEN: Obese, soft, nontender, nondistended.
NAD|no acute distress|NAD|1734|1736|PHYSICAL EXAM GENERAL|Outpatient prescriptions as of _%#MMDD2006#%_: TRENTAL 400 MG TAB take 1 tablet (400mg) by oral route 2 times per day with meals DAPSONE 100 MG TAB take 1 tablet (100mg) by oral route once daily FENTANYL 75 MCG/HR 72 HR TRANSDERM PATCH take one patch every 72 hours KEFLEX 500 MG CAP take 1 capsule (500mg) by oral route every 6 hours PERCOCET 5 MG-325 MG TAB take 1 tablet by oral route every 12 hours as needed NICOTINE 21MG/24HR-14MG/24HR-7MG/24HR DAILY TRANSDERM PATCH,SEQUENTIAL use daily PREDNISONE 10 MG TAB 3 tabs bid VICODIN 5 MG-500 MG TAB take 1 tablet by oral route every 4-6 hours as needed for pain PROTONIX 40 MG TAB take 1 tablet (40mg) by oral route once daily LIDOCAINE 5 % (700 MG/PATCH) ADHESIVE PATCH 1 Patch Transdermal EVERY MORNING off at night for neck CYCLOBENZAPRINE 10 MG TAB 10 mg Oral 3 TIMES A DAY AS NEEDED neck head pain LACTULOSE 10 G/15 ML ORAL SOLN 30 ML 20 g Oral 3 TIMES A DAY LISINOPRIL-HYDROCHLOROTHIAZIDE 20 MG-12.5 MG TAB take one tablet by mouth every day. LEVOTHYROXINE 200 MCG TAB take 1 tablet (200mcg) by oral route once daily WELLBUTRIN SR 150 MG TAB one po bid REVIEW OF SYSTEMS: CONSTITUTIONAL: no fevers, + weight gain over past 2 months EYES: no vision changes HEENT: no sores in mouth, wears dentures, no sore throat PULM: no cough, SOB CV: no chest pain, palpitations, orthopnea, PND GI: no N/V/D, may have had some blood in BMs once or twice in the past couple months GU: no dysuria/hematuria RHEUM: no joint pains or swelling ENDO: no heat/cold intolerance, no polyuria/polydipsia LYMPH: lower leg swelling over past 2 months MSK: ingrown toenail removed a few weeks ago NEURO: no weakness, numbness or paresthesias of the extremities PHYSICAL EXAM GENERAL: Alert, obese man in NAD EYES: PERRLA, EOMI, no scleral icterus HEENT: upper dentures, OC/OP clear without ulcers, erythema, exudates or petechiae NECK: obese habitus, supple, no JVD PULM: good air entry bilaterally, no crackles, few expiratory wheezes CV: RRR, S1/S2, no m/r/g ABD: obese, mildly distended, + normal BS, no HSM GU: no genital or anal lesions SKIN: extensive ulcerated lesions over both legs up to the thighs, some being at least 10 cm in diameter.
NAD|no acute distress|NAD.|193|196|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 101.6 degrees, blood pressure 93/66, pulse 127, respiratory rate 18, oxygen saturation 96% on room air. GENERAL: Somewhat cachectic, otherwise is NAD. He is able to speak in complete sentences without shortness of breath. HEENT: NC/AT. PERRL, EOMI, OP clear. Posterior pharynx is nonerythematous and no exudate.
NAD|no acute distress|NAD.|241|244|PHYSICAL EXAMINATION|She has had orthostatic dizziness for quite some time. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.5; pulse 71; blood pressure 127/70; respiratory rate 16; oxygen saturations at 97% on room air. GENERAL: She was alert and oriented x3, NAD. HEENT: Head was normocephalic and atraumatic. PERRLA, EOMI. Could not achieve visualization of fundi. Ears were not examined, normal externally.
NAD|no acute distress|NAD.|232|235|PHYSICAL EXAMINATION|SOCIAL HISTORY: Divorced. One adopted child, a son who is 33 years old and stationed in Iraq. No history of smoking. Denies alcohol use. PHYSICAL EXAMINATION: GENERAL: Well-appearing, pleasant, quite talkative middle-aged female in NAD. SKIN: Fair skinned with a facial flush. HEENT: NC/AT. PERRLA; EOMI. No conjunctivitis. Sclera anicteric. Ears: Able to hear the crackle of paper in both ears.
NAD|no acute distress|NAD.|165|168|ADMISSION PHYSICAL EXAMINATION|ADMISSION PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile, pulse 76, blood pressure 153/90, respirations 18, O2 sats 95. She is pleasant, alert, oriented, lying in bed, NAD. HEAD: Normocephalic, atraumatic. EYES: PERRLA, EOMI. NECK: Soft without lymphadenopathy or thyromegaly. CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops.
NAD|nothing abnormal detected|NAD.|127|130|PHYSICAL EXAMINATION|She appears alert and oriented, but distressed, anxious, and in pain, and is requested PCA and regular pain medications. SKIN: NAD. HEENT: Dry lips and tongue. CHEST: CTA bilateral. HEART: No murmurs are noted. CVA tenderness, right, is present. Right flank is tender on exam. The patient is not allowing abdominal exam to be done secondary to be pain.
NAD|no acute distress|NAD.|211|214|PHYSICAL EXAMINATION|He is married. He is a vo-tech graduate. REVIEW OF SYSTEMS: Denies chest pain, shortness of breath, polyuria, polydipsia. Review of systems is otherwise negative. PHYSICAL EXAMINATION: GENERAL: He appears well, NAD. VITAL SIGNS: Blood pressure 136/86, height 68 1/2 inches, weight 151 pounds. Temperature 97.5, pulse 88. HEENT: TMs normal. Pupils are equal, round and reactive to light.
NAD|no acute distress|NAD.|144|147|HISTORY OF PRESENT ILLNESS|She does have a history of infertility. SOCIAL HISTORY : She denies smoking. She works in management. PHYSICAL EXAMINATION : A caucasian female NAD. Temperature 98.3, blood pressure 94/49, heart rate 83, respirations 16, reflexes 1+ and no clonus. Urinalysis is negative for leukocytes or nitrates. WBC's 0 to 5 per HPF.
NA|Narcotics Anonymous|NA|335|336|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at the _%#CITY#%_ Outpatient Chemical Dependency Treatment Program, client was involved in tasks and assignments designed to address chemical dependency, sobriety and recovery issues. His participation included daily Chemical Health Groups, daily Community Feelings check-in groups, on and off site AA and NA meetings, weekly individual counseling, developmental asset-building activities 3 times a week, weekly spirituality groups, daily recreational activities and 2 hours of onsite schooling per day when school in session.
NA|Narcotics Anonymous|NA|217|218|DIMENSION VI|He may require further assistance in the area of family relationships and is therefore referred to Family Counseling. Staff provided client with resources and support systems in recovery such as information on AA and NA meetings. He also took part in recreational activities during treatment program. He was able to discuss concepts of a support system and to identify activities to avoid boredom.
NA|Narcotics Anonymous|NA|292|293|DISCHARGE PLANS AND RECOMMENDATIONS|DISCHARGE PLANS AND RECOMMENDATIONS: Upon completion, it is recommended that _%#NAME#%_ participate in the phase 2 aftercare program through the FUMC Crystal site. It is additionally recommended that he receive random drug screens, that he follow a home contract, that he attend weekly AA or NA meetings, that he engage in therapy and participate in a school support group if available. Dimension scale ratings upon admission were: DIMENSION 1: 0. DIMENSION 2: 0.
NA|Narcotics Anonymous|NA|273|274|HOSPITAL COURSE|_%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, mental health and recovery. She participated in stated groups, multifamily groups, gender groups, spirituality groups, in house school, mental health groups, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset-building activities, chemical dependency, mental health and related lectures. PROGRESS AND SIGNIFICANT EVENTS: She had difficulty expressing her feelings during her stay.
NA|Narcotics Anonymous|NA,|221|223|DISCHARGE PLAN AND RECOMMENDATIONS|She was sent home with medication and she will return to the dual outpatient program, awaiting residential treatment program opening. She was asked to continue with medication followup, individual and family therapy, AA, NA, and Alanon for family.
NA|Narcotics Anonymous|NA|221|222|AXIS II|By _%#MM#%_ _%#DD#%_, 2004, it was determined he was physically stable, out of detoxification, and ready to be discharged. He is to be discharged with a 30-day supply of medication, to return to the community, and AA and NA meetings in the community. DISCHARGE STATUS: He was alert, oriented, and cooperative. His speech was regular in rhythm and rate and normal in volume and tone.
NA|Narcotics Anonymous|NA|243|244|PROBLEMS PRESENTED AT ADMISSION|While at Fairview Adolescent Inpatient Treatment Program _%#NAME#%_ was involved in various tasks and assignments designed to address chemical- dependency, sobriety, mental health, and recovery. She attended step groups, gender groups, AA and NA meetings on-site, therapeutic recreation, developmental asset building activities, chemical- dependency, mental health, and related lectures. On _%#MMDD2004#%_ Dr. _%#NAME#%_ ordered an additional family planning meeting to address outpatient site options for follow-up care.
NA|Narcotics Anonymous|NA|206|207|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreation, and leisure skills by engaging in his community of appropriate maturity level will be important of _%#NAME#%_ to continue of life development. Attending AA and NA support groups may prove beneficial for _%#NAME#%_ encountering a more helpful peer group and potential role models. _%#NAME#%_ and his family are recommended to continue with family therapy as well as _%#NAME#%_ obviously benefiting from individual therapy of understanding his responsibility and involvement of current circumstance.
NA|Narcotics Anonymous|NA|138|139|PROGRAM PARTICIPATION|_%#NAME#%_ has attended both the weekly family groups and the intensive family week program. She has attended both on and off site AA and NA meetings. PROGRESS: While attending the outpatient program _%#NAME#%_ has completed work on steps 1 through 5 of the AA Program as well as a relapse prevention plan, a triggers packet, and a graduation assignment.
NA|Narcotics Anonymous|NA,|159|161|SIGNIFICANT EVENTS|The parents were unable to participate in the intensive family week program. _%#NAME#%_ was able to identify a workable support system, which included AA, and NA, parents, and sober peers. DISCHARGE PLAN/RECOMMENDATIONS: At discharge _%#NAME#%_ was recommended to attend phase 2 at our Fairview-University Medical Center _%#CITY#%_ _%#CITY#%_ site.
NA|Narcotics Anonymous|NA|260|261|DISCHARGE PLAN/RECOMMENDATIONS|DISCHARGE PLAN/RECOMMENDATIONS: At discharge _%#NAME#%_ was recommended to attend phase 2 at our Fairview-University Medical Center _%#CITY#%_ _%#CITY#%_ site. It was also recommended that he return to _%#CITY#%_ _%#CITY#%_ High School, continue weekly AA and NA attendance, follow probation expectations, and abide by his home contract, including random urinalyses. _%#NAME#%_ _%#NAME#%_, CDC II
NA|Narcotics Anonymous|NA|297|298|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at _%#CITY#%_ _%#CITY#%_ A.D.C.P., _%#NAME#%_ _%#NAME#%_ was involved in various tasks and assignments designed to change chemical dependency, sobriety, and recovery. She attended step groups, weekly family groups, spirituality groups, in house school, outside AA and NA meetings, developmental asset building activities, and chemical dependency and related lectures. SIGNIFICANT EVENTS/PROGRESS: _%#NAME#%_ reported that her relapse was due to letting things build up and some unresolved issues surrounding her relationship with her father.
NA|Narcotics Anonymous|NA.|225|227|DISCHARGE RECOMMENDATIONS|DISCHARGE RECOMMENDATIONS: 1. Complete _%#CITY#%_ _%#CITY#%_ A.C.D.P. Phase II after care program. 2. Continue with individual counseling with _%#NAME#%_ _________. 3. Continue with family counseling. 4. Attend weekly AA and NA. 5. Attend school support group.
NA|Narcotics Anonymous|NA|271|272|DISCHARGE PLAN/RECOMMENDATIONS|DISCHARGE PLAN/RECOMMENDATIONS: Recommendations upon completion include that she enter the phase 2 programming through the Fairview-University Medical Center _%#CITY#%_ _%#CITY#%_ Program, that she receive random drug screens, follow a home contract, attend weekly AA or NA meetings, that she continue with family therapy and medication management. If one is available it would also be recommended that she participate in a school support group.
NA|Narcotics Anonymous|NA|217|218|HOSPITAL COURSE|In the end, with the answers he would provide, it was decided that chemical dependency intensive treatment would not be needed at this time. The patient did state he was interested in attending AA meetings as well as NA meetings as an outpatient. There seems to be a temporal relationship between the patient's worsening depression and his recent arm burn.
NA|Narcotics Anonymous|NA|315|316|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at the _%#CITY#%_ Outpatient Chemical Dependency Treatment Program, the client was involved in various tasks and assignments aimed at addressing chemical dependency, sobriety and recovery. She participated in daily chemical health groups, daily community groups, on and off site AA and NA meetings, weekly individual counseling, developmental asset building activities 3 times a week, weekly spirituality groups, daily recreational activities and 2 hours of onsite schooling per day.
NA|Narcotics Anonymous|NA|153|154|HISTORY OF PRESENT ILLNESS|Lately, he has been using heroin daily for 4 months. The patient was detoxed with buprenorphine. He did fairly well. His plans were to get back with his NA and AA group. He attended AA at least once a day. He was to talk to the counselor about outpatient treatment.
NA|Narcotics Anonymous|NA|165|166|SIGNIFICANT EVENTS|These seemed to be beneficial to _%#NAME#%_ and she communicated openly at discharge. It was recommended that _%#NAME#%_ attend Phase II programming, attend AA, and NA weekly, abide by her home contract, receive random urinalysis, pursue one-to-ones, and family therapy. DISCHARGE DIMENSION: Dimension one, 0; dimension two, 0; dimension three, 1; dimension four, 1; dimension five, 1; and dimension six, 2.
NA|Narcotics Anonymous|NA|291|292|DISCHARGE PLAN/RECOMMENDATIONS|DISCHARGE PLAN/RECOMMENDATIONS: At the time of discharge, the client is recommended to continue chemical dependency treatment at the Phase II Program in _%#CITY#%_. Additional recommendations include family and individual counseling, school support group attendance, participation in AA and NA meetings, following home contract agreements, resolving all legal issues, and remaining abstinent passing all drug tests.
NA|Narcotics Anonymous|NA|205|206|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the S.T.O.P. Unit _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. She attended grief group, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset building activities, and chemical dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_ a social history was finished with the client.
NA|Narcotics Anonymous|NA|281|282|DISCHARGE PLANS AND RECOMMENDATIONS|DISCHARGE PLANS AND RECOMMENDATIONS: It is our recommendation that _%#NAME#%_ complete primary chemical dependency treatment on an outpatient basis. _%#NAME#%_'s parents chose Hazelden inpatient for his treatment. We are also recommending that _%#NAME#%_ continue to attend AA and NA meetings, and obtain a sober sponsor, and also continue to build sober social skills through his NA and AA attendance, and also his treatment attendance and reintegration into his public school.
NA|Narcotics Anonymous|NA|281|282|PROGRAM PARTICIPATION|He has a family history of chemical dependency. He has a history of attention deficit hyperactivity disorder, by previous diagnosis. PROGRAM PARTICIPATION: Since admission to the STOP Unit, _%#NAME#%_ has been involved in step groups, therapeutic recreation, gender groups, AA and NA meetings, daily asset building activities, chemical dependency lectures, and other related lectures. SIGNIFICANT EVENTS: _%#NAME#%_ came to the STOP Unit for evaluation of chemical dependency issues.
NA|Narcotics Anonymous|NA|323|324|PROGRAM PARTICIPATION|There is a positive family history for chemical dependency. _%#NAME#%_'s father is an alcoholic with numerous treatment attempts. _%#NAME#%_ has been previously diagnosed with ADHD. PROGRAM PARTICIPATION: Since admission to the stop unit, _%#NAME#%_ has been involved in step groups, therapeutic recreation, gender groups, NA and AA meetings, daily asset building activities, chemical dependency lectures and other related lectures. SIGNIFICANT EVENTS: _%#NAME#%_ attended all activities. His attitude was quite negative throughout his entire stay.
NA|Narcotics Anonymous|NA|215|216|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety and recovery. She attended gender group, spirituality group, NA and AA meetings on site, individual therapy, therapeutic recreation, developmental asset-building activities, and chemical dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_, _%#NAME#%_ met with unit staff concerning social histories and current levels of functioning.
NA|Narcotics Anonymous|N.A.|164|167|DISCHARGE PLAN AND RECOMMENDATIONS|_%#NAME#%_ needs his medication evaluated as well as his chemical use. Staff further recommends _%#NAME#%_ follow any recommendations of _%#NAME#%_, attend A.A. or N.A. meetings and upon returning home, engage in family therapy.
NA|Narcotics Anonymous|NA|162|163|HOSPITAL COURSE|The Seroquel at bedtime was increased to 600 mg. By _%#MM#%_ _%#DD#%_, 2005, it was determined that she could safely be discharged. She will continue with AA and NA meetings in the community. DISCHARGE STATUS: She was alert, oriented, and cooperative. Her speech was regular in rhythm and rate, normal in volume and tone.
NA|Narcotics Anonymous|NA|200|201|PROGRAM PARTICIPATION|While at _%#CITY#%_ Program, the client took part in daily community groups, 2 hours of on site schooling per day, asset building groups 3 x a week, weekly spirituality groups, on and off site AA and NA meetings, and daily group therapy sessions. Additionally, the client took part in three day family program with mother and father. SIGNIFICANT EVENTS: At admission the client appeared somewhat reserved and apprehensive about starting treatment program.
NA|Narcotics Anonymous|NA|337|338|DISCHARGE PLAN/RECOMMENDATIONS|DISCHARGE PLAN/RECOMMENDATIONS: At the time of discharge, the client is recommended to continue chemical dependency treatment in the Phase 2 program at Fairview-University Medical Center _%#CITY#%_ site. Additional recommendations for client include family and individual counseling, school support group participation, attending AA and NA meetings two x a week, remaining abstinent and passing drug tests, as well as medication management. Dimension scale ratings at admission: Dimension one; 0, dimension two; 0, dimension three; 1, dimension four; 1, dimension five; 2, and dimension six; 1.
NA|Narcotics Anonymous|NA|385|386|DISCHARGE PLAN AND RECOMMENDATIONS|Discharge Dimension Scale ratings were as follows: Dimension #1: 0; Dimension #2: 0; Dimension #3: 0; Dimension #4: 0; Dimension #5: 2; Dimension #6: 2. DISCHARGE PLAN AND RECOMMENDATIONS: At discharge recommendations included Phase 2 at the Fairview _%#CITY#%_ site, 1 to 1 and family counseling, reassessment for depression and possible medications, random urinalyses, weekly AA and NA meetings, follow home contract she and her mother had devised, and follow through with a Rule 25 assessment for possible halfway house placement as a backup referral.
NA|Narcotics Anonymous|NA|157|158|DISCHARGE PLAN|1. He is to continue the prescribed medication. 2. He is encouraged to refrain from the use of mood altering chemicals. 3. He is encouraged to attend AA and NA groups in the community. 4. He was given numbers to arrange a chemical dependency treatment program if he chose to do so.
NA|Narcotics Anonymous|NA|198|199|DISCHARGE PLANS AND RECOMMENDATIONS|She will return to her mother's home until there is space available for her at the halfway house. Additional recommendations for _%#NAME#%_ would include engaging in therapy, attending weekly AA or NA meetings, receiving random drug screens, attending a sober school and reassessing the need for possible medication to treat her issues of depression.
NA|Narcotics Anonymous|NA|225|226|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure skills of his community would seem important towards _%#NAME#%_ replacing previously unhealthy choices with more growth oriented ideas. Attending a community AA and NA support group would also prove beneficial toward _%#NAME#%_ accessing a healthy peer network and/or potential role models of support. _%#NAME#%_ finally is recommended to continue with individual and family therapy towards introspection and realizing a more stable adolescent experience.
NA|Narcotics Anonymous|NA|237|238|DISCHARGE PLAN/RECOMMENDATIONS|Continuing to build sober social, recreational and leisure skills by engaging of his community and/or school is recommended at a time when _%#NAME#%_, family members, and consequent treatment team deem fit. Accessing community AA and/or NA groups would seem important towards _%#NAME#%_ encountering a healthy peer group for support, and/or potential role models. As mentioned previously individual therapy may also benefit client of self expression and potential anger management issues.
NA|Narcotics Anonymous|NA|292|293|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While in the _%#CITY#%_ _%#CITY#%_ Adolescent Chemical dependency program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. The He attended chemical dependency groups in the house school, AA, and NA meetings, developmental asset building activities, and chemical dependency and related lectures. _%#NAME#%_ and his mother did not participate in family week due to a conflict with her work schedule.
NA|Narcotics Anonymous|NA|215|216|DISCHARGE PLAN|The patient is to return to her home school, and the family was given information regarding sober schools for future planning. The patient is to continue building her sober support system by participating in AA and NA support group meetings, as well as aftercare programming. It was also recommended that the family participate in family therapy, and the patient continue individual therapy.
NA|Narcotics Anonymous|NA|301|302|PROGRAM PARTICIPATION|The patient has a learning disability. PROGRAM PARTICIPATION: While at the STOP Program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. He attended step groups, weekly family groups, gender groups, spirituality groups, AA and NA meetings on site, individual therapy, therapeutic recreation, music therapy, developmental asset building activities, and chemical dependency and mental health related lectures.
NA|Narcotics Anonymous|NA|159|160|PROGRESS|The patient is to attend school on site at the treatment program. The patient is to continue building a sober support network. The patient is to attend AA and NA support groups. It is also recommended that the patient continue individual therapy to deal with his anger management issues, and to identify feelings and healthy ways of coping with those feelings.
NA|Narcotics Anonymous|NA|209|210|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety and recovery. _%#NAME#%_ attended gender group, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset building activities and chemical dependency and related lectures. On _%#MMDD2002#%_ _%#NAME#%_ met with unit staff concerning social history and current issues of functioning.
NA|Narcotics Anonymous|NA|223|224|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. He attended gender group, spirituality groups, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset-building activities, and chemical dependency and related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_, _%#NAME#%_ met with unit staff concerning social histories and current issues of functioning.
NA|Narcotics Anonymous|NA|236|237|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. He attended grief group, gender group, spirituality groups, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset-building activities, and chemical dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_, _%#NAME#%_ met with unit staff regarding social history and current circumstances.
NA|Narcotics Anonymous|NA|206|207|DISCHARGE PLAN AND RECOMMENDATIONS|Family and individual therapy are highly recommended toward client developing skills of expression and hopefully resolving the seemingly self-destructive momentum of his choices. Accessing community AA and NA support groups would seem important toward _%#NAME#%_ encountering a more positive peer group and potential role models. At a time when chemical health, behavioral issues, and mental health issues seem effectively addressed, the client is encouraged to return to academic and/or vocational pursuits.
NA|Narcotics Anonymous|NA|212|213|PROBLEMS PRESENTED UPON ADMISSION|PROGRAM PARTICIPATION: While on the STOP program, _%#NAME#%_ was involved in varies tasks and assignments designed to address chemical dependency, sobriety and recovery. _%#NAME#%_ attended gender groups, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset building activities, and chemical dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_ _%#NAME#%_ completed drug chart history and presented this for his therapy group.
NA|Narcotics Anonymous|NA|222|223|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure skills by engaging in community, treatment program, and school would seem important of _%#NAME#%_ improving adolescent experience. Accessing his community AA and NA support groups would seem important towards _%#NAME#%_ encountering a more healthful peer groups and/or potential role models. As mentioned previously _%#NAME#%_ is encouraged to proceed with individual and family therapy as directed by the attending chemical dependency professionals.
NA|Narcotics Anonymous|NA|264|265|DISCHARGE PLAN AND RECOMMENDATIONS|5. Continuing to build sober social, recreational and leisure skills be engaging in community and/or school activities would seem important to _%#NAME#%_ in realizing a more healthy adolescent experience and young adulthood identity. 6. Attending community AA and NA support groups may prove helpful in _%#NAME#%_ accessing a more healthful peer group and/or potential role models. 7. As mentioned previously, _%#NAME#%_ is encouraged to access individual therapy for herself in processing issues of shame and/or other difficulties of her current circumstance.
NA|Narcotics Anonymous|NA|242|243|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to stress chemical dependency, sobriety, and recovery. _%#NAME#%_ attended grief group, gender group, spirituality group, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset-building activities, and chemical dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2003#%_ _%#NAME#%_, his mother, and his stepfather met with unit staff concerning family history and current issues of functioning.
NA|Narcotics Anonymous|NA|223|224|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended grief group, gender group, AA and NA meetings on site, individual therapy, therapeutic recreation, multifamily group, developmental asset-building activities, and chemical dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2003#%_ _%#NAME#%_ completed a drug chart history and presented this for her therapy group.
NA|Narcotics Anonymous|NA|375|376|PROGRAM PARTICIPATION|Defer, with mixed personality traits and hysteroid/avoidant/passive-aggressive. PROGRAM PARTICIPATION: While at Fairview STOP Program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, mental health, and recovery. She attended step groups, weekly multifamily groups, gender groups, chemical dependency groups, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset-building activities, chemical dependency and mental health related lectures. PROGRESS AND SIGNIFICANT EVENTS: _%#NAME#%_ was able to endorse significant self-criticism or self-hatred and worthlessness, with feeling of minimal pleasure in life or enjoyment, also losing interest in others and activities.
NA|Narcotics Anonymous|NA|135|136|HISTORY OF PRESENT ILLNESS|He was stable medically and discharged on _%#MM#%_ _%#DD#%_, 2005. He was to attend lifestyle's outpatient treatment. He was to attend NA and AA. He was discharged on Suboxone to take 2 mg a day for 3 days then 1 mg a day for 4 days. DISCHARGE DIAGNOSIS: Opiate dependence.
NA|Narcotics Anonymous|NA|254|255|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at our _%#CITY#%_ outpatient program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety and recovery. He participated in chemical health group, community group, AA and NA meetings, on- site schooling, developmental asset building activities, spirituality groups, recreational activities, weekly family programming, and weekly one-to-ones.
NA|Narcotics Anonymous|NA.|155|157|DISCHARGE DIAGNOSES|She was to take Suboxone 4 mg b.i.d. today, then 2 mg b.i.d. for 3 days, then 2 mg daily for 3 days, and 1 mg daily for 4 days. She is to return to AA and NA. In addition, she was to continue her admission medications of Neurontin 900 mg b.i.d., Seroquel 100 mg b.i.d., Advair 1 puff b.i.d., albuterol 2 puffs q.i.d. p.r.n.
NA|Narcotics Anonymous|NA|253|254|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at Fairview _%#CITY#%_ _%#CITY#%_, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical- dependency, sobriety, and recovery. He participated in chemical health group, community group, AA and NA meetings on-site and in the community, in-house school, developmental asset building activities, spirituality groups, recreation activities, weekly family programming, and individual counseling.
NA|Narcotics Anonymous|NA|255|256|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at our _%#CITY#%_ Outpatient Program _%#NAME#%_ was involved in various tasks and assignments designed to address chemical-dependency, sobriety, and recovery. She participated in chemical health group, community group, AA and NA meetings, on- site schooling, developmental asset building activities, spirituality groups, recreational activities, and weekly family programming. PROGRESS: Dimension 1 - medical: Throughout _%#NAME#%_'s treatment stay there were no intoxication or withdrawal concerns.
NA|Narcotics Anonymous|NA|356|357|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While involved in the _%#CITY#%_ Outpatient Chemical Dependency Treatment Program, the client resided at the Adolescent Female Lodging Program and took a part in all groups and services. During the Day Treatment Program, the client was involved in daily chemical health groups, daily community group sessions, on and off-site AA and NA meetings, two hours of on-site schooling per day, a minimum of weekly individual sessions with staff counselors, developmental asset-building activities three times a week, weekly spirituality groups and daily recreational activities.
NA|Narcotics Anonymous|NA|306|307|DISCHARGE PLANS AND RECOMMENDATIONS|The purpose of this placement to reunite _%#NAME#%_ with her daughter in the hope that she can work towards regaining custody. It is additionally recommended that she participate in the Phase II aftercare program through Fairview _%#CITY#%_, that she have random drug screens, that she attend weekly AA or NA meetings, that she follow a home contract, and that she engage in family and individual therapy. Dimension Scale Rating upon admission were: Dimension 1 - 0; Dimension 2 - 0; Dimension 3 - 0, Dimension 4 - 1; Dimension 5 - 2; Dimension 6 - 3.
NA|Narcotics Anonymous|NA|331|332|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at _%#CITY#%_ Outpatient Chemical Dependency Treatment Program the client was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. Additionally the client participated in daily chemical health groups, daily community groups, on and off site AA and NA meetings, weekly individual counseling, developmental asset building activities 3 x a week, weekly spirituality groups, and daily recreational activities.
NA|Narcotics Anonymous|NA|204|205|HISTORY OF PRESENT ILLNESS|He was very eager to leave on _%#MMDD2006#%_. He was advised that another day would be helpful. He was not interested in treatment and did not stay for discharge planning. He said he planned to go to his NA meetings and also had an outpatient mental health group that he was going to attend. He was not interested in treatment. He was discharged on tapering Suboxone.
NA|Narcotics Anonymous|NA|268|269|PROGRAM PARTICIPATION|During the treatment program day, she was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery issues. Her participation included daily chemical health groups, daily community group sessions, on and off site AA and NA meetings, and weekly individual counseling, developmental asset building activities 3 times a week, weekly spirituality groups, and daily recreational activities and two hours of onsite schooling each day.
NA|sodium|NA|167|168|CURRENT MEDICATIONS|2. Wellbutrin 200 mg p.o. q.a.m. 3. Trileptal 300 mg p.o. t.i.d. 4. Verapamil 240 mg p.o. q.a.m. 5. Atacand 32 mg p.o. q.a.m. 6. Lexapro 30 mg p.o. q.a.m. 7. Docusate NA 50 mg p.o. b.i.d. 8. Vitamin D 400 international units q.a.m. 9. Allopurinol 450 mg p.o. at bedtime. 10. Ranitidine 150 mg p.o. b.i.d. 11. Viagra p.r.n. SOCIAL HISTORY: He is a nonsmoker, denies any significant alcohol use.
NA|Narcotics Anonymous|NA|185|186|DISCHARGE DIAGNOSIS|DISCHARGE PLAN AND RECOMMENDATIONS: The patient was discharged to the care of his mother to follow up with the outpatient _%#CITY#%_ _%#CITY#%_ chemical dependency program. Also AA and NA meetings, individual and family therapy.
NA|Narcotics Anonymous|NA|244|245|PROGRAM|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended step groups, gender group, spirituality groups, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset building activities and chemical dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_ _%#NAME#%_ met with unit staff concerning social history and current issues of functioning.
NA|Narcotics Anonymous|NA.|194|196|DISCHARGE PLAN AND RECOMMENDATIONS|DISCHARGE PLAN AND RECOMMENDATIONS: 1. _%#CITY#%_ _%#CITY#%_ aftercare. 2. Individual therapy. 3. Family therapy. 4. AA and/or NA attendance. 5. Participation in sober social network per AA and NA. 6. Home restriction compliance. 7. Followup with primary doctor in 2-4 weeks for evaluation of medications and home restrictions.
NA|Narcotics Anonymous|NA|238|239|PROGRESS|Continuing to build sober social, recreational and leisure time skills by engaging in his community with healthy peers and/or role models would be important for _%#NAME#%_ to continue in adolescent development. Access in community AA and NA support groups would be important to _%#NAME#%_ encountering a more healthful peer group and/or potential role models. Tony is seemingly appropriate of proceeding of individual and/or family therapy at a time when chemical dependency professional deem it appropriate of inclusion.
NA|Narcotics Anonymous|NA|223|224|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended grief group, gender group, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset building activities, and chemical dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2003#%_, while on the Fairview _%#CITY#%_ Adolescent Mental Health Unit, _%#NAME#%_ and her mother met with unit staff concerning family histories and current issues of functioning.
NA|Narcotics Anonymous|NA|230|231|DISCHARGE PLAN AND RECOMMENDATIONS|_%#NAME#%_ is encouraged of involving herself of her community, towards replacing previously unhealthy choices with more healthful ideas, and continuing of adolescent development and identify formation. Accessing community AA and NA support groups may prove beneficial towards _%#NAME#%_ encountering a more healthful peer group and/or potential role models. _%#NAME#%_ is recommended to continue with individual and/or family therapy at a time when chemical dependency professionals deem it appropriate of inclusion.
NA|Narcotics Anonymous|NA|305|306|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: At Fairview Adolescent Inpatient Treatment STOP Program _%#NAME#%_ was involved in various tasks and assignments designed to address chemical-dependency, sobriety, mental health, and recovery. He attended step groups, multi-family groups, gender groups, mental health group, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset building activities, chemical-dependency, mental health, and related lectures. PROGRESS AND SIGNIFICANT EVENTS: _%#NAME#%_ was compliant at points. He became somewhat impulsive at times.
NA|Narcotics Anonymous|NA,|247|249|DISCHARGE PLAN AND RECOMMENDATIONS|Mother had scheduled a return to the New Connections _%#CITY#%_ Outpatient Program with an intake scheduled on _%#MMDD2003#%_. Also as part of the recommendation was individual therapy, family therapy, follow-up with the physician, as well as AA, NA, and to obtain a sober sponsor.
NA|Narcotics Anonymous|NA|186|187|DISCHARGE PLAN AND RECOMMENDATIONS|Mother was given several options pending consolidated funds for funding of that treatment. It was recommended that _%#NAME#%_ continue with individual therapy, family therapy, and AA or NA meetings.
NA|Narcotics Anonymous|NA|222|223|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the Stop Unit _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended gender group, grief group, AA and NA meetings on site, individual therapy, multi-family group, therapeutic recreation, developmental asset building activities, and chemical dependency and related lectures.
NA|Narcotics Anonymous|NA|272|273|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at _%#CITY#%_ _%#CITY#%_ ACDP, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. He attended Step groups, weekly family group, spirituality group, in-house school, AA and NA meetings, developmental asset-building activities, and chemical dependency and related lectures. SIGNIFICANT EVENTS AND PROGRESS: While in treatment, _%#NAME#%_ completed a group introduction, a drug chart, a drug history, AA Steps 1 through 3, and relapse prevention assignment.
NA|Narcotics Anonymous|NA|210|211|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended gender group, AA and NA meetings on site, individual therapy, multifamily group, therapeutic recreation, music therapy, developmental asset-building activities, and chemical dependency and related lectures.
NA|Narcotics Anonymous|NA|230|231|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure skills by engaging of his community may prove beneficial towards the patient proceeding of a more robust adolescent experience and young adult identity. Attending AA and NA support groups may prove beneficial for the client as to encountering more healthful peer group and potential role models. The client is recommended to proceed of family therapy and individual therapy at a time chemical-dependency professionals deem this appropriate of addition.
NA|Narcotics Anonymous|NA|196|197|DISCHARGE PLAN AND RECOMMENDATIONS|At a time when chemical health, behavioral health, and emotional issues seem effectively addressed, the client is encouraged to continue with academic and/or vocational pursuits. Attending AA and NA supports may prove beneficial for the client as to encountering a more healthful peer group and potential role models.
NA|Narcotics Anonymous|NA.|395|397|DISCHARGE PLAN AND RECOMMENDATIONS|DISCHARGE PLAN AND RECOMMENDATIONS: _%#NAME#%_ was discharged to his mother to attend intensive chemical dependency program on an outpatient basis at the Anthony Lewis Center in _%#NAME#%_ or American Family Services, also to have psychosocial evaluation at treatment and sexuality program at the U of M or the program Pathfinders. Individual and family therapy and support groups such as AA or NA. Follow up with county case management, _%#NAME#%_ _%#NAME#%_.
NA|Narcotics Anonymous|NA|168|169|DISCHARGE PLAN|I urged him to follow up with outpatient CD treatment, supportive treatments, i.e., NA and AA which the patient has not been able to comply with in the past. No AA and NA meetings. Time spent on discharge planning was 30 minutes plus.
NA|Narcotics Anonymous|NA|248|249|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at UMMC _%#CITY#%_ _%#CITY#%_, the client was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. He participated in chemical health group, community group, AA and NA on site and in the community, developmental asset building activities, spirituality groups, recreation activities, weekly family programming, and individual counseling.
NA|Narcotics Anonymous|NA|264|265|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at Fairview _%#CITY#%_ _%#CITY#%_, he was involved in various tasks and assignments designed to address chemical dependency, sobriety and recovery. He participated in daily chemical health groups, daily community groups, weekly AA and NA meetings, both community-based and on-site, two hours of on-site schooling per day, three times weekly developmental asset-building activities, weekly spirituality groups, daily recreational activities, weekly family programming and one-to-one's with staff/individual counseling.
NA|Narcotics Anonymous|NA|136|137|DISCHARGE PLAN AND RECOMMENDATIONS|1. Attend Phase II aftercare. 2. Individual and family therapy. 3. Continue to have medications managed by outside MD. 4. Attend AA and NA meetings on a regular basis. Prognosis is good if he follows all recommendations.
NA|Narcotics Anonymous|NA|218|219|PROGRAM PARTICIPATION|She was also involved in tasks and assignments designed to address chemical dependency, sobriety and recovery issues. Participation included daily chemical health groups, daily community groups, on and off-site AA and NA meetings, individual counseling weekly, weekly family programming, developmental asset building activities 3 times a week, weekly spirituality groups, daily recreational activity, 2 hours of on-site schooling per day.
NA|Narcotics Anonymous|NA|216|217|DIMENSION VI|She reported her relationship with her mother was improving while in the program and was able to complete and follow home contract. Staff provided client with resources and support systems in recovery such as AA and NA meetings. She also took part in recreational activities during treatment program. She will likely require further attention in this area to keep herself occupied and enjoy herself in sobriety.
NA|Narcotics Anonymous|NA|255|256|ADMISSION DATE|He was discharged on tapering suboxone to take 8 mg today and then 2 mg t.i.d. for 3 days, then 2 mg b.i.d. for 3 days, then 2 mg daily for 3 days, then 1 mg daily for 4 days. He will proceed with chemical dependency treatment should his plan of going to NA failed. DISCHARGE DIAGNOSIS: Heroin dependence.
NA|Narcotics Anonymous|NA|202|203|DIMENSION 6|She will likely require further assistance in the area of family relationships, and is referred to Family Counseling. Staff provided client with resources and support systems in recovery such as AA and NA meeting information. She also took part in recreational activities during treatment programming. She was able to discuss the concepts of a support system and to identify activities to avoid boredom.
NA|sodium|NA|139|140|MEDICATIONS|1. Left mastectomy. 2. Cataracts. 3. Laser surgery of 1 eye. MEDICATIONS: 1. Lasix 40 mg b.i.d. 2. Lisinopril 40 mg a day. 3. Propoxyphene NA Pap 100/650 t.i.d. p.r.n. restless legs. 4. Coumadin 5 mg on Sunday, Tuesday, Thursday, Saturday 7.5 on Monday, Wednesday, Friday.
NA|Narcotics Anonymous|NA|102|103|DISCHARGE PLAN AND RECOMMENDATIONS|He was discharged on Motrin 600 mg q.i.d. p.r.n. He was to live with a sober friend and attend AA and NA regularly. He declined an option to go back to Lodging Plus. DISCHARGE DIAGNOSES: Opiate dependence, cocaine dependence, fractured fifth metacarpal.
NA|Narcotics Anonymous|NA.|205|207|DISCHARGE PLANNING|Following the court recommendations, consideration should be made for halfway house placement. _%#NAME#%_ should be involved in individual therapy and continued support should be maintained through AA and NA.
NA|Narcotics Anonymous|NA.|199|201||He did very well with this for detoxification and was discharged on a tapering schedule with plans to take it over the next 10 days to finish his last dose on _%#MMDD2003#%_. He was to attend AA and NA. He came in for detox only. He was medically stable at the time of discharge. DISCHARGE DIAGNOSIS: Opiate dependence.
NA|Narcotics Anonymous|NA|257|258|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While involved in the Fairview STOP program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, mental health, and recovery. He also attended step groups, gender groups, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset- building activities, chemical dependency, mental health, and other related lectures.
NA|Narcotics Anonymous|NA|181|182|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure skills by engaging of her community would at some point be an important issue for _%#NAME#%_ to engage. Attending AA and NA support groups may prove beneficial for _%#NAME#%_ to encounter more healthful peer group and potential role models. The client is recommended to proceed with medication management of a community psychiatrist and also to continue with individual and family therapy towards understanding herself and proceed with life more healthfully.
NA|Narcotics Anonymous|NA|258|259|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure skills by engaging in his community and/or school would be potentially beneficial for _%#NAME#%_ as to continue with adolescent development and eventually young adulthood identity. Attending AA and NA support groups may prove helpful towards _%#NAME#%_ encountering a more healthful peer group and/or potential role models. It is recommended that _%#NAME#%_ proceed with individual and family therapy.
NA|Narcotics Anonymous|NA|229|230|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended multifamily group, gender group, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset-building activities, and chemical dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2003#%_ _%#NAME#%_ completed personality testing assigned by her attending psychiatrist.
NA|Narcotics Anonymous|NA|156|157|PROGRESS|Her behavior while in this treatment program was very negative. _%#NAME#%_ struggled with following just basic treatment rules. She refused to attend AA or NA meetings, and she did not complete a home contract. _%#NAME#%_ was placed on a responsibility contract on _%#MMDD2003#%_ but could not follow through with those expectations either.
NA|Narcotics Anonymous|NA|256|257|DISCHARGE|At this time, _%#NAME#%_ seems invested in recovery. DISCHARGE: _%#NAME#%_ will return to _%#CITY#%_ _%#CITY#%_ High School, South Campus, where he will have counselors to support him in recovery. He is scheduled to attend _%#CITY#%_ Phase 2, weekly AA or NA meetings, and to continue with random urine drug screens. Hopefully, all of the above will enable _%#NAME#%_ to continue to work at building a sober support system to aid him in sobriety and recovery.
NA|Narcotics Anonymous|NA|131|132|DISCHARGE PLAN AND RECOMMENDATIONS|Also consider a sober school network upon completion of treatment. She is also encouraged to get involved and participate in AA or NA for support of her sobriety. We also recommend individual and family therapy to work on self-esteem issues and communication with family.
NA|Narcotics Anonymous|NA|145|146|SOCIAL HISTORY|He states he has a total of seven children. Several of his children are by a former wife and some of the children are by other women. He attends NA in the community. He is currently not working, but applying for Social Security Disability.
NA|Narcotics Anonymous|NA|316|317|PROGRAM PARTICIPATION|She reported an association with several using adults. PROGRAM PARTICIPATION: While in the _%#CITY#%_ _%#CITY#%_ Adolescent Chemical Dependency Program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. She attended chemical dependency groups, NA meetings, developmental asset-building activities, and chemical dependency and related lectures. PROGRESS AND SIGNIFICANT EVENTS: While in treatment, _%#NAME#%_ presented her group introduction and her AA first step.
NA|Narcotics Anonymous|NA|293|294|PROGRESS AND SIGNIFICANT EVENTS|She was confronted by staff after a treatment peer informed them that _%#NAME#%_ was offering methamphetamines to a new treatment peer. She denied this at first, then said, "I'm drawing a blank." _%#NAME#%_ did admit to breaking home restriction by calling friends and having them meet her at NA meetings. _%#NAME#%_'s mother drove her to NA on _%#MMDD2004#%_. _%#NAME#%_ cut off her HEM ankle bracelet and went on run.
NA|Narcotics Anonymous|NA|264|265|PROGRAM PARTICIPATION|He attended daily AA Step groups, individual counseling, spirituality groups, on-site AA meetings, therapeutic recreation, developmental asset-building activities, and lectures and videos related to chemical dependency. _%#NAME#%_ was resistant to attending AA or NA meetings. We have urged mother to attend Al- Anon. As there are various issues needing attention, we have recommended some individual and family counseling if and when _%#NAME#%_ remains abstinent.
NA|Narcotics Anonymous|NA|233|234|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP Unit, _%#NAME#%_ was involved with various tasks and assignments designed to address chemical-dependency, sobriety, and recovery. _%#NAME#%_ attended multi- family group, gender group, AA and NA meetings on-site, individual therapy, therapeutic recreation, developmental asset building activities, and chemical-dependency related lectures. On _%#MMDD2004#%_ the client completed drug chart history and presented this for his therapy group.
NA|Narcotics Anonymous|NA|277|278|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at _%#CITY#%_ _%#CITY#%_ A.C.D.P., the client was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. She attended step groups, weekly family group, spirituality group, in house school, AA and NA meetings on site and in the community, developmental asset building activities, and chemical dependency and related lectures. SIGNIFICANT EVENTS: The client was placed on contract on _%#MMDD2004#%_ after she was confronted by treatment peers about going out with friends.
NA|sodium|NA|240|241|LABORATORY DATA|NEURO: Normal. SKIN: Normal. LABORATORY DATA: CBC, white blood cell count 6.9 with 66% neutrophils, 30% lymphocytes and 4% monocytes, hemoglobin of 13.8, hematocrit 39.8, platelets 362,000. Basic metabolic profile includes a glucose of 55, NA of 140, K of 4.9, CL of 102, CO2 of 16, BUN of 33, chloride 0.50, CA 10.1. Urinalysis is negative except for ketones and protein.
NA|Narcotics Anonymous|NA,|176|178|PLAN|She gradually improved and was ready for discharge by _%#MMDD2007#%_. She had five years of sobriety prior to the recent relapse and had an active recovery program by going to NA, AA and Women for Sobriety. She had two sponsors. She planned to go back to her recovery program. DISCHARGE MEDICATIONS: 1. Lexapro 20 mg daily. 2. Maxzide 1 daily.
NA|Narcotics Anonymous|NA|256|257|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the adolescent MICD unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety and recovery. She attended weekly family group, gender groups, spirituality groups, AA and NA meetings on site and therapeutic recreation. _%#NAME#%_ completed a number of chemical dependency related assignments. SIGNIFICANT EVENTS: Weekly family group participation proved beneficial for _%#NAME#%_.
NA|Narcotics Anonymous|NA|284|285|PROGRAM PARTICIPATION|_%#NAME#%_ has a diagnosis of depression and actual diagnosis of dysthymia and has been on medication for this. PROGRAM PARTICIPATION: Since admission to the S.T.O.P. Unit _%#NAME#%_ has been involved in daily chemical dependency groups, therapeutic recreation, gender groups, AA and NA meetings, daily asset building activities, chemical dependency lectures and other related lectures. SIGNIFICANT EVENTS: _%#NAME#%_ participated in all unit activities. His behavior was appropriate.
NA|Narcotics Anonymous|NA|217|218|DISCHARGE PLANS AND RECOMMENDATIONS|DISCHARGE PLANS AND RECOMMENDATIONS: It is our recommendation that _%#NAME#%_ attend primary treatment and his mother has chosen _%#CITY#%_ Recovery Center. We are also recommending that _%#NAME#%_ continue to attend NA and AA meetings and obtain a sober sponsor. It is also recommended that mom look into a sober school for _%#NAME#%_ as well.
NA|Narcotics Anonymous|NA|144|145|DISCHARGE PLANS|It was also recommended that the patient complete random urine tox screens. The patient is to continue addressing CD issues by attending weekly NA or AA meetings after treatment and aftercare. The family was given a list of sober high schools to contact, and the family was to arrange for a psych eval follow- up appointment in 2-4 weeks.
NA|Narcotics Anonymous|NA|308|309|DISCHARGE PLAN AND RECOMMENDATIONS|At a time when chemical health, behavioral issues, and mental health issues seem effectively addressed _%#NAME#%_ is encouraged to return to academic and/or vocational pursuits. Continuing to build sober social, recreational, and leisure skills of her community is highly encouraged. Accessing her community NA and AA support groups would seem also beneficial toward _%#NAME#%_ realizing a more helpful peer group, and potential role models.
NA|Narcotics Anonymous|NA|293|294|DISCHARGE STATUS CODE|PROGRAM PARTICIPATION: While in the _%#CITY#%_ _%#CITY#%_ Adolescent Chemical-Dependency Program, _%#NAME#%_ as involved in various tasks and assignments designed to address chemical dependency, sobriety, and relapse prevention. He attended chemical-dependency groups, in-house school, AA and NA meetings, developmental aspect building activities, and chemical dependency and related lectures. _%#NAME#%_ and his parents did not attend family. _%#NAME#%_ attended 1 family group with his mother.
NA|Narcotics Anonymous|NA|168|169|DISCHARGE DIAGNOSIS|His withdrawal was mild and he seemed motivated. His plan was to attend outpatient treatment, a relapse program at Fairview _%#CITY#%_. He was to attend lots of AA and NA meeting. He was to keep himself busy and stay with friends and relatives. He was motivated for recovery. His prognosis is thought to be fair due to his good motivation.
NA|Narcotics Anonymous|NA|274|275|RECOMMENDATIONS AND DISCHARGE PLANS|He Haiti trip was a previously planned trip for approximately the last 6 months to a year by her family and her family and church supported her going to that. RECOMMENDATIONS AND DISCHARGE PLANS: It is recommended a continuation of individual therapy, family therapy, AA or NA support groups and to get a sponsor as soon as possible. We also recommend that she attend school support group if possible, follow a safety plan that she completed on the program after discharge, and to review and update as much as possible and to follow up on all medications and medication compliance.
NA|Narcotics Anonymous|NA|176|177|DISCHARGE PLAN AND RECOMMENDATIONS|It is also requested that he attend school and the outpatient program, and possibly consider a sober school upon completion of that program. He is encouraged to participate in NA and AA, and find a sponsor for him to support his recovery.
NA|Narcotics Anonymous|NA|486|487|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While in Dual MICD Treatment Program _%#NAME#%_ participated in various tasks and assignments designed to address mental health and chemical-dependency problems. She participated in the following: mental health group therapy, chemical- dependency group therapy, individual therapy, developmental asset- building activities, therapeutic recreational activities, daily in-house schooling, educational lectures, spirituality groups, exercise programming, and AA and NA support groups in house. PROGRESS: _%#NAME#%_ gained a better understanding of both her mental health and chemical dependency diagnoses and the interrelationship of these dual disorders.
NA|Narcotics Anonymous|NA|232|233|DISCHARGE PLAN AND RECOMMENDATIONS|Parents have scheduled a _%#CITY#%_ _%#CITY#%_ _%#CITY#%_ Outpatient Program. Also recommended he attend school on-site, and consider a sober education environment upon completion of the program. He is also encouraged to join AA or NA and client seek out a sponsor. We are also recommending individual and family therapy for parents, and also encouraged him to become involved with some type of support group.
NA|Narcotics Anonymous|NA|433|434|PROGRAM PARTICIPATION|PROBLEMS PRESENTED AT ADMISSION: At the time of admission the client presented with problems that included relapse on alcohol and cannabis, history of cocaine use, mood disorders, and parent-child conflict. PROGRAM PARTICIPATION: While at the Fairview Adolescent Inpatient Treatment Program, the client participated in step groups, weekly family group, gender group, spirituality groups, in-house school, mental health group, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset-building activities, chemical health, mental health, and related lectures. PROGRESS: While in the program, _%#NAME#%_ demonstrated progress in recognizing her chemical dependency issues and in building some sober social, recreational, and leisure skills within the unit.
NA|Narcotics Anonymous|NA|402|403|DISCHARGE PLANS AND RECOMMENDATIONS|_%#NAME#%_ seems to be have positive goal for herself. DISCHARGE PLANS AND RECOMMENDATIONS: Recommendations upon discharge include that _%#NAME#%_ participate in the Phase Two Continuing Care Program through the Fairview- University Medical Center _%#CITY#%_ _%#CITY#%_ Program. It is also recommended that she receive random drug testing, that she follow a home contract, that she attend weekly AA or NA meetings, that she continue to have her medication monitored, and that she follow through with all legal requirements. _%#NAME#%_ has successfully completed primary treatment as of _%#MMDD2004#%_.
NA|Narcotics Anonymous|NA|205|206|DISCHARGE|At this point _%#NAME#%_ seems quite enthusiastic about sobriety. DISCHARGE: _%#NAME#%_ and his parents are exploring sober high school options. He is scheduled to attend _%#CITY#%_ phase II, weekly AA or NA meetings, and to continue with random urinalyses. Hopefully all of the above will encourage _%#NAME#%_ to continue abstinence and work at building a sober support system.
NA|Narcotics Anonymous|NA.|183|185|DISCHARGE DIAGNOSIS|DISCHARGE MEDICATIONS: She was discharged on tapering buprenorphine to take 12 mg today, then 8 mg for 2 days, 4 mg for 2 days, 2 mg for 2 days, and 1 mg for 2 days. She is to attend NA. She refused treatment at this time due to her need to work. Her laboratory work was essentially normal.
NA|Narcotics Anonymous|NA|137|138|HISTORY OF PRESENT ILLNESS|She does not drink alcohol. She uses occasional marijuana. She now enters for further evaluation. She has had most success with going to NA as far as her recovery goes. PAST MEDICAL HISTORY: 1. The patient has had a cholecystectomy and a hysterectomy.
NA|Narcotics Anonymous|NA|149|150|DISCHARGE PLAN/RECOMMENDATIONS|DISCHARGE PLAN/RECOMMENDATIONS: Discharge plans for _%#NAME#%_ are to attend phase 2 at our _%#CITY#%_ site, follow her home contract, attend AA and NA weekly, and abide by random urinalysis. _%#NAME#%_'s mother reported on discharge that they would not follow through with the after care recommendations due to scheduling conflicts.
NA|Narcotics Anonymous|NA|231|232|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended gender group, spirituality groups, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset building activities and chemical dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_ client completed psychological testing. Client's results were later interpreted to reveal personality issues suggestive of avoidant traits.
NA|Narcotics Anonymous|NA|242|243|DISCHARGE PLAN/RECOMMENDATIONS|Continuing to build sober social, recreational and leisure skills by engaging his community and/or school would seem important for _%#NAME#%_ to replace previously unhealthy choices with more healthful growth oriented ideas. Attending AA and NA support groups of his community may prove helpful of _%#NAME#%_ encountering a more healthful peer group and/or potential role models.
NA|Narcotics Anonymous|NA|222|223|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure time skills by engaging in his community and/or school would seem important towards _%#NAME#%_ developing a more healthful young adult identity. Accessing AA and NA support groups would seem important of _%#NAME#%_ at a time when he idealizes encountering a more healthful peer group and/or potential role models.
NA|Narcotics Anonymous|NA|214|215|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the Stop Unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety and recovery. He attended grief group, gender group, AA and NA meetings onsite, individual therapy, therapeutic recreation, developmental asset-building activities and chemical dependency-related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_, _%#NAME#%_ met with unit staff concerning social history and these areas of functioning.
NA|Narcotics Anonymous|NA|226|227|RECOMMENDATION|This is due to his depressive diagnosis and past history of suicidal ideation and also his substance dependence diagnosis. He is encouraged to attend school on sight at the treatment program. He is recommended to attend AA or NA for support in his goal of sobriety. He is also encouraged to continue to take his medication and go to family and individual therapy.
NA|Narcotics Anonymous|NA|162|163|ADMISSION DIAGNOSIS|He will continue to attend Ivan Sand Community School to continue his academic progress. He is recommended to complete (_______________) after care, attend AA or NA weekly, and maintain contact with his sponsor, return to individual therapy, and follow up with his medical doctor for medication management.
NA|Narcotics Anonymous|NA|221|222|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the Stop Unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety and recovery. He attended gender group, spirituality group, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset-building activities and chemical dependency-related lectures. SIGNIFICANT EVENTS: On _%#MMDD2003#%_, _%#NAME#%_ met with unit staff concerning social history and current issues of functioning.
NA|Narcotics Anonymous|NA|244|245|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP Unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended grief group, gender group, spirituality groups, AA and NA meetings on-site, individual therapy, therapeutic recreation, developmental asset-building activities, and chemical dependency-related lectures. SIGNIFICANT EVENTS: On _%#MMDD2003#%_, _%#NAME#%_ completed psychological testing. Client's personality testing later revealed concerns of mildly minimizing issues.
NA|Narcotics Anonymous|NA|286|287|PROBLEMS PRESENT UPON ADMISSION|PROGRAM PARTICIPATION: While in the _%#CITY#%_ _%#CITY#%_ Adolescent Chemical Dependency Program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. She attended chemical dependency groups, in-house school, AA, and NA meetings, developmental affect-building activities and chemical dependency and related lectures. PROGRESS AND SIGNIFICANT EVENTS: While in treatment, _%#NAME#%_ completed her introduction, social/chemical use history, and AA First Step.
NA|Narcotics Anonymous|NA|243|244|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended grief group, gender group, spirituality group, AA and NA meetings on site, individual therapy, therapeutic recreation, multifamily groups, developmental asset- building activities, and chemical dependency related lectures.
NA|Narcotics Anonymous|NA|210|211|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure skills by engaging her community and family would be important in _%#NAME#%_ resolving emotional and developmental issues. Attending community AA and NA support groups would seem important for _%#NAME#%_ in encountering a more healthful peer group and potential role models. This writer would cite _%#NAME#%_ firstly requiring sobriety, though just as importantly proceeding with individual therapy toward resolving the numerous issues yet to be dealt with from her childhood and adolescent life.
NA|Narcotics Anonymous|NA|304|305|DISCHARGE PLAN AND RECOMMENDATIONS|DISCHARGE PLAN AND RECOMMENDATIONS: The patient is being discharged to home on a two week home restriction contract and recommended to intensive outpatient chemical-dependency program at Dellwood. Individual and family therapy recommended to continue with _%#NAME#%_ _%#NAME#%_, along with weekly AA and NA meetings.
NA|Narcotics Anonymous|NA|206|207|DISCHARGE PLAN AND RECOMMENDATIONS|DISCHARGE PLAN AND RECOMMENDATIONS: Completion of a primary chemical dependency treatment program in the future when amenable. Additional recommendations are participation in a school support group; AA and NA meeting attendance; following a home contract; continued individual counseling and medication management; and remaining abstinent, passing all drug tests. _%#NAME#%_ _%#NAME#%_, CDC II
NA|Narcotics Anonymous|NA|149|150|HISTORY OF THE PRESENT ILLNESS|He has a long history of opiate addiction. He completed detoxification with buprenorphine and went to treatment and did well. He was going to AA and NA and maintaining sobriety until this summer. He relapsed about a month or 2 ago. He is not sure why. Simply says he had been thinking about it and got up one morning and started using OxyContin.
NA|Narcotics Anonymous|NA|271|272|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at Fairview Adolescent Inpatient Treatment Program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, mental health, and recovery. She attended Step groups, spirituality group, AA and NA meetings on site, family assessment, therapeutic recreation, developmental asset-building activities, chemical dependency, mental health, and related lectures. SIGNIFICANT EVENTS: Significant events while _%#NAME#%_ was hospitalized include _%#NAME#%_'s inability to attend the family assessment.
NA|Narcotics Anonymous|NA|142|143|DISCHARGE PLAN AND RECOMMENDATIONS|Continue to build sober social, recreational, and leisure skills by engaging in social behaviors with sober friends, sober activities, AA and NA support group. No medications at this time. The referral meeting was extensive. It was long. Child adolescent therapist, _%#NAME#%_ _%#NAME#%_, spent a lot of time reviewing the evaluation and providing education about chemical dependency.
NA|Narcotics Anonymous|NA|244|245|PROGRAM PARTICIPATION|While involved in the _%#CITY#%_ Day Treatment Program the client took part in daily community group sessions, two hours of on-site schooling per day, asset building groups three times a week, weekly spirituality groups, on and off-site AA and NA meetings, and daily group therapy sessions. Additionally, the client took part in weekly family group sessions. She did not complete the four day family program at Fairview- University Medical Center because she adenopathy mother completed that program during a previous treatment episode.
NA|Narcotics Anonymous|NA|250|251|DISCHARGE PLAN AND RECOMMENDATIONS|DISCHARGE DIAGNOSIS: 304.40. DISCHARGE PLAN AND RECOMMENDATIONS: Recommendations include return home. _%#NAME#%_ to attend Fairview _%#CITY#%_ Phase II programming, attend school support groups if available or consider a sober school, participate in NA or AA weekly, follow a home contract, pass random UAs, resolve all her legal matters, and that the family participate in support group services through Lao Family Services.
NA|Narcotics Anonymous|NA|196|197|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended AA and NA meetings on site, individual therapy, multifamily group, therapeutic recreation, developmental asset-building activities, and chemical dependency related lectures. On _%#MMDD2003#%_ the client met with unit staff concerning social history and current issues of functioning.
NA|Narcotics Anonymous|NA|177|178|DISCHARGE PLAN AND RECOMMENDATIONS|The client is encouraged to engage his community and exercise healthful judgment toward building sober social, recreational, and leisure-time skills. Accessing community AA and NA support groups may prove beneficial for _%#NAME#%_ to encounter a more healthful peer group and/or potential role models. _%#NAME#%_ is encouraged to continue with individual and family therapy toward the issues explained.
NA|Narcotics Anonymous|NA|391|392|PROGRAM PARTICIPATION|She did sign herself in. PROGRAM PARTICIPATION: While at the Fairview Adolescent Inpatient Treatment Program _%#NAME#%_ _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, mental health, and recovery. She has attended step groups, weekly family groups, gender groups, spirituality groups, in house school, mental health groups, AA and NA meetings, individual therapy, family week that started the week of _%#MMDD2003#%_, therapeutic recreation, developmental asset building activities, chemical dependency, mental health, and related lectures.
NA|Narcotics Anonymous|NA|309|310|DISCHARGE PLAN AND RECOMMENDATIONS|He also worked on improving his self-esteem. DISCHARGE PLAN AND RECOMMENDATIONS: The patient is discharged to home and to continue services in the Dual Diagnosis Outpatient Program at _%#CITY#%_ _%#CITY#%_. He will also be continuing to build sober, social, recreation, and leisure skills by attending AA and NA groups. Individual and family therapy are strongly recommended. The patient will continue with medication management for his depression.
NA|Narcotics Anonymous|NA|188|189|DISCHARGE PLAN/RECOMMENDATIONS|Staff recommends he complete an outpatient chemical dependency treatment program, engage in individual therapy, obtain a mental health evaluation, follow recommendations, and attend AA or NA meetings weekly. The client's parents report that they will follow through with arranging a mental health evaluation and therapy, but will not follow through with the chemical dependency treatment at this time.
NA|Narcotics Anonymous|NA|248|249|HOSPITAL COURSE|Chemical dependency assessor evaluated the patient, and recommended he attend a residential CD treatment program with an MI/CD component. The patient refused to attend further chemical dependency treatment, but stated that he was willing to attend NA and to find a sponsor. The patient was followed medically throughout his stay by Dr. _%#NAME#%_ _%#NAME#%_. The patient had no physical complaints. Discharge planning was made with the patient, the patient's PO, and mother.
NA|Narcotics Anonymous|NA|455|456|DISCHARGE PLAN/RECOMMENDATIONS|Dimension scale ratings at discharge: Dimension one,0; dimension two, 0; dimension three, 1; dimension four, 1; dimension five, 1; and dimension six, 1. DISCHARGE PLAN/RECOMMENDATIONS: At the time of discharge the client is recommended to continue chemical dependency treatment at the Fairview-University Medical Center _%#CITY#%_ site, additionally, the client is recommended to participate in individual and family counseling with mother, attend AA and NA meetings, follow home contract, maintain medication management, and remain abstinent passing all drug tests. _%#NAME#%_ _%#NAME#%_, CDC II
NA|Narcotics Anonymous|NA|198|199|PROGRAM PARTICIPATION|She had one-to-ones with staff members, received on- site schooling, and participated in weekly developmental asset building and spirituality workups. _%#NAME#%_ attended both on and off-site AA or NA meetings while attending the outpatient program. _%#NAME#%_ and her mother participated in the weekly family programming and her mother was also available for family meetings.
NA|Narcotics Anonymous|NA.|432|434|DISCHARGE PLANS AND RECOMMENDATIONS|DISCHARGE PLANS AND RECOMMENDATIONS: It is recommended that if _%#NAME#%_ and her mother are interested in pursuing further treatment services for _%#NAME#%_ that they would explore the option of having her participate in a dual diagnosis program. Additional recommendations for _%#NAME#%_ would include that she engage in individual therapy, that she receive medication management, and that she attend support groups such as AA or NA. Dimension Scale Rating upon admission were: Dimension 1 - 0; Dimension 2 - 0; Dimension 3 - 1, Dimension 4 - 2; Dimension 5 - 2; Dimension 6 - 2.
NA|Narcotics Anonymous|NA|130|131|OPERATIVE PROCEDURE|He said that he did not have a good insurance coverage and he needs to stay home as his wife worked. He was planning on attending NA and getting a sponsor. He was stabilized medically and discharged on _%#MMDD2007#%_. He was to take Suboxone 6 mg on _%#MMDD2007#%_ and then 2 mg t.i.d. for 3 days, then 2 mg b.i.d. for 3 days, then 2 mg daily for 3 days, then 1 mg daily for 4 days.
NA|Narcotics Anonymous|NA|242|243|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP Unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety and recovery. _%#NAME#%_ attended step group, gender group, spirituality groups, AA and NA meetings on site, individual therapy, multi-family group, therapeutic recreation, developmental asset- building activities, and chemical dependency and related lectures.
NA|Narcotics Anonymous|NA|176|177|DISCHARGE PLAN AND RECOMMENDATIONS|DISCHARGE PLAN AND RECOMMENDATIONS: The client will continue to live with his parents. Staff recommends that he complete _%#CITY#%_ _%#CITY#%_'s Phase II Program, attend AA or NA meeting weekly, maintain contact with his sponsors, and continue in individual therapy with _%#NAME#%_ _%#NAME#%_. The client and his family reported willingness to follow through with all of these recommendations and prognosis at this time is good.
NA|Narcotics Anonymous|NA|174|175|DISCHARGE PLAN AND RECOMMENDATIONS|The patient is also willing to continue individual and family therapy at _%#CITY#%_ Counseling Center. She will continue to build sober social peer groups by attending AA or NA twice a week.
NA|Narcotics Anonymous|NA|335|336|DISCHARGE PLAN AND RECOMMENDATIONS|DISCHARGE PLAN AND RECOMMENDATIONS: _%#NAME#%_ was discharged to the care of his mother with an intake scheduled at Anthony Louis Center, _%#CITY#%_, inpatient treatment program on _%#MMDD2004#%_ at 10:30 a.m. Also recommended is ongoing individual and family therapy, which mother will set up through her insurance, as well as AA and NA for _%#NAME#%_ and Al-Anon for parents (mom and fiance). Prognosis at this time appears to be good.
NA|Narcotics Anonymous|NA,|212|214|SIGNIFICANT EVENTS|_%#NAME#%_ and his mother were active participants in weekly family groups, where they report an increase in communication at home. _%#NAME#%_ was able to identify a workable support system which included AA and NA, parents, and sober peers. DISCHARGE PLAN AND RECOMMENDATIONS: At discharge _%#NAME#%_ was recommended to Phase 2 at our Fairview _%#CITY#%_ _%#CITY#%_ site, continued weekly AA or NA attendance, abide by his home contract, continued random urinalyses, and for _%#NAME#%_ to pursue individual therapy.
NA|Narcotics Anonymous|NA|264|265|DISCHARGE PLAN AND RECOMMENDATIONS|_%#NAME#%_ was able to identify a workable support system which included AA and NA, parents, and sober peers. DISCHARGE PLAN AND RECOMMENDATIONS: At discharge _%#NAME#%_ was recommended to Phase 2 at our Fairview _%#CITY#%_ _%#CITY#%_ site, continued weekly AA or NA attendance, abide by his home contract, continued random urinalyses, and for _%#NAME#%_ to pursue individual therapy. _%#NAME#%_ _%#NAME#%_, CDC II
NA|Narcotics Anonymous|NA|129|130|PROGRESS|She appears to be able to manipulate mother and make her feel really bad if she does not get her way. She participated in AA and NA groups and lectures to give her more insight into the seriousness of her use, which she openly participated in. DISCHARGE PLAN AND RECOMMENDATIONS: Due to the substance dependency diagnosis the recommendation was for outpatient chemical-dependency treatment.
NA|Narcotics Anonymous|NA|122|123|DISCHARGE DIAGNOSES|The plan was to detox, get back on buprenorphine and then follow up with Dr. _%#NAME#%_. The patient was also involved in NA and AA in the past and will reconnect with them. The patient was detoxed without complications. He was restarted on his buprenorphine with good results.
NA|Narcotics Anonymous|NA|277|278|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at _%#CITY#%_ _%#CITY#%_ A.C.D.P., the client was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. He attended step groups, weekly family groups, spirituality group, in house school, AA and NA meetings on site, and in the community, developmental asset building activities, and chemical dependency and related lectures. PROGRESS: While in treatment, the client completed a thorough chemical use history, including a progression of his chemical use and consequences.
NA|Narcotics Anonymous|NA|135|136|DISCHARGE|Due to transportation problems he is unable to attend the _%#CITY#%_ Phase II. _%#NAME#%_'s after care will consist of increased AA or NA meetings, weekly family groups at _%#CITY#%_, and individual and family counseling and continued random urinalyses. Hopefully all of the above will enable _%#NAME#%_ to continue to work at building a sober support system to aid him in sobriety and recovery.
NA|Narcotics Anonymous|NA,|266|268|SIGNIFICANT EVENTS/PROGRESS|_%#NAME#%_ and his mother were active participants in weekly family groups where they reported an increase in communication at home. Throughout _%#NAME#%_'s treatment he attended weekly AA or NA meetings, and developed a sober support network, which included AA and NA, family and sober peers. DISCHARGE PLAN/RECOMMENDATIONS: _%#NAME#%_ graduated from our program on _%#MMDD2005#%_. Discharge recommendations include phase 2 at our Fairview _%#CITY#%_ Outpatient site, that _%#NAME#%_ return to Northeast Metro ALC, that he follow his home contract, abide by probation expectations, continue AA or NA attendance one-time a week, and random urinalysis.
NA|Narcotics Anonymous|NA|465|466|DISCHARGE PLAN/RECOMMENDATIONS|Throughout _%#NAME#%_'s treatment he attended weekly AA or NA meetings, and developed a sober support network, which included AA and NA, family and sober peers. DISCHARGE PLAN/RECOMMENDATIONS: _%#NAME#%_ graduated from our program on _%#MMDD2005#%_. Discharge recommendations include phase 2 at our Fairview _%#CITY#%_ Outpatient site, that _%#NAME#%_ return to Northeast Metro ALC, that he follow his home contract, abide by probation expectations, continue AA or NA attendance one-time a week, and random urinalysis. _%#NAME#%_ _%#NAME#%_, CDC II
NA|Narcotics Anonymous|NA|294|295|SIGNIFICANT EVENTS|SIGNIFICANT EVENTS: While attending the outpatient program, _%#NAME#%_ had acknowledged some ambivalence regarding sobriety and would often offer mixed messages to the peer group and to staff. _%#NAME#%_ would at times engage in junkie pride but would then also report attending numerous AA or NA meetings and working with a sponsor. On the day that _%#NAME#%_ was scheduled to complete the Primary Outpatient Program, _%#NAME#%_ and his mother reported to this staff that his mother had found an over-the-counter medication named Coricidin and some crushed Adderall pills in his belongings in his room.
NA|Narcotics Anonymous|NA|219|220|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the S.T.O.P. Unit _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. She attended grief group, gender group, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset building activities, chemical dependency and related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_ _%#NAME#%_ completed a drug chart use history.
NA|Narcotics Anonymous|NA|159|160|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober, recreational, and leisure skills seems important towards _%#NAME#%_ experiencing unimproved adolescent experience. Accessing AA and NA involvement would seem beneficial towards _%#NAME#%_ accessing a peer group, most likely being more available towards helping _%#NAME#%_. As stated previously, family therapy and individual therapy seems crucial towards _%#NAME#%_ developing community and/or emotional expression.
NA|Narcotics Anonymous|NA|123|124|HISTORY OF PRESENT ILLNESS|She has a history of heroin dependence. She is unemployed and has a 13-year-old daughter. She has had some sober time with NA in the past. Recently she was oversedated with methadone. She relapsed to heroin when her maintenance dose was decreased. During the past 3 weeks prior to this admission the patient has been using heroin only a daily basis.
NA|Narcotics Anonymous|NA|231|232|PROGRAM PARTICIPATION|_%#NAME#%_ is currently on medication, which is also being monitored by an outside doctor. PROGRAM PARTICIPATION: Since admission to the Stop Unit, _%#NAME#%_ had been involved in step groups, therapy to recreation, gender groups, NA and AA meetings, daily asset building activities, chemical dependency lectures, and other related lectures. SIGNIFICANT EVENTS: _%#NAME#%_ attended all scheduled activities and was passively compliant.
NA|Narcotics Anonymous|NA|215|216|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety and recovery. She attended grief group, gender group, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset building activities and chemical dependency and related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_ _%#NAME#%_ with unit staff concerning social histories and current issues of functioning.
NA|Narcotics Anonymous|NA|306|307|DISCHARGE PLAN AND RECOMMENDATIONS|DISCHARGE PLAN AND RECOMMENDATIONS: The patient was discharged home to parents with a recommendation to the outpatient MI/CD program at Fairview _%#CITY#%_ where he will attend school onsite. The patient is to continue to build a sober support system by attending outpatient treatment and attending AA and NA support groups. He also should obtain a sponsor. It is also recommended that the patient continue seeing his individual therapist and the family participate in family therapy.
NA|Narcotics Anonymous|NA|312|313|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at Fairview Adolescent Treatment Program _%#NAME#%_ was involved in various tasks and assignments designed to address denial, dependency, sobriety, Nembutal health and recovery. She attended step groups, weekly family group, spirituality group, gender group, in-house-school, AA and NA meetings, music therapy, individual therapy, therapeutic recreation, developmental asset building activities, chemical dependency and mental health related lectures. SIGNIFICANT EVENTS/PROGRESS: While on the unit at Fairview _%#NAME#%_ participated in and completed many assignments revolving around relapse and her triggers to relapse and her depression.
NA|Narcotics Anonymous|NA|223|224|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP Unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. She attended grief group, spirituality groups, AA and NA meetings on-site, individual therapy, therapeutic recreation, and developmental asset building activities. Client also completed various chemical dependency and recovery oriented assignments, and also related lectures of topic.
NA|Narcotics Anonymous|NA|238|239|DISCHARGE PLAN AND RECOMMENDATION|Continuing to build sober social, recreational, and leisure skills by becoming involved of her community would seem important towards _%#NAME#%_ replacing previous unhealthy choices with more growth oriented ideas. Proceeding with AA and NA support groups of her community would seem important toward _%#NAME#%_ accessing a helpful peer group and/or potential role models. Client is also recommended for individual and family therapy. Client's parents are recommended to pursue ongoing support such as Alanon or Families Anonymous.
NA|Narcotics Anonymous|NA|356|357|DISCHARGE PLANS AND RECOMMENDATIONS|She has additionally done well with the expectations of the lodging facility. DISCHARGE PLANS AND RECOMMENDATIONS: Recommendations upon discharge include participation in the Phase II Program through the Fairview-University Medical Center _%#CITY#%_ site, that she receive random drug screens, that she follow a home contract, that she attend weekly AA or NA meetings, that she resolve her legal issues, and that she engage in therapy. Dimension Scale upon admission is as follows: Dimension I, 0; II, 0; III, 1; IV, 2; V, 2; VI, 2.
NA|Narcotics Anonymous|NA|228|229|DISCHARGE PLAN/RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure time skills by engaging of his community would seem important for _%#NAME#%_ to increase self esteem and/or discover potentials unknown. Accessing his community AA and NA support groups would seem important towards _%#NAME#%_ encountering more helpful peer group and/or potential support and role models. Client is also encouraged or recommended to proceed with individual and family therapy.
NA|Narcotics Anonymous|NA|286|287|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at _%#CITY#%_ _%#CITY#%_ Adolescent Chemical Dependency Program, the client was involved in various tasks and assignments designed to address chemical dependency, sobriety and recovery. She attended step groups, spirituality groups, in-house school, AA and NA meetings in the community, developmental asset-building activities and chemical dependency and related lectures. PROGRESS: While in treatment, the client completed Step 1 of the AA model and was working on a feelings' assignment at the time of discharge.
NA|Narcotics Anonymous|NA|237|238|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP Unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. She attended step groups, gender group, spirituality groups, AA and NA meetings on-site, individual therapy, therapeutic recreation, developmental asset-building activities, and chemical dependency-related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_, _%#NAME#%_ met with Unit staff concerning social histories and current issues of functioning.
NA|Narcotics Anonymous|NA|196|197|DISCHARGE PLAN AND RECOMMENDATIONS|Mother was provided phone numbers with her expected contact in program admit. _%#NAME#%_ was also prompted of her commitment to home restriction and/or behavioral-type agreement. Attending AA and NA support groups may prove helpful to _%#NAME#%_ as to herself encountering a more healthful peer group and/or potential role models.
NA|Narcotics Anonymous|NA|272|273|DISCHARGE PLAN/RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure time skills by engaging of community and/or family would seem important of _%#NAME#%_ increasing self-esteem and/or proceeding of adolescence, and young adulthood development/identity. Accessing community AA and NA support groups may prove helpful towards _%#NAME#%_ encountering a more healthful peer group, and potential role models. _%#NAME#%_ is recommended to continue medication management with her community psychiatrist of her psychiatric medications started while on the unit.
NA|Narcotics Anonymous|NA|222|223|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure-time skills by engaging in her community and/or social system would be important for _%#NAME#%_ continuing her adolescent development. Accessing community AA and NA support groups would be important for _%#NAME#%_ encountering a more healthy peer group and potential role models. _%#NAME#%_ is recommended to proceed with individual and family therapy at a time when chemical dependency professionals deem it important of inclusion.
NA|Narcotics Anonymous|NA|198|199|DISCHARGE PLAN AND RECOMMENDATIONS|At a time when chemical health, behavioral and mental health issues seem effectively addressed, the client is encouraged to return to academic and/or vocational pursuits. Accessing community AA and NA support groups may prove beneficial towards _%#CITY#%_ accounting a more healthful peer group and a potential role model. The client is encouraged of continuing with antidepressant medication of a community psychiatrist.
NA|Narcotics Anonymous|NA|264|265|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at our _%#CITY#%_ Outpatient Program _%#NAME#%_ was involved in various tasks and assignments designed to address chemical-dependency, sobriety, and recovery. He participated in chemical health groups, community groups, on-site AA and NA meetings, on-site school, developmental asset building activities, spirituality groups, recreational activities, and weekly family programming. PROGRESS: Dimension 1 - medical; throughout _%#NAME#%_'s treatment there were no intoxication or withdrawal concerns.
NA|sodium|NA|204|205|LABORATORY DATA|Comprehensive metabolic battery was within normal limits. Glucose by meter was high at 161. TSH reflex was low at 0.07. Subsequent free thyroxine was high at 1.90, folic acid, vitamin B12, troponin 1 and NA were normal. Urinalysis was within normal limits and the urine drug screen was negative. ASSESSMENT AND PLAN: 1. Bipolar disorder, treatment to be continued and followed by Dr. _%#NAME#%_.
NA|Narcotics Anonymous|NA.|155|157|HISTORY OF PRESENT ILLNESS|He was detoxed with buprenorphine and did well. He required only 8 mg per day. He did not want to go to treatment. He did not want to participate in AA or NA. He was seen by Dr. _%#NAME#%_ in psychiatric consultation who suggested Cymbalta. The patient was agreeable to take it. He was discharged on _%#MM#%_ _%#DD#%_, 2006.
NA|Narcotics Anonymous|NA|253|254|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at Fairview _%#CITY#%_ _%#CITY#%_, the client was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. She participated in chemical health group, community group, AA and NA meetings on-site and in the community, in-house school, developmental asset building activities, spirituality groups, recreational activities, weekly family programming and individual counseling.
NA|Narcotics Anonymous|NA.|182|184|DISCHARGE PLAN AND RECOMMENDATIONS|DISCHARGE DIAGNOSIS: 304.80, polysubstance dependence. DISCHARGE PLAN AND RECOMMENDATIONS: 1. Maintain sobriety. 2. Complete UMMCF ACDP Phase II programming. 3. Attend weekly AA and NA. 4. Family and individual therapy. 5. Attend sober school. 6. Complete any legal obligations. PROGNOSIS: At this time appears fair to good if _%#NAME#%_ completes all discharge recommendations.
NA|Narcotics Anonymous|NA|235|236|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at the STOP Unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety and recovery. He attended grief group, gender group, spirituality groups, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset building activities, chemical dependency and related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_, _%#NAME#%_ completed a drug chart/drug history.
NA|Narcotics Anonymous|NA|214|215|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP Unit _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. He attended grief group, gender group, AA and NA meetings on site, individual therapy attempts, therapeutic recreation, developmental asset building activities, and chemical dependency and related lectures. Significant events. Important of _%#NAME#%_'s production on the STOP Unit is an overwhelming difficulty of treatment engagement.
NA|Narcotics Anonymous|NA|170|171|DISCHARGE PLAN AND RECOMMENDATIONS|During the interim, _%#NAME#%_ is to participate in CD aftercare at our _%#CITY#%_ satellite site. She is to continue building sober support. She is also to attend AA or NA support groups. _%#NAME#%_ is to participate in random urine drug screening over the next year. _%#NAME#%_ is to be involved in individual therapy and family mediation/counseling.
NA|Narcotics Anonymous|NA|284|285|PROBLEMS PRESENTED ON ADMISSION|PROGRAM PARTICIPATION: While in the _%#CITY#%_ _%#CITY#%_ Adolescent Chemical Dependency Program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. He attended chemical dependency groups, in-house school, AA and NA meetings, developmental asset building activities and chemical dependency and related lectures. _%#NAME#%_ and his mother did not participate in family week due to a conflict with mother's work schedule.
NA|Narcotics Anonymous|NA|207|208|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP Unit, _%#NAME#%_ was involved in various tasks and assigned designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended gender group, AA and NA meetings on-site, individual therapy, therapeutic recreation, developmental asset building activities, and chemical dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_ _%#NAME#%_ completed a drug chart history.
NA|Narcotics Anonymous|NA|212|213|DISCHARGE PLAN AND RECOMMENDATIONS|DISCHARGE PLAN AND RECOMMENDATIONS: _%#NAME#%_ was discharged to lower level of care with return to New Connections in _%#CITY#%_ _%#CITY#%_. Recommendations include individual therapy, family therapy, AA and/or NA attendance, and home restrictions. _%#NAME#%_ is to follow up with primary physician in two to four weeks for evaluation of treatment and/or medications.
NA|Narcotics Anonymous|NA|352|353|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at Fairview Adolescent Inpatient Treatment Program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, mental health, and recovery. She attended Step groups, weekly multifamily groups, gender group, spirituality groups, in-house school, mental health groups, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset-building activities, chemical dependency, mental health, and related lectures. PROGRESS AND SIGNIFICANT EVENTS: _%#NAME#%_ presented moderate depression with mild to marked symptoms.
NA|Narcotics Anonymous|NA,|512|514|DISCHARGE PLAN AND RECOMMENDATIONS|Staff processed his need to acknowledge his responsibilities due to his aggressive behaviors and need for ongoing counseling to address understanding his emotions or lack thereof due to his actions. DISCHARGE PLAN AND RECOMMENDATIONS: _%#NAME#%_ was discharged into the care of his parents with a referral of returning to an outpatient level of care, individual and family therapy to follow recommendations of probation per legal issues and work toward establishing a sober support network and attendance to AA, NA, or other sober support groups.
NA|Narcotics Anonymous|NA|342|343|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at adolescent inpatient treatment program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, mental health, and recovery. He attended step groups, weekly multifamily groups, gender groups, spirituality groups, in-house school, mental health group, AA and NA meetings on site, individual therapy, family meetings, therapeutic recreation, developmental asset-building activities, chemical dependency, mental health, and related lectures.
NA|Narcotics Anonymous|NA.|120|122|HISTORY OF PRESENT ILLNESS|He has had two previous chemical dependency treatments. He has had some years of sobriety. He has been active in AA and NA. He works a good program. He has been unable to maintain sobriety. He has recently been on methadone maintenance and has been tapered up to 120 mg per day.
NA|Narcotics Anonymous|NA|391|392|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended therapeutic chemical dependency lectures, developmental asset-building activities, individual therapy, therapeutic recreation, chemical dependency peer groups, gender group, spirituality groups, AA and NA meetings. SIGNIFICANT EVENTS: On _%#MMDD2003#%_ _%#NAME#%_ completed a drug history and presented this to her therapy group.
NA|Narcotics Anonymous|NA|196|197|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended AA and NA meetings on site, individual therapy, multifamily group, therapeutic recreation, developmental asset-building activities, and chemical dependency and related lectures. SIGNIFICANT EVENTS: On _%#MMDD2003#%_ the client met with unit staff concerning social history and current issues of functioning.
NA|Narcotics Anonymous|NA|189|190|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP Unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. She attended AA and NA meetings on site, individual therapy, multifamily group, therapeutic recreation, developmental asset-building activities, and chemical dependency and related lectures. SIGNIFICANT EVENTS: On _%#MMDD2003#%_ _%#NAME#%_ met with unit staff concerning social histories and current issues of functioning.
NA|Narcotics Anonymous|NA|119|120|DISCHARGE PLAN AND RECOMMENDATIONS|He was also encouraged to attend school at the program to which he has been referred. We encourage him to attend AA or NA for support of his sobriety.
NA|Narcotics Anonymous|NA|156|157|RECOMMENDATIONS|He was encouraged and recommended for him to participate in a school program (the program that he was referred to). He was also encouraged to attend AA and NA for continued support of his sobriety. We are also recommending that the family participate in individual and/or family therapy.
NA|Narcotics Anonymous|NA|282|283|PROGRAM PARTICIPATION|While at the crystal outpatient program, the client was involved in tasks and assignments designed to address chemical dependency, sobriety and recovery issues. During that time, her participation included daily chemical health groups, daily community groups, on and offsite AA and NA meetings, individual counseling sessions, developmental asset building activities, daily recreational activities and 2 hours of onsite schooling per day. PROGRESS: DIMENSION I: The client reported last use was 1 or 2 days prior to STOP admission using marijuana.
NA|Narcotics Anonymous|NA|193|194|DISCHARGE PLAN AND RECOMMENDATIONS|This level of care has been recommended due to increased family strain. Patient is to explore sober school settings and to continue building her sober support system by attending weekly AA and NA support groups in addition to treatment. It was also recommended that patient participate in individual and family therapy sessions.
NA|Narcotics Anonymous|NA|216|217|PROGRAM PARTICIPATION WHILE AT THE ADOLESCENT STOP PROGRAM|PROGRAM PARTICIPATION WHILE AT THE ADOLESCENT STOP PROGRAM: _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. She attended gender group, AA and NA meetings on site, therapeutic recreation, developmental asset building activities, chemical dependency, and mental health related lectures. PROGRESS/SIGNIFICANT EVENTS: _%#NAME#%_ had difficulty socializing with certain peers on the unit.
NA|Narcotics Anonymous|NA|190|191|DISCHARGE PLAN AND RECOMMENDATIONS|It is recommended that the patient participate in the primary outpatient program at the Haven in _%#CITY#%_. The patient is to continue building her sober support system by attending AA and NA support groups. The patient is to obtain a sponsor, and it is also recommended that the patient continue receiving individual counseling and begin family counseling sessions with her mother.
NA|Narcotics Anonymous|NA|239|240|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved with various tasks and assignments designed to address chemical dependency, sobriety, and recovery. She attended grief group, gender group, spirituality groups, AA and NA meetings on site, therapeutic recreation, developmental asset-building activities, and chemical dependency and related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_, _%#NAME#%_ met with unit staff concerning social history and current issues of functioning.
NA|Narcotics Anonymous|NA|265|266|DISCHARGE PLAN AND RECOMMENDATIONS|_%#NAME#%_ is also encouraged to engage in her community of sober social, recreational, and leisure skills by whatever choices she would make towards herself realizing a more rounded adolescent experience. _%#NAME#%_ is encouraged to attend and/or engage in AA and NA support groups towards her hopefully encountering a more healthy peer group and/or potential role models. _%#NAME#%_ was also recommended for individual and/or family therapy for gaining introspection as to how to best address and learn from previous experience.
NA|Narcotics Anonymous|NA|213|214|DISCHARGE PLAN AND RECOMMENDATIONS|_%#NAME#%_ is encouraged to continue with building sober social, recreational, and leisure skills via engagement of her community and/or appropriate social realms. The client is encouraged to continue with AA and NA support group involvement of her community toward herself encountering a more healthful peer group and/or potential role models. The client is also encouraged to continue with medication management of a community psychiatrist, continuing medications initiated while at the Fairview programs.
NA|Narcotics Anonymous|NA|274|275|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at _%#CITY#%_ _%#CITY#%_ ACDP, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. She attended step groups, weekly family group, spirituality groups, in-house school, AA and NA meetings in the community, developmental asset-building activities, and chemical dependency and related lectures. SIGNIFICANT EVENTS: Client had one relapse of methamphetamine during treatment.
NA|Narcotics Anonymous|NA|267|268|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at the Fairview Adolescent STOP Program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended step groups, gender group, spirituality groups, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset-building activities, and chemical dependency related lectures. PROGRESS AND SIGNIFICANT EVENTS: On _%#MMDD2002#%_, _%#NAME#%_ completed the drug chart history and presented this for her therapy group.
NA|Narcotics Anonymous|NA|244|245|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended grief group, spirituality groups, gender group, AA and NA meetings, individual therapy, therapeutic recreation, developmental asset building activities, and chemical dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_ _%#NAME#%_ completed a drug chart history and presented this for her therapy group.
NA|Narcotics Anonymous|NA|260|261|DISCHARGE PLAN/RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure time skills by engaging of her community, and/or school would seem important as to _%#NAME#%_ replacing previously unhealthy choices with more healthy avenues of activity. Accessing community AA, and NA support groups may prove beneficial for _%#NAME#%_ to encounter a more healthful peer group, and potential role models. Once again the client is encouraged to continue with medication management of community psychiatrist, and to continue with family, and individual therapy for previous mental health professionals.
NA|Narcotics Anonymous|NA|327|328|PROBLEMS PRESENT ON ADMISSION|He offered minimal insight. He needs to continue working on avoidance behavior, trust issues, feeling identification. PLAN AND RECOMMENDATIONS: Home. He was recommended to attend the inpatient treatment or an outpatient treatment with a lodging component and follow with recommendations of after care 1 to 2 times a week AA or NA meetings with a sponsor, random urine toxicology screenings weekly, individual and family therapy, follow with his legal guidelines, and medication management.
NA|Narcotics Anonymous|NA.|154|156|DISCHARGE PLAN AND RECOMMENDATIONS|He is also to get involved in and continue with individual family therapy. Continued support should be gained through social support groups such as AA or NA. During the referral meeting, the parents stated that they would like to follow a contract with _%#NAME#%_ and not initially follow through with the outpatient recommendation but contract for him to attend treatment if he is unable to follow the contract.
NA|Narcotics Anonymous|NA|198|199|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure skills, may prove beneficial towards _%#MM#%_ replacing previously unhealthy choices, with more healthful opportunities. Attending AA and NA support groups, may prove beneficial towards _%#MM#%_ encountering a more healthful peer group, and potential role models. _%#MM#%_ is recommended to continue with individual therapy as well as she and her family participating in family therapy.
NA|Narcotics Anonymous|NA|309|310|DISCHARGE PLAN|He reports that he strives towards being a healthy adult that is a recovering role model for his younger sister upon discharge. DISCHARGE PLAN: Return to his grandmother's home. Return to _%#CITY#%_ _%#CITY#%_ Dual Outpatient to complete the program and all recommendations of his discharge: to attend AA and NA meetings regularly, obtain a sponsor as soon as possible, and attend individual therapy weekly.
NA|Narcotics Anonymous|NA|242|243|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP Unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. While on the unit, _%#NAME#%_ attended grief group, gender group, AA and NA meetings on site, individual therapy, multifamily group, developmental asset-building activities, and chemical dependency and related lectures. SIGNIFICANT EVENTS: On _%#MMDD2004#%_ _%#NAME#%_ and his biological parents met with unit staff concerning family history and current issues of functioning.
NA|Narcotics Anonymous|NA,|144|146|HISTORY OF PRESENT ILLNESS|He did not follow-through with treatment, but was actually able to maintain sobriety for up until three weeks ago. He went to meetings, went to NA, had a sponsor and working the program. He had some issues come up a few weeks ago which were hard for him, and he relapsed.
NA|Narcotics Anonymous|NA|282|283|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at treatment _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety and recovery. He attended step groups, multi- family group, grief group, gender groups, spirituality groups, in-house school, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset building activities, chemical dependency/psychotherapy groups, and related lectures.
NA|Narcotics Anonymous|NA|233|234|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social/recreational, and leisure skills by engaging of his community and school seem important towards _%#NAME#%_ filling time previously occupied of drug use and/or drug identity. Accessing community AA or NA support seems important towards _%#NAME#%_ discovering a new peer group for potential support. _%#NAME#%_ was also started with anti-depressant medication while on the S.T.O.P. Unit with the attending psychiatrist recommending continued treatment of community.
NA|Narcotics Anonymous|NA.|148|150|PRESENT ILLNESS|He has been a poly-substance user, went through treatment in 1992, and did have seven or more years of subsequent sobriety. He was active in AA and NA. A few years ago, he became addicted to OxyContin after a back injury. His use progressed. He was obtaining from a street source.
NA|Narcotics Anonymous|NA|149|150|DISCHARGE PLANS AND RECOMMENDATIONS|He is also encouraged to attend a school on site of the treatment program that he will be attending. We also recommend that he be involved in AA and NA support groups.
NA|Narcotics Anonymous|NA|223|224|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended grief group, gender group, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset building activities, and chemical dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2003#%_ _%#NAME#%_ completed the drug chart history and presented this for her therapy group.
NA|Narcotics Anonymous|NA|140|141|DISCHARGE PLAN AND RECOMMENDATIONS|He has been asked to comply with the following recommendations. 1. He will complete _%#CITY#%_ _%#CITY#%_ Aftercare Program 2. Attend AA or NA weekly and obtain a male sponsor. 3. Attend the school's sober support group. 4. Participate in family therapy.
NA|Narcotics Anonymous|NA|168|169|DISCHARGE|DISCHARGE: _%#NAME#%_ will return to _%#CITY#%_ Middle School where he will have support in recovery. He is scheduled to attend _%#CITY#%_ Continued Care, weekly AA or NA meetings, and to continue with random UAs. Hopefully, all of the above will encourage _%#NAME#%_ to work at building a sober support system to aid him in recovery.
NA|Narcotics Anonymous|NA|221|222|PROBLEMS PRESENTED UPON ADMISSION|PROGRAM PARTICIPATION: While in the _%#CITY#%_ _%#CITY#%_ Adolescent Chemical Dependency Program, _%#NAME#%_ was involved in various tasks and assignments. She attended chemical dependency groups, in-house school, AA and NA meetings, developmental asset-building activities, and chemical dependency and related lectures. PROGRESS AND SIGNIFICANT EVENTS: While in the assessment process, _%#NAME#%_ completed her group introduction and her social/chemical use history.
NA|Narcotics Anonymous|NA|213|214|DISCHARGE PLAN|DISCHARGE: _%#NAME#%_ will return to _%#CITY#%_ _%#CITY#%_ Alternative Learning Center where she will have counselors to support her in recovery. She is scheduled to attend _%#CITY#%_ Continued Care, weekly AA or NA meetings, and to continue with random UAs. Hopefully, all of the above will enable _%#NAME#%_ to continue to work at building a sober support system to aid her in sobriety and recovery.
NA|Narcotics Anonymous|NA|250|251|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended multifamily group, spirituality groups, gender group, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset-building activities, and chemical dependency-related lectures. SIGNIFICANT EVENTS: On _%#MMDD2003#%_ _%#NAME#%_ met with unit staff concerning social histories and current issues of functioning.
NA|Narcotics Anonymous|NA|238|239|DISCHARGE PLAN AND RECOMMENDATIONS|He should continue to build sober social, recreational, and leisure skills by engaging in his community would surely assist _%#NAME#%_ in developing a more helpful adolescent experience and adolescent identity. Attending community AA and NA sport groups would be helpful for _%#NAME#%_ towards encountering a more helpful peer group and potential role models. It is recommended that _%#NAME#%_ continue with medication management at a community psychiatrist and also proceed with individual and family therapy at a time when chemical health professionals deem it appropriate for inclusion.
NA|Narcotics Anonymous|NA.|330|332|DISCHARGE PLAN AND RECOMMENDATIONS|We recommend family therapy to work on their communication level and the parenting issues that are currently being addressed and he is also to attend school at the program that he will be attending which is _%#CITY#%_ _%#CITY#%_ Recovery Center and have his education needs met there. We are also encouraging attendance in AA and NA.
NA|Narcotics Anonymous|NA|219|220|DISCHARGE|DISCHARGE: _%#NAME#%_ will return to _%#CITY#%_ _%#CITY#%_ High School, South Campus, where she will have counselors to support her in recovery. She is scheduled to attend _%#CITY#%_ Continued Care, attend weekly AA or NA meetings, and to continue with random UAs. Hopefully, all of the above will enable _%#NAME#%_ to continue to work at building a sober support system to aid her in sobriety and recovery.
NA|Narcotics Anonymous|NA|155|156|DISCHARGE AND RECOMMENDATIONS|In the meantime, he is working with his parents regarding possible alternatives. _%#NAME#%_ is scheduled to attend _%#CITY#%_ Continued Care, weekly AA or NA meetings, and to continue with random UAs. Hopefully, all of the above will enable _%#NAME#%_ to continue to wok at building a sober support system to aid him insobriety.
NA|Narcotics Anonymous|NA|199|200|DISCHARGE PLAN AND RECOMMENDATIONS|_%#NAME#%_ seemed available of such issue with the evaluation team citing _%#NAME#%_ likely needing time and/or opportunity of practicing sober skills and step principles. Attending community AA and NA support groups would be appropriate of _%#NAME#%_ encountering a more healthful peer group and/or potential role models. The client would seem a likely candidate of individual therapy and is also recommended to continue with family therapy at a time when chemical health officials deem it appropriate of inclusion.
NA|Narcotics Anonymous|NA|190|191|DISCHARGE PLAN|DISCHARGE PLAN: _%#NAME#%_ will be attending Place Program School where he will have counselors to support him in recovery. He is scheduled to attend _%#CITY#%_ Continued Care, weekly AA or NA meetings, and to continue with random UAs. Hopefully, _%#NAME#%_ will remain sober long enough to see the value in recovery and work at building a sober support system to aid him in this endeavor.
NA|deoxyribonucleic acid:DNA|NA|221|222|PHYSICAL EXAMINATION|TSH 2.54, free T4 1.52. Urine analysis with 15 ketones, leukocyte esterase trace, bacteria trace and moderate squamous epithelial cells. Labs from North Memorial show positive urine hCG, positive Neisseria gonorrhoeae by NA probe, negative Chlamydia trachomatis by NA probe. ASSESSMENT/PLAN: 1. This is a 24-year-old female who is sexually active, who is currently pregnant and has a positive GC test.
NA|Narcotics Anonymous|NA|234|235|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreational and leisure skills by engaging in her community and family would be important for _%#NAME#%_ to proceed with adolescent development and, hopefully, young adult identity formation. AA and NA support groups may prove beneficial towards _%#NAME#%_ encountering a more healthful peer group and more potential role models. Once again, _%#NAME#%_ is recommended to proceed with individual therapy and family therapy, as well as parents encourage to access community parent support groups.
NA|Narcotics Anonymous|NA|188|189|DISCHARGE PLAN AND RECOMMENDATIONS|He will return to _%#CITY#%_ High School where he is in twelfth grade, he will continue to build sober social recreational and leisure skills by complying with his no-use contract, AA and NA support. No medications at this time.
NA|Narcotics Anonymous|NA|173|174|DISCHARGE PLAN AND RECOMMENDATIONS|He entered for detox. The patient was detoxed with buprenorphine and did fairly well. He was not interested in more treatment. He wanted to detox only. He planned to attend NA meetings 2-3 times per week. He was stable medically by _%#MMDD2007#%_ and was discharged. He was to continue at home, Wellbutrin-SR 150 mg b.i.d., Strattera 80 mg daily, ibuprofen 800 mg t.i.d. for pain.
NA|Narcotics Anonymous|NA|224|225|REFERRED BY|DISCHARGE PLAN AND RECOMMENDATIONS: _%#NAME#%_ was discharged on _%#MM#%_ _%#DD#%_, 2002. Recommendations included home restriction, outpatient primary chemical dependency treatment, individual and family therapy and AA and NA meetings. His parents chose the outpatient site of New Connections in _%#CITY#%_. No medications were prescribed upon discharge.
NA|Narcotics Anonymous|NA|311|312|PROBLEMS PRESENTED ON ADMISSION|PROGRAM PARTICIPATION: While in the inpatient MICD program the patient was involved in various tasks and assigned designed to address his chemical dependency, mental health, sobriety and recovery issues. He attended step groups, weekly family groups, gender groups, spirituality groups, in-house school, AA and NA meetings on site, individual therapy, therapeutic recreational, development asset building activities and chemical dependency and medical health related lectures.
NA|Narcotics Anonymous|NA|224|225|DISCHARGE PLANS AND RECOMMENDATIONS|DISCHARGE PLANS AND RECOMMENDATIONS: _%#NAME#%_ was not diagnosable with any chemical dependency or abusiveness at this point in time. We are recommending that _%#NAME#%_ go home on a no-use contract and recommending AA and NA meetings. We also recommend that _%#NAME#%_ continue to attend individual and family therapy. _%#NAME#%_ _%#NAME#%_, CDC II
NA|Narcotics Anonymous|NA|231|232|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While in the STOP Unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended gender group, spirituality groups, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset-building activities, and chemical dependency and related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_, client met with staff concerning social histories and current issues of functioning.
NA|Narcotics Anonymous|NA|371|372|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at the Fairview Adolescent Inpatient MI/CD Treatment Program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, mental health, and recovery. She attended step groups, multifamily groups, gender groups, spirituality meetings individually, in-house school, mental health groups, AA and NA meetings on site, individual therapy, family week, therapeutic recreation, developmental asset- building activities, and chemical dependency, mental health, and related lectures.
NA|Narcotics Anonymous|NA|124|125|HISTORY OF PRESENT ILLNESS|She was detoxed in jail. After River Place, she went to Progress Valley Halfway House and then home. She has been active in NA and was able to put together 22 months of sobriety. She came in contact with an old using friend of hers who convinced her to skip a meeting, and she relapsed.
NA|Narcotics Anonymous|NA|289|290|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at the Fairview-University Medical Center STOP Program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, mental health and recovery. He attended step groups, weekly family group, gender groups, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset-building activities, chemical dependency, mental health, and other related lectures. PROGRESS AND SIGNIFICANT EVENTS: While involved in the STOP Program,. _%#NAME#%_ worked toward identifying issues relating to substance abuse, and its subsequent impact on him at school and at home.
NA|Narcotics Anonymous|NA|210|211|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended gender group, AA and NA meetings on site, individual therapy, multifamily group, therapeutic recreation, developmental asset-building activities, and chemical dependency and related lectures. SIGNIFICANT EVENTS: On _%#MMDD2003#%_ the client met with unit staff concerning social histories and current issues of functioning.
NA|Narcotics Anonymous|NA.|145|147|DISCHARGE PLAN AND RECOMMENDATIONS|There is a strong need for family therapy to occur between _%#NAME#%_ and her mother. Continued community support should be sought through AA or NA.
NA|Narcotics Anonymous|NA|226|227|DISCHARGE PLAN AND RECOMMENDATION|He is required to attend the school services provided at the on-site program in Hazelden. We are also recommending individual and family therapy. He is also recommended, for continued support of his sobriety, to attend AA and NA and get a sponsor.
NA|Narcotics Anonymous|NA|242|243|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure skills by engaging in her community and/or treatment/school would important for _%#NAME#%_ in continuing her adolescent development and young adult goals. Accessing community AA and NA support groups may prove beneficial towards _%#NAME#%_ encountering a more healthful peer and/or potential role models. It is also recommended the client continue individual and family therapy towards understanding her historical and current life stressors.
NA|Narcotics Anonymous|NA|285|286|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While in the _%#CITY#%_ _%#CITY#%_ Adolescent Chemical-Dependency Program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical-dependency, sobriety, and recovery. She attended chemical-dependency groups, in-house school, AA and NA meetings, developmental asset building activities, and chemical-dependency and related lectures. PROGRESS AND SIGNIFICANT EVENTS: While in the evaluation process, _%#NAME#%_ completed a group introduction, a drug chart, a drug history, and a social/chemical use history.
NA|Narcotics Anonymous|NA|606|607|PROGRAM PARTICIPATION|The client met at least 5 of the 7 DSM-IV criteria to support a diagnosis of 304.80 polysubstance dependence (marijuana, amphetamine and over-the- counter medications.) PROGRAM PARTICIPATION: While involved in the _%#CITY#%_ Outpatient Chemical Dependency Treatment Program, the client resided at Nord House Lodging Facility, and took part in all Nord House Program, groups and services. While at _%#CITY#%_ Program, the client took part in daily community group sessions, asset building groups three times a week, two hours of on site schooling per day, weekly spirituality groups, on and off site AA and NA meetings, and daily group therapy sessions. SIGNIFICANT EVENTS: At admission the client was open to returning to treatment program for the second time, and open to pursuing halfway house placement.
NA|Narcotics Anonymous|NA|247|248|DISCHARGE|Hopefully all of the above will enable _%#NAME#%_ to continue to work at building a sober support system to aid him in sobriety, and recovery. In the event that transportation is a problem in attending Phase II, we recommend he increase his AA or NA meetings, and be involved in private counseling.
NA|Narcotics Anonymous|NA|324|325|PROGRAM PARTICIPATION|He also presented with a history of being abused. PROGRAM PARTICIPATION: At _%#CITY#%_ _%#CITY#%_ Adolescent Chemical dependency Program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. He attended chemical dependency groups, in-house school, AA and NA meetings, developmental asset building activities, and chemical dependency, and related lectures. TREATMENT: _%#NAME#%_'s behavior was compliant and he consistently displayed good group skills.
NA|Narcotics Anonymous|NA|196|197|DISCHARGE|_%#NAME#%_ reports he has resumed interest in sober activities such as playing his guitar. DISCHARGE: _%#NAME#%_ is working on his GED. He is scheduled to attend _%#CITY#%_ Phase II, weekly AA or NA meetings, and to continue with random urinalyses. Hopefully, all of the above will enable _%#NAME#%_ to continue to work at building a sober support system to aid him in sobriety and recovery.
NA|Narcotics Anonymous|NA|245|246|DISCHARGE PLAN/RECOMMENDATIONS|She was open about her feelings and concerns related to these issues and process with staff. DISCHARGE PLAN/RECOMMENDATIONS: The client was discharged on _%#MMDD2005#%_. She was recommended to attend Phase 2 program at _%#CITY#%_, attend AA and NA meetings in the community, comply with random urinalysis, follow her home contract, and participate in family therapy.
NA|Narcotics Anonymous|NA|231|232|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended gender group, spirituality groups, AA and NA meetings on-site, individual therapy, therapeutic recreation, developmental asset building activities, and chemical dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2003#%_ _%#NAME#%_ completed and presented a drug chart for his therapy group.
NA|Narcotics Anonymous|NA|168|169|PROGRESS|At a time when chemical health and behavioral issues seem effectively addressed client is encouraged to return to academic and/or vocational pursuits. Accessing AA and NA support groups may prove helpful towards _%#NAME#%_ encountering a more helpful peer group and/or potential role models. This writer would identify emotional maturity and/or deeper secondary type change lacking for _%#NAME#%_.
NA|Narcotics Anonymous|NA|222|223|DISCHARGE PLAN AND RECOMMENDATIONS|DISCHARGE PLAN AND RECOMMENDATIONS: The client was discharged on _%#MMDD2003#%_ with the following recommendations: 1. Complete the F-UMC _%#CITY#%_ Nord House program. 2. Continue with individual therapy. 3. Attend AA or NA regularly. 4. Obtain a female sponsor. 5. Follow up with her medical doctor for medication as needed.
NA|Narcotics Anonymous|NA|221|222|DISCHARGE PLAN AND RECOMMENDATIONS|He is to continue to take medication as prescribed. Medications are Effexor 75 mg and Ativan 0.5 mg. Follow- up for medication is to be followed up by a psychiatrist. Also recommending that _%#NAME#%_ attend either AA or NA and obtain a sponsor. The team is also recommending family therapy and individual therapy.
NA|Narcotics Anonymous|NA|312|313|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at Fairview STOP assessment program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, mental health, and recovery. He attended step groups, multifamily groups, gender groups, spirituality groups, mental health group, AA and NA meetings on site, individual therapy, family meetings, therapeutic recreation, developmental asset-building activities, chemical dependency, mental health and related lectures.
NA|Narcotics Anonymous|NA|246|247|DISCHARGE PLAN AND RECOMMENDATIONS|He was able to self-relate and participate actively. He does very well in structured settings. DISCHARGE PLAN AND RECOMMENDATIONS: The patient was recommended to an intensive outpatient treatment program and follow with home restrictions, AA and NA meetings, and with his legal commitments.
NA|Narcotics Anonymous|NA|361|362|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at the Fairview Adolescent MICD and STOP Inpatient Program _%#NAME#%_ was involved in various tasks and assignments designed to address mental health issues, chemical dependency, sobriety, and recovery. She attended step groups, multi- family groups, gender groups, spirituality groups, in-house school, mental health group, AA and NA meetings on site, individual therapy, family therapy, therapeutic recreation, developmental asset-building activities, chemical dependency, mental health, and related lectures.
NA|Narcotics Anonymous|NA|188|189|DISCHARGE PLAN AND RECOMMENDATIONS|At points she was more passive than assertive. DISCHARGE PLAN AND RECOMMENDATIONS: She was discharged to parents to go home on home restrictions, individual and family therapy, and AA and NA meetings. A plan was developed, parents in charge of developing the plan for patient, to go on stay home awaiting for a residential treatment program such as Gilfillan, Omegon, Gerard, or _%#CITY#%_ _%#CITY#%_ Children's Home, and patient on the waiting list.
NA|Narcotics Anonymous|NA|233|234|DIAGNOSES|HOSPITAL COURSE: While at Fairview Adolescent STOP, _%#NAME#%_ was involved in various tasks and assignments to be assigned to address chemical dependency, sobriety, mental health, and recovery. He attended multifamily groups, AA or NA meetings inside, individual therapy, therapeutic recreation, developmental asset building activities, chemical dependency, mental health, and related lectures. PROGRESS AND SIGNIFICANT EVENTS: _%#NAME#%_ was compliant but guarded, defensive, passive, aggressive, and blaming towards parents.
NA|Narcotics Anonymous|NA|244|245|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended grief group, gender group, spirituality groups, AA and NA meetings on site, individual therapy, multi-family group, therapeutic recreation, developmental asset- building activities, and chemical dependency-related lectures.
NA|Narcotics Anonymous|NA|235|236|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure skills by engaging in her community and/or family, would be important for _%#NAME#%_ to proceed with adolescent development and launching her into adulthood. Attending AA and NA support groups may prove beneficial for _%#NAME#%_ as to encountering a more healthful peer group and of potential role models.
NA|Narcotics Anonymous|NA|314|315|DISCHARGE PLAN AND RECOMMENDATIONS|The family has been recommended to begin family counseling. DISCHARGE PLAN AND RECOMMENDATIONS: At the time of discharge the client is recommended to continue chemical-dependency treatment at the _%#CITY#%_ Phase 2 Program. Additionally, she is recommended to begin individual and family counseling, attend AA and NA meetings twice a week, re-assess depression symptoms and continue medication management, follow home contract, and remain abstinent. _%#NAME#%_ _%#NAME#%_, CDC II
NA|Narcotics Anonymous|NA|178|179|DISCHARGE PLAN AND RECOMMENDATIONS|At a time when chemical health and behavioral issues seem effectively addressed, the client is recommended to continue with academic and/or vocational pursuits. Attending AA and NA support groups may prove beneficial towards the client encountering a more healthful or more stable peer group. The client is recommended to continue with medication management with a community psychiatrist, as well as family and individual therapy.
NA|Narcotics Anonymous|NA|272|273|DISCHARGE PLANS AND RECOMMENDATIONS|She, however, was consistent in her stated desire for sobriety. DISCHARGE PLANS AND RECOMMENDATIONS: At the time of discharge, recommendations included that _%#NAME#%_ participate in the phase II programming through the F-UMC _%#CITY#%_ site; that she attend weekly AA or NA meetings; that she follow her home contract, and that she receive random drug screening. It is also recommended that she participate in a sober support group at her school if such a group is available.
NA|sodium|NA|157|158|LABORATORY DATA|Rectovaginal exam reveals no masses. Stool guaiac negative. LABORATORY DATA: White blood count 4.6, hemoglobin 12.2, platelets 178, MCV 103. MG 127. CA 8.6. NA 141. Potassium 4.0. CL 108. Bicarb 28. BUN 25, creatinine 0.88, glucose 84. Total protein 7.0, albumin 3.8, total bilirubin 0.4, alkaline phosphatase 79.8, ALT 7, AST 20.
NA|Narcotics Anonymous|NA|289|290|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at the Fairview-University Medical Center STOP Program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, mental health and recovery. She attended step groups, weekly family group, gender group, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset-building activities, chemical dependency, mental health and other related lectures. PROGRESS/SIGNIFICANT EVENTS: While involved in programming on the STOP Unit, _%#NAME#%_ made efforts to understand her chemical dependency issues and what she needed to do to better take care of herself and focus on beginning to address issues for sobriety.
NA|Narcotics Anonymous|NA|297|298|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While in the _%#CITY#%_ _%#CITY#%_ Adolescent Outpatient Chemical Dependency Program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. She attended chemical dependency groups, in- house school, AA and NA meetings, developmental asset-building activities, and chemical dependency and related lectures. SIGNIFICANT EVENTS/PROGRESS: While in treatment, _%#NAME#%_ completed AA Steps 1 through 5, a group introduction, a drug chart, and a drug history.
NA|Narcotics Anonymous|NA|410|411|DISCHARGE PLAN AND RECOMMENDATIONS|At a time when chemical health, behaviorally issues and emotional issues seem effectively addressed, the client is encouraged for continuing with academic and/or vocational pursuits, to continue on building sober social, recreational, and leisure skills by engaging of her community would prove important for the client continuing of adolescent development and young adult identify formation. Attending AA and NA support groups may prove beneficial towards the client encountering a more helpful peer group and/or role models. The client is recommended to continue with medication management of a community psychiatrist, and is also recommended to continue with individual and family therapy at a time when treatment professionals deem this appropriate of inclusion.
NA|Narcotics Anonymous|NA|170|171|SIGNIFICANT EVENTS|After four days on the unit, _%#NAME#%_ presented his relapse drug chart to a peer group and stated that he wanted to return to a recovery program, which included weekly NA meetings, and meetings with his sponsor. _%#NAME#%_ also completed an assignment to learn more about bipolar illness. DISCHARGE PLAN AND TEAM RECOMMENDATION: _%#NAME#%_ was discharged on _%#MMDD2004#%_ to home with the recommendation for the Intensive Outpatient Treatment Program at _%#CITY#%_.
NA|Narcotics Anonymous|NA|188|189|DISCHARGE PLAN AND RECOMMENDATIONS|He plans to continue his academic progress by attending the Ivan Sand Alternative School. Staff have recommended that he complete the _%#CITY#%_ _%#CITY#%_ Aftercare Program, attend AA or NA meetings weekly, maintain contact with his AA sponsor, attend the school support group, and participate in individual and family therapy.
NA|Narcotics Anonymous|NA|306|307|PROGRAM PARTICIPATION|He has also experimented with ecstasy and mushrooms. PROGRAM PARTICIPATION: While the client was in the STOP Program he was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. He attended chemical-dependency peer groups, gender group, in-house AA and NA meetings, individual therapy, a family assessment, developmental asset building activities, therapeutic recreation, music therapy, chemical dependency and related lectures, and multi-family group.
NA|Narcotics Anonymous|NA|551|552|PROGRAM PARTICIPATION|The client met at least 6 of 7 DSM-IV criteria to support a diagnosis of 304.80 polysubstance dependence (amphetamines, cannabis, and speed/caffeine pills.) PROGRAM PARTICIPATION: While involved in the _%#CITY#%_ Outpatient Treatment Program, the client resided at Nord House Lodging Facility and took part in all Nord House programs and services prior to discharge. At the _%#CITY#%_ Treatment Program, the client took part in daily community group sessions, three asset building sessions, two hours of on site school per day, on and off site AA and NA meetings, one family group session, one weekend treatment group at Nord House, and daily group therapy sessions. The client was scheduled to attend a four- day family program at Fairview-University Medical Center with mother and stepfather, but was discharged prior to attending.
NA|Narcotics Anonymous|NA|283|284|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While involved at the adolescent female lodging, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety and recovery. She participated in chemical health groups, community group, weekly on and offsite AA and NA meetings, onsite schooling, developmental asset- building activities three times a week, weekly spirituality groups, recreational activities, weekly family programming, individual counseling and Saturday treatment programming.
NA|Narcotics Anonymous|NA|255|256|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at our _%#CITY#%_ Outpatient Program _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. He participated in chemical health groups, community group, AA and NA meetings, on site schooling, developmental asset building activities, spirituality groups, recreational activities, weekly family programming, and weekly one-to- ones.
NA|Narcotics Anonymous|NA|255|256|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at _%#CITY#%_ Adolescent Outpatient, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety and recovery. She participated in chemical health groups, community group, AA and NA meetings, on-site school, developmental asset building activities, spirituality groups, recreation activities and weekly family programming. PROGRESS: Dimension 1: There were no medical issues throughout _%#NAME#%_'s treatment stay.
NA|Narcotics Anonymous|NA|286|287|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at the _%#CITY#%_ _%#CITY#%_ Adolescent Chemical Dependency Program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety and recovery. She participated in chemical health group, community group, AA and NA meetings, school, developmental asset-building activities, spirituality groups, recreational activities, weekly family programming and individual counseling. PROGRESS: Dimension 1; Medical: Acute intoxication/withdrawal potential: No intoxication or withdrawal reported.
NA|Narcotics Anonymous|NA|262|263|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. While on the unit, _%#NAME#%_ attended grief group, gender group, spirituality groups, AA and NA meetings on-site, individual therapy, multifamily group, therapeutic recreation, developmental asset building activities, and chemical-dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2004#%_ _%#NAME#%_ met with unit staff concerning psychological testing.
NA|Narcotics Anonymous|NA|189|190|PROGRAM PARTICIPATION|While involved in the _%#CITY#%_ Program, the client took part in daily community group sessions, asset- building groups 3 times a week, weekly spirituality groups, on and off- site AA and NA meetings, and daily group therapy sessions. She was unable to take part in family groups or family program due to the logistical issues of parents' distance from _%#CITY#%_.
NA|Narcotics Anonymous|NA|198|199|DISCHARGE PLAN AND RECOMMENDATIONS|DISCHARGE PLAN AND RECOMMENDATIONS: _%#NAME#%_ will return to New Life Academy where she will have counselors to support her in recovery. She is scheduled to attend _%#CITY#%_ Phase 2, weekly AA or NA meetings, and to continue with random urinalyses. Hopefully, all of the above will enable _%#NAME#%_ to continue to work at building a sober support system to aid her in sobriety and recovery.
NA|Narcotics Anonymous|NA|244|245|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended grief group, gender group, spirituality groups, AA and NA meetings on site, individual therapy, multifamily group, therapeutic recreation, developmental asset-building activities, and chemical dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2004#%_ the client completed drug chart history and presented this for his therapy group.
NA|Narcotics Anonymous|NA|269|270|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While involved in the _%#CITY#%_ Outpatient Treatment Program, the client took part in daily community group sessions, 2 hours of on-site schooling per day, asset-building groups 3 times a week, weekly spirituality groups, on and off-site AA and NA meetings, and daily group therapy sessions. The client took part in weekly family groups with mother, as well as attending 2 of 4 days in the family program at F-UMC with mother.
NA|Narcotics Anonymous|NA|372|373|DISCHARGE PLAN AND RECOMMENDATIONS|_%#NAME#%_ states that the loss of trust and relationship with her family is the most significant consequence that she experienced. DISCHARGE PLAN AND RECOMMENDATIONS: Upon completion of the outpatient program, it is recommended that _%#NAME#%_ participate in the phase 2 program at the University of Minnesota Medical Center _%#CITY#%_ site, that she attend weekly AA or NA meetings, that she follow a home contract, that she have random drug screens, and that she engage in therapy. It is also recommended that if she encounters struggles with her recovery process that she would consider entering a halfway house as a backup plan.
NA|Narcotics Anonymous|NA|152|153|LABORATORY|By _%#MM#%_ _%#DD#%_, 2005, it was determined that she could be discharged and that she was medically stable at that point. She is follow up with AA or NA meetings in the community. She is also to follow up with her primary medical physician regarding anemia. She was seen by the pain management people, who agreed with using Zanaflex for chronic daily headache and neck pain.
NA|Narcotics Anonymous|NA|250|251|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While in our _%#CITY#%_ Outpatient Program Luke was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. He participated in chemical health groups, community groups, AA and NA meetings, on site schooling, developmental asset building activities, spirituality groups, recreational activities, weekly family programming, and weekly individual one-to-ones.
NA|Narcotics Anonymous|NA|293|294|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While involved in the _%#CITY#%_ Outpatient Treatment Program, the client took part in daily community group sessions, 2 hours of on site schooling per day while school was in session, asset building groups 3 x a week, weekly spirituality groups, on and off site AA and NA meetings, one-on-one sessions with staff, and daily group therapy sessions. The client was unable to participate in any offered family groups due to parents schedule conflicts, and other issues.
NA|Narcotics Anonymous|NA|214|215|PROGRESS|Family issues appear significant for client, and he is referred to individual counseling to further address these. Additionally, staff provided client with resources and support systems in recovery, such as AA and NA meetings. He also took part in recreational activities during the treatment program. He was able to discuss concepts of a support system and identified some activities to continue in, to keep himself active and to combat boredom.
NA|Narcotics Anonymous|NA|203|204|PROGRESS|Family issues appear significant for client and she is referred to individual counseling to further address these. The staff provided client with resources and support systems in recovery such as AA and NA meetings. She also took part in recreational activities during this program. She was able to discuss concepts of a support system and identify some activities to continue to keep self active and to combat boredom.
NA|Narcotics Anonymous|NA.|131|133|FOLLOW UP|He was ready for discharge on _%#MM#%_ _%#DD#%_, 2005. FOLLOW UP: He was to follow up with his aftercare plan and attend an AA and NA. He was discharged, and I will extend a taper of Suboxone to take 2 mg t.i.d. for a week, 2 mg b.i.d for a week, 2 mg daily for a week, and 1 mg daily for a week.
NA|Narcotics Anonymous|NA|223|224|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While involved in the _%#CITY#%_ Outpatient Treatment Program, the client took part in daily community groups, asset building groups 3 times a week, weekly spirituality groups, on and off-site AA and NA meetings, and daily group therapy sessions. Additionally, the client took part in all 4 weeks of the weekly family group programming with her parents.
NA|Narcotics Anonymous|NA|245|246|DISCHARGE PLAN AND RECOMMENDATIONS|DISCHARGE PLAN AND RECOMMENDATIONS: The client will continue to live at home with his parents. He plans to return to _%#CITY#%_ _%#CITY#%_ High School. Staff recommended he complete the _%#CITY#%_ _%#CITY#%_ Phase 2 program, attend weekly AA or NA meetings, obtain a male sponsor, attend sober support group at his school, and follow all obligations of probation.
NA|Narcotics Anonymous|NA|270|271|DISCHARGE PLAN AND RECOMMENDATIONS|DISCHARGE DIAGNOSES: 1. 30430. 2. Epilepsy with seizures. DISCHARGE PLAN AND RECOMMENDATIONS: _%#NAME#%_ will reside at home until the week of _%#MMDD2006#%_ where he will begin Job Corp and live on site. Additional discharge recommendations include: 1. Continue AA and NA attendance one time a week. 2. Attend Job Corp and live on site. 3. Continue individual therapy with _%#NAME#%_ _%#NAME#%_.
NA|Narcotics Anonymous|NA|128|129|DISCHARGE RECOMMENDATIONS|DISCHARGE RECOMMENDATIONS: 1. Phase II at our Fairview _%#CITY#%_ site. 2. Return to _%#CITY#%_ High School. 3. Continue AA and NA attendance one time a week and obtain a sponsor. 4. Continue to follow home contract with random UAs. PROGRESS: Good.
NA|Narcotics Anonymous|NA|207|208|PROGRESS|He was able to complete and follow home contract and was reportedly able to follow expectations at home. Additionally, staff provided the client with resources and support systems in recovery such as AA and NA meetings. He also took part in recreational activities during the treatment program. He was able to identify a support system following treatment and identified several activities to continue to keep himself active and to combat boredom.
NA|Narcotics Anonymous|NA|416|417|DISCHARGE PLANS AND RECOMMENDATIONS|DISCHARGE PLANS AND RECOMMENDATIONS: Upon completion of the outpatient program, it is recommended that _%#NAME#%_ participate in a phase II after program whether through the Fairview Crystal Site or a facility closure to the family's home community. Additional recommendations would be that she receive random drug screens, that she follow a home contract, that she attend sober school, that she attend weekly AA or NA meetings, that she engage in therapy and that she has her ADHD diagnosis and recommendation for medication therapy re-evaluated.
NA|Narcotics Anonymous|NA|194|195|DIMENSION V|She may require further assistance in the area of family relationships and is referred to family counseling. Staff provided client with resources and support systems and recovery such as AA and NA meetings. She also took part in recreational activities during treatment program. She was able to discuss concepts of a support system and to identify activities to avoid boredom.
NA|Narcotics Anonymous|NA|298|299|DISCHARGE PLAN AND RECOMMENDATIONS|SIGNIFICANT EVENTS: _%#NAME#%_ has been diagnosed poly-substance abuse (304.80), dysthymia, rule out an additional affecting disorder, eating disorder by history. DISCHARGE PLAN AND RECOMMENDATIONS: Patient was discharged to home with parents to attend Fountain Lake Treatment Center, follow AA or NA meetings plus individual and family therapy, follow with primary doctor for medication management.
NA|Narcotics Anonymous|NA|215|216|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP Unit _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. She attended grief group, gender group, AA and NA meetings on-site, individual therapy, therapeutic recreation, developmental asset building activities, and chemical dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_ client completed and presented a drug chart history for her therapy group.
NA|Narcotics Anonymous|NA|152|153|PROGRESS|It seems also important for _%#NAME#%_ to build sober social, recreational, and leisure skills towards herself accomplishing her adult identity. AA and NA involvement would seem beneficial as to _%#NAME#%_ at a time when she identifies she in fact needs such support. Continuing with individual therapy and family therapy is also recommended.
NA|Narcotics Anonymous|NA|221|222|DISCHARGE PLAN AND RECOMMENDATIONS|DISCHARGE PLAN AND RECOMMENDATIONS: _%#NAME#%_ was discharged on _%#MMDD2002#%_ to the care of his parents. The client is referred to intensive outpatient services of Anthony Lewis Center in _%#CITY#%_, Minnesota. AA and NA involvement is recommended.
NA|Narcotics Anonymous|NA|236|237|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at the STOP Unit _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. She attended grief group, gender group, spirituality groups, AA and NA meetings on-site, individual therapy, therapeutic recreation, developmental asset building activities, chemical dependency and related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_ _%#NAME#%_ completed and presented a drug chart for her therapy group.
NA|Narcotics Anonymous|NA|216|217|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. She attended step groups, gender group, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset-building activities, and chemical dependency and related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_, _%#NAME#%_ met with unit staff concerning social functioning and history.
NA|Narcotics Anonymous|NA|262|263|PROGRAM PARTICIPATION|Client arrived on the STOP Unit involuntarily. PROGRAM PARTICIPATION: While on the STOP Unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. He attended grief group, gender group, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset building activities, and chemical dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_, _%#NAME#%_ met with unit staff concerning social histories and current issues of functioning.
NA|Narcotics Anonymous|NA|238|239|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure time skills would seem important for _%#NAME#%_ to replace previously unhealthy activities and/or identities with more appropriate adolescent choices. Accessing community AA and NA support groups seems indicated towards _%#NAME#%_ realizing a more healthful peer group and/or potential resource of role models. Client is encouraged to continue with medication management of community psychiatric professionals.
NA|Narcotics Anonymous|NA|211|212|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety and recovery. She attended grief group, gender group, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset building activities, and chemical dependency related lectures. Client also completed various assignments, specifically addressing personal issues of circumstance.
NA|Narcotics Anonymous|NA|206|207|DISCHARGE PLAN/RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure time skills by replacing previously unhealthy choices with more appropriate choices would seem obviously beneficially. Accessing community AA and NA support groups could provide _%#NAME#%_ with a support of peer group and/or potential role modeling. As mentioned previously family therapy and individual therapy is recommended as to reconnecting a family member and for _%#NAME#%_ to work through issues of shame and trust.
NA|Narcotics Anonymous|NA|210|211|DISCHARGE PLAN AND RECOMMENDATIONS|In the event of _%#NAME#%_ not being capable of maintaining his sobriety and/or abstinence from chemicals, the client is encouraged to pursue inpatient treatment. The client is also recommended to attend AA or NA meetings daily, obtain a sponsor of self-help group, re-engage of healthy family activities, and also to abstain from any Internet use for 2 weeks.
NA|Narcotics Anonymous|NA|121|122|DISCHARGE PLAN AND RECOMMENDATIONS|2. The patient is to abide by the home restriction guidelines while in the outpatient program. 3. He is to attend AA and NA meetings. 4. The patient is to obtain a sponsor. 5. The patient's family is encouraged to continue family therapy. _%#NAME#%_ _%#NAME#%_, CDCII
NA|Narcotics Anonymous|NA,|329|331|DISCHARGE PLAN|I did not identify any other issues or concerns in his life at this point in time. DISCHARGE PLAN: Recommendations upon discharge: Due to his marijuana dependence diagnosis and family discord _%#NAME#%_ was referred to attend treatment in an outpatient program for chemical dependency, also individual and family therapy, AA and NA, and possible sober school upon completion of treatment. NON-STAFF
NA|Narcotics Anonymous|NA|292|293|PROBLEMS PRESENTED AT ADMISSION|While in the treatment program, _%#NAME#%_ was involved in various tasks and assignments designed to address his chemical dependency, sobriety and recovery, and mental health status. He attended therapeutic group, weekly family group, gender group, spirituality group, in home school, AA and NA meetings on site, individual therapy, family week, therapeutic recreation, developmental asset building activities, and chemical dependency and related lectures.
NA|Narcotics Anonymous|NA|241|242|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks, assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended step groups, gender group, spirituality groups, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset building activities and chemical dependency and related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_ _%#NAME#%_ met with unit staff concerning social history and current issues of functioning.
NA|Narcotics Anonymous|NA,|164|166|TYPE OF DISCHARGE|Followup with their psychiatrist for medication management. Contact _%#CITY#%_ Human Services for individual and family therapy. Also per insurance coverage AA and NA, Alanon and Family's Anonymous meetings, per their choice.
NA|Narcotics Anonymous|NA|240|241|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the S.T.O.P. Unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. He attended grief group, gender group, spirituality groups, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset building activities, and chemical dependency and related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_ client completed and presented a drug chart for his therapy group.
NA|Narcotics Anonymous|NA|365|366|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at Fairview Adolescent Inpatient Treatment Program. _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, mental health, and recovery. She was able to attend step groups, weekly multifamily groups, gender group, spirituality, a meeting, in-house school, mental health group, AA and NA meetings outside, individual therapy, family assessment, therapeutic recreation, developmental ______ building activities, chemical dependency and mental health related lectures.
NA|Narcotics Anonymous|NA|262|263|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at the STOP Program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. He attended step groups, weekly family groups, gender groups, spirituality groups, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset building activities, and chemical dependency and mental health related lectures.
NA|Narcotics Anonymous|NA|122|123|RECOMMENDATIONS UPON DISCHARGE|Continue to build social sober recreational skills by attending sober activities. We also encouraged her to attend AA and NA to support her growth and her sobriety.
NA|Narcotics Anonymous|NA|222|223|PROGRESS|DISCHARGE PLAN And RECOMMENDATIONS: The client was discharged on _%#MM#%_ _%#DD#%_, 2002 having successfully completed the program. Staff recommends that she complete _%#CITY#%_ _%#CITY#%_ After Care, attend regular AA or NA meetings and obtain a female sponsor, individual and family therapy. The client will continue to live with her mother and plans to return to _%#CITY#%_ Park High School in the fall.
NA|Narcotics Anonymous|NA|275|276|DISCHARGE PLAN AND RECOMMENDATIONS|Client is expected to proceed with chemical dependency treatment and also is recommended of continuing with individual and/or family therapy. Client is also encouraged to continue with antidepressant medication therapy of a community psychiatrist. Accessing community AA and NA support groups may prove beneficial for _%#NAME#%_ to encounter more helpful peer group and/or potential role models.
NA|Narcotics Anonymous|NA|141|142|DISCHARGE PLAN AND RECOMMENDATIONS|Also, he is to attend school on-site at the treatment program that he will be attending. We are also encouraging _%#NAME#%_ to attend AA and NA for support for his sobriety.
NA|Narcotics Anonymous|NA|238|239|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the Stop Unit Taylor was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended multi-family group, grief group, gender group, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset building activities, and chemical-dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2003#%_, _%#NAME#%_ and his family met with unit staff concerning family histories and current issues of functioning.
NA|Narcotics Anonymous|NA|227|228|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober and social recreational and leisure skills by engaging community and/or appropriate adolescent opportunities would be important in _%#NAME#%_ developing a healthy adolescent identity. Attending AA and NA support groups may prove helpful toward _%#NAME#%_ encountering a more healthful peer group and potential role models. The client is encouraged to continue with medication management, family therapy, and individual therapy with a community professional.
NA|Narcotics Anonymous|NA|232|233|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober, social, recreational, and leisure time skills by engaging in his community, would be important for _%#NAME#%_ to proceed with adolescent development and, eventually, young adult identity. Attending AA and NA support groups may prove beneficial for _%#NAME#%_ to encounter a potentially more positive peer group as role models. _%#NAME#%_ is recommended to continue with individual and family therapy at a time when chemical dependency professionals deem this appropriate.
NA|Narcotics Anonymous|NA|301|302|PROGRAM PARTICIPATION|Rule out dysthymia. PROGRAM PARTICIPATION: While at Fairview Dual Program, _%#NAME#%_ was involved ________________ designed to address chemical dependency, sobriety, mental health, and recovery. He attended step groups, multifamily groups, gender groups, in-house school, mental health group, AA and NA meetings on site, individual therapy, therapeutic recreation, ________ asset-building activities, chemical dependency, mental health, and related lectures. PROGRESS AND SIGNIFICANT EVENTS: _%#NAME#%_ was transferred to the MICD Dual Program to do a first step, stabilize to a lower level of care.
NA|Narcotics Anonymous|NA,|376|378|DISCHARGE PLAN AND RECOMMENDATIONS|DISCHARGE PLAN AND RECOMMENDATIONS: _%#NAME#%_ was discharged was to the care of his mother to be transferred right away to the Umbilay House where he had an appointment that same day at 10:30 a.m. that morning. Also, he was given medication and be followed up with medication follow-up with medication management, family therapy, individual therapy, Alanon Family Anonymous, NA, and AA meetings.
NA|Narcotics Anonymous|NA|201|202|PROGRAM PARTICIPATION|He has also participated in therapeutic recreation and developmental assets, building groups to work on self-esteem building and social skills development. He has also attended gender group and AA and NA meetings on the unit. _%#NAME#%_ also participated in lectures related to chemical dependency and mental health and medical issues. PROGRESS: _%#NAME#%_ appears to have much insight into the seriousness of his relapse.
NA|Narcotics Anonymous|NA|337|338|PROBLEMS PRESENTED ON ADMISSION|PROGRAM PARTICIPATION: While at Fairview adolescent inpatient treatment. _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, mental health and recovery. She attended step groups, multi-family groups, gender groups, spirituality groups, in-house school, mental health groups, AA or NA meetings on site, individual therapy, family sessions, therapeutic recreation, developmental (_______________) building activities, chemical dependency, mental health and related lectures.
NA|Narcotics Anonymous|NA|237|238|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. She attended grief group, gender group, spirituality groups, AA and NA meetings on site, therapeutic recreation, and developmental asset building activities, and chemical dependency, and related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_ _%#NAME#%_ met with unit staff concerning social histories and issues of functioning occurring recently.
NA|Narcotics Anonymous|NA|252|253|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at _%#CITY#%_ _%#CITY#%_ ACDP, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. He attended step groups, spirituality groups, in-house school, AA and NA meetings on site and in the community, developmental asset building activities, and chemical dependency and related lectures. PROGRESS: While in treatment the clinic completed an introduction detailing his chemical use history, steps one through five of the AA model, and additional assignments related to feelings and relapse prevention.
NA|Narcotics Anonymous|NA|313|314|STAFF RECOMMENDATIONS|He plans to continue to live with his mother and father. He will attend school at Ivan Sand Community School. STAFF RECOMMENDATIONS: Attend Fairview-University Medical Center _%#CITY#%_ _%#CITY#%_ Aftercare, individual and family therapy, follow up with his medical doctor for medication management, attend AA or NA at least one time weekly, obtain a male sponsor, attend the school's Sober Support Group.
NA|Narcotics Anonymous|NA|236|237|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended Step groups, gender group, grief group, AA and NA meetings on site, individual therapy, multi-family group, therapeutic recreation, developmental asset- building activities, and chemical dependency and related lectures.
NA|Narcotics Anonymous|NA|215|216|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure skills by engaging in his community would be important for _%#NAME#%_ as to developing adolescent identity and relevant skills. Attending community AA and NA support groups may prove helpful to _%#NAME#%_ encountering a more helpful peer group and a potential role models. As mentioned previously, individual and family therapy is recommended for _%#NAME#%_ at a time when chemical health professionals deem it appropriate for inclusion.
NA|Narcotics Anonymous|NA|302|303|DISCHARGE PLAN AND RECOMMENDATIONS|They provide transportation to the outpatient program. We are also recommending he continue to attend school in the outpatient program to which he is being referred or the special education school he was attending prior to his admission to STOP. We are also encouraging him to get involved and join an NA or AA support group, along with finding a sponsor. We continue to recommend individual and family therapy.
NA|Narcotics Anonymous|NA.|174|176|DISCHARGE INSTRUCTIONS|He was detoxed with buprenorphine. DISCHARGE INSTRUCTIONS: He was discharged on a tapering schedule to be completed by _%#MMDD2003#%_. He was to follow up by going to AA and NA. DISCHARGE DIAGNOSIS: Opiate dependence.
NA|Narcotics Anonymous|NA|242|243|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. While on the unit, _%#NAME#%_ attending step groups, grief group, AA and NA meetings on site, individual therapy, multifamily group, therapeutic recreation, developmental asset-building activities, and chemical dependency related lectures. On _%#MMDD2003#%_ _%#NAME#%_ and her arriving mother met with unit staff concerning family history and current issues of functioning.
NA|Narcotics Anonymous|NA|222|223|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure skills by engaging her community and/or school would be important for _%#NAME#%_ proceeding with adolescent and young adult identity personhood. Attending AA and NA support groups would be important for _%#NAME#%_ encountering a more healthful peer group and potential role models. _%#NAME#%_ is recommended to continue with medication management with a community psychiatrist and to also proceed with individual and family therapy at a time deemed appropriate of including by chemical dependency professionals.
NA|Narcotics Anonymous|NA|224|225|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended step groups, gender groups, AA and NA meetings on site, individual therapy, multifamily group, therapeutic recreation, developmental asset-building activities, and chemical dependency and related lectures. SIGNIFICANT EVENTS: On _%#MMDD2003#%_ _%#NAME#%_ completed psychological testing which was later interpreted by hospital professionals.
NA|Narcotics Anonymous|NA|244|245|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended step groups, gender group, spirituality groups, AA and NA meetings on site, individual therapy, multifamily group, therapeutic recreation, developmental asset- building activities, and chemical dependency and related lectures.
NA|Narcotics Anonymous|NA|272|273|HISTORY OF PRESENT ILLNESS|_%#NAME#%_ was also diagnosed with cannabis abuse. DISCHARGE PLAN AND RECOMMENDATIONS: The patient was recommended to outpatient chemical dependency treatment at new connections in _%#CITY#%_ _%#CITY#%_. Individual and family therapy are also strongly recommended. AA and NA meetings are also suggested.
NA|Narcotics Anonymous|NA|247|248|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure skills by engaging in his community in more appropriate adolescent activities, could obviously influence _%#NAME#%_ in a more stable and/or robust adolescent experience. Attending AA and NA support groups could help _%#NAME#%_ as to encountering a more healthful peer group and potential role models. Alex is recommended to continue with individual and family therapy, as well as AA and NA support groups, and also, anger management classes in light of difficulties with emotional expression.
NA|Narcotics Anonymous|NA.|124|126|DISCHARGE PLAN AND RECOMMENDATIONS|He should also be involved in individual therapy and family therapy. Continued sober support should be sought out in AA and NA. It is going to be important that the client link up with a sponsor and some sober activities.
NA|Narcotics Anonymous|NA|135|136|DISCHARGE PLAN AND RECOMMENDATIONS|We strongly recommend family therapy and individual therapy for _%#NAME#%_. Continued community support should be sought through AA or NA meetings.
NA|Narcotics Anonymous|NA|223|224|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended grief group, gender group, AA and NA meetings on site, individual therapy, therapeutic recreation, multifamily group, developmental asset-building activities, and chemical dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2003#%_ the client met with unit staff concerning social history and current issues of functioning.
NA|Narcotics Anonymous|NA|279|280|DISCHARGE PLAN AND RECOMMENDATIONS|The team is also recommending that the family attend family therapy and _%#NAME#%_ also attend individual therapy to work on grief issues, family issues, and for continued monitoring of ADHD. _%#NAME#%_ will also need to become involved in community support groups such as AA or NA for his recovery plan.
NA|Narcotics Anonymous|NA|196|197|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended AA and NA meetings on site, individual therapy, multifamily group, developmental asset-building activities, and chemical dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2003#%_ client met with unit staff and parents concerning family history and current issues of functioning.
NA|Narcotics Anonymous|NA|404|405|DISCHARGE PLANS AND RECOMMENDATIONS|She was also inconsistent as far as her willingness to accept feedback. DISCHARGE PLANS AND RECOMMENDATIONS: Recommendations upon discharge would include that the _%#NAME#%_ participate in the continuing care program through the F-UMC _%#CITY#%_ office, that she receive random drug screening, that she follow a home contract, that she engage in both individual and family therapy, that she attend AA or NA meetings weekly, that she participate in a school support group, if one is available to her, and that she follow the terms of her legal probation.
NA|Narcotics Anonymous|NA|217|218|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure skills by engaging in his community will be important for _%#NAME#%_ to proceed with adolescent development and young adult identity goals. Attending AA and NA support groups may prove beneficial towards the client developing a more helpful peer group and potential role models. It is also recommended that the client continue with individual and family therapy toward gaining emotional maturity and achieving developmental goals expected of age.
NA|Narcotics Anonymous|NA|128|129|DISCHARGE PLAN AND RECOMMENDATIONS|It is also being recommended that _%#NAME#%_ see an individual therapist and that the family be seen for family therapy. AA and NA meetings were recommended along with Al-Anon for the parents.
NA|Narcotics Anonymous|NA|195|196|DISCHARGE PLANS AND RECOMMENDATIONS|Parents became dissatisfied with the services of the program and chose to discharge patient against medical advice. DISCHARGE PLANS AND RECOMMENDATIONS: We recommend that _%#NAME#%_ attend AA or NA meetings, individual therapy, family therapy, continue to work with the Life Skills worker, continue to work with the child protection services (_%#NAME#%_ _%#NAME#%_ of _%#COUNTY#%_ _%#COUNTY#%_), as well as participate in an outpatient dual-diagnosis program as soon as possible.
NA|Narcotics Anonymous|NA|197|198|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure skills by engaging in her community and school, would be important for _%#NAME#%_ to proceed in these adolescent years. Attending AA and NA support groups would likely prove beneficial for _%#NAME#%_ encountering a more healthful peer group and potential role models. _%#NAME#%_ is recommended to proceed with individual and family therapy, with _%#NAME#%_ and her family members also cautioned of potential depressive issues.
NA|Narcotics Anonymous|NA|361|362|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at the Fairview Adolescent MICD and STOP Inpatient Program _%#NAME#%_ was involved in various tasks and assignments designed to address mental health issues, chemical dependency, sobriety, and recovery. She attended step groups, multi- family groups, gender groups, spirituality groups, in-house school, mental health group, AA and NA meetings on site, individual therapy, family therapy, therapeutic recreation, developmental asset-building activities, chemical dependency, mental health, and related lectures.
NA|Narcotics Anonymous|NA|354|355|HOSPITAL COURSE|HOSPITAL COURSE: Program participation - While at Fairview in the dual-diagnosis program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, mental health, and recovery. He attended step groups, multifamily groups, gender groups, spirituality groups, in-house school, mental health groups, AA and NA meetings on the side, individual therapy, therapeutic recreation, skilled mental asset building activities, chemical dependency, mental health, and related lectures.
NA|Narcotics Anonymous|NA|299|300|PROGRAM PARTICIPATION|While at the inpatient Dual Program _%#NAME#%_ was involved in various tasks and assignments designed to address chemical-dependency, sobriety, mental health, and recovery. He attended step groups, multifamily groups, gender groups, spirituality groups, in-house school, mental health group, AA and NA meetings on-site, individual therapy, therapeutic recreation, developmental asset building activities, chemical-dependency, mental health and related lectures. PROGRESS AND SIGNIFICANT EVENTS: This is his four admission to our unit.
NA|Narcotics Anonymous|NA|236|237|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While in the STOP Unit _%#NAME#%_ was involved in various tasks and assignments designed to address chemical- dependency, sobriety, and recovery. _%#NAME#%_ attended step groups, grief group, gender group, AA and NA meetings on-site, individual therapy, therapeutic recreation, developmental asset building activities, and chemical-dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2004#%_ the client notes from milieu staff concerning social histories and current issues of functioning.
NA|Narcotics Anonymous|NA|236|237|DISCHARGE PLAN AND RECOMMENDATIONS|He seems to have appreciated the AA groups that he has attended. DISCHARGE PLAN AND RECOMMENDATIONS: Recommendations upon discharge include that _%#NAME#%_ participate in the phase 2 continuing care program, that he attend weekly AA or NA meetings, that he have random drug screening, that he continue to engage in therapy, and that he continue to have his medications managed.
NA|Narcotics Anonymous|NA|339|340|DISCHARGE PLAN AND RECOMMENDATIONS|The client is currently on the waiting list. The client's family, however, did sent a 2- page letter detailing the reasons why they will not have the client continue in Phase 2 or the Dual Program. Additional recommendations for the client include individual and family counseling, school support group attendance, participation in AA and NA meetings 2 times a week, following a home contract, maintaining medication management, and remaining abstinent, passing all drug tests. _%#NAME#%_ _%#NAME#%_, CDC II
NA|Narcotics Anonymous|NA|212|213|DISCHARGE PLAN AND RECOMMENDATIONS|They are also recommending school at the location she attending treatment, and consider a sober school upon completion of treatment. We will encourage her to build sober activities and skills by attending AA and NA weekly, and trying to get a sponsor. She will need to continue on with her medications, per Dr _%#NAME#%_'s orders for her depression.
NA|Narcotics Anonymous|NA|169|170|RECOMMENDATIONS|2. Primary outpatient chemical dependency treatment at New Connection Program in Hastings. 3. Individual and family therapy. 4. Academic reintegration. 5. Ongoing AA or NA attendance for _%#NAME#%_. 6. Al-Anon for the client's parents. 7. _%#NAME#%_ is sent home on a home engagement contract to provide a safety net while integrating into the primary outpatient program at New Connections.
NA|Narcotics Anonymous|NA|366|367|DISCHARGE PLAN AND RECOMMENDATIONS|DISCHARGE PLAN AND RECOMMENDATIONS: _%#NAME#%_ was discharged to the care of her parents with a referral to Hazelden Adolescent Residential Treatment Program, scheduled for Tuesday, _%#MMDD2004#%_. At the time of discharge the following recommendations were made: individual and family therapy on an ongoing basis, medication management with psychiatric care, AA or NA meetings for _%#NAME#%_ and Al-Anon for parents, and Hazelden After Care Follow up Program.
NA|Narcotics Anonymous|NA|243|244|DISCHARGE PLAN AND RECOMMENDATIONS|However, the client's parents choose instead to transport her back to Idaho where her caseworker arranged for the client to attend another phase 2 program. The client is additionally recommended to attend a school support group, attend AA and NA meetings two times a week, follow a home contract with grandparents in Idaho. Resolve all legal issues, remain abstinent passing all drug tests, and to reassess depression and attention-deficit/hyperactivity disorder symptoms and diagnoses.
NA|Narcotics Anonymous|NA,|306|308|PROGRESS|_%#NAME#%_ and her parents did not participate in any family groups because they did not speak English, instead _%#NAME#%_ and her father participated in weekly review meetings where both reported an increase in communication. _%#NAME#%_ was able to identify a workable support system which included AA or NA, family and sober peers. DISCHARGE PLAN AND RECOMMENDATIONS: At discharge _%#NAME#%_ was recommended to the youth program at Vietnamese Social Services of Minnesota to continue receiving sober support.
NA|Narcotics Anonymous|NA|235|236|DISCHARGE PLAN AND RECOMMENDATIONS|This will help him to continue building a sober support network as well as to give him additional support in staying sober. He should return to the _%#CITY#%_ area learning center for school. _%#NAME#%_ should continue to attend AA or NA weekly, follow his home contract, and follow through with random urinalyses. He should also follow all probation expectations.
NA|Narcotics Anonymous|NA|155|156|DISCHARGE PLAN/RECOMMENDATIONS|She did, however, remain consistent in her stated desire for sobriety. DISCHARGE PLAN/RECOMMENDATIONS: Recommendations upon discharge include weekly AA or NA meetings, random drug screening, therapy, medication management, home structure such as a home contract, and further treatment services when and if she is amenable to participate in them.
NA|Narcotics Anonymous|NA|135|136|DISCHARGE PLANS AND RECOMMENDATIONS|DISCHARGE PLANS AND RECOMMENDATIONS: Recommendations upon discharge include therapy, random drug screening, and participate with AA or NA meetings. It is also recommended that she meet the terms of her legal probation. Dalenna was discharged without completion of the program on _%#MMDD2005#%_.
NA|Narcotics Anonymous|NA|153|154|HISTORY OF PRESENT ILLNESS|He admits to progression, adverse effects, and inability to control. He admits to withdrawal symptoms when he tries to stop. He had been going to AA and NA regularly. The patient has had several previous treatments. He has been to St. Joe's. He has been to _%#CITY#%_.
NA|Narcotics Anonymous|NA|131|132|DISCHARGE PLAN AND RECOMMENDATIONS|DISCHARGE PLAN AND RECOMMENDATIONS: The recommendation is for _%#NAME#%_ to begin Phase II. He should also continue going to AA or NA and obtain a permanent sponsor. _%#NAME#%_ should become involved in individual therapy to address continued anger issues and to increase coping skills for triggers to anger.
NA|Narcotics Anonymous|NA|265|266|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at _%#CITY#%_ A.C.D.P., _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. He attended step-groups, weekly family group, spirituality group, in house school, AA and NA meetings, on site and in community, developmental asset building activities, and chemical dependency and related lectures. PROGRESS: While in treatment, the client completed a thorough chemical use history as well as steps 1-5 of the 12-step model.
NA|Narcotics Anonymous|NA|244|245|DISCHARGE PLAN/RECOMMENDATIONS|DISCHARGE PLAN/RECOMMENDATIONS: The client was discharged on _%#MMDD2005#%_. He will continue to live with his parents and return to _%#CITY#%_ _%#CITY#%_ Lake High School. The client is recommended to attend _%#CITY#%_ Phase 2 Program, AA and NA meetings weekly, obtain a male sponsor, and comply with random urinalysis, as well as the terms of his probation.
NA|Narcotics Anonymous|NA|249|250|DATE OF DISCHARGE IS 4/18/2005|He was discharged to home on _%#MMDD2005#%_ on tapering suboxone to take 8 mg per day for three days, then 4 mg per day for three days, then 2 mg per day for three days, then 1 mg per day for three days. He is to participate in his aftercare AA and NA meetings. He was to contact his sponsor. He was not thought to be in need of more treatment at this time. DISCHARGE DIAGNOSES: 1. Opiate dependence. 2. Low back pain.
NA|Narcotics Anonymous|NA|233|234|DISCHARGE PLAN/RECOMMENDATIONS|DISCHARGE PLAN/RECOMMENDATIONS: _%#NAME#%_ has chosen to discontinue the treatment process therefore the recommendations are that she maintain abstinence, that she submit to random drug screening, engage in therapy, and attend AA or NA meetings on a weekly basis. It is also recommended that Lauren be allowed to experience natural consequences. _%#NAME#%_ has been discharged from the outpatient program as of _%#MMDD2005#%_ without completion of the program.
NA|Narcotics Anonymous|NA|136|137|DISCHARGE PLAN|3. She is to get a Rule 25 evaluation for chemical dependency treatment at African-American Family Family Services. 4. She is to attend NA and AA groups in the community. 5. She is to follow up with her physician, her psychiatrist at _%#COUNTY#%_ _%#COUNTY#%_ Medical Center for medication refills and checks.
NA|Narcotics Anonymous|NA|288|289|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While involved in the _%#CITY#%_ Adolescent Outpatient Chemical Dependency Treatment Program, the client took part in daily community groups, 2 hours of on site schooling per day, asset building groups 3 x a week, weekly spirituality groups, on and off site AA and NA meetings, and daily group therapy sessions. Additionally, the client took part in family groups and programming with his parents. SIGNIFICANT EVENTS: Include at admission the client appeared to have some personal insight and to be accepting of program guidelines.
NA|Narcotics Anonymous|NA|324|325|PROGRESS|_%#NAME#%_ made it very clear on _%#MMDD2005#%_ that he was not invested in sobriety, and on _%#MMDD2005#%_ was discharged due to not wanting to follow expectations laid out for him. _%#NAME#%_ was given a chance to complete the program. Staff informed him that he would need to attend 2 AA or NA meetings, receive an AA or NA sponsor, and complete his assignment of writing out what he would need to do to maintain his sobriety. He was to complete this by the morning of _%#MMDD2005#%_ as we had an 8:00 meeting.
NA|Narcotics Anonymous|NA|183|184|DISCHARGE PLAN|8. Suboxone per taper (see chart). DISCHARGE PLAN: 1. He is to refrain from the use of mood altering chemicals. 2. He is to continue the prescribed medication. 3. He is followup with NA group. 4. He is to have is sutures removed on the following Tuesday or Thursday after discharge. He is to see his primary medical physician for suture removal.
NA|Narcotics Anonymous|NA|451|452|PROGRAM PARTICIPATION|INITIAL DIMENSION SCALE RATINGS: Dimension 1: 0, Dimension 2: 0, Dimension 3: 1, Dimension 4: 2, Dimension 5: 2, and Dimension 6: 1. PROGRAM PARTICIPATION: While involved in the _%#CITY#%_ Outpatient Chemical Dependency Treatment Program, the client took part in daily community group sessions, 2 hours of on-site schooling per day while school was in session, asset-building groups 3 times a week, weekly spirituality groups, on- and off-site AA and NA meeting attendance, one on one sessions with staff counselors, and daily group therapy sessions. Additionally, the client took part in weekly family group services.
NA|Narcotics Anonymous|NA|246|247|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at Fairview _%#CITY#%_ _%#CITY#%_, the client was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. He attended chemical health groups, community group, AA and NA meetings on site, school, development asset-building activities, recreation activities, and individual counseling. PROGRESS: Medical: Dimension 1. The client did not report any intoxication or withdrawal concerns.
NA|Narcotics Anonymous|NA|325|326|PLAN|Please refer to internal medicine. AXIS IV: Severe stressors, loss of job and income, increasingly isolated from family because of chemical dependency behaviors and suffers from subjective depressive symptoms which were greatly improved with reinstitution of the patient's medication. PLAN: Discharge to home, follow up with NA and AA meetings, a rule 25 assessment the day of discharge, _%#MM#%_ _%#DD#%_, 2006. Appointments were made for the patient prior to his leaving the unit.
NA|Narcotics Anonymous|NA|202|203|DIMENSION VI|Family issues appear significant for the client and she is referred to individual counseling to further address this. Staff provided client with resources and support systems in recovery such as AA and NA meetings. She also took part in recreational activities during the treatment program. She was able to discuss the concepts of a support system, identified some activities to continue and to keep self active.
NA|Narcotics Anonymous|NA|319|320|DISCHARGE PLAN AND RECOMMENDATIONS|DISCHARGE PLAN AND RECOMMENDATIONS: Upon completion, it is recommended that _%#NAME#%_ participate in aftercare services through a facility closer to her home community such as The Haven. It is additionally recommended that she receive random drug screens, that she follow a home contract, that she attend weekly AA or NA meetings, that she engage in therapy, that she receive medication management, and that she participate in either a school support group or that she transfer to a sober school program.
NA|Narcotics Anonymous|NA|215|216|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. He attended grief group, gender group, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset building activities, and chemical dependency and related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_ _%#NAME#%_ completed and presented a drug chart for his therapy group.
NA|Narcotics Anonymous|NA|190|191|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure skills would seem important as to _%#NAME#%_ accomplishing appropriate adolescent development. Participating and accessing AA and NA involvement of his community would seem also important as to himself encountering a healthy peer group. At a time when _%#NAME#%_'s issues have been addressed, family therapy would seem beneficial, as would individual therapy towards _%#NAME#%_ realizing insight of circumstance.
NA|Narcotics Anonymous|NA|215|216|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety and recovery. She attended grief group, gender group, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset building activities and chemical dependency and related lectures. On _%#MMDD2002#%_ while admitted to the adolescent mental health unit, client and mother met with unit staff for a family assessment.
NA|Narcotics Anonymous|NA|182|183|DISCHARGE PLAN/RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure skills is also important towards _%#NAME#%_ realizing a healthful and/or positive adolescent experience. Accessing AA and NA involvement of community is also recommended towards _%#NAME#%_ accessing a healthy peer group and/or support of current situation.
NA|Narcotics Anonymous|NA|215|216|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at the STOP Unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. He attended grief group, gender group, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset building activities, and chemical dependency and related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_, client met with Unit staff regarding social history and historical dynamics.
NA|Narcotics Anonymous|NA|234|235|DISCHARGE PLANS AND RECOMMENDATIONS|DISCHARGE PLANS AND RECOMMENDATIONS: It is our recommendation that _%#NAME#%_ complete primary treatment. We were recommending that she enroll in _%#CITY#%_ outpatient treatment. We are also recommending that _%#NAME#%_ attend AA and NA meetings, and obtain a sponsor. At this point, it appears that _%#NAME#%_ has not shown up to _%#CITY#%_ for her admission.
NA|Narcotics Anonymous|NA|205|206|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreational and leisure skills by accessing healthy hobbies and/or activities of community seems also important of _%#NAME#%_ in these adolescent years. Accessing AA and NA support groups would seem also important toward _%#NAME#%_ developing a helpful peer network of friends and acquaintances. _%#NAME#%_ would seem a prime candidate of both individual and/or family therapy concerning issues of identity, expression and issues concerning self-defeating behaviors and/or problems of communication.
NA|Narcotics Anonymous|NA|205|206|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure skills seems also important towards _%#NAME#%_ replacing previously unhealthy activities with more beneficial action. Access in community AA and NA meetings would seem important towards _%#NAME#%_ accessing or developing peer group and potential male role models.
NA|Narcotics Anonymous|NA|278|279|PROBLEMS PRESENTED UPON ADMISSION|PROGRAM PARTICIPATION: While in _%#CITY#%_ _%#CITY#%_ Adolescent Chemical Dependency Program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety and recovery. He attended chemical dependency group, in-house school, AA and NA meetings, developmental asset building activities and chemical dependency and related lectures. PROGRESS: While in treatment, _%#NAME#%_ completed a group introduction, a drug chart, a social/chemical use history, AA steps 1-3 and quitting marijuana packet.
NA|Narcotics Anonymous|NA|259|260|PROGRAM PARTICIPATION|He is on Adderall 40 mg, and this should be monitored by his outside physician. PROGRAM PARTICIPATION: Since his admission to the STOP Unit, _%#NAME#%_ has been involved in daily chemical dependency groups, daily therapeutic recreation, gender groups, AA and NA meetings, daily asset building activities, music therapy, chemical dependency lectures and other related lectures. SIGNIFICANT EVENTS: _%#NAME#%_ was passively compliant with programming and unit activities.
NA|Narcotics Anonymous|NA|284|285|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While in the _%#CITY#%_ _%#CITY#%_ Adolescent Chemical Dependency Program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety and recovery. She attended chemical dependency groups, in-house school, AA and NA meetings, developmental asset building activities and chemical dependency and related lectures. _%#NAME#%_ and her parents did not attend family week due to conflicts with their work schedules.
NA|Narcotics Anonymous|NA|271|272|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at _%#CITY#%_ _%#CITY#%_ ACDP, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. He attended set groups, weekly family group, spirituality groups, in-house school, AA or NA meetings on site and in the community, developmental asset-building activities, and chemical dependency and related lectures. PROGRESS: During treatment, the client completed a thorough chemical use history including progression of use and consequences, a first-step review, and additional assignments related to feelings and self- esteem.
NA|Narcotics Anonymous|NA|268|269|PROGRAM PARTICIPATION|While in the STOP Program patient was involved in various tasks, and assignments designed to address chemical dependency, mental health, sobriety, and recovery. He attended step groups, weekly family groups, gender groups, spirituality groups, in-house school, AA and NA meetings on-site, therapeutic recreation, individual therapy, developmental asset building activities, and chemical dependency, and mental health related lectures. SIGNIFICANT EVENTS: None. PROGRESS: In the area of chemical dependency patient appeared to minimize the chemical use he was involved in.
NA|Narcotics Anonymous|NA|145|146|DISCHARGE PLAN AND RECOMMENDATIONS|Patient is to be referred to an intensive inpatient treatment program if he is not successful on an outpatient basis. Patient is to attend AA or NA meetings weekly. The family should participate in family therapy. Patient should continue to build sober support systems to include obtaining a sponsor.
NA|Narcotics Anonymous|NA|269|270|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at Adolescent Stop Program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. He attended step groups, weekly family groups, gender groups, spirituality groups, AA and NA meetings in site, individual therapy, therapeutic recreation, music therapy, developmental asset building activities, and chemical dependency and mental health-related lectures.
NA|Narcotics Anonymous|NA|321|322|DISCHARGE PLAN AND RECOMMENDATIONS|The family was given the following recommendations: Complete an aftercare program, weekly AA or NA attendance, and obtain a male sponsor and family therapy. The client and family decided not to follow through with the recommendations and made an alternative plan for the client to attend anger management classes, AA, or NA meetings, and enter inpatient treatment if he was unable to maintain sobriety. The parents plan to follow up with random drug screens.
NA|Narcotics Anonymous|NA|165|166|DISCHARGE PLAN/RECOMMENDATIONS|DISCHARGE PLAN/RECOMMENDATIONS: The patient was discharged to mother on return to MICD Outpatient Treatment Program in _%#CITY#%_ _%#CITY#%_ to house arrest, AA and NA and to have rule 25 assessment for alternative halfway house situation. He is also to continue medication management.
NA|Narcotics Anonymous|NA|265|266|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While in the STOP program, _%#NAME#%_ was involved in various tasks and assignments to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended step group daily, weekly family group, and gender group. She also participated in NA and AA meetings on site. She also attended therapeutic recreation, focusing on social-skills' development. She also attended lectures and groups related to chemical dependency.
NA|Narcotics Anonymous|NA|343|344|PROGRAM PARTICIPATION|3. ADHD by history. 4. Dysthymia, tentatively. PROGRAM PARTICIPATION: While at the MI/CD treatment program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, mental health and recovery. He attended step groups, weekly family groups, gender groups, spirituality groups, inhouse school, NA and AA meetings on site, individual therapy, family week, therapeutic recreation, developmental asset-building activities, chemical dependency, mental health and related lectures.
NA|Narcotics Anonymous|NA|242|243|DISCHARGE PLAN/RECOMMENDATIONS|DISCHARGE PLAN/RECOMMENDATIONS: Recommendation is for safety to attend outpatient treatment at either Anthony Lewis Center or New Connections. She is also required to attend school on site at treatment program she is attending, attend AA and NA for support for her sobriety. Also we are recommending that she get involved in some type of grief therapy along with family and individual therapy.
NA|Narcotics Anonymous|NA|234|235|DISCHARGE PLAN AND RECOMMENDATIONS|Building sober social, recreational, and leisure skills by engaging with community and/or school would seem important to _%#NAME#%_ developing self-esteem/resolving shame issues evidenced during evaluation. Access in community AA and NA support groups would seem important for _%#NAME#%_ to encounter a more healthful peer group and/or potential role models. The client is recommended to continue with medication management of a community psychiatrist and to continue with individual and family therapy with _%#NAME#%_ _%#NAME#%_, Park Nicollet Clinic.
NA|Narcotics Anonymous|NA|230|231|PROGRAM|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended grief group, spirituality groups, AA and NA meetings on site, individual therapy, developmental asset building activities, and chemical dependency related lectures. On _%#MMDD2002#%_ _%#NAME#%_ and her mother met with unit staff concerning family histories and current issues of functioning.
NA|Narcotics Anonymous|NA|237|238|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. She attended step groups, gender group, spirituality groups, AA and NA meetings on site, individual therapy, therapeutic recreation, and developmental asset-building activities, and chemical dependency and related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_ _%#NAME#%_ completed a drug chart and history, and presented this to her therapy group.
NA|Narcotics Anonymous|NA|209|210|PROGRESS|Issues of Mother would seem important of several issues such as difficulties of communication, potential grief and loss as to relationship, and other adolescent developmental tasks. Accessing community AA and NA support groups would seem important for _%#NAME#%_ to encounter a more healthful peer group and/or potential role models. The attending psychiatrist also diagnosed _%#NAME#%_ as having major depression, and began antidepressant therapy.
NA|Narcotics Anonymous|NA|243|244|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at the Stop Unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety and recovery. _%#NAME#%_ attended grief group, gender group, spirituality groups, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset-building activities and chemical dependency-related lectures. On _%#MMDD2002#%_, the client completed a drug chart history and presented this for his therapy group.
NA|Narcotics Anonymous|NA|174|175|PROGRAM NAME|1. Complete _%#CITY#%_ _%#CITY#%_ Aftercare. 2. Continue with individual and family therapy. 3. Follow up with his psychiatrist for medication management. 4. Continue AA and NA meeting attendance. 5. Consideration of a dual-diagnosis treatment program should be made if client relapses with chemicals and/or is unable to manage his mental health concerns at home.
NA|Narcotics Anonymous|NA|215|216|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While in the STOP Program _%#NAME#%_ was involved in staff and assignments designed to address chemical dependency, sobriety, and recovery. He attended therapeutic group, gender group, AA and NA meetings on the side, individual therapy, therapeutic recreation, developmental asset building activities, and chemical dependency and related lectures. SIGNIFICANT EVENTS: _%#NAME#%_ appeared to be more involved in focusing on the social center in the Adolescent STOP Program.
NA|Narcotics Anonymous|NA|271|272|PRIMARY CARE PHYSICIAN|DISCHARGE PLAN AND RECOMMENDATIONS: The patient was discharged with all belongings at 2050 to mother to home to attend MICD outpatient program at _%#CITY#%_ _%#CITY#%_. The patient will continue to develop sober and social recreational leisure skills by attending AA and NA support groups, and he will also be involved in attending family therapy support groups.
NA|Narcotics Anonymous|NA|151|152|DISCHARGE PLAN AND RECOMMENDATIONS|These are likely to include individual therapy and in-home family therapy, as well as medication management. _%#NAME#%_ was encouraged to attend AA or NA support groups, and return to home school.
NA|Narcotics Anonymous|NA|328|329|PROGRAM PARTICIPATION|_%#NAME#%_ also presented with a sexual assault by history. PROGRAM PARTICIPATION: While at Fairview, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, mental health, and recovery. She attended: step groups, weekly family group, gender group, spirituality group, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset-building, chemical dependency and mental health related lectures. SIGNIFICANT EVENTS IN PROGRESS: Initially, upon referral to the Dual Program, Hope expressed a strong belief that she did not need to be here.
NA|Narcotics Anonymous|NA|197|198|DISCHARGE PLAN AND RECOMMENDATIONS|DISCHARGE PLAN AND RECOMMENDATIONS: 1. Attend chemical-dependency aftercare at Fairview _%#CITY#%_. 2. Resume individual therapy at Park Nicollet. 3. Participate in family therapy. 4. Attend AA or NA meetings weekly. 5. Participate in regular medication checks. 6. Follow home restrictions. 7. Return to school.
NA|Narcotics Anonymous|NA|237|238|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the Stop Unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. She attended grief group, gender group, spirituality groups, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset building activities, and chemical dependency and related lectures. SIGNIFICANT EVENTS: On _%#MMDD2002#%_ _%#NAME#%_ met with unit staff concerning social histories, and current issues of functioning.
NA|Narcotics Anonymous|NA|358|359|DISCHARGE PLAN AND RECOMMENDATIONS|At a time when chemical health, behavioral issues, and emotional issues seem effectively addressed _%#NAME#%_ is encouraged to return to academic and/or vocational pursuits. Continuing to build sober social, recreational, and leisure skills would seem important of _%#NAME#%_ developing a more appropriate adolescent experience, engaging of community AA and NA support groups may prove helpful towards _%#NAME#%_ encountering a more healthful peer group and/or potential role models. This writer notes _%#NAME#%_'s age of 17 contrasting considerably as to emotional maturityp and her seeming blaming and lack of accountability.
NA|Narcotics Anonymous|NA|157|158|DISCHARGE PLAN/RECOMMENDATIONS|He was also recommended to attend school at the outpatient chemical dependency program that he will be attending. We also recommended that he participate in NA or AA for support for his sobriety. He is also to continue build sober, social, recreational and leisure skills by doing things with his family members, finding activities that he can do that requires no substance use.
NA|Narcotics Anonymous|NA|238|239|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure-time skills by engaging in his community and/or school would be important in _%#NAME#%_ developing self-esteem and/or realizing his fullest potential. Accessing community AA and NA support groups would be important in _%#NAME#%_ encountering a more healthful peer group and potential role models. _%#NAME#%_ is also encouraged to continue with antidepressant medication of a community psychiatrist and to proceed with individual and/or family therapy at a time when chemical use professionals deem it appropriate of inclusion.
NA|Narcotics Anonymous|NA|216|217|DISCHARGE PLAN AND RECOMMENDATIONS|She will continue to live with her parents and plans to return to her alternative school in the _%#CITY#%_ District. Staff have recommended that she complete the _%#CITY#%_ _%#CITY#%_ Aftercare Program, attend AA or NA weekly and maintain contact with her sponsor, participate in individual and family therapy, consider evaluation for depression with her medical doctor, and follow all the terms of her probation.
NA|Narcotics Anonymous|NA|192|193|DISCHARGE PLAN AND RECOMMENDATIONS|Client will continue his academic progress at Ivan Sand Community School. Staff have made the following recommendations for him: Complete _%#CITY#%_ _%#CITY#%_ Aftercare Program, attend AA or NA at least one time a week and obtained a male sponsor, and participated in individual and family therapy.
NA|Narcotics Anonymous|NA|231|232|DISCHARGE PLAN AND RECOMMENDATIONS|The client is encouraged to continue to build sober social, recreational, and leisure skills by engaging in his community toward realizing a more healthful adolescent experience and young adult identity. Accessing community AA and NA support groups would prove beneficial toward _%#NAME#%_ encountering a more healthful peer group and potential role models. Once again, the client is strongly recommended to proceed with individual and family therapy toward understanding the current conflicts in his life and maintaining self of obvious stressors.
NA|Narcotics Anonymous|NA,|221|223|DISCHARGE PLAN AND RECOMMENDATIONS|She is also to follow a home contract and follow her social contract that was developed during the meeting. The team also stresses a need for a sober support system in the home. _%#NAME#%_ should become involved with AA, NA, or other community support groups and obtain a sponsor.
NA|Narcotics Anonymous|NA|231|232|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended gender group, spirituality groups, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental asset-building activities, and chemical dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2003#%_the client presented a drug chart for her therapy group.
NA|Narcotics Anonymous|NA|251|252|DISCHARGE PLAN AND RECOMMENDATIONS|Building sober social, recreational, and leisure skills by engaging her community, school, and treatment group would be important to _%#NAME#%_ establishing and proceeding with adolescent development and identity formation. Access in community AA and NA support groups will be important for _%#NAME#%_ encountering a more healthful peer group and potential role models. The client is recommended to continue with medication management with community psychiatrist and is also recommended to engage in individual and family therapy.
NA|Narcotics Anonymous|NA|234|235|DISCHARGE PLAN AND RECOMMENDATIONS|DISCHARGE PLAN AND RECOMMENDATIONS: Discharge to lower level of care with treatment on 7A, Fairview _%#CITY#%_ MICD Outpatient Program. Patient to continue to build sober social skills and resources within the community via AA and/or NA attendance, compliance with programming, and mental health to be followed up by primary physician in two to four weeks.
NA|Narcotics Anonymous|NA.|253|255|DISCHARGE PLAN AND RECOMMENDATIONS|Upon completion of treatment, follow-up with community day treatment provided by Y.T.P. Medication management is also necessary via family doctor or therapist. The team is also recommending that _%#NAME#%_ attend a community support group such as AA or NA.
NA|Narcotics Anonymous|NA|205|206|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure time skills, by engaging in his community, will be important for _%#NAME#%_ to continue with an expected adolescent experience. Attending AA and NA support groups, may prove beneficial towards _%#NAME#%_ encountering a more healthful peer group, and of potential role models. _%#NAME#%_ is encouraged to continue with medication management with a community psychiatrist, and once again, is encourage to proceed with individual and family therapy towards resolving a difficult history and proceeding in light of them.
NA|Narcotics Anonymous|NA|196|197|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the Stop unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended AA and NA groups on site, individual therapy, multi-family group, therapeutic recreation, developmental asset building activities, and chemical dependency related lectures.
NA|Narcotics Anonymous|NA|238|239|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure time skills by engaging in community is recommended for _%#NAME#%_ toward a more stable adolescent experience. _%#NAME#%_ is recommended to continue with community attendance of NA or AA support groups. As mentioned previously, individual and family therapy is recommended for _%#NAME#%_. This writer would predict notable therapeutic issues of likely barrier to be trust, shame, and general emotional identification/expression skills needed for improved health.
NA|Narcotics Anonymous|NA|384|385|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While in the Dual Adolescent Inpatient Program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. He attended chemical dependency and related lectures, mental health group, developmental asset-building activities, therapeutic recreation activities, family week, individual therapy, AA and NA meetings on site, in-house school, spirituality groups, gender groups, grief groups, multifamily groups, and step groups. SIGNIFICANT EVENTS/PROGRESS: Initially, while _%#NAME#%_ was involved in the Dual Inpatient Program, he was quite grandiose to the point of delusional imagination.
NA|Narcotics Anonymous|NA|227|228|DISCHARGE PLAN AND RECOMMENDATIONS|DISCHARGE PLAN AND RECOMMENDATIONS: _%#NAME#%_ was discharged on _%#MMDD2003#%_ for an Intake with _%#CITY#%_ _%#CITY#%_ Lodging Plus. He is also to continue to be involved in individual and family therapy, and to attend AA or NA and obtain a sponsor.
NA|Narcotics Anonymous|NA.|213|215|DISCHARGE PLAN AND RECOMMENDATIONS|Recommend that there is a sober home. Also recommend that the family become involve in family therapy, and _%#NAME#%_ get involved in individual therapy. Continued community support should be sought through AA or NA.
NA|Narcotics Anonymous|NA|120|121|SOCIAL HISTORY|She has 2 children. She is a former inmate. She has an IV drug abuse history. She denies prostitution. She is in AA and NA 3 times weekly as mandated by the court. She has apparently been compliant with this. She has allegedly been sober for 6 months per the patient.
NA|Narcotics Anonymous|NA|168|169|DISCHARGE|DISCHARGE PLAN: _%#NAME#%_ plans on attending Sobriety High where he will have much support in his recovery. He is scheduled to attend _%#CITY#%_ Phase 2, weekly AA or NA meetings, and to continue with random UAs. Hopefully, all of the above will enable _%#NAME#%_ to continue to work at building a sober support system to aid him in sobriety and recovery.
NA|Narcotics Anonymous|NA|223|224|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP Unit _%#NAME#%_ was involved in various tasks and assignments designed to address chemical- dependency, sobriety, and recovery. _%#NAME#%_ attended grief group, gender group, AA and NA meetings on-site, individual therapy, multifamily group, therapeutic recreation, developmental asset building activities, and chemical-dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2004#%_ _%#NAME#%_ and his arriving grandmother met with unit staff concerning family history and current issues of functioning.
NA|Narcotics Anonymous|NA|209|210|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit the client was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. The client attended gender group, AA and NA meetings on site, individual therapy, multi-family group, therapeutic recreation and developmental asset building activities, and chemical dependency-related lectures.
NA|Narcotics Anonymous|NA.|328|330|DISCHARGE PLAN AND RECOMMENDATIONS|Admission date was set for _%#MMDD2004#%_. Recommendation for the family would be to follow up with the original lodging recommendation if outpatient treatment is unsuccessful. _%#NAME#%_ should also be involved in family therapy and individual therapy and continue to build sober support through community groups such as AA or NA.
NA|Narcotics Anonymous|NA,|216|218|PRESENT ILLNESS|She could not get enough off the internet so had to call in prescriptions and obtained it from several doctors. She was arrested twice for forging prescriptions and was placed on probation and ordered that she go to NA, but she never stopped using. She also had a couple seizures secondary to her Ultram use when she was taking double or triple what she takes now.
NA|Narcotics Anonymous|NA|316|317|PROGRAM PARTICIPATION|She reported an association with several using adults. PROGRAM PARTICIPATION: While in the _%#CITY#%_ _%#CITY#%_ Adolescent Chemical Dependency Program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. She attended chemical dependency groups, NA meetings, developmental asset-building activities, and chemical dependency and related lectures. PROGRESS AND SIGNIFICANT EVENTS: While in treatment, _%#NAME#%_ presented her group introduction and her AA first step.
NA|Narcotics Anonymous|NA|283|284|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While in the _%#CITY#%_ _%#CITY#%_ Adolescent Chemical-Dependency Program _%#NAME#%_ was involved in various tasks and assignments designed to address chemical-dependency, recovery, and sobriety. He attended chemical-dependency groups, in-house school, AA and NA meetings, developmental asset building activities, and chemical-dependency and related lectures. PROGRESS AND SIGNIFICANT EVENTS: While in treatment, _%#NAME#%_ completed a group introduction, AA steps one through three, and relapse prevention workup.
NA|Narcotics Anonymous|NA|318|319|PROGRAM PARTICIPATION|He was in grade 12 on an EBD IEP. PROGRAM PARTICIPATION: While in the _%#CITY#%_ _%#CITY#%_ Adolescent Chemical-Dependency Program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical-dependency, sobriety, and recovery. He attended chemical-dependency groups, in-house school, AA and NA meetings, developmental asset building activities, and chemical-dependency and related lectures. PROGRESS AND SIGNIFICANT EVENTS: The first behavior in treatment ranged from compliance to defiance.
NA|Narcotics Anonymous|NA|245|246|PROGRESS|DISCHARGE PLAN AND RECOMMENDATIONS: At the time of discharge, the client is recommended to continue treatment in the _%#CITY#%_ Phase II program. additional recommendations include family and individual counseling, school support groups, AA and NA meetings 2 times per week, following a home contract, remaining abstinent and passing all drug tests, and continuing medication management with a doctor.
NA|Narcotics Anonymous|NA|336|337|PROGRAM PARTICIPATION|He also presented with a history of legal problems. PROGRAM PARTICIPATION: While in the _%#CITY#%_ _%#CITY#%_ Adolescent Chemical Dependency Program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. He attended chemical dependency groups, in house school, AA and NA meetings, developmental asset building activities, and chemical dependency and related lectures. PROGRESS/SIGNIFICANT EVENTS: Here in treatment ranged from compliance to verbal defiance.
NA|Narcotics Anonymous|NA|293|294|DISCHARGE PLAN/RECOMMENDATIONS|DISCHARGE PLAN/RECOMMENDATIONS: At the time of discharge, the client is recommended to continue chemical dependency treatment at the _%#CITY#%_ Phase II Group. Additional recommendations include family and individual counseling, sober school or participation in a school support group, AA and NA meeting attendance two times a week, following a home contract, maintaining medication management, and remaining abstinent passing all drug tests.
NA|Narcotics Anonymous|NA|335|336|HISTORY OF PRESENT ILLNESS|She has been prescribed opiates for the last 2 years for "hydronephrosis." She had been to Abbott Northwestern Hospital pain clinic for consultation and was told that they did not think she should continue on the opiates, and then went back to her primary-care physician and asked to be tapered off the opiates. She had been attending NA meetings in the community, after she was told it was not a good idea to continue on opiates. However, she used for 1 month of oxycodone in the last 2 weeks and _%#MMDD2006#%_ was to be the start of taper off opiates.
NA|Narcotics Anonymous|NA|118|119|PRESENT ILLNESS|Her last admission here was about three years ago. She has been able to put together some recovery. She was active in NA for a while working with a sponsor. She fell away from the program and then started using again. Her use has increased in the past several months. She had some stresses.
NA|Narcotics Anonymous|NA.|158|160|PRESENT ILLNESS|He has been detoxed with methadone. He has never been on methadone maintenance. He had some years of sobriety just doing it on his own without going to AA or NA. He relapsed a few months ago and his use has progressed again. He is now using daily. He admits to IV use.
NA|Narcotics Anonymous|NA|188|189|IDENTIFICATION|He reordered liver panel studies. On _%#MM#%_ _%#DD#%_, 2005, it was determined that she could be safely discharged to the community. She will continue the Suboxone taper. She will attend NA meetings in the community. DISCHARGE STATUS: She was alert, oriented, and cooperative. Her speech was regular in rhythm and rate and normal in volume and tone.
NA|Narcotics Anonymous|NA|178|179|DISCHARGE PLAN|3. Protonix 40 mg twice daily. DISCHARGE PLAN: 1. She is to continue the prescribed medication. 2. She is to refrain from the use of mood-altering chemicals. 3. She is to attend NA meetings in the community.
NA|Narcotics Anonymous|NA.|237|239|PLAN|Good peripheral pulses. No edema. NEUROLOGIC: Grossly normal. ASSESSMENT: Opiate dependence, alcohol dependence, depression, attention deficit disorder. PLAN: Stabilize the Buprenorphine then discharge on Suboxone taper. Continue AA and NA.
NA|Narcotics Anonymous|NA|154|155|HISTORY OF PRESENT ILLNESS|He reports there was a period of sobriety between 1993 and 1998. He was able to abstain from alcohol with the use of naltrexone and going to exercise and NA groups. He reports tolerance, blackouts, history of seizures, legal problems, DUIs, financial problems, relationship problems, work problems. He also reports a period when he used marijuana, cocaine, barbiturates, PCP, LSD, crank, mushrooms, and cannabis.
NA|Narcotics Anonymous|NA|123|124|PLAN|PLAN: The patient will continue aftercare here with fairview. She plans to go to a sober house. She will continue to go to NA and AA groups. She will continue on Antabuse, Lexapro 20 mg, Seroquel 100 mg b.i.d..She was asked to see a psychiatrist for a floow up.
NA|Narcotics Anonymous|NA,|133|135|HISTORY OF PRESENT ILLNESS|He was here a month ago and relapsed fairly quickly. He now realizes that he may need to live with other people. He goes to four AA, NA, or CA meetings per week but may need more. At this point, he may need detox treatment and then a group home.
NA|Narcotics Anonymous|NA|132|133|HISTORY OF PRESENT ILLNESS|He was here last _%#MM#%_ and detoxed with buprenorphine. Treatment was suggested but he refused. He was said he was going to go to NA but never did. He is unclear as to the exact date of his relapse. It is apparent that his use increased in _%#NAME#%_ when he came into some money.
NA|sodium|NA|229|230|LABORATORY DATA|CBC with differential reveals white blood count at 3.7, red blood cells at 3.62, hemoglobin 11.0, hematocrit 31.6, neutrophils 38%, and ABS Neut at 1.4, with the remainder within normal limits. Comprehensive metabolic panel with NA at 126, anion gap 4, CA 8.4, with the remainder within normal limits. ASSESSMENT/PLAN: 1. Depression and bulimia per Dr. _%#NAME#%_. 2. Hyponatremia, most likely due to Trileptal, which the patient is taking for seizures.
NA|sodium|NA|265|266|PHYSICAL EXAMINATION|TSH 2.54, free T4 1.52. Urine analysis with 15 ketones, leukocyte esterase trace, bacteria trace and moderate squamous epithelial cells. Labs from North Memorial show positive urine hCG, positive Neisseria gonorrhoeae by NA probe, negative Chlamydia trachomatis by NA probe. ASSESSMENT/PLAN: 1. This is a 24-year-old female who is sexually active, who is currently pregnant and has a positive GC test.
NA|Narcotics Anonymous|NA|187|188|ASSESSMENT/PLAN|Consult with University Neurology team on _%#MMDD2003#%_ to consider changing the patient to another seizure medication. We will recheck NA, serum osmolality, urine osmolality, and urine NA on _%#MMDD2003#%_. 3. Hematuria and proteinuria: This may be due to a contaminated sample. We will recheck a urinalysis/urine culture. The patient denies having menses at this time.
NA|Narcotics Anonymous|NA|188|189|DEMOGRAPHICS AND BACKGROUND INFORMATION|He denied feeling panic symptoms or obsessive-compulsive symptoms. This patient first tried marijuana at age 14. He has been using on a daily basis because of stress. He would like to try NA meetings and last used just prior to admission. He even smoked at school couple times. He first tried alcohol on New Year's in 2000 and has been intoxicated in the past.
NA|not applicable|NA|185|186|G  3  P 1021				LMP|This testing revealed that _%#NAME#%_ carries a pericentric inversion of chromosome 10. Pregnancy History: G 3 P 1021 LMP: not pregnant Age: 19 EDC (LMP): not pregnant Age at Delivery: NA EDC (U/S): Gestational Age: NA weeks * No significant complications or exposures were reported in the current pregnancy. * _%#NAME#%_ reported a history of two first trimester miscarriages.
NA|not applicable|NA|216|217|G  3  P 1021				LMP|This testing revealed that _%#NAME#%_ carries a pericentric inversion of chromosome 10. Pregnancy History: G 3 P 1021 LMP: not pregnant Age: 19 EDC (LMP): not pregnant Age at Delivery: NA EDC (U/S): Gestational Age: NA weeks * No significant complications or exposures were reported in the current pregnancy. * _%#NAME#%_ reported a history of two first trimester miscarriages.
NA|Narcotics Anonymous|NA|191|192|RECOMMENDATIONS|5. 2, he has been in treatment before. 6. 1, he does not have an outside support system. RECOMMENDATIONS: Outpatient chemical dependency treatment at _%#CITY#%_ followed by phase 2 and AA or NA weekly and the patient wants to think about treatment and will call. The initial service plan is to continue under doctor's care.
NA|Narcotics Anonymous|NA|152|153|RECOMMENDATION|He does not have an outside support system. RECOMMENDATION: As an outpatient, chemical dependency treatment at _%#CITY#%_ followed by phase 2 and AA or NA weekly. The patient wants some time to think about going to treatment and will call if interested in treatment. INITIAL SERVICE PLAN: To continue under doctors care. RATIONALE: The client meets the DSM-IV criteria for substance dependency.
NA|Narcotics Anonymous|NA|131|132|RECOMMENDATIONS|RECOMMENDATIONS: Go back to Pride, institute treatment and to go back to his halfway house where he was living and to attend AA or NA daily. The initial service plan is to continue under doctor's care. RATIONALE: The client meets the DSM-IV criteria for substance dependency.
NA|Narcotics Anonymous|NA,|161|163|DEMOGRAPHICS AND BACKGROUND INFORMATION|He stated, "I wasn't working as hard on my sobriety in the last month as I should have. I got cocky and thought I could do this on my own." He still is going to NA, MA and AA meetings every other day. He has been able to maintain sobriety for cocaine for over a year and with marijuana for more than seven months.
NA|Narcotics Anonymous|NA,|211|213|SUMMARY OF TEST FINDINGS|He did admit that he became "too cocky" and felt that he could maintain sobriety with alcohol on his own without any further treatment or support. As stated earlier, though, he still plans to continue to attend NA, MA and AA meetings. His only depressive symptoms seem to be more related to breaking up with his girlfriend. Otherwise, he denied any significant depressive or anxiety symptoms, as well as underlying psychopathology.
NA|Narcotics Anonymous|NA|287|288|HISTORY OF PREVIOUS TREATMENT/COUNSELING|HISTORY HEALTH HISTORY/MEDICATIONS: See medical records. HISTORY OF PREVIOUS TREATMENT/COUNSELING: This client has been in 2 prior chemical dependency treatments, one in 2004 in Nordhouse which was inpatient - she was sober for 3 months - plus the STOP program. She also attended AA and NA briefly. HISTORY OF ALCOHOL AND DRUG USE: She began using alcohol at age 16.
NA|sodium|NA|193|194|LAB DATA|There is some pulmonary vasculature congestion. Post-second intubation ABGs were 7.34/46/70/25/92%. ER labs show hemoglobin 13.2, white count 14,500, platelets 270,000. BUN 21, creatinine 1.0. NA 139, K 4.5, chloride 105, CO2 20, ALT 15, AST 31, glucose 349. Troponin initially was less than 0.3, first follow-up is 16.
NA|Narcotics Anonymous|NA|150|151|PLACEMENT CRITERIA|Dimension 4: 2. He is ready for treatment. Dimension 5: 2. He has been in treatment and detox before the evaluation Dimension 6: 1. Has been going to NA . RECOMMENDATION: Outpatient chemical dependency treatment at _%#CITY#%_ and to attend phase 2 and NA daily.
NA|sodium|NA|151|152|LABS|NEURO: Sensation is intact in the distal extremities, no tremors SKIN: No jaundice or rash. PSYCHIATRIC: Mood is anxious. Affect is appropriate. LABS: NA 133, potassium 4.7, chloride 104, CO2 29, creatinine is 1.72, INR is 1.27 ASSESSMENT AND PLAN: Diabetes type 1. The patient will be started on insulin pump in the a.m. when he received the piece.
NA|Narcotics Anonymous|NA|227|228|PAST MEDICAL HISTORY|The patient is requesting this and this is reasonable. Discussed with her chemical dependency treatment and she does not want to, nor feel she needs to, pursue relapse treatment with regard to this relapse. She says she has an NA group that she will reconnect with and feels confident that she will be able to do so. RECOMMENDATIONS: At this point, would recommend: 1. Methadone 30 mg now, then 20 mg tomorrow on 10 mg the next day.
NA|sodium|NA|191|192|HISTORY OF PRESENT ILLNESS|On _%#MM#%_ _%#DD#%_, 2004, the patient had labs drawn. A complete blood count: white blood cells 8.4, hemoglobin 13.3, platelets 292, differential N 54/L 39/M 6/ E 1. Basic metabolic panel: NA 139, K 4.4, chloride 97, bicarbonate 29, BUN 60, creatinine 3.13, calcium 7, phosphorus 8.6. On the day of admission, the patient was still retaining fluid, but now the fluid had become cloudy.
NA|nurse anesthetist|NA|166|167|SOCIAL HISTORY|She quit smoking in _%#MM2006#%_. She does not drink an excessive amount of alcohol. She appears to be fairly active but does have intermittent claudication. Retired NA worked in the ER and Endoscopy. REVIEW OF SYSTEMS: Complete review of systems was obtained and unremarkable other than what is already mentioned.
NA|Narcotics Anonymous|NA|228|229|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the Evaluation unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended step group, gender group, AA and NA meetings on site, individual therapy, multi-family group, developmental asset-building activities, and chemical dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2004#%_, the client met with unit staff concerning social histories and current issues of functioning.
NA|sodium|NA.|255|257|ASSESSMENT AND PLAN|2. Acute renal failure and hyponatremia. This is likely secondary to dehydration and osmotic diuresis from his elevated blood sugar. We will continue intravenous fluids and follow the creatinine and BUN. We will restrict free water secondary to decreased NA. We will also check serum osmims and urine osimims. 3. Diabetes mellitus. Increased, poorly controlled diabetic. We will start him on an insulin drip times 24 hours and then adjust his Lantus dose as his needs predict after this period.
NA|sodium|NA,|125|127|MEDICATIONS|3. Simvastatin, 80 mg 1/2 tablet p.o. daily. 4. Lorazepam, 1 mg p.o. b.i.d. 5. Wellbutrin, 150 mg p.o. b.i.d. 6. Rabeprazole NA, 20 mg 2 tablets p.o. daily. 7. Isordil, 20 mg 2 tablets p.o. t.i.d. 8. Glipizide, 10 mg p.o. b.i.d. 9. Actos, 45 mg p.o. daily. 10. Altace, 10 mg p.o. daily.
NA|Narcotics Anonymous|NA|228|229|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended step groups, multifamily group, AA and NA meetings on site, individual therapy, therapeutic recreation, music therapy, developmental asset-building activities, and chemical dependency related lectures. SIGNIFICANT EVENTS: On _%#MMDD2003#%_ _%#NAME#%_ presented a drug chart for his therapy group.
NA|Narcotics Anonymous|NA|217|218|DISCHARGE PLAN AND RECOMMENDATIONS|Continuing to build sober social, recreational, and leisure skills by engaging his community and/or place of occupation would be important for _%#NAME#%_ improving self-esteem and/or identity issues. Attending AA and NA support groups would be helpful in _%#NAME#%_ encountering a more healthful peer group and potential role models. _%#NAME#%_ was recommended to monitor his depression symptoms with himself seeking antidepressant intervention if depression issues do not subside.
NA|Narcotics Anonymous|NA,|237|239|BACKGROUND AND REFERRAL INFORMATION|_%#NAME#%_ was provided with diagnoses of dysthymic disorder, cannabis dependence, alcohol abuse and ODD as a result of the psychological evaluation. Recommendations were made for _%#NAME#%_ to participate in individual treatment, AA or NA, family therapy and to become reengaged in school. Socially, _%#NAME#%_ was described in the hospital admission records as having a history of engaging in physical fights since approximately the 5th grade.
NA|Narcotics Anonymous|NA|300|301|RECOMMENDATIONS|4. It is recommended that _%#NAME#%_ work with an adolescent psychologist on a weekly basis who has experience with chemical dependency issues, ADHD and emotional and behavioral difficulties. A family component to her treatment is also recommended. 5. _%#NAME#%_'s ongoing participation in AA and/or NA is also supported. 6. _%#NAME#%_'s regular monitoring by a psychiatrist for medication managment is also recommended. She may also benefit from medication to address her ADHD symptoms.
NA|not applicable|NA|178|179|G  0  P	0000				LMP|She came to clinic with her husband, _%#NAME#%_ _%#NAME#%_, for a pre-pregnancy genetic consultation to address several family history issues. Pregnancy History: G 0 P 0000 LMP: NA Age: 27 EDC (LMP): not pregnant Age at Delivery: NA EDC (U/S): Gestational Age: NA weeks Counseling regarding Myotonic dystrophy type 2 (DM2): _%#NAME#%_ reported that his father was diagnosed with DM2 at the University of Minnesota's Muscular Dystrophy clinic.
NA|not applicable|NA|230|231|G  0  P	0000				LMP|She came to clinic with her husband, _%#NAME#%_ _%#NAME#%_, for a pre-pregnancy genetic consultation to address several family history issues. Pregnancy History: G 0 P 0000 LMP: NA Age: 27 EDC (LMP): not pregnant Age at Delivery: NA EDC (U/S): Gestational Age: NA weeks Counseling regarding Myotonic dystrophy type 2 (DM2): _%#NAME#%_ reported that his father was diagnosed with DM2 at the University of Minnesota's Muscular Dystrophy clinic.
NA|not applicable|NA|216|217|G  0  P	0000				LMP|This testing revealed that _%#NAME#%_ carries a pericentric inversion of chromosome 10. Pregnancy History: G 3 P 1021 LMP: not pregnant Age: 19 EDC (LMP): not pregnant Age at Delivery: NA EDC (U/S): Gestational Age: NA weeks * No significant complications or exposures were reported in the current pregnancy.
NA|not applicable|NA|175|176|G  0  P					LMP|She came to clinic for pre-conceptual genetic counseling due to concerns about occupational exposures. Pregnancy History: G 0 P LMP: NA Age: 29 EDC (LMP): NA Age at Delivery: NA EDC (U/S): Gestational Age: NA weeks * _%#NAME#%_ was not pregnant at the time of our visit. Counseling regarding occupational exposures: _%#NAME#%_ works as a naturalist at the Lee and Rose Warner nature Center.
NA|not applicable|NA|206|207|G  0  P					LMP|She came to clinic for pre-conceptual genetic counseling due to concerns about occupational exposures. Pregnancy History: G 0 P LMP: NA Age: 29 EDC (LMP): NA Age at Delivery: NA EDC (U/S): Gestational Age: NA weeks * _%#NAME#%_ was not pregnant at the time of our visit. Counseling regarding occupational exposures: _%#NAME#%_ works as a naturalist at the Lee and Rose Warner nature Center.
NA|Narcotics Anonymous|NA|141|142|TREATMENT RECOMMENDATIONS|2. Family psychotherapy may be necessary to focus on improved communication within the family dynamic. 3. This patient may also benefit from NA and AA meetings to aid with sobriety. 4. Random urine drug screens should be done to ensure sobriety. 5. This clinician will continue to consult with this patient, this patient's family and Dr. _%#NAME#%_, if necessary.
NA|sodium|NA|218|219|RELEVANT HISTORY AND REASON FOR REFERRAL|Medical records indicate a history of renal cell carcinoma and left cerebellar intracranial bleed, as described above, with no other significant medical history noted. Medication as of _%#MMDD2003#%_ included Docusate NA Plus, Furosamide, heparin, pantoprazole, dexamethasone, metoprolol, and .....tazowin. Family medical history is reportedly noncontributory. BEHAVIORAL OBSERVATIONS: During the evaluation Mr. _%#NAME#%_ was pleasant and cooperative.
NA|not applicable|NA|201|202|G  1  P 1001				LMP|We also discussed several medications that _%#NAME#%_ uses and discussed carrier testing for recessive conditions based upon ethnic background. Pregnancy History: G 1 P 1001 LMP: NA Age: 32 EDC (LMP): NA Age at Delivery: NA EDC (U/S): Gestational Age: NA * _%#NAME#%_ was not pregnant at the time of our visit. Background: We discussed the fact that all couples face a 2-3% risk for having a child with significant cognitive or medical concerns at birth.
NA|Narcotics Anonymous|NA|245|246|TREATMENT RECOMMENDATIONS|This patient will need a comprehensive substance dependency treatment program as he has relapsed for more than 6 months now and has a long history of polysubstance abuse and dependence. 2. This patient should also be encouraged to attend AA and NA meetings on a weekly basis. 3. This patient should be encouraged to pursue individual psychotherapy to focus on improved coping mechanisms.
NA|Narcotics Anonymous|NA|165|166|DIAGNOSTIC IMPRESSION|This patient would benefit from an ongoing outpatient drug and alcohol treatment center focus on sobriety. 2. This patient may also benefit from attending AA and/or NA groups to maintain sobriety over a long period of time. 3. The patient will need to be encouraged to develop a new social network of individuals who do not use alcohol or drugs.
NA|not applicable|NA|161|162|G  1  P 0010				LMP|The results revealed trisomy 21 (Down syndrome) to be the cause of the loss. Pregnancy History: G 1 P 0010 LMP: Age: 42 EDC (LMP): Not pregnant Age at Delivery: NA EDC (U/S): Gestational Age: NA * As you are aware, _%#NAME#%_ suffered a first trimester pregnancy loss in _%#MM#%_ of 2006.
NA|Narcotics Anonymous|NA|178|179|PLAN|NEUROLOGICAL: Grossly normal. ASSESSMENT: 1. Benzodiazepine dependence. 2. Anxiety disorder. 3. Hypertension. PLAN: Detox. The patient refuses treatment. She says she will go to NA or AA.
NA|Narcotics Anonymous|NA.|193|195|DISCHARGE PLAN AND RECOMMENDATIONS|_%#NAME#%_ should begin individual therapy to address coping skills for stress and anger management issues. _%#NAME#%_ should continued attending community support group meetings such as AA or NA.
NA|Narcotics Anonymous|NA|234|235|HISTORY OF PRESENT ILLNESS|Seroquel has not worked. Multiple antidepressants have not worked. The patient reports that he moved in with a gal after his divorce and she basically tells him that alcohol will take his problems away. The patient does try to attend NA and AA meetings, but reports that benzodiazepines are must. The patient experiences frequent panic attacks for a long time. He could not drive a car or even go to the grocery store.
NA|Narcotics Anonymous|NA|333|334|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While involved in the _%#CITY#%_ Outpatient Chemical Dependency Treatment program, client resided at the Adolescent Female Lodging program and took part in all groups and services. During the course of treatment, client took part in chemical health groups daily, daily community groups, on and off site AA and NA meetings, individual counseling on a weekly basis, developmental asset- building activities 3 times a week, weekly spirituality groups, daily recreational activities, and additionally 1 session of the weekly family programming with her mother.
NA|not applicable|NA|155|156|G  2  P 0020				LMP|She was not pregnant at the time of our visit. Pregnancy History: G 2 P 0020 LMP: NA Age: 35 EDC (LMP): NA Age at Delivery: NA EDC (U/S): Gestational Age: NA * _%#NAME#%_ reported a history of a single unexplained first trimester miscarriage. She had requested that chromosome testing be performed with the miscarriage, but technical issues precluded a chromosome analysis.
NA|Narcotics Anonymous|NA|254|255|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP inpatient evaluation program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended gender group, spirituality group, AA and NA meetings on site, individual therapy, multifamily group, therapeutic recreation, developmental asset-building activities, and chemical dependency and related lectures. SIGNIFICANT EVENTS: On _%#MMDD2003#%_ the client completed a drug chart history and presented this for therapy group.
NA|Narcotics Anonymous|NA|342|343|DISCHARGE PLAN AND RECOMMENDATIONS|DISCHARGE PLAN AND RECOMMENDATIONS: The client is discharged from this program _%#MMDD2006#%_ due to breaking conditions of the responsibility contract she was on after suspension due to suspected use. She is referred to continue individual counseling and family counseling, to attend a sober school or school support group, to attend AA and NA meetings two times a week, to follow home contract agreements, to remain abstinent, and to complete a primary chemical dependency treatment program when amenable to such a program's guidelines and expectations.
NA|Narcotics Anonymous|NA|268|269|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While at the inpatient MICD program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety and recovery. She attended step groups, weekly family groups, gender groups, in-house school, AA and NA meetings on site, individual therapy, therapeutic recreation, developmental assay ability and activities and chemical dependency and related lectures. _%#NAME#%_ also participated in mental health groups to help her deal with her depression.
NA|Narcotics Anonymous|NA|284|285|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While in the _%#CITY#%_ _%#CITY#%_ Adolescent Chemical-Dependency Program, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. He attended chemical-dependency groups, in-house school, AA and NA meetings, developmental asset-building activities, and chemical-dependency and related lectures. PROGRESS AND SIGNIFICANT EVENTS: While in treatment, _%#NAME#%_ completed his group introduction, social/chemical-use history, drug chart, drug history, and AA step one.
NA|Narcotics Anonymous|NA|121|122|PROBLEMS PRESENTED ON ADMISSION|The patient is to explore sober school settings. He is to continue to build sober support by attending aftercare, AA and NA support groups. The patient needs to obtain a sponsor and continue to take his medication as prescribed. It is also recommended that patient continue individual therapy and his mother seek family support groups such as Al-Anon.
NA|Narcotics Anonymous|NA|430|431|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While involved in the _%#CITY#%_ Chemical Dependency Treatment Program, the client resided at the Nord House Lodging facility and took part in all Nord House Program groups and services. At the _%#CITY#%_ Treatment Program, the client took part in daily community group sessions, 2 hours of on-site schooling per day, asset-building groups 3 times a week, weekly spirituality groups, on and off-site AA and NA meetings, and daily therapeutic group sessions. SIGNIFICANT EVENTS: Upon admission, the client appeared open and willing to participate in treatment program.
NA|Narcotics Anonymous|NA|151|152|PROGRAM PARTICIPATION|While involved he participated in daily community group sessions, asset building groups 3 x a week, weekly spirituality groups, on and off site AA and NA meetings, and daily group therapy sessions. Additionally, the client participated in the weekly family programming with his mother and father.
NA|Narcotics Anonymous|NA,|148|150|DISCHARGE PLANS AND RECOMMENDATIONS|3. He is to continue to build sober recreational leisure skills by attending sober activities. 4. Also, _%#NAME#%_ was recommended to attend AA and NA, for continued support of his sobriety. 5. Also, _%#NAME#%_ was encouraged to continue on with his medications related to his depression.
NA|Narcotics Anonymous|NA|223|224|PROGRAM PARTICIPATION|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended grief group, gender group, AA and NA meetings on site, individual therapy, multifamily group, therapeutic recreation, developmental asset-building activities, and chemical dependency and related lectures. SIGNIFICANT EVENTS: On _%#MMDD2003#%_ the client met with unit staff concerning social history and current issues of functioning.
NA|sodium|NA|133|134|PHYSICAL EXAMINATION|Cool to the touch. There is decrease dorsalis Pedis and posterior tibial plulses. Lab: WBC8.9, HB 13.3. Platelet 249,000. Chemistry: NA 141, K=.4. chloride 106, CO2 28, BUN 26, creatinine 1.40. INR 1.09, Glucose 157. ASSESSMENT: 70-year-old male being admitted with possible left gangrenous great toe.
NA|Narcotics Anonymous|NA|149|150|DISCHARGE PLAN AND RECOMMENDATIONS|He is encouraged to attend his home school and possibly consider a sober school upon completion of treatment. He is also recommended to attend AA or NA for continued support of his substance abuse issues.
NA|Narcotics Anonymous|NA,|449|451|HOSPITAL COURSE|Mother and _%#NAME#%_ did not wish to complete a family assessment at that time. _%#NAME#%_ was discharged on _%#MM#%_ _%#DD#%_, 2004, at approximately 10 a.m. Recommendations of the program was to abstain from all chemicals, complete a rule 25 assessment at either _%#STREET#%_ _%#STREET#%_ or African- American Family Services or Turning Point, to contact possibly the Basics Program for chemical dependency outpatient treatment, to attend AA and NA, seek individual and family therapy for increased coping strategies.
NP|nasopharyngeal|NP|181|182|HISTORY OF PRESENT ILLNESS|Infant was seen in the Emergency Room at St Francis Hospital last evening. A chest x-ray was done which was negative. She was diagnosed with a viral illness and discharged to home. NP swab for RSV was not done. Parents report that today patient seems less active than usual.
NP|nasopharyngeal|NP|202|203|PLAN|Will also place on continuous pulse oximetry. No nebs. Oxygen supplementation per nasal cannula p.r.n. to keep sats greater than 92%. 3. Cardiovascular. Will place on CR monitor. 4. Infectious disease. NP swabs pending. No medications. 5. Social. Plan was discussed at length with parents. They are in agreement.
NP|nurse practitioner|NP|184|185|FOLLOW-UP|11. Magic mouthwash 5 mL swish and swallow q.i.d. for sore throat and painful swallowing. FOLLOW-UP: Mrs. _%#NAME#%_ was to call on _%#MMDD2007#%_ and speak with _%#NAME#%_ _%#NAME#%_ NP at Masonic Cancer Center regarding chemotherapy appointment with Dr. _%#NAME#%_. Dr. _%#NAME#%_ appointment is to be scheduled with _%#NAME#%_ _%#NAME#%_ by phone.
NP|nurse practitioner|NP|207|208|FOLLOW-UP INSTRUCTIONS|6. Lipitor 10 mg p.o. q.h.s. to be changed to Simvastatin 20 mg p.o. q.h.s. this week per PMD instruction 7. Ginseng 1 tablet every other day FOLLOW-UP INSTRUCTIONS: 1. Follow up with Minnesota Heart Clinic NP or PA visit in 1 to 2 weeks. 2. Follow up with Dr. _%#NAME#%_ in 4 to 6 months. 3. Follow-up lipid panel in 4 to 6 months. Note: The patient is following with PMD with regard to recent cholesterol medication change, and he believes the appointment is in the next 1 to 2 months.
NP|nurse practitioner|NP.|207|209|TRANSFERRING MEDICATIONS|5. Lantus 10 units subcutaneously q.a.m. 6. Aspart NovoLog sliding scale with meals coverage if 150-202 two units; 201-250 four units; 251-300 six units; 301-350 eight units; greater than 350 call the MD or NP. 7. Calcium carbonate with vitamin D one tablet p.o. b.i.d. DISCHARGE AND FOLLOWUP PLANS: 1. The patient will be transferred to _%#CITY#%_ Methodist Health Care and then eventually a _%#CITY#%_ Court on their same campus is apparently a board and care facility with which the patient's son who lives in Wisconsin is in agreement.
NP|nurse practitioner|NP|232|233|FOLLOWUP INSTRUCTIONS|FOLLOWUP INSTRUCTIONS: 1. The patient will follow up with her primary MD in _%#CITY#%_, Minnesota on _%#MMDD2004#%_ to have her INR level checked, and any adjustment made to her warfarin dose. 2. She will see _%#NAME#%_ _%#NAME#%_, NP on Wednesday, _%#MMDD2004#%_ to reevaluate her hypercalcemia and hyperkalemic states. The patient will have a CBC with differential and a BMP drawing to the visit with Ms. _%#NAME#%_.
NP|nurse practitioner|NP|42|43|PRIMARY PHYSICIAN|PRIMARY PHYSICIAN: _%#NAME#%_ _%#NAME#%_, NP (_%#CITY#%_ Medical Clinic - Group) CAUSE OF DEATH: 1. Arrrhymogenic cardiac arrest. 2. Severe anoxic brain injury.
NP|nurse practitioner|NP.|439|441|FOLLOW-UP|His TPN solution is dextrose 12.5%, amino acids 2.5 gm/kg/day, sodium 4 mEq/kg/day, potassium 2 mEq/kg/day, calcium 0.9 mEq/kg/day, magnesium 0.6 mEq/kg/day, phosphorus 0.5 millimoles/kg/day, 1:1 chloride to acetate ratio, standard pediatric vitamins, standard pediatric trace elements, 2 mg per day vitamin K, 2 mg per day zinc. FOLLOW-UP: _%#NAME#%_ should follow up in clinic on _%#MMDD2006#%_ at 11 o'clock with _%#NAME#%_ _%#NAME#%_, NP. He should return or call if he has a temperature greater than 100.4. It was a pleasure to take care of _%#NAME#%_ during his hospitalization.
NP|nurse practitioner|NP|149|150|LABS ON DAY OF DISCHARGE|He also wanted Dr. _%#NAME#%_ to discuss the possibility of a bi-v defibrillator down the rode with this patient. The patient will follow-up with an NP or PA at Minnesota Heart Clinic in two weeks. He will see Dr. _%#NAME#%_ _%#MMDD2005#%_. I have reviewed medications, activities and follow-up with the patient.
NP|nurse practitioner|NP,|164|166|DISCHARGE INSTRUCTIONS|As his mouth pain is better controlled, he is also encouraged to resume intake of fluids orally. 2. The patient will be seen in follow up by _%#NAME#%_ _%#NAME#%_, NP, on Wednesday, _%#MM#%_ _%#DD#%_, 2005. 3. The patient will resume his radiation treatments again on Monday, _%#MM#%_ _%#DD#%_, 2005. His last session is scheduled for Friday, _%#MM#%_ _%#DD#%_, 2005.
NP|nurse practitioner|NP|170|171|LABORATORY VALUES ON ADMISSION|SYSTEM #4: Infectious disease. The patient did continue to have occasional temperature spikes throughout her course. Due to her history of upper respiratory symptoms, an NP wash was obtained and was found to be positive for RSV. It was negative for influenza and viral cultures were pending at the time of discharge.
NP|nurse practitioner|NP,|221|223|DISCHARGE INSTRUCTIONS|She is doing quite well at this time frame. She will be discharged home today in neurologically stable condition with the following discharge instructions. DISCHARGE INSTRUCTIONS: 1. Follow-up with _%#NAME#%_ _%#NAME#%_, NP, in four weeks, at #_%#TEL#%_. Please have patient call for this appointment. 2. No lifting greater than 10 pound. No bending over or driving for two weeks. 3. The patient is to watch her incision daily and contact our office if there is any opening or draining of the incision.
NP|nurse practitioner|NP|164|165|DISCHARGE PLANS|1. Patient is to follow up with Dr. _%#NAME#%_ in one week's time to reassess progress and IV antibiotic duration. 2. She will follow up with Dr. _%#NAME#%_ in the NP clinic on _%#MM#%_ _%#DD#%_, 2002, for removal of her external ethmoid sinus drain.
NP|nurse practitioner|NP|218|219|FOLLOW UP|9. MiraLax as directed. 10. OxyContin 40 mg p.o. b.i.d., taper off over 2 weeks. FOLLOW UP: 1. Follow up with Dr. _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2005, at 9:30 a.m. 2. Follow up with _%#NAME#%_ _%#NAME#%_, NP on _%#MM#%_ _%#DD#%_, 2005, at 1:00 p.m. 3. The patient was instructed to let us know if he develops increasing pain, fever, or increasing swelling in the extremities.
NP|nurse practitioner|NP,|157|159|PAST MEDICAL HISTORY|15. Duoneb standard pre-mix 3 cc neb q.i.d. schedule. PAST MEDICAL HISTORY: I would refer you to the history and physical dictated by _%#NAME#%_ _%#NAME#%_, NP, on _%#MMDD2005#%_. She has had morbid chronic obesity, as well as status post pneumonia in 2001. She has had numerous episodes during her initial hospitalization that required intubation.
NP|nurse practitioner|NP|63|64|IMPRESSION, PLAN|_%#MMDD2005#%_ _%#NAME#%_ _%#NAME#%_, MD _%#NAME#%_ _%#NAME#%_ NP Green Central _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_, MN _%#55400#%_ _%#TEL#%_ _%#TEL#%_ fax Dear Dr. _%#NAME#%_ and _%#NAME#%_, Thank you for accepting the care of _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ from the Neonatal Intensive Care Unit of University of Minnesota Children's Hospital, Fairview.
NP|nurse practitioner|NP|199|200|HISTORY OF PRESENT ILLNESS|18. Ciprofloxacin 250 mg b.i.d. x 10 days. 19. Baclofen pump as preset by Dr. _%#NAME#%_. HISTORY OF PRESENT ILLNESS: Please refer to dictated Transitional Services H and P by _%#NAME#%_ _%#NAME#%_, NP on _%#MMDD2005#%_. The patient is a 66-year-old female who is admitted with a long-standing history of paraplegia from a gunshot wound in the mid 1970s at the T10 level.
NP|nurse practitioner|NP,|172|174|HISTORY OF PRESENT ILLNESS|Appropriate skin bathing to be done prior to surgery based on Dr. _%#NAME#%_'s recommendations. Please refer to updated history and physical done by _%#NAME#%_ _%#NAME#%_, NP, on _%#MMDD2006#%_. PAST MEDICAL HISTORY: 1. Left hip wound with underlying osteomyelitis.
NP|nurse practitioner|NP,|179|181|DISCHARGE INSTRUCTIONS|10. Plavix 75 mg p.o. q.d. 11. Percocet 1-2 tablets p.o. q.4-6h. p.r.n. pain. DISCHARGE INSTRUCTIONS: The patient will schedule a follow-up appointment with _%#NAME#%_ _%#NAME#%_ NP, in 2 weeks on _%#MMDD2002#%_. The patient will follow a regular diet. Activity is as tolerated. The patient was instructed to avoid heavy lifting more than 10 pounds for six weeks.
NP|nurse practitioner|NP,|182|184|FOLLOW UP|DISCHARGE MEDICATIONS: 1. Prilosec 20 mg p.o. daily. 2. Nystatin powder to groin daily. 3. Oxycodone 5 to 10 mg p.o. q.4h. p.r.n. FOLLOW UP: 1. Follow-up with _%#NAME#%_ _%#NAME#%_, NP, on _%#MM#%_ _%#DD#%_, 2005, at 1 p.m. in Masonic Cancer Clinic to follow his liver function tests. 2. Follow-up with Dr. _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2005, at 2:30 p.m. with repeat CT scans.
NP|nurse practitioner|NP.|35|37|PRIMARY-CARE PROVIDERS|PRIMARY-CARE PROVIDERS: _%#NAME#%_ NP. CHIEF COMPLAINT: Dizziness. HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old female with history significant for type 2 diabetes, who was experiencing symptoms of dizziness, headache, and vomiting beginning just 2-3 hours prior to admission. She describes the dizzy sensation as "feeling like I am being pulled to the right." This sensation came over her after she had eaten at McDonalds.
NP|nurse practitioner|NP,|146|148|DISCHARGE PLAN|2. The patient has followup in the clinic on Monday, _%#MM#%_ _%#DD#%_, 2006. He has an appointment at 2 o'clock p.m. with _%#NAME#%_ _%#NAME#%_, NP, and _%#NAME#%_ _%#NAME#%_, MD, medical oncologist. He will arrive at 1:30 for lab work. The patient had failed his last appointment with Dr. _%#NAME#%_ and, per Dr. _%#NAME#%_'s request, he wanted to see the patient for evaluation next week.
NP|nurse practitioner|N.P.|198|201|HOSPITAL  COURSE|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 67-year-old female who was admitted following an attempt at cardioversion. HOSPITAL COURSE: The patient was referred to _%#NAME#%_ _%#NAME#%_, N.P. Dr. _%#NAME#%_ attempted cardioversion and reader is referred to his attempt at cardioversion. This was unsuccessful as the patient had atrial stand-still post-DC shock.
NP|nurse practitioner|NP|162|163|DISCHARGE PLAN|DISCHARGE PLAN: 1. Follow up at INR clinic on Wednesday, _%#MM#%_ _%#DD#%_ for recheck of INR. Target INR is 1.8 to 2.2. 2. Follow up with _%#NAME#%_ _%#NAME#%_, NP at Minnesota Heart Clinic in 2-3 weeks and subsequently with Dr. _%#NAME#%_ _%#NAME#%_. 3. Patient to call us if there is any increased swelling or pain of her left upper extremity or infraaxillary region.
NP|nurse practitioner|NP,|208|210|DISCHARGE FOLLOW-UP|The patient will be given Plavix for nine months and stressed the importance of uninterrupted therapy. He is stable for discharge home. Follow up appointments will be in two weeks with _%#NAME#%_ _%#NAME#%_, NP, and in 2-3 months with Dr. _%#NAME#%_. As he does have a mild cardiomyopathy, Lasix was administered, 20 mg daily, which is a new prescription.
NP|nurse practitioner|NP|422|423|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|The patient's overall status was also impaired in part by virtue of his history of Kennedy's syndrome, which is spinal bulbar atrophy, which is associated with chronic and progressive weakness, as well as his underlying diagnoses of silicosis and chronic obstructive pulmonary disease. For further details regarding the patient's general history, please refer to the history and physical dictated by _%#NAME#%_ _%#NAME#%_ NP from _%#MMDD2006#%_. In short, Mr. _%#NAME#%_'s overall health status was very variable for a long time, and while he briefly did return to _%#COUNTY#%_ Rehabilitation Hospital on more than one occasion he unfortunately was never able to wean off of the ventilator.
NP|nurse practitioner|NP|137|138|FOLLOW UP|19. Protonix 40 mg p.o. daily. 20. Flonase 2 sprays each nare daily basis. FOLLOW UP: The patient will be seen by _%#NAME#%_ _%#NAME#%_, NP in cystic fibrosis clinic on _%#MM#%_ _%#DD#%_, 2006. She will have pulmonary function tests prior to that visit. She will have tobra kinetics, BUN, creatinine, potassium, and magnesium drawn on a weekly basis in the meantime.
NP|nurse practitioner|NP|278|279|DISCHARGE INSTRUCTIONS/FOLLOWUP|1. The patient will follow up with her primary oncologist, Dr. _%#NAME#%_ in clinic at the Masonic Cancer Center within 3-5 days follow up with this hospitalization and further treatment options. 2. The patient will follow up in the Cardiology Clinic with other physician PA or NP for evaluation of her underlying cardiomyopathy. 3. The patient will have CBC and chem-10 drawn on the day of the visit with Dr. _%#NAME#%_.
NP|nurse practitioner|NP.|262|264|DISCHARGE MEDICATIONS|19. Imipenem 500 mg IV q8 hours. 20. Regular insulin sliding scale for blood glucoses every 6 hours: 200- 250 give two units, 251-300 give 4 units, 301-350 give 6 units, 351-400 give 8 units. If the blood sugar is less than 60 or greater than 400 call the MD or NP. 21. Miconazole 2% powder to bilateral axilla t.i.d. 22. Free H2O flushes 300 cc per the G-tube q.i.d. ALLERGIES: 1. Ceftazidime. 2. Piperacillin. OTHER NURSING CARE: 1. Groshong PICC protocol all flushes with 10 cc of normal saline before and after medications.
NP|nurse practitioner|NP,|144|146|HOSPITAL COURSE|Her mentation remained the same. It is clear she is demented. This will be followed as an outpatient. She is followed by _%#NAME#%_ _%#NAME#%_, NP, and Dr. _%#NAME#%_ _%#NAME#%_ in the nursing home. The T-tube and J-P drains were not able to be removed due to increased lethargy, elevated bilirubin, and excessive drainage.
NP|nasopharyngeal|NP|226|227|HOSPITAL COURSE|Prior to admission, she has had three weeks of illness, consisting of an off and on fever, cough. She was seen in our clinic several times with a negative chest x-ray, negative. sinus x-ray, and lab work within normal limits. NP for pertussis was sent. Over the weekend prior to admission, fever, cough, vomiting increased. The patient was seen in Fairview Ridges Emergency Department and diagnosed with left lower lobe pneumonia and admitted to the floor for VI antibiotics.
NP|nurse practitioner|NP,|523|525|HISTORY OF PRESENT ILLNESS|She was initially admitted to the University of Minnesota Medical Center, Fairview, Transitional Services Unit for subacute care on _%#MMDD2006#%_ but based on her overall progress there, was evaluated by Physical Medicine and Rehabilitation who felt she was a candidate for acute rehabilitation and as such, she is being transferred to the Acute Rehabilitation facility at this time. For further details regarding the patient's most recent hospitalizations, I refer you to the discharge summary from _%#NAME#%_ _%#NAME#%_ NP, which was from _%#MMDD2006#%_ as well as the recent discharge summary from Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2006#%_. PAST MEDICAL HISTORY: 1. Depression.
NP|nurse practitioner|NP|154|155|DISCHARGE MEDICATIONS|4. Lisinopril 2.5 mg p.o. q. day. 5. Zocor 80 mg p.o. q. day. 6. Sublingual nitroglycerin p.r.n. Follow up with Dr. _%#NAME#%_ in 1 month. Follow up with NP at MHC in 2 weeks. Follow up with Dr. _%#NAME#%_ in 3-4 months.
NP|nurse practitioner|NP,|164|166|DISCHARGE INSTRUCTIONS|2. Lisinopril was a new medication for the patient and I will have him check a BMP in two weeks time. 3. The patient will follow up with me, _%#NAME#%_ _%#NAME#%_, NP, in one-two weeks time at MN Heart Clinic. 4. The patient will follow up with Dr. _%#NAME#%_ in three months time. 5. The patient will follow up with his PMD in the next couple of weeks.
NP|nasopharyngeal|NP|256|257|HOSPITAL COURSE|2. Respiratory: The child was noted to have diffuse expiratory wheeze, harsh cough, did require oxygen supplementation for roughly 36 hours and gradually improved. He was suctioned for nasal congestion but was not treated with nebs. 3. Infectious Disease: NP swab for RSV was positive. Chest x-ray was negative. The child did not receive any antibiotics while hospitalized.
NP|nurse practitioner|NP|241|242|PAST MEDICAL HISTORY|3. Status post tubal pregnancy several years ago. 4. She has otherwise had no prior abdominal surgeries. 5. Documented abdominal aortic aneurysm, which has been followed conservatively for now. Her primary provider is _%#NAME#%_ _%#NAME#%_, NP of the Fairview Northeast Clinic. ALLERGIES: Biaxin. REVIEW OF SYSTEMS: Also positive for chronic low back pain believed to be secondary to degenerative joint disease of the spine.
NP|nurse practitioner|NP,|252|254|DISCHARGE FOLLOW-UP|5. Metoprolol 25 mg b.i.d. 6. Desyrel 50 to 100 mg daily at bedtime p.r.n. sleep as prescribed by the PMD. 7. Wellbutrin 300 mg daily. DISCHARGE FOLLOW-UP: The patient is to follow up at Minnesota Heart clinic in two weeks with an appointment with the NP, PA with a CBC and basic metabolic profile. LABORATORY DATA: Sodium 141, potassium 4.1, chloride 104, BUN 15, creatinine 1.23, troponin 0.04, TSH 0.81, total cholesterol 211, triglycerides 204, HDL 23, LDL 148, VLDL 41, ratio of 9.3, hemoglobin 13.5, hematocrit 38.5, and platelets 255,000.
NP|nurse practitioner|NP|158|159|HISTORY OF PRESENT ILLNESS|His line site is not bothering him. He has no nausea, vomiting or diarrhea. Allergies, Past Medical History, Family History and Social History are as per the NP note. PHYSICAL EXAMINATION: GENERAL: On exam, Mr. _%#NAME#%_ looks well. He is an obese gentleman.
NP|nasopharyngeal|NP|135|136|DOB|Will add some Pulmocort to her nebs and measure her oxygen. If she goes under 92 percent, she will receive blow by O2. Will also check NP culture for RSV and other viral illnesses.
NP|nasopharyngeal|NP|320|321|A/P|Here with acute sinusitis and worsening dyspnea. Has multiple reasons for dyspnea (extremely poor lung function from chronic rejection, mitral regurgitation, pulmonary hypertension, chronic pulmonary embolism, dialysis-dependent). 1) Acute sinusitis Failed to respond to doxycycline, but only received 2 days so far --> NP swab for bacteria and virus cultures --> Add Afrin NS x 3 days --> Switch from Flonase to Nasonex AQ (complains of burning with Flonase) --> Moxifloxacin to cover sinuses more aggresively 2) Dyspnea Continue to suspect multifactorial nature of this complaint as above.
NP|nurse practitioner|NP|146|147|LABORATORY DATA|LABORATORY DATA: Her labs are normal with a hemoglobin of 11.7, potassium 4.1, creatinine 0.84. The patient will be seen by _%#NAME#%_ _%#NAME#%_ NP in 2-4 weeks and we will make arrangements for that today. As well, she will need to be seen by outpatient nutrition and cardiac rehab.
NP|nurse practitioner|NP|153|154|DISCHARGE FOLLOW-UP|2. She will follow-up with the device RN in five to seven days for an interrogation and a wound check. 3. She will follow-up with _%#NAME#%_ _%#NAME#%_, NP in one month. 4. She will follow-up with _%#NAME#%_ _%#NAME#%_ in the CHF Clinic in two months. DISCHARGE MEDICATIONS: 1. Premarin 0.625 mg, take as directed.
NP|nurse practitioner|NP|154|155|DISCHARGE FOLLOW UP|2. The patient will follow up with the Device Clinic at the Minnesota Heart Clinic in one week. 3. The patient will follow up with _%#NAME#%_ _%#NAME#%_, NP in one month. 4. The patient will follow up with Dr. _%#NAME#%_ _%#NAME#%_ in three months. 5. The patient should follow up with Dr. _%#NAME#%_ _%#NAME#%_, as previously arranged.
NP|nurse practitioner|NP|157|158|HISTORY|Her pregnant is complicated with gestational diabetes, starting at 28 weeks and has been on insulin control. She was under the care of _%#NAME#%_ _%#NAME#%_ NP at _%#CITY#%_ Bloomington Clinic and has had diabetes controlled with insulin. The blood sugar control has been reasonably very good and ultrasound showed normal growth of the baby.
NP|nurse practitioner|NP|37|38|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, NP (_%#CITY#%_ Medical Group - _%#NAME#%_) DISCHARGE DIAGNOSIS: 1. Acute febrile illness presumed to be ascending cholangitis, resolved on antibiotic therapy.
NP|nurse practitioner|NP)|210|212|DISCHARGE FOLLOW-UP|3. Chronic pain. 4. Secondary diabetes. DISCHARGE FOLLOW-UP: The patient is discharged home and it is recommended she continue follow-up with a developing relationship with primary care (_%#NAME#%_ _%#NAME#%_, NP) and also follow up with Dr. _%#NAME#%_ regarding the cholangitis and pancreatic exocrine insufficiency in one week. DISCHARGE MEDICATIONS: Medicines at discharge include: 1. Univasc 7.5 mg daily for hypertension along with Hyzaar 50/12.5 mg.
NP|nurse practitioner|N.P.,|174|178|DISCHARGE FOLLOW-UP|5. Perindopril 8 mg po bid. 6. K-Dur 20 mEq po q day. 7. Coumadin as she takes at home. DISCHARGE FOLLOW-UP: 1. Follow-up with Minnesota Heart Clinic, _%#NAME#%_ _%#NAME#%_, N.P., for heart failure in three weeks. 2. Follow-up with her regular primary care physician in one to two weeks. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is an 81-year-old woman who presented to the emergency room on _%#MMDD2004#%_ when she developed dyspnea on exertion.
NP|nasopharyngeal|NP|279|280|ALLERGIES|He will be treated with Pulmicort nebs twice a day, prednisolone 15 mg twice a day, Singulair 4 mg once a day, Atrovent nebs 0.5 mg every 8 hours and Xopenex nebs 1.25 mg every 2 hours times 4 and then decrease the frequency as tolerates. ___________ culture will be done and an NP culture for viral isolation will also be done. Zithromax will be given 200 mg/5 ml 1 tsp once a day for three days. He is drinking adequately and is adequately hydrated and so at this point does not need an IV.
NP|nurse practitioner|NP|174|175|HOSPITAL COURSE|6. Protonix 20 mg p.o. daily. 7. Senokot-S two tablets p.o. each day at bedtime. 8. Tylenol 650 mg p.o. q. 6 h p.r.n. HOSPITAL COURSE: Please refer to _%#NAME#%_ _%#NAME#%_, NP discharge summary, which was dictated on _%#MMDD2006#%_. This is an addendum to that discharge summary. The patient was in Fairview Transitional Care Services for ongoing medical care.
NP|nurse practitioner|NP,|208|210|REFERRING PHYSICIANS|REFERRING PHYSICIANS: 1. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD, care of _%#CITY#%_ Clinic, _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#CITY#%_, MN _%#55700#%_. 2. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, NP, care of _%#CITY#%_ Clinic, _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#CITY#%_, MN _%#55700#%_. DIAGNOSES ON ADMISSION: 1. _%#NAME#%_ _%#NAME#%_, a 55-year-old female with bilateral complex ovarian masses.
NP|nurse practitioner|NP.|111|113|DISCHARGING MEDICATIONS|10. Lopressor 6.25 mg p.o. b.i.d., again hold for systolic blood pressure less than 100 and call the MD or the NP. 11. Milk of magnesia 30 mL p.o. each day at bedtime p.r.n. 12. Fleet enema 133 mL per rectum daily p.r.n. if no BM every 1-2 days.
NP|nurse practitioner|NP|221|222|DISCHARGE MEDICATIONS|3. Headache. 4. Diabetes. DISCHARGE MEDICATIONS: Same as admission. Follow up with Dr. _%#NAME#%_ _%#NAME#%_ in one to two weeks at the _%#CITY#%_ _%#CITY#%_, Dr. _%#NAME#%_ in two to three months, Minnesota heart clinic NP at Lakes clinic in 2 weeks.
NP|nurse practitioner|N.P.|244|247||I also spoke with the patient's daughter, _%#NAME#%_ _%#NAME#%_, regarding the patient's successful procedure. She has been advised to continue taking Coumadin. She will follow-up with either Dr. _%#NAME#%_ _%#NAME#%_ or _%#NAME#%_ _%#NAME#%_, N.P. from our clinic in three weeks time. ADDENDUM Mrs. _%#NAME#%_ went back into atrial fibrillation again with a rate of between 80-100 about an hour after the previous cardioversion.
NP|nasopharyngeal|NP|138|139|PLAN|If no further problems overnight, will follow up at the Noran Clinic for evaluation next week with any EEG at that visit. We will also do NP swab for pertussis and RSV to rule out infectious possibilities.
NP|nurse practitioner|NP,|142|144|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|We are still awaiting the pathology and we will contact her once that pathology is identified. She will follow up with _%#NAME#%_ _%#NAME#%_, NP, next Monday for suture removal purposes. She has been instructed to keep the incision clean and dry until the sutures are discontinued.
NP|nurse practitioner|NP|143|144|INSTRUCTIONS|I have also restricted his lifting of no greater than 10 pounds for the next two weeks until he follows up with Minnesota Heart Clinic with an NP or PA. The patient will also need to obtain a basic metabolic profile panel in approximately one week's time and also a lipid profile in six weeks.
NP|nurse practitioner|NP|237|238|INSTRUCTIONS|We will also get an exercise thallium stress test in approximately one month for re-evaluation of her circumflex artery as she did have an 80% chronic lesion. The patient will follow-up at the Minnesota Heart Clinic in 1-2 weeks with an NP or PA. She will follow up with her cardiologist in 3-4 months. The patient was discharged home from Fairview Southdale Hospital in good condition.
NP|nurse practitioner|NP|23|24||_%#NAME#%_ _%#NAME#%_, NP Green Central Clinic _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_, MN _%#55400#%_ _%#MM#%_ _%#DD#%_, 2004 Dear Ms. _%#NAME#%_, Thank you for accepting care of _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ from the Neonatal Intensive Care Unit of Fairview-University Children's Hospital.
NP|nurse practitioner|NP.|383|385|ASSESSMENTPLAN|ASSESSMENTPLAN: End-stage multiple-system atrophy. At this point I certainly think that it is appropriate that his code status is DNR-DNI and is purely hospice. I appreciate the input from Transitions And Life Choices and although there is no note currently I know they have met with the family since I talked to the wife and she indicated that she spoke with _%#NAME#%_ _%#NAME#%_, NP. At this point I would not do any further intervention, I would not give him any medications and I would go ahead and discontinue the normal saline that is currently running.
NP|nurse practitioner|NP|100|101|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: 1. The patient will be seen by Dr. _%#NAME#%_ and by _%#NAME#%_ _%#NAME#%_, NP on _%#MMDD2005#%_ at 1 p.m. He will have CBC with differential, complete metabolic panel, magnesium and phosphorus drawn that day.
NP|nurse practitioner|NP|158|159|IMPRESSION/PLAN|4. Dyslipidemia. He is being treated with Lovastatin as well as gemfibrozil. He will be discharged home later today and follow-up with _%#NAME#%_ _%#NAME#%_, NP in approximately two weeks as well as a follow-up with Dr. _%#NAME#%_ in approximately three months. If he has any problems in the interim, I would certainly be happy to see him sooner.
NP|nurse practitioner|NP|414|415|PROBLEM #3|We discussed that at this point, she should concentrate on pain control as her number one priority and she was thus also finding liquid easier to tolerate than solids, thus after trial as an inpatient of controlling her pain with oxycodone for breakthrough, she was discharged with OxyContin longacting and oxycodone liquid for breakthrough pain. She is to follow up in one week's time with _%#NAME#%_ _%#NAME#%_, NP to ensure that pain control regimen at home as adequate as her appointment with Dr. _%#NAME#%_ is not for several weeks. PROBLEM #4: GI: CT scan of the abdomen did reveal worsening metastatic disease throughout the abdomen and pelvis with small bowel obstruction in the deep pelvis.
NP|nurse practitioner|NP.|46|48|PRIMARY CARE PROVIDER|PRIMARY CARE PROVIDER: _%#NAME#%_ _%#NAME#%_, NP. DISCHARGE DIAGNOSES: 1. Left lower extremity cellulitis. 2. Psoriasis, severe, involving left foot primarily but also hands.
NP|nurse practitioner|NP|204|205|BRIEF HISTORY AND PHYSICAL AND HOSPITAL COURSE|Malignancy in this region could not be excluded. On _%#MMDD2007#%_, the patient had an MRI of the breast bilaterally, which revealed no evidence of abnormality. The patient presented on _%#MMDD2007#%_ to NP _%#NAME#%_ _%#NAME#%_ for further evaluation and preparation for carboplatin desensitization with admission for Thursday _%#MMDD2007#%_. REVIEW OF SYSTEMS: Twelve point review of systems was obtained and was positive for chronic constipation, but otherwise negative.
NP|nurse practitioner|NP|193|194|DISCHARGING MEDICATIONS|13. Glyburide 1.25 mg p.o. every p.m. 14. Aspart/NovoLog sliding scale insulin with meals if Accu-Chek 201-250 give 1 unit, 251-300 give 3 units, 301-350 5 units, and greater than 350 call the NP or the MD. 15. Potassium chloride 20 mEq p.o. twice daily. DISCHARGE AND FOLLOWUP PLANS: 1. I will have the secretary here to make an appointment with Neurosurgery per their request, the first or second week of _%#MM#%_ and they would like a CAT scan of the head prior to that day appointment without contrast to "evaluate for residual subdural hematoma."
NP|nurse practitioner|NP|133|134|FOLLOWUP VISITS|DISCHARGE DIAGNOSIS: Allergic bronchopulmonary aspergillosis exacerbation. FOLLOWUP VISITS: 1. With _%#NAME#%_ _%#NAME#%_, Pulmonary NP for followup of his ABPA exacerbation in three weeks. At that time he should get a chest x-ray and an IgE level drawn.
NP|nurse practitioner|NP|237|238|DISCHARGE FOLLOW-UP|16. Compazine 10 mg p.o. t.i.d. 17. Albuterol inhaler 2 puffs p.o. q.i.d. 18. Flovent inhaler 2 puffs p.o. b.i.d. DISCHARGE FOLLOW-UP: 1. _%#NAME#%_ _%#NAME#%_ has follow-up with the Minnesota Heart Clinic (CORE), _%#NAME#%_ _%#NAME#%_, NP on Monday, _%#MMDD2007#%_ at 10:45 a.m. The patient will have a basic metabolic panel at that time. 2. The patient will see Dr. _%#NAME#%_ _%#NAME#%_ at the _%#CITY#%_ Oxboro clinic in 2 weeks.
NP|nurse practitioner|NP|201|202|DISCHARGE FOLLOW-UP|3. He will follow-up with Dr. _%#NAME#%_ at Fairview Lakes in _%#CITY#%_, _%#MM#%_ _%#DD#%_. 4. He will follow-up with the device clinic on _%#MMDD#%_. 5. He will follow-up with _%#NAME#%_ _%#NAME#%_, NP at the Minnesota Heart Clinic Core Clinic on _%#MMDD#%_. He will be followed as a new patient. During this hospital admission, his Toprol-XL was changed to Sotalol for a run of ventricular tachycardia which occurred.
NP|nurse practitioner|NP,|517|519|DISCHARGE MEDICATIONS AND PLAN|She may resume activities as tolerated. She is discharged on Naprosyn 500 mg b.i.d. for seven days, oxycodone 20 mg one twice a day for seven days and then 10 mg twice a day for seven days and 10 mg once a day for seven days and then discontinue, Percocet one to two tablets every four hours as needed for breakthrough pain, Valium 5 mg up to t.i.d. as needed for muscle spasm, Robaxin 750 mg t.i.d. for muscle spasms. The patient should be seen in follow-up by Dr. _%#NAME#%_ _%#NAME#%_ or by _%#NAME#%_ _%#NAME#%_, NP, on _%#MMDD2004#%_. Will follow-up with Dr. _%#NAME#%_ as required. _%#NAME#%_ _%#NAME#%_ was admitted on _%#MMDD2005#%_ and underwent a C5-6 surgery per Dr. _%#NAME#%_, I believe this is a diskectomy and anterior fusion, please refer to his operative report.
NP|nurse practitioner|NP|97|98|DISCHARGE MEDICATIONS|7. Imdur 30 mg p.o. q day 8. Amaryl 8 mg daily 9. Aciphex 20 mg daily I recommend follow-up with NP in two weeks. Follow up with Dr. _%#NAME#%_ or Dr. _%#NAME#%_ in two to three months. I recommend repeat angiogram with rotablator in one month with Dr. _%#NAME#%_.
NP|nurse practitioner|NP|240|241|DISCHARGE FOLLOW-UP|His lab work this morning is within normal limits with a troponin of 0.46. This troponin value is within our guidelines for discharge. His EKG does not show any ischemic changes. DISCHARGE FOLLOW-UP: 1. Mr. _%#NAME#%_ will follow up with a NP or PA in two to three weeks. 2. He will have a stress test in six weeks to serve as a baseline. 3. He will then follow up with Dr. _%#NAME#%_ in six to eight weeks to go over the stress test results.
NP|nurse practitioner|NP,|245|247|HISTORY OF PRESENT ILLNESS|The patient was given full information on her surgical procedure and risks, benefits and complications were explained to her regarding anesthesia and surgery. She will have her preoperative exam by her nurse practitioner, _%#NAME#%_ _%#NAME#%_, NP, prior to her surgery.
NP|nurse practitioner|NP|141|142|PRIMARY CARE PHYSICIAN|SURGEON: _%#NAME#%_ _%#NAME#%_, MD ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC COMPLICATIONS: None. PRIMARY CARE PHYSICIAN: _%#NAME#%_ _%#NAME#%_, NP DATE OF SURGERY: _%#MMDD2005#%_ HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ underwent laparoscopic Roux-en-Y under general anesthesia which was uncomplicated.
NP|nurse practitioner|NP;|85|87|PRIMARY CARE PHYSICIAN|PRIMARY CARE PHYSICIAN: 1. _%#NAME#%_ _%#NAME#%_, MD; ENT. 2. _%#NAME#%_ _%#NAME#%_, NP; VA Medical Center. DISCHARGE DIAGNOSES: 1. Minimally displaced intracapsular fracture of right hip, status post open reduction and internal fixation of the right hip fracture on _%#MMDD2006#%_.
NP|nasopharyngeal|NP|93|94|LABORATORY DATA|No medical problems. ALLERGIES: No known drug allergies. MEDICATIONS: None. LABORATORY DATA: NP swab for RSV and influenza A and B are pending. CBC, chest x-ray and electrolytes are pending. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature was 97, O2 sats were approximately 87% on room air.
NP|nurse practitioner|NP|260|261|DISCHARGE PLAN|There was equal 1+ bilateral lower extremity edema. LABORATORY DATA: Creatinine 1.29 and a stable electrolyte panel with a potassium of 5.0, sodium of 134. Her last hemoglobin was 8.9 on _%#MMDD2005#%_. DISCHARGE PLAN: Home with plans to see Dr. _%#NAME#%_ or NP in MOHP-_%#CITY#%_ clinic within one week. The patient may resume her previous home medications.
NP|nurse practitioner|NP.|140|142|HOSPITAL COURSE|She was breast-feeding her infant and declined any form of birth control at the time of discharge as she will discuss this with her primary NP. Her blood type is O positive. She is rubella immune. DISCHARGE INSTRUCTIONS: 1. She is to follow up in 6 weeks for a postpartum check with her primary OB MD, Dr. _%#NAME#%_.
NP|nurse practitioner|NP|153|154|ASSESSMENT AND PLAN|2. Hypertension. The patient's blood pressure is in the 130s/80s today. She will be followed up in 1-2 weeks' time with _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ NP at which time lisinopril can be further titrated as necessary. 3. Dyslipidemia. The patient is currently maintained on Lipitor 40 mg.
NP|nasopharyngeal|NP|192|193|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: A 2-1/2-month-old infant with a history of prematurity and family history of asthma presents with wheezing most likely due to bronchiolitis. 1. Wheezing. We will check an NP swab for viruses. Symptomatic treatment with albuterol nebs q.4h. with q.1h. p.r.n. Apnea and oxygen monitors are in place. Begin oxygen by nasal cannula as needed. We will repeat chest x-ray in the a.m. due to the possibility that this is an early pneumonia that was not yet evident.
NP|nurse practitioner|NP.|138|140|COURSE OF HOSPITALIZATION|His previous dose had been 20 mg po q day. Follow-up BNP check at Minnesota Heart Clinic with the results called to Dr. _%#NAME#%_ or his NP. The patient is additionally instructed to have a follow-up appointment with Dr. _%#NAME#%_ or an NP the day after this BNP is obtained.
NP|nurse practitioner|NP,|180|182|DISCHARGE FOLLOWUP|10. 5-fluorouracil started _%#MM#%_ _%#DD#%_, 2005, at 8:40 and to continue for a total 4-day dose of 7500 mg. DISCHARGE FOLLOWUP: 1. Interval followup with _%#NAME#%_ _%#NAME#%_, NP, at Masonic Cancer Clinic on _%#MM#%_ _%#DD#%_, 2005, at 1 p.m. 2. Follow up with Dr. _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2005, at 10 a.m.
NP|nurse practitioner|NP,|223|225|DISPOSITION|Her INR was therapeutic with just 3 days of Coumadin therapy and on the day of discharge it was 2.7. 2. Follow up with one of our nurse practitioners, either _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, PAC, or _%#NAME#%_ _%#NAME#%_, NP, in 2 weeks' time. She will have an echocardiogram to see if her left ventricular systolic function normalizes with restoration of normal sinus rhythm.
NP|nurse practitioner|NP.|201|203|DISPOSITION|3. Basic metabolic panel at dialysis on _%#MMDD2007#%_. 4. Follow up appointment with the Core Clinic at Minnesota Heart Clinic in five to seven days. She has been seen there by _%#NAME#%_ _%#NAME#%_, NP. Follow up with myself or Dr. _%#NAME#%_ in six to eight weeks.
NP|nurse practitioner|N.P.,|189|193|DISCHARGE FOLLOW-UP|Medications discontinued during this hospitalization: 1. Digoxin at 0.125 mg daily. 2. Toprol XL 50 mg daily. DISCHARGE FOLLOW-UP: 1. The patient will follow up with _%#NAME#%_ _%#NAME#%_, N.P., at Minnesota Heart Clinic in one week with a 12-Lead EKG. 2. The patient will have a follow up INR at Minnesota Heart Clinic in one week.
NP|nurse practitioner|N.P.,|168|172|PHYSICAL EXAMINATION|I do not have his complete record at hand, however, he does have a history of ischemic heart disease with previous stenting in the past. Perhaps _%#NAME#%_ _%#NAME#%_, N.P., can discuss this more with Mr. _%#NAME#%_ and look over his most recent stress test. The patient will be on Sotalol at an increased dose of 160 mg b.i.d. for short term.
NP|nurse practitioner|NP|123|124|DISCHARGE DISPOSITION|He will follow up with Minnesota Heart on _%#MMDD2007#%_ for limited echo to check for a pericardial effusion. Also see an NP at Minnesota Heart on Tuesday, _%#MM#%_ _%#DD#%_ at 1030and Dr. _%#NAME#%_ on _%#MMDD#%_ at 9:45. He will see Dr. _%#NAME#%_ in two weeks.
NP|nurse practitioner|NP.|47|49|PRIMARY CARE PROVIDERC|PRIMARY CARE PROVIDERC: _%#NAME#%_ _%#NAME#%_, NP. CHIEF COMPLAINT: Fall with head injury HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 54-year-old female patient with a history noted below who fell today "for no reason". This morning around 8:00 as she was standing in her home she said that she fell backwards "for no reason".
NP|nurse practitioner|NP|150|151|DISCHARGING MEDICATIONS|DISCHARGING MEDICATIONS: 1. Tenormin 25 mg p.o. every day, hold for heart rate less than 60 or blood pressure less than 100 and also notify the MD or NP if the heart rate is consistently greater than 90. 2. Dulcolax suppository 10 mg rectally every day p.r.n. 3. MiraLax 17 g p.o. twice daily 4. Senokot-S 1-2 tablets p.o. b.i.d., hold for loose stools.
NP|nurse practitioner|NP,|204|206|DISCHARGE INSTRUCTIONS|I do not have his last cholesterol results available in my hand; however, he did tell me that his values were quite high. DISCHARGE INSTRUCTIONS: 1. The patient will follow up with _%#NAME#%_ _%#NAME#%_, NP, in one to two weeks for a groin check, and I have encouraged him to bring any questions to that office visit that he may have in regard to his new diagnosis.
NP|nurse practitioner|NP,|238|240|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: Constitutional, Eyes, ENT, respiratory, CV, GI, GU, musculoskeletal, neurological, dermatological-Negative except for recent profound fatigue. She has apparently been seeing her primary provider, _%#NAME#%_ _%#NAME#%_, NP, at Fairview _%#CITY#%_ clinic for this, and preliminary workup has been negative. There was discussion about referral to Infectious Diseases presumably for workup of chronic fatigue syndrome.
NP|nurse practitioner|NP|176|177|ALLERGIES, PAST MEDICAL HISTORY, CURRENT MEDICATIONS, FAMILY HISTORY AND SOCIAL HISTORY|He has no shortness of breath or cough. No chest pain. No other issues. ALLERGIES, PAST MEDICAL HISTORY, CURRENT MEDICATIONS, FAMILY HISTORY AND SOCIAL HISTORY: Are as per the NP note. PHYSICAL EXAMINATION: GENERAL: On exam Mr. _%#NAME#%_ appears well. He is alert, oriented in no acute distress.
NP|nurse practitioner|NP,|283|285|HOSPITAL COURSE|She did not have diarrhea and has no evidence of ongoing C. diff colitis which is something she had had in the past, although she initially was maintained on a lower dose of Flagyl. She is being discharged on the above medicines and this was communicated with _%#NAME#%_ _%#NAME#%_, NP, who is the accepting clinician. Abstinence from alcohol was discussed with her and that this would be a necessary component to any chance of liver transplant in the future.
NP|nurse practitioner|NP.|85|87|PRIMARY CARE PROVIDER|PLANNED DISCHARGE DATE: _%#MMDD2007#%_ PRIMARY CARE PROVIDER: _%#NAME#%_ _%#NAME#%_, NP. DISCHARGE DIAGNOSES: 1. Traumatic right-sided subarachnoid hemorrhage with subgaleal hematoma.
NP|nurse practitioner|NP.|230|232|DISCHARGING MEDICATIONS|21. Sliding scale insulin with NovoLog before meals with the following: If 127-150 two units, 151-200 four units, 201-250 six units, 251-300 eight units, if 301-350 ten units, 351-400 twelve units, greater than 400 call the MD or NP. 22. Hyperglycemic protocol. 23. Calcium carbonate with vitamin D 1250 mg 1 tablet twice daily. DISCHARGE AND FOLLOWUP PLANS: 1. He will be followed by the nurse practitioner or physician at SLE, to which he goes.
NP|nurse practitioner|NP|85|86|PRIMARY CARE PHYSICIAN|PLANNED DISCHARGE DATE: _%#MMDD2007#%_ PRIMARY CARE PHYSICIAN: _%#NAME#%_ _%#NAME#%_ NP DISCHARGE DIAGNOSIS: 1. Chest pain, probable gastroesophageal reflux. 2. Borderline hypertension. 3. Hyperlipidemia.
NP|nurse practitioner|NP|180|181|CURRENT MEDICATIONS LIST|2. Neurontin 300 mg twice daily today and tomorrow and then he will taper to 300 mg at bedtime x3 days. If he has increased pain, then the nurses should discuss with the MD or the NP as to whether he should be return to his 300 mg t.i.d. dosing, which he has been on for several weeks. Otherwise, this medication can discontinued. 3. Seroquel 12.5 mg p.o. b.i.d.
NP|nurse practitioner|NP.|131|133|CURRENT MEDICATIONS LIST|5. Lopressor 150 mg p.o. twice daily, hold for systolic blood pressure less than 100 or heart rate less than 60 and call the MD or NP. 6. Prinivil 40 mg p.o. daily, hold for systolic blood pressure less than 100 and notify the MD or the NP. 7. Mylanta 30 mL p.o. every 4 hours p.r.n.
NP|nurse practitioner|NP.|237|239|CURRENT MEDICATIONS LIST|5. Lopressor 150 mg p.o. twice daily, hold for systolic blood pressure less than 100 or heart rate less than 60 and call the MD or NP. 6. Prinivil 40 mg p.o. daily, hold for systolic blood pressure less than 100 and notify the MD or the NP. 7. Mylanta 30 mL p.o. every 4 hours p.r.n. 8. Clonidine patch 400 mcg apply every week at 1600 hours on Friday.
NP|nurse practitioner|NP,|236|238|HISTORY OF PRESENT ILLNESS|It seems to resolve on its own. She has prior visits to the clinic with normal electrocardiograms. Her most recent episode began yesterday with similar upper chest tightness. She presented through her clinic, saw _%#NAME#%_ _%#NAME#%_, NP, and was sent to the Emergency Department. The patient denies any leg asymmetry. No fevers or chills. She had a common cold about three weeks ago.
NP|nurse practitioner|NP,|166|168|FOLLOW-UP|2. The patient is to follow up with his primary-care physician Dr. _%#NAME#%_ on _%#MMDD2005#%_ at 10 a.m. 3. The patient is to follow up with _%#NAME#%_ _%#NAME#%_, NP, on Tuesday, _%#MMDD2005#%_, at 10:30 a.m. 4. The patient will have labs drawn when he sees _%#NAME#%_ and Dr. _%#NAME#%_, including a CBC with differential, platelets, basic metabolic profile, and magnesium phosphorus.
NP|nurse practitioner|NP|37|38|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, NP (_%#CITY#%_ Medical Clinic- _%#CITY#%_) IDENTIFICATION: This is a 33-year-old patient. CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_.
NP|nurse practitioner|NP|42|43|PRIMARY PHYSICIAN|PRIMARY PHYSICIAN: _%#NAME#%_ _%#NAME#%_, NP (_%#CITY#%_ Medical Group - _%#CITY#%_, Internal Medicine) DISCHARGE DIAGNOSES: 1. Benign positional vertigo. 2. Peripheral artery disease with symptomatic claudication from right femoral lesion.
NP|nurse practitioner|NP,|194|196|DISCHARGE FOLLOW-UP|DISCHARGE MEDICATIONS: 1. Lisinopril 10 mg p.o. daily. 2. Aspirin 325 mg p.o. daily. 3. Multivitamin one p.o. daily. DISCHARGE FOLLOW-UP: Follow-up with primary care with _%#NAME#%_ _%#NAME#%_, NP, at _%#CITY#%_ Medical Group - _%#CITY#%_, Internal Medicine. Recommend checking blood pressure with new lisinopril, verifying compliance with medication.
NP|nasopharyngeal|NP|205|206|HOSPITAL COURSE BY SYSTEMS|He was given albuterol nebs times two on the day of admission, however did not require nebs through the night or on the day of discharge. He had no significant respiratory distress. 3. Infectious disease. NP swab for influenzae was positive, NP swab for RSV was negative. DISCHARGE INSTRUCTIONS: He was discharged home in parents care in good condition.
NP|nurse practitioner|NP|381|382|DISCHARGE FOLLOW-UP|DISCHARGE FOLLOW-UP: 1. I impressed upon this patient who important it is for him to follow up with his primary physician early next week to have a basic metabolic panel checked, especially in light of the fact that he was started on such a high dose of Aldactone. I did explain to him about the potential for hyperkalemia with his medication usage. 2. He should follow up with an NP or PA in two weeks' time to ensure that he is remaining stable and not having any side effects or problems with his new medications.
NP|nurse practitioner|NP,|148|150|FOLLOW UP|4. Compazine 10 mg p.o. q. 6 h. p.r.n. 5. Percocet 5/325 one to two p.o. q. 4-6 h. p.r.n. pain. FOLLOW UP: 1. Follow up with _%#NAME#%_ _%#NAME#%_, NP, in Masonic Cancer Clinic on _%#MM#%_ _%#DD#%_, 2005, at 1 p.m. with lab work including CBC with differential, platelets, CMP, INR, and PTT.
NP|nurse practitioner|NP,|203|205|FOLLOW UP|7. Senna 1 to 2 tablets b.i.d. p.r.n. constipations. 8. Bactrim 1 tablet p.o. b.i.d. for 14 days. Starting day is _%#MM#%_ _%#DD#%_, 2006. FOLLOW UP: The patient has followup with _%#NAME#%_ _%#NAME#%_, NP, in hematology/oncology clinic on _%#MM#%_ _%#DD#%_, 2006, at 11 a.m. PENDING STUDY: The ID as well as sensitivity of the Gram-negative bacteria is still pending.
NP|nurse practitioner|NP,|212|214|DISCHARGE INSTRUCTIONS|DISCHARGE DIAGNOSES: 1. Alcoholic hepatitis improving. 2. Alcohol abuse. 3. Migraine resolved. 4. Constipation resolving. DISCHARGE INSTRUCTIONS: _%#NAME#%_ _%#NAME#%_ is to follow up with _%#NAME#%_ _%#NAME#%_, NP, at Neighborhood Involvement Clinic in one week or when discharged from inpatient rehab. Would recommend LFTs at that time. Would also recommend a liver biopsy when patient gets insurance.
NP|nurse practitioner|NP|199|200|DISCHARGE FOLLOW-UP|I have discussed with him that Niaspan may be an option to raise his HDL, although he does have sclerosing cholangitis which complicates the picture. 2. He will follow-up with _%#NAME#%_ _%#NAME#%_, NP in one to two weeks to check the groin. 3. He should have primary care follow-up as scheduled. Thank you very much for allowing me to participate in his care.
NP|nurse practitioner|NP|220|221|DISCHARGE INSTRUCTIONS|Of note, at his appointment with Dr. _%#NAME#%_ in _%#MM#%_, it will be determined if _%#NAME#%_ will be continued in his regimen. At his follow-up office visit with _%#NAME#%_ _%#NAME#%_, PA-C or _%#NAME#%_ _%#NAME#%_, NP in one to two weeks, it will be determined if Norvasc needs to be readded to his medication list. 3. He will have a follow-up appointment in one to two weeks with _%#NAME#%_ _%#NAME#%_, PA-C or _%#NAME#%_ _%#NAME#%_, NP to recheck blood pressure and review hospitalization.
NP|nurse practitioner|NP|309|310|DISCHARGE INSTRUCTIONS|At his follow-up office visit with _%#NAME#%_ _%#NAME#%_, PA-C or _%#NAME#%_ _%#NAME#%_, NP in one to two weeks, it will be determined if Norvasc needs to be readded to his medication list. 3. He will have a follow-up appointment in one to two weeks with _%#NAME#%_ _%#NAME#%_, PA-C or _%#NAME#%_ _%#NAME#%_, NP to recheck blood pressure and review hospitalization. 4. He was recommended to follow up with Dr. _%#NAME#%_ in two to three weeks. 5. He will have a BMP at Dr. _%#NAME#%_ office later this week.
NP|nurse practitioner|NP|269|270|FOLLOWUP.|Her primary oncologist will decide if Lovenox treatment is indicated for pulmonary embolism and a taper of her Decadron should be initiated when she follows up on _%#MMDD#%_ to the primary oncologist. FOLLOWUP. 1. The patient will follow up with _%#NAME#%_ _%#NAME#%_, NP in the Heme/Onc Clinic on _%#MMDD2007#%_ at 11 a.m. As noted above, the decision to restart Lovenox, the Decadron taper and obtain the patient's previous MRI should all be addressed at this appointment.
NP|nurse practitioner|NP,|195|197|DISCHARGE INSTRUCTIONS|5. Follow-up appointment is recommended with _%#NAME#%_ _%#NAME#%_, physician assistant, in one to two weeks. 6. Follow-up appointment with _%#NAME#%_ _%#NAME#%_, PA-C, or _%#NAME#%_ _%#NAME#%_, NP, in 4-6 weeks at Minnesota Heart Clinic. 7. She was recommended for outpatient sleep study as she does have symptoms consistent with sleep apnea which could be a trigger of her atrial arrhythmia.
NP|nurse practitioner|NP|58|59|PRIMARY CARE PHYSICIAN|PRIMARY CARE PHYSICIAN: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, NP at Fairview _%#CITY#%_ _%#CITY#%_ Clinic. CHIEF COMPLAINT: Chest pressure, palpitations, light-headedness. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 43-year-old Caucasian female who is otherwise healthy.
NP|nurse practitioner|NP|142|143|RECOMMENDED FOLLOW UP|2. Chest discomfort. RECOMMENDED FOLLOW UP: 1. With primary care clinic, Dr. _%#NAME#%_. 2. INR check in two to three days. 3. Follow up with NP at Minnesota Heart Clinic in one to two weeks. 4. Follow up with Dr. _%#NAME#%_ in two months. 5. Follow up with Dr. _%#NAME#%_ or Dr. _%#NAME#%_ in four to six months.
NP|nurse practitioner|NP|187|188|DISCHARGE PLAN|ABDOMEN: Soft, nontender. EXTREMITIES: No lower extremity edema, no calf tenderness. DISCHARGE PLAN: 1. The patient is to follow up with her primary care provider, _%#NAME#%_ _%#NAME#%_, NP at the Fairview Northeast Clinic in 1-2 weeks. 2. The patient should follow up with her primary pulmonologist, Dr. _%#NAME#%_, at Minnesota Lung in approximately 3 months for recommended repeat CT scan of the chest to follow the newly noted lung nodule in the right upper lobe.
NP|nurse practitioner|NP,|108|110|REASON FOR HOSPITALIZATION|He is followed by Dr. _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_, NP. Per discussions with _%#NAME#%_ _%#NAME#%_, NP, and the patient he has generally been noncompliant with a diabetic diet. The patient states that he hates the food at the nursing home and would generally eat from Subway and other fast food establishments.
NP|nurse practitioner|NP|55|56|REFERRING PHYSICIAN|REFERRING PHYSICIAN: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, NP (_%#CITY#%_ Clinic, PA - Family Practice) ADMISSION DIAGNOSIS: Morbid obesity. DISCHARGE DIAGNOSIS: Morbid obesity. PROCEDURE: Laparoscopic Roux-en-Y gastric bypass. SURGEON: _%#NAME#%_ _%#NAME#%_, MD HOSPITAL COURSE: On _%#MMDD2005#%_ _%#NAME#%_ _%#NAME#%_.
NP|nurse practitioner|NP.|47|49|PRIMARY-CARE PHYSICIAN|PRIMARY-CARE PHYSICIAN: _%#NAME#%_ _%#NAME#%_, NP. DISCHARGE DIAGNOSES: 1) Epistaxis, status post endoscopic control with placement of posterior nasal packing on _%#MM#%_ _%#DD#%_, 2005. 2) Status post right internal maxillary artery embolization on _%#MM#%_ _%#DD#%_, 2005.
NP|nurse practitioner|NP|266|267|DISCHARGE INSTRUCTIONS|16. Viscous lidocaine 2% 5 to 10 mL p.o. 4-6 times daily p.r.n. mouth pain. 17. Fentanyl patch 50 mcg TD q.72 h. 18. DermaZinc ointment 1%, apply b.i.d. p.r.n. DISCHARGE INSTRUCTIONS: The patient was discharged to home and will follow up with _%#NAME#%_ _%#NAME#%_, NP at the Masonic Cancer Center on _%#MM#%_ _%#DD#%_, 2005, at 9 a.m. to determine the timing of his next chemotherapy.
NP|nurse practitioner|NP,|200|202|FOLLOW UP|This was started on _%#MM#%_ _%#DD#%_, 2006, and the patient should have been sent home with a 5-day supply. FOLLOW UP: The patient will be assessed in Masonic Cancer Clinic by _%#NAME#%_ _%#NAME#%_, NP, on _%#MM#%_ _%#DD#%_, 2006. At this time, his creatinine can be monitored once again. The patient was also scheduled to be seen by Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2006, at 11 a.m.
NP|nurse practitioner|NP|241|242|PROPOSED ANESTHESIA|We discussed the options of treatment for menorrhagia, including hormonal options and surgery, such as the NovaSure ablation. The patient was very interested in pursuing the ablation. She returned to our office to see _%#NAME#%_ _%#NAME#%_, NP on _%#MMDD2006#%_. She had an ultrasound which showed normal size uterus with a stripe of 13.6 mm, possibly a small endometrial polyp, less than 1 cm and an anterior hemorrhoid just barely impinging on the canal, measuring in greatest diameter 1.8 cm.
NP|nurse practitioner|NP|112|113|DISCHARGE MEDICATIONS|12. Acetaminophen 500 mg every 4 hours as needed for pain. 1. Stop lisinopril. 2. Hold metoprolol until seen by NP _%#NAME#%_ on _%#MMDD2007#%_. HOSPITAL COURSE: 77-year-old female recently admitted for dehydration with acute renal failure and severe hyperkalemia presented to University of Minnesota Medical Center ER with nausea and vomiting.
NP|nurse practitioner|N.P.|149|152|PLAN|Informed written consent will be obtained on the day of surgery. As stated above, she is having her history and physical with _%#NAME#%_ _%#NAME#%_, N.P. on _%#MMDD2007#%_.
NP|nurse practitioner|NP|154|155|DISCHARGE PLAN|Peripheral pulses are intact distally and there is no peripheral edema present. DISCHARGE PLAN: 1. The patient will follow-up with _%#NAME#%_ _%#NAME#%_, NP at Minnesota Heart Clinic in one to two weeks. 2. He will continue his current medication regimen which includes Plavix which will be taken indefinitely.
NP|UNSURED SENSE|NP.|145|147|HISTORY|The patient feels that she has had symptoms for approximately one year, but in the past couple of weeks has had severe distention of her abdomen NP. In the past week she has been experiencing diarrhea, difficulty eating, and early satiety. Dr. _%#NAME#%_ ordered a CT scan, which revealed a large complex solid cystic mass in the abdomen and pelvis, ascites, and omental thickening.
NP|nurse practitioner|NP|205|206|FOLLOWUP|Home PT/OT also was ordered as outpatient. DISCHARGE DISPOSITION: Discharged home. ACTIVITY: As tolerated. DIET: Low salt diet. FOLLOWUP: Follow up with Dr. _%#NAME#%_ _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_ NP at Fairview Northeast Clinic in 1 week. DISCHARGE MEDICATIONS: 1. Lisinopril 10 mg daily. 2. Flexeril 10 mg p.o. t.i.d.
NP|nurse practitioner|NP|148|149|DISCHARGE INSTRUCTIONS|6. Colace 200 mg p.o. twice a day p.r.n. constipation. DISCHARGE INSTRUCTIONS: 1. The patient was instructed to followup with _%#NAME#%_ _%#NAME#%_ NP in the department of oncology to followup for rectal cancer and obstipation in 4 to 6 weeks. 2. The patient was instructed to follow up with her primary care physician Dr. _%#NAME#%_ _%#NAME#%_ for hospitalization followup in 1 to 2 weeks.
NP|nurse practitioner|NP|142|143|PHYSICAL EXAMINATION|Flutter ablation may have its place. 4. BiV pacing if that is a consideration. 5. CORE Heart Failure Clinic with follow-up in _%#CITY#%_ with NP and physician backup. I reviewed each of these issues with him. Although he realizes it is a lot of work, he is unwilling to proceed.
NP|nurse practitioner|NP|38|39|PLAN|_%#MMDD2007#%_ _%#NAME#%_ _%#NAME#%_, NP _%#CITY#%_ Children's Clinic _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_, MN _%#55400#%_ Phone: _%#TEL#%_ Fax: _%#TEL#%_ Dear _%#NAME#%_ _%#NAME#%_: Thank you for accepting the care of _%#NAME#%_ _%#NAME#%_ from the Neonatal Intensive Care Unit of University of Minnesota Children's Hospital, Fairview. He was born on _%#MMDD2007#%_ at 1039 hours, transferred to the NICU on _%#MMDD2007#%_ and discharged on _%#MMDD2007#%_.
NP|nurse practitioner|NP,|188|190|FOLLOW-UP|He will have someone pick him up by 10:00 a.m. tomorrow morning or as directed. Questions are answered. FOLLOW-UP: The patient will follow up with Dr. _%#NAME#%_ or _%#NAME#%_ _%#NAME#%_, NP, in the future.
NP|nurse practitioner|NP|119|120|DISCHARGE FOLLOW-UP|11. Diclofenac 25 mg 3 times daily. DISCHARGE FOLLOW-UP: Follow up with Minnesota heart clinic in 1 week and also with NP in one to two weeks with JE 4-6 weeks. Follow with primary care p.r.n.
NP|nurse practitioner|NP|672|673|FOLLOW UP|DISCHARGE MEDICATIONS: Vitamin K 5 mg p.o. q. day p.r.n. hemoptysis, Protonix 40 mg p.o. q. day, albuterol metered dose inhaler 2 puffs q.4 hours p.r.n., Os-Cal with vitamin D 1 p.o. b.i.d., Mucomyst 20% 30 mL p.o. p.r.n. constipation, pamidronate 30 mg IV q.3 months, tobramycin 160 mg IV q.12 hours, ceftazidime 2 g IV q.8 hours, albuterol 2.5 mg nebs q.i.d., cromolyn 20 mg nebs q.i.d., Mucomyst 20% 4 mL neb q.i.d., Pancrease MT 16, 8 to 9 capsules with meals or six to seven snacks, multivitamin 1 p.o. b.i.d., and azithromycin 250 mg q. day. FOLLOW UP: The patient will follow up in the cystic fibrosis clinic on _%#MM#%_ _%#DD#%_, 2006, with _%#NAME#%_ _%#NAME#%_, NP with PFTs. At that time, a hemoglobin should be rechecked. Homecare will be provided by OptionCare who will provide IV antibiotics and PICC line care as well as lab draws as needed.
NP|nurse practitioner|NP|47|48||_%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_, NP Green Central Clinic _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_, MN _%#55400#%_ Dear Ms. _%#NAME#%_; Thank you for accepting the care of _%#NAME#%_ _%#NAME#%_ from the Neonatal Intensive Care Unit of University of Minnesota Children's Hospital, Fairview.
NP|nurse practitioner|NP,|128|130|DISCHARGE INSTRUCTIONS|6. The patient will follow up with Minnesota Heart Clinic and see Dr. Minnesota Heart and see _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, NP, in two weeks. 7. The patient is to maintain a low-salt diet. PRINCIPAL DISCHARGE DIAGNOSIS: Atrial fibrillation.
NP|nurse practitioner|NP.|196|198|DISCHARGE FOLLOW-UP|10. Levothyroxine 150 mcg per day. 11. Avandia 4 mg per day. DISCHARGE FOLLOW-UP: 1. He will be seen by Dr. _%#NAME#%_ _%#NAME#%_ in one to two weeks by nurse practitioner, _%#NAME#%_ _%#NAME#%_, NP. 2. Also Minnesota Heart Clinic in two to three weeks. 3. Follow-up with Dr. _%#NAME#%_ _%#NAME#%_ in four to six weeks. His appointment with Dr. _%#NAME#%_ _%#NAME#%_ in on _%#MMDD2002#%_ at 3:45 at the _%#CITY#%_ Office of Minnesota Heart Clinic.
NP|nurse practitioner|NP.|197|199|PLAN|14. To see nurse practitioner, _%#NAME#%_ _%#NAME#%_, in approximately one week. The patient to call for appointment and to have liver function studies obtained when seen by _%#NAME#%_ _%#NAME#%_, NP.
NP|nurse practitioner|NP|128|129|DISCHARGE FOLLOW-UP|2. I will also have him follow up in the Coumadin Clinic in 7-10 days. 3. I will have him follow up with _%#NAME#%_ _%#NAME#%_, NP (Minnesota Heart Clinic) in 2-3 weeks. 4. He will follow up with Dr. _%#NAME#%_ in approximately 3 months. 5. I have also asked that he follow up with Dr. _%#NAME#%_ in a week or two.
NP|nurse practitioner|NP|205|206|DISPOSITION|DISPOSITION: 1. The patient will follow up with Dr. _%#NAME#%_ in two to four weeks. 2. The patient will follow with Dr. _%#NAME#%_ in 8-12 weeks. 3. The patient will follow up with _%#NAME#%_ _%#NAME#%_, NP in seven to ten days. 4. INR at the Ridges Clinic on _%#MMDD2007#%_. 5. See usual pacemaker guidelines for follow-up instructions after pacemaker implantation.
NP|nurse practitioner|NP)|291|293|DISCHARGE FOLLOW-UP|The patient will participate in outpatient cardiac rehabilitation. He will return to the emergency room if he has chest discomfort, shortness of breath, light-headedness or dizziness. The patient will follow up with the nurse practitioner from Minnesota Heart Clinic (_%#NAME#%_ _%#NAME#%_, NP) at Fairview Lakes on Tuesday _%#MMDD2007#%_ at 10:00. He also was scheduled to follow up with Dr. _%#NAME#%_ at Fairview _%#CITY#%_ on _%#MMDD2008#%_ at 1:00 p.m. He will also have a lipid panel drawn at that appointment and is scheduled to follow up with Dr. _%#NAME#%_ at Wyoming Family Practice in 1-2 weeks.
NP|nurse practitioner|NP.|260|262|DISCHARGE DISPOSITION|Discharge INR was 1.79. 4. The patient will follow up with the nurse practitioner _%#NAME#%_ _%#NAME#%_ on Monday, _%#MMDD2007#%_ at 2:30. The patient will have a basic metabolic panel on _%#MMDD#%_ at 1:30 prior to the appointment with _%#NAME#%_ _%#NAME#%_, NP. 5. The patient will have a fasting lipid profile in 6-8 weeks at Minnesota Heart Clinic. 6. The patient will have her INR at Dr. _%#NAME#%_'s Office on _%#MMDD2007#%_.
NP|nurse practitioner|NP|44|45|PRIMARY CARE DOCTOR|PRIMARY CARE DOCTOR: _%#NAME#%_ _%#NAME#%_, NP The patient is a poor historian. Information obtained from the patient, ER physician and old records here.
NP|nurse practitioner|NP|202|203|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 39-year-old male with a history of idiopathic cardiomyopathy who was followed at Fairview Southdale by Dr. _%#NAME#%_ and nurse practitioner, _%#NAME#%_, NP at Fairview Southdale. Mr. _%#NAME#%_ has a history of familial cardiomyopathy and has been reasonably well compensated, although very near criteria for transplantation.
NP|nurse practitioner|NP|131|132|HOSPITAL COURSE|I have asked her to contact us if she notices mood changes. She was asked to refrain from work for at least a week until follow-up NP visit and then can go back to work if she is doing well on light duty and then full duty in about a month.
NP|nasopharyngeal|NP|171|172|PLAN|Will administer dexamethasone IM in clinic prior to admission. Close observation of respiratory status and hydration status. Also plan chest x-ray, lateral neck x-ray and NP swab for RSV and for pertussis.
NP|nurse practitioner|NP.|304|306|PRIMARY CARE PROVIDER|PREVIOUS HOSPITALIZATION: Fairview Southdale hospital, _%#MMDD#%_ to _%#MMDD2006#%_. PRIMARY CARE PROVIDER: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ MD, Oxboro Fairview Clinic, telephone #_%#TEL#%_. New primary care provider after discharge is Fairview Partners Team Nurse Practitioner is _%#NAME#%_ _%#NAME#%_, NP. Her fax number is _%#TEL#%_. PROBLEMS ADDRESSED DURING TRANSITIONAL CARE STAY: Ms. _%#NAME#%_ is a 69-year-old woman who had bilateral total hip replacements approximately 2-1/2 years ago, first on the right side and subsequently on the left.
NP|nurse practitioner|NP,|181|183|DISCHARGE PLAN|She has a scheduled followup with Dr. _%#NAME#%_ of Fairview Southdale Orthopedics in 1-2 weeks for further evaluation as well. I reviewed her care plan with _%#NAME#%_ _%#NAME#%_, NP, The Fairview Partners who will coordinate her care at Martin Luther Manor. It should be noted that greater than 30 minutes was spent in discharge plan and care coordination and physical examination on the date of discharge, _%#MMDD2006#%_.
NP|nasopharyngeal|NP|141|142|LABORATORY DATA|Cath urinalysis was obtained, which showed specific gravity 1.010, small blood, small protein and no white blood cells per high power field. NP swab for influenza and RSV were negative. Chest x-ray and abdominal flat plates were also normal. Her electrolytes were normal with a sodium of 136, potassium 5.9, chloride 101, bicarb 25, BUN 7, creatinine 0.2, and a glucose of 100 and calcium 10.6. A lumbar puncture was performed.
NP|nurse practitioner|NP,|208|210|IMPRESSION/PLAN|4. Follow-up appointments are as instructed with INR check in 5-7 days as mentioned above. Also incision check would be recommended at Device Clinic in 7-10 days time. Appointment with _%#NAME#%_ _%#NAME#%_, NP, or _%#NAME#%_ _%#NAME#%_, PA-C, to be checked in one month at Minnesota Heart Clinic. 5. The patient will be discharged later this morning upon her stable status.
NP|nurse practitioner|NP.|154|156|HOSPITAL COURSE|The neonatal nurse practitioner was present due to the maternal fever and to assess the baby at birth. The vigorous baby was given the Apgar scores by an NP. The baby's temperature was initially 103 degrees and he was transferred to Special Care for observation. No episiotomy was performed but there was a very symmetric second degree midline tear that was repaired in layers.
NP|nasopharyngeal|NP|150|151|2. RESP|3. HEME: A CBC was checked on admission and was remarkable only for a predominance of lymphocytes in the WBC differential. 4. ID: A blood culture and NP swabs for viral culture, RSV ag, Pertussis and Chlamydia were sent on admission. Blood culture, rapid RSV and Chlamydia were negative. Pertussis PCR and viral culture were pending at time of discharge.
NP|nasopharyngeal|NP|117|118|HISTORY OF PRESENT ILLNESS|On examination, he was found to have O2 saturations in the 80%. He was wheezing and in mild respiratory distress. An NP swab done at that time was positive for RSV. The remainder of the examination was unremarkable. HOSPITAL COURSE: The patient was admitted to Fairview Ridges.
NP|nurse practitioner|NP|48|49|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, NP (_%#CITY#%_ _%#CITY#%_ Clinic) CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 72- year-old Asian female followed by _%#NAME#%_ _%#NAME#%_, NP at _%#CITY#%_ _%#CITY#%_ Clinic for a history of hypertension, elevated cholesterol, and diabetes mellitus.
NP|nurse practitioner|NP|228|229|PLAN|If her findings are consistent with congestive heart failure (CHF) we will continue to diurese the patient and consider the addition of an ACE inhibitor to her regimen. 4. Will obtain outside records from _%#NAME#%_ _%#NAME#%_, NP at _%#CITY#%_ _%#CITY#%_ Clinic. 5. Additionally, the patient will be maintained on a sliding scale of insulin per protocol and have Accu-Chek readings.
NP|nurse practitioner|NP|165|166|DISCHARGE FOLLOW-UP|DISCHARGE FOLLOW-UP: 1. Follow up with Dr. _%#NAME#%_ _%#NAME#%_ (Oncology) in 2-3 months. 2. Follow up with me in a month. 3. Follow up with _%#NAME#%_ _%#NAME#%_, NP in Dr. _%#NAME#%_' office (Neurology). a. She should have an odontoid view and lateral C-spine x-ray at that time. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a very pleasant 81-year- old female who was recently found to have breast carcinoma after a mammogram showed a suspicious lesion and an ultrasonic biopsy confirmed this.
NP|nasopharyngeal|NP|297|298|PROBLEM #1|His laboratory results on admission were significant for a white count of 17.5, hemoglobin 13.9, platelet count of 371, creatinine on admission was 1.3. The patient was admitted to the Bone Marrow Transplant Ward with the following problems: PROBLEM #1: Pulmonary. Chest CT showed no infiltrates. NP swabs for RSV and influenza virus antigens were negative; viral cultures pending. Patient was treated with broad spectrum antibiotics and Tamiflu. PROBLEM #2: ENT.
NP|nurse practitioner|NP,|211|213|CONSULTATIONS DURING HOSPITALIZATION|6. Effexor XR tapering dose of 112.5 mg p.o. daily x5 days, then 75 mg q.a.m. x5 days, then 37.5 mg p.o. q.a.m. x5 days, then discontinue. CONSULTATIONS DURING HOSPITALIZATION: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, NP, of pain Management and _%#NAME#%_ _%#NAME#%_ of Psychiatry. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 64-year-old white female currently living with her son, daughter-in-law and their children for the last several years after moving from _%#CITY#%_ _%#CITY#%_.
NP|nurse practitioner|NP.|124|126||For the complete medical discharge summary, please see the one dictated by Dr. _%#NAME#%_ or Dr. _%#NAME#%_ _%#NAME#%_, his NP. THE FOLLOWING IS A REHAB DISCHARGE SUMMARY Following admission to acute rehab _%#NAME#%_ _%#NAME#%_ participated in PT, OT and speech b.i.d. and showed progress.
NP|nurse practitioner|NP,|211|213|DISCHARGE INSTRUCTIONS|However, the patient tells me she is planning to go to Arizona for three months beginning in the middle of _%#MM#%_. 6. She does have existing appointment scheduled on _%#MMDD2008#%_ with _%#NAME#%_ _%#NAME#%_, NP, and CBC will be added to review hemoglobin with mild drop. Of note, this change in hemoglobin was reviewed with Dr. _%#NAME#%_, as well as a mild increase in a troponin with concern to just monitor at present.
NP|nurse practitioner|NP|47|48|PRIMARY CARE PHYSICIAN|PRIMARY CARE PHYSICIAN: _%#NAME#%_ _%#NAME#%_, NP CHIEF COMPLAINT: Pain in G-tube site. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 82-year-old white male who is status post CVI with right-sided weakness and expressive aphasia who was hospitalized in _%#MM2006#%_ for right hip ORIF.
NP|nasopharyngeal|NP|147|148|IMPRESSION|He was treated for four days with Acyclovir. The CSF was negative for HSV by PCR. No HSV was isolated from the rectal swab done on _%#MMDD2007#%_. NP and eye cultures for HSV were also done on _%#MMDD2007#%_ and were still pending at the time of discharge. The family has been instructed to observe Dominic for vesicles and have also been informed of the signs of sepsis including poor feeding and markedly decreased activity and tone.
NP|nurse practitioner|NP|176|177|DISCHARGE FOLLOW-UP|2. The patient will follow up with Dr. _%#NAME#%_ at the Minnesota Heart Clinic in approximately two to three months. 3. The patient will follow up with _%#NAME#%_ _%#NAME#%_, NP at the Fairview Northeast Clinic in approximately two to four weeks. 4. The patient will have an INR at the Fairview Northeast Clinic in three days, or on _%#MMDD2007#%_, with a goal for the INR of 2-3.
NP|nurse practitioner|NP,|155|157|DISCHARGE FOLLOW-UP|No heavy lifting of greater than 10 pounds for two weeks. 4. Diet: Low cardiac, low salt. DISCHARGE FOLLOW-UP: 1. Follow-up is with _%#NAME#%_ _%#NAME#%_, NP, Minnesota Heart Clinic in one to two weeks. 2. Follow-up with Dr. _%#NAME#%_ at _%#CITY#%_ or _%#CITY#%_ in one to three months.
NP|nurse practitioner|NP,|325|327|DISCHARGE MEDICATIONS|The patient will have a follow-up INR and CMP in Minnesota Heart Clinic on _%#MMDD2002#%_, and subsequent BMP in a week and a month in light of the fact that she has recently been started on an Ace Inhibitor. She will follow-up in our Coumadin Clinic on Friday, _%#MMDD2002#%_. She will follow-up with _%#NAME#%_ _%#NAME#%_, NP, in one month's time and have an EKG at that point to see if she is indeed maintaining sinus rhythm. She will follow-up with Dr. _%#NAME#%_ as directed by him.
NP|nurse practitioner|NP,|160|162|PLAN|Patient to call blood sugar results to Dr. _%#NAME#%_'s Office on _%#MMDD2003#%_. 6. To follow-up with Dr. _%#NAME#%_. 7. Follow-up with _%#NAME#%_ _%#NAME#%_, NP, with Dr. _%#NAME#%_ etal. 8. Patient received continuing outpatient diabetic education. 9. To follow-up with Dr. _%#NAME#%_ as needed.
NP|nurse practitioner|NP,|219|221|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Transferred back from the Orthopedic Service after revision of left wrist surgery for rehabilitation and IV antibiotic administration. HISTORY OF PRESENT ILLNESS: Please refer to _%#NAME#%_ _%#NAME#%_, NP, admission history and physical dated _%#MMDD2004#%_ for more information. In brief, this is a 50-year-old white male with a past medical history significant for trauma to the left wrist in 2002.
NP|nurse practitioner|NP|121|122|DISCHARGE MEDICATIONS|Temazepam 7.5 mg po q hs prn insomnia. Multivitamin 1 po q day. The patient should follow up with _%#NAME#%_ _%#NAME#%_, NP at the Fairview _%#CITY#%_ Clinic after she has recovered and undergone colonoscopy. Hemoglobin can be checked at that visit and if colonoscopy is negative, can look for other occult causes of the anemia.
NP|nurse practitioner|NP|182|183|DISCHARGE PLAN|This should be followed as an outpatient. DISCHARGE PLAN: 1. Followup. The patient has an appointment on _%#MMDD2008#%_ in the Hematology/Oncology Clinic with _%#NAME#%_ _%#NAME#%_, NP and she is to continue receiving intrathecal methotrexate biweekly. 2. The patient has an appointment on _%#MMDD2008#%_ with Dr. _%#NAME#%_ with Hematology/Oncology. DISCHARGE MEDICATIONS: 1. Acyclovir 400 mg p.o. b.i.d.
NP|nurse practitioner|NP,|171|173|DISCHARGE INSTRUCTIONS|She is being discharged to home in neurologically stable condition today with the following instructions. DISCHARGE INSTRUCTIONS: 1. Follow-up with _%#NAME#%_ _%#NAME#%_, NP, in four weeks. Please call to schedule this appointment. 2. The incision is allowed to get wet at this time frame and incisional glue will fall off independently.
NP|nurse practitioner|NP,|130|132|FOLLOW-UP CARE|The patient was scheduled to have a CBC with differential q. Monday and q Tuesday, which is to be faxed to _%#NAME#%_ _%#NAME#%_, NP, at (_%#TEL#%_) _%#TEL#%_. He is also scheduled for vincristine to be received locally in Dr. _%#NAME#%_'s office on _%#MMDD2002#%_ and _%#MMDD2002#%_. His next admission is scheduled for _%#CITY#%_ on _%#MMDD2002#%_ for chemotherapy, and his next F-UMC admission is scheduled for _%#MMDD2002#%_.
NP|nurse practitioner|NP|140|141|IMPRESSION AND PLAN|We will also ask Social Services to follow up as I do suspect he will need increased assistance upon discharge home. _%#NAME#%_ _%#NAME#%_, NP Minnesota Oncology
NP|nurse practitioner|NP,|70|72|PRIMARY CARE|CHIEF COMPLAINT: Abdominal pain. PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, NP, _%#CITY#%_ Medical Group. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 42-year-old white female who had abdominal pain starting last Wednesday afternoon.
NP|nurse practitioner|NP|102|103|DISCHARGE MEDICATIONS|201-250 Give 4 units 251-300 Give 6 units 301-350 Give 8 units 351-400 Give 10 units ( 400 Call MD or NP 7. Lantus insulin 24 units q.a.m. starting on _%#MMDD2005#%_. 8. Prednisone 2.5 mg p.o. p.o. each day. 9. CellCept 1000 mg p.o. t.i.d. 10. Benefiber 2 tbsp q.i.d. incorporated into water flushes for tube feeds.
NP|nurse practitioner|NP.|133|135|HISTORY OF PRESENT ILLNESS|She was given some Estrogen cream to use in the vagina prior to her surgery. She had her preoperative exam by _%#NAME#%_ _%#NAME#%_, NP. MEDICATIONS: 1. Atenolol. 2. Diovan. 3. Evista. 4. Protonix. We explained to her the minor cardiopulmonary, neurological risks from anesthesia, and also the risks of GI injury, GU injury, blood loss, infection from the cone biopsy, and further management will depend after the cone biopsy results are available.
NP|nasopharyngeal|NP|144|145|HISTORY OF PRESENT ILLNESS|Urine culture is pending. Repeat ABG done at 10:00 p.m. showed pH of 6.89, PO2 of 428, bicarbonate of 4, and CO2 of 20. The patient also had an NP swab for influenza which was negative. Chest x-ray showed no definitive infiltrate. In the emergency room, the patient has had a line placed.
NP|nurse practitioner|NP,|315|317|HISTORY OF PRESENT ILLNESS|DOB: _%#MMDD1952#%_ CHIEF COMPLAINT: Heavy vaginal bleeding. HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old white woman, gravida 3, para 3-0-0-3, whose last menstrual period was _%#MMDD2005#%_, status post postpartum tubal ligation in the past, who was originally sent to me by Dr. _%#NAME#%_ _%#NAME#%_, NP, because of the heavy vaginal bleeding that she had had. She also had a thickened endometrial stripe on a recent ultrasound.
NP|nasopharyngeal|NP|124|125|HOSPITAL COURSE|The Port-A-Cath access was cultured again today before he left. Questionable etiology of fever may be due to growth factor. NP swabs were negative for influenza. Antibiotics were given for 3 days, including vancomycin and ceftazidime. They were discontinued today. The patient will receive ceftriaxone in the clinic, 2 g IV daily, until his counts recovery.
NP|nurse practitioner|NP.|145|147|DISCHARGE MEDICATIONS|4. Coumadin to be 1 mg p.o. daily for anticoagulation. All other medications remained the same as previously dictacted by _%#NAME#%_ _%#NAME#%_, NP. HOSPITAL COURSE: The patient underwent a pull back of both right and left nephroureterograms on _%#MMDD2008#%_ as well as removal of the bilateral internal and external nephroureteral drains.
NP|nurse practitioner|N.P.|150|153|EXAMINATION|ABDOMEN - soft, flat, nontender, no hepatosplenomegaly or masses appreciated. PELVIC - the pelvic examination was performed by _%#NAME#%_ _%#NAME#%_, N.P. External genitalia/BUS are within normal limits. VAGINA - moderate amount of dark red blood in the vault. CERVIX - no lesions. UTERUS - normal size, shape and contour.
NP|nurse practitioner|NP,|172|174|REASON FOR CONSULTATION|We did have the opportunity today to review _%#NAME#%_ _%#NAME#%_ _%#NAME#%_'s clinical history as well as imaging studies. My colleague, _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, NP, carried out the consultation note and I have no addition to her outstanding assessment. I met with the patient and his family. We have defined a plan and further discussions will be carried out in the morning.
NP|nurse practitioner|NP.|326|328|TRANSFERRING MEDICATIONS|19. Percocet one to two tablets p.o. q. 4-6 h p.r.n. 20. Wound care, as described in the transfer form. 21. Humalog sliding scale insulin if Accu-Chek 150-200, 2 units subcu; 201-250, 4 units; 251-300, 6 units; 301-350, 8 units; 351-400, 10 units; 401-450, 12 units; and if greater than 450, 14 units and notify the MD or the NP. SOCIAL HISTORY, FAMILY HISTORY, IMMUNIZATIONS, AND HEALTH MAINTENANCE: Documented in the last H and P on _%#MMDD2004#%_, so I would refer you to that.
NP|nurse practitioner|NP,|191|193|FOLLOW-UP|6. Percocet (Amend) 80 mg p.o. on _%#MMDD#%_ and _%#MMDD2005#%_. (The patient was given prescriptions for all of these medications). FOLLOW-UP: 1. The patient will see _%#NAME#%_ _%#NAME#%_, NP, on _%#MMDD2005#%_ at 10 a.m. for a CBC with differential, basic metabolic panel, magnesium and phosphorus to be drawn and to be followed.
NP|nurse practitioner|NP,|47|49|PRIMARY CARE PROVIDERS|PRIMARY CARE PROVIDERS: _%#NAME#%_ _%#NAME#%_, NP, _%#NAME#%_ _%#NAME#%_, M.D. DISCHARGE DIAGNOSES: 1. Angioedema, likely secondary to lisinopril also possibly secondary to Mevacor.
NP|nurse practitioner|NP|187|188|DISCHARGE FOLLOW-UP|13. Combivent inhaler two puffs q.i.d. 14. Ensure one can daily. DISCHARGE FOLLOW-UP: The patient has been advised to have his INR checked tomorrow at Dr. _%#NAME#%_ _%#NAME#%_'s office. NP appointment on _%#MM#%_ _%#DD#%_ at 1 p.m. Follow up at the CORE clinic with _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_ at 9:30 a.m. with a BMP to be checked before that visit.
NP|nurse practitioner|NP,|156|158|FOLLOWUP INSTRUCTIONS|15. Augmentin SR 2 tablets p.o. q.12h. x7 days. FOLLOWUP INSTRUCTIONS: The patient is scheduled to be seen in followup by _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, NP, on Wednesday, _%#MM#%_ _%#DD#%_, 2005. She will then follow up with Dr. _%#NAME#%_ for routine management in the future. The patient is instructed if she develops any recurrent fever in excess of 100.5, significant dyspnea, productive cough, or significantly increased pain, that she should contact the clinic or after-hours care team prior to her next clinic visit.
NP|nurse practitioner|N.P.,|279|283|HISTORY OF PRESENT ILLNESS|She is aware of alternative contraceptives, but her partner will not consider vasectomy or use condoms and she does not want to deal with hormonal pills, injections, or patches, or IUD. She has given long thought to this procedure and she was consulted by _%#NAME#%_ _%#NAME#%_, N.P., also. The patient wants to undergo the above procedure for permanent sterilization so she does not have to deal with the pills. She does understand her alternatives and she does understand that this is a permanent sterilization and cannot be reversed.
NP|nurse practitioner|NP,|53|55|PRIMARY HEALTH CARE PROVIDER|PRIMARY HEALTH CARE PROVIDER: _%#NAME#%_ _%#NAME#%_, NP, Park Nicollet. (_%#NAME#%_ _%#NAME#%_ is not an Oxboro Clinic patient. She is being admitted to the Oxboro Clinic internal medicine service as an unassigned patient.) CHIEF COMPLAINT: Chest pressure.
NP|nurse practitioner|NP,|197|199|MEDICATIONS|His blood pressure is 127/67. Pulse is 82 and regular. His pocket is without hematoma or signs of infection. He will follow up in seven to ten days with a device RN and with _%#NAME#%_ _%#NAME#%_, NP, on _%#MMDD2004#%_.
NP|nurse practitioner|NP|137|138||She is going to check with her primary care physician for an INR on Monday. She will follow with Dr. _%#NAME#%_ in two months and with a NP or PA at Minnesota Heart Clinic in two weeks. DISCHARGE LABORATORY DATA: Sodium 142. Potassium 4.0. BUN 12. Creatinine 0.69. Hemoglobin 12.6. Platelets 147.
NP|nurse practitioner|NP,|178|180|DISCHARGE DIAGNOSES|DISCHARGE FOLLOWUP: Daily radiation therapy at 1:45 p.m. Follow up with Dr. _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2005, at 11:30 a.m. Follow up with _%#NAME#%_ _%#NAME#%_, NP, on _%#MM#%_ _%#DD#%_, 2005, at 1 p.m.
NP|nurse practitioner|N.P|144|146|DISCHARGE FOLLOW-UP|7. Plavix 75 mg once a day, this is also a new medication. This medicine should be kept on indefinitely. DISCHARGE FOLLOW-UP: 1. He will have a N.P or P.A. visit in one to two weeks at Minnesota Heart Clinic. 2. He will have a basic metabolic panel and a CBC drawn in one week, both to check his kidney function and his potassium since due to starting his Ace Inhibitor and also check his platelets due to starting his Plavix in the setting of low platelets.
NP|nurse practitioner|NP|222|223|TRANSFERRING MEDICATIONS|12. Valcyte 400 mg p.o. each day. 13. Novalog sliding scale insulin. Blood Sugar Insulin Dose 100-150 2 units 151-200 4 units 201-250 6 units 251-300 8 units 301-350 10 units 351-400 12 units ( 401 14 units and call MD or NP ALLERGIES: No known drug allergies. HABITS: He quit smoking about 20 years ago and does not use alcohol.
NP|nasopharyngeal|NP|236|237|HISTORY OF PRESENT ILLNESS|PROBLEM #3. Infectious disease: On _%#MMDD2005#%_ the patient spiked a fever to 102.9 degrees Fahrenheit and was 101.1 on _%#MMDD2005#%_ and defervesced after that. Blood cultures were negative during hospitalization. CMV was negative, NP swabs were negative. He was treated with acyclovir with thought that possibly the leg pain was shingles, and will be discontinued on discharge.
NP|nurse practitioner|NP,|289|291|HOSPITAL COURSE|He subsequently contacted me and noted that the primary caregiver did not feel comfortable with the patient dying at home and had requested that the patient be transferred to the emergency room. The patient was subsequently transferred to the eighth floor and I had _%#NAME#%_ _%#NAME#%_, NP, of Transitions And Life Choices see the patient. The patient subsequently expired later in the afternoon without incident.
NP|nurse practitioner|NP,|231|233|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: 1. She will follow up with _%#NAME#%_ _%#NAME#%_, NP, at _%#CITY#%_ _%#CITY#%_ Park Nicollet. 2. She is to have an INR on _%#MMDD2005#%_ and _%#MMDD2005#%_. 3. She will follow up with _%#NAME#%_ _%#NAME#%_, NP, regarding her genetic testing for the DVT. Time spent during discharge is approximately 20 minutes.
NP|nurse practitioner|NP,|135|137|DISCHARGE FOLLOW-UP|2. The patient will follow up with me at Minnesota Heart Clinic in 2 months. 3. The patient will follow up with _%#NAME#%_ _%#NAME#%_, NP, in two weeks (C.O.R.E. Clinic of the Minnesota Heart Clinic). a. At that time, basic metabolic panel will be performed.
NP|nurse practitioner|NP,|224|226|ADDENDUM|Per speech therapist, diet has been advanced to a dysphagia level 2 diet with nectar thick liquids. Flu shot will be given to the patient prior to discharge. The patient's case has been discussed with _%#NAME#%_ _%#NAME#%_, NP, from Physical Medicine and Rehabilitation.
NP|nurse practitioner|NP,|224|226|DISCHARGE INSTRUCTIONS|His EKG showed sinus rhythm with no EKG changes. Lungs are clear to auscultation and heart tones are normal with no murmurs, rubs or gallops. DISCHARGE INSTRUCTIONS: 1. The patient will follow up with _%#NAME#%_ _%#NAME#%_, NP, in one week for groin check and to assess for any symptomatology. 2. I have recommended that this patient participate in cardiac rehabilitation 3x per week, and he will be seen by them today prior to his discharge.
NP|nasopharyngeal|NP|109|110|PHYSICAL EXAMINATION|He did have O2 saturations checked prior to his first nebulization and his room air saturations were 95%. An NP swab done in the Fairview Ridges emergency room was negative for influenza A, influenza B and RSV. ASSESSMENT: Bronchiolitis. PLAN: Admission for continued albuterol nebulization. We will start prednisolone at 12 mg p.o. b.i.d. for five days.
NP|nurse practitioner|NP,|267|269|HOSPITAL COURSE|d. After discussion with patient and his family, the plan is for patient to follow up with Geriatric Services at _%#CITY#%_ Veterans Affairs Medical Center with their psychiatrist, Dr. _%#NAME#%_ _%#NAME#%_, and with his primary care provider, _%#NAME#%_ _%#NAME#%_, NP, at that facility. Currently he is stable for discharge and will be discharged back to Heritage of _%#CITY#%_ Health Care with home health care evaluation as per Social Work.
NP|nurse practitioner|NP|44|45|REFERRING PHYSICIAN|REFERRING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, NP at Fairview University _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_, MN _%#55400#%_ Phone #_%#TEL#%_, Fax #_%#TEL#%_ DISCHARGE DIAGNOSIS: Acute lymphoblastic leukemia. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 17-year-old young man with a history of pre-B cell high-risk ALL diagnosed on _%#MM#%_ _%#DD#%_, 2005.
NP|nurse practitioner|N.P.|152|155|DISPOSITION|2. Lisinopril 5 mg p.o. q. day. 3. Protonix 40 mg p.o. q. day. DISPOSITION: 1. Patient to follow up with her primary care who is _%#NAME#%_ _%#NAME#%_, N.P. at _%#CITY#%_ Medical Group, _%#CITY#%_ in 1-2 weeks, earlier p.r.n. 2. Patient to have stress echocardiogram to evaluate for cardiac ischemia within the next week with results to primary care for follow-up.
NP|UNSURED SENSE|NP|201|202|PROCEDURES|SECONDARY DIAGNOSES: 1. Atrial fibrillation. 2. COPD. 3. New onset diabetes mellitus. PROCEDURES: 1. Right heart cath. The patient had a right atrial pressure of 2, right ventricular pressure of 32/2, NP of 52/14, and a rate of 11. Cardiac output was 5. Cardiac index was 2.5. 2. Thoracentesis which showed a red blood cell count of 1600 with 3 nucleated red blood cells with 30% of neutrophils and 30% monocytes.
NP|nurse practitioner|NP|101|102|PRIVATE MEDICAL DOCTOR|CHIEF COMPLAINT: Chest pain with shortness of breath. PRIVATE MEDICAL DOCTOR: _%#NAME#%_ _%#NAME#%_, NP at _%#CITY#%_ Medical Group. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 50-year-old white female with a history of an ascending aortic aneurysm repair in _%#MM2006#%_ by Dr. _%#NAME#%_.
NP|nasopharyngeal|NP|170|171|LABORATORY DATA|NEURO: Normal tone, infant reflexes intact, moves all extremities. SKIN: Warm, pink and intact. LABORATORY DATA: RSV nasopharynx swab negative for RSV antigen. Pertussis NP swab still pending. Chest x-ray results still pending. IMPRESSION: Bronchiolitis, stable. Rule out pneumonia, rule out pertussis.
NP|nurse practitioner|NP,|150|152|FOLLOW UP|8. Ativan 0.5 mg orally q.4 h p.r.n. 9. Salt and soda mouth rinses 4-6 times a day and as needed. FOLLOW UP: 1. Follow up with _%#NAME#%_ _%#NAME#%_, NP, at 2 p.m. on _%#MM#%_ _%#DD#%_, 2005, for symptom management. 2. Follow up with _%#NAME#%_ _%#NAME#%_, PA, at 10 a.m. on _%#MM#%_ _%#DD#%_, 2005, prior to her next cycle of cisplatinum.
NP|nurse practitioner|NP|115|116|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD (Fairview _%#TOWN#%_ _%#TOWN#%_ Clinic); _%#NAME#%_ _%#NAME#%_, NP (Minnesota Gastroenterology, P.A. - _%#CITY#%_) CHIEF COMPLAINT: Acute confusion. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 56-year-old man with hepatitis C and apparent cirrhosis.
NP|nurse practitioner|NP.|187|189|ASSESSMENT/PLAN|f. Low protein diet. g. Stop interferon and ribavirin. h. IV fluids. 2. Hepatic lesions. a. He had an ultrasound done as an outpatient on _%#MMDD2005#%_ ordered by _%#NAME#%_ _%#NAME#%_, NP. This shows two lesions, the larger of the right lower lobe measuring 3.4 x 3.5 x 2.9-cm. The second lesion in the superior aspect of the lateral right lobe is 2.5 x 3.2 x 2.5-cm. These lesions have increased compared to _%#MMDD2005#%_ and could represent hepatic carcinoma.
NP|nurse practitioner|NP|166|167|FOLLOW-UP|6. Norvasc 5 mg daily. 7. Toprol XL 25 mg daily (one-fourth of a 100 mg tablet per the patient's request). FOLLOW-UP: 1. This patient will see _%#NAME#%_ _%#NAME#%_, NP at Minnesota Heart Clinic, our _%#CITY#%_ office on Friday, _%#MMDD2005#%_ at 8:00 a.m. 2. He will have a fasting lipid profile drawn with an ALT prior to his appointment on _%#MMDD2005#%_ at the _%#CITY#%_ Office of Minnesota Heart Clinic at 7:45 a.m.
NP|nurse practitioner|NP|133|134|FOLLOWUP CARE|12. Senna 1 to 2 tablets p.o. b.i.d. 13. Colace 100 mg p.o. b.i.d. FOLLOWUP CARE: The patient will be seen by _%#NAME#%_ _%#NAME#%_, NP on Friday, _%#MM#%_ _%#DD#%_, 2005.. He is tentatively scheduled for G-tube placement on _%#MM#%_ _%#DD#%_, 2005. The patient is then to be rescheduled for followup as needed until _%#MM#%_ _%#DD#%_, when he will again be seen by Dr. _%#NAME#%_.
NP|nasopharyngeal|NP|181|182|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: 1. Wheezing and pneumonia. The patient will be admitted to Fairview Ridges Hospital for further care. IV Rocephin will be given for treatment of her pneumonia. NP swabs will be obtained for influenza RSV and Methylprednisolone will be given on a q 6 hour basis for treatment of her wheezing.
NP|nurse practitioner|N.P.|164|167|DOB|He is discharged on his admit meds plus Plavix to be taken daily for six months. He understands he should remain on aspirin indefinitely. He will follow up with an N.P. or P.A. in one to two weeks, will have thallium stress test in six months and follow up with Dr. _%#NAME#%_ in six months. His LDL goal should be 70 or less.
NP|nurse practitioner|NP|37|38|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, NP (_%#CITY#%_ Medical Group - _%#CITY#%_ Clinic, Internal Medicine) DISCHARGE DIAGNOSIS: 1. Hyponatremia, resolved. 2. Hypokalemia, resolved. 3. Dementia. 4. Hypertension.
NP|nurse practitioner|NP,|156|158|DISCHARGE FOLLOW-UP|5. Os-Cal with vitamin D one tab p.o. b.i.d. No hydrochlorothiazide. No Lasix. DISCHARGE FOLLOW-UP: The patient is to follow up with _%#NAME#%_ _%#NAME#%_, NP, in 1-2 weeks with electrolytes at that time. DISCHARGE INSTRUCTIONS: The patient is to have home physical therapy and occupational therapy evaluation and also recommend a driving evaluation before resuming driving.
NP|nurse practitioner|NP|237|238|ADDENDUM|_%#NAME#%_ was a term AGA female infant, 3317 gm at 40 4/7 weeks gestation, with a length of 19 inches and head circumference of 13.25 inches. She was transferred to the NICU for a petechial rash that was noticed on delivery. A Neonatal NP was asked to evaluate _%#NAME#%_'s petechial rash in the newborn nursery in the first hour of life. The admission physical examination was significant for a vigorous female infant petechial rash.
NP|nurse practitioner|NP|207|208|FOLLOW-UP CARE|16. Pain medications her per primary care physician. She is requesting a change from Vicodin and this will be arranged prior to her discharge. FOLLOW-UP CARE: 1. This patient will see _%#NAME#%_ _%#NAME#%_, NP at Minnesota Heart Clinic on _%#MM#%_ _%#DD#%_, 2006 at 1:30 p.m. 2. She will follow up with Dr. _%#NAME#%_ in approximately three to four months.
NP|nurse practitioner|NP,|953|955|FOLLOW UP|DISCHARGE MEDICATIONS: At the time of discharge: Tobramycin 150 mg IV q.12 h.; ceftazidime 2 g IV q.8 h.; Pancrease MT 20, 12-15 capsules p.o. with meals and 6-10 capsules with snacks; beta carotene 25,000 units p.o. b.i.d.; vitamin E 400 units p.o. b.i.d.; vitamin K 5 mg p.o. daily; multivitamin 1 tablet p.o. daily; vitamin C 1000 mg p.o. daily; azithromycin 250 mg p.o. daily; Protonix 40 mg p.o. daily; Advair 50/500, 1 puff b.i.d.; Balmex 8 mg p.o. b.i.d.; Actigall 300 mg p.o. t.i.d. with meals; albuterol 2.5 mg aerosol q.i.d.; Atrovent 500 mcg aerosol q.i.d., and 20 mg aerosol q.i.d.; Mucomyst 10% solution 4 mL aerosol q.i.d.; Pulmozyme 2.5 mg aerosol b.i.d.; Lantus 30 units subcutaneous daily; NovoLog insulin 2 units per carbohydrate unit subcutaneous with meal and snack; and NovoLog insulin correction scale according to written (provided to the patient at the time of discharge). FOLLOW UP: Followup will be with _%#NAME#%_ _%#NAME#%_, NP, in CF clinic on _%#MM#%_ _%#DD#%_, 2006.
NP|nurse practitioner|N.P.,|447|451|FOLLOW UP|7. Pancrease 6-8 capsules by mouth with meals and 3-6 capsules with snacks; beta-carotene 50,000 units by mouth daily; vitamin E 400 units by mouth twice daily; ADEKs chew tablets 2 by mouth daily; multivitamins 1 by mouth daily; vitamin C 500 mg by mouth daily; azithromycin 250 mg by mouth daily; meropenem 1 g intravenously q.8 h.; Tylenol 325-650 mg by mouth q.4 h. as needed for pain. FOLLOW UP: Follow up will be with _%#NAME#%_ _%#NAME#%_, N.P., on _%#MM#%_ _%#DD#%_, 2006.
NP|nurse practitioner|NP,|336|338|HISTORY OF PRESENT ILLNESS|As well for the last several days starting on Wednesday the patient had what was described as clear leakage from the top of her incision and a small approximately 1 cm area of the incision that was open at the top. The rehabilitation services were concerned for a CSF leak. This case was discussed initially with _%#NAME#%_ _%#NAME#%_, NP, and it was felt that the patient should come back to clinic on Monday. However, over the weekend the rehab staff noticed the continued drainage, as well as some worsening of her intermittent confusion and agitation.
NP|nurse practitioner|NP|205|206|FOLLOW-UP|Follow up with Dr. _%#NAME#%_ _%#NAME#%_ at _%#CITY#%_ on Thursday _%#MMDD2006#%_ at 10:45 a.m. 2. Follow up with Dr. _%#NAME#%_ _%#NAME#%_ at Fairview Lakes _%#MMDD2006#%_ at 10:15 a.m. 3. Follow up with NP in one week's time at Fairview Lakes. 4. Lipid profile in 6 weeks' time. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 38-year-old gentleman who was admitted by Dr. _%#NAME#%_ _%#NAME#%_ with chest, neck and arm discomfort with profound sweating.
NP|nurse practitioner|NP,|167|169|DISCHARGE PLANS|Peripheral pulses are intact distally. There is no bruit to auscultation of his groin site. DISCHARGE PLANS: 1. The patient will follow-up with _%#NAME#%_ _%#NAME#%_, NP, or another nurse practitioner or PA at Minnesota Heart Clinic in one to two weeks. 2. The patient will follow-up with Dr. _%#NAME#%_ in _%#MM2006#%_ of _%#MM2007#%_.
NP|nurse practitioner|NP.|37|39|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, NP. CHIEF COMPLAINT: Rapid heart rate, left shoulder pain, alcohol intoxication. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 58-year-old Caucasian male with a longstanding history of alcohol abuse as well as paroxysmal atrial fibrillation and depression, who presents to the hospital with a rapid heart rate and atrial fibrillation and alcohol intoxication and left shoulder pain.
NP|nurse practitioner|N.P.,|166|170|DISCHARGE FOLLOW-UP|6. Nitroglycerin 0.4 mg 1 tablet sublingual q5 minutes x3 doses as needed for chest pain. DISCHARGE FOLLOW-UP: 1. This patient will be seen by _%#NAME#%_ _%#NAME#%_, N.P., Minnesota Heart Clinic, in approximately 1-2 weeks. 2. He will have a basic metabolic panel one week to assess his kidney function after starting on lisinopril.
NP|nurse practitioner|NP,|198|200|FOLLOWUP PLANS AND PENDING ISSUES|FOLLOWUP PLANS AND PENDING ISSUES: The patient should follow up with Dr. _%#NAME#%_ _%#NAME#%_ in Neurology in approximately 2-3 weeks. The patient should also follow up with _%#NAME#%_ _%#NAME#%_, NP, in 10-14 days. She should also have outpatient followup with Ophthalmology, to be determined by her primary care provider, _%#NAME#%_ _%#NAME#%_, NP, on this suspected glaucoma as noted in the original HPI dictated by Dr. _%#NAME#%_ _%#NAME#%_.
NP|nurse practitioner|NP,|322|324|FOLLOW UP|FOLLOW UP: Follow up will be with Dr. _%#NAME#%_ _%#NAME#%_ in the Pulmonary Hypertension Clinic in _%#MM#%_ _%#DD#%_, 2006, at 09:40 a.m. She is directed to weigh herself daily and call _%#NAME#%_ _%#NAME#%_ at _%#TEL#%_ with an a.m. weight gain of greater than 31 pounds. She is to follow up with _%#NAME#%_ _%#NAME#%_, NP, in _%#CITY#%_, Minnesota, within 1 week for a BMP. She is to maintain her 2-g sodium diet and fluid restriction.
NP|nurse practitioner|NP|183|184|DISCHARGE PLAN|4. She will be placed on Plavix 75 mg for a minimum of one year. 5. She will have a nuclear stress test in 2 to 3 months. 6. She will follow up with _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, NP on _%#MMDD2006#%_ at 2 p.m. 7. She will follow up with Dr. _%#NAME#%_ or _%#NAME#%_ in 2 to 3 months after nuclear stress test is complete.
NP|nurse practitioner|NP|156|157|IMPRESSION/PLAN|She will be discharged home today and I have given her all of her follow-up instructions. She should follow up at Minnesota Heart Clinic in 2 weeks with an NP or PA and follow up with Dr. _%#NAME#%_ in approximately 3 months. Thank you for allowing us to be involved in the care of Ms. _%#NAME#%_.
NP|nasopharyngeal|NP|138|139|LABORATORY|LABORATORY: Labs done in the ER revealed a white count of 3.5, 49% lymphocytes, 33% neutrophils, 17% monocytes. Blood culture is pending. NP swab was negative for influenza and RSV. IMPRESSION: 1. A 4 year old with pneumonia and asthma exacerbation.
NP|nurse practitioner|NP|264|265|ALLERGIES|She denies any worsening of pain with activity. She has no other associated symptoms with the chest pain that she describes. ALLERGIES: Sulfa and amoxicillin cause rash. Current medications, past medical history, family history, and social history are part of the NP note. PHYSICAL EXAMINATION: GENERAL: _%#NAME#%_ is a morbidly obese African American woman who is lying in bed comfortably.
NP|nurse practitioner|NP|181|182|ALLERGIES, PAST MEDICAL HISTORY, FAMILY HISTORY, SOCIAL HISTORY, AND ADMISSION MEDICATIONS|No abdominal pain. The diarrhea is two to three times per day and watery stools. ALLERGIES, PAST MEDICAL HISTORY, FAMILY HISTORY, SOCIAL HISTORY, AND ADMISSION MEDICATIONS: Per the NP note. PHYSICAL EXAMINATION: GENERAL: On exam, Ms. _%#NAME#%_ is talking with some difficulty related to mucositis.
NP|nurse practitioner|NP|135|136|PRIMARY PULMONARY PHYSICIANS|ATTENDING PHYSICIAN: Dr. _%#NAME#%_. PRIMARY PULMONARY PHYSICIANS: Dr. _%#NAME#%_, Pulmonary Clinic. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, NP CC: CF with diarrhea and dehydration. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 14-month-old girl with history of cystic fibrosis who presented with 1 week of worsened diarrhea and fevers.
NP|nurse practitioner|NP)|87|89|ADDENDUM|ADDENDUM: I have reviewed the discharge summary (as dictated by _%#NAME#%_ _%#NAME#%_, NP) and agree with the discharge and followup plans and hospital course. DISCHARGE MEDICATIONS ADDENDUM: The patient's pain control remained to be a challenge toward the end of hospitalization and as such the Relafen was returned to the 500 mg doses b.i.d. After which, the patient's pain improved.
NP|nurse practitioner|NP.|130|132|DISCHARGE MEDICATIONS ADDENDUM|Lisinopril was started last week. 2. Norvasc 2.5 mg p.o. daily. Hold for systolic blood pressure less than 100 and call the MD or NP. The covering physician or nurse practitioner may decide to wean this entirely off and simply go up on the ACE inhibitor. 3. Detrol LA 2 mg p.o. daily. Started today for overactive bladder.
NP|nurse practitioner|N.P.,|195|199|HOSPITAL COURSE|Please see HPI for the patient's previous treatment modalities. She will follow up with Dr. _%#NAME#%_. Follow-up appointment is currently scheduled on _%#MMDD2007#%_ with _%#NAME#%_ _%#NAME#%_, N.P., at Women's Health Clinic and with Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2007#%_. The patient did have a CT scan of the chest, abdomen and pelvis to evaluate for residual disease on _%#MMDD2007#%_.
NP|nasopharyngeal|NP|136|137|PHYSICAL EXAMINATION|A chest x-ray was obtained and has bilateral fluffy infiltrates, unknown if it viral versus bacterial. A rapid strep test was negative. NP swab for RSV and other viruses are pending and a white count of 9,100. ASSESSMENT: Bilateral otitis media, probable pneumonia, dehydration. PLAN: Admit to Fairview Ridges for IV antibiotics and IV fluids and albuterol nebs as needed.
NP|nurse practitioner|NP,|223|225|DISCHARGE FOLLOW-UP|Creatinine 1.01. His physical exam is otherwise unremarkable. DISCHARGE DISPOSITION: This patient will be discharged to home in the care of himself and his family. DISCHARGE FOLLOW-UP: 1. He will see _%#NAME#%_ _%#NAME#%_, NP, at Minnesota Heart Clinic in two weeks. 2. He will see Dr. _%#NAME#%_ in three to six months and have a treadmill nuclear stress test performed to assess her restenosis at six months.
NP|nurse practitioner|NP|196|197|FOLLOW-UP|He has no groin or abdominal pain. DISCHARGE DISPOSITION: This patient will be discharged to home in the care of himself and his family. FOLLOW-UP: 1. This patient will see _%#NAME#%_ _%#NAME#%_, NP and Dr. _%#NAME#%_ on _%#MMDD2006#%_ at Minnesota Heart Clinic. 2. He will be seeing Dr. _%#NAME#%_ next week. We would recommend aggressive lipid control with an LDL less than or equal to 70, HDL greater than 40-45, triglycerides less than 150.
NP|nasopharyngeal|NP|187|188|PLAN|Then give 1-1/4 maintenance fluids. Will check lytes on admission and repeat in the morning. Will repeat CBC in the a.m. as well. Send repeat UA after hydration as well as urine culture. NP swab for influenza. Will repeat x-ray in the morning after hydration as well. No antibiotics at this point unless clinically worsening.
NP|nurse practitioner|NP|174|175|FOLLOWUP PLANS|FOLLOWUP PLANS: 1. He is to be seen by _%#NAME#%_ _%#NAME#%_, PA-C in hematology oncology clinic on _%#MMDD2007#%_ at 1:00 p.m. 2. He is to be seen by _%#NAME#%_ _%#NAME#%_, NP in hematology oncology clinic on _%#MMDD2007#%_. 3. He is to be seen by Dr. _%#NAME#%_ _%#NAME#%_ from ENT on _%#MMDD2007#%_. DISCHARGE MEDICATIONS: 1. Magnesium 250 mg p.o. b.i.d. 2. Omeprazole 20 mg p.o. daily.
NP|nurse practitioner|NP,|231|233|DISCHARGE PLANS|To continue to monitor her weights on a daily basis and to call with any increasing shortness of breath. 12.The patient will have an echocardiogram follow-up in one month's time prior to her appointment with _%#NAME#%_ _%#NAME#%_, NP, to see if she did have any recovery of her LVEF. ADDENDUM: _%#NAME#%_, _%#NAME#%_. The patient's steroid taper dosage was changed to 20 mg p.o. b.i.d. x3 days, then 20 mg daily x3 days, then 10 mg daily x3 days, then discontinue.
NP|nurse practitioner|NP,|231|233|IMPRESSION/PLAN|I did instruct him to contact us should he note any fever or chills or significant bleeding in the pacer sites. 3. Follow-up appointments as recommended in one week's time with an EKG and an appointment with _%#NAME#%_ _%#NAME#%_, NP, _%#NAME#%_ _%#NAME#%_, PA-C. 4. Follow-up INR is already scheduled by the patient next week. 5. Did discuss his unsteadiness on his feet and given his presence of anticoagulation I did recommend utilization of walker which is available for him at home.
NP|nurse practitioner|NP|174|175|DISCHARGE MEDICATIONS|6. Ecotrin 81 mg p.o. q day The patient will be arranged for outpatient rehab at Fairview Ridges Hospital. The patient was instructed not to return to work until seen by the NP in two weeks' time. Plans for possible functional test to determine the significance of the obtuse marginal artery lesion.
NP|nurse practitioner|N.P.,|168|172|FOLLOWUP|2. The patient is to follow up on _%#MMDD2007#%_ for recheck of his hemoglobin. 3. The patient is to follow up with Dr. _%#NAME#%_ _%#NAME#%_ or _%#NAME#%_ _%#NAME#%_, N.P., in the GI Clinic. RESTRICTIONS: None. DIET: Regular. It was a pleasure to be involved in this patient's medical care.
NP|nurse practitioner|NP,|179|181|DISCHARGE INSTRUCTIONS|8. He is to have a follow-up visit with Dr. _%#NAME#%_ in two to four weeks. 9. Follow-up visit with Dr. _%#NAME#%_ in two months. 10. Follow-up visit with _%#NAME#%_ _%#NAME#%_, NP, at Minnesota Heart Clinic in one to two weeks. 11. The patient is to have a stress nuclear test in six to eight weeks at Minnesota Heart Clinic.
NP|nurse practitioner|NP,|183|185|DISCHARGE FOLLOW-UP|5. Tylenol 325 mg 1-2 p.o. q.6h. p.r.n. DISCHARGE FOLLOW-UP: 1. Follow up with Dr. _%#NAME#%_ in two weeks. 2. Device Clinic in one week for staple removal. 3. _%#NAME#%_ _%#NAME#%_, NP, in three months. 4. INR check _%#MMDD2002#%_ at the nursing home with results to the Coumadin Clinic please.
NP|nasopharyngeal|NP|343|344|IMPRESSION|We will obtain urine culture and blood culture and we will empirically treat the patient with antibiotics for a presumed urinary tract infection as she has no allergies to any antibiotics, we will most likely use Tequin 400 mg p.o. q. day or IV if she is unable to take p.o. Pain management will be per orthopedics. The patient will also have NP swabs performed and axillary swabs for MRSA. She will be placed in the contact isolation because of her previous history of MRSA.
NP|nurse practitioner|NP|46|47|PRIMARY CARE PROVIDER|PRIMARY CARE PROVIDER: _%#NAME#%_ _%#NAME#%_, NP (Fairview _%#CITY#%_ Clinic). This is a Fairview _%#CITY#%_ Clinic patient--this patient is not a Fairview Oxboro Clinic patient. CHIEF COMPLAINT: Seven days of left upper quadrant pain. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 35- year-old, G1-0-0-1, female, nondrinker, who complains of a seven-day history of persistent left upper quadrant burning with radiation to the left chest, made worse after eating.
NP|nasopharyngeal|NP|247|248|ASSESSMENT AND PLAN|Patient will be admitted for respiratory observation overnight to assess for significant or severe apneic episodes associated with this upper respiratory symptom. He will be placed on an oximeter with apnea cardiorespiratory monitor being placed, NP swab will be sent for RSV, and his clinical status will be monitored closely. Should significant change or deterioration occur, he will be reevaluated as soon as possible.
NP|nurse practitioner|NP|251|252|IMPRESSION/PLAN|IMPRESSION/PLAN: Ischemic cardiomyopathy, specifically right- sided failure. She will receive a Nesiritide infusion for six hours and if her vital signs are stable, she will go home. She has a follow-up appointment with myself, _%#NAME#%_ _%#NAME#%_, NP at the Minnesota Heart Clinic on _%#MM#%_ _%#DD#%_. At that time, her case will be reviewed with Dr. _%#NAME#%_ again and a decision will be made if she will return for another Nesiritide infusion.
NP|nasopharyngeal|NP|162|163|HOSPITAL COURSE BY SYSTEMS|3. Gastrointestinal: The child had no clinical evidence of gastroesophageal reflux during his hospital stay. 4. Infectious disease: NP swab for RSV was negative. NP swab for pertussis was negative. However, on the second day of hospital stay the child was noted to have an acute otitis media.
NP|nurse practitioner|NP|41|42|PRIMARY PROVIDER|PRIMARY PROVIDER: _%#NAME#%_ _%#NAME#%_, NP HISTORY OF PRESENT ILLNESS: This is a 71-year-old white male with multiple medical problems, who is status post right total knee arthroplasty due to degenerative joint disease. He underwent right minimally invasive total knee arthroplasty on _%#MMDD2006#%_.
NP|nurse practitioner|NP|196|197|PROBLEM #3|The medicine was therefore dropped to 150 mg b.i.d. and we do recommend a repeat CSA level on Friday, _%#MMDD#%_. This case was discussed in detail with accepting provider, _%#NAME#%_ _%#NAME#%_, NP at the _%#CITY#%_ campus and I am very confident that he will continue to receive quality care at that institution.
NP|nurse practitioner|NP|414|415|DISCHARGE FOLLOW-UP|DISCHARGE MEDICATIONS: Amiodarone 200 mg qd, aspirin 81 mg qd, benzonatate 100 mg t.i.d., Capoten 12.5 mg t.i.d., Prevacid 30 mg b.i.d., Lopressor 12.5 mg b.i.d., Remeron 15 mg qhs, Spironolactone 25 mg qd, Nitroglycerin, 0.4 mg sublingual prn chest pain, and Noroxin 20 mg per mL - 5 to 10 mg sublingual q2h prn shortness of breath. DISCHARGE FOLLOW-UP: She is to have an office visit with _%#NAME#%_ _%#NAME#%_, NP at Minnesota Heart Clinic on _%#MM#%_ _%#DD#%_.
NP|nasopharyngeal|NP|463|464|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: Wheezing, associated respiratory illness. Patient will be admitted for further treatment of his wheezing including albuterol nebulization treatments q.4h or q.2h p.r.n. Prelone will be given for anti-inflammatory affect at a dose of 5 mg b.i.d. Chest x-ray was reviewed and it does show streaking consistent with possible left lower lobe pneumonia. Pending the x-ray reading, the patient will be started on Zithromax for antibiotic coverage. NP swab will be sent for RSV, and oximetry will be monitored with oxygen provided to maintain saturations. The patient's clinical status will be monitored closely and should deterioration occur, he will be reevaluated as soon as possible.
NP|nurse practitioner|N.P.|23|26||_%#NAME#%_ _%#NAME#%_, N.P. Green Central community Clinic _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_, MN. _%#55400#%_ _%#MMDD2003#%_ Dear Ms. _%#NAME#%_, Thank you for accepting care of _%#NAME#%_ _%#NAME#%_ from the Neonatal Intensive Care Unit of Fairview-University Children's Hospital.
NP|nurse practitioner|NP|175|176|CONCLUSION|I reviewed activities with the patient. His labs were within normal limits with the exception of Troponin which was elevated at .62. He will follow up in two weeks with a PA, NP in _%#CITY#%_ and then with Dr. _%#NAME#%_ his first available. Dictated by _%#NAME#%_ _%#NAME#%_, PA
NP|nasopharyngeal|NP|119|120|LABS|No other medical problems. ALLERGIES: No known drug allergies. SOCIAL: Lives with parents. LABS: Chest x-ray negative. NP swab for RSV was positive, NP swab for influenza was negative. O2 saturations 87 to 89% on room air. PHYSICAL EXAM: On exam she is alert, tracking and pink.
NP|nurse practitioner|NP|23|24||_%#NAME#%_ _%#NAME#%_, NP Fairview _%#TOWN#%_ _%#TOWN#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_ _%#CITY#%_, MN _%#55100#%_ _%#MM#%_ _%#DD#%_, 2004 Dear Ms. _%#NAME#%_, Thank you for accepting care of _%#NAME#%_ _%#NAME#%_ from the Neonatal Intensive Care Unit of Fairview-University Children's Hospital.
NP|nurse practitioner|NP|138|139|DISCHARGE MEDICATIONS|Diet and exercise were reviewed in thorough detail. The patient will follow up at the Minnesota Heart Clinic in one to two weeks with the NP or PA and then will follow up with Dr. _%#NAME#%_ in approximately three to four months, or sooner if he should have problems.
NP|nurse practitioner|NP|127|128|DISCHARGE FOLLOW UP|Mr. _%#NAME#%_ will follow up with a repeat stress test in 6 weeks time for a new baseline. He does not feel he needs a 2-week NP visit as he has no further questions and feels comfortable with his diagnoses and interventions. Again Mr. _%#NAME#%_ is moving out of state at the end of the summer and would like to move up his appointment with Dr. _%#NAME#%_ for some time in late summer.
NP|nurse practitioner|NP,|174|176|DISCHARGE FOLLOW-UP|5. Metoprolol 50 mg one p.o. b.i.d. 6. Multivitamins once a day. 7. Zocor 40 mg one p.o. q.h.s. DISCHARGE FOLLOW-UP: 1. _%#NAME#%_ will follow up with _%#NAME#%_ _%#NAME#%_, NP, in 1-2 weeks at Minnesota Heart Clinic. 2. She will follow up with either Dr. _%#NAME#%_ or Dr. _%#NAME#%_ in 4-8 weeks. DISCHARGE DIAGNOSES: 1. Coronary artery disease, status post stenting of the distal left anterior descending lesion.
NP|nurse practitioner|NP,|69|71|PRIMARY CAREFIVE|PRIMARY CAREFIVE: She is a primary patient of _%#NAME#%_ _%#NAME#%_, NP, at Fairview Northeast Clinic. CHIEF COMPLAINT: The patient was admitted with chief complaint of fever, chills, vomiting and diarrhea.
NP|nurse practitioner|NP|200|201|HISTORY OF PRESENT ILLNESS|The procedure was explained to the patient. The risks of GI, GU injury, blood loss, infection, possible thromboembolism, blood transfusion were discussed with her. Because of the meconium present and NP was notified to be present at the time of cesarean section. All of her questions were answered regarding the cesarean section.
NP|nurse practitioner|NP|126|127|DISCHARGE MEDICATIONS|He is not symptomatic and reports that he has been somewhat bradycardic most of his life. He will follow up in two weeks with NP or PA and with Dr. _%#NAME#%_ in _%#MM#%_ of 2004. I reviewed medications, follow-up, and activities with the patient.
NP|nurse practitioner|NP.|180|182|DISCHARGING AND TRANSFER MEDICATIONS|9. Sliding scale coverage with lispro if Accu-Chek 200 to 250 2 units, 251 to 300 4 units, 301 to 350 6 units, 351 to 400 8 units, and greater than 401 10 units and call the MD or NP. This coverage is for meals only and not at bedtime. 10. Psyllium (Metamucil) one tablespoon p.o. q. day in an 8 ounce glass of water.
NP|nasopharyngeal|NP|158|159|IMPRESSION|We will admit her to the ICU. We will place her on Accu-Cheks q.i.d. and sliding scale insulin. We will send an RSV NP rapid antigen and also a parainfluenza NP swab. After her cultures have been obtained, we will start the Tequin 400 mg IV q. day.
NP|nurse practitioner|NP|220|221|DISCHARGE INSTRUCTIONS|6. Lantus and Humalog, as well as Glucophage 1000 mg b.i.d., as stated he is to hold this for another 24 hours. 7. He has also been started on Pravachol 40 mg p.o. q.h.s. DISCHARGE INSTRUCTIONS: He should follow up with NP or PA from the Minnesota Heart Clinic in _%#CITY#%_, and will see Dr. _%#NAME#%_ in _%#CITY#%_ in two months time. Reviewed medications, activities and follow-up with this patient and he states understanding.
NP|nurse practitioner|N.P|220|222|IMPRESSION/PLAN|There is 2+ pedal pulses. NEUROLOGICAL EXAM: She is alert and oriented times three. IMPRESSION/PLAN: 1. Angina with positive nuclear stress test. This was discussed with Dr. _%#NAME#%_ and through _%#NAME#%_ _%#NAME#%_, N.P it was decided that this patient should under go coronary angiogram. The patient has been through this procedure in _%#MM#%_ 2004 with results noted above.
NP|nasopharyngeal|NP|128|129|ASSESSMENT AND PLAN|In the airport he had combative episode, unclear if this was a seizure. He certainly did have altered mental status however. An NP was done in the Emergency Department but the results are pending. At this time he does results that show no organism seen but his protein was elevated at 290 and his glucose was 247.
NP|nurse practitioner|NP.|213|215|DISCHARGE MEDICATIONS|5. Prozac 60 mg daily by mouth. 6. Regular insulin sliding scale as follows: 150 to 200 3 units, 201 to 250 6 units, 251 to 300 8 units, 301 to 351 10 units, 351 to 400 12 units, greater than 400 call the M.D. or NP. 7. Lantus insulin 6 units q.p.m. now being given at 1800. 8. Zosyn 3.375 gm IV q.6 h. which we will continue through the _%#DD#%_ then discontinue.
NP|nurse practitioner|NP,|304|306|DISCHARGE MEDICATIONS|7. Nystatin 5 cc p.o. q.i.d. swish and swallow. 8. Fluticasone two sprays every nostril daily. 9. Albuterol inhaler two puffs q.i.d. 10. Insulin sliding scale with Regular insulin if 200 to 250, give 2 units; 251 to 300, 4 units; 301 to 350, 6 units; 351 to 400, 8 units; greater than 400 call the MD or NP, and it is a sliding scale for before meals only, not at bedtime. 11. Magic Mouth Wash 15 to 30 cc, 15 to 30 minutes before meals and medications, as well as p.r.n.
NP|nurse practitioner|NP|69|70|FOLLOW-UP APPOINTMENTS|She will have a fasting lipid profile in 2-3 months. She will see an NP or PA in two weeks at the Minnesota Heart Clinic. I have reviewed her medications, her activities and follow-up instructions and she states an understanding and is discharged in good condition.
NP|nurse practitioner|NP|178|179|FOLLOW-UP|6. Sublingual nitroglycerin 0.4 mg one tablet sublingual q five minutes by three doses prn chest pain. FOLLOW-UP: 1. The patient will be following up with _%#NAME#%_ _%#NAME#%_, NP on _%#MMDD2005#%_ at 2:30 p.m. 2. Follow-up with Dr. _%#NAME#%_ on _%#MMDD2005#%_ at 9:45 a.m. at Fairview Ridges Hospital. 3. Lipid profile at Fairview Ridges Hospital in six weeks time.
NP|nurse practitioner|NP|152|153|DISCHARGE FOLLOW-UP|His LDL triglycerides are so well- controlled. 11. Nitroglycerin 1/150 prn. DISCHARGE FOLLOW-UP: The patient will follow up with Minnesota Heart Clinic NP in 1 to 2 weeks and with Dr. _%#NAME#%_ in approximately three months.
NP|nurse practitioner|NP,|142|144|DISCHARGE FOLLOWUP|DISCHARGE FOLLOWUP: 1. Chemotherapy at Masonic Cancer Clinic on _%#MM#%_ _%#DD#%_, 2005, at 1:30 p.m. 2. Followup with _%#NAME#%_ _%#NAME#%_, NP, on _%#MM#%_ _%#DD#%_, 2005, at 9 a.m. 3. PIC line to be discontinued after cycle #1 chemotherapy completed.
NP|nurse practitioner|N.P.,|138|142|HOSPITAL COURSE|The patient was also started on Protonix 20 mg po daily. The patient to follow-up with her primary care physician, _%#NAME#%_ _%#NAME#%_, N.P., of _%#CITY#%_ Lake Clinic in one week. _%#NAME#%_ _%#NAME#%_ to arrange for patient's outpatient abdomen/pelvis CT scan in one week.
NP|nurse practitioner|NP,|113|115|FOLLOW UP|7. Hytrin 5 mg p.o. q day. 8. Lasix decreased to 20 mg p.o. b.i.d. FOLLOW UP: 1. Follow up with patient's clinic NP, PA or nurse in 7-10 days. 2. Sleep study scheduled for next week. 3. Upgrade to biventricular ICD in three weeks' time.
NP|nurse practitioner|NP,|94|96|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ has been under treatment by _%#NAME#%_ _%#NAME#%_, NP, from the Fairview _%#CITY#%_ Clinic for the past 7 days. He developed soreness in his right ankle. He did not have any injury that was recalled.
NP|nurse practitioner|NP|136|137|PLAN|4. Lipitor 80 mg daily. 5. Nitroglycerin p.r.n. 6. Niaspan 2,500 mg hs. PLAN: 1. The patient will follow-up with Minnesota Heart Clinic NP in 1-2 weeks. 2. Follow-up with Dr. _%#NAME#%_ in approximately 8 weeks. 3. The patient was instructed to call Dr. _%#NAME#%_ for general follow-up.
NP|nurse practitioner|NP,|200|202|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Protonix 40 mg PO daily. 2. Compazine 10 mg PO q.6h. p.r.n. nausea. 3. Oxycodone 5 mg 1-2 tablets q.4h. p.r.n. pain. FOLLOWUP: 1. The patient will see _%#NAME#%_ _%#NAME#%_, NP, in the Masonic Cancer Center at 11 a.m. on _%#MM#%_ _%#DD#%_, 2005. He will have a CBC and comprehensive metabolic panel drawn at this visit.
NP|nurse practitioner|NP|184|185|DISCHARGE AND FOLLOWUP PLANS|1. He will be transferred tomorrow at 0930 hours to _%#CITY#%_ Methodist nursing home. The phone number there is _%#TEL#%_. The fax number is _%#TEL#%_. The _%#CITY#%_ Methodist MD or NP will then be his primary care physician. 2. He should have a basic metabolic panel, magnesium, and hemoglobin drawn on _%#MMDD2005#%_ and the covering physician or nurse practitioner notified.
NP|nasopharyngeal|NP|287|288|ASSESSMENT|Treatment will include albuterol nebulization treatments q.2.h. and q.1.h. p.r.n., IV Solu-Medrol for anti-inflammatory effect and blood culture will be obtained with IV Rocephin being given pending culture results. Chest x- ray will be obtained on admission and the patient with have a NP swab check for RSV and influenza. The patient's oximetry will be monitored with oxygen being provided to maintain saturations.
NP|nurse practitioner|NP,|200|202|FOLLOW UP|The patient did receive Neulasta on her day of discharge in the Oncology Clinic, 6 mg subcutaneously, on _%#MM#%_ _%#DD#%_, 2005. 2. The patient has a followup appointment with _%#NAME#%_ _%#NAME#%_, NP, and Dr. _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2005. She will have lab work; CBC/DP, comprehensive metabolic, LDH, magnesium, and phosphorus at that visit.
NP|nurse practitioner|NP|205|206|DISCHARGE INSTRUCTIONS|She should return to her physician if she notes increased chest pain, breathing difficulty, or an elevated temperature above 101. She will follow up with her primary care physician, _%#NAME#%_ _%#NAME#%_, NP at the Midway Clinic in 1 week for a groin check. Additionally, she should follow up with Dr. _%#NAME#%_ in the division of cardiology here in 4 to 8 weeks at which time she should have a repeat echocardiogram for followup of pericardial effusion.
NP|nurse practitioner|NP,|143|145|DISCHARGE PLAN|2. The patient is to follow discharge instructions including no driving or lifting. 3. The patient is to follow up with _%#NAME#%_ _%#NAME#%_, NP, at Minnesota Heart Clinic in two weeks. 4. The patient is to follow up with Dr. _%#NAME#%_ _%#NAME#%_ in 2-3 months.
NP|nurse practitioner|NP.|85|87|PRIMARY CARE PHYSICIAN|ATTENDING PHYSICIAN: Dr. _%#NAME#%_. PRIMARY CARE PHYSICIAN : _%#NAME#%_ _%#NAME#%_, NP. DISCHARGE DIAGNOSIS: 1. Fever plus neutropenia. 2. Metastatic desmoplastic round cell tumor.
NP|nurse practitioner|N.P.,|37|41|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, N.P., Fairview Uptown Clinic. CHIEF COMPLAINT: Neck pain, bilateral upper extremity numbness. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 55-year-old man with a history of hypertension who presented to the emergency department with about a two week history of neck discomfort.
NP|nurse practitioner|NP|207|208|DISCHARGE PLAN|Patient and his family are aware of this. A copy for this discharge summary will be forwarded to Presbyterian Homes of _%#CITY#%_. His new Primary Care team will be Dr. _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_, NP through the HealthPartners Partnering Care Services program. It should be noted that greater than 30 minutes was spent in discharge planning, care coordination, and physical examination on the date of discharge, _%#MMDD2005#%_.
NP|nurse practitioner|NP,|144|146|ADMISSION LABORATORY|Her symptoms rapidly improved. The main issue became her constant pain that was chronic. She was seen in consultation by _%#NAME#%_ _%#NAME#%_, NP, for pain management who recommended Lyrica, MS Contin and morphine, immediate release for her symptoms. Also, ketoprofen gel applied t.i.d. for her cervical degenerative disease.
NP|nurse practitioner|NP.|239|241|LABORATORY DATA|Recent echocardiogram may show some increased pulmonary pressures for which optimal blood pressure would be appropriate therapy. Her lisinopril was recently increased prior to this admission at her office visit with _%#NAME#%_ _%#NAME#%_, NP. DISCHARGE DISPOSITION: 1. This patient will be discharged to home in the care of herself and her family.
NP|nurse practitioner|NP|164|165|DISCHARGE DISPOSITION|DISCHARGE DISPOSITION: 1. This patient will be discharged to home in the care of herself and her family. 2. Follow-up: This patient will see _%#NAME#%_ _%#NAME#%_, NP on _%#MM#%_ _%#DD#%_, 2006 at 8:30 a.m. and have a basic metabolic panel drawn at that time as she was increased on her ACE inhibitor recently.
NP|nurse practitioner|NP,|213|215|FOLLOW-UP INSTRUCTIONS|FOLLOW-UP INSTRUCTIONS: 1. Post cath care and instructions were reviewed with the patient in detail. 2. Plavix was recommended for one year uninterrupted. 3. The patient will follow up with _%#NAME#%_ _%#NAME#%_, NP, in 3-4 weeks time. 4. The patient will be continued on other home meds. 5. The patient will be discharged home.
NP|nurse practitioner|NP.|251|253|FOLLOW UP|FOLLOW UP: 1. Followup appointments with Dr. _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2006, in the cystic fibrosis clinic at 11:20 a.m. 2. Additional pre-lung transplantation evaluation to be completed with the assistance of _%#NAME#%_ _%#NAME#%_, NP. 3. Tobra kinetics, BUN, creatinine, potassium, and magnesium on a weekly basis through his home health company with results to be faxed to the cystic fibrosis center at the University of Minnesota Medical Center, Fairview, and that number is _%#TEL#%_.
NP|nurse practitioner|NP|158|159|DISCHARGE CONDITION|DISCHARGE CONDITION: Stable. Follow up with Dr. _%#NAME#%_ _%#NAME#%_ in _%#MDMD2006#%_ as scheduled. Follow up with Primary Care Clinic with Ms. _%#NAME#%_, NP at Fairview Northeast Clinic in 1 week. DISCHARGE DIET: Low-salt diet. ACTIVITY: As tolerated.
NP|nasopharyngeal|NP|202|203|REVIEW OF SYSTEMS|PAST MEDICAL HISTORY: Denies any chronic medical conditions. REVIEW OF SYSTEMS: Constitutional negative for weight change, positive for fevers and chills as above. Eyes negative for any visual changes. NP negative for sore throat, cough, runny nose, nasal congestion. Respiratory negative for cough and shortness of breath. Cardiovascular negative for chest pain and palpitations.
NP|nurse practitioner|NP|302|303|DISCHARGE FOLLOW-UP|His distal pulses are intact as well . LABORATORY DATA: Creatinine 0.96, BUN 15, potassium 3.8, hemoglobin 13.8, post procedure troponin 0.15. DISCHARGE DISPOSITION: This patient will be discharged to home in the care of himself and his wife. DISCHARGE FOLLOW-UP: 1. He will see _%#NAME#%_ _%#NAME#%_, NP with Dr. _%#NAME#%_ in two weeks. 2. He will see Dr. _%#NAME#%_ in 2 to 3 months. 3. He will need stress testing likely at six months and I will defer the type of stress testing to Dr. _%#NAME#%_, albeit stress echocardiogram versus nuclear stress testing.
NP|nurse practitioner|NP|138|139|IMPRESSION/PLAN|5. Cardiac rehab and dietary scheduled to see this patient prior to discharge home. 6. Follow-up appointment to be scheduled with the PA, NP in 1 to 2 weeks and with Dr. _%#NAME#%_ _%#NAME#%_ in 2 to 4 months. 7. If the patient should develop chest discomfort, perhaps secondary to small occluded vessel that did have collateral flow, indirect could be considered, per Dr. _%#NAME#%_'s note on cath.
NP|nurse practitioner|NP,|234|236|DISCHARGE FOLLOW-UP|Hematocrit is 31.1, creatinine 1.14, BUN 16, potassium 4.3 and troponin less than 0.04. EKG does demonstrate normal sinus rhythm with no ST changes noted. DISCHARGE FOLLOW-UP: 1. The patient will follow up with _%#NAME#%_ _%#NAME#%_, NP, in 1-2 weeks time at MN Heart Clinic or may follow with a NP or PA at _%#CITY#%_ in two weeks time. 2. The patient will follow up with Dr. _%#NAME#%_ in three months time.
NP|nurse practitioner|(NP),|184|188|FOLLOWUP|5. Ativan 1 mg p.o. t.i.d. p.r.n. Sertraline, citalopram, and ziprasidone were discontinued. FOLLOWUP: 1. The patient is to be seen by her primary care provider, _%#NAME#%_ _%#NAME#%_ (NP), at Community University Health Care, _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#CITY#%_. The patient was instructed to call for an appointment. Her primary care provider is to arrange for further evaluation of the small solitary nodule noted on the chest x-ray.
NP|nurse practitioner|NP.|244|246|PRIMARY CARE PHYSICIAN|PREOPERATIVE DIAGNOSIS: Morbid obesity. POSTOPERATIVE DIAGNOSIS: Morbid obesity. PROCEDURE: Laparoscopic gastric bypass. SURGEON: Dr. _%#NAME#%_ _%#NAME#%_. ASSISTANT: _%#NAME#%_ _%#NAME#%_, PA-C PRIMARY CARE PHYSICIAN: _%#NAME#%_, _%#NAME#%_, NP. HOSPITAL COURSE: She underwent laparoscopic gastric bypass under general anesthesia, uncomplicated.
NP|natriuretic peptide|NP|144|145|HISTORY OF PRESENT ILLNESS|Blood sugar was high at 195. Myoglobin and troponin were negative. EKG is unremarkable. The end terminal BNP was elevated at 441 but the B-type NP was 90. She was admitted for antibiotics, steroids and oxygen. PAST SURGICAL HISTORY: She had a bladder repair. Hospitalizations otherwise only for pulmonary fibrosis.
NP|nurse practitioner|NP.|235|237|PROBLEM #2|PROBLEM #2: Hepatitis C, previously diagnosed. Her interferon and ribavirin were not restarted, as her immune thrombocytopenia is felt secondary to her hepatitis C treatment. She will follow up in GI clinic with _%#NAME#%_ _%#NAME#%_, NP. PROBLEM #3: Bipolar disorder, previously diagnosed. We continued her Lithium and her mood remained stable.
NP|nurse practitioner|NP|202|203|FOLLOW-UP|9. Prednisone 65 mg p.o. daily until _%#MMDD2007#%_. Further tapering will be done by the GI nurse practitioner _%#NAME#%_ _%#NAME#%_. FOLLOW-UP: She will be seen in GI Clinic by _%#NAME#%_ _%#NAME#%_, NP on _%#MMDD2007#%_.
NP|nurse practitioner|NP|161|162|DISPOSITION|9. Aspirin has been discontinued due to increased bleeding risk associated with Coumadin. DISPOSITION: 1. The patient will follow up with _%#NAME#%_ _%#NAME#%_, NP at Minnesota Heart Clinic in two weeks for post-procedure evaluation. 2. Follow up with Dr. _%#NAME#%_ on a p.r.n. basis as needed. 3. Follow up with Dr. _%#NAME#%_ at HealthPartners. 4. INR on Monday, _%#MMDD#%_ at HealthPartners or through home health care, with results to be managed by Dr. _%#NAME#%_.
NP|nasopharyngeal|NP|145|146|PLAN|ABDOMEN: Soft, no masses. SKIN: Negative. ASSESSMENT: Possible ALTE. PLAN: Admit to Peds for observation. Continue with pulse ox and CR monitor. NP swab for pertussis and RSV. We will also check CBC and electrolytes.
NP|nurse practitioner|NP.|303|305|ASSISTANT|PREOPERATIVE DIAGNOSIS: Morbid obesity. POSTOPERATIVE DIAGNOSIS: Morbid obesity. PROCEDURE: Laparoscopic placement of gastric band #10 and incidental repair of hiatal hernia. SURGEON: _%#NAME#%_ _%#NAME#%_, MD ASSISTANT: _%#NAME#%_ _%#NAME#%_, PA-C Family health care provider is _%#NAME#%_ _%#NAME#%_, NP. CURRENT HOME MEDICATIONS: 1. Norvasc. 2. Albuterol. 3. Advair. No known drug allergies.
NP|nurse practitioner|NP.|308|310|FOLLOW-UP INSTRUCTIONS|7. Celebrex 200 mg p.o. b.i.d. 8. Calcium 500 mg tablet p.o. q.i.d. p.r.n. Of note, metoprolol 25mg p.o. b.i.d. has been discontinued from his medication regimen. FOLLOW-UP INSTRUCTIONS: Patient was instructed to follow up at Minnesota Heart Clinic with _%#NAME#%_ _%#NAME#%_, PA-C or _%#NAME#%_ _%#NAME#%_, NP.
NP|nurse practitioner|NP|150|151|HISTORY OF PRESENT ILLNESS|The patient was recently discharged on _%#MMDD#%_, she took steroids orally until _%#MMDD#%_ and was doing quite well. She saw _%#NAME#%_ _%#NAME#%_, NP at Crosstown Clinic and was in fact doing well this past Tuesday. However, on Friday the patient noted that she began to have increasing shortness of breath with wheezing and she also had a sore throat.
NP|nurse practitioner|NP|161|162|INDICATION FOR CARDIAC CONSULTATION|His past medical history, family history, social history and medications as well as allergies have been outlined in detail by my colleague _%#NAME#%_ _%#NAME#%_ NP on her dictation of _%#MMDD2006#%_. I have reviewed that; I have nothing to add to that. REVIEW OF SYSTEMS: CONSTITUTIONAL: Tiredness. EYES: Negative. ENT: Negative. CARDIOVASCULAR: As above.
NP|nurse practitioner|NP.|134|136|TRANSFERRING MEDICATIONS|3. Lopressor 75 mg p.o. twice daily, hold for systolic blood pressure less than 100 or heart rate less than 60 and call the MD or the NP. 4. Pravachol 40 mg p.o. every night at bedtime (she had been on Zocor. This was discontinued by the Transplant Team to Lipitor which was then discontinued to the Pravachol secondary to a high risk of rhabdomyolysis with the patient being on cyclosporin as well as amiodarone).
NP|nurse practitioner|N.P.|186|189|HOSPITAL COURSE|Discussion was carried out regarding further evaluation. The patient was discharged on that date to follow up at _%#CITY#%_-Lake Clinic with her primary provider, _%#NAME#%_ _%#NAME#%_, N.P. in two to three days. She was to call or return sooner if increasing discomfort in the meantime. DISCHARGE INSTRUCTIONS: 1) Medications; Ortho Tricycline, Tylenol with codeine elixir two to three teaspoons q. four hours p.r.n., Vitamin B12, and Multivitamin.
NP|nurse practitioner|NP,|159|161|HISTORY OF PRESENT ILLNESS|She developed vomiting with her coughing, and continued to do that. She had some diarrhea on the day before hospital admission. She saw _%#NAME#%_ _%#NAME#%_, NP, at the Fairview Northeast Clinic today, and was sent to the Emergency Room. She was examined there and x-rayed, and admitted with acute pneumonia.
NP|nurse practitioner|NP,|201|203|DISCHARGE FOLLOW-UP|DISCHARGE FOLLOW-UP: 1. The patient will have follow-up INR at Minnesota Heart Clinic on _%#MMDD2002#%_ with also recheck of electrolytes at that time. 2. He will follow up with _%#NAME#%_ _%#NAME#%_, NP, at Minnesota Heart Clinic and Cardiomyopathy Clinic in approximately one week. 3. He will follow up with his usual physician, Dr. _%#NAME#%_ _%#NAME#%_, in 1-2 months.
NP|UNSURED SENSE|NP,|202|204|DOB|DOB: _%#MMDD1955#%_ A pleasant 47-year-old white female recently relocated here from Texas presented to the emergency room with a three-day history of lower abdominal pain, vomiting, no bowel movement, NP, and anorectic. In the emergency room, evaluation including flat plate and upright of the abdomen showed distended loops of small bowel consistent with small- bowel obstruction.
NP|nurse practitioner|NP,|41|43|PRIMARY PROVIDER|PRIMARY PROVIDER: _%#NAME#%_ _%#NAME#%_, NP, at Fairview Northeast. DISCHARGE DIAGNOSES: 1. Clostridium difficile colitis. 2. Dehydration. HISTORY OF PRESENT ILLNESS: The patient is a _%#1914#%_ female who was recently discharged from the hospital after being treated for Clostridium-difficile-positive colitis.
NP|nurse practitioner|NP,|44|46|REFERRING PHYSICIAN|REFERRING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, NP, at Altru Clinic HISTORY OF PRESENT ILLNESS: This 62-year-old female presented with a 1- to 2-month history of increasing abdominal girth, right upper quadrant pain, shortness of breath for 1-2 months. Her workup in North Dakota led to a CT scan of the abdomen and pelvis, which demonstrated a left adnexal mass 5-6 cm with calcification, cystic and solid components.
NP|nurse practitioner|NP,|222|224|FOLLOW UP|This should continue through _%#MM#%_ _%#DD#%_, 2003. 12. Percocet 1 to 2 tablets p.o. q.4-6h. p.r.n. for pain. FOLLOW UP: 1. The patient should make an appointment to see her primary care physician _%#NAME#%_ _%#NAME#%_, NP, in 1 to 2 weeks at Fairview Northwest Clinic. 2. The patient has a followup appointment with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2003, at 9:30 in the morning.
NP|nurse practitioner|NP|23|24||_%#NAME#%_ _%#NAME#%_, NP _%#CITY#%_ Occupational Health Care _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, WI _%#53500#%_ _%#MM#%_ _%#DD#%_, 2003 Dear Mr. _%#NAME#%_: Thank you for accepting care of _%#NAME#%_ _%#NAME#%_ from the Neonatal Intensive Care Unit of Fairview-University Children's Hospital.
NP|nurse practitioner|NP,|103|105|DISCHARGE MEDICATIONS|2. Ferrous sulfate in the form of Slo-Fe tabs one daily. He will follow up with _%#NAME#%_ _%#NAME#%_, NP, in our clinic next week for follow up hemoglobin. He will also return to work on Monday. The patient was counseled to avoid all alcohol now and in the future.
NP|nurse practitioner|NP|23|24||_%#NAME#%_ _%#NAME#%_, NP Westside Community Health Services La Clinica En Lake _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_, MN _%#55400#%_ _%#MM#%_ _%#DD#%_, 2003 Dear Ms. _%#NAME#%_: I am writing to you to summarize the brief re- and post-natal course of _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, the infant daughter of your patient _%#NAME#%_ _%#NAME#%_.
NP|nurse practitioner|NP|121|122|DISCHARGE MEDICATIONS|7. Nitroglycerin 1/150th sublingually p.r.n. 8. Folate 2.2 mg a day. He will follow up in our office in a month with our NP and with me in three months. He will have an echo in three months. We will get a lipid profile in three months.
NP|nurse practitioner|NP|37|38|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, NP (Allina Medical Clinic - _%#CITY#%_) HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 62-year- old woman with known chronic obstructive pulmonary disease (COPD) who was in her usual state of health until approximately two days prior to admission when she developed rhinorrhea and a cough and because of increasing shortness of breath the patient presented to the emergency room.
NP|nasopharynx|NP,|178|180|PHYSICAL EXAMINATION|General: Well-built, well-nourished female sitting comfortably in bed. HEENT: No rashes or lesions. Head: Normocephalic and atraumatic. Pupils equal round and reactive to light. NP, OP normal. Neck: Supple, no lymphadenopathy. Cardiovascular: Regular rate and rhythm without murmurs, rubs or gallops. Lungs clear to auscultation bilaterally. Abdomen soft nontender, nondistended, bowel sounds positive.
NP|nurse practitioner|NP.|175|177|DISCHARGE DIAGNOSES|1. Status post right great toe amputation secondary to osteomyelitis. The patient is followed closely by the Wound Clinic and Dr. _%#NAME#%_ as well as _%#NAME#%_ _%#NAME#%_, NP. He does have a wound vac in place which was placed last Friday with which he will go home. 2. Diabetes. Hemoglobin A1c was over 8 here. We have done extensive diabetic education as well as have adjusted his diabetic medications to obtain better control.
NP|nurse practitioner|NP.|185|187|DISCHARGE MEDICATIONS|7. Lisinopril 2.5 mg q.a.m. 8. Augmentin 500 mg twice daily indefinitely until evaluated and changed by the wound clinic under the auspices of Dr. _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_, NP. 9. Percocet one to two tablets p.o. q. every 4 to 6 hours p.r.n. pain. ALLERGIES: No known drug allergies.
NP|nurse practitioner|NP|139|140|DISCHARGE FOLLOW-UP|8. Plavix 75 mg 1 p.o. q.d. x 6 months (new medication). DISCHARGE FOLLOW-UP: 1. Mr. _%#NAME#%_ will follow up with _%#NAME#%_ _%#NAME#%_, NP (Minnesota Heart Clinic) in one week's time prior to him leaving for Florida for the winter. 2. He will have a follow-up visit with Dr. _%#NAME#%_ when he returns from Florida in the spring.
NP|nurse practitioner|NP|311|312|DISCHARGE PLAN|DISCHARGE PLAN: He will follow up with Dr. _%#NAME#%_. I did explain to him that because his cholesterol is elevated that his Lipitor dose was increased to 20 p.o. q.h.s. He should follow up with Dr. _%#NAME#%_ in six weeks to have a fasting lipid profile. He will follow up with Minnesota Heart Clinic with an NP or PA in two weeks, and with Dr. _%#NAME#%_ in 12 weeks. I reviewed medications, activities and follow-up with the patient and he states understanding.
NP|nurse practitioner|NP,|145|147|DISCHARGE FOLLOW UP|2. Vicodin 1-2 p.o. q.4-6h. p.r.n. severe headache (dispensed #10). DISCHARGE FOLLOW UP: The patient is to follow up with _%#NAME#%_ _%#NAME#%_, NP, at Fairview _%#TOWN#%_ _%#TOWN#%_ Clinic, in 5-7 days. At that time, the patient can get the results of the PCR from the CSF for enterovirus, which are currently pending.
NP|nurse practitioner|NP|240|241|DISCHARGE INSTRUCTIONS|The patient was discharged to home on _%#MM#%_ _%#DD#%_ with aspirin, Lipitor, amiodarone, Zantac, Oxycodone and Coumadin. He will see Dr. _%#NAME#%_ in two to four weeks and Dr. _%#NAME#%_ in four weeks. He will see _%#NAME#%_ _%#NAME#%_, NP at the Minnesota Heart Clinic in one week and Dr. _%#NAME#%_ in three weeks.
NP|nasopharyngeal|NP|204|205|HOSPITAL COURSE BY PROBLEMS|The patient was asked to complete eight days of Augmentin as an outpatient for a total of 10 days of antibiotic therapy. 3. Reactive airway disease flare-up in the context of RSV: The patient did have an NP swab which was positive for RSV during his hospitalization. The patient initially required every 4-hour nebulizations and blowby O2 supplementation.
NP|nasopharyngeal|NP|277|278|PHYSICAL EXAM|White blood cell count is 13,800 with 14 lymphocytes. Cath urine was obtained with moderate blood, moderate leukocytes, 10-20 white blood cells, few bacteria. Urine culture is pending. Blood culture will be obtained in the hospital. Chest x-ray was obtained and looked normal. NP for RSV was also obtained. Secondary to age and respiratory status the patient was admitted to Special Care Status at Peds Ridges floor for cardiac and oxygen monitoring, IV antibiotics, Albuterol nebs, IV fluids.
NP|nurse practitioner|NP|187|188|DISCHARGE DIAGNOSES|4. Abdominal pain secondary to pelvic mass. 5. Myoclonus. _%#NAME#%_ _%#NAME#%_ is DNR/DNI and is being discharged on "comfort care" to hospice. For questions call _%#NAME#%_ _%#NAME#%_, NP at the TLC team palliative care at _%#TEL#%_. DISCHARGE MEDICATIONS: 1. Duragesic 50 mcg patch, change q. 72 h.
NP|nurse practitioner|NP|144|145|DISCHARGE FOLLOW-UP|Her new medications include Lipitor 20 mg once daily, and Plavix 75 mg once daily. DISCHARGE FOLLOW-UP: 1. Ms. _%#NAME#%_ will follow up with a NP or PA visit in one to two weeks at Minnesota Heart Clinic. 2. She will have a repeat heart cath in two to three weeks for her to have an intervention on her left anterior descending artery.
NP|nurse practitioner|NP|37|38|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, NP (_%#CITY#%_ Lake Clinic) DISCHARGE DIAGNOSIS: 1. Lateral tibial plateau fracture. 2. Anemia. BRIEF HISTORY: _%#NAME#%_ _%#NAME#%_.
NP|nurse practitioner|NP,|242|244|HISTORY OF PRESENT ILLNESS|(The patient herself reports that she did not really have major symptoms during that test.) The patient had an episode lasting 4 minutes today. She also had fevers. She presented to _%#CITY#%_ Lake Clinic where she saw _%#NAME#%_ _%#NAME#%_, NP, who ordered a blood count which showed a white count 5.6, hemoglobin 13.7, platelets 383 and because of that she was advised to go to Fairview Southdale Hospital emergency room where she was evaluated by Dr. _%#NAME#%_ _%#NAME#%_ who placed her on oxygen which improved her symptoms.
NP|nurse practitioner|NP|37|38|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, NP (HealthPartners Regions Specialty Clinics) DISCHARGE DIAGNOSIS: 1. Skin abscess at the left axilla and superior right shoulder.
NP|nurse practitioner|NP|122|123|TRANSFERRING MEDICATIONS|A. If 200 to 250, 2 units. B. If 251 to 300, 4 units. C. If 301 to 350, 6 units. D. If 351 to 400, 8 units. E. Call MD or NP if it is greater than 400. 16. Lopressor 25 mg p.o. b.i.d. Hold for systolic blood pressure less than or equal to 100, or heart rate less than or equal to 60.
NP|nurse practitioner|NP|245|246|HISTORY OF THE PRESENT PROBLEM|She has been seeing a therapist, Dr. _%#NAME#%_, through the Isles Allina Clinic. Dr. _%#NAME#%_ referred _%#NAME#%_ to our program. _%#NAME#%_ has been receiving psychiatric medicines, including Zoloft and trazodone from _%#NAME#%_ _%#NAME#%_, NP with the Allina Clinic. PAST CHEMICAL DEPENDENCY HISTORY: None known. PAST PSYCHIATRIC HISTORY: Significant for onset of treatment approximately 1958.
NP|nurse practitioner|NP,|309|311|DISPOSITION AT DISCHARGE|He is to follow up with his primary nephrologist in _%#CITY#%_, ND, on Thursday, _%#MMDD2007#%_, at 11 a.m. The patient is to have kidney transplant discharge appointment with Dr. _%#NAME#%_ on _%#MMDD2007#%_ at 8 a.m. The patient is to have a kidney discharge 1-month appointment with _%#NAME#%_ _%#NAME#%_, NP, on _%#MMDD2007#%_ at 8:30 a.m., and patient is to have a kidney discharge 3-month appointment with Dr. _%#NAME#%_ again, on _%#MMDD2007#%_, at 2:40 p.m. The patient is tentatively scheduled for dialysis in _%#CITY#%_ _%#CITY#%_ on _%#MMDD2007#%_, _%#MMDD2007#%_, and _%#MMDD2007#%_ at 6 a.m., and in _%#CITY#%_ on _%#MMDD2007#%_ (patient to arrange for _%#CITY#%_).
NP|nurse practitioner|NP|23|24|ASSESSMENT AND PLAN|_%#NAME#%_ _%#NAME#%_, NP Southdale OB-GYN _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_, MN _%#55300#%_ Dear Nurse Practitioner _%#NAME#%_: Thank you for the kind referral of your patient, _%#NAME#%_ _%#NAME#%_, who was seen for genetic counseling at the Maternal-Fetal Medicine Center at University of Minnesota Medical Center, Fairview on _%#MM#%_ _%#DD#%_, 2006. As you know, Ms. _%#NAME#%_ was referred for first trimester screening.
NP|nurse practitioner|NP|157|158|PLAN|Wife is unclear regarding no further antibiotics at this time and intervention that can be done at the nursing facility. 2. Nurse practitioner will call the NP who sees the patient in the nursing facility and relate the do-not hospitalize goal and family unclear at this point about antibiotics which can continue to be sorted out while in the nursing home.
NP|nurse practitioner|NP,|89|91|FOLLOW-UP CARE|2. The patient is scheduled for follow-up with Dr. _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_, NP, at the Oncology Clinic on _%#MMDD2002#%_ at 9:00 a.m. 3. The patient is scheduled for readmission to the Children's Center on _%#MMDD2002#%_ for her next phase of her chemotherapy.
NP|nurse practitioner|NP|177|178|PLAN|6. TLC will continue to follow to assist with end of life symptoms and to support family. We will evaluate whether transfer to hospice is appropriate in the a.m. 7. Please call NP for concerns 24/7 at _%#TEL#%_ Thank you very much for allowing TLC to participate in this patient's journey at this time.
NP|nurse practitioner|NP|240|241|ACTION PLAN|2) Jerky movements with slightly crying out, appears uncomfortable. Will start rectal methadone with Dilaudid for breakthrough. 3) Discontinue IV fluids and change to hep lock. 4) Hospice consult. 5) Message left for son _%#NAME#%_ to call NP to review any questions family might have. 6) TLC will continue to follow. Thank you very much for this consult. Time in evaluation of patient and discussion with staff was one hour.
NP|nurse practitioner|NP|23|24||_%#NAME#%_ _%#NAME#%_, NP Fairview Northeast Clinic _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_, MN _%#55400#%_ Dear _%#NAME#%_: Update on Ms. _%#NAME#%_ who recently was referred to me by yourself because of anemia secondary to iron deficiency refractory to orally administered iron products.
NP|nurse practitioner|NP|145|146|PLAN|1. Briefly discussed with the patient the goal of comfort but it was difficult for him to talk, although patient very pleasant and receptive. 2. NP talked to his wife briefly and the plan is for her and a family member to be here for a conference to review the patient's status with the patient and the goals of care.
NP|nurse practitioner|NP,|167|169|HISTORY OF PRESENT ILLNESS|The patient is nonambulatory and transports with her wheelchair. The patient is not currently taking any analgesics for knee pain. I spoke with _%#NAME#%_ _%#NAME#%_, NP, and he informed me that the patient was interested in receiving Botox injections but was told that she would need to try cortisone injections first.
NP|nurse practitioner|NP|99|100||Mrs. _%#NAME#%_ _%#NAME#%_ is a 34-year-old patient, kindly referred by Ms. _%#NAME#%_ _%#NAME#%_, NP at Fairview _%#TOWN#%_ _%#TOWN#%_ Clinic. Mrs. _%#NAME#%_ is referred for colonoscopy. The procedure has been performed without any problems. The whole colon and the terminal ileum look fine.
NP|nurse practitioner|NP|345|346|AP|3) Comfortable, p.r.n. morphine is available. 4) Consider family conference tomorrow to discuss nutrition options, nasogastric tube to start with, and evaluate return of swallow in a few weeks in a rehabilitation center perhaps. 5) TLC chaplain to visit and address spiritual concerns. 6) TLC social worker to evaluate psychosocial concerns and NP to continue to monitor symptoms. Team will assist in clarifying treatment goals. 7) Any questions please call.
NP|nurse practitioner|NP,|191|193|HISTORY OF PRESENTING ILLNESS|Over the past couple of months, she has had dyspnea on exertion, significant shortness of breath, paroxysmal nocturnal dyspnea and orthopnea. She was seen yesterday by _%#NAME#%_ _%#NAME#%_, NP, in our clinic, and was started on Demadex and atenolol. Unfortunately, last evening, she had a terrible evening with having to sit upright in a chair all night because of shortness of breath, and she came in today to see Dr. _%#NAME#%_, and was subsequently admitted to the hospital.
NP|nasopharyngeal|NP|193|194|IMPRESSION|Will switch from dobutamine to dopamine. Will await blood, urogenital and urine cultures to return. Will check a TSH in the morning. Will replace her potassium as she is hypokalemic. I sent an NP swab to rule out influenza although I feel this is not compatible with her history. Further decisions on antibiotics will be based on the results of urine cultures and blood cultures as they become available, trying to direct the antibiotic therapy to include gram- positives, both aerobic and anaerobic as well as methicillin-resistant Staphylococcus aureus, gram-negative rods including Pseudomonas and gram-negative anaerobic rods which should be accomplished with the regimens recommended above.
NP|nurse practitioner|NP|85|86|PRIMARY CARE|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, NP (Fairview EdenCenter Clinic). REASON FOR CONSULTATION: Thank you for asking me to evaluate this 48-year-old female for evaluation and treatment of methicillin-resistant Staphylococcus aureus (MRSA) pneumonia and urinary tract infection (UTI) postoperatively after sigmoid perforation and sigmoidectomy.
NP|nurse practitioner|N.P.|344|347|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Chronic daytime fatigue, shortness of breath with activity, sleep disturbances, heartburn, high blood pressure exacerbated by morbid obesity. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 43-year-old African-American female who has been referred into our program from her primary care physician _%#NAME#%_ _%#NAME#%_, N.P. She describes a 17 year struggle with her weight where she has attempted to lose weight on her own through exercise and dieting and over-the-counter medications.
NP|nurse practitioner|NP|161|162|PHYSICAL EXAMINATION|CARDIOVASCULAR: Difficult to assess as well. ABDOMEN: Appears distended. Does have reduced bowel sounds and is also sensitive to touch. EXTREMITIES: Yelled when NP barely touched her feet SKIN: Cool, dry, hypersensitive to touch everywhere. PLAN: 1. As discussed with Dr. _%#NAME#%_, will discontinue the MS Contin and start with methadone at 4 mg p.o. every 8 hours, with p.r.n. morphine 2 mg every 1 hour for breakthrough.
NP|nurse practitioner|NP,|193|195|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Morbid obesity . HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 39-year-old African-American female referred to Southdale weight loss surgery by _%#NAME#%_ _%#NAME#%_, NP, of North Memorial Family Physicians clinic. The patient reports being morbidly obese for the last 15 to 20 years. In the last 10 years, the patient has made numerous attempts at weight loss to include diet changes, exercise and two physician-monitored weight loss attempts through medication and monitoring.
NP|nurse practitioner|NP|43|44|REFERRING PHYSICIAN|REFERRING PHYSICIAN: _%#NAME#%_ _%#NAME#%_ NP REASON FOR CONSULTATION: Evaluate for potential transfer to the fifth floor. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 59-year-old gentleman with previous history of alcohol abuse, hypertension and nonsmall cell cancer with metastasis to his brain who on _%#MMDD2007#%_ experienced sudden onset of right hemiplegia and difficulty speaking while fishing.
NP|nurse practitioner|NP|37|38|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, NP (_%#CITY#%_ Lake Clinic). DISCHARGE DIAGNOSIS: Urticaria possibly secondary to carpet pad. PROCEDURES THIS ADMISSION: None. DISCHARGE MEDICATIONS: 1. Benadryl 50 mg p.o. q.8h. p.r.n. pruritus x 2 days.
NP|nurse practitioner|NP.|144|146|ASSESSMENT AND PLAN|Thank you very much for the consultation. TLC will continue to follow. One and a half hours spent in discussion with nursing staff and Evercare NP. More than 50% of this time was spent gathering and exchanging information.
NP|nurse practitioner|NP|255|256|ACTION AND PLAN|2. Son wants to discuss overall goals of care with his mother before deciding on dc of tele and change in full code status. 3. Son will contact Dr. _%#NAME#%_ to discuss prognosis/function return and then would appreciate family conference. Son will call NP to arrange that time. 4. Liquid Senokot for PEG for his bowels. 5. First step mattress. 6. Try to get patient up out of bed b.i.d.
NP|nurse practitioner|NP.|45|47|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, NP. REASON FOR CONSULTATION: Evaluate shortness of breath and cough. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 47-year-old female, who is a 10+ pack year tobacco smoker who was admitted for further evaluation of chest pain.
NP|nurse practitioner|NP.|65|67|REQUESTING PHYSICIAN|TBA: _%#MMDD2005#%_ REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, NP. PROCEDURE: Shallow LEEP cone biopsy of the cervix HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 54-year-old white female, gravida 0, para 0, who had a Pap smear on _%#MM#%_ _%#DD#%_, 2005, that indicated epithelial cell abnormality, atypical squamous cells of undetermined significance, but cannot rule out high grade intraepithelial lesion. The patient was then seen by me and she underwent colposcopy that showed a white epithelium with a sharp border and some mosaic consistent with CIN-II.
NP|nurse practitioner|N.P.|279|282|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Hypertension, hypothyroidism, reflux and fatigue exacerbated by morbid obesity. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 48-year-old Caucasian female who is referred into our program from her primary care provider _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, N.P. The patient describes a 30 year plus struggle with her weight where she has had at least ten different attempts at Weight Watchers.
NP|nurse practitioner|N.P.|186|189|PLAN|NEUROLOGIC: Cranial nerves II-XII are grossly intact. PLAN: The patient is a 48-year-old Caucasian female referred into our program from her primary care provider _%#NAME#%_ _%#NAME#%_, N.P. Her internist is Dr. _%#NAME#%_ MD The patient has already started her psychological evaluation with Dr. _%#NAME#%_ and will complete that. We have asked her to get a letter of recommendation from her therapist as well.
NP|nurse practitioner|NP,|331|333|REASON FOR CONSULTATION|He was admitted today through the emergency room for weakness and shortness of breath that has been progressive over the last several weeks and actually not feeling himself since a _%#MM#%_ admission when he had pneumonia. He has known chronic renal failure with creatinines up to 3.6 and BUN 67 as noted by _%#NAME#%_ _%#NAME#%_, NP, at an office visit in _%#MM#%_ of this year. He takes Lasix 80 mg twice per day and tends to notice that he does have ankle swelling.
NP|nurse practitioner|NP|69|70|REQUESTING CARE PROVIDER|TBA: _%#MMDD2004#%_ REQUESTING CARE PROVIDER: _%#NAME#%_ _%#NAME#%_, NP HISTORY: _%#NAME#%_ _%#NAME#%_ is a 24-year-old female patient referred by _%#NAME#%_ _%#NAME#%_ from Family Practice department for consultation regarding a ventral abdominal hernia. The patient has been in her normal state of health until about a week ago when she started developing a bulge above her umbilicus in the mid abdomen and it was quite painful initially.
NP|nurse practitioner|NP|159|160|DISPOSITION|DISPOSITION: 1) Depending on bed availability, discharge could likely be tomorrow. Will update Dr. _%#NAME#%_ after our family meeting this afternoon. 2) Call NP for comfort concerns 24 hours a day, 7 days a week. 3) When pain controlled with check bowels. Thank you very much for the opportunity to care for this patient and his family.
NP|nurse practitioner|NP,|297|299|REASON FOR CONSULTATION|_%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 57-year- old patient with chronic lymphocytic leukemia (CLL) who has been on chemotherapy and just underwent his third cycle of therapy about three weeks ago. He was seen earlier today by Dr. _%#NAME#%_'s nurse practitioner, _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, NP, who noted significant tenderness in the right lower quadrant. The patient had a history of 3-4 days of increasing abdominal pain and now seeming to localize to the right lower quadrant.
NP|nurse practitioner|NP|243|244|ACTION & PLAN|Evaluate mood and appetite after dyspnea is controlled. Small frequent meals may be more likely tolerated and will change IV to TKO. 5. Comfort care and referral will be made to hospice. 6. Above reviewed with Dr. _%#NAME#%_ and in agreement. NP will review steroid dosing with Dr. _%#NAME#%_. 7. TLC will continue to follow and provide psychosocial, spiritual and symptom support.
NP|nurse practitioner|NP|163|164|HISTORY OF PRESENT ILLNESS|Dr. _%#NAME#%_ told her that her back was inoperable, and she is currently seeking a second opinion. Her pain is currently being managed by _%#NAME#%_ _%#NAME#%_, NP at Fairview Uptown Clinic. She complains of right wrist pain, after bumping it on an exam table last week. She says she had surgery on the right wrist in 1994.
NP|nurse practitioner|NP|267|268|ASSESSMENT|1. Depression, treatment per Dr. _%#NAME#%_. 2. Chronic pain and neuropathy; will request Fairview rounding physician to see her for treatment and labs. She declined Lidoderm patch and will discuss its use with the rounder. She is a patient of _%#NAME#%_ _%#NAME#%_, NP at Fairview Uptown Clinic. 3. Gastroesophageal reflux disease (GERD). Will continue Protonix as per hospital formulary. 4. Asthma, controlled with Atrovent. No changes made. Thank you for this consultation.
NP|nurse practitioner|NP|235|236|DISPOSITION|Unit spiritual health services resident, _%#NAME#%_, is with family. They are requesting to take hand prints of their mother and equipment for that was left with the family to do later. Will continue to follow this family and patient. NP is available 24/7 this evening by beeper to assist with any comfort concerns. TIME SPENT WITH PATIENT AND FAMILY: 1 1/2 hours. Thank you very much for this consultation, 85% of the time was spent in exchange of information with family and spiritual health and nursing staff.
NP|nurse practitioner|NP,|206|208|PLAN/SUGGESTIONS|6. We will continue diabetes education in our office (if his health insurance allows) or at Allina Medical Group, if not (this week). We will schedule him for an appointment with _%#NAME#%_ _%#NAME#%_, RN, NP, CDE, in 2-3 days. The patient said this would be no problem depending on insurance coverage. 7. Probably home tomorrow on Metformin 500 mg b.i.d., Glyburide 2.5 mg b.i.d., and Humalog insulin by sliding scale.
NP|nurse practitioner|NP|140|141|IMPRESSION|I will call my office and we will try to schedule her for an echocardiogram on Monday, either at the hospital or my office with a follow-up NP or MD visit. If all the tests are normal she can proceed with her planned surgery. I also gave the patient my card so that she can call us if there is a problem.
NP|nurse practitioner|NP|45|46|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, NP (North Memorial Family Practice) CHIEF COMPLAINT: Arthritic changes in knees bilaterally, sleep apnea (not diagnosed), exacerbated by morbid obesity. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 21-year-old female referred by _%#NAME#%_ _%#NAME#%_, NP of North Memorial Family Practice Clinic.
NP|nurse practitioner|NP|85|86|PRIMARY CARE|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, NP (_%#CITY#%_ Medical Clinic - _%#CITY#%_, Internal Medicine) CHIEF COMPLAINT: Anemia. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 59-year-old female with a history of alcoholism, fatty liver, elevated liver function tests, chronic anemia, and left mandibular carcinoma who had a hip fracture in _%#MM#%_ of 2005.
NP|nurse practitioner|NP,|209|211|HISTORY OF PRESENT ILLNESS|She also received 1-g of Ancef. Also, please note her urine output was about 200-cc during the surgery. Estimated blood loss was about 200-300 cc. She had a preoperative evaluation with _%#NAME#%_ _%#NAME#%_, NP, and she was cleared for surgery. Her preoperative hemoglobin was 10.6, platelet count 196,000, AST 46, ALT 10, creatinine 1.3. Currently, she is on her second unit of blood and is hemodynamically stable.
NP|nasopharyngeal|NP|183|184|RECOMMENDATIONS|3. Consider other differential diagnoses such as respiratory viruses which can be ruled out with a rapid influenza, rapid RSV assay, and a respiratory viral culture after obtained an NP swab or wash. Also one could consider EBV and rule that out with an EBV PCR. Thank you for this consultation. We will follow with you.
NP|nurse practitioner|NP|47|48|ASSESSMENT/PLAN|_%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_, NP _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_, MN _%#55400#%_ Dear Nurse Practitioner _%#NAME#%_: Thank you for the kind referral of your patient, _%#NAME#%_ _%#NAME#%_, who was seen, along with her husband, _%#NAME#%_, for genetic counseling at the Maternal Fetal Medicine Center at Fairview Southdale Hospital on _%#MM#%_ _%#DD#%_, 2006. As you know, Ms. _%#NAME#%_ was referred for discussion of the influence of maternal age on pregnancy outcomes.
NP|nurse practitioner|NP|198|199|PLAN/ACTION|Discussed with physicians, pulmonologists and nursing staff. PLAN/ACTION: 1. Discuss full code with patient and she wants Do Not Resuscitate. 2. The patient wrote the question "Do I have a chance?" NP explained that she most likely will not survive if extubated but team would make sure she was comfortable. 3. The patient is alert and oriented and able to make own decisions.
NP|nurse practitioner|NP|45|46|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, NP at Fairview Eden Center Clinic INDICATIONS: _%#NAME#%_ _%#NAME#%_ is a 60-year-old female who presents for routine screening for colon cancer. She denies any change in her bowel habits or any blood in her stool.
NP|nurse practitioner|NP|145|146|ACTION & PLAN|4. Disposition - Consider family meeting to discuss the patient's prognosis and to prepare family system. Clarify best setting to be discharged. NP will call sister and query about a family meeting. TLC continuing to follow. Hospice case manager was updated and reviewed plan with Dr. _%#NAME#%_.
NP|nurse practitioner|NP,|192|194|HISTORY OF PRESENT ILLNESS|Ejection fraction at that time was 61%. He once again, however, continued to have some chest discomfort and was evaluated by one of our physician assistants, _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, NP, in _%#MM#%_ of this year. At that time he was having nondescript chest discomfort which he was able to reproduce with motion.
NP|nurse practitioner|NP|110|111|PLAN|Call _%#NAME#%_ prior to any transfer out of the nursing home. PLAN: 1. Discussed with _%#NAME#%_ _%#NAME#%_, NP who requests that prn breakthrough be sent with patient which is Vicodin. 2. Transfuse as ordered. 3. Contact with family to clarify goals at nursing facility.
NP|nurse practitioner|N.P|193|195|PHYSICAL EXAMINATION|VITAL SIGNS: 98.8, 70, 20 and 133/82. Patient refused physical exam. She states she is cold. Thank you very much for this consult. Total time spent in discussion with Ortho, primary doctor and N.P at the nursing home, review of chart and nursing staff and family members was two hours.
NP|nurse practitioner|NP|60|61||I was asked to see Mr. _%#NAME#%_ by _%#NAME#%_ _%#NAME#%_, NP and _%#NAME#%_ _%#NAME#%_, MD for assessment of ongoing rehabilitation needs. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 67-year-old gentleman who presented to Southdale Hospital _%#MM#%_ _%#DD#%_ with shortness of breath and generalized weakness.
NP|nurse practitioner|NP|23|24||_%#NAME#%_ _%#NAME#%_, NP Boynton Health Service _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_, MN _%#55400#%_ Dear Ms. _%#NAME#%_, On _%#MMDD2006#%_, _%#NAME#%_ _%#NAME#%_ presented to the Maternal-Fetal Medicine Center, University of Minnesota Medical Center, Fairview, for consultation with questions regarding known upper urinary tract abnormalities and an intermittent cardiac dysrhythmia, and in what way these problems might or might not impact a future pregnancy.
NP|nurse practitioner|NP|45|46|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, NP - North Memorial Family Physicians CHIEF COMPLAINT: Shortness of breath and immobility exacerbated by morbid obesity. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 22-year-old African American female, referred by _%#NAME#%_ _%#NAME#%_ of North Memorial Family Physicians.
NP|nurse practitioner|NP|45|46|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, NP Ms. _%#NAME#%_ _%#NAME#%_ is a 36-year-old patient kindly referred by _%#NAME#%_ _%#NAME#%_, NP. Patient is seen again because of recurrent dysphagia. Patient was first seen a couple of years ago with dysphagia.
NP|nurse practitioner|NP.|141|143|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, NP Ms. _%#NAME#%_ _%#NAME#%_ is a 36-year-old patient kindly referred by _%#NAME#%_ _%#NAME#%_, NP. Patient is seen again because of recurrent dysphagia. Patient was first seen a couple of years ago with dysphagia. She was found to have a soft stricture at the EG junction at the site of a small hiatus hernia.
NP|nurse practitioner|NP.|93|95||Ms. _%#NAME#%_ _%#NAME#%_ is a 35-year-old teacher kindly referred by _%#NAME#%_ _%#NAME#%_, NP. Ms. _%#NAME#%_ has a long history of dysphagia and she had been seen a year ago and she was found to have a hiatus hernia and a benign looking stricture at the EG junction.
NP|nurse practitioner|NP,|189|191|SOCIAL HISTORY|SOCIAL HISTORY: The patient is a smoker, she smokes 1 pack a day. She drinks alcohol on occasion, not often. She denies any street drug use. Her primary physician is _%#NAME#%_ _%#NAME#%_, NP, _%#CITY#%_ _%#CITY#%_ Family Practice. REVIEW OF SYSTEMS: She Denies any chest pain, denies any difficulty breathing, any cough or URI symptoms.
NP|nurse practitioner|NP|47|48|PLAN|_%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_, NP Southdale OB-GYN Consultants, PA _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_, Mn _%#55400#%_ Dear Ms. _%#NAME#%_: Thank you for the kind referral of your patient, _%#NAME#%_ _%#NAME#%_, who is seen for genetic counseling at the Maternal Fetal Medicine Center at Fairview Southdale Hospital on _%#MM#%_ _%#DD#%_, 2006.
NP|nurse practitioner|NP|210|211|ACTION PLAN|2) Rabbi reviewed ritual of prayer. 3) Comfort care. 4) Reviewed process of extubating using morphine; goal is IV infusion p.r.n. and also p.r.n. Ativan. 5) May transfer to other unit when appropriate. 6) Call NP for comfort concerns. 7) Telephone call to Dr. _%#NAME#%_; he is agreeable to proceeding.
NP|nurse practitioner|NP,|174|176|DISPOSITION|c. He has had no atypical symptoms, no chest pain, no abdominal pain whatsoever. DISPOSITION: The patient is discharged to home and, as I said before, _%#NAME#%_ _%#NAME#%_, NP, from Social Work, and Dr. _%#NAME#%_'s clinic will be made aware of this.
NP|nurse practitioner|NP|44|45|CONSULTING PROVIDER|CONSULTING PROVIDER: _%#NAME#%_ _%#NAME#%_, NP REASON FOR CONSULTATION: Goals of care and discussing patient's care with daughters. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a _%#1914#%_ African American female who was admitted to Fairview Southdale Hospital in early _%#MM#%_ 2004, after a fall at home.
NP|nurse practitioner|NP|47|48|ASSESSMENT/PLAN|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, NP Fairview Lakes Medical Center _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_, MN _%#55000#%_ Dear Dr. _%#NAME#%_: Thank you for the kind referral of your patient, _%#NAME#%_ _%#NAME#%_, who was seen along with her mother, _%#NAME#%_, for genetic counseling at the Maternal-Fetal Medicine Center at the University of Minnesota Medical Center, Fairview, on _%#MMDD2007#%_.
NP|nurse practitioner|NP|189|190|SOCIAL HISTORY|She has failed the assisted living with around the clock home health aid. Family are in agreement to this plan to promote emotional and physical comfort, and to eliminate hospitalizations. NP feels that it is important to provide the expert nursing services that would be available at a residential hospice. Bed is not available at this time, and we will assist with transfer when bed available.
NP|nurse practitioner|NP.|175|177|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 51-year-old Caucasian female who is self-referred into our program. Her primary care provider is _%#NAME#%_ _%#NAME#%_, NP. Her husband had surgery with our program 2 years ago. The patient describes a lifelong struggle with her weight. She has had attempts for weight loss, including Weight Watchers Programs over 10 times, Jenny Craig and NutriSystem programs as well.
NP|nurse practitioner|N.P.,|130|134|INDICATION FOR CARDIAC CONSULTATION|Past medical history, family history, social history, as well as allergies have been outlined in detail by _%#NAME#%_ _%#NAME#%_, N.P., my colleague, of the dictation of _%#MMDD2006#%_. I have reviewed this and have nothing to add to that. Also, the past medical history which needs to be it is that his he had a recent fractured coccyx in _%#MM2006#%_, therefore, which he is on narcotics.
NP|nurse practitioner|NP|240|241|SOCIAL HISTORY|CODE STATUS: Full code. ADVANCE DIRECTIVE: On chart. The patient indicates he would want CPR and artificial measures for a limited time. SOCIAL HISTORY: Met with wife briefly, who had been told NP would be present to see her in 20 minutes. NP was not aware of this and the patient's wife was distressed when I met with her a couple of hours later. She requested I call her later this evening to discuss the situation with her husband.
NP|nurse practitioner|NP|147|148|SOCIAL HISTORY|5. Hypertension. 6. Stroke 2001. 7. Bilateral hematomas. ALLERGIES: No known allergies. CODE: Comfort care now, DNR/DNI. SOCIAL HISTORY: Two sons. NP met with son _%#NAME#%_. Both are in agreement. The patient has been very clear regarding no artificial measures and wanting to be kept comfortable with her dignity.
NP|(drug) NP|NP.|106|108|CURRENT MEDICATIONS|PAST MEDICAL HISTORY: Ulcerative colitis. PAST SURGICAL HISTORY: None. CURRENT MEDICATIONS: 1. Chalazal 6 NP. 2. Prednisone. 3. Folate. 4. Cefotaxime. 5. Flagyl. 6. Hydrocortisone. 7. Protonix. 8. Solu-Medrol. PHYSICAL EXAMINATION: GENERAL: The patient is a quiet and withdrawn girl.
NP|nurse practitioner|NP|175|176|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ NP _%#NAME#%_ _%#NAME#%_ is a 26-year-old nurse, kindly referred by Dr. _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ NP with a history of ulcerative colitis. The patient had been in good general health. Her medical history started about 8 years ago.
NP|nasopharynx|NP,|227|229|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: T1, N3, M0 WHO 3 nasopharynx cancer HPI: Patient originally noted neck mass Exam: Mass seen on roof of NP, bilateral and SC nodes Assessment and Plan: We are planning to treat with combined CT and RT.
NP|nurse practitioner|NP,|151|153||Patient was seen in the Transitional Unit at University of Minnesota Medical Center, Fairview, _%#CITY#%_ campus. He belongs to _%#NAME#%_ _%#NAME#%_, NP, who requested this consult. REASON FOR CONSULT: Evaluation of antibiotic management. IMPRESSION: 1. This is a 55-year-old gentleman here for the last 3 weeks for continued management of L4-5 of intervertebral disk space infection and possible vertebral osteomyelitis.
NP|nurse practitioner|NP|185|186|PLAN|PLAN: We will watch him very closely and consider ultrafiltration if we cannot get him dry. This may be actually quite effective for him. I will be chatting with _%#NAME#%_ _%#NAME#%_, NP and the physician who is supposed to see him tomorrow to see if there is anything else that they would recommend and I will review some of the records from his previous hospitalization.
NP|nurse practitioner|NP|23|24||_%#NAME#%_ _%#NAME#%_, NP _%#CITY#%_ _%#CITY#%_ Clinic _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_ _%#CITY#%_, SD _%#57100#%_ Dear Ms. _%#NAME#%_: Mr. _%#NAME#%_ _%#NAME#%_ was seen in the _%#CITY#%_ IV infusion Center.
NP|nurse practitioner|NP,|164|166|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 26-year-old African-American female who has been referred by her primary care clinic, _%#NAME#%_ _%#NAME#%_, NP, to our program. She describes a twelve-year struggle with her weight for which she has had multiple attempts for weight loss including Weight Watchers four different times, exercise programs, over-the-counter supplements and programs to try to lose weight, and all of her weight loss attempts have failed for permanent weight loss.
NP|nurse practitioner|NP,|187|189||Consult requested by Dr. _%#NAME#%_ to assist with clarifying treatment goals and monitoring for symptoms. No family was present during the assessment. Messages left for grandson to call NP, and no answer at the patient and wife's home. IMPRESSIONS: 1) _%#NAME#%_ _%#NAME#%_ is an 83-year-old white married male admitted on _%#MM#%_ _%#DD#%_, 2003 from home after a fall and sustaining a right femoral hip fracture.
NP|nurse practitioner|NP|113|114|CHIEF COMPLAINT|CHIEF COMPLAINT: Status post CVA and multiple bilateral pulmonary embolisms. Was asked to see in consultation by NP _%#NAME#%_ _%#NAME#%_ to assist with rehab assessment and coordination of care. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a pleasant 81-year-old Caucasian female who has had a complicated medical course beginning last _%#MM2006#%_.
NP|nurse practitioner|NP.|137|139|HISTORY OF PRESENT ILLNESS|She was started on carboplatin and Taxol on _%#MMDD2007#%_. On _%#MMDD2007#%_, she was seen on a walk-in basis by _%#NAME#%_ _%#NAME#%_, NP. At that time she complained of double vision, an occasional left occipital headache, as well as confusion. She also notes a 2-week history of difficulty with lower extremity and upper extremity coordination.
NP|nurse practitioner|NP|216|217|INFECTION CONTROL|INFECTION CONTROL : ED culture follow up: Patient rapid strep negative now growing streptococcus pneumoniae, spoke with patient's mother who states patient continues to be ill. Faxed results to _%#NAME#%_ _%#NAME#%_ NP at Park Nicollet _%#CITY#%_ per parent's request.
NP|nurse practitioner|NP.|175|177|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 45-year-old Caucasian female who is self-referred into our program. Her primary care provider is _%#NAME#%_ _%#NAME#%_, NP. The patient describes a lifelong struggle with her weight where she has had multiple attempts for weight loss including structured programs such as Weight Watchers, Nutri-Systems, Jenny Craig and New Day.
NP|nurse practitioner|NP.|182|184|PLAN|NEUROLOGIC: Cranial nerves II-XII are intact. PLAN: The patient is a 45-year-old Caucasian female self-referred into our program. Her primary care provider is _%#NAME#%_ _%#NAME#%_, NP. The patient has already scheduled a psychological evaluation to be done. She will have her laboratory tests sent over from her primary care.
NP|nurse practitioner|NP|249|250|ASSESSMENT AND PLAN|5) Discontinue Ativan. 6) Disposition: Immediate goal at this time is to promote comfort and then clarify goals of care along with Dr. _%#NAME#%_ with the family. TLC team will continue to follow for support and symptom management. You may call the NP 24/7 if comfort concerns exist. One and a half hours spent in discussing with the patient's wife, Dr. _%#NAME#%_ and nursing staff.
NP|nurse practitioner|NP|23|24||_%#NAME#%_ _%#NAME#%_, NP _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_, MN _%#55400#%_ Dear _%#NAME#%_: I thought I would bring you up to date on the situation with _%#NAME#%_ _%#NAME#%_. As you know, she is a very pleasant 48-year-old female who was diagnosed back in _%#MM2003#%_ with a stage III left breast cancer.
NP|nurse practitioner|NP.|118|120|HISTORY|He had noted labile blood pressures. He was evaluated by the nurse practitioner in the clinic, _%#NAME#%_ _%#NAME#%_, NP. The patient is currently sedated. He is not responsive to questions.
NP|nurse practitioner|NP.|192|194|ASSESSMENT AND PLAN|EXTREMITIES: Above-knee amputation left leg; right foot black, necrotic toes seen through dressing. ASSESSMENT AND PLAN: 1) FULL CODE; daughter wants comfort. Husband is not returning call to NP. a. Not eating. b. End-stage diabetes with peripheral vascular disease. c. Pain/comfort/sedation vs pain. 2) Discuss with husband and see what he is considering with overall goal, and then the long goal would be to get all family together to discuss a hospice approach, and where.
NP|nurse practitioner|NP|172|173|ASSESSMENT/PLAN|Wife wants to see how her husband does after the transfer to 88. 6. Continue to discuss hospice options on _%#MMDD#%_. 7. Continue p.r.n. MS and Ativan and O2. 8. May call NP for comfort concerns, 24/7. Gave wife the books "Hard Choices" and the other book is "Journey Through the Dying Process".
NP|nurse practitioner|NP|51|52|ASSESSMENT AND PLAN|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, RN, NP Obstetrics & Gynecology Specialists _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_, MN _%#55400#%_ Dear Ms. _%#NAME#%_: Thank you for referring your patient, _%#NAME#%_ _%#NAME#%_, who was seen for genetic counseling at the Maternal Fetal Medicine Center at Fairview Southdale Hospital on _%#MM#%_ _%#DD#%_, 2007.
NP|nurse practitioner|NP,|178|180|ACTION/PLAN|CODE: DNR. REVIEW OF SYSTEMS: Unable. PHYSICAL EXAMINATION: Vented, feeding tube. ACTION/PLAN: 1. Met briefly with patient's daughter, Dr. _%#NAME#%_, and _%#NAME#%_ _%#NAME#%_, NP, to establish TLC Team, and established informal TLC contract with _%#NAME#%_. Her goal today is to clarify and have some "action" around funeral arrangements.
NP|nurse practitioner|NP.|206|208|PLAN|NEUROLOGIC: Cranial nerves II-XII are grossly intact. PLAN: The patient is a 29-year-old Caucasian female who is referred to Dr. _%#NAME#%_ _%#NAME#%_ from her primary care physician, _%#NAME#%_ _%#NAME#%_ NP. She had recently had laboratory work done at her primary care and she will have those results sent to us. She has not yet scheduled a psychological evaluation. She is a smoker and therefore needs to be smoke-free for 4 months and was told that she should start today.
NP|nurse practitioner|NP|45|46|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, NP CHIEF COMPLAINT: Shortness of breath with activity, knee pain, sleep disturbances, exacerbated by morbid obesity. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 26-year-old African-American female who is referred into our program from her primary care provider, _%#NAME#%_ _%#NAME#%_, NP.
NP|nurse practitioner|NP|188|189|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 47-year-old African-American female referred to Dr. _%#NAME#%_ _%#NAME#%_ of Southdale Weight Loss Surgery by _%#NAME#%_ _%#NAME#%_, NP of North Memorial Family Physicians. Ms. _%#NAME#%_ has numerous medical comorbidities directly affected by her morbid obesity. The patient reports struggling with obesity since age 38. The patient has attempted numerous weight loss diets, but has been unsuccessful in keeping the weight that she has lost off.
NP|nurse practitioner|NP|47|48|ASSESSMENT AND PLAN|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, NP HealthEast _%#CITY#%_ Clinic _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_, MN _%#55100#%_ Dear Ms. _%#NAME#%_: This is an update on _%#NAME#%_ _%#NAME#%_, our mutual patient, who I saw for you back in _%#MM2007#%_.
NP|nurse practitioner|NP|138|139|PHYSICAL EXAMINATION|4. The patient wants to "fight" and wants to see his daughter from California who is arriving this evening. 5. Family is in agreement. 6. NP is available 24/7 for comfort concerns at _%#TEL#%_. 7. TLC team will continue to follow, although not in the hospital on the weekend.
NP|UNSURED SENSE|NP|274|275|LABORATORY DATA|He will eat and has a good suck. LABORATORY DATA: Venous laboratory studies show good RV contractility, there is questionable increased gradient from the Glenn shunt. Laboratory studies are remarkable for CRP on new range with normal <8), 39 today, previously 192 on 12/18. NP is normal. IMPRESSION: This is an 8-month-old male with hypoplastic left heart syndrome status post a Norwood/Sano and Glenn with persistent irritability and some consolability.
NP|nurse practitioner|NP.|185|187|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 60-year-old, Caucasian female who is self-referred into our program. Her primary care provider, _%#NAME#%_ _%#NAME#%_, NP. The patient describes a lifelong struggle with her weight where she has had attempts for weight loss which include Weight Watchers programs, an Atkin's over-the-counter, she has done Omnutrition programs in the past, she has worked with her doctor one on one to try to lose weight.
NP|nurse practitioner|NP.|184|186|PLAN|NEUROLOGIC: Cranial nerves II-XII are intact. PLAN: The patient is a 60-year-old, Caucasian female, self-referred into our program. Her primary care provider is _%#NAME#%_ _%#NAME#%_, NP. The patient has not yet scheduled a psychological evaluation. She will have her laboratory tests completed with her primary care doctor and sent to us.
NP|nurse practitioner|NP|133|134|PLAN|Would recommend 0.5 mg morphine with 1.0 mg boluses p.r.n. during the night and then discharge with MS Contin 15 mg p.o., p.r. q12h. NP will be available for nursing staff if they have questions about the patient's comfort. 3) DC labs. 4) DC vital signs and all procedures; the patient is comfort care.
NP|nurse practitioner|NP.|53|55|PHYSICIAN REQUESTING CONSULT|PHYSICIAN REQUESTING CONSULT: _%#NAME#%_ _%#NAME#%_, NP. REASON FOR CONSULTATION: For rehab placement. HISTORY OF PRESENT ILLNESS: This is a 36-year-old man with a history CMML who was admitted on _%#MMDD2007#%_ due to complain of hypoxia after bronchoscopy/EGD and flex sigmoidoscopy which was done for progressive dyspnea and hypoxia.
NP|nurse practitioner|NP|147|148|ACTION PLAN|3. Wife prefers not to wait for children to arrive. 4. TLC will continue to follow for comfort management and end of life symptoms and support. 5. NP continued to stay present with family for two hours while managing pharmacological treatment of end of life symptoms. Thank you very much for asking our care of _%#NAME#%_ _%#NAME#%_.
NP|nurse practitioner|NP|50|51|CONSULTATION REQUESTED BY|CONSULTATION REQUESTED BY: _%#NAME#%_ _%#NAME#%_, NP HISTORY OF PRESENT ILLNESS: This man was admitted to the hospital in mid _%#MM#%_ with abdominal pain and nausea and vomiting, was found to have acute cholecystitis and underwent a cholecystectomy. He was then transferred to rehab for strengthening and has been here since _%#MM#%_ _%#DD#%_, 2006, but with minimal improvement according to both himself and his wife.
NP|nurse practitioner|NP|56|57|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, NP REASON FOR CONSULTATION: General weakness. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a pleasant 78- year-old woman.
NP|nurse practitioner|NP,|181|183|ACTION AND PLAN|Option of family meeting to discuss, but the patient does not seem clear that he wants to change from treatment (DNR/DNI is in place) to comfort care. 2) Consider Fairview Partners NP, MD team to follow in nursing facility if primary physician is okay with this. This may help with transitions in nursing facility from rehabilitation to long-term care (the rehab may not be well tolerated), and switching to comfort care.
NP|nurse practitioner|N.P.|152|155|HISTORY OF PRESENT ILLNESS|He reports no other injuries or loss of consciousness. He has no other complaints of pain. Orthopedic evaluation is requested by _%#NAME#%_ _%#NAME#%_, N.P. in the emergency room. He does have a history of a previous arm fracture treated by Dr. _%#NAME#%_, as well as multiple stitches. PAST MEDICAL AND SURGICAL HISTORY: Otherwise noncontributory.
NP|nurse practitioner|NP|47|48|RECOMMENDATIONS|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, NP _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#ADDRESS#%_ _%#CITY#%_, Minnesota _%#55300#%_ Re: _%#NAME#%_ _%#NAME#%_ MR: 40-46-22-66 Dear Ms. _%#NAME#%_: Thank you for the referral of your patient, _%#NAME#%_ _%#NAME#%_, who was seen on _%#MM#%_ _%#DD#%_, 2007, at the Fairview Southdale Hospital Maternal Fetal Medicine Center.
NP|nurse practitioner|NP.|77|79|REQUESTING PROVIDER|DATE OF SURGERY: _%#MMDD2005#%_. REQUESTING PROVIDER: _%#NAME#%_ _%#NAME#%_, NP. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 41-year- old patient of Dr. _%#NAME#%_'s, sent to me recently regarding changes in her left breast.
NP|nurse practitioner|NP|47|48|PLAN|_%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_, NP _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_, MN _%#55400#%_ Dear Nurse Practitioner _%#NAME#%_: Thank you for referring your patient, _%#NAME#%_ _%#NAME#%_, for genetic counseling at the Maternal Fetal Medicine Center at Fairview Southdale on _%#MM#%_ _%#DD#%_, 2006. She came with her husband, _%#NAME#%_. She was referred to our clinic for genetic counseling regarding her age-related pregnancy risk and for the first trimester screen.
NP|nurse practitioner|NP|44|45|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_ NP INDICATIONS: Atrial fibrillation. PATIENT HISTORY: _%#NAME#%_ _%#NAME#%_ is a 70-year-old woman with chronic atrial fibrillation who has previously undergone synchronous cardioversion. She was admitted by Dr. _%#NAME#%_ to the hospital at the request of _%#NAME#%_ _%#NAME#%_ who follows her at the Fairview Northeast Clinic.
NP|nurse practitioner|NP|37|38|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, NP (Fairview Uptown Clinic) REASON FOR CONSULTATION: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a pleasant 36- year-old female, status post bilateral reduction mammoplasty approximately two months ago, who presents with increasing redness, swelling and induration of the right breast despite being on multiple antibiotics and Silvadene.
NP|nurse practitioner|NP.|184|186|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 20-year-old African-American female who has been referred to our program from her primary care physician, _%#NAME#%_ _%#NAME#%_, NP. The patient has attended informational session with Dr. _%#NAME#%_. She describes a life-long struggle with her weight where she has tried losing weight through a diabetic diet, meeting with a dietitian, her own over-the-counter diets and exercise.
NP|nurse practitioner|NP.|144|146|PLAN|PLAN: The patient is a 20-year-old African-American female who is referred to our program from her primary care provider _%#NAME#%_ _%#NAME#%_. NP. The patient recently had laboratory work done with her primary care and she will have these sent over to us and all the appropriate labs completed.
NP|nurse practitioner|NP|199|200|ASSESSMENT AND PLAN|d. Continue Dilaudid continuous infusion with breakthrough doses of Dilaudid. Agitation is most likely discomfort and Ativan may make agitation and confusion worse. Will discontinue Ativan. May call NP if you find this is not helpful. DISPOSITION: 1) Met with family for 45 minutes. 2) The patient never discussed end of life wishes, but was very independent and did not want to live in a nursing facility.
NP|nurse practitioner|NP.|225|227|ASSESSMENT AND PLAN|2. Send for CSF studies: Gram stain, CBC with differential, glucose, protein, anaerobic and aerobic cultures. 3. Send serum studies: CRP, ESR, CBC with differential, chem-7. 4. Follow up in clinic with _%#NAME#%_ _%#NAME#%_, NP.
NP|nurse practitioner|NP|23|24||_%#NAME#%_ _%#NAME#%_, NP _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_ _%#CITY#%_, MN _%#55300#%_ Dear Dr. _%#NAME#%_, Thank you for the referral of your patient, _%#NAME#%_ _%#NAME#%_, who was seen on _%#MM#%_ _%#DD#%_, 2006 at the Maternal-Fetal Medicine Center at the University of Minnesota Medical Center, Fairview.
NP|nurse practitioner|NP.|213|215|PLAN|NEUROLOGIC: Cranial nerves II-XII are intact. Reflexes are brisk. PLAN: The patient is a 30-year-old African-American female who is referred into our program from her primary care provider, _%#NAME#%_ _%#NAME#%_, NP. She has not yet scheduled a psychological evaluation but she will have her laboratory tests done with _%#NAME#%_ _%#NAME#%_ when she sees her in the next couple weeks.
NP|nurse practitioner|NP.|186|188|PLAN|NEUROLOGIC: Cranial nerves II-XII are intact. PLAN: The patient is a 29-year-old Caucasian female who is referred into our program from her primary care provider, _%#NAME#%_ _%#NAME#%_, NP. The patient is very well educated about the surgery, having had a good friend who had surgery 4 months ago and another friend who had it a year ago with another program.
NP|nurse practitioner|NP|47|48|IMPRESSION AND PLAN|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, NP Southdale OB-GYN Consultants PA _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_, Minnesota _%#55400#%_ Dear Ms. _%#NAME#%_: Thank you for referring your patient, _%#NAME#%_ _%#NAME#%_, who was seen, along with her son for genetic counseling at the Maternal Fetal Medicine Center at Fairview Southdale Hospital on _%#MMDD2007#%_.
NP|nurse practitioner|NP.|176|178|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 25-year-old, Caucasian female who is self-referred into our program. Her primary care provider is _%#NAME#%_ _%#NAME#%_, NP. The patient describes a lifelong struggle with her weight where she has had many attempts for weight loss including Weight Watchers programs, she has done the South Beach over-the-counter diet and exercise.
NP|nurse practitioner|NP|47|48||_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, NP Fairview Northeast Clinic _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_, MN _%#55400#%_ Dear _%#NAME#%_: This is an update on _%#NAME#%_ _%#NAME#%_, our mutual patient, who was diagnosed with breast cancer. You should have received my original consult note from _%#MMDD2007#%_ revised on _%#MMDD2007#%_ regarding my thoughts at that time.
NP|nurse practitioner|NP|47|48|ASSESSMENT AND PLAN|_%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_, NP Southdale OB-GYN Consultants _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_, Minnesota _%#55300#%_ Dear Ms. _%#NAME#%_: Thank you for referring your patient, _%#NAME#%_ _%#NAME#%_, who was seen along with an interpreter, for genetic counseling at the Maternal Fetal Medicine Center at Fairview Southdale Hospital on _%#MMDD2006#%_.
NP|nurse practitioner|NP,|23|25||_%#NAME#%_ _%#NAME#%_, NP, requested the consultation. REASON FOR CONSULTATION: Evaluation of antibiotic management. IMPRESSION: 1. This is a 54-year-old man here for continued management of cervical spine epidural abscess associated methicillin-sensitive Staph aureus.
NP|nurse practitioner|NP,|241|243|ASSESSMENT|1. Intracranial pressure. Many of her symptoms including the mental status changes and recalcitrant nausea may be due to this life-threatening condition. We have discussed the case with the primary care team including _%#NAME#%_ _%#NAME#%_, NP, and we all agree that transfer to Fairview- University Medical Center is the most prudent course. Neurosurgery has been contacted. Her primary team has given her IV Decadron to alleviate intracranial pressure.
NP|nurse practitioner|NP|37|38|REQUESTED BY|REQUESTED BY: _%#NAME#%_ _%#NAME#%_, NP REASON FOR CONSULTATION: Please evaluate for rehabilitation needs. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 66-year-old woman with an undiagnosed preexisting cognitive dysfunction, who was hospitalized on _%#MMDD2005#%_ with sudden onset right lower extremity clumsiness.
NP|nurse practitioner|NP|45|46|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, NP CHIEF COMPLAINT: Diabetes, reflux, high cholesterol and joint pains exacerbated by morbid obesity. HISTORY OF PRESENTING PROBLEM: _%#NAME#%_ _%#NAME#%_ is a 43-year-old old African-American female who has been referred to Dr. _%#NAME#%_ _%#NAME#%_ from her primary care provider, _%#NAME#%_ _%#NAME#%_, nurse practitioner.
NP|nurse practitioner|NP|136|137|PRIMARY CARE|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD (Fairview Southdale Hospital, Hospitalist Service) PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, NP (_%#CITY#%_ Lake Clinic) REASON FOR CONSULTATION: _%#NAME#%_ _%#NAME#%_ is a 58-year-old female who came to Fairview Southdale Hospital emergency room yesterday with chest discomfort while at work. Her chest discomfort is very difficult for her to describe, particularly given the fact that she has a speech impediment and hearing impediment that are congenital.
NP|nurse practitioner|NP.|185|187|ASSESSMENT/PLAN|We will ask the chaplain to see the patient for spiritual support. TLC social worker to see the patient for further support. The patient was seen and examined by _%#NAME#%_ _%#NAME#%_, NP. Thank you for this consultation.
NP|nurse practitioner|NP|47|48|ASSESSMENT/PLAN|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, NP CUHCC Clinic _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_, MN _%#55400#%_ Dear Ms. _%#NAME#%_: Thank you for the referral of your patient, _%#NAME#%_ _%#NAME#%_, who was seen along with her husband, _%#NAME#%_, on _%#MMDD2007#%_ at the Maternal Fetal Medicine Center at the University of Minnesota Medical Center, Fairview.
NP|nurse practitioner|NP.|166|168|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 34-year-old female who has been referred to our program from her primary care provider, _%#NAME#%_ _%#NAME#%_, NP. She has already attended an informational session with Dr. _%#NAME#%_. She describes a ten year struggle with her weight where she has had multiple attempts for weight loss including Weight Watchers, exercise, dietitian visits and working with her physician and using medications such as Meridia.
NP|nurse practitioner|NP.|174|176|PLAN|NEUROLOGIC: Cranial nerves II-XII are intact. PLAN: The patient is a 34-year-old female who is referred to our program from her primary care provider, _%#NAME#%_ _%#NAME#%_, NP. She has already attended an information session with Dr. _%#NAME#%_. She will have her laboratory tests drawn today. She has not yet scheduled a psychological evaluation.
NP|nurse practitioner|NP|47|48|LABORATORY DATA|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, NP _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#ADDRESS#%_ _%#CITY#%_, Minnesota _%#55300#%_ RE: _%#NAME#%_ _%#NAME#%_ MR: 40-21-35-68 Dear Ms. _%#NAME#%_: Thank you for referring your patient, _%#NAME#%_ _%#NAME#%_, who was seen for genetic counseling at the Maternal Fetal Medicine Center at Fairview Southdale Hospital on _%#MM#%_ _%#DD#%_, 2007.
NP|nurse practitioner|NP|249|250|BRIEF HISTORY OF THIS ADMISSION|He was admitted to the University of Minnesota Acute Rehab Unit on _%#MMDD2006#%_ for re- conditioning and continuation of medical care. For additional information, please refer to history and physical examination dictated by _%#NAME#%_ _%#NAME#%_, NP and discharge summary dated by Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2006#%_ for additional details. The patient was initially admitted to the University of Minnesota Medical Center, Fairview, on _%#MMDD2006#%_ because of worsening gait abnormalities, progressive memory loss and tremors.
NP|nurse practitioner|NP|301|302|HOSPITAL COURSE|Based she was older than usual for ITP and had no drugs available to incriminate, the possibility of an underlying lymphoma or myeloid disorder was entertained; a high uric acid and an above-normal hemoglobin (16 g/dL) increased this concern. Bone marrow biopsy was attempted on _%#MMDD2007#%_ by the NP and staff physician from Hematopathology; due to her body size, satisfactory samples could not be obtained. Because it is unclear how long she will have to be on steroids, we started calcium and vitamin D 1250 mg p.o. b.i.d. to help prevent osteoporosis.
NP|nasopharyngeal|NP|170|171|HOSPITAL COURSE|She was begun on prophylactic fluconazole at admission. Gatifloxacin was started on _%#MMDD2004#%_ for prophylaxis. Due to concern about rhinorrhea and dry cough, RC and NP were sent on _%#MMDD2004#%_ and were found to be negative. She remained afebrile throughout her hospital stay. CMV antigenemia and Aspergillus galactomannan antigen have all remained negative.
NP|nasopharyngeal|NP|230|231|HISTORY OF PRESENT ILLNESS|The patient is experiencing some pleuritic chest pain when he takes a deep breath, but denies hemoptysis. The patient came to the BMT clinic for workup of new and worsening respiratory symptoms. When he was seen on _%#MMDD#%_, an NP swab for negative for influenza A and B as well as RSV rapid antigen as well as respiratory viral culture.
NP|nurse practitioner|NP|142|143|ALLERGIES|He is also to follow up with the diabetes nurse clinician in the next week. He was also instructed to call the hospital operator and page the NP endocrine resident on call with any problems or concerns regarding insulin or blood sugar checks. DISCHARGE MEDICATIONS: 1. Albuterol 0.5% nebulizer b.i.d. with VEST treatments.
NP|nasopharyngeal|NP|299|300|PERTINENT  LABORATORY TESTS|_%#NAME#%_ was maintained on parenteral nutrition from _%#MMDD#%_ until _%#MMDD2007#%_. Problem #2: Hydrops Fetalis. Workup included chromosomes; Parvovirus B19 antibodies; Parvovirus, blood DNA by PCR; Toxoplasmosis IgG and IgM antibodies; CMV IgG and IgM antibodies; Urine CMV culture; rectal and NP viral cultures; peritoneal fluid for flow cytometry; urine for organic acids and HMA/UMA; plasma amino acids; serum IgM; pleural and peritoneal fluid cultures, Head ultrasound, Cranial MRI.
NP|nasopharyngeal|NP|225|226|ADMISSION DIAGNOSIS|She was given oxygen, blood was drawn. Cefotaxime was started, and the patient was stabilized on 1 liter of O2 by nasal cannula, saturating at 98% to 100%. Her heart rate was decreased from 206 to 170 after Tylenol. Her last NP culture for the last hospital admission was _%#MM#%_ _%#DD#%_, 2002, and was H. influenzae pan-sensitive out of 3, and influenza during that last hospitalization was negative.
NP|nurse practitioner|NP.|346|348|CURRENT MEDICATIONS|8. Lantus insulin 20 units subcu q.h.s. 9. NovoLog insulin sliding scale: glucose 71 to 150 - no insulin; glucose less than 71 - 1 amp D50; glucose 151 to 200 - 2 units; glucose 201 to 250 - 4 units; glucose 251 to 300 - 6 units; glucose 301 to 350 - 8 units; glucose 351 to 400 - 10 units; glucose greater than 400 - 12 units and call the MD or NP. 10. Colace 100 mg p.o. b.i.d. 11. Senna 2 tablets p.o. b.i.d. p.r.n. 12. Calcium carbonate with vitamin D 500 mg p.o. t.i.d.
NP|nurse practitioner|NP|123|124|9. GERD|He did have a temperature of 100.8 today when he was admitted, but now it is 99. We will follow closely and call the MD or NP if the temperature is greater than 101. 4. Chronic right pleural effusion: The patient was followed by the pulmonary team and was tapped on _%#MMDD2003#%_, with cultures being negative.
NP|nurse practitioner|N.P.|154|157|IMPRESSION AND PLAN|I will, however, defer this to Dr. _%#NAME#%_ once he is closer to being stable and discharge plans are more concrete. Dictated by _%#NAME#%_ _%#NAME#%_, N.P. for MN Oncology/Hematology, Dr. _%#NAME#%_
NP|nurse practitioner|NP,|127|129|DISCHARGE PLAN|DISCHARGE PLAN: His visit history for appointments will be as follows: 1. He will be seen by _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, NP, at the University of Minnesota Medical Center, Fairview, Outpatient Clinic Ambulatory Pulmonary on _%#MMDD2006#%_ at 9:30 a.m. 2. He will follow up with his primary care physician, Dr. _%#NAME#%_ _%#NAME#%_, in Wisconsin.
NP|nasopharyngeal|NP|139|140|DISCHARGE INSTRUCTIONS|5. The patient will be seen on Wednesday, _%#MMDD2005#%_ in the Bone Marrow Transplant Clinic at 10:30 a.m. where he will have a follow-up NP swab for RSV. 6. The patient will have a cyclosporine level drawn today, which is pending. This needs to be followed up.
NP|nasopharyngeal|NP|206|207|HOSPITAL COURSE|It was also noted that he had what appeared to be herpetic lesions in his mouth, and Acyclovir was started as prophylaxis for this. Following 3 days' administration of amphotericin-B he did defervesce. His NP swabs for influenza and parainfluenza were also negative. He did continue on the ampho-B and will be switched to Voriconazole with anticipation of discharge.
NP|nurse practitioner|NP.|234|236|HISTORY OF PRESENT ILLNESS|COMPLICATIONS: None apparent. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 37-year-old female with a newly diagnosed pelvic mass sent to the University of Minnesota Medical Center, Fairview for evaluation by _%#NAME#%_ _%#NAME#%_, NP. The patient was seen in consultation by Dr. _%#NAME#%_ on _%#MMDD2007#%_. Ms. _%#NAME#%_ initially presented to her primary care physician in early _%#MM#%_ complaining of abdominal discomfort reflux symptoms, diarrhea, nausea and vomiting.
NP|nurse practitioner|NP,|138|140|RECOMMENDATIONS|I am writing down the order of Seroquel 25 mg p.o. in the discharge medications. This issue is also discussed with _%#NAME#%_ _%#NAME#%_, NP, who is going to follow the patient while she is staying at the transitional service.
NP|nasopharyngeal|NP|370|371|HOSPITAL COURSE|He was treated with vancomycin, which then was switched to Unasyn based on susceptibility to penicillins, and then the patient was switched to Augmentin 875 mg p.o. b.i.d. Augmentin was discontinued on discharge as the patient has been treated for 12 days. The patient did have repeat nasopharyngeal swabs post ribavirin therapy, and the respiratory viral cultures from NP swabs on _%#MMDD2006#%_ are negative as well as negative RSV as well as influenza A and B. The patient does have pentamidine for PCP prophylaxis instead of Bactrim due to low counts.
NP|nasopharyngeal|NP|178|179|HOSPITAL COURSE|On _%#MMDD2007#%_, CMV PCR was 100. Currently, a repeat CMV PCR from _%#MMDD2008#%_ is pending. As noted, the patient had a negative rapid influenza and strep screen. Currently, NP swabs to check for RC and parainfluenza are still pending at this time. In addition, the patient developed some blisters on his posterior palate, these were somewhat painful.
NP|nurse practitioner|NP,|326|328|FOLLOW UP|DISCHARGE DIET: High-calorie, high-protein, high-sodium diet to continue p.o. ad lib and Peptamen 1.5 for a goal of 65 mL/h by 8 hours over night or 2 cans of the Peptamen 1.5 per night. FOLLOW UP: The patient was to see Dr. _%#NAME#%_ with pediatric surgery _%#MM#%_ _%#DD#%_, 2005, at 1:15 p.m. , and _%#NAME#%_ _%#NAME#%_, NP, on _%#MM#%_ _%#DD#%_, 2005, to have PFTs at 7:40 and appointment at 8:30. DISCHARGE ACTIVITY: Full, as tolerated. It was a pleasure being involved in _%#NAME#%_'s care.
NP|nurse practitioner|NP|177|178|DISCHARGE RECOMMENDATIONS|3. Followup appointments have been scheduled as follows, Neurosurgery Clinic in 8 weeks, PM&R Dr. _%#NAME#%_ _%#NAME#%_ in 8 weeks, primary care providor _%#NAME#%_ _%#NAME#%_, NP at Fairview _%#CITY#%_ Clinic in the next available appointment. 4. He needs to wear his helmet whenever out of bed until his cranial flap is replaced in approximately 6 weeks.
NP|nasopharyngeal|NP|146|147|HISTORY OF PRESENT ILLNESS|He was discharged home on _%#MMDD2005#%_. At the time of discharge the patient had signs of rhinorrhea and had been experiencing nose congestion. NP swabs were negative. Then, over a course of a few days, the patient's symptoms seemed to increase, with facial tenderness, increased congestion, and a temperature of 102.2. He presented to the Bone Marrow Transplant Clinic on the day of admission and was admitted for evaluation and management of fevers.
NP|nurse practitioner|NP.|95|97|REFERRING PHYSICIAN|REFERRING PHYSICIAN : Dr. _%#NAME#%_ _%#NAME#%_. PRIMARY CARE PROVIDER: _%#NAME#%_ _%#NAME#%_, NP. ADMISSION DIAGNOSES: 1. Grade 2 endometrial carcinoma. 2. Hypertension. 3. Obesity. POSTOPERATIVE DIAGNOSES: 1. Grade 1, stage IB endometrial carcinoma.
NP|nasopharyngeal|NP|240|241|PROBLEM #5|He will be discharged on higher doses of Levaquin. His counts have started to recover, however, this appears to be his initial cells coming in. He is not completely dropped. During his hospitalization he did continue with nasal congestion. NP swabs were done on _%#MMDD2006#%_, and these were negative for RSV or influenza. He did have a sinus CT performed on _%#MMDD2006#%_, which did show worsening pansinusitis.
NP|nurse practitioner|NP|162|163|DISCHARGE INSTRUCTIONS|Full weightbearing and activity as tolerated and prescribed by physical therapy. Followup doctor visit with her nurse practitioner, who is _%#NAME#%_ _%#NAME#%_, NP at _%#TOWN#%_ _%#TOWN#%_ Clinic in 1 to 2 weeks after discharge from the transitional care unit. FOLLOWUP LABS: INR and BMP to be drawn on _%#MMDD2007#%_.
NP|nurse practitioner|NP,|160|162|FOLLOW-UP APPOINTMENTS|16. Boost high protein, vanilla flavor, four cans q.day for nutrition supplementation. FOLLOW-UP APPOINTMENTS: 1. His primary caregiver, _%#NAME#%_ _%#NAME#%_, NP, in two to three days. Mother will call for appointment. 2. Dr. _%#NAME#%_ in the Transplant Clinic on Monday, _%#MMDD2003#%_.
NP|nurse practitioner|NP|113|114|HISTORY OF PRESENT ILLNESS|She is presenting with first episode of hemetemesis. The patient was seen in GI Clinic by _%#NAME#%_ _%#NAME#%_, NP yesterday. She was complaining of her first episode of vomiting out some blood clots. At the time it was decided that the patient should have an outpatient upper endoscopy for further evaluation.
NP|nurse practitioner|NP|47|48|PRIMARY CARE PHYSICIAN|PRIMARY CARE PHYSICIAN: _%#NAME#%_ _%#NAME#%_, NP PLANNED DATE OF DISCHARGE: _%#MMDD2007#%_ DISCHARGE DIAGNOSES: 1. Intractable nausea and vomiting. 2. Depression. DISCHARGE MEDICATIONS: 1. Zoloft 25 mg daily.
NP|nasopharyngeal|NP|249|250|PROBLEM #2|A repeat herpes PCR from the second spinal tap, which was obtained on _%#MMDD2003#%_ in the Pediatric Intensive Care Unit here, was not able to be performed secondary to extra CSF sample that was not in a frozen form. Also pending on discharge were NP and rectal swabs for viral culture. _%#NAME#%_ was empirically started on ceftriaxone and acyclovir in _%#CITY#%_. He was continued on those medications, with the addition of doxycycline, upon admission here at Fairview-University Medical Center.
NP|UNSURED SENSE|NP|197|198|PHYSICAL EXAMINATION|No organomegaly. Extremities: There is pitting edema to the mid-shin bilaterally. Neurological exam is grossly nonfocal with normal strength. She does complain of significant pain in the bilateral NP joints of both feet which is mildly swollen and tender to even a light touch. LABS ON ADMISSION: White blood count 2.0, hemoglobin 9.3, platelet count 109,000 with an ANC of 0.9, ALC of 0.7, sodium 144, potassium 3.8, chloride 105, bicarb 26, BUN 14, creatinine 1.1, glucose 81, calcium 8.6, troponin less than 0.3, albumin 3.2, alk phos 103, ALT 6, AST 18, total protein 6.4, total bilirubin 0.5. Chest x-ray demonstrated increased interstitial markings in the left lower lobe consistent with an infiltrate.
NP|nurse practitioner|NP,|44|46|REFERRING PHYSICIAN|REFERRING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, NP, women's health center. DIAGNOSES ON ADMISSION: 1. Morbid obesity. 2. Ventral wall hernia. 3. Tobacco abuse.
NP|nasopharyngeal|NP|160|161|ADDENDUM|_%#NAME#%_ was provided this information in her written discharge instructions. 2. Growth factor was discontinued today. Monitor counts in the clinic daily. 3. NP swabs are pending today as she has persistent nasal congestion. She does have a dry cough. However, she remains afebrile, and therefore no further studies were done.
NP|nasopharyngeal|NP|254|255|1. FEN|Last WBC was 6.8 on _%#MMDD2003#%_. 5. ID: Ampicillin, gentamicin were continued for a total 4 day course, but discontinued when bacterial cultures remained negative. Acyclovir was continued at admit and continued for a total 24 day course upon positive NP swab for HSV. Of note, rapid rectal HSV and CSF HSV PCR (both from SPCH admission) were negative. A repeat LP on _%#MMDD#%_ resulted in negative CSF cultures and negative HSV PCR; however, protein was elevated at 222.
NP|nurse practitioner|NP|47|48|DISPOSITION|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, NP Southdale OB GYN Consultants _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_, MN _%#55300#%_ Dear Ms. _%#NAME#%_: Thank you for referring your patient, _%#NAME#%_ _%#NAME#%_, who was seen for genetic counseling at the Maternal Fetal Medicine Center at Fairview Ridges Hospital on _%#MMDD2007#%_.
NP|nurse practitioner|NP,|133|135||Mr. _%#NAME#%_ is a delightful 50-year-old gentleman followed at Minnesota Heart Clinic by Dr. _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_, NP, whom I am asked to see by Dr. _%#NAME#%_ for management of prior cardiac arrest. Briefly, Mr. _%#NAME#%_ was for the first time diagnosed with heart disease in the summer of 2005 and presented with acute myocardial infarction and underwent coronary angiogram by Dr. _%#NAME#%_ which showed severe stenosis of a large ramus intermedius and 2 stents were placed in this vessel.
NP|nurse practitioner|NP|37|38|REQUESTED BY|REQUESTED BY: _%#NAME#%_ _%#NAME#%_, NP REASON FOR CONSULTATION: Evaluate for rehabilitation needs. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 45- year-old female with difficulties with menorrhagia earlier this year and is status post total abdominal hysterectomy, bilateral salpingo- oophorectomy on _%#MMDD2005#%_.
NP|nurse practitioner|NP|47|48|IN SUMMARY|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, NP Southdale Ob-Gyn Consultants _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_, MN _%#55300#%_ RE: _%#NAME#%_, _%#NAME#%_ DOB: _%#MMDD1972#%_ MRN: _%#MRN#%_ Dear _%#NAME#%_ _%#NAME#%_: Thank you for referring your patient, _%#NAME#%_ _%#NAME#%_, who was seen, along with her partner, _%#NAME#%_, for genetic counseling at the Maternal Fetal Medicine Center on _%#MMDD2007#%_.
NP|nurse practitioner|NP|47|48|IN SUMMARY|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, NP Southdale OB GYN _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#ADDRESS#%_ _%#CITY#%_, MN _%#55300#%_ Dear Ms. _%#NAME#%_: Thank you for referring your patient, _%#NAME#%_ _%#NAME#%_, who was seen for genetic counseling at the Maternal Fetal Medicine Center at Fairview Ridges Hospital on _%#MMDD2007#%_.
NP|nurse practitioner|NP,|165|167|REFERRING PHYSICIAN|REFERRING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, NP, _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ MD. Palliative/TLC consult requested by Hospitalist Service, _%#NAME#%_ _%#NAME#%_, NP, as well as attending Dr. _%#NAME#%_ to see this patient in rehab with diagnosis with multiple myeloma for goals of care discussion as well as any symptom suggestions that might improve her quality of life.
NP|nurse practitioner|NP|51|52|PLAN|_%#NAME#%_ _%#NAME#%_, 2007 _%#NAME#%_ _%#NAME#%_, NP Southdale Ob-Gyn Consultants _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_, MN _%#55300#%_ Dear Ms. _%#NAME#%_: Thank you for referring your patient, _%#NAME#%_ _%#NAME#%_, who was seen, along with her friend, for genetic counseling at the Maternal Fetal Medicine Center at Fairview Southdale Hospital on _%#MM#%_ _%#DD#%_, 2007.
OP|oblique presentation/occiput posterior|OP|120|121|HOSPITAL COURSE|The patient was delivered of a 8 pound zero ounce female infant with Apgars of 8 at 1 minute and 9 at 5 minutes from an OP presentation. Please refer to the operative report for other details of the intraoperative course. The patient's postoperative course was unremarkable. A postoperative hemoglobin measures 12.2 compared to a preoperative value of 14.7. The patient remained afebrile throughout her hospital course.
OP|oblique presentation/occiput posterior|OP|164|165||She had arrest of dilation during labor and therefore she underwent primary cesarean section delivery with low transverse incision on the uterus. Twin A was vertex OP position, 6 pound 1 ounce, Apgar score of 9 at 1 minute, 9 at 5 minutes. One loop of nuchal cord around the neck, male infant.
OP|oropharynx|OP|483|484|PHYSICAL EXAM|FAMILY HISTORY: Pt unable to provide secondary to respiratory distress ROS: As above in HPI, o/w denies fever, chills, N/V, aspiration, CP, palpitations, abdominal pain, reflux, constipation, diarrhea, dysuria, numbness, tingling. Neuropathic pain is well controlled. PHYSICAL EXAM 98 136/50 90 20 100% non rebreather mask GEN: working hard to breath, whispers, able to speak several words before next breath, alert, no nasal flaring HEENT: PERRL, EOMI, no icterus/injection/pallor, OP clear/dry, dentures NECK: 2 cm palpable, hard, somewhat fixed L submandibular LN, no bruits, brisk carotid upstrokes, no stridor LUNGS: decreased, CTAB.
OP|oropharynx|OP|201|202|PHYSICAL EXAMINATION|Weight is 119 pounds. GENERAL: He is a very pleasant intelligent young man in no acute distress. HEENT: Normocephalic, atraumatic. Sclerae nonicteric, pupils are equal. Extraocular muscles are intact. OP is clear. NECK: Supple without lymphadenopathy. HEART: Regular with a hyperdynamic PMI but no murmurs, rubs or gallops. LUNGS: Decreased breath sounds bilaterally at the bases without any wheezes.
OP|oropharynx|OP|195|196|PHYSICAL EXAMINATION|Height 65 inches, weight 111 kilograms. Immunizations are current for age. HEAD, EYES, EARS, NOSE AND THROAT: Normocephalic. Eyes were clear. PERRLA. Negative for photosensitivity. Nares patent, OP is clear. NECK: supple. CHEST: clear on the left. Right scattered crackles in the bases. No respiratory distress. Coughing with deep breaths HEART: Rate is regular, no murmurs.
OP|oropharynx|OP|198|199|PHYSICAL EXAMINATION|Weight 86 kg. GENERAL APPEARANCE: Alert and oriented x3 in no acute distress. HEENT: Head, normocephalic. Eyes, Pupils are equal, round and reactive to light. External ocular motility intact. Mouth OP clear. NECK: No lymphadenopathy. No thyromegaly. CARDIOVASCULAR: Regular rate and rhythm without murmurs, gallops or rubs. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Bowel sounds are present.
OP|oropharynx|OP|166|167|PHYSICAL EXAMINATION|Quite jovial elderly white male. HEENT: Normocephalic, atraumatic. Pupils are equal, round, reactive to light. Extraocular muscles are intact, anicteric bilaterally. OP is clear. Mucous membranes are moist. Does have chewing tobacco in at this point. No other identified lesions. No JVD, HVR or HJR, bruits or mass. CARDIOVASCULAR: Regular rate and rhythm, distant heart tones, no murmurs, rubs or gallops.
OP|oropharynx|OP|188|189|PHYSICAL EXAMINATION ON ADMISSION|GENERAL: Alert, in no acute distress. HEAD: Positive alopecia, normocephalic, atraumatic. EYES: Sclerae clear. PERRL, EOMI. EARS: TMs clear bilaterally. NOSE, MOUTH, THROAT: Clean coryza, OP clear, mildly erythematous throat without oral lesions. NECK: Supple. CARDIOVASCULAR: Regular rate and rhythm without murmur. LUNGS: Clear auscultation bilaterally.
OP|oblique presentation/occiput posterior|OP|258|259||Despite pushing with good effort and good contractions, she failed to bring the vertex past 0 station. On _%#DDMM2006#%_ she underwent primary low segment transverse cesarean section for failure to descend in labor of an 8 pound 1 ounce male from the direct OP position with Apgars of 8 at 1 minute and 9 at 5 minutes. The uterus, tubes, and ovaries were normal. Postoperatively, she remained afebrile.
OP|oblique presentation/occiput posterior|OP|245|246|DISCHARGE MEDICATIONS|Because of the vertex being only at +1 to +2 station, the decision was made to proceed with primary cesarean section, due to arrest of descent, chorioamnionitis and a poor vacuum candidate. The patient went on to deliver a viable male infant in OP presentation, weighing 9 pounds 5 ounces with Apgars of 7 and 9 by low segment transverse cesarean section. There was also thin meconium noted at the time of delivery.
OP|operative|OP|181|182|HISTORY OF PRESENT ILLNESS|On _%#DDMM2005#%_ the patient was electively taken back for aortic valve replacement. The patient tolerated the procedure well. The procedure was without complication (see specific OP note for details). Following the patient's first day in the Surgical Intensive Care Unit, the patient was transferred up to 6D, where he stayed for the remainder of the hospitalization.
OP|oblique presentation/occiput posterior|OP|191|192|PATIENT IDENTIFICATION|On _%#DDMM2005#%_, the patient underwent a primary low segment transverse cesarean section. She was delivered of an infant female 7 pounds 4 ounces with Apgars of 8 and 9. The baby was in an OP position, ROP. There was a nuchal cord times one. The fluid was meconium stained and was suctioned appropriately. The uterus, tubes, and ovaries were normal.
OP|oropharynx|OP|185|186|OBJECTIVE|Blood pressure 130s/80s. Respiratory rate 20. Saturation 93 to 96% on room air. GENERAL: Alert young male walking around the room. HEENT: PERRL. EOM I. NECK: Supple without adenopathy. OP is clear. Mucous membranes are moist. NECK: Supple without adenopathy or thyromegaly. CARDIOVASCULAR: Regular rate and rhythm. No murmurs, rubs, or gallops. CHEST: Clear to auscultation bilaterally.
OP|oropharynx|OP|136|137|OBJECTIVE|O2 saturation 100 percent on room air. In general, this is a very pleasant woman, who is comfortable, lying supine. HEENT: PERRL, EOMI. OP is moist. NECK is supple without adenopathy or thyromegaly. HEART: Regular S1, S2. No murmurs, gallops, or rubs. No carotid bruits.
OP|operative|OP|163|164|PAST SURGICAL HISTORY|On _%#MM#%_ _%#DD#%_, 2005, the patient decided for an elective primary cesarean section and underwent cesarean section without any complications. Please refer to OP note dictation for further details of the procedure. POSTOPERATIVE COURSE: The patient was in a stable condition. Her pain was controlled with oral pain medications.
OP|oropharynx|OP|173|174|OBJECTIVE|ALLERGIES: No known drug allergies. OBJECTIVE: Afebrile. Blood pressure 113/64, heart rate 75, respiratory rate 20. General, alert young female tired, but NAD. HEENT, EOMI, OP clear. Neck supple without adenopathy or thyromegaly. Mucous membranes are most. Cardiovascular regular rate and rhythm, no murmurs, rubs, or gallops.
OP|oropharynx|OP|167|168|OBJECTIVE|Weight is 284 lbs, temperature 98.2, pulse 77, respirations 18, blood pressure 138/79. HEENT: Conjunctivae normal. TMs normal. Nares are slightly boggy and edematous. OP is moist without lesions. NECK: Supple without adenopathy or thyromegaly. HEART: Regular S1, S2, no murmurs. LUNGS: Clear bilaterally. ABDOMEN: Soft.
OP|oropharynx|OP|223|224|OBJECTIVE|OBJECTIVE: Temperature 98.2, blood pressure 110/72, pulse 110, respirations 20, O2 saturations 99 percent on room air. This is a very pleasant woman in no acute distress. HEENT: PERRLA. EOMI. Sclerae anicteric. TMs normal. OP is dry. NECK: Supple without adenopathy or thyromegaly. HEART: Regular S1, S2. No murmurs. LUNGS: Clear to auscultation bilaterally. No rhonchi or wheezes.
OP|oropharynx|OP|208|209|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 122/74, pulse 97, respiratory rate 12, O2 sat 96%, temp 99.4. GENERAL: The patient is a pleasant male in no acute distress. HEENT: PERRL, conjunctivae clear. OP with moist mucous membranes. NECK: Supple. LUNGS: CTA bilaterally. HEART: Regular rate and rhythm; no murmur. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: Left lower extremity with no edema and intact pedal pulses.
OP|oblique presentation/occiput posterior|OP|157|158|HOSPITAL COURSE|Thus ITN was initiated. ITN improved her pain and she had good pain relief. She was called complete at 1600 hours. Plus 1 station noted. She was noted to be OP position. The patient delivered a viable female infant weighing 6 pounds 14 ounces at 1812 hours. Infant's Apgars were 9 at one minute and 9 at five minutes.
OP|oblique presentation/occiput posterior|OP|269|270|HISTORY OF THE PRESENT ILLNESS|her temperature went to 102 and we added Clindamycin 900 mg intravenous. Then, these lates were not resolving with the change in position, oxygenation, hydration and secondary stage and there was no descent of the fetal heart past the ischial spine and the baby was on OP position too and we attempted manual rotation without any success. We explained to the patient because of fetal distress, we would proceed with the Cesarean section and the procedure, risks and benefits, complications were explained to the patient and consent was signed and OR was notified.
OP|oropharynx|OP|159|160|PHYSICAL EXAMINATION|GENERAL: When I saw the patient on the floor she was lying in her hospital bed. She would open her eyes, but did not respond verbally otherwise. HEENT: PERRL. OP very dry mucous membranes. NECK: Supple. LUNGS: CTA bilaterally. HEART: RRR, no murmur. ABDOMEN: Soft and seemed to be tender to palpation as she did groan a bit with abdominal examination.
OP|oropharynx|OP|207|208|PHYSICAL EXAMINATION|VITAL SIGNS: Stable. Blood pressure 150s to 180s/70s. Heart rate 80. Respiratory rate 18. Afebrile. Oxygen saturation 96% on room air. GENERAL: Alert older male, NAD. HEENT: N/C, N/T. EOM I wearing glasses. OP is clear. Mucous membranes are moist. NECK: Supple without adenopathy, thyromegaly, or carotid bruits. CARDIOVASCULAR: Regular rate and rhythm. No murmurs, rubs, or gallops.
OP|occiput posterior|(OP)|226|229|PHYSICAL EXAMINATION|HEENT: Anterior fontanelle soft and flat. Has large cephalohematoma, posterior occiput, which is resolving. Has a small scab. Eyes are clear. No icterus. Positive red reflex. Tympanic membrane exam deferred. Occiput posterior (OP) is clear. Moist mucous membranes. Slightly jaundiced. Nose with patent nares bilaterally. HEART: Heart rate regular without murmur. Well perfused. LUNGS: Bilateral breath sounds, clear to auscultation, equal.
OP|operative|OP|259|260|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: I have been asked to see the patient on behalf of Dr. _%#NAME#%_ for the patient's preoperative evaluation for her upcoming breast biopsies to be done by _%#NAME#%_ at Ridges Hospital on _%#DDMM2006#%_. Please see Dr. _%#NAME#%_'s OP note for details. _%#NAME#%_ notes that she has had recent biopsies done and from looking at the pathology, it looks like she had atypical hyperplasia and Dr. _%#NAME#%_ is planning on doing an additional biopsies to evaluate further.
OP|oropharynx|OP|207|208|OBJECTIVE|OBJECTIVE: Temperature 98.3, blood pressure 128/86, pulse 72, respirations 18, 99% O2 saturation on room air. This is an uncomfortable gentleman holding his abdomen. HEENT: PERRL, EOMI. Sclera is anicteric. OP is moist without lesions. NECK: Supple without adenopathy. HEART: Regular S1, S2, no murmurs. LUNGS: Clear bilaterally. ABDOMEN: Looks distended.
OP|oblique presentation/occiput posterior|OP|277|278|HOSPITAL COURSE|Throughout her labor, she was making appropriate cervical change, and on _%#MM#%_ _%#DD#%_, 2006, the patient received a vacuum-assisted vaginal delivery secondary to prolonged second stage and maternal exhaustion producing a viable male infant of 7 pounds 13 ounces in direct OP position. The patient experienced a second-degree laceration which was repaired with 3-0 Vicryl. EBL was 500 cc. Venous pH was 7.36 with base excess of negative 3.1 and arterial pH of 7.23 with base excess negative 4.9. Apgars were unavailable at the time of dictation.
OP|oropharynx|OP|155|156|PHYSICAL EXAMINATION|Blood pressure 140/50. General: Alert, smiling, talkative female, no acute distress. HEENT: PERRL. EOMI. Neck is supple without adenopathy. TMs are clear. OP clear. CV: Regular rate and rhythm with a I/VI systolic ejection murmur. Chest: There are bi-basilar crackles, right greater than left, no wheezes or rhonchi.
OP|oropharynx|OP|153|154|PHYSICAL EXAMINATION|General: Alert and oriented x 3, in no acute distress but looks tired and fatigued. HEENT: Sclerae nonicteric. No lymphadenopathy. PERRLA. Neck: Supple. OP is clear. Cardiovascular Exam: S1, S2 normal, no murmurs, gallops or rubs. Lungs: Clear to auscultation. Abdomen: Soft, mild diffuse tenderness. Bowel sounds positive.
OP|oropharynx|OP|267|268|PHYSICAL EXAMINATION|ORTHOSTATICS: Lying - blood pressure 142/72 with a heart rate of 91; standing, blood pressure is 138/76 with a heart rate of 114. General - this is an alert, pleasant woman in no acute distress. HEENT: PERRL. EOMI. Sclera anicteric. Conjunctivae is pale. TMs normal. OP is clear. NECK - supple without adenopathy or thyromegaly. HEART - regular S1, S2 with a soft I/VI systolic ejection murmur.
OP|oropharynx|OP|233|234|ADMISSION PHYSICAL EXAMINATION|She has three sisters that are alive and well. ADMISSION PHYSICAL EXAMINATION: Blood pressure is 142/96, pulse is 60, respirations are 16-18, temperature is 98.9, weight is 167 pounds. HEAD, EYES, EARS, NOSE AND THROAT: EOMI, PERRL. OP clear. NECK: Is soft and supple. CHEST: Lungs clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm, normal S-1 and S-2, no murmur ABDOMEN: Is soft, non-distended, non-tender with some scarring.
OP|oropharynx|OP|229|230|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Temperature is 101.6, heart rate 102, respirations 44, blood pressure 161/86, O2 saturations on room air 91 percent. This is an alert, obese gentleman, who is tachypneic. HEENT: PERRL. EOMI. TMs are normal. OP is clear. NECK: Supple. No lymphadenopathy or thyromegaly. HEART: Regular S1, S2. Tachycardic. No murmurs. Distant heart sounds. LUNGS: Decreased breath sounds bilaterally, but no rhonchi or wheezes or rubs.
OP|oropharynx|OP|141|142|PHYSICAL EXAMINATION (HLI)|Patient is a poor historian, but appears comfortable. HEENT: Pupils equally, round, and reactive to light and accommodation. Neck is supple. OP is clear. Cardiovascular exam, S1 S2 normal. No murmurs, gallops, or rubs. Lungs clear to auscultation. Abdomen soft, non-tender, nondistended.
OP|oropharynx|OP:|185|187|PHYSICAL EXAMINATION|Head is normocephalic and atraumatic. Eyes: Pupils are equal, round and reactive to light. Extraocular muscles intact. Ears: Tympanic membranes clear bilaterally. Landmarks identified. OP: Clear. No exudate. Large tonsils. Nares patent. Neck supple. Positive anterior cervical lymphadenopathy bilaterally. No thyromegaly. Cardiovascular: Positive S1, S2.
OP|oropharynx|OP|181|182|PHYSICAL EXAMINATION|General: Alert, oriented times three not in acute distress, appears comfortable. Head, eyes, ears, nose and throat: Sclarea not icterus, no lymphadenopathy. PERRLA, neck is supple, OP is clear. Cardiovascular exam S1, S2 normal, no murmurs, rubs or gallops. Lungs clear to auscultation. Abdomen soft, nontender, nondistended, bowel sounds positive.
OP|oropharynx|OP|198|199|PHYSICAL EXAMINATION|Temperature 96.4, heart rate 76, blood pressure 140/70, respiratory rate 22. Weight is 56.5 kg (down 11.66 lbs since _%#MM#%_, 2002). Height 5'7". HEENT: PERRL. EOMI. Sclerae anicteric. TMs normal. OP is clear. NECK: Supple without adenopathy or thyromegaly. HEART: Regular S1, S2. No murmurs. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft. There is some mild tenderness to palpation of the right mid abdomen and mid epigastric area.
OP|oblique presentation/occiput posterior|OP|266|267|PHYSICAL EXAMINATION UPON ADMISSION|She was begun on IV, given her multiparous status, and hemoglobin type and screen was checked upon admission. Pitocin induction was begun, given her irregular contractions. The patient, subsequently, went on to deliver normal spontaneous vaginal delivery at term in OP presentation, female infant, Apgars 8 at one minute, 9 at five minutes. Weight was 8 pounds 0 ounces. Some terminal meconium was noted upon delivery.
OP|oropharynx|OP|213|214|PHYSICAL EXAM|PHYSICAL EXAM: Blood pressure 121/78, pulse 133, temperature afebrile, and O2 sat 100 percent. GENERAL: Alert, oriented x 3, not in acute distress. HEENT: Pupils equally round and reactive to light. NECK: Supple. OP is clear. Tongue is rather dry. CARDIOVASCULAR EXAM: Irregularly irregular. LUNGS: Clear to auscultation. ABDOMEN: Soft, nontender, nondistended. Bowel sounds positive.
OP|oropharynx|OP|138|139|OBJECTIVE|This is a very pleasant and alert woman in no acute distress. She is oriented x 3. HEENT: PERRL. EOMI. Sclerae are anicteric. TMs normal. OP is clear. NECK is supple without adenopathy or thyromegaly. HEART: Regular S1 and S2. No murmurs. No carotid bruits. LUNGS have diminished breath sounds bilaterally with prolonged expiratory phase and bilateral expiratory wheezes.
OP|oropharynx|OP|179|180|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure is stable. His temperature is 101. HEENT: Sclerae anicteric. No lymphadenopathy. Pupils are equally round and reactive to light. OP is clear. NECK: Supple. CARDIOVASCULAR: S1, S2 normal. No murmur, gallops or rubs. No carotid bruits. LUNGS: Clear to auscultation. ABDOMEN: Soft, nontender, nondistended.
OP|oropharynx|OP|249|250|OBJECTIVE|OBJECTIVE: VITAL SIGNS: Blood pressure is 88/58, pulse is 88, respirations are 20, temperature is 98.1 and O2 saturation is 92% on room air, 95% on 2 liters O2. GENERAL: This is an alert, comfortable woman who is in no distress. HEENT: PERRL. EOMI. OP is moist. NECK: Supple without adenopathy or thyromegaly. HEART: Regular S1, S2. No murmurs, gallops or rubs. No carotid bruits. LUNGS: Clear bilaterally. No rhonchi or wheezes. ABDOMEN: Soft. There are good bowel sounds.
OP|oropharynx|OP|132|133|PHYSICAL EXAMINATION|O2 saturations 95% on room air. Weight is 91.4 kg. GENERAL: This is a pale gentleman who appears uncomfortable. HEENT: PERRL, EOMI. OP is moist. No obvious lesions. NECK: Supple without adenopathy or thyromegaly. HEART: Regular S1 and S2. No murmurs. LUNGS: Clear to auscultation bilaterally.
OP|oropharynx|OP|141|142|OBJECTIVE|This is an elderly appearing woman who appears younger than her stated age. She is alert and clear speech and mentation. HEENT: PERRL, EOMI. OP is very dry with dry lips and dry tongue. NECK: Supple, without adenopathy or thyromegaly. HEART: Irregularly irregular S1, S2 with a prominent II/VII murmur best heard at the left lower sternal border.
OP|oropharynx|OP|160|161|ADMISSION EXAM|General: Playful, smiling, comforted by parents, visibly cyanotic. HEENT: Atraumatic. Pupils equal, round, and reactive to light. Extraocular movements intact. OP clear without lesions, erythema, or exudate. Small amount of rhinorrhea. Neck: Supple without lymphadenopathy, no masses. Lungs: Tachypneic. Good air entry, symmetric.
OP|operative|OP|195|196|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: I have been asked to see the patient by Dr. _%#NAME#%_ _%#NAME#%_ of ENT for the patient's preop evaluation for her upcoming stapedectomy. Please see Dr. _%#NAME#%_'s OP note for details of the procedure. _%#NAME#%_ notes that she has been doing well other than some abdominal pain that she has been having recently.
OP|oropharynx|OP|221|222|PHYSICAL EXAMINATION|In general, she is alert, withdrawn, no acute distress. Head: Alopecia/thinning hair, normocephalic, atraumatic. Eyes: Conjunctivae clear. Ears: Bilateral TMs clear. Nose, mouth, and throat: Mucous membranes dry/cracked. OP clear of lesions, no erythema, no exudates. Neck: Supple, nontender. No lymphadenopathy. Cardiovascular: Hyperdynamic, normal S1 and S2. No murmurs.
OP|oropharynx|OP|130|131|PHYSICAL EXAMINATION|Weight 169.3 pounds. Height 5 foot 9 inches. GENERAL: He is a pleasant, articulate gentleman who is belching. HEENT: PERRL. EOMI. OP is clear. NECK: Supple without adenopathy or thyromegaly. HEART: Regular S1, S2. No murmurs, gallops or rubs. LUNGS: Clear bilaterally.
OP|oblique presentation/occiput posterior|OP|238|239|ASSESSMENT|She got to complete dilation but had arrest of descent and underwent primary low segment transverse cesarean section with delivery of a 6 pounds 14 ounces female infant. Apgars 8 at one minute and 9 at five minutes. The infant was direct OP The patient's postpartum and postoperative course was minimally complicated.
OP|oropharynx|OP|203|204|OBJECTIVE|HEENT: She has large hematoma and swelling present around the left eye and above the left eyebrow. Extraocular muscles are intact Pupils are equal, round and reactive. TM's look normal. Nares are clear. OP is moist without trauma. NECK supple without adenopathy. Range of motion of neck is normal. HEART: Regular S1, S2, no murmurs, no carotid bruits. LUNGS are clear to auscultation bilaterally.
OP|oropharynx|OP|236|237|OBJECTIVE|OBJECTIVE: Temperature is 97.2, blood pressure 118/70, pulse 56, respirations 18, O2 saturations 97 percent on 2 liters. This is a very pleasant gentleman, alert, in no acute distress. HEENT: PERRL. EOMI. Sclerae anicteric. TMs normal. OP is clear. NECK is supple without adenopathy or thyromegaly. HEART: Regular S1, S2. No murmurs, gallops, or rubs. No carotid bruits. LUNGS are clear bilaterally.
OP|oropharynx|OP|161|162|PHYSICAL EXAMINATION|This is a very pleasant, alert woman in no acute distress. She is oriented times three. HEENT: PERRL. EOMI with some lag of eye movements noted. TMs are normal. OP is clear, dentures noted upper and lowers. NECK is supple. There is no palpable adenopathy. She does have a multinodular goiter noted and an enlarged thyroid gland, nontender.
OP|oropharynx|OP|208|209|PHYSICAL EXAM|P: 90. R: 20. Oxygen saturation 92-955 on room air, 97% on two liters nasal cannula oxygen. This is an alert and oriented gentleman x 3. HEENT: PERRL. EOMI. Sclerae anicteric. TMs are normal. Ears are clear. OP is clear. Neck is supple without palpable adenopathy or thyromegaly. HEART: Regular S1, S2 with some ectopy. No murmurs. No carotid bruits. LUNGS: Have crackles two-thirds of the way up bilaterally.
OP|oropharynx|OP|210|211|PHYSICAL EXAM|O2 sat 96 percent. GENERAL: Alert, oriented x 3. The patient is in mild distress secondary to her pain. HEENT: Sclerae not icteric. No lymphadenopathy. Pupils equally round and reactive to light. NECK: Supple. OP is clear. CARDIOVASCULAR EXAM: S1, S2 normal. No murmurs, gallops, or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft, nondistended.
OP|oblique presentation/occiput posterior|OP|175|176|HOSPITAL COURSE|The patient underwent primary low segment transverse cesarean section, sustaining an estimated blood loss of 700 cc. She delivered a male infant in vertex presentation in the OP position, with Apgars of 8 at 1 minute and 9 at 5 minutes, weighing 8 pounds. Normal uterus, tubes and ovaries seen. Arterial blood gas showed pH 7.27, base excess -3.
OP|oropharynx|OP|136|137|PHYSICAL EXAM|GENERAL: Alert, oriented x 3. Appears chest pain free and comfortable. HEENT: Pupils equally round and reactive to light. NECK: Supple. OP is clear. No lymphadenopathy noted. CARDIOVASCULAR EXAM: S1, S2 normal. No murmurs, gallops, or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft, nontender, nondistended.
OP|oropharynx|OP|188|189|ADMISSION PHYSICAL EXAMINATION|Weight 67.9 kg. GENERAL: This is an elderly woman in no acute distress. HEENT: Normocephalic and atraumatic. Pupils equal, round and reactive to light and accommodation. Conjunctiva pale, OP clear, mucous membranes clear. NECK: Supple. CARDIOVASCULAR: Regular rate, and rhythm, tachycardiac, S1, S2 normal. Murmurs, rubs, gallops 0. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Bowel sounds positive, non-tender, and non-distended.
OP|oropharynx|OP.|186|188|CURRENT MEDICATIONS|P: 107. T: 99.6. RR: 16. Oxygen sat 98% on room air. GENERAL: The patient is alert, oriented, pleasant, slightly resistant to questioning regarding details. HEENT: Normal sclera, normal OP. LUNGS: Clear to auscultation bilaterally. CV: Regular rate and rhythm, no rubs, gallops, or murmurs, tachycardic. ABDOMEN: Soft, nontender, nondistended. SKIN: She is flushed, no clear rashes.
OP|oropharynx|OP|269|270|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 146/76, heart rate 99, respiratory rate 22, afebrile with 97% oxygen saturation on room air. GENERAL: The patient is a pleasant male who is in obvious distress with any type of motion. HEENT: PERRL, conjunctivae clear, OP dry mucous membranes and dentures both up and down. NECK: Supple. LUNGS: CTA bilaterally. HEART: Regular rate and rhythm with occasional premature beat and 2/6 systolic ejection murmur.
OP|oblique presentation/occiput posterior|OP|290|291|ADMISSION DIAGNOSES|At 1900 hours on _%#MM#%_ _%#DD#%_, 2004, the patient gave informed consent for a primary cesarean section secondary to arrest of dilation and failed induction of labor. She underwent cesarean section on 2100 hours on _%#MM#%_ _%#DD#%_, 2004, she delivered a viable male infant in straight OP presentation with Apgars of 8 and 9 at 1 and 5 minutes. Weight was 9 pounds 6 ounces. Normal uterus, fallopian tubes and ovaries.
OP|operative|OP|250|251|BRIEF HISTORY AND HOSPITAL COURSE|His diet was advanced to regular prior to discharge. He did have bowel movements prior to discharge without any evidence of persistent air leak. This perforated duodenal ulcer was oversewn intraop as described above. Please refer to Dr. _%#NAME#%_'s OP note for details. In addition, he was feeling quite depressed. He had just learned that his little sister had died suddenly.
OP|oropharynx|OP|235|236|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature is 98.3, heart rate 71, blood pressure 101/52, respirations 18, O2 saturation 98% on room air. GENERAL: This is a pleasant, soft-spoken young man in no acute distress. HEENT: PERRL, EOMI. OP is clear. There is no facial asymmetry. NECK: Supple without palpable adenopathy or thyromegaly. HEART: Regular S1 and S2. No ectopy. LUNGS: Clear bilaterally. ABDOMEN: Soft. There are good bowel sounds.
OP|oblique presentation/occiput posterior|OP|130|131|HISTORY OF PRESENT ILLNESS|She progressed to complete dilatation. By 4:45, she had been pushing for approximately 3 hours. The infant was noted to be in the OP position with a centimeter of caput. Her station progressed to 0. While pushing, she did develop a fever, and moderate meconium was noted.
OP|oropharynx|OP|180|181|EXAMINATION|I do not have them in front of me right now. HEENT: Head normocephalic. No lesions. Atraumatic. Eyes: PERRLA. EOMI bilateral with no scleral conjunctival injections. Nasal normal. OP normal. NECK: Supple. There is no lymphadenopathy or thyromegaly. HEART: Regular rate. S1, S2. No murmurs. LUNGS: Clear to auscultation bilaterally.
OP|operative|OP|246|247|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: I am asked to see the patient on behalf of Dr. _%#NAME#%_ of neurosurgery for the patient's upcoming right carpal tunnel release to be done at Fairview Southdale Hospital on _%#DDMM2007#%_. Please see Dr. _%#NAME#%_'s OP note for details of the procedure. _%#NAME#%_ notes that he has been having some discomfort in his hands but otherwise has been doing well.
OP|operative|OP|265|266|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: I have been asked to see the patient on behalf of Dr. _%#NAME#%_ for the patient's preop evaluation for his upcoming right knee surgery to be done by Dr. _%#NAME#%_ at Fairview Southdale Hospital next Friday. Please see Dr. _%#NAME#%_'s OP note for details of the procedure. The patient notes that he has been doing well with no specific complaints. PAST MEDICAL HISTORY: 1. LASIK eye surgery. 2. Hypercholesterolemia.
OP|oropharynx|OP|144|145|PHYSICAL EXAMINATION ON ADMISSION|HEENT: He has frontal bossing, left esotropia, no icteric injection. His left pinna is malformed and he has a hearing aid in his right ear. His OP was clear. NECK: Supple with no lymphadenopathy. CARDIOVASCULAR: Regular rate and rhythm. A 1/6 systolic ejection murmur was noted. LUNGS: no wheezes, occasional crackles in the right upper lobe.
OP|oropharynx|OP|141|142|PHYSICAL EXAMINATION|GENERAL: Oriented to person only, not oriented to place or time. HEENT: Cannot see light shine in eyes. Pupils sluggishly reactive to light. OP clear. CHEST: Clear to auscultation bilaterally. HEART: Tachycardic and regular. Unchanged holosystolic murmur. ABDOMEN: Hypoactive bowel sounds, soft, nontender, no hepatosplenomegaly.
OP|oropharynx|OP|254|255|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 99/53; heart rate 106; respiratory rate 18; O2 saturations at 97% on two liters nasal cannula; afebrile. In general the patient is a cachectic-appearing pleasant male in no acute distress. HEENT: PERRLA. OP with dry mucous membranes. Dentures up and down. NECK: Supple, no lymphadenopathy, no thyromegaly. LUNGS: No wheezes. Poor air exchange.
OP|oropharynx|OP.|329|331|PHYSICAL EXAM|95% on room air. PHYSICAL EXAM: General, patient is laying in bed, no acute distress, attends well to the examiner, is pleasant, cooperative though has some difficulty following relatively simple commands. She often turns to her husband for the answer of questions. HEENT - normal sclerae, extraocular eye motions intact, normal OP. NECK - no lymphadenopathy, no thyromegaly. LUNGS - clear to auscultation bilaterally. CV - regular rate and rhythm, no rubs, gallops, or murmurs.
OP|oropharynx|OP|147|148|HISTORY OF PRESENT ILLNESS|Eyes: Pupils are equal and reactive to light. There is no icterus. Ears: TMs are clear bilaterally. Nose: There is no discharge. Mouth and throat: OP is clear without erythema or exudate. Neck is supple. Lungs are clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, S1, S2, with a 2/6 systolic ejection murmur.
OP|oropharynx|OP|213|214|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 163/93; pulse 65; respiratory rate 16; temperature 95.6; oxygen saturation at 98% on room air. HEENT: Normocephalic and atraumatic. PERRL. Conjunctivae are clear. OP with moist mucous membranes. Face without evidence of trauma. NECK: Supple and nontender. LUNGS: CTA anteriorly. HEART: RRR, no murmur. ABDOMEN: Obese, soft, nontender. EXTREMITIES: Right upper extremity is in a sling and this was not removed for further examination.
OP|oropharynx|OP|142|143|OBJECTIVE|Height 5'9". This is a very pleasant, alert gentleman in no acute distress. HEENT: PERRL, EOMI. Sclerae are slightly yellow. Nares are clear. OP is moist without lesions. NECK is supple without adenopathy. HEART: Regular S1, S2. No murmurs. LUNGS are clear bilaterally. ABDOMEN is soft. There are good bowel sounds. There is no tenderness whatsoever with deep palpation over the right upper quadrant.
OP|oblique presentation/occiput posterior|OP|237|238|DISCHARGE DIAGNOSIS|ADMISSION DIAGNOSIS: A 26-year-old gravida 1, para 0, at 38 +2 weeks' gestation, admitted in active labor. DISCHARGE DIAGNOSIS: Status post primary low transverse cesarean section via Pfannenstiel skin incision for arrest of descent and OP position. HISTORY OF PRESENT ILLNESS: The patient was admitted as a 26- year-old gravida 1, para 0, at 38 +2 weeks' gestation, who was admitted with spontaneous rupture of membranes at 1:45 a.m. on _%#MM#%_ _%#DD#%_, 2004.
OP|oblique presentation/occiput posterior|OP|303|304|HOSPITAL COURSE|Fetal position was right occiput posterior. The patient was consulted for a primary low transverse cesarean section via Pfannenstiel skin incision for arrest of descent and OP position at 28 +2 weeks. The patient underwent this procedure and had a 700 mL EBL and delivered a viable female infant in the OP position with Apgars at 9 at 1 minute, 9 at 5 minutes. On postoperative day #1 she was doing well. She was denying bowel movements and flatus.
OP|operative|OP|177|178|HISTORY OF PRESENT ILLNESS|HOSPITAL COURSE: The patient was taken to the operating room on _%#MM#%_ _%#DD#%_, 2004, at which time an uneventful laparoscopic cholecystectomy was completed. Please refer to OP report. Postoperative, patient developed significant ileus and urinary retention. The urinary retention resolved within a day or 2 and the ileus likewise slowly improved.
OP|oblique presentation/occiput posterior|OP|293|294|PHYSICAL EXAMINATION|The patient was then taken to the operating room after obtaining informed consent where under spinal anesthesia repeat low transverse cesarean section was done without any complications. There was a 500 cc estimated blood loss. There was delivery of a viable male infant who was in the direct OP position at 1631. Apgars were 9 and 9 at 1 and 5 minutes respectively and the weight was 7 pounds 9 ounces.
OP|oblique presentation/occiput posterior|OP|210|211|HOSPITAL COURSE|Pitocin was started as her contractions spaced and the patient proceeded to undergo a normal spontaneous vaginal delivery at 04:08 on _%#DDMM2007#%_ with a viable male infant weighing 7 pounds 15 ounces in the OP presentation. This was without complication. The patient did well postpartum. Her vital signs remained stable with no episodes of tachycardia or syncope.
OP|oropharynx|OP|150|151|PHYSICAL EXAMINATION|HEENT: Head normocephalic with no lesions. Ears - atraumatic. Eyes - PERRLA. EOMI bilaterally with no scleral conjunctival injection. Nasal - normal. OP is normal. NECK: Supple. No lymphadenopathy or thyromegaly. HEART: Regular rate. S1, S2. No murmurs. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Gravid and nontender to palpation.
OP|oropharynx|OP|240|241|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITALS SIGNS: Temperature 97.2, pulse 82, blood pressure 136/86, respirations 16, O2 saturation 96-98% on room air. GENERAL: This is a pleasant, frail-appearing, elderly woman who has clear speech. HEENT: PERRL. EOMI. OP is moist without trauma. NECK: Supple without adenopathy or thyromegaly. HEART: Regular S1 and S2, no murmurs. LUNGS: Clear bilaterally. ABDOMEN: Soft. There is good bowel sounds. No tenderness whatsoever.
OP|oropharynx|OP|203|204|PHYSICAL EXAMINATION ON ADMISSION|PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.6. Blood pressure 197/85. Heart rate 90. Respirations 20. Oxygen saturation 97% on room air. Alert and oriented, NAD. Sclerae are clear. PERRL and EOMI. OP clear. No rhinorrhea. Thyroid normal. No JVD. There is a 3/6 systolic ejection murmur at the apex. Lungs are clear with unlabored respirations. Abdomen benign without hepatosplenomegaly.
OP|oropharynx|OP|172|173|PHYSICAL EXAM ON ADMISSION|Respirations 12, 95% room air. The patient is seen after a dose of morphine for pain, somnolent and falls asleep in midsentence. NC/AT. Pupils 2 mm and minimally reactive. OP with mild erythema. Mucosa is tacky. Palpable thyroid, slightly larger on the left with a bruit over the left lobe. No cervical lymphadenopathy. Questionable bruit over the right carotid. Tachycardic.
OP|oropharynx|OP|174|175|PHYSICAL EXAM|PHYSICAL EXAM: T: Afebrile. P: 93-94. BP: 140/71. HEENT: Sclerae anicteric. No lymphadenopathy. Pupils equally round and reactive to light and accommodation. Neck is supple. OP is clear. CARDIOVASCULAR: S1, S2 normal. No murmur, gallops, or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft. Decreased bowel sounds. Mild tenderness in the epigastric area. No tenderness in the right upper quadrant area.
OP|oropharynx|OP|216|217|PHYSICAL EXAM|PHYSICAL EXAM: Blood pressure 146 /82, pulse 58, respirations 22, and temperature afebrile. HEENT: Sclerae not icteric. No lymphadenopathy. Pupils equally round and reactive to light and accommodation. NECK: Supple. OP is clear. CARDIOVASCULAR EXAM: S1, S2 normal. No murmurs, gallops, or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft, nontender, nondistended.
OP|oropharynx|OP|173|174|PHYSICAL EXAMINATION|GENERAL: WN/WD, NAD. HEAD: NC/AT, soft anterior fontanel. EYES: Small conjunctival hemorrhage in both eyes. EARS: Patent, clear TMs bilaterally. NOSE: Patent. MOUTH/THROAT: OP is clear. NECK: Supple. No lymphadenopathy. LUNGS: CTA bilaterally. BREASTS: Tanner stage I. CARDIOVASCULAR: RRR; no murmurs, rubs, or gallops; regular S1 and S2.
OP|oblique presentation/occiput posterior|OP|151|152|HOSPITAL COURSE|Estimated blood loss was 1000 mL. Normal tubes, uterus and ovaries were visualized. Paratubal cyst x2 on the left. Viable male infant delivered in the OP position at 2038 on _%#MM#%_ _%#DD#%_, 2004. Apgars 9 and 9. NICU was present. Arterial pH 7.3. Base excess 1.1. Venous pH 7.36, base excess 0.2. Please see operative note for complete details of procedure.
OP|oblique presentation/occiput posterior|OP|195|196|HOSPITAL COURSE|Therefore, the patient was taken to the operating room and a STAT cesarean section was performed under general anesthesia with a vertical skin incision. A viable female infant was delivered from OP presentation at 2041 with Apgars of 9 and 9, weight of 7 pounds 15 ounces. Blood gases showed an arterial of 7.25 with a -1.6 base excess.
OP|oropharynx|OP|283|284|DISCHARGE DIAGNOSES|The patient does have polydipsia without polyuria. EXAM ON ADMISSION: The patient was afebrile, pulse was 70s to 80s, blood pressure was 110/60-70, respiratory rate was 20. Satting 94% on room air. His weight was 65 kg. He was alert, oriented, cachectic. Sclerae were anicteric. His OP was clear without any exudate. Cardiovascular: Normal rate and rhythm, no murmurs, rubs, or gallops. Lungs: He had prolonged expiration with minimal wheezes and scattered expiratory crackles bilaterally.
OP|oropharynx|OP|183|184|OBJECTIVE|Blood pressure 150 to 190s over 70s to 80s. GENERAL: Alert, older female, NAD. HEENT: PERRLA with slight bilateral cataracts. EOMI. NECK: Supple without adenopathy or carotid bruits. OP is clear. Mucous membranes are moist. CV: Regular rate and rhythm, no murmurs, rubs, or gallops. CHEST: Clear to auscultation bilaterally. ABDOMEN: Bowel sounds are positive, soft, nontender, nondistended.
OP|oblique presentation/occiput posterior|OP|117|118|DISCHARGE SUMMARY|She received ampicillin 2 grams and gentamycin 80 mg and then with second stage she started to push. The baby was in OP position and there was fetal distress in the second stage, late decelerations. The patient was on oxygen, had adequate IV fluids. We stopped the Pitocin.
OP|oropharynx|OP|172|173|PHYSICAL EXAM|This is a very pleasant, obese woman who appears much older than her stated age. She is uncomfortable. HEENT - PERRL, EOMI, sclerae anicteric, TMs normal. Nares are clear. OP is clear. NECK - supple, no adenopathy or thyromegaly. HEART - regular S1, S2, no murmurs, no gallops, no ectopy. LUNGS - have bibasilar crackles present bilaterally. ABDOMEN - soft, there are good bowel sounds, no tenderness.
OP|oropharynx|OP|127|128|PHYSICAL EXAMINATION|GENERAL: The patient is a pleasant female sitting at the edge of her bed eating lunch. HEENT: PERRL, EOMI, conjunctivae clear; OP with dry mucous membranes. NECK: Supple; no lymphadenopathy, no thyromegaly. LUNGS: Bibasilar crackles and diffuse wheeze. HEART: Regular rate and rhythm with 2/6 systolic murmur. ABDOMEN: Soft; nontender.
OP|operative|OP|219|220|HISTORY OF PRESENT ILLNESS|This was for proposed full thickness skin graft. After explaining the risks and benefits, the patient was taken to the operative theater on _%#DDMM2007#%_. The patient's OR course was without complication (see specific OP notes for details). Following the patient's OR course, the patient was admitted to 5A for the remainder of her hospitalization. The patient's hospitalization was without complication. On postoperative day #3, the patient was ambulatory with crutches and had received teaching from physical therapy.
OP|oropharynx|OP|273|274|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature is 98.7, pulse is 70, blood pressure is 149/84, respiratory rate 20, sats 98% on 2 liters. GENERAL: She is pleasant, in no acute distress. HEENT: Normocephalic, atraumatic. Her color is sallow. Extraocular muscles are intact. OP is clear. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Regular without murmurs, rubs, gallops. LUNGS: Decreased breath sounds in the bases, right greater than left.
OP|oropharynx|OP|222|223|PHYSICAL EXAMINATION|GENERAL: She is a very pleasant elderly Chinese woman who appears younger than her stated age in no acute distress. HEENT: Normocephalic, atraumatic. Pupils are equal and reactive to light. Extraocular muscles are intact. OP is clear. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Heart is irregularly irregular with a 2-3/6 systolic murmur along the left sternal border.
OP|oropharynx|OP|252|253|DISCHARGE PHYSICAL EXAMINATION|VITAL SIGNS: Temperature is 98.8, pulse is 82, blood pressure is 101/60, respiratory rate 16, saturations are 97% on room air. GENERAL: She is in no acute distress. HEENT: Normocephalic, atraumatic, sclerae are icteric. Extraocular muscles are intact. OP is clear. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Regular without murmurs, rubs or gallops. LUNGS: Clear bilaterally. BACK: No midline or CVA tenderness. ABDOMEN: Soft, with ascites.
OP|oropharynx|OP|282|283|OBJECTIVE|MUSCULOSKELETAL: Bruised right knee, otherwise generalized osteoarthritis, quiescent. OBJECTIVE: VITAL SIGNS: Temperature 96.4, pulse 63, blood pressure 154/81, O2 saturation 100% on room air. GENERAL: This is a pleasant, slightly pale woman who is oriented x3. HEENT: PERRL, EOMI, OP is dry. NECK: Supple with bulky adenopathy bilaterally which is nontender. HEART: Regular S1, S2, no murmurs. LUNGS: Clear to auscultation bilaterally.
OP|operative|OP|289|290|NAME  OF PROCEDURE|9. History of aortic valve replacement on chronic Coumadin, some possible left ventricular outflow tract obstruction according to the transesophageal echocardiogram back in _%#MM2007#%_. NAME OF PROCEDURE: Right distal femur intramedullary pinning per Orthopedic Surgery. Please see their OP note for details. BRIEF HISTORY AND HOSPITAL COURSE: An 80-year-old female with complicated past medical history presented here with a fall.
OP|oropharynx|OP|203|204|PHYSICAL EXAMINATION|GENERAL: This is a pleasant gentleman who is speaking in full sentences, no acute distress. HEENT: PERRL. EOMI. Conjunctivae are beefy red with some yellow mattering present bilaterally. TMs are normal. OP moist. There is minimal posterior erythema. No exudates. NECK: Supple without adenopathy or thyromegaly. HEART: Regular S1 and S2 with audible click.
OP|oropharynx|OP|177|178|PHYSICAL EXAMINATION|02 SATs are 99% on room air. In general, the patient is a very pleasant male who is very aware of his medical history. He is no acute distress. HEENT: PERRL. Conjunctiva clear. OP clear with moist mucous membranes. Neck supple. No lymphadenopathy. No thyromegaly. No JVD. Lungs clear to auscultation bilaterally. No respiratory distress. Heart: Regular rate and rhythm, no murmur.
OP|oblique presentation/occiput posterior|OP|173|174|STAGE II|STAGE II: Perineum was infiltrated with one percent Carbocaine and a midline episiotomy made. At 0749 hours, she spontaneously delivered an 8-lb, 13-oz male from the direct OP position. Mouth and nares was suctioned of clear fluid, and the rest of the baby delivered without difficulty. There was a cord looped over the baby's shoulder. The cord was doubly clamped and cut.
OP|oropharynx|OP|183|184|OBJECTIVE|Cognitive - no deficits. OBJECTIVE: Temperature 96.9, pulse 84, respirations 16, and blood pressure 158/96. This is an alert, pleasant woman who appears nervous. HEENT - PERRL, EOMI, OP is clear. Cranial nerves are intact with the exception of decreased hearing in the right ear, patient has subjective left facial numbness.
OP|oropharynx|OP|179|180|OBJECTIVE|OBJECTIVE: Temperature 97.9, blood pressure 175/74, pulse 45, respirations 20, O2 saturations 100% on 2 liters. This is a fatigued, tearful woman. HEENT - PERRL, EOMI, TMs clear, OP clear. NECK - supple without adenopathy or thyromegaly. HEART - regular S1, S2, with a 2/6 soft systolic murmur. No carotid bruits. LUNGS - clear to auscultation bilaterally. ABDOMEN - soft, there are good bowel sounds, no tenderness.
OP|oblique presentation/occiput posterior|OP|198|199|HOSPITAL COURSE|On _%#DDMM2003#%_, she underwent a Cesarean section with an estimated blood loss of 800 cc under spinal anesthesia with Dr._%#NAME#%_ and Dr. _%#NAME#%_. Findings revealed a viable female infant in OP presentation with Apgar of 9 and 9, a weight of 7 pounds 7 ounces, normal uterus, tubes and ovaries. For further details, please see the operative report from that date.
OP|oblique presentation/occiput posterior|OP|113|114|HOSPITAL COURSE|She was delivered of a 7 pound, 15 ounce female infant with Apgars of 9 at one minute, 9 at five minutes from an OP presentation. Please refer to operative report regarding details of the patient's intraoperative course. Postoperative hemoglobin measured 10.2 grams/dl. The patient remained afebrile throughout her postoperative course.
OP|oropharynx|OP|174|175|DISCHARGE EXAM|HEENT: ANTERIOR FONTANELLE is soft and flat. There is some facial hemangiomas over the eyelids and upper lip. They are not raised. EYES show positive red reflex bilaterally. OP is moist. There is no cleft. There is good suck. EARS and NOSE are patent. TM's look normal. CHEST looks normal.
OP|oropharynx|OP|193|194|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Temperature is 98.1, blood pressure 139/64, pulse 64, respirations 20, weight is 153.6 lb. This is an elderly woman who is pleasant, minimal distress. HEENT: PERRL. EOMI. OP is moist. NECK is supple without palpable adenopathy or thyromegaly. HEART - regular, S1, S2, no murmurs or ectopy. LUNGS are clear to auscultation bilaterally.
OP|operative|OP|346|347|OPERATIONS/PROCEDURES PERFORMED|3. Status post lysis of adhesions for small-bowel obstruction. OPERATIONS/PROCEDURES PERFORMED: Patient had lysis of adhesions for small-bowel obstruction and went to the operating room on _%#MM#%_ _%#DD#%_, 2005, for lysis of adhesions, exploratory laparotomy, repair of small-bowel enterotomy x1 without any complications. For full report, see OP note. The patient also underwent an EGD on _%#MM#%_ _%#DD#%_, 2005, by GI. She also underwent a filter replacement on _%#MM#%_ _%#DD#%_, 2005, by interventional radiology for a history of DVTs and PE.
OP|oropharynx|OP|240|241|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure is 150/81, pulse is 85 and temperature is 100.3. GENERAL: Alert and oriented x3. She appears to be comfortable. HEENT: Sclerae are anicteric. Pupils are equally round and reactive to light. OP is clear. NECK: Supple. No lymphadenopathy. CARDIOVASCULAR: S1 and S2 are normal. No murmurs, gallops or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft, diffuse tenderness particularly in epigastric area.
OP|oropharynx|OP|144|145|PHYSICAL EXAMINATION|She appears to be comfortable. HEENT: Sclera are non-icteric. No lymphadenopathy. Pupils are equally round and reactive to light. NECK: Supple. OP is clear. CARDIOVASCULAR: S1, S2 are normal. No murmur, gallops, or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft, nontender, no distended. Bowel sounds are positive.
OP|operative|OP|163|164|PROCEDURES PERFORMED|DISCHARGE DIAGNOSIS: 1. Left ureterolithiasis. 2. Hypertension. PROCEDURES PERFORMED: Cystoscopy with stenting on _%#DDMM2006#%_. Please refer to Dr. _%#NAME#%_'s OP note for details. BRIEF HISTORY AND HOSPITAL COURSE: A 43-year-old male with a 1-week history of left flank pain which had been intermittent with some radiation to the left groin.
OP|oblique presentation/occiput posterior|OP|220|221|OPERATIVE COURSE|OPERATIVE COURSE: The patient underwent primary low-transverse cesarean section via Pfannenstiel skin incision under an epidural anesthesia with EBL of 1000. Complications were none. She produced a viable male infant in OP asynclitic presentation with Apgars of 9 and 9 at one and five minutes with a weight of 6 pounds 11 ounces with otherwise normal uterus, tubes, and ovaries.
OP|oropharynx|OP|156|157|PHYSICAL EXAMINATION|Good eye contact. Willing to provide information. HEENT: Normocephalic, atraumatic. Pupils are equal and reactive to light. Extraocular muscles are intact. OP is clear. TMs are clear bilaterally. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Regular with a very soft 1/6 systolic murmur heard along the left sternal border.
OP|oropharynx|OP|141|142|PHYSICAL EXAM|GENERAL: She is a very pleasant woman who appears her stated age in no acute distress. HEENT: Normocephalic, atraumatic. Sclerae nonicteric. OP is clear. Extraocular muscles are intact. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Regular without murmurs, rubs or gallops. BREASTS: Not examined. LUNGS: Clear bilaterally. BACK: No midline or CVA tenderness.
OP|oblique presentation/occiput posterior|OP|279|280|HOSPITAL COURSE|At this time, there had been a fair amount of bleeding, and there were occasional variables with a late component, but overall excellent variability and a baseline of 150s-160s. The patient remained febrile to 101.2 despite Tylenol. Cervical exam revealed the infant to be in an OP or possibly OT presentation. The cervix remained 9 cm and was swollen. As this patient had remained 9 cm now with adequate labor for over 3 hours, and there was concern about abnormal vertex presentation as well as chorioamnionitis, the decision was made to proceed with cesarean section.
OP|oropharynx|OP|166|167|PHYSICAL EXAMINATION|GENERAL: She looks quite comfortable, in no acute distress. HEENT: Normocephalic, atraumatic. Pupils are equal and reactive to light. Extraocular muscles are intact. OP is clear. TMs are not examined. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Regular without murmurs, rubs or gallops. There are no carotid bruits.
OP|oropharynx|OP|185|186|PHYSICAL EXAMINATION|GENERAL: He is a pleasant man who appears his stated age in no acute distress. HEENT: Normocephalic, atraumatic. Pupils are equal and reactive to light. Extraocular muscles are intact. OP is clear. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Regular without murmurs, rubs or gallops. LUNGS: Expiratory wheezes bilaterally, greater on the right than the left.
OP|oropharynx|OP|197|198|PHYSICAL EXAMINATION|HEENT: Head is normocephalic. Features are symmetric. Anterior fontanelle is soft and flat. Eyes: Positive red reflex bilaterally. Nose: Nares patent. Throat: Moist mucous membrane. Palate intact. OP clear. CHEST: Clear to auscultation bilaterally. Easy effort. Nipples are symmetric. HEART: Rate regular S1, S2. No murmurs. Well perfused. ABDOMEN: Soft. Positive bowel sounds. No HSM. Umbilical cord is clean, dry and intact.
OP|oropharynx|OP|263|264|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Blood pressure 130/80, pulse 60, respiratory rate 20, afebrile, weight 203.7, oxygen saturation 93% on room air. In general, the patient is a pleasant female in no acute distress. She seems in good spirits. HEENT: PERRL. Conjunctivae clear. OP with dry mucous membranes. Neck supple, without lymphadenopathy. Lungs clear to auscultation bilaterally. Heart: Irregularly irregular rhythm.
OP|oropharynx|OP|208|209|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Blood pressure 89/49, heart rate 93, respiratory rate 28, temp 96 orally. General: The patient is a pleasant, thin, elderly female in no acute distress. HEENT: PERRL. Conjunctiva clear. OP with moist mucous membranes. She wears dentures both up and down. Neck: Supple, no thyromegaly. Lungs: Few bibasilar crackles. Heart: Regular rate and rhythm with 2/6 systolic ejection murmur at the right upper sternal border.
OP|oblique presentation/occiput posterior|OP|111|112|HOSPITAL COURSE|A low segment transverse cesarean section was performed with delivery of a male, weighing 6 lb 13 oz, from the OP position. Apgars were 8 and 9. Postoperatively, the patient did well and she was discharged home on the third postoperative day.
OP|oblique presentation/occiput posterior|OP|227|228|COMPLICATIONS|The patient was then transferred to labor and delivery. The patient received an epidural for pain relief. Penicillin was continued. The patient rapidly progressed to complete cervical dilatation. A viable female infant, direct OP position, was delivered at 1324 hours, weight 1810 g, Apgars 8 at 1 minute, 9 at 5 minutes, NICU present for delivery.
OP|oropharynx|OP|227|228|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature afebrile. Blood pressure 144/101. GENERAL: Alert, oriented x 3, not in any acute distress. HEENT: Sclera anicteric. No lymphadenopathy. Pupils equally round and reactive to light. OP is clear. NECK: Supple. CARDIOVASCULAR: S1, S2 normal. No murmurs, gallops, or rubs. LUNGS: Clear to auscultation. ABDOMEN: Benign. EXTREMITIES: No edema. LABORATORY: White count is 7.
OP|oblique presentation/occiput posterior|OP|185|186|HOSPITAL COURSE|She then progressed to full dilatation at 1550 hours and began to have the urge to push around 1600 hours. She was unable to move the baby's head. On examination the baby was in direct OP position. The fetal heart rate had been reactive throughout labor. In the last 30 minutes of pushing, there was decreased variability and the patient herself developed a temperature.
OP|oropharynx|OP|198|199|PHYSICAL EXAMINATION|These vitals were obtained on the Medical floor. GENERAL: The patient is a pleasant female who is lying still in a dark room with a cool washcloth on her forehead. HEENT: PERRL, conjunctivae clear. OP with dry mucous membranes. NECK: Supple. LUNGS: CTA bilaterally. HEART: Regular rate and rhythm, no murmur. ABDOMEN: Soft, nontender. BILATERAL LOWER EXTREMITIES: No edema. BACK: Lumbar puncture site is covered with a bandage, and there is no sign of bleeding.
OP|oblique presentation/occiput posterior|OP|126|127|OPERATIONS/PROCEDURES PERFORMED|ANESTHESIA: Epidural. EBL: 1000 mL. URINE OUTPUT: 75 mL of clear at the end of the procedure. FINDINGS: Viable male infant in OP position, presence of meconium. No nuchal cord noted. Apgars of 8 and 9. Weight of 9 pounds. Delivered at 9:34 p.m. The uterus, ovaries, and tubes were anatomically normal.
OP|oblique presentation/occiput posterior|OP|149|150|FINDING|PROCEDURE: The patient underwent repeat low-transverse cesarean section via Pfannenstiel. EBL was 1000 cc. FINDING: Included viable female infant in OP presentation with nuchal cord x1, Apgars of 9 and 9 at one and five minutes respectively. Weight 6 pounds 9 ounces, dense scarring from skin to fascia and fascia to anterior bladder.
OP|oblique presentation/occiput posterior|OP|181|182|HISTORY/HOSPITAL COURSE|Fetal tracings showed decreased variability and tachycardia to the 180s, therefore the decision was made to proceed with cesarean section. She went on to deliver a viable female in OP presentation, weighing 7 pounds 10 ounces, with Apgars of 9 and 9. There was terminal meconium. Her postoperative course was uneventful. She remained afebrile and had a postoperative hemoglobin of 10.9. She was discharged on the fourth postoperative day with a return appointment in six weeks for postpartum check.
OP|oropharynx|OP|146|147|PHYSICAL EXAMINATION|Alert and oriented. HEENT: Normocephalic, atraumatic. Sclerae nonicteric. Pupils are equal and reactive to light. Extraocular muscles are intact. OP is clear. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Regular without murmurs, rubs or gallops appreciated but she has a very bulky dressing across her anterior chest.
OP|oropharynx|OP|185|186|PHYSICAL EXAMINATION|GENERAL: She is very pleasant and in no acute distress. HEENT: Normocephalic and atraumatic. Pupils are equal and reactive to light. Extraocular muscles are intact. Sclerae nonicteric. OP is clear. TMs are not examined. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Regular with a 2/6 systolic murmur. LUNGS: Clear bilaterally. BACK: No midline or CVA tenderness. BREASTS: Not examined.
OP|oropharynx|OP|212|213|PHYSICAL EXAMINATION|GENERAL: She is very pleasant, does not appear to be in any acute distress and appears younger than her stated age. HEENT: Normocephalic, atraumatic. Pupils are reactive to light. Extraocular muscles are intact. OP is clear. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Regular without murmurs, rubs or gallops. LUNGS: Decreased in the bases bilaterally but clear. BACK: No midline or CVA tenderness.
OP|oblique presentation/occiput posterior|OP|137|138|FINDINGS|She underwent this procedure without complication on _%#DDMM2007#%_. EBL for this procedure was 1000 mL. FINDINGS: Viable male infant in OP presentation with Apgars of 8 and 9 at 1 and 5 minutes respectively. Weight 8 pounds 8 ounces. There was noted to be filmy adhesions over the fimbriae bilaterally.
OP|oblique presentation/occiput posterior|OP|144|145|HOSPITAL COURSE|She dilated up to an anterior lip and then regressed to 7 cm with edema forming on the cervix. The baby remained at a +1 station and persistent OP for several hours. At this point, cesarean section was performed through a low transverse incision utilizing the existing epidural for pain relief.
OP|oropharynx|OP|135|136|PHYSICAL EXAMINATION|HEENT: Normocephalic, atraumatic. The left pupil is larger than the right. Both are reactive to light. Extraocular muscles are intact. OP is clear. TMs are clear. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Sounds are difficult to hear secondary to his very loud respiratory effort but appears regular.
OP|oblique presentation/occiput posterior|OP|188|189|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 32-year-old white female, gravida 2, para 1 who had previous C-section delivery because of arrest of dilatation and descent with the OP position and delivered 8 pounds 11 ounces female infant at Fairview Southdale Hospital with low transverse incision on the uterus. The patient has refused VBAC in this pregnancy. Her last menstrual period was _%#DDMM2003#%_ and due date was _%#DDMM2004#%_, which was confirmed by the ultrasound at 21 weeks gestation.
OP|oropharynx|OP|163|164|PHYSICAL EXAMINATION|O2 saturation on two liters is 98%. This is a morbidly obese woman who is very pleasant but appears dyspneic. HEENT: PERRL, EOMI. TMs are normal. Nares are clear. OP is moist. There are no lesions. NECK is supple without palpable adenopathy or thyromegaly. HEART tones are distant, but there is a 2/6 systolic murmur heard best at the right upper sternal border.
OP|oblique presentation/occiput posterior|OP|239|240|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: This is a 23-year-old gravida 1, para 1-0- 0-1 status post primary low segment transverse cesarean section for non- reassuring fetal heart tones, remote from delivery. A suspected macrosomia. Abnormal pelvic inlet and OP position of the fetus. OPERATIONS/PROCEDURES THIS ADMISSION: 1. Epidural placement. 2. Primary low segment transverse cesarean section.
OP|oropharynx|OP|229|230|ADMISSION PHYSICAL EXAMINATION|ADMISSION PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.1, pulse 68, respirations 16, blood pressure 120/80, O2 sats 100% on room air. GENERAL: He was alert, lying in bed, in no acute distress. HEENT: PERRL, EOMI, anicteric. OP clear. No LAD. CARDIOVASCULAR: Regular rate and rhythm, normal S1, S2; no murmurs, rubs, or gallops. RESPIRATORY: Clear to auscultation bilaterally. ABDOMEN: Bowel sounds positive. Mild tenderness in the epigastrium and bilateral flanks; nondistended; no hepatosplenomegaly, no masses.
OP|oblique presentation/occiput posterior|OP|203|204|HISTORY OF PRESENT ILLNESS|The patient was started on Pitocin augmentation in anticipation for a NSVD and given ampicillin for positive GBS. However, secondary to inability to tolerate labor, and arrest of dilatation secondary to OP positioning and prominent sacral promontory, the patient underwent a primary low-transverse cesarean section on _%#MM#%_ _%#DD#%_, 2004, at 2300 hours with Fairview _%#CITY#%_ Womens Clinic, attending Dr. _%#NAME#%_ and Dr. (_______________).
OP|oblique presentation/occiput posterior|OP|182|183|DISCHARGE DIAGNOSES|2. Oligohydramnios. 3. OP presentation. 4. Arrestive dilatation and arrestive descent. 5. Thick meconium. DISCHARGE DIAGNOSES: 1. IUP at 40+6 weeks gestation. 2. Oligohydramnios. 3. OP presentation. 4. Arrestive dilatation and arrestive descent. 5. Thick meconium. PROCEDURES: Primary low transverse cesarean section. COMPLICATIONS None.
OP|oblique presentation/occiput posterior|OP|204|205|DELIVERY NOTE|DELIVERY NOTE: The patient was taken to the operating room and given spinal anesthesia and underwent a primary low transverse C- section and without complications. A viable male infant delivered from the OP position at 00:31 on _%#DDMM2004#%_. Weight was 9 pounds 0 ounces. Apgars of 6 and 9. A thick meconium was noted. Cord pH arterial was 7.26, with a base excess of -35, venous pH of 7.33, base excess -3.8. EBL 1,000 cc.
OP|oropharynx|OP|175|176|PHYSICAL EXAMINATION|GENERAL: This is a very obese gentleman who appears dyspneic, using supracostal muscles to speak, speaks in fragmented sentences. HEENT: Head is normocephalic and atraumatic. OP is moist without. Tongue is midline. Uvula rises symmetrically. Speech appears slightly slurred. NECK: Supple without adenopathy or thyromegaly. HEART: Regular S1 and S2, no murmurs.
OP|operative|OP|158|159|ADMISSION DIAGNOSIS|Please refer to that OP report. During the procedure, we had some problems with omental bleeding and as such conversion to open technique. Again, refer to my OP report. Postop hemoglobin was followed. This remained stable. _%#NAME#%_ did have some difficulty with weakness and requested an extra day of recovery time here.
OP|oblique presentation/occiput posterior|OP|121|122|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: Intrauterine pregnancy, 39+ weeks gestation, arrest of descent in the 2nd stage of labor, suspected OP position. DISCHARGE DIAGNOSES: Intrauterine pregnancy, 39+ weeks gestation, arrest of descent in the 2nd stage of labor, OP position and a single nuchal cord, status post primary low segment transverse cesarean section.
OP|operative|OP|162|163|PROCEDURE|CONSULTATIONS during hospitalization Orthopedic consultation Dr. _%#NAME#%_. PROCEDURE: Right hip ORIF Dr. _%#NAME#%_. Please see separately dictated consult and OP note in this regard. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a _%#1914#%_-year-old Caucasian female with advanced dementia.
OP|oropharynx|OP|149|150|EXAMINATION|HEENT: Head normocephalic with no lesions. Ears atraumatic. Eyes: PERRLA. EOMI bilaterally with no scleral or conjunctival injections. Nasal normal. OP normal. NECK: Supple with no lymphadenopathy or thyromegaly. HEART: Regular rate, S1, S2, no murmurs. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Protuberant, soft. Good bowel sounds.
OP|oropharynx|OP:|172|174|PHYSICAL EXAMINATION|HEENT: Head normocephalic with no lesions. Ears: Atraumatic. Eyes: PERRLA, extraocular movements intact bilaterally with no scleral/conjunctival injections. Nasal: Normal. OP: Normal. NECK: Supple, there is no lymphadenopathy or thyromegaly. HEART: Regular rate S1, S2, no murmurs. LUNGS: Clear to auscultation bilaterally.
OP|oblique presentation/occiput posterior|OP|154|155|HOSPITAL COURSE|She then underwent an uncomplicated primary cesarean via low-segment transverse incision with a 2 layer uterine closure. She delivered a viable female in OP position weighing 7 pounds 0 ounces with Apgars of 9 at 1 minute and 9 at 5 minutes. Arterial cord pH of 7.35 with a base excess of 0.1, venous cord pH of 7.31 with a base excess of 0.8. ESTIMATED BLOOD LOSS: Less than 750- cc.
OP|oropharynx|OP|140|141|PHYSICAL EXAMINATION|HEENT: Head is normocephalic. Eyes - PERRLA. EOMI bilaterally with no scleral or conjunctival injection. Ears are atraumatic. Nasal normal. OP is normal. NECK: Supple. No lymphadenopathy or thyromegaly. HEART: Tachycardic. S1, S2. No murmurs. LUNGS: Clear to auscultation bilaterally. ABDOMEN: She has good bowel sounds.
OP|oropharynx|OP|160|161|PHYSICAL EXAMINATION|She is cooperative with the exam. HEENT: Normocephalic, atraumatic. Pupils are equal and reactive to light. Sclerae nonicteric, extraocular muscles are intact. OP is slightly dry but without lesions. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Regular without murmurs, rubs or gallops. BREASTS: Not examined. LUNGS: Clear bilaterally. BACK: No midline or CVA tenderness.
OP|oropharynx|OP|139|140|ADMISSION PHYSICAL|HEAD: Normocephalic and atraumatic, except the right eye, which had a black eye apparently due to a fall while he was drunk. EARS: Normal. OP was clear. NECK: No lymphadenopathy. EXTREMITIES: Positive for edema left greater than right. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: Rhonchi was heard in both lower and mid right and left lobes.
OP|ophthalmic|OP|186|187|MEDICATIONS ON ADMISSION|1. Hydrochlorothiazide 20 mg p.o. daily. 2. The remaining list is as per clinical records, although she did not report taking these medications, Atenolol 50 mg daily. 3. Travatan 0.004% OP solution 1 drop in left eye each day at bedtime. 4. Alphagan 0.15 % OP solution 1 drop left eye t.i.d.
OP|oropharynx|OP|165|166|PHYSICAL EXAMINATION|Respiratory rate in the 30s and heart rate 120s. O2 sats on room air 96 to 98%. HEENT: He has clear eyes. TMs normal landmarks. Nose mucous drainage and congestion. OP is clear without erythema or exudate. NECK: Supple. No masses. CARDIOVASCULAR: Heart rate is regular without murmurs, well perfused. He is tachycardic in the 130s.
OP|operative|OP|200|201|ADMISSION DIAGNOSIS|HOSPITAL COURSE: The patient was taken to the operating room on _%#MM#%_ _%#DD#%_, 2005, at which time a hydrops of the gallbladder with significant acute cholecystitis was noted. Please refer to the OP report. Postoperative course was rather slow as the patient had difficulty with urinary retention and was catheterized several times including a Foley.
OP|oblique presentation/occiput posterior|OP|199|200|HISTORY OF PRESENT ILLNESS|She became febrile and had arrest of descent. The patient was taken to the operating room where she underwent a primary low transverse cesarean section with indication of arrest of descent, probable OP presentation. She delivered a viable female infant from the OP presentation at 2007 hours with Apgar scores 8 and 8. Please see the operative report for further details. Postoperatively, the patient's hemoglobin was 9.8. She was blood type AB positive and Rubella immune.
OP|oblique presentation/occiput posterior|OP|262|263|HISTORY OF PRESENT ILLNESS|She became febrile and had arrest of descent. The patient was taken to the operating room where she underwent a primary low transverse cesarean section with indication of arrest of descent, probable OP presentation. She delivered a viable female infant from the OP presentation at 2007 hours with Apgar scores 8 and 8. Please see the operative report for further details. Postoperatively, the patient's hemoglobin was 9.8. She was blood type AB positive and Rubella immune.
OP|oropharynx|OP|235|236|PHYSICAL EXAMINATION|GENERAL: The patient is a pleasant female with physical deformities lying comfortably in her hospital bed. HEENT: Left TM and canal clear. Right canal with some cerumen, but visualized portion of TM is clear. PERRL. Conjunctiva clear. OP with dry mucous membranes. NECK: Supple. LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm, no murmur. ABDOMEN: Soft. She self-caths her bladder through her umbilicus. EXTREMITIES: Bilateral lower extremities with chronic deformities.
OP|oropharynx|OP|161|162|OBJECTIVE|Heart rate 60. Blood pressure 130/57. Respiratory rate 16. Saturation 93% on room air. GENERAL: Alert older female, appears tired, but NAD. HEENT: PERRL. EOM I. OP is clear. Mucous membranes are moist. NECK: Supple without adenopathy, thyromegaly, or carotid bruits. CARDIOVASCULAR: Regular rate and rhythm. CHEST: Clear to auscultation bilaterally.
OP|oblique presentation/occiput posterior|OP|163|164|PROCEDURE|Estimated blood loss was 800 cc. There were no complications during the procedure. A viable male infant weighing 7 pounds 9 ounces was delivered from the straight OP position at 1640 p.m. Apgars were 9 at 1 minute and 9 at 5 minutes. The baby was taken to the regular newborn nursery. POSTOPERATIVE COURSE: Following the patient's surgical procedure, she was transferred to the postpartum floor.
OP|oblique presentation/occiput posterior|OP|295|296|ADMISSION MEDICATIONS|Patient continued on magnesium sulfate throughout the induction. On the evening of _%#MM#%_ _%#DD#%_, 2005, patient achieved complete dilatation and +2 station. Unfortunately, terminal bradycardia developed; therefore, a forceps-assisted vaginal delivery was performed. The infant was in direct OP position. Estimated blood loss was 300 mL. Infant did well and was sent to the NICU for prematurity at 32 plus 3 weeks' estimated gestational age.
OP|operative|OP|257|258|HOSPITAL COURSE|He has had several surgeries, most recently _%#MM#%_ _%#DD#%_, 2006, when there was an exploratory of the posterior cervical wound with debridement, partial removal of the posterior cervical fusion hardware, and the halo placement (I would refer you to the OP report for _%#MM#%_ _%#DD#%_, 2006). He then was deemed ready for rehab and was transferred here on _%#MM#%_ _%#DD#%_. He did, of note, have a rehab stay _%#MM#%_ _%#DD#%_, 2006, through _%#MM#%_ _%#DD#%_, 2006, prior to his last surgery.
OP|oropharynx|OP|232|233|OBJECTIVE|OBJECTIVE: VITAL SIGNS: Blood pressure 131/83, pulse 82, respiratory rate 18, O2 saturation was 97% on room air. GENERAL: This is a very pleasant thin woman who appears somewhat uncomfortable with her breathing. HEENT: PERRL, EOMI, OP is dry. There is glossitis present. NECK: Supple without adenopathy or thyromegaly. HEART: Irregularly irregular, S1, S2, with a very faint soft systolic ejection murmur.
OP|oropharynx|OP|183|184|PHYSICAL EXAMINATION|O2 saturations initially on room air 87%, 93% on 2 liters oxygen. GENERAL: This is a pleasant woman who is speaking in full sentences. She appears slightly frail. HEENT: PERRL. EOMI. OP is clear. NECK: Has a well-healing incision at the left side with Steri-Strips in place with small amount of dry drainage.
OP|oropharynx|OP|181|182|PHYSICAL EXAMINATION|GENERAL: The patient is a pleasant but frail-appearing elderly female sitting in a wheelchair today. She still has her nightgown and housecoat on. HEENT: PERRL, conjunctivae clear. OP with slightly dry mucous membranes. No dentures. She does have intact dentition. NECK: Supple, no lymphadenopathy or thyromegaly. LUNGS: CTA bilaterally. HEART: RRR, no murmurs.
OP|oropharynx|OP|267|268|PHYSICAL EXAMINATION ON ADMISSION|PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: Temperature of 36, pulse 97, blood pressure 104/58, respiratory rate 26 and O2 sats 93%. GENERAL: The patient is alert, lying in bed in no acute distress. HEENT: Alopecia. Eyes, PERRL. Ears, clear. Nose, mouth, throat, OP clear. Moist mucous membranes. Throat has no erythema or exudate. There is a small ulcer under the tongue on the right. NECK: Supple. CARDIOVASCULAR: Regular rate and rhythm. No murmurs. LUNGS: Good air entry, scattered wheezes bilaterally.
OP|oropharynx|OP|150|151|PHYSICAL EXAMINATION|HEENT: Normocephalic, atraumatic. Pupils equal, round and reactive to light and acceptation. Extraocular movements are intact. TMs clear bilaterally. OP has moist mucous membranes and is clear. The patient has upper and lower dentures. Neck has no lymphadenopathy, supple, no bruits, no JVD.
OP|oropharynx|OP|238|239|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Blood pressure 188/72, pulse 45, respiratory 22, and temperature afebrile. General: Alert and oriented x 3, in no acute distress, comfortable. HEENT: Sclerae are nonicteric. No lymphadenopathy. PERRLA. Neck: Supple. OP is clear. Cardiovascular examination: S1, S2 normal. No murmurs, gallops, or rubs. No carotid bruits. Lungs: Clear to auscultation. Abdomen: Soft, nontender, nondistended, bowel sounds positive, no hepatosplenomegaly.
OP|oropharynx|OP|208|209|PHYSICAL EXAMINATION|GENERAL: She is a very pleasant, appears her stated age in no acute distress. Alert and oriented. HEENT: Normocephalic, atraumatic. Pupils are somewhat irregular but reactive. Extraocular muscles are intact. OP is clear. TMs are clear. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Regular without murmurs, rubs or gallops. LUNGS: Clear bilaterally. BACK: No midline or CVA tenderness. BREASTS: Not examined.
OP|oropharynx|OP|142|143|PHYSICAL EXAMINATION|She has received Dilaudid recently. HEENT: Normocephalic, atraumatic. Pupils are equal and reactive to light. Extraocular muscles are intact. OP is clear. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Regular without murmurs, rubs, gallops. BREASTS: Not examined. LUNGS: Clear bilaterally.
OP|oblique presentation/occiput posterior|OP,|249|251|ADMISSION PHYSICAL EXAMINATION|VITAL SIGNS: Stable. Temperature of 98.4, BP was 145/70, nadir to 112/62, heart rate 65, respirations 18. On sterile speculum exam: no pooling, Nitrazine negative, ferning negative. Bedside ultrasound showed singleton intrauterine pregnancy, vertex OP, positive fetal motion. AFI was 4.4. The vaginal exam was deferred. HOSPITAL COURSE: The patient was admitted to labor and delivery and was evaluated for HELLP syndrome.
OP|UNSURED SENSE|OP|258|259|PAST MEDICAL HISTORY|SOCIAL HISTORY: A 30-pack-year smoking history of tobacco, quit last year. FAMILY HISTORY: Assessed and deemed noncontributory. PAST MEDICAL HISTORY: Severe COPD, undergoing transplant workup, hypothyroidism, depression, hypertension, microscopic hematuria, OP and GERD. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.1, pulse 107, blood pressure 135/72.
OP|oropharynx|OP|144|145|PHYSICAL EXAMINATION|Sclerae nonicteric. Pupils seem a little prominent and I do not know if that is old or new for her. She has no nystagmus. TMs are not examined. OP is clear. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Heart has prominent PMI. No murmurs, rubs or gallops. LUNGS: Clear bilaterally. ABDOMEN: Soft, nontender.
OP|operative|OP|310|311|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: I have been asked to see the patient on behalf of Dr. _%#NAME#%_ of colon and rectal surgery for the patient's preoperative evaluation for her upcoming low anterior resection to be done by Dr. _%#NAME#%_ at Fairview Southdale Hospital on _%#DDMM2007#%_. Please see Dr. _%#NAME#%_'s OP note for details of the procedure. _%#NAME#%_ notes that she has been doing well other than her vaginal discharge issues.
OP|operative|OP|270|271|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: I have been asked to see the patient on behalf of Dr. _%#NAME#%_ _%#NAME#%_ for the patient's preop evaluation for upcoming bunion surgery to be done by Dr. _%#NAME#%_ at Fairview Southdale Hospital on _%#DDMM#%_. Please see Dr. _%#NAME#%_'s OP note for details of the procedure. _%#NAME#%_ sounds like she has been doing relatively well other than some musculoskeletal complaints.
OP|oropharynx|OP|158|159|PHYSICAL EXAMINATION|As described above, she does open her eyes briefly and responds to most yes/no questions, but is, otherwise, quite sedated. HEENT: PERRL, conjunctivae clear. OP with somewhat dry mucous membranes. NECK: Supple, no lymphadenopathy, no thyromegaly. LUNGS: CTA bilaterally. HEART: Regular rate and rhythm, no murmur.
OP|oropharynx|OP|149|150|OBJECTIVE|GENERAL: This is a very pleasant obese woman who appears diaphoretic and dyspneic, speaking in short sentences. HEENT: PERRL, EOMI, nares are clear. OP is moist. NECK: Supple without adenopathy or thyromegaly. HEART: Regular S1, S2, no murmurs or gallops. CHEST: Clear at the apices, scant crackles at the bases are noted and expiratory wheezes are also noted at the bases.
OP|oropharynx|OP|199|200|OBJECTIVE|GENERAL: This is a profoundly depressed appearing woman with a very flat affect. She has intermittent eye contact and her speech is slightly slurred, but she has clear sentences. HEENT: PERRL. EOMI. OP is slightly dry. There is tenderness with palpation over the frontal sinuses and the maxillary sinuses. NECK: Supple without palpable adenopathy or thyromegaly. HEART: Regular S1, S2.
OP|oropharynx|OP|182|183|PHYSICAL EXAMINATION|HEENT: Head is normocephalic with no lesions. Ears are atraumatic. Eyes: PERRLA. Extraocular muscles are intact bilaterally with no scleral conjunctival injections. Nasal is normal. OP is normal. Neck is supple. No lymphadenopathy or thyromegaly. HEART: Regular rate, S1, S2. No murmurs. LUNGS: Clear to auscultation bilaterally.
OP|oropharynx|OP|193|194|PHYSICAL EXAMINATION|GENERAL: He is pleasant, appears his stated age and in no acute distress, just a little mild discomfort. HEENT: Normocephalic/atraumatic. Pupils are equal and reactive to light. TMs are clear. OP is clear. NECK: Supple without lymphadenopathy or thyromegaly. There were no carotid bruits. HEART: Regular without murmurs, rubs, or gallops. LUNGS: Clear bilaterally.
OP|oblique presentation/occiput posterior|OP|208|209|HISTORY|Therefore, it was elected to have her continue pushing, she did for another hour and a half; however then, she showed no progression by 0215 hours on _%#DDMM2002#%_. The baby was still thought to be possible OP position and maternal temp was elevating up to 100.7; therefore, the plan was to proceed to C-section. Beyond the temperature, other vital signs were stable with normal blood pressures.
OP|oblique presentation/occiput posterior|OP|133|134|HOSPITAL COURSE|She had a repeat low segment transverse cesarean section via vertical skin incision with a scar revision to deliver a viable male in OP vertex presentation with a weight of 7 pounds 14 ounces. Apgar scores were 8 at one and 9 at five minutes. Time of delivery was 0832 hours. Placenta was normal with two blood vessels, and there was a normal-appearing uterus, ovaries and fallopian tubes bilaterally.
OP|oropharynx|OP|149|150|EXAM|Funduscopic exam is very difficult secondary to the cataracts. She has tender maxillary sinuses and frontal sinuses upon palpation. TMs look normal. OP - clear. NECK - supple without adenopathy or thyromegaly. HEART - regular S1, S2, no murmurs. LUNGS - clear bilaterally. ABDOMEN - soft, there are good bowel sounds, no tenderness, no abdominal bruits appreciated.
OP|oropharynx|OP|166|167|CHIEF COMPLAINT|Respiratory rate 20, weight 166.4. On physical examination, in general awake, alert, in mild distress. HEENT: Pupils equal, round, and reactive to light. EOM intact. OP cavity is moist with no lacerations. Posterior pharynx nonerythematous. Buccal surface with white plaques. Cardiovascular: Regular rate and rhythm without murmurs, gallops, or rubs.
OP|oblique presentation/occiput posterior|OP|207|208|HOSPITAL COURSE|However, she pushed for greater than 3 hours and fetal head did not descent past 0 station. At this point, primary low transverse cesarean section was recommended. The patient delivered a viable infant from OP position with Apgars of 9 and 9 and weight of 8 pounds and 14 ounces at 1432 on _%#DDMM2007#%_. Normal uterus, tubes and ovaries were noted. EBL was 1000 mL.
OP|oblique presentation/occiput posterior|OP|112|113||The surgery was uncomplicated and a healthy female infant was delivered. The baby was noted to be in the direct OP position which was probably the cause for the arrest of dilatation. The Apgars of the baby was 9 at 1 minute and 9 at 5 minutes.
OP|operative|OP|169|170|PROCEDURES DURING HOSPITALIZATION|PROCEDURES DURING HOSPITALIZATION: 1. Upper GI endoscopy. Please see separately dictated note in this regard. 2. Dental carie extraction. Please see separately dictated OP note in this regard. HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ is a 67-year-old male who had been feeling poorly in the 2 days prior to admission.
OP|oropharynx|OP|143|144|PHYSICAL  SIGNS|GENERAL: This is a very pleasant woman who looks somewhat disheveled, but her speech is clear and her eye contact is good. HEENT: PERRL, EOMI. OP is moist. NECK: Supple without adenopathy or thyromegaly. HEART: Regular S1, S2, no murmurs. LUNGS: Clear bilaterally. ABDOMEN: Soft.
OP|operative|OP|156|157|OPERATIONS AND PROCEDURES PERFORMED|OPERATIONS AND PROCEDURES PERFORMED: Open treatment of the right lateral tibial plateau fracture with allograft performed by Dr. _%#NAME#%_. Please see his OP note for details. BRIEF HISTORY AND HOSPITAL COURSE: The patient is a 34-year-old female who presents here after reportedly being struck by a motor vehicle in a parking lot at the Office Depot in _%#CITY#%_ _%#CITY#%_.
OP|oblique presentation/occiput posterior|OP|266|267|PREOPERATIVE COURSE|The patient is aware of the risks, benefits and alternatives to the surgery. The patient was taken to the Operating Room on _%#DDMM2006#%_ at which time she underwent a repeat low segment transverse cesarean section with findings of a vigorous female infant from an OP presentation through clear fluid at 11:00 a.m. with Apgars of 9 and 9 at 1 and 5 minutes respectively and a birth weight of 7 lb, 11 oz.
OP|oropharynx|OP|202|203|PHYSICAL EXAM|Oxygen saturation is 99% on room air. GENERAL: Alert, oriented x3. He appears to be comfortable. HEENT: Sclerae nonicteric, no lymphadenopathy. Pupils equally round and reactive to light. NECK: Supple, OP is clear. CARDIOVASCULAR: S1, S2 normal, no murmurs, gallops or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft, tenderness in the right upper quadrant area, nondistended.
OP|oblique presentation/occiput posterior|OP,|131|133|FINDINGS|ESTIMATED BLOOD LOSS: 1 L. DRAINS: Foley. FLUIDS: 2 L. URINE OUTPUT: 300 cc. FINDINGS: 1. Viable female infant delivered in direct OP, Apgars of 8 and 8, weighing 1580 g. 2. Viable female infant delivered complete breech position with Apgars of 5 and 8, weighing 1392 g.
OP|operative|OP|133|134|PLAN|The patient will be allowed a regular diet unless she has made n.p.o. for the ERCP. Will defer to GI in this regard. 5. Will get the OP report from North Memorial Hospital regarding the "left portion of the gallbladder." Will also check a chest x-ray and EKG to evaluate patient's surgical risk should this be required.
OP|oropharynx|OP|378|379|PHYSICAL EXAMINATION ON ADMISSION|FAMILY HISTORY: Noncontributory. ALLERGIES: Penicillin, Demerol, codeine. PHYSICAL EXAMINATION ON ADMISSION: She was afebrile, pulse in the 90's, respirations 18, O2 sats 98-100% on room air, blood pressure initially in the emergency rom 177/113, came down without medications to 146/79. General - the patient was pleasant, normal speech, no acute distress. HEENT: PERRL. EOMI. OP clear. NECK - supple. No lymphadenopathy. No carotid bruits. CARDIOVASCULAR - regular rate and rhythm with a 2/6 systolic ejection murmur.
OP|oropharynx|OP|234|235|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Height is 64", weight is 250 pounds, blood pressure 130/80, pulse 80, respiratory rate 16, temperature 97.9. In general the patient is an alert, obese female in no acute distress. HEENT: Translucent TMs, PERRLA, OP is clear. NECK: Supple without thyromegaly, nodules, or carotid bruits. HEART: Regular rate and rhythm without murmur. LUNGS: Clear bilaterally.
OP|oblique presentation/occiput posterior|OP|303|304|HOSPITAL COURSE|Despite adequate contractions, she did not dilate further and developed significant cervical edema. Given the situation, she underwent a primary low segment transverse cesarean section, and delivered a single live female 8 pounds 12 ounces, with Apgars of 7 and 8 at 1 and 5 minutes respectively in the OP position. Her postoperative course was essentially uneventful and was discharged to home in good condition on _%#DDMM2003#%_.
OP|ophthalmic|OP|137|138|ADMISSION MEDICATIONS|3. Terazosin 5 mg q.d. 4. _______ 100 mg b.i.d. 5. Sulfasalazine 500 mg three tablets b.i.d. 6. Lipitor 10 mg q.h.s. 7. Betoptic 0.25 mg OP b.i.d. 8. Glyburide 5 mg p.o. b.i.d. 9. Humulin 70/30 40 units q.a.m. 10. Allegra 60 mg p.o. q.d. 11. Hydrocortisone cream p.r.n. 12. Pilocarpine solution OP q.i.d. 13. Zilactin solution 0.5% q.h.s.
OP|oropharynx|OP|196|197|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Blood pressure 100/64, heart rate 74, respiratory rate 18, afebrile. In general, the patient is a pleasant male in no acute distress. HEENT: Sclerae markedly icteric. PERRL. OP with dry mucous membranes. He is missing his upper teeth, but states he has upper dentures somewhere. Neck supple, without lymphadenopathy or thyromegaly. Lungs clear to auscultation bilaterally.
OP|operative|OP|202|203|PROBLEM #2|PROBLEM #2: Alcoholism: Excessive drinking history despite negative consequences of recurrent pancreatitis. CD was consulted. The patient was offered an inpatient assessment, but he preferred to pursue OP evaluation. The patient was not currently sort out as an imminent linger. No evidence of withdrawal currently. PROBLEM #3: Mild asthma: The patient has a history of mild asthma.
OP|oropharynx|OP|212|213|PHYSICAL EXAMINATION|She seemed almost fearful when I initially came into the room and is a little slow with her responses but appropriate. She is somewhat cachectic. HEENT: Normocephalic, atraumatic. Extraocular muscles are intact. OP is a little dry. TMs were not examined. NECK: Supple without lymphadenopathy. HEART: Regular without murmurs, rubs or gallops. LUNGS: Clear bilaterally.
OP|operative|OP|240|241|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: I have been asked to see the patient on behalf of Dr. _%#NAME#%_ _%#NAME#%_ for the patient's upcoming TURP to be done by Dr. _%#NAME#%_ at Fairview Southdale Hospital early next week. Please see Dr. _%#NAME#%_' OP note for details of the procedure. The patient notes that he has been doing well with no other complaints other than some BPH type symptoms.
OP|oropharynx|OP|173|174|ADMISSION PHYSICAL EXAMINATION|GENERAL: The patient was alert, awake and oriented x3. He was agitated. HEAD: Normocephalic, atraumatic. EYES: PERRLA, EOMI x2. NOSE, MOUTH, THROAT: Mucous membranes moist, OP clear. NECK: Supple and no JVD. EXTREMITIES: No edema. CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs or gallops. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender, nondistended, bowel sounds positive.
OP|oropharynx|OP|179|180|PHYSICAL EXAMINATION|GENERAL: He is pleasant. He does not appear to be in any acute distress. HEENT: Normocephalic, atraumatic. Pupils are equal and reactive to light. Extraocular muscles are intact. OP is clear. TMs are not examined. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Regular without murmurs, rubs, or gallops appreciated.
OP|oblique presentation/occiput posterior|OP|182|183|HOSPITAL COURSE|The patient was taken to the operating room for an uncomplicated repeat low transverse cesarean section. Estimated blood loss was 600 mL. A viable female infant was delivered in the OP presentation with Apgars of 9 and 9, weighing 8 pounds 8 ounces. Please see operative report for further details. The patient did well postoperatively.
OP|operative|OP|293|294|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: I have asked see the patient on behalf of Dr. _%#NAME#%_ of Neurosurgery for the patient's preoperative evaluation for his upcoming right L4-L5 hemilaminectomy to be done by Dr. _%#NAME#%_ at Fairview Southdale Hospital on _%#DDMM2007#%_. Please see Dr. _%#NAME#%_ OP note for details of the procedure. Mr. _%#NAME#%_ notes that other than his back pain, he has been doing well. He denies having any angina or anginal equivalents and states that he has done well with surgeries in the past.
OP|oropharynx|OP|149|150|PHYSICAL EXAMINATION|O2 saturation on room air 89%, on 2 liters 99%. GENERAL: This is a pleasant gentleman who speaks in full sentences. No distress. HEENT: PERRL. EOMI. OP is slightly dry. NECK: Supple without adenopathy or thyromegaly. HEART: Regular S1, S2. No murmurs or gallops. LUNGS: Bibasilar crackles with some expiratory wheezes throughout.
OP|oropharynx|OP|216|217|PHYSICAL EXAMINATION|Temperature is 96.5. GENERAL: In general he is a pleasant gentleman who does not appear to be in any acute distress. HEENT: Normocephalic and atraumatic. Extraocular muscles are intact. Pupils are reactive to light. OP is clear. TMs are clear. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Regular without murmurs, rubs or gallops. He has a sternotomy scar in his anterior chest consistent with his previous bypass surgery.
OP|oropharynx|OP|158|159|PHYSICAL EXAM|Temperature afebrile. GENERAL: Alert, oriented x 3, not in acute distress. HEENT: Pupils equally round and reactive to light and accommodation. NECK: Supple. OP is clear. CARDIOVASCULAR EXAM: S1, S2 normal. No murmurs, gallops, or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft, nontender, nondistended.
OP|oropharynx|OP|157|158|PHYSICAL EXAM|The patient appears comfortable. HEENT: Sclerae not icteric. No lymphadenopathy. Pupils equally round and reactive to light and accommodation. NECK: Supple. OP is clear. No evidence of stiff neck. CARDIOVASCULAR EXAM: S1, S2 normal. No murmurs, gallops, or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft, nontender, nondistended.
OP|oblique presentation/occiput posterior|OP|233|234|DISCHARGE INSTRUCTIONS|I was notified at 7 a.m. that C-section was scheduled for 8 a.m. On _%#DDMM2002#%_ she underwent repeat low segment transverse cesarean section under spinal anesthetic without complications. Findings were 9 pound 7 ounce female from OP position with Apgars of 8 at one minute and 9 at five minutes. The uterus had an 8x10 cm intramural and subserosal fibroid protruding anteriorly at the upper third of the uterus.
OP|oblique presentation/occiput posterior|OP,|214|216|DISCHARGE INSTRUCTIONS|He was discharged on _%#MM#%_ _%#DD#%_, 2002. The mother's pregnancy was complicated by Group B strep. She received three doses of Penicillin prior to _%#NAME#%_'s birth. The infant was delivered vaginally, direct OP, with Apgar scores of one at one minute, three at five minutes, and four at ten minutes. _%#NAME#%_ was a post-term LGA male infant, 4400 gm at 41 and 5/7 weeks gestation, with a length of 55.5 cm and head circumference of 38 cm.
OP|oropharynx|OP|191|192|PHYSICAL EXAM|GENERAL: Alert, oriented x 3, not in acute distress. HEENT: Sclerae not icteric. No lymphadenopathy. Pupils equally round and reactive to light. No hematoma or bruises noted. NECK is supple. OP is rather dry. CARDIOVASCULAR EXAM: S1, S2 normal. No murmurs, gallops, or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft, nontender, nondistended.
OP|operative|OP|125|126|HOSPITAL COURSE|He was taken to the OR by orthopedics and underwent I and D and hardware removal of the infected right ankle. Please see the OP report for further details of this procedure. During his hospital course, he was continued on the factor VIII infusion and there were no bleeding complications.
OP|oblique presentation/occiput posterior|OP|167|168|HOSPITAL COURSE|Complications included a uterine incision extension to the lower edge of the cervix in the right inferior portion of the uterus. She delivered a viable male infant in OP position with a birth weight of 7 pounds 10.5 ounces, Apgars of 8 and 8 at 1936 on _%#MM#%_ _%#DD#%_, 2003. Postoperatively she was transferred to the Postpartum Service. Her immediate postop hemoglobin had fallen from 11.7 preop to 7.1 postop.
OP|oropharynx|OP|256|257|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure in the ER was 181/89, heart rate 83, respiratory rate 26, temp 97 degrees, and O2 sats 94% on room air. GENERAL: The patient is a large pleasant male in no acute distress. HEENT: PERRL, conjunctivae clear, OP clear. NECK: Supple. No JVD appreciated, no thyromegaly. LUNGS: Distant breath sounds due to patient's body habitus. No crackles or wheezes appreciated.
OP|oropharynx|OP:|149|151|PHYSICAL EXAMINATION|She is not in any acute distress. HEENT: Sclera are non-icteric, no lymphadenopathies. Pupils are equally round and reactive to light. NECK: Supple. OP: Clear. CARDIOVASCULAR: S1, S2 are normal; no murmurs, gallops, or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft, non-tender, non-distended, bowel sounds are positive.
OP|oropharynx|OP|179|180|PHYSICAL EXAM|PHYSICAL EXAM: VITAL SIGNS: Blood pressure 140/80, pulse 100, temperature afebrile. O2 sat 98 percent on room air. GENERAL: Alert, oriented x 3, not in acute distress. HEENT: His OP is dry, otherwise unremarkable. Sclerae not icteric. No lymphadenopathy. NECK: Supple. CARDIOVASCULAR EXAM: S1, S2 normal. No murmurs, gallops, or rubs.
OP|oropharynx|OP|253|254|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 120/96; heart rate 80; respiratory rate 16; afebrile in the emergency room. GENERAL: The patient is a pleasant female who is comfortable lying in her hospital bed. HEENT: PERRLA, conjunctivae are clear. OP is dry. NECK: Supple with no lymphadenopathy, no thyromegaly. LUNGS: With bibasilar crackles. HEART: RRR. ABDOMEN: Soft, slightly distended, it is diffusely tender to palpation with some mild guarding and no rebound.
OP|oropharynx|OP|134|135|PHYSICAL EXAMINATION|He is 6 foot 4 inches tall. HEENT: Normocephalic, atraumatic. Pupils are equal and reactive to light. Extraocular muscles are intact. OP is clear. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Regular with a prominent murmur along the left sternal border, 2/6.
OP|oropharynx|OP|181|182|PHYSICAL EXAMINATION|GENERAL: She is a pleasant woman in no acute distress. HEENT: Normocephalic, atraumatic. Pupils are equal and reactive to light. Extraocular muscles are intact. Sclerae nonicteric. OP is clear. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Regular with a soft systolic murmur on the left sternal border without rubs or gallops.
OP|oropharynx|OP|153|154|PHYSICAL EXAMINATION|HEENT: Normocephalic, atraumatic. Pupils are equal and reactive to light. Extraocular muscles are intact. Sclerae nonicteric. TMs are clear bilaterally. OP is clear NECK: Supple without lymphadenopathy or thyromegaly. HEART: Regular with a very soft murmur along the left sternal border. LUNGS: Clear bilaterally. BACK: No midline or CVA tenderness. BREASTS: Not examined.
OP|oropharynx|OP|158|159|PHYSICAL EXAMINATION|She is not currently complaining of any pain to me. HEENT: Normocephalic, atraumatic. Pupils are equal and reactive to light. Extraocular muscles are intact. OP is clear. TMs are not examined. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Irregularly irregular without murmurs, rubs or gallops.
OP|oropharynx|OP|194|195|DISCHARGE EXAMINATION|She is tolerating a regular diet. VITAL SIGNS: Temperature is 98.4, pulse 67, blood pressure is 135/82, respiratory rate 16 and saturations 94% on room air. HEENT: Normocephalic and atraumatic. OP shows poor dictation. NECK: Supple without lymphadenopathy. HEART: Regular. LUNGS: Clear. ABDOMEN: Soft and nontender with positive bowel sounds. EXTREMITIES: No clubbing, cyanosis or edema. Discharge hemoglobin again is 10.6. DISPOSITION: To home.
OP|oblique presentation/occiput posterior|OP|137|138|HISTORY|The C-section was uncomplicated. Findings were significant for a viable male infant with medical record _%#MRN#%_. The infant was in the OP position. Vaginal hand was required to facilitate the delivery as vertex was slightly wedge in the maternal pelvis. Weight of the infant was 9 pounds, 4 ounces. Arterial pH of 7.27 with base excess of 0.6 and a venous pH of 7.31 with base excess of 1.4. Apgars were 8 and 9 at 1 and 5 minutes respectively.
OP|oropharynx|OP|152|153|PHYSICAL EXAMINATION|HEENT: Normocephalic, atraumatic. Pupils are equal and reactive to light. Extraocular muscles are intact. TMs are not able to be seen secondary to wax. OP is clear and moist. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Regular without murmurs, rubs, gallops. LUNGS: Clear bilaterally. BACK: No midline or CVA tenderness.
OP|oropharynx|OP|240|241|PHYSICAL EXAMINATION|GENERAL: She is very pleasant, in no acute distress. She is very hard of hearing so it is somewhat difficult to communicate with her. HEENT: Normocephalic, atraumatic. Pupils are equal and reactive to light. Extraocular muscles are intact. OP is quite dry. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Regular without murmurs, rubs or gallops. LUNGS: Clear bilaterally.
OP|oropharynx|OP|134|135|PHYSICAL EXAMINATION|General: The patient is a thin, weak-appearing male, lying on the ER cart. He is poorly responsive. HEENT: PERRL. Conjunctivae clear. OP with very dry, tacky mucous membranes. Neck: Supple. No thyromegaly. No lymphadenopathy. Carotids strong and symmetric, without bruit. Lungs: CTA bilaterally anteriorly. Heart: Regular rate and rhythm, no murmur.
OP|oropharynx|OP:|164|166|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Vital signs: Stable. General: Alert, oriented x 3, not in acute distress. HEENT: Sclerae not icteric. No lymphadenopathy. PERR. Neck: Supple. OP: Clear. Cardiovascular Exam: S1, S2, normal. No murmurs, gallops or rubs. Lungs: Clear to auscultation. Abdomen: Soft, nontender, nondistended, bowel sounds positive.
OP|oblique presentation/occiput posterior|OP,|288|290|BRIEF HISTORY|BRIEF HISTORY: _%#NAME#%_ _%#NAME#%_ is a 27-year-old with multiple miscarriages who had been followed as a high-risk pregnancy because of the miscarriages who presented to the hospital with spontaneous labor. She progressed with the aid of Pitocin to 9 cm however remained at persistent OP, began developing anterior cervical edema and had no descent below +1 station. Significant molding was also present on the baby's vertex. This arrest of dilatation and descent was documented for a total of three hours.
OP|oropharynx|OP|125|126|OBJECTIVE|She speaks Spanish, and her daughter interprets. HEENT: PERRL, EOMI. TMs are normal. The patient does have her hearing aids. OP is clear. NECK is supple without palpable adenopathy or thyromegaly. HEART: Regular S1, S2. No murmurs. There are no carotid bruits. LUNGS are clear in the apices, but have crackles with the bases bilaterally.
OP|oropharynx|OP|217|218|EXAM|EXAM: Vital signs - blood pressure 188/77, temperature afebrile, pulse 66, O2 sat. 99% on room air. General - sleepy but arousable. Patient looks very cachectic. HEENT - sclerae nonicteric, no evidence of adenopathy. OP is moist. CARDIOVASCULAR - S1, S2 normal, no murmur, gallop or rub. LUNGS - poor inspiratory effort but otherwise clear to auscultation.
OP|oropharynx|OP|156|157|PHYSICAL EXAMINATION|There is no redness or discharge. There is no proptosis. Ears revealed normal tympanic membranes bilaterally. There was no discharge present from his nose. OP was clear, without redness or ulcerations. Neck was supple with scars noted on the right side and cervical lymphadenopathy on the right.
OP|oropharynx|OP|139|140|OBJECTIVE|This is a thin, elderly female, who has some respiratory distress. HEENT: PERRL. EOMI. Sclerae are anicteric. TMs normal. Nares are clear. OP is clear. NECK is supple without adenopathy or thyromegaly. HEART: S1 and S2, bradycardic, irregularly irregular with JVD to roughly 8 cm.
OP|oropharynx|OP|151|152|PHYSICAL EXAM|The patient is in a moderate amount of pain. HEENT: Sclerae anicteric. No lymphadenopathy. Pupils equal, round, and reactive to light. Neck is supple. OP is clear. CARDIOVASCULAR: S1, S2 normal. No murmur, gallops, or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft, nontender, nondistended. Bowel sounds positive.
OP|oropharynx|OP|200|201|OBJECTIVE|She smokes one-half pack of cigarettes per day. OBJECTIVE: Temperature 99.1, blood pressure 124/86, vital signs stable. General: Alert young female in no acute distress. HEENT: TMs clear bilaterally. OP clear. Neck supple, without adenopathy. Chest clear to auscultation bilaterally. Abdomen; Soft, non-tender and non- distended, with positive bowel sounds.
OP|oblique presentation/occiput posterior|OP|249|250|HOSPITAL COURSE|A primary low transverse cesarean section was performed under spinal anesthesia with an endotracheal general anesthesia to finish closure. The indication for a cesarean section was protracted active phase of labor, arrest of descent, and persistent OP presentation. A viable 9-pound 6-ounce male infant with Apgars of 8 and 9 was delivered at 7:40 on _%#MM#%_ _%#DD#%_, 2003. Postoperatively, the patient was transferred to the Postpartum Service. She remained afebrile through her hospital course.
OP|oblique presentation/occiput posterior|OP,|228|230|HOSPITAL COURSE|The patient progressed to complete dilatation and with excellent voluntary effort the second stage was accomplished. At 2033 hours on _%#DDMM2003#%_, she was delivered of a 7-pound 14-ounce viable, Apgar 8/9 male infant, direct OP, over and intact perineum. A single nuchal cord was removed with ease. Labor analgesia had been provided with intrathecal narcotics.
OP|oblique presentation/occiput posterior|OP|206|207|HOSPITAL COURSE|The patient was brought to the operating room on _%#MM#%_ _%#DD#%_, 2004, and under spinal anesthesia underwent a repeat low segment transverse cesarean section with delivery of a viable female in straight OP position at 1549 hours. Apgar scores were 8 and 9, and weight was 7 pounds 10 ounces. Blood loss during surgery was 1000 mL. There were no apparent complications.
OP|oblique presentation/occiput posterior|OP|164|165|HOSPITAL COURSE|She was confirmed to be ruptured at that time. The patient had her magnesium turned off. She progressed to complete. She delivered a viable male infant in straight OP position with Apgars of 3 and 8 at 1 and 5 minutes, respectively. Arterial pH was 7.20 with base excess of -3.2 and venous pH of 7.27 with pH of -2.3. There was a loose nuchal cord that was reduced on delivery of the head.
OP|oblique presentation/occiput posterior|OP|162|163|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Intrauterine pregnancy at term, delivered via primary low transverse cesarean section secondary to arrest of dilation, thick meconium and OP presentation. 2. Active labor. OPERATIONS/PROCEDURES PERFORMED: Primary low transverse cesarean section .
OP|oblique presentation/occiput posterior|OP|139|140|HOSPITAL COURSE|The patient was consented for C-section and proceeded onto a C-section. Please see dictation for full details. After it was found to be in OP position, Apgars of 8 and 9. POSTOPERATIVE COURSE: The patient's postoperative day #1, hemoglobin was 9.7. She remained afebrile through her entire stay.
OP|oblique presentation/occiput posterior|OP|326|327|HOSPITAL COURSE|The patient then progressed through a normal labor curve, received an epidural for anesthesia, and was completely dilated at 02:50 A.M. The patient began expulsive efforts at 3:00 A.M. A neonatologist was in attendance for the delivery and she went on to deliver a viable female infant at 03:15 hours. The infant was directly OP in presentation and had a nuchal hand at the time of delivery. Apgars were 7 and 8 at one and five minutes, respectively, with a birth weight of 4 lb 14 oz.
OP|oropharynx|OP|127|128|OBJECTIVE|This is an alert gentleman, whose speech is clear and normal in content. He is oriented to self and place. HEENT: PERRL, EOMI. OP is clear. NECK is supple without adenopathy or thyromegaly. HEART: Regular S1, S2. No ectopy or murmurs. LUNGS are clear to auscultation bilaterally.
OP|oropharynx|OP|171|172|OBJECTIVE|This is a very alert woman who is slightly hard of hearing but very pleasant. Speech is normal. HEENT: Pupils equal, round, reactive to light. Extraocular motions intact. OP is clear. Neck is supple without adenopathy or thyromegaly. Heart: Regular, S1, S2, no murmurs. Lungs are clear to auscultation bilaterally.
OP|oblique presentation/occiput posterior|OP|162|163|HOSPITAL COURSE|The risks and benefits were discussed. The patient underwent this procedure without difficulty. A viable male infant was delivered; weight 4819 grams in straight OP position. Apgars were 7 at one minute and 8 at five minutes. Estimated blood loss from this procedure was 900 cc. The patient was then transferred to postpartum for the remainder of her hospital course.
OP|oropharynx|OP|195|196|PHYSICAL EXAM|Alert, oriented x 3, not in acute distress, talking in full sentences. HEENT: Sclerae anicteric. No lymphadenopathy. Pupils equal, round, and reactive to light and accommodation. Neck is supple. OP is clear. CARDIOVASCULAR: S1, S2 normal. No murmur, gallops, or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft, nontender, nondistended.
OP|oblique presentation/occiput posterior|OP|175|176|HOSPITAL COURSE|Decision was made to proceed with a primary low transverse cesarean section. EBL was 800 ccs. The attending physician was Dr. _%#NAME#%_. Findings: Viable male infant, in the OP presentation, with a cord pH of 7.25, Apgars of 8 and 9, weight of 6 pounds, 10 ounces, normal tubes, uterus, and ovaries.
OP|oropharynx|OP|190|191|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Blood pressure 132/86, pulse 110, respirations 20, and temperature afebrile. General: Tired and less responsive. HEENT: Sclerae nonicteric. No lymphadenopathy. PERRLA. OP is dry. Neck: Supple. Cardiovascular examination: S1, S2 normal, no murmurs, gallops, or rubs. Lungs: Clear to auscultation. Abdomen: Soft, nontender, nondistended, bowel sounds positive.
OP|oropharynx|OP|177|178|PHYSICAL EXAMINATION|GENERAL: Alert, oriented x 3, not in acute distress. HEENT: Sclerae not icteric. No lymphadenopathy. Pupils equally round and reactive to light and accommodation. NECK: Supple. OP is clear. CARDIOVASCULAR EXAM: S1, S2 normal. No murmurs, gallops, or rubs. LUNGS: Inspiratory squeak and expiratory wheezing is heard throughout.
OP|oropharynx|OP|158|159|PHYSICAL EXAMINATION|The patient appears comfortable. HEENT: Sclera non-icteric, no lymphadenopathy. Pupils equally round and reactive to light and accommodation. Neck is supple. OP is clear. Cardiovascular: S1, S2 normal. No murmur, gallops, or rubs. Lungs: Clear to auscultation on anterior exam. Abdomen: Soft, nontender, nondistended. Bowel sounds positive. Nephrostomy tube and Miami pouch noted.
OP|oropharynx|OP|251|252|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Vital signs: blood pressure 140/76, respiratory 18, temperature afebrile, heart rate of 80, T-max is 99.5. General: alert, oriented x 3, not in acute distress. HEENT: sclerae nonicteric. No lymphadenopathy. PERRLA. Neck: supple. OP is clear. Cardiovascular examination: S1, S2 normal, no murmurs, gallops, or rubs. Lungs: clear to auscultation. Abdomen: soft, nontender, nondistended, bowel sounds positive.
OP|oropharynx|OP|194|195|PHYSICAL EXAMINATION|GENERAL: Alert and oriented x 3, not in acute distress, speaking in full sentences. HEENT: Sclerae not icteric. No lymphadenopathy. Pupils equally round and reactive to light and accommodation. OP is dry. CARDIOVASCULAR EXAM: S1, S2 normal. No murmurs, gallops, or rubs. LUNGS: Wheezing noted in both inspiratory and expiratory phases. Her breath sounds are slightly decreased.
OP|oblique presentation/occiput posterior|OP|153|154|DOB|The patient pushed for over an hour and a half and had moved the baby almost to only from a +1 to only slightly lower. It was felt possibly the baby was OP and also felt that the baby was 9 lbs. It was discussed with the patient and her husband and family that I felt that placing a vacuum would not be advisable.
OP|oropharynx|OP|184|185|ALLERGIES|GENERAL: The patient appears in moderate distress. He has upper airway audible sounds. HEENT: Head is atraumatic. Eyes: Pupils equally reactive to light and accommodation. Nonicteric. OP clear. Oral cavity without any ulcers or thrush. CHEST: Port-A-Cath in the right upper chest, nontender, nonerythematous. NECK: No JVD.
OP|oropharynx|OP|204|205|OBJECTIVE|OBJECTIVE: VITAL SIGNS: Temperature 101.2; heart rate in the 90's; respiratory rate 18; blood pressure 117 to 147/70; O2 saturations at 100% on room air. GENERAL: Alert, uncomfortable female. NAD. HEENT: OP is clear. NECK: Supple without adenopathy or thyromegaly. PERRLA, EOMI. CHEST: Clear to auscultation bilaterally. CV: Regular rate and rhythm, 2/6 systolic ejection murmur in the left upper sternal border.
OP|oropharynx|OP:|203|205|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Vital signs: Temperature 99, pulse 80, blood pressure 120/85. General: Alert and oriented x 3 in no acute distress. HEENT: Pupils equally round and reactive to light. Neck: Supple. OP: Clear. Cardiovascular: S1, S2 normal, no murmurs, gallops or rubs. Lungs: Clear to auscultation. Abdomen: Soft, non- tender, non-distended. Bowel sounds positive.
OP|oblique presentation/occiput posterior|OP|469|470|ADMISSION DIAGNOSIS|DOB: ADMISSION DIAGNOSIS: Intrauterine pregnancy 40+ weeks gestation, status post induction of labor for low amniotic fluid volume, lack of satisfactory descent in the second stage of labor with suspected OP position and asynclitic position, advanced maternal age. POSTOPERATIVE DIAGNOSIS: Intrauterine pregnancy 40+ weeks gestation, status post induction of labor for low amniotic fluid volume, lack of satisfactory descent in the second stage of labor with suspected OP position and asynclitic position, advanced maternal age.
OP|oropharynx|OP|202|203|OBJECTIVE|HEENT: Pupils have changes from previous cataract surgery bilaterally. Extraocular muscles are intact, but the patient has somewhat difficult time following this command, and eye pursuit is not smooth. OP is dry. The tongue is midline. NECK is supple. No palpable adenopathy or thyromegaly. HEART: Regular S1 and S2. No murmurs. LUNGS have scant bilateral wheezes. No rhonchi or rales.
OP|operative|OP|145|146|HISTORY OF PRESENT ILLNESS|In addition to minimal progress of her labor, she also had uric acid 6.6 up from 5.8 the day before and continued to have worsening edema. BRIEF OP NOTE: Preoperative Diagnosis: IUP at 39 weeks, severe preeclampsia and failed induction of labor remote from delivery. Postoperative Diagnosis: IUP at 30 weeks, severe preeclampsia and failed induction of labor remote from delivery.
OP|oblique presentation/occiput posterior|OP|129|130|DISCHARGE DIAGNOSES|Only complication noted was that there was thick meconium present. FINDINGS AT THE TIME OF DELIVERY: A viable infant male in the OP position with Apgars at 6 at 1 minute and 9 at 5 minutes. Weight was 7 pounds 8 ounces. Umbilical artery pH was 7.19 with a base excess of minus 6.7 and the venous pH was 7.23 with base excess of minus 6.4. The patient had normal uterus, tubes, and ovaries bilaterally.
OP|oblique presentation/occiput posterior|OP|176|177|HISTORY OF PRESENT ILLNESS|Therefore, at this point, discussed with the patient the risks, benefits, and alternatives of proceeding with a primary C-section secondary to arrest of dilatation with likely OP presentation. Informed consent was obtained. The patient was taken to the operating room. Please refer to the operative report for the details of her surgery.
OP|oblique presentation/occiput posterior|OP|121|122|PAST MEDICAL HISTORY|There was no cervical change in the meconium. The cervix remained 8 to 9/90% minus 2 and very enteric consistent with an OP presentation. Discussion with patient regarding risks, procedure, and rational for cesarean section and the patient consented. On _%#DDMM2002#%_ the patient underwent primary second transverse cesarean section.
OP|oropharynx|OP|150|151|OBJECTIVE|Weight is 234 lb. This is a very pleasant gentleman who appears anxious. ]HEAD, EYES, EARS, NOSE, THROAT: PERRL, EOMI. Sclerae anicteric. TMs normal. OP is clear. NECK supple without palpable adenopathy or thyromegaly. HEART: Regular S1-S2 with a flowing holosystolic murmur present throughout.
OP|oropharynx|OP|261|262|OBJECTIVE|OBJECTIVE: Temperature is 97.9, blood pressure 82/60, pulse 115, respirations 18, O2 saturation 99 percent on room air. Weight is 84.5 kg. This is a very pleasant gentleman, who appears somewhat uncomfortable. HEENT: PERRL. EOMI. Sclerae anicteric. TMs normal. OP is clear. NECK is supple without adenopathy or thyromegaly. HEART: Regular S1 and S2. No murmurs, gallops, or rubs. LUNGS are clear to auscultation bilaterally.
OP|oropharynx|OP|234|235|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 140/69, heart rate 76, respiratory rate 18, O2 saturations 97% on room air. Afebrile. GENERAL: The patient is a pleasant female in no acute distress. HEENT: PEERL, conjunctivae clear; OP slightly dry, dentition intact. NECK: Supple; no lymphadenopathy; no thyromegaly. LUNGS: CTA bilaterally. HEART: RR with 2/6 systolic ejection murmur.
OP|operative|OP|330|331|HOSPITAL COURSE|Tocodynamometry showed contractions every 3 to 5 minutes. HOSPITAL COURSE: Patient was admitted and underwent primary low transverse cesarean section under spinal anesthesia without any complication. Delivered a viable male infant. Apgar 9 and 9. Birth weight 2835 gm on _%#MM#%_ _%#DD#%_, 2004, at 08:27 a.m. Please refer to the OP note dictation for further details. Postoperatively, the patient was in stable condition. Her catheter was removed on postop day number 1.
OP|operative|OP|146|147|HOSPITAL COURSE|The patient underwent prophylactic cervical cerclage by McDonald method without any complications on _%#MM#%_ _%#DD#%_, 2004. Please refer to the OP note dictation for further details of the procedure. Postoperatively, the patient had difficulty with voiding. She had a straight catheterization done.
OP|operative|OP|214|215|PROCEDURES PERFORMED|Pacemaker placement. The patient is a 70-year-old female who presented on _%#DDMM2005#%_ for elective coronary artery bypass grafting. She was taken to the OR on this date. OR course was without complications (see OP note for specific details). During her hospital course, she had acute renal failure, which was managed without dialysis. She also had glucose control issues, which were managed initially with insulin drips and then converted to scheduled insulin regimen.
OP|oropharynx|OP|160|161|ADMISSION MEDICATIONS|HEAD: Normocephalic, atraumatic. Eyes with mild bilateral injection. No pus exudate. PERRL. TMs were normal bilaterally. NOSE: No rhinorrhea. MOUTH AND THROAT: OP dry, but with no lesions. Neck is supple. No LAD. LUNGS: Clear to auscultation bilaterally. No wheezing. Her central line site is clean, dry, and intact.
OP|oropharynx|OP|162|163|REVIEW OF SYSTEMS|General: Alert and oriented x 3. Not in acute distress. HEENT: Sclera nonicteric. No lymphadenopathy. Pupils equally round and reactive to light. Neck is supple. OP is clear. Normocephalic and atraumatic. Cardiovascular exam: S1, S2 normal. No murmurs, gallops or rubs. Lungs clear to auscultation. Abdomen soft, nondistended.
OP|oblique presentation/occiput posterior|OP|175|176|ALLERGIES|The patient was augmented with Pitocin at 3 milliunits per minute. At 11:00 a.m., one-half hour after rupture of membranes, she remained at 9 cm, vertex was not well applied, OP position. Pitocin augmentation was initiated. Approximately one hour later, she was still 9 cm. Pitocin at 12:50 p.m. was up to 3 milliunits per minute.
OP|oropharynx|OP:|157|159|PHYSICAL EXAMINATION|GENERAL: Alert and oriented x 3, not in acute distress. HEENT: No scleral icterus, no lymphadenopathy. Pupils equal, round, reactive to light. NECK: Supple. OP: Clear. CARDIOVASCULAR: S1, S2, normal; no murmur, no gallop, no rub. LUNGS: Clear to auscultation. ABDOMEN: Benign. EXTREMITIES: No edema noted, except mild swelling in the left ankle.
OP|oropharynx|OP|154|155|PHYSICAL EXAMINATION|GENERAL: The patient was somewhat ____________ cachectic, reddy complexion, mildly diaphoretic, alert, talking, in no acute distress. HEENT: PERRL. EOMI. OP clear. No lesions or thrush noted. NECK: Supple. No lymphadenopathy. CARDIOVASCULAR: Borderline tachycardic, regular rhythm, no murmur. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft with diffuse moderate tenderness in all four quadrants, minimal bowel sounds, colostomy bag with brown liquid stool.
OP|oropharynx|OP|207|208|PHYSICAL EXAMINATION|HEENT: Normocephalic and atraumatic. Eyes, PERRL. She cannot follow commands for EOMI, but this is grossly intact, as I can get her to look in different directions using different commands. Nares are clear. OP is moist. NECK: Supple without palpable adenopathy or thyromegaly. HEART: Regular S1 and S2, tachycardic, no murmurs. LUNGS: Have rales at the left lower lobe but no wheezes present.
OP|oropharynx|OP.|214|216|PHYSICAL EXAM|PHYSICAL EXAM: GENERAL: The patient is an alert, oriented, pleasant in no acute distress. She is able to speak in complete sentences. HEENT: Pupils equal, round and reactive to light and accommodate. Sclera normal OP. NECK: Normal JVP, no thyromegaly, no lymphadenopathy, no axillary lymphadenopathy. LUNGS: Diffuse wheezing, prolonged exploration and poor moderate air flow.
OP|oropharynx|OP|181|182|PHYSICAL EXAMINATION|Extraocular muscles intact. No conjunctival inflammation. Ears: Tympanic membranes dull with a positive light reflex; landmarks present; no effusion. Nose clear bilaterally. Mouth: OP clear, without erythema, exudate, or petechiae. Moist mucous membranes. Neck is supple without lymphadenopathy. Lungs: Bilateral coarse upper lobe crackles, right more than left, clear at the bases, good air exchange and no wheezes or signs of increased work of breathing.
OP|oropharynx|O.P|273|275|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: Basically non-significant except for the things mentioned in the "History of Present Illness." PHYSICAL EXAMINATION: VITAL SIGNS: Temperature is 96.9, pulse 90, blood pressure 90/40, satting 95% on room air. The patient is alert and oriented x 3. HEENT: O.P is clear. Oral mucosa is moist. NECK: Without JVD or lymphadenopathy. CARDIOVASCULAR: Regular rhythm without murmur or rubs. LUNGS: Very poor air entry with mild expiratory wheezes. No crackles.
OP|oropharynx|OP|176|177|OPERATIONS/PROCEDURES PERFORMED|Blood pressure is 117/72. His respiratory rate is 18, saturating 90% on room air. His weight is 75.7 kg. He is alert and oriented x3. HEENT: Exam without any sinus tenderness. OP clear. Mucous membranes are moist. LUNGS: His lung exam shows some right lower lobe crackles with expiratory rhonchi on the left side.
OP|oropharynx|OP|269|270|PHYSICAL EXAMINATION|COGNITIVE: Normal mentation. PHYSICAL EXAMINATION: Temperature is 97, blood pressure 127/81, pulse 79, respirations 24, O2 saturation 94 percent on 3 liters. This is a frail-appearing elderly gentleman, who is dyspneic, speaks in partial sentences. HEENT: PERRL. EOMI. OP is very dry. Throat is without erythema. NECK is supple without adenopathy. HEART: Distant S1, S2. No murmurs, gallops, or rubs.
OP|oropharynx|OP|142|143|PHYSICAL EXAMINATION|HEENT: Head was normocephalic and atraumatic. Pupils are equal, round, reactive to light and accommodation. Extraocular movements are intact. OP was clear. NECK: No lymphadenopathy. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, bowel sounds are positive. Positive right upper quadrant tenderness with no rebound, guarding, or rigidity.
OP|oblique presentation/occiput posterior|OP|258|259|HOSPITAL COURSE|With the deep variable decelerations, there was a possibility of uterine rupture, and the decision was made to proceed with emergent repeat cesarean section. The patient underwent a repeat cesarean section on _%#DDMM2005#%_, and delivered a viable female in OP presentation, weighing 6 pounds 15 ounces, with Apgars of 8 and 9. There was one nuchal loop. The lower uterine segment was very thin.
OP|oropharynx|OP|285|286|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Most recent vitals include a blood pressure of 115/61, heart rate 62, respiratory rate 16, oxygen saturations 97%, and temperature 100.1. GENERAL: The patient is a pleasant healthy appearing male who is lying in his hospital bed. HEENT: PERRL. Conjunctiva clear. OP clear with moist mucous membranes. NECK: Supple. No lymphadenopathy. No thyromegaly. LUNGS: CTA bilaterally. HEART: RRR, no murmur. ABDOMEN: Soft, non-tender, non- distended. Normoactive bowel sounds. No organomegaly.
OP|oropharynx|OP|282|283|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure is 112/60, heart rate is 83, respiratory rate is 16, temperature is afebrile and O2 sat is 95% on room air. GENERAL: Alert and oriented x3, not in acute distress. HEENT: Pupils are equally round and reactive to light. NECK: Supple. OP is clear. CARDIOVASCULAR: S1, S2 normal. No murmur, gallop or rub. LUNGS: Decreased breath sounds in both lungs but clear to auscultation otherwise.
OP|oropharynx|OP|189|190|PHYSICAL EXAMINATION|GENERAL: This is a very pleasant and alert woman who has good clarity of speech, no acute distress. HEENT: Head is normocephalic and atraumatic. Pupils are equal, round, reactive to light. OP is moist and tongue is midline. TMs are normal. NECK: Supple without adenopathy or thyromegaly. HEART: Regular S1 and S2, no murmurs.
OP|oblique presentation/occiput posterior|OP|143|144|HOSPITAL COURSE|Procedure was primary low transverse cesarean section and On-Q pump placement. The patient did have a viable female infant delivered in direct OP presentation with clear fluid, Apgar scores of 9 and 9, weight 9 pounds 1 ounce. Please see the operative report for further details. Postoperatively, the patient did well.
OP|oblique presentation/occiput posterior|OP|230|231|HOSPITAL COURSE|The strip was reviewed with the staff. Decision was made to proceed with primary low transverse cesarean section. The patient underwent a primary low transverse cesarean section without complications. Viable female infant, direct OP position, weight 6 pounds 12 ounces, Apgars 9 at 1 minute, 9 at 5 minutes without complications. The rest of her postoperative course was uncomplicated. The patient remained afebrile.
OP|oblique presentation/occiput posterior|OP,|146|148|HOSPITAL COURSE|HOSPITAL COURSE: At 1150 hours on _%#MM#%_ _%#DD#%_, 2004, the patient was delivered of an 8 pound 13 ounce, viable Apgars 8 and 9 female infant, OP, over an intact perineum. The baby cried and breathed spontaneously and was passed to the newborn intensive care unit team for care and support.
OP|oropharynx|OP|211|212|PHYSICAL EXAMINATION|GENERAL: The patient is a cachectic-appearing, disheveled male in no apparent distress when I saw him. He apparently was in respiratory distress upon initial arrival in the ED. HEENT: PERRL, conjunctivae clear. OP with dry mucous membranes, poor dentition. NECK: Supple, no lymphadenopathy. LUNGS: Occasional crackle, no wheezes, and good air exchange. However, the ER MD noted that initial exam was remarkable for wheezes and rales, primarily on the right.
OP|oropharynx|OP|154|155|REVIEW OF SYSTEMS|GENERAL: The patient is a pleasant male, who is up and walking about his room. HEENT: PERRLA, conjunctivae clear, EOMI. TMs and canals clear bilaterally. OP clear with dry mucous membranes and poor dentition. NECK: Supple, no lymphadenopathy, no thyromegaly. LUNGS: CTA bilaterally. HEART: Regular rate and rhythm with 2/6 systolic ejection murmur.
OP|oropharynx|OP|183|184|PHYSICAL EXAMINATION|She was afebrile and had 98% O2 sats on room air. GENERAL: She is a pleasant female currently in no acute distress, though she has received morphine. HEENT: PERRL. Conjunctiva clear. OP with moist mucous membranes now that she has been rehydrated. Neck supple, no lymphadenopathy, no thyromegaly. Lungs clear to auscultation bilaterally.
OP|oropharynx|OP|201|202|PHYSICAL EXAM|GENERAL: Alert, oriented x 3. The patient is in mild discomfort secondary to abdominal pain. HEENT: Sclerae not icteric. No lymphadenopathy. Pupils equally round and reactive to light. Neck is supple. OP is clear. CARDIOVASCULAR EXAM: S1, S2 normal. No murmurs, gallops, or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft. Bowel sounds positive, mildly distended. There is some tenderness in the right and left lower quadrant areas.
OP|operative|OP|234|235|FAMILY HISTORY|HOSPITAL COURSE: At 1503 on _%#MM#%_ _%#DD#%_, 2005, a viable male infant was delivered, cephalic presentation with Apgars of 8 and 9. Evidence of uterine rupture initially appeared on incision through the fascia. Please see dictated OP note for full details. Weight 7 pounds, 11 ounces. Cord gases: Arterial 7.32, pH base excess 0.6, venous pH 7.36, base excess 2.1. Infant initially hypoglycemic and monitored in the NICU.
OP|oropharynx|OP|267|268|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 97/42; pulse 62; respiratory rate 14; temperature is afebrile; oxygen saturations at 95% on room air. GENERAL: Alert and oriented x3 in no acute distress. Pupils are equally round and reactive to light. NECK: Supple. OP is clear. CARDIOVASCULAR: S1, S2 are normal. No murmur, gallops, or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft, nontender, nondistended, bowel sounds are positive.
OP|oropharynx|OP|200|201|PHYSICAL EXAMINATION|GENERAL: Alert and oriented x3. She appears to be comfortable and not in respiratory distress. HEENT: Sclerae anicteric; no lymphadenopathy; pupils, equally round and reactive to light. NECK: Supple. OP is clear. CARDIOVASCULAR: S1, S2 normal; no murmurs, gallops, or rubs. LUNGS: Clear to auscultation. ABDOMEN: Some mild tenderness in the epigastric area.
OP|oropharynx|OP|133|134|OBJECTIVE|Weight is 119.2 kg, height 5 feet 9 inches. GENERAL: This is a pleasant gentleman, obese, in no acute distress. HEENT: PERRLA. EOMI. OP is clear. NECK: Supple without adenopathy or thyromegaly. HEART: Regular. S1 and S2. No murmurs, gallops or rubs. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Obese. There is mild midepigastric tenderness, otherwise normal.
OP|oropharynx|OP|151|152|PHYSICAL EXAMINATION|HEENT: Head is normocephalic and atraumatic. Sclerae are nonicteric. No lymphadenopathy. Pupils are equally round and reactive to light. NECK: Supple. OP is clear. CARDIOVASCULAR: S1, S2 normal. No murmur, gallop or rub. LUNGS: Coarse breath sounds, but otherwise clear to auscultation. ABDOMEN: Soft, nontender and nondistended.
OP|oblique presentation/occiput posterior|OP|162|163|OPERATIVE DELIVERY NOTE|Please see Dr. _%#NAME#%_ _%#NAME#%_' dictation for details. In summary, the patient had an estimated blood loss of 800 cc. She delivered a viable male infant in OP presentation. Apgars were 6 at one minute and 8 at five minutes, weighing 7 pounds and 11 ounces. She had normal uterus, ovaries, and fallopian tubes. POSTOPERATIVE COURSE SUMMARY: The patient's postoperative course was complicated by wound cellulitis which she developed on postoperative day #3 for which she was started on Keflex at discharge.
OP|oropharynx|OP|171|172|PHYSICAL EXAMINATION|No alcohol for 9 years. Retired grocer, as above. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: Alert, cachectic male NAD. HEENT: Mucous membranes are slightly dry. OP is clear. NECK: Supple without adenopathy. Cranial nerves are intact CARDIOVASCULAR: Regular in rhythm. A loud 2 to 3/6 systolic ejection murmur at the upper left sternal border.
OP|oropharynx|OP:|137|139|ADMISSION PHYSICAL EXAMINATION|Head: Normocephalic, atraumatic. Eyes: Pupils were equal, round, and reactive to light bilaterally and extraocular movements are intact. OP: Clear. Mucous membranes moist. Neck: Supple with no lymphadenopathy. Cardiovascular: Regular rate and rhythm. No murmurs. Lungs: Clear to auscultation bilaterally.
OP|oropharynx|OP|171|172|PHYSICAL EXAMINATION|GENERAL: Alert, middle-aged female, NAD. HEENT: PEERL, EOMI. NECK: Supple without adenopathy. Nerve block on the right is still present. No thyromegaly or carotid bruits. OP is clear. Mucous membranes are moist. CV: Regular rate and rhythm, no murmurs, rubs, or gallops. CHEST: Mostly clear with possible decrease in air movement on the right.
OP|oropharynx|OP|152|153|DISCHARGE DIAGNOSIS|GENERAL: He is in no acute distress and pleasant. HEAD: Some small abrasions on his chin. EYES: Pupils were equal, round, and reactive to light. MOUTH: OP clear, no exudate. NECK: No lymphadenopathy. CARDIOVASCULAR: Regular, rate, and rhythm with occasional dropped beats and a 2/6 holosystolic murmur.
OP|oropharynx|OP|279|280|OBJECTIVE|4. HCTZ 25 mg daily. 5. Metformin 500 mg p.o. b.i.d. OBJECTIVE: VITAL SIGNS: Afebrile, blood pressure 117/61, heart rate 70, respiratory rate 20, 97% on room air. GENERAL: Alert female with a flat affect, NAD. HEENT: NC/NT, EOMI, PERRL, cranial nerves II-XII intact bilaterally, OP is clear, mucous membranes are moist. NECK: Supple without adenopathy or thyromegaly. CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; no carotid bruits.
OP|oropharynx|OP|156|157|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: Alert and oriented. She is very tired. HEENT: Sclera are not icteric. No lymphadenopathy. NECK: Supple. OP is dry. CARDIOVASCULAR: S1, S2 are normal, no splitting, murmur, gallops, or rubs. Her heart rate is tachycardiac. LUNGS: Clear to auscultation on anterior exams.
OP|operative|OP|267|268|OPERATIONS AND PROCEDURE PERFORMED|13. Code status DNR/DNI. CONSULTATIONS: Including pulmonary, pain consult, oncology, infectious disease and urology as well as nephrology. OPERATIONS AND PROCEDURE PERFORMED: Subtotal colectomy and ileostomy dated _%#DDMM2006#%_ by Dr. _%#NAME#%_ Please refer to the OP note for details. HISTORY: The patient is a 69-year-old male well known to our service who was diagnosed with metastatic stage 4 transitional cell bladder cancer who had been treated at the Mayo Clinic who presents here with severe abdominal pain.
OP|oropharynx|OP|159|160|PHYSICAL EXAMINATION ON THE DAY OF ADMISSION|VITAL SIGNS: Unremarkable. GENERAL: Non-ill-appearing. HEAD: Normocephalic. EYES: Pupils equal, round and reactive to light. Sclerae clear. OROPHARYNX: Mouth, OP clear. NECK: Supple. No thyromegaly. LYMPHATICS: No palpable supraclavicular, cervical, axillary, or inguinal adenopathy. CARDIOVASCULAR: Regular rate and rhythm without murmurs, gallops, or rubs.
OP|operative|OP|175|176|HOSPITAL COURSE|The patient required a PCA follow-up blood cultures came back negative. The patient went on to require surgery with Dr. _%#NAME#%_ on _%#DDMM#%_. Please refer to his dictated OP note for details. Postoperatively, patient had intermittent low-grade fevers. She required a PCA which was eventually weaned off. She was not very ambulatory at first and, therefore, was placed on DVT prophylaxis in the form of Lovenox.
OP|oropharynx|OP|153|154|PHYSICAL EXAM|GENERAL: This is a very pleasant, conversant woman who appears thin and frail. She is alert and oriented to self and place and time. HEENT: PERRL, EOMI, OP is clear. HEART: Regular S1, S2, no murmurs or ectopy. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, there are good bowel sounds, no tenderness.
OP|oblique presentation/occiput posterior|OP|309|310|DELIVERY NOTE|A primary low transverse cesarean section via Pfannenstiel skin incision with a 2-layer uterine closure was performed by Dr. _%#NAME#%_ with the assistance of Dr. _%#NAME#%_ under epidural anesthesia. There were no complications. Estimated blood loss was 800 cc. Findings included a viable infant male in the OP position, vertex, and delivered at 11:19 a.m. with Apgars of 9 and 9 at one and five minutes respectively weighing 8 pounds 15 ounces.
OP|operative|OP|225|226|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: I have been asked to see the patient on behalf of Dr. _%#NAME#%_ _%#NAME#%_ of orthopedic services for the patient's preop evaluation for her upcoming shoulder surgery. Please see Dr. _%#NAME#%_'s OP note for details of the procedure. _%#NAME#%_ notes that she has been doing well except for her orthopedic problems. She denies having any angina or anginal equivalents and states that she can exercise without any chest pain.
OP|operative|OP|278|279|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: I have been asked to see the patient on behalf of Dr. _%#NAME#%_ _%#NAME#%_ for the patient's preop evaluation for his upcoming left rotator cuff surgery to be done at Fairview Southdale Hospital tomorrow, _%#DDMM2006#%_. Please see Dr. _%#NAME#%_'s OP note for details of the procedure. Mr. _%#NAME#%_ notes that he has been doing well with no specific complaints. He denies having any angina or anginal equivalents and states that he is quite active including walking and he states that he still plays hockey even at his age.
OP|operative|OP|230|231|OPERATIONS AND PROCEDURE PERFORMED|5. Urinary retention secondary to obstructive uropathy. OPERATIONS AND PROCEDURE PERFORMED: Cystourethroscopy and prostate needle biopsy as well as bilateral scrotal orchiectomy on _%#DDMM2006#%_. Please refer to Dr. _%#NAME#%_'s OP report for details. Bone scan dated _%#DDMM2006#%_. Findings: Multiple axial skeletal mets. Please refer to report for details on locations. MRI of abdomen dated _%#DDMM2006#%_. Findings: Complex cystic 2.7 cm left renal mass worrisome for cystic renal carcinoma.
OP|oropharynx|OP|146|147|PHYSICAL EXAMINATION|HEENT: Head normocephalic, no lesions. Eyes: PERRLA, EOMI bilaterally, with no scleral or conjunctival injections. Ears atraumatic. Nasal normal. OP normal. NECK: Supple. There is no lymphadenopathy or thyromegaly. HEART: Regular rate, S1, S2, no murmurs. LUNGS: Clear to auscultation bilaterally.
OP|oropharynx|OP|182|183|OBJECTIVE|GENERAL: This is a pleasant-appearing male who appears jittery and has slurred speech but content is appropriate. He is cooperative. HEENT: PERRL. EOMI. TMs are normal. Nares clear. OP is dry. Lips cracked. NECK: Supple without adenopathy or thyromegaly. HEART: Regular. S1 and S2. No murmurs. LUNGS: Clear bilaterally. ABDOMEN: Soft. There are good bowel sounds. No tenderness whatsoever.
OP|oropharynx|OP|197|198|PHYSICAL EXAMINATION|In general, alert and oriented x 3. She is comfortable and appears to be in no respiratory distress. HEENT: Sclerae are not icteric. No lymphadenopathy. Pupils are equal, round, reactive to light. OP is clear. Neck: Supple. Cardiovascular: S1 and S2 are normal. Grade 3/6 holosystolic murmur heard best at the apex. No gallops or rubs.
OP|ova and parasites|OP|114|115|ASSESSMENT/PLAN|At this time we suggest upper endoscopy to rule out an upper GI source. She has had a colonoscopy. Unless she has OP positive stools, I am not sure she needs another one in her lifetime. 2. B12 within the normal range but in the very low to normal range.
OP|oblique presentation/occiput posterior|OP|200|201|HOSPITAL COURSE|She underwent a primary low transverse cesarean section on _%#DDMM2005#%_, with delivery of a healthy 8 pound 3 ounce male, with Apgars of 9 at one minute and 9 at five minutes. The vertex was in the OP presentation, and was wedged tightly in the pelvis, with a large amount of caput. An On-Q catheter was placed for additional pain control at the time of the procedure.
OP|oblique presentation/occiput posterior|OP|218|219|HOSPITAL COURSE|The baby was felt to be in an occiput posterior position and the head was able to be displaced from the pelvis. The patient was quite uncomfortable and given the evidence of cephalopelvic disproportion, likely from an OP Presentation, and a persistent anterior lip, the decided was made to proceed with Cesarean section. In addition at this time, fetal heart tone baseline increased to 160s to 170s, it was felt that delivery was appropriate.
OP|oblique presentation/occiput posterior|OP|162|163|REASON FOR ADMISSION|She underwent a primary low transverse cesarean section with delivery of a healthy 7 pound 7 ounce male. The baby was wedged tightly in the pelvis and was in the OP presentation. On postoperative day #0-1, her pain was well controlled with IV pain medications. Her Foley was discontinued. Her IV was discontinued and ambulation was begun.
OP|oropharynx|OP|135|136|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: HEENT: Sclera are non-icteric, no lymphadenopathy. Pupils are equally round and reactive to light. NECK: Supple. OP is clear. CARDIOVASCULAR: S1, S2 are normal; no murmur, gallops, or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft, nontender, nondistended. Bowel sounds are positive.
OP|UNSURED SENSE|OP|134|135|PROCEDURE|For full details of the procedure, please see the operative note dictated by Dr. _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2006, in OP scripts. HOSPITAL COURSE: The patient tolerated the procedure well, but on postoperative day #2, the patient did complain of clearly severe gas pain and inability to pass flatus or stool.
OP|oropharynx|OP|151|152|PHYSICAL EXAMINATION|GENERAL: The patient is a very pleasant female here with her husband lying on her hospital bed in no acute distress. HEENT: PERRL. Conjunctivae clear. OP with slightly dry mucus membranes. NECK: Supple. No lymphadenopathy. No thyromegaly. LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm. No murmur. ABDOMEN: Soft except for the right lower quadrant which does seem to have a feeling of firmness and tenderness but no rebound or guarding.
OP|oblique presentation/occiput posterior|OP|193|194|HOSPITAL COURSE|Cesarean section was discussed with the patient who elected to proceed with primary cesarean section for arrest of descent. On _%#DDMM2000#%_, the patient delivered a viable male infant in the OP position at 1026. Apgars were 9 and 9 at 1 and 5 minutes respectively. A vertical skin incision was made to avoid areas of cellulitis.
OP|oropharynx|OP|156|157|PHYSICAL EXAMINATION|HEENT: Head is normocephalic with no lesions. Eyes - PERRLA. EOMI bilaterally with no scleral or conjunctival injection. Ears - atraumatic. Nasal - normal. OP is normal. NECK: Supple. No lymphadenopathy or thyromegaly. HEART: Regular rate. S1, S2. No murmurs. LUNGS: Clear to auscultation bilaterally.
OP|oropharynx|OP|184|185|PHYSICAL EXAMINATION|Again, he was cooperative with the interview and the exam. HEENT: normocephalic/atraumatic. Pupils are equal and reactive to light. Extraocular muscles are intact. Sclerae nonicteric. OP is clear. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Regular without murmurs, rubs, or gallops. There were no carotid bruits. BACK: No midline or CVA tenderness. LUNGS: He has a few wheezes in the right base.
OP|oblique presentation/occiput posterior|OP|242|243|OPERATIONS/PROCEDURES PERFORMED|She, therefore, was consented for a primary low transverse cesarean section following a complete discussion of the risks, benefits, and alternatives with Dr. _%#NAME#%_. The patient went on to deliver a viable female in cephalic presentation OP position weighting 6 pounds 11 ounces with Apgars of 9 at one minute and 9 at five minutes. Arterial pH was 7.23 with a base excess of -3.4 and venous pH was 7.30 with a base excess of -4.5. Her procedures were complicated by a complete cervical extension repaired in an unusual fashion.
OP|oropharynx|OP|204|205|OBJECTIVE|PSYCHE: Negative. OBJECTIVE: VITAL SIGNS: Afebrile. Pulse 80s to 90s, respiratory rate 22 to 24, 91 to 94% on room air, 140s to 150s/80s to 90s, weight 161. GENERAL: Alert male, no acute distress. HEENT: OP is clear. NECK: Supple without adenopathy. EOMI. CARDIOVASCULAR: Regular rate and rhythm. No murmurs, rubs, or gallops. CHEST: Decreased breath sounds on the right with scattered wheezing.
OP|oropharynx|OP|155|156|PHYSICAL EXAMINATION VITAL SIGNS|HEENT: PERRL. EOMI. Left TM is normal. Right TM is retracted with some clear fluid present. The right ear canal is slightly erythematous. Nares are clear. OP is moist, no lesions. Neck is supple without adenopathy. HEART: Regular S1, S2, no murmurs. LUNGS: Have clear breath sounds bilaterally.
OP|oblique presentation/occiput posterior|OP|208|209|PROCEDURE|PROCEDURE: The patient was taken to the operating room and a primary low transverse cesarean section was performed under epidural anesthesia. Estimated blood loss 1,000 cc. Male infant was delivered from the OP position with Apgars 8 at one minute and 9 at five minutes. The baby weighed 8 pounds 8 oz. The baby was taken to the regular new born nursery in stable condition.
OP|oropharynx|OP|185|186|PHYSICAL EXAMINATION|GENERAL: He is pleasant in no acute distress. Speaking easily with me, alert and oriented. HEENT: Normocephalic, atraumatic. Pupils are equal and reactive to light. Sclerae nonicteric. OP is clear. NECK: Supple without adenopathy or thyromegaly. HEART: Regular without murmurs, rubs or gallops. He has no carotid bruits. LUNGS: Clear bilaterally. BACK: No midline or CVA tenderness. ABDOMEN: Soft, nontender, no hepatosplenomegaly and positive bowel sounds.
OP|oropharynx|OP|227|228|PHYSICAL EXAMINATION|GENERAL: She is a pleasant woman who appears her stated age who is speaking in full sentences without apparent distress. HEENT: Normocephalic, atraumatic. Pupils are equal and reactive to light. Extraocular muscles are intact. OP is clear. TMs are not examined. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Regular with an audible click throughout the precordium.
OP|operative|OP|288|289|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: I have been asked to see the patient on behalf of _%#NAME#%_ _%#NAME#%_ of Podiatry for the patient's preop evaluation for his upcoming right foot surgery to be done by Dr. _%#NAME#%_ at Fairview Southdale Hospital early next week. Please see Dr. _%#NAME#%_'s OP note for details of the procedure. The patient notes that he has been doing well with no specific complaints. He denies having any angina or anginal equivalents and states that he works on his truck for 3-4 hours at a time without any problems.
OP|operative|OP|278|279|HOSPITAL COURSE|HOSPITAL COURSE: On _%#DDMM2007#%_, the patient was admitted to the hospital and after initial decline in her mental status and neurological exam, Ms. _%#NAME#%_ was emergently taken to the operating room for decompressive craniectomy. For more details, please see the dictated OP note. Postoperatively, the patient was taken to the Surgical Intensive Care Unit and was on ventilatory support. Her neurological exam was poor including disconjugate gaze and on _%#DDMM2007#%_, there was a family conference and it was decided to make Ms. _%#NAME#%_ on comfort cares.
OP|oropharynx|OP|208|209|PHYSICAL EXAMINATION|Her weight is 139.7. General, alert and oriented times three not in acute distress. HEENT, sclerae non-icteric, no lymphadenopathy. Pupils equal round and reactive to light and accommodation. Neck is supple. OP is clear. Cardiovascular, S1, S2 normal. Grade II out IV systolic ejection murmur heard best at the apex. No gallops or rubs. Lungs clear to auscultation. Abdomen soft, nontender, nondistended, bowel sounds positive.
OP|oblique presentation/occiput posterior|OP|186|187|HOSPITAL COURSE|The patient had a primary cesarean section. Her cesarean section was uncomplicated. She had a total of 700 cc of estimated blood loss. She delivered a vigorous male infant in the vertex OP presentation with Apgars of 8 and 9, weight 6 pounds 15 ounces. Her postoperative course was complicated by postoperative fever. She had labs drawn that were negative.
OP|ophthalmic|OP|194|195|ADMISSION MEDICATIONS|5. Ischemic cardiomyopathy with ejection fraction 20-25% and a history of congestive heart failure ADMISSION MEDICATIONS: 1. Aspirin 325 mg a day 2. Metformin 500 mg b.i.d. 3. Econopred Plus 1% OP four times a day 4. Toprol XL 50 mg q. day 5. Lisinopril 5 mg q. day 6. Nexium 40 mg a day 7. Theragran M. one tablet q. day 8. Nitroquick p.r.n. PHYSICAL EXAMINATION: This is an elderly patient appearing his stated age.
OP|operative|OP|174|175||There were some mildly enlarged lymph nodes in both the external iliac region as well as the left periaortic region and these were removed. Details of the surgery are in the OP report. Final diagnosis showed the omentum had metastatic grade II adenocarcinoma, consistent with metastasis from a primary peritoneal adenocarcinoma.
OP|oropharynx|OP|128|129|PHYSICAL EXAMINATION|Sclerae have slightly icteric apparently dramatically improved from what they were a month ago. Extraocular muscles are intact. OP is clear. NECK: Supple without lymphadenopathy, thyromegaly. HEART: Regular with a soft 2/6 systolic murmur, no bruits. LUNGS: Clear bilaterally. ABDOMEN: Soft. He has a palpable hard mass in his right upper quadrant consistent with his liver cancer.
OP|oropharynx|OP|129|130|STAFF ADMIT NOTE|Fever to > 103. Eating well, still interactive. No rash, URI, or GI symptoms. VS reviewed. Alert, cooperative, NAD Clear sclera, OP clear, TMs clear. Neck supple, no LAD. Lungs clear, no crackles. Heart regular, no murmur. Abdomen soft, NT. No rash or bruises. No muscle or joint pain.
OP|oropharynx|OP|151|152|PHYSICAL EXAMINATION|She is alert with stimulation. HEENT: Normocephalic, atraumatic. Her pupils are small but reactive, somewhat sluggish. Extraocular muscles are intact. OP is clear. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Tachycardic without murmurs, rubs or gallops. LUNGS: Clear bilaterally. BACK: No midline or CVA tenderness. ABDOMEN: Tightly distended with moderate pain with just light palpation along the right side of her belly, basically from the umbilicus and rightward.
OP|oropharynx|OP|268|269|ALLERGIES|SOCIAL HISTORY: Positive for alcohol and tobacco dependency. PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: Temperature 99.7, blood pressure 156/87, heart rate 75, respirations 16. GENERAL: This is a 50-year-old gentleman in no apparent distress. HEAD: NC/AT. PERRL. OP is clear without thrush. No cervical lymphadenopathy. HEART: Normal S1 and S2 with regular rate and rhythm. No murmur. LUNGS: Clear bilaterally. ABDOMEN: Tender to palpation in the epigastric area without rebound or guarding.
OP|oblique presentation/occiput posterior|OP.|200|202|SOCIAL HISTORY|Both infants had clear fluid. Anesthesia was an epidural. She received Pitocin augmentation for Twin B, up to 18 milliunits/minute. Twin A presented ROA, and was delivered OA. Twin B was a persistent OP. She had a first degree perineal laceration, which was repaired with 3-0 Vicryl. She received a pudendal block of 1% Polocaine. Following delivery of the second twin, she was given Pitocin.
OP|oblique presentation/occiput posterior|OP|256|257|DOB|She pushed for a total of at least 2-1/2 3 hours, pushing even longer after Dr. _%#NAME#%_ evaluated her because of what appeared to be apparent progress. However, then it became clear that she was making no progress and since the baby seemed to be in the OP position with low grade fever the plan was for C-section. The patient's past medical history was significant only for the mild depression.
OP|oropharynx|OP|149|150|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Blood pressure 132/60, afebrile, and a pulse of 75. General: alert, oriented x 3, not in acute distress. PERRLA. Neck: supple. OP is clear. Cardiovascular examination: S1, S2 normal, no murmurs, gallops, or rubs. Lungs: clear to auscultation. Abdomen: soft, nontender, nondistended, bowel sounds positive.
OP|occiput posterior|(OP)|169|172|HOSPITAL COURSE|Vacuum extraction failed after six contractions and therefore cesarean section was performed. The patient went on to deliver a viable female infant in occiput posterior (OP) presentation weighing 8-pounds- 9-ounces. There were no intraoperative complications. The patient's postoperative course was uneventful and her postoperative hemoglobin was 10.9. DISCHARGE PLAN: She was discharged on the fourth postoperative day with a return appointment in six weeks.
OP|oropharynx|OP:|174|176|PHYSICAL EXAMINATION|Foley catheter in place to gravity drainage. Vitals: Blood pressure 158/78, pulse of 84, weight 181 pounds. HEENT: EOMI. Neck: Supple without lymphadenopathy or thyromegaly. OP: NL. Cardiovascular: Regular rate and rhythm, II/VI systolic murmur noted, no rubs or gallops noted, no JVD. Abdomen: Soft, nontender, nondistended, well-healed surgical scars midline and in left lower quadrant, positive bowel sounds, no organomegaly, graft tenderness, or bruits noted.
OP|oropharynx|OP|134|135|PHYSICAL EXAMINATION ON ADMISSION|She appears comfortable with a productive cough, but continues to have audible wheezes. Head: NCAT. Eyes with white sclerae and EOMI. OP clear, but poor dentition noted. Tympanic membranes are clear bilaterally with good landmarks. Neck is supple with no lymphadenopathy and a nonpalpable thyroid.
OP|oropharynx|OP|183|184|PHYSICAL EXAM|PHYSICAL EXAM: BP: 119/75. T: Afebrile. P: 72. Oxygen sat 99%. GENERAL: Alert, oriented x 3, not in acute distress. HEENT: Pupils equally round and reactive to light. Neck is supple. OP is clear. CARDIOVASCULAR: S1, S2 normal. No murmur, gallop, or rub. LUNGS: Clear to auscultation on the right side, slightly decreased on the left side.
OP|oropharynx|OP|130|131|PHYSICAL EXAMINATION|GENERAL: The patient is a pleasant female sitting up and conversing in no acute distress. HEENT: PERRL. EOMI. Conjunctivae clear. OP clear, with slight dry mucous membranes. She wears dentures up and down. NECK: Supple; no lymphadenopathy; no thyromegaly.
OP|oropharynx|OP|187|188|PHYSICAL EXAM|O2 sat 100 percent. GENERAL: Alert. The patient is moderate discomfort secondary to nausea and vomiting and also pain. HEENT: Sclerae not icteric. No lymphadenopathy. No lymphadenopathy. OP is clear. CARDIOVASCULAR EXAM: S1, S2 normal. No murmurs, gallops, or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft. Mild to moderate diffuse tenderness.
OP|oropharynx|OP|148|149|PHYSICAL EXAMINATION|GENERAL: no acute distress. HEAD: NC/AT. EYES: pupils equal, round and reactive to light; extraocular movements intact; no scleral icterus. THROAT: OP is clear; mucus membranes are dry. NECK: supple, no lymphadenopathy. HEART: regular rate and rhythm without murmurs, rubs, or gallops.
OP|oropharynx|OP|197|198|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Blood pressure 135/63, pulse 51, respiratory rate 18, afebrile, 99% on room air. General: The patient is a pleasant female in no acute distress. HEENT: Sclera are nonicteric. OP is slightly dry. Neck: Supple, no thyromegaly. Lungs: Clear to auscultation bilaterally. Heart: Regular rate and rhythm with 2/6 systolic ejection murmur.
OP|oblique presentation/occiput posterior|OP|193|194|OPERATIONS/PROCEDURES PERFORMED|OB was consulted and the patient was recommended for a cesarean section. On _%#MM#%_ _%#DD#%_, 2002, the patient underwent primary low transverse cesarean section via Pfannenstiel incision. An OP presentation was noted. Surgeon was Dr. _%#NAME#%_ _%#NAME#%_, assistants were Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_. Anesthesia was spinal. EBL was 700 cc.
OP|oblique presentation/occiput posterior|OP|138|139|HOSPITAL COURSE|This was done on _%#DDMM2002#%_. Please see the dictation for the details. She delivered a male infant weighing 7 pounds 3 ounces from an OP position, with Apgars of 8 and 9. Her postoperative course was essentially unremarkable. DISPOSITION: She did well and was discharged home on postoperative day #3.
OP|oropharynx|OP|164|165|PHYSICAL EXAM|GENERAL: Alert but sleepy. HEENT: Sclerae not icteric. No lymphadenopathy. Pupils equally round and reactive to light. Pupils are approximate 2.5 mm. NECK: Supple. OP is clear. CARDIOVASCULAR EXAM: S1, S2 normal. No murmurs, gallops, or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft, nontender, nondistended.
OP|oropharynx|OP|206|207|OBJECTIVE|Respirations 16. This is a sleepy but arousable adolescent. She is cooperative and calm. HEENT: PERRL. EOMI. Pupils appears slightly enlarged but are symmetric. TMs normal. Nares are clear. No ulcerations. OP is without trauma. Throat is clear. NECK is supple without adenopathy or thyromegaly. HEART: Regular S1, S2. Slightly tachycardia. No murmurs. ABDOMEN is soft.
OP|oropharynx|OP|200|201|PHYSICAL EXAM|O2 saturations 87 to 89% on room air. PHYSICAL EXAM: On exam she is alert, tracking and pink. Mucous membranes moist. TM's are clear bilaterally. Mucoid rhinitis was present in the nares bilaterally. OP is clear. Uvula midline. NECK is supple. Fontanelle is flat. No cervical adenopathy. Respiratory rate in the 50's. Mild substernal retractions are present.
OP|oropharynx|OP|218|219|OBJECTIVE|Weight is 121.5. General: Alert female, oriented to self, place, and situation, in no acute distress. Neurologic: Affect is flat. She has a slight head tremor, slight rigidity. HEENT: Bilateral cataracts. EOMI intact. OP is clear. Neck: Supple, without adenopathy. No bruits auscultated. CV: Regular rate and rhythm, no murmurs, rubs, or gallops. Chest: Clear to auscultation bilaterally. Abdomen: Bowel sounds are positive, soft, non-tender, non-distended, no HSM or masses.
OP|oblique presentation/occiput posterior|OP|138|139|HOSPITAL COURSE|AROM was approximately at 1710 hours with clear, amniotic fluid. She was completely dilated at 1940 hours. Infant delivered in the direct OP position. There was no episiotomy, however, she did have secondary perineal laceration that was repaired. Total EBL for the delivery was 250 cc. Infant's Apgars were 9 and 9.
OP|oblique presentation/occiput posterior|OP|365|366|HISTORY OF THE PRESENT ILLNESS|The head started to show slight caput and the position on the baby was occipital posterior, very deflexed head and then we put the Pitocin starting from 6 milliunits back up and with each contraction, the baby would have variable decelerations again. Therefore, we decided to do the Cesarean section delivery because of fetal distress and arrest of dilatation with OP position. We explained to the patient the nature of the surgery, the risks of blood loss, blood transfusions, gastrointestinal, genitourinary injuries, thromboembolism were all explained to her and the alternative and consent was obtained.
OP|oropharynx|OP|161|162|OBJECTIVE|GENERAL: An alert, elderly female coughing with contusions on her face and eye from a remote fall without loss of consciousness or mental status changes. HEENT: OP is clear. Nose is congested. There is a cataract on the right. PERRLA, EOMI. NECK: Supple without adenopathy, thyromegaly, or carotid bruits.
OP|oblique presentation/occiput posterior|OP|139|140|HOSPITAL COURSE|The patient was admitted, placed on hands and knees to encourage rotation. The patient went on to deliver a 8-pound 1 ounce male infant in OP position over a first-degree perineal laceration which was repaired with 4-0 chromic. At that time 3 cm of soft swelling was noted in the fourchette.
OP|oropharynx|OP.|157|159|PHYSICAL EXAM|O2 sat 100% on 2 liters. GENERAL: The patient is alert and oriented, pleasant in no acute distress lying in bed as appropriate. HEENT: Normal sclera, normal OP. Tympanic membranes are clear bilaterally. NECK: No nuchal rigidity. Neck is supple. No lymphadenopathy, no thyromegaly. LUNGS: Clear to auscultation bilaterally. CV: Regular rate and rhythm.
OP|oblique presentation/occiput posterior|OP|210|211|DIAGNOSES ON DISCHARGE|2. Latent labor. DIAGNOSES ON DISCHARGE: Repeat low segment transverse cesarean section and delivery of viable male infant at 0250 hours on _%#DDMM2003#%_. Birth weight 8 pounds 5 ounces. Apgar scores 7 and 9. OP presentation. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 17-year-old G2, para 1-0-0-1, who presented at 40+5 weeks by LMP of _%#DDMM2003#%_ consistent with a 19+2 week ultrasound in _%#MM#%_ 2003, giving an EDC of _%#DDMM2003#%_.
OP|oropharynx|OP|164|165|PHYSICAL EXAMINATION|She also has cushingoid features. She has limited English, and therefore a care giver also interprets for her. HEENT: PERRL. EOMI. TMs are normal. Nares are clear. OP is slightly dry without lesions. NECK has tracheostomy without erythema. There is no adenopathy. HEART: S1, S2, tachycardic. No murmur. LUNGS: There are decreased breath sounds at the right lower and right upper lobes, but no rhonchi or wheezes are noted.
OP|oblique presentation/occiput posterior|OP|112|113|HISTORY OF PRESENT ILLNESS|The patient was delivered of a viable female infant, Apgars 8 and 9, weight 5 pounds 1 ounce, delivered from an OP vertex presentation at 21:22. Tubes and ovaries were normal. There was thick meconium. There were multiple subserosal myomata.
OP|oropharynx|OP|283|284|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: In the emergency room her blood pressure was 153/100; pulse 100; respiratory rate 16; oxygen saturations within normal limits, temperature 100.2. GENERAL: The patient is a pleasant female in no acute distress. HEENT: PERRL, conjunctivae are clear, OP with moist mucous membranes. NECK: Supple, no lymphadenopathy, no thyromegaly. LUNGS: CTA bilaterally. HEART: RRR, no murmur. ABDOMEN: Distended, but soft with mild diffuse tenderness to palpation.
OP|oropharynx|OP|152|153|PHYSICAL EXAMINATION|O2 saturation on room air is 98 percent. GENERAL: This is avery pleasant woman in no acute distress. HEENT: PERRL. EOMI. Sclerae anicteric. TMs normal. OP is dry. NECK is supple without adenopathy or thyromegaly. HEART: Regular S1, S2. no murmurs. LUNGS are clear to auscultation bilaterally. ABDOMEN is soft.
OP|oropharynx|OP|142|143|PHYSICAL EXAMINATION|GENERAL: The patient is a thin elderly female in no acute distress. HEENT: Pupils are oblong and consistent with history of cataract surgery. OP with moist mucous membranes and partial dentures: NECK: Supple; no lymphadenopathy, no thyromegaly. LUNGS: CTA bilaterally. HEART: RRR with II/VI systolic ejection murmur.
OP|outpatient|OP|116|117|DISCHARGE FOLLOW-UP|1. Establish care with an internist in the next one to two weeks. 2. To see his allergist in the next one month. 3. OP CD assessment It has been a pleasure to be a participant in the care of this patient.
OP|oropharynx|OP|260|261|OBJECTIVE|OBJECTIVE: VITAL SIGNS: Afebrile, heart rate 70s to 80s, blood pressure 130s to 150s/60s to 80s, respiratory rate 20, 98% on 3 L. GENERAL: Alert, older female sitting up in a chair oriented times person, year, presidential candidate, NAD. HEENT: PERRLA, EOMI, OP is clear. NECK: Supple without adenopathy or bruits. TM are clear. CARDIOVASCULAR: Regular rate and rhythm, 2/6 systolic ejection murmur left upper sternal border.
OP|oropharynx|OP|160|161|DISCHARGE EXAMINATION|Lusty crying. SKIN: Mild jaundice on the face, no scleral icterus. There is no cyanosis. HEENT: Red reflexes present bilaterally. TMs normal. Nares are patent. OP is moist without lesions. No cleft palate. NECK is supple. There is no adenopathy or thyromegaly. HEART: Regular S1, S2 with a harsh pansystolic murmur heard best at the left upper sternal border.
OP|oropharynx|OP|187|188|OBJECTIVE|Blood pressure 88/56, heart rate 74, respiratory rate 16, 91% on room air, and afebrile. GENERAL: The patient is a pleasant female in no acute distress. HEENT: PERRL, conjunctivae clear, OP with dry mucous membranes. NECK: Supple. No lymphadenopathy. No thyromegaly. LUNGS: CTA bilaterally. HEART: RRR with holosystolic murmur at the apex.
OP|oropharynx|OP|198|199|FAMILY HISTORY|She weighed 109 kg. She was a obese female in no apparent distress, alert and oriented times 3. Her pupils were equal, round, and reactive to light. Extraocular motions were intact bilaterally. Her OP was clear. The mucous membranes were moist. Neck was soft and supple with no lymphadenopathy, no bruits, no thyromegaly.
OP|oblique presentation/occiput posterior|OP|263|264|HOSPITAL COURSE|Her cervix was very unfavorable and she had Pitocin started and actually cervix progressed to 6 cm and became very thick and puffy and did not dilate any more. There were variable decelerations with some late components on the fetal heart and the baby was in the OP position. Because of arrest of descent and dilatation, and variable decelerations, the patient underwent primary cesarean section with low transverse incision on the uterus under epidural analgesia.
OP|oblique presentation/occiput posterior|OP|246|247|HOSPITAL COURSE|Because of arrest of descent and dilatation, and variable decelerations, the patient underwent primary cesarean section with low transverse incision on the uterus under epidural analgesia. A live male infant was delivered at 6 pounds 4 ounces in OP position with Apgar scores of 9 and 9. The postoperative course was uneventful. Urinary bowel functions were normal. The pathology on placenta showed term placenta with no infarction, no evidence of neoplasia and postoperative hemoglobin was 9.2. She was placed on iron therapy and her pain control was fairly well with initially PCA followed by Percocet.
OP|oropharynx|OP|244|245|PHYSICAL EXAMINATION|GENERAL: Elderly Caucasian female. Sleeping but easily aroused. Appears comfortable and in no acute distress. She is oriented to first name only. HEENT: Head: Normocephalic and atraumatic. Eyes: Anicteric with no conjunctival injection. PERRL. OP clear. NECK: Supple without lymphadenopathy. CARDIOVASCULAR: Regular rate and rhythm without murmurs. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Decreased bowel sounds. Soft, nondistended. Mildly tender. No rebound tenderness.
OP|oropharynx|OP|216|217|ALLERGIES|98% on room air, weight 169 pounds. General: Very thin, cachectic-appearing, Somali man in no acute distress, alert and oriented x3, pleasant and cooperative. Head: Normocephalic, atraumatic, anicteric, PERRL, EOMI. OP clear. Neck supple without lymphadenopathy. Cardiovascular: Regular rate and rhythm without murmurs. Peripheral pulses are palpable and symmetric. Lungs: Clear to auscultation bilaterally. No crackles, rubs, or wheezes.
OP|oblique presentation/occiput posterior|OP|138|139|HOSPITAL COURSE|The patient went to the OR and had a primary low transverse cesarean section performed. At this time, it was noted that the infant was in OP position. EBL was 800. She delivered a viable male infant in vertex position with meconium noted and this infant was resuctioned.
OP|oropharynx|OP|151|152|PHYSICAL EXAMINATION|GENERAL: The patient is a pleasant female in no acute distress. She is able to speak in full sentences comfortably. HEENT: PERRLA, conjunctivae clear. OP with dry mucous membranes. NECK: Supple, no thyromegaly. LUNGS: CTA bilaterally. HEART: RRR, no murmur. ABDOMEN: Slightly obese and soft with no tenderness and no palpable mass.
OP|UNSURED SENSE|OP|231|232|ASSESSMENT/PLAN|The patient and his mom report no travel history but neurocysticercosis is the most likely etiology but other considerations would be infection, abscess, and neoplasm. 1. Admit to 5A or B. 2. Ask for Infectious Disease consult. 3. OP is planned for today. 4. We will send CSF for cysticercosis.
OP|oropharynx|OP|259|260|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Blood pressure 134/86, heart rate 100, respiratory rate 20, and afebrile on presentation to the ER. General: The patient is a pleasant female in no acute distress, although she appears somewhat weakened. HEENT: PERRL. Conjunctiva clear. OP clear with slightly dry mucous membranes. Neck supple, no lymphadenopathy, no thyromegaly. Lungs clear to auscultation bilaterally. Heart regular rate and rhythm, no murmur. Abdomen soft with mild diffuse tenderness to palpation, no mass.
OP|oropharynx|OP|157|158|OBJECTIVE|This is an elderly woman who appears fatigued, hanging her head and closing her eyes. She understands commands and her speech is clear. HEENT - PERRL, EOMI, OP is moist. NECK - supple. She has a hard time holding her head up secondary to profound fatigue. Neck is supple without adenopathy or thyromegaly. HEART - regular S1, S2, bradycardiac with a very soft 2/6 murmur.
OP|oblique presentation/occiput posterior|OP|144|145|HOSPITAL COURSE|Four attempts were made over 8-1/2 minutes with no popoff. There was no success with the vacuum extraction likely secondary to anterior lip and OP position. The patient was consented for cesarean section. She underwent a primary low transverse cesarean section via Pfannenstiel skin incision after failed spinal anesthesia and then conversion to general.
OP|oropharynx|OP|277|278|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: On admission: Vital Signs: Blood pressure 97/42, pulse 62, respiratory rate 14, temperature is afebrile, O2 saturation at 95% on room air. General: Alert and oriented x 3, in no acute distress. Pupils are equal, round and reactive to light. Neck: Supple. OP is clear. Cardiovascular: S1, S2 are normal. No murmur, gallops or rubs. Lungs: CTA, abdomen, soft, nontender, nondistended bowel sounds are positive.
OP|oropharynx|OP|214|215|PHYSICAL EXAMINATION|EYES: Pupils are equal, round and reactive to light and accommodation. No conjunctivitis. Obvious asymmetrical eye movements. NOSE/MOUTH/THROAT: No nasal drainage or drainage/exudate/tonsillar hypertrophy noted on OP examination. NECK: Supple. CARDIOVASCULAR: Regular rate and rhythm without murmur. LUNGS: Clear to auscultation bilaterally. ABDOMEN/RECTAL: Positive bowel sounds. Soft, non-tender and non-distended. Multiple surgical scars on abdomen apparent.
OP|oblique presentation/occiput posterior|OP|159|160|PROCEDURE|POSTOPERATIVE DIAGNOSES: 1. Intrauterine pregnancy term delivered. 2. Idiopathic thrombocytopenia. 3. Arrest of descent due to cephalopelvic disproportion. 4. OP presentation. SURGEON: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD ASSISTANT: _%#NAME#%_ _%#NAME#%_, MD ANESTHESIA: General endotracheal.
OP|oblique presentation/occiput posterior|OP|240|241|HOSPITAL COURSE|At that time, a primary cesarean section was discussed and the patient did consent to undergo surgery for nonreassuring fetal heart tones, remote from delivery. On _%#MM#%_ _%#DD#%_, 2005, _%#NAME#%_ was delivered of a viable male fetus in OP presentation, Apgar is 8 and 9. Weight 8 pounds 3 ounces. Cord gases; arterial pH 7.30, base excess 0.6, venous pH 7.40, base excess 0.4. Preoperative hemoglobin 12.3. Postoperative hemoglobin 11.7. Postoperative course complicated by fever spike to 100.8. Otherwise, vitals remained stable.
OP|oblique presentation/occiput posterior|OP|250|251|REASON FOR ADMISSION|Her labor progressed without complication until the second stage, where she developed deep variable decelerations in the fetal heart rate with slow return to baseline and reflex tachycardia. The station was high and the vertex was noted to be in the OP presentation, therefore I recommended we proceed with Cesarean section. She underwent a primary low-transverse Cesarean section on _%#DDMM2005#%_. She delivered a healthy 6 pound 9 ounce female with Apgars of 8 at one minute and 9 at five minutes.
OP|oropharynx|OP|199|200|PHYSICAL EXAMINATION|GENERAL: This is a very pleasant gentleman who articulates with clear speech. HEENT: Head is normocephalic and atraumatic. Pupils are equal and reactive bilaterally. TMs are normal. Nares are clear. OP is moist without trauma. NECK: Supple without adenopathy. HEART: Regular S1 and S2. No murmurs. LUNGS: Clear bilaterally. ABDOMEN: Soft. There is good bowel sounds.
OP|oropharynx|OP|176|177|PHYSICAL EXAMINATION|GENERAL: Alert, oriented x3. She is not in acute respiratory distress. HEENT: Sclerae nonicteric. No lymphadenopathy. Pupils equally round and reactive to light. NECK: Supple. OP is clear. CARDIOVASCULAR: S1, S2 normal; no murmurs, gallops or rubs. LUNGS: Rales noted at the bases. ABDOMEN: Soft, nontender, nondistended.
OP|operative|OP|213|214|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient has had increasing pain below the right hip. Investigation by her orthopedic surgeon reveals a nonunion fracture of the femur requiring ORIF. Please see separately dictated OP note in this regard. The patient went to surgery earlier today and has done well. Currently, the patient complains of a great deal of pain.
OP|oblique presentation/occiput posterior|OP|179|180|DELIVERY NOTE|She was also started on Pitocin with a maximum range of 1 milliunit per minute, she being complete. After 2 hours of pushing, there was no descent of the fetal head with probable OP position. A cesarean section was recommended. After risks, benefits, and alternatives were discussed and all questions were answered, surgical consent was obtained.
OP|oblique presentation/occiput posterior|OP|214|215|OPERATIVE FINDINGS|A cesarean section was recommended. After risks, benefits, and alternatives were discussed and all questions were answered, surgical consent was obtained. OPERATIVE FINDINGS: Included viable infant, female, in the OP position at 1920 on _%#MM#%_ _%#DD#%_, 2006, with Apgars of 8 and 9 at one and five minutes respectively, weight 7 pounds 14 ounces.
OP|operative|OP|243|244|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: I am asked to see the patient on behalf of Dr. _%#NAME#%_ for the patient's preop evaluation for her upcoming lap hysterectomy to be done at Fairview Southdale Hospital on _%#DDMM2006#%_. Please see Dr. _%#NAME#%_' OP note for details of the procedure. _%#NAME#%_ notes she has been doing relatively well other than heavy menstrual bleeding.
OP|operative|OP|244|245|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: I have been asked to see the patient on behalf of Dr. _%#NAME#%_ _%#NAME#%_ of Gyn/Onc for the patient's upcoming hysterectomy to be done at Fairview Southdale Hospital on _%#DDMM2000#%_. Please see Dr. _%#NAME#%_'s OP note for details of the procedure. The patient noted that she has been doing relatively well with minimal complaints.
OP|oropharynx|OP,|248|250|PHYSICAL EXAMINATION|GENERAL: The patient was alert and cooperative, thin appearing. HEENT: Alopecia, head is normocephalic and atraumatic. No scalp tenderness. Pupils are equal, round and reactive to light. Extraocular eye movements were intact. His nares look clear. OP, clear, no signs of mucositis. CARDIOVASCULAR: He was tachycardic, but with a regular rhythm. S1 and S2. No murmurs. LUNGS: Clear to auscultation bilaterally. SPINE: He had no spinal tenderness, but did have left CVA tenderness on palpation.
OP|oropharynx|OP|158|159|PHYSICAL EXAMINATION|HEENT: She has a contusion over the left frontal area of her scalp. No open laceration. Eyes are equal. Pupils are reactive. TMs are normal. Nares are clear. OP is dry. Tongue is midline. NECK: Supple without adenopathy. HEART: Regular S1 and S2, no murmurs. LUNGS: Clear bilaterally. ABDOMEN: Soft, there is good bowel sounds. EXTREMITIES: Warm, there is no edema whatsoever.
OP|oropharynx|OP,|147|149|DISCHARGE EXAM|Blood sugar is 138. GENERAL: She is pleasant, speaking in full sentences and does not appear short of breath. HEENT: Normocephalic and atraumatic. OP, edentulous. NECK: Supple without lymphadenopathy. HEART: Regular without murmurs, rubs or gallops. LUNGS: Crackles in the right base, otherwise clear.
OP|oropharynx|OP|256|257|OBJECTIVE|NEUROLOGIC: History of stroke, no residual deficits. OBJECTIVE: VITAL SIGNS: Temperature 97.3, blood pressure 142/68, pulse 74, respirations 18, 02 saturation 98% on 2 liters. GENERAL: This is a pleasant woman in absolutely no distress. HEENT: PERL, EOMI. OP is clear. NECK: Supple, without adenopathy or thyromegaly. HEART: Irregularly irregular S1, S2, no murmurs, no carotid bruits. LUNGS: Decreased breath sounds but are clear bilaterally, no wheezes or rhonchi.
OP|oropharynx|OP|147|148|PHYSICAL EXAMINATION (HLI)|General: Alert, oriented times three, in no acute distress. HEENT: Pupils equally, round, and reactive to light and accommodation. Neck is supple. OP is clear. Cardiovascular exam, S1 S2 normal. Grade 2/6 systolic ejection murmur, heard best at the apex. No carotid bruits. JVD not appreciated. Lungs clear to auscultation.
OP|oropharynx|OP|214|215|PHYSICAL EXAMINATION|HEENT: Normocephalic. She does have a few sutures in her occipital region with some surrounding bruising. She is quite tender to try and set up in bed. Pupils are reactive to light. Extraocular muscles are intact. OP is clear. NECK: Supple without lymphadenopathy. HEART: Regular without murmurs, rubs or gallops but it is very difficult to hear secondary to her overwhelming inspiratory phase and expiratory wheezing.
OP|operative|OP|332|333|HOSPITAL COURSE|HOSPITAL COURSE: On admission, the patient was initially set up for an elective resection 2 days after admission; however, the patient developed signs of herniation on hospital day #1 and was therefore taken emergently to the to the operating room for decompressive craniectomy and biopsy. For more detailed information, please see OP note on _%#DDMM2007#%_. The patient was taken back to the operating room for further resection of the brain tumor and for cranioplasty.
OP|oropharynx|OP|193|194|PHYSICAL EXAMINATION|GENERAL: She is a very pleasant woman who appears her stated age in no acute distress. HEENT: Normocephalic, atraumatic. Pupils are equal and reactive to light. Extraocular muscles are intact. OP is clear. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Regular without murmurs, rubs, gallops. BREASTS: Not examined. She does have a port in her right anterior chest.
OP|oropharynx|OP|148|149|PHYSICAL EXAMINATION|She appears comfortable. HEENT: Sclera anicteric. No lymphadenopathy. Pupils equally round and reactive to light and accommodation. Neck is supple. OP is clear. Cardiovascular: S1, S2 normal. Soft ejection murmur heard loudest at the base. Lungs are clear to auscultation. Abdomen : Soft, nontender, nondistended. Bowel sounds positive. No organomegaly.
OP|oblique presentation/occiput posterior|OP|122|123|PHYSICAL EXAMINATION|The patient delivered a viable male infant. Apgars were 7 and 9. Weight was 7 pounds 8 ounces. Delivery was from a direct OP vertex presentation. There was a uterine extension from the apex of the incision. The patient's postoperative course was complicated by some shortness of breath on postoperative day one.
OP|oblique presentation/occiput posterior|OP|211|212|HISTORY OF PRESENT ILLNESS|The patient's birth was complicated by a fourth degree laceration that required repair in the operating room by Dr. _%#NAME#%_ with an estimated blood loss of 50 cc. The fourth degree laceration secondary to an OP delivery of an 8 pound 5 ounce male infant in the OP position. POSTPARTUM COURSE: The patient's postpartum course was complicated by symphysis pubis separation that decreased the patient's mobility and increased the level of suprapubic pain.
OP|oropharynx|OP|205|206|PHYSICAL EXAM|GENERAL: Alert and oriented to self. The patient is not in respiratory distress. HEENT: Sclerae not icteric. No lymphadenopathy. Pupils equally round and reactive to light and accommodation. NECK: Supple. OP is clear. CARDIOVASCULAR EXAM: S1, S2 normal. Grade II/VI systolic ejection murmur. LUNGS: Poor inspiratory effort. Decreased breath sounds, otherwise clear to auscultation.
OP|oblique presentation/occiput posterior|OP|269|270|HOSPITAL COURSE|She also received IV hydration. Upon evaluation in Labor and Delivery, she was contracting every 7 minutes and her cervix was closed, long, and high. On _%#DDMM2002#%_ she was seen by Perinatology and an ultrasound was performed. The infant was found to be vertex with OP presentation. The patient was found to have polyhydramnios. The infant was macrosomic. Doppler flow profile was consistent with placental insufficiency and BPP was 2 out of 8.
OP|oropharynx|OP|131|132|PHYSICAL EXAMINATION|HEENT: Sclera anicteric. No lymphadenopathy. Pupils are equal, round, and reactive to light and accommodation. The neck is supple. OP is clear. Cardiovascular examination: Distant heart sounds secondary to size. Lungs: Decreased breath sounds secondary to obesity, but the remainder of the lung fields are clear to auscultation.
OP|oblique presentation/occiput posterior|OP|421|422|CONSULT|On _%#MM#%_ _%#DD#%_, 2002, at approximately 12:20, Dr. _%#NAME#%_ was consulted and upon exam, the patient was complete in +1 station and the decision was made to proceed with a primary low transverse cesarean section and she was also noted to have had some late decelerations so on _%#MM#%_ _%#DD#%_, 2002, a primary low transverse cesarean section via a Pfannenstiel incision was performed for a viable male infant in OP presentation. Apgar's of 9 and 9, weight 9 pounds 9 ounces, normal uterus tubes and ovaries, cord pH of 7.28, base excess of 1.9. She did well postoperatively.
OP|oropharynx|OP|198|199|OBJECTIVE|OBJECTIVE: Temperature 98, heart rate 62, respirations 16, blood pressure 90/70, weight 59 kilos. Pleasant young woman who appears uncomfortable. HEENT - PERRL, EOMI, sclerae anicteric. TMs normal. OP is clear. NECK - supple without adenopathy. HEART - regular S1, S2, no murmurs. LUNGS - clear bilaterally. ABDOMEN - soft, there is diffuse abdominal pain right upper quadrant, worse than other quadrants.
OP|oblique presentation/occiput posterior|OP|154|155|PROCEDURE|HOSPITAL COURSE: She was admitted to Labor and Delivery, and expectantly managed. She progressed to 6 to 7 cm, 90%, and 0 station, and was found to be in OP presentation. She requested pain relief and received ITM. However, she did not progress after approximately 5 hours, and the decision was made to proceed with primary low transverse cesarean section.
OP|oropharynx|OP|181|182|PHYSICAL EXAMINATION (HLI)|PHYSICAL EXAMINATION (HLI): Blood pressure 114/78, weight 160. In general, patient is a pleasant male who is not agitated at this time and in no acute distress. HEENT, PERRL, EOMI, OP clear with moist mucous membranes, left TM clear, right TM obscured with cerumen. Neck supple. No lymphadenopathy. No thyromegaly. Carotids strong and symmetric.
OP|oropharynx|OP|199|200|PHYSICAL EXAM|GENERAL: Alert, oriented x 3. Appears to be in distress secondary to pain. HEENT: Sclerae not icteric. No lymphadenopathy. Pupils equally round and reactive to light and accommodation. NECK: Supple. OP on the dry side. CARDIOVASCULAR EXAM: S1, S2 normal. No murmurs, gallops, or rubs. LUNGS: Clear to auscultation on anterior exam.
OP|oropharynx|OP|175|176|PHYSICAL EXAM|GENERAL: Alert, oriented x 3. Appears comfortable. HEENT: Sclerae not icteric. No lymphadenopathy. Pupils equally round and reactive to light and accommodation. NECK: Supple. OP is clear. CARDIOVASCULAR EXAM: S1, S2 normal. No murmurs, gallops, or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft. Mild tenderness in epigastric area. Nondistended. Bowel sounds positive. No peritoneal signs of guarding.
OP|oblique presentation/occiput posterior|OP.|138|140|PAST MEDICAL HISTORY / FAMILY HISTORY / SURGICAL|The patient had minimal progress despite adequate contractions, so she was taken to the Operating Room for arrest of descent and probable OP. She delivered a male infant in LOP presentation with a weight of 7 pounds 13 ounces, Apgars of 9 at 1 and 9 at 5 minutes, with apparently normal tubes, uterus, and ovaries bilaterally, and an estimated blood loss of 1000 cc.
OP|oropharynx|OP|149|150|PHYSICAL EXAM|Temperature 100.5, heart rate 123, respirations 22, blood pressure 154/87, O2 saturations 94% on 2 liters nasal cannula oxygen. HEENT - PERRL, EOMI. OP - slightly dry. TMs - normal. NECK - supple, there is some firm thyroid gland midline which is nontender, no adenopathy.
OP|oblique presentation/occiput posterior|OP|111|112|HOSPITAL COURSE|Findings at the time of surgery were an 8 pound 11 ounce male infant with Apgars of 9 and 9. The infant was in OP presentation, with a nuchal cord. Estimated blood loss was 700 cc, and there were no complications. Please see the operative report for further details. Her postoperative course was overall uncomplicated.
OP|oropharynx|OP|203|204|PHYSICAL EXAM|PHYSICAL EXAM: Temperature 100.3, pulse 112, respiratory 32, blood pressure 143/78, and O2 sat 94 percent. HEENT: His sclerae are icteric. No lymphadenopathy. Pupils equally round and reactive to light. OP is clear. CARDIOVASCULAR EXAM: S1, S2 normal. No murmurs, gallops, or rubs. LUNGS: Clear to auscultation bilaterally except decreased breath sounds in the right lower lobe.
OP|oropharynx|OP|268|269|PHYSICAL EXAMINATION|Hematologic: No bleeding tendencies. PHYSICAL EXAMINATION: Temperature 98.6, blood pressure 153/49, pulse 70, respirations 18, weight is 54 kg. This is an alert and oriented woman who is very fatigued and pale appearing. She appears uncomfortable. HEENT: PERRL. EOMI. OP is moist. NECK is supple without palpable adenopathy or thyromegaly. HEART - regular S1, S2. No murmurs. LUNGS have rhonchi bilaterally with diminished breath sounds at the left base and bilateral wheezes and expiratory wheezes.
OP|oropharynx|OP|160|161|PHYSICAL EXAM|O2 sat 95 percent on room air. GENERAL: Alert and oriented, not in acute respiratory distress. HEENT: Pupils equally round and reactive to light. NECK: Supple. OP is clear. No lymphadenopathy. CARDIOVASCULAR EXAM: S1, S2 normal. No murmurs, gallops, or rubs. LUNGS: Bronchial breath, otherwise clear to auscultation.
OP|oropharynx|OP|142|143|ADMISSION PHYSICAL EXAM|Respirations 20, blood pressure 102/72, weight 227 pounds. General, patient is alert and oriented, no apparent distress. HEENT - EOMI, PERRL, OP clear. NECK -soft and supple without thyromegaly or lymphadenopathy. Conjunctivae are clear. CHEST - lungs clear to auscultation bilaterally. CARDIOVASCULAR - regular rate and rhythm, normal S1, S2, no murmur.
OP|oropharynx|OP|143|144|REVIEW OF SYSTEMS|Blood pressure 127/79, pulse 88, temperature afebrile, O2 sats 94%. General: Alert and oriented x 3. HEENT: Pupils equally round and reactive. OP is clear. No lymphadenopathy. Cardiovascular: S1, S2 normal, no murmurs, gallops or rubs. Lungs: Clear to auscultation. Abdomen: Soft, non- tender, non-distended. Bowel sounds positive.
OP|oblique presentation/occiput posterior|OP|110|111|HOSPITAL COURSE|The patient was delivered of a viable female infant (Apgars 8 and 9, weight 9 pounds 12 ounces) from a vertex OP presentation at 1932. The tubes and ovaries were normal. There was a prominent sacral promontory. Estimated blood loss in surgery was 800 cc. The patient's postoperative course was uncomplicated.
OP|oblique presentation/occiput posterior|OP|116|117|HOSPITAL COURSE|Findings were of a viable female infant, Apgars of 9 and 9 at one and five minutes, weight was 8 pound 4 ounces, in OP presentation. Estimated blood loss was 700 cc. The patient tolerated the procedure without complications. The patient remained afebrile throughout her entire hospital course. She had slow return of bowel function.
OP|oropharynx|OP|247|248|OBJECTIVE|OBJECTIVE: Temperature 98.2, heart rate 128, respirations 18, blood pressure 127/93, O2 saturations 98% on room air, weight 260. This is a pleasant young woman who appears nervous and tremulous. HEENT - PERRL, EOMI. Sclerae anicteric, TMs normal. OP is clear. NECK - supple without adenopathy or thyromegaly. HEART - tachycardiac S1, S2. LUNGS - clear to auscultation bilaterally. ABDOMEN - soft, there are good bowel sounds, there is mild mid epigastric and left and right upper quadrant tenderness.
OP|UNSURED SENSE|OP|290|291|HOSPITAL COURSE|Following surgery, the patient had an uncomplicated hospital course. An NG was in place after surgery, and this was discontinued on the third postoperative day, and the diet was advanced to sips of liquids as tolerated. On postoperative day #1, the patient's total bilirubin, ALT, AST, and OP had normalized. By the fourth postoperative day, the patient was tolerating a regular diet without any complications of nausea and vomiting.
OP|oblique presentation/occiput posterior|OP|432|433|OPERATIONS/PROCEDURES PERFORMED|OPERATIONS/PROCEDURES PERFORMED: Repeat low transverse cesarean section. HISTORY OF PRESENT ILLNESS: The patient is a 32-year-old gravida 2, para 1-0-0-1 with intrauterine pregnancy at 38 +0 weeks by last menstrual period of _%#MM#%_ _%#DD#%_, 2002, who presented to Fairview University Medical Center on _%#MM#%_ _%#DD#%_, 2003, for a repeat cesarean section. The patient has a history of cesarean section for arrest of descent in OP presentation. The patient had good fetal movements, denied any leakage of fluid or contractions. Prenatal care was through Dr. %#NAME#%_ at University Specialists. She is A positive, Rubella immune, VDRL negative, hepatitis surface antigen negative, HIV negative.
OP|oropharynx|OP|159|160|PHYSICAL EXAM|GENERAL: Alert, oriented x 3. Not in acute distress. HEENT: Sclerae not icteric. No lymphadenopathy. Pupils equally round and reactive to light. NECK: Supple. OP is clear. CARDIOVASCULAR EXAM: S1, S2 normal. No murmurs, gallops, or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft, nontender, nondistended. Bowel sounds positive.
OP|oropharynx|OP|182|183|PHYSICAL EXAMINATION|General: Well-built, well-nourished female sitting comfortably in bed. HEENT: No rashes or lesions. Head: Normocephalic and atraumatic. Pupils equal round and reactive to light. NP, OP normal. Neck: Supple, no lymphadenopathy. Cardiovascular: Regular rate and rhythm without murmurs, rubs or gallops. Lungs clear to auscultation bilaterally. Abdomen soft nontender, nondistended, bowel sounds positive.
OP|oblique presentation/occiput posterior|OP|182|183|HOSPITAL COURSE|The patient was complete at 1920 hours and required a forceps-assisted vaginal delivery. Please see operative report for details. A viable male infant was delivered at 2230 hours in OP presentation weighing 7 pounds 5 ounces. She sustained a 3rd-degree laceration which was repaired. Her EBL was 800 mL. Postoperatively the patient did well. She remained afebrile throughout her admission.
OP|oropharynx|OP|249|250|OBJECTIVE|She does not recall my visit two days ago. HEENT: She has a firm, indurated area at the left posterior occiput. No overlying laceration or drainage. She denies tenderness with palpation. Eyes: PERRL. EOMI. Ears: Normal bilaterally. Nares are clear. OP is dry. There is no posterior erythema. NECK is supple without palpable adenopathy or thyromegaly. HEART: Regular S1, S2. No murmurs. LUNGS have bibasilar crackles, which are dry, otherwise clear.
OP|oblique presentation/occiput posterior|OP|239|240|HISTORY OF PRESENT ILLNESS|On _%#MM#%_ _%#DD#%_, 2004, 2140 hours, patient underwent a primary LTCS with a Pfannenstiel skin incision with Dr. _%#NAME#%_ secondary to arrest of dilatation and nonreassuring fetal heart tones. Patient produced a viable male infant in OP position that weighed 7 pounds 1 ounce and Apgars of 8 and 9. At that time, she was found to have normal uterus, tubes and ovaries.
OP|oblique presentation/occiput posterior|OP|130|131|HOSPITAL COURSE|On _%#DDMM2004#%_, a low segment transverse cesarian section was done with delivery of a female weighing 6 pounds 3 ounces in the OP position. Apgars were 8 and 9 respectively. Postoperatively, the patient did well. She was discharged home on the fourth postoperative day.
OP|oblique presentation/occiput posterior|OP|300|301|HOSPITAL COURSE|She agreed to proceed and was consented for a primary low transverse cesarean section for arrest of dilatation. Her Pitocin was discontinued. She underwent a primary low transverse cesarean section via Pfannenstiel skin incision under spinal anesthesia, where she delivered a viable female infant in OP position with Apgars of 8 at 1 minute, 9 at 5 minutes. She sustained an 800 mL EBL. Her preoperative hemoglobin was 12.3 and postoperatively was 10.1. The infant was transferred to the NICU secondary to stridor.
OP|oblique presentation/occiput posterior|OP|148|149|ASSESSMENT|However, good variability throughout and sometimes marked accelerations. ASSESSMENT: The patient with long labor now failure to descent. Baby in an OP position. Will proceed with a primary cesarean section under regional anesthesia. Patient and husband agree with the plan and will proceed.
OP|oropharynx|OP|199|200|PHYSICAL EXAM|99% on room air. General, alert and oriented times three but appears to be slightly drowsy. HEENT - sclerae nonicteric, no lymphadenopathy. Pupils equally round and reactive to light. NECK - supple. OP - clear. There is no nystagmus noted. CARDIOVASCULAR - S1, S2 normal, no murmur, gallops or rubs. LUNGS - clear to auscultation. ABDOMEN - soft, nontender, nondistended, bowel sounds positive.
OP|oropharynx|OP:|187|189|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Stable. GENERAL: alert and oriented X3; in no acute distress. HEENT: Pupils equally round and reactive to light; pupils are about 1.5 mm. NECK: Supple. OP: Clear. CARDIOVASCULAR: S1 and S2 are normal; no murmurs, rubs, or gallops. LUNGS: Scattered crackles in both lungs. ABDOMEN: Soft, non-tender, non-distended; positive bowel sounds.
OP|oropharynx|OP|197|198|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Blood pressure 127/75, heart rate 82, respiratory rate 28, afebrile. General: The patient is a pleasant, talkative male in no acute distress. HEENT: PERRL. Conjunctiva clear. OP clear with moist mucous membranes. Neck is supple with no lymphadenopathy and no thyromegaly. Carotids strong and symmetric without bruits.
OP|oropharynx|OP|204|205|PHYSICAL EXAMINATION|GENERAL: He is resting quietly in bed, does not appear to be acutely intoxicated anymore and is in no acute distress. HEENT: Normocephalic, atraumatic. Sclerae nonicteric, extraocular muscles are intact. OP is clear. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Regular without murmurs, rubs, gallops. LUNGS: Clear bilaterally. BACK: No midline or CVA tenderness. ABDOMEN: Has a previous surgical scar that is well-healed, soft, nontender, no hepatosplenomegaly and positive bowel sounds.
OP|oropharynx|OP|206|207|PHYSICAL EXAMINATION|I am interviewing her after she received 7 nebs and her breathing is much improved, both subjectively and objectively. She is able to answer my questions in full sentences. HEENT: PERRL; conjunctiva clear; OP clear with moist mucus membranes. Neck: supple, no lymphadenopathy; no thyromegaly. Lungs: CTA bilaterally with slightly diminished breath sounds.
OP|oropharynx|OP|233|234|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 146/89, heart rate 78, respiratory rate 18, afebrile. GENERAL: The patient is a pleasant, but confused man in no acute distress. HEENT: PERRL, conjunctivae clear, sclerae nonicteric, OP with dry mucous membranes. NECK: Supple, no lymphadenopathy, no thyromegaly. LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm, no murmur. ABDOMEN: Soft, with mild epigastric and right upper quadrant tenderness to palpation, no rebound, no guarding, no hepatosplenomegaly, no mass, normoactive bowel sounds.
OP|operative|OP|132|133|HISTORY OF PRESENT ILLNESS|He presented here yesterday for right second toe incision and debridement of an abscess and ulcer with possible amputation. Per the OP note there was no amputation performed by the incision and debridement. Infectious disease has already been consulted. They do recommend Tequin and Ancef for now.
OP|oropharynx|OP|190|191|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VS: 38.6, 111, 152/76, 16, 95% RA GENERAL: Sleeping, appears stated age, most of the information came from husband, daughter, and son, NAD, resting comfortably. HEENT: OP dry, eyes closed, does not follow commands, nontender thyroid, non palpable, no LAD CHEST: + decrease BS at bases, + coarse crackles at bases.
OP|oropharynx|OP|203|204|SOCIAL HISTORY|GENERAL: Alert and oriented x 3. The patient is comfortable and not in acute respiratory distress. HEENT: Sclerae anicteric. No lymphadenopathy. Pupils equally round and reactive to light. NECK: Supple. OP is clear. CARDIOVASCULAR EXAM: S1 and S2 normal. No murmurs, gallops, or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft, nontender, and nondistended.
OP|oropharynx|OP|272|273|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 138/98; pulse 117; respiratory rate 24; temperature afebrile; O2 saturations at 97% on room air. HEENT: Sclera are not icteric, there are no lymphadenopathies. Pupils are equally round and reactive to light. NECK: Supple. OP is clear. CARDIOVASCULAR: S1, S2 are normal; no murmurs, gallops, or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft, non-tender, non-distended, bowel sounds are positive.
OP|oropharynx|OP|310|311|PE|He denies any tobacco or alcohol use. FAMILY HISTORY: noncontributory. PE: vitals reviewed I/O's reviewed - patient has been borderline oliguric since hospitalization alert, thin, evidence of malnutrition with bilateraly temporal wasting, chronicially ill appearing, in NAD non-toxic NCAT, no conj, no icterus OP clear neck supple and NT without LAD RRR +murmur no JVD appreciated CTAB +bowel sounds, distended abdomen but soft and NT, no rebound, no guarding, did not appreciate splenomegaly +edema in LE R>L neuro non-focal labs reviewed, including his admission HCT and most recent CXR on _%#MMDD#%_ renal biopsy from _%#MM#%_ _%#DD#%_, 2006 reviewed (creatinine was 2.7 at that time) - no rejection but has FSGS path from the bilateral native nephrectomy reviewed, and it appears that only the right adrenal gland was removed as the left adrenal gland was not noted on the report A/P: 62 year old male with a very complicated medical history, who is s/p LDKT 1996.
OP|oropharynx|OP|158|159|PHYSICAL EXAM|GENERAL: Alert, appears dyspneic. HEENT: Sclerae not icteric. No lymphadenopathy. Pupils equally round and reactive to light and accommodation. NECK: Supple. OP is clear. CARDIOVASCULAR EXAM: S1, S2 normal. No murmurs, gallops, or rubs. LUNGS: Bibasilar crackles. ABDOMEN: Soft, distended, nontender. The patient has appreciable fluid wave.
OP|oblique presentation/occiput posterior|OP|129|130|PAST SURGICAL HISTORY|PAST MEDICAL HISTORY: Non-contributory. PAST SURGICAL HISTORY: Cesarean section in _%#MM2004#%_, for arrest of dilation at 5 cm, OP presentation. Appendectomy in 1984 and dilation and curettage in 2002. ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: Prenatal vitamin daily. SOCIAL HISTORY: Married, no alcohol, tobacco, or drug use.
OP|oropharynx|OP|215|216|PHYSICAL EXAMINATION|MEDICATIONS: Reviewed. ALLERGIES: Reviewed. FAMILY HISTORY: Reviewed and unchanged. SOCIAL HISTORY: No current tobacco use. PHYSICAL EXAMINATION: VITAL SIGNS: Reviewed and stable. GENERAL: No acute distress. HEENT: OP clear. NECK: Supple. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: No crackles. ABDOMEN: Soft, non-tender. No graft tenderness or signs of infection.
OP|oropharynx|OP|223|224|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: A 10-point review was completed. Pertinant + as above. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 36.6, 84, (148/88) 97% on RA, RR ? 20 GENERAL: Alert and Oriented X 3, NAD, appears stated age HEENT: OP clean, poor dentition, no TM, no LAD LUNGS: decrease BS at bases, + ronchi CARDIOVASCULAR: RRR, no rubs, no gallops ABDOMEN: Soft NT/ND, +BS, + scars consistent with surgeries EXTREMITIES: no cyanosis/clubbing, edema NEUROLOGIC: grossly intact.
OP|operative|OP|154|155|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 53-year-old female who had a left total knee arthroplasty today for advanced DJD. According to the OP note, there was about 75 cc of blood loss and she was given 2.9 liters of lactated Ringer's. Her intraoperative blood pressure started around 120 and did dip to around 95 towards the end of the operation.
OP|oropharynx|OP|153|154|PHYSICAL EXAMINATION|The patient appears comfortable. HEENT: Scattered icteric, no lymphadenopathy. Pupils are equal and reactive to light and accommodation. Neck is supple. OP is slightly dry. Cardiovascular: S1, S2, normal, without ectopic beat. No murmur, gallops, or rubs. Lungs: Clear to auscultation bilaterally.
OP|operative|OP|314|315|IMPRESSION|This patient presently does not appear to have acute small bowel obstruction or any signs of bowel ischemia, however, she does continue with symptomatic ventral hernia that will be complicated at best given her multiple previous surgeries and probable placement of mesh from previous surgery. I cannot locate that OP report but is suspect that mesh was used. She also has a Mitrofanoff at the umbilicus and that will also make surgery difficult.
OP|oropharynx|OP|170|171|SOCIAL HISTORY|The patient is in mild discomfort as a result of pain. HEENT: Sclerae are nonicteric. No lymphadenopathy. Pupils are equally round and reactive to light. Neck is supple. OP is clear. Cardiovascular exam: S1, S2 normal. No murmur, gallops, or rubs. Lungs: Clear to auscultation. Abdomen: Soft, nontender, nondistended.
OP|operative|OP|196|197|HISTORY OF PRESENT ILLNESS|However, because of an MRI on _%#DDMM2006#%_, which showed some enlargement of 2 lymph node areas along the right iliac chain, Dr. _%#NAME#%_ performed a laparoscopic lymph node sampling. Per the OP note there was some fibrotic tissue along the right side and frozen section from 1 of these areas was positive. In total, the patient had 60 lymph nodes removed, 5 of which were positive for involvement of carcinoma.
OP|oropharynx|OP|193|194|PHYSICAL EXAMINATION|16. She is afebrile and her weight is 261 pounds. GENERAL: The patient is a pleasant, obese female lying in bed in the middle of the day. HEENT: Hair is dyed yellow; PERRL, conjunctivae clear; OP with moist mucous membranes. NECK: Supple; no lymphadenopathy, no thyromegaly. LUNGS: CTA bilaterally. HEART: RRR, no murmur. ABDOMEN: Obese; soft; nontender. EXTREMITIES: Bilateral lower extremities without edema.
OP|operative|OP|289|290|HISTORY OF PRESENT ILLNESS|17. History left elbow debridement. HISTORY OF PRESENT ILLNESS: 80-year-old woman known to the hospitalist department for her multiple medical admissions who underwent lumbar surgery today. Estimated blood loss was 400 cc. There is no complications noted. Please refer to Dr. _%#NAME#%_'s OP note for specific details. The patient's main complaint currently is lumbar pain in the surgical site.
OP|oropharynx|OP|201|202|PHYSICAL EXAMINATION|GENERAL: The patient looks tired and drowsy, and appears not to be in respiratory distress. HEENT: Sclera are not icteric, no lymphadenopathy. Pupils are equal, round, reactive to light. NECK: Supple. OP is clear. CARDIOVASCULAR: S1, S2 are normal, grade 2/6 systolic ejection murmur heard in the right second intercostal space that radiates along the left lower sternal border.
OP|ophthalmic|OP|115|116|MEDICATIONS|7. Zanaflex 4 mg p.o. q.i.d. 8. Lyrica 50 mg p.o. 1-2 tablets b.i.d. 9. Allegra 60 mg p.o. b.i.d. 10. Patanol 0.1% OP b.i.d. 11. Nasonex 1 squirt each nostril b.i.d. 12. Decadron taper, started _%#MM#%_ _%#DD#%_ ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient states he drinks alcohol occasionally. He denies any tobacco or drug use.
OP|oropharynx|OP|318|319|PE|SOCIAL HISTORY: The patient is married. He has 2 children. He denies tobacco or alcohol use. PE: vitals reviewed he has been afebrile since being transferred here overnight he is making good amounts of urine in general, he appears chronically ill and weak however he was in no acute distress NCAT, no conj, no icterus OP clear neck supple and NT RRR no murmurs slight bibasilar crackles but non-labored breathing, no wheezing +bowel sounds, soft, NT, ND, no rebound, no guarding +edema in LE but much improved since his last admission CXR and CT scans reviewed stool studies all sent and are pending at this time UA was not suggestive of UTI, although UC pending sodium 132, potassium 5.7, chloride 112, bicarb 14, BUN 53, creatinine 2.95 (baseline before rejection episode was 2.5) calcium 7.7, magnesium 1.6, phosphorus 6.0 WBC 7.3, Hgb 9.6, Plt 111 tacrolimus 15 CMV pending A/P: 60 year old male s/p kidney transplant with recent IIB rejection that has responded with Thymo.
OP|UNSURED SENSE|OP|240|241|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|PROCEDURES PERFORMED: Revision right subtalar fusion. HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 43-year-old female who had previously undergone a right subtalar fusion. The patient had revision of this with OP 1 used as well. The patient was on significant amount of pain medication prior to admission to the hospital. This was her main issue during the hospital course. She was getting her pain out of control.
OP|operative|OP|164|165|PAST MEDICAL HISTORY|Associated anorexia. Obstipation not noted, however, patient admits that he has not had much flatus. PAST MEDICAL HISTORY: As noted above. Please refer to previous OP reports and Admission notes. MEDICATION: List is long and will refer to the chart.
OP|oropharynx|OP|231|232|ALL|5. Methylprednisone 50mg po bid 6. Metoprolol 50mg po bid 7. Dilantin 250mg qday ALL: NKDA PExam: VS-37.1, 78, 146/51, 24, 98% on RA Very cachectic female, laying in bed, does not track, does not respond to stimulus, warm to touch OP clear, no LAD, dry MM, no TM appreciated, nontender Neck no goiter RRR no rubs, no gallops CTAB (anterior exam), no rales, no ronchi Schaphoid abdomen, no organomegaly, + BS, G-tube in place No cyanosis, clubbing, edema, warm to touch, moist.
OP|oropharynx|OP|172|173|PHYSICAL EXAMINATION|GENERAL: She is sleepy but arouses and is appropriate once awake. HEENT: Normocephalic, atraumatic. Extraocular muscles are intact. Pupils are equal and reactive to light. OP is clear. TMs are not examined. NECK: Supple without lymphadenopathy or thyromegaly. HEART: Regular without murmurs, rubs, gallops. BREASTS: Not examined. LUNGS: Clear bilaterally.
OP|operative|OP|123|124|PLAN|PLAN: 1. Will follow up on the preop labs that will be ordered as part of routine protocol. 2. Will try to obtain previous OP reports from the patient's previous surgeries. 3. Will follow. Thank you for the consultation
OP|oropharynx|OP|417|418|HEENT|8) Gastritis, hiatial hernia 9) s/p choley 10) h/o ankle fracture FH/SH: No thyroid, +HTN, no CAD, + smoke (quit 3 months ago) no OH, Medications: ASA Coreg Celexa Digoxin MVI KCL Coumadin Wellbutrin Ambien Lasix Aldactone Milrinone Ferrous Sulfate ALL: Heparin Morphine Sotalol Keflex Physical Exam: VS ? 80s-90s. BP range (90s-100/60-70s) General: awake, appears stated age, resting comfortably in bed flat. HEENT: OP clear, MMM, poor dentition, no TM, no nodules CV: distant HS, no rubs, no gallops Pulmonary: + crackles lower lung fields, no wheezing Abdomen: soft NT/ND, + BS Extremities: cool, trace peripheral edema, no ulcers lesions Neuro: DTR 2/4 bilateral, symmetrical Labs: _%#DDMM2007#%_ TSH- 8.28 fT4- 1.11 T3- 94 _%#DDMM2007#%_ TSH - 11.79 fT4 - 1.14 T3 - 84 A/Plan: Ms. _%#NAME#%_ is a 20yo female with HCOM (EF < 25%).
OP|operative|OP|191|192|HISTORY|Subsequent to that she was on Augmentin with the main pathogen growing being Staph aureus. She had not had fevers, chills, sweats or other signs of infection at that time. In reviewing those OP reports there is no mention of any mesh and the wound did track all the way down to the psoas area but did not appear to have gone deeper or down to where the hardware is There was not obvious intra-abdominal infection seen either.
OP|oropharynx|OP|203|204|PHYSICAL EXAMINATION|General: Alert and oriented x 3, and appears comfortable. HEENT: Sclerae are anicteric. There is no lymphadenopathy. Pupils are equal, round, and reactive to light and accommodation. The neck is supple. OP is clear. Cardiovascular examination: S1, S2 normal, no murmurs, rubs, or gallops. Lungs are clear to auscultation. Abdomen: soft, slightly distended, mildly tender throughout.
OP|operative|OP|206|207|HISTORY OF PRESENT ILLNESS|The patient was referred to Dr. _%#NAME#%_. It was recommended the patient have a hemilaminectomy L4-5 with a microdiskectomy. This was accomplished earlier this morning and was without complication as per OP note, estimated blood loss was less than 25 cc and the patient did well. Currently, the patient states that he is having no pain.
OP|oropharynx|OP|256|257|PE|No tuberculosis. 2 sons, both healthy, ages 15 & 10. SH: no EtOH PE: vitals reviewed I/O's reviewed - patient oliguric since admission although urine output appears to be increasing alert, appears dyspnic, somewhat toxic NCAT, no conjunctivitis, jaundiced OP clear neck supple and NT without LAD RRR diminished breath sounds at the bases, otherwise clear decreased bowel sounds, incision site C/D/I trace edema in LE neuro exam non-focal labs, imaging studies, cultures since admission reviewed A/P: 48 year old male with acute kidney injury likely multifactorial - elevated Prograf level, suspect hypotensive/septic episode at home given ERCP findings, and dehydration.
OP|oropharynx|OP|820|821|PE|PMH: 1. ESKD secondary to congenital renal agenesis, this was discovered when he had an accident in 2004 and was found to have an elevated creatinine, he apparently had only his right kidney, s/p LDKT _%#MM2007#%_ without a complicated post-operative course, no rejection episodes, but for the past few months has been running a low Prograf level 2. history of HD from _%#MM2007#%_-_%#MM2007#%_ 3. history of MVA in 2004 Current Medications: Prograf 2.5 mg bid MMF 500 mg bid sodium bicarbonate amlodipine 5 mg bid metoprolol 50 mg bid Protonix Calcium with vitamin D Bactrim Allergies: IVP dye needs prophylaxis SH: he is college student at UND denies smoking, EtOH abuse, and recreational drug use FH: non-contributory to this admission PE: vitals reviewed alert, pleasant, non-toxic, in NAD NCAT, no conj, no icterus OP clear neck supple and NT RRR no murmurs CTAB no crackles abdomen soft and NT, no rebound, no guarding, allograft non-tender no edema in LE neuro grossly non-focal today's labs reviewed, including CBC and coags creatinine 2.5 (per patient was 2.6 yesterday) A/P: 18 year old male s/p LDKT _%#MM2007#%_ with evidence of rejection on biopsy _%#MMDD#%_.
OP|UNSURED SENSE|OP|131|132|PROCEDURES PERFORMED|8. Right heart catheterization _%#DDMM2007#%_: Elevated RA, PA, and PA OP pressures (RA mean 7 mmHg, PA 49/19 and mean 29 mmHg, PA OP mean 23 mmHg). PA OP shows elevated V wave. Cardiac output performed by Fick and thermodilution methods are low (Fick cardiac output 3.6, thermodilution cardiac output 3.3).
OP|oropharynx|OP|180|181|PHYSICAL EXAMINATION|HEAD: Normocephalic and atraumatic. EYES: Icteric bilaterally. Extraocular movements were intact. Eyes were PERRL. NOSE, MOUTH AND THROAT: Poor dentition but no lesions. Otherwise OP was clear. NECK: She did have a positive JVD up to her jawline. No lymphadenopathy. Neck was supple. CARDIOVASCULAR: Regular rate and rhythm during my exam.
OP|occiput posterior|(OP)|270|273|BRIEF HISTORY|The pregnancy was dated by an early ultrasound. Her pregnancy was complicated by advanced maternal age and a previous low-segment C-section. The C-section was performed in 2002 for a failed induction and arrest of cervical dilatation at 9.0-cm, direct occiput posterior (OP) fetal position. The patient also had pregnancy-induced hypertension (PIH) and was treated with magnesium sulfate during that labor. That pregnancy was cmoiplicated also by preterm labor. She subsequently conceived, she progressed to term, and she had preterm uterine activity during this pregnancy which was treated with decreased activity.
OP|oropharynx|OP|192|193|PHYSICAL EXAMINATION ON ADMISSION|GENERAL: Alert. HEENT: Head: Normocephalic and atraumatic. Eyes: No icterus or conjunctivitis noted. Neck: Supple with full range of motion. Nose/mouth/throat: Mucous membranes are moist with OP clear. CARDIOVASCULAR: Regular rate and rhythm without murmur. RESPIRATORY: Lungs are clear to auscultation bilaterally without wheeze, crackles or rales.
OP|oropharynx|OP|227|228|ABDOMEN|She is slightly lethargic. HEENT: Normocephalic and atraumatic. Eyes: Positive for scleral icterus. Pupils are equal, round, reactive to light. Extraocular movements are intact. The patient's mucous membranes are tachy without OP erythema. NECK: No lymphadenopathy or thyromegaly. CARDIOVASCULAR: Regular rate and rhythm, S1, S2. Systolic ejection murmur best heard at the left upper sternal border.
OP|oropharynx|OP|191|192|PHYSICAL EXAMINATION|General: Positive diaphoresis, positive facial fullness, positive strained voice, no apparent distress. Eyes: Pupils equal, round, and reactive to light. Extraocular movements intact. Mouth: OP clear with no erythema or exudates. Neck: Anterior fullness, no pain with palpation. Lungs: Markedly decreased breath sounds in the right lower lobe, no wheezes, rales, or rhonchi.
OP|oropharynx|OP|145|146|PHYSICAL EXAMINATION|HEAD: Normocephalic and atraumatic, alopecia. EYES: Pupils are equal, round and reactive to light. Sclerae anicteric, conjunctivae clear. MOUTH: OP clear without lesions. HEART: Regular rate and rhythm without murmurs, gallops or rubs. LUNGS: Clear to auscultation bilaterally without adventitious sounds. ABDOMEN: Bowel sounds are present throughout.
OP|operative|OP|247|248|COMPLICATIONS|The risks include bleeding, infection, and injury to organs including but not limited to blood vessels, nerves, bowel and bladder. We chose to proceed with surgery. The patient will undergo bowel prep for surgery on _%#MM#%_ _%#DD#%_, 2004. BRIEF OP NOTE: Date of procedure _%#MM#%_ _%#DD#%_, 2004. PREOP DIAGNOSIS: Stage IIIC primary peritoneal carcinoma status post 4 cycles of chemotherapy.
OP|oblique presentation/occiput posterior|OP|126|127|ISCHARGE MEDICATIONS|There was a rapid return to baseline in between. The mother pushed for approximately 1 hour 45 minutes. The infant was in the OP position at the time of delivery. After 2 hours 15 minutes of pushing, a discussion occurred with the family about vacuum assistance.
OP|oropharynx|OP|207|208|PHYSICAL EXAMINATION|He is nontoxic. Head: Normocephalic, atraumatic. Eyes: PERRLA, EOMI, slightly injected conjunctivae. Dark circles under eyes. Ears: Clear bilaterally. Nose: Clear. Mouth and throat have dry mucus membranes. OP is clear. Neck supple and full with no lymphadenopathy. Lungs clear to auscultation bilaterally. Cardiovascular regular rate and rhythm with normal S1 and S2, no murmurs.
OP|oropharynx|OP|153|154|PHYSICAL EXAMINATION|VITAL SIGNS: Stable. SKIN: Very pale with normal temperature, sweaty back, cool hands and feet, and normal texture without any peripheral striae. HEENT: OP is clear. Oral mucosa are moist. The fundi were normal on the left on limited non-dilated examination and right fundus was less well visualized.
OP|oropharynx|OP|192|193|ADMISSION PHYSICAL EXAMINATION|HEAD: Normocephalic, atraumatic. EARS: Some erythema, scant fluid behind the right TM. EYES: Extraocular movements intact. Pupils equal, round, and reactive to light. NOSE, MOUTH, THROAT: Her OP was clear with no erythema, and her mucous membranes were moist. NECK: Supple without lymphadenopathy or thyromegaly. CARDIOVASCULAR: Her heart had a regular rate and rhythm without murmur.
OP|oropharynx|OP|178|179|PHYSICAL EXAMINATION|HEAD: Normocephalic and atraumatic with thinned hair. EARS: Deferred. EYES: Pupils are equal, round and reactive to light. Sclerae are anicteric. Extraocular muscles are intact. OP is clear, slightly erythematous. THROAT: Bilaterally, slightly poor dentition, no postnasal drainage. NECK: No bruits, no lymphadenopathy, no thyromegaly.
OP|oropharynx|OP.|241|243|PHYSICAL EXAMINATION|O2 sat 99 percent on 3 liters. PHYSICAL EXAMINATION: GENERAL: The patient is alert, oriented, pleasant with limited English, in no acute distress. She was able to complete sentences, does not appear breathless. HEENT: Normal sclerae, normal OP. NECK: Normal JVP without bounding carotid pulse. No thyromegaly. No lymphadenopathy. LUNGS: Diffuse wheezes with prolonged expiration, decreased air movement, trace crackles at the right base.
OP|oropharynx|OP|156|157|PHYSICAL EXAMINATION|HEENT: Head is normocephalic. Eyes are PERRLA, EOMI bilaterally with no scleral conjunctival injections. Ears are atraumatic, no drainage. Nasal is normal. OP is normal. NECK: Supple; there is no lymphadenopathy or thyromegaly or masses. SKIN: No rashes, lesions, or ulcerations. She does have multiple moles on the trunk and extremities.
OP|oropharynx|OP:|138|140|REVIEW OF SYSTEMS|The patient looks in no acute distress. She is cachectic; however, she is lying in bed on her side and was in distress secondary to pain. OP: No thrush. Neck: Without any adenopathy. Cardiovascular: Regular irregular rhythm, a 2/6 systolic ejection murmur at the right upper sternal border.
OP|oropharynx|OP|153|154|PHYSICAL EXAMINATION|HEENT: Head is normocephalic and atraumatic. Eyes, pupils are equal, round and reactive to light. Extraocular muscles are intact. Sclerae are anicteric. OP is moist with no lesions, has multiple fillings. NECK: Supple, no bruits, no palpable lymphadenopathy. Scar on left neck status post biopsy is well healed but contains a firm mask.
OP|oropharynx|OP|227|228|OBJECTIVE|HEENT: She has some fluttering eye movements and some evidence of eyes rolling backwards in her head but she is able to follow commands to look at my hand in all of her visual fields, therefore, extraocular muscles are intact. OP is clear. Tongue is midline. NECK: Supple. There is no adenopathy or thyromegaly. HEART: Regular S1, S2, no murmurs. LUNGS: Clear to auscultation bilaterally.
OP|oropharynx|OP:|214|216|PHYSICAL EXAMINATION|GENERAL: Middle aged small white male pleasant, resting comfortably in bed, and in no apparent distress. HEAD: Normocephalic and atraumatic. EYES: PERRLA, extraocular muscles intact, conjunctiva/sclarea are clear. OP: Mucous membranes are moist. OP is clear. No lesions. NECK: The patient does have JVD to the level of the jaw (estimate right atrial pressure to be right at 20).
OP|oropharynx|OP|191|192|ADMISSION PHYSICAL EXAMINATION|His fontanelle was flat. His eyes showed pupils equal and reactive to light with extraocular motion intact. Ears, tympanic membranes were intact bilaterally. Nose, mouth and throat exam, his OP and NP were clear, mildly tacky. NECK: Supple without lymphadenopathy. CARDIOVASCULAR: Regular rhythm with normal S1 and S2, 2-3/6 systolic murmur was heard best at the left vertebral sternal border.
OP|oropharynx|OP|203|204|PHYSICAL EXAMINATION|HEAD: Normocephalic, atraumatic. EYES: Pupils equal, round, react to light. Extraocular movements were intact. Conjunctivae and sclerae are clear without lesions. OROPHARYNX: Mucous membranes are moist. OP is clear without lesions. NECK: The patient does have JVD with hepatojugular reflux measured at approximately 18-20 cm of water, estimating a right atrial pressure of roughly 20.
OP|oropharynx|OP|207|208|ADMISSION PHYSICAL EXAMINATION|GENERAL: The patient is articulate, awake, alert, appears mildly anxious, but in no acute distress. SKIN: Jaundice, few spider angiomas and multiple cherry hemangiomas. HEENT: Scleral icterus, PERRLA, EOMI, OP clear. LUNGS: Clear, rare faint wheezes. CARDIOVASCULAR: Tachycardic, irregular. No rubs, murmurs or gallops. ABDOMEN: Distended, but soft. Bowel sounds present, positive hepatomegaly and splenomegaly.
OP|oropharynx|OP|259|260|PHYSICAL EXAMINATION|The remainder of her review of systems is unremarkable. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature of 96.3, pulse of 81 and blood pressure 119/63. GENERAL: No apparent distress, alert and oriented. HEENT: Normocephalic with alopecia, PERRLA, EOMs intact, OP is moist without lesions. NECK: Supple without any cervical adenopathy. CARDIOVASCULAR: Regular rate and rhythm with no murmur, rub or gallop. LUNGS: Clear to auscultation bilaterally without any adventitious breath sounds.
OP|oropharynx|OP|130|131|PHYSICAL EXAMINATION|HEENT: Head is normocephalic and atraumatic. Eyes: Pupils are equal, round and reactive to light. EOMI. Sclerae anicteric. Mouth: OP clear, no lesions. NECK: No adenopathy. CARDIOVASCULAR: Regular rate and rhythm with normal S1 and S2 without murmur. LUNGS: Clear to auscultation bilaterally without wheeze. ABDOMEN: Good bowel sounds throughout.
OP|oropharynx|OP.|218|220|PHYSICAL EXAM|PHYSICAL EXAM: General, patient appears ill, moaning, slightly confused at times though is able to answer simple questions appropriately, complaining of vague lower abdominal discomfort. HEENT - normal sclerae, normal OP. NECK - normal JVP. LUNGS - essentially clear to auscultation bilaterally, possibly decreased breath sounds at the bases. CV - regular rate and rhythm, no rubs, gallops, murmurs, tachycardiac.
OP|ophthalmic|OP|163|164|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1. Aspirin 81 mg daily. 2. Unclear if she is on Keflex. 3. She is on Macrobid, dosing is unclear 4. Metoprolol 12.5 mg b.i.d. 5. Patanol 0.1% OP solution 2 drops in each eye b.i.d. p.r.n. 6. Lasix 20 mg daily. 7. Synthroid 100 mcg daily. 8. Digoxin 125 mcg p.o. daily. REVIEW OF SYSTEMS: CARDIOVASCULAR: See HPI.
OP|operative|OP|325|326|PLAN|IMPRESSION: This is a 58-year-old gentleman who had an initial T2 N0 squamous cell carcinoma of his right tongue status post surgery to the primary and a right modified radical neck dissection, who we believe now has a recurrence. PLAN: We are going to obtain a postoperative diagnostic CT scan. From Dr. _%#NAME#%_ surgical OP note, he states that he was "unable to identify the parapharyngeal space mass." We need to assess what disease is left in his neck at this time before we proceed with radiation therapy.
OP|oropharynx|OP|276|277|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: Somali male not in apparent distress, sitting up on bed, awake, alert, responsive. Did not seem confused, answered questions appropriately. Cachectic appearing. HEENT: Normocephalic, atraumatic. PERRL; extraocular movement intact. Mild icterus. OP clear. Poor dentition, multiple missing teeth. Otherwise OP clear. NECK: No lymphadenopathy. Supple. LUNGS: Clear to auscultation bilaterally.
OP|operative|OP|219|220|HOSPITAL COURSE|PAST SURGICAL HISTORY: C5-C6 fusion, tonsillectomy, appendectomy and cholecystectomy. HOSPITAL COURSE: The patient went to the operating room early morning on _%#DDMM2007#%_ with Dr. _%#NAME#%_. Please see his detailed OP note for further information intraoperatively. This surgery was uneventful. Postoperatively, the patient did well. His pain was well controlled. Zofran was administered for his nausea. The patient remained hemodynamically stable.
OP|operative|OP|138|139|IMPRESSION|However, CT scan with findings as noted above, certainly have to suspect metastatic ovarian cancer recurrence. I do not have her previous OP report nor her previous staging but I suspect it was advanced. At this point, given her significant improvement and no signs of any sort of bowel compromise I would suggest continue conservative therapy to include n.p.o. status today and if she continues to improve, we could try her on fluids tomorrow.
OR|operating room|OR|121|122|DISCHARGE AND POSTOPERATIVE DIAGNOSIS|DISCHARGE AND POSTOPERATIVE DIAGNOSIS: Osteoarthritis of the left hip. On _%#DDMM2006#%_, the patient was brought to the OR where she underwent general anesthetic, the patient tolerated this well. The patient then underwent a left total hip arthroplasty utilizing the two-incision technique.
OR|operating room|OR|243|244|HOSPITAL COURSE|HOSPITAL COURSE: After explanation of the risks, benefits and alternatives to surgical treatment, Mr. _%#NAME#%_ elected to undergo an open duodenal switch with Dr. _%#NAME#%_. After informed consent was obtained, the patient was taken to the OR and underwent the above-mentioned procedure without any complications. The patient on postop day 0 was transferred to the floor in stable condition and was maintained n.p.o. with NG tube in place until return of bowel function.
OR|operating room|OR|160|161|HOSPITAL COURSE|So, CT of abdomen was done for her, which showed inflamed appendix with a white count elevation and spiking fever up to 100.8. So, the patient was taken to the OR immediately by Dr. _%#NAME#%_ and had an appendectomy. The patient had generalized peritonitis with an appendix rupture that was identified in the OR.
OR|operating room|OR|120|121|HOSPITAL COURSE|Her admission WBC was 7.4 and her temperature spiked that night at 101.9. Sed rate on admission was 81. She went to the OR the next morning, on _%#DDMM2007#%_, and underwent an irrigation and debridement of the low back wound, by Dr. _%#NAME#%_. Postoperatively, she had been doing well, she was on bed rest for a couple of days, her pain was minimal and she was doing well.
OR|operating room|OR|147|148|PROBLEMS ADDRESSED DURING TRANSITIONAL CARE STAY|He was admitted for paracentesis on _%#DDMM2006#%_. Fortunately, the patient's liver transplant became available at that time. He was taken to the OR and underwent simultaneous liver and kidney transplant on _%#DDMM2006#%_. Postoperatively, he had difficulty with pain. He has a history previously of narcotic dependence, worsening pain led to a repeat CT scan on _%#DDMM2006#%_, which showed some thickened bowel in mesentry.
OR|operating room|OR|220|221|PROCEDURES PERFORMED DURING THIS HOSPITALIZATION|After extensive workup and evaluation, it was deemed the patient was appropriate for surgical intervention for her obesity. So, on _%#DDMM2006#%_, after obtaining written and verbal consent, the patient was taken to the OR (see specific operative note for details). Following the patient's postoperative course, the patient was admitted to 7-beta.
OR|operating room|OR|168|169|REASON  FOR ADMISSION AND HOSPITAL COURSE|1. A 77-year-old woman who has a history of COPD and is oxygen dependent, fell and injured her right hip. She sustained a right femoral neck fracture, was taken to the OR by Dr. _%#NAME#%_ and had a right hemiarthroplasty. After the surgery, she had trouble keeping her oxygen saturation in the normal range despite high flow oxygen, so she was transferred to the Intensive Care Unit and was treated with frequent nebulizer, BiPAP and had a blood transfusion for postoperative anemia.
OR|operating room|OR|186|187|HOSPITAL COURSE|Two 15 round Jackson-Pratt drains were placed intraoperatively in addition to insertion of jejunostomy feeding tube. The patient tolerated the procedure well and was discharged from the OR in stable condition. The patient was then admitted to station 73 where she remained for the duration of her hospital stay.
OR|operating room|OR|223|224|ADMISSION DIAGNOSIS|HOSPITAL COURSE: On _%#MM#%_ _%#DD#%_, 2004, the patient was taken to the OR for an elective Nissen fundoplication and reduction of paraesophageal hernia. Patient tolerated the OR course without complication. Following the OR course, the patient had his first day in the post-anesthesia care unit followed by admit to 6D for the remainder of her hospitalization.
OR|operating room|OR|282|283|HISTORY OF PRESENT ILLNESS|After hospitalization, she returned to the clinic, with drainage from her neck incision, increased erythema, pain, and profuse foul purulent drainage. She was examined in the clinic. The purulent foul-smelling fluid was removed, and a brief incised and drained was scheduled in the OR for the same day on an emergent basis in attempt to save the pectoralis flap. HOSPITAL COURSE: Ms. _%#NAME#%_ was taken to the operating room on the same day she was seen in clinica, and was found to have a grossly- infected and necrotic pectoralis flap with surrounding soft tissue very foul-smelling, anaerobic infection.
OR|operating room|OR|207|208|HOSPITAL COURSE|LABORATORY: His laboratories on admission showed an INR of 1.42, sodium 138, potassium 5.0, chloride 103, bicarbonate 29, BUN 41, creatinine 2.3. HOSPITAL COURSE: 1. Airway stenosis. The patient went to the OR on _%#MM#%_ _%#DD#%_, 2004, for a left main airway stenosis. A balloon dilatation and stent placement in the left mainstem airway was performed by Dr. _%#NAME#%_ _%#NAME#%_, Dr. _%#NAME#%_ _%#NAME#%_, and Dr. _%#NAME#%_ _%#NAME#%_.
OR|operating room|OR|153|154|SUMMARY OF HOSPITAL COURSE|The patient was admitted to Fairview University Medical Center electively on _%#MM#%_ _%#DD#%_, 2005. She underwent the above-mentioned procedure in the OR under general anesthesia without any significant complications. The patient subsequently was transferred to the floor for continuation of care. The patient remained stable throughout her hospital stay and was able to tolerate adequate p.o. intake.
OR|operating room|OR|208|209|PAST SURGICAL HISTORY|9. Atrial fibrillation - status post ablation. PAST SURGICAL HISTORY: Status post orthotopic heart transplant performed in _%#MM2000#%_. HOSPITAL COURSE: The patient was admitted in stable condition into the OR on _%#MM#%_ _%#DD#%_, 2004, for living related donor kidney transplant, done to the left iliac vessels. Postoperatively he developed an episode of supraventricular tachycardia, which was believed to be secondary to rapid fluid shift changes postoperatively.
OR|operating room|OR|198|199|HOSPITAL COURSE|The patient was admitted to the hospital service for further care with Orthopedic consultation. HOSPITAL COURSE: 1. Left hip fracture: Orthopedics was consulted. Dr. _%#NAME#%_ took the patient the OR for insertion of bipolar prosthesis. The patient had uneventful perioperative course. She worked with PT and OT. She was able to bear weight by discharge. She is being discharged to a transitional care unit for further physical therapy prior to being discharged back to home.
OR|operating room|OR|278|279|HOSPITAL COURSE|The patient is in no acute distress, but continues to have an audible fistula on auscultation on the right side to which Dr. _%#NAME#%_ has done daily dressing changes in the OR with fibrin glue application to the flexible bronchoscopy. Again, the patient was taken back to the OR for this procedure on _%#DDMM2006#%_, _%#DDMM2006#%_, _%#DDMM2006#%_, _%#DDMM2006#%_, _%#DDMM2006#%_ and _%#DDMM2006#%_. The patient was ambulating and having daily bowel movements and stable.
OR|operating room|OR|332|333|* FEN|Discharge medications, treatments and special equipment: * Reglan 0.5mg oral every 6 hours * Zantac 7.5mg oral every 12 hours * Nystatin 50,000 units oral every 6 hours * Miconazole ointment to perineal area every 3 hours as needed Discharge measurements and exam: Weight 3220 gm, length 52 cm, OFC 35 cm. Physical exam was normal. OR Physical exam was normal except for (describe abnormalities). Follow-up appointments: The parents were asked to make an appointment for _%#NAME#%_ to see you within one week.
OR|operating room|OR|151|152|HOSPITAL COURSE|The patient was seen by urology and it was felt that his stone ablation should take place during his hospitalization. He underwent the ablation in the OR on _%#MM#%_ _%#DD#%_, 2006. Please see the operative report for full details regarding this. The patient tolerated the procedure well. He did have it done under spinal anesthesia and had no obvious complications from this.
OR|operating room|OR|205|206|HOSPITAL COURSE|She completed a 7-day course of these antibiotics and defervesced quickly once starting the antibiotics. Her blood cultures and urine cultures all remained no growth to date. An abdominal culture from the OR grew out mixed intestinal flora. Problem #5: GI. As described above, she was watched on the floor for the day and her abdominal exam worsened, and she was then taken to the OR where they found a perforated appendix with a fecalith.
OR|operating room|OR|130|131|HISTORY OF PRESENT ILLNESS|The PDA was dilated but was too small to stent and the patient was sent to surgery for LAD bypass. The patient was brought to the OR for coronary artery bypass grafting X2. PAST MEDICAL HISTORY: Please see HPI. PAST SURGICAL HISTORY: Please see HPI.
OR|operating room|OR|267|268|HOSPITAL COURSE|All of her questions were answered satisfactorily in the preoperative period as well after the risks, benefits and alternatives to surgery were explained in detail by Dr. _%#NAME#%_. HOSPITAL COURSE: After obtaining consent for surgery, Ms. _%#NAME#%_ was brought to OR on _%#DDMM2002#%_ where a right sided cochlear implantation with facial nerve monitoring was performed by Dr. _%#NAME#%_. The patient tolerated the procedure well and there were no complications noted.
OR|operating room|(OR|199|201|DISCHARGE MEDICATIONS|12. Zetia 10 mg p.o. q. day. The patient is also discharged with the following instructions to see Dr. _%#NAME#%_ in hematology oncology clinic in 2 weeks, Dr. _%#NAME#%_ in 2 weeks for bronchoscopy (OR visit). The patient will be contacted once the OR time is established. Once again, the patient has had multiple trips to the OR for rigid bronchoscopy, has undergone with YAG laser treatment and multiple debulking procedures.
OR|operating room|OR|163|164|DOB|She is unclear whether the patient has had myocardial infarction in the past. She is DNR/DNI according to the nursing home form. Patient is scheduled to go to the OR for an ORIF of the right hip at 4:00 p.m. SOCIAL HISTORY: Patient is currently a resident at _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_.
OR|operating room|OR|207|208|PREOPERATIVE AND ADMITTING DIAGNOSIS|PREOPERATIVE AND ADMITTING DIAGNOSIS: Osteoarthritis of the right hip. POSTOPERATIVE AND DISCHARGE DIAGNOSIS: Osteoarthritis of right hip. OPERATIVE PROCEDURE: The patient on _%#MM2005#%_, is brought to the OR where she underwent a spinal anesthesia without complication. She underwent a right total hip arthroplasty utilizing the two-incision technique.
OR|operating room|OR|123|124|HOSPITAL COURSE|The patient was empirically started on IV vancomycin and Primaxin. On _%#MM#%_ _%#DD#%_, 2005, the patient was sent to the OR for washout of sternum. Status post washout, the patient resumed his regular diet. This wound debridement had been done by Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2005, due to the patient being afebrile, continuing to do well, eating his diet without problem.
OR|operating room|OR|287|288|ASSESSMENT/PLAN|She complains of a little bit of nausea currently. ASSESSMENT/PLAN: The patient is a 75-year-old female with a history of hypertension, hypothyroidism, hyperlipidemia, who presents with left subtrochanteric hip fracture. 1. Subtrochanteric hip fracture. The patient will be going to the OR tonight. The patient is clinically with no evidence of cardiac problems. She is very active. She is a low risk candidate. I would avoid Toradol in this patient who is greater than 60 years of age.
OR|operating room|OR|186|187|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 59-year-old lady who was admitted to the hospital with severe degenerative arthritis of her right knee. She was prepared for surgery and taken to the OR where a right total knee arthroplasty was done. Postoperatively she did extremely well, had a minimal amount of pain. She rapidly increased her range of motion to 72 degrees the second day.
OR|operating room|OR|144|145|HISTORY OF PRESENT ILLNESS|The patient was taken back to the OR for a pectoralis flap. The superficial portion of the pectoralis flap died, and we took the patient to the OR on _%#MM#%_ _%#DD#%_, 2005, for full-thickness skin graft to the neck wound. HOSPITAL COURSE: The patient did very well during the procedure, without any complications.
OR|operating room|OR|154|155|PLAN|ASSESSMENT: Infected surgical wound. PLAN: We are admitting him to the hospital. He will be placed NPO at midnight. In the morning he will brought to the OR for a formal I and D, where cultures will be obtained and to guide the anticipated antibiotic course.
OR|operating room|OR|242|243|HOSPITAL COURSE|The option of continuing Cytotec for induction versus delaying induction versus proceeding with cesarean section were discussed with the patient and husband at length. The patient wanted to proceed with cesarean section. She was taken to the OR and underwent an uncomplicated primary low transverse cesarean section. Her postop course was uncomplicated as well. She remained afebrile throughout her stay, was advanced to a regular diet without complications and was discharged home on postop day # 3 with instructions to follow-up in the office in two weeks, as well as six weeks.
OR|operating room|OR|210|211|HOSPITAL COURSE|HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was admitted on the above date with an intertrochanteric fracture. He was seen by medicine, seen by myself. On _%#DDMM2006#%_, the day after admission, was brought to the OR and underwent an unremarkable open reduction and internal fixation of the hip. He was brought back to the floor postoperatively, postoperatively followed by medicine.
OR|operating room|OR|195|196|HOSPITAL COURSE|She has had good vision to her left eye without any evidence of decreased acuity or extraocular muscle impingement. She denies any pain in the eye. A Merocel sponge was placed in the nose in the OR and removed on postop day 2. There remains in the nose a silastic sheeting sutured to the septum. There has not been any bleeding of the nose postoperatively.
OR|operating room|OR|168|169|HOSPITAL COURSE|Lungs: Clear to auscultation bilaterally. Abdomen: Soft, non-tender, obese. EKG: Normal sinus rhythm HOSPITAL COURSE: Patient presented in good condition. Taken to the OR where laparoscopic gastric bypass was performed without difficulty. Postoperatively, patient was extubated and taken to the postoperative recovery area where she remained stable.
OR|operating room|OR|196|197|HOSPITAL COURSE|Lungs: Bilaterally clear to auscultation without wheezes, crackles or rales. Abdomen: Soft, nondistended and nontender. HOSPITAL COURSE: PROBLEM #1. Operative course. The patient proceeded to the OR for procedures as described above. PROBLEM #2: Postoperative course. The patient had a routine and expected postoperative course.
OR|operating room|OR|295|296|HISTORY OF PRESENT ILLNESS|The review of systems was negative for headache, visual changes, nausea and vomiting, neck pain, chest pain, shortness of breath, palpitations, abdominal pain, and extremity paresthesias. He was transferred to the Fairview-University Medical Center for continuation of cares and admitted to the OR Radiology Service. He was admitted to the general surgical floor and started on an antibiotic regimen of clindamycin. The risks, benefits, and alternatives to surgery were explained to the patient prior to taking him to the operating room on _%#DDMM2002#%_.
OR|operating room|OR|249|250|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: End stage chronic obstructive pulmonary disease. DISCHARGE DIAGNOSIS: End stage chronic obstructive pulmonary disease. OPERATIONS/PROCEDURES PERFORMED: Single right lung transplant. HOSPITAL COURSE: The patient was taken to the OR on _%#MM#%_ _%#DD#%_, 2002, for a single right lung transplant. OR course was largely uneventful. The patient was then transferred to SICU for recovery and observation.
OR|operating room|OR|241|242|OPERATIONS/PROCEDURES PERFORMED|Toprol 50 mg p.o. q.d., Synthroid 50 mcg p.o. q.d., p.r.n. Tylenol as well as B and O suppositories 15A 1 p.r. q.8h. p.r.n. bladder spasm. FOLLOW UP: The patient is to follow up next week with Dr. _%#NAME#%_. We will call the patient for an OR date. At this time our assessment is this patient has a very high grade transitional cell carcinoma of the bladder for which definitive therapy is a total cystectomy as well as a urinary diversion.
OR|operating room|OR|197|198|PHYSICAL EXAMINATION|She does have some osteoarthritic changes in her KNEES with thickening of the bone in this area as well as in the MCP and PIP joints of her hands. No tenderness on palpation over the WRISTS, HANDS OR ELBOWS. SKIN examination shows dilated capillaries particularly around the ANKLES, but other than the erythema noted above, no significant changes.
OR|operating room|OR|188|189|IMPRESSION|More importantly, he notes that with physical activity, he has no chest pain or chest discomfort and he at times is quite active on his farm. Based on all of this, I feel he can go to the OR this evening without any risk of any cardiopulmonary complications. I will send a copy of his EKG and CBC with him over to the OR.
OR|operating room|OR|303|304|HOSPITAL COURSE|MRSA was growing off her line peripheral blood cultures and urine so she had a CT of the chest, abdomen, and pelvis demonstrating a large collection in the abdomen which was present on the previous studies. This collection was stabbed and also had MRSA. At that point, the patient was taken back to the OR for re-exploration performed on _%#DDMM2006#%_. After that, she recovered from her sepsis episode and eventually got extubated requiring about 3 more days after being extubated in the Intensive Care Unit.
OR|operating room|OR|185|186|ADMISSION DIAGNOSIS|ADMITTING PREOPERATIVE DIAGNOSIS: Osteoarthritis, right hip. DISCHARGE AND POSTOPERATIVE DIAGNOSIS: Osteoarthritis, right hip. The patient on _%#MM#%_ _%#DD#%_, 2006 was brought to the OR where she underwent general anesthetic without complication. She then underwent right 2- incision total hip arthroplasty. The patient tolerated this procedure well.
OR|operating room|OR|263|264|HOSPITAL COURSE|It was determined that the patient would need radiation, but the need for chemotherapy had yet to be determined based on these results. 2. Orthopedics. The patient had a wound VAC in place until _%#MM#%_ _%#DD#%_, 2006, at which point the patient returned to the OR for removal of the wound VAC and reconstruction of the wound by plastic surgery. Following this , the patient briefly had a JP drain in place, but quickly recovered and was ambulating at the time of discharge on _%#MM#%_ _%#DD#%_, 2006.
OR|operating room|OR|119|120|HOSPITAL COURSE|2. Pain in lower back and hips. 3. Tonsillectomy. ALLERGIES: To codeine. HOSPITAL COURSE: The patient was taken to the OR on _%#DDMM2006#%_ where he underwent an open Roux-en-Y gastric bypass with liver biopsy and ring gastropexy. The patient tolerated this procedure without difficulty and was taken to the regular floor.
OR|operating room|OR|181|182|HOSPITAL COURSE|The radiologist was unable at the first attempt to get across the common bile duct obstruction and the decison was made for repeat PTC in the OR by Interventional Radiology. Due to OR and Interventional Radiology scheduling conflicts, the patient did not get her second PTC done until _%#DDMM2006#%_, with successful crossing of the malignant biliary obstruction at the stenotic sites, stent placement and cholangioplasty.
OR|operating room|OR|182|183|HISTORY OF PRESENT ILLNESS|She was found to have a large pedunculated polyp about 2 inches in the rectum at that time. The exam was then stopped and she was scheduled for a colonoscopy with polypectomy in the OR on _%#MM#%_ _%#DD#%_, 2002. She presents at the time of admission for bowel prep prior to the procedure. She normally has about 5 stools per day. They are described as light tan and soft.
OR|operating room|OR|133|134|HISTORY/HOSPITAL COURSE|COMPLICATIONS: Associated overall comorbidities none apparent. HISTORY/HOSPITAL COURSE: This is a 55-year-old gentleman taken to the OR same day of admission and underwent left total knee arthroplasty. He is afebrile, wounds are benign, negative Homan's test, hemoglobin was stable at 12.7. He is doing well currently with range of motion past 65 degrees.
OR|operating room|OR.|135|137|HOSPITAL COURSE|PAST MEDICAL HISTORY: Tubular aggregate myopathy. HOSPITAL COURSE: After informed consent was obtained, the patient was brought to the OR. The above mentioned operation was performed and the patient was transferred to 7A unit of the hospital. The patient did well post operatively. He was able to ambulate very soon.
OR|operating room|OR|293|294|PAST MEDICAL HISTORY|The patient received a Rhogam injection on _%#MM#%_ _%#DD#%_. During this pregnancy, the patient has had a documented weight gain of 32 pounds, going from 150 to a current weight of 182. She has had 13 prenatal visits this gestation. PAST MEDICAL HISTORY: Is significant for NO DRUG ALLERGIES OR SENSITIVITIES. FAMILY HISTORY: Of a grandfather with colon cancer and a father with a heart attack.
OR|operating room|OR|268|269|PROCEDURES PERFORMED|The patient is a 38-year-old male with a history significant for morbid obesity and multiple musculoskeletal disease processes as a result. The patient presents on _%#DDMM2003#%_ for elective vertical banded gastroplasty and liver biopsy. The patient was taken to the OR on _%#DDMM2003#%_. OR was without incident. After a short stay at the post anesthesia care unit, the patient was transferred to 7B for continued care and observation.
OR|operating room|OR|156|157|STAFF|He presented today for cranioplasty of the defect, and increasing of neurofibromas in the periorbital area. HOSPITAL COURSE: The patient was brought to the OR and he underwent a bicoronal approach and placement of Medpor implant to cover the scalp defect, and excision of neurofibromas in the left periorbital area.
OR|operating room|OR|325|326|HISTORY OF PRESENT ILLNESS|He was last seen by Dr. _%#NAME#%_ on _%#DDMM2003#%_, and he presents complaining of bilateral epistaxis. He had been packed with Merocel at that time, which temporized the epistaxis, however, it is felt that he should be admitted for Gram-positive antibiotics while the Merocels were in place, as well as to be taken to the OR for bilateral nasal endoscopy, with control of bilateral epistaxis. HOSPITAL COURSE: The patient was brought into the hospital on _%#DDMM2003#%_.
OR|operating room|OR|193|194|PLAN|PELVIC: Deferred to ER. EXTREMITIES: No cyanosis, clubbing or edema. Nontender. ASSESSMENT: 35-year-old para 2-0-0-2, who desires permanent sterilization. PLAN: The patient will proceed to the OR on _%#DDMM2004#%_ at 12:00 at Fairview-Southdale Hospital for laparoscopic tubal ligation via Water's technique.
OR|operating room|OR|278|279|HOSPITAL COURSE|ADMISSION DIAGNOSIS: Extreme obesity. DISCHARGE DIAGNOSIS: Extreme obesity. HOSPITAL COURSE: PROBLEM #1. After evaluation and extensive work-up which included a psychological evaluation, the patient was deemed fit for surgery, and on _%#DDMM2003#%_ the patient was taken to the OR for an elective conversion of a previous vertical banded gastroplasty to a Roux-en-Y gastrojejunal bypass. The OR course was without complications. The operation was done in an open fashion.
OR|operating room|OR|142|143|HOSPITAL COURSE|MRI was done initially and the patient was monitored closely. Repeat MRI on the 23rd did show some worsening and the patient was taken to the OR for I&D which diagnosed the necrotizing fasciitis. Cultures eventually grew out strep pyogenes. Infectious disease followed the patient throughout her stay and managed antibiotics.
OR|operating room|OR|202|203|HOSPITAL COURSE|Patient was then sent to the NICU. Her lab continues to be stable at 8.2. On postoperative day #1, she underwent a uterine artery embolization procedure. This was followed by taking patient back to the OR for a removal of her packing. She also had a cystoscopy done at the same time. Cystoscopy did show no evidence of sutures through the wall of the bladder.
OR|GENERAL ENGLISH|OR|164|165|CODE STATUS|REVIEW OF SYSTEMS: The patient is not able to give a report. CODE STATUS: The patient is DNR, DNI, NO INTRAVENOUS FLUIDS, HOSPITALIZATIONS WITHOUT FAMILY'S CONSENT OR ARTIFICIAL FEEDINGS. OBJECTIVE: A _%#1914#%_ female, in no apparent distress. In the emergency room, her blood pressure was 160/70, her respiratory rate was 28, she was afebrile, pulse was 74, her O2 saturation on room air was 90%.
OR|operating room|O.R.|118|121|HOSPITAL COURSE|Tocodynamometer showed contractions every 2 to 5 minutes. HOSPITAL COURSE: The patient was consented and taken to the O.R. and underwent a primary cesarean section through a Pfannenstiel incision. Infant was 5 pounds 14 ounces, male, born at 12:11, Apgar scores 8 and 9 at one and five minutes respectively.
OR|operating room|OR|189|190|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old female who presents on _%#MM#%_ _%#DD#%_, 2004, for an elective excisional biopsy of left lung nodule. The patient was taken to the OR on _%#MM#%_ _%#DD#%_, 2004, at which point the patient began with a video-assisted thoracoscopic procedure which was converted to thoracotomy.
OR|operating room|OR|154|155|PLAN|This is likely exacerbated by her narcotics. PLAN: 1. Obstipation. Colorectal surgery had already been consulted and does plan to take the patient to the OR later today for disimpaction. Once she is disimpacted will start her on an aggressive stool regimen to try to prevent this further.
OR|operating room|OR|140|141|HOSPITAL COURSE|He was planned to have a right neck dissection 2 days after the first dissection to give time for neck edema to resolve. He was sent to the OR on _%#DDMM2007#%_. He had the right modified radical neck dissection. He tolerated the procedure well and he was sent to the floor on the same day as the operation with a right JP drain.
OR|operating room|OR|114|115|SUMMARY OF HOSPITAL COURSE|1. Right hip fracture. The patient initially presented with right hip pain and a fracture. She was brought to the OR and had a right hip cemented bipolar prosthetic replacement. This went well and she had an unremarkable postoperative course.
OR|operating room|OR|171|172|HISTORY OF PRESENT ILLNESS|This biopsy grew out Staph aureus, which was resistant to all antibiotics except for penicillin. Given the findings of this biopsy, the patient was asked to return to the OR for a more extensive debridement procedure. The risks and benefits of the procedure were discussed in the detail and the patient elected to proceed.
OR|operating room|OR|258|259|PLAN|PLAN: Patient is consented for cesarean section. Risks including bleeding, possible need for blood transfusion and infection, and damage to adjacent organs are discussed with her. Consent is signed. Patient is type and screened, and hemoglobin is performed. OR is notified. Will proceed to operating room for cesarean section.
OR|operating room|OR|137|138|HOSPITAL PROGRESS AND PROCEDURES|Consultation with CVTS, Dr. _%#NAME#%_ _%#NAME#%_ was obtained, given the precordial nature of the LV lead. The patient was taken to the OR on _%#DDMM2007#%_ ad underwent explantation of the generator. During the surgery, the proximal portion of the pacing lead and ICD leads were also performed as far as the lead were assessable.
OR|operating room|OR.|167|169||He then developed severe erythema and pain with range of motion of his fingers. He was diagnosed with a deep-space infection. On Monday evening, he was brought to the OR. The palmar wart or mass was excised and then ellipsed and then the incision was extended proximally and distally and there was gross pus.
OR|operating room|OR.|145|147|PLAN|Continue with blood pressure medication. NPO after midnight, on call to ER. If needed, she could take medications with sips of water, on call to OR. Borderline diabetes mellitus, check fasting blood sugars b.i.d. to t.i.d. Recheck hemoglobin A1c. I would recommend that if the orthopedic surgeon wants to proceed with surgery, consider spinal anesthesia for this patient.
OR|operating room|OR|303|304|HOSPITAL COURSE|INR 1.98, PTT 110, PT 15.0, fibrinogen 154. Electrolytes: Sodium 150, potassium 3.8, chloride 108, bicarbonate 25, BUN 13, creatinine 0.4, glucose 176, calcium 13.2, ionized calcium 6.8, magnesium 2.9, phosphorus 3.7. HOSPITAL COURSE: 1. Fluid, electrolytes and nutrition: The patient returned from the OR on IV fluids, 2/3 maintenance, and was maintained on this level until he began to take p.o. We had Lasix started on postoperative day 1 and was switched to Bumex on postoperative day 3 until the final day when he was switched to p.o. Lasix.
OR|operating room|O.R.|217|220|HOSPITAL COURSE|The patient does take aspirin. SOCIAL HISTORY: Negative x3. REVIEW OF SYSTEMS: Negative. HOSPITAL COURSE: The patient was admitted on the afternoon of _%#MM#%_ _%#DD#%_, 2002, for bowel preparation in preparation for O.R. on _%#MM#%_ _%#DD#%_, 2002. However, secondary to being unable to tolerate the GoLYTELY as well as magnesium citrate, the patient's surgery has been canceled.
OR|operating room|OR.|154|156|HISTORY OF PRESENT ILLNESS|ED evaluation suggested that an abscess and possibly some necrotic tissue had formed. _%#NAME#%_ is admitted for surgical evaluation and treatment in the OR. PAST MEDICAL HISTORY: The patient's past medical history is significant primarily for multiple sclerosis, although she does have depression associated with that.
OR|operating room|OR|153|154|PLAN|ASSESSMENT: A patient with underlying diagnosis of multiple sclerosis and possible injection site related to necrosis and/or abscess formation. PLAN: To OR for I and D by Dr. _%#NAME#%_ per his note this afternoon. This is clear for general anesthesia.
OR|operating room|OR|126|127|HISTORY OF PRESENT ILLNESS|He had no complaints of pain up until that point. His parents had been cleaning the wound daily. It was noted that during his OR procedure on the day prior to admission, he did have the toe debrided somewhat and cleaned. In _%#CITY#%_, a white count was drawn and found to be 17.8 with significant bandemia.
OR|operating room|OR|264|265|HOSPITAL COURSE|SURGEON: _%#NAME#%_ _%#NAME#%_, M.D. HOSPITAL COURSE: On _%#DDMM2000#%_, _%#NAME#%_ _%#NAME#%_, a 39-year-old, was admitted to the hospital and prepared for surgery. The patient underwent surgery and tolerated the surgery well. The patient was discharged from the OR in stable condition. The patient was then admitted to station 33, Surgical Specialties, where he made good progress. The patient did have pneumonia that was diagnosed by Radiology.
OR|operating room|OR|125|126|HOSPITAL COURSE|The distal phalanx appears destroyed except for the base compatible with a history of osteomyelitis. The patient went to the OR on _%#DDMM2007#%_ by Dr. _%#NAME#%_ and had a second digit amputation. The bone culture is pending but has a moderate growth of nonhemolytic strep and heavy growth of gram negative rods.
OR|GENERAL ENGLISH|OR|325|326|PAST MEDICAL HISTORY|3. Bilateral total knee arthroplasty. 4. Appendectomy, tonsillectomy, hemorrhoidectomy, right incisional herniorrhaphy, COPD, hypertension, blood loss anemia, hyperlipidemia, cholelithiasis, depression, degenerative joint disease 5. Previous tobaccoism, history of GI bleed, peptic ulcer disease, and herpes zoster ALLERGIES OR INTOLERANCES TO The FOLLOWING MEDICATIONS, SULFA (HIVES) PERCOCET (CNS) CODEINE( HIVES), ACE INHIBITORS (SHORTNESS OF BREATH), DARVON AND SINGULAR (SHORTNESS OF BREATH) AND PULMICORT (DIZZINESS).
OR|operating room|OR|244|245|OPERATIONS/PROCEDURES PERFORMED|ADMISSION DIAGNOSIS: Perirectal abscess. OPERATIONS/PROCEDURES PERFORMED: 1. The patient was taken to the operating room on _%#MM#%_ _%#DD#%_, 2002, for drainage of a perirectal abscess and placement of a drain. 2. The patient was taken to the OR on _%#MM#%_ _%#DD#%_, 2002, for reexamination of perianal abscess with further drainage on that date, _%#MM#%_ _%#DD#%_, 2002. HISTORY OF PRESENT ILLNESS: This is a 31-year-old female with a 2-year history of anal fissure previously relieved by Xylocaine ointment, who was admitted with increasing pain and perianal cellulitis.
OR|operating room|OR,|80|82|PLAN|The opportunity for questions is given. Informed consent was obtained. PLAN: To OR, IV antibiotics given, routine paraoperative cares.
OR|operating room|OR,|273|275|DATE OF SURGERY|Please see operative note for details. The patient did tolerate the procedure but on the night following surgery he was found to have a lot of blood from the chest tube and it was decided the patient should go back and it was found to be a re-bleed. On the way back to the OR, the patient coded for several minutes and was resuscitated. After the operation, the patient's bleeding was stopped and the patient returned to the floor.
OR|operating room|OR|323|324|IMPRESSION|She understands that this is permanent and irreversible sterilization. She has also been counseled regarding the potential risks of the procedure including bleeding, the need for transfusion, infection, and risk of injury to surrounding structures. At this time the patient is stable and we will make arrangements with the OR for surgery at the nearest possible time.
OR|operating room|OR|230|231|HOSPITAL COURSE|Parents brought him back to the ER the day after the emesis was drained because it was getting larger in size and he was running a low grade temp. He was admitted to the hospital at that time. HOSPITAL COURSE: He was taken to the OR by surgery and had surgical draining done under anesthesia. He tolerated the procedures well. The lesion in his neck was packed with sterile dressing.
OR|operating room|OR|193|194|RECOMMENDATIONS|There is no acute airway obstruction at this time, stridor or retractions. RECOMMENDATIONS: Admit to the ICU for observation. In the morning the patient would benefit from being brought to the OR under controlled conditions with an awake fiberoptic intubation if possible, or otherwise tracheostomy under local anesthesia, and then panendoscopy and biopsy both to evaluate the mass, tumor map it, and make the appropriate diagnosis, then appropriate therapy can be performed.
OR|operating room|OR|172|173|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 26-year-old single female who was admitted today to 4A for observation after a bone marrow harvest, which was done today in the OR by Dr. _%#NAME#%_ _%#NAME#%_, who took about 700 cc bone marrow from the posterior iliac crest. The patient tolerated the procedure well with no complications. In the OR, the patient received 1000 cc lactated Ringer's and 1 unit of packed rbc's.
OR|operating room|OR,|137|139|HOSPITAL COURSE STAY|No palpitations or orthopnea. He did have the onset of generalized edema since being placed back onto the ward from the OR. While in the OR, he received 3.5 liters. This certainly contributed to his edema. For this, he was given Lasix, which seemed to help with the edema.
OR|operating room|OR.|262|264|DISCHARGE MEDICATIONS|The patient had 400 cc blood loss intraoperative and another 400 cc following the delivery. The placenta was adherent to the left fundal region. After manual removal and curettage, she was given Pitocin 20 units in a liter and IV and also a gram of Ancef in the OR. Postoperatively, the patient's hemoglobin was 7.0. She remained afebrile and her vital signs were stable.
OR|operating room|OR.|264|266|HOSPITAL COURSE|Retroperitoneal mass was identified and excised. This was fortunately not invading any other structures, and the operation was significantly shorter than expected and technically easier than expected. The patient tolerated the procedure well, was extubated in the OR. After a brief recovery in the PACU, she was transferred to the general care floor. She remained n.p.o. initially, and her pain was controlled with PCA pump.
OR|operating room|OR|180|181|HISTORY OF PRESENT ILLNESS|ADMISSION DIAGNOSIS: Basilar apex aneurysm. DISCHARGE DIAGNOSIS: Basilar apex aneurysm. HISTORY OF PRESENT ILLNESS: This is a 47-year-old right-handed female who is employed as an OR technician. The patient reports the sudden onset of global headache with accompanying nausea and vomiting at approximately 11 p.m on _%#DDMM2002#%_.
OR|operating room|OR|129|130|ADMISSION DIAGNOSIS|HOSPITAL COURSE: The patient was evaluated in the Emergency Room and admitted to 7-A for IV pain control. He was added on to the OR schedule that same day and was taken to the operating room for the above listed procedure which was tolerated well.
OR|operating room|OR|263|264|HOSPITAL COURSE|She received an epidural for analgesia. She progressed to complete and pushed for 3+ hours with good maternal effort, however, arrest of descent was noted at 0-1+ station. Therefore, the patient was consented for primary low transverse C-section and taken to the OR on _%#DDMM2007#%_. Please see the dictated operative note for full details. Briefly, the procedure was uncomplicated. Total estimated blood loss was 900 mL. The patient delivered a viable female infant in the vertex presentation at 0239 with Apgars of 2, 8 and 9 at 1, 5, and 10 minutes respectively.
OR|operating room|OR|221|222|SURGICAL INDICATIONS|SURGICAL INDICATIONS: This is a 43-year-old male who has had 4 days of abdominal pain which is now localized to the right lower quadrant. CT evaluation has shown massive retrocecal appendix. The patient is brought to the OR at this time for appendectomy. Therefore, on _%#DDMM2007#%_, patient underwent operative procedure including appendectomy under general anesthesia with estimated blood loss of 100 cc.
OR|operating room|OR|167|168|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|Thus after obtaining verbal and written consent and explaining the risks and benefits, the patient was taken to the operative theater on _%#DDMM2007#%_. The patient's OR course was without complication. Following the patient's operation, the patient spent a short time in the PACU followed by admit to 7B for the remainder of his hospitalization.
OR|operating room|OR|205|206|HISTORY OF PRESENT ILLNESS|Cystoscopy and proctoscopy were also performed at that time. Options were discussed at that time and the patient desired a total pelvic exoneration for the central recurrence. The patient was taken to the OR on _%#MM#%_ _%#DD#%_, 2003, where she had a total pelvic exoneration with Miami pouch creation of new vagina. She also received radiation treatment with iridium needles. On _%#MM#%_ _%#DD#%_, 2003, the patient had bilateral nephrostomy tubes placed secondary to ureteral leakage with a nephrostomy bag left in place.
OR|operating room|OR|287|288|PHYSICIANS|Her other past medical history includes fibromyalgia, degenerative joint disease of the hips and knees and A-V fistula in the left temporal region treated with pellets in 1990s, bilateral hip replacements and a knee replacement. The patient subsequently after further workup went to the OR on _%#MMDD#%_ and at that time Dr. _%#NAME#%_ performed a mitral valve repair utilizing a #34 CE ring annuloplasty and closure of the patent foramen ovale.
OR|operating room|OR|207|208|HOSPITAL COURSE|The fellow was called to evaluate the patient for concerns for vaginal bleeding and pelvic pain. Blood pressure 160s/68, pulse 106. Vaginal vault with clot present. Abdomen soft. The patient returned to the OR for repair of bleeding at the vaginal cuff. EBL from this procedure was 50 cc and there were no complications. The rest of the hospital course will be discussed in a systems-based manner.
OR|operating room|OR|114|115|ASSESSMENT, PLAN|ASSESSMENT, PLAN: 1. Hip fracture on the left. Ortho has been consulted. Likely the patient is going to go to the OR this morning. Plan per ortho. 2. Coronary artery disease. Patient is currently asymptomatic. Will continue his current medications. 3. Recent diagnosis of prostate cancer.
OR|operating room|OR|173|174|HOSPITAL COURSE|The patient went through surgery for laparoscopy and finished with an open Roux-en-Y gastric bypass. The patient tolerated the surgery very well and was discharged from the OR in stable condition. The patient was then admitted to station 33, Surgical Specialties, where she continued to make excellent progress.
OR|operating room|OR.|161|163|HOSPITAL COURSE|He was changed back to ciprofloxacin. The patient very poorly continued to have pain in the testicle, continued to occasionally have fevers. He was taken to the OR. Had orchiectomy of left testicle with urology. Cultures have grown vancomycin-resistant enterococci. The patient was switched to the linezolid and is discharged on linezolid.
OR|operating room|OR|246|247|PROCEDURES|Preoperative hemoglobin was 10.1. PROCEDURES: 1. Gynecologic. The patient underwent exploratory laparotomy and supracervical abdominal hysterectomy via Pfannenstiel incision. The uterus was sent to pathology as was a cervical cone biopsy. In the OR the findings included enlarged uterus with approximately 12-week size. 2. Multiple uterine fibroids. 3. Pedunculated anterior fibroid measuring approximately 4 x 5 cm.
OR|operating room|OR|166|167|BRIEF  HISTORY AND HOSPITAL COURSE|He was admitted to the intensive care unit overnight and his atrial fibrillation had been under good control. On the second hospitalization stay, he was taken to the OR by Dr. _%#NAME#%_ for an appendectomy. No obvious complications from this procedure. His diet was slowly advanced from clears to a regular diet at discharge.
OR|operating room|OR|164|165|HOSPITAL COURSE|HOSPITAL COURSE: After explanation of the risks, benefits and alternatives to surgical treatment, informed consent was obtained and Ms. _%#NAME#%_ was taken to the OR theater where she underwent a laparoscopic Roux-en-Y gastric bypass. Intraoperative findings included: 1. A left-sided ovarian cyst. This did not look malignant.
OR|operating room|OR|293|294|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is an 82-year-old white female who was electively admitted to the hospital for a left shoulder reverse total arthroplasty. This was performed today. Again we are being consulted for management of her preexisting hypertension. While in the OR she had an estimated 250 mL of blood loss and got 1500 mL of lactated ringers. She is complaining that her fingers are numb currently but she did also received I believe some marcan at the time of surgery to help with postoperative pain.
OR|operating room|OR|238|239|HISTORY AND HOSPITAL COURSE|HISTORY AND HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is about a year old child who was born with transposition of the great vessels, VSD, pulmonary stenosis and crisscross heart. After tremendous amount of evaluation, he was brought to the OR on _%#DDMM2007#%_ for a bidirectional Glenn and near ligation of his MPA. He did exceedingly well with this, was extubated shortly after surgery and was transferred out of the ICU on _%#DDMM2007#%_.
OR|operating room|OR|169|170|OPERATIVE PROCEDURE|Immediately following, Dr. _%#NAME#%_ _%#NAME#%_ performed a right pectoralis major transposition flap repair of the sternal defect. Again, the patient was taken to the OR on _%#DDMM2007#%_, Dr. _%#NAME#%_, along with Dr. _%#NAME#%_ _%#NAME#%_ then performed an evacuation of the hematoma of the right chest with irrigation and ligation of bleeding vessel and re-advancement of the pectoralis major muscle flap through an island pedicle technique.
OR|GENERAL ENGLISH|OR|149|150|ALLERGIES|9. Viagra 100 mg p.r.n. 10. Aricept 10 mg daily. 11. Citracal 950 mg b.i.d. 12. Nitro-Quick 0.4 S L p.r.n. ALLERGIES: HE DENIES MEDICATION ALLERGIES OR INTOLERANCES. SOCIAL HISTORY: He remains independent and very active. He is retired.
OR|operating room|OR.|228|230|HOSPITAL COURSE|Given the fact that the patient was bacteremic, the decision was made to take the patient to the operating room, and she underwent the removal of her right-sided Hickman catheter with a left-sided Hickman catheter placed in the OR. The patient tolerated that procedure well, and was sent to the floor. She was continued on IV vancomycin and IV cefepime. On _%#MM#%_ _%#DD#%_, 2005, the patient was afebrile for 48 hours on antibiotics, white blood cell count was normal.
OR|operating room|OR|174|175|SUMMARY|SUMMARY: The patient is a 58-year-old female who is morbidly obese, who has had recurrent episodes of diverticulitis. On the day of admission, the patient was brought to the OR for a laparoscopic-assisted sigmoid colectomy. She had a cysto and bilateral ureteral stents placed by Dr. _%#NAME#%_ _%#NAME#%_. These were removed at the end of the procedure.
OR|operating room|OR|174|175|HOSPITAL COURSE|Because he was in acute renal failure and very dehydrated, it was elected to treat him with IV antibiotics and hydration for the first day. The following day, he went to the OR and had a successful laparoscopic cholecystectomy with intraoperative cholangiogram. The intraoperative cholangiogram did show a distal common bile duct stone. The GI consultant did not thiink an ERCP was indicated because the stone was so distal.
OR|operating room|OR.|230|232|HOSPITAL COURSE|It was discontinued on postop day #1. The patient was able to void spontaneously after the Foley was removed and continued to do so at the time of discharge. 7. Infectious disease: The patient received 2 g of Ancef on call to the OR. The patient was afebrile throughout her hospitalization. 8. Cardiovascular: No issues. 9. Pulmonary: The patient was given an incentive spirometer during the hospitalization and was encouraged to use it 10 times an hour immediately postop.
OR|operating room|OR|132|133|HISTORY OF PRESENT ILLNESS/SUMMARY OF TRANSITIONAL CARE STAY|He was admitted to the Colorectal Service and underwent a surgical resection and removal of these lesions. He was taken back to the OR on 2 separate occasions for bleeding and for debridement. His last surgery was _%#DDMM2007#%_. A diverting ileostomy was placed with his initial surgery to keep the wound site clean of fecal contaminant.
OR|GENERAL ENGLISH|OR|142|143|DISCHARGE INSTRUCTIONS|4. Occupational Therapy and Physical Therapy to evaluate and treat. 5. Follow-up with primary care physician in a week. 6. DO NOT RESUSCITATE OR INTUBATE. 7. Diet as tolerated. SUMMARY OF HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 52-year-old gentleman who came in essentially due to a fall with an injury to his right shoulder, as well as blood in his urine.
OR|operating room|OR|186|187|HOSPITAL COURSE|The risks, benefits and alternatives to surgical treatment were discussed with the patient and informed consent was obtained. The patient elected to undergo surgery and was taken to the OR for exploratory laparotomy and after opening, an umbilical hernia was discovered. The hernia sac was resected without difficulty. There is no bowel content within the hernia sac and the abdomen was explored and as it turns out the distal small bowel was herniated through the jejunojejunostomy defect which was reduced without causing any enterotomy or injury and no need for any bowel resection.
OR|operating room|OR|209|210|HOSPITAL COURSE|ADMITTING AND PREOPERATIVE DIAGNOSIS: Osteoarthritis of the left knee. DISCHARGE AND POSTOPERATIVE DIAGNOSIS: Osteoarthritis of the left knee. HOSPITAL COURSE: The patient on _%#DDMM2007#%_ was brought to the OR where he underwent general anesthetic without complication. He then underwent a left total knee arthroplasty utilizing the minimally invasive technique.
OR|operating room|OR,|236|238|HOSPITAL COURSE|X-rays revealed a dislocated hip. Talked with the family of risks, benefits and she is admitted at this time for a revision. Therefore, on _%#DDMM2007#%_, the patient after being medically stable or medically cleared was brought to the OR, where revision of her hip was performed. The patient postoperatively was on IV antibiotics until cultures came back, which did come back positive and we kept her on IV medication throughout her hospital course.
OR|operating room|OR|214|215|HOSPITAL COURSE|He otherwise had a normal sinus rhythm with premature atrial contractions. Preoperative EKG performed on _%#DDMM2007#%_ was similar. HOSPITAL COURSE: The patient was admitted on _%#DDMM2007#%_ and was taken to the OR that same day for a left superficial femoral artery to posterior tibial artery bypass using saphenous vein. Please see Dr. _%#NAME#%_'s operative dictation dated _%#DDMM2007#%_. The patient's postoperative course was notable for admission immediately postoperatively to the surgical ICU for intensive monitoring.
OR|operating room|OR|62|63||_%#NAME#%_ is a 43-year-old healthy male who was taken to the OR today for bone marrow harvest for an unrelated recipient. Patient had no recent illnesses or infection. The patient has a history of wisdom teeth extraction, upper endoscopy, left shoulder dislocation repair.
OR|operating room|OR|216|217|ADMISSION DIAGNOSIS|OPERATIONS/PROCEDURES PERFORMED: Open reduction and internal fixation of a left subtrochanteric femoral fracture. HOSPITAL COURSE: The patient was admitted on _%#MM#%_ _%#DD#%_, 2004, and subsequently brought to the OR for the above-mentioned procedure. The induction of anesthetic as well as the procedure itself was uneventful and the patient was subsequently brought to PACU in satisfactory condition.
OR|operating room|OR.|255|257|OPERATIONS/PROCEDURES PERFORMED|4. Final pathology results are not yet available. The patient is a 58-year-old female with known nonsmall cell cancer of the left upper lobe. The patient presented on _%#MM#%_ _%#DD#%_, 2005 for an elective resection of this. The patient was taken to the OR. OR course was without complications; the patient had negative nodes on mediastinoscopy, thus, we proceeded with left upper lobectomy via thoracotomy.
OR|operating room|OR|239|240|HOSPITAL COURSE|This issue will be discussed further below. Because the patient is young and does not have any significant risk factors, a homocystine level was checked and was normal. He was seen by the CV surgeons, who agreed to take the patient to the OR for bypass surgery pending the resolution of his anemia. The bypass was tentatively scheduled for the week of _%#MMDD#%_, assuming his anemia had resolved, and the work-up was completed such that it would be safe to operating on him.
OR|operating room|OR|175|176|ADMISSION DIAGNOSIS|Thus, after consultation with cardiovascular surgery service, it was determined that the patient would benefit from coronary artery bypass. Thus, the patient was taken to the OR on _%#MM#%_ _%#DD#%_, 2005. The patient's OR course was without complications. Following the OR, the patient was transferred to the surgical intensive care unit.
OR|operating room|OR,|271|273|ADMISSION DIAGNOSIS|Thus, after consultation with cardiovascular surgery service, it was determined that the patient would benefit from coronary artery bypass. Thus, the patient was taken to the OR on _%#MM#%_ _%#DD#%_, 2005. The patient's OR course was without complications. Following the OR, the patient was transferred to the surgical intensive care unit. The patient spent 2 days in the surgical intensive care unit.
OR|operating room|OR|247|248|HISTORY OF PRESENT ILLNESS|She presented to University of Minnesota Medical Center, Fairview on her second day of life after she was diagnosed with hypoplastic right heart, pulmonary atresia, and tricuspid atresia. Upon transfer, she on _%#MM#%_ _%#DD#%_, 2006, went to the OR with Dr. _%#NAME#%_ and received the modified BT shunt, atrial septectomy, and PDA ligation. She required brief inotropic support postoperatively. She was initially weaned off inotropes by _%#MM#%_ _%#DD#%_, 2006, and was extubated on the same day.
OR|operating room|OR|188|189|HOSPITAL COURSE|The patient had been living in assisted living and was able to walk beforehand. The patient had x-rays done which showed a nondisplaced fracture of the right femoral neck. She went to the OR with Dr. _%#NAME#%_ on _%#DDMM2006#%_ and had the open reduction and internal fixation, right femoral neck fracture. This was done without complication. The patient tolerated the procedure well.
OR|operating room|OR.|122|124|HISTORY OF PRESENT ILLNESS|Procedure went without complications, and the patient was sent to the floor postoperatively after he was extubated in the OR. Thoracic surgery was consulted on the day of surgery. Gastrografin upper GI study performed on admission showed no leak. However, the patient was admitted under the care of thoracic surgery team, and he was kept n.p.o. and followed up on daily basis for any change in vital signs, chest pain for another upper GI swallow study which was done 7 days after his symptoms started.
OR|operating room|OR|147|148|HOSPITAL COURSE|8. Tubal ligation in 1986. 9. C-section in 1982. ALLERGIES: 1. Sulfa. HOSPITAL COURSE: The patient was admitted on _%#DDMM2006#%_ and taken to the OR for laparoscopic Roux-en-Y gastric bypass. The patient was slow to wean from her anesthesia sedation, so therefore it was decided that the patient will be taken to the SICU for extubation.
OR|operating room|OR.|219|221|HOSPITAL COURSE|It was discontinued on postop day #1 and the patient was able to void spontaneously after the Foley was removed and continued to do so at the time of discharge. 6. ID. The patient received IV antibiotics on call to the OR. The patient remained afebrile for 48 hours prior to discharge. 7. Cardio. The patient has no cardiovascular issues. 8. Pulmonary.
OR|operating room|OR|291|292|HISTORY OF PRESENT ILLNESS|PROCEDURES PERFORMED: Revision of vertical banded gastroplasty to Roux-en-Y gastrointestinal bypass, hepatic biopsy, lysis of adhesions, mesh removal, repair of ventral hernia and esophagogastroduodenoscopy. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 70-year-old female, who was in the OR for 7 hours with a past medical history significant for obesity, vertical banded gastroplasty, mitral valve repair, atrial fibrillation, hepatitis C, hypertension and congestive heart failure, who underwent conversion of a vertical banded gastroplasty to Roux-en-Y gastrointestinal bypass for intractable nausea, vomiting and failed weight reduction.
OR|operating room|OR|258|259|HOSPITAL COURSE|HOSPITAL COURSE: The patient was followed for apparent small bowel obstruction, conservative with NGD decompression, however, the patient continued with abdominal pain and distention with xrays showing continued small bowel obstruction. She was taken to the OR on _%#DDMM2002#%_ at which time b_________ abdomen was found and very long and difficult case was completed. Please refer to the OR report. Post operatively the patient remained hemodynamically stable, however, she did develop some chest pain and cardiology consult was completed, refer to those notes.
OR|operating room|OR,|213|215|ADMISSION DIAGNOSIS|She was brought in the night before operation and underwent bowel prep, which included GoLYTELY, neomycin and Flagyl. She was made NPO at midnight before the operation. On _%#MM#%_ _%#DD#%_, 2005, she went to the OR, where she underwent a total proctocolectomy and distal ileectomy. She had a diverting loop ileostomy created and ileo J pouch with ileo J pouch pull- through soave procedure.
OR|operating room|OR.|196|198|LABOR COURSE|She declined VBAC and postpartum tubal ligation. The risks of the procedure were discussed with the patient, and she wished to proceed. Informed consent was obtained. The patient was taken to the OR. PROCEDURE: The patient had a repeat low transverse cesarean section via Pfannenstiel skin incision on _%#MM#%_ _%#DD#%_, 2005.
OR|operating room|OR|112|113|IMPRESSION/PLAN|Right clavicle x-ray reveals a mid clavicle fracture. IMPRESSION/PLAN: 1. Multiple fractures: He will go to the OR in the a.m. per orthopedics for repair. I will check a preoperative EKG. 2. Hypertension: We will restart him on his home regimen.
OR|operating room|OR|169|170|ADMISSION DIAGNOSIS|HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted on _%#MM#%_ _%#DD#%_, 2002, for insertion of an intravascular access device. This was performed under MAC anesthesia in the OR by interventional radiology without incident. He recovered uneventfully on the floor and was discharged to home under the care of his wife.
OR|operating room|OR|222|223|CHIEF COMPLAINT/HPI|Regular rate and rhythm, clear to auscultation bilaterally. LABORATORY: Hemoglobin 10.6, potassium 4.1, creatinine 1. EKG: No ectopy, sinus rhythm. HOSPITAL COURSE: This is a 27-year-old morbidly obese woman. To go to the OR for Roux-en-Y gastric bypass with primary repair of hiatal hernia and liver biopsy. The above procedures were performed on _%#MM#%_ _%#DD#%_, 2002, without complication.
OR|operating room|OR|204|205|HISTORY OF PRESENT ILLNESS|He was subsequently seen at Fairview Ridges Emergency Room where he was assessed and was noted to have moderate abdominal pain. CT of the abdomen revealed appendicitis. _%#NAME#%_ was soon taken into the OR for emergency appendectomy by Dr. _%#NAME#%_. Admission labs revealed a glucose of 244. Urine showed trace ketones.
OR|operating room|OR|161|162|BRIEF HISTORY AND HOSPITAL COURSE|Soft tissue CT was consistent with his thyroglossal cyst abscess. He was pan cultured and started on IV Unasyn. ENT was consulted and brought the patient to the OR the same day. He underwent local incision and drainage and placement of a drain. Abscess culture did grow out group A strep beta hemolytic.
OR|operating room|OR|159|160|HOSPITAL COURSE|She had had a remote appendectomy and cholecystectomy. Conservatively treated with NG suction was tried but patient was unresponsive to this. She was taken to OR room _%#DDMM2006#%_ where she was found to have obstruction due to the adhesive bands from her prior surgeries. Bowel was quite viable. She tolerated the procedure well. Postoperatively, she was treated with NG suction, along with DVT prophylaxis.
OR|operating room|OR|178|179|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: This is a 22-year-old male with gunshot wound to the left index finger and left thigh with fragment lodged in the left tibia. The plan is to take him to the OR for incision and drainage of the left index finger. At that time we will most likely loosely approximate the tissues.
OR|operating room|OR.|218|220||The patient was admitted to the University of Minnesota Medical Center, Fairview, following a bone marrow harvest for an unrelated donor. Preoperative hemoglobin was 10.7 g/dL. Bone marrow 1300 mL was harvested in the OR. Postprocedure hemoglobin was 7.4 g/dL. The patient received transfusion with autologous packed red blood cells. Hemoglobin at the time of discharge was 9.3 g/dL. The procedure was tolerated without any complications.
OR|operating room|OR.|197|199|PHYSICAL EXAMINATION|Cardiac, regular rate and rhythm without murmur. Abdomen, soft, nontender nondistended. Bowel sounds in all four quadrants. Gynecological exam was deferred as the patient was going straight to the OR. Extremities there was no erythema, edema, tenderness or cords. Peripheral pulses were palpated bilaterally. HOSPITAL COURSE: 1. Disease. The patient had known grade 1 endometrial cancer before the surgery was performed.
OR|operating room|OR|247|248|IMPRESSION|CT scan of the abdomen and pelvis is ordered to rule out any abscess. Consultation with surgeon, Dr. _%#NAME#%_, was done and IV antibiotics started, IV fluids, and the patient will be NPO after midnight, should we have to take the patient to the OR for revision of wound.
OR|operating room|OR|162|163|HOSPITAL COURSE|3. Diet is regular. HOSPITAL COURSE: This is a 14-year-old gentleman who presented to the Pediatric Surgery Clinic with a pectus excavatum. He was brought to the OR on _%#DDMM2006#%_ for an elective pectus excavatum repair. This was performed without complication. For more details regarding the procedure, please see the procedure dictation note by Dr. _%#NAME#%_.
OR|operating room|OR|140|141|HOSPITAL COURSE|The patient was brought to the operating room on _%#DDMM2002#%_. She was given 1 gm of Ancef in the holding room. She was then taken to the OR where a right total knee arthroplasty was performed without any significant complications. Estimated blood loss was less than 300 cc. The patient was then transferred to the PACU where she was closely monitored prior to her transfer back up to the orthopedic floor.
OR|operating room|OR|170|171|HOSPITAL COURSE|The patient was cleared for surgery prior to his admission. The patient was given 1 gram of Ancef preoperatively in the holding room. The patient was then brought to the OR where an open reduction, internal fixation of his right ankle fracture was performed without any complications. Estimated blood loss was less than 25 cc. The patient was then transferred to the PACU in stable condition where he was closely monitored prior to his transfer up to the Orthopedic floor.
OR|GENERAL ENGLISH|OR|159|160|ALLERGIES|5) Metoprolol 25 mg b.i.d. 6) Allopurinol 100 mg b.i.d. 7) Advil 200 mg daily. 8) Tartrate 25 mg daily. ALLERGIES: THERE IS NO HISTORY OF MEDICATION ALLERGIES OR INTOLERANCES. SOCIAL HISTORY: The patient does not use tobacco or alcohol.
OR|operating room|OR.|152|154|PHYSICAL EXAMINATION|No murmurs, rubs or gallops. ABDOMEN: Soft and nondistended and nontender with no masses. EXTREMITIES: Not edematous and nontender. PELVIC: Deferred to OR. She did have a pelvic exam in _%#MM#%_ 2003 which was unremarkable. ASSESSMENT/PLAN: This is a 30-year-old female, gravida 0 with severe dysmenorrhea as well as left pelvic pain and rectal pain with her menses which are all suggestive of an endometriosis.
OR|operating room|OR|139|140|HOSPITAL COURSE|2. Left leg hematoma: The patient developed a left leg hematoma approximately 4 days following her ICU stay. The patient was taken back to OR where a hematoma was evacuated by our Vascular Surgery colleagues. They did not see any damage to the vessel nor did they see any current bleeding upon their OR exploration.
OR|operating room|OR|191|192|HOSPITAL COURSE|The patient was taken back to OR where a hematoma was evacuated by our Vascular Surgery colleagues. They did not see any damage to the vessel nor did they see any current bleeding upon their OR exploration. The patient was discharged with a healing, not enlarging, hematoma in her left groin extending more distally. Of note the patient did develop this hematoma while being anticoagulated with heparin and Coumadin for her pulmonary embolism.
OR|operating room|OR|190|191|HOSPITAL COURSE|For more details, please see the dictated operative note from this date. Following this procedure, the patient was monitored and was neurologically stable. On _%#DDMM2007#%_, he went to the OR for permanent implantation of the electrode with implantation of an IPG of implanted pulse generator and 2 left-sided lead extensions to connect the generator to the electrodes.
OR|operating room|OR|160|161|HOSPITAL COURSE|The patient was seen in clinic by Dr. _%#NAME#%_ for evaluation and treatment. HOSPITAL COURSE: The patient was admitted on _%#DDMM2007#%_ and was taken to the OR for abdominoperineal resection. The patient tolerated the procedure well and was transferred to PACU and ultimately to her room on unit 7C. The patient progressed well with good return of GI function on postoperative day #3.
OR|operating room|OR|195|196|PLAN OF CARE|ASSESSMENT: This is a 3-year-old front-facing car seat passenger in a head-on motor vehicle collision transferred from an outside hospital. She appears to have high cord injury. PLAN OF CARE: To OR for C1-C2 fusion, C5-C7 laminectomy and exploration, on an urgent/emergent basis. I have personally examined the patient, reviewed and edited the resident's note and agree with the plan of care.
OR|operating room|OR|122|123|HOSPITAL COURSE|There was some questionable of the viability of the bowel. On the same day later in the evening, he was taken back to the OR for reexploration of the abdomen and damage control closure for suspected leakage from the open abdominal wound. No leakage was found on re-exploration and he was brought back to the SICU and intubated.
OR|operating room|OR|194|195|OPERATIONS/PROCEDURES PERFORMED|OPERATIONS/PROCEDURES PERFORMED: Right total hip arthroplasty. REASON FOR PROCEDURE: Right hip arthritis. HISTORY OF PRESENT ILLNESS: On _%#MM#%_ _%#DD#%_, 2002, Ms. _%#NAME#%_ was taken to the OR after discussion with her about possible complications. After understanding that in full, she still wanted to go ahead with the procedure. She was taken to the OR under spinal anesthesia. Through a posterior approach, a right total hip arthroplasty was done.
OR|operating room|OR|146|147|PLAN|PLAN: Cardiac catheterization (both right and left heart) today. Pending what the cardiac catheterization shows, the patient will be taken to the OR for aortic valve replacement, plus/minus coronary artery bypass grafting. Since the patient has a history of dye allergy, he will be treated with steroids and hydration.
OR|operating room|OR|176|177|HOSPITAL COURSE|Because of the swelling, he thought this was unlikely and recommended a hand surgeon evaluation. Dr. _%#NAME#%_ did see the patient and felt she needed to go emergently to the OR where she did an I&D of a pocket of pus on the dorsal aspect of her right hand. The patient was seen by Dr. _%#NAME#%_, ID specialist. Her antibiotics were changed.
OR|operating room|OR|166|167|PATIENT IDENTIFICATION|The patient was admitted by Dr. _%#NAME#%_ _%#NAME#%_ for elective and emergent amputation of the right second toe. I am asked to do preoperative evaluation prior to OR this morning. PAST MEDICAL HISTORY: 1. Depression 2. Diabetes mellitus, adult onset with large insulin needs.
OR|operating room|OR|312|313|PLAN|LABORATORY DATA: CBC, chem 10 and INR/PTT are pending. ASSESSMENT: Primary generalized dystonia 1 year status post bilateral Globus pallidus internus deep brain stimulator electrode placement, now with clinical and programming evidence of a malfunctioning right DBS system. PLAN: 1. Obtain preoperative labs. 2. OR on Monday _%#DDMM2007#%_ for exploration of battery and extension cable with likely replacement in order to restore the patient's functionality of his right DBS system.
OR|GENERAL ENGLISH|OR|180|181|ALLERGIES|12. Lantus 20 units daily at noon and 7 units of regular insulin in the morning, 6 units regular insulin at noon and 5 units of regular insulin dinner. ALLERGIES: HE HAS ALLERGIES OR INTOLERANCE TO PENICILLIN, SPIRONOLACTONE AND GEMFIBROZIL. SOCIAL HISTORY: He is presently married and lives with his wife who is his primary caregiver living in south _%#CITY#%_.
OR|operating room|OR,|135|137|HOSPITAL COURSE|ABDOMEN: Soft and nondistended with bowel sounds throughout. HOSPITAL COURSE: Disease: On _%#DDMM2007#%_, the patient was taken to the OR, where she underwent an exam under anesthesia, placement of Syed needles. The patient went on to receive interstitial brachytherapy. She received her therapy on _%#DDMM2007#%_ and _%#DDMM2007#%_.
OR|operating room|OR|186|187|HOSPITAL COURSE|Total bilirubin 0.3, albumin 4.0, total protein 6.7, and alkaline phosphatase 79. HOSPITAL COURSE: _%#NAME#%_ was admitted for chemotherapy after he had his left knee manipulated in the OR by Dr. _%#NAME#%_. Dr. _%#NAME#%_ was able to flex the knee to 130-degrees in the operating room after _%#NAME#%_ had mild pain associated with knee flexion for the first day.
OR|operating room|OR|168|169|PROBLEMS|6. Osteoporosis. 7. Postop anemia, status post blood transfusion. ALLERGIES: NKDA. CODE STATUS: Full code. PROBLEMS: 1. Left hip fracture. The patient was taken to the OR on _%#MM#%_ _%#DD#%_, 2003. Her postoperative course was complicated by postoperative anemia. This did drift to 7.9, and she was transfused 2 units of packed red cells.
OR|operating room|OR|135|136|HOSPITAL COURSE|ABDOMEN: Non-tender; non-distended; morbidly obese. EXTREMITIES: Full range of motion. HOSPITAL COURSE: The patient was brought to the OR where she had the laparoscopic gastric bypass performed without complication. Postoperatively she was extubated and taken to the recovery area where she was eventually transferred to 7B.
OR|operating room|OR|111|112|HOSPITAL COURSE|The patient was also placed on Decadron. The patient was on the unit during this time. The patient went to the OR for resection of the posterior fossa mass. The pathology showed this to be a mixed glioma. According to the Pathology records, this appeared to be identical to the one that was resected back in 1963.
OR|operating room|OR|269|270|SUMMARY OF HOSPITAL COURSE|A transesophageal echo performed on _%#DDMM2003#%_ at F-UMC revealed a large mass on the pulmonary valve, roughly 3.3 x 2.9 cm, which is prolapsing into the right ventricle through the pulmonic valve. No other abnormal findings were noted. The patient was taken to the OR on _%#DDMM2003#%_ for a coronary artery bypass graft x 1 and removal of a pulmonic valve mass. A 3 cm valvular mass was removed at this time, as well as a smaller satellite lesion on the medial leaflet of the pulmonic valve.
OR|operating room|OR|65|66|PLAN|ASSESSMENT: 41-year-old female with acute appendicitis. PLAN: To OR for appendectomy. IV antibiotics started.
OR|operating room|OR|159|160|HOSPITAL COURSE|The patient was prepared for surgery including prophylactic antibiotics for valvular heart disease and standard colon surgery preparation and was taken to the OR where she underwent right hemicolectomy. Initially an attempt was made to do it by laparoscopy, however, because of the presence of previous adhesions, it had to be converted into an open laparotomy.
OR|operating room|OR|164|165|HOSPITAL COURSE|HOSPITAL COURSE: After explanation of the risks, benefits and alternatives to surgical treatment, informed consent was obtained and Mr. _%#NAME#%_ was taken to the OR suite where he underwent the above-mentioned procedure without complication. EBL was approximately 150 mL. He was extubated and arrived to the SICU in stable condition where he was monitored overnight.
OR|operating room|OR|282|283|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|3. Rituxan doses x2 for PTLD. HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: The patient is a 65-year-old male with history of advanced PTLD presented with altered mental status and abdominal pain. He had CT scan with contrast that showed a bowel perforation. He was rushed to the OR where he had bowel resection with end-to-end anastomosis. He has extensive PTLD and received Rituxan for treatment. He, unfortunately, did not respond well.
OR|operating room|OR|151|152|INITIAL EXAM|She was extubated on post operative day #2. However, later that day she had acute drop in her hemoglobin 12 to 9 and the patient was taken back to the OR for exploratory laparotomy for possible bleeding. Please refer to operative note dictated by Dr. _%#NAME#%_ on _%#DDMM2002#%_ for further details. In brief, 400 cc of blood were found in the abdomen and small amount of bleeding was seen from hepatic artery was noted.
OR|operating room|OR|224|225|PROCEDURES DURING HOSPITALIZATION|ADMITTING DIAGNOSIS: Hem/Onc. DISCHARGE DIAGNOSES: 1. Lower extremity weakness and numbness with epidural mass. 2. Metastatic carcinoma, workup pending. PROCEDURES DURING HOSPITALIZATION: Neurosurgery brought patient to the OR for T7-T8 decompression laminectomy resection of epidural mass at T7-T8. Segmental instrumentation with pedicle screws T6-T7, T9-T10, T6-T10 fusion with allograft.
OR|operating room|OR|203|204|PHYSICAL EXAMINATION|He was admitted to the hospital on _%#DDMM2002#%_ and after discussion of options and obtaining consent a rectal sigmoid resection with low anterior anastomosis was performed. Specimen was opened in the OR which demonstrated the previously identified lesion with a 4 cm margin distally. Re-anastomosis was performed and the patient was brought to postanesthesia care unit and then regular care floor.
OR|operating room|OR.|215|217|PLAN|3. Other medical problems include hypertension, hyperlipidemia and obesity. PLAN: 1. Repeat urinalysis. 2. Surgical consult. 3. The patient should be a relatively good surgical candidate should he need to go to the OR.
OR|operating room|OR|288|289|OPERATIONS/PROCEDURES PERFORMED|However, a definite diagnosis was not made, and by the time patient was transferred to the floor from the ICU after a week of management, she was basically unresponsive and doing fairly poorly. Patient was originally at _%#CITY#%_ for basically rehab after receiving a BKA and was in the OR on the _%#MM#%_ _%#DD#%_, 2004, noted to have multiple finger amputation, however, this was delayed because of atrial fibrillation. Shortly after that, patient, on the day of admission to the ICU at Fairview, basically developed acute mental status changes and was with left-sided facial droop and inability to move her left extremities as well as right-side gaze, and she was sent to the MICU for further management.
OR|operating room|OR|139|140|ALLERGIES|Patient was seen by surgery on _%#MM#%_ _%#DD#%_, 2004, and was started on antibiotics and local wound care. Patient was consented for the OR to have further debridement and amputation of the right second toe. Patient was taken to the OR on _%#MM#%_ _%#DD#%_, 2004, and underwent amputation of the right second toe.
OR|operating room|OR|201|202|HOSPITAL COURSE|The patient underwent the procedure on _%#DDMM2004#%_ and tolerated the procedure well. He was transferred to the general thoracic ward only on supplemental oxygen. Pleural fluid cultures taken in the OR showed fusiform bacilli on the aerobic culture that was susceptible to clindamycin, metronidazole, penicillin, and cefotaxime. The patient was started on levofloxacin and metronidazole. When he was admitted, he was continued on his antibiotics.
OR|operating room|OR.|126|128|HISTORY OF PRESENT ILLNESS|The patient was noted to have an intraoperative hemoglobin of 8.7 and was transfused 2 units of packed red blood cells in the OR. Her hemoglobin postop was 12.6. Hemoglobin prior to discharge was 12.4. 3. Pain. The patient was given a Dilaudid PCA following her surgery.
OR|operating room|OR|220|221|IMPRESSION/PLAN|3. Hypothyroidism. Continue with medication. 4. Gastroesophageal reflux disease. Patient will be placed on IV Protonix while in-house. 5. Atrial fibrillation. Patient on Rythmol. 6. Patient will probably be taken to the OR in the a.m. by orthopedic consultants. Quello Clinic to follow for medical issues.
OR|GENERAL ENGLISH|OR|180|181|ASSESSMENT AND PLAN|The patient at this point will be started on Levaquin and I will await urine culture results. 7. I discussed code status with the patient. AT THIS POINT HE IS UNSURE AS TO WHETHER OR NOT HE WANTS TO BE FULL CODE OR DNR, DNI AND WISHES TO THINK ABOUT THIS. At this point, therefore HE WILL BE MADE FULL CODE.
OR|operating room|OR|158|159|HOSPITAL COURSE|DISCHARGE AND POSTOPERATIVE DIAGNOSIS: Osteoarthritis of left knee with retained hardware. HOSPITAL COURSE: On _%#DDMM2007#%_, the patient was brought to the OR where she underwent general anesthetic without complications. She then underwent a left total knee arthroplasty as well as hardware removal from the left tibia.
OR|operating room|OR|269|270|PENDING DISCHARGE 11/06/07|On _%#DDMM2007#%_ she underwent a 3 vessel coronary artery bypass graft off-pump with a LIMA to her LAD, saphenous vein graft to her ramus and then sequential to her OM. She tolerated the procedure well, but did have a significant amount of bleeding. She did return to OR approximately 6 hours p.m. for exploration. No significant bleeding was found, just generalized oozing. She will be continued to be treated with plasma and platelets.
OR|operating room|OR|280|281|DISCHARGE MEDICATIONS|Due to his poor progress a decision was made to admit the patient to University of Minnesota Medical Center, Fairview _%#CITY#%_ Hospital where he could also be followed by Dr. _%#NAME#%_, his primary care provider. The initial plan had been to ultimately take the patient to the OR for debridement of the bony pelvis, which was exposed in a number of these wound bases particularly the left gluteal and the right IT.
OR|operating room|OR|153|154|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: 1. 81-year-old female with a left hip fracture. Orthopedics has been consulted. We will reverse Coumadin and have patient go to the OR tomorrow if possible. 2. Dementia and depression. Will continue outpatient medications. Hold ECT until orthopedically stable. 3. Cardiovascular. Stable, but possibly slight increased fluid per chest x- ray and oxygen saturations.
OR|operating room|OR|173|174|HOSPITAL COURSE|7. Status post ventral hernia repair with appendectomy. 8. VBG in 1987, with revision in 1995. HOSPITAL COURSE: The patient presented on _%#DDMM2003#%_ and was taken to the OR for her modified duodenal switch. The OR course was uneventful. The patient was then transferred to 7B for further observation and care.
OR|operating room|OR|304|305|HOSPITAL COURSE|HISTORY OF PRESENT ILLNESS: The patient is a 39-year-old female who presented on _%#DDMM2003#%_ for elective resection of a rectosigmoid which was initially believed to be a second primary (the patient had a prior history of mucinous appendiceal carcinoma). HOSPITAL COURSE: The patient was taken to the OR on _%#DDMM2003#%_ where the patient underwent a completion colectomy with en bloc ureteral resection with a subsequent ileorectal anastomosis and ureteroneovesicostomy.
OR|operating room|OR|193|194|HOSPITAL COURSE|The enteroclysis revealed some dilated loops of bowel leading to an area of suspicion for a recurrent ventral hernia. Given the imaging results and clinical exam, the patient was scheduled for OR on _%#DDMM2003#%_ for repair of the ventral hernia and abdominal wall reconstruction. The patient underwent the procedure without any complications. Please see the dictated note for details.
OR|operating room|OR|242|243|DISCHARGE DIAGNOSIS|She was admitted at Fairview Ridges on _%#DDMM2004#%_ for preterm labor, placed on tocolysis, and did well for several days. However, she developed vaginal bleeding with increased volume on the morning of _%#DDMM2004#%_. She was taken to the OR at that time for an emergency C- section. _%#NAME#%_ was delivered by a C-section with an Apgar score of 5 at one minute, 6 at five minutes.
OR|operating room|OR|177|178|ASSESSMENT AND PLAN|Right upper extremity not tested except for normal grip on the right. Nonfocal exam. ASSESSMENT AND PLAN: 1. Humeral fracture. Orthopedic consult. Patient will likely go to the OR in the morning. At this time, I feel the patient is medically optimized for the proposed procedure. He is low risk I believe. 2. Cardiac. The patient does have several cardiac risk factors, namely dyslipidemia and his significant family history of dyslipidemia and coronary artery disease.
OR|GENERAL ENGLISH|OR|248|249|PLAN|The head ultrasound was done on _%#DDMM2005#%_. Problem #8: Screening Examinations/Immunizations. PKU, galactosemia, hypothyroidism, hemoglobinopathy, adrenal hyperplasia screening NEEDS TO BE SENT AFTER 3:45 am on _%#DDMM2005#%_ (24 hours of age) OR SOONER IF GOING TO SURGERY OR RECEIVING A BLOOD TRANSFUSION BEFORE THAT TIME. Hearing: BG Xiong needs to have the ABR hearing-screening test.
OR|operating room|OR|124|125|HOSPITAL COURSE|At that time it was felt there was a good likelihood that this was a septic shoulder, and therefore the patient went to the OR for irrigation and debridement. According to the OR note, immediately upon piercing of the bursa a huge amount of rusty-colored purulence was noted; irrigation was done and the patient was continued on antibiotics.
OR|operating room|OR.|160|162|HOSPITAL COURSE|It was felt that he would need an irrigation and debridement of his foot, questioning of infection. The patient was cleared for this surgery and brought to the OR. The patient's admission date was _%#DDMM2005#%_. The patient was again worked up and cleared for surgery and on _%#DDMM2005#%_, the patient was brought to the operating room where he underwent a general anesthetic without complication.
OR|operating room|OR|173|174|ADMISSION DIAGNOSIS|Extraocular movements are intact. The patient is symmetric on his midline. He moved all extremities well without drift. After informed consent was obtained, he was taken to OR and had a right frontal VP shunt placed with strata valve at 1.5. Good CSF flow was obtained. Postoperative head CT showed ventricular catheter in good position and shunt series showed an intact shunt.
OR|operating room|OR|227|228|ALLERGIES|HOSPITAL COURSE: 1. FEN: Secondary to the patient's metabolic deficiency, he is on a high-carbohydrate and low-fat diet at home. This was continued initially during the patient's hospitalization; however, prior to going to the OR the patient was made n.p.o. At that time, he was maintained on D10 solution and IV fluids to help maintain glucose levels.
OR|operating room|OR|273|274|PLAN|The patient understands this. She desires to proceed with this approach. She understands also we probably will have to get her to a rehabilitation center for five to seven days while we contemplate revising this, because we will need about a six- to eight-hour slot in the OR and very likely will need a custom prosthesis ala tumor type, where we build up the bone rather than bony resection.
OR|operating room|OR|130|131|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Exploratory laparoscopy _%#MM2003#%_ secondary to query partial small bowel obstruction. At the time of the OR the findings were of an ileitis. HOSPITAL COURSE: After undergoing a laparoscopic nephrectomy on _%#MM#%_ _%#DD#%_, 2003, the patient had an unremarkable postoperative course.
OR|operating room|OR.|188|190|HOSPITAL COURSE|She subsequently was evaluated by the colon and rectal surgery service since she was having some hemorrhoid and rectal discomfort and they felt that she should be further evaluated in the OR. On _%#MMDD#%_ she went into the OR and had a removal of a perianal skin tag along with repair of an anal fissure.
OR|operating room|OR|193|194|HISTORY OF THE PRESENT ILLNESS|She has been admitted directly by Dr. _%#NAME#%_ (orthopedist) after coordinating with her primary MD. The majority of her history is obtained from the chart and her daughter-in- law who is an OR nurse at Fairview Ridges. The patient has been residing at the nursing home for three years. She is noted to have severe dementia and is not oriented to time, place, and person.
OR|operating room|OR,|234|236|HOSPITAL COURSE|CURRENT MEDICATIONS: 1. Claritin D. 2. Advil. 3. Albuterol inhaler p.r.n. HOSPITAL COURSE: The patient was admitted to the hospital on _%#DDMM2003#%_ in preparation for her orthognathic surgery procedure. The patient was taken to the OR, the surgery completed and was extubated without difficulty. She was then returned to the floor. Her stay in the hospital has been relatively uneventful except for episodes of nausea, which were treated promptly with Zofran.
OR|operating room|OR.|139|141|ALLERGIES|Please refer to the operative report for full details of this procedure. The patient tolerated her operation well and was extubated in the OR. She was observed for a short period of time in the PACU and transferred to the floor. Her postoperative course was unremarkable. A routine surveillance of her GI swallow study was performed on postoperative day #1 which showed patent anastomoses with no evidence of leak.
OR|operating room|OR|481|482|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Prostate cancer, He has had local metastasis to lymph nodes, status post radical retropubic prostatectomy 17 years ago, status post radiation therapy x2 to the prostate, status post multiple stents to the right ureter secondary to obstruction from metastasis, status post ileal conduit for urinary diversion on _%#MM#%_ _%#DD#%_, 2005, readmitted on _%#MM#%_ _%#DD#%_, 2005, for nausea, vomiting, dehydration, and abdominal pain. They took him back to the OR and dissolved some stones and sent the patient home. The patient was readmitted on _%#MM#%_ _%#DD#%_, 2005, with increased weakness and found to have pancreatitis.
OR|operating room|OR|107|108|PLAN|Electrolytes are normal. CT shows early acute appendicitis. IMPRESSION: Early acute appendicitis. PLAN: To OR for appendectomy, IV antibiotics started.
OR|operating room|OR|313|314|ADMISSION DIAGNOSIS|The patient tolerated the procedure well. PAST MEDICAL HISTORY: The patient's past medical history is significant for above stated nonsmall cell carcinoma and likely COPD and hypertension. The patient has no other significant past medical history. HOSPITAL COURSE: Following this, the patient was admitted to the OR where she remained until _%#MM#%_ _%#DD#%_, 2005. The patient's OR course was without complication. The patient had her chest tube discontinued on postoperative day 2 without any complication and confirmed by chest x-ray, which did not reveal any significant pneumothorax.
OR|operating room|OR.|232|234|PLAN|I had the surgery service evaluate her, and they felt that at this point in time the best course of action would be to keep watching for underlying bleeding, along with pain, and if she manifests either, to possibly take her to the OR. Certainly, at this point in time, she appears to be resting comfortably, and actually her abdomen is fairly benign. I will go ahead and treat her diverticulitis with Zosyn, especially in light of her elevated white blood cell count, and continue to monitor her clinically.
OR|operating room|OR|290|291|HOSPITAL COURSE|His electrolytes remained stable. Repeat CBC was stable. Because of difficulty swallowing, he underwent an esophagram, which showed the previous banding procedure but no other abnormalities. The patient was seen in consultation by Oral Surgery on _%#MM#%_ _%#DD#%_, and he was taken to the OR for extraction of teeth #s 7, 8 and 9 for fractured teeth and an alveolar fracture. Follow-up was recommended in 10-14 days and Peridex. The patient also had an echo because of his atrial fibrillation, which the preliminary report on _%#MM#%_ _%#DD#%_ showed left ventricular function within normal limits with an estimated ejection fraction of 60%.
OR|operating room|OR|167|168|HOSPITAL COURSE|She was placed in a shoulder immobilizer and was given pain medications. She was fairly uncomfortable the day of admission and the following day until she went to the OR in the late afternoon/evening. Please refer to Dr. _%#NAME#%_'s operative note on the procedure. Postoperatively she did well aside from on postop day one, she had some O2 saturations in the upper 80s to low 90s.
OR|operating room|OR,|180|182|ADMISSION DIAGNOSIS|Patient had originally come to Dr. _%#NAME#%_ on a referral from Dr. _%#NAME#%_, who had been treating Mr. _%#NAME#%_ with 4 rounds of chemotherapy prior to surgery. Following the OR, the patient had a short stay in the post-anesthesia care unit followed by admit to 6C for the remainder of the hospitalization.
OR|operating room|OR|205|206|HOSPITAL COURSE|Retropharyngeal internal carotid arteries bilaterally. Right mastoid fluid inflammation. MRI orbit and __________ of the neck was also performed that showed the above results. The patient was taken to the OR on _%#DDMM2004#%_ and the above-mentioned procedure along with a tracheotomy was performed. The mass was found to be a hematoma. The tracheostomy cares were recommended initially, and as the patient improved it was advised that the tracheostomy be removed.
OR|operating room|OR.|134|136|IMPRESSION|We will have ortho make this decision. Dilaudid for pain control. Tylenol for pain control. The patient should be NPO if going to the OR. We will obtain PTT, INR and CBC 2. Nutritional status. We will have nutrition see the patient regarding tube feeds.
OR|operating room|OR|244|245|HOSPITAL COURSE|She had a persistent nonhealing and draining wound, and she was admitted on _%#MM#%_ _%#DD#%_, 2005, for incision and debridement as well as IV antibiotic therapy. HOSPITAL COURSE: The patient's hospital course has been marked by return to the OR for repeat I and D on _%#MM#%_ _%#DD#%_, 2005. A consultation from the infectious disease service was obtained. Her intraoperative culture showed that she had a staphylococcus aureus species that was resistant to levofloxacin, penicillin, gatifloxacin, erythromycin, and clindamycin.
OR|operating room|OR|133|134|HOSPITAL COURSE|Ophthalmology exam was normal. Renal ultrasound showed no specific evidence of fungus infection of the kidneys. She was taken to the OR on _%#MM#%_ _%#DD#%_, 2005, where she had a new Port-A-Cath placed in her left subclavian. The Port-A-Cath placement was complicated by a left carotid arterial puncture resulting in a acute blood loss requiring a single pack red blood cell transfusion.
OR|operating room|OR.|121|123|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Lupus, recently diagnosed. 2. Ten year history of rash. 3. Broken leg at age 5, repaired in the OR. 4. Lymph node biopsy about six months ago that was benign. ALLERGIES: No known drug allergies. MEDICATIONS: None. FAMILY HISTORY: Mother has had breast cancer.
OR|operating room|OR|182|183|HOSPITAL COURSE|ALLERGIES: PENICILLIN. HOSPITAL COURSE: Mr. _%#NAME#%_ was seen in the ED. A CT scan of the abdomen was obtained, and it showed appendicitis. The patient was then transferred to the OR for appendectomy. He was then admitted to the floor after the surgery for continued monitoring and management. Throughout his hospital stay, the patient was doing very well; no active issues.
OR|operating room|OR|207|208|HOSPITAL COURSE|On hospital day 2, _%#NAME#%_ had a water-soluble contrast enema performed which was concerning for an internal abdominal hernia. A surgery was consulted immediately. On hospital day 3, she was taken to the OR for an exploratory laparotomy where Dr. _%#NAME#%_ discovered that her right colon was non-fixated. He performed a cecopexy and also did an inversion appendectomy.
OR|operating room|OR|153|154|POSTOPERATIVE COURSE|She was on a fentanyl pump. On _%#MM#%_ _%#DD#%_, 2006, the patient was still having fevers for a total of 3 days, and the patient was taken back to the OR for a re-exploration which had minimal findings seen to it. She had an abdominal washout and closure of the abdomen leaving the skin open.
OR|operating room|OR|280|281|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is an 82-year-old female who was admitted to FSH on _%#DDMM2008#%_ after sustaining a fall at home. She had an open fracture of her right wrist and a closed distal humerus intracondylar fracture. She was taken urgently to the OR at 7 a.m. on _%#DDMM2008#%_ and underwent irrigation and debridement of her open fracture and external fixation with percutaneous K wires of her right distal radius fracture.
OR|operating room|OR|281|282|HOSPITAL COURSE|The patient was admitted to the ICU. An ICU consult was obtained to manage a variety of medical issues this patient had, including acute on chronic renal failure, type 2 diabetes, hypertension, metabolic acidosis and the need for TPN. On _%#DDMM2007#%_ the patient returned to the OR for a second look and small bowel anastomosis. A new JP drain was placed and the patient was closed. He left the OR in stable condition and was admitted back to the ICU.
OR|operating room|OR|165|166|HOSPITAL COURSE|HOSPITAL COURSE: This patient was referred to Dr. _%#NAME#%_ at the University of Minnesota for repair of the above. On _%#MM#%_ _%#DD#%_, 2005, he was taken to the OR and the procedure was performed without complication. Postoperatively, he came to the intensive care unit where he was admitted for cardiopulmonary monitoring and resuscitation.
OR|operating room|OR|162|163|HOSPITAL COURSE|2. Respiratory: _%#NAME#%_ was diagnosed with a right lower lobe pneumonia complicated by pleural effusions. On the second day of admission, she was taken to the OR by Intervention Radiology and a pigtail catheter was placed in her pleural space and there was drainage of approximately 160 mL of clear fluid.
OR|operating room|OR|218|219|OPERATIONS/INTERVENTIONS PERFORMED DURING THIS ADMISSION|2. Mild mitral regurgitation. 3. Mild/borderline hypertension. OPERATIONS/INTERVENTIONS PERFORMED DURING THIS ADMISSION: 1. Placement of a vascular Port-A-Cath catheter. On _%#DDMM2006#%_, the patient was taken to the OR by Interventional Radiology and Vaxcel Port-A- Cath was placed. 2. Gastrostomy tube placement. A G-tube was placed by Interventional Radiology also on _%#DDMM2006#%_.
OR|operating room|OR|125|126|SUMMARY OF HOSPITAL COURSE|He required TPN nutrition during the acute illness, but worked his way up to full feeds by mouth plus G-tube. He went to the OR on _%#MM#%_ _%#DD#%_, 2006, for esophagogastroduodenoscopy and esophageal dilatation on _%#MM#%_ _%#DD#%_, 2006. He had spiked a fever and noticed to have decreased perfusion.
OR|operating room|OR|199|200|DIAGNOSES|DIAGNOSES: 1. Displaced femoral neck fracture. 2. Coronary artery disease. 3. Acute blood loss anemia. _%#NAME#%_ _%#NAME#%_ underwent endoprosthesis without problems. It took two days to get in the OR because he had to neutralize his Coumadin, postoperatively he is back on it, presumably for his cardiac. Atrial fib is negative, he is going to low dose.
OR|operating room|OR|259|260||She was admitted by one of my colleagues, Dr. _%#NAME#%_ _%#NAME#%_, who took her to the OR on the date of admission and did an irrigation and debridement of the right hip and placed two strands of antibiotic beads. Three days later I brought her back to the OR and we did a revision of the acetabular polyethylene and revision of the femoral head, a repeat irrigation and debridement of the right hip and placement of antibiotic beads utilizing Tobramycin as she had E-coli growing out of her hip fluid.
OR|operating room|OR.|158|160|HISTORY OF PRESENT ILLNESS|She is admitted for this hospitalization to undergo surgical removal followed by chemotherapy. Risk, surgical consent was obtained prior to proceeding to the OR. PAST MEDICAL HISTORY: 1. Ovarian cancer. 2. Osteoporosis. 3. History of duodenal ulcer.
OR|operating room|OR|182|183||ADMITTING AND PREOPERATIVE DIAGNOSIS: Failed right total hip arthroplasty. DISCHARGE AND POSTOPERATIVE DIAGNOSIS: Failed right total hip arthroplasty. The patient was brought to the OR on _%#MM#%_ _%#DD#%_, 2006, where she underwent general anesthetics without complication. She then underwent a revision right total hip arthroplasty with both the femoral and acetabular components.
OR|operating room|OR|85|86|DIAGNOSIS|DIAGNOSIS: Chronic infections, right leg. _%#NAME#%_ _%#NAME#%_ was brought into the OR originally for biopsy in the hopes of finding a clean wound, but the day before admission it started draining from a subcutaneous pocket/a seroma-like area. She has had a complex history. See old records for that please.
OR|operating room|OR;|238|240|DISCHARGE INSTRUCTIONS|The patient is to follow up with Dr. _%#NAME#%_, the pulmonologist on _%#MM#%_ _%#DD#%_, 2005. The patient is to follow up with endocrinology Dr. _%#NAME#%_, on _%#MM#%_ _%#DD#%_, 2006, as the patient's sternum appeared to be soft in the OR; therefore, an endocrine consult was obtained. No lifting greater than or equal to 10 pounds x3 weeks. No driving x4 weeks. No driving while on cardiac medications.
OR|operating room|OR|189|190|HOSPITAL COURSE|He was admitted to the hospital for anticipated incision and drainage and IV antibiotics. HOSPITAL COURSE: The patient was admitted to the hospital on _%#DDMM2005#%_. He was brought to the OR where incision and drainage was performed. Cultures were taken. He remained afebrile with normal laboratories throughout his hospitalization.
OR|operating room|OR|184|185|HOSPITAL COURSE|Infectious Disease has been following him and had made the above recommendations regarding appropriate antibiotic coverage. Orthopaedic Surgery was also consulted. He was taken to the OR for irrigation and debridement x2. After the initial debridement, he had a wound vac placed. After a few days he went back to the OR for the second I&D and the wound was closed.
OR|operating room|OR|130|131|OPERATIVE PROCEDURE|Her preoperative history and physical offered no contraindications to the plan. OPERATIVE PROCEDURE: The patient was taken to the OR in good condition. She underwent an atraumatic nasotracheal intubation and induction and was prepped and draped in the usual fashion for this procedure.
OR|operating room|OR.|115|117|PROBLEM #1|The stent migration is likely etiology of her pain. PROBLEM #1: Stent migration. The patient will be scheduled for OR. Dr. _%#NAME#%_ and Dr. _%#NAME#%_ will anticipate stent removal. We will obtain standard labs to include CBC with plates, PT and INR.
OR|operating room|OR|121|122|ADMISSION DIAGNOSIS|Apparently, initial cultures grew out staphylococcus. HOSPITAL COURSE: She was admitted to the hospital and taken to the OR on _%#MM#%_ _%#DD#%_, 2002. She underwent resection of an infected total ankle arthroplasty. Cultures were taken at the time of surgery.
OR|operating room|OR|177|178|HOSPITAL COURSE|DISCHARGE DIAGNOSIS: Abdominal wound infection. PROCEDURE PERFORMED: Incision and drainage of abdominal wound infection. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was taken to the OR on the day of admission for drainage of an abdominal abscess. Cultures revealed MRSA. She was in the hospital for wet to dry dressing changes until postoperative day 4 at which point she was comfortable with home treatment.
OR|operating room|OR|311|312|CLINICAL NOTE|He did well in the postoperative. However, once he was extubated and attempted to feed he had great deal of issues and on _%#DDMM2006#%_ he had and upper GI which demonstrated severe reflux and aspiration. He had a PICC line placed on _%#DDMM2006#%_ thereafter in which convincing for the family he went to the OR on _%#DDMM2006#%_ as well to have a Nissen fundoplication G-tube placement. He was then discharged home in the care of his family on _%#DDMM2006#%_.
OR|operating room|OR|139|140|HOSPITAL COURSE|HOSPITAL COURSE: The patient was admitted on _%#DDMM2007#%_. She received an intraaortic balloon pump preoperatively. She was taken to the OR on _%#DDMM2007#%_ where she underwent an insertion of a HeartMate II LVAD. The patient was admitted to the ICU postoperatively. She did well.
OR|operating room|OR>|210|212||She was admitted to the hospital after undergoing bilateral free TRAM breast reconstruction. Her postoperative course was complicated by venous congestion of the left TRAM flap which necessitated return to the OR> An interposition saphenous vein graft was used to assist in establishing venous outflow for the left TRAM. Due to the amount of edema within the flap, the wound was unable to be closed primarily at the time of the second surgery and this necessitated return to the OR several days later for a final wound closure.
OR|operating room|OR|172|173|ASSESSMENT AND PLAN|1. Perforated viscus, unknown location, possible peptic ulcer disease versus diverticulosis versus other. I spoke with Dr. _%#NAME#%_, who plans to take the patient to the OR tonight. Actually, the patient is going to be en route very shortly at the time of this dictation. 2. Memory loss, possible Alzheimer's. Neurologic evaluation is in process.
OR|operating room|OR|139|140|HISTORY OF PRESENT ILLNESS|He had undergone radiation in 2003 for T-cell lymphoma and has had peristent ulceration since then. On _%#DDMM2007#%_, he was taken to the OR for a definitive treatment of the wound. However, on entering wound, it was determined that the damage was too extensive with necrotic muscle bellies and determined that the patient required either a below or above the knee amputation.
OR|operating room|OR|155|156|HOSPITAL COURSE|1. Insulin, 10 units Regular b.i.d. 2. Insulin, 12 units, Ultralente b.i.d. 3. Claritin, 10 mg p.o. q.d. HOSPITAL COURSE: The patient was extubated in the OR and was brought to the Post Anesthesia Recovery unit. The patient did well post- operatively, but had trouble voiding. The patient mentioned to us that he had similar trouble voiding after his last operation.
OR|operating room|OR|137|138|HOSPITAL COURSE|He was admitted for elective open durolaminoplasty. HOSPITAL COURSE: After informed consent was obtained Mr. _%#NAME#%_ was taken to the OR where the above named procedure was performed. He tolerated procedure well post operatively and he was managed on the neurosurgery ward.
OR|operating room|OR|138|139|HOSPITAL COURSE|An Upper GI was performed which showed an esophageal leak into the right chest, the pneumonectomy side. The patient was then taken to the OR at the time for a Clagett procedure after extensive debridement of the right chest. Intraoperatively, the entire right chest was solid with saliva and the entire mediastinum was rock solid preventing us from any type of repair of the esophagus.
OR|operating room|OR|312|313|PROCEDURES PERFORMED DURING HOSPITALIZATION|Mechanical ventilation. During the patient's hospitalization, she had required mechanical ventilation, once secondary to respiratory distress for 2 days, and on two other occasions for operative procedures, including tracheostomy placement and PEG tube placement. 2. Tracheostomy. The patient was brought to the OR and had tracheostomy without complications. 3. PEG tube placement. The patient was brought to the OR for PEG tube placement. No complications. 4. Bronchoscopy. The patient had bronchoscopy on two different occasions for clearing secretions and mucous plugging.
OR|operating room|OR|176|177|PROCEDURE PERFORMED|ADMIT DIAGNOSIS: Morbid obesity. DISCHARGE DIAGNOSIS: Morbid obesity. PROCEDURE PERFORMED: Laparoscopic GIB. The patient presents on _%#DDMM2002#%_ for laparoscopic Roux-en-Y. OR course was uncomplicated. Following OR course, the patient was admitted to 7B for further care and observation. The patient's hospital course was uneventful and followed normal course of care.
OR|operating room|OR|195|196|HOSPITAL COURSE|Etanercept and Prograf were started on day 0 and 1 posttransplant respectively. Informed consent was obtained for mini laparotomy and intraportal islet infusion, and the patient was taken to the OR on _%#DDMM2002#%_. She underwent a mini laparotomy under local anesthesia with IV sedation and intraportal islet cell infusion via an omental vein.
OR|operating room|OR|124|125|HOSPITAL COURSE|The patient had some what appeared to be guarding, no rebound tenderness, however. Decision was made to take the patient to OR for wound exploration to rule out necrotizing fascitis. The patient was taken to OR on _%#DDMM2002#%_ without incident. The patient's lower abdominal wound was opened, fascia was exposed, fascia was biopsied, sent off for Gram's stain, and was negative for Gram's stain.
OR|operating room|OR|177|178|HOSPITAL COURSE|HOME MEDICATIONS AT THE TIME OF ADMISSION: 1. Insulin. 2. Prinivil. 3. Synthroid. 4. Lorazepam. HOSPITAL COURSE: PROBLEM #1: Pericardial tamponade. The patient was taken to the OR for surgical decompression of pericardial tamponade on the day of his admission. The procedure went well. Please see the operative note for details.
OR|operating room|OR|189|190|HOSPITAL COURSE|The Cardiology Team deemed it necessary to have a dobutamine stress echo to evaluate for perioperative cardiac risk factors. He was cleared by Cardiology for surgery. He was brought to the OR for transplant nephrectomy which was performed without complications. He had an uneventful postoperative course. He was ambulating well and tolerating PO intake well.
OR|operating room|OR|238|239|HISTORY OF PRESENT ILLNESS|Along with the partial sternectomy, an omental flap was raised and placed over the remaining sternum, and bilateral PEG flaps were mobilized for definitive closure. Skin was closed primarily, and retention sutures were left in place. The OR course was largely uneventful. The patient returned to the SICU and remained there with similar complications prior to definitive closure.
OR|operating room|OR|147|148|HOSPITAL COURSE|The expressed understanding of these and desired to proceed with surgical treatment. HOSPITAL COURSE: On _%#DDMM2002#%_ the patient was brought to OR for the above listed procedure was performed. The patient tolerated the procedure well and there were no complications. Post operatively she was transferred to pediatric floor. She did quite well.
OR|operating room|OR|162|163|HOSPITAL COURSE|2. Neurogenic bladder. 3. Psychotic disorder. ALLERGY: NKDA. HOSPITAL COURSE: Uneventful for neurological, hematological, or infectious complications. please see OR report for details of procedure on _%#DDMM2002#%_. Placement of bilateral DBS generators. Post operatively the patient had good pain control, was voiding spontaneously, ambulating with minimal assistance and at baseline.
OR|operating room|OR|216|217|ADMISSION DIAGNOSIS|HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old male with a history significant for morbid obesity who, on _%#MM#%_ _%#DD#%_, 2003, presents for elective laparoscopic Roux-en-Y gastric bypass. The patient's OR course was unremarkable. After a short stay on the post anesthesia care unit, the patient was transferred to 7B for continued care and observation.
OR|operating room|OR|153|154|PLAN|Speech clear. LABS: Include hemoglobin 16.8, white count 20,200, lytes are normal. CT shows acute appendicitis. ASSESSMENT: Acute appendicitis. PLAN: To OR for appendectomy, I.V. antibiotics ordered.
OR|operating room|OR|172|173|HOSPITAL COURSE|The patient was then seen by Plastic Surgery Service and was taken to the operating room on _%#DDMM2003#%_. The wound was evaluated and debrided. The plan was to go to the OR on _%#DDMM2003#%_. She was taken to the operating room on _%#DDMM2003#%_ and left latissimus dorsi muscular flap closure procedure was performed.
OR|operating room|OR|182|183|HOSPITAL COURSE|The tumor that was visualized was felt not to be amenable to therapy with laser. Therefore, it was decided that the patient should undergo a procedure in the OR. He was taken to the OR on _%#DDMM2003#%_, and the tracheal mass was resected. The patient was extubated on _%#DDMM2003#%_ and has had no difficulty since in regard to his respiratory status.
OR|operating room|OR|140|141|BRIEF CLINICAL HISTORY|He was placed on the transplant approximately a year or so ago. Lungs became available for him on _%#DDMM2003#%_, and he was brought to the OR for lung transplant. PRIMARY DIAGNOSIS: Alpha-1 antitrypsin deficiency. SECONDARY DIAGNOSIS: 1. Anxiety.
OR|operating room|OR|146|147|HOSPITAL COURSE|Abdomen: Soft and nondistended, nontender. Genitourinary Exam: Deferred to OR. HOSPITAL COURSE: 1. Operative Course: The patient proceeded to the OR with Dr. _%#NAME#%_, at which time she underwent diagnostic laparoscopy with right salpingo- oophorectomy, biopsy of pelvic phlegmon, biopsy of the liver, lysis of adhesions, dilation and curettage, and repair of umbilical hernia.
OR|operating room|OR,|146|148|DISCHARGE MEDICATIONS|The infant was delivered vaginally with Apgar scores of 7 at one minute and 7 at five minutes. The baby did not require extra oxygen while in the OR, but was grunting with subcostal retractions and was admitted to the NICU due to respiratory distress. _%#NAME#%_ was a preterm AGA infant with a length of 48 cm and head circumference of 31 cm.
OR|operating room|OR|239|240|HOSPITAL COURSE|Plan of care involved that she would return on the evening of _%#MM#%_ _%#DD#%_, 2004, for a repeat INR check and attempts at lowering her INR to a (_______________) level for a major abdominal surgery. She will, therefore, proceed to the OR on _%#MM#%_ _%#DD#%_, 2004, for further procedures. DISCHARGE MEDICATIONS: As per admission medications.
OR|operating room|OR|215|216|FOLLOW UP|9. Senna-S 2 tablets twice daily. FOLLOW UP: 1. Hematologic followup with Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ in 2 to 3 weeks. 2. Surgical followup with Dr. _%#NAME#%_; specific time to be arranged once a specific OR time has been set for her splenectomy. 3. GYN followup for slight uterine enlargement noted on CT; to be done after a splenectomy.
OR|operating room|OR|323|324|BRIEF HISTORY AND HOSPITAL COURSE|BRIEF HISTORY AND HOSPITAL COURSE: Patient is a 39-year-old female who presented with acute abdominal pain described as migratory from her epigastrium to periumbilical area, down to her right lower quadrant. Her abdominal CT is positive for appendicitis. She was admitted and general surgery was consulted. She went to the OR on hospital day #1 and had an open appendectomy. She was given IV Ceftin times two. Her post-op course had been unremarkable with some improvement in her pain.
OR|operating room|OR|135|136|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: This is a 52-year-old female with an infected ventriculoperitoneal shunt. 1. Technicare head/hair scrub. 2. Go to OR this afternoon for removal of her ventriculoperitoneal shunt and placement of an external ventricular drainage system. 3. Following the operation, we will transfer her to the Surgical Intensive Care Unit for close monitoring and antibiotics.
OR|operating room|OR|136|137|ALLERGIES|Upon completion of the gastrograph and enema, patient was supposed to have a 2-day bowel prep with clear liquids. She was placed on the OR schedule on _%#MM#%_ _%#DD#%_, 2004. Patient, however, on _%#MM#%_ _%#DD#%_, 2004, decided that she does not want to have the surgery. She wanted to leave right away. She states, "I'll just die at home with this tumor in me.
OR|operating room|OR|244|245|ALLERGIES|OTHERWISE NO KNOWN ALLERGIES. HOSPITAL COURSE: The patient was admitted on _%#MM#%_ _%#DD#%_, 2004, for possible resection of known adenocarcinoma. The patient underwent exploratory laparoscopy with laparoscopic ultrasound. It was noted in the OR that the patient had multiple sites of peritoneal implants. These implants were biopsied in the OR, and the patient was subsequently closed without any further resection.
OR|operating room|OR|170|171|DISCHARGE DIAGNOSES|The patient is an 83-year-old male who presents on _%#DDMM2005#%_ for elective resection of right upper lobe mass, known to be non-small cell cancer. He was taken to the OR on _%#DDMM2005#%_. It was complicated with pulmonary artery laceration necessitating cardiopulmonary bypass for repair. Following this, the patient had a prolonged Intensive Care Unit course secondary to slow return of neurologic (mental status) function, bilateral pneumonia, and bacteremia.
OR|operating room|OR|195|196|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 52-year-old female who comes in with a complicated medical history with fevers, chills, night sweats. After these findings it was decided to take her to the OR for a debridement of her infected abdominal wound. She underwent this on _%#MM#%_ _%#DD#%_, 2005, which she tolerated. Postoperative she had some hypotension which responded to fluids, but she spiked a temperature on postop day 2 when she was getting ready for discharge.
OR|operating room|OR|134|135|SUMMARY OF HOSPITAL COURSE|A CT demonstrated a ventral hernia with incarcerated small bowel and subsequent small-bowel obstruction. The patient was taken to the OR for open ventral hernia repair with mesh. The patient was transferred to the SICU, intubated, on _%#MM#%_ _%#DD#%_. A PICC line was started, and the patient received her nutrition through TPN.
OR|operating room|OR|166|167|ADMISSION DIAGNOSIS|It was very difficult for them to extubate her. Each time they tried to extubate, she failed extubation. They then consulted ENT, and they decided to take her to the OR and extubate her in the OR. After extubating her in the OR, they did a laryngoscopy, and they found multiple mucous membrane obstructing her upper airway.
OR|operating room|OR.|193|195|ADMISSION DIAGNOSIS|It was very difficult for them to extubate her. Each time they tried to extubate, she failed extubation. They then consulted ENT, and they decided to take her to the OR and extubate her in the OR. After extubating her in the OR, they did a laryngoscopy, and they found multiple mucous membrane obstructing her upper airway.
OR|operating room|OR|195|196|ASSESSMENT AND PLAN|Blood sugar 95, calcium 8.8. EKG reviewed by myself shows normal sinus rhythm, no ischemic changes. ASSESSMENT AND PLAN: Right midshaft humeral fracture completely displaced. She is to go to the OR at this time. From a medical standpoint, she appears to be medically optimized.
OR|operating room|OR|131|132|HISTORY OF PRESENT ILLNESS|The patient was in the hospital for a significant amount of time, prior to a an available heart. The patient had been taken to the OR on a prior occasion and was found to have severe pulmonary hypertension. Once on the operating table, the operation was canceled and the patient eventually received a heart on _%#DDMM2004#%_.
OR|operating room|OR|224|225|HOSPITAL COURSE|HOSPITAL COURSE: The patient is a 48-year-old male who unfortunately has metastatic rectal cancer. He has undergone preoperative chemoradiation therapy. Given his ongoing disease in his liver, he is now being brought to the OR for abdominal perineal resection to resect the primary tumor, to then focus treatment more on the metastatic disease. The patient was brought to the operating room on the day of admission.
OR|operating room|OR|202|203|PREOPERATIVE AND ADMITTING DIAGNOSIS|HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old female who is cleared for surgery prior to admission to Fairview _%#CITY#%_ Hospital. On _%#MM#%_ _%#DD#%_, 2005, the patient was brought to the OR where she underwent a spinal anesthetic. The patient then underwent a right total hip arthroplasty utilizing two-incision technique.
OR|operating room|OR|134|135||Finally, an MRI was performed which definitively showed the presence of a femoral neck fracture on the left side. Patient went to the OR on _%#DDMM2005#%_ and had percutaneous pinning of her left hip. Postoperatively, patient did well. She had good I&O, normal O2 sats., normal blood sugars.
OR|operating room|OR|141|142|ALLERGIES|Her urine output is over 2-1/2 to 3 L a day, and she is tolerating the p.o. liquids and advanced to regular diet. She had a JP placed in the OR which was removed on the second day postop. Foley catheter was removed on postop day number 4. She was able to void after its removal.
OR|operating room|OR.|180|182|BRIEF HISTORY AND HOSPITAL COURSE|His CT did demonstrate dilated loops of small bowel consistent with bowel obstruction. An NG tube was placed for bowel decompression. Surgery was consulted and he was taken to the OR. He did have an incidental intussusception that was found on the CT. He went to the OR and had an exploratory laparotomy with findings of severe adhesive bands.
OR|operating room|OR|185|186|HISTORY OF PRESENT ILLNESS|Therefore, on _%#MM#%_ _%#DD#%_, 2006, pediatric surgery was consulted for evaluation of laparoscopic Nissen fundoplication and on _%#MM#%_ _%#DD#%_, 2006, the patient was taken to the OR for a laparoscopic Nissen fundoplication. This procedure was performed by Dr. _%#NAME#%_ _%#NAME#%_. The patient tolerated this procedure without difficulty and was taken back to the regular floor in stable condition.
OR|operating room|OR.|120|122|PHYSICAL EXAMINATION|We immediately the results on platelets which was 116,000 and hemoglobin was 13.1 and we took the patient back into the OR. Anesthesia was notified and NP was notified to be present at the time of C-section and the patient and the interpreter and her family was notified regarding the C-section.
OR|operating room|OR|138|139|BRIEF HISTORY AND HOSPITAL COURSE|She was admitted for definitive management. Orthopedics was consulted and did agree that the patient needed surgery. She was taken to the OR on _%#DDMM2006#%_ and underwent an ORIF. Please see Dr. _%#NAME#%_'s note for details on the report. She did develop some progressive left lower extremity swelling during this stay and had an ultrasound of her left lower extremities.
OR|operating room|OR|98|99|PLAN|PRELIMINARY ASSESSMENT: Shunt failure, both clinically and radiographically. PLAN: Proceed to the OR for revision as soon as possible. This is most likely a proximal catheter occlusion on the right, but we will anticipate revision of any portion of the system that is necessary during intraoperative testing.
OR|operating room|OR|128|129|HOSPITAL COURSE|The patient had a spontaneous delivery of the placenta. OB was consulted due to the 4-degree tear. The patient was taken to the OR for the laceration repair. Please see the operative note done by _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2006, with a postoperative diagnosis of perineal laceration.
OR|operating room|OR|215|216|PROCEDURES DONE DURING THIS HOSPITAL STAY|2. Gastroesophageal reflux. 3. Nephrolithiasis. PROCEDURES DONE DURING THIS HOSPITAL STAY: I & D left thumb trapezial excision and ligament reconstruction done by Dr. _%#NAME#%_, Gram stain and culture taken in the OR showed gram positive organism. The final result is still pending. Per Dr. _%#NAME#%_ it could be enterococcus versus group A strep.
OR|operating room|OR|206|207|PHYSICAL EXAMINATION|We explained to the patient the necessity of Cesarean section delivery. The risks of infection, excessive bleeding, uterine atony, blood transfusions, thromboembolism were all explained to the patient. The OR was notified and consent for Cesarean section was taken.
OR|operating room|OR,|216|218|HOSPITAL COURSE|Abdomen is soft, nontender, and nondistended. There is a small healing incision site in the umbilical region. The stoma is pink. HOSPITAL COURSE: The patient was admitted on _%#MM#%_ _%#DD#%_, 2006, was taken to the OR, a cystoscopy and EUA were done by gynecology. Please see operative report for those details.
OR|operating room|OR|228|229|HOSPITAL COURSE|This fluid was expressed as much as possible, and arrangements were made to take her to the operating room after a CT with and without contrast was obtained to demonstrate the depth of the wound infection. She returned from the OR on _%#DDMM2006#%_ and was transferred to the Progressive Care Unit. She continued to do well after that. She was seen by Infectious Disease, and a 6-week course of IV ceftriaxone and IV vancomycin was started.
OR|operating room|OR|211|212|FOLLOW UP|Pending laboratory. At the time of _%#NAME#%_'s discharge, HVA, VMA, VIP, and official read on the chest, abdomen, and pelvis CT are pending. We have already ordered a type and screen with blood on-call for the OR on _%#MM#%_ _%#DD#%_, 2006.
OR|GENERAL ENGLISH|OR|124|125|* FEN|Discharge measurements and exam: Weight 2640 gm ( 10 %), length 43 cm ( <3 %), OFC 34 cm ( 40 %). Physical exam was normal. OR Physical exam was normal except for (describe abnormalities). Follow-up appointments: The parents were asked to make an appointment for _%#NAME#%_ to see you within one week of discharge.
OR|operating room|OR|125|126|HOSPITAL COURSE|The patient continued on antibiotics and steroids for approximately 48 hours and on hospital day #2, the patient went to the OR for frontal sinus cranialization. This was a combined procedure with otolaryngology and neurosurgery. Opthalmology was consulted intraoperatively.
OR|operating room|OR|181|182|HOSPITAL COURSE|PROCEDURE: On _%#DDMM2007#%_ a laparoscopic appendectomy was performed without any complications. HOSPITAL COURSE: On _%#DDMM2007#%_ the patient was admitted and was brought to the OR for laparoscopic appendectomy. Postoperatively the patient did fine without any complications. The patient had an uncomplicated hospital course and on postop day 1 the patient was afebrile, vitals signs were stable.
OR|operating room|OR|193|194|HOSPITAL COURSE|This was sent for triglycerides which was again high. In light of a failed pleurodesis, the options were discussed with the patient and he elected to return to the OR. He was taken back to the OR on _%#DDMM2007#%_ and again no chylous liquids demonstrated on VATS procedure and he was re-talced. Following this the patient became mildly hypotensive overnight in response to the talc pleurodesis.
OR|operating room|OR,|219|221|LABORATORY DATA ON ADMISSION|Sodium 138, potassium 5.8 on a hemolyzed specimen. Chloride 102, bicarb 12, BUN 21, creatinine 2.21, glucose 191. WBC 13.1, hemoglobin 13.4, platelets clumped. Troponin was 0.22. Lactate greater than 11.8. Prior to the OR, repeat ABG was pH 6.91, PCO2 28, PO2 363, bicarb 5, O2 sat 99%, WBC 20.8, hemoglobin 11.2, platelets 294, sodium 134, potassium 5.1, chloride 104, bicarb 8, BUN 18, creatinine 2.04, glucose 304, calcium 8.0. Total bilirubin 2.7, albumin 2.2, troponin 4.9, alkaline phosphatase 345, ALT 162, AST 470.
OR|operating room|OR|214|215|HOSPITAL COURSE|However, on _%#DDMM2007#%_ postop day 6 the patient was noted to have increased output from his chest tubes, approximately 900 mL came out of his chest tube. This was sanguinous in nature. He was taken back to the OR for reexploration. He was found to have a moderate amount of clot in the periatrial space at the time of exploration with oozing from outflow graft anastomosis.
OR|operating room|OR|146|147|HOSPITAL COURSE|Because of these findings, Dr. _%#NAME#%_ was consulted for pericardiectomy to release the restriction on the heart. The patient was taken to the OR on _%#DDMM2007#%_ where she underwent a pericardiectomy, paracentesis. She also had bilateral chest tubes placed. Postoperatively, the patient did well.
OR|operating room|OR|103|104|PLAN|He is typed and crossed. Antibiotics are started. He has stabilized sufficiently to go to OR. PLAN: To OR for exploration. Proceed as indicated, likely oversewing a duodenal ulcer. Possibility of colostomy discussed with the family as well.
OR|operating room|OR|94|95|RECOMMENDATIONS|It was elected to revise his shunt as quickly as possible. RECOMMENDATIONS: He will go to the OR for a shunt exploration and revision tonight.
OR|operating room|OR|212|213|LABOR COURSE|She had an epidural for pain control. At 5 cm dilated, OB was consulted because there were repetitive late decelerations. The recommendation was made to proceed with cesarean section. When the patient was in the OR and the surgery was about to begin, there was persistent bradycardia to the 60s for 3-4 minutes. Therefore, a stat cesarean section was called. PROCEDURE: On _%#DDMM2007#%_, the patient underwent a primary low transverse cesarean section.
OR|operating room|OR|158|159|DIAGNOSIS ON ADMISSION|Bowel sounds present. Obese. Scar in the right upper quadrant. Extremities have full range of motion. No edema. HOSPITAL COURSE: The patient was taken to the OR where the gastric bypass and liver biopsy were performed without difficulty by Drs. _%#NAME#%_, _%#NAME#%_ and _%#NAME#%_ without complication. The patient was extubated and taken to the postoperative recovery area where she continued to improve.
OR|operating room|OR.|146|148|HOSPITAL COURSE|The Port-A-Cath was removed under fluoroscopy and PICC line was used for access. Flexible bronchoscopy was performed by Pulmonary Medicine in the OR. A large, right mainstem sputum plug was removed and the bronchi were healthy. Fungal cultures from postoperative sputa and bronchoscopy specimens grew Aspergillus Fumigatus.
OR|operating room|OR|167|168|HOSPITAL COURSE|HOSPITAL COURSE: The patient was admitted to the hospital and taken OR where the above noted procedure was done without complication. For further details see dictated OR note. Post operatively the patient was taken to patient care unit 8A where she was maintained initially on a Dilaudid PCA.
OR|operating room|OR.|164|166|SOCIAL HISTORY|SOCIAL HISTORY: The patient is married and lives with her husband _%#NAME#%_. He is a retired physician. She is a former assistant head nurse in Fairview Southdale OR. She does not smoke cigarettes or drink alcohol on a regular basis. FAMILY HISTORY: Significant for lung cancer in patient's mother but otherwise negative in terms of malignancy.
OR|operating room|OR|149|150|HOSPITAL COURSE|Patient was evaluated by Surgey. It was felt that the abscesses were healing well, and they did not look infected. However, patient was taken to the OR with another excision and drainage procedure. Patient tolerated the procedure well. Patient remained afebrile during the hospital course. PROBLEM #2: Presumed Line Sepsis. The right IJ was removed.
OR|operating room|OR|147|148|OPERATIONS/PROCEDURES PERFORMED|OPERATIONS/PROCEDURES PERFORMED: After transfusion of 2 units PRBCs for hemoglobin of 8.1 on admission, the patient was consented and taken to the OR with presumed IIB cervical cancer. EUA/cysto/procto was performed with less than 10 cc blood loss. Examination revealed an 8-cm cervical mass with extension to the left perimetrium, but free on the right.
OR|operating room|OR|205|206|PAST MEDICAL HISTORY|ALLERGY: NKDA. PAST MEDICAL HISTORY: 1. V-fib arrest in 1988 leading to ARCD placement. Pacer placed in 1988, 1990, and 1994. 2. Status post infection of the pacer leads last in _%#DDMM2002#%_. He went to OR for removal of infected pacemeter and defibrillator leads. The organism was staphylococcus hemolyticus. 3. Hyperlipidemia. 4. History of SVC thrombus in 1985.
OR|operating room|OR.|265|267|PAST MEDICAL HISTORY|At this point, cardiovascular/thoracic surgery was consulted. Dr. _%#NAME#%_ saw the patient and determined that the patient was in need of emergent coronary artery bypass to prevent is having a catastrophic MI. On _%#DDMM2002#%_, the patient was taken back to the OR. The patient's OR course was uneventful. The patient underwent four- vessel coronary artery bypass.
OR|operating room|OR,|266|268|HOSPITAL COURSE|ABDOMEN: Gravid, soft, and non-distended, non-distended. External fetal monitoring revealed fetal heart tones in the 150s with minimal variability reassuring. TOCO no contractions. HOSPITAL COURSE: PROBLEM #1: Labor and delivery course: The patient proceeded to the OR, where she underwent a primary classical cesarean section, and during this procedure a viable female infant weighing 6 pounds 2 ounces, with Apgars of 6 at 1 and 8 at 5 minutes, was delivered at 0834.
OR|operating room|OR|151|152|HOSPITAL COURSE|HOSPITAL COURSE: The patient is a 56-year-old morbidly obese female who presented on _%#MM#%_ _%#DD#%_, 2003, for her laparoscopic gastric bypass. The OR course was uneventful. The patient was eventually transferred to 7B for further observation and care. On postop day 1, the patient demonstrated bowel function and had upper GI study which revealed no abnormalities.
OR|operating room|OR.|135|137|HOSPITAL COURSE|Normal neurological exam. HOSPITAL COURSE: The patient was admitted and started on Unayn for antibiotics while he awaited to go to the OR. Once taken to the OR, he had a laparoscopic appendectomy performed by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_, without complications. Postoperatively, the patient was given a regular diet after he was taken back to 7B.
OR|operating room|OR|246|247|HOSPITAL COURSE|2. Bowel ischemia. Patient went to the OR on _%#MM#%_ _%#DD#%_, and was found to have an infarcted jejunum with multiple skip areas requiring resection. She seemed to be improving but then worsened on _%#MM#%_ _%#DD#%_ and again went back to the OR and was found to have probable anastomotic leak and small bowel infarction, and again required bowel resection. She has slowly been improving since that time without further recurrence of abdominal symptoms.
OR|operating room|O.R.|262|265|HOSPITAL COURSE|Her ABG at admission was 7.31, 76, 46, and 23.8. HOSPITAL COURSE: The patient was taken in said condition and admitted to the Medicine Service in the Medical Intensive Care Unit. Her workup resulted in her eventually being taken by Cardiovascular Surgery to the O.R. where she had a coronary artery bypass grafting procedure done on _%#DDMM2003#%_. Her postoperative hospital day has been significant for the following issues: PROBLEM #1: Pain control.
OR|operating room|OR|148|149|HISTORY OF PRESENT ILLNESS|He had been on antibiotics, but this had failed to improve. He was found to have some fluid under there and subsequently set for being taken to the OR for irrigation and drainage of this. HOSPITAL COURSE: The patient was admitted the day prior to surgery.
OR|operating room|OR|193|194|HISTORY OF PRESENT ILLNESS|Thus after significant outpatient workup, the patient was brought to the hospital on _%#DDMM2004#%_ for a total pancreatectomy and auto-islet cell transplantation. The patient was taken to the OR on _%#DDMM2004#%_. The OR course was unremarkable. See specific operative note for details. The patient spent the remainder of her hospitalization on 6B.
OR|operating room|OR|166|167|DISCHARGE DIAGNOSIS|ADMISSION DIAGNOSIS: Left L5-S1 herniated disc. DISCHARGE DIAGNOSIS: Left L5-S1 herniated disc. The patient was admitted for pain control overnight, and he is on the OR schedule for a left L5-S1 HLMD on _%#MM#%_ _%#DD#%_, 2004, with Dr. _%#NAME#%_. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 45-year-old man with pain along the back of his left leg and buttocks, and weakness in his left leg, primarily dorsi and plantar flexion of his foot, and also some weakness in leg flexion.
OR|operating room|OR,|170|172|HISTORY OF PRESENT ILLNESS|The patient was transferred to the University of Minnesota. The patient was continued on IV antibiotics and taken to the operating room for incision and drainage. In the OR, the patient was noted to have purulent drainage coming out of a fistula, and apparently almost all the purulence had already drained by the time we got him to the operating room.
OR|operating room|OR|343|344|HOSPITAL COURSE|PROCEDURES PERFORMED: Aortic valve repair with mechanical valve. HOSPITAL COURSE: This is a 50-year-old gentleman with known aortic stenosis with relatively asymptomatic but felt to have progressive aortic stenosis and thought to be amenable to surgical repair. Patient was admitted by the cardiovascular surgery service and then taken to the OR on the above-named day for the above-named procedure. The patient tolerated the procedure well and was transferred to the surgical intensive care unit postoperatively with an uncomplicated extubation in the immediate postoperative period.
OR|operating room|OR|175|176|HOSPITAL COURSE|He developed satisfactory ?????? that the patient was felt to be a suitable candidate for the placement of a permanent ventricular assist device. The patient was taken to the OR on _%#DDMM2005#%_ and had heart LVAD placement. The patient's postoperative course after that was significant for inner coccal pneumonia that delayed his extubated which was treated adequately with antibiotics with subsequent recovery.
OR|operating room|OR,|196|198|HOSPITAL COURSE|Her preoperative exam was significant for decreased sensation in her left lower extremity and some mild diffuse weakness in her left leg. After informed consent was obtained, she was taken to the OR, and had thoracic laminectomy and release of her cord. Postoperatively, she did well. She remained afebrile. Her wound remained clean, dry, and intact.
OR|operating room|OR|235|236|HOSPITAL COURSE|HOSPITAL COURSE: 1. Right neck abscess. The patient was admitted and initially started empirically on Levaquin and clindamycin and ENT consult was obtained and felt that the right neck abscess needed to be drained. Patient went to the OR on _%#DDMM2005#%_ with exploration and drainage of the deep neck abscess. Cultures were sent, which came back positive for Streptococcus abiotrophic species.
OR|operating room|OR|241|242|HISTORY OF PRESENT ILLNESS|He was afebrile. CT of the abdomen showed an enlarged appendix with an appendicolith but no definite evidence of inflammation. Surgery consultation was obtained and it was felt that he likely had evolving appendicitis. He was brought to the OR and he had an uneventful appendectomy. On the day following his appendectomy, his diet was advanced without problem. His abdominal pain had completely resolved. He only has mild incisional pain.
OR|operating room|OR|197|198|HOSPITAL COURSE|ALLERGIES: No known drug allergies. HOSPITAL COURSE: The patient was admitted on _%#DDMM2007#%_ for an elective deceased-donor simultaneous pancreas and kidney transplant. The patient was taken to OR that evening. Please see operative note for details. The patient received a simultaneous deceased-donor pancreas and kidney transplant with bladder drainage on _%#DDMM2007#%_ with the pancreas in the right iliac fossa and the kidney transplant in the left iliac fossa.
OR|operating room|OR|186|187|HOSPITAL COURSE|An ultrasound was done to assess for any hydronephrosis or flow abnormalities. Ultrasound revealed very poor arterial blood flow to the grafted kidney. The patient was taken back to the OR for a high degree of suspicious of graft thrombosis. Please see the operative note for details regarding this procedure, which resulted in removal of the graft.
OR|operating room|OR,|217|219|HOSPITAL COURSE|It was determined that the patient had a large amount of fluid in her abdomen and decreasing blood pressure. The decision was made at that time to take the patient to the OR for an exploratory laparotomy. Once in the OR, it was found that the patient had a leak at the proximal duodenal pancreatic anastomosis. See the operative report for specific details. Following a short stay in the ICU to continue to monitor the patient's hypotension, the patient was transferred up to unit 6B for the remainder of her hospitalization.
OR|operating room|OR|178|179|HISTORY OF PRESENT ILLNESS|Currently the patient is on trach dome during the day. He also has a wound VAC placed on _%#MMDD#%_. Today the patient unfortunately has heard that he will need to return to the OR tomorrow as a recent evaluation by the surgeon shows that he needs to have his wound drained again. This patient had his conference scheduled for this Thursday on _%#DDMM2007#%_, however, this will be delayed until next week.
OR|operating room|OR|186|187|IMPRESSION|1. _%#NAME#%_ _%#NAME#%_ is a 51-year-old male with acute sepsis, Klebsiella growing in the blood, including some abdominal pain and found to have a small bowel perforation, went to the OR last p.m. for I&D and had abscess and perforation present. Continues to have low-grade sepsis syndrome. 2. End-stage renal disease on chronic dialysis.
OR|operating room|OR|163|164|ASSESSMENT  AND PLAN|EKG looks like a ventricularly paced rhythm. Underlying rhythm appears to be atrial fibrillation. ASSESSMENT AND PLAN: 1. Status post hip fracture, is planned for OR in the morning. One plan is to deactivate her pacer during surgery. We will ask the rep to assist us with this. She otherwise appears to be medically optimized for the procedure indicated.
OR|operating room|OR|244|245|HISTORY OF PRESENT ILLNESS|Blood pressure at that time was 107. X-rays showed bimalleolar fracture of the right ankle joint with subluxation bordering on dislocation of the talus laterally. She was discharged home and followed up with Orthopedic Surgery. She went to the OR today and underwent ORIF of the right ankle without complications and her postoperative vital signs have been unremarkable.
OR|operating room|OR.|213|215|HISTORY|She is moving all four extremities though as we note is sedated. The major issue at this time appears to be perhaps urine output, as we note only 25 cc over the past two hours and decreasing since return from the OR. PAST MEDICAL HISTORY: 1. Hypertension. 2. Ongoing apparent tobacco use.
OR|operating room|OR.|152|154|ASSESSMENT/PLAN|2) Type 2 diabetes. Insulin sliding scale with q.i.d. Accu-Cheks. 3) Hyponatremia, possibly SIADH. Continue 1500 cc fluid restriction. IV fluids in the OR. Saline lock postoperative if taking p.o. Will follow her sodium. 4) Hypothyroidism. Will recheck her TSH and continue her Synthroid. 5) Pulmonary. Incentive spirometry. 6) Dementia. She is at high risk for delirium.
OR|operating room|OR|280|281|HISTORY OF PRESENT ILLNESS|She denied loss of consciousness or hitting her head. Her airbag deployed and she sustained a contusion on her forehead but no head injury. She had to be extracted from his vehicle. The patient sustained multiple lower extremity fractures bilaterally. She went immediately to the OR for fasciotomies of her left lower extremity, ORIF of her left fibula, left tibial pilon fracture closed reduction and left talon neck attempted closed reduction.
OR|operating room|OR;|387|389|ASSESSMENT AND PLAN|When I went to see the patient in greater detail later in the morning, the patient was severely obtunded and had signs of an acute abdomen; indeed, his lactic acid came back at 16 and the surgeons were deciding to take the patient to he operating room. We discussed the situation and our views with the surgery resident in the ICU; we agreed with the decision to take the patient to the OR; we said we would be happy to continue to be involved in the patient's care if seemed likely to be helpful, but that we thought the problem was not primarily a hematologic one.
OR|operating room|OR|108|109|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ _%#NAME#%_ is a 47- year-old patient who is just now out of the OR after a mitral valve replacement. We were asked to see her and follow her post-op per Dr. _%#NAME#%_. She has a past history, I believe, of asthma, but had been doing well, ib, after the year 2000.
OR|operating room|OR,|201|203|ASSESSMENT AND PLAN|As she is sleepy and just had surgery, I doubt she is going to be able to take p.o. Dilantin. Will have pharmacy dose this for IV equivalent. 3. Oversedation. The patient had 1.3 mg of Dilaudid in the OR, which is a large dose. She also is currently on a PCA pump of Dilaudid 0.1 mg q.10. At present will hold her Dilaudid pump until she is more alert.
OR|operating room|OR|137|138|PLANS|If so, Staph aureus is much more likely than other pathogens. 2. Healthy male. PLANS: Agree with Ancef and gentamicin. Await findings in OR as well as culture. Should not need an extended IV course. Oral antibiotics should be acceptable. HISTORY: This 13-year-old male was in his usual state of health until _%#MM#%_ _%#DD#%_, at which time he was playing on the floor, jumped up and landed on his toe with extension and injury to the toe.
OR|(drug) OR|OR|176|177|REVIEW OF SYSTEMS|CURRENT MEDICATIONS: 1. Coumadin 5 mg once daily, which was stopped on Monday. 2. Timoptic 0.5% ophthalmic solution. 3. Calcium 500 mg supplement two tablets daily. 4. Centrum OR tablets. 5. Humulin R 100 mg units, 16 units q.a.m. and q.p.m. 6. Methotrexate 2.5 mg OR tablet four tablets orally once weekly.
OR|operating room|OR|216|217|HISTORY|When I asked the patient whether she had any lumbar punctures prior to the operation she says "yes", but I do not see any such evidence in the outside record. However, the patient has just come to the floor from the OR and it is possible that she is slightly confused, especially given her background cognitive dysfunction. PAST MEDICAL HISTORY: Significant for 1. Diabetes for 30 years on insulin.
OR|operating room|OR.|172|174|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 100/55, pulse 75, respiratory rate 16, temperature 98.2, O2 sat 97% on 1 liter nasal cannula. He had 2600 cc fluid in the OR. GENERAL: The patient is alert and oriented, no acute distress. HEENT: Pupils are equal, round and reactive to light and accommodating, normal sclerae and normal oropharynx.
OR|operating room|OR|121|122|REQUESTING PHYSICIAN|On admission her labs showed normal hemoglobin, protein and calcium level. She did have quite a bit of blood loss in the OR and dropped her hemoglobin for which she received five units of packed RBC transfusion. She is otherwise a very healthy woman currently working with a review of systems that is fairly unremarkable.
OR|operating room|OR|223|224|HISTORY|The abscess area was drained and a cholecystectomy done with CVD drainage and small bowel was resected and liver biopsy performed plus incidental umbilical hernia repaired. She has been hypotensive since returning from the OR with blood pressure in the 70s. CVP was 12-14. She has had several liters of IV fluids and a liter of Hespan and 2 units of packed cells.
OR|operating room|OR|131|132|HISTORY OF PRESENT ILLNESS|Blood sugar was elevated at 153. CT showed appendicitis and a right lower lobe pneumonia. He was started on Zosyn and taken to the OR where an appendectomy was performed by Dr. _%#NAME#%_. There were no obvious surgical complications. The patient is on a full liquid diet currently.
OR|operating room|OR,|196|198|PHYSICAL EXAMINATION|He has family in town. HABITS: No tobacco, alcohol or drugs. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 35.3 Celsius, blood pressure 120-170s over 90s to 110s in the ICU and were lower in the OR, heart rate 60s-90s, respiratory rate 12 at a set rate of 12, tidal volume 600, PEEP of 5, 100% at 50% FIO2. His weight is 75.2 kg. GENERAL: On physical examination in general he is intubated, sedated and paralyzed.
OR|operating room|OR,|207|209|HISTORY OF PRESENT ILLNESS|She went to University of Minnesota Medical Center, Fairview, _%#CITY#%_ Emergency Department. An abdominal pelvic CT scan showed pneumoperitoneum and incarcerated right ventral hernia. She was taken to the OR, where she underwent exploratory laparotomy, lysis of adhesions, central hernia repair, limited right colon resection with primary anastomosis and ileocolostomy.
OR|operating room|OR|232|233|PLAN|ASSESSMENT: This is a 54-year-old male with acute obstructive hydrocephalus and upward transtentorial herniation resulting from a likely right-sided cerebellar infarct and the resulting mass effect/edema. PLAN: 1. We will go to the OR stat for a posterior fossa decompression. 2. We will give 50 g of mannitol stat. 3. The patient will be intubated at this time. 4. This case represents a life-threatening neurosurgical emergency and will require us to proceed at the time with the presumed consent from the patient though he is unable to give it.
OR|operating room|OR|132|133|PLAN|If the patient continues to require blood transfusions an/or if he becomes hemodynamically unstable he will need to be taken to the OR for cystoscopy with clot evacuation. Since his surgery was so recently performed we would rather try to hold off on this, however, as not to disrupt the anastomosis with his new transplanted kidney.
OR|UNSURED SENSE|OR|217|218|DOB|This is consistent with the patient's own desires to "not treat her cancer". The only other treatment options would be: 1. aromatase inhibitor treatment (Femara/letrozole, Arimidex/anastrozole or eramycin/exemestane) OR 2. Faslodex/fulvestrant (an estrogen receptor antagonist), which is given by monthly injection. Despite these available treatment options, however, it is well known that aromatase inhibitors can "worsen" osteoporosis or underlying bone abnormalities.
OR|operating room|OR,|201|203|HISTORY OF PRESENT ILLNESS|The patient had estimated blood loss of 1100 mL. No complications were noted. At this time, the patient denies chest pain, nausea or vomiting or other acute complaints. She appears comfortable. In the OR, it was noted that the patient had periods when her heart rate varied between 45-90 beats per minute. The patient has had PACs noted on the rhythm strip on the PACU, but otherwise has been hemodynamically stable.
OR|operating room|OR|120|121|HISTORY OF PRESENT ILLNESS|A hematology consult has been done. The workup of her coagulopathy has not yet been determined. The patient went to the OR it looks like again on _%#DDMM2000#%_. She had an estimated blood loss then of 50 cc with 300 cc of lactated Ringer's infused.
OR|GENERAL ENGLISH|OR|157|158|PENICILLIN, BACTRIM, DOXYCYCLINE, AND ZITHROMAX,|She has no previous surgeries. She HAS A NUMBER OF MEDICATION ALLERGIES INCLUDING PENICILLIN, BACTRIM, DOXYCYCLINE, AND ZITHROMAX, ALL OF WHICH PRODUCE RASH OR DIFFICULTY With BREATHING. She REPORTS THAT ERYTHROMYCIN HAS CAUSED PROBLEMS With STOMACH DISCOMFORT. SOCIAL HISTORY: Is that she is single and works as a middle school teacher, I believe in the _%#CITY#%_ School District.
OR|operating room|OR|107|108|CXR|CXR: stable from surgical standpoint A/P Long gap EA Because of scheduling things, he is scheduled for the OR in approximately 4 days. I discussed this with mom at length. She is very dissatisfied with the course. However, I indicated to her that given the current surgical situation, this is the best we can do at present.
OR|operating room|OR|160|161|HISTORY OF PRESENT ILLNESS|A 600 pound high beam fell on his left foot today. He sustained a crush injury. He came to the Emergency Department for evaluation. He was seen and went to the OR for wash out. He will likely require another surgery in the next several days. Postoperatively, I am seeing him and he seemed okay. He has a little bit of cough.
OR|operating room|OR|170|171|IMPRESSION|She is comfortable with that plan and tentatively knows she will be seeing me early in the morning to reexamine and check her progress. Will also tentatively schedule an OR room for tomorrow morning and again we can certainly go sooner if she deteriorates. Thank you for asking me to see this patient in consultation.
OR|GENERAL ENGLISH|OR|203|204|REASON FOR CONSULT|Past surgical history is significant for right total hip arthroplasty, hysterectomy, cholecystectomy, rectocele repair, and bilateral cataract surgery. ALLERGIES: ALLERGY PROFILE INDICATES A SENSITIVITY OR INTOLERANCE TO DARVON WHICH INDUCES NAUSEA. SOCIAL HISTORY: The patient is not a smoker. She has used alcohol in the past but not within the past several months.
OR|operating room|OR|198|199|REASON FOR CONSULTATION|Since doing the intermittent catheterization at bedtime, he has been able to sleep during the night but continues to have some leakage into his diaper. His wife is a nurse that has practiced in the OR in the past and is familiar with sterile and clean techniques and catheterizations, but should have one of the nurses on the floor review the catheterization techniques and observe the wife doing this while the patient is in house.
OR|operating room|OR.|135|137|PHYSICAL EXAMINATION|She states she can't move and she understands this. We can find her a nursing home if this is going to be a few days to get her to the OR. In my opinion, it is not an emergent admission. The patient is declining to leave and she is aware though that it may be a day or two or three to get to the hospital.
OR|operating room|OR|134|135|RECOMMENDATIONS|2. Septic shock secondary to #1. 3. Neutropenia developing secondary to sepsis. RECOMMENDATIONS: 1. The patient is being taken to the OR for ERCP procedure. 2. Discussed with anesthesiologist. They will place a central line in the OR. 3. Following surgery, monitor CVPS, fluid resuscitation pending CVP results and clinical status.
OR|GENERAL ENGLISH|OR|146|147|ALLERGIES|MEDICATIONS: At the time of admission were 1. Hydrochlorothiazide 25 mg daily. 2. aspirin 81 mg daily. ALLERGIES: SHE DENIES MEDICATION ALLERGIES OR INTOLERANCES. REVIEW OF SYSTEMS: She has otherwise has been feeling well without cough, wheeze, hemoptysis, fever or chills.
OR|operating room|OR|229|230|HISTORY OF PRESENT ILLNESS|In the late morning of _%#MM#%_ _%#DD#%_, 2004, she was noted to have some acute mental status changes. She underwent MRI which showed expansion of the right frontal hematoma. Neurosurgery was consulted, and she was taken to the OR for emergent evacuation. There were no intraoperative complications. She was discharged to the ICU and remains intubated. Physical Occupation and Speech Therapy are consulted. As she is below her functional baseline, a Physical Medicine and Rehab consult was requested.
OR|GENERAL ENGLISH|OR|97|98|ALLERGIES|She quit smoking about 1990 when she was 74 or after about 5 decades. ALLERGIES: SHE IS ALLERGIC OR INTOLERANT TO BENADRYL AND DILTIAZEM. MEDICATIONS: Before admission Lanoxin, Levaquin, Tylenol, Lorazepam .5 mg 1 to 1 1/2 tablets bid prn, Advil prn. SOCIAL HISTORY: She is single, lives alone. She has a nephew who is her nearest living relative.
OR|operating room|OR.|199|201|PLAN|The family will consent to this procedure. We will have the interpreter here for a final discussion. She is n.p.o. She has been cleared medically. We will proceed at the soonest convenience with the OR.
OR|operating room|OR,|242|244|DOB|His intraoperative course was unremarkable. Patient is currently without complaints of shortness of breath, cough, wheezing, fevers, chills, chest pain, exertional chest pain, exercise intolerance currently within the last seven days. In the OR, he did receive 2 liters of IV fluids and 300 cc in the PACU. No coronary artery disease, myocardial infarction or heart failure. Patient will be admitted to the Telemetry Unit.
OR|operating room|OR|132|133|ASSESSMENT/PLAN|I have discussed the risks and benefits of surgery in detail and he wishes to proceed. This will be scheduled expeditiously pending OR availability. I have discussed risks, benefits and surgery with him in detail and he wishes to proceed.
OR|operating room|OR.|182|184|IMPRESSION|We will give her vigorous hydration and follow her electrolytes and bicarbonate and nutrition. We will start TPN presumptively tomorrow morning after a central line is placed in the OR. We will adjust the TPN for acute renal failure.
OR|operating room|OR|271|272|PLAN|I have discussed the risks, benefits, and alternatives including but not restricted to infection, anesthesia, bleeding, potential for nonunion, and reoperation. She understands these. She will be preop'd by Dr. _%#NAME#%_. We will plan on fixing this within 24 hours per OR scheduling. Orders will be NPO 8 hours before. We will have her sign a consent for intramedullary nailing, right tibia fracture.
OR|operating room|OR.|154|156|ASSESSMENT AND PLAN|His problems are as follows: 1. Postoperative day zero. This is per urology. We will watch the fluids carefully, as the patient got about 3 liters in the OR. He may need some Lasix, but we will continue to follow. Please note that his preoperative weight was 94 kilograms. We will continue to follow.
OR|operating room|OR.|170|172|PHYSICAL EXAMINATION|The patient will be dialyzed today, _%#DDMM2000#%_. Will try to get her on the operative schedule. Will watch her carefully as she will probably need to be ______ in the OR. The patient is at high risk for loss of limb in both legs. In combination I think she is single, and has a total denial of the problem and a laissez faire attitude about it, but I do not think we are going to change that at this time.
OR|operating room|OR|231|232|REASON FOR CONSULTATION|She did not have any signs of cellulitis, masses and there was no evisceration or obvious dehiscence, but her large amount of serous sanguinous fluid was concerning. Of note, the patient is morbidly obese. Just after my arrival in OR the obstetrics gynecology service removed the skin staples under sterile conditions. The wound was then explored. Both Dr. _%#NAME#%_ and myself evaluated the fascia.
OR|operating room|OR|175|176|ASSESSMENT/PLAN|Preoperative hemoglobin was 14.4. ASSESSMENT/PLAN: 1. Left comminuted distal humerus fracture. The patient is postop day 0. She has possible failure of her fixator and repeat OR eval is pending today. She is currently seen in postop and is stable with no evidence of any cardiac ischemia or fluid overload.
OR|operating room|OR,|154|156|HISTORY OF PRESENT ILLNESS|Pain was ranked from the ambulance of 8/10. In the ambulance her blood pressure was 122/80. Pulse of 120. Respiratory rate 20. O2 SATs in the 80s. In the OR, the patient received 500 cc of Hespan and 3000 cc of lactated ringers, and 300 cc of normal saline. Zosyn was given in the ER. She had elevated LPs were noted in the ER and she had a liver biopsy done in the OR.
OR|operating room|OR|228|229|HPI|He had a roughly 50% improvement of his pain, but because of persistent symptoms a repeat CT scan was performed that revealed a residual mass. Because of this the patient was admitted to the hospital and eventually taken to the OR for abdominal exploration on _%#MM#%_ _%#DD#%_. He is now recovering without incident postoperatively. He has not yet had good bowel recovery but has not noted unusual pain and denies nausea or vomiting.
OR|operating room|OR|192|193|HISTORY OF PRESENT ILLNESS|The patient was discharged from Southdale on _%#DDMM2006#%_, but the next day he had a coughing fit and an abdominal dehiscence. He presented to Fairview Lakes and was taken emergently to the OR where he had an abdominal surgical repair. He continued to ooze from this and his hemoglobin reached a nadir of 6.1. He was transfused 2 units and then it came up to 8.9. He continued to bleed so he was transferred back here to Fairview Southdale.
OR|operating room|OR|213|214|IMPRESSION|Patient tolerated the procedure well and had marked improvement of her pain and range of motion following this. IMPRESSION: Drainage of right arm abscess. This likely will be the definitive treatment and unlikely OR drainage will be necessary. We will follow the patient clinically.
OR|operating room|OR|210|211|HISTORY OF PRESENT ILLNESS|The patient had a follow-up ABG at approximately 6:10 p.m. with a pH of 7.23, pCO2 of 84, pO2 of 77 and bicarb 34. Her O2 sat was 93%. She is now more awake. She did have estimated blood loss of 1800 cc in the OR and did receive two units of PRBCs. Dr. _%#NAME#%_ did review her chest x-ray and said that her lungs on the left did expand after the decortication.
OR|operating room|OR|122|123|ASSESSMENT AND PLAN|Preoperative hemoglobin was 14.4. ASSESSMENT AND PLAN: 1. Cardiomyopathy. He did get 2 liters of Lactated Ringer's in the OR and is on IV fluids now. Given the fact that he is eating, I would recommend stopping his IV fluids.
OR|operating room|OR|271|272|HISTORY OF PRESENT ILLNESS|Abdominal x-ray showed that he had free air and subsequently went to the operating room where he was found to have a gangrenous small bowel and underwent small bowel resection. The patient over the next 24 hours had a persistent lactic acidosis so he brought back to the OR today and nothing was noted. There was no anastomotic leak, and there was no ischemia. The patient remains on vasopressors oxygenating well, but he is requiring 100% 02.
OR|operating room|OR|140|141|IMPRESSION|She understands and consents. She is also aware that conversion to open cholecystectomy is occasionally necessary. She will be taken to the OR this evening.
OR|operating room|OR|315|316|HISTORY OF PRESENT ILLNESS|Ulnar nerve neuropraxic injuries were also discussed. Unless there is a need to open the fracture for alignment, the nerve would not be explored, and we will allow the presumed stretch injury to resolve with time. Other risks and benefits were reviewed. The patient's family understands, and we will proceed to the OR when available.
OR|operating room|OR|164|165|SUMMARY OF CASE|She had her surgical procedure carried out on the night of admission by laparoscopic instrumentation. The procedure was difficult and she had an extended period of OR time. In the postoperative state, she had an ileus and had slowly been improving with only occasional low-grade fevers, but over the past 2 to 3 days she has been having periodic temperature spikes, and she reached 103 degrees last night.
OR|operating room|OR.|358|360|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: We were asked by Dr. _%#NAME#%_ to see this pleasant 54-year-old male who presented with the acute onset of abdominal pain status post an exploratory laparotomy with findings of a perforated duodenal ulcer. We were asked to see him following for postoperative medical management. His perforated duodenal ulcer was oversewn in the OR. According to the patient, his abdominal pain is much better this morning and is controlled with PCA. In retrospect, he noted a fall at work approximately two weeks ago and was started on ibuprofen 600 mg p.o. t.i.d. He does report tobacco use.
OR|operating room|OR.|422|424|ASSESSMENT AND PLAN|Electrolytes: Sodium 135, potassium 4.2, chloride 102, carbon dioxide 26, BUN 21, creatinine 1.0, glucose 193, calcium 9.0, magnesium 1.7, phosphorous 5.0, total bilirubin 14.5, conjugated 4.2, AST 368, ALT 193, alkaline phosphatase 81, total protein 5.5, albumin 2.2. ASSESSMENT AND PLAN: The patient is a 65-year-old male status post cadaveric liver transplant. The patient has a grossly unremarkable course through the OR. He remains intubated on the unit. Neuro: The patient is asleep and intubated. He will remain sedated until his mechanical ventilation is weaned sufficiently for extubation.
OR|operating room|OR|181|182|PLAN|4. Duodenal ulcer with bleeding. 5. Prior history of Lyme's disease, which sounds clear cut, should not be cause of current symptoms. PLAN: Ancef now until cultures are back. Await OR findings of crystals, etc. HISTORY: This 52-year-old male seen in consultation with Dr. _%#NAME#%_, et.
OR|operating room|OR|187|188|HISTORY OF PRESENT ILLNESS|Other than her hip pain, she denies any shortness of breath, chest discomfort, abdominal pain. Remainder of review of systems is noted below. Reviewing of the anesthesia records from the OR reveals the patient developed some hemodynamic instability during the procedure with a drop in blood pressure to the lowest of approximately 85-90 systolic over 50.
OR|operating room|OR|221|222|PLAN|We did review risks of Ommaya reservoir placement, which include infection, bleeding, hematoma, device malfunction and toxicity. She indicates she is aware and is ready to proceed with this procedure. We tentatively have OR set up for Tuesday afternoon at about 4:30. She indicates she will be discharged tomorrow from the hospital, so we will proceed with making outpatient arrangements for admission for surgery on Tuesday, _%#MMDD#%_.
OR|GENERAL ENGLISH|OR|263|264|ALLERGIES|5. Duodenal ulcer. 6. History of generalized osteoarthritis including a prior total knee arthroplasty without evidence of problems present with that. See more details from Dr. _%#NAME#%_'s note from _%#DDMM2004#%_. ALLERGIES: WHETHER THERE IS A TRUE ALLERGY HERE OR NOT IS UNCLEAR. FAMILY HISTORY: Nothing relative to the current illness. SOCIAL HISTORY: Much of the recent time in the nursing home but has been home more recently.
OR|operating room|OR|225|226|HISTORY OF PRESENT ILLNESS|In the two to three days prior to her admission she began to note pain, swelling, and redness in the area of the right hip incision. She was seen by Dr. _%#NAME#%_ and admitted to the hospital. Yesterday she was taken to the OR where she had debridement of the wound. It sounds as though this may have been a more superficial wound and not around the hardware.
OR|operating room|OR|197|198|HISTORY OF PRESENT ILLNESS|After discharge he almost immediately started having increasing abdominal pain with generalized fevers, chills, nausea and malaise. A subsequent CT scan here showed a leak. He was then brought the OR and had closure of the leak. He had some peritonitis at surgery but it was apparently not too bad, including no major or significant abscess formation.
OR|operating room|OR,|230|232|LABORATORY DATA|No ischemic change. White count 4000 on _%#DDMM2003#%_, with hemoglobin 13.6, platelet count 146,000, sodium 141, potassium 4.5, chloride 102, C02 28, BUN 13, creatinine 0.8, glucose 89. EKG rhythm strip at 9:03, I believe in the OR, demonstrated periods of normal sinus rhythm with periods of bigeminy, with occasional multifocal couplet. ASSESSMENT: 1. Arthroscopic left knee surgery with left tibial corticotomy and application of circular fixator for left lower extremity discrepancy.
OR|operating room|OR|99|100|HISTORY OF PRESENT ILLNESS|The site of the Camino was clean, dry, and intact. The plan for this patient is to take him to the OR for mainstem bronchus repair. The case will be discussed with Dr. _%#NAME#%_
OR|operating room|OR|274|275|REASON FOR CONSULTATION|REASON FOR CONSULTATION: Were we asked by Dr. _%#NAME#%_ to evaluate the patient for abdominal pain and history of Crohn's disease and possible Crohn's exacerbation. In the interim and underwent a CT scan which showed free air in the abdomen and was taken emergently to the OR by general surgery at which time resection of terminal ileum as well as a part of right colon. PAST MEDICAL HISTORY: His pertinent past medical history is remarkable for a history of Crohn's ileitis, he underwent a small resection in 2003, for presumed appendicitis.
OR|operating room|OR|210|211|SUBJECTIVE|REASON FOR CONSULTATION FOLLOWUP: Surgical planning for symptomatic left pleural effusion. SUBJECTIVE: I am seeing Mr. _%#NAME#%_ in followup for symptomatic left pleural effusion. Because of the timing in the OR and several emergencies there, we cannot perform his left VATS pleurodesis today. Because in the interim he has increasing shortness of breath in interviewing him, we need to drain the fluid today, and I have discussed this with him.
OR|operating room|OR.|186|188|IMPRESSION|Chronic obstructive pulmonary disease. The patient is also a current smoker. Continue with her MDIs and give her perioperative nebulizers as needed with one Albuterol neb on-call to the OR. A nicotine patch is also made available. The patient has slight elevation of her BUN and creatinine.
OR|operating room|OR|194|195|ASSESSMENT|b. Therapeutic bronchoscopy. c. Elective intubation for this procedure with brief mechanical ventilation given the degree of hypoxemia. d. No Intensive Care Unit beds available, will plan to do OR with anesthesia. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a _%#1914#%_ female who has a history of osteoporosis and Paget's Disease with osteitis deformans who presented with increasing left leg pain.
OR|operating room|OR|161|162|HISTORY OF PRESENT ILLNESS|In the recovery room, the patient has received 50 mg of IV Benadryl, 8 mg of IV Decadron, 125 mg of IV Solu-Medrol and two doses of IV Demerol. In review of the OR record, he received Marcaine with epinephrine, as well as 1% lidocaine with epinephrine mixed with sodium bicarbonate. His anesthetic was fentanyl and midazolam, as well as propofol.
OR|GENERAL ENGLISH|OR|469|470|ALLERGIES|She is status left tympanoplasty. She is a nonsmoker. MEDICATIONS BEFORE ADMISSION: Medrol Dosepak started yesterday by her clinic for dyspnea, Singulair 4 mg daily, Effexor 150 mg daily, Pulmicort, the intake says two puffs b.i.d. but I would suspect it is one puff b.i.d. because it is a turbo inhaler; Ambien 10 mg q.h.s., albuterol nebulizations or inhaler p.r.n., Tylenol p.r.n. CURRENT MEDICATIONS: Also include prednisone 40 mg a day. ALLERGIES: SHE IS ALLERGIC OR INTOLERANT TO PENICILLIN, ERYTHROMYCIN, SULFA, AND VELOSEF. She developed a rash with the antibiotics. FAMILY HISTORY: Noncontributory except that her 3-year-old son has been ill recently with a respiratory syndrome similar to hers, as have her students.
OR|operating room|OR|188|189|REASON FOR CONSULTATION|Prior to the hospitalization, the Coumadin was held for 3 or 4 days and she was treated with Lovenox. On admission, she had a normal CBC and the INR was 1.09. The patient was taken to the OR where she underwent TAH, BSO, appendectomy and low anterior resection of what proved to be a diverticular abscess involving and extending to the ovary.
OR|operating room|OR|227|228|PLANS|4) Hypertension. 5) Mild renal insufficiency. PLANS: Continue the Zosyn, which is covering the isolated Proteus and also other similar pathogens. Needs amputation of at least that toe and probably more tissues than that. Await OR plans from Orthopedics. Will add vancomycin for gram-positive coverage. HISTORY: This 48-year-old male is well known to me from prior admissions.
OR|operating room|OR,|219|221|IMPRESSION|Further wound management per surgery and Dr. _%#NAME#%_. In regards her type 2 diabetes, I would continue with her oral agents following her labs closely while she is on the metformin. If she does require a trip to the OR, we would consider holding some of these medications. In the interim, she will showed get q.i.d. Accu-Cheks and utilize the regular sliding scale.
OR|operating room|OR|142|143|DOB|Apparently this had shown approximately 300 cc of frank blood per Dr. _%#NAME#%_'s report. With the obstruction, however, he was taken to the OR by Dr. _%#NAME#%_ and an adhesion was traversed, and actually he stabilized quite easily. He has had an NG tube in place now since surgery with only a few hundred cc of what appears to be old blood.
OR|operating room|OR|159|160|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: He denies any cardiovascular, respiratory, gastrointestinal, or urinary symptoms. He had a Foley placed by Dr. _%#NAME#%_ in Urology in the OR as they had difficulty passing a Foley due to phimosis. Foley is draining clear yellow urine. MUSCULOSKELETAL: Please see history of present illness.
OR|operating room|OR,|129|131|LABORATORY DATA|He is interested in proceeding ahead. He understands there is a high probability this will have to be open. Will take him to the OR, attempt closed reduction under general anesthesia with her paralysis, if that does not work, do an open. There is the possibility things could bye broken and deranged, could require future surgical intervention.
OR|operating room|(OR)|278|281|HISTORY|There was some evidence of diverticulitis and this was thought to be the mechanism by which the sigmoid perforated. She underwent a sigmoid colectomy, Hartmann pouch. Postoperatively, she had persistent hypotension and drop in her hemoglobin and went back to the operating room (OR) for re-exploration but no source of bleeding or other problems were found. The bowel reportedly looked quite good. Since that time, she has done quite well.
OR|operating room|OR.|208|210|ISSUES WHILE IN THE HOSPITAL|3. Respiratory compromise. Intubated for airway protection and hypoxia and agitation. The patient has been on minimal sedation and was on propofol since his last intubation on _%#MM#%_ _%#DD#%_, 2006, in the OR. On _%#MM#%_ _%#DD#%_, 2006, we tried to wean the propofol off and started the patient on fentanyl gtt. and also started the patient on scheduled Haldol. The goal is to get him off propofol and extubate him when his agitation improves.
OR|operating room|OR|200|201|HOSPITAL COURSE|She was treated conservatively and went to a nursing home for an anticipated short term stay on _%#MMDD#%_. She presented early this morning with severe left lower quadrant pain. She was taken to the OR by Dr. _%#NAME#%_ at which time a laparotomy showed multiple abnormalities prompting a sigmoid resection and a resection of a small segment of small bowel.
OR|operating room|OR.|193|195|HISTORY OF PRESENT ILLNESS|His blood gases revealed that he was in acute respiratory failure with respiratory acidosis. He required intubation but due to complications with his airway, required surgical treatment in the OR. PAST MEDICAL HISTORY: 1. Hypertension 2. Coronary artery disease
OR|operating room|OR|142|143||_%#NAME#%_ is an 80-year-old woman I am asked to see in consultation by Dr. _%#NAME#%_ for postoperative pain management. She received in the OR intrathecal Marcaine and fentanyl around 0700 and then a right femoral nerve block single shot also at that time. She also did not receive any opioid in the pack q.
OR|operating room|OR|342|343|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 85-year-old female, admitted with acute abdominal pain, starting at 6:00 am this morning, which occurred in a band across her mid abdomen associated with nausea and vomiting. She was brought into the ER by her granddaughter. The patient was diagnosed with volvulus by CT and brought to OR this evening with resection of ischemic ileum and right colon. The patient was seen in PAR by internal medicine. At that time she was initially still sedated and intubated.
OR|operating room|OR|151|152|ASSESSMENT/PLAN|4. Fluids electrolytes and nutrition: Will start normal saline at 65 cc per hour. The patient did receive aggressive IV fluids boluses and has been in OR today. 5. Code status: Son to bring in health directives in am. Currently per son the patient wishes are DNR/DNI and further clarification will be performed in am.
OR|GENERAL ENGLISH|OR|312|313|ALLERGIES|PAST MEDICAL HISTORY: Significant for COPD as above, hypertension, prostate cancer, gastroesophageal reflux, hearing loss (he wears a hearing aid), tonsillectomy and adenoidectomy in 1948, hemorrhoidectomy in 1975, right TKA in 1990, left TKA in 1993, prostatectomy in 1995 for cancer. ALLERGIES: HE IS ALLERGIC OR INTOLERANCE TO AUGMENTIN, which upset his stomach, AND MORPHINE, which caused headache. MEDICATIONS BEFORE ADMISSION: Calan SR 240 mg daily, Prinivil 10 mg daily, Combivent two puffs q.i.d., hydrochlorothiazide 25 mg daily, Prilosec 20 mg daily, prednisone tapering dose 20 mg a day.
OR|operating room|OR|263|264|HISTORY OF PRESENT ILLNESS|The mass was found to measure 8 cm, and pathology report demonstrated it to be a high-grade sarcoma, grade 3 of 3, most likely malignant fibrous histiocytoma. At that same surgery, a hernia repair was performed after excision of the shoulder mass, but with a new OR setup, according to the operative report. Because of the histology, Mr. _%#NAME#%_ was referred to Dr. _%#NAME#%_ _%#NAME#%_ at Fairview-University Medical Center.
OR|operating room|OR|394|395|PE|Will ensure that _%#NAME#%_ _%#NAME#%_ reviews spirometry with Dr. _%#NAME#%_ --> Will schedule levalbuterol nebs QID for assistance with pulmonary toilet. Hx of accelerated idioventricular rhythm (will try to find more details), so not using albuterol. --> Discussed with patient importance of pulmonary toilet --> Done w/10d levofloxacin today for decline in PFTs at clinic. s/p ertapenem in OR (lasts for 24h). Will discuss further antibiotics w/Dr. _%#NAME#%_ in a.m. 2) Heart failure Has severe systolic heart failure.
OR|operating room|OR,|146|148|IMPRESSION|Postoperatively, relatively early on, has had some degree of wound drainage and now progressive worsening without major systemic symptoms. In the OR, it was not clear how deep it went, although did have debridement down the screws with rod of course still in place, all cultures from surgery are growing Staph aureus with sensitivities to follow.
OR|operating room|OR|216|217|HISTORY OF PRESENT ILLNESS|He was back to the OR 2 days later on, _%#DDMM2007#%_ again, for a washout of his left subphrenic abscess. During that operation he was evaluated to probably have an intracutaneous fistula. Again, he was back to the OR on _%#DDMM2007#%_ for change of his wound VAC. The patient was back to the OR yesterday for a wound VAC change. Today he is denying significant abdominal pain. He has no nausea or vomiting.
OR|operating room|OR|203|204|ASSESSMENT AND PLAN|No stridor. CARDIOVASCULAR: Brisk capillary refill. ASSESSMENT AND PLAN: 1. 39-year-old man, 7 days status post tonsillectomy and septorhinoplasty now with a post tonsillectomy bleed, active. 2. Planned OR on an emergent basis for cautery of the active oropharyngeal bleeding. 3. Admit to the floor for observation. 4. IV fluids at maintenance.
OR|operating room|OR|163|164|HISTORY|There was a drop in one sat that was 92 and she was 97 or above, end tidals were 35 to 42. The case was very brief with general anesthesia. She was febrile in the OR of 103.9. She was extubated and was on ten liters, then she required increasing amount of O2 and became in more distress and the hospitalist then saw the patient and recommended transferred to the ICU which has been accomplished.
OR|operating room|OR|234|235|IMAGING|I discussed this with both the daughter and the patient, and the patient would like to proceed with the surgery. The family is aware of the complications and has decided to proceed, so we will go ahead with that this evening when the OR has time available.
OR|operating room|OR|188|189|ASSESSMENT AND PLAN|He is best served by operative intervention likely in the form of left hip hemiarthroplasty. I discussed risks, benefits of surgery in detail with them. Surgery will be performed, pending OR availability. They understand that that likely may not occur pending OR availability of this. They wished to proceed. Also, they understand that this will be likely performed by my partner, Dr. _%#NAME#%_, based upon OR availability.
OR|operating room|OR|334|335|7.  FEN/GI|She had no tenderness on bony points and spine MRI on _%#DDMM2006#%_ showed a disc bulge T11-T12 and L5-S1 without significant spinal canal or neuroforaminal narrowing suggestive of mild degenerative disc disease. Postoperatively, the patient complained of sore throat. The patient has sore throat likely related to intubation in the OR as well as stiff muscular neck pain, which decreased with Tylenol, morphine, Valium p.r.n. 7. FEN/GI: On admission, the patient was initially placed on p.o. diet appropriate for age.
OR|operating room|OR|143|144|FAMILY HISTORY|3. Pulmonary: The patient has a history of COPD and history of pulmonary embolus. She did undergo reversal of her anticoagulation prior to the OR and was placed on heparin. She was discharged on her Coumadin. 4. Cardiovascular: The patient has a history of MI with cardiac catheterization and an adenosine stress test showed milt-to-moderate ischemia.
OR|operating room|OR,|243|245|ADMISSION MEDICATIONS|She did collect poorly for stem cells. She had 1 stem cell collection, and collections were ended due to less than 0.1% CD 34 per kg. The patient was allowed to recover, and she then had a bone marrow harvest. The patient was harvested in the OR, and bone marrow was infused. Complications of the recent transplant include a neutropenic fever, enlargement of pulmonary nodules.
OR|operating room|OR|247|248|HISTORY OF PRESENT ILLNESS|Cystoscopy and proctoscopy were also performed at that time. Different treatment modalities were discussed with the patient, including total pelvic exenteration for this central recurrence. The patient desired this procedure, and was taken to the OR on _%#DDMM2003#%_, where she had a total pelvic exenteration with Miami pouch created, as well as a neovagina. She also did receive radiation treatment with iridium needles. The patient subsequently had been following up with the clinic as well as interventional radiology, as she had bilateral nephrostomy tubes in place at the time of her discharge from her previous surgery.
OR|operating room|OR.|212|214|PROBLEM #7|She was started on Macrobid 100 mg q.d. for prophylaxis and she will be d/c to the Rehabilitation Center with this Foley in place. PROBLEM #7: Infectious Disease. She received one gram of Ancef IV on call to the OR. The patient was afebrile throughout her hospitalization. She was started on Macrobid 100 mg p.o. q.d. prophylaxis for an indwelling Foley catheter.
OR|operating room|OR|209|210|HOSPITAL COURSE|HOSPITAL COURSE: The patient was pre-admitted and had anesthesia consult preoperatively secondary to her cardiac history. Clearance was obtained for her surgery. On _%#DDMM2002#%_ the patient was taken to the OR where she had radical vulvectomy with bilateral inguinofemoral lymph node dissection, direct inguinal hernia repair. This was done under general anesthesia with EBL of 350 cc.
OR|operating room|OR|246|247|PREOPERATIVE HOSPITAL COURSE|Therefore, after clearance was obtained, it was clear the patient needed definitive surgical management for diagnosis and treatment of her ascites. Therefore, preoperative bowel prep was planned, and an ICU bed was reserved prior to going to the OR for postoperative care. PROCEDURES: On _%#DDMM2004#%_, the patient underwent exploratory laparotomy, bilateral salpingo-oophorectomy, supracervical hysterectomy, omentectomy, appendectomy and suboptimal debulking with Dr. _%#NAME#%_.
OR|operating room|OR|181|182|HOSPITAL COURSE|HOSPITAL COURSE: 1. Fluid, electrolytes, nutrition. The patient was placed on maintenance IV fluids, and NG to suction with fluid replacement for NG secretions. When he went to the OR on _%#DDMM2002#%_, he had a PICC line placed, and was maintained on TPN when he was NPO after surgery. This was DC'd on _%#DDMM2002#%_. His electrolytes remained stable throughout his admission.
OR|operating room|OR|155|156|HOSPITAL COURSE|As mentioned before, the patient's MRI had showed a fluid collection which was felt to be cervical epidural abscess. The patient was urgently taken to the OR to perform a C5-C6 and C6-C7 discectomy and drainage of the anterior epidural space fluid collection. At the same time, the patient's posterior wound which was opened on admission was washed out and packed.
OR|operating room|OR|358|359|OPERATIONS, PROCEDURES, AND SIGNIFICANT RESULTS|Gastroenterology and liver transplant surgeons were consulted. Mr. _%#NAME#%_'s case was discussed at the liver transplant meeting, where a decision was made to place an indwelling peritoneal catheter to drain the ascitic fluid with an abdominal binder. This was suggested as a trial; however, if this trial fails, in 2-4 weeks the surgeons will take him to OR for repair of the fascial dehiscence and placement of the catheter again to control the ascites. All of these discussions and meetings were explained extensively to the patient and to his family.
OR|GENERAL ENGLISH|OR|159|160|ALLERGIES|THE PATIENT DENIES THIS. SHE ALSO HAS ALLERGY LISTED TO ASPIRIN. CLINIC CHART NOTES SPECIFICALLY STATES PATIENT HAS NOT HAD REACTIONS WITH SHORTNESS OF BREATH OR RASH WITH ASPIRIN USE. THE PATIENT IS UNAWARE WHAT HER REACTION HAS BEEN. UPON FURTHER QUESTIONING, THIS PATIENT STATES THIS MAY BE DUE TO BEING TOLD TO AVOID ASPIRIN WITH HER HISTORY OF GASTRIC ULCERS.
OR|operating room|OR|118|119|HOSPITAL COURSE|The patient was found to have a wound dehiscence in the upper half of the incision. The patient was taken back to the OR under antibiotic coverage, and the patient underwent dehiscence repair. At this time, the patient did not have her skin closed. She had retention sutures placed. She had wound dressing changes with wet-to-dry gauze during the hospital stay.
OR|operating room|OR|133|134|ASSESSMENT AND PLAN|He is going to be splinted in the ER. We will get Orthopedic consultation. Given his renal failure, he will not be able to go to the OR tomorrow if that is required. Will provide pain control. 7. Type 2 diabetes, poor control. Will place him back on his usual Lantus with high resistance to insulin, sliding scale.
OR|GENERAL ENGLISH|OR|163|164|CURRENT ISSUES|He is on other medical regimen to prevent hepatic encephalopathy which includes rifaximin and also zinc sulfate. IF THE PATIENT CONTINUED TO REFUSE LACTULOSE P.O. OR PER RECTUM, PLEASE CONSIDER STARTING THE PATIENT ON SODIUM BENZOATE. We also anticipate a tunnel catheter insertion on _%#DDMM2006#%_ for him to get outpatient dialysis.
OR|operating room|OR|144|145|HOSPITAL  COURSE|She had pain over the left lower extremity. X-ray showed left intertrochanteric hip fracture. Orthopedic surgery was consulted. She went to the OR and tolerated the above procedure. She tolerated this well, however, she did have some postoperative anemia with hemoglobin in the 7 range.
OR|operating room|OR|302|303|PROBLEM #2|_%#NAME#%_'s electrolytes remained stable throughout her hospital stay. She did have two episodes of slightly low glucose levels in the high 40s and low 50s. On recheck her glucose levels were normal. She did remain on her multivitamin q.d. PROBLEM #2: Genitourinary: _%#NAME#%_ did come back from the OR with a Foley catheter in placed given her history of perineal breakdown during chemotherapy. The Foley remained in place for the first day and a half of admission, at which time, it was discontinued because the suspected chemotherapeutic agents were already administered by that time.
OR|operating room|OR|182|183|ALLERGIES|INR was 1.08, APTT was 31 seconds, preoperative hemoglobin is 17.9, preoperative platelets 224, ALT elevated at 55, AST elevated at 102. HOSPITAL COURSE: 1. Patient was taken to the OR on _%#MM#%_ _%#DD#%_, 2005. Prior to induction of anesthesia, patient had an episode of emesis and was felt to have aspirated gastric contents.
OR|operating room|OR|171|172|HOSPITAL COURSE|7. Status post appendectomy. 8. Status post incisional biopsy of breast with benign pathology. 9. Status post tonsillectomy. HOSPITAL COURSE: The patient was taken to the OR on _%#DDMM2006#%_. Mediastinal nodes were sent to pathology for frozen section evaluation, which showed it was negative and then the surgeons proceeded with thoracoscopic left upper lobectomy.
OR|operating room|OR.|198|200|5. GI|She was placed on Bactrim prophylaxis and will return 10 days postoperative for a trial of void and Foley catheter removal. 7. Infectious Disease: The patient received IV antibiotics on call to the OR. She received Ancef 2 g. The patient remained afebrile throughout her hospital course. She was also placed on Bactrim prophylaxis while her Foley catheter is in place.
OR|operating room|OR|276|277|HOSPITAL COURSE|We then consulted general surgery while in the intensive care unit, and they recommended an exploratory laparotomy to rule out a toxic megacolon or ischemic bowel that may be causing the patient's profound sepsis and lactic acidosis. The patient was subsequently taken to the OR early in the morning on _%#MM#%_ _%#DD#%_, 2006, and an exploratory laparotomy, total colectomy, and damage control closure was performed by Dr. _%#NAME#%_.
OR|operating room|OR|387|388|HOSPITAL COURSE|PAST SURGICAL HISTORY: Significant for total abdominal hysterectomy, inferior vena cava filter placement in _%#MM2007#%_, history of horizontal banded gastroplasty approximately 20 years ago, status post duodenal switch with splenectomy in _%#MM2007#%_. HOSPITAL COURSE: Ms. _%#NAME#%_ was admitted on _%#DDMM2007#%_ with persistent perigastric fluid collection. The patient went to the OR with Dr. _%#NAME#%_'s and thoracic surgery to undergo esophagogastroscopy and this was combined with Interventional Radiology placement of drain into the area.
OR|GENERAL ENGLISH|OR|151|152|ALLERGIES|14. omeprazole 20 mg p.o. daily. 15. Multivitamin one tablet p.o. daily. 16. Spiriva one inhalation 1 puff daily. ALLERGIES: APPEARS TO BE ORAL KEFLEX OR WHATEVER MEDICATION HE WAS JUST PRESCRIBED BY CARDIOLOGY FOR HIS PROPHYLAXIS PER PATIENT. FAMILY HISTORY: Father died of pancreatic cancer. Mother died of unknown cause.
OR|operating room|OR|223|224|HOSPITAL COURSE|Dr. _%#NAME#%_, the cardiologist who saw this patient, recommended that he would not need a coronary angioplasty based on his stress thallium. But, the best thing to do would be for him to have pulmonary artery line in the OR to monitor pulmonary capillary wedge pressure and his volume status. Also, he would need to be adequately coagulated with a goal of an INR between 2 and 3.
OR|operating room|OR.|213|215|DISPOSITION AT DISCHARGE|Both Echo reports were preliminary reports at the time of transfer. Final readings were pending. _%#NAME#%_ _%#NAME#%_ had thrombocytopenia requiring a platelet transfusion on _%#DDMM2004#%_ prior to going to the OR. Her platelet count of 83,000 prior to the transfusion was her lowest during hospitalization. At transfer, her platelet counts was 184. _%#NAME#%_ was diagnosed with transient myleoproliferative disorder after having increased blasts in her WBC differential.
OR|operating room|OR.|145|147|LABORATORY DATA|The calcium was 7.9, and INR was 1.8, this was up from 1.38 on _%#DDMM2007#%_. It is noted that he was transfused at the outside hospital in the OR. His hemoglobin on his _%#MMDD#%_ admission and was 16.2 and fell to 8.7 on _%#DDMM2007#%_. Hemoglobin recheck as of _%#DDMM2008#%_ was 10.0. His RDW on admission was 13.8 and MCV was 100.
OR|operating room|OR|169|170|OPERATIONS/PROCEDURES PERFORMED|2. On _%#MM#%_ _%#DD#%_, 2005, he was returned to the OR for surgical transection of his IVC and right autograft of his left renal vein. 3. He then returned back to the OR on _%#MM#%_ _%#DD#%_, 2005, for placement of a tunneled hemodialysis catheter. 4. He also received hemodialysis while inpatient. 5. Multiple renal ultrasounds during his stay.
OR|operating room|OR,|188|190|396,000.  BMP|She was metoprolol for her rate control as well as hypertension. She was being followed on telemonitoring and by cardiology. Cardiology recommended using IV beta blockers as needed in the OR, which was done. Postoperatively the patient continued on metoprolol, as well as Coumadin and heparin for a history of atrial fibrillation.
OR|GENERAL ENGLISH|OR|196|197|ALLERGIES|ALLERGIES: MSG WHERE HE HAS HAD ANAPHYLAXIX AND BETA BLOCKERS WHERE HE HAS HAD FATIGUE. ALSO LISTED ON HIS CHART ARE PERCOCET, PROPAFENONE, FLECAINIDE, DILTIAZEM, AMIODARONE-ALL CAUSING HEADACHES OR NAUSEA. VERAPAMIL HAVING EFFECT AS LISTED AS JUST CARDIAC. PAST MEDICAL HISTORY: 1. Allergy to MSG and medications listed above. 2. Atrial fibrillation.
OR|operating room|OR,|215|217|HOSPITAL COURSE|4. GI. _%#NAME#%_ experienced some nausea and vomiting status post Hickman placement and once during hemodialysis. After such time, no increased episodes of nausea or vomiting occurred. 5. Heme. Upon admission from OR, hemoglobin was 6.6. Post dialysis hemoglobin recheck was 12.3, and upon discharge hemoglobin was 12.5. DISCHARGE INSTRUCTIONS: 1. Diet. Continue specialized renal diet that _%#NAME#%_ has already been following.
OR|operating room|OR|260|261|PROBLEM #4|_%#NAME#%_ tolerated this well. PROBLEM #3: Cardiovascular. The patient remained hemodynamically stable throughout this admission. PROBLEM #4: Respiratory. The patient remains on tracheostomy throughout this admission. His tracheostomy tube was changed in the OR on _%#MM#%_ _%#DD#%_, 2004. He was continued on his Pulmicort and albuterol and tobramycin nebs. The tobramycin nebs were discontinued after a full 14 days of antibiotics.
OR|operating room|OR|159|160|HOSPITAL COURSE|Rectal exam was performed. There were no masses palpated. Guaiac was performed and found to be hemoccult positive. HOSPITAL COURSE: 1. The patient went to the OR on _%#MM#%_ _%#DD#%_, 2005. Final pathology came back as papillary serous endometrial carcinoma. The procedure performed was exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, and partial omentectomy with bilat eral pelvic and periaortic lymph node dissection.
OR|operating room|OR|234|235|HOSPITAL COURSE|Upon admission here to the Fairview University Hospital, the patient went to the operating room and underwent incision and drainage and debridement of the abscess. A wound V.A.C. was applied. The patient subsequently went back to the OR 5 more times for wound V.A.C. changes per Pediatric General Surgery. On the patient's last visit to the ER on _%#DDMM2007#%_, the wound V.A.C. dressing was removed and the area was irrigated copiously.
OR|operating room|OR.|145|147|HOSPITAL COURSE|_%#NAME#%_ did receive fresh frozen plasma on _%#MM#%_ _%#DD#%_, 2005, for an INR of 1.3, PTT of 40, and fibrinogen of 650 prior to going to the OR. He was then started on vitamin K 5 mg p.o. daily for his coagulopathy. _%#NAME#%_ was entered into this _%#PROTOCOL#%_ study protocol for Hodgkin's lymphoma.
OR|operating room|OR|408|409|HOSPITAL COURSE|There is a second posterior esophageal fistula fusion of C5 through C7 vertebra with bony erosion destruction of the anterior C5-C6 vertebra, unchanged. After receiving the results of the CT scan and the esophagogram, explanation of the risks, benefits and alternatives of surgical treatment was discussed with the patient and informed consent was obtained and the patient on _%#DDMM2007#%_ was taken to the OR suite for incision and drainage of a deep abscess of his neck and esophagostomy and placement of plastics salivary stent.
OR|operating room|OR|252|253|BRIEF HOSPITAL COURSE|The patient was brought to the emergency room via EMS from her nursing home after it was noticed that there was evisceration through the abdominal wound from prior surgeries and there were bowel contents at the open wound. The patient was taken to the OR shortly after presentation. The wound was explored and an ileal diversion with enterostomy was repeated and 2 JP drains were placed.
OR|operating room|OR.|178|180|HISTORY OF THE PRESENT ILLNESS|He says his blood pressures have been well controlled on the Coreg and the Diovan. He notes his "blood pressures just shoot up when I'm around doctors." He is just back from the OR. His AICD was restarted. There was no complications from the record. The patient has no complaints at this time. He is currently on Lactated Ringers at 75 cc.
OR|operating room|OR|151|152|HISTORY OF PRESENT ILLNESS|We do not have the scans or the reports, but she states that these were negative. She was then referred to the Mayo Clinic, where she was taken to the OR on _%#MM#%_ _%#DD#%_, 2001. Initially a vaginal approach was utilized and the nodule was biopsied. Frozen section demonstrated a grade II adenocarcinoma. This procedure was then changed to a laparotomy and she underwent resection of her right vaginal fornix.
OR|operating room|OR|165|166|HISTORY OF PRESENT ILLNESS|The patient states she has been using opiates for several years due to chronic back pain. She states she initially hurt her back in 1991 while she was working as an OR nurse. Since then, she has had 3 back surgeries. She currently rates her low back pain as 6/10 and notes it to be in the SI region bilaterally.
OR|operating room|OR|172|173|HISTORY OF PRESENT ILLNESS|He sustained multiple injuries including pelvic and sacral fractures, he had an open right forearm and wrist fracture as well as a left knee effusions. He was taken to the OR immediately for temporary stabilization with an external fixator of his right forearm. He also had repair of facial lacerations under anesthesia. From the time of his accident throughout his early evaluation his Glasgow coma score was 15.
OR|operating room|OR|180|181|HISTORY OF PRESENT ILLNESS|After his arrival Dr. _%#NAME#%_ determined that the fracture did not involve the fusion mass but primarily the patient had zone 1 injuries of the sacrum. He therefore went to the OR on _%#MMDD#%_ for percutaneous ileal sacral screw fixation and application of pelvic external fixator. He also had exploration of the right forearm wound by Dr. _%#NAME#%_ who put did a split thickness skin grafting on the right forearm wound using the right thigh as the donor site.
OR|GENERAL ENGLISH|OR|276|277|COMMENT|His performance became more prone to error on the inhibition/switching task, possibly in response to his realizing he was making errors but not being able to adjust his behavior to such a complex task. Thus, the more steps he had to perform (remembering to name the ink color OR read the word, depending on context), the worse his performance became. _%#NAME#%_ seemed to have difficulty attending to more than one aspect of a situation.
OR|operating room|OR.|182|184|REASON FOR CONSULTATION|The vascular surgery service evaluated him, but because of his connection with an outside surgeon, an eminent followup appointment was done. They have not planned to take him to the OR. Finally, this patient had a pain consultation for this admission to assist with management of pain from his right hand finger lesions and also pain due to a sacral ulcer.
OR|operating room|OR|421|422|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 65-year-old white female with a history of asthma, allergic rhinitis, gastroesophageal reflux disease, elevated cholesterol, osteoporosis, phlebitis, recurrent UTIs and osteoarthritis who is admitted electively following a left total knee arthroplasty by Dr. _%#NAME#%_ _%#NAME#%_ on _%#DDMM2003#%_ for a history of chronic left knee pain and osteoarthritis. In the OR the procedure was done under spinal anesthesia. The patient had an estimated blood loss of 50 cc, urine output of 200 cc and received 1000 cc of lactated ringer's.
OR|operating room|OR.|140|142|CLINICAL IMPRESSION|In regards to preoperative pain medication recommendations: If not contraindicated, would dose him with 30 mg IV Toradol x1 hour on-call to OR. Would also consider giving him 1 dose of Neurontin 300 mg p.o. x1 prior to being NPO the day prior to surgery. I would consider changing the time interval on his current Vicodin which is 1-2 tablets to q.4 from the current q.6h. p.r.n. One could also consider changing him to straight oxycodone 5-10 mg p.o. q.2-4h. p.r.n. for pain management.
OR|operating room|OR|164|165|HISTORY OF PRESENT ILLNESS|She has received leech therapy for the last week. The plan is for her to have this through the next few days. There is a possibility she will have to return to the OR to have her flap repaired. However, this might not be for at least the next few weeks. Another post-op complication is significant right quadriceps weakness of 1/5.
OR|operating room|OR|161|162|HISTORY OF PRESENT ILLNESS|The patient has received teaching for changing the ostomy bag and also teaching for TPN replacement. There was a discussion with the patient of returning to the OR in about 6 to 8 weeks to reattach the GI tract. On discharge, the patient is ambulating with the NG tube clamped while taking clear liquids.
OR|operating room|OR|155|156|HOSPITAL COURSE|4. Left AV fistula placement, 2004. 5. CABG x 4, 2004. HOSPITAL COURSE: She was admitted on _%#DDMM2004#%_. It was determined that she needed to go to the OR for surgical wound debridement. Over the course of 24 hours, she was started on vancomycin, and while she was febrile before the hospital stay, she became afebrile.
OR|operating room|OR|161|162|ADMISSION DIAGNOSIS|ENoG study demonstrated a 5% remaining function in the nerve. He was, therefore, a candidate for emergent decompression of the facial nerve. He was taken to the OR on the evening of _%#MM#%_ _%#DD#%_, 2005. The procedure was successful in that the nerve was adequately decompressed and visualized.
OR|operating room|OR|209|210|HOSPITAL COURSE|He also had mild abdominal pain. He also had some hypertensive episodes, and Norvasc was started. He continued to improve until _%#DDMM2002#%_ when he developed severe abdominal pain. He was taken back to the OR and had primary repair of small bowel perforation. He did well subsequent to that and was discharged on _%#DDMM2002#%_. He will follow up in the Surgery Clinic. He had good kidney and liver function at the time of discharge and was tolerating a regular diet.
OR|operating room|OR|244|245|HOSPITAL COURSE|The patient has, over the past couple of years, developed significant ascites, requiring frequent paracentesis, as well as esophageal varices, which have been banded approximately eight months ago. HOSPITAL COURSE: The patient was taken to the OR on _%#DDMM2003#%_ and received a living-related right lobe liver transplant. The patient's course was unremarkable. The patient was then transferred to surgical intensive care unit for continued care and observation.
OR|operating room|OR|171|172|ASSESSMENT|Risks, benefits and alternatives to the procedure were discussed. The patient verbalized understanding and this was confirmed by her husband. The patient was taken to the OR on _%#DDMM2007#%_ for removal of a right breast implant.
OR|operating room|OR|144|145|LABORATORY|As this appeared to be early cholecystitis, she was started on Unasyn for antibiotic coverage. On _%#MM#%_ _%#DD#%_, 2004, she was taken to the OR with Dr. _%#NAME#%_ and a laparoscopic cholecystectomy was performed without any complications. Her LFTs returned to normal, and her white count came down.
OR|operating room|OR,|302|304|HOSPITAL COURSE|HOSPITAL COURSE: 1. Abdominal abscesses. The patient is a 38- year-old gentleman with a history of Crohn's disease who presented on _%#DDMM2005#%_ at _%#CITY#%_ Hospital with three weeks of abdominal pain, diarrhea and apparently two episodes of melena. He was diagnosed with appendicitis, went to the OR, ended up having an open procedure. Apparently there was no perforated appendicitis but it was found to be necrotic. He was discharged on _%#MMDD#%_. He had escalating right lower quadrant pain, fevers, chills and diarrhea over the course of the week, having approximately three stools a day.
OR|operating room|OR.|155|157|PHYSICAL EXAMINATION|No wheezes, no rales or rhonchi. BACK: No costovertebral angle tenderness. ABDOMEN: Soft, nontender and nondistended. No organomegaly. PELVIC: Deferred to OR. EXTREMITIES: No clubbing, cyanosis or edema, nontender. ASSESSMENT: 24-year-old P 0-0-1-0 with cervical dysplasia (CIN II/III).
OR|GENERAL ENGLISH|OR|235|236|SOCIAL HISTORY|SOCIAL HISTORY: Is significant in that she is married, she does not drink alcohol or utilize illegal drugs. She does occasionally have a cup of tea. She is on prenatal vitamins, otherwise no medications She HAS NO KNOWN DRUG ALLERGIES OR SENSITIVITIES. PAST MEDICAL HISTORY: No medical illnesses. FAMILY HISTORY: Not of consequence SURGICAL HISTORY: The laparoscopy as mentioned above in _%#MM2005#%_.
OR|operating room|OR|103|104|RECOMMENDATION|ASSESSMENT: The patient has suspicious CT for appendicitis with good physical exam. RECOMMENDATION: To OR for appendectomy. IV antibiotics started.
OR|GENERAL ENGLISH|OR|240|241|ALLERGIES|11. Irritable bowel syndrome with a history of chronic constipation. ALLERGIES: THE PATIENT DEVELOPED AGITATION AFTER TAKING COMPAZINE. THIS ADMISSION, COMPAZINE HAS NOW BEEN ADDED TO HIS ALLERGY LIST. HE DID NOT DEVELOP TARDIVE DYSKINESIA OR OVERTLY ALTERED MENTAL STATE. HOSPITAL COURSE: 1. Bronchitis: The patient 's admission chest x-ray did not show an acute infiltrate, and after hydration, his chest x-ray remained unchanged.
OR|operating room|OR|195|196|SUMMARY|On the day of admission, the patient underwent a colonoscopy by myself, which revealed a nonobstructing, but near obstructing mass at 15 cm consistent with a cancer. The patient was taken to the OR later that day and underwent exploratory laparotomy, total abdominal hysterectomy and bilateral salpingo-oophorectomy by Dr. _%#NAME#%_ and a low anterior resection with myself. She had a 1300 cc blood loss but was stable postoperatively.
OR|operating room|OR|136|137|PROBLEM #5|Briefly, the patient had bilateral knee staple removal along with a right proximal tibia plate placement. The patient returned from the OR to the post-anesthesia unit and then came back to the floor. She was able to initiate feeds and did wonderfully. Per the Orthopedic note, the patient should remain in Ace wraps until postop day #3.
OR|operating room|OR|128|129|ASSESSMENT AND PLAN|She may be overtreated with her diuretic. Obviously this can be followed postoperatively but does not preclude her going to the OR tomorrow morning. 4. SHE HAS AN INTOLERANCE TO MORPHINE AND VICODIN CAUSING UPSET STOMACH AND LOW BLOOD PRESSURE. OBVIOUSLY POSTOPERATIVE PAIN CONTROL, MAYBE A LITTLE MORE CHALLENGING BUT I SUSPECT THAT SHE SHOULD DO WELL WITH SOME TYPE OF NARCOTIC PAIN RELIEVERS AND NONSTEROIDALS.
OR|operating room|OR|223|224|HOSPITAL COURSE|Given recent administration of orals, and the already prolonged nature since her original tear, she could not be taken to the operating room in an expedient fashion. Therefore, as soon as we were able, she was taken to the OR at 16:00 on _%#DDMM2003#%_. For further details of her third degree laceration repair, please note the procedure note by Dr. _%#NAME#%_. Third degree laceration was repaired under spinal anesthesia with an EBL of less than 25 cc.
OR|GENERAL ENGLISH|OR|371|372|ALLERGIES|HISTORY OF THE PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is a 42-year-old white male who has a probable bowel perforation following a colonoscopy this morning. PAST MEDICAL HISTORY: Is significant for a newly diagnosed stage IV cancer of the colon and hypertension PRIOR SURGERY: Appendectomy in the distant past MEDICATIONS: Norvasc ALLERGIES: HE HAS NO DRUG ALLERGIES OR LATEX ALLERGIES. He is a non-smoker, rarely drinks alcohol. There is no history of easy bleeding or easy bruising.
OR|operating room|OR.|128|130|HISTORY OF PRESENT ILLNESS|Good urine output. The surgery went well with no complications. He had received approximately 500 to 700 cc of IV fluids in the OR. He returned to the floor intubated secondary to the sedation given during his surgery. PAST MEDICAL HISTORY: 1. _%#NAME#%_ was born at 38 weeks' gestation and was small for gestational age at 5 pounds 4 ounces.
OR|operating room|OR|244|245|HOSPITAL COURSE|MRI done on _%#MM#%_ _%#DD#%_ shows a 7 x 6 x 2 cm multi loculated fluid collection posterior to the lateral femoral condyle on the left and subcutaneous tissue suspicious for abscess, no evidence of osteomyelitis. The patient was taken to the OR on two occasions for incision and drainage and debridement and tolerated this well. He was treated with vancomycin for the week of his hospitalization and is being discharged on the above oral antibiotics.
OR|operating room|OR|198|199|HOSPITAL COURSE|She had limited motion in her right hip with valgus deformity of the right knee and x-rays confirmed arthritis of her right hip with the left knee and hip replacements. The patient was taken to the OR on the day of her admission. She underwent a right total hip replacement which was uncomplicated. Postoperatively she made a satisfactory recovery with the wound healing primarily.
OR|operating room|OR|305|306|PROCEDURE|_%#NAME#%_ _%#NAME#%_ is a 78-year-old Caucasian female who has had a history of breast carcinoma and ovarian carcinoma who presented with an enlarging pulmonary nodule in the right lung field. Options were discussed in detail with the patient. She elected to proceed with resection. She was taken to the OR on _%#DDMM2003#%_ where she underwent a right video assisted thoracic surgery with wedge resection of a portion of her right lower lobe.
OR|operating room|OR|183|184|IMPRESSION|The patient understood. She had the opportunity to ask questions and agreed to proceed. Informed consent was obtained. Preoperative antibiotics have been given and the plan is to the OR with the room ready. I see no contraindications to general anesthetic.
OR|operating room|OR|316|317|HOSPITAL COURSE|HOSPITAL COURSE: This is a 46-year-old white woman with a past medical history of multiple sclerosis, who was admitted to the neurosurgery service on _%#MM#%_ _%#DD#%_, 2005, for elective thoracic surgery, after having been found to have a thoracic epidural lipoma with spinal cord compression. She was taken to the OR on _%#MM#%_ _%#DD#%_, 2005, and underwent MRI-guided T3 to T8 decompressive laminectomy with resection of the lipoma. The patient was subsequently transferred to University of Minnesota Medical Center, Fairview acute rehabilitation facility for aggressive physical and occupational therapy.
OR|GENERAL ENGLISH|OR|210|211|MEDICATIONS ON ADMISSION|She has recently noticed increase in depression as well and has just started Celexa and this did cause a little bit of diarrhea. MEDICATIONS ON ADMISSION: Include 1. Altace 2. Celexa 3. Aspirin She IS ALLERGIC OR INTOLERANT TO BETA BLOCKERS. The patient is a former smoker, she does not drink alcohol on a regular basis.
OR|GENERAL ENGLISH|OR|276|277|ALLERGIES|7. Possible pulmonary hypertension. The patient states he thinks the doctor told him he had it, but he does not know the details and does not think he is on any medicines for it. 8. UTI with pyelonephritis, 15 years ago. ALLERGIES: NEURONTIN, DEPAKOTE, AND EITHER OF LAMICTAL OR TEGRETOL, THOUGH THE PATIENT UNSURE WHICH ONE ACTUALLY CAUSED THE RASH. BRIEF HISTORY OF HOSPITALIZATION: The patient is a 57-year- old male with a history of bipolar disorder, ethanol dependence, and recent diagnosis of atrial fibrillation, who presented to the emergency room with chest pain that started at 4 p.m. on the day of admission.
OR|operating room|OR.|266|268|PROCEDURE|A CT was then ordered and read by Dr. _%#NAME#%_ _%#NAME#%_ and it was read as an infrarenal abdominal aortic aneurysm with dimensions of 4.2 x 6 cm with a prominent eccentric saccular component along the left side of the aneurysm. The patient was then taken to the OR. The patient's abdominal aortic aneurysm was repaired using an 18 mm straight graft. The patient tolerated the procedure and was transferred to the Intensive Care Unit.
OR|operating room|OR|134|135|ASSESSMENT  AND PLAN|1. Right hip fracture. Ortho has been consulted and will do pain control. The patient is on Pneumoboots for the time being. Hopefully OR today or tomorrow. 2. History of Parkinson's; will look into if she is currently on Sinemet 3. History of MI. She should be placed on perioperative beta blockers; her blood pressures actually have dropped a little bit down to the low 100s to low 90s, therefore if blood pressures are greater than 100 will try to put her on a low dose beta blocker for cardioprotection 4. History of pacemaker.
OR|operating room|OR|207|208|PLAN|The UPT is negative. The electrolytes are normal. A CT shows probable appendicitis with a prominent appendix, particularly the tip, which is 1 cm down in the pelvis. ASSESSMENT: Acute appendicitis. PLAN: To OR for appendectomy. IV antibiotics ordered.
OR|operating room|OR|297|298|DISCHARGE DIAGNOSIS|This is a 40-year-old female with history of non-small cell lung carcinoma who received a pneumonectomy for the originally cancer, however, she has had difficult time post operatively from this due to poor healing and had multiple surgical debridements and ongoing infection. She was taken to the OR electively on _%#DDMM2002#%_ for repeat debridement and thoracotomy was performed. The patient was packed with Kerlix and the wound was partially closed and the patient returned to the floor.
OR|operating room|OR|208|209|ADMISSION DIAGNOSIS|He underwent right composite resection of the floor of mouth with platysma and myocutaneous flap reconstruction on _%#DDMM2003#%_, which proceeded without difficulty. Postoperatively he was taken back to the OR emergently for arterial bleeding from the trachea site. The bleeding was found to be from an arterial source on the left strap muscles.
OR|operating room|OR|342|343|PROBLEM #3|A nuclear medicine abscess radiolabeled with white blood cell track scan was performed on _%#DDMM2004#%_ that showed increased activity within the left ischium and findings compatible with left ischial osteomyelitis. The patient was initially treated with Zosyn; however, according to the Plastic Surgery recommendations, he was taken to the OR for debridement and a VAC placement on _%#DDMM2004#%_. A PICC line was placed on this patient for long-term antibiotics.
OR|operating room|OR|202|203|HISTORY AND PHYSICAL|Her ascites was tapped, and SBP was ruled out. She had no other sources for infection. She also underwent an LP. An organ became available on _%#MM#%_ _%#DD#%_, 2006, and the patient was brought to the OR for transplantation. Because there was an injury to the liver graft, the decision was made in conjunction with the family not to proceed with the transplant due to the risk of hepatic artery thrombosis.
OR|GENERAL ENGLISH|OR|169|170|ALLERGIES|3. Aspirin 325 mg p.o. q. day. 4. Terazosin 1 mg p.o. q. day. 5. Zetia 10 mg p.o. q. day. ALLERGIES: BRAZIL NUTS, HAZELNUTS, TOMATOES ALL OF WHICH GIVE HIM LIP SWELLING OR SWELLING. FAMILY HISTORY: Is significant for coronary artery disease in six out of his 12 siblings.
OR|operating room|OR|137|138|BRIEF HISTORY AND HOSPITAL COURSE|GYN was consulted who agreed that this might be gynecological although Meckel's diverticulum cannot be ruled out. She was brought to the OR for diagnostic laparoscopy on _%#DDMM2007#%_ and was found to have actually a right ovarian cyst. This was drained with no events. The pain seems to have been more controlled.
OR|operating room|OR|122|123|PLAN|Both the long history and degree of tenderness on examination are concerning for perforation. PLAN: IV antibiotics and to OR for appendectomy. ADDENDUM: Preoperative EKG showed some inferior T wave inversions and conduction delay.
OR|operating room|OR|168|169|ASSESSMENT AND PLAN|The EXTREMITIES have no edema and good pulses. The NEUROLOGIC exam and SKIN exam are intact. ASSESSMENT AND PLAN: 1. Acute appendicitis. Plan: He is going to go to the OR today with Dr. _%#NAME#%_ _%#NAME#%_. He has cefotetan started now in the ER. For his diabetes, we will put him on an ADA diet, b.i.d. Accu-Cheks.
OR|operating room|OR|219|220|HISTORY OF PRESENT ILLNESS|Thus after significant outpatient workup, the patient was brought to the hospital on _%#DDMM2004#%_ for a total pancreatectomy and auto-islet cell transplantation. The patient was taken to the OR on _%#DDMM2004#%_. The OR course was unremarkable. See specific operative note for details. The patient spent the remainder of her hospitalization on 6B.
OR|operating room|OR|158|159|HOSPITAL COURSE|S1 and S2. ABDOMEN: Soft and non-tender. Bowel sounds present. EXTREMITIES: All full range of motion. No edema. HOSPITAL COURSE: The patient was taken to the OR on _%#MMDD#%_ and underwent the stated procedure. She tolerated the procedure well and transferred to the surgical floor in stable condition.
OR|GENERAL ENGLISH|OR|135|136|ALLERGIES|4) Neurontin. 5) Prevacid. 6) Toprol. 7) Zocor. 8) Septra for a recent urinary-tract infection. 9) Insulin. ALLERGIES: SHE IS ALLERGIC OR INTOLERANT TO PENICILLIN AND LEVAQUIN. FAMILY HISTORY: Negative for hematologic and oncologic illnesses. SOCIAL HISTORY: The patient does not smoke cigarettes nor drink alcohol on a regular basis.
OR|operating room|OR.|107|109|PLAN|LABORATORY: His white count is normal. Other labs are normal. IMPRESSION: Acute appendicitis. PLAN: To the OR. Risks and benefits of the procedure were explained to the patient and his mother and both are agreeable to proceeding.
OR|operating room|OR|148|149|IMPRESSION|Given the patient's high fever of 103, I do have a high suspicion of a perianal abscess possibly due to the fissure. The plan is to take her to the OR for examination under anesthesia and possible drainage of an abscess.
OR|operating room|OR|227|228|IMPRESSION|The atenolol dose is apparently 50 mg daily. Her heart rate is slow, most likely related to this. She had a rash over her left upper extremity which at the moment appears to be related to a local issues with trauma down in the OR and pre and postoperative area in relation to her blood pressure cuff and needle stick in the left hand. I do not think this is a reaction to the Ancef and therefore I think we should continue the Ancef for now and just monitor the rash and see how it goes.
OR|operating room|OR|340|341|REASON FOR CONSULTATION|A Gastrografin upper GI small bowel follow might be of help, although the detail one sees with this is not good and if she does, in fact, have an impaction, a barium load through the GI tract might result in a surgical situation where one currently does not exist. In short, this is a very tight corner. I do not see that taking her to the OR at this point would serve any purpose. She understands that and we will follow her with you.
OR|operating room|OR|135|136|PLAN|The patient has no tenderness in that location. I would recommend proceeding with appendectomy based on his toxic appearance. PLAN: To OR for appendectomy and IV antibiotics.
OR|operating room|OR|218|219|PLAN|CT scan of his head on admission was negative. PLAN: The plan will be to put him on IV Zosyn and treat the wound superficially with Silvadene cream with twice a day dressing changes. We will arrange to take him to the OR tomorrow once his medical condition is stable and under a light general anesthetic debride the various wounds involved. Probably will continue to treat with Silvadene at this point.
OR|operating room|OR|175|176|HISTORY OF PRESENT ILLNESS|The pain did persist for less than a half hour and subsided by itself. Also in terms of risk factors for PE, she has not been recumbent or sedentary. She just came out of the OR and has not been sedentary for a long time. REVIEW OF SYSTEMS: Other than mentioned, was significant for fatigue, anemia and generalized achiness from the postoperative condition.
OR|GENERAL ENGLISH|OR|242|243|ALLERGIES|PAST MEDICAL HISTORY/SURGERIES: She has had the angioplasty and stenting in 2003 and hysterectomy. MEDICAL PROBLEMS: The coronary artery disease, hypertension, hyperlipidemia. ALLERGIES: PENICILLIN, ERYTHROMYCIN, SULFA ALL WHICH CAUSED HIVES OR GI INTOLERANCE. CURRENT MEDICATIONS: Plavix 75 mg a day, aspirin 81 mg a day, Toprol 25 mg BID, Zocor 40 mg a day, fish oil capsules 3 a day, Folgard 1 daily, Imdur 60 mg daily, Lisinopril 40 mg daily.
OR|GENERAL ENGLISH|OR|182|183|HISTORY OF PRESENT ILLNESS|She suffered a left- sided TIA after back surgery in _%#MM2001#%_. She did well with this and had been on Coumadin. However, she had an ALLERGIC REACTION EITHER TO HER ACE INHIBITOR OR COUMADIN and both of these were discontinued. She is currently on Plavix for this. She has had some right hand tingling and it is not clear if this is related to her stroke symptoms or note.
OR|GENERAL ENGLISH|OR|130|131|ALLERGIES|MEDICATIONS: Adderall 20 mg q.d. and Lexapro q.d. Lamisil orally for fungal infection of her toes. ALLERGIES: SULFA CAUSES A RASH OR HIVES. SOCIAL HISTORY: Nonsmoker, rare alcohol. PHYSICAL EXAMINATION: Height is 5 feet 8 inches, weight 132 pounds, blood pressure 90/60, hemoglobin today 16.5. CARDIOVASCULAR: Regular rate and rhythm.
OR|GENERAL ENGLISH|OR|148|149|ALLERGIES|13) Prednisone 4 mg daily. 14) Valsartan. On admission the patient was on Coumadin; this has recently been held. ALLERGIES: THE PATIENT IS ALLERGIC OR INTOLERANT TO KEFLEX. FAMILY HISTORY: Otherwise noncontributory aside from the family's lack of bleeding abnormalities.
OTC|over the counter|OTC,|182|185|HOME  MEDICATIONS|4. Dyslipidemia. 5. TMJ. 6. Negative stress test in the past. HOME MEDICATIONS: Atenolol, Cardizem, lisinopril, Prevacid, aspirin, triamterene, hydrochlorothiazide, niacin, which is OTC, Benadryl, Tylenol, calcium and ibuprofen. ALLERGIES: Penicillin and erythromycin. SOCIAL HISTORY: She is a lifelong nonsmoker.
OTC|ornithine transcarbamoylase|OTC|75|77|PRIMARY DIAGNOSES|PRIMARY DIAGNOSES: 1. Hyperammonemia syndrome exacerbation associated with OTC urea cycle defect. 2. Dehydration. SECONDARY DIAGNOSES: 1. Ornithine transcarbamoylase deficiency, confirmed by genetic testing in _%#MM2007#%_.
OTC|ornithine transcarbamoylase|OTC|156|158|HOSPITAL COURSE|His electrolytes remained within normal limits throughout the hospital course. 2. Metabolic: The patient presented with increased ammonia due to underlying OTC disorder, but of unclear precipitating factor, possibly due to mild URI with decreased p.o. intake. He was followed by Dr. _%#NAME#%_ and he was given a loading dose of Ammonul IV followed by maintenance dose to decrease ammonia.
OTC|over the counter|OTC|157|159|CURRENT MEDICATIONS|2. Synthroid 50 mcg p.o. daily. 3. Lasix 20 mg p.o. daily. 4. Calcium 1500 mg p.o. daily. 5. Potassium chloride 20 mEq p.o. p.r.n. palpitations. 6. Multiple OTC vitamin supplements. SOCIAL HISTORY: Denies tobacco use. Drinks approximately 2-3 glasses of wine every 1-2 days, but denies any alcohol use within the past week.
OTC|over the counter|OTC,|228|231|HISTORY OF PRESENT ILLNESS|She started to have an increase in her heartburn symptoms per patient report and so she did stop the etodolac, but then started ibuprofen. She reports 2 days ago she began to have more severe heartburn and started taking Zantac OTC, but her heartburn continued and she developed nausea. She reports the heartburn felt like a pain in the mid upper stomach and lower sternal area.
OTC|over the counter|OTC|209|211|DISCHARGE MEDICATIONS|DOB: _%#DDMM1932#%_ DISCHARGE DIAGNOSIS: Acute vertigo, probable labyrinthitis. DISCHARGE MEDICATIONS: As on admission with the addition of meclizine 25 mg p.o. t.i.d. p.r.n., Imdur 30 mg p.o. daily, Prilosec OTC 20 mg p.o. daily, Maxzide 25 1 p.o. daily, Zetia 10 mg p.o. daily, Atenolol 50 mg p.o. daily, aspirin 325 mg p.o. daily. Discharge activity and diet are unchanged and not restricted.
OTC|over the counter|OTC|164|166|MEDICATIONS ON DISCHARGE|6. Gastroesophageal reflux disease. 7. Osteoporosis. MEDICATIONS ON DISCHARGE: Lexapro 10 mg once a day, Zyprexa 2.5 mg q. h.s., Aricept 10 mg once a day, Prilosec OTC 20 mg once a day, Evista 60 a day, Coreg 3.125 b.i.d., lisinopril 2.5 q. d., quinine 260 p.o. q. h.s. Daily weights. If greater than 3 pound weight gain in 24 hours, give Lasix 20 mg once.
OTC|over the counter|OTC.|144|147|MEDICATIONS AT TIME OF DISCHARGE|2. He is also instructed if he has heartburn or abdominal pain to either try Zantac 75 mg p.o. b.i.d. over-the-counter or may even try Prilosec OTC. If he does have another syncopal episode or has significant GI bleeding he is instructed to come into the emergency room.
OTC|over the counter|OTC|135|137|DISCHARGE DIAGNOSES|7. Nifedipine XL 1 tablet p.o. by mouth daily. 8. Prevacid 1 p.o. daily. Note that we did discuss that she may change this to Prilosec OTC if this is available and if this is less expensive. 9. Albuterol neb as a premed for her pentamidine. Her pentamidine is due _%#MM#%_ _%#DD#%_, 2005.
OTC|over the counter|(OTC|254|257|DISCHARGE  MEDICATIONS|DISCHARGE PLAN: The patient should follow up with Dr. _%#NAME#%_ for an office visit on a p.r.n. basis should schedule a CT of the abdomen in 3 months through him. DISCHARGE MEDICATIONS: 1. Tricor 145 mg daily. 2. Allegra 180 mg daily p.r.n. 3. Benadryl (OTC ) p.r.n. 4. Hyzaar 50/12.5 one daily. 5. Protonix 40 mg daily. 6. Lyrica 200 mg b.i.d. 7. Tylenol p.r.n. 8. baby Aspirin 81 mg daily. 9. Septra-DS one b.i.d. x5 doses
OTC|over the counter|OTC|171|173|DISCHARGE MEDICATIONS|7. Amlodipine 10 mg p.o. b.i.d. 8. Reglan 5 mg p.o. b.i.d. before breakfast and dinner. 9. Senna plus 2 tablets p.o. nightly. 10. Torsemide 15 mg p.o. b.i.d. 11. Prilosec OTC 20 mg p.o. b.i.d. 12. Miralax powder 8.5 g in 4 ounces water q. day. 13. Atenolol 75 mg p.o. daily.
OTC|over the counter|OTC|106|108|MEDICATIONS|5. Metoprolol 50 mg one-half po bid. 6. Fluoxetine 20 mg po daily. 7. Lipitor 40 mg po daily. 8. Prilosec OTC daily. 9. Albuterol inhaler prn. PAST MEDICAL HISTORY: 1. History of diabetes mellitus Type 2 for at least five years.
OTC|over the counter|OTC|137|139|ADMISSION MEDICATIONS|1. Calcium OTC 500 mg p.o. daily. 2. Estradiol 2 mg p.o. daily. 3. Levoxyl 100 mg p.o. daily. 4. Zoloft 100 mg p.o. daily. 5. Maxi-Gamma OTC 2 caplets p.o. daily. 6. Antioxidant factor 2 caplets p.o. daily. 7. Vitamin C 500 mg p.o. b.i.d. 8. Omega 1 OTC 3 capsules p.o. daily.
OTC|over the counter|OTC|173|175|ADMISSION MEDICATIONS|5. Maxi-Gamma OTC 2 caplets p.o. daily. 6. Antioxidant factor 2 caplets p.o. daily. 7. Vitamin C 500 mg p.o. b.i.d. 8. Omega 1 OTC 3 capsules p.o. daily. 9. Magnesium oxide OTC 250 mg p.o. q. i.d. 10. Chromium picolinate 200 mcg p.o. t.i.d. 11. Green tea extract 315 mg p.o. b.i.d. 12. Gymnema sylvestre 400 mg p.o. once daily. 13. Vitamin E 400 international units p.o. b.i.d.
OTC|over the counter|OTC|196|198|LABORATORY|3. Certican or RAD 1.5 mg twice daily. 4. Valganciclovir 450 mg 2 tablets once daily. 5. Pentoxifylline 400 mg 1 tablet t.i.d. 6. Mycelex troche 1 tablet to dissolve in mouth q.i.d. 7. Maxi-Gamma OTC 2 capsules once daily. 8. Omega T 3 capsules b.i.d. 9. Antioxidant factor OTC 2 capsules once daily. 10. Vitamin C 500 mg p.o. q.i.d.
OTC|over the counter|OTC|160|162|MEDICATIONS|1. Warfarin on a chronic basis for greater than 10 years for atrial fibrillation. He usually takes a dose of 5 mg daily. 2. Metoprolol 50 mg daily. 3. Prilosec OTC on a prn basis for gastroesophageal reflux. LABORATORY DATA: Normal electrolytes, normal glucose, BUN and creatinine elevated further to 41 and 3.6, and a calcium markedly higher at 13.7. Renal ultrasound shows slight prominence of the right renal pelvis but no true convincing caliectasis.
OTC|ornithine transcarbamoylase|OTC|160|162|HISTORY OF PRESENT ILLNESS|She is admitted preoperatively for reduction mammoplasty to prevent metabolic decompensation that is associated with prolonged fasting in individuals with OTC. OTC deficiency is a recyclic defect that during periods of stress i.e. fasting, or intercurrent illness, can result in hyperreninemia.
OTC|over the counter|OTC|139|141|DISCHARGE MEDICATIONS|2. Vitamin D 400 units daily. 3. Prozac 40 mg p.o. daily. 4. Iron 50 mg orally daily. 5. Multiple vitamin 1 tablet p.o. daily. 6. Prilosec OTC 20 mg p.o. daily. 7. Prednisone 5 mg p.o. daily. 8. Tylenol p.r.n. 9. Lovenox 80 mg subcutaneously b.i.d. for the next 5 days until her INR is therapeutic or as recommended by the INR clinic.
OTC|over the counter|OTC|195|197|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. daily. 2. Lisinopril 10 mg p.o. daily. 3. Nortriptyline 20 mg p.o. nightly. 4. Crestor 10 mg p.o. daily. 5. Premarin 0.625 mg p.o. daily. 6. Prilosec OTC 20 mg p.o. daily. 7. Celebrex 200 mg p.o. daily. 8. Diltiazem 240 mg p.o. daily. FOLLOW UP: 1. The patient is to receive a stress echocardiogram on an outpatient basis on Monday, _%#MM#%_ _%#DD#%_, 2005.
OTC|over the counter|OTC|126|128|DISCHARGE MEDICATIONS|In addition, arrangements for home hospice care were made. DISCHARGE MEDICATIONS: 1. Klor-Con 20 mEq p.o. q. day. 2. Prilosec OTC 20 mg two capsules (40 mg total) p.o. q. day. 3. Keppra 500 mg p.o. b.i.d. 4. Ciprofloxacin 500 mg p.o. q.12 h. x7 days.
OTC|over the counter|OTC|108|110|DISCHARGE MEDICATIONS|11. Toprol XL 100 mg daily. 12. Darvocet-N 100 mg 1 to 2 tablets p.o. q.4h. as needed for pain. 13. Imodium OTC use as directed. 14. Lisinopril 20 mg 1 p.o. daily. 15. Green tea extract. 16. Septra single strength 1 tablet by mouth daily.
OTC|over the counter|OTC.|182|185|MEDICATIONS|PAST MEDICAL HISTORY: Heartburn. PAST SURGICAL HISTORY: Negative. ALLERGIES: No known drug allergies. MEDICATIONS: Occasional over-the-counter heartburn medications such as Prilosec OTC. SOCIAL HISTORY: He denies tobacco, alcohol or drug abuse.
OTC|over the counter|OTC|177|179|DISCHARGE PLANS|DISCHARGE PLANS: The patient was sent to the nursing home in a declining state. DNR/DNI. Stage 1 dysphagia diet, nectar thickened liquids, on Synthroid 0.1 mg daily, omeprazole OTC 20 mg daily, Ativan 0.5 mg b.i.d. p.r.n. restlessness or agitation. We will make our usual nursing home rounds on Mrs. _%#NAME#%_.
OTC|over the counter|OTC|162|164|DISCHARGE MEDICATIONS|ADVANCED DIRECTIVES: He remains full code. ALLERGIES: He has a known intolerance to ACE inhibitors, Flagyl, and beta blockers. DISCHARGE MEDICATIONS: 1. Prilosec OTC 20 mg p.o. daily. 2. Vitamin K 5 mg p.o. daily. 3. Lantus 2 units daily at h.s. 4. Cellcept 250 mg p.o. b.i.d. 5. Prograf 0.5 mg p.o. b.i.d.
OTC|over the counter|OTC|149|151|DISCHARGE MEDICATIONS|4. Advair 100/50 mcg, 1 puff b.i.d. 5. Combivent inhaler 2 puffs q.4h. p.r.n. 6. Dilantin 200 mg p.o. b.i.d. 7. Nephrocaps 1 p.o. daily. 8. Prilosec OTC 20 mg p.o. b.i.d. 9. Artificial tears, 1 drop to both eyes q.i.d. 10. Calcium carbonate 500 mg p.o. t.i.d. with meals. 11. Benadryl 25 mg p.o. every morning and evening.
OTC|over the counter|OTC|125|127|DISCHARGE MEDICATIONS|1. Lipitor 40 mg per day. 2. Niaspan 500 mg per day. 3. Aspirin 81 mg per day. 4. Colchicine 0.6 mg p.r.n. 5. Prilosec 20 mg OTC p.r.n. DISCHARGE FOLLOW-UP: 1. Follow-up with Dr. _%#NAME#%_ _%#NAME#%_ as needed for stress management. 2. Routine appointment with Dr. _%#NAME#%_ _%#NAME#%_ as previously scheduled.
OTC|over the counter|OTC,|175|178|DISCHARGE MEDICATIONS|8. Advair, 250/50 mg one puff b.i.d. 9. Maxair auto-inhaler, two puffs q.i.d. p.r.n. shortness of breath. 10. Nitroglycerin, 0.4 mg sublingual p.r.n. chest pain. 11. Prilosec OTC, 20 mg p.o. b.i.d. for two weeks, then 20 mg daily. 12. Prednisone, 40 mg daily for 4 days. 13. Zocor, 40 mg q.h.s.
OTC|over the counter|OTC|151|153|HISTORY OF PRESENT ILLNESS|She denies any ear pain or pressure. No viral URI-type symptoms, but has had tinnitus present for the past several days. No new medications. No recent OTC medication changes. No focal weakness. No sick contacts. No fevers or chills. Patient without any diarrhea. REVIEW OF SYSTEMS: Rest of constitutional, eyes, ears, nose, mouth, throat, respiratory, cardiovascular, GI, GU, musculoskeletal, neurologic, endocrine, hematologic, lymphatic and psychiatric review of systems otherwise negative.
OTC|over the counter|OTC|168|170|DISCHARGE MEDICATIONS|3. Doxycycline 100 mg p.o. b.i.d. 4. Cipro 750 mg p.o. b.i.d. 5. Bupropion 100 mg p.o. b.i.d. 6. Celexa 30 mg p.o. b.i.d. 7. Creon 10 with meals or snacks. 8. Prilosec OTC twenty mg p.o. b.i.d. 9. Vitamin K 5 mg p.o. weekly. 10. Vitamin C p.o. daily. 11. Vitamin E p.o. daily. 12. Multivitamin 1 p.o. daily.
OTC|over the counter|OTC|114|116|MEDICATIONS|3. Glucovance 5/500 one tab b.i.d. 4. Lisinopril HCT 20/12.5 mg, 1 tab b.i.d. 5. Lipitor 10 mg daily. 6. Prilosec OTC 20 mg daily. ALLERGIES: The patient has no known drug allergies. HABITS: The patient has 3-4 lite beers once a week.
OTC|over the counter|OTC|206|208|MEDICATIONS|The patient's diagnosis of right elbow pain is consistent with a chronic lateral epicondylitis and now he will be admitted for surgical management. PAST MEDICAL HISTORY: None. ALLERGIES: None. MEDICATIONS: OTC only including glucosamine, chondroitin, flaxseed, fish oil and multivitamins. PREVIOUS USUAL ADULT ILLNESSES: No previous hospitalizations or surgeries. FAMILY HISTORY: Mother was born in 1935, did have a deep venous thrombosis with a status post pulmonary emboli.
OTC|over the counter|OTC|308|310|HOSPITAL COURSE|We will have her continue on her Coumadin with a goal INR of 1.8 to 2.2. She should follow up with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2006, as well as with _%#NAME#%_ in physical therapy on _%#MM#%_ _%#DD#%_, 2006. She should continue with her home medications of: 1. Prozac 20 mg p.o. q. day. 2. Claritin OTC 10 mg p.o. q. day. 3. Propranolol 80 mg p.o. b.i.d. 4. Fibertab 625 mg 2 tablets p.o. q. day. 5. Calcium 600 mg p.o. q. day. 6. Glucosamine/chondroitin 1500 mg p.o. q. day.
OTC|over the counter|OTC|132|134|DICHARGE MEDICATIONS|3. Citalopram 40 mg daily. 4. Ferrous sulfate 325 mg daily. 5. Isosorbide SA 90 mg 3 times daily. 6. Cozaar 5 mg daily. 7. Prilosec OTC 20 mg daily. 8. Torsemide 40 mg twice daily. 9. Metoprolol 50 mg twice daily. 10. Metolazone 50 mg every other day.
OTC|over the counter|OTC|244|246|PAST MEDICAL HISTORY, HOSPITALIZATIONS, AND SURGERIES|I think as a younger teenage child, he ended up in the hospital a couple of times with hematomas of his knees secondary to biking accidents. He has no known allergies. He does not smoke nor drink any alcohol. He is currently on no medications, OTC or by prescription, other than the Silvadene cream. FAMILY HISTORY: This is positive only for some heavy smokers.
OTC|over the counter|OTC|150|152|MEDICATIONS AT ADMISSION|1. Aspirin 81 mg a day. 2. Plavix 75 mg a day. 3. Toprol 50 mg a day. 4. Lisinopril 10 mg a day. 5. Zocor 40 mg p.o. each day at bedtime. 6. Prilosec OTC two tablets q. day. ALLERGIES: He has no known drug allergies. HABITS: He does not smoke cigarettes. Smoked briefly in his 20s.
OTC|over the counter|OTC.|160|163|DISCHARGE MEDICATIONS|8. Aspirin 81 mg p.o. q. day. 9. Levaquin 500 mg p.o. q. day x6 more days. 10. Lisinopril 5 mg p.o. q. day. 11. Metoprolol 50 mg p.o. b.i.d. 12. Nicotine patch OTC. 13. Coumadin 5 mg x1 on _%#MMDD#%_. INR is to be checked on _%#MMDD#%_ with results called to Dr. _%#NAME#%_ who will dose _%#MMDD#%_ and subsequent. 14. Lovenox 90 mg subcu b.i.d. DC when INR between 2 and 3.
OTC|over the counter|OTC.|184|187|DISCHARGE  MEDICATIONS|The patient also apparently sees occasional primary care doctor at Park Nicollet DISCHARGE MEDICATIONS: Include 1. Toprol-XL 25 mg a day. 2. The patient also takes occasional Prilosec OTC. 3. Xanax 0.5 mg p.o. q.h.s. p.r.n.
OTC|over the counter|OTC|268|270|HOSPITAL COURSE|Problem #2: Dizziness. The patient had a bilateral carotid ultrasound showing no hemodynamically significant stenosis in the bilateral common and internal carotid arteries. Problem #3: Reflux. The patient was started on Protonix, 40 mg p.o. q.day and discontinued her OTC Prilosec. RESULTS PENDING: The final reading of the dobutamine stress echo is pending. However, cardiology staff phoned our service to let us know there was no evidence of ischemia.
OTC|over the counter|OTC|152|154|DISCHARGE MEDICATIONS|1. Paxil 10 mg p.o. daily. 2. Mestinon 30 mg p.o. t.i.d. 3. Azathioprine 50 mg p.o. b.i.d. 4. Cozaar 50 mg daily. 5. Vitamin B12 injections. 6. Imodium OTC as directed p.r.n. DISCHARGE PLAN: The patient will be discharged to home.
OTC|over the counter|OTC|126|128|MEDICATIONS|PAST SURGICAL HISTORY: None. MEDICATIONS: Robitussin, no benefit. Zithromax, 1 dose, and Rocephin IM, 1 dose yesterday. Advil OTC p.r.n. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature is 99.2, weight is 50 pounds, respiratory rate is 36, oxygen saturation is 97% on room air and heart rate is 120 at rest.
OTC|over the counter|OTC|163|165|DISCHARGE  MEDICATIONS|2. Lasix 40 mg p.o. q. day. 2. M3. etoprolol 12.5 mg p.o. b.i.d. 3. R4. emeron 15 mg p.o. each day at bedtime. 5. Multivitamin one tablet p.o. q. day. 6. Prilosec OTC 40 mg p.o. q. day. 6. G7. as-X 1 tablet p.o. q.i.d. p.r.n. 7. K8. Cl 10% liquid 15 cc p.o. b.i.d. 8. T9. ylenol 500 mg 1-2 tabs p.o. q.6h. p.r.n.
OTC|over the counter|OTC|186|188|HOSPITAL COURSE|She ended up leaving for that appointment before being seen by staff. DISCHARGE MEDICATIONS: 1. Dilantin 300 mg daily (increased from 150 mg daily). 2. Atenolol 25 mg daily. 3. Prilosec OTC 20 mg daily. FOLLOW UP: Follow up with Dr. _%#NAME#%_ at _%#CITY#%_ Clinic of Neurology in _%#CITY#%_ _%#CITY#%_ regarding the seizures.
OTC|over the counter|OTC|127|129|DISCHARGE MEDICATIONS|2. Iron, ferrous gluconate 1 tablet p.o. b.i.d. 3. Neoral cyclosporine 25-mg capsules 5 tablets 125 mg p.o. b.i.d. 4. Prilosec OTC 1 tablet p.o. daily. 5. _%#NAME#%_ was instructed to stop taking the Bactrim that he was taking prior to admission. FOLLOW UP: _%#NAME#%_ is to follow up with his primary care provider early next week.
OTC|over the counter|OTC|114|116|DISCHARGE MEDICATIONS|1. Vancomycin 1500 mg IV q.12 h. x2 weeks. 2. Clindamycin 300 mg p.o. 4 times daily for 2 more weeks. 3. Prilosec OTC 20 mg p.o. daily.
OTC|over the counter|OTC|126|128|DISCHARGE MEDICATIONS|4. Ongoing tobacco abuse. 5. Hypertension. 6. Hyperlipidemia. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. daily. 2. Prilosec OTC 20 mg p.o. daily. 3. Lisinopril 10 mg p.o. daily. 4. Lipitor 40 mg p.o. daily. 5. Albuterol inhaler 2 puffs q.i.d. p.r.n. DISCHARGE INSTRUCTIONS AND FOLLOW UP: The patient is urged to resume compliance with medical management and medications as outlined above.
OTC|over the counter|OTC|189|191|PLAN|3. Digoxin 0.125 mg p.o. q. day if heart rate greater than or equal to 75 per minute. 4. Lisinopril 10 mg p.o. q. day. 5. Ativan 0.5 mg b.i.d. p.r.n. 6. Metoprolol 50 mg b.i.d. 7. Prilosec OTC 20 mg p.o. q. day taken 30 minutes before first meal daily. 8. Darvocet-N 100 1-2 p.o. q.4-6h. p.r.n. pain relief.
OTC|over the counter|OTC|137|139|DISCHARGE MEDICATIONS|3. Combivent 2-4 puffs MDI t.i.d. 4. Synthroid 0.1 mg p.o. daily. 5. Celexa 20 mg p.o. daily. 6. Lopressor 50 mg p.o. daily. 7. Prilosec OTC 1 tablet p.o. daily. 8. Tamoxifen 10 mg p.o. daily. 9. Lisinopril 5 mg p.o. daily. 10. Ultram 50 mg p.o. every 4 hours p.r.n. pain.
OTC|ornithine transcarbamoylase|OTC|189|191|1. FEN|_%#NAME#%_'s mother then underwent a liver biopsy with genetic analysis for OTC deficiency carrier status, but no genetic mutation was discovered. However, it is known that at least 25% of OTC mutations are not yet identifiable by current laboratory techniques. As a result, _%#NAME#%_ required evaluation for a possible OTC deficiency (X- linked).
OTC|over the counter|OTC|132|134|HISTORY OF PRESENT ILLNESS|No bright red blood per rectum. Abdominal discomfort typically aggravated by spicy food. He has not self-medicated with antacids or OTC Zantac, Tagamet, etc. Did take two Aleve two days ago for a headache. Denies chronic use of nonsteroidals. Does smoke one pack per day.
OTC|over the counter|OTC.|158|161|MEDICATIONS|MEDICATIONS: Currently include: 1. Aspirin daily for antiplatelet effects. 2. Colace 100 mg p.o. q.d. 3. Ferrous sulfate 324 mg p.o. q.d. 4. Visine eye drops OTC. 5. Lisinopril 10 mg p.o. b.i.d. 6. Metoprolol 50 mg p.o. b.i.d. 7. Paxil 10 mg h.s. 8. Lumigan eye drops 0.3% one drop q.h.s. both eyes.
OTC|over the counter|OTC|449|451|MEDICATIONS|PREVIOUS HOSPITALIZATIONS AND SURGERIES: Include right wrist fracture, ORIF in 1997; left knee arthroscopy in 1999, right total hip arthroplasty in 2000, splenectomy in _%#MM2000#%_; hospitalization for a left neck Staph infection in _%#MM2001#%_; pneumonia in _%#MM2002#%_; right elbow cellulitis in _%#MM2003#%_. MEDICATIONS: Include Atarax 25 mg in the morning, 50 mg in the evening; Spectazole cream once daily to the right foot, Tagamet 200 mg OTC p.r.n. for reflux, fluocinolone cream 0.01 percent once to twice daily to the scalp. ALLERGIES: Include penicillin, erythromycin, latex, and topical antibiotic bacitracin. HABITS: He quit smoking in 1978.
OTC|over the counter|OTC|287|289|DISCHARGE MEDICATIONS|The case was discussed with Dr. _%#NAME#%_ on the day of discharge and he plans to most likely start 6MP in a couple weeks' time following further treatment with prednisone for now 60 mg daily dose. DISCHARGE MEDICATIONS: 1. Prednisone 60 mg daily. 2. Lipitor 10 mg po q hs. 3. Prilosec OTC 20 mg daily for GI protection (of note, the patient's health insurance will not cover PPI unless Prilosec failure). DISCHARGE INSTRUCTIONS: 1. The patient will follow-up with Dr. _%#NAME#%_ in two weeks' time.
OTC|over the counter|OTC|155|157|FAMILY HISTORY|Father recently died. MEDICATIONS: 1. Neurontin 300 mg p.o. t.i.d. 2. Cymbalta 60 mg p.o. daily. 3. Valium 10 mg p.o. t.i.d. 4. Halcion q.h.s. 5. Prilosec OTC 1 p.o. daily. DRUG ALLERGIES: Tetracycline. SOCIAL HISTORY: She smokes 1-2 packs per day. No recent alcohol use.
OTC|over the counter|OTC.|147|150|MEDICATIONS|PAST SURGICAL HISTORY: Laparoscopy for suspected but apparently not diagnosed endometriosis some years back. MEDICATIONS: 1. Prinivil. 2. Prilosec OTC. 3. GlycoLax. 4. Topical steroids as needed. ALLERGIES: No known drug allergies. No latex allergies. HABITS: Tobacco none, alcohol moderate.
OTC|over the counter|OTC.|127|130|MEDICATIONS ON DISCHARGE|MEDICATIONS ON DISCHARGE: 1. Prinivil 5 mg p.o. daily. 2. Some topical corticosteroids as needed on a p.r.n. basis 3. Prilosec OTC. 4. Percocet 1-2 tablets p.o. q.4h. as needed for pain.
OTC|over the counter|OTC|185|187|MEDICATIONS|MEDICATIONS: 1. Metoprolol 50 mg twice a day which was given for 5 days. 2. Fosamax 70 mg weekly. 3. Lisinopril/hydrochlorothiazide 20/25 mg daily. 4. Aspirin 325 mg daily. 5. Prilosec OTC 20 mg. 6. Multivitamins daily. ALLERGIES: No known drug allergies. PERSONAL AND SOCIAL HISTORY: She denies smoking, drinking or doing drugs.
OTC|over the counter|OTC|211|213|CURRENT MEDICATIONS|1. Diabetes type 1 diagnosed in 1989 2. History of high cholesterol which he recently was started on Zocor SURGERIES: Right knee surgery x2. CURRENT MEDICATIONS 1. He is taking Humalog sliding scale 2. Claritin OTC 3. occasional Viagra 4. Zocor 20 mg daily. FAMILY HISTORY: Is significant for coronary artery disease, father with quadruple bypass times, uncle with a bypass also, mother with hypertension.
OTC|over the counter|OTC|175|177|CURRENT MEDICATIONS|2. Prescription for alprazolam 90 tablets dispensed on the _%#DD#%_ of _%#MM#%_ and again on the _%#DD#%_ of _%#MM#%_. 3. Hydrocodone/guaifenesin cough syrup. 4. Naproxen. 5. OTC Tylenol plus diphenhydramine. ALLERGIES: Iodine. SOCIAL HISTORY: The complete social history cannot be obtained secondary to the patient's lack of cooperation with the interview.
OTC|over the counter|OTC|146|148|CURRENT MEDICATIONS|8. Code status is DNR/DNI. CURRENT MEDICATIONS: 1. Metoprolol XL 100 mg a day. 2. Lisinopril 10mg p.o. b.i.d. 3. Aspirin 81 mg a day. 4. Prilosec OTC one tablet daily. SOCIAL HISTORY: The patient is a widow. She lives at home with her granddaughter. Her daughter is also involved in her care.
OTC|over the counter|OTC|111|113|DISCHARGE  MEDICATIONS|1. Lovenox 90 mg subq q.12h. 2. Coumadin 5 mg p.o. q. day. 3. Levaquin 500 mg p.o. q. day x7 days. 4. Prilosec OTC 20 mg p.o. q. day. 5. Vicodin 1-2 tabs p.o. q.4h. p.r.n. pain. 6. Fish oil 2 capsules daily. 7. Glucosamine chondroitin daily.
OTC|over the counter|OTC|120|122|DISCHARGE MEDICATIONS|5. Aldactone 100 mg q day. 6. Metformin 500 mg b.i.d. 7. Avandia 8 mg q day. 8. Cipro 500 mg q.12h x5 days. 9. Prilosec OTC 20 mg b.i.d. DISCHARGE INSTRUCTIONS: The patient will follow up with Dr. _%#NAME#%_ in one week, on a weekly basis for the next month the patient needs a chemistry panel, INR and weight measurement.
OTC|over the counter|OTC|124|126|ASSESSMENT AND PLAN|Insulin sliding scale for now. 3. Hypercholesterolemia: We will hold Lipitor. 4. BPH: Hold Flomax. 5. GERD: Change Prilosec OTC to IV Protonix, following the patient.
OTC|over the counter|OTC.|259|262|MEDICATIONS|He is uncertain about his compliance with prescribed medications. PAST MEDICAL HISTORY: Seizure disorder and gastric bypass 10 years ago. ALLERGIES: No known drug allergies. MEDICATIONS: Dilantin 200 mg t.i.d., Keppra 250 mg b.i.d., Ativan p.r.n. and Tylenol OTC. FAMILY HISTORY: Negative. SOCIAL HISTORY: The patient lives at home by himself and he is wheelchair bound.
OTC|ornithine transcarbamoylase|OTC|252|254|OPERATIONS/PROCEDURES PERFORMED|The patient was most recently at FUMC and transferred to Abbott Northwest in late _%#MM2004#%_ for titrating down of her antiepileptic drugs. The patient was found during her last hospital stay to have hyperammonemia. This was thought either due to an OTC deficiency or due to her antiepileptic medications. The patient had her antiepileptic medications titrated down and a 24-hour EEG monitoring at Abbott Northwest and was then transferred back to FUMC.
OTC|over the counter|OTC|139|141|CURRENT MEDICATIONS|2. Duloxetine 60 mg p.o. daily. 3. Zolpidem 10 mg p.o. each day at bedtime, which the patient has used for a few days. No herbal remedies, OTC medications, minerals, vitamins, supplements or alternative therapies per the patient. SOCIAL HISTORY: The patient quit smoking in 2002. He denies alcohol or other recreational drug use.
OTC|over the counter|OTC|206|208|DISCHARGE MEDICATIONS|1. Plavix 75 mg p.o. q. day with instructions for at least one year uninterrupted if at all possible. 2. Ferrous sulfate 227 mg daily. 3. Lisinopril 5 mg daily. 4. Lopressor 25 mg p.o. b.i.d. 5. Loratadine OTC 20 mg once a day. 6. Multivitamins once a day. 7. Nitroglycerin sublingual p.r.n. 8. Zocor 40 mg at bedtime. 9. 81 mg of aspirin per day.
OTC|over the counter|OTC|154|156|HISTORY OF PRESENT ILLNESS|He has been involved in AA. He has had two 5-year periods of sobriety. Lately he has been relapsing. He has been drinking alcohol. He has also been using OTC Benadryl. He was admitted to Fairview Ridges a few days ago with a high blood alcohol level greater than 0.4. He was discharged to home with some Ativan and started to take this more frequently with alcohol and Benadryl.
OTC|over the counter|OTC|124|126|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Norvasc 5 mg q.d. 2. Aspirin 325 mg q.d. 3. Avapro 300 mg q.d. 4. Lasix 40 mg q.d. 5. He will use OTC potassium chloride. 6. Atenolol 50 mg q.d. 7. Start Lopid 60 mg q.d. Follow up in 3 1/2 weeks to check potassium, lipids, and needs to be fasting.
OTC|over the counter|OTC|300|302|HISTORY OF PRESENT ILLNESS|3. Probable gastritis. HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old black male with a long history of chemical dependency, polysubstance abuse who was admitted to the emergency room due to alcohol intoxication and chest wall pain. HOSPITAL COURSE: The patient was treated with IV fluids, OTC analgesics for his chest wall pain and observation. He shows no significant signs of withdrawal. He was treated with atenolol due to tachycardia.
OTC|over the counter|OTC|199|201|MEDICATIONS|He has been on and off Coumadin for the above and most recently has been on only aspirin which he will be holding after today. MEDICATIONS: 1. Zocor 10 mg daily. 2. Aspirin 325 mg daily. 3. Prilosec OTC was recently changed to Nexium 40 mg b.i.d. 4. Tums prn. 5. Reglan 10 mg, one-half tablet before meals and at hs.
OTC|over the counter|OTC|186|188|HISTORY OF PRESENT ILLNESS|The patient reports no fever, no chills, no discoloration of his sclera. The patient has not been around any sick people. To relieve his abdominal discomfort the patient has been taking OTC Zantac and Maalox with partial relief. When the patient was seen in the emergency department on _%#MM#%_ _%#DD#%_, 2004, his hemoglobin and hematocrit was 17.7/52.3 and in the emergency department yesterday the H and H was 12.6 and 37.6. The patient reports no dizziness, no loss of consciousness, and no seizure disease.
OTC|over the counter|OTC|140|142|MEDICATIONS|MEDICATIONS: Include Methadone 30 mg po tid, Glyburide dose uncertain, Klonopin dose uncertain but she takes it three times a day. Prilosec OTC 10 mg po daily. ALLERGIES: NOTED TO PENICILLIN, CODEINE, IODINE AND COMPAZINE.
OTC|over the counter|OTC|100|102|DISCHARGE MEDICATIONS|4. Lastly, consider a sleep study. DISCHARGE MEDICATIONS: 1. Lisinopril 20 mg po Q Day. 2. Prilosec OTC 20 mg po Q Day. 3. Albuterol meter dose inhaler 1-2 puffs every six hours as needed. 4. Multiple vitamin with iron 1 tablet po Q Day.
OTC|over the counter|OTC.|151|154|HISTORY OF PRESENT ILLNESS|He could work when he would take the Ultram and nobody would notice. He started to use more. Last summer we went to South America and could buy Ultram OTC. His use increased and he went on to a daily habit. Over the past year he has used everyday. He admits to progression, adverse effects, and inability to control.
OTC|over the counter|OTC|137|139|MEDICATIONS|PAST MEDICAL HISTORY: Significant for multiple otitis media and otherwise had a full-term delivery. MEDICATIONS: As above, Augmentin and OTC Benadryl. IMMUNIZATIONS: Up to date. ALLERGIES: Denies statin, which causes GI distress, and influenza shot.
OTC|over the counter|OTC|145|147|MEDICATIONS|2. Allegra 180 mg p.o. daily. 3. Amoxicillin 875 mg one tablet twice daily for 10 days, starting _%#DDMM2007#%_ for sinus infection. 4. Prilosec OTC 20 mg p.o. daily. REVIEW OF SYSTEMS: GENERAL: No recent history of weight loss or gain, fatigue or fevers.
OTC|over the counter|OTC|149|151|DISCHARGE MEDICATIONS|6. Torsemide 20 mg q.a.m. 7. Lasix 20 mg alternating with 40 mg. 8. Isosorbide mononitrate 60 mg daily. 9. Levothyroxine 0.15 mg daily. 10. Prilosec OTC 20 mg p.o. daily. 11. Coreg 12.5 mg b.i.d. 12. Spironolactone 12.5 mg q.a.m. 13. Calcium plus D as previously dosed.
OTC|over the counter|OTC|150|152|DISCHARGE MEDICATIONS|1. At-home medications which included vientnamese herbals. These can be continued if he desires. 2. Protonix 40 mg daily but he can also use Prilosec OTC 20 mg daily. This is less expensive. 3. Compazine 5-10 mg p.o. q 6 hours p.r.n. for nausea or vomiting or Compazine suppository 25 mg b.i.d. p.r.n. for nausea and vomiting.
OTC|over the counter|OTC.|200|203|HOSPITAL COURSE|He has been smoking, but had no problems with tobacco withdrawal in the hospital using nicotine patches and Chantix. He wants to continue the Chantix. If he needs patches, he will be able to get them OTC. This gentleman's MI occurred in the setting of having his wife die in the Emergency Room.
OTC|over the counter|OTC|171|173|DISCHARGE INSTRUCTIONS|3. Amoxicillin 500 mg p.o. b.i.d. for days 3-14 of his H. pylori treatment. 4. Clarithromycin 500 mg p.o. b.i.d. days 3-14 of his H. pylori treatment regimen. 5. Prilosec OTC 20 mg 2 tabs p.o. 2 times per day as part of his H. pylori treatment regimen days 3-14 of this regimen. FOLLOWUP: The patient is to follow up with Dr. _%#NAME#%_ in his clinic in approximately 2 weeks' time and is given a number to do so.
OTC|over the counter|OTC|125|127|MEDICATIONS|PAST MEDICAL HISTORY: Type 2 diabetes 10 years standing, dyslipidemia. MEDICATIONS: Recently finished a Zithromax pack. Only OTC analgesics. SOCIAL HISTORY: Denies tobacco or alcohol abuse. No illicit drug use. He is unemployed, a Southeast Asian immigrant, married as well.
OTC|over the counter|OTC|117|119|MEDICATIONS|He also has a history of erectile dysfunction and GERD. MEDICATIONS: 1. Cialis 20 mg before intercourse. 2. Prilosec OTC 20 mg daily. 3. Multivitamin daily. 4. Aspirin daily, which he is currently holding. ALLERGIES: None. FAMILY HISTORY: Unremarkable. He father did die at age 69 of lung cancer.
OTC|over the counter|OTC|229|231|PROBLEM #3|PROBLEM #3: Hypertension. After increasing her Cozaar and hydrochlorothiazide, her blood pressure was adequately controlled. It was felt the patient was taking too many Advil, on top of her Vioxx, and she was advised not to take OTC Advil or ibuprofen, which could have contributed to her leg edema and shortness of breath. In terms of her overall course, her blood pressure was adequately controlled.
OTC|over the counter|OTC|211|213|HOSPITAL COURSE|Given his stressors, certainly an UGI source could be implicated but clinically it supports more of an acute diverticular bleed. With his stressors and increased symptoms though, he could certainly use Prilosec OTC for next two weeks or so and then reassess. His hemoglobin did stabilize at 10.9 to 11.1 range without hypotension, orthostasis.
OTC|over the counter|OTC|159|161|DISCHARGE MEDICATIONS|16. History of tuberculosis. 17. Bladder cancer. 18. Chronic obstructive pulmonary disease. DISCHARGE MEDICATIONS: 1. DuoNebs 4 times daily p.r.n. 2. Prilosec OTC daily. 3. Carafate 1 mg solution 4 times daily x 4 weeks. 4. Cosopt 1 drop to each eye b.i.d. 5. Flomax 0.4 mg daily.
OTC|over the counter|OTC.|154|157|MEDICATIONS|9. Diltiazem 180/24 p.o. q day. 10. Propranolol 200 mg p.o. q day. 11. Premarin 0.625 mg p.o. q day. 12. Furosemide one-half tab p.o. q day. 13. Prilosec OTC. SOCIAL HISTORY: The patient has been widowed for 15 years.
OTC|over the counter|OTC,|175|178|MEDICATIONS|8. Foltex, one tablet q. day. 9. Quetiapine, 25 mg b.i.d. 10. Senna, one tablet b.i.d. 11. Quinine, 2 tablets at dialysis. 12. __________, 3 tablespoons a day. 13. Omeprazole OTC, 20 mg q. day. 14. Paroxetine, 20 mg q. day. 15. Zinc, 25 mg q. day. 16. Simvastatin, 40 mg q. day. 17. Albuterol, 2 puffs q.i.d.
OTC|over the counter|OTC|193|195|DISCHARGE MEDICATIONS|4. Ferrous sulfate 350 mg p.o. t.i.d. 5. Ambien 5 mg nightly p.r.n. insomnia. 6. Ativan 0.5 mg q.6 h. p.r.n. anxiety. 7. Extra Strength Tylenol 500 to 1000 mg q.4-6 h. p.r.n. pain. 8. Prilosec OTC 20 mg p.o. b.i.d. 9. Caltrate 1 tablet p.o. daily. DISCHARGE CONDITION: Stable. Discharged to home. FOLLOWUP: She is to follow up with her primary medical physician Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ at Fairview Uptown on _%#MM#%_ _%#DD#%_, 2005, at 10 a.m.
OTC|over the counter|OTC.|239|242|MEDICATIONS AT THE TIME OF PRESENTATION|CODE STATUS: Full code. ALLERGIES: Diltiazem, tetracycline, codeine. MEDICATIONS AT THE TIME OF PRESENTATION: 1. Norvasc 5 mg daily. 2. Metoprolol 150 mg p.o. b.i.d. 3. Hydrochlorothiazide 25 mg daily. 4. Potassium supplement. 5. Prilosec OTC. 6. Recent eye drops for her cataract surgery. FAMILY HISTORY: Noncontributory at this point. LABORATORY: Reviewed, and essentially all unremarkable. PHYSICAL EXAMINATION: GENERAL: On exam, she is alert, awake, oriented x3, a very pleasant, elderly lady, in no distress, sitting comfortably in bed.
OTC|over the counter|OTC|164|166|MEDICATIONS|2. Claritin 10 mg p.o. q. day. 3. Ativan 0.5 mg p.o. b.i.d. p.r.n. 4. Milk of magnesia 15 mL p.o. daily at bedtime. 5. Remeron 7.5 mg p.o. at bedtime. 6. Cranberry OTC 600 mg p.o. b.i.d. 7. Prilosec 20 mg p.o. q. day. 8. Paxil 20 mg p.o. daily. 9. Risperdal 1 mg p.o. q. day. 10. Senokot two tablets by mouth daily at bedtime.
OTC|over the counter|OTC|127|129|DISCHARGE MEDICATIONS|7. Sublingual nitro p.r.n. 8. Zocor 10 mg each day at bedtime. 9. Aspirin 81 mg day. 10. Glucophage 500 mg b.i.d. 11. Prilosec OTC 20 mg q. day. The patient will be scheduled for a capsule endoscopy through Minnesota GI next week and should follow up with Dr. _%#NAME#%_ in the next 1-2 weeks.
OTC|over the counter|OTC|165|167|DISCHARGE MEDICATIONS|2. Aspirin 81 mg daily. 3. Darvocet-N 100 one twice a day p.r.n. for pain. 4. Compazine suppository 25 mg rectally q.12h. p.r.n. for nausea or vomiting. 5. Prilosec OTC 20 mg 1 a day. 6. Norvasc 10 mg daily. 7. Lipitor 20 mg daily. 8. Lasix 20 mg b.i.d. 9. Isordil 40 mg b.i.d. 10. Reglan 5 mg t.i.d. 30 minutes prior to each meal scheduled.
OTC|over the counter|OTC|146|148|DISCHARGE MEDICATIONS|13. Levaquin 250 mg q.48h. for UTI for 4 more doses. Next dose is due on _%#DDMM2007#%_ at p.m. dosing time 14. Aspirin 325 mg q. day 15. Tylenol OTC 500 to 1000 mg q.6h. p.r.n. pain DISCHARGE DISPOSITION: _%#NAME#%_ _%#NAME#%_ will be going to Masonic Home.
OTC|over the counter|OTC|99|101|CURRENT MEDICATIONS|4. Hypertension. CURRENT MEDICATIONS: 1. Norvasc 5 mg daily. 2. Lotrel 5/10 one daily. 3. Prilosec OTC 20 mg daily. 4. Metformin 500 mg daily. 5. Avapro 300 mg daily. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 55-year-old woman who presents with recurrent episodes of acute epigastric abdominal pain with nausea.
OTC|over the counter|OTC|132|134|MEDICATIONS|8. Hypertension 9. Tobacco use, ongoing at a pack of cigarettes daily MEDICATIONS: According to the patient now include 1. Prilosec OTC one tablet daily 2. Lasix unknown dose two tablets. She denies taking any other specific medications as present ALLERGIES: No known drug allergies.
OTC|over the counter|OTC|160|162|PLAN|Associated contraindications including mouthwash with alcohol and lotion with alcohol. Clearly there are most likely alternatives to those alcoholic-containing OTC products.
OTC|over the counter|OTC|145|147|DISCHARGE MEDICATIONS|5. Micardis 40 mg daily. 6. Metoprolol 50 mg b.i.d. 7. Zocor 40 mg p.o. q h.s. 8. Nitroglycerin 0.4 mg sublingual p.r.n. chest pain. 9. Prilosec OTC 20 mg daily, p.r.n. heart burn. DISHARGE INSTRUCTIONS: The patient will follow with Dr. _%#NAME#%_ in one week at the HealthPartners _%#CITY#%_ Clinic.
OTC|over the counter|OTC|129|131|CURRENT MEDICATIONS|Denies dysuria or frequency. PAST MEDICAL HISTORY: Sinusitis. PAST SURGICAL HISTORY: Ventral hernia repair. CURRENT MEDICATIONS: OTC medications. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Denies alcohol, tobacco, or drug abuse.
OTC|over the counter|OTC|182|184|MEDICATIONS|8. Neurontin 800 mg p.o. t.i.d. 9. Coumadin 5 mg on Tuesday, Thursday, and Saturday, 8.5 mg on Monday and Wednesday. 10. Oxycodone 1 to 2 tablets q. 4 to 6 hours p.r.n. 11. Prilosec OTC 20 mg p.o. q. day. SOCIAL HISTORY: The patient lives is a nursing home.
OTC|over the counter|OTC|143|145|ADMISSION DIAGNOSIS|6. Ogen 1.25 mg p.o. daily. 7. Ferrous sulfate 50 mg p.o. daily. 8. Prozac 40 mg p.o. daily. 9. Flagyl 500 mg p.o. 4 times a day. 10. Prilosec OTC 20 mg p.o. daily. 11. Prednisone 5 mg p.o. daily. 12. Tylenol 325 mg p.o. q.6 h. p.r.n. 13. B12 injection once per week.
OTC|over the counter|OTC|166|168|DISCHARGE MEDICATIONS|The patient was discharged home feeling strong. DISCHARGE MEDICATIONS: She was discharged on Flagyl 500 mg p.o. t.i.d. for five days. Also, Pepto-Bismol as directed, OTC for diarrhea. Her only other prescription medication was Ambien 5 mg p.o. p.r.n. q.h.s. for sleep. She is be discharged and will be followed by her primary at Crosstown Clinic.
OTC|over the counter|OTC|345|347|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_is a 34-year-old white gentleman with a past medical history of obsessive-compulsive disorder and depression was on Nardil which is an MAO inhibitor for five years. Since MAO inhibitors have a lot of restriction and interaction with other drugs, he could not use other common OTC drugs. For that reason the patient was advised to stop Nardil by the psychiatrist, Dr. _%#NAME#%_ and then after one week he was started on Cymbalta, which is a new medication for him.
OTC|over the counter|OTC,|163|166|REVIEW OF SYSTEMS|However, he has continued to use albuterol daily due to symptoms. He has had increased indigestion with heartburn, gassiness, and upset stomach. He tried Prilosec OTC, but had significant nasal congestion and discontinued. He states that he has chronic problems with diarrhea and constipation which has been worse since the Tikosyn and better when he takes Citrucel regularly.
OTC|over the counter|OTC|110|112|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1. Oxycodone 5 to10 mg p.o. q.6. h. p.r.n. for pain. 2. Humira 14 mcg subcu q. month. 3. OTC medications, Tylenol. FAMILY HISTORY: The patient's mother and her maternal uncle have been diagnosed to have Crohn's disease.
OTC|over the counter|OTC|113|115|MEDICATIONS|4. Folic acid 1 mg daily. 5. Lexapro 10 mg daily. 6. Lisinopril 7.5 mg daily. 7. Plavix 75 mg daily. 8. Prilosec OTC 20 mg daily. 9. Simvastatin 20 mg daily. REVIEW OF SYSTEMS: Unobtainable. PHYSICAL EXAMINATION: GENERAL: The patient is awake but confused.
OTC|over the counter|OTC|239|241|DISCHARGE MEDICATIONS|Continue outpatient omeprazole. Discussed he may need to take it twice a day as he is on multiple medications that can irritate his stomach lining. DISCHARGE MEDICATIONS: 1. Niaspan 500 mg 2 tablets p.o. each day at bedtime. 2. Omeprazole OTC 20 mg 1-2 tablets p.o. daily. NEW PRESCRIPTIONS: 1. Prednisone 40 mg p.o. daily x5 days. 2. Naproxen 500 mg p.o. b.i.d. with food.
OTC|over the counter|OTC|166|168|DISCHARGE DIAGNOSES|3. CT positive for moderate sacroiliac joint arthropathy. This diagnosis was discussed with the patient and the patient was advised that if he has symptoms for which OTC Tylenol is inadequate that this should be worked up further. 4. Nicotine dependence. The patient is aware that this is a harmful habit, but is in the precontemplative phase of nicotine cessation.
OTC|over the counter|OTC|158|160|MEDICATIONS|3. Relpax p.r.n. migraines. 4. Effexor XR 150 mg p.o. daily. 5. Lipitor 10 mg p.o. daily. 6. Ativan p.r.n. 7. Zofran ODT p.r.n. 8. Ibuprofen p.r.n. 9. Pepcid OTC p.r.n. 10. Neosporin on incisions. ALLERGIES: No known drug allergies. Primary facial plastic surgeon Dr. _%#NAME#%_.
OTC|over the counter|OTC|123|125|MEDICATIONS ON ADMISSION|9. Iron controlled release 50 mg p.o. daily. 10. Actos 30 mg p.o. daily. 11. Oxygen 2-4 L continuous by nose. 12. Prilosec OTC p.o. 30 mg daily. 13. Flaxseed oil 0.1 mg. 14. Multivitamin. 15. Furosemide 80 mg p.o. daily. 16. Synthroid 125 mcg p.o. daily. 17. Vitamin C 1000 mg p.o. daily.
OTC|over the counter|OTC|231|233|HISTORY OF PRESENT ILLNESS|Symptoms started three days ago. HISTORY OF PRESENT ILLNESS: The patient three weeks ago was seen at _%#TOWN#%_ _%#TOWN#%_ Clinic for upper respiratory infection type symptoms. She was diagnosed with a viral infection and had used OTC medications including Tylenol, Sudafed, and Nyquil. Over the past few weeks she was gradually improving except for a mild residual cough.
OTC|over the counter|OTC|201|203|DISPOSITION|Of note, he has had colchicine in the past, but it has caused uncontrollable diarrhea. He also will be on a proton pump inhibitor because he buys the majority of his medications - we will try Prilosec OTC since it is only 80 cents a tablet and he will be in to see me in approximately a week. We will check a hemoglobin and white count at that point in time and probably a creatinine and also his blood pressure.
OTC|ornithine transcarbamoylase|OTC.|214|217|PAST OB HISTORY|2. SAB x 2. 3. Approximately 1991, 21-week delivery, complicated by spotting throughout the 2nd trimester with probable abruption and chorioamnionitis. 4. _%#DDMM1995#%_: SVD, 34 weeks, 7 pounds 5 ounces. Baby has OTC. The patient was on bed rest x 5 months. PAST MEDICAL HISTORY: 1. Laparoscopy, hysteroscopy approximately 1992 for pain and abnormal bleeding.
OTC|over the counter|OTC|185|187|CURRENT MEDICATIONS|8. _________ 750 mg p.o. b.i.d. 9. Vicodin 500 mg p.o. q. 4 hours. 10. Ketoconazole cream b.i.d. to feet. 11. Nystatin powder to feet. 12. Triamcinolone ointment to hands. 13. Prilosec OTC 20 mg p.o. daily. PHYSICAL EXAMINATION: GENERAL: He is an obese male in no apparent distress or discomfort.
OTC|over the counter|OTC.|210|213|MEDICATIONS|Unfortunately, she also has significant cognitive decline secondary to CVIs and vascular dementia and again it was felt that she was unsafe to go back to her assisted living apartment. MEDICATIONS: 1. Prilosec OTC. 2. Furosemide 40 mg p.o. every other day and 20 mg alternating days. 3. Plavix 75 mg daily. 4. Isosorbide 30 mg three a day.
OTC|over the counter|OTC|136|138|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Levothyroxine 100 mcg p.o. daily. 2. Paroxetine 30 mg p.o. daily. 3. Lisinopril 10 mg p.o. daily. 4. Prilosec OTC 20 mg p.o. daily. 5. Multivitamin 1 tablet p.o. daily. 6. Combivent inhaler 2 puffs inhaled q. 4 hours p.r.n. shortness of breath. OUTPATIENT FOLLOWUP: 1. The patient will follow with her physician's assistant, _%#NAME#%_ _%#NAME#%_ for weekly hemoglobin checks and/or have transfusions as necessary through the Infusion Center at Fairview, Southdale Hospital.
OTC|over the counter|OTC.|145|148|HISTORY OF PRESENT ILLNESS|The pain was with swallowing and it seemed to radiate upwards. The patient stopped the antibiotics and started taking Rolaids, Tums and Prilosec OTC. The pain was related to swallowing and was not related to exercise. For the last two days, the pain seemed to radiate upwards also in the posterior part of the left upper arm.
OTC|over the counter|OTC|138|140|DISCHARGE MEDICATIONS|3. Colace 100 mg p.o. daily p.r.n. 4. Folic acid 1 mg p.o. daily. 5. Neurontin 100 mg p.o. t.i.d. 6. Synthroid 50 mcg p.o. daily. 7. ____ OTC 15 mg p.o. daily. 8. Potassium supplement OTC 25 mg p.o. daily 9. Bromelin 20 mg p.o. daily. 10. Multivitamin tab p.o. daily.
OTC|over the counter|OTC|118|120|DISCHARGE MEDICATIONS|5. Neurontin 100 mg p.o. t.i.d. 6. Synthroid 50 mcg p.o. daily. 7. ____ OTC 15 mg p.o. daily. 8. Potassium supplement OTC 25 mg p.o. daily 9. Bromelin 20 mg p.o. daily. 10. Multivitamin tab p.o. daily. 11. Prilosec 20 mg p.o. b.i.d. 12. Prednisone 5 mg p.o. b.i.d.
OTC|over the counter|OTC.|163|166|MEDICATIONS ON ADMISSION|2. Synthroid, dose of which is not known. 3. Metformin, dose not known. 4. Lasix 20 mg a day. 5. Glipizide, dose not known. 6. Lisinopril 20 mg a day. 7. Prilosec OTC. 8. She does take a few other medications, none of which she remembers. Her pharmacy is Cub Pharmacy in _%#CITY#%_. PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile, blood pressure 138/60, heart rate 64, respiratory rate 14.
OTC|over the counter|OTC|132|134|DISCHARGE  MEDICATIONS|4. Resume prior medications of: Furosemide 20 mg p.r.n. 5. Lisinopril 2.5 mg daily. 8. Ativan 0.5 mg at bed-time p.r.n. 9. Prilosec OTC 20 mg b.i.d. 10. Paroxetine 20 mg daily. 11. Quinine sulfite 325 mg p.r.n. which she only uses very rarely 12. Carafate 1 gram b.i.d. with meals. 13. Aspirin 81-325 mg daily.
OTC|over the counter|OTC|155|157|MEDICATIONS|ALLERGIES: None. MEDICATIONS: No regular medicines. Most recently she has been taking the albuterol nebulizer x 1 prior to ER. She also received a dose of OTC Benadryl prior to ER. PAST MEDICAL HISTORY: This is a former 29-week premie born at Abbott Northwestern, was born early due to preterm labor.
OTC|over the counter|OTC|157|159|DISCHARGE MEDICATIONS|2. Flagyl 500 mg to be taken every 8 hours for an additional two weeks. 3. Vicodin one to two tabs to be taken every 6 hours as needed for pain. 4. Prilosec OTC 1 tab to be taken daily.
OTC|over the counter|OTC|120|122|CURRENT MEDICATIONS|6. Lisinopril 20 mg daily. 7. Lipitor 20 mg daily. 8. Zoloft 100 mg daily. 9. Flexeril 10 mg t.i.d. p.r.n. 10. Prilosec OTC 20 mg, 1 tablet b.i.d. Of note, the patient has finished a course of Rifaximin 200 mg, 2 tablets t.i.d. p.r.n., per Dr. _%#NAME#%_'s note.
OTC|over the counter|OTC|127|129|DISCHARGE MEDICATIONS|2. Prednisone 40 mg every morning and 20 mg every evening 3. Ambien 5-10 mg p.o. daily at bedtime p.r.n. for sleep. 4. Tylenol OTC 500-1000 mg q. 6 hours p.r.n. for pain or fever. DISPOSITION: 1. She will be going home. 2. She will follow-up with Minnesota GI next week.
OTC|over the counter|OTC|237|239|HOSPITAL COURSE|He did have an episode of reflux on the night prior to discharge and was given Mylanta which helped, but he had been on PPIs in the past, but really had not been having symptoms until this episode. He decided that he would prefer to try OTC Prilosec for this at discharge. Therefore, on _%#DDMM2006#%_, he was discharged with plan to go to outpatient dialysis in _%#CITY#%_ for his run this afternoon.
OTC|over the counter|OTC|122|124|HOSPITAL COURSE|3. History of hiatal hernia. It is suspected that this may be the cause of his discomfort. The patient has taken Prilosec OTC episodically. The patient is asked to continue this for the next four to six weeks. 4. Hepatic panel abnormalities. The patient had mild elevation of his transaminases in the 100s.
OTC|over the counter|OTC|128|130|DISCHARGE MEDICATIONS|He had no further syncope or presyncopal episodes since then. DISCHARGE MEDICATIONS: 1. Toprol-XL 25 mg p.o. daily. 2. Prilosec OTC daily. DISPOSITION: The patient discharged home and is to follow up with his primary care physician in 2 weeks with a hepatic panel and follow up with this his hepatitis C testing and blood pressure follow up.
OTC|over the counter|OTC|114|116|MEDICATIONS|ALLERGIES: The patient denies allergies. MEDICATIONS: 1. Crestor 10 mg daily. 2. Flomax 0.4 mg daily. 3. Prilosec OTC once daily. 4. Aspirin 81 mg daily. 5. Altace 5 mg p.o. daily. 6. Nitroglycerin sublingually p.r.n. FAMILY HISTORY: Mother died at age 62 probably of an MI.
OTC|over the counter|OTC|120|122|DISCHARGE MEDICATIONS|2. Ativan 1 mg for anxiety, taken as needed. 3. Toprol-XL 50 mg p.o. daily. 4. Lisinopril 20 mg p.o. daily. 5. Prilosec OTC 20 mg p.o. daily. REVIEW OF SYSTEMS: GENERAL: He has been coughing up a small amount of blood.
OTC|over the counter|OTC|309|311|MEDICATIONS|She was given Augmentin dose x1 today earlier at 11:00 in the morning and again was not helpful and then this evening was given 300 cc D5 normal saline bolus with no improvement in symptoms, therefore sent to be admitted to Fairview Ridges due to no available bed at St. Francis. MEDICATIONS: As above, takes OTC Claritin for allergic rhinitis. ALLERGIES: No drug allergies. PAST SURGICAL HISTORY: None. PAST MEDICAL HISTORY: Hospitalizations none.
OTC|over the counter|OTC.|210|213|DISCHARGE MEDICATIONS|a. Troponins negative times 3. b. D-dimer negative. c. Stress echocardiogram showed no evidence of ischemia. DISCHARGE MEDICATIONS: 1. Nexium 40 mg p.o. daily x1 month as a therapeutic trial. 2. P.r.n. Tylenol OTC. DISCHARGE DISPOSITION: I have asked him to follow up with Dr. _%#NAME#%_ next week if he is not improving.
OTC|over the counter|OTC|91|93|MEDICATIONS|Alcoholism in father as well. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Prilosec OTC 40 mg per day. 2. Toprol XL 50 mg per day. 3. Lexapro 20 mg per day. REVIEW OF SYSTEMS: GENERAL: Not feeling well over the last week with abdominal pain as above.
OTC|over the counter|OTC|133|135|PAST  MEDICAL HISTORY|CHIEF COMPLAINT: Chest pain. PAST MEDICAL HISTORY: Chronic shoulder pain for which he has not sought medical attention but does take OTC ibuprofen. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 52-year-old man who works as an auto transporter was in his usual state of health until around 11:30 when he was in his kitchen and developed substernal chest squeezing.
OTC|over the counter|OTC|180|182|MEDICATIONS|2. Seroquel 100 mg p.o. daily p.r.n. agitation. 3. Ativan 1 mg p.o. 3 x daily p.r.n. agitation. 4. Ambien 12.5 mg p.o. one time at night. 5. Cerovite 1 tab p.o. daily. 6. Prilosec OTC 20 mg p.o. 2 times daily. 7. Senna 2 table p.o. one time daily. 8. Seroquel 300 mg p.o. one time daily.
OTC|over the counter|OTC|116|118|CURRENT MEDICATIONS|8. Trazodone 75 mg p.o. daily. 9. Simvastatin 40 mg p.o. each day at bedtime. 10. Mexiletine 150 mg p.o. t.i.d. 11. OTC iron tablets. SOCIAL HISTORY: The patient quit using a pipe 4 years ago.
OTC|over the counter|OTC.|145|148|DISCHARGE MEDICATIONS|6. Tylenol p.r.n. 7. Ambien 5 mg p.o. each day at bed-time p.r.n. 8. Spironolactone 25 mg p.o. t.i.d. 9. Aspirin 81 mg p.o. q. day. 10. Prilosec OTC. 11. Stool softeners. 12. Nasonex. 13. Mucinex. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 77-year-old woman who presented to Fairview Southdale ER on _%#DDMM2006#%_ with left flank pain, associated nausea and vomiting.
OTC|over the counter|OTC|132|134|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Vicodin one to two tablets every six hours as needed for pain, #15 dispensed with no refills. 2. Prilosec OTC 20 mg once a day for one month, then once a day as needed. DISCHARGE FOLLOW-UP: 1. Dr. _%#NAME#%_ at the Oxboro Clinic in _%#CITY#%_ in approximately one month or sooner as needed.
OTC|over the counter|OTC|267|269|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 30-year-old female with past medical history significant for ornithine transcarbamylase (OTC) deficiency who went to the emergency department today after a 2-day history of increasing somnolence. She was diagnosed with OTC at birth and has been followed by the pediatric genetics and metabolism group here at the University of Minnesota. _%#NAME#%_ has not been compliant with her outpatient medication for control of her deficiency including buphenyl.
OTC|ornithine transcarbamoylase|OTC|328|330|ASSESSMENT|LABORATORY DATA: Most recent ammonia level of 65 at 6:20 p.m. Sodium 139, potassium 3.8, chloride 108, bicarbonate 23, glucose 148, BUN 4, creatinine 0.45, calcium 8.1. White count 4.9, hemoglobin 11.7, platelets 263. Magnesium 2, phosphorus 3. ASSESSMENT: This is a 30-year-old female with past medical history significant for OTC deficiency who presents with an exacerbation secondary to poor outpatient medicine compliance. PLAN: 1. OTC deficiency: Will start the patient on L-argine and Ammonul as prescribed by Dr. _%#NAME#%_.
OTC|over the counter|OTC|218|220|PLAN|Magnesium 2, phosphorus 3. ASSESSMENT: This is a 30-year-old female with past medical history significant for OTC deficiency who presents with an exacerbation secondary to poor outpatient medicine compliance. PLAN: 1. OTC deficiency: Will start the patient on L-argine and Ammonul as prescribed by Dr. _%#NAME#%_. Dr. _%#NAME#%_ can be paged at any time at pager _%#TEL#%_.
OTC|over the counter|OTC|130|132|DISCHARGE MEDICATIONS|In addition, he had a catheter in his Monti. DISPOSITION: Patient is to be discharged to home. DISCHARGE MEDICATIONS: 1. Prilosec OTC 10 mg p.o. daily. 2. MS Contin 90 mg p.o. b.i.d. 3. Valium 10 mg p.o. every night. 4. Flexeril 10 mg p.o. t.i.d. 5. Norvasc 10 mg p.o. daily.
OTC|over the counter|OTC|137|139|MEDICATIONS|4. Plavix 75 mg po daily which is currently being held and will be for over a week prior this surgery. 5. Tylenol arthritis. 6. Prilosec OTC one capsule po daily. ALLERGIES: No known drug allergies, although the patient is sensitive to niacin which causes a rash.
OTC|ornithine transcarbamoylase|OTC,|293|296|ADMISSION DIAGNOSIS|HISTORY OF PRESENT ILLNESS: This is a 28-year-old female who presents to University of Minnesota Medical Center, Fairview, for breast reduction mammoplasty; that was performed on _%#MM#%_ _%#DD#%_, 2005 The patient was admitted a day earlier since she has a history of liver enzyme deficiency OTC, and she needed preoperative evaluation by the metabolism service. PAST MEDICAL HISTORY: OTC. PAST SURGICAL HISTORY: D&C x2, appendectomy, and tubal ligation.
OTC|over the counter|OTC|232|234|DISCHARGE MEDICATIONS|2. Microscopic hematuria which may be chronic, no evidence for acute urinary tract infection and negative urine culture. 3. Hypertension. 4. Hyperlipidemia. 5. Depression. 6. Anxiety. DISCHARGE MEDICATIONS: Will add either Prilosec OTC 20 mg p.o. daily or Protonix 40 mg p.o. once daily for possible gastroesophageal reflux as a cause for his epigastric pain.
OTC|over the counter|OTC.|172|175|DISCHARGE MEDICATIONS|3. Synthroid 0.075 mg p.o. q day. 4. Actonel 35 mg p.o. q week. 5. Multivitamin one p.o. q day. 6. Zantac 75 to 150 mg p.o. b.i.d.; if this does not work may take Prilosec OTC. 7. Flexeril 5 mg p.o. t.i.d. She was given 20 of these with one refill.
OTC|over the counter|OTC|128|130|DISCHARGE MEDICATIONS|5. Decreased alcohol intake. 6. Consider Florinef as an outpatient. DISCHARGE MEDICATIONS: 1. Atenolol 50 mg daily. 2. Prilosec OTC 20 mg daily. 3. Carafate 1 g q.i.d. 4. Allopurinol 300 mg daily. 5. Diltiazem extended-release 240 mg daily. 6. Diovan 160 mg b.i.d.
OTC|over the counter|OTC|153|155|DISCHARGE MEDICATIONS|15. Aspirin 81 mg daily 16. Multiple vitamin 1 pill daily. 17. Saw palmetto 2 pills daily 18. Flomax 0.4 mg every Monday, Wednesday, Friday 19. Prilosec OTC 20 mg daily. 20. Levaquin 250 mg daily for 4 days 21. Tapering dose of prednisone. That would be 10 mg daily for 3 days, then 5 mg daily for 3 days, then back to his baseline dose of 5 mg every other day.
OTC|over the counter|OTC|238|240|MEDICATIONS|Alcohol, 2-3 per year. He is retired from 3M. ALLERGIES: He has hayfever, for which he has taken allergy shots in the past but these have been discontinued. No allergies to medication. MEDICATIONS: 1. Klonopin 0.5 at bedtime. 2. Prilosec OTC 1 daily. 3. Low strength aspirin daily. 4. Multivitamin daily. REVIEW OF SYSTEMS: Unremarkable. PHYSICAL EXAMINATION: GENERAL: He is a healthy appearing male in no acute distress.
OTC|over the counter|OTC|155|157|HOSPTAL COURSE|He should then follow up with Dr. _%#NAME#%_ in approximately 6 weeks for stent removal. He will be discharged on his home medications to include Prilosec OTC 20 mg p.o. q. day p.r.n. heartburn, in addition to Colace 100 mg p.o. b.i.d. for constipation, Levaquin 500 mg p.o. q. day for 3 days, Percocet 5/325 one to two p.o. q.4h. p.r.n. pain and he was instructed to notify physician if he should have any increasing pain or elevation of fever greater than 101.5.
OTC|over the counter|OTC|180|182|DISCHARGE MEDICATIONS|He was discharged on a full liquid diet. DISCHARGE MEDICATIONS: 1. Albuterol 90 mcg two puffs inhaled q.6h. p.r.n. wheezing. 2. Crestor 10 mg p.o. q. day crush tablet. 3. Prilosec OTC one tablet p.o. q. day crush tablet. 4. Advair Diskus two puffs inhaled b.i.d. 5. Lortab Elixir 15 mL p.o. q.4-6h. p.r.n. pain 500 mL dispensed with 0 refills.
OTC|over the counter|OTC|167|169|MEDICATIONS|10. Lipitor 20 mg. q. day. 11. Glucosamine and chondroitin sulfate. 12. Vicodin q.i.d. p.r.n. 13. She is temporarily off her Ranitidine 150 mg b.i.d. and her Prilosec OTC 20 mg once a day. CHRONIC DISEASES: 1. Rheumatoid arthritis. Methotrexate use and Remicade use.
OTC|over the counter|OTC|172|174|MEDICATIONS|She lives with her husband. MEDICATIONS: 1. Norvasc 10 mg p.o. daily. 2. Avandia 8 mg p.o. daily. 3. Glipizide 5 mg p.o. b.i.d. 4. Metformin 500 mg p.o. b.i.d. 5. Prilosec OTC 20 mg p.o. daily. 6. Aspirin 81 mg p.o. daily. 7. Avapro 150 mg p.o. daily. ALLERGIES: No known drug allergies. EXAM ON ADMISSION: VITAL SIGNS: Temperature 99.0, blood pressure 146/82, pulse 107, respiratory rate 16 and O2 sats 97% on room air.
OTC|over the counter|OTC|138|140|MEDICATIONS|MEDICATIONS: At admission include atenolol 50 mg b.i.d. He already took an atenolol dose this morning. Allopurinol 150 mg daily, Prilosec OTC half tablet p.o. daily and p.r.n., an electrolyte supplement and aspirin 81 mg daily. ALLERGIES: He has a history of diffuse rash and itchy throat and ears from sulfa and ibuprofen.
OTC|over the counter|OTC|151|153|HISTORY OF PRESENT ILLNESS|The patient was found by neighbors with altered mental status and being lethargic. Per the patient he had taken more than 20 tablets of Tylenol PM and OTC cough syrup and 3 tablets of Celexa. The patient took the above medication more than 12 hours ago. Per mother _%#NAME#%_ has a history of depression over the past 3 years.
OTC|over the counter|OTC|93|95|DISCHARGE MEDICATIONS|12. Enuresis. 13. Diaphragmatic hernia. 14. Hearing loss. DISCHARGE MEDICATIONS: 1. Prilosec OTC 20 mg daily. 2. Lisinopril 5 mg daily. 3. Ferrous sulfate 324 mg daily. 4. Klor-Con 10 mEq 2 tabs daily. 5. Calcium D 600/250 daily. 6. Furosemide 80 mg daily.
OTC|over the counter|OTC|183|185|ADMISSION MEDICATIONS|The patient felt well enough to go home. She was discharged in stable condition. DISCHARGE MEDICATIONS: Wellbutrin 150 mg p.o. b.i.d., Claritin D, allergen drops submucosa, nasalcrom OTC spray, hydrocortisone cream p.r.n., colace 100 mg q.6-8h. p.r.n. constipation, percocet 2.5/325, 1 tab p.o. q.6-8h. p.r.n. pain. DISCHARGE INSTRUCTIONS: The patient should advance to a soft diet and advance the diet as tolerated.
OTC|over the counter|OTC|164|166|DISCHARGE DIAGNOSIS|PAST MEDICAL HISTORY: 1. Removal of a cutaneous cyst. 2. Asthma attack 6 months ago. Seen at _%#COUNTY#%_ _%#COUNTY#%_ Medical Center ER. ADMISSION MEDICATIONS: 1. OTC aspirin. 2. OTC bronchodilators. 3. Nyquil. ALLERGIES: Seasonal allergies. No known drug allergies. FAMILY HISTORY: Negative for coronary artery disease or cancer.
OTC|over the counter|OTC|128|130|MEDICATIONS|PAST MEDICAL HISTORY: See above. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Fish oil 1 capsule once a day. 2. Prilosec OTC one tablet daily. SOCIAL HISTORY: The patient is a computer programmer, works for ConAgra foods, does not smoke.
OTC|over the counter|OTC|156|158|MEDICATIONS|However, other people did not eat the same foods that she did eat. MEDICATIONS: 1. Glucosamine/chondroitin sulfate. 2. Synthroid 100 mcg a day. 3. Prilosec OTC 1 tablet daily. 4. Multivitamin. The patient does not take an aspirin, but she did take several aspirins yesterday because she was not feeling very good.
OTC|over the counter|OTC|169|171|PROBLEMS PRESENTED ON ADMISSION|PROBLEMS PRESENTED ON ADMISSION: The client met at least 3 of 7 DSM-IV criteria to support a diagnosis of 304.80, polysubstance dependence (alcohol, marijuana, cocaine, OTC caffeine pills, inhalants). Additional problems include use related strain on relationship with father, estranged relationship with mother, family history of chemical dependency and treatment, the need to develop a sober support system, the need to establish a safe living situation, a history of self-injurious behavior, allergies, and a history of asthma.
OTC|over the counter|OTC|126|128|CURRENT MEDICATIONS|9. Nitroglycerin 0.4 sublingual p.r.n. 10. Oxycodone 5 mg t.i.d. as needed for back pain. 11. Plavix 75 mg daily. 12 Prilosec OTC 20 mg daily. 13 Senna S daily 14. Seroquel 200 mg daily at h.s. for sleep. 15. Spironolactone 25 mg daily. 16 Xanax 0.5 mg t.i.d. for anxiety.
OTC|over the counter|OTC|509|511|DISCHARGE  MEDICATIONS|I initiated the patient on Flomax 0.4 mg daily. I would recommend urology outpatient consultation prior to discontinuation of the catheter if complications arise from the use of a chronic indwelling catheter. DISCHARGE MEDICATIONS: Aspirin 300 mg suppository rectally daily, clindamycin 400 mg feeding tube q.8h. times six days, Colace 100 mg feeding tube daily, Advair 250/50 one puff p.o. b.i.d., Lasix 40 mg p.o. b.i.d. Xopenex 1.25 mg per 3 cc, one vial p.o. t.i.d., metoprolol 50 mg p.o. b.i.d. Prilosec OTC or omeprazole 20 mg p.o. daily, prednisone syrup 30 mg feeding tube daily until _%#MMDD#%_, then 20 mg feeding tube daily until _%#MMDD#%_ and then 10 mg daily until _%#MMDD#%_.
OTC|over the counter|OTC|139|141|DISCHARGE  MEDICATIONS|Follow up with GI for small bowel follow-through on _%#MMDD#%_. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg per day for four weeks 2. Prilosec OTC 1 tablet b.i.d. (the patient prefers Prilosec OTC secondary to cost). 3. Compazine 10 mg every 6 hours as needed. 4. Vicodin one to two tabs q.6h. as needed. 5. Paxil 5 mg p.o. q. day.
OTC|over the counter|OTC|132|134|DISCHARGE  INSTRUCTIONS|3. Lisinopril 20 mg p.o. q day 4. Allegra 60 mg b.i.d. 5. Albuterol 2 puffs q. 6h. p.r.n. 6. Enbrel 25 mg twice weekly. 7. Prilosec OTC 20 mg b.i.d. The patient will follow up with me in the next 2-3 weeks, at which point we will arrange for followup ultrasound which should be done in the next 3-6 months.
OTC|over the counter|OTC|164|166|DISCHARGE MEDICATIONS|3. Cozaar 100 mg daily. 4. Synthroid 0.125 mg daily. 5. Amiodarone 200 mg 3x daily for two weeks, and 2x daily for two weeks, followed by 200 mg daily. 6. Prilosec OTC 20 mg at bedtime. 7. Levaquin 250 mg daily for 10 days. 8. Zofran 4 mg orally q.6h. p.r.n. for nausea.
OTC|over the counter|OTC|163|165|HOSPITAL COURSE|The patient is symptom-free at time of discharge and is felt to be hemodynamically stable for discharge. The patient has been advised to take ibuprofen or Tylenol OTC for her symptoms.
OTC|over the counter|OTC|145|147||Some abdominal pain at that time. Had what started out as normal bowel movement proceeded to diarrhea and gas with increasing pain. Did not take OTC medications for this, pain persisted, and came into the emergency room for further evaluation. Evaluation in the ER included CT, which did show some probable sigmoid diverticulitis.
OTC|over the counter|OTC|214|216|PAST MEDICAL HISTORY|History of pneumonia x4, last being about three years ago, hospitalized at North Memorial. Gastrointestinal - history of diverticulitis as noted above. Has occasional upper GI gastritis/ulcer usually relieved with OTC H2 blockers. Gives history of prostatitis x1, episode in the 1960s. PAST SURGICAL HISTORY: Includes tonsillectomy and adenoidectomy at age 5, a left testicular torsion at age 15, right total knee _%#MM2002#%_, Dr. _%#NAME#%_ _%#NAME#%_, left knee surgery for detached quadriceps in the past, and some previous right knee surgery "35 years ago."
OTC|over the counter|OTC|91|93|DISCHARGE MEDICATIONS|SECONDARY DIAGNOSIS: None. DISCHARGE DISPOSITION: Home. DISCHARGE MEDICATIONS: 1. Prilosec OTC 20 mg p.o. daily. 2. Tylenol 650 mg p.o. q.4-6h. as needed for pain. CONSULTATIONS: 1. Gastroenterology with Dr. _%#NAME#%_ _%#NAME#%_. 2. General Surgery with Dr. _%#NAME#%_ _%#NAME#%_.
OTC|over the counter|OTC|221|223|MEDICATIONS|He has done well with the initial surgery and is using a cane intermittently and anxious for the second stage of the two-stage surgery. MEDICATIONS: Unchanged from previous. 1. Cialis 20 mg before intercourse 2. Prilosec OTC 20 mg daily 3. Multivitamin daily 4. Aspirin daily which he is currently holding for one week preoperatively. ALLERGIES: None. FAMILY HISTORY, REVIEW OF SYSTEMS: Unchanged other than he does have a complaint of cold symptoms for the past 5 days.
OTC|over the counter|OTC|151|153|DISCHARGE  MEDICATIONS|1. Percocet 1-2 p.o. q 4 hours p.r.n. 2. Fosamax 70 mg q week. 3. Vitamin C 500 mg q day. 4. Aspirin 325 mg q day. 5. Colace 100 mg b.i.d. 6. Prilosec OTC 20 mg q day. 7. lisinopril/hydrochlorothiazide 20/25 one daily. 8. Vitamin E 400 units q day 9. Toprol XL 25 mg q day x5 days, then stop 10.Multi-vitamin 1 q day.
OTC|over the counter|OTC|155|157|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Fosamax 70 mg p.o. q. week. 2. Vitamin C 500 mg p.o. daily. 3. Aspirin 325 daily. 4. Colace 100 mg b.i.d. as needed. 5. Prilosec OTC 20 mg daily. 6. Vitamin E 400 International units p.o. daily. 7. Multivitamin one a day. 8. Vitamin D 400 International units p.o. daily. 9. Tylenol Extra Strength 1000 mg every 6 hours as needed.
OTC|over the counter|OTC|137|139|MEDICATIONS|She has hypertension which is stable. She has hyperlipidemia. The patient has asthma. MEDICATIONS: 1. Lisinopril 5 mg a day. 2. Prilosec OTC as needed. 3. Lipitor 20 a day. 4 Avandia 4, one b.i.d. 5. Metformin 500, one b.i.d. 6. Advair 250/50, one every day.
OTC|over the counter|OTC|148|150|MEDICATION LIST AS FOLLOWS|4. Triavil 2/25 three tablets at bedtime. 5. 324 mg daily iron 6. Metoprolol 25 mg b.i.d. 7. Lipitor 20 mg daily 8. Colace 100 mg daily 9. Prilosec OTC one daily
OTC|over the counter|OTC|117|119|CURRENT MEDICATIONS|2. Amaryl 2 mg in the morning and 4 mg in the p.m. 3. Iron sulfate 325 mg tab taken up to 3 times a day. 4. Prilosec OTC 20 mg p.o. q. day p.r.n. 5. Zoloft 100 mg a day. 6. Atenolol 50 mg p.o. q.a.m. 7. Flexeril 5 mg p.o. t.i.d. p.r.n. 8. Relafen 750 mg p.o. b.i.d. p.r.n.
OTC|over the counter|OTC|269|271|AT HOME MEDICATIONS|1. Coumadin 5 mg daily. 2. Amiodarone 4 mg b.i.d. through _%#DDMM2007#%_, then he will go to 400 mg daily for 20 days and then 200 mg daily for a month. 3. Plavix 75 mg daily. 4. Aspirin 81 mg a day, 5. Lisinopril 2.5 mg b.i.d. 6. Metoprolol 12.5 mg b.i.d. 7. Prevacid OTC 20 mg a day. 8. Simvastatin 40 mg daily. 9. Nitroglycerin sublingual 0.4 mg p.r.n. ALLERGIES: Sulfa. SOCIAL HISTORY: He is a nonsmoker.
OTC|over the counter|OTC|128|130|DISCHARGE MEDICATIONS|5. Bactrim Single Strength one p.o. two times per week (Mondays and Thursdays). 6. Mycelex troche 10 mg p.o. q.i.d. 7. Prilosec OTC 20 mg p.o. daily. 8. Maalox 10 ml p.o. q.i.d. p.r.n. 9. Fosamax 10 mg p.o. daily. 10. Ferrous sulfate 324 mg p.o. daily. 11. Magnesium oxide 400 mg p.o. daily.
OTC|over the counter|OTC|204|206|MEDICATIONS|FAMILY HISTORY: Father had prostate cancer. Mother died postop, question of PE. ALLERGIES: None. MEDICATIONS: Dilantin 100 mg, 2 b.i.d.; aspirin 325, one-half a day; Tylenol p.r.n., decongestants p.r.n., OTC cough medicines. SOCIAL HISTORY: Does not smoke and drinks 1-2 drinks a day.
OTC|over the counter|OTC.|167|170|MEDICATIONS AT DISCHARGE|4. Lasix 40 mg b.i.d., new increased dose from 40 mg once a day. 5. Lisinopril 20 mg a day. 6. Toprol XL 25 mg b.i.d. This is decreased from 50 mg a day. 7. Cranberry OTC. 8. Multivitamin one tablet daily. 9. Calcium plus vitamin D 1 tablet b.i.d. 10. Protonix 40 mg b.i.d. 11. Carafate 1 gram p.o. daily.
OTC|over the counter|OTC.|140|143|MEDICATIONS|FAMILY HISTORY: No family history of diabetes or heart disease. Denies any clotting disorders. No history of cancers. MEDICATIONS: Prilosec OTC. CODE STATUS: Full code. PHYSICAL EXAMINATION: GENERAL: The patient is alert and oriented, in no acute distress.
OTC|over the counter|OTC|178|180|HISTORY OF PRESENT ILLNESS|Follow up imaging endoscopy was scheduled for this Friday, _%#DDMM2007#%_ at HCMC. Mrs. _%#NAME#%_ was discharged on a low-fat diet. She was instructed to take daily MiraLax and OTC fiber supplements for irritable bowel and constipation. She continued her once daily depression medication, citaprolam. Thirty-six hours before her visit to the Emergency Room, she experienced the onset of increasing upper abdominal pain in the diaphragmatic area which felt the same as her previous pain.
OTC|over the counter|OTC|152|154|MEDICATIONS|ILLNESSES: GERD with feline esophagus, history of diverticulitis. ALLERGIES: None. HABITS: Nonsmoker, occasional wine, no coffee. MEDICATIONS: Prilosec OTC 20 mg daily, ASA 81 mg q day FAMILY HISTORY: Negative for allergic reaction to anesthesia or bleeding diathesis.
OTC|over the counter|OTC|171|173|MEDICATIONS|2. History of hepatitis A and hepatitis B. 3. History of pulmonary nodules in right upper lobe. ALLERGIES: No known drug allergies. MEDICATIONS: No medication. She denies OTC or herbal medications. SOCIAL HISTORY: No tobacco or alcohol. She is married, has two children, and lives in _%#CITY#%_.
OTC|over the counter|OTC|153|155|DISCHARGE MEDICATIONS|2. Compazine 10 mg p.o. q 6 hours p.r.n. for nausea and vomiting. 3. Compazine suppository 25 mg rectally q.12h. P.r.n. nausea and vomiting. 4. Prilosec OTC 20 mg to take one daily for GERD, he can take his instead of his Zantac of if the Zantac controls his symptoms, he can continue the Zantac which is 150 mg once to twice daily p.r.n. for GERD.
OTC|over the counter|OTC|171|173|PROBLEMS PRESENTED AT ADMSSION|PROBLEMS PRESENTED AT ADMSSION: The client presented with a 3-1/2 year chemical use history that had included alcohol, marijuana, mushrooms, acid, crack, prescription and OTC drugs. The client reported consequences that included school truancy and family problems related to his chemical use. He had no history of previous mental health or CD treatment.
OTC|over the counter|OTC|296|298|DISCHARGE MEDICATIONS|He did have significant photophobia with the headache. The day of discharge, he was also noted to have some oral mucosal discomfort with some erythema and whitish exudate typical of oral thrush and would be discharged on oral Nystatin suspension, as well as morphine for headache, as well as any OTC analgesics that would be of benefit. He was advised to either follow up with his primary provider, Dr. _%#NAME#%_ at the _%#CITY#%_ HealthPartners Clinic or with myself in four to five days.
OTC|over the counter|OTC|133|135|PAST MEDICAL HISTORY|No abdominal pain, nausea, vomiting, constipation, diarrhea, or rectal bleeding. He has an occasional heartburn treated readily with OTC agents. He has no dysuria, increased urinary frequency, or urgency. No skin rashes or concerning moles. No headaches, weakness, paresthesias, incoordination. No temperature intolerance or excessive thirst.
OTC|over the counter|OTC|311|313|HISTORY OF PRESENT ILLNESS|Hepatitis B surface antigen testing was negative. Alpha fetoprotein testing was within normal limits at 16 weeks as was glucose tolerance testing at 28 weeks. Weight gain for the pregnancy was 33 pounds. Apart from the breech position, the only other complication was acid reflux which the patient treated with OTC remedies. The risks of vaginal breech delivery versus cesarean section were reviewed.
OTC|over the counter|OTC|164|166|DISCHARGE MEDICATIONS|3. Vioxx 25 mg daily p.o. prn pain. 4. Vicodin one to two table p.o. q 4-6 hours prn severe pain. 5. Delsym one to two teaspoons p.o. b.i.d. prn cough. 6. Prilosec OTC 20 mg p.o. daily prn epigastric discomfort with anti- inflammatory use. 7. Premarin 0.625 mg daily (continued from outpatient). 8. Provera 2.5 mg p.o. daily (continued outpatient therapy).
OTC|over the counter|OTC|410|412|DISCHARGE MEDICATIONS|She has been instructed to get her INR checked in 2 days and to see her primary physician, Dr. _%#NAME#%_ _%#NAME#%_ in two weeks. DISCHARGE MEDICATIONS: Coumadin, none on _%#MM#%_ _%DD#%_ and _%#DD#%_, then 2.5 mg daily, prednisone 20 mg daily for 5 days, then 10 mg daily for five days, then 5 mg a day for five days, then stop, allopurinol 200 mg daily, digoxin 0.125 mg daily, Cozaar 50 mg daily, Prilosec OTC 20 mg daily, Armour Thyroid at 60 mg daily, Cardizem CD 240 mg daily, potassium 20 mEq daily, nadolol 20 mg daily, Lasix 80 mg three times daily, Advair 500/50 1 puff every 12 hours, Combivent 2 puffs every four hours p.r.n. wheezing, Lantus insulin 50 units every morning, also use same sliding scale regular or Humalog insulin as before admission, sorbitrate 50 mg daily, Miacalcin 1 spray daily, Celebrex 200 mg daily, colchicine 0.6 mg daily, Darvocet N 100 1 every four hours p.r.n. pain.
OTC|over the counter|OTC|234|236|DISCHARGE MEDICATIONS|Her renal and hepatic function were normal. The chest x-rays showed gradual clearing of the left lower lobe infiltrates. DISCHARGE PLANS: Discharge to home. DISCHARGE MEDICATIONS: 1. Ferrous sulfate 325 once or twice daily. 2. Zantac OTC p.r.n. The patient is to follow up with pulmonary medicine as an outpatient within a few weeks.
OTC|over the counter|OTC|229|231|DISCHARGE PLAN|DISCHARGE PLAN: Transfer to _%#NAME#%_ Nursing Home. Her meds at the time of discharge are Arimidex 1 mg p.o. daily, hydrochlorothiazide 25 mg p.o. daily, _____ 10 mEq daily, nifedipine extended release 60 mg daily and meclizine OTC as needed. The followup arrangements will be with me in approximately a week and with Dr. _%#NAME#%_ as an outpatient.
OTC|over the counter|OTC|168|170|MEDICATIONS ON ADMISSION|Admission chest x-ray was unremarkable as was the EKG and abdominal ultrasound with portal vein Doppler. MEDICATIONS ON ADMISSION: Prozac 40mg QD, insulin, and various OTC supplements. HOSPITAL COURSE: The patient was found to meet all inclusion criteria and the cross match test was negative.
OTC|ornithine transcarbamoylase|OTC|52|54|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: Increased ammonia secondary to OTC deficiency. HISTORY OF PRESENT ILLNESS: The patient is a 25-year-old with a known OTC deficiency who has in the past bouts of hyperammonemia. She stated that she had been fine until 24 hours prior to admission.
OTC|over the counter|OTC|138|140|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: Increased ammonia secondary to OTC deficiency. HISTORY OF PRESENT ILLNESS: The patient is a 25-year-old with a known OTC deficiency who has in the past bouts of hyperammonemia. She stated that she had been fine until 24 hours prior to admission.
OTC|over the counter|(OTC|130|133|MEDICATIONS|1. Levoxyl. 2. Prinzide. 3. Paxil. 4. Lipitor, 10 mg per day. 5. Aspirin, 325 mg per day. 6. Vitamin E. 7. Vitamin C. 8. Legatrin (OTC product for leg cramps). 9. Fosamax, 70 mg every Monday. ALLERGIES: Sulfa which causes a rash. HEALTH HABITS: One small glass of wine per day. Smoked once at age 17.
OTC|ornithine transcarbamoylase|OTC.|131|134|DISCHARGE DIAGNOSES|2. Preterm contractions. DISCHARGE DIAGNOSES 1. 19 plus 1 week intrauterine pregnancy with preterm cervical change. 2. Carrier for OTC. PROCEDURES PERFORMED Cervical cerclage placement. HISTORY OF PRESENT ILLNESS The patient is a 38-year-old gravida 5, para 1-1-1-2 with intrauterine pregnancy at 18 plus 6 weeks by last menstrual period and first trimester ultrasound who presents to Labor and Delivery on _%#DDMM2004#%_ with the complaint of occasional contractions and vaginal spotting.
OTC|ornithine transcarbamoylase|OTC.|193|196|FAMILY HISTORY|PAST GYNECOLOGIC HISTORY Regular menses, no sexually transmitted disease or abnormal pap smears. FAMILY HISTORY Father with heart disease and diabetes. Mother with hypertension and carrier for OTC. Family has been screened for OTC secondary to the son who was positive for OTC. PRENATAL LABS Available in the chart which is not available at this time.
OTC|ornithine transcarbamoylase|OTC.|176|179|FAMILY HISTORY|FAMILY HISTORY Father with heart disease and diabetes. Mother with hypertension and carrier for OTC. Family has been screened for OTC secondary to the son who was positive for OTC. PRENATAL LABS Available in the chart which is not available at this time.
OTC|over the counter|OTC|139|141|CURRENT MEDICATIONS|DRUG SENSITIVITIES: Iodine, penicillin, succinylcholine, Betadine, Arthrotec, IVP dye, (?Primapone). CURRENT MEDICATIONS: 1. Norvasc 5. 2. OTC calcium. 3. OTC Tylenol extra strength. 4. Prevacid 15 p.r.n. 5. ASA, discontinued prior to surgery. 6. Macrobid 100 b.i.d. REVIEW OF SYSTEMS: The patient denies cardiovascular, pulmonary, and CNS-type symptoms.
OTC|over the counter|OTC|166|168|DISCHARGE MEDICATIONS|His appetite increased as well as his activity level. He was able to be discharged this evening after the 48-hour culture result was negative. DISCHARGE MEDICATIONS: OTC Tylenol and Motrin p.r.n. fever, headache. DISCHARGE INSTRUCTIONS: Dietary instructions were given, diet as tolerated.
OTC|over the counter|OTC|80|82|MEDICATIONS|2. Essential hypertension. 3. Gastroesophageal reflux. MEDICATIONS: 1. Prilosec OTC 20 mg daily. 2. Nifedipine ER 30 mg daily. 3. Metoprolol 50 mg b.i.d. 4. Isosorbide 20 mg b.i.d. or t.i.d. 5. Perhaps lisinopril although it is not clear from current records whether that is still in place.
OTC|over the counter|OTC|163|165|CURRENT MEDICATIONS|2. Acute arterial occlusion in 2003 treated with tissue plasminogen activator (t-PA) lytic therapy. 3. Arthroscopic knee surgery. CURRENT MEDICATIONS: 1. Prilosec OTC 20 mg daily. 2. Lovastatin 40 mg daily. 3. Toprol XL 25 mg daily. 4. Aspirin 81 mg daily. 5. Capoten 100 mg daily.
OTC|over the counter|OTC|156|158|HISTORY OF PRESENT ILLNESS|Slightly nauseated, but no emesis. Appetite has been good, even today. No fever. No blood per stool. Denies melena or dyspepsia. Not taking any aggravating OTC preparations. PAST MEDICAL HISTORY: Childbirth x 2, otherwise no chronic or significant acute disease.
OTC|over the counter|OTC|179|181|HISTORY OF PRESENT ILLNESS|While driving back to work, he noticed a squeezing pain in his left chest associated with tingling going down the left arm. He thought it may be reflux, but it did not respond to OTC gastroesophageal reflux disease medications. In retrospect, he noted similar symptoms for the past 1 to 2 weeks with less intensity. ALLERGIES: No known drug allergies. SOCIAL HISTORY: No tobacco, social alcohol use.
OTC|over the counter|OTC|155|157|ALLERGIES|2. Colace 100 mg p.o. b.i.d. 3. The patient is to continue home medications of Coumadin 5 mg p.o. every day. 4. Atenolol 25 mg p.o. every day. 5. Prilosec OTC p.r.n. 6. Panacase enzymes with meals and snacks. 7. Timolol eyedrops as needed. DISCHARGE INSTRUCTIONS: 1. Regular diet. 2. No lifting greater than 10 pounds for a period of 6 weeks after the day of surgery.
OTC|over the counter|OTC|165|167|DISCHARGE MEDICATIONS|3. Smoker. 4. Elevated cholesterol, on treatment. 5. History of obsessive compulsive disorder. DISCHARGE MEDICATIONS: 1. Aspirin. 2. Celexa. 3. Lipitor. 4. Prilosec OTC for 2 weeks. 5. He was given a prescription for nitroglycerin sublingual p.r.n. HISTORY: _%#NAME#%_ _%#NAME#%_ is a pleasant 55-year-old male with no cardiac history but several cardiac risk factors admitted with three to four days of atypical chest pain.
OTC|over the counter|OTC|153|155|DISCHARGE MEDICATIONS|4. Tums 500 mg b.i.d. The patient is not to take this at the time of her Zithromax. 5. If having acid reflux symptoms, the patient may purchase Prilosec OTC 20 mg daily. DISCHARGE INSTRUCTIONS: 1. The patient will follow up with Dr. _%#NAME#%_ _%#NAME#%_ in two weeks time.
OTC|over the counter|OTC|129|131|DISCHARGE MEDICATIONS|3. Avandia 4 mg PO daily. 4. Florinef 0.1 mg PO b.i.d. 5. Fluoxetine 20 mg PO daily. 6. Gemfibrozil 600 mg PO b.i.d. 7. Prilosec OTC 20 mg PO daily. 8. Albuterol MDI p.r.n. wheezing. 9. Lipitor 40 mg PO daily. 10. New medications are lisinopril 10 mg one q. day.
OTC|over the counter|OTC|550|552|PAST MEDICAL HISTORY|She vomited once. They did not take her temperature. It turns out that she's been coughing for two days, but they have not observed any apparent dyspnea. PAST MEDICAL HISTORY: Medicines = Neurontin 300 mg three times daily; Tramadol 50mg four times daily (with meals and at bedtime); Glipizide 15 mg daily; atenolol 50 mg daily; Norvasc 7.5 mg daily at bedtime; Effexor XR 75 mg daily; Levothyroxine 112 mcg daily; trazodone 100 mg daily at bedtime; Aricept 10 mg daily; prednisone 2 mg daily; Lipitor 10mg daily; Lasix 60 mg every morning; Prilosec OTC 20 mg daily; Cozaar 100 mg daily; Ocuvite one pill daily; multiple vitamin one daily; Promethazine 25 mg every 8 hours p.r.n. nausea; Meclizine 25 mg every 8 hours p.r.n. vertigo; Zofran 4 mg every 6 hours p.r.n. nausea; Lidoderm match 2 mg (apply for 12 hours daily).
OTC|over the counter|OTC|150|152|CURRENT MEDS|7. Renagel with food 8. Lantus 20 units q hs 9. Regular insulin sliding scale with meals 10. 81 mg of aspirin 11. Renafor once a day 12. Simply Sleep OTC q hs FAMILY HISTORY: Positive for diabetes. SOCIAL HISTORY: Nonsmoker. Nondrinker. Married, lives at home with her husband.
OTC|over the counter|OTC|218|220|ASSESSMENT|Will await CARDS evaluation. Likely will need a repeat stress test, although, he reports he had one early this year which was reported to him as negative. Otherwise will discharge if he clears cardiac-wise on Prilosec OTC 20 daily for a month. Follow-up I our clinic in a few weeks if discharged.
OTC|over the counter|OTC|181|183|MEDICATIONS|5) Hyperlipidemia. 6) Osteopenia. 7) Gastroesophageal reflux disease. 8) Osteoarthritis. MEDICATIONS: 1) Synthroid 0.2 mg p.o. daily. 2) Verapamil SR 180 mg p.o. daily. 3) Prilosec OTC one daily. 4) Actonel 35 mg p.o. weekly. 5) Zoloft 50 mg p.o. daily. 6) Hydrochlorothiazide 25 mg p.o. daily.
OTC|over the counter|OTC,|271|274|HOSPITAL COURSE|Cardiology consult obtained due to patient's concerns and per Cardiology they also do not feel that his chest pain is clearly consistent with CAD at this time. Recommendation was for patient to increase exercise, monitor blood pressures, to possibly start niacin therapy OTC, and to follow up with PMD with nuclear stress if symptoms should recur. The patient would like to have adenosine Cardiolite arranged regardless as he would like further testing to evaluate for heart disease other than angiogram at this time.
OTC|over the counter|OTC.|153|156|DISCHARGE MEDICATIONS|See admit H&P for further details. ALLERGIES: No known drug allergies. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. q.d. 2. Slow niacin 500 mg p.o. q.d. OTC. DISCHARGE EXAMINATION: The patient is afebrile. Temperature is 97.6, pulse 59, respiratory rate 16, blood pressure is 100/68, and sats are 97% on room air.
OTC|over the counter|OTC|123|125|DISCHARGE MEDICATIONS|2. Norvasc 5 mg q.a.m. 3. Keflex 250 t.i.d. for seven days. 4. Celexa 40 mg q.a.m. 5. Synthroid 0.05 mg daily. 6. Prilosec OTC 20 mg daily. 7. Tylenol prn. 8. Metformin 500 mg b.i.d. 9. Her diuretic, hydrochlorothiazide 12.5 mg was not restarted and her blood pressure and follow up post treatment urinalysis and potassium and sodium will be left for follow up with Dr. _%#NAME#%_ when he sees her in the office in approximately one week.
OTC|over the counter|OTC|181|183|DISCHARGE MEDICATIONS|9. The patient was also discharged on G-CSF 480 mcg subcutaneously daily. 10. Lomotil 1 tablet p.r.n. for loose stools. 11. Protonix 40 mg p.o. b.i.d. which was changed to Prilosec OTC 20 mg p.o. b.i.d. 12. Ambien 5 mg p.o. nightly for sleep. FOLLOW UP: The patient will follow up in bone marrow transplant clinic on _%#MM#%_ _%#DD#%_, 2004, at 11 a.m. for this hospitalization stay.
OTC|over the counter|OTC|188|190|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prednisone 60 mg po q day until seen by Hematology/Oncology on _%#MM#%_ _%#DD#%_, 2005. 2. Lotrel 5/20, two tablets po q day. 3. Aspirin 81 mg q day. 4. Prilosec OTC 20 mg q day (or formulary equivalent). DISCHARGE FOLLOW-UP: 1. Hematology/Oncology clinic on _%#MM#%_ _%#DD#%_, 2005.
OTC|over the counter|OTC|131|133|DISCHARGE INSTRUCTIONS|DISCHARGE MEDICATIONS: Lisinopril 20 mg daily. DISCHARGE INSTRUCTIONS: If the patient has recurrent symptoms he is to try Prilosec OTC 20 mg daily for possible gastroesophageal reflux disease-related esophageal spasm. He will follow up with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_ at 7:30 a.m. at Fairview Oxboro Clinic.
OTC|over the counter|OTC|141|143|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS 1. Verapamil 240 mg p.o. daily. 2. Glipizide 10 mg p.o. b.i.d. 3. Enteric coated 81 mg aspirin p.o. daily. 4. Prilosec OTC 1 p.o. q.a.m. 5. Lisinopril/hydrochlorothiazide 10/12.5 1 p.o. daily. 6. Spiriva inhaler 1 puff daily. 7. Lantus 20 units subcu daily.
OTC|over the counter|OTC|189|191|MEDICATIONS|2. Allergic rhinitis. 3. Gastroesophageal reflux disease. MEDICATIONS: 1. Lipitor 10 mg daily. 2. Allegra 180 mg daily. 3. Flonase two puffs daily. 4. Most recently has been using Prilosec OTC 20 mg daily for his reflux symptoms. ALLERGIES: No known drug allergies. REVIEW OF SYSTEMS: Negative. PHYSICAL EXAMINATION: Blood pressure is 142/82.
OTC|over the counter|OTC|162|164|DISCHARGE MEDICATIONS|6. Coreg 6.25 mg p.o. b.i.d. 7. Plavix 75 mg p.o. daily., 8. Folic acid 1 mg p.o. daily. 9. Zestril 10 mg p.o. daily. 10. Multivitamin 1 p.o. q.a.m. 11. Prilosec OTC 1 p.o. q.a.m. 12. Elidel 1% topical cream as needed 13. Aldactone 12.5 mg p.o. q.a.m. 14.Spiriva 18 mcg inhaled daily 15.
OTC|over the counter|OTC|145|147|DISCHARGE  MEDICATIONS|1. Metoprolol 25 mg b.i.d. 2. Lipitor 20 mg daily. 3. Glyburide 1.25 mg p.o. q.a.m., 3.75 mg p.o. q.p.m. 4. Metformin 1000 mg b.i.d. 5. Prilosec OTC 20 mg b.i.d. 6. Azmacort 2 puffs b.i.d. 7. Albuterol metered dose inhaler 2 puffs q.i.d. p.r.n. shortness of breath.
OTC|over the counter|OTC|135|137|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Celexa 40 mg p.o. daily. 2. Gemfibrozil 600 mg p.o. daily. 3. Multivitamins 1 tablet p.o. daily. 4. Prilosec OTC 20 mg p.o. p.r.n. 5. Levaquin 500 mg p.o. q.day. 6. Actigall 300 mg p.o. t.i.d. 7. Roxicet 5 to 10 mL p.o. q. 4-6 h. p.r.n. pain.
OTC|over the counter|OTC|136|138|DISCHARGE MEDICATIONS|4. Albuterol metered dose inhaler 2 puffs q.i.d. as needed. 5. Prednisone 40 mg once a day for four days, then discontinue. 6. Claritin OTC 10 mg once a day as needed. DISCHARGE FOLLOW-UP: Follow up with her primary allergist. (She has his contact information at home and will make an appointment.)
OTC|over the counter|OTC|190|192|MEDICATIONS ON DISCHARGE|2. Labetalol 50 mg p.o. q day. 3. Premarin 0.625 mg p.o. q day (the patient was on this medication prior to admission). 4. Lisinopril 5 mg p.o. q day. 5. Reglan 5 mg p.o. t.i.d. 6. Prilosec OTC one p.o. b.i.d.
OTC|over the counter|OTC|204|206|FURTHER REVIEW OF SYSTEMS|Pulmonary: Nonproductive cough. Dyspnea and asthma as previously noted. She is a nonsmoker. Gastrointestinal: Denies abdominal pain, jaundice, or _____________. She has reflux and has been using Prilosec OTC for several months. Genitourinary: Denies urinary frequency, urgency, or dysuria. She has no menstrual periods due to hysterectomy in 2001.
OTC|over the counter|OTC|371|373|CURRENT MEDICATIONS|ALLERGIES: PEANUTS. CURRENT MEDICATIONS: 1) Prolixin Decanoate I.M. q2 weeks. 2) Cogentin 1 mg p.o. t.i.d. 3) Clozaril 100 mg p.o. q a.m. 4) Clozaril 500 mg p.o. q h.s. 5) Benadryl 50 mg p.o. h.s. 6) Colace 100 mg p.o. b.i.d. 7) Femhrt 1 mg/5 mcg tab q a.m. 8) Ferrous sulfate 325 mg p.o. q a.m. 9) Synthroid ______ mg p.o. q a.m. 10) Ativan 1 mg p.o b.i.d. 11) Prilosec OTC 40 mg q a.m. 12) Singulair 10 mg p.o. q h.s. 13) Wellbutrin SR 150 mg p.o. b.i.d. 14) Prolixin 5 mg p.o. q2h p.r.n. 15) Ativan 1 mg p.o. b.i.d. p.r.n 16) Albuterol 90 mcg inhaler two puffs q.i.d. SOCIAL HISTORY: The patient works in an assembly shop.
OTC|over the counter|OTC,|197|200|DISCHARGE MEDICATIONS|8. Pentoxifylline 400 mg 1 tablet t.i.d. 9. Mycelex Troche 10 mg 1 tablet to dissolve in mouth q.i.d. 10. Maxi-Gamma 2 capsule once daily. 11. Omega-T 3 capsules once daily. 12. Antioxidant factor OTC, 2 capsules once daily. 13. Vitamin C 500 mg OTC 1 tablet b.i.d. 14. Calcium with vitamin D OTC 1 tablet daily. 15. Chromium picolinate 200 mg 1 tablet t.i.d.
OTC|over the counter|OTC|144|146|DISCHARGE MEDICATIONS|10. Maxi-Gamma 2 capsule once daily. 11. Omega-T 3 capsules once daily. 12. Antioxidant factor OTC, 2 capsules once daily. 13. Vitamin C 500 mg OTC 1 tablet b.i.d. 14. Calcium with vitamin D OTC 1 tablet daily. 15. Chromium picolinate 200 mg 1 tablet t.i.d.
OTC|over the counter|OTC|119|121|DISCHARGE MEDICATIONS|12. Antioxidant factor OTC, 2 capsules once daily. 13. Vitamin C 500 mg OTC 1 tablet b.i.d. 14. Calcium with vitamin D OTC 1 tablet daily. 15. Chromium picolinate 200 mg 1 tablet t.i.d. 16. Green tea extra at 300-mg tablet, 1 tablet twice a day.
OTC|over the counter|OTC|119|121|DISCHARGE MEDICATIONS|17. Gymnema sylvestere 400 mg 1 tablet once a day. 18. Magnesium oxide OTC 250 mg 1 tablet 4 times a day. 19. FiberCon OTC 4 tablets twice daily. 20. Soy isoflavone 1 tablet twice a day. 21. Enalapril 5 mg 1 tablet twice a day.
OTC|over the counter|OTC|132|134|MEDICATIONS|5. Entocort 3 mg b.i.d. 6. Diltiazem ER 180 mg daily. 7. Acidophilus one cap daily. 8. Questran Light one packet daily. 9. Prilosec OTC 20 mg daily. 10. Ibuprofen 400 mg, one tablet b.i.d. 11. Calcium with vitamin D 600 mg t.i.d. 12. Tylenol. 13. Ocean Spray prn for nasal congestion. 14. Aricept 10 mg daily.
OTC|over the counter|OTC|144|146|MEDICATIONS|2. Lipitor 10 mg q.o.d. 3. Accuretic 20/12.5 two in the a.m. 4. Levothyroxine 0.05 mg a day. 5. Cholysteramine one scoop every day. 6. Prilosec OTC p.r.n. 7. Multivitamins. 8. Vitamins with calcium. 9. FiberCon. REVIEW OF SYSTEMS: The remainder of the review of systems for the other ten systems are normal.
OTC|over the counter|OTC|180|182|DISCHARGE MEDICATIONS|2. Lisinopril 20 mg p.o. q. day. 3. Stop lisinopril/HCTZ. 4. Prevacid 30 mg p.o. b.i.d. x14 days, then once daily (if Prevacid not covered, substitute omeprazole 40 mg or Prilosec OTC 20 mg or Protonix 40 mg, etc.). 5. Biaxin 500 mg p.o. b.i.d. x14 days and amoxicillin 500 mg p.o. b.i.d. x14 days, then discontinue.
OTC|over the counter|OTC.|190|193|MEDICATIONS|Current medical conditions - heartburn, chronic constipation. Other surgery is thyroglossal duct cyst removed in her 30's. FAMILY HISTORY: No one with colon cancer. MEDICATIONS: 1) Prilosec OTC. 2) Vitamin B complex. 3) Silver Centrum. 4) Calcium tablets. ALLERGIES: No known drug allergies. SOCIAL HISTORY: She is married.
OTC|over the counter|OTC|202|204|MEDICATIONS|5. Esophageal web status post dilation. PAST SURGICAL HISTORY: Appendectomy and partial finger amputation. MEDICATIONS: 1. Aspirin 325 mg daily. 2. Zetia 10 mg daily. 3. Plavix 75 mg daily. 4. Prilosec OTC 1 tablet daily. 5. Lisinopril 20mg daily. 6. Metoprolol XL 25 mg daily. ALLERGIES: NKDA. SOCIAL HISTORY: He is a retired pilot. He is married, has 2 children who are grown and moved from the home.
OTC|over the counter|OTC|102|104|MEDICATIONS|6. Depression. 7. Glaucoma. 8. Hypothyroidism. 9. Multiple DVTs in the past. MEDICATIONS: 1. Prilosec OTC 20 mg/day. 2. Amitriptyline 75 mg at bedtime. 3. Lasix 40 mg daily. 4. Restoril 30 mg at bedtime. 5. Tegretol 20 mg b.i.d. 6. Vicodin as needed.
OTC|over the counter|OTC,|151|154|DISCHARGE MEDICATIONS|She will be discharged to home to follow up with Dr. _%#NAME#%_. She was told to call if more bleeding. DISCHARGE MEDICATIONS: She will be on Prilosec OTC, and the aspirin and Plavix will be held. ADDENDUM: The nurse called me today because the patient's daughter, _%#NAME#%_, was upset regarding the possibility of discharge.
OTC|over the counter|OTC|149|151|MEDICATION|ALLERGIES: No known drug allergies. MEDICATION: 1. Prozac 60 mg p.o. q.h.s. 2. Plavix 75 mg p.o. daily. 3. Synthroid 125 mcg p.o. daily. 4. Prilosec OTC 1 tablet p.o. daily. 5. Dulcolax capsules 4 p.o. daily. 6. Megace 800 mg p.o. daily. 7. Oxycodone 30 mg 1 tablet p.o. daily.
OTC|over the counter|OTC|137|139|DISCHARGE MEDICATIONS|She will resume her metoprolol and lisinopril after discharge. DISCHARGE MEDICATIONS: 1. Cipro 500 mg b.i.d. for seven days. 2. Prilosec OTC 20 mg once daily for GERD type symptoms that were a bit worse on admission here. She can take this as she needs it, and decide about longer term treatment after her discharge.
OTC|over the counter|OTC.|198|201|DISCHARGE DIAGNOSIS|Antabuse was discussed with him but he declined. He was to begin outpatient treatment on _%#MM#%_ _%#DD#%_, 2005. DISCHARGE MEDICATIONS: He was discharged on no medications. He was to take Prilosec OTC.
OTC|over the counter|OTC|148|150|DISCHARGE MEDICATIONS|12. Combivent MDI two puffs q.i.d. 13. Lorazepam 0.5 mg one to two tablets p.o. q.6h. p.r.n. 14. Potassium chloride 20 mEq p.o. b.i.d. 15. Prilosec OTC 20 mg p.o. every day. 16. Pulmicort nebs 0.5 mg/2 ml b.i.d. 17. Senokot S two tablets p.o. q.i.d. p.r.n. FOLLOW UP: The patient will be discharged to home.
OTC|over the counter|OTC|145|147|CURRENT MEDICATIONS|4. Calcium plus Vitamin D 1 tablet twice daily. 5. Lisinopril/hydrochlorothiazide 5/6.25 mg once daily. 6. Multiple vitamin 1 a day. 7. Prilosec OTC 20 mg once a day. 8. DuoNeb 4 times a day and as needed. 9. Prednisone currently on a 30 mg dose. (Her prednisone dosing varies between 15-30 mg depending on her breathing state).
OTC|over the counter|OTC|172|174|DISCHARGE MEDICATIONS|3. Digoxin 0.125 mg p.o. q. day 4. Lopressor 50 mg p.o. in the morning, 25 mg p.o. in the evening 5. Lasix 40 mg p.o. in the morning, 20 mg p.o. in the evening 6. Prilosec OTC 20 mg p.o. q. day 7. Darvocet-N 100 1 p.o. q.6h. p.r.n. 8. Ativan 0.125 mg p.o. b.i.d. The patient was to have her wound change once daily.
OTC|ornithine transcarbamoylase|OTC|173|175|OTHER DIAGNOSES|_%#NAME#%_ was a full-term AGA infant with a length of 51.5 cm and head circumference of 34 cm. Physical examination was normal. Primary diagnosis on admission was possible OTC deficiency due to family history. Problems during his hospitalization included the following: Problem #1: Fluids/Electrolytes/Nutrition.
OTC|ornithine transcarbamoylase|OTC|176|178|OTHER DIAGNOSES|Due to the possibility of OTC deficiency, protein containing IVF's were not used. His ammonia levels were followed serially. Once it was determined that he did not likely have OTC deficiency he was started on enteral feeds. Feedings were started on _%#DDMM2006#%_. At the time of discharge, he was bottling and breastfeeding all of his feedings of Similac 20 or Breastmilk.
OTC|ornithine transcarbamoylase|OTC|193|195|OTHER DIAGNOSES|The most likely etiology for the hyperbilirubinemia was physiologic. This problem has resolved. Problem #3: Metabolism. Prior to his birth, it was suspected that _%#NAME#%_ _%#NAME#%_ may have OTC deficiency. This was due to the fact that his sister was found to be a carrier for OTC deficiency during a failure to thrive work-up.
OTC|ornithine transcarbamoylase|OTC|146|148|OTHER DIAGNOSES|Orotic acids were found in his urine, however, his serum glutamine level was normal. Therefore, it was thought to be unlikely that he had typical OTC deficiency. However, it is possible that he has a variant of OTC deficiency due to the orotic aciduria. Enteral feeds were started on DOL 2, he tolerated them well without an increase in his ammonia level.
OTC|over the counter|OTC|164|166|DICHARGE MEDICATIONS|DICHARGE MEDICATIONS: Continued on home meds. 1. Mevacor 20 mg at bedtime. 2. Lasix 40 mg b.i.d. 3. Klor-Con 20 mEq q. day. 4. Synthroid 112 mcg q.a.m. 5. Prilosec OTC 20 mg b.i.d. 6. Toprol XL 50 mg b.i.d. 7. Allopurinol 100 mg q. day. 8. Simethicone 125 mg t.i.d. 9. Lorazepam 0.25-0.5 mg b.i.d. on a p.r.n. basis for anxiety.
OTC|over the counter|OTC.|193|196|MEDICATIONS|2. Hernia repair x2 in the 1970s. 3. Benign prostatic hypertrophy, status post transurethral resection of the prostate. MEDICATIONS: 1. Hydrochlorothiazide. Patient unsure of dose. 2. Prilosec OTC. 3. Celexa 20 mg p.o. daily. 4. Piroxicam p.r.n. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He is a nonsmoker, nondrinker. Current retired. FAMILY HISTORY: Unremarkable.
OTC|over the counter|OTC|157|159|MEDICATIONS|10. Gerd. ALLERGIES: Sulfa, question of Percocet. MEDICATIONS: 1. Aspirin 81 mg. 2. Klonopin 0.5 mg t.i.d. 3. Will start Boniva 150 mg q. month. 4. Prilosec OTC 20 mg q. day. 5. HCTZ 12.5 q. day. 6. Vicodin 1-2 q.i.d. 7. Miconazole powder to groin q. day. 8. MiraLax 17 grams with 8 ounces of water q. day.
OTC|over the counter|OTC|157|159|DISCHARGE MEDICATIONS|2. Diet is as tolerated. 3. Activity is as tolerated. DISCHARGE MEDICATIONS: 1. Multivitamin with iron 1 tablet daily. 2. Polyiron 150 mg daily. 3. Prilosec OTC 20 mg daily. 4. Risperdal 0.5 mg, half tablet in the morning and full tablet at bedtime. 5. Effexor XR 1 tablet daily. 6. Levothyroxine 0.1 mg oral at bedtime.
OTC|ornithine transcarbamoylase|OTC|202|204|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSES: 1. Ornithine transcarbamoylase deficiency. 2. Gastritis. OPERATIONS/PROCEDURES PERFORMED: None. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is an 18-year-old Caucasian female with known OTC deficiency. She is followed by Dr. _%#NAME#%_ _%#NAME#%_ as an outpatient and has been well controlled over the last many years.
OTC|ornithine transcarbamoylase|OTC|151|153|HOSPITAL COURSE|LABORATORY: Admission labs were pertinent for an ammonia of 300, phos of 2.5, a UPT that was negative, and a UA that was negative. HOSPITAL COURSE: 1. OTC Deficiency: With her acute hyperammonia status, she was made NPO and started on one and half times maintenance of fluid with sugar substrate and other IV substrate including IV Ammonul.
OTC|over the counter|OTC.|202|205|MEDICATIONS|3. Gastroesophageal reflux disease (GERD). 4. Renal cell carcinoma, status post nephrectomy in 2001. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Amaryl 1 mg p.o. each day at bedtime 2. Prilosec OTC. 3. Reglan 10 mg p.o. q.i.d. SOCIAL HISTORY: He is married. He is a computer programmer for a medical supply company.
OTC|over the counter|OTC|116|118|MEDICATIONS|MEDICATIONS: 1. Advair 250/50 2 puffs b.i.d. 2. oxygen 4-6 liters a minute 3. Celexa 20 mg p.o. q. day. 4. Prilosec OTC 20 mg p.o. q. day. 5. lovastatin 40 mg q.h.s. 6. lisinopril 10 mg p.o. q. day. 7. hydrochlorothiazide 25 mg p.o. q. day. 8. albuterol nebs q.i.d. p.r.n.
OTC|over the counter|OTC|159|161|DISCHARGE MEDICATIONS|2. Trazodone 150 mg at bedtime. 3. Celexa 80 mg p.o. daily. 4. Valtrex 500 mg daily. 5. Prenatal vitamin 1 daily. 6. Vitamin C 1000 mg p.o. daily. 7. Prilosec OTC 20 mg p.o. daily. DISCHARGE INSTRUCTIONS: The client was discharged home.
OTC|over the counter|OTC|161|163|DISCHARGE MEDICATIONS|She had a stress echocardiogram which was normal. Therefore, the patient was discharged. DISCHARGE MEDICATIONS: 1. Tylenol 650 mg p.o. t.i.d. p.r.n. 2. Prilosec OTC 20 mg, one tab p.o. daily p.r.n. DISCHARGE INSTRUCTIONS: 1. The patient is in the process of finding a new primary MD.
OTC|over the counter|OTC|124|126|CURRENT MEDICATIONS|Was just seen a couple of weeks ago. CURRENT MEDICATIONS: 1. Tamoxifen 20 mg p.o. daily. 2. Plaquenil 210 mg p.o. b.i.d. 3. OTC vitamins and calcium. ALLERGIES: Codeine. She gets shaky, morphine itching.
OTC|over the counter|OTC|170|172||At the time of her discharge, her medications included: 1. Lisinopril 5 mg daily 2. Ranitidine 10 mg daily 3. multivitamins 4. Tylenol. 5. Plavix 75 mg daily 6. Prilosec OTC 20 mg twice a day before meals 7. Trazodone 50 mg at night 8. Celexa 40 mg as well. 9. Digitek 0.125 mg daily 10. Lasix 40 mg twice a day.
OTC|over the counter|OTC|120|122|DISCHARGE MEDICATIONS|3. Magnesium oxide 400 mg 1 p.o. t.i.d. with meals 4. Levaquin 500 mg p.o. daily x4 days, then discontinue. 5. Prilosec OTC 20 mg p.o. q. day. FOLLOW-UP APPOINTMENT: Dr. _%#NAME#%_ _%#NAME#%_ in 3 to 4 weeks for followup of blood pressure, electrolytes and hemoglobin.
OTC|over the counter|OTC|183|185|CURRENT MEDICATIONS|3. Depression. 4. Osteoarthritis. 5. History of remote prostate cancer, status post reactive seed implantation. 6. History or urosepsis in late 2005. CURRENT MEDICATIONS: 1. Prilosec OTC 20 mg p.o. q day. 2. Vitamin E 400 units p.o. q day. 3. Bupropion 100 mg p.o. b.i.d. 4. Seroquel 25 mg p.o. q h.s.
OTC|over the counter|OTC|155|157|MEDICATIONS|10. Status post left ankle surgery with plates and pins in place. MEDICATIONS: 1. Synthroid 0.2 mg p.o. q day. 2. Verapamil 360 mg p.o. q day. 3. Prilosec OTC one p.o. q day. 4. Actonel 35 mg p.o. q week. 5. Zoloft 100 mg p.o. q day. 6. Hydrochlorothiazide 25 mg p.o. q day.
OTC|over the counter|OTC|156|158|DISCHARGE DISPOSITION|GI has reviewed that report and recommended no further therapy at this time. The patient was instructed to stop his aspirin and alcohol, use daily Prilosec OTC and follow up with Dr. _%#NAME#%_ next week. It is unclear if this was a diverticular or upper GI bleed but in any case it is obviously stabilized with no sign of bleeding at this time.
OTC|over the counter|OTC|135|137|DISCHARGE MEDICATIONS|She had no difficulties with swallowing. She felt less emesis and less pain. DISCHARGE MEDICATIONS: 1. Protonix 40 mg daily. 2. Zofran OTC up to 3 times a day as needed. 3. Levaquin 500 mg for 1 day for urinary tract infection. 4. Requip for restless leg syndrome. 5. Methadone. 6. Zanaflex.
OTC|over the counter|OTC|119|121|DISCHARGE  MEDICATIONS|5. Centrum one tablet p.o. q. day 6. Hydrochlorothiazide 25 mg p.o. q. day 7. Metoprolol 25 mg p.o. b.i.d. 8. Prilosec OTC 20 mg p.o. q. day 9. Senna 1 tablet p.o. q. day 10. Trazodone 25 mg p.o. q.h.s. p.r.n.
OTC|over the counter|OTC|127|129|MEDICATIONS|MEDICATIONS: 1. Creon 3 t.i.d. 2. Lexapro 10 mg daily. 3. Amitriptyline 25 mg at bedtime. 4. Actonel 35 mg a week. 5. Prilosec OTC 1 a day. 6. Maxalt p.r.n. 7. Topamax 50 mg b.i.d. ALLERGIES: Codeine and phenobarbital. SOCIAL HISTORY: She is a smoker.
OTC|over the counter|OTC|117|119|DISCHARGE MEDICATIONS|3. Metoprolol/Toprol-XL 50 mg p.o. b.i.d. 4. Lisinopril 40 mg p.o. daily. 5. Prednisone 1 mg p.o. daily. 6. Prilosec OTC 20 mg p.o. daily. 7. This is a new medication at discharge for her iron 725 mg p.o. daily. 8. Clonidine 0.1 mg p.o. b.i.d. FOLLOWUP: She will continue with her outpatient hemodialysis on Monday, Wednesday and Friday.
OTC|over the counter|OTC|161|163|DISCHARGE MEDICATIONS|9. Polycythemia vera, stable. DISCHARGE MEDICATIONS: 1. Norvasc 10 mg p.o. daily. 2. Diovan HCT 160/12.5 p.o. daily. 3. Toprol XL 100 mg p.o. daily. 4. Prilosec OTC 20 mg p.o. daily. 5. Hydroxyurea 500 mg p.o. b.i.d. 6. Detrol LA 4 mg p.o. q.48 h. 7. Plavix 75 mg p.o. daily. 8. Aspirin 81 mg p.o. daily. 9. Levaquin 250 mg 1 p.o. daily, to be stopped on _%#DDMM2007#%_ for UTI and bronchitis.
OTC|over the counter|OTC|121|123|DISCHARGE MEDICATIONS|She will make an appointment with him. DISCHARGE MEDICATIONS: 1. Estrace 2 mg daily. 2. Aspirin 81 mg daily. 3. Prilosec OTC one a day until her pain is gone. SUMMARY OF HOSPITAL COURSE: Chest pain. _%#NAME#%_ _%#NAME#%_ initially presented with substernal chest pain.
OTC|over the counter|OTC|121|123|DISCHARGE MEDICATIONS|5. Lidoderm patch 2 patches to the back 12 hours on, 12 hours off, changed daily. 6. Toprol-XL 125 mg a day. 7. Prilosec OTC 1 tablet a day. DISCHARGE INSTRUCTIONS: 1. The hospice team is to follow.
OTC|over the counter|OTC|116|118|DISCHARGE  MEDICATIONS|3. Plavix 75 mg daily. 4. Aspirin 81 mg daily. 5. Lisinopril 2.5 mg b.i.d. 6. Metoprolol 12.5 mg b.i.d. 7. Prevacid OTC 20 mg daily. 8. Simvastatin 40 mg daily. 9. Nitroglycerin 0.4 sublingual p.r.n.. DISCHARGE FOLLOWUP. He will follow up in the INR clinic in two days.
OTC|over the counter|OTC,|188|191|DISCHARGE MEDICATIONS|Electrolytes normal. Creatinine normal. DISCHARGE DIAGNOSIS: 1. Urosepsis secondary to E. coli. 2. Rheumatoid arthritis. DISCHARGE MEDICATIONS: 1. Cipro 500 mg b.i.d. x7 days. 2. Prilosec OTC, 1 a day. 3. Sulindac, 200 mg t.i.d. 4. Prednisone 10 mg q. day. Follow up with Dr. _%#NAME#%_ for further prostate evaluation to rule out any kind of urethral or prostatic obstruction.
OTC|over the counter|OTC|148|150|DISCHARGE  MEDICATIONS|3. Citalopram 40 mg daily. 4. Cipro 500 mg b.i.d. for five days, and then Septra-DS one tab daily chronically. 5. Seroquel 25 mg b.i.d. 6. Prilosec OTC 20 mg b.i.d. for 2 weeks, then daily. DISCHARGE INSTRUCTIONS: The patient will have a hemoglobin checked at the Oxboro Clinic early next week.
OTC|over the counter|OTC.|136|139|MEDICATIONS|DISCHARGE CONDITION: Stable. DISCHARGE DISPOSITION: Discharged to home. MEDICATIONS: 1. Advair. 2. Albuterol. 3. Allegra-D. 4. Prilosec OTC. 5. Elidel 1% cream. 6. Multivitamin. 7. Bactrim. 8. Roxicet. 9. Actigall. DISCHARGE INSTRUCTIONS: The patient is to continue with clear liquids.
OTC|over the counter|OTC|174|176|CURRENT MEDICATIONS|CURRENT MEDICATIONS: The patient's present medications include: 1. Naprosyn 500 mg b.i.d. 2. Darvocet N-100, 1 p.o. q6h p.r.n. for pain. 3. Fosamax 70 mg weekly. 4. Prilosec OTC 20 mg daily. 5. Calcium 1 pill b.i.d. 6. Multivitamin 1 pill daily. 7. Recently the patient has been on Cipro 500 mg b.i.d.
OTC|over the counter|OTC|286|288|MEDICATIONS|Celexa 80 mg 1 q.d. Lamictal 150 mg 1 in a.m., 1 in p.m. Atenolol 50 mg 1 q.a.m. Norvasc 5 mg 1 q.a.m. Enalapril 10 mg or losartan 50 mg or placebos for each, this is part of the R.A.S.S. kidney study at the University of Minnesota. Prevacid 30 mg 1 q.a.m. Xenical 120 mg before meals. OTC medications include B complex in the a.m., calcium with minerals, multivitamin supplementation 81 mg ASA q.a.m. She is putting this on hold as of today.
OTC|over the counter|OTC,|152|155|DISCHARGE MEDICATIONS|3. Multivitamin, 1 p.o. q. day. 4. Magnesium oxide, 400 mg p.o. q. day. 5. Calcium carbonate with vitamin D, 1,250 mg 1 tablet p.o. q. day. 6. Prilosec OTC, 20 mg p.o. b.i.d. (The patient reports not taking this regularly, therefore this will be restarted, though if she has further reflux symptoms, she likely will need introduction of a branded PPI.) DISPOSITION: The patient will follow up with Dr. _%#NAME#%_ in 2 weeks, Dr. _%#NAME#%_ (psychiatry) as previous scheduled.
OTC|over the counter|OTC|208|210|DISCHARGE MEDICATIONS|2. Norvasc 5 mg once daily. 3. Prednisone 60 mg once a day for 2 weeks and then 50 mg once a day for 2 weeks and then 40 mg a day until further notice, under the direction of the renal physician. 3. Prilosec OTC 20 mg once a day. 4. No nonsteroidal anti-inflammatory drugs such as Advil, Motrin, ibuprofen or Aleve. FOLLOW-UP APPOINTMENTS: 1. Dr. _%#NAME#%_ at the renal clinic on _%#MMDD#%_ at 3:30 p.m.
OTC|over the counter|OTC|158|160|DISCHARGE MEDICATIONS|9. Evista 60 mg daily. 10. Warfarin 5 mg daily or as directed. 11. Atenolol 50 mg daily. 12. Furosemide 40 mg daily. 13. Potassium 20 mEq daily. 14. Prilosec OTC 20 mg daily. 15. Acetaminophen 650 mg every four hours p.r.n. pain. TOTAL TIME SPENT IN DISCHARGE PREPARATION: 45 minutes, including preparing this summary, doing paperwork and discussing discharge planning with the patient's nurse.
OTC|over the counter|OTC|133|135|DISCHARGE MEDICATIONS|7. Claritin 10 mg daily. 8. Seroquel 50 mg daily at bedtime. 9. Zocor 20 mg at bedtime. 10. Spironolactone 20 mg daily. 11. Prilosec OTC 20 mg daily. Follow up with primary M.D. in 1 week. See discussion above for other discharge plans, Home Health Nurse.
OTC|over the counter|OTC|126|128|DISCHARGE  MEDICATIONS|2. Combivent two puffs q.i.d. 3. Spiriva one inhalation daily. 4. Levoxyl 50 mcg daily. 5. Lovastatin 20 mg a day. 6 Prilosec OTC one a day. 7 Cozaar 50 mg daily 8. Aspirin one a day. 9. Vicodin h.s. p.r.n. 10. Os-Cal b.i.d. HISTORY: _%#NAME#%_ _%#NAME#%_ is an 86-year-old female who lives in a nursing home who was sent to the ER for two to three days of diarrhea.
OTC|over the counter|OTC|141|143|CURRENT MEDICATIONS|7. Prior helicobacter pylori infection. 8. Esophageal stricture. 9. Gastritis. CURRENT MEDICATIONS: 1. Aspirin 81 mg p.o. daily. 2. Prilosec OTC 20 mg p.o. daily. 3. Zetia 25 mg p.o. daily by prior medication sheet but from his medication list from the Oxboro Clinic it reads 10 mg p.o. daily.
OTC|over the counter|OTC|88|90|MEDICATIONS|PAST MEDICAL HISTORY: 1. Bilateral inguinal hernia repair. 2. Reflux. MEDICATIONS: Only OTC Prilosec. ALLERGIES: The patient has no known allergies. SOCIAL HISTORY: The patient does not drink nor smoke. He is married.
OTC|over the counter|OTC|122|124|DISCHARGE MEDICATIONS|3. Ativan 0.5 mg p.o. b.i.d. 4. Nicotine patch 7 mg q. 24 hours. Change daily while she is in the rehab unit. 5. Prilosec OTC 20 mg p.o. daily. 6. Metamucil one packet p.o. daily for constipation. Dilute in juice. 7. Senna/docusate two tabs p.o. at bedtime for constipation.
OTC|over the counter|OTC|203|205|MEDICATIONS|She denies other recent illnesses, etc. MEDICATIONS: 1. Prevacid, 1 daily times four days. 2. Tegretol, 300 mg q.a.m. and 400 mg q.p.m. 3. Advair, 500/50 one puff daily. 4. Ventolin inhaler p.r.n. 5. No OTC meds, etc. ALLERGIES: No known drug allergies, though the patient describes many allergies to foods and is unclear if she has an allergy to shellfish or not.
OTC|over the counter|OTC.|197|200|MEDICATIONS|FAMILY HISTORY: Positive for a mother with stomach cancer and then the heart disease noted above. ALLERGIES: IODINE AND SHELLFISH. MEDICATIONS: Nexium 40 mg a day, aspirin 81 mg a day, and enzymes OTC. SOCIAL HISTORY: He is married. He is active physically. He rarely drinks alcohol.
OTC|over the counter|OTC|184|186|HISTORY OF PRESENT ILLNESS|No repeat endoscopy was done. There is a strong family history of ulcer disease in his father, who had it from the Second World War until the time of his death. He has been using some OTC migraine medicine fairly heavily for the last five weeks, at least two tablets daily. The name of the medicine is Migraine Relief. He does not know if contains aspirin but assumes that it does.
OTC|over the counter|OTC.|122|125|MEDICATIONS|His has three living children, two sons and one daughter, who are healthy. MEDICATIONS: Only the migraine relief medicine OTC. ALLERGIES: None to medicine. ADVANCE DIRECTIVES: None. He wishes full resuscitation code. REVIEW OF SYSTEMS: He has had a bowel movement every week for the last two years.
OTC|over the counter|OTC|165|167|NURSING HOME MEDICATIONS|3. Sorbitol b.i.d. p.r.n. constipation. 4. Neurontin 300 mg p.o. t.i.d. 5. Enteric coated aspirin 325 mg p.o. every day. 6. Robitussin 10 cc p.o. t.i.d. 7. Prilosec OTC 20 mg p.o. every day. 8. Azmacort MDI two puffs with spacer b.i.d. 9. Atrovent per neb q8h scheduled. 10. Atenolol 50 mg p.o. every day.
OTC|over the counter|OTC|229|231|DISCHARGE INSTRUCTIONS|At the time of birth this _%#NAME#%_ was exposed in- utero to a number of medications including: Digoxin, Lasix, Amytriptaline, Prozac, KCl, metoprolol, morphine, Dilaudid. It is also worth noting that _%#NAME#%_'s mother used a OTC supplement called ExtraSharp throughout her pregnancy to treat headaches. This contains about 30 herbal supplements including Ginko, ginseng, and others.
OTC|over the counter|OTC|304|306|SOCIAL HISTORY|ALLERGIES: None. MEDICATIONS: Actos 45 mg and Glucovance 5/500 one t.i.d. FAMILY HISTORY: Mother CAB, DM, father COPD, smoker, no HTN, cancer, asthma or allergies in the family. HABITS: Does not smoke, occasional alcohol. SOCIAL HISTORY: Married, three children, one child has cerebral palsy. Denies any OTC drug use. REVIEW OF SYSTEMS: Otherwise is essentially negative.
OTC|over the counter|OTC|213|215|DISCHARGE MEDICATIONS|DOB: _%#DDMM1914#%_ DISCHARGE DIAGNOSIS: 1. Exacerbation of congestive heart failure. 2. Hypertension. 3. Pneumonia ruled out. DISCHARGE MEDICATIONS: Lasix 40 mg p.o. b.i.d., potassium chloride 8 mEq p.o. b.i.d., OTC Zantac 75 mg p.r.n. Eye drops which include timolol one drop OU q.d., Alphagan one drop OU b.i.d., Xalatan one drop OU q.h.s., niacin 50 mg q.i.d., vitamin E one daily, vitamin B combination one daily.
OTC|over the counter|OTC|163|165|DISCHARGE MEDICATIONS|He was felt safe to discharge to home. DISCHARGE MEDICATIONS: 1. Effexor XR 75 mg p.o. daily. 2. Lisinopril 2.5 mg daily. 3. Metoprolol 12.5 mg b.i.d. 4. Prilosec OTC 20 mg daily prn GERD/reflux symptoms. DISCHARGE INSTRUCTIONS: The patient will follow up with his primary care physician Dr. _%#NAME#%_ in a couple weeks.
OTC|over the counter|OTC.|149|152|CURRENT MEDICATIONS|4. Atenolol 25 mg every day. 5. Aspirin 1 every day. 6. Lipitor 10 mg every day. 7. Prevacid 30 mg every day. 8. Lisinopril 10 mg every day. 9. Iron OTC. ALLERGIES: The patient has no adverse reactions to medications.
OTC|over the counter|OTC|115|117|MEDICATIONS|Also, statin medications have caused myalgias and rise in CK levels. MEDICATIONS: Imdur 30 mg p.o. daily. Prilosec OTC 20 mg p.o. daily. Maxzide 25 one p.o. daily. Zetia 10 mg p.o. daily. Atenolol 50 mg p.o. daily. Aspirin 325 mg p.o. daily.
OTC|over the counter|OTC.|165|168|MEDICATIONS PRIOR TO ADMISSION|4. Pseudotumor cerebri. 5. Depression. ALLERGIES: 1. Penicillin 2. Sulfa MEDICATIONS PRIOR TO ADMISSION: 1. Fluoxetine 30 mg p.o. daily. 2. Microgestin. 3. Prilosec OTC. 4. Aspirin 81 mg daily. 5. Multivitamins daily. 6. Sonata p.r.n. 7. Roxicet 5 to 10 mL p.o. q4-6 h p.r.n. pain.
OTC|over the counter|OTC.|142|145|DISCHARGE MEDICATIONS|2. Zofran ODT 4 mg sublingual q6 h p.r.n. nausea. 3. Lasix 40 mg p.r.n. swelling. 4. Fluoxetine 30 mg p.o. daily. 5. Microgestin. 6. Prilosec OTC. 7. Aspirin 81 mg p.o. daily. 8. Multivitamins daily. DISCHARGE INSTRUCTIONS: 1. Follow up in Dr. _%#NAME#%_'s clinic on _%#MM#%_ _%#DD#%_, 2004. 2. Continue a pureed diet until follow up in clinic.
OTC|over the counter|OTC|147|149|MEDICATIONS|4. No latex allergies. MEDICATIONS: 1. Trileptal 300 mg three tablets at hs. 2. Cymbalta 60 mg q.a.m. and 60 mg q.h.s. for depression. 3. Prilosec OTC 20 mg one q. day. 4. Flonase nasal spray two sprays each nostril once daily. 5. Atrovent nasal spray 0.6 t.i.d. 6. B12 injections once a month, status post gastric bypass.
OTC|over the counter|OTC,|216|219|PAST MEDICAL HISTORY|1. Vitamin B12, 100 mcg subcutaneous monthly. 2. Cortef (which is hydrocortisone), 20 mg every morning and 10 mg every evening. 3. Folic acid, 1 mg/day. 4. K-Dur, 20 mEq daily. 5. Levoxyl, 112 mcg daily. 6. Prilosec OTC, 20 mg daily. 7. Coumadin 2.5 mg daily. 8. Lorazepam, 0.25 mg b.i.d. 9. Albuterol nebulization b.i.d. 10. Lisinopril, 10 mg daily. ADMISSION LABS: When she was seen in the emergency room, the ultrasound was as dictated above.
OTC|over the counter|OTC|149|151|DISCHARGE MEDICATIONS|8. Mycelex troche 10 mg q.i.d. 9. Maxi-Gamma OTC 1 capsule by mouth twice daily. 10. OmegaT OTC 1 capsule p.o. 3 times a day. 11. Antioxidant Factor OTC 1 capsule by mouth twice daily. 12. Vitamin C 500 mg 1 tablet b.i.d. 13. Enbrel 25 mg subcutaneous injection to be performed on days _%#MM#%_ _%#DD#%_, 2005, _%#MM#%_ _%#DD#%_, 2005, and _%#MM#%_ _%#DD#%_, 2005.
OTC|over the counter|OTC|116|118|HOSPITAL COURSE|She is to call my office if she has any questions, and this number will be provided to her. She is directed to take OTC pain medications after her Vicodin for further relief of discomfort. DISCHARGE MEDICATIONS: 1. Atenolol 50 mg daily. 2. Hydrochlorothiazide 25 mg daily.
OTC|over the counter|OTC|137|139|DISCHARGE MEDICATIONS|8. Calcium with Vitamin D 1 q p.m. 9. Lisinopril 40 mg daily. 10. Lasix 40 mg q a.m. 11. Potassium chloride 10 mEq 2 daily. 12. Prilosec OTC 20 mg daily. Greater than 30 minutes was spent in time of discharge management.
OTC|over the counter|OTC|179|181|ADMISSION MEDICATIONS|13. History of stress incontinence. ADMISSION MEDICATIONS: 1. Neoral 175 mg q.a.m., 200 mg q.p.m. 2. RAD (everolimus) 2 mg p.o. twice daily. 3. Dapsone 50 mg daily. 4. Maxi-gamma OTC 2 caplets once a day. 5. Omega-T OTC 3 caplets once a day. 6. Antioxidant factor OTC 2 caps once a day.
OTC|over the counter|OTC|135|137|ADMISSION MEDICATIONS|4. Maxi-gamma OTC 2 caplets once a day. 5. Omega-T OTC 3 caplets once a day. 6. Antioxidant factor OTC 2 caps once a day. 7. Vitamin C OTC 500 mg q.i.d. 8. Calcium with vitamin D OTC 600 mg 1 p.o. daily. 9. Chromium picolinate 200 mcg p.o. t.i.d. OTC. 10. Green tea extract OTC 300 mg 2 capsules daily.
OTC|over the counter|OTC|152|154|ADMISSION MEDICATIONS|7. Vitamin C OTC 500 mg q.i.d. 8. Calcium with vitamin D OTC 600 mg 1 p.o. daily. 9. Chromium picolinate 200 mcg p.o. t.i.d. OTC. 10. Green tea extract OTC 300 mg 2 capsules daily. 11. Magnesium oxide OTC 250 mg p.o. q.i.d. 12. Zoloft 100 mg daily. 13. Levoxyl 100 mcg daily. 14. Estradiol 2 mg daily.
OTC|over the counter|OTC|135|137|DISCHARGE MEDICATIONS|6. Omega-T OTC 3 caplets p.o. daily. 7. Antioxidant factor OTC 2 caps p.o. daily. 8. Vitamin C 500 mg b.i.d. 9. Calcium with Vitamin D OTC 600 mg daily. 10. Chromium picolinate 200 mcg t.i.d. 11. Green tea extract OTC 300 mg p.o. t.i.d. 12. Magnesium oxide OTC 250 mg q.i.d. 13. Zoloft 100 mg 1 p.o. daily.
OTC|over the counter|OTC|132|134|DISCHARGE MEDICATIONS|8. Vitamin C 500 mg b.i.d. 9. Calcium with Vitamin D OTC 600 mg daily. 10. Chromium picolinate 200 mcg t.i.d. 11. Green tea extract OTC 300 mg p.o. t.i.d. 12. Magnesium oxide OTC 250 mg q.i.d. 13. Zoloft 100 mg 1 p.o. daily. 14. Levoxyl 100 mcg 1 p.o. daily. 15. Estradiol 2 mg 1 p.o. daily.
OTC|over the counter|OTC|175|177|DISCHARGE MEDICATIONS|8. Vitamin C 500 mg b.i.d. 9. Calcium with Vitamin D OTC 600 mg daily. 10. Chromium picolinate 200 mcg t.i.d. 11. Green tea extract OTC 300 mg p.o. t.i.d. 12. Magnesium oxide OTC 250 mg q.i.d. 13. Zoloft 100 mg 1 p.o. daily. 14. Levoxyl 100 mcg 1 p.o. daily. 15. Estradiol 2 mg 1 p.o. daily.
OTC|over the counter|OTC|139|141|DISCHARGE MEDICATIONS|14. Levoxyl 100 mcg 1 p.o. daily. 15. Estradiol 2 mg 1 p.o. daily. 16. Tylenol 650 mg p.o. p.r.n. 17. Zyrtec 10 mg p.o. p.r.n. 18. Imodium OTC use as directed. 19. Humalog via pump was given at 0.1 unit every hour for basal correction scale is 1 unit per 45 g carbohydrates.
OTC|over the counter|OTC|149|151|DISCHARGE MEDICATIONS|20. Zyprexa 10 mg p.o. q.a.m. 21. Lexapro 30 mg p.o. q.a.m. 22. Combivent 2 puffs three times a day. 23. DuoNeb four times daily p.r.n. 24. Prilosec OTC 20 mg p.o. every day. 25. Haldol 0.5 mg p.o. twice a day p.r.n.
OTC|over the counter|OTC.|160|163|CURRENT MEDICATIONS|Social drinker. She is a nurse. FAMILY HISTORY: Coronary artery disease. Father MI at 53. Mother alive and well. CURRENT MEDICATIONS: Bromocriptine and Allegra OTC. REVIEW OF SYSTEMS: Essentially negative, with patient denying any angina or anginal equivalent.
OTC|over the counter|OTC|186|188|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. daily. 2. Lipitor 40 mg p.o. daily. 3. Synthroid 50 mcg p.o. daily. 4. Metoprolol 37.5 mg p.o. b.i.d. 5. Imdur 30 mg p.o. daily. 6. Prilosec OTC 20 mg p.o. daily. 7. Premarin 0.625 mg daily. FOLLOW UP: The patient is to see her primary care physician within 2- 4 weeks, which the patient's daughter will schedule.
OTC|over the counter|OTC|176|178|ADMISSION MEDICATIONS|Reports a history of "chipped vertebra," T7 through T9, status post MVA. ADMISSION MEDICATIONS: 1. Coumadin 2 to 3 mg per day, alternating days, alternating weeks. 2. Prilosec OTC 20 mg per day. 3. Claritin D 10 mg daily. 4. Cephalexin 500 mg q.i.d. Had been on 3 days on the date of admission.
OTC|over the counter|OTC.|115|118|MEDICATIONS|3. Altace 20 mg p.o. q. day. 4. Insulin 20 in the a.m., 40 in the p.m. 5. Aspirin, which will be held. 6. Prilosec OTC. REVIEW OF SYSTEMS: Negative with no cardiovascular complaints, no infections.
OTC|over the counter|OTC|140|142|MEDICATIONS|Drinks no alcohol. ALLERGIES: Sulfa MEDICATIONS: 1. Atenolol 25 mg p.o. daily. 2. Ambien 10 mg p.o. each day at bed time p.r.n. 3. Prilosec OTC p.r.n. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.3, pulse 76, respiratory rate 16, blood pressure 170/92, sats 96% on room air.
OTC|over the counter|OTC|141|143|MEDICATIONS|PAST MEDICAL HISTORY: SURGICAL: None. MEDICAL: 1) History of migraines. 2) Gastroesophageal reflux. MEDICATIONS: 1) Zomig p.r.n. 2) Prilosec OTC 20 mg daily p.r.n. ALLERGIES: SULFA AND PROZAC. REVIEW OF SYSTEMS: Negative. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 114/80, pulse 80 and regular.
OTC|over the counter|OTC|214|216|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Advair 250/50 1 inhalation b.i.d. 2. Albuterol two puffs 4 times a day as needed. 3. Cefuroxime 500 mg b.i.d. x7 days and discontinue. 4. Hydrochlorothiazide 25 mg p.o. q.a.m. 5. Prilosec OTC 20 mg p.o. daily. 6. Potassium chloride 20 mEq p.o. daily. 7. O2 at 2-3 liters per nasal cannula, anticipate a need for oxygen 2-4 weeks.
OTC|over the counter|OTC|238|240|HOSPITAL COURSE|The patient has a well-established history of esophageal reflux and what has been termed functional dyspepsia. She did have some discomfort on the morning of discharge which was ultimately relieved with belching. She has been on Prilosec OTC once daily, at discharge we will increase this to b.i.d. with the hope of alleviating some of the patient's nocturnal symptoms.
OTC|over the counter|OTC.|155|158|CURRENT MEDICATIONS|He denies any prior family history of gallstones or individuals requiring cholecystectomy. CURRENT MEDICATIONS: None with the exception of occasional Tums OTC. DRUG SENSITIVITIES AND ALLERGIES: The patient reports sensitivity to penicillin derivatives, cephalosporin derivatives and sulfa.
OTC|over the counter|OTC|95|97|PLAN|8. Amitriptyline 100 mg at bed-time. 9. He uses betamethasone for his eczema. He denies taking OTC meds. Denies taking any herbal supplements. He is not aware of any recent blood loss. He is denies any melena or hematochezia.
OTC|over the counter|OTC|185|187|DISCHARGE MEDICATIONS|2. The patient is to follow up with her primary care physician, Dr. _%#NAME#%_, within 1 week of discharge. DISCHARGE MEDICATIONS: 1. Dilantin 200 mg p.o. q.a.m. and q.p.m. 2. Prilosec OTC 40 mg p.o. b.i.d. 3. Arimidex 1 mg p.o. q. day. 4. Norethindrone 5 mg p.o. daily. 5. Zyrtec 10 mg p.o. daily.
OTC|over the counter|OTC|173|175|CURRENT MEDICATIONS|3. Lisinopril 20 mg q. day. 4. Allegra 60 mg twice a day as needed for allergies. 5. Albuterol 2 puffs four times a day as needed. 6. Enbrel 25 mg twice a week. 7. Prilosec OTC 20 mg once a day. ALLERGIES: Tetracycline causes yeast infections. SOCIAL HISTORY: The patient is divorced.
OTC|over the counter|OTC|191|193|HISTORY OF PRESENT ILLNESS|The patient describes some left shoulder area pain when she moved her shoulder and general discomfort from the left iliac area up to the axilla. This pain has been treated with ice, heat and OTC analgesics with moderate benefit. The pain has gradually lessened and has been recently 4/10 in intensity, per her report. As mentioned above, the patient has been starting a new business selling Herbalife products, etc.
OTC|over the counter|OTC|138|140|CURRENT MEDICATIONS|ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: 1. Plavix 75 mg q day. 2. Aspirin 81 mg daily. 3 Avapro 300 mg q day. 4 Prilosec OTC one tablet daily. 5 Flonase daily. 6 Zocor 40 mg q day. 7. Toprol XL 25 mg q day. 8 Proscar 5 mg q day.
OTC|over the counter|OTC|153|155|DISCHARGE MEDICATIONS|6. History of depression, with possible anxiety. Cannot rule out rash or dyspnea being somewhat related. DISCHARGE MEDICATIONS: 1. Imdur 30 mg daily. 2. OTC Benadryl p.r.n. 3. Aspirin 81 mg daily. 4. Protonix 40 mg daily. 5. Cozaar 50 mg daily. 6. Toprol XL 50 mg daily
OTC|over the counter|OTC|109|111|HOSPITAL COURSE|We harped on her repeatedly about not using any more aspirin or NSAIDs for the long term. She needs to be on OTC Prilosec (because it is cheaper than Protonix for her) 20 mg b.i.d. for a month, and then each evening for the rest of her life.
OTC|over the counter|OTC|263|265|MEDICATIONS|She was admitted for further evaluation and treatment. I should add that the patient has never had ischemic colitis, diverticulitis or Clostridium difficile colitis. ALLERGIES: She is allergic to aspirin. MEDICATIONS: Ambien 5 mg p.o. at h.s. as needed otherwise OTC tablet antacids. Operations will be elaborated in assessment and plan. REVIEW OF SYSTEMS: CONSTITUTIONAL: She has been running a fever and felt weak.
OTC|over the counter|OTC|89|91|MEDICATIONS|Sister with gynecologic cancer. ALLERGIES: Morphine, shellfish. MEDICATIONS: 1. Prilosec OTC 20 mg p.o. daily. 2. Azathioprine 50 mg p.o. t.i.d. 3. Allegra dose unknown 1 tab p.o. daily. 4. Levothyroxine 150 mcg p.o. daily. 5. Prednisone 100 mg p.o. daily.
OTC|over the counter|OTC|43|45|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. OTC deficiency. 2. OTC metabolic crisis. 3. Placement of chest port-A-Cath on _%#DDMM2006#%_ performed by Dr. _%#NAME#%_ without complications. DISCHARGE: The patient is to be discharged to home.
OTC|over the counter|OTC|155|157|MEDICATIONS|1. Lipitor 10 mg p.o. each day at bed-time. 2. Coumadin until today. 3. Multivitamin. 4. Lasix 20 mg p.o. q. day. 5. Inderal 40 mg p.o. t.i.d. 6. Prilosec OTC 20 mg p.o. q. day. 7. Iron. SOCIAL HISTORY: He is a nonsmoker. He lives with his wife.
OTC|over the counter|OTC|156|158|DISCHARGE MEDICATIONS|3. Paroxetine 60 mg once a day. 4. Pravastatin 40 mg p.o. each day at bedtime. 5. Vitamin D once a week. 6. Calcium carbonate one tablet b.i.d. 7. Prilosec OTC 20 mg once a day (or formulary equivalent). 8. Flexeril 10 mg p.o. t.i.d. as needed for spasms and headaches. FOLLOW-UP APPOINTMENTS: 1. Dr. _%#NAME#%_ _%#NAME#%_ at the Oxboro Clinic in 3-4 weeks.
OTC|over the counter|OTC|125|127|DISCHARGE MEDICATIONS|7. Imdur 30 mg h.s. and 60 mg q.a.m. 8. Synthroid 0.125 mcg a day. 9. Nitroglycerin spray p.r.n. 10. I will suggest Prilosec OTC everyday. Follow up in 2 weeks with Dr. _%#NAME#%_.
OTC|over the counter|OTC|215|217|HOSPITAL COURSE|He will be discharged with instructions to take Percocet for pain and Colace for constipation. He is instructed regarding activity, bathing and followup. He may continue his home medications, which include Prilosec OTC 1 q.d. and M.V.I 1 q.d.
OTC|over the counter|OTC|149|151|DISCHARGE MEDICATIONS|3. L-thyroxine 0.088 mg daily. 4. Lisinopril 10 mg daily. 5. Tylenol arthritis 1300 mg t.i.d. 6. Multiple vitamins. 7. Tylenol #3 p.r.n. 8. Prilosec OTC 20 mg every morning. 9. Tums 500 mg t.i.d. after meals. His Celebrex, trimethoprim sulfa, saw palmetto, warfarin, aspirin and meclizine are on hold.
OTC|over the counter|OTC|118|120|MEDICATIONS|6. Hysterectomy. MEDICATIONS: 1. Centum Silver one tablet p.o. daily. 2. Vitamin C one tablet p.o. daily. 3. Prilosec OTC one tablet p.o. daily. 4. Ferrous sulfate 324 mg p.o. daily. 5. Spironolactone 25 mg p.o. daily. 6. Lasix 40 mg p.o. daily. 7. Meclizine over-the-counter one tablet p.o. t.i.d. p.r.n. ALLERGIES: The patient has no known allergies.
OTC|over the counter|OTC|153|155|DISCHARGE MEDICATIONS|DIET: Regular. ACTIVITY: As tolerated. CODE STATUS: FULL DISCHARGE MEDICATIONS: 1. Tylenol over the counter 500 to 1,000 mg q6h p.r.n. pain. 2. Prilosec OTC 20 mg one daily. 3. Flomax 400 mcg daily. 4. Saw palmetto one daily. 5. Occuvite one tab daily. SUMMARY OF HOSPITAL COURSE: 1. Abdominal pain; the patient presented to the Emergency Department because of longstanding abdominal pain.
OTC|over the counter|OTC|178|180|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Decadron 4 mg p.o. q.6h. 2. Colace 100 mg p.o. b.i.d. 3. Lovenox 40 mg subq b.i.d. until INR is greater than 2. 4. Zofran 4 mg p.o. q. day. 5. Prilosec OTC 1 tablet p.o. q. day. 6. Zosyn 4.5 grams IV q.8 hours for 14 days. 7. Temodar 120 mg p.o. q. day. 8. Coumadin 5 mg p.o. q. day, however, adjust per INR.
OTC|over the counter|OTC.|203|206|HOSPITAL  COURSE|She has occasional small amount of bright red blood which she says she has hard stool with hemorrhoidal bleeding. At this point, would continue her on her current medications. We will recommend Prilosec OTC. She should have a hemoglobin in two to three weeks and at this point I have also ordered iron studies to further evaluate.
OTC|over the counter|OTC|137|139|DISCHARGE MEDICATIONS|8. Glipizide 5 mg p.o. daily. 9. Labetalol 400 mg p.o. t.i.d. 10.Lisinopril 20 mg p.o. q. day. 11.Minoxidil 5 mg p.o. daily. 12.Prilosec OTC 1 tablet p.o. q. day. 13.Potassium chloride 20 mEq p.o. daily. 14.Sertraline 100 mg p.o. at bedtime. 15.Zocor 20 mg p.o. q. day.
OTC|over the counter|OTC|116|118|DISCHARGE MEDICATIONS|2. Fosinopril 40 mg p.o. q. day., crush tablet. 3. Hydrochlorothiazide 50 mg p.o. q. day., crush tablet. 4. Mucinex OTC 2 tablet p.o. p.r.n. cough, crush tablet. 5. Beclomethasone 80 mcg 2 puffs inhaled b.i.d. 6. Serevent 2 puffs inhaled b.i.d.
OTC|over the counter|OTC|201|203|DISCHARGE MEDICATIONS|12. Roxicet 5 mL to 10 mL p.o. q. 4-6h. p.r.n. pain, 500 mL dispensed with no refills. 13. Ferrous gluconate 325 mg p.o. b.i.d., crush tablet. 14. Chantix 1 mg p.o. q. day., crush tablet. 15. Prilosec OTC 1 tablet p.o. q. day., crush tablet. 16. Polyethylene glycol p.r.n. constipation.
OTC|over the counter|OTC|250|252|ADDENDUM|Also, low dose aspirin, Ecotrin 81 mg p.o. daily will be started in two weeks. 5. Glaucoma. 6. Osteoporosis. 7. Other diagnosis by the admission history and physical ADDENDUM: It will be recommended that the patient stay on over-the-counter Prilosec OTC indefinitely. Greater than 30 minutes was put on the discharge and discharge planning of this patient.
OTC|over the counter|OTC.|170|173|MEDICATIONS|She understands and accepts these risks. PAST MEDICAL HISTORY: The patient has had previous oral surgery, history of anemia, currently resolved. MEDICATIONS: 1. Sprintec OTC. 2. Amitriptyline. ALLERGIES: Sulfa. HABITS: Smoking - none. Alcohol - occasional. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Negative for current chest pain, shortness of breath, breast lumps, sore throat, or any upper respiratory symptoms.
OTC|over the counter|OTC|174|176|MEDICATIONS AT THE NURSING HOME|10. Combivent 2 puffs q.i.d. (the patient per the chart does have history of COPD though she denies any history of cigarette use). 11. Lamictal 300 mg x3 daily. 12. Prilosec OTC 20 mg daily. 13. Zonegran 100 mg daily. 14. Vitamin D 50,000 units monthly. 15. Actonel 35 mg weekly. 16. Ferrous gluconate 325 mg daily.
OTC|over the counter|OTC|173|175|DISCHARGE MEDICATIONS|2. Synthroid 88 mcg daily. 3. Progesterone 200 mg on days 1-12 of her cycle. 4. Zocor 20 mg at bedtime. 5. Effexor XR 75 mg at bedtime 6. Aspirin 325 mg daily. 7. Ibuprofen OTC 200 mg to take 400 to 600 mg q. 6 hours p.r.n. for neck or arm pain. I told her to take a couple scheduled doses over the next day, and if her pain is gone, she can just take it p.r.n. DISCHARGE DISPOSITION: Destination home.
OTC|over the counter|OTC.|227|230|CURRENT MEDICATIONS|8. Duragesic patch 100 mcg q.3-4 days. She is currently at every two days, but had not changed her current patch for last four days per patient. 9. Procrit q. week IM. Has not had any for the last 2-3 weeks. 10. Stool softener OTC. REVIEW OF SYSTEMS: HEENT: Positive for glasses. Denies sore throat or URI symptoms. GENERAL: Positive for chills, night sweats, and weight loss as above.
OTC|over the counter|OTC|131|133|DISCHARGE MEDICATIONS|2. Augmentin 875 mg down feeding tube b.i.d. x 14 days if fever. The patient is to resume home medications, including: 1. Prilosec OTC 1 tablet down feeding tube daily. 2. Allopurinol 100 mg down feeding tube daily.
OTC|over the counter|OTC.|141|144|MEDICATIONS|10. Miacalcin nasal spray, one spray alternate nares daily. 11. Mirtazapine 50 mg p.o. daily. 12. Triamcinolone 0.1% ointment. 13. Vanicream OTC. REVIEW OF SYSTEMS: Reviewed. The patient is essentially negative for most of the review of systems, patient does endorse weakness and productive sputum.
OTC|over the counter|OTC|214|216|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. He will be sent home then on instead of his usual term on 50 mg bid on Labetalol 100 mg bid. 2. Coated aspirin once a day. 3. Synthroid 75 mcg daily. 4. Meclizine 25 mg q6h prn. 5. Zantac OTC 75 mg bid. 6. Allopurinol 300 mg a day. On talking with him this morning, he is an rational gentleman who questions many things, but he says that indeed that his headache is quite a bit better.
OTC|over the counter|(OTC|214|217|MEDICATIONS|Otherwise he has had no reoccurrence, has no other episodes of noted tachycardia or limitation of his activities. MEDICATIONS: Lisinopril 10 mg on hold, aspirin occasionally, Prostata b.i.d, Advil p.r.n. and R____ (OTC antioxidants). ALLERGIES: None. Intolerance to Cipro. REVIEW OF SYSTEMS: Pertinent for chronic sinus drainage, controlled by antioxidants?.
OTC|over the counter|OTC|198|200|MEDICATIONS|2. She should see her primary physician, Dr. _%#NAME#%_ _%#NAME#%_, in one to two weeks after colonoscopy to review results and plan. MEDICATIONS: 1. Tequin 200 mg daily times four days. 2. Imodium OTC prn. 3. Fosamax 70 mg weekly. 4. Cardura 1 mg daily. 5. Aspirin 81 mg daily. 6. Nasonex two sprays q day, q naris prn.
OTC|over the counter|OTC.|147|150|CURRENT MEDICATIONS|4. Metoprolol, 50 mg p.o. b.i.d. 5. Isosorbide, 60 mg p.o. q. day. 6. Gemfibrozil, 600 mg p.o. b.i.d. 7. Temazepam, 30 mg p.o. q. day. 8. Prilosec OTC. 9. Multi-vitamin. 10. Low-dose aspirin. SOCIAL HISTORY: No tobacco, but prior tobacco use.
OTC|over the counter|OTC|117|119|DISCHARGE MEDICATIONS|2. Ibuprofen 600 mg p.o.q. 6 hours p.r.n. pain. 3. Tylenol No. 3 one to two tablets p.o.q. 4-6 hours p.r.n. pain. 4. OTC Tylenol p.r.n., however, total Tylenol not to exceed 4 grams per day. FOLLOW UP: Follow up with primary physician at _%#CITY#%_ Clinic within 1 week.
OTC|over the counter|OTC|251|253|DISCHARGE MEDICATIONS|We discussed the typical convalescence period for mononucleosis, including the expected fatigue and the decreased energy for the next few weeks potentially. DISCHARGE MEDICATIONS: 1. Prednisone 40 mg p.o. q.d. x 3 days, then discontinued. 2. Prilosec OTC 20 mg p.o. q.d. for 1 to 2 weeks, then once daily as needed. 3. Hurricane/Cetacaine spray (or over-the-counter Chloraseptic spray) q.i.d. as needed, especially before meals.
OTC|over the counter|OTC|159|161|PAST MEDICAL HISTORY|14. Lispro insulin three times daily before meals on sliding scale. 15. Cardizem CD 24 mg daily. 16. Advair 500/50 one inhalation every 12 hours. 17. Prilosec OTC 20 mg daily. 18. Warfarin 2.5 mg daily; skipping Wednesdays. 19. Diazepam 2.5 mg twice daily p.r.n. 20. Miacalcin one spray daily.
OTC|over the counter|OTC|166|168|DISCHARGE MEDICATIONS|8. Penicillin 250 mg p.o. daily. 9. Calcium with vitamin D 600 mg p.o. b.i.d. 10. Lipitor 20 mg p.o. daily. 11. Multivitamin with zinc 1 tab p.o. daily. 12. Prilosec OTC 1 tab p.o. daily. FOLLOW-UP: The patient should follow up tomorrow with routine transplant labs as well as a repeat hemoglobin in clinic.
OTC|over the counter|OTC|107|109|DISCHARGE MEDICATIONS|On the day of discharge, the patient's serum creatinine was 2.59 mg/dL. DISCHARGE MEDICATIONS: 1. Prilosec OTC 1 tablet p.o. daily. 2. Centrum Silver 1 tablet p.o. daily. 3. Synthroid 0.88 mg p.o. daily. 4. Prednisone 5 mg p.o. daily. 5. Bactrim single-strength 1 tablet p.o. daily.
OTC|over the counter|OTC|123|125|DISCHARGE MEDICATIONS|8. Heparin 5000 units subcu 3 times daily (every 8 hours, discontinue when INR is greater than or equal to 2). 9. Prilosec OTC 20 mg p.o. daily. 10. Effexor 150 mg p.o. daily. 11. Multivitamin 1 p.o. daily. 12. Lantus insulin 34 units subcu q.h.s.
OTC|over the counter|OTC|180|182|MEDICATIONS ON ADMISSION|She has had no recent viral illnesses. PAST MEDICAL HISTORY: Deviated septal surgery. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Multivitamins 1 every day 2. OTC digestive enzymes every day. SOCIAL HISTORY: She denies any tobacco use. She has occasional alcohol use. FAMILY HISTORY: Her father has diabetes and coronary artery disease status post CABG.
OTC|ornithine transcarbamoylase|OTC|148|150|SOCIAL HISTORY/FAMILY HISTORY|SOCIAL HISTORY/FAMILY HISTORY: _%#NAME#%_ is the only male in his family who is affected, however, both his mother and sister are heterozygotes for OTC deficiency. The parents are all very involved in his care and this is very challenging difficult situation for which they are to be congratulated owing to the successful management.
OTC|over the counter|OTC|113|115|OUTPATIENT MEDICATIONS|10. Aspirin 5 grains p.o. q. day. 11. Synthroid 88 mcg p.o. q. day. 12. Multivitamin 1 p.o. q. day. 13. Prilosec OTC 20 mg p.o. q. day. ALLERGIES: Codeine. SOCIAL HISTORY: The patient is a resident of Ebenezer Care Center.
OTC|over the counter|OTC|165|167|MEDICATIONS|She denies any suicidal ideations at this time. MEDICATIONS: She has been taking Wellbutrin and restoril through her psychiatrist. She has also been taking Prilosec OTC per her nurse practitioner. SOCIAL HISTORY: As above. FAMILY HISTORY: Father with lung cancer.
OTC|ornithine transcarbamoylase|(OTC),|459|464|PLAN|_%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD University Specialists _%#ADDRESS#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#ADDRESS#%_ _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: This letter will summarize the information discussed with your patient, _%#NAME#%_ _%#NAME#%_, who was seen on _%#DDMM2003#%_ in the Perinatal Center at Fairview-University Medical Center for genetic counseling regarding her diagnosis of ornithine transcarbamylase deficiency (OTC), and its implication on her pregnancy and outcome. _%#NAME#%_ is a 26-year-old gravida 2, para 0-0-1-0, who is currently eight weeks and five days gestation.
OTC|ornithine transcarbamoylase|OTC;|389|392|PLAN|Previously, _%#NAME#%_ had mutational analysis for OTC performed by Dr. _%#NAME#%_ _%#NAME#%_ at Children's National Medical Center, which indicate that she has a DNA sequence change; GCT to CCT in exon 5, codon 174 in the OTC gene. This resulted in amino acid frame change from ALA-174-PRO. According to the report from Children's National Medical Center, this is likely the cause of her OTC; however, because there have been no expression studies of this mutation, there is still a small chance that this mutation represents a rare polymorphism.
OTC|ornithine transcarbamoylase|OTC|199|201|PLAN|Some heterozygous females do not have any symptoms, but others have developmental delay, learning problems, recurrent vomiting, lethargy or irritability, abnormal hair texture, ataxia, and seizures. OTC is an X-linked condition, which means that if _%#NAME#%_ had a future son, he would be at 50% risk of having OTC, and _%#NAME#%_'s future daughters have a 50% risk of being a carrier, which may have mild to moderate symptoms of the disease.
OTC|ornithine transcarbamoylase|(OTC)|159|163|ISSUES AND PLAN|HEART: No murmur. ABDOMEN: Soft with quiet bowel sounds; she has right lower quadrant point tenderness. ISSUES AND PLAN: Ornithine transcarbamylase deficiency (OTC) is an X-linked disorder. Affected females typically develop hyperammonemia and can suffer coma during periods of stress and low p.o. intake.
OTC|over the counter|OTC.|269|272|MEDICATIONS ON ADMISSION|She had history of total abdominal hysterectomy for uterine cancer, rectal surgery for fissures and hemorrhoids, and bilateral cataract extractions. ALLERGIES: Lodine and Librium. MEDICATIONS ON ADMISSION: 1. Celebrex. 2. Hydrochlorothiazide. 3. Synthroid. 4. Prilosec OTC. FAMILY HISTORY: Significant for asthmatic symptoms.
OTC|over the counter|OTC.|128|131|MEDICATIONS|The patient's last reconstructive surgery was approximately three years ago. MEDICATIONS: 1. Pain medications p.r.n. 2. Tagamet OTC. 3. Claritin 10 mg p.r.n. ALLERGIES: No known drug allergies. FAMILY HISTORY: The patient has a significant family history of morbid obesity, diabetes mellitus, cardiovascular disease.
OTC|over the counter|OTC|179|181|HISTORY OF PRESENT ILLNESS|Since that time, his symptoms have waxed and waned. Currently, he is not experiencing any stomach pains. He does have reflux a few times a week, mostly at night. He uses Prilosec OTC p.r.n. for this, which seems to help. His 2nd medical complaint is just of a general headache.
OTC|over the counter|OTC|240|242|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: Positive for occasional difficulties with headaches related to muscular tension which is easily relieved with Tylenol or ibuprofen. Denies fevers or chills. Complains of mild allergy symptoms for which she has been using OTC preparations on a nearly daily basis with fair effect. No chest pain or dyspnea. No abdominal pain, nausea, vomiting, constipation, diarrhea, or urinary complaints.
OTC|over the counter|OTC|130|132|REASON FOR PROCDURE|No unusual cough. Possibly some nausea. Bowel habits did not change. There were no other symptoms. The patient tried the Prilosec OTC 20 mg daily and it seemed to help some. However, it did not relieve the discomfort completely and the patient was seen in the office.
OTC|over the counter|OTC|173|175|OUTPATIENT MEDICATIONS|PAST SURGICAL HISTORY: A LEEP biopsy to remove precancerous cells 1992 and 1993. OUTPATIENT MEDICATIONS: 1. Seroquel. 2. Klonopin. 3. Topamax 100 mg p.o. daily. 4. Prilosec OTC 20 mg p.o. b.i.d. 5. Yaz birth control 1 pill p.o. daily. 6. Midol 2 pills p.o. daily. 7. Citalopram HPR. The patient states taking Midol 2 pills plus ibuprofen 800 mg 4 tablets concurrently every q.4 h. p.r.n. cramps.
OTC|over the counter|OTC|132|134|MEDICATIONS|6. Pituitary adenoma with subsequent adrenal insufficiency. 7. Hyperlipidemia. MEDICATIONS: 1. Amiodarone 200 mg daily. 2. Prilosec OTC 20 mg b.i.d. 3. Spironolactone 50 mg daily. 4. Keflex 500 mg q.i.d. for 5 days for treatment of UTI and pneumonia.
OTC|over the counter|OTC|137|139|OUTPATIENT MEDICATIONS|4. Lipitor 20 mg p.o. daily. 5. Campral 666 mg p.o. t.i.d. 6. Lisinopril 10 mg p.o. t.i.d. 7. Amoxicillin 875 mg p.o. b.i.d. 8. Prilosec OTC 20 mg p.o. b.i.d. ALLERGIES: Sulfa produces a rash. SOCIAL HISTORY: The patient does not smoke cigarettes but chews tobacco.
OTC|over the counter|OTC|155|157|HISTORY OF PRESENT ILLNESS|He also has a history of migraine-type headaches. He states that he has photophobia along with seeing spots when headaches first start. He currently takes OTC pain medications, primarily Tylenol, for these headaches. These headaches cause mild to moderate pain in a uniform pattern over the head, with an aura origination in the neck.
OTC|over the counter|OTC|180|182|MEDICATIONS|Again, her last colonoscopy was 8 years ago. No history of peptic ulcer disease, only GERD. ALLERGIES: None. MEDICATIONS: 1. 6MP 50 mg daily. 2. Prilosec 20 mg q. day. 3. Claritin OTC p.r.n. 4. Ortho Tri-Cyclen Low. PAST MEDICAL HISTORY: 1. Crohn's disease diagnosed 11 years ago. 2. Chronic sinusitis.
OTC|over the counter|OTC|140|142|MEDICATIONS|8. Right knee replacement in 1990. 9. Tonsillectomy and bunionectomy. 10. Hypertension MEDICATIONS: Prior to admission included 1. Prilosec OTC 2. Toprol-XL 50 mg p.o. q. day. 3. Benicar 40 mg p.o. q. day. 4. Lasix 40 mg p.o. q. day. 5. Celexa 10 mg p.o. q. day.
OTC|over the counter|OTC|132|134|MEDICATIONS|MEDICATIONS: 1. Verapamil 240 mg daily. 2. Terazosin 5 mg q.p.m. 3. Lisinopril 10 mg q.p.m. 4. Synthroid 100 mcg daily. 5. Prilosec OTC on a p.r.n. basis. ALLERGIES: Naprosyn. SOCIAL HISTORY: Gentleman lives alone and works as a baker.
OTC|over the counter|OTC|138|140|REVIEW OF SYSTEMS|He notes chronic difficulties with eczema sighting his anterior elbows as well as his posterior knees. He states he has tried a number of OTC ointments and generally always has an outbreak. He also acknowledges dry skin around his face, in particular his eyes. PHYSICAL EXAMINATION: VITAL SIGNS: Stable, he is afebrile. HEENT: Head was normocephalic and atraumatic.
OTC|ornithine transcarbamoylase|OTC|365|367|FAMILY HISTORY|I reviewed tonight, suggesting that a second male may have died an infant death (this was also relayed by telephone by Dr. _%#NAME#%_ _%#NAME#%_, although the documentation and details are not clear. It is also noted that _%#NAME#%_'s mother is "mentally ill." It is not clear if there are any other male deaths that could be attributed to X-linked transmission of OTC mutant gene, but this would be important information to have if it is available. REVIEW OF SYSTEMS: Review of systems is quite complex and limited at this point and it is unclear if she has any neurologic, integument, gastrointestinal, respiratory, endocrine, skeletal, muscular abnormalities insofar as she is not a good historian, although some of this information was queried.
OTC|ornithine transcarbamoylase|OTC|133|135|PHYSICAL EXAMINATION|2. Plasma amino-acid study in which case an elevated glutamine and possibly an elevated alanine would be suggestive of an underlying OTC deficiency. 3. A urine orotic acid level was requested and I understand that this result will be obtained some time next week.
OTC|ornithine transcarbamoylase|OTC|111|113|PHYSICAL EXAMINATION|There will be some increase in level; however, if the level is very high, this would be suggestive of being an OTC carrier. I have given Dr. _%#NAME#%_ some references in the New England Journal of Medicine, such as _%#NAME#%_ et al "allopurinol-induced orotidinuria," 322(23):1641- 1645,1990.
OTC|ornithine transcarbamoylase|OTC|195|197|PHYSICAL EXAMINATION|In addition, it might even explain at least some of her neuropsychiatric baseline disorder. Additional family members should be studied if it is found that _%#NAME#%_ is, indeed, a carrier of an OTC mutation. Many thanks for the opportunity of being involved in this case.
OTC|over the counter|OTC|174|176|MEDICATIONS|MEDICATIONS: 1. Coumadin 2 mg daily. 2. Amiodarone 100 mg daily. 3. Crestor 5 mg daily. 4. Lorazepam 0.5 mg q.h.s. (may repeat x3) 5. Levothyroxine 88 mcg daily. 6. Prilosec OTC 20 mg daily. 7. Iron sulfate 65 mg daily. 8. chondroitin Sulfate . 9. anti allergy medication PAST SURGICAL HISTORY: 1. Left corneal transplant approximately 2000 with good results.
OTC|over the counter|OTC|154|156|IMPRESSION|This pain does have features of GERD such as the positional nature, the increased symptoms with abdominal distention and it is possible that the Prilosec OTC is an insufficient dose for him. He is a fairly hefty person and may require more medication. 2. The GERD is being exacerbated by the chronic diarrhea and the use of Imodium.
OTC|over the counter|OTC|117|119|MEDICATIONS|1. Aspirin 325 mg daily. 2. Plavix 75 mg daily. 3. Lisinopril 20 mg daily. 4. Metoprolol XL 25 mg daily. 5. Prilosec OTC 20 mg daily. 6. The patient also has a Viadur implant for his prostate cancer. PAST MEDICAL HISTORY: 1. Atherosclerotic coronary vascular disease, status post stenting of his LAD in _%#MM2005#%_.
OTC|over the counter|OTC|173|175|MEDICATIONS|MEDICATIONS: She takes diltiazem, Cozaar, Lasix, metoprolol, Tylenol. She is taking an aspirin 325 mg p.o. daily. She is on no proton pump inhibitor. She is taking Prilosec OTC 20 mg p.o. q.day. SOCIAL HISTORY: No alcohol or tobacco. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: VITAL SIGNS: Currently, her vital signs are stable.
OTC|over the counter|OTC|248|250|MEDICATIONS|5. She does have her history of herpes simplex virus infection as well and has used Valtrex at times. 6. She also notes a history of adult ADD. MEDICATIONS: Home medications include Gaviscon, trazodone 150 mg, prenatal vitamins, Fioricet, Prilosec OTC as needed, folic acid, vitamin C, Valtrex, Celexa 60 mg and Sudafed. ALLERGIES: No drug allergies. SOCIAL HISTORY: She is married and has a 4-1/2 year old child at home.
OTC|over the counter|OTC|144|146|MEDICATIONS|She believes she was prescribed Ativan during her last episode of postpartum depression and denies using any Ativan in the interim. 2. Prilosec OTC 1 p.o. daily. 3. Valtrex 725 mg daily. 4. Celexa 80 mg daily. 5. Advil 600 mg q.i.d. p.r.n. ALLERGIES: NO KNOWN DRUG ALLERGIES.
OTC|over the counter|OTC|142|144|CURRENT MEDICATIONS|8. Tylenol CR, 650 mg daily. 9. Multivitamin 1 p.o. daily. 10. Fosamax 70 mg one tablet q. week. 11. Viactiv Chews 600 mg t.i.d. 12. Prilosec OTC 20 mg daily. 13. Aspirin 81 mg p.o. daily. PAST MEDICAL HISTORY: 1. Status post hemorrhoidectomy at age 20.
OTC|over the counter|OTC|204|206|REVIEW OF SYSTEMS|He smokes a pack of cigarettes daily. Denies other chemicals being abused. FAMILY HISTORY: Not obtained. REVIEW OF SYSTEMS: Complains of difficulty with facial acne which he has periodically treated with OTC remedies without much success. Denies cold symptoms of late. Denies general constitutional complaints other than diminished appetite. He believes that he has lost about 10 pounds over the past year.
OTC|over the counter|OTC|232|234|IMPRESSION|She did not appear to be in major distress, but we are concerned about the use of IV narcotics. When discussing this with the father we decided that we would suggest backing off quickly on the narcotics, trying to transition her to OTC type medications, perhaps using Toradol in the meantime, and offering her other non-medicine alternatives to see if we could deal with the headaches with less medication.
OTC|over the counter|OTC|158|160|REVIEW OF SYSTEMS|She has been sexually active with one partner in the past year. No history or symptoms of STDs. She carries a diagnosis of recent athlete's foot treated with OTC antifungal agent. FAMILY AND SOCIAL HISTORY: The patient is single and currently unemployed.
OTC|over the counter|OTC|188|190|ADMISSION MEDICATIONS|7. Osteoarthritis, limited. Naprosyn is used when necessary. 8. History of sinus surgery. 9. Depression, diagnosed 3 years ago. ADMISSION MEDICATIONS: 1. Prinivil 40 mg q.a.m. 2. Prilosec OTC 20 mg q.a.m. 3. Claritin 10 mg q.a.m. 4. Paxil 40 mg q.a.m. 5. Ativan 1 mg t.i.d. 6. Trazodone 50 to 100 mg q.h.s. 7. Advair Disk 1 puff b.i.d.
OTC|over the counter|OTC|262|264|REVIEW OF SYSTEMS|Denies a history of IV drug use. FAMILY HISTORY: Her mother may have cervical cancer, per the patient report, otherwise noncontributory. REVIEW OF SYSTEMS: GENERAL: The patient states that she had a fever and some shortness of breath after she had taken several OTC sleep aids 2 days ago to try and get high, but that has since resolved. Denies current fevers, chills, or significant weight change. HEENT: Negative.
OTC|over the counter|OTC|161|163|PAST MEDICAL HISTORY|He has not been on any aspirin or non-steroidal agents. PAST MEDICAL HISTORY: 1) Gastroesophageal reflux disease since childhood. He has been placed on Prilosec OTC now for the past one month. He has not had preceding upper endoscopy. 2) Umbilical hernia. 3) Ocular migraines. 4) Occasional palpitations. MEDICATIONS: Prilosec OTC. ALLERGIES: NONE KNOWN.
OTC|over the counter|OTC.|126|129|MEDICATIONS|1. Biliary tract disease and stones as noted above. PAST SURGICAL HISTORY: Status post cholecystectomy. MEDICATIONS: Prilosec OTC. The patient was recommended to take Actigall following her last ERCP, but the patient found this to be very expensive and has not taken it after the last prescription ran out after her last ERCP.
OTC|over the counter|OTC|132|134|HISTORY OF PRESENT ILLNESS|He reports that the treatment with Kerodex cream twice a day has helped the dry skin on his hands greatly. He is currently using an OTC cream for maintenance therapy and denies the need for the prescriptive cream at this time. Today the patient is denying any acute medical concerns. Reports that he is feeling just a little bit fatigued, but otherwise feeling well.
OTC|over the counter|OTC|121|123|CURRENT MEDICATIONS|One in the morning and 2 in the evening. 8. Triamcinolone cream to the rash on her legs. 9. Xanax on a p.r.n. basis. 10. OTC laxative at h.s. ALLERGIES: Multiple and include penicillin which causes a rash, sulfa which causes an unknown reaction, Seroquel which causes mouth sores, Macrobid which causes an unknown reaction, Zithromax which causes an unknown reaction.
OTC|over the counter|OTC|177|179|OUTPATIENT MEDICATIONS|9. Norvasc 2.5 mg p.o. q.a.m. 10. Zyrtec 10 mg p.o. q.h.s. 11. Astelin 5 mL, 2 sprays each nares b.i.d. 12. Acidophilus 1 p.o. daily. 13. Lysine 500 mg p.o. b.i.d. 14. Prilosec OTC 80 mg b.i.d. x 5 doses, then 40 mg p.o. b.i.d. 15. Toradol 2 mL IM p.r.n., maximum 4 tablets or 4 mL a day x 5 days.
OTC|over the counter|OTC|140|142|OUTPATIENT MEDICATIONS|10. Status post vertical banded gastroplasty with subsequent takedown. 11. Status post cholecystectomy. OUTPATIENT MEDICATIONS: 1. Prilosec OTC 20 mg p.o. b.i.d. 2. Nasacort HQ 1 to 2 sprays each nostril q.h.s. 3. Patanol 0.1% eyedrops 1 to 2 drops each eye b.i.d.
OTC|over the counter|OTC|273|275|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. GI issues as noted. 2. Chronic kidney disease creatinines over the past several months never been less than 1.5 mg/dl. 3. No known diabetes or hypertension, no use of cardiac meds. 4. She denies the use of nonsteroidal anti-inflammatories or other OTC pain medication. MEDICATIONS ON ADMISSION: 1. Octreotide Attai 25 mcg b.i.d.
OTC|over the counter|OTC|365|367|PLAN|X-rays again were reviewed with Dr. _%#NAME#%_. PLAN: I have discussed with this patient that she is not a surgical candidate at this time and that we should continue with conservative treatment and that she should follow up in the clinic with Dr. _%#NAME#%_ upon discharge which would be tomorrow. In the meantime I have stated that the patient should keep taking OTC anti- inflammatories and apply ice 3 times a day, no more than 20 minutes each time p.r.n. pain. I have discussed this plan with the patient. She states she understands and accepts this form of treatment.
OTC|over the counter|OTC|181|183|MEDICATIONS PRIOR TO ADMISSION|PAST MEDICAL HISTORY: Primarily remarkable for his orthopedic concerns. He has had previous hip arthroplasties, as well as bunionectomy. MEDICATIONS PRIOR TO ADMISSION: 1. Prilosec OTC 20 mg a day. 2. Feldene 20 mg a day. 3. Multivitamins. 4. Calcium. 5. Vitamin E. 6. Hydrocodone. ALLERGIES: No known drug allergies.
OTC|over the counter|OTC.|204|207|CURRENT MEDICATIONS|PAST MEDICAL HISTORY: Nephrolithiasis, chronic renal insufficiency, pacemaker placement, TURP, prostatic hypertrophy. CURRENT MEDICATIONS: 1. Coumadin, 5 mg a day. 2. Metoprolol, 50 mg a day. 3. Prilosec OTC. ALLERGIES: None. SOCIAL HISTORY: Married. Owns a business.
OTC|over the counter|OTC|133|135|MEDICATIONS|PAST MEDICAL HISTORY: 1. Depression. 2. Obesity. MEDICATIONS: 1. Seroquel 100 mg q.h.s. p.r.n. 2. Lamictal 200 mg q.h.s. 3. Claritin OTC p.r.n. ALLERGIES: Zithromax, amoxicillin. SOCIAL HISTORY: _%#NAME#%_ lives with her partner, and works as a load service representative for Well Fargo Bank.
OTC|over the counter|OTC|172|174|ADMISSION MEDICATIONS|3. History of social phobia. 4. History of panic disorder. 5. History of polysubstance abuse. 6. Asthma. ADMISSION MEDICATIONS: The patient was not taking any prescription OTC or herbal supplements prior to admission. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient smokes approximately 1/2 pack of cigarettes per day.
OTC|over the counter|OTC|164|166|ASSESSMENT|3. Weight loss, I suspect related to underlying depression. PLAN: 1. No medical intervention indicated. 2. I suspect her viral syndrome will resolve spontaneously. OTC decongestants could be used. 3. Her weight will probably improve with treatment of her depression.
OTC|over the counter|OTC,|424|427|PERTINENT PAST MEDICAL HISTORY|There was diverticulosis noted in the sigmoid colon. The patient had been told to abstain from any nonsteroidals after the procedure given the risk of bleeding, but the patient has been taking Aleve as well as aspirin. Other pertinent past medical history shows he has a history of pilonidal cyst resection in the past, history of Lasik surgery, history of gastroesophageal reflux disease which he is maintained on Prilosec OTC, has history of type 2 diabetes, history of hyperlipidemia, history of arthritis for which he takes Aleve. He also has a history of hypertension. HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old gentleman, very pleasant, presented to the emergency room yesterday with painless bright red blood per rectum.
OTC|over the counter|OTC|125|127|MEDICATIONS|1. Metformin 500 mg tablet p.o. b.i.d. 2. Norvasc 5 mg p.o. daily. 3. Aspirin 81 mg p.o. q. day. 4. Aleve p.r.n. 5. Prilosec OTC 1 tablet p.o. daily. 6. Lisinopril 40 mg p.o. daily. 7. Toprol 50 mg p.o. daily. 8. Simvastatin 40 mg p.o. daily.
OTC|over the counter|OTC|132|134|CURRENT MEDICATIONS|5. Claritin 10 mg p.o. daily. 6. Aspirin 325 mg p.o. daily. 7. Meclizine 25 mg p.o. daily. 8. Feldene 20 mg p.o. daily. 9. Prilosec OTC 20 mg p.o. daily. 10. Azmacort 100 mcg per actuation during inhalations b.i.d. 11. Bactroban 2% applied to affected area as directed. ALLERGIES: No known drug allergies.
OTC|over the counter|OTC|128|130|REVIEW OF SYSTEMS|She says they are frontal, occipital, and nuchal in location. She says they are related to stress and are partially relieved by OTC medications. She also complains of insomnia. She has also had several weeks of a cough, occasionally productive of a whitish sputum.
OTC|over the counter|OTC|202|204|REVIEW OF SYSTEMS|CHRONIC DISEASE/MAJOR ILLNESS: Denied. REVIEW OF SYSTEMS: He has headaches 3-4 times a week, they are frontal, temporal and retro-orbital in location and they can last for hours at a time. He has tried OTC medications without relief and headaches have been present for years and have not progressed. He has been having some swollen glands in his neck, which have also been present for many months without change.
OTC|over the counter|OTC|209|211|REVIEW OF SYSTEMS|PRIOR HOSPITALIZATIONS: None. CHRONIC DISEASE/MAJOR ILLNESSES: Has a history of lactose intolerance. REVIEW OF SYSTEMS: Positive for occasional headaches about every other week. Frontal pressure relieved with OTC analgesics. No other neurologic symptoms. He has diarrhea periodically related to dairy ingestion from his lactose intolerance. Has no history of sexually transmitted diseases. He has not been sexually active over the past year.
OTC|over the counter|OTC|248|250|PLAN|I suggested to the patient that she stays on a soft or full liquid diet today and I would advise her against smoking or drinking coffee or alcohol. She should not take any aspirin or Ibuprofen. We can see how things go. I asked her to use Prilosec OTC one table twice a day for the next few day and she will also use Maalox or Mylanta prn. I would expect her to do well. If necessary, she could call back and at that time we could consider looking in the esophagus if she continues have problems.
OTC|over the counter|OTC|147|149|MEDICATIONS|5. Fibromyalgia. MEDICATIONS: 1. Trileptal 900 mg h.s., which she takes for sleep. 2. Cymbalta 60 mg in the morning, and 60 mg at h.s. 3. Prilosec OTC 20 mg daily. 4. Flonase nasal spray 2 sniffs each nostril once daily. 5. Atrovent nasal spray t.i.d. 6. B12 injections monthly.
OTC|over the counter|OTC|144|146|MEDICATIONS ON ADMISSION|20. Anemia. MEDICATIONS ON ADMISSION: 1. Propafenone 150 mg p.o. t.i.d. 2. Lisinopril 2.5 mg p.o. q.d. 3. Toprol XL 50 mg p.o. q.d. 4. Prilosec OTC 20 mg p.o. q.d. 5. Centrum Silver one p.o. q.d. 6. Meclizine 25 mg p.o. q.d. 7. Allegra 180 mg p.o. q.d. 8. Ferrous gluconate 325 mg p.o. q.d. 9. Warfarin 2.5 mg on Tuesdays, Thursdays, Saturdays with 3.75 on Mondays, Wednesdays, Fridays and Sundays.
OTC|over the counter|OTC|142|144|MEDICATIONS PRIOR TO ADMISSION|4. Lisinopril 10 mg daily. 5. Metoprolol XL 50 mg daily. 6. K-tabs 10 mEq daily. 7. Zoloft 100 mg daily. 8. Celebrex 20 mg daily. 9. Prilosec OTC one daily. 10. Vicodin p.r.n. PAST MEDICAL HISTORY: Medical: 1. History of congestive heart failure with an ejection fraction of 40-45% in 2005.
OTC|over the counter|OTC|143|145|REQUESTING PHYSICIAN|Her echocardiogram showed well preserved systolic function, mild MR, ejection fraction 60%. She had been having symptoms of URI, had used some OTC nasal decongestants and Robitussin DM and it was thought that she may have had an episode of accelerated hypertension causing brief cardiac decompensation.
OTC|over the counter|(OTC)|165|169|MEDICATIONS|MEDICATIONS: 1. Prozac 20 mg t.i.d. 2. Detrol 2 mg b.i.d. 3. Butal prn for migraines (the patient reports that she has not had migraines in several years). 4. Advil (OTC) one to two tabs prn as needed for joint pain. ALLERGIES: 1. Lanolin 2. Adhesive tape used in surgeries.
OTC|over the counter|OTC|142|144|MEDICATIONS|He has been taking three tablets 3-4 times per day. ALLERGIES: No allergies. MEDICATIONS: List at this time includes Plavix, aspirin, Avapro, OTC Prilosec, Flonase, Zocor, Toprol, Proscar. PAST MEDICAL HISTORY: Surgeries include carpal tunnel and hernia. Medically he has been treated for organic heart disease, hyperlipidemia, reflux, prostatitis, DJD, and known diverticulosis.
OTC|over the counter|OTC|187|189|MEDICATIONS|ALLERGIES: No known drug allergies. MEDICATIONS: 1. Bactrim 1 tablet b.i.d. on Monday, Wednesday and Friday. 2. Calcium 500 mg 1 tablet daily. 3. Multivitamin 1 tablet daily. 4. Prilosec OTC 20 mg delayed-release tablet 1 tablet daily. REVIEW OF SYSTEMS: A 10-point review of systems is significant for requirement of glasses for corrective vision.
OTC|over the counter|OTC|122|124|ASSESSMENT/PLAN|7. Hypertension. 8. Hyperlipidemia. 9. Gallstone in place. 10. Dizziness, especially when he rolls in bed. I recommend an OTC meclizine. 11. Rheumatoid arthritis. 12. Elevated D-dimer, unknown significance. 13. Ongoing tobacco smoking in spite of our pleas to try and stop The patient discharged home and will follow up with me.
OTC|over the counter|OTC|139|141|ASSESSMENT|LABORATORY: As above. ASSESSMENT: 1. Major depressive disorder, recurrent, severe with PTSD. Details per Dr. _%#NAME#%_. 2. Tylenol PM and OTC sleep aid (question diphenhydramine) overdose without lingering clinical sequelae. No suggestion of acetaminophen toxicity. 3. Self cutting radial aspect of the left wrist.
OTC|over the counter|OTC|179|181|MEDICATIONS|6. Shortness of breath with activity attributed to her weight. 7. Possible sleep apnea. MEDICATIONS: 1. Synthroid 2. Avandia 3. Glimepiride. 4. Byetta. 5. Citalopram. 6. Prilosec OTC 7. Hydrochlorothiazide. ALLERGIES: Penicillin. PAST SURGICAL HISTORY: 1. Tonsils and adenoids removed in 1960.
OTC|over the counter|OTC.|271|274|REVIEW OF SYSTEMS|There is a question of whether she has sleep apnea and will be sent for a sleep study CARDIOVASCULAR: The patient denies any cardiovascular complaints or concerns or disease processes. GASTROINTESTINAL: The patient has had intermittent reflux disorder. She uses Prilosec OTC. She had an appendectomy in 1987. She also had a C-section one year before, no other gastrointestinal surgeries.
OTC|ornithine transcarbamoylase|OTC|322|324|PAST MEDICAL HISTORY|Her extremities are warm and well perfused. Laboratories reveals a normal hematocrit at 48.9, a platelet count of 295,000, a white count of 7.3. Her ammonia at admission was 190 mmol/L. This morning, it was 150 mmol/L. Repeat is pending. In summary, this is a 31-year-old woman with ornithine transcarbamylase deficiency. OTC is an X-linked disorder that in males presents with hyperammonemia shortly after birth. Females have variable courses depending on the level of X inactivation.
OTC|over the counter|OTC|136|138|MEDICATIONS|16. Accu-Chek prn 17. Aspirin 81 mg a day 18. Actos 15 mg daily 19. Albuterol meter dose inhaler 1-2 puffs q 4-6 hours prn 20. Prilosec OTC 20 mg 1 daily 21. DuoNeb currently on hold because of the Spiriva 22. Detrol LA 4 mg one daily 23. Topical Nystatin to lip corners daily
OTC|over the counter|OTC|178|180|ADMISSION MEDICATIONS|6. History of negative cardiac stress test and echocardiography approximately 2 months ago. PAST SURGICAL HISTORY: None. ADMISSION MEDICATIONS: 1. Celexa. 2. Ativan. 3. Prilosec OTC 20 mg 1 tab p.o. daily. 4. Glucosamine 500 mg 2 tabs p.o. b.i.d. 5. Flomax 0.4 mcg p.o. q.h.s. 6. Darvocet-N 100 one tab p.o. q.4 p.r.n. pain. 7. Levaquin 750 mg p.o. 1/2 tab q.a.m.
OTC|over the counter|OTC|77|79|MEDICATIONS|ALLERGIES: CODEINE, PERCOCET, TETRACYCLINE, FLAGYL. MEDICATIONS: 1) Prilosec OTC 20 mg p.o. q day. 2) Zofran p.r.n. 3) Rocephin 1 gm x 1. 4) Ceftin 300 mg p.o. b.i.d. x ten days, started _%#MM#%_ _%#DD#%_, 2005.
OTC|over the counter|OTC|130|132|CURRENT MEDICATIONS|1. Toprol XL 50 mg a day. 2. Lipitor 20 mg a day. 3. Hyzaar 50/12.5 one a day. 4. Aspirin 1 a day. 5. Multivitamin 1 a day. 6. No OTC medications. HABITS: Distant history of tobacco abuse, none x2 years.
OTC|over the counter|OTC|291|293|HISTORY OF PRESENT ILLNESS|He states as a child he had some type of skin condition of uncertain type which apparently had resolved for the most part, although states he has been quite prone to areas of dry skin over much of his life. The patient states that he has been trying to treat himself with different kinds of OTC lotions on a periodic basis, but has had no significant improvement. He denies fevers or chills. He does complain of poor sleep.
OTC|over the counter|OTC.|135|138|OUTPATIENT MEDICATIONS|ALLERGIES: The patient has allergies to codeine which causes nausea. OUTPATIENT MEDICATIONS: 1. Fosamax 70 mg p.o. weekly. 2. Prilosec OTC. 3. Darvocet p.r.n. 4. Naprosyn p.r.n. FAMILY HISTORY: The patient's family history is unable to be obtained due to the patient's retching.
OTC|over the counter|OTC|82|84|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 21-year-old female with a history of OTC drug abuse who was admitted to the hospital after she overdosed on 6 tablets of Dramamine. The patient was apparently confused, twitching, and disoriented after taking the Dramamine.
OTC|ornithine transcarbamoylase|OTC|197|199|MMC 185|As you know, this child has been hospitalized on multiple occasions for metabolic crisis related to the underlying genetic disorder ornithine transcarbamylase deficiency. Present since birth, this OTC condition is usually fatal or nearly so in the first few days of life. However, this little child has had relatively minor metabolic crises, thus far, which have required hospitalization and in comparison to the classic form of OTC deficiency, has been serious but not as severe as the most severe classic forms.
OTC|over the counter|OTC,|616|619|MEDICATIONS|PAST MEDICAL HISTORY: Rather complicated. She has a long-standing history of hypertension, coronary vascular disease for which she has had two stents, questionable previous stroke with a confusional episode in 2003 which led to hospitalization, right total knee arthroplasty, diffuse degenerative joint disease, including degenerative joint disease of the spine, osteoarthritis, diverticulosis of the colon, bladder surgery, chronic low back pain and chronic sciatica for which is she is on chronic pain medications. ALLERGIES: The patient has no known medication allergies. MEDICATIONS: She is on Fosamax, Prilosec OTC, metoprolol, multivitamins, Lipitor, trazodone, a baby aspirin a day, calcium, hydrocodone, cyclobenzaprine, NitroQuick, and fentanyl patch. REVIEW OF SYSTEMS: This was obtained from the family. The patient did not have any significant complaints lately, other than her usual complaints related to her chronic conditions described above.
OTC|over the counter|OTC.|180|183|MEDICATIONS|PAST MEDICAL HISTORY: Past history is limited, although he has had a previous hernia repair and significant mental health history. MEDICATIONS: 1. Lithium. 2. Zyprexa. 3. Prilosec OTC. 4. Ambien. 5. Tramadol ER. ALLERGIES: Diazepam. PHYSICAL EXAMINATION: The patient is currently alert and oriented, in no apparent distress, sitting comfortably in bed.
OTC|over the counter|OTC|105|107|MEDICATIONS|2. Aspirin 81 mg p.o. q. day. 3. Lisinopril 20 mg p.o. q. day. 4. Metoprolol 50 mg p.o. b.i.d. 5. Niacin OTC 100 mg p.o. b.i.d. 6. He is now on IV diltiazem as well. He has not received heparin. REVIEW OF SYSTEMS: Complete review of systems was performed and is negative except as noted above in history of present illness.
OTC|over the counter|OTC|114|116|ADMISSION MEDICATIONS|2. Aspirin 325 mg 1 tab p.o. daily. 3. Multivitamin. 4. Nicoderm 21 mg every 24 hours, 1 patch daily. 5. Prilosec OTC 20 mg 1 tab p.o. daily. 6. Inderal LA 60 mg 1 tab p.o. daily. 7. Geodon. 8. Ativan. 9. Folate 1 mg 1 tab p.o. daily.
OTC|ornithine transcarbamoylase|OTC|129|131|LABORATORY DATA|She had ketones in her urine upon admission. Urine organic acids are pending. She has been seen by Metabolic Genetics, who think OTC partial deficiency is unlikely but needs to be excluded. IMPRESSION: 1. Normal developmental neuro exam for age. 2. A second episode of recurrent vomiting in the setting of chronic constipation.
OTC|ornithine transcarbamoylase|OTC,|110|113|IMPRESSION|We did suggest an ammonia level on the rare chance that she could have a variant of urea cycle defect such as OTC, but that also seems unlikely. I would not repeat her imaging or other neurological studies at this point unless there is a major change in her clinical course.
OTC|over the counter|OTC|176|178|PAST MEDICAL HISTORY|She has had no problems with vision. _%#NAME#%_ has no known drug allergies. _%#NAME#%_ is receiving no allopathic medication at the present time and she receives no herbal or OTC medications. Aside from the above, a complete review of systems was negative. _%#NAME#%_ ambulated independently and verbalized at the expected ages. _%#NAME#%_ is currently in the 1st grade.
OTC|over the counter|OTC|282|284|SUMMARY OF CASE|She is currently on Epivir 300 mg daily, Effexor XR 150 mg daily, Mycobutin 150 mg Tuesday, Thursdays and Saturdays, Vicodin every six hours on a p.r.n. basis for break-through pain, lorazepam 0.5 mg every 4 hours p.r.n. anxiety, agitation and sleep disturbance. She takes Prilosec OTC 20 mg per day. She is on a Fentanyl patch 50 mcg every three days, Lexapro 20 mg daily, Levaquin 250 mg daily, fluconazole 100 mg daily and Fuzeon 40 mg subcu every 12 hours also for HIV disease.
OTC|over the counter|OTC|153|155|ADMISSION MEDICATIONS|10. Risperdal 2 mg po q hs. 11. Ventolin inhaler qid. 12. Dilantin 200 mg po bid. 13. Azmacort inhaler two puffs bid. 14. Nephrocaps daily. 15. Prilosec OTC 20 mg po daily. PAST MEDICAL HISTORY: 1. Systemic lupus erythematosus-complicated lupus nephritis with end stage renal disease on hemodialysis.
OTC|over the counter|OTC.|195|198|ASSESSMENT/PLAN|I suggested to her that she take her Duonebs q.4h as needed for shortness of breath, continue the Advair inhaler once daily. I told her to take an expectorant such as Robitussin-DM as prescribed OTC. Will give empiric antibiotic doxycycline 100 mg twice daily with food for seven days. She was able to tolerate that, although with some stomach upset.
OTC|over the counter|OTC|195|197|HISTORY OF PRESENT ILLNESS|The patient is an IV drug user and has been admitted for suicidal ideation as well as depression as well as having a known MRSA infection in his arm. The patient has been injecting apparently an OTC medication that he has broke out on the caplets called Sominex. He has not been taking any of his psychiatric medications that he has been on in the past.
OTC|over the counter|OTC|111|113|ADMISSION MEDICATIONS|2. Lantus 20 units q.h.s. 3. Lipitor 40 mg q.a.m. 4. Lisinopril 5 mg q.a.m. 5. Plavix 75 mg q.a.m. 6. Prilosec OTC 20 mg q.h.s. 7. Toprol 50 mg twice a day. ALLERGIES: 1. Aspirin. 2. Iodine. 3. Shell fish for which the patient has an anaphylactic reaction.
OTC|over the counter|OTC|117|119|MEDICATIONS|MEDICATIONS: 1. Hytrin 5 mg p.o. daily. 2. Nasonex spray 1 to 2 puffs in each naris q.a.m. p.r.n. 3. Sudafed 12-hour OTC 1 tablet p.o. daily. The patient may have overlapped this dose last night and this morning. 4. Citrucel p.r.n. 5. Ibuprofen 200 mg 3 tablets q.4-6 hours p.r.n.
OTC|over the counter|OTC|177|179|CURRENT MEDICATIONS|ALLERGIES: Penicillin and aspirin. SOCIAL HISTORY: Does not smoke. CURRENT MEDICATIONS: The patient is on: 1. Roxitrol 10 mg once a day. 2. Lipitor 10 mg once a day 3. Prilosec OTC once daily. 4. Xanax 0.5 mg 1 tablet q.i.d. as needed for anxiety. 5. Folic acid. 6. Vitamin C. 7. Glucosamine/chondroitin. REVIEW OF SYSTEMS: CONSTITUTIONAL: Fever as mentioned above.
OTC|over the counter|OTC|133|135|MEDICATIONS|2. Neurontin 300 t.i.d. 3. Avandia 4 q.d. 4. Norvasc 5 q.d. 5. Ditropan XL 10 q.d. 6. Lasix 40 q.d. 7. Motrin 600 t.i.d. 8. Prilosec OTC 20 q.d. 9. Darvocet-N 100 one to two p.r.n. 10. Cardura 2 q.d. 11. Atenolol 50 q.d. ALLERGIES: No history of medication allergies or intolerances.
OTC|over the counter|OTC|132|134|MEDICATIOINS PRIOR TO ADMISSION|4. Benign prostatic hypertrophy 5. Coronary artery disease with recent stenting of LAD MEDICATIOINS PRIOR TO ADMISSION: 1. Prilosec OTC 20 mg daily. 2. Aspirin 81 mg a day 3. Motrin 600 mg prn 4. Glucosamine 500 mg a day 5. Benicar 40 mg every day 6. Plavix 75 mg every day
OTC|over the counter|OTC|189|191|REVIEW OF SYSTEMS|CHRONIC DISEASE/MAJOR ILLNESSES: History of ADD, otherwise, denied. REVIEW OF SYSTEMS: Has occasional headaches that are nuchal in location. They occur once a month. They are relieved with OTC medications. He is sexually active. He has had three partners in the past year. He uses condoms. He has no history or symptoms of STDs.
OTC|over the counter|OTC|204|206|MEDICATIONS ON ADMISSION|FAMILY HISTORY: Noncontributory. MEDICATIONS ON ADMISSION: 1) Advair 250/50 one puff b.i.d. 2) Spiriva one puff q day. 3) Lisinopril 10 mg p.o. q day. 4) Hydrochlorothiazide 25 mg p.o. q day. 5) Prilosec OTC 30 mg p.o. q day. 6) Verapamil SR 240 mg p.o. q day. LABORATORY DATA: Chest x-ray shows a diffuse left-sided upper/lower lobe infiltrate with a right lower lobe infiltrate which is new.
OTC|over the counter|OTC|129|131|OUTPATIENT MEDICATIONS|3. Flonase 0.05 two sprays each naris daily. 4. Lexapro 20 mg p.o. daily. 5. Remeron 15 mg p.o. each day at bedtime. 6. Prilosec OTC 20 mg p.o. daily. ALLERGIES: No known drug allergies. SOCIAL HISTORY AND FAMILY HISTORY: Reviewed and per documentation on FCIS.
OTC|over the counter|OTC|160|162|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: She has been bothered by longstanding headaches. They are frontal and occipital in location. Pressure sensation intermittently relieved with OTC medication. She has lost 10 pounds over approximately 2 months. No other GI complaints. She has regular periods. Her last period was a week ago.
OTC|over the counter|OTC.|200|203|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: HEENT: The patient is nearsighted. CARDIORESPIRATORY: Negative. GASTROINTESTINAL: See history of present illness. The patient does have reflux symptoms and is currently on Prilosec OTC. GENITOURINARY: There had been a history of a fistula from the pouch to the bladder treated years ago, no hematuria. No prostate difficulty. SKIN: Negative. ENDOCRINE: Negative. HEMATOLOGIC: Negative. NEUROPSYCHIATRIC: Unremarkable.
OTC|over the counter|OTC|127|129|OUTPATIENT MEDICATIONS|She does have family members checking in on her frequently. ALLERGIES: None known to date. OUTPATIENT MEDICATIONS: 1. Prilosec OTC 1 tab daily. 2. Lumigan eyedrops daily. 3. Timolol eye drops daily. 4. Multivitamin daily. 5. An unknown antibiotic for her recent lung infiltrate.
OTC|over the counter|OTC.|172|175|HISTORY OF PRESENT ILLNESS|He has ongoing shortness of breath and dyspnea on exertion, but this has been stable. He denies any sick contacts. He denies any NSAID use. He takes an occasional Prilosec OTC. He is also on Percocet and Compazine. In the Emergency Department he was found to have acute renal failure, coagulopathy, significant leukocytosis and a hemoglobin of 12.
OTC|over the counter|OTC,|104|107|MEDICATIONS|Father has peptic ulcer disease and is alive. ALLERGIES: No known drug allergies. MEDICATIONS: Prilosec OTC, Kytril, Compazine and Percocet, all p.r.n. SOCIAL HISTORY: He is single, lives alone and is followed by Dr. _%#NAME#%_ _%#NAME#%_ and his primary oncologist Dr. _%#NAME#%_.
OTC|over the counter|OTC|133|135|MEDICATIONS|MEDICATIONS: 1. Fentanyl 150 mcg patch. 2. Prozac 40 mg p.o. b.i.d. 3. Lamictal 100 mg b.i.d. 4. Trazodone 150 mg daily. 5. Prilosec OTC daily. 6. Neurontin 1200 mg 3 times daily. 7. Lovenox 40 mg subcutaneously daily for a period of 21 days since the diagnosis of superficial thrombophlebitis.
OTC|over the counter|OTC|124|126|MEDICATIONS|ALLERGIES: The patient is not allergic to any medications. MEDICATIONS: 1. Vytorin 10/40 mg 1 tablet every day. 2. Prilosec OTC 20 mg a day. 3. Ventolin HFA 2 puffs 4x a day as needed. 4. Valium 5 mg 1 tablet at night. 5. Xopenex HFA 45 mcg 2 puffs 4x a day as needed for wheezing.
OTC|over the counter|OTC|127|129|ADMISSION DIAGNOSIS|8. MaxiGamma, over-the-counter medication, 2 capsules once daily. 9. Omega T OTC 3 capsules once daily. 10. Antioxidant factor OTC 2 capsules once daily. 11. Vitamin C 500 mg p.o. q.i.d. 12. Gymnema Silvestre 450 mg OTC once daily. 13. Calcium with vitamin D OTC 100 mg every day.
OTC|over the counter|OTC|112|114|ADMISSION DIAGNOSIS|10. Antioxidant factor OTC 2 capsules once daily. 11. Vitamin C 500 mg p.o. q.i.d. 12. Gymnema Silvestre 450 mg OTC once daily. 13. Calcium with vitamin D OTC 100 mg every day. 14. Chromium picolinate 200 mcg OTC p.o. t.i.d. 15. Magnesium oxide OTC 250 mg q.i.d.
OTC|over the counter|OTC|155|157|ADMISSION DIAGNOSIS|10. Antioxidant factor OTC 2 capsules once daily. 11. Vitamin C 500 mg p.o. q.i.d. 12. Gymnema Silvestre 450 mg OTC once daily. 13. Calcium with vitamin D OTC 100 mg every day. 14. Chromium picolinate 200 mcg OTC p.o. t.i.d. 15. Magnesium oxide OTC 250 mg q.i.d. 16. Soy isoflavone OTC 1 tablet b.i.d. 17. Enalapril 5 mg p.o. b.i.d.
OTC|over the counter|OTC|126|128|ADMISSION DIAGNOSIS|12. Gymnema Silvestre 450 mg OTC once daily. 13. Calcium with vitamin D OTC 100 mg every day. 14. Chromium picolinate 200 mcg OTC p.o. t.i.d. 15. Magnesium oxide OTC 250 mg q.i.d. 16. Soy isoflavone OTC 1 tablet b.i.d. 17. Enalapril 5 mg p.o. b.i.d.
OTC|over the counter|OTC|302|304|ALLERGIES|Humalog sliding scale is going to be for 150-180 mg/dL blood glucose the patient will inject 0.5 units of Humalog; at 181-200 mg/dL of blood glucose the patient will inject 1 unit; and anything over 250, the patient will inject 1.5 units and to call. 8. MaxiGamma OTC 2 capsules once daily. 9. Omega T OTC 3 capsules once daily. 10. Antioxidant factor OTC 2 capsules once daily. 11. Vitamin C 500 mg OTC p.o. q.i.d. 12. Gymnema Silvestre OTC 450 mg daily. 13. Calcium with vitamin D OTC 100 mg daily.
OTC|over the counter|OTC|187|189|ALLERGIES|8. MaxiGamma OTC 2 capsules once daily. 9. Omega T OTC 3 capsules once daily. 10. Antioxidant factor OTC 2 capsules once daily. 11. Vitamin C 500 mg OTC p.o. q.i.d. 12. Gymnema Silvestre OTC 450 mg daily. 13. Calcium with vitamin D OTC 100 mg daily. 14. Chromium picolinate OTC 200 mcg 3 times a day.
OTC|over the counter|OTC|196|198|ALLERGIES|10. Antioxidant factor OTC 2 capsules once daily. 11. Vitamin C 500 mg OTC p.o. q.i.d. 12. Gymnema Silvestre OTC 450 mg daily. 13. Calcium with vitamin D OTC 100 mg daily. 14. Chromium picolinate OTC 200 mcg 3 times a day. 15. Magnesium oxide OTC 250 mg q.i.d. 16. Soy isoflavone OTC 1 tablet twice a day.
OTC|over the counter|OTC|156|158|ALLERGIES|12. Gymnema Silvestre OTC 450 mg daily. 13. Calcium with vitamin D OTC 100 mg daily. 14. Chromium picolinate OTC 200 mcg 3 times a day. 15. Magnesium oxide OTC 250 mg q.i.d. 16. Soy isoflavone OTC 1 tablet twice a day. 17. Enalapril 5 mg 1 tablet twice a day.
OTC|over the counter|OTC|193|195|ALLERGIES|12. Gymnema Silvestre OTC 450 mg daily. 13. Calcium with vitamin D OTC 100 mg daily. 14. Chromium picolinate OTC 200 mcg 3 times a day. 15. Magnesium oxide OTC 250 mg q.i.d. 16. Soy isoflavone OTC 1 tablet twice a day. 17. Enalapril 5 mg 1 tablet twice a day. 18. Aspirin 81 mg p.o. daily. 19. Primrose oil OTC 1000 mg once daily.
OTC|over the counter|OTC|171|173|FOLLOW UP|15. Magnesium oxide OTC 250 mg q.i.d. 16. Soy isoflavone OTC 1 tablet twice a day. 17. Enalapril 5 mg 1 tablet twice a day. 18. Aspirin 81 mg p.o. daily. 19. Primrose oil OTC 1000 mg once daily. 20. Debacterol 1 swab, apply directly to oral aphthous ulcer as needed. 21. Fosamax 70 mg once daily. 22. Enoxaparin 30 mg subcutaneously today and then b.i.d.
OTC|over the counter|OTC|175|177|PAST MEDICAL HISTORY|9) Women's ultra megavitamins. 10) Calcium 2,000 mg daily split with meals. 11) Vitamin C 500 mg daily. 12) Vitamin D 50,000 I.U. q Saturday. 13) Forteo injections q day. 14) OTC potassium occasionally p.r.n. charliehorses at night. 15) In the past the patient was on Combivent two puffs q.i.d. and albuterol metered-dose inhaler p.r.n. ILLNESSES: 1) Hyperlipidemia.
OTC|over the counter|OTC|188|190|REVIEW OF SYSTEMS|After the hip replacement her back pain worsened quite a bit. She has done physical therapy. She occasionally gets a nighttime charliehorse in her left leg that seems to be relieved by an OTC potassium taken p.r.n. Yesterday she saw one of her physicians, who diagnosed a right greater trochanteric bursitis resulting from a fall in _%#MM#%_.
OTC|over the counter|OTC|181|183|MEDICATIONS UPON TRANSFER|11. Propofol titrate for sedation. 12. Normal saline at 25 mL per hour. 13. Nicotine patch 21 mg per 24 hours. 14. Lorazepam 1 mg IV p.r.n. for agitation. 15. No reported herbal or OTC medicines. SOCIAL HISTORY: The patient currently lives in _%#ADDRESS#%_ _%#ADDRESS#%_, which is located approximately 300 miles outside of _%#CITY#%_ _%#CITY#%_ area.
OTC|over the counter|OTC,|202|205|REVIEW OF SYSTEMS|She does have perennial rhinitis symptoms which are now reasonably controlled with Claritin, but have not always been controlled with that in the past. She, also, for her GERD symptoms, has used Pepcid OTC, but because of financial problems has not recently been able to afford that although reports not having a lot of GERD symptoms recently.
OTC|over the counter|OTC|94|96|CURRENT MEDICATIONS|4. Status post total abdominal hysterectomy for menorrhagia. CURRENT MEDICATIONS: 1. Prilosec OTC one tablet daily times five days. 2. Celebrex 200 mg p.o. daily. 3. Meridia 50 mg p.o. daily. 4. Ibuprofen in doses exceeding 800 mg t.i.d. which the patient was taking regularly through _%#MM#%_ _%#DD#%_.
OTC|over the counter|OTC|121|123|CURRENT MEDICATIONS|7. Olanzapine 15 mg q.h.s. 8. One multivitamin per day. 9. Sodium bicarbonate 650 mg tablets, 3 tablets twice a day. 10. OTC "Joint Advantage." 11. Tylenol as needed. SOCIAL HISTORY: She lives with her husband. She does not smoke. Her first husband did smoke. She has not drunk alcohol since her kidney disease was diagnosed.
OTC|over the counter|OTC|135|137|MEDICATIONS AT THE TIME OF ADMISSION|1. Remeron 37.5 each day at bedtime. 2. Aspirin 81 mg daily. 3. Multivitamin 1 per day. The patient states that she takes no herbal or OTC medications. SOCIAL HISTORY: The patient reports she did not smoke tobacco, consume alcohol or ingest other substances, which may be illegal.
OTC|over the counter|OTC|166|168|DISCHARGE MEDICATIONS|5. Insulin resistance. 6. Right tib fib fracture. 7. Nephrogenic diabetes insipidus. DISCHARGE MEDICATIONS: 1. Calcium chloride (Tums) 1 gm p.o. twice a day. May use OTC chewable tablets. 2. Tylenol 650 mg p.o. every four hours as needed for pain. FOLLOW UP: 1. With primary physician, Dr. _%#NAME#%_ _%#NAME#%_ on _%#DDMM2004#%_.
OTC|over the counter|OTC|131|133|FAMILY HISTORY/SOCIAL HISTORY|He has a 40 pack year history of tobacco use, but quit smoking in 1998. He has only rare social alcohol consumption. He denies any OTC or complimentary herbal medication use. There is no illegal substance use. Family history shows his mother deceased at age 69 from liver disease related to transfusion.
OTC|over the counter|OTC|189|191|RECENT MEDICATIONS|RECENT MEDICATIONS: 1. Prednisone 20 mg p.o. b.i.d. as part of a slow taper. 2. Ambien 10 mg p.o. each day at bedtime p.r.n. 3. Jantoven 5 mg p.o. daily. 4. Advair twice daily. 5. Prilosec OTC 2 tablets p.o. daily. 6. Albuterol nebs q.i.d. p.r.n. 7. Wellbutrin-SR 300 mg p.o. daily. FAMILY HISTORY: The patient's mother apparently had colon cancer and his father had diabetes.
OTC|over the counter|OTC|296|298|PAST MEDICAL HISTORY|On recent stress testing prior to surgery he had an area of small change noted by Dr. _%#NAME#%_ of Fairview Southdale Cardiology Service. He was subsequently started on Toprol XL 12.5 mg daily and has follow up scheduled. 3. Benign prosthetic hypertrophy. The patient currently is on Flomax and OTC saw palmetto. 4. Hyperlipidemia. He is currently on Crestor 20 mg daily at bedtime. 5. Health maintenance. He currently is on Protonix for GI protection as well as vitamin D and 81 mg chewable tablets of aspirin.
OTC|over the counter|OTC|182|184|DISCHARGE MEDICATIONS|11. Xanax 0.25 mg p.o. t.i.d. as needed for severe anxiety only. 12. Protonix 40 mg p.o. daily. (If the Protonix is not covered substitute omeprazole 20 mg p.o. daily). 13. Prilosec OTC 20 mg daily. 14. Prevacid 30 mg p.o. daily or whatever suitable formulary substitution. 15. Florastore 500 mg b.i.d. x2 months. 16. Lactobacillus 1 p.o. b.i.d. x2 months.
OTC|over the counter|OTC|257|259|CURRENT MEDICATIONS|Review of his medication record at Smiley's revealed that he also takes a prenatal vitamin with folate once daily, uses ketoconazole shampoo 2% p.r.n. and uses loperamide 2 mg p.r.n. loose stools. The patient denies any herbal medications and is not taking OTC such as Tylenol or Motrin. REVIEW OF SYSTEMS: The patient admits to low energy and some numbness and tingling in the left hand and ulnar distribution, which is worse with position change.
OTC|over the counter|OTC|118|120|CURRENT MEDICATIONS|1. Lipitor 10 mg q. day. 2. Toprol XL 50 mg p.o. b.i.d. 3. Diovan 80 mg q. day. 4. Fosamax 70 mg q. week. 5. Prilosec OTC 20 mg q. day. 6. Vitamins. PAST MEDICAL HISTORY: 1. Chest pain, diagnosed as pleurisy in 1990, in _%#CITY#%_, Washington.
OTC|over the counter|OTC,|133|136|MEDICATIONS ON ADMISSION|2. Enteric-coated aspirin, 325 mg q. day. 3. Certagen Senior tablet, one p.o. q. day. 4. Ferrous sulfate, 325 mg q. day. 5. Prilosec OTC, 20 mg with supper q. day. 6. Tylenol, 325 mg p.r.n. 7. Trazodone, 50 mg, one-half tablet q. evening; 50 mg tablet p.o. q. morning. 8. Furosemide, 80 mg b.i.d.
OTC|over the counter|OTC.|190|193|CURRENT MEDICATIONS|ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: 1. Lisinopril. 2. Atenolol. 3. HCTZ. 4. Norvasc. 5. Isosorbide. 6. Voltaren. 7. Aspirin. 8. Multivitamin. 9. Vitamin C. 10. Prilosec OTC. 11. Nitrostat p.r.n. REVIEW OF SYSTEMS: A 12-system review was conducted and is pertinently positive as per HPI.
OTC|over the counter|OTC|181|183|PAST MEDICAL HISTORY|6. Fibromyalgia. Treated with regular exercise. 7. History of gastroesophageal reflux disease with EGD 2004 demonstrating small hiatal hernia and gastritis. Presently maintained on OTC Prilosec for GI upset (epigastric discomfort) attributed to prednisone. 8. Idiopathic hypersomnolence on long acting Ritalin. 9. History of renal calculus disease x2.
OTC|over the counter|OTC|217|219|REVIEW OF SYSTEMS|Intermittent dyspnea with peak flow in the 250 range. Not yet back to baseline. No palpitations. Denies nausea, vomiting, or dyspepsia. Did have epigastric burning and nausea attributed to prednisone. Controlled with OTC Prilosec. Denies diarrhea or constipation. No signs of GI blood loss. No voiding complaints. Last menses ended 2 days ago. No rash.
OTC|over the counter|OTC|118|120|CURRENT MEDICATIONS|4. Prednisone 10 mg p.o. every day. 5. Darvocet N100, 1 to 2 p.o. q.6 h. 6. Temazepam 15 mg q.h.s. p.r.n. 7. Prilosec OTC 20 mg p.o. every day. 8. Ibuprofen 400 mg p.o. three times a day. 9. An eye drop for her glaucoma. 10. Ocuvite. 11. Calcium supplement, dose could not be obtained.
OTC|over the counter|OTC|227|229|RECOMMENDATIONS|4. Low sodium diet, which has already been started. 5. Recommend EGD and will do this in the morning since the patient has eaten today. 6. The patient also needs to be on long-term PPIs and I will fax this in for her, Prilosec OTC which should be less expensive for her. She does have good drug coverage. 3. The patient does have a low-grade temps and I agree with the use of covering antibiotics for SBP.
OTC|over the counter|OTC|155|157|MEDICATIONS ON ADMISSION|12. Tylenol 500 to 1000 tid 13. Xalatan Ophthalmic drops hs 14. Propoxyphene 65 mg prn 15. Nitroglycerin 0.4 prn 16. Advair Diskus 250/50 bid 17. Prilosec OTC q d 18. Gaviscon prn ALLERGIES: SHE NOTES ALLERGIES OR INTOLERANCES TO PENICILLIN DUE TO A RASH, SOME OTHER ANTIBIOTIC WHICH MAYBE CLARITHROMYCIN, WHICH GAVE HER DIARRHEA.
OTC|over the counter|OTC|196|198|REVIEW OF SYSTEMS|He denies any sore throat, dysphagia or esophageal symptomatology. He denies any stiff neck. He reports a chronic daily headache, which is described as bifrontal to vertex and is nonresponsive to OTC medications. It is not associated with nausea, photophobia, phonophobia and he does not feel that it is related to his lifestyle and more likely is related to the events.
OTC|over the counter|OTC|164|166|DISCHARGE MEDICATIONS|DISCHARGE DIAGNOSES: 1. Gastrointestinal bleed, source unknown. 2. Duodenal erosion. 3. History of alcoholism. 4. Kidney stones. DISCHARGE MEDICATIONS: 1. Prilosec OTC 1 b.i.d. 2. Start iron 1 b.i.d. Avoid NSAIDs and aspirin. He will follow up for a physical. He will setup his outpatient colonoscopy.
OTC|over the counter|OTC|147|149|CONTINUE PREVIOUS MEDICATIONS AT HOME|3. Lisinopril 10 mg p.o. daily. 4. Toprol XL 50 mg p.o. daily. 5. Robaxin 740 mg p.o. daily p.r.n. 6. Lasix at regular home regimen. 7. Folic acid OTC 1 tab p.o. daily. PROCEDURES IN HOSPITAL: None. HISTORY OF PRESENT ILLNESS: The patient presented with painful left lower extremity to the ER.
OTC|over the counter|OTC|211|213|DISCHARGE MEDICATIONS|4. Thyroid replacement 90 mg p.o. q. day (the exact formulation is unknown but this is the dose that she has been taking). 5. Enteric-coated aspirin 81 mg p.o. daily. 6. Labetalol 100 mg p.o. b.i.d. 7. Prilosec OTC 20 mg p.o. q. day as needed. 8. Nitroglycerin 0.4 mg sublingual as needed for chest pain.
OTC|over the counter|OTC|116|118|MEDICATIONS|Her son or grandson and husband are present with her in the patient room. ALLERGIES: None. MEDICATIONS: 1. Prilosec OTC 1 p.o. b.i.d. 2. Fosamax 70 mg p.o. q. Sunday. 3. Maxzide 37.5/25 q. day. 4. Lipitor 20 mg p.o. q. day. 5. Os-Cal 500 mg q. day.
OTC|over the counter|OTC|150|152|DISCHARGE MEDICATIONS|1. Lipitor 20 mg daily. 2. Glucophage XR 500 mg daily in the p.m. 3. Aspirin 81 mg daily. 4. Tylenol prn pain. 5. Lisinopril 10 mg daily. 6. Prilosec OTC 20 mg daily prn GERD or recurrent atypical chest pain symptoms to assess for possible esophageal spasm component. DISCHARGE INSTRUCTIONS: 1. The patient will maintain a diabetic, low cholesterol diet and will follow up with Dr. _%#NAME#%_ _%#NAME#%_ in weeks' time.
PAC|physician assistant certification|PAC|43|45|DOB|DOB: _%#DDMM1914#%_ _%#NAME#%_ _%#NAME#%_, PAC dictating for _%#NAME#%_ _%#NAME#%_, M.D. CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a delightful 80- year-old female who had presented to Fairview Ridges Hospital with some complaints of burning chest discomfort that had started on Sunday.
PAC|premature atrial contraction|PAC|158|160|PHYSICAL EXAMINATION|PSYCH: The patient is awake, alert and oriented X 3. Electrocardiogram compared with _%#MMDD#%_, there is no significant change. She is sinus rhythm with one PAC and non-specific STT wave changes along with LVH. Rhythm strip obtained in the Emergency Department does show frequent PAC's.
PAC|premature atrial contraction|(PAC).|149|154|EKG|White count 6.0, hemoglobin 15.2, platelets 237. Troponin less than 0.07. INR 1.07. EKG: EKG reveals sinus rhythm with premature atrial contractions (PAC). No ischemic changes. CHEST X-RAY: Chest x-ray is unremarkable. ASSESSMENT/PLAN: This is a 70-year-old with recent angiogram and angioplasty presenting with chest pain.
PAC|premature atrial contraction|(PAC).|232|237|ASSESSMENT/PLAN|The other possibility is that this could be muscular pain as he did have pain upon palpation of his chest. 2. History of atrial fibrillation. a. He appears to be currently in sinus rhythm with frequent premature atrial contractions (PAC).
PAC|physician assistant certification|PAC|158|160|DISCHARGE FOLLOW-UP|DISCHARGE DISPOSITION: This patient will be discharged to home in the care of his family. DISCHARGE FOLLOW-UP: 1. The patient will see _%#NAME#%_ _%#NAME#%_, PAC at Minnesota Heart Clinic on Tuesday, _%#MM#%_ _%#DD#%_, 2005 at the _%#CITY#%_ Clinic at 02:30 p.m. 2. He will follow up with Dr. _%#NAME#%_ and have a thallium stress test in approximately six months' time.
PAC|premature atrial contraction|PAC.|306|309|LABORATORY STUDIES|LABORATORY STUDIES: His troponin is less than 0.07, myoglobin is 202, white count is 14.2, hemoglobin is 17.4, platelets are 204, INR is 1.04, electrolytes are normal, BUN is 17, creatinine is 0.95, CK is 276, urinalysis is unremarkable. EKG shows a normal sinus rhythm with a rate of 84 with one isolated PAC. There is evidence of left ventricular fascicular block. Chest x-ray shows a left clavicle fracture. There are clavicle x-rays again showing the fracture. Head CT shows a focal bleed in the right frontal lobe as well as other small bleeds on the right at the mid medial margin of the falx and another at the left side of the falx slightly more posterior and another small adjacent focus more posterior.
PAC|physician assistant certification|PAC|153|155|DISCHARGE INSTRUCTIONS|Electrolytes, BUN and creatinine every week, along with a CBC. She is to follow up with Dr. _%#NAME#%_ in a month, follow up with _%#NAME#%_ _%#NAME#%_, PAC in a week, and repeat her echocardiogram early _%#MM#%_ with a pacemaker check at that time. She is to get PT/OT, follow a low-fat, low-cholesterol, low-sodium diet.
PAC|premature atrial contraction|PAC,|162|165|HOSPITAL COURSE|She was continued on lisinopril for the hypertension and Crestor for hyperlipidemia without adverse event. She was also continued on diltiazem for her history of PAC, but remained in sinus rhythm during hospitalization. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. daily. 2. Lisinopril 10 mg p.o. daily.
PAC|premature atrial contraction|PAC.|237|240|PHYSICAL EXAMINATION|ABDOMEN: Benign. GU: Testicles are descended without masses. Prostate exam was not done as this was done in _%#MM#%_ and was fine. EXTREMITIES: No edema. EKG showed normal sinus rhythm, Q wave in III but no ST-T wave changes. Occasional PAC. Hemoglobin 12.7, potassium pending as is creatinine. IMPRESSION: This is a 78-year-old gentleman seen preoperatively.
PAC|premature atrial contraction|PAC.|164|167|HOSPITAL COURSE|His QT intervals were acceptable. He underwent electrical cardioversion on _%#DDMM2002#%_, and converted to sinus rhythm. He maintained sinus rhythm with one block PAC. His QT interval was 0.44. His Coumadin level varied between 1.8 and 2.0. He should maintain Coumadin at a level of 2.0 to 3.0 for at least two months, to prove that he will maintain sinus rhythm, at which time we can entertain discontinuing the Coumadin.
PAC|premature atrial contraction|(PAC).|198|203|HISTORY OF PRESENT ILLNESS|When she aroused she was not confused. There was no loss of urine or stool. EKG at _%#CITY#%_ Memorial Hospital emergency room showed normal sinus rhythm with frequent premature atrial contractions (PAC). CAT scan of the head showed cerebral atrophy, otherwise was negative. Urinalysis showed 5-10 WBC, 2+ bacteria, positive nitrite. She was treated for bladder infection and observed overnight and released the following day after an uneventful hospital stay.
PAC|premature atrial contraction|(PAC)|196|200|EKG|Troponin is negative. Liver function tests show an alkaline phosphatase 235, ALT 19, AST 31, albumin 4.0. EKG: EKG reveals sinus rhythm. No ischemic changes. Probable premature atrial contraction (PAC) with aberrancy. CHEST X-RAY: Chest x-ray shows a probable right lower lobe atelectasis versus infiltrate.
PAC|physician assistant certification|PAC|128|130|SURGEON|PROCEDURE: Laparoscopy, open Roux-en-Y on _%#DDMM2005#%_. SURGEON: Dr. _%#NAME#%_ _%#NAME#%_. ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC SECOND PROCEDURE: _%#DDMM2005#%_ Re-exploration for gastric pouch leak.
PAC|physician assistant certification|PAC.|71|74|ASSISTANT|SURGEON: _%#NAME#%_ _%#NAME#%_, M.D. ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC. PROCEDURE: Laparoscopic Roux-en-Y with adhesion lysis. PRIMARY CARE PHYSICIAN: _%#NAME#%_ _%#NAME#%_, M.D. PREOPERATIVE DIAGNOSIS: Morbid obesity.
PAC|premature atrial contraction|PAC,|229|232|REMARKABLE LABS AND PROCEDURE|The decision was to intubate at the emergency room, and the patient was admitted to the MICU to evaluate his respiratory status. REMARKABLE LABS AND PROCEDURE: 1. Serial cardiac enzymes were negative. EKG: Sinus tachycardia with PAC, right axis deviation, right atrial enlargement, and no acute ST-T change. 2. CT of chest was negative for PE. Status post right pneumonectomy.
PAC|physician assistant certification|PAC,|246|249|FOLLOW-UP|DISPOSITION: Patient will be discharged to home in the care of his wife later after his troponin levels are back and are negative. FOLLOW-UP : 1. Fasting lipid profile in one week at his primary care physician's office. 2. _%#NAME#%_ _%#NAME#%_, PAC, at Minnesota Heart Clinic on Tuesday, _%#MM#%_ _%#DD#%_, 2006 at 9:30 a.m. 3. Dr. _%#NAME#%_ _%#NAME#%_ on Wednesday, _%#MM#%_ _%#DD#%_, 2006 at 8:45 a.m. in the _%#CITY#%_ office of Minnesota Heart Clinic.
PAC|physician assistant certification|PAC|210|212|FOLLOW UP|FOLLOW UP: I will see her back in the office in 2 weeks for suture removal at which time she will need a true AP and outlet radiograph of the left shoulder. She was discharged by a _%#NAME#%_ (_______________) PAC in my absence.
PAC|premature atrial contraction|PAC,|196|199|ADMISSION LABS AND TESTING|Protein 6.6, albumin 3.9, alkaline phosphatase 96, bili .7, delta less than .1. ALT 18, AST 19. EKG by my interpretation: Normal sinus rhythm with a rate of 86, axis - 25, some artifact change, 1 PAC, no ischemic change, poor R-wave progression . Repeat EKG is pending. Abdominal X-ray: Formal report: Surgical clips from the cholecystectomy.
PAC|post anesthesia care|PAC|208|210|HOSPITAL COURSE|She was then taken to the OR where a total knee arthroplasty using a J&J total knee system was used without any complications. Estimated blood loss is less than 50 cc. The patient was then transferred to the PAC in stable condition where she was closely monitored prior to her transfer up to the orthopedic floor. The patient was started on DVT prophylaxis, which was Lovenox 30 mg subcu b.i.d. the first evening of surgery and to be given to complete a seven day course.
PAC|physician assistant certification|PAC|144|146|POSTOPERATIVE COURSE|He was recommended to call Dr. _%#NAME#%_'s office prior to that point if he had other questions or concerns. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, PAC dictating for Dr. _%#NAME#%_ _%#NAME#%_
PAC|premature atrial contraction|PAC.|168|171|PAST MEDICAL HISTORY|She has clear chest to auscultation. She is grossly neurologically intact except for some slight disorientation to time. She has a regular heart rhythm with occasional PAC. Her abdomen is soft and nontender. Her pelvis is stable there are some small abrasions on her knees, but otherwise her extremities were unremarkable.
PAC|physician assistant certification|PAC|140|142|SURGEON|PREOPERATIVE DIAGNOSIS: Morbid obesity. POSTOPERATIVE DIAGNOSIS: Same. SURGEON: Dr. _%#NAME#%_ _%#NAME#%_ ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC PRIMARY CARE PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_. PROCEDURE: Laparoscopic gastric bypass with incidental cholecystectomy for cholelithiasis.
PAC|physician assistant certification|PAC.|194|197|ASSISTANT|PREOPERATIVE DIAGNOSIS: Morbid obesity. POSTOPERATIVE DIAGNOSIS: Morbid obesity. PROCEDURE: Laparoscopic Roux-en-Y. SURGEON: Dr. _%#NAME#%_ and Dr. _%#NAME#%_. ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC. PRIMARY CARE: Dr. _%#NAME#%_ _%#NAME#%_. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ traversed all the postoperative protocol steps without any difficulty.
PAC|premature atrial contraction|PAC,|155|158|PHYSICAL EXAMINATION|TMs are clear bilaterally. She has dentures. Oropharynx is clear. NECK: Supple without lymphadenopathy. HEART: Regular rate and rhythm; she has occasional PAC, no murmurs, gallops, or rubs appreciated. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender, bowel sounds are positive, nondistended.
PAC|physician assistant certification|PAC.|184|187|ASSISTANTS|PREOPERATIVE DIAGNOSIS: Morbid obesity. PROCEDURE: Laparoscopic gastric bypass. SURGEON: _%#NAME#%_ _%#NAME#%_, M.D. ASSISTANTS: _%#NAME#%_ _%#NAME#%_, M.D. and _%#NAME#%_ _%#NAME#%_, PAC. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ underwent laparoscopic gastric bypass procedure under general anesthesia, uncomplicated with minimal blood loss.
PAC|physician assistant certification|PAC|139|141|ASSISTANT|REASON FOR ADMISSION: Laparoscopic gastric bypass for morbid obesity. SURGEON: _%#NAME#%_ _%#NAME#%_, MD ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC and _%#NAME#%_ _%#NAME#%_, MD PRIMARY CARE PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD SURGICAL PROCEDURE: Laparoscopic gastric bypass (Roux-en-Y).
PAC|physician assistant certification|PAC|290|292|FIRST ASSIST|PROCEDURE: Bilateral groin exploration, Dacron patch angioplasty of left common femoral anastomosis, cross femoral bypass with 8 mm PTFE graft from the left limb of aortofemoral graft to right profunda femoris artery. SURGEON: _%#NAME#%_ _%#NAME#%_, MD FIRST ASSIST: _%#NAME#%_ _%#NAME#%_, PAC HISTORY: _%#NAME#%_ _%#NAME#%_ is a 66-year-old male who presented to the Emergency Department on _%#DDMM2006#%_ with right leg _________ of sudden onset.
PAC|physician assistant certification|PAC.|164|167|FIRST ASSIST|2. Right carotid endarterectomy with Dacron patch angioplasty. SURGEON: Dr. _%#NAME#%_ _%#NAME#%_. FIRST ASSIST: _%#NAME#%_ _%#NAME#%_, PAC, _%#NAME#%_ _%#NAME#%_, PAC. REFERRING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, M.D. HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ is a 45-year-old gentleman with multiple atherosclerotic risk factors who had a carotid ultrasound performed, demonstrating a greater than 70% stenosis of the right internal carotid artery.
PAC|premature atrial contraction|PAC.|198|201|LABORATORY STUDIES|Chest x-ray shows impressive cardiomegaly. There is mild pulmonary vascular congestion. No evidence of pneumothorax. CT scan is outlined above. EKG reveals sinus tachycardia with occasional PVC and PAC. ST segments are unremarkable. IMPRESSION: 76-year-old gentleman who presents following a syncopal episode.
PAC|UNSURED SENSE|PAC|80|82|ADMISSION LABORATORIES|Cranial nerves II through XII are grossly intact. ADMISSION LABORATORIES: VBGs: PAC 734. pCO2 37. pO2 22. Bicarbonate 19. SVO2 35%. SMA10: BUN 42. Creatinine 1.3. Glucose 92. Magnesium 2.5. CBC: WBC 2600. Hemoglobin 7.3. MCV 100.
PAC|physician assistant certification|PAC,|203|206|HISTORY OF PRESENT ILLNESS|She did take seven days of Levaquin. She, however, still does not feel good. She describes this mostly as just feeling tired and woozy, especially when she stands. She was seen by _%#NAME#%_ _%#NAME#%_, PAC, today and was advised to be admitted as she has had some weight loss and also was worried that the patient was dehydrated.
PAC|premature atrial contraction|PAC.|132|135|LABORATORY DATA|EXTREMITIES: No edema. NEUROLOGIC: Grossly nonfocal. LABORATORY DATA: EKG shows normal sinus rhythm at a rate of 61 with occasional PAC. No appreciable ST abnormalities. Chest x-ray has been ordered and is pending. Electrolytes are normal with specifically a sodium of 139, potassium 4.5, BUN 22, creatinine 1.0, white count 14.8, hemoglobin 15.9, platelets 245.
PAC|premature atrial contraction|PAC|343|345|LABORATORY STUDIES|LABORATORY STUDIES: His comprehensive panel including electrolytes, BUN, creatinine, glucose, liver function tests are normal and are slightly elevated at 1.15, the upper limit of normal being 1.14. Myoglobin is slightly elevated at 142, troponin is less than 0.07. PTT 28. EKG from the ambulance reveals a normal sinus rhythm with occasional PAC and premature ventricular contraction. EKG here shows a sinus rhythm, rate of 85, there is evidence of a right bundle branch block.
PAC|physician assistant certification|PAC|255|257|ASSISTANT|PREOPERATIVE DIAGNOSIS: Morbid obesity. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE: Laparoscopic Roux-en-Y (gastric bypass). COMPLICATIONS: None. ANESTHESIA: General. BLOOD LOSS: Minimal. SURGEON: _%#NAME#%_ _%#NAME#%_, MD ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC PRIMARY PHYSICIAN: Self-referred. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ underwent laparoscopic gastric bypass on _%#DDMM2006#%_ which was uncomplicated.
PAC|physician assistant certification|PAC|185|187|SURGEON|PROCEDURE: Redo left femoral to below the knee popliteal bypass with a 6 mm. externally supported PTFE graft. SURGEON: _%#NAME#%_ _%#NAME#%_, M.D. 1st Assistant: _%#NAME#%_ _%#NAME#%_, PAC _%#NAME#%_ _%#NAME#%_ is a 62-year-old female who was admitted on _%#DDMM2006#%_ for left leg pain.
PAC|premature atrial contraction|PAC.|230|233|PHYSICAL EXAMINATION|Disks are sharp, sclerae are anicteric. Mouth is unremarkable. NECK: Neck supple, without masses, thyromegaly, bruits or JVP. LUNGS: Clear to auscultation and percussion. CARDIOVASCULAR: Regular rate and rhythm with an occasional PAC. There is no murmur, rub or click. ABDOMEN: Obese, bowel sounds are present, the abdomen is soft, nontender, nondistended.
PAC|post anesthesia care|PAC|178|180|SOCIAL HISTORY|She was noted to have a normal uterus, ovaries, and fallopian tubes at that time. The placenta was delivered and intact with three- vessel cord noted. She was transferred to the PAC unit in stable condition. POSTPARTUM COURSE: The patient continued on magnesium until 24 hours after delivery for her preeclampsia. At this time, it was discontinued. The patient's blood pressures remained normal, and she never required treatment for her blood pressures.
PAC|premature atrial contraction|PAC.|210|213|EKG|Sodium 139, potassium 3.3, chloride 95, bicarbonate 38, anion gap 6, glucose 155, BUN 26, creatinine 1.25. Troponin less than 0.04. Urinalysis negative. EKG: Normal sinus rhythm with a rate of 94, with PVC and PAC. No ST-T changes. CT OF THE HEAD: Pending. ASSESSMENT: 1. Imbalance. 2. Frequent falls, without any major injury. 3. History of myasthenia gravis.
PAC|picture archiving communication|PAC|176|178|LABORATORY DATA|No changes of acute coronary syndrome no changes of pericarditis and creatinine 1. Troponin I 1.29, hemoglobin 15.4, hematocrit 44.8, platelets 256. CT chest reviewed by me on PAC shows no evidence of dissection. No evidence of pulmonary embolism. IMPRESSION REPORT AND PLAN: 1. Acute coronary syndrome. 2. Hypertension, dyslipidemia. Mr. _%#NAME#%_ likely represents acute coronary syndrome and is still having pain and will attempt to optimize his blood pressure and heart rate while here continue his Integrilin and heparin.
PAC|premature atrial contraction|PAC.|114|117|LABORATORY|BNP test was 70. Serum potassium 3.7, serum creatinine 1.1. Electrocardiogram showed sinus rhythm with occasional PAC. First degree block was noted. His left bundle branch block was reconfirmed. A follow-up chest x-ray was not performed by me, as this has been followed by his oncologist.
PAC|physician assistant certification|PAC|100|102|IDENTIFICATION|IDENTIFICATION: _%#NAME#%_ _%#NAME#%_ is a 34-year-old patient of _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, PAC of Park Nicollet, also primary psychiatrist is Dr. _%#NAME#%_. HISTORY OF PRESENT ILLNESS: The patient is a 34-year-old.
PAC|physician assistant certification|PAC|139|141|DISCHARGE FOLLOW-UP|There are no ST abnormalities noted. DISCHARGE FOLLOW-UP: The patient will follow up at Minnesota Heart clinic in two weeks with the NP or PAC with follow-up lab work including a basic metabolic profile and CBC. Baseline creatinine was stable at 1.23. We did add lisinopril during this hospitalization and creatinine and potassium will need to be monitored.
PAC|post anesthesia care|PAC|318|320|HOSPITAL COURSE|PROCEDURE PERFORMED: Left-sided L5-S1 laminotomy discectomy. HOSPITAL COURSE: The patient was admitted on _%#DDMM2003#%_ and subsequently brought to the OR for the above mentioned procedure. Induction of general endotracheal anesthesia. The procedure itself was uneventful. The patient was subsequently brought to the PAC room in satisfactory condition. Postoperatively, there was note of complete relief of the left-sided leg pain with note of intact motor function, but with residual left S1 dermatome numbness.
PAC|premature atrial contraction|PAC.|141|144|PHYSICAL EXAMINATION|NECK: Carotid arteries are palpable although they are not bounding. There are no bruits. HEART: Shows normal sinus rhythm with an occasional PAC. ABDOMEN: Rounded. I hear no abdominal bruits. EXTREMITIES: His peripheral extremities show rather thin skin but the skin of his feet are warm.
PAC|physician assistant certification|PAC,|125|128|PLAN|PLAN: 1. Repeat platelet count on _%#MMDD#%_ at Minnesota Heart Clinic at 2:30 p.m. 2. Follow up with _%#NAME#%_ _%#NAME#%_, PAC, at Minnesota Heart Clinic on _%#MMDD#%_ at 3:30 p.m. 3. If his platelet count is above 70, we will start him on Coumadin as per Dr. _%#NAME#%_ _%#NAME#%_'s note.
PAC|premature atrial contraction|PAC.|230|233|HISTORY/HOSPITAL COURSE|His troponin levels are normal. His hemoglobin has only dropped from 11.5 to 11.2. Potassium is normal. Kidney function is also normal with a BUN of 15 and creatinine of 0.93. EKG showed normal sinus rhythm with some PVCs and one PAC. Blood pressure is elevated today at 156/81. PHYSICAL EXAMINATION: On exam, the patient had a 2/6 systolic murmur noted best at the base.
PAC|premature atrial contraction|(PAC)|212|216|LABORATORY DATA|Basic metabolic panel is normal. Chest x-ray was reviewed as above. EKG shows no significant ST or Q waves. Telemetry has shown multiple premature ventricular contractions (PVC) and premature atrial contractions (PAC) and some short runs of nonsustained ventricular tachycardia. ASSESSMENT AND PLAN: 1. Shortness of breath with wheezing. The differential diagnosis includes congestive heart failure, asthma or lung infection; the current clinical data would suggest asthma more than anything.
PAC|premature atrial contraction|PAC|135|137|HISTORY OF PRESENT ILLNESS|Chest x-ray normal bilaterally, however, there were some small fibrous/atelectasis in the right lung base. Echo was negative. ECG with PAC and inferior infarct of age undetermined. Te patient was admitted to acute rehab for decreased ADLs, needs PT/OT speech. PAST MEDICAL HISTORY: Type 2 diabetes, right BKA, neuropathy, hypertension, dyslipidemia, dependent edema, back surgery x2, obesity and depression.
PAC|premature atrial contraction|PAC.|181|184|DIAGNOSTICS|EXTREMITIES: Without edema. His right leg is braced. NEUROLOGIC: Grossly nonfocal to the extent that we can examine him. DIAGNOSTICS: EKG shows sinus tachycardia with an occasional PAC. No significant ST segment abnormalities. LABORATORY: Urinalysis is unremarkable except for trace ketones. Cell counts are normal, but there was bacteria.
PAC|premature atrial contraction|PAC|305|307|CLINICAL PROFILE|This Holter monitor recording was undertaken, since there was some concern that the recording from _%#CITY#%_ _%#CITY#%_ _%#CITY#%_ may have contained some artifact due to the exceedingly high heart rate recorded from time to time. The Holter monitor at the University of Minnesota showed only occasional PAC and significant sinus arrhythmia. Exceedingly high heart rates were not recorded. Electrophysiologic study similarly revealed a benign situation, with no evidence of inducible tachyarrhythmias.
PAC|premature atrial contraction|PAC,|267|270|CLINICAL PROFILE|Exceedingly high heart rates were not recorded. Electrophysiologic study similarly revealed a benign situation, with no evidence of inducible tachyarrhythmias. Occasional PAC were once again noted. Based on these findings, we believe that Mr. _%#NAME#%_ has frequent PAC, and significant sinus arrhythmia. Otherwise, he shows no significant cardiac arrhythmia, and no worrisome underlying structural heart disease.
PAC|premature atrial contraction|PAC.|152|155|LABORATORY DATA|Computer calls atrial fibrillation, but clearly P-waves are identified and I do not see that this is an atrial fibrillation rhythm. There is occasional PAC. His white count is 12.8. Hemoglobin is 13.9. Platelets 306. IMPRESSION: This 79-year-old gentleman with orthostatic hypotension, dehydration secondary to a recently diarrheal illness.
PAC|picture archiving communication|PAC|250|252|LABS|PAC viewer error occurred and no images are viewable. EKG bradycardia 60 beats per minute, sinus rhythm. No acute ST-T wave changes. Urinalysis negative. Hemoglobin 13.6. Potassium 4.1. INR 1.03. X-ray of femur and hip also verbal report only as the PAC viewer not currently functioning, unable to access the images, but by verbal report the right intertrochanteric femur fracture.
PAC|premature atrial contraction|PAC|175|177|PHYSICAL EXAMINATION|No cyanosis or clubbing. Lower extremities normal. No pedal edema. Peripheral vascular system normal. Electrocardiogram showed presence of atrial fibrillation with occasional PAC and PVC. Hemoglobin was 9.6 grams, BUN, creatinine, electrolytes were normal. Serum calcium was 7.7 but this is because of the hypoproteinemia with an albumin of 2.8 grams%.
PAC|physician assistant certification|PAC.|202|205|HISTORY OF PRESENT ILLNESS|He was placed in a CAM walker this morning by Fairview Orthotics and this was changed to a fiberglass cast in neutral position at approximately 13:00 on _%#DDMM2005#%_ by myself, _%#NAME#%_ _%#NAME#%_, PAC. The patient tolerated this procedure well and was discharged from the hospital. He received good p.o. analgesia and follow-up instructions. He will follow up with Dr. _%#NAME#%_ in two weeks for a wound check.
PAC|premature atrial contraction|PAC,|140|143|LABORATORY DATA|Troponin less than 0.07. Urinalysis unremarkable. Head CT as above. EKG demonstrated sinus tachycardia with left axis deviation, occasional PAC, no ischemic change. ASSESSMENT: 87-year-old female admitted with the following: 1. Unresponsive subsequent to episode of choking.
PAC|physician assistant certification|PAC,|142|145|DISCHARGE FOLLOWUP|We did discuss the increased risk of myalgias on these three drugs, and he verbalizes an understanding. 3) He will see _%#NAME#%_ _%#NAME#%_, PAC, for Dr. _%#NAME#%_ _%#NAME#%_ in _%#CITY#%_ within two weeks of discharge. 4) He will follow up with Dr. _%#NAME#%_ at his first available visit in _%#CITY#%_.
PAC|premature atrial contraction|PAC.|139|142|PHYSICAL EXAMINATION|There is no hepatosplenomegaly. CARDIOVASCULAR: S1 and S2 regular rhythm. No murmurs, rubs, or gallops are present. There is an occasional PAC. EXTREMITIES: Extremities are without edema, though the patient states that she normally has no trace edema. NEURO: The patient is alert, and oriented times three. This is a nonfocal exam.
PAC|premature atrial contraction|PAC.|205|208|OBJECTIVE|OBJECTIVE: GENERAL: A well-preserved elderly female lying semi-upright on the cart in no distress. Alert. Oriented to place. VITAL SIGNS: Blood pressure initially is 186/87, heart rate 70s with occasional PAC. Respirations normal, temperature normal. O2 saturation 99% on room air. HEENT: HEENT demonstrated head to be atraumatic. Extraocular movements are full.
PAC|physician assistant certification|P.A.C.|196|201|ASSISTANT SURGEON|He was advised to follow-up at the Surgical Clinic in one week to be re-evaluated and have the Jackson-Pratt removed. SURGEON: Dr. _%#NAME#%_ _%#NAME#%_. ASSISTANT SURGEON: _%#NAME#%_ _%#NAME#%_, P.A.C. _%#NAME#%_ _%#NAME#%_, P.A.C. REFERRING PHYSICIAN: Dr. _%#NAME#%_, Crossroads Clinic, _%#CITY#%_.
PAC|premature atrial contraction|(PAC).|192|197|PHYSICAL EXAMINATION|LUNGS: Crackles at the bases and occasional coarse breath sounds. HEART: Cardiac exam shows regular rhythm and rate. Telemetry shows sinus rhythm with occasional premature atrial contractions (PAC). Respiratory rate now has come down to the 20s. No appreciable S3, S4 or murmur. Neck veins are distended. ABDOMEN: Soft. Bowel sounds present and normal in character.
PAC|post anesthesia care|PAC|144|146|HOSPITAL COURSE|This procedure was performed for his sigmoid volvulus. There were no complications during the procedure, and the patient was transported to the PAC unit in stable condition. On _%#MMDD#%_, postop day 2, the patient does have a temperature of 101 degrees. This was felt to be a postoperative fever. On postop day 4, the patient had an output of nearly 1000 cc out of the NG tube.
PAC|premature atrial contraction|PAC|123|125|HISTORY|He also says that the rapid heart beat typically occurs after a skipped beat, making me think that he is possibly having a PAC or PVC which is stimulating the development of an SVT. He does not tend to get this with exertion. Today his blood pressure initially was high when he came into the office as you can see, but he a repeat blood pressure was 128/68, indicating that he may have possibly white-coat hypertension initially when he comes in.
PAC|post anesthesia care|PAC|277|279|HOSPITAL COURSE|He had a granuloma of the skin at the right side of his ileostomy and pathologically this was confirmed to be inflammatory and consistent with lichen simplex chronicus. The operation went well and postoperatively the patient experienced no complications. He was comfortable in PAC on the first postoperative day. By the second day, he had bowel sounds and passed flatus and his diet was advanced.
PAC|premature atrial contraction|(PAC).|204|209|PHYSICAL EXAMINATION|Skin: No rash. Bones/Joints: No further trouble with arthralgias or arthropathy. PHYSICAL EXAMINATION: VITAL SIGNS: Cardiac monitor shows normal sinus rhythm with occasional premature atrial contractions (PAC). She is afebrile. GENERAL: On examination, the patient is alert and oriented, somewhat of a vague historian. HEENT: Pupils are equal. Tongue is moist. NECK: Carotids are clear.
PAC|post anesthesia care|PAC,|163|166|HOSPITAL COURSE|Here, a redo thoracotomy with exploration was performed. Please refer to the operative note for full details of this procedure. The patient was transferred to the PAC, extubated, and sent to the general care floor. Over the subsequent days, he had an unremarkable recovery. His chest tube output remained serous and was tapering at the time of discharged.
PAC|physician assistant certification|PAC.|202|205|ASSISTANT|PREOPERATIVE DIAGNOSIS: Morbid obesity. POSTOPERATIVE DIAGNOSIS: Morbid obesity. PROCEDURE: Laparoscopic gastric bypass procedure. SURGEON: _%#NAME#%_ _%#NAME#%_, M.D. ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC. PRIMARY CARE DOCTOR: _%#NAME#%_ _%#NAME#%_, M.D. in _%#CITY#%_, Minnesota.
PAC|picture archiving communication|PAC|105|107|IMPRESSION AND PLAN|He currently feels that things are improving. Of note, I need to work on getting a new pass word for the PAC System. At this time I have been unable to view though RT has been paged to assist with this. Otherwise, at this time, currently starting a Z Pak and the chest x-ray can be viewed in the morning.
PAC|premature atrial contraction|PAC.|142|145|HOSPITAL COURSE|This then recurred for another couple minutes about 15 minutes later. In the emergency room, the patient had an EKG that showed an occasional PAC. He had negative cardiac enzymes x3 and then had a stress test on _%#DDMM2006#%_. The patient exercised for approximately 10 minutes and he had the stress echo reviewed by Dr. _%#NAME#%_ Minnesota Heart Clinic who faxed the report that the patient's stress test was normal.
PAC|premature atrial contraction|(PAC)|172|176|EKG|Reflexes are symmetrical. Sensation is intact. CHEST X-RAY: Chest x-ray shows no infiltrate. EKG: EKG shows sinus tachycardia with occasional premature atrial contractions (PAC) and left axis deviation with Q waves in V1 and V2. LABORATORY DATA: Sodium 139, potassium 3.6, chloride 109, bicarbonate 26, BUN 26, creatinine 1.2, glucose 134.
PAC|premature atrial contraction|(PAC).|227|232|PAST MEDICAL HISTORY|8. Laparoscopic cholecystectomy in _%#MM2002#%_. 9. OD cataract extraction and IOL in _%#MM2002#%_. PAST MEDICAL HISTORY: 1. Lumbar and cervical osteoarthritis. 2. Atrophic vaginitis. 3. History of premature atrial contraction (PAC). 4. History of hyperlipidemia. ALLERGIES: None. CURRENT MEDICATIONS: Aspirin one a day. HABITS: Nonsmoker.
PAC|premature atrial contraction|PAC.|87|90|LABS ON ADMISSION|She may have a subtle right lower lobe infiltrate. EKG demonstrates sinus at 64 with 1 PAC. Normal axis and intervals and no acute ST-T wave changes. ASSESSMENT AND PLAN: Patient is an 87-year-old woman with COPD, presenting with likely pneumonia and acute COPD exacerbation.
PAC|premature atrial contraction|PAC|166|168|LABORATORY DATA|Final result is pending. Sodium 143, potassium 3.9, chloride 108, bicarbonate 25, BUN 17, creatinine 0.8, glucose 96. BNP is 32. Troponin less than 0.04. EKG shows a PAC with no evidence of ischemia. ASSESSMENT AND PLAN: Ms. _%#NAME#%_ is a 41-year-old female with history of coronary disease who presents with recurrent chest pain.
PAC|premature atrial contraction|(PAC).|199|204|PHYSICAL EXAMINATION|HEENT: Ears/Nose/Throat: Unremarkable. CHEST: Coarse rhonchi and wheezing bilaterally with some prolongation of the expiratory time. HEART: Regular rate and rhythm with premature atrial contractions (PAC). ABDOMEN: Soft and nontender. EXTREMITIES: No edema. Radial and dorsalis pedis pulses are full. SKIN: Unremarkable. NEUROLOGIC: Cranial nerves II-XII are intact. Motor function is good to the upper and lower extremities.
PAC|premature atrial contraction|PAC|125|127|DISCHARGE DIAGNOSES|We did not find any evidence of atrial fibrillation while she was on telemetry. We did see a sinus rhythm with an occasional PAC There was no evidence of cardiac source for her stroke. b. _%#DDMM2006#%_ MRI/MRA day of the brain and neck showed a small area of recent infarction left anterior parietal white matter in the periventricular region, mild chronic white matter disease.
PAC|physician assistant certification|PAC,|192|195|DISPOSITION|Her INR was therapeutic with just 3 days of Coumadin therapy and on the day of discharge it was 2.7. 2. Follow up with one of our nurse practitioners, either _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, PAC, or _%#NAME#%_ _%#NAME#%_, NP, in 2 weeks' time. She will have an echocardiogram to see if her left ventricular systolic function normalizes with restoration of normal sinus rhythm.
PAC|premature atrial contraction|PAC.|139|142|LABORATORY STUDIES|Chest x-ray reviewed by me shows no active disease, no abnormalities. EKG reviewed by me shows normal sinus rhythm, no ischemic changes, 1 PAC. Normal intervals, no prolonged QTC. ASSESSMENT, PLAN: Presyncope likely related to dehydration.
PAC|physician assistant certification|PAC|356|358|HISTORY OF PRESENT ILLNESS AND SUMMARY OF ACUTE REHAB STAY|TRANSPLANT SURGEON: _%#NAME#%_ _%#NAME#%_, M.D. TRANSPLANT COORDINATOR: _%#NAME#%_ _%#NAME#%_, RN. HISTORY OF PRESENT ILLNESS AND SUMMARY OF ACUTE REHAB STAY: Please refer to the admission history and physical dictated by myself on _%#DDMM2007#%_ for details regarding her acute hospitalization and the discharge summary dictated by _%#NAME#%_ _%#NAME#%_, PAC on _%#DDMM2007#%_ as well. In brief, she is a 51-year-old woman with a longstanding past medical history of end-stage renal disease.
PAC|premature atrial contraction|PAC.|145|148|LABORATORY STUDIES|Chest x-ray reviewed by myself is negative. Urinalysis negative. EKG initial study shows normal sinus rhythm with a heart rate of 78. There is a PAC. No signs of ischemia. Follow up EKG showed AFIB with RVR. ASSESSMENT AND PLAN: 1. New onset atrial fibrillation with RVR, currently in a normal sinus rhythm.
PAC|physician assistant certification|PAC|89|91|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, MD (_%#CITY#%_ Lake Clinic); _%#NAME#%_ _%#NAME#%_, PAC (_%#CITY#%_ Lake Clinic) PRIMARY DIAGNOSIS: 1. Sickle cell crisis. 2. Macrocytic anemia.
PAC|post anesthesia care|PAC|236|238|HOSPITAL COURSE|She underwent a cadaveric kidney transplant. There were no complications to the procedure, and the intraoperative blood loss was minimal. She was taken to postanesthesia in stable condition, and then transferred up to the floor per the PAC criteria. Postoperatively, the patient did have decreased hemoglobin for which she was treated with two units of packed red blood cells.
PAC|physician assistant certification|PAC|166|168|DISPOSITION|DISPOSITION: 1. This patient will be discharged to home in the care of his family. His wife will be transporting him. 2. This patient will see _%#NAME#%_ _%#NAME#%_, PAC at Minnesota Heart Clinic on _%#MMDD#%_ at 7:00 am. 3. He will follow-up with Dr. _%#NAME#%_ in 2-3 months. 4. He needs a lipid panel with ALT two months after starting his Lipitor therapy.
PAC|physician assistant certification|PAC.|209|212|ASSISTANT|PREOPERATIVE DIAGNOSIS: Morbid obesity. POSTOPERATIVE DIAGNOSIS: Morbid obesity. PROCEDURE: Laparoscopic Roux-en-Y. SURGEON: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, M.D. ASSISTANT: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, PAC. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ went through the post-bariatric surgery program without any difficulty, advancing her diet appropriately, complaining of some discomfort around the left lateral 12 mm port that was used for the ____ stapler.
PAC|physician assistant certification|PAC.|137|140|SURGEON|PROCEDURE: Laparoscopic roux-en-Y with incidental cholecystectomy. SURGEON: Dr. _%#NAME#%_ _%#NAME#%_. ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC. PRIMARY CARE PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_ HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 49-year-old patient, traversed the bariatric protocol without any difficulty.
PAC|premature atrial contraction|PAC,|161|164|ASSESSMENT|It could be that he has an early pneumonia. 2. Irregular heart rhythm. I have just been handed his ECG and he now is in sinus rhythm, there is not even a single PAC, so whatever he had is now resolved or was just sinus rhythm with ectopy. 3. Renal failure, prerenal in nature. 4. Hypertension, not controlled at this time, but he has not had his medicines today.
PAC|premature atrial contraction|PAC.|197|200|PHYSICAL EXAMINATION|EXTREMITIES: Femoral pulses were normal bilaterally. Lower extremities showed no sign of peripheral edema. Telemetry overnight showed normal sinus rhythm throughout the entire period with a single PAC. He was then discharged home in a stable condition. DISCHARGE MEDICATIONS: 1. He was advised to take aspirin 81 mg daily in combination with Coumadin 10 mg daily for at least 1 month.
PAC|physician assistant certification|PAC.|154|157|DISCHARGE FOLLOW-UP|DISCHARGE FOLLOW-UP: 1. He will follow up next week with Minnesota Gastroenterology, P.A. at the _%#CITY#%_ Clinic, initially with _%#NAME#%_ _%#NAME#%_, PAC. 2. He will follow up with Dr. _%#NAME#%_ in 2 weeks' time at which time a repeat chest x-ray should be obtained to further evaluate any resolution of the left lower lobe pneumonia and parapneumonic effusion.
PAC|picture archiving communication|PAC|241|243|IMAGING|Upon attempting ambulation the patient was connected to too many wires he stated and he sat down after attempting Romberg test which he had some truncal unsteadiness. IMAGING: A head CT done at Fairview Lakes emergency room, which is on are PAC system on _%#DDMM2007#%_ which is without contrast shows: 1. Left heterogeneous subdural hematoma. 2. This hematoma is thickest in diameter, which is around 2 cm around 4 cm from the left external auditory meatus rostrally.
PAC|post anesthesia care|PAC|137|139|HISTORY OF PRESENT ILLNESS|The induction of general endotracheal anesthesia as well as the procedure itself was uneventful. The patient was subsequently brought to PAC in satisfactory condition. Postoperatively, there was noted intact motor and sensory function. The patient was placed on PCA and subsequently weaned off this and placed on oral pain medications.
PAC|premature atrial contraction|PAC|168|170|ELECTROCARDIOGRAM|Motor, sensory, and coordination are grossly nonfocal. She is able to stand and ambulate but gait is quite unsteady. ELECTROCARDIOGRAM: Normal sinus rhythm. Occasional PAC but no acute appearing changes. LABORATORY DATA: Urinalysis negative. Troponin less than 0.07. Comprehensive metabolic profile was normal.
PAC|physician assistant certification|PAC,|180|183|FOLLOW UP|2. Vistaril 25-50 mg p.o. q.4-6h. p.r.n., 80 were given. 3. Colace 100 mg p.o. b.i.d. FOLLOW UP: He will follow up in 2 weeks with Dr. _%#NAME#%_'s nurse or _%#NAME#%_ _%#NAME#%_, PAC, and in 6 weeks with Dr. _%#NAME#%_ with x-rays of this right ankle 3 views. He should keep his foot elevated and keep the cast clean and dry and be toe-touch weightbearing with crutches or a walker.
PAC|premature atrial contraction|PAC|208|210|HISTORY OF PRESENT ILLNESS|She was feeling ill today, mainly with skipped beats, so she went to North Memorial Medical Center after she was advised to go to the emergency room by the clinic. There they noted that she had an occasional PAC and PVC, per patient. There was no report given to the patient that she had atrial fibrillation. Her potassium was checked and apparently was low. They gave her some supplemental potassium, and asked her to follow up with her regular physician.
PAC|physician assistant certification|PAC.|149|152|ASSISTANT|SURGERY: Right hemicolectomy on _%#DDMM2006#%_ with segmental resection of sigmoid colon. SURGEON: Dr. _%#NAME#%_. ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ had essentially an unremarkable hospital course.
PAC|premature atrial contraction|PAC.|181|184|LABORATORY  DATA|Heart size appears normal. No evidence of pulmonary edema. There is an effusion in the left with possible infiltration there. EKG reveals a sinus rhythm, rate of 70 with occasional PAC. There is slight peaking of the T waves and there is no appreciable ST segment abnormalities. BNP 61, sodium 133, potassium 6.6, chloride 103, bicarbonate 17, glucose 68, BUN 81, creatinine 4.58. LFTs are normal.
PAC|premature atrial contraction|(PAC)|259|263|PHYSICAL EXAMINATION|She is adopted so it is difficult to get the specific history, but she states that she does know the prior history of these in the past. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 120/60. Heart rate 65 with noted frequent premature atrial contractions (PAC) on rhythm strip. GENERAL: She is in no acute distress resting comfortably. NECK: Supple. No lymphadenopathy. Carotid arteries appear normal. HEART: Regular with no murmurs, gallops or rubs.
PAC|premature atrial contraction|PAC|223|225|PHYSICAL EXAMINATION|CHEST: Lungs are clear. She is moving air well. HEART: Regular rate and rhythm, no gallop or murmur are heard. EKG shows normal sinus rhythm. Her telemetry shows normal sinus rhythm without anything more than an occasional PAC ABDOMEN: Benign. BACK: Benign, no CVA tenderness. EXTREMITIES: Full range of motion. No bone, joint or soft tissue abnormality. NEUROLOGIC: Her exam was entirely intact.
PAC|premature atrial contraction|PAC|305|307|LABORATORY  DATA|EXTREMITIES: No edema. SKIN: dry. LABORATORY DATA: White count is 13.0, hemoglobin 12.5, MCV 80, platelets 238,000, INR 1.03. Her electrolytes are normal with a low potassium 3.3, glucose 145, BUN 26, creatinine 0.9, BNP 222, troponin and myoglobin are normal. EKG shows sinus tachycardia with occasional PAC IMPRESSION: 1. 82-year-old woman with acute respiratory failure with acute pneumonia and acute chronic obstructive pulmonary disease exacerbation.
PAC|physician assistant certification|PAC|176|178|FIRST ASSISTANT|He also underwent a partial right adrenalectomy with pylorus-sparing Billroth-II and gastrojejunostomy. SURGEON: _%#NAME#%_ _%#NAME#%_. FIRST ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 48-year-old male who presented with multiple episodes of dizziness on standing.
PAC|premature atrial contraction|PAC.|147|150|HOSPITAL COURSE|In the overnight observation the patient maintained sinus rhythm without atrial fibrillations. The 12-lead EKG showed sinus rhythm with occasional PAC. The patient is discharged to home. He will come back to the EP Clinic to see Dr. _%#NAME#%_ in one month.
PAC|premature atrial contraction|PAC|210|212|HISTORY OF PRESENT ILLNESS|The orthopedic surgery team is now asking for our input in her case given her complex medical history. Of note, the patient has an EKG this morning just after midnight that was generally normal with occasional PAC but did have a borderline troponin that was 0.05. The patient herself is a poor historian but denies any significant chest pain or shortness of breath.
PAC|premature atrial contraction|PAC|148|150|PHYSICAL EXAMINATION|CHEST: She does have some wet crackles, more on the base on the right side. CARDIOVASCULAR: Regular heart beat except there are some ectopic beats, PAC versus PVC. There is a systolic murmur with a rate of about 4/6 in the apex leading to the axilla and questionable diastolic murmur.
PAC|premature atrial contraction|PAC.|105|108|PHYSICAL EXAMINATION|KUB shows marked amount of stool throughout, no free air. EKG showed normal sinus rhythm with occasional PAC. No acute ST or T-wave changes. LABS: Sodium is 137, potassium is 3.8, chloride is 102, bicarb is 24, BUN is 27, creatinine is 1.3 and glucose is 161, calcium is 8.7. White count is 7.3, hemoglobin is 10.3, platelet count is 187.
PAC|picture archiving communication|PAC|229|231|IMPRESSION|Impression at time of admission was distal femur fracture and distal fibular fracture, right leg. 2. Osteoarthritis. 3. Hypertension. 4. Hyperlipidemia. 5. Exogenous obesity. X-rays were reviewed with the family members over the PAC system. Time spent 90+ minutes.
PAC|physician assistant certification|PAC|47|49|PRIMARY CARE PHYSICIAN|PRIMARY CARE PHYSICIAN: _%#NAME#%_ _%#NAME#%_, PAC DISCHARGE DIAGNOSES: 1. Chest pain, probably cardiac, treated medically with resolution(probable angina secondary to coronary artery disease).
PAC|premature atrial contraction|PAC|155|157|HOSPITAL COURSE|Patient tolerated the procedure well and during her transjugular portal pressure evaluation, she also got transjugular hepatic biopsy done to evaluate for PAC as a cause of her symptoms and portal pressure elevation. After the TIPS procedure, the patient was stable. Her ammonia levels were normal.
PAC|physician assistant certification|PAC|146|148|POSTOPERATIVE COURSE|The patient was in understanding of these recommendations, therefore, was discharged to home on _%#DDMM2005#%_. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, PAC dictating for Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_
PAC|UNSURED SENSE|PAC|185|187|PATIENT INFORMATION|PATIENT INFORMATION: _%#NAME#%_ _%#NAME#%_ is a 46-year-old male followed by Dr. _%#NAME#%_ _%#NAME#%_ at Fairview Oxboro clinic. Information from office chart. Case was discussed with PAC with _%#NAME#%_ _%#NAME#%_ PAST MEDICAL HISTORY: 1. Non-Hodgkin's lymphoma, follicular, 2005. 2. Pericarditis. 3. Tobacco abuse.
PAC|physician assistant certification|PAC,|189|192|DISCHARGE PLAN|His peripheral pulses are intact distally. Otherwise, his physical examination is unremarkable. DISCHARGE PLAN: 1. The patient is to follow up with either _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, PAC, or _%#NAME#%_ _%#NAME#%_, NP, in 2 weeks. 2. The patient is to follow up with Dr. _%#NAME#%_ _%#NAME#%_ in 3 months. 3. The patient is to have a lipid panel in 6-8 weeks as Zetia was added to his medication regimen.
PAC|premature atrial contraction|(PAC)|182|186|EKG|HEART: S1 and S2 with a systolic murmur heard along the left sternal border that increases with inspiration. EKG: EKG showed sinus rhythm with frequent premature atrial contractions (PAC) with aberrant conduction and poor R-wave progression. No previous EKG with which to compare. MRI: She did have an MRI of the head which showed no acute pathology.
PAC|premature atrial contraction|PAC|164|166|HOSPITAL COURSE|He denies other symptoms. HOSPITAL COURSE: 1. ATYPICAL CHEST PAIN: His EKG was without any ST or T wave changes and troponin was negative. He did have intermittent PAC or bigeminy was present per EKG telemetry. TSH was done and was normal. His electrolytes were unremarkable. He did have an echo to evaluate his heart structure and function and it was essentially normal.
PAC|physician assistant certification|PAC,|76|79|DOB|DOB: _%#DDMM1995#%_ This is a 7-year-old referred by _%#NAME#%_ _%#NAME#%_, PAC, from Cedar Ridge Clinic. We discussed risks, benefits, and alternatives to adenoidectomy including the risk of general anesthetic, bleeding, velopharyngeal incompetence, and inflammation.
PAC|post anesthesia care|PAC|180|182|HOSPITAL COURSE|HOSPITAL COURSE: On _%#DDMM2002#%_, the patient underwent an open left nephrectomy. There were no complications. Estimated blood loss was 50 cc. The patient was transported to the PAC Unit and to the floor in stable condition. On postoperative day #1, the patient had low urine output and was given 1 L of normal saline flush.
PAC|premature atrial contraction|PAC,|177|180|HOSPITAL COURSE|An echocardiogram was obtained that did not show any pericardial effusions. Her extremities were clear of edema or evidence of DVTs. She was in a sinus rhythm with nonconducted PAC, she was consulted on the second day by Cardiology as well as Nephrology. Nephrology to keep her on her regular schedule of dialysis.
PAC|picture archiving communication|PAC|169|171|IMAGING|IMAGING: A CT scan of his head done with and without contrast on _%#DDMM2007#%_, which is today in comparison to _%#DDMM2007#%_ MRI, the CT scan and MRI are both in our PAC system and are done at our institution: 1. No new contrast enhancement. 2. No new edema. 3. No new blood. 4. Stable tumor in the right frontal lobe. There is mass effect and minimal midline shift.
PAC|premature atrial contraction|PAC|434|436|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSIS: Tuberous sclerosis. MEDICATIONS: None. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 34+6 week female who was born at 34+2 weeks via C-section to a 25-year-old G2, P0-0-1- 0, with known cardiac rhabdomyomas with cardiac arrhythmias who was transferred to the Pediatric Intensive Care Unit from HCMC to further evaluate the cardiac tumors. At HCMC she was noted to have hypotension along with arrhythmias, including PAC and PVC. Prior to her delivery mother did receive 2 doses of betamethasone on _%#DDMM2006#%_ and _%#DDMM2006#%_, and she was induced on _%#DDMM2006#%_ with delivery on _%#DDMM2006#%_.
PAC|premature atrial contraction|PAC|173|175|HISTORY OF PRESENT ILLNESS|Cord blood was sent for the tuberous sclerosis complex, DNA testing, and a newborn screen was sent. Upon arriving to the Pediatric Intensive Care Unit she was noted to have PAC and PVC present, and a Cardiology consult was obtained. Labs at the time of admission showed a WBC 10.1, hemoglobin 15.3, platelet count 306.
PAC|premature atrial contraction|PAC|161|163|PROBLEM #2|At the time of transfer she was changed over to formula feeds which we are going to start at 5 cc q.3h. PROBLEM #2: Cardiovascular: _%#NAME#%_ was noted to have PAC and PVC on her initial EKG along with some ST elevation. A troponin was checked and found to be 0.12 on the day of admission.
PAC|premature atrial contraction|(PAC).|229|234|PHYSICAL EXAMINATION|NECK: Supple. There is an internal jugular vein catheter on the right tunneling out over the chest with a clean tract and exit site. LUNGS: No wheezes or rales. HEART: Cardiac exam is irregular with premature atrial contractions (PAC). Normal S1 and S2. No rub or murmur. ABDOMEN: Normal bowel sounds, soft and nontender. No hepatosplenomegaly. GENITOURINARY: Normal female pattern. EXTREMITIES: Left upper extremity shows a recent surgical incision with some erythema and drainage that looks like stitch abscesses.
PAC|post anesthesia care|PAC.|290|293|ADMISSION DIAGNOSIS|HOSPITAL COURSE IN DETAIL: The patient was admitted on _%#MM#%_ _%#DD#%_, 2002 at which point she went to the operating room and underwent an uncomplicated left donor nephrectomy. This went well and without any complications. The patient was extubated in the operating room and went to the PAC. Postoperatively she recovered on the floor. Her urine output was brisk. Over the next several days, she was able to ambulate, eat, urinate, and stool without any difficulty.
PAC|premature atrial contraction|(PAC).|260|265|EKG|EKG: EKG on admission demonstrates dual-chamber pacing with 100% ventricular pacing except for occasional premature beats. Premature beats demonstrate a right bundle-branch block morphology without ST changes; these may represent premature atrial contractions (PAC). LABORATORY DATA: Hemoglobin 13.6, white count 10.8, platelet count 251,000.
PAC|premature atrial contraction|PAC.|256|259|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Temperature is afebrile. Blood pressure 104/73. Initially heart rate was 101, currently heart rate is in the 80s with apparent normal sinus rhythm. There is one previous rhythm strip that did show normal sinus rhythm with an isolated PAC. Respirations 24. O2 SATs 96% on 2 L nasal cannula. Of note, the patient is on chronic home O2 I believe. GENERAL: Mildly ill-appearing woman in no respiratory distress. She looks better than she has than previous hospitalizations.
PAC|premature atrial contraction|(PAC)|295|299|HOSPITAL COURSE|He has had a little bit of a headache. He underwent a CT scan of his head which only showed some mild atrophy, appropriate for age. Cardiology did see him, thinking that he was in atrial fibrillation, and determined that he was in normal sinus rhythm with numerous premature atrial contractions (PAC) and he required no further treatment. DISCHARGE PHYSICAL EXAMINATION: VITAL SIGNS: Stable. The patient is afebrile.
PAC|premature atrial contraction|(PAC).|202|207|ASSESSMENT|3. Atherosclerotic heart disease, status post coronary artery bypass. 4. Dysuria with probable urinary tract infection (UTI). 5. Hypokalemia--resolved. 6. Dyslipidemia. 7. Premature atrial contractions (PAC). DISCHARGE PLAN: We will discharge the patient to home.
PAC|premature atrial contraction|PAC.|256|259||His respiratory status was stable. He did have a complication of atrial fibrillation with intermittent rapid ventricular response which was treated with metoprolol, amiodarone and digoxin and has now converted to sinus rhythm in the 50s with an occasional PAC. Prior to discharge, he has not had any fast heart rate for the last 24 hours. He diuresed well postoperatively. His INR is therapeutic upon transfer.
PAC|premature atrial contraction|PAC.|180|183|LABORATORY DATA|Chest x-ray shows scattered fibrotic changes throughout both lungs, also the hila or prominent and somewhat displaced upward. EKG shows normal sinus rhythm, nonspecific occasional PAC. CAT scan of the chest shows no evidence of pulmonary embolism, no typical consolidation of bacterial pneumonia. There is moderate diffuse bilateral bronchiectasis, prominent cystic bronchiectasis in the right middle lobe and also changes in bilateral upper lobes to secondary retraction of hila, mucus plugging; it is suggested that these changes could be due to chronic infection.
PAC|premature atrial contraction|PAC|217|219|LABORATORY DATA|There is some ecchymosis and some slight swelling. Reflexes in the upper extremities show hyperreflexia, however, this is symmetric. LABORATORY DATA: EKG shows a sinus rhythm with a first degree AV block and isolated PAC Head CT shows no acute changes. There is opacification of the left sphenoid sinus. Myoglobin and troponin are normal, CBC is normal, coags normal, sodium 143 to is 4.1, chloride 102, bicarbonate 34, glucose 111, BUN 23, creatinine 1.24. LFTs are normal.
PAC|premature atrial contraction|PAC|124|126|LABS|NEURO EXAM: Muscle strength +5/5. Sensory is intact. Cranial nerves II-XII intact. LABS: EKG shows normal sinus rhythm with PAC and PVC on the rhythm strip. On 12-lead EKG, it shows normal sinus rhythm. Head CT is negative. Sodium 141, potassium 3.8, creatinine 0.9, BUN 13. INR is 1.
PAC|premature atrial contraction|PAC,|161|164|LABS|INR 1.07, PTT 24. Myoglobin 61, troponin 0.19. Urinalysis negative. Chest CT reveals massive bilateral pulmonary thrombus EKG shows sinus rhythm with occasional PAC, mild left ventricular hypertrophy, nonspecific ST and T wave changes. ASSESSMENT/PLAN: 1. Bilateral large pulmonary thrombus, causing shortness of breath with exertion: Given the patient's history of venostasis in his left leg secondary to a World War II injury, he most likely has a chronic deep venous thrombosis in this leg, and may have had occasional silent pulmonary emboli.
PAC|physician assistant certification|PAC,|154|157|DISCHARGE FOLLOW-UP|4. Imdur 60 mg q d. 5. Maxzide 25/37.5 mg po q d. 6. Lipitor 20 mg q d. DISCHARGE FOLLOW-UP: 1. The patient will be seeing myself, _%#NAME#%_ _%#NAME#%_, PAC, at Minnesota Heart Clinic in two weeks time. 2. In addition, he will see Dr. _%#NAME#%_, his regular cardiologist, in approximately three months for continued follow-up.
PAC|picture archiving communication|PAC|238|240|DISPOSITION AT DISCHARGE|Reflexes were brisker on the left. The patient reported reduced sensation on the left and did not identify left-sided stimuli with double simultaneous tactile stimulation. We have requested that his films be scanned for entering into the PAC system. We will assess the status of risk factor control. We will assess the intracranial vessels using MR angiography.
PAC|physician assistant certification|PAC,|142|145|DOB|However, she wanted to go to _%#CITY#%_ _%#CITY#%_ for the weekend, so she did not get seen. She was seen yesterday by _%#NAME#%_ _%#NAME#%_, PAC, at Cedar Ridge for otalgia, nasal congestion, clear yellow rhinitis, cough, fever without chills or sweats, sinus pressure, postnasal drip, and bronchospasm.
PAC|premature atrial contraction|(PAC).|194|199|PHYSICAL EXAMINATION|Mother with dementia. No diabetes in the family. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 128/60. Pulse 100 and the monitor shows normal sinus rhythm with premature atrial contractions (PAC). Temperature 100.6. Respiratory rate 18. GENERAL: He is thin. He is alert and oriented. He has a nasal duodenal tube in and Foley catheter.
PAC|premature atrial contraction|PAC|175|177|PHYSICAL EXAMINATION|Mouth shows good dentition. Posterior Pharynx: Clear. Mucous membranes are dry. NECK: Supple. No adenopathy. LUNGS: Diminished breath sounds in the bases. No wheezing. HEART: PAC with normal S1 and S2. No murmur. ABDOMEN: Normal bowel sounds. Nontender to palpation. No hepatosplenomegaly. GENITOURINARY: Foley catheter in place.
PAC|premature atrial contraction|(PAC)|187|191|EKG|NEUROLOGIC: Normal deep tendon reflexes (DTR). SKIN: Psoriatic plaques. LABORATORY DATA: Laboratory data was normal. EKG: EKG showed sinus bradycardia with a premature atrial contraction (PAC) and right bundle-branch block with a rate of 57. (I see on the monitor that his rate is changing between the 40s and 50s.)
PAC|premature atrial contraction|(PAC).|236|241|PHYSICAL EXAMINATION|ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: Buffered aspirin one q.d. PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile. Blood pressure 130s/80s. Heart rates 50s with sinus bradycardia and occasional premature atrial contraction (PAC). Respiratory rate 16. Oxygen saturation 100% on room air. GENERAL: Elderly-appearing man in no respiratory distress. He is awake, alert and oriented. He is able to give a very good history.
PAC|physician assistant certification|PAC|128|130|HISTORY OF PRESENT ILLNESS|The patient was observed and sent home with Tylenol #3 for recurrent headaches. She was followed up in the office by __________ PAC Thursday morning, noted headache had subsided but the patient was complaining of low back pain. The back pain intensified in the evening and returned to the emergency room Thursday evening with low back pain, pain in the area of where she had had the spinal tap.
PAC|post anesthesia care|PAC|113|115|HOSPITAL COURSE|The procedure was without complication. Estimated blood loss was 200 cc. The patient was then transferred to the PAC in stable condition, where she was closely monitored prior to her transfer up to the orthopedic floor. The patient was started on anticoagulation therapy with Lovenox 30 mg subq b.i.d. to be completed over seven days.
PAC|physician assistant certification|P.A.C.|145|150|RECOMMENDATIONS|She will be followed by Dr. _%#NAME#%_ over the weekend. Dr. _%#NAME#%_ will be aware of her condition after the weekend, _%#NAME#%_ _%#NAME#%_, P.A.C. will follow along with her as well.
PAC|premature atrial contraction|PAC,|286|289|PLAN|4. Anemia with hemoglobin 10.3, appears to be new. This will be evaluated as an outpatient, again this does not appear be a counter indication to stent placement. 5. No known coronary artery disease. Most recent EKG from _%#MM2002#%_, which revealed normal sinus rhythm with occasional PAC, it is of left axis deviation and right bundle branch block. An EKG was not obtained today.
PAC|patient-controlled analgesia:PCA|PAC|154|156|ASSESSMENT|At this point and time, please see orders for details. We will place her on Rocephin 2 gm every 12 hours until cultures are back as well as Solu- Medrol. PAC pump for anesthesia. Tylenol as needed. Nicoderm patch for smoking. Heating pad for comfort. Trazodone for sleep. Celexa for anxiety.
PAC|premature atrial contraction|(PAC)|166|170|HOSPITAL COURSE|He did not feel that a pacemaker was indicated at this time. The patient was monitored for 24 hours after the procedure with occasional premature atrial contractions (PAC) but no tachyarrhythmia or bradyarrhythmias. She was ambulatory without difficulty. Her groin site was clean and dry and pulses were normal. This patient had been on hydrochlorothiazide and subsequently developed hypokalemia.
PAC|picture archiving communication|PAC|250|252|LABS|PAC viewer error occurred and no images are viewable. EKG bradycardia 60 beats per minute, sinus rhythm. No acute ST-T wave changes. Urinalysis negative. Hemoglobin 13.6. Potassium 4.1. INR 1.03. X-ray of femur and hip also verbal report only as the PAC viewer not currently functioning, unable to access the images, but by verbal report the right intertrochanteric femur fracture.
PAC|post anesthesia care|PAC|297|299|HOSPITAL COURSE|ADMISSION/DISCHARGE DIAGNOSES: Morbid obesity. SERVICE: Surgery. HOSPITAL COURSE: On _%#DDMM2004#%_ _%#NAME#%_ _%#NAME#%_, a 33-year-old female, was admitted to the hospital and prepared for a Roux-en-Y gastric bypass surgery. The patient tolerated the surgery very well and was discharged to the PAC unit. The patient was then admitted to Surgical Specialties, station 33, where she continued to make excellent progress. At the time of discharge, the patient was ambulating well, had no nausea or vomiting, and pain management was good.
PAC|premature atrial contraction|(PAC)|302|306|HOSPITAL COURSE|He attributes this to leaning on the cardiac monitor. Again the patient was counseled that we would recommend him staying over the weekend to have an adenosine thallium test to be done on Monday and the patient refuses to do this. The patient does have a known history of premature atrial contractions (PAC) and his monitor did show these. He has enough of his medications including fresh nitroglycerin. He was counseled that if he develops chest pain or any worsening symptoms he should return to the emergency room.
PAC|physician assistant certification|PAC,|161|164|CHIEF COMPLAINT|CHIEF COMPLAINT: Left wrist pain. _%#NAME#%_ _%#NAME#%_ is an 85-year-old gentleman who was seen at Quello on Friday _%#MM#%_ _%#DD#%_ by _%#NAME#%_ _%#NAME#%_, PAC, diagnosed with possible cellulitis and then thought that it also may be gout. The patient was placed on Indocin and Prednisone.
PAC|premature atrial contraction|PAC|115|117|IMPRESSION|IMPRESSION: 1. Foot discomfort, as per Dr. _%#NAME#%_. 2. Intermittent mitral valve prolapse. She does have a rare PAC in her electrocardiogram today when I had her lay on her left side. 3. Hypothyroid. 4. Hyperlipidemia. 5. Small left axillary lymph node, unchanged.
PAC|(drug) PAC|PAC|141|143|MEDICATIONS|2. Tequin 200 mg daily 3. Lactulose 30 cc b.i.d. 4. Slo-Mag 64 mg every other day 5. Aldactone 50 mg b.i.d. 6. Demadex 20 mg b.i.d. 7. Entex PAC one tablet each morning for the last couple days. 8. She is on Risperdal 0.25 mg prn. for severe anxiety 9. Darvocet and Tylenol for pain 10. The patient has been on Cephalosporins and Penicillins during the past month and a half without any difficulty She lives at a _%#CITY#%_ Nursing home.
PAC|physician assistant certification|PAC|151|153|ADMISSION DIAGNOSIS|Use a walker or cane. She should elevate and ice it for the next week. She will follow up in 2 weeks with Dr. _%#NAME#%_, his nurse, or _%#NAME#%_ the PAC and in 6 weeks with Dr. _%#NAME#%_. She should keep her case clean and dry until that time.
PAC|premature atrial contraction|(PAC)|236|240|PHYSICAL EXAMINATION|No lymphadenopathy. No thyromegaly. Negative jugular venous distention (JVD). LUNGS: Clear to auscultation bilaterally without any wheezes, rhonchi, or rales. HEART: Slightly irregular with some occasional premature atrial contractions (PAC) with regular rate. No murmurs, rubs or gallops noted.. ABDOMEN: Soft with positive bowel sounds, nondistended and nontender to palpation.
PAC|premature atrial contraction|(PAC),|162|167|EKG|Palpable dorsalis pedis and posterior tibial pulses. NEUROLOGIC: She moves all extremities easily. EKG: EKG shows sinus rhythm with premature atrial contractions (PAC), Q waves in leads III and aVF, flattened ST in lead I, T wave inversion in aVL. LABORATORY DATA: BNP 229. Potassium slightly elevated at 5.4. BUN 26, creatinine 1.55, glucose 126.
PAC|premature atrial contraction|PAC,|386|389|LABORATORY DATA|LABORATORY DATA: INR is 1.21, PTT 30, troponin less than 0.07, myoglobin 648, blood cultures pending, white count 10.5, hemoglobin 15.2, platelets 211,000, sodium 139, potassium 3.9, chloride 105, bicarb 22, BUN 36, creatinine 1.39, glucose 114, and liver function tests are normal. Chest x-ray reveals right lower lobe posterior infiltrate. Electrocardiogram reveals sinus rhythm, one PAC, and no significant STT wave changes. ASSESSMENT/PLAN: 1. Sepsis with aspiration pneumonia and possible necrotizing fasciitis of the abdomen, status post left inguinal herniorrhaphy.
PAC|post anesthesia care|PAC|264|266|HOSPITAL COURSE|HOSPITAL COURSE: On _%#MM#%_ _%#DD#%_, 2005, the patient underwent a right calcaneal osteotomy, advancement of the tibialis posterior tendon and Strayer gastroc lengthening. She tolerated the procedure well, was extubated in the operating room, transferred to the PAC and then transferred to the general care floor in stable condition. Postoperatively, her pain was first controlled with IV pain medications and then transitioned to oral pain medication.
PAC|premature atrial contraction|PAC|221|223|PHYSICAL EXAMINATION|LUNGS: Crackles at the bases, lower 1/3 bilaterally and occasional crackle in the upper air field. There are no wheezes. Airflow is fair-to- good. CARDIAC: Tachycardic. Heart rate estimated at 100 with occasional PVC and PAC on telemetry. Neck veins are flat. No appreciable carotid bruits. There is a II/VI systolic murmur at the aortic area. There is no appreciable S3 or S4. ABDOMEN: Soft. Bowel sounds present and of normal character.
PAC|premature atrial contraction|(PAC).|327|332|EKG|LABORATORY DATA: Hemoglobin 12.6, platelet count 292, white blood cell count 8.1. Sodium 135, potassium 3.8, chloride 98, bicarbonate 25, BUN 20, creatinine 0.9, glucose 99, calcium 8.8. INR 1.04. Troponin 0.08. BNP 188. EKG: EKG shows left ventricular hypertrophy (LVH), normal sinus rhythm, with premature atrial contraction (PAC). Inferior Q waves consistent with old inferior myocardial infarction. Poor R wave progression. IMPRESSION/PLAN: _%#1914#%_-year-old with right facial droop which has resolved.
PAC|premature atrial contraction|PAC|221|223|PHYSICAL EXAM|OROPHARYNX - pink and moist, no lesions noted. NECK - supple, no lymphadenopathy or thyromegaly noted. LUNGS - clear to auscultation bilaterally. CARDIOVASCULAR - regular rate and rhythm, intermittent occasional possible PAC or PVC. Very slight 2/6 systolic murmur heard best along the left sternal border. ABDOMEN - soft, nontender, nondistended. Positive bowel sounds, no hepatosplenomegaly appreciated.
PAC|premature atrial contraction|PAC|196|198|HISTORY OF PRESENT ILLNESS|Post procedure the patient continued to have sinus tachycardia likely related to her underlying severe pulmonary disease with frequent PACs. It was therefore decided to continue her Diltiazem for PAC suppression but to discontinue her digoxin, as she will no longer need both of these medications for rate control after the ablation procedure.
PAC|premature atrial contraction|PAC.|157|160|OBJECTIVE|LUNGS: Clear. No crackles, rhonchi or wheezes. HEART: Normal S1, S2, without murmurs, rubs or gallops. She has an occasional which on the monitor was like a PAC. ABDOMEN: Soft and nontender. No bowel sounds, no masses. EXTREMITIES: Good pedal pulses, no edema. SKIN: Normal. NEURO: Normal. Her EKG today really shows nothing but sinus arrhythmia and no sign of ischemia in her ST segments or T waves.
PAC|premature atrial contraction|PAC|133|135|HOSPITAL COURSE|She underwent an echocardiogram which revealed a severe aortic stenosis. They felt she was more in a sinus tachycardia with frequent PAC pattern. They did not believe this needed to be treated at this time. However, because of her history of a stroke, she was started on aspirin and Plavix.
PAC|prostate-specific antigen:PSA|PAC|145|147|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Non-small cell lung cancer as outlined above. 2. Prostate cancer, status-post prostatectomy in 1995, with slowly rising PAC as above. 3. Chemotherapy related anemia and anemic of chronic disease. SOCIAL HISTORY: He is married and lives with his wife.
PAC|premature atrial contraction|PAC,|153|156|PROBLEM #4|This was then converted to p.o. medications at time of discharge. PROBLEM #4: Cardiovascular. History of hypertension. Her initial EKG showed occasional PAC, but otherwise within normal limits, and patient was on her usual home medications. PROBLEM #5: Pulmonary. No issues. PROBLEM #6: GI. See above.
PAC|premature atrial contraction|(PAC).|244|249|PHYSICAL EXAMINATION|He is married. PHYSICAL EXAMINATION: At this point in time the patient is in the Intensive Care Unit (ICU) on the ventilator on controlled monitor ventilation regime. VITAL SIGNS: Pulse 60 per minute with frequent premature atrial contractions (PAC). Blood pressure 130/70. GENERAL: He is unconsciousness. He cannot be waken up by calling his name or asking him to open his eyes.
PAC|physician assistant certification|P.A.C.,|152|158|DISCHARGE DIAGNOSES|DISCHARGE DISPOSITION: This patient will be discharged to home in the care of herself and her family. FOLLOW-UP: 1. She will see _%#NAME#%_ _%#NAME#%_, P.A.C., for Dr. _%#NAME#%_ _%#NAME#%_ in three weeks which is scheduled on _%#DDMM2005#%_, at 7:30 a.m., _%#CITY#%_ office of Minnesota Heart Clinic.
PAC|premature atrial contraction|PAC,|104|107|FAMILY HISTORY|His daughter is here with him along with his wife. He is a retired engineer. FAMILY HISTORY: Father had PAC, had a cancer, but otherwise is fairly negative review. REVIEW OF SYSTEMS: He says vision is okay. Hearing is somewhat diminished.
PAC|premature atrial contraction|PAC.|193|196|ADDENDUM|5. Gastroesophageal reflux. 6. Anxiety and depression. 7. Distant history of deep vein thrombophlebitis, none present at this time. ADDENDUM: EKG shows a normal sinus rhythm with an occasional PAC. Chest x-ray shows a cardiothoracic ratio of 13:28. No evidence of heart failure. Normal heart size and clear lungs at this time. It should be noted that this lady will need an internist to follow her at Fairview Ridges in relationship to her many problems as outlined above and most specifically her diabetes.
PAC|premature atrial contraction|(PAC)|218|222|DISCHARGE DIAGNOSES|1. Cholecystitis with cholelithiasis requiring laparoscopic cholecystectomy. 2. Abnormal liver function tests, status post liver biopsy (report pending at time of discharge). 3. Increased premature atrial contractions (PAC) likely driven by the cholecystitis. No evidence of atrial fibrillation was identified while he was hospitalized. 4. Hydrocele. DISCHARGE MEDICATIONS: None.
PAC|post anesthesia care|PAC|224|226|ADMISSION DIAGNOSIS|However, upon extubation, the patient was noted to be unresponsive and had difficulty breathing and therefore had to be reintubated. However, after re- extubation, the patient was able to wake up and the rest of the stay at PAC was uneventful. Postoperatively there was noted intact motor and sensory function of the left lower extremity. The drain was pulled out several hours after the procedure.
PAC|premature atrial contraction|PAC,|96|99|PHYSICAL EXAMINATION|EXTREMITIES: Normal NEUROLOGIC: No deficits. SKIN: No worrisome lesions EKG shows sinus rhythm, PAC, otherwise normal. Troponins negative. Electrolytes are normal. INR is 1.10. D-dimer is elevated at 1.0. Hemoglobin is 6.7, white count 10.4, platelet count 483,000.
PAC|physician assistant certification|PAC.|226|229|ASSISTANT|PREOPERATIVE DIAGNOSIS: Morbid obesity. POSTOPERATIVE DIAGNOSIS: Morbid obesity. PROCEDURE: Laparoscopic Roux-en-Y on _%#DDMM2005#%_. COMPLICATIONS: None. SURGEON: _%#NAME#%_ _%#NAME#%_, M.D. ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC. PRIMARY CARE PHYSICIAN: _%#NAME#%_ _%#NAME#%_, M.D. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 50-year-old, Caucasian female, who presented with morbid obesity since age 22.
PAC|premature atrial contraction|PAC|184|186|LABORATORY DATA|Reflexes are full and symmetric. Gait is normal based and steady. LABORATORY DATA: Electrolytes: BUN and creatinine are unremarkable. CBC is unremarkable. Head CT is normal. EKG shows PAC but otherwise normal sinus rhythm. ASSESSMENT: 1. Probable transient ischemic attack. We will check carotid ultrasound and cardiac echo.
PAC|post anesthesia care|PAC|238|240|HISTORY OF PRESENT ILLNESS|The femoral head deformity resembles slipped capital femoral epiphysis. It was elected to proceed with the above procedure, due to progress of debilitating symptoms. The patient tolerated the procedure well, and he was transferred to the PAC unit in stable condition. Postoperatively, his pain was controlled initially using PCA. Subsequently, oral Percocet. He was allowed ambulation with weight bearing as tolerated. He was also allowed to resume his routine medication as well as a regular diet.
PAC|physician assistant certification|PAC|268|270|FIRST ASSISTANT|DISCHARGE DIAGNOSIS: Ruptured left iliac aneurysm. PROCEDURE: Repair of bilateral iliac aneurysm, including the ruptured left iliac aneurysm with an 18- x 9.0-mm aortobiiliac bypass graft. SURGEON: _%#NAME#%_ _%#NAME#%_, MD FIRST ASSISTANT: _%#NAME#%_ _%#NAME#%_, MS, PAC HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was admitted to Fairview Southdale Hospital through the emergency room with a chief complaint of back pain and left lower quadrant pain.
PAC|premature atrial contraction|(PAC),|190|195|EKG|No reproducible chest pain. ABDOMEN: Soft. Bowel sounds present. EXTREMITIES: Lower extremities have very mild edema. EKG: EKG shows sinus rhythm with frequent premature atrial contractions (PAC), premature ventricular contractions (PVC) and sinus arrhythmia. The P-R interval is normal. QRS complex shows old Q waves in the inferior leads.
PAC|physician assistant certification|PAC|206|208|ASSISTANT|PREOPERATIVE DIAGNOSIS: Acute cholecystitis. POSTOPERATIVE DIAGNOSIS: Acute cholecystitis. PROCEDURE: Laparoscopic cholecystectomy, uncomplicated. SURGEON: Dr. _%#NAME#%_. ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ had an essentially benign postoperative course.
PAC|premature atrial contraction|PAC|208|210|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient was alert, no acute distress epigastric discomfort was gone VITAL SIGNS: Systolic blood pressure 170, pulse is regular. On the monitor the patient had an occasional PAC and occasional PVC. O2 saturation on room air 100%. Respirations not labored. MENTAL STATUS: Clear and appropriate. He is alert elderly male in no acute distress. HEENT: Left cataract extraction.
PAC|premature atrial contraction|PAC|310|312|LABORATORY DATA|LABORATORY DATA: White count of 5900, hemoglobin 12.7, sodium 142, potassium 4, glucose 104, urea nitrogen 16, creatinine 1.06. Liver function tests normal. Troponin negative, myoglobin negative. Lipase normal. EKG shows sinus bradycardia, slight nonspecific ST-T wave changes, again monitor showed occasional PAC and PVC. Chest x-ray: No active lung disease seen. There was a double shadow seen in the area under the left hemidiaphragm.
PAC|physician assistant certification|PAC.|177|180|FOLLOW UP|Vistaril 25 to 50 mg p.o. q.4-6h. p.r.n., 80 were given, Colace 100 mg p.o. b.i.d. FOLLOW UP: He will follow up in 2 weeks with Dr. _%#NAME#%_'s nurse or _%#NAME#%_ _%#NAME#%_, PAC. He will follow up in 3 days with his primary care physician for Foley catheter removal and a trial of voiding.
PAC|picture archiving communication|PAC|193|195|HISTORY OF PRESENT ILLNESS|Since then, the patient has noted that his urine is tea-colored. He still has pain in his knees. He had x-rays of his knees in the Emergency Room, the results of these are not available on the PAC system. The patient says he has had a cold for the last week.
PAC|picture archiving communication|PAC|236|238|LABORATORY & DIAGNOSTIC DATA|Urinalysis showed brown turbid in color, trace ketones, blood large, protein greater than 300, 0-2 WBCs, 5-10 RBCs, 25-50 granular casts and many amorphous urates. X-rays of his knees done in the Emergency Room are not available on the PAC system. ASSESSMENT/PLAN: 1. Bilateral knee pain after fall. We will have Ortho see him in the morning.
PAC|physician assistant certification|P.A.C.,|258|264|HISTORY OF PRESENT ILLNESS|His ejection fraction by echocardiography recently was 25% and continues to be 25-30% by left ventriculogram in the Cath Lab yesterday. His ejection fraction does fit with Madit-II criteria. I will defer further discussions of this to _%#NAME#%_ _%#NAME#%_, P.A.C., and Dr. _%#NAME#%_ _%#NAME#%_. HOSPITAL COURSE: The patient was electively admitted and underwent successful percutaneous coronary intervention with Cypher drug-alluding stent placement to the right coronary artery without complications.
PAC|physician assistant certification|P.A.C.,|233|239|HISTORY OF PRESENT ILLNESS|DISCHARGE DISPOSITION: 1. The patient will be discharged to home later this morning in the care of his wife. 2. He will have an INR drawn at Minnesota Heart Clinic on _%#DDMM2005#%_ at 10:45 AM. 3. He will see _%#NAME#%_ _%#NAME#%_, P.A.C., with Dr. _%#NAME#%_ _%#NAME#%_ in 1-2 weeks. 4. He will need an adenosine walking thallium stress test in six months and a visit with Dr. _%#NAME#%_ at that time.
PAC|premature atrial contraction|PAC|212|214|HISTORY OF PRESENT ILLNESS|His platelet count went to as low as 18 and he had 6 units of platelet transfusions. He also received about 3 liters of normal saline for orthostatic hypotension. His EKG showed sinus tachycardia with occasional PAC and PVCs. The patient was seen by Dr. _%#NAME#%_, who is a hematologist/oncologist yesterday. Because of orthostatic hypotension he continues to be weak and not able to participate in rehabilitation.
PAC|physician assistant certification|PAC.|180|183|ASSISTANT|PREOP DIAGNOSIS: Morbid obesity. POSTOP DIAGNOSIS: Morbid obesity. SURGICAL PROCEDURE: Laparoscopic Roux-en-Y. SURGEON: _%#NAME#%_ _%#NAME#%_, MD ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC. PRIMARY CARE PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ underwent laparoscopic Roux-en-Y on _%#DDMM2005#%_ under general anesthesia uncomplicated with minimal blood loss.
PAC|physician assistant certification|PAC.|137|140|ASSISTANT|PROCEDURE: Laparoscopic Roux-en-Y gastric bypass, incidental cholecystectomy. SURGEON: Dr. _%#NAME#%_. ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 56-year-old woman who has had a 40-year struggle with her weight.
PAC|premature atrial contraction|PAC,|139|142|HOSPITAL COURSE|The patient's symptoms improved and he can ambulate in the corridor and walk around without any limitation. An EKG monitor only shows some PAC, but no other arrhythmia. The patient is stable to go home.
PAC|physician assistant certification|PAC)|172|175|DISCHARGE  INSTRUCTIONS|2. He will follow up with Dr. _%#NAME#%_ _%#NAME#%_ at Minnesota Heart Clinic in ten weeks. 3. He will follow up with nurse practitioner (_%#NAME#%_ _%#NAME#%_ _%#NAME#%_, PAC) on _%#DDMM2006#%_ at 9:30 a.m. 4. He is tentatively scheduled for an electrophysiology study and possible ICD placement on _%#DDMM2006#%_ at 9:00 a.m.
PAC|post anesthesia care|PAC|174|176|HOSPITAL COURSE|The above-mentioned surgery was done under spinal anesthesia. The patient tolerated the surgery and the anesthesia very well. Post surgery the patient was transferred to the PAC Unit in stable condition and subsequently to the floor. On the floor, the patient was put on IV antibiotics for 24 hours.
PAC|premature atrial contraction|PAC.|130|133|LABORATORY|Other neurological exam was grossly normal. LABORATORY: He has an EKG, which showed sinus rhythm (regular rhythm) with occasional PAC. His labs revealed a negative UA. Glucose 93. White cell count of 4.7, hemoglobin 10.6, platelet 333. ANC 2.9. Sodium 141, potassium 4.1, urea 9. Creatinine 9.85. His LFTs were in the normal range.
PAC|physician assistant certification|PAC,|263|266|LABORATORY DATA|Lipid panel from our clinic on _%#MM#%_ _%#DD#%_ showed a total cholesterol of 225, triglycerides 269, LDL 139, HDL 32 and as noted, ALT 27. Dr. _%#NAME#%_ recommended her Zocor be increased on the recommendation of 20 mg daily recently by _%#NAME#%_ _%#NAME#%_, PAC, to 40 mg q.h.s. Certainly we need to keep close tabs on her liver enzymes with this level of Zocor starting.
PAC|picture archiving communication|PAC|131|133|PHYSICAL EXAMINATION|PSYCHIATRIC: Awake, alert, oriented times three. Head CT no acute pathology. No evidence of bleed. Chest x-ray by report negative. PAC system is down and films are unavailable for personal review. LABORATORY: Myoglobin 103, troponin less than 0.07, INR 1.03, sodium 137, potassium 4.1, chloride 99, bicarbonate 30, BUN 30, creatinine 1.16, white count 4.4, hemoglobin 12.3, platelets 200,000.
PAC|physician assistant certification|PAC.|294|297|ASSISTANT|PREOPERATIVE DIAGNOSIS: Morbid obesity. POSTOPERATIVE DIAGNOSIS: Morbid obesity. PROCEDURE: Laparoscopic converted to open Roux-en-Y gastric bypass procedure with placement of gastrostomy tube and JP drain; cholecystectomy. SURGEON: Dr. _%#NAME#%_ _%#NAME#%_. ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC. REFERRING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_. HOSPITAL COURSE:_%#NAME#%_ _%#NAME#%_ is a 43-year-old man.
PAC|physician assistant certification|PAC|223|225|ASSISTANT|PRE-OPERATIVE DIAGNOSIS: Morbid obesity. POST-OPERATIVE DIAGNOSIS: Morbid obesity. PROCEDURE: Laparoscopic gastric bypass and incidental cholecystectomy. SURGEON: _%#NAME#%_ _%#NAME#%_, MD ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC Admission BMI: 44.4. Weight: 275.3 Height: 5 foot 6 inches HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ underwent gastric bypass and incidental cholecystectomy under general anesthesia uncomplicated.
PAC|premature atrial contraction|PAC|172|174|LABORATORY DATA|NEUROLOGIC: He has no focal neurologic abnormalities at this time. LABORATORY DATA: His EKG in the past shows sinus rhythm, borderline first degree AV block and occasional PAC and irregular beats. His INR is pending this morning as is basic metabolic panel. His hemoglobin today is 11.1. He did have an adenosine nuclear which will be faxed to hospital and is in the Fairview Southdale records and a recent echocardiogram which are reassuring.
PAC|physician assistant certification|PAC:|264|267|SURGEON|PREOPERATIVE DIAGNOSIS: Morbid obesity. POSTOPERATIVE DIAGNOSIS: Morbid obesity. PROCEDURE: Laparoscopic gastric bypass (Roux-en-Y) and incidental cholecystectomy. PRIMARY PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD, Internal Medicine. SURGEON: _%#NAME#%_ _%#NAME#%_, MD PAC: _%#NAME#%_ _%#NAME#%_ HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ underwent laparoscopic gastric bypass and laparoscopic cholecystectomy under general anesthesia uncomplicated.
PAC|premature atrial contraction|PAC|298|300|LABORATORY DATA|NEURO: Symmetric. LABORATORY DATA: Hemoglobin of 12.3, white count 5.7, platelet count 258,000, glucose 97, sodium 145, potassium 4.4, chloride 106, CO2 26, BUN 22, creatinine 0.7, calcium 9.0. Urinalysis was normal. No evidence of infection. Electrocardiogram shows a normal sinus rhythm with one PAC and is otherwise entirely normal. Chest x-ray shows clear lungs with cardiothoracic ratio of 13 to 27 that is unchanged from 2004. IMPRESSION: This is a 71-year-old white female scheduled for varicose vein surgery on her left lower extremity by Dr. _%#NAME#%_ on _%#MMDD2006#%_ at Fairview Southdale Hospital.
PAC|premature atrial contraction|PAC,|125|128|LABORATORY DATA|She is alert. LABORATORY DATA: Shows an EKG which I interpret as sinus bradycardia with first degree AV block and occasional PAC, not atrial fibrillation. Urinalysis shows a large amount of blood, negative leukocyte esterase, negative nitrite, there are many bacteria present, there are red cells present.
PAC|premature atrial contraction|(PAC).|218|223|EKG|EXTREMITIES: Warm and well perfused. No edema. LABORATORY DATA: Hemoglobin 16.2 today. EKG: EKG shows normal sinus rhythm of 60 beats per minute, partial right bundle-branch block, and one premature atrial contraction (PAC). No acute ST-T wave changes. Otherwise normal EKG. ASSESSMENT: 70-year-old female cleared for upcoming vitrectomy.
PAC|premature atrial contraction|PAC|375|377|IMPRESSION|Glucose 120. Liver function tests normal. Potassium 4.1, uric acid 5.4, magnesium 1.8. PTT 32.3. IMPRESSION: Patient is a relatively low risk candidate for the above procedure with the exception of having a past TIA in _%#MM#%_, 2006, mildly positive lupus anticoagulant, and atrial fibrillation intermittently. On today's exam he appears to have some sinus bradycardia with PAC couplets. PLAN: 1. At this time, I would decrease his metoprolol to 25 mg b.i.d.
PAC|post anesthesia care|PAC|248|250|HISTORY OF PRESENT ILLNESS|The patient expressed his desire to proceed. The patient was admitted on _%#MM#%_ _%#DD#%_, 2005, to have his knee revised. The patient underwent the procedure on the same day. The patient tolerated the procedure well and he was transferred to the PAC unit in stable condition. Postoperative course was in the PAC unit. The patient developed rapid atrial fibrillation.
PAC|post anesthesia care|PAC|186|188|HISTORY OF PRESENT ILLNESS|The patient underwent the procedure on the same day. The patient tolerated the procedure well and he was transferred to the PAC unit in stable condition. Postoperative course was in the PAC unit. The patient developed rapid atrial fibrillation. Due to the rapid atrial fibrillation, the patient was transferred to the ICU for cardioversion.
PAC|physician assistant certification|PAC.|250|253|ASSISTANT|PREOPERATIVE DIAGNOSIS: Cholecystitis. POSTOPERATIVE DIAGNOSIS: Cholecystitis. PROCEDURE: Laparoscopic converted to open cholecystectomy on _%#DDMM2005#%_ at around 7 p.m. SURGEON: Dr. _%#NAME#%_ and Dr. _%#NAME#%_. ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC. The procedure was done under general. Estimated blood loss 280 cc. Drain was placed in the gallbladder fossa.
PAC|premature atrial contraction|PAC|167|169|PHYSICAL EXAMINATION|CARDIOVASCULAR: Regular rate and rhythm with normal S1, S2. ABDOMEN: Positive bowel sounds, soft and nontender. EXTREMITIES: No edema. EKG shows sinus rhythm with one PAC LABORATORY DATA: His TSH was 1.83. Electrolytes: Sodium 139, potassium 4.2, chloride 101, bicarbonate 27, glucose 92, BUN 19, creatinine 1.08, calcium 9.4, INR 0.91, PTT of 27.
PAC|premature atrial contraction|PAC|128|130|PHYSICAL EXAMINATION|HEART: S1, S2. with a 1/6 systolic ejection murmur. There is again the bradycardic rate with a normal rhythm with an occasional PAC noted. ABDOMEN: Soft, nontender, nondistended with good bowel sounds. No hepatosplenomegaly. BACK: No CVA or flank tenderness. EXTREMITIES: Full and symmetric range of motion throughout with good strength and pulses.
PAC|physician assistant certification|PAC|156|158|SURGEON|DIAGNOSIS: Lower gastrointestinal bleed PROCEDURE: Subtotal colectomy SURGEON: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, M.D. 1ST ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC _%#NAME#%_ _%#NAME#%_ is a 40-year-old male who had a history of multiple episodes of bright red blood per rectum which he states had started approximately _%#MM2006#%_.
PAC|patient-controlled analgesia:PCA|PAC|186|188|ASSESSMENT AND PLAN|In addition will check UA. 2. Chronic abdominal pain with associated increased nausea and retching recently along with increased loose stools. We will continue analgesics and methadone. PAC initially. Antiemetics p.r.n. Check stool cultures. 3. Low thyroid. Restart Synthroid, recheck TSH.
PAC|physician assistant certification|PAC|120|122|SURGEON|Debridement of ulcers right foot. SURGEON: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, M.D. 1ST ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC HISTORY OF THE PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 81-year-old white female with an extensive past medical history who presented with increasing redness in the right foot.
PAC|post anesthesia care|PAC|213|215|HOSPITAL COURSE|HOSPITAL COURSE: The patient was admitted on the day of the operation and underwent the above operation without complication. The patient received perioperative antibiotics. He was subsequently transferred to the PAC unit to the floor for further observation and management. The patient was maintained initially on a PCA for pain control and slowly transitioned to oral medications.
PAC|premature atrial contraction|PAC.|117|120|LABORATORY DATA|In _%#MM#%_, 2000 she had a hemoglobin of 12.2 with MCV of 77. EKG shows a sinus rhythm, rate of 86 with an isolated PAC. IMPRESSION: _%#1914#%_-year-old woman who fell, possibly related to a syncopal spell.
PAC|premature atrial contraction|(PAC)|234|238|DISCHARGE DIAGNOSIS|1. Dilated cardiomyopathy of unknown etiology. 2. Ischemic cardiomyopathy. 3. First-degree heart block and left bundle-branch block. Marked sinus bradycardia and hypersensitive carotid sinus syndrome. 4. Premature atrial contractions (PAC) and premature ventricular contractions (PVC). 5. Pulmonary hypertension. 6. Aortic root dilatation. HISTORY OF PRESENT ILLNESS: Briefly, _%#NAME#%_ _%#NAME#%_ is a patient of Dr. _%#NAME#%_'s.
PAC|premature atrial contraction|PAC.|176|179|PHYSICAL EXAMINATION|NEUROLOGIC: The patient is alert and oriented x3. Ambulation is slow but confident. Chest x-ray is normal. ECG shows normal sinus rhythm with a rate of 65. There is occasional PAC. ST-T wave abnormalities are present in the anterior and lateral leads. IMPRESSION: An 85-year-old woman with vascular ulcer at the right ankle scheduled to undergo angiography and possible angiographic vs surgical revascularization.
PAC|premature atrial contraction|PAC.|173|176|LABORATORY DATA|EXTREMITIES: Good peripheral pulses. No pedal edema. LABORATORY DATA: Hemoglobin 16.1. White blood cell count 4,500. EKG is within normal limits. He does have an occasional PAC. There is no current atrial fibrillation. Potassium is pending at the time of dictation. Chest x-ray is clear. ASSESSMENT: The patient has clearance for the above surgery.
PAC|post anesthesia care|PAC|312|314|HOSPITAL COURSE|The patient was medically cleared prior to his surgery. He was brought to the operating room on _%#DDMM2002#%_ where a successful left open reduction and internal fixation of the left ankle was performed without any difficulties. Estimated blood loss was less than 15 ml. The patient was then transferred to the PAC in stable condition where he was closely monitored prior to his transfer up to the orthopedic floor. The patient ambulated well with the use of crutches. It was felt suitable to discharge the patient to his home as his pain was well tolerated with Percocet.
PAC|post anesthesia care|PAC|115|117|HOSPITAL COURSE|The procedure was without complications. Estimated blood loss was 1700 cc. The patient was then transferred to the PAC in stable condition, where she was closely monitored prior to her transfer up to the orthopedic floor. The patient was started on DVT prophylaxis of Lovenox 30 mg subq b.i.d. to be completed over a total of seven days.
PAC|premature atrial contraction|(PAC).|160|165|HOSPITAL COURSE|Dr. _%#NAME#%_ was consulted and she underwent successful cardioversion on _%#DDMM2002#%_ resulting in sinus rhythm with frequent premature atrial contractions (PAC). She was continued on her beta blocker and chronic anticoagulation. She refused stronger antiarrhythmic therapy. Drs. _%#NAME#%_ and _%#NAME#%_ commented that if she would revert back to atrial fibrillation, the best plan would be rate control without repeated attempts at cardioversion.
PAC|premature atrial contraction|PAC.|250|253|OBJECTIVE|No arthralgias or rash. No focal neurologic complaints. OBJECTIVE: General: This is a relatively well-preserved elderly male in no distress. He is alert and oriented. Vital signs: Blood pressure 144/78, heart rate 60s to 80s, regular with occasional PAC. O2 sat 97% on one liter. Urine output 325 last shift. HEENT: Head atraumatic. Extraocular movements full. No Nystatin. Pupils equal and reactive symmetrically.
PAC|premature atrial contraction|PAC,|147|150|LABORATORY DATA|Troponin is less than 0.3. Chest x-ray per ER MD shows negative infiltrate. EKG by my interpretation shows sinus tachycardia, rate 106, occasional PAC, no ST-T changes to suggest ischemia. ASSESSMENT AND PLAN: An 82-year-old woman with a history of asthma and allergies as well as supraventricular tachycardia, who was admitted with over a week history of asthma exacerbation, also currently hypertensive and tachycardic.
PAC|post anesthesia care|PAC|133|135|HOSPITAL COURSE|The patient tolerated the procedure well. There were no complications. He was extubated in the operating room and transferred to the PAC in stable condition. On postoperative day #1, his magnesium was replaced, and his liver function tests were within normal limits.
PAC|premature atrial contraction|PAC,|181|184|EKG|X-RAY: Chest x-ray shows cardiomegaly, no infiltrate or effusion, some mild pulmonary vascular congestion (preliminary read by myself). EKG: EKG shows sinus tachycardia, occasional PAC, some intraventricular conduction delay and T wave inversion at III and AVF. LABORATORY DATA: None for review at present. IMPRESSION/PLAN: 1. Cyanosis and hypoxia.
PAC|premature atrial contraction|(PAC)|148|152|DISCHARGE DIAGNOSES|PRIMARY PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD (Southdale Family Practice) DISCHARGE DIAGNOSES: 1. Vasovagal syncope. 2. Premature atrial contraction (PAC) on telemetry. 3. Recent stroke, without evidence of recurrent stroke. 4. Oral candidiasis. 5. Diastolic dysfunction on echocardiogram. PROCEDURES AND TESTS: 1. Admission chemistry is remarkable for a potassium of 2.8, BUN 17, creatinine 0.9. Lipase elevated at 279 with normal liver function studies.
PAC|post anesthesia care|PAC,|180|183|HOSPITAL COURSE|Frozen section was sent, and it came back preliminary diagnosis of lymphoma. The patient tolerated the procedure well, was extubated in the operating room, then transferred to the PAC, then transferred to the general care floor in stable condition. She used a sling for comfort, and she was started back again on her PCA.
PAC|premature atrial contraction|(PAC).|206|211|PHYSICAL EXAMINATION|Thyroid gland is not palpably enlarged. No neck masses. LUNGS: Clear to percussion and auscultation. HEART: Heart sounds were rather distant, normal S1 and S2, with occasional premature atrial contractions (PAC). LYMPHATICS: Negative. ABDOMEN: Nontender. No mass is detected. RECTAL: Deferred at this time. EXTREMITIES: No edema. Good pedal pulses and posterior tibial pulses.
PAC|premature atrial contraction|(PAC)|202|206|HOSPITAL COURSE|He was also given albuterol and Atrovent nebulizers. He improved and remained afebrile through the course of his admission. Electrocardiogram showed sinus tachycardia with premature atrial contractions (PAC) complexes and a right bundle-branch block with a left anterior bifascicular block. It should be noted that his diarrhea cleared and that culture results were entirely negative and this was most likely on a viral basis.
PAC|premature atrial contraction|(PAC)|153|157|HOSPITAL COURSE|The patient was no longer inducible into her atrial flutter. Post-procedure she did have occasional sinus tachycardia with premature atrial contractions (PAC) and premature ventricular contractions (PVC) but no other significant SVT. She developed some mild hypotension the day after the procedure.
PAC|premature atrial contraction|PAC|159|161|OBJECTIVE|LUNGS: Were clear to auscultation. No rales, rhonchi or wheezing is present. CARDIOVASCULAR: Regular rate and rhythm. She has what appears to be an occasional PAC present. However, she only has a I/VI systolic ejection murmur present, best heard at the left sternal border. I did not hear any gallops today. She has no carotid or abdominal bruits detected.
PAC|post anesthesia care|PAC|132|134|HOSPITAL COURSE|The induction of general endotracheal anesthesia as well as the procedure itself was uneventful, and the patient was brought to the PAC in satisfactory condition. Postoperatively there was not of intact motor and sensory function. The wound was noted to be clean, dry, and with no signs of infection.
PAC|premature atrial contraction|PAC.|324|327|LABORATORY DATA|She does not appear to have any memory defects. LABORATORY DATA: Laboratory studies: Electrolytes were normal with a normal creatinine. Urinalysis was normal. INR was 1.86 on admission. White count is normal with normal hemoglobin 11.9. EKG shows incomplete left bundle branch block with largely paced rhythm and occasional PAC. ASSESSMENT/PLAN: 1. Hip fracture, severity is being investigated by Dr. _%#NAME#%_.
PAC|physician assistant certification|PAC|168|170|DISCHARGE FOLLOW-UP|8. Imdur 60 mg p.o. q.d. (new dose). 9. Norvasc 5 mg p.o. q.d. (newly added medication) DISCHARGE FOLLOW-UP: 1. The patient is to follow up with _%#NAME#%_ _%#NAME#%_, PAC (Minnesota Heart Clinic, Congestive Heart Clinic) in 7-10 days with a basic metabolic screen at that time. 2. The patient is to follow up with Dr. _%#NAME#%_ _%#NAME#%_ (Minnesota Heart Clinic) in 8-12 weeks.
PAC|physician assistant certification|PAC,|185|188|DISCHARGE FOLLOW-UP|8. Carbidopa/levodopa 50/200 mg q.d. 9. Claritin 10 mg p.o. q.d. 10. Pletal 100 mg b.i.d. for four months. DISCHARGE FOLLOW-UP: The patient should follow up with _%#NAME#%_ _%#NAME#%_, PAC, in one week and have a repeat hemoglobin and platelet count at that time. He also should have a follow-up thallium stress test in 4-8 weeks with Dr. _%#NAME#%_.
PAC|UNSURED SENSE|PAC.|231|234|LABORATORY DATA|Sodium 140, potassium 3.8, chloride 103, CO2 26, BUN 25, creatinine 1.3, glucose 156, platelets 187, troponin less than 0.07, myoglobin 109, hemoglobin 12.6, white count 17.9 with a left shift. Prior hemoglobin was 12.2. EKG as in PAC. Head CT per report is no acute event. Chest x-ray shows no evidence of pulmonary edema or infiltrate. ASSESSMENT: A 75-year-old gentleman with episodes of unresponsiveness and loss of consciousness of unsure etiology.
PAC|physician assistant certification|P.A.C.,|146|152|HOSPITAL COURSE|She also did report some poor appetite but did force herself to eat on a regular basis. A physical examination was done by _%#NAME#%_ _%#NAME#%_, P.A.C., and no further medical intervention was required. DISCHARGE MENTAL STATUS: _%#NAME#%_ is alert and oriented in no acute distress.
PAC|premature atrial contraction|PAC.|218|221|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1: Palpitations, presyncopal symptoms. The patient was admitted to the floor on telemetry. Telemetry was uneventful except for occasional PAC's. The EKG's were normal except for an occasional PAC. Serial troponins were negative. The patient had a decline in her cardiac palpitations. She was able to perceive the PAC's when she was focused.
PAC|patient-controlled analgesia:PCA|PAC|185|187|ASSESSMENT AND PLAN|However, we will presume that this may require treatment and two grams of amoxicillin one hour prior to dilatation and curettage is appropriate. This can be instilled intravenously and PAC or if there is an option for an oral treatment that would be fine. I will defer that to the anesthesiology team. Nonetheless for now, antibiotic prophylaxis is appropriate and an echo can be completed postoperatively to determine if she needs any further antibiotic prophylaxis in the future.
PAC|premature atrial contraction|PAC|178|180|LABORATORY DATA|SKIN: Normal with healed incision in abdomen, left lower leg and left hip area. LABORATORY DATA: Hemoglobin 10.9, glucose initially 120-150. EKG shows right bundle branch block, PAC and first degree heart block. Sinus rate of 72. IMPRESSION: 1. Colon cancer. 2. Status post left hip fracture.
PAC|physician assistant certification|PAC,|142|145|FOLLOW-UP|The patient was given instructions on postoperative care of drains and incision. FOLLOW-UP: The patient will be seeing _%#NAME#%_ _%#NAME#%_, PAC, at the Southdale Weight Loss Surgery Clinic on _%#DDMM2004#%_ for her first postoperative visit. During that time, the Jackson-Pratt drain will most likely be removed.
PAC|premature atrial contraction|PAC|184|186|HOSPITAL COURSE|Her peak blood pressure was 142/68 and she had a double product of 23,000. She stopped secondary to fatigue, but did not have any chest pain. She had an EKG which showed an occasional PAC and some diffuse flat T-waves, but there was no change in her EKG with stress. The echo portion showed normal wall motion and a normal response to stress.
PAC|premature atrial contraction|PAC|360|362|PRENATAL LABORATORY|PRENATAL LABORATORY: Blood type B Positive, antibody negative, Rubella immune, hemoglobin 11.1, urine culture negative, hepatitis B surface antigen negative, RPR negative, GC and chlamydia negative, HIV negative, sickle (_______________) negative, GCT 111, GBS negative. The patient's prenatal course was complicated by an irregular heart rate consistent with PAC or PVC, heard on her new OB exam, which was evaluated by her primary physician at the _%#CITY#%_ Clinic. In addition, she was treated for bacterial vaginosis with her new OB.
PAC|patient-controlled analgesia:PCA|PAC.|236|239|ASSESSMENT AND PLAN|It is my feeling that due to the narcotic use prior to surgery, she has increased narcotic tolerance and a low threshold for pain. There is no evidence of any infection. Currently, actually, the patient is well controlled with morphine PAC. We will continue to finish off her course of Levaquin and Flagyl. If she does well the plan will be to switch her to oral pain medications tomorrow with discharge home.
PAC|post anesthesia care|PAC|145|147|HOSPITAL COURSE|The induction of general endotracheal anesthetics as well as the procedure itself was uneventful and the patient was subsequently brought to the PAC in satisfactory condition. Postoperatively, there was note of intact motor and sensory function, as well as intact perfusion of the limb.
PAC|premature atrial contraction|(PAC)|177|181|DISCHARGE DIAGNOSES|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, MD (Allina Medical Clinic - _%#CITY#%_) DISCHARGE DIAGNOSES: 1. Vasovagal syncope. 2. Palpitations, with only premature atrial contractions (PAC) noted on the monitor. 3. Hypertension with alteration of medications. PROCEDURES AND TESTS: 1. Admission chemistries with a low potassium of 3.1. CBC unremarkable.
PAC|premature atrial contraction|(PAC),|252|257|PROCEDURES AND TESTS|d. Carotid ultrasound with mild-to-moderate bilateral internal carotid artery plaques but without significant stenosis, antegrade vertebral flow. 4. Cardiac Studies: a. EKG revealing sinus rhythm with sinus arrhythmia and premature atrial contractions (PAC), left ventricular hypertrophy (LVH) by voltage criteria. b. Echocardiogram with preliminary reading of normal ejection fraction, abnormal diastolic function, mild aortic insufficiency.
PAC|premature atrial contraction|PAC.|128|131|HOSPITAL COURSE|He had normal heart rate and blood pressure response to exercise. No EKG changes consistent with ischemia. He had an occasional PAC. He had a negative stress echocardiogram for ischemia. At rest, his left ventricular ejection fraction was 55%. All segments of his left ventricle augmented appropriately with exercise.
PAC|picture archiving communication|PAC|226|228|PHYSICAL EXAMINATION|He has a rotational deformity to the tip of the finger and when the hand is brought down into a cascade it is malrotated. A copy of his Fairview Southdale Hospital x-rays are enclosed with the paperwork. The x-rays are on the PAC System. IMPRESSION: A spiral fracture with a rotational deformity.
PAC|post anesthesia care|PAC|156|158|HOSPITAL COURSE|She was given 2020 crystalloid and 500 Hespan. She was taken to the postoperative anesthesia recovery room in stable condition. Physical examination in the PAC revealed that she had bilateral straight leg raises intact. EHL/FHL/tibialis anterior intact. She had intact sensation at the bilateral lower extremities.
PAC|physician assistant certification|PAC|131|133|ASSESSMENT/PLAN|ASSESSMENT/PLAN: Right ankle fracture. The patient is to have surgery this evening with Dr. _%#NAME#%_. By: _%#NAME#%_ _%#NAME#%_, PAC
PAC|post anesthesia care|PAC|147|149|HISTORY OF PRESENT ILLNESS|DOB: _%#DDMM1954#%_ CHIEF COMPLAINT: Left-sided thoracic pain. HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ is a 51-year-old woman who works in the PAC unit here at Ridges Hospital. Also works at times for the rehabilitation service and in the past has also been a preschool teacher.
PAC|premature atrial contraction|PAC|126|128|PHYSICAL EXAMINATION|Blood pressure 156/65, pulse 54, respirations 16. She is afebrile, sating 94% on room air. EKG in the ER showed sinus rhythm, PAC with left atrial enlargement and left ventricular hypertrophy, question anterior infarct, ST abnormality considering lateral ischemia. NEUROLOGICAL EXAM: She has maybe a mild right facial droop that is very minimal.
PAC|premature atrial contraction|PAC|274|276|HOSPITAL COURSE|She has no seizure history, no brain trauma. Dr. _%#NAME#%_ of Neurology requested that Cardiology also be consulted to rule out a possible cardiac etiology. The patient did have an electrocardiogram performed on admission which was notable for some bradycardia and perhaps PAC versus a wondering atrial pacemaker, but otherwise was negative. She had several troponins that were negative. She had an echocardiogram that was essentially normal.
PAC|physician assistant certification|PAC|193|195|SURGEON|PREOPERATIVE DIAGNOSIS: Morbid obesity with sleep apnea and type 2 diabetes. PROCEDURE: Laparoscopic Roux-en-Y. SURGEON: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD. ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC _%#NAME#%_ _%#NAME#%_, MD. COMPLICATIONS: None. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ underwent the usual bariatric postop protocol, without any difficulty.
PAC|physician assistant certification|PAC.|123|126|ASSISTANT|PROCEDURE: Laparoscopic gastric bypass (Roux-en-Y). SURGEON: _%#NAME#%_ _%#NAME#%_, M.D. ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC. PRIMARY CARE PHYSICIAN: _%#NAME#%_ _%#NAME#%_, M.D. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ underwent a laparoscopic Roux-en-Y under general anesthesia, uncomplicated.
PAC|physician assistant certification|PAC|206|208|SURGEON|DIAGNOSIS: Abdominal pain with nausea. PROCEDURE: Abdominal exploration, lysis of adhesions, small bowel resection. SURGEON: Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_. FIRST ASSISTANT: _%#NAME#%_ _%#NAME#%_, MS PAC REFERRING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_ HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 48-year-old female who presented with lower abdominal pain associated with nausea.
PAC|premature atrial contraction|PAC.|181|184|OBJECTIVE|SKIN: Skin without significant lesion. NEURO: Exam nonfocal throughout including cranial nerves, strength, sensation, and reflexes. EKG shows normal sinus rhythm with an occasional PAC. Electrolytes show sodium normal at 140. Potassium 4.0. BUN 16. Creatinine 0.87. Glucose 99. Anion gap is 8. Calcium is 9.4. Hemoglobin 13.9. White count 7.6. Normal platelets at 211.
PAC|physician assistant certification|PAC,|168|171|ASSISTANTS|FINAL DIAGNOSIS: Sigmoid colon obstruction secondary to fecal mass, large right inguinal hernia. SURGEON: Dr. _%#NAME#%_ _%#NAME#%_. ASSISTANTS: _%#NAME#%_ _%#NAME#%_, PAC, _%#NAME#%_ _%#NAME#%_, PAC. REFERRING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_. PROCEDURE: Sigmoid colon resection with colostomy, right inguinal hernia repair with mesh and incidental appendectomy.
PAC|physician assistant certification|PAC,|168|171|ASSISTANTS|FINAL DIAGNOSIS: Sigmoid colon obstruction secondary to fecal mass, large right inguinal hernia. SURGEON: Dr. _%#NAME#%_ _%#NAME#%_. ASSISTANTS: _%#NAME#%_ _%#NAME#%_, PAC, _%#NAME#%_ _%#NAME#%_, PAC. REFERRING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_. PROCEDURE: Sigmoid colon resection with colostomy, right inguinal hernia repair with mesh and incidental appendectomy.
PAC|physician assistant certification|PAC|202|204|SURGEON|PREOPERATIVE DIAGNOSIS: Ventral anterior abdominal wall hernia. PROCEDURE: Laparoscopic ventral hernia repair with mesh. SURGEON: Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_. ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC COMPLICATIONS: None. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 48-year-old gentleman who is 6 feet 3 inches, 320 pounds, who tolerated the procedure well, but in the following 24 hours, he was having increasing abdominal discomfort and at least one episode of high fever up to 102.
PAC|post anesthesia care|PAC|168|170|HOSPITAL COURSE|There was an estimated blood loss of 50 mL, 1750 mL of crystalloid was given intraoperatively. There were no intraoperative complications. The patient was taken to the PAC in stable condition where a postoperative examination revealed a patient who was comfortable with stable vital signs. Her exam revealed that she had a completely intact CNS distally.
PAC|physician assistant certification|PAC.|209|212|ASSISTANT|PREOPERATIVE DIAGNOSIS: Ventral incisional hernia. PROCEDURE: Laparoscopic repair of ventral incisional hernia with PROCEED surgical mesh. SURGEON: Dr. _%#NAME#%_ _%#NAME#%_. ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ spent the night in the hospital and this morning she is doing just fine.
PAC|physician assistant certification|PAC.|102|105|ASSISTANT|PROCEDURE: Takedown ileostomy. SURGEON: _%#NAME#%_ _%#NAME#%_, M.D. ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC. HISTORY: _%#NAME#%_ _%#NAME#%_ is an 80-year-old, extremely healthy female who was admitted for takedown of an ileostomy.
PAC|physician assistant certification|PAC|239|241|SURGEON|PLANNED DISCHARGE DATE: _%#DDMM2007#%_ PREOPERATIVE DIAGNOSIS: Morbid obesity. POSTOPERATIVE DIAGNOSIS: Morbid obesity. PROCEDURE: Laparoscopic gastric bypass procedure. SURGEON: Dr. _%#NAME#%_ _%#NAME#%_ ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC SUMMARY OF HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 53-year-old patient with a BMI of 51.5 underwent laparoscopic gastric bypass procedure under general anesthesia, uncomplicated, and went to recovery and to the bariatric floor in good condition.
PAC|physician assistant certification|PAC.|196|199|ASSISTANT|PREOPERATIVE DIAGNOSIS: Morbid obesity. POSTOPERATIVE DIAGNOSIS: Morbid obesity. SURGICAL PROCEDURE: Laparoscopic Roux-en-Y. SURGEON: _%#NAME#%_ _%#NAME#%_, M.D. ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC. PRIMARY CARE PHYSICIAN: _%#NAME#%_ _%#NAME#%_, M.D. COMPLICATIONS: None.
PAC|physician assistant certification|PAC|162|164|ASSISTANT|SURGICAL PROCEDURE: Laparoscopic Roux-en-Y and incidental cholecystectomy on _%#DDMM2006#%_. SURGEON: _%#NAME#%_ _%#NAME#%_, MD ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC PRIMARY-CARE PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD COMPLICATIONS: None.
PAC|premature atrial contraction|PAC.|249|252|ADDENDUM|1. Inguinal hernia. 2. See medical problem list. PLAN: Possibly at higher risk for pulmonary embolus. Early mobilization important. The patient approved for surgery. ADDENDUM: Hemoglobin is 12.9, normal indices, and EKG showed old inferior MI and a PAC.
PAC|premature atrial contraction|PAC.|179|182|LABORATORY STUDIES|Her hemoglobin in _%#MM2006#%_ was 11.5. Her hemoglobin in _%#MM2006#%_ was 10.8. EKG shows sinus rhythm, rate of 71. There is evidence of a first-degree AV block and an isolated PAC. IMPRESSION: An 89-year-old woman who has subjective complaint of shortness of breath.
PAC|physician assistant certification|PAC|209|211|SURGEON|PREOPERATIVE DIAGNOSIS: Morbid obesity POSTOPERATIVE DIAGNOSIS: Morbid obesity SURGICAL PROCEDURE: Laparoscopic gastric bypass (Roux-en-Y ) SURGEON: Dr. _%#NAME#%_ _%#NAME#%_ ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC PRIMARY CARE: Dr. _%#NAME#%_ _%#NAME#%_ COMPLICATIONS: None HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was admitted following an uneventful surgery and post anesthesia care, placed on the bariatric protocol which he managed to do just fine.
PAC|post anesthesia care|PAC|167|169|HOSPITAL COURSE|The above-mentioned surgery was done under general anesthesia. The patient underwent surgery and anesthesia very well. Postoperatively, the patient was transferred to PAC when in stable condition and, subsequently, to the floor. On the floor, the patient was put on IV antibiotics in the form of injection, Ancef initially.
PAC|premature atrial contraction|PAC.|163|166|IMPRESSION|EKG was normal. Chest x-ray results pending. IMPRESSION: This patient has a history of palpitations. While I was interviewing him, I noticed on the monitor he had PAC. His troponin is slightly elevated on set #1, but set #2 is already negative. I suspect that this is actually a false positive and that there is no myocardial ischemia.
PAC|premature atrial contraction|PAC,|276|279|HISTORY OF PRESENT ILLNESS|In the local ER, she was noted to have an arrhythmia that initially was interpreted as a Mobitz type II AV block. She was transferred here for further evaluation, but upon carefully evaluating the EKG from the local ER, apparently there is no second degree of AV block due to PAC, which was kind of interfering with native rhythm, causing a functional block. The patient does have some cardiac history, including history of hypertension, taking medication to control that, and two years ago a heart murmur was found consistent with aortic regurgitation.
PAC|premature atrial contraction|PAC,|148|151|LABORATORY DATA|Liver and spleen not palpable. EXTREMITIES: No edema. LABORATORY DATA: Electrocardiogram shows incomplete right bundle branch block with occasional PAC, otherwise normal. A copy was given to the patient. Potassium is pending at the time of this dictation. IMPRESSION: 1. Left knee meniscus tear. 2. Essential hypertension.
PAC|premature atrial contraction|PAC|182|184|LABORATORY DATA|EKG showed sinus rhythm with frequent PACs, 63 beats per minute. Chest x-ray was normal. Telemetry shows sinus arrhythmia, sinus arrest or pose, sinus exit block, frequent PACs, and PAC couplets, occasional PVCs and 1 short burst of SVT. ASSESSMENT/PLAN: A 54-year-old gentleman with a history of Grave's disease, hypertension, hypercholesterolemia, and status post kidney transplant who was admitted today with chest discomfort, nausea, dizziness, and irregular heart beat.
PAC|premature atrial contraction|PAC,|158|161|HOSPITAL COURSE|Her heart rhythm during this hospitalization has been stable except for occasional PVCs. The EKG is done this morning prior to discharge, shows an occasional PAC, but is clearly a normal trace with no evidence of prior scar or ischemia, and very similar to prior EKGs that I remember reviewing one day prior to yesterday when I visited with her initially.
PAC|post anesthesia care|PAC|156|158|TYPE OF PROCEDURE|TYPE OF PROCEDURE: Routine defibrillation threshold testing. After discussion of the procedure with the patient, Mr. _%#NAME#%_ _%#NAME#%_ was brought into PAC area in a fasting state. I have reviewed the chest x-ray taken today and there was no indication of a malfunction of his ICD device, which is a Guidant T177.
PAC|physician assistant certification|PAC|400|402|SURGEON|DIAGNOSES: Abdominal aortic aneurysm with proximal aortic ectasia POSTOPERATIVE DIAGNOSES: Abdominal aortic aneurysm with proximal aortic ectasia PROCEDURE: Abdominal aortic aneurysm repair with aorto bilateral common iliac artery bypass using a 16 x 8 mm. Dacron graft. SURGEON: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, M.D. 1st Assistant: _%#NAME#%_ _%#NAME#%_, M.D. 2nd Assistant: _%#NAME#%_ _%#NAME#%_, PAC _%#NAME#%_ _%#NAME#%_ is a 63-year-old male who came into consultation with Dr. _%#NAME#%_ regarding incidental finding for abdominal aortic aneurysm.
PAC|physician assistant certification|PAC|45|47|PRIMARY PEDIATRICIAN|PRIMARY PEDIATRICIAN: _%#NAME#%_ _%#NAME#%_, PAC HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 15-year-old female with a history of anxiety, depression, posttraumatic stress disorder and attention deficit hyperactivity disorder. She presents with a 4-year history of GI bleeding. She reports bright red blood per rectum 1-2 times per month, sometimes it fills the entire toilet bowl.
PAC|premature atrial contraction|PAC.|173|176|PHYSICAL  EXAMINATION|All other review of systems are negative. PHYSICAL EXAMINATION: VITAL SIGNS: Current blood pressure 138/89, pulse 100 with occasional premature atrial contractions and rare PAC. Respiratory rate is 16-18 and unlabored, 96% saturated. GENERAL: The patient is an alert white male appearing his stated age in no acute distress.
PAC|physician assistant certification|PAC|206|208|DISCHARGED PLAN|He is encouraged to follow up with him closely as some of his medications have been adjusted. 3. The patient will have an appointment in our office in three to five weeks with either _%#NAME#%_ _%#NAME#%_, PAC or _%#NAME#%_ _%#NAME#%_, PAC. 4. Lisinopril was increased for hypertensive control from 5 mg up to 10 mg p.o. b.i.d. 5. We will get a B_P in seven to ten days to follow up with the adjustment of his Lisinopril.
PAC|premature atrial contraction|(PAC)|199|203|HISTORY OF PRESENT ILLNESS|It did shock appropriately and take him out of the ventricular tachycardia rhythm. He is currently being paced in via the pacer in the ventricular lead and has multiple premature atrial contractions (PAC) and is "irritable" per the Guidant representative who has just finished the interrogation. The patient reports questionable fever and some sweats in the past couple of days to a week.
PAC|premature atrial contraction|PAC,|138|141|LABORATORY|Lipids on _%#DDMM2007#%_, total cholesterol 188, triglycerides 101, HDL 48, LDL 120, AST 20. EKG shows normal sinus rhythm, rate of 66, 1 PAC, LAD, otherwise unremarkable. Troponin less than 0.04. Head CT negative. IMPRESSION: Syncope. The patient without any symptoms.
PAC|post anesthesia care|PAC|183|185|HOSPITAL COURSE|He was brought to the OR where a left total hip arthroplasty was performed without any significant complications, estimated blood loss was 720 cc. The patient was then transferred to PAC in stable condition. He was closely monitored prior to his discharge up to the orthopedic floor. The patient was started on anticoagulation therapy with Lovenox 30 mg subq p.o. b.i.d. on postoperative day number one.
PAC|post anesthesia care|PAC|195|197|HOSPITAL COURSE|She was then brought to the Operating Room where a right total knee arthroplasty was performed without any complications. Estimated blood loss was 100 cc. The patient was then transferred to the PAC in stable condition where she was closely monitored prior to her transfer up to the Orthopedic Floor. She was started on an anti-coagulation therapy of Lovenox 30 mg subcu b.i.d. The first dose being the evening of surgery.
PAC|post anesthesia care|PAC|183|185|HOSPITAL COURSE|For complete surgical details please refer to the operative dictation. She tolerated the procedure well. There were no acute complications and she subsequently was transferred to the PAC UN Floor in stable condition. Immediately postop her pain was adequately controlled with a morphine PCA and she remained clinically stable.
PAC|physician assistant certification|P.A.C.|36|41|DICTATED BY|DICTATED BY: _%#NAME#%_ _%#NAME#%_, P.A.C. The patient is scheduled for right ankle surgery on _%#MM#%_ _%#DD#%_, 2002, by Dr. _%#NAME#%_ at Fairview-University Medical Center. HISTORY OF PRESENT ILLNESS: This is a 55-year-old female with rheumatoid arthritis scheduled for right ankle surgery.
PAC|premature atrial contraction|PAC.|190|193|OBJECTIVE|No rash. No other focal neurologic complaint. OBJECTIVE: Well-preserved elderly female in no distress. Alert and oriented. Blood pressure 108/66, heart rate 70's and regular with occasional PAC. Respirations normal. HEENT: extraocular movements full, no nystagmus. Pupils equal, reacting symmetrically. Sclerae are nonicteric. Fundi: sharp discs with mild arteriolar narrowing.
PAC|premature atrial contraction|PAC|206|208|LABORATORY DATA|Labs from _%#MM#%_ _%#DD#%_ show a total bilirubin of 1.0, alkaline phosphatase 141, ALT 25 and AST 66. Electrocardiogram shows atrial fibrillation with a rate in the upper 60's. No acute ST/T changes. One PAC is noted. ASSESSMENT/PLAN: 1. Cholelithiasis with recent common bile duct obstruction. The patient appears medically stable to undergo a laparoscopic cholecystectomy under general anesthesia.
PAC|premature atrial contraction|PAC.|147|150|PHYSICAL EXAMINATION|LUNGS: Remarkable for crackles halfway up the lungs. There is no wheezing. CV: Irregular skipped beat occasionally consistent with either a PVC or PAC. Normal S1, S2. There is no S3 or S4 appreciated. There is a II/VI systolic murmur along the left sternal border.
PAC|premature atrial contraction|(PAC).|203|208|PHYSICAL EXAMINATION|LUNGS: Clear bilaterally without crackles or wheezes. HEART: Regular. No appreciable murmur, rub or gallop. The monitor currently reveals a sinus tachycardia with occasional premature atrial contraction (PAC). ABDOMEN: Soft. Bowel sounds present and are normal in character. No appreciable hepatosplenomegaly. Nontender. Right flank does have a nephrostomy tube.
PAC|premature atrial contraction|PAC,|92|95|LABORATORY DATA|If abnormal will get angiogram and needs endoscopy. LABORATORY DATA: Sinus tachycardia with PAC, possible old inferior. Await results from lab.
PAC|post anesthesia care|PAC|225|227|HOSPITAL COURSE|LABS: Hemoglobin on admission 13.1. HOSPITAL COURSE: The patient was admitted as an outpatient and underwent a bilateral breast reduction surgery on _%#DDMM2003#%_. She tolerated the procedure well and was transferred to the PAC unit in stable condition and then to the general surgery ward, after which she had an uneventful night. The patient did not have any postoperative complications. She had no evidence of bleeding.
PAC|patient-controlled analgesia:PCA|PAC|200|202|HOSPITAL COURSE|Postoperatively she did well, although she did have some issues with pain management. She had been on a Fentanyl patch and p.o. pain medications prior to her surgery therefore had difficulty with her PAC and oral pain medications following her surgery. On _%#DDMM2003#%_ her hemoglobin was 9.3. At the time of discharge her incisions were clean and dry.
PAC|post anesthesia care|PAC|165|167|HOSPITAL COURSE|The patient was extubated in the operating room and taken to the post-anesthesia care unit in stable condition. She was then transferred to the floor, following the PAC criteria, in stable condition. Upon admission to the floor, the patient had an NG tube in place and was receiving PCA morphine for pain.
PAC|post anesthesia care|PAC,|192|195|HOSPITAL COURSE|HOSPITAL COURSE: On _%#DDMM2002#%_, the patient underwent a left total knee arthroplasty. The patient tolerated the procedure well, was extubated in the operating room, and transferred to the PAC, was then transferred general care floor in stable condition. Postoperatively, the patient did very well. She remained afebrile and vital signs stable during her hospital stay.
PAC|physician assistant certification|PAC|188|190|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Possible right peritonsillar abscess. HISTORY OF PRESENT ILLNESS:. The patient is new to our clinic. She is asked to see us today at the request of _%#NAME#%_ _%#NAME#%_, PAC at Northland _%#CITY#%_ Clinic for a possible right peritonsillar abscess. The patient stated she first noticed a sore throat last evening.
PAC|physician assistant certification|PAC,|125|128|DOB|TBA: _%#DDMM2004#%_ DOB: _%#DDMM1957#%_ _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 46-year-old referred by _%#NAME#%_ _%#NAME#%_, PAC, with a history of persistent squamous cell carcinoma of the left vocal cord extending into the ventricle. We discussed the risks, benefits, and alternatives to hemilaryngectomy, including the risk of a general anesthetic, the risk of bleeding, the risk of continued problems with hoarseness and vocal production.
PAC|premature atrial contraction|PAC.|142|145|PHYSICAL EXAMINATION|Ambulation is normal. Deep tendon reflexes are symmetric. Chest x-ray is clear. Electrocardiogram reveals normal sinus rhythm with occasional PAC. LABORATORY DATA: Pending. IMPRESSION: Healthy 69-year-old man scheduled for left inguinal herniorrhaphy. The patient is a good candidate for the anesthesia and surgery proposed.
PAC|patient-controlled analgesia:PCA|PAC|223|225||Her use has increased to two every four hours. She was admitted to the hospital on _%#DDMM2004#%_ with an episode of diarrhea and abdominal pain was not controlled with Vicodin. She received hydration and was on a Dilaudid PAC with good control. Amniocentesis was done for lung maturity at that time which was 35 weeks gestation and was immature showing LS SPINE 1.5, DSL 300, PG absent.
PAC|post anesthesia care|PAC|270|272|DETAILS OF HOSPITAL STAY|DETAILS OF HOSPITAL STAY: The patient was admitted on _%#DDMM2004#%_ and subsequently brought to the operating room for the above-mentioned procedures. The .......general anesthetic as well as the procedure itself was uneventful. The patient was subsequently brought to PAC in satisfactory condition. ........of intact motor intensity function as well as intact vascular status. The patient was on an epidural anesthetic for 48 hours, after which it was discontinued, and she was placed on oral pain medications.
PAC|premature atrial contraction|PAC.|152|155|PHYSICAL EXAMINATION|diameter clear blister that is intact on the left shin area. The skin of the lower extremities is brown. EKG monitor shows sinus rhythm with occasional PAC. Chest x-ray shows cardiomegaly which is chronic and some bibasilar fibrosis. This is compared to x-rays of at our clinic. A CT scan of the chest taken to rule out pulmonary emboli is negative per report.
PAC|physician assistant certification|PAC|211|213|PRESENTING PROBLEM|He was subsequently admitted to a mental health unit and then transferred to alcohol detox University of Minnesota Medical Center, Fairview. PRESENTING PROBLEM: The patient was staffed by _%#NAME#%_ _%#NAME#%_, PAC on the alcohol detox unit. At that time he was having a moderate level of distress from alcohol withdrawal.
PAC|premature atrial contraction|(PAC)|264|268|HOSPITAL COURSE|She was admitted for observation and telemetry. On exam, the only finding was gait unsteadiness with difficulty walking in tandem. She was maintained on telemetry for 24 hours. She had an occasional sinus arrhythmia with an occasional premature atrial contraction (PAC) and intermittently her heart rate dipped into the 50s, especially when resting. This was considered probably not to be of any significance.
PAC|physician assistant certification|PAC|42|44|PRIMARY PHYSICIAN|PRIMARY PHYSICIAN: _%#NAME#%_ _%#NAME#%_, PAC (Fairview Cedar Ridge Clinic) HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 32-year-old patient who presented with anal pain and was found to have a deep chronic posterior anal fissure She was advised on the fact that surgical correction was indicated.
PAC|physician assistant certification|PAC.|213|216|PHYSICAL EXAMINATION|No murmurs. Heart is not enlarged to percussion. BREASTS: Free of masses. No axillary lymphadenopathy. ABDOMEN: No masses. No tenderness. Liver and spleen not palpable. PELVIC: Negative per _%#NAME#%_ _%#NAME#%_, PAC. EXTREMITIES: Good range of motion. No pedal edema. NEUROLOGIC: Physiologic. RECTAL: Chronic posterior anal fissure and a marked anal stenosis.
PAC|physician assistant certification|PAC|43|45|DOB|DOB: _%#DDMM1951#%_ _%#NAME#%_ _%#NAME#%_, PAC dictating for _%#NAME#%_ _%#NAME#%_, M.D. PROCEDURE: Right total hip arthroplasty. Patient was taken to the operating room where Dr. _%#NAME#%_ _%#NAME#%_ performed the right total hip arthroplasty.
PAC|premature atrial contraction|(PAC).|328|333|HISTORY OF PRESENT ILLNESS|In the past she apparently was evaluated with a Holter monitor which was apparently done at Park Nicollet Clinic which showed a normal sinus rhythm with sinus tachycardia 54% of the time, heart rate from 70- 145. There were rare isolated unifocal premature ventricular contractions (PVC) and a rate premature atrial contraction (PAC). The patient apparently had sinus tachycardia at 123 when she reported breathless shaking with T wave changes. (The patient herself reports that she did not really have major symptoms during that test.) The patient had an episode lasting 4 minutes today.
PAC|physician assistant certification|PAC,|157|160|FOLLOW UP|5. Colace 100 mg p.o. b.i.d., 60 were given. FOLLOW UP: She will follow up with Dr. _%#NAME#%_ in 6 weeks and with Dr. _%#NAME#%_'s nurse or _%#NAME#%_, the PAC, in 2 weeks. Her diet should be general as tolerated. Her activity is weightbearing as tolerated with crutches. She should use a cast or bunion shoe p.r.n. She can remove the dressing on postoperative day #3 or #4 and replace it with gauze and an Ace.
PAC|premature atrial contraction|PAC.|225|228|LABORATORY DATA|EXTREMITIES: Without cyanosis, clubbing, or edema. SKIN: Without rashes. NEUROLOGICAL: Alert and oriented x 3. Strength and sensation are intact. LABORATORY DATA: Electrocardiogram showed sinus tachycardia with an occasional PAC. Glucose was elevated at 193. RDW slightly elevated at 15.5. ASSESSMENT AND PLAN: 1. Benzodiazepine withdrawal. Withdrawal protocol will be done. Phenobarbital 30 mg p.o. b.i.d. Seroquel 25 mg to 50 mg q.4 h. p.r.n. for withdrawal, start with 25 mg dose.
PAC|physician assistant certification|PAC,|124|127|DISPOSITION AT DISCHARGE|The patient is to have an angiogram next week for preop workup for a living donor kidney transplant. The patient is to call PAC, _%#NAME#%_ at _%#TEL#%_ for scheduling. The patient is to resume dialysis at his home dialysis center on Friday. The patient was told to monitor for fever and blood pressures.
PAC|physician assistant certification|PAC|405|407|PRESENTING PROBLEM|IDENTIFYING INFORMATION: This patient presented to the emergency room at the University of Minnesota Medical Center, Fairview, sent by his home health nurse because of increasing difficulty in caring for self, disheveled state of the patient's apartment, as well as the patient himself. Also some difficulties with speech and walking. PRESENTING PROBLEM: The patient was staffed by _%#NAME#%_ _%#NAME#%_, PAC on inpatient mental health unit of the University of Minnesota Medical Center, Fairview. The patient reports being depressed, being more sad and down.
PAC|physician assistant certification|PAC.|147|150|PRESENTING PROBLEM|PRESENTING PROBLEM: Mr. _%#NAME#%_ was staffed on the detox unit at the University of Minnesota Medical Center, Fairview by _%#NAME#%_ _%#NAME#%_, PAC. He reports that he has been consuming a pint or more of alcohol a day for approximately the last 20 years.
PAC|picture archiving communication|PAC|130|132|PHYSICAL EXAMINATION|A scar on his chest gives credence to the fact that he had bypass in 94. The chest x-ray is normal and reviewed by me through the PAC system. We talked about his symptoms not being exertional and not associated with breathlessness being somewhat atypical and the recommendation is that we should watch him walk about in the hospital, that we should plan to do a walking adenosine stress tomorrow and that it would not be unreasonable to do a GI to institute some GI medications even though GI symptoms are lacking.
PAC|premature atrial contraction|PAC.|156|159|IMPRESSION|2. New onset atrial fibrillation with rapid ventricular response. Onset approximately two hours ago. Now on telemetry. He is back to sinus tachycardia with PAC. His atrial fibrillation was probably due to fever with a temperature up to 38.6 last night, hypoxia, hypertension with acute elevation of blood pressures, pain and anemia in the setting of underlying heart disease.
PAC|premature atrial contraction|PAC,|208|211|PHYSICAL EXAMINATION|Skin is benign. Neurologic and cognitive are benign. All other review of systems are unremarkable. PHYSICAL EXAMINATION: VITAL SIGNS: Current blood pressure is 181/98, pulse is 72 and regular with occasional PAC, respiratory rate 22-30, and the patient is 97% saturated. HEENT: Normocephalic and atraumatic without xanthoma. No arcus senilis. No oropharyngeal lesions.
PAC|premature atrial contraction|PAC.|193|196|EKG|NEUROLOGIC: Left side power is about 4 to 4+/5. She is oriented to time, place and person. EKG: (On admission.) Sinus rhythm with left anterior fascicular block and first degree AV block and a PAC. Resting heart rate was 49 beats per minute. TELEMETRY: Sinus bradycardia with first degree AV block.
PAC|physician assistant certification|PAC,|136|139|IMPRESSION AND PLAN|Thank you very much for this interesting consultation, and I appreciate being involved in Ms. _%#NAME#%_'s care. _%#NAME#%_ _%#NAME#%_, PAC, for _%#NAME#%_ _%#NAME#%_, M.D.
PAC|physician assistant certification|PAC|64|66|REQUESTING PROVIDER|TBA: _%#DDMM2005#%_ REQUESTING PROVIDER: _%#NAME#%_ _%#NAME#%_, PAC HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 47-year-old female referred by _%#NAME#%_ _%#NAME#%_ at _%#CITY#%_ Lake Clinic. The patient has been having many years of chronic left breast pain.
PAC|premature atrial contraction|PAC.|139|142|LABORATORY DATA|I ordered a stat portable chest x-ray which is pending, and I ordered an electrocardiogram which shows sinus tachycardia with one isolated PAC. There is first degree AV block. There are no appreciable ST segment abnormalities. There are small R's in III and AVF. Aside from the tachycardia, there is no appreciable difference from previous electrocardiogram recorded on the chart.
PAC|physician assistant certification|PAC|63|65|REASON FOR CONSULTATION|REASON FOR CONSULTATION: I was asked by _%#NAME#%_ _%#NAME#%_, PAC to evaluate _%#NAME#%_ _%#NAME#%_ for bilateral knee pain. HISTORY OF PRESENT ILLNESS: The patient states that he has a chronic history of osteoarthritis in both of his knees for quite some time.
PAC|post anesthesia care|PAC|83|85|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old woman who is seen in the PAC postoperatively after having right total hip arthroplasty for DJD by Dr. _%#NAME#%_. The patient lost 500 cc of blood in this surgery and has lost an additional 250 cc in the recovery room.
PAC|premature atrial contraction|PAC.|182|185|PHYSICAL EXAM|No history of anemia, no thyroid abnormalities. All other review of systems are unremarkable. PHYSICAL EXAM: Current blood pressure is 82/48, pulse is 85 and regular with occasional PAC. The patient is afebrile. Respiratory rate is 20 and relatively unlabored. She is 100% oxygenated. HEENT: Normocephalic, atraumatic without xanthoma. No arcus senilis.
PAC|premature atrial contraction|(PAC).|196|201|EKG|MR ANGIOGRAM: MR angiogram of the circle of Willis vessels and of the carotids in the neck and these are also normal. EKG: EKG has shown sinus rhythm with occasional premature atrial contractions (PAC). TRANSTHORACIC ECHOCARDIOGRAM/BUBBLE STUDY: His transthoracic echocardiogram and bubble study did show a positive bubble study but no other abnormalities or source of thrombus.
PAC|physician assistant certification|PAC.|235|238|HISTORY OF PRESENT ILLNESS|Prior to surgery she was at her baseline but she did of course have some right leg pain secondary to her back problems. The operative note was reviewed as well as her preop history and physical which was done by _%#NAME#%_ _%#NAME#%_, PAC. She had at that time had a CBC as well as an EKG. PAST MEDICAL HISTORY: Significant for hypertension and hyperlipidemia. PAST SURGICAL HISTORY: Appendectomy, right inguinal herniorrhaphy and left knee replacement.
PAC|physician assistant certification|PAC,|209|212|ASSESSMENT AND PLAN|The abdominal pain could also be secondary to the GERD or alcoholic gastritis. 4. Hypertension. We changed the patient's atenolol dosage to 50 mg q.day instead of 25 mg q.day. Note that _%#NAME#%_ _%#NAME#%_, PAC, should be called tomorrow afternoon with an update on the patient's blood pressure.
PAC|premature atrial contraction|PAC,|217|220|LABORATORY & DIAGNOSTIC DATA|Femoral pulses are 2+ and symmetric. The lower extremities are without cyanosis, clubbing or edema. Neurological exam is grossly intact. LABORATORY & DIAGNOSTIC DATA: 12-lead EKG shows normal sinus rhythm, occasional PAC, and evidence of atrial enlargement. ASSESSMENT/PLAN: Overall, the patient is a pleasant, 66-year-old female. Family history of premature coronary artery disease.
PAC|premature atrial contraction|PAC.|187|190|PHYSICAL EXAMINATION|Oral exam is grossly normal. There is no thyromegaly. Lungs: Clear. Cardiac Exam: Reveals a regular rate and rhythm without murmurs. There are occasional extrasystolic beats, most likely PAC. Abdomen: Soft, there is no hepatosplenomegaly. Extremity Exam: Reveals no edema nor clubbing. There is no sign of trauma. Neurologically, she is alert, fully oriented. She is not tremulous.
PAC|premature atrial contraction|PAC,|225|228|STUDIES|EXTREMITIES: No edema. His left leg is externally rotated. STUDIES: Chest x-ray shows a rotated prominent aorta, but no infiltrate. Hip x-ray shows a left femoral neck fracture. EKG shows sinus rhythm with occasional PVC and PAC, and right bundle branch block. No old EKGs yet to compare. Labs show a sodium of 139, potassium 4.6, chloride 103, bicarbonate 25, BUN 46, creatinine 2.2 (was 1.9 on _%#DDMM2002#%_), estimated GFR 32, calcium 8.1, hemoglobin 11.2, white count 8.1, platelet count 204,000, and he had 71% neutrophils, 12% lymphocytes, 11% monocytes and 4% eosinophils.
PAC|premature atrial contraction|PAC|310|312|PHYSICAL EXAMINATION|I did order an EKG today which showed sinus rhythm, heart rate is 52 beats per minute, first degree AV block, some suggestion of left atrial enlargement, there was PAC, but with ventricular aberrancy. I also reviewed all the monitor tracing and showed some sign of bradycardia with some first degree AV block, PAC and PVC, but there is no apparent second degree AV block to me. Magnesium 1.3, potassium 3.2, normal _________ and TSH was 0.03. Chest x-ray was normal, no cardiomegaly and no pulmonary infiltrate.
PAC|premature atrial contraction|(PAC),|172|177|HISTORY|Mr. _%#NAME#%_ does not typically experience classic anginal complaints, but rather complains of palpitations. His Holter monitors have shown premature atrial contractions (PAC), premature ventricular contractions (PVC) and at times short runs of supraventricular tachycardia (SVT) and these usually are worse when he has ischemic issues ongoing.
PAC|physician assistant certification|PAC.|284|287|ASSESSMENT AND PLAN|5. Vaginal itching; rule out STD. Call if wet prep is abnormal; call if GC, Chlamydia or cervical ......probe are abnormal; order HIV antibody, hepatitis surface antigen, hepatitis B core antibody, and RPR. Call if tests are abnormal. The patient was seen with _%#NAME#%_ _%#NAME#%_, PAC. I will be available for followup should other issues arise during hospitalization.
PAC|physician assistant certification|PAC,|193|196|SOCIAL HISTORY|ALT 17. AST 25. TSH 1.46. GTT 15. ASSESSMENT AND PLAN: 1. Depression with suicidal ideation per Dr. _%#NAME#%_. 2. Fibromyalgia is well controlled. 3. Vaginal discharge. _%#NAME#%_ _%#NAME#%_, PAC, to see the patient for cultures/pelvic exams on _%#MM#%_ _%#DD#%_, 2006. 4. Gastroesophageal reflux disease is well controlled. 5. Constipation. Add Senokot-S 2 tablets p.o. nightly.
PAC|premature atrial contraction|PAC.|129|132|LABORATORY DATA|LABORATORY DATA: Labs postoperatively are ordered and are pending. Preoperative EKG revealed normal sinus rhythm with occasional PAC. There are no acute-appearing changes. There is left axis deviation.
PAC|premature atrial contraction|PAC.|174|177|LABORATORY DATA|Electrocardiogram demonstrated a sinus tachycardia with heart rate in the low 100s. Normal PR, QRS and QT interval. Minor nonspecific T-wave flattening laterally. Occasional PAC. ASSESSMENT: 65-year-old female admitted with the following: 1. Concern regarding inability to provide adequate self care/potential self risk in the setting of alcohol excess.
PAC|premature atrial contraction|PAC|149|151|HISTORY OF PRESENT ILLNESS|While the patient has been here at Fairview Ridges, he has been noted to have a couple episodes of 1 to 1.5 second pauses. Both episodes have been a PAC followed by the pause. Again, both episodes were asymptomatic. PAST MEDICAL HISTORY: 1. History of coronary artery bypass grafting done in 1997 in Alabama, I do not have details.
PAC|physician assistant certification|PAC|23|25||_%#NAME#%_ _%#NAME#%_, PAC Fairview Northland Clinic _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_, Minnesota _%#55300#%_ RE: _%#NAME#%_ _%#NAME#%_ Dear Ms. _%#NAME#%_: Thank you for the referral of your patient, _%#NAME#%_ _%#NAME#%_, who was seen along with the father of this pregnancy, _%#NAME#%_, on _%#MM#%_ _%#DD#%_, 2007 at the Maternal Fetal Medicine Center at University of Minnesota Medical Center, Fairview.
PAC|premature atrial contraction|(PAC)|210|214|EKG|LABORATORY DATA: INR 0.96. White count 8.8, hemoglobin 13.9, platelet count 360 with 88 neutrophils, 12 lymphocytes, 7 monocytes. EKG: EKG showed sinus rhythm at a rate of 67 with premature atrial contractions (PAC) and premature ventricular contractions (PVC) and also intraventricular conduction delay. ASSESSMENT/PLAN: _%#NAME#%_ _%#NAME#%_ is a 75-year-old who has an intertrochanteric hip fracture.
PAC|physician assistant certification|PAC,|198|201|ASSESSMENT/PLAN|9. Erectile dysfunction. We will have the patient follow up with his primary doctor for this concern. 10. Shortness of breath secondary to anxiety. We appreciate the consult. _%#NAME#%_ _%#NAME#%_, PAC, also saw this patient and agrees with the assessment and plan. Thank you _%#NAME#%_ and Dr. _%#NAME#%_ for allowing me to assist in the care of your patient.
PAC|premature atrial contraction|PAC.|172|175|PHYSICAL EXAMINATION|He attends to the examiner. He is not able to speak except for guttural sounds when uncomfortable. Temperature 97, pulse is about 120, sinus tachycardia with an occasional PAC. Blood pressure is 120/70. Respirations are calm and comfortable at 12-14 per minute with oxygen saturation on room air of 97%.
PAC|premature atrial contraction|(PAC)|250|254|HISTORY OF PRESENT ILLNESS|On the morning of admission she had gone to the bathroom and had felt slightly more marked dizziness. She has not had complete or true syncope. She has had documented sinus rhythm with intermittent sinus bradycardia and premature atrial contractions (PAC) and occasional ventricular premature complexes (VPC) in the past during monitoring. She was admitted to the hospital on _%#DDMM2003#%_ with a couple days of not feeling well and pressure in the chest.
PAC|picture archiving communication|PAC|193|195|INFORMANT SOURCES|CHIEF COMPLAINT: Osteopetrosis, developmental assessment. INFORMANT SOURCES: Old medical records, discussion of team, interview with father, personal review of the cranial CT and x-rays on the PAC system. _%#NAME#%_ was a 2.015 kg product of a 35-week gestation to a G3, P0, AB 2 female with pregnancy complicated by polysubstance abuse of methadone, Xanax, marijuana, clonazepam and tobacco with a 5 month attempt at getting her into drug rehab, finally successful at 8 days prior to delivery, who presented with oligohydramnios and IUGR and delivered by cesarean section without antenatal steroid doses.
PAC|premature atrial contraction|PAC|191|193|STUDIES|ABDOMEN: Benign, except for some epigastric discomfort. EXTREMITIES: 2+ bilateral peripheral edema. STUDIES: 12-lead electrocardiogram, dated _%#DDMM2005#%_, at 1534, shows sinus rhythm with PAC at a rate of 94 beats per minute. There is right atrial enlargement and left anterior fascicular block. Chest x-ray shows normal cardiac silhouette with emphysematous lung fields.
PAC|premature atrial contraction|PAC).|139|143|PHYSICAL EXAMINATION|No need for suturing. No evidence for soft tissue infection. Chest: Clear lungs fields. Cardiac exam regular, with occasional premature (? PAC). There is no gallop, murmur, click, or jugular venous distention. Abdomen: Mildly obese, otherwise soft and nontender, without organomegaly or mass.
PAC|premature atrial contraction|(PAC)|188|192|HISTORY OF PRESENT ILLNESS|His heart rates have been recorded on the nursing notes as being anywhere from 52-79 beats per minute. Monitoring showed sinus rhythm with occasional blocked premature atrial contractions (PAC) and first-degree A-V block in the 220-240 msec range. His QRS shows a bundle-branch block but no high-degree A-V block has been noted.
PAC|premature atrial contraction|(PAC)|150|154|IMPRESSION|IMPRESSION: 1. A-V conduction system dysfunction. 2. Sinus rhythm with left bundle-branch block associated with blocked premature atrial contractions (PAC) and junctional rhythm at 40-45 beats per minute. 3. History of hypertension, currently not an issue. 4. No signs of significant heart disease otherwise.
PAC|physician assistant certification|PAC.|203|206|ASSESSMENT/PLAN|We will continue to monitor. The patient is to follow up with primary MD. 5. Myalgias. Increasing muscle aches and soreness. Vioxx 50 mg p.o. q.d. p.r.n. The patient was seen with _%#NAME#%_ _%#NAME#%_, PAC.
PAC|physician assistant certification|PAC,|140|143|HISTORY OF THE PRESENT ILLNESS|She called my office yesterday saying that she was having a hard time breathing when she lay supine. She was seen by _%#NAME#%_ _%#NAME#%_, PAC, who felt that she should be admitted. In the emergency room at Fairview Southdale Hospital, she was found to have bilateral pleural effusions.
PAC|patient-controlled analgesia:PCA|PAC.|129|132|MEDICATIONS|4. Humulin N. insulin 22 units Q a.m. Humulin R. 10 units t.i.d. with adjustment per sliding scale. 5. Here, he is on a morphine PAC. 6. He is getting Ancef and a bowel regime. PHYSICAL EXAMINATION: Temperature is afebrile. Blood pressures are 110s/80s. Heart rate is 70s to 80s, respirations are normal.
PAC|physician assistant certification|PAC,|282|285|REASON FOR CONSULTATION|This was followed by a stress echo done in _%#MM#%_ of this year that showed left ventricular hypertrophy (LVH), induced a very transient atrial flutter and subsequently rapidly resolved in just a very short time. She has recently been started on Coumadin by _%#NAME#%_ _%#NAME#%_, PAC, as paroxysmal atrial fibrillation which does carry with it a similar risk of continued atrial fibrillation and this patient's risk per year would be related to the following: age over 75, hypertension, diabetes, and fluid retention and probably is somewhere between 5-10% stroke risk per year.
PAC|post anesthesia care|PAC|203|205|DISCUSSION|At baseline he is quite active in chopping down trees and participating in other outdoor activities without limitation. The patient's intraoperative course was uncomplicated. When he was admitted to the PAC he was noted to be quite sleepy and subsequently became unresponsive. He was also noted to be quite hypertensive and diaphoretic.
PAC|premature atrial contraction|(PAC)|223|227|HISTORY OF PRESENT ILLNESS|Currently his fever is down, his blood pressure is improved, and his dopamine dose is declining. His heart rate is likewise down. His rhythm has returned to normal sinus rhythm with occasional premature atrial contractions (PAC) and his diltiazem dose is decreasing. Blood cultures this morning show growth of gram-negative rods as well as gram-positive cocci in chains.
PAC|premature atrial contraction|PAC.|233|236|PHYSICAL EXAMINATION|REVIEW OF SYSTEMS: Not obtainable. PHYSICAL EXAMINATION: Reveals a gentleman who is no longer intubated, lying in bed comfortably, mostly sleepy. When I arouse him, his speech is simply gibberish. He is in a sinus rhythm with a rate PAC. Heart rate 82, blood pressure consistently in the 150 range/90. Temperature is 37.2. SKIN: Exam is benign. HEAD, EYES, EARS, NOSE AND THROAT: He is non-icteric.
PAC|physician assistant certification|PAC,|126|129|IMPRESSION/PLAN|If you have any questions or concerns regarding today's evaluation, please do not hesitate to call us. _%#NAME#%_ _%#NAME#%_, PAC, for _%#NAME#%_ _%#NAME#%_, M.D.
PAC|premature atrial contraction|(PAC).|230|235|REASON FOR CONSULTATION|He also has sleep apnea, gout, and several additional diagnoses as well outlined in the record. He has been started on amiodarone for his atrial fibrillation and is now in sinus rhythm with occasional premature atrial contraction (PAC). He has been switched from Norvasc to metoprolol, now at 25 mg twice per day, and tolerating that quite well with current blood pressure and heart rate in good range at 115/65 and 85, respectively.
PAC|premature atrial contraction|PAC,|215|218|PHYSICAL EXAMINATION GENERAL|PHYSICAL EXAMINATION GENERAL: Patient is lying still. When she is lying still, she is actually fine from a pain management standpoint. VITAL SIGNS: Blood pressure 100/56, pulse is 89 and she does have an occasional PAC, temperature is 100.2, respirations are 18, oxygen saturations 99% on 1-4 liters per minute. She is 0 on a FLACC score which is a pain intensity score that is nonverbal.
PAC|premature atrial contraction|PAC.|153|156|LABORATORY DATA|GENITALIA AND RECTAL: Exam deferred. NEUROLOGIC: Grossly nonfocal. LABORATORY DATA: Includes a preop EKG demonstrating sinus bradycardia with occasional PAC. Heart rate in the high 50s. Normal PR, QRS and QT interval. No ischemic change. White count 4600, hemoglobin 15.9 with MCV 96.2, platelet count 227,000.
PAC|premature atrial contraction|PAC|263|265|LABORATORY DATA|GENITALIA/RECTAL: Deferred. NEUROLOGIC: Grossly nonfocal. LABORATORY DATA: Preop hemoglobin 15.1. Potassium 4.4. Postop blood sugar in PACU was 158. EKG demonstrated normal sinus rhythm and axis. Normal PR, QRS and QT interval without ischemic change. Occasional PAC noted. ASSESSMENT: 56-year-old male with the following: 1. Right total knee arthroplasty.
PAC|premature atrial contraction|PAC.|125|128|LABORATORY & DIAGNOSTIC DATA|Cranial nerves II-XII are intact. Motor and sensory intact. LABORATORY & DIAGNOSTIC DATA: EKG demonstrates sinus rhythm with PAC. There is very poor R wave progression from V1 to V3, with marked ST segment elevation up to 5 mm with hyperacute T waves noted from V1 to V6, and I and aVL.
PAC|picture archiving communication|PAC|188|190|PLAN|As already mentioned, the patient trembled or shivered throughout the period of observation and examination. Toes were downgoing. Imaging from Fairview Northland was available through the PAC system. A recent MRI scan had been performed and was unfortunately obscured by movement artifact. Nevertheless, major structural lesions are excluded by the study. Also in the T2 weighted sequences, the findings of hypertensive encephalopathy (posterior T2 hyperintensity of white matter and gray matter) was not apparent.
PAC|premature atrial contraction|(PAC),|240|245|HISTORY|Reviewing the chart, there is no history of heart disease, although the patient is diabetic. I have been asked to see the patient because while he was here in the Intensive Care Unit (ICU) he was noted to have premature atrial contractions (PAC), some multifocal atrial tachycardia, and an eight-beat run of nonsustained ventricular tachycardia; this occurred when he was agitated and being moved in his bed.
PAC|premature atrial contraction|PAC,|249|252|ASSESSMENT/RECOMMENDATIONS|The sodium was 135 and potassium was 4.3. ASSESSMENT/RECOMMENDATIONS: Evaluation of the monitor indicates that the patient is having clinically insignificant pauses. The P-waves are difficult to see and so there does appear to be at least 1 blocked PAC, but it is possible that there are other P waves which can not be imaged. The pauses are not long enough to represent 2:1 second-degree AV block, even if the P-wave were present.
PAC|premature atrial contraction|(PAC)|146|150|HISTORY|The patient has been doing well since then. He is being hydrated. Here in the hospital he is noted to have numerous premature atrial contractions (PAC) and premature ventricular contractions (PVC). His EKG shows nonspecific ST changes in the inferior leads and in V2 to V4. Twelve- lead EKG shows multifocal PVCs. The patient does not have a cardiac history.
PAC|premature atrial contraction|PAC|217|219|LABORATORY DATA|There is mild to modest left ventricular hypertrophy. Monitor during the night showed sinus bradycardia. There is also one episode of what appeared to be around 2.8 second pause. This could easily have been a blocked PAC also, given his bradycardia. He was asymptomatic at the time and denied any nausea, cough or discomfort. He was sleeping and does have possibility of an apnea episode precipitating this.
PAC|premature atrial contraction|PAC.|290|293|IMPRESSION|Given his course, I think he merits early angiography. I discussed the indications, risks and alternatives of angiography and angioplasty with the patient and he elected to proceed. I will try to arrange that for today. 2. Bradycardia with pause. As noted, it is possible this is a blocked PAC. He certainly is very bradycardic with his beta blockers and these will be held at this time and will continue monitoring.
PAC|premature atrial contraction|(PAC)|324|328|EKG|EKG: Reviewing the EKG shows a relatively low voltage and an irregularly irregular heart rhythm of atrial fibrillation that apparently started in the early hours of this morning so that now she is less than 24 hours from the event. Reviewing the EKG from _%#DDMM2005#%_ shows sinus rhythm with premature atrial contractions (PAC) and significantly higher voltage. Review of the EKG from _%#DDMM2005#%_, however, shows voltage findings similar to the current electrocardiogram in atrial fibrillation.
PAC|premature atrial contraction|(PAC).|175|180|ASSESSMENT/PLAN|a. I agree with checking an echocardiogram and looking at diastolic indices. 2. Palpitations, probable premature ventricular contraction (PVC) or premature atrial contraction (PAC). a. Recommend telemetry monitor for 24 hours. 3. Peripheral vascular disease in a patient with severe peripheral vascular disease, status post angioplasty.
PAC|physician assistant certification|PAC:|29|32|NOTE|NOTE: _%#NAME#%_ _%#NAME#%_, PAC: Please note that dictation volumes are extremely low, with very indistinct words at times. Thank you. ORTHOPAEDIC CONSULTATION HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old female with significant history of medical issues including cerebral aneurysm in 2003, for which she underwent a craniotomy with sequelae from replacement of skull later.
PAC|premature atrial contraction|PAC|140|142|HISTORY OF PRESENT ILLNESS|The patient complains of orthopnea. The patient denies chest pain. She states that she has occasional dependent edema. She has a history of PAC which she was treated for, but no longer requires treatment. The patient states that she has a poor appetite. She denies nausea, vomiting, constipation, or diarrhea.
PAC|physician assistant certification|PAC.|160|163|LABORATORY DATA|The urinalysis micro did show a few bacteria. Urine tox was negative. During the same visit on _%#MMDD#%_ she had a full pelvic and Pap exam by _%#NAME#%_, the PAC. Wet prep, chlamydia, gonorrhea, PCR, and HIV were all negative. She did have an EKG today in order to clear her for the ECT therapy, which showed a heart rate of 88, normal sinus rhythm, with nonspecific T-wave abnormalities and with no acute changes.
PAC|physician assistant certification|PAC|23|25||_%#NAME#%_ _%#NAME#%_, PAC Fairview Northland Clinic _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_, MN _%#00000#%_ Dear _%#NAME#%_: I met with your patient, _%#NAME#%_ _%#NAME#%_, on _%#MM#%_ _%#DD#%_, 2006, along with her mother at the Maternal Fetal Medicine Center at University of Minnesota Medical Center, Fairview. As you know, she was initially referred for a follow up ultrasound due to suspected ventriculomegaly seen on ultrasound performed at your clinic.
PAC|premature atrial contraction|PAC.|130|133|ASSESSMENT|3. Irregular rhythm with EKG upon review demonstrating runs of PACs, i.e., 3 in a row followed by sinus beats, occasional blocked PAC. Potentially related to increased catecholamine release perioperatively. Possible effect from anesthesia. Rule out hypokalemia. Rule out low magnesium. No history of hyperthyroidism.
PAC|physician assistant certification|PAC|172|174|ASSESSMENT/PLAN|We will also watch his blood pressure throughout his stay here, and if there are any concerns will consider a different treatment plan at that time. _%#NAME#%_ _%#NAME#%_, PAC also saw this patient and agrees with the assessment and plan. Thank you for allowing me to assist in the care of your patient.
PAC|premature atrial contraction|(PAC).|224|229|EKG|There is some ST depression in V2 through V6 and also in I, II, and aVF. Maximal ST depression was in V4 to V5 and about 0.5-mm. There is some wide QRS complex presumably either aberrancy versus premature atrial contraction (PAC). ECHOCARDIOGRAM: Echocardiogram was performed and shows left ventricular function (LVF) of 60%.
PAC|premature atrial contraction|PAC.|340|343|LABORATORY DATA|NEURO: Normal-appearing locomotor strength. LABORATORY DATA: Pertinent lab values show a white count of 8.7, hemoglobin 10.6, hematocrit of 30.6, platelet 186,000, sodium 125, potassium 3.8, creatinine 1.23, BUN 18, troponin negative. Electrocardiogram as read by me shows a normal sinus rhythm with normal intervals and axis, and with one PAC. Telemetry shows predominant sinus rhythm with 1 or 2 runs of five beat PACs and one run of five beats of wide complex tachycardia that appears to be right bundle branch morphology.
PAC|premature atrial contraction|PAC,|210|213|IMPRESSION|IMPRESSION: Ms. _%#NAME#%_ _%#NAME#%_ is a _%#1914#%_-year-old woman with a fall and right ankle fracture. Apparently she has no right hip fracture. She has an irregular heart rhythm which is sinus rhythm with PAC, according to the EKG. I do not see atrial fibrillation. I doubt that she has any cardioembolic issues related to atrial fibrillation, based on the lack of that rhythm identified here.
PAC|physician assistant certification|PAC.|45|48|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, PAC. REASON FOR CONSULTATION: To assess for rehabilitation needs/placement. HISTORY OF PRESENT ILLNESS: This is a 55-year-old female with a history of kidney and pancreatic transplant with a history of bladder drainage in _%#MM2006#%_ with complicated UTIs.
PAC|premature atrial contraction|PAC.|208|211|LABORATORY STUDIES|Preoperatively, hemoglobin 10.9, platelet count 226, white blood cell count 6.4. Sodium 142, potassium 5.0, BUN 34, and creatinine 1.5. Chloride 105, bicarb 27. EKG showed normal sinus rhythm with occasional PAC. Chest x- ray showed no heart failure. ASSESSMENT AND PLAN: 1. Status post right total knee replacement.
PAC|(drug) PAC|PAC|154|156|REQUESTING PHYSICIAN|She was on multiple medications on admission 1. Diflucan 2. Aldactone 3. Risperdal 4. Lactulose 5. Slo-Mag 6. Tequin 7. She also takes Aldactone 8. Entex PAC one tablet Q day She STATES THAT She IS ALLERGIC TO PENICILLIN AND CEPHALOSPORINS.
PAC|premature atrial contraction|PAC,|159|162|PAST SURGICAL HISTORY|Portable chest x-ray performed on _%#MM#%_ _%#DD#%_, 2005, showed mild cardiac enlargement and aortic calcification. EKG performed on _%#MM#%_ _%#DD#%_, 2005, PAC, otherwise normal. Echo on _%#MM#%_ _%#DD#%_, 2005, normal left ventricular function with moderate aortic stenosis, and the patient had past CT scans on _%#MM#%_ _%#DD#%_, 2005, showing greater trochanter and lesser trochanter free fragments.
PAC|premature atrial contraction|PAC.|239|242|PAST SURGICAL HISTORY|2. Coronary status is stable as of now. The patient does have a history of ASCVD with history of AMI, hypertension, progressive diabetes type 2, and PAD. Echo shows normal left ventricular function with moderate aortic stenosis. EKG shows PAC. A chest x-ray shows mild cardiac enlargement with aortic calcification. The patient has slight to moderate cardiac problems perioperatively. We will follow the patient's blood pressure and medications perioperatively.
PAC|premature atrial contraction|PAC.|125|128|OBJECTIVE|VITAL SIGNS: Blood pressure in the 160s-190s/80s-low 100s. Heart rate in the low 100s with sinus tachycardia with occasional PAC. Temperature 101 degrees. Urine output 275 over the last shift. HEENT: Pupils equal and reacting symmetrically. Sclerae non-icteric. Fundi deferred.
PAC|premature atrial contraction|PAC,|127|130|LABORATORY DATA|EXTREMITIES: There was no evidence of pedal edema. NEUROLOGIC: Unremarkable. LABORATORY DATA: Her EKG showed sinus rhythm with PAC, couplets and isolated PVCs. There is no conduction abnormality or sinus pauses. ASSESSMENT AND RECOMMENDATIONS: This 77-year-old white female had a single episode of syncope with very little warning.
PAC|premature atrial contraction|(PAC)|254|258|HISTORY OF PRESENT ILLNESS|The patient came into the emergency room following the, I believe, fourth episode of palpitations, feeling her heart skipped and some shortness of breath. Evaluation in the emergency room found her to be in sinus rhythm with premature atrial contraction (PAC) and premature ventricular contraction (PVC). There is no acute EKG changes. Upon my seeing the patient she is resting comfortably and denies any chest pain, shortness of breath, or palpitations.
PAC|physician assistant certification|PAC.|147|150|PLAN|PLAN: The patient is a 46-year-old, Caucasian female, referred to Dr. _%#NAME#%_ _%#NAME#%_ from her primary care provider, _%#NAME#%_ _%#NAME#%_, PAC. The patient is already scheduled to do her psychological evaluation with Dr. _%#NAME#%_, and will get her laboratory tests done as well.
PAC|premature atrial contraction|(PAC);|186|191|HISTORY OF PRESENT ILLNESS|He also had a Holter monitor done which revealed sinus bradycardia, intermittent first-degree block but no other significant findings other than occasional premature atrial contractions (PAC); no arrhythmia were noted. On that workup of early-_%#MM#%_ the patient actually did have hypotension. When he had his episode of presyncope his blood pressure at that time was systolic approximately 80.
PAC|premature atrial contraction|PAC.|238|241|LABORATORY EVALUATION|Protein 7.9, WBC 7.6, hemoglobin 14.4, hematocrit 41.1. Electrocardiogram demonstrated a normal sinus rhythm with no acute ST abnormalities. PR, QRS and QTR intervals are within normal limits. Another electrocardiogram showed an isolated PAC. CLINICAL IMPRESSION: 1. Atypical chest discomfort, rule out angina pectoris (doubt).
PAC|premature atrial contraction|PAC;|216|219|LABORATORY DATA|MENTAL STATUS EXAMINATION: Per Dr. _%#NAME#%_. LABORATORY DATA: Potassium 3.1, creatinine 2.1, liver function tests are normal. Hemoglobin is 14.5. The EKG reveals sinus bradycardia at a rate of 48 and an occasional PAC; there are no acute- appearing changes.
PAC|premature atrial contraction|PAC.|368|371|LABORATORY DATA|Strength 5/5 bilaterally in the upper extremities. LABORATORY DATA: Preop labs done at _%#CITY#%_ _%#CITY#%_ Medical Clinic on _%#DDMM2007#%_ showed hemoglobin of 12.6 and hematocrit 37.8. CMP was significant for an elevated potassium of 5.1 and an alkaline phosphatase of 156. TSH was 0.37. Chest x-ray was within normal limits. EKG showed normal sinus rhythm with 1 PAC. ASSESSMENT/PLAN: 1. Status post right mid-foot osteotomy and fusion per Dr. _%#NAME#%_.
PAC|premature atrial contraction|PAC).|218|222|OBJECTIVE|OROPHARYNX: Clear. Dentition adequate repair. NECK: Carotid upstroke brisk without bruits. No thyromegaly or lymphadenopathy. SKIN: Unremarkable. CHEST: Clear lung fields. CARDIAC: Regular with occasional premature (? PAC). No gallop, click, murmur or jugular venous distention. ABDOMEN: Non-distended, soft and non-tender without organomegaly or mass. Bowel sounds normal.
PAC|picture archiving communication|PAC|175|177|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a very pleasant 82-year-old woman who was admitted because of shortness of breath and a large right pleural effusion. The PAC system and does not contain the recent chest x-ray. On _%#DDMM2007#%_, she had a right-sided thoracentesis of 1300 cc of a transudative fluid and had been seen by Dr. _%#NAME#%_ at that time.
PAC|physician assistant certification|PAC.|178|181|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 40-year-old, Caucasian female, who has been referred to our program from her primary care provider, _%#NAME#%_ _%#NAME#%_, PAC. The patient has attended an informational session with Dr. _%#NAME#%_. She describes a struggle with her weight for the last five years where she has had significant weight gain because of chronic neck pain and other health issues.
PAC|physician assistant certification|PAC.|139|142|PLAN|PLAN: The patient is a 40-year-old, Caucasian female who is referred to our program from her primary care provider, _%#NAME#%_ _%#NAME#%_, PAC. She has already done her psychological evaluation, first half of it, and will complete that. She will have her laboratory tests drawn today. I have asked to get a letter of advice from her pain clinic regarding treatment post-surgically for medications.
PAC|premature atrial contraction|PAC|252|254|ASSESSMENT|Details per Psychiatry. 2. Obesity, presumably exogenous. 3. Skin eruption beneath the breasts consistent with intertrigo. 4. Tension/muscle contraction headache. 5. Occasional premature on cardiac examination, clinically benign, possibly secondary to PAC or isolated PVC. 6. Borderline elevation in diastolic blood pressure potentially related to stress with the visit or cuff that is too small for the patient's arm.
PAC|premature atrial contraction|PAC,|199|202|LABORATORY DATA|Urinalysis is normal. ECG showed normal sinus rhythm with first degree AV block and occasional PVCs. There is one episode of a dropped QRS complex. I do not see a P wave to suggest that it a blocked PAC, it appears to be sinus node dysfunction with an atrial escape beat. Follow-up ECG was normal. IMPRESSIONS: 1. Near syncope. The patient had two brief episodes of near syncope prior to admission, occurring while he was at rest.
PAC|physician assistant certification|PAC,|175|178|ASSESSMENT AND PLAN|Thank you for allowing me to participate in the care of this very delightful patient, and I would be happy to see him again in the future. Diactated by _%#NAME#%_ _%#NAME#%_, PAC, for _%#NAME#%_ _%#NAME#%_, M.D.
PAC|picture archiving communication|PAC|141|143|LABORATORY DATA|Small bowel distal to this area is decompressed and therefore there is a component of partial small bowel obstruction. The films reviewed on PAC and the report noted. Upper endoscopy was performed and revealed a large amount of brown fluid in the stomach and much of this was suctioned out.
PAC|post anesthesia care|PAC|177|179|HISTORY OF PRESENT ILLNESS|Indication for this procedure was presumed mesenteric ischemia and her bowel was all deemed to be viable. Her operative course can be reviewed. She was seen and examined in the PAC postprocedure. She is sedated but does arouse according to nursing staff.
PAC|premature atrial contraction|PAC|165|167|LABORATORY DATA|No pedal edema. LABORATORY DATA: Electrocardiogram demonstrated atrial ventricular pacing with a premature beat of the same axis as the paced beat consistent with a PAC or PVC. Other laboratories include troponins all less than 0.07 on serial measurements. Triglycerides were 535 mg/dl. Sodium 136, potassium 3.7, BUN 20, and creatinine 1.0. Hemoglobin 14.9, white blood cell count 5.9, and platelet count 99,000.
PAC|premature atrial contraction|PAC|266|268|LABORATORY AND DIAGNOSTIC DATA|SKIN: Otherwise benign. NEUROLOGIC: Alert and oriented x3. Cranial nerves II through XII grossly intact. Affect is normal. LABORATORY AND DIAGNOSTIC DATA: EKG sinus bradycardia with rates as low as 35-45 and up to 1.8-second pauses with what appears to be a blocked PAC There are PVCs as well. White count 7200, hemoglobin 11.6. Lactic acid 0.9. Electrolytes are normal.
PAC|premature atrial contraction|PAC,|224|227|HISTORY OF PRESENT ILLNESS|The most recent electrocardiogram done at 7:30 this morning shows additional T changes that suggest an acute inferolateral myocardial process. This morning's EKG additionally shows, as the other ones also did, an occasional PAC, one of which was nonconducted. The patient does have a previous history of coronary disease, and had a balloon angioplasty done in 1996 at Methodist Hospital, which was preceded by an acute, albeit small myocardial infarction.
PAC|premature atrial contraction|PAC|125|127|PAST MEDICAL HISTORY|She did have a thrombophilia workup, as mentioned above, during this pregnancy which was negative per patient. 2. History of PAC and PVCs. 3. History of a miscarriage. 4. History of postpartum depression. 5. Status post liposuction surgery. CURRENT MEDICATIONS: Medications prior to admission included Zoloft, heparin for prophylaxis, which was stopped two days prior to admission, and Tums p.r.n. DRUG ALLERGIES: None.
PAC|picture archiving communication|PAC|118|120|OBJECTIVE ASSESSMENT|However, this is concerning enough considering her disseminated cancer that I requested an x-ray. The x-ray is on the PAC system and shows diffusely hypointense areas in her ribs on the left side. I know that this has been worked up previously with rib studies in the Emergency Department as well.
PAC|physician assistant certification|PAC|111|113|ASSESSMENT AND PLAN|We will just observe for any new infections. We will treat those at that time. We appreciate the consultation. PAC also saw this patient and agrees with the assessment and plan. Thank you _%#NAME#%_ and Dr. _%#NAME#%_ for allowing me to assist in the care of your patient.
PAC|premature atrial contraction|PAC|124|126|HISTORY|Looking at the pacing intervals it appears to me that it is capturing appropriately. There is one episode where there was a PAC and the beat that follows was both A paced and V paced appropriately showing that the pacer appropriately senses and captures.
PAC|physician assistant certification|PAC|150|152|REASON FOR CONSULTATION|Differential diagnosis at this time includes tumor versus cavernoma versus hemorrhage. RECOMMENDATIONS: 1. Dilantin load. 2. Frequent neurochecks. 3. PAC to evaluate increased LFTs. 4. We will review the imaging with team tomorrow and decide what if any treatments are required.
PAC|physician assistant certification|PAC|23|25||_%#NAME#%_ _%#NAME#%_, PAC Fairview Northland Clinic _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_, MN _%#00000#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the University of Minnesota Medical Center, Fairview, Maternal-Fetal Medicine Center on _%#DDMM2007#%_.
PAC|post anesthesia care|PAC|81|83|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old man who was seen in the PAC after having spinal decompression with numerous lumbar spinal osteotomies for flat back syndrome with chronic back pain with radiculopathy. The patient is unable to provide history right now as he is rather sedated related to pain medication and anesthesia in the recovery room.
PAC|premature atrial contraction|PAC|145|147|PHYSICAL EXAMINATION|She has 2+ distal pulses throughout. Her EKG shows normal sinus rhythm at 98 beats per minute. There is poor R-Wave progression noted. She has a PAC on the tracing. There are some nonspecific ST-T abnormalities in the inferior and lateral leads. LABS: Sodium 143, potassium 3.6, chloride 106, bicarb 27, anion gap of 10, BUN 27, creatinine 0.9, glucose 109, INR was 1.06. White count was elevated at 15.6, hemoglobin 11.6, hematocrit 34.0, platelets 246,000.
PAC|physician assistant certification|PAC,|80|83|ASSESSMENT/PLAN|Treatment per Dr. _%#NAME#%_. We appreciate the consult. _%#NAME#%_ _%#NAME#%_, PAC, also saw this patient and agrees with the assessment and plan. Thank you _%#NAME#%_ and Dr. _%#NAME#%_ for allowing me to assist in the care of your patient.
PAC|premature atrial contraction|PAC.|257|260|PHYSICAL EXAMINATION|No chest pain. No shortness of breath. PHYSICAL EXAMINATION: GENERAL: Elderly, chronically ill-appearing female lying in bed, arousable but lethargic. VITAL SIGNS: Blood pressure ranges from 120-140 systolic. Her heart rate is 50-60 and regular. Occasional PAC. Respiratory rate appears to be in the mid teens. Her sats are adequate on nasal cannula oxygen. HEENT: Normocephalic, atraumatic.
PAC|premature atrial contraction|(PAC)|246|250|HISTORY|He denies palpitations, syncope, or presyncope. When he was hospitalized in _%#MM#%_ he also had an irregular heart rhythm that was originally thought to be atrial fibrillation, but Dr. _%#NAME#%_ felt that this was premature atrial contractions (PAC) and premature ventricular contractions (PVC) and not atrial fibrillation. (I do not have that old chart to review this.) The patient is somewhat debilitated since his previous hip fracture.
PAC|premature atrial contraction|(PAC).|233|238|ELECTROCARDIOGRAM|No lower extremity edema. LABORATORY DATA: Significant laboratory tests include a peak troponin of 7.53. ELECTROCARDIOGRAM: I personally viewed her electrocardiogram which shows normal sinus rhythm with premature atrial contractions (PAC). There is borderline left ventricular hypertrophy. Anterior and anteroseptal T wave inversions which are suggestive of ischemia. Slight anteroseptal ST elevation which has not changed significantly compared to her last electrocardiogram.
PAC|premature atrial contraction|PAC|170|172|ADDENDUM|Glucose 89, BUN 26, creatinine 1.4, sodium 141, potassium 4.7, chloride 102, C02 31. Electrocardiogram - Bradycardia rate of 52. There is left axis deviation. Occasional PAC and there is no change from previous ECG. Chest x-ray does show increased basilar markings consistent with pulmonary fibrosis unchanged from previous.
PAC|premature atrial contraction|PAC|279|281|LABORATORY DATA|LABORATORY DATA: Sodium 132, potassium 3.8, chloride 97, CO2 24, creatinine 0.9, BUN 23, glucose 113, WBC 9.0, hemoglobin 11.8, platelet count 311,000. Patient did have a head CT scan which was described as negative. Patient's electrocardiogram showed a normal sinus rhythm with PAC noted, possible left atrial abnormality and slight decrease in R wave progression in V1 and V2, probably mostly related to lead placement.
PAC|post anesthesia care|PAC|152|154|PLAN|Apparently last night she told the nurses she did not want to change her gown so she was still awake and alert at that time. Today she was taken to the PAC for ECT and Dr. _%#NAME#%_ felt she was too hemodynamically unstable to proceed. We have been asked to consult. Dr. _%#NAME#%_ has given her a fluid flush in attempt to get her blood pressure up which was successful.
PAC|premature atrial contraction|PAC,|272|275|PHYSICAL  EXAMINATION|GASTROINTESTINAL: History of colonoscopy approximately 1-2 years ago and he notes that he is due to have this again in the next 1-2 weeks. All other review of systems are negative. PHYSICAL EXAMINATION: VITAL SIGNS: Current blood pressure 103/86, pulse 71 with occasional PAC, 99% saturated. GENERAL: The patient is an alert black male appearing his stated age in no acute distress. HEENT: Normocephalic, atraumatic, without xanthoma. No arcus senilis. No oropharyngeal lesions.
PAC|physician assistant certification|PAC|44|46|REQUESTING PROVIDER|REQUESTING PROVIDER: _%#NAME#%_ _%#NAME#%_, PAC _%#NAME#%_ _%#NAME#%_ is a 24-year-old female with onset of gallbladder symptoms. The patient has recently gone through childbirth and since that time has developed right upper quadrant abdominal pain which comes just about every time that she eats and saw her primary care physicians for evaluation.
PAC|premature atrial contraction|PAC.|115|118|PHYSICAL EXAM|PHYSICAL EXAM: Reveals a pleasant gentleman in no apparent distress. He is in a sinus rhythm, rate of 68 with rare PAC. His blood pressure is currently 142/70. SKIN - benign. There are no petechiae, rashes, xanthoma. HEENT - benign. NECK - supple without thyromegaly or adenopathy.
PAC|physician assistant certification|PAC,|121|124|IMPRESSION AND PLAN|Thank you for allowing us to participate in the care of this very delightful patient. Dictated by _%#NAME#%_ _%#NAME#%_, PAC, for _%#NAME#%_ _%#NAME#%_, MD
PAC|physician assistant certification|PAC|58|60|DOB|Revised Report DOB: _%#DDMM1914#%_ _%#NAME#%_ _%#NAME#%_, PAC dictating for _%#NAME#%_ _%#NAME#%_, M.D. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a delightful _%#1914#%_- year-old gentleman who presented here from his assisted living facility for an episode of acute shortness of breath.
PAC|pulmonary arterial concentration|PAC|238|240|ASSESSMENT|The patient has hypoventilation and respiratory acidosis. Likely has obstructive sleep apnea, possibly a component of central sleep apnea, however, the CO2 retention in general, patients with central apnea from heart failure may have low PAC O2s. The patient is at risk for aspiration. the patient should be on BiPAP with a backup rate. If she cannot be managed on this she will need intubation discussed with her husband.
PAC|premature atrial contraction|PAC.|184|187|INDICATION FOR PROCEDURE|AP patches were placed; 1 single 100 joule anteroposterior shock was delivered with restoration of sinus rhythm, initially with frequent PACs and subsequently sinus rhythm with a rare PAC. She was followed post-cardioversion. She had no obvious complications. She is currently awakening slowly and has been hemodynamically and respiratory stable.
PAC|premature atrial contraction|PAC|240|242|HISTORY OF PRESENT ILLNESS|While in Dr. _%#NAME#%_ Office a rhythm strip was performed for about 30 seconds which showed frequent episodes of pauses up to seconds in duration. These were asymptomatic. They were occurring in the context of sinus rhythm and followed a PAC with a prolonged pause. During these pauses he has felt flushing but no chest pain or shortness of breath. He has not had syncope and has not fallen as a result of these episodes.
PAC|premature atrial contraction|(PAC).|196|201|EKG|Electrolytes are normal including a potassium of 3.7. Creatinine of 1.08 and hemoglobin 146. EKG: EKG on admission demonstrated sinus rhythm with moderately frequent premature atrial contractions (PAC). Intervals were normal and there was no ST segment abnormality. ECHOCARDIOGRAM: As noted, recent echocardiogram demonstrated normal left ventricular function without wall motion abnormality.
PAC|premature atrial contraction|PAC|259|261|PREOPERATIVE LABORATORY DATA|EXTREMITIES: Her right lower extremity is wrapped and that is per orthopedics. She PREOPERATIVE LABORATORY DATA: Including a creatinine of 1.1. She had an EKG that almost impossible to read, such a poor quality but does look like sinus rhythm with possibly a PAC ASSESSMENT AND PLAN: The patient is a 64-year-old female with history of hypertension, hyperlipidemia, depression, anxiety, probably some urinary incontinence.
PAC|premature atrial contraction|PAC|137|139|LABORATORY & DIAGNOSTIC DATA|EXTREMITIES: Lower extremities show no edema and normal peripheral pulse. LABORATORY & DIAGNOSTIC DATA: EKG shows sinus rhythm with some PAC and otherwise normal QRS morphology and normal ST-T segment. Chest x-ray showed no pulmonary infiltrate. Her labs show troponin first one 0.55, on repeat is 7.29. Liver function tests is normal.
PAC|premature atrial contraction|(PAC).|226|231|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: The patient on exam shows no response to verbal cues on propofol. VITAL SIGNS: Her temperature is normal. Pulse is regular sinus rhythm in the 80s with an occasional premature atrial contraction (PAC). Blood pressure is 100/60. Respirations are controlled at 12. Oxygen saturation is 100% with an FIO2 of 0.7. . SKIN: Pale and cool. HEENT: Now shows equal and reactive pupils bilaterally.
PAC|physician assistant certification|PAC,|179|182|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 35-year-old male admitted on a 72-hour hold for depression and possible polydrug overdose/suicide attempt. I was asked by _%#NAME#%_, PAC, to see the patient for an Internal Medicine consult, and the patient was examined on _%#DDMM2006#%_. The patient is currently experiencing intense low back pain and occasional tension headaches.
PAC|premature atrial contraction|PAC.|148|151|LABORATORY DATA|Total protein 7.2. Electrocardiogram shows a normal sinus rhythm without acute ST abnormality present. There is slight leftward axis and occasional PAC. CLINICAL IMPRESSION: 1. Chest discomfort consistent with probable angina pectoris. 2. History of hyperlipidemia.
PAC|premature atrial contraction|PAC,|163|166|LABORATORY DATA|Also noted are cardiomegaly, colonic diverticuli, prostate enlargement, urinary bladder diverticulum and renal cysts. EKG dated _%#MMDD#%_ shows sinus rhythm with PAC, borderline LVH by voltage, incomplete right bundle branch block. QTC was 496 by the computer, although visually it appears shorter than that.
PAC|premature atrial contraction|(PAC)|214|218|EKG|CHEST X-RAY: Chest x-ray shows a 9.0-cm mass in the right lung which is new fromm_%#DDMM1998#%_. Bibasilar interstitial fibrosis is also noted. EKG: EKG demonstrates sinus rhythm with premature atrial contractions (PAC) and alternating with ectopic atrial rhythm. There are slightly peaked T waves in leads V2 and V3. There are no acute ST-T wave changes. CT SCAN: CT scan of the chest was just performed and results are pending.
PAC|premature atrial contraction|(PAC).|459|464|EKG #1|NEUROLOGIC: Nonlocalizing. LABORATORY DATA: Cardiac enzymes were normal serially. Electrolytes were unremarkable with a sodium 141, potassium 4.1, creatinine 0.9. Hemoglobin 16.0, white count 7.6. CHEST X-RAY: Chest x-ray demonstrated bilateral upper lobe vascular congestion and more prominently at the bases and was interpreted as a congestive heart failure (CHF) pattern. EKG #1: EKG demonstrated sinus rhythm with occasional premature atrial contractions (PAC). There were nonspecific minor inferolateral T wave changes, but no acute ST segment changes. This is without significant change from _%#MM2003#%_ other than the previous significant T waves inferiorly are now not electrocardiographically significant.
PAC|premature atrial contraction|PAC|102|104|PHYSICAL EXAMINATION|Normal bowel sounds. No vascular bruit. EXTREMITIES: No peripheral edema. EKG shows sinus rhythm with PAC and a rS in II and aVF with T wave inversion in leads III and V6. LABORATORY: Troponin 0.05, BNP 676. WBC 12.1, hemoglobin 11.1. Sodium 143, potassium 3.5, chloride 103, bicarb 20.
PAC|premature atrial contraction|(PAC)|175|179|PHYSICAL EXAMINATION|No recent fevers or infection. Review of systems is otherwise negative. PHYSICAL EXAMINATION: VITAL SIGNS: He is in sinus rhythm with occasional premature atrial contractions (PAC) and somewhat frequent unifocal premature ventricular contractions (PVC). Heart rate in the mid-50s (again, he is on high-dose atenolol). His blood pressure generally is still running 150- 160 systolic and it is symmetric in both arms.
PAC|picture archiving communication|PAC|126|128|PHYSICAL EXAMINATION|There is strong dorsalis pedis and posterior tibial pulses present at the right lower extremity. X-rays are reviewed from the PAC system that were performed on _%#DDMM2007#%_. They show dislocation at the Lisfranc joint, consistent with Charcot neuroarthropathy. There is generalized bone degradation in through the mid foot that is again consistent with the Charcot process.
PAC|physician assistant certification|PAC.|130|133|ASSESSMENT AND PLAN|6. Herpes stomatitis, sore on upper lip. Valtrex 500 mg p.o. b.i.d. X five days. The patient was seen with _%#NAME#%_ _%#NAME#%_, PAC.
PAC|premature atrial contraction|PAC|302|304||He had been on atenolol 50 mg per day prior to coming to the hospital. The atenolol was discontinued. The patient continues to run bradycardia, but his heart rate is slowly increasing, now close to 100 beats per minute, and he did have a short run of SVT noted in the record that was precipitated by a PAC with rates of about 150 per minute with 8 beats participating in this. It turns out that at Walter Reed he was thought to have WPW and was kept out of flight school for that reason.
PAC|premature atrial contraction|PAC)|207|210|SOCIAL HISTORY|Frontal headache attributed to lack of caffeine. Dizziness with upright posture. No visual change. No chest discomfort or dyspnea. No orthopnea. No palpitations. I can palpate occasional premature (question PAC) and a.m. cough productive of yellow sputum. Denies nausea or vomiting. Well-developed dyspepsia with certain foods. No abdominal pain. Alternate diarrhea and constipation. No signs of GI blood loss.
PAC|post anesthesia care|PAC|219|221|PHYSICAL  EXAMINATION|REVIEW OF SYSTEMS: This is otherwise negative except as mentioned in history of present illness. PHYSICAL EXAMINATION: GENERAL: Female in no acute distress. VITAL SIGNS: Pulse 62, blood pressure 153/104. Temperature in PAC 36.1. HEENT: Pupils approximately 2 mm bilateral and equal, appear sluggish to nonreactive. NECK: No adenopathy. No thyromegaly. LUNGS: Slightly coarse breath sounds.
PAC|premature atrial contraction|PAC,|121|124|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: The patient's blood pressure is 125/56 mmHg, pulse is 66. Telemetry shows normal sinus rhythm with PAC, some are non-conducted. The patient's saturation is 93%. HEENT: Normocephalic, atraumatic. Pupils were small but reactive to light. Extraocular movements were intact. NECK: Supple. She has rapid carotid upstrokes bilaterally.
PAC|premature atrial contraction|(PAC)|202|206|PHYSICAL EXAMINATION|Teeth are in moderate repair. NECK: Supple. Jugular venous distention (JVD) is not discernible. CHEST: Clear anteriorly. CARDIOVASCULAR: Regular rate and rhythm with a few premature atrial contractions (PAC) noted, S1 and S2. No rub is noted. Peripheral pulses are intact. No carotid bruits. ABDOMEN: Soft and nontender. Bowel sounds are present. EXTREMITIES: Extremities show 1+ edema on the left and 2+ edema on the right and previous evidence of vein stripping as well.
PAC|premature atrial contraction|PAC|122|124|ASSESSMENT|Overnight oximetry done with average saturation of 95%. ASSESSMENT: 1. Schizophrenia. 2. Mild tachycardia with occasional PAC versus PVC. The patient is totally asymptomatic. 3. Status post brain surgery in _%#MM#%_. The patient has nonfocal exam and no additional workup is needed at this time.
PAC|premature atrial contraction|PAC.|166|169|PHYSICAL EXAMINATION|Tongue is mildly dry. NECK: Supple without adenopathy or thyromegaly. CHEST: With good air movement and clear. HEART: Regular rate and rhythm, S1, S2 with occasional PAC. There is a systolic murmur noted. ABDOMEN: Soft, nontender, no abdominal bruits, no masses, no organomegaly. EXTREMITIES: Without clubbing, cyanosis or edema NEUROLOGIC: Grossly nonfocal. LABORATORY DATA: Chemistries from today: 138/3.6/107/22, BUN 63, creatinine 3.73, calcium 8.9, hemoglobin noted to be 9.9 on admission.
PAC|premature atrial contraction|PAC.|148|151|PHYSICAL EXAMINATION|No kyphosis or scoliosis. CARDIAC: Regular rate and rhythm, normal S1 and S2, without gallop. There is an occasional ectopic, which on monitor is a PAC. Rare couplet. There is no murmur. No heave, rub or thrill. No jugular venous distention or hepatojugular reflux. Pulses are all intact with only a soft right femoral bruit.
PAC|physician assistant certification|PAC,|131|134|ASSESSMENT|We will draw CBC to follow up on leukopenia that was noted on _%#DDMM2006#%_, results of which are pending. _%#NAME#%_ _%#NAME#%_, PAC, also saw this patient and agrees with the assessment and plan.
PAC|premature atrial contraction|(PAC).|176|181|PHYSICAL EXAMINATION|Jugular venous distention (JVD) is not grossly elevated. CHEST: Decreased air movement throughout. CARDIOVASCULAR: Regular S1, S2, with occasional premature atrial contraction (PAC). PMI is nondisplaced. ABDOMEN: Soft with diffuse tenderness throughout. No rebound. No voluntary guarding. GENITALIA: Normal male anatomy. EXTREMITIES: Warm and dry with no cyanosis, clubbing or edema.
PAC|premature atrial contraction|PAC|144|146|OBJECTIVE|She is alert and oriented. Her blood pressure is 100/80 sitting and standing. Heart rate is 70s and regular with rare premature consistent with PAC clinically. Temperature is normal. Respirations are normal. HEENT: Extraocular movements are full, no nystagmus. Pupils are equal and reacting symmetrically. Sclerae are anicteric. Fundoscopic examination was deferred.
PAC|premature atrial contraction|(PAC).|141|146|EKG|Follow-up EKG the next morning shows resolution of the ST segment changes with sinus rhythm at 80 and frequent premature atrial contractions (PAC). The monitor shows sinus rhythm with frequent nonsustained in 2-3 second runs of either SVT or what may be atrial flutter. LABORATORY DATA: Current hemoglobin 10.7, white count 6.0, having been 23 on admission.
PAC|physician assistant certification|PAC,|113|116|ASSESSMENT/PLAN|3. Moderate dehydration. We will encourage p.o. fluids verbally to the patient. Thank you _%#NAME#%_ _%#NAME#%_, PAC, and Dr. _%#NAME#%_ for allowing me to assist in the care of your patient. _%#NAME#%_ _%#NAME#%_ also see this patient and agrees with the assessment and plan.
PAC|premature atrial contraction|PAC.|155|158|ELECTROCARDIOGRAM|LABORATORY DATA: Included normal CBC, electrolytes and liver function tests. ELECTROCARDIOGRAM: Revealed normal sinus rhythm on admission, with occasional PAC. No acute-appearing change and the EKG appears to be within normal limits. I will happy to following if other medical issues arise during his hospitalization.
PAC|physician assistant certification|PAC,|129|132|PLAN|5. Urine culture. Pending results start Cipro 500 mg b.i.d. 6. Pelvic examination by physician assistant, _%#NAME#%_ _%#NAME#%_, PAC, prior to discharge to check for STD. If the patient discharged beforehand advise follow-up with her primary care provider. Thank you for the consultation. We will follow along as indicated.
PAC|premature atrial contraction|PAC,|129|132|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Current blood pressure is 142/68 on the right, 140/61 on the left, pulse is 70 and regular with occasional PAC, the patient is afebrile, respiratory rate 18 and unlabored. Weight 53.1 kilograms. GENERAL: The patient is an alert white female appearing much younger than her stated age in no acute distress.
PAC|premature atrial contraction|(PAC)|353|357|HISTORY OF PRESENT ILLNESS|She has been known to have what looks like tachybrady syndrome looking at her rhythm strips; she will have brief episodes of paroxysmal atrial tachycardia (PAT) and then marked sinus bradycardia. There have been no long pauses. A question of atrial fibrillation was also raised but I think what is happening that they were premature atrial contractions (PAC) and the P wave was just not evident on the lead that was chosen since it turns out it is only in the leads where the QRS is negative that the P waves were not visible and on all of the leads where the QRS was positive one can see P waves throughout.
PAC|post anesthesia care|PAC|213|215|LABORATORY DATA|ABDOMEN: Benign. EXTREMITIES: No edema. CMS intact. NEUROLOGIC: Cranial nerves are intact. Motor exam shows symmetric strength. LABORATORY DATA: Preoperative hemoglobin was 12.6, potassium 4.1, blood sugar 170 3, PAC blood sugar 123. PREOPERATIVE ELECTROCARDIOGRAM: Shows low voltage and is otherwise within normal limits.
PAC|premature atrial contraction|PAC|175|177|IMPRESSIONS, RECOMMENDATIONS|There was T-wave inversion in leads II, III and AVF. Ischemic could not be excluded. The patient does have voltage criteria for left ventricular hypertrophy. He does have one PAC on that tracing. I did not see any evidence for atrial fibrillation. However, I do not have any telemetry strips to review.
PAC|physician assistant certification|PAC.|180|183|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 53-year-old, Caucasian female, who has been referred into our program from her primary care provider, _%#NAME#%_ _%#NAME#%_, PAC. The patient has attended recently an information session where she learned a lot about the surgery. She describes a 45-year struggle with her weight, where she has attempted many weight loss programs, including Weight Watchers twice, Tops for over a year, exercise programs, and even tried some diet pills to lose weight.
PAC|physician assistant certification|PAC.|146|149|PLAN|PLAN: The patient is a 53-year-old, Caucasian female, who has been referred to our program from her primary care provider, _%#NAME#%_ _%#NAME#%_, PAC. The patient has not yet scheduled her psychological evaluation and will do so, and also get her laboratory tests done. Once they are into the clinic for review and all is positive, she may then see the surgeon of her choice for further evaluation.
PAC|premature atrial contraction|PAC.|192|195|LABORATORY STUDIES|White count is 12.9, differential shows slight increased absolute neutrophil count with hemoglobin 13.3, INR .91, myoglobin and troponin are normal. EKG reveals a sinus rhythm with occasional PAC. There is 1 mm ST depression in V4 and V5, biphasic T in V3 and inverted T in V6 compared to an old EKG from _%#DDMM2000#%_, there is slight ST depression in V5, V6 with biphasic T in V4.
PAC|premature atrial contraction|PAC|140|142|EKG|CT is otherwise negative. Chest x-ray normal. No acute infiltrates. EKG: Moderately frequent premature ventricular contractions, occasional PAC and block PAC. There is a left bundle branch block. No previous EKGs for analysis. ASSESSMENT: 1. An 81-year-old white female presents for substernal chest pressure.
PAC|pulmonary artery catheter|PAC|240|242|HOSPITAL COURSE|10. Obesity with history of fatty liver. 11. Iron deficiency first diagnosed in _%#MM2002#%_, treated with oral iron supplements which the patient has been taking since diagnosis. HOSPITAL COURSE: PROBLEM #1. Hypotension: The patient had a PAC placed which showed a septic-like picture; however, blood cultures were negative. She was placed on several days of Cipro and Zosyn as empiric therapy.
PAC|premature atrial contraction|PAC.|204|207|ASSESSMENT|8. History of nephrolithiasis. 9. Type 2 diabetes mellitus with excellent control on diet (pre-op). 10. Osteopenia. 11. Aortic sclerosis. 12. Non-specific ST, T-wave change on EKG with a suspect aberrant PAC. Stable tracing per record. No symptoms to suggest a cardiac ischemia. 13. Prior surgeries as above. PLAN: 1. Intravenous fluids until adequate p.o.
PAC|picture archiving communication|PAC|106|108|IMAGING|IMAGING: An MRI was done at an outside institution. However, it is not in her chart, and it is not on our PAC system. The consulting team stated that they would place it on our PAC system. However, I have not seen it, and I have not seen the CT either, and I cannot find it.
PAC|picture archiving communication|PAC|177|179|IMAGING|IMAGING: An MRI was done at an outside institution. However, it is not in her chart, and it is not on our PAC system. The consulting team stated that they would place it on our PAC system. However, I have not seen it, and I have not seen the CT either, and I cannot find it. LABORATORY DATA: Pending. ASSESSMENT: Ms. _%#NAME#%_ is a 62-year-old female with rapid progressive dementia over the past 3 months with a family history of probable .......disease. Our plan is to get appropriate labs, to schedule a biopsy and consent from family members.
PAC|picture archiving communication|PAC|188|190|IMAGING|IMAGING: A head CT done without contrast today _%#DDMM2007#%_ in comparison to a head CT done without contrast on _%#DDMM2007#%_, both of which were done at our institution and are in her PAC system shows: 1. Slight involution in the right temporal intraparenchymal hemorrhage. 2. A new 1.5x1.4 intraparenchymal hemorrhage in the right posterior occipital pole.
PAC|premature atrial contraction|(PAC)|222|226|EKG|Urinalysis showed trace blood (although it was a catheterized urinalysis) with specific gravity of 1.025. EKG: EKG on _%#DDMM2005#%_ showed normal sinus rhythm and normal axis. There were two premature atrial contractions (PAC) noted. There were no Q waves. No ST elevation or depression. Rate was 70. ASSESSMENT/PLAN: 64-year-old with fracture of the left subtrochanteric region.
PAC|picture archiving communication|PAC|186|188|HISTORY OF PRESENT ILLNESS|He called me about her last night and we telephonically discussed her case. He reported appropriately that she was neurologically intact. Her imaging was not available for review on the PAC System, so I agreed to review her case this morning. She is currently a 61-year-old female. Her right thigh liposarcoma was treated with a wide excision in 1999 followed by postoperative radiation therapy.
PAC|premature atrial contraction|(PAC)|170|174|REASON FOR CONSULTATION|He had some bubble gas on one of the images which appears to be artifact to me, but was admitted for inpatient management. He did have some premature atrial contractions (PAC) and premature ventricular contractions (PVC) and was seen in the Intensive Care Unit (ICU) for telemetry. Today, he states that he is back to baseline. He is unaware of any neurological complaints.
PAC|picture archiving communication|PAC|277|279|IMAGING|I could not assess for finger-nose-finger testing or tandem walking either because of the patient not being cooperative. IMAGING: An MRI of her cervical spine done on _%#DDMM2007#%_ which is without contrast, which is of good quality at an outside institution, which is in our PAC system shows 1 cervical 2-3 intervertebral T2 hyperintensity extending posteriorly, which also extends superiorly and inferiorly into the vertebral bodies of C2 and C3 without any cord compression.
PAC|premature atrial contraction|PAC.|211|214|EKG|ABDOMEN: Soft, nontender. Bowel sounds present. EXTREMITIES: There is trace edema in the left lower extremity. MUSCULOSKELETAL: Not done. EKG: Sinus bradycardia ventricular rate at 48 per minute with occasional PAC. No acute ST-T wave changes. CHEST X-RAY: No acute process. LABORATORY: CBC, white count is 9.2, hemoglobin 12.9, hematocrit 38.0, platelets are 205,000.
PAC|premature atrial contraction|PAC,|184|187|ELECTROCARDIOGRAM|EXTREMITIES: He has good pedal pulses. SKIN: Normal. PSYCHIATRIC: Affect is normal. Ability to get up and move about is normal. ELECTROCARDIOGRAM: Reviewed and does show an occasional PAC, a question of left atrial enlargement but is otherwise unremarkable, except for a left axis deviation. My bias is that he can go home and come back.
PAC|physician assistant certification|PAC|38|40|DISCHARGE FOLLOWUP|_%#DDMM2007#%_ _%#NAME#%_ _%#NAME#%_, PAC Fairview _%#CITY#%_ Clinic _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_, MN _%#00000#%_ Phone: _%#TEL#%_ Fax: _%#FAX#%_ Dear Mr. _%#NAME#%_; Thank you for accepting the care of _%#NAME#%_ _%#NAME#%_ from the Neonatal Intensive Care Unit at University of Minnesota Children's Hospital, Fairview.
PAC|premature atrial contraction|PAC|138|140|LABORATORY STUDIES|ALT 24, AST 21, total bilirubin is 0.3, alkaline phosphatase 129, albumin 4.0. EKG shows right bundle branch block. Sinus rhythm with one PAC noted. This is essentially unchanged compared to _%#MM2002#%_. Chest x-ray, no infiltrate or mass seen. Heart size is normal.
PAC|premature atrial contraction|PAC.|125|128|LABORATORY DATA|There is a first degree A-V block which is old. There is right bundle branch block which is old. There is occasional PVC and PAC. The ST segments and lateral leads are not changed from previous. Urinalysis: no white cells and no red cells. Trace amount of blood, otherwise unremarkable.
PAC|picture archiving communication|PAC|244|246|LABORATORY|INR is 4.87, basic metabolic panel is essentially normal with mildly elevated BUN at 28 and creatinine of 0.7. Imaging chest film apparently demonstrates extensive right middle lobe infiltrate. I am currently unable to pull up the image on the PAC viewer. ASSESSMENT: This is a 46-year-old woman with long standing, progressive, severe multiple sclerosis and a new onset of community acquired pneumonia of several day's duration.
PAC|premature atrial contraction|(PAC)|195|199|EKG|Slight pulmonary vascularity increased. EKG: EKG shows normal sinus rhythm with a heart rate of 98. Left atrial enlargement. Previous anterolateral infarct. A single premature atrial contraction (PAC) is noted. CT SCAN: Head CT on initial reading shows no mass, mass effect or intracranial hemorrhage.
PAC|premature atrial contraction|PAC|361|363|PROBLEM #2|PROBLEM #2: Mycobacterium avium complex: The patient had multiple episodes of fevers during her hospitalization. These were felt due to disseminated mycobacterium avium complex. Multiple cultures were obtained with temperature spikes and the only significant positive results were the CSF being positive for CMV The patient is currently receiving treatment for PAC with ethambutol, rifabutin, levofloxacin, azithromycin, and should continue to receive this treatment until she is re-evaluated by Dr. _%#NAME#%_. PROBLEM #3: Adrenal insufficiency: The patient came in with hypotension and low temperature.
PAC|physician assistant certification|PAC|127|129|DATED|Says she falls nearly every day and uses a walker at home." Progress note dated _%#DDMM2006#%_ by _%#NAME#%_ _%#NAME#%_, MPAS, PAC stated: "Patient out of bed and chair, refusing food and liquids. Continues to refuse meds. She has minimal response to questions.
PAC|physician assistant certification|PAC|150|152|DATED|She has had thoughts of cutting her wrist. Insight is poor. Judgment impaired." Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_, MPAS, PAC summarized in the examiner's statement in support of petition for commitment: "The patient was brought into Emergency Room with increased symptoms of severe depression, no self-cares, not eating, not drinking, delusional, admitting to feelings of stabbing, hopeless and helplessness.
PAC|premature atrial contraction|(PAC)|154|158|ASSESSMENT/PLAN|She has some rhonchi and we will use it sparsely. We do not want to invoke a rhythm problem. She is already having a lot of premature atrial contractions (PAC) and I suspect she is a patient who may easily go into atrial fibrillation, especially with any fluid overload.
PAC|premature atrial contraction|PAC|182|184|PHYSICAL EXAMINATION|Her dorsalis pedis pulses are 2+ bilaterally. Her chest x-ray showed infiltrated in left upper lobe. Her EKG showed normal sinus rhythm with a rate of 87 with an occasional probably PAC with aberrant conduction. She also has T-wave inversion V1 through V3, there is no old EKG to compare. Labs on admission, her INR is 1.16, PPT of 31, pH of 7.43, pO2 of 132, pCO2 of 33, bicarb of 22.
PAC|post anesthesia care|PAC|190|192|HOSPITAL COURSE|Her tubal ligation was done and a portion of her left and portions of both her right and left Fallopian tubes were sent to pathology after her tubal was done. The patient was brought to the PAC in stable condition (please see operative note for details). POSTOPERATIVE COURSE: The patient did well postoperatively. Hemoglobin on postoperative day #1 was 10.8. She was breast feedi ng her infant.
PAC|physician assistant certification|PAC|594|596|HISTORY OF PRESENT ILLNESS|The patient felt better on _%#DDMM2006#%_, as her abdominal pain began to decline, and although there has been some recurrence of her intermittent abdominal pain with nausea and vomiting since _%#DDMM2006#%_, she was felt to be more stable in regards to this, and has transferred to our service again for further Physical Therapy and Occupational Therapy and ongoing care of her multiple medical problems here at the Transitional Services Unit. For further details regarding the patient's hospital course, I refer you to the dictated note from _%#DDMM2006#%_, dictated by _%#NAME#%_ _%#NAME#%_ PAC of the Transplant Service. PAST MEDICAL HISTORY: 1. Type 2 diabetes, insulin dependence for most of her life.
PAC|premature atrial contraction|(PAC).|224|229|EKG|NEUROLOGIC: The patient was reported to be mildly confused and slow at presentation, though now seems to be mentating normally. SKIN: No rash. EKG: EKG shows normal sinus rhythm with occasional premature atrial contractions (PAC). No ischemic changes. CHEST X-RAY: Chest x-ray reading is pending, but to me it appears normal.
PAC|premature atrial contraction|PAC,|321|324|LABS ON ADMISSION|Spine: No CVA tenderness. Skin: Large moles on back. Neuro: Cranial nerves 2 through 12 intact. DTRs 2+ patella bilaterally. LABS ON ADMISSION: WBC 11.7, hemoglobin 12.6, platelets 265,000, INR 1.00, PTT 28, sodium 140, potassium 3.8, chloride 101, bicarb 31, BUN 15, creatinine 0.71, glucose 94, calcium 9.5. EKG showed PAC, then normal sinus rhythm after fluid resuscitation. HOSPITAL COURSE: PROBLEM #1: GI. Patient was admitted to the intensive care unit.
PAC|premature atrial contraction|PAC|142|144|HISTORY OF PRESENT ILLNESS|It showed normal left ventricular function performance. With exercise, it was hyperdynamic. No regional wall motion abnormality. They noticed PAC or more likely atrial fibrillation. For that, she was scheduled for a Holter monitor which showed a sinus rhythm, first degree AV block and bundle branch block with ectopics and SVT but no atrial fibrillation.
PAC|premature atrial contraction|PAC|211|213|LABORATORY|Urinalysis reveals moderate leukocyte esterase and moderate bacteria. Chem 18 essentially normal. INR is normal. CBC is normal. EKG reveals sinus tachycardia with heart rate in the 1 teens. There are occasional PAC as well. There is no acute appearing changes. ASSESSMENT: 1. Low back pain, bilateral lower extremity pain, and general weakness following a fall 5 days ago.
PAC|premature atrial contraction|(PAC)|331|335|EKG|NEUROLOGIC: Nonfocal. SKIN: Otherwise clear. CHEST X-RAY: Chest x-ray shows chronic obstructive pulmonary disease (COPD)/asthmatic changes with hyperinflation and mild emphysematous changes, but no distinct infiltrate. EKG: EKG demonstrates normal sinus rhythm with a heart rate of 88. There are some premature atrial contractions (PAC) that appear unifocal, but there is nothing acute. (The computer reads this atrial flutter with a variable block, although I do not agree with this.) LABORATORY DATA: Urinalysis notable for trace leukocytes and many bacteria.
PAC|premature atrial contraction|(PAC)|180|184|REASON FOR CONSULTATION|Chest x-ray showed bilateral pulmonary infiltrates compatible with both pneumonitis and possibly heart failure. EKG showed sinus rhythm with frequent premature atrial contractions (PAC) and a rare premature ventricular contraction (PVC). There were ischemic-looking inferolateral ST depressions which were nondiagnostic but worrisome.
PAC|premature atrial contraction|PAC|245|247|HISTORY OF PRESENT ILLNESS|No signs of GI blood loss. Subsequent to admission, an electrocardiogram was obtained to evaluate either a history or symptoms of an irregular heartbeat. A tracing dated _%#DDMM2003#%_ at 2149 demonstrated normal sinus rhythm with an occasional PAC and normal P-R, QRS, and Q-T interval, with a heart rate in the 60s. There was subtle nonspecific ST-wave depression inferiorly, as well as across the anterolateral precordium.
PAC|premature atrial contraction|(PAC)|201|205|ELECTROCARDIOGRAM|CBC shows a hemoglobin of 10.7. ELECTROCARDIOGRAM: I reviewed the ECG and it shows sinus rhythm with a leftward axis and an incomplete left bundle-branch block. There are premature atrial contractions (PAC) present but no ischemic-appearing changes. NUCLEAR STRESS TEST: Nuclear stress test was done after admission and demonstrated a moderate-sized, mostly reversible inferior and inferolateral defect suggesting moderate-sized territory of ischemia.
PAC|physician assistant certification|PAC,|100|103|ASSESSMENT AND PLAN|We will just observe. 14. DT was updated due to her self-injurious behavior. _%#NAME#%_ _%#NAME#%_, PAC, also saw this patient and agrees with the assessment and plan. Thank you _%#NAME#%_ and Dr. _%#NAME#%_ for allowing me to assist in the care of your patient.
PAC|premature atrial contraction|(PAC)|231|235|IMPRESSION|There was a question raised in the chart about a junctional rhythm. The EKG in the chart is misread--he does not have a junctional rhythm, he was in sinus rhythm, and he has had sinus rhythm with only premature atrial contractions (PAC) noted on telemetry here. With the previous history of adrenal adenoma I would probably recommend that we get a cortisol level just as you are doing to rule out Addison's disease but Addison's disease would not account for the lack of tachycardia which he should have had when he became orthostatic.
PAC|UNSURED SENSE|PAC|197|199|HISTORY OF PRESENT ILLNESS|However, Ms. _%#NAME#%_ was found to have progressed. Her treatment was then changed to thalidomide, dexamethasone, and Velcade. She unfortunately had further progression. Treatment was changed to PAC chemotherapy from which she was found to be refractory. Ms. _%#NAME#%_ was experiencing increasing back pain. She was found to have involvement in her lumbar spine.
PAC|premature atrial contraction|(PAC).|193|198|EKG|NEUROLOGIC: Alert and oriented x 3. Cranial nerves II-XII are grossly intact. EKG: EKG shows left bundle-branch block, normal sinus rhythm, sinus arrhythmia versus premature atrial contraction (PAC). LABORATORY DATA: INR is normal. Troponin less than 0.07. Myoglobin 23.
PAC|premature atrial contraction|PAC.|168|171|LABORATORY DATA|GENITALIA/RECTAL: Exam deferred. NEUROLOGIC: Grossly nonfocal. LABORATORY DATA: Electrocardiogram dated _%#DDMM2006#%_ demonstrates a sinus bradycardia with occasional PAC. Normal PR, QRS, and QT interval. No ischemic change. BMP dated _%#DDMM2006#%_ demonstrated sodium 140, potassium 4.2, chloride 108, CO2 29, anion gap 4, glucose 111, BUN 19, creatinine 1.15. Hemoglobin at that time was 14.1 g% with platelet count 224,000.
PAC|premature atrial contraction|PAC.|137|140|ASSESSMENT/PLAN|I cannot entirely rule out short ectopics arising from the ventricle. The only telemetry strip during admission that I could see had one PAC. At this time, her telemetry for the last 24 hours has shown no further arrhythmias. She did have a low magnesium prior to admission and this has been replaced aggressively.
PAC|premature atrial contraction|PAC|220|222|PHYSICAL EXAMINATION|Bowel sounds present. EXTREMITIES: Without cyanosis or edema. Pulses 1 to 2+ below the femorals; 2+ above. NEURO: Examination appeared to be grossly intact. Electrocardiogram shows a normal sinus rhythm with an isolated PAC and nonspecific ST-T wave changes. Chest x-ray and laboratory data are pending.
PAC|physician assistant certification|PAC|185|187|ASSISTANT|PREOPERATIVE DIAGNOSIS: Morbid obesity. POSTOPERATIVE DIAGNOSIS: Morbid obesity. PROCEDURE: Laparoscopic Roux-en-Y. SURGEON: _%#NAME#%_ _%#NAME#%_, MD ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC COMPLICATIONS: None. PRIMARY CARE PHYSICIAN: _%#NAME#%_ _%#NAME#%_, NP DATE OF SURGERY: _%#DDMM2005#%_ HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ underwent laparoscopic Roux-en-Y under general anesthesia which was uncomplicated.
PAC|premature atrial contraction|PAC.|207|210|PHYSICAL EXAMINATION|Dyspnea as mentioned above. All other review of systems are unremarkable. No cold intolerance, fevers, or chills. PHYSICAL EXAMINATION: Current blood pressure is 125/65, pulse 50 and regular with occasional PAC. Respiratory rate is 16-18 and unlabored. Current weight is 68.8 kg. In general, the patient is an alert white female with a cushingoid appearance, in no acute distress.
PAC|premature atrial contraction|(PAC),|207|212|HISTORY OF PRESENT ILLNESS|His basic rhythm is sinus rhythm with bundle-branch block. He has had multitudes of runs of monomorphic fast ventricular tachycardia. Intermittent and interspersed with that is premature atrial contractions (PAC), premature ventricular contractions (PVC) a brief paroxysmal atrial tachycardia (PAT) and I think even an episode of atrial fibrillation. This raises the possibility that it is possible that this is all supraventricular tachycardia (SVT) with aberrancy but from the three- lead Holter monitor and looking at it I would believe that this is monomorphic ventricular tachycardia since it often starts with a PVC without a P wave preceding it.
PAC|premature atrial contraction|PAC.|159|162|HISTORY|Estimated blood loss 1375 cc. Postoperative hypotensive treated with Efedron and fluids with good response. Normal sinus rhythm on EKG with occasional PVC and PAC. No ischemic changes. Negative serial troponins. Serial hemoglobin of 10.9 on _%#DDMM2006#%_ with subsequent stabilization in the 10 g% range.
PAC|post anesthesia care|PAC|185|187|REQUESTING PHYSICIAN|She fell, without any loss of consciousness and broke her left knee. The patient has undergone ORIF of the left patella today. During the early postsurgical period, it was noted in the PAC area that at about 9 p.m. she developed atrial fibrillation with rapid ventricular response at approximately 150 beats per minute, associated with transient hypotension with a systolic blood pressure in the 80s.
PAC|post anesthesia care|PAC|108|110|REQUESTING PHYSICIAN|I have been asked by Dr. ________, the anesthesiologist, to comment on her management. On my arrival to the PAC area about 90 minutes later, the patient was still in atrial fibrillation with rapid ventricular response at about 140 beats per minute with stable blood pressures and she was unaware of that.
PAC|premature atrial contraction|PAC|166|168|PHYSICAL EXAM|No known hyper or hypothyroidism. All other review of systems are unremarkable. PHYSICAL EXAM: Current blood pressure is 115/80, pulse 84 and regular with occasional PAC which the patient is aware of. Respiratory rate 16, 94% saturated on room air, weight 90.6 kilograms. In general, the patient is an alert white male appearing his stated age in no acute distress.
PAC|physician assistant certification|PAC,|90|93|ASSESSMENT/PLAN|In addition , call MD if labs abnormal. We appreciate the consult. _%#NAME#%_ _%#NAME#%_, PAC, also saw this patient and agrees with the assessment and plan. Thank you _%#NAME#%_ and Dr. _%#NAME#%_ for allowing me to assist in the care of your patient.
PAC|physician assistant certification|PAC.|309|312|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is seen in consultation at the request of Dr. _%#NAME#%_ _%#NAME#%_ for pericarditis and pleuritis, with a question of whether he might have a rheumatic condition as the cause for these problems. His primary care giver in _%#CITY#%_, Wisconsin is _%#NAME#%_ _%#NAME#%_, PAC. _%#NAME#%_ was without any symptoms suggestive of pericarditis or pleuritis until _%#DDMM2006#%_.
PAC|physician assistant certification|PAC|47|49|PRIMARY CARE PHYSICIAN|PRIMARY CARE PHYSICIAN: _%#NAME#%_ _%#NAME#%_, PAC from Fairview Northeast Clinic CHIEF COMPLAINT: Weakness, diarrhea and weight loss. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 68-year-old male with history of hypertension, alcohol abuse who was sent from the clinic because of complaint of back pain and generalized weakness.
PA|posterior-anterior|PA|158|159|LABORATORY AND DIAGNOSTIC STUDIES|Reflexes are diminished bilaterally. Pupils are reactive to light. Romberg could not could not be assessed. LABORATORY AND DIAGNOSTIC STUDIES: 1. Chest x-ray PA and lateral shows a 5 cm mass in the right upper lobe and some minor infiltrates in the right middle lobe.
PA|physician assistant|PA|199|200|DISCHARGE AND FOLLOWUP PLAN|2. Followup appointment with Dr. _%#NAME#%_ at the neuro clinic 1A PWB building at the University of Minnesota _%#DDMM2007#%_ at 10:00 a.m. 3. Follow up on _%#DDMM2007#%_ with _%#NAME#%_ _%#NAME#%_, PA at the oncology clinic at 3:00 p.m. Prior to that she should have a chest CT at noon. 4. Follow up with Dr. _%#NAME#%_ _%#DDMM2007#%_ at 4:00 p.m. in the oncology clinic.
PA|pulmonary artery|PA|252|253|HOSPITAL COURSE|She had increasing lower extremity edema and abdominal girth. She was admitted for medical management of pulmonary hypertension and heart failure. HOSPITAL COURSE: 1. Pulmonary hypertension: A Swan-Ganz catheter was placed on the date of admission and PA pressure was initially 80/50. We attempted to increase her Flolan from 6 to 7 and then 8 ng/kg/minute. The patient had adverse reaction to this in the form of persistent vomiting and did not tolerate it.
PA|posterior-anterior|PA|135|136|PROCEDURES|11. Lantus 60 units injection subcutaneous q.a.m. for diabetes. 12. Insulin regular human correction scale q.i.d. PROCEDURES: 1. Chest PA x-ray which was negative. 2. ECG which was negative. 3. Pelvis with lateral hip x-ray, no evidence of fracture. 4. Femur AP lateral right x-ray which was within normal limits.
PA|posterior-anterior|PA|187|188|DISPOSITION|8. Prednisone 5 mg daily. 9. Imuran 100 mg daily. 10. Prograf 0.5 mg b.i.d. 11. Gabapentin 600 mg t.i.d. DISPOSITION: The patient is to follow up with Pulmonary in 1-2 weeks, chest x-ray PA and lateral to evaluate stent stability.
PA|pulmonary artery|PA|169|170|MAJOR PROCEDURES|3. Poorly controlled hypertension. 4. Possible MEN syndrome. MAJOR PROCEDURES: 1. Coronary angiogram - normal coronary arteries, right heart cath showed RA pressure 12, PA pressure 35/19, wedge pressure 17, cardiac output 8.3. 2. Transesophageal echo - normal global function. No evidence of thrombus. 3. DC cardioversion - conversion to normal sinus rhythm.
PA|posterior-anterior|PA|187|188|KEY IMAGING STUDIES AND PROCEDURES PERFORMED DURING THIS HOSPITALIZATION|1. CT of the head without contrast performed on _%#DDMM2006#%_; conclusion was atrophy of the brain and white matter changes consistent with small vessel ischemic disease. 2. Chest x-ray PA and lateral performed on _%#DDMM2006#%_; impression was congestive heart failure pattern with increasing pleural effusions since _%#DDMM2006#%_. 3. Video swallow study. HOSPITAL COURSE: 1. Confusion and weakness; the patient was admitted for an episode of confusion and weakness.
PA|pulmonary artery|PA|680|681|PROCEDURES PERFORMED DURING THIS HOSPITALIZATION|PROCEDURES PERFORMED DURING THIS HOSPITALIZATION: 1. Echocardiogram _%#DDMM2004#%_ showed severe decreased left ventricular function with an estimated EF of 20%, moderate left ventricular dilatation of 70 mm, mild to moderate right ventricular dilatation, increased right ventricular systolic pressure estimated at 55 mmHg plus RAP, mild to moderate left atrial enlargement, and mild mitral regurgitation. 2. Right heart catheter _%#DDMM2004#%_ showed right atrial pressure of 24, RV pressure of 70/24, PA pressure of 70/40, pulmonary capillary wedge pressure of 40, mixed venous 02 saturation of 53%, cardiac index by FICC 1.73. With medical therapy, these numbers improved to a PA pressure of 54/30, pulmonary capillary wedge pressure of 28, and a cardiac index of 2.8. PERTINENT TRANSPLANT WORKUP LABORATORY VALUES: Hemoglobin A1c 7.7. Hepatitis B surface antigen, core antibody, surface antibody negative, hepatitis C antibody negative, hepatitis A antibody positive.
PA|posterior-anterior|PA|142|143|PLAN OF ACTION|Will check bilateral lower extremity Doppler ultrasounds to rule out DVTs in this patient with a history of bilateral calf pain. Recheck CXR, PA and lateral in the a.m. Will obtain a cardiology consult as well, but this just does not seem cardiogenic to me at this time.
PA|posterior-anterior|PA|270|271|HOSPITAL COURSE|Because of his mental status changes he also received a CT scan that did demonstrate old areas of small ischemic disease and volume loss with no acute infarct or hemorrhage demonstrated. For further evaluation of the patient's mental status changes, he did have a chest PA and lateral, which demonstrated bilateral infiltrates as well as slight pulmonary edema. The patient did dramatically improve throughout the course of his first day here and was alert and oriented the next morning, after only one dose of ceftriaxone.
PA|posterior-anterior|PA|137|138|DISPOSITION|2. He is to follow up with Dr. _%#NAME#%_ in electrophysiology as scheduled. 3. The patient will have a follow-up outpatient chest x-ray PA and lateral, next Wednesday. We will also obtain old film jacket from the Fairview Crosstown Clinic for comparison with his most recent chest x- ray; results to patient's oncologist and to Dr. _%#NAME#%_ for follow-up.
PA|physician associates|PA)|74|76|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, MD (France Avenue Family Physicians, PA) CHIEF COMPLAINT: 1. Acute diarrheal illness which appears to be community acquired, resolving spontaneously.
PA|posterior-anterior|PA|178|179|PROCEDURES AND ADMISSION LABS AND STUDIES PERFORMED|PROCEDURES AND ADMISSION LABS AND STUDIES PERFORMED: 1. CT without contrast, dated _%#DDMM2005#%_. Impression: No acute intraparenchymal hemorrhage is identified. 2. Chest x-ray PA and lateral. Heart is enlarged in size. There are diffuse reticular nodular changes in the lungs bilaterally, unchanged from the prior study.
PA|physician assistant|PA|172|173|FOLLOW-UP|FOLLOW-UP: The patient will be seen at the Fairview Southdale Weight Loss Clinic in two weeks for a post-operative visit. The patient will be seeing _%#NAME#%_ _%#NAME#%_, PA at the Fairview Southdale Weight loss Clinic.
PA|posterior-anterior|PA|127|128|PHYSICAL EXAMINATION|EXTREMITIES: Notable for superficial abrasions on the left elbow and right knee. No obvious bony deformities. NEURO: Nonfocal. PA and lateral chest x-ray performed here in the Emergency Department notable only for a small, perhaps 5 cm left apical pneumothorax.
PA|posterior-anterior|PA|380|381|HOSPITAL COURSE|Also, the chest had a few dry rales, the heart was regular, the blood pressure was moderately elevated as noted, the abdomen was soft, and there were no focal neurologic findings. The hemoglobin was 12.8, electrolytes were normal, nonfasting sugar was 150, and creatinine was normal at 1.02. CT scan of the chest was unremarkable except for the right shoulder dislocation, as was PA and lateral chest x-ray. Electrocardiographic monitoring showed normal sinus rhythm. The patient was admitted after dislocation reduction in the emergency department.
PA|posterior-anterior|PA|131|132|HOSPITAL COURSE|Troponin < 0.07. BNP was 91. TSH was normal at 4.57. An electrocardiogram showed moderate voltage, and otherwise was unremarkable. PA and lateral chest x-ray showed some haziness in the left hilum, otherwise unremarkable. CT scan with contrast showed some mild ground glass infiltrate, but no evidence of pulmonary emboli, although the study was limited secondary to the prosthetic right shoulder joint causing artifact on the CT, but they were confident that there were none in the main pulmonary artery nor in the first subdivisions.
PA|posterior-anterior|PA|204|205|HOSPITAL COURSE|Blood pressure and pulse were stable. Her BNP was elevated at 957. Electrolytes were unremarkable, creatinine was normal 0.59. Hemoglobin was normal at 12.6. Troponin was minimally elevated at 0.46 and a PA and chest x-ray showed cardiomegaly and interstitial prominence in vascular congestion typical of congestive heart failure. The patient was admitted. Troponins would fall back into the normal range and she would be asymptomatic after admission.
PA|pulmonary artery|PA|243|244|HOSPITAL COURSE|She also had an echocardiogram done on _%#DDMM2005#%_ which showed severe biventricular failure. Her aortic valve area was 1.4 cm squared, which was consistent with mild aortic stenosis. She had moderate-to-severe tricuspid regurgitation. Her PA pressure was elevated to 50-55%. Her left ventricular ejection fraction was decreased at 15-20%, as previously noted. She was seen by her cardiologist who agreed with the diagnosis of biventricular failure, and with diuresing her and treating her chronic obstructive pulmonary disease.
PA|pulmonary artery|PA|281|282|HOSPITAL COURSE|The patient was therefore taken off diltiazem and put back on metoprolol. He underwent an echocardiogram on _%#DDMM2002#%_ which showed an ejection fraction of 60-65%, left ventricular function within normal limits, mild aortic sclerosis, 2+ tricuspid regurgitation with increased PA pressures (consistent with his COPD), no pericardial effusion, normal right ventricular function. The patient was seen in consultation by Dr. _%#NAME#%_, who increased his metoprolol to 50 mg b.i.d., and then subsequently to 75 mg b.i.d. on _%#DDMM2002#%_.
PA|posterior-anterior|PA|187|188|HOSPITAL COURSE|A portable chest x-ray done in the emergency room does show what appears to be some atelectasis in the left lung as well as what appears to be a pleural effusion on that side. An upright PA and lateral will be obtained to further delineate this. At this time, we plan to admit the patient, start IV vancomycin and gentamicin, until the source of the fever is identified.
PA|physician assistant|PA|45|46||_%#NAME#%_ _%#NAME#%_, MD Pediatric Services PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_, MN _%#55400#%_ _%#DDMM2002#%_ Dear Dr. _%#NAME#%_, Thank you for accepting care of _%#NAME#%_ _%#NAME#%_ from the Neonatal Intensive Care Unit of Fairview-University Children's Hospital.
PA|physician assistant|PA.|242|244|HOSPITAL COURSE|HOSPITAL COURSE: On _%#MM#%_ _%#DD#%_, 2003, the patient underwent mitral valve repair with also repair of the right coronary artery saphenous vein graft. Surgeons were _%#NAME#%_ _%#NAME#%_, _%#NAME#%_ _%#NAME#%_, and _%#NAME#%_ _%#NAME#%_, PA. Cross-clamp time was 2 hours 59 minutes, cardiopulmonary bypass time 5 hours 25 minutes. The patient was taken in critical condition to the SICU that night.
PA|pulmonary artery|PA|170|171|HOSPITAL COURSE|The patient was started on IV nitroprusside because of his elevated pulmonary artery pressures. He had good result with Nipride and Lasix. Within less than 12 hours, his PA pressures had dropped to 50 mmHg at a pulmonary capillary wedge pressure of 19 with a CDP of 4. The patient's oral effusions medications were titrated up. His hydralazine was increased to 100 four times daily, Imdur 90 daily, Lasix 80 mg p.o. t.i.d., his nitride was weaned off and the patient was transfused on _%#MM#%_ _%#DD#%_, 2006.
PA|pulmonary artery|PA|211|212|HOSPITAL COURSE|To evaluate her pulmonary pressures, a Swan was placed on _%#DDMM2006#%_ which showed initial PA pressure 60/24. She was started on a Nipride drip which was tolerated as her systolic pressures tolerated and her PA pressures subsequently decreased to 46/14 and reached a low of 39/11. Her wedge pressure decreased from 19 to 13 and cardiac index of 3.2. based on this response, it was deemed that she did have somewhat good response __________________ dilation and this may allow her to be a transplant candidate down the road.
PA|pulmonary artery|PA|167|168|LABORATORY DATA|Sclerotic aortic valve was noted. There was mild mitral regurg, moderate to severe tricuspid regurgitation. There was moderate to severe pulmonary hypertension with a PA systolic pressure estimated at 56 mmHg plus right atrial pressure. There was a problem of pseudo normal diastolic relaxation pattern.
PA|pulmonary artery|PA|143|144|PROCEDURES|2. Right heart catheterization, _%#DDMM2006#%_. Significant findings include mean right arterial pressure of 2 mmHg, RV pressure of 19/3 mmHg, PA pressure of 13/2 mmHg and mean PAWP of 3 mmHg. PVR was 40. PA saturation was 78%. 3. Transthoracic echocardiogram with bubble study, _%#DDMM2006#%_.
PA|physician assistant|PA,|277|279|DISCHARGE INSTRUCTIONS|15. She is to elevate her right lower extremity whenever possible, wrapping this leg with an Ace wrap until she receives her panty hose style compression garments. 16. Follow-up is to be in the office with Dr. _%#NAME#%_ _%#NAME#%_ in one week. 17. Follow-up with cardiologist PA, _%#NAME#%_ in two weeks.
PA|posterior-anterior|PA|175|176|DISCHARGE MEDICATIONS|The patient should follow up by primary physician within one week. The patient should have follow-up x-ray and following head CT scan without contrast next week. Chest x-ray, PA and lateral, next week. Blood test next week in the form of basic metabolic panel and CBC. The patient has a few stitches over the posterior scalp area to be removed within a few days, i.e. 7-10 days from the suturing date.
PA|posterior-anterior|PA|218|219|DIAGNOSTIC STUDIES|CBC and metabolic panel were within normal limits with the exception of a slightly elevated glucose probably secondary to Decadron therapy. Total protein and albumin were slightly elevated but not out of line. X-ray - PA and lateral chest x-ray results showed no active infiltrate. TREATMENT DURING HOSPITALIZATION: Included high dose Decadron home therapy, physical therapy, occupational therapy, speech counseling, and educational programs.
PA|pulmonary artery|PA|132|133|LABORATORY DATA|Musculoskeletal: No synovitis. Pelvic/rectal deferred. Neurologic: Grossly nonfocal. LABORATORY DATA: Lab data includes chest x-ray PA and lateral with hyper-expanded lung fields consistent with COPD. No definite infiltrate (reviewed with radiologist). ASSESSMENT: A 75-year-old female with the following: 1. Upper respiratory infection consistent with bronchitis.
PA|physician associates|PA)|78|80|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, MD (_%#CITY#%_ Sports Health & Wellness, PA) CHIEF COMPLAINT: Constipation. PAST MEDICAL HISTORY: 1. Hypothyroidism. 2. Chronic constipation. 3. L-5 nerve root injection by Dr. _%#NAME#%_ _%#NAME#%_ (Physical Medicine & Rehabilitation) in _%#MM#%_ 2001.
PA|pulmonary artery|PA|241|242|HISTORY OF PRESENT ILLNESS|He had undergone a transplant work-up which included an initial catheterization on _%#DDMM2003#%_ which Mr. _%#NAME#%_ tolerated well. Findings at that time included a right atrial pressure of 8 and 12, right ventricular pressure was 66/20, PA pressure was 66/36, wedge was 36, and cardiac index was not listed. Notably, Mr. _%#NAME#%_ was randomized in the Escape Trial to a Swan-Ganz catheterization during a previous admission.
PA|posterior-anterior|PA|96|97|CHEST X-RAY|Normal muscle power to all extremities. Deep tendon reflexes symmetric throughout. CHEST X-RAY: PA and lateral film is reviewed and appears to show a left lower lobe infiltrate with no cardiomegaly, effusions, or masses.
PA|posterior-anterior|PA|195|196|IMPRESSION|I suspect he has been unable to clear his secretions and, therefore, has been deteriorating. The patient will require admission. He is clinically mildly dehydrated. We will check a chest x- ray, PA and lateral, as well as a basic metabolic panel and CBC. We will initiate gentle IV hydration, start empiric IV steroids and Tequin after we obtain a sputum culture.
PA|posterior-anterior|PA|384|385|LABORATORY DATA|SKIN: Shows no evidence of rash LABORATORY DATA: Include a white count of 12.1 with 84% neutrophils and hemoglobin of 9.8 and platelet count of 371,000, creatinine is 1.07, INR of 1.17. Lipase is 50, troponin is 0.04. Chest x-ray shows what appears either to be some rotation or dextrocardia. I think this may be secondary to his kyphosis and rotation. He has got what appears on the PA film and have some right lower lobe haziness and then the left lower lobe appears to be an infiltrate in the posterior field and maybe even a small effusion that is more prominent on the lateral film.
PA|posterior-anterior|PA|146|147|HOSPITAL COURSE|Heart was regular. Abdomen was soft. Hemoglobin was normal 11.7. INR was therapeutic as noted at 2.57. Electrolytes were normal. Creatinine 1.23. PA and lateral chest x-ray showed the pacemaker and otherwise was unremarkable. Troponin I was less than 0.04 on two measurements 5 hours apart.
PA|posterior-anterior|PA|263|264|HOSPITAL COURSE|Discharge diet is low sodium. Activity as tolerated. PT, OT are asked to consult and treat the patient for ADLs and patient's code status remains DNR/DNI. Standing nursing home orders are approved. The patient is to have a CBC, basic metabolic panel, chest x-ray PA and lateral in one weeks' time. Follow up with Dr. _%#NAME#%_ 1-2 weeks' time. She is to be maintained on oxygen by nasal prongs 2 liters to titrate to keep O2 sats greater than 90%
PA|pulmonary artery|PA|221|222|HOSPITAL COURSE|To compare the results of the 2 right heart caths, the right heart cath on _%#DDMM2006#%_ had shown that his baseline PA pressure was 77/41 with a mean of 57 and a mean wedge of 30. This value decreased with Nipride. The PA pressures after Nipride were 52/30 with a mean of 41 and a mean wedge of 22. The right heart cath on _%#DDMM2006#%_ immediately after hemodialysis showed that the PA pressures dropped down to 32/14 with a mean of 22 and a mean wedge of 6 only.
PA|posterior-anterior|PA|97|98|PROCEDURES|3. History of coronary artery disease. 4. Tobacco use disorder. 5. Marijuana use. PROCEDURES: 1. PA and lateral chest x-ray on _%#DDMM2007#%_. Significant findings, clear lung fields. 2. ECG, significant findings, no changes from previous ECGs following coronary angiogram in _%#MM2007#%_.
PA|posterior-anterior|PA,|233|235|IMAGING STUDIES|CONSULTATION: Neurology, Dr. _%#NAME#%_ _%#NAME#%_. IMAGING STUDIES: Imaging studies include chest x-ray on _%#MM#%_ _%#DD#%_, 2002, noted left-sided infiltrate compatible with pneumonia. Previous studies done at the clinic included PA, lateral and left rib detail which raised the question of left-sided rib fractures. CT scan of the head done _%#MM#%_ _%#DD#%_, 2002; report noted some small vessel changes and empty sella.
PA|physician associates|PA)|125|127|DISCHARGE PLAN|7. Multivitamin with iron. 8. Nystatin swish and swirl q.i.d. DISCHARGE PLAN: Dr. _%#NAME#%_ (Minnesota Oncology Hematology, PA) will be notified of the patient's location for ongoing radiation as deemed appropriate by those care providers.
PA|posterior-anterior|PA|254|255|PLAN|2. Was given nitroglycerin 0.4 mg sublingual and one full strength aspirin at clinic prior to transport by ambulance to Fairview-University Medical Center. 3. Will check q.i.d. finger stick blood sugars and cover with sliding scale insulin. 4. Will need PA and lateral chest x-ray on admission for further evaluation of shortness of breath. 5. Dr. _%#NAME#%_ _%#NAME#%_ is to assume care of the patient upon admission.
PA|posterior-anterior|PA|136|137|PROCEDURES DONE|5. Hypoxemia and dyspnea. 6. Gastroparesis. 7. Gastroesophageal reflux disease. 8. Bilateral blindness. PROCEDURES DONE: 1. Chest x-ray PA and lateral on _%#DDMM2003#%_. Left lower lobe subsegmental atelectasis of undetermined etiology. 2. Abdominal flat and upright on _%#DDMM2003#%_. No abnormalities identified. 3. CT of abdomen and pelvis without contrast on _%#DDMM2003#%_.
PA|posterior-anterior|PA|275|276|LABORATORY FINDINGS|Full range of motion seen throughout. NEUROLOGIC: Grossly nonfocal. LABORATORY FINDINGS: Review of labs drawn at _%#CITY#%_ _%#CITY#%_ Medical Center shows a normal CBC. Chest x-ray, which I have reviewed and interpreted personally, shows a somewhat poor quality film on the PA projection. There is a suggestion of infiltrate primarily in the left lower lobe. The lateral projection also suggests an infiltrate in the lower lung fields.
PA|pulmonary artery|PA|121|122|HISTORY OF PRESENT ILLNESS|He has been able to protect his lungs due to a pulmonary gradient of 85-90 mmHg on most recent echo and has not required PA banding to this point. Overall, the plan is for _%#NAME#%_ to proceed to a Glenn procedure sometime in _%#MM2004#%_ to _%#MM2004#%_.
PA|physician associates|PA),|204|207|DISCHARGE FOLLOW-UP|f. For blood sugars greater than 400, 8 units. DISPOSITION: The was discharged to home. DISCHARGE FOLLOW-UP: 1. He is to have follow-up with Dr. _%#NAME#%_ _%#NAME#%_ (Endocrinology Clinic of _%#CITY#%_, PA), an endocrinologist, in 1-2 weeks for a post- hospital 30-minute visit. 2. He is to have follow-up with his primary care physician in 7-10 days.
PA|posterior-anterior|PA|203|204|PHYSICAL EXAMINATION|It is less evident in the other view. There are also some surgical sutures present from an old abdominal surgery present in the patient's abdominal films. Other laboratory findings include a chest x-ray PA and lateral that was significant for old rib fractures but no evidence of any foreign bodies or infiltrates. A soft tissue x-ray of the neck was negative for any foreign bodies.
PA|physician assistant|PA|143|144|PLAN|We will obtain a follow-up Holter monitor I 1-2 weeks to look for any sustained runs of PVCs. PLAN: The patient will see _%#NAME#%_ _%#NAME#%_ PA in two weeks. At that time hopefully his Toprol can be titrated for improvement of left ventricular function. We will also need to determine when to repeat an echocardiogram.
PA|pulmonary artery|PA|155|156|PROCEDURES PERFORMED|PROCEDURES PERFORMED: 1. Right heart catheterization, _%#DDMM2007#%_. RA 5/0, PA pressure 119/44 with a mean of 75, PCWP of 1 mmHg. Post Flolan challenge, PA pressure was 120/44 with a mean of 66 mmHg. Fick cardiac index was 1.16 before Flolan and 1.51 L/min/m2 after Flolan.
PA|posterior-anterior|PA|194|195|NOTE|Patient has been complaining of cough with yellow sputum production and some crackles could be heard on the left lung base. However, her chest x-ray initially in the emergency room and repeated PA and lateral were negative for infection. Nevertheless, we treated her empirically with a course of Z-Pak which led to the resolution of elevated white count.
PA|posterior-anterior|PA|184|185|PROCEDURES AND CONSULTS|DISCHARGE DIAGNOSES: 1. Hyperthyroidism, likely Grave's disease, acute presentation. 2. Hypercalcemia, greatly resolved. PROCEDURES AND CONSULTS: 1. Endocrine consult. 2. Chest x-ray, PA and lateral with a normal result. 3. Intervenous hydration. 4. Pamidronate IV infusion. 5. Multiple laboratory studies. 6. Urinalysis with micro - no evidence of UTI. BRIEF SUMMARY OF HISTORY AND PRESENTATION: Patient is a 24-year-old female with 1Q+ syndrome, developmental delay and mental retardation who had a two to three month slow presentation of recurrent vomiting, soft stools, poor oral intake, tremors and significant weight loss.
PA|posterior-anterior|PA|164|165|LABORATORY WORK-UP|INR is fine, CBC with differential is unremarkable. Basic metabolic profile is also normal, but with a creatinine of 1.28 and a GFR estimated to be 43. Chest x-ray PA and lateral was normal per the emergency room doctor. ASSESSMENT: The patient is a complex patient with apparent mild coronary artery disease, congestive heart failure and bipolar disorder who now comes in with apparent new atrial fibrillation.
PA|posterior-anterior|PA|210|211|HISTORY OF PRESENT ILLNESS|The patient notes that for about the last month, she has been getting progressive dyspnea with exertion. In addition, she has noted orthopnea. The patient was evaluated. Her left lung was found to be dull, and PA and lateral chest x-rays suggested a large left pleural effusion. At the time of my evaluation, the patient is resting reasonably comfortably at about a 45-degree position, with 2 liters of nasal oxygen.
PA|pulmonary artery|PA|51|52|OPERATIONS/PROCEDURES PERFORMED|OPERATIONS/PROCEDURES PERFORMED: Replacement of RV PA conduit and 18 mm Contegra graft and debridement of subaortic muscle bundles on _%#MM#%_ _%#DD#%_, 2005. CLINICAL NOTE: _%#NAME#%_ _%#NAME#%_ is an infant with double outlet right ventricle status post Rastelli procedure and permanent pacemaker done shortly around 6 months of age.
PA|posterior-anterior|PA|234|235|BACKGROUND HISTORY|3. Sternal mass. The patient does have a left superior sternal mass, most likely believed to be a plasmacytoma. She is to be evaluated by radiation-oncology for possible palliative radiation therapy to this lesion. Chest x-rays, both PA and lateral were performed to rule out any kind of airway obstructions secondary to this mass. Her airway is clear, and it is not deviated in any way secondary to this mass.
PA|physician associates|PA)|78|80|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, MD (_%#CITY#%_ Sports Health & Wellness, PA) DISCHARGE DIAGNOSES: 1. Acute myocardial infarction (MI) due to occlusion of the left circumflex artery.
PA|posterior-anterior|PA|237|238|STAFF|Ms. _%#NAME#%_ _%#NAME#%_ was observed overnight in the hospital following implantation of a dual chamber implantable cardiac defibrillator. Her vital signs remained stable. Telemonitoring did not reveal any abnormal rhythm. Chest x-ray PA and lateral the day after the procedure revealed no pneumothorax and leads in good position. The device was interrogated and all the device measurements were found to be satisfactory.
PA|pulmonary artery|PA|199|200|BRIEF HISTORY OF PRESENT ILLNESS|He denied chest pain. The patient was last admitted on _%#DDMM2007#%_ with similar symptoms of shortness of breath and elevated PA and PCWP. He was started on IV and p.o. vasodilatory agents and his PA and PCWP significantly improved. He was last seen by Dr. _%#NAME#%_ on _%#DDMM2007#%_. Given that his coronary artery disease was deemed non-correctable and he had progressive worsening of symptoms, he is also being worked up for a potential heart transplant if his medical management fails.
PA|pulmonary artery|PA|141|142|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: 1. Cardiac per-kidney transplant evaluation. 2. Right cardiac catheterization showed severe pulmonary hypertension with PA pressures of 80/30 and a wedge pressure of 30. Cardiac output is 7.7 which is thought to be elevated secondary to the patient's dialysis fistula.
PA|posterior-anterior|PA|129|130|ASSESSMENT AND PLAN|We will iron studies, B12, folate, TSH, peripheral smear, and stool for ...x 3. 4. Pleural effusion. We will check a chest x-ray PA and lateral in the morning. Patient, if she shows and effusion, may need to have that tapped to rule out any malignancy.
PA|physician associates|PA|207|208|DIET|DISCHARGE MEDICATIONS: None. CONSULTATIONS: None. PROCEDURES: None. DIET: Breast fed ad lib. Activity as tolerated. Follow up: She will see Dr. _%#NAME#%_ _%#NAME#%_ at Metropolitan Pediatrics, Specialists, PA for her routine two week well child visit and repeat of her neonatal bilirubin. They will have bilirubin done at Fairview Southdale outpatient laboratory prior to that visit.
PA|physician assistant|PA|137|138|HOSPITAL COURSE|I spoke with the patient's oncologist, Dr. _%#NAME#%_ at Regions Hospital as well as his daughter, _%#NAME#%_, who is a pharmacist and a PA at the VA down in Arizona. I also confirmed these details with the patient with the assistance of a professional interpreter on several occasions.
PA|posterior-anterior|PA|204|205|LABORATORY|Lumbar and thoracic spine CT scan: As above. Electrocardiogram was normal. Chest x-ray showed some mild haziness on the lateral film in the lower lung fields, but could not identify an abnormality on the PA view and will await final review. ASSESSMENT AND PLAN: 1. Fall. We will check a CPK in the morning and get PT, OT, and Social Services to discuss.
PA|physician associates|PA)|79|81|PRIMARY PHYSICIAN|PRIMARY PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD (France Avenue Family Physicians, PA) DISCHARGE DIAGNOSIS: Acute labyrinthitis. PROCEDURES DURING HOSPITALIZATION: 1. Noncontrast head CT scan on _%#DDMM2004#%_ which showed normal findings.
PA|physician assistant|PA|203|204|DISCHARGE DIAGNOSIS|He should return to us if he notes any drainage at all, or increased pain, swelling, or temperature greater than 101.5. He has followup appointments made with Dr. _%#NAME#%_ in 6 weeks and with nurse or PA visit in 2 weeks for a wound check. At the Dr. _%#NAME#%_ visit he should get 3 views of his left ankle. He was sent home with the following medications: Percocet 1 to 2 tablets p.o. q.4-6h. p.r.n. pain, Vistaril 25 to 50 mg p.o. q.4-6h. p.r.n. pain, and Colace 100 mg p.o. b.i.d. In addition, he is to resume all his home medications.
PA|posterior-anterior|PA|158|159|HISTORY OF PRESENT ILLNESS|At this time, it was decided that it would be better to observe him overnight in the hospital. He was given an epinephrine neb here in the clinic, received a PA and lateral neck x-ray. He had a white blood cell count that was 4600, and he had a dose of prednisolone 18 mg, 1 mg/kg.
PA|physician assistant|PA|114|115|PRIMARY CARE PROVIDER|DATE OF ADMISSION: _%#DDMM2005#%_ DATE OF DISCHARGE: _%#DDMM2005#%_ PRIMARY CARE PROVIDER: _%#NAME#%_ _%#NAME#%_, PA DISCHARGE DIAGNOSIS: Atypical chest pain. Suspect musculoskeletal. HISTORY OF PRESENTING ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 51-year-old woman with a history of hypertension and diabetes, and also a history of right shoulder pain, who presented to the emergency room with an episode of chest pressure, radiating to her right shoulder and her right upper extremity.
PA|pulmonary artery|PA|248|249|HISTORY OF PRESENT ILLNESS|Right and left heart catheterization showed a right atrial oxygen saturation of 89%, pulmonary vein saturation 99%, IVC saturation 75%, lower right atrium saturation 67%, LV saturation 89%, right ventricular saturation 62%, SVC saturation 66%, and PA saturation at 63%. The patient had a stent placed in the mid left anterior descending artery at _%#COUNTY#%_ _%#COUNTY#%_ on _%#MM#%_ _%#DD#%_, 2005, uneventfully.
PA|physician associates|PA|247|248|DISCHARGE PLAN|He is advised to stay off of his feet and use Lovenox twice a day based on his significant symptoms, in addition to starting Coumadin. DISCHARGE PLAN: 1. I advised him to have a blood count and INR done on Monday at Minnesota Oncology Hematology, PA (MOHPA) office and to have an INR done on Saturday. 2. He is advised to report to the emergency room if he has any worsening symptoms of shortness of breath, pleuritic chest pain, etc.
PA|posterior-anterior|PA|202|203|DISCHARGE MANAGEMENT PLAN|The patient tolerated this well and slowly improved. By _%#MM#%_ _%#DD#%_, though after 5 days of heparin, it was noted the patient was still mildly hypoxemic although reasonably asymptomatic. A repeat PA and lateral chest x-ray showed some elevation of the white I diaphragm but was otherwise unremarkable. Arterial blood gases on room air showed a pH of 7.42 pCO2 of 47 and she was mildly elevated at pO2 of 48, % saturation would be 84.
PA|pulmonary artery|PA|238|239|DISCHARGE MEDICINES|We found on echocardiography though that she had normal left ventricular systolic function, normal right atrial size, normal right ventricular systolic function and most notably on the echocardiogram she had pulmonary hypertension with a PA systolic pressure being 50 mmHg. The patient underwent pulmonary function testing. Her room air arterial blood gases on _%#MMDD#%_ revealed a pH of of 7.42 and pCO2 of 37 and pO2 of 48.
PA|physician assistant|PA.|406|408|DISCHARGE INSTRUCTIONS AND FOLLOW UP CARE|DISCHARGE INSTRUCTIONS AND FOLLOW UP CARE: 1. The patient was instructed to contact the Masonic Cancer clinic or after hours care team if he develops at fevers with temperature in excess of 100.5 degrees, nausea or vomiting not controlled by antiemetic medications, shortness of breath, or chest pain. 2. The patient will be seen in the clinic on Monday, _%#MM#%_ _%#DD#%_, 2005, by _%#NAME#%_ _%#NAME#%_, PA. He will be evaluated for any toxicity secondary to chemo and if he is doing well, will be admitted later that same day for a third dose of high dose methotrexate.
PA|posterior-anterior|PA|364|365|HOSPITAL COURSE|He remains remarkably weak and we do not have definite documentation whether this was syncope or generalized weakness. His evaluation at admission showed an INR 3.12, hemoglobin 11.4, white count 7600, platelets were 324,000, sodium was 135, potassium 4.5, chloride 99, glucose 77, creatinine 1.21, calcium 8.1, troponin was less than 0.07. Digoxin level was 1.1. PA and lateral chest x-ray would reveal atelectasis or infiltrate of left base which was chronic. There was no change from a film of _%#DDMM2006#%_. A CT scan of the brain revealed generalized atrophy and low attenuation in the white matter is consistent with small vessel ischemic disease.
PA|pulmonary artery|PA|248|249|PROCEDURES DONE DURING THIS HOSPITALIZATION|Additionally, a small isolated region of hyper-enhancement in the anteroseptal wall of 25-50%, wall thickness is also noted. 3. Right and left heart catheterization with coronary angiogram on _%#DDMM2007#%_. 4. Right atrium pressure, 15, RV 50/17, PA 46/24, pulmonary arterial wedge pressure 20, Fick cardiac output 5.7. 5. Coronary angiogram: Left main 40% lesion, LAD occluded, large ramus intermedius with diffuse disease, proximal left circumflex had 80% lesion, RCA occluded, RPDA and RPLA filled by collaterals.
PA|posterior-anterior|PA|154|155|PROCEDURES|She had a left lower extremity venous Doppler ultrasound on _%#DDMM2003#%_ with no evidence of DVT or other soft tissue pathology. In addition, she had a PA and lateral chest x-ray on _%#DDMM2003#%_, with a small stable nodule on the left upper lobe, consistent with a granuloma, as well as granulomatous disease in the left hilar region.
PA|pulmonary artery|PA|268|269|HOSPITAL COURSE|_%#NAME#%_ underwent placement of an AICD pacemaker in the catheterization lab on _%#MM#%_ _%#DD#%_, 2002, by Dr. _%#NAME#%_ for persistent ventricular ectopy in the face of diminished ventricular function. At that time he was found to have a pulmonary wedge of 20, a PA mean pressure of 24, a mixed venous saturation of 52%, and a right atrial pressure mean of 5. A Medtronic single-chamber PCD was placed, and he was successfully defibrillated on one test occasion.
PA|pulmonary artery|PA|133|134|MAJOR DIAGNOSTIC AND THERAPEUTIC PROCEDURES|Following angioplasty, a 40% to 50% residual stenosis remained. 3. Right heart catheterization with a right atrial pressure of 22/5, PA pressure 23/9, pulmonary capillary wedge pressure of 4. The cardiac index of 2.83. A endomyocardial biopsy demonstrated no evidence of a rejection with grade 1A inflammation.
PA|posterior-anterior|PA|267|268|HOSPITAL COURSE|HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ is a 62-year-old who presented to Southdale Emergency Room with symptoms of dyspnea, a percent saturation of oxygen decreased 87% and a chest exam that showed decreased breath sounds and a few rales in the right lower lung. PA and lateral chest x-ray would reveal a right lower lung and right middle lung infiltrate. The patient was admitted and treated with oxygen and intravenous Levaquin, which was converted to oral Levaquin.
PA|posterior-anterior|PA|131|132|DISCHARGE MANAGEMENT PLAN|2. The patient is to do self-catheterization t.i.d. 3. He should follow up with Dr. _%#NAME#%_ in 7-10 days, and at that time have PA and lateral chest x-ray regarding potential lower lobe infiltrates which are somewhat interstitial in nature. 4. He should follow up with Dr. _%#NAME#%_ of Neurosurgery in three to four weeks for further decision upon appropriate treatment of the vascular malformation in the basal ganglia.
PA|posterior-anterior|PA|124|125|LABORATORY DATA|Urine culture would grow greater than 10,000 colonies of E. coli. Blood cultures were sterile. The patient had mild pyuria. PA and lateral chest x-ray was normal. Ultrasound of the kidney showed dilatation of the left pelvicaliceal collecting system. CT scan of the abdomen with IV contrast would reveal resolution of a moderately dilated left intrarenal collecting system.
PA|pulmonary artery|PA|286|287|REASON FOR ADMISSION|Due to the complaints of back pain she had an MRI of the thoracic spine which revealed lytic obstructive ______ and ______ with a large extraosseous component in the paraspinal region, right greater than left, as well as descending into the spinal canal and bilateral _______ and right PA ______. Mild cord compression and cord deformity. In order for them to find the brain mass an MRA scan of the brain was done which revealed a large mass in the left frontal temporal region which was approximately 5 x 6.3 x 6.8 cm in size.
PA|posterior-anterior|PA|199|200|HOSPITAL COURSE|His hemoglobin remained stable throughout his hospital course. His hemoptysis symptoms were associated with continued sternal and anterior rib pain, likely associated with his cardiac resuscitation. PA and lateral chest x-rays were performed on day of discharge which revealed no pneumothorax and stable left pleural effusion with associated atelectasis.
PA|physician assistant|PA|47|48|PRIMARY CARE|PRIMARY CARE: France Avenue Family Physicians, PA CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 62-year-old white female who was traveling with her husband from Arizona to Connecticut.
PA|posterior-anterior|PA|274|275|RADIOGRAPHIC|No wheezes noted, but again noted are substernal and intercostal retractions. ABDOMEN: Soft, nontender, nondistended, with no hepatosplenomegaly. EXTREMITIES: Normal. RADIOGRAPHIC: The patient had a chest x-ray which showed a questionable right middle lobe pneumonia on the PA film and repeat 02 saturation about 40 minutes after her second nebulization showed that her 02 saturation had again dropped to 87-88%.
PA|posterior-anterior|PA|160|161|PROCEDURES PERFORMED|2. Presentation with probable congestive heart failure. 3. Newly-diagnosed dilated cardiomyopathy. 4. No evidence for febrile illness. PROCEDURES PERFORMED: 1. PA and lateral chest x-ray performed on two occasions, _%#DDMM2006#%_ and _%#DDMM2006#%_, the initial film demonstrating bilateral interstitial infiltrates consistent with congestive heart failure.
PA|posterior-anterior|PA|128|129|PHYSICAL EXAMINATION|ORTHOPEDIC: Joints are normal. Spine is straight. Tenderness really across almost her entire back and neck region. X-rays chest PA and lateral, shoulder right side, lumbar spine and thoracic spine were all negative for fractures or abnormalities. LABORATORY DATA: Urinalysis normal. Other blood work pending at the time of this dictation.
PA|posterior-anterior|PA|291|292|IMPRESSION|White blood count 8.4 thousand, hemoglobin 13.5. IMPRESSION: 1. A patient with right upper quadrant pain, unlikely pneumonia, without cough and CT scan did get a view of the right lower lung. We will check a chest x-ray in case it was early atelectasis evolving into infiltrates. Will check PA and lateral chest x-ray today a. Consider acalculous cholecystitis. There is no significant gallbladder wall thickening or air in the gallbladder wall.
PA|pulmonary artery|PA|135|136|HISTORY OF PRESENT ILLNESS|He also had a wide open ductus arteriosus which was kept open with PGE in _%#CITY#%_ _%#CITY#%_. His peak gradient across the stenosed PA was 60-65 mmHg and he also had RVH with mild hyperdynamic obstruction in right ventricular outflow tract. As stated he was started on prostaglandin in an outside hospital in order to maintain the ductus in anticipation on cardiac cath for which he was transferred to Fairview University.
PA|pulmonary artery|PA|423|424|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSES: 1. Congenital heart disease with secondary pulmonary hypertension. 2. Hypertension. 3. Hyperlipidemia. 4. Previous residual right hemiparesis. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 50-year-old male with a history of congenital heart disease and secondary pulmonary hypertension with Eisenmenger physiology, was admitted for evaluation and starting of medication to improve his improve PA pressures. HOSPITAL COURSE: PROBLEM #1: Congenital heart disease with Eisenmenger physiology.
PA|pulmonary artery|PA|171|172|REQUESTING PHYSICIAN|He has had variable blood pressures, as high as 165 systolic. Now he is down to 140's systolic. Temperature is 34.2. His rhythm is sinus rhythm and sinus bradycardia. His PA is 26/16, RA 13, cardiac output 5.0, SVR 11.67. His admission weight was 89.7 kilograms. PAST MEDICAL HISTORY: 1. Diabetes 2. Hyperlipidemia 3. Hypertension
PA|posterior-anterior|PA|129|130|LABORATORY AND DIAGNOSTICS|His glucose is elevated at 148. BUN and creatinine are elevated at 38 and 1.85, which is baseline for him. Calcium level is 8.6. PA and lateral chest x-ray shows blunting of the left costophrenic angle, likely indicating a small left pleural effusion; infiltrate or atelectasis is also possible.
PA|pulmonary artery|PA|114|115|PROCEDURES PERFORMED DURING THIS HOSPITAL STAY|PROCEDURES PERFORMED DURING THIS HOSPITAL STAY: On _%#DDMM2007#%_, pulmonary venous obstruction repair, bilateral PA plasty, ligation of BT shunt placement of 4-mm central shunt on _%#DDMM2007#%_ and bronchoscopy with Dr. _%#NAME#%_ on _%#DDMM2007#%_. HOSPITAL COURSE: _%#NAME#%_ is a 12-month-old child born with complex congenital heart disease consisting of a single ventricle, common atrium, pulmonary atresia, AV canal, total obstructive pulmonary venous return, dextrocardia, heart attacks and asplenia.
PA|posterior-anterior|PA|300|301|IMPRESSION|I believe that this has compounded by her being mildly dehydrated with evidence of acute renal failure with her BUN up at 66 and her creatinine mildly elevated at 1.4. We will get blood cultures times three, urinalysis and urine culture. We will IV hydrate the patient. We will check the chest x-ray PA and lateral. We will place her empirically on Zosyn 3.375 gm IV piggyback q8h. We will place her on sliding scale insulin. We will hold her Bumex today.
PA|physician assistant|PA|186|187|OPERATIONS/PROCEDURES PERFORMED|The patient is instructed to follow up with Dr. _%#NAME#%_ in 1 week for removal of the staples. In addition, the patient will follow up with Dr. _%#NAME#%_ and will be contacted by his PA to set up that appointment.
PA|pulmonary artery|PA|338|339|HISTORY OF PRESENT ILLNESS|3. The wedge pressure was 30. 4. Cardiac index is 1.92. 5. PO2 was 54%. HISTORY OF PRESENT ILLNESS: A 38-year-old gentleman with past medical history of nonischemic cardiomyopathy, presumably viral with EF of 20% who was recently seen on _%#MM#%_ _%#DD#%_, 2005, at which time his right heart catheter showed a wedge pressure of 17 and a PA pressure of 38 with a cardiac index of 2.4. His creatinine was 2.7 at that time. His Bumex was deceased from 1 mg b.i.d. to 0.5 mg b.i.d. Today, he presented for a scheduled right heart cath and was found to have high PA pressures and was admitted for management of decompensated heart failure.
PA|pulmonary artery|PA|193|194|HOSPITAL COURSE|The patient had an echocardiogram performed, which showed a normal global left ventricular systolic function. No regional wall motion abnormalities. Normal right ventricular size and function. PA pressures were not estimated. There was no valvular disease noted. EF was not noted as well. The patient had an adenosine stress thallium test which was performed the following day for which the patient had no significant signs of ischemia and no evidence of any abnormalities.
PA|pulmonary artery|PA|146|147|HOSPITAL COURSE|Cath noted the mitral valve replacement with a porcine valve. Her PAs were measured with a mean of 29 and a wedge of 15. Her Fick CI was 1.9 with PA sat of 61%. She had a normal LM with a proximal LAD without significant disease. She had a large D1 with an 80% proximal stenosis, mild LAD with 60% stenosis after the D1 takeoff, and no significant disease of the apical LAD.
PA|pulmonary artery|PA|213|214|MAJOR IMAGING AND PROCEDURES|2. Paroxysmal atrial fibrillation. 3. Hyperlipidemia. 4. Hypertension. MAJOR IMAGING AND PROCEDURES: 1. Right heart catheterization was done which showed right atrial pressure of 4 mmHg, RV pressure of 36/4 mmHg, PA pressure of 36/18 mmHg, wedge pressure of 12 mmHg, cardiac index of 1.8 L/min/m2 by thermodilution, and 1.9 L/min/m2 by Fick.
PA|pulmonary artery|PA|341|342|PROCEDURES PERFORMED|DISCHARGE DIAGNOSES: 1. Dilated cardiomyopathy. 2. Hereditary spherocytosis. 3. Hemachromatosis. PROCEDURES PERFORMED: 1. Right and left heart catheterization. Impression: Right heart cath revealed significantly elevated right and left filling pressures and reduced cardiac output (right atrial mean pressure 70 mmHg, right ventricle 48/19, PA 48/31, mean 39, PCPW -- 30, cardiac output -- 3.7 liters per meter (fixed) and 4 liters per minute (thermal)).
PA|posterior-anterior|PA|264|265|IMAGING STUDIES|LABORATORY EVALUATION: Laboratories today demonstrate white blood cell count 8.7, hemoglobin 8.8, platelets 274, BUN 42, creatinine 2.99 (baseline 2.2-2.6). Urinalysis: Positive for 4 white blood cell counts, urine culture is pending. IMAGING STUDIES: Chest x-ray PA and lateral from _%#DDMM2007#%_ demonstrated no acute airspace disease. ASSESSMENT AND PLAN: Sixty-four-year-old male with history of short bowel syndrome secondary to ischemic gut, thrombophilia with factor V Leiden deficiency, chronic kidney disease secondary to focal segmental glomerular sclerosis with recent discharge for pyelonephritis on _%#DDMM2007#%_ presented with continuing fevers.
PA|pulmonary artery|PA|156|157|HOSPITAL COURSE|We, therefore, had aborted the transplant. For full details of the operation, please see dictated operative note. Postoperatively in the ICU, the patient's PA pressures failed to improve and Cardiology Heart Failure consultation was obtained for management of pulmonary hypertension. They tried multiple different interventions to reduce portal pulmonary hypertension and none of these were very successful.
PA|physician assistant|PA|97|98|DISCHARGE FOLLOW-UP|8. Nitroglycerin sublingual p.r.n. 9. calcium supplement. DISCHARGE FOLLOW-UP: 1. Follow up with PA _%#DDMM2007#%_ at 2:30 p.m. in the Minnesota Heart Clinic with _%#NAME#%_. 2. Follow-up with adenosine thallium _%#DDMM2008#%_ at Minnesota Heart Clinic 9:00 a.m.
PA|physician associates|PA)|78|80|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, MD (_%#CITY#%_ Sports Health & Wellness, PA) CHIEF COMPLAINT: Abdominal pain and fever. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 73-year-old female with a history of hypertension and a recent knee arthroplasty back in early _%#MM#%_ who presents with abdominal pain.
PA|posterior-anterior|PA|159|160|PROCEDURES/TREATMENT PERFORMED|1. Endoscopic retrograde cholangiopancreatography (ERCP), _%#DDMM2005#%_: Findings revealed no stones noted in the patient's common bile duct. 2. Chest x-ray, PA and lateral views: (1) Moderate left-sided pleural effusion with associated atelectasis; (2) Right lower lobe atelectasis versus likely pneumonia.
PA|physician assistant|PA|180|181|HOSPITAL COURSE|The patient was then admitted to station 33, Surgical Specialty, where she continued to make excellent progress. At the time of discharge the patient had met with Dr. _%#NAME#%_'s PA and nurse educator. All answers were given for discharge recommendations. At the time of discharge the patient was ambulating without assist, reporting good pain management, no nausea or vomiting and was reporting a good understanding of postoperative diet expectations.
PA|posterior-anterior|PA|273|274|LABORATORY DATA|LABORATORY DATA: Basic metabolic panel within normal limits. CBC with differential showed white blood count of 12,000 with elevated neutrophils of 85%, hemoglobin mildly elevated at 16.3, INR and PTT within normal limits. CT head without contrast is negative. Chest x-ray, PA and lateral, did not show any infiltrate. EKG showed sinus bradycardia with normal sinus rhythm and no acute ST/T changes. MRI of the brain with and without contrast, MRI/MRA of the neck without contrast, reported by Dr. _%#NAME#%_, was negative.
PA|posterior-anterior|PA|146|147|DISPOSITION|DISPOSITION: 1. The patient will follow up with her primary care physician, Dr. _%#NAME#%_, in 1-2 weeks. 2. She is to have follow-up chest x-ray PA and lateral in 10-14 days with results to her PMD for follow-up.
PA|posterior-anterior|PA|162|163|OPERATIONS/PROCEDURES PERFORMED|3. End-stage renal disease. 4. Coronary artery disease. OPERATIONS/PROCEDURES PERFORMED: Imaging/Investigations done during this hospitalization: 1. Chest x-ray, PA and lateral, _%#MM#%_ _%#DD#%_, 2006. Impression #1. Extensive fibrosis in the right hemithorax that has not significantly changed. Impression #2. Clear left lung. 2. Chest x-ray, _%#MM#%_ _%#DD#%_, 2006.
PA|posterior-anterior|PA|80|81|IMAGING|There is no ST or T-wave changes. There are no bundle branch blocks. IMAGING: A PA and lateral chest x-ray on _%#DDMM2007#%_: The lungs are clear. ASSESSMENT AND PLAN: Ms. _%#NAME#%_ is an 85-year-old female with a past medical history of possible coronary disease who now presents with a short episode of chest pain, which was most likely noncardiac.
PA|posterior-anterior|PA|146|147|PROCEDURES DONE DURING HOSPITALIZATION|DISCHARGE DIAGNOSES: 1. Fevers of suspected infectious source. 2. Metastatic cholangiocarcinoma. PROCEDURES DONE DURING HOSPITALIZATION: 1. Chest PA lateral done on _%#DDMM2007#%_. Impression, A. Slight increase in loculated left pleural effusion that extends up the left lateral chest wall.
PA|posterior-anterior|PA|146|147|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1: Inflammatory polyarthritis. On this admission, Mr. _%#NAME#%_ underwent x-ray series of his right wrist as well as a PA chest x-ray. Neither studies revealed significant bony joint destruction of the affected joints. His CRP and ESR were significantly elevated however at 119.8 and 110 respectively.
PA|posterior-anterior|PA|168|169|DISCHARGE MEDICATIONS|12. Ambien 5 mg at night p.r.n. sleep, several doses provided. She should be on a low-sodium diet. Follow up with Dr. _%#NAME#%_ in 2 weeks. No ibuprofen. Chest x-ray, PA and lateral at Fairview Ridges Hospital radiology department on _%#DDMM2007#%_ and thoracentesis ultrasound-guided by radiology if right pleural effusion is moderate to large in size.
PA|posterior-anterior|PA.|46|48|PRIMARY CARE PROVIDER|PRIMARY CARE PROVIDER: _%#NAME#%_ _%#NAME#%_, PA. CHIEF COMPLAINT: Palpitations, chest pain. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 55-year-old Caucasian male with prior history of intermittent presyncopal symptoms as well as occasional palpitations, who presents to Fairview Southdale Hospital with symptoms of palpitations and chest pain.
PA|physician assistant|PA|188|189|DISCHARGE LAB  DATA|Blood pressure stable at 122/67, pulse 61 and regular. She was discharged on all of her admit medications which includes Plavix indefinitely. She will follow-up in 2-3 weeks with an NP or PA at Minnesota Heart Clinic and then will see Dr. _%#NAME#%_ in 3-4 months for follow-up. As always she was encouraged to contact us prior to her next scheduled visit if she has problems or concerns.
PA|physician assistant|PA|48|49|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, PA (Fairview Cedar Ridge Clinic - Family Practice); _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD (Fairview Cedar Ridge Clinic - Family Practice) CHIEF COMPLAINT: Chest pain.
PA|posterior-anterior|PA|114|115|ASSESSMENT/PLAN|This could also be just an upper respiratory infection or a viral infection. At this time I would like to check a PA and lateral chest x-ray once he is ruled out. 1. Chest pain, question as above. Once he has ruled out consider a stress echo.
PA|posterior-anterior|PA|131|132|ASSESSMENT/PLAN|1. Chest pain, question as above. Once he has ruled out consider a stress echo. Fasting lipid panel will be checked. We will get a PA and lateral chest x-ray to rule out pneumonia. 2. Elevated white blood cell count and fever. Check a urine analysis and blood culture.
PA|pulmonary artery|PA|448|449|HOSPITAL COURSE|I have been notified by administrative staff here that this exceeds what we are able to do at Fairview Southdale Hospital and I was advised that this course of therapy would need to be administered at the University of Minnesota Hospital and we have therefore made arrangements for this transfer. My clinical impression is that there is severe pulmonary hypertension with possible mixture of idiopathic pulmonary arterial hypertension and elevated PA pressures due to mitral insufficiency. To complicate matters further, the patient also has chronic renal insufficiency and titration of his diuretics and reduction of his pulmonary capillary wedge pressure needs to be done very carefully so as not to worsen his renal insufficiency.
PA|posterior-anterior|PA|216|217|IMAGING|Cranial nerves II-XII appear intact. IMAGING: Twelve-lead EKGs obtained at 2029 and 2222 both show an underlying atrial flutter rhythm with 100% ventricular pacing and no obvious acute ischemic changes. Chest x-ray, PA and lateral, shows cardiomegaly, pacemaker status and fibrosis in both lung bases, but shows no obvious change compared with _%#DDMM2006#%_.
PA|posterior-anterior|PA|377|378|HOSPITAL COURSE|16. Potassium will be increased to 20 b.i.d. 17. Albuterol nebs t.i.d. HOSPITAL COURSE: This is a 78-year-old female who was admitted with signs and symptoms of sepsis, initial evaluation showed some coarse rhonchi and the possibility of aspiration pneumonia was entertained. The patient's white count was 9600, hemoglobin 9.3. Electrolytes were unremarkable, creatinine 1.58. PA and lateral chest x-ray actually would be normal. The patient has a chronic wound on the left foot. She had some elements of induration. Culture would be pure staph aureus which was sensitive to all antibiotics tested including Cefazolin and oxacillin.
PA|posterior-anterior|PA|181|182|PLAN|The patient was given Levaquin, will add Solu-Medrol and hold her prednisone. We will maintain pulmonary toilet. 2. Right upper and right middle lobe pneumonia. We will recheck her PA and lateral chest x-ray in the morning. Continue her on Levaquin and Tylenol. 3. Obstructive sleep apnea. Will use CPAP at night time. 4. History of hypertension ,but now with hypotension.
PA|posterior-anterior|PA|227|228|MAJOR PROCEDURES DURING HOSPITALIZATION|DISCHARGE DIAGNOSES: 1. Cellulitis. 2. Transformed lymphoma. MAJOR PROCEDURES DURING HOSPITALIZATION: 1. Ultrasound of right upper extremity showing no DVT, nonocclusive thrombus in the brachial portion of the basilic vein. 2. PA and lateral chest x-ray showing no focal air-space opacity and stable mediastinal lymphadenopathy. HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old male with history of follicular cell lymphoma.
PA|posterior-anterior|PA|154|155|KEY IMAGING AND PROCEDURES PERFORMED DURING THIS HOSPITALIZATION|DISCHARGE DIAGNOSIS: Dyspnea, probably related to allergies/environmental allergens. KEY IMAGING AND PROCEDURES PERFORMED DURING THIS HOSPITALIZATION: 1. PA and lateral chest x-ray performed on _%#DDMM2007#%_. Findings: Negative chest. 2. Dobutamine echocardiogram stress study performed on _%#DDMM2007#%_. It was Negative.
PA|pulmonary artery|PA|163|164|MAJOR IMAGING AND PROCEDURES|MAJOR IMAGING AND PROCEDURES: 1. A right and left heart cath, was done on _%#DDMM2007#%_. Right heart cath shows an RA pressure of 11, RV 31/11 with a mean of 19, PA pressure 31/11 with mean of 19, wedge pressure 12, cardiac index 1.5. Left heart cath was done which shows an ejection fraction of 48%.
PA|posterior-anterior|PA|115|116|PROCEDURAL DETAILS|He was noted to be bradycardic and has been atrial paced at set lower rate of 70 beats per minute. The patient had PA and lateral x-ray performed which shows stable lead positions. Device check on _%#DDMM2007#%_ revealed no change in pacing and sensing thresholds.
PA|posterior-anterior|PA|285|286|LAB DATA|There was no evidence for hydronephrosis. The echogenicity of the kidneys may have been slightly increased as they appear isoechoic to the liver. The urinary bladder was not fully distended, and unremarkable. Discharge hemoglobin was 14.3, recheck hemoglobin was 14.9, and chest x-ray PA and lateral as noted above. At the time of discharge pending exams included HIV 1 and 2 antibody were negative.
PA|physician assistant|PA,|157|159|DISCHARGE PLAN|3. I also put her on some Macrobid 100 mg p.o. b.i.d. for three days for her urinary tract infection (UTI). 4. Follow-up will be with _%#NAME#%_ _%#NAME#%_, PA, at _%#CITY#%_ Lake Clinic (_%#ADDRESS#%_ _%#ADDRESS#%_ location). Lipase at discharge was 9820 and her amylase was 140.
PA|physician assistant|PA|146|147|HOSPITAL COURSE|In the meantime, since his rate is controlled and he has converted to sinus he is stable to be discharged. I discussed with him and also with his PA by phone followup INR check tomorrow and ultimate followup in the office with Minnesota Heart to kind of substantiate whether or not he really needs to be on long-term anticoagulation since his age is only 55 and his CHAD score would be 0, although I think this is probably paroxysmal atrial fibrillation which was probably the episodes of the presyncope that he had a few months back which prompted the stress echo.
PA|pulmonary artery|PA|221|222|LABORATORY DATA|Ultrasound of the abdomen shows cholelithiasis with mild gallbladder wall thickening at 4 mm and stones in the gallbladder. There is no significant change since ultrasound of _%#DDMM2007#%_. ABG: The pH is 7.48, pCO2 25, PA O2 104, bicarbonate 18, O2 saturation 97% room air. Urinalysis is negative. ASSESSMENT AND PLAN: A 48-year-old woman with gallstone pancreatitis.
PA|physician assistant|PA|144|145|DISCHARGE FOLLOW UP|No femoral bruit appreciated. EXTREMITIES: Without edema. DISCHARGE FOLLOW UP: 1. The patient will follow up with myself _%#NAME#%_ _%#NAME#%_, PA in 1-2 weeks at Minnesota Heart Clinic. At that time he will have a basic metabolic panel drawn. 2. He should have primary care follow up as scheduled.
PA|posterior-anterior|PA|224|225|LABORATORY AND DIAGNOSTIC STUDIES|LUNGS: Diminished sounds at the bases, no significant bronchospasm. EXTREMITIES: There is 2-3+ edema bilaterally. LABORATORY AND DIAGNOSTIC STUDIES: Her end terminal pro BNP is elevated at 2,500. Troponin is less than 0.04. PA and lateral chest x-ray demonstrates hyperinflation with some slight increased left pleural effusion and a small amount of right pleural effusion.
PA|posterior-anterior|PA|200|201|DISPOSITION|3. The patient to have outpatient adenosine nuclear stress test to be arranged per cardiology. 4. Follow up LFTs in 2 weeks with results to PMD for follow up. 5. Patient to have follow-up chest x-ray PA and lateral in 1-2 weeks, results to PMD for follow up.
PA|posterior-anterior|PA|127|128|KEY IMAGING STUDIES AND PROCEDURES PERFORMED DURING THE HOSPITALIZATION|DISCHARGE DIAGNOSES: Cystic fibrosis exacerbation. KEY IMAGING STUDIES AND PROCEDURES PERFORMED DURING THE HOSPITALIZATION: 1. PA and lateral chest x-ray performed on _%#MM#%_ _%#DD#%_, 2006. 2. PICC placement. IMPRESSION: Increased interstitial and airspace opacities when compared to previous (from _%#MM#%_ 2004).
PA|posterior-anterior|PA|190|191|FOLLOW-UP|She should call _%#TEL#%_, and ask for Dr. _%#NAME#%_ _%#NAME#%_, with any questions. FOLLOW-UP: The patient should follow up with Dr. _%#NAME#%_ in three to four weeks, with a chest x-ray, PA and lateral, prior to her follow-up appointment.
PA|posterior-anterior|PA|146|147|CHEST X-RAY|He did have blood cultures done which were negative. Hemoglobin was 20.3, white count 11,300. Video swallow showed severe dysphagia. CHEST X-RAY: PA and lateral chest x-ray showed actually no signs of any active process. (His diagnosis is more on clinical grounds.) ASSESSMENT: 1. Aspiration pneumonia secondary to severe dysphagia with feeding tube placement.
PA|posterior-anterior|PA|226|227|LABORATORY STUDIES ON ADMISSION|He has no abdominal tenderness anywhere. LABORATORY STUDIES ON ADMISSION: Included white count of 17,100, hemoglobin 10.1, which was no change from discharge. His troponin I was less than 0.07. Platelets 313,000. Chest x-ray, PA and lateral of the abdomen, and hand x-ray are all pending official reading, but per ER were reportedly normal. Creatinine 2.9, glucose 167, sodium 142, potassium 4.2, calcium 8.1. ASSESSMENT: A debilitated individual with a fall and fractured metacarpal bone.
PA|posterior-anterior|PA|179|180|PROBLEM #3|PROBLEM #3: Pulmonary. Chest x-ray performed on _%#MMDD#%_ revealed a right paratracheal density that was felt to possibly represent a pulmonary nodule. This was only seen on the PA view and was not previously noted. For that reason, he has been set up for an outpatient CT of his chest to further evaluate this.
PA|physician assistant|PA|270|271|DISCHARGE INSTRUCTIONS|Tricuspid regurgitation was mild. He did well during cardiac rehab without any recurrent chest discomfort or shortness of breath symptoms and was discharged in the p.m. of _%#DDMM2007#%_. DISCHARGE INSTRUCTIONS: 1. The patient will follow up with _%#NAME#%_ _%#NAME#%_, PA or other primary doctor at Quello Clinic in one to two weeks. 2. The patient will follow up with Minnesota Heart Clinic in one to two weeks for post-procedure evaluation and discussion.
PA|posterior-anterior|PA|229|230|PROCEDURES PERFORMED DURING THIS HOSPITALIZATION|PROCEDURES PERFORMED DURING THIS HOSPITALIZATION: Coronary angiogram done on _%#DDMM2007#%_ showed focal 25-50% ostial stenosis of the left anterior descending artery. There was no hemodynamically significant lesion. Chest x-ray PA and lateral done on _%#DDMM2007#%_ showed no acute disease within the chest. An echocardiogram done in _%#DDMM2007#%_ showed normal left ventricular wall thickness, normal left ventricular size.
PA|posterior-anterior|PA|135|136|IMPRESSION/REPORT/PLAN|3. Permanent pacemaker. 4. Hypertension. Regarding the possible electrical stimulation for Mr. _%#NAME#%_, we will have a chest x-ray, PA and lateral, performed to assess the placement of his pacemaker. In addition, we will have his pacemaker interrogated by the Medtronic rep to look for any changes in the impedance to suggest that he has had a wire or insulation defect.
PA|posterior-anterior|PA|135|136|IMAGING|Bowel sounds are present. No masses felt. EXTREMITIES: No clubbing, cyanosis, or edema. CNS EXAM: Grossly intact. IMAGING: Chest x-ray PA and lateral reviewed by me personally shows no new infiltrates or effusions, and is unchanged from prior chest x-rays. LABORATORY DATA: BUN 14, creatinine 1.1, which is slightly elevated from prior numbers.
PA|physician assistant|PA|153|154|FOLLOWUP|5. Lisinopril 5 mg p.o. daily. FOLLOWUP: The patient will follow up with Cardiology in two to three months' time. He will also follow up with Cardiology PA in two weeks' time. He will follow up at the University of Minnesota for planned visit with _%#NAME#%_ from the Department of Otolaryngology DIET: Low salt.
PA|posterior-anterior|PA|112|113|STUDIES AND PROCEDURES|6. Chronic diagnoses of type 2 diabetes, Wolff-Parkinson-White and hypertension.' 7. STUDIES AND PROCEDURES: 1. PA and lateral chest x-ray _%#DDMM2007#%_. Impression: Allowing for the supine position, overlapping EKG leads and suboptimal inspiration, the chest appears within normal limits.
PA|physician associates|PA)|81|83|PRIMARY CARE PHYSICIAN|PRIMARY CARE PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD (_%#CITY#%_ Family Physicians, PA) DISCHARGE DIAGNOSIS: 1. Possible transient ischemic attack (TIA) versus inner ear disturbance.
PA|posterior-anterior|PA|134|135|KEY IMAGING STUDIES AND PROCEDURES PERFORMED THIS HOSPITALIZATION|KEY IMAGING STUDIES AND PROCEDURES PERFORMED THIS HOSPITALIZATION: 1. Chest x-ray performed during _%#MM#%_ _%#DD#%_, 2007. Findings: PA and lateral views of the chest. Lungs are clear. Heart is normal size. No effusions evident and no pneumothorax. No interval change. 2. Cardiac catheterization performed on _%#DDMM2007#%_. Findings: "Normal coronaries".
PA|posterior-anterior|PA|187|188|DISCHARGE FOLLOW-UP|3. Dyslipidemia. 4. Hypertension. DISCHARGE DISPOSITION: 1. Condition stable improved. 2. Destination home. DISCHARGE FOLLOW-UP: Follow-up with Dr. _%#NAME#%_ in a month. He should get a PA and lateral chest x-ray prior to that visit to follow up on the infiltrate. If he feels ill before a months' time, he should see Dr. _%#NAME#%_ sooner.
PA|posterior-anterior|PA|225|226|KEY IMAGING AND PROCEDURES PERFORMED DURING THIS HOSPITALIZATION|Impression: Impacted mildly angulated fracture of the intertrochanteric region of the right femur. 4. Hip films on _%#DDMM2007#%_. Two images revealed plate and screw fixation of an intertrochanteric fracture. 5. Chest x-ray PA and lateral performed on _%#DDMM2007#%_. Findings: Linear atelectasis less prominent than on _%#MMDD#%_. May be minimal ___of the left costophrenic angle. Otherwise no significant change.
PA|posterior-anterior|PA|123|124|IMAGING|Nails show clubbing. EXTREMITIES: Warm and well perfused. No pitting edema. LABORATORY DATA: Pending. IMAGING: Chest x-ray PA and lateral on admission is unchanged from previous film of _%#MM2005#%_ on preliminary report, pending formal read by radiology.
PA|posterior-anterior|PA|123|124|CHEST X-RAY|NEUROLOGIC: Cranial nerves II- XII intact. Deep tendon reflexes symmetric throughout and gait narrow based. CHEST X-RAY: A PA and lateral obtained yesterday shows obvious right lower lobe nodular type infiltrate, also an acute infiltrative process in the left upper lobe, perhaps less so in the right upper lobe.
PA|posterior-anterior|PA|205|206|HISTORY OF PRESENT ILLNESS|Workup there included electrolytes which were unremarkable, serum glucose which was 123, BUN of 14, and creatinine of 0.3. A urinalysis and culture were obtained. Urinalysis was unremarkable. Chest x-rays PA and lateral were negative, and a head CT was done which showed no acute intracranial pathology with incidental finding of a small right subcutaneous "lesion." The white count was 6100 with 63% neutrophils, 17% lymphocytes, 16% monocytes, with a platelet count of 230,000.
PA|posterior-anterior|PA|255|256|ASSESSMENT/PLAN|2. Possible residual pleural fluid. Of note, the patient had minor transudative pleural effusions which were aspirated postoperatively during her last hospitalization. Due to that and the unclear chest x-ray finding as delineated above, we will recheck a PA and lateral chest film on the patient in the morning. We will additionally do a lateral decubitus film to check the layering of pleural fluid.
PA|posterior-anterior|PA|179|180|PLAN|PLAN: She is scheduled to undergo DFT testing at Fairview Southdale Hospital today with Dr. _%#NAME#%_. The procedure was explained to her in full. She will obtain a chest x-ray, PA and lateral, to assess lead integrity. She has never had problems with anesthesia and does understand what will be happening at the visit today.
PA|posterior-anterior|PA|235|236|LABORATORY DATA|The patient was asymptomatic. Complete blood count: Hemoglobin 14, white count 7,700, Depakote level was ordered, but was not obtained prior to discharge. Chest x-ray revealed a small amount of right infrahilar infiltrate seen only on PA view and not confirmed on the lateral view. Increased AP diameter from chronic obstructive pulmonary disease, electrocardiogram, atrial fibrillation with a left anterior fascicular block and possible anterior infarct, age indeterminant.
PA|pulmonary artery|PA|302|303|PAST MEDICAL HISTORY|5. History of coronary artery disease, coronary artery bypass graft times two _%#DDMM2003#%_ with LIMA to the left main and a vein to a circumflex, but myocardial infarction. Repeat cath six months ago showed his grafts were open. 6. History of constrictive pericarditis with stripping _%#DDMM2003#%_, PA wedge was 43/18 with an ejection fraction of 65%. 7. History of paroxysmal atrial fibrillation 8. History of recurrent pleural fluid with recent thoracentesis which was transudate in nature.
PA|posterior-anterior|PA|198|199|PLAN|7. Recent olecranon bursal infection. PLAN: 1. Admit for observation antibiotics. 2. Vancomycin as given in the ER. 3. Add ceftriaxone for gram negative coverage and also for pneumonia coverage. 4. PA and lateral chest x-ray. 5. Ultrasound of lower extremity to rule out DVT. 6. Continue seizure medications. 7. Likely to require a consultation from vascular surgery and orthopedic surgery while in-house.
PA|pulmonary artery|PA|156|157|HISTORY OF PRESENT ILLNESS|2. Fevers, rule out sepsis. HISTORY OF PRESENT ILLNESS:_%#NAME#%_ is a 7-month-old male with a past medical history of a double inlet ventricle status post PA banding, omphalocele with malrotation, and partial small-bowel obstruction. The patient was scheduled for a Glenn procedure on the morning of _%#MM#%_ _%#DD#%_, 2003.
PA|pulmonary artery|PA|290|291|PROCEDURES|3. Transthoracic echo on _%#DDMM2003#%_ shows severe decrease in systolic function, with an ejection fraction of 15-20%, left ventricular dilation with global hypokinesis, and moderate biatrial enlargement. 4. Right heart cath on _%#DDMM2003#%_ shows secondary pulmonary hypertension, with PA pressure 64/24, right atrial pressure 15, pulmonary artery wedge pressure of 21, consistent with congestive cardiomyopathy, likely idiopathic.
PA|posterior-anterior|PA|160|161|PHYSICAL EXAMINATION|There is no tenderness. Distal extremities are normal. There is no peripheral edema. The patient has no prior history of bleeding problems. At today's visit, a PA chest x-ray, CBC, basic metabolic panel, INR and PTT were all drawn and results should be available prior to his upcoming surgery.
PA|posterior-anterior|PA|161|162|PROCEDURES|6. Bowel obstipation. 7. Dementia with associated delirium secondary to respiratory failure and polypharmacy. 8. Malnourished state. PROCEDURES: 1. Chest x-ray, PA and lateral on admission showing nodular density overlying the region of the left anterior rib. Marked scoliosis. 2. Pelvis with lateral hip x-ray, no fracture.
PA|posterior-anterior|(PA|224|226|LABORATORY DATA|LABORATORY DATA: Electrocardiogram: Sinus rhythm. No ischemic changes. INR 1.3. CBC: Notable for hemoglobin 13.2, platelets 280,000. Basic metabolic panel normal. Urinalysis: Few bacteria. Negative for nitrites. Chest x-ray (PA and Lateral) revealed hyperinflation of the lungs with some chronic fibrotic changes and postoperative changes noted with metallic rod extending from T12 down to L2.
PA|pulmonary artery|PA|48|49|PROCEDURES PERFORMED DURING THIS HOSPITAL STAY|PROCEDURES PERFORMED DURING THIS HOSPITAL STAY: PA band on _%#DDMM2007#%_. CLINICAL NOTE: _%#NAME#%_ is a newborn child who was born with double inlet LVL transposition of the great vessels with right aortic arch.
PA|posterior-anterior|PA|203|204|PROCEDURES AND IMAGING|DISCHARGE DIAGNOSES: 1. Weakness and arthralgias secondary to Crohn's disease versus Infliximab delayed hypersensitivity. 2. Rectovaginal fistula. 3. Crohn's disease. PROCEDURES AND IMAGING: Chest x-ray PA and lateral on _%#DDMM2007#%_ showing clear lungs. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 60-year-old woman with a past medical history significant for Crohn's disease, hypertension and GERD who presents with a 3-day history of progressive arthralgias.
PA|posterior-anterior|PA|147|148|DIAGNOSTICS|Glucose a little increased at 151. Creatinine is 1.05 which gives a calculated GFR of 54. Troponin I is less than 0.04. Myoglobin 61. DIAGNOSTICS: PA and lateral chest x-ray was unremarkable. CT scan of the abdomen and pelvis with contrast suggests a right ureteropelvic junction obstruction with dilatation of the right renal pelvis and CT evidence of pyelonephritis.
PA|posterior-anterior|PA|196|197|HOSPITAL COURSE|She was seen, evaluated, and admitted for IV antibiotic therapy. An Infectious Diseases consult was obtained. The patient was given IV antibiotics according to ID recommendations. She underwent a PA and lateral chest demonstrating no significant acute changes. An MRI of the left thigh and leg were done for evaluation, demonstrating a 2.5 x < 1 cm fluid collection subcutaneously, adjacent to the proximal incision site in the left thigh.
PA|physician assistant|PA|179|180|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 26-year- old, gravida 2 para 1, at 21 weeks' gestation. She was seen at the _%#NAME#%_ _%#NAME#%_ Ob/Gyn Clinic, PA on _%#DDMM2003#%_ at which time she had a urinalysis which was consistent with a bladder infection. She was placed on Macrobid to treat that. She had no flank pain and no additional pain.
PA|posterior-anterior|PA|99|100|PROCEDURES PERFORMED|DISCHARGE DIAGNOSIS: Sickle cell crisis. PROCEDURES PERFORMED: 1. Chest x-ray on admission, X-ray, PA and lateral on _%#MM#%_ _%#DD#%_, 2003. Immunosuppression: No significant change bilateral interstitial prominence, likely sequelae of recent and/or remote inflammatory or thromboembolic disease.
PA|posterior-anterior|PA|105|106|PHYSICAL EXAMINATION|The most proximal extent is not able to be visualized. Hemoglobin 14.3, INR 0.98, PTT 26. A chest x-ray, PA and lateral, has been performed and will require reviewing. Of note, a chest x-ray report from the clinic from _%#MM#%_ _%#DD#%_, showed a patchy right middle lobe infiltrate.
PA|posterior-anterior|PA|117|118|LABORATORY DATA|LABORATORY DATA: Arterial blood gasses, pH of 7.41, pCO2 of 33, pO2 67, bicarb 22, sats 93% on room air. Chest x-ray PA and lateral showed increased pulmonary markings and were otherwise negative for infiltrate or effusion as read by me. White count is 10,200, hemoglobin 15.4, platelets 167. ANC is normal.
PA|posterior-anterior|PA|148|149|PHYSICAL EXAMINATION|Cranial nerves II-XII are intact. The patient moves all extremities with equal strength and facility, and deep reflexes are symmetric. Chest x-ray: PA and lateral appears normal to my reading. Abdominal two-view x-ray shows one or two loops of bowel with an air-fluid level on one film but mostly reveals a nonspecific gas pattern.
PA|posterior-anterior|PA|483|484|HOSPITAL COURSE|The ejection fraction was normal. As the patient had no specific symptoms of angina, asymptomatic with ambulation, it was felt appropriate to treat her medically, especially seeing that she had a normal ejection fraction. Laboratory data during the course of the patient's hospital stay showed a sodium of 142, potassium 5.3, chloride 108, CO2 of 25, glucose 88, creatinine 1.62, calcium 9.0, hemoglobin 12.2, white count 7200, troponin 0.7 on three different measurements, INR 1.0. PA and lateral chest x-ray showed mild cardiomegaly, and slight linear fibrosis in both mid-lung fields, but no other abnormalities were appreciated.
PA|pulmonary artery|PA|152|153|PROCEDURES PERFORMED|3. Right heart catheterization performed on _%#DDMM2004#%_ demonstrated right atrial pressures of 9, 7, 4, which were A/V/mean pressures, respectively. PA pressures were 24/11 with a mean of 17. Pulmonary artery wedge pressure was 10, 8, 7, which were A/V/mean pressures, respectively.
PA|pulmonary artery|PA|223|224|PROCEDURES DURING THIS HOSPITALIZATION|1. Transthoracic echocardiogram, there is lateral wall akinesis. Biplane noncontrast left ventricular ejection fraction of 43%. The left ventricle is mildly dilated. The TR jet is of poor quality but, if accurate, suggests PA pressure upper limits of normal or mildly increased. 2. Portable chest x-ray on _%#DDMM2007#%_. Impression new pulmonary edema. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 70-year-old man with history of coronary artery disease, status post four vessel CABG with prior stenting and possible mild COPD versus asthma and also possible obstructive sleep apnea who awoke from sleep at 3:00 a.m. with acute shortness of breath.
PA|posterior-anterior|PA|363|364|PLAN|2. We will obtain labs tonight including a CBC with differential, platelets, prothrombin time, partial thromboplastin time (PTT), basic metabolic panel, AST, ALT, alkaline phosphatase, total protein, lipase, albumin, calcium, phosphorus, BUN, creatinine, electrolytes, urinalysis, sedimentation rate, CEA level, CA 19-9. 3. I will order an EKG and a chest x-ray, PA and lateral, in the morning. 4. I will also place the patient on IV heparin per the protocol by the pharmacist.
PA|physician assistant|PA|222|223|FOLLOW-UP|At the end of the hospitalization the patient was ambulating without assist, reporting no difficulties with diet, was well-versed on postoperative expectations. FOLLOW-UP: The patient will be seeing _%#NAME#%_ _%#NAME#%_, PA in the Southdale Weight Loss Surgery Clinic for her first postoperative visit next week, _%#MM#%_ _%#DD#%_. The patient is leaving the hospital with a Jackson-Pratt drain in place.
PA|posterior-anterior|PA|67|68|DISCHARGE MANAGEMENT PLAN|Hemoglobin was normal at 12.8. Electrocardiogram was unremarkable. PA and lateral chest x-ray was normal. Soft tissue of neck was normal. Sodium was repeat 131. The patient is discharged as noted above. She was feeling better after intravenous Solu-Medrol, switched to prednisone, along with Atrovent and albuterol nebs, although, she had trouble with albuterol and Xopenex secondary to palpitations, thus, will just use Atrovent.
PA|physician assistant|PA,|170|172|HOSPITAL COURSE|Otherwise, her central nervous system exam seemed intact, though the lateral antibrachial cutaneous nerve had some dysthesia, as well. Dr. _%#NAME#%_ was notified by his PA, as he was in surgery. Otherwise, Ms. _%#NAME#%_ was doing fine postoperatively. With some minor adjustments, her pain was controlled with p.o. medications prior to discharge.
PA|posterior-anterior|PA|173|174|IMPRESSION|At this point, I will check baseline labs studies including CBC, liver function tests, basic metabolic panel. I will also send off a prostate specific antigen. We will do a PA and lateral chest x- ray. We will ask Dr. _%#NAME#%_ to see the patient in regards to his orthopedic issues and we will ask Dr. _%#NAME#%_ or _%#NAME#%_ to see for psychiatric evaluation.
PA|posterior-anterior|PA|130|131|LABORATORIES|White blood cell count 9400 with 87 neutrophils, 10 lymphocytes, 2 monocytes, 1 eosinophil. Blood culture is pending. Chest x-ray PA and lateral shows an apparent right-sided infiltrate affecting the right cardiac silhouette and right hemidiaphragm. We will await Radiology overread. The 12-lead ECG shows some inferior Q waves and occasional PVCs.
PA|pulmonary artery|PA|258|259|PROCEDURES PERFORMED|13. Oxygen at 2 to 3 liters nasal cannula. Titrate to keep O2 saturation greater than 90%. PROCEDURES PERFORMED: 1. Enrollment into Carperitide study. 2. Right heart catheterization showing a right atrial pressure of 22, right ventricular pressure of 66/22, PA pressure of 66/31, and a wedge of 31, and a cardiac index of 2.2 consistent with reduced cardiac output and restrictive physiology and moderate to severe pulmonary hypertension.
PA|physician assistant|PA|215|216|HOSPITAL COURSE|No deep venous thrombosis was identified. The patient also received Lovenox injections throughout hospitalization for deep venous thrombosis prophylaxis. The patient will be following up with _%#NAME#%_ _%#NAME#%_, PA at the Fairview Southdale Weight Loss Surgery Clinic next week, _%#DDMM2005#%_, for her first post-operative visit. At that time, her Jackson- Pratt drain will most likely be removed.
PA|posterior-anterior|PA|140|141|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: 1. The patient will follow up with Dr. _%#NAME#%_ in approximately four weeks. 2. The patient will have chest x-ray PA and lateral prior to his appointment with _%#NAME#%_. DISCHARGE MEDICATION: 1. Spironolactone. 2. Metoprolol. 3. Protonix. 4. Percocet as needed.
PA|pulmonary artery|PA|168|169|PROCEDURES|3. Pulmonary arterial hypertension. 4. Normal left ventricular function on LV-gram. 2. Right heart catheterization, with hemodynamic evaluation. Results: 1. CVP: 8. 2. PA pressures: 39/22. 3. Pulmonary artery wedge pressures: 16. 4. Cardiac output: 5.6, with an index of 3.4. 3. Transesophageal echocardiogram. Results: 1. Normal global LV systolic function.
PA|UNSURED SENSE|PA|386|387|HOSPITAL COURSE|The patient did have a good history for chronic gastroesophageal reflux disease (GERD)/possible spasm, but there were no unusual findings and the findings of the esophagus, stomach, duodenal bulb and second part of the duodenum were all noted to be normal. Dr. _%#NAME#%_ recommended that we give him proton pump inhibitor (PPI) therapy b.i.d. for one month and then consider a 24-hour PA study to rule out gastroesophageal reflux disease. DISPOSITION: The patient was discharged ot home in improving condition.
PA|physician associates|PA)|84|86|NEUROLOGIST|PRIMARY CARE: None. NEUROLOGIST: _%#NAME#%_ _%#NAME#%_, MD (Neurologic Consultants, PA) PRIMARY DIAGNOSIS: 1. Abdominal pain of unclear etiology. Negative esophagogastroduodenoscopy (EGD) and negative evaluation.
PA|physician assistant|PA,|232|234|ASSISTANT|DOB: ADMISSION DIAGNOSIS: Severe degenerative arthrosis, right knee. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE: Minimally invasive right total knee arthroplasty. SURGEON: _%#NAME#%_ _%#NAME#%_, M.D. ASSISTANT: _%#NAME#%_ _%#NAME#%_, PA, Certified. HISTORY: The patient is a 74-year-old female with a history of severe and progressive degenerative arthrosis involving her right knee.
PA|posterior-anterior|PA|183|184|PLAN|Based on this I think it would be wise to put him in the hospital and have a rheumatologist take a look at him. In the meantime I will get a CBC, liver function tests and chest x-ray PA and lateral to make sure that he is OK to be started on methotrexate. In the meantime I would just cover his pain with morphine IV until we figure out the GI issues.
PA|pulmonary artery|PA|171|172|PROCEDURES PERFORMD THIS HOSPITALIZATION|DISCHARGE DIAGNOSES: Fatigue. PROCEDURES PERFORMD THIS HOSPITALIZATION: 1. Right heart catheterization and biopsy. Measured pressures included right atrial pressure of 8, PA pressure of 28/13, wedge 14, cardiac index 3. Biopsy revealed no evidence of rejection, inflammatory grade 1B. 2. Echocardiogram showed normal LV function, EF 55%. No valvular abnormalities.
PA|physician associates|PA)|78|80|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, MD (_%#CITY#%_ Sports Health & Wellness, PA) DISCHARGE DIAGNOSIS: 1. Abdominal pain, suspect functional, with possible narcotic-seeking behavior. 2. Leukocytosis.
PA|physician associates|PA.|193|195|HISTORY OF PRESENT ILLNESS|The patient had multiple tests demonstrating low iron index but no real clear etiology of the bleeding. The patient was also seen by Dr. _%#NAME#%_ _%#NAME#%_ of Minnesota Oncology Hematology, PA. The patient was placed on erythropoietin (EPO) at that time and this was prior to receiving coronary angiogram by Dr. _%#NAME#%_ _%#NAME#%_. The patient's echocardiogram demonstrated 45% ejection fraction, regional wall motion abnormality, and significant vessel disease.
PA|pulmonary artery|PA|201|202|PAST MEDICAL HISTORY|Mild mitral insufficiency. Pulmonary artery pressure at 55 + right atrial pressure. Mild bilateral atrial enlargement. Left and right heart catheterization at the same time revealed normal coronaries. PA pressure 80/25. Wedge pressure 22/31. Right ventricular pressure 86/5. Cardiac output 6.1. Index 3.84. 3. Type 2 diabetes. 4. Hypothyroidism. 5. Peptic ulcer disease. 6. Gastroesophageal reflux disease.
PA|posterior-anterior|PA|172|173|PROCEDURES|5. Diabetes mellitus, insulin-dependent. 6. Hypokalemia. PROCEDURES: 1. Abdominal ultrasound, demonstrating cholelithiasis, hepatosplenomegaly, and a patent TIPS shunt. 2. PA and lateral chest x-ray. HOSPITAL COURSE: 1. Alcoholic pancreatitis. _%#NAME#%_ _%#NAME#%_ is a 45-year-old male who on the first two house days was kept n.p.o. and rehydrated with IV fluids.
PA|posterior-anterior|PA|135|136|CHEST X-RAY|Glucose was elevated to 173. Blood cultures are pending. Influenza antigen screen was negative. INR this morning was 3.0. CHEST X-RAY: PA and lateral was apparently negative per the emergency room doctor. Final reading of that and abdominal films is negative. ASSESSMENT: The patient is an elderly 82-year-old with fever, myalgias, and pain centered around the right knee.
PA|physician assistant|PA,|218|220|DISCHARGE FOLLOW UP|This is due _%#DDMM2004#%_. _%#NAME#%_ does not require any premedication for blood products. DISCHARGE FOLLOW UP: _%#NAME#%_ will be seen in the Bone Marrow Transplant Clinic on _%#DDMM2004#%_. _%#NAME#%_ _%#NAME#%_, PA, will see him at 9 o'clock a.m. At that time, he will have a cyclosporin level drawn.
PA|posterior-anterior|PA|279|280|PLAN|PLAN: 1. Postop shortness of breath with hypoxemia. Differential diagnosis including CHF exacerbation with volume overload versus postop pneumonia versus COPD exacerbation with a history of 20-pack-year smoking history and lesser likelihood of pulmonary embolus. We will check a PA and lateral chest x-ray, obtain sputum for cultures and gram stains. We will start with IV torsemide and hold his p.o. Lasix for now.
PA|physician associates|PA)|74|76|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, MD (France Avenue Family Physicians, PA) CHIEF COMPLAINT: Right-sided chest pain. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 68-year- old male with no previous history of coronary artery disease admitted to Fairview Southdale Hospital with right-sided chest pain.
PA|posterior-anterior|PA|140|141|DISPOSITION|1. The patient is to follow-up with her primary care physician, Dr. _%#NAME#%_ _%#NAME#%_, in one to two weeks. 2. Will obtain chest x-ray, PA and lateral in one to two weeks prior to appointment with PMD with films to PMD for follow-up. 3. The patient was evaluated while inpatient with physical therapy and occupational therapy and these have recommended outpatient ongoing physical therapy and occupational therapy therapies.
PA|posterior-anterior|PA|133|134|LABORATORY DATA|Hepatic panel was normal. Hemoglobin 12.0, white count 7900. INR was elevated at 4.45. Troponin < 0.07 on three different occasions. PA and lateral chest x-ray revealed prominence of the bronchial vascular markings, and changes compatible with emphysema and honeycombing.
PA|posterior-anterior|PA|28|29|PROCEDURES|PROCEDURES: 1. Chest x-ray, PA and lateral, done on admission on _%#DDMM2005#%_, showed suboptimal inspiration. Aortic calcification. Slight elevation of the right hemidiaphragm. 2. Retroperitoneal ultrasound: There is ectasia of the abdominal aorta with greatest transverse diameter mid distally (2.5 cm).
PA|physician assistant|PA,|176|178|PLAN|The patient was afebrile and vital signs were stable. The patient seemed to understand postoperative expectations. PLAN: The patient will follow-up with _%#NAME#%_ _%#NAME#%_, PA, Fairview Southdale Weight Loss Surgery Clinic next week for her first operative visit. At that time her Jackson Pratt drain will most likely be removed.
PA|pulmonary artery|PA|128|129|HOSPITAL COURSE|Patient was started on a milrinone drip and was kept on it for about 24 hours. The patient's cardiac index increased to 2.5 and PA pressures dropped down to 36/10. The patient was also symptomatically feeling much better and milrinone was discontinued and patient was placed back on his oral medications.
PA|posterior-anterior|PA|195|196|HOSPITAL COURSE|Patient was asymptomatic after admission. Troponin I would be less than 0.07 on three 3 occasions and her electrocardiogram the next morning showed just mild nonspecific ST segment flattening. A PA and lateral chest x-ray was normal. Initial calcium was mildly elevated at 10.7 with normal in our laboratory up to 10.4, but a repeat fasting calcium the next day was 9.
PA|posterior-anterior|PA|356|357|DISCHARGE INSTRUCTIONS|She is not to soak her wound x3 weeks. The patient is to call the thoracic surgery resident or fellow on- call if she has any increased drainage, pain, swelling, shortness of breath, chest pain, or temperature greater than 101.5 degrees Fahrenheit. She is to return to thoracic surgery clinic to follow up with Dr. _%#NAME#%_ in approximately 3 weeks with PA and lateral chest x-ray. DISCHARGE MEDICATIONS: The patient is going to return to her home vitamins and is discharged with Percocet 1 to 2 tablets p.o. q.4 h p.r.n. pain #40.
PA|pulmonary artery|PA|262|263|HOSPITALIZATION|4. Type 1 diabetes mellitus. HOSPITALIZATION OPERATIONS AND PROCEDURES PERFORMED DURING THIS HOSPITALIZATION: 1. Right heart catheterization performed on _%#MM#%_ _%#DD#%_, 2006: Shows biventricular diastolic dysfunction and moderate pulmonary hypertension with PA pressure of 57/26 and a pulmonary artery wedge pressure of 35 with a cardiac index of 1.8. 2. Swan-Ganz catheter measurements. 3. Transthoracic echocardiogram performed on _%#MM#%_ _%#DD#%_, 2006, shows severely decreased LV systolic function with visually estimated ejection fraction of 20%, moderate to severe LV dilation, moderate MR, moderate LAE, moderate RA dilation, moderate RV dilation, moderate to severely decreased right ventricular function, moderate to severe tricuspid regurgitation.
PA|posterior-anterior|PA|161|162|LABORATORY AND DIAGNOSTIC DATA|Vital were normal. LABORATORY AND DIAGNOSTIC DATA: White count was 5100 with hemoglobin of 13.7. Electrolytes were normal. Hepatic panel was normal. BNP was 23. PA and lateral chest x-ray showed no acute changes. Urinalysis was unremarkable. CT scan of the abdomen was obtained and would show changes in the left lower quadrant that would be compatible with colitis.
PA|physician assistant|PA|213|214|DISCHARGE INSTRUCTIONS|8. Nexium 40 mg p.o. q. day. 9. Senna 2 to 4 tablets p.o. b.i.d. DISCHARGE INSTRUCTIONS: The patient was discharged home on a regular diet with activity as tolerated. Followup care includes _%#NAME#%_ _%#NAME#%_, PA for inpatient followup at the Masonic Clinic on _%#MM#%_ _%#DD#%_, 2006, at 2 p.m. and Dr. _%#NAME#%_ for a regular followup at the Masonic Clinic on _%#MM#%_ _%#DD#%_, 2006, at 4 p.m. Please note at the time of the visit with _%#NAME#%_ _%#NAME#%_ that the patient's changed dose of metoprolol should be addressed as the dose was decreased during the hospitalization because her systolic blood pressure was noted to be in the mid 80s on occasion.
PA|pulmonary artery|PA|552|553|OPERATIONS/PROCEDURES PERFORMED|2. Transesophageal echocardiography done on _%#MM#%_ _%#DD#%_, 2004, showed mildly to moderately decreased left ventricular function with visually estimated ejection fraction of 40%, mild mitral annular calcification, severe left atrial enlargement, severe right atrial enlargement, trace aortic regurgitation, mild-to-moderate mitral regurgitation, significant SEC in left atrium, small PFO with left-to-right shunt. 3. Right heart catheterization on _%#MM#%_ _%#DD#%_, 2004, showed a right atrial pressure of 18, right ventricular pressure of 49/17, PA 46/21, and pulmonary arterial wedge pressure of 24. Cardiac output by Fick was 5.4 with an index of 2.9. 4. Generator change of biventricular pacer on _%#MM#%_ _%#DD#%_, 2004, by Dr. _%#NAME#%_.
PA|pulmonary artery|PA|292|293|OPERATIONS/PROCEDURES PERFORMED|PAST MEDICAL HISTORY: 1. Heart transplant in 1989. 2. Coronary artery disease status post transplant with coronary artery bypass graft in 2000, with a LIMA to LAD, saphenous venous graft to the OM-1. 3. Last right heart catheterization, _%#MM#%_ _%#DD#%_, 2004, showed an RA of 17, RV 43/10, PA 46/26, PCW 21, and grade 1-B rejection. 4. Last echocardiogram showed ejection fraction of 50 to 55% with LVH, mild MR, RV dilatation, and moderate TR.
PA|pulmonary artery|PA|185|186|PAST MEDICAL HISTORY|4. History of PA banding. 5. History of thrombosis of mechanical pulmonary valve with subsequent development of distal conduit obstruction. 6. History of excision of right ventricle to PA conduit, and mechanical valve replacement with St. Jude Mechanical Pulmonic Valve (_%#DDMM2004#%_). ADMISSION PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 95/48, pulse 222, respiratory rate 30, weight 97 kg.
PA|physician associates|PA|100|101|ADDENDUM|_%#MM#%_ _%#DD#%_, 2004 _%#NAME#%_ _%#NAME#%_, _%#NAME#%_ M.D. Affiliated Community Medical Centers PA _%#CITY#%_ MN _%#56200#%_ Dear Dr. _%#NAME#%_; Thank you for accepting the care of _%#NAME#%_ _%#NAME#%_ from the Neonatal Intensive Care Unit of Fairview-University Children's Hospital.
PA|posterior-anterior|PA|307|308|LABORATORY DATA|No lower extremity edema. LABORATORY DATA: Workup does reveal a slightly elevated white count at 13.7 with a slight shift at 89% neutrophils, which might be just a stress reaction. Comprehensive metabolic profile was normal with slightly elevated albumin at 4.7, amylase and lipase were normal. Chest x-ray PA and lateral was apparently negative per the emergency room doctor. Abdominal flat and upright films showed no sign of any ileus or small bowel obstruction and no free air.
PA|physician associates|PA)|74|76|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, MD (France Avenue Family Physicians, PA) CHIEF COMPLAINT: Left-sided chest pressure and pain. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 45-year-old healthy white male with no significant medical history other than right knee anterior cruciate ligament (ACL) repair in the past who is not on any medications who presents to Fairview Southdale Hospital with a two-week history of chest pain.
PA|pulmonary artery|PA|170|171|OPERATIONS/PROCEDURES PERFORMED|He was admitted and enrolled in the Carperitide study in which he had a continuous infusion of a VNP-like drug over a 24-hour period which showed marked reduction in his PA pressures and increase in his cardiac index. He was then brought up to the floor and started on upward titration of his ACE inhibitor as well as a long-term up titration of Imdur and hydralazine.
PA|posterior-anterior|PA|175|176|LABORATORY DATA|B-type natriuretic peptide was negative. Blood gas shows a little bit of alkalosis at 7.46 pH. Her CO2 was reduced to 27, arterial O2 was 77 mm and bicarb was 77. Chest x-ray PA and lateral is not currently available but per the emergency room doctor it shows bilateral infiltrates. Sputum culture is pending. Gram stain shows predominance of gram-negative rods.
PA|posterior-anterior|PA|152|153|PLAN|We will do continuous pulse ox because of her episode of respiratory depression due to opiates in the emergency room. We will repeat again chest x-ray, PA and lateral, to follow up on the possible infiltrate, but I will treat her with antibiotics pending that. Minnesota Ortho will be consulted. We will continue her home medicines for now.
PA|posterior-anterior|PA|196|197|LABORATORY DATA|LFTs are completely normal. Lipase is 23. BNP 52. Urinalysis is normal. Alcohol level was 0.32. Chest x-ray shows a left lower lobe infiltrate which in comparison to the _%#DDMM2006#%_ films, the PA is about the same, however, today's film is slightly worse in comparison to the lateral. EKG states a normal sinus rhythm, rate 81, there is evidence of LVH and there is flattening of the T waves laterally which may be related to LVH.
PA|pulmonary artery|PA|209|210|OPERATIONS/PROCEDURES PERFORMED|4. _%#MM#%_ _%#DD#%_, 2006, right heart catheterization now with results of RAP mean of 16, PA pressures of 86/31 with the mean of 51, pulmonary capillary wedge pressure was 7, FICK cardiac index of 1.82, and PA saturation of 53%. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 36-year-old male with idiopathic pulmonary hypertension who is status post right heart catheterization in _%#MM#%_ _%#DD#%_, 2005, at that time with right atrial pressures of 14, PAP of 92/42, PCWP of 9 with a total pulmonary vascular resistance of 854 with a FICK cardiac output of 5.3 and index of 2.6. He also had an echocardiogram in _%#MM#%_ 2006 with RVSP of 104.
PA|physician associates|PA)|130|132|PRIMARY MEDICAL DOCTOR|CHIEF COMPLAINT: Double vision and dizziness. PRIMARY MEDICAL DOCTOR: _%#NAME#%_ _%#NAME#%_, MD (France Avenue Family Physicians, PA) HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 79-year-old female patient with a history of hyperlipidemia, hypothyroidism and osteoarthritis who presents today with symptoms of double vision and dizziness. She states that she had an episode of dizziness earlier in the morning at home.
PA|posterior-anterior|PA|228|229|LABORATORY|Initial troponin negative. BNP was 6. Chest x-ray with increased density at the lung bases, question of some related superimposed soft-tissue change. This was a portable chest. No definite consolidation; however, recommending a PA and lateral. D-dimer 0.4, not elevated. HOSPITAL COURSE: 1. Pulmonary: Was admitted for clinical pneumonia and mild COPD exacerbation.
PA|pulmonary artery|PA|303|304|PROCEDURES PERFORMED DURING THIS ADMISSION|4. Echocardiogram, _%#DDMM2006#%_, _____________ study, normal global systolic function, loculated pericardial effusion noted posteriorly approximately 1.6 cm in size. No evidence of right-to-left shunt on echo contrast study. 5. Hemodynamic evaluation and coronary arteriography mildly elevated RA and PA pressures, elevated wedge pressure. No square root sign noted on the diastolic filling of RV, LV and RV. ED pressures are within 6 mmHg simultaneous LV and RV pressures not consistent with constrictive heart disease.
PA|posterior-anterior|PA|129|130|IMPRESSION|Will get a CBC with differential, BMP, liver panel, INR, UA, UC, blood cultures x2, CRP and sed rate. We will get a chest x-ray, PA and lateral. Will get a CT scan of the abdomen with and without contrast if the patient's creatinine is okay.
PA|pulmonary artery|PA|157|158|PROCEDURES THIS ADMISSION|RCA was large in caliber and consisted of a right PDA and several small right PL branches. No disease in the RCA system. LVEDP was 34. RA 11 mmHg, RV 44/11, PA 47/30 with a mean of 39, wedge was 34, She was admitted to the Cardiac ICU for observation while on Swan- Ganz.
PA|physician associates|PA|83|84|PLAN|_%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, M.D. Pediatric Services, PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_, MN _%#55400#%_ Dear Dr. _%#NAME#%_; Thank you for accepting the care of _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, _%#NAME#%_. from the Neonatal Intensive Care Unit (NICU) of University of Minnesota Children's Hospital (UMCH), Fairview.
PA|posterior-anterior|PA|226|227|HISTORY OF PRESENT ILLNESS|CSF glucose 59, which was normal. The fluid was clear and no organisms seen on Gram stain. Initial WBCs in the emergency department 18,200 with 57% neutrophils, 31% lymphocytes. Basic metabolic panel was normal. RSV negative. PA and lateral chest x-ray normal. Flat and upright of the abdomen normal. Urine significant for a large amount of blood, 40 mg per deciliter of ketones, 40 red blood cells, just a few bacteria, otherwise negative.
PA|physician assistant|PA|124|125|HOSPITAL COURSE|There was no evidence of any abscess. Based on this she was discharged to follow up in 2-3 days with _%#NAME#%_ _%#NAME#%_, PA who works with Dr. _%#NAME#%_, the patient's primary oncologist. PROBLEM #6. Code Status: Prior to discharge we had a conversation with the patient about code status.
PA|posterior-anterior|PA|220|221|PROCEDURES AND LAB TESTS|CT pelvis with contrast on _%#DDMM2006#%_, cellulitis in the midline and left buttock region without evidence of underlying abscess or osteomyelitis. Chest x-ray, AP portable on _%#DDMM2006#%_, clear lungs. Chest x-ray, PA and lateral on _%#DDMM2007#%_ minimal right lower lobe atelectasis otherwise clear lungs. Ultrasound of the abdomen on _%#DDMM2007#%_: Impression: 1. Cholelithiasis and gallbladder sludge without evidence for cholecystitis.
PA|pulmonary artery|PA|311|312|LABORATORY DATA|They are very tender to touch. There is no cyanosis or clubbing. LABORATORY DATA: Labs on admission were white count of 5, hemoglobin 9.9, platelets 143, sodium 136, potassium 4.5, BUN 147, creatinine 3.78, calcium 9.5, INR 1.78. Right heart cath done on the day of admission showed right atrial pressure of 9, PA pressure of 75/17, pulmonary wedge pressure of 22, cardiac index of 2.2. ASSESSMENT: This is a 62-year-old female with a history of ischemic cardiomyopathy and severe systolic heart failure.
PA|pulmonary artery|PA|361|362|PAST MEDICAL HISTORY/PRIOR HOSPITALIZATIONS|_%#NAME#%_ did well throughout the cardiac catheterization procedure. She returned to the intensive care unit in stable condition requiring minimal blow-by O2 to maintain her saturations greater than 65% (her baseline of late). PAST MEDICAL HISTORY/PRIOR HOSPITALIZATIONS: 1. Balloon atrial septostomy on _%#MM#%_ _%#DD#%_, 2005. 2. Aortic arch reconstruction, PA banding, _%#MM#%_ _%#DD#%_, 2005. 3. Mediastinal washout and closure, _%#MM#%_ _%#DD#%_, 2005. 4. PA band adjustment with sternal closure, _%#MM#%_ _%#DD#%_, 2005.
PA|pulmonary artery|PA|171|172|HISTORY OF PRESENT ILLNESS|2. Pulmonary edema. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 5 almost 6-month male with tricuspid atresia, detransposition of the great arteries, large VSD status post PA banding and repair of his coarctation in infancy. He was recently discharged from Fairview University Medical Center 2 days ago on _%#DDMM2007#%_ after having a cardiac catheterization for balloon dilatation of his aorta and aortopulmonary collateral coil occlusions.
PA|pulmonary artery|PA|301|302|PHYSICAL EXAMINATION|She is in moderate distress secondary to abdominal pain. Vital signs: Afebrile, blood pressure 154/92, weight 238.6, pulse 91, 97% sats, BG is 214 and was higher overnight. HEENT: Dry mouth, otherwise normal. Neck is supple, nontender, no thyromegaly, adenopathy, bruits or masses. Lungs are clear to PA and A. Heart: Regular S1, S2 with no extra sounds. The abdomen is soft, positive bowel sounds. Left upper quadrant is tender with plus/minus rebound.
PA|posterior-anterior|PA|180|181|HOSPITAL COURSE|His BUN was 47, creatinine was 4.8. Hepatic panel was unremarkable except for minimal elevation of AST at 56. Blood cultures were obtained and unremarkable. Urinalysis was normal. PA and lateral chest x-ray showed only chronic changes. The patient was admitted. He had a low-grade temperature up to 100 and then 99.8. He was asymptomatic after admission.
PA|physician assistant|PA|221|222|DISCHARGE FOLLOW UP|DISCHARGE FOLLOW UP: 1. Ms. _%#NAME#%_ is to have a basic metabolic panel with magnesium, phosphorus and CBC with differential done on _%#DDMM2007#%_ prior to her appointment. 2. She is to follow up with Dr. _%#NAME#%_'s PA or nurse practitioner on _%#DDMM2007#%_. She will call for an appointment. This is to take place at the Masonic Cancer Center. She has been instructed to return if she should develop a fever or uncontrolled nausea and vomiting.
PA|posterior-anterior|PA|128|129|PROBLEM #4|Per report, the patient had an abnormal chest x-ray at his primary care physician's office last week. Will repeat a chest x-ray PA and lateral today. He has had a dry nonproductive cough and this is a potential source of the fevers. He has had some sick contacts as well. Additionally, we will check a CMV antigen.
PA|pulmonary artery|PA|154|155|MAJOR IMAGING AND PROCEDURES|2. Chest x-ray on _%#DDMM2007#%_ showed mildly enlarged heart with otherwise clear lungs. 3. Right heart cath on _%#DDMM2007#%_ showed RA pressure of 14, PA pressure of 41/21, wedge pressure of 27, cardiac index of 1.4. BRIEF HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 30-year-old female with a history of heart transplant in several years ago for hypertrophic cardiomyopathy.
PA|pulmonary artery|PA|190|191|PROCEDURES|PROCEDURES: 1. CT chest without contrast showing rounded mass in the right lower lobe consistent with rounded atelectasis, bilateral pleural effusions. 2. Right heart catheterization with a PA pressure of 50/12 with a mean of 25, wedge of 15 and a cardiac index of 2.3 with a pulse of 51. 3. Hepatic ultrasound showing hepatomegaly patent but enlarged IVC, some gallbladder sludge and bilateral kidney cysts.
PA|pulmonary artery|PA|155|156|PRINCIPAL DIAGNOSIS|HOSPITAL COURSE: The patient was admitted to the hospital the day prior to the procedure for placement of lines. In the SICU under fluoroscopic guidance a PA catheter was placed in the left subclavian vessel. Preoperatively he was appropriate. His heart was functioning well. The following day he was taken to the operating room, and soon after induction and intubation and the patient's bilateral groin incisions the patient developed hypotension upon administration of Ancef.
PA|pulmonary auscultation|PA.|154|156|OBJECTIVE|Localized tenderness in the posterior cervical region in the left but no focal neurologic defects. No thyromegaly or bruits on neck exam. CHEST: Clear to PA. CARDIAC: No S3, S4, murmurs, or rubs. ABDOMEN: No organomegaly. Nontender. Scars from the laparoscopic cholecystectomy noted. No palpable aneurysm.
PA|posterior-anterior|PA|176|177|PLAN|In addition during the course of her hospital stay, her TSH was noted to be in the normal range. Renal ultrasound revealed normal sized kidneys and was otherwise unremarkable. PA and lateral chest x-ray showed mild cardiomegaly, some mild chronic fibrotic changes and otherwise was unremarkable. The patient will follow-up with Intermed regarding her renal disease and Dr. _%#NAME#%_ regarding her general medical problems.
PA|posterior-anterior|PA|139|140|PLAN|PLAN: _%#NAME#%_ _%#NAME#%_ is discharged to home. She is to follow-up with Dr. _%#NAME#%_ _%#NAME#%_ in two weeks where she should have a PA and lateral chest x-ray, lytes, creatinine, BUN, TSH, liver profile, and a CBC and follow-up. Follow-up with Dr. _%#NAME#%_ _%#NAME#%_ in one month regarding her mitral valve disease.
PA|pulmonary artery|PA|283|284|HOSPITAL COURSE|He was started on a diltiazem drip, and his atenolol was increased. The patient was seen by Cardiology who felt that he had congestive heart failure, left ventricular systolic function, likely cardiomyopathy which was nonischemic, left ventricular hypertrophy, mitral regurgitation, PA pressure 33 plus the right atrial pressure, moderate right ventricular diastolic dysfunction with a dilated inferior vena cava, chronic atrial fibrillation, and left bundle branch block.
PA|pulmonary artery|PA|269|270|PROCEDURES|2. Severe hypertension. 3. Severe mitral regurgitation. 4. Osteoporosis. PROCEDURES: 1. Coronary angiography and hemodynamic evaluation with right heart catheterization. Right heart catheterization shows right atrial pressure of 1, right ventricular pressure of 47/11, PA pressure of 48/16, with a pulmonary capillary wedge pressure of 29, with a large B-wave confirmed with a wedge saturation of 95%.
PA|posterior-anterior|PA|176|177|PROCEDURES|Indication: History of severe asthma in patient with Churg-Strauss. Findings: Opacification of the paranasal sinuses consistent with polyposis and chronic sinusitis. 2. Chest, PA and lateral. Indication: Patient with shortness of breath. Findings: Questionable nodular opacities in the right lower lung zone. These are most consistent with pneumonia. Short-term follow-up chest x-ray is suggested for further evaluation.
PA|posterior-anterior|PA|216|217|PHYSICAL EXAM|LABORATORY WORKUP: Remarkable for a somewhat elevated white count at 13.3 consistent of 77% neutrophils. Fragment D-dimer was elevated to 3.3, of questionable etiology. Basic metabolic panel was normal. Chest x-ray, PA and lateral, reportedly per the ER doctor seems to show signs of a right pulmonary abscess. A CT scan is currently pending with contrast to rule out pulmonary emboli.
PA|posterior-anterior|PA|119|120|PROCEDURES|DISCHARGE DIAGNOSIS: Urinary tract infection versus sterile pyuria. PROCEDURES: 1. CT of the head without contrast. 2. PA and lateral chest x-ray. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 61-year-old who was admitted with vague sensations of weakness and malaise, but did not have a syncopal episode.
PA|posterior-anterior|PA|159|160|ASSESSMENT AND PLAN|Repeat liver functions will be done to see if his bilirubin continues to climb. Also, if he has any complaints of worsening shortness of breath a chest x-ray, PA and lateral, will also be completed to rule out any type of pleural effusion. No other changes will be made at this time.
PA|physician assistant|PA.|207|209|HOSPITAL COURSE|HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was admitted and underwent gastric bypass. She had an excellent postoperative course and went home on _%#DDMM2003#%_. Follow up in one week with _%#NAME#%_ _%#NAME#%_, PA. MEDICATIONS: 1. Roxicet. 2. Vioxx.
PA|posterior-anterior|PA|150|151|HISTORY OF PRESENT ILLNESS|Admission exam was unremarkable with stable vital signs. Chest x-ray was suggestive of right middle lobe infiltrate. This was not borne out on repeat PA and lateral chest x-rays. Admission labs were unremarkable, except for a somewhat elevated creatinine of 2.5. Liver function tests were within normal limits.
PA|physician associates|PA)|83|85|PRIMARY PHYSICIAN|PRIMARY PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD (_%#CITY#%_ Sports Health & Wellness, PA) DISCHARGE DIAGNOSES: 1. Chronic colonic atony. 2. Mild anemia. 3. Asthma, well controlled.
PA|pulmonary artery|PA|203|204|OPERATIONS/PROCEDURES THIS ADMISSION|DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Congestive heart failure. OPERATIONS/PROCEDURES THIS ADMISSION: Coronary angiography, with results as follows: Hemodynamics measured: RA 16, TV 59/14, PA 59/23, mean of 39, and PCWP is 22. Sixth cardiac index was 1.92. PCI of the ostial mid and distal RCA. HISTORY OF PRESENT ILLNESS: In brief, the patient is a 76-year- old female with a history of coronary artery disease status post coronary angiogram in _%#MM2004#%_, which showed significant RCA lesions but the patient declined PCI at that time.
PA|posterior-anterior|PA|185|186|LABORATORY|CT scan of the abdomen by verbal report shows a few loops of small bowel with air fluid levels and ductal dilatation at the upper limits of normal without definite stone. Chest x- ray, PA and lateral, appears normal. A 12-lead EKG also appears entirely normal. ASSESSMENT: Diffuse upper abdominal pain particularly in the epigastrium, right upper quadrant, in a patient with abnormal liver function tests, questionable acute versus chronic LFT abnormalities.
PA|pulmonary artery|PA|374|375|HOSPITAL COURSE|Problem #2: Cardiovascular. The patient was assessed by serial troponins, all of which remained negative with levels of 0.13, 0.20, 0.22, and 0.17 in that order. A transthoracic echo was obtained and demonstrated a good ejection fraction of 74%, a structurally normal heart, normally arising coronary ostia, trace tricuspid regurgitation, trace pulmonary insufficiency, and PA pressure is measured at 16 mmHg plus CVP and good biventricular function. He was monitored on telemetry and did have some mild bradycardia throughout the night.
PA|posterior-anterior|PA|205|206|DISCHARGE DIAGNOSIS|The patient was treated with Omeprazole, Zofran and Phenergan. The patient responded poorly to this and return on the _%#DD#%_ with continued recurrent episodes of vomiting. Evaluation would show a normal PA and lateral chest x-ray, a normal flat plate and upright of the abdomen. Electrolytes were normal. Non-fasting sugar was 128, creatinine was 1.9, white count was 11,100, hemoglobin was 13.6, urinalysis was normal and urine culture was sterile.
PA|posterior-anterior|PA|194|195|STUDIES|SKIN: No evidence of skin rashes. STUDIES: His EKG showed a paced rhythm at a rate of 60. Chest x-ray, on the lateral, to me, looks like a retrocardiac infiltrate versus an effusion, but on the PA it appears more consistent with an infiltrate. INR 1.63. Myoglobin elevated at 76, troponin < 0.07. White cell count 16.5, hemoglobin 15.3, platelet count 173,000, MCV 93.
PA|physician associates|PA)|74|76|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, MD (France Avenue Family Physicians, PA) DISCHARGE DIAGNOSES: 1. Right shoulder arthroplasty. 2. Acute respiratory failure related to chronic obstructive pulmonary disease (COPD) exacerbation.
PA|posterior-anterior|PA|165|166|PLAN|PELVIC exam was deferred to the operating room. EXTREMITIES show no clubbing, cyanosis, or edema. ASSESSMENT: Micro-invasive cervical carcinoma. PLAN: 1) Will get a PA and lateral chest x-ray and EKG for preoperative purposes. 2) She understands the indication for the procedure which is to hopefully cure her micro-invasive cervical cancer and remove any residual dysplasia.
PA|physician assistant|PA|252|253|CONSULTS|A urine GC/chlamydia test was negative by PCR. Cervical wet prep revealed no clue cells, no Trichomonas, and no yeast. CONSULTS: A medicine consultation was performed by Dr. _%#NAME#%_ _%#NAME#%_. A vaginal exam was performed by _%#NAME#%_ _%#NAME#%_, PA for vaginal discharge. No masses or cervical motion tenderness was found. A cervical wet prep and urine GC/chlamydia were collected and were negative for infection as reported in the laboratory section above.
PA|posterior-anterior|PA|225|226|DISPOSITION|DISPOSITION: 1. The patient is to follow up with new primary care physician, Dr. _%#NAME#%_ _%#NAME#%_, at Fairview Ridges internal medicine clinic in one to two weeks, earlier p.r.n. 2. He should have follow-up chest x-ray, PA and lateral, in one week with results to private medical doctor for follow-up. 3. Outpatient follow up chest CT in three months to be ordered by patient's private medical doctor for follow-up of lung nodule.
PA|physician assistant|PA|183|184|DISCHARGE/FOLLOW-UP PLAN|15. Ventolin 2.5 inhaled q. 6 h. p.r.n. shortness of breath, or cough. DISCHARGE/FOLLOW-UP PLAN: 1. The patient said he has an appointment with his primary-care giver who is either a PA or a nurse practitioner in the Brainerd area at the VA Clinic up there. He will get the complete name and spelling for me prior to discharge, and I will send a copy of records with him to see this individual, who will assume his primary care.
PA|physician associates|PA)|70|72|PRIMARY PHYSICIAN|PRIMARY PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD (Diamond Women's Center, PA) DISCHARGE DIAGNOSES: 1. Atypical chest pain with negative stress echo during this hospitalization.
PA|posterior-anterior|PA|219|220|PLAN|Chest x-ray does show possible right middle lobe pneumonia with patchiness though this is not very impressive and the patient has been treated with two days of levofloxacin. We will continue this treatment and obtain a PA and lateral chest x-ray tomorrow morning and change to IV given the patient has had episodes of vomiting earlier today.
PA|posterior-anterior|PA,|128|130|IMAGING STUDIES|An oblique fracture through the distal fibula is also present with 20 degrees medial angulation at the fracture site. Follow up PA, lateral of the right ankle showing considerable reduction in the displacement of the comminuted fracture through the distal tibia and fibula.
PA|posterior-anterior|PA|270|271|PROCEDURES AND SIGNIFICANT LABORATORY VALUES|U/A on _%#DDMM2005#%_ showed glucose 50, blood small, leukocyte esterase negative, nitrite negative, white blood cells negative, rbc's negative. On _%#DDMM2005#%_, influenza A and B rapid antigen panel negative for influenza A, negative for influenza A. 2. Chest x-ray, PA and lateral, _%#DDMM2005#%_, showed clear chest. 3. Rapid strep A screen was negative. 4. Throat culture was significant for light growth of beta hemolytic strep group A.
PA|pulmonary artery|PA|226|227|DISCHARGE DIAGNOSES|4. Mild to moderate mitral regurgitation by cardiac catheterization. By echocardiogram, this was 2 to 3+ (moderate to moderately severe). 5. Moderately severe tricuspid regurgitation. 6. Moderate pulmonary hypertension with a PA systolic pressure of 39 mm of mercury plus right atrial pressure. 7. Atrial fibrillation with rapid ventricular response requiring up-titration of his Toprol XL and the addition of Digoxin.
PA|physician associates|PA)|119|121|PRIMARY CARE|CHIEF COMPLAINT: Hyperglycemia weakness. PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, MD (_%#CITY#%_ Sports Health & Wellness, PA) HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 73-year-old female who was just discharged from Fairview Southdale Hospital on _%#DDMM2006#%_ after admission for an exacerbation of chronic obstructive pulmonary disease (COPD).
PA|posterior-anterior|PA|663|664|HOSPITAL COURSE|Laboratory tests included CBC, platelet count, coagulation battery, fibrinogen, factor V, antithrombin-3, protein-C, protein-S, factor V Leiden, chemistry, basic metabolic panel, magnesium, phosphorus, serum electrophoresis, HDL, LDL, cholesterol, triglycerides, amylase, SGOT, bilirubin, alkaline phosphatase, thyroid function, CPK, aldolase, lipoprotein screen, virology titers for EBV IgG, EBV IgM, VBNA, EBV PCR quantitative, VZ, HSV, hepatitis profile for A, B, and C, HIV I and II, immunology, ABO type and screen, HLA A, B, C, and DR typing, PRA and antileukocytic antibody screening, quantitative immunoglobulin. Additional tests included: 1. Chest x-ray PA and lateral. 2. Stool guaiacs x 3. 3. A 12-lead EKG. 4. Echocardiogram. 5. Spine thoracic, lumbar, and hip x-rays. 6. Bone age for children.
PA|pulmonary artery|PA|188|189|HOSPITAL COURSE|He had an echocardiogram to assess cardiac function. The results of this echo showed good left ventricular function and ejection fraction of 66%. There was tricuspid regurgitation and the PA pressure was 32 mm of mercury. DISCHARGE MEDICATIONS: 1. G-CSF 130 mcg subcu daily to start on _%#MM#%_ _%#DD#%_, 2005, and to be continued until the counts recover.
PA|pulmonary artery|PA|384|385|HISTORY OF PRESENT ILLNESS|3. Pulmonary capillary wedge pressure of 34. 4. Cardiac index by Fick 1.92. HISTORY OF PRESENT ILLNESS: This is a 28-year-old gentleman with past medical history of nonischemic cardiomyopathy, probably viral, with an EF of 20% who was recently seen in the cardiology clinic on _%#MM#%_ _%#DD#%_, 2005. At that time, his right heart catheterization showed a wedge pressure of 17 and a PA pressure of 32 and an index of 2.4. His creatinine was 2.7. His Bumex was decreased to 0.5 mg p.o. b.i.d. from 1 mg p.o. b.i.d., and Coreg was increased to 6.25 mg p.o. b.i.d. Today, he presented for a scheduled right heart catheterization.
PA|pulmonary artery|PA|179|180|PROCEDURES|PROCEDURES: He did have a right heart catheterization to evaluate his hemodynamic and take an endomyocardial biopsy. The endomyocardial biopsy is pending. Cardiac output was 5.9, PA pressure was mildly elevated with a mean of 26 mmHg, pulmonary artery wedge pressure was 19 mmHg, and RA pressure was a mean of 9 mmHg.
PA|posterior-anterior|PA|204|205|LABORATORY|NEUROLOGIC: The patient is grossly nonfocal. SKIN: Skin is warm-to-hot to the touch, slightly flushed. No rash noted. LABORATORY: Chest x-ray shows hyperinflated lungs but no infiltrate identified on the PA and lateral. Influenza A and B are negative. Electrolytes are significant for a sodium of 135, potassium 2.5, chloride 100, bicarbonate 23, BUN 13, creatinine 0.93, glucose 113.
PA|pulmonary artery|PA|196|197|HOSPITAL COURSE|She did respond quite well to IV diuretics with significant improvement on physical exam the following day. She did get a right heart cath, day after admission after some diuresis, which did show PA pressures 71/12. This has been minimally improved from her previous right heart cath and this is after approximately 3 months of treatment with Bosentan.
PA|physician assistant|PA,|290|292|FOLLOWUP CARE|FOLLOWUP CARE: 1. Fairview Home Infusion will provide services to manage and disconnect the portable pump for the continuation of the 5-fluorouracil for the remaining portion of the 96-hour continuous infusion. 2. The patient will be seen in the clinic by _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, PA, on Tuesday, _%#MM#%_ _%#DD#%_, 2005. 3. The patient has a followup scheduled with Dr. _%#NAME#%_ on Wednesday, _%#MM#%_ _%#DD#%_, 2006. 4. In the interim, the patient will continue his daily radiation therapy as scheduled by the radiation oncology department.
PA|physician assistant|PA|181|182|DISCHARGE PLAN|Heart tones are regular in rate and rhythm with no S3, S4 or murmur auscultated. Abdomen is unremarkable. DISCHARGE PLAN: 1. The patient will follow up with a nurse practitioner or PA at Minnesota Heart Clinic in two weeks for right groin check. I will have a basic metabolic panel drawn that day to assess his kidney function and potassium level given his change in ACE inhibitor.
PA|pulmonary artery|PA|146|147|PROBLEM #1|These pressors were weaned off overnight. The patient had a Swan- Ganz placed initially at admission. The patient's wedge pressure was 18 and the PA pressures were 34/10. The patient was diuresed overnight; however, after that further cardiac interventions were not performed immediately because of the concerning neurological status as follows.
PA|posterior-anterior|PA|174|175|ADMISSION HISTORY|DISCHARGE DIAGNOSIS: 1. Dyspnea. 2. Severe chronic obstructive pulmonary disease. Imaging studies and procedures performed during the hospitalization: Chest x-ray performed, PA and lateral, performed on _%#MM#%_ _%#DD#%_, 2006; impression is chronic interstitial lung disease. No active disease. ADMISSION HISTORY: This is a 69-year-old female patient with severe chronic obstructive pulmonary disease, GERD, and anxiety disorder, who presents to the ER today with dyspnea.
PA|physician assistant|PA|194|195|FOLLOW-UP|FOLLOW-UP: 1. Follow up with Dr. _%#NAME#%_ _%#NAME#%_ in two to four weeks at the Community Clinic, south _%#CITY#%_. 2. Follow up with Dr. _%#NAME#%_ in two to three months. 3. Follow up with PA or nurse practitioner at Minnesota Heart Clinic in one to two weeks. 4. Lipid profile in six to eight weeks' time at Minnesota Heart Clinic.
PA|pulmonary artery|PA|265|266|MAJOR IMAGING AND PROCEDURES|The right coronary artery was normal, the left main was normal, the circumflex was normal, the LAD had a 50 to 60% lesion. No intervention was done. Also, a right heart catheterization was done, which shows a mean right atrial pressure of 14, RV pressure of 55/14, PA pressure of 50/28 with a mean of 38, a wedge pressure of 29, and a cardiac index of 2.0 by thick. 2. Transthoracic echocardiogram was done on _%#DDMM2006#%_ showing mild LV dilatation, EF of 20%, moderate mitral regurgitation, pulmonary artery pressures were normal, and no pericardial effusions.
PA|posterior-anterior|PA|196|197|FOLLOW-UP PLANS|Potassium may need to be replaced, and the patient's creatinine should be closely monitored. 6. TSH, free T4 and total T3 should be checked approximately six weeks after discharge. 7. Chest x-ray PA and lateral prior to Dr. _%#NAME#%_'s appointment. CODE STATUS: Full code. The patient has a health care directive in the chart.
PA|posterior-anterior|PA|112|113|PROCEDURES PERFORMED DURING STAY|DISCHARGE DIAGNOSES: 1. Pneumonia. 2. Gastroenteritis, viral. PROCEDURES PERFORMED DURING STAY: 1. Chest x-ray, PA and lateral, _%#DDMM2006#%_: Impression of left lower lobe patchy opacity. 2. Bilateral venous ultrasound of lower extremities, _%#DDMM2006#%_: Negative for deep venous thrombosis (DVT).
PA|pulmonary artery|PA|266|267|PROCEDURES PERFORMED ON ADMISSION|DISCHARGE DIAGNOSES: 1. Intractable slow VT. 2. History of idiopathic dilated cardiomyopathy. PROCEDURES PERFORMED ON ADMISSION: Right heart catheterization was performed during the current admission, which showed a mean artery pressure of 10, RV pressure of 60/10, PA pressure of 60/30 and a mean wedge pressure of 15. BRIEF HISTORY OF PRESENTING ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is a 61-year-old with a history of idiopathic dilated cardiomyopathy and bicuspid aortic valve, status post St. Jude aortic valve replacement and aortic root repair in _%#MM#%_ 2005, status post permanent pacemaker placement with ICD on _%#DDMM2005#%_ and AP ablation of right ventricular upper tract VT on _%#DDMM2005#%_.
PA|pulmonary artery|PA|187|188|HOSPITAL COURSE|Her PA pressures were 44/26 with a wedge of 22 with a CVP of 10 and her heart rate of 120 to 139. Her cardiac index (_______________) was 3. Nursing made aggressive attempts to bring her PA pressures down and on the day 2 of admission, she was found to have her Nipride running at 7 mcg/kg/minute. This was quickly weaned, and captopril instituted with hydralazine as needed.
PA|physician assistant|PA|139|140|FOLLOW-UP|6. Nystatin swish and swallow qid. 7. Paxil 20 mg p.o. daily. 8. Magnesium oxide 400 mg p.o. b.i.d. FOLLOW-UP: The patient will be seen by PA _%#NAME#%_ _%#NAME#%_ in the Outpateint Clinic on Monday, _%#DDMM2006#%_.
PA|physician assistant|PA|262|263|HISTORY OF PRESENT ILLNESS|She has been admitted multiple times in the past as noted on her previous discharge summaries and admissions in the medical record. She denies any current hallucinations or syncope. PAST MEDICAL HISTORY: Patient's primary care provider is _%#NAME#%_ _%#NAME#%_, PA at Park Nicollet in _%#CITY#%_. 1. History of withdrawal in the past. Self-reported history of withdrawal seizures per witness from family; however this has never been documented medically as noted in prior discharge summaries.
PA|posterior-anterior|PA|177|178|MAJOR TESTS AND PROCEDURES PERFORMED|DISCHARGE DIAGNOSES: 1. Acute asthma exacerbation. 2. Status post TAHBSO for grade I endometrioid cancer. 3. Hypertension. MAJOR TESTS AND PROCEDURES PERFORMED: 1. Chest x-ray, PA and lateral showing right middle lobe subsegmental atelectasis, otherwise clear lungs. BRIEF HISTORY OF PRESENT ILLNESS: This is a 47-year-old lady with history of asthma and status post TAHBSO who came to the Emergency Room after having increasing shortness of breath over the past two to three days.
PA|physician assistant|PA|188|189|FOLLOW-UP|8. Aspirin 81 mg p.o. q. day 9. Sublingual nitroglycerin 0.4 mg x3 doses p.r.n. chest discomfort FOLLOW-UP: 1. The patient will follow up with nurse practitioner or _%#NAME#%_ _%#NAME#%_, PA in 1 to 2 weeks' time, follow up with Dr. _%#NAME#%_ _%#NAME#%_ in 2 to 3 months' time, follow up with Dr. _%#NAME#%_ _%#NAME#%_ in 1 to 2 weeks' time. 2. Echocardiogram in 1 month.
PA|posterior-anterior|PA|191|192|HOSPITAL COURSE|His hemoglobin was 15, white count 5800, ketones were negative, electrolytes were normal, blood sugar was 350, creatinine was 0.107, hepatic panel normal, and ethanol level was unmeasurable. PA and lateral chest x-ray was normal. TSH was normal at 2.26 and D-dimer was 0.2. The patient was admitted and by the morning of the _%#DD#%_, he is eating without difficulty and his mental status and neurologic exam were normal.
PA|posterior-anterior|PA|101|102|PROCEDURES THIS ADMISSION|DISCHARGE DIAGNOSES: 1. Atypical chest pain. 2. Anxiety. 3. Hypertension. PROCEDURES THIS ADMISSION: PA and lateral chest x-ray, _%#DDMM2007#%_. Significant findings include normal fields. BRIEF HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 51-year-old male who was recently hospitalized on the Cardiology Service and is status post left heart catheterization with PCI to the LAD, who returns to the emergency department with atypical epigastric chest discomfort and associated symptoms of anxiety and shortness of breath.
PA|pulmonary artery|PA|186|187|PROCEDURES PERFORMED DURING THIS HOSPITLIZATION|5. Mechanical valve. 6. Gout flare. PROCEDURES PERFORMED DURING THIS HOSPITLIZATION: 1. Right heart catheterization on _%#DDMM2007#%_ that revealed a mean right atrial pressure of 19, a PA pressure of 44/20 with a wedge of 22, and a cardiac index of 1.4. 2. Right heart catheterization on _%#DDMM2007#%_, which showed a mean right atrial pressure of 10, a pulmonary artery pressure of 43/25, a wedge pressure of 20, and a cardiac index of 3.2. Of note, this was on milrinone.
PA|posterior-anterior|PA|173|174|MAJOR TESTS AND PROCEDURE PERFORMED|DISCHARGE DIAGNOSES: 1. Sickle cell pain crisis. 2. Possible pneumonia. 3. Evaluation for possible acute chest syndrome. MAJOR TESTS AND PROCEDURE PERFORMED: 1. Chest x-ray PA and lateral shows minimal left basilar atelectasis, otherwise no significant interval change. Of note, there is evident sclerosis about the left humeral head.
PA|posterior-anterior|PA|155|156|KEY IMAGING STUDIES AND PROCEDURES PERFORMED DURING THIS HOSPITALIZATION|Old infarct in the left middle cerebral artery territory. No new infarct. Probably left mastoiditis. 2. Chest x-ray performed on _%#DDMM2007#%_. Findings: PA and lateral views of the chest. Lungs are clear. Heart is normal size. No effusions evident and no pneumothorax. 3. Renal ultrasound performed on _%#DDMM2007#%_. Impression: Indistinctness to the cortex and medullary portions of both kidneys, which could be secondary to renal parenchymal disease.
PA|physician assistant|PA|308|309|PHYSICIAN FOLLOW-UP|6. Potassium chloride (K-Dur) 40 mEq p.o. for 4 days. CHANGE OF MEDICATIONS: The patient used to take 2000 mg of Hydrea, but we are discharging the patient on 1000 mg of Hydrea. DIET: Regular diet. ACTIVITY: As tolerated. PHYSICIAN FOLLOW-UP: The patient is supposed to follow up with _%#NAME#%_ _%#NAME#%_, PA on _%#DDMM2007#%_ at 02:30 p.m. at Masonic Cancer Center.
PA|posterior-anterior|PA|174|175|LABORATORY|SKIN: Chest wall lesions as noted above. LABORATORY: The results are pending at the time of this dictation and include hemoglobin, WBC, metabolic panel, and ALT. Chest x-ray PA and lateral is done and independently reviewed by me. There are no active infiltrates identified. This does raise a question of shaggy right heart border concerning for an underlying process, possibly lymphangitic involvement.
PA|posterior-anterior|PA|137|138|RADIOGRAPHIC STUDIES DURING THIS ADMISSION|PRINCIPLE DIAGNOSIS: Aspiration pneumonia. SECONDARY DIAGNOSIS: Prader-Willi syndrome. RADIOGRAPHIC STUDIES DURING THIS ADMISSION: Chest PA and lateral x-ray on _%#DDMM2007#%_. Impression: 1. Right pneumonia. 2. Small right pleural effusion. HISTORY OF PRESENT ILLNESS: The patient is a 24-year-old man with Prader-Willi syndrome, who has a history of recurrent aspiration pneumonias.
PA|posterior-anterior|PA|253|254|PROCEDURES PERFORMED DURING THIS HOSPITALIZATION|OTHER DIAGNOSES: 1. Status post renal transplant in 1999 secondary to glomerulonephritis, status post renal transplant secondary to glomerulonephritis in 1999. 2. Hypertension. PROCEDURES PERFORMED DURING THIS HOSPITALIZATION: Includes: 1. Chest x-ray, PA and lateral done on _%#DDMM2007#%_. Findings are mild cardiomegaly. Tiny right pleural effusion. Mild pulmonary venous hypertension. 2. Pulmonary function tests on _%#DDMM2007#%_. Findings are FEV1 and FVC were reduced.
PA|posterior-anterior|PA|140|141|LABORATORY DATA|AST 28. ALT 23. Total bilirubin 0.9. Total protein 6.9. ESR 59. CRP 13.6. Pulmonary function tests show: FVC 2.45 (74%). FEV1 1.29 (43%). A PA and lateral chest x-ray showed new patchy air space disease in the left perihilar and left basilar regions compatible with focal area of bronchopneumonia.
PA|posterior-anterior|PA|190|191|PLAN|At the time of surgery we will decide whether the patient needs left ureteral interposition, possible Boari flap, or possible nephroureterectomy. In regards to pre-op the patient did have a PA and lateral chest x-ray performed in house which showed pleural calcifications of the upper lung consistent with pulmonary fibrosis, and some pleural calcifications over the left hemidiaphragm that was consistent with possible asbestos exposure.
PA|posterior-anterior|PA|190|191|ASSESSMENT AND PLAN|He will under DFT testing with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2002. His echocardiogram will be repeated on _%#MM#%_ _%#DD#%_, 2002. His DFT testing was explained to him. A chest x-ray PA and lateral will be obtained on admission to assess the integrity of his leads. I will plan on seeing him in follow up on _%#MM#%_ _%#DD#%_, 2002 to review his echocardiogram with him.
PA|posterior-anterior|PA|205|206|PROCEDURES|3. Urine culture on _%#DDMM2002#%_ grew greater than 10,000 colonies of E. coli that was susceptible to Ciprofloxacin, gentamicin, nitrofurantoin, cefazolin, but resistant to ampicillin, carbenicillin. 4. PA and lateral chest x-ray on _%#DDMM2002#%_ showed surgical changes of coronary artery bypass surgery, a right convexed curvature of the thoracic spine but otherwise unremarkable.
PA|physician assistant|PA,|149|151|FOLLOW-UP APPOINTMENTS AND REFERRALS|FOLLOW-UP APPOINTMENTS AND REFERRALS: 1. Follow up with primary cardiologist, Dr. _%#NAME#%_, and with primary care provider, _%#NAME#%_ _%#NAME#%_, PA, in 3 to 5 weeks. 2. Follow up with Dr. _%#NAME#%_ in the Neurology Clinic at F-UMC in 4 weeks.
PA|UNSURED SENSE|PA|151|152|PHYSICAL EXAMINATION|NECK: No palpable masses, no lymphadenopathy. Carotids full bilaterally, no bruit, no jugular venous distention, no thyromegaly. LUNGS: Good air entry PA and posteriorly. HEART: Regular, no gallop rhythm, no rub, S3 or S4, no appreciable murmur. ABDOMEN: Soft without tenderness, benign exam; I could not feel masses or organomegaly.
PA|posterior-anterior|PA|95|96|PLAN|6. History of melanoma. 7. Blood pressure control adequate. PLAN: 1. Dialysis today. 2. Repeat PA and lateral chest x-ray. 3. Stool for C-difficile. 4. Supportive care. 5. Consider treatment for C-difficile after stool is sent.
PA|posterior-anterior|PA|227|228|ASSESSMENT AND PLAN|In addition, her LDL is 151. At this point will get cardiac enzymes x 3 and plan to do a stress echo in the morning if these are negative. The patient also has some rales but does not have any symptoms. Will get a chest x-ray, PA and lateral, to evaluate this. Will also get a BNP added to the a.m. labs in the morning. Will consider cardiac echo tomorrow for further evaluation of this if need be.
PA|posterior-anterior|PA|91|92|IMAGING DONE DURING HOSPITALIZATION|DISCHARGE DIAGNOSES: 1. Pneumonia 2. Hypoxia IMAGING DONE DURING HOSPITALIZATION: 1. Chest PA and Lateral done on _%#DDMM2003#%_. Pulmonary vessels within normal limits. Increased patchy air space density in left lower lobe and slight increased density in the right middle lobe, when compared to the previous linear lung markings at the left apex which likely are artefactual.
PA|pulmonary artery|PA|309|310|HOSPITAL COURSE|He stabilized the day following and was slowly weaned off nitric oxide. At this time, his pulmonary hypertension is still unexplained but it is improved with the latest cardiac echo being today done off nitric oxide with a half a nitro patch changed daily at 0.1 mg per hour and Viagra at 3 mg p.o. q.8h. His PA pressures were 40 plus CVP, and he was noted to have a coarct with a gradient of 6, which is clinically insignificant.
PA|pulmonary artery|PA|257|258|PAST MEDICAL HISTORY|His last echo was in _%#MM2002#%_, which showed mild LV dilatation, with moderate to severe decrease in LV function, with an EF of 30%. He had a coronary angiogram done in _%#MM2002#%_, which revealed normal coronary but severe pulmonary hypertension, with PA pressures of 67/37, with a measure of 23. No rejection per his last biopsy done in _%#MM2003#%_. 2. DVT. 3. Chronic renal insufficiency. 4. History of renal stones.
PA|pulmonary artery|PA|321|322|OPERATIONS/PROCEDURES PERFORMED|6. New York class 3-4 heart failure needing intermittent inotropic support. OPERATIONS/PROCEDURES PERFORMED: The patient had a right heart catheterization which showed on _%#MM#%_ _%#DD#%_, 2003, RA pressures of 13 with an RV of 38/16, PA pressure of 39/23 with a wedge of 18, cardiac output of 2.9, a Fick of 2.5 with a PA sat of 37.9%, hemoglobin 9.9. The patient had an echocardiogram done which on _%#MM#%_ _%#DD#%_, 2003, showed moderate LV dilation, severely decreased left ventricular function estimated at 20%, moderate right ventricular dilation, severely decreased left ventricular function, increase in right systolic function to 40+ right atrial mean, and moderate to severe tricuspid regurg.
PA|pulmonary artery|PA|166|167|PRINCIPAL DIAGNOSIS|Surveillance of her RV to PA conduit has revealed significant stenosis. She now presents for correction. She was admitted on _%#MM#%_ _%#DD#%_, 2003. Underwent RV to PA conduit change with placement of a 20-mm Gore- Tex vascular graft. On postoperative day #1, the patient was noted to have an increasing right hemopneumothorax.
PA|posterior-anterior|PA|169|170|ASSESSMENT|SKIN is pink and dry. ASSESSMENT: While his chest x-ray in the Emergency Room suggested a right lower lobe pneumonia, his clinical course does not, and I think a repeat PA and lateral good quality chest x-ray would help resolve this. In the mean time because of his known tendency to aspirate, I do recommend switching his coverage from Rocephin and Zithromax to Zosyn and Zithromax to better cover possible aspiration.
PA|pulmonary artery|PA|196|197|PROBLEM #2|After a period of time he was four kilos up and he was secondarily diuresed aggressively. His echocardiogram on this admission showed normal LV function, but evidence of diastolic dysfunction and PA pressures of 25 plus RA with LVH. His Imdur was increased from 30 mg a day to 60 mg a day. His hydralazine was also maximized at 20 mg p.o. t.i.d. with hopes of significant after load reduction.
PA|pulmonary artery|PA|145|146|CLINICAL NOTE|She came in _%#DDMM2003#%_ and underwent a complete repair of tetralogy of flow with removal of the shunt and completion of repair with an RV to PA homograft. The patient had what we felt was a transfusion reaction at the end of the operation. She had some ascites, erythema, and pulmonary edema, and difficulty with mechanical ventilation.
PA|pulmonary artery|PA|256|257|HOSPITAL COURSE|There was no mitral regurgitation. Ejection fraction was estimated at 25- 30%. Left ventricular end-diastolic pressure (LVEDP) was normal at approximately 9.0 with pulmonary capillary wedge pressure (PCWP) of 7.0. Right heart pressures were also normal at PA of 18/5 and a right atrial pressure (RAP) of 7.0- to 8.0-mmHg. The patient tolerated the left and right heart catheterization well without complications.
PA|posterior-anterior|PA|159|160|DISCHARGE MEDICATIONS|10. Risperdal 0.25 mg 1 p.o. b.i.d. 11. K-Dur 20 mEq p.o. daily. The nursing home is to keep the sats at more than or equal to 95%. An outpatient chest x-ray, PA and lateral, in four weeks to follow up on her right-sided pleural effusion. She did have a chest x-ray done on _%#MM#%_ _%#DD#%_, 2005, during her hospitalization that showed a moderate right pleural effusion, although no comparison was done.
PA|posterior-anterior|PA|119|120|OPERATIONS/PROCEDURES PERFORMED|SECONDARY DIAGNOSES: 1. Multiple sclerosis. 2. Status post heart transplant. OPERATIONS/PROCEDURES PERFORMED: 1. Chest PA and lateral. This showed cardiomegaly, no overt pulmonary edema. Lungs are essentially clear. 2. CT abdomen with contrast. This showed interval resolution of a fluid collection in the subcutaneous tissues surrounding the suprapubic catheter.
PA|physician assistant|PA|166|167|HOSPITAL COURSE|He is being discharged to a nursing home. We will make follow-up arrangements if he is unable to be transported to our facility for routine follow up. We will have a PA visit for routine postoperative care.
PA|physician assistant|PA|267|268|HISTORY|HISTORY: Ms. _%#NAME#%_ is a 46-year-old white female admitted through Fairview _%#CITY#%_ Emergency Room yesterday evening with complaints of right flank pain and fever. The patient noted the onset of the above complaints along with some dysuria on Friday and saw a PA at _%#TOWN#%_ _%#TOWN#%_ Urgent Care. She was started empirically on Levaquin. We do not have the culture result of that visit. However, the patient's fever and pain persisted over the weekend.
PA|physician associates|PA|62|63|PLAN|_%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_, MD Ob Gyn West PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_, Suite 130 _%#CITY#%_, MN _%#55400#%_ Dear Dr. _%#NAME#%_: Thank you for referring your patient, _%#NAME#%_ _%#NAME#%_, for genetic counseling at the Maternal Fetal Medicine Center at Fairview Southdale Hospital on _%#MM#%_ _%#DD#%_, 2006.
PA|physician associates|PA)|80|82|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD (Consultants-Internal Medicine, PA) REASON FOR CONSULTATION: We were asked to see _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ in orthopedic consultation at the request of Dr. _%#NAME#%_.
PA|physician associates|PA)|74|76|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, MD (France Avenue Family Physicians, PA) FINAL DIAGNOSES: 1. Acute myelogenous leukemia (AML) in first complete remission. 2. Cardiomyopathy probably due to medication cause.
PA|physician associates|PA|89|90|ASSESSMENT/PLAN|_%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_, MD Obstetrics/Gynecology and Infertility, PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_, W400 _%#CITY#%_, MN _%#55400#%_ Dear Dr. _%#NAME#%_, Thank you for the kind referral of your patient, _%#NAME#%_ _%#NAME#%_, who was seen along with her husband, _%#NAME#%_, for genetic counseling at the Maternal Fetal Medicine Center at Fairview Southdale Hospital on _%#DDMM2006#%_.
PA|physician assistant|PA|211|212|PLAN|He was not thought to have symptoms likely to represent coronary artery disease. Dr. _%#NAME#%_ did not think it necessary to pursue additional stress testing at that time. He was seen by _%#NAME#%_ _%#NAME#%_, PA in our office, who did identify the nonsustained ventricular tachycardia on a Holter monitor. She repeated his echo which has not significantly changed and actually shows improvement in cardiac function since the previous echo and planned to do a nuclear stress test for him this coming Thursday.
PA|physician assistant|PA|205|206|ASSESSMENT AND PLAN|EKG on _%#DDMM2006#%_ was normal. ASSESSMENT AND PLAN: 1. Right hallux valgus repair per Dr. _%#NAME#%_. 2. Hypertension, probably secondary to pain medication and blood pressure medication. Per patient's PA _%#NAME#%_ at Dr. _%#NAME#%_'s office, we agreed to hold Coreg for systolic blood pressure less than 95 and agreed to decrease Lisinopril to 10 mg p.o. q. a.m.
PA|physician associates|PA|74|75|ASSESSMENT AND PLAN|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, WHCNP Clinic Sofia OB-GYN, PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 490 _%#CITY#%_, Minnesota _%#55400#%_ Dear Ms _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2007. She came to clinic with her husband, _%#NAME#%_, for genetic consultation and first trimester screening due to advanced maternal age in pregnancy.
PA|physician associates|PA|80|81|ASSESSMENT AND PLAN|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, MD Southdale OB-GYN Consultants, PA 3625 West _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 100 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2007.
PA|pulmonary artery|(PA)|135|138|REASON FOR CONSULTATION|1. Diabetes. 2. Neuropathy. 3. Hypertension. 4. AV fistula repair in the right femoral area. 5. Cataract surgery. Her pulmonary artery (PA) pressures have been at 100 (systolic)/27 (diastolic). ALLERGIES: The patient has allergies to penicillin and Levaquin.
PA|physician associates|PA|46|47||_%#NAME#%_ _%#NAME#%_, MD Clinic Sofia Ob-Gyn PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_, Suite #490 _%#CITY#%_, MN _%#55400#%_ Dear Dr. _%#NAME#%_: Thank you for the referral of your patient _%#NAME#%_ _%#NAME#%_, who was seen along with husband, _%#NAME#%_, on _%#DDMM2007#%_ at the Maternal-Fetal Medicine Center at the University of Minnesota Medical Center, Fairview.
PA|posterior-anterior|PA|157|158|ASSESSMENT|There is no forearm or elbow pain. ASSESSMENT: This is an 18-year-old male with a probable fracture of the metacarpals or carpal bones. PLAN: We will obtain PA and lateral views of the wrist and hand on the right and will follow up with this patient tomorrow with a treatment plan depending on x-ray findings.
PA|physician associates|PA|62|63|ASSESSMENT AND PLAN|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, MD OB GYN West PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 103 _%#CITY#%_, MN _%#55400#%_ Dear Dr. _%#NAME#%_: Thank you for the referral of your patient, _%#NAME#%_ _%#NAME#%_, who was seen along with her friend _%#NAME#%_ on _%#DDMM2007#%_ at the Maternal-Fetal Medicine Center at the University of Minnesota Medical Center, Fairview.
PA|physician associates|PA|80|81|ASSESSMENT AND PLAN|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, MD Southdale OB-GYN Consultants, PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 100 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2007.
PA|pulmonary artery|PA|206|207|LABORATORY|An echo performed during his recent hospital admission showed severely decreased LV function with an EF of 10%, mod TR, mod MR. The patient has had a Swans-Ganz catheter which shows a cardiac index of 1.3. PA pressures are 63 by 40, CMP of 16. ASSESSMENT/PLAN: A 42-year-old gentleman with dilated cardiomyopathy with severely decompensated congestive heart failure.
PA|physician associates|PA)|78|80|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD (Southdale Internal Medicine, PA) REASON FOR CONSULTATION: Thank you for asking me to evaluate this 81-year-old male with gram-negative rod septicemia, right lower lobe pneumonia, respiratory failure and non-Hodgkin's lymphoma. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 81-year-old male who had transformation of chronic lymphocytic leukemia (CLL) to non-Hodgkin's lymphoma or Richter's transformation in _%#MM#%_ of 2006.
PA|physician assistant|PA.|123|125|PHYSICAL EXAMINATION|No edema or swelling reported. PHYSICAL EXAMINATION: He is examined about 6 o'clock tonight. He was examined earlier by my PA. He has definitely made improvements by both his report and my assistant's report throughout the day. It seemed to correlate with administration of intravenous Solu- Medrol.
PA|physician associates|PA)|74|76|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, MD (France Avenue Family Physicians, PA) ADMISSION DIAGNOSIS: Dysarthria, dysphagia and possible transient ischemic attack. DISCHARGE DIAGNOSIS: Myasthenia gravis. CONSULTATIONS: Neurology consultation. (Please see separately dictated note in this regard.)
PA|posterior-anterior|PA|177|178|LABORATORY DATA|Urinalysis done today does show bacteria and positive nitrites, consistent with urinary tract infection. EKG is normal sinus rhythm at 70 with no ischemic changes. Chest x-ray, PA and lateral, is normal. IMPRESSION: 1. Acute cholecystitis with stones present.
PA|physician associates|PA|70|71|ASSESSMENT AND PLAN|_%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_, MD Clinic Sofia Ob-Gyn PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_, Suite 490 _%#CITY#%_, MN _%#55400#%_ Dear Dr. _%#NAME#%_: Thank you for referring your patient, _%#NAME#%_ _%#NAME#%_, who was seen, along with her brother and an interpreter, for genetic counseling at the Maternal Fetal Medicine Center at Fairview Southdale Hospital on _%#MM#%_ _%#DD#%_, 2006.
PA|posterior-anterior|PA|127|128|PHYSICAL EXAMINATION|ABDOMEN - obese, there is no guarding or tenderness. EXTREMITIES - show no cyanosis, clubbing or edema. SKIN - pink and dry. A PA and lateral chest x-ray which I ordered and reviewed, showed a small left lower lobe infiltrate associated with left lower lobe atelectasis.
PA|physician associates|PA)|80|82|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD (Consultants-Internal Medicine, PA) CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a pleasant 36-year-old female with a history of hypertension and also spontaneous coronary dissection in the left circumflex territory which was treated medically.
PA|posterior-anterior|PA|102|103|LABORATORY|Peripheral pulses are palpable. NEUROLOGIC: The patient is grossly nonfocal. LABORATORY: Chest x-ray, PA and lateral, shows no acute infiltrate or effusion. She had a left knee x-ray due to a popping sound and pain. This does not show any acute fracture. PTT is 25, INR 1.
PA|pulmonary artery|PA|188|189|HISTORY OF PRESENT ILLNESS|The patient was diagnosed with pulmonary hypertension shortly after the birth of her third child. She underwent a right heart catheter at Abbott-Northwestern Hospital. Was found to have a PA pressure greater than 110. She was treated for a while with Revatio and bosentan, but eventually clinically worsened.
PA|physician associates|PA|62|63|ASSESSMENT/PLAN|_%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_, MD OB-GYN West PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2006.
PA|pulmonary artery|PA|285|286|PAST  MEDICAL HISTORY|8. Hypertension. 9 Congestive heart failure. 10. Hand surgery. Prior to surgery he had a dilated left ventricle with significant moderate to severe mitral regurgitation. Ejection fraction was about 25% with right ventricular systolic dysfunction and severe pulmonary hypertension with PA pressures in the 60s. He had significant tricuspid valve regurgitation as well. PREOPERATIVE MEDICATIONS: Allopurinol, cyclosporine, Vasotec, Nexium, Zetia, ferrous sulfate, Toprol-XL, CellCept, Pravachol, prednisone, and Demadex.
PA|pulmonary artery|PA|245|246|ALLERGIES|His pulmonary arteries are large. ASSESSMENT AND PLAN: A 69-year-old with emphysema, secondary pulmonary hypertension due to his emphysema, and obstructive sleep apnea. His obstructive sleep apnea is now treated, and he still has extremely high PA pressures. 1. Emphysema: I recommend to continue on inhalers with his Advair and Combivent. 2. Pneumonia: The patient has community acquired pneumonia. I recommend ceftriaxone and azithromycin.
PA|physician associates|PA|72|73|ASSESSMENT AND PLAN|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, WHCNP OB/GYN Specialists PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 600 _%#CITY#%_, Minnesota _%#55400#%_ Dear Ms _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2007. She came to clinic for genetic consultation and first trimester screening due to advanced maternal age in pregnancy.
PA|posterior-anterior|PA|335|336|LABORATORY DATA|No edema. No appreciable left calf tenderness through the Ace wrap. GENITALIA/RECTAL: Exam deferred. NEUROLOGIC: Grossly nonfocal. LABORATORY DATA: Available laboratory data from _%#MMDD#%_ includes hemoglobin of 9.9. Sodium was 138, potassium 3.8, chloride 105, CO2 27, anion gap 5.2, glucose 125, BUN 9, creatinine 0.8. Chest x-ray, PA and lateral on _%#MMDD#%_ demonstrates the tip of the right PICC line projecting over the right atrium; otherwise, no active disease.
PA|pulmonary artery|PA|103|104|LABORATORY AND DIAGNOSTIC DATA|Creatinine 0.57. Arterial blood gas 7.17/102/86/35. Echocardiogram shows normal ejection fraction 70%, PA pressure is 90- 100. No effusions. No valvular disease detected. RV is moderately dilated with decreased RV function. PHYSICAL EXAMINATION: Mechanical ventilator assist control, tidal volume 600, FI02 50%, rate is 16, PEEP +5.
PA|posterior-anterior|PA|145|146|IMPRESSION|We will get a CBC, BMP, liver panel, INR, and troponin currently. We will also have the patient get an EKG tonight. We will repeat a chest x-ray PA and lateral. We will continue the patient on his home medications and will also allow the patient to have clear liquids as he tolerates them.
PA|posterior-anterior|PA|156|157|IMAGING|These values are consistent with previous admissions. Electrolyte panel only demonstrates bicarbonate of 34 as the only abnormality. IMAGING: Patient had a PA and lateral chest x-ray performed overnight which demonstrates increased nodules but in number of size in the left lung with complete opacification of the right lung.
PA|pulmonary artery|PA|116|117|PHYSICAL  EXAMINATION|Blood pressure also variable at about 100/60 with augment pressure of about 110. His aortic balloon pump is at 1:1. PA pressure 36/21 and RA pressure 10. HEENT: No evidence of head trauma. Pupils are round and reactive, about 3.0-mm in size.
PA|pulmonary artery|PA|167|168|REVIEW OF SYSTEMS|Concentric left ventricular hypertrophy, bi-atrial enlargement, normal left ventricular function, moderate tricuspid regurgitation with severe pulmonary hypertension, PA pressure estimated at 67+CVP. Mild mitral regurgitation and PR. A 12 lead EKG shows atrial fibrillation, occasional PVC.
PA|physician assistant|PA,|146|148|ASSESSMENT|No overt evidence of tinea pedis. Recommended washing of her slippers. 4. Issue of unprotected sexual activity. I will ask _%#NAME#%_ _%#NAME#%_, PA, to perform pelvic exam on _%#DDMM2002#%_. Check urine pregnancy test. 5. Asthma, well-compensated. 6. Exogenous obesity. PLAN: 1. Review screening labs as ordered. 2. Pelvic exam by Physician Assistant, as above.
PA|pulmonary artery|PA|225|226|PAST MEDICAL HISTORY|He was electively intubated, being unable to tolerate BiPAP. PAST MEDICAL HISTORY: Significant for severe pulmonary disease including history of severe asthma, obstructive sleep apnea, severe pulmonary hypertension. Previous PA pressure was estimated at 69 mmHg plus CVP, dilated IVC, evidence of pressure overload from the right ventricle, flattening of ventricular septum, right ventricular enlargement.
PA|physician assistant|PA|225|226|IMPRESSION|She likely has some volume overload issues. She has a low ejection fraction which may be contributing to this. She likely has a moderate left effusion. We will get a CT and likely therapeutic tap. I spoke to Dr. _%#NAME#%_'s PA in this regard. Her history is also consistent with obstructive sleep apnea. I would recommend an outpatient polysomnogram and we will arrange for that.
PA|pulmonary artery|PA|201|202|HISTORY OF PRESENT ILLNESS|An echocardiogram shows moderate to severe tricuspid insufficiency and a PFO as well as normal left ventricular function and size with concentric LVH. She also has moderate pulmonary hypertension with PA pressures in the 60's. She gave a history then as now of having had an injury to the right leg at Easter time with discomfort and reddening of the area above the right ankle with swelling of both legs intermittently.
PA|pulmonary artery|PA|168|169|PHYSICAL EXAMINATION|She is still intubated. She is just now starting to wake up and just starting to follow some simple commands. She is in a sinus rhythm at 65. Blood pressure is 122/64. PA pressure is 28/13. SKIN: Exam is benign. HEAD, EYES, EARS, NOSE AND THROAT: She has mild arcus. NECK: Is relatively supple without thyromegaly or adenopathy. She has a Swan-Ganz catheter in her right neck.
PA|pulmonary artery|PA|223|224|ASSESSMENT/PLAN|To support his blood pressure, we will place him on Levophed as he has an adequate CVP and appears to be volume resuscitated. 2. Pulmonary hypertension. Echo during his hospital stay showed some pulmonary hypertension with PA systolics in the 40s and a dilated RV. This may be secondary to IV drug abuse in the past. He likely needs higher filling pressures and may have a limited cardiac output due to his pulmonary hypertension.
PA|posterior-anterior|PA|136|137|IMAGES|Her hemoglobin A1c is 5.8%. Urinalysis is positive for nitrites. Culture is greater than 100,000 citrobacter. IMAGES: 1. She did have a PA and lateral chest x-ray which showed no changes since _%#MM#%_. No evidence of pneumonia. 2. An MRI of her brain shows several ring enhancing lesions.
PA|physician associates|PA|62|63|ASSESSMENT AND PLAN|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, MD OB-GYN West PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 130 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2007.
PA|physician associates|PA|70|71|ASSESSMENT|_%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_, MD Clinic Sofia OB-GYN PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 490 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2006.
PA|physician associates|PA|81|82|ASSESSMENT/PLAN|_%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_, CNP Southdale OB-GYN Consultants, PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 393 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2006.
PA|physician associates|PA|217|218|REASON FOR CONSULTATION|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD REASON FOR CONSULTATION: _%#NAME#%_ _%#NAME#%_ is a 35-year-old man whom I have been asked to see by Dr. _%#NAME#%_ and the physicians at Minnesota Oncology Hematology, PA (MOHPA) to evaluate his diarrhea. This man was admitted to the hospital three days ago with severe diarrhea and abdominal cramping which had been present for a few days and escalated quite significantly such that he has had anywhere up to thirty bowel movements a day.
PA|physician associates|PA|80|81|G  2  P 1001				LMP|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, MD Southdale OB-GYN Consultants, PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 100 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: I am writing to you in follow up regarding your patient, _%#NAME#%_ _%#NAME#%_.
PA|physician associates|PA|70|71|ASSESSMENT AND PLAN|_%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_, MD OB-GYN Infertility, PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 400 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2006.
PA|physician associates|PA|62|63|ASSESSMENT AND PLAN|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, MD OB-GYN West PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2007.
PA|pulmonary artery|PA|187|188|IMPRESSION|I have discussed this with Dr. _%#NAME#%_ and we are in agreement that he can be listed as a transplant candidate. However, prior to his final listing, we need to assess reversibility of PA pressure.
PA|pulmonary artery|PA|139|140|PHYSICAL EXAMINATION|He is mildly sedated, although he is arousable. CARDIOVASCULAR: LVAD flow is 4.5 liters with fixed rate of 8800, pulsatility index is 4.2, PA pressure is 36.24, CVP 18. DRIPS: Epinephrine 0.2, vasopressor 4, neosynephrine 50. RESPIRATORY: He is stable on the ventilator. EXTREMITIES: Lower extremities are warm and well perfused with mild pedal edema.
PA|physician associates|PA|71|72|ASSESSMENT AND PLAN|_%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_, MD Clinic Sofia OB-GYN, PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 490 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2006.
PA|physician associates|PA|62|63|ASSESSMENT/PLAN|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, MD OB-GYN West PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 130 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2007.
PA|physician assistant|PA,|131|133|REQUESTING PHYSICIAN/REASON FOR CONSULTATION|REQUESTING PHYSICIAN/REASON FOR CONSULTATION: The patient is a 61-year-old female who I was asked to see by _%#NAME#%_ _%#NAME#%_, PA, for evaluation of urinary retention. HISTORY OF PRESENT ILLNESS: The patient is status post a kidney transplant on _%#DDMM2007#%_ to her right lower quadrant due to end-stage renal disease which is due to diabetes.
PA|physician associates|PA|62|63|SOCIAL HISTORY|_%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_, MD OB-GYN West PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 103 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Thank you for referring your patient, _%#NAME#%_ _%#NAME#%_, who was seen, along with her husband, _%#NAME#%_, for genetic counseling at the Maternal Fetal Medicine Center at Fairview Southdale Hospital on _%#DDMM2006#%_.
PA|physician associates|PA)|80|82|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD (Minnesota Oncology Hematology, PA) REASON FOR CONSULTATION: Abdominal pain. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is an 80- year-old woman admitted to Fairview Southdale Hospital with abdominal pain with nausea.
PA|posterior-anterior|PA|180|181|RADIOLOGY|GGT 49. TSH 0.44. Urine toxicology positive for benzodiazepines, cannabinoids, and cocaine. RADIOLOGY: CT of the head on _%#DDMM2007#%_: Impression is normal CT of the head. Chest PA and lateral _%#DDMM2007#%_: Impression: Mild cardiomegaly. Degenerative changes seen in the thoracic spine. The chest is otherwise unremarkable. ASSESSMENT AND PLAN: 1. Schizoaffective disorder, borderline personality type, polysubstance abuse.
PA|pulmonary artery|(PA)|160|163|REASON FOR CONSULTATION|We did a stress echo study that showed moderate mitral regurgitation prior to exercise and severe mitral regurgitation with an increase in his pulmonary artery (PA) pressures post exercise. He went for approximately 6 minutes. I do not have the exact date but it was very convincing for exercise-induced increase in his mitral regurgitation.
PA|pulmonary artery|PA|228|229|PAST MEDICAL HISTORY|An echocardiogram was performed during his recent hospitalization which showed normal left ventricular size and function and normal right ventricular size and function. Mild to moderate pulmonary hypertension was present with a PA systolic pressure estimated at 35 mmHg plus right atrial pressure. He had no significant valvular heart disease. SOCIAL HISTORY: He quit smoking some 25 years ago.
PA|pulmonary artery|PA|177|178|MEDICATIONS|PHYSICAL EXAMINATION: The patient is orally intubated. Pupils are pinpoint. He blinks spontaneously. Vital signs reveal a blood pressure of 99/57, pulse 112, temperature 100.4. PA pressure is 22/12. Cardiac output 6.7, index 3.4, SVR 597. Chest: He has coarse breath sounds throughout without wheezes or rales.
PA|pulmonary embolus:PE|PA.|296|298|LABORATORY DATA|LABORATORY DATA: Sodium 139, potassium 4.2, chloride 114, bicarbonate 19, anion gap of 7, BUN 6, creatinine 0.5, glucose 82, white count 6.8, TSH 4.18, free T4 0.84, ALT and AST were normal. Alkaline phosphatase was up just slightly. Calcium was 8.2. D-dimer was 1.1. V/Q scan was negative for a PA. IMPRESSION AND PLAN: _%#NAME#%_ _%#NAME#%_ is a 25-year-old woman who was currently 33 weeks pregnant.
PA|posterior-anterior|PA|114|115|PLAN|The knee seems to be recovering normally making it as a source seem less likely in addition. PLAN: 1. Will obtain PA and lateral chest x-ray. 2. Hemogram with differential and platelets, blood cultures times two. 3. Will check a second troponin. 4. Institute some intravenous saline.
PA|posterior-anterior|PA|185|186|PHYSICAL EXAMINATION|The PR interval is 120 milliseconds. The P waves are negative in II, III and AVF. QRS duration is 90 milliseconds. Chest x-ray shows cardiomegaly, with bibasilar infiltrates. This is a PA film. LABORATORY: INR 1.67, magnesium 1.6, albumin 2.6, troponin less than 0.04, hemoglobin 12.2, white cell count 8.7, platelets 133, sodium 140, potassium 4.5, BUN 49, creatinine 2.68.
PA|physician associates|PA|69|70|ASSESSMENT AND PLAN|_%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_, MD OB-GYN Infertility PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite W400 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2006.
PA|pulmonary artery|PA|138|139|IMPRESSION|Pulses are intact. Extremities are somewhat cyanotic. NEUROLOGIC: Grossly normal. IMPRESSION: Patient with tricuspid atresia, status post PA banding and Fontan procedure, who is now ready for a cardiac transplant. I have discussed risks and possible benefits of the procedure.
PA|pulmonary artery|PA|164|165|IMPRESSION AND PLAN|In the meantime, he should continue on all his current medications. I will obtain an echocardiogram for further assessment of his biventricular function as well as PA pressures. Further recommendations may follow.
PA|physician assistant|PA|71|72|G  2  P 1001				LMP|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, MD Clinic Sofia OB-GYN, PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite #490 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: I am writing in follow-up to your patient, _%#NAME#%_ _%#NAME#%_.
PA|physician assistant|PA,|347|349|HISTORY OF PRESENT ILLNESS|He has been told in the past by Dr. _%#NAME#%_, his cardiologist about two years ago, that he did not need a pacemaker but that at some in the future he might need a permanent pacemaker, indicating that some conduction disease has been noted in the past. Past medical history and medications have been outlined in detail by _%#NAME#%_ _%#NAME#%_, PA, from our office this year. I reviewed this today and have nothing to add. FAMILY HISTORY: Positive for coronary artery disease.
PA|physician assistant|PA|45|46|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, PA CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is a 58-year-old gentleman who states he has had some nonspecific abdominal pain over the last two days.
PA|posterior-anterior|PA|231|232|HISTORY OF PRESENT ILLNESS|The patient was begun on CHOP chemotherapy x 6 cycles, given q. 3 weeks. She ultimately finished chemotherapy on _%#DDMM2003#%_. A rundown of her laboratory and imaging during chemotherapy is as follows: On _%#DDMM2003#%_, a plain PA chest x-ray showed decrease in the anterior mediastinal mass and perihilar lymphadenopathy, with some mild residual soft tissue density. On _%#DDMM2003#%_, her lactate dehydrogenase was 425. On _%#DDMM2003#%_, a chest CT (compared to the outside CT from _%#DDMM2003#%_) showed significant improvement with a small amount of residual retrosternal soft tissue density, with a maximum thickness of 1 cm.
PA|pulmonary artery|PA|202|203|LABORATORY DATA|He has bilaterally decreased breath sounds. Normal S1 and S2, without S3, S4, murmurs, gallops, or rubs. LABORATORY DATA: I reviewed his cardiac echo which revealed normal pulmonary artery paces with a PA pressure of 24/12 estimated. There is no report on the bubble study. ASSESSMENT/PLAN: We discussed for at least 30 minutes the risk, benefits, and outcome data of a lung transplantation and compared that to other solid organ transplants like the liver, heart, and kidney.
PA|physician associates|PA)|80|82|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD (Minnesota Oncology Hematology, PA) CHIEF COMPLAINT: Evaluate confusion, weakness, flank pain, hyponatremia. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a _%#1914#%_-year-old man with stage 1 non-small-cell lung cancer presenting with a solitary nodule in the right lung in mid-2004.
PA|pulmonary artery|PA|144|145|PHYSICAL EXAMINATION|The Echocardiogram that was performed in _%#MM#%_ showed an ejection fraction of 10% with severe mitral and tricuspid valve regurgitations. His PA pressure measured was 52/19. A right heart catheterization exam showed his right atrial pressure of 18 mm of mercury. His RV pressure was 50/7. His PA pressure was 54/21.
PA|posterior-anterior|PA|150|151|RADIOLOGY|A CEA level done preoperatively was not elevated in that it was less than 0.5. The electrolytes performed on _%#DDMM2003#%_ were normal. RADIOLOGY: A PA lateral chest was performed on _%#DDMM2003#%_ preoperatively and found to be negative. The pathology from the procedure is as described above.
PA|posterior-anterior|PA|171|172|PHYSICAL EXAMINATION|Her abdomen is soft and nontender. There is no inguinal or axillary adenopathy. She was seen Dr. _%#NAME#%_ later today who will perform a pelvic examination. Chest x-ray PA and lateral was done. There is no evidence of metastasis. IMPRESSION: NAD. DISPOSITION: She will return in 6 months for reevaluation.
PA|physician associates|PA|131|132|PLAN|PLAN: My plan is to have Social Services see her. She will follow up with Dr. _%#NAME#%_ _%#NAME#%_ (Obstetrics & Gynecology West, PA - _%#CITY#%_ _%#CITY#%_) next week in clinic. We did discuss some options for medication including selective serotonin reuptake inhibitor to help with anxiety and she will consider this and talk with Dr. _%#NAME#%_.
PA|physician associates|PA|80|81|ASSESSMENT AND PLAN|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, MD Southdale OB-GYN Consultants, PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 100 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2007.
PA|physician associates|PA|62|63|ECHOCARDIOGRAM 12/28/04|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, MD OB-GYN West PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 103 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2007.
PA|physician associates|PA)|80|82|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD (Minnesota Oncology Hematology, PA) REASON FOR CONSULTATION: Hyperkalemia and acute renal failure. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 68-year-old female with a history of ovarian cancer who presents for resection surgically today but the procedure was canceled due to elevated creatinine, hyperkalemia and hyponatremia.
PA|physician associates|PA|62|63|ASSESSMENT AND PLAN|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, MD OB-GYN West PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 103 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2007.
PA|pulmonary artery|PA|214|215|PHYSICAL EXAMINATION VITAL SIGNS|There is also an ostial 20% lesion in the right coronary artery as well as 50% lesion in the proximal PDA which appears to be a small vessel. Right heart catheterization hemodynamics, mean right atrial pressure 5, PA pressure is 48/16 with a pulmonary artery wedge pressure of 15. Cardiac index by Fick is 2.6. ASSESSMENT AND PLAN: A 78-year-old female with a past medical history of coronary artery disease, atrial fibrillation, diabetes mellitus, now diagnosed to have severe aortic stenosis and coronary artery disease with atrial fibrillation.
PA|physician associates|PA|81|82|ASSESSMENT/PLAN|_%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_, CNP Southdale OB-GYN Consultants, PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 100 _%#CITY#%_, Minnesota _%#55400#%_ Dear Ms _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2006. She came to clinic with her husband, _%#NAME#%_ _%#NAME#%_, for genetic consultation and first trimester screening.
PA|physician associates|PA|69|70|ASSESSMENT/PLAN|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, MD OB-GYN Infertility PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite W400 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2007.
PA|physician assistant|PA|144|145|LABORATORY DATA|Testicular ultrasound was performed at _%#CITY#%_ _%#CITY#%_ and the images and final report are not available. However, verbal report from the PA at the primary clinic, where the patient was seen today, reports that there was normal blood flow to bilateral testicles.
PA|pulmonary artery|PA|137|138|HISTORY|She has also had some urine output since return from the PAR. Swan-Ganz catheter is in place and filling pressures are still rather low; PA 20/8 range and RACVP of 5 to 6. PAST MEDICAL HISTORY: 1) Perforation with exploration and colostomy in 2004.
PA|physician associates|PA|70|71|G  2 P	0010				LMP|_%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_, MD Clinic Sofia Ob/Gyn PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 490 _%#CITY#%_, Minnesota _%#55400#%_ RE: _%#NAME#%_, _%#NAME#%_ _%#NAME#%_ MR: _%#MRN#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2006.
PA|physician assistant|PA.|58|60|PHYSICIAN REQUESTING CONSULTATION|PHYSICIAN REQUESTING CONSULTATION: _%#NAME#%_ _%#NAME#%_, PA. REASON FOR CONSULTATION: Evaluate for rehabilitation placement. HISTORY OF PRESENT ILLNESS: This is an 80-year-old male who has been admitted to the University of Minnesota Medical Center, Fairview on _%#DDMM2007#%_ with a fall from a roof.
PA|pulmonary artery|PA|352|353||_%#NAME#%_ _%#NAME#%_ is a 62-year-old woman well known to me because of previous evaluation for severe mitral regurgitation and pulmonary hypertension who was scheduled for an outpatient right and left heart catheterization. She was found to have very severe mitral regurgitation on her left ventriculogram and significant pulmonary hypertension with PA pressures in the 60s. Accordingly I felt it was important to bring her into the hospital to optimize her pulmonary artery pressures before surgery in as much as pulmonary hypertension is a risk factor for surgical mortality.
PA|physician assistant|PA,|104|106|HISTORY OF THE PRESENT ILLNESS|The patient has been taken to Fairview Southdale Hospital for emergent evaluation. On examination by my PA, _%#NAME#%_ _%#NAME#%_, she was found to be flaccid in her bilateral lower extremities, 0-5 for hip flexion, knee extension, knee flexion, plantar flexion, dorsiflexion, extensor hallucis longus.
PA|physician associates|PA|179|180|REVIEW OF SYSTEMS|In 1995, she was seen by Dr. _%#NAME#%_ _%#NAME#%_ for some leg pain. She was also seen by Dr. _%#NAME#%_ _%#NAME#%_ about 15 years ago when she was at Noran Neurological Clinic, PA (results of that evaluation are unavailable). She had been seen by Dr. _%#NAME#%_ _%#NAME#%_ (Noran Neurological Clinic, PA) as indicated by an MRI report done in 2000.
PA|pulmonary artery|PA|176|177|RECOMMENDATIONS|4. His smoking history requires formal pulmonary functions and pulmonary consult. 5. In view of his abnormal renal function, we will obtain a renal evaluation. 6. His elevated PA pressures need optimizing. He probably either needs a preoperative Swan-Ganz catheter or another echo. It is probable that the patient should ideally remain in the hospital.
PA|posterior-anterior|PA|237|238|IMPRESSION|I would like to observe what happens over the next 12-24 hours before making a final decision on whether or not to recommend specific antimicrobial treatment. PLAN: a. Recheck peripheral white blood cell count in the morning. b. Recheck PA and lateral chest x-ray in the morning. c. If she develops any the following, then began antimicrobial treatment with Cipro 500 mg by mouth twice daily and vancomycin intravenously (Pharmacy to dose).
PA|pulmonary artery|PA|129|130|ASSESSMENT/PLAN|At this time, I would suggest: a. Echocardiogram to assess ejection fraction. Use contrast as necessary. We will also assess the PA pressures. b. IV Lasix for diuresis, along with KCl supplementation. c. I would suggest doing an ABG given that he has an elevated bicarbonate and may have CO2 retention.
PA|physician associates|PA|80|81|ASSESSMENT AND PLAN|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, MD Southdale OB-GYN Consultants, PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 100 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2007.
PA|physician associates|PA|80|81|ASSESSMENT AND PLAN|_%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_, MD Southdale OB-GYN Consultants, PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite #100 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2006.
PA|tissue plasminogen activator:TPA|PA,|187|189|DISCUSSION|Hypertension was controlled satisfactorily with labetalol. Initial diagnostic studies suggested a right hemispheric nonhemorrhagic infarction. The patient was prepared for infusion of t- PA, per protocol, which was subsequently aborted when he developed a major motor seizure, rendering the t-PA infusion contraindicated.
PA|physician associates|PA|62|63|ASSESSMENT AND PLAN|_%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_, MD OB-GYN West PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 103 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2006.
PA|pulmonary artery|PA|182|183|HISTORY OF PRESENT ILLNESS|An echocardiogram done at that time showed an ejection fraction of 65%. She did have moderate to moderately severe mitral insufficiency. She had severe pulmonary hypertension with a PA systolic pressure over 80. She had done fairly well up until last night. She is relatively restricted in her activity, and does not walk very far.
PA|pulmonary artery|PA|159|160||His CO is >2.9 L/min/m2. There is minimal CT output. A/P: 1. S/p OHTx. Excellent immediate result. 2. I/S written for. 3. Will keep the pt sedated to keep his PA pressure as low as possible today. Will also continue on NO.
PA|pulmonary artery|PA|154|155|REQUESTING PHYSICIAN|She has shortness of breath with activity. She had an echo, which showed normal sized LV with hypertrophy and severe pulmonary artery hypertension with a PA pressure of 50 plus RAP. She denied any leg pain or swelling, history of phlebitis or clots. She was on Coumadin for new onset atrial fibrillation during the past month.
PA|pulmonary artery|PA|370|371|REASON FOR CONSULTATION|Mr. _%#NAME#%_ _%#NAME#%_ is an 80-year-old man well-known to our service after evaluation in _%#MM#%_ of this year for pleural effusions and pulmonary hypertension. I last saw him in our office on _%#MMDD#%_. He has severe pulmonary hypertension and has had previous evaluation with an echocardiogram, pre and post-Viagra administration and had paradoxical increase in PA pressures on Viagra. He also had an ultrasound-guided thoracentesis on _%#MMDD#%_ productive of 700 cc of clear yellow fluid which was clearly transudative in nature.
PA|physician assistant|PA|142|143|RECOMMENDATIONS|RECOMMENDATIONS: Routine labs including hemoglobin, thyroid function tests, and electrolytes will be obtained. _%#NAME#%_ will be seen by our PA for gynecologic assessment. I will be available to see her during this hospitalization for these and any other medical concerns.
PA|physician associates|PA)|80|82|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD (Consultants-Internal Medicine, PA) CHIEF COMPLAINT: Rest pain and superficial ulcerations, left foot and toes. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ presented to the office last week with progressive rest pain in her left foot along with very superficial ulcerations.
PA|pulmonary artery|PA|161|162|REQUESTING PHYSICIAN|After being admitted, she was diuresed which has resulted in improvement of her symptoms. She had an echocardiogram that showed preserved systolic function with PA systolic pressure of 90 mmHg and severe tricuspid regurgitation. This is consistent with severe long-standing pulmonary hypertension. We are asked to address further assessment and ongoing management.
PA|physician associates|PA|70|71|ASSESSMENT AND PLAN|_%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_, MD Clinic Sofia OB-GYN PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 490 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2006.
PA|physician associates|PA|79|80|PLAN|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, MD Southdale OB-GYN Consultants PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 100 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2007.
PA|physician associates|PA)|74|76|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, MD (France Avenue Family Physicians, PA) CHIEF COMPLAINT: Dizziness, blurred vision and unsteadiness. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 87-year-old woman with a history of "borderline hypertension" presents to the Emergency Department with a three-day history of increasing unsteadiness on her feet, blurred vision and lightheadedness.
PA|physician associates|PA)|80|82|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD (Consultants-Internal Medicine, PA) REASON FOR CONSULTATION: We were asked to see _%#NAME#%_ _%#NAME#%_ in orthopedic consultation at the request of Dr. _%#NAME#%_. Ms. _%#NAME#%_ is seen today with her husband in attendance.
PA|posterior-anterior|PA,|127|129|LABORATORY AND DIAGNOSTIC STUDIES|LABORATORY AND DIAGNOSTIC STUDIES: I ordered and reviewed PA and lateral x-rays which are good. Radiographs of her right ankle PA, lateral and oblique, as well as foot x-rays, demonstrate a combination of both a talus, ankle and calcaneus fracture. The CT scan was reviewed with reconstruction and demonstrates a subtalar dislocation, a lateral calcaneal wall fracture, a talar body fracture, an ankle fracture of the medial malleolus concentrated on the posterior half, as well as a talar head fracture.
PA|posterior-anterior|PA|145|146|HISTORY OF PRESENT ILLNESS|CT scan on _%#DDMM2003#%_ demonstrated postoperative changes in the neck. Soft tissue fullness in the right parapharyngeal region was also seen. PA and lateral chest x-ray on _%#DDMM2003#%_ did not show any evidence of metastatic disease. These were outside reports. We did review the outside CT scan ourselves.
PA|physician associates|PA|70|71|ASSESSMENT AND PLAN|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, MD Clinic Sofia Ob/Gyn PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 490 _%#CITY#%_, Minnesota _%#55400#%_ RE: _%#NAME#%_, _%#NAME#%_ _%#NAME#%_. MR: _%#MRN#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2007.
PA|posterior-anterior|PA|207|208|IMPRESSION|We will continue the patient's Protonix 4. For his farmer's lung, we will continue his Advair. Will consider initiation of Duonebs prior to surgery. We will get bedside spirometry. We will get a chest x-ray PA and lateral, we will get an EKG. We will check an echo to evaluate the patient's right-sided pressures and for wall motion abnormalities as well as ejection fraction and will get his records from his primary clinic.
PA|pulmonary artery|PA|191|192|PHYSICAL EXAMINATION|Abdomen: Soft, nontender, nondistended. Nonsurgical scars. Ankles: No edema. I had the chance to review his cardiac catheterization which was negative for bubble study, there is no shunting, PA pressure is 30/16. There is no significant coronary artery disease with (?) a few (?) 35% stenosis right coronary system with left ventricular functions preserved.
PA|pulmonary artery|PA|251|252|HISTORY OF PRESENT ILLNESS|His most recent echocardiogram from our clinic in _%#MM2007#%_, shows an ejection fraction of 40-45% with left ventricular hypertrophy, mild aortic stenosis, mild mitral regurgitation, normal RV size and function, moderate pulmonary hypertension with PA pressures of 35+ CVP. The patient was in atrial fibrillation at that point in time. REVIEW OF SYSTEMS: CONSTITUTIONAL: Negative for fever, chills. RESPIRATORY: Negative for cough.
PA|physician associates|PA)|81|83|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD (Consultants- Internal Medicine, PA) INDICATION FOR CARDIAC CONSULTATION: Congestive heart failure (CHF) and shortness of breath. HISTORY OF PRESENT ILLNESS: Thanks very much for asking me to see _%#NAME#%_ _%#NAME#%_. _%#NAME#%_, a _%#1914#%_-year-old female patient, who has had worsening ejection fraction over the last 2 years. When seen in 2002 her ejection fraction was approximately 40-45%; it had dropped then down to 25% in _%#MM#%_ 2003, and now is estimated to be approximately 50% now.
PA|physician associates|PA)|81|83|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD (Consultants- Internal Medicine, PA) CHIEF COMPLAINT: Left hip pain. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is an 84-year- old woman who lives alone in her own home.
PA|physician associates|PA)|79|81|REFERRING PHYSICIAN|REFERRING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD (Consultants-Internal Medicine, PA) REASON FOR CONSULTATION: We were asked to see _%#NAME#%_ _%#NAME#%_ at the request of Dr. _%#NAME#%_. Ms. _%#NAME#%_ is an 88-year-old woman who fell in her kitchen sustaining a left hip fracture.
PA|pulmonary artery|PA|224|225|PHYSICAL EXAMINATION|FAMILY HISTORY: Noncontributory to his current problems. REVIEW OF SYSTEMS: Not possible given the patient's acute illness. PHYSICAL EXAMINATION: Temperature is 99.5, respirations 14, pulse is 100, blood pressure is 110/80. PA pressure is 24/13 with a CVP of 15. HEENT: His head and face look quite puffy, but no evidence of trauma.
PA|pulmonary artery|PA|429|430|PHYSICAL EXAMINATION|Chest x-ray shows hyperinflated lungs with flat diaphragms but otherwise are clear. Echocardiogram performed recently during his previous hospitalization on Echocardiogram performed recently during his previous hospitalization on _%#MM#%_ _%#DD#%_, 2002 shows normal left ventricular size and function with concentric left ventricular hypertrophy, mild tricuspid regurgitation with mild to moderate pulmonary hypertension with a PA systolic pressure estimated at 45 to 50, mild mitral regurgitation and left atrial enlargement. IMPRESSION: Mr. _%#NAME#%_ _%#NAME#%_ is a 71-year-old noncompliant patient who returns to the hospital after leaving AMA over a week ago with recurrent shortness of breath and throat pain.
PA|physician assistant|PA|251|252|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a very pleasant Asian female who has developed significant abdominal pain with and nausea over the weekend. The pain was described as mid epigastric, radiating to the right and to the back. Her daughter is a PA student and served as interpreter through this visit. The patient reports her abdominal discomfort has improved dramatically since presentation.
PA|physician associates|PA)|78|80|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD (Southdale Internal Medicine, PA) REASON FOR CONSULTATION: I have been asked to evaluate _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ for progressive thrombocytopenia. The patient has a very interesting and extensive past history which dates back to 1991 when she presented with a cerebrovascular infarction (CVI) that was thought to be on the basis of vasculitis .
PA|posterior-anterior|PA|293|294|PALLIATIVE MEDICINE RECOMMENDATIONS|The former is more sedating and has more anticholinergic properties and under the circumstances of both sedation and constipation, I would recommend that it (amitriptyline) be discontinued. Her admission chest films were both portable and should she improve sufficiently to get either regular PA and lateral chest films or preferably even thoracic spine films, that we need to exclude a new (another) vertebral compression fracture.
PA|physician associates|PA|62|63|RECOMMENDATIONS|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, MD OB-GYN West PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 130 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2007.
PA|physician associates|PA|80|81|PLAN|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, MD Southdale OB-GYN Consultants, PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 100 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2007.
PA|physician assistant|PA|23|24|ASSESSMENT AND PLAN|_%#NAME#%_ _%#NAME#%_, PA LaClinica En Lake Suite 1100 _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_, MN _%#55400#%_ Dear PA _%#NAME#%_: Thank you for referring your patient, _%#NAME#%_, who was seen with her partner, _%#NAME#%_, for genetic counseling at the Maternal-Fetal Medicine Center at the University of Minnesota Medical Center - Fairview, _%#CITY#%_ on _%#DDMM2006#%_. At your request, _%#NAME#%_ was referred here to discuss the results of her maternal serum screen, which indicated increased risk of Down syndrome in the pregnancy.
PA|posterior-anterior|PA|146|147|IMPRESSION|The patient may need steroids in the form of Solu-Medrol after the pretreatment for iodine allegy is done for her COPD. We will get a chest x-ray PA and lateral. We will get a CBC, lipids, basic metabolic panel, liver panel, type and screen, TSH, a chest x-ray, EKG. Would check an echo for wall motion abnormalities and chamber size, would consider an ultrasound of the patient's carotids but will defer for that to Dr. _%#NAME#%_.
PA|pulmonary artery|PA|433|434|REQUESTING PHYSICIAN|Her BNP was elevated at 2670 and troponin was less than 0.07. She did have some chest and upper abdominal discomfort, not clearly angina but very possibly anginal as toward the end of _%#MM#%_ she had a non-Q myocardial infarction and was found to have an ejection fraction of 25-30% with anterior apical and inferior wall hypokinesis. An ECG from our office documenting that is currently in the chart. Pulmonary hypertension with a PA pressure of 62 plus right atrial pressure is noted. Nonspecific calcification of the mitral valve with moderate MR was also seen and question was raised as to whether the MR was actually moderate to severe.
PA|pulmonary artery|PA|230|231|ASSESSMENT|ASSESSMENT: 1) The patient is a 49-year-old white female status post mitral valve replacement with St. Jude medical valve on _%#MM#%_ _%#DD#%_, 2003 for mitral stenosis and pulmonary hypertension. She has done well since surgery. PA pressures are unchanged to slightly lower post surgery. Her rhythm is junctional or sinus bradycardia at a rate of 50. No atrial fibrillation for now. I do not believe it is necessary to add any medications at this time.
PA|physician associates|PA|70|71|ASSESSMENT AND PLAN|_%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_, MD Clinic Sofia Ob/Gyn PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 490 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2006.
PA|physician associates|PA)|78|80|REQUESTING PHYSICIAN|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD (Southdale Internal Medicine, PA) CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: Asked by Dr. _%#NAME#%_ to evaluate Mr. _%#NAME#%_ for his abdominal pain.
PA|posterior-anterior|PA|181|182|RECOMMENDATIONS|I think in view of his central nervous system findings a CT of his head would be good. I would also suggest, after having looked at his x-ray, that an x-ray taken in main Radiology PA and lateral might be helpful. While this illness does not sound typical for either tuberculosis or histoplasmosis, I think a PPD and perhaps even, depending upon the results of a good chest x-ray, a CT of his chest might be helpful.
PA|posterior-anterior|PA|201|202|IMPRESSION|Alternatively, he could be developing an early pneumonia based on his recent viral upper respiratory symptoms and tobacco use, although his lung fields are clear. At this point would send him down for PA and lateral chest x-ray and make further determinations based on that. If he has infiltrates, clearly he would need antibiotics. If he does not have an infiltration I would observe him the rest of the afternoon and if he seems stable he potentially could be discharged and I asked that he follow up with his regular physician later this week.
PA|physician associates|PA|62|63|RECOMMENDATIONS|_%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_, MD OB-GYN West PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2006.
PA|pulmonary artery|PA|189|190|IMAGING STUDIES|Small left-sided pleural effusion. Cardiomegaly with enlarged right ventricle. 2. Echocardiogram reports cardiomegaly with ejection fraction of 50%, biventricular hypertrophy and estimated PA pressure for 35 mmHg. ASSESSMENT AND PLAN: 1. Aspiration pneumonia with sputum showing many gram-positive cocci.
PA|physician associates|PA|73|74|SUGGESTIONS|_%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_, WHCNP OB-GYN Specialists, PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 600 _%#CITY#%_, Minnesota _%#55400#%_ Dear Ms _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2006. She came to clinic for genetic consultation and first trimester screening due to advanced maternal age in pregnancy.
PA|physician associates|PA|80|81|ASSESSMENT|_%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_, MD Southdale OB-GYN Consultants, PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 100 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2006.
PA|physician associates|PA|73|74|G  2  P 1001				LMP|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, MD Diamond Women's Center PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_, Suite 540 _%#CITY#%_, MN _%#55400#%_ Dear Dr. _%#NAME#%_: Thank you for the referral of your patient, _%#NAME#%_ _%#NAME#%_, who was seen along with her husband, _%#NAME#%_, on _%#DDMM2007#%_ at the Maternal-Fetal Medicine Center.
PA|posterior-anterior|PA|246|247|LABORATORY DATA|EXTREMITIES: No edema. LABORATORY DATA: CA-125 47, sodium 139, potassium 3.9, chloride 97, bicarb 31, BUN 19, creatinine 1.15, glucose 95, calcium 10, white count 13.0, hemoglobin 13.6, hematocrit 39.3, inhibin less than 10, platelets 347. Chest PA and lateral 3-mm right upper lobe granuloma, lungs otherwise clear. Blood type O positive. Troponin negative x3, magnesium 2.1, phosphorus 2.8.
PA|pulmonary artery|PA|207|208|HOSPITAL COURSE|2. Ischemic cardiomyopathy. The patient had previous ejection fraction of 25% as determined by LV gram during his previous hospital admission. He had a repeat transthoracic echocardiogram after his elevated PA and pulmonary capillary wedge pressures post catheterization. His transthoracic echocardiogram was significant for a worsening and his LV systolic function and a large area of akinesis, essentially over the entire distal left ventricle.
PA|posterior-anterior|PA|165|166|IMPRESSION|Could also have acute renal failure secondary to decreased PO intake and diarrhea while continuing Ace and Lasix. Need to check an EKG, need to check a chest x-ray, PA and lateral. Pneumonia could also be a cause of the patient's symptoms in an elderly patient, although she denies cough and there is no audible pneumonia on exam.
PA|posterior-anterior|PA|145|146|LABORATORY & DIAGNOSTIC DATA|His speech is fluent. Cranial nerves II-XII are intact. He moves all extremities with equal strength. LABORATORY & DIAGNOSTIC DATA: Chest x-ray, PA and lateral films, is normal with no free subdiaphragmatic air. Twelve-lead EKG shows a first-degree AV block and somewhat delayed anterior R wave progression, no obvious acute ischemic changes.
PA|pulmonary artery|PA|132|133|OPERATIONS/PROCEDURES PERFORMED|3. Atrial fibrillation. OPERATIONS/PROCEDURES PERFORMED: 1. Right heart catheterization on _%#MM#%_ _%#DD#%_, 2004. Findings were a PA pressure of 57/24, pulmonary capillary wedge pressure mean of 16. 2. Transthoracic ultrasound. Findings are unavailable at the time of this dictation.
PA|pulmonary artery|PA|131|132|MAJOR INVESTIGATIONS AND PROCEDURES DONE DURING THIS HOSPITALIZATION|Right heart catheterization done during this procedure revealed a mean right atrial pressure of 15, RV pressures of 39 and 15. The PA pressure was 31/21 and the pulmonary artery wedge pressure was 16. The patient had drug-eluting stents placed to the mid left anterior descending coronary artery, apical left anterior descending coronary artery, the left PLA which comes off the circumflex artery, and the mid right coronary artery.
PA|physician associates|PA)|78|80|PRIMARY CARE|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, MD (_%#CITY#%_ Sports Health & Wellness, PA) RHEUMATOLOGIST: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD (Arthritis and Rheumatology Consultants, PA) BRIEF HISTORY: _%#NAME#%_ _%#NAME#%_. _%#NAME#%_ is a 60-year-old male who came back in on _%#DDMM2003#%_ with chest discomfort relieved by nitroglycerin, similar to what he had with his recent myocardial infarction (MI) that involved the circumflex artery.
PA|posterior-anterior|PA|158|159|PROCEDURES DONE DURING HOSPITALIZATION|6. Rifampin ___ 600 mg p.o. q. day. 7. Clarithromycin 500 mg p.o. b.i.d. 8. (?)FESO 325 mg p.o. t.i.d. PROCEDURES DONE DURING HOSPITALIZATION: 1. Chest x-ray PA and lateral. Indications: Left arm pain. Findings: Indeterminant lesion in the right upper lobe with an ill-defined nodular density right axillary region; this is indeterminant.
PA|posterior-anterior|PA|232|233|LABORATORY DATA|Troponin less than 0.04, hemoglobin 11.8, white count 6.4, platelet count 148,000, sodium 139, potassium 4.3, chloride 98, bicarb 30, anion gap 13, glucose 219, BUN 65. Chest X ray reveals right mild to moderate pleural effusion on PA lateral film. IMPRESSION: The patient is an 82-year-old gentleman with end-stage renal disease as well as what appears to be ischemic cardiomyopathy.
PA|posterior-anterior|PA|161|162|STUDIES|Bowel sounds are present. No masses felt. CENTRAL NERVOUS SYSTEM EXAMINATION: Grossly intact. EXTREMITIES: No clubbing, cyanosis, or edema. STUDIES: Chest x-ray PA and lateral (reviewed by me). Shows worsening left lower lobe infiltrate when compared with CXR done two days. Labs done today shows white count to be significant elevated at 23.3. His electrolytes are stable with a BUN of 45 and a creatinine 2.27. This is stable from 2 days ago but still definitely elevated from his baseline.
PA|pulmonary artery|PA|168|169|IMAGING STUDIES|There is moderate left ventricular diastolic dysfunction. Mild tricuspid regurgitation, trivial MR, trace ER. No aortic insufficiency. Moderate pulmonary hypertension. PA pressure is 41 plus RA. No pericardial effusion. Aortic root normal. 2. Admission chest x-ray shows hyperinflated lungs. No acute pulmonary process. No pulmonary edema. Cardiomegaly. 3. Chest CT with contrast shows no pulmonary embolus.
PA|physician assistant|PA,|168|170|INSTRUCTIONS|16. Magnesium oxide 400 mg p.o. b.i.d. 17. 1/2 normal saline one liter IV over 8 h each night. INSTRUCTIONS: 1. The patient is to follow up with _%#NAME#%_ _%#NAME#%_, PA, in Pediatric Bone Marrow Transplant Clinic on _%#DDMM2004#%_ at 11:00. The patient should have laboratories drawn per clinic cardex and CSA level.
PA|pulmonary artery|PA|111|112|LABORATORY|Right heart catheterization data: Right atrium shows A-wave of 5, V- wave of 25, and a mean of 11. RV is 30/7. PA is 33/15 with a mean of 23. Wedge is 18. Pulmonary vascular resistance is 113. Mixed venous O2 saturation is 56.6%. Cardiac output is 1.8 liters per minute by thermodilution.
PA|pulmonary artery|PA|191|192|PROCEDURES|A stump was identified that was thought to represent either the Saphenous vein graft to the OM or LAD. No further grafts were seen. Moderate secondary pulmonary hypertension was present with PA pressure of 60/28 and a mean wedge pressure of 22. 5. Coronary angiogram with angioplasty and stenting of the proximal left anterior descending artery on _%#DDMM2003#%_.
PA|posterior-anterior|PA|338|339|LABORATORY & DIAGNOSTIC DATA|His urine drug screen is negative, alcohol less than 0.01. Albumin is 4.4, AST 171, ALT 138, alkaline phosphatase 110, total bilirubin 1.4, glucose 334, creatinine 0.84. The rest of his electrolytes - chloride is 92, bicarbonate 27. Chest x-ray shows a patient who is very obese. His right hemidiaphragm is elevated and is a poor quality PA film. ASSESSMENT/PLAN: The patient is a 34-year-old male with a history of alcoholism, history of diabetes, hypertension, not taking his medications, who was on a recent alcohol binge, who presents with probable alcohol withdrawal.
PA|pulmonary artery|PA|144|145|HOSPITAL COURSE|An EKG was obtained which was normal. An echocardiogram was obtained which showed a structurally normal heart, trace tricuspid regurgitation, a PA pressure of 20 mmHg plus CVP, and good biventricular function. Two 12-lead EKGs during this time were obtained and were normal.
PA|pulmonary artery|PA|320|321|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Coronary artery disease. The patient underwent a heart cath in _%#MM2004#%_ which showed a 40% plaque in the circumflex prior to the OM-I take-off and an 80-90% ostial stenosis of the first OM-I. There is 40% stenosis of the proximal first diagonal branch of the LAD. 2. Pulmonary hypertension. PA pressures during heart cath were noted to be 61/22 with a mean of 36. 3. Severe mitral stenosis with a calculated mitral valve area of 0.5 to square cm and a gradient of 12.2 mm of mercury at time of heart cath.
PA|posterior-anterior|PA|118|119|RADIOLOGY|Potassium 3.9. Chloride 102. Bicarbonate 26. BUN 14. Creatinine 0.64. Glucose 95. Calcium 8.7. RADIOLOGY: Chest x-ray PA and lateral was performed this evening and was clear. ASSESSMENT/PLAN: 44-year-old female with history of chronic atopic dermatitis presenting with left hand cellulitis with pustular type lesion.
PA|posterior-anterior|PA|97|98|PHYSICAL EXAMINATION AT THE TIME OF ADMISSION|Decreased air entry was also noted. EXTREMITY: Shows no clubbing cyanosis or edema. Chest x-ray, PA and lateral done at the time of admission showed increasing left lower lobe infiltrate when compared with chest x-ray done two days ago.
PA|posterior-anterior|PA|102|103|OPERATIONS/PROCEDURES PERFORMED|DISCHARGE DIAGNOSES: 1. Shortness of breath. 2. Chest pain. OPERATIONS/PROCEDURES PERFORMED: 1. Chest PA and lateal _%#MM#%_ _%#DD#%_, 2004, unremarkable. 2. Chest CT with contrast _%#MM#%_ _%#DD#%_, 2004, no definite pulmonary embolism identified.
PA|pulmonary artery|PA|165|166|PROCEDURES AND TESTS|PROCEDURES AND TESTS: 1. On _%#DDMM2002#%_ the patient underwent a right and left heart catheterization. The right heart cath showed high right-sided pressures with PA pressures in the 60s. Angiogram showed a mid-LAD with moderate lesion, proximal left circumflex has moderate disease and RCA is occluded with some antegrade flow.
PA|posterior-anterior|PA|166|167|HOSPITAL COURSE|They also were unable to come up with the ideas for a source of infection in her. They did recommend chest x- ray views to evaluate any pleural effusions. However, a PA view of the chest showed no significant pleural effusions that would be appropriate for a thoracentesis. When the decision was made to pursue a liver biopsy as detailed below, we did obtain additional peritoneal fluid on hospital day #9.
PA|posterior-anterior|PA|180|181|PERTINENT IMAGING AND PROCEDURES|His cannulized umbilical vein consistent with portal hypertension. No evidence of portal vein thrombosis. Large amount of ascites. Tethered-small bowel mesentery. Splenomegaly. 3. PA and lateral chest x-ray performed on _%#DDMM2007#%_. Impression: Blunting of the left costophrenic angle laterally, which may be due to chronic sparing.
PA|posterior-anterior|PA|198|199|ADMISSION DIAGNOSIS|RA/RV enlargement, increased RVSP, increased PADP, no pericardial effusion. Spiral CT of the lungs to rule out pulmonary embolism was negative. Cardiac cath showed normal coronaries. RA pressure 8, PA pressure 20, wedge pressure 11, questionable mitral stenosis. Ultrasound compression of pseudoaneurysm secondary to cardiac cath through the right groin was successfully done on 2 attempts of compression x 15 minutes each.
PA|posterior-anterior|PA|187|188|LABORATORY DATA|CT scan of the head and facial bones show no evidence for fracture or active bleeding. Following x-rays were read by the emergency room doctor and conveyed to this physician. Chest x-ray PA and lateral read as negative. Bilateral forearms - questionable radial neck fracture on the left side.
PA|posterior-anterior|PA|234|235|HOSPITAL COURSE|The patient was immediately started on vancomycin and ceftazidime. The patient was also started on Abelcet due to her history of fungal infection of the lung. Blood cultures taken at admission and subsequently daily showed no growth. PA and lateral chest x-ray showed no significant change from previus study. A CT of the sinuses showed some mucosal thickening and fluid in the right maxillary sinus.
PA|posterior-anterior|PA|114|115|LABORATORY DATA|EKG shows sinus tachycardia with right axis deviation. Chest x-ray shows no obvious infiltrates or lesions on the PA or lateral film. She does have what appears to be possibly some osteoporosis. I am unable to pull up any comparison chest x-rays, but there is no obvious infiltrate.
PA|posterior-anterior|PA|346|347|ASSESSMENT AND PLAN|3. Pruritus -likely secondary to hyperbilirubinemia: I will continue his hydroxyzine and BuSpar as previously prescribed. We may consider adding doxepin if pruritus persists. 4. Dyspnea with exertion -likely secondary to possible pleural effusions plus infiltrates secondary to history of liver failure with ascites: We will evaluate this with a PA and lateral chest x-ray on his admission for documentation of these possible effusions. We will treat with diuresis as above. 5. Fatigue and deconditioning: We will have physical therapy and occupational therapy evaluate and treat during this hospitalization.
PA|posterior-anterior|PA|215|216|PROCEDURES PERFORMED|PROCEDURES PERFORMED: 1. Right fifth toe amputation with debridement of the local tissue. No evidence of abscess or cross-evidence of osteomyelitis. 2. Quinton external catheter placement for hemodialysis. 3. Chest PA and lateral on _%#DDMM2002#%_ which did not show any definite consolidation or atelectasis. There was some vague increased density in the left retrocardiac and costophrenic angle with indistinctness of the left hemidiaphragm which could pneumonia.
PA|posterior-anterior|PA|111|112|PLAN|Prior dislodgement spontaneously which has not been a recent issue. PLAN: 1. Admit to medicine. 2. Chest x-ray PA and lateral. 3. Aggressive pulmonary toilet with scheduled Duonebs and frequent suctioning. Review antibiotics with Dr. _%#NAME#%_ from infectious disease (with multiple past intolerances).
PA|pulmonary artery|PA|270|271|PREVIOUS CARDIAC STUDIES|PREVIOUS CARDIAC STUDIES: 1. Transthoracic echocardiogram _%#MM#%_ _%#DD#%_, 2006: Hyperdynamic LV with EF 70%. 2. Last angiogram _%#MM#%_ _%#DD#%_, 2000: Normal coronaries, LV gram shows EF of 50%, right heart pressures show mild pulmonary arterial hypertension with a PA pressure of 34/16 and a mean of 21. FAMILY HISTORY: Significant for paternal uncle who has multiple MIs and paternal grandfather with history of coronary artery disease.
PA|posterior-anterior|PA|199|200|LABORATORY|Her IgG level on _%#MM#%_ _%#DD#%_, 2006, was 668. Her albumin level on _%#MM#%_ _%#DD#%_, 2006, was 4.2. Her CMV DNA on _%#MM#%_ _%#DD#%_, 2006 was 1600. On _%#MM#%_ _%#DD#%_, 2006, her chest x-ray PA lateral was clear with no infiltrates. Her FUC was 2.36 and FEV was 2.08 on _%#MM#%_ _%#DD#%_, 2006, with ratio of 88. Her reflex was stable at the BUN of 27, creatinine of 2.24. HOSPITAL COURSE: Ms _%#NAME#%_ was admitted to the hospital at which time all her Rapamune and CellCept and Bactrim was all stopped.
PA|posterior-anterior|PA|198|199|LABORATORY DATA|NEUROLOGIC: Examination demonstrated an irritable boy with no focal changes, symmetric reflexes and 5/5 symmetric strength throughout. LABORATORY DATA: At this time an EKG, followup echocardiogram, PA and lateral chest x-ray and multiple labs are pending, and will be followed prior to his surgical procedure tomorrow.
PA|posterior-anterior|PA|246|247|CHIEF COMPLAINT|ASSESSMENT: This is a 37-year-old male with a past medical history of seasonal allergies, who presents with an acute episode of reactive airway disease with recent upper respiratory infection. PLAN: The patient is to be admitted for observation, PA and lateral chest film, for an ABG and albuterol and Atrovent nebulizers and steroids. COURSE IN HOSPITAL BY PROBLEMS: PROBLEM #1: Respiratory. Throughout his hospital stay, the patient's breathing became gradually better.
PA|posterior-anterior|PA|227|228|RECOMMENDATIONS|5. History of anxiety and depression: Currently, the patient is appropriate, and this seems to be adequately controlled. RECOMMENDATIONS: 1. Admission labs, including CBC, differential, chem-10, and venous blood gas. 2. Obtain PA and lateral chest x-ray. If there is a change from her baseline, I would have a low threshold for obtaining a chest CT scan.
PA|pulmonary artery|PA|120|121|OBJECTIVE|Respiratory rate 10 with O2 saturation 97 to 99% on 50% FIO2. Chest tube output was 50. Urine output 130 since surgery. PA pressures in the 40s/20s. HEENT demonstrates alopecia. Extraocular movements appear full. There is no nystagmus. Pupils equal, round and reacting symmetrically.
PA|pulmonary artery|PA|161|162|HISTORY OF PRESENT ILLNESS|Coronary artery angiogram showed the two vein grafts to be patent. He also has a significantly increased pulmonary artery pressure, which was 70/30, with a main PA pressure of 43. He has a pulmonary artery wedge pressure of 25. His right atrial pressure is 15. With this high pulmonary artery pressure, his central aortic pressure is only 84/58.
PA|physician associates|PA|73|74|PLAN|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, MD Ob-Gyn and Infertility PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_, Suite W400 _%#CITY#%_, MN _%#55400#%_ Dear Dr. _%#NAME#%_: Thank you for referring your patient, _%#NAME#%_ _%#NAME#%_, who was seen, along with her husband, _%#NAME#%_, for genetic counseling at the Maternal Fetal Medicine Center at Fairview Southdale on _%#MM#%_ _%#DD#%_, 2007.
PA|tissue plasminogen activator:TPA|PA|177|178|HISTORY OF PRESENT ILLNESS|The patient has been seen in the Emergency Room and evaluated with routine blood work, chest x-ray, head CT. She has been seen by Neurology and felt not to be a candidate for T PA The patient currently denies any abdominal pain, any diarrhea, any fevers, chills, night sweats, weight loss or anorexia. . PAST MEDICAL HISTORY: Remarkable for: 1. Adult onset diabetes mellitus, poorly controlled for 10 years with a hemoglobin A1c of 8.3.
PA|posterior-anterior|PA|166|167|ASSESSMENT AND PLAN|His wound culture done yesterday, Gram stain, did not show any organisms, wbc's, but the fluid culture does show moderate growth of Gram-positive cocci. Chest x-ray, PA and lateral, done yesterday shows poor inspiratory film but increased markings at bases of both lungs. No effusions noted when compared to the prior chest x-rays.
PA|posterior-anterior|PA|252|253|HISTORY|Unremarkable basic metabolic panel. No coronary artery disease with prior coronary artery bypass surgery. Troponin less than 0.07. BNP 49. CT scan of the head without contrast on _%#DDMM2004#%_ demonstrated no acute intracranial pathology. Chest x-ray PA and lateral demonstrated change related to previous sternotomy. Aortic calcification. Mild to moderate cardiac enlargement. No infiltrates. Urinalysis was unremarkable.
PA|physician assistant|PA|93|94|REQUESTING PHYSICIAN|ATTENDING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_. REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, PA PRIMARY CARE PHYSICIAN: Dr. _%#NAME#%_. ENT PHYSICIAN: Dr. _%#NAME#%_. REASON FOR CONSULTATION: Goals of care.
PA|pulmonary artery|PA|151|152|HISTORY|Right coronary artery had only mild luminal irregularities. There was a normal left ventriculogram. She had mild to severe pulmonary hypertension with PA pressure 61/22 and a mean of 36 mmHg. She had severe mitral stenosis with a calculated mean gradient of 12 mmHg and a calculated mitral valve area of 0.52 cm squared.
PA|pulmonary artery|PA|337|338|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: T-max 101.1, currently 100.4, blood pressure is 70s to 120s/30s to 50s, heart rate 90s-100s, respiratory rate 18-24 with a sedimentation rate of 18, tidal of 600, PEEP of 8, sats 98% at 40% FIO2. Weight today is 134.5 kilograms, down from 135.9 yesterday but up from 126 kilograms preop. CVP is 18-22. PA pressure is 43-49/24-28. 24 hour ins 18,750+, outs 3,750 of urine and 2,800 from the chest tube and 13,000 blood loss in the OR.
PA|pulmonary artery|PA|187|188|HISTORY OF PRESENT ILLNESS|He had an angiogram done by Dr. _%#NAME#%_ in 2004 that showed a 40-50% LAD lesion, a 60% right coronary lesion, a 30% obtuse marginal lesion. He had severe pulmonary hypertension with a PA pressure systolic of 66, this in the setting of aortic pressures which were in the very low 100s. Therefore, he was slightly below the two-thirds cutoff that we sometimes use for a recalcitrant of pulmonary hypertension.
PA|posterior-anterior|PA|132|133|PLAN|We will continue with parenteral Decadron protocol as ordered by Dr. _%#NAME#%_. 2. Follow-up by urine culture. Obtain chest x-ray, PA and lateral, to ensure no evidence for pneumonia (doubt clinically). CT scan of the abdomen and pelvis to insure no evidence for diverticulitis (low clinical suspicion).
PA|pulmonary artery|PA|144|145|HISTORY OF PRESENT ILLNESS|There is evidence of RV volume and pressure overload on former echocardiograms. The last echocardiogram was done in _%#MM2007#%_ and revealed a PA pressure of 48 plus estimated right atrial pressure, which was thought to be elevated in the 15-20 range. This suggests moderate to severe pulmonary hypertension. The patient does follow with our CHF clinic regularly.
PA|posterior-anterior|PA|280|281|IMPRESSION|With continual antibiotics and unless there is convincing evidence of osteomyelitis either radiographically or by profound elevation of the patient's sed rate and/or CRP, should achieve adequate levels with Flagyl and ciprofloxacin in bony tissues. Will also check a chest x-ray, PA and lateral, in this patient to evaluate a cardiac size. Would continue ECG for baseline, as she may have a surgical procedure.
PA|pulmonary artery|PA|240|241|ASSESSMENT AND PLAN|Contrast agent was used to improve endocardial definition. He likely has underlying diastolic dysfunction given his uncontrolled hypertension. His blood pressure was 180/115 on admission. He also has evidence of pulmonary hypertension. The PA pressure mentioned on the preliminary report showed 50 estimated right atrial pressure. Although I think the PA pressures are limited on my review of the echocardiogram, this value appears to be somewhat of an overestimate given the technical difficulty in measuring the PA pressure.
PA|posterior-anterior|PA|173|174|PLAN|Check O2 sat to ensure adequate on room air. Prophylax with albuterol prior to treatment if planned. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Chest x-ray PA and lateral, EKG. 3. Add sedimentation rate and CPK to laboratories. 4. Check O2 sat. 5. Z-pack 500 mg day #1 and 250 mg q. day x 4.
PA|physician associates|PA|62|63|ASSESSMENT AND PLAN|_%#MM#%_ _%#DD#%_, 2007 _%#NAME#%_ _%#NAME#%_, MD OB-GYN West PA _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ Suite 130 _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was seen at the Fairview Southdale Maternal Fetal Medicine Center on _%#MM#%_ _%#DD#%_, 2007. She came to clinic for genetic consultation and level II ultrasound due to advanced maternal age in pregnancy.
PCP|primary care physician|PCP|149|151|SPECIFIC DISCHARGE INSTRUCTIONS|8. If unable to attend scheduled followup appointment stated below need to reschedule. Followup appointments, referrals and labs, 1. Dr. _%#NAME#%_, PCP Smileys Clinic as scheduled for _%#DDMM2007#%_ at 4. p.m. 2. Dr. _%#NAME#%_, neurologist, PWB as scheduled for _%#DDMM2007#%_ at 11 a.m.
PCP|phencyclidine|PCP,|195|198|HOSPITAL COURSE|I would recommend a repeat TSH and free thyroxine level as an outpatient to assess her thyroid status more thoroughly. Of interest, her urine tox screen on admission was negative for evidence of PCP, cannabinoids, acetaminophen, metanephrine, barbiturates, benzodiazepines, cocaine, opiates and tricyclic antidepressants. This is despite the fact that she was on some of these medicines including a fentanyl patch.
PCP|Pneumocystis jiroveci pneumonia|PCP,|247|250|HOSPITAL COURSE|She was initiated on vasopressin and continued with aggressive fluid boluses and I.V. hydration and blood products. She was intubated at the scene. Pulmonary was consulted. She was initiated on broad-spectrum antibiotics including antibiotics for PCP, namely I.V. Bactrim. Her pH came back at 6.85, pCO2 of 14, pO2 206, bicarbonate less than 3. Chest x-ray showed bilateral extensive infiltrates. She had abnormal LFTs showing shock liver.
PCP|Pneumocystis jiroveci pneumonia|PCP|171|173|HOSPITAL COURSE|For full details of the history of present illness, past medical history and physical examination, please refer to the H&P from the date of admission. HOSPITAL COURSE: 1. PCP pneumonia: Upon admission, the patient began requiring a significant amount of oxygen. Pulmonary was consulted for bronchoscopy, which was done on the first hospital day.
PCP|Pneumocystis jiroveci pneumonia|PCP.|221|224|HOSPITAL COURSE|HOSPITAL COURSE: 1. PCP pneumonia: Upon admission, the patient began requiring a significant amount of oxygen. Pulmonary was consulted for bronchoscopy, which was done on the first hospital day. This ended up growing out PCP. She was started on pentamidine and prednisone because of an allergy to sulfa medications. Over the rest of her hospital course, she gradually required less oxygen and her coughing had significantly improved.
PCP|primary care physician|PCP.|247|250|HISTORY OF PRESENT ILLNESS|However, the patient has a history of loss of weight in the last one year of about 25 pounds, however, she has a history of trying to diet. For hypertension, the patient used to take 100 mg atenolol daily which was cut down to 50 mg p.o. daily by PCP. REVIEW OF SYSTEMS: No headache, no visual disturbances. No focal weakness.
PCP|primary care physician|PCP|134|136|DISCHARGE PLAN|Follow up with primary care doctor, Dr. _%#NAME#%_, for further prevention of regimen as per below. DISCHARGE PLAN: 1. Follow up with PCP Dr. _%#NAME#%_ at Fairview Uptown in 1 week for review of migraine headache regimen and repeat LFTs. 2. Dr. _%#NAME#%_, ID clinic in 1-2 months
PCP|Pneumocystis jiroveci pneumonia|PCP|109|111|C.|8. Tylenol 325 mg p.o. q.6 as a pre-medication as well as for fevers. 9. Pentamidine 140 mg IV q. monthly as PCP prophylaxis as he is allergic to Bactrim. 10. His antibiotics were usually voriconazole on a prophylactic level; this on the day of admission was increased to an IV treatment dose.
PCP|Pneumocystis jiroveci pneumonia|PCP|161|163|PAST MEDICAL HISTORY|These seem to be improved by taking Tylenol. PAST MEDICAL HISTORY: 1. She has end-stage AIDS. 2. History of CMV retinitis with left eye blindness. 3. History of PCP infection. 4. HSV. The patient was admitted to North Memorial Medical Center from _%#MM#%_ _%#DD#%_, 2004, until _%#MM#%_ _%#DD#%_, 2004, for an HSV outbreak, nausea, and vomiting, treated wit acyclovir and HSV symptoms resolved, but fevers, nausea, and vomiting continued.
PCP|primary care physician|PCP|203|205|HISTORY OF PRESENT ILLNESS|He initially developed some upper respiratory type symptoms and went in to see his primary care provider on _%#DDMM2004#%_, which is two days prior to admission. The patient states that he talked to his PCP about his headache and upper respiratory symptoms and was given azithromycin. He took 500 mg on _%#DDMM2004#%_, then 250 mg yesterday, the day prior to admission.
PCP|Pneumocystis jiroveci pneumonia|PCP,|155|158|PAST MEDICAL HISTORY|His primary care is with Dr. _%#NAME#%_ at the University of Minnesota. He has had multiple complications with opportunistic infection, including Giardia, PCP, Mycobacterium avium, for which he is currently receiving treatment with amikacin because it was resistant to other medications. He also has a history of toxic megacolon secondary to Campylobacter and history of Salmonella.
PCP|Pneumocystis jiroveci pneumonia|P.C.P.|141|146|HOSPITAL COURSE|Chest x- ray shows diffuse bilateral infiltrates. HOSPITAL COURSE: PROBLEM #1: P.C.P. Pneumonia. Patient underwent bronchoscopy which showed P.C.P. on his pleural fluid as well as the transbronchial biopsy. Induced sputums were attempted. However, the patient was unable to produce sputum.
PCP|Pneumocystis jiroveci pneumonia|PCP|182|184|HOSPITAL COURSE|The patient was started on Ceftriaxone and Azithromycin on admission to cover community acquired pneumonia. The patient's most recent CD4 was 395 done in _%#MM2004#%_. Suspicion for PCP was low. The patient was not treated for PCP. Also, given patient's history of lymphoma, CT scans were obtained of the chest, abdomen and pelvis to rule out lymphoma.
PCP|primary care physician|PCP|177|179|CHIEF COMPLAINT|DISCHARGE DIAGNOSIS: Anemia, secondary to gastrointestinal bleeding, plus secondary to endstage renal disease. HISTORY OF PRESENT ILLNESS: The patient came with a referral from PCP (primary care physician). At the time of admission, the patient was asymptomatic. He denies any chest pain, shortness of breath, or confusion.
PCP|primary care physician|PCP.|223|226|DIET|ACTIVITY: As tolerated. FOLLOW UP: He has an appointment with primary care physician on _%#MM#%_ _%#DD#%_, 2005. The patient was given information about necessity of hemodialysis. He will be discussing this option with his PCP. ADVANCED DIRECTIVES: The patient wants to be a full code.
PCP|phencyclidine|PCP,|144|147|LABORATORY DATA|CT of the head showed no acute bleed. Alcohol level is nondetectable. Myoglobin is 520, U-Tox shows cannabis, otherwise negative for tricyclic, PCP, cocaine, barbiturates, methamphetamine and amphetamine. Next, acetaminophen and salicylate level are negative. Glucose is 135, potassium is 4.1, creatinine is 1.7, NI gap is 30.
PCP|Pneumocystis jiroveci pneumonia|PCP|277|279|ASSESSMENT/PLAN|LFTs within normal limits. Troponin less than 0.07, myoglobin 24, TSH of 10.19, and magnesium 1.9, free thyroxin 1.21 and chest x-ray shows an infiltrate in the right lower lobe, also some diffuse interstitial process. ASSESSMENT/PLAN: 1. Pneumonia in HIV patient; worry about PCP (Pneumocystis carinii pneumonia). We will start prednisone and IV Bactrim and will also continue Levaquin and sputum has been collected in the emergency room to make sure this is also send for PCP.
PCP|Pneumocystis jiroveci pneumonia|PCP|274|276|HOSPITAL COURSE|We requested Hematology-Oncology consult as the patient's white count has not been increasing in spite of holding MMF and Valasate. Hematology-Oncology consult advised at this point not to perform bone marrow biopsy, but to continue Bactrim, which the patient is taking for PCP prophylaxis, being immunocompromised status post heart transplant, and replace it with sulfamethoxazole and pentamidine. We will continue holding Cellcept until the patient's white count comes back to approximately 5000.
PCP|Pneumocystis jiroveci pneumonia|PCP|182|184|HOSPITAL COURSE|She was maintained on prophylactic fluconazole, Keflex, and Cipro. In addition, she received acyclovir for CMV prophylaxis. She is allergic to sulfa and will receive pentamidine for PCP prophylaxis following engraftment. Of note, she was bacteremic during the time of her peripheral blood stem cell collections. The collected product was cultured and found to be negative; however, in order to prevent complications, she received vancomycin two days prior to transplant and will be discharged on daily vancomycin.
PCP|phencyclidine|PCP|219|221|LABS AT ADMISSION|He has bruising notable on the left arm and a superficial skin tear at the left upper shoulder. Pulses are markedly decreased throughout. LABS AT ADMISSION: Include a urine tox. with positive for barbiturates, opiates, PCP and TCAs. Urinalysis is positive with 50-100 WBCs and many bacteria. Basic metabolic is notable for a BUN 31 with creatinine 2.1, and glucose 130, but otherwise normal.
PCP|Pneumocystis jiroveci pneumonia|PCP,|195|198|HISTORY OF PRESENT ILLNESS|We appreciate the help of the Pulmonary team with this. Bronch results are negative at this time. The (_______________) to pathology was negative for organisms, negative for fungus, negative for PCP, negative for CMV. However, the CMV rapid shell viral culture came back positive. ADDENDUM: This was discussed at length with the pulmonary and with the infectious disease consulting teams.
PCP|Pneumocystis jiroveci pneumonia|PCP.|213|216|HOSPITAL COURSE|HOSPITAL COURSE: Given the history of HIV positivity we were worried about the possible PE versus opportunistic infection in his lungs. We initially started him on IV gatifloxacin and Bactrim dose therapeutic for PCP. Infectious Disease was consulted as well as Pulmonary. They recommended a high resolution chest CT which did not show any underlying abnormality as well as VQ scan and bilateral venous lower extremity dopplers.
PCP|phencyclidine|PCP.|253|256|LABS|CBC showed hemoglobin of 14.4 and 14.3, white blood cell count of 11,100 and 12,900, platelet count normal at 365,000. Drug analysis showed acetaminophen level < 10, salicylate level < 1, ethanol level < 0.01. Drug screen was positive for methadone and PCP. ASSESSMENT/PLAN: This is a 28-year-old female patient with a history of depression, for which she is maintained on two medications, who last night ingested 96 tablets of sleeping pills which contained diphenhydramine HCL.
PCP|phencyclidine|PCP,|224|227|HISTORY OF PRESENT ILLNESS|For this reason, he was given multi vitamins. There is no family history of early heart disease or sudden death. The patient smokes, average 1-3 packs per day for many years. Also does illegal drugs. He smokes cocaine, LSH, PCP, marijuana, hashish. The last time he used them was several months ago. PAST MEDICAL HISTORY: No previous heart failure or myocardial infarction.
PCP|phencyclidine|PCP,|186|189|SOCIAL HISTORY|He tries to do personal self improvement . He is single and has two children. He denies alcohol intake. History of drug abuse as mentioned above. Previous Cocaine, smoking cocaine, LSH, PCP, marijuana and hashish. FAMILY HISTORY: One brother and one sister. No family history of heart disease, or sudden death. REVIEW OF SYSTEMS: GENERAL: No previous HIV as stated.
PCP|Pneumocystis jiroveci pneumonia|PCP|208|210|HISTORY OF PRESENT ILLNESS|He was admitted with fevers, chills, and nausea. The patient's temperature had risen to 102.2 and he was started on vancomycin and ceftriaxone, given his chronic immunosuppression. Of note, the patient is on PCP prophylaxis with Bactrim. PHYSICAL EXAMINATION: Once admitted on the floor, the patient's fever had decreased to 98.7. His vital signs were stable throughout his admission.
PCP|Pneumocystis jiroveci pneumonia|PCP|141|143|HOSPITAL COURSE|The patient is to follow up with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_. PROBLEM #2. Wegner's disease. Patient was continued on prednisone with PCP and fungal prophylaxis. PROBLEM #3. GI prophylaxis. Patient was given steroids and b.i.d. PPI.
PCP|Pneumocystis jiroveci pneumonia|PCP|472|474|HISTORY OF PRESENT ILLNESS|He was admitted to the medicine service. For pneumonia, the patient had a chest x-ray in the emergency room that was compatible with a right lower lobe pneumonia, although the patient had to receive a dose of Bactrim in the ER because of concerns of possible PCP pneumonia, that was doubted as a diagnosis because of the patient not being on any sort of prophylaxis, and therefore likely to have a CD4 count of more than 200. Infiltrate also was not likely to be one of a PCP pneumonia. It was decided then to treat the patient with IV ciprofloxacin and azithromycin that was later changed to PO levofloxacin, the patient was discharged when he was afebrile for the 24 hours.
PCP|Pneumocystis jiroveci pneumonia|PCP|362|364|DISCHARGE MEDICATIONS|For that, the patient will get CT without contrast evaluation as an outpatient next time he sees Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2006. DISCHARGE MEDICATIONS: Ciprofloxacin 500 mg orally twice a day for 7 days, Augmentin 500 mg orally twice a day for 7 days to complete antibiotic course for neutropenic fevers, Bactrim single strength tablet once a day for PCP prophylaxis, Decadron 2 mg orally 3 times a day, Lantus 30 units subcutaneously every evening, regular insulin sliding scale, CellCept 250 mg orally once a day, Trileptal 450 mg orally twice a day, atenolol 100 mg orally twice a day, Norvasc 10 mg orally once a day, lisinopril 10 mg orally once a day, hydrochlorothiazide 12.5 mg once a day orally, Colace 100 mg orally twice a day, and Protonix 40 mg orally twice a day, Lexapro 10 orally daily, Risperdal 50 mg orally every evening, and furosemide 80 mg orally twice a day.
PCP|Pneumocystis jiroveci pneumonia|PCP|204|206|HOSPITAL COURSE|Given her status as an Ethiopian emigrant, we were concerned for organisms other than just community- acquired organisms. Specifically, we were worried about tuberculosis and possible concomitant HIV and PCP infection. She was therefore evaluated for HIV. This was a negative. She had a PPD that was placed, and this was negative as well.
PCP|Pneumocystis jiroveci pneumonia|PCP|213|215|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: The patient is a 44-year-old man with history of HIV admitted for treatment of pneumonia with no prior history of opportunistic infections He is started on IV Levaquin. Further evaluation for PCP pneumonia might be considered dependent on his response to current treatment.
PCP|Pneumocystis jiroveci pneumonia|PCP|278|280|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 43-year-old female who was admitted in _%#MM#%_ for non-myeloablative umbilical cord transplant for treatment of AML. Previously at an outside hospital, she had been receiving induction. This was complicated by the development of PCP and VRE pneumonia requiring transfer to the University of Minnesota Medical Center, Fairview, and a long hospital course. She also has a history of cutaneous HSV and presumed fungal infections of the brain, eyes and lung.
PCP|primary care physician|PCP|82|84|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Albuterol MDI p.r.n. as he was taking at home. Follow with PCP p.r.n.
PCP|Pneumocystis jiroveci pneumonia|PCP|292|294|HISTORY OF PRESENT ILLNESS|2. Severe COPD. 3. Metastatic lung cancer. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a pleasant 60- year-old female with a history of metastatic lung cancer, severe COPD, and, recently, deep venous thrombosis and pulmonary embolism. Patient was receiving pentamidine treatment for PCP prophylaxis on _%#DDMM2002#%_ when she became increasingly short of breath. At that time she was transferred to Fairview University Medical Center where she had a respiratory arrest and was intubated.
PCP|Pneumocystis jiroveci pneumonia|PCP.|145|148|HOSPITAL COURSE|Bronchial specimens were sent for PCP, fungus, TB, staph, and viral cultures. The initial bronchial lavage results were positive for Candida and PCP. The Candida was thought to be a contaminate, but the patient was already on treatment for his PCP. The biopsy results were pending by the time of discharge.
PCP|Pneumocystis jiroveci pneumonia|PCP|147|149|PROBLEM #3|To explain the eosinophilia, stools were sent for ova and parasites which came back negative as well. His eosinophilia was likely secondary to his PCP infection. PROBLEM #4: Peripheral neuropathy. The patient has a history of frostbite with tingling and numbness as well as shooting pain down his right leg.
PCP|Pneumocystis jiroveci pneumonia|PCP|183|185|PROBLEM #5|He had minimal GI toxicity, and had normal p.o. intake at the time of discharge. PROBLEM #5: Infectious disease. The patient continues on prophylactic acyclovir and gatifloxacin. His PCP prophylaxis with Bactrim will begin after his counts have recovered. He was afebrile throughout his hospital course. PROBLEM #6: Hepatitis C.
PCP|Pneumocystis jiroveci pneumonia|PCP|180|182|DISCHARGE MEDICATIONS|2. Azithromycin 1200 mg p.o. q week 3. Diflucan mouthwash swish and swallow X7 days 4. OxyContin 20 mg p.o. q.4-6h p.r.n. pain 5. Bactrim DS one tab p.o. b.i.d. for prophylaxis of PCP PROCEDURES PERFORMED: PICC line placement. OTHER DISCHARGE INSTRUCTIONS: 1. PICC line cares. 2. Follow up with Infectious Disease Clinic within the next one week of discharge.
PCP|phencyclidine|PCP,|250|253|PROBLEMS PRESENTED AT ADMISSION|DISCHARGE DATE: _%#DDMM2006#%_. DISCHARGE STATUS: Successfully completed. PROBLEMS PRESENTED AT ADMISSION: At admission, _%#NAME#%_ reported daily marijuana use, weekly alcohol use, as well as amphetamine use, barbiturates in the last 2-6 months and PCP, shrooms, Robitussin and cocaine within his lifetime. He has had significant school problems, family conflict, legal problems and struggles with issues surround possible depression and anxiety.
PCP|primary care physician|PCP|113|115|DISCHARGE FOLLOW-UP|8. Diovan 160 mg daily. 9. Toprol 50 mg daily. 10. Lasix 20 mg daily. DISCHARGE FOLLOW-UP: 1. Follow-up with her PCP in 1-2 weeks with electrolytes to be performed at that time. 2. Follow-up with Dr. _%#NAME#%_ as previously scheduled.
PCP|primary care physician|PCP.|227|230|DISCHARGE INSTRUCTIONS|He was strongly advised against flying within 24 hours of his procedure due to medical risks and he was given a note which should excuse him as far as the airlines are concerned. 2. Recheck hemoglobin on return office visit to PCP. 3. Follow up with PCP within 1 week.
PCP|primary care physician|PCP.|178|181|HISTORY OF PRESENT ILLNESS|The patient had been in heavy and progressive fatigue over 2 weeks prior to admission and was getting progressively worse. A week prior to admission, the patient was seen by her PCP. She was found to have a creatinine of 4.9. At that time, the patient's primary decided to just watch the creatinine level, however, on the day of admission, the patient was returned to a clinic and her creatinine was noted to be elevated to 5.6. The patient was also noting increased ileostomy output at that time as well.
PCP|primary care physician|PCP,|129|132|FOLLOW-UP|It was a pleasure serving in _%#NAME#%_'s care. Please do not hesitate to contact me with questions or concerns. FOLLOW-UP: With PCP, Dr. _%#NAME#%_, on the week after discharge as a follow-up from hospitalization. He is discharged on lactobacillus 1 packet p.o. daily x5 days.
PCP|primary care physician|PCP|108|110|DISCHARGE INSTRUCTIONS|14. K-Dur 20 mEq p.o. daily as a potassium supplement along with Lasix. DISCHARGE INSTRUCTIONS: Follow with PCP in 1 week for creatinine and hemoglobin.
PCP|primary care physician|PCP|251|253|DISCHARGE INSTRUCTIONS|After taking Zofran 4 mg p.o. q.6h. p.r.n., if nausea still persists, the patient should change her Zofran and Reglan to b.i.d. as a scheduled dose. Follow with Dr. _%#NAME#%_ on _%#DDMM2007#%_ for discussion of the biopsy reports and follow with the PCP in 1 week's time.
PCP|primary care physician|PCP|148|150|BRIEF HISTORY AND PHYSICAL|He had positive stress test outside the hospital done by his primary care physician. Initially, it was planned to treat him medically, but when his PCP learned that the patient still had a constant chest pain, he was transferred to Fairview Medical Center for possible intervention.
PCP|Pneumocystis jiroveci pneumonia|PCP|181|183|HOSPITAL COURSE|All blood cultures were negative. She had a positive throat culture for heavy growth of Candida albicans and nystatin was added to her antibiotic regimen. Bactrim was initiated for PCP prophylaxis prior to discharge. She also remains on fluconazole and acyclovir for antifungal and antiviral prophylaxis respectively.
PCP|Pneumocystis jiroveci pneumonia|PCP|177|179|PERTINENT LABS|The patient fill followup with Pulmonary, Dr. _%#NAME#%_, to have this steroid dose tapered over a long period of time. The patient was also started on Bactrim for prophylactic PCP coverage given her immune- compromised state. The patient during her hospital stay did have a biopsy done of her right middle lobe to confirm the diagnosis of ARDS.
PCP|Pneumocystis jiroveci pneumonia|PCP|133|135|DISCHARGE MEDICATIONS|3. The patient is not currently taking Nystatin, Norvasc, or daily Bactrim for bacterial prophylaxis. Instead, he will need to begin PCP prophylaxis with Bactrim once his counts have recovered. DISCHARGE STATUS: The patient will be discharged to home accompanied by his wife.
PCP|Pneumocystis jiroveci pneumonia|PCP|239|241|PROBLEM #2|He was treated with G-CSF and had a marked increase in his ANC up to 6.6 upon discharge from 0.2 upon admit. His Bactrim PCP prophylaxis was held for a total of one month. In replacement, he received Pentamidine aerosolized inhalation for PCP prophylaxis to cover him for the next month. Granulocyte antibody screen was negative. PROBLEM #3: Neutropenic fevers. The patient was pancultured and did have a chest x-ray which was unremarkable for infection.
PCP|Pneumocystis jiroveci pneumonia|PCP|135|137|DISCHARGE INSTRUCTIONS|3. The patient will need to be started on Bactrim double strength 1 tab p.o. b.i.d. q. Monday and Tuesday, starting _%#DDMM2003#%_ for PCP prophylaxis. 4. The patient needs an orthopedic consult upon arrival for possible fracture of the right triquetrum bone.
PCP|phencyclidine|PCP.|237|240|LABORATORY STUDIES|Thyroid function tests reveal a free T4 of 1.11, and TSH of 1.69, both within normal limits. Urine drug screen is negative for methamphetamines, barbiturates, benzodiazepines, tricyclic antidepressants, cannabinoids, cocaine, opiates or PCP. EKG reveals a pattern of normal sinus rhythm, with a rate of 96, with no ST segment elevation noted. IMPRESSION: The patient is a 53-year-old Caucasian female with a presentation of bizarre neurological findings, although no acute sensory or motor dysfunction is noted.
PCP|Pneumocystis jiroveci pneumonia|PCP.|214|217|PLAN|3. We will also start her today on Bactrim DS b.i.d. for any possible PCP, because of the fact that she is on prednisone and methotrexate. 4. We will send for blood cultures and sputum cultures, and check also for PCP. 5. Providing that the cultures are negative, we will continue with the antibiotics for ten days. 6. As the patient gets better, we will start to ambulate her, and test whether or not she needs oxygen.
PCP|Pneumocystis jiroveci pneumonia|PCP|232|234|PROBLEM 3|She should continue prophylaxis with fluconazole and Tequin. Acyclovir was discontinued in the clinic. However, was resumed after DLI infusion and resolution of her elevated LFTs. Also, she received Pentamidine on _%#DDMM2004#%_ as PCP prophylaxis. PROBLEM #4: Mood. She should continue Zoloft and trazodone. PROBLEM #5: Skin. She presented with a faint maculopapular rash upon admission.
PCP|Pneumocystis jiroveci pneumonia|PCP.|277|280|HISTORY OF PRESENT ILLNESS|If she continues to have her complaints of substernal burning discomfort and nausea, she should probably be sent for esophagoduodenoscopy to rule out some peptic ulcerative condition. Return otherwise on a p.r.n. basis but she is to be seen in the office in two weeks with her PCP.
PCP|Pneumocystis jiroveci pneumonia|PCP|401|403|ADMISSION DIAGNOSIS|LABORATORY RESULTS ON DISCHARGE: Sodium 138, potassium 3.5, chloride 103, CO2 33, glucose 95, BUN 4, creatinine 0.49, calcium 8.3, methotrexate level 0.08. CBC from _%#MM#%_ _%#DD#%_, 2004, showed white blood cell count 2.3, hemoglobin 10.7, platelets 163, differentia 15% monocytes with 59% neutrophils, 24% lymphocytes. DISCHARGE MEDICATIONS: 1. Bactrim DS 1 p.o. b.i.d. on Mondays and Tuesdays for PCP prophylaxis, 2. Colace 100 mg p.o. b.i.d. 3. Prilosec 10 mg p.o. daily. 4. Zoloft 25 mg p.o. daily. 5. Allegra 180 mg p.o. daily.
PCP|Pneumocystis jiroveci pneumonia|PCP|196|198|PROBLEM #3|She had no positive blood cultures during her hospitalization and rapidly defervesced. At the time of discharge, she remains on prophylactic Levaquin, voriconazole, and acyclovir. Her Bactrim for PCP prophylaxis has not been started yet. As a prophylactic measure, _%#NAME#%_ was started on Tamiflu and should continue a full seven-day course at prophylactic doses.
PCP|primary care physician|PCP|284|286|DISCHARGE FOLLOWUP|The patient also takes Vicodin for pain. He is not provided a script for any extra Vicodin at this time and does need to follow up with his primary care physician for anymore Vicodin. DISCHARGE FOLLOWUP: With Dr. _%#NAME#%_ in cardiology in 3-4 weeks, also with Dr. _%#NAME#%_ in the PCP clinic in 2 weeks. DISCHARGE DIET: Cardiac, low-saturated fat, low-cholesterol diet.
PCP|Pneumocystis jiroveci pneumonia|PCP|504|506|HISTORY OF PRESENT ILLNESS|6. Relapse ALL with recent consolidation. For Interim Summary through admission through _%#MM#%_ _%#DD#%_, 2002, please see discharge dictation by _%#NAME#%_ _%#NAME#%_ on the Medical ICU. HISTORY OF PRESENT ILLNESS: In brief, this is a 51-year-old female with relapsed ALL status post induction in _%#DDMM2002#%_ with consolidation in _%#DDMM2002#%_, undergoing intrathecal consolidation with methotrexate, Ara-C, at the time of admission, admitted _%#DDMM2002#%_ for shortness of breath, found to have PCP and CMV pneumonia which resulted in ARDS, intubated on _%#DDMM2002#%_ through _%#DDMM2002#%_. The patient transferred to floor on _%#DDMM2002#%_ after being extubated 2 days prior.
PCP|phencyclidine|PCP|201|203|HISTORY OF PRESENT ILLNESS|She was found in her bedroom with decreased level of consciousness and periods of apnea. She was transported to the emergency room. Evaluation there was unremarkable including CT of her head and labs. PCP was found in her urine, but all her other labs were okay. She was somewhat hypoxic and was admitted for further evaluation of her decreased level of consciousness.
PCP|Pneumocystis jiroveci pneumonia|PCP|313|315|PROBLEM #3|His CSA level is therapeutic at this time. PROBLEM #3: Infectious disease. He has remained afebrile throughout his hospitalization and will be discharged on routine antifungal prophylaxis with fluconazole, antibacterial prophylaxis with gatifloxacin, high-dose antiviral prophylaxis with acyclovir and will start PCP prophylaxis with Bactrim as an outpatient. PROBLEM #4: GI. He did have intermittent nausea and vomiting throughout his hospitalization and initially had trouble keeping his food down.
PCP|phencyclidine|PCP,|185|188|PHYSICAL EXAMINATION|The film is not currently available for my current review. Urine tox screen is positive for amphetamines and methamphetamines. Negative for barbiturates, benzodiazepines, THC, cocaine, PCP, opiates, and tricyclics and antidepressants. Her salicylate and Tylenol levels are negative. Urinalysis reveals 80 mg per dl of ketones, but is otherwise within normal limits.
PCP|Pneumocystis jiroveci pneumonia|PCP,|208|211|PRINCIPAL DIAGNOSIS|He developed a generalized erythroderma and fevers which he did not measure at home. PAST MEDICAL HISTORY: His past medical history is significant for HIV diagnosed in 1995. His associated diseases have been PCP, thrush, HFC. His most recent CD4 count was 16 in _%#DDMM2004#%_. His other past medical history is significant for anxiety, chronic pain syndrome, status post right ankle repair, and status post tonsillectomy in childhood.
PCP|phencyclidine|PCP|168|170|LABORATORY DATA|INR and PTT were normal. Acetaminophen and salicylate levels were normal. CBC was normal except for RDW of 16.9, hemoglobin was 15.9. Urine tox screen was positive for PCP and cocaine, but negative for benzodiazepines or marijuana. The results of this urine tox screen are questionable because the patient admits to taking benzodiazepines prior to admission but totally denies PCP.
PCP|phencyclidine|PCP.|303|306|LABORATORY DATA|CBC was normal except for RDW of 16.9, hemoglobin was 15.9. Urine tox screen was positive for PCP and cocaine, but negative for benzodiazepines or marijuana. The results of this urine tox screen are questionable because the patient admits to taking benzodiazepines prior to admission but totally denies PCP. ASSESSMENT: 1. Status post Ativan overdose in an attempt to treat narcotic withdrawal.
PCP|phencyclidine|PCP,|237|240|PAST MEDICAL HISTORY|He has requested assistance in finding out what has been going on over the last three days and as stated above he has requested that I speak to his mother who I have spoken to. PAST MEDICAL HISTORY: 1. Polysubstance drug abuse including PCP, marijuana, cocaine and shrooms, as well as alcohol. 2. Gunshot wound 20 years ago to right calf. PAST SURGICAL HISTORY: None.
PCP|phencyclidine|PCP,|246|249|PENDING DISCHARGE 07/02/2007|Her potassium was 4.6, sodium 139, BUN was 38, creatinine 1.57. The remaining of filtration rate calculated was 33 MS per minute. Lorazepam level was less than 10. UA was negative. Leukocyte esterase was negative. Urine screen for drugs included PCP, cannabinoids, amphetamine, barbiturates, benzodiazepines, cocaine, opiates, tricyclics, all of them were not detected. Urine culture showed 10-50,000 colonies of multiple species most likely contamination.
PCP|Pneumocystis jiroveci pneumonia|PCP|184|186|ASSESSMENT AND PLAN|He will receive GVHD prophylaxis with tacrolimus and methotrexate. 2. ID: The patient will have standard antimicrobial prophylaxis with fluconazole, high-dose acyclovir, Levaquin, and PCP prophylaxis with pentamidine per institutional protocol. 3. Heme: The patient has pulmonary nodules due to his disease, which increases his risk for bleeding.
PCP|primary care physician|PCP|245|247|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Pantoprazole 5 mg suspension by J tube every night and fluticasone, propionate 110 mcg MDI 2 puffs inhaled twice daily for asthma prophylaxis. Follow up as scheduled with Dr. _%#NAME#%_ _%#NAME#%_ for 2 weeks and with the PCP as needed. The patient has no restrictions. Dietary restrictions include no liquids, no thinner than honey consistency. It was a pleasure to be involved in _%#NAME#%_ _%#NAME#%_'s medical care.
PCP|primary care physician|PCP|433|435|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 44-year-old white gentleman who about a week ago went on a camping trip and on _%#MMDD#%_ noticed an insect bite on the dorsum of the right foot which had turned into a papule, which he relates to a deer tick bite since he had noticed a tick inside his sock when he came back from the camping trip. The right foot dorsum started swelling and became red; the patient went to his PCP and was started on Augmentin. With no relief with Augmentin the patient came to the ER on _%#MMDD#%_, where Dr. _%#NAME#%_ _%#NAME#%_ saw the patient and started him on ciprofloxacin p.o.
PCP|Pneumocystis jiroveci pneumonia|PCP,|329|332|PROBLEM #3|The patient has had a good response and was due to start his mid cycle treatment of #3, but admitted just prior to restarting this chemotherapy with dyspnea, fever and pulmonary infiltrates. Infectious disease and ID were consulted. The patient required bronchoscopy and broad-spectrum antibiotics including Bactrim for possible PCP, Levaquin, antivirals, etc. The patient also received empiric steroids. With this aggressive treatment, the patient's respiratory status was significantly improved.
PCP|Pneumocystis jiroveci pneumonia|PCP|351|353|HOSPITAL COURSE|Pain went away, and he was restarted feeding. He was fed on _%#MMDD#%_ with clear liquids, which he tolerated very well, and on _%#MMDD#%_ was advanced to regular diet, and he was discharged home without any side effects. Antibiotics were held on _%#MMDD#%_, and after discussion with ID, there was no reason to start him on therapeutic treatment for PCP since he has been taking prophylaxis for a long time. In summary, this is a patient with HIV, recurrent pancreatitis with an acute episode of pancreatitis, and diabetes, who was admitted for active flare-up of his pancreatitis.
PCP|Pneumocystis jiroveci pneumonia|PCP|154|156|PROBLEM #2|PROBLEM #2: I.D. Blood cultures were drawn X3 days. He was started on vancomycin and ceftazidime. He was continued on his home prophylactic, Bactrim, for PCP and was administered Tylenol for temperature spikes. Blood cultures were subsequently negative, and the morning after admission the number of papular lesions had grown.
PCP|phencyclidine|PCP,|133|136|HISTORY OF PRESENT ILLNESS|She denies use of other drugs. The patient was quite agitated in the _%#CITY#%_ Emergency Room. A urine drug screen was positive for PCP, cocaine, opiates, barbiturates, tricyclics, and methadone. The patient denies using all the drugs, except for IV Vicodin. She agreed to come in for further evaluation and treatment.
PCP|Pneumocystis jiroveci pneumonia|PCP|177|179|PROBLEM #2|She was restarted at a low dose of 250 mg b.i.d., and should continue on this. She was continued on her other usual immunosuppressants, which include prednisone and dapsone for PCP prophylaxis. She will follow up with Dr. _%#NAME#%_ in clinic. PROBLEM #3: Mild chronic renal insufficiency. On admission, the patient's creatinine was noted to be 2.0. Her baseline is approximately 1.7. She received some fluids.
PCP|Pneumocystis jiroveci pneumonia|PCP.|120|123|PAST MEDICAL HISTORY|He had a CD-4 count of 111 a month ago and a viral load of 256,000. He hs had no AIDS-defining illnesses, no history of PCP. 2) History of depression. He has had two suicide attempts with pills in the past. 3) History of shingles. MEDICATIONS: Vicodin for foot pain related to his recent foot injury.
PCP|Pneumocystis jiroveci pneumonia|PCP|172|174|IMPRESSION|The patient will undergo bronchoscopy to rule out any other pathogens that may be present. For now, we will titrate his oxygen as needed and continue his antibacterial and PCP treatment. 2. ID. As above, the patient may have complicating illness secondary to what is already known. We will pursue with bronchoscopy. 3. Psych. The patient was started on Risperdal prior to his discharge secondary to anxiety.
PCP|Pneumocystis jiroveci pneumonia|PCP|122|124|ALLERGIES|In addition, he was found to have colonization with Candida glabrata and will be on nystatin for 2 weeks. His Bactrim for PCP prophylaxis should not be initiated until his counts are stable off growth factor.3. Gastrointestinal: Mr. _%#NAME#%_ had a moderate amount diarrhea which was culture negative.
PCP|primary care physician|PCP|280|282|FOLLOW UP|The patient was instructed to seek medical attention, if she had increased drainage, increased pain, increased swelling, elevated temperatures greater than 101.5, no further bowel movements, there was no continued nausea or vomiting. FOLLOW UP: The patient is to follow up with a PCP within 2 to 4 weeks. She is to follow up with Dr. _%#NAME#%_, in 1 week.
PCP|primary care physician|PCP.|123|126|PLAN|13. Nitrostat 400 mcg sublingual p.r.n. 14. Aspirin 81 mg p.o. daily. 15. K-Dur SA 24 mEq p.o. daily. PLAN: Follow up with PCP. Patient has an appointment tomorrow.
PCP|primary care physician|PCP|123|125|PLAN|7. Roxicodone 5 mg q. 3 hours p.r.n. 8. Advair Discus 250/50 one puff b.i.d. 9. Spiriva nebulizer daily. PLAN: Follow with PCP in one week's time.
PCP|Pneumocystis jiroveci pneumonia|PCP|134|136|ASSESSMENT AND PLAN|Will discuss with Renal as to how to proceed and whether we should continue these at this time. He is also on Bactrim for, I presume, PCP prophylaxis. 6. Osteoporosis. Will continue Fosamax. 7. Gastroesophageal reflux disease. Will continue his Protonix. 8. Pulmonary: Trace crackles on exam. Will check a chest x-ray to evaluate for bilateral infiltrates, which he has had a chronic persisting cough.
PCP|phencyclidine|PCP,|136|139|HISTORY OF PRESENT ILLNESS|Her Tylenol level on admission was 276, AST 60, ALT 91, alkaline phosphatase 74, total bilirubin 2.7. Urine tox screen was positive for PCP, benzodiazepines, opioids, and methamphetamine. ABG was negative at that time. She was also noted to have a prolonged QT. It should be noted that the mother did find the patient with multiple empty pill bottles beside her and there is also concern for a verapamil overdose in addition to alprazolam, Ambien, Equate PM.
PCP|phencyclidine|PCP|309|311|LAB ON ADMISSION|Her hepatic panel was within completely normal limits. Her white blood cell count is 7.8. Hemoglobin is 13.5. Other parameters of depression were within normal limits. Beta hCG was negative. Her drug screen consisting of amphetamine, barbiturates, benzodiazepine, cannabinoids, cocaine, atenolol, opioids and PCP were negative. Her Keppra level at the time of her transfer from floor to psych unit was pending. On _%#DDMM2007#%_, the Keppra level was 9.1. HOSPITAL COURSE: PROBLEM #1: Seizure disorder: History of the spells, but this time her behavioral/outburst episode was consistent with the psych disorder.
PCP|Pneumocystis jiroveci pneumonia|PCP|358|360|470.  CD4|A PICC line was also placed. The following day, her T-cell subset profile returned, and it was found that her total CD4 cells were at 11%, which was extremely low, with the normal range being 40-62%. The total CD4 count was 77. CD8 was 470. CD4:CD8 ratio was 0.16, the normal being 1.4-2.6. In light of this new finding, it was decided to put the patient on PCP prophylaxis, using Bactrim Double Strength (that is, trimethoprim/sulfamethoxazole Double Strength) once daily. In addition, it was decided to initiate the patient on azithromycin two tablets orally once a week.
PCP|Pneumocystis jiroveci pneumonia|PCP|331|333|PROBLEM #2|If he developed a Staphylococcus infection as an outpatient, he could be desensitized to Vancomycin or we could use another antibiotic specific to the bacterial infection. He will be discharged on routine prophylactic fluconazole and will continue low-dose acyclovir treatment for one more month when he will also start Bactrim or PCP prophylaxis within the next 1-2 weeks when his white blood cell count stabilizes. PROBLEM #3: Graft-versus-host disease. He has not had any symptoms suspicious for graft-versus-host disease up to this point.
PCP|phencyclidine|PCP,|220|223|INR 0.9.|Serum chemistry reveals sodium of 142, potassium 3.8, glucose 78, BUN 16, creatinine 0.9, calcium level 9.4. Urine drug screen is negative for amphetamine, barbiturate, and benzodiazepine as well as cocaine and opiates, PCP, and tricycle antidepressant. However, it is positive for cannabinoids. The patient's erythrosedimentation rate is 4, INR 0.9. His EKG reveals pattern of normal sinus rhythm with minimal LVH pattern.
PCP|Pneumocystis jiroveci pneumonia|PCP|148|150|PROBLEM LIST UPON DISCHARGE|Given absence of fevers and good respiratory status, the patient was not discharged on oral antibiotics. He should continue monthly Pentamidine for PCP prophylaxis given his sulfa allergy. 2. Infectious disease. The patient should continue fluconazole and acyclovir prophylaxis per protocol.
PCP|Pneumocystis jiroveci pneumonia|PCP|202|204|PLAN|4. Will ask Dr. _%#NAME#%_ to see the patient for advice regarding his antimicrobial treatment. 5. I will hold off Bactrim for now based on the suspected GI intolerance and may consider alternative for PCP prophylaxis. 6. New prescription will not be given based on his Neulasta dose today.
PCP|Pneumocystis jiroveci pneumonia|PCP|181|183|PAST MEDICAL HISTORY|This showed a right internal carotid stenosis. PAST MEDICAL HISTORY: 1. HIV/AIDS, 1992. 2. Coronary artery disease status post stenting of left coronary artery in _%#MM#%_ 2004. 3. PCP in 1999. 4. Recurrent anxiety and depression. 5. Hypercholesterolemia. 6. Bilateral feet neuropathy secondary to antivirals.
PCP|primary care physician|PCP|135|137|DISPOSITION|DISPOSITION: The patient was discharged home to her apartment on _%#MM#%_ _%#DD#%_, 2006. We recommended followup at Smiley's with her PCP within 1 week. Did request social work evaluation for start of PCA help with cleaning and bathing.
PCP|primary care physician|PCP.|156|159|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|He was admitted with GI work up. IV fluids, Protonix IV. Meanwhile before the GI work up could be done, the patient left AMA. The patient does not have any PCP. Upon discharge his hemoglobin had been 14.6 and he had stopped vomiting. The patient also had a chemical dependency evaluation order which he refused.
PCP|Pneumocystis jiroveci pneumonia|PCP|147|149|IMPRESSION|I have added an LDH, this is pending at the time. IMPRESSION: Marked shortness of breath, profound in a patient with HIV with poor compliance with PCP prophylaxis with a CD4 count of 194 in 2006 and an unknown viral load, unknown compliance with his medications.
PCP|Pneumocystis jiroveci pneumonia|PCP|174|176|ADDENDUM  TO PREVIOUS DISCHARGE SUMMARY OF 09/18/2007.|E. Coli is covered by the Z-pack or cefuroxime which he is still taking. Candida albican is most likely colonization vs normal flora and will not treat at this time but pt's PCP to consider flucanozole if pt's clinic condition worsen. Pt was strongly advised to follow up with Dr _%#NAME#%_ within a week.
PCP|Pneumocystis jiroveci pneumonia|PCP.|289|292|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Phoslo 1 p.o. with each meal, prednisone 20 mg p.o. q. day, Zantac 150 mg p.o. q.h.s., Demadex 40 mg p.o. b.i.d., and Septra Social Services 1 p.o. q. day. The latter is to provide prophylaxis for this immunosuppressed patient against Pneumocystis carinii pneumonia PCP.
PCP|phencyclidine|PCP.|241|244|ADMISSION PHYSICAL EXAMINATION|ADMISSION STUDIES (From _%#COUNTY#%_ _%#COUNTY#%_ Medical Center). UA 3+ ketones, 1+ bilirubin, 1 to 5 hyaline casts, and trace blood. Urine tox is negative for amphetamines, barbiturates, benzodiazepines, cannabinoids, cocaine, opiates, or PCP. INR was 2.4, PT was 24.6 Valproic level was 10 mg/dL (low). Salicylates were less than 0.5. Acetaminophen level was 42 (normal range 10 to 30).
PCP|Pneumocystis jiroveci pneumonia|PCP|149|151|ASSESSMENT AND PLAN|3. Remote history of atrial fibrillation: At this point in time, the patient is in normal sinus rhythm. Continue Toprol as previously prescribed. 4. PCP prophylaxis: Continue the patient on dapsone three times a week. 5. Chronic renal insufficiency: The patient has a creatinine that normally runs in the 1.2 range.
PCP|Pneumocystis jiroveci pneumonia|(PCP|217|220|PROCEDURES PERFORMED DURING THIS ADMISSION|Otherwise, clear lungs. 3. CT angiogram, _%#DDMM2003#%_, secondary to patient having acute chest pain. Impression: No evidence of pulmonary embolism. Bilateral upper lobe ground glass density suspicious for infection (PCP or CMV) or less likely hemorrhage. 4. EKG, _%#DDMM2003#%_, secondary to acute chest pain showed normal sinus rhythm with heart rate of 75.
PCP|primary care physician|PCP|114|116|FOLLOW-UP APPOINTMENTS|2. Follow up in interventional radiology in two to three months for nephrostomy tube change 3. Follow up with his PCP in approximately 2-3 weeks. 4. He will be having follow up with Dr. _%#NAME#%_ and Dr. _%#NAME#%_ and a follow up for interventional radiology in 2-3 months.
PCP|Pneumocystis jiroveci pneumonia|PCP|158|160|PROBLEM #3|At the time of discharge she had been afebrile for 4 days, and off empiric antibiotic coverage for 2 days. She was discharged on prophylactic antibiotics for PCP and for antifungal coverage. It has been a pleasure participating in the care of _%#NAME#%_ _%#NAME#%_.
PCP|Pneumocystis jiroveci pneumonia|PCP|236|238|PROBLEM #3|PROBLEM #3: Infectious disease. _%#NAME#%_'s CMV and HSV negative. He remained afebrile throughout this admission. He was discharged on fluconazole. Bactrim was held secondary to its myelosuppressive effects and should be restarted for PCP prophylaxis when his absolute neutrophil count is greater than or equal to 1,000 for two consecutive days. At discharge his white blood cell count was 0.2. Ceftin was added for antibacterial prophylaxis and should continue until Nat engrafts.
PCP|primary care physician|PCP,|169|172|ADMISSION DIAGNOSIS|ADMISSION MEDICATIONS: He is on medications, Norvasc, Cymbalta, Diovan, Lasix, Seroquel, Prevacid, multivitamins, Ambien, ciprofloxacin which was just prescribed by his PCP, and he is on Coumadin. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: Unremarkable. PHYSICAL EXAMINATION GENERAL: He is not jaundiced.
PCP|Pneumocystis jiroveci pneumonia|PCP|159|161|PROBLEM #2|Chest x-ray was negative. Blood cultures were negative. Antifungal prophylaxis is with voriconazole per protocol for Fanconi anemia. He will begin Bactrim for PCP prophylaxis on _%#DDMM2006#%_. PROBLEM #3: Fluid, electrolytes, and nutrition. _%#NAME#%_ did well at maintaining his appetite throughout most of his hospital course.
PCP|primary care physician|PCP|233|235|ASSESSMENT AND PLAN|Parents feel very comfortable with the feeding schedule, knowing that they have to supplement with a bottle if baby does not take enough by breast, although primarily is a breastfeeding baby. They were asked to please follow up with PCP early this coming week, either Monday or Tuesday. They feel very comfortable taking the baby home.
PCP|primary care physician|PCP|161|163|HISTORY OF PRESENT ILLNESS|The patient is prediabetic and has been asked to watch her diet. The patient is not seen her primary physician in a year. She goes to _%#CITY#%_ Medical and her PCP is Dr. _%#NAME#%_. ALLERGIES: Her allergies are Cipro and sulfa. MEDICATIONS: She is on Lexapro and Synthroid.
PCP|Pneumocystis jiroveci pneumonia|PCP|122|124|HOSPITAL COURSE|His creatinine and potassium are okay on the first day after starting it but this will need to be rechecked in clinic. 7. PCP pneumonia. The patient developed PCP pneumonia was seen by infectious disease. He was started on Bactrim and his steroids were increased.
PCP|primary care physician|PCP|133|135|DISCHARGE MEDICATIONS|12. Vicodin, 5/325 mg 1 q. 4 hours p.r.n. 13. Insulin sliding scale, low resistance. 14. Lantus, 2 units subcu q.a.m. Follow up with PCP at _%#CITY#%_ Care Center. The patient should have INR's checked periodically to keep the INR between 2-3 and adjustment of the Coumadin dose if needed and also check her potassium level since the patient is on Lasix and she has a chronic kidney disease.
PCP|primary care physician|PCP|153|155|HISTORY OF PRESENT ILLNESS|The parents were instructed to return for follow up with Dr. _%#NAME#%_ at his outpatient clinic in 2 weeks. They were also advised to see the patient's PCP Dr. _%#NAME#%_ at Fairview Ridge Pediatrics in _%#CITY#%_ within the following week. DISCHARGE MEDICATIONS: Tylenol 40 mg per dose p.o. elixir every 4 hours as needed for pain.
PCP|primary care physician|PCP|146|148|SUMMARY OF HOSPITAL COURSE|4. Right Kidney mass. The patient was notified of this finding. This was an incidental finding and thus he was discharged with follow-up with his PCP to discuss the future evaluation of this. 35 minutes spent in discharge planning time today.
PCP|phencyclidine|(PCP),|395|400|LABORATORY DATA|Sodium 146, potassium 4.4, chloride 114, bicarbonate 19, BUN 14, creatinine 1.5, glucose 221 at that time, calcium 8.5; total bilirubin 0.4, albumin 3.7, total protein 7.5, alkaline phosphatase 244, AST 103, ALT 45, lipase 41. INR 1.48. Urine toxicology was done which was negative for amphetamines, methamphetamines, barbiturates, benzodiazepines, cannabinoids, cocaine, opiates, phencyclidine (PCP), and tricyclics. Routine urinalysis was normal. Urine microscopic exam was normal as well. ASSESSMENT/PLAN: 1. Basically, we will be admitting the patient to the ICU and we will put her on the ETOH protocol for benzodiazepines.
PCP|primary care physician|PCP,|143|146|HOSPITAL COURSE|The patient is also legally blind. In this circumstance, it may be appropriate to discontinue Coumadin, although I will defer this decision to PCP, as I do not have more history. The patient and her husband were instructed to follow up at her primary care doctor and address this issue specifically.
PCP|Pneumocystis jiroveci pneumonia|PCP|157|159|HOSPITAL COURSE|He had been hydrated aggressively with IV fluids during his episodes of diarrhea, but his symptoms and chest x-ray findings seemed consistent with recurrent PCP pneumonia. He also had discontinued his Bactrim prior to admission. He was treated with high dose Bactrim and his symptoms rapidly improved.
PCP|primary care physician|PCP|150|152|DISCHARGE MEDICATION|DISCHARGE MEDICATION: Hydrochlorothiazide 50 mg p.o. daily which is his home medication. The patient is advised to stop drinking alcohol. Follow with PCP in one weeks time.
PCP|Pneumocystis jiroveci pneumonia|PCP.|199|202|ASSESSMENT/PLAN|His oxygen saturations are good at room air, although we will ambulate the patient to see if he does desaturate. If he does, I think we should increase him to more of a treatment dose of Bactrim for PCP. He does not manifest any evidence of an intraperitoneal infection or other pneumonia. I do not see any skin rash. We will obtain urine to rule out UTI.
PCP|Pneumocystis jiroveci pneumonia|PCP,|165|168|PROBLEM|The patient had a bronchoscopy performed, which had the following culture and Gram stain results. There were no organisms seen. He was sent for no cardia, RSV, CMV, PCP, fungal and viral culture all of which were negative. His bronch cultures had light growth of Candida albicans and light growth coag-negative Staph.
PCP|primary care physician|PCP.|132|135|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|Since then the patient has not taken any statin or Zetia. The patient is willing to get back on Crestor with subsequent follow with PCP. DISCHARGE MEDICATIONS: 1. Atenolol 50 mg daily. 2. Demerol 50 mg p.o. daily p.r.n.
PCP|primary care physician|PCP|149|151|HISTORY OF PRESENT ILLNESS|She is diagnosed in _%#DDMM2002#%_ and was treated with external beam radiation. She had no problems until _%#DDMM2006#%_ when a CT scan done by her PCP showed a large right upper lobe mass approximately 5 x 5 cm. This was biopsied and showed metastatic adenocarcinoma consistent with endometrial origin.
PCP|Pneumocystis jiroveci pneumonia|PCP|297|299|HOSPITAL COURSE|3. Infectious Disease. She remained afebrile throughout her hospitalization and was continued on her prophylactic fluconazole and Peridex. Given her history of noncompliance with Bactrim, she was switched over to pentamidine on Neb in conjunction with an Albuterol Neb which will be continued for PCP prophylaxis and be given once every 4 to 6 weeks with her chemo hospitalizations. DISCHARGE INFORMATION: Date of admission: _%#DDMM2002#%_ Date of discharge: _%#DDMM2002#%_ Patient was discharged to home.
PCP|phencyclidine|PCP,|196|199|LABORATORY DATA|Arterial Blood Gases: pH 7.36; pCO2 35; pO2 202. Sodium 147, potassium 3.5, chloride 106, bicarbonate 23, BUN 4, creatinine 0.8, glucose 144. Calcium 8.7. Urine toxicology screen was negative for PCP, benzodiazepines, cocaine, amphetamines, cannabinoids, opiates, barbiturates, and tricyclic antidepressants. Alcohol level was 0.25. Tylenol level is less than 10.0. Salicylate level is 6.0. EKG: EKG showed normal sinus rhythm with a rate of 97.
PCP|primary care physician|PCP,|153|156|FOLLOWUP|She was also instructed to test when _%#NAME#%_ had signs or symptoms of hypoglycemia and to treat with juice or GlucoGel. FOLLOWUP: Will follow up with PCP, Dr. _%#NAME#%_ _%#NAME#%_ and pediatric endocrinologist, Dr. _%#NAME#%_ _%#NAME#%_. It was a pleasure working with _%#NAME#%_. We are happy to see that he is getting well.
PCP|Pneumocystis jiroveci pneumonia|PCP|218|220|PROBLEM #6|PROBLEM #5: GI: _%#NAME#%_ did not have any issues of constipation during this hospital stay and did not require any additional bowel medications. PROBLEM #6: Infectious disease: _%#NAME#%_ was kept on her Bactrim for PCP prophylaxis, was also discharged on that medication. DISCHARGE DIAGNOSIS: Stage IV neuroblastoma with metastasis to her skull, pelvis and bladder.
PCP|phencyclidine|PCP|116|118|PAST MEDICAL HISTORY|With his previous history of a rhabdo with hypothermia and acute renal failure it is likely that he has used either PCP or ecstasy in the past. 5. Ongoing tobacco use. HOME MEDICATIONS: None, though uses over-the-counter dextromethorphan.
PCP|primary care physician|PCP|353|355|HOSPITAL COURSE|HOSPITAL COURSE: Mr. _%#NAME#%_ is a 64-year-old WM with multiple medical problems as delineated above, including CAD - status post stenting in 2004 by Dr. _%#NAME#%_, hypertension, type 2 insulin requiring DM, hyperlipemia who was admitted to University of Minnesota Medical Center, Fairview on _%#DDMM2007#%_ for hyperkalemia. He had presented to his PCP on _%#DDMM2007#%_ for a preoperative evaluation in anticipation of ENT surgery (per patient has a history of recurrent/chronic otitis media for which he had ventilation tubes first placed approximately 6 years ago and Dr. _%#NAME#%_ _%#NAME#%_ intended to replace ventilation tubes in right ear and rebuild TM on left)and at that time was found to have a potassium of 6.8.
PCP|Pneumocystis jiroveci pneumonia|PCP,|291|294|SUMMARY OF CASE|The patient's diffuse muscle weakness apparently became progressive and associated with respiratory failure, requiring long-term ventilator dependence, and also the creation of a tracheostomy. The patient's last bronchoscopic evaluation occurred on _%#DDMM2005#%_ that was negative for CMV, PCP, fungi, or malignancy. The patient had coagulase-negative Staph bacteriemia and urinary tract infection, secondary to E. coli, treated with antibiotics prior to transfer to _%#COUNTY#%_ unit.
PCP|Pneumocystis jiroveci pneumonia|PCP|240|242|DISCHARGE MEDICATIONS|She was on Zofran drip with scheduled dexamethasone. She did not have issues with constipation or anal fissures this admission. DISCHARGE MEDICATIONS: Fluconazole 100 mg PO q. day. Pentamidine neb scheduled for _%#MM#%_ _%#DD#%_, 2005, for PCP prophylaxis. Dilaudid 2 mg PO q.4 hours p.r.n. pain, Colace 100 mg PO b.i.d. p.r.n. constipation, MiraLax 17 g PO q. day p.r.n.
PCP|Pneumocystis jiroveci pneumonia|PCP|231|233|HOSPITAL COURSE|His CD4 count was 3 this hospital stay. The patient did not have not have bronchoscopy but his sputum was tested for PCP and for Nocardia, both of which were negative. The patient was empirically started on trimethoprim sulfa at a PCP treatment dose of 2 double strength tablets b.i.d. This is being continued as an outpatient somewhat empirically. His white blood count and platelet count have been stable.
PCP|Pneumocystis jiroveci pneumonia|PCP|121|123|HOSPITAL COURSE|His white blood count and platelet count have been stable. It can be determined in the clinic when to drop him back to a PCP prophylaxis dose. The patient has chronic malnutrition. A prealbumin level measured _%#DDMM2005#%_ was 13.
PCP|primary care physician|PCP.|171|174|DISCHARGE MEDICATIONS|Also, of note, the patient is advised to have a referral with a neurologist since she has a recurrent vestibular neuritis. The patient should obtain the referral from the PCP. At the same time, the patient was advised to repeat physical therapy for her dizziness related to vestibular neuritis as an outpatient, that she should continue.
PCP|primary care physician|PCP|104|106|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Multivitamin 1 tablet daily which the patient is to take at home. Follow up with PCP in 1 week's time. At that time he should check his lipid panel.
PCP|primary care physician|PCP|153|155|DISCHARGE MEDICATIONS|This again should be followed by her primary care physician. DISCHARGE MEDICATIONS: 1. Allopurinol 150 mg p.o. q. day. 2. Norvasc 5 mg p.o. q. day until PCP f/u. 3. Lipitor 40 mg p.o. q. day. 4. Bimatoprost 0.03% in both eyes q.p.m. 5. Bentyl 10 mg p.o. q. day. 6. Folic acid 1 tablet p.o. q. day
PCP|Pneumocystis jiroveci pneumonia|PCP:|141|144|DISCHARGING DIAGNOSES|15. Infectious disease issues: She had polymicrobial pneumonia sinus infection, pseudomonas and VRE pneumonia for which she was treated. 16. PCP: She was treated and also was on prophylaxis with Bactrim until last week on _%#MMDD#%_. DISCHARGING MEDICATIONS: 1. Coumadin: This dose for Saturday and Sunday will be decided by Dr. _%#NAME#%_ tomorrow pending the INR.
PCP|Pneumocystis jiroveci pneumonia|PCP|95|97|HOSPITAL COURSE|He had only been taking valganciclovir for CMV retinitis prophylactically. HOSPITAL COURSE: 1. PCP pneumonia. The patient was seen by the Infectious Disease Team and it was decided his PCP pneumonia would be treated with atovaquone 1500 mg daily.
PCP|Pneumocystis jiroveci pneumonia|PCP.|188|191|OPERATIONS/PROCEDURES PERFORMED|Cultures: Negative. KOH: Negative for fungal elements, cultures negative. PCR myoplasm: Negative. Cultures for Chlamydia: Negative. Cytology: CMV inclusions negative. Presence of moderate PCP. AFB stain: Negative, cultures pending. Rapid Shell vial culture: Positive. HISTORY OF PRESENT ILLNESS: The patient is a 43-year-old man with HIV disease diagnosed in 1986.
PCP|Pneumocystis jiroveci pneumonia|PCP|151|153|PROBLEM #2|Her fluids and electrolytes will be repleted as needed. In addition, the patient has a history of MAI and continues on azithromycin and Ethambutol and PCP prophylaxis is being covered with pentamidine. For fungal prophylaxis, she is on fluconazole and remained so. PROBLEM #3: Fluids, electrolytes and nutrition status. The patient received several doses of calcium and magnesium while inpatient.
PCP|primary care physician|PCP|255|257|* FEN|Discharge measurements and exam: Weight 3530 gm (50th -90th %tile), length 51.5 cm (50th -90th %tile), OFC 36 cm (50th -90th %tile). Physical exam was normal, no murmur appreciated. Follow-up appointments: After discharge, per normal newborn routine. The PCP is listed below and will receive a copy of this transfer letter. Thank you again for allowing us to share in the care of your patient.
PCP|primary care physician|PCP,|122|125|FOLLOWUP PLAN|2. Pantoprazole 20 mg p.o. daily. 3. Amoxicillin. 4. Azithromycin. FOLLOWUP PLAN: 1. The patient is to follow up with his PCP, Dr. _%#NAME#%_ within 1-2 weeks of hospital course, follow up pneumonia and clinic management of nutrition. 2. The patient is to follow up in 1-2 weeks with Neurology (Dr. _%#NAME#%_) to follow up regarding seizure control on Keppra and regarding his EEG done on the day of discharge.
PCP|primary care physician|PCP.|127|130|INFORMANT|CHIEF COMPLAINT: Apparent life-threatening event early this evening. INFORMANT: Grandmother, nurse, Dr. _%#NAME#%_ _%#NAME#%_, PCP. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 5-1/2-year-old female known to me with history of non-accidental trauma at age 6, status post VP-shunt with severe cystic encephalomalacia, profound microcephaly, and developmental arrest, severe spasticity, episodes of shaking attributed to abnormal EEG, and treated with antiseizure medications without confirmation of events being seizures, and diffuse panhypopituitarism, morbid obesity with questionable compliance to diet, and recent onset of increased temperature and new onset apparent life-threatening event.
PCP|phencyclidine|PCP,|283|286|LABORATORY DATA|TSH is 0.69, magnesium is elevated at 2.4 but she is on magnesium supplements, urinalysis is unremarkable with specific gravity of 1.015 with pH of 8. Urine drug screen is negative for amphetamines, methamphetamines, barbiturates, benzodiazepines and cannabinoids, cocaine, opiates, PCP, tricyclic antidepressants, with sediment, shows 0-2 white cells and 0-2 red blood cells. It is unclear if this has been performed, if it has not we will get this done.
PCP|Pneumocystis jiroveci pneumonia|PCP,|365|368|HOSPITAL COURSE|Secondary to development of diarrhea during hospitalization, stool studies were obtained and demonstrated Clostridium difficile toxin positive with excellent resolution after starting metronidazole. Also on admission, the patient had PA and lateral chest x-ray demonstrating left lower lobe infiltrate suspicious for either atypical community-acquired pneumonia or PCP, and the patient's symptoms remarkably improved with empiric treatment for both. After 5 days of hospitalization, infectious disease recommended initiation of antiretroviral triple therapy which the patient is currently tolerating well with only minimal nausea.
PCP|phencyclidine|PCP.|461|464|DISCHARGE DIAGNOSIS|Her lab testing showed normal sodium, potassium, chloride, bicarbonate, anion gap, glucose, blood urea nitrogen, creatinine, calcium, albumin, alkaline phosphatase, alanine transaminase, AST, total bilirubin less than 0.1. Total protein, TSH and cholesterol slightly elevated and patient was nonfasting at the time it was drawn at 10:55 in the day. Urine screens positive for cannabinoids, negative for amphetamines, barbiturates, cocaine, ethanol, opiates and PCP. Her urine was normal with specific gravity of 1.014. She had normal qualitative urine for pregnancy was negative. HOSPITAL COURSE: She was much more open and help seeking than previously noted.
PCP|Pneumocystis jiroveci pneumonia|PCP|148|150|ASSESSMENT|ASSESSMENT: 1. Forty-three-year-old man with long-standing AIDS and multiple previous infections including toxo and cryptococcal meningitis, not on PCP prophylaxis. Picture is consistent with Pneumocystis pneumonia. Will start him with IV Bactrim and steroids. Will also consult Pulmonary regarding need for a BAL. This patient was discussed with ID and they did not suggest broadening his antibiotic coverage at this point unless he would deteriorate.
PCP|phencyclidine|PCP.|216|219|LABS AND STUDIES ON ADMISSION|Acetaminophen level at Ridges was 11. A repeat level prior to transport to Fairview-University Medical Center was less than 10. Urine tox was also performed which was negative except for benzodiazepines, opiates and PCP. EKG was normal sinus rhythm with no evidence of QT prolongation.
PCP|Pneumocystis jiroveci pneumonia|PCP|298|300|ALLERGIES|The cultures from bronchoscopy eventually grew Candida albicans. However, the bacterial cultures, Gram's stain, mesalamine silver stain for PCP, CMV, and cytology for malignant cells all were negative. When the patient had increasing pulmonary infiltrates the patient was also started on high dose PCP therapy with prednisone and amphotericin B. At this time the patient's oxygen requirements had increased. On _%#MM#%_ _%#DD#%_, 2002, the patient was requiring 60% FIO2.
PCP|phencyclidine|PCP|267|269|ASSESSMENT/PLAN|We will monitor closely. 6. Chronic renal insufficiency. The patient's baseline creatinine is 1.6. Now creatinine is 1.4. We will continue to monitor and hydrate the patient. 7. Hepatitis C is not being treated at this time. Liver function tests are mildly elevated. PCP to follow-up with this issue as an outpatient. DISPOSITION Possible discharge home in 1-2 days.
PCP|primary care physician|PCP,|182|185|FOLLOWUP PLAN|FOLLOWUP PLAN: 1. The patient is to follow up with neurosurgery in the next week to 2 weeks, as arranged by their department. 2. Also recommended that the patient follow up with her PCP, Dr. _%#NAME#%_ _%#NAME#%_, as needed. It has been a pleasure to be involved in _%#NAME#%_'s medical care during her hospitalization.
PCP|Pneumocystis jiroveci pneumonia|PCP|161|163|HOSPITALIZATION COURSE|ABDOMEN: Soft, nontender. LABORATORY DATA: Admission ABG, pH was 7.44, pCO2 of 28, pO2 of 62 and saturation 91% on room air. HOSPITALIZATION COURSE: PROBLEM #1: PCP pneumonia unlikely in the setting of a normal LDH level and atypical chest x-ray findings, the patient in the past was treated with dapsone and was instructed to take Mepron for PCP prophylaxis, however, this patient was noncompliant with Mepron therapy.
PCP|Pneumocystis jiroveci pneumonia|PCP|170|172|HOSPITALIZATION COURSE|The patient was given bronchodilation therapy and her wheezing improved as well as her O2 saturations back to baseline. She will be discharged home on Mepron therapy for PCP prophylaxis. PROBLEM #2: HIV AIDS. Ms. _%#NAME#%_ has CD4 count of 8.
PCP|Pneumocystis jiroveci pneumonia|PCP|143|145|HOSPITAL COURSE|3. Dry skin secondary to radiation therapy: Aquaphor topical was given during hospitalization, which seemed to help somewhat with dry skin. 4. PCP prophylaxis: _%#NAME#%_ was on a schedule of Bactrim every Friday and Saturday, so none was given during the hospitalization. She was discharged on the same schedule. DISCHARGE DIAGNOSIS: Retroperitoneal primitive neuroectodermal tumor.
PCP|Pneumocystis jiroveci pneumonia|PCP|168|170|HOSPITAL COURSE|He will follow up closely with his pulmonology and hopefully eventually weaned off the steroids as well as the oxygen. He will also continue on Bactrim prophylaxis for PCP as he will remain on high dose steroids. 2. Rash. Yesterday the patient developed a red rash his right arm in the axillary area.
PCP|primary care physician|PCP,|122|125|DISCHARGE TEACHING|He will be provided with numbers of clinic prior to discharge. DISCHARGE TEACHING: The patient was instructed to call his PCP, Neurosurgery Clinic or go to the nearest emergency department, should he have fevers, chills, redness of his incision site, discharge from his incision site, intractable nausea and vomiting or aphasia, vision changes or right-sided weakness or numbness.
PCP|primary care physician|PCP|267|269|HOSPITAL COURSE|This was most likely secondary to IV Solu-Medrol/steroid treatment. The patient was placed on hydralazine 10 mg p.o. t.i.d. on top of his home dose of lisinopril and Norvasc. The patient had good response to addition of hydralazine. The patient will have followup at PCP Clinic where his antihypertensive medication should be further optimized. DISCHARGE MEDICATIONS: 1. Hydralazine 10 mg p.o. t.i.d. 2. Aranesp 60 mcg subcutaneously every 2 weeks.
PCP|Pneumocystis jiroveci pneumonia|PCP|173|175|ASSESSMENT AND PLAN|Both transplanted organs are functioning appropriately. Will continue patient on his immunosuppressive medications of CellCept, prednisone, and Neoral. He is on Bactrim for PCP prophylaxis. 4. Cardiovascular. History of coronary artery disease and hypertension.
PCP|primary care physician|PCP|126|128|HISTORY OF PRESENT ILLNESS|The patient himself, however, had never been cultured before. The patient was started on Bactrim following his visit with his PCP on _%#DDMM2006#%_. Within 30-45 minutes after his first dose of Bactrim, the patient complained of abdominal pain, chills, pruritus and flushing.
PCP|primary care physician|PCP|143|145|FOLLOWUP|It also recommended to the mother that if the patient continues to develop fevers for the next several days that she should follow up with her PCP to seek out a possible second source of infection. However, this remains a remote possibility at this point, as the patient looks greatly clinically improved.
PCP|primary care physician|PCP|264|266|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|Her troponin also is trending down. Today it is 0.38. The patient is oxygenating well with room air at about 95% which drops down to 92% with activity. The patient says that she has a narrowing of the windpipe somehow from the acid reflux disease, was told by the PCP and usually takes Nexium at home. She has never used the albuterol inhaler before. Now that the patient is relatively better, her sepsis has resolved, she will be discharged home in stable condition.
PCP|patient-controlled analgesia:PCA|PCP|237|239|HISTORY OF PRESENT ILLNESS|I also had several discussions with the patient's brothers who understand the situation. The patient is going to be discharged on the following medications; Tequin 400 mg IV every 24 hours for 7 days, morphine sulfate 1 mg/hour morphine PCP pump with 0.5 mg bolus q.10 minutes, Tylenol suppositories p.r.n. for temperature more than 100.5, Dulcolax suppositories p.r.n., Zofran ODT 8 mg p.r.n. q.8h., D5 normal saline IV 1000 cc every other day.
PCP|Pneumocystis jiroveci pneumonia|PCP|229|231|HOSPITAL COURSE|The patient remained afebrile for the last 72 hours. Plan was made to complete the course of linezolid and Levaquin. Considering his immunosuppressed status the plan is to initially complete the therapeutic course of Bactrim for PCP and then will continue patient on Bactrim prophylaxis dose. Will also continue patient on prophylactic antifungal regime. 2. Acute-on-chronic sinusitis: Given the patient has MRSA pneumonia we thought that the patient might also have MRSA sinusitis and given that we switched the patient from vancomycin to linezolid given that linezolid has better soft tissue penetration.
PCP|primary care physician|PCP|222|224|ASSESSMENT AND PLAN|3. Hypothyroidism, controlled. Continue with prescribed meds. Follow- up with PCP on a p.r.n. basis. 4. Chronic Lyme disease. Follow-up with specialists in an outpatient setting. 5. Asthma control via meds. Follow-up with PCP on a p.r.n. basis. 6. Torn right toenail. Podiatrist consult to evaluate foot. Continue re- bandaging and changing dressing daily.
PCP|primary care physician|PCP|207|209|FOLLOWUP|He should call the GI Clinic in approximately 1 week for test results and discussion. The patient should report to Fairview _%#CITY#%_ Day Clinic as scheduled on _%#DDMM2007#%_ and should follow up with his PCP as indicated. No restrictions. In sum, it was a pleasure to be involved in _%#NAME#%_'s medical care.
PCP|Pneumocystis jiroveci pneumonia|(PCP|152|155|MEDICATIONS AT DISCHARGE|10. Verapamil 240 mg p.o. daily. 11. Aspirin 325 mg p.o. daily. 12. Acyclovir 400 mg p.o. t.i.d. 13. Dapsone 50 mg p.o. q. Monday, Wednesday and Friday (PCP prophylaxis - used instead of Bactrim because of the hyperkalemia problems). 14. Magnesium oxide 400 mg p.o. b.i.d. 15. Albuterol nebulizer q.i.d. as needed for wheezing.
PCP|primary care physician|PCP.|241|244|THE FOLLOWING IS A REHAB DISCHARGE SUMMARY|X-ray showed good healing, however, a faint heterotopic ossification is noted to be developing close to the greater tuberosity. At this point we are recommending to continue range of motion exercises and these are to be followed on with the PCP. This is a preliminary discharge summary.
PCP|Pneumocystis jiroveci pneumonia|PCP|113|115|PROBLEM #7|He was continued on his chlorambucil as well as his prednisone 20 mg daily. We noted that the patient was not on PCP prophylaxis; that may be appropriate if he is destined to remain on prednisone for a long time at the current level. This was not started during this hospitalization (we left that question to the physicians following him longitudinally).
PCP|primary care physician|PCP|146|148|DISCHARGE INSTRUCTIONS|DISCHARGE MEDICATION: Protonix 40 mg p.o. daily. DISCHARGE INSTRUCTIONS: The patient is advised to stay away from the fatty foods. Follow-up with PCP as and when needed.
PCP|Pneumocystis jiroveci pneumonia|PCP|186|188|HEMATOLOGY|She was placed on prophylactic antibiotics, which included low dose acyclovir at 400 mg p.o. b.i.d. She is CMV negative, HSV positive as well as fluconazole and Levaquin. Her Bactrim or PCP prophylaxis is on hold until her counts returned. She did come into the hospital with some chronic upper respiratory tract symptoms, which did not resolve with a 5-day course of Z-Pak, which was completed on _%#DDMM2007#%_.
PCP|primary care physician|PCP,|214|217|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 19-year-old white female diagnosed with cystic fibrosis a few years ago at the University of Minnesota. She is usually on oxygen 2 liters 24 hours followed by PCP, usually getting a pseudomonal infection in the past, usually treated with Zithromax and Cipro. The patient had a same flare-up of her bronchiectasis. She is feeling short of breath and also bringing up green colored sputum.
PCP|primary care physician|PCP|283|285|HOSPITAL COURSE|2. Hypertension: The patient has had borderline hypertension for a while, but it has been very irregularly, mainly has high blood pressure during her admissions and we will start the patient on a lose dose at 12.5 mg of metoprolol and the patient will have to get rechecked with the PCP on discharge. 3. Depression: The patient's mood was normal during her stay. She did not have any suicidal ideations; however, we continued her Wellbutrin XL during the stay.
PCP|primary care physician|PCP|222|224|ALLERGIES|Her sutures are to be removed by her primary care physician between _%#MM#%_ _%#DD#%_, 2003, and _%#MM#%_ _%#DD#%_, 2003. 4. The patient is to return to Dr. _%#NAME#%_'s clinic in 4 weeks. 5. She should follow up with her PCP for suture removal. Her PCP is at Trinity Health in _%#CITY#%_. DISCHARGE MEDICATIONS: Percocet 1 to 2 tablets p.o. q.4-6h. p.r.n.
PCP|Pneumocystis jiroveci pneumonia|PCP|139|141|HOSPITAL COURSE|In regards to her rheumatoid arthritis she is on long-term prednisone, which was continued in the hospital, and she is also on Bactrim for PCP prophylaxis. She then was transferred to rehabilitation. REHABILITATION COURSE: The patient slowly met the goals of physical therapy and occupational therapy.
PCP|Pneumocystis jiroveci pneumonia|PCP|113|115|DISCHARGE MEDICATIONS|7. Tylenol No. 3 325 mg/5 two tabs p.o. q.4h. p.r.n. cough. 8. Bactrim DS 1 tab p.o. on Monday and Thursdays for PCP prophylaxis. 9. Protonix 40 mg p.o. daily. 10. Zofran 8 mg p.o. q.6-8h. p.r.n. nausea.
PCP|Pneumocystis jiroveci pneumonia|PCP|181|183|HISTORY OF PRESENT ILLNESS|The patient received radiation therapy as well as additional chemotherapy that ended in _%#MM#%_ of 2004. The patient had a complicated hospital course, including CMV pneumonia and PCP in _%#MM#%_ of 2004. On the day of admission, the patient reported having some dry eyes and dry mouth, and occasional shortness of breath.
PCP|primary care physician|PCP|92|94|PHYSICIAN FOLLOWUP|ACTIVITY: As tolerated, but avoid strenuous activity. PHYSICIAN FOLLOWUP: 1. Follow up with PCP in 1-2 weeks. 2. Follow up with Cardiology in 4-6 weeks.
PCP|phencyclidine|PCP.|407|410|LABORATORY|LABORATORY: On admission, the patient's comprehensive metabolic panel was within normal limits. Her thyrotropin was 3.93, which is within normal limits. Her ethanol was 0.28. Her lithium level was less than 0.2 on admission, but by the time of discharge it was therapeutic at 0.9. Her urine toxicity was negative for amphetamines, barbiturates, benzodiazepines, cannabinoids, cocaine, ethanol, opiates, and PCP. Her pregnancy test was negative. Her urinalysis was negative. Her CBC with differential was within normal limits.
PCP|Pneumocystis jiroveci pneumonia|PCP|267|269|ASSESSMENT/PLAN|HIV status is pending. PCP stain is also pending. Sputum gram stain and cultures are pending. With the very severe hypoxia and the patient's very critical appearance at this time, until the PCP stain comes back, I will treat him empirically with Bactrim for possible PCP pneumonia, although I think it appears as though he has quite extensive consolidation. Until I can obtain more information, I think its worth treating him with the Bactrim.
PCP|Pneumocystis jiroveci pneumonia|PCP|193|195|PROBLEM #8|She was found to have a herpes 6 IgG antibody, which suggest current or past exposure. A follow up HSV 6 DNA PCR should be followed up in the outpatient clinic. She required pentamidine IV for PCP prophylaxis secondary to a Bactrim allergy. PROBLEM #9: Neurology:_%#NAME#%_ required a fentanyl drip for control of mucositis and abdominal discomfort.
PCP|phencyclidine|PCP,|162|165|DOB|She denied any suicidal gesture. Blood and urinalysis revealed no evidence of amphetamines, no evidence of barbiturates, no benzodiazepines, no cocaine, opiates, PCP, tricyclics, or methamphetamines. However, she did admit to several questionable suicide attempts in the past, including "driving over a ravine," and is felt prudent to admit the patient to ICU on a 72-hour hold so Psychiatry has a chance to evaluate her.
PCP|primary care physician|PCP|263|265|OPERATIONS/PROCEDURES PERFORMED|HISTORY OF PRESENT ILLNESS: The patient is an 18-year-old woman with a 3-day history of right neck pain and fever to 100 and 101.5. No dysphasia or hoarseness. No upper respiratory symptoms or that it hurts to move her neck. No sick contacts. She was seen by her PCP the day prior to admission and was found to have a positive monospot test, leukocytosis, and a CT showing a right neck abscess.
PCP|primary care physician|PCP.|116|119|DISCHARGE MEDICATIONS|19. Folic acid 1 mg p.o. daily. 20. Iron sulfate 325 mg p.o. daily. 21. Lovenox 5 mg p.o. q.p.m. to be adjusted per PCP. Her goal INR is 2.0 to 2.5. 22. Lovenox 40 mg subcu b.i.d. until INR is 1.8, then may discontinue. 23. Tequin 400 mg p.o. daily x 7 days.
PCP|Pneumocystis jiroveci pneumonia|PCP|256|258|PROBLEM #4|However, this will not go through until Monday. She therefore will receive her doses of atovaquone in the clinic until we can further clarify this issue. If insurance does not ultimately cover this drug, we would use inhaled pentamidine 300 mg monthly for PCP prophylaxis. DISCHARGE INSTRUCTIONS: The patient will be seen in Bone Marrow Transplant Clinic on the day following discharge on _%#DDMM2004#%_.
PCP|Pneumocystis jiroveci pneumonia|PCP|150|152|DISCHARGE DIAGNOSES|A culture was sent. A CT of the chest without contrast is pending. This is awaiting final read. It should be noted that the patient is on dapsone for PCP prophylaxis. There is no known TB exposure in the past. 4. Pain control. The patient's current pain regimen includes 50 mcg of fentanyl topically every 3 days and breakthrough pain is covered with oxycodone 5 mg every 4 to 6 hours as needed.
PCP|primary care physician|PCP|167|169|HISTORY OF PRESENT ILLNESS|The patient states that she became dizzy around noon today with no syncope. Recently started on Mirapex on _%#MM#%_ _%#DD#%_, 2005, for restless legs syndrome, called PCP today, and he recommended discontinuing the Mirapex. The patient has history of atrial fibrillation in the past but unreliable to give details regarding the treatments or the symptoms.
PCP|Pneumocystis jiroveci pneumonia|PCP|154|156|PROBLEM #4|She did receive the IV Solu- Medrol prior to discharge. Also with respect to her immunosuppression as well as leukopenia, a pentamidine neb was given for PCP prophylaxis. DISCHARGE INFORMATION: 1. Discharge date: _%#DDMM2003#%_.
PCP|Pneumocystis jiroveci pneumonia|PCP|175|177|HOSPITAL COURSE|Also of note, the patient's leukopenia present during her previous admission had resolved. At that time she had a white count of less than 2 and was taken off her Bactrim for PCP prophylaxis in favor of pentamidine. She was also treated with G-CSF. As her white count remained around 6 throughout this admission, her G-CSF was discontinued as well as her pentamidine.
PCP|primary care physician|PCP|316|318|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 77-year-old white male with a past medical history significant for atrial fibrillation, ventricular tachycardia, slight ventricular fibrillation, coronary artery disease, hypertension, hyperlipidemia, and numerous other medical conditions was referred from his PCP clinic for evaluation of productive cough. The patient reports a productive cough of brownish sputum times one week. No fevers or chills. The patient's friend who regularly visits the patient has similar symptoms.
PCP|primary care physician|PCP|172|174|FOLLOW UP|11. She will continue with the study drug SU011248 as before. FOLLOW UP: She will follow up with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2005. She will also followup with her PCP locally in one week locally for monitoring her INRs and managing her Coumadin.
PCP|Pneumocystis jiroveci pneumonia|PCP,|345|348|PROBLEMS|He was discharged on the same diet. 3. Gastrointestinal. _%#NAME#%_ was continued on his home regimen of Colace and MiraLax p.r.n., and established a normal bowel movement pattern during his stay in the hospital. 4. Prophylaxis. _%#NAME#%_ was continued on the following: Acyclovir for HSV, fluconazole for fungal yeast esophagitis, Bactrim for PCP, nystatin for thrush. These were all prophylactic antibiotics. DISCHARGE DIAGNOSES: 1. History of nasopharyngeal rhabdomyosarcoma, now on week 31 of chemotherapy.
PCP|Pneumocystis jiroveci pneumonia|PCP|181|183|HOSPITAL COURSE|2. HIV. Patient was continued on his antiretrovirals during this hospitalization without adverse event. He was also continued on his prophylactic medications, including dapsone for PCP prophylaxis and azithromycin for MAC prophylaxis, without adverse event. DISCHARGE MEDICATIONS: 1. Metoprolol 150 mg p.o. b.i.d. 2. Norvasc 5 mg p.o. daily.
PCP|primary care physician|PCP|274|276|PRIMARY CARE PHYSICIAN|Her wound drainage was getting better, so she was sent home with a prescription for Levaquin 250 mg p.o. q. daily for 10 days and Colace 100 mg p.o. b.i.d. p.r.n. for constipation. FOLLOW UP: Follow up with Dr. _%#NAME#%_ in 1 week for colorectal issues, and follow up with PCP in 3 to 4 weeks.
PCP|Pneumocystis jiroveci pneumonia|PCP|199|201|PROBLEM #2|_%#NAME#%_ is asplenic so gatifloxacin was initiated for encapsulated organism prophylaxis at discharge. He will continue on prophylactic acyclovir therapy through day 100. He is also on Bactrim for PCP prophylaxis. PROBLEM #3: Graft-versus-host disease. _%#NAME#%_ was weaned from systemic steroids, and cyclosporin was discontinued during his last admission to induce a graft versus leukemia effect secondary to his relapsing disease.
PCP|Pneumocystis jiroveci pneumonia|PCP|172|174|PROBLEM #4|He stooled appropriately during the hospitalization. PROBLEM #4: Infectious disease. _%#NAME#%_ was afebrile throughout this hospital stay. He was continued on Bactrim for PCP prophylaxis. PROBLEM #5: Pain. _%#NAME#%_ had no pain concerns during this hospitalization.
PCP|phencyclidine|PCP|295|297|LABORATORY STUDIES|MENTAL STATUS: Is as noted above. PSYCHIATRICALLY: The patient was asked if he has any suicidal ideation and he denied such. LABORATORY STUDIES: At this time reflect a urine tox that was negative for amphetamines, methamphetamines, barbiturates, benzodiazepines, cannabinoids, cocaine, opiates, PCP or tricyclic antidepressants. His serum ethanol level was less than 0.01 grams per deciliter which is essentially negative. Electrolytes show a sodium of 145, potassium of 4.4, chloride of 108, bicarb was 20, BUN of 8, creatinine 0.68, glucose was 86, anion gap was calculated to be 16.
PCP|Pneumocystis jiroveci pneumonia|PCP,|155|158|DISCHARGE MEDICATIONS|7. Paxil 20 mg daily. 8. For restless legs Mirapex 0.25 mg q at bed-time. 9. For interstitial lung disease prednisone 60 mg daily. 10. For prophylaxis for PCP, Bactrim 800 160, one Monday, Wednesday, Friday. 11. For sleep Ambien 5 mg q at bed-time. 12. For history of pulmonary emboli DVT within the last six months.
PCP|Pneumocystis jiroveci pneumonia|PCP|175|177|ASSESSMENT/PLAN|3. Bilateral pulmonary infiltrates, currently of unclear etiology with associated acute respiratory failure. Possibly atypical pneumonia, also need to consider possibility of PCP versus potential failure/pulmonary edema/vasculitis flare. We will start empiric IV levofloxacin and Bactrim, empiric IV steroids and O2 support for now.
PCP|Pneumocystis jiroveci pneumonia|PCP|208|210|HISTORY OF PRESENT ILLNESS|He was admitted with fevers, chills, and nausea. The patient's temperature had risen to 102.2 and he was started on vancomycin and ceftriaxone, given his chronic immunosuppression. Of note, the patient is on PCP prophylaxis with Bactrim. PHYSICAL EXAMINATION: Once admitted on the floor, the patient's fever had decreased to 98.7. His vital signs were stable throughout his admission.
PCP|primary care physician|PCP.|265|268|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|However, they have decided ultimately the patient is not going to have any kind of surgery on her carotids so they refused the vascular surgery consultation for the carotid stenosis. If at all they decide again, they will consider it as an outpatient through their PCP. The patient was already on aspirin 81 mg at home.
PCP|primary care physician|PCP|206|208|DISCHARGE DIAGNOSIS|She denied any increasing leg edema, orthopnea, or PND. She denied any increase in weight as well. She did contact her primary care physician for increasing shortness of breath, at which point in time, her PCP referred her to the ER. PAST MEDICAL HISTORY: 1. Status post CABG in 1990, LIMA to LAD, SVG to ramus and OM 2, SVG to OM 3.
PCP|primary care physician|PCP,|174|177|DISCHARGE INSTRUCTIONS|6. Prednisone 5 mg PO q. day. 7. Bactrim SS one tab PO q. day. 8. Valcyte 450 mg PO b.i.d. DISCHARGE INSTRUCTIONS: The patient is asked to follow up with Dr. _%#NAME#%_, his PCP, in 2 to 3 weeks. It will be scheduled on _%#MM#%_ _%#DD#%_, 2005, at 2 p.m. The patient should also follow up with Dr. _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_. Dr. _%#NAME#%_ _%#NAME#%_'s appointment is on _%#MM#%_ _%#DD#%_, 2005, at 11:30 in the morning.
PCP|phencyclidine|PCP|198|200|SOCIAL HISTORY|SOCIAL HISTORY: The patient has history of chronic alcohol abuse since age 11, drinks one quart a day of vodka. He tried marijuana before daily when he was sober. He also tried ectasy, amphetamine, PCP before. He denies any IV drug use. He smokes occasionally. REVIEW OF SYSTEMS: HEAD, EYES, EARS, NOSE AND THROAT: No complaints.
PCP|Pneumocystis jiroveci pneumonia|PCP.|156|159|ASSESSMENT/PLAN|3. Pneumonia: The pathogen is unknown. We will continue Levaquin and Bactrim for possible PCP. We will obtain sputum and both cultures and silver stain for PCP. 4. Nausea and vomiting: Continue Compazine and Phenergan for symptom relief.
PCP|Pneumocystis jiroveci pneumonia|PCP|194|196|HOSPITAL COURSE|The patient underwent bronchoscopy on _%#MM#%_ _%#DD#%_, 2005, and this was suggestive of an infectious process. ID recommended treating the patient with treatment doses of Bactrim for possible PCP pneumonia. In addition, the patient had blood cultures and sputum cultures drawn which evaluated for AFB and other organisms. The patient underwent induced sputum to obtain samples. So now, the first AFB culture is negative and he has other specimens which are currently pending.
PCP|Pneumocystis jiroveci pneumonia|PCP|220|222|HOSPITAL COURSE|His had chest x-ray showed the above findings. He was requiring 10 liters face mask oxygen to keep his sats above 92%. He was very tachypneic and had bilateral crackles. There was concern for atypical pneumonia possibly PCP pneumonia. He was initiated on Levaquin and Bactrim along with steroids. Infectious disease and pulmonary medicine were both consulted. He underwent bronchoscopy.
PCP|Pneumocystis jiroveci pneumonia|PCP.|178|181|HOSPITAL COURSE|He was initiated on Levaquin and Bactrim along with steroids. Infectious disease and pulmonary medicine were both consulted. He underwent bronchoscopy. He was smear positive for PCP. He was initiated on higher dose Solu-Medrol and Bactrim was changed to IV Bactrim. He did ultimately require transfer to the Intensive Care Unit with BiPAP, given significant hypoxemia and respiratory failure.
PCP|Pneumocystis jiroveci pneumonia|PCP|249|251|HISTORY OF PRESENT ILLNESS|The patient is reported to be febrile since yesterday which prompted him to go to the emergency department today where he spiked a temperature up to 105 and was subsequently admitted. In the emergency department there was concern that this could be PCP pneumonia. He was started on IV Bactrim. REVIEW OF SYSTEMS: Aside from as described above in the history of present illness, the patient denies any cardiac problems, shortness of breath, other respiratory symptoms, chest pain, abdominal pain, diarrhea, constipation, urinary difficulties, neurologic symptoms, or psychiatric symptoms.
PCP|primary care physician|PCP.|253|256||We talked about follow up with the primary care physician and the possible need for referral to an allergist to ascertain the exact cause of the reaction. Also for a prescription for an EpiPen junior to have it all the time as deemed appropriate by the PCP. I told mom that the next reaction could be the same, or possibly worse, and she needs to be ready for that.
PCP|primary care physician|PCP|110|112|HOSPITAL COURSE|Problem #6: Calciphylaxis. The patient is followed by both surgery as well as renal doctor, and she has a new PCP Dr. _%#NAME#%_ _%#NAME#%_ who can assist in the management of calciphylaxis. The patient is stable for discharge. She will follow up as recommended with Dr. _%#NAME#%_, her surgeon, on _%#DDMM2006#%_, with Dr. _%#NAME#%_ _%#NAME#%_ this upcoming Monday for dialysis, and she will follow up with Dr. _%#NAME#%_ _%#NAME#%_ as scheduled.
PCP|primary care physician|PCP|124|126|HOSPITAL COURSE|The medical team would like him to establish care with an endocrinologist at UMMC as he does not have an endocrinologist or PCP at this time. 3. Hypertension. Mr. _%#NAME#%_'s blood pressures were very elevated upon admission. Nephrology made the recommendation to increase labetalol to 400 mg t.i.d. He continued to have some elevated blood pressures, but the administration of his medications were erratic for the procedures that were being performed.
PCP|Pneumocystis jiroveci pneumonia|PCP,|188|191|HOSPITAL COURSE|Her ARDS was believed to be a secondary phenomenon to her pyelonephritis and E. coli bacteremia. During her ICU stay, a bronchoscopy was also performed, which was found to be negative for PCP, CMV. Fungus and AFB stain. She was also tested for ANA, rheumatoid factor and cultures were all negative. Her last chest x-ray was performed on _%#DDMM2006#%_, which was read as clear lungs with no infiltrates noted.
PCP|phencyclidine|PCP,|252|255|LABORATORY DATA|Sodium is 138, potassium is 4.0, chloride 107, bicarb 25, glucose is 82, BUN is 7, creatinine is 0.67, calcium is 7.9. Salicylate level is less than 1. Acetaminophen level is less than 10. Ethanol level is 0.24. Urine drug screen rapid is negative for PCP, cannabinoids, amphetamines, methamphetamines, barbiturates, positive for benzodiazepine and negative for cocaine, opiates and tricyclic antidepressants. EKG shows no acute changes and normal sinus rhythm. Chest x-ray shows no definitive infiltrate, normal cardiac silhouette.
PCP|Pneumocystis jiroveci pneumonia|PCP,|247|250|HISTORY OF PRESENT ILLNESS/BRIEF HOSPITAL COURSE|HISTORY OF PRESENT ILLNESS/BRIEF HOSPITAL COURSE: Mr. _%#NAME#%_ is a 65-year-old gentleman who was admitted in the Fairview Hospital with shortness of breath and was found to have diffuse bilateral infiltrate. Initially he was treated as diffuse PCP, but underwent VATS biopsy which showed BOOP/IPF. He was started on IV steroids. Initially, he had some response, but continued to deteriorate.
PCP|primary care physician|PCP|189|191|FOLLOWUP|The patient does have history of prostate CA. The patient was discharged on postop day #4 to subacute rehab. MEDICATIONS: Flomax 0.4 mg p.o. once daily. FOLLOWUP: In addition to seeing his PCP for suture removal in 7 to 10 days, he is also to see his PCP for his symptoms of urinary retention.
PCP|primary care physician|PCP|251|253|FOLLOWUP|The patient does have history of prostate CA. The patient was discharged on postop day #4 to subacute rehab. MEDICATIONS: Flomax 0.4 mg p.o. once daily. FOLLOWUP: In addition to seeing his PCP for suture removal in 7 to 10 days, he is also to see his PCP for his symptoms of urinary retention.
PCP|Pneumocystis jiroveci pneumonia|PCP|234|236|HOSPITAL COURSE|Dapsone was discontinued and this trended down nicely, currently tolerating p.o. intake without nausea, vomiting or abdominal pain. Lipase was at normal values currently. He will remain on fungal prophylaxis with fluconazole. Further PCP prophylaxis may be pursued with pentamidine. Bactrim was not used given his acute renal insufficiency. 7. Hyperglycemia. The patient does have known type 1 diabetes and did have extreme hyperglycemia during his hospitalization with blood sugar levels reaching close to 700 to 800.
PCP|Pneumocystis jiroveci pneumonia|PCP|146|148|DISCHARGE INSTRUCTIONS|2. Platelets were preordered for a anticipated transfusion need on _%#MMDD#%_. 3. Continue Mycophenolate through _%#MMDD#%_. 4. Begin Bactrim for PCP prophylaxis when the ANC is > or = 1. 5. Follow-up CSA level which was drawn on _%#MMDD#%_. It has been pleasure to be involved with _%#NAME#%_'s care.
PCP|Pneumocystis jiroveci pneumonia|PCP.|172|175|HISTORY OF PRESENT ILLNESS|This patient is being discharged today in good condition with following medications: 1. Prilosec 20 mg p.o. daily for GERD. 2. Vitamin B12 subcutaneously every month _____ PCP. 3. Calcium carbonate two 500 mg tablets p.o. b.i.d. 4. Percocet 1-2 tabs p.o. q.4h. p.r.n. for pain. 5. Iron sulfate 325 mg p.o. b.i.d. x 2 weeks.
PCP|primary care physician|PCP|172|174|HOSPITAL COURSE|She did not have any withdrawal signs of symptoms. We also gave multivitamin and folate and thiamin at admission. The patient should need treatment for her alcohol and her PCP will schedule for her after discussion with the patient. DISCHARGE MEDICATIONS: 1. Levaquin 500 mg p.o. once a day for 10 days.
PCP|primary care physician|PCP|164|166|DISCHARGE MEDICATIONS|11. The patient is advised not to take aspirin for next 10 days and then resume aspirin 81 mg p.o. daily. Follow with Dr. _%#NAME#%_ on _%#MMDD2007#%_. Follow with PCP in 2 weeks' time.
PCP|primary care physician|P.C.P.|169|174|PROBLEMS|4. Musculoskeletal. The patient apparently has thoracic disc herniation per him. I will place him on morphine 1 to 2 mg IV q.4 h. p.r.n. I will also get record from his P.C.P. clinic to confirm this diagnosis. I am aware the patient has a history of chemical dependency but I will go ahead and treat him w/ morphine for now.
PCP|Pneumocystis jiroveci pneumonia|PCP,|168|171|HOSPITAL COURSE|In addition, there was granulomatous disease. In light of these CT findings a bronchoscopy was performed on _%#MM#%_ _%#DD#%_, 2002. This bronchoscopy was negative for PCP, fungus, CMV, RSV, influenza. No organisms were identified. Mr. _%#NAME#%_ was treated on Levofloxacin for broad spectrum coverage per Pulmonary's recommendations.
PCP|phencyclidine|PCP.|150|153|PHYSICAL EXAMINATION|Platelet count normal at 288,000. Electrolytes unremarkable. Drug tox urine screen was positive for benzodiazepines, cocaine, methadone, opiates, and PCP. A copy of this was sent to the patient's drug counselor/coordinator at _%#COUNTY#%_ _%#COUNTY#%_. ASSESSMENT: 1. Cellulitis, left hand. 2. Drug abuse. PLAN: During the conversation with the drug counselor at the nursing station the patient left against medical advice.
PCP|Pneumocystis jiroveci pneumonia|PCP|136|138|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. His past medical history is notable for HIV/AIDS diagnosed 9 years ago with opportunistic infection history of PCP pneumonia and thoracotomy for pleurodesis. Also, with complications of thrush and elevated LFTs secondary to meds. Has had a history of herpes zoster in addition.
PCP|Pneumocystis jiroveci pneumonia|PCP.|124|127|HOSPITAL COURSE|The washings returned normal bronchial flora as well as some budding yeast. Psychology was negative as was test for CMV and PCP. The patient improved somewhat with the empiric steroids and antibiotics and she will be discharged to home on these. DISCHARGE MEDICATIONS: 1. Atenolol 25 mg q.d. 2. Tequin 200 mg q.d. times ten days.
PCP|Pneumocystis jiroveci pneumonia|PCP,|174|177|BRIEF HISTORY OF PRESENT ILLNESS|His bronchioalveolar lavage from the 19th showed 10 turbid fluid, with 3750 red blood cells, 17,313 mucleated cells. There was no evidence of malignancy. It was negative for PCP, negative for CMV shell vial. The gram stain was positive for budding yeast and rare Pseudo Hyphae. The culture grew out Stenotrophomonas maltophilia. This strain was resistant to the bacterium and intermediately sensitive to tobramycin and Timentin, and resistant to all other organisms tested, and so far the bronchial culture is also growing a single colony of a filamentous fungus that is yet unidentified.
PCP|Pneumocystis jiroveci pneumonia|PCP|181|183|ADMISSION DIAGNOSIS|Upon starting the Bactrim treatment he again became febrile, showed AST and ALT elevations, as well as elevations in his amylase and lipase. The Bactrim IV was discontinued and his PCP treatment was continued with clindamycin and Primaquine again. During his hospital course his chest x-ray exams improved as did his physical exam findings over his lung fields.
PCP|Pneumocystis jiroveci pneumonia|PCP|205|207|SOCIAL HISTORY|HOSPITAL COURSE: 1. Infectious disease. _%#NAME#%_ was initially started on imipenem and Cipro for good coverage of past positive blood culture sensitivities. He was also continued on his Bactrim for good PCP prophylaxis. Once sensitivities of this pseudomonas were determined he was switched to Cipro and tobramycin for good double coverage of this bacteria.
PCP|Pneumocystis jiroveci pneumonia|PCP|204|206|STUDIES|NEUROLOGIC: Cranial nerves are grossly intact. Otherwise grossly nonfocal. DERM: No obvious ulcers, lesions, rash STUDIES: 1. Shoulder films in the emergency room are negative. 2. Urinalysis positive for PCP and opiates. Discussed with laboratory and significant incidence of high false positive for PCP does occur with many over the counter medications.
PCP|Pneumocystis jiroveci pneumonia|PCP|177|179|STUDIES|1. Shoulder films in the emergency room are negative. 2. Urinalysis positive for PCP and opiates. Discussed with laboratory and significant incidence of high false positive for PCP does occur with many over the counter medications. IMPRESSION: A 42-year-old female with progressive depression which is requiring increasing and alternative pharmaceutical interventions who now presents with acute onset of intractable and progressive left shoulder pain with negative EKG, no obvious source for infection, no asymmetry or other obvious clinical abnormalities on examination other than pain with range of motion and over a diffuse and unusual area that does not include all portions of the same muscle groups.
PCP|primary care physician|PCP.|152|155|ASSESSMENT AND PLAN|The patient's fasting glucose is ranging 119 to 120. Therefore, at this time, she will not be treated for diabetes. This needs to be followed up by her PCP. The patient does not have any other risk factor for coronary artery disease, except her age. No other identifiable problem we need to work on at this time.
PCP|Pneumocystis jiroveci pneumonia|PCP|219|221|PROBLEM #3|A _%#DDMM2003#%_ CMV antigenemia is pending. She has had occasional fevers, but no positive blood cultures, and is on prophylactic antimicrobial and antifungal coverage. Bactrim is scheduled to start _%#DDMM2003#%_ for PCP prophylaxis. On the day of discharge, she had prominent rhinorrhea. A nasopharyngeal swab was obtained and a culture is currently pending.
PCP|Pneumocystis jiroveci pneumonia|PCP|146|148|PROBLEM #2|CMV antigenemia _%#MMDD#%_ negative. Treatment includes acyclovir IV for active herpes virus. He was started on Bactrim q. Monday and Tuesday for PCP prophylaxis. _%#NAME#%_ had been treated with pentamidine secondary to neutropenia, but his white counts have improved greatly over the past two weeks.
PCP|Pneumocystis jiroveci pneumonia|PCP|173|175|PROBLEM #7|PROBLEM #7: Infectious disease. Mr. _%#NAME#%_ was afebrile throughout his hospital course. He will continue with prophylactic use of fluconazole and acyclovir. Bactrim for PCP prophylaxis should be started since he is engrafted. PROBLEM #8: Fluid, electrolytes, and nutrition. Mr. _%#NAME#%_ has fairly decent p.o. intake, but will likely require IV hydration in the clinic on a daily basis.
PCP|Pneumocystis jiroveci pneumonia|PCP,|203|206|DIAGNOSES|Over the course of this hospitalization, the patient was intubated and extubated twice, and had seizures. His major problems included persistent severe pneumonia from multiple infections, including CMV, PCP, and Aspergillus. He was treated with multiple medications throughout his hospitalization, all of which failed to improve his pulmonary status. In addition, the patient had a CNS lesion that was thought to be Toxoplasmosis, for which he was treated for a short period of time, versus CNS lymphoma versus invasive Aspergillus.
PCP|UNSURED SENSE|PCP|175|177|DISCHARGE MEDICATIONS|2. Colace 100 mg p.o. b.i.d. 3. Senna two tabs p.o. q.d. 4. Aspirin 325 mg p.o. q.d. 5. Humulin 70/30 5 units subq q.a.m. and q. dinner. 6. Regular insulin, sliding scale. 7. PCP 1 gm p.o. b.i.d. 8. Metoprolol 50 mg q.a.m., 25 mg q.p.m. 9. Fluconazole 400 mg p.o. q.d. 10. Rivoglitazone 4 mg p.o. q.d. 11. Ethambutol 1 gm p.o. q.d.
PCP|Pneumocystis jiroveci pneumonia|PCP|166|168|DISCHARGE MEDICATIONS|8. Zofran 8 mg p.o. q.8h. 9. Ativan 2 mg p.o. q.6-8h. p.r.n. for nausea or anxiety. 10. Compazine 10 mg p.o. q.6h p.r.n. for nausea. 11. Inhaled pentamidine nebs for PCP prophylaxis. DISCHARGE INSTRUCTIONS: 1. Follow up with Dr. _%#NAME#%_ _%#DDMM2004#%_. 2. Return if patient experiences fever, chills, or increase in symptoms such as nausea, vomiting, or decreased appetite.
PCP|primary care physician|PCP|164|166|DISCHARGE MEDICATIONS|2. Pantoprazole 40 mg p.o. q.d. 3. Phenergan 12.5 mg, 1 to 2 tabs p.o. q.6 hours p.r.n. nausea. PRIMARY CARE PHYSICIAN FOLLOWUP: The patient should follow with his PCP in 1 to 2 weeks. FOLLOWUP DIET: Regular. FOLLOWUP ACTIVITY: As tolerated.
PCP|Pneumocystis jiroveci pneumonia|PCP,|167|170|ALLERGIES|Fungal culture and bronchial culture demonstrates no positive findings. AFB on concentrated smear was also negative, and the bronchial washings were negative for CMV, PCP, and fungus. His oxygen requirement decreased throughout the course of his hospitalization, and he was weaned to room air 2 days prior to discharge.
PCP|primary care physician|PCP|188|190|DISPOSITION|1. The patient has been discharged in stable condition at home. 2. The patient will follow up with Dr. _%#NAME#%_ _%#NAME#%_, on _%#MM#%_ _%#DD#%_, 2005. 3. The patient follow up with his PCP in 2 weeks. 4. The patient will have follow up with Dr. _%#NAME#%_ in 1 month. 5. The patient will have his CBC checked and will fax the report to the transplant coordinator.
PCP|primary care physician|PCP|141|143|FOLLOW UP|1. Prevacid 5 mg per mL, 3 mL daily. 2. Cosopt ophthalmic solution 1 drop to both eyes. FOLLOW UP: Follow up with Dr. _%#NAME#%_ _%#NAME#%_, PCP at the La Clinica En Lake and Dr. _%#NAME#%_ _%#NAME#%_ in 6 months to monitor development, there will be no change in medical therapy for these spells.
PCP|Pneumocystis jiroveci pneumonia|PCP|162|164|IMPRESSION AND PLAN|6. Herpes zoster with Ramsey Hunt syndrome. He is on Valtrex x14 days. On prednisone for 14 days. Will continue these and monitor closely for skin infections. 7. PCP prophylaxis: He is on dapsone. 8. Osteoporosis risk secondary to prednisone and steroid use: He is on Fosamax and will add calcium and vitamin D.
PCP|Pneumocystis jiroveci pneumonia|PCP|200|202|SOCIAL HISTORY|There is a reddish purplish discoloration on the cheeks. Neurologic examination was completely normal. HOSPITAL COURSE/PROBLEMS: 1. Pneumonia: There was a concern of opportunistic infection including PCP pneumonia. The patient was initially started on Bactrim, but the patient also had methemoglobinemia on dapsone; therefore, it was switched to atovaquone on the ID recommendation.
PCP|Pneumocystis jiroveci pneumonia|PCP.|296|299|SOCIAL HISTORY|The patient will be followed by Dr. _%#NAME#%_ in one week for further assessment. The patient was given atovaquone for PCP. 4. Methemoglobinemia, which was most likely secondary to the dapsone use; therefore, the patient's dapsone was discontinued, and the patient was started on atovaquone for PCP. DISCHARGE MEDICATIONS: 1. Flagyl 250 mg p.o. t.i.d. for a total of 2 more days.
PCP|primary care physician|PCP|303|305|RESULTS PENDING|In addition, they are concerned that Mr. _%#NAME#%_ has so many different specialists to see that they no longer have anyone from a primary care perspective coordinating his general medical care and understanding the interactions of the various specialists. For the last 2 years, he has nominally had a PCP at the _%#CITY#%_ Clinic who he is not "hooked in" with very well. He expressed the wish to come to the primary care clinic here at the University of Minnesota Physicians Practice and was given the list of doctors working in that clinic along with the phone number and suggestions for how to set up a new primary care doctor here.
PCP|Pneumocystis jiroveci pneumonia|PCP,|198|201|PROBLEMS|MMF was discontinued. 3. Infectious disease. The patient has been afebrile for the last 4 days. Blood cultures are negative to date. She will be discharged on Bactrim q. on Mondays and Tuesdays for PCP, acyclovir 400 mg p.o. b.i.d., voriconazole 300 mg p.o. b.i.d. for prophylaxis. CMV antigen and Aspergillus antigen were negative on _%#DDMM2005#%_.
PCP|Pneumocystis jiroveci pneumonia|PCP|137|139|ASSESSMENT/PLAN|He will be discharged on _________, acyclovir, Levaquin, and high-dose fluconazole to ______________ in his liver. He will start Bactrim PCP prophylaxis as well today. 5. Graft-versus-host disease: He has no GVH to date. He will continue MMF to day 30. He does have a CSA level pending from _%#DDMM2005#%_.
PCP|Pneumocystis jiroveci pneumonia|PCP|294|296|HOSPITAL COURSE|The patient received some nitroglycerin drip in the ED because of her blood pressures were high when she came in, 212/116, and she received nitroglycerin drip and Decadron 10 mg and some Zofran and Bactrim IV as the patient has history of CD4 count about 100 in _%#DDMM2006#%_ and questionable PCP pneumonia, but unsure. The patient then was transferred to ICU and was put on BiPAP as her sats were 80 to 90 on room air when she came in and she was put on BiPAP and her sat was maintained more than 98 percent.
PCP|Pneumocystis jiroveci pneumonia|PCP.|287|290|PAST MEDICAL HISTORY|He received IV antibiotics, blood cultures, chest x-ray, and IV magnesium replacement in the Bone Marrow Transplant Clinic prior to admission. PAST MEDICAL HISTORY: 1. X linked severe combined immunodeficiency disease. 2. Hospitalizations for respiratory syncytial virus, Rotavirus, and PCP. 3. Status post open lung biopsy _%#DDMM2004#%_, with a lymphocytic lung infiltrate. 4. Chronic maxillary sinusitis and otitis media. ALLERGIES: No known drug allergies.
PCP|Pneumocystis jiroveci pneumonia|PCP|183|185|PLAN|6. Pancytopenia. PLAN: 1. The patient is to continue on Rituxan every week per Hematology- Oncology. 2. He is to continue his HIV medications, as well as Bactrim and azithromycin for PCP and MAC prophylaxis. 3. He will have follow-up appointment with Oncology in 2 weeks. 4. In the meantime, I will check for his C.
PCP|phencyclidine|PCP|490|492|LABORATORY DATA|LABORATORY DATA: In the ER, she had the following laboratory studies done: She had a CBC which was entirely within normal limits with a white count of 9.2, hemoglobin 12.3, platelet count of 261,000, normal electrolytes, a BUN of 11, creatinine 0.89, normal liver function tests, Tylenol level of less than 10, a salicylate level of less than 1. She had a urine drug screen which was negative for amphetamines, metamphetamines, barbiturates, benzodiazepine, cannabinoids, cocaine, opiates, PCP and tricyclic antidepressants. She had a urine pregnancy test that was negative, a urinalysis that was unremarkable and an EKG that showed a normal sinus rhythm, and a TSH of 2.76. Her electrolytes were repeated in the morning and were normal.
PCP|primary care physician|PCP|185|187|ACTIVITY|DISCHARGE INSTRUCTIONS DIET: Clears. ACTIVITY: As tolerated. No driving while taking pain medications. No bath x2 weeks but may shower. No heavy lifting x6 weeks. The patient is to see PCP regarding diabetes management. The patient was to seek medical attention if she had increased drainage, increased pain, increased swelling, elevated temperatures greater than 101.5, persistent nausea or vomiting, and/or no flatus or bowel movements.
PCP|primary care physician|PCP|131|133|DISCHARGE MEDICATIONS|9. Change in the home medications: The patient is advised not to take Lasix at home until the creatinine comes back to normal when PCP will advise him to start back on Lasix. Also he is advised not to take Celebrex. There are no new medications for the patient.
PCP|primary care physician|PCP.|207|210|PHYSICIAN FOLLOWUP|This is a new medication for PCP. The patient to discuss duration of therapy with Dr. _%#NAME#%_ at followup appointment. PHYSICIAN FOLLOWUP: 1. Dr. _%#NAME#%_ _%#NAME#%_, pulmonary clinic, for follow up to PCP. _%#NAME#%_ _%#NAME#%_, RN, to call the patient. 2. Dr. _%#NAME#%_ of the medicine clinic for follow up to dermatomyositis on _%#MM#%_ _%#DD#%_, 2006, at 8 a.m.
PCP|Pneumocystis jiroveci pneumonia|PCP,|203|206|HOSPITAL COURSE|That appointment is on _%#MMDD#%_ at 2 p.m. HOSPITAL COURSE: This lady came over here posttransplantation on the _%#MMDD#%_. She has had numerous complications actually prior to her transplantation with PCP, VRE pneumonia during her prehospitalization induction phase. She also had cutaneous herpes simplex virus, she of course had her chemotherapy and total body irradiation in preparation for transplantation, which greatly affected her immune systems.
PCP|primary care physician|PCP|120|122|HOSPITAL COURSE|15. Lopressor 25 mg b.i.d. 16. Myfortic 360 mg p.o. b.i.d. 17. Protonix 40 mg once a day. Followup appointment with the PCP and with Dr. _%#NAME#%_ in a couple of weeks in clinic and he is to be followed by his coordinator and labs Monday, Wednesday and Friday for PT/INR keep it between 2 and 3 for Coumadin a total of 3 months and his labs we will watch on Monday, Wednesday and Friday until his creatinine normalizes.
PCP|primary care physician|PCP|197|199|MEDICATIONS|4. Prednisone 40 mg daily x2 days, given to her by her primary care physician for possible inflammation associated with this retrosternal chest pain. 5. Magic mouthwash x2 days given to her by her PCP to help her swallow the prednisone. 6. Multivitamin daily. SOCIAL HISTORY: She lives with her parents and her brother in an apartment in _%#CITY#%_.
PCP|primary care physician|PCP,|306|309|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|SECONDARY DIAGNOSIS: CAD and macular degeneration. HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is an 87-year-old white female with severe COPD with recurrent pneumonia, O2 dependent, was brought in for shortness of breath and fatigue. The patient was initially given Zithromax by PCP, however, with no improvement. The patient had a harsh cough, unable to bring out any sputum. In the ER the patient had a respiratory rate of 24-30 with a harsh cough and green colored sputum, afebrile.
PCP|primary care physician|P.C.P.|108|113|FOLLOW-UP|2. Metronidazole 500 mg p.o. q.6 h. x 10 days. INSTRUCTIONS: Low-residue diet. FOLLOW-UP: 1. Follow-up with P.C.P. Dr. _%#NAME#%_ _%#NAME#%_ at the Fairview Uptown Clinic in 4 to 8 weeks. 2. Have P.C.P. set patient up for outpatient colonoscopy in 8 weeks for follow-up of diverticulitis.
PCP|Pneumocystis jiroveci pneumonia|PCP|138|140|DISCHARGE MEDICATIONS|4. Rifabutin 150 mg orally once a day 3 days a week on Mondays, Wednesdays and Fridays. 5. Bactrim double strength one tab p.o. daily for PCP prophylaxis. 6. Valganciclovir 900 mg p.o. daily for CMV prophylaxis. 7 Atazanavir 300 mg p.o. daily for HIV. 8. Emtriva 200 mg p.o. daily for HIV. 9. Ritonavir 100 mg p.o. daily for HIV.
PCP|primary care physician|PCP,|174|177|DISCHARGE INSTRUCTIONS|He will return to my clinic in about a week to have the stitches removed and we will follow up with chest x-ray to reassess his left lung. 4. He will also follow up with his PCP, for long control of his hypertension. DISCHARGE MEDICATIONS: 1. Controlled-release oxycodone. 2. Immediate-release oxycodone. 3. Senokot.
PCP|Pneumocystis jiroveci pneumonia|PCP|315|317|HOSPITAL COURSE|4. Infectious disease: _%#NAME#%_ was initially treated with vancomycin and ceftazidime and switched to Ancef and ceftazidime after 48 hours and ceftazidime was stopped on _%#DDMM2007#%_. She was started on Voriconazole and her prophylactic fluconazole was stopped on_%#DDMM2007#%_. She has remained on Bactrim for PCP prophylaxis. She had a urine culture from admission that grew pseudomonas and group D enterococcus. She was treated with a 9-day course of ceftazidime for those infections, however, it was thought that these were likely due to contaminant.
PCP|primary care physician|PCP|139|141|DISCHARGE FOLLOWUP|DISCHARGE FOLLOWUP: 1. Dr. _%#NAME#%_ at the transplant clinic on _%#DDMM2006#%_ at 11:30 a.m. 2. Dr. _%#NAME#%_ _%#NAME#%_, the patient's PCP in _____ Clinic within 1-2 weeks for hospital followup. 3. Follow up with psychiatry at the next available appointment for further followup with them.
PCP|primary care physician|PCP.|205|208|ASSESSMENT|5. Multi vitamin two tablets p.o. daily. 6. Aspirin enteric coated 81 mg p.o. daily. 7. Zoloft 25 mg p.o. daily for two weeks to be increased to 50 mg p.o. daily, thereafter with short term follow up with PCP. _%#NAME#%_ will be discharged to the Presbyterian Home for outpatient rehab.
PCP|Pneumocystis jiroveci pneumonia|PCP|222|224|ASSESSMENT AND PLAN|PROBLEM #1 Pulmonary. Community acquired pneumonia, which is most likely diagnosis after review by infectious disease. He will continue his Levaquin and Bactrim and oxygen as needed. He was on prednisone dose for possible PCP as well. PROBLEM #2 Cardiovascular. For his orthostasis he was taken off Flomax and started on midodrine.
PCP|primary care physician|PCP|399|401|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Cellulitis of the lower extremities. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 35-year-old white female, postpartum about 10 months, who fell down the stairs with the baby and sustained small cuts on the lower extremities bilaterally, turned into a cellulitis with increased swelling, pain and redness who failed the therapy with Augmentin for the last 7 days given by PCP and finally came to the ER. In the ER the patient had an ultrasound of the lower extremities which ruled out DVT, however, has a small collection of fluid over the shin in the left leg.
PCP|Pneumocystis jiroveci pneumonia|PCP|148|150|PAST MEDICAL HISTORY|2. He has been evaluated for hepatitis C, hepatitis B, toxoplasmosis, and RPR, which were all negative. 3. Status post hospitalization for probable PCP pneumonia in _%#DDMM2006#%_. Diagnosed based on imaging. No positive cultures were obtained. 4. History of sleep apnea, but does not tolerate BiPAP.
PCP|primary care physician|PCP|146|148|DISPOSITION|Patient encouraged to drink plenty of fluids, he agreed. Rx for Zofran, Dilaudid, and Senna-S provided as noted in medication list above. FU with PCP next week.
PCP|primary care physician|PCP|325|327|PLAN|ABDOMEN: Soft, nontender. NEUROLOGIC: Basically nonfocal. LABORATORY DATA: At discharge, sodium 139, potassium 4.3, chloride 105, CO2 of 28, BUN 8, creatinine 0.7, glucose 83, WBC 3.4, hemoglobin 11.5. ASSESSMENT: Severe headache due to aseptic meningitis with good improvement. PLAN: Discharge home today and follow up with PCP in one week.
PCP|Pneumocystis jiroveci pneumonia|PCP|186|188|BRIEF HISTORY|The patient was electively intubated and bronchoscopy was performed. Given his long-term history of chronic steroid use for sarcoidosis, there was concern that the patient suffered from PCP pneumonia. Bronchoalveolar lavage demonstrated negative mucicarmine and silver stain, Bactrim, which was started empirically was discontinued after BAL results returned.
PCP|primary care physician|PCP|107|109|FOLLOWUP|FOLLOWUP: 1. The patient is to follow up with Dr. _%#NAME#%_ in 2 weeks for wound check. 2. Follow up with PCP in 1-2 weeks for DVT management and bridging to p.o. anticoagulation. May have staples removed 2 weeks postop.
PCP|primary care physician|PCP|403|405|FOLLOW UP|Her acute renal failure is most likely due to prerenal azotemia caused by dehydration and her renal function returned to normal on the day of discharge with a creatinine of 0.97. FOLLOW UP: The patient will need to follow up with her cardiologist in 1 or 2 weeks for medication readjustment. She will need to follow up with her primary care physician in 3-5 days with repeat chem-7 and INR prior to her PCP appointments. DISCHARGE MEDICATIONS: She will be discharged with following medications: 1. Allopurinol 100 mg p.o. daily.
PCP|primary care physician|PCP|346|348|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|The patient was given a choice to be evaluated by orthopedic surgeon here, however, insists on continuing physical therapy for now and she will follow up with PCP. The patient has a history of fibromyalgia, however, husband had doubt that patient may have had Lyme disease for which she needed some investigation and which I have referred him to PCP again. DISCHARGE MEDICATIONS: 1. Home medications Elavil 50 mg p.o. each day at bed-time.
PCP|Pneumocystis jiroveci pneumonia|PCP.|201|204|ISSUES|We thought this could be related to his HIV. We continued the HIV medication without any change. The CD4 count done during this admission was 90 and therefore he was started on Bactrim prophylaxis for PCP. 2. Mental status decline. The patient has a subacute decline in his mental status for the last 3 months. His current mental status was thought to be his baseline and therefore he was discharged to the nursing home.
PCP|primary care physician|PCP,|231|234|FOLLOW-UP|FOLLOW-UP: Follow-up with primary care physician, Dr. _%#NAME#%_, in two days which is Monday _%#DDMM2002#%_, the day after tomorrow. She will get a CBC and electrolyte panel that day and it will be reviewed and followed-up by her PCP, Dr. _%#NAME#%_. She will also get Levaquin 500 mg once a day for bronchitis for 10 days. If she feels any worse, she is advised to come back to the ER.
PCP|Pneumocystis jiroveci pneumonia|PCP|122|124|IMPRESSION/PLAN|In the event that there is further decompensation of her pulmonary status, I would be quick to add trimethoprim sulfa for PCP treatment at this time. An LDH will also be sent. 2. Cardiac. Non-specific electrocardiogram changes. The patient is on aspirin. Serial troponins initial one was negative.
PCP|Pneumocystis jiroveci pneumonia|PCP|206|208|HISTORY|Her first transplant of a five out of six unrelated cord blood on _%#DDMM2002#%_ failed to engrafted. _%#NAME#%_ originally presented with a persistent cough to _%#CITY#%_ Childrens, and was diagnosed with PCP on _%#DDMM2002#%_. SCID was diagnosed by Dr. _%#NAME#%_ in leu of her absent tonsils, absent thymus, absolute lymphopenia, with absent CD3 in nineteen cells, absent IgA, IgM, low IgG, and abnormal mitogen stimulation test for lymphocytic blastogenesis.
PCP|phencyclidine|PCP,|187|190|PROBLEM PRESENTED AT ADMISSION|The patient has an extended history of substance abuse issues upon entry into program including abuse of marijuana and alcohol, with experimental use of Valium, cocaine, methamphetamine, PCP, hallucinogens, ecstasy and GHP. The patient was not presently taking medications upon arrival, but relates a history of Depakote, Zoloft, Zyprexa, and Trazodone.
PCP|Pneumocystis jiroveci pneumonia|PCP|77|79|DISCHARGE MEDICATIONS|3. Lansoprazole 30 mg p.o. q.d. 4. Bactrim SS 1 tablet p.o. twice weekly for PCP prophylaxis on Mondays and Thursdays. 5. Zenapax (daclizumab) 65 mg IV q.14 days, to be done at the Transplant Clinic. 6. Mycophenolate (Cellcept) 1 gram p.o. b.i.d. (transplant?). 7. Prednisone 5 mg p.o. b.i.d.
PCP|primary care physician|PCP|244|246|DISCHARGE INSTRUCTIONS/FOLLOW-UP|The patient was also educated as to her dressing changes, which will be done every day by the home health care nurses and will eventually be done either by the patient herself or by her caretaker at home. 2. The patient will follow up with her PCP in approximately two to three days. The patient will make that appointment for herself. 3. The patient will also follow up at the Wound Clinic at the Fairview- University Medical Center in approximately one week.
PCP|Pneumocystis jiroveci pneumonia|PCP|176|178|HISTORY OF PRESENT ILLNESS|An ID consult was also sought. It was decided to continue the patient's antiretroviral medications. It was also decided to change the patient's Bactrim which he was taking for PCP prophylaxis to PCP treatment dose. The patient started improving with these treatment modalities in place.
PCP|Pneumocystis jiroveci pneumonia|PCP,|230|233|HISTORY OF PRESENT ILLNESS|The patient was treated with ceftazidime and ciprofloxacin throughout this admission, and a PICC line was placed for an anticipated 3 weeks of home IV ceftazidime. Cytopathology from bronchoscopy was negative for malignancy, CMV, PCP, or fungus. The patient was also continued on daily Zithromax and twice-daily itraconazole for a history of Aspergillus. 2. Sinusitis. A CAT scan on _%#MM#%_ _%#DD#%_, 2003, revealed moderate pansinusitis with bony erosions.
PCP|Pneumocystis jiroveci pneumonia|PCP.|156|159|OPERATIONS/PROCEDURES THIS ADMISSION|3. Brush smears and bronchial fluid: Negative for malignancy. No organisms are identified on gram stain histologic specimen. Negative for CMV. Negative for PCP. Negative for fungus. 4. Right middle lobe endobronchial biopsy: Chronic bronchitis with squamous cell metaplasia. No evidence for malignancy. 5. Bronchoalveolar lavage: Body fluid appearance is cloudy.
PCP|Pneumocystis jiroveci pneumonia|PCP,|183|186|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old gentleman with a past medical history significant for HIV complicated by CMV and toxoplasma IgG positive status, a history of PCP, and peripheral myopathy and neuropathy. The patient was seen by his primary infectious disease physician on Friday with complaints of a week and a half of chronic cough and associated chest pain.
PCP|phencyclidine|PCP|273|275|ASSESSMENT|Neurosurgery would like to see her as an outpatient and arrange surgery for her as soon as cardiology feels she is stable to undergo surgery. Microcephaly. Irritability managed on Ativan. Mom's admission toxicology screen for amphetamine, opioids, cocaine, canabinoids and PCP were negative, as was the toxicology on the meconium. _%#NAME#%_ still arches, and has a high-pitched cry, but she is much calmer now and no longer needs ativan.
PCP|Pneumocystis jiroveci pneumonia|PCP.|151|154|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. HIV-AIDS, last CD4 count 1, _%#DDMM2004#%_. 2. Cryptococcal meningitis. 3. Toxoplasmosis of the brain. 4. Cryptosporidium. 5. PCP. 6. Status post VP shunt 1998. 7. Pulmonary aspergillosis diagnosed _%#DDMM2005#%_. HOSPITAL COURSE: PROBLEM #1: Electrolyte abnormalities: Because it is quite common to get electrolyte abnormalities with amphotericin, and because these abnormalities were persistent over the first few days of his hospitalization, we did switch the patient to caspofungin.
PCP|phencyclidine|PCP.|176|179|PAST PSYCHIATRIC HISTORY|The patient reports in the past he has taken ecstasy twice a week for 2 weeks straight and cocaine he reports that he experimented. He denied using methamphetamine, heroin and PCP. The patient minimizes his use of alcohol and drugs. VITAL SIGNS: Temperature 98.2, pulse of 96, respiratory rate of 16, blood pressure of 130/90.
PCP|Pneumocystis jiroveci pneumonia|PCP|244|246|HOSPITAL COURSE|The final report on that study is still pending. Drug toxicity that can cause central lobular necrosis includes that from Bactrim, as well as Prograf, and during his hospital stay his Bactrim was discontinued, and he was started on Dapsone for PCP prophylaxis. Upon completion of his Thymoglobulin treatment, we discontinued his Prograf and initiated Rapamune as part of his maintenance immunosuppression.
PCP|phencyclidine|PCP,|206|209|HISTORY OF PRESENT ILLNESS|He reports tolerance, blackouts, history of seizures, legal problems, DUIs, financial problems, relationship problems, work problems. He also reports a period when he used marijuana, cocaine, barbiturates, PCP, LSD, crank, mushrooms, and cannabis. He reports that he preferred cocaine. Please refer to the adult chemical dependency evaluation done on _%#DDMM2007#%_ for further details about his substance use.
PCP|Pneumocystis jiroveci pneumonia|PCP|314|316|HOSPITAL COURSE|Recommendations were to hold Bactrim, Cellcept, and Valcyte. No bone marrow morphology was needed at this time, but if white blood cell count and neutrophil count did not increase over the next 2 weeks, the patient will need to have a bone marrow biopsy. The patient was given a pentamidine treatment to cover for PCP prophylaxis while Bactrim is discontinued. The patient was also seen by Infectious Disease to follow up on the clinical management of his persistent CMV infection.
PCP|Pneumocystis jiroveci pneumonia|PCP|156|158|HISTORY OF PRESENT ILLNESS|The patient now presents with a creatinine of 2.7 mg/dL and a wound infection. She has been followed by Dr. _%#NAME#%_ _%#NAME#%_ in Infectious Disease for PCP pneumonia. She has been receiving IV pentamidine since _%#DDMM2007#%_ for treatment of this pneumonia. Her pentamidine has been held today, and she will be admitted to the University of Minnesota Medical Center, Fairview, for further workup.
PCP|Pneumocystis jiroveci pneumonia|PCP|164|166|HISTORY OF PRESENT ILLNESS|His present medications have been Sustiva and Combivir. He also takes rifabutin, Zithromax, and Nembutal for MAC infection. He evidently also takes pentamidine for PCP prophylaxis. He came to the emergency room on Saturday with intermittent severe abdominal discomfort not associated with nausea, diarrhea, bowel movements, etc.
PCP|Pneumocystis jiroveci pneumonia|PCP|148|150|PAST MEDICAL HISTORY|4. Diabetic gastroparesis. 5. Diabetic nephropathy with chronic renal insufficiency. 6. Cerebrovascular accident x2. 7. Hypertension. 8. History of PCP pneumonia. 9. Current CMV retinitis. 10. History of sinusitis in _%#DDMM2005#%_. 11. Sphenoid sinusitis. TRANSPLANT HISTORY: 1. Deceased-donor pancreas transplantation with bladder drainage in 1999.
PCP|Pneumocystis jiroveci pneumonia|PCP|182|184|HISTORY OF PRESENT ILLNESS|Her last CD-4 count was 159, with an undetectable viral load. She is also on insulin, nephrocaps, folic acid, Phos-Lo, Zestril, and Percocet on a p.r.n. basis. She takes Bactrim for PCP prophylaxis. She takes multivitamins. She takes Klonopin for restless legs. She takes Norvasc, presumably for hypertension. Her family history is positive for diabetes and cerebrovascular disease.
PCP|phencyclidine|PCP|163|165|LABORATORY DATA|LABORATORY DATA: 1. CBC within normal limits. 2. CMP revealed a high 8, total bilirubin 1.8. 3. TSH reflex within normal limits. 4. Urine drug screen positive for PCP and cannabinoids, otherwise negative. 5. Pregnancy test negative. ASSESSMENT: 1. Psychiatric conditions per Dr. _%#NAME#%_. 2. Mildly elevated total bilirubin, likely secondary to Gilbert's disease.
PCP|phencyclidine|PCP|146|148|IMPRESSION/RECOMMENDATIONS|In terms of management, I suggest that the patient should have supportive management with a ventilator, and probably benzodiazepines due to acute PCP intoxication, and I would anticipate gradual improvement of her mental status. I will plan to obtain an EEG on the patient tomorrow, and follow her clinically.
PCP|Pneumocystis jiroveci pneumonia|PCP|145|147|PHYSICAL EXAMINATION|He has undergone renal and pancreas transplants. He is, of course, on immunosuppressive therapy for these. He is receiving ongoing treatment for PCP infection. The patient is a retired draftsman. On examination, the patient was alert and insightful. Pulses were palpable in his lower extremities.
PCP|Pneumocystis jiroveci pneumonia|PCP|265|267|IMPRESSION|4. She also apparently has a history of being exposed to TB and having a positive TB skin test in the past with no history of treatment for latent tuberculosis infection. There are no other obvious epidemiologic risk factors for an unusual infection. She is taking PCP prophylaxis. A bronchoscopy performed _%#MM#%_ _%#DD#%_ had at least one negative AFB . She did have beta lactamase negative hemophilus isolated from direct bronchoscopy on _%#MM#%_ _%#DD#%_, 2004.
PCP|primary care physician|PCP|127|129|ASSESSMENT/PLAN|ASSESSMENT/PLAN: 1. Chemical dependence, depression per Dr. _%#NAME#%_. 2. Hypertension controlled per patient. Follow up with PCP on a p.r.n. basis. 3. Sleep apnea controlled per patient. Follow up with PCP on a p.r.n. basis. The patient is currently not using CPAP. The patient does not wish to have CPAP inpatient.
PCP|Pneumocystis jiroveci pneumonia|PCP|276|278|IMPRESSION AND PLAN|Given that the patient did have Fludarabine, she is at risk of opportunistic infection with underlying chronic lymphocytic leukemia and the recent chemotherapy. Hence, if she spikes a fever, we should pan culture her in addition to obtaining an ID consult and starting her on PCP treatment. Regarding the bilateral effusion, this could be secondary to a recent Rituxan versus possible DIS from her chronic lymphocytic leukemia as these were present prior to her chemotherapy.
PCP|Pneumocystis jiroveci pneumonia|PCP.|192|195|ASSESSMENT|Although it would certainly allow us to rule out some of the atypical pathogen, it would most likely not tell us exactly what he does have. He is already covered for those pathogens including PCP. The procedure most likely to yield a firm and fairly rapid diagnosis is a video assisted thorascopic surgical lung biopsy.
PCP|Pneumocystis jiroveci pneumonia|PCP|301|303|HISTORY OF PRESENT ILLNESS|On admission the patient was found to have profound anemia with a hemoglobin of 6.4. He also had acute renal failure with a creatinine up to 4.5 and a BUN of 119. He also had an abnormal chest x-ray which showed acute bilateral interstitial infiltrates. He was presumptively started on IV Bactrim for PCP treatment. In addition, his urinalysis showed some red blood cells and his sed rate was elevated. In the past the patient was treated with IV steroids and then maintenance steroids for his disease.
PCP|Pneumocystis jiroveci pneumonia|PCP|171|173|PLAN|d. She is too tenuous for a safe (nonintubated) bronchoscopy with BAL to look for infection. PLAN: 1. Check Duplex ultrasound 2. Check D-Dimer 3. Check sputum culture for PCP 4. Prn. C-PAP may be helpful for hypoxemia. 5. We should focus on treatable/reversible etiologies given her wishes for DNR, DNI.
PCP|phencyclidine|PCP|133|135|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 23-year-old female who presents to the Chemical Dependency Unit for treatment related to PCP dependence. She was reportedly using a substance called "Wet" which is PCP laced with formaldehyde. I was asked by Dr. _%#NAME#%_ to see this patient to address medical concerns.
PCP|phencyclidine|PCP|208|210|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 23-year-old female who presents to the Chemical Dependency Unit for treatment related to PCP dependence. She was reportedly using a substance called "Wet" which is PCP laced with formaldehyde. I was asked by Dr. _%#NAME#%_ to see this patient to address medical concerns. PAST MEDICAL HISTORY: 1. History of intussusception at age 3.
PCP|phencyclidine|PCP|124|126|ASSESSMENT AND PLAN|Sensation intact. Gait within normal limits. LABORATORY DATA: CMP and CBC are within normal limits. ASSESSMENT AND PLAN: 1. PCP dependence. History and diagnosis is per Dr. _%#NAME#%_. 2. Migraine headaches. These are very mild and only occur one time per year. Motrin is available p.r.n. if needed. Thank you for this consultation.
PCP|phencyclidine|PCP.|185|188|LABORATORY DATA|Acetaminophen level less than 1. Alcohol less than 0.01. Salicylate level less than 1. HCG negative. Urinalysis shows a few bacteria, otherwise negative. Urine drug screen positive for PCP. Formic acid urine is pending. ASSESSMENT AND PLAN: 1. Polysubstance abuse; per Dr. _%#NAME#%_.
PCP|Pneumocystis jiroveci pneumonia|PCP.|151|154|RECOMMENDATIONS|RECOMMENDATIONS: 1. Continue Levaquin for now. 2. Would DC azithromycin. 3. No treatment for positive blood culture. 4. Check LDH as often elevated in PCP. 5. Respiratory therapy to induce sputum for PCP, fungus and cytology in the a.m. 6. Watch temperature for now. 7. Await the official CT report.
PCP|Pneumocystis jiroveci pneumonia|PCP,|192|195|HISTORY OF PRESENT ILLNESS|REQUESTING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_. REASON FOR CONSULTATION: Bilateral pneumothoraces. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 33-year-old unfortunate male with HIV-AIDS, PCP, and ARDS, who has persistent bilateral air leaks despite bilateral small chest tubes. He is still on a ventilator. However, on low pressure and a PEEP of 5.
PCP|phencyclidine|PCP,|181|184|LABORATORY DATA|ABDOMEN: Soft, nontender. SKIN: No rashes noted. NEUROLOGIC: Alert and oriented. Motor, sensory and coordination intact. LABORATORY DATA: Urine drug screen positive for opiates and PCP, white blood cell count 11.7. All other labs are essentially normal. ASSESSMENT: 1. Psychiatric conditions per Dr. _%#NAME#%_. 2. History of hypertension with elevated blood pressures on admission, patient agrees to start low dose antihypertensive medication.
PCP|phencyclidine|PCP,|150|153|SOCIAL HISTORY|She denies use of alcohol, marijuana, or other chemicals of abuse. I would add that her recent urine tox screen from Ridges Hospital was positive for PCP, however, the patient adamantly denies any use of PCP or knowledge of anyone using PCP. She does state, however, that she had taken some trazodone and Sonata tablets from a friend of her with the intention of using these to help her sleep.
PCP|Pneumocystis jiroveci pneumonia|PCP.|176|179|PLAN|2. Recheck ABG. 3. Antibiotics, per Dr. _%#NAME#%_. 4. Possible bronchoscopy next week, if he is continuing to remain febrile and not improve. 5. Check sputum for cytology for PCP. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is an 83-year- old male who was previously in the hospital at the end of _%#MM#%_/early _%#MM#%_, with infiltrates and hypoxemia, with profound blood eosinophilia.
PCP|phencyclidine|PCP,|260|263|LABORATORY DATA|LABORATORY DATA: The patient had a urine pregnancy test done on _%#DDMM2004#%_ which was negative. She also had a urine tox screen on _%#DDMM2004#%_ which was positive for cocaine, but negative for amphetamine, benzodiazepines, barbiturates, alcohol, opiates, PCP, and marijuana. The patient has old tests available, but no further current tests were available at this time. On review of old laboratory data, a TSH of 0.49 was normal on _%#DDMM2003#%_.
PCP|Pneumocystis jiroveci pneumonia|PCP.|179|182|RECOMMENDATIONS|These include histoplasma antigen and numerous immunologic screening studies. 2. All cultures are negative to date. 3. Check Chlamydia, mycoplasma serology, and induce sputum for PCP. 4. No antibiotic recommendations at this time. SUMMARY OF CASE: The patient is a 72-year-old woman admitted around _%#DDMM2006#%_ with a syndrome of dyspnea, though is said to be associated with a UTI.
PCP|Pneumocystis jiroveci pneumonia|PCP|209|211||He also has a history of HIV and AIDS. He was discharged from the University Hospital and transferred here after having a prolonged hospitalization for sepsis, including colitis with secondary dehydration and PCP pneumonia. These illnesses had substantially resolved and he is feeling well at this time. He also has a history of toxic megacolon in the past and is status post colectomy and ileostomy.
PCP|Pneumocystis jiroveci pneumonia|PCP|182|184|ASSESSMENT|Electrolytes and renal function studies are normal. Liver function tests are normal. LP was negative for infection on recent check. ASSESSMENT: 1. HIV/AIDS with recent treatment for PCP pneumonia and colitis related to C. diff and Salmonella, clinically resolved. 2. Mental status changes, probably due to psychosis, with delusional thought disorder, leading to avoidance of his recommended medications.
PCP|phencyclidine|PCP,|306|309|PAST MEDICAL HISTORY|2. Presumed hypercholesterolemia, on Lipitor 20 mg q.h.s. Lipids during Fairview Southdale hospitalization demonstrated total cholesterol of 276, LDL 135, VLDL 113, triglycerides 565. 3. History of chemical dependency, including cannabis and alcohol. Indication per record that prior joint was "laced with PCP, cocaine, and amphetamines. PAST SURGICAL HISTORY: 1. Appendectomy. 2. "Micro-surgery," left hand. He denies known heart disease, diabetes, asthma, hypertension, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, thyroid disease, documented seizures, tuberculosis, or anemia.
PCP|Pneumocystis jiroveci pneumonia|PCP|242|244|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: A 29-year-old gentleman with HIV/AIDS with 10-day history of increasing shortness of breath, dry cough and bilateral infiltrates on chest x-ray. The differential diagnosis for this includes an infectious etiology such as PCP versus viral versus atypical pneumonia. Besides PCP the culprits could include Legionella, chlamydia, Klebsiella, less likely not tuberculous mycobacterium.
PCP|Pneumocystis jiroveci pneumonia|PCP|151|153|ADMISSION MEDICATIONS|1. Prozac 20 mg p.o. b.i.d. 2. Oxycodone 5 mg p.o. b.i.d. 3. Lisinopril 80 mg every day. 4. Dapsone 100 mg p.o. every Friday, Saturday, and Sunday for PCP prophylaxis. 5. Buspirone 15 mg p.o. q.a.m. 6. Glyburide 10 mg p.o. q.a.m. 7. Nexium 40 mg p.o. b.i.d. 8. Senokot S two pills p.r.n.
PCP|primary care physician|PCP|208|210|ASSESSMENT AND PLAN|2. Mild hypoglycemia, probably secondary to alcohol or alcohol withdrawal. Check BMP _%#DDMM2005#%_. 3. Alcoholic cirrhosis, possibly secondary to alcohol dependence. Check BMP _%#DDMM2005#%_. Follow up with PCP or specialist on a p.r.n. basis. 4. Hypertension controlled via medications. Follow up with PCP on a p.r.n. basis. 5. Headache secondary to alcohol withdrawal. Give Tylenol on a p.r.n. basis.
PCP|primary care physician|PCP|111|113|ASSESSMENT AND PLAN|Follow up with PCP or specialist on a p.r.n. basis. 4. Hypertension controlled via medications. Follow up with PCP on a p.r.n. basis. 5. Headache secondary to alcohol withdrawal. Give Tylenol on a p.r.n. basis.
PCP|phencyclidine|PCP,|130|133|HISTORY OF PRESENT ILLNESS|Her pO2 is decreased at 68 on room air. Urinalysis was negative for evidence of infection. Her urine drug screen was negative for PCP, cannabinoids, amphetamines, methamphetamine, barbiturates, benzodiazepine, cocaine, opiates or tricyclic antidepressants. CT scan of the head demonstrated cerebral atrophy with white matter changes consistent with a history of multiple sclerosis.
PCP|Pneumocystis jiroveci pneumonia|PCP,|139|142|IMPRESSION|2. History of myasthenia gravis on chronic prednisone 15 mg every other day, is a mild/moderate dose. Could increase her risk for possible PCP, although her CT scan does not suggest this. PLAN: 1. Will review her prior CT scan to compare the pattern; she might benefit from another bronchoscopy if her sputum culture is nondiagnostic and clinically she does not improve over the next 24 to 48 hours.
PCP|phencyclidine|PCP,|229|232|HABITS|ALLERGIES: The patient admits to a sulfa allergy. HABITS: The patient admits to smoking 1.5 packs of cigarettes a day x8 years. The patient is in recovery for alcohol, admits to attending AA. IV drug abuse. The patient admits to PCP, barbiturates, heroin, marijuana, poppers, ........nitrates. FAMILY HISTORY: The patient admits to migraines, GERD, alcoholism, headache, asthma, hyperthyroidism and hypothyroidism.
PCP|Pneumocystis jiroveci pneumonia|PCP|357|359|ASSESSMENT AND PLAN|However, unless the EKG and chest x-ray are abnormal, surgery does not have to be held per report of his cardiac echo as the patient is very functional and able to run three miles three times a week without problems. The patient is interested, however, in getting a cardiac echo as he never had a follow-up one done after the one done last year when he had PCP pneumonia.
PCP|phencyclidine|PCP,|187|190|LABORATORY DATA|Of note the patient does have obstructive sleep apnea. LABORATORY DATA: That is currently available includes an ethanol level of less than 0.01. A urine drug screen that was negative for PCP, cannabinoids, amphetamines, barbiturates, benzodiazepine, cocaine, opiates and tricyclic antidepressants. His hemoglobin is 14.7, MCV is 92, white count is 5900 with platelet count of 194,000.
PCP|phencyclidine|PCP.|135|138|LABORATORY DATA|Motor exam shows symmetric strength. Cerebellar exam is normal. Gait is normal. LABORATORY DATA: Tox screen positive for marijuana and PCP. Urine pregnancy test is negative. Urinalysis shows a few RBCs, chemistry panel and CBC were normal. TSH normal. ASSESSMENT: 1. Chemical dependency. 2. Tobacco abuse.
PCP|Pneumocystis jiroveci pneumonia|PCP,|209|212|IMPRESSION|The CT scan is not consistent with a typical bacterial pneumonia and his symptoms are subacute. I would hold the Levaquin pending further evaluation. The differential diagnosis includes lymphoma, Aspergillus, PCP, viral, Cryptococcus or Nocardia, routine and atypical bacterial causes including Mycobacterium. I tend to doubt many of these and would feel that lymphoma or Aspergillus or PCP are most likely.
PCP|Pneumocystis jiroveci pneumonia|PCP|239|241|PLAN|The patient is on some steroid dosing; not major long-term ongoing steroids, but still at significant risk with Hodgkin's lymphoma. PLAN: 1. Add Zithromax for atypical coverage. Will switch from Zosyn to Rocephin and add Septra up to full PCP doses. The patient is 130 kg and needs high doses. 2. Would favor bronchoalveolar lavage (BAL) even though PCP likely. It is desirable to prove diagnosis both for the potential to add steroids into this if he worsens, plus if he does worsen, may lose the opportunity to do diagnostic tests and it is certainly possible this patient has some alternative diagnosis present.
PCP|Pneumocystis jiroveci pneumonia|PCP|191|193|LABORATORY|CT scan shows diffuse pulmonary infiltrates process consistent with Pneumocystis carinii pneumonia. Also consistent with fluid or other opportunistic infection, although fairly typical early PCP appearance. CBC unremarkable. Adequate PMNs. Thank you very much for this consultation.
PCP|phencyclidine|PCP,|205|208|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Alcohol abuse. He has had history of nine chemical dependency treatment programs, was abstinent for nine months in his 30's. 2. History of multiple drug abuse including marijuana, PCP, speed, LSD and benzodiazepines. 3. Hepatitis C. 4. Pancreatitis. 5. History of multiple head injuries secondary to falls while intoxicated.
PCP|Pneumocystis jiroveci pneumonia|PCP|226|228|HISTORY|HISTORY: The patient is a 45-year-old man with AIDS. He presented to the hospital with shortness of breath that began approximately 10 days prior to his admission, which was on _%#DDMM2007#%_. The patient is being treated for PCP and MAC, the latter of which was diagnosed on fine needle lung biopsy. The patient's respiratory symptoms progressed to acute respiratory failure requiring ventilatory support with high PEEPS and Flolan and nitric oxide for control of his pulmonary hypertension.
PCP|Pneumocystis jiroveci pneumonia|PCP|129|131|HISTORY OF PRESENT ILLNESS|He has had several PCP pneumonias in the past. His presentation and diagnosis of AIDS was given in 1995 when he presented with a PCP pneumonia then. This is his most severe episode of PCP pneumonia, however, to date. The patient is also being seen by Ophthalmology for right eye keratitis.
PCP|Pneumocystis jiroveci pneumonia|PCP.|227|230|IMPRESSION|I would favor this as a relapse of Pneumocystis as he has not been on secondary prophylaxis. I doubt he needs vancomycin or Zosyn, but would favor Levaquin, Septra to cover community acquired pneumonia, atypical pathogens, and PCP. 2. Bloody diarrhea, new. Differential includes CMV, bacterial, C. difficile colitis, fungal, paracytic. Paracytic is less likely. 3. Chronic pancytopenia and red cell aplasia.
PCP|Pneumocystis jiroveci pneumonia|PCP|149|151|ADMISSION MEDICATIONS|The patient is unsure if she has ever had a Pap smear. If she has, she does not know the result. ADMISSION MEDICATIONS: Prograf, Ursodiol, sulfa for PCP prophylaxis, 70/30 sliding scale and NovoLog sliding scale. The patient was also started on Zosyn 3.375 gm q. six and Ceftriaxone 2 gm IV X1. SOCIAL HISTORY: The patient smokes a half-pack per day.
PCP|Pneumocystis jiroveci pneumonia|PCP|325|327|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 55-year- old man recently diagnosed with AIDS when he presented with a 50 pound weight loss, recurrent Candidiasis, cachexia and afebrile illness associated with diffuse pneumonitis. His HIV status was found to be positive. He was treated empirically for PCP pneumonia, but was transferred to the ICU this morning because of progressive tachypnea and respiratory distress associated with respiratory rates in the 40's and 50's.
PCP|phencyclidine|PCP.|154|157|HISTORY OF PRESENT ILLNESS|His parents became concerned about the possibility of chemical use, and he was given a urinalysis on Sunday which was positive for marijuana, cocaine and PCP. The patient denies any use of PCP whatsoever, although he does acknowledge using cocaine approximately a year ago. He states he used opium one time about three months ago and does use marijuana on a regular basis.
PCP|Pneumocystis jiroveci pneumonia|PCP|149|151|RECOMMENDATIONS|2. Bronchoscopy and bronchoalveolar lavage with aspirates sent for a broad spectrum of microbiology studies including routine bacteria, AFB, fungus, PCP and viral cultures. 3. Agree with fluid resuscitation and replacing bicarbonate. 4. If the patient remains hypotensive after fluid, would suggest vasopressor.
PCP|phencyclidine|PCP.|201|204|LABORATORY DATA|Motor exam shows symmetric strength. Cerebellar exam is normal. Gait is normal. LABORATORY DATA: CBC and chemistry panel are essentially normal. Tox screen is positive for benzodiazepines, opiates and PCP. ASSESSMENT: 1. Depression/anxiety disorder. 2. Status post mesothelioma resection without recurrence.
PCP|phencyclidine|PCP,|231|234|DATA|AST is 47. Troponins are negative times 3. White blood cell count 11,900, hemoglobin 16, hematocrit 49. Drug tox screen is positive for amphetamine use, positive for THC, positive for opiates, positive for tricyclics, negative for PCP, methadone, and cocaine. Chest x-ray shows complete right opacification as well as what appear to be metallic foreign bodies.
PCP|phencyclidine|PCP,|295|298|SOCIAL HISTORY|SOCIAL HISTORY: The child is in the 12th grade, living at home with his mother, two siblings, and a friend of the family. He denies any history of IV drug use. He has a history of heavy chemical abuse, including alcohol, marijuana, opium, mushrooms, ecstasy, morphine, methamphetamines, speech, PCP, and cocaine. FAMILY HISTORY: Not obtained. REVIEW OF SYSTEMS: Negative for headaches, fevers, chills, dyspnea, chest pain, abdominal pain, nausea, vomiting, constipation, diarrhea, or urinary complaints.
PCP|phencyclidine|PCP|173|175|DOB|Platelet count was negative. Salicylate and acetaminophen levels were negative. Drug screen for amphetamines, barbiturates, benzodiazepines, cannabinoids, cocaine, opiates, PCP and tricyclics were done. All results were negative except for urine tricyclics. Apparently she had been on some Elavil. Urinalysis was unremarkable. CSF gram stain was negative. According to her husband, she had been on Xanax up until about two weeks ago.
PCP|phencyclidine|PCP.|161|164|LABORATORY VALUES OF INTEREST|Potassium 3.5, sodium 138, chloride 108, CPK 365 which is elevated, creatinine .7. Her urine drug screen was positive for tricyclic antidepressant, opiates, and PCP. This is a screening test only. Serum drug screen has not yet been ordered. The lab reports that they have recently had some suspicion that are PCP urine screen test has been giving too many false positives.
PCP|Pneumocystis jiroveci pneumonia|PCP|148|150|RECOMMENDATIONS|RECOMMENDATIONS: 1. Vent changes to maximize oxygenation and increase PEEP. 2. Recheck ABGs post above. 3. Agree with empiric Acyclovir and empiric PCP treatment. 4. Check 2-D echo to evaluate for LV systolic and diastolic function and valvular functioning. 5. Can perform bronchoscopy for directed BAL in the a.m. _%#DDMM2004#%_.
PCP|Pneumocystis jiroveci pneumonia|PCP|141|143|RECOMMENDATIONS|To this I will add Azithromycin for Legionella, Mycoplasma and Chlamydial coverage and discontinue the Tequin. Because I believe the risk of PCP is not small I will go ahead and start Bactrim at treatment doses of two double strength tablets t.i.d. and orally and try to induce sputums for diagnosis of Pneumocystis, as well as other possible pathogens.
PCP|phencyclidine|PCP|214|216|HISTORY|Presently homeless. Off meds for approximately one month. Known history of polysubstance abuse with drugs of choice crack cocaine, marijuana and alcohol. He has used mushrooms, methamphetamine, heroin, ecstasy and PCP in the past. No intravenous drug use. Using crack cocaine up to $200 daily with one joint of marijuana weekly and 3-4 shots when coming off of crack.
PCP|Pneumocystis jiroveci pneumonia|PCP|254|256|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Significant for the following: 1. Philadelphia positive acute lymphocytic leukemia, status post chemotherapy, and umbilical cord blood transplant in _%#MM#%_. 2. Diuretic cardiomyopathy. 3. Bilateral pleural effusion. 4. History of PCP pneumonia. 5. Status post bilateral breast augmentation and breasts lifts. CURRENT MEDICATIONS: 1. Protonix 40 mg daily. 2. Fluconazole 100 mg p.o. daily.
PCP|Pneumocystis jiroveci pneumonia|PCP|151|153|RECOMMENDATIONS|2) Empiric broad-spectrum antibiotics with good atypical coverage. 3) Agree with 2D echo to evaluate LV function and PA pressures. 4) Consider empiric PCP treatment. 5) Check ANA, ESR, fungal serologies. 6) Urinary Legionella, serum mycoplasma. 7) May need bronchoscopy with BAL and possible transbronchial biopsies to evaluate for the above.
PCP|Pneumocystis jiroveci pneumonia|PCP|184|186|PROBLEM #3|Given her history of voriconazole versus the yeast, she received fungal prophylaxis with caspofungin, bacterial prophylaxis with levofloxacin staring _%#DDMM2005#%_, and she will have PCP prophylaxis with Bactrim. This started when her absolute neutrophil count was greater than 1000 for 2 days, which was on _%#DDMM2005#%_. PROBLEM #4. Neutropenic fevers. She developed neutropenic fever on _%#DDMM2005#%_.
PCP|phencyclidine|PCP,|117|120|LABORATORY DATA|Motor strength grossly symmetrical. Gait appears normal. LABORATORY DATA: Urine drug screen positive for ethanol and PCP, otherwise negative. Acetaminophen level less than 10. White blood cell count 13.5. All other labs essentially normal. LFTs within normal limits. TSH within normal limits.
PCP|primary care physician|PCP|116|118|HPI|Her family was not in contact with her over the weekend. On Monday, her son came to see her and took her to see her PCP who due to confusion and lethargy. She was diagnosed with hypothyroidism and started on medication (?dose). 5 days after this she was found in the kitchen after she fell and hurt her head.
PCP|phencyclidine|PCP|191|193|SOCIAL HISTORY|2. Cipro results in rash. SOCIAL HISTORY: The patient smokes up to 2-1/2 packs per day of cigarettes. Alcohol use is in remission for 2 years. Drug use has included meth, cocaine, marijuana, PCP and heroin. FAMILY HISTORY: Significant for alcohol dependence. Father had MI at age 44 and died.
PCP|Pneumocystis jiroveci pneumonia|PCP|184|186|REQUESTING PHYSICIAN|He required a platelet transfusion on his prior admission and had been also on Augmentin. The patient is admitted with pulmonary infiltrates, was just started on antibiotics including PCP coverage. I spoke to Dr. _%#NAME#%_ who said that he does not need initial bronchoscopy now, however, if he does not improve he may need bronchoscopy and certainly ongoing evaluation for his respiratory status.
PCP|phencyclidine|PCP,|119|122|SOCIAL HISTORY|He also has a number of grandparents and sibling at home. He is in the seventh grade. He describes the use of cocaine, PCP, marijuana, and vodka regularly, although he states he stopped 5 days ago. FAMILY HISTORY: Not obtained. REVIEW OF SYSTEMS: Negative for headaches, fevers, chills, dyspnea, chest pain, abdominal pain, nausea, vomiting, constipation, diarrhea or urinary complaints.
PCP|phencyclidine|PCP.|155|158|LABORATORY DATA|He is not tremulous. Motor sensory and coordination are intact. LABORATORY DATA: As above, they are remarkable for a urine tox screen positive for THC and PCP.
PCP|phencyclidine|PCP.|128|131|HISTORY OF PRESENT ILLNESS|Hemogram, differential, platelet count within normal limits. UA within normal limits. GGT 18, U. tox positive for marijuana and PCP. ASSESSMENT AND PLAN: 1. Polysubstance abuse. Treatment to be continued per Dr. _%#NAME#%_, along with his ADHD. 2. Elevated blood pressure. It is unclear to me whether or not this patient does have a diagnosis of hypertension.
PCP|phencyclidine|PCP|142|144|LABORATORY DATA|Acetaminophen less than 10. Ethanol level less than 0.01. Salicylate level less than 1. Urine tox screen was positive for benzodiazepines and PCP (question cross reaction). CBC remarkable for elevated white count of 12,300 likely representing a stress or leukemoid response. Hemoglobin 15 g% with MCV of 92. Platelet count of 249,000.
PCP|phencyclidine|PCP.|189|192|LABORATORY DATA|CBC values within normal limits. Drug screen performed in the _%#CITY#%_ Campus ER was negative for amphetamines, barbiturates, benzodiazepines, cannabinoids, cocaine, ethanol, opiates and PCP. MRI pending for primary psychotic episode. B12, folate and RPR are also pending to rule out organic causes of psychosis. Urinalysis and urine culture are also pending. ASSESSMENT/PLAN: 1. Depression with suicidality versus psychosis, not otherwise specified, per Dr. _%#NAME#%_.
PCP|phencyclidine|PCP,|143|146|REVIEW OF SYSTEMS|MUSCULOSKELETAL: Negative. NEUROLOGIC: The patient did have a headache, dizziness, and tingling in her fingers and toes after she ingested the PCP, but that is now resolved. SKIN: No rashes. NEUROLOGIC: The patient is alert and oriented. PHYSICAL EXAMINATION: GENERAL: The patient is a well- nourished, well-hydrated female in no acute distress.
PCP|phencyclidine|PCP.|194|197|STUDIES|STUDIES: Comprehensive metabolic panel was within normal limits. Hemogram, differential, and platelet count was within normal limits. Reflex TSH was 0.59. U. tox. was positive for marijuana and PCP. Urine pregnancy test was negative. Tylenol level was less than 1 and salicylate level was less than 1. ASSESSMENT/PLAN: 1. Depression versus substance induced mood disorder and chemical dependency issues.
PCP|phencyclidine|PCP,|224|227|SOCIAL HISTORY/HABITS|The patient states he smokes on average 1 pack of cigarettes per day; last use 1 week ago. The patient states he drinks approximately 5x per week. Past history of illicit drug use is significant for cocaine, marijuana, LSD, PCP, mushrooms, prescription narcotic pain killers, amphetamines and benzodiazepines. FAMILY HISTORY: Not obtained. REVIEW OF SYSTEMS: The patient admits to intermittent heartburn secondary to spicy foods.
PCP|primary care physician|PCP|147|149|MEDICATIONS|6. Multivitamin one tablet daily. 7. Norvasc 5 mg daily. 8. Plavix 75 mg every other day. The patient was advised to take another anticoagulant by PCP after having tested positive for congenital hypercoagulable state. However, the patient decided not to take it, since she is taking Plavix. The patient did not have any history of blood clots in the past.
PCP|Pneumocystis jiroveci pneumonia|PCP|176|178|SUMMARY OF CASE|She remained pancytopenic. She also had previous chemotherapy for her malignant condition. She had prior hospitalizations with infection complications including VRE pneumonia, PCP pneumonia and possibly fungal pulmonary infection. She also had been treated with acyclovir for cutaneous HSV infection. The patient had steroid induced hyperglycemia, hypertension and is also chronically malnourished.
PCP|Pneumocystis jiroveci pneumonia|PCP|311|313|HISTORY|He was started on Rocephin and Zithromax and seemed to be improving, but now in the last couple days has continued to have temperatures going into the 101 degree range with sweats, chills, malaise and no apparent response. He has had a bronchoscopy done just yesterday with no obvious immediate answer present. PCP prep and most of the smears are still pending. Cultures have all been negative so far. He feels no different now than when he came in the hospital so far.
PCP|phencyclidine|PCP|127|129|LABORATORY DATA|She had no real explanation for this. She was seen in the Emergency Room. Drug screen was obtained which was positive for both PCP and barbiturates. Chem profile was normal. Alcohol 0. Urine analysis negative. CBC - hemoglobin 11.5, white count 12.2. I did not find any CNS imaging studies as having been performed.
PCP|Pneumocystis jiroveci pneumonia|PCP|138|140|ASSESSMENT/PLAN|Heart size was normal. The vasculature was minimally prominent. The patient is back on retroviral therapy and is also back on dapsone for PCP prophylaxis. His medications had actually been discontinued by himself earlier in the summer months. Now, he is reestablished on his retroviral therapy taking it faithfully.
PCP|Pneumocystis jiroveci pneumonia|PCP|237|239|PLAN|He is recovering from Pneumocystis pneumonia. PLAN: 1. We asked the patient to discontinue his clindamycin and Primaquine today. We will lower his Valganciclovir dosage to 400 mg b.i.d. We will prescribe atovaquone 750 mg b.i.d. and his PCP treatment and/or prophylaxis. 2. I gave him Librax 1 p.o. b.i.d. for gastrointestinal cramping. 3. We will put him on Vioxx 25 mg q.d. and an anti-inflammatory drug.
PCP|Pneumocystis jiroveci pneumonia|PCP|293|295|SUMMARY OF CASE|He has no oxygen requirements. Of extreme importance is the fact that on the lung biopsy from two days ago, there was indication of hyphes compatible with but not necessarily diagnostic of aspergillus. In summary, this 3-year-old with T-cell acute lymphocytic leukemia is in remission and had PCP on bronchoscopy. His recent chest CT scan showed evolution of progress in the lungs and a pneumatocele. The lung biopsy has now revealed aspergillus at least histopathologically.
PCP|phencyclidine|PCP.|271|274|SOCIAL HISTORY|SOCIAL HISTORY: The patient denies smoking. He states that he usually has six to ten beers per day. He does have a history of using marijuana eight months ago and approximately three years ago he was using cocaine, amphetamines, hallucinogens, heroin, morphine, LSD, and PCP. FAMILY HISTORY: The patient states that his father had diabetes along with his maternal grandmother and several cousins.
PCP|Pneumocystis jiroveci pneumonia|PCP|197|199|IMPRESSION|2. Questionable past history of hepatitis, but no current evidence of active inflammatory changes other than elevated globulin level. 3. Question recent history of Pneumocystis cranii currently on PCP prophylaxis. 4. History of depression currently not on medication. PLAN: We had a long chat today about various healthy issues and strategies.
PCP|Pneumocystis jiroveci pneumonia|PCP|244|246|IMPRESSION|2. Pulmonary fibrosis secondary to lupus. As noted above, I suspect there is a modest interval worsening of her fibrotic changes on her scan. She is already on increased dose of prednisone compared to baseline. It may be reasonable to initiate PCP prophylaxis given her high dose of steroid, and the potential need to maintain this greater intensity of immunosuppression over a longer period.
PCP|Pneumocystis jiroveci pneumonia|PCP|158|160|HISTORY OF PRESENT ILLNESS|Plan as described above. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 55-year-old, immunosuppressed female with recently diagnosed histiocytosis X, PCP and CMV, readmitted with fever, chills and shortness of breath. She was hospitalized from _%#DDMM#%_ through _%#DDMM2004#%_ with shortness of breath.
PCP|phencyclidine|PCP.|197|200|LABORATORY DATA|Abdomen is soft, non-tender, and non-distended. Extremity exam reveals no sign of trauma. LABORATORY DATA: TSH slightly low at 0.71. BNP was normal. ALT 31, AST 58. Urine tox positive for meth and PCP. WBC 7000, hemoglobin 15.3, platelet count 142,000. EKG: sinus tachycardia, otherwise normal.
PCP|primary care physician|PCP|185|187|PLAN|2. For asymptomatic bacteruria the patient does not need any antibiotics coverage until she develops symptoms. For now she will be continued on all her home medications. 3. Follow with PCP at the nursing home. I have suggested my recommendation about transferring the patient to the nursing home with Dr. _%#NAME#%_ _%#NAME#%_ and he is in agreement with this
PCP|Pneumocystis jiroveci pneumonia|PCP,|174|177|PHYSICAL EXAMINATION|The patient is a 52-year-old female with a very long complicated medical history, including pancreas transplant in 1992 for diabetes mellitus, CMV antigenemia and retinitis, PCP, MAI ethmoid sinusitis, now with chronic renal failure. She was admitted for repetitive fevers and was found on CT scan to have a left hilar mass.
PCP|Pneumocystis jiroveci pneumonia|PCP,|152|155|IMPRESSION|IMPRESSION: 1. _%#NAME#%_ _%#NAME#%_ is a 38-year-old female with acute abdominal pain, nausea, fever and cough. Question opportunistic infection, MAI, PCP, question conventional bacterial infection, not much focal or localizing either on CT scan, x-ray or labs to date. 2. Advanced acquired immune deficiency syndrome on deep salvage treatment without good response mainly due to poor compliance.
PCP|Pneumocystis jiroveci pneumonia|PCP.|191|194|RECOMMENDATIONS|5. Long-term arthritis, possibly rheumatoid, with associated fibromyalgia and chronic pain syndrome. 6. Depression. RECOMMENDATIONS: 1. Check blood and sputum cultures and a sputum stain for PCP. 2. Check a CD4 lymphocyte count. She may need PCP prophylaxis if it is less than 200. 3. We would agree with the use of Levaquin for broad spectrum coverage of pneumonia and would change it depending on the results of cultures or clinical progress.
PCP|phencyclidine|PCP,|188|191|HISTORY|The patient indicates he was "committed" for alcoholism. Indicates he had one beer two months ago. Denies other "street drug" use for one to two months. Prior record indicates use of LSD, PCP, and marijuana. Remote history of apparent closed head injury sustained in a motor vehicle accident 12 to 13 years ago. The patient indicates he was in a coma for one month.
PCP|phencyclidine|PCP.|207|210|LABORATORY DATA|No lateralizing extremity weakness. Romberg negative. Cerebellar function is intact. There is no tremor or rigidity. LABORATORY DATA: From _%#DDMM2007#%_ includes a urine tox screen positive for cocaine and PCP. From this morning, white count 7,300, hemoglobin 15 grams percent with MCV 88, platelet count 222,000. Complete metabolic profile was unremarkable. GGT was normal at 8.
PCP|phencyclidine|PCP.|185|188|ASSESSMENT|Rule out substance-induced mood disorder (defer to Psychiatry). 2. Polysubstance abuse with history of smoking cigarettes laced with formaldehyde and positive urine tox for cocaine and PCP. 3. Nicotine addiction. 4. Asthma, clinically well compensated. 5. History of peptic ulcer disease with alleged GI bleed (no documentation available).
PCP|phencyclidine|PCP,|188|191|INDICATION FOR CONSULTATION|Urinalysis was unremarkable. Electrolytes were normal, creatinine 1.2, BUN 24, potassium 4.1, sodium 143, hemoglobin 13.5 grams, white count 7000. A drug screen was otherwise negative for PCP, marijuana, amphetamines, barbiturates, cocaine, etc. Lipid profile showed a total cholesterol of 169, LDL 88, HDL 67 and triglycerides 67. Cardiac echo was done and it showed relatively normal LV systolic function and non-dilated left ventricle.
PCP|phencyclidine|PCP|147|149|LABORATORY DATA|Romberg negative. Cerebellar function intact. Mild tremor of distal upper extremities. No rigidity. LABORATORY DATA: Urine tox screen positive for PCP (question cross reaction with meds). Urine pregnancy test was negative (?). White count 7500, hemoglobin 12.3, MCV 92, platelet count 248,000.
PCP|phencyclidine|PCP,|147|150|LABORATORY DATA|TSH was normal. CBC is remarkable for white count 14,900. Urinalysis revealed 3 WBCs, 3 RBCs. Urine tox screen was positive for amphetamines, THC, PCP, and was negative for opiates.
PCP|Pneumocystis jiroveci pneumonia|PCP|185|187|HISTORY|At that time he was found to have liver metastases, bone metastases, and involvement of the lymph nodes. Currently, the patient is intubated secondary to acute respiratory failure with PCP pneumonia and progressively lung cancer. The patient continues to be hypotensive/sepsis and is on pressor support. Family has gathered to support wife in decision making and clarification of treatment goals.
PCP|phencyclidine|PCP|131|133|MEDICATIONS IN THE HOSPITAL|6. Multivitamin 1 tablet p.o. daily MEDICATIONS IN THE HOSPITAL: 1. Milk of Magnesia p.r.n. 2. Desyrel p.r.n. 3. Vicodin p.r.n. 4. PCP which has just been discontinued. ALLERGIES: No known drug allergies. FAMILY HISTORY: Mother has history of hypertension, arthritis and hyperlipidemia.
PCP|Pneumocystis jiroveci pneumonia|PCP,|231|234|LABORATORY DATA|Creatinine 1.09. Blood cultures from _%#DDMM2004#%_ were negative. Bronchoscopy samples from _%#DDMM2004#%_ and _%#DDMM2004#%_ were negative except for yeast, and on _%#DDMM2004#%_ with usual respiratory flora. Stains negative for PCP, fungus, AFB, and tumor. CT of chest from _%#DDMM2004#%_: Decrease in left pneumothorax.
PCP|phencyclidine|PCP.|135|138|HISTORY OF PRESENT ILLNESS|Admits to alcohol intake.3 to 4 times weekly, to the point of intoxication. Denied other recent drug use. Urine tox screen positive or PCP. Incidental finding of trichomonas, for which she was given Flagyl. PAST MEDICAL HISTORY: 1. Bipolar disorder, as above. Details per Dr. _%#NAME#%_.
PCP|primary care physician|PCP|325|327|PAST MEDICAL HISTORY|She also has never had a colonoscopy. On admission her hemoglobin was 12.6. She was admitted to the floor for further monitoring and we have been asked to evaluate her for the above. PAST MEDICAL HISTORY: Significant only for childbirth x3. She has had no surgeries, no hospitalizations and as I stated, she has not seen her PCP and many years. MEDICATIONS: She takes an 81 mg aspirin daily, occasionally will take Tylenol for aches and pains.
PCP|phencyclidine|PCP|190|192|SOCIAL HISTORY|Smokes up to 1 pack per day of cigarettes. Last used alcohol _%#MMDD#%_. Past history of illicit drug use is significant for Valium abuse, cocaine, methamphetamine, marijuana, ecstasy, LSD, PCP and Vicodin. REVIEW OF SYSTEMS: The patient admits to becoming severely intoxicated 2 days ago and subsequently fell and apparently chipped her front upper tooth.
PCP|phencyclidine|PCP,|163|166|LABORATORY DATA|2. Comprehensive metabolic battery within normal limits. 3. TSH reflex within normal limits. 4. Urinalysis within normal limits. 5. Urine drug screen positive for PCP, otherwise negative. ASSESSMENT AND PLAN: 1. Depression: Treatment to be continued and followed by Dr. _%#NAME#%_.
PCP|phencyclidine|PCP.|181|184|ASSESSMENT|No lingering clinical sequelae. Past history of bipolar illness. Deferred to Psychiatry. 2. Polysubstance abuse with alcohol and marijuana, in particular. Remote use of cocaine and PCP. 3. Asthma, presently well compensated clinically. Good air movement. No bronchospasm. Possible superimposed bronchitis with cough/secretion purulence. Reasonable to cover with antibiotics in this setting.
PCP|phencyclidine|PCP|153|155|PAST MEDICAL HISTORY|We reviewed medical records as best able including stabilization records here in the emergency room. PAST MEDICAL HISTORY: Polysubstance abuse including PCP marijuana, cocaine and mushrooms as well as alcohol. Gun shot wound 20 years ago, right calf PAST SURGICAL HISTORY: None ALLERGIES: No known drug allergies MEDICATIONS: None known.
PCP|primary care physician|PCP|232|234|HISTORY OF PRESENT ILLNESS|Patient states that she has been in relatively good health all of her life and intended to have new teeth placed, both upper and lower a few months ago when at that time dentist noticed blood pressure was quite elevated. She had no PCP at that time so she went to Urgent Care where she was placed on metoprolol 50 mg daily. At the time of this Urgent Care visit she brought to the attention of physician that she had a lesion on the back of her right leg which had been present for 2-3 months and she had previously ascribed to a "bug bite." The physician at Urgent Care immediately arranged a CT scan, which revealed a mass, later to be determined leiomyosarcoma involving superficial compartment of the right posterior medial thigh.
PCP|primary care physician|PCP,|218|221|IMPRESSION AND PLAN|The fact that she has a malignancy immediately places her at a lifelong increased risk for further thromboembolic phenomenon. Whether or not she should remain on Coumadin indefinitely will be an issue discussed by her PCP, Dr. _%#NAME#%_, and patient in the future.
PCP|primary care physician|PCP|177|179|LABS|She most likely has a component of insulin resistantce. For now we would continue her SSI Aspart and add Regular Insulin 10 Units to each TPN bag. She should follow up with her PCP post discharge for glucose tolerance test.
PCP|Pneumocystis jiroveci pneumonia|PCP|166|168|ASSESSMENT AND PLAN|5. Respiratory acidosis secondary to underlying chronic obstructive pulmonary disease and heart failure. Will continue with BiPAP and her hypoxia is improved now. 6. PCP pneumonia. The patient's CD4 count at last visit is 100. Apparently, she did not have pneumonia, but she was treated at present only for that.
PCP|Pneumocystis jiroveci pneumonia|PCP|182|184|PROBLEM #4|The patient was continued on aztreonam to cover potential Gram-negative organisms because she was allergic to penicillin. In addition, she was on Levaquin as well as pentamidine for PCP prophylaxis. The patient's other infectious disease issues included C. diff toxin positive on _%#DDMM2007#%_ and the patient was treated with 10 days of Flagyl and her subsequent C.
PCP|Pneumocystis jiroveci pneumonia|PCP|140|142|PROBLEM #3|Due to a drop in _%#NAME#%_'s white blood cell count, her Bactrim was placed on hold and she has received pentamidine on _%#DDMM2007#%_ for PCP prophylaxis. We will continue to monitor her counts as an outpatient and instruct _%#NAME#%_ as to when to resume her prophylactic Bactrim, if her counts continued trending up and/or repeat a dose of pentamidine on _%#DDMM2007#%_.
PCP|Pneumocystis jiroveci pneumonia|PCP|231|233|HOSPITAL COURSE|She became neutropenic roughly nine days after her Cytoxan. Her counts, however, recovered significantly with G-CSF (please see below). After her treatment with Cytoxan, she was maintained on oral steroids. She was also started on PCP prophylaxis with Dapsone (Bactrim was not started given her renal failure). She was also started on calcium and vitamin D for bone protection.
PCP|Pneumocystis jiroveci pneumonia|PCP|150|152|DISCHARGE MEDICATIONS|2. Positive PPD with a negative chest x-ray on isoniazid therapy. DISCHARGE MEDICATIONS: 1. Bactrim DS 1 tab p.o. b.i.d. every Monday and Tuesday for PCP prophylaxis. 2. Isoniazid 300 mg p.o. daily. 3. Colace 100-200 mg p.o. b.i.d. as needed for constipation. 4. Compazine 5-10 mg p.o. q.6-8h as needed for nausea.
PCP|primary care physician|PCP,|283|286|SUMMARY|SUMMARY: This is a 52-year-old female with a history of lung resection, bronchiolitis obliterans, hypothyroidism, obesity and DJD, who was admitted with a complaint of shortness of breath, cough, and wheezing, that had been ongoing for approximately ten days. When she first saw her PCP, she was started on Zithromax, and that did not help. This past Tuesday, the patient had again seen the PCP, and the patient was started on Augmentin.
PCP|Pneumocystis jiroveci pneumonia|PCP|183|185|SYSTEM #4|The patient has been receiving IV Unasyn during her SPCH hospitalization, which was continued here. It was discontinued at discharge. b. She was started on Bactrim as prophylaxis for PCP infection, given her state of neutropenia. This medication was continued at the time of discharge. c. Nystatin troche was started for thrush prophylaxis and was continued at the time of discharge.
PCP|Pneumocystis jiroveci pneumonia|PCP|158|160|PROBLEM #7|Obviously, long-term enoxaparin therapy is less than ideal especially in a gentleman already at significant risk for progression of osteoporosis. PROBLEM #7: PCP prophylaxis. The patient is on Pneumocystis prophylaxis, given that, he is status post lung transplant. He is to take one single strength Bactrim tablet daily.
PCP|primary care physician|PCP.|169|172|PHYSICAL EXAMINATION|However, for the narcotic, he needed to see his primary physician and discuss a pain contract as we could not refill those except at predetermined times by his assigned PCP. He got very angry, said that he could never get in, that his next appt at Smiley's was more than a week away, and that he was going to cancel it and go somewhere else to get his medications.
PCP|Pneumocystis jiroveci pneumonia|PCP|186|188|HOSPITAL COURSE|Problem #2: Pneumocystis carinii pneumonia. This diagnosis was confirmed by bronchoscopy. He was empirically started on IV Bactrim and prednisone at the time of his admission. After the PCP was confirmed, the patient had his IV Timentin, which had been started on admission discontinued. The patient cleared 21-day course of Bactrim Double Strength and prednisone for approximately 15 days.
PCP|Pneumocystis jiroveci pneumonia|PCP|138|140|PROBLEM #3|She was also pre- hydrated prior to the onset of her chemotherapy. PROBLEM #3: Infectious disease. The patient remained under Bactrim for PCP prophylaxis and also Fluconazole as an antifungal prophylaxis during her hospitalization. She remained afebrile throughout her hospital course. PROBLEM #4: Pulmonary.
PCP|Pneumocystis jiroveci pneumonia|PCP|164|166|DISCHARGE MEDICATIONS|2. Plaquenil 200 mg p.o. daily. 3. Tums one tablet p.o. t.i.d. 4. Protonix 40 mg p.o. daily. 5. Bactrim DS one tablet p.o. every Monday, Tuesday, and Wednesday for PCP prophylaxis. 6. Detrol LA 4 mg p.o. q.h.s. 7. Imodium 2 mg p.o. q. 1 h p.r.n. for diarrhea.
PCP|Pneumocystis jiroveci pneumonia|PCP|183|185|HOSPITAL COURSE|An echocardiogram was done looking for vegetations, which was clear. On discharge, the patient is afebrile. He is being sent home on prophylactic acyclovir for virus, pentamidine for PCP prophylaxis, and voriconazole. Problem #4. GI: The patient received Zofran and Decadron through day 0 with minimal GI upset.
PCP|Pneumocystis jiroveci pneumonia|PCP,|263|266|HOSPITAL COURSE|This was done on _%#MM#%_ _%#DD#%_, 2002, showing copious mucopurulent secretions in the tracheal bronchial tree and evidence of previous surgery in the right lower lobe. Results of the biopsy and BAL showed no evidence of malignancy and stains were negative for PCP, CMV and positive for budding yeast and pseudohyphae. Final cultures showed moderate growth of candida albicans and AFB staining culture pending at the time of discharge.
PCP|phencyclidine|PCP|209|211|HOSPITAL COURSE|No acute pathology. The patient also had urine drug screen checked which was basically positive for cocaine and opiates, otherwise, it was negative for amphetamine, barbiturates, benzodiazepine, cannabinoids, PCP and ethanol. Gastroenterology was consulted and the gastroenterology CNP nurse came and saw the patient. Their recommendation is to take the quantitative gallbladder emptying study with ejection fraction if gallbladder empty flow and if the patient complained of abdominal pain and follow up with the pain clinic service regarding pain management.
PCP|primary care physician|PCP|185|187|HOSPITAL COURSE|Renin and aldosterone levels were checked as well as serum osmolality and urine osmolality and electrolytes. He also had renal ultrasound with Doppler which is to be followed up by his PCP after discharge. Nephrology found the patient to be euvolemic at the time of consult and suspected that there may have been diabetes insipidus component or chronic mild hypovolemia.
PCP|Pneumocystis jiroveci pneumonia|PCP|163|165|PROBLEM #4|PROBLEM #4: Infectious disease: Mr. _%#NAME#%_ receive routine prophylaxis with gatifloxacin, fluconazole, and acyclovir. In addition, he received pentamidine for PCP prophylaxis following engraftment due to his allergy to sulfa. With his initial temperature spike Mr. _%#NAME#%_ received vancomycin, ceftazidime, and tobramycin.
PCP|Pneumocystis jiroveci pneumonia|PCP|192|194|HISTORY OF PRESENT ILLNESS|His second cycle consisted of cyclophosphamide, cytarabine, 6-MP and methotrexate. He did relatively well with these chemotherapy cycles, and had a clinical remission. However, he did develop PCP pneumonia in _%#MM#%_, 2004. Due to having a sibling that was not HLA compatible, the patient was evaluated for umbilical cord blood transplant.
PCP|Pneumocystis jiroveci pneumonia|PCP|167|169|HOSPITAL COURSE|At the time of discharge, she will continue on routine prophylactic antimicrobials including fluconazole, Levaquin and high-dose acyclovir. Pentamidine is on hold for PCP prophylaxis to begin after engraftment, and to be given in the clinic. 4. GI: Ms. _%#NAME#%_ tolerated her chemotherapy well. She has a mild nausea that responded well to Zofran, Dextran and p.r.n. Ativan and Compazine.
PCP|Pneumocystis jiroveci pneumonia|PCP|168|170|EM #3|Acyclovir will be given in two 400-mg doses due to recent nausea, vomiting and patient able to take larger pills. _%#NAME#%_ has a sulfa allergy and will be started on PCP prophylactic with pentamidine instead of Bactrim scheduled to be started on day +28 (_%#DDMM2007#%_). This will be determined by clinic. CMV, HHV-6 and EBV were also tested on _%#DDMM2007#%_, all found to be negative due to fluctuating counts, recurrent rash.
PCP|Pneumocystis jiroveci pneumonia|PCP|291|293|OPERATIONS/PROCEDURES PERFORMED|The was considered the most likely etiology in this patient as his coags did improve throughout his hospital stay with improvement of his salicylate level. Problem #4: Pulmonary infection. As per HPI, the patient was given Bactrim and steroids at _%#CITY#%_ _%#CITY#%_ Hospital for presumed PCP pneumonia prior to his transfer here. Although he had been hypoxic at the outside hospital per report, he was found to be saturating nearly 100% on room air at his time of presentation here.
PCP|Pneumocystis jiroveci pneumonia|PCP|131|133|PROBLEM #4|Her viral status is CMV positive, HSV negative. We will begin following weekly CMV PCR beginning a day plus 14. Her Bactrim DS for PCP prophylaxis will remain on hold until her counts are covered. PROBLEM #5: Fluid, electrolyte and nutrition: _%#NAME#%_ was able to maintain adequate oral intake during this hospitalization.
PCP|Pneumocystis jiroveci pneumonia|PCP|238|240|PROBLEM #3.  GVHD|He has battled with persistent fever throughout his hospitalization. Chest x-ray and chest CT were done which revealed questionable left lower lobe infiltrate. Bronchoscopy was done on _%#DDMM2005#%_ and was negative for malignancy, CMV, PCP and fungus. He was switched over to voriconazole and fevers have since resolved, and x-ray reveals a small pleural effusion on the left, but does not appear to be infectious.
PCP|Pneumocystis jiroveci pneumonia|PCP|251|253|PROBLEM #2|The patient's vancomycin was discontinued on _%#DDMM2004#%_. The patient's voriconazole was continued, as well as his ceftazidime and tobramycin. The patient was also continued on Flagyl 500 mg p.o. as well. The patient was also put on Bactrim DS for PCP prophylaxis. As the patient had a rash and he was no longer neutropenic, the patient's antibiotics were discontinued on _%#DDMM2004#%_.
PCP|Pneumocystis jiroveci pneumonia|PCP|146|148|PROBLEM #4|He was treated with a course of vancomycin and also was treated with meropenem for his history of sinusitis. He will be discharged on Bactrim for PCP prophylaxis, Valtrex, voriconazole and caspofungin as stated above. Of note, his last CMV PCR level on _%#DDMM2008#%_ was negative. PROBLEM #5: Cardiovascular: The patient did have several days of hypertension in which he did take nifedipine XL for a while, but then refused to take the medication.
PCP|Pneumocystis jiroveci pneumonia|PCP|188|190|LAB  DATA|Also in the differential could be histiocytosis X, causing fever, although Dr. _%#NAME#%_ in the past has thought this is unlikely. In the mean time, I will continue her on her Mepron for PCP prophylaxis and again are-start the Vancomycin. At this point I do not plan to start broad spectrum antibiotics as again she has had this long history of fever of unknown origin and I planned to watch her for the next day and allow cultures to come back a nd try to treat according to them.
PCP|Pneumocystis jiroveci pneumonia|PCP|228|230|ASSESSMENT AND PLAN|We will continue to monitor her renal function. She is making good urine during this acute hospitalization. Will continue on immunosuppression as well as prophylaxes. We will contact the transplant service regarding her lack of PCP prophylaxes at this time. 3. Abdominal discomfort. She will continue with her Zelnorm as previous and will have limited use of opiates.
PCP|Pneumocystis jiroveci pneumonia|PCP|142|144|HOSPITAL COURSE|High dose acyclovir for history of HSV, sinusitis and esophagitis and TMP-SMX prophylaxis were discontinued. Pentamidine was used instead for PCP prophylaxis (due next _%#DDMM2007#%_, to be given in clinic). If remainder of bone marrow studies returned normal, etiology on neutropenia will be attributed to a combination of linezolid and trimethoprim sulfa.
PCP|Pneumocystis jiroveci pneumonia|PCP|179|181|HOSPITAL COURSE|15. Infectious: The patient was treated empirically with vancomycin and ceftriaxone. All blood cultures, however, were negative. Issues to be discussed in the future will include PCP prophylaxis and penicillin prophylaxis. Indeed, it is unclear at this point whether the patient's pneumococcal vaccination was adequate in view of his underlying immunodeficiency.
PCP|Pneumocystis jiroveci pneumonia|PCP|133|135|PAST MEDICAL HISTORY|His transplant course was essentially uncomplicated until this point. 2. Chronic low back pain. 3. Hypercholesterolemia. 4. Possible PCP in _%#MM#%_ 2006 treated Mepron. 5. History of strabismus corrected by surgery as an infant. REVIEW OF SYSTEMS: Positive for weakness, nausea, vomiting, and diarrhea as in HPI.
PCP|primary care physician|PCP.|193|196|HEALTH MAINTENANCE|She also has a half-brother and half-sister who are alive and well. HEALTH MAINTENANCE: Last mammogram was normal in _%#MM2000#%_. Denies colorectal screening. Cholesterol is being followed by PCP. Her DEXA scan was normal approximately 2 years ago per patient report. Her last Pap smear as stated above. PHYSICAL EXAMINATION AT THE TIME OF PRESENTATION: Shows a female who is 139.7 kg with a temperature of 98.7, blood pressure 135/107, pulse 95, and respirations 24.
PCP|Pneumocystis jiroveci pneumonia|PCP|143|145|PROBLEM #5|The patient's INR was elevated on a dose of Coumadin of 4 mg q.d. The variability of his INR was thought secondary to changes with his Bactrim PCP prophylaxis. The patient had been off of Bactrim secondary to the lower extremity swelling and change in antibiotics. However, with resuming his Bactrim, his INR increased. As a result, his Bactrim was discontinued, and the patient was put on pentamidine nebulizers for long term prophylaxis.
PCP|Pneumocystis jiroveci pneumonia|PCP|172|174|HOSPITAL COURSE|On postoperative day #5, the patient did well on the general ward. BUN and creatinine increased, at which time the Prograf was held. The patient was started on Dapsone for PCP prophylaxis, as the patient is sulfa allergic and could not tolerate Bactrim. The patient had no adverse events on the floor. He remained afebrile.
PCP|Pneumocystis jiroveci pneumonia|PCP|179|181|HOSPITAL COURSE|Jaw pain had also improved. There was no evidence of infection. She also received Peridex and fluconazole prophylactic therapies. Her next pentamidine neb (instead of Bactrim for PCP prophylaxis due to sulfa allergy) was due _%#MM#%_ _%#DD#%_, 2005. 3. Pain. Related to synovial sarcoma. The patient was treated with oxycodone p.r.n. Colace and MiraLax were prescribed due to risk for constipation.
PCP|Pneumocystis jiroveci pneumonia|PCP|134|136|HISTORY OF PRESENT ILLNESS|On _%#MMDD#%_, she has no recollection that any medication was substituted for her to take. She is uncertain if she is going to be on PCP prophylaxis. Review of her nursing home records also shows that her prednisone was increased on the 18th from 10 mg a day to 30 mg a day for three days and then to 20 mg a day until this week, it was switched on the _%#DD#%_ to 10 mg a day.
PCP|Pneumocystis jiroveci pneumonia|PCP|231|233|PAST MEDICAL HISTORY|1. She has a diagnosis of histiocytosis X made during a _%#MM#%_, 2004 evaluation here and confirmed at the Mayo Clinic. 2. She has a history of a right ovarian mass that is being followed with ultrasounds. 3. She has a history of PCP pneumonia diagnosed in _%#MM#%_ of 2004 4. She has a history of CMV antigenemia positivity from _%#MM#%_ _%#DD#%_, 2004 under the treatment of Dr. _%#NAME#%_
PCP|Pneumocystis jiroveci pneumonia|PCP|212|214|IMPRESSION|Chest x-ray was reviewed and it appears to either be a difference in technique or progression of her infiltrates mild. Urinalysis is unremarkable. IMPRESSION: Persistent fever despite treatment in a patient with PCP and presumed CMV and a history of histiocytosis X. The patient needs further evaluation for the persistent fevers. Dr. _%#NAME#%_ previously saw the patient and did not think that the histiocytosis X was contributing to her current temperature.
PCP|Pneumocystis jiroveci pneumonia|PCP.|171|174|IMPRESSION|We will also ask for Dr. _%#NAME#%_ or his partner to be involved. The patient will be restarted on Clindamycin 600 mg intravenous piggy back Q 8 hours and Primaquine for PCP. Her Mepron which she is on will be held. We will continue her Protonix 40 mg PO Q day. We will continue her multivitamins one PO Q day. We will continue Tylenol for her.
PCP|Pneumocystis jiroveci pneumonia|PCP|294|296|PROBLEM #3|PROBLEM #3: Infectious Disease: Mr. _%#NAME#%_ has had no infectious issues to date. He continues prophylaxis with voriconazole due to history of pulmonary nodules, Levaquin and high-dose acyclovir (CMV positive). Bactrim will be given in clinic on Monday for ANC greater than 1000 x2 days for PCP prophylaxis. Prior to discharge, the patient was switched from acyclovir 5 times daily to Valtrex 1 g t.i.d. with hope for better patient compliance.
PCP|Pneumocystis jiroveci pneumonia|PCP|196|198|HOSPITALCOURSE|HOSPITALCOURSE: PROBLEM #1: Pneumonia. Patient had a chest x-ray repeated at Fairview University Medical Center which revealed patchy ground glass appearance bilaterally which was consistent with PCP Sputum on hospital day #3 revealed PCP by silver stain. Patient's acid fast bacilli were pending at time of discharge. Initial ABG at outside hospital had a PO2 of 70 on four liters, thus prednisone was added to continued treatment with SMX/TMP (Bactrim).
PCP|Pneumocystis jiroveci pneumonia|PCP|107|109|DISCHARGE MEDICATIONS|18. Routine PICC line cares with heparin flushes. 19. Lasix 20 mg oral daily. 20. Dapsone 100 mg daily for PCP prophylaxis. 21. Os-Cal 500 with vitamin D daily for osteoporosis. OTHER INSTRUCTIONS: The PICC line in her left upper extremity placed on approximately _%#DDMM2007#%_ can be discontinued when frequent INR or blood checks are not needed.
PCP|phencyclidine|PCP,|129|132|LABORATORY DATA|Creatinine is 46, also slightly low. Troponin and myoglobin are unremarkable. She had a urine drug screen which was negative for PCP, cannabis, amphetamines, barbiturates, benzodiazepines, opiates and cocaine. EKD was unremarkable aside from minimal elevation of ST segment in the anterior chest leads which is probably non diagnostic.
PCP|Pneumocystis jiroveci pneumonia|PCP|175|177|ASSESSMENT AND PLAN|In the meantime, we will send out blood cultures, sputum cultures, sputu m Gram stain, sputum AFB stains and AFB culture, sputum India ink stain plus an LDH for evaluation of PCP pneumonia and other possible etiologies. 2. Candidiasis, oral: The patient seems to have oral Candidiasis, most likely by Candida species.
PCP|Pneumocystis jiroveci pneumonia|PCP|188|190|HOSPITAL COURSE|Prior to discharge he was changed to Prograf and a new lab letter was sent, so that these levels will be checked on a regular basis. He was placed on monthly pentamidine via nebulizer for PCP prophylaxis since he could not take Bactrim due to his sulfa allergy and the dapsone has been discontinued since it may have been causing some bone marrow supression.
PCP|Pneumocystis jiroveci pneumonia|PCP|193|195|PROBLEM #4|Mr. _%#NAME#%_ will also continue to receive prophylactic Levaquin 250 mg daily while receiving corticosteroids. He also will continue to receive Bactrim DS b.i.d. every Monday and Tuesday for PCP prophylaxis (held x2 weeks due to LFT elevation) and Mr. _%#NAME#%_ was more recently restarted on prophylactic fluconazole in preparation for discharge home.
PCP|Pneumocystis jiroveci pneumonia|PCP|166|168|DISCHARGE DISPOSITION|She will also receive IV vancomycin for coag-negative staph bacteremia through _%#DDMM2007#%_. It was noted by this provider that the patient is currently not on any PCP prophylaxis; if this is warranted, it should be considered in the outpatient setting. Also, of note, the patient had a bone marrow biopsy on _%#DDMM2007#%_, which was less than 5% cellular with 1% blasts and 8% monocytes, which were demonstrating an aberrant immunophenotype with CD-56 positivity.
PCP|Pneumocystis jiroveci pneumonia|PCP|241|243|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 42-year-old HIV positive woman who has had multiple AIDS-defining conditions, including Mycobacterium avium complex isolated from the blood during a 1-week hospitalization in _%#MM2004#%_, and PCP infection in _%#MM2000#%_. By report, she has had a CD4 count of less than 25 for more than 5 years. She previously received her care with Dr. _%#NAME#%_ _%#NAME#%_, but left his care in _%#DDMM2005#%_, and is now seen by Dr. _%#NAME#%_ at Regions Hospital.
PCP|Pneumocystis jiroveci pneumonia|PCP|195|197|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1: Infectious disease. Mr. _%#NAME#%_ had a severe pneumonia based on his oxygen needs at the time of admission. Obviously, due to his HIV, PCP was the primary concern. PCP treatment was initiated with Bactrim and steroids. He was broadly covered with gram-negative, gram-positive, and anaerobic coverage as well.
PCP|Pneumocystis jiroveci pneumonia|PCP|187|189|PROBLEM #5|The patient remains on prophylactic antibiotics including voriconazole 200 mg p.o. b.i.d., Levaquin 250 mg p.o.d. and pentamidine 300 mg nebulized monthly, next due on _%#DDMM2007#%_ for PCP prophylaxis. Incidentally, the patient had an EBV on _%#DDMM2007#%_ that was less than 1000 and an HHB 6 on _%#DDMM2007#%_ that was less than 500.
PCP|primary care physician|PCP|131|133|PROBLEM #6|The patient is not having any active bleeding at this time. Repeat liver function tests and CBC to be done next week by either his PCP or pain clinic. CODE STATUS: Full.
PCP|Pneumocystis jiroveci pneumonia|PCP|333|335|HOSPITAL COURSE|GI was consulted and they considered that this patient had been studied completely during this hospitalization and should be followed in case it was necessary as an outpatient, but they considered him to be more of a surgery candidate. 3. ID: He continued on his Bactrim Double Strength 1 tablet p.o. b.i.d. Mondays and Tuesdays for PCP prophylaxis. He also was given ganciclovir 350 mg IV Monday through Friday for his CMV viremia. He was started on fluconazole for prophylaxis on Candida albicans at 200 mg p.o. daily.
PCP|Pneumocystis jiroveci pneumonia|PCP|215|217|ASSESSMENT/PLAN|My biggest concern is that she has an acu te bacterial infection, most likely would be in her lung, but given her immune status she could also have a fungal or a mycobacterial source at this time. I cannot rule out PCP as well, and that should be on our differential. She does not have anything else in terms of symptoms pointing to CNS syndrome, and she does not have anything concerning for GI or GU infectious syndrome either.
PCP|Pneumocystis jiroveci pneumonia|PCP,|154|157|KEY PROCEDURES/STUDIES PERFORMED|The BAL was negative for malignancy. No organisms were identified. GMS stains had no pathologic assessments. This was also negative for CMV, negative for PCP, and negative for fungus. MICROBIOLOGY RESULTS: 1. Histoplasma antigen was negative. 2. Aspergillus with galactose antigen was positive on _%#MM#%_ _%#DD#%_.
PCP|Pneumocystis jiroveci pneumonia|PCP|169|171|HOSPITAL COURSE|The patient will then be re-evaluated by a sinus CT scan. Bactrim is on hold due to slow count recovery. The patient was placed on pentamidine while in the hospital for PCP coverage. When counts recover, we will re-challenge him with Bactrim. PROBLEM #2: Bone marrow transplant. Mr. _%#NAME#%_ received his unrelated donor cord blood transplant on _%#DDMM2005#%_.
PCP|Pneumocystis jiroveci pneumonia|PCP|188|190|PROBLEM #5|In light of this, his Vancomycin will be continued; however, other empiric antibiotics will be discontinued, and he will remain only on prophylactic fluconazole and acyclovir. Bactrim for PCP prophylaxis has not been initiated yet. PROBLEM #6: GI. Mr. _%#NAME#%_ had some mild nausea and vomiting but his primary GI complaint was diarrhea.
PCP|Pneumocystis jiroveci pneumonia|PCP|134|136|ASSESSMENT AND PLAN|She had intracranial thrombosis but no known stroke apparently. She was on steroids for a period of time, but this was complicated by PCP pneumonia. She is currently on Coumadin but not taking regularly. We will need to speak with her primary MD tomorrow to get further details.
PCP|Pneumocystis jiroveci pneumonia|PCP|150|152|HOSPITAL COURSE|The patient is recently post autologous bone marrow transplant in _%#MM#%_ of 2004. She did not come to the University of Minnesota Medical Center on PCP prophylaxis. The patient has pancytopenia; therefore, she was not placed on oral Bactrim. She will be given nebulized pentamidine for a month. Counts will be re-evaluated at that time.
PCP|Pneumocystis jiroveci pneumonia|PCP|200|202|PROBLEM #5|PROBLEM #5: Infectious disease. He continues on Levaquin and fluconazole. He is CMV and HSV negative, therefore does not require acyclovir. He will start pentamidine monthly with Albuterol premed for PCP prophylaxis once he has engrafted. He will be discharged on higher doses of Levaquin. His counts have started to recover, however, this appears to be his initial cells coming in.
PCP|Pneumocystis jiroveci pneumonia|PCP|194|196|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Dr. _%#NAME#%_ is a 78-year-old male with a history of CLL and severe aortic stenosis. He was transferred to the hematology/oncology team from the MICU with presumed PCP pneumonia. He had been noting progressive shortness of breath requiring home O2, 2-3 L nasal cannula, for the last six weeks. He has seen Dr. _%#NAME#%_ from cardiology and it was determined he had severe aortic stenosis requiring potential aortic valve replacement.
PCP|Pneumocystis jiroveci pneumonia|PCP|153|155|HOSPITAL COURSE|He was empirically started on Zosyn and gatifloxacin. He was evaluated by pulmonary on admission who recommended also treating with Bactrim for possible PCP given the patient's long history of being on prednisone. The patient slowly seemed to improve from a respiratory standpoint and was transferred out of the ICU to the Hematology/Oncology Service on _%#DDMM2004#%_.
PCP|Pneumocystis jiroveci pneumonia|PCP|209|211|PAST MEDICAL HISTORY|5. Seropositive for EBV, VZV, HCV and CMV. 6. History of seizures on _%#DDMM2007#%_. 7. History of burr hole to obtain brain biopsy. 8. Port-A-Cath placement in the left chest in _%#DDMM2003#%_. 9. History of PCP as well as Aspergillus pneumonia. 10. Dog bite to the face as a child. 11. MRI of the brain significant for a small abnormal enhancing focus of the right parietal lobe consistent with underlying diagnoses.
PCP|Pneumocystis jiroveci pneumonia|PCP|180|182|DISCHARGE DIAGNOSES|Therefore, the Bactrim was discontinued for a short period of time; however, the eosinophilia persisted. This was restarted secondary to the patient being on immunosuppression for PCP prophylaxis. There is also a concern that the sotalol used for atrial fibrillation withdrawal could also be a culprit. This was discontinued after a cardiology consultation was obtained. The patient will follow up with his primary care physician, Dr. _%#NAME#%_ _%#NAME#%_ as an outpatient.
PCP|Pneumocystis jiroveci pneumonia|PCP|108|110|ASSESSMENT AND PLAN|7. Cutaneous HSV by history. The patient currently has no rash that I can identify. She is on Acyclovir. 8. PCP VRE pneumonia pre-hospital, currently t reated with antibiotic therapy. 9. Graft versus host prophylaxis. She currently is on her pentamidine as well as her Prograf.
PCP|primary care physician|PCP,|250|253|FOLLOWUP|FOLLOWUP: 1. The patient should follow up with Dr. _%#NAME#%_ within 1 month regarding her myasthenia gravis treatment. 2. Follow up with GI physician _%#NAME#%_ _%#NAME#%_ in 1-2 weeks, regarding persistent nausea. 3. Follow up with Dr. _%#NAME#%_, PCP, to address increase in blood pressure medications. ATTENDING ON DISCHARGE: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD. RESIDENT: _%#NAME#%_ _%#NAME#%_, MD.
PCP|Pneumocystis jiroveci pneumonia|PCP,|163|166|PROBLEM #4|She was placed on BiPAP to help her breath. Pulmonary was consulted. She was febrile at the time. Pulmonary did a BAL on _%#DDMM2006#%_. BAL was negative for CMV, PCP, and fungal elements, as well as negative for malignancy. AFB culture remains negative. Gram stain showed no organisms seen. No polys. The bronchial lavage culture grew out normal respiratory flora.
PCP|Pneumocystis jiroveci pneumonia|PCP|244|246|PROBLEM #3|PROBLEM #3: Diffuse alveolar hemorrhage. Ms. _%#NAME#%_ developed respiratory distress and required intubation on _%#DDMM2002#%_. Bronchoscopy revealed findings consistent with diffuse alveolar hemorrhage. Her bronch wash was negative for CMV, PCP or fungus. The bronch wash did grow coag-negative Staphylococcus. She was treated with high-dose methylprednisolone for her hemorrhage as well as Vancomycin for the coag-negative staff.
PCP|Pneumocystis jiroveci pneumonia|PCP.|137|140|ASSESSMENT|The patient is also on a prophylactic antifungal, which includes caspofungin. The patient was also placed on pentamidine prophylaxis for PCP. He was also treated with ceftazidime, as well as azithromycin to cover atypical pneumonia. 4. Pulmonary: As stated above, the patient was intubated shortly and did undergo bronchoscopies.
PCP|Pneumocystis jiroveci pneumonia|PCP|123|125|HISTORY OF PRESENT ILLNESS|The patient was most recently hospitalized at the University of Minnesota from late _%#MM#%_ to early _%#MM#%_ of 2005 for PCP pneumonia. The patient was hospitalized for approximately two weeks. He was treated with Bactrim DS tid. The patient was discharged on _%#DDMM2005#%_ with a plan to continue to take Bactrim DS for two weeks, then follow that with Bactrim single strength for an additional two weeks of therapy.
PCP|Pneumocystis jiroveci pneumonia|PCP|204|206|PAST MEDICAL HISTORY|The patient does receive 2-3 units of packed red blood cell transfusions every two weeks for problems with anemia. He recently had a bone marrow biopsy in _%#DDMM2005#%_ which showed red cell aplasia. 5. PCP pneumonia requiring hospitalization at the University of Minnesota in _%#DDMM2005#%_ with recent discharge _%#DDMM2005#%_. 6. Status post kidney transplant in _%#DDMM1998#%_. 7. Status post pancreatic transplant in _%#DDMM2003#%_ with loss of function of his transplant in _%#DDMM2004#%_.
PCP|Pneumocystis jiroveci pneumonia|PCP|156|158|PROBLEM #4|He was treated with a course of vancomycin and also was treated with meropenem for his history of sinusitis. He currently will be discharged on Bactrim for PCP prophylaxis, Valtrex, anti-viral prophylaxis, voriconazole and caspofungin as stated above. His last CMV PCI level on _%#DDMM2008#%_ was negative. PROBLEM #5: Cardiovascular: The patient did have several days of hypertension in which he did take nifedipine XL for a while, but then refused to take medications.
PCP|Pneumocystis jiroveci pneumonia|PCP|181|183|HOSPITAL COURSE|Problem #2. Suspected neutropenic pancolitis and ileitis: The patient continued on antibiotic therapy consisting of Flagyl, vancomycin, and ceftazidime. He continues on Bactrim for PCP prophylaxis at the present time. Problem #3. Recurrent post-transplant lymphoproliferative disorder: This has been followed by Hematology, and he has been restarted on Rituxan therapy and will continue Rituxan chemotherapy on Tuesdays at least for the next four weeks with follow-up by Hematology.
PCP|phencyclidine|PCP.|292|295|LABORATORY DATA ON ADMISSION|Salicylate level was less than 1. Ethanol level is less than 0.01. Blood culture drawn at the time of the admission, which were negative after 2 days. Drug urine screen was done, which is positive for opiates and negative for amphetamine, barbiturates, benzo, cannabinoids, cocaine, alcohol, PCP. Chest x-ray was done, which showed right mid lung and perihilar pulmonary infiltrate. HOSPITAL COURSE: PROBLEM #1: Overdose. There is a concern for polydrug use because the patient reported that he used several pain medications for his lower chronic back pain and his Tylenol level was high at the time of the admission.
PCP|Pneumocystis jiroveci pneumonia|PCP|219|221|PAST MEDICAL HISTORY|4. Pancreas transplant in 1999 with an enteric conversion for urological complication and an anastomotic bladder leak in 2000. 5. Cerebrovascular accident x2 with no significant sequelae. 6. Hypertension. 7. History of PCP (Pneumocystis carinii pneumonia) _%#DDMM2004#%_. 8. History of cytomegalovirus retinitis which began _%#DDMM2004#%_ and is persistent to this day. 9. History of pancreas allograft rejection most recently _%#DDMM2005#%_.
PCP|Pneumocystis jiroveci pneumonia|PCP|348|350|PROBLEM #6|PROBLEM #7. Infectious disease. Infectious Disease was consulted, and it was recommended that we continue ampicillin for group D enterococcus until her chest x-ray is clear, continue Abelcet until the chest x-ray is clear for fungal infection, continue Biaxin and cefoxitin until _%#DDMM2004#%_ for atypical mycobacterium, and continue Bactrim for PCP prophylaxis. Therefore, _%#NAME#%_ was sent home on all of the above antibiotics. PROBLEM #8: Cardiovascular system. _%#NAME#%_ had problems with hypertension. However, during her hospital stay she required very few p.r.n. medications for a blood pressure over 160.
PCP|Pneumocystis jiroveci pneumonia|PCP|391|393|HISTORY OF PRESENT ILLNESS|She does wear a BiPAP at home for sleep apnea related to her pulmonary hypertension as well as elevated right-sided heart pressures. The Renal Transplant Service saw her as well secondary to her elevated creatinine and recommended holding her cyclosporin indefinitely, and continuing simply with her Imuran and prednisone for renal transplant immunosuppression as well as the Bactrim SS for PCP prophylaxis. She has had loose stools which it was felt by the medicine firm to be due to diabetic autonomic neuropathy, so the patient was started on Metamucil.
PCP|Pneumocystis jiroveci pneumonia|PCP|382|384|HOSPITAL COURSE|PROBLEM #2. Alveolar hemorrhage: The patient had multiple pulmonary events including a CBP above 22, requiring diuresis as well as hemoptysis requiring evaluation by bronchoscopy as dictated above, which revealed classic signs for bronchoalveolar hemorrhage. Due to excessive blood, it was a nondiagnostic specimen. No organisms were specifically identified, and stains for CMV and PCP were negative; however, it was difficult due to the excessive blood. He has also had aspergillus rapid antigen tests throughout this hospitalization which have been negative to date.
PCP|Pneumocystis jiroveci pneumonia|PCP|200|202|HOSPITAL COURSE|She was treated with a full course initially with Bactrim and then subsequently with Papsona. She continues to be on Bactrim prophylactically at 1 tablet single-strength daily for prophylaxis for her PCP through her feeding tube every day. Mrs. _%#NAME#%_ currently requires the ventilator for some support. She is currently now able to be on a trach dome with an FiO2 of 40% for approximately 12 hours.
PCP|Pneumocystis jiroveci pneumonia|PCP|255|257|PROBLEM #2|The patient was never febrile during his posttransplant course; however, with his Hickman line it was felt he should be covered for the bacteremia. He was continued on the prophylaxis per protocol, including fluconazole for yeast prophylaxis, Bactrim for PCP prophylaxis when his counts returned this week, and acyclovir IV until he was taking oral. Due to his Mirabavir study, he was on a lower IV dose of 600 mg q. 8 h; however, per study protocols he can take the full dose of 800 mg of acyclovir five times a day for his previous CMV positivity.
PCP|Pneumocystis jiroveci pneumonia|PCP|171|173|BRIEF HISTORY|His goal tacrolimus level is between 8 and 10 due to his chronic kidney disease. Current tacrolimus level, 12- hour trough, is pending. The patient remains on Bactrim for PCP prophylaxis. 5. DVT/pulmonary emboli prophylaxis. The patient is status post IVC filter. His INR was at goal upon discharge at 2.36. He will continue his warfarin as per usual.
PCP|Pneumocystis jiroveci pneumonia|PCP.|220|223|HISTORY OF PRESENT ILLNESS|The patient has not had any history of severe opportunistic infections apart from the fact that he does remember having herpes zoster in the past, and about a month ago he was admitted with pneumonia and was treated for PCP. At that time, the patient received treatment with Bactrim and prednisone and also with levofloxacin for community-acquired pneumonia.
PCP|Pneumocystis jiroveci pneumonia|PCP|211|213|MAJOR PROCEDURES AND TESTS|3. Tracheostomy on _%#MM#%_ _%#DD#%_, 2002, since removed. 4. Multiple bronchoscopies. Most recent bronchoscopy was _%#MM#%_ _%#DD#%_, 2002, which grew out Aspergillus fumigatus. Cultures were negative for CMV, PCP and RSV. 5. EGD performed _%#MM#%_ _%#DD#%_, 2002, showing akinetic stomach with erythematous gastropathy. 6. Sinus CT performed _%#MM#%_ _%#DD#%_, 2002, which was negative for evidence of sinusitis.
PCP|Pneumocystis jiroveci pneumonia|PCP|234|236|ASSESSMENT AND PLAN|4. Cystic fibrosis exacerbation: She has been on chronic antibiotics because of her severe lung disease. Will continue meropenem and tobramycin along with Zithromax and doxycycline. She will remain on Bactrim prophylaxis for possible PCP as the patient is on prednisone. In addition will continue with Vest therapy and nebs. 5. History of ABPA, on prednisone. Most likely the cause for her significant asthmatic component.
PCP|Pneumocystis jiroveci pneumonia|PCP|239|241|PROBLEM #2|The patient was left on voriconazole per attending physician at 200 mg b.i.d. The patient will continue on prophylaxis during steroids to include fluconazole, Flagyl, acyclovir and Levaquin. The patient will also continue with Bactrim for PCP prophylaxis. PROBLEM #3: Thyroiditis. The patient was found to have a right-sided nodule on his thyroid during exam.
PCP|Pneumocystis jiroveci pneumonia|PCP|295|297|HOSPITAL COURSE|The Stenotrophomonas is only sensitive to prophylactic Bactrim for which she was taking twice a week and this was changed to Bactrim double strength p.o. b.i.d. to be taken for three weeks. This three weeks will be finished on _%#DDMM2002#%_ after which she should take Bactrim twice a week for PCP prophylaxis. Problem #2. Cardiovascular: During the patient's hospital stay she did not have any cardiovascular issues, and she was hemodynamically stable.
PCP|Pneumocystis jiroveci pneumonia|PCP|232|234|PROBLEM #3|Due to a history of prolonged neutropenia and extensive therapy, it was decided to use Vfend for antifungal prophylaxis beginning on day #1. Previous to this the patient was put on fluconazole. The patient was placed on Bactrim for PCP prophylaxis when she engrafted and she continues with this. The patient had neutropenic fevers during her hospitalization. These started approximately day +5.
PCP|Pneumocystis jiroveci pneumonia|PCP|330|332|PROBLEM #3|There is a nodular focus of ground- glass opacity in the right lower lobe which is improved, ______ atelectasis at the right lung bases bilaterally. Caspofungin was discontinued. The patient remains on prophylactic acyclovir 400 mg p.o. b.i.d., Levaquin 500 mg IV daily, and voriconazole 300 mg p.o. daily, as well as Bactrim for PCP prophylaxis. PROBLEM #4: Gastrointestinal. The patient received Zofran and Decadron through day zero as well as Ativan and Compazine p.r.n. The patient had some problems with nausea and vomiting throughout her hospitalization.
PCP|Pneumocystis jiroveci pneumonia|PCP|179|181|HOSPITAL COURSE|The patient was sent home with a PICC in place with the plan of continuing her imipenem through _%#MM#%_ _%#DD#%_, 2004. Because the patient did not seem to tolerate Bactrim, her PCP prophylaxis was changed to a once a month pentamidine neb. The patient's coagulase negative Staphylococcus was not treated as it was deemed a contaminant.
PCP|Pneumocystis jiroveci pneumonia|PCP|232|234|DISCHARGE ASSESSMENT/PLAN|Hemoglobin on _%#DDMM2007#%_ was 10.5 and stable. UA on _%#DDMM2007#%_ was negative. DISCHARGE ASSESSMENT/PLAN: 1. Bronchiolitis obliterans-organizing pneumonia. We will continue his treatment with high-dose prednisone and continue PCP prophylaxis with Bactrim weekly per Pulmonology recommendations. His bedside spirometry was completed today, results are not available at this time. I would recommend continuing his Advair and albuterol as well and will use home oxygen 1-2 liters at rest and 2-3 liters while ambulating.
PCP|phencyclidine|PCP.|333|336|LABORATORY  DATA|Sodium 141, potassium 3.6, chloride 104, CO2 27, BUN 11, creatinine 0.6, calcium 9.8, total bilirubin 0.5, albumin 5.8, total protein 8.5, alkaline phosphatase 102, ALT 20, AST 21. Urinalysis was unremarkable. Drugs of abuse screen was negative for amphetamines, barbiturates, benzodiazepines, cannabis, cocaine, ethanol, opioids or PCP. Urine culture has thus far been negative, and a CT of the head was performed revealing no evidence of any acute abnormality and no convincing evidence for shunt malfunction, per the radiologist's report.
PCP|phencyclidine|PCP|159|161|DEMOGRAPHIC/BACKGROUND INFORMATION|He also tried Adderall a couple times a week, and was using heroin for the first time 4 to 5 months ago and was using 3 days in a row. This patient also tried PCP a single time a year ago and believe that he had a "bad trip," as a result he believes that he has been having "flashbacks" since then.
PCP|Pneumocystis jiroveci pneumonia|PCP|597|599|ROS|_%#NAME#%_ has a history of seizures, unclear of some "muscle twitching" is seizure. Followed by neuro Past Medical History: ALD diagnosed _%#DDMM2007#%_ Seizures Visual Hearing deficits Skin Gut GVHD Adenvirus Pancreatitis resolved secondary to VPA Hypertension with PRES Hyperglycemia related to steroids ROS: Pertinent findings outlined in HPI from following areas reviewed: (Pain, Respiratory, CV, GI, GU, Constitutional, Psychiatric, Neurological, Skin, Musculoskeletal, Eyes, ENT) Medications: Anti-infectives: Cidofovir 45 mg 3X/week with Probenecid 375 mg, Voriconazole 200 mg BID Bactrim PCP prophylaxis 80 mg BID qMON &Tues, Ribovarin 400 mg po via NG qday, Ancef 750 q8h, Meropenem 500 q8h BP Meds: Prazosin 4 q8, clonidine 0.1 mg q10pm, Amlodipine 7.5 q12h, Nifidepine prn 4mg q8h Hydralazine IV prn, Diltiazem 15 q6h, Lasix 15 IV qd, labetolol 30 q4h Anti-GVHD meds: Methylprednisolone 15 mg q12h, CSA IV drip 4.5 mg/hr, HCT 1% cream, Triamcinolone to face Endocrine: Hydrocortisone 30 mg IV for Addison disease, Florinef 0.05 mg, Insulin drips Analgesics/Antipyretics:acetaminophen prn MISCELLANEOUS: Ditropan 5 mg BID,aranesp 12.5 mcg IV qweek CNS active meds: Gabapentin 167 mg q8h, Keppra 300 mg BID, Melatonin 15 mg qhs, Risperdal 0.375 mg q2 am GI/GU meds: Pantoprazole 30 mg IV Social History: _%#NAME#%_'s family consists of parents _%#NAME#%_ and _%#NAME#%_, and siblings _%#NAME#%_ 20, _%#NAME#%_ 12, and _%#NAME#%_'s twin _%#NAME#%_ Physical Exam Weight 32.8 kg exam deferred Summary of Discussion Overall Goals of Care/Concerns _%#NAME#%_ shared that her greatest concern for _%#NAME#%_ is his overall quality of life.
PCP|Pneumocystis jiroveci pneumonia|PCP,|163|166|PHYSICAL EXAMINATION|The densest areas appeared to be the posterior right upper lobe and the posterior left base. The ground glass appearance is nonspecific and could represent edema, PCP, pneumonia, inflammatory pneumonitis such as hypersensitivity pneumonitis, alveolar leak or hemorrhage and a more chronic process, such as lymphoma, with a superimposed process, such as edema.
PCP|Pneumocystis jiroveci pneumonia|PCP,|153|156|ASSESSMENT AND PLAN/HOSPITAL COURSE|(Also, the patient had a PPD with controls placed which were anergic). I believe metastatic disease can account for the pulmonary nodules. As far as the PCP, the patient has absolutely no symptoms for this as well. His lymphocytes are well above what would be expected to allow for PCP pneumonia.
PCP|Pneumocystis jiroveci pneumonia|PCP|236|238|HISTORY OF PRESENT ILLNESS|He is incarcerated. He was admitted to the University of Minnesota Medical Center, Fairview, on _%#DDMM2006#%_ with ARDS and respiratory failure. He was found to be HIV positive. His respiratory condition was thought to be secondary to PCP pneumonia. In addition, he developed multiple opportunistic infections, including CMV retinitis, histoplasmosis and fungemia. His initial CD-4 count was 1. He eventually was started with antiretrovirals.
PCP|phencyclidine|PCP,|237|240|DEMOGRAPHIC/BACKGROUND INFORMATION|He has a significant history of polysubstance abuse. He stated that he started using cocaine at age 12 and was up to 4 gm a week. He started marijuana at age 11, up until recently. He also started using mushrooms at age 10. He was using PCP, ectasy, LSD, Vicodin, Robitussin, speed, and methamphetamines starting at age 12. He also started using alcohol at age 10. As stated earlier, he eventually went to treatment at New Connections in _%#CITY#%_ _%#CITY#%_ four months ago.
PCP|phencyclidine|PCP|262|264|RELEVANT INTERVIEW INFORMATION|In terms of personal health history, Mr. _%#NAME#%_ denied any history of traumatic brain injury that resulted in loss of consciousness, heart attack, or other ongoing medical conditions. He was reportedly hospitalized on one previous occasion related to taking PCP "on accident" at age 14. Apparently, he had been given marijuana that had been laced with PCP without his knowledge. He does not recall where he was hospitalized, but believes that he was admitted overnight for observation.
PCP|phencyclidine|PCP|168|170|RELEVANT INTERVIEW INFORMATION|He was reportedly hospitalized on one previous occasion related to taking PCP "on accident" at age 14. Apparently, he had been given marijuana that had been laced with PCP without his knowledge. He does not recall where he was hospitalized, but believes that he was admitted overnight for observation.
PCP|Pneumocystis jiroveci pneumonia|PCP.|200|203|RECOMMENDATIONS|Because this patient is currently on high dose cortisol replacement therapy and it is not clear at what point she will be on her optimized steroid replacement therapy, she is at risk of recurrence of PCP. It is likely that when she first developed PCP in _%#MM#%_ this was due to endogenous adenoma cortisol production resulting in immunodeficiency with decreased CD4 count.
PCP|Pneumocystis jiroveci pneumonia|PCP|248|250|RECOMMENDATIONS|Because this patient is currently on high dose cortisol replacement therapy and it is not clear at what point she will be on her optimized steroid replacement therapy, she is at risk of recurrence of PCP. It is likely that when she first developed PCP in _%#MM#%_ this was due to endogenous adenoma cortisol production resulting in immunodeficiency with decreased CD4 count. Although I am confident that her CD count at this time should be within normal range that would normally suggest that PCP could not develop, I am concerned because she is currently on a high-dose daily hydrocortisone therapy, and Endocrinology appears to still be working on optimizing her cortisone dose.
PCP|Pneumocystis jiroveci pneumonia|PCP|288|290|RECOMMENDATIONS|It is likely that when she first developed PCP in _%#MM#%_ this was due to endogenous adenoma cortisol production resulting in immunodeficiency with decreased CD4 count. Although I am confident that her CD count at this time should be within normal range that would normally suggest that PCP could not develop, I am concerned because she is currently on a high-dose daily hydrocortisone therapy, and Endocrinology appears to still be working on optimizing her cortisone dose.
PCP|Pneumocystis jiroveci pneumonia|PCP|166|168|SUMMARY OF CASE|She had a very stormy hospital course with polymicrobial opportunistic infection. She had MRSA bacteremia, HSV pneumonitis labialis, and tracheobronchitis as well as PCP and RSA, pseudomonas, and aspergillus pneumonia. She also had polymicrobial sinus infection. Unfortunately she was also diagnosed with right lobe pulmonary embolism, atrial fibrillation, proctitis, pancytopenia secondary to Valcyte and electrolyte abnormalities.
PCP|Pneumocystis jiroveci pneumonia|PCP,|198|201|PAST MEDICAL HISTORY|2. Cushing's disease diagnosed _%#DDMM2007#%_. The patient had numerous complications including infection and PE. 3. Polymicrobial pneumonia including MRSA, VRE, pseudomonas, aspergillus fumigatus, PCP, branhamella catarrhalis, and CMV. 4. PE in _%#DDMM2007#%_ and _%#DDMM2007#%_. Status post IVC filter replacement _%#DDMM2007#%_. 5. Brief episode of atrial fibrillation _%#DDMM2007#%_. 6. Pancytopenia secondary to Valcyte.
PCP|Pneumocystis jiroveci pneumonia|PCP|230|232|PERTINENT INVESTIGATIONS|The patient has also grown out coag-negative staphylococcus from the broncho which was thought to be just a colonizer and not a Staphylococcus pneumoniae. In terms of prophylaxis, the patient is on Bactrim single strength for his PCP and on azithromycin 1200 mg p.o. once a week for MAI prophylaxis. The patient currently has had multiple mycobacterium cultures drawn and all have been negative so far.
PCP|Pneumocystis jiroveci pneumonia|PCP,|180|183|PAST MEDICAL HISTORY|His viral lobe was either 15,000 or 150,000. He has a history of thrush that was noted three months ago, and he was treated with medications for the thrush. He denies a history of PCP, MAI, or Caprices sarcoma. 3. History of withdrawal seizures that required treatment with barbiturates x 16 days. Apparently, the patient was in some type of barbiturate-induce coma secondary to the seizures.
PCP|phencyclidine|PCP.|238|241|LABORATORY DATA|Subsequent values have been 69 in the morning, 101 at noon, and 127 just prior to dinner. Drug screen done yesterday in the clinic was negative for amphetamines, barbiturates, benzodiazepines, cannabinoids, cocaine, alcohol, opiates, and PCP. Normal white count with a normal differential was seen as well as a normal hemoglobin. A basic metabolic panel was done which showed: Normal sodium at 139.
PCP|Pneumocystis jiroveci pneumonia|PCP|171|173|ASSESSMENT|His prompt response to antibacterial treatment suggests that the problem is a bacterial pneumonia. The CT scan is more compatible with bacterial pneumonia than it is with PCP and the clinical findings seem to support this. I considered a bronchoalveolar lavage with bronchoscopy and I actually discussed it with his wife this morning, but he has stabilized, is improving, and is moderately hypoxemic.
PCP|Pneumocystis jiroveci pneumonia|PCP.|218|221|PROBLEM #4|He requires very little for pain medication, and again, has been off oxygen for several days. PROBLEM #4: SIADH: Mr. _%#NAME#%_ was hyponatremic on admission, but this rapidly resolved with FFP and steroid therapy for PCP. The hyponatremia returned, and although Mr. _%#NAME#%_ has been asymptomatic, he has had sodium levels as low at 115. Urine sodium and urine osms are consistent with SIADH. This also fits his clinical picture of refractory pneumothorax and PCP pneumonia.
PCP|Pneumocystis jiroveci pneumonia|PCP|120|122|HISTORY OF PRESENT ILLNESS|The patient is currently receiving Sustiva and Truvada as part of HAART therapy. He has received full treatment for his PCP pneumonia and CMV. However, his recent CMV titers show an increase in quantitative PCRs. The patient was therefore restarted on ganciclovir for this infection.
PCP|Pneumocystis jiroveci pneumonia|PCP;|242|245|PAST MEDICAL HISTORY|During this hospitalization, the patient has been diagnosed with HIV/AIDS and is currently on antiretroviral therapy. Other current issues include bilateral pneumothoraces; multiple opportunistic infections including CMV, histoplasmosis, and PCP; intractable nausea; pancytopenia; depression/anxiety; and deconditioning. ALLERGIES/DRUG SENSITIVITIES: The patient has no drug allergies listed. However, during this hospitalization, he did have an episode of neuroleptic malignant syndrome secondary to antidopaminergic agents.
PCP|Pneumocystis jiroveci pneumonia|PCP|157|159|HOSPITAL COURSE|The patient had a CD4 count drawn which showed a CD4 count of 48. The patient has not been taking her HIV medications and is also not on any prophylaxis for PCP or MAI. On admission, the patient's O2 saturations were 90% on room air and with walking also. The patient had an ABG drawn which showed a pO2 of 73.
PDA|patent ductus arteriosus|PDA|255|257|FOLLOWUP INSTRUCTIONS|_%#NAME#%_ was initially maintained on a parenteral glucose infusion. We were able to start parenteral nutrition on _%#DDMM2006#%_. Feedings were initially started on _%#DDMM2006#%_,but were held due to feeding intolerance and subsequently because of her PDA and indomethacin therapy. Feedings were again started on _%#MM#%_ _%#DD#%_, 2006 and have been increased slowly to her current feedings of 6 mL Q 2 hours.
PDA|posterior descending artery|PDA.|179|182|DISCHARGE DIAGNOSES|11. Exchange of Levotronix right ventricular assist device with implantable Thoratec RVAD, IVAD. 12. Beating heart off pump coronary artery bypass grafting x 1 with vein graft to PDA. SURGEON: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ MD. ADMITTING HISTORY AND PHYSICAL: This is a 36-year-old female who initially presented to an outside hospital in _%#CITY#%_, North Dakota with chest pain.
PDA|posterior descending artery|PDA|232|234|SUMMARY OF HOSPITAL COURSE|Dr. _%#NAME#%_ _%#NAME#%_ was then consulted for emergent CAB. He underwent a 6-vessel coronary artery bypass grafting on _%#DDMM2007#%_ with a LIMA to his LAD, saphenous vein graft to his D2, D1 and OM, saphenous vein graft to his PDA and posterolateral right. He tolerated the procedure fair. He was transferred to the Intensive Care Unit. An intraaortic balloon pump remained in. The patient progressed slowly with the need of inotropes for blood pressure control and low urine output.
PDA|posterior descending artery|PDA.|257|260||Mr. _%#NAME#%_ _%#NAME#%_ is a 76-year-old gentleman who underwent aortic valve replacement with a redo sternotomy and a coronary artery bypass x1. His valve replacement with a 20 mm ATF supra-annular mechanical prosthesis and a saphenous vein graft to his PDA. He was transferred to the ICU in stable condition. His postoperative course was complicated with renal insufficiency which was a preop diagnosis and has returned to baseline prior to discharge.
PDA|posterior descending artery|PDA.|257|260|HISTORY OF PRESENT ILLNESS|His proximal circumflex had focal severe stenosis and his OM2 which is a large branching vessel has severe stenosis of the ostium as well as focal stenosis in both branches. His RCA showed patent stents, but severe focal lesions in the proximal PLA and mid PDA. He underwent uneventful stenting of both PLA and PDA with drug-eluting stents as well as his proximal circumflex. He will be monitored overnight and discharged in a.m. if his hospital stay remains uneventful.
PDA|posterior descending artery|PDA|135|137|HOSPITAL  COURSE|There was spasm in the catheter which was relieved by intracoronary nitroglycerin. Mid RCA had a tubular discrete 80% stenosis. Distal PDA and PL branches were free of significant disease. Left main was normal and bifurcates into the left anterior descending and left circumflex.
PDA|patent ductus arteriosus|PDA.|180|183|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Born 32 weeks by C-section due to partial abruption. Three weeks in the NICU, intubated 3-4 days with hyaline membrane disease. History of reflux. History of PDA. History of phototherapy for hyperbilirubinemia. ADMISSION EXAMINATION: VITAL SIGNS: Pulse 113, respiratory rate 24, blood pressure 90/41, weight 17.4 kg, temperature 97.7. GENERAL: She was alert and appropriate.
PDA|posterior descending artery|PDA.|261|264|HISTORY/HOSPITAL COURSE|Clinical impression of unstable angina - acute anterior infarct was made and she subsequently went to Cardiac Catheterization, done by my associate, Dr. _%#NAME#%_ _%#NAME#%_. She had a 30% stenosis of her RCA, proximal, mid and distally. A 50% stenosis of her PDA. She had mild disease of the LAD and circumflex with a 98% stenosis of a large ramus intermediate branch to her anterior wall.
PDA|patent ductus arteriosus|PDA.|131|134|DOB|Head ultrasound on DOL #7 was normal. 5. CV-Echocardiogram performed on _%#MMDD#%_ for a II/VI LUSB systolic murmur showed a small PDA. _%#NAME#%_ was treated with indomethacin with resolution of his murmur. 6. ID-_%#NAME#%_ was treated with ampicillin and gentamicin for 72 hours for rule-out sepsis, maternal GBS status unknown, and respiratory distress.
PDA|patent ductus arteriosus|PDA,|158|161|ASSESSMENT|EXTREMITIES: Hips are negative. Ortolani negative Barlow. NEURO: Nonfocal. ASSESSMENT: 1. Prematurity, EGA 29 5/7th weeks. 2. Triple #1. 3. RDS, resolved. 4. PDA, resolved. 5. Normal head ultrasound. 6. No retinopathy or prematurity. 7. Passed OAEs bilaterally. 8. Resolved hyperbilirubinemia of prematurity.
PDA|posterior descending artery|PDA|197|199|PAST MEDICAL HISTORY|OM2 has minimal disease with 40% lesion and OM3 had 30% to 40% lesion. PDA was 70% to 75% diffusely disease on the proximal portion. The patient had diffuse disease with significant disease of the PDA and D1, which were small caliber vessels. At that point, medical therapy had been opted on. 2. Left pharmacologic stress adenosine was performed on _%#DDMM2003#%_, which revealed nondiagnostic for ischemia, with T-wave inversions noted in recovery with myocardial perfusion imaging revealing a normal stress thallium study.
PDA|posterior descending artery|PDA|157|159|HOSPITAL COURSE|The patient will be followed by an outpatient cardiologist in 3 to 4 weeks for another percutaneous intervention of the distal left circumflex, OM and right PDA as discussed during this hospitalization. It is also noted that the patient has a history of dye allergy, therefore, he will be pre-treated with steroids before the angiogram.
PDA|patent ductus arteriosus|PDA.|311|314|HOSPITAL COURSE|3. Fluid, electrolytes, nutrition. The patient experienced an episode of fluid retention on _%#MM#%_ _%#DD#%_ with some periorbital edema, significant weight increase and worsening respiratory symptoms. He received IV Lasix with a significant improvement. 4. Cardiovascular: Patient is known to have an ASD and PDA. Because of the episode of fluid retention, a follow-up echocardiogram was done, which showed a possible slight increase in pulmonary artery pressures compared to the echo of _%#MM#%_ of 2004 but aside from the ASD and trace to mild aortic insufficiency, nothing was substantially changed since his prior echo.
PDA|patent ductus arteriosus|PDA.|205|208|PAST MEDICAL HISTORY|Other past medical history significant for an imperforate anus status colostomy on _%#MM#%_ _%#DD#%_, 2004. She is awaiting takedown of the colostomy and AV canal defects with a bidirectional VSD, PFO and PDA. Her baseline O2 saturation is greater than 98% on room air. She has gastroesophageal reflux disease, and she is currently on Zantac.
PDA|posterior descending artery|PDA.|157|160|LABORATORY DATA|40% OM-1 lesion, healed bisection involving second diagonal artery. Circumflex stents patent. Posterolateral branch is 100% occluded, 70-75% stenosis of the PDA. (Blood vessels are small). 2. Renal arteriogram performed during cardiac catheterization demonstrated no significant renal artery stenosis. 3. Echocardiogram demonstrated dilated left ventricle with a left ventricular function of 30%.
PDA|posterior descending artery|PDA,|495|498|PROCEDURES AND TESTS|4. Echocardiogram with technically difficult study, ejection fraction estimated at 15-20%, global hypokinesis with relative preservation of the basal anterior and septal walls, impaired ventricular relaxation, normal right heart size and function, insignificant valvular heart disease, tissue density ventricle likely accessory cord structures. 5. Cardiology consult with later angiogram with a 30% lesion in a nondominant RCA, 50% LAD lesion, 60% distal LAD lesion, multiple 30% lesions in the PDA, obtuse marginal (see separate report). HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 77-year-old man with severe dementia who is otherwise fairly functional.
PDA|posterior descending artery|PDA|309|311|DISCHARGE PLAN|LABORATORY & DIAGNOSTIC DATA: His potassium is 4.2, BUN 20, creatinine 1.63, hemoglobin of 16, troponin small bump at 0.37. EKG is unchanged this morning. DISCHARGE PLAN: Mr. _%#NAME#%_ will be discharged home today with the plan for him to return in two to three weeks for a second stage intervention on the PDA vessel. DISCHARGE MEDICATIONS: 1. Plavix 75 mg one p.o. q. day.
PDA|patent ductus arteriosus|PDA|199|201|MMC 94|Blood and urine cultures obtained on _%#DDMM2000#%_ were negative at the time of transfer. Problem #3: Patent Ductus Arteriosus. _%#NAME#%_ was started on Alprostadil (PGE1) at admission to keep his PDA open as it is needed for adequate systemic circulation. Cardiac evaluation, including an echocardiogram and cardiac consult was obtained immediately following delivery.
PDA|patent ductus arteriosus|PDA|181|183|FEN|_%#NAME#%_ had an echocardiogram on _%#MMDD#%_ due to possibility of starting ECMO. This ECHO revealed normal structure, good systolic function, interventricular septum flat, large PDA all right to left flow, normal pulmonary veins, PFO with bi-directional shunting, no coarctation and trivial TR. Problem #9: Screening Examinations/Immunizations. * PKU, galactosemia, hypothyroidism, hemoglobinopathy, adrenal hyperplasia screening was sent on _%#MMDD#%_ and the results were normal.
PDA|posterior descending artery|PDA|219|221|HISTORY OF PRESENT ILLNESS|4. Chronic renal failure. HISTORY OF PRESENT ILLNESS: A 56-year-old female with kidney disease and diabetes mellitus who was scheduled for staged percutaneous coronary intervention. She underwent direct stenting of the PDA with DES 2.5 x 18-mm Cypher, and mid LAD was also directly stented with DES Cypher 3.5 x 18 mm. A left radial approach was used due to difficulty in accessing the groin during diagnostic coronary angiography.
PDA|posterior descending artery|PDA|178|180|HISTORY OF PRESENT ILLNESS|He had a positive screening CT through the Cardiovascular Screening Center and was sent for catheterization. This revealed a 90% stenosis, a small PDA, and a high-grade LAD. The PDA was dilated but was too small to stent and the patient was sent to surgery for LAD bypass. The patient was brought to the OR for coronary artery bypass grafting X2.
PDA|posterior descending artery|PDA.|242|245|HISTORY|Left circumflex mildly occluded soft, plaque. Proximal right coronary artery mildly occluded with soft plaque, mid right coronary artery mildly occluded with mixed plaque.. Distal right coronary artery heavily calcified at bifurcation of the PDA. Stress study was completed which showed a markedly abnormal stress EKG. The echo portion of the stress study was suspicious, but non-diagnostic for inferior ischemic due to technically difficult imaging and late image acquisition.
PDA|posterior descending artery|PDA|119|121|OPERATIONS/PROCEDURES THIS ADMISSION|The ramus had 100% lesion. The RCA was subtotally occluded. The vein graft to the distal RCA was widely patent and the PDA as well as the PLA were without significant disease. The LIMA to the long first diagonal was patent. The distal diagonal had mild disease; however, the insertion site of the LIMA to the first diagonal had a 60% lesion.
PDA|posterior descending artery|PDA|205|207|HOSPITAL COURSE|BUN and creatinine were normal. Platelet count was normal. ALT and AST were within normal limits. HOSPITAL COURSE: The patient underwent coronary angiography which revealed patent grafts. The graft to the PDA was also patent. There was a 90% stenosis in the small _____ posterolateral branch at the origin. All of the graft of the PDA was patent because of the stenosis at the origin of the PLA, this vessel could be potential cause of his angina.
PDA|posterior descending artery|PDA|134|136|HISTORY OF PRESENT ILLNESS|The RCA has a proximal stent with a mild in-stent stenosis. The mid RCA has an 80% lesion and the the distal RCA is 95% occluded. The PDA gets some collateralization from the left circulation. The SVG to PDA is occluded. The left main and proximal circumflex were dilated over a balance wire with a 2.5 x 2.0 Voyager balloon.
PDA|patent ductus arteriosus|PDA|163|165|PLAN|Pharmacy will follow kidney function and gentamicin levels. Cardiovascular Surgery consultation will be necessary at some point. I expect a surgical repair of the PDA and subaortic membrane may be necessary after a full course of antibiotics has been performed and this infection has been cured.
PDA|posterior descending artery|PDA|133|135|HOSPITAL COURSE|Ejection fraction was listed at 20-25% with moderate MR. He went on to bypass surgery, this was an incomplete revascularization. The PDA and posterolateral branches were too small to bypass. He had an LIMA graft to the distal LAD, a vein graft to the proximal LAD, a vein graft to OM and a vein graft to the diagonal vessel, these were all separate grafts.
PDA|posterior descending artery|PDA.|220|223|HOSPITAL COURSE|On left ventriculography there was inferobasilar hypokinesis with a mildly depressed left ventricular systolic function. The ejection fraction was estimated to be 50%. The culprit lesion was thought to be a small distal PDA. It was felt to be about 80% narrowed. Given the location of this lesion and the size of the vessel, this was not felt to be amenable to percutaneous coronary intervention.
PDA|posterior descending artery|PDA,|151|154|PAST MEDICAL HISTORY|1. ASCVD with history of congestive heart failure, ejection fraction of 30%. A. Coronary artery by-pass grafting with three vessel LIMA to LAD, SCG to PDA, SCG to I. B. Hyperlipidemia on Whelcol. 2. DDDR secondary to AV block in _%#DDMM2001#%_. 3. Bicuspid aortic valve with aortic stenosis. 4. Barrett's esophagus with his most recent EGD showing no progression of disease.
PDA|posterior descending artery|PDA|110|112|PROCEDURES DONE|V1 proximal 70% stenosis. RCA proximally occluded. SVD to D.1. graft is known to be occluded. The RIMA to the PDA is patent. The LV gram showed the akinetic inferior wall with EF of 40%. They recommended optimum medical management, and no further revascularization process.
PDA|posterior descending artery|PDA.|188|191|DISPOSITION|Her last sodium was 136 and her last potassium was 3.9 on _%#DDMM2002#%_. 6. Cardiovascular- A cardiac echo on _%#MMDD#%_ showed normal cardiac anatomy with good LV and RV function and no PDA. 7. Ophthalmology- A retinal exam on _%#MMDD#%_ showed posterior zone 2, grade 2 retinopathy. A repeat exam was suggested for _%#MMDD#%_.
PDA|posterior descending artery|PDA;|273|276|PROCEDURES PERFORMED|2. Unstable angina. 3. Postpolio syndrome. 4. Atherosclerotic heart disease. PROCEDURES PERFORMED: Coronary artery bypass grafting x4, left internal mammary, side-to-side to the proximal LAD; left internal mammary end-to-side to the distal LAD; saphenous vein graft to the PDA; left radial artery to obtuse marginal #2. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 71-year-old patient admitted with acute coronary syndrome with exquisite tenderness associated with diaphoresis, shortness of breath, and had a troponin rise and was sent to the angiography suite.
PDA|posterior descending artery|PDA.|125|128|HOSPITAL  COURSE|Left circumflex had a severe proximal lesion of approximately 80 to 85% and the right coronary had a 30-40% narrowing in the PDA. The right coronary was occluded near its ostium. There was a large PDA and posterolateral branch and 30-40% narrowing in the PDA near the ostium and at least 70% narrowing in the posterolateral network.
PDA|posterior descending artery|PDA|197|199|HOSPITAL  COURSE|Left circumflex had a severe proximal lesion of approximately 80 to 85% and the right coronary had a 30-40% narrowing in the PDA. The right coronary was occluded near its ostium. There was a large PDA and posterolateral branch and 30-40% narrowing in the PDA near the ostium and at least 70% narrowing in the posterolateral network.
PDA|posterior descending artery|PDA,|193|196|PROCEDURE PERFORMED|ADMISSION DIAGNOSIS: Unstable angina. DISCHARGE DIAGNOSIS: Unstable angina. PROCEDURE PERFORMED: On _%#DDMM2005#%_ coronary bypass x3 off pump with LIMA to LAD, reverse saphenous vein graft to PDA, reverse saphenous vein graft to OM3. HOSPITAL COURSE: Postoperatively, _%#NAME#%_ _%#NAME#%_'s course was uneventful. He was initially in the ICU and was transferred to the floor.
PDA|posterior descending artery|PDA,|117|120|BRIEF HISTORY|2. CABG #2 done in 2005 at University of Minnesota Medical Center, Fairview, RIMA to free graft LAD, SVG to aorta to PDA, and SVG to D1/circumflex. 3. CABG #3 done in 2006 at _%#CITY#%_ _%#CITY#%_ which involved removal of LAD stents, radial free graft to the LAD, and an SVG to D1.
PDA|posterior descending artery|PDA.|246|249|PROCEDURE PERFORMED|An 8 French long sheath was used. Selective coronary angiography of the right coronary artery showed a severely calcific long lesion in the mid to distal right coronary artery. There was competitive flow distally from the vein graft to the right PDA. There was a 95% lesion in the ostial segment of the right posterolateral. Successful percutaneous intervention was performed to the mid to distal right coronary artery and right posterolateral branch.
PDA|posterior descending artery|PDA|284|286|HISTORY|While it is possible that the inferior wall was actually infarcted from the left PDA and that she had spasm of the LAD, we felt that the diffuse EKG changes were more supportive of Tako-Tsubo. It is conceivable that what happened was she developed Tako-Tsubo in the same chronic left PDA lesion and that with the left ventricle dilating, this increased wall stress and was causing intermittent angina from the left PDA.
PDA|posterior descending artery|PDA|257|259|HISTORY|It is conceivable that what happened was she developed Tako-Tsubo in the same chronic left PDA lesion and that with the left ventricle dilating, this increased wall stress and was causing intermittent angina from the left PDA. Dr. _%#NAME#%_ felt that this PDA vessel was rather small, and although it certainly could be angioplastied, it certainly would not explain her clinical syndrome.
PDA|posterior descending artery|PDA,|407|410|BRIEF SUMMARY OF HOSPITAL COURSE|3. A 2-D transthoracic echocardiogram performed on _%#DDMM2006#%_ showed an improved ejection fraction from previous on _%#DDMM2006#%_ to 35% to 40% with old posterior-inferior wall hypokinesia and mitral valve and aortic valve gradients at 12 and 22, respectively. BRIEF SUMMARY OF HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ is a 75-year-old gentleman with a history of CABG with LIMA to LAD, SVG to right PDA, who was referred for elective coronary angiography after presenting with chest discomfort on _%#DDMM2006#%_. His past medical history is also significant for severe mitral regurgitation and aortic stenosis for which the patient had an aortic valve replacement and mitral valve replacement during his CABG surgery in _%#DDMM2006#%_.
PDA|posterior descending artery|PDA|297|299|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: 1. Unstable angina pectoris. 2. Coronary artery disease, 30-40% proximal LAD, 60-70% ostial disease in the first diagonal branch, 20% disease in the circumflex, 20-50% diffuse disease on the entire right coronary artery with 50% stenosis in the PDA. A small sub branch of the PDA is totally occluded and this is the culprit lesion. 3. Viral gastroenteritis. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. q. day. 2. Plavix 75 mg p.o. q. day for one year as per the cure trial results.
PDA|posterior descending artery|PDA|208|210|HOSPITAL  COURSE|The right coronary artery was diffusely diseased with a 30-40% proximal stenosis with diffuse mid-vessel stenosis in the 20-30% stenosis range. There was a 60% stenosis just before the crux of the heart. The PDA and posterolateral branch arteries did not have significant disease but were mildly irregular. Left ventriculogram showed a moderate sized apical area of severe hypokinesis to akinesis with the remainder of the heart hyperdynamic and an ejection fraction estimated at 50%.
PDA|patent ductus arteriosus|PDA|200|202|IMPRESSION|The initial echocardiogram at your facility showed mild TI and MI, trivial AI, PFO, PDA and pulmonary Hypertension. A repeat echocardiogram done on _%#DDMM2007#%_ showed normal cardiac anatomy; small PDA with mostly right to left shunt at 2.4 m/s, mild tricuspid regurgitation, no PFO and good bi-ventricular function. Problem #4: Sepsis. We are treating _%#NAME#%_ with ampicillin, gentamicin and clindamycin.
PDA|patent ductus arteriosus|PDA|217|219|1. FEN|He was extubated on DOL 2 without difficulty. His respiratory status remained stable thereafter. 3. CV: A grade III/VI murmur was noted in the newborn nursery at Fairview Southdale, and an echo was done that showed a PDA (primarily left to right shunt), a small PFO (4 mm), and elevated RV pressure (36 mm Hg) consistent with mild pulmonary hypertension.
PDA|posterior descending artery|PDA.|399|402|PROCEDURES PERFORMED|4. Urinary tract infection. 5. Anemia. PROCEDURES PERFORMED: 1. Coronary angiography which revealed 30% proximal stenosis at the left main, proximal LAD occlusion with thrombus, circumflex with hazy midportion 70-80% lesion followed by distal portion before the OM branch significant stenosis (80%). OM2 was occluded. RCA had moderate disease in the midportion and moderate to severe disease in the PDA. The LAD was proximally stented, and the mid vessel was stented as well. The apical LAD had slow flow and the apical segment was dilated with a balloon with marginal improvement.
PDA|posterior descending artery|PDA,|258|261|PROCEDURE PERFORMED WHILE IN THE HOSPITAL|ADMISSION DIAGNOSES: 1. Congestive heart failure. 2. Diabetes. 3. Hypertension. 4. Hypercholesterolemia. 5. Obesity. PROCEDURE PERFORMED WHILE IN THE HOSPITAL: Coronary artery bypass grafting x 4, with left internal mammary to the LAD, left radial artery to PDA, sequential left saphenous vein end-to-side to obtuse marginal #2, with interposition graft at diagonal #1. BRIEF HISTORY: _%#NAME#%_ _%#NAME#%_ is a 72-year-old Caucasian male, a patient of Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_, who over the past ten years has had fleeting episodes of shortness of breath and easy fatigability.
PDA|patent ductus arteriosus|PDA|142|144|PAST MEDICAL HISTORY|2. Minor cardiac abnormalities on _%#MMDD#%_ echo: mild mitral insufficiency, mitral valve prolapse, small PFO with left to right flow, small PDA with left to right flow. Ejection fraction equal 62%, normal PA pressures. 3. History of oral candidiasis and diaper rash, treated with Diflucan.
PDA|patent ductus arteriosus|PDA.|187|190|DISCHARGE INSTRUCTIONS|She received 2 courses of Indomethacin. Cardiac ECHO on _%#MMDD#%_ confirmed persistence of PDA. Fluid restriction was continued, and cardiac ECHO on _%#MMDD#%_ showed persistence of the PDA. A surgical ligation was done on _%#MMDD#%_. 4. Neurological: _%#NAME#%_ received an initial two doses of Indocin for IVH prophylaxis.
PDA|posterior descending artery|PDA,|153|156|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. History of coronary artery disease, status post four-vessel CABG in _%#MM#%_ of 2003 (LIMA to LAD, saphenous vein grafts to OM, PDA, and posterior lateral artery.) History of aortic stenosis and mitral regurgitation. These had been documented at the time of CABG, however, right heart cath revealed a fairly well maintained cardiac output, and a wedge of 10 to 11, as well as an aortic valve area of 1.6 cm2, and transesophageal echo prior to CAB revealed only mild mitral regurgitation.
PDA|patent ductus arteriosus|PDA|315|317|PAST MEDICAL HISTORY|Patient will be discharged on ibuprofen 800 mg p.o. t.i.d. p.r.n. for his pain, hydrochlorothiazide 25 mg p.o. q.d., gatifloxacin 200 mg p.o. b.i.d. for 3 more days, Urocit-K 1080 mg p.o. t.i.d., and phenytoin 2 tablets p.o. b.i.d. PAST MEDICAL HISTORY: 1. History of seizures, on Dilantin currently. 2. History of PDA repaired as a newborn. 3. History of testicular torsion, status post surgical repair.
PDA|posterior descending artery|PDA|117|119|PROCEDURES PERFORMED|7. History of 1-vessel CAB in 1994 PROCEDURES PERFORMED: 1). Redo CABG x4 with LIMA to the LAD, vein grafts to OM-2, PDA and D1. 2). Mitral valve repair with 30 mm CG annuloplasty ring. Hospital Course: The patient underwent the above mentioned procedures by Dr. _%#NAME#%_.
PDA|posterior descending artery|PDA|307|309|PAST MEDICAL HISTORY|The patient denies any palpitations. The patient denies any acute blood loss. PAST MEDICAL HISTORY: 1. Ischemic heart disease with what appears to be an angiogram done at Minnesota Heart Clinic with a stent placed to one of his coronary arteries I belive the a prominent diagonal branch in _%#MM2005#%_ his PDA was distally occulded and RCA was 50 per stenosis.He was non specific with symptoms then as he is now. History of Plavix use for six months after coronary artery stent.
PDA|posterior descending artery|PDA|182|184|HOSPITAL COURSE|As noted above, this showed that his saphenous venous graft placed in 2001 to the OM was now occluded. However, the LIMA to the LAD and remaining saphenous venous graft to the right PDA were patent. An attempt was made to perform PCI in the native OM1 which was partially successful with balloon angioplasty.
PDA|posterior descending artery|PDA.|254|257||He has been consulted by Dr. _%#NAME#%_ _%#NAME#%_ for coronary artery disease, proceeded with coronary artery bypass grafting on _%#DDMM2006#%_ by Dr. _%#NAME#%_ _%#NAME#%_ with a LIMA to his LAD, saphenous vein graft to D1, saphenous vein graft to his PDA. He did need a right thigh Hemovac placed with endovein harvest on the left, he had a right open vein graft harvest on the right.
PDA|patent ductus arteriosus|PDA.|221|224|HOSPITAL COURSE|3. Cardiovascular. On day 2 of life, _%#NAME#%_ was noted to have a soft systolic murmur as well as an ejection click. Therefore, an echo was obtained. This echo showed normal valvular function. She did have a small 2 mm PDA. At the time of this dictation, the echocardiogram has been read by the tech only. The official dictation is pending the reading by the cardiologist.
PDA|patent ductus arteriosus|PDA|233|235|HOSPITAL COURSE|She did have a small 2 mm PDA. At the time of this dictation, the echocardiogram has been read by the tech only. The official dictation is pending the reading by the cardiologist. I did ask the neonatology on service about this size PDA and he felt that it would, in all likelihood, close. In the future, we will continue to listen for murmurs at her weight check and her 2 week well child visit.
PDA|posterior descending artery|PDA,|234|237|SUMMARY OF HOSPITAL COURSE|Otherwise medical history is negative. Dr. _%#NAME#%_ _%#NAME#%_ was consulted and patient underwent coronary artery bypass graft on _%#DDMM2007#%_ by Dr. _%#NAME#%_ _%#NAME#%_with CAB x4, LIMA to his LAD, saphenous vein graft to his PDA, posterolateral right and OM1. The patient tolerated the procedure well and went to the ICU. Postop course was uneventful. The patient was then discharged on _%#DDMM2007#%_ to his home with instructions for incisional care, sternal precautions given, and to have follow-up with Dr. _%#NAME#%_ in 2 to 3 weeks, Dr. _%#NAME#%_ in one week and Dr. _%#NAME#%_ _%#NAME#%_ at Minnesota Heart Clinic in 2-3 months.
PDA|patent ductus arteriosus|PDA|188|190|DISCHARGE FOLLOW-UP|She was born prematurely, and although she was getting along well, she had a large patent ductus arteriosis which was causing significant difficulties in her management. Because her large PDA was complicating the efforts to have her gain satisfactory weight as well as for potential long term consequences, closure was recommended.
PDA|patent ductus arteriosus|PDA|304|306|DISCHARGE FOLLOW-UP|Because her large PDA was complicating the efforts to have her gain satisfactory weight as well as for potential long term consequences, closure was recommended. The medical approach failed and an attempt was made to close it surgically at _%#CITY#%_ _%#CITY#%_'s Children's Hospital. Unfortunately, the PDA could not be located and closed at that operation. Because the PDA persisted as a large structure, transferred to University of Minnesota Children's Hospital was recommended.
PDA|posterior descending artery|PDA|172|174|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Coronary artery disease. Status post coronary artery bypass graft of the LIMA to LAD, saphenous vein graft to OM and a saphenous vein graft to the PDA in 1993. Again, he had multiple interventions done in _%#MM#%_ of 2004 which included placement of a drug alluding stent to the native RCA as well as a saphenous vein graft to the PA.
PDA|posterior descending artery|PDA.|259|262|HISTORY OF PRESENT ILLNESS|His coronary angiogram revealed 70% OM1 stenosis, otherwise mild disease in the circumflex, the LAD has only mild disease and a normal left main but his RCA was found to have 99% proximal stenosis and 85% distal stenosis with left to right collaterals to the PDA. He underwent successful PCI with RCA with three Cypher stents and was monitored overnight. His OM1 was not intervened upon and may be considered if his symptoms really did not resolve.
PDA|posterior descending artery|PDA,|150|153|HOSPITAL COURSE AND TREATMENT GIVEN|His end diastolic pressure was 23. It was recommended that the patient undergo multivessel coronary artery bypass, probably to his LAD, diagonal, OM, PDA, and PLA. Consultation was had with Dr. _%#NAME#%_ _%#NAME#%_, who concurred with Dr. _%#NAME#%_'s recommendation that the patient be a candidate for revascularization.
PDA|posterior descending artery|PDA.|102|105||Apparently his first myocardial infarction was in 2000 at which time he had a NIR stent placed to his PDA. In 2003 he had two Cypher stents placed in his midcircumflex coronary artery. The patient states he has recently become much more engaged in his care in the last two weeks with Dr. _%#NAME#%_ _%#NAME#%_ who is doing full court press on his diabetes.
PDA|posterior descending artery|PDA|132|134|PAST MEDICAL HISTORY|He had a PTCA x 3, in 1997 and 1999, and on _%#DDMM2003#%_, with a 15 x 3 mm stent placed in the SVG to OM-1 graft. The RIMA to the PDA and the LIMA to the LAD were wide open, but there was some stenosis of the native LAD beyond the anastomosis of the LIMA.
PDA|patent ductus arteriosus|PDA|262|264|DOB|For her feedings, she initially had a UVC line in place and received TPN, but at the time of the transfer back to Fairview Ridges Hospital, she was receiving nasogastric tube feedings with breast milk supplemented with formula to increase calories. She also had PDA for which she received two courses of indomethacin, and the PDA had resolved. She did have a small muscular VSD at the time of her return back to Ridges.
PDA|posterior descending artery|PDA,|136|139|DOB|Initial feedings were gavage feedings through NG tube. 3. Sepsis was ruled out at Fairview University Hospital. 4. She did have a small PDA, but did not have any run off and remained in compensated stage. 5. Hyperbilirubinemia, which was physiologic and secondary to prematurity, for which she was under phototherapy.
PDA|posterior descending artery|PDA|170|172|TESTS AND PROCEDURES|TESTS AND PROCEDURES: The patient had angiography that showed a co-dominant system with two-vessel coronary artery disease; the RCA was occluded at the ostium. The right PDA fed by collaterals from the LAD. The left main had 40% stenosis, and the circumflex had only mild atherosclerotic disease.
PDA|posterior descending artery|PDA|145|147|HOSPITAL COURSE|At that time he had a left internal mammary artery to his LAD and endarterectomy with his right coronary artery with saphenous vein graft to his PDA segment of the right coronary artery. The patient awoke soon after his operation, did well in the Intensive Care Unit and was transferred to the floor on the first postoperative day.
PDA|posterior descending artery|PDA.|192|195|OPERATIONS/PROCEDURES PERFORMED|2. Cardiac catheterization dated _%#MM#%_ _%#DD#%_, 2004, demonstrated single vessel coronary artery disease that was physiologically insignificant. This involved a 60% narrowing in the right PDA. There was mild diffuse disease involving all vessels. HISTORY OF PRESENT ILLNESS: The patient is a 42-year-old healthy male who presented to the emergency department with chest pain of 1 day's duration.
PDA|posterior descending artery|PDA|129|131|HOSPITAL COURSE|Up to 90% mid right coronary artery stenosis was noted, followed by a long area of diffuse disease with narrowing of 30-40%. The PDA was noted to be normal. Angioplasty was therefore subsequently attempted, but was unsuccessful.
PDA|posterior descending artery|PDA.|160|163|HOSPITAL COURSE|Dr. _%#NAME#%_ performed angioplasty of the mid circumflex with a 3.5 x 16 Taxus stent with good residual. There was a persistent cutoff, he notes, of the left PDA. LVEDP of 23. Left ventricular ejection fraction of 45%. The patient did well following the procedure with decreasing troponins, his peak troponin was elevated at 21.5. Lipid profile showed an LDL cholesterol of 67.
PDA|posterior descending artery|PDA|181|183|IMPRESSION|IMPRESSION: 1. Suspected but not proven unstable angina. 2. Coronary artery disease. 3. Previous five-vessel bypass as noted above with bypass to LAD, diagonal, OMI, OM, and distal PDA of RCA. 4. Diminished LV function in the past. EF of 40%. 5. Systolic apical murmur. 6. Coronary artery disease. PLAN: As above.
PDA|posterior descending artery|PDA|119|121|PLAN|He was again treated with indocin starting on day 15 of life. Cardiac ECHO done on _%#DDMM2002#%_ still shows a "small PDA with no evidence of run off in the abdominal aorta". 6. Intraventricular hemorrhage: Head ultrasound done on _%#DDMM2002#%_ was normal, no change noted on the _%#DDMM2002#%_ one month follow-up.
PDA|patent ductus arteriosus|PDA|170|172|DISCHARGE FOLLOW UP|7. Retinopathy of prematurity: Examination done on _%#DDMM2002#%_ was normal. No ROP noted. Vascularization to zone 3. Recheck in 6 weeks. 8. Patent Ductus arteriosus: A PDA murmur was heard and diagnosis confirmed by echocardiogram on _%#DDMM2002#%_. _%#NAME#%_ received a course of indocin. On _%#DDMM2002#%_ _%#NAME#%_'s murmur recurred and echocardiogram again confirmed a PDA, a second indocin course was given.
PDA|patent ductus arteriosus|PDA,|238|241|DISCHARGE FOLLOW UP|8. Patent Ductus arteriosus: A PDA murmur was heard and diagnosis confirmed by echocardiogram on _%#DDMM2002#%_. _%#NAME#%_ received a course of indocin. On _%#DDMM2002#%_ _%#NAME#%_'s murmur recurred and echocardiogram again confirmed a PDA, a second indocin course was given. A murmur persisted in the absence of PDA symptoms and is now intermittent best heard peripherally.
PDA|posterior descending artery|PDA|213|215|CHIEF COMPLAINT/REASON FOR ADMISSION|CHIEF COMPLAINT/REASON FOR ADMISSION: A 4-1/2-month- old female with Down syndrome presents to the pediatric ICU status post repair of a complete balanced AV canal and resection of subpulmonary muscle bundles and PDA ligation and PFO closure. Bypass time 2 hours 54 minutes. Cross-clamp time 2 hours 28 minutes.
PDA|posterior descending artery|PDA,|235|238|HOSPITAL COURSE|This was performed on _%#DDMM2004#%_. This showed a patent internal mammary artery to the LAD, a patent saphenous vein graft to the diagonal artery, and a patent radial graft to the RCA. However, there was a moderate lesion in the mid PDA, which the patient underwent successful stenting of this artery. Remaining vessels showed a completely occluded native right coronary artery.
PDA|posterior descending artery|PDA|196|198|DISCHARGE PLAN|He had no ventricular tachycardia during this admission. He will need to be watched very closely for congestive heart failure. He may also need to come back at a later time for angioplasty of his PDA vessel but I would not do it when he is only metastable at this point. 3. The patient was encouraged to stop smoking which he has now done on this admission.
PDA|posterior descending artery|PDA,|130|133|ASSESSMENT|Ischemia would be the most likely cause of this, though he did have an angiogram done. His angiogram did show 60% stenosis in the PDA, ramus 75 to 80% stenosis, and this may be the reason for the chest pain and signs of pulmonary edema. 2. History of hypertension fairly well controlled. 3. Hyperlipidemia. Continue on Zetia.
PDA|posterior descending artery|PDA.|169|172|PAST MEDICAL HISTORY|1. Coronary artery disease as described above with a coronary artery bypass graft times three with a LIMA to the LAD and saphenous vein graft to the obtuse marginal and PDA. 2. Hyperlipidemia. 3. Obesity. 4. Hypertension. 5. Previous inferior wall MI and V-fib arrest. 6. Right bundle branch block. 7. Borderline hypertensive. 8. History of tobacco abuse, however, patient still smokes a rare cigar two to three times a year.
PDA|patent ductus arteriosus|PDA|200|202|DISCHARGE FOLLOW-UP|Problem #3: Cardiovascular. _%#NAME#%_ had an echocardiogram on _%#MMDD#%_ due to a 2/6 systolic murmur and focal echogenicity on prenatal ultrasound which was normal. Findings included a PFO, a tiny PDA with left to right shunt, tiny echogenic foci within normal limits. Problem #4: Neurologic. _%#NAME#%_ had an ultrasound _%#MMDD#%_ that showed bilateral choroid cysts, but a repeat ultrasound _%#MMDD#%_ did not reveal choroid cysts.
PDA|posterior descending artery|PDA|278|280|LABORATORY|BUN and creatinine were normal. Cardiac catheterization - This was a complicated procedure with right coronary artery dominant vessel with a proximal dissection and a visible luminal thrombus with TIMI 3 flow to the distal vessel on initial injection. Complete occlusion of the PDA with an intraluminal filling defect was noted. Posterolateral branch was also thought to be occluded. EF was 50% with moderate inferior hypokinesis.
PDA|posterior descending artery|PDA,|231|234|OPERATIONS/PROCEDURES PERFORMED|DISCHARGE DIAGNOSIS: Status post coronary angiogram. OPERATIONS/PROCEDURES PERFORMED: Coronary angiogram was performed on _%#MM#%_ _%#DD#%_, 2005, which showed native 3-vessel coronary artery disease. It showed patent SVG to right PDA, SVG to mid LAD and OM1, LIMA to distal LAD. Unsuccessful PCI of LIMA to LAD due to inability to see the guiding catheter.
PDA|posterior descending artery|PDA|353|355|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Coronary artery disease with recent stress echocardiogram showing wall motion abnormality in the right coronary artery distribution with dilatation of the left ventricle. 2. Coronary angiogram revealing 100% occlusion of the right coronary artery with collateral flow from the LAD and a likely significant lesion proximal to the PDA branch; 100% occlusion of the mid-circumflex which was successfully angioplastied and stented with a 2.75 X 32 mm Taxus drug-eluting stent. Ongoing OM lesions of 20%, 15% lesion in the proximal LAD that is calcified with a distal LAD of 35%, ejection fraction approximately 40% by LV gram with severe hypokinesis in the inferior wall.
PDA|posterior descending artery|PDA|206|208|DOB|There was concern for significant coronary artery disease and the possibility of acute coronary syndrome and he underwent an urgent angiogram. This showed 20 to 30% LAD circumflex and RCA lesions and a 50% PDA lesion. His ejection fraction is 65%. There was some suggestion that he might have apical hypertrophic cardiomyopathy and so he also underwent a transthoracic echocardiogram.
PDA|posterior descending artery|PDA.|159|162||On _%#DDMM2007#%_ she underwent a 3 vessel coronary artery bypass graft with a LIMA to her LAD, saphenous vein graft to the ramus, saphenous vein graft to her PDA. She was very slow to awaken from anesthetic. Mrs. _%#NAME#%_ has a significant history for osteoporosis with severe back pain and has undergone a coronary workup in preparation for extensive back surgery.
PDA|patent ductus arteriosus|PDA,|162|165|DISCHARGE MEDICATIONS|Problem #2: Cardiovascular. _%#NAME#%_ had an echocardiogram on _%#DDMM2007#%_ due to a systolic soft, grade II/VI murmur. Results of the ECHO are as follows: No PDA, small PFO with left to right flow, normal anatomy and function. Problem #3: Hyperbilirubinemia. _%#NAME#%_'s blood type is O positive. Maternal blood type is O positive.
PDA|posterior descending artery|PDA,|195|198|PROCEDURES PERFORMED|5. History of sleep apnea. PROCEDURES PERFORMED: On _%#DDMM2007#%_ the patient underwent coronary artery bypass grafting x3 with a LIMA to D2, saphenous vein graft to RI, saphenous vein graft to PDA, by Dr. _%#NAME#%_ _%#NAME#%_ surgeon. BRIEF HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 57-year-old male with a past medical history significant for ischemic cardiomyopathy, referred to surgical evaluation by Dr. _%#NAME#%_ _%#NAME#%_.
PDA|posterior descending artery|PDA|300|302|HOSPITAL COURSE|He ruled out for a myocardial infarction. The decision was made to proceed with coronary angiography which demonstrated a high grade stenosis within the mid right coronary artery of 95%. There was competitive flow distally with evidence of contralateral collaterals. The patient also had mild distal PDA stenosis at 30-40%, PLA stenosis of 30%, and 20% proximal LAD stenosis, 30% proximal circumflex artery stenosis with a 60% stenosis before the first obtuse marginal.
PDA|posterior descending artery|PDA|366|368|PROCEDURES DONE DURING THIS ADMISSION|2. Heart cath dated _%#DDMM2004#%_ showing severe multivessel CAD with a very tight LAD stenosis after the first diagonal, as well as a tight stenosis after the second diagonal and diffuse disease along the entire length both first and second diagonals have severe disease. Circumflex is subtotally occluded. RCA has a 95% proximal stenosis, as well as a 99 and 95% PDA stenosis, severe left ventricular dysfunction, systolic hypertension with elevated end diastolic pressure. The patient is not a candidate for surgery due to multiple underlying medical issues.
PDA|posterior descending artery|PDA.|185|188|PROCEDURES PERFORMED WHILE IN HOSPITAL|1. Coronary artery bypass x 4 with left internal mammary to the LAD. 2. Saphenous vein graft to diagonal #1. 3. Left radial artery to obtuse marginal #2. 4. Saphenous vein graft to the PDA. BRIEF HISTORY: _%#NAME#%_ _%#NAME#%_ is a 73-year-old woman from the Wyoming area who was admitted for chest pain, which was continuous over the past four to five days.
PDA|posterior descending artery|PDA|147|149|DISCHARGE DIAGNOSES|5. Patent saphenous vein graft to the posterolateral and posterior descending arteries by sequential graft with at most 50% disease present in the PDA and mild disease in the posterolateral artery. LIMA to the LAD, but also radial graft arises from the mid portion of the LIMA and goes to the diagonal and this is patent.
PDA|posterior descending artery|PDA|118|120|PHYSICAL EXAMINATION|The RCA has proximal stent with good flow. The obtuse marginal too, had 50% lesion. The PLA has 75% to 90% occlusion. PDA has moderately diffused irregularities. The patient had angioplasty to D1 with a stent placed. The patient's hemoglobin was low, so she was given a blood transfusion, and subsequently was discharged home.
PDA|posterior descending artery|PDA|201|203|PAST MEDICAL HISTORY|1. Coronary artery disease, with history of 4-vessel bypass surgery in 1997 with a left internal mammary to the LAD, saphenous vein graft to obtuse marginal, to circumflex, and saphenous vein graft to PDA and the left ventricular branch arteries. Patient also had proximal LAD intracoronary stenting in _%#MM#%_ 2004 for unstable angina and shortness of breath.
PDA|posterior descending artery|PDA|249|251|HISTORY OF PRESENT ILLNESS|His troponin initially was elevated up to 0.64. He was sent for coronary angiography which revealed severe stenosis in his right coronary artery, which was the dominant vessel. Two Cypher stents were placed in the right coronary artery. The PLA and PDA were free of significant disease. The left coronary system had only mild disease. He had a large inferoposterior wall motion abnormality on his left ventriculogram with ejection fraction 40 to 45%.
PDA|posterior descending artery|PDA|161|163|PROCEDURES PERFORMED|The OM1 was occluded proximally. The OM2 was filled by the SVG which had no significant stenosis. Patent LIMA to LAD with no significant stenosis. Patent SVG to PDA with mild 30% to 40% distal disease. Patent SVG Y-graft to OM2 and D1 with severe stenosis of the distal D1 graft.
PDA|posterior descending artery|PDA|152|154|PROCEDURES PERFORMED|Coronary angiography revealed a mid LAD lesion of 80%, 50% proximal right coronary artery lesion, 10% distal right coronary artery lesion, 40% proximal PDA lesion. The patient underwent a mid LAD lesion stent with the proximal portion being dilated. There were no complications. ADMISSION MEDICATIONS: 1. Toprol XL 50 mg p.o. q.d.
PDA|patent ductus arteriosus|PDA|289|291|SUMMARY OF HOSPITAL COURSE|Problem #3: Cardiovascular. _%#NAME#%_ had an echocardiogram on _%#DDMM2007#%_ which revealed severe pulmonary hypertension, mild tricuspid regurgitation and a small patent ductus arteriosus. An alprostadil drip was started on _%#DDMM2007#%_ to allow increased R->L blood flow through the PDA given very high pulmonary artery pressures. Extracorporeal membrane oxygenation (ECMO) was contemplated. A repeat echocardiogram on _%#DDMM2007#%_ showed slight improvement in the pulmonary hypertension and a widely patent ductus arteriosus with bidirectional flow.
PDA|patent ductus arteriosus|PDA|209|211|SUMMARY OF HOSPITAL COURSE|His weight at the time of discharge was 2930 gm (20%). Problem #2: Cardiovascular. _%#NAME#%_ had an echocardiogram on _%#DDMM2007#%_ due to Trisomy 21, which revealed a tiny muscular VSD (L to R shunt), tiny PDA (L to R shunt), 2+ tricuspid regurgitation with right ventricular systolic pressure of 33mmHg and good function. This murmur had resolved at the time of discharge. Cardiology would like to see _%#NAME#%_ for a follow-up in one to two months and will not need an echocardiogram before the visit.
PDA|patent ductus arteriosus|PDA.|197|200|DIAGNOSES DURING HOSPITALIZATION INCLUDE|2. Respiratory distress syndrome. 3. Apnea of prematurity. 4. Anemia of prematurity. 5. Possible necrotizing enterocolitis grade I. 6. Poor feeding. 7. Hyponatremia, resolved. 8. VSD, resolved. 9. PDA. PROCEDURES DONE DURING THIS HOSPITALIZATION: Transfusion on _%#MM#%_ _%#DD#%_ and _%#MM#%_ _%#DD#%_.
PDA|patent ductus arteriosus|PDA,|262|265|SIGNIFICANT LABORATORY DURING HOSPITALIZATION|Hemoglobin 7.2 and hematocrit of 21.8 prior to transfusion on _%#MM#%_ _%#DD#%_ and subsequently 12 and 33.9. Results of echocardiogram done on _%#MM#%_ _%#DD#%_ showed small muscular VSD and a small PDA. Repeat echocardiogram on _%#MM#%_ _%#DD#%_ showed a tiny PDA, small PFO, otherwise normal. HOSPITAL COURSE: This patient was transferred to Fairview Ridges Hospital at approximately 10 days' of age with resolving respiratory distress syndrome in a very premature infant.
PDA|patent ductus arteriosus|PDA|172|174|1. FEN|Initial heart echo showed a small PDA, a small PFO and Pulmonary hypertension. Blood pressures and heart rate have been stable since extubation. A repeat echo showed small PDA vs ASD. 4. ID: _%#NAME#%_ was born to mother with prolonged rupture of membranes and chorioamnionitis.
PDA|posterior descending artery|PDA,|222|225|HOSPITALIZATION|At the time of angiography, the patient had PTCA and placement of a 2.5 x 18 Cypher drug-eluting stent in the LAD. There was some slow flow afterwards. Given his renal insufficiency and the small territory supplied by the PDA, we elected not to intervene on the 70% PDA lesion. In the recovery, the patient did well. He had a slight increase in his creatinine of 2 from a baseline of 1.8. He denied any shortness of breath or chest pain on the date of discharge.
PDA|posterior descending artery|PDA|173|175|HISTORY OF PRESENT ILLNESS|Additionally, there was an 80% OM2 lesion as well as total occlusion of the proximal right coronary artery. There was some filling from the left to right collaterals of the PDA and PLA. The left main coronary artery had moderate disease estimated to be 50% by angiography. Finally, there was also distal stenosis noted at the bifurcation of the PDA and RPLA of approximately 75% to 90%.
PDA|posterior descending artery|PDA.|195|198|PROCEDURES PERFORMED|D1 small in caliber at 1.5 to 1.7 mm and not ideal for revascularization. Distal LAD with minimal disease. Ramus small and minimal disease. Left circumflex with a large bifurcating OM and a left PDA. There was diffuse 40% disease in the left PDA and 70% disease in the small branch of the left PLA. Left ventriculogram showed an EF of 52% with mild apical hypokinesis.
PDA|posterior descending artery|PDA|126|128|DISCHARGE MEDICATIONS|2. Lisinopril 20 mg daily. This is an increased dose from 10 mg . 3. Imdur 30 mg one PO daily. This is for the lesions in the PDA which were unable to be intervened upon. 4. Plavix 75 mg one PO daily for nine months. This is also a new medication. 5. Glucophage will be held for two days and the patient will contact her primary care physician in regards to re-starting this medication.
PDA|patent ductus arteriosus|PDA.|191|194|HOSPITAL COURSE|The results of that echo are as follows, "Normal cardiac anatomy. Good left ventricular and right ventricular size and function. Right echogenic 'dot' on ventricular septum. Normal valve. No PDA. Small PFO, left to right. PICC line in the RA and RV." _%#NAME#%_ will have a follow-up visit with a cardiologist for a repeat echo at 6 months of age.
PDA|patent ductus arteriosus|PDA|196|198|HOSPITAL COURSE|A cardiac consult was obtained. Stone was hemodynamically stable initially and required no respiratory or cardiovascular support. Repeat echocardiogram performed on _%#DDMM2006#%_ showed that the PDA had closed. As pulmonary vascular resistance dropped, Stone remained stable. At the time of transfer his oxygen saturations was > 97% on room air.
PDA|posterior descending artery|PDA|148|150|PROCEDURES PERFORMED DURING THIS HOSPITAL STAY|PROCEDURES PERFORMED DURING THIS HOSPITAL STAY: 1. On _%#DDMM2007#%_, balloon atrial septostomy followed by a cutting balloon atrial septostomy and PDA dilatation. 2. On _%#DDMM2007#%_, arterial switch operation. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a newborn infant who was diagnosed with detransposition of the great vessels and was transferred here from _%#CITY#%_ _%#CITY#%_ Children's for an arterial switch operation.
PDA|posterior descending artery|PDA|394|396|CARDIAC RISK FACTORS|I am uncertain about the procedures, but it is clear from the note of Dr. _%#NAME#%_ _%#NAME#%_ who performed the coronary angiogram on the patient in 2002, that the patient had at that time completely occluded proximal LAD of his right patent LIMA graft, completely occluded proximal RCA with occluded SVG graft to this vessel with right to right collaterals and some collateralization to the PDA artery from the distal circumflex. His circumflex itself was patent, but a large OM branch was occluded and SVG graft to this vessel was also occluded.
PDA|patent ductus arteriosus|PDA|380|382|PAST MEDICAL HISTORY|On admission to the emergency department, her vital signs were blood pressure 107/69, respiratory rate of 24, pulse of 69, temperature of 103.2, and her chest x-ray showed a "right lower lobe pneumonia." She was subsequently admitted to the intensive care unit for therapy for her pneumonia and evaluation for her fever. PAST MEDICAL HISTORY: 1. Tetralogy of Fallot repaired with PDA ligation at 2 months. 2. Duodenal atresia status post repair. 3. Chronic aspiration tracheomegaly. 4. Status post jejunostomy tube placement. 5. Esophageal atresia with stretching procedure on _%#MM#%_ _%#DD#%_, 2003, and _%#MM#%_ _%#DD#%_, 2003, with a split fistula placed.
PDA|patent ductus arteriosus|PDA|149|151|PAST MEDICAL HISTORY|She is followed by Dr. _%#NAME#%_ and has home oxygen, usually needing 1/8 liter by nasal cannula. Her goal saturations are over 92%. 2. Status post PDA ligation _%#DDMM2003#%_. 3. Pseudomonas tracheitis. 4. Retinopathy of prematurity early zone 2, stage 2, resolving per mother. 5. Patent foramen ovale found on echo _%#DDMM2003#%_. No follow-up echo performed.
PDA|patent ductus arteriosus|PDA|194|196|F-UMC PICU|5. NPO while awaiting surgical repair. 6. Interpretation of renal and cranial ultrasounds pending. Transfer medications, treatments and special equipment: 1. Prostin 0.05 mcg/kg/min to maintain PDA patency. 2. Caffeine Citrate 25 mg every 24 hours (6 mg/kg/day) for apnea prevention while on Prostin drip. Discharge measurements: Weight 3890 gms; length 53 cm; OFC 34 cm.
PDA|posterior descending artery|PDA|212|214|HOSPITAL COURSE|It was felt that although his pain had resolved, his ST segment changes had not and Dr. _%#NAME#%_ recommended emergent cath lab therapy, which was accomplished quickly. He was found to have a thrombotic 90% mid PDA lesion as well as some moderate disease elsewhere within the coronary tree. Dr. _%#NAME#%_ repaired the PDA with a PTCA alone. The proximal vessel was too tortuous to pass a stent and the vessel was relatively small.
PDA|posterior descending artery|PDA,|165|168|HOSPITAL COURSE|HOSPITAL COURSE: The patient underwent a coronary artery bypass procedure with a redo sternotomy. Grafting sequence was LIMA to the LAD, saphenous vein graft to the PDA, saphenous vein graft to the ramus intermedius. She awakened postoperatively, was extubated, and basically within a day went into respiratory failure requiring intubation.
PDA|posterior descending artery|PDA|230|232|PROCEDURE PERFORMED|There is only mild disease in the first diagonal. The left circumflexed coronary artery reveals diffuse but only mild irregularities. The RC is dominant with 25% mid lesion and 90% narrowing at its bifurcation involving the right PDA and right PLA. Successful percutaneous intervention was performed to the distal right coronary artery and AV segment groove as well as the proximal right PDA.
PDA|patent ductus arteriosus|PDA.|215|218|ASSESSMENT/PLAN|The echocardiogram done on _%#DDMM2006#%_ was significant for a bicuspid Aortic valve, coarctation of the aorta, and a wide PDA. It was decided to start Christian on PGE1 in an effort to maintain the patency of his PDA. This was started at a dose of 0.05 mcg/kg/min. Cardiology was notified of Christian's situation and will be scheduling him for a corrective surgery for his coarctation of the aorta.
PDA|patent ductus arteriosus|PDA,|177|180|FOLLOWUP|At the time of discharge he was in no respiratory distress. Problem #3: Patent Ductus Arteriosus (PDA). Physical examination on _%#DDMM2006#%_ revealed a murmur consistent with PDA, which was confirmed by echocardiogram. Treatment included fluid restriction and two doses of indomethacin. The third dose of indomethacin was held due to elevated creatinine and oliguria.
PDA|posterior descending artery|PDA.|135|138|HISTORY OF PRESENT ILLNESS|His left circumflex was found to be not significantly diseased, but his right coronary artery gives rise to a severely diseased osteal PDA. An additional mid PDA lesion was documented. He underwent successful PCI in drug-eluting stent placement x2 of his osteal mid PDA, _%#DDMM2007#%_.
PDA|patent ductus arteriosus|PDA|136|138|PAST MEDICAL HISTORY|Another echocardiogram at 10 days of age showed the PDA to be virtually closed. An echocardiogram done on _%#DDMM2006#%_ showed a small PDA and an echocardiogram done on _%#DDMM2007#%_ at _%#CITY#%_ _%#CITY#%_ Hospital showed a wide open PDA. The patient also has a history of poor weight gain.
PDA|patent ductus arteriosus|PDA.|158|161|PAST MEDICAL HISTORY|An echocardiogram done on _%#DDMM2006#%_ showed a small PDA and an echocardiogram done on _%#DDMM2007#%_ at _%#CITY#%_ _%#CITY#%_ Hospital showed a wide open PDA. The patient also has a history of poor weight gain. There is a questionable history of tracheomalacia. The patient does breath noisily depending on her positioning.
PDA|patent ductus arteriosus|PDA.|140|143|HOSPITAL COURSE|3. Pulmonary. The patient has a history of pneumonia with persistent oxygen needs. This is possibly due to pulmonary edema secondary to her PDA. The patient may also have tracheomalacia. She is to follow up with her pulmonologist in _%#CITY#%_ _%#CITY#%_ scheduled for _%#DDMM2007#%_, so no pulmonary consult was obtained while she was in the hospital.
PDA|posterior descending artery|PDA.|359|362|HISTORY AND HOSPITAL COURSE|The patient underwent bypass surgery as well as aortic valve replacement surgery on _%#DDMM2007#%_. At that time the patient had a 25 mm porcine Medtronic aortic valve replaced with bypass surgery consisting of an IMA to the LAD as well as individual saphenous vein bypass graft to the first obtuse marginal artery, the second obtuse marginal artery, and the PDA. Postoperatively, the patient did develop a period of atrial fibrillation for which amiodarone and beta blocker was started.
PDA|patent ductus arteriosus|PDA|179|181|PROBLEM #1|No recent fevers, cough, congestion or shortness of breath. He had been feeding well. HOSPITAL COURSE: PROBLEM #1: Patent ductus arteriosis. _%#NAME#%_ was admitted following the PDA closure via heart cath to evaluate for evidence of bleeding. A repeat hemoglobin following admission demonstrated a stable hemoglobin of 10.3. Additionally, he got a significant load of IV contrast during the procedure nearing 7 mL/kilo.
PDA|patent ductus arteriosus|PDA|250|252|FOLLOWUP|Her last chest x-ray on _%#DDMM2007#%_ showed borderline cardiomegaly, but was otherwise normal. Problem #3: Cardiovascular. Because of a murmur that was heard intermittently, _%#NAME#%_ had an echocardiogram on _%#DDMM2007#%_ which revealed a small PDA with minimal left to right shunting, a small patent foramen ovale with minimal shunting, and multiple small mid-muscular and apical-muscular defects in the ventricular septum.
PDA|posterior descending artery|PDA.|190|193|IMPORTANT TESTS AND IMAGING PERFORMED DURING ADMISSION|There is a ramus intermedius with an 80% stenosis. The LAD has 80% stenosis in its mid segment after D1 which is 100% occluded. There are left-to-right collaterals to the acute marginal and PDA. The estimated EF is 40%. b. The right heart hemodynamics of obtained during catheterization were RA pressure 5 mmHg, PA 25/11 with a mean of 18, pulmonary artery wedge pressure of 14 mmHg and Fick cardiac index was 1.6 L/minute/m2.
PDA|patent ductus arteriosus|PDA|87|89|OPERATIONS/PROCEDURES PERFORMED|OPERATIONS/PROCEDURES PERFORMED: 1. Cardiac catheterization for placement of Amplatzer PDA occluder, _%#MM#%_ _%#DD#%_, 2004. 2. Surgical removal of PDA occluder and ligation of ductus, _%#MM#%_ _%#DD#%_, 2004. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 9-month-old infant with a patent ductus arteriosus.
PDA|patent ductus arteriosus|PDA|198|200|HOSPITAL COURSE|HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 9-month-old infant with a patent ductus arteriosus. She went to the catheterization laboratory on _%#MM#%_ 2004, for a catheter placement of an Amplatzer PDA occluder. The occluder cut loose and ended up in the left pulmonary artery, and after multiple attempts to extract it, they were unable to remove it from the left pulmonary artery.
PDA|posterior descending artery|(PDA)|239|243|HOSPITAL COURSE|He was also noted to have a significant lesion in a small first diagonal (D1) which was felt to be too small for percutaneous intervention unless it was causing severe symptoms. There is moderate disease in the posterior descending artery (PDA) and modest-sized second diagonal (D2). Ejection fraction was normal at 55% with an inferior hypokinesis. He had an uncomplicated postoperative course and was discharged in stable condition.
PDA|posterior descending artery|PDA|160|162|OPERATIONS/PROCEDURES PERFORMED|The RCA has mild proximal disease. The mid vessel has 75% stenosis. The distal vessel has moderate stenosis. There is an early take- off PDA supplying a distal PDA territory and the smaller PDA supplying a proximal territory. Just distal to the PDA take-off the ostia of PLA is 100% occluded and fills the collaterals.
PDA|posterior descending artery|PDA|177|179|OPERATIONS/PROCEDURES PERFORMED|The distal vessel has moderate stenosis. There is an early take- off PDA supplying a distal PDA territory and the smaller PDA supplying a proximal territory. Just distal to the PDA take-off the ostia of PLA is 100% occluded and fills the collaterals. The LIMA to LAD graft is widely patent, fills the mid and distal LAD and diagonals.
PDA|posterior descending artery|PDA.|120|123|SUBJECTIVE|Regarding 3-vessel CAGB, the patient had bypass of LIMA to LAD, saphenous vein graft to OM1 and saphenous vein graft to PDA. On most recent cath of _%#DDMM2003#%_ the patient is noted to have no occlusion of LIMA to LAD, no occlusion of saphenous vein graft to PDA.
PDA|posterior descending artery|PDA.|136|139|SUBJECTIVE|On most recent cath of _%#DDMM2003#%_ the patient is noted to have no occlusion of LIMA to LAD, no occlusion of saphenous vein graft to PDA. The patient's LAD was 100% occluded proximal to the left circumflex artery. The POA was a 100% occlusion and SVG to OM1 graft is occluded.
PDA|posterior descending artery|PDA|257|259|HISTORY|PRIMARY CARE PHYSICIAN: Dr. _%#NAME#%_, _%#CITY#%_, MN CHIEF COMPLAINT: Chest, shoulder and arm discomfort. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 55-year-old Caucasian male with history of coronary artery disease including stenting of his RCA in 2003 and his PDA as well a couple months later, with longstanding history of alcohol abuse with a DUI and congenital bicuspid valve with aortic insufficiency.
PDA|posterior descending artery|PDA|160|162|HOSPITAL COURSE|He was transferred up to the floor without further complications. The vein graft to the right coronary artery was patent, his stents were patent and the distal PDA will need to be watched quite closely due to the hyperplasia that was noted. We have recommended that he have a nuclear stress test in four to six weeks for a baseline.
PDA|posterior descending artery|PDA,|122|125|HOSPITAL COURSE|She was taken to the OR emergently on _%#DDMM2006#%_ for CABG x 3 vessels with LIMA to LAD, right saphenous vein graft to PDA, and right saphenous vein graft to D1. She also required Levotronic BiVAD implantation at the time of CABG to support her cardiac function.
PDA|patent ductus arteriosus|PDA.|216|219|1. F/E/N|_%#NAME#%_ will be scheduled for a follow-up ultrasound and an appointment with Dr. _%#NAME#%_ in one month. 4. Cardiac: PDA and PFO diagnosed by echocardiogram early on. Treated with indomethacin with resolution of PDA. A repeat echocardiogram on _%#DDMM2002#%_ showed normal intracardiac anatomy and function. Initially, _%#NAME#%_ had episodes of bradycardia with her apneic spells.
PDA|posterior descending artery|PDA|228|230|PAST MEDICAL HISTORY|He denies any other symptoms. PAST MEDICAL HISTORY: Coronary artery disease, status post coronary artery bypass graft on _%#DDMM2007#%_ by Dr. _%#NAME#%_ _%#NAME#%_, with CABG x4, LIMA to his LAD and saphenous vein graft to his PDA posterior lateral right and OM-1. History of hypertension after the bypass graft and hyperlipidemia. ALLERGIES: No medication allergies.
PDA|posterior descending artery|PDA,|141|144|PROCEDURES DURING HOSPITALIZATION|Left ventriculogram revealed normal left ventricular function. Right coronary artery was dominant. There was no significant narrowing in the PDA, posterior branch had a stenosis of 30-40%, left main was without any disease. The circumflex artery was tortuous, giving off 2 large obtuse marginal arteries in the area of the tortuosity; seen best in the LAO caudal view there was an area of narrowing up to around 50%, on other views it was less than 50%.
PDA|patent ductus arteriosus|PDA,|160|163|PAST MEDICAL HISTORY|5. During first 2 years of life she had 3 hospitalizations for rotavirus, diarrhea and dehydration. 6. She has bilateral radial ray defects, mild. 7. She has a PDA, status post spontaneous closure. 8. She has a poor growth. Her immunizations are up-to-date. PHYSICAL EXAMINATION: VITAL SIGNS: Her temperature is 99.4 degrees Fahrenheit.
PDA|posterior descending artery|PDA;|161|164|OPERATIONS/PROCEDURES PERFORMED|SUMMARY: Angiography demonstrated a codominant coronary system with single-vessel coronary artery disease. The RCA was small in caliber and gave rise to a small PDA; no PL branches seen. The LMCA was normal. There was a small ramus branch with 70% ostial narrowing, unchanged from the prior angiography.
PDA|posterior descending artery|PDA|130|132|HOSPITAL COURSE|He underwent an urgent coronary angiogram, which showed occlusion of his proximal LAD. There was also a 40 to 50% stenosis of his PDA and a 20 to 30% narrowing of his ramus intermedius. He underwent PTCA with Cypher stenting of the LAD with excellent results.
PDA|posterior descending artery|PDA.|307|310|HISTORY OF PRESENT ILLNESS|Briefly, he had an anterior wall infarction in 1990 with angioplasty and stent procedures subsequently performed prior to five-vessel bypass surgery in 1995 at North Memorial Medical Center. He had a left internal mammary artery to the LAD, saphenous vein grafts to the diagonal, ramus, obtuse marginal and PDA. His last angiography was performed in _%#MM#%_, 2002. He had some stenting performed of the ostium of the vein graft to the diagonal artery and restenosis was identified on that angiogram.
PDA|posterior descending artery|PDA.|254|257|HISTORY OF PRESENT ILLNESS|A Y-shaped vein graft with one limb going to the ramus and the other was apparently a graft to the second obtuse marginal artery. I believe he has a left dominant system and may have had then a sequential graft from the obtuse marginal to the left-sided PDA. When I saw the patient he was having episodic chest pain and had had an adenosine Cardiolite stress test performed on _%#DDMM2005#%_.
PDA|posterior descending artery|PDA,|199|202|HISTORY/HOSPITAL COURSE|She did have coronary angiogram at that time which demonstrated an occluded LAD with remaining circumflex disease, a 50% osteal, first diagonal of 80% stenosis and a 60% right coronary artery of the PDA, with an ejection fraction of approximately 40%. She did receive a Pixel stent 2.5 mm to the LAD lesion. The patient is followed regularly by Dr. _%#NAME#%_ at Fairview Wyoming Clinic.
PDA|patent ductus arteriosus|PDA|159|161|HOSPITAL COURSE|He also had a patent PFO with a bidirectional shunt, normal pulmonary veins and aorta was noted. His second cardiac echo showed normal anatomy, small PFO. His PDA had closed and he had trivial tricuspid regurgitation. Normal arch anatomy was noted. 4. Infectious Disease: _%#NAME#%_ did receive ampicillin and gentamicin x48 hours and continued on prophylactic antibiotics until his VCUG was done on _%#DDMM2006#%_ after which it was discontinued.
PDA|posterior descending artery|PDA|157|159|PAST MEDICAL HISTORY|ALLERGIES: 1. Penicillin. 2. Niacin. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post bypass in 2003 with a LIMA to D1, vein graft to the right PDA and a vein graft to the ramus. 2. Hypertension. 3. Hyperlipidemia. 4. Left knee surgery. SOCIAL HISTORY: No tobacco and minimal alcohol.
PDA|posterior descending artery|PDA|234|236|MAJOR PROCEDURES/IMAGING PERFORMED|Because patient presented with shortness of breath and it was thought to be anginal equivalent the patient underwent angiogram. It showed right dominant circulation. RCA had long 80% stenosis throughout the mid and distal vessel. The PDA appears occluded at the ostium. LAD had moderate calcification and moderate to severe mid-LAD lesion. Eighty percent lesion in the apical LAD distal to LIMA anastamosis.
PDA|posterior descending artery|PDA|337|339|HOSPITAL COURSE|Serial troponins and EKGs were normal. The patient was started initially on heparin and on _%#MMDD#%_, she underwent coronary angiogram which showed diffuse coronary disease, but there was an acute lesion (90% ostial occlusion at the LIMA graft at the point of the juncture with the LAD). Also there were 2 other acute lesions, 1 in the PDA and the PLA. PDA was stented, the PLA was opened with balloon angioplasty without stenting. The patient had a staged angioplasty and stent placement the next day and underwent on _%#DDMM2007#%_, a thickened angiogram with successful angioplasty and stenting of the LIMA to LAD.
PDA|posterior descending artery|PDA|354|356|HOSPITAL COURSE|Serial troponins and EKGs were normal. The patient was started initially on heparin and on _%#MMDD#%_, she underwent coronary angiogram which showed diffuse coronary disease, but there was an acute lesion (90% ostial occlusion at the LIMA graft at the point of the juncture with the LAD). Also there were 2 other acute lesions, 1 in the PDA and the PLA. PDA was stented, the PLA was opened with balloon angioplasty without stenting. The patient had a staged angioplasty and stent placement the next day and underwent on _%#DDMM2007#%_, a thickened angiogram with successful angioplasty and stenting of the LIMA to LAD.
PDA|posterior descending artery|PDA|99|101|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Coronary artery disease with prior bypass grafting. 2. PTCA/PCI to RCA and PDA 2.5 x 28.0; 2.75 x 33.0 (Cypher for both). 3. Hypertension. 4. Dyslipidemia. HOSPITAL COURSE: Ms. _%#NAME#%_ _%#NAME#%_ was admitted for elective coronary angiogram to care suites.
PDA|posterior descending artery|PDA|155|157|HOSPITAL COURSE|She underwent coronary angiogram on _%#DDMM2007#%_ without complication. Her ejection fraction was 60%. Her LVEDP was 19. She had stenting to her RCA into PDA with a 2.5 x 28.0 Cypher, 2.75 x 33.0 Cypher. There was no residual obstruction, TIMI-3 flow post procedure. The following day after procedure she was doing well, was up walking around, her groin site was normal.
PDA|posterior descending artery|PDA,|260|263|PAST MEDICAL HISTORY|He quit 20-30 years ago. He drinks occasional alcohol. FAMILY HISTORY: He has a brother with significant coronary artery disease. He lives with his roommate. PAST MEDICAL HISTORY: 1. CABG x 4 in 1981 and 1994, with his anatomy as follows: He had an SVG to the PDA, to the LAD, to D1, and to the OM1, and also had a LIMA to the D1. 2. He had atrial fibrillations, status post cardioversion in _%#DDMM2001#%_.
PDA|posterior descending artery|PDA,|272|275|SUMMARY OF HOSPITAL COURSE|He was admitted to Fairview Southdale Hospital on _%#DDMM2002#%_ and underwent four-vessel coronary artery bypass grafting using left internal mammary artery to graft the left anterior descending, saphenous vein graft, obtuse marginal, saphenous vein graft separately the PDA, and radial artery graft the second obtuse marginal. He received no blood transfusion and had a smooth postoperative recovery without complication.
PDA|posterior descending artery|PDA|327|329|PROBLEM #7|PROBLEM #7: Neurologic and sedation: _%#NAME#%_ was maintained on pain control with morphine and Ativan throughout his hospital course. Summary: Multiple discussions occurred with _%#NAME#%_'s parents regarding his multiple congenital anomalies, with options given to them including an initial repair of his heart surgery with PDA stent and PA banding with the need of multiple heart surgeries down the road. Additionally, it was felt that his esophagus would require multiple dilatations to maintain patency with interim feedings.
PDA|posterior descending artery|PDA|215|217|SUMMARY|He underwent angiography on _%#DDMM2007#%_. He was found to have mild LAD disease and ostial 90% lesion of his circumflex artery, mid 50% lesion in the same artery and a hazy mid right coronary artery stenosis. The PDA had a 50% mid stenosis. The LVEDP was 12. It was felt by Dr. _%#NAME#%_ _%#NAME#%_, the interventional cardiologist, that the culprit lesion was the right coronary artery lesion and a 3.0 x 28 mm Cypher stent was inserted without complications.
PDA|patent ductus arteriosus|PDA.|160|163|DISCHARGE MEDICATIONS|This was stopped on _%#DDMM2006#%_. As noted above, _%#NAME#%_ had an echo on the day of admission that showed a small left ventricle, small aorta, and a large PDA. Peds Cardiology was consulted and a Rashkind procedure was performed on the evening of admission (_%#DDMM2006#%_) to allow maximal atrial mixing.
PDA|posterior descending artery|PDA|256|258|PROCEDURES DONE DURING ADMISSION|DISCHARGE DIAGNOSIS: Coronary artery disease status post percutaneous transluminal coronary angioplasty of ostial first diagonal. PROCEDURES DONE DURING ADMISSION: Include a coronary angiogram, which showed right dominant coronary circulation although his PDA was supplied by a vein graft, which is currently occluded and receiving minimal flow from collaterals. His left vein has less than 25% stenosis. His LAD system is diffusely diseased with proximal 80% LAD stenosis of stenting into an ostial 80% to 90% D1 lesion.
PDA|posterior descending artery|PDA|215|217|PROCEDURES PERFORMED|There were mild luminal irregularities throughout the LAD. A myocardial bridge was present in the mid-LAD. The left circumflex and marginal branches were free of disease. The previously stented areas of the RCA and PDA were free of significant restenosis. There was 30% stenosis of the ostium of the PDA. A left ventricular gram revealed a left ventricular ejection fraction of 55% with no evidence of hypokinesis.
PDA|patent ductus arteriosus|PDA|209|211|1. FEN|She has not experienced apneic or bradycardic episodes. 3. Cardiovascular: Echocardiography was obtained on the day of admission to evaluate _%#NAME#%_'s cardiac murmur. This study revealed a moderately-sized PDA with a left to right shunt, trivial tricuspid regurgitation, and left to right shunting through a patent foramen ovale. The murmur resolved and _%#NAME#%_ exhibited no signs or symptoms of heart failure on _%#DDMM2003#%_.
PDA|patent ductus arteriosus|PDA|191|193|HOSPITAL COURSE|DOB: _%#DDMM2002#%_ HOSPITAL COURSE: This is a 5-month-old, ex-primi, who was delivered at 29-weeks of age. He has had a significant history for about five days of mechanical ventilation and PDA surgery. He has been on synergist injections and received his most recent one a couple of days prior to his admission. He presented to the emergency room on the day of admission with cough and difficulty breathing.
PDA|posterior descending artery|PDA|171|173|HISTORY|There was a mid 60-70% right coronary artery stenosis which was unchanged from previous and a 6% proximal PDA irregularity. The right coronary system supplying the distal PDA was of modest size. The LAD remained occluded and the circumflex did not contain any lesion greater than 25%. The patient was again hospitalized _%#MM#%_ _%#DD#%_, 2003, for the same symptoms.
PDA|patent ductus arteriosus|PDA,|141|144|DISCHARGE MEDICATIONS|He required no supplemental O2, and maintained O2 saturations of 95 - 100% on room air. 3. CV. Repeat echo showed normal pulmonary veins, no PDA, normal anatomy and function, and a patent PFO with left to right shunt. 4. GI. Continued on Zantac for reflux diagnosed by UGI at Rice Memorial Hospital.
PDA|posterior descending artery|PDA|245|247|HOSPITAL COURSE|The culprit lesion was a large posterolateral branch and this lesion also involved the ostium and the posterior descending artery. He underwent successful direct angioplasty for his MI with stenting both the posterolateral branch ostium and the PDA ostium. He had an uncomplicated postoperative course and was tolerating cardiac rehabilitation normally.
PDA|posterior descending artery|PDA,|240|243|HISTORY  OF PRESENT ILLNESS|He has had a bypass surgery in _%#DDMM1998#%_ performed by Dr. _%#NAME#%_ _%#NAME#%_ at Fairview Southdale with the following anatomy: Saphenous vein graft to the right coronary artery with a vein to vein anastomosis from this graft to the PDA, saphenous vein graft from the aorta to the circumflex marginal, a saphenous vein graft to the diagonal branch of the LAD, and left internal mammary artery to the LAD.
PDA|posterior descending artery|PDA|175|177|HISTORY OF PRESENT ILLNESS|The patient reported similar symptoms in 2003 when he was diagnosed with CAD and required CABG for two-vessel disease of RCA and LAD, when patient had LIMA to mid LAD, SVG to PDA and diagonal 1. 2. Denies change in activity level. Does exercise lifting and cardio for 1 hour 3 times a week. Last stress test ordered by Dr. _%#NAME#%_ was on treadmill, did well according to the patient in _%#DDMM2007#%_ prior to patient's right kidney surgery.
PDA|patent ductus arteriosus|PDA|231|233|HISTORY OF PRESENT ILLNESS|She did need some caffeine for apnea and bradycardia, which was stopped a long time prior to discharge. She was discharged on a home apnea monitor without any significant lung issues. Cardiovascular-wise, she did have a persistent PDA at the time of discharge and was sent home on diuretics and fluid restriction. That was halted after her first followup echo in _%#MM#%_ and has not needed to be restarted.
PDA|patent ductus arteriosus|PDA|180|182|HISTORY OF PRESENT ILLNESS|She has not had her 6 month or 1 month vaccines, and she has not been restarted on her Synagis. She has had a followup with Cardiology in the last week, and mother states that her PDA persists and that the plan is to see her back in 6 months and consider surgical intervention if it persists at that time.
PDA|posterior descending artery|PDA|181|183|PROCEDURES AND INVESTIGATIONS|The length of occlusion was approximately 12 mm. There were also faint left collaterals. The RCA had 50% ostial narrowing and mild disease in the mid and distal segments. The right PDA was very large with minimal disease. the right PL had a focal 60-70% stenosis. Right heart cath reveals RAP mean 9 mmHg, RV 51/5 mmHg, RAP 55/22 with mean PA pressure of 34 mmHg, PCW 20 mmHg and cardiac index is 1.82 liters per minute per meter square by Fick.
PDA|posterior descending artery|PDA|47|49|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: Chest pain and PCI of the PDA vein graft. OPERATIONS/PROCEDURES PERFORMED: The patient underwent coronary angiography, which showed a 40% lesion in the distal portion of the PDA vein graft, 75% stenosis at the distal end of that vein graft with irregularity.
PDA|posterior descending artery|PDA|141|143|HOSPITAL COURSE|He was noted to have a diagonal 1 90% lesion, 40% narrowing in his ramus, mild luminal irregularities in his circumflex no greater than 20%, PDA 60% narrowing, 80% blockage at the posterolateral branch. LV-gram was not performed. He therefore underwent stenting of a 2.75 x 33 mm and 2.5 x 13 mm drug-eluting stent to his mid-LAD long calcified area re-establishing good flow with 0% residual stenosis.
PDA|patent ductus arteriosus|PDA|191|193|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 4-year-old girl with known history of large patent ductus arteriosus who was taken to the catheterization lab on _%#DDMM2007#%_ for PDA closure. The initial device slipped during placement and migrated to the right iliofemoral artery where it lodged and a clot formed.
PDA|posterior descending artery|PDA.|153|156|PROCEDURE PERFORMED|A left heart cath was done via the right femoral artery using a 6-French sheath. A JR4 guide was used and the wire was used to cross the lesion into the PDA. The lesion was directly stented with a 3 x 5 x 13 mm Cypher stent at 20 bars. The stent was post dilated with a 4 x 8 mm power sail balloon.
PDA|posterior descending artery|PDA|249|251|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a patient of Dr. _%#NAME#%_ who has had 15 stents and had 4-vessel CABG in _%#MM#%_ of 2004 with 4-vessel bypass with LIMA to LAD, sequential radial graft to diagonal and obtuse marginal, RIMA to PDA branch of the RCA. Following this, he developed angina when he presented to Dr. _%#NAME#%_' office on _%#DDMM2007#%_. He had a nuclear stress test which revealed inferior wall ischemia.
PDA|posterior descending artery|PDA.|152|155|HOSPITAL COURSE|He was admitted to the hospital. He was brought to the Cardiac Catheterization Laboratory and was found to have an occluded saphenous vein graft to the PDA. Interestingly, however, Dr. _%#NAME#%_ felt that the graft had a feeling of being a chronic occlusion. However, he was able to open it and place a stent with a good result.
PDA|posterior descending artery|PDA.|117|120|HOSPITAL COURSE|The native LAD had disease distal to the graft insertion. He had a triple sequential vein graft to OM1, OM2 and left PDA. The graft itself looked good proximally, there is a stent within the graft. There is a 20% narrowing within this vessel. Anastomosis to OM1 where there is a subtotal distal anastomosis of 95%.
PDA|posterior descending artery|PDA,|138|141|PROCEDURES PERFORMED DURING HOSPITALIZATION|There is diffuse disease in the distal left circ which is unchanged. RCA shows 50% lesion in the mid segment as well as 50% lesion in the PDA, both of which are not flow-limiting by appearance. No intervention was recommended. 2. Echocardiogram showed normal LV size and function.
PDA|posterior descending artery|PDA|161|163|HOSPITAL COURSE|The right coronary appeared small in caliber with diffuse disease. There was an 80% focal proximal stenosis. There was mild disease in the mid distal RCA, right PDA and right PL. There were right-to-left collateral supplying the mid septum. The left main was normal. The stents in the mid LAD and D1 were patent with mild in-stent restenosis.
PDA|posterior descending artery|PDA|197|199|PROCEDURES PERFORMED THIS HOSPITALIZATION|There were narrowings up to around 30% in the circumflex artery as well as the obtuse marginal artery. No significant large vessel epicardial stenosis was seen. There was collateral filling of the PDA to a good degree. The right coronary artery was patent with a possible recannulized vessel. Straddling a relatively undiseased RV marginal branch, there was a subtotal stenosis before and afterwards in an angulated part of the vessel.
PDA|posterior descending artery|PDA.|238|241|PROCEDURES PERFORMED|The left circumflex also had mild diffuse disease with up to a 50% narrowing, and the LAD had diffuse 30%-40% narrowing with the stent in the proximal segment widely patent. There was also noted to be a 40% residual stenosis in the right PDA. HISTORY OF PRESENT ILLNESS: This is a 51-year-old female with a history of coronary artery disease who presented to the emergency department after 2 hours of substernal chest pain associated with mild shortness of breath and nausea.
PDA|posterior descending artery|(PDA)|328|332|HOSPITAL COURSE|He was found to have heavily calcified vessels with multiple moderate lesions, including a 50% left main, 40-50% proximal and midcircumflex, and a discrete 90% stenosis in the mid-LAD (left anterior descending). He also had a 60% stenosis in the distal LAD. The circumflex was dominant. He had a 70% posterior descending artery (PDA) lesion as well. The only flow-limiting lesion was the mid-LAD which was successfully stented using a balloon to pre-dilate and then eventually a 3.0- x 8.0-mm Express stent with less than 0% residual stenosis and no complications.
PDA|posterior descending artery|PDA.|181|184|PROCEDURES PERFORMED|The RCA had diffuse disease supplying a large posterolateral area of the myocardium. There was 40% proximal disease, 50% mid-disease, 95% distal disease at the takeoff of the right PDA. Thus, this distal RCA was predilated with a 3.0 x 15 mm balloon and stented. The left main is normal. LAD has 40% proximal disease, 60% mid-disease and 70% apical disease.
PDA|posterior descending artery|PDA.|172|175|HOSPITAL COURSE|HOSPITAL COURSE: During that procedure, her right coronary artery was angioplastied and extended from the proximal through the mid and distal RCA, extending into the right PDA. The proximal and mid-RCA were stented with initially a BX velocity stent 2.5 x 28 mm, and the distal RCA was stented with a ______ 2.5 x 8 mm stent that was placed in an overlapping fashion over the first stent.
PDA|posterior descending artery|PDA|177|179|DISCHARGE DIAGNOSES|There are significant areas of anterolateral and lateral ischemia present and an extensive area of inferior and posterior myocardial infarction. The saphenous vein graft to the PDA has a 70% stenosis but was not treated with angioplasty. This may have been flow-limiting, but supplies infarcted territory.
PDA|posterior descending artery|PDA.|159|162|PROCEDURES DURING THIS HOSPITALIZATION|The saphenous vein graft to the RCA touched down on the bifurcation of the right PDA and was widely patent. There was a 30 to 40% osteal stenosis of the right PDA. 2. CT angiogram of the chest with PE protocol reveals cardiomegaly, changes consistent with congestive heart failure, no pulmonary embolus was identified.
PDA|posterior descending artery|PDA|134|136|SECONDARY DIAGNOSES|3. Hyperlipidemia with LDL of 138. 4. Hypertension. SECONDARY DIAGNOSES: 1. Previous known cardiac disease, status post stents to the PDA at Fairview Southdale Hospital in _%#DDMM2000#%_ with associated MI. 2. Multiple sclerosis diagnosed in 1998 with left optic neuritis in the past.
PDA|posterior descending artery|PDA|144|146|HISTORY OF PRESENT ILLNESS|He underwent coronary artery bypass grafting in the 1980s and 1990s. It appears that this included a LIMA graft to the LAD and SVG graft to the PDA and one of the OM branches. He had extensive defects on Cardiolite testing in 2002 but no ischemia. In 1999, an ICD was placed because of sustained monomorphic ventricular tachycardia induced during an electrophysiology study in the setting of a lead dysfunction.
PDA|patent ductus arteriosus|PDA|172|174|* FEN|This echocardiogram revealed pulmonary atresia with an intact ventricular septum and sinusoids. He had an echocardiogram on _%#DDMM2007#%_ following birth which revealed a PDA and hypoplasia of the right ventricle and tricuspid valve in addition to the previous findings. Prostaglandin therapy and caffeine were started on admission. Troponins were initially checked daily; values peaked at 0.61 and trended down to normal prior to discharge.
PDA|posterior descending artery|PDA|200|202|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Tetralogy of Fallot. Status post dilation of pulmonary valve. Status post complete repair with resection of pulmonary valve and infundibular muscle and LPA plasty status post PDA ligation. No residual shunting at the level of the ventricles. Wide open pulmonary regurgitation. 2. Small for gestational age. Birth weight of 2.5 kg.
PDA|patent ductus arteriosus|PDA|309|311|PAST MEDICAL HISTORY|She had a positive DEB test of her chromosomes. She was admitted on _%#MM#%_ _%#DD#%_, 2003, for a matched sibling cord blood transplant. ALLERGIES: No known drug allergies. PAST MEDICAL HISTORY: Multiple surgeries including: duodenal atresia repair, ectopic anus repair, PDA and PFO with a coil to close the PDA in 1995, nephrectomy in 1996, absent thumbs and short radius repaired in 1995. PHYSICAL EXAMINATION: VITALS: At the time of admission _%#NAME#%_'s temperature was 97.6, heart rate 100, respiratory rate 20, blood pressure 115/70, weight 25.6 kg, height 116 cm.
PDA|posterior descending artery|PDA|464|466|HOSPITAL COURSE|_%#NAME#%_ _%#NAME#%_ is a 58-year-old male who was admitted with symptoms of chest discomfort, consistent with unstable angina. He has a history of coronary artery disease with PTCA 14 years prior to admission, coronary artery bypass surgery in _%#MM#%_ 2002, with repeat angiography in _%#MM#%_ 2003 with the LIMA patent, with saphenous vein graft to the ramus intermedius occluded, faint collaterals to the ramus intermedius, saphenous vein bypass graft to the PDA with significant disease with 50% proximal narrowing, and ejection fraction of 50%. He had recurrent chest pain, and was apparently started on IV heparin and nitroglycerin, and subsequently had beta blocker and IIb/IIIa agents started at the time of his admission.
PDA|patent ductus arteriosus|PDA|142|144|SPECIAL INSTRUCTIONS|Dopamine and dobutamine for blood pressure support throughout the first week of life. Echocardiogram was obtained which did not demonstrate a PDA but a PFO was identified. At 39 days of age, this child was transferred back to the special care unit at Fairview Southdale Hospital where gavage feedings were continued and advanced.
PDA|posterior descending artery|PDA,|203|206|HISTORY OF PRESENT ILLNESS|Left circumflex and its OM branches were normal. There was a ramus branch which was normal. Proximal RCA had a 70% lesion just proximal to takeoff of the first marginal branch. The remainder of the RCA, PDA, and PLA were normal. After discussion of the patient, we elected to pursue PCA of the proximal RCA lesion. Lesion was initially dilated with a 2.5- x 15-mm Maverick balloon, then it was stented with a 3.5- x 28-mm CYPHER stent.
PDA|patent ductus arteriosus|PDA|226|228|DISCHARGE INSTRUCTIONS|Initial thyroid function tests done on _%#DDMM2004#%_ showed TSH 11.5 and free T4 2.5, which were both somewhat elevated, but not consistent with hypothyroidism (T4 would be low). Cardiac echo done showed small bi-directional PDA and small left to right shunt through PFO, with overall function of heart was within normal limits. Dr. _%#NAME#%_ _%#NAME#%_ from the Down Syndrome Clinic at FUMC spoke with _%#NAME#%_' parents, and _%#NAME#%_ will be seen in Dr. _%#NAME#%_'s clinic after discharge.
PDA|patent ductus arteriosus|PDA.|255|258|* FEN|Briefly, _%#NAME#%_'s pre-transfer history is that of an ex 25 + 1 week female with a problem list including respiratory distress syndrome, for which she received one dose of surfactant. She was noted to have a murmur on DOL#3. A subsequent echo showed a PDA. _%#NAME#%_ failed ibuprofen therapy times two, so she was transferred here for ligation. Primary diagnoses during hospitalization included: 1. PDA-s/p ligation on _%#DDMM2007#%_.
PDA|posterior descending artery|PDA|227|229|HOSPITAL COURSE|The left main coronary artery was normal. The LAD had a proximal 10% stenosis. Circumflex coronary artery was normal and the right coronary artery was a large dominant vessel without evidence of atherosclerosis, but very small PDA and PL branches. The patient recovered uneventfully. She was initiated on labetalol for antihypertensive therapy as her blood pressures were high in the hospital.
PDA|posterior descending artery|PDA,|200|203||Most recently, he presented with worsening ischemic symptoms, mainly dyspnea on exertion, and an abnormal stress thallium. Angiography in _%#MM#%_ of 2001 demonstrated a recent total occlusion of the PDA, a severe posterolateral lesion and a significant mid right coronary lesion. There was also a chronic total occlusion of the mid LAD which was supplied by collaterals.
PDA|posterior descending artery|PDA|171|173|HOSPITAL COURSE|The circumflex had moderate diffuse disease and a 70% stenosis of OM2, possibly at the site of a known three graft insertion. The native RCA had mild diffuse disease. The PDA was occluded, the graft filled, and the PLA had a long 70% stenosis that extended into a lateral branch. The native vessel was similar to the _%#DDMM2001#%_ angiogram. Plavix and aspirin for one month were recommended, as well as reduction in LDL cholesterol to less than 85 mg/dl significant for atherosclerotic prevention.
PDA|posterior descending artery|PDA|146|148|OPERATIONS/PROCEDURES PERFORMED|The patient has had recent bypass surgery with a LIMA to the LAD that was now subtotally occluded and a saphenous vein graft from the LIMA to the PDA that was occluded. 2. Echocardiogram on _%#MM#%_ _%#DD#%_, 2002, that showed mildly decreased left ventricular function with an EF of 52%, normal right ventricular size and function.
PDA|posterior descending artery|PDA,|182|185|HISTORY OF PRESENT ILLNESS|He had a subtotal thrombotic occlusion of right coronary artery with successful angioplasty with stent placement of the proximal right coronary artery, successful angioplasty of the PDA, and successful angioplasty of the proximal LAD with a stent. The PDA was not stented. Left ventricular systolic dysfunction was mild, and he had left ventricular diastolic dysfunction with a hyperkinetic inferior wall.
PDA|posterior descending artery|(PDA)|328|332|HOSPITAL COURSE|He had no known risk factors and underwent coronary angiography revealing a 30% distal left main stenosis, 90% and 80% serial lesions in the left anterior descending (LAD), 70% stenosis of the intermediate branch, 90% stenosis of the obtuse marginal branch. There is mild-to- moderate disease of the posterior descending artery (PDA) and posterolateral artery (PLA). Left ventricular function was mildly reduced with apical akinesia and distal anterior wall hypokinesia. He underwent the above-mentioned procedure on _%#DDMM2004#%_ without complications. His postoperative course was uneventful.
PDA|posterior descending artery|PDA|266|268|HOSPITAL COURSE|The patient underwent successful angioplasty and Cypher drug-eluting stent placement to the proximal and mid right coronary artery with a 0% residual lesion. He also underwent successful cutting balloon angioplasty and Taxus drug-eluting stents to the ostium of the PDA and mid PDA with 0% residual lesions. The morning after the procedure, Mr. _%#NAME#%_ is doing very well. He never had symptoms prior to his bypass surgery, so he did not have symptoms prior to this past intervention.
PDA|posterior descending artery|PDA|139|141|DISCHARGE DIAGNOSES|His right coronary artery was occluded at the first acute marginal. He does have patent grafts that went to the distal RCA that filled the PDA and posterior lateral artery and collateral flow to the lateral wall, as well as a patent graft to the LAD along with a distal LAD occlusion.
PDA|patient-controlled analgesia:PCA|PDA|209|211|COMPLICATIONS|Cervidil was placed for induction of labor. This was done at 4 a.m. on _%#MM#%_ _%#DD#%_, 2005. At 8 a.m. on _%#MM#%_ _%#DD#%_, 2005, and Cytotec 600 mcg was placed per vagina. The patient received a Dilaudid PDA for pain control during her labor. She progressed to complete and delivered a live born previable female infant at 0955. Apgars were 1 at 1 minute and 1 at 5 minutes.
PDA|posterior descending artery|PDA|235|237|INDICATION|This was complicated by a coronary dissection. Nonetheless, it was successfully stented with a 3.0 Express stent and, more proximally, a 3.5 mm Express stent. After re-establishment of flow, there was noted to be a subtotally occluded PDA which was too small for repair. Additional disease was demonstrated in the first diagonal branch, which was subtotally occluded, but the LAD contained only minimal luminal irregularities.
PDA|patent ductus arteriosus|PDA.|166|169|NICU COURSE PRIOR TO TRANSFER|3. Cardiac. A cardiac echogram was performed due to hypo-oxygenation and acute deterioration. It did demonstrate total anomalies pulmonary venous return with a large PDA. The patient was begun on dopamine and dobutamine, each at 20 mcg/kg/min. 4. Hematology. The infant received 1 transfusion of fresh frozen plasma after initial coagulation studies of INR 1.3, PTT 35.2, fibrinogen 162, and D-dimer 12,097.
PDA|posterior descending artery|PDA|178|180|MEDICATIONS|He underwent a CAB x6 vessels. A LIMA to his LAD, saphenous vein graft to his diagonal, saphenous vein graft to his ramus, sequential to his OM-1 and saphenous vein graft to his PDA and then sequential to his PLA. Postoperatively he experienced thrombocytopenia, probably secondary to pump run, some postop anemia, hyperglycemia, fever, probable atelectasis all resolved prior to discharge.
PDA|posterior descending artery|PDA,|227|230||He was admitted to Fairview Southdale Hospital electively on _%#DDMM2007#%_ for coronary artery bypass grafting x5 with a LIMA to his LAD, saphenous vein graft to his ramus, sequential to his OM and saphenous vein graft to his PDA, sequential to his PLA. He tolerated the procedure well. Postoperatively, his hypertension was treated aggressively. Dr. _%#NAME#%_ was consulted for diabetic management. He received diabetic supplies and education.
PDA|posterior descending artery|PDA|166|168|DISCHARGE DIAGNOSES|2. Status post successful bypass surgery on this admission with sequential LIMA grafted D2 and LAD, sequential left radial from D1 to OM2, sequential vein graft from PDA to PLA. 3. Attention Deficit Disorder. 4. Diabetes mellitus. 5. Hypertension. 6. Hyperlipidemia. 7. Medical noncompliance. 8. Attention Deficit Disorder. HISTORY OF PRESENT ILLNESS: Briefly, _%#NAME#%_ _%#NAME#%_ is a 50- year-old male with the above risk factors.
PDA|posterior descending artery|PDA|234|236|OPERATIONS/PROCEDURES PERFORMED|C. Anterior ischemia by nuclear stress test. 2. Hyperlipidemia. 3. Hypertension. OPERATIONS/PROCEDURES PERFORMED: Please refer to procedure log. Status post successful percutaneous coronary intervention of the proximal LAD and ostial PDA using drug-eluting stent. HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old male with a history of inferior myocardial infarction status post multiple percutaneous interventions with subsequent in-stent restenosis who presents with recurrent chest pain with minimal exertion and a positive stress test with mild anterior ischemia.
PDA|posterior descending artery|PDA|202|204|HOSPITAL COURSE|He subsequently underwent successful percutaneous coronary intervention at the proximal RCA using a bare-metal stent ultra 4.5 x 18 mm. It was post dilated to 4.5 mm to 0% residual stenosis. The ostial PDA was successfully revascularized using a Sirolimus eluting stent 2.5 x 12 mm with 0 residual stenosis. There were no complications from the coronary intervention. An Angio- Seal closure device was placed at the right femoral arteriotomy site with good hemostasis initially.
PDA|posterior descending artery|PDA.|291|294|HOSPITAL COURSE|HOSPITAL COURSE: The patient was taken to the cardiac catheterization laboratory where he was noted to have a 20% left main lesion, diffuse mild irregularities in the LAD, 25% stenosis in the proximal circumflex, 90% proximal OM-1, and a 25% mid RCA, 40% distal RCA, 90% stenosis in the mid PDA. He underwent successful drug-eluting stenting of the OM-1 and PTCA of the right PDA. Attempts were made to deliver the stent into the right PDA but because of the small caliber and the tortuosity of the right coronary artery, we were not able to do so.
PDA|patent ductus arteriosus|PDA|226|228|PAST MEDICAL HISTORY|He has been doing well at home, tolerating feeds. His most recent OFC was 41.6 cm on _%#DDMM2004#%_. PAST MEDICAL HISTORY: 1. Complex congenital heart defect as outlined above. Status post balloon dilation of aortic stenosis, PDA ligation, atrial septectomy, pulmonary artery banding, aortopulmonary shunt placement. 2. Heart failure in cardiogenic shock secondary to above. 3. Acute renal failure secondary to #1. History of peritoneal dialysis.
PDA|patent ductus arteriosus|PDA|224|226|HISTORY OF PRESENT ILLNESS|She had a follow-up echocardiogram which showed persistent PDA. The murmur resolved following the second course of indomethacin. However, it returned. An echocardiogram performed on _%#MM#%_ _%#DD#%_ showed a moderate sized PDA with left to right shunt, some left atrial enlargement and it was recommended to follow this. The murmur persisted throughout her hospital course on and off.
PDA|patent ductus arteriosus|PDA|283|285|FINAL DIAGNOSES|3. Cardiovascular. _%#NAME#%_ was noted several times throughout her hospital course to have a murmur, which was consistent with a patent ductus arteriosis, which had been noted on cardiac echo. A final echocardiogram performed three weeks prior to dismissal showed a stable closing PDA with no further echo needed while in hospital. It was recommended that she follow up at six months of age as an outpatient for further evaluation.
PDA|posterior descending artery|PDA|141|143|PROCEDURES|2. Cardiac catheterization _%#DDMM2005#%_. 2-vessel coronary disease, RCA and LAD. RCA with mild irregularity except for a distal very large PDA which had severe diffuse narrowing at the apex. However, this was not intervened on as the vessel is not ideal for angioplasty due to the size and the distal nature of the stenosis.
PDA|patent ductus arteriosus|PDA|244|246|PAST MEDICAL HISTORY|He was subsequently transferred to the pediatric ICU because an echocardiogram showed absence of the right pulmonary artery. On _%#MM#%_ _%#DD#%_, 2005, he had his right pulmonary artery re-anastomosis to his main pulmonary artery as well as a PDA ligation. He also has a history of an elevated TSH, but a normal free T4, thought secondary to SICU thyroid.
PDA|posterior descending artery|PDA|226|228|OPERATIONS/PROCEDURES PERFORMED|9. History of gastroesophageal reflux disease. OPERATIONS/PROCEDURES PERFORMED: 1. The patient had a coronary angiography performed which showed right dominant system with noted occlusion of the proximal RCA. There is a large PDA that fills by the apical LAD. There is also a posterior descending lateral branch that fill via septals. The left main appears normal. The LAD has diffuse disease with a 50% to 60% focal lesion in the mid vessel.
PDA|posterior descending artery|PDA.|149|152|PAST MEDICAL HISTORY|1. Coronary artery disease status post CABG in _%#MM#%_ 2003 with a LIMA to LAD and a saphenous vein graft to OM1 and then a saphenous vein graft to PDA. He presented with V-fib arrest at that time that occurred during exercise. 2. History of AICD implanted in _%#MM#%_ 2003 after V-fib arrest.
PDA|posterior descending artery|(PDA)|228|232|DISCHARGE DIAGNOSIS|2. Successful angioplasty and stenting of the proximal left anterior descending (LAD) artery with a drug-eluting stent. 3. 50% left main disease. 4. 50-60% midcircumflex disease. 5. 50-60% left-sided posterior descending artery (PDA) disease. 6. Moderate reduction in left ventricular function with an ejection fraction of 35%.
PDA|posterior descending artery|PDA|170|172|PAST MEDICAL HISTORY|The first one was 33 years ago and the most recent one was 14 years ago. 2. The patient is status post 5-vessel bypass in 1990 which had a LIMA to the LAD and SVG to the PDA and SVG to the PLA and SVG to the OM and SVG to a diagonal. The patient also has a history of heart failure that was documented by a TTA as of _%#MM#%_ 2003 which showed an ejection fraction of 25% with a moderately dilated LV and akineses in the posterior and inferior walls.
PDA|posterior descending artery|PDA|247|249|HISTORY|There was a 70% narrowing into the posterolateral branch and a drug-eluting stent was also placed there and it was patent. The ejection fraction was 30% with moderate mitral insufficiency. Dr. _%#NAME#%_ then performed angioplasty. He stented the PDA ostium, taking the narrowing down to 30%. He angioplastied with PDA but the initial stent in the PDA was disrupted and therefore stenting of the RCA was necessary.
PDA|posterior descending artery|PDA|159|161|HOSPITAL COURSE|There is worse narrowing with up to 80%. The right coronary artery was heavily calcified; it had diffuse narrowing, 20% throughout the entire mid portion. The PDA is a small vessel with diffuse narrowing up to 70 to 80%. Posterolateral branch #1 is normal, posterolateral branch #2 is occluded.
PDA|posterior descending artery|PDA,|188|191|HOSPITAL COURSE|However, en route his symptoms recurred and were unrelieved. He was taken emergently to the Cath Lab, where angiography demonstrated the culprit lesion to be thrombolytic occlusion of the PDA, which was successfully stented with a drug-eluting stent. He had a small marginal with a 50-60% stenosis, and no other lesions over 30%.
PDA|posterior descending artery|PDA|310|312|HOSPITAL COURSE|The results of the cardiac catheterization revealed severe re-stenotic lesion in the mid-RCA and at the origin of the PDA, with mild-to- moderate disease noted in the left anterior descending artery. Also, left circumflex artery showed some small proximal lesions, too small again for intervention. The distal PDA and mid-RCA were stented. PROBLEM #2: Hypertension. Continued patient's home regimen of blood pressure medications. However, his systolic blood pressures were still in the 140s.
PDA|posterior descending artery|PDA|141|143|PAST MEDICAL HISTORY|2. Gastroesophageal reflux disease. 3. Aspiration pneumonia in _%#MM#%_ 2004, treated with Augmentin for 10 days. 4. Status post ligation of PDA and coarctation repair in _%#MM#%_ 2004. 5. G-tube placement _%#DDMM2004#%_. The patient elected not to have a Nissen fundoplication at this time.
PDA|posterior descending artery|PDA.|167|170|PAST MEDICAL HISTORY|There were no other stenoses in the LAD or diagonal branches. The left circumflex had a long 80% to 90% stenosis extending from a distal left circumflex into the left PDA. The left posterolateral emerged from the diseased segment of the PDA. The distal left circumflex was angioplastied with placement of a 2.25 x 28-mm Minivision stent.
PDA|posterior descending artery|PDA|190|192|ASSESSMENT/PLAN|8. Actos 45 mg, 1 p.o. q. day. 9. Valium 2 mg p.o. p.r.n. 10. Provigil 100 mg p.o. q. day. ASSESSMENT/PLAN: 1. Coronary artery disease, status post primary stenting to distal circumflex and PDA with Cypher drug-eluted stent. He does have other mild to moderate disease that remains, however, no other significant lesions noted.
PDA|posterior descending artery|PDA|162|164|PAST MEDICAL HISTORY|During that hospitalization, a gastrojejunostomy tube was placed and overnight enteral feeds were initiated. She was evaluated by Cardiology and at that time her PDA was not felt to a significant contributory to her failure to thrive. She was noted to have borderline hypothyroidism and was started on Synthroid.
PDA|patent ductus arteriosus|PDA|172|174|PROBLEM #3|An echo showed a patent foramen ovale shunting right to left and large PDA with low velocity bidirectional shunting and equal PA in systemic pressures. The murmur for this PDA had resolved by the time of discharge and she remained asymptomatic. Therefore, no followup echocardiogram was done. Regarding her initial hypertension, she did require dopamine and hydrocortisone early Neonatal Intensive Care Unit course to maintain blood pressures.
PDA|posterior descending artery|(PDA)|261|265|DISCHARGE DIAGNOSIS|3. Known diffuse coronary artery disease with totally occluded left anterior descending (LAD) proximally and 100% occlusion distally, normal circumflex coronary, moderately diffuse disease in the right coronary artery (RCA) mid 50%, posterior descending artery (PDA) 30% with right-to-left collateralization to the LAD territory. Ventriculography was not performed at the time of the stent placement and the time of the acute infarct on _%#DDMM2004#%_.
PDA|posterior descending artery|PDA.|163|166|HISTORY/HOSPITAL COURSE|He had an 80-90% marginal vessel lesion which I chose not to do since it was not the acute infarct vessel. He also had a subtotally to totally occluded very small PDA. His heart attack healed up. He continued to have chest pain but it was not clear if this was angina. He was very confused during this admission. I felt that the chest pain was either noncardiac or if it was cardiac, it was coming from the occluded PDA or the OM.
PDA|posterior descending artery|PDA.|162|165|PAST MEDICAL HISTORY|She also has known PDA disease, however, unfortunately this angiogram was complicated by aortic dissection and, therefore, there was no intervention taken in the PDA. 3. History of GI bleeding/hemorrhagic gastritis. 4. CVI in 1997. 5. Hypertension. 6. Anemia. 7. Status post tonsillectomy. 8. Status post cystic tumor of her left femur.
PDA|posterior descending artery|PDA|163|165|SUMMARY|SUMMARY: _%#NAME#%_ is a 2-week-old infant who had pulmonary stenosis with intact ventricular septum. His echocardiogram prior to discharge revealed 1-mm residual PDA with left-to-right shunting and good flow across the right ventricular outflow tract with a 45-mm gradient. It was a pleasure being involved in _%#NAME#%_'s care. Please do not hesitate to contact us if you have any questions.
PDA|posterior descending artery|PDA|124|126|CHIEF COMPLAINT|Further noted that the RCA had diffuse disease with 50% to 60% narrowing in the proximal mid and distal segments. The right PDA had a 60% ostial stenosis, and the remainder of the right PDA had diffuse 40% disease. The right PL had a 40% ostial narrowing and a long 80% stenosis in the proximal segment.
PDA|posterior descending artery|PDA.|211|214||_%#NAME#%_ _%#NAME#%_ is an 80-year-old woman, DOB _%#DDMM1925#%_, admitted for interventional therapy on _%#DDMM2006#%_ with subsequent discharge on _%#DDMM2006#%_ having had stenting of the mid RCA and of the PDA. Slow flow and a small linear dissection at the distal edge of the stent was successfully treated by PTCA, adenosine and nitro to resume flow, with a minor troponin bump of 4.69 noted at 6 o'clock in the morning on one, _%#MM#%_.
PDA|posterior descending artery|PDA|176|178|OPERATIONS/PROCEDURES PERFORMED|The left circumflex also had an 85% proximal stenosis at the OM takeoff just distal to this. This vessel gave off a PLA branch. The RCA was a small vessel and gave off a small PDA from the distal RCA, and also the RV marginal branch continued to feed the distal PDA territory. Angioplasty was performed using an XP guide. The OM circumflex lesions were crossed with All Star wires.
PDA|posterior descending artery|PDA.|225|228||Dr. _%#NAME#%_ _%#NAME#%_ was consulted and he underwent coronary artery bypass grafting x4 on _%#DDMM2007#%_ with a LIMA to his LAD, saphenous vein graft to his OM1, sequential to his diagonal 1, saphenous vein graft to his PDA. His distal RCA was very calcified, his mid-LAD was calcified and it was intramyocardial. His diagonal 1 had a proximal vessel heavily calcified and his diagonal 2 was less than 1 mm, not graftable.
PDA|posterior descending artery|PDA|306|308|HISTORY/HOSPITAL COURSE|A stress echocardiogram was completed as part of her evaluation and she was found to have hypertensive response with stress and a 1.5 mm ST segment depression in the inferior leads. She was referred for cardiac catheterization for further investigation. She was determined to have a ruptured plaque in her PDA off the right coronary artery which was eccentric in nature. Angioplasty and stent was completed and TIMI III flow was achieved.
PDA|posterior descending artery|(PDA)|129|133|DISCHARGE DIAGNOSIS|3. Coronary artery disease. 4. 40% stenosis at the crux of the distal right coronary artery. 5. Mild posterior descending artery (PDA) disease. 6. 40% calcific diffuse mid right coronary artery disease. 7. 20% first diagonal disease. 8. 10% proximal left anterior descending (LAD) disease.
PDA|posterior descending artery|PDA.|225|228|PAST MEDICAL HISTORY|Most angiogram on _%#MM#%_ _%#DD#%_, 2005, done for a positive stress test of the inferior wall, showed moderate disease of the LAD and circumflex arteries, severe proximal and mid disease in the RAC, and mild disease in the PDA. A stent was placed in the mid-RCA, which was complicated by a perforation of the PLA, which was also stented. LABORATORY: White blood cell count 10.9, hemoglobin 14.9, hematocrit 44.8, and CV 92, platelets 332,000.
PDA|patent ductus arteriosus|PDA|239|241|PAST MEDICAL HISTORY|She was admitted for further observation and investigation of causes for her decreased oxygen saturations. PAST MEDICAL HISTORY: 1. Right hypoplastic heart, pulmonary atresia, tricuspid atresia. 2. Status post BT shunt, atrial septectomy, PDA ligation on _%#MM#%_ _%#DD#%_, 2006. 3. History of slow esophageal motility, on Reglan. PHYSICAL EXAMINATION: On admission, temperature 98.4, pulse 157, respirations 56, blood pressure 99/53, and weight 3.02 kg.
PDA|posterior descending artery|PDA,|150|153|SUMMARY OF HOSPITAL COURSE|The patient was taken to the operating room on the following day where he underwent a three-vessel coronary artery bypass graft. LIMA to LAD, RSVG to PDA, RSVG to OM1, RCA endarterectomy. The procedure was without complications, and the patient tolerated the procedure well. Please refer to the operative note dated _%#MM#%_ _%#DD#%_, 2006, for a full details of the procedure.
PDA|posterior descending artery|PDA|351|353|HOSPITAL COURSE|The most likely etiology for the hyperbilirubinemia was physiologic. _%#NAME#%_ is going home with a bili blanket and needs to have her bilirubin and platelet count checked _%#DDMM2006#%_. Problem #5: Cardiovascular. _%#NAME#%_ had an echocardiogram on _%#DDMM2006#%_ due to a murmur and large heart on chest x-ray, which revealed a moderate to large PDA with aortic runoff and left atrial enlargement and PFO but otherwise normal anatomy and function. No intervention at this time but may be considered if _%#NAME#%_ develops feeding intolerance or cardio-respiratory compromise.
PDA|posterior descending artery|PDA|157|159|HOSPITAL COURSE|The left circumflex only had mild luminal irregularities. The right coronary artery had a proximal to mid 90% stenosis. The distal right coronary artery and PDA have mild luminal irregularities. Left ventriculogram did show mild global hypokinesis and mild mitral regurgitation. Again, she did have a 3.5 x 8 mm Cypher drug-eluting stent placed to the left anterior descending artery with 0% residual, and she did have a 3.5 x 13 mm Cypher drug-eluting stent placed at the right coronary artery with 0% residual stenosis.
PDA|posterior descending artery|PDA|205|207|HOSPITAL COURSE|Her left circumflex was essentially normal. Right coronary artery had an ostial stenosis of 50%. It continues on as a dominant vessel. Distal to the bifurcation, there were mild irregularities of 20%. The PDA and PL branches were free of significant disease. Her left ventriculogram showed a LV EF of 75% with severe mitral annular calcification noted.
PDA|patent ductus arteriosus|PDA|140|142|PHYSICAL EXAMINATION|Her lungs were clear to auscultation bilaterally with good breath sounds. Her cardiac exam was significant for a gallop rhythm as well as a PDA murmur. Her abdomen was soft, nontender, and nondistended. Her peripheral pulses were 2+ bilaterally, and she had good movement bilaterally.
PDA|patent ductus arteriosus|(PDA)|214|218|DISCHARGE INSTRUCTIONS|Ureaplasma culture was negative. Problem # 7: Cardiovascular. _%#NAME#%_ had an echocardiogram (ECHO) on _%#DDMM2006#%_ in preparation for possible need for ECMO. The ECHO revealed a large patent ductus arteriosus (PDA) with right to left shunting. This was repeated on _%#DDMM2006#%_ and showed large left sided pleural effusion, no PDA, and small PFO with left to right shunt.
PDA|posterior descending artery|PDA.|335|338|OPERATIONS/PROCEDURES PERFORMED|There was mildly increased right ventricular pressures. 3. Cardiac catheterization performed on _%#MM#%_ _%#DD#%_, 2005, demonstrated in-stent re-stenosis of the distal portion of the mid LAD of 70%, vein graft to distal RCA had an 86% ostial lesion, severe in-stent re-stenosis of 75% in ostial PLA, and severe 80% stenosis of ostial PDA. Stenting was performed on the mid LAD, distal RCA, and ostial PLA along with ostial saphenous vein graft to RCA. Please refer to cardiac catheterization record for details of the procedure.
PDA|posterior descending artery|PDA|289|291|DISCHARGE FOLLOW-UP|He underwent angiography which demonstrated a chronic total occlusion of his mid LAD and of a nondominant right coronary artery and of his dominant circumflex. The LIMA graft to his LAD was widely patent. The Y graft with one limb to the ramus intermedius and one limb to the OM1 and left PDA showed a 99% lesion in the main body of the graft as well as a chronic occlusion of the limb to the OM1/left PDA.
PDA|posterior descending artery|PDA|243|245|HOSPITAL COURSE|Fractional flow of diagonal 2 was obtained and not significant with a value of 0.89. The fractional flow of the PDA was 0.71, and significant intervention on the right coronary artery was performed. Successful stenting of the proximal RCA and PDA were done, and the patient was transferred to the telemetry floor, and we were able to discharge Mr. _%#NAME#%_ the following day, on _%#MM#%_ _%#DD#%_, 2006. He remained chest pain free during his stay.
PDA|posterior descending artery|PDA|126|128|PROCEDURES THIS ADMISSION|D1 was moderate in caliber without disease, D2 and D3 were both very small. RCA was large in caliber and consisted of a right PDA and several small right PL branches. No disease in the RCA system. LVEDP was 34. RA 11 mmHg, RV 44/11, PA 47/30 with a mean of 39, wedge was 34, She was admitted to the Cardiac ICU for observation while on Swan- Ganz.
PDA|posterior descending artery|PDA,|132|135|HISTORY OF PRESENT ILLNESS|He underwent a three-vessel coronary artery bypass grafting x4. LIMA to his LAD, saphenous vein graft to the PLA, sequential to his PDA, saphenous vein graft to his OM. He had tolerated the procedure fine and was transferred to the ICU in stable condition where the patient's postop course was complicated by an episode of atrial fibrillation, treated with amiodarone.
PDA|posterior descending artery|PDA.|247|250|HISTORY OF PRESENT ILLNESS|His diagonal 1 had a 50% ostial lesion. His left circumflex has 40% in its midcircumflex and 60% in the lateral branch of his OM1. His RCA stent was widely patent in the proximal RCA and only mild-to-moderate diffuse disease in mid RCA and in the PDA. Normal LV function and normal wall motion. His LVEP was elevated though above 30 mmHg, no aortic valve gradient was seen.
PDA|posterior descending artery|PDA|243|245|DISCHARGE DIAGNOSES|2. Prior stenting of the diagonal branch of the LAD with the proximal drug-eluting stent being without evidence of restenosis, the subsequent bare metal stent has mild restenosis of 30-40%. There is also residual disease of 70-80% in the left PDA which was felt to be so small that intervention was not recommended unless the patient has recurrent symptoms. There is also a 70%-80% mid-right coronary artery stenosis in what was described as a "non-dominant" vessel which was also small.
PDA|patent ductus arteriosus|PDA.|155|158|PLAN|4. Iron supplementation 2 mg elemental iron (1 mg/kg/dose) t.i.d. x1 month, then repeat CBC. 5. Follow up echocardiogram at 3-4 months of age for followup PDA. 6. Follow up head ultrasound within the next few weeks for questionable "slight" posterior echogenicity.
PDA|posterior descending artery|PDA,|136|139|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Chest pain secondary to coronary artery disease. a. Coronary angiography, _%#DDMM2006#%_, revealed an 80% right PDA, for which a drug-eluting stent was placed. She was also found to have preserved left ventricular function with inferior basilar hypokinesis.
PDA|posterior descending artery|PDA|157|159|PLAN|He is also noted by his routine labs to have a low potassium. PLAN: The patient has already been brought for an acute PCI at the time of this dictation. His PDA was found to be obstructed and was successfully repaired using a Cypher drug-eluting stent. He is also found to have extensive and quite severe diffuse atherosclerotic changes with multiple lesions in the 40-80% range, including the LAD and mid right coronary artery.
PDA|posterior descending artery|PDA|149|151|HOSPITAL COURSE|The right coronary artery had a mid 25% stenosis and 35 to at most 50% narrowing. The distal right coronary artery only had mild irregularities. The PDA was essentially normal. The patient had had an echocardiogram performed just prior to his angiogram that did show mild mitral insufficiency, however, through left ventricular gram, it appeared that he had severe mitral insufficiency with left atrial enlargement.
PDA|patent ductus arteriosus|PDA|300|302|DISCHARGE MEDICATIONS|Cultures were negative. Problem #5: Cardiovascular. _%#NAME#%_ had an echocardiogram on _%#DDMM2006#%_ due to the diaphragmatic hernia which revealed PFO vs ASD, and that the heart was displaced to the right secondary to the diaphragmatic hernia. There was evidence of bi-directional shunting at the PDA and atrial levels. Repeat echo was normal. Problem #6: Surgical. _%#NAME#%_ required surgery for congenital diaphragmatic hernia on _%#DDMM2006#%_.
PDA|posterior descending artery|PDA|155|157|DISCHARGE MEDICATIONS|He underwent aortic valve replacement on _%#DDMM2007#%_ with a 23 mm tissue prosthesis and a CAB x2 with a LIMA to his LAD and saphenous vein graft to his PDA by Dr. _%#NAME#%_ _%#NAME#%_. The patient's postoperative course was complicated with some postoperative bleeding controlled with blood products.
PDA|posterior descending artery|PDA|219|221|HOSPITAL COURSE|His end diastolic pressure was 12. He had significant disease including a 75% stenosis in his mid right coronary artery and a 90% stenosis in the first obtuse marginal. There was a 60% stenosis in the distal RCA at the PDA bifurcation point. There was minimal disease in the LAD. The circumflex was felt to be the culprit. He had angioplasty performed of his first marginal branch. He also had angioplasty performed of the mid right coronary artery.
PDA|posterior descending artery|PDA.|133|136|MAJOR PROCEDURES/IMAGING PROFILE|Left circumflex ended after getting a large OM. Right coronary artery with large dominant vessel giving posterior long PLA after the PDA. The report was consistent with nonischemic cardiomyopathy, idiopathic versus tachycardia mediated. Repeat echocardiogram was performed before putting in the pacemaker. It showed the presence of a small thrombus in the left arterial appendage.
PDA|patent ductus arteriosus|PDA|141|143|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 5-month-old from a 28 week primi-twin with a history of twin-to-twin transfusion syndrome, BPD, PDA status post indomethacin, vesicoureteral reflux, grade 2 IVH. Mom states that the patient was doing well until 6:00 p.m. the night before.
PDA|patent ductus arteriosus|PDA|222|224|HOSPITAL COURSE|The proximal LAD stent was open. The second obtuse marginal branch had a subtotal occlusion that was evident on the _%#DDMM2002#%_ exam. The rest of the angio is unchanged from _%#DDMM2002#%_. Further clarification of the PDA was obtained with a follow up echo. The patient's nitro drip was stopped, as well as his heparin drip.
PDA|posterior descending artery|PDA.|206|209|HOSPITAL COURSE|She had originally presented to an outside hospital, but was transferred to F-UMC for catheterization. During her catheterization, her coronary arteries were found to be blocked in the LAD, RCA, and distal PDA. The patient was somewhat dynamically stable and, thus, a balloon pump was placed in order to discuss an emergency consultation for coronary revascularization.
PDA|posterior descending artery|PDA|121|123||Cardiac catheterization showed moderate but non-critical coronary disease. He had a mid 60% LAD lesion, a mid 50% to 60% PDA lesion, and mild coronary disease otherwise. LVEF was about 40% with a non-ischemic cardiomyopathy. This was global and not segmental.
PDA|posterior descending artery|PDA.|269|272|DIAGNOSIS|2. Coronary artery disease. 3. Status post angioplasty and stenting of a 100% occluded mid-RCA (right coronary artery) and above a 90% posterior descending artery (PDA). A 3.5- x 24-mm Express stent was placed in the mid-RCA, a 3.0- x 20-mm Express stent placed in the PDA. There was 50% proximal left anterior descending (LAD) artery disease, 40% mid-LAD disease, 50% distal-LAD disease; 60% diagonal artery disease; 50% mid-circumflex disease; 60% second obtuse marginal (OM-2); 95% disease of a distal branch of the posterolateral artery; 40-50% proximal- RCA disease.
PDA|posterior descending artery|PDA,|208|211|HOSPITAL COURSE|At his heart catheterization on _%#DDMM2001#%_, the patient had moderately severe aortic stenosis with a calculated valve area of 0.66. He had a patent internal mammary to the LAD, a patent vein graft to the PDA, and a patent vein graft to the obtuse marginal. He did have significant reduction in the ejection fraction at 30%.
PDA|posterior descending artery|PDA|179|181|HOSPITAL COURSE|Specifically, the patient was noted to have 50% stenosis in the proximal LAD, 95% mid vessel stenosis of OM-1 80-90% stenosis, right coronary artery with multiple irregularities, PDA with 75-80% stenosis. It was also noted that the patient had moderate aortic stenosis at this time as well. Based on the patient's angiography, it was felt that he should undergo four vessel bypass as well as aortic bioprosthesis valve replacement.
PDA|patent ductus arteriosus|PDA|259|261|ASSESSMENT/PLAN|3. Cardiovascular: Initial chest x-ray revealed an enlarged heart. Pre- and post-ductal oxygen saturations revealed a 10% difference. For this reason a cardiac echo was performed and revealed concentric left ventricular hypertrophy (diabetic cardiomyopathy), PDA and patent foramen ovale. No treatment was necessary. 4. Gastrointestinal: _%#NAME#%_ experienced gastroesophageal reflux. He was started on zantac, reglan and reflux precautions. These medications have been discontinued.
PDA|patent ductus arteriosus|PDA|123|125|PAST MEDICAL HISTORY|3. Cleft lip and palate repair. 4. TE fistula and esophageal atresia status post repair. 5. GERD status post Nissen x2. 6. PDA status post ligation. 7. Bilateral pleural effusions. 8. Recurrent otitis. 9. Port-A-Cath placement and removal. ALLERGIES: LATEX. PHYSICAL EXAM ON ADMISSION: Temperature 98.3, pulse 137, respirations 30, blood pressure 94/68, weight 13.8 kg.
PDA|posterior descending artery|PDA|257|259|FOLLOW UP|An echocardiogram was ordered to be done on _%#DDMM2003#%_. This showed a small PDA with a left to right shunt and a small PFO, with otherwise normal anatomy. She had a repeat echocardiogram on _%#DDMM2003#%_ which showed that there continued to be a small PDA with a left to right shunt, but normal cardiac anatomy and good ventricular function. Amber was watched clinically and continued to do well, she was not treated with indomethacin for her PDA.
PDA|posterior descending artery|PDA,|204|207|PROCEDURE|DISCHARGE DIAGNOSIS: Chest pain; likely angina. PROCEDURE: Coronary angiography on _%#DDMM2003#%_. Results: Severe native three-vessel coronary artery disease. Patent LIMA to LAD, SVG to D1, SVG to right PDA, occluded SVG to OM. HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old gentleman status post four-vessel CABG in 1991, with multiple angioplasties and stents since then.
PDA|patent ductus arteriosus|PDA|182|184|1. 1.  FEN|A systolic murmur, grade III/VI, was detected and an echocardiograph was obtained to further evaluate her murmur and cardiac function. The echocardiography indicated a moderate size PDA (left to right shunt), normal cardiac anatomy, and good ventricular function. She did not require Indocin. The murmur is resolving. The goal is to watch this clinically to see if it will spontaneously close.
PDA|patent ductus arteriosus|PDA|210|212|3. FEN|She has lungs which are clear to auscultation bilaterally. Her heart reveals a regular sinus rhythm with an intermittent grade I/VI systolic ejection murmur at the left upper sternal border consistent with the PDA listed above. She is well perfused throughout. She is pink. Her abdomen is soft and nontender and nondistended without any hepatosplenomegaly.
PDA|patent ductus arteriosus|PDA:|179|182|1. FEN|Ongoing problems: 1. FEN: On discharge _%#NAME#%_ is taking exclusively breast milk every 3 hours. 2. GI: Elevated bilirubin will be checked again the day following discharge. 3. PDA: routine follow-up. To be seen by cardiology only if murmur is heard again. Discharge medications, treatments and special equipment: No medications Discharge measurements: Weight 4300 gms; length 55.8 cm; OFC 35.5 cm.
PDA|posterior descending artery|PDA|272|274|ALLERGIES|The RCA, PDA proximal to the graft insertion had a tortuous area that appeared to have moderate to severe stenosis. A marked gradient was seen with a pressure wire. It was felt that given this might be hemodynamically significant and contribute to his dyspnea, and so the PDA PLA was stented which was complicated by proximal edge dissection which was stented with another stent successfully. Recommendations were to continue Plavix 75 mg q.d. indefinitely and to perform a CT angiogram to look for thromboembolic disease.
PDA|posterior descending artery|(PDA)|154|158|HOSPITAL COURSE|There was only TIMI grade 1-2 flow down this vessel and there was not complete penetration of dye into the posterolateral and posterior descending artery (PDA) system, rather those vessels filled from left-sided collaterals. There was also 50-60% narrowing in the mid-LAD. The left circumflex gives off a very large OM-1 which had approximately 50-60% disease.
PDA|posterior descending artery|PDA|227|229|PROCEDURES PERFORMED|2. Coronary angiogram: demonstrated a right dominant coronary system with single vessel coronary artery disease. The RCA was moderate in caliber with a patent stent in the right PDA. No obvious instant restenosis. Distal right PDA has 25% narrowing. Left main LAD and circumflex all appear normal. HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old female with a history of coronary artery disease who comes in with sudden onset of bilateral arm pain and pressure.
PDA|posterior descending artery|PDA|191|193|PROCEDURES|No significant complications or infections during this hospitalization. PROCEDURES: 1. Echocardiography. 2. Left heart catheterization, coronary angiography, PTCA and stent placement in left PDA and branch of the circumflex coronary artery. DISCHARGE DIAGNOSES: 1. Unstable angina pectoris. 2. Moderate three vessel coronary artery disease.
PDA|posterior descending artery|PDA|308|310|PROCEDURE PERFORMED|Coronary angiography revealed 40% to 50% distal left main lesion with diffuse moderate disease along the LAD, with a high-grade apical lesion and 70% proximal first diagonal disease. The left circumflex was also diffusely diseased, with a totally occluded proximal LM1 and a high-grade proximal and mid-left PDA lesion. Stenting of the first obtuse marginal branch was attempted, but unsuccessful. Coronary artery bypass graft was recommended based on the results of this angiography.
PDA|posterior descending artery|PDA.|242|245|HISTORY OF PRESENT ILLNESS|The left circumflex was without significant disease, although the first obtuse marginal was totally occluded and filled via right collaterals. The right coronary artery revealed minimal in-stent restenosis and a high-grade lesion and a small PDA. The procedure was tolerated without complications and post catheterization course was uneventful. DISCHARGE MEDICATIONS: 1. Aspirin 162 mg q.d. 2. Lasix 40 mg q.d.
PDA|posterior descending artery|(PDA)|163|167|HOSPITAL COURSE|The previous stent placed in the right coronary artery (RCA) was functioning well, however, there was severe downstream disease in the posterior descending artery (PDA) and posterolateral branch. There was also significant severe disease in the circumflex stent and the left anterior descending (LAD) artery was occluded compromising flow into a fairly enlarged diagonal.
PDA|posterior descending artery|PDA|156|158|HISTORY|The SVG to the OM-I is small with 70-80% distal anastomotic stenosis. The SVG to the RCA and PL branches is severely and diffusely diseased throughout. The PDA is chronically occluded. Dr. _%#NAME#%_ then inserted a stent into the left main.
PDA|posterior descending artery|PDA|138|140|PROCEDURES|A copy should be given to Dr. _%#NAME#%_ but it shows single vessel coronary artery disease with bifurcation lesion at the takeoff of the PDA of the right coronary artery. There was an angioplasty done. Stent was attempted but not able to be done. It was felt at this time that optimal medical management should occur.
PDA|posterior descending artery|PDA.|212|215|HOSPITALIZATION|He has a history of diabetes, hypertension and hyperlipidemia, status post coronary artery bypass grafting with placement of a LIMA to the LAD, a saphenous vein graft to the OM, and a saphenous vein graft to the PDA. He recently had multiple interventions, including one in _%#MM#%_ of 2004, which included placement of drug-eluting stents to his native RCA, as well as a saphenous vein graft to the PA.
PDA|posterior descending artery|PDA|184|186|HOSPITAL COURSE BY SYSTEMS|However the next day, a holosystolic murmur was heard prominently along the left sternal heart border. EKG and cardiac echo was obtained at that point in time which revealed a closing PDA and a small muscular VSD. The murmur has not been heard throughout the rest of the hospital stay. The baby is voiding and stooling and stools are transitional.
PDA|posterior descending artery|PDA|190|192|OPERATIONS/PROCEDURES PERFORMED|LAD had diffuse disease and there was a single diagonal branch that was fed. LAD diagonal system was not grafted due to severe calcification. Mid RCA was 100% occluded. The SVG to the right PDA was patent and provided flow to both the right PDA and retrograde to the distal RCA right PR system. The target vessels had mild, diffuse disease but no focal stenosis.
PDA|patent ductus arteriosus|(PDA)|137|141|PAST MEDICAL HISTORY|Ventriculoperitoneal shunt for porencephalic cyst. 2. Cardiac ventricular septal defect, status post repair. 3. Patent ductus arteriosus (PDA) status post ligation. 4. Coarctation of the aorta, status post dilatation. SOCIAL HISTORY: He presents with his mother and grandmother and he has completed grade 8.
PDA|patent ductus arteriosus|PDA.|142|145|PLAN|_%#NAME#%_ was treated with indomethacin with resolution of his blood pressure instability and murmur. Echocardiogram on _%#MMDD#%_ showed no PDA. _%#NAME#%_ had apneic and bradycardic episodes consistent with prematurity and was treated with caffeine. 6. GI-_%#NAME#%_ was treated phototherapy for a bilirubin of 6.3 from _%#MMDD#%_- _%#MMDD#%_.
PDA|posterior descending artery|PDA.|153|156|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Coronary artery disease. A. Status post coronary artery bypass grafting in 1983 with LIMA to the LAD with saphenous graft to the PDA. B. Status post percutaneous coronary intervention with a bare-metal stent to the D1 on _%#DDMM2005#%_. 2. Chronic obstructive pulmonary disease. 3. Chronic lung disease.
PDA|posterior descending artery|PDA|152|154|DISCHARGE DIAGNOSIS|PAST MEDICAL HISTORY: 1. History of quintuple bypass in 2000. 2. History of non-ST elevation MI in _%#MM#%_ of 2004; at that time she had stents placed PDA x2. 3. History of hyperlipidemia. 4. History of hyperhomocystinemia. 5. History of rhabdomyolysis while on gemfibrozil and Lipitor. 6. Hypertension. 7. Gout. 8. Diabetes mellitus type 2.
PDA|posterior descending artery|PDA|137|139|HOSPITAL COURSE|The patient underwent a coronary angiogram which showed normal coronary arteries. She has a codominant coronary artery system with small PDA branches from both CX and RCA. All of her vessels have smooth contours with no focal stenosis. Left ventricular end diastolic pressure was 14 mmHg and left ventriculogram revealed normal left ventricular function with no wall motion abnormalities.
PDA|posterior descending artery|PDA.|167|170|HOSPITAL COURSE|There were no lesions thought to be amenable to further PTCA and stenting. The most significant stenosis was a high-grade stenosis of the posterolateral branch of the PDA. Her medical management was augmented with Imdur, which will be started at discharge. She will also continue p.o. Lasix. 3. Congestive heart failure.
PDA|patent ductus arteriosus|PDA.|147|150|PAST SURGICAL HISTORY|There was no diarrhea. She had a normal bowel movement yesterday. No signs of GI bleeding. PAST SURGICAL HISTORY: Left thoracotomy with closure of PDA. PAST MEDICAL HISTORY: Gastroesophageal reflux disease. MEDICATIONS: Birth control. ALLERGIES: None.
PDA|posterior descending artery|PDA,|201|204|PAST MEDICAL HISTORY|c. Surgical revascularization at Fairview Southdale Hospital 1995 with a LIMA to the LAD, saphenous vein graft to the first diagonal and second diagonal and third diagonal, saphenous vein graft to the PDA, and posterolateral. d. Acute coronary syndrome 2002 with angioplasty and stenting at Southdale. See separate records, but he had multiple lesions including small vessel disease.
PDA|posterior descending artery|PDA|168|170|HOSPITAL COURSE|She was taken for angiogram which revealed that she had a 90% stenosis of the mid-LAD. This was angioplastied and stented successfully. In addition she had some distal PDA disease that was left dominant system. Ejection fraction was approximately 50%. Postoperatively the patient did fairly well. Medications are fairly unchanged. Imdur has been discontinued. She was started on aspirin and Plavix along with her Coumadin.
PDA|posterior descending artery|PDA|298|300|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSIS: Angina. OPERATIONS/PROCEDURES PERFORMED: Adenosine thallium stress test. HISTORY OF PRESENT ILLNESS: This 53-year-old Caucasian male with known coronary artery disease status post bypass of LIMA to LAD and SVG to D1, D2, and PDA in _%#MM#%_ 2004, and status post PCI of SVG to PDA in _%#MM#%_ 2004, HIV positive, and hypercholesterolemia, presented to the emergency department with a 3- to 4-day history of chest pain and left arm pain similar to what he presented to when his bypass was performed.
PDA|posterior descending artery|PDA.|127|130|HISTORY AND HOSPITAL COURSE|The right coronary artery was found to be small but dominant with mid vessel 50% stenosis and distal 50% stenosis prior to the PDA. There was hypokinesis of the mid inferior wall with estimated ejection fraction of 50 to 55%. Dr. _%#NAME#%_ did write for this patient to be on Plavix for one year; however, there is no note whether he would recommend this indefinitely.
PDA|posterior descending artery|PDA|223|225|HISTORY OF PRESENT ILLNESS|Coronary angiogram shows normal left main coronary artery. LAD is normal with no focal disease. Left circumflex has alone 90% stenosis in the proximal segment. Right coronary artery has calcified 74% mid segment narrowing. PDA with 50% lesion at the take off. PCI of left circumflex was performed by predilating the lesion and DES (cypher 2.5/23 mm) was deployed with good results.
PDA|posterior descending artery|PDA|219|221|DISCHARGE DIAGNOSIS|Date of Discharge: _%#DDMM2005#%_. DISCHARGE DIAGNOSIS: 1. Coronary artery disease with abnormal stress test and symptoms of angina. 2. Complex coronary intervention on _%#DDMM2005#%_. The patient had severe paroxysmal PDA stenosis of 90%. In the course of that angioplasty and stent procedure, a 60% RCA stenosis was treated with angioplasty and stent in order to provide access to the distal artery.
PDA|posterior descending artery|PDA|234|236|PAST MEDICAL HISTORY|He denies any headache or focal neural complaints. No prior history of strokes. Denies any history of DVT. PAST MEDICAL HISTORY: Remarkable for hypertension, hypercholesterolemia and coronary artery disease with previous stent of his PDA as well as his mid and distal LAD and first and second diagonal. Please see FCIS for Dr. ____________ cardiac cath note in _%#DDMM2004#%_.
PDA|posterior descending artery|(PDA)|403|407|HISTORY OF PRESENT ILLNESS|He is fairly deconditioned after turbulent course following knee replacement complicated by Staphylococcus infection and multiple hospitalizations earlier this year. There is a history of nonischemic cardiomyopathy with ejection fraction of 30-35%, moderate aortic stenosis, and coronary disease with catheterization in _%#MM#%_ 2004 showing a chronically occluded mid right posterior descending artery (PDA) and a severe obtuse marginal lesion which was successfully stented. PAST MEDICAL HISTORY: 1. Coronary disease as above. 2. Nonischemic cardiomyopathy.
PDA|posterior descending artery|PDA|168|170|HOSPITAL COURSE|HOSPITAL COURSE: This patient has a history of nonischemic cardiomyopathy with an EF of 30-35% and with moderate aortic stenosis. He had a chronically occluded mid mid PDA and a severe obtuse marginal lesion which has been successfully repaired in _%#MM#%_ of 2004. He also has a history of rheumatic fever. He was admitted by Dr. _%#NAME#%_ who felt that this was probably gastrointestinal.
PDA|posterior descending artery|PDA|173|175|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 64-year-old female with a past medical history significant for coronary artery disease. She has a history of stenting of her PDA and LAD in 2001. She presented to the emergency room with an approximately 3- to 4-week history of exertional chest pain.
PDA|posterior descending artery|PDA|160|162|HISTORY AND HOSPITAL COURSE|The right coronary artery had a 90% ostial and 80% diffuse long segment disease in the posterior descending artery. Angioplasty was performed. First, the right PDA was pre-dilated using a 2.0-mm balloon and stented using a 2.5 x 18 mm Cypher drug-eluting stent. The ostial right circumflex artery was primarily stented using a 3.5 x 13 mm and a 3.5 x 8 mm Cypher drug-eluting stents.
PDA|patent ductus arteriosus|PDA|229|231|PAST MEDICAL HISTORY|ALLERGIES: Vancomycin (mild Redman syndrome). PAST MEDICAL HISTORY: 1. ALL diagnosed with pre B-cell in _%#DDMM2006#%_. 2. Port placement on _%#DDMM2006#%_. 3. History of pneumonia on _%#DDMM2006#%_. 4. Trisomy 21. 5. History of PDA closure. 6. Corynebacterium on _%#DDMM2006#%_. 7. History of PE tubes x2. PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: Respiratory rate 18, pulse 135, blood pressure 112/66, temperature 96.7, weight 13 kg and height 36.3 cm.
PDA|posterior descending artery|PDA|176|178|PAST  MEDICAL HISTORY|The right coronary artery was ostially occluded with collateral from atrial branch of the left circumflex artery to the conus artery and then from the distal circumflex to the PDA and distal right. The distal right had a moderate 40-50% stenosis prior to the PDA. Based on this angiogram it was recommended medical management be undertaken.
PDA|patent ductus arteriosus|PDA|132|134|PAST MEDICAL HISTORY|BIRTH HISTORY: Born 28 weeks C-section, weight 12 pounds 65 ounces, Apgars 6 and 8, twin-twin transfusion. PAST MEDICAL HISTORY: 1. PDA seen last confirmed on echo on _%#DDMM2007#%_ with also a small PFO at that time. 2. History of coag-negative Staphylococcus bacteremia and Staphylococcus aureus trachitis while on the NICU.
PDA|patent ductus arteriosus|PDA|278|280|PAST MEDICAL HISTORY|There is no history of known sick contacts. His caregiver thinks that he has "gasping" for air and breathing harder than usual, although his cough is no worse than usual. PAST MEDICAL HISTORY: 1. Cardiac: He has an extensive cardiac history. He had a surgical aortic valvotomy, PDA ligation, ASD closure, possible coarctation repair, possible left ventricular aneurysm plication, all done during his infancy. He had an aortic aneurysm repair at age 1-1/2. He had a recent cardiac catheterization on _%#DDMM2006#%_ with balloon dilatation (valvuloplasty) that showed residual moderate/severe aortic stenosis, bicuspid aortic valve, aortic stenosis status post surgical repair and aortic aneurysm status post repair.
PDA|patent ductus arteriosus|PDA|260|262|BRIEF HISTORY OF PRESENTING ILLNESS|Ejection fraction was 69%. BRIEF HISTORY OF PRESENTING ILLNESS: The patient is a 64-year-old male with past medical history significant for coronary artery disease status post 4 vessel coronary artery bypass graft. LIMA to LAD, reverse saphenous vein graft to PDA to OM and intermediate coronary artery was admitted for dizziness and vomiting, which was initially thought to be anginal equivalent.
PDA|patent ductus arteriosus|PDA|329|331|FOLLOWUP|An echocardiogram on _%#DDMM2007#%_ showed mild to moderate pulmonary valve stenosis, patent ductus arteriosus, patent foramen ovale and ventricular septal defect consistent with a diagnosis of tetralogy of Fallot. Lesion was not ductal dependent so prostaglandin was stopped. A repeat echo late evening on _%#DDMM2006#%_ showed PDA to be very minimal. _%#NAME#%_ was maintaining his SaO2 in the mid- high 90's% and feeding well. He is currently not exhibiting any signs of congestive heart failure and is being discharged on no cardiac medications.
PDA|posterior descending artery|PDA|166|168|PROCEDURES PERFORMED DURING HOSPITALIZATION|Please see formal report for details. 2. Coronary angiogram. This showed right dominant circulation. There is moderate-to-severe proximal lesion in RCA. However, the PDA is filled with a patent saphenous venous graft. LAD has mild proximal disease and is 100% occluded after the D1. However, the distal LAD is filled by a patent LIMA.
PDA|posterior descending artery|PDA|187|189|MAJOR PROCEDURES|The right PL system was extensive but the vessels were small in caliber and not ideal for PCI. There was up to 75% narrowing in a long segment of one of the PL branches. The SVG to right PDA graft was widely patent and the right PDA had mild disease. There was comparative flow between right PDA via the SVG and right PL via the native RCA system.
PDA|posterior descending artery|PDA|232|234|HOSPITAL COURSE|There was diffuse mild-to-moderate distal LAD irregularity in the right coronary artery in the mid portion where he previously had a stent, and had a 40% instent restenosis. Distally, it was widely patent with 0% residual stenosis. PDA had diffuse mid and distal 40-50% disease of his posterolateral branch with a 60% stenosis in the AV groove portion. Again, ejection fraction was measured to be approximately 35%, with a moderately large region of inferior and posterior akinesis.
PDA|posterior descending artery|PDA|142|144||_%#NAME#%_ _%#NAME#%_ is an 85-year-old gentleman with history of coronary artery disease, status post inferior wall MI with occlusion of the PDA artery in _%#DDMM2004#%_. No stent was placed due to the tortuosity of the proximal vessels. The patient had an episode of chest discomfort in the winter of 2005 without a diagnosis, but felt that it was not coronary artery disease.
PDA|posterior descending artery|PDA|225|227|HISTORY|The patient was brought to the heart catheterization lab on day 1, angiogram showed thevein graft to the right coronary artery and the LIMA graft to LAD were widely patent. There was, however, a subtotal occlusion of a small PDA after the graft insertion and 70-80% narrowing in a small posterolateral branch after the vein graft insertion. The LIMA graft was fine, there was a 50% mid-LAD lesion after the graft which was not flow limiting.
PDA|posterior descending artery|PDA|262|264|PROCEDURES|DISCHARGE DIAGNOSES: Diffuse coronary artery disease with unstable angina. Status post coronary artery bypass grafting three times in the past. PROCEDURES: On _%#DDMM2000#%_ Fourth time redo coronary artery bypass graft x1 with off-pump gastroepiploic artery to PDA and TMR via partial laparotomy. ADMITTING SURGEON: _%#NAME#%_ _%#NAME#%_, MD. ADMITTING HISTORY AND PHYSICAL: This is a 60-year-old male with past medical history significant for coronary artery disease.
PDA|posterior descending artery|PDA.|239|242|DISCHARGE MEDICATIONS|He underwent a 4-vessel bypass with mitral valve replacement with a tissue valve, 31 mm bovine pericardial, on _%#DDMM2007#%_ with a LIMA to the LAD, saphenous vein graft to OM1, sequential to a diagonal, and a saphenous vein graft to the PDA. He tolerated the procedure well and was transferred to the ICU in stable condition where his postoperative course was uneventful.
PDA|posterior descending artery|PDA.|175|178||On _%#DDMM2007#%_ she underwent a coronary artery bypass graft x4 with a LIMA to her LAD, saphenous vein graft to her ramus, sequential to her OMm saphenous vein graft to her PDA. the patient's ascending aorta was 4 cm. It was not replaced. The root was within normal limits. Postop course was complicated by atrial fibrillation with rapid ventricular response, resistant to metoprolol at 100 mg b.i.d., amiodarone bolus load and placed on 400 mg p.o. b.i.d. along with Cardizem for rate control.
PDA|posterior descending artery|PDA,|136|139|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Coronary artery bypass graft x 4 in _%#MM#%_, 1981, and _%#MM#%_, 1994. This was a saphenous vein graft to his PDA, LAD, D-1, and OM-1. 2. History of atrial fibrillation with cardioversion in _%#MM#%_ of 2001. 3. Stable angina. 4. BPH. 5. GERD. 6. Hypertension.
PDA|posterior descending artery|PDA|176|178|HOSPITAL COURSE|There was evidence of thrombus. Angioplasty and stent placement was performed in the right coronary artery with placement of a 4.0 mm stent. There was a 50-60% stenosis of the PDA which was considered to be non-flow limiting. Angioplasty was attempted on the third obtuse marginal branch which was very small and which closed after attempted angioplasty.
PDA|posterior descending artery|PDA,|200|203|HOSPITAL COURSE BY PROBLEM|He had 3 troponins, which were all negative. He was subsequently taken to the Cath lab given his history. The patient was found to have 3-vessel coronary artery disease with patent stents in the RCA, PDA, PLA and LAD. He then had a stent placed to the LAD. He had successful angioplasty of the mid LAD again with stent placement to that artery.
PDA|patent ductus arteriosus|PDA|241|243|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Non-small cell lung CA. 2. Status post right upper lobectomy with chest wall resection, on _%#DDMM2002#%_. 3. COPD. 4. History of diverticulitis. 5. History of hyperlipidemia. No medical treatment. 6. Osteopenia. 7. PDA repair at FUMC. 8. Additional surgical history includes a hysterectomy, cystocele and rectocele repair, appendectomy, and ovarian cystectomy.
PDA|patent ductus arteriosus|PDA|148|150|FOLLOW UP|2. Respiratory - stable on room air. 3. CV - stable, requiring no medications. Cardiac Echo - normal cardiac anatomy, good ventricular function, no PDA or PFO. 4. ID - mom GBS +, received 2 doses of penicillin during labor. _%#NAME#%_ showed no signs of sepsis and no antibiotics were started.
PDA|posterior descending artery|PDA|223|225|OPERATIONS/PROCEDURES PERFORMED|In brief details, there was 3-vessel disease without left main lesion, proximal LAD was totally occluded with a thrombotic lesion. The mid-circumflex was 70% stenosis, and OM2 was 90% stenosis. RCA diffuse disease, and the PDA was totally occluded and filled by right collaterals. LV gram showed normal left ventricular function. This was a catheterization done in 2000.
PDA|posterior descending artery|PDA.|115|118|PROCEDURES IN HOSPITAL|Dr. _%#NAME#%_ _%#NAME#%_ placed a LIMA to the LAD, a left radial artery graft to the OM and a S- V-G to the right PDA. 2. Cardiac catheterization performed by Dr. _%#NAME#%_ _%#NAME#%_. In brief, the LAD is 100% occluded at its origin. There is an 80% proximal circumflex stenosis. A 90% OM1 stenosis and a 90% mid RCA stenosis were also present.
PDA|posterior descending artery|(PDA)|294|298|HOSPITAL COURSE|Cardiac catheterization was subsequently carried out. He was found to have a total occlusion of the proximal right coronary artery (RCA) and total occlusions of the mid left anterior descending artery (LAD) and mid circumflex artery. However, his vein grafts to the posterior descending artery (PDA) and obtuse marginal 2 (OM2) were open. His LIMA to the LAD was also widely patent. Therefore, this gentleman is considered fully revascularized at this stage.
PDA|posterior descending artery|PDA|237|239|HOSPITAL COURSE|There was mild circumflex and mid LAD irregularity. He underwent successful stenting of a long segment of the proximal and mid RCA with a total of three serial stents. Angiographic result. He underwent cutting balloon angioplasty of the PDA lesion with an excellent result. He had an uncomplicated postoperative course. DISCHARGE PLANS: He was discharged home in stable condition on the above medications.
PDA|posterior descending artery|PDA,|227|230|HOSPITAL COURSE|This eventually led to catheterization yesterday demonstrating a severe lesion in the vein graft to the obtuse marginal branch. His native arteries and most of his branch arteries were essentially occluded, a patent graft to a PDA, a patent Y graft to the diagonal and the LAD. Ejection fraction was 30%. Pressures are as noted above. The patient underwent extension of the culprit lesion and had an uncomplicated postoperative course with no ECG changes and stable labs the next day.
PDA|patent ductus arteriosus|PDA,|204|207|3. CV|He continued to maintain his oxygenation effectively in room air prior to discharge. 3. CV: An ECHO was performed during this admission with results showing normal cardiac anatomy and function, an absent PDA, and a small PFO with a left to right shunt. No further concerns regarding his cardiovascular system were raised prior to discharge.
PDA|posterior descending artery|PDA|169|171|PROCEDURES PERFORMED|Left circumflex is nondominant. There is mild diffuse disease, but no significant stenosis. The RCA is dominant and occluded in midportion. No graft to this vessel. The PDA is partially collateralized by the apical LAD and left circumflex. RI is a large vessel and has a large, 60% stenosis in its very proximal segment.
PDA|posterior descending artery|PDA.|272|275|HOSPITAL COURSE|Circumflex also had mild lumenal irregularities. The right coronary artery had a mild stenosis in the mid-segment of about 20-30%, and distally there was a subtotal occlusion with TIMI grade I flow to the distal vessel. This obstruction occurred before the takeoff of the PDA. The patient's ejection fraction on the catheterization was estimated at 55%. The patient underwent successful angioplasty and stenting of the distal right coronary artery, with a Cypher drug-eluting stent.
PDA|posterior descending artery|PDA.|228|231|HOSPITAL COURSE|The distal vessel did not contain any severe disease. The right coronary artery is a relatively small in caliber vessel. It had a 60 to 70% smooth stenosis in its mid segment and a very tight 95% stenosis for the takeoff of the PDA. Left ventriculogram was normal in size and shape. Ejection fraction was normal. The patient underwent angioplasty and stenting of the distal right coronary artery with a drug- alluding stent.
PDA|posterior descending artery|PDA.|167|170|3. CV|3. CV: A new systolic murmur was detected on day 2 of life. Echocardiogram on _%#DDMM2003#%_ revealed thickened and bicuspid pulmonary and aortic valves, a VSD, and a PDA. No cardiac medications have been considered per parent's request. 4. GI: _%#NAME#%_ was started on phototherapy on day 2 of life for elevated total bilirubin (direct bilirubin 0).
PDA|posterior descending artery|PDA|258|260|COURSE OF HOSPITALIZATION|She was admitted; she was ruled out for myocardial infarction. Because of the equivocal nature of her recent stress testing angiography was performed, which revealed a normal left ventricular function of 65%, a 100% OM-2 lesion, a 70% OM-1 lesion, a 50% mid PDA lesion and a stent in the right coronary artery, which was entirely not changed from the previous catheterization. He was advised by the Cardiology consultant, Dr. _%#NAME#%_ _%#NAME#%_, that he be treated medically.
PDA|patent ductus arteriosus|PDA|179|181|DISCHARGE MEDICATIONS|He is currently off caffeine as of _%#DDMM2003#%_. His desaturations have resolved and his respiratory status is stable on room air. 3. CV - He had a murmur on initial exam and a PDA by echo, requiring Indomethicin. He required Dopamine for hypotension for 7 days. A cardiac echo conducted on _%#DDMM2003#%_ showed normal cardiac anatomy.
PDA|posterior descending artery|PDA|202|204|HOSPITAL COURSE|She was suspicious of having unstable angina pectoris. She underwent a repeat cardiac catheterization which showed patent stent in the right coronary with 20% proximal narrowing and 60-70% narrowing of PDA branch. There was a patent stent in both the LAD and diagonal. Circumflex had a 60% narrowing in the proximal portion of the vessel.
PDA|posterior descending artery|PDA.|124|127|HOSPITAL COURSE|He underwent a previous bypass grafting in 1992 with a LIMA graft to the LAD, vein graft to the OM1 and a vein graft to the PDA. The patient had a recurrent angina in 1998, underwent angioplasty and stenting of the LAD and diagonal. The patient has been asymptomatic for approximately five years; however last _%#MM#%_ he began again to experience chest pain and shortness of breath with exertion.
PDA|posterior descending artery|PDA,|183|186|REASON FOR ADMISSION|She was premedicated with Enocilsystine. However, at the time of the angiography showed that the RCA graft was occluded and the native RCA has a long distal lesion extending into the PDA, the LIMA at the LAD was patent. OM2 was occluded and filled via collateral and not by passable per ____ line.
PDA|posterior descending artery|PDA|128|130|ALLERGIES|There was a diffuse 70% narrowing in the mid segment of the right coronary artery with diffusely segmented and small both right PDA and right posterolateral artery. There was 70% mid narrowing of the left anterior descending artery and 80% to 90% osteal narrowing of the diagonal vessel.
PDA|posterior descending artery|PDA|193|195|HISTORY|His native LAD had an 80-90% stenosis and this was angioplastied and stented. The native right coronary artery was completely occluded, but a widely patent saphenous vein graft was seen with a PDA stenosis. The circumflex artery had mild disease. The patient was again admitted for chest pain evaluation in _%#MM#%_ of 2002. Angiography again demonstrated a 40% in-stent restenosis, but nothing further.
PDA|posterior descending artery|PDA|124|126|HISTORY OF PRESENT ILLNESS|A circumflex was free of significant disease but the right coronary artery was noted to be subtotally occluded with a small PDA and posterolateral system. The patient also has a history of aortic stenosis with an aortic valve area estimated apparently at 0.8 cm squared in the past.
PDA|posterior descending artery|PDA.|110|113|PHYSICAL EXAMINATION|The patient has also had a cardiac echocardiogram, which showed her to have 2 small VSDs, small PFO and small PDA. She did have other valvular issues as well. ASSESSMENT/PLAN: This is a 3-day-old infant with trisomy 21 with jejunoileal atresia.
PDA|patent ductus arteriosus|PDA|229|231|HISTORY OF PRESENT ILLNESS|This gentleman does have a history of coronary artery disease and I have been asked to make sure he is fine for planned ECT. The patient had an abnormal stress echocardiogram last year. On angiography he was found to have an 80% PDA lesion. He does have nonobstructive disease elsewhere. A drug-eluting stent was successfully inserted into the PDA. He has been free of chest pain since then. A nuclear study in _%#MM#%_ of this year showed no evidence of ischemia.
PDA|posterior descending artery|PDA|266|268|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. ICD as above. 2. Coronary artery disease with bypass surgery. 3. Hypertension. 4. Hyperlipidemia. 5. The patient had angiogram on _%#MMDD#%_ showing LIMA graft to the LAD was patent, vein graft to the OM1 was patent, vein graft to the right PDA was patent, EF 35 to 40% with inferior posterior wall motion abnormality. He was felt to be fully re-vascularized.
PDA|posterior descending artery|PDA|165|167|HISTORY OF PRESENT ILLNESS|The patient's past cardiac history includes coronary artery bypass grafting in 2003, with a LIMA to the LAD, saphenous vein graft to a diagonal, and vein graft to a PDA branch. At the same time, she had a mitral valve replaced, and a tricuspid annuloplasty. She has a history of dilated cardiomyopathy, with an ejection fraction of 40-45%.
PDA|posterior descending artery|PDA|292|294|HISTORY OF PRESENT ILLNESS|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a pleasant 80-year-old gentleman with known history of coronary artery disease. In _%#DDMM2005#%_ the patient had angiography in _%#CITY#%_ _%#CITY#%_, Iowa, where he had angioplasty to the PDA and PL branch and Taxus stents placed in the proximal and mid right coronary artery. He was found to have small vessel disease of the LAD with a mid vessel 50-80% stenosis.
PDA|posterior descending artery|PDA|285|287|RECOMMENDATIONS|He has a history of coronary disease. This is a gentleman who presented with essentially unstable angina in _%#MM#%_ of 2007 and underwent CABG at that time for vessel coronary disease including LIMA to LAD, saphenous vein graft to OM, and sequential saphenous vein graft to the right PDA and PLA. There was noted to be a small third obtuse marginal which could not be grafted had a 70% lesion. He did well after that clinically and was without any symptoms.
PDA|patent ductus arteriosus|PDA|206|208|SUBJECTIVE|After his initial stabilization in the NICU he was started on dopamine and transferred to the PACU for further management. He underwent correction on _%#DDMM2006#%_ with correction of the TAPVR PA banding, PDA ligation, atrial septectomy, on bypass for 1 hour and 35 minutes and 31 minutes of circulatory arrest. He was found to have small pulmonary veins. Initial laboratory studies showed an INR of 1.18, PTT 80.
PDA|patent ductus arteriosus|PDA|254|256|DIAGNOSTICS|DIAGNOSTICS: Review of his chest x-ray shows clear lung fields bilaterally, with bowel within the left chest and partially part of the left segment of the liver. Cardiac echocardiogram performed on the day of birth, shortly after birth, demonstrates his PDA to be open, with a small shunt present. ASSESSMENT/PLAN: A term male infant with diaphragmatic hernia. The child is critical but relatively stable and seems to be doing well on the oscillatory ventilator and is improved through the nighttime hours.
PDA|patent ductus arteriosus|PDA|198|200|ASSESSMENT AND RECOMMENDATIONS|Genetic amniocentesis on _%#DDMM2007#%_, had shown a 46,XY karyotype. A postnatal echocardiogram showed a large perimembranous VSD with an ASD that shunts from left to right. There was also a large PDA and coarctation of the aorta. There was transposition of the great vessels. The neonate was reported as having a relatively small phallus and scrotum.
PDA|posterior descending artery|PDA|310|312|LABORATORY DATA|LABORATORY DATA: Creatinine is 1.5, hemoglobin 10.4, platelet count 212, and INR of 1.35. Review of his coronary angiogram reveals a right-dominant system, three-vessel coronary artery disease. The right coronary artery was heavily calcified with multiple stents in the proximal mid segments. The distal right PDA was ..........target. There was minimal left main coronary artery disease of 25% stenosis. There was also 80% proximal stenosis in the ostial LAD, as well as 95% stenosis in the ostial left circumflex.
PDA|posterior descending artery|PDA|173|175|HISTORY OF PRESENT ILLNESS|The first and second obtuse marginal branches were occluded, but are small, as are all of her vessels. The right coronary artery had about 20- 30% instent stenosis, and the PDA was about 80% stenotic. Left ventricular ejection fraction was judged to be about 45% with anteroapical hypokinesis. She has a history of pulmonary hypertension, biventricular heart failure, diabetes mellitus, and diastolic dysfunction.
PDA|posterior descending artery|PDA.|203|206|PATIENT HISTORY|She returned with chest discomfort about two weeks later and underwent repeat heart catheterization . This demonstrated no lesion greater than 40% in the left system and a 70-75% area of stenosis in the PDA. The mid-right coronary artery had a 50% stenosis but the stent site was widely patent. The area of stenosis in the posterior descending artery was noted to be difficult with regard to possible coronary intervention.
PDA|posterior descending artery|PDA.|197|200|HISTORY OF PRESENT ILLNESS|The right coronary artery was diffusely diseased in its proximal segment, probably to a mild to moderate degree. There was a complex lesion in the distal right coronary artery at the origin of the PDA. The PDA originated nearly parallel to the right coronary artery and then was demonstrated to have a 70% stenosis of that proximal extent.
PDA|posterior descending artery|PDA|238|240|PAST MEDICAL HISTORY|Subsequent angiography found significant left main coronary artery disease, and Dr. _%#NAME#%_ _%#NAME#%_ performed bypass surgery with a left internal mammary graft to the LAD and diagonal, and a left radial arterial graft to bypass the PDA of the right coronary artery. She was admitted to Fairview Ridges Hospital last year with chest pain. A stress nuclear study performed at that time showed only a small area of apical ischemia with preserved overall left ventricular systolic function, and therefore we elected to manage her medically.
PDA|posterior descending artery|PDA.|107|110|HISTORY OF PRESENT ILLNESS|The reader is referred to his report, basically he was found to have a severe lesion in the circumflex and PDA. The circumflex was stented. PDA was angioplastied with good angiographic results. He has also had some syncope and/or dizziness episodes. The patient previously had refused workup for that.
PDA|patent ductus arteriosus|PDA|178|180|HISTORY OF PRESENT ILLNESS|He was first diagnosed with coronary artery disease in 2003 when and angiogram showed a 95% circumflex stenosis which was stented. He also had moderate LAD disease and 60 to 70% PDA disease. Subsequently PDA was occluded in the mid portion. The lesions have been treated medically with good results. He was seen last by _%#NAME#%_ in _%#MM#%_ 2004 and was doing well.
PDA|posterior descending artery|PDA|115|117|LAD.|The ramus graft backfilled the entire circumflex, as well as the proximal LAD. There was also evidence of a distal PDA that fills distal LAD. ASSESSMENT AND PLAN: The patient is a 64-year-old gentleman, status post coronary artery bypass grafting, now admitted with inferior wall myocardial infarction.
PDA|posterior descending artery|PDA,|463|466|PAST MEDICAL HISTORY|There is no history of kidney dysfunction. The past medical history is remarkable for diabetes mellitus. I reviewed her cardiac angiogram which revealed significantly decreased left ventricular function with an ejection fraction of 30-35%, inferior akinesis, marked degree of left main disease, significant three-vessel coronary artery disease with a total and critical occlusion of the proximal RCA which shows retrograde out of the left stent into a very small PDA, 95% lesion in the proximal circumflex and LAD which does affect the large diagonal branch. I revisited the patient in the intensive care unit while on the balloon pump with good augmentation and hemodynamically stable.
PDA|posterior descending artery|PDA|190|192|PHYSICAL EXAMINATION|Left ventricular hypertrophy. Angiography showing 70-80% stenosis of the left anterior descending, 95% stenosis of the intermediate branch, 70% stenosis of the large obtuse marginal branch. PDA is occluded. ASSESSMENT/PLAN: Overall, patient is a pleasant 46-year-old gentleman, bicuspid aortic valve, hyperlipidemia, strong family history of heart disease who presents post now aortic valve replacement and coronary artery bypass surgery with a high degree AV block postoperatively.
PDA|posterior descending artery|(PDA),|332|337|REASON FOR CONSULTATION|He has had echocardiogram showing an ejection fraction of about 45% with apical anteroseptal hypokinesis to akinesis with a mildly sclerotic aortic valve and trace tricuspid regurgitation. He underwent coronary angiography showing an ejection fraction of 25% with anterior akinesis, mild stenosis in the posterior descending artery (PDA), 50% proximal left anterior descending (LAD) artery stenosis, and midvessel 95% stenosis of the LAD with distal 90%. The LAD is diffusely diseased. The LAD is large and wraps around the apex.
PDA|posterior descending artery|PDA|200|202|IMPRESSION|IMPRESSION: 1. Post-operative atrial fibrillation, now back in sinus rhythm, post- treatment with amiodarone. 2. Status-post coronary artery bypass grafting with incomplete revascularization with the PDA and posterolateral not being bypassed. The right coronary artery is chronically occluded. 3. History of hypertension and hypercholesterolemia, pre-operatively.
PDA|posterior descending artery|(PDA)|644|648|HISTORY OF PRESENT ILLNESS|REFERRING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, DO (Fairview Crosstown Clinic) REASON FOR CONSULTATION: Recurrent pericardial effusion with early tamponade. HISTORY OF PRESENT ILLNESS: Thank you very much for asking me to see _%#NAME#%_ _%#NAME#%_, a very pleasant 68-year-old gentleman, who underwent a bovine aortic valve replacement on _%#DDMM2006#%_ with coronary artery bypass grafting in a left internal mammary artery (LIMA) to his left anterior descending (LAD), a sequential graft to the ramus intermedius and to the first obtuse marginal (OM-1), and then another saphenous vein graft (SVG) sequentially to the posterior descending artery (PDA) and posterolateral artery. Unfortunately 17 days post surgery he developed a pericardial tamponade which required pericardiocentesis.
PDA|posterior descending artery|PDA.|299|302|SUMMARY|I have reviewed and independently interpreted this. This shows 50% distal left main in the range of 75%, a 90% mid-LAD involving the diagonal, occlusion of the circumflex with faint filling of the marginal by right-to- left collateral, 90% stenosis of the PDA and distal right at the takeoff of the PDA. Her ejection fraction is 40% with infrawall hypokinesia. She has had an echocardiogram showing posterolateral hypokinesia, left ventricular hypertrophy, and pulmonary hypertension with pulmonary artery pressures of 46 with left atrial enlargement.
PDA|posterior descending artery|PDA|208|210|HISTORY OF PRESENT ILLNESS|She has a history of mitral and tricuspid valve disease as well as coronary disease post-multivessel bypass grafting in 1998 with LIMA to LAD, saphenous vein to OM1 and a sequential saphenous vein to PLA and PDA at that time. She has a pacemaker in place for Bradycardia/tachycardia syndrome and does have paroxysmal atrial fibrillation with some episodes of mode switching documented on the pacemaker.
PDA|posterior descending artery|PDA.|211|214||This revealed about a 40-50% distal left main stenosis and about an 80% ostial LAD lesion and about a 40% left circumflex stenosis. Right coronary artery was subtotally occluded in the midportion and gave off a PDA. Left ventriculogram revealed quite well preserved left ventricular function. The patient has a bilateral shoulder discomfort while walking even fairly short distance, which resolves when he stops.
PDA|posterior descending artery|PDA|148|150|PAST MEDICAL HISTORY|2. History of diverticulosis found on screening colonoscopy approximately five or six years ago. 3. Degenerative joint disease. 4. Hypertension. 5. PDA repair in 1957. 6. Status post ovarian cystectomy, nephrectomy, c-section, hysteroscopy. 7. Elevated lipids. 8. History of labyrinthitis. MEDICATIONS: Metoprolol, baby aspirin, Avapro, Lipitor, Os-Cal, vitamin E and garlic.
PDA|posterior descending artery|PDA.|167|170|CARDIAC HISTORY|CARDIAC HISTORY: 1. Coronary artery bypass surgery. This was performed in 1990. At that time SVG was inserted into the PL branch and another SVG was inserted into the PDA. She had repeat cardiac catheterization in 1999. The SVG to PL was patent but the SVG to the PDA was totally occluded.
PDA|posterior descending artery|PDA|219|221|HISTORY OF PRESENT ILLNESS|At that time angiography showed three vessel disease with a 60% LAD distal lesion, a 60% first diagonal, and a 50% second diagonal lesion. There is a 30% circumflex lesion and an 80% ramus lesion. There is a 50% ostial PDA lesion. The patient has done well except for the past three to four days. He has been noticing increased cough, both productive and nonproductive.
PDA|posterior descending artery|PDA|213|215|ASSESSMENT|I told him that if his angina continues to be at risk that he should not wait that long. I would plan to graft the LAD and diagonal of the internal mammary artery and use the right radial artery for bypassing the PDA and the PLA and possibly vein for the obtuse marginal branch, although it is possible that bypassing that would result in competitive blood flow and either the graft, native artery or both might clot off.
PDA|posterior descending artery|(PDA)|291|295|HISTORY OF PRESENT ILLNESS|He subsequently had repeat angiography and was set up by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ for bypass surgery. Indeed he had a left internal mammary artery (LIMA) to the left anterior descending (LAD) and a saphenous vein graft (SVG) to the posterior descending artery (PDA) of the right coronary artery (RCA) and a saphenous vein graft to the obtuse marginal (OM). He came through surgery relatively uneventfully. Frequent blood gases were obtained but essentially he has had a normal pH of 7.44, pO2 218, pCO2 39.
PDA|posterior descending artery|PDA.|172|175|PAST MEDICAL HISTORY|10. Advair 250/50 b.i.d. 11. Metoprolol 25 b.i.d. 12. Prilosec 20 mg b.i.d. 13. Flagyl t.i.d. PAST MEDICAL HISTORY: 1. Coronary artery disease status post PCI to the right PDA. 2. Non-Hodgkin's lymphoma. 3. Recent GI bleed status post laser therapy. 4. Hypertension. 5. Recent pneumonia with bacteremia. 6. Chronic obstructive pulmonary disease.
PDA|posterior descending artery|PDA|122|124|HISTORY OF PRESENT ILLNESS|The details of her surgery included ligation of a coronary to pulmonary artery fistula, grafts to an OM1 and 2 as well as PDA and LIMA to the LAD. She has underlying hypertension that has been difficult to control. In this past year from Christmas previous to _%#MM#%_ of this year and Dr. _%#NAME#%_ who is her primary cardiologist has made multiple changes as has Dr. _%#NAME#%_, some of which led to a feeling of withdrawal and an excess of medication but finally things are on an even keel at this point.
PDA|patent ductus arteriosus|PDA|210|212|PEDIATRIC INFECTIOUS DISEASE CONSULTATION|Later on the 16th and 17th the baby had a temperature to 101 degrees, but there has been no fever the 18th or 19th. Transesophageal echo was performed postoperatively and showed a 1 mm residual VSD, no ASD, no PDA with normal ventricular function, and no outflow obstructions with normal pulmonary artery pressures. Perihilar edema or infiltrate bilaterally was noted after surgery, but parenchymal lung changes more peripherally have not been noted to date.
PDA|posterior descending artery|PDA|222|224|IMPRESSION|IMPRESSION: Ms. _%#NAME#%_ _%#NAME#%_ is a 75-year-old woman with daily recurrent chest pain over the last several weeks with a history of coronary artery disease and angioplasty and stent of the right coronary artery and PDA in _%#MM#%_ 2005. She does have residual coronary artery disease within the diagonal branch artery which is moderate to severe, but her recent exercise Cardiolite stress test was completely normal and indicated no evidence of myocardial ischemia or infarction.
PDA|posterior descending artery|PDA|193|195||He had coronary artery bypass grafting performed with a left internal mammary artery to the LAD, radial graft to the obtuse marginal artery and saphenous vein graft to the diagonal artery. The PDA was not grafted. The patient's blood pressure was controlled by Nipride postoperatively. He has been switched over to oral metoprolol 25 mg p.o. b.i.d. after having had intravenous doses of metoprolol.
PDA|posterior descending artery|PDA|385|387|LABORATORY DATA|Further, there is mild to moderate mitral regurgitation. Review of his coronary angiogram reveals normal left main coronary artery, total occlusion of the left anterior descending artery as well as total occlusion of the circumflex artery. The right coronary artery is a large dominant vessel. There is significant calcification and disease in the mid and distal vessels with a normal PDA which is large in caliber. IMPRESSION: This is a 52-year-old gentleman with ischemic cardiomyopathy as well as moderate mitral regurgitation and heart failure.
PDA|posterior descending artery|PDA.|166|169|HISTORY OF PRESENT ILLNESS|Apparently, the LAD graft was then known to be occluded, while the PDA graft was stenosed and collaterals went from the circumflex coronary artery to the LAD and the PDA. The left ventricular function is not known. The patient notes that he underwent cardiac catheterization recently at Methodist hospital and was told that he would "never be studied" again.
PDA|patent ductus arteriosus|PDA.|170|173|PAST MEDICAL HISTORY|The pregnancy was complicated with a history of diabetes. 2. Pierre-Robin sequence with cleft palate. Karyotype and FISH are pending. 3. History of aortic stenosis, VSD, PDA. 4. History of optic nerve hypoplasia bilaterally. 5. Renal hypoplasia as demonstrated by renal ultrasound. MEDICATIONS: 1. Ceftazidime 165 mg q.8h. 2. Clindamycin 30 mg q.8h.
PDA|posterior descending artery|PDA|209|211|INDICATION FOR CARDIAC CONSULTATION|Thank you very much for asking me to see Mr. _%#NAME#%_ _%#NAME#%_ who is a 61-year-old patient who in _%#MM2004#%_ suffered and acute myocardial infarction secondary to a thrombotic occlusion of an accessory PDA which was stented with a drug-eluting stent by Dr. _%#NAME#%_ _%#NAME#%_ with a good result. He has moderate disease in the circumflex, no more than 50%, and a very apical left anterior descending artery to 90% stenosis with the vast majority of the LAD having no significant flow limiting disease at all.
PDA|posterior descending artery|PDA|192|194||He had a congenitally small first circumflex of 30% stenosis and the right coronary artery was a very large vessel with a 70% stenosis in a branch vessel off the posterior lateral artery. The PDA was normal. The patient had a complex angioplasty stenting of the LAD and diagonal artery with a 0% residual lesion. With that in mind, today the patient took three Aleves for headache and developed an itch all over.
PDA|posterior descending artery|PDA.|176|179|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Coronary artery disease, the patient had a two-vessel CABG in 1992 and had a redo in 1997 with St. Jude mitral valve replacement and vein graft to the PDA. Angiograms have been showing an occluded vein graft to the LM, patent internal mammary to the LAD and a patent PDA graft.
PDA|posterior descending artery|PDA|111|113|PAST MEDICAL HISTORY|Angiograms have been showing an occluded vein graft to the LM, patent internal mammary to the LAD and a patent PDA graft. The patient also had a large inferior myocardial infarction back in 1992 and has been left with an ischemic cardiomyopathy and an ejection fraction of approximately 30% last noted on thallium scan in _%#MM#%_ of this year.
PDA|posterior descending artery|PDA|278|280|CORONARY ANGIOGRAM, 1/10/2006|NUCLEAR STRESS TEST, _%#DDMM2005#%_: Again shows moderate size inferior septal and inferior myocardial infarction with no ischemia, stress....................... CORONARY ANGIOGRAM, _%#DDMM2006#%_: Shows severe triple vessel disease with distal right coronary artery occlusion, PDA and posterior lateral artery fill by collaterals. Left main is normal. The ostial LAD has 60 to 70% stenosis and moderately diffuse disease in remainder of LAD.
PDA|patent ductus arteriosus|PDA|195|197|PLAN|This baby was documented to have grade 3 and 4 intracranial hemorrhages on ultrasound. He also had a bowel perforation with exploratory laparotomy and abdominal drain placed. Also the baby had a PDA ligation. The infant has been on antibiotics for sepsis and recently has been more stable. The mother reports the baby will briefly open the eyes, moves about, and nurses also say there is some movement of the extremities at the side from time to time with occasional tremoring and jerkiness, but no arrhythmic tonic-clonic movements of any duration.
PDA|posterior descending artery|PDA|153|155|LABORATORY DATA|The patient had stenting and angioplasty, stenting to the left anterior descending. He had a 60-70% first diagonal lesion, 60-70% OM-1, 80% OM-2 and the PDA was stented as well as the left dominant system. I will plan on taking the patient emergently to the heart catheterization, coronary angiogram and coronary intervention.
PDA|posterior descending artery|PDA|244|246|HISTORY  OF PRESENT ILLNESS|She is scheduled to have a carotid endarterectomy done tomorrow and I was asked to see her preoperatively because of her cardiac history. The patient has had coronary artery disease documented in the past. She underwent stenting of her LAD and PDA about 3-4 years ago in _%#CITY#%_ _%#CITY#%_. She had a follow-up angiogram in _%#MM#%_ of last year which was at least a year out from her stenting.
PDA|posterior descending artery|PDA|188|190|HISTORY OF PRESENT ILLNESS|He also had an 80% first obtuse marginal stenosis treated with angioplasty and stent. Residual disease was present with an 80% proximal first diagonal stenosis and a 70% RCA stenosis. The PDA was proximally occluded. Ejection fraction was 30-35%. Apparently he was then discharged and a Holter monitor was done showing nonsustained VT, and he was brought back for an EP study, which showed inducible ventricular tachycardia and an ICD was placed.
PDA|posterior descending artery|PDA|154|156|HISTORY OF PRESENT ILLNESS|This was a small caliber vessel. The patient then had a small myocardial infarction in the year 2000 and underwent another angiogram which now showed the PDA to be occluded and continued to show only minimal disease elsewhere. At that time, he had a decreased ejection fraction and elevated end-diastolic pressure, all consistent with hypertensive cardiomyopathy.
PDA|posterior descending artery|PDA.|197|200|PAST MEDICAL HISTORY|6. Coronary artery disease, status post cardiac catheterization in _%#MM#%_ 2002. She underwent stenting of proximal and mid-RCA at that time. She also had successful angioplasty of distal RCA and PDA. 7. History of left upper extremity deep venous thrombosis 6 years prior to this admission at the site of PICC line. 8. Sinus surgery 6 years ago. 9. Hyperlipidemia. ALLERGIES: Sulfa and codeine.
PDA|posterior descending artery|(PDA)|133|137|PAST MEDICAL HISTORY|a. He had an angiogram which showed documented 95% proximal left anterior descending (LAD) and a 95% mid posterior descending artery (PDA) lesion. He had percutaneous transluminal coronary angioplasty (PTCA) and a stent of the LAD and the PDA of the right coronary artery (RCA).
PDA|posterior descending artery|PDA|186|188|DOB|Vein graft to the circumflex was widely patent, and he had a patent sequential vein graft to the LAD and first diagonal. In fact, the right coronary is also sequential vein graft to the PDA and native right. At that time, left ventricular function was already substantially reduced with evidence for a calcified aneurysm of the anteroapical segment.
PDA|posterior descending artery|PDA|306|308|HISTORY|Urgent catheterization angiography was performed. This confirmed the existence of critical aortic stenosis with a peak gradient of 60 mmHg, a calcified aortic valve and two vessel coronary artery disease with a high grade osteal LAD lesion as well as a moderate to severe mid right coronary artery lesion. PDA itself was not well visualized We were asked to see him and consider both valve replacement and bypass surgery.
PDA|posterior descending artery|PDA|169|171|SUMMARY|He has severe three vessel coronary artery disease with 50 and 90% proximal stenosis in the right coronary artery, followed by a 40% prior to the take-off of a PDA. The PDA itself has an 80% stenosis. The left main appears normal. The LAD was occluded after the diagonal and the diagonal itself has long areas of 90% stenosis.
PDA|posterior descending artery|PDA.|195|198|SUMMARY|This showed a 20-30% left main, occlusion of the LAD with reconstitution by right to left collateral. The right coronary artery had a proximal 50% and mid 70% stenosis with a good quality distal PDA. The circumflex had a proximal 40% mid vessel between two moderate sized marginals of 70%, and stenosis in the first obtuse marginal of about 60-70%.
PDA|patent ductus arteriosus|PDA|148|150|HISTORY OF PRESENT ILLNESS|Transferred from the NICU to PICU in early _%#MM#%_ with a shunt VP procedure to drain in order to do a fenestration. In addition, she had previous PDA ligation and BPD from prematurity. On _%#MMDD#%_ in the morning, there was seen intermittent rhythmic movement of the left eye progressing to involve both eyes, mouth and left side of the face with a clinical episode lasting less than 5 minutes.
PDA|posterior descending artery|PDA|153|155|HISTORY OF PRESENT ILLNESS|Because of the size of the graft compared to the distal vessel, it was felt that there was no significant flow limiting lesion. There was disease in the PDA distal to the anastomosis that was treated with a 2.5 x 8 mm Cypher drug-eluting stent. The patient was admitted in _%#MM#%_ while in Arizona for similar symptoms like he had today.
PDA|posterior descending artery|PDA|208|210|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction times two. 2. Coronary artery bypass grafting with a LIMA to the LAD and diagonal sequentially and left radial artery to the PDA in the year 2000, performed by Dr. _%#NAME#%_ at Fairview Southdale Hospital. 3. Hypertension. 4. Hyperlipidemia. 5. Type 2 diabetes mellitus times one year. 6. Obesity.
PDA|posterior descending artery|PDA|176|178|HISTORY OF PRESENT ILLNESS|At that time he had emergent cardiac catheterization performed. He had a stent placed in his left circumflex coronary artery at that time. His first obtuse marginal branch and PDA were completely occluded. His OM-2 was subtotally occluded. After the procedure the patient had a defibrillator placed. His last stress test was done in _%#MM#%_ 2004; at that time he was found to have a fixed inferior-wall defect consistent with his prior infarct.
PDA|posterior descending artery|PDA|181|183|IMPRESSION/PLAN|The patient is status post cardiac arrest in _%#MM#%_, 2003; he had a stent placed in the left circumflex coronary artery and also had a defibrillator placed at that time. OM-1 and PDA were occlude, OM-2 was subtotally occluded. His last stress test showed a fixed inferior-wall defect consistent with prior infarct; however, there was a reversible lateral-wall defect; it makes me wonder if his OM-2 lesion is causing ischemia which is subsequently causing his rhythm disturbances.
PDA|posterior descending artery|PDA|119|121|HISTORY OF PRESENT ILLNESS|This was done on _%#DDMM2004#%_. (Note, the typed report has an error and said this was the LAD). He also had an osteo PDA lesion which was very tortuous, a cutting balloon was placed in the ostium of this PDA, taking the narrowing down to 20% or less.
PDA|posterior descending artery|PDA.|165|168|REASON FOR CONSULTATION|Subsequently, she underwent coronary artery bypass surgery, where a LIMA was placed at the LAD. An SVG was placed to a distal LAD and separate SVG was placed to the PDA. She has had congestive heart failure at least since 1993. She receives her cardiac care at Region Hospital. From the notes, it would appear that she has also had several single episodes.
PDA|posterior descending artery|PDA.|197|200|HISTORY|A single saphenous vein graft was used to bypass the LAD, the second diagonal, the first diagonal, the intermediate ramus, the left ventricular branch of the right coronary artery and finally, the PDA. He has done well in the intervening years and his last stress nuclear study done 1 1/2 years ago was unremarkable.
PDA|posterior descending artery|PDA,|289|292|HISTORY OF PRESENT ILLNESS|The patient has known atherosclerotic coronary vascular disease and is status post first obtuse marginal percutaneous transluminal coronary angioplasty _%#DDMM2000#%_. At that time she had diffuse coronary artery disease, including 30% right coronary artery proximally and distally in the PDA, a totally occluded diagonal branch artery, 50% mid and 80% more distal LAD stenosis, 80% distal circumflex artery stenosis and a 95% stenosis of the first obtuse marginal branch artery.
PDA|posterior descending artery|PDA.|236|239|REQUESTING PHYSICIAN|A stress test recently showed no reversible provisional defect. However, the symptoms persist and hence admission for recurrent angina at rest. Coronary angiogram performed today shows a severe stenosis of the vein graft to the PLA and PDA. Other grafts were patent. The patient had PCI with excellent result. His EF has been known to be reduced at 30-35%. The patient denies any history of near-syncope or syncope. He is in excellent functional class at I-II.
PDA|posterior descending artery|PDA|164|166|STUDIES|She had an underlying narrow complex rhythm at a rate of 60. There were P waves with a short PR interval present on the monitor. These were upright in lead II. The PDA appeared to move in and out of the initial portion of the QRS interval, suggesting the possibility of competing atrial and junctional rhythms.
PDA|posterior descending artery|PDA|217|219|HISTORY OF PRESENT ILLNESS|Coronary angiogram from _%#MM#%_ 2005 was reviewed and revealed diffuse native vessel disease with mid LAD occlusion. Her LIMA was noted to be patent as were vein grafts to first OM and a sequential vein graft to the PDA and PLA. Given her mildly positive stress test in the past from _%#MM#%_ 2005, it was felt that she would be best served by medical management and no intervention was performed.
PDA|posterior descending artery|PDA|248|250|CONCLUSION|She also developed chest pain. CONCLUSION: This patient presents with two weeks of chest pain suspicious for unstable angina or myocardial infarction. Her stress test, although not dramatically abnormal, is still suggestive of distal LAD or distal PDA disease. I believe heart catheterization is indicated. The risks and benefits of angiogram, possible angioplasty or bypass surgery including the risks of stroke, heart attack, and death were discussed with the patient.
PDA|posterior descending artery|PDA|149|151|HISTORY OF PRESENT ILLNESS|He has had multiple surgeries including a PENA procedure to correct a bladder/rectal fistula. In _%#MM#%_ 1993 procedures were performed to closed a PDA and ASD. In _%#MM#%_ 1994 a procedure to close the colostomy was done. In _%#MM#%_ 1994 he had a circumcision, laparoscopy, orchiopexy as well as placement of PE tubes and bone marrow aspiration.
PDA|posterior descending artery|PDA.|221|224|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Remarkable for ischemic cardiomyopathy. In _%#DDMM2005#%_ he underwent a coronary angiogram which showed a 30-40% proximal RCA lesion, 40-60% right RCA lesion in the mid area and 80% prior to the PDA. It showed a left circumflex with obtuse one marginal with a 30-50% lesion in an LAD with a D1 lesion of 90%. His ejection fraction at that time was 24%. When he was most recently admitted in _%#DDMM2006#%_, he had had angiogram which was compared side by side with his angiogram from _%#DDMM2005#%_ and there were no visible differences.
PDA|posterior descending artery|PDA|183|185|* GERD|She had a VCUG on _%#DDMM2008#%_, which was normal. A renal ultrasound on _%#DDMM2008#%_ was normal. This problem has resolved. Problem #12: Surgical. _%#NAME#%_ required surgery for PDA ligation on _%#DDMM2008#%_. Surgery was performed by Dr. _%#NAME#%_ without complications. Problem #13: Endocrine. _%#NAME#%_ had a positive 14-day newborn metabolic screen for congenital hypothyroidism.
PDA|posterior descending artery|PDA|465|467|IMPRESSION|IMPRESSION: 1. Acute anterior wall myocardial infarction _%#DDMM2005#%_. 2. Successful angioplasty and stenting of the mid-LAD, reducing 100% stenosis to 0%, resulting in TIMI3 flow through the midportion of the LAD, TIMI1 flow through the apical portion of the LAD despite AngioJet ballooning and a total of three CYPHER stents, intracoronary adenosine, diltiazem and nitroglycerin. 3. Residual 70% first obtuse marginal stenosis. 4. Fifty percent stenosis in the PDA with a 30% proximal RCA stenosis. 5. Initial ejection fraction of 25% but by echo 40-45% just prior to discharge. 6. Placement of an intra-aortic balloon initially post-intervention. 7. Recurring hypotension, initially thought related to pericardial tamponade with pericardial drainage surgically performed.
PDA|patent ductus arteriosus|PDA.|195|198|FOLLOW UP|Problem #4: Patent Ductus Arteriosus. A systolic murmur was noted along the left lower sternal border on _%#DDMM2005#%_ with diastolic pressures below 20, and an echocardiogram confirmed a small PDA. This PDA did lead to respiratory and cardiovascular compromise. Treatment included fluid restriction and indomethacin on _%#DDMM2005#%_. The murmur, however, reoccurred on _%#DDMM2005#%_, and a second round of indomethacin was administered.
PDA|patent ductus arteriosus|PDA,|144|147|FOLLOW UP|Chest x-ray was unremarkable with no evidence of cardiomegaly or left mainstem bronchus elevation. A follow-up ECHO on _%#DDMM2005#%_ showed no PDA, but a small PFO with left to right shunting. This murmur did resolve after the second treatment of indomethacin.
PDA|patent ductus arteriosus|PDA|223|225|1. FEN|Dr. _%#NAME#%_ _%#NAME#%_ will be following _%#NAME#%_ for her oxygen needs on _%#DDMM2004#%_ at the _%#CITY#%_ Ridges Office. Goal oxygen saturations are > 90%. 3. Cardiovascular: _%#NAME#%_ had a coarctation repair and a PDA ligation on _%#DDMM2004#%_. In addition , she has four muscular VSDs and a small PFO.
PDA|patent ductus arteriosus|PDA,|212|215|* ID|She did not require phototherapy. Her jaundice was likely physiologic. Evaluation of the twins' anatomy was done with abdominal ultrasound, echocardiogram and two abdominal CTs. The results revealed: Echo: small PDA, small PFO with normal anatomy. Abdominal U/S and CTs: Each twin has 2 branches of the portal vein that communicate with the other twin's liver.
PDA|patent ductus arteriosus|PDA,|203|206|PAST MEDICAL HISTORY|Her parents reported that she was not having any respiratory distress at the time. PAST MEDICAL HISTORY: 1. Birth history: Full term, no complications, cesarean section. 2. Trisomy 21. 3. Moderate sized PDA, treated with diuretics that have been weaned somewhat. She does require SBE prophylaxis, but her PDA is not thought to be contributing significantly to her symptoms, by Cardiology.
PDA|patent ductus arteriosus|PDA|239|241|HOSPITAL COURSE|Speech thought that this was not consistent with aspiration, especially since the usual course with Down syndrome is to improve over time. It was most likely thought to be due to reflux, although there was also a concern as to whether her PDA could be contributing if late in the day she was fatiguing with eating. A swallow study was performed on _%#DDMM2007#%_ which showed no evidence of reflux, penetration or aspiration with honey-thickened liquid.
PDA|patent ductus arteriosus|PDA|249|251|DISCHARGE INSTRUCTIONS|He required some O2 via nasal cannula, but is currently stable on room air with some rare desaturations during feeds. 3. CV - _%#NAME#%_ had an echocardiogram performed on his first day of life which showed the heart pushed into right hemithorax, a PDA of moderate size with bi-directional shunting (mostly left to right), PFO with left to right shunting and diminished right ventricular functioning, and tricuspid regurgitation.
PDA|posterior descending artery|PDA|311|313|PAST MEDICAL HISTORY|This was done by Dr. _%#NAME#%_. Coronary artery angiogram performed _%#MMDD#%_ showed three vessel disease with a left main that was 40% diseased a left anterior descending that had a diffuse proximal 80% lesion, left circumflex with mild irregularities, right coronary artery that was occluded proximally and PDA that filled by right to left collaterals from the LAD. There is a LIMA to the mid LAD that appeared normal, a saphenous vein graft to the right that appeared chronically occluded.
PDA|patent ductus arteriosus|PDA|166|168|PAST MEDICAL HISTORY|Mother had cesarean section, as the previous children had all been cesarean sections. 2. PDA: It was perinatally that she was known to have a moderate to large sized PDA on echocardiogram along with a PFO at that time. She did experience some signs of heart failure and was treated with diuretics, which have since been weaned.
PDA|patent ductus arteriosus|PDA.|204|207|FOLLOW-UP|A PDA was noted on _%#DDMM2006#%_. An echocardiogram confirmed this diagnosis. Treatment included fluid restriction and treatment with Indomethacin. A follow-up echocardiogram on _%#DDMM2006#%_ showed no PDA. Problem # 6: Patent Foramen Ovale (PFO). _%#NAME#%_ had an echocardiogram on _%#DDMM2007#%_ that revealed a small PFO with a left to right shunt, trace tricuspid regurgitation, and normal function.
PDA|patent ductus arteriosus|PDA,|174|177|PAST MEDICAL HISTORY|Initial Apgars were 4 at 1 minute, 8 at 5 minutes and 8 at 10 minutes. 2. RDS: The patient was intubated for approximately 2 weeks. She did receive surfactant. 3. History of PDA, status post indomethacin. 4. Hyperbilirubinemia, physiologic. 5. History of intraventricular hemorrhage. Initially started as a grade 1 hemorrhage on the left, which progressed into bilateral grade 2 IVH.
PDA|patent ductus arteriosus|(PDA)|308|312|FOLLOWUP|3. Cardiovascular: During initial resuscitation _%#NAME#%_ did not require chest compression or resuscitation medications. Dopamine was started on days 5-8 for pressure support. Due to increasing ventilator requirements an echocardiogram was ordered on day 3 and revealed a moderate Patent Ductus Arteriosus (PDA) along with a Patent Foramen Ovale both of which had left to right flow. Indocin was given for three doses. Repeat echocardiogram 3 days later revealed that the PDA had closed.
PDA|patent ductus arteriosus|PDA|159|161|DISCHARGE INSTRUCTIONS AND FOLLOW-UP APPOINTMENTS|A repeat Echo on _%#MMDD#%_, after being placed on ECMO, showed a mild/moderate left ventricular dysfunction and mild right ventricular dysfunction. The large PDA showed a continuous right to left shunt. A post CDH repair echo on _%#MMDD#%_ had a new finding of a linear thrombus in the right atrium but this was resolved on a repeat echo on _%#MMDD#%_ and showed no evidence of thrombus.
PDA|patent ductus arteriosus|PDA|261|263|* FEN|Problem #6: Hypotension. In order to maintain his systemic blood pressure and improve peripheral perfusion, _%#NAME#%_ required treatment with hydrocortisone. However, the hydrocortisone was stopped on _%#DDMM2007#%_ when he was started on neoprofen. After his PDA was ligated, he was restarted on hydrocortisone for a total of 3 additional days. Due to issues of persistent hypotension, he was restarted on IV steroids with hydrocortisone on _%#DDMM2008#%_.
PDA|posterior descending artery|PDA|161|163|HISTORY OF PRESENT ILLNESS|Her coronary angiogram revealed significant native 3-vessel coronary artery disease along with patent LIMA to LAD. She had occluded saphenous vein grafts to her PDA along with her OM. She had both a right- and left-heart catheterization, which showed low right- and left-sided filling pressures.
PDA|patent ductus arteriosus|PDA|140|142|3. CV|_%#NAME#%_ was given two more doses of indomethacin after respiratory status deteriorated due to the PDA and fluid overload. He underwent a PDA surgical ligation on _%#DDMM2002#%_. On _%#DDMM2003#%_, (DOL 102), _%#NAME#%_ developed supraventricular tachycardia with max rate at 260 per minute. This lasted 10-15 minutes, during which vagal maneuvers were performed in order to reverse the SVT.
PDA|posterior descending artery|PDA|156|158|OPERATIONS/PROCEDURES PERFORMED|The LIMA to the LAD was diffusely atretic and touched down to the distal LAD. The anastomosis was widely patent. The RCA was occluded proximally. The right PDA filled by collaterals from the LAD system. Angiography of the LFA showed the arteriotomy superior to the SFA takeoff. 2. On _%#MM#%_ _%#DD#%_, 2004, a right heart catheterization demonstrated the RA pressure was 13, wedge was 16.
PDA|patent ductus arteriosus|PDA|190|192|HOSPITAL COURSE|She received a total of 2 echocardiograms on _%#MM#%_ _%#DD#%_, 2005, and _%#MM#%_ _%#DD#%_, 2005. Echocardiogram on _%#MM#%_ _%#DD#%_, 2005, showed normal cardiac anatomy of twin A with no PDA constriction, and twin B with normal cardiac anatomy and function. PDA was low normal in size, with 2 mmHg gradient. On _%#MM#%_ _%#DD#%_, 2005, at 28 plus 5 weeks, both twins showed normal ventricular dimensions and contractility, and normal anatomy.
PDA|patent ductus arteriosus|PDA,|259|262|DISCHARGE INSTRUCTIONS|Prior to her discharge, she showed appropriate weight gain, taking full nutritional requirements orally without difficulty. 2. Cardiology- Initial ECHO showed an Ebstein malformation with severe tricuspid regurgitation, mild pulmonary insufficiency, a patent PDA, and a small ASD. Follow up ECHO on _%#DDMM2004#%_ demonstrated a persistently patent, small ductus arteriosus. She was placed on a short course of PGE, pressor support was required until DOL 7 to maintain mean arterial pressures, and nitric oxide was given to reduce pulmonary vascular resistance.
PDA|patent ductus arteriosus|PDA|224|226|5. ID|She was changed to conventional ventilation on DOL #3. She was maintained on mechanical ventilation for a total of 30 days before being extubated to nasal CPAP on _%#DDMM2007#%_. (During that period, on _%#MMDD#%_ she had a PDA ligation and on _%#MMDD#%_, she underwent placement of a ventriculo-subgaleal (V-SG) shunt.) _%#NAME#%_ required reintubation on _%#DDMM2007#%_-_%#DDMM2007#%_; she was then maintained on CPAP, high-flow nasal cannula, and then standard nasal cannula supplemental oxygen.
PDA|patent ductus arteriosus|PDA|206|208|XY.|Cardiac evaluation, including an echocardiogram, confirmed this diagnosis. Treatment included fluid restriction and indomethacin (_%#MMDD#%_-_%#MMDD#%_). Follow up echocardiogram (_%#DDMM2006#%_) showed no PDA and small PFO with left to right shunt. This murmur had resolved at the time of discharge. Problem #4: Apnea of Prematurity.
PDA|posterior descending artery|PDA|261|263|PAST MEDICAL HISTORY|Angiogram on _%#DDMM2003#%_ showed less than 25% lesion, LAD has proximal occlusion, Cx OM2 with subtotal occlusion and reconstitution distally. RCA not imaged. Lima to LAD was not imaged due to inability to cannulate subclavian artery. Saphenous vein graft to PDA was patent. The patient was treated medically. 3. Status post biventricular AICD placement on _%#DDMM2003#%_ secondary to prolonged QT intervals and end stage heart failure.
PDA|patent ductus arteriosus|PDA|165|167|FOLLOW UP|A repeat echocardiogram before discharge on _%#DDMM2006#%_ showed a bicuspid aortic valve with mild stenosis and thickened pulmonary valve. She had no evidence of a PDA and a normal arch. _%#NAME#%_ will also need antibiotic prophylaxis to prevent sub acute bacterial endocarditis. Problem #5: Renal. _%#NAME#%_ had a renal ultrasound on _%#DDMM2005#%_, which revealed "bilateral collecting system dilatation right greater than left, possible reflux." She was placed on Amoxicillin for UTI prophylaxis.
PDA|patent ductus arteriosus|PDA,|154|157|PHYSICAL EXAMINATION|He required dopamine for a total of 5 days. He received prophylactic indomethacin for PDA closure. Followup echo at 10 days of age showed no demonstrable PDA, but with ventricular hypertrophy. The exact etiology of the ventricular hypertrophy was unclear. _%#NAME#%_ again developed significant hypotension at 10 days of age, again requiring volume infusion along with dopamine and dobutamine.
PDA|posterior descending artery|PDA.|220|223|* FEN|Significant tachypnea (to 110/minute) developed on _%#DDMM2007#%_ (DOL 26). F/U echo showed large PDA with left-sided enlargement. The ductus was ligated on _%#DDMM2007#%_ (DOL 29) and follow-up echocardiogram showed no PDA. This problem has resolved at the time of discharge. Problem #8: Sepsis. _%#NAME#%_'s mother was GBS negative. Rupture of membranes occurred at delivery.
PDA|patent ductus arteriosus|PDA.|364|367|HISTORY OF PRESENT ILLNESS|The patient has had bypass surgery in the past and has a LIMA to the second diagonal branch, a saphenous vein graft to the LAD, a saphenous vein graft to the obtuse marginal branch and saphenous vein graft to the posterior descending artery. Her saphenous vein graft to the posterolateral branch is chronically occluded. The patient has had stenting to her native PDA. The patient was admitted to Fairview Southdale Hospital from _%#MM#%_ _%#DD#%_ to through _%#MM#%_ _%#DD#%_, 2006. During that hospitalization, she had stenting to the first diagonal branch.
PDA|posterior descending artery|PDA|231|233|HISTORY OF PRESENT ILLNESS|Angiogram performed at that time had shown that she had a right coronary that showed severe diffuse disease with flow distal flow with a proximal 80% occlusion with a marginal branch that appeared to have bridging collaterals. The PDA appeared to be occluded. The left main appeared normal. The LAD showed a 80 to 90% occlusion, as well as the first diagonal.
PDA|patent ductus arteriosus|PDA|209|211|PAST MEDICAL HISTORY|She also has a history of graft-versus-host disease of the skin grade II treated with triamcinolone and hydrocortisone cream. 2. Recurrent otitis media, status post PE tubes in _%#MM#%_ of 2002. 3. History of PDA diagnosed at age 6 days. 4. History of cardiomegaly and cardiomyopathy followed by Dr. _%#NAME#%_ in Pediatric Cardiology. 5. History of bilateral corneal cloudiness with normal fundi. She is followed by Dr. _%#NAME#%_ in Pediatric Ophthalmology.
PDA|patent ductus arteriosus|PDA|172|174|1. FEN|Tachypnea improved over time. 3. CARDIO: _%#NAME#%_ received continuous drip of dobutamine for pulmonary hypertension and for BP support. Cardiac echo revealed a PFO and a PDA with a left to right shunt. An indomethacin course was given for the patent ductus arteriosus at DOL #5. Subsequent Echo confirmed PDA closure. 4. GI: A diverting sigmoid colostomy was done on _%#DDMM2003#%_ for an imperforate anus.
PDA|patent ductus arteriosus|PDA.|169|172|8. GENETICS|Surgery was performed by Dr. _%#NAME#%_ _%#NAME#%_ without complications. Persistent murmur and echocardiogram on _%#DDMM2007#%_ demonstrated incomplete ligation of the PDA. This deficit was small, however, and _%#NAME#%_ remained clinically stable. It was believed that the small remaining PDA would likely close on its own.
PDA|posterior descending artery|(PDA)|159|163|HOSPITAL COURSE|There were collaterals via the proximal and mid acute marginal branches to the posterolateral artery and retrograde filling of the posterior descending artery (PDA) also noted. There were collaterals to the septal perforator of the LAD as well. Saphenous vein graft (SVG) to the posterior descending artery was occluded at its origin.
PDA|patent ductus arteriosus|PDA|198|200|3. DIC|The study revealed normal cardiac anatomy, a large PDA with bidirectional shunting, a bidirectional PFO and evidence of pulmonary hypertension. A repeat echocardiogram showed normal anatomy, closed PDA and resolved pulmonary hypertension. Problem #4: Hypotension. In order to maintain her systemic blood pressure and improve peripheral perfusion, _%#NAME#%_ required treatment with dopamine, dobutamine, and hydrocortisone.
PDA|posterior descending artery|PDA.|116|119|PAST MEDICAL HISTORY|Vessels involved included LIMA to LAD, vein graft from aorta to left circumflex, and vein graft from aorta to right PDA. 3. Obesity. 4. Diabetes. 5. Seizure disorder. 6. Atrial fibrillation/flutter. 7. Congestive heart failure. 8. Exploratory laparotomy for evaluation of pneumoperitoneum on _%#DDMM2004#%_.
PDA|patent ductus arteriosus|PDA,|153|156|* FEN|An EKG on _%#DDMM2004#%_ revealed a normal sinus rhythm with an extreme left axis deviation. A follow-up echo on _%#DDMM2004#%_, revealed closure of the PDA, VSD with low velocity left to right shunt, PFO and PDA with left to right shunt, equal PA and AO pressures, and normal values.
PDA|patent ductus arteriosus|PDA,|200|203|TEACHING AFTER DISCHARGE|We have arranged for him to be seen in Ophthalmology Clinic with his sister. Problem #9: Cardiovascular. _%#NAME#%_ had an echocardiogram on _%#DDMM2005#%_ due to a holosystolic murmur suspicious for PDA, which revealed a PDA with a left to right shunt and a PFO. Repeat echos on _%#MMDD#%_ and _%#MMDD#%_ did not show any evidence of PDA.
PDA|patent ductus arteriosus|PDA|270|272|5. ID|Prophylactic Clindamycin and Amphotericin B were started on _%#DDMM2007#%_ and were continued until after the second esophagram done on _%#DDMM2007#%_. Problem # 8: Patent Ductus Arteriosus. _%#NAME#%_ had an echocardiogram on _%#DDMM2007#%_ (DOL # 2), which revealed a PDA with left to right shunting. Three doses of ibuprofen were given and a follow-up ECHO showed no PDA. Clinically, her condition deteriorated on _%#DDMM2007#%_ consistent with ductal opening and the ductus was surgically ligated on _%#DDMM2007#%_.
PDA|posterior descending artery|PDA|136|138|PROCEDURES PERFORMED|Circumflex was unchanged since _%#MMDD#%_, with total occlusion of OM1 and OM2. RCA was totally occluded mid vessel, with occluded SVG. PDA partially filled collaterals from left system, but with multiple lesions present. There was unsuccessful angioplasty of the mid right coronary artery.
PDA|posterior descending artery|PDA|140|142|HISTORY OF PRESENT ILLNESS|The patient's previous bypass included a three-vessel bypass with saphenous vein graft to diagonal and another to the OM and a third to the PDA done in 1995 by Dr. _%#NAME#%_. The patient had a postoperative chest wound which required prolonged hospitalization and IV antibiotics.
PDA|posterior descending artery|PDA|161|163|PAST MEDICAL HISTORY|7. History of retinopathy of prematurity, status post scleral buckle. 8. Status post T-tube and Nissen for feeding difficulty and reflux disease. 9. Status post PDA ligation, _%#MM2002#%_. 10. History of constipation, on MiraLax daily. FAMILY HISTORY: Mom is in good health. SOCIAL HISTORY: No smoking, lives with her mother, and has a home health aide.
PDA|patent ductus arteriosus|PDA|141|143|HISTORY OF PRESENT ILLNESS|A repeat echocardiogram was done and an ejection fraction was 58%, with normal left ventricular size and function, normal left atrium, small PDA with left-to-right shunt, mild MR, mild TR, and intact atrial septum. Her digoxin was continued at her current dose of 27.5 mcg p.o. b.i.d. She has had a recent otitis media in mid-_%#MM#%_ that was treated with antibiotics.
PDA|patent ductus arteriosus|PDA|280|282|1. FEN|A pediatric cardiology consult was obtained. Bidirectional flow of PDA suggested increased pulmonary vascular resistance and/or possible coarctation of aorta. VSD's were thought to be of no hemodynamic significance. Repeat echocardiograms were followed to evaluate for closure of PDA and change in possible coarctation. Cardiology recommended repair of coarctation ( if present )after closure of PDA. Cardiac ECHO's from _%#DDMM2004#%_, _%#DDMM2004#%_, _%#DDMM2004#%_, and _%#DDMM2004#%_ showed no change despite changes in her clinical status.
PDA|patent ductus arteriosus|PDA|158|160|1. FEN|Tenatively the plan is for PDA ligation and surgical evaluation of this possible coarctation, and if necessary, coarct repair. Problem List: 1. Bidirectional PDA and pulmonary HTN, with resultant progressive congenital heart failure and pulmonary edema 2. Possible Coarctation of the Aorta, but no clinical evidence at this time
PDA|posterior descending artery|PDA|149|151|PATIENT HISTORY|There was a 90% narrowing of the ostial OM2 The right coronary artery was a small but dominant vessel with severe disease throughout its course. The PDA vessel was not obstructed but was a small vessel. The circumflex coronary artery provided collaterals to the distal right coronary artery.
PDA|patent ductus arteriosus|PDA|219|221|ASSESSMENT/RECOMMENDATIONS|Her electrolytes were normal. Her serum calcium was slightly low. An echocardiogram was obtained which showed a thickened left ventricular wall and septum, with mild tricuspid regurgitation, a small muscular VSD, and a PDA with a left-to- right shunt and a small right-to-left shunt to the patent foramen ovale. She was started on dobutamine and dopamine. However, in light of her echocardiographic findings, dobutamine was discontinued, and she was continued only on dopamine.
PDA|patent ductus arteriosus|PDA.|150|153|* IUGR|Problem #3: Cardiovascular. Following extubation, _%#NAME#%_ remained tachypneic with evidence of a systolic murmur on physical exam concerning for a PDA. _%#NAME#%_'s symptoms persisted and an initial echocardiogram at Fairview Ridges was concerning for a persistent PDA and coarctation of the aorta.
PDA|patent ductus arteriosus|PDA|415|417|HCM|Problem #10: Cardiovascular. _%#NAME#%_ had an echocardiogram on _%#DDMM2006#%_ due to systolic murmur, which revealed a small muscular ventricular septal defect with a left to right shunt, an atrial septal defect or patent foramen ovale, and a moderate-sized patent ductus arteriosus with a left to right shunt and mild runoff from the aorta. A repeat echocardiogram on _%#DDMM2006#%_ to evaluate acute opening of PDA showed normal anatomy and a hyperdynamic ventricle secondary to hypovolemic status. A follow up echocardiogram should be performed in 6-9 months to re-evaluate the atrial septum.
PDA|patent ductus arteriosus|PDA|180|182|DISCHARGE  DIET|He was treated with three doses of indomethacin from _%#DDMM2006#%_ - _%#DDMM2006#%_. Follow-up echocardiogram on _%#DDMM2006#%_ and _%#DDMM2006#%_ revealed a muscular VSD, but no PDA was noted at this point. The 2/6 systolic murmur loudest at the cardiac apex continued and did not cause the patient any respiratory or cardiac compromise, which is clinically consistent with a VSD.
PDA|patent ductus arteriosus|PDA.|174|177|HOSPITAL COURSE|Due to the initiation of indomethacin a fetal echo was initiated as once weekly with her first fetal echo on _%#DDMM2007#%_ revealing normal cardiac anatomy with a wide open PDA. The patient also did talk with the NICU staff in regards to the possible outcomes of the fetus if it should deliver at this gestational age.
PDA|posterior descending artery|PDA.|237|240|HISTORY OF PRESENT ILLNESS|There was an occluded saphenous vein graft to M1 segment of the graft from M1-M2, patent filling from native circumflex, which has severe diffuse disease. There is a patent LIMA graft to diagonal, LAD, and patent saphenous vein graft to PDA. Recommendation was medical management versus a redo of CABG. According to the patient's wife, medical management was the plan at that time according to the patient's primary MD and primary cardiologist.
PDA|posterior descending artery|PDA|249|251|OPERATIONS/PROCEDURES PERFORMED|8. History if automatic implantable cardioverter-defibrillator infection. OPERATIONS/PROCEDURES PERFORMED: 1. Coronary angiogram and right heart catheterization. The patient had a coronary angiogram on _%#MM#%_ _%#DD#%_, 2003 that showed a proximal PDA lesion of 50% to 60% but otherwise no change. It did not seem flow limiting, and no intervention was performed.
PDA|posterior descending artery|PDA|204|206|HISTORY OF PRESENT ILLNESS|The specifics showed a 30% lesion of the LAD. The left circumflex was unremarkable. The most significant lesion was on the RCA; it was a dominant vessel which had mild irregularities to the ostium of the PDA where there was a moderate stenosis estimated at 60% of approximately 2-2.25 mm of the vessel. LV function was 55%. Medical management was recommended. The patient currently does not know what medications she is on, she states that she is allergic to aspirin and does not take that.
PDA|posterior descending artery|PDA|220|222|PLAN|His blood gases were mixed metabolic acidosis and respiratory acidosis, concerning for persisting fetal circulation. He was extubated on _%#DDMM2002#%_ without issues. He was later intubated for surgical ligation of his PDA and extubated without difficulty. _%#NAME#%_ is currently on room air. CV - _%#NAME#%_ was hypotensive on admission to the NICU with recurrence after fluid resuscitation.
PDA|patent ductus arteriosus|PDA,|142|145|IMPRESSION AND PLAN|An echocardiogram done on _%#DDMM2006#%_ revealed normal anatomy and function and was negative for a PDA. An echo on _%#DDMM2006#%_ showed no PDA, a tiny left to right PFO, and norma l LV and RV function. His most recent cardiac ECHO was done on _%#DDMM2006#%_. Results were as follows: mild right ventricular hypertrophy, normal intracardiac anatomy, and normal left ventricular size and contractility.
PDA|posterior descending artery|PDA|355|357|PLAN|She does have extensive 3-vessel coronary disease in the past and with a new troponin elevation, it was felt it would be prudent to pursue coronary angiography and reassess her coronary anatomy. It is also possible that part of her troponin elevation was a reflection of demand ischemia due to underlying coronary stenosis, especially the occluded distal PDA and severe small-sized diagonal vessel, along with precipitating factors of sinus tachycardia and anemia. However, it is conceivable that she has progression of her lesions in the major epicardial coronary arteries.
PDA|posterior descending artery|PDA,|232|235|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 75-year-old female with a past medical history of coronary artery disease, status post coronary artery bypass surgery in 1990 when the patient had a saphenous vein graft to the PDA, saphenous vein graft to the circumflex and left internal mammary artery to the LAD. She subsequently had repeat angiography in 1992 and they found that the vein grafts were occluded.
PDA|posterior descending artery|(PDA)|181|185|HISTORY|Coronary angiography was performed at that time and demonstrated moderate 35% stenosis in the proximal and distal right coronary artery (RCA) with a 90% posterior descending artery (PDA) stenosis. The proximal left anterior descending (LAD) contained a calcified 90-95% stenosis of the circumflex artery, less than a 30% stenosis.
PDA|posterior descending artery|PDA,|237|240|PAST MEDICAL/SURGICAL HISTORY|9. History of chronic obstructive pulmonary disease with FEV1 of 36% and FVC of 40%, showing both obstructive, as well as restrictive features. 10. Arteriosclerotic cardiovascular disease with three-vessel bypass surgery in 1997, SVG to PDA, and SVG to diagonal, as well as LIMA to LAD. 11. The patient most recently underwent angiogram and I believe stenting on _%#DDMM2007#%_.
PDA|posterior descending artery|PDA|252|254|PAST MEDICAL HISTORY|She is not on Coumadin. She takes aspirin and Plavix, although her stent was in 2002 _%#MM#%_. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Status post bypass surgery in 2002 with LIMA to the diagonal branch and a saphenous venous graft to the PDA and saphenous venous graft to the obtuse marginal going up to the PLA. Repeat angiography in _%#DDMM2002#%_ showed that the saphenous venous graft to the obtuse marginal branch had a 95% stenosis which was intervened.
PDA|posterior descending artery|PDA|242|244|IMPRESSION|2. Status post atrial flutter ablation in the past. 3. History of concentric left ventricular hypertrophy and longstanding hypertension with dynamic mid-ventricular gradient. 4. History of coronary artery disease with a 70% lesion in a small PDA that was small sized and best treated medically. 5. Mildly elevated troponin which appears to be related to demand ischemia secondary to rapid ventricular rate and underlying coronary artery disease.
PDA|posterior descending artery|PDA|212|214|HISTORY OF PRESENT ILLNESS|She was first seen by me in _%#DDMM2004#%_ when she was admitted with rapid atrial fibrillation. She had mild elevation of troponin at that time. Coronary angiography at that time revealed a 60-70% lesion in the PDA coming off a dominant side. This was small caliber vessel and was best treated medically. Subsequently, she underwent atrial flutter ablation by Dr. _%#NAME#%_. Unfortunately, she went back into atrial fibrillation following a successful atrial flutter ablation.
PDA|posterior descending artery|PDA|146|148|PAST MEDICAL HISTORY|She does have concentric LVH and has long-standing hypertension, which is not well controlled. 9. CAD. Her worst stenosis in _%#DDMM2004#%_ was a PDA coming off her dominant circumflex and a 60-70% stenosis. SOCIAL HISTORY: She smoked intermittently but quit permanently in 2004.
PDA|posterior descending artery|PDA|170|172|HISTORY OF PRESENT ILLNESS|The patient underwent 3 vessel coronary artery bypass grafting surgery in 2003 with mitral valve repair. The patient has a LIMA to the LAD, a saphenous vein graft to the PDA and a saphenous vein graft to the RCA. The patient's postoperative course was complicated by atrial fibrillation and wound dehiscence.
PDA|posterior descending artery|PDA|234|236|HISTORY|Her circumflex was not described as having disease. The right coronary artery was described as having diffuse disease with more than an 80% lesion in the mid-vessel, followed by moderately severe diffuse disease and distal occlusion. PDA and posterolateral branches were of adequate size, and appeared to have excellent collateral from the left coronary system. Left ventriculogram showed normal left ventricular systolic function. There was a completely occluded right coronary artery with significant diffuse disease throughout the vessel, particularly in the mid-vessel.
PDA|posterior descending artery|PDA|212|214|HISTORY|Left ventriculogram showed normal left ventricular systolic function. There was a completely occluded right coronary artery with significant diffuse disease throughout the vessel, particularly in the mid-vessel. PDA and posterolateral branches had good collateral in the left system with a 50% proximal LAD. The angiogram was discussed with an interventional cardiologist, and it was felt that because of a large amount of thrombus in the proximal right coronary artery, and a diffuse long lesion distally, she was not an excellent candidate for interventional therapy.
PDA|posterior descending artery|PDA|137|139|HISTORY  OF PRESENT ILLNESS|This vessel filled from collaterals from the right coronary artery. The right coronary artery was dominant with a 40-50% stenosis in the PDA and a large posterolateral branch artery with minor irregularity. The LAD was then treated with thrombectomy and a Taxus drug-eluting stent.
PDA|posterior descending artery|PDA|135|137|PAST MEDICAL HISTORY|The first diagonal vessel was occluded. The sequential vein graft to the OM-1 and OM-2 was occluded and the vein graft was open to the PDA but there was diffuse PDA disease. We had previously angioplastied the native right coronary artery and it was still widely patent on the last angiogram in 2003.
PDA|posterior descending artery|PDA,|221|224|HISTORY OF PRESENT ILLNESS|She has tried multiple medications, and eventually blood pressure was successfully controlled with Toprol-XL and hydralazine. She also has coronary artery disease with an angiogram done in _%#MM#%_ 2004, which revealed a PDA, there was 70-80% narrowed, but this was a very small vessel, not amenable to percutaneous intervention. She did have a hyperdynamic LV function on the LV gram with some mid cavity obliteration.
PDA|posterior descending artery|PDA|185|187|PAST MEDICAL HISTORY|Because of her multiple cardiac issues, she was admitted. Her BNP was elevated on admission at 1220, and today it is 1090. PAST MEDICAL HISTORY: 1. Coronary artery disease with a small PDA artery that has 70-80% stenosis, managed medically. 2. Hypertension, which is uncontrolled for many years and recently has been controlled with hydralazine and Toprol.
PDA|posterior descending artery|PDA|124|126|HISTORY|All of her bypasses were patent. His ejection fraction, however, was noted to be 20-25%. He continued to have severe distal PDA stenosis, as well as a 30% LAD stenosis proximally with distal competitive flow. There is diffuse disease through the mid and distal circumflex artery of 50% with competitive flow in the first obtuse marginal.
PDA|posterior descending artery|PDA|120|122|PAST SURGICAL HISTORY|Negative diabetes. Negative hypertension. Negative for thyroid disease. PAST SURGICAL HISTORY: Attempted coiling of the PDA in _%#MM2004#%_ and _%#MM2004#%_. Tonsils and adenoids removed as a child. Myringotomy bilaterally as a child with tube placement. HABITS: Negative for tobacco, alcohol, or intravenous drug use. She has used tobacco in the past at 3 to 7 cigarettes per day.
PDA|posterior descending artery|PDA|138|140|REASON FOR CONSULTATION|Unfortunately his LIMA to the LAD was open. In 2001, he had another angiography, which I believe showed very similar results. The RCA and PDA territories have collateral supply from the LAD. In 2002, he had a stress nuclear study, which showed an LVEF of 43% with small-to-moderately sized partially reversible inferior and inferoseptal defect.
PDA|posterior descending artery|PDA|229|231|PAST MEDICAL HISTORY|She has a Port-A-Cath in place. Her heart catheterization in 2005 showed left main of 40%, LAD was calcified 50% and then 90-95% but the vessel is less than 2 mm. at this point, 60% OM lesion and diffuse RCA disease with the mid PDA of 80% and posterolateral branch of 80%. (See echocardiogram results above.) Previous pseudoaneurysm found on her angiogram with history of compression (femoral artery).
PDA|posterior descending artery|PDA|252|254|IMPRESSION|He does have small areas of noted ischemia with a posterior descending artery (PDA) and posterolateral branch fed by collaterals from the left system. He most likely has small vessel diabetic disease too which cannot be revascularized; neither are the PDA or posterolateral branches which are small. 3. Chronic renal insufficiency. Current creatinine is approximately 1.6. 4. Peripheral vascular disease. 5. Hypertension. 6. Hypertensive heart disease.
PDA|posterior descending artery|PDA.|282|285|PAST MEDICAL HISTORY|That catheterization was performed again showing occlusion or subtotal occlusion of all his native vessels proximally with a patent LIMA graft and a severe 90% stenosis of the saphenous vein graft to the obtuse marginal and diffuse severe disease of the saphenous vein graft to the PDA. The OM graft was treated with angioplasty and stent with the distal protection device satisfactorily. It was noted that the basket of the distal protection device was heavily filled with atherosclerotic debris.
PDA|patent ductus arteriosus|PDA|125|127|PAST MEDICAL HISTORY|He also has associated single vessel CAD affecting the PDA. He had an angiogram in 1998 and 2000. Initially there was severe PDA which was treated medically and then it was noted to be occluded in 2000. The rest of the arteries have no significant disease. Initial ejection fraction in 1998 and 2000 was 30% which has since improved.
PDA|posterior descending artery|PDA|178|180|PAST MEDICAL HISTORY|A CT scan of the chest with contrast on admission showed possible infiltrate in the left lung, but no PE. PAST MEDICAL HISTORY: 1. Diabetes. 2. Coronary artery disease, occluded PDA in 2000. 3. Cardiomyopathy thought to be non ischemic related to hypertension, which has now improved up to 40-45%. 4. GERD. 5. Hypertension. 6. BPH. 7. Moderate restrictive defect on PFT
PDA|posterior descending artery|PDA.|135|138|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Coronary artery disease with bypass surgery with sequential vein graft to LAD, diagonal and vein graft to the PDA. This original surgery was more than 20 years ago. He had a redo bypass in 2000. 2. He has panvascular disease with known carotid artery narrowing.
PDA|posterior descending artery|PDA|202|204|PAST MEDICAL HISTORY|There was a saphenous vein graft sequential to the distal obtuse marginal posterior descending arteries with both arteries being very small. The distal obtuse margin had no significant disease with the PDA quite small. There were well developed collaterals to the posterior branch artery with a vein graft to the two obtuse marginal branch arteries.
PDA|posterior descending artery|PDA|183|185|HISTORY|The details are not clear. On _%#DDMM2005#%_ Dr. _%#NAME#%_ took her to the heart catheterization lab. His note shows that the LIMA graft to the LAD was patent, the vein graft to the PDA was patent, the sequential vein graft to the first diagonal ramus intermedius was normal to the ramus, but he did not see any connection to the diagonal, therefore I do not know if that was a truly sequential graft or close to the diagonal vessel.
PDA|posterior descending artery|PDA|145|147|CLINICAL IMPRESSION|1. Recurrent chest pain, ? angina versus GI symptoms (i.e. possible reflux). 2. History of ischemic heart disease status post PTCA of the ostial PDA _%#MM2002#%_ and _%#MM2002#%_ (restenosis). 3. History of hyperlipidemia. 4. Possible history of gastroesophageal reflux disease. DISCUSSION: The patient's symptoms are atypical for his recurrent angina pectoris in that they are not exertional, although he has not had an extensive GI evaluation to this point, other than being treated with proton pump inhibiting agents.
PDA|posterior descending artery|PDA|166|168|HISTORY|Also noted was an 80% D-1 lesion. The left circumflex had no significant disease. The right coronary artery was 99 to 100% occluded with TIMI-I flow and a very small PDA and posterolateral system that was unchanged from a previous study. There is no mention what her aortic valve area was then. In one place earlier in the chart, it says that she has severe aortic stenosis and in another area it says she has only mild to moderate aortic stenosis.
PDA|patent ductus arteriosus|PDA|146|148|PAST MEDICAL HISTORY|2. Minor cardiac abnormalities on _%#DDMM2004#%_ echo: mild mitral insufficiency, mitral valve prolapse, small PFO with left to right flow, small PDA with left to right flow. Ejection fracture equal to 62%. Normal PA pressures. 3. History of oral Candidiasis and diaper rash, treated with Diflucan.
PDA|patent ductus arteriosus|PDA.|137|140|IMPRESSION|IMPRESSION: 1. Progressive right heart failure. A. Secondary to pulmonary hypertension, cause unclear. 2. History remotely of closure of PDA. 3. Parkinson's disease on carbidopa and levodopa. PLAN: Diuresis and echocardiogram. We will follow with you acutely.
PDA|patent ductus arteriosus|(PDA).|132|137|DISCHARGE DIAGNOSES|The proximal left anterior descending (LAD) has 40% stenosis. This is a left dominant symptom with a large patent ductus arteriosus (PDA). 3. Hypertension. 4. Tobacco abuse. The patient is eager to quit smoking. DISCHARGE MEDICATIONS: 1. Plavix 75 mg p.o. q.d. for six months.
PDA|patent ductus arteriosus|PDA|235|237|PROBLEM #3|By discharge, the patient was not on any antihypertensives. On day of life #1, the patient had a history of a PDA on echocardiogram. While in the PICU, the patient received a follow-up echocardiogram on _%#DDMM2004#%_, which showed no PDA and was otherwise within normal limits. PROBLEM #4: Infectious disease: The patient had no infections during the hospitalization.
PD|peritoneal dialysis|PD|50|51|PROCEDURES|DIAGNOSIS: Cystic renal dysplasia. PROCEDURES: 1. PD catheter placement and omentectomy. 2. Ultrasound of aorta and IV seen. 3. Renal ultrasound. DISCHARGE MEDICATIONS: 1. NaCl 20 mEq p.o. NG three times a day.
PD|peritoneal dialysis|PD|164|165|HOSPITAL COURSE|Reflexes were 2+ at the patella bilaterally. HOSPITAL COURSE: PROBLEM #1: Fluids, electrolytes, nutrition. Denis initially had some edema and was volume up after a PD catheter placement. His dialysis was adjusted to take more fluid off, and eventually achieved state at the time of discharge.
PD|peritoneal dialysis|PD|179|180|PROBLEM #3|PROBLEM #2: Cardiorespiratory. _%#NAME#%_ remained stable throughout this hospitalization and required no O2. PROBLEM #3: Genitourinary. Denis has chronic renal failure and had a PD catheter placed on hospital day #2 without complication. Peritoneal dialysis was initiated and fine-tuned to the regimen he was discharged on, which takes off about 100 to 130 mL of fluid each night.
PD|peritoneal dialysis|PD|194|195|PROBLEM #4|He tolerates his 200 mL fill volumes very well in addition to his overnight drip feed. PROBLEM #4: Infectious disease. _%#NAME#%_ did have 1 fever spike to 102 and had a positive culture of his PD fluid that showed alpha hemolytic strep not group D with pan sensitivities. Antibiotics were added to his PD fluid for a week.
PD|peritoneal dialysis|PD|242|243|PROBLEM #4|PROBLEM #4: Infectious disease. Denis did have 1 fever spike to 102 and had a positive culture of his PD fluid that showed alpha hemolytic strep not group D with pan sensitivities. Antibiotics were added to his PD fluid for a week. Follow up PD cultures were negative and Denis remained afebrile. Blood cultures remained negative. _%#NAME#%_ was afebrile for a week prior to discharge and all ensuing PD cultures were negative.
PD|peritoneal dialysis|PD|174|175|PROBLEM #4|Follow up PD cultures were negative and _%#NAME#%_ remained afebrile. Blood cultures remained negative. _%#NAME#%_ was afebrile for a week prior to discharge and all ensuing PD cultures were negative. _%#NAME#%_ will remain on prophylactic antibiotics as an outpatient. PROBLEM #5: Transplant. _%#NAME#%_' transplant work up, labs and imaging were completed during this hospitalization.
PD|peritoneal dialysis|PD|182|183|ALLERGIES|Normal S1 and S2 with no murmur. Lungs are clear to auscultation bilaterally. Abdominal Exam: Baseline prune belly, distended with palpable liver and spleen, but soft and nontender. PD catheter site is clean, dry, and intact. Skin: There is no rash. He is warm and well perfused. Neuro Exam: Grossly normal.
PD|police department|PD|315|316|HISTORY OF THE PRESENT ILLNESS|PRIMARY CARE PHYSICIAN: _%#COUNTY#%_ _%#COUNTY#%_ Medical Center HISTORY OF THE PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 46-year-old white gentleman who has extensive history of alcoholism, checked out from a halfway house last Thursday and was living in the shed for three days and then found by the _%#CITY#%_ PD on his Mom's driveway. His ex-wife called 911 for help for him. The wife called the emergency department and told the R.N. that he had attempted to commit suicide five months ago.
PD|peritoneal dialysis|PD|169|170|PAST MEDICAL HISTORY|Since then she has been either on hemodialysis or peritoneal dialysis. She most recently was hemodialyzing by a translumbar hemodialysis catheter until placement of the PD catheter in _%#MM#%_ of 2001. She has had multiple episodes of peritonitis in the past, two in the last year. 2. Hypertension. 3. Seizure disorder. 4. Hyperlipidemia. ALLERGIES: PENICILLIN and PERCOCET.
PD|peritoneal dialysis|PD|246|247|HISTORY OF PRESENT ILLNESS|FOLLOW UP: 1. He is to follow up with his primary doctor, Dr. _%#NAME#%_ in one week. At that time, he is to have the following labs drawn: Electrolytes including magnesium, phosphorus, and ionized calcium, and the results are to be faxed to the PD Nurse and to the Renal Clinic to Dr. _%#NAME#%_. 2. He is to follow up with Dr. _%#NAME#%_ _%#NAME#%_, in Pediatric Renal Clinic in 2 weeks.
PD|peritoneal dialysis|PD|157|158|HISTORY OF PRESENT ILLNESS|She had a very complicated posttransplant course, complicated with BOD disease and renal failure requiring peritoneal dialysis. She subsequently has had her PD catheter removed and throughout this time has had an umbilical hernia, which has been followed and has developed into a giant umbilical hernia.
PD|police department|PD|146|147|SOCIAL HISTORY|ALLERGIES: None. MEDICATIONS: Not readily available. She states that she takes about 8 medications. SOCIAL HISTORY: Socially, again brought in by PD after being arrested for shoplifting. She had just fled the hospital after being admitted to the third floor tele and was re-arrested again at home depot.
PD|peritoneal dialysis|PD|217|218|OPERATIONS/PROCEDURES PERFORMED|OPERATIONS/PROCEDURES PERFORMED: Procedures performed during this hospital stay: 1. _%#MM#%_ _%#DD#%_, 2005, heart transplant. 2. _%#MM#%_ _%#DD#%_, 2005, mediastinal washout. 3. _%#MM#%_ _%#DD#%_, 2005, placement of PD catheter. 4. _%#MM#%_ _%#DD#%_, 2005, mediastinal washout and closure. 5. _%#MM#%_ _%#DD#%_, 2005, flexible bronchoscopy, removal of thrombus from airway.
PD|peritoneal dialysis|PD|184|185|OPERATIONS/PROCEDURES PERFORMED|4. _%#MM#%_ _%#DD#%_, 2005, mediastinal washout and closure. 5. _%#MM#%_ _%#DD#%_, 2005, flexible bronchoscopy, removal of thrombus from airway. 6. _%#MM#%_ _%#DD#%_, 2005, removal of PD catheter. 7. _%#MM#%_ _%#DD#%_, 2005, abdominal exploration with temporary abdominal closure and wedge liver biopsy. 8. _%#MM#%_ _%#DD#%_, 2005, abdominal washout and packing. 9. _%#MM#%_ _%#DD#%_, 2005, abdominal washout and closure.
PD|peritoneal dialysis|PD|208|209|CLINICAL NOTE|He went to the operating room for fairly high risk heart transplant, returned to the Peds ICU with his chest open and the retractor in the chest due to abdominal and liver edema compromising chest closure. A PD catheter was placed, and he was dialyzed and this improved things remarkably. He had a washout on _%#MM#%_ _%#DD#%_, 2005, and we were eventually able to get his chest closed on _%#MM#%_ _%#DD#%_, 2005.
PD|peritoneal dialysis|PD|126|127|PLAN|PLAN: We will admit, do serial enzymes. If that is negative, we will get a stress echo done. The patient also is in need when PD is available, getting the updated. She has also never had a flexible sigmoidoscopy. She is up to date or mammogram and pap smears.
PD|peritoneal dialysis|PD|188|189|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. At birth: TEF repaired. 2. TOS, status post RV conduit, status post VP shunt with multiple surgeries. 3. Status post open head trauma age 5. 4. History of ATN and PD after heart surgery in 1990. 5. Status post tubal ligation. 6. "Allergic to heparin." On _%#DDMM2001#%_ platelets became thrombocytopenic while on heparin.
PD|pancreatic duct|PD|194|195|HOSPITAL COURSE|The common bile duct was freely cannulated and was slightly dilated at 10 to 12 mm. There were no definite stones. Sphincterotomy and two balloon sweeps were done with no stones identified. The PD was not entered. On the day of discharge, his total bilirubin had fallen to 2.5, ALT 140, AST 51. He felt well, was eating OK and denied abdominal pain.
PD|posterior descending|PD.|149|151|HISTORY|He subsequently had coronary artery bypass grafting surgery with a LIMA to the LAD, saphenous vein graft to diagonal, saphenous vein graft to OM and PD. He was a bit lost to follow-up although he has seen Dr. _%#NAME#%_ on and off over the years. One and one-half years ago he came back to attention and was found to have decrease in ejection fraction with EF of 20 to 25%.
PD|peritoneal dialysis|PD|138|139|HISTORY OF PRESENT ILLNESS|He did have a left shift in his differential with 70% neutrophils. A culture and Gram's stain performed on a concentrated specimen of his PD fluid revealed no organism seen on Gram's stain, but many neutrophils in the fluid. HOSPITAL COURSE: 1. Renal failure. _%#NAME#%_ continues to be dialysis dependent.
PD|peritoneal dialysis|PD|189|190|HOSPITAL COURSE|At that time, he was switched to IV ciprofloxacin and had cefazolin added to his peritoneal dialysis fluid at a concentration of 125 mg per liter for a total of 14 days of antibiotics. His PD fluid cell count responded quickly and, by _%#MM#%_ _%#DD#%_, his PD fluid was sterile by culture. By the time of discharge, _%#NAME#%_ typically had fewer than 10 white blood cells on a cell count differential of his PD fluid.
PD|peritoneal dialysis|PD|322|323|HOSPITAL COURSE|1. FEN: _%#NAME#%_ was maintained on his drip feeds Similac PM 60/40 and Similac Advance during the day because he was more willing to bottle it during this hospitalization and peritoneal dialysis was continued at home regimen. His potassium was monitored, and Kayexalate amount in his feeds was adjusted accordingly. His PD had to be discontinued on _%#MM#%_ _%#DD#%_, 2006, because he underwent a surgical drainage of his right ureter as will be described below, and the PD could no longer be continued due to a hole in the peritoneum.
PD|peritoneal dialysis|PD|220|221|HOSPITAL COURSE|His PD had to be discontinued on _%#MM#%_ _%#DD#%_, 2006, because he underwent a surgical drainage of his right ureter as will be described below, and the PD could no longer be continued due to a hole in the peritoneum. PD was held and the patient was started on hemodialysis on _%#MM#%_ _%#DD#%_, 2006. 2. Respiratory: During the admission, Lance has had several periods of respiratory difficulty requiring oxygen, but he was able to be weaned off oxygen by _%#MM#%_ _%#DD#%_, 2006.
PD|peritoneal dialysis|PD|200|201|PAST MEDICAL HISTORY|The patient was then admitted to the kidney transplant service for further workup and followup on his fever. PAST MEDICAL HISTORY: 1. Left nephrectomy in _%#MM#%_ 2005. 2. Kidney stone removal x2. 3. PD catheter placement in _%#MM#%_ 2004. 4. Percutaneous drainage of infection. 5. Deceased donor kidney transplant, _%#MM#%_ _%#DD#%_, 2006. HOSPITAL COURSE: The patient's hospital course was very unremarkable. He was admitted to the kidney transplant floor.
PD|peritoneal dialysis|PD.|142|144|IMPRESSION|I called the home dialysis nurses and they will come and talk to her about the possibility of some form of home dialysis such as home hemo or PD. The patient seems interested in this. We will also ask vascular surgery to see her for vascular access in the left arm. There is no irritant need for dialysis. We will put her on a renal diet.
PD|peritoneal dialysis|PD|187|188|PAST MEDICAL HISTORY|4. Recent admission to _%#COUNTY#%_ _%#COUNTY#%_ Medical Center at the end of _%#MM#%_ with volume depletion and abdominal pain. He did at that time have diphtheroids cultured out of his PD fluid that is gram positive bacilli as well as gram positive cocci. The identity of these organisms turned out to be diphtheroid bacillus, not Corynebacterium JKM.
PD|peritoneal dialysis|PD|199|200|PLAN|5. Hypocalcemia, principally related to Sensipar. 6. Elevated AST and ALT of uncertain etiology, hepatitis C antibody negative, hepatitis B surface antigen negative. 7. Hypokalemia. PLAN: 1. Cycling PD tonight and proceeding with exchanges of peritoneal dialysate will hasten his recovery from the peritonitis. 2. Intravenous Ancef and gentamicin while awaiting cultures. 3. Pain control.
PD|police department|PD|347|348|HISTORY OF THE PRESENT ILLNESS|CHIEF COMPLAINT: Found on the floor. HISTORY OF THE PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 87-year- old female with a history of hypertension reportedly long ago, but has not been on medications since then who was found by neighbors on the floor. Most of the information is via the emergency department physician, social services as well as PD reports and neighbors. According to neighbors, she has lived alone for many years, is quoted 31 years and was found to be significant isolated and only contact with the outside world would be the neighbors and even then her neighbors have never been in the patient's home for the past 30+ years.
PD|police department|PD|156|157|HISTORY OF THE PRESENT ILLNESS|She denies any loss of consciousness, headache, visual changes, focal weakness or numbness. She denies hearing the phone every ringing. Upon arrival of the PD and paramedics, they noted that the house smelled strongly of urine and stool. The PD felt that the house was unsuitable for living had had contacted environmental services.
PD|police department|PD|150|151|HISTORY OF THE PRESENT ILLNESS|She denies hearing the phone every ringing. Upon arrival of the PD and paramedics, they noted that the house smelled strongly of urine and stool. The PD felt that the house was unsuitable for living had had contacted environmental services. They had found that the patient had been urinating in milk cartons and had been using bowel movements in a crock pot as her toilet was not functioning appropriately.
PD|patent ductus|PD|231|232|PAST MEDICAL HISTORY|1. Small for gestational age, intubated after delivery secondary to respiratory distress, had multiple dysmorphic features noted at birth. 2. History of TE fistula status post repair and esophageal atresia, status post repair with PD ligation in _%#DDMM2000#%_. 3. Choanal atresia repair, Nissen and G-tube placement in _%#DDMM2000#%_. 4. Status post cleft lip and palate repair in _%#DDMM2000#%_.
PD|pancreatic duct|PD|263|264|HISTORY OF PRESENT ILLNESS|This led to a ERCP yesterday. The findings demonstrates an unusual appearance of the proximal common bile duct, but likely not significant and PSC was doubted by Dr. _%#NAME#%_, who performed the examination. The biliary was swept with a basket and was negative. PD was cannulated at the start of the procedure but not injected. A biliary sphincterotomy was performed. Following the procedure, the patient developed severe upper abdominal pain and was admitted for further pain control.
PD|peritoneal dialysis|PD|206|207|PAST SURGICAL HISTORY|8. Hypothyroidism. 9. Depression. 10. Seasonal allergic rhinitis. PAST SURGICAL HISTORY: 1. Living donor kidney transplant _%#DDMM2006#%_. 2. Subtotal thyroidectomy for papillary carcinoma _%#MM2006#%_. 3. PD catheter placed _%#DDMM2006#%_. 4. Ureteral implants x2 as a child. FAMILY HISTORY: Mother has type 2 diabetes. Father had lymphoma 30 years ago.
PD|police department|PD|196|197|HISTORY OF PRESENT ILLNESS|3. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 49-year-old gentleman with known history of depression with prior suicide attempt 12 years ago, who was brought in by EMS after the local PD convinced him not to jump off the top of his house. He has had multiple social stressors in the past year.
PD|peritoneal dialysis|PD|178|179|HISTORY OF PRESENT ILLNESS|He was then given a trial of dialysis for 2 weeks. They tried restarting his dialysis on _%#MMDD#%_, but the alarm went off throughout the night. They subsequently had attempted PD on _%#MMDD#%_, _%#MMDD#%_ and _%#MMDD#%_ with intermittent success. Also the mother states that she contaminated the catheter and that should be needed to be changed out.
PD|peritoneal dialysis|PD|164|165|HISTORY OF PRESENT ILLNESS|Otherwise, the patient states he has been feeling quite well. He has had some decreased energy level over the past few days as sleep has been poor secondary to his PD problems. Otherwise, no pain, fever, shortness of breath. He has had a mild cough and running nose over the last few days.
PD|peritoneal dialysis|PD|323|324|HOSPITAL COURSE BY SYSTEM|His electrolytes were followed daily. He had an elevated phosphorus to 6.9. This gradually decreased on the day of discharge it was 5.2. His albumin was generally well throughout hospitalization at 2.7 or 2.8. 2. Renal: The patient was started on peritoneal dialysis. He had a large fibrin clot that was mobilized from his PD catheter and his PD improved after this time. He received TPA to his catheter and had heparin in his PD fluid. His creatinine decreased nicely with the initiation of his peritoneal dialysis.
PD|peritoneal dialysis|PD|130|131|HOSPITAL COURSE BY SYSTEM|Renal: The patient was started on peritoneal dialysis. He had a large fibrin clot that was mobilized from his PD catheter and his PD improved after this time. He received TPA to his catheter and had heparin in his PD fluid. His creatinine decreased nicely with the initiation of his peritoneal dialysis.
PD|peritoneal dialysis|PD|214|215|HOSPITAL COURSE BY SYSTEM|Renal: The patient was started on peritoneal dialysis. He had a large fibrin clot that was mobilized from his PD catheter and his PD improved after this time. He received TPA to his catheter and had heparin in his PD fluid. His creatinine decreased nicely with the initiation of his peritoneal dialysis. On the day of discharge, his creatinine was 10.6. His BUN stayed in the 50s; however, it was 106 on admission.
PD|peritoneal dialysis|PD|190|191|HOSPITAL COURSE BY SYSTEM|On the day of discharge, his creatinine was 10.6. His BUN stayed in the 50s; however, it was 106 on admission. 3. Gastrointestinal: The patient had abdominal x-ray on admission to check his PD catheter placement. The catheter appeared to be in appropriate position in the right lower quadrant. However, it is noted that he has large amount of stools throughout his colon.
PD|peritoneal dialysis|PD|154|155|HOSPITAL COURSE BY SYSTEM|He had excellent response with repeat abdominal studies showing improvement of constipation. After his bowels were cleaned out, he had improvement in his PD function. Therefore, it was thought that its original dysfunction was likely secondary to constipation. 4. Respiratory: The patient has a history of right-sided pleural effusion.
PD|peritoneal dialysis|PD|270|271|FOLLOWUP|7. Epogen 5000 units subcutaneous weekly. FOLLOWUP: The patient is to return to University of Minnesota Childrens Hospital for a pleurodesis on _%#MMDD#%_. He was discharged home on peritoneal dialysis with fluid volume of 645-minute cycles x12 hours. He had a standard PD solution with 2.5% dextrose.
PD|peritoneal dialysis|PD|129|130|PAST SURGICAL HISTORY|PAST TRANSPLANT HISTORY: 1. Living donor kidney transplant in 2005. 2. Subtotal thyroidectomy in 2066. PAST SURGICAL HISTORY: 1. PD catheter placement on 2006. 2. Ureteral reimplantation following living donor kidney transplant. PHYSICAL EXAMINATION: GENERAL: She was in no apparent distress.
PD|peritoneal dialysis|PD|152|153|LABORATORY DATA|NEUROLOGIC: No focal signs or deficits. LABORATORY DATA: On admission, included white count of 2.3, hemoglobin 11.5, platelets 310,000, ANC of 1.2. Her PD fluids showed one nucleated cell. Her chest x-ray was clear. Her electrolytes were within normal limits with a BUN of 82 and creatinine of 6.2. CRP is 23.3 on admission.
PD|peritoneal dialysis|PD|186|187|PHYSICAL EXAMINATION|NECK: Supple, there is no adenopathy or thyromegaly. LUNGS: Show clear bilateral breath sounds. CARDIAC: Regular rate and rhythm, normal S1, S2, no murmur, rub or gallop. ABDOMEN: Shows PD catheter in the left lower quadrant with a clean exit site. There are minimal bowel sounds, however, it is soft and there is no tenderness, guarding or rebound and I cannot feel the liver or spleen.
PD|peritoneal dialysis|PD.|188|190|IMPRESSION|IMPRESSION: This patient has a picture that could be consistent with gastroenteritis. He may have peritonitis associated with peritoneal dialysis. He has end-stage renal disease and is on PD. We will continue this. We will send a Gram stain and culture as well as cell count differential of the PD fluid.
PD|peritoneal dialysis|PD|204|205|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 10-year-old female with history of Wolf-Hirschhorn syndrome associated with profound developmental delay, seizure disorder and stage VI chronic kidney disease, PD dependent who was admitted on _%#DDMM2007#%_ with seizure and intubated because of decreased mental status for airway protection. The patient was brought in by ambulance after suffering an approximate 8-minute seizure, that day, the patient's _____ also noticed increase in the frequency of her stooling.
PD|peritoneal dialysis|PD|219|220|HOSPITAL COURSE|3. Infectious disease. On admission, _%#NAME#%_ was felt to have right upper lobe pneumonia, was started on Zosyn. She also received a dose of IV tobramycin. The patient did have an elevated nucleated cell count in her PD fluid from _%#DDMM2007#%_. Because of the severity of illness, the decision was made to treat with vancomycin to finish a 14-day course.
PD|peritoneal dialysis|PD|176|177|HOSPITAL COURSE|As of discharge, the patient returned to her home seizure medicine with the addition of essential amino acids. 6. Renal. _%#NAME#%_ has stage VI chronic kidney disease and was PD dependent. Her PD was adjusted throughout her hospital stay to help with her fluid balance and to maintain blood pressure.
PD|peritoneal dialysis|PD|194|195|HOSPITAL COURSE|As of discharge, the patient returned to her home seizure medicine with the addition of essential amino acids. 6. Renal. _%#NAME#%_ has stage VI chronic kidney disease and was PD dependent. Her PD was adjusted throughout her hospital stay to help with her fluid balance and to maintain blood pressure. Prior to discharge, she was returned to her home PD regimen.
PD|peritoneal dialysis|PD|161|162|HOSPITAL COURSE|Her PD was adjusted throughout her hospital stay to help with her fluid balance and to maintain blood pressure. Prior to discharge, she was returned to her home PD regimen. DISCHARGE LABORATORY DATA: A metabolic panel was sent on _%#DDMM2007#%_.
PD|peritoneal dialysis|PD.|257|259|HISTORY OF PRESENT ILLNESS|She is status post CVC placement on the right and we will arrange for her to get dialysis in the _%#COUNTY#%_ _%#COUNTY#%_ Unit because she lives in _%#CITY#%_. She will need a Tenckhoff catheter placed during this hospitalization and will eventually go to PD. She has been eating poorly with a decreased appetite and some anorexia.
PD|peritoneal dialysis|PD|135|136|IMPRESSION|We will start her on Protonix. 4. End-stage renal disease. She is uremic, we will start her on hemodialysis initially with hopefully a PD catheter replacement during this hospitalization and then we will arrange for outpatient dialysis. 5. Diabetes. We will continue her NPH and sliding scale insulin.
PD|peritoneal dialysis|PD|144|145|FOLLOW UP|7. Calcium carbonate 500 mg p.o. t.i.d. 8. Indomethacin 50 mg p.o. t.i.d. FOLLOW UP: The patient will contact the peritoneal dialysis nurse for PD catheter care. Also she will schedule a follow-up appointment with Dr. _%#NAME#%_ _%#NAME#%_, and the patient will have protein/creatinine ratio in spot urine prior to Dr. _%#NAME#%_'s appointment.
PD|peritoneal dialysis|PD.|124|126|HOSPITAL COURSE|Again, given his fever and hemoptysis, it was felt appropriate to keep the patient in isolation until proven that he has no PD. PPD with controls including Candida and mumps were placed. Patient is anergic and had no reaction to any of the subcutaneous injections.
PD|peritoneal dialysis|PD|260|261|HOSPITAL COURSE|He underwent a washout on _%#MM#%_ _%#DD#%_, 2004, and at that time had had significant renal insufficiency, so a peritoneal dialysis catheter was placed. In the process of Dr. _%#NAME#%_ operating on the child and following the sternal washout but before the PD cath placement, the child had several sudden dips in blood pressure that did not respond to volume and a full code was initiated.
PD|peritoneal dialysis|PD|291|292|HISTORY OF PRESENT ILLNESS|PROCEDURES: Cadaveric kidney transplant. HISTORY OF PRESENT ILLNESS: The patient is a 24-year-old female with end-stage kidney disease secondary to uteropelvic junction obstruction since age 3. She had cadaveric kidney transplant in 1990 which failed after her pregnancy. The patient was on PD since 2002 and has never been on HD. PAST MEDICAL HISTORY: 1. Hypertension since 1987. 2. Hypothyroidism.
PD|peritoneal dialysis|P.D.|110|113|HISTORY OF PRESENT ILLNESS|He was found by his brother when his brother came over to pick up some money and his brother called the local P.D. He was brought in by ambulance. In the ED the bleeding was already controlled and he was sutured in the ED with five continuous sutures across a 7 cm lac on the right and 4 lacerations on the left.
PD|peritoneal dialysis|PD|127|128|HISTORY OF PRESENT ILLNESS|He underwent placement of peritoneal dialysis catheter and initiation of peritoneal dialysis but this failed due to leakage of PD fluid into the scrotum. He underwent repositioning of the catheter but this did not correct the problem and so peritoneal dialysis was discontinued and he recently had his PD catheter pulled.
PD|peritoneal dialysis|PD|147|148|PAST MEDICAL HISTORY|2. Chronic renal failure on peritoneal dialysis. 3. Ischemic cardiomyopathy with ejection fraction 20 to 25%. 4. Diabetes mellitus. 5. Status post PD catheter placement. 6. Status post exploratory laparotomy and abdominal washout. ALLERGIES: No known drug allergies. The patient was admitted to the surgical intensive care unit for monitoring following placement of his intraaortic balloon pump on _%#DDMM2005#%_.
PD|peritoneal dialysis|PD|196|197|PAST MEDICAL HISTORY|4. He has had several episodes of peritonitis, the first in _%#DDMM2006#%_ when he was hospitalized at _%#COUNTY#%_ _%#COUNTY#%_ Medical Center. At that time diphtheroids were cultured out of his PD fluid and he was profoundly volume depleted. 5. The second occurred in _%#DDMM2006#%_ when he was hospitalized at Fairview Southdale Hospital and was found to have gram negative peritonitis with Serratia marcescens and Providencia rettgeri.
PD|peritoneal dialysis|PD|150|151|PROBLEM #3|His creatinine on admission was 2.25 and his last creatinine prior to discharge on _%#DDMM2007#%_ was 2.52. There was some discussion about placing a PD catheter. As his creatinine and his potassium improved and he was making urine, it was decided to hold off on this and it will be followed as an outpatient.
PD|peritoneal dialysis|PD|162|163|BRIEF HISTORY AND HOSPITAL COURSE|In addition he took 6 tablets of trazodone 200 mg which was prescribed by his psychiatrist at the VA Medical Center. He did express some suicidal ideation to the PD which prompted his ER admission. He states he did not care about living anymore and he felt like drinking to "end it all." However, he denies any specific plans at this point in time.
PD|police department|PD|183|184|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Advil overdose, alcohol intoxication. HISTORY OF PRESENT ILLNESS: The patient is a 39-year-old gainfully employed "scientist" at 3M who was brought in involuntary by PD on a hold after they were dispatched when wife called 911 for an ibuprofen overdose. He has some marital stressors right now and reports being in the midst of a divorce.
PD|peritoneal dialysis|PD|60|61|PROCEDURE|DIAGNOSIS: S/P PD catheter placement. PROCEDURE: Removal of PD catheter HISTORY OF PRESENT ILLNESS: This is a 54-year-old Asian male status post cadaveric kidney transplant since _%#DDMM2002#%_ with good graft function. The patient has a PD catheter in the left mid quadrant of his abdomen and is scheduled to have this surgically removed on _%#DDMM2002#%_.
PD|peritoneal dialysis|PD|401|402|PAST MEDICAL HISTORY|The patient has a PD catheter in the left mid quadrant of his abdomen and is scheduled to have this surgically removed on _%#DDMM2002#%_. PAST MEDICAL HISTORY: Past medical history includes end-stage renal failure secondary to glomerulonephritis, hypertension, right subdural hematoma, hyperparathyroidism, umbilical hernia repair, left inguinal hernia repair, history of positive PPD, and history of PD with three to four episodes of peritonitis. ALLERGIES: No known drug allergies. HOSPITAL COURSE: He underwent the peritoneal dialysis removal surgically on _%#DDMM2002#%_ without any complications.
PD|peritoneal dialysis|PD|336|337|PAST MEDICAL HISTORY|The last was in early _%#MM#%_ and she was advised by Dr. _%#NAME#%_ that her current symptoms may be related to that procedure and he was somewhat reluctant to do another esophagogastroduodenoscopy because of the friability of the esophagus. PAST MEDICAL HISTORY: 1. Systemic lupus erythematosus with chronic renal failure. She was on PD and hemodialysis and received a living related donor transplant in 1996, stable renal function since then. 2. Bilateral total hip arthroplasties. 3. Two transient ischemic attacks both in the 1990's associated with hemiparesis, right sided on the first and left sided on the second with no residuals.
PD|peritoneal dialysis|PD|183|184|HISTORY OF PRESENT ILLNESS|NEPHROLOGY/ADMISSION NOTE HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 35-year- old, peritoneal dialysis patient admitted for treatment of peritonitis and a non-functioning PD catheter. Mr. _%#NAME#%_ had end-stage kidney failure secondary to IgA nephropathy and underwent a renal transplant in _%#CITY#%_ in 2000.
PD|peritoneal dialysis|PD|261|262|HISTORY OF PRESENT ILLNESS|He is followed by Dr. _%#NAME#%_ _%#NAME#%_. About three days ago he noted some cloudy fluid and is being treated for peritonitis with IP antibiotics. Last night he was unable to drain after placing 2 liters of fluid into the peritoneal space. He contacted the PD nurses who instructed him to hook up another bag and drain, which he was able to do. After this, however, drainage failed again and he came to the Emergency Room for evaluation.
PD|peritoneal dialysis|PD|227|228|PLAN|2. X-rays of abdomen to localize catheter placement. 3. We will discuss with Interventional Radiology as to the feasibility of some type of dye study and perhaps wire passage through the catheter. 4. Discuss the above with the PD nursing staff at _%#COUNTY#%_ _%#COUNTY#%_ Medical Center, where he was trained. 5. We will continue IV Fortaz, he did receive a dose of vancomycin in the ER, we will check vancomycin levels.
PD|peritoneal dialysis|PD.|201|203|HISTORY OF PRESENT ILLNESS|The patient pulled on his peritoneal dialysis catheter and immediately some bleeding was noted around the site. At that point, the parents called the renal nurse and were instructed to try to continue PD. They were to report any leakage. They did not have any further leakage or bleeding; however, thought that maybe the ultrafiltration was not as good as usual.
PD|peritoneal dialysis|PD|191|192|CURRENT MEDICAL PROBLEM LIST|Most recently she dialyzed under the direction of Kidney Disease at the _%#CITY#%_ _%#CITY#%_ unit. She has had three previously failed Gore-Tex loop grafts placed. She has previously been a PD patient. Her current dialysis access is a right IJ tunnel catheter. 2. Long-standing hypertension, multiple antihypertensives as ongoing medications. 3. Recent apparent cellulitis of her thrombosed loop graft requiring _____ p.o.
PD|pancreatic duct|PD|76|77|ADDENDUM|ADDENDUM: _%#NAME#%_ _%#NAME#%_ had ERCP performed with balloon dilation of PD stricture and balloon sweet with extraction of fragments of PD stone. Placement of a 4 French x 9 French pancreatic stent. _%#NAME#%_ was advanced on clears until regular diet. She tolerated this without pain and then laboratory results were followed on the next day prior to discharge and she was sometime on amylase of 50 and lipase of 162 prior to being sent home.
PD|peritoneal dialysis|PD|195|196|PROBLEM #2|Her electrolytes were followed intermittently and placed appropriately as needed. PROBLEM #2: _%#NAME#%_ remained on peritoneal dialysis initially while in the pediatric intensive care unit. Her PD cycles and fluid were adjusted by pediatric nephrology periodically to account for her fluctuation in fluid status and overall clinical status.
PD|peritoneal dialysis|PD|253|254|PROBLEM #2|Her PD cycles and fluid were adjusted by pediatric nephrology periodically to account for her fluctuation in fluid status and overall clinical status. On the morning of _%#DDMM2007#%_, some brown particulate matter concerning for stool was noted in her PD fluid, so her PD catheter was capped at that time and her peritoneal dialysis was held from that point on. PROBLEM #3: Cardiovascular. After transfer to the pediatric intensive care unit, _%#NAME#%_ developed worsening hypertension and shock.
PD|peritoneal dialysis|PD|270|271|PROBLEM #2|Her PD cycles and fluid were adjusted by pediatric nephrology periodically to account for her fluctuation in fluid status and overall clinical status. On the morning of _%#DDMM2007#%_, some brown particulate matter concerning for stool was noted in her PD fluid, so her PD catheter was capped at that time and her peritoneal dialysis was held from that point on. PROBLEM #3: Cardiovascular. After transfer to the pediatric intensive care unit, _%#NAME#%_ developed worsening hypotension and shock.
PD|peritoneal dialysis|PD|181|182|PROBLEM #5|An ID consult was obtained shortly after transfer. Enterobacter coli grew from a culture for PD fluid. Antibiotic therapy was adjusted appropriately and tobramycin was added to her PD fluid in addition to her vancomycin and imipenem systemically. She was also treated with fluconazole empirically. She remained on the this antimicrobials up till the time of death.
PD|peritoneal dialysis|PD|237|238|PROBLEM #6|She was also treated with fluconazole empirically. She remained on these antimicrobials up till the time of death. PROBLEM #6: GI. In the morning of _%#DDMM2007#%_, brown particulate matter concerning for stool was noted in _%#NAME#%_'s PD fluid. A flat plate and cross-table lateral abdominal x-ray was obtained, which suggested free air and supported our concern for bowel preparation.
PD|peritoneal dialysis|PD|160|161|DISCHARGE DIAGNOSES|ADMITTING DIAGNOSES: 1. Status post cadaveric kidney transplant. 2. Lymphocele. DISCHARGE DIAGNOSES: 1. Status post cadaveric kidney transplant. 2. Status post PD catheter removal. PROCEDURE: PD catheter removal and lymphocele drainage with drain placement on _%#DDMM2003#%_.
PD|peritoneal dialysis|PD|112|113|PROCEDURE|DISCHARGE DIAGNOSES: 1. Status post cadaveric kidney transplant. 2. Status post PD catheter removal. PROCEDURE: PD catheter removal and lymphocele drainage with drain placement on _%#DDMM2003#%_. HISTORY OF PRESENT ILLNESS: The patient is an Arabic female who underwent cadaveric kidney transplant in _%#DDMM2003#%_.
PD|peritoneal dialysis|PD|171|172|SUMMARY OF HOSPITAL STAY|3. History of peritoneal dialysis. 4. History of left knee arthritis. SUMMARY OF HOSPITAL STAY: The patient is a 39-year-old Arabic female who was admitted for removal of PD catheter. She also had a lymphocele. The above-mentioned procedure was performed on the day of admission, and was without complication.
PD|peritoneal dialysis|PD|256|257|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 9-month-old boy with a history of renal failure and dialysis dependence secondary to a renal dysplasia and obstructive uropathy. He has been hospitalized much of the past two months, initially being admitted for PD catheter placement. His most recent hospitalization was from _%#DDMM2003#%_ to _%#DDMM2003#%_ for dehydration, vomiting and diarrhea. During this last hospitalization, he was rehydrated and discharged to home.
PD|peritoneal dialysis|PD|149|150|PAST MEDICAL HISTORY|Removal of peritoneal dialysis catheter and placement of hemodialysis catheter. 8. Replacement of peritoneal dialysis catheter and re-institution of PD on _%#DDMM2003#%_. ADMISSION PHYSICAL EXAMINATION: Temperature 97.6. Pulse 136. Respiratory rate 36.
PD|peritoneal dialysis|PD|139|140|ADMISSION PHYSICAL EXAMINATION|Normal S1 and S2. No murmurs. Capillary refill less than 2 seconds. ABDOMEN: Positive bowel sounds. Soft and non-distended. No drainage at PD catheter site. ADMISSION LABORATORY DATA: Sodium 142, potassium 3.8, chloride 96, bicarbonate 32, BUN 6, creatinine 4.3, calcium 8.8, magnesium 1.1, phosphorus 4.6. HOSPITAL COURSE: PROBLEM #1: Fluid, electrolytes and nutrition.
PD|peritoneal dialysis|PD|172|173|MMC 712|On admission to the NICU, physical examination was significant for edema, lungs clear bilaterally, II/VI systolic murmur, prominent superficial veins on chest and abdomen, PD catheter with slight erythema at the site, and a distended abdomen. Primary diagnosis on admission was chronic renal failure due to bilateral dysplastic kidneys.
PD|peritoneal dialysis|PD|147|148|MMC 712|Problem #2: Infectious Disease. We treated _%#NAME#%_ with a 14 day course of vancomycin, ceftazadime, and gentamicin given in the dialysate after PD cultures grew Serratia marcescens, Klebsiella pneumonia, and Group D enterococcus. PD cultures from _%#MMDD#%_-_%#MMDD#%_ grew Serratia marcescens with altered sensitivities.
PD|peritoneal dialysis|PD|390|391|MMC 712|Problem #2: Infectious Disease. We treated _%#NAME#%_ with a 14 day course of vancomycin, ceftazadime, and gentamicin given in the dialysate after PD cultures grew Serratia marcescens, Klebsiella pneumonia, and Group D enterococcus. PD cultures from _%#MMDD#%_-_%#MMDD#%_ grew Serratia marcescens with altered sensitivities. _%#NAME#%_ was treated with piperacillin/tazobactam given IV and PD as well as vancomycin given PD. His subsequent cultures have had no growth, including fungal PD cultures _%#MMDD#%_ and _%#MMDD#%_, PD bacterial cultures _%#MMDD#%_x2, _%#MMDD#%_, _%#MMDD#%_, _%#MMDD#%_, _%#MMDD#%_, _%#MMDD#%_, and _%#MMDD#%_, and a blood culture _%#MMDD#%_.
PD|peritoneal dialysis|PD|161|162|MMC 712|_%#NAME#%_ was treated with piperacillin/tazobactam given IV and PD as well as vancomycin given PD. His subsequent cultures have had no growth, including fungal PD cultures _%#MMDD#%_ and _%#MMDD#%_, PD bacterial cultures _%#MMDD#%_x2, _%#MMDD#%_, _%#MMDD#%_, _%#MMDD#%_, _%#MMDD#%_, _%#MMDD#%_, and _%#MMDD#%_, and a blood culture _%#MMDD#%_. He is currently just on Zosyn (200 mg IV Q8) and Nystatin 50,000 Units PO Q6.
PD|peritoneal dialysis|PD|186|187|PAST MEDICAL HISTORY|2. _%#MM#%_ _%#DD#%_, 2005, admitted to the PICU with acute renal failure, metabolic acidosis, hyponatremia, and hyperkalemia. Peritoneal dialysis restarted. 3. _%#MM#%_ _%#DD#%_, 2005, PD catheter replaced, transferred to the NICU at Fairview-University Medical Center. 4. _%#MM#%_ _%#DD#%_ 2005, transferred back to the PICU. 5. _%#MM#%_ _%#DD#%_, 2005, Klebsiella pneumonia and Serratia peritonitis. 6. _%#MM#%_ _%#DD#%_, 2005, Klebsiella oxytoca peritonitis.
PD|peritoneal dialysis|PD|273|274|PAST MEDICAL HISTORY|5. _%#MM#%_ _%#DD#%_, 2005, Klebsiella pneumonia and Serratia peritonitis. 6. _%#MM#%_ _%#DD#%_, 2005, Klebsiella oxytoca peritonitis. 7. _%#MM#%_ _%#DD#%_, 2005, return of Serratia peritonitis. 8. _%#MM#%_ _%#DD#%_, 2005, Serratia peritonitis. 9. _%#MM#%_ _%#DD#%_, 2005, PD catheter removed. 10. _%#MM#%_ _%#DD#%_, 2005, PD catheter replaced. 11. _%#MM#%_ _%#DD#%_, 2005, PD stopped secondary to leakage. MEDICATIONS DURING HOSPITAL STAY PRIOR TO DISCHARGE: 1. Poly-Vi-Sol 1 mg p.o. NG daily.
PD|peritoneal dialysis|PD|188|189|PAST MEDICAL HISTORY|7. _%#MM#%_ _%#DD#%_, 2005, return of Serratia peritonitis. 8. _%#MM#%_ _%#DD#%_, 2005, Serratia peritonitis. 9. _%#MM#%_ _%#DD#%_, 2005, PD catheter removed. 10. _%#MM#%_ _%#DD#%_, 2005, PD catheter replaced. 11. _%#MM#%_ _%#DD#%_, 2005, PD stopped secondary to leakage. MEDICATIONS DURING HOSPITAL STAY PRIOR TO DISCHARGE: 1. Poly-Vi-Sol 1 mg p.o. NG daily. 2. Folate 15 mcg p.o. NG q. 12 hours.
PD|peritoneal dialysis|PD|239|240|PAST MEDICAL HISTORY|7. _%#MM#%_ _%#DD#%_, 2005, return of Serratia peritonitis. 8. _%#MM#%_ _%#DD#%_, 2005, Serratia peritonitis. 9. _%#MM#%_ _%#DD#%_, 2005, PD catheter removed. 10. _%#MM#%_ _%#DD#%_, 2005, PD catheter replaced. 11. _%#MM#%_ _%#DD#%_, 2005, PD stopped secondary to leakage. MEDICATIONS DURING HOSPITAL STAY PRIOR TO DISCHARGE: 1. Poly-Vi-Sol 1 mg p.o. NG daily. 2. Folate 15 mcg p.o. NG q. 12 hours. 3. Iron sulfate, FeSO4, 75 mg (15 mg elemental iron p.o. q. 12 hours).
PD|peritoneal dialysis|PD|191|192|PHYSICAL EXAMINATION|Lungs are clear to auscultation bilaterally. Heart: Unchanged 1/6 systolic ejection murmur. Capillary refill less than 2 seconds. Peripheral pulses 2+. Abdomen soft, nontender, nondistended. PD catheter in place, covered by gauze. Extremities: No peripheral edema noted. ASSESSMENT AND PLAN: _%#NAME#%_ is a 3-month-old male with chronic renal failure secondary to bilateral renal dysplasia with resolving peritonitis and several PD catheter revisions, most recently secondary to leakage, off PD since _%#MM#%_ _%#DD#%_, 2005, to allow for healing of new PD catheter placement and in anticipation of resumption of PD.
PD|peritoneal dialysis|PD|239|240|ASSESSMENT AND PLAN|PD catheter in place, covered by gauze. Extremities: No peripheral edema noted. ASSESSMENT AND PLAN: _%#NAME#%_ is a 3-month-old male with chronic renal failure secondary to bilateral renal dysplasia with resolving peritonitis and several PD catheter revisions, most recently secondary to leakage, off PD since _%#MM#%_ _%#DD#%_, 2005, to allow for healing of new PD catheter placement and in anticipation of resumption of PD.
PD|peritoneal dialysis|PD|364|365|ASSESSMENT AND PLAN|PD catheter in place, covered by gauze. Extremities: No peripheral edema noted. ASSESSMENT AND PLAN: _%#NAME#%_ is a 3-month-old male with chronic renal failure secondary to bilateral renal dysplasia with resolving peritonitis and several PD catheter revisions, most recently secondary to leakage, off PD since _%#MM#%_ _%#DD#%_, 2005, to allow for healing of new PD catheter placement and in anticipation of resumption of PD. PROBLEM LIST: 1. FEN/GI. Electrolytes per _%#MM#%_ _%#DD#%_, 2005, sodium 139, potassium 3.7, chloride 101, bicarbonate 27, BUN 38, creatinine 6.65, glucose 80, calcium 9.7, magnesium 2.3, phosphorus was 3.3. As stated above, _%#NAME#%_ will be discharged to the Ronald McDonald House for approximately 2 weeks.
PD|peritoneal dialysis|PD.|423|425|ASSESSMENT AND PLAN|PD catheter in place, covered by gauze. Extremities: No peripheral edema noted. ASSESSMENT AND PLAN: _%#NAME#%_ is a 3-month-old male with chronic renal failure secondary to bilateral renal dysplasia with resolving peritonitis and several PD catheter revisions, most recently secondary to leakage, off PD since _%#MM#%_ _%#DD#%_, 2005, to allow for healing of new PD catheter placement and in anticipation of resumption of PD. PROBLEM LIST: 1. FEN/GI. Electrolytes per _%#MM#%_ _%#DD#%_, 2005, sodium 139, potassium 3.7, chloride 101, bicarbonate 27, BUN 38, creatinine 6.65, glucose 80, calcium 9.7, magnesium 2.3, phosphorus was 3.3. As stated above, _%#NAME#%_ will be discharged to the Ronald McDonald House for approximately 2 weeks.
PD|peritoneal dialysis|PD|218|219|PROBLEM LIST|He will leave on a fluid restriction of 450 cc per 24 hours of breast milk, Similac 26 kcal per day, with 3 g per kg per day of Beneprotein plus 1/2 teaspoon of Kayexalate. He will return in approximately 2 weeks, and PD will be resumed. Goal weight will be 5.1 to 5.2 kg. _%#NAME#%_ will be visited daily by a home nurse for 1 week and then 3 days a week thereafter.
PD|posterior descending|PD|138|139|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Significant for coronary artery bypass graft which shows a LIMA to mid LAD. 2. SVG to D1 3. SVG to D2. 4. SVG to PD RCA. 5. AAA repair in the past. 6. Right carotid artery stenosis 80% stenosis. 7. Obstructive sleep apnea on CPAP at night. 8. Hypertension.
PD|peritoneal dialysis|PD|209|210|PAST MEDICAL HISTORY|The patient will be admitted for IV fluid administration and symptomatic therapy. PAST MEDICAL HISTORY: 1) Diabetes type I for many years with retinopathy and peripheral neuropathy. 2) ESRD with initiation of PD in _%#MM#%_, 2001. She uses a nighttime cycler with two five-liter bags. With this apparently she has been adequately dialyzed. 3) Diabetic retinopathy and peripheral neuropathy.
PD|peritoneal dialysis|PD|214|215|PHYSICAL EXAMINATION|Thyroid not palpable. Lungs clear to percussion and auscultation. Heart: Normal sinus rhythm, no murmur or gallop. Abdomen is soft and nontender, liver and spleen not palpable, active bowel sounds are present. The PD catheter in the left lower quadrant is normal at the exit site; there is no tenderness over the tunnel. Neuro: No focal signs, sensory function not tested. Skin: Dry and decreased turgor.
PD|peritoneal dialysis|PD|196|197|HISTORY OF PRESENT ILLNESS|Emesis is non-bilious and without any blood. Emesis is noted to immediately follow p.o. intake. _%#NAME#%_ has had no diarrhea or upper respiratory infection symptoms. His mother reports that the PD and all line sites have been clear. There have been no major changes to PD regimen over this time period, and PD has been tolerated as usual.
PD|peritoneal dialysis|PD|141|142|HISTORY OF PRESENT ILLNESS|His mother reports that the PD and all line sites have been clear. There have been no major changes to PD regimen over this time period, and PD has been tolerated as usual. The mother does report that she has recently been changing formulas from breast milk with Neocate to Similac, and then back to straight Neocate without any improvement in his symptoms.
PD|peritoneal dialysis|PD|157|158|PAST MEDICAL HISTORY|Apgars noted to be 1 at one minute, 3 at five minutes, and 3 at 10 minutes. 2. ATN, cortical necrosis secondary to perinatal depression. _%#NAME#%_ has been PD dependent since day of life #3. 3. Hypoxic ischemic brain injury secondary to perinatal depression. 4. History of DIC while in the Neonatal Intensive Care Unit.
PD|peritoneal dialysis|PD|213|214|PROBLEM #4|As mentioned in the first paragraph, his emesis did seem to resolve following aggressive rehydration and NG feeds. PROBLEM #4: Infectious Disease. _%#NAME#%_ did not receive any antibiotics during this admission. PD fluid was monitored for any signs of peritonitis, but all labs were within normal limits. Specifically, the nucleated cell count in his PD was not elevated during this admission.
PD|peritoneal dialysis|PD|139|140|PROBLEM #4|PD fluid was monitored for any signs of peritonitis, but all labs were within normal limits. Specifically, the nucleated cell count in his PD was not elevated during this admission. He was not febrile during his hospitalization. He did have one loose stool which was found to be negative for rotavirus and C.
PD|peritoneal dialysis|PD|123|124|HOSPITAL COURSE 1. RENAL|As his renal function worsened, he was changed to a renal diet. In addition, preparations were made for the placement of a PD catheter. But subsequently, his creatinine deceased, and a PD catheter was not necessary. His creatinine at the time of discharge was 2.22. Because of the significant hypertension, a renal ultrasound was done during his hospitalization.
PD|peritoneal dialysis|PD|253|254|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: End-stage renal disease. PROCEDURES PERFORMED DURING THIS HOSPITAL STAY: Kidney transplant. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 60-year-old male with end-stage renal disease secondary to polycystic kidney disease and PD currently has been here for a cadaveric kidney transplant. He has been on peritoneal dialysis for 1-1/2 years and he attempted HD access, but there were multiple clots formed and he failed this.
PD|peritoneal dialysis|PD|304|305|PAST SURGICAL HISTORY|PAST SURGICAL HISTORY: Significant for 2-vessel CABG x2 in 2004, brain aneurysm in _%#DDMM2004#%_, cataracts of the left eye, he had a TURP in _%#DDMM2007#%_; he had arthroscopic knee surgeries x2. In 2005, there was an attempted left upper extremity fistula, this has failed due to clot and there was a PD catheter placed in 2005 as well. PAST MEDICAL HISTORY: Significant for, 1. Hypertension. 2. End-stage renal disease secondary to polycystic kidney disease.
PD|peritoneal dialysis|PD|154|155|HOSPITAL COURSE|HOSPITAL COURSE: 1. Talc pleurodesis. Talc pleurodesis was performed on the 7th. He was kept on suction for longer than normal, five days, because of his PD dialysis situation. PD dialysis was held in conjunction with the nephrologist for the first six days on the 6th day it was noticed that the patient had minuscule effusions on chest x-ray and a chest CT was obtained.
PD|peritoneal dialysis|PD|177|178|HOSPITAL COURSE|HOSPITAL COURSE: 1. Talc pleurodesis. Talc pleurodesis was performed on the 7th. He was kept on suction for longer than normal, five days, because of his PD dialysis situation. PD dialysis was held in conjunction with the nephrologist for the first six days on the 6th day it was noticed that the patient had minuscule effusions on chest x-ray and a chest CT was obtained.
PD|peritoneal dialysis|PD.|215|217|HISTORY OF PRESENT ILLNESS|He had never been transplanted. He was started on hemodialysis and did this through a port for 3 months before beginning PD. He is healthy and he has no symptoms. Previous transplants, none. Baseline creatinine and PD. REVIEW OF SYSTEMS: These were reviewed and 14-point review of systems was negative.
PD|peritoneal dialysis|PD|152|153|PHYSICAL EXAMINATION|HEENT: Within normal limits. NECK: Show no JVD and no nodes. PULMONARY: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender and nondistended. A PD catheter was in place in the left lower quadrant. EXTREMITIES: Without lower extremity edema. SKIN: He had no rash. BACK: Normal. HEART: Slightly tachy with a normal S1 and normal S2.
PD|peritoneal dialysis|PD|146|147|HOSPITAL COURSE|2. Hypertension: The patient's metoprolol was increased to 50 mg p.o. b.i.d. during the hospital stay for high blood pressure and tachycardia. 3. PD catheter removal: Actually, it was clear that the transplanted kidney was working optimally. PD catheter was removed and this was done on _%#DDMM2007#%_.
PD|peritoneal dialysis|PD|242|243|HOSPITAL COURSE|2. Hypertension: The patient's metoprolol was increased to 50 mg p.o. b.i.d. during the hospital stay for high blood pressure and tachycardia. 3. PD catheter removal: Actually, it was clear that the transplanted kidney was working optimally. PD catheter was removed and this was done on _%#DDMM2007#%_. This also allowed the patient to get his last dose of Thymoglobulin.
PD|peritoneal dialysis|PD|148|149|PHYSICAL EXAMINATION|LUNGS: Show clear breath sounds. CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmur, rub or gallop. ABDOMEN: Exquisitely tender. There is a PD catheter in the left lower quadrant. The exit site is clean except for minimal crusting. GENITOURINARY: Normal male pattern.
PD|peritoneal dialysis|PD|183|184|IMPRESSION|EXTREMITIES: Normal pulses. No edema. NEUROLOGIC: Symmetric cranial nerves. Normal mental status. Moves all four extremities well. IMPRESSION: Peritonitis, most likely related to his PD exchanges and catheter. We will send a bag for culture, gram stain, cell count and differential. We will start him on vancomycin and ceftazidime IV. Eventually, we can switch over to intraperitoneal.
PD|peritoneal dialysis|PD|185|186|FOLLOW-UP VISIT|Reticulocyte count was 502.6 absolute and 11.5% on _%#DDMM2004#%_. Due to the increased hematopoesis and early onset of significant hyperbilirubinemia, a peripheral smear and Glucose 6 PD screening test were drawn on _%#DDMM2004#%_. The results of these tests were pending at the time of transfer. _%#NAME#%_ was on phototherapy with one bank of lights at the time of transfer.
PD|peritoneal dialysis|PD|287|288|PROBLEM #2.  GI|PROBLEM #3. Renal: The patient had admission creatinine of 5.55 and at the time of discharge her last creatinine checked was 4.50. She was continued on her home peritoneal dialysis. This includes 14 hours of a 17-cycles at 45 minutes for volumes of 800 mL on 2.5% dextrose solution. Her PD site was cultured at one point due to some erythema at which time she was found to have a pseudomonal infection.
PD|peritoneal dialysis|PD|201|202|HOSPITAL COURSE|2. Renal: _%#NAME#%_ was placed on peritoneal dialysis and was switched to 1.5% dextrose dialysate due to his dehydration. After rehydrating _%#NAME#%_, he was then switched back to 2.5% dextrose. His PD fluid analysis demonstrated no nucleated cells and cultures were negative 3. Hematology: _%#NAME#%_ continues to be anemic. Iron studies were obtained and showed a low borderline level of iron.
PD|peritoneal dialysis|PD|215|216|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Complex cyanotic congenital heart disease with dextrocardia and levoversion, single ventricle physiology. 2. Status post fenestrated Fontan procedure _%#MM#%_ _%#DD#%_, 2001. 3. Status post PD catheter placed _%#MM#%_ _%#DD#%_, 2001. status post AAIR mode permanent pacemaker with a rate of 125 on _%#MM#%_ _%#DD#%_, 2001.
PD|peritoneal dialysis|PD|164|165|PAST MEDICAL HISTORY|She then progressed to end-stage renal disease. She was maintained on peritoneal dialysis in _%#DDMM1992#%_, with left partial kidney resection. Complications from PD included peritonitis and necrotic obstructive bowel, with partial large bowel resection and appendectomy. From _%#DDMM1992#%_ to _%#DDMM1993#%_, she was maintained on hemodialysis. On _%#DDMM1993#%_, she had a living related donor transplant from her father.
PD|peritoneal dialysis|PD|223|224|DISCHARGE PLAN|He will return home under his own care. His medications will remain unchanged with the exception that we will add MiraLax in place of the previously ordered stool softener to maintain bowel care. He will follow up with the PD nurses as an outpatient.
PD|peritoneal dialysis|PD|269|270||The patient got intubated needing mechanical ventilation on _%#DDMM2007#%_. During the process, the patient had acute renal failure requiring maximum doses of diuretics. The patient had abdominal distention and fluid accumulation secondary to hepatic failure requiring PD catheter placed for drainage. Because of persistent respiratory problems, the patient was changed to a high-frequency oxidative ventilator on _%#DDMM2007#%_.
PD|peritoneal dialysis|PD|134|135|HISTORY OF PRESENT ILLNESS|He is on a cycler at night with 2.5% Dianeal. He uses 12 liters total with the last fill of 2 liters. He has had no problems with his PD and, again, no abdominal pain and clear bags. He is admitted because of inability to maintain p.o. intake and dehydration.
PD|peritoneal dialysis|PD|202|203|PAST SURGICAL HISTORY|2. Diabetes. 3. Hypertension. 4. Hyperlipidemia. 5. ASCVD status post recent angiogram with medical management. 6. Gastroesophageal reflux disease. PAST SURGICAL HISTORY: He had a nexus removed and his PD catheter placed. No other surgeries. SOCIAL HISTORY: He is divorced, a retired business owner, three children.
PD|peritoneal dialysis|PD|196|197|PAST MEDICAL HISTORY|4. History of pulmonary hypertension. 5. Aspiration pneumonitis in _%#DDMM2005#%_. 6. Posterior urethral valvuloplasty in _%#DDMM2005#%_. 7. Bilateral nephrostomy tubes placed in _%#MM2005#%_. 8. PD catheter placed in _%#MM2004#%_. MEDICATIONS ON ADMISSION: 1. Neoral. 2. Imuran. 3. Bactrim. 4. Valcyte. 5. Prevacid.
PD|peritoneal dialysis|PD|259|260|PAST MEDICAL HISTORY|6. Severe peripheral vascular disease secondary to diabetes. 7. Multiple eye procedures starting in 1990, including multiple laser surgeries, vitrectomies, and cataract surgeries on both sides. 8. Biopsy on the right chest in 1996 was negative for cancer. 9. PD in _%#MM1999#%_. 10. Surgery to fix a scar from his first transplant, which was unstable. Plastic Surgery did this procedure. It started again 2-1/2 years later when a peritoneal dialysis catheter was placed.
PD|peritoneal dialysis|PD|292|293|HOSPITAL COURSE|Recently he has had several hospital admissions for abdominal pain during which time he has been treated for peritonitis and various diagnostic tests have been done without clear etiology developing. He has not clearly had peritonitis and did not clearly have it this time. On this admission PD fluid was done, there were 620 white cells, 60% polys, but negative culture and Gram stain. He did receive a dose of vancomycin. He underwent peritoneal dialysis using a cycler and daytime exchange without problems.
PD|phosphate dehydrogenase|PD|183|184|ASSESSMENT AND PLAN|The patient currently will be observed; symptoms controlled with Tylenol, and increased IV fluids. Will start her on chloroquine today and start primaquine as well, as soon as her G6 PD status can be determined. Also have infectious disease see her in case there is any other interventions that need to be taken at this point in time.
PD|police department|PD|141|142|BRIEF HISTORY AND HOSPITAL COURSE|His speech was described as slurred and insensible. He then apparently spoke with police officers but does not remember talking to the local PD there. He was brought to the ER at a local hospital in Iowa. He remembers walking into the truck office, but does not remember much until he arrived in the hospital.
PD|police department|PD|129|130|BRIEF HISTORY AND HOSPITAL COURSE|The nursing staff tried to contact the family using different modalities, but unable to contact them. They even called the local PD at _%#CITY#%_ to check the house. No one was home. They called the numbers that were listed on the Cardex with the family friend and was unable to reach anyone.
PD|peritoneal dialysis|PD|222|223|HOSPITAL COURSE|So _%#NAME#%_ was started on atenolol 3 mg b.i.d. His peritoneal dialysis was adjusted, and so frequently his off weights of dialysis were 8.6 kg. Chest x-rays were obtained to assess her pulmonary edema, and with the new PD regimens, there was evidence of pulmonary edema. Chest x-ray, however, had demonstrated cardiomegaly. During this hospitalization, an echocardiogram was obtained to assess the etiology.
PD|peritoneal dialysis|PD|140|141|PROCEDURES|DIAGNOSES: 1. Wound infection post kidney transplant. 2. Elevated creatinine, rule out renal allograft rejection. PROCEDURES: 1. Removal of PD catheter. 2. Kidney biopsy of allograft, no rejection seen. This is a 65-year-old gentleman previously on PD who is postoperative day #13 from cadaveric kidney transplant done for end-stage renal disease secondary to membranous glomerulonephritis.
PD|peritoneal dialysis|PD|135|136|PAST MEDICAL HISTORY|PROCEDURES: 1. Removal of PD catheter. 2. Kidney biopsy of allograft, no rejection seen. This is a 65-year-old gentleman previously on PD who is postoperative day #13 from cadaveric kidney transplant done for end-stage renal disease secondary to membranous glomerulonephritis.
PD|peritoneal dialysis|PD|157|158|ALLERGIES|This was negative for rejection. The patient was also started on Unasyn for wound infection given the culture results obtained from fluid draws drawn on the PD catheter the previous day. The patient had three attempts at a kidney biopsy given the first time and second time inadequate sample obtained.
PD|peritoneal dialysis|PD|127|128|ALLERGIES|GU were consulted for this. However, they were unable to see the patient during this hospitalization. The patient also had his PD catheter removed at the bedside. He will be discharged on _%#MM#%_ _%#DD#%_, 2002 to follow-up at the transplant center on _%#MM#%_ _%#DD#%_, 2002.
PD|peritoneal dialysis|PD|206|207|PHYSICAL EXAMINATION|RESPIRATORY: Lungs were clear to auscultation bilaterally without rales, rhonchi or wheezes. CARDIOVASCULAR: Regular rate and rhythm, S1 and S2 were normal, no audible murmur or gallop. GASTROINTESTINAL: A PD catheter was in place. Bowel sounds were present, abdomen soft. MUSCULOSKELETAL: Full range of motion in the upper and lower extremities bilaterally.
PD|peritoneal dialysis|PD|149|150|MAJOR IMAGING AND PROCEDURES DONE DURING HOSPITALIZATION|Mid LAD is 100% occluded prior to D1. The left circ is small and gives off 1 large OM1 without significant disease. RCA has mild irregularities. The PD has occluded. The SVG to D1 graft is widely patent. The SVG to PDF is well ? and supplies a large territory and fills the PLA branches.
PD|posterior descending|PD|192|193|PAST SURGICAL HISTORY|PAST SURGICAL HISTORY: Prostate cancer resection in 1992, history of benign colon polyps removed in 1995, and history of coronary artery disease with circ stented in _%#MM#%_, 2002. His right PD was 70%, LAD was 70%, first diagonal was 70%, second diagonal was 60%, and there was 70% bifurcation of the first septal perforator with cardiomyopathy with an ejection fraction of approximately 40%.
PD|police department|PD|132|133|HISTORY OF PRESENT ILLNESS|He was supposed to meet his daughter at the library, which was only a quarter- mile away from his home. He never showed up, and the PD was contacted. He reports drinking more in the past two months since separating from his wife. He states that his wife left him secondary to his alcohol abuse.
PD|police department|PD|220|221|HISTORY AND HOSPITAL COURSE|DISCHARGE DIAGNOSIS: Alcohol abuse, dependence with mild withdrawal. ADDITIONAL DIAGNOSIS: Alcoholic related hepatitis. HISTORY AND HOSPITAL COURSE: The patient is a 46-year-old gentleman who was brought in by the local PD because of acute alcohol intoxication. He has a long-standing history of alcohol abuse and dependence and had been drinking as early as age 7.
PD|peritoneal dialysis|PD|148|149|ASSESSMENT  AND PLAN|He did bring a Baxter adapter so he would be able to do this without having problems. He also brought some fluid with him. A. We will plan to start PD exchange tonight with a 1.5% bag. 2. Hypertension. Pressures is up a little bit now. Some of that is pain related. A. Continue current meds. B. Pain control as needed.
PD|police department|PD|177|178|HISTORY|The patient opted for peritoneal dialysis. He had intraperitoneal catheter placed at _%#COUNTY#%_ _%#COUNTY#%_ Medical Center in and around that time. He was scheduled to begin PD training on _%#DDMM2007#%_. Unfortunately, over the past two weeks he has had progressive weakness, increasing nausea, decreased appetite and general failure to thrive.
PD|peritoneal dialysis|PD|162|163|INDICATION FOR PROCEDURE|She started hemodialysis seven weeks ago. She had a fistula put in her arm two weeks ago, this is not yet ready for use. She also had a failed attempt to place a PD catheter that was approximately two weeks ago. TRANSPLANT HISTORY: right sided intraperitoneal kidney transplants x 2, s/p 1st transplant nephrectomy.
PD|phosphate dehydrogenase|PD|226|227|PERTINENT LABS AND STUDIES|PERTINENT LABS AND STUDIES: The baby had initial TSB prior to admission to the hospital of 17.1 at 72 hours of age. Baby O+, Mom O=. -Coombs. Hemoglobin 18.5. Pending are CBC, reticulocyte count, peripheral smear, test for G6 PD deficiency and repeat bili. IMPRESSION: 3 d.o. old male with exaggerated physiologic jaundice.
PD|phosphate dehydrogenase|PD|202|203|PLAN|3. Maintenance intravenous fluids if can obtain intravenous access 4. Breast feed and formula feed ad lib 5. Intake and output 6. Daily weights 7. Check bili, CBC, reticulocyte, peripheral smear and G6 PD deficiency with 1600 labs 8. Recheck bili in the a.m. 9. Await All About Children's rounder in the a.m.
PD|peritoneal dialysis|PD|195|196|MEDICAL HISTORY|1. Methylmalonic aciduria diagnosed on day #5 of life. Hospitalized that day for respiratory failure. At that time the ammonium level was greater than 1,000. The patient needed emergent dialysis PD x eight days. 2. Hypsarrhythmia infantile spasms diagnosed _%#DDMM2003#%_. The patient was started on ACTH _%#MMDD#%_ for a two week course. The patient was free of seizures. 3. History of hypernoic coma.
PD|peritoneal dialysis|PD|205|206|MEDICAL HISTORY|2. Hypsarrhythmia infantile spasms diagnosed _%#DDMM2003#%_. The patient was started on ACTH _%#MMDD#%_ for a two week course. The patient was free of seizures. 3. History of hypernoic coma. 4. History of PD catheter placement. 5. History of portal vein thrombosis seen on CT _%#MMDD#%_, normal ultrasound _%#MMDD#%_, negative for thrombosis.
PD|peritoneal dialysis|PD|132|133|PROCEDURES PEERFORMED|2. _%#DDMM2003#%_, mediastinal washout. 3. _%#DDMM2003#%_, sterile closure of atrial septal defect. 4. _%#DDMM2003#%_, placement of PD catheter. 5. _%#DDMM2003#%_, opening of atrial septal defect snare. 6. _%#DDMM2003#%_, mediastinal washout. 7. _%#DDMM2003#%_, mediastinal washout. 8. _%#DDMM2003#%_, mediastinal washout.
PD|peritoneal dialysis|PD|265|266|CLINICAL NOTE|She returned to the Pediatric Intensive Care Unit. She did well for the first eight hours after surgery and then began having some hemodynamic instability, which responded to increased inotropic support. On _%#DDMM2003#%_, her urine output had dropped off and so a PD catheter was placed. Echos performed at that time demonstrated that she had retained systolic function of her heart with diastolic dysfunction and she was beginning to become quite edematous.
PD|peritoneal dialysis|PD|149|150|PAST SURGICAL HISTORY|She has been on dialysis for 3 years. She is admitted for a deceased-donor kidney and pancreas transplant. PAST SURGICAL HISTORY: 1. Eye surgery. 2. PD catheter placement. PAST MEDICAL HISTORY: 1. Type 1 diabetes mellitus. 2. Cardiac pathology.
PD|peritoneal dialysis|PD|235|236|HOSPITAL COURSE|HOSPITAL COURSE: The patient's mother underwent successful training for home peritoneal dialysis under the guidance of _____ _%#NAME#%_, the pediatric peritoneal dialysis nurse practitioner. The course was complicated by an episode of PD catheter exit site cellulitis that was treated with antibiotic levofloxacin 200 mg every other day for treatment course. The PD catheter exit site culture was positive for heavy growth of staph aureus.
PD|peritoneal dialysis|PD|172|173|HOSPITAL COURSE|The course was complicated by an episode of PD catheter exit site cellulitis that was treated with antibiotic levofloxacin 200 mg every other day for treatment course. The PD catheter exit site culture was positive for heavy growth of staph aureus. Hyperphosphatemia developed during the hospitalization with phosphorus levels of 6.2 to 6.3. Her calcium carbonate dose was increased from 600 t.i.d. to 1200 mg t.i.d. The patient was discharged on _%#DDMM2007#%_.
PD|(device) PD|PD|180|181|MEDICATIONS ON ADMISSION|7. Doxycycline 100 mg p.o. b.i.d. 8. Vitamin K 5 mg p.o. every week. 9. Multivitamins 1 tablet p.o. q.d. 10. Vitamin ADEKs 2 tablets p.o. q.d. 11. Albuterol MDI 2 puffs p.r.n. 12. PD vest b.i.d. SOCIAL HISTORY: No tobacco, quit alcohol _%#DDMM2001#%_, and no IV drug use.
PD|(device) PD|PD|324|325|PROBLEM #2|Since the patient had recent shortness of breath and hemoptysis prior to his discharge, the patient was started on Cipro 750 mg p.o. b.i.d., TOBI nebulizer b.i.d. and ceftazidime 2 g IV q.8h. x 2 weeks. The patient had PICC line placed during this hospital course for home IV antibiotics. The patient was unable to continue PD Vest treatment during this hospital course, especially the 2 days after PEG tube placement. It was offered to the patient to take pain medication so he would be able to perform his PD Vest, but the patient refused.
PD|(device) PD|PD|219|220|PROBLEM #2|The patient was unable to continue PD Vest treatment during this hospital course, especially the 2 days after PEG tube placement. It was offered to the patient to take pain medication so he would be able to perform his PD Vest, but the patient refused. Just prior to discharge, the patient was able to use the PD Vest without any difficulties.
PD|peritoneal dialysis|PD|188|189|HISTORY OF PRESENT ILLNESS|He presents for scheduled placement of a peritoneal dialysis catheter. The patient had been on peritoneal dialysis (PD) since birth, up until about three weeks prior to admission when his PD catheter was removed and a Broviac catheter placed secondary to peritoneal dialysis catheter dysfunction due to Staph aureus peritonitis.
PD|peritoneal dialysis|PD|248|249|PAST MEDICAL HISTORY|4. Bilateral hydrocele repair _%#DDMM2003#%_. 5. Mild pulmonic stenosis seen on echocardiogram in _%#DDMM2003#%_. 6. History of severe hyperkalemia while on peritoneal dialysis. 7. Hospitalization in _%#DDMM2003#%_ for Staph aureus peritonitis and PD catheter dysfunction; removal of PD catheter with placement of hemodialysis catheter. PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: Temperature 98.4, pulse 147, respiration rate 36, blood pressure 136/49.
PD|peritoneal dialysis|PD|162|163|HOSPITAL COURSE|Peritoneal dialysis was begun after his surgery at volumes of 10 ml/kg at 80 ml/pass, at half-hour passes, 1.5% dextrose with heparin. For the first half day the PD went well, however, he did begin to develop some leaking around the catheter and had very poor ultrafiltrate volumes.
PD|peritoneal dialysis|PD|174|175|HOSPITAL COURSE|The volume was then titrated up and the ultrafiltrate volumes also were improved. Over the next few days the volumes were titrated up, and the patient was kept on continuous PD with q1h passes. Ultrafiltrate volumes became very generous, and actually the patient became somewhat volume depleted. Eventually the number of passes per day was decreased, and the frequency of the passes increased.
PD|peritoneal dialysis|PD,|131|133|PROBLEM #2|His electrolytes were fairly stable throughout the admission. As stated above, he was somewhat volume depleted after a few days on PD, and he was given IV fluids into his hemodialysis catheter. He was also followed by Nutrition. During the admission it was noted that for a few days he was not taking substantial p.o. formula for his caloric needs, but this improved by the time of discharge.
PD|peritoneal dialysis|PD|283|284|PROBLEM #3|He was also followed by Nutrition. During the admission it was noted that for a few days he was not taking substantial p.o. formula for his caloric needs, but this improved by the time of discharge. PROBLEM #3: Infectious disease. Three days after peritoneal dialysis was begun, his PD fluid white blood cell count was up to 200, with a differential of 25% neutrophils and 57% eosinophils. However, at the time it was thought that treatment should be initiated because of his history of Staph aureus peritonitis.
PD|peritoneal dialysis|PD|167|168|PROBLEM #3|However, at the time it was thought that treatment should be initiated because of his history of Staph aureus peritonitis. Vancomycin and cefotaxime were added to the PD fluid, and this was continued for seven days. PD fluid cultures were taken at that time, and have had no growth. DISCHARGE INFORMATION: The patient was discharged on _%#DDMM2003#%_. On that day, his hemodialysis catheters were removed by Dr. _%#NAME#%_ in the operating room.
PD|peritoneal dialysis|(PD)|159|162|HOSPITAL COURSE|The patient was treated initially with vancomycin and ceftazidime and subsequently with Ancef. He was given laxatives after evaluating the peritoneal dialysis (PD) catheter. His catheter began working again with good fills and drains. He was put back on a chronic intermittent peritoneal dialysis (CIPD) schedule and treated with IV Ancef twice a day.
PD|peritoneal dialysis|PD|194|195|PAST MEDICAL HISTORY|6. History of retinopathy, status post laser treatment. 7. History of total abdominal hysterectomy and bilateral salpingo- oophorectomy. 8. History of dialysis catheter placement. 9. History of PD catheter placement. ALLERGIES: The patient has an allergy to sulfa. HOSPITAL COURSE: The patient was admitted for t.i.d. dressing changes.
PD|UNSURED SENSE|PD|340|341|LABORATORY DATA|Electrolytes are sodium 139, potassium 3.2, bicarbonate 24, BUN 22, creatinine 1.46. Glucose is 369, albumin 2.9, total bilirubin and alkaline phosphatase were normal with AST and ALT elevated, her first troponin I was 0.04. Chest x-ray shows bilateral infiltrates consistent with pulmonary edema. Blood gases showed severe acidosis with a PD of 6.77. IMPRESSION: 1. Status post cardiac arrest. She is on dopamine and dobutamine from the ER.
PD|peritoneal dialysis|PD|194|195|DISCHARGE DIAGNOSES|1. Stage IV neuroblastoma status post peripheral autologous transplant on _%#DDMM2007#%_. 2. Chronic kidney disease secondary to chemotherapy, previously hemodialysis dependent, now status post PD catheter placement on _%#DDMM2007#%_. 3. GJ tube dependent. 4. Hypertension. 5. Developmental delay. 6. History of C. diff. 7. History of fungal pneumonia.
PD|peritoneal dialysis|PD|318|319|HISTORY OF PRESENT ILLNESS|CONSULTS DURING THIS HOSPITAL ADMISSION: Renal. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 3-year-old boy with stage IV neuroblastoma, now approximately 4 months status post autologous peripheral blood stem cell transplant, he was day +132 on admission. He was admitted for an upper GI study, bone marrow biopsy, and PD catheter placement. Patient tolerated the procedure well and was extubated in the OR, and was transferred to the floor for further monitoring.
PD|peritoneal dialysis|PD|188|189|PLAN|We will repeat his PTH. If this remains elevated, I think consideration to a relatively emergent parathyroidectomy needs to be given. 4. Chronic renal failure. We will continue him on his PD regimen and have him continue follow up with Renal for this. 5. Chronic steroid use. The patient has been on steroids for 30 years.
PD|peritoneal dialysis|PD|215|216|PHYSICAL EXAMINATION ON ADMISSION|Neck supple, without lymphadenopathy. Lungs clear to auscultation bilaterally. Heart: Regular rate and rhythm, with normal murmurs, rubs or gallops. Abdomen: Somewhat firm, non-distended, and diffusely tender, with PD catheter in the left abdomen. No hepatosplenomegaly or masses. Positive bowel sounds. Spine: No CVA tenderness. Skin: Without rash. No erythema or drainage around the peritoneal dialysis catheter site; however, there was focal tenderness at the catheter size.
PD|peritoneal dialysis|PD|142|143|HOSPITAL COURSE|HOSPITAL COURSE: SYSTEM #1: Fluid, electrolytes, nutrition. The patient was on a regular diet upon admission. During the time period when his PD catheter was removed and he was awaiting hemodialysis, he was placed on a low potassium, low phosphorus, and fluid-restricted diet.
PD|peritoneal dialysis|PD|286|287|PROBLEM #4|He is on stool softeners, and declined and suppositories. He also had some episodes of nausea, with decreased appetite, but this was improving toward the end of his hospital stay. PROBLEM #4: ID. Initial peritoneal dialysis fluid drawn on admission showed gram-positive cocci. When the PD catheter was removed and cultured, it showed one colony of Staph aureus. The patient was subsequently started on vancomycin, which was initially given in the peritoneal dialysis fluid and subsequently given IV.
PD|peritoneal dialysis|PD|270|271|SPECIAL INSTRUCTIONS|Speech therapy, PT, OT. SPECIAL INSTRUCTIONS: Diet: He is discharged on a diet of Similac PM 60/40 plus Beneprotein, add Kayexalate and let sit for 4 hours then pour off formula to use feeds 250 mL boluses 4 times a day and then 65 mL per hour for 8 hours at night. His PD discharge orders were 10 hours on PD, off 14 hours. Passes will be 60 minutes. Fill volume 310 mL with a last bag fill volume 150 mL.
PD|peritoneal dialysis|PD|115|116|SPECIAL INSTRUCTIONS|Passes will be 60 minutes. Fill volume 310 mL with a last bag fill volume 150 mL. He is on the standard commercial PD #2 and dextrose of 1.5%. Dextrose 1.5% and calcium 3.5 mEq per L with no heparin. It is a pleasure to be involved in _%#NAME#%_' medical care.
PD|peritoneal dialysis|PD|368|369|PAST SURGICAL HISTORY|10. Past hospitalizations include mild acute transplant rejection in _%#MM#%_ 2005, enterococcus UTI in _%#MM#%_ 2005, UTI with dehydration in _%#MM#%_ 2005, and RSV bronchiolitis in _%#MM#%_ 2005, UTI and respiratory distress in _%#MM#%_ 2004, and peritonitis in _%#MM#%_ 2004, PAST SURGICAL HISTORY: 1. Living unrelated kidney transplant with right orchiectomy, and PD catheter removal on _%#MM#%_ _%#DD#%_, 2005. 2. Tunneled CV catheter, _%#MM#%_ 2005. 3. Urologic procedures, _%#MM#%_ 2004, _%#MM#%_ 2004, _%#MM#%_ 2004, and _%#MM#%_ 2005.
PD|peritoneal dialysis|PD|174|175|PAST SURGICAL HISTORY|2. Tunneled CV catheter, _%#MM#%_ 2005. 3. Urologic procedures, _%#MM#%_ 2004, _%#MM#%_ 2004, _%#MM#%_ 2004, and _%#MM#%_ 2005. 4. Left hip open reduction, _%#MM#%_ 2004. 5. PD catheter placement revision, replacement, and finally removal in _%#MM#%_ 2005. PHYSICAL EXAMINATION VITAL SIGNS: On admission, weight 13.45 kg, temperature at 98.8 degrees, pulse 118, and O2 saturation 100%.
PD|(drug) PD|PD|696|697|DISCHARGE PLANS|DISCHARGE PLANS: The patient's medications at discharge include Norvasc 10 mg p.o. q.d., enteric-coated aspirin 81 mg p.o. q.d., Protonix 40 mg p.o. q.d., Lasix 40 mg p.o. q.d., Kay Ciel 20 mEq p.o. b.i.d., lorazepam 0.5 mg p.o. b.i.d., Combivent inhaler 4 puffs q.i.d. Please note this was reduced from 4 puffs q.2-4h. which she had been prescribed before. Toprol XL 25 mg p.o. q.d., Theophylline CR 200 mg p.o. b.i.d., Synthroid 0.1 mg (100 mcg) p.o. q.d., albuterol nebs q.2-4h. p.r.n. shortness of breath, ampicillin 500 mg p.o. b.i.d. for 7 more days to complete treatment for UTI diagnosed prior to admission, O2 2 L per nasal cannula, Ocuvite 1 p.o. q.d., Haldol 2 mg p.o. q.h.s., Guaifed PD 1 p.o. b.i.d. p.r.n. The patient's diet will be low fat, low cholesterol. She can be weightbearing and activity ad lib with assistance.
PD|peritoneal dialysis|PD|166|167|ADMISSION PHYSICAL EXAMINATION|LUNGS: Clear to auscultation bilaterally; no crackles or wheezes. ABDOMEN: Soft; mild distention; positive bowel sounds. He does have an erythematous rash around his PD site. GENITOURINARY: No rash. Testicles are descended. He is a circumcised Tanner I male. BACK: He does have bilateral pyelostomies. ADMISSION LABORATORY DATA: Sodium 139.
PD|peritoneal dialysis|PD|208|209|HOSPITAL COURSE|Therefore, the ceftazidime was stopped at that time. On the fourth hospital day _%#NAME#%_'s peritoneal dialysis was changed to his regular at- home regimen of cycling only at night. On the following day his PD cell count was up to 2500. He developed an increased temperature and was irritable. His PD was then changed back to continuous cycles and he was started on tobramycin.
PD|peritoneal dialysis|PD|299|300|HOSPITAL COURSE|Therefore, the ceftazidime was stopped at that time. On the fourth hospital day _%#NAME#%_'s peritoneal dialysis was changed to his regular at- home regimen of cycling only at night. On the following day his PD cell count was up to 2500. He developed an increased temperature and was irritable. His PD was then changed back to continuous cycles and he was started on tobramycin. Following that his cultures continued to be negative for 48 hours.
PD|peritoneal dialysis|PD|134|135|HOSPITAL COURSE|Following that his cultures continued to be negative for 48 hours. The tobramycin was stopped and the vancomycin was continued in the PD solution. On his eighth hospital day a leak was noticed in his peritoneal dialysis catheter and it was also noted that his catheter had pulled back since the previous time that he was seen in clinic.
PD|peritoneal dialysis|PD.|163|165|HOSPITAL COURSE|The patient had no complications after this or leaking since that time. Since the repositioning of the catheter, _%#NAME#%_ has been switched back to his standard PD. Currently the volume is 120 mL. He will continue to increase the volume either here or as an outpatient. At this time peritoneal dialysis consists of: Fill volume 120 mL, dwell time 55 minutes, fill time 3 minutes, drain time 2 minutes, last bag fill 60 mL with 13 cycles using 1.5% dextrose and 3.5 mEq/L calcium.
PD|peritoneal dialysis|PD|256|257|HOSPITAL COURSE|At this time peritoneal dialysis consists of: Fill volume 120 mL, dwell time 55 minutes, fill time 3 minutes, drain time 2 minutes, last bag fill 60 mL with 13 cycles using 1.5% dextrose and 3.5 mEq/L calcium. Upon discharge, the patient's calcium for his PD will be changed to 2.5 mEq/L. The patient has undergone transplant workup and has completed everything except for a VCUG. PROBLEM #2: Fluid, electrolytes, nutrition/gastrointestinal. Secondary to the patient's persistent vomiting, an upper GI with small bowel follow through was performed and was read as normal.
PD|peritoneal dialysis|PD|142|143|PROBLEM #2|Thus this ruled out any sort of small bowel obstruction or stricture that might be causing the vomiting. At this time it was thought that the PD catheter being pushed in too far might have been the etiology; however, after the repositioning of the catheter, the patient continued to have vomiting.
PD|dorsalis pedis:DP|PD|273|274|PHYSICAL EXAMINATION|The right foot at the tip of the first and second toes there is a large blister which is ripped and is a little wet, and necrotic wound spreading to around the nails and one-third of the tip. There is no lymphangitis. The rest of the foot is unremarkable with normal skin, PD and PP pulses are palpable. SKIN: Warm. Sensation is intact, other than the necrotic area of the wound site. NEURO: Cranial nerves II-XII intact. Sensory and motor is intact.
PD|posterior descending|PD|200|201|PAST MEDICAL HISTORY|The artery is occluded 100% after OM1. The right coronary artery had an 80% lesion in the proximal segment. There was subtotal disease in what appears to be the right ventricular marginal branch. The PD right coronary artery is not seen. After the catheterization was done and troponins found to be negative, it was decided to continue medical management and to encourage strongly smoking cessation prior to discharge.
PD|phosphate dehydrogenase|PD|107|108|PAST MEDICAL HISTORY|He, otherwise, reports that things have been going well at his rehabilitation. PAST MEDICAL HISTORY: 1. G6 PD deficiency, as well as recent coronary artery disease. Most recently he had chest pain evaluation and a coronary angiogram which showed a small-sized intermedius narrowed at the ostium at approximately 70%.
PD|phosphate dehydrogenase|PD|203|204|PROBLEM #4|Continue to be followed to maintain tight control of his blood sugars. PROBLEM #4: G6 PD deficiency. Again, caution should be used in the future in order to avoid side effects of medications with his G6 PD deficiency. PROBLEM #5: Coronary artery disease risk factor modification. Given his lipid profile and continued symptoms, omega-3 fatty acids were added to his medical regimen to help prevent future coronary artery disease.
PD|peritoneal dialysis|PD|231|232|PAST MEDICAL HISTORY|2. End-stage renal disease secondary to obstructive uropathy secondary to anterior valve reflux. 3. Peritoneal dialysis dependent since birth. 4. Status post living related renal transplant on _%#DDMM2004#%_. 5. History of several PD catheter infections. 6. History of bilateral pyelostomies. 7. History of multiple peritoneal dialysis catheter placements and revisions. 8. Status post bilateral inguinal hernia repair. 9. Status post circumcision.
PD|peritoneal dialysis|PD|158|159|PHYSICAL EXAMINATION|Cardiovascular: Regular rate and rhythm with 1/6 soft systolic murmur. Lungs clear to auscultation bilaterally. Abdomen with normoactive bowel sounds. GT and PD catheter in place. There was no erythema or guarding. Skin with no rashes. Neurologic: Awake and alert. Lymphatics: No lymphadenopathy.
PD|peritoneal dialysis|PD.|148|150|PHYSICAL EXAMINATION   VITAL SIGNS|No murmurs, gallops, or extra heart sounds noted. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Prune belly. Scarring from previous surgeries, PD. It is soft, nontender and nondistended. GU: Uncircumcised male. No right testicle palpated. Left testicle removed. SKIN: No rash or lesions. It is warm and well-perfused.
PD|peritoneal dialysis|PD|202|203|FOLLOW UP|Home PD is a total treatment volume of 4000 mL and total treatment time of 12 hours, fill volume of 240 mL, last bag fill volume of 120 mL. He had 16 cycles plus the final fill on a standard commercial PD tube. Heater bag 500 mL 2.5% dextrose and then one 3 L bag of 1.5% dextrose and one 3 L bag of 2.5% dextrose.
PD|peritoneal dialysis|PD|147|148|FOLLOW UP|Three weeks ago a peritoneal dialysis catheter was placed without incident at HCMC in preparation for his desire to go on peritoneal dialysis. The PD training was started at the DaVita _%#CITY#%_ _%#CITY#%_ _%#CITY#%_ facility on _%#DDMM2005#%_ without incident for the first few days. He has had no real pain with filling or mechanical problems with drainage.
PD|peritoneal dialysis|PD|199|200|PLAN|PLAN: 1. Will simply observe him for the next several hours and if he remains stable, may be able to discharge. 2. If pain recurs, we will ask general surgery to examine him. 3. Will probably resume PD and if pain or cloudy fluid, then will need to cover with antibiotics. Initially there was no sign of any change in the fluid color or any pain with the PD procedure.
PD|peritoneal dialysis|PD|180|181|PLAN|3. Will probably resume PD and if pain or cloudy fluid, then will need to cover with antibiotics. Initially there was no sign of any change in the fluid color or any pain with the PD procedure. 4. Will begin to taper his diuretics.
PD|peritoneal dialysis|PD.|240|242|HISTORY OF PRESENT ILLNESS|Of note, he has had recently been hospitalized 1 week prior to admission with fever and diagnosed with strep positive pharyngitis. He was currently on day 7 of a 10-day course of penicillin. _%#NAME#%_ has not been having any problems with PD. REVIEW OF SYSTEMS: His review of systems is otherwise negative.
PD|peritoneal dialysis|PD|205|206|PROBLEMS|His current dose of 2.5 mg q.i.d. could potentially be increased to 5 mg q.i.d. if it is shown that he has significant beneficial effects from this medication. 2. Renal: _%#NAME#%_ continued on his normal PD schedule, 10 1-hour cycles each night. He did not have any problems with PD throughout hospitalization. His electrolytes remained stable, and creatinine was also stable. Because of the current hospitalization for fever, decision was made with the renal transplant team to hold off on his upcoming renal transplant for a few weeks in order to allow for full recovery.
PD|peritoneal dialysis|PD|166|167|PROBLEMS|3. Infectious Disease: _%#NAME#%_ had a total of 6 days of fever, some of which were high fevers of 103 degrees fahrenheit. There were multiple cultures of blood and PD fluid sent; however, no growth from any site. His CRP at the time of admission was 5.87, this was slightly elevated from his last CRP of 5.67 on _%#MM#%_ _%#DD#%_, 2005.
PD|peritoneal dialysis|PD|227|228|DISCHARGE MEDICATIONS|5. Miralax half a capful p.o./NG p.r.n. constipation. 1. Continue PD 10 1-hour cycles per day, total treatment volume 7000 cc, total treatment time 10 hours. Fill volume 650 mL, last bag fill volume 350 mL. Standard commercial PD solution dextrose 1.5% 5-liter bag volume of dialysate 5 liters, container site 5 liters, Dextrose 1.5%, calcium 3.5 mEq/L. ACTIVITY: Regular, ad lib. DIET: Half-strength Nepro formula 120 mL q.3h. x 5 during daytime, and 100 mL per hour x 6 hours every night at bedtime from 10:00 p.m. to 4:00 a.m.
PD|peritoneal dialysis|PD|125|126|HISTORY OF PRESENT ILLNESS|He was admitted after a cat had bit his peritoneal dialysis line. _%#NAME#%_ and his parents were staying with his aunt. His PD line had drained and fell down. His parents noticed that it was leaking. The cat did not directly scratch or bite the patient.
PD|peritoneal dialysis|PD|194|195|HOSPITAL COURSE|2. ID. _%#NAME#%_ was treated with ceftazidime and Unasyn and his peritoneal dialysis fluid secondary to concern for Pasteurella multocida or other bacterial infections from the cat bite to his PD line. Culture of his home PD fluid and in-hospital PD fluid, cultures remained negative. The patient remained afebrile without clinical signs of infection during his hospitalization.
PD|peritoneal dialysis|PD|248|249|HOSPITAL COURSE|2. ID. _%#NAME#%_ was treated with ceftazidime and Unasyn and his peritoneal dialysis fluid secondary to concern for Pasteurella multocida or other bacterial infections from the cat bite to his PD line. Culture of his home PD fluid and in-hospital PD fluid, cultures remained negative. The patient remained afebrile without clinical signs of infection during his hospitalization. 3. Immune. _%#NAME#%_ has low serum IgG treated once in a month with IV IgG likely secondary to losses from peritoneal dialysis.
PD|peritoneal dialysis|PD|126|127|PHYSICAL EXAMINATION  VITAL SIGNS|LUNGS: Clear without wheezes or crackles. ABDOMEN: Showed moderate distention but was soft. Good bowel sounds, no masses. The PD catheter looked good, and the site is not erythematous. He has good pulses distally with no pitting edema. LABORATORY: Admission labs showed a sodium of 139, potassium 4.7, BUN of 36, creatinine of 2.77, alkaline phosphatase 4.1, and albumin of 2.9. White count of 12.7 with 48% lymphocysts and 33% neutrophils, CRP of 42, and ionized calcium of 5.5. An initial chest x- ray showed a patchy left upper lobe opacity worsening for pneumonia.
PD|peritoneal dialysis|PD|209|210|HOSPITAL COURSE|HOSPITAL COURSE: 1. Peritoneal dialysis: Upon admission, his peritoneal dialysis was increased in dextrose content from 1.5% to 2.5% in an attempt to diurese him further. Over the first 24 hours, although his PD did not seem to drain very well and only took off correctly 190 mL where as normal is 200 to 300. It seemed to be going in well and coming out without alarming on the machine, and so it was unclear as to the cause of this.
PD|peritoneal dialysis|PD|172|173|HOSPITAL COURSE|On discharge, he will be placed back on 1.5% in the same plan that he had been at home. He will be following up in nephrology clinic in approximately 1 month. Of note, his PD did seem to drain better on hospital day 2, and this might also be due to the fact that he had a large stool.
PD|peritoneal dialysis|PD|185|186|HISTORY OF PRESENT ILLNESS|He has also been more easily fatigued with activity and breathing faster with activity and at rest. He continues to have peritoneal dialysis catheter in his abdomen but has not been on PD since his last hospitalization. He had no fever, no cough, no vomiting, no jaundice, no dysuria, no change in urine color, no rashes.
PD|peritoneal dialysis|PD|255|256|HOSPITAL COURSE|He continued a 14-day course of amoxicillin. 4. Heme: Two days after admission, the patient did fall out of his crib and did have some blood in his peritoneal fluid for which he was started on heparin. At the time of discharge, there was no bleeding from PD fluid. 5. Cardiovascular: The patient did not need any inotropic support during his hospitalization. He continued on his Enalapril for hypertension associated with his renal disease.
PD|peritoneal dialysis|PD|134|135|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 5-month-old male with renal failure secondary to posterior urethral valve. He has been on PD since five days of age. He has been having problems with emesis and retching at the end of his PD x2 weeks. They had been attempting to adjust his PD volume with a renal nurse, but they have seen no change.
PD|peritoneal dialysis|PD|113|114|HISTORY OF PRESENT ILLNESS|He has been on PD since five days of age. He has been having problems with emesis and retching at the end of his PD x2 weeks. They had been attempting to adjust his PD volume with a renal nurse, but they have seen no change. They saw Dr. _%#NAME#%_ in the clinic on the morning of admission, at which time his chest x-ray showed new right-sided pleural effusion.
PD|peritoneal dialysis|PD|234|235|HISTORY OF PRESENT ILLNESS|When they attempted to do 15-1/2 hours with 21 cycles on 2.5/4.25% along with a heater bag of 2.5% to goal of 400 mL, they were unable to reach this. The decision was made for the patient to be admitted to the hospital to work on his PD volumes to attempt to pull off more fluid. PHYSICAL EXAMINATION: Physical exam at the time of admission revealed weight of 7.62 kg, blood pressure 102/60, pulse 150, O2 saturation 98%, temperature 36.8 and respiratory rate 46.
PD|peritoneal dialysis|PD|208|209|LABORATORY|NEUROLOGIC: She is awake and alert. She has decreased tone and strength globally. She is nonverbal and has few purposeful movements. LABORATORY: Laboratory studies at the time of admission showed analysis of PD fluid to be clear and colorless with 2 RBCs and 1 nucleated cell. CBC revealed a white count of 13.6, a hemoglobin 14.4, platelets of 412,000.
PD|peritoneal dialysis|PD|168|169|PERITONEAL DIALYSIS|4. Lamictal 175 mg G-tube b.i.d. 5. Folate 0.5 mg G-tube daily. 6. Ferrous sulfate 25 mg G-tube daily. 7. Sodium chloride 25 mEq G-tube t.i.d. PERITONEAL DIALYSIS: Her PD is to be continued per her previous home regime without changes. FOLLOW UP: _%#NAME#%_ is to see Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2005, in the pediatric nephrology clinic.
PD|peritoneal dialysis|PD|363|364|* FEN|Please weight-adjust dose as needed. Discharge medications, treatments and special equipment: * Amoxicillin 50mg po q24hr * Epogen 500 units SQ 3 times per week * Ferrous sulfate 16mg po daily * Folic Acid 30 mcg po daily * Calcitriol 0.025 mcg daily Discharge measurements and exam: Weight 2500 gm, length 45.5 cm, OFC 32 cm. Physical exam was normal except for PD catheter in place, palpable kidneys bilaterally and edema. Thank you again for allowing us to share in the care of your patient.
PD|peritoneal dialysis|PD|200|201|PAST MEDICAL HISTORY|The patient was then admitted to the kidney transplant service for further workup and followup on his fever. PAST MEDICAL HISTORY: 1. Left nephrectomy in _%#MM#%_ 2005. 2. Kidney stone removal x2. 3. PD catheter placement in _%#MM#%_ 2004. 4. Percutaneous drainage of infection. 5. Deceased donor kidney transplant, _%#MM#%_ _%#DD#%_, 2006. HOSPITAL COURSE: The patient's hospital course was very unremarkable. He was admitted to the kidney transplant floor.
PD|peritoneal dialysis|PD;|219|221|HISTORY OF PRESENT ILLNESS|However, due to some issues with the home care services provider, the patient had not yet received her vest. The patient has been using BiPAP at night. She has been instructed to use BiPAP four to five times daily with PD; however, the patient is not doing the BiPAP therapy with the PD. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: The patient lives with her mother, uncle, aunt, and grandmother.
PD|phosphate dehydrogenase|PD|86|87|HOSPITAL COURSE|She needs a repeat ESR and CRP as an outpatient as well. Please also note that her G6 PD level was normal, so she does not have G6 PD deficiency. The patient will follow up Dr. _%#NAME#%_ in the office in 1-2 weeks to just sort of reassess how she is doing post hospitalization.
PD|Parkinson disease|PD|230|231|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Bilateral lower extremity contracture and rigidity, most likely secondary to Parkinson disease. 2. Left upper extremity contracture, most likely secondary to Parkinson disease. 3. Hallucinations related to PD and/or medications Discharged to home. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 74-year-old right-handed female with a diagnosis of Parkinson disease since 2005.
PD|peritoneal dialysis|PD,|124|126|HOSPITAL COURSE|She was initiated on hemodialysis after a tunneled catheter was placed. Because she wishes eventually to do her dialysis by PD, a Tenckhoff catheter was placed in the abdomen by Dr. _%#NAME#%_. She tolerated both of these well. She underwent two hemodialysis treatments without problems and was continued on her usual medications.
PD|peritoneal dialysis|PD|170|171|PAST MEDICAL HISTORY|FAMILY HISTORY: Dad with peripheral vascular disease and with diabetes. Otherwise is clean. PAST MEDICAL HISTORY: 1. End-stage kidney disease on HD from _%#MM2006#%_ and PD from 2004-2006. 2. Diabetes mellitus type 2. 3. Hypertension. 4. Status-post appendectomy and tonsillectomy. 5. Hyperlipidemia. REVIEW OF SYSTEMS: Remarkable for some shortness of breath post-PD dialysis.
PD|peritoneal dialysis|PD|170|171|PAST SURGICAL HISTORY|5. Hyperlipidemia. REVIEW OF SYSTEMS: Remarkable for some shortness of breath post-PD dialysis. PAST SURGICAL HISTORY: 1. Laparoscopic appendectomy. 2. Tonsillectomy. 3. PD catheter placement in 2004. 4. Roux-en-Y gastric bypass surgery in _%#DDMM2006#%_. PHYSICAL EXAMINATION: GENERAL: The patient was in no apparent distress when she was examined.
PD|posterior descending|PD|253|254|CHIEF COMPLAINT|The summary states that he had an ulcerated 80% stenosis, which was dilated and stented with a 3.5 x 28 mm long tetra balloon, which was post dilated with a 4.0 mm balloon to 16 atmosphere and 0 residual stenosis. The distal RCA had a 70% lesion at the PD branch. This was also stented with a 3.0 mm tetra balloon to 14 mm. The RCA was moderately diseased with other 40- 50% lesions.
PD|peritoneal dialysis|PD|217|218|HOSPITAL COURSE|The patient's peritoneal dialysis regimen at discharge was 13 hours on, 45-minute cycles, fill volume is 800 mL, last _____ fill volume of 400 mL for a total of 17 cycles. The patient does receive standard commercial PD solution with a 2:1 mix of 2.5% dextrose and 4.25% dextrose. The patient will continue to be followed as an outpatient by the peritoneal dialysis team and will have twice a week cell counts and CRPs drawn to evaluate for further evidence of peritonitis.
PD|UNSURED SENSE|PD|194|195|FOLLOWUP|FOLLOWUP: 1. Nephrology Clinic. The patient will follow up with Dr. _%#NAME#%_ in Nephrology Clinic in 1-2 weeks after discharge. 2. Home health. The patient will have every Monday and Thursday PD cell count, differential and CRP done through home health. It was a pleasure to be involved in this patient's medical care.
PD|peritoneal dialysis|PD|235|236|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 44-year-old male with a history of diabetes mellitus type 1, endstage renal disease. From this, reports for a six-antigen-match kidney. The patient has been on peritoneal dialysis for one year and PD catheter for two years. He has had endstage renal disease for three years now and makes very little urine. REVIEW OF SYSTEMS: Remarkable for chronic diarrhea, also chronic nausea and vomiting.
PD|peritoneal dialysis|PD|113|114|PAST SURGICAL HISTORY|7. Passive regressive. 8. History of atrial arrhythmia. 9. Secondary hyperparathyroidism. PAST SURGICAL HISTORY: PD catheter placement. PHYSICAL EXAMINATION: GENERAL: The patient showed acute in no apparent distress.
PD|peritoneal dialysis|PD|174|175|PROBLEM #5|_%#NAME#%_ was started on broad spectrum IV antibiotics on transfer to the PACU. An ID consult was obtained shortly after transfer. Enterobacter coli grew from a culture for PD fluid. Antibiotic therapy was adjusted appropriately and tobramycin was added to her PD fluid in addition to her vancomycin and imipenem systemically.
PD|peritoneal dialysis|PD|181|182|PROBLEM #5|An ID consult was obtained shortly after transfer. Enterobacter coli grew from a culture for PD fluid. Antibiotic therapy was adjusted appropriately and tobramycin was added to her PD fluid in addition to her vancomycin and imipenem systemically. She was also treated with fluconazole empirically. She remained on these antimicrobials up till the time of death.
PD|peritoneal dialysis|PD|197|198|HOSPITAL COURSE|4. Appendectomy. 5. Tubal ligation. 6. Dialysis catheter placement. HOSPITAL COURSE: The patient was admitted. The patient was followed by renal, transplant, eventually seen by urology and GI. The PD catheter was removed on _%#MM#%_ _%#DD#%_, 2002. The patient had two chest x- rays that were unremarkable for low saturations.
PD|peritoneal dialysis|PD|302|303|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 6-month-old ex-33 6/7th week preemie with renal failure due to bladder outlet obstruction in utero caused by posterior urethral valves. He has had associated pulmonary hypoplasia due to oligohydramnios caused from the bladder outlet obstruction. He has been PD dependent with a prolonged NICU and hospital course. On _%#DDMM2008#%_, he developed some respiratory distress with increasing need for oxygen.
PD|peritoneal dialysis|PD|235|236|HISTORY OF PRESENT ILLNESS|He also had some hypokalemia during this time in the Intensive Care Unit and was supplemented with IV potassium chloride bumps along with holding of the Kayexalate prior to transfer to the floor. His weight did go up significantly and PD was adjusted per renal guidance and we will defer to Renal's expertise for further pediatric adjustments. He had a nasal wash done that is on _%#DDMM2008#%_ with the pending viral culture at this time.
PD|posterior descending|PD|132|133|DISCHARGE DIAGNOSES|The OM2 is large and has a proximal 80% stenosis. The RCA has a 70% ostial lesion and a 50% stenosis in the mid portion. The ostial PD has a 40% lesion. A stent was placed in the OM1 and RCA, both resulting in flow. HISTORY OF PRESENT ILLNESS: The patient is an 89-year-old female with a past medical history of hypertension, hyperlipidemia who presents with 1 day of weakness and chest heaviness.
PD|peritoneal dialysis|PD|206|207|HISTORY OF PRESENT ILLNESS|Upon transfer to Fairview-University Medical Center on _%#MMDD#%_, his creatinine was up to 2.1. His BUN was 96. His potassium was 5.1. Hemoglobin was 8.8, and platelets were 24,000. He was admitted, and a PD catheter was placed as well as a femoral line. The child was started on peritoneal dialysis and transferred out of the PICU one day after admission.
PD|posterior descending|PD|253|254|HISTORY|The first diagonal had a 50% stenosis. The left circumflex was a large caliber vessel, with a large OM with a 95% lesion. Just beyond the OM was diffuse diseased and then totally occluded. The right coronary artery was normal caliber, 30% stenosis. The PD had a 80 to 90% mid vessel lesion. The vessel was 2 mm and felt too small to be considered for revascularization.
PD|posterior descending|PD|137|138|HISTORY OF PRESENT ILLNESS|Coronary angiography at that time showed subtotal occlusion of the LAD, 60% stenosis of a diagonal branch, 70% left circumflex and a 90% PD lesion with normal LV function. Subsequent to that he has done very well until the last couple of years when he has noted a progressive pattern of shortness of breath on exertion.
PD|UNSURED SENSE|PD|159|160|OPERATIONS/PROCEDURES PERFORMED|HISTORY OF PRESENT ILLNESS: The patient is a 6-month-old infant who was born with trisomy 21 and a complete AV canal. She also had a severe reflux disease and PD deflection and she had a G-tube placed. She came in on _%#MM#%_ _%#DD#%_, and underwent a complete repair of her AV canal.
PD|peritoneal dialysis|PD|149|150|HISTORY OF PRESENT ILLNESS|He has been dialysis dependent since birth and on hemodialysis since early _%#MM#%_ 2004 after 2 episodes of staphylococcus aureus, peritonitis, and PD catheter dysfunction. He is admitted after urologic surgery performed by Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ which included bilateral pyelostomies, right pyeloplasty and left nephrectomy.
PD|pancreatic duct|PD|168|169|ADMISSION DIAGNOSIS|2. End-stage liver disease with cirrhosis (secondary to alcoholism). 3. Rupture of pancreatic pseudocyst. OPERATIONS/PROCEDURES PERFORMED: 1. ERCP with sphincterotomy, PD stent placement. 2. Exploratory laparotomy with G- and J-tube placement. 3. Right chest tube placement. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 51-year-old gentleman who was recently admitted 3 weeks prior for acute pancreatitis.
PD|pancreatic duct|PD|217|218|ADMISSION DIAGNOSIS|The patient was clinically worsening with tachypnea, oliguria, and increased right pleural effusion. Surgery was consulted, and it was felt that the patient had an apparent rupture of a pancreatic pseudocyst into his PD likely, leading to pancreatic ascites. For this, the patient underwent exploratory laparotomy with J- and G-tube placement and drains placed. On _%#MM#%_ _%#DD#%_, 2004, a right chest tube was also placed to drain his pleural effusion.
PD|posterior descending|PD|270|271|BRIEF HISTORY AND HOSPITAL COURSE|DISCHARGE DIAGNOSIS: Angina. STUDIES: Cardiac catheterization. BRIEF HISTORY AND HOSPITAL COURSE: This is a 58-year-old female with a history of known coronary artery disease (status post coronary artery bypass graft surgery in 1999 with an LIMA to LAD graft, radial to PD RCA graft, and saphenous vein graft to the obtuse marginal 2), presenting with chest pain with radiation to both arms. The chest pain was improved, status post sublingual nitroglycerin x 3.
PD|posterior descending|PD|191|192|HISTORY OF PRESENT ILLNESS|Cardiac catheterization again was remarkable for 3-vessel coronary artery disease without left main disease. The grafts for the patient per LIMA to LAD, saphenous vein grafts to OM1, D2, and PD right coronary artery, are observed to be patient. The OH1 stent that was placed in _%#DDMM2004#%_ was also noted to be patent. The patient was asymptomatic during observation, and medical management was continued.
PD|peritoneal dialysis|PD|213|214|HOSPITAL COURSE|For those reasons we decided to first deal with the skin sores that she has on her stomach and left breast and postpone the elective procedures. The first one would be probably the periumbilical hernia repair and PD catheter replacement with temporary hemodialysis and subsequently the coronary stenting. The patient was discharged home today. PRINCIPAL DIAGNOSIS: 1. Cellulitis.
PD|peritoneal dialysis|PD|197|198|HOSPITAL COURSE|HOSPITAL COURSE: His hospital course was significant for serratia peritonitis and another revision of his catheter replacement on _%#MM#%_ _%#DD#%_, 2005. After the most recent catheter placement, PD was reinitiated. However, began to leak again and on _%#MM#%_ _%#DD#%_, 2005, PD was discontinued, and _%#NAME#%_ again was managed with fluid restrictions.
PD|peritoneal dialysis|PD|406|407|HOSPITAL COURSE|After the most recent catheter placement, PD was reinitiated. However, began to leak again and on _%#MM#%_ _%#DD#%_, 2005, PD was discontinued, and _%#NAME#%_ again was managed with fluid restrictions. _%#NAME#%_ will be discharged today from the hospital to the Ronald McDonald House where he is anticipated to return in 2 weeks giving his catheter site a chance to heal and with anticipation of resuming PD again in approximately 2 weeks. BIRTH HISTORY: _%#NAME#%_ was born at 35 plus 3 weeks gestation to a 25-year-old G1, P0, mother, born at 25.80 g.
PD|pulmonary embolus:PE|PD.|399|401|LABS|Neurologic exam is unremarkable. LABS: Sodium 133; chloride 91; potassium 4.4; bicarb 34; BUN 14; creatinine 0.6; anion gap 8; platelets 222; white blood cell count 11.9 with 76% neutrophils; hemoglobin 13.8; platelets 247, D-dimer 0.7; troponin less than 0.7. Brain natriuretic peptide is 69. Glucose is 150. Electrocardiogram shows no fast rhythm. No ischemic changes. CT of chest is negative for PD. It does show a couple of small mid-mediastinal nodes. IMPRESSIONS: 1. Dyspnea with hypoxia. No acute cause found in the emergency department.
PD|peritoneal dialysis|PD|210|211|PHYSICAL EXAMINATION|Cardiovascular exam shows a regular rate and rhythm with no murmurs. Lungs are clear to auscultation bilaterally with good air movement. Abdomen is soft, nontender, and nondistended with no hepatosplenomegaly. PD catheter site is nonerythematous with no drainage. Skin shows no rashes and no lesions. Musculoskeletal exam is unremarkable with normal range of motion.
PD|peritoneal dialysis|PD|230|231|DISCHARGE MEDICATIONS|The fill volume of 440 mL with the fill time of 2 minutes, the dual time of 40 minutes, the drain time of 3 minutes, and bag down volume of 220 mL. Number of cycles including final fill is 16 plus final fills. Standard commercial PD solution is used at 3 bags of 1.5% dialysate dextrose 3 L in size, cycler heater bags of 1 L, container size of 1 L, and dextrose 1.5%, that is to be obtained on pre- and post dialysis.
PD|pulmonary embolus:PE|PD|203|204|PROCEDURES|2. Lower extremity Dopplers _%#DDMM2005#%_ demonstrates no evidence for deep venous thrombosis in either lower extremity. No interval change in the left popliteal cyst. 3. CT angiogram of the chest with PD protocol _%#DDMM2005#%_: Demonstrates no evidence for pulmonary embolism. The patient has stable pulmonary nodules noted bilaterally that are not increased in size.
PD|peritoneal dialysis|PD|222|223|VITAL SIGNS|HEENT: Normal. CARDIOVASCULAR: Exam reveals normal S1 and S2, without any murmurs. LUNGS : Reveal good aeration without crackles or wheezes. ABDOMEN: Abdominal exam reveals soft, nondistended with normal bowel sounds. Her PD catheter and G-tube sites are both dressed and dry. No rashes are seen. EXTREMITIES: Cool but this is normal per father.
PD|peritoneal dialysis|PD|164|165|IDENTIFICATION|IDENTIFICATION: Mr. _%#NAME#%_ is a 34-year-old single male, never married, and does not have any children. He currently lives in _%#CITY#%_, Minnesota. He has had PD treatment four times previously. His drug of choice currently is alcohol . He has had prior psychiatric exams with a diagnosis of depression.
PD|posterior descending|PD|259|260|PROCEDURES PERFORMED|DISCHARGE DIAGNOSIS: Unstable angina. PROCEDURES PERFORMED: Coronary angiography; this showed a patent LIMA to the distal LAD, patent sequential saphenous vein graft to first OM and first diagonal, 90 to 95% stenosis of the sequential saphenous vein graft to PD and PLA, status post CYPHER stent in the saphenous vein graft to PD and PLA with excellent result. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a delightful 79-year-old gentleman with a history of known coronary artery disease status post bypass surgery with mildly reduced left ventricular function who presented with unstable angina at rest.
PD|posterior descending|PD|327|328|PROCEDURES PERFORMED|DISCHARGE DIAGNOSIS: Unstable angina. PROCEDURES PERFORMED: Coronary angiography; this showed a patent LIMA to the distal LAD, patent sequential saphenous vein graft to first OM and first diagonal, 90 to 95% stenosis of the sequential saphenous vein graft to PD and PLA, status post CYPHER stent in the saphenous vein graft to PD and PLA with excellent result. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a delightful 79-year-old gentleman with a history of known coronary artery disease status post bypass surgery with mildly reduced left ventricular function who presented with unstable angina at rest.
PD|peritoneal dialysis|PD|146|147|PAST MEDICAL HISTORY|Postnatal ultrasound and workup showed normal adrenals and kidney exam. 2. Primary oxalosis: See above history of present illness. 3. Status post PD catheter placement. 4. Status post hemodialysis line placement. 5. Status post liver biopsy. PHYSICAL EXAMINATION: Exam on admission per Dr. _%#NAME#%_ _%#NAME#%_.
PD|peritoneal dialysis|PD|195|196|PHYSICAL EXAMINATION|HEENT: Exam is unremarkable. HEART: Regular rate and rhythm without murmur. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, nondistended and nontender with a midline vertical scar and a PD catheter in place. Line is straight. NEURO: Exam is nonfocal. LABORATORY DATA: Electrolytes were within normal limits with the exception of a low phosphorus level of 2.4. BUN is 27, creatinine is 2.18, albumin is 5, calcium is 11.
PD|peritoneal dialysis|PD|197|198|HOSPITAL COURSE|The patient was febrile for first 2 days of hospitalization and remained afebrile for last 3 days of hospitalization, one of those days without antibiotic coverage. Erythema overlying the presumed PD catheter hub diminished during hospitalization. Surgery was consulted and did not believe this was a source of infection and recommended removal in the clinic at a future date.
PD|peritoneal dialysis|PD|362|363|HOSPITAL COURSE|PROCEDURE: Peritoneal dialysis. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is an 80-year-old peritoneal dialysis patient who was admitted with nausea, vomiting, diarrhea, poor p.o. intake and weakness. He did not have abdominal pain. Initially there was some concern over peritonitis associated with peritoneal dialysis but Gram stain, cell count and culture of the PD fluid were not consistent with this diagnosis and he was felt simply to have a viral gastroenteritis. He was treated with continued peritoneal dialysis with 1.5% Dianeal to limit ultrafiltration.
PD|peritoneal dialysis|PD|236|237|HOSPITAL COURSE|He was treated with continued peritoneal dialysis with 1.5% Dianeal to limit ultrafiltration. He was also given extra intravenous fluids. He was initially started on antibiotics including vancomycin and ceftazidime but once cultures of PD fluid came back negative, these were stopped. A CT scan of the abdomen and pelvis was done which showed some free air consistent with the patient being on peritoneal dialysis.
PD|peritoneal dialysis|(PD)|235|238|HISTORY OF PRESENT ILLNESS|She presented to the outside hospital with weakness and dizziness, light-headedness, poor p.o. intake and 3-4 day history of nausea, vomiting and severe diarrhea. She had recently been switched from hemodialysis to peritoneal dialysis (PD) but developed Tenckhoff catheter exit site infection. She was treated with various oral antibiotics, most recently Cipro. She also has some IV vancomycin. Apparently the exit site cultures grew out Enterobacter.
PD|peritoneal dialysis|PD|148|149|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: End-stage renal disease due to polycystic kidney disease. She began hemodialysis in 2004. She has been on peritoneal dialysis PD for the last couple weeks using a cycler with 2 x 6 liter exchanges at night with one daytime exchange.
PD|pulmonary embolus:PE|PD|230|231|ASSESSMENT/PLAN|1. Respiratory. Findings consistent with right middle lobe pneumonia. However, given her significant pain, tachycardia and shortness of breath I think differential should include pulmonary embolus. No significant risk factors for PD except a history of malignant melanoma. Plan for now will be to treat with Zithromax and Rocephin, O2 as needed. We will also check a D-Dimer and repeat CT in the morning.
PD|peritoneal dialysis|PD|108|109|PROCEDURES|PROCEDURES: Status post-simultaneous pancrease and kidney transplant. The patient had his renal failure and PD dialysis since 1999. The patient had a cardiac catheter done in _%#MM#%_ of 2000, which revealed three-vessel coronary artery disease.
PD|peritoneal dialysis|PD|162|163|PAST MEDICAL HISTORY|1. Diabetes mellitus Type II for seventeen years. 2. Retinopathy status post vitrectomy. 3. Status post CABG times four on _%#DDMM2000#%_. 4. Renal failure arrow PD since _%#MM1999#%_. 5. History of TIA in 1996. 6. Hypertension. 7. History of right ankle fracture. 8. History of exposure to CMV and EBB. 9. Status post T+A.
PD|peritoneal dialysis|PD|183|184|HISTORY OF PRESENT ILLNESS|SVC balloon thrombectomy, bilateral lymphatic ligation, pleural ablation secondary to cholopoiesis. 4. _%#MM#%_ _%#DD#%_, 2001, right PA thrombus removal. 5. _%#MM#%_ _%#DD#%_, 2001, PD catheter placement. 6. _%#MM#%_ _%#DD#%_, 2001, PD catheter removal. 7. _%#MM#%_ _%#DD#%_, 2002, bronchoscopy. 8. _%#MM#%_ 2002, gastrostomy with Nissen, history of seizure. Last EEG _%#MM#%_ _%#DD#%_, 2002.
PD|peritoneal dialysis|PD|234|235|HISTORY OF PRESENT ILLNESS|SVC balloon thrombectomy, bilateral lymphatic ligation, pleural ablation secondary to cholopoiesis. 4. _%#MM#%_ _%#DD#%_, 2001, right PA thrombus removal. 5. _%#MM#%_ _%#DD#%_, 2001, PD catheter placement. 6. _%#MM#%_ _%#DD#%_, 2001, PD catheter removal. 7. _%#MM#%_ _%#DD#%_, 2002, bronchoscopy. 8. _%#MM#%_ 2002, gastrostomy with Nissen, history of seizure. Last EEG _%#MM#%_ _%#DD#%_, 2002.
PD|peritoneal dialysis|PD|174|175|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Coronary artery disease, status post bypass surgery this admission with LIMA graft to the LAD, vein graft to the ramus intermedius, vein graft to the PD branch of the right coronary artery. 2. Ligation of left atrial appendage. 3. Right middle lobe wedge resection of the lung for biopsy, showing chronic inflammation.
PD|(device) PD|PD|324|325|PROBLEM #2|Since the patient had recent shortness of breath and hemoptysis prior to his discharge, the patient was started on Cipro 750 mg p.o. b.i.d., TOBI nebulizer b.i.d. and ceftazidime 2 g IV q.8h. x 2 weeks. The patient had PICC line placed during this hospital course for home IV antibiotics. The patient was unable to continue PD Vest treatment during this hospital course, especially the 2 days after PEG tube placement. It was offered to the patient to take pain medication so he would be able to perform his PD Vest, but the patient refused.
PD|(device) PD|PD|219|220|PROBLEM #2|The patient was unable to continue PD Vest treatment during this hospital course, especially the 2 days after PEG tube placement. It was offered to the patient to take pain medication so he would be able to perform his PD Vest, but the patient refused. Just prior to discharge, the patient was able to use the PD Vest without any difficulties.
PD|(device) PD|PD|180|181|PROBLEM #2|It was offered to the patient to take pain medication so he would be able to perform his PD Vest, but the patient refused. Just prior to discharge, the patient was able to use the PD Vest without any difficulties. The patient's PFTs during this hospital course revealed as follows: PFT was done _%#MM#%_ _%#DD#%_, 2002, with FVC of 4.06, 91%, which was about the same as on _%#MM#%_ _%#DD#%_, 2002, which had a FVC of 4.05. FEV1 of 2.7 or 72% on _%#MM#%_ _%#DD#%_, 2002, that was 2.31 on _%#MM#%_ _%#DD#%_, 2002.
PD|posterior descending|PD,|163|165|HOSPITAL COURSE|However, the patient was taken back to the Operating Room on _%#DDMM2002#%_. The procedures performed were coronary artery bypass x 3, IMA. to LAD, SVG to OM, and PD, mitral valve with ring/implant Duran size 31. The patient did well and was transferred to the floor on the second postoperative day, _%#DDMM2002#%_.
PD|peritoneal dialysis|PD|116|117|DISCHARGE MEDICATIONS|21. ____________ 2.5 mg p.o. qTuesdays and Thursdays. 22. Ambien 5 mg p.o. q.h.s. p.r.n. 23. Vancomycin 1500 mg per PD p.r.n. 24. Gentamicin 400 mg per PD p.r.n. peritonitis. It was our pleasure to be involved in the health care of Ms. _%#NAME#%_.
PD|peritoneal dialysis|PD|231|232|PROBLEM #2|_%#NAME#%_ developed hyperphosphatemia treated with calcium carbonate and received Amphojel for several days to stabilize the phosphorus level. He was sent home on Renagel. PROBLEM #2: Renal. Creatinine peaked at 5.5 on the day of PD catheter placement and then decreased through his hospital stay. A renal ultrasound on admission showed large echogenic kidneys, with the right kidney measuring 8.9 cm, and the left 9.1 cm .
PD|peritoneal dialysis|PD|285|286|PROBLEM #2|A renal biopsy was performed on hospital day 10 (_%#DDMM2003#%_), which showed MPGN. _%#NAME#%_ received a burst of methylprednisolone of 600 mg IV daily for three days, and then was started on prednisone 50 mg p.o. t.i.d. His urine output continued to decrease, and he was started on PD on hospital day 12, with good results, but his BUN remained quite high. _%#NAME#%_ was continued on the prednisone dose of 15 mg p.o. t.i.d. for one month, then he was tapered to the same dose every morning.
PD|peritoneal dialysis|PD|194|195|PROBLEM #2|_%#NAME#%_ was continued on the prednisone dose of 15 mg p.o. t.i.d. for one month, then he was tapered to the same dose every morning. With his creatinine improving to 1.3, he was tried off of PD with success and had adequate weight without development of fluid overload. Of note, _%#NAME#%_ had his PD catheter repositioned laparoscopically after developing abdominal pain and an abdominal x-ray showing the PD catheter in the right upper quadrant, rather than in the pelvis.
PD|peritoneal dialysis|PD|274|275|PROBLEM #2|With his creatinine improving to 1.3, he was tried off of PD with success and had adequate weight without development of fluid overload. Of note, _%#NAME#%_ had his PD catheter repositioned laparoscopically after developing abdominal pain and an abdominal x-ray showing the PD catheter in the right upper quadrant, rather than in the pelvis. His albumin was rechecked prior to discharge home, and it was 2.3. A repeat renal ultrasound on _%#DDMM2003#%_ was unchanged, with a right kidney of 9.2 cm, and left 9.3. Vitamin D was started, and a PTH level during the hospital stay was within normal limits.
PD|peritoneal dialysis|PD|176|177|HOSPITAL COURSE|He also had his two-month immunizations on _%#DDMM2003#%_. On _%#DDMM2003#%_ in the PICU, he developed a peritoneal infection and was treated with vancomycin, ceftazidime, and PD x 10 days. He did not have any further issues with peritonitis. Though, on the day of discharge, a routine peritoneal fluid culture, sent on _%#DDMM2003#%_, grew out a single colony of micrococcus species that was pan-susceptible.
PD|posterior descending|PD|276|277|HOSPITAL COURSE|Bypass surgery was recommended and accepted. Dr. _%#NAME#%_ did multiple vessel revascularization on _%#DDMM2004#%_ with a LIMA to the LAD, OM3 received a saphenous vein graft and there was a sequential saphenous vein graft going to OM4 to the LV branch of the RCA and to the PD of the RCA. The last three vessels were all sequentially done. Postoperatively it took three days to get off the ventilator.
PD|peritoneal dialysis|PD|198|199|PAST MEDICAL HISTORY|17. History of VRE from postoperative abdominal wound infection and small bowel fistula. 18. Anemia secondary to chronic disease. 19. History of left 4th finger contracture, which was released. 20. PD history. 21. Diabetic gastroparesis. PAST SURGICAL HISTORY: 1. Living donor kidney transplant from brother in _%#DDMM2000#%_. 2. Deceased donor pancreas transplant with bladder drainage in _%#DDMM2000#%_.
PD|peritoneal dialysis|PD|147|148|HISTORY OF PRESENT ILLNESS|Her CBC was within normal limits, INR was normal. ERCP went without complications. She had a normal-appearing papilla except for slightly red. The PD was partially injected and appears normal. Common bile duct with no evidence of stones, slightly dilated. A sphincterotomy was performed and there was thought to be still a narrowed area 2-4 cm distal to the papilla and the sphincterotomy site, but was a smooth tapered area, and there was concern about extrinsic compression.
PD|police department|PD|211|212|ASSESSMENT|I did try contacting the _%#CITY#%_ Police department who stated that there was no report of calls for any physical assault today for that matter. She does live in _%#CITY#%_ and after contacting the _%#CITY#%_ PD there apparently was a call out to her apartment but there is some note of a individual being somewhat confused.
PD|peritoneal dialysis|PD|214|215|DISCHARGE PLAN|4. If the kidney dysfunction does not resolve, she most likely will need to go back on peritoneal dialysis. Her PD catheter was removed at the time of transplantation. Therefore, she would need reimplantation of a PD catheter in the future if the kidney does not turn around.
PD|peritoneal dialysis|PD|193|194|ASSESSMENT/PLAN|There are no obvious signs of infections. She has no fevers, chills, or sweats, but we will pan culture her and also obtain white count. She does have an indwelling catheter and recently had a PD catheter that was infected. She has been on tobramycin for this. We will check a CBP to assess her volume status. By exam, she appears to be hypervolemic as she has a pleural fusion and lower extremity edema.
PD|peritoneal dialysis|PD|189|190|PAST SURGICAL HISTORY|14. Chronic peritoneal dialysis, onset _%#MM#%_ 2004. She cycles nightly. 15. History of gingival hyperplasia. PAST SURGICAL HISTORY: 1. Bilateral retinal photocoagulation. 2. Placement of PD catheter _%#MM#%_ 2004. 3. Surgical reduction of gums. ALLERGIES: 1. Penicillin, which causes hives. 2. Erythromycin and cipro, which cause vomiting.
PD|peritoneal dialysis|PD|186|187|DISCHARGE INSTRUCTIONS|The patient may be sponge bathed but he should not soak in a bathtub or swim in a pool for the next 2 weeks. He should continue to have a dry gauze pressure dressing placed over his old PD catheter site as needed. His parents have been taught in the routine care of a tunneled central venous catheter. They have been provided with the contact information for his transplant coordinator, _%#NAME#%_ _%#NAME#%_, at _%#TEL#%_, and instructed to call her should they have any questions.
PD|posterior descending|PD.|145|147|INDICATION FOR CONSULTATION|I am not convinced that this dictation is correct, but be that as it may, she had a Possis graft placed connected to her OM and subsequently the PD. There was some native coronary disease and a 50 percent ostial graft stenosis at the OM with no other significant lesions amenable or approachable with either bypass or catheters.
PD|posterior descending|PD,|127|129|IMPRESSION|4. Previous multiple vessel bypass with anatomy as noted above including a LIMA to an unclear vessel and a Possis graft to OM, PD, and the superior vena cava. 5. Diabetes mellitus. 6. Peripheral vascular arterial disease with previous iliofemoral surgeries. 7. Chronic hemodialysis. PLAN: Medical therapy if at all possible.
PD|posterior descending|PD|213|214|CHIEF COMPLAINT|On _%#MM#%_ _%#DD#%_, 2003, he had repeat angiography with angioplasty and stenting. This study showed 1) total occlusion of the native circumflex, 2) high-grade stenosis of the proximal saphenous graft to OM and PD which was dilated and stented, 3) subtotally occluded ramus intermedius branch, 4) total occlusion of RCA, 5) totally occluded LAD with a widely patient LIMA to the distal LAD, 6) LVEF of 35-40%.
PD|posterior descending|PD.|160|162|PAST MEDICAL HISTORY|He does not remember this but it is documented on his old records. PAST MEDICAL HISTORY: 1) Coronary artery disease. 2) Previous bypass surgery to LAD, OM, and PD. 3) Diminished LV function, LVEF of 35-40%. 4) Ten years of diabetes mellitus. 5) Peripheral vascular arterial disease with chronic claudication. 6) Hypertension.
PD|posterior descending|PD|142|143|PAST MEDICAL HISTORY|5) gastroesophageal reflux disease. 6) Moderately severe mitral insufficiency. 7) Prior stenting of the distal right coronary artery prior to PD and PL branches. 8) Prior knee surgery. 9) Fibromyalgia. 10) Irritable bowel. 11) Hypertension. 12) Carpal tunnel. 13) Panic disorder. 14) Squamous cells cancer of the right forearm.
PD|phosphate dehydrogenase|PD|217|218|LABORATORY DATA|I have discussed this with the primary-care doctor. He will confirm if this is hemolysis with hematoglobulin, and reticulocyte count. He will check a B12, folate, and ferritin level. In addition, we will check for G6 PD deficiency. We will check cryoglobulins and cold agglutinin. I have recommended that she be well hydrated and that we give her supplemental folic acid, and that the INR be corrected.
PD|posterior descending|PD|192|193|CORONARY ANGIOGRAM, 2/21/05|CORONARY ANGIOGRAM, _%#DDMM2005#%_: Revealed a right dominant coronary system and triple vessel coronary artery disease. IVUS the left main coronary artery has non-critical disease. The right PD and right PL2 by collaterals from the left ....................LAD. The right heart cath revealed PA pressure of ...........17 x 16 x 23 with mean of 39, and pulmonary wedge pressure of 21.
PD|personality disorder|PD,|193|195|PAST MEDICAL HISTORY|6. Suspected CVA (1996) with slurred speech, TIA (left-sided hemiparesis) _%#DDMM2007#%_. 7. Acute head injury on 2 occasions: 2005 and another unknown date. 8. Psychiatric history (GAD, PTSD, PD, ADHD, personality disorder NOS, major depressive disorder, meth dependency, borderline personality disorder, and antisocial personality disorder). PAST SURGICAL HISTORY: 1. Hysterectomy. 2. Nephrectomy (left). 3. Gastrectomy (secondary to gastric ulcers).
PD|peritoneal dialysis|PD|182|183|PHYSICAL EXAMINATION|GENERAL: He is a well-developed, thin male with a left internal carotid central line in place. He has areas of previous sticks on the left side and no other IVs in place. There is a PD catheter in place in the left lower quadrant. HEENT: The left ear is pulled up due to the Tegaderm strip on the central line.
PD|peritoneal dialysis|PD|151|152|PHYSICAL EXAMINATION|There are no teeth. NECK: Supple. LUNGS: Clear. CARDIOVASCULAR: Heart sounds are normal. ABDOMEN: Soft and nontender. There was no organomegaly, and a PD catheter is in place. SPINE: He has a straight, tender spine. There are no dimples. EXTREMITIES: No extremity contractures. NEUROLOGIC: Neurologic exam found him sleeping and arousing to light and/or tactile stimulation, with spontaneous eye opening and looking around.
PD|peritoneal dialysis|PD|146|147|PHYSICAL EXAMINATION|Abdominal exam: The patient has well- healed previous incisions. a right lower quadrant transplant incision, a midline incision and several small PD incisions on the right and left side of her abdomen. Her abdomen is mildly distended, is moderately diffusely tender with more point tenderness on the left, tender to direct palpation.
PD|prism diopter|PD|131|132|ASSESSMENT|She also has a moderate depression deficit of the right eye. On muscle balance testing in primary gaze at distance, I measured a 4 PD esotropia combined with a 3 PD right hypotropia. At near we measured a 5 PD esotropia. Her slit lamp examination was normal as was her funduscopic examination.
PD|prism diopter|PD|162|163|ASSESSMENT|She also has a moderate depression deficit of the right eye. On muscle balance testing in primary gaze at distance, I measured a 4 PD esotropia combined with a 3 PD right hypotropia. At near we measured a 5 PD esotropia. Her slit lamp examination was normal as was her funduscopic examination.
PD|prism diopter|PD|146|147|ASSESSMENT|On muscle balance testing in primary gaze at distance, I measured a 4 PD esotropia combined with a 3 PD right hypotropia. At near we measured a 5 PD esotropia. Her slit lamp examination was normal as was her funduscopic examination. Cycloplegic retinoscopy was +1.00 +2.50 x 120 in the right eye and +2.75 + 1.50 x 43 on the left.
PD|posterior descending|PD|120|121|HISTORY OF PRESENT ILLNESS|In _%#DDMM2003#%_ he had a four-vessel bypass with, as best I can tell, LIMA to the LAD, saphenous vein graft to OM and PD and one other vessel bypassed; but it is not exactly clear. Presumably there was a sequential bypass from the OM to the diagonal branch with the saphenous vein graft noted.
PD|posterior descending|PD|176|177|HISTORY|A coronary angiogram done today also demonstrates 3-vessel coronary artery disease. The patient has a codominant right system with what appears to be a distal total circumflex PD or PLA being supplied by right vessels. In addition, there is a rather severe 90% stenosis at a branching of the large marginal circumflex vessel.
PD|peritoneal dialysis|PD|224|225|HISTORY OF PRESENT ILLNESS|In regards to his renal function, the patient has a history of chronic renal failure and developed an acute-on-chronic picture while he was on the rehabilitation unit. Nephrology was consulted and the decision is to place a PD catheter. He is scheduled to have this prior to his discharge (scheduled for Thursday). Although he does not require dialysis yet he will likely need it in the very near future.
PD|peritoneal dialysis|PD|224|225|ASSESSMENT/RECOMMENDATIONS|ASSESSMENT/RECOMMENDATIONS: This is a 67-year-old man who is known to the rehabilitation services who was transferred from Acute Rehab because of an aspiration pneumonia and developing acute-on-chronic renal failure. He has PD catheter placement pending. He has focal cord paralysis. He is NPO on tube feedings. He does have impairment of strength, balance, endurance and ADLs, but is almost back to baseline function.
PD|UNSURED SENSE|PD|188|189|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: Finds persistent growth along the 1st percentile for OFC, height and weight. He has no cardiac or pulmonary issues. No allergies. He has intermittent wretching from the PD and Nissen fundoplication. He has not had significant infections. There is no bleeding, bruising or anemia. The skin is in good shape and development is thought to be normal.
PD|peritoneal dialysis|PD|210|211|PHYSICAL EXAMINATION|Sclerae and conjunctivae are clear. SPINE: Straight. HEART: Normal cardiac exam with regular rate and rhythm, normal S1 and S2 and no murmurs. LUNGS: He has clear lungs bilaterally. ABDOMEN: Has a G-tube and a PD catheter in place. It is soft, nontender. I did not appreciate significant organomegaly. He has an uncircumcised phallus, descended testes, straight nontender spine and normal skin.
PD|peritoneal dialysis|PD|196|197|HISTORY|The patient has ESRD secondary to lupus nephritis. She initiated dialysis over four years ago. Hemodialysis was tried initially, but because of multiple vascular access problems, she then went to PD and subsequently had problems with that and is back on hemodialysis over the past year or so using a tunneled IJ catheter as access.
PD|peritoneal dialysis|PD|202|203|PHYSICAL EXAMINATION|RESPIRATORY: He was spontaneously breathing. Lungs were clear bilaterally. CARDIOVASCULAR: Heart sounds were normal with a normal S1 and S2; I heard no rhythm. ABDOMEN: The abdomen was full of fluid; a PD catheter was in place. GENITOURINARY: The scrotum was swollen. I could not appreciate testes. The penis is uncircumcised. EXTREMITIES: There are good femoral pulses.
PD|posterior descending|PD.|267|269|CHIEF COMPLAINT|Cardiac history is positive for coronary artery disease. Remotely she had coronary artery bypass in _%#MM#%_ of 2003 with a LIMA to the LAD, a radial to the OM2 with an interpositional graft to the first diagonal, saphenous vein graft to OM3, saphenous vein graft to PD. Her LV EF has been approximated at 45-50% to as high as normal. She has moderate biatrial enlargement. She has also had moderately severe to severe pulmonary hypertension.
PD|peritoneal dialysis|PD|145|146|MEDICATIONS|12. Lantus 30-40 units at bedtime, depending on sugars 13. NovoLog 5-15 twice a day with breakfast and supper which breakfast is late due to his PD fluids 14. Spiriva 1 inhalation in the morning 15. Timolol 0.5 to his left eye 1 drop in the morning, 1 drop at hs.
PD|peritoneal dialysis|PD|160|161|RECOMMENDATIONS|2. The patient on continuous ambulatory peritoneal dialysis (CAPD). 3. Scrotal cellulitis probably not Fournier's gangrene. RECOMMENDATIONS: 1. Continue manual PD therapy with 2.5% bags 5 times daily 2. We can arrange for Cycler to be set up for nocturnal PD, though patient tends to prefer his manual technique.
PD|peritoneal dialysis|PD,|132|134|RECOMMENDATIONS|RECOMMENDATIONS: 1. Continue manual PD therapy with 2.5% bags 5 times daily 2. We can arrange for Cycler to be set up for nocturnal PD, though patient tends to prefer his manual technique. 3. May need some adjustment of his anemia therapy. Will check on his outpatient erythropoietin and iron dosing.
PD|peritoneal dialysis|PD|153|154|HISTORY|Normally the patient dialyzes with 5 exchanges daily, all 2.5% dextrose. With this, he has been able to maintain weight. He has had no major issues with PD except for one episode of peritonitis early in the course of his treatment which was treated with appropriate intraperitoneal antibiotics.
PD|peritoneal dialysis|PD|154|155|PAST SURGICAL HISTORY|Other medical issues, insulin-dependent diabetes mellitus. Hypertension controlled, problems in the past. PAST SURGICAL HISTORY: Placement of a Tenckhoff PD catheter. MEDICATIONS ON ADMISSION: 1. Toprol-XL 200 daily. 2. Renal caps (vitamins one daily).
PD|peritoneal dialysis|PD|145|146|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: Denies shortness of breath, cough, chest pains, no pulmonary issues. He has had no abdominal pain or anything associated with PD drainage. The PD fluid is without incident. No current neurologic symptoms. The rest of the ROS is negative. SOCIAL HISTORY: He is married, lives with wife, does not smoke and denies alcohol use.
PD|peritoneal dialysis|PD|223|224|PHYSICAL EXAMINATION|VITAL SIGNS: Blood pressure is 148/73, temperature is 101.9 degrees, pulse is 95 and regular. HEENT: No scleral icterus. NECK: No JVD or lymphadenopathy. LUNGS: Clear. HEART: Sinus rhythm, no murmur or gallop. ABDOMEN: The PD site looks clean. EXTREMITIES: There is no tenderness. GENITALIA: See urology report. Some left scrotal drainage noted and cellulitis involving the surrounding areas of skin.
PD|peritoneal dialysis|PD|151|152|LABORATORY DATA|Electrolytes 135/3.2/98/23 creatinine 12.2, BUN 55, calcium 8.2, glucose 224. Thanks for the consultation. We will assist in further management of his PD while here in the hospital.
PD|peritoneal dialysis|PD|142|143|LABORATORY DATA|There was no cardiac murmur. The lungs were clear to auscultation. The abdomen was slightly distended but nontender. The gastrostomy tube and PD catheter were in place. Neurological examination found _%#NAME#%_ to be alert and interactive. _%#NAME#%_ may have a component of divergent strabismus.
PD|purified protein derivative:PPD|PD|165|166|ASSESSMENT|2. Hypokalemia, mild noted prior to admission. 3. Borderline hypertension noted since admission. I am not aware of a history of hypertension. 4. History of positive PD treated last year. It is not clear if the patient is compliant with a complete course and what type of follow-up he has had for this.
PD|posterior descending|PD|241|242|CHIEF COMPLAINT|Coronary angiography was done and this revealed a 50% distal left main stenosis, total occlusion of her circumflex which lead to the posterolateral wall motion abnormality noted and a 95% proximal LAD lesion, 50% origin RCA stenosis, 40-50% PD stenosis. She had revascularization performed by Dr. _%#NAME#%_, having a LIMA going sequentially to the diagonal branch and then the LAD and a sequential saphenous vein graft doing to the posterior descending and posterolateral branches.
PD|phosphate dehydrogenase|PD|296|297|IMPRESSION|We will await the results of her hemoglobin electrophoresis and quantitative hemoglobin A2 and F levels will be obtained. If her labs confirm hemolysis with a negative Coombs' test and the absence of spherocytes, other possible causes for hemolytic anemia may need to be considered, including G6 PD deficiency. The situation was reviewed with the patient, and we will follow along with you while she remains hospitalized.
PD|peritoneal dialysis|PD|395|396|SUBJECTIVE|CHIEF COMPLAINT: New onset ankle clonus bilaterally. SUBJECTIVE: _%#NAME#%_ is a 13-year-old Hmong male with AML who underwent related donor bone marrow transplant 18 days ago and now has had multiple complications of therapy including veno-occlusive disease of the liver, renal failure with peritoneal dialysis started 2 days ago with a secondary hyperglycemia from high glucose content of the PD fluid, bilateral pleural effusions status post chest tube placement, and failure to wean from the ventilator following PD catheter insertion along with persistent fever and neutropenia. Today during rounds from the ICU bilateral ankle clonus was noted.
PD|peritoneal dialysis|PD|517|518|SUBJECTIVE|CHIEF COMPLAINT: New onset ankle clonus bilaterally. SUBJECTIVE: _%#NAME#%_ is a 13-year-old Hmong male with AML who underwent related donor bone marrow transplant 18 days ago and now has had multiple complications of therapy including veno-occlusive disease of the liver, renal failure with peritoneal dialysis started 2 days ago with a secondary hyperglycemia from high glucose content of the PD fluid, bilateral pleural effusions status post chest tube placement, and failure to wean from the ventilator following PD catheter insertion along with persistent fever and neutropenia. Today during rounds from the ICU bilateral ankle clonus was noted.
PD|peritoneal dialysis|PD|126|127|PHYSICAL EXAMINATION|HEART: The precordium is hyperdynamic with a soft flow murmur S1 and S2 are heard. ABDOMEN: Tense with PD fluid in place. The PD catheter is in place. The dressing is dry. The central line is in place. That dressing also is dry. Right chest tube is in place.
PD|peritoneal dialysis|PD,|217|219|IMPRESSION|IMPRESSION: 1) Hypoglycemia; will hold the 70/30 insulin, provide sliding-scale insulin, continue the Amaryl. She is taking p.o. well; will give her a diabetic dialysis diet. 2) End-stage renal disease; will continue PD, four exchanges a day, 2,000 cc of 2.5%, and will follow her labs. 3) Heel ulcer; it looks good. I will have the wound care nurse see her.
PD|(drug) PD|PD.|136|138|MEDICINES ON ADMISSION|5. Amitriptyline 10 HS 6. She is taking hydrocodone APAP 5/500 one tablet every 4-6 hours as needed for pain. 7. She is on some Guaifed PD. 8. She has been on Xenical 120 t.i.d. 9. Multivitamins ALLERGIES: Sulfa drugs. Smoking history - none. Alcohol use - none.
PD|peritoneal dialysis|PD|194|195|HISTORY OF PRESENT ILLNESS|She does have one allograft still in place. She has had multiple complications with vascular access and is now running on a translumbar catheter exiting on the right. She tells me she has tried PD in the past, but this also failed. Today, she feels okay. She does complain still of abdominal pain but no other pain.
PD|peritoneal dialysis|PD|215|216|LABORATORY DATA|Abdominal tissue taken at the time of exploratory laparotomy has grown moderate Candida albicans with a light growth of group D Enterococcus and a light growth of a Staphylococcus species as yet not identified. The PD catheter tip which was cultured on _%#MMDD#%_ also grew Candida albicans and group D Enterococcus. ASSESSMENT: In summary, this 6-1/2-month-old has continued peritonitis and is now five days postoperative exploratory laparotomy and removal of the peritoneal dialysis catheter.
PD|posterior descending|PD|265|266|LABORATORY DATA|80% stenosis in ramus vessel, diffuse disease in the left circumflex artery, 90% long stenosis of the second obtuse marginal vessel, which is a large vessel with a lateral branch. There is 50% stenosis in the right coronary artery with proximal disease in both the PD as well as the posterolateral artery. Review of his echocardiogram reveals moderately decreased left ventricular function with visually estimated ejection fraction of 35%.
PD|peritoneal dialysis|PD|124|125|PAST MEDICAL HISTORY|She offers no complaints. She denies history of diabetes or heart disease. PAST MEDICAL HISTORY: End-stage renal disease on PD and using a cycler, hypertension, GI bleed and seizures. SOCIAL HISTORY: She is visiting from Alaska. She is single.
PD|posterior descending|PD|175|176|CORONARY ANGIOGRAM|There is a 70% lesion in the 1st diagonal artery. Moderate disease in the left circumflex with 2 large OM1 and OM2 vessels. Subtotally occluded right coronary artery with the PD and PL filling with left right collaterals. STRESS TEST: Evaluation of stress test performed on _%#MM#%_ _%#DD#%_ shows severely abnormal myocardial SPECT study.
PD|posterior descending|PD|181|182|RECOMMENDATIONS|He had a four vessel bypass done _%#MMDD#%_ with a LIMA to the left anterior descending and a saphenous vein graft to the circumflex OM and a sequential saphenous vein graft to the PD and PL branches of the right coronary artery. He also had an aortic valve replacement with a #23 stented pericardial valve.
PD|posterior descending|PD|218|219|REVIEW OF SYSTEMS|FAMILY HISTORY: Non-contributory. REVIEW OF SYSTEMS: Low-grade fever with her maximum temperature over the last 24 hours being 100.9. She has not had bleeding noted from her nose or mouth. No wheezing noted. She has a PD catheter in place for dialysis. She has been continuously dialyzed today. No blood noted on the peritoneal fluid. She also has significant liver injury with hyperbilirubinemia. No purpuric lesions.
PD|peritoneal dialysis|PD|135|136|PHYSICAL EXAMINATION|She is warm and well-perfused. ABDOMEN: soft, non-distended. Her liver is palpable about 3 cm below the right costal margin. She has a PD catheter in place and the site is not oozing. No peripheral edema is noted. Her most recent chest x-ray shows fluffy opacities on both sides, but predominantly on the mid and lower areas on her right side and left lower lobe.
PD|posterior descending|PD,|224|226|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is 71. He has a history of coronary artery disease and previous three vessel bypass surgery in 1998 at Fairview Southdale Hospital. He had a lima to the LAD saphenous vein graft, a PD, and to distal RCA. Subsequently, he had diminished LV function with ejection fraction of 25-30 percent which was treated with a heart failure program.
PD|posterior descending|PD|138|139|LABS|The left circumflex has a 90% middle lesion after the 1st obtuse marginal artery. Complete occlusion of the right coronary artery and the PD and posterolateral filled by left and right collaterals. Review of his echocardiogram reveals moderate LV dilatation with severely decreased left ventricular function, with a measured estimated EF at 20%, mild mitral regurgitation, trace aortic incompetence.
PD|posterior descending|PD|245|246|REASON FOR CONSULTATION|Indeed when he was assessed in 1997 with coronary angiography, after his bypass operation he had severe multiple vessel, native coronary artery disease with a patent saphenous vein graft to an OM marginal. He had a patent saphenous graft to the PD and posterolateral branch. He had a patent saphenous vein graft to a diagonal branch with a patent LIMA that skipped from the mid to distal LAD.
PD|peritoneal dialysis|PD|144|145|PHYSICAL EXAMINATION|There is no nasal discharge. CARDIOVASCULAR: There is no cardiac murmur. LUNGS: The lung sounds are clear. ABDOMEN: The abdomen is full, with a PD catheter. EXTREMITIES: He has clubbing on the fingers and toes. SKIN: There are no skin lesions. NEUROLOGIC: He is responsive to sound with eye blinking. He did not respond to commands and showed no interest upon command in the world around him.
PD|peritoneal dialysis|PD|137|138|PSH|See HPI. PSH 1. Partial hysterectomy for varicose veins 2. Cholecystectomy. 3. Appendectomy. 4. Hernia repair, incisional, 2-3 times. 5. PD catheter placement. 6. Right AV fistula placement. 7. Cardiac stents, 1995 and 2001. 8. Left total knee arthroplasty. 9. Ovarian cyst removal, age 16.
PD|pancreatic duct|PD|221|222|HISTORY OF PRESENTING ILLNESS|The patient did have an EGD done here on _%#DDMM2007#%_ that was unremarkable except for some evidence of some bile reflux into the stomach without any gastritis. A CT scan done yesterday showed calcifications and distal PD dilation, which is consistent with severe chronic pancreatitis without evidence of acute pancreatitis. Amylase and lipase have been normal. ALLERGIES: No known medication allergies.
PD|peritoneal dialysis|PD|324|325|PROBLEM #2|On his day of discharge,_%#MM#%_ _%#DD#%_, his creatinine was 2.1, BUN was 12, and his potassium was 4.0. He was initially maintained on continuous peritoneal dialysis, until his transfer to Fairview-University Medical Center, where he was started on one hour continuous cycles with 100 cc fill volumes, standard commercial PD solution with 1.5 Dextrose. Over the following ten days, he was successfully weaned to his discharge peritoneal dialysis of 12 hours - 45 minute cycles with 120 cc fill volumes, 2.5 Dextrose and a low calcium PD solution.
PD|peritoneal dialysis|PD|181|182|PROBLEM #2|Over the following ten days, he was successfully weaned to his discharge peritoneal dialysis of 12 hours - 45 minute cycles with 120 cc fill volumes, 2.5 Dextrose and a low calcium PD solution. His PD cultures, as well as, gram stains were always negative at Fairview-University Medical Center. At _%#CITY#%_ _%#CITY#%_ Children's he did have several peritoneal dialysate cultures growing Clostridium and one instance in Staphylococcus and another, both treated with antibiotics.
PD|peritoneal dialysis|PD,|227|229|PROBLEM #5|As above, he did have several episodes of peritoneal dialysate growing Clostridium and Staphylococcus, both treated with antibiotics. His last course of antibiotics was on _%#MM#%_ _%#DD#%_, 2003. He was afebrile with negative PD, gram stain, cultures, and cell counts during his hospitalization at Fairview-University Medical Center. PROBLEM #6: Hyperbilirubinemia: _%#NAME#%_ had a peaked direct bilirubin level of 10.7 on _%#DDMM2003#%_, was initially treated with phenobarbital and then Actigall.
PD|peritoneal dialysis|PD|132|133|DISCHARGE MEDICINES|11. Eucerin cream p.r.n. to the face. 12. Simethicone 20 mg p.o. q6h p.r.n. gaseousness. 13. Tylenol 40 mg p.o. q6h p.r.n. 14. Home PD 12 hours on, 12 hours off, 45 minute cycles with low calcium 2.5 mEq/L in 2.5% Dextrose solution. FOLLOW-UP: 1. Mother was instructed to return for evaluation for increased pain, increased swelling, elevated temp greater than 101 or decreased oral intake.
PD|peritoneal dialysis|PD|200|201|RESTRICTIONS|At discharge, a plasma amino acid assay showed elevated glutamine and pyruvic acid levels. Urine organic acids and urine orotic acid levels were pending. A skin biopsy was obtained at the time of his PD catheter removal to culture fibroblasts and test for genetic assays. _%#NAME#%_ will need further follow-up as the etiology of his hyperammonemia is not certain at this time.
PD|peritoneal dialysis|PD|157|158|RESTRICTIONS|He had a renal ultrasound on _%#DDMM2007#%_, which revealed normal kidneys and no evidence of renal vein thrombosis. He had no urinary tract infections. His PD catheter was removed on _%#DDMM2007#%_ without any complications. Problem #10: Surgical. _%#NAME#%_ required surgery for peritoneal dialysis catheter placement on _%#DDMM2007#%_.
PD|peritoneal dialysis|PD|234|235|* FEN|Ongoing problems and suggested management: * FEN: _%#NAME#%_ was discharged on breastmilk fortified with Enfamil HMF to 24 kcal/oz, taking 40ml every 3 hours. * Cardiovascular: A repeat echocardiogram was not performed because of the PD dressing which did not allow for good visualization of the heart. _%#NAME#%_ will need an echocardiogram as a follow-up to his initial echo that showed cardiac dysfunction.
PD|peritoneal dialysis|PD|133|134|PAST MEDICAL HISTORY|The patient receives 4 boluses of 205 mL during the day, and he receives drip feeds at 65 mL an hour for 8 hours overnight. His home PD regimen includes total time of 10 hours, total volume 4200 mL, fill volume 400 mL, last fill 200 mL, 10 cycles 1 hour each, and dextrose of 1.5% throughout.
PD|peritoneal dialysis|PD|167|168|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Multicystic kidney disease, PD dependent. 2. Atrial septal defect, status post device closure in _%#MM#%_ 2005. 3. Pulmonary hypertension. 4. PD catheter placement in _%#MM#%_ 2004. 5. Posterior urethral valvuloplasty in _%#MM#%_ 2005. 6. History of aspiration pneumonitis in _%#MM#%_ 2005.
PD|peritoneal dialysis|PD,|140|142|REVIEW OF SYSTEMS|8. Immunizations are up to date. REVIEW OF SYSTEMS : Positive for decrease in weight, for rhinorrhea, and for increased fluid pulled off in PD, as well as elevated temperature and irritability. Review of systems is negative for shortness of breath, cough, or increased edema.
PD|peritoneal dialysis|PD|200|201|REVIEW OF SYSTEMS|Neck: Supple, no lymphadenopathy. Cardiovascular: Regular rate and rhythm. Normal S1 and S2, no murmur. Lungs: Clear to auscultation bilaterally with good air movement. Abdomen: Protuberant but soft, PD site clear. Abdomen is nontender. Spine: No CVA tenderness. Lymphatics: No edema. Skin: No rashes. Musculoskeletal: Consistent with rickets in radial, tibial, and ulnar bone.
PD|peritoneal dialysis|PD|152|153|REVIEW OF SYSTEMS|Skin: No rashes. Musculoskeletal: Consistent with rickets in radial, tibial, and ulnar bone. Neurologic: Appropriate for age. LABORATORY: On admission, PD fluid analysis reveals 33 nucleated cells, 6% lymphocytes, 4% neutrophils, and 11 red cells. Gram stain of the fluid shows no organisms and few white cells.
PD|peritoneal dialysis|PD|164|165|REVIEW OF SYSTEMS|Therefore, in addition to his feeds, the patient did also receive a few normal saline flushes of approximately 10mL/kg each. _%#NAME#%_ was maintained on his usual PD regimen while in the hospital. We modified his enteral formula as needed, based on his electrolytes most notably his potassium.
PD|peritoneal dialysis|PD|257|258|REVIEW OF SYSTEMS|Regarding his elevated temperature, this was thought to be most likely viral in nature. However, when a repeat CRP was performed on _%#MM#%_ _%#DD#%_, 2005, it showed an increase to 19.8 from his admission level of 10.4, blood cultures were sent as well as PD fluid analysis and culture, and antibiotics were started for a 48-hour rule out. The patient remained afebrile, and all studies came back negative and so his antibiotics were discontinued.
PD|pancreatic duct|PD|139|140|LABORATORY STUDIES|There was no new discreet pancreatic lesions or peripancreatic fluid collection on the 17th and no dilation of the common bile duct or the PD at this time. There was still mild prominence of the intrahepatic ducts at that time. ASSESSMENT AND PLAN: This is a 20-year-old female with new diagnosis of inflammatory bowel disease per verbal report from the gastrointestinal doctor on call as well as ongoing mild pancreatitis.
PD|peritoneal dialysis|PD|205|206|PROBLEM #4|_%#NAME#%_ is fairly gaggy and does spite up a foamy white material from time to time, but it is unclear how much of this is due to reflux versus increasing intraabdominal pressure secondary to increasing PD volumes. _%#NAME#%_ is also currently on Protonix for reflux. PROBLEM #5: Renal issues. Renal ultrasound at birth suggested bilateral multicystic dysplastic kidneys with hydronephrosis.
PD|peritoneal dialysis|PD|241|242|PROBLEM #5|The PD catheter site had a history of leaking while in the PICU, but has not done so within the last 3 weeks. _%#NAME#%_ should also have a VCUG in the future to rule out physical ureteral reflux. At the time of discharge _%#NAME#%_'s final PD routine is as follows. _%#NAME#%_ was on a home twice PD cycler with 150 mL dwells with 1 hour cycles split as follows, a 2 minute infusion, a 55 minute dwell, and a 3 minute drain, with a 75 cc last fill.
PD|peritoneal dialysis|PD|188|189|PROBLEM #5|_%#NAME#%_ should also have a VCUG in the future to rule out physical ureteral reflux. At the time of discharge _%#NAME#%_'s final PD routine is as follows. _%#NAME#%_ was on a home twice PD cycler with 150 mL dwells with 1 hour cycles split as follows, a 2 minute infusion, a 55 minute dwell, and a 3 minute drain, with a 75 cc last fill.
PD|peritoneal dialysis|PD|205|206|PROBLEM #7|C. difficile toxin was negative. Because of a history of some watery stools in the last 2 weeks it was decided to place _%#NAME#%_ on a 10- day course of metronidazole. _%#NAME#%_ has been afebrile and no PD cultures have been positive since arriving on the floor. _%#NAME#%_ also has a history of IgG requiring replacement. His most recently IgG was drawn on _%#MM#%_ _%#DD#%_ and was 464.
PD|peritoneal dialysis|PD|263|264|RESTRICTIONS/DIET/SPECIAL INSTRUCTIONS|The feed is to be treated with Kayexalate as previously mentioned. The patient was also sent home with home O2, a peritoneal dialysis machine, a blood pressure machine, apnea monitor, a feeding pump, a back pack with supplies, suction machine, suction catheters, PD dressings with supplies, pulse oximeter, and an O2 regulator and cart. It was a pleasure to be involved in _%#NAME#%_'s care.
PD|peritoneal dialysis|PD|169|170|ADMITTING DIAGNOSES|The patient previously did require peritoneal dialysis into _%#MM#%_ 2003 for anuric renal failure, however, this was stopped when the patient developed peritonitis and PD catheter was removed. The patient also has hypertension with blood pressures running from 100 to 120 mmHg systolic. ADMISSION MEDICATIONS: 1. Lasix 9 mg p.o. b.i.d. 2. Amlodipine 2.5 mg p.o. b.i.d. PHYSICAL EXAMINATION: Temperature 101.1 degrees Fahrenheit.
PD|peritoneal dialysis|PD|98|99|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. PD peritonitis. 2. Branchiootorenal syndrome. 3. End-stage renal failure, PD dependent. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 12-month-old boy with branchiootorenal syndrome and end-stage renal disease who is PD dependent.
PD|peritoneal dialysis|PD|169|170|HISTORY OF PRESENT ILLNESS|3. End-stage renal failure, PD dependent. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 12-month-old boy with branchiootorenal syndrome and end-stage renal disease who is PD dependent. He had been doing well at home with mom until 2 days prior to admission when he began to be fussy and not quite acting like himself, per mom.
PD|peritoneal dialysis|PD|253|254|HISTORY OF PRESENT ILLNESS|He had been doing well at home with mom until 2 days prior to admission when he began to be fussy and not quite acting like himself, per mom. In addition, _%#NAME#%_ had been acting hungry, but not eating well. He had also been retaining fluid with his PD treatments. Up until this time, the patient had been afebrile. The patient was seen in renal clinic on _%#MM#%_ _%#DD#%_, 2004, by Dr. _%#NAME#%_ for retention of fluid.
PD|peritoneal dialysis|PD|220|221|HISTORY OF PRESENT ILLNESS|Basic metabolic panel: NA 139, K 4.4, chloride 97, bicarbonate 29, BUN 60, creatinine 3.13, calcium 7, phosphorus 8.6. On the day of admission, the patient was still retaining fluid, but now the fluid had become cloudy. PD fluid was sent for cell counts and culture and at this time showed 259 white cells with a differential of N 74/L 10/M 16.
PD|peritoneal dialysis|PD|180|181|HISTORY OF PRESENT ILLNESS|PD fluid was sent for cell counts and culture and at this time showed 259 white cells with a differential of N 74/L 10/M 16. The patient was subsequently admitted for treatment of PD peritonitis. PAST MEDICAL HISTORY: 1. Branchiootorenal syndrome - patient has short stature and developmental delay.
PD|peritoneal dialysis|PD|181|182|PAST MEDICAL HISTORY|2. Bilateral pulmonary hyperplasia, status post HFOV x 2 days in NICU. Followed by Dr. _%#NAME#%_ at _%#CITY#%_ _%#CITY#%_ Children's pulmonary clinic. 3. End-stage renal disease - PD since _%#MM#%_ _%#DD#%_, 2004 - schedule prior to admission was 1.5% dextrose, 180 cc with 16 x 45-minute passes. Peak creatinines between 5 and 6. He has a single right kidney.
PD|peritoneal dialysis|PD|182|183|ADMISSION PHYSICAL|GU: Bilaterally descended testes, the patient is circumcised. Lymphatics: No inguinal lymphadenopathy. Musculoskeletal: MAE, FRON. Skin: No rash or lesions present . ADMISSION LABS: PD fluid - clear, 259 white blood cells - diff N 74/L 10/M 16. Complete blood count: White blood cell 17.2, hemoglobin 13.9, hematocrit 41.9, platelets 322, diff 73/23/4.
PD|peritoneal dialysis|PD|258|259|HOSPITAL COURSE|It was felt that calcium carbonate was sufficient as a phosphate binder and the dosage was changed on the calcium carbonate at the time discharge to 3.2 mL t.i.d. 2. Renal: The patient was started on vancomycin and ceftazidime in his PD for treatment of his PD peritonitis. Continuous PD was also started at the time of admission. The patient did well on this regimen. On day 3 of antibiotics, the ceftazidime was discontinued and the patient was continued solely on vancomycin.
PD|peritoneal dialysis|PD|183|184|HOSPITAL COURSE|The patient did well on this regimen. On day 3 of antibiotics, the ceftazidime was discontinued and the patient was continued solely on vancomycin. He was continued on his continuous PD until day 5 of admission. At this time, he was switched to his home regimen of PD (1.5% dextrose, 180 mL - 16 x 45-minute cycles over 12 hours).
PD|peritoneal dialysis|PD|203|204|HOSPITAL COURSE|At this time, he was switched to his home regimen of PD (1.5% dextrose, 180 mL - 16 x 45-minute cycles over 12 hours). On day 8 of admission, it was noted that the number of white cells in the patient's PD fluid level was increasing. On 2 days prior to discharge, the count was 1 red blood cell, 84 white blood cells, differential 18/20/62.
PD|peritoneal dialysis|PD|142|143|HOSPITAL COURSE|On 2 days prior to discharge, the count was 1 red blood cell, 84 white blood cells, differential 18/20/62. On the day prior to discharge, the PD fluid was rechecked and at that time the white count was 160, differential was 60 neutrophils, 11 lymphocytes, 73 monocytes.
PD|peritoneal dialysis|PD|215|216|HOSPITAL COURSE|We will continue to watch _%#NAME#%_'s peritoneal fluid cultures after discharge and if any organisms are identified, we will notify Dr. _%#NAME#%_ at that time. 3. Infectious disease: The patient was admitted with PD peritonitis and started on vancomycin and ceftazidime in his PD fluid. A light growth of coag-negative Staph was identified on day 2 of admission, ceftazidime was discontinued on day 3.
PD|peritoneal dialysis|PD|117|118|HOSPITAL COURSE|3. Infectious disease: The patient was admitted with PD peritonitis and started on vancomycin and ceftazidime in his PD fluid. A light growth of coag-negative Staph was identified on day 2 of admission, ceftazidime was discontinued on day 3.
PD|peritoneal dialysis|PD|195|196|HOSPITAL COURSE|A light growth of coag-negative Staph was identified on day 2 of admission, ceftazidime was discontinued on day 3. The patient was continued on vancomycin for a planned 10-day antibiotic course. PD cell counts and gram stains were followed throughout admission. The blood culture that was drawn was negative and all subsequent PD cultures showed no growth.
PD|peritoneal dialysis|PD|132|133|HOSPITAL COURSE|PD cell counts and gram stains were followed throughout admission. The blood culture that was drawn was negative and all subsequent PD cultures showed no growth. The patient was febrile for the first several days of admission, but this resolved. The patient was afebrile at the time of discharge. In addition, the patient had a history of low IgG.
PD|peritoneal dialysis|PD|167|168|PROCEDURES|7. Renal osteopenia. PROCEDURES: 1. Intubation and bilateral chest tube placement,_%#DDMM2007#%_. 2. UVC placement, _%#DDMM2007#%_. 3. Vesicostomy, _%#DDMM2007#%_. 4. PD catheter placement, _%#DDMM2007#%_. 5. IJ placement. 6. IJ removal and PICC placement, _%#DDMM2007#%_. 7. NJ tube placement in _%#DDMM2007#%_. 8. Right inguinal hernia repair, bilateral orchiopexy, circumcision, _%#DDMM2008#%_.
PD|peritoneal dialysis|PD|208|209|PROCEDURES|7. NJ tube placement in _%#DDMM2007#%_. 8. Right inguinal hernia repair, bilateral orchiopexy, circumcision, _%#DDMM2008#%_. 9. Vesicostomy closure and posterior urethral valves ablation, _%#DDMM2008#%_. 10. PD catheter removal, _%#DDMM2008#%_. 11. Second PD catheter placement and PICC replacement, _%#DDMM2008#%_. 12. PICC replacement, _%#DDMM2008#%_. 13. Port-A-Cath placement _%#DDMM2008#%_. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 10-month-old male, previously an ex-preemie born at 33 plus 6 week gestation, with renal failure secondary to obstructive uropathy in utero from posterior urethra valves.
PD|peritoneal dialysis|PD|256|257|PROCEDURES|7. NJ tube placement in _%#DDMM2007#%_. 8. Right inguinal hernia repair, bilateral orchiopexy, circumcision, _%#DDMM2008#%_. 9. Vesicostomy closure and posterior urethral valves ablation, _%#DDMM2008#%_. 10. PD catheter removal, _%#DDMM2008#%_. 11. Second PD catheter placement and PICC replacement, _%#DDMM2008#%_. 12. PICC replacement, _%#DDMM2008#%_. 13. Port-A-Cath placement _%#DDMM2008#%_. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 10-month-old male, previously an ex-preemie born at 33 plus 6 week gestation, with renal failure secondary to obstructive uropathy in utero from posterior urethra valves.
PD|peritoneal dialysis|PD|190|191|INFECTIOUS DISEASE|a. Pseudomonas tracheitis: Piperacillin - ceftazidime _%#DDMM2008#%_ to _%#DDMM2008#%_. b. CONS peritonitis: Vancomycin, _%#DDMM2008#%_ to _%#DDMM2008#%_. c. CONS bacteremia: Vancomycin and PD fluid, _%#MM2008#%_. d. Enterobacter cloacae peritonitis: Ceftazidime and tobramycin and PD fluid, and IV meropenem, in _%#DDMM2008#%_. e. Peritoneal dialysis fluid Gram stain showed TPC in pairs and chains, blood culture negative, treated with 3 days of meropenem.
PD|peritoneal dialysis|PD|196|197|INFECTIOUS DISEASE|b. CONS peritonitis: Vancomycin, _%#DDMM2008#%_ to _%#DDMM2008#%_. c. CONS bacteremia: Vancomycin and PD fluid, _%#DDMM2008#%_. d. Enterobacter cloacae peritonitis: Ceftazidime and tobramycin and PD fluid, and IV meropenem, in _%#DDMM2008#%_. e. Peritoneal dialysis fluid Gram stain showed TPC in pairs and chains, blood culture negative, treated with 3 days of meropenem.
PD|peritoneal dialysis|PD.|195|197|INFECTIOUS DISEASE|i. VRE peritonitis in _%#DDMM2008#%_, treated with 3 weeks of IV linezolid and one week of intraperitoneal linezolid. j. CONS peritonitis: _%#DDMM2008#%_, completed three weeks of vancomycin and PD. k. Clostridium difficile colitis in _%#DDMM2008#%_, completed 14-day course of metronidazole. l. For 3 months prior to discharge, all gram stains and cultures of peritoneal fluid had remained negative.
PD|peritoneal dialysis|PD|213|214|UROLOGY|His vesicostomy was closed and his posterior urethral valves were ablated in _%#DDMM2008#%_. His Foley was removed in _%#DDMM2008#%_. In _%#MM#%_, _%#NAME#%_ started having scrotal edema, particularly with larger PD volumes. A testicular ultrasound that month showed a right inguinal tubular fluid collection that communicated with the peritoneal cavity.
PD|peritoneal dialysis|PD|283|284|PAST MEDICAL HISTORY|4. NAC, status post ileal resection on _%#MM#%_ _%#DD#%_, 2003, status post ileostomy takedown on _%#MM#%_ _%#DD#%_, 2003, status post bowel resection and reanastomosis on _%#MM#%_ _%#DD#%_, 2003. 5. History of Candida peritonitis on _%#MM#%_ _%#DD#%_, 2003. 6. Status post numerous PD catheter placements with the most recent being on _%#MM#%_ _%#DD#%_, 2004, and an adjustment of the catheter on _%#MM#%_ _%#DD#%_, 2004. 6. History of an ASD with a PFO. 7. Anemia secondary to renal failure.
PD|peritoneal dialysis|PD|324|325|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 22-month-old male on peritoneal dialysis since 3 days of age for stage VI chronic kidney disease secondary to obstructive uropathy due to penile and bladder agenesis. He has been doing well on home peritoneal dialysis until the evening of _%#MMDD#%_ when his dad noticed that his PD catheter was leaking. It appeared that the catheter had been worn down where the adopter enters the catheter and that his dialysis fluid was leaking out into his bed.
PD|peritoneal dialysis|PD|318|319|ADMISSION PHYSICAL EXAMINATION|CARDIOVASCULAR: He has a regular rate and rhythm, 2+ peripheral pulses in bilateral lower extremities, 2 to 3/6 systolic crescendo murmur heard throughout the precordium, which has been worked out as an outpatient per mom. ABDOMEN: His belly is soft and nondistended, no hepatosplenomegaly, positive bowel sounds, his PD catheter is broken, at this point where the adopter enters the catheter. GENITOURINARY: The patient has not penis, his testes are descended bilaterally.
PD|peritoneal dialysis|PD|174|175|ADMISSION LABORATORY DATA|ADMISSION LABORATORY DATA: His peritoneal fluid gram-stain showed no organisms and a few white blood cells. There were 7 red blood cells and only a 11 nucleated cells in the PD fluid at the time of admit. He had a BMP done, which showed a sodium of 146, potassium 3.6, chloride 92, bicarbonate 37, BUN 79, creatinine 6.23, glucose 101 and calcium 9.7.
PD|peritoneal dialysis|PD|236|237|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a now 26-month-old male who was admitted to the hospital initially with a bloody emesis and subsequently found to have hepatorenal dysplasia of unknown etiology. His end-stage renal disease was PD dependent and was transferred to HD and also has chronic lung disease and is ventilator dependent with the tracheostomy.
PD|peritoneal dialysis|PD.|132|134|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #: End stage renal disease secondary to hepatorenal dysplasia. At the time of admission, _%#NAME#%_ was on PD. Over the course of his admission, he has had repeated episodes of peritonitis. Initially, his episodes were relatively asymptomatic, but in _%#DDMM2008#%_ he had more systemic symptoms and was requiring inotropic support with more difficulty clearing his peritoneal infections.
PD|peritoneal dialysis|PD.|247|249|PROBLEM #2|He has had a marked amount of ascites, but since transitioned to hemodialysis, this has been improved. Gastroenterology feels that this ascites is probably multifactorial due to portal hypertension, cirrhosis, recurrent peritonitis and history of PD. _%#NAME#%_ did get 1 paracentesis at the end of _%#MM#%_ which was done for diagnostic purposes and proved that he had cleared his peritonitis after that.
PD|peritoneal dialysis|PD|165|166|GI|He was on peritoneal dialysis with 200 mL passes every 55 minutes with 11 cycles. He was on overnight peritoneal dialysis with 1.5% dextrose and standard commercial PD solution. _%#NAME#%_ had no significant changes with his peritoneal dialysis, and he tolerated well during his hospital stay. He was continued on his Bactrim for UTI prophylaxis. His blood pressure was slightly elevated following this urological procedure, and we had to increase his antihypertensives.
PD|peritoneal dialysis|PD|159|160|ID|ID: _%#NAME#%_ did spike an occasional fever during his hospital stay, and he was evaluated for sepsis; however, all of his blood cultures, urine culture, and PD culture remained negative. _%#NAME#%_ remained afebrile for at least a week prior to his discharge from the hospital. He was briefly started on antibiotics, but those were discontinued as his cultures all remained negative.
PD|peritoneal dialysis|PD|196|197|HISTORY OF PRESENT ILLNESS|He has been followed as an outpatient by Dr. _%#NAME#%_ in pediatric pulmonary clinic, as well as by Dr. _%#NAME#%_ in pediatric cardiology. His nephrologist is Dr. _%#NAME#%_ and his stable home PD regimen has been 10 hours total with a total volume of 4200 mL and fill volume of 400 mL, 10 cycles of 1 hour each and the last fill of 200 mL, these are done with dextrose of 1.5%, and he typically appears to use an ultrafiltrate of 200 mL a day plus some urine according to his mother.
PD|peritoneal dialysis|PD|284|285|PAST MEDICAL HISTORY|He is currently being worked up for renal transplant. PAST MEDICAL HISTORY: _%#NAME#%_ was born at 35 weeks with known multicystic dysplastic kidneys identified on a 28-week ultrasound that also showed oligohydramnios. He had bilateral pyelostomies placed on _%#MM#%_ _%#DD#%_, 2004. PD catheter was placed with omentectomy on _%#MM#%_ _%#DD#%_, 2004. On _%#MM#%_ _%#DD#%_, 2005, he had a transurethral incision of a posterior urethral valves with aspiration pneumonitis in _%#MM#%_ 2005 as well.
PD|peritoneal dialysis|PD|277|278|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a delightful 52-year-old woman with end-stage kidney disease secondary to diabetes type 2 who now comes for a living donor kidney transplant. She was initially on hemodialysis in _%#DDMM2006#%_ and was then switched over to PD following catheter readiness. The patient was seen by pulmonary again in _%#MM#%_ and again in _%#MM#%_ for abnormal PFTs. This was thought to be from unrecognized asthma and possibly acute viral symptoms.
PD|peritoneal dialysis|PD|124|125|HISTORY OF PRESENT ILLNESS|Her blood glucose had been elevated in the week prior to transplant most of them greater than 200. She had no change in her PD fluids and she feels like she in her baseline state of health. She denies any urinary URI, abdominal or GI complaints at this time.
PD|peritoneal dialysis|PD.|195|197|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. End-stage renal disease likely secondary to diabetic nephropathy, although she never had a biopsy. She was started on hemodialysis in _%#DDMM2006#%_. This was changed to PD. 2. Diabetes mellitus type 2 diagnosed in 1983 on insulin since 1987. She has mild neuropathy and denies retinopathy. 3. Hypertension.
PD|peritoneal dialysis|PD|173|174|HISTORY OF PRESENT ILLNESS|_%#NAME#%_ was discharged to the Ronald McDonald House on _%#MM#%_ _%#DD#%_, 2005, to allow for a two-week break off peritoneal dialysis. This was in an effort to allow his PD catheter site to heal. He was readmitted to the University of Minnesota Medical Center to restart peritoneal dialysis at low volumes.
PD|peritoneal dialysis|PD|205|206|HISTORY OF PRESENT ILLNESS|His HEENT exam was unremarkable. Lungs were clear bilaterally. Cardiovascular exam showed a regular rate and rhythm without any murmurs. His abdominal exam showed a clean dressing and bandage covering his PD catheter site. The remainder of his abdomen was soft and nondistended with good bowel sounds. GU exam was unremarkable. Neurological exam was grossly intact. ADMISSION LABORATORIES: The patient's metabolic panel on admission showed a sodium of 132, potassium 4.3, chloride 90, bicarbonate 28, BUN 46, creatinine 7.79, and glucose of 71.
PD|peritoneal dialysis|PD|310|311|HISTORY OF PRESENT ILLNESS|Postnatal renal ultrasound showed bilateral hydronephrosis. Peritoneal dialysis was started on _%#MM#%_ _%#DD#%_, 2004, secondary to renal failure and decreased urine output. He does have a history of hypertension, and a renal ultrasound on _%#MM#%_ _%#DD#%_, 2004, was inconclusive for venous thrombosis. His PD catheter began to malfunction on _%#MM#%_ _%#DD#%_, 2004, and his dialysis was subsequently held. He tolerated this well with good urine output and stable electrolytes.
PD|peritoneal dialysis|PD|140|141|HOSPITAL COURSE|Peritoneal dialysis was initially started on _%#MM#%_ _%#DD#%_, 2004, because of worsening renal function and decreased urinary output. The PD was stopped on _%#MM#%_ _%#DD#%_, 2004, because of malfunctioning of the catheter thought likely to be secondary to blockage from omentum.
PD|peritoneal dialysis|PD|186|187|HOSPITAL COURSE|The PD was stopped on _%#MM#%_ _%#DD#%_, 2004, because of malfunctioning of the catheter thought likely to be secondary to blockage from omentum. He tolerated the discontinuation of his PD well and was subsequently transferred to Fairview University to have the PD catheter removed. His surgery was postponed twice, once due to scheduling confusion and the second time because of fever.
PD|peritoneal dialysis|PD|235|236|1. FEN|He was on Bumex for several subsequent weeks. His creatinine gradually increased throughout his hospitalization to a max of 6, at which time he was scheduled for peritoneal dialysis catheter placement on _%#DDMM2003#%_. Since being on PD Levi has had urine output that is correlated with his serum creatinine, varying from 1.1 cc/kg/d to 0.02 cc/kg/d. His fill volumes have been increased gradually to 100 cc Q1hour for 24 hours per day.
PD|peritoneal dialysis|PD|202|203|1. FEN|Blood cultures remained negative, so ampicillin was stopped. He remains on oral amoxicillin (25 mg/kg/d) for UTI prophylaxis. His IgG level was low on _%#DDMM2004#%_ and he received IVIG 400 mg/kg. His PD effluent has had neither growth nor significant WBCs to date. On _%#DDMM2004#%_ he was noted to have a low-grade elevated temperature and a very red, tender, and exudative supraumbilical area of cellulitis spreading towards his PD cath tunnel; he was immediately started on oral Keflex and the area improved over the next 24 hours.
PD|peritoneal dialysis|PD|244|245|5. ID|11. Sucrose 0.5 cc PRN 12. EMLA cream PRN Discharge measurements: Weight 3590 gms; length 46 cm; OFC 34 cm. Physical exam was normal except for baseline soft, distended belly with lack of abdominal wall musculature; non-palpable testes; intact PD catheter site; bilateral intact pyelostomies on the back; bilaterally dislocated hips; and a slightly erythematous peri-umbilical area with scant cloudy-yellow drainage from a patent urachus.
PD|peritoneal dialysis|PD|201|202|HOSPITAL COURSE|Her sodiums also climbed during her hospitalization due to the fact of her need for bicarb. Her potassium slowly became elevated by the day of her death as well as her phosphorus. As mentioned before, PD was started the day before her death. 2. Cardiovascular. The patient initially was hypotensive on transfer from Methodist to Fairview-University Medical Center.
PD|peritoneal dialysis|PD|171|172|HOSPITAL COURSE|She had elevated CKs. Her creatinine went from 1 to 2.7; BUNs went high as well. She had decreased urine output on _%#MMDD#%_ as well as on _%#MMDD#%_. She was started on PD dialysis on the night of _%#MMDD#%_ and tolerated that very well reportedly. 6. Infectious disease. The patient was started on antibiotics at the outside hospital; however, those were discontinued upon her transfer for no evidence of infection at that time or aspiration, which is why she was started at the outside hospital.
PD|peritoneal dialysis|PD|198|199|PHYSICAL EXAMINATION ON ADMISSION|HEENT: Unremarkable. CARDIOVASCULAR: Normal, with regular rate and rhythm and no murmurs. RESPIRATORY: Lungs clear to auscultation bilaterally without wheezes or crackles. ABDOMEN: Flaccid abdomen; PD catheter in place. Positive bowel sounds without distention, tenderness, or masses. Healing surgical incision from recent laparoscopy. BACK: Notable for bilateral pyelonephrostomies.
PD|peritoneal dialysis|PD|326|327|PHYSICAL EXAMINATION ON ADMISSION|Healing surgical incision from recent laparoscopy. BACK: Notable for bilateral pyelonephrostomies. MUSCULOSKELETAL: On initial exam by the pediatric renal team, the patient was already in a modified spica cast, with openings in the back for his pyelostomies, and in the perianal area and abdominal area to allow access to his PD catheter. HOSPITAL COURSE: PROBLEM #1: Fluid, electrolytes, nutrition. _%#NAME#%_ has always been a poor feeder, and gets by with a combination of bottle and gavage feeds, as well as drip feeds overnight for a total of 600 mL per day of Similac fortified with Beneprotein, and treated with Kayexalate to remove potassium.
PD|peritoneal dialysis|PD|233|234|DISCHARGE DIAGNOSES|3. Peritoneal dialysis catheter malfunctioning. 4. Drainage from urachus and pyelostomy site. DISCHARGE DIAGNOSES: 1. Prune-belly syndrome. 2. End-stage renal disease secondary to bilateral renal dysplasia from obstructive uropathy, PD dependent. 3. Malfunctioning peritoneal dialysis catheter, status post laparoscopic repositioning. 4. Urachus infection. 5. Coagulase negative Staphylococcus peritonitis. PROCEDURES: The patient underwent a laparoscopic revision of his peritoneal dialysis catheter on _%#MM#%_ _%#DD#%_, 2004.
PD|peritoneal dialysis|PD|183|184|PAST MEDICAL HISTORY|3. Prune-belly syndrome. The patient has bilateral cryptorchidism, confirmed by testicular ultrasound. The patient has renal dysplasia and is PD dependent. His baseline creatinine on PD is 1.5 to 2.5. He is scheduled for a renal transplant with mom as a donor, likely in _%#MM#% of 2004. 4. Anemia, secondary to end-stage renal disease. 5. Patent urachus.
PD|peritoneal dialysis|PD|204|205|PAST MEDICAL HISTORY|4. Anemia, secondary to end-stage renal disease. 5. Patent urachus. Patient also had bilateral nephrostomies created on _%#DDMM2003#%_. 6. History of pulmonary hypoplasia secondary to oligohydramnios. 7. PD catheter placement on _%#DDMM2003#%_. 8. Developmental dysplasia of the hips, left greater than right. Dr. _%#NAME#%_ follows the patient for this. He is scheduled for surgery on _%#DDMM2004#%_.
PD|peritoneal dialysis|PD|201|202|PROBLEM #2|Coagulase negative Staph grew out from the peritoneal fluid on _%#MM#%_ _%#DD#%_, and he was subsequently started on antibiotics in his PD fluid. Peritonitis was thought to be contributing to the poor PD draining. Once the antibiotics were started, however, he continued to have poor draining from his catheter. After further evaluation of the catheter, it appeared that there was a mechanical obstruction.
PD|peritoneal dialysis|PD|190|191|PROBLEM #2|On _%#MM#%_ _%#DD#%_, 2004, he was taken to the operation room and underwent laparoscopic repositioning of his peritoneal dialysis catheter. After the surgery, he had good draining from his PD catheter. However, on postoperative day #3 he again had poor draining from his catheter. He did subsequently pass one small blood clot from the catheter and after that had good drainage.
PD|peritoneal dialysis|PD|137|138|PROBLEM #2|The heater bags are 2.5% dextrose and the side bags are 1.5% dextrose. Mom was instructed to adjust the dextrose in conjunction with the PD nurse if needed. PROBLEM #3: Gastrointestinal. An initial abdominal x-ray revealed the dilated stomach and moderate amount of stool in the colon.
PD|peritoneal dialysis|PD|163|164|PROBLEM #6|Uncertain whether the Coag negative Staph was a contaminant. However, it was felt that the patient should be treated with antibiotics since his cell count and his PD fluid was elevated. The patient was treated with a 10-day course of Vancomycin and Tobramycin in his peritoneal dialysis fluid.
PD|peritoneal dialysis|PD|123|124|FOLLOW-UP INSTRUCTIONS|At night he can have drip feeds if daytime intake is less than 600 mL. 5. Peritoneal dialysis, over night for 12 hours per PD orders. Mom was instructed to page _%#NAME#%_ _%#NAME#%_ tonight to reprogram his PD machine. 6. The patient should be seen for any increased pain and any temperature greater than 100.5 or any other problems with his peritoneal dialysis catheter.
PD|peritoneal dialysis|PD|151|152|PHYSICAL EXAMINATION ON ADMISSION|There were no murmurs and his peripheral capillary refill was less than 2 seconds. ABDOMEN: Mildly distended, soft, with normal bowel sounds. He had a PD catheter and G-tube in place, both without any noted erythema. GENITALIA: Tanner 1 male. EXTREMITIES: He had no noted pitting edema on his extremities.
PD|peritoneal dialysis|PD|269|270|HOSPITAL COURSE BY SYSTEM|SKIN: Clear of any significant rashes or jaundice. LABORATORY ON ADMISSION: BUN 79 and creatinine 2.33. Hemoglobin was 8.7 and platelets were 29,000. HOSPITAL COURSE BY SYSTEM: 1. RENAL: _%#NAME#%_ was maintained on peritoneal dialysis. He was transitioned from manual PD over to the automatic cycler shortly after admission. Some adjustments were made in his peritoneal dialysis schedule and dextrose regimen based on labs and weight.
PD|peritoneal dialysis|PD|306|307|2.  FLUID, ELECTROLYTES AND NUTRITION|Cultures returned negative with the exception of the peritoneal fluid culture from _%#DDMM2006#%_ which grew coag negative staph in the broth only on day 5, thought to be a contaminant. Given that cultures were negative, antibiotics were discontinued. On _%#DDMM2006#%_, he again had a fever and blood and PD cultures were again sent but no antibiotics were started at that time. He has remained afebrile since that time and is on no current antimicrobials.
PD|peritoneal dialysis|PD|165|166|PHYSICAL EXAMINATION  VITAL SIGNS|NECK: Double lumen IJ in place. CARDIOVASCULAR: Regular rate and rhythm. S1 and S2 present. No murmurs. LUNGS: Clear bilaterally. ABDOMEN: Bowel sounds are present. PD catheter is in place. No obvious distention. There is a small ulceration just superior to the umbilicus with mild erythema.
PD|peritoneal dialysis|PD|167|168|HOSPITAL COURSE|He was transferred here with peritoneal dialysis catheters in place. However, his BUN and creatinine were normal and stable here. He did not require any dialysis. His PD catheters were removed by pediatric surgery on _%#MM#%_ _%#DD#%_, 2006, without complication. 5. Infectious disease. _%#NAME#%_ did have a rule out sepsis workup performed at the outside hospital which was essentially negative except for an abnormal urinalysis, but no urine culture was obtained prior to antibiotics, and a urine culture done on antibiotics which was negative.
PD|peritoneal dialysis|PD|381|382|PROBLEM #3|PROBLEM #3: Pretransplant workup. The transplant coordinator, _%#NAME#%_ _%#NAME#%_, was informed of the patient's admission and noted that the patient had undergone most of the necessary tests while as an outpatient and therefore did not need to have any further workup done as an inpatient, and she would be following up with him later over the telephone. The patient did have a PD placed here while in the hospital, which was read and was negative. PROBLEM #4: Obstructive sleep apnea. The patient appeared not to be having a restful night of sleep and therefore underwent an overnight oximetry test.
PD|(drug) PD|PD,|186|188|CURRENT MEDICATIONS|He denies any chest pain and denies feeling that he has any more leg swelling or increased bloating beyond his usual. ALLERGIES: Sulfa, nuts, and dust. CURRENT MEDICATIONS: 1. Bromfenex PD, 2 tablets p.o. 2 to 3 times per day. 2. Lasix 40 mg p.o. twice a day. 3. Glipizide 10 mg p.o. twice a day.
PD|peritoneal dialysis|PD|144|145|HOSPITAL COURSE|Dr. _%#NAME#%_ and renal consult team recommended PD scan for peritoneal dialysis; however, the patient will be discharged home and will have a PD catheter later as outpatient. Nephrotic protein resulting in severe orthostatic hypotension and hypercoagulable state because of losing entico relation factors.
PD|UNSURED SENSE|PD|409|410|DISCHARGE DIAGNOSES|OPERATIONS/PROCEDURES PERFORMED: Major procedures: 1. _%#MM#%_ _%#DD#%_, 2006, chest x-ray.2. _%#MM#%_ _%#DD#%_, 2006, right heart catheterization.3. Findings, mild to moderate pulmonary hypertension, normal left filling pressures, severely decreased cardiac function. RA is 12/5 with a mean of 8, RV 48/10 with a mean of 12, PA pressures 45/22 with a mean of 24, wedge pressure of 16, PA saturation of 52.7, PD thermal dilution cardiac output 3.02 with a cardiac index of 1.65. A Fick cardiac output 3.56, cardiac index 1.95. This is calculated on a body surface area of 1.9 sq m and a height of 178 cm.
PD|peritoneal dialysis|PD|157|158|HOSPITAL COURSE BY SYSTEM|She is on stable peritoneal dialysis at this time. She was initially on a 14-hour on, 10 hours off regimen which was slowly transitioned to a 13-1/4 hour on PD schedule for future correlation with home or school attendance. Her electrolytes were monitored roughly once in a week and were stable throughout her hospitalization.
PD|peritoneal dialysis|PD|224|225|HOSPITAL COURSE BY SYSTEM|4. Infectious disease: The patient has had a history of multiple systemic infections, but during this admission, she was stable without any episodes of sepsis or instability. She did grow Pseudomonas from her culture of her PD site skin which is being treated with topical gentamycin at the time of her discharge. Peritoneal dialysate were consistently negative. During the flu season, she had multiple influenza rapid and antigens and along with RSV culture and antigens which were all consistently negative.
PD|peritoneal dialysis|PD|180|181|HOSPITAL COURSE BY SYSTEM|12. Social: There was a question that the patient may be suffering from medical neglect given the poor state of health in the home. The family was unable to comply with any of the PD cares given that this was essential for the patient's livelihood. The patient required in-home nursing care. The family was unable to work with the nursing in the home, and the patient has been asked to be placed in a medical foster home.
PD|peritoneal dialysis|PD|188|189|PRIOR HOSPITALIZATIONS, SURGERIES AND MEDICAL PROBLEMS|6. Depression and anxiety with history of a suicide attempt. 7. Migraine headaches. 8. GERD. 9. PTSD status post sexual assault in _%#MM#%_ 2004. 10. Subcutaneous abdominal abscess at her PD cath site. The infecting organism was MRSA. Infection acquired on _%#DDMM2005#%_. 11. History of hypertensive retinopathy/papilledema.
PD|peritoneal dialysis|PD|260|261|OROPHARYNX|LUNGS: Clear to auscultation bilaterally. No wheezes or crackles. CARDIOVASCULAR: The patient had a 2/6 systolic blowing murmur at the left sternal border. ABDOMEN: Stria were present. Abdomen was soft. There was scar at the right middle quadrant secondary to PD catheter placement. Bowel sounds were present. There was no hepatosplenomegaly. The patient's left flank was tender to palpation. EXTREMITIES: There was no lymphedema. The patient had no pretibial edema bilaterally.
PD|peritoneal dialysis|PD.|387|389|PROBLEM #4|This was investigated on his current admission as well and, given the presence of a granulomatous lesion that was assessed, however, not clearly characterized as being consistent with any particular etiology, the patient did undergo subsequent testing for a bronchial alveolar lavage in order to rule out tuberculosis, as well. The patient reportedly did have a robust response to P and PD. However, it was deemed to be unreliable, as the patient presented in the wake of one of his confused spells, with some suggestion of possible alteration of his wound, which may have occurred unbeknownst to the patient during one of his episodes.
PD|peritoneal dialysis|PD|181|182|HOSPITAL COURSE|However, due to worsening uremia, he was transferred back to the PICU for reinitiation of peritoneal dialysis. Peritoneal dialysis was slowly transitioned from manual continuous to PD auto-cycler when he was tolerating the auto-cycler and then was transferred back to the general floor and was followed by the Renal Service.
PD|peritoneal dialysis|PD|194|195|HOSPITAL COURSE BY SYSTEMS|This skin has healed and his G-tube feeds were essentially increased enabling him to stop his TPN. He also had a history of low phosphorus. He had had multiple relative supplementation into his PD as well as by mouth; however, it was noted when he does get phosphorus by mouth, it increases his diarrhea, which leads to his perianal breakdown.
PD|peritoneal dialysis|PD|169|170|PROBLEM #3|His last bag fill volume is 200 and uses the same dextrose for the final fill. His total number of cycles including the final fill is 16+1. He is on standard commercial PD solution of 1 bag of the 3 liter bag of 1.5% dextrose and 1 bag of the 3 liter bag of 2.5% dextrose. His heater bag is 3 liters of dialysate; container size 3 liters, 1.5% dextrose and 3.5 mEq per liter of calcium.
PD|peritoneal dialysis|PD|224|225|HOSPITAL COURSE|His fill volumes were systematically increased over the last few months and his current fill volume is 290 mL per cycle. He currently runs at 12 hours 45 minutes per day on 45-minute cycles, a 2:1 ratio of 2.5-1.5% dextrose PD solution. During the course of his hospital stay, _%#NAME#%_ has been primarily using the APD cycler, but was briefly on manual PD from _%#MMDD#%_ and _%#MMDD#%_.
PD|peritoneal dialysis|PD|234|235|HOSPITAL COURSE|He currently runs at 12 hours 45 minutes per day on 45-minute cycles, a 2:1 ratio of 2.5-1.5% dextrose PD solution. During the course of his hospital stay, _%#NAME#%_ has been primarily using the APD cycler, but was briefly on manual PD from _%#MMDD#%_ and _%#MMDD#%_. He will be discharged on a home cycling machine. His estimated current dry weight is approximately 9 kg.
PD|peritoneal dialysis|PD|128|129|HOSPITAL COURSE|On _%#MMDD#%_, his peritoneal fluid grew out Klebseilla pneumoniae, which was treated with a 14-day course of gentamicin in his PD fluid. PD fluid on _%#MMDD#%_ grew out coag-negative Staphylococcus without signs of peritonitis. In addition, he was C. difficile toxin positive on the _%#MMDD#%_ and finished a 14-day course of Flagyl.
PD|peritoneal dialysis|PD|271|272|HOSPITAL COURSE|The workup at this point included echocardiogram, CT of the abdomen, ultrasound of the kidneys and the abdomen, chest x-ray, abdominal x-ray and peritoneal dialysis cultures, which were all negative. On _%#MMDD#%_, _%#NAME#%_ again grew out Enterobacter cloacae from his PD fluid in a broth culture only. Sensitivities on these bacteria showed it to be sensitive to only imipenem. _%#NAME#%_ received a 7-day course of imipenem in his PD fluid followed by a 7-day of course of IV imipenem.
PD|peritoneal dialysis|PD|130|131|HOSPITAL COURSE|Sensitivities on these bacteria showed it to be sensitive to only imipenem. _%#NAME#%_ received a 7-day course of imipenem in his PD fluid followed by a 7-day of course of IV imipenem. No subsequent cultures showed these bacteria. Three days prior to discharge, _%#NAME#%_ developed a fever of 101.
PD|peritoneal dialysis|PD|188|189|SPECIAL INSTRUCTIONS|SPECIAL INSTRUCTIONS: _%#NAME#%_ will be receiving peritoneal dialysis through a homecare service. Changes in peritoneal dialysis composition will be handled by _%#NAME#%_ _%#NAME#%_, the PD nurse for the renal service. _%#NAME#%_ will also be receiving laboratory draws twice a week with 2 renal batteries per week and 1 CBC per week.
PD|peritoneal dialysis|PD|181|182|HISTORY OF PRESENT ILLNESS|Increase in creatinine and BUN with poor urine output despite the Bumex drip. Continued oxygen need and electrolyte abnormalities. He was transferred to the pediatric ICU following PD catheter placement on _%#MM#%_ _%#DD#%_, 2006, for initiation PD. He was transferred back to 5A on _%#MM#%_ _%#DD#%_, 2006. PAST MEDICAL HISTORY: He was diagnosed with atypical HUS at 6 months of age.
PD|peritoneal dialysis|PD|145|146|PAST MEDICAL HISTORY|He was transferred back to 5A on _%#MM#%_ _%#DD#%_, 2006. PAST MEDICAL HISTORY: He was diagnosed with atypical HUS at 6 months of age. He was on PD for several days initially and has had no PD since. The cause of his hemolytic uremic syndrome is factor H deficiency.
PD|peritoneal dialysis|PD|132|133|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: He was diagnosed with atypical HUS at 6 months of age. He was on PD for several days initially and has had no PD since. The cause of his hemolytic uremic syndrome is factor H deficiency. Plasmapheresis was initially tried but was unsuccessful. His disease has subsequently been controlled with FFP infusions to replace factor H.
PD|peritoneal dialysis|PD|159|160|HOSPITAL COURSE|Catheters for peritoneal dialysis was placed on _%#MM#%_ _%#DD#%_, 2006. He was initially on 24-hour PD with good response. He was slowly titrated down on his PD and was discontinued on _%#MM#%_ _%#DD#%_, 2006. After discontinuing his PD, he continued to have good urine output, and at discharge was not having any issues with decreased urine output.
PD|peritoneal dialysis|PD,|162|164|HOSPITAL COURSE|He was initially on 24-hour PD with good response. He was slowly titrated down on his PD and was discontinued on _%#MM#%_ _%#DD#%_, 2006. After discontinuing his PD, he continued to have good urine output, and at discharge was not having any issues with decreased urine output. His nutrition status was initially poor, and he required NG feedings of Nepro from _%#MM#%_ _%#DD#%_, 2006, to _%#MM#%_ _%#DD#%_, 2006.
PD|peritoneal dialysis|PD|158|159|HISTORY OF PRESENT ILLNESS|He also had his PD catheter revised on the same day. He stayed in the pediatric ICU while his fill volume was slowly advanced to a point that could be on the PD cycle. Fill volume at the time of discharge was 140 mL with 45-minute passes 16 passes a day for a total of 12 hours a day.
PD|peritoneal dialysis|PD|150|151|HISTORY OF PRESENT ILLNESS|Fill volume at the time of discharge was 140 mL with 45-minute passes 16 passes a day for a total of 12 hours a day. He is using 2.5% Dextrose for is PD at this time. He did have 1 episode of peritonitis while on dialysis positive for staphyloncus species in the NICU and he was treated appropriately.
PD|peritoneal dialysis|PD|181|182|HISTORY OF PRESENT ILLNESS|Heart: Regular rate and rhythm with a soft 2 over 6 systolic ejection. Lungs were clear to auscultation bilaterally. Abdomen was soft and nondistended with normal bowel sounds. The PD catheter site was clean and intact and dry. Extremities: He was moving all 4 extremities. There was no edema. Capillary refill was less than 3 seconds. Skin was warm and well perfused with no rash.
PD|peritoneal dialysis|PD|189|190|DISCHARGE INSTRUCTIONS|2. Peritoneal dialysis instructions: Peritoneal dialysis at 114 mL volume with 16 passes at 45 minutes each for 12 hours a day. He is using 2.5% Dextrose plus a heater bag. Dextrose in his PD bag may be changed in consultation with the PD nurse. He is to be weighted twice daily while on PD and vital signs are to be obtained twice daily also.
PD|peritoneal dialysis|PD|160|161|DISCHARGE INSTRUCTIONS|He is using 2.5% Dextrose plus a heater bag. Dextrose in his PD bag may be changed in consultation with the PD nurse. He is to be weighted twice daily while on PD and vital signs are to be obtained twice daily also. He is to call his primary doctor if his systolic blood pressure is less than 75 or greater than 120 or if his temperature is above 100.5 degree Fahrenheit.
PD|peritoneal dialysis|PD|168|169|DISCHARGE INSTRUCTIONS|At that time, he is to get electrolytes including magnesium, phosphorus, and ionized calcium and to have it faxed to the renal clinic at _%#TEL#%_ _%#TEL#%_ and to the PD nurse _%#NAME#%_ _%#NAME#%_ at _%#TEL#%_. He is to follow up with Dr. _%#NAME#%_ _%#NAME#%_ in pediatric nephrology clinic in 1 month and he is also to follow up with urology when he is 6 to 7 months old for arrangements for reconstructive surgery.
PD|peritoneal dialysis|PD|275|276|BRIEF HISTORY OF PRESENT ILLNESS AT THE TIME OF ADMISSION|He also notes that he has developed additional peripheral edema and is generally not feeling well. He does do his own peritoneal dialysis roughly 3 times per week with 5 exchanges, but recently took a 3-day trip to see his family in the southern United States and forgot his PD solutions and machine. PHYSICAL EXAMINATION: Exam at the time of admission was significant for a temperature of 101.9, pulse of 110, blood pressure 174/111, respiratory rate of 40, and oxygen saturation 96% on room air.
PD|peritoneal dialysis|PD|259|260|PROBLEM #3|While abdominal pain and fever were his primary presenting complaints, Mr. _%#NAME#%_ did not meet criteria for secondary peritonitis at the time of admission nor at any other time throughout his hospitalization. While we did start him on antibiotics and his PD fluid, we discontinued these on the second or third hospital day secondary to lack of criteria for secondary bacterial peritonitis.
PD|peritoneal dialysis|PD|185|186|DISCHARGE DIAGNOSES|2. Orthostatic hypotension secondary to albumin-wasting nephropathy. 3. Intractable nausea and vomiting. 4. Gastric erosion secondary to NSAID use. 5. Peritonitis secondary to infected PD catheter. PROCEDURES: 1. EGD. Showing gastric erosion consistent with NSAID use.
PD|peritoneal dialysis|PD|151|152|PHYSICAL EXAMINATION ON ADMISSION|She had a 2/6 mid-systolic murmur best heard at the left lower sternal border. Abdomen: Soft, non-tender, non-distended, with normal bowel sounds. The PD catheter site looked clean, dry and intact. Musculoskeletal: Normal tone and good muscle strength. Skin: No cyanosis, no pallor. She did have trace edema of the lower extremities. Neurologic: Cranial nerves II through XII are intact.
PD|peritoneal dialysis|PD|416|417|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 1-year-old male with a history of prune belly syndrome and chronic renal failure/end-stage renal disease status post multiple urologic surgeries on _%#MM#%_ _%#DD#%_, 2004, who was recently discharged from Fairview-University Children's Center on _%#MM#%_ _%#DD#%_, 2004. He returns on the day of admission with concerns by his mother regarding diarrhea, "cruddy" looking PD fluid, and a cracked Foley catheter. _%#NAME#%_'s last hospital course was complicated by leaky PD fluid, a small anastomosis between the urology tract and peritoneum, and also significant hypoxic and bradycardic spells.
PD|peritoneal dialysis|PD|199|200|HISTORY OF PRESENT ILLNESS|He returns on the day of admission with concerns by his mother regarding diarrhea, "cruddy" looking PD fluid, and a cracked Foley catheter. _%#NAME#%_'s last hospital course was complicated by leaky PD fluid, a small anastomosis between the urology tract and peritoneum, and also significant hypoxic and bradycardic spells. Most recently, since _%#NAME#%_'s discharge, _%#NAME#%_ had diarrhea 2 days prior to admission.
PD|peritoneal dialysis|PD|174|175|SOCIAL HISTORY|2. Renal: _%#NAME#%_ was continued on his peritoneal dialysis regimen. He was admitted due to concerns of possible peritonitis because there were fibrin strands found in his PD fluid. Heparin was added to his PD regimen while he was hospitalized. Creatinine remained stable. 3. Genitourinary: _%#NAME#%_ was also seen by urology regarding his broken Foley.
PD|peritoneal dialysis|PD|181|182|HISTORY OF PRESENT ILLNESS|He was in his usual state of health until 2 days prior to admission when he had a temperature of 100.7, but otherwise appeared healthy without any diarrhea, cough, fever or rashes. PD cell count at that time had an increase of PMN count and subsequently was positive for coagulase-negative Staph.
PD|peritoneal dialysis|PD|308|309|HISTORY OF PRESENT ILLNESS|He was in his usual state of health until 2 days prior to admission when he had a temperature of 100.7, but otherwise appeared healthy without any diarrhea, cough, fever or rashes. PD cell count at that time had an increase of PMN count and subsequently was positive for coagulase-negative Staph. A followup PD cell count from today, _%#DDMM2006#%_, had 800 WBC, positive for coagulase-negative Staph, and needing admission for antibiotic therapy and monitoring.
PD|peritoneal dialysis|PD|305|306|PAST MEDICAL HISTORY|8. Status post tracheostomy on _%#DDMM2006#%_ and home vent dependent on SIMV pressure support with a tidal volume of 55, PEEP of 8, pressure support of 15 and respiratory rate of 30. 9. Status post left and right PA stenting on _%#DDMM2006#%_ secondary to proximal bilateral PA stenosis. 10. Status post PD catheter placement on _%#DDMM2006#%_ secondary to medical renal disease/ischemia, home PD regimen is at 150 mL of 1:1, 1.5-2.5% cycles every 45 minutes for a total of 16 cycles a day and 12 hours daily.
PD|peritoneal dialysis|PD|150|151|LABORATORY DATA UPON ADMISSION|LABORATORY DATA UPON ADMISSION: He had a blood culture on _%#DDMM2006#%_ from _%#CITY#%_ _%#CITY#%_ Medical Center, which was reported as negative. A PD culture from the _%#MMDD#%_ and _%#MMDD#%_, both from _%#CITY#%_ _%#CITY#%_, which reported coagulase-negative Staph susceptible to vancomycin and Gram stain that had shown moderate PMN and a second PD from _%#DDMM2006#%_ with Gram stain reported as 46% PMN, 3% lymphs, clear colorless and 140 cells.
PD|peritoneal dialysis|PD|352|353|LABORATORY DATA UPON ADMISSION|LABORATORY DATA UPON ADMISSION: He had a blood culture on _%#DDMM2006#%_ from _%#CITY#%_ _%#CITY#%_ Medical Center, which was reported as negative. A PD culture from the _%#MMDD#%_ and _%#MMDD#%_, both from _%#CITY#%_ _%#CITY#%_, which reported coagulase-negative Staph susceptible to vancomycin and Gram stain that had shown moderate PMN and a second PD from _%#DDMM2006#%_ with Gram stain reported as 46% PMN, 3% lymphs, clear colorless and 140 cells. HOSPITAL COURSE: PROBLEM #1: FEN: He continued during his hospitalization with his home regimen of feeds of PM 60/40 of 150 mL x5 boluses, which he tolerated well.
PD|peritoneal dialysis|PD|184|185|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1: FEN: He continued during his hospitalization with his home regimen of feeds of PM 60/40 of 150 mL x5 boluses, which he tolerated well. He continued on his PD cycles of 150 mL passes, which were alternated at different points depending on his fluid and weight balance between 1.2-2.5, 1:1 to intermittent days of 2.5 and 4.25% dextrose.
PD|peritoneal dialysis|PD|494|495|PROBLEM #4|He also continued with his folic acid at 0.5 mg daily with a normal CBC of hemoglobin of 14.4, hematocrit of 42.9, platelets of 480,000 and WBC 9.7. His blood pressures range from 95-80 systolic over 70-55 and continued on aspirin 41 mg daily and Coreg 0.3 mg q.12h. PROBLEM #4: Infectious Disease: His PD fluids were only positive from his cultures from _%#CITY#%_ _%#CITY#%_ on the _%#MMDD#%_ and _%#MMDD#%_ for coagulase-negative Staph and was started on vancomycin 90 mg on each bag in his PD fluid. He was afebrile and is T-Max was 100.6, but soon was afebrile, which improved as well as his CRP from admission, which was 9.3 during his hospitalization, normalized to 6.1 and finally on discharge to less than 0.3. His neutrophil count and his PD also decreased during the hospitalization and he was discharged once he was afebrile.
PD|peritoneal dialysis|PD|749|750|PROBLEM #4|He also continued with his folic acid at 0.5 mg daily with a normal CBC of hemoglobin of 14.4, hematocrit of 42.9, platelets of 480,000 and WBC 9.7. His blood pressures range from 95-80 systolic over 70-55 and continued on aspirin 41 mg daily and Coreg 0.3 mg q.12h. PROBLEM #4: Infectious Disease: His PD fluids were only positive from his cultures from _%#CITY#%_ _%#CITY#%_ on the _%#MMDD#%_ and _%#MMDD#%_ for coagulase-negative Staph and was started on vancomycin 90 mg on each bag in his PD fluid. He was afebrile and is T-Max was 100.6, but soon was afebrile, which improved as well as his CRP from admission, which was 9.3 during his hospitalization, normalized to 6.1 and finally on discharge to less than 0.3. His neutrophil count and his PD also decreased during the hospitalization and he was discharged once he was afebrile. His blood cultures never were positive and he had 48 hours of his PD culture that was negative.
PD|peritoneal dialysis|PD|400|401|PROBLEM #4|He was afebrile and is T-Max was 100.6, but soon was afebrile, which improved as well as his CRP from admission, which was 9.3 during his hospitalization, normalized to 6.1 and finally on discharge to less than 0.3. His neutrophil count and his PD also decreased during the hospitalization and he was discharged once he was afebrile. His blood cultures never were positive and he had 48 hours of his PD culture that was negative. PROBLEM #5: Renal: He continued on his 45-minute cycles with 1:1 mix of 4.25 and 2.5% on average daily ultrafiltration of 380 mL to keep his weight as previously mentioned between 7 and 7.1 kilos.
PD|peritoneal dialysis|PD|285|286|PROBLEM #5|He was originally started before knowing susceptibilities of the coagulase-negative Staph on both vancomycin and ceftazidime, but as soon as we knew the susceptibilities and certain resistant to cephalosporins, the ceftazidime was discontinued and was sent home with vancomycin on his PD bags. His lactic acid also improved from admission from 5.9 to 3.6. PROBLEM #6: GI: He continued on his Lactobacillus, Sime thicone p.r.n. and pantoprazole.
PD|peritoneal dialysis|PD|134|135|DISCHARGE MEDICATIONS|20. Tylenol with codeine T3, 2.5 mL per G-tube once p.r.n. during trach changes. 21. Three liters of 4.25% dextrose bag dialysate for PD catheter and 3 L of 2.5 dextrose bags for dialysate PD catheter to do 150 mL passes every 60 minutes. 22. 500 mL dextrose 4.25 cycler heater bag PD catheter treatment to be given in a liter bag when home care is in place, change total volume to 85 mL and sensitivity to 1.
PD|peritoneal dialysis|PD|189|190|DISCHARGE MEDICATIONS|20. Tylenol with codeine T3, 2.5 mL per G-tube once p.r.n. during trach changes. 21. Three liters of 4.25% dextrose bag dialysate for PD catheter and 3 L of 2.5 dextrose bags for dialysate PD catheter to do 150 mL passes every 60 minutes. 22. 500 mL dextrose 4.25 cycler heater bag PD catheter treatment to be given in a liter bag when home care is in place, change total volume to 85 mL and sensitivity to 1.
PD|peritoneal dialysis|PD|201|202|DISCHARGE MEDICATIONS|21. Three liters of 4.25% dextrose bag dialysate for PD catheter and 3 L of 2.5 dextrose bags for dialysate PD catheter to do 150 mL passes every 60 minutes. 22. 500 mL dextrose 4.25 cycler heater bag PD catheter treatment to be given in a liter bag when home care is in place, change total volume to 85 mL and sensitivity to 1.
PD|peritoneal dialysis|PD|118|119|HOSPITAL COURSE|There is 200 mL fill, 55 mL dwell time, and 2-3 minutes each of fill time and drain time. It is a standard commercial PD solution with a calcium of 3.5 mEq/L and a dextrose of 1.5%. _%#NAME#%_ is on an autocycling peritoneal dialysis. The attending physician for dialysis is Dr. _%#NAME#%_ _%#NAME#%_ at the University of Minnesota Medical Center, Fairview.
PD|peritoneal dialysis|PD,|284|286|SUMMARY AND CONCLUSIONS|Based upon information obtained through the clinical interview and record review, it appears that the primary etiology of these impairments is Parkinson's disease or other parkinsonian movement disorder that has been accompanied by cognitive impairment. At this point, in addition to PD, it appears that a variety of other potential conditions (e.g., progressive supranuclear palsy, multiple systems atrophy, cortical basal degeneration) remain within the realm of possibility.
PD|UNSURED SENSE|PD|575|576|S/P HSCT 3/07|_%#NAME#%_'s skin is healing though he is noted to not like to be touched at times, though there are times he enjoys therapy and having his hand held _%#NAME#%_ currently receives fluid/nutrition by NJ and has an OG for suction those this has not been needed for suction more recently Past Medical History: ALL diagnosed _%#DDMM2001#%_ S/P HSCT _%#DDMM2007#%_ Encephalopathy of unclear etiology with report from _%#NAME#%_ of some purposeful responsiveness prior to a code on _%#DDMM2007#%_, again seems more "alert" this past week. VOD recovered Renal Dialysis currently on PD Tracheostomy ROS: The following areas were reviewed: Pain/Irritability, Respiratory (Dyspnea/Respiratory Distress), Cardiovascular, GI (Vomiting, Constipation, Nausea, Feeding Intolerance), Genitourinary, Constitutional (Insomnia, Fatigue), Psychiatric (Anxiety, Depression), Neurological (Delirium), Skin/Integument, Musculoskeletal, Eyes, ENT, Endocrine, Hematologic, Allergic/Immunologic Pertinent findings: Pain/agitation - reviewed in HPI Skin - significant breakdown, healing and improving gradually Neuro - depressed sensorium, unclear etiology for significant change in neurologic function, eveluated previously by neurology Insomnia - more awake at night, chronic Endocrine - hyperglycemia exacerbated by chronic steroids Hematologic - iron overload Medications: Fentanyl 50 mcg IV Q 1 hr prn Versed 0.5 ? 1 mg IV Q 1 hr prn agitation Keppra 750 BID Protonix 40 mg BID Vitamin E Carnitine Voriconazole 200 mg BID Ceftazidime Q 24 hr Levaquin 250 mg Q 24 hr Flagyl 250 mg Q 8 hr CaCO3 1250 TID Ursodial 200 mg BID KCL 40 meq Q day Epogen Insulin Hydrocortisone taper Nifedipiine 5 mg dbp >85, sbp >120 Family History: _%#NAME#%_ denies any acute or chronic medical concerns in herself or other immediate family members.
PD|posterior descending|PD|194|195|HISTORY OF PRESENT ILLNESS|His RCA stents were seen to be patent. He was found to have sequential 40% stenosis of the LAD, some mild left circumflex disease, and 95% stenosis in the first bifurcating PD branch and second PD branch. His RPLA branch was dilated. The main PLA trunk was stented. The LAD and D1 were also stented. The following day the patient was discharged home in good condition.
PD|posterior descending|PD|115|116|PAST MEDICAL HISTORY|Coronary angiogram showed proximal LAD stenosis, large obtuse marginal severe stenosis, and severe stenosis in the PD of the right coronary artery. Left ventricular and diastolic pressure was 10 mm of mercury. She had internal mammary to the diagonal of the LAD, vein graft to the PDA of the right coronary artery and a vein graft to the ramus circumflex artery.
PD|posterior descending|PD|136|137|INDICATION FOR CONSULTATION|He had a four vessel bypass at Region's Hospital with a LIMA to the LAD and individual vein grafts to a diagonal branch and OM into the PD I presume of the RCA. His LVEF's have been approximated both by thallium and by cardiac catheterization to be about 45% with scarring of the inferolateral wall compatible with a previous infarct.
PD|peritoneal dialysis|PD|451|452|PAST HISTORY REVIEW|10. Fentanyl given several times for pain as well as Dilaudid. PAST HISTORY REVIEW: Includes hospitalizations for lupus, hypertension, renal ablation, questionable diagnosis of lupus cerebritis, left ventricular hypertrophy, two admissions for suicide attempts, and one medication overdose, admission for gastroesophageal reflux disease, history of anxiety, and chronic methicillin resistant Staphylococcus aureus carrier state after abscess near the PD cite. PAST MEDICAL HISTORY: Prematurity 32 weeks gestation. FAMILY HISTORY: Remarkable only for glaucoma.
PD|peritoneal dialysis|PD|209|210|IMPRESSION|He may have peritonitis associated with peritoneal dialysis. He has end-stage renal disease and is on PD. We will continue this. We will send a Gram stain and culture as well as cell count differential of the PD fluid. We will treat him with vancomycin and ceftazidime IV. We will switch him from his cycler to CAPD doing six exchanges with 1.5% Dianeal.
PD|pancreatic duct|PD|220|221|FOLLOWUP PLANS|3. We will refer her to pain clinic at University of Minnesota for chronic pain control so that she could be seen in approximately 2-4 weeks' time. 4. She need an x-ray/EGD in 2 weeks to check for spontaneous passage of PD stent, if still present EGD needs to be performed for removal of the stent. It has been a pleasure to be involved in this patient's care.
PD|peritoneal dialysis|PD|97|98|PROCEDURE PERFORMED DURING THE HOSPITAL STAY|PROCEDURE PERFORMED DURING THE HOSPITAL STAY: 1. Deceased donor kidney transplant. 2. Removal of PD catheter. INDICATION FOR PROCEDURE: End-stage renal disease secondary to chronic glomerulonephritis.
PD|peritoneal dialysis|PD|147|148|DISCHARGE INSTRUCTIONS|DISPOSITION: To home. DISCHARGE INSTRUCTIONS: The patient was instructed to change her dressing to her abdomen twice daily or as needed for at the PD catheter site. She was instructed to keep her incisions clean and dry. She was told that she may shower in one to two days.
PD|peritoneal dialysis|(PD)|163|166|HOSPITAL COURSE|Please see the admission history and physical for more details. HOSPITAL COURSE: PROBLEM #1: Renal. The patient was initially kept on his home peritoneal dialysis (PD) regimen with tidal peritoneal dialysis. On _%#DDMM2004#%_ Pediatric Surgery repositioned his peritoneal dialysis catheter, since it had been pushed in more than it should have been.
PD|police department|PD|124|125|IDENTIFYING INFORMATION|IDENTIFYING INFORMATION: _%#NAME#%_ _%#NAME#%_ is a 53-year-old Caucasian male who was found in his truck by the _%#CITY#%_ PD with a Breathalyzer of 0.325, was transferred to the University of Minnesota Medical Center, where he was subsequently admitted to the ER for depression and suicidal thoughts. PRESENTING PROBLEM: _%#NAME#%_ reports he had a one-day relapse and drank a half a bottle of Crown Royal.
PD|peritoneal dialysis|PD|190|191|PROBLEM #3|PROBLEM #3: Renal. On admission, _%#NAME#%_'s peritoneal dialysis was decreased to 1.5% dextrose to pull off less volume. Once _%#NAME#%_ tolerated feeds, she was increased back to her home PD regimen of straight 2.5% dextrose with 800 mL fill volumes for a treatment time of 13 hours and 10 minutes. Peritoneal dialysis fluid was sent and daily cell counts for _%#DDMM2007#%_, _%#DDMM2007#%_ and _%#DDMM2007#%_, all revealed no nucleated cells.
PD|peritoneal dialysis|PD|286|287|HISTORY|The seizure was thought secondary to the hypertension. During that hospitalization, a transplant nephrectomy was done because of concern that it was contributing to her blood pressure lack of control. She developed pancreatitis in the hospital and subsequently had to be converted from PD to hemodialysis (_%#DDMM2005#%_). She was admitted just last week because of DVT in her left arm.
PD|peritoneal dialysis|PD|187|188|PROBLEM #2|Last extubated on _%#DDMM2004#%_. He has since had a decreasing oxygen requirement currently requiring blow by oxygen only when sleeping. His saturations have been noted to drop while on PD overnight down to roughly 88%. The patient does not appear to be symptomatic at these levels, but for safety precautions the patient was also discharged with home O2.
PD|peritoneal dialysis|PD|217|218|PHYSICAL EXAMINATION  VITALS|EYES: Eyes were sunken without any erythema or discharge. MOUTH: Mucous membranes were moist. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. ABDOMEN: PD catheter was in place, covered by a dressing without any signs of erythema or leaking past the dressing. Abdomen was soft, nontender, and had positive bowel sounds. There was some erythema on the skin at the site of prior tape applications.
PD|peritoneal dialysis|PD|150|151|DISCHARGE MEDICATIONS|13. Glycerine suppository 1 PR. q. day. p.r.n. constipation. 14. Nystatin cream to the affected areas p.r.n. 15. Gentamicin topical 0.1% apply to the PD site q. day. 16. Poly-Vi-Sol 1 mL to the abdominal G-tube q. day. 17. Erythropoietin 1500 units SC every Monday.
PD|peritoneal dialysis|PD|199|200|PROCEDURES|4. Gastric erosion secondary to NSAID use. 5. Peritonitis secondary to infected PD catheter. PROCEDURES: 1. EGD. Showing gastric erosion consistent with NSAID use. 2. Dialysis catheter placement. 3. PD catheter removal and mini-laparotomy. 4. Ultrasound of upper extremity to evaluate for AV fistula formation for permanent hemodialysis. HISTORY OF THE PRESENT ILLNESS: This patient is a 58-year-old female, recently hospitalized, with a history of renal amyloidosis and has had problems with intractable nausea and vomiting and albumin-wasting nephropathy.
PD|peritoneal dialysis|PD|153|154|PHYSICAL EXAMINATION ON ADMISSION|There is no murmur. LUNGS: Lung exam slightly decreased at the bases, right greater than left. There are no crackles or wheezes. ABDOMEN: Demonstrates a PD catheter in place. There is no tenderness. He has positive bowel sounds. SPINE: Spine is straight with no CVA tenderness. SKIN: His skin exam demonstrates bilateral lower extremity edema that is nonpitting to his knees.
PD|peritoneal dialysis|PD|198|199|PHYSICAL EXAMINATION|CHEST: Lungs show clear bilateral breath sounds. HEART: Regular rate and rhythm, normal S1, S2, no murmurs, rubs or gallops. ABDOMEN: Normal bowel sounds. There are two dressings in place where his PD catheter has been removed. These dressings look clean. Abdomen is soft and nontender, no hepatosplenomegaly. GU: Normal male pattern. EXTREMITIES: Good pulses and no edema.
PD|peritoneal dialysis|PD|170|171|PAST MEDICAL HISTORY|6. History of severe hyperkalemia while on peritoneal dialysis. 7. Hospitalization in _%#DDMM2003#%_ for Staph aureus peritonitis and PD catheter dysfunction; removal of PD catheter with placement of hemodialysis catheter. PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: Temperature 98.4, pulse 147, respiration rate 36, blood pressure 136/49.
PD|peritoneal dialysis|PD|168|169|PHYSICAL EXAMINATION|Capillary refill was less than 2 seconds, and full peripheral pulses. Lungs were clear to auscultation bilaterally. Abdomen was soft, nontender, positive bowel sounds. PD site intact. Spine: Straight without costovertebral angle tenderness. No rashes. No extremity edema. Musculoskeletal: Full range of motion x 4 extremities.
PD|peritoneal dialysis|PD|169|170|HOSPITAL COURSE|Initially, he did have a leukocytosis up to 25,000. He was empirically started on Unasyn. Over the time, his white count normalized and he was taken off the Unasyn. His PD fluid did get and sent for culture upon admission and was ultimately negative. Because of his delayed graft function, he underwent percutaneous ultrasound-guided biopsy on _%#MM#%_ _%#DD#%_, 2006.
PD|peritoneal dialysis|PD|186|187|PHYSICAL EXAMINATION|LUNGS: Have a few expiratory wheezes bilaterally here and there. Otherwise, he has good breath sounds with good air exchange. ABDOMEN: Large, obese. Normal active bowel sounds. He has a PD catheter in the left lower quadrant which appears to be good with no surrounding cellulitis. Belly is nontender. EXTREMITIES: Lower extremities, really without any major edema.
PD|peritoneal dialysis|PD|117|118|PHYSICAL EXAMINATION ON DISCHARGE|NECK: No JVD or thyromegaly. CARDIOVASCULAR: Regular rate and rhythm. No murmurs, gallops or rubs. ABDOMEN: He has a PD catheter in the mid left lower quadrant. There is normal bowel sounds. He has mild epigastric tenderness to deep palpation.
PD|phosphate dehydrogenase|PD|86|87|PROBLEM #4|Continue to be followed to maintain tight control of his blood sugars. PROBLEM #4: G6 PD deficiency. Again, caution should be used in the future in order to avoid side effects of medications with his G6 PD deficiency.
PD|peritoneal dialysis|PD|234|235|HPI|The tube was kept in place for several days. On _%#MM#%_ _%#DD#%_ the patient was found to have a pulmonary hemorrhage upon bronchoscopy. Around this time he was also found to have renal failure and placed on peritoneal dialysis. The PD catheter was discontinued on _%#MM#%_ _%#DD#%_, 2005. In addition, around _%#MM#%_ _%#DD#%_ this patient was found to have a junctional rhythm and intermittently have a wide complex tachycardia suggestive of a slow ventricular tachycardia.
PD|peritoneal dialysis|PD,|307|309|SPECIAL INSTRUCTIONS|Speech therapy, PT, OT. SPECIAL INSTRUCTIONS: Diet: He is discharged on a diet of Similac PM 60/40 plus Beneprotein, add Kayexalate and let sit for 4 hours then pour off formula to use feeds 250 mL boluses 4 times a day and then 65 mL per hour for 8 hours at night. His PD discharge orders were 10 hours on PD, off 14 hours. Passes will be 60 minutes. Fill volume 310 mL with a last bag fill volume 150 mL.
PD|peritoneal dialysis|PD|136|137|PROBLEM #2|Coagulase negative Staph grew out from the peritoneal fluid on _%#MM#%_ _%#DD#%_, and he was subsequently started on antibiotics in his PD fluid. Peritonitis was thought to be contributing to the poor PD draining. Once the antibiotics were started, however, he continued to have poor draining from his catheter.
PD|peritoneal dialysis|PD|162|163|PAST SURGICAL HISTORY|PAST MEDICAL HISTORY: 1. End-stage renal disease secondary to glomerulonephritis. 2. Gout. 3. Hypertension. PAST TRANSPLANT HISTORY: Zero. PAST SURGICAL HISTORY: PD catheter placement in 2004. PHYSICAL EXAMINATION: GENERAL: He is in no apparent distress. He was mildly obese.
PD|peritoneal dialysis|PD|165|166|PROBLEM #2|With his creatinine improving to 1.3, he was tried off of PD with success and had adequate weight without development of fluid overload. Of note, _%#NAME#%_ had his PD catheter repositioned laparoscopically after developing abdominal pain and an abdominal x-ray showing the PD catheter in the right upper quadrant, rather than in the pelvis.
PE|pulmonary embolus|PE|243|244|RECOMMENDATIONS|RECOMMENDATIONS: My recommendations for follow-up of her hemoglobin would be for her to have hemoglobin check on _%#DDMM2007#%_ at the Oxboro Clinic. Her primary physician, Dr. _%#NAME#%_, will follow up on the results. With regards to recent PE and IVC filter placement, the patient does not have any signs of cardiopulmonary compromise at this time. Given her current status, will continue to hold anticoagulation for now and this can be reinstituted on an outpatient basis under the supervision of her primary care physician.
PE|pulmonary embolus|PE.|171|173|HISTORY OF PRESENT ILLNESS|Also, has sleep apnea, usually wears BiPAP with some oxygen at night. In the ER, the patient had a normal chest x-ray. Also VQ scan was done which was low probability for PE. BNP was at 2080 and she was admitted to Cardiac Unit for CHF. REVIEW OF SYSTEMS: No headache, no dizziness, no chest pain.
PE|pulmonary embolus|PE.|163|165|LABORATORY DATA|The patient's blood pressures continued to be somewhat elevated. On _%#DDMM2006#%_, the patient developed chest pain and there were concerns that he had developed PE. He was started on Lovenox 100 mg b.i.d. The patient's oxygenation was noted to be 80% to 92% on face O2 by facemask at this time.
PE|pulmonary embolus|PE.|212|214|SUMMARY OF HOSPITALIZATION|However, she was unaware of any elevation of homocystine level. The patient had taken multivitamins as well as folic acid during the pregnancy and was taking low dose Lovenox at 40 mg subcutaneously prior to her PE. The patient is going to continue with breast feeding. We did discuss the use of anticoagulation in further pregnancies.
PE|pulmonary embolus|PE.|219|221|HISTORY OF PRESENT ILLNESS|We are awaiting results of the nuclear medicine test. The patient says she did develop some nausea after she received morphine in the ER for chest pain, but otherwise had no other symptoms. She has no history of DVT or PE. No history of CAD or MI. No fevers or chills. No cough. The patient walks at her mall for exercise and does not develop any significant chest pressure.
PE|pulmonary embolus|PE|173|174|HOSPITAL COURSE|This PE is in a different location than the PE in _%#DDMM2006#%_. It is probably attributable to a subtherapeutic INR, but hematology consult was requested due to recurrent PE on anticoagulation. They recommended lupus anticoagulant and anticardiolipin testing which are pending at the time of discharge. Hematology also recommended an adjustment in Coumadin dosing which is being made on discharge.
PE|pulmonary embolus|PE,|126|128|ASSESSMENT/PLAN|ASSESSMENT/PLAN: 1. This is a 57-year-old with onset of diaphoresis today while at physical therapy. Although this could be a PE, given her heart history and her diabetes, as well as smoking, I feel she needs to have evaluation for cardiac etiology first.
PE|pulmonary embolus|(PE)|122|125|ASSESSMENT/PLAN|CT SCAN: CT scan of the chest shows left-sided pulmonary embolism (PE). ASSESSMENT/PLAN: 1. Left-sided pulmonary embolism (PE) in this 32-year-old female with no other risk factors except for recent birth control pill use which was stopped 4 months ago.
PE|pulmonary embolus|PE|216|217|PHYSICAL EXAMINATION|EXTREMITIES: Mild trace edema on the left. The patient had Dopplers of his lower extremities which were negative. This was because he had a D-dimer that was 5.5. however, it was not pursued further for evaluation of PE as they felt it was unlikely. Troponin is negative. Basic metabolic panel is normal with sodium 139, potassium 4.8, creatinine 1.17. BNP 543.
PE|pulmonary embolus|PE.|192|194|IMPRESSION/PLAN|The patient's chest x-ray and BNP seem to be most consistent with congestive heart failure exacerbation. It did come on fairly suddenly and that is what made the ER physician want to rule out PE. However, despite the elevated D-dimer I think it is unlikely that this is an embolic event. Also I think it is unlikely to be pneumonia. However he does have significant pleural effusion that has gotten larger since his last x-ray in _%#MM#%_.
PE|pulmonary embolus|PE|217|218|PROBLEM #2|Her goal INR would be 2 to 2.5, and she should continue on Coumadin for 6 months and her IVC filter should be kept up to 6 months. The patient was seen by the hematology team that thought the most likely cause of her PE is because of her bed immobilization secondary to her pneumonia. There is no evidence of coagulation abnormality in her and in her family, and no further work up is necessary.
PE|pulmonary embolus|PE,|236|238|HISTORY OF PRESENT ILLNESS|She presented to the Emergency Room, with marked hypoxia and O2 SAT of 67%, tachypnea, and complaining of severe shortness of breath. Her pulse was in the 80's, and her blood pressure is 120/60. The ER had a high clinical suspicion for PE, and she was sent for a CT angiogram, which showed a large bilateral central pulmonary emboli. Heparin was started, and she was admitted here.
PE|pulmonary embolus|PE|117|118|HOSPITAL COURSE|He had a normal lung perfusion scan. His saturations were noted to be 99% on room air and therefore the diagnosis of PE seemed to be very unlikely. The patient had a normal troponins which were all negative. He had a normal hemoglobin of 15.1, normal white blood cell count of 6.8 and normal platelet count of 263,000.
PE|pulmonary embolus|PE|157|158|HISTORY OF PRESENT ILLNESS|The patient did have surgery 1 week, as noted at an outside facility, for a left THA, and subsequently developed resting tachycardia and was found to have a PE on a CT angiogram at an outside facility. The patient was started on Coumadin INR, and subsequently had a bleed in to his left thigh area with noted ecchymosis at the time of admission.
PE|pulmonary embolus|PE|154|155|HOSPITAL COURSE|Vasospasm may be another possibility. The echocardiogram was normal, and there was no pericardial effusion. The patient's history was not consistent with PE or gastroesophageal reflux disease. 2. Family history of Brugada syndrome. An EP consult was placed, and they decided to do an EP study with procainamide challenge which was normal.
PE|pulmonary embolus|PE|183|184|HISTORY OF PRESENT ILLNESS|She now has complaints of bilateral persistent achy pain in the same distribution. Chest CT was obtained to rule out dissection of the aorta. Chest CT did result in findings of acute PE in the segmental pulmonary artery branches within the left lower lobe and a moderate hiatal hernia. The patient does take two full strength aspirin daily and has a history of CVI with vertebral artery stenosis.
PE|pulmonary embolus|(PE)|297|300|HISTORY OF PRESENT ILLNESS|PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, MD (_%#CITY#%_ _%#CITY#%_ - Crystal Medical Clinic) CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 62-year-old Russian-speaking female with morbid obesity, hypercholesterolemia, hypertension, questionable pulmonary embolus (PE) in the past, adult-onset diabetes mellitus (poorly controlled), anxiety disorder, degenerative joint disease (DJD) of her knees requiring bilateral total knee arthroplasties and spinal disease which has been limiting for her who states to me that she has never had a cholecystectomy but in previous records in the emergency room here on a previous visit it is reported that she had one.
PE|pulmonary embolus|PE|106|107|HOSPITAL COURSE|The remainder of her labs were unremarkable aside from an INR of 3.42. She was on Coumadin for history of PE in the past. She was admitted and given IV fluids. Her diagnosis was gastroenteritis. Overnight, her symptoms did improve somewhat. Her hydrochlorothiazide was held secondary to dehydration, and she was rehydrated with IV fluids.
PE|pressure equalization|PE|168|169|PHYSICAL EXAMINATION ON ADMISSION|Eyes: Pupils are equal, round, and reactive to light. Extraocular muscles are intact with no conjunctivitis. He did have puffy eyelids. Ears: His TMs had scarring, and PE tubes were in place bilaterally. Nose: Showed crusted, clear drainage. Mouth and throat: There was no erythema or lesions. Neck: Soft with palpable lymphadenopathy on the left, greater than on the right.
PE|pulmonary embolus|PE,|178|180|HISTORY OF PRESENT ILLNESS|Initially, it was thought that she had a pulmonary embolus, and she was empirically started on heparin in the emergency room. She underwent a CAT scan. The CAT scan did not show PE, but did show significant right hilar lymphadenopathy and peritracheal nodes. Of note, this patient has Graves' disease with exophthalmos that has been increasingly troublesome to her over the last four months.
PE|pulmonary embolus|PE|195|196|LABORATORY DATA|There are no focal findings on her neurologic exam. LABORATORY DATA: Chest x-ray and CT are examined. They show hyperexpansion of the lungs but no other abnormalities whatsoever, specifically no PE and no pneumonia. No infiltrate nor effusion. Her white blood cell count is completely within normal limits. Basic metabolic is notably only for a very low potassium at 2.6. ECG shows flattened T waves and U waves consistent with the low potassium.
PE|pressure equalization|PE|238|239|BRIEF HISTORY OF PRESENT ILLNESS|She presented to Dr. _%#NAME#%_'s office with a spontaneous CSF leak that had been present for approximately three months. The patient initially was seen by a physician outside of the University for headaches and chronic serous effusion. PE tube was placed at that time, which resulted in copious amounts of clear drainage. This was eventually sent for beta-2 transferrin, and turned out to be positive, as an indicator for CSF.
PE|pulmonary embolus|PE.|279|281|HISTORY OF PRESENT ILLNESS|Significant in her history is recent hospitalization elsewhere for 4 times a day shots for a week for MS, to be followed by methylprednisolone taper which she is on now, nearing the end. Workup in the Emergency Room was unrevealing. Chest x-ray was OK. CT chest was negative for PE. There was a left lower lobe atelectasis identified with surrounding bronchiectasis, size about 1-2 cm. Also noted was posterior medial left lower lobe nodule. The radiologist recommended a followup CT in 8 weeks.
PE|pulmonary embolus|PE|268|269|BRIEF HISTORY OF PRESENT ILLNESS|2. Status post filter placements in bilateral iliac veins. 3. Laboratory workup for hypercoagulable state. BRIEF HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 51-year-old gentleman with past history of mild hypertension, as well as a newly diagnosed DVT with PE who initially presented on _%#MMDD2006#%_ with shortness of breath and then presented to Fairview _%#CITY#%_ _%#CITY#%_ and was diagnosed with saddle embolus PE.
PE|pulmonary embolus|PE.|113|115|LABORATORY|BNP 150. Troponin normal. White count 3200, hemoglobin low at 10.0 (which was 12 three days ago). No evidence of PE. Posterior lobe infiltrate versus edema. Small bilateral pleural effusions. ASSESSMENT: 1. Chest pain, probably pleurisy, rule out pericardial effusion.
PE|pressure equalization|PE|209|210|DISCHARGE FOLLOWUP|3. Pediatric clinic with Dr. _%#NAME#%_, _%#MMDD2006#%_ at 1 p.m. This appointment is pending the opinion of ENT for possible G-tube placement. 4. Tentatively scheduled in the OR on _%#DDMM2006#%_ at 8:30 for PE tube placement and G-tube placement. Again, G-tube placement is pending opinion from ENT at the time of discharge. 5. Radiation to begin _%#DDMM2006#%_. It was a pleasure to be involved in _%#NAME#%_'s medical care.
PE|pleural effusion|PE.|289|291|CT|EXTREMITIES: 2+ pedal edema without calf tenderness. LABORATORY DATA: Hemoglobin 14.1, WBC 9.2, PTT 24, troponin less than 0.07. Sodium 139, potassium 4.3, bicarb 24, creatinine 0.8, blood glucose 119. CT: Chest CT: 1. Small filling defect along the right upper lung consistent with small PE. 2. Left pleural effusion with extensive areas of infiltrate in the left lung. 3. 5x3 cm irregular mass with small area of cavitation in the right lower lobe; may represent a malignant lesion.
PE|pulmonary embolus|PE|164|165|DISCHARGE INSTRUCTIONS|I requested that she check her sugar once to twice a day. I discussed with patient her risk with pregnancy. By past history, she has had one definite, one probable PE associated with pregnancy. She says at this point she would want to have further children. I told her that would be a very high risk situation for her and she should discuss this with her primary MD or possibly an ob/gyn and to get more particulars on her risk with this.
PE|pulmonary embolus|PE.|161|163|HISTORY OF PRESENT ILLNESS|2. Pulmonary embolism. The patient was noted to have increasing shortness of breath, and a V/Q scan was then done which was suggestive of a high probability for PE. She was then started on IV heparin without any complications. She was then started on Coumadin; however, it did take an increased amount of time for anticoagulation.
PE|pulmonary embolus|PE|118|119|FAMILY HISTORY|FAMILY HISTORY: Mother had osteoporosis, she had diabetes, she fractured her hip was in rehab, she suffered a DVT and PE and then died in the hospital at age 70. Father died a sudden death unwitnessed at 70. He has had 4 brothers, 3 are healthy, one died of AIDS.
PE|pulmonary embolus|PE|160|161|PHYSICAL EXAMINATION|Her chest x-ray shows infiltrates patchy, left greater than right, which look suspicious for congestive heart failure. CT of her chest was done which showed no PE and bilateral infiltrates. LABORATORY DATA: White count of 62.6, hemoglobin 8.6, platelet count 225; she had 1 neutrophil on differential, 99 lymphocytes with INR 1.20, sodium 128, potassium 5.6, chloride 95, bicarbonate 24, glucose 143, BUN 43, creatinine 1.35, calcium 8.2. LFTs were within normal limits.
PE|pulmonary embolus|PE|418|419|HISTORY OF PRESENT ILLNESS|He recently underwent coronary angiography _%#MM#%_ _%#DD#%_, 2006 which showed no left main disease, a circumflex with 10-20% mild disease, an LAD that shows 2 stents; 1 in the mid-LAD and 1 going from the LAD into the first diagonal as well as some 30% disease in the mid-RCA, an EF of 60% with no evidence for any wall motion abnormality. He also had a CT scan done at that hospital stay that showed no evidence of PE or any intrinsic lung disease. The patient was admitted with medical therapy and scheduled to follow up with Dr. _%#NAME#%_ _%#NAME#%_. He now presents this evening that occurs at rest, he describes this pain as starting underneath his breast and radiating down his left arm as well up into his neck.
PE|pulmonary embolus|PE|323|324|ASSESSMENT AND PLAN|The patient will be started on Lovenox and Coumadin. Consultation should be undertaken with her oncologist to address the status of her colon CA and comment upon the risk-benefit ratio of the patient bleeding from her intraperitoneal mets seen on recent CT scan while on Coumadin as opposed to benefit in terms of reducing PE risk for the long term. If the patient will be anticoagulated for the short term I would favor perhaps a shorter three- to six-month course as opposed to a longer six- to twelve-month course in this patient given her metastatic lesions seen on recent CT scan.
PE|pulmonary embolus|PE|225|226|FOLLOWUP CARE|DISCHARGE ACTIVITY: As tolerated. FOLLOWUP CARE: 1. With Dr. _%#NAME#%_, neurology, for followup of neuromuscular disorder within 1 week of discharge. 2. Dr. _%#NAME#%_ _%#NAME#%_, internal medicine, for followup of presumed PE and acute renal failure by _%#DDMM2006#%_ at _%#CITY#%_ _%#CITY#%_ Medical Center, phone number _%#TEL#%_, fax _%#FAX#%_. 3. PMP and outpatient lab here at the University of Minnesota Medical Center, Fairview, on Sunday, _%#DDMM2006#%_; or Monday, _%#DDMM2006#%_ for creatinine check.
PE|pulmonary embolus|PE|160|161|HISTORY OF PRESENT ILLNESS|She had a normal stress test on _%#DDMM2006#%_. She has a cardiac history, and had a CABG in 2005, and an MI in 2003. The patient had a CT scan which ruled out PE and pneumonia. She started having arm pain and a sore throat. The pain was not related to exertion. She did have some nausea with the pain, but she denied any shortness of breath.
PE|pulmonary embolus|PE|209|210|IMPRESSION AND PLAN|Doubt pulmonary embolism with a negative D-dimer. Given her complaints of leg edema and her previous DVT history, however, we will perform ultrasound to rule out DVT. If this is negative, would not workup for PE further. Finally, we will check an albumin level to evaluate for other possible causes of hypervolemia. We will also perform a transthoracic echocardiogram to evaluate right and left heart function.
PE|pulmonary embolus|PE|140|141|ADMISSION HISTORY OF PRESENT ILLNESS|ADMISSION HISTORY OF PRESENT ILLNESS: A 55-year-old nursing home patient sent to the ED for psych issues, noted to be hypoxic. CT chest for PE done, negative for PE _____ bilateral posterior lower lobe consolidation. The patient progressively hypoxic, arrived in ICU with SpO2 of 60s, rapidly intubated, thick secretions noted because of hypotension, became hypotensive and responded to fluid flushes.
PE|pulmonary embolus|PE|125|126|REVIEW OF SYSTEMS|She is a nonsmoker. She rarely drinks alcohol. REVIEW OF SYSTEMS: Please see HPI for details. No fevers or chills. No DVT or PE history. No cardiac history. No chest pain or shortness of breath. No dysuria symptoms or hematuria. Review of systems is otherwise negative for cardiovascular, respiratory, GI, renal, urinary, hematologic, integument, endocrine, musculoskeletal, neurologic, and cognitive complaints.
PE|pulmonary embolus|PE|116|117|HISTORY OF PRESENT ILLNESS|She has no history of ulcers or heartburn. No loss of consciousness or syncope. No MI, CAD, COPD history. No DVT or PE history. In the ER, the patient's vital signs were notable for a temperature of 99.7 and saturation 98% on room air.
PE|pulmonary embolus|PE|350|351|LABORATORY DATA|EXTREMITIES: No edema. LABORATORY DATA: Sodium 137, potassium 3.2, chloride 102, bicarbonate 17, glucose 170, BUN 13, creatinine 0.9, albumin 5.0, D- dimer 0.6, INR 0.91, PTT 24, myoglobin 167, troponin less than 0.07, alcohol less than 0.01. Head CT as outlined above. Tox screen negative. Glucose this morning is 114. Chest CT shows no evidence of PE or other abnormalities. EKG shows sinus tachycardia at a rate of 123. Unremarkable ST segments.
PE|pulmonary embolus|PE.|191|193|HISTORY OF PRESENT ILLNESS|He did not have fever, chills or sweats. Pulmonary function tests demonstrated a decrease in his FEV1 from approximately 1.8 L to 1.1 L. D-dimer was normal, suggesting that he did not have a PE. A CT Scan of the chest demonstrated a clear lung field on the left and emphysema on the right. Also noted, was a suggestion of bronchial narrowing on the left.
PE|pulmonary embolus|PE|213|214|HISTORY OF PRESENT ILLNESS|The patient's INR was labile. During this time, the patient was undergoing chemotherapy and had poor p.o. intake. Since his INR was so difficult to control, he was placed on 100 mg subcu Lovenox a day for DVT and PE treatment. PAST MEDICAL HISTORY: 1. Non-small cell bronchogenic carcinoma. The patient has metastases to the hilum and mediastinum with bone lesions.
PE|pulmonary embolus|PE.|148|150|HOSPITAL COURSE|His hemoglobin on admission was 11.1, and on the day of discharge 10.3. CODE STATUS: The patient is full code. HOSPITAL COURSE: PROBLEM #1. DVT and PE. The patient was found to have progression of known DVTs and pulmonary emboli, secondary to under- anticoagulation in the face of ongoing chemotherapy for an advanced lung cancer.
PE|pressure equalization|PE|265|266|DOB|_%#NAME#%_ _%#NAME#%_ is a 14-year-old girl who has a history of cleft palate, palate repair, and multiple ear tube surgeries, up to 7, as well as tympanic membrane surgery x 2 and mastoidectomy x 2. She has a right PE tube in place and is scheduled to have a left PE tube inserted. Other health concerns include attention-deficit hyperactivity disorder and history of asthma and allergies, which are quiet at this time.
PE|pulmonary embolus|PE.|355|357|PHYSICAL EXAMINATION|Platelet count is 166, MCV is 77. INR is 1.06, PTT is 31, D-Dimer is 1.3. Sodium is 145, potassium is 3.2, chloride is 100, bicarb is 34, glucose is 131, BUN is 22, creatinine is 1.1, troponin is less than .07, myoglobin is 106, BNP is 115. D-Dimer was elevated at 1.3. CT of the chest reveals atelectasis, no infiltrate or effusion, no rib fractures, no PE. There is, however, bilateral renal hydronephrosis noted. The upper abdominal images obtained with CT of the chest. Additionally the dome of the bladder is visible in the upper abdomen.
PE|pulmonary embolus|PE|150|151|ASSESSMENT/PLAN|The episode that he had during my examination could be construed as a possible absence seizure. We will ask Neurology to see him today. 2. History of PE and DVT. We will continue his Coumadin, and follow daily INRs.
PE|pulmonary embolus|PE|280|281|BRIEF HISTORY AND HOSPITAL COURSE|2. Probable underlying chronic obstructive pulmonary disease. BRIEF HISTORY AND HOSPITAL COURSE: A 59-year-old male who presents with progressive dyspnea and cough after returning from a trip from Arizona. He had a chest CT on admission which was negative for PE. He had no other PE risk factors. His x-ray was clear of infiltrates. He likely had acute bronchitis with likely underlying COPD with his extensive smoking history.
PE|pulmonary embolus|PE|197|198|ASSESSMENT|Will check cardiac enzymes and watch her tonight. At this point, I do not feel that she needs Lovenox unless her enzymes are positive or she starts having more chest pain. I do not think she has a PE and I do not think we need a CT at this point, I also doubt aneurysm.
PE|pulmonary embolus|PE|137|138|ASSESSMENT|Chest x-ray and D-dimer were normal. ASSESSMENT: 1. Right chest pain with episodic shortness of breath and flushing. I still worry about PE in spite of normal D-dimer. I am going to check chest CT. I am also going to rule out for MI. We will have cardiology see in the morning. 2. Episodic dysarthria.
PE|pulmonary embolus|PE.|225|227|LABORATORY DATA|Prominent interstitium with approximately 1.8 cm mass or conglomerate of lymph nodes in the superior mediastinum. Additional enlarged lymph nodes noted in the right tracheal brachial region measuring 1.5 cm. No evidence of a PE. Influenza swab is negative. Her pro-BNP is 11,100. Electrolytes demonstrates a creatinine of 0.75. Nonspecific LFTs with a AST of 79, ALT 68.
PE|pulmonary embolus|PE|252|253|SUMMARY OF HOSPITAL COURSE|She additionally she had a transthoracic echocardiogram done here which found her EF to be 60-65% with no significant valvular heart disease nor did she have any wall motion abnormalities. She had a spiral CT for PE done in the ER which did not show a PE but showed a small pericardial effusion though this was not confirmed on the echo. Given the normal angiogram, she was sent home. My instructions to her would be that it is very likely that she will get a recurrent chest heaviness, that it will be noncardiac and that the initial treatment will be Tylenol and antacid if the chest pain becomes recurrent occurring more than one to two times per week.
PE|pulmonary embolus|PE|185|186|HOSPITAL COURSE|HOSPITAL COURSE: 1. Shortness of breath and chest pain. In this hospital admission we did the lower extremity Doppler, which was negative for any clots and we also did the CT scan with PE protocol and that was also negative for any clots. That also did not show any infiltrates in his lungs. That did show small bilateral pleural effusions and a 3 mm nodule of uncertain significance.
PE|pulmonary embolus|PE,|190|192|PROCEDURES DONE DURING THIS HOSPITALIZATION|7. History of appendectomy and hysterectomy in 1993. PROCEDURES DONE DURING THIS HOSPITALIZATION: 1. CT scan of chest with PE protocol, which was done on _%#DDMM2007#%_. It was negative for PE, but did show multiple superior mediastinal lymph nodes and some hiatal hernia with some right apical blebs. The report also included seeing some upper and lower paratracheal adenopathy with the largest measuring 1.3 cm in shot axes.
PE|pressure equalization|PE|207|208|DOB|DOB: _%#DDMM1994#%_ The patient is a 6-year-old referred by Dr. _%#NAME#%_ _%#NAME#%_ with a persistent PE tube in the left eardrum. We discussed the risks, benefits, and alternatives to removal of the left PE tube and Gelfoam patching, including the risk of a general anesthetic, risk of bleeding, the risk of continued perforation, the risk of otorrhea, the risk of hearing.
PE|UNSURED SENSE|PE|188|189|HISTORY OF PRESENT ILLNESS|The patient had sudden onset of chest pain yesterday evening, ranks it a 7.5 out of 10. This occurred under her left breast. It is nonstop and today it is worse. It is very similar to the PE pain she had in 2000 when she was hospitalized here. The patient says it does not radiate. It is not associated with diaphoresis, nausea or vomiting.
PE|pulmonary embolus|PE,|230|232|IMPRESSION/PLAN|However, last night he began to develop slowly progressive dyspnea, came back to the Emergency Room and has been readmitted to the hospital. In the Emergency Room the patient had another CT scan of the chest performed to rule out PE, which is negative. In addition, he has had a little bit of questionable double vision and because of this a head CT scan was done without contrast that is also negative aside for an old lacunar infarct.
PE|pulmonary embolus|PE.|168|170|HEALTH MAINTENANCE|DEXA scan in 2002 was within normal limits. Mammogram was a few years ago. Her last tetanus was in 1998. Spiral CT performed after atrial fibrillation was negative for PE. Per the patient, an echo was performed at that time. We do not have those results, however. SOCIAL HISTORY: She did smoke.
PE|pulmonary embolus|PE,|150|152|PERTINENT LABORATORY DATA|PERTINENT LABORATORY DATA: White count 6200. Hemoglobin 15.9. Potassium 4.5. Creatinine 0.7. Glucose 94. D-dimer 0.8. A chest CT was done to rule out PE, which was negative. Troponin 0.07. ECG: No ischemia; within normal limits for age. IMPRESSION: Neck pain with nausea. The symptoms are atypical for cardiac symptoms; however, the patient has multiple risk factors and it is very reasonable to stress her to rule out coronary artery disease.
PE|pulmonary embolus|PE|190|191|HISTORY|He normally does not have dyspnea on exertion. He has had no chest pain. He has had no shortness of breath at rest. No orthopnea, paroxysmal nocturnal dyspnea or edema. He has no history of PE or deep venous thrombosis. He was seen by Dr. _%#NAME#%_ _%#NAME#%_ yesterday before my visit. At that time, I discussed with Dr. _%#NAME#%_ whether to admit him, but the patient wished to try medical therapy as an outpatient.
PE|pulmonary embolus|PE|130|131|LABORATORY|There is evidence of an old inferior infarct/Q-waves. Chest x-ray did not show any acute abnormalities. CT scan of the chest, per PE protocol, did not show any evidence for PE. Lungs were noted to be clear. IMPRESSION: 1. Chest pain. The patient apparently had a fairly severe episode, but the patient himself does not have a good recollection of this.
PE|pulmonary embolus|PE.|169|171|PROBLEM #4|PROBLEM #4: History of deep vein thrombosis and pulmonary embolism. The patient has a history of antiphospholipid antibody possibly. Also, he has a history of DVT and a PE. He was on Coumadin 2.5 mg as an outpatient. He is currently on Coumadin 10 mg, but his INR is 2.11, so we decreased his Coumadin to 5 mg once a day.
PE|pulmonary embolus|PE.|196|198|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|This was followed by subsequent chest x-rays, as she was having persistent chest pain. I was somewhat suspicious that she may have been developing hemothorax or a more complicated course with her PE. Her x-rays, however, were pretty stable and her pain has it has improved quite a bit. At this point, I suspect that she will recover from this uneventfully.
PE|pulmonary embolus|PE,|123|125|ASSESSMENT|Cardiac enzymes are negative. At this point, will plan for stress test this morning. Will also obtain chest CT to rule out PE, although this seems less likely. Patient continues on proton pump inhibitor. Character of the pain is suggestive of gastroesophageal reflux.
PE|pressure equalization|PE|234|235|PAST MEDICAL HISTORY|The patient improved and had decreased nausea and vomiting with increased p.o. intake, and her diarrhea also resolved. The patient was than discharged on _%#DDMM2002#%_. PAST MEDICAL HISTORY: 1. Status post appendectomy. 2. Recurrent PE tubes. 3. Status post mandibular osteotomy and distraction in 1997. 4. Status post Nissen and G tube in 1997. 5. Status post soft palate repair in 1998. 6. Status post tonsillectomy in 1999.
PE|pulmonary embolus|PE|218|219|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Nausea, abdominal pain and fever. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 66-year-old white male who was just discharged two days prior to admission. The patient had been admitted for a PE and had to have a Greenfield filter placed after he developed a left rectus muscle hematoma. This was done on _%#MM#%_ _%#DD#%_, 2002. He was not restarted on anticoagulation.
PE|pulmonary embolus|PE|179|180|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Synovial cell sarcoma, diagnosed in _%#DDMM2001#%_. He is status post multiple cycles of CAV-IMV, and he is also status post x-ray therapy. 2. History of PE and DVT in _%#DDMM2001#%_. He remains on warfarin. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He lives in _%#CITY#%_ with his family.
PE|pulmonary embolus|PE.|221|223|HOSPITAL COURSE|3. Fluid, electrolytes, nutrition. The patient was on IV fluids and IV medication and was taking a regular diet throughout her stay. 4. Pulmonary. See infectious disease. A V-Q scan was done and showed low probability of PE. CT scan was not performed secondary to patient's allergy to IV contrast. DISCHARGE INSTRUCTIONS: Regular diet and activity as tolerated. Call if temperature greater than 100.4, increased pain or increased swelling or any nausea or vomiting.
PE|pulmonary embolus|(PE)|168|171|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Left femur fracture _%#DDMM2000#%_, leaving her wheelchair bound as it is nonhealing. She had a deep vein thrombosis (DVT) with pulmonary embolus (PE) in 2001 following her femur fracture. Chronic medical condition: diabetes, atrial fibrillation, osteoporosis, hypertension, and hyperlipidemia. MEDICATIONS 1. Glyburide 10 mg (two 5-mg tablets) p.o. every day.
PE|pulmonary embolus|PE,|245|247|OPERATIONS AND PROCEDURES PERFORMED|There are regions of calcification in the left lung base and to a lesser degree in the left apex, which could represent postobstructive pneumonia. This mass extends into the aortic-pulmonary window and subcarinal region. Exam was suboptimal for PE, although no definite PE was noted. 2. Bronchoscopy dated _%#DDMM2005#%_ with findings: Bronchial washings positive for malignancy and consistent with small cell lung carcinoma.
PE|pulmonary embolus|PE|270|271|OPERATIONS AND PROCEDURES PERFORMED|There are regions of calcification in the left lung base and to a lesser degree in the left apex, which could represent postobstructive pneumonia. This mass extends into the aortic-pulmonary window and subcarinal region. Exam was suboptimal for PE, although no definite PE was noted. 2. Bronchoscopy dated _%#DDMM2005#%_ with findings: Bronchial washings positive for malignancy and consistent with small cell lung carcinoma.
PE|pulmonary embolus|PE|217|218|HOSPITAL COURSE|The clinical picture of hypoxia made us feel that the patient did, in fact, have a pulmonary embolism. Therefore, she was started on IV heparin. The patient had significant GERD symptoms and prior to the diagnosis of PE we asked Dr. _%#NAME#%_ to come by for consideration of EGD. Unfortunately, with the diagnosis of chronic obstructive pulmonary disease, she required anticoagulation in the form of heparin and, therefore, her PPI was increased to b.i.d. and EGD is delayed while she is on the anticoagulation.
PE|pulmonary embolus|PE,|120|122|REASON FOR ADMISSION AND HOSPITAL COURSE|So Interventional Radiology did not recommend putting an IVC filter at this time except if there is a recurrence of the PE, despite inadequate anticoagulation. Note: The patient reports he had a normal stress test in _%#DDMM2005#%_, 4 months ago. 2. Diabetes mellitus: On oral hypoglycemic. 3. Pulmonary hypertension: Possibly related to recurrent pulmonary embolus, however, the patient might have obstructive sleep apnea and he should be worked up for obstructive sleep apnea in the near future.
PE|pulmonary embolus|PE|197|198|REVIEW OF SYSTEMS|No dysuria. The patient has noticed some trouble getting words out for the past several days. This is an acute change for her. No weakness. No nausea, vomiting. No GI complaints. No DVT history or PE history. No chest pain or shortness of breath. No cardiac history. The family has also noted a significant amount of weight loss for the past several months with decreased appetite.
PE|pulmonary embolus|PE|176|177|KEY IMAGING STUDIES AND PROCEDURES PERFORMED ON HOSPITALIZATION|Lungs are otherwise clear. Instrumentation rods are seen in the spine. There is a ventricular peritoneal catheter over the right hemithorax. Heart size is stable. 2. Chest CT. PE protocol on _%#DDMM2007#%_. (See FCIS for complete details.) Impression small right pleural effusion and right lower lobe atelectasis with elevated right hemidiaphragm.
PE|pulmonary embolus|PE|181|182|HOSPITAL COURSE|She was tender on palpation of her right lower ribs. CT scan was also performed which was normal. Given the normal CT scan in addition to negative Dopplers and also the negative CT PE protocol, it was felt that the likelihood of a PE was probably ruled out and the risks of a pulmonary angiogram were felt to be higher than benefit.
PE|pulmonary embolus|PE.|138|140|HISTORY OF PRESENT ILLNESS|Upon arrival the patient was seen by Dr. _%#NAME#%_ who in the course of evaluation ordered a CT scan of the chest which was negative for PE. There was noted to be mild atelectasis right lung and a 1 cm left adrenal mass. The patient is feeling better but his main complaint now is chills.
PE|pulmonary embolus|PE|299|300|HISTORY OF PRESENT ILLNESS|The patient states that she does lift weights and was playing tennis last week but does not recall any acute injury to the chest wall and has not seen any chest wall lesions. The patient denies any central chest pain, palpitations or shortness of breath. The patient denies history of pneumothorax, PE or DVT. PAST MEDICAL HISTORY: Epilepsy diagnosed at age 8.
PE|pulmonary embolus|PE|191|192|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|Sputum cultures were obtained and they eventually revealed methicillin resistant staphylococcus aureus. Given the elevated D-Dimer a CT scan of the chest was obtained, which was negative for PE and showed the bilateral infiltrates as described above with a left pleural effusion. She was hypoxic and required oxygen for most of her hospitalization.
PE|pressure equalization|PE|236|237|FOLLOW-UP|2. He also will follow up with Dr. _%#NAME#%_ in1 week following discharge to address tolerance of his feeds and further G-tube drip rate alterations. 3. ENT Clinic will have an appointment established in 2 weeks' time for follow up of PE tubes and adenoidectomy. It was a pleasure being involved in _%#NAME#%_'s medical care.
PE|pulmonary embolus|PE,|188|190|ASSESSMENT|LABORATORY DATA: He did receive vitamin K 2 mg. His INR still is high as noted. ASSESSMENT: 1. Right shoulder fracture. 2. Possible hip fracture. 3. Chronic Coumadin use due to history of PE, DVT and prior stroke. Certainly he will be at higher risk of clots postop because of this. 4. Chronic right-sided paralysis. PLAN: 1. He should okay for the OR if needed according to Dr. _%#NAME#%_.
PE|pulmonary embolus|PE|139|140|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: The patient has chronic pyelonephritis and right hydroureter as per above. She also has asthma. She has a history of PE and a clot in her right arm for which she takes Lovenox 100 mg b.i.d. She also has a history of ruptured appendix for which she underwent an appendectomy.
PE|pulmonary embolus|PE.|149|151|ASSESSMENT AND PLAN|If febrile we will perform blood cultures, send sputum cultures, and evaluate for pyelonephritis. 3. Hematologic. The patient is status post DVT and PE. We will continue Lovenox at present. Check INR, PTT, and consider anti-factor Xa level to determine therapeutic Lovenox dosing if this seems to be indicated.
PE|pulmonary embolus|PE.|191|193|HISTORY OF PRESENT ILLNESS|In the emergency room he had a variety of laboratory studies including an elevated D-dimer which precipitated a CT scan of the chest to rule out pulmonary embolus (PE). This was negative for PE. There were calcified coronary arteries noted, however, as well as some calcifications throughout his tortuous aorta. There were some renal cysts noted and some renal calcifications but no evidence of obstruction.
PE|pulmonary embolus|PE.|160|162|LABORATORY DATA|Hemoglobin of 7.8-10.7, white count initially was 15.2, platelet count of 589,000. INR is 1.05. Troponin peaked at 0.72. She had a negative CT of the chest for PE. Chest x-ray does show a question of an infiltrate in the left mid lung. Serum iron was low at 18. B12 was OK at 487.
PE|pulmonary embolus|PE|183|184|HISTORY  OF PRESENT ILLNESS|He was also short of breath especially with exertion. He was noted to be diaphoretic when he came in. In the ER, he was found to have a right lower extremity DVT as well as bilateral PE and admitted for further definitive therapy. PAST MEDICAL HISTORY: Remarkable for BPH, previous neck and rotator cuff surgery.
PE|pulmonary embolus|PE,|196|198|LABORATORY DATA|NEUROLOGIC: The patient appears grossly intact and nonfocal. SKIN: No significant rashes or lesions. LABORATORY DATA: Lower extremity ultrasound is negative for DVT. Chest CT scan is negative for PE, but does show a right-sided infiltrate consistent with pneumonia. Troponin level was 0.05. BNP was 525. D. dimer is 2.1. Coagulation studies are essentially normal.
PE|pulmonary embolus|PE|168|169|IMPRESSION|IMPRESSION: The patient is a 75-year-old white female with shortness of breath over the last couple days of unclear etiology at this point in time. She does not have a PE on her CT scan and no signs of any infiltrate. She does have an elevated white blood cell count, but this is most likely due to her PV.
PE|pulmonary embolus|PE.|210|212|IMPRESSION|Chest x-ray shows changes consistent with possible acute pulmonary edema. IMPRESSION: 1. Hypoxia, etiology likely acute pulmonary edema secondary to rule out myocardial infarction. Doubt pulmonary infection or PE. The patient currently is adequately anticoagulated. 2. Acute pulmonary edema, possibly biventricular failure given her underlying severe pulmonary hypertension PFO with right to left shunt.
PE|pulmonary embolus|PE,|262|264|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: Mrs. _%#NAME#%_ is an 86-year-old woman who presents with A-fib with RVR, mild hypotension, urinary tract infection and lightheadedness. She has a history of esophageal cancer resection, coronary artery disease with stent placement, DVT and PE, breast cancer. She does have a stool positive for blood but is on iron. 1. Lightheadedness. This seems most likely related to atrial fibrillation with RVR.
PE|pulmonary embolus|PE,|167|169|PRINCIPAL PROCEDURES|PRINCIPAL PROCEDURES: 1. Orthopedics consultation for operative repair of hip fracture. 2. Chest CT scan with contrast to rule out pulmonary embolism, no evidence for PE, atelectasis noted. Also noted was a 1.5 cm thyroid nodule with recommendation for ultrasound workup. REASON FOR ADMISSION: Please see dictated history and physical.
PE|pulmonary embolus|PE|184|185|MAJOR PROCEDURES|MAJOR PROCEDURES: 1. Chest x-ray on _%#DDMM2007#%_, which demonstrated no interval change in the appearance of the lungs. 2. A CT angiogram of the chest with and without contrast with PE protocol on _%#DDMM2007#%_, which demonstrated: a. No CT evidence of pulmonary emboli on this technically adequate study. b. Extensive reticular opacities with bronchiectasis and paucity off ground-glass appearance are again noted.
PE|pulmonary embolus|PE|142|143|BRIEF HISTORY AND HOSPITAL COURSE|If she cannot reach her predicted heart rate at that time, dobutamine will be used instead. She did undergo a chest CT which did not show any PE or vascular abnormality. For completeness, we ordered some PFTs given her complaints of dyspnea on exertion. There was no evidence to suggest a restrictive or obstructive defect.
PE|pulmonary embolus|PE|186|187|ASSESSMENT/PLAN|ASSESSMENT/PLAN: 54-year-old female with acute exacerbation of chronic back pain and nausea and vomiting. 1. Back pain. Exam and imaging does not show any evidence of aortic dissection, PE or intra-abdominal etiology of the patient's symptoms. She has no significant neurological findings, though it is unlikely that she has a nerve compression either.
PE|pulmonary embolus|PE|157|158|HOSPITAL COURSE|Would also encourage good blood pressure and cholesterol control. History of breast cancer. The patient had been on tamoxifen for 3 years. Due to her recent PE and a small risk from this from tamoxifen, her tamoxifen was discontinued. However, I would like to have her follow up fairly quickly with her oncologist about this change in her medication.
PE|pulmonary embolus|PE.|219|221|LABORATORY DATA|A CBC demonstrates a white count of 11.7. Her chem panel demonstrates an elevated creatinine of 2 with a BUN of 56. Her D-Dimer is elevated a 2.9. Chest CT demonstrates left lower lobe PE with multiple areas of smaller PE. This was given by verbal report by Dr. _%#NAME#%_ in the ED. ASSESSMENT: This is a 64-year-old female, who presents with acute pulmonary emboli.
PE|pulmonary embolus|PE|142|143|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: He has had a myocardial infarction 35 years ago. History of asthma, COPD, bronchitis, and history of DVT and history of PE on anticoagulation. History of hyperlipidemia. History of psoriasis. History of increased PSA. Past surgeries: CABG 32 years ago. Hernia surgery. Prostate biopsy.
PE|pulmonary embolus|PE|234|235|IMPRESSION|Nonetheless, she will need to be ruled out for myocardial infarction and undergo stress echocardiogram. In the interim, because of the mild pleuritic component, possible rub, we will send her down for CT scan of her chest to rule out PE and to better look at that left upper lobe and the mediastinum. Because of her cough, this will better look for possible pneumonia, although she is not febrile and she does not have an elevated white blood count.
PE|pulmonary embolus|PE|158|159|PROCEDURES PERFORMED|(My note: Consolidation was very wedge-shaped and peripheral, reviewed with Pulmonology, and it was felt this could very well be consistent with a peripheral PE with pulmonary infarct.) 2. Ventilation-perfusion scan was officially read as low probability scan for pulmonary embolism with a ventilation defect in the right lower lobe but no corresponding perfusion defect, and there was a small matched ventilation-perfusion defect in the left lower lobe.
PE|pulmonary embolus|PE|118|119|PAST MEDICAL HISTORY|He denies calf pain. He has no history of claudication. There are no claudication symptoms. He has never had a DVT or PE in the past. No history of blood clotting disorders. No family history of clotting disorders. He denies any significant immobility recently aside from the car travel.
PE|pulmonary embolus|PE.|208|210|HOSPITAL COURSE|HOSPITAL COURSE: Syncope: The patient had a syncopal episode, which is likely neurocardiogenic in origin; however, the patient was eventually transferred to the ER and evaluated for potential causes, such as PE. Once it was clear that the patient had no obvious underlying disorder, she was transferred to the medicine team for overnight telemetry and further evaluation.
PE|pulmonary embolus|PE|166|167|IMPRESSION|Chest x-ray shows no acute process, perhaps some evidence of emphysema. IMPRESSION: 1. Respiratory distress with hypoxia. There is no evidence of pneumonia. Consider PE with significant hypoxia. A VQ scan has been ordered. The patient is a poor candidate for CT angio at this time with her acute renal failure.
PE|pulmonary embolus|PE,|143|145|PAST MEDICAL HISTORY|Please see History of Present Illness. 2. CMV negative, HSV positive and EBV positive. 3. Donor CMV negative. 4. History of DVT and associated PE, diagnosed _%#MM#%_ 2005 and treated with Coumadin. 5. History of seizure disorder, last treated in his early 20s. HOSPITAL COURSE: PROBLEM #1: Bone marrow transplant: Nonmyeloablative allogeneic sibling bone marrow transplant for recurrent mantle cell lymphoma occurred on _%#DDMM2006#%_.
PE|pulmonary embolus|PE|310|311|DISCHARGE MEDICATIONS|On the day of discharge, her hemoglobin is 10.7. Her anemia is likely secondary to her recent chemotherapy and given the fact that her count have resolved, her hemoglobin is also stable at this point. Her platelet count is also stable at 69,000. DISCHARGE MEDICATIONS: 1. Lovenox 40 mg subcu daily for DVT and PE prophylaxis. 2. Azithromycin 500 mg p.o. daily x5 more days. 3. Magic mouthwash 15 mL t.i.d. 4. Calcium carbonate 1000 mg p.o. t.i.d.
PE|pulmonary embolus|PE.|220|222|HISTORY OF PRESENT ILLNESS|The patient was admitted yesterday evening with a pulmonary embolism in the left lower lobe diagnosed by CT. Of note, there is noted to be an area of infiltration or infarction in the left lower lobe associated with the PE. The patient was started on Lovenox and Coumadin. Lower extremity ultrasound was performed which did not show any DVTs. The patient also has a history of DVT when she was 15 years old and she also carries a diagnosis of MTH FR enzyme mutation (methylene tetrahydrofolate reductase).
PE|pulmonary embolus|PE.|196|198|HISTORY OF PRESENT ILLNESS|She was kept on Coumadin. She presented to Fairview Northland Hospital with acute onset of chest pain, shortness of breath that woke her up from sleep. A CT scan of the chest was done to rule out PE. There was no PE on exam, however. She had a large pericardial effusion. She was transferred to University of Minnesota Medical Center for further management.
PE|pressure equalization|PE|214|215|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. The patient was born at 36 plus 6 weeks gestational age via normal spontaneous vaginal delivery, no pregnancy complications. 2. Nasolacrimal obstruction. 3. Recurrent ear infection, status PE tubes in _%#DDMM2006#%_. 4. Hyperbilirubinemia requiring bili lights, likely secondary to hematoma related to birth trauma. 5. Croup x2 requiring steroids, but no prior hospitalizations. PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: Temperature 36.8, pulse of 140, blood pressure 124/68, respirations were 24, oxygen saturation 99% on room air, weight was 11.99 kg.
PE|pulmonary embolus|PE|126|127|REVIEW  OF SYSTEMS|She has not yet had this evaluated by her primary care physician. She does not have a history of diabetes mellitus. No DVT or PE history. No travel history. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 120/68, pulse 60, respirations 12.
PE|pulmonary embolus|PE,|188|190|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1: Shortness of breath: Given the patient's recent history of surgery and immobilization, there was concerned about PE. His chest CT did not show any evidence of PE, but it showed extensive emphysema. There were also 2 large lymph nodes. Also, given his known coronary disease, there was concerned about significant coronary obstruction.
PE|pulmonary embolus|PE.|138|140|PROCEDURES|CONSULTATIONS: Pulmonary. PROCEDURES: 1. He had a CAT scan of his lungs which showed the right upper lobe pneumonia, but no evidence of a PE. 2. He also an ultrasound of both legs which did not show a deep venous thrombosis. He had a sed rage which was 90 and angiotensin converting enzyme level which was normal and a neutrophil cytoplasmic antibody screen which was negative.
PE|pulmonary embolus|PE,|295|297|HISTORY OF PRESENT ILLNESS|He was treated conservatively, and serial abdominal exams were performed. Potential need for surgery was obviated, and he finally started to have bowel movements; however, around _%#MM#%_ _%#DD#%_, 2005, he began to develop strange sensations in the chest, and because he had a prior history of PE, he underwent an extensive workup including EKG, troponins, stress echocardiogram, and bilateral upper extremity and lower extremity duplex ultrasound to rule out DVT as well as a spiral CT scan of the chest.
PE|pulmonary embolus|(PE)|160|163|PAST MEDICAL HISTORY|3. Pacemaker. 4. Complete heart block. 5. Status post multiple CVAs with bilateral weakness and aphasia. 6. Deep venous thrombosis (DVT) and pulmonary embolism (PE) history on Coumadin therapy. 7. Recent GI bleed with negative endoscopy. 8. Hypothyroid. SOCIAL HISTORY: Patient lives in community-assisted living.
PE|pulmonary embolus|PE|160|161|HOSPITAL COURSE|UA done on _%#DDMM2006#%_ showed improvement. HOSPITAL COURSE: PROBLEM #1. Right-sided pleural effusion of unknown etiology: The thought behind this was due to PE versus recurrent non-Hodgkin lymphoma versus infection. The patient had a diagnostic and therapeutic thoracentesis done on _%#DDMM2006#%_. The fluid removed from this included Gram stain which was negative, LDH which was 582, protein which was normal, body fluid analysis which was clear with some red cells and nucleated cells, fungal cultures negative at 1 week but still pending, the fluid culture was negative, and cytopathology.
PE|pulmonary embolus|PE|193|194|HOSPITAL COURSE|She underwent gamma knife treatment on _%#DDMM2006#%_ at rehab and was doing well until she developed sudden change in her respiratory status. Spiral CT scan was performed and showed a massive PE on the right. She was transferred to the _%#CITY#%_ ICU and was followed by the primary team, as well as the ICU team and oncology.
PE|pulmonary embolus|PE|143|144|LABORATORY DATA|Electrolytes are within normal limits except for a potassium of 3.3. Liver function tests were within normal limits. D-dimer 0.6. CT scan with PE protocol as above. IMPRESSION: 1. Left lung pneumonia. 2. Suspected urinary tract infection. 3. Depression/anxiety disorder and panic attacks.
PE|pulmonary embolus|PE,|318|320|BRIEF HISTORY OF PRESENT ILLNESS|7. Daily blood cultures from _%#MMDD#%_ to _%#MMDD#%_ have shown no growth to date. BRIEF HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old female with complex past medical history including status post left lung transplant in 2001, coronary artery disease, chronic kidney disease, diabetes and history of DVT, PE, who was at Regency Hospital for rehab on her trach, and was transferred to The University Minnesota Medical Center, Fairview, on _%#DDMM2006#%_ for some dark ulcers that were noted on her feet over The last few days.
PE|pressure equalization|PE|232|233|HOSPITAL COURSE|HOSPITAL COURSE: On _%#DDMM2007#%_, Ms. _%#NAME#%_ _%#NAME#%_ was admitted to the hospital and taken to the operating room. There she had her repair of the left temporal bone encephalocele along with a fat myringoplasty, removal of PE tube and placement of lumbar drain. Postoperatively, she was stable and taken to 6-A PC. On postoperative day #1, however, she started to have slight CSF clear drainage out of her left ear.
PE|pulmonary embolus|(PE)|167|170|HOSPITAL COURSE|In the past it was treated with Gas-X. At present, he is convinced that his chest pain is from chronic bronchitis. b. He was evaluated for possible pulmonary embolism (PE) during his hospital stay. His D-dimer and high resolution CT studies were negative. DISCHARGE MEDICATIONS: Levofloxacin 500 mg p.o. q.d. x 6 more days.
PE|pressure equalization|PE|125|126||She has had progressive increase in conducted hearing loss along with perforation of the left eardrum. She also has retained PE tube on the right. We discussed the risks, benefits and alternatives to exploration of the left ear and possible tympanomastoidectomy with a possible cartilage graft and possible ossicular reconstruction.
PE|pulmonary embolus|PE|170|171|REVIEW  OF SYSTEMS|No fevers or chills. No cough. No dysuria. No bright red blood per rectum or melena. She began her menses yesterday which have been normal for her. She denies any DVT or PE history. She did endorse a bit of abdominal pain, which she thinks started after the morphine was given. She felt a bit bloated and feels perhaps a bit constipated.
PE|pulmonary embolus|PE|159|160|PROCEDURES DONE DURING HOSPITALIZATION|3. Anorexia. 4. Pulmonary embolism. 5. Metastatic nonsmall lung cancer with old right pneumonectomy. PROCEDURES DONE DURING HOSPITALIZATION: CT angiogram with PE protocol. Impression: 1. Small pulmonary embolus in the left lower lobe, medial basilar segment. 2. Stable mass posterior to the distal esophagus. 3. Unchanged lingular opacity possibly representing metastatic disease.
PE|pulmonary embolus|PE|188|189|LABORATORY AND DIAGNOSTIC STUDIES|LUNGS: Diminished at the left base. EXTREMITIES: Without edema. LABORATORY AND DIAGNOSTIC STUDIES: EKG shows normal sinus rhythm with a 1st degree AV block, otherwise no acute changes. CT PE protocol again demonstrates no PE. Left lower lobe consolidation is demonstrated with multiple tiny nodules. ASSESSMENT AND PLAN: 1. Left-sided chest pain, suspect secondary to his local invasive tumor with some pleurisy.
PE|pulmonary embolus|PE,|212|214|PAST MEDICAL HISTORY|SOCIAL HISTORY: Denies. FAMILY HISTORY: Family history of breast and colon cancer. PAST MEDICAL HISTORY: Recurrent UTIs, spinal bifida, Arnold Chiari type 2, malformation with VP shunt neurodermatitis history of PE, asthma, obesity, bilateral BKA amputation second toe osteomyelitis, obstructive sleep apnea, depression, multiple abdominal surgeries, colectomy with colostomy and urostomy with ileal conduit and chronic enterocutaneous fistulas diabetes mellitus type 2.
PE|pulmonary embolus|PE.|188|190|HISTORY OF PRESENT ILLNESS|A lower extremity Doppler was done which was negative for acute DVT in the day of admission. Her symptoms worsen and she arrived in the ED where she underwent CT angiogram, which revealed PE. She also complained today of midsternal pressure-like chest pain 5-6/10 in intensity _____ breathing. She denies previous symptoms. MEDICATIONS: 1. Dilantin. 2. Vicodin. SOCIAL HISTORY: Denies alcohol, tobacco.
PE|pulmonary embolus|PE.|303|305|PLAN|He does also have a clear reason for his pneumonia with a bilateral infiltrate on his CT and chest x-ray and the productive cough. However, if he does not improve or there is any concerning new symptom, another repeat CT scan of the chest or a V/Q scan might be helpful to further evaluate and rule out PE.
PE|pressure equalization|PE|131|132|PHYSICAL EXAMINATION|HEENT: Atraumatic, normocephalic. The TMs had PE tubes bilaterally. TMs were erythematous. Dad could not remember when this set of PE tubes was placed. PERRLA. Extraocular movements intact. Both upper lids and lower lids on the left side were involved. She did have a positive bilaterally red reflex. No photophobia.
PE|pulmonary embolus|PE|187|188|DIAGNOSTIC STUDIES|Urinalysis was negative. Troponin was negative x1. DIAGNOSTIC STUDIES: CT scan of the chest showed marked bile duct dilation at pancreatic head with no identifiable cause. No evidence of PE or infiltrates. ASSESSMENT AND PLAN: This is a 72-year-old Laotian male with history of GERD, hyperlipidemia and hypothyroidism, who presents with complaints of right upper quadrant pain, nausea and vomiting, who is found to have marked bile duct dilation and increased bilirubin with eosinophilia on laboratory investigation.
PE|pulmonary embolus|PE.|21|23|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: PE. DISCHARGE DIAGNOSES: 1. PE. 2. DVT. 3. Small cell invasive bladder and urethral cancer, status post radical cystectomy and ileostomy.
PE|pressure equalization|PE|140|141|PAST MEDICAL HISTORY|He had recurrent acute otitis media in infancy. He has a history of asthma, for which he last received medications at age 4-5 years. He had PE tubes placed at age 11 months. Immunizations are up to date. DRUG ALLERGIES: Erythromycin, penicillin, Zithromax, sulfa, Augmentin, Cefzil, Septra and Biaxin, all of which are stated to cause a rash.
PE|pulmonary embolus|PE.|154|156|HOSPITAL COURSE|He was instructed to seek medical attention if he has persistent diarrhea. 3. Right subclavian occlusive thrombus. This was noted on chest CT to rule out PE. Upper extremity Doppler showed occlusive thrombus. Patient has had previous dialysis catheter at that site at _%#COUNTY#%_ _%#COUNTY#%_ and was noted to have a clot at that site.
PE|pulmonary embolus|PE|141|142|HISTORY OF PRESENT ILLNESS|The studies from her lumbar punctures as well as other labs have been unremarkable and nonhelpful for her diagnosis. Of note, she also had a PE that was diagnosed during a prior admission. Today, she came into the clinic again for a stealth-guided biopsy for this lesion and tissue was needed in order to obtain a diagnosis.
PE|pulmonary embolus|PE,|100|102|6.  GU|7. Infectious disease: See above GU section. 8. Cardiovascular: No issues. 9. Pulmonary: History of PE, thus anticoagulation was continued throughout this admission. DISCHARGE INSTRUCTIONS: The patient will follow up with Dr. _%#NAME#%_ in 3 weeks' time for further treatment planning.
PE|pulmonary embolus|PE|176|177|HOSPITAL COURSE|EKG: Rate of 88. Normal sinus rhythm. No acute ST or T changes. HOSPITAL COURSE: Dyspnea on exertion. The spiral CT initially was interpreted as possibly having a subsegmental PE in the left upper lobe. However, the final read on the morning after admission was that there was clearly no evidence of PE.
PE|pulmonary embolus|PE.|205|207|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 76-year-old man who is about three weeks status-post right hip unipolar hemiarthroplasty. He was initially admitted with a femoral neck fracture and had problems with a PE. For this reason, he was placed on Coumadin and was admitted to the ICU for an extended period of time. He had a filter placed. He subsequently underwent a right hip unipolar hemiarthroplasty.
PE|pulmonary embolus|PE.|271|273|LABORATORY DATA|Neuro: Cranial nerves II through XII are intact, nonfocal. LABORATORY DATA: Chest CT of the chest with IV contrast shows no evidence of dissection, masses or adenopathy. Limited opacification of smaller vessels with some decreased filling but no definitive PE or central PE. Cannot rule out small right lower lobe PE per Radiology. No infiltrate or pneumothorax. Sodium was 141, potassium 3.8, glucose 80, creatinine 0.7, bicarb 24, chloride 106, BUN 9.0, WBC 5.5, hemoglobin 12.6, normal differential.
PE|pulmonary embolus|PE.|185|187|SECONDARY DIAGNOSIS|The patient had low probability of a PE, had negative bilateral lower extremity Dopplers per our ultrasound lab and also an additional repeat CT with PE protocol which was negative for PE. She did show some bilateral basilar atelectasis which was consistent with previous CTs and x-rays. 3. CV. The patient had negative troponin and no significant ST wave changes, so this is likely not the etiology of her mental status changes.
PE|pulmonary embolus|PE|315|316|LABORATORY DATA|rate was 129, myoglobin 17, troponin less than 0.07. White count 5.3, red blood cell count 2.88, hemoglobin 8.5, hematocrit 25.3. She has neutrophils increased, bands 94%, metamyelocytes at 0.1%, platelets 316,000. Her chemistries - D-dimer was positive but the patient is allergic to contrast dye so a CT scan for PE was not done. BUN 23, calcium 7.8, chloride 92, bicarb 18, creatinine 0.8, glucose 110. Potassium 5.1, platelets 316,000, sodium level 120. IMPRESSION: 1. At this time is respiratory distress.
PE|pulmonary embolus|PE|148|149|HISTORY  OF PRESENT ILLNESS|He had an EKG which shows a corrected prolonged QTC of 599 which is new compared to _%#DD2007#%_. In addition, a chest CT with contrast to rule out PE showed no PE, however, there was prominent collateral flow in the left hemithorax, suggesting a high grade stenosis or occlusion of the proximal left upper extremity.
PE|pulmonary embolus|PE.|167|169|HOSPITAL COURSE|His discharge hemoglobin is 10.9. While in the emergency room, the emergency room physician considered pulmonary embolism, obtained a CT scan of the chest to rule out PE. There was no PE, however, there was incidental findings of new mediastinal and hilar adenopathy. This was felt to be new compared to 2004. Oncology was called in for consultation and will continue to pursue workup in the outpatient setting.
PE|pulmonary embolus|PE|177|178|HOSPITAL COURSE|The patient did have echocardiogram which showed positive bubble study. This may need to be assessed later on. The patient did have a CT scan of the chest that was negative for PE but which did show a pulmonary nodule which should be followed up in 3-6 months. Overall there are no at risk events on monitor. The patient did have one spell during the stay after her ultrasound where she developed chest pain and had a moment where she did not remember recent conversation that took place.
PE|pulmonary embolus|PE|168|169|HISTORY OF PRESENT ILLNESS|She got some nitroglycerin and Ativan, and with this her pain levels improved. It is now about 2/10. Her D-dimer was slightly positive, and thus she had a CT chest per PE protocol, which did not show a PE. Given the fact that she has a lot of risk factors for heart disease, I was contacted to admit her.
PE|pulmonary embolus|PE.|204|206|TESTS DONE DURING THIS HOSPITALIZATION|2. Echocardiogram done on _%#DDMM2007#%_ showed an ejection fraction of 45-50% with mild-to-moderate anterior septal and apical hypokinesia. 3. VQ scan of the lung done on _%#DDMM2007#%_ was negative for PE. REASON FOR ADMISSION AND HOSPITAL COURSE: The patient is a 50-year-old man with a history of non-Hodgkin's lymphoma in remission and IgA nephropathy and ITP status post splenectomy.
PE|pulmonary embolus|PE|341|342|ASSESSMENT  AND PLAN|I probably feel there is a component of anxiety here, but she has been more depressed, lying around, sleeping a lot and has had this left leg pain, although with negative ultrasounds and I think it is probably arthritic, but with the more shortness of breath and chest pressure that comes on suddenly, I will need to rule out things such as PE and cardiac. 2. Hypertension, continue her atenolol, lisinopril, hydrochlorothiazide. 3. Arthritis, continue some tramadol and Tylenol for pain. 4. Recent diagnosis of depression, started on medication, continue that.
PE|pulmonary embolus|PE,|254|256|HOSPITAL COURSE|HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 79-year-old female with a history of rheumatic heart disease, status post mitral valve replacement _%#DDMM1999#%_. The patient also has been troubled with strokes, chronic atrial fibrillation, COPD, history of PE, H. pylori infections. The patient presented to the hospital complaining of bright red blood per rectum. Initial evaluation demonstrated a hemoglobin of 11.7. The differential diagnosis of ischemic colitis versus diverticular bleed.
PE|pressure equalization|PE|241|242|PAST MEDICAL HISTORY|MEDICATIONS: Lisinopril 10 mg a day. MAJOR DIAGNOSES: Hypertension, history of sleep apnea, thyroid ductal cyst, mild obesity. HOSPITALIZATIONS: None. SURGERIES: He is status post a thyroglossal cyst removal, hernia repair, uvulectomy, T&A, PE tube placement. FAMILY HISTORY: His father had colon cancer but at age 68.
PE|pulmonary embolus|PE.|122|124|HOSPITAL COURSE|Because of this she underwent CT scan of her chest. Of note, the patient was in in _%#MM#%_ 2006 and was some concern for PE. However, given that it was a very marginal suggestion on a CT scan and that she had negative Doppler, it was felt that given her age and her clinical stability that anticoagulation was not indicated.
PE|pulmonary embolus|PE|180|181|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1: Chest pain/shortness of breath: The patient was ruled out for myocardial infarction with serial troponins. His EKG was unchanged. He was ruled out for PE with a CT angiogram of the chest. Ultimately, it was felt that his pain was not related to an intrinsic process, but was rather chest wall pain likely from contusion suffered from one of his falls.
PE|pulmonary embolus|PE|162|163|HISTORY OF PRESENT ILLNESS|She states that she has had multiple arterial clots related to her phospholipid syndrome. She has had an infarct to her kidney and to her legs as well as DVT and PE the past. She is currently on Warfarin, but had been noted on _%#DDMM2006#%_ to have a subtherapeutic INR of 1.87 and a factor 2 level of 31%.
PE|pulmonary embolus|PE|111|112|HISTORY OF PRESENT ILLNESS|He has noticed some increasing lower extremity edema, but has not noticed any weight changes. He has no DVT or PE history. He does not endorse any cardiac history, but his medication package includes medications like lisinopril and Lasix. Apparently today, while the patient was trying to get up, he fell down and was unable to get up from the floor.
PE|pressure equalization|PE|208|209|PAST MEDICAL HISTORY|Also, see his note, as well. The patient is also in the process of workup to determine the etiology of her panuveitis, as well. She will be seeing a rheumatologist on _%#DDMM2003#%_. PAST MEDICAL HISTORY: 1. PE tube placement in 1991. 2. Tendon laceration and repair as a child to her right foot. 3. Mononucleosis age 7. 4. History of right strabismus, but at this point with it being more uveitis, I really felt that she probably does not have any further strabismus.
PE|pulmonary embolus|PE.|220|222|PLAN|Did have episode of bradycardia down to the 30s in the ER at Ridges and for that reason beta blockers were avoided at that point. Did have a CT of the chest, which showed some granulomatous disease, but was negative for PE.
PE|pulmonary embolus|PE,|168|170|PHYSICAL EXAM|His EKG reviewed by me is normal except for right bundle branch block. His labs otherwise are unremarkable, including his initial enzymes. CT of the chest was done for PE, and that is unremarkable. He had a mildly elevated D-Dimer. ASSESSMENT AND PLAN: Shortness of breath. I doubt cardiac, but feel it would be appropriate to rule him out for that.
PE|pressure equalization|PE|176|177|HISTORY OF PRESENT ILLNESS|As mentioned above, the patient has seen Dr. _%#NAME#%_ for this in the past and had PE tube placed approximately three years ago. He states that for the next six months after PE tube was placed, he had no episodes of vertigo whatsoever. Once the ET tube fell out his symptoms have recurred. No recent follow up in this regard. Interestingly, when he blows his trumpet, sometimes he will create the same pressure and improve his vertiginous symptoms should they be present.
PE|pulmonary embolus|PE|163|164|HISTORY OF PRESENT ILLNESS|In the emergency department, her oxygen saturations were in the 70% range and she was put on 15 liters of oxygen by face mask. V/Q scan showed high probability of PE and she was admitted for pulmonary embolus. PAST MEDICAL HISTORY: This is obtained from the previous chart.
PE|pulmonary embolus|PE.|216|218|IMAGING|It may also represent some small vessel ischemic changes. No acute findings or hemorrhage. 2. CT of chest with contrast showed transient fibrosis in both lungs. Old bilateral rib fractures. Otherwise, no evidence of PE. 3. MRA of brain showed scattered nonspecific signal hyperintensities in the supratentorial white matter and brain stem. These are nonspecific but most likely due to chronic small vessel ischemic changes.
PE|pulmonary embolus|PE|163|164|ASSESSMENT|Her presentation is not consistent with intraabdominal abscess; however, this may be in the differential. Her shortness of breath and chest pain was evaluated for PE and no evidence of PE or cardiac ischemia at this point. ASSESSMENT: 1. Abdominal pain. 2. Chest tightness and shortness of breath.
PE|pulmonary embolus|PE|206|207|ASSESSMENT AND PLAN|3. Diabetes mellitus. Blood sugar control is adequate, rarely requiring insulin. We will continue the glipizide. 4. History of atrial fibrillation/PE. Continue with anticoagulation at this time. While this PE was quite sometime ago and his atrial fibrillation was recent and recurrent. 5. Deconditioning. We will consider PT/OT to work with the patient while he is in the hospital.
PE|pulmonary embolus|PE.|143|145|PAST MEDICAL HISTORY|So Coumadin has been stopped since. 2. History of prolonged hospitalization after a fall 3 years ago complicated by deep venous thrombosis and PE. She has been on Coumadin for the last 3 years until _%#MM#%_ of this year when she had the cerebral bleed. 3. COPD. 4. History of MI and coronary artery disease.
PE|pulmonary embolus|PE,|363|365|HISTORY OF PRESENT ILLNESS|That seems to have resolved at this point and she has had again some improvement in the right leg symptoms. She was seen in clinic and was noted to have quite a bit of swelling unilaterally and she was referred for an ultrasound to rule out or rule in DVT as well as a CAT scan due to her complaint of chest pain and dyspnea; both tests were positive for DVT and PE, respectively. PAST MEDICAL HISTORY: Significant for breast cancer. The patient was initially diagnosed in 1986 with ductal carcinoma in situ of the right breast treated with lumpectomy and radiation in 2004.
PE|pulmonary embolus|PE|141|142|REVIEW OF SYSTEMS|No nausea, vomiting or abdominal pain. Bowels are irregular, no blood in the stool. No GU symptoms. No history of transfusion, no history of PE or DVT. He has back pain for which he obtained an MRI of his thoracic spine showing some mild disk bulges.
PE|pulmonary embolus|PE.|170|172|REVIEW OF SYSTEMS|RESPIRATORY: Negative. GI: Negative. GU: Negative. MUSCULOSKELETAL: Positive for bad back helped by physical therapy, is about 99% better. No previous transfusion DVT or PE. Sleeps well, energy level is fine. The rest of the review of systems normal or negative. PHYSICAL EXAMINATION: The patient is 338 pounds. VITAL SIGNS: Blood pressure 142/86.
PE|pressure equalization|PE|155|156|PAST SURGICAL HISTORY|6. History of opioid abuse, remission since 2000. 7. History of alcohol abuse. 8. Pneumonia in _%#DDMM2006#%_. PAST SURGICAL HISTORY: 1. Tonsillectomy. 2. PE tubes. 3. Tympanoplasty. 4. Mastoidectomy. 5. Left foot surgeries. REVIEW OF SYSTEMS: GENERAL: The patient denies fevers or weight changes, but does have multiple allergies and is noting shortness of breath and sputum production with cough.
PE|pulmonary embolus|PE|122|123|HOSPITAL COURSE|This CT scan was read by staff radiologist at the University of Minnesota and felt that there was no evidence for a large PE but that a smaller PE could not be ruled out. The radiologist felt that this study was inadequate and that the patient might benefit from a CT angiogram.
PE|pulmonary embolus|PE.|175|177|HOSPITAL COURSE|There was a concern for possible reocclusion and/or other complications. There was also concern for possible pulmonary embolism. The patient's CT chest angio was negative for PE. Additionally, the patient's troponins were mildly elevated with value of _____(1:24)_. The patient was started empirically on heparin drip. Overall, her EKG was negative, and her troponins were negative.
PE|pulmonary embolus|PE,|232|234|IMPRESSION|The pain does have some typical and atypical features in it, although the fact that it is associated with exertional fatigue makes it more likely to be of cardiac origin. There does not appear to be any significant risk factors for PE, normal recent recumbency or trauma. It also does not appear to be musculoskeletal. PLAN: 1. We will admit the patient to the cardiac floor and we will use the chest pain, rule out MI pathway with serial enzymes and EKGs.
PE|pulmonary embolus|PE,|189|191|HISTORY OF PRESENT ILLNESS|There was no chest pain. The patient was given fluids, he was brought to ER. In the ER, he received 1 liter of normal saline and blood pressure improved. Patient had a CT chest to rule out PE, and this was negative. The patient had undergone a CT of the head in _%#MM#%_.
PE|pulmonary embolus|PE,|245|247|HOSPITAL COURSE|He was also given inhaled bronchodilator therapy, which was changed to his home medication regimen at the time of discharge. PROBLEM #3. Acute blood loss anemia: The patient was on warfarin on his admission to the hospitalization for his recent PE, however he developed melena halfway through his hospitalization. Hemoglobin dropped to as low as 7 and the patient required 3 units of packed red blood cells to be transfused while his INR was noted to be supratherapeutic at 3.9. This was thought to be secondary to medication related effect.
PE|pulmonary embolus|PE,|188|190|HOSPITAL COURSE|The patient understands if her symptoms do get worse to come back to the ER or follow up with Dr. _%#NAME#%_ with a more recent scan. 2. Dyspnea on exertion. The patient was ruled out for PE, possibly asthma secondary to cancer progression. However, the patient did well on the inhalers and nebulizers, and the patient will go home with an inhaler.
PE|pulmonary embolus|PE,|133|135|HOSPITAL COURSE|She was subsequently transferred to Fairview Ridges. In the emergency room, she underwent a VQ scan which was highly suggestive of a PE, a CT scan which showed a left pulmonary artery emboli. She was subsequently started on heparin and admitted to the hospital.
PE|pulmonary embolus|PE,|275|277|HOSPITAL COURSE|The rheumatology service ultimately recommended that Ms. _%#NAME#%_ be discharged on her outpatient regimen of prednisone with the added precaution of not restarting her methotrexate too soon in the postoperative period. Regarding her anticoagulation and history of DVT with PE, Ms. _%#NAME#%_ was started on enoxaparin, and a hematology consult was obtained to further evaluate her anticoagulation status. Their recommendations were to continue her enoxaparin on discharge and for her to follow up with her primary care physician to determine the necessity of continuing with this anticoagulation.
PE|pulmonary embolus|PE.|127|129|HOSPITAL COURSE|The patient's breathing had not improved much so we did a chest CT with pulmonbary embolus protocol which was negative for any PE. The patient did continue to be more anxious and thus his Prednisone was tapered down to 20 mg po q d per pulmonary. Despite being treated for his COPD the patient and the patient's family did opt for a second opinion with her primary M.D.
PE|pulmonary embolus|PE.|198|200|OPERATIONS/PROCEDURES PERFORMED|Because the contrast extravasated into the patient's left upper extremity, it was not performed with contrast. It did, however, show some patchy infiltrates bilaterally. 2. VQ scan was negative for PE. HOSPITAL COURSE: Patient presented to the emergency department with acute severe shortness of breath and cough.
PE|pressure equalization|PE|118|119|HISTORY OF PRESENT ILLNESS|Admitting diagnosis is acute gastroenteritis with dehydration. She is being admitted for IV fluids and will defer her PE tube surgery until a later date. We will check a CBC and electrolytes, and Dr. _%#NAME#%_ will assess her in the morning.
PE|pulmonary embolus|(PE)|186|189|HISTORY OF PRESENT ILLNESS|The patient denied any pain. The patient was evaluated by Dr. _%#NAME#%_ _%#NAME#%_ and chest x-ray failed to reveal pneumonia. A CT scan was obtained of the chest and pulmonary embolus (PE) was ruled out. The patient was still slightly confused and ataxic. She was given 1-g Rocephin and 500-mg of azithromycin and admitted to the Medicine Service.
PE|pulmonary embolus|PE.|231|233|LABORATORY DATA|LABORATORY DATA: White count is elevated at 15.4, hemoglobin is 12.6, potassium 3.3 with a creatinine of 0.75. His proBNP is normal. UA is negative. VQ scan demonstrates mass in the left lobe, defect considered low probability for PE. Ventilation defect appears to be slightly greater then perfusion. Chest x-ray on my read demonstrates a hazy opacity in the left lower lobe and quite suspicious for infiltrate.
PE|pulmonary embolus|PE|195|196|PLAN|These include her history of symptoms with exertion. 2. The fact that the pain is quite reproducible makes it much more significantly related to musculoskeletal cause. I doubt that she has had a PE with negative VQ scan and symptoms are not consistent with a pulmonary acute pulmonary embolism. PLAN: 1. Stress test this a.m. 2. Start her on some NSAIDs.
PE|pulmonary embolus|PE.|201|203|HISTORY OF PRESENT ILLNESS|His symptoms seem to come and ago. He has been sleeping somewhat poorly because of his discomfort. He has not had similar symptoms in the past. The patient has no cardiac history. No history of DVT or PE. In addition to the above, the patient has noticed a bit of decreased oral intake for the past several days related to his pain.
PE|pulmonary embolus|PE|217|218|HISTORY|HISTORY : _%#NAME#%_ _%#NAME#%_ is a 37-year-old white female with onset of back pain yesterday that caused moderately severe pain, hurt to move, hurt to breathe. She vomited at one occasion, came to the ER. Scan for PE was positive in the lung. She was admitted. At the moment she is being examined, she denies any significant pain.
PE|pulmonary embolus|PE|187|188|MAJOR INVESTIGATIONS DONE DURING THIS HOSPITALIZATION|DIAGNOSES: 1. Acute pulmonary embolism with pulmonary infarction, pleurisy, and hemoptysis. 2. Depression. MAJOR INVESTIGATIONS DONE DURING THIS HOSPITALIZATION: 1. CT scan of the chest, PE protocol done on _%#DDMM2007#%_. The CT scan showed a small pulmonary embolus in the left medial basal segment of the pulmonary artery with an area of ground glass opacity consistent with ischemia or early infarction of the lung parenchyma.
PE|pulmonary embolus|PE|253|254|PAST MEDICAL HISTORY|She has had arthritis, polymyalgia rheumatica, hiatal hernia, GERD, coronary artery disease, DVT, pulmonary embolus, hypertension, hyperlipidemia. She has had both knees replaced, three-vessel bypass in 1988, oophorectomy for benign mass in 1995, small PE in 1997, cataracts, bulging disc, small myocardial infarction in 1997, and a history of a villous adenoma removed in 1999. FAMILY HISTORY: Negative. ALLERGIES: 1. Sulfa. 2. Morphine. 3. Penicillin.
PE|pulmonary embolus|PE.|153|155|PROBLEM #4|In light of the improved respiratory status of the patient and a negative Doppler, it was felt that the indeterminate VQ scan did not represent an acute PE. Heparin was therefore discontinued and Coumadin was not started. DISPOSITION: Follow up with Dr. _%#NAME#%_ in one to two weeks. CBC, differential, platelets, and SMA-10.
PE|pulmonary embolus|PE|119|120|ASSESSMENT AND PLAN|2. History of glioblastoma multiforme. This is stable. He can take his own thalidomide at night. 3. History of DVT and PE with IVC filter in place. Will continue his Coumadin. 4. Chest pain preceded his fracture. Given his history of cancer, will check CT of his chest to rule out a metastatic process or infection.
PE|pulmonary embolus|PE,|127|129|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|He also had lower extremity doppler which found no evidence for DVT. His vital signs have not been necessarily consistent with PE, i.e. his heart rate has been normal and his O2 sats have been acceptable on room air. He was admitted for further evaluation and treatment. He was ruled out for myocardial infarction by serial EKGs and troponins.
PE|pulmonary embolus|PE.|171|173|FAMILY HISTORY|She had heart disease, breast cancer, fibroids, and died of a stroke. Grandfather on the mother's side had blindness and prostate cancer. Father died in the late 50s of a PE. The patient has one sister with type II diabetes diagnosed in the age 50s and fibroids. There is no ovarian or colon cancer present in the family.
PE|pulmonary embolus|PE|235|236|PLAN|Will continue to monitor it. 6. Pulmonary. Concern for PE with her metastatic cancer, family history, smoking. Unfortunately, with her creatinine, unable to do a CT scan to rule out this out, thus we will treat her as if she has had a PE until we are able to get a scan with enoxaparin.
PE|pulmonary embolus|(PE)|195|198|PROCEDURES AND TESTS|2. Imaging studies with initial chest x-ray revealing anomalous hemidiaphragms bilaterally, calcified granuloma, prominent nipple shadow on the right. CT scan of the chest for pulmonary embolism (PE) confirming granuloma, identifying two additional tiny mid lateral lung nodules. No evidence for pulmonary embolism (PE). No evidence for mass.
PE|pulmonary embolus|PE|206|207|HOSPITAL COURSE|Liver enzymes were negative on _%#DDMM2004#%_. Venous doppler of the lower extremity was negative bilaterally on _%#DDMM2004#%_. Chest x-ray was negative on _%#DDMM2004#%_. CT of the chest showed extensive PE with branches of both main pulmonary arteries, also a small clot in the right main pulmonary artery. Additional information: The patient had Greenfield filter placed approximately 10 years ago.
PE|pulmonary embolus|PE|215|216|HISTORY OF PRESENT ILLNESS|He also had an MRI _%#DDMM2004#%_ which showed possible metastases of right L-4 vertebral body and left lateral disc protrusions at L2-3 and L3-4 with associated foraminal stenosis. The patient also had question of PE at that time, but it was deemed to be low probability. He was admitted at that time with left back and hip, right flank and right abdominal pain.
PE|pulmonary embolus|(PE),|340|344|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is an 85-year- old white female with a history of breast cancer, uterine cancer with a history of radiation enteritis, status post colon resection and subsequent colostomy, kidney stones, recurrent urinary tract infections (UTI), deep vein thrombosis (DVT) and pulmonary embolus (PE), vitamin B12 deficiency, who is followed by Dr. _%#NAME#%_ _%#NAME#%_. The patient awoke last evening with chills, her stomach felt funny and she was nauseated, and she had some crampy abdominal pain.
PE|pulmonary embolus|PE|170|171|CHIEF COMPLAINT|The brain parenchyma and subarachnoid spaces are normal. There was no evidence for intracranial hemorrhage or focal lesion. With the concerns that the patient may have a PE causing his shortness of breath, PE protocol was performed. With complaints of abdominal pain, a CT of his abdomen and pelvis was also obtained.
PE|pulmonary embolus|PE,|133|135|HOSPITAL COURSE|Because the patient had some pleuritic component and some chest pressure with a deep breath, he underwent a CT angiogram to rule out PE, which was negative. However, a pulmonary nodule was seen on this CT scan. The pulmonary team was consulted. There was a question of whether there may be a malignant process, given that the patient also has concomitant voice hoarseness.
PE|pulmonary embolus|PE.|252|254|HISTORY OF PRESENT ILLNESS|Briefly, Mr. _%#NAME#%_ _%#NAME#%_ is a 50-year-old gentleman with a history of Kartagener syndrome and severe bronchiectasis, who underwent bilateral single lung transplant in _%#DDMM2006#%_. The patient's course was complicated by history of DVT and PE. He presented to the Emergency Department with a 48-hour history of fatigue, chills, weakness and fevers up to 102 degrees. A chest x-ray done in the Emergency Department was felt to show a new left lower lobe infiltrate; therefore, the patient was admitted for treatment of pneumonia.
PE|pulmonary embolus|PE|179|180|HOSPITAL COURSE|She was also started on quinine for her leg cramps which she did seem to improve. 5. Acute on chronic renal insufficiency. The patient had a CT pulmonary angiogram throughout her PE which was negative. Unfortunately the dye load put her in worsening of her renal failure. Her ACE inhibitor and Lasix were held for a couple of days and her creatinine did come down with a current discharge creatinine of 1.56. The patient was restarted on her Lasix and lisinopril.
PE|pulmonary embolus|PE.|192|194|PHYSICAL EXAMINATION|Left leg without edema. Chest x-ray shows possible pulmonary vascular congestion and a right hilar infiltrate. CT of her chest showed air space disease consistent with infiltrate or edema. No PE. Urinalysis was trace of blood, WBC 5-10. Sodium 128, potassium 3.5, chloride 88, bicarb 31, BUN 8, creatinine 0.66, glucose 141.
PE|pulmonary embolus|PE.|138|140|HOSPITAL COURSE|The patient was started on empiric antibiotics, ceftriaxone, azithromycin. CT scan of the chest was performed and there is no evidence of PE. There was cholelithiasis with numerous small gallstones. There was concern of a early right lower lobe pneumonia on plain x-ray. The patient also had a head CT because of her confusion.
PE|pulmonary embolus|PE.|125|127|HISTORY OF PRESENT ILLNESS|They have been told that the leg edema is more likely secondary to "old age." Her family is not aware of a history of DVT or PE. It is not clear if the patient does have a history of hypertension. Again, her family is not aware of a history of cardiac or pulmonary disease.
PE|pulmonary embolus|PE.|159|161|LABORATORY DATA|LABORATORY DATA: Her EKG showed normal sinus rhythm with a rate of 66. Chest x-ray needs to be reviewed but was negative per ER report. CT of her chest had no PE. She had a BNP that was 50, D- Dimer that was 0.4. Her white count was 8.4, hemoglobin 12.6. Her diff had 68 neutrophils, 26 lymphs, 5 monos, 1 eos.
PE|pulmonary embolus|PE.|183|185|HOSPITAL COURSE|Since she has a recent history of DVT and PE, she was started also on anticoagulation and will need to continue anticoagulation, possibly lifelong as she has previously had a DVT and PE. This issue will need to be addressed with her primary care physician when she is discharged from the rehab facility. Also, the patient has had a recent skin graft and a history of falls, so Physical Therapy/Occupational Therapy has seen her and evaluated her.
PE|pulmonary embolus|PE.|131|133|HOSPITAL COURSE|A follow-up VQ scan was obtained which showed a matched defect in the lower lobe and was essentially low to indeterminate risk for PE. By the end of this workup period, the patient was able to ambulate without assistance, was breathing without oxygen with excellent saturations and was tolerating oral pain medication with good results as well as a general diet.
PE|pulmonary embolus|PE|185|186|PAST MEDICAL HISTORY|1. Recent hospitalization _%#DDMM#%_ to _%#DDMM#%_ with MRSA, tracheal bronchitis, mildly acute rejection. CMV positive on bronch, anemia, and with an intubated ICU stay. 2. History of PE in 2002 in her right transplanted lung. 3. Status post-right lung transplant 2001 for COPD and emphysema. 4. Hypertension. 5. Hypercholesterolemia. 6. Diabetes. 7. GERD. 8. Paroxysmal atrial fibrillation.
PE|pulmonary embolus|PE.|203|205|PROCEDURES|She currently lives with her husband. She has been in and out of the hospital recently, with a decrease in her ability to function in her daily activities. PROCEDURES: 1. CT of chest without evidence of PE. There is a patchy ground-glass attenuation of the transplant lung, but is much less extensive compared to previous study. 2. Echocardiogram showed mild LVH with a normal global LV systolic function.
PE|pulmonary embolus|PE.|202|204|PAST MEDICAL HISTORY|4. Recurrent CVA in _%#MM#%_ 2003 with MRI, MRA, and head CT, all showing small vessel ischemic disease but no infarct. 5. History of spiral CT with contrast of the chest in _%#MM#%_ 2003. Negative for PE. 6. Factor V Leiden deficiency diagnosed in 1992 during a workup for excessive menstrual bleeding. 7. Fibromyalgia. 8. Migraine and tension headaches chronically. 9. Degenerative joint disease.
PE|pressure equalization|PE|224|225|FAMILY HISTORY|5. ADHA with a trial of Ritalin. FAMILY HISTORY: Family history is also known for father who has frequent otitis and PE tubes until he was nine years of age. He also has a 1-year-old sister who has frequent otitis media and PE tube placed. There is no other significant family history. SOCIAL HISTORY: Please see the History of Present Illness.
PE|pulmonary embolus|PE|167|168|HOSPITAL COURSE|She passed flatus but had not had a bowel movement at the time of discharge. On postoperative day #1, she had some chest pain and shoulder pain and had a workup for a PE which was negative. She was seen by the hospitalist and the findings were felt to be negative. She did have some residual hypertension. Her blood pressure has been in the 140's/70-80's.
PE|pulmonary embolus|PE|208|209|ASSESSMENT AND PLAN|He does not have any lower extremity edema. ASSESSMENT AND PLAN: Spinal stenosis with polyradiculopathy status post laminectomy, deconditioning secondary to pulmonary embolus. Begin a bowel program, DVT, and PE management for primary care physician converting to Coumadin. DISCHARGE PLANNING: We will schedule another conference. Again, estimated length of stay is 7 to 10 days with a good prognosis.
PE|pulmonary embolus|PE.|137|139|ADMISSION DIAGNOSIS|Workup was performed, which included a spiral CT to evaluate for PE as well as possible pneumonia. The spiral CT scan was negative for a PE. The diagnosis was most likely a pneumonia. The patient was started on IV antibiotics with Zosyn followed by Levaquin. She did develop a reaction to Zosyn and was switched over to Levaquin.
PE|pulmonary embolus|PE.|187|189|5. GYN|2. Infectious Disease/sepsis: The patient was treated with IV antibiotics. This did evolve into a pneumonia which was changed to aggressive IV antibiotic therapy. She was ruled out for a PE. 3. Heme: Hemoglobin dropped from 9.8 to 8.3 postoperatively, and secondary to acute blood loss the patient did experience, concerns for initial DIC with elevated coagulopathy; however, platelets did remain stable, but the patient was transferred to the ICU for care.
PE|pulmonary embolus|PE|209|210|PROCEDURE/STUDIES PERFORMED|The patient was actually switched to enoxaparin and this is also in response to the anticipation of upcoming chemotherapy treatment. The patient will remain on enoxaparin therapy because of the history of her PE and left atrial clot. DISCHARGE MEDICATIONS: 1. Neurontin 300 mg p.o. b.i.d for 3 days and then 300 mg p.o. t.i.d. That can be increased if she is still having trouble controlling pain.
PE|pulmonary embolus|PE.|166|168|PROBLEMS|PROBLEMS: 1. Shortness of breath and chest pain. As above, the patient had a full evaluation in the emergency department on _%#MM#%_ _%#DD#%_, which was negative for PE. However, given the patient's history of hypercoagulability and recent pelvic procedure, we felt that additional studies were indicated to adequately rule out PE.
PE|pulmonary embolus|PE.|241|243|ASSESSMENT AND PLAN|There is no true S1Q3T3 pattern. VQ scan is reportedly low probability, although I have not seen the official report. ASSESSMENT AND PLAN: 1. Back pain/posterior thoracic chest pain. The etiology is unclear. Given elevated D-Dimer, consider PE. VQ scan is low probability. Also consider kidney stone given the radiation and migration of the pain around the right front part of the abdomen.
PE|pulmonary embolus|PE,|174|176|EXAMINATION|ABDOMEN: Bowel sounds are present, soft, nontender, nondistended. No hepatosplenomegaly. GENITALIA: Deferred. EXTREMITIES: No edema. Calves are nontender. Chest CT showed no PE, but there was a right upper lobe infiltrate with some mediastinal adenopathy. ECG showed a sinus rhythm with occasional PVCs and possible atrial left enlargement.
PE|pulmonary embolus|PE.|226|228|PROCEDURES|4. Question of obstructive sleep apnea. PROCEDURES: Chest x-ray on admission showing some density along the right heart border which may represent prominent fat pad atelectasis or infiltrate. Chest CT with contrast showing no PE. No consolidation or pleural effusions. Area of scarring in the left mid lung. Fatty liver incidentally noted. Followup chest x-ray showing no significant interval change from _%#DDMM2004#%_.
PE|pulmonary embolus|PE|207|208|HISTORY OF PRESENT ILLNESS|She does have one prior history of a panic attack and severe dyspnea from this, though states that the current symptoms are somewhat different. No other complaints. CT scan of the chest was done to rule out PE and is negative for same. MEDICATIONS: 1. Vicodin two q.i.d. for knee pain. 2. Toprol XL 25 mg daily.
PE|pressure equalization|PE|152|153|PHYSICAL EXAMINATION|GENERAL: He complained of a frontal headache which he rated as a 6 on a 0 to 10 scale. His physical examination was remarkable for periorbital edema, a PE tube in the left ear, and the right tympanic membrane was scarred. He had a well-healed large incision on his abdomen and his cheeks were very flushed.
PE|pulmonary embolus|PE|145|146|IMPRESSION|As I noted, I think it is more likely that he might have had an underlying neurological event, especially in light of the fact that he has had a PE in the past and has had a TIA in Florida. His echocardiogram done in the Ed indicated possible dehydration with no signs of any vegetations on any of his valves per the preliminary report by the ultrasound tech.
PE|pulmonary embolus|PE.|167|169|LABORATORY DATA|ABDOMEN: Positive bowel sounds, soft and nontender. EXTREMITIES: No edema. DP pulses are palpable. Chest x-ray showed no infiltrates. CT of her chest was negative for PE. EKG showed normal sinus rhythm with possible left atrial enlargement.
PE|pulmonary embolus|PE.|118|120|HISTORY OF PRESENT ILLNESS|He presented to the Fairview Emergency Department on _%#MM#%_ _%#DD#%_. He was worked up for chest pain. Negative for PE. Negative for cardiac etiology. Subsequently, his wound came open during a rehabilitation session with a small amount of drainage. He presented to the clinic and was evaluated by Dr. _%#NAME#%_.
PE|pulmonary embolus|PE|177|178|REVIEW OF SYSTEMS|There was no pain with this episode and denies any current ankle edema and just felt it was related to jet lag. He did go see the doctor in China at this time but no workup for PE was every done. When the patient stands up quickly he does not "feel well". This is the dizzy sensation that he is describing whenever he stands up.
PE|pulmonary embolus|PE|155|156|ASSESSMENT  AND PLAN|1. Chest pain -- concern for unstable angina given her history. Gastrointestinal etiologies such as esophageal spasm could also present with this picture. PE less likely with her negative CT scan. Plan will be to admit to telemetry for monitoring. Follow serial troponins. Hold heparin unless change in troponins or EKG and keep patient n.p.o. for possible stress test versus angiogram in the morning.
PE|pulmonary embolus|PE.|206|208|REVIEW OF SYSTEMS|Chest x-ray was unremarkable for infiltrates or effusions. The patient did show his left hemidiaphragm was elevated, and thus there were concerns within the Emergency Department that the patient may have a PE. In light of his history of deep venous thrombosis, the patient also had a spiral CT of his chest that was negative for evidence of PE.
PE|pulmonary embolus|PE|191|192|PAST MEDICAL HISTORY|The patient does have persistent pain in the thoracic spine secondary to scoliosis. PAST MEDICAL HISTORY: 1. Grade 3 invasive ductile adenocarcinoma, status post chemotherapy. 2. Status post PE secondary to DVT in _%#DDMM2003#%_. She is status post Coumadin therapy, which was stopped at her last admission. 3. Left temporal subdural hematoma, admitted _%#DDMM2004#%_, reversal of Coumadin with FFP and non-operative management.
PE|pulmonary embolus|PE,|190|192|ASSESSMENT/PLAN|We will give her IV steroids and some albuterol and Atrovent nebs in case COPD is also playing a part in this exacerbation. Although her D-dimer is slightly elevated, I doubt that she has a PE, given the fact that she has almost therapeutic on her INR, and has been on Coumadin except for the last two days.
PE|pulmonary embolus|PE|224|225|HISTORY OF PRESENT ILLNESS|She denied any chest pain or hemoptysis. She had been off her warfarin therapy for at least 1 year. She denied a history of hypercoagulability, denies knowledge of a hypercoagulable workup, and also thinks that her previous PE was during a hospitalization for COPD exacerbation. She denied any known DVTs. PAST MEDICAL HISTORY: 1. COPD, on home O2. 2. Asthma. 3. Status post hernia repair, abdominal. 4. Hysterectomy.
PE|pulmonary embolus|PE|135|136|ASSESSMENT|I do not think this is ischemic in nature, but certainly her coronary artery disease and valve disease is likely contributing. I doubt PE or infectious process. 2. Known coronary artery disease. She does have chest pain, but this is improved. I do not really think she has unstable angina, but certainly will rule her out.
PE|pulmonary embolus|PE,|159|161|ADMISSION LABORATORY DATA|Normal liver function tests. Potassium was low at 3.3. Other electrolytes, BUN and creatinine were normal. Calcium was normal at 9.6. Chest x-ray was done for PE, which was negative. D-dimer was slightly elevated at 1.8. Troponin was unremarkable, and the magnesium was slightly high at 2.6. EKG showed sinus tachycardia and borderline LVH.
PE|pulmonary embolus|PE,|156|158|OPERATIONS/PROCEDURES PERFORMED|DISCHARGE DIAGNOSES: 1. Chest pain. 2. Hypotension. 3. Abdominal pain. OPERATIONS/PROCEDURES PERFORMED: 1. Computed tomography of the chest. No evidence of PE, small bilateral pleural effusions and compressive atelectasis, and indeterminate right upper lobe pulmonary nodule. 2. Echocardiogram. Normal LV systolic function, mild mitral regurgitation, mild to moderate right atrial dilatation.
PE|pulmonary embolus|PE|217|218|ADMISSION DIAGNOSIS|There was no abscess cavity. She was also noted to have a fluid collection above her liver on the right side. Of note, while she was in the ICU. She also underwent a CT and pulmonary angiogram, which was negative for PE which showed atelectasis and some pleural effusions. The patient continued to be nauseated after her CT scan postoperative ileus remained.
PE|pulmonary embolus|PE,|151|153|POSTOPERATIVE COURSE|On _%#DDMM2005#%_, it was noted the patient had an episode of weakness and decreased O2 saturations. He underwent a CT, which did not show evidence of PE, but did show basilar pleural effusion and infiltrates. The patient was transferred to the ICU for further observation and monitored during this time on telemetry.
PE|pulmonary embolus|PE.|167|169|IMPRESSION|Looking into her old labs, she did have a weak lupus anticoagulant which would put her at risk for a hypercoagulable state. Therefore, we will check a VQ scan to rule PE. In addition, we will check an echocardiogram to ensure that her ejection fraction looks okay. Of note, the patient does have a positive pregnancy test.
PE|pressure equalization|PE|130|131|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. History of hospitalization for RSV at 2 months of age. 2. History of recurrent otitis media, status post PE tube placement. 3. Hurler syndrome diagnosed during the workup for a heart murmur. 4. Status post unrelated cord blood transplantation on _%#MM#%_ _%#DD#%_, 2005.
PE|pulmonary embolus|PE.|118|120|DISCUSSION|I have been asked by Dr. _%#NAME#%_, to see her to assess her medical candidacy for surgery in view of the history of PE. Please see Dr. _%#NAME#%_'s notes for details regarding indications for surgery. _%#NAME#%_ has noted progressive pain which has limited her activity level.
PE|pulmonary embolus|PE|106|107|RELEVANT IMAGING AND OTHER STUDIES PERFORMED|2. Left lower extremity ultrasound for DVT which was negative. 3. CT angiogram which was negative for any PE or pulmonary arterial problems.
PE|pulmonary embolus|PE|151|152|IMAGING|Creatinine 0.7, albumin 2.4, INR 1.37, bilirubin 9.7, alkaline phosphatase 481, ALT 156, and AST 214. IMAGING: 1. Chest x-ray normal. 2. Chest CT with PE protocol: Negative for PE; there was some atelectasis in both bases. 3. CT of abdomen: Slight increase in fluid in the pelvis.
PE|pulmonary embolus|PE|210|211|HOSPITAL COURSE|Her white count decreased on the 9th to 15.5. On the 10th it was down to 15.6. Her chest x-ray remained stable. She did have a V/Q scan on the 9th because there was some question as to whether she could have a PE and it was negative. She was placed on Lovenox for DVT prophylaxis. On the day prior to discharge, her electrolytes were normal.
PE|pulmonary embolus|PE|168|169|ASSESSMENT AND PLAN|Problems are as follows: 1. Pulmonary embolus. He has classic findings including tachycardia, sinus tachycardia on EKG, chest pain and CT scan findings consistent with PE as well as elevated D-dimer. He will be started on Lovenox, Coumadin will be started. This evening he will be instructed on Lovenox and pain management.
PE|pulmonary embolus|PE,|186|188|PHYSICAL EXAMINATION|NEUROLOGIC: The patient has no focal sensory or motor deficits. PSYCHIATRIC: He is alert x3 and answers questions appropriately. CT of the chest was performed which shows no evidence of PE, lung parenchyma are within normal limits without any evidence of atelectasis or infiltrates. LABORATORY DATA: White count of 8.6 with a normal differential.
PE|pulmonary embolus|PE.|141|143|ASSESSMENT AND PLAN|Her differential of course, her chest includes pulmonary etiology, however, D-dimer is normal and a saturation is normal. I do not suspect a PE. She did have some travel recently, however, she does not have what appears to be a PE. Cardiac chest pain probably utmost consideration.
PE|pulmonary embolus|PE,|192|194|ADMISSION LABORATORY AND DIAGNOSTIC STUDIES|TSH is 2.47, BNP 219, negative myoglobin and troponin. Chest x-ray is reported as showing hazy infiltrates in the bases. A preliminary verbal report of the CT scan notes it to be negative for PE, showing a right basilar infiltrate. CT of the head has a small lacunar infarct in the right basal ganglion, but no acute findings.
PE|pulmonary embolus|PE|186|187|IMPRESSION|2. Hypoxia. The patient has a long history of tobacco use and may have some underlying chronic obstructive pulmonary disease. This is contributing in an acute manner. The possibility of PE still exists, though this appears less likely given the relatively normal CT scan. Her fever and left lower lobe crackles could be early signs of a developing pneumonia, though she is without an elevated white blood count or other symptoms at this time and this can be monitored clinically and if she has more symptoms treat appropriately.
PE|pulmonary embolus|PE.|229|231|LABORATORY DATA|D-dimer was mildly elevated at 1.6. Troponin was less than 0.07. Normal INR at 1.09. BNP was also normal at 11. ALT, AST, bili, total protein, albumin, alkaline phosphatase, amylase and lipase were all normal. Chest CT showed no PE. Leg Doppler showed no DVTs. Abdominal film and chest x-ray were unremarkable. ASSESSMENT AND PLAN: 1. Chest pressure. Patient with some risk factors for cardiac disease.
PE|pulmonary embolus|PE|261|262|HOSPITAL COURSE|The patient was doing well until the day of admission and on that day she again began to experience pleuritic pain and elbow pain on the left. The patient presented to the emergency room where she underwent a CT scan of the chest which was normal and ruled out PE as well as pneumonia but she did have an elevated D-dimer of 0.6. The patient was noted to be in atrial fibrillation with rapid ventricular response treated with increased beta blocker.
PE|pulmonary embolus|PE|191|192|HOSPITAL COURSE|Antibiotic was discontinued and there is no pneumonia and no bronchitis. The patient was complaining of total body ache most likely related to her cold symptoms and CT scan of the chest with PE protocol negative, CT scan of the abdomen and pelvis shows no acute pathology. The patient was given Tylenol p.r.n. The patient was admitted in telemetry bed.
PE|pulmonary embolus|PE|206|207|HISTORY OF PRESENT ILLNESS|5. Bronchoscopy on _%#DDMM2007#%_. HISTORY OF PRESENT ILLNESS: Please refer to initial H&P for details. Briefly, Mr. _%#NAME#%_ is a 78-year-old gentleman with refractory CLL as well as recent diagnosis of PE on anticoagulation. He also has a recent diagnosis of Coombs-positive hemolytic anemia. He presents with productive cough and fever up to 101 degrees on the morning of admission.
PE|pressure equalization|PE|131|132|HISTORY OF PRESENT ILLNESS|HEENT: Normocephalic/atraumatic. Pupils equally round and reactive to light. Extraocular eye movements intact. No scleral icterus. PE tubes present bilaterally, open and not draining. TMs clear bilaterally. Oropharynx clear without erythema or exudate. No rhinorrhea. NECK: Soft and supple without lymphadenopathy. CARDIOVASCULAR: Regular rate and rhythm.
PE|pulmonary embolus|PE|134|135|LABORATORY WORK|Sodium 142, potassium 4.5, creatinine 0.8, BUN 17, calcium 8.8. ABGs on admit 7.40/40/185/24 on 4 liters. Chest CT showed no signs of PE or infiltrate. ASSESSMENT: 1. Acute bronchitis, may be at risk for aspiration. 2. Status post brain tumor with radiation and chemotherapy leaving psychomotor retardation and right hemiparesis.
PE|pulmonary embolus|(PE)|146|149|DISCHARGE DIAGNOSIS|5. Glaucoma. 6. Deep vein thrombosis (DVT) which his chronic in the left leg for which she is on Coumadin. 7. Bilateral multiple pulmonary emboli (PE) in 2003 for which she is on Coumadin. 8. Hiatal hernia. 9. Bilateral shoulder replacements. 10. Gastroesophageal reflux disease (GERD).
PE|pulmonary embolus|PE.|247|249|IMPRESSION|LABORATORY DATA: A D-dimer assay was performed and was slightly elevated at 0.8 (normal up to 0.5). IMPRESSION: Questionable right upper lobe filling defect seen on CT with PE protocol. At present this is being empirically treated as if it were a PE. It does not explain her chest wall discomfort and she has no hemoptysis or hypoxemia. Excluding a pulmonary embolism is important to make a decision about long-term anticoagulation.
PE|pulmonary embolus|PE|205|206|ASSESSMENT  AND PLAN|The patient will continue on her chronic nebs for her COPD and nebs and inhalers for her COPD, however. If she does not quickly improve, would consider putting on a short course of steroids. 3. History of PE will continue on Coumadin. 4. Mild hyponatremia. We will follow up in the a.m.
PE|pulmonary embolus|(PE)|278|281|HOSPITAL COURSE|HOSPITAL COURSE: In the hospital she was diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD) and was admitted and placed on steroids, nebulizers, and O2. A Pulmonary consultation with Dr. _%#NAME#%_ was obtained who felt that pulmonary embolism (PE) needed to be ruled out. She underwent a CT of the chest on _%#DDMM2002#%_ which showed no clear evidence of PE, however, a smoothly marginated, oval, posterior mediastinal mass approximately 2.5-cm in diameter was found.
PE|pulmonary embolus|PE|283|284|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|His laboratory values were normal including normal basic metabolic panel and CBC, however, his cholesterol showed a total cholesterol of 344, triglycerides 498, HDL 37, LDL was unable to be calculated. He also had a TSH which was normal at 0.83 and CT of the chest with contrast for PE protocol showed no PE, however, 2 very tiny right lung nodules. PLAN: 1. Chest pain/dyspnea on exertion: He has many risk factors for coronary artery disease, however, troponins were negative signifying that this is not a myocardial infarction.
PE|pressure equalization|PE|201|202|REFERRING PHYSICIAN|8. _%#MM#%_ _%#DD#%_ to _%#MM#%_ _%#DD#%_, 2002: Etoposide, ifosfamide, and mesna. 9. _%#MM#%_ _%#DD#%_ to _%#MM#%_ _%#DD#%_, 2002: Total thyroidectomy. 10. Seasonal allergic rhinitis. 11. Status post PE tubes x 4 from 12 months of age on. 12. Status post adenoidectomy as a child.
PE|pulmonary embolus|PE|147|148|HOSPITAL COURSE|Urinalysis and urine culture were negative. Chest x-ray revealed pleural effusion. She underwent a chest CT with PE protocol which demonstrated no PE but did have bilateral pleural effusions with underlying atelectasis. Antibiotics were changed to Cefotetan and this was discontinued prior to discharge as the patient has been afebrile and cultures negative.
PE|pulmonary embolus|PE.|285|287|IMPRESSION|LABORATORY DATA: Sodium 119, potassium 4.3, chloride 85, CO2 of 25, BUN 12, creatinine 0.9, glucose 119, myoglobin 51, troponin less than 0.3, hemoglobin 15.6, white blood count 5,000, platelet count 187,000. IMPRESSION: 1. Probable pulmonary embolism. Preliminary chest CT suggests a PE. She also has tachypnea and mild tachycardia. Her leg exam, however, is unremarkable for DVT and there is no history of any chest pain or even significant dyspnea.
PE|pulmonary embolus|PE|268|269|ASSESSMENT|Since its positive predictive value is not very good, if a VQ scan ordered for later today is low probability for PEs I would discharge him on his same medications. He will then follow up with Dr. _%#NAME#%_ in one to two weeks. If the VQ scan is high probability for PE we will then begin anticoagulation and have a Pulmonary consult done.
PE|pressure equalization|PE|138|139|DISCHARGE DIAGNOSIS|PAST MEDICAL HISTORY: 1. Papillary thyroid carcinoma as above. 2. Status post tubal ligation. 3. Status post tonsillectomy. 4. History of PE tube. ADMISSION MEDICATIONS: 1. Cytomel 30 mcg q.d. stopped _%#MM#%_ _%#DD#%_, 2002.
PE|pulmonary embolus|PE|199|200|HISTORY OF PRESENT ILLNESS|She has been on dialysis since _%#DDMM2001#%_. She dialyzes through a left antecubital fistula. The patient also has a history of hypertension, gastroesophageal reflux disease; and also a history of PE and DVTs, for which she has had a clot removed from her right atrium in _%#DDMM2002#%_. HOSPITAL COURSE: The patient was taken to the operating room on _%#DDMM2003#%_, and received a living nonrelated kidney transplant without complication.
PE|pulmonary embolus|PE|200|201|PAST MEDICAL HISTORY|2. Hemophilia A with penetration. 3. Cholecystectomy. 4. Thyroid cancer, status post thyroidectomy. 5. Multiple abdominal surgeries resulting in total colectomy and permanent ileostomy. 6. History of PE after vena caval injury and Hickman placement. 7. Hepatic and renal failure secondary to dehydration and lipid toxicities. ALLERGIES: 1. Vancomycin. 2. Clindamycin. 3. Toradol. 4. Ibuprofen.
PE|pulmonary embolus|PE|208|209|LABORATORY|Chest x- ray by verbal report - lung fields are clear, but possible atelectasis of the left base. I have attempted to visualize the x-rays and CT scan on the digital imaging without success. CT scan done for PE protocol due to his left pleuritic symptoms, was also reported as negative and also not accessible via the computer. I will need to look into those separately.
PE|pulmonary embolus|PE|129|130|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: HEENT: Negative. Cardiovascular: Negative. No central chest pain, shortness of breath or edema. No history of PE or deep venous thrombosis. Respiratory: As above. Review of systems is otherwise negative. GI and GU: In general negative. PHYSICAL EXAMINATION: GENERAL: Very pleasant, alert and in no distress.
PE|pulmonary embolus|PE|316|317|SIGNIFICANT FINDINGS|She had several episodes of variable blood sugars and had been to the emergency rooms before that. She had elevated creatinines, therefore a dye was not given for a CT scan, but a V/Q scan showed moderate size perfusion defects in the left lower lobe, in the right upper lobe with a moderate to high probability for PE with a D-dimer that was 1.3. Her initial creatinine was 2.9. Her creatinine gradually improved on to about 1.8. CT scan showed a mass in the head of pancreas about 4 cm.
PE|pressure equalization|PE|184|185|PAST SURGICAL HISTORY|C-section x 2. "Shattered elbow and wrist" in 1996 after a fall with some hardware in the elbow reported. Repaired tympanic membrane of the right ear in _%#MM#%_ of 2002 and evidently PE tube placed. MEDICATIONS: Atenolol, dose unclear, once daily; ranitidine, dose unclear, b.i.d.; calcium, multivitamin, and aspirin 81 mg p.o. daily, as well as sublingual nitroglycerin p.r.n. ALLERGIES: No allergies reported.
PE|pulmonary embolus|PE|181|182|HEAD, EYES, EARS, NOSE, THROAT|EXTREMITIES edema, warm, pink, dry. SKIN no lesions. CT of the chest shows tricuspid valve abnormality with right decompensation and questionable small cyst on the right kidney. No PE seen. EKG showed paced beats. Lab chloride slightly increased 110, creatinine 1.9, calcium low at 8.3. Troponin normal. Hemoglobin 12.6 with normal indices. White count 4700.
PE|pulmonary embolus|(PE)|163|166|PAST MEDICAL HISTORY|Case discussed with emergency room physician. PAST MEDICAL HISTORY: 1. Extensive history of hypercoagulability. Patient with multiple episodes of pulmonary emboli (PE) and deep vein thrombosis (DVT), most recent episode approximately four years ago with relatively low INR of 1.3. 2. History of lupus anticoagulant felt to be the reason for hypercoagulability.
PE|pulmonary embolus|PE.|172|174|LABORATORY DATA|ALT 155, AST 155. EKG: Normal sinus rhythm. No acute ST wave changes. Chest x-ray negative per Emergency Department report, other than cardiomegaly. Chest CT: Negative for PE. It does show bilateral bibasilar atelectasis. ASSESSMENT/PLAN: 1. Acute myocardial infarction. The patient is ruling in for cardiac ischemia.
PE|pulmonary embolus|PE|203|204|HISTORY|10. There was evidence of fluid overload despite her normal EF, consistent with diastolic dysfunction. Lasix has been given. She did have episodes of shortness of breath with hypoxemia, but there was no PE seen on CT of her lung. A followup chest x-ray is pending for today, and she will be discharged on some Lasix.
PE|pressure equalization|PE|153|154|DOB|He is said to be allergic to penicillin. Immunizations are said to be current, and otherwise past history unremarkable. His only hospitalization was for PE tubes, dad said, as a toddler. _%#NAME#%_ now states he feels much better in regard to his breathing and coughing than when he was admitted while on the floor.
PE|pulmonary embolus|PE|238|239|HISTORY OF PRESENT ILLNESS|He had a chest x-ray done, which showed the question of a little enlarged heart, otherwise negative. It was concerning for PE, and so at that point, he had a D-Dimer done, which was mildly elevated at 1.0. He then had a chest CT done per PE protocol, which showed no evidence of a PE, aneurysm, or dissection, possibly a mildly enlarged heart with question of congestive heart failure and mild mediastinal adenopathy.
PE|pulmonary embolus|PE.|129|131|ASSESSMENT|Her symptoms suggest acute coronary syndrome. The patient's serial troponin and EKG were negative. Her chest CT was negative for PE. The patient was treated with aspirin and nitroglycerin sublingually p.r.n. x2. The patient's symptoms had completely resolved this morning. She is back to her baseline at this time.
PE|pressure equalization|PE|131|132|PHYSICAL EXAM|HEAD - atraumatic. EYES - sclerae anicteric, normal conjunctivae, lids and pupils. Right TM and canal appear normal. Left TM has a PE tube in place with somewhat distorted TM architecture but no erythema and no purulence. OROPHARYNX - shows normal oral mucosa and no erythema or exudate.
PE|pulmonary embolus|PE,|330|332|IMAGING|LABORATORIES: CBC and comprehensive metabolic panel are entirely negative except for a slightly elevated, nonfasting glucose of 118 and the protein slightly elevated at 8.6. The D-dimer was negative in the Emergency Department. IMAGING: CT scan felt the chest revealed possibly a lingular infiltrate, but otherwise no evidence of PE, and the mediastinal structure were normal and unremarkable as well. ASSESSMENT: 1. Right-sided chest pain. 2. Right-sided upper back pain.
PE|pulmonary embolus|PE|99|100|HISTORY OF PRESENT ILLNESS|He is admitted with pain and swelling in the right lower extremity. The patient was diagnosed with PE in 2003. The patient was treated with Coumadin for about 3-4 months. Etiology of PE is unknown. The patient was doing well up until five days before admission, when he complained of pain and swelling in the right lower extremity.
PE|pulmonary embolus|PE|169|170|HOSPITAL COURSE|She did have some known pain with deep breathing, although it is fairly nonspecific and did not hurt with coughing. It was felt that this was most likely related to old PE that she had had previously as her pain did not significantly change since that time. A CT angio was considered to the possibility of another pulmonary embolus, but with her saturating at 100% on room air, it was felt that if an angiogram was obtained, the emboli would have to be so small that they would not be detectable by CT angiogram and would not affect her management anyway.
PE|pulmonary embolus|PE|121|122|HISTORY OF PRESENT ILLNESS|The patient had a previous bypass graft in 1987. He also has a history of hypertension, hyperlipidemia. He has no DVT or PE history but apparently his brother did have a PE and his brother is prone to clot formation. The patient apparently had a test for this clot formation abnormality and was slightly positive for it, although the patient has never had a clot personally to his knowledge.
PE|pulmonary embolus|PE|160|161|ALLERGIES|On hospital day #5, Mr. _%#NAME#%_ received 1 unit of blood transfusion, it brought his hemoglobin from 9.5 to 10.3. Given Mr. _%#NAME#%_'s condition of recent PE and his internal bleeding due to heparin and Coumadin treatment, at this time, the patient seemed to be suitable for temporary Greenfield filter placement.
PE|pulmonary embolus|PE|192|193|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|He returned for reevaluation on _%#DDMM2005#%_. At that time, he was referred for a CT. He was found to have extensive bilateral nonocclusive pulmonary emboli. He has no real risk factors for PE such as prolonged travel, fracture or known malignancy. He has no localizing symptoms that would suggest malignancy. I did initiate a hypercoagulability workup.
PE|pulmonary embolus|PE.|115|117|LABORATORY DATA|The patient has a past history of pulmonary emboli and was started on Lovenox 40 mg once a day for prophylaxis for PE. The day after surgery, his hemoglobin is 8.4 after hydration and then two days after was 7.4. The patient probably has had some chronic anemia and she was asymptomatic.
PE|pressure equalization|PE|171|172|INDUCTION|The operating room microscope was brought in after the patient had undergone mask anesthesia. INDUCTION: The right ear was examined, culture of the otorrhea was done. The PE tube was in place. This was removed and a Goode PE tube was placed in the same hole. The left ear was then examined, culture was taken of the otorrhea.
PE|pulmonary embolus|PE|463|464|HISTORY OF PRESENT ILLNESS|Triamcinolone 1% cream applied to upper back b.i.d. p.r.n. PROCEDURES DURING THIS HOSPITAL COURSE: Right lower extremity ultrasound was obtained on _%#DDMM2006#%_ which showed deep venous thrombosis in the right femoral, popliteal, posterior tibial, and lesser saphenous vein. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 80-year-old white female with past medical history significant for non-small-cell carcinoma which was diagnosed in _%#MM#%_ 2005, PE and DVT of left peroneal lower extremity which was diagnosed on _%#DDMM2005#%_ and has been on Coumadin as an outpatient. Her INR was 2.38 when she noted right leg swelling and pain.
PE|pulmonary embolus|PE.|190|192|POSTOP DIAGNOSIS|She knows how to get a hold of me. She will resume all prehospital care plans, diet and medications. POSTOP DIAGNOSIS: 1. Severe osteoarthrosis of the right knee. 2. Diabetes. 3. History of PE. 4. Acute blood loss anemia. 5. Urinary tract infection. See admitting notes for all other problems. We will see her back in the office 2 weeks postop.
PE|pulmonary embolus|PE.|230|232|HOSPITAL COURSE|She also had an EEG that is also pending for now. She had an elevated D-Dimer in the emergency department, 0.9, so they did a CT of her chest to rule out PE, which showed a right middle lobe lung nodule to 12 mm, but otherwise no PE. The patient was doing fine in the hospital, did not have any further episodes.
PE|pulmonary embolus|PE|157|158|HISTORY OF PRESENT ILLNESS|The patient has no history of coronary artery disease or cardiac history, no chest pain or shortness of breath, no hypertension or hyperlipidemia, no DVT or PE history. The patient was seen by the orthopedist Dr. _%#NAME#%_ in the Emergency Department, and he requested a preoperative H&P prior to taking the patient to the operating room today.
PE|pressure equalization|PE|257|258|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: On admission, weight was 7.18 kg, temperature is 37.1, pulse 138, blood pressure 98/64, respiratory rate 56 and satting 95% on room air. HEENT: Significant findings on exam included Down facies. Her ears were low set with PE tubes in place bilaterally. She also had nasal stuffiness and large tongue. HEART: Regular rate and rhythm with no murmurs. She did have a midline sternotomy scar. Her pacer was palpable in the right upper quadrant.
PE|pulmonary embolus|PE|179|180|IMAGING STUDIES AND PROCEDURES PERFORMED DURIGN HOSPITALIZATION|1. Abdominal ultrasound performed on _%#DDMM2006#%_; conclusion was no acute abdominal findings noted. Incidental finding of benign left renal cortical cysts. 2. CT of the chest, PE protocol with contrast, performed on _%#MMDD#%_; conclusion was pulmonary emboli seen in the right lower lobe, possibly also on the left. Please see Radiology report for details. 3. Bilateral lower extremity venous ultrasound performed _%#MMDD#%_.
PE|pulmonary embolus|PE,|430|432|PAST MEDICAL HISTORY|The patient went home and developed chest pressure which was radiating to the back and the cardiology clinic called her and advised her to discontinue the Toprol and restart the Coreg at 3.125 mg b.i.d. As her symptoms increased, the patient went to the ER for evaluation. PAST MEDICAL HISTORY: History of ASCVD, large MI in _%#DDMM2006#%_ with ejection fraction of 25%, history of CHF, osteoarthritis, hyperlipidemia, history of PE, history of anemia, ischemic cardiomyopathy. PAST SURGICAL HISTORY: Bilateral knee replacements, total abdominal hysterectomy, appendectomy, gallbladder removal.
PE|pressure equalization|PE|119|120|PAST SURGERIES|The patient does have positive ill contacts via daycare, siblings, and mother (works as a teacher). PAST SURGERIES: 1. PE tubes in _%#DDMM2006#%_. 2. Circumcised as a newborn. PAST MEDICAL ILLNESSES: 1. Prematurity of 34 weeks gestation, twin, 20-day hospital stay, birth weight 5 pounds 3 ounces, born via cesarean section due to maternal preeclampsia.
PE|pulmonary embolus|PE|179|180|HOSPITAL COURSE|She received serial troponins x3 and serial EKGs which were negative for ischemia. The patient had stable blood pressures, normal heart rate and no evidence of hypoxia which made PE less likely. There were no pulmonary infiltrates to suggest pneumonia. She had a negative D-dimer in the ER. She also underwent right upper quadrant ultrasound to evaluate for gallbladder or liver pathology.
PE|pulmonary embolus|PE.|257|259|PLAN|Also, of pertinent concern is the patient's incontinence. I suspect that this is most likely temporary due to the recent Foley catheter and bladder irritation. PLAN: 1. D-dimer will be obtained. If this is elevated we will proceed with CAT scan to rule out PE. I am not contemplating giving antibiotics at this time given lack of sufficient evidence. The patient will be pan cultured should fever of 101 and/or positive cultures occur, then would restart antibiotics.
PE|pulmonary embolus|PE,|305|307|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|His laboratory values were normal including normal basic metabolic panel and CBC, however, his cholesterol showed a total cholesterol of 344, triglycerides 498, HDL 37, LDL was unable to be calculated. He also had a TSH which was normal at 0.83 and CT of the chest with contrast for PE protocol showed no PE, however, 2 very tiny right lung nodules. PLAN: 1. Chest pain/dyspnea on exertion: He has many risk factors for coronary artery disease, however, troponins were negative signifying that this is not a myocardial infarction.
PE|pulmonary embolus|PE.|179|181|HOSPITAL COURSE|He also received an echocardiogram, which showed preserved cardiac function. No overt abnormalities. He also underwent a CT angio of his chest, which do not reveal any events for PE. The Cardiology Service initially started the patient on diltiazem drip, then transitioned to digoxin and finally to amiodarone. At this point, the patient did well on amiodarone and metoprolol.
PE|pressure equalization|PE|268|269||We discussed the risks, benefits and alternatives to an adenotonsillectomy including the risk of a general anesthetic, bleeding, velopharyngeal incompetence and inflammation. This will be scheduled for their convenience at Ridges. We will also plan to remove the left PE tube and Gelfoam patch in the ear drum. The risk of general anesthetic, bleeding, velopharyngeal incompetence, perforation, otorrhea, and the risk of hearing were discussed today.
PE|pulmonary embolus|PE|238|239|HISTORY OF PRESENT ILLNESS|She describes shortness of breath that had sudden onset, that woke her from sleep and is worse when she does not prop herself up with pillows. She denies chest pain. She denies fevers, chills or night sweats. The patient had a history of PE and had a history of pneumonia. The patient also has a history of left shoulder pain and of right femur fracture that was managed medically, per her and her caregiver's report.
PE|pulmonary embolus|PE|186|187|TESTS DONE DURING THIS HOSPITAL STAY|6. MRI of the left upper extremity shows no evidence of abscess, nonspecific subcutaneous edema in the forearm extending in to the distal aspect of the arm. 7. Chest CT scan to rule out PE showed no evidence of pulmonary embolus. REASON FOR ADMISSION AND HOSPITAL COURSE: The patient is a 42-year-old man who was admitted through the Emergency Room with left elbow and arm cellulitis.
PE|pressure equalization|PE|142|143|ADMISSION PHYSICAL EXAMINATION|GENERAL: _%#NAME#%_ was alert, active and talkative. HEENT: Head was normocephalic with alopecia. Eyes had no injection. TMs were normal with PE tubes in place bilaterally. Oropharynx was clear with no lesions or erythema. NECK: Supple. HEART: Regular rate and rhythm without murmur. LUNGS: Clear. ABDOMEN: Soft, nontender, nondistended with normal bowel sounds and a well-healed surgical scar.
PE|pressure equalization|PE|201|202|PHYSICAL EXAMINATION|In general she was alert, no acute distress. HEENT: normocephalic, atraumatic, pupils equal, round and reactive to light without scleral injection or icterus. Tympanic membranes were significant for a PE tube on the left without erythema and a PE tube in the canal of the right tympanic membrane. Oropharynx/oral cavity: moist mucus membranes, no erythema, no nasal discharge.
PE|pulmonary embolus|PE|306|307|LABORATORIES|ECG shows a normal sinus rhythm with PVC. V/Q scan shows _______ with light perfusion defects in the left upper lobe with a defect on ventilation scan slightly smaller than perfusion defects. This is an indeterminate probability for PE. Chest CT with contrast confirms the findings consistent with massive PE to both left and right pulmonary arteries with a large filling defect. There are also extensive clots in the lower lobe vessels.
PE|pressure equalization|PE|212|213|MEDICAL HISTORY|He has no significant history of respiratory problems. All other systems are negative. MEDICAL HISTORY: The medical history is significant for his multiple episodes of otitis media, and the only prior surgery is PE tube placed in _%#MM#%_ 2002 without any complications. MEDICATIONS: He is not currently on any medications. ALLERGIES: He has no known drug allergies.
PE|pressure equalization|PE|80|81|PAST SURGICAL HISTORY|PAST MEDICAL HISTORY: 1. Asthma. 2. Chronic ear pain. PAST SURGICAL HISTORY: 1. PE tubes. 2. Tonsillectomy and adenoidectomy. 3. Cesarean section. 4. Elective abortion. 5. Tubal ligation. 6. Teeth extraction secondary to a motor vehicle accident.
PE|pulmonary embolus|PE.|223|225|HOSPITAL COURSE|CPK and troponin immediate evaluation expressed an emergent spiral CT of the chest to rule out pulmonary embolus. CK and troponin remained within normal limits. Unfortunately, the spiral CT of the chest disclosed bilateral PE. The patient was started immediately on heparin protocol with great improvement in his shortness of breath. The antibiotics were continued empirically for exacerbation of COPD/pneumonia. The pain in his right lower extremities is much improved as well.
PE|pulmonary embolus|PE.|196|198|DISCHARGE MEDICATIONS|3. Benadryl 25 mg q.6h. p.r.n. pruritus. 4. Tylenol 650 p.o. q.4-6h. p.r.n. pain or fever. 5. Oxygen supplementation by nasal cannula, to keep saturations greater than 92%, secondary to bilateral PE. 6. Atenolol 50 mg p.o. q. day for hypertension. 7. Synthroid 100 mcg p.o. q. day for hypothyroidism. 8. Lansoprazole 30 mg p.o. q. day for ulcer.
PE|pulmonary embolus|PE|173|174|PAST MEDICAL HISTORY|5. Hypertension. 6. Childhood polio. 7. Status post total abdominal hysterectomy. 8. History of DVT to the right jugular with right ventral line. 9. Questionable history of PE 20 years ago. ADMISSION MEDICATIONS: Please see chart. ALLERGIES: Please see chart. FAMILY HISTORY: Please see chart. SOCIAL HISTORY: Please see chart.
PE|pulmonary embolus|PE|154|155|HOSPITAL COURSE|She notes that she has been sick with a cough productive of thick yellowish green sputum for approximately two weeks. She has a history significant for a PE in the past. Upon initial presentation she had a temperature of 101 and a left lower lobe infiltrate. The patient was placed on the community acquired pneumonia pathway and a pulmonary consultation was obtained.
PE|pressure equalization|PE|200|201|PAST MEDICAL/SURGICAL HISTORY|Of note she did receive cefotetan 2 gm IV at 12 and 24 hours postoperatively for a total of three doses, the first given at the time of surgery. 2. The patient had ear surgery in childhood related to PE tubes. MEDICATION: Prenatal vitamins. ALLERGIES: No known drug allergies. FAMILY HISTORY: Unremarkable.
PE|pressure equalization|PE|221|222|PHYSICAL EXAMINATION|Respiratory rate 20. Blood pressure 100/70. Weight 16.9 kg. Height 103.5 cm. GENERAL: He was awake and talkative. HEAD: Normocephalic/atraumatic. EYES: PERRL. EOMI. No conjunctival inflammation. No scleral icterus. EARS: PE tubes bilaterally. NOSE: No discharge. MOUTH/THROAT: Clear. NECK: Supple. No lymphadenopathy. LUNGS: Clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm, with a 3/6 systolic murmur.
PE|pressure equalization|PE|173|174|SURGERIES|SURGERIES: 1. She is status post stress incontinence repair times four. 2. Cholecystectomy 3. Bilateral hip repair 4. Hysterectomy 5. Oophorectomy 6. Rotator cuff repair 7. PE tube placement. 8. Left shoulder repair 9. Right knee replacement 10. Endoscopic retrograde cholangiopancreatography 11. Right endolymphatic enhancement.
PE|pulmonary embolus|PE|112|113|HOSPITAL COURSE|We checked the D-Dymer which was slightly elevated and then proceeded to check CT scan of the chest to rule out PE which was negative for PE. There was focal lingular density which the radiologist felt was atelectasis but they did recommend a follow-up CT scan or chest x-ray in three months to ensure resolution.
PE|pulmonary embolus|(PE)|217|220|HOSPITAL COURSE|By the fourth postoperative day she started having more dizziness and was a little unsteady and started having some signs of pulmonary hypertension. She was put back into the Intensive Care Unit and pulmonary embolus (PE) was ruled out and her acute respiratory distress was associated with pulmonary hypertension. Pulmonary Medicine saw the patient in consultation and she had continued diaphoresis.
PE|pulmonary embolus|PE|149|150|HOSPITAL COURSE|She was diverted to the _%#CITY#%_ _%#CITY#%_. Workup in our emergency room revealed that she had had a pulmonary embolus. The patient was placed on PE protocol and was doing well, however, on _%#DDMM2004#%_, she had a syncopal episode in her room which was noted on telemetry to be significant bradycardia down to 28.
PE|pulmonary embolus|PE,|181|183||_%#NAME#%_ _%#NAME#%_ is a very pleasant 52-year-old woman with metastatic breast cancer. She was admitted to the hospital with progressive dyspnea. CT scan revealed no evidence of PE, but she did have evidence of pulmonary edema and congestive heart failure confirmed by echocardiogram with a decreased ejection fraction of 25%.
PE|pulmonary embolus|PE.|190|192|HOSPITAL COURSE|As mentioned above, the patient's diet was advanced to regular which she tolerated by the time of discharge. She was also passing flatus. 6. Hematology. The patient has a history of DVT and PE. Therefore, she was placed on Lovenox immediately postoperatively which was transitioned to Coumadin. She is discharged to home on Lovenox 60 mg b.i.d. subcutaneously.
PE|pulmonary embolus|PE|162|163|HOSPITAL COURSE|The urine did come back fairly positive and appeared to be the site of it. Because he was having some chest pain at the time a chest CT scan was done looking for PE or other abnormalities. There was an area of questioned prominence around the bronchium versus retained fluid versus other and was felt further workup was necessary.
PE|pulmonary embolus|PE.|153|155|LABORATORY TESTINGS|CO2 was 28, BUN 19, creatinine 1.0. Glucose was 120. INR 0.93, PTT 24, D-Dimer 0.7, which is slightly elevated. A spiral CT of the chest is negative for PE. Troponin I #1 and #2 are less than 0.07. Beta natriuretic peptid is 53. ASSESSMENT: 1. Chest pain in a patient with existing coronary artery disease and one month status post RCA stenting.
PE|pulmonary embolus|PE.|197|199|HISTORY OF PRESENT ILLNESS|He now has had some kind of migratory pain sometimes in his right knee up into his chest and his left arm. He mentioned this in the emergency room and he had a chest CT there that was negative for PE. It sounds like he may have had an MRI of his neck that was also unremarkable. Today, however, he is having significant pain in his foot, specifically his right toe.
PE|pulmonary embolus|PE|107|108|ASSESSMENT AND PLAN|No increase in girth is noted. Peripheral pulses are intact. ASSESSMENT AND PLAN: 1. Difficult to rule out PE as you can see from the above history. We will observe. We will do lower extremity dopplers. I did call in the tech and the radiology resident on-call to have this arranged.
PE|pressure equalization|PE|183|184|PROBLEM #3|The patient's fever trended down and Tmax was 100.8 on _%#DDMM2005#%_. PROBLEM #3: ENT: ENT re-evaluated patient on _%#DDMM2005#%_ and found no signs of active infection and that the PE tubes were patent. They required no further follow-up. Throughout hospitalization the patient refused vital signs intermittently and would refuse certain medications and cares.
PE|pressure equalization|PE|178|179|RECURRENT MEDICAL PROBLEMS|RECURRENT MEDICAL PROBLEMS: 1. Term baby who had a clavicle fracture at delivery. 2. DiGeorge syndrome. 3. Ventriculoseptal defect. 4. Cleft palate. 5. GE Reflux. 6. Status post PE tube placement. 7. Status post GJ tube placement. 8. He has had a number of hospital stays. REVIEW OF SYSTEMS: Unremarkable except for the "History of Present Illness." PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: Temperature 101.9. His respiratory rate and other vital signs are within normal limits.
PE|pulmonary embolus|PE.|213|215|PAST MEDICAL HISTORY|He does complain of pain in the right knee.. FAMILY HISTORY: Significant for 1 of 10 children. PAST MEDICAL HISTORY: His previous medical history is noted for mild myasthenia gravis, as noted above and history of PE. REVIEW OF SYSTEMS: He complains of pain in the right knee.
PE|pulmonary embolus|PE|183|184|LABORATORY DATA|CT scan of chest, abdomen and pelvis shows a left pulmonary embolus at the left pulmonary artery bifurcation with extension at the left lower lobe and left upper lobe. No right-sided PE noted. Also, noted is left pleural effusion. Postoperative changes in the mid pelvis with prominence of the right gonadal vein.
PE|pulmonary embolus|PE.|187|189|REVIEW OF SYSTEMS|HEENT cataract surgery. Has subconjunctival hemorrhage which he attributes to episodes of cough. Cardiac - no history of heart disease. He has chest pain as detailed, pleuritic type with PE. Respiratory -shortness of breath with hypoxia requiring oxygen at this time. GI, no nausea, vomiting, diarrhea, constipation. His bowel movements are regular.
PE|pulmonary embolus|PE|207|208|ASSESSMENT/PLAN|Certainly on echocardiogram RV function is significantly depressed. She also has wide open tricuspid regurgitation, likely secondary to annular dilatation. Etiology of the pulmonary hypertension is unclear. PE has been ruled out by VQ scan. Recommend at this point in time right heart catheterization to obtain pulmonary pressures.
PE|pulmonary embolus|(PE)|308|311|PLAN|Primary pulmonary hypertension would be a diagnosis of exclusion. Spirometry showed mixed restrictive and obstructive lung disease which could be due to congestive heart failure alone with "cardiac asthma." PLAN: 1. Mucomyst, diet prophylaxis due to renal insufficiency, then CT scan with pulmonary embolism (PE) protocol and high-resolution tests to better evaluate parenchyma. 2. Screening oximetry. Possible polysomnogram as an outpatient. 3. I wonder if a right heart catheterization would be useful to assess pulmonary capillary wedge pressure and help distinguish between secondary and primary pulmonary hypertension.
PE|pulmonary embolus|PE|113|114|HISTORY OF PRESENT ILLNESS|The patient has no coronary disease history. She denies any chest pain or shortness of breath. She has no DVT or PE history. Blood pressure is well controlled with the use of atenolol. The patient was seen postoperatively on arrival to the medical/surgical floor.
PE|pressure equalization|PE|177|178|PAST MEDICAL HISTORY|He denies fevers, chills, nausea, vomiting or other complaints. PAST MEDICAL HISTORY: 1. Psychiatric history. This is per Dr. _%#NAME#%_. 2. History of enuresis. 3. Status post PE tube placement. 4. History of occasional headaches. 5. Asperger's. This was diagnosed last Wednesday. ALLERGIES: The patient has no known drug allergies.
PE|pulmonary embolus|PE.|261|263|IMPRESSION|This should be 75 mg subcu b.i.d. of Lovenox. We need to get baseline laboratory studies including a basal metabolic panel, CBC, troponin, BNP, and a portable chest x-ray. If her creatinine is normal will then send her down for CT scan of her chest to rule out PE. The patient clinically does not have significant volume overload based on her examination. I would expect her to have significantly more crackles on her pulmonary examination.
PE|pressure equalization|PE|197|198|PAST  MEDICAL HISTORY|11. Epilepsy. 12. Pseudoseizures. 13. Suicide attempts. 14. Bipolar disorder. 15. Borderline personality disorder. 16. Schizoaffective disorder. 17. Hysterectomy. 18. Cyst surgery on tailbone. 19. PE tubes as a child. This is a past medical history per the patient. No old charts available to verify. ADMISSION MEDICATIONS: 1. Bactrim 20/40 mg oral suspension 2 tsp.
PE|pulmonary embolus|PE.|201|203|ASSESSMENT AND PLAN|On top of this it is suspicious for chronic thromboembolic disease as he has had progressive dyspnea on exertion in three days of lower extremity edema. This would not be consistent with only an acute PE. Likely this represents acute PE, and chronic process. Therefore, the benefit of lytics would be minimal, and he would be at moderate risk of bleeding at his puncture sites.
PE|pulmonary embolus|PE.|182|184|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Pulmonary embolism. HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old woman with a history significant for kidney and pancreas transplant who has a recurrent PE. She was first diagnosed with a pulmonary embolism about 3 months ago. There were no clear inciting factors at the time. There was no extensive travel, surgery, illness or bedrest.
PE|pulmonary embolus|PE.|171|173|ASSESSMENT|b. Renal failure secondary to chronic renal insufficiency compounded by acute GI bleed. c. Right heart failure/cor pulmonale/chronic obstructive pulmonary disease/chronic PE. d. Hypotension with anemia and GI bleed. e. Morbid obesity. PLAN: 1. Continue vent. We will adjust pending arterial blood gases.
PE|pressure equalization|PE|203|204|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Significant primarily for previous psychiatric hospitalizations with a history of depression, and possibly bipolar disorder. She has a history of trichotillomania. 2. History of PE tube placement. 3. Asthmatic bronchitis. MEDICATIONS: Depakote, Eskalith, Levora birth control pills, Zoloft.
PE|pulmonary embolus|PE|258|259|IMPRESSION/PLAN|IMPRESSION/PLAN: 1. Mrs. _%#NAME#%_ is a 27-year-old Mexican woman who presents with a small pulmonary embolism and bilateral pulmonary infiltrates five months after her C-section. The patient has been symptomatic for two months. She could have had a larger PE in her postpartum setting from which she has been asymptomatic and now presents with a small pulmonary embolism, she could also have developed an infectious process in her lungs and has an underlying hypercoagulable state that has lead to a pulmonary embolism.
PE|pressure equalization|PE|147|148|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Multiple sclerosis diagnosed at the age of 17. 2. Schizoaffective disorder. 3. History of seizure disorder. 4. History of PE tube placement. MEDICATIONS: 1. Tegretol 200 mg twice a day. 2. Baclofen 10 mg t.i.d.
PE|pulmonary embolus|PE|186|187|HISTORY OF PRESENT ILLNESS|He remains intubated. He was in a coma until today when he has been opening his eyes. He remains sedated. His wife is in the room. The cardiac arrest has been thought to be related to a PE and possibly an myocardial infarction. An echocardiogram was done and showed the patient with an ejection fraction of 20%, severe aortic stenosis, mitral regurg and tricuspid regurg.
PE|pulmonary embolus|PE.|394|396|LABORATORY|D-Dimer was 0.8, myoglobin 61, Troponin less than 0.04, sodium 141, potassium 4.1, chloride 102, CO2 29, BUN 17, creatinine 0.6 with glucose of 106, calcium 9.7, white blood cell count was 13.4, hemoglobin 13.8, hematocrit 41.2, platelet count 282, 81% neutrophils, 12% lymphocytes, absolute neutrophils 10.9. EKG showed normal sinus rhythm without ST changes. CT of the chest was negative for PE. Rhonchi were filled with low attenuation tissue. Multiple indeterminate pulmonary nodules in the right lung base. Additional bands of peripheral infiltrate or consolidation of the right midlung are identified, infectious versus inflammatory, however, malignancy was not excluded with extensive emphysematous changes.
PE|pulmonary embolus|(PE)|210|213|REASON FOR CONSULTATION|The patient denies upper respiratory infection (URI) symptoms, fevers, chills, sweats, chest pain, cough, sputum, wheezing. He has had no hemoptysis and no leg pain. He has had pedal edema. No pulmonary emboli (PE) in the past. He was admitted in _%#MM#%_ and was told he had pneumonia, however, reviewing that it appears he also had heart failure and renal failure and Dr. _%#NAME#%_ _%#NAME#%_ at that time did not think he had pneumonitis.
PE|pressure equalization|PE|262|263|PHYSICAL EXAMINATION|Head is normal cephalic, face reveal heavier epicanthal folds. Eyes: Extraocular muscles intact, PERRLA, right tympanic membrane was not visualized secondary to cerumen impaction. Left tympanic membrane revealed mild erythema surrounding intact patent appearing PE tube without discharge. Oropharynx unremarkable. Neck is supple. No lymphadenopathy or thyromegaly. Heart regular rate and rhythm, no murmurs, rubs or gallops.
PE|pulmonary embolus|PE|380|381|ASSESSMENT|If there is significant pericardial fluid a pericardial tap for cytology, consideration of repeating a tap of the left effusion; if it has not changed substantially in size it may not be useful to completely remove; there may be a trapped lung given the surgery and radiation therapy. Also, given the history of cancer, atrial arrhythmias and risk factors would recommend CT with PE protocol. We will arrange for the latter test.
PE|pressure equalization|PE|237|238|PAST MEDICAL HISTORY|We did discuss the possible interaction of beta blockers and depressive-type symptoms, and I recommended that he follow up with his primary care doctor for advice in this regard. 2. Status post tonsillectomy and adenoidectomy. 3. Recent PE tube placement in the right ear for correction of chronic otitis with hearing loss. 4. History of concussion with brief loss of consciousness one year ago.
PE|pulmonary embolus|PE.|151|153|REVIEW OF SYSTEMS|He denied any skin or lymph problems. HEENT: Positive for glasses, otherwise unremarkable. He denies any history of cardiac symptoms. Prior history of PE. Gastrointestinal as noted above. Genitourinary otherwise unremarkable for nocturia or difficulty urinating. He denies any hematologic, neuro or endocrine problems. PHYSICAL EXAMINATION: The patient is a well-developed, well- nourished, overweight white male, very pleasant, in no acute distress.
PE|pressure equalization|PE|119|120|PAST SURGERIES|3. Congenital ataxia. 4. Asthma. 5. Migraine headaches. PAST SURGERIES: 1. Ankle reconstruction. 2. LEEP procedure. 3. PE tubes and T&A. MEDICATIONS: 1. Lamictal 100 mg every morning. 2. Seroquel 50 mg every morning.
PE|pressure equalization|PE|184|185|HISTORY OF PRESENT ILLNESS|The patient denies any current medical complaints. His past medical history is significant for one previous psychiatric hospitalization within the last year. He describes a history of PE tubes placed for chronic ear infections as a very young child. Apparently he has not had any recent recurrence. Past medical history significant for the use of Neurontin, Depakote, guaifenesin.
PE|pulmonary embolus|PE.|355|357|IMPRESSION|5. History of methotrexate treatment: The patient is on a small dose and has been on this for quite some time, but this certainly raises the possibility of a superimposed component of drug-associated interstitial lung disease. 6. Hypertension. 7. Paroxysmal atrial fibrillation. 8. History of DVT with recent negative Doppler studies and CT angiogram for PE. RECOMMENDATIONS: 1. Would stop methotrexate. 2. Would continue high dose corticosteroids.
PE|pressure equalization|PE|249|250|PAST MEDICAL/ SURGICAL HISTORY|He presents to our clinic today at the request of Dr. _%#NAME#%_ _%#NAME#%_ for evaluation of a transplant and to discuss the possibility of radiation condition. PAST MEDICAL/ SURGICAL HISTORY: 1. Multiple otitis media treated with the placement of PE tubes. Developed chronic perforated tympanic membranes, has had multiple surgical attempts to repair. 2. Mitral valve prolapse. ALLERGIES: No known drug allergies.
PE|pulmonary embolus|PE.|152|154|REQUESTING PHYSICIAN|She has no seasonal allergies and no sinusitis. No GERD, no triggering factors. No family history of asthma and no pleurisy, leg swelling, phlebitis or PE. No fevers, chills. She has had some sweats. No weight loss. REVIEW OF SYSTEMS: She snores, no known apnea but she is not refreshed upon awakening.
PE|pulmonary embolus|PE.|214|216|ASSESSMENT AND PLAN|2. Hypopnea. Initially was felt secondary to narcotics, although her last narcotics was yesterday morning. She was given Narcan x 4 with some equivocal response. She underwent a VQ scan, which was negative for any PE. I suspect that this possibly represents central hypopnea with her central findings. Apparently, her sats are stable, and we will monitor this closely.
PE|pulmonary embolus|PE.|224|226|REQUESTING PHYSICIAN|This showed a normal white blood count of 10.1 and a normal platelet count of 199,000, but mild anemia with a hemoglobin of 12.5 and an MCV of 85. As part of his work up, he has also had a CT scan of the chest to rule out a PE. This was negative for PE, though the CT scan of the chest did reveal very slight borderline mediastinal lymphadenopathy.
PE|pressure equalization|PE|193|194|IMPRESSION|Currently _%#NAME#%_ is 3 years old and has about a 1 year motor delay and very limited speech with no well formed words. She does use about 7 signs. Her medical history is remarkable only for PE tubes x 2 and an adenoidectomy. PAST MEDICAL HISTORY: The patient's past medical history is unremarkable.
PE|pulmonary embolus|PE|164|165|PHYSICAL EXAMINATION|LUNGS: Clear to auscultation. CARDIAC: Regular rate and rhythm. ABDOMEN: Benign. EXTREMITIES: No clubbing, cyanosis or edema. D-dimer is positive. CT of chest with PE protocol positive for bilateral pulmonary emboli. IMPRESSION: 1. Acute pulmonary embolism. 2. Evidence of right heart strain with hypoxia and hypotension.
PE|pulmonary embolus|(PE),|233|237|HISTORY|She states that this is not the kind of pain that she had two years ago with her angioplasty but she also readily admits she does not remember what kind of pain she had two years ago. She has no history of pleurisy, pulmonary emboli (PE), deep vein thrombosis (DVT). Of note, her medication list does not match up with what one would expect for a patient who has had angioplasty.
PE|pulmonary embolus|PE|138|139|REASON FOR CONSULTATION|He was admitted now with left-sided chest discomfort, green sputum production and shortness of breath. He had a CT of his chest done with PE protocol and this was negative for pulmonary embolism, but demonstrated bibasilar parenchymal fibrotic changes and mild emphysematous changes. PAST MEDICAL HISTORY: Notable for: 1. Tobacco use, quit seven years ago.
PE|pulmonary embolus|PE|219|220|PHYSICAL EXAMINATION|EXTREMITIES: Without cyanosis, clubbing, or edema. Dorsalis pedis and posterior tibial pulses 2+ and symmetric. Previous CT scan showed an atherosclerosis in the ascending aorta with some mural thrombus. No evidence of PE or bilateral pleural effusions. LABORATORY RESULTS: Include a hemoglobin of 11.2, white count 15.1. Troponin of 1.8. Creatinine of 1.98, BUN of 40.
PE|pulmonary embolus|PE.|289|291|RECOMMENDATIONS|Cecostomy tube was placed to relieve toxic megacolon. The patient apparently had had a recent admission at the University of Minnesota Hospitals for end-stage COPD with possible left lower lobe pneumonia for which she was treated with levofloxacin. At that time she was found also to have PE. The patient currently has concurrent respiratory failure requiring mechanical ventilation. Chest x-ray shows bibasilar infiltrate and pleural effusion. She is afebrile and has a normal white count, but sputum at this point is showing gram positive cocci in clusters.
PE|pulmonary embolus|PE.|203|205|IMPRESSION|White blood cell count now 15.5, up from 4.1 preadmission and pre-steroids. IMPRESSION: 1. Right lower lobe pneumonia. 2. Asthma exacerbation. 3. Hypoxemia, likely secondary to above. 4. CT negative for PE. RECOMMENDATIONS: 1. Continue steroids and antibiotics. 2. I am not sure that the bacterial coverage of Rocephin plus azithromycin is much different than the levofloxacin she was on previously-either would be fine.
PE|pulmonary embolus|PE.|192|194|RECOMMENDATIONS|He had some dyspnea with wheezing as well. He saw his physician at Park Nicollet Clinic and was sent to Fairview Southdale Emergency Room. There chest x-ray and CT scan of the chest showed no PE. It showed chronic right upper lobe changes along with probable acute left-sided infiltrate. After admission and blood cultures were done, he was started on Rocephin and Zithromax.
PE|pulmonary embolus|PE.|137|139|RECOMMENDATIONS.|5. Ultrasound of the legs bilaterally. Should this demonstrates DVT or should right heart pressures be elevated, would strongly consider PE. The risks and benefits would be such that I would pursue this with either VQ scan and/or CT scanning while starting heparin.
PE|pulmonary embolus|PE.|132|134|PAST MEDICAL HISTORY|_%#NAME#%_ has been maintained on Coumadin, I believe, for the last couple of years because of this. I am not aware of a history of PE. 3. Hypothyroidism. 4. Hyperlipidemia. MEDICATIONS: 1. Klonopin 1 mg at h.s. 2. Benadryl 100-300 mg at h.s. on a p.r.n. basis.
PE|pressure equalization|PE|204|205|PAST MEDICAL HISTORY|He had a renal/bladder ultrasound and KUB. He was started on Ditropan XL which has improved his urinary symptoms but he periodically has encopresis. 3. Asthma, mild, persistent. 4. Seasonal allergies. 5. PE tube placement. 6. Tonsillectomy and adenoidectomy. ADMISSION MEDICATIONS 1. Singulair 5 mg p.o. q. h.s. 2. Advair 100/50 inhaled b.i.d. 3. Allegra 30 mg p.o. b.i.d.
PE|pulmonary embolus|PE.|177|179|HISTORY OF PRESENT ILLNESS|She presented to the Emergency Department this morning where she was evaluated. Her initial troponin and myoglobin were normal. She underwent a CT scan of the chest to look for PE. This was negative. Also of note her D-Dimer was negative. An EKG showed a sinus rhythm, rate of 72 with a left bundle branch block.
PE|pressure equalization|PE|245|246|PAST MEDICAL HISTORY|1. Primarily significant for psychiatric concerns. He has had an EEG and MRI during his last hospitalization both of which were reported to be unremarkable. He is noted to have a pervasive developmental disorder and ADHD. 2. History of multiple PE tube placements. 3. History of cleft lip repair. 4. Asthma, mild, intermittent. 5. Obesity, exogenous likely with superimposed atypical antipsychotic effect.
PE|pulmonary embolus|(PE)|200|203|IMPRESSION|EKG: EKG shows sinus tachycardia. IMPRESSION: 1. Dyspnea and bronchospasm likely secondary to chronic obstructive pulmonary disease (COPD)/asthma exacerbation. a. Doubt significant pulmonary embolism (PE) with negative spiral CT scan and negative lower Doppler ultrasounds. 2. Underlying chronic obstructive pulmonary disease (COPD) with cor pulmonale.
PE|pressure equalization|P.E.|193|196|ASSESSMENT|2. Pansinusitis. We would recommend bilateral nasal endoscopy with maxillary sinus taps and washouts for viral, fungal, bacterial, aerobic, and anaerobic cultures. We would recommend bilateral P.E. tubes at the same time for his otomastoiditis. Thank you for allowing me to see this patient in consultation.
PE|pulmonary embolus|PE|205|206|IMPRESSION|Will give her the Lasix. Will get a urinalysis and urine culture. Will place the patient on daily weights. If the patient does not have findings that explain her current condition, will consider a CT with PE protocol to rule out pulmonary embolus.
PE|pressure equalization|PE|178|179|HISTORY OF PRESENT ILLNESS|This revealed fullness in the left nasopharynx without mucosal lesion. There was a palpable mass at left level 2A, not discrete, and serous otitis media on the left. He placed a PE tube on the left ear drum and referred the patient to Dr. _%#NAME#%_ and to us. Dr. _%#NAME#%_ saw the patient earlier today and apparently recommended combined chemotherapy and radiation therapy.
PE|pulmonary embolus|PE|183|184|PAST MEDICAL HISTORY|It is not clear at this time what diagnostic evaluations she has had in the past. She has been seen at the Mayo Pain Clinic .................. approximately 1 year ago. 2. History of PE 2 years ago. 3. History of TIAs. 4. Sleep apnea 5. Obesity. 6. History of bilateral mastectomies for breast CA. 7. Irritable bowel syndrome.
PE|pressure equalization|PE|150|151|PAST MEDICAL HISTORY|3. History of pneumonia x 2, apparently severe, resistant case requiring chest tube. No apparent sequelae. 4. Right foot fracture at the age of 3. 5. PE tube placement remotely. 6. Jaw surgery _%#MM#%_ of this year to prepare for tooth implants. MEDICATIONS: 1. Depakote 2. Lexapro 3. Strattera 4. Lamictal
PE|pulmonary embolus|PE|172|173|PLAN|He is essentially a nonsmoker. He smoked in the service one pack every two weeks for two years and then quit. He has no family history of asthma. He has no DVT symptoms or PE symptoms. He has had no recent illnesses. He denies any cardiac symptoms, palpitations, MIs, congestive heart failure, orthopnea, or PND.
PE|pulmonary embolus|PE|191|192|IMPRESSION|Question actual source of hemoptysis. Question related to vasculitic process or infective process. 3. Question pulmonary embolus. There is no obvious evidence of this on CT of the chest with PE protocol. 4. Density in the left main stem. I feel this does not likely represent a primary in the bronchial lesion but mucous plugging, although will need to be further evaluated.
PE|pulmonary embolus|PE.|241|243|HISTORY OF PRESENT ILLNESS|She was having some chest pain and upper extremity weakness. This patient is currently on methadone and we have been asked to come in and consult for her chest pain, which has now been ruled out the possibility of any cardiac involvement or PE. PAST MEDICAL AND SURGICAL HISTORY: Cholecystectomy in 1998, gastrectomy partial in 2002, full in 2004 and a feeding tube placement in 2004.
PE|pulmonary embolus|PE|201|202|REVIEW OF SYSTEMS|She has no history of atrial fibrillation. She has a history of left bundle branch block, but has never been told that she had a myocardial infarction. No known CAD history to her knowledge. No DVT or PE history. No heart failure history. In the ER, the patient was noted to have a heart rate in the 140 range.
PE|pressure equalization|PE|120|121|HISTORY OF PRESENT ILLNESS|He has no history of seizures. There has been no history of head trauma noted. He has a past personal history of having PE tubes placed at age 9 months, and having a tonsillectomy/adenoidectomy at age 4. PHYSICAL EXAMINATION: The patient's examination shows him to be an obese ruddy-complexioned active, in fact hyperactive young man, who is difficult to focus.
PE|pulmonary embolus|PE.|152|154|IMPRESSION AND PLAN|The patient at this time does not have any risk factors for increased embolic events such as diabetes, LV dysfunction, or prior history of CVA, DVT, or PE. Given that he has no risk factors and he is under 65 years of age, I would not recommend long-term anticoagulation unless this becomes an ongoing issue.
PE|pulmonary embolus|PE|153|154|HISTORY OF PRESENT ILLNESS|Her ejection fraction was normal. She had borderline LVH and her nuclear test did not suggest any ischemia. She of course also had a CT of her chest for PE and this showed the aneurysm. Additionally, she was found to have thrombocytopenia with a platelet count of 30,000, though on further review and a blood smear was noted that she has likely a pseudo-thrombocytopenia which is likely related to an EDTA antibody.
PE|pulmonary embolus|PE|177|178|ASSESSMENT|Certainly, symptoms are atypical for pneumonia, but he does have some chest pain without a cough or fever and I think it is prudent to treat for this. I doubt this represents a PE or tumor. 3. Hydronephrosis due to stone. 4. Hypertension, on therapy. RECOMMENDATIONS: 1. I will add Levaquin for treatment of the infiltrate to be safe.
PE|pulmonary embolus|PE|153|154|PLAN|I do not see any contraindications to anticoagulation. 4. I will arrange for an echocardiogram to be done. 5. The BNP is very high. This may be due to a PE and a pulmonary embolism might be considered and evaluated. 6. According to the emergency room, the resting oxygen saturation was dipping into the 80s.
PE|pulmonary embolus|PE.|165|167|DIAGNOSTIC STUDIES|Blood culture, sputum culture and urine culture pending. DIAGNOSTIC STUDIES: 1. Chest x-ray with bilateral interstitial infiltrates. 2. Chest CT without evidence of PE. Has extensive bilateral infiltrates. Thank you very much for this consultation. Part two job
PE|pulmonary embolus|PE|275|276|IMPRESSION|I doubt this represents coronary ischemia, however considering his past history, further evaluation is warranted. More concerning is the possibility of pulmonary embolism. He did have lower sats earlier today and because of his symptoms, CT scan with IV contrast to rule out PE is warranted. Further investigation based upon the patient's clinical course and results of these studies.
PE|pressure equalization|PE|245|246|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: VITAL SIGNS: Weight is 19.2 kg, blood pressure 115/90, pulse 84, respiratory rate 20, temperature 96.8 degrees Fahrenheit. GENERAL: He is a well-developed, well- nourished male with dry skin, mildly blood shot eyes. HEENT: PE tubes present bilaterally. No nasal discharge. He bit his lips with dry blood. The oropharynx is otherwise moist without lesions. NECK: He has shotty cervical nodes on the right side, none on the left.
PE|pulmonary embolus|PE|200|201|PLAN|2. Cough - question whether this is secondary to #1 or does he truly have an ongoing pneumonia which is not obvious radiographically. 3. Primary sclerosing cholangitis. PLAN: 1. CT scan of chest with PE study to rule out PE, AVM, or pneumonia. 2. ENT consultation with Dr. _%#NAME#%_ since he sees him in clinic. 3. Echocardiogram to evaluate his murmur and rule out mitral valve disease.
PE|pulmonary embolus|PE|207|208|REVIEW OF SYSTEMS|There is also significant cardiovascular disease. REVIEW OF SYSTEMS: Constitutional: No fever, chills. She has mild fatigue, no night sweats. Cardiac: No history of heart disease. Respiratory: As above with PE and lung cancer. Gastrointestinal: No nausea or vomiting, no diarrhea, constipation. Genitourinary: Negative. Integumentary: Nodule under the anterior abdomen from Lovenox.
PE|pressure equalization|PE|218|219|PAST MEDICAL HISTORY|2. History of mysterious leg injury in _%#MM#%_ 2003. Apparently at that time, he was refusing to move his leg. I do not have details regarding the evaluation although in general no problem was detected. 3. History of PE tube placement. 4. History of rotavirus at 9 months of age. MEDICATIONS: Clonidine 0.1 mg p.o. q. h.s. ALLERGIES: No known drug allergies.
PE|pulmonary embolus|PE,|142|144|ASSESSMENT|A. Hypoxemia - unclear etiology, could be pulmonary embolus, could be COPD. B. Risk factors for pulmonary embolus include previous history of PE, and metastatic prostate cancer. 2. Metastatic prostate cancer. 3. Hematuria. PLAN: 1. Non-evasive evaluation - including duplex ultrasound of lower extremities, D-dimer.
PE|pulmonary embolus|PE|149|150|HISTORY OF PRESENT ILLNESS|Since switching to Lovenox, she has been aware of some discomfort in her legs and some shortness of breath and she feels this is very similar to her PE last _%#MM#%_. At that time, her lower extremity Dopplers were negative and they remain negative. PAST MEDICAL HISTORY: Otherwise, negative. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Nonsmoker.
PE|pulmonary embolus|PE|163|164|HISTORY|CT scan of the chest on _%#MM#%_ _%#DD#%_, two days after that first scan, showed thrombosis in the left subclavian vein extending into the superior vena cava. No PE was found. There is inflammation and induration in the soft tissues of the left lower neck extending into the upper mediastinum.
PE|pulmonary embolus|PE|117|118|PAST MEDICAL HISTORY|She has a history of atrial fibrillation and hypertension. 2) History of TIA/CIA. 3) She has a history of DVT with a PE in 1978. She is anticoagulated on Coumadin for both her PE and also her atrial fibrillation. 4) Pulmonary hypertension. 5) GERD. 6) Hypothyroidism. HISTORY OF PRESENT ILLNESS: The patient is a very pleasant 85- year-old female who resides in _%#CITY#%_ who presented to the emergency room with episode of hematemesis times one.
PE|pulmonary embolus|PE|148|149|PHYSICAL EXAMINATION|EXTREMITY: Shows trace pedal edema but no cyanosis or clubbing. CT scan of the chest was done to rule out pulmonary embolus and this did not show a PE but does show an elevated right hemidiaphragm as well an area of atelectasis and infiltrate at the right lung base.
PE|pulmonary embolus|PE.|130|132||She has had absolutely no chest pain. She has had some chronic edema for a few weeks. This has not changed. She has no history of PE. She has had no cough. No hemoptysis. No fevers, chills or night sweats. Of significance is the fact that she was just here _%#MM#%_ _%#DD#%_ with a discharge date of _%#MM#%_ _%#DD#%_ for shortness of breath and a pleural effusion.
PE|pressure equalization|PE|108|109|PAST MEDICAL HISTORY|He vomited about half an hour later. At this time, he denies any acute complaints. PAST MEDICAL HISTORY: 1. PE tube placement remotely. 2. History of large intestine infection as an infant. Details not available to me. To my knowledge, no sequela.
PE|pulmonary embolus|PE|237|238|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: Please see HPI for details. Review of systems notable for feelings of lethargy and disconnected as well as complaints of right knee pain postoperatively. No chest pain, shortness of breath or abdominal pain. No DVT or PE history. No focal weakness. Review of systems is otherwise negative for cardiovascular, respiratory, GI, renal, urinary, hematologic, integument, endocrine, musculoskeletal, neurologic and cognitive complaints besides that described above.
PE|pulmonary embolus|PE.|121|123|PAST MEDICAL HISTORY|He started chemotherapy in _%#MM#%_ of this year and has been on interferon for the last three weeks. 2. History of DVT, PE. It sounds like he had his diagnosis from having had a CT scan of the chest in _%#MM#%_ of 2005 and they found he had bilateral pulmonary embolus and right popliteal DVT.
PE|pulmonary embolus|PE|265|266|PHYSICAL EXAMINATION|Marked muscle atrophy. No tenderness or inflammation. No varicosities. It is my impression that this patient has abdominal pain, now raises the issue of chest pain which has been an issue previously. He has had been on Coumadin and has had two negative workups for PE with CT in _%#MM#%_ and _%#MM#%_, making this significantly less likely. I will do a ventilation perfusion lung scan and venous Doppler.
PE|pressure equalization|PE|192|193|PAST MEDICAL HISTORY|The patient denies any acute medical complaints at present. PAST MEDICAL HISTORY: Is significant for previous psychiatric hospitalization with last treatment _%#MM#%_ of this year. History of PE tube placement as well as bilateral tympanoplasties for recurrent otitis media. He has had no recent episodes. No other known chronic medical illness.
PE|pulmonary embolus|PE,|127|129|IMPRESSION|He presents with right leg swelling and chest pain which is pleuritic in nature. Even though his CT scan is negative for acute PE, it is possible that he may have had small PEs to the lung peripheries causing his pleuritic chest pain.
PE|pulmonary embolus|PE,|175|177|HISTORY OF PRESENT ILLNESS|Abdominal CT was done for abdominal pain and distention and shows some ascites and mechanical small-bowel obstruction and multiple renal cysts. Because of the patient's acute PE, the urologists have requested evaluation and treatment of the patient's pulmonary embolism. Dr. _%#NAME#%_ has ordered IV heparin which patient has just received.
PE|pulmonary embolus|PE|147|148|IMPRESSION|I will order lower extremity Doppler ultrasounds to evaluate for potential underlying DVT. If there is no evidence of DVT, it is possible that the PE could have originated from the pelvic veins. The patient also has evidence of hypokalemia which will require correction.
PE|pulmonary embolus|PE.|157|159|IMPRESSION|5. Infectious Disease has been consulted. 6. Cultures have shown coag negative staph on _%#DDMM2007#%_. 7. Pleural effusions on CT scan without evidence for PE. Unclear cause at this point, however, based on x-ray on _%#DDMM2007#%_ this appears to be new. Could be related to congestive heart failure or possibly infection.
PE|pulmonary embolus|PE.|157|159|LABORATORY DATA|HEART: S1 and S2, rate 80. ABDOMEN: Nontender. EXTREMITIES: Showed a paralyzed left side. LABORATORY DATA: Her CT scan of the chest is as above. There is no PE. Hemoglobin 14.3, white count 8600, BNP markedly elevated at 1,140 with normal being up to 450, INR 1.98 on Coumadin and blood gasses reveal a pH of 734, pCO2 44, pO2 207.
PE|pulmonary embolus|(PE)|150|153|HISTORY|She has subsequently been found to have an extensive right lower extremity deep venous thrombosis (DVT) and clinically likely has a pulmonary embolus (PE) as well. She was begun on anticoagulation with heparin on _%#DDMM2002#%_ as well as antibiotics with Rocephin and Zithromax for possible pneumonia.
PE|pulmonary embolus|(PE)|260|263|IMPRESSION AND RECOMMENDATIONS|The patient's autonomic dysfunction is probably multifactorial including blood loss during surgery of approximately 3-g, fever and leukocytosis suggestive of infection of unclear source, and sleep deprivation. I have a very low suspicion for pulmonary embolus (PE) as the patient has no other symptoms suggestive of this. I am more concerned about possible infection. I would like to obtain surveillance culture as well as a chest x-ray and urinalysis.
PE|pressure equalization|PE|197|198|PAST MEDICAL HISTORY|She denies cough, headache, or ear pain. PAST MEDICAL HISTORY: Unremarkable for asthma. There is a history of occasional sinusitis and otitis as a younger child. She is status post myringotomy and PE tube placement in 2002. Other surgeries include an appendectomy. MEDICATIONS: Medications prior to surgery were none.
PE|pulmonary embolus|PE.|180|182|LABORATORY & DIAGNOSTIC DATA|LABORATORY & DIAGNOSTIC DATA: Laboratory studies are reviewed and are notable for a troponin of 0.36, electrocardiogram which shows early repolarization. Chest CT was negative for PE. ASSESSMENT: This is a gentleman with the following issues: 1. Chest pain.
PE|pulmonary embolus|PE|263|264|PROBLEM #2|In addition, it was recommended that she pursue physical therapy as an outpatient and a referral to a Fairview center near her home was made at the time of discharge. PROBLEM #2: Pulmonary emboli: On admission the patient did not present with typical symptoms of PE including shortness of breath, tachypnea, hemoptysis, tachycardia or pleuritic chest pain, although a component of chest pain related to the neck and shoulder pain could not be ruled out.
PE|pulmonary embolus|PE|106|107|LABORATORY DATA|Urinalysis shows a moderate amount of blood. I think this is probably from some acute trauma. CT scan for PE on _%#DDMM2007#%_ mild infiltrate right upper lobe no pe. The patient did have a CT scan of his head just two days ago which was also negative.
PE|pressure equalization|PE|127|128|PHYSICAL EXAMINATION|HEENT: Head is normocephalic and atraumatic. Ears, both TMs with otosclerosis present but no erythema or effusions noted. Left PE tube in the canal and right PE tube in the canal. Eyes, there is mild conjunctival injection. Nose reveals slightly injected nasal passages.
PE|pulmonary embolus|PE|137|138|PROCEDURES PERFORMED DURING THIS ADMISSION|3. Altered mental status. PROCEDURES PERFORMED DURING THIS ADMISSION: 1. IVC filter placement done on _%#DDMM2007#%_. 2. CT of the chest PE protocol done on _%#DDMM2007#%_ shows a saddle pulmonary embolus with extension of the thrombus into both intralobar pulmonary arteries, the segmental pulmonary arteries and subsegmental pulmonary arteries.
PE|pulmonary embolus|PE|221|222|PROCEDURE PERFORMED DURING THIS ADMISSION|1. Chest x-ray done on _%#DDMM2007#%_ shows left lower lobe airspace disease consistent with a pneumonia given clinical history, probable with subsegmental atelectasis also seen at the right lung base. 2. CT of the chest PE protocol done on _%#DDMM2007#%_ shows no evidence for pulmonary embolism. There were multiple nodular opacities including a cavitary nodule and a right lung apex.
PE|pulmonary embolus|PE|196|197|PROCEDURES/IMAGING|There are distal tibial and fibular fractures with callus formation and they do not appear changed from the comparison exam on _%#DDMM2007#%_. 5. Chest CT for PE done on _%#DDMM2007#%_ showing no PE but rather bibasilar airspace opacification, right greater than left concerning for pneumonia and mosaic attenuation that may represent small airway disease.
PE|pulmonary embolus|PE,|239|241|ASSESSMENT/PLAN|We will notify the covering oncologist of the patient's admission, and we will ask for any additional input in the meantime. The patient's symptoms could be PE or sepsis and respiratory alkalosis. Because of the patient's prior history of PE, he is at high risk that he may have recurrence at this point. This differential diagnosis was discussed with the patient's family members.
PE|pulmonary embolus|PE.|90|92|LABORATORY|Chest x-ray per ED - Left lower lobe haziness. Await formal report. Chest CT negative for PE. ECG - Normal sinus rhythm. No acute ST-T wave changes. ASSESSMENT/PLAN: 1. Chest pain, probably musculoskeletal etiology.
PE|pulmonary embolus|PE|136|137|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Metastatic breast cancer status post oral Xeloda and Herceptin treatment. 2. Lower extremity DVT with bilateral PE status post filter placement. 3. Pneumonia with CMV currently undergoing treatment. 4. Coag-negative staph bacteremia now treated and resolved.
PE|pulmonary embolus|(PE),|301|305|PAST MEDICAL HISTORY|6. Left cerebrovascular infarction (CVI) on _%#DDMM2004#%_. 7. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) at least dating back to 2001 when she had a sodium of 130. The patient and her daughter deny any history of diabetes mellitus, deep vein thrombosis (DVT), pulmonary embolus (PE), asthma, seizure disorder, peptic ulcer disease, emphysema. PAST SURGICAL HISTORY: 1. Right cataract extraction. 2. Angioplasty and stent.
PE|pulmonary embolus|PE|195|196|IMPRESSION|17) Status post open reduction and internal fixation right ankle with resultant ulcer lateral malleolus. 18) Insomnia for many years. 19) Gastritis. 20) Gastroesophageal reflux disease. 21) 1998 PE while in hospital. PLAN: 1) Pulmonary consult; will try to control her diabetes.
PE|pulmonary embolus|(PE)|189|192|REVIEW OF SYSTEMS|Negative for thyroid disease. Respiratory: Shortness of breath over the last 10 days of gradual onset. No cough. No pleuritic pain. No hemoptysis. No previous history of pulmonary embolism (PE) or deep venous thrombosis (DVT). Cardiovascular: No chest pain, no palpitations, no PND, no orthopnea. Positive for ankle edema. Positive for shortness of breath. No congenital heart disease, no valvular heart disease.
PE|pulmonary embolus|PE|268|269|IMPRESSION|They are most prominent in the apices, and one would expect them in the bases for pulmonary fibrosis, but given her family history, this at least needs to be considered. In addition to therapy for COPD, she will be continued on her home medication and be treated with PE prophylaxis. We will check a nasal swab for influenza, and if the rapid antigen is positive, Tamiflu will be initiated as well.
PE|pulmonary embolus|PE,|220|222|HISTORY OF PRESENT ILLNESS|Problem #2. Hypoxia. During the patient's hospitalization, it was noted that she was steadily requiring more oxygen supplementation. A chest x- ray was performed, which demonstrated no new infiltrates. Given concern for PE, especially with the patient's history of antiphospholipid antibody syndrome and multiple thrombotic complications, a CT scan, PE protocol was obtained.
PE|pulmonary embolus|PE,|143|145|PROBLEM #1|During this hospital course a chest CT with contrast was obtained to evaluate the patient for possible pulmonary embolism. CT was negative for PE, but showed bibasilar infiltrate, left worse than right. The patient was continued on her _%#COUNTY#%_ antibiotics, which included Bactrim, Flagyl, and vancomycin.
PE|pulmonary embolus|PE,|298|300|HOSPITAL COURSE|Because the patient's DVT and PE were over a year ago and the recommended treatment is Coumadin for three to six months, it was felt that the Coumadin could be discontinued as well as the heparin, which could be increasing the DIC. It was felt that if the patient needed protection against further PE, a Greenfield filter could be placed if this was felt to be appropriate, considering her long- term prognosis as well as code status.
PE|pulmonary embolus|PE|123|124|IMPRESSION AND PLAN|It was read as small on recent CT scan. Tapping would be complicated in this patient given that she is on Coumadin for her PE history. Ultimately, if tapping is indicated, would need to reverse her INR with vitamin K, place the patient on heparin, perform the tap, and then restart the Coumadin.
PE|pulmonary embolus|PE.|270|272|PROCEDURES|2. CT of head without contrast showed progression of right parietooccipital infarct evidenced on _%#DDMM2003#%_ head CT consistent with an evolving infarct. No significant mass effect. No bleeding identified. Otherwise unremarkable. 3. CT of chest showed no evidence of PE. It revealed large left and moderate right-sided pleural effusions, extensive consolidation of left lower lobe, and possible infiltrates in the remainder of both lungs.
PE|pulmonary embolus|PE.|184|186|PROBLEM #4|However, her chest x-ray remained normal. She did have some hypoxia transiently, she was on room air and saturating well at the time of her discharge. There was no evidence of further PE. PROBLEM #5: Urinary retention. The patient had some trouble with urinary retention while on Dilaudid.
PE|pulmonary embolus|PE.|243|245|ASSESSMENT AND PLAN|With the incomplete right bundle branch block, the elevated bicarb and the fact that the pain got better with oxygen I somewhat question pulmonary etiology. We will check a D-dimer, and if positive we would send her for a CT chest to rule out PE. If no PE I would rule her out for a myocardial infarction, although that is very low on my list, and consider further evaluation although not very likely.
PE|pulmonary embolus|PE.|152|154|PROBLEM #3|Lasix was given as well as a CT chest to rule out PE and supplemental O2 at the time and the IV fluids were discontinued. The CT chest was negative for PE. However, it did show ground glass opacities in the right upper lobe, right middle lobe, increasing consolidation in the right lower lobe concerning for infection, new small left pleural effusion.
PE|pulmonary embolus|PE,|129|131|PROCEDURES|The renal artery and veins are patent. 4. CT pulmonary angiogram done to rule out pulmonary embolism, which shows no evidence of PE, right-sided effusion, no evidence of pulmonary nodular lymphadenopathy. There was a wedge-shaped area within the anterior aspect of the spleen, which was suggestive of an infarct.
PE|pulmonary embolus|PE|169|170|IMPRESSION|The patient wishes to be full code. I believe the chronic obstructive pulmonary disease is probably stable and not contributing to his symptoms. He only risk factor for PE is sedentary lifestyle. His d-dimer is falsely elevated. PLAN: For Accelerated hypertension and pulmonary edema with respiratory failure.
PE|pulmonary embolus|PE|426|427|HISTORY OF PRESENT ILLNESS|PRIMARY ONCOLOGIST: Dr. _%#NAME#%_ _%#NAME#%_ of Minnesota Hematology Oncology clinic. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 71-year-old Black female who has colon cancer with diffuse liver metastases who presented to the emergency room this afternoon with increasing upper abdominal pain that radiated across the anterior chest. The patient does have a history of hypertension. The patient was scanned for a PE in the Emergency Room and secondary report reported no active pulmonary embolism, the formal radiology report is pending. The patient was given Dilaudid for pain relief which completely relieved her chest pain and upper abdominal pain.
PE|pulmonary embolus|PE.|203|205|FAMILY HISTORY|She worked in a plastic factory in _%#CITY#%_. FAMILY HISTORY: Positive for lung cancer in her maternal grandmother and prostate cancer in her paternal grandfather and an uncle. Her father had a DVT and PE. PROCEDURES, TESTS, AND LABS: 1. On _%#DDMM2003#%_: myeloablative unrelated donor double-cord transplantation performed. 2. On _%#DDMM2003#%_: CT scan of the abdomen and pelvis revealed nonspecific free fluid in the pelvis.
PE|pulmonary embolus|PE.|247|249|IMPRESSION AND PLAN|Other possibilities to consider include a pulmonary embolism. The patient does not have significant risk factors for this, but certainly should consider it. Will check a D-Dimer. If positive, will likely proceed with a chest CT scan to rule out a PE. Regarding his chest x-ray, there is no obvious pneumonia to explain his chest discomfort. 4. Sore throat. The patient has a rather benign appearing exam with a negative strep titer.
PE|pulmonary embolus|PE|120|121|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. History of DVT in 2002 in her left lower extremity for which she has a filter. 2. History of a PE and a DVT in 2002; at this time she also had pleural effusion which was drained but subsequently developed pneumothorax and needed a chest tube.
PE|pulmonary embolus|PE.|133|135|HOSPITAL COURSE|The patient did have a VQ scan done during her hospitalization which showed only the defect from the pleural effusion and she had no PE. 4. Episodic congestive heart failure probably due to diastolic dysfunction. Patient had a cardiac echo done on _%#DDMM2002#%_ which showed normal left ventricular cavity size and wall thickness.
PE|pulmonary embolus|PE.|190|192|PROCEDURES AND INVESTIGATIONS|5. Status post gastrectomy for stomach and renal carcinoma. 6. History of thromboembolism on anticoagulation. PROCEDURES AND INVESTIGATIONS: 1. Bilateral pulmonary angiography, negative for PE. Mild pulmonary hypertension. 2. Chest x-ray which showed left pleural effusion and left basilar atelectasis. Right apical airspace opacity. Interstitial pulmonary edema. Prominent right hilum.
PE|pressure equalization|PE|142|143|PHYSICAL EXAMINATION ON ADMISSION|HEAD: Positive for alopecia, normocephalic, atraumatic. EYES: Pupils equal, round, and reactive to light. Extraocular movements intact. EARS: PE tubes in place bilaterally without erythema. NOSE: No congestion or drainage. MOUTH AND THROAT: No sores, no pharyngeal erythema. NECK: Supple. LUNGS: Clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm without murmur.
PE|pulmonary embolus|PE|144|145|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. P 3-0-0-3. 2. Diverticulitis. 3. History of colostomy, with reversal in 2000. 4. History of deep venous thrombosis and PE in 2002. 5. Congestive heart failure, _%#DDMM2002#%_. 6. Osteoarthritis. 7. Anemia. PAST SURGICAL HISTORY: Colostomy, 2000. See complete details of surgeries in the history of the present illness.
PE|pulmonary embolus|PE.|176|178|ASSESSMENT AND PLAN|Some of the coagulation testing was ordered and is pending and will be back in several days and will be sent to his primary care physician. The patient's mother has suffered a PE. The patient will be treated with a 9-month treatment of anticoagulants unless the coagulation testing becomes positive and he will need at that time life-long anticoagulation with Coumadin.
PE|pulmonary embolus|PE.|178|180|HOSPITAL COURSE|He also started chest percussor during the hospital stay. On _%#DDMM2006#%_, he had significant right upper chest pain which was evaluated with CT angiogram and did not show any PE. He had a new mucoid infection. He required some narcotics for pain control. Despite the above therapy FEV1 did not improve significantly though he felt better clinically.
PE|pulmonary embolus|PE.|189|191|HISTORY OF PRESENT ILLNESS|Her creatinine has been relatively stable but she has had significant third spacing and edema. She developed a complaint of dyspnea over the past weekend and a CT scan was done to rule out PE. The PE was negative but was notable for bilateral pleural effusions secondary to her ascites. CARDIOVASCULAR: She has had some tachycardia, an echo on _%#DDMM2006#%_ noted an ejection fraction of 75% and was otherwise normal.
PE|pulmonary embolus|PE,|396|398|HOSPITAL COURSE|He was initially started on meropenem and tobramycin IV; ciprofloxacin, Bactrim, and azithromycin p.o. but after review fo his cultures, it was determined that Cipro did not add significantly to other antibiotics, so this was discontinued, and he was maintained on the meropenem, tobramycin, Bactrim, and azithromycin. Given his chest pain and lower extremity pain, there was concern for DVT and PE, but CT scan of the chest revealed only right middle lobe and possible right lower lobe infiltrate and bronchiectatic changes but no PE.
PE|pulmonary embolus|PE|123|124|PAST MEDICAL HISTORY|3. Recurrent falls. 4. History of DVT, for which she has been on Coumadin for approximately six months. She has also had a PE in the past. 5. Reflex sympathetic dystrophy in bilateral hands ever since a fall at work. 6. History of bilateral hand and arm cellulitis in the past, especially with IV's.
PE|pulmonary embolus|PE|286|287|IMPRESSION|At this point, cannot rule out pneumonia. I suspect that there may be some underlying chronic lung disease that has been undiagnosed as she did smoke one pack of cigarettes daily for many, many years. Certainly, her degree of hypoxia warrants further evaluation. Further evaluation for PE may prove to be difficult. Please see the discussion below. 3. Acute renal failure, perhaps related to initiation of lisinopril.
PE|pulmonary embolus|PE|150|151|HOSPITAL COURSE|Abdominal exam was benign. She was in no acute distress. It was felt that she was not hypoxic, not tachypneic, and not tachycardic. Further workup of PE was not pursued. An electrocardiogram showed signs consistent with LVH. She had a follow up electrocardiogram with chest pain, again, and it showed no changes other than LVH.
PE|pulmonary embolus|PE.|219|221|REVIEW OF SYSTEMS|No cough, shortness of breath, or history of asthma.No abdominal pain, blood in the stool, black tarry stools, or urinary burning, frequency, or urgency. No history of abnormal bleeding tendencies. No history of DVT or PE. No loss of consciousness, seizure, severe unusual headache, focal numbness or weakness, and no vertigo at this time. The rest of the review of systems is negative except for some flare of eczema.
PE|pulmonary embolus|PE|239|240|LABORATORY DATA|LABORATORY DATA: A CT scan done on _%#DDMM2007#%_ compared to the prior CT scan of his chest shows that he has worsening left upper lobe consolidation with possible atelectasis when compared to the prior CT scan done on _%#DDMM2006#%_. No PE was noted on that. Chest x-ray PA and lateral done today shows stable bronchiectatic changes in his lungs, with elevation of his left hemidiaphragm again which is not new No new infiltrates or effusions are noted.
PE|pulmonary embolus|PE.|282|284|IMPRESSION|I think the most important diagnosis to make would be pulmonary embolism as this would require urgent treatment to prevent subsequent blood clots which could potentially be life-threatening. Thus, despite his mildly elevated creatinine, I would recommend a CT angiogram to rule out PE. I would encourage you to hydrate the patient before and after the dye load, and also treat with the standard Mucomyst protocol to try to reduce the risk of nephrotoxicity.
PE|pulmonary embolus|PE.|230|232|REVIEW OF SYSTEMS|ENDOCRINE: The patient is euthyroid; however, he does have a diagnosis of diabetes, starting on insulin at age 18. HEMATOLOGY: He complains of easy bruising and bleeding, secondary to his anticoagulation of Coumadin for a DVT and PE. ALLERGIES: As listed above. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 126/78, pulse 100, respiratory rate 12, temperature 96.8, weight 268.8 pounds, height 6 feet 1 inch.
PE|pulmonary embolus|PE.|289|291|HISTORY OF PRESENT ILLNESS|Chest x- ray, which was a portable, and compared with a prior chest x-ray from _%#MM#%_, showed a possible infiltrate in the right lower lung, also increased interstitial markings. The heart size does appear normal. CT of the chest done _%#DDMM2003#%_ showed emphysematous changes, but no PE. The patient had been on Coumadin due to a stroke and has __________ ASD.
PE|pulmonary embolus|PE.|160|162|HISTORY OF PRESENT ILLNESS|It also shows or an increase in right ventricular size and decrease in right-sided function compared to _%#MMDD#%_ echo. He was started on heparin for presumed PE. His troponins are rising. The patient had decent urine output yesterday and had 600 cc out in the first 8 hours today.
PE|pulmonary embolus|PE|177|178|IDENTIFICATION|She presented here on _%#DDMM2007#%_ with progressive shortness of breath over the last number of week prior to her hospitalization. She was investigated in regards to possible PE that showed not to be the case on CT scan. She was started on heparin prophylaxis and a chest x-ray was thought to suggest pneumonia, for which she was started on antibiotics.
PE|pulmonary embolus|PE.|131|133|PAST MEDICAL HISTORY|13. Iron deficiency anemia. 14. Seizure disorder diagnosed in 1985, treated with Dilantin. 15. History of lower extremity DVT with PE. Has been on long term Coumadin for 20 years. 16. Depression. 17. Myocardial infarction in 2001 status post stent placement.
PE|pulmonary embolus|PE.|188|190|ASSESSMENT AND PLAN|I would like to check anti-Xa activity to make sure that he is fully anticoagulated, and I would rather given him a dose of Lovenox twice daily instead of once daily since he had a recent PE. Do a 24-hour urine collection for protein and send it for immunofixation to look for any monoclonal quantification. Consider kidney biopsy to exclude amyloidosis or vasculitis as an etiology for his renal failure.
PE|pulmonary embolus|PE|209|210|IMPRESSION|Acute thrombosis is possible due to his presumed hypercoagulable state even with a good INR and so antiphospholipid screen is ordered. Percarditis has not been ruled out yet. I do not think this is pneumonia, PE or dissection. The patient's diabetes appears to be well controlled. We will have to make sure that he does have tight control during this period of acute strain.
PE|pressure equalization|PE|178|179|PAST MEDICAL HISTORY|He feels well, he is tolerating the chemotherapy well. PAST MEDICAL HISTORY: 1 High grade, partial small bowel obstruction in _%#DDMM2005#%_, which was treated conservatively. 2 PE tubes placed for chronic otitis media when he was age 2 and 5. 3 Tonsillectomy in _%#DDMM2006#%_. 4 Influenza A. MEDICATIONS: 1 Bactrim.
PE|pressure equalization|PE|137|138|PALLIATIVE MEDICINE SUMMARY|Delivery was vaginal without complication. _%#NAME#%_ underwent strabismus surgery at 4 years of age. He underwent tympanoplasty. He had PE tubes placed on three occasions. During _%#NAME#%_'s prior psychiatric hospitalization, _%#NAME#%_'s psychoactive medications were discontinued and only therapy with topiramate and oxcarbazepine maintained.
PE|pulmonary embolus|PE|263|264|LABORATORY AND RADIOLOGY RESULTS|The patient will be taken off of IV antibiotics for his left apical pneumonia and switched to Levaquin and should be continued till _%#DDMM2007#%_. LABORATORY AND RADIOLOGY RESULTS: A chest x-ray done on _%#MMDD#%_ showed unremarkable chest. A CT of the chest on PE protocol on _%#MMDD#%_ showed left lung apex infiltrate and no evidence of pulmonary embolism or vascular calcifications according to the coronary artery.
PE|pulmonary embolus|PE|164|165|PROCEDURES|At discharge, there was no evidence that there was any cardiac dysfunctions. CONSULTATIONS: Cardiology. PROCEDURES: Echocardiogram. Chest CT which was negative for PE or acute process. On telemetry, she had no significant arrhythmias. DISCHARGE INSTRUCTIONS: The patient is discharged to home.
PE|pulmonary embolus|PE|163|164|ADMISSION DIAGNOSIS|The patient was fully sensate and fully functional with his right upper extremity. PAST MEDICAL HISTORY: The patient's past medical history is significant for: 1. PE in the remote past. 2. Ewing sarcoma, status post excision and chemoradiation. 3. Catheter sepsis.
PE|pressure equalization|PE|173|174|PROCEDURE PERFORMED|ADMISSION DIAGNOSIS: Obstructive sleep apnea. DISCHARGE DIAGNOSIS: Obstructive sleep apnea. PROCEDURE PERFORMED: Tonsillectomy, adenoidectomy, bilateral myringotomy without PE tubes. HISTORY OF PRESENT ILLNESS: Patient is a 6-year-old boy who has had obstructive sleep apnea symptoms and recurrent otitis media.
PE|pressure equalization|PE|294|295|PROCEDURES PERFORMED DURING THIS HOSPITALIZATION|ADMISSION DIAGNOSES: Recurrent otitis media, reflux disease, and obstructive sleep apnea. DISCHARGE DIAGNOSES: Same including MRSA isolation precautions. PROCEDURES PERFORMED DURING THIS HOSPITALIZATION: Tonsillectomy, adenoidectomy, esophagoscopy with biopsy, and bilateral myringotomies with PE tube placement. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 2-year-old female with a history of reflux disease refractory to medical therapy and has also developed significant obstructive symptoms and otitis media.
PE|pulmonary embolus|(PE)|141|144|CT SCAN|CHEST X-RAY: Chest x-ray was reviewed and suggests mild pulmonary edema. CT SCAN: Chest CT scan was apparently negative for pulmonary emboli (PE) although the formal report is pending. IMPRESSION: Chest pain of unclear etiology, but highly suggestive of a cardiac process.
PE|pulmonary embolus|PE|224|225|REVIEW OF SYSTEMS|CARDIAC/RESPIRATORY: Please see HPI. GI: Positive for 1% of diarrhea last week not bloody, which resolved. GU: Positive for nocturia x3 unhelped by either Flomax or Uroxatral. No bleeding tendencies. ORTHOPEDIC: No previous PE or DVT. Lately he has had very poor quality sleep, daytime fatigue, no fever but he did have the shaking chills last night.
PE|pulmonary embolus|PE|194|195|HOSPITAL COURSE|Associated peripheral shunt as well, all of which was felt to contribute to the patient's significant degree of persisting hypoxemia. HOSPITAL COURSE: The patient did undergo CT angiogram using PE protocol showing no evidence for pulmonary embolism. Significant component of pulmonary hypertension felt to exacerbate the right-to-left shunt. Consultation by pulmonary. Protracted treatment using above modalities. Progressive weakness with continued periods of significant hypoxemia.
PE|pulmonary embolus|PE:|188|190|PROBLEM #3|She did respond to DuoNeb treatment. She is sating well on 2 L nasal cannula upon discharge, which is the regimen that she came in on. PROBLEM #3: Prothrombin gene mutation and history of PE: Upon initial presentation, the patient's factor II level was low, which was supratherapeutic. This was thought to be secondary to the antibiotic regimen interfering with her metabolism of warfarin.
PE|pulmonary embolus|PE|149|150|OPERATIONS/PROCEDURES PERFORMED|2. Lower extremity deep venous thrombosis. OPERATIONS/PROCEDURES PERFORMED: 1) Chest CT dated _%#DDMM2004#%_. Findings - right main pulmonary artery PE which does extend to the right lower lobe, and somewhat into the right upper and middle lobe. There is also some distal left-sided pulmonary embolus appreciated. 2) Lower extremity ultrasound bilaterally demonstrates a left lower extremity DVT measuring approximately 2 cm in the left popliteal vein which is non-occlusive.
PE|pulmonary embolus|(PE)|156|159|CT SCAN|Troponin is negative. EKG: EKG reveals atrial fibrillation without any ischemic changes. CT SCAN: CT of the chest reveals no evidence of pulmonary embolism (PE) or pneumothorax. There is, however, a right mid lung infiltrate that is new and a chronic upper lobe infiltrate. There also is some subclavian stenosis noted.
PE|pulmonary embolus|PE.|81|83|DISCHARGE DIAGNOSIS|REASON FOR ADMISSION: Right lower lobe PE. DISCHARGE DIAGNOSIS: Right lower lobe PE. DISCHARGE DISPOSITION: Home. DISCHARGE MEDICATIONS: 1. Lovenox injections 100 mg subcutaneously twice a day for the next 5 days.
PE|UNSURED SENSE|PE|214|215|ADMISSION PHYSICAL|NECK: Supple. No lymphadenopathy. HEART: Regular rate and rhythm. Normal S1, S2, no murmurs. LUNGS: Clear to auscultation bilaterally. Good air entry. ABDOMEN: Soft, nontender, nondistended, positive bowel sounds. PE site was clean, dry, and intact. G-tube site clean, dry, and intact with some leakage. SPINE: Straight. No CVA tenderness. No peripheral edema. No rashes.
PE|pulmonary embolus|PE|162|163|FAMILY  HISTORY|1. Albuterol two to four puffs inhaled b.i.d. p.r.n. 2. Oral contraceptive pills 3. ibuprofen 600 mg b.i.d. p.r.n. FAMILY HISTORY: Mother has a history of recent PE and is on Coumadin currently.. Father died of a PE at age 38. Paternal grandfather had a DVT apparently in the setting of melanoma.
PE|pressure equalization|PE|96|97|PROCEDURE PERFORMED|DISCHARGE DIAGNOSIS: Fever in light of a prior cochlear implant. PROCEDURE PERFORMED: Bilateral PE tubes. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 1-year-old child who has received cochlear implant in the past.
PE|pressure equalization|PE|153|154|PHYSICAL EXAMINATION|She was alert, well hydrated, and in moderate respiratory distress. Her O2 sat was 85 percent. HEENT: Atraumatic, normocephalic. The TMs were clear. The PE tube was in the canal. The right PE tube was in place. PERRLA. Extraocular movements intact. Nasal mucosa was clear. Posterior oropharynx was clear.
PE|pulmonary embolus|PE|215|216|HOSPITAL COURSE|PHYSICAL EXAMINATION: Exam was nonfocal. She did have fevers earlier, but none after she had been on the antibiotics for the pneumonia. Vital signs were stable. HOSPITAL COURSE: The patient was admitted to the CSC. PE was ruled out. She was also evaluated for a myocardial infarction which was negative. She continued with chest pain, back pain, and intermittent abdominal pain.
PE|pressure equalization|PE|223|224|PAST MEDICAL HISTORY|The patient describes her pain as being most intense now in the right lower quadrant and it is not improved overnight at all. PAST MEDICAL HISTORY: Significant for tonsillectomy and adenoidectomy at about six years of age. PE tubes at less than two years of age. Asthma, mild and intermittent. The patient is unimmunized. MEDICATIONS: Include only albuterol. SOCIAL HISTORY: There is a smoker in the house, but mom states that she smokes only outside of the home and not in the car.
PE|pulmonary embolus|PE|218|219|HISTORY OF PRESENT ILLNESS|2. Ultrasound of the lower extremities showed occlusive thrombus in the left popliteal vein, bilaterally enlarged inguinal lymph nodes. HISTORY OF PRESENT ILLNESS: Patient is a 58-year-old male who was found to have a PE incidentally on a followup CT scan on the day of admit. He has a history of rheumatoid arthritis complicated by pleural effusion and empyema with most recent admission being 2 weeks ago.
PE|pulmonary embolus|PE.|139|141|PROBLEM #4|PROBLEM #3: COPD exacerbation. The patient received high-dose steroids, to which he responded well. Also nebulizers were used. PROBLEM #4: PE. No evidence of PE. PROBLEM #5: Atrial fibrillation, which is paroxysmal. This needs to be followed up at the primary clinic ASAP.
PE|pulmonary embolus|PE.|161|163|REVIEW OF SYSTEMS|No diarrhea although he did have some loose stools the other day, which has now resolved. No bloody stools. HEMATOLOGIC: No history of bleeding disorder, DVT or PE. DERMATOLOGIC: No rash. ENDOCRINE: No leg swelling, sweats, tremors or weight loss. No known thyroid disease or diabetes. MUSCULOSKELETAL: No new joint complaints, joint swelling or erythema.
PE|pulmonary embolus|PE|92|93|FAMILY HISTORY|He is a former plumber. He lives independently with his wife. FAMILY HISTORY: No history of PE or DVT. REVIEW OF SYSTEMS: As above. All other systems are negative. PHYSICAL EXAMINATION: GENERAL: Very pleasant, alert, in no distress.
PE|pressure equalization|PE|292|293|PAST MEDICAL HISTORY|The CT showed moderate fluid in the pelvis but was otherwise unremarkable. She is unable to tolerate oral pain medicine and, in fact, was feeling itchy on Tylenol No. 3 so was admitted for pain control and further evaluation. PAST MEDICAL HISTORY: 1. Mild intermittent asthma. 2. She has had PE tubes as a 16 month old, otherwise largely unremarkable. MEDICATIONS: Albuterol p.r.n. Apparently used some Zovirax Cream for cold sores.
PE|pressure equalization|PE|178|179|PAST SURGICAL HISTORY|PAST MEDICAL HISTORY: No major medical problems other than some mild seasonal allergies for which he takes Benadryl. CURRENT MEDICATIONS: None. PAST SURGICAL HISTORY: He has had PE tubes placed x2 for recurrent otitis media when he was younger and he has not had an ear infection in a long time. ALLERGIES: He has no known drug allergies. SOCIAL HISTORY: He is doing well in school.
PE|pressure equalization|PE|155|156|PAST MEDICAL HISTORY|_%#NAME#%_ lives at home with older half brother and half sister, each from parents' previous relationship. PAST MEDICAL HISTORY: Remarkable for bilateral PE tubes inserted at age 3 associated with hearing loss and dysarthria. Adenoidectomy earlier than that. He was a term birth with low Apgar scores.
PE|pressure equalization|PE|144|145|PAST MEDICAL HISTORY|She is O positive, rubella immune, VDRL negative, hepatitis B surface antigen negative, and HIV negative. PAST MEDICAL HISTORY: Significant for PE tubes as a child, otherwise no other surgeries or hospitalizations. No significant medical illnesses. FAMILY HISTORY: Significant only for grandfather with a stroke, otherwise healthy.
PE|pressure equalization|PE|150|151|PAST SURGICAL HISTORY|She and Mom have both helped recount the story over the past few days. PAST SURGICAL HISTORY: She had surgery, a hymenectomy 1 1/2 years ago. She had PE tubes as a child. One of those times, she also had her adenoids removed. She had no complications with any of those surgeries. PAST MEDICAL ILLNESSES: She has not previously been hospitalized PERTINENT FAMILY HISTORY: No history of severe allergic reactions DRUG ALLERGIES: She is allergic to sulfa drugs and now has the dystonic reaction to Compazine.
PE|pressure equalization|PE|133|134|PAST HISTORY|He was exposed to rotavirus at a daycare setting, and he has otherwise been a healthy boy. PAST HISTORY: No hospitalizations. He had PE tubes in _%#MM#%_ 2000. No current medications. No allergies. FAMILY HISTORY: The family history is remarkable for diabetes in great-grandparents.
PE|pulmonary embolus|PE|233|234|OPERATIONS/PROCEDURES PERFORMED|Ultrasound on _%#MM#%_ _%#DD#%_, 2003, showed a 4 x 5 x 4-cm left adnexal mass with small to moderate free fluid. Ultrasound on day of admission showed similar. PAST MEDICAL HISTORY: The patient's medical history is remarkable for a PE in 2002. She was hospitalized in the ICU per patient report for that problem. She had been on the Ortho Evra patch at the time.
PE|pulmonary embolus|PE,|160|162|STUDIES|EXTREMITIES: Warm and pink. There is 2+ edema, right ankle with slight tenderness. Calves and thighs nontender. STUDIES: CT scan not available, but reported as PE, right lower lobe. Doppler, right leg, shows no phlebitis. INR 1.14, PTT 118, platelet count 169,000, creatinine 1.3.
PE|pulmonary embolus|PE,|260|262|FAMILY HISTORY|3. History of pneumonia and bronchitis three years ago. PAST SURGICAL HISTORY: Labial tumor resection, tonsillectomy, appendectomy, thyroid cyst removal, C-section times three, and exploratory laparoscopy three years ago. FAMILY HISTORY: Unremarkable. No DVT, PE, or sudden death. No heart disease. ALLERGIES: Morphine and Levaquin. CURRENT MEDICATIONS: Depakote 1 gram daily, Seroquel 12.5 mg daily p.r.n. SOCIAL HISTORY: She smokes one pack per day for the last 12 years, no alcohol.
PE|pressure equalization|PE|297|298|PAST MEDICAL/SURGICAL HISTORY|_%#NAME#%_ presents to our clinic today, accompanied by her mother at the request of Dr. _%#NAME#%_ _%#NAME#%_ to determine her eligibility for total body irradiation conditioning prior to an umbilical cord blood transplant. PAST MEDICAL/SURGICAL HISTORY: Recurrent otitis media with placement of PE tubes. ALLERGIES: Amphotericin causes rigors and shortness of breath. MEDICATIONS: Bactrim.
PE|pressure equalization|PE|130|131|PAST MEDICAL HISTORY|She has also tried fiber pills, which she states were not effective. PAST MEDICAL HISTORY: 1. Tonsillectomy and adenoidectomy. 2. PE tube placement. MEDICATIONS: Depo-Provera. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient smokes a pack of cigarettes daily.
PE|pressure equalization|PE|119|120|SURGICAL HISTORY|3. History of fracture of his left hand. 4. Chemical-dependency with marijuana. SURGICAL HISTORY: 1. Tonsillectomy. 2. PE tubes placed. ADMISSION MEDICATIONS: Concerta 54 mg p.o. q. day. ALLERGIES: No known drug allergies. Environmental allergy to dust.
PE|pressure equalization|PE|247|248|PAST MEDICAL HISTORY|Presently the patient endorses a number of physical symptoms including headache, earache, sore throat, nose pain, abdominal pain. She does appear generally nontoxic. PAST MEDICAL HISTORY: Obtained from the old chart. 1. The patient has history of PE tube placement. 2. History of admission times two for "GI disturbance." This is of unclear cause. There is no evidence of surgical repair with examination of the abdomen.
PE|pulmonary embolus|(PE),|189|193|CT SCAN|Bowel sounds are normal. No bruit noted. RECTAL: Deferred. EXTREMITIES: Essentially normal. X-RAYS: X-ray studies are as noted. CT SCAN: Chest CT scan shows no evidence of pulmonary emboli (PE), aortic dissection, or adenopathy. There may be left ventricular hypertrophy. ULTRASOUND: Venous Doppler ultrasound was negative for deep vein thrombosis (DVT).
PE|pressure equalization|PE|257|258|PAST SURGICAL HISTORY|She has had recurrent bouts of this similar lower abdominal pain over the last several years with frequent evaluations and never an underlying etiology. PAST MEDICAL HISTORY: Is significant for insulin-dependent diabetes. PAST SURGICAL HISTORY: She has had PE tubes. MEDICATIONS: She takes insulin and birth control pill. ALLERGIES: Penicillin which causes a rash.
PE|pressure equalization|PE|201|202|PAST MEDICAL HISTORY|I believe she has been treated with a number of medications in the past, although apparently none recently. ALLERGIES: No known drug allergies. PAST MEDICAL HISTORY: 1. Bipolar disorder. 2. History of PE tube placement remotely. CURRENT MEDICATIONS: None. SOCIAL HISTORY: The patient lives at home in the care of her mother and stepfather.
PE|pulmonary embolus|PE|130|131|RELEVANT LABORATORY DATA|EXTREMITIES: No digital clubbing or peripheral cyanosis or edema. RELEVANT LABORATORY DATA: A CT scan of the chest done without a PE protocol was negative on _%#DDMM2003#%_. The patient's INR is 0.99. Electrolytes were all within normal limits. CBC is normal. Platelet count is 213,000. IMPRESSION/RECOMMENDATIONS: See above.
PE|pressure equalization|PE|217|218|PAST SURGICAL HISTORY|Given epinephrine and Albuterol nebs in the ED. Responded well to Nebs but requiring additional doses 1-2 hours later. Negative for epiglotittis. Contacted Children's Care Center for admission. PAST SURGICAL HISTORY: PE tubes. PAST MEDICAL HISTORY: First croup episode at 6 months of age.
PE|pulmonary embolus|PE|119|120|IMPRESSION|Hemoglobin 14.9, serum electrolytes within normal limits. D- dimer assay less than 0.2. IMPRESSION: 1. No evidence for PE based on our CT scan with PE protocol, normal lower extremity Dopplers and normal D-dimer assay. 2. Slight hypoxia by arterial blood gas likely due to slight atelectasis seen on our CT.
PE|pressure equalization|PE|111|112|PAST SURGICAL HISTORY|PAST MEDICAL HISTORY: 1. Hypertension. 2. Type 2 diabetes. 3. History of kidney stones. PAST SURGICAL HISTORY: PE tube placement. ALLERGIES: None to medications. CURRENT MEDICATIONS: 1. Metformin 500 mg b.i.d.
PE|pressure equalization|PE|102|103|PAST SURGICAL HISTORY|6. Eczema on arms, stomach, and neck. 7. History of recent left ear infection. PAST SURGICAL HISTORY: PE tubes at age 9 months. ADMISSION MEDICATIONS: 1. Risperdal 2 mg p.o. each day at bedtime. 2. Albuterol inhaler 2 puffs q.4-6 h. p.r.n.
PE|pressure equalization|PE|128|129|PAST MEDICAL HISTORY|He just finished an unknown antibiotic with good effect. He has no persistent difficulties. PAST MEDICAL HISTORY: 1. History of PE tube placement x 3. 2. Chronic sinusitis. MEDICATIONS: Celexa which was discontinued secondary to apparent oculogravic crisis.
PE|pressure equalization|PE|270|271|PAST MEDICAL HISTORY|He apparently has had a feeling that people are out to get him, possibly kill him, and he acknowledges receiving special messages from the TV or the radio telling him to kill himself or hurt himself in some way. PAST MEDICAL HISTORY: Essentially negative other than for PE tube placement remotely. I am not aware of chronic medical ailments. CURRENT MEDICATIONS: None. ALLERGY: Neomycin. SOCIAL HISTORY: The patient has been using marijuana heavily on a daily basis for 2 or more years.
PE|pulmonary embolus|PE|150|151|FAMILY HISTORY|He travels to Florida to see his family fairly frequently. He has three children all alive and well. FAMILY HISTORY: Positive in that his brother had PE for which he is now on anticoagulation. His father passed away from complications of DVT. His mother passed away from cancer.
PE|pressure equalization|PE|189|190|PRIOR SURGERIES|CURRENT MEDICATIONS: Paxil and birth control pills. CHRONIC DISEASE/MAJOR ILLNESSES: 1. Recurrent depression. 2. Exercise-induced asthma. 3. Ovarian cyst. PRIOR SURGERIES: None, except for PE tubes. REVIEW OF SYSTEMS: She has had some hearing loss she believes related to the PE tubes.
PE|pressure equalization|PE|114|115|PAST MEDICAL HISTORY|His pain is worse with attempts at range of motion or with palpation and is better at rest. PAST MEDICAL HISTORY: PE tubes. MEDICATIONS: None. ALLERGIES: Penicillin and cephalosporins.
PE|pressure equalization|PE|150|151|PAST SURGICAL HISTORY|7. Tension headaches. 8. Recurrent otitis media. 9. Polysubstance abuse. PAST SURGICAL HISTORY: 1. Congenital diaphragmatic hernia repair in 1985. 2. PE tubes x 3. FAMILY HISTORY: Her mother is age 50 with GERD. A maternal aunt has heart disease and a maternal grandfather with colon cancer who died at age 72.
PE|pulmonary embolus|PE.|215|217|PROBLEM #4|She did remain anemic during the hospitalization with a normochromic normocytic anemia with normal erythropoietin levels. A hemoglobin at the time of discharge was 8.4. PROBLEM #4: Factor V Leiden with a history of PE. The patient was maintained on Warfarin throughout the hospitalization, although this was reversed prior to procedures. She was reinitiated on heparin as bridging therapy, and should resume previous Warfarin dosing once INR is therapeutic.
PE|pulmonary embolus|(PE)|135|138|REVIEW OF SYSTEMS|GU: Denies urinary urgency, frequency, or dysuria. He has had no hematuria. Hematologic: Currently on Coumadin for a pulmonary embolus (PE) of last year and states his INR last Friday (_%#DDMM2003#%_) was approximately 7.0. It was recommended that he hold his Coumadin over the weekend and have it rechecked today.
PE|pulmonary embolus|PE.|272|274|COURSE IN HOSPITAL|He was totally asymptomatic from respiratory standpoint, but considering the fact that he had a recent surgery, we decided to go ahead to do a CT chest with PE protocol to rule out PE being the etiology of the infiltrate and also his lower chest pain. COURSE IN HOSPITAL: PE. As mentioned above, we proceeded with CT scan with PE protocol for above reason. His CT scan did show an evidence of pulmonary embolism at right lower lobe pulmonary artery area.
PE|pulmonary embolus|PE|124|125|PROCEDURES|Home Care is going to be ordered as well as OT and PT for home. CODE STATUS: Unknown. PROCEDURES: CT scan chest to rule out PE on _%#DDMM2007#%_ showed no evidence of pulmonary embolus. There seemed to be some patchy bilateral changes. Two nodules, one measuring 3 mm and one measuring 7 mm noted in the right upper lobe.
PM|afternoon|PM|189|190|DIET|4. Acetaminophen 120 mg p.o./NG q.4h. p.r.n. pain 5. Kayexalate was to be added to formula and allowed to sit for 4 hours prior to decanting and using. DIET: The patient's diet was Similac PM 60/40 at 58 mL per hour x12 hours for total fluid. Restriction of 750 mL per day. ACTIVITY: As tolerated. RESTRICTIONS: Total fluid intake of 750 mL per day.
PM|afternoon|PM|190|191|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|He has history of inpatient psychiatric admissions as a child 11 and 15 years of age. He has been having marital troubles. On the morning of admission at about 5:30, he took over 80 Tylenol PM tablets. He did not seek help. His wife woke up and noticed there was an empty bottle and the patient had decreased level of consciousness.
PM|afternoon|P.M.|141|144|DISCHARGE MEDICATIONS|3. She is released to activities as tolerated. DISCHARGE MEDICATIONS: 1. Allegra 180 mg p.o. q. day. 2. The patient will continue with Advil P.M. 1 tablet p.o. q.h.s. with food. 3. Zantac 150 mg p.o. b.i.d. 4. Albuterol inhaler 2 puffs q.4-6h. p.r.n. Note: The patient was asked to discontinue her hydrochlorothiazide until seen again by her physician.
PM|physical medicine and rehabilitation:PMR|PM|208|209|FOLLOWUP APPOINTMENT|FOLLOWUP APPOINTMENT: 1. Dr. _%#NAME#%_, Neurology Seizure Clinic. 2. Followup hospitalization on possible VNS therapy in 4 weeks. 3. Dr. _%#NAME#%_, Pulmonology Clinic followup CF Clinic. 4. Dr. _%#NAME#%_, PM and R will followup Botox injection for spasticity. DISCHARGE MEDICATIONS: 1. Polycitra 20 mL down feeding tube t.i.d.
PM|afternoon|PM|174|175|MEDICATIONS|3. Urethritis. She has had multiple cystoscopies with urethral dilatation, the last was 3 to 4 years ago. 4. Fibrous dysplasia. MEDICATIONS: Inhaler which is Maxair, Tylenol PM as needed. ALLERGIES: NO KNOWN DRUG ALLERGIES. PAST SURGICAL HISTORY: Cystoscopy and bone biopsy in the back.
PM|afternoon|PM|199|200|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a _%#1914#%_-year-old woman who lives about five days a week with her daughter, but spends living in her own apartment. This afternoon at about 3 PM she fell in the hallway outside her apartment and could not get up due to pain in her left thigh. Her daughter arrived shortly, and arrangements were made to bring her to the Emergency Room.
PM|physical medicine and rehabilitation:PMR|PM|170|171|FOLLOW UP APPOINTMENTS|FOLLOW UP APPOINTMENTS: The patient is to follow up with Dr. _%#NAME#%_ as previously scheduled in _%#MM#%_ 2005. The patient is also to follow up with Dr. _%#NAME#%_ in PM and R in approximately 1 month at the _%#CITY#%_ Campus. He is to be scheduled for a wheelchair sitting evaluation while there.
PM|physical medicine and rehabilitation:PMR|PM|194|195|HISTORY OF PRESENT ILLNESS|As medically stable, the patient is transferred back to the rehabilitation unit on _%#MM#%_ _%#DD#%_, 2005, to continue physical and occupational therapy. Again, followed by Dr. _%#NAME#%_ from PM and R. Gradual progress with the therapies. Issue of chronic sinusitis with a persistent congestion and episodic epistaxis. ENT consultation with sinus CT demonstrating change consistent with chronic sinusitis.
PM|afternoon|PM|170|171|HISTORY OF PRESENT ILLNESS|ADMISSION DIAGNOSES: 1. Acetaminophen overdose. 2. Depression. HISTORY OF PRESENT ILLNESS: The patient is a 28-year-old who took a handful of approximately 10-15 Tylenol PM on the night prior to admission in an attempt, according to her, that she wanted to make sure that she slept, as she has been having insomnia since she broke up with her boyfriend. She reports that this was not an attempt to injure herself.
PM|physical medicine and rehabilitation:PMR|PM|146|147|PLAN|Public health nurse, again, because the oxygen is new as well as a home health aide. Physician followup with Dr. _%#NAME#%_ at _%#CITY#%_ Clinic, PM and R on an as- needed basis. DISCHARGE MEDICATIONS: 1. OxyContin 10 mg p.o. q.12 h, #50, no refills.
PM|physical medicine and rehabilitation:PMR|PM|189|190|DISCHARGING FOLLOW UP|7. Trazodone 50 mg p.o. at bedtime. 8. PhosLo 667 mg p.o. with meals. 9. Potassium chloride 30 mEq p.o. t.i.d. DISCHARGING FOLLOW UP: 1. She has a followup appointment with Dr. _%#NAME#%_, PM and R doctor, _%#MM#%_ _%#DD#%_, 2006, at 1 p.m. outpatient. 2. She needs to make her own appointment with Dr. _%#NAME#%_ _%#NAME#%_ from neurology in 4 weeks, _%#TEL#%_. 3. She needs to make an appointment at The Methodist Hospital Eating Disorder Clinic, _%#TEL#%_.
PM|afternoon|PM|137|138|DISCHARGE MEDICATIONS|13. PhosLo 667 mg p.o. t.i.d. 14. Protonix 40 mg p.o. q. day. 15. Tricor 160 mg p.o. q. day. 16. Tylenol 650 mg p.o. q. day. 17. Tylenol PM 500/25, 1 tablet p.o. q.h.s. 18. Plavix 75 mg p.o. q.a.m. x 6 months. 19. Aspirin 81 mg p.o. q. day.
PM|afternoon|P.M.|122|125|HOSPITAL COURSE|4) Pilocarpine 4% both eyes at bedtime. 5) Detral LA 4 mg p.o. daily. 6) Diltiazem 120 mg two tablets in the A.M. and one P.M. 7) Triamterene hydrochlorothiazide 7.5/25 p.o. daily. 8) Lorazepam 0.5 mg b.i.d. p.r.n. 9) Seroquel 50 mg at bedtime. 10) Aricept 10 mg at bedtime. 11) Lisinopril 20 mg b.i.d.
PM|physical medicine and rehabilitation:PMR|PM|177|178|FOLLOW UP|13. Ibuprofen 400 mg p.o. q.4 h. p.r.n. 14. Zofran 4 mg dissolvable tablet q.6 h. p.r.n. 15. Temazepam 7.5 mg p.o. nightly p.r.n. FOLLOW UP: The patient will be followed by the PM and R providers in acute rehab, and will follow up after discharge from there.
PM|afternoon|P.M.|250|253|HISTORY OF PRESENT ILLNESS|DOB: _%#DDMM1970#%_ HISTORY OF PRESENT ILLNESS: This is a 32-year-old, gravida 5 para 4-0-0-4, who is status post normal spontaneous vaginal delivery at 14:15 hours today. She is requesting a postpartum tubal ligation. She has been n.p.o. since last P.M. about 19:00 hours and there is a go ahead for surgery this afternoon with Dr. _%#NAME#%_ _%#NAME#%_. PAST MEDICAL HISTORY: Significant for seizures which have been controlled with phenobarbital.
PM|afternoon|PM|162|163|MEDICATIONS|3. Prinzide 20/12.5 mg a day. 4. Pravachol 20 mg at hs. 5. Aspirin daily. 6. Calcium daily. 7. Actonel weekly. 8. Vitamin B complexes. 9. Zantac prn. 10. Tylenol PM prn. Appetite, bowel and urinary functions have been normal.
PM|afternoon|PM,|140|142|HISTORY OF PRESENT ILLNESS|He called his primary care physician that day and was told to go to the emergency department. When he reached the emergency department at 1 PM, his pain was 5 out of 10 in severity. After taking two nitroglycerins, he had no relief. After a third nitroglycerin, his pain decreased to 1 out of 10.
PM|afternoon|P.M.|158|161|PRESENTING COMPLAINT|DOB: _%#DDMM1964#%_ PRESENTING COMPLAINT: Mr. _%#NAME#%_ is a 39-year-old gentleman who presented to the Fairview Ridges emergency room at approximately 5:30 P.M. today. The patient has a history of standing on the step of a boat trailer at 2:30 P.M. when he lost his balance and fell.
PM|afternoon|P.M.|191|194|HISTORY OF PRESENT ILLNESS|She has chronic back pain that is quite difficult and requires a lot of medication, mostly acetaminophen and some aspirin products. She tends to have insomnia, inactivity, and to use Tylenol P.M. for sleep. In addition, she has used Ambien for sleep. _%#NAME#%_, while in the hospital, underwent plain film series of her lumbosacral spine, which showed osteo-spondylitic spurring only.
PM|afternoon|PM|186|187|HISTORY OF PRESENT ILLNESS|He was tried on Enfamil 20 Kcal fortified with Iron for one day, but his serum phosphorus level increased again. At the time of discharge, he was bottling all of his feedings of Similac PM 60/40 20 Kcal on an ad-lib on demand schedule. His weight at the time of discharge was 2352 gm with a head circumference of 33 cm and length of 43.18 cm.
PM|afternoon|PM|212|213|* FEN|Hearing: _%#NAME#%_ passed the ABR hearing-screening test. * Immunizations: Hepatitis B vaccine was given on _%#DDMM2005#%_. Ongoing problems and suggested management: * FEN: _%#NAME#%_ was discharged on Similac PM 60/40 20 Kcal formula on an ad-lib on demand schedule. * Elevated Phosphorus: Please recheck Phosphorus level at follow-up appointment on Monday _%#MM#%_ _%#DD#%_, 2005.
PM|afternoon|P.M.|131|134|PROBLEM #5|PROBLEM #4: Cardiac. Continued to be in afibrillation with rate of 95. Diltiazem was not restarted. PROBLEM #5: Diabetes mellitus. P.M. blood glucose was 163, and A.M. was 91. She was maintained on sliding scale as well as her usual diabetic medications.
PM|afternoon|PM|151|152|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Intentional overdose. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 25-year-old female who took approximately 75 tablets of Tylenol PM and Benadryl this evening as an intentional overdose. Apparently the patient had an argument with her boyfriend and took the Tylenol PM in response to this.
PM|afternoon|P.M.|347|350|MEDICATIONS|She has had some weakness, no focal neurologic changes. PAST MEDICAL HISTORY: Significant for degenerative joint disease in bilateral knees and history of shingles in the past. SURGERIES: Tonsillectomy as a child. MEDICATIONS: All over-the-counter: Tylenol t.i.d. to q.i.d. also Aleve 2 tablets b.i.d., glucosamine/chondroitin, occasional Tylenol P.M. She did stop the Aleve approximately a week to two weeks ago. ALLERGIES: She has no allergies FAMILY HISTORY: Reviewed and is noncontributory.
PM|afternoon|PM|274|275|CHIEF COMPLAINT|CHIEF COMPLAINT: Tylenol overdose. HOSPITAL COURSE: The patient was admitted via the emergency department here at Fairview _%#CITY#%_ after ingesting an unknown amount of Tylenol. She states that she was drinking and using street drugs and became suicidal. She took Tylenol PM and unfortunately was groggy enough that she could not remember exactly when she took it or how much she took. She states it was 1 to 2 bottles, but she was not sure how full they were and it might have been more bottles than that.
PM|afternoon|PM|149|150|MEDICATIONS|2. Pyridostigmine 60 mg p.o. 5 times daily. 3. Prednisone 10 mg p.o. daily. 4. Finasteride 5 mg p.o. daily. 5. Oscal D 500 mg p.o. b.i.d. 6. Tylenol PM one tab p.o. q.h.s. 7. Tylenol #3 one p.o. q4 to 6h p.r.n. ALLERGIES: PENICILLIN and sulfa, Norvasc, tetracycline, carbamazepine, oxycodone, and pramipexole - reactions undocumented.
PM|physical medicine and rehabilitation:PMR|PM|138|139|DISCHARGE AND FOLLOWUP PLANS|4. He will need outpatient occupational therapy as well as physical therapy and speech language pathology, which is being arranged by the PM and R, and social worker. 5. Per PM and R recommendations, the patient may need outpatient neuropsych evaluation, have discussion and family conference.
PM|afternoon|P.M.|210|213|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 76-year-old, right- handed white male with unremarkable past medical history besides being a smoker for many years, who presented on _%#DDMM2002#%_ at about 2:30 P.M. with a feeling of left-sided weakness with some dizziness. These symptoms lasted about five minutes and then resolved. The patient recovered completely and returned to his previous baseline.
PM|afternoon|P.M.,|265|269|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Continued as on admission with the addition of intravenous vancomycin 1300 mg IV q 48 hours and further adjustments if needed as directed by Infectious Disease. Additional medications - Novolin insulin 70/30 28 units each A.M., 22 units each P.M., Zocor 40 mg daily, Zantac 150 mg p.o. b.i.d., Accupril 40 mg p.o. daily, Avandia 8 mg p.o. daily, Meridia 10 mg p.o. daily, aspirin 81 mg p.o. daily, Tylenol 325 mg one to two tablets p.o. every 4-6 hours p.r.n. pain, Darvocet N-100 one to tablets p.o. q 4-6 hours p.r.n. pain.
PM|afternoon|P.M.,|167|171|FINAL DISCHARGE DIAGNOSES|9. Status post bilateral rheumatoid arthritis foot surgical repair. The patient was at home under the care of her five daughters. She was doing her ADL's. Around 5:00 P.M., she fell backwards because of unsteady gait without dizziness, light headedness, loss of consciousness. Hit the doorway and then the tile. Noted the onset of low back pain and left pelvic pain.
PM|afternoon|PM,|274|276|PAST MEDICAL HISTORY|8. History of gout. 9. HISTORY OF ALLERGIES TO HYDROCHLOROTHIAZIDE AND TRIAMTERENE. 10. Code status DNR/DNI. Her medications currently have been Amaryl 1 mg daily, aspirin 81 mg daily, lisinopril 5 mg daily, multivitamin 1 mg daily, Demadex 40 mg in the AM and 20 mg in the PM, and Coreg 3.125 mg b.i.d. Social history shows that she is a widow who lives at Ebenezer Ridges Nursing Home. Has two attendant daughters living in the area. Family history was reviewed and fairly noncontributory except for a few members that have had heart disease and diabetes.
PM|physical medicine and rehabilitation:PMR|PM|223|224|HOSPITAL COURSE|An Orthopedic consultation was obtained because of his hip pain, and it was thought that he would need revision of his total hip arthroplasty on the left. It was recommended that he be fitted with a walker, which was done. PM and R consultation was obtained, and it was felt that his gait difficulties were more due to hip pain, and he was encouraged to follow up with his orthopedist in _%#CITY#%_, North Dakota.
PM|afternoon|P.M.|146|149|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: The patient was discharged in good condition with a follow up appointment to see Dr. _%#NAME#%_ on _%#DDMM2003#%_ at 2:45 P.M. She was instructed to follow a cardiac diet and remain up and about with her activity level. Her restrictions included: No lifting greater than 10 pounds for the next six weeks and no driving for four weeks after surgery.
PM|afternoon|P.M.|233|236|DISCHARGE MEDICATIONS|She improved in terms of her affect. Her ability to move her arm and function improved, and she is discharged at this time doing better. DISCHARGE MEDICATIONS: She is discharged on her previous medications which included: 1. Tylenol P.M. at bedtime, 2. Ecotrin as necessary in the morning. 3. Imuran 50 mg t.i.d. 4. Dulcolax rectally daily, as needed. 5. Calcium carbonate. 6. Lanoxin 0.25 mg/day. 7. Cardizem CD 240 mg q.d.
PM|physical medicine and rehabilitation:PMR|PM|170|171|PROBLEM #4|His renal function will need to be closely followed as an outpatient. PROBLEM #4: Deconditioning. The patient was assessed by Physical Therapy, Occupational Therapy, and PM and R. It was recommended that the patient undergo a short course of rehabilitation at a transitional care unit. MEDICATIONS: 1. Amiodarone 200 mg p.o. q. daily.
PM|afternoon|PM|202|203|DISCHARGE MEDICATIONS|With these issues as described, the patient is ready for discharge and will be discharged to home. DISCHARGE MEDICATIONS: 1. Prednisone 5 mg p.o. one daily. 5. Prevacid 30 mg p.o. one daily. 6. Tylenol PM one-two two tablets p.r.n. 7. Eye drops. 8. Lortab elixir 5-10 cc p.o. q.6h p.r.n. 9. Colace 100-200 mg p.o. b.i.d. 10. Senokot one to two tablets p.o. b.i.d.
PM|physical medicine and rehabilitation:PMR|PM|335|336|DISCHARGE RECOMMENDATIONS|DISCHARGE RECOMMENDATIONS: From a rehab standpoint, it is recommend she continue with outpatient occupational therapy and physical therapy with the predominant goals of improving the quality of her ambulation and balance as well as ambulation for independent living skills also just in general to improve her endurance. Follow up with PM and R on a p.r.n. basis.
PM|physical medicine and rehabilitation:PMR|PM|217|218|HOSPITAL COURSE|A swallow study was performed by Speech Pathology, as well as an esophogram, which were negative for aspiration and leaks. The patient was subsequently started on a clear-liquid diet on postop day 7. On postop day 8, PM and R was consulted to evaluate if the patient would be a candidate for inpatient rehab, and as per their recommendation, the patient would benefit from inpatient rehab and is now being transferred to Fairview inpatient rehabilitation, _%#CITY#%_.
PM|afternoon|PM.|153|155|HOSPITAL COURSE|HOSPITAL COURSE: _%#NAME#%_ is a 19-year-old male who was admitted on _%#DDMM2006#%_ after a drug overdose. It appeared to be intentional, using Tylenol PM. He had been using some alcohol earlier in the evening and came home to his grandmother's house. She felt that he was not acting normally, checked on him about an hour later, was unable to arouse him and called paramedics.
PM|afternoon|P.M.|167|170|HOSPITAL COURSE|3. Cardiovascular was stable throughout his stay. 4. Jaundice. A bilirubin was 7.1 on _%#DDMM2002#%_, went up to 8.4 on _%#DDMM2002#%_ A.M. and 11.7 on _%#DDMM2002#%_ P.M. Phototherapy was initiated. On _%#DDMM2002#%_, type and Coombs was obtained which revealed blood type A+, negative Coombs. Bilirubin went down to 6.3 on _%#DDMM2002#%_ at which time phototherapy was discontinued.
PM|afternoon|PM.|411|413|HISTORY OF PRESENT ILLNESS|PRIMARY CARE PHYSICIAN: Unknown. CHIEF COMPLAINT: Tylenol overdose. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 17-year-old unfortunate male who has a history of posttraumatic stress disorder (PTSD) apparently from sexual abuse as well as borderline diabetes and depression and with a significant psychiatric history who presented to Fairview Southdale Hospital after ingesting 50 tablets of Tylenol PM. The patient is a junior at Vale Educational Center and on his way to school took about 50 tablets of Tylenol PM.
PM|afternoon|P.M.|154|157|MEDICATIONS|3. Vitamin E 4. Neuro replete which is apparently an over the counter preparation, probably gingko 5. Zinc products 6. Several Tylenol products including P.M. ES, Sinus at least 7. Also Vicodin which he had stopped taking two days prior to admission. 8. He was also taking some Zantac. 9. He had several different antihistamines.
PM|afternoon|P.M.|319|322|HOSPITAL COURSE|Her postoperative course was marked by progressive hypotension not responding to maximal pressures and evidence of multi-organ system failure manifested by a rise in serum creatinine and anuria, also evidence of liver failure evidenced by jaundice and a rise in her INR. Her condition deteriorated and just after 12:30 P.M. on the date of death, she was treated with ACLS protocol with intravenous epinephrine and Atropine, maximal doses of intravenous Levophed, and CPR.
PM|afternoon|PM|125|126|CURRENT MEDICATIONS|8. Morphine and postoperative morphine pumps causing intense nausea. CURRENT MEDICATIONS: 1. Zantac 150 mg b.i.d. 2. Verelan PM 200 mg b.i.d. 3. Celebrex 200 mg daily. 4. Maxzide 1/2 tablet daily. 5. Zetia 60 mg daily.
PM|afternoon|PM|143|144|MEDICATIONS|7. Metolazone 2.5 mg po qd. 8. Lipitor 10 mg po qd. 9. Compazine 10 mg po q6h prn for nausea. 10. Centrum Silver one tablet po qd. 11. Tylenol PM one tablet po qhs. 12. Anzemet 12.5 mg IV q12h for three days after chemotherapy. ALLERGIES: The patient is intolerant to isosorbide dinitrate, estrogen, indomethacin, Darvocet, and Ultram.
PM|afternoon|P.M.|174|177|ASSESSMENT/PLAN|The patient is somewhat agreeable to this plan. Will hold her medications for now since we do not know what dosages she is supposed to be on. Will put the patient on Tylenol P.M. for sleep. Leukocytosis with left shift could be secondary to stress from the episode of falling. The patient does not appear toxic, she is afebrile, urinalysis and chest x-ray are negative as well.
PM|afternoon|PM|147|148|1. FEN|* He passed the ABR hearing screening test. * Immunizations: Hepatitis B vaccine was given on _%#DDMM2004#%_. _%#NAME#%_ was discharged on Similac PM 60/40 formula with Kayexalate as above on an ALD schedule. The parents were asked to make an appointment for their child to see you within one week.
PM|afternoon|PM.|256|258|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 50-year-old African American male with a history of hepatitis C, depression, and substance abuse who was found unresponsive in his home on _%#MM#%_ _%#DD#%_, 2004, after having ingested at least 100 tablets of Tylenol PM. Earlier that day, he called his girlfriend stating he was going to kill himself. She later went to his apartment and found him unresponsive on the floor surrounded by vomit with approximately 20 pills of Tylenol PM in the vomitus.
PM|afternoon|PM|131|132|HISTORY OF PRESENT ILLNESS|She later went to his apartment and found him unresponsive on the floor surrounded by vomit with approximately 20 pills of Tylenol PM in the vomitus. The patient was taken to the _%#CITY#%_ Emergency Department, where the acetaminophen level was found to be 180.
PM|afternoon|PM|156|157|DISCHARGE MEDICATIONS|3. Lupron injection every 3 months per the recommendation of Dr. _%#NAME#%_. 4. Citrucel 1 to 2 tablespoons q.d. p.r.n. to prevent constipation. 5. Tylenol PM 1 to 2 p.o. q.h.s. p.r.n. for insomnia. 6. Aspirin 81 mg p.o. q.d. 7. Dyazide 37.5/25 mg 1 p.o. q.d. 8. Klor-Con 10 mEq p.o. q.d.
PM|afternoon|P.M.|96|99|MEDICATIONS ON ADMISSION|3. Whooping cough as a child. 4. History of stomach ulcer. MEDICATIONS ON ADMISSION: 1. Tylenol P.M. p.r.n. for insomnia. 2. Tylenol p.r.n. for pain or fever. SOCIAL HISTORY: The patient smoked in the remote past.
PM|afternoon|PM.|160|162|MEDICATIONS|12. Aspirin 81 mg daily. 13. Synthroid 300 mcg daily, dose increased on _%#DDMM2007#%_ (after the Synthroid), 14. Zocor 20 mg q.p.m., 15. Calcitrol, 0.25 mg q. PM. 16. Folgard, 17. Folic acid. 18. Vitamin B6 and 12 19. Multivitamin without any iron 20. Lomotil p.r.n. 21. Imodium p.r.n.
PM|afternoon|PM|236|237|REASON  FOR ADMISSION|In brief, Ms. _%#NAME#%_ is a 56-year-old female with a history of depression, admitted after an intentional overdose. Please see H&P for pertinent details. The patient reports that she took overdose of sleeping pills, possibly Tylenol PM or Excedrin PM. She was admitted to the hospital service after being put on hold in the Emergency Department. HOSPITAL COURSE: 1. Overdose: The patient remained medically stable during her stay.
PM|afternoon|PM|203|204||The patient was awake and alert and had informed her that he had ingested 72 Tylenol PM tablets. The wife noted that he bought three complete whole bottles, each bottle containing 100 tablets of Tylenol PM at around 11:00 last night and those bottles were found next to him and they were all devoid of any pills. EMS was activated and the patient was brought to the Emergency Room at Fairview Ridges Hospital.
PM|physical medicine and rehabilitation:PMR|PM|180|181|FOLLOWUP APPOINTMENTS|6. Vicodin 5/500 mg 1 tablet as needed every 6-8 hours for pain. 7. Botox injections as needed per PM and R. FOLLOWUP APPOINTMENTS: The patient is to follow up with Dr. _%#NAME#%_ PM and R. The patient will call this week with update. The patient also will follow up with Dr. _%#NAME#%_ _%#NAME#%_ or _%#NAME#%_ _%#NAME#%_ of internal medicine within 1-2 weeks to establish primary care.
PM|afternoon|P.M.|143|146|MEDICATIONS|7. Minoxidil 2.5 mg q.day. 8. Celexa 20 mg a day. 9. Aggrenox 200 mg b.i.d. 10. Labetalol 200 mg b.i.d. 11. Glyburide 25 mg a day. 12. Tylenol P.M. on an occasional basis as well. FAMILY HISTORY: Father deceased at age 74, problems with diabetes.
PM|physical medicine and rehabilitation:PMR|PM|89|90|HOSPITAL COURSE|The patient was followed by both services while in the hospital. The patient was seen by PM & R and was deemed fit to go to acute rehabilitation. The patient was brought up to a regular neurosurgical floor on _%#DDMM2002#%_.
PM|afternoon|PM|251|252|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 43-year-old white male who came to the Emergency Room with the complaint of epigastric pain which started last night. The patient said he was fine before admission. Then, yesterday at around 1:00 PM he ate lunch and at 11:00 PM he ate some fries. After that he developed epigastric pain with no radiation. This was also associated with nausea, and the patient also had vomiting.
PM|afternoon|P.M.|349|352|HOSPITAL COURSE|HOSPITAL COURSE: Gastric ulcer. The patient is a 49-year-old woman with a history of ulcerative colitis with recent hospitalization two weeks prior to this admission who presented with similar complaints of nausea, abdominal pain, and emesis. The patient presented to the emergency room with persistent nausea and vomiting since approximately 10:00 P.M. the night before. No hematemesis or bloody stools. She also has her menses at this time with crampy abdominal pain. Her vital signs were essentially within normal limits. She was afebrile throughout her hospital stay.
PM|afternoon|P.M.|163|166|ADMISSION MEDICATIONS|6. Optimal cytoreduction with total abdominal hysterectomy and bilateral salpingo- oophorectomy and debulking in _%#MM#%_ 2004. ADMISSION MEDICATIONS: 1. Excedrin P.M. 2. Fosamax weekly. 3. Lorazepam p.r.n. 4. Maxzide 75/50 mg p.o. daily. 5. MVI daily. 6. Potassium chloride 20 mEq 2 p.o. b.i.d.
PM|afternoon|P.M.|146|149|DISCHARGE MEDICATIONS|6) Synthroid 125 mcg daily. 7) Nasonex two sprays each nostril daily. 8) Dilantin 200 mg b.i.d. 9) Phenobarbital 60 mg in the A.M., 100 mg in the P.M. 10) Kay Ciel 20 meq p.o. b.i.d. 11) Serevent one puff b.i.d. 12) Zocor 80 mg at bedtime. 13) Prednisone 40 mg p.o. until _%#MMDD2005#%_; then 20 mg daily for three days; prednisone 10 mg daily for three days; then stop.
PM|afternoon|PM,|166|168|CURRENT MEDICATIONS|4. Xalatan 0.005% 1 drop daily. 5. Tylenol as needed. 6. Celexa 40 mg daily. 7. Atenolol 35 mg a week. 8. Benicar HCT 40/25 daily. 9. Multivitamin a day. 10. Tylenol PM, which she takes on average about once a week for sleep. Initially the son had thought that this was a new medication and perhaps tied to her behavior, but again the patient is insistent that she has been taking this for quite a while on a periodic basis.
PM|physical medicine and rehabilitation:PMR|PM|90|91|PROCEDURES|In addition, PM and R was consulted for placement. PROCEDURES: 1. Chest x-ray. 2. OT, PT, PM and R. ALLERGIES: Newly developed allergy to ceftriaxone or azithromycin, not clear which one.
PM|afternoon|PM|142|143|MEDICATIONS|PAST MEDICAL HISTORY: Raynaud's. PAST SURGICAL HISTORY: Cesarean section x1. Wisdom tooth extraction. MEDICATIONS: Prenatal vitamins, Tylenol PM as needed. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.3, blood pressure 117/77, pulse 81, respiratory 18.
PM|physical medicine and rehabilitation:PMR|PM|144|145|DISCHARGE AND FOLLOWUP PLANS|DISCHARGE AND FOLLOWUP PLANS: 1. Follow up with Physical Medicine and Rehabilitation, Dr. _%#NAME#%_ as they reccomend. 2. Home Care, PT, OT as PM and R recommends. 3. He needs to establish with a primary care physician and I will have an appointment made at the Primary Care Clinic here at the University for 1-2 weeks post-hospitalization and "post C3-C4 central cord contusion."
PM|afternoon|P.M.|217|220|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 73-year-old male with type 2 diabetes who was admitted with hypoglycemia. His wife returned from out of town today and found the patient unresponsive in bed at approximately 2:00 P.M. on the day of admission. She called the paramedics. His finger stick blood glucose was 30 at the time. He did receive 1 amp of Dextrose 50 and his mental status returned to baseline.
PM|physical medicine and rehabilitation:PMR|PM|151|152|HOSPITAL COURSE|Due to lack of substantial MRI findings, the patient was not deemed to be a good operative candidate. The patient was, therefore, referred back to her PM and R physician, Dr. _%#NAME#%_, for RF injections, as the patient had previously planned. The patient was kept in the 7A unit of the hospital, and was provided pain control.
PM|physical medicine and rehabilitation:PMR|PM|189|190|DISCHARGE INSTRUCTIONS AND FOLLOW UP PLAN|1. OxyContin 20 mg p.o. q.12h. 2. Percocet 5/325 1-2 tablets p.o. q.4h p.r.n. 3. Colace 100 mg p.o. b.i.d. DISCHARGE INSTRUCTIONS AND FOLLOW UP PLAN: 1. The patient will follow up with her PM and R physician, Dr. _%#NAME#%_, in less than 1 week. 2. The patient will not lift more than 10 pounds for the next 2 weeks.
PM|physical medicine and rehabilitation:PMR|PM|148|149|HOSPITAL COURSE|Her left leg seemed to be the majority of the problem with weakness and spasticity despite the use of AFO orthotic. She was evaluated by PT/OT, and PM and R services during her hospital stay, and a Pain service evaluation was obtained. DISCHARGE EXAMINATION: Vitals: afebrile, vital signs are stable. In general, she is a thin white female in a moderate amount of pain.
PM|afternoon|PM.|316|318|SUMMARY OF CASE|He was discharged back to the Rehabilitation Unit on the above date with instructions to continue attentive wound care and management and to continue the heparin drip while being converted to oral Coumadin therapy. He will be kept on the Sinemet 25/100 1 tablet every morning, noon, and at 5 PM, and 1/2 tablet at 8 PM. He is also staying on digoxin 0.125 mg daily and atenolol 25 mg b.i.d. He takes Percocet on a p.r.n. basis for pain control and uses Colace and Senna for a bowel program.
PM|afternoon|P.M.|210|213|MEDICATIONS|1. Essential hypertension. 2. Hypercholesterolemia. 3. Known interstitial fibrosis. 4. History of depression. MEDICATIONS: 1. Corgard 10 mg daily. 2. Mevacor 20 mg daily. 3. Flonase two puffs daily. 4. Tylenol P.M. ALLERGIES: No known drug allergies. REVIEW OF SYSTEMS: Otherwise negative. Patient has had a weight loss, but some of this seems to be related to her worry about this procedure.
PM|afternoon|PM|114|115|MEDICATIONS|7. Vitamin B12 daily. 8. Vitamin B6 daily. 9. Zetia 10 mg PO Q day. 10. Zantac 300 mg PO Q day p.r.n. 11. Tylenol PM q hs. 12. Lovastatin 10 mg PO Q day. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.4, blood pressure 138/79, pulse 61, respiratory rate 20, sats 96% on room air, 89.3 kilos.
PM|afternoon|PM|469|470|MEDICATIONS ON ADMISSION|Previous hospitalizations and surgeries include a TURP x 2 in 1992, three vessel coronary artery bypass graft surgery in 1996, and left frontal cerebrovascular accident with resolved aphagia and dysphagia in 2002. MEDICATIONS ON ADMISSION: Norvasc 5 mg p.o. daily, atenolol 25 mg p.o. daily, hydrochlorothiazide 25 mg p.o. daily, lisinopril 40 mg p.o. daily, Lipitor 80 mg p.o. daily, potassium chloride 20 mEq daily, Plavix 75 mg daily, Tagamet 800 mg q.h.s., Tylenol PM 2 at h.s., Tylenol p.r.n. for pain, and Viagra 50 mg p.r.n. ALLERGIES: He has no allergies. HABITS: He is a 50+ pack-year smoker, quit in about 1990.
PM|afternoon|P.M.,|220|224|HOSPITAL COURSE|Will have to very carefully watch her weights and electrolytes on an outpatient basis. Her discharge medications include prednisone 20 mg twice a day for three additional days, Lasix 80 mg each morning and 40 mg at 3:00 P.M., potassium chloride - she will hold for now but start on the date after discharge at 40 meq daily, Lipitor 20 mg daily, Lantus - she will use 20 units q.h.s., Fibercon - she will use daily, she is not to take any Coumadin as this will be checked and followed up in clinic.
PM|afternoon|PM|181|182|MEDICATIONS|MEDICATIONS: 1. Coumadin 3 mg Monday. And Friday, 2 mg on Tuesday, Wednesday, Thursday, Saturday and Sunday. 2. Lanoxin 0.25. 3. Tylenol 1,000 every four hours for pain. 4. Tylenol PM at at bed-time. 5. Antivert 12.5, as needed dizziness. 6. Lomotil 2.5 mg p.o. as needed diarrhea. 7. Zantac 150 p.o. daily.
PM|afternoon|PM|210|211|HOSPITAL COURSE|The patient's rhythm remained in atrial fibrillation. She was adequately rate controlled with her home medication of diltiazem. Her blood pressure was controlled with p.r.n. labetalol. OT, PT, speech path, and PM and R consults were obtained. OT and PT agreed the patient would benefit from subacute rehabilitation. This was also joined by our PM and R colleagues.
PM|afternoon|PM|191|192|DISCHARGE MEDICATIONS|7. Lovastatin. 8. The discharge eyedrops include: A. Zymar 1 drop to the left eye 4 times a day. B. Artificial tears every 2 hours left eye. C. Pred Forte twice a day in left eye. D. Refresh PM in the left eye 4 times a day. E. Xalatan twice a day both eyes. F. Alphagan twice a day in both eyes.
PM|physical medicine and rehabilitation:PMR|PM|209|210|HOSPITAL COURSE|Please see the operative note for details. There were no perioperative or postoperative complications. A head CT and shunt series was obtained, and reviewed following the revision. The patient was seen by the PM and R physicians who recommended a week of acute rehab at Fairview _%#CITY#%_ for intensive therapy. It is felt that his rehabilitation potential is very good, after which he may return to an assisted living situation.
PM|physical medicine and rehabilitation:PMR|PM|161|162|FOLLOW-UP|5. Multivitamins 1 tab p.o. daily. 6. Sinemet 25/100 mg p.o. t.i.d. 7. Tylenol 325 to 650 mg p.o. q.4 h. p.r.n. FOLLOW-UP: The patient will be following up with PM and R through Fairview Transitional Services Unit. He will also be following up at the Motor Disorder Clinic through neurology and Podiatry as well.
PM|afternoon|PM|104|105|DISCHARGE MEDICATIONS|4. Xanax 0.5 mg p.o. nightly. 5. Aspirin 81 mg p.o. q. day. 6. Ocuvite 1 tablet p.o. q. day. 7. Tylenol PM 2 tablets p.o. nightly. 8. MS Contin 15 mg p.o. b.i.d.
PM|afternoon|PM|127|128|MEDICATIONS|10. Glipizide 5 mg twice a day 11. Zetia 10 mg daily. 12. Folic acid 1 mg daily. 13. Metoprolol 100 mg twice a day 14. Tylenol PM 2 tablets q.h.s. p.r.n. ALLERGIES: He is not allergic to any known medications.
PM|afternoon|PM.|193|195|HISTORY OF PRESENT ILLNESS|It should be noted that the mother did find the patient with multiple empty pill bottles beside her and there is also concern for a verapamil overdose in addition to alprazolam, Ambien, Equate PM. The patient was given calcium gluconate in the emergency department and started on insulin with aggressive IV fluid hydration. The patient remained stable overnight at which time her ALT and AST climbed into the 3000s, INR climbed from 1.5 on admission to 3.7 at the time of transfer.
PM|afternoon|P.M.|187|190|DISCHARGE MEDICATIONS|The patient may resume previous medications at his discretion including: 6. Vitamin B12 1000 mcg daily. 7. Vitamin C 1000 mg p.o. daily. 8. Fish oil 1-gm capsule by mouth daily. 9. Advil P.M. at bedtime p.r.n. 10. Unicap multivitamin supplement once daily. 11. Aspirin 81 mg p.o. daily. HOSPITAL COURSE: Please see Dr. _%#NAME#%_'s interim summary for details of this hospital stay.
PM|metacarpophalangeal:MP|PM|210|211|HOSPITAL COURSE|In fact, she was on a cruise in the Middle East and Rome and saw the ship's doctor, who gave her nitroglycerin as well as diclofenac. She had discomfort that occurred substernally, radiating to the left arm in PM joints. She also had some indigestion. She returned from her trip and was seen in consultation by Dr. _%#NAME#%_. A stress echocardiogram was performed showing anterior wall ischemia and coronary angiogram was recommended.
PM|afternoon|PM|225|226|SECONDARY DIAGNOSES|2. History of seizure disorder and myofascial pain syndrome. 3. Degenerative disk disease in the lumbosacral spine. Medications at the time of discharge include Carbatrol 300 mg p.o. b.i.d., Prilosec 20 mg p.o. q.d., Tylenol PM p.r.n., Celebrex 200 mg p.o. q.d. p.r.n., Augmentin 875 mg p.o. b.i.d. for 10 days, and Flexeril 10 mg one- half to one tablet p.o. q.8 h. p.r.n.
PM|physical medicine and rehabilitation:PMR|PM|133|134|HOSPITAL COURSE|He was also on nimodipine throughout his hospital stay. He was also on seizure prophylaxis throughout his hospital stay. PT, OT, and PM and R were all consulted regarding this patient. They recommended acute rehab for this patient. At the time of discharge, the patient was able to ambulate independently.
PM|physical medicine and rehabilitation:PMR|PM|146|147|IMPRESSION/PLAN|9. She does have irregular menses, and we will have that evaluated as an outpatient with OB/GYN. 10. Deconditioning and weakness secondary to #1: PM and R is covering these rehab issues and OT and PT are seeing the patient.
PM|afternoon|PM|164|165|CURRENT MEDICATIONS|He is unemployed. He used to work for a moving company as a mover but was laid off because there was not enough work. ALLERGIES: None. CURRENT MEDICATIONS: Tylenol PM but no other medications. PHYSICAL EXAMINATION: VITAL SIGNS: On arrival, temperature 98.2, blood pressure 114/81, respirations 16, heart rate 97, oxygen saturation 96% on room air.
PM|afternoon|P.M.|182|185|HOSPITAL COURSE|The patient's family were present and requested comfort care for the patient in the hospital. The patient was given morphine, O2 provided per face mask. The patient expired at 11:45 P.M.
PM|afternoon|PM|141|142|DISCHARGE MEDICATIONS|9. Fosamax 35 mg orally every Monday. 10. Calcitrol 0.25 mg orally daily. 11. Calcium citrate plus vitamin D 1 tab orally daily. 12. Tylenol PM 1/2 tab orally q.h.s. 13. Nitroglycerin 0.4 mg sublingual every 5 minutes x 3 as needed for chest pain. 14. Lantus insulin 10 units subcu q.h.s. 15. Magnesium oxide 400 mg orally b.i.d. x 7 days and then discontinue.
PM|afternoon|PM|234|235|DISCHARGE MEDICATIONS|5. Lisinopril 5 mg p.o. daily. 6. Lopressor 25 mg p.o. daily, which the patient was doubtful that he would fill the prescription for. 7. Zetia 10 mg p.o. daily. 8. Prilosec 40 mg p.o. daily. 9. Midrin 1 tablet p.o. t.i.d. 10. Tylenol PM 1 tablet p.o. nightly p.r.n. for sleep. DISCHARGE FOLLOWUP: 1. The patient is to follow up with his primary care provider, Dr. _%#NAME#%_ _%#NAME#%_, with the HealthPartners Clinic Central Care within 1 to 2 weeks of this hospitalization.
PM|afternoon|PM|165|166|HISTORY OF PRESENT ILLNESS|Her baseline liver function tests were normal. The total bilirubin was 0.2, ALT 20, AST 32, and alkaline phosphatase 54. The Tylenol level on _%#DDMM2006#%_ at 1:00 PM was 35 mg/liter. On _%#DDMM2006#%_ at 4:00 PM, it came down to 13 mg/liter. Since then, her Tylenol levels have been undetectable. The patient tolerated an advancement of her diet.
PM|afternoon|PM|204|205|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. daily. 2. Atenolol 100 mg p.o. q.a.m. and 50 mg p.o. q.p.m. 3. Plavix 75 mg p.o. daily. 4. Imdur 30 mg p.o. q.a.m. 5. Vitorin 10/80 mg p.o. daily. 6. Excedrin PM two tablets p.o. q.p.m. 7. Diltiazem extended release 240 mg p.o. daily. 8. Metformin 500 mg p.o. t.i.d. 9. Benicar 20 mg p.o. daily. 10. Glipizide 5 mg p.o. b.i.d.
PM|physical medicine and rehabilitation:PMR|PM|146|147|IMPRESSION AND PLAN|2. Right-sided hemiparesis related to #1: It appears his right-sided hemiparesis is worse, hence he does require acute rehab, and the PT, OT, and PM and R doctors are involved with this aspect of his care. 3. Seizure disorder secondary to #1: He did have a seizure today prior to transfer here.
PM|afternoon|PM|166|167|DISCHARGE DIAGNOSES|3. Gastroesophageal reflux disease controlled with Nexium. 4. History of osteoporosis. 5. Pain secondary to stroke, right leg. 6. Smoking: She has discussed with the PM and our doctor, Dr. _%#NAME#%_ that she would be willing to discuss taking Nicoderm patches or Wellbutrin and that has been passed on to him and discussed with the patient prior to discharge.
PM|afternoon|PM|228|229|HISTORY OF PRESENT ILLNESS|REASON FOR ADMISSION: Drug overdose. HISTORY OF PRESENT ILLNESS: 25-year-old female with a history of depression and multiple suicidal ideation and drug overdose presents with drug overdose. The patient took 24 pills of Tylenol PM at 10:00 p.m. _%#DDMM2007#%_. She took a couple of Tylenol PM to go to sleep, but she decided to take the whole bottle of Tylenol in an attempt to commit suicide.
PM|afternoon|PM.|165|167|MEDICATIONS AT THE TIME OF DISCHARGE|She was instructed to call _%#TEL#%_ to schedule this appointment. MEDICATIONS AT THE TIME OF DISCHARGE: 1. Prozac. 2. Estrone. 3. Synthroid. 4. Norvasc. 5. Tylenol PM. 6. Maxzide. 7. Percocet 1-2 tabs p.o. q. 4 hours p.r.n. pain. 8. Colace 100 mg p.o. b.i.d. p.r.n. constipation. 9. Vistaril 25-50 mg p.o. q. 4 hours p.r.n. pain.
PM|afternoon|PM|166|167|DISCHARGE MEDICATIONS|3. Dysphagia. 4. Weakness with deconditioning and poor insight. 5. Suspected neurodegenerative disorder. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. daily. 2. Tylenol PM 1 tablet each day at bed-time. 3. K-Dur 20 mEq p.o. daily. 4. Tylenol 1-2 tablets q. 4-6 hours p.r.n. DISPOSITION: 1. The patient discharged to Transitional Care Unit.
PM|afternoon|PM|155|156|MEDICATIONS|9. Ipratropium 18 mg inhaled daily. 10. Albuterol metered-dose inhaler q.4 hours p.r.n., shortness of breath. 11. One-A-Day vitamin for women. 12. Tylenol PM 2 times a week. 13. Benadryl 25 mg p.o. q.4 hours p.r.n. SOCIAL HISTORY: Past 80-pack-year history. The patient quit 4 years ago. She currently drinks about 1 drink per year.
PM|afternoon|P.M.|107|110|MEDICATIONS|5. Aspirin 81 mg a day. 6. Colace 100 mg a day. 7. Plavix 75 mg a day. 8. Prilosec 20 mg a day. 9. Tylenol P.M. 2 tabs h.s. 10. Multivitamin. 11. Nitroglycerin 0.4 mg as needed. 12. Tums 1 tab t.i.d. ALLERGIES: Bee stings. FAMILY HISTORY: She has two children in town, positive for Alzheimer's disease.
PM|afternoon|PM.|265|267|ALLERGIES|Her hemoglobin upon admission was 7.5. PAST MEDICAL HISTORY: Significant for heart attack last summer. She also has hypothyroidism, osteoarthritis, osteoporosis, hypercholesterolemia, and hypertension. ALLERGIES: No true allergies but she is "sensitive" to Tylenol PM. PAST SURGICAL HISTORY: Right total hip replacement for osteoarthritis by my partner, Dr. _%#NAME#%_ _%#NAME#%_.
PM|afternoon|PM|82|83|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 73-year-old white male, who was admitted last PM with the chief complaint of "not feeling well". Apparently the patient was going out to eat dinner and developed some abdominal burning, radiating up into his chest.
PM|physical medicine and rehabilitation:PMR|PM|160|161|PROBLEM #3|Physical Medicine and Rehab was also consulted due to the nature of the patient's condition and recent increase in weakness. Their opinion was that no specific PM and R therapy was needed. However, she would continue to benefit from physical therapy, occupational therapy, and assessment of any adaptive needs in addition to her walker.
PM|afternoon|PM|153|154|HISTORY OF PRESENT ILLNESS|He was started on Timentin overnight and given Tylenol for fever. He has no more complaints at this time and has been afebrile since approximately 10:00 PM on the day prior to admission. The decision was made to transfer him to the Cardiology Service for further workup of his fever.
PM|afternoon|PM.|212|214|MEDICATIONS|ALLERGIES: Penicillin. MEDICATIONS: See home admission medication list. They include: 1. Allopurinol. 2. Avandia. 3. Ferrous gluconate. 4. Lasix. 5. Lisinopril. 6. Multivitamin. 7. Sodium bicarbonate. 8. Tylenol PM. 9. Tylenol No. 3 p.r.n. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.3, blood pressure 139/72, respiratory rate 18, pulse 65, oxygen saturations 99% on room air.
PM|afternoon|PM|142|143|CURRENT MEDICATIONS|10. Centrum multivitamin. 11. Digoxin 0.125 mg daily. 12. Simvastatin 40 mg daily. 13. CoQ-10 one daily. 14. Aspirin 81 mg daily. 15. Tylenol PM as needed. ALLERGIES: Niaspan. SOCIAL HISTORY: The patient quit smoking in 1993.
PM|physical medicine and rehabilitation:PMR|PM|128|129|CONSULTATIONS THIS ADMISSION|3. Right eyebrow laceration. 4. Bruised right thorax. 5. Urinary-tract infection. CONSULTATIONS THIS ADMISSION: Pulmonology and PM and R. PROCEDURES PERFORMED DURING THIS ADMISSION: Re-dosing of the Dilantin, repair of the chin and eyebrow laceration, and pain control.
PM|afternoon|PM|343|344|HISTORY|CHIEF COMPLAINT: Polysubstance overdose, depression, suicidal ideation. HISTORY: Patient is a 33-year-old woman with a history of depression x3 years, who presents to the Emergency Department following a polysubstance overdose. At 6:30 p.m. on the evening of admission the patient ingested a combination of medications including 20-30 Tylenol PM tablets, Robaxin tablets, valium and Percocet. She ingested the pills while at home with her husband and 3 sons. She told her husband, who brought her to the Emergency Department.
PM|afternoon|PM|138|139|CURRENT MEDICATIONS|3. Metformin 1500 mg in the morning and 1000 mg q.p.m. 4. Glyburide 5 mg q. day. 5. Lipitor 40 mg daily. 6. Lasix 80 mg daily. 7. Tylenol PM two tablets each day at bedtime. 8. Spiriva 18 mcg once a day. 9. Xopenex nebs t.i.d. 10. Advair 250/50 one puff b.i.d. REVIEW OF SYSTEMS: HEENT: Denies any headache.
PM|afternoon|PM.|152|154|MEDICATIONS|2. Hypertension. 3. Hyperlipidemia. MEDICATIONS: 1. Atenolol. 2. Simvastatin 10 mg daily. 3. Avapro 150 mg daily. 4. Ranitidine. 5. Centrum. 6. Tylenol PM. 7. Allergy tabs. ALLERGIES: She is not allergic to any known medications.
PM|UNSURED SENSE|PM|172|173|DISCHARGE ACTIVITY|The patient should use a platform walker or crutches. He should participate in therapy for active range of motion and active assisted range of motion of the left knee. See PM also. DISCHARGE MEDICATIONS: Those of admission. The exception is that we will hold his methotrexate until _%#MM#%_ _%#DD#%_, 2004.
PM|physical medicine and rehabilitation:PMR|PM|141|142|ADMISSION DIAGNOSIS|She was kept on flat bed rest. Head CT was obtained prior to pulling the drains which showed no new fluid collection. She was seen by PT and PM and R and was discharged to Elder Care in stable condition. DISCHARGE INSTRUCTIONS: 1. Follow up with Dr. _%#NAME#%_ in 2-4 weeks.
PM|afternoon|PM,|172|174|PAST MEDICAL HISTORY|She did not have a fever. No recent history of travel. PAST MEDICAL HISTORY: Medicines: Prilosec 20 mg daily. Also takes vitamins, glucosamine, and fish oil. Also, Tylenol PM, one at bedtime p.r.n. sleep. Allergies: None. Surgery: Open reduction and internal fixation of left hip fracture. Right inguinal hernia repair done earlier this year; the hernia had become incarcerated.
PM|afternoon|PM|165|166|DISCHARGE MEDICATIONS|f. Diovan 80 mg per day. g. Astelin nasal spray one inhalation b.i.d. h. Actonel 35 mg p.o. q. week. i. Aspirin 81 mg per day. j. Calcium 500 mg per day. k. Tylenol PM p.r.n. DISCHARGE FOLLOW-UP: Follow up with Dr. _%#NAME#%_ _%#NAME#%_ in one month to verify stabilization of her asthma.
PM|afternoon|PM.|108|110|CURRENT MEDICATIONS|PAST MEDICAL HISTORY: 1. Pancreatitis. 2. Cholecystectomy. 3. Hysterectomy. CURRENT MEDICATIONS: 1. Tylenol PM. 2. Occasional Advil. She was on Flagyl for vaginitis though that was stopped 10 days ago.
PM|afternoon|PM|223|224|MEDICATIONS|She has never been pregnant. The patient states an allergy to Penicillin, but her response to Penicillin is that she develops a vaginal yeast infection. MEDICATIONS: 1. Vicodin as needed. 2. Ibuprofen as needed. 3. Tylenol PM as needed. 4. She received Lupron 3.75 mg on _%#DDMM2005#%_. PAST SURGICAL HISTORY: Oral surgery. Transfusions none. HABITS: Smoking none.
PM|afternoon|PM|142|143|CURRENT MEDICATIONS|3. Ditropan, 15 mg daily. 4. Ambien, 5 mg q.h.s. 5. Calcium Plus Vitamin D, 600 mg twice daily. 6. Multivitamin, one tablet daily. 7. Tylenol PM at bedtime p.r.n. 8. Aspirin, 81 mg daily. 9. Levoxyl, 25 mcg daily. 10. Actonel, which is currently on hold. 11. Diclofenac, also currently on hold. ALLERGIES: There are no known drug allergies.
PM|afternoon|P.M.|226|229|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 23-year-old, gravida 2, para 0-0-1-0, who presented to Labor and Delivery at 39+4- week's gestational age on _%#MM#%_ _%#DD#%_, 2005 after spontaneous rupture of membranes at 11:30 P.M. on _%#MM#%_ _%#DD#%_, 2005. The fluid was noted to be moderate meconium stained. She was Group B strep positive and also a chronic hepatitis B carrier.
PM|physical medicine and rehabilitation:PMR|PM|136|137|HOSPITAL COURSE|On _%#MM#%_ _%#DD#%_, 2006, the patient is stable for discharge to his primary chronic care facility with followup to Dr. _%#NAME#%_ in PM and R, and Neurology as needed.
PM|afternoon|PM|204|205|BRIEF HISTORY OF PRESENT ILLNESS|BRIEF HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is an 83-year- old woman with a previous history of severe hypertension who was in her usual state of health until the day prior to admission when at 2:00 PM she had the sudden onset of left arm weakness. She states she was pushing potatoes through a chopper in the kitchen, and suddenly she found it difficult to lift her left arm.
PM|UNSURED SENSE|PM|325|326|HOSPITAL COURSE|At any rate, he did need an esophagectomy. He got through that procedure fine, though was found to have a probable infiltrate or pneumonia and was started on Timentin and was transferred here to the acute rehab setting. He has tolerated PT and OT. He can have his diet advanced to full liquids today. Per discussion that the PM and our doctor, Dr. _%#NAME#%_ had met the surgeon earlier this week. He has had minimal pain, his vital signs were stable, so been removed.
PM|afternoon|PM.|180|182|MEDICATIONS|PAST SURGICAL HISTORY: 1. Kidney transplant _%#MM#%_ 2001. 2. Pancreas transplant _%#MM#%_ 2001. MEDICATIONS: 1. Cellcept 1 gram PO b.i.d. 2. Prograf 4 grams PO q AM, 3 grams PO q PM. 3. Prednisone 5 mg PO q day. 4. Valacet 900 mg PO q day. 5. Sodium bicarbonate 1,300 mg PO q.i.d. 6. Bactrim one single strength tab PO q day.
PM|afternoon|PM,|133|135|PLAN|PLAN: We will give him a soft diet for breakfast. If this is well tolerated, a regular diet for lunch. If he has no symptoms by 3:00 PM, will discharge him home. His discharge medications would be Cipro 250 mg bid for 10 days, Flagyl 250 mg tid for ten days. He is on the IV form of both at this point as well as IV fluids.
PM|afternoon|PM.|209|211|HOSPITAL COURSE|Her hemoglobin has gone from 14 down to 13, and she has not had any bloody stools since last night. We are going to have her start eating a regular diet at lunch time, ambulate, and check a hemoglobin at 2:00 PM. If stable, she will be discharged to home. Her discharge medicines will include Adalat CC 90 mg a day which she came in on, Fosamax 35 mg weekly, Synthroid 0.088 mg per day and Lasix 20 mg a day.
PM|afternoon|PM.|102|104|IMPRESSION|I reviewed her chest x-ray which also appears normal. IMPRESSION: 1. Over-dose of aspirin and Tylenol PM. 2. Situational depression following an argument with her boyfriend. 3. Otherwise healthy, athletic and scholarly young lady. PLAN: 1. I have reviewed the Micromedics Toxicity Chart for acetaminophen.
PM|afternoon|PM.|103|105|DISCHARGE MEDICATIONS|2. Colace 100 mg PO b.i.d. 3. Sinemet 50/200 1-1/2 tabs PO q 7 PM and q 7 AM, 1 tab PO q 11 AM and q 3 PM. 4. Amantadine 100 mg PO q 7 AM, 11 AM, and 3 PM. 5. Requip 1 mg PO q 7 AM, 11 AM, and 3 PM.
PM|afternoon|PM|128|129|DISCHARGE MEDICATIONS|2. Toprol-XL 50 mg p.o. b.i.d. for one month, with one refill. Chronic medications: 3. Premarin 0.625 mg p.o. a day. 4. Tylenol PM 1 tablet p.o. at nighttime. 5. Calcium carbonate 1 tablet at nighttime, and 2 tablets during the day. 6. Spiriva 1 inhalation daily. 7. Albuterol 2 puffs daily p.r.n. shortness of breath.
PM|afternoon|PM|174|175|ASSESSMENT AND PLAN|Alcohol level 0.22. Urine toxicology positive for alcohol only. ASSESSMENT AND PLAN: The patient is a 39-year-old white female who attempted suicide by overdosing on Tylenol PM and alcohol. Liver function tests within normal limits but acetaminophen normogram showed Tylenol in toxic range. MELD score is 7. She appears to be hemodynamically stable at this time.
PM|afternoon|PM|141|142|MEDICATIONS|1. Lipitor 10 mg daily. 2. Citracal 2 tablets daily. 3. Synthroid 25 mcg daily 4. Calcium 600 mg with vitamin D one tablet daily. 5. Tylenol PM Extra Strength at bedtime. SOCIAL HISTORY: She is widowed. Her husband recently died in the summer of 2007. She lives alone, has three children.
PM|afternoon|PM.|145|147|CURRENT MEDICATIONS|ALLERGIES: None documented. CURRENT MEDICATIONS: 1. Levothyroxine. 2. Reserpine. 3. Amlodipine. 4. Finasteride. 5. Tylenol. 6. Aleve. 7. Tylenol PM. 8. Hydrochlorothiazide. 9. Levobunolol drops. PAST MEDICAL HISTORY: 1. Legally blind. 2. Hypothyroidism. 3. Hypertension. 4. Benign prostatic hypertrophy. 5. Hemorrhoids.
PM|physical medicine and rehabilitation:PMR|PM|176|177|PROBLEM #4|PROBLEM #3: Diabetes: The patient was seen by endocrine service and initiated on insulin regimen with good glucose control. PROBLEM #4: Rehabilitation: The patient was seen by PM and R and felt that she did not require inpatient rehabilitation, but would be a good candidate for outpatient rehabilitation.
PM|afternoon|PM.|146|148|MEDICATIONS|5. Sinus surgery x2. 6. Tonsillectomy and adenoidectomy. MEDICATIONS: 1. Compazine. 2. Ibuprofen. 3. Imitrex. 4. Lexapro. 5. Fioricet. 6. Tylenol PM. 7. Prilosec. 8. Ativan. ALLERGIES: Amoxicillin causing rash. FAMILY HISTORY: The patient's mother had lung cancer and died of leukemia at age 74 and possibly had uterine cancer as well.
PM|afternoon|PM|164|165|HISTORY OF PRESENT ILLNESS|The police saw her at that time and she told them that she is waiting for a friend. She then 90 minutes later called 911 and told them that she ingested 24 Tylenol PM and half a bottle of Nyquil. Also, she drank 1-2 Mike's hard Lemonade. She was afraid apparently to tell the police and called the paramedics later, stating that she had an overdose.
PM|physical medicine and rehabilitation:PMR|PM|154|155|FOLLOW UP|It is recommended he find one here in town and see one within the next month. 2. Followup with his neurologist in 1 month. 3. Followup with Ikramuddin in PM and R in 1 month. Addendum: The patient has a longstanding history of preexisting history of low back pain.
PM|afternoon|PM|124|125|DISCHARGE MEDICATIONS|22. Aspirin once a day, 325 mg. 23. Extra Strength Tylenol, 4 a day. 24. Fish omega oil 500 mg orally once day. 25. Refresh PM as needed. 26. Artificial Tears 4 times daily.
PM|afternoon|P.M.|135|138|PLAN|She apparently had been feeling depressed of late and I believe had some sort of disagreement with her husband. At approximately 10:45 P.M. last night she took a handful of pills. It was a mixture of acetaminophen, diphenhydramine and amitriptyline. The paramedics were summoned and they arrived at roughly 11:00.
PM|afternoon|PM|118|119|HOSPITAL COURSE|He recently had problems with his relationship with his girlfriend. He was found to have two empty bottles of Tylenol PM containing 100 pills. The patient called his friend from a park who went to the park to check on him and found him unconscious.
PM|afternoon|PM|175|176|PROBLEM #4|PROBLEM #3: Hepatitis B and C. We will continue his daily Epivir with this hospitalization. PROBLEM #4: Insomnia. We will continue patient on his scheduled Ambien and Tylenol PM for insomnia. PROBLEM #5: Fluids, electrolytes and nutrition. Currently, patient has an excellent appetite and good oral intake.
PM|physical medicine and rehabilitation:PMR|PM|212|213|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: 1. Diet: Dysphagia 3 with thin liquids. She should have tube feeds of Nutren 1.5 with fiber at 40 mL per hour. This can be weaned off as her oral intake improves, per physical therapy and PM & R. 2. Weightbearing status: Ad lib. 3. Activity level: She should not lift anything greater than 50 pounds otherwise her activity is ad lib.
PM|afternoon|PM|294|295|HISTORY OF PRESENT ILLNESS|A tox screen later came back positive for acetaminophen. Throughout the course of her 2-day hospital stay, the patient's liver function tests rose above 10,000. Her INR trended from normal to 4.3 prior to transfer today. The patient later endorsed history of ingesting approximately 50 Tylenol PM tablets in the hours prior to her initial presentation. She was subsequently referred to University of Minnesota Medical Center, Fairview, today for fulminant hepatic failure with evaluation for liver transplantation.
PM|afternoon|PM|307|308|HISTORY OF THE PRESENT ILLNESS|HISTORY OF THE PRESENT ILLNESS: This 35-year-old man presented to the emergency department this evening with a history provided of an indigestion of a disputed number of Tylenol PM and trazodone tablets over a disputed time range. A consistent number that is reported is approximately 10 Tylenol or Tylenol PM tablets and 3 trazodone tablets. This was originally reported to have been ingested all within the last several hours. However, the patient now states that this number of pills has been ingested since roughly 4 a.m. early Saturday morning.
PM|afternoon|PM|129|130|HISTORY OF PRESENT ILLNESS|The patient has had multiple hypoglycemic episodes with confusion since starting the new insulin regimen of Lantus 32 units at 5 PM and Humalog 8 to 10 before meals. Those episodes had prompt response to D50 or eating. Because this episode was prolonged, the patient received HCT which was negative and underwent laboratory work-up with normal results.
PM|afternoon|PM,|190|192|HISTORY OF PRESENT ILLNESS|Today the patient was into the Emergency Department complaining of right leg pain x 1 day, which he reports as very typical for a sickle cell crisis for him. The pain began yesterday in the PM, and the patient denies any history of trauma or abnormal activity of the right lower extremity. Other than the pain, the patient has not noticed any other possible signs or symptoms of infection including a recent change in cough, no increased shortness of breath, no increase in sputum production, no dysuria or change in urinary or bowel habits.
PM|afternoon|PM|175|176|DISCHARGE MEDICATIONS|Problems during his hospitalization included the following: Problem #1: Fluids/Electrolytes/Nutrition. _%#NAME#%_ was allowed to breast-feed and was supplemented with Similac PM 60/40 (low-phosphorus formula). His labs on admission were as follows: Ca 5.7 mg/dL, Mg 0.8 mg/dL, Phos 10.1 mg/dL. He received one dose of IV magnesium sulfate. He also received oral calcium carbonate four times daily.
PM|afternoon|PM|191|192|DISCHARGE MEDICATIONS|8. Vitamin B12 1000 mcg IM once monthly. 9. Calcium carbonate 600 mg p.o. b.i.d. 10. Estratest 1.25-0.625 mg p.o. daily. 11. Restasis eyedrops 1 drop in the left eye twice daily. 12. Refresh PM ointment 1/4 inch to both eyes at bedtime. 13. Pred Forte 1% drops to the left eye twice daily. 14. Multivitamin 1 tablet p.o. daily. 15. Trazodone 50 mg p.o. daily.
PM|afternoon|PM|251|252|HISTORY OF PRESENT ILLNESS|He has only lived in Minnesota approximately 4 months and was previously treated by a Dr. _%#NAME#%_ _%#NAME#%_ at a clinic called Provinia in _%#CITY#%_, Illinois. At approximately 6 o'clock p.m. yesterday, he states that he took 24 tablets of Advil PM and began drinking, a total of approximately 12 bottles of Miller Genuine Draft and 1 vodka and cranberry juice since yesterday.
PM|afternoon|PM|216|217|HISTORY OF PRESENT ILLNESS|The emergency room physician was told by the patient that he took them today but I was told by the patient that he took them approximately 28 hours ago. When the police arrived, they found two empty bottles of Advil PM in his room which were empty.
PM|afternoon|PM|119|120|DISCHARGE DIAGNOSES|DATE OF ADMISSION: _%#DDMM2007#%_ DATE OF DISCHARGE: _%#DDMM2007#%_ DISCHARGE DIAGNOSES: 1. Suicidal attempt. 2. Advil PM overdose. 3. Bipolar disorder. 4. Polysubstance abuse history. CONSULTATIONS OBTAINED: Dr. _%#NAME#%_ from Psychiatry.
PM|physical medicine and rehabilitation:PMR|PM|111|112|FOLLOW UP|No driving, no using alcohol. Outpatient PT and speech and language pathology. FOLLOW UP: With Dr. _%#NAME#%_, PM and R at the University of Minnesota Medical Center, Fairview, in 3 to 4 weeks.
PM|physical medicine and rehabilitation:PMR|PM|332|333|HOSPITAL COURSE|The CT angio was unsuccessful due to no contrast. Video swallow was done on the _%#DD#%_ of _%#MM#%_, which showed a laryngeal (_______________) with nectar-thick consistency, and a repeat CT scan on _%#MM#%_ _%#DD#%_ showed no changes acutely. She then did come to the acute rehab setting and was followed by Dr. _%#NAME#%_ from a PM and R standpoint. She has progressed well with physical therapy, occupational, and speech and has been advanced to a regular diet with thin liquids as of a swallow evaluation last week.
PM|afternoon|PM|109|110|DISCHARGE DIET|She will continue on her 40 mL of free water 3 times a day as previously ordered. DISCHARGE DIET: 1. Similac PM 60/40 24 kcal/oz formula, 1 drip feed 40 mL an hour for 12 hours overnight. 2. Three to four ounces 3 times a day p.o. plus NG (Mother is to NG what is not p.o.'ed). DISCHARGE ACTIVITY: As tolerated.
PM|afternoon|PM.|156|158|PAST GYNECOLOGIC HISTORY|2. Ativan 0.5 mg p.o. nightly which was also started recently in regards to her bipolar disorder, to prepare for delivery. 3. Prenatal vitamins. 4. Tylenol PM. ALLERGIES: PENICILLIN AND AMOXICILLIN WHICH CAUSE HIVES.
PM|physical medicine and rehabilitation:PMR|PM|183|184|DISCHARGE PLANS|5. The patient has an appointment with Dr. _%#NAME#%_ of Neurology scheduled in the Parkinson Clinic in _%#DDMM2007#%_, this is already scheduled. 6. Follow-up with Dr. _%#NAME#%_ in PM and R for possible baclofen pump placement. 7. The patient is to have a brain MRI set up in the next 1 to 4 weeks from discharge.
PM|physical medicine and rehabilitation:PMR|PM|40|41|TRANSFER/DISCHARGE SUMMARY|TRANSFER/DISCHARGE SUMMARY Discharge to PM and R Service and the Acute Rehab Unit on the 5th floor. DISCHARGE DIAGNOSES: 1. Right medial malleolar fracture with dislocation of the right ankle status post ORIF.
PM|afternoon|PM,|194|196|MEDICATIONS ON ADMISSION|7. Admission for syncope _%#DDMM2001#%_. 8. History of total abdominal hysterectomy. MEDICATIONS ON ADMISSION: Avapro 300 mg q day, Toprol XL 100 mg q day, Paxil 40 mg po q day, Ativan 0.5 mg q PM, Coumadin 3 mg q day, Zocor 40 mg q PM, Trazodone 150 mg po q PM, Premarin one q day, aspirin 81 mg q day, Prevacid 30 mg q day.
PM|afternoon|PM|263|264|HISTORY OF PRESENT ILLNESS|The patient reports a history of a Nissen fundoplication in the late 80's and therefore has not been able to vomit since that procedure was completed. The patient has not had any passage of flatus since the onset of pain. Mr. _%#NAME#%_ admits that up until 2:00 PM today he was at his baseline state of health. He denies any recent history of fevers, chills, or night sweats.
PM|afternoon|PM|254|255|HISTORY OF PRESENT ILLNESS|He has taken only water or ice chips in order to take pills, but is complaining of significant dry mouth and weakness, suspecting that he is dehydrated. He has continued with TPN on a 16-hour per day regimen, off eight hours from roughly 8:00 AM to 4:00 PM each day. The patient had contacted the clinic with these problems of fevers, chills, dizziness, and intractable pain which prompted him to be admitted directly to the floor to improve pain control and provide further workup of fevers and possible hypotension.
PM|afternoon|PM|130|131|DISCHARGE MEDICATIONS|DISCHARGE DIAGNOSIS: Left foot cellulitis. DISCHARGE MEDICATIONS: 1. Xanax 0.5 mg p.o. q.d. 2. Maxzide 25 mg p.o. q.d. 3. Tylenol PM 1 p.o. q.h.s. 4. Centrum Silver 1 p.o. q.d. 5. Rocephin 1 gm IV q.d. x 3 weeks, per Dr. _%#NAME#%_ _%#NAME#%_. DISCHARGE FOLLOW UP: The patient is to follow up with Dr. _%#NAME#%_ in one week, and is to have an outpatient CRP in one week.
PM|afternoon|PM|274|275|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ is an 80-year-old woman with sudden onset word-finding and sentence completion difficulties at approximately 10 AM on the day of admission. The patient's daughter reported that she was intact of speech at about 9 AM and that at 3 PM when the daughter spoke with the patient again, the symptoms were not resolving and so the daughter brought the patient into the emergency department.
PM|afternoon|PM|124|125|CURRENT MEDICATIONS|4. Coumadin 3 mg q.d. (on hold). 5. Tambocor 50 mg b.i.d. 6. Klor-Con 10 mEq q.d. 7. Spironolactone 12.5 mg bi d 8. Tylenol PM 1 or 2 q.i.d. p.r.n. for arthritis pain and/or insomnia. 9. Vitamin E 400 units per day. 10. MiraLax 1 capful in fluid daily p.r.n. for constipation.
PM|afternoon|PM|174|175|HISTORY OF PRESENT ILLNESS|Her menses are regular, without any post-coital or unscheduled bleeding. She has a day that she flows very heavily with passage of large clots and "chunks." She uses Tylenol PM for discomfort, denies any fevers, chills, black and tarry stools, bloody stools or urinary symptoms, no lightheadedness, dizziness or signs of anemia.
PM|afternoon|PM.|184|186|IMPRESSION|He seems withdrawn. He denies hallucinations. He is still suicidal, stating that he still wants to end it all. LABORATORY DATA: Summarized above. IMPRESSION: 1. Overdosed with Tylenol PM. The acetaminophen component is the most concerning in the long-term. Given his 2 ingestions, it is going to be difficult to use the nomogram.
PM|afternoon|PM.|157|159|HISTORY|He has noticed it in the left groin, left flank and left abdomen. It has been waxing and waning and he was able to sleep fairly well last night with Tylenol PM. Nothing seems to make it better or worse. He has had nausea but no vomiting. He has had no fever. No urinary burning, blood or frequency or changes.
PM|afternoon|PM,|382|384|ASSESSMENT AND PLAN|INR is 2.26, calcium 9.5, sodium 137, potassium 3.6, bicarbonate 30, BUN and creatinine 18 and 1.0 respectively, anion gap 12, blood sugar is 80, proBNP at 2400, troponin negative, myoglobin 44, TSH 2.67. White blood cell count 8.6, platelet count 264,000, hemoglobin 11.4. ASSESSMENT AND PLAN: 1. Altered mental status: This appears to be multifactorial secondary to her 2 Tylenol PM, which contain Benadryl and what appears to be a urinary tract infection and polypharmacy including Ultram and Zoloft. She also seems dehydrated. She is on Lasix. We will hydrate the patient, we will have fall precautions and aspiration precautions.
PM|afternoon|P.M.|157|160|MEDICATIONS|8. Meclizine 25 mg per day. 9. GlycoLax 17 grams per day. 10. Allopurinol 100 mg b.i.d. 11. Glucosamine chondroitin. 12. Calcium with vitamin D. 13. Tylenol P.M. at night. ALLERGIES: Penicillin. FAMILY HISTORY: Her father was a smoker and had unspecified lung problems.
PM|physical medicine and rehabilitation:PMR|PM|213|214|HOSPITAL COURSE|Overnight, there were no new issues or complaints. There was no fecal or urinary incontinence and the patient was basically fitted for a TLSO on date of admission. The TLSO was placed on hospital day 2. PT/OT and PM and R consults were called after TLSO films were done and alignment was noted. SPECIFIC DISCHARGE INSTRUCTIONS: 1. The patient should not drive while on narcotic medications.
PM|afternoon|PM|193|194|ADMISSION MEDICATIONS|ADMISSION MEDICATIONS: 1. L-citrulline 10 capsules daily. 2. Stresstabs 1 tablet daily. 3. Flaxseed oil capsule 1 to 2 tablets p.o. daily. 4. Buffinol 5 tablets p.o. 6 times a day. 5. Excedrin PM 1 tablet q.h.s. p.r.n. 6. Carnitine. 7. Lorazepam 0.5 mg p.o. q.4-6 h. p.r.n. ALLERGIES: She has no known allergies. SOCIAL HISTORY: The patient smoked 1-1/2 packs per day, quitting 15 years ago.
PM|afternoon|PM|197|198|MEDICATIONS|1. Senna Plus 1 tablet orally b.i.d. 2. Calcium citrate with vitamin D 1 tab b.i.d. 3. Gabapentin 300 mg b.i.d. 4. Quinine sulfate 260 mg at bedtime. 5. Biotin 300 mcg daily at bedtime. 6. Tylenol PM 1 orally daily at bedtime. 7. Alphagan 0.15% eyedrops in the left eye b.i.d. 8. Timolol 0.5% eyedrops in both eyes daily. 9. Aspirin 81 mg daily.
PM|afternoon|PM|149|150|MEDICATIONS|6. Plavix 75 mg p.o. daily 7. Cozaar 50 mg p.o. daily 8. Synthroid 0.025 mg p.o. daily 9. Centrum multivitamin 1 daily 10. Ambien p.r.n. 11. Tylenol PM q.h.s. p.r.n. 12. Centrum vitamins. ALLERGIES: None known. SOCIA HISTORY: She lives at the Rivers.
PM|physical medicine and rehabilitation:PMR|PM|235|236|HISTORY OF PRESENT ILLNESS|On _%#MMDD#%_, he underwent bilateral ureteral stent placement and he had postoperative diuresis for 48 hours. By _%#MMDD#%_, the patient was transferred to subacute rehab. During the rehab admission the patient was being evaluated by PM & R for shoulder and back pain. They had discussed the possibility of an EMG in the future. For the past few days, the patient has had little output from his colostomy.
PM|physical medicine and rehabilitation:PMR|PM|143|144|PROBLEM # 8|PROBLEM # 8: Orthotic on the right hand and wrist. This was adjusted while an inpatient by Winkley Orthotics. He will need a new orthotic, and PM and R, Dr. _%#NAME#%_, will prescribe a new one at his follow-up visit next week. DISCHARGE PLANS: The patient was treated for osteomyelitis with the IV antibiotics, with a Hickman catheter placed for home IV antibiotics.
PM|afternoon|P.M.|224|227|DISCHARGE PLANNING|The patient already has a prescription for prednisone. Discharge planning includes phoresis tomorrow (_%#MMDD#%_) and the final one on Monday (_%#MMDD#%_). He will follow-up with me on the _%#DD#%_ of _%#MM#%_, 2002 at 4:00 P.M. at the _%#CITY#%_ _%#CITY#%_ Clinic. He has been made aware of discharge plans and medications. If he has problems, he will contact me in the meantime.
PM|afternoon|PM.|168|170|MEDICATIONS|His most recent one was this past spring and that was complicated by a Staphylococcus infection. MEDICATIONS: 1. Insulin 26 units of regular and 26 units of NPH AM and PM. 2. Lisinopril. HOSPITAL COURSE: The patient was admitted to the ward.
PM|afternoon|P.M.|174|177|HISTORY OF PRESENT ILLNESS|It's onset occurred at roughly 10:00 A.M. yesterday morning while in Wisconsin hunting. He eventually came to the emergency department in a town in Wisconsin at roughly 2:00 P.M. where he was observed and treated for roughly five hours before being discharged to home. He believes he was diagnosed with a "3 mm" kidney stone on the left side.
PM|afternoon|P.M.,|168|172|DISCHARGE MEDICATIONS|8. Protonix, 40 mg q.d. 9. Norvasc, 10 mg q.d. 10. Milk of Magnesia, 1 tablespoon q.d. p.r.n. constipation. 11. Lorazepam, 15-30 mg q.h.s. p.r.n. insomnia. 12. Tylenol P.M., 1 or 2 q.h.s. p.r.n. insomnia. 13. Plain Tylenol, 650 mg q.i.d. p.r.n. for mild pain. 14. Hydrocodone/APAP (5/500) 1 q. 6 hours p.r.n. for intense pain.
PM|physical medicine and rehabilitation:PMR|PM|138|139|DISCHARGE RECOMMENDATIONS|I would recommend she continue with occupational therapy, physical therapy and social service consultation. She does not need any routine PM and R followup, but if experiences difficulties in her rehabilitation program certainly available, if needed.
PM|afternoon|PM|171|172|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Lisinopril/hydrochlorothiazide 20/12.5 p.o. q. day. 2. Melatonin 3 mg p.o. each day at bedtime. 3. Benadryl p.r.n. 4. Dulcolax p.r.n. 5. Tylenol PM p.r.n. 6. Multivitamin 1 p.o. q. day 7. Aspirin 325 p.o. q. day. 8. Hydrocodone/acetaminophen 5/325 p.o. q. 4 hours p.r.n.
PM|afternoon|PM|146|147|CURRENT MEDICATIONS|16. Sinemet 25/100, 1-1/2 tablets 5 times per day. 17. Quinine sulfate 260 mg p.o. at bedtime. 18. Clonazepam 0.5 mg p.o. at bedtime. 19. Tylenol PM 1 tablet p.o. at bedtime. 20. Zoloft 50 mg p.o. at bedtime. 21. Artificial tears. REVIEW OF SYSTEMS: Other than stated in the HPI, I was unable to obtain due to the patient's aphasia.
PM|physical medicine and rehabilitation:PMR|PM|265|266|HOSPITAL COURSE|When she was originally examined, she was alert and oriented to place and person but often not able to answer questions appropriately and many of her sentences were a combination of nonsensical words. During her stay here, she vigorously worked with the PT, OT and PM and R staff. She has had no falls. She has improved and met the goals of therapy. She was found to have a DVT in distal popliteal vein as previously noted and required an IVC filter placement secondary to her not being a candidate for anticoagulation.
PM|physical medicine and rehabilitation:PMR|PM|222|223|IMPRESSION AND PLAN|9. Seizure disorder: Stable. No recent seizures. He is on Dilantin and we will check labs on Monday. 10. Small PFO per echocardiogram, which had been reviewed by Cardiology at the hospital. 11. Deconditioning: PT, OT, and PM & R will see the patient and follow him up on the acute rehab unit. 12. DVT prophylaxis. He is on subcutaneous heparin at this time.
PM|afternoon|PM.|131|133|MEDICATIONS|3. Status post total colectomy with ileostomy. 4. Primary sclerosing cholangitis with cirrhosis of the liver. MEDICATIONS: Tylenol PM. HABITS: Nonsmoker. No alcohol. FAMILY & SOCIAL HISTORY: The patient is unmarried.
PM|afternoon|PM|131|132|ADL STATUS|PAIN: Negative. ADL STATUS: Energy: Almost back to normal. Eating: She is eating well. Sleeping: She is sleeping with some Tylenol PM and some Ativan; otherwise she does not sleep well. Maintaining weight: Yes. FAMILY HISTORY/SOCIAL HISTORY: Her mother is living at 87.
PM|afternoon|PM|197|198|MEDICATIONS|MEDICATIONS: On admission: 1. Metoprolol 100 mg b.i.d. 2. Lipitor 40 mg daily. 3. Pacerone 200 mg daily. 4. Baby Aspirin 81 mg daily. 5. Gemfibrozil 600 b.i.d. 6. Zantac 150 p.o. p.r.n. 7. Tylenol PM p.r.n. 8. Lasix is listed. There is no dose listed. PAST MEDICAL HISTORY: History of atrial fibrillation with pacemaker. She has had an aortic valve replacement which is a bovine valve.
PM|afternoon|PM|122|123|DISCHARGE MEDICATIONS|4. Lipitor 10 mg p.o. q.d. 5. Flexeril 10 mg p.o. q.d. 6. Prinivil 10 mg p.o. q.d. 7. Aspirin 325 mg p.o. q.d. 8. Tylenol PM 1-2 tablets p.o. q.h.s. 9. Glyburide 5 mg two tablets p.o. q.d. to be started on _%#MMDD#%_. 10. Synthroid 50 mcg p.o. q.d. 11. Percocet 1-2 tablets p.o. q.4h. p.r.n.
PM|afternoon|PM.|174|176|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Candesartan 16 mg PO q.h.s. 2. Nortriptyline 50 mg PO q.h.s. 3. Lipitor 80 mg PO q PM. 4. Glucovance 5/500 tablets, 500 mg PO q AM and 1000 mg PO q PM. 5. Os-Cal 500 mg PO q AM and 1000 mg PO q PM. 6. Atenolol 75 mg PO q day. DISCHARGE INSTRUCTIONS: The patient is to follow-up with his primary care physician, Dr. _%#NAME#%_ _%#NAME#%_, in one to two weeks.
PM|afternoon|PM|179|180|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ is a 78-year-old African-American male who lives with his children. This afternoon he had the usual supper with soup and some spicy meal. Soon after around 7:15 in PM he started complain of increased dyspnea, shortness of breath. He was sitting in his bathroom when all of a sudden he fell down and experienced respiratory arrest.
PM|afternoon|P.M.|213|216|HOSPITAL COURSE|Fairview Home Care is involved as well. The patient had persistent nocturia. Dr. _%#NAME#%_ reconsulted on this patient and suggested again catheterization. Rather, he supported Flomax at night along with Tylenol P.M. DISPOSITION: The patient returns home. His daughter will be staying with him and attempting to improve his social situation.
PM|afternoon|P.M.|171|174|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Coumadin 2 mg per day. 2. Toprol XL 50 mg per day. 3. Flomax 0.4 mg p.o. h.s. 4. Keflex 500 mg p.o. q six hours for three more doses. 5. Tylenol P.M. one to two tablets p.o. h.s. for sleep. (These are the same medications as on admission.) FOLLOWUP: 1. Home Care with INR check in three days.
PM|afternoon|P.M.|346|349|MEDICATIONS ON DISCHARGE|Will continue OT and PT and will also have Speech Therapy follow her because of her aspiration risk. MEDICATIONS ON DISCHARGE: Lovenox 40 mg sub-Q q day until her INR gets to be greater than 2.0, Coumadin 5 mg per day with INR's checked q Monday, Wednesday, and Friday, digoxin 0.25 mg load for heart rhythm control at morning of discharge, 6:00 P.M. on the day of discharge, and 7:00 A.M. on _%#DDMM2004#%_ and then she will get 0.125 mg q day. She will have furosemide 40 mg q day, lisinopril 10 mg q day, Toprol XL 50 mg q day, potassium 20 meq b.i.d., Tequin 200 mg q day for seven days, Imdur 30 mg q day, Protonix 40 mg q day, Liquibid 600 mg b.i.d. for seven days, Tylenol Extra Strength p.r.n. pain.
PM|afternoon|PM.|93|95|PSYCHIATRIC DIAGNOSIS|Alcohol dependence. Axis II Deferred. Axis III Status post unintentional overdose of Tylenol PM. Axis IV Psychosocial stressors: Severe - Marital and financial difficulties. Axis V Global Assessment of Functioning: 75.
PM|afternoon|PM,|185|187|HISTORY OF PRESENT ILLNESS|She was brought to the Fairview Ridges Hospital on the morning of admission by her son. She had consumed approximately 9 beers the evening before, and had taken approximately 6 Tylenol PM, according to the patient. However, the HPI states that she took anywhere from 4 to 6 to 12 to 15 Tylenol PM tablets. LABORATORY DATA: Labs drawn at the Fairview Ridges ER were significant for a blood alcohol level of 0.17, on initial .........a level of 148 with a repeat level of 103 several hours later.
PM|afternoon|PM.|221|223|ASSESSMENT|She denies suicidal ideation. ASSESSMENT: This is a 40-year-old woman with a history of alcohol abuse. She was probably admitted inappropriately due to her intoxicated state and poor judgment regarding the use of Tylenol PM. She denies any suicidal thoughts, although she does admit that she has a problem with alcohol. PLAN: 1. The patient was discharged and told that she has problems with alcohol.
PM|afternoon|PM|173|174|DISCHARGE MEDICATIONS|With these treatments, his nausea was under excellent control. DISCHARGE MEDICATIONS: 1. Protonix 40 mg p.o. daily. 2. Compazine 10 mg p.o. as needed for nausea. 3. Tylenol PM two tablets every night at bedtime as needed for sleep. FOLLOW-UP INSTRUCTIONS: 1. Follow up with Dr. _%#NAME#%_ _%#NAME#%_ in radiation therapy on _%#DDMM2007#%_ for planning of radiation therapy.
PM|afternoon|PM|186|187|DISCHARGE MEDICATIONS|20. Baby powder sprinkled to groin b.i.d. 21. Biotene mouth wash one teaspoon swish and spit q.i.d. 22. Bactrim double-strength tablet one p.o. b.i.d. on Monday and Tuesday. 23. Refresh PM eye ointment q. evening to eyes. 24. Lac-Hydrin 12% cream daily to thin skin. 25. MiraLax 17 gm orally once daily as needed for constipation.
PM|afternoon|PM|153|154|DISCHARGE MEDICATIONS|1. Baclofen 10 mg p.o. q.i.d. p.r.n. 2. Senokot one tab p.o. q.i.d. 3. Multivitamin one tab q.d. 4. Calcium 500 mg b.i.d. 5. Intrathecal baclofen as per PM and R at 60 mcg per 2 cc with continuous infusion. 6. Ambien 10 mg p.o. h.s. p.r.n. 7. Zofran 4-8 mg IV q. 6h. p.r.n.
PM|physical medicine and rehabilitation:PMR|PM|226|227|ALLERGIES|In their opinion, the patient would need placement for subacute rehabilitation and benefit from long-term rehabilitation. Patient continued to receive physical therapy and occupational therapy daily while in the hospital. The PM and R service also recommended neuropsych testing. The neuropsych evaluation recommended long-term rehabilitation. Their assessment revealed that the patient lacks insight into the severity of his cognitive impairments, maybe impulsive, will likely require at least some supervision for his safety upon discharge.
PM|afternoon|P.M.|193|196|HOSPITAL COURSE|A morning cortisol was obtained which was 5.3, normal. Endocrine was consulted for possible adrenal insufficiency. A cosyntropin skin test was performed. Adrenal cosyntropin was 1366. Baseline P.M. cortisol 5.4, 30 minute cortisol 7.1, 60 minute cortisol 6.3. The Endocrine Team saw the patient and felt that she had multiple endocrine insufficiency, which is known as Schmidt syndrome.
PM|afternoon|P.M.,|555|559|DISCHARGE MEDICATIONS|3. Hypokalemia due to diuretics, replaced. 4. Type 2 diabetes mellitus. 5. Chronic oral anticoagulation due to intermittent atrial dysrhythmias. DISCHARGE MEDICATIONS: Bumex 1 mg two p.o. b.i.d., spironolactone 12.5 mg p.o. daily, Zaroxolyn 2.5 mg p.o. each Monday only, digoxin 0.25 mg one-half tablet p.o. each Monday, Wednesday, and Friday, Actos 45 mg p.o. daily each noon, Norvasc 10 mg p.o. daily with dinner, Imdur 60 mg 2-1/2 tablets p.o. q.h.s., Proscar 5 mg p.o. q Tuesday, Thursday, Saturday, glyburide 5 mg p.o. each A.M. and 7.5 mg p.o. each P.M., Toprol XL 100 mg p.o. q.h.s., Lantus 10 units sub-Q q.h.s., Coumadin 5 mg p.o. each Monday, Wednesday, and Friday, and 2.5 mg p.o. each Tuesday, Thursday, Saturday, and Sunday, Tylenol PM one p.o. q.h.s. DISCHARGE INSTRUCTIONS AND FOLLOW-UP: The patient will have home care evaluation prior to discharge and possibly home care assistance.
PM|afternoon|P.M.|139|142|HISTORY OF PRESENT ILLNESS|The patient states that it began on _%#DDMM2000#%_ prior to 2 o'clock. It continued until her arrival in the emergency room at about 10:00 P.M. The patient did state that this was improved with Nitro spray. At the time of evaluation, the patient said that her chest pain or heaviness was her usual angina, however, it was more severe.
PM|afternoon|P.M.|216|219|FOLLOW UP|The patient had begun to use Tylenol P.M. up to two per night as a sleep aid. She began to note auditory hallucinations which she feels started after she began the Tylenol P.M. During her hospitalization the Tylenol P.M. was discontinued and she was given Restoril as a sleep aid and did not have problems with hallucinations and had a good night's sleep.
PM|afternoon|PM|177|178|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1. Lisinopril 5 mg p.o. q.d. 2. Piroxicam 20 mg p.o. q.d. 3. BuSpar 5 mg p.o. b.i.d. 4. Fiber-Lax one p.o. b.i.d. 5. Tylenol 1000 mg p.o. b.i.d. 6. Tylenol PM q.h.s. as well. 7. Sotalol 30 mg p.o. b.i.d. 8. Os-Cal 500 mg p.o. t.i.d. 9. Nexium 20 mg p.o. q.h.s. 10. Imodium p.r.n. SOCIAL HISTORY: The patient is widowed and lives at the Arbors at Ridges Assisted Living Facility.
PM|afternoon|PM|229|230|MEDICATIONS|Mirapex 1.5 mg, 1 tablet t.i.d. Misoprostol 100 mcg tablet q.i.d. Nystatin cream to the perineum p.r.n. q.i.d. Omeprazole 20 mg capsule, one daily. Plaquenil 200 mg b.i.d. Prochlorperazine 5 mg suppository p.r.n. nausea. Tylenol PM Extra Strength at h.s. as needed. ALLERGIES: Amoxicillin caused diarrhea only. She has allergy to sulfa; I am uncertain of the reaction.
PM|afternoon|P.M.|308|311|MEDICATIONS|FAMILY HISTORY: Noncontributory. ALLERGIES: No known drug allergies. MEDICATIONS: 1) Tylenol 500 mg two tablets q.i.d. 2) Aspirin 81 mg p.o. q.d. 3) Lisinopril 20 meq p.o. q.d. 4) Multivitamin one p.o. q.d. 5) B12 1000 mg IM q month. 6) Seroquel 25 mg p.o. one tablet q 8:00 A.M., q noon; two tablets q 8:00 P.M. 7) Lexapro 10 mg p.o. q.d. 8) Lomotil 2.5 mg p.o. q.i.d. p.r.n. 9) Fiberlax 625 mg one p.o. q.d. p.r.n. 10) Motrin 200 mg 1-2 q.8.h. p.r.n. 11) Neosporin two drops both eyes t.i.d. p.r.n. 12) Tramadol 50 mg one p.o. q 4-6 hours p.r.n. 13) Trazodone 50 mg one p.o. q.h.s. 14) Seroquel 25 mg one p.o. q 1-2 hours p.r.n., not to exceed four pills in 24 hours.
PM|afternoon|PM|137|138|SPECIAL INSTRUCTIONS|Bladder scan in a month to a month and a half. Speech therapy, PT, OT. SPECIAL INSTRUCTIONS: Diet: He is discharged on a diet of Similac PM 60/40 plus Beneprotein, add Kayexalate and let sit for 4 hours then pour off formula to use feeds 250 mL boluses 4 times a day and then 65 mL per hour for 8 hours at night.
PM|physical medicine and rehabilitation:PMR|PM|183|184|HOSPITAL COURSE|Sensation was intact, and deep tendon reflexes were 2+. The wound remained clean, dry, and intact, and he was afebrile throughout his hospitalization. He was evaluated by PT, OT, and PM and R, and he was recommended for rehabilitation placement, and a place was found for him at the _%#CITY#%_ Health and Rehabilitation Center.
PM|physical medicine and rehabilitation:PMR|PM|162|163|ASSESSMENT/PLAN|ASSESSMENT/PLAN: 1. Status post left temporal lobe ischemic stroke: Aggressive blood pressure treatment for secondary prevention of stroke, aggressive rehab with PM and R consult. A number of tests have been recommended after discharge by Neurology, including a driving assessment, neuropsych testing, audiology exam, and visual field testing.
PM|afternoon|PM.|276|278|FOLLOW-UP|2. The patient is to have CBC with differential and platelets drawn twice weekly on Monday and Thursdays at a local clinic and have results faxed to _%#NAME#%_ _%#NAME#%_ at _%#TEL#%_. 3. The patient is to have a CT of the chest, abdomen, and pelvis on _%#DDMM2003#%_ at 1:15 PM. 4. The patient is to call the Hematology/Oncology Service for any increased pain, swelling, drainage, or elevated temperature of 100.5 degrees or higher.
PM|afternoon|PM|169|170|PROBLEM #2|A nasogastric tube was placed on _%#DDMM2003#%_ and he was started on drip feeds of Pediasure with fiber. His current feeding schedule is 45 cc/hour overnight from 8:00 PM to 8:00 AM and then 120 cc boluses three times per day (11:00 AM, 2:00 PM, and 5:00 PM). PROBLEM #3: Hematology. Anthony's current transfusion parameters are to keep his hemoglobin greater than 8 and his platelets greater than 40,000.
PM|afternoon|PM|231|232|DISCHARGE DIET|13. GCSF 50 mcg IV q. daily until his ANC is greater than 2.5 on three consecutive days (this will be administered in clinic). DISCHARGE DIET: Pediasure with fiber via a nasogastric tube at 45 cc/hour x 12 hours at night from 8:00 PM to 8:00 and 120 cc boluses at 11:00, 14:00, and 17:00. He can also have a general diet as tolerated. ACTIVITY: No restrictions.
PM|afternoon|PM|137|138|MEDICATIONS|7. Flomax 0.4 mg q.d. 8. Combivent 2 puffs q.i.d. 9. Aspirin 81 mg q.d. 10. Lipitor 40 mg q.d. 11. Guaifenesin 200 mg b.i.d. 12. Tylenol PM p.r.n. 13. Vioxx 12.5 mg q.d. 14. Iron pills. CHRONIC DISEASES: 1. Coronary artery disease, status post bypass.
PM|afternoon|PM|222|223|HISTORY OF THE PRESENT ILLNESS AND HOSPITAL COURSE|At the time of discharge, her medications are as follows: Macrodantin 100 mg p.o. b.i.d. Colace 100 mg p.o. daily p.r.n. Tylenol 500 mg two tabs p.o. in the morning and midday. The patient is going to continue her Tylenol PM two tabs at h.s. Synthroid 0.075 mg p.o. daily. Protonix 40 mg p.o. daily. Folic acid 2 mg p.o. daily. Ditropan XL; the patient believes she takes 5 mg p.o. daily.
PM|afternoon|PM|102|103|CURRENT MEDICATIONS|4. Prevacid 30 mg PO QD. 5. Senna one tablet PO QD prn. 6. Sorbitol 15 cc PO b.i.d. prn. 7. Refresh - PM eye drops two drops to both eyes QHS 8. Zanaflex 4 mg PO b.i.d. 9. Tylenol PM two tablets PO at bedtime prn.
PM|afternoon|P.M.|177|180|HOSPITAL COURSE|I was notified of this change and noted of her DNR/DNI status also and also regarding her family wishes. Spiritual Health Services was summoned also. On _%#DDMM2003#%_, at 2:50 P.M. the hospitalist was called and pronounced the patient dead. There were no respirations, no pulse, no heart sounds.
PM|afternoon|P.M.|147|150|HOSPITAL COURSE|She was admitted to the hospital, started on oral Prelone, and initially required some frequent racemic Epi nebs. Her last neb though was at 10:00 P.M. and overnight did well with no further stridor or respiratory distress. She was taking p.o. well at the time of discharge. Physical exam was normal. Lungs were clear to auscultation. PLAN: Will discharge her to home.
PM|afternoon|PM.|160|162|ADL STATUS|PAIN: She gets abdominal pain on and off but none at present. ADL STATUS: Energy: Good. Eating: She is eating well. Sleeping: She is sleeping well with Tylenol PM. Maintaining weight: Yes. LABORATORY DATA: Normal. Her x-rays were done in _%#MM#%_ and were normal.
PM|afternoon|PM|188|189|SUMMARY OF HOSPITAL COURSE|She was discharged to home in good condition. DISCHARGE MEDICATIONS: 1. Lidocaine 5% patch transdermal 12 hours on and 12 hours off p.r.n. 2. Albuterol nebulizer inhaled p.r.n. 3. Tylenol PM 1 tablet p.o. nightly p.r.n. 4. Prochlorperazine 5 mg p.o. q.6-8h. p.r.n. 5. Albuterol MDI 1 to 2 puffs inhaled q.4-6h. p.r.n.
PM|afternoon|P.M.|135|138|DISCHARGE MEDICATIONS|3) Levaquin 250 mg q day (all antibiotics to be through _%#MM#%_ _%#DD#%_). 4) Tylenol 500 mg at 8:00 A.M., 2:00 P.M.; 1000 mg at 6:00 P.M. and 10:00 P.M. 5) Thyroxin 88 mcg q day. 6) Prinivil 5 mg q day. 7) Memantine 10 mg b.i.d. 8) Metoprolol 50 mg b.i.d. 9) Protonix 20 mg q day. 10) Lidoderm patch 5% p.r.n.
PM|afternoon|PM|127|128|CURRENT MEDICATIONS|12. Multivitamin 1 tab p.o. daily. 13. Metamucil 1 tab p.o. t.i.d. 14. Tylenol Arthritis 2 tabs p.o. at suppertime 15. Tylenol PM 1 tab p.o. each day at bedtime. 16. PhosLo 1 tab p.o. t.i.d. with meals. 17. Plavix 75 mg p.o. daily. 18. Nitroglycerin 0.4 mg p.o. q. 5 minutes x3 p.r.n. FAMILY HISTORY: Father and mother both died at 90.
PM|afternoon|PM,|343|345|HISTORY|PRIMARY CARE PHYSICIAN: Dr. _%#NAME#%_ of _%#CITY#%_, Minnesota. CHIEF COMPLAINT: Tylenol p.m. overdose. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 39-year-old Caucasian female with prior history of multiple suicide attempts, with the most recent one, that was admitted to Fairview Southdale Hospital in _%#DDMM2005#%_ after she overdosed on Tylenol PM, presents to the hospital with the same complaints of having taken 150 tablets of Tylenol PM. The patient has been feeling depressed for at least the past month and today attempted to call her ex-boyfriend.
PM|physical medicine and rehabilitation:PMR|PM|136|137|HOSPITAL COURSE|The patient was started on clindamycin for his aspiration pneumonia. He was also noted to have severe spasticity, so he was seen by the PM and R staff. They recommended increasing his baclofen. The patient was also seen by Speech Pathology for better assessment of aspiration risk.
PM|afternoon|PM.|226|228|HISTORY OF PRESENT ILLNESS|As her arthritis has been bothering her recently when she was up north and it was raining she just recently gave herself some Embral shots. This past month she has been taking 2 Aleve nightly. She has also been taking Tylenol PM. REVIEW OF SYSTEMS: GENERAL: She denies any fevers, sweats, or chills.
PM|afternoon|PM|160|161|ASSESSMENT/PLAN|3. Asthma has been stable. Continue Advair. 4. Insomnia. We will write for Restoril. Will not give Tylenol PM> 5. Dry mouth. Discussed with the patient Tylenol PM with the Benadryl most likely is causing this symptoms verses the Prilosec. 6. Anxiety. Continue her Celexa and sedation to avoid panic attack.
PM|afternoon|PM.|113|115|MEDICATIONS|MEDICATIONS: He only takes ibuprofen, which he takes at night because of his knee pain, and he uses some Tylenol PM. He has aspirin and vitamins that he is not presently taking because of the radiation therapy. PAST MEDICAL HISTORY: He has had three hospitalizations for his Clostridium difficile, the last one in 2004.
PM|physical medicine and rehabilitation:PMR|PM|405|406|HOSPITAL COURSE|Also while on the rehab unit, she was instructed by the rehab nursing as well as the patient learning center for management of a pump which is hoped to deliver more nutrition to her through her PEG tube than she was able to do with a bolus prior to this hospitalization. Rehab recommendations for her to be seen by the physical therapist after discharge for continued treatment for her deconditioning. No PM and R followup indicated.
PM|afternoon|PM|140|141|HISTORY  OF PRESENT ILLNESS|She was reportedly involved in an argument with her dad, subsequent to which she felt quite agitated and took possibly 5 tablets of Tylenol PM and 20 pills of lorazepam (0.5 mg). She also went to the garage and drank two cupfuls of antifreeze. This was not verified by the family, however, some old empty bottles of Tylenol were found in her room.
PM|afternoon|P.M.|178|181|DISCHARGE|_%#NAME#%_ reports that he has resumed interest in sober activities such as being active in his church youth group and reading for pleasure. DISCHARGE: _%#NAME#%_ will return to P.M. High School where he will have counselors to support him in recovery. He is scheduled to attend _%#CITY#%_ Phase II, weekly AA or NA meetings, and to continue with random urinalyses.
PM|afternoon|PM|142|143|MEDICATIONS|8. Vitamin B12 shots q. monthly; last shot received on _%#MM#%_ _%#DD#%_, 2005. 9. Coumadin 1 mg p.o. daily for port prophylaxis. 10. Tylenol PM nightly. ALLERGIES: 1. AMOXICILLIN, which causes hives.
PM|afternoon|PM|126|127|DISCHARGE MEDICATIONS|2. Trazodone 50 mg PO q.h.s. 3. Septra DS one tablet PO q. day. 4. Tylenol Extra Strength 1-2 tablets p.r.n. pain. 5. Tylenol PM one tablet at bedtime. DISCHARGE FOLLOW-UP: Will be with Dr. _%#NAME#%_ _%#NAME#%_. I is recommended in 5-7 days. They will need to follow up for the results of the H.
PM|afternoon|PM,|135|137|HISTORY OF PRESENT ILLNESS|Consumption of one-half to three-fourths fifth of vodka last evening. Desire for sleep prompting intake of 1 mg of Klonopin, 1 Tylenol PM, and 1 melatonin. According to _%#COUNTY#%_ _%#COUNTY#%_ Medical Center EMS record, the patient was noted to be intoxicated and agitated.
PM|afternoon|P.M.|91|94|MEDICATIONS|_%#NAME#%_ does not smoke or drink. ALLERGIES: Codeine and Demerol MEDICATIONS: 1. Tylenol P.M. 2. Multi-vitamin 3. Calcium 4. Celebrex 200 mg q.day 5. Diovan 80 mg 1/2 tabs q.day 6. ASA 325 mg q.day 7. Plavix 75 mg q.day 8. Levothyroxine 0.1 mg q.day
PM|afternoon|P.M.|288|291|DISCHARGE INSTRUCTIONS AND FOLLOW-UP|7) Alprazolam 0.25 mg p.o. daily p.r.n. 8) Coumadin - dosing and instructions yet to be established, no doses on the date of discharge are required. DISCHARGE INSTRUCTIONS AND FOLLOW-UP: The patient is to follow-up in the INR clinic at Ridges Clinic on Friday, _%#MM#%_ _%#DD#%_, at 1:45 P.M. where he may pick up a Coumadin prescription and directions on dosing. The Coumadin nurse has been contacted.
PM|afternoon|PM|132|133|HISTORY OF PRESENT ILLNESS|She found out this afternoon that her husband was involved in an elicit affair. At 3:30 she took the remaining tablets of a Tylenol PM bottle. While it had expired two years ago, there was perhaps as many 50 tablets in the bottle. This calculates to 25 gm of Tylenol and 1250 mg of Benadryl.
PM|afternoon|PM,|229|231|HISTORY OF PRESENT ILLNESS|She was afraid to buy three different kinds of sleeping pills at the same store for fear that she would raise suspicion. About noon on Monday, she took a bottle of Unisom, a bottle of Sominex, the majority of a bottle of Tylenol PM, and also some ibuprofen. She fell asleep and slept for the next 28 hours. Yesterday afternoon, when she woke up, she told a neighbor what she had done and requested that the neighbor bring her into the ER for evaluation.
PM|afternoon|PM,|157|159|IMPRESSION|NEUROLOGIC EXAM is unremarkable. SKIN appears normal. Peripheral pulses are normal and symmetric. LABS: Summarized above. IMPRESSION: 1. Overdose of Tylenol PM, Unisom, and Sominex, and some ibuprofen. Of these, the most worrisome is certainly the Tylenol PM. She does not really have a good idea of how many she took, but the fact that her level at 28 hours is 59 is worrisome, especially in light of her already elevated liver function test.
PM|physical medicine and rehabilitation:PMR|PM|186|187|ADMISSION DIAGNOSIS|Sensation was intact. Deep tendon reflexes were 2+ throughout. Wound remained clean, dry, and intact, and he was afebrile throughout his hospitalization. He was evaluated by PT, OT, and PM and R and he was recommended for rehabilitation. A place was found for him at the _%#CITY#%_ Health Rehabilitation Center and he is anticipated to be discharged on _%#MM#%_ _%#DD#%_, 2005.
PM|physical medicine and rehabilitation:PMR|PM|187|188|HOSPITAL COURSE|5. Deep vein thrombosis prophylaxis with inferior vena cava filter. HOSPITAL COURSE: Rehabilitation course: The patient was admitted to acute rehab unit and was followed primarily by the PM and R doctor Dr. _%#NAME#%_ and orthopedic doctors from Minnesota. Orthopedic specialists also followed her and guided her rehab. She saw PT/OT and neuropsych specialties, and she gradually improved as things went along.
PM|afternoon|PM|139|140|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prednisone 5 mg p.o. daily. 2. Nexium 40 mg p.o. b.i.d. 3. Lunesta 2 mg p.o. q.h.s. p.r.n., insomnia. 4. Tylenol PM 2 tablets p.o. q.h.s. p.r.n., pain at night. 5. Ultram 50 mg p.o. q.6 hours p.r.n., pain. 6. Toradol 30 mg IV q.6 hours p.r.n., pain. 7. OxyContin 10 mg p.o. b.i.d.
PM|afternoon|P.M.|178|181|MEDICATIONS|ALLERGIES: Ranitidine and minocycline. MEDICATIONS: 1. Effexor 75 mg daily. 2. Lipitor 10 mg q.h.s. 3. Ibuprofen 600 mg q.6.h. p.r.n. 4. Estrogen replacement therapy. 5. Tylenol P.M. p.r.n. REVIEW OF SYSTEMS: CARDIOVASCULAR: See HPI. No known heart disease or hypertension, no anginal like symptoms.
PM|afternoon|PM.|214|216|BRIEF HISTORY OF PRESENT ILLNESS|BRIEF HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 21-year-old gentleman with a history of asthma and depression who was brought to the emergency room by his girlfriend after he swallowed 180 tablets of Tylenol PM. In the emergency room, the patient was noted to have significant change in mental status and agitation and concerns about airway protection.
PM|afternoon|PM|287|288|PLAN|We were able to start parenteral nutrition on _%#DDMM2005#%_. She was maintained on this until _%#DDMM2005#%_, when she was tolerating enough feedings via the enteral route. Feedings were started on _%#DDMM2005#%_, and she tolerated the increase in volume and strength of breastmilk and PM 60/40 fortified with 1.3g Kayexalate (per 225mL formula). She was subsequently switched to PM 60/40 plus Kayexalate or breastmilk fortified to 26 Kcals.
PM|afternoon|PM|207|208|PLAN|Feedings were started on _%#DDMM2005#%_, and she tolerated the increase in volume and strength of breastmilk and PM 60/40 fortified with 1.3g Kayexalate (per 225mL formula). She was subsequently switched to PM 60/40 plus Kayexalate or breastmilk fortified to 26 Kcals. At the time of discharge, she was bottling all of her feedings of PM 60/40 plus Kayexalate fortified to 26 kcal, with a daily maximum of 150 mL/kg (378 mL).
PM|afternoon|P.M.|227|230|MEDICATIONS AT THE TIME OF ADMISSION|PAST OB HISTORY: On _%#MM#%_ _%#DD#%_, 2005, at 38 and 6 weeks, she delivered a 6-pound 10-ounce female via spontaneous vaginal delivery augmented with Pitocin. MEDICATIONS AT THE TIME OF ADMISSION: A.M. 24 NPH and 10 Regular. P.M. 14 NPH and 10 Regular. ALLERGIES: NO KNOWN DRUG ALLERGIES. HOSPITAL COURSE: Physical examination on admission: Fetal heart tones were in the 130s with good long-term variability.
PM|afternoon|PM|54|55|CHIEF COMPLAINT|PRIMARY CARE PROVIDER: None. CHIEF COMPLAINT: Tylenol PM overdose. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 18-year-old man with no previous history of depression or suicide attempts who was brought in to the Emergency Department by the paramedics today.
PM|afternoon|PM|179|180|HISTORY  OF PRESENT ILLNESS|She is not cooperative. A significant portion of the history is therefore obtained from Dr. _%#NAME#%_. The patient apparently at about 8 p.m. today took she claims 20-25 Tylenol PM tablets. She denies taking anything else. She denies taking any illicit drugs or alcohol. Urine tox, however, in the emergency room was positive for cocaine and alcohol levels were also elevated.
PM|afternoon|PM|194|195|ASSESSMENT  AND PLAN|Acetaminophen level was 159. ASSESSMENT AND PLAN: This is a 26-year-old woman who presents following an overdose of Tylenol PM whose urine is also positive for cocaine. Suicide attempt, Tylenol PM overdose. The patient will be admitted and placed on a 72-hour hold. A sitter will also be obtained. The patient will be started on N-acetylcysteine.
PM|afternoon|PM.|203|205|DISCHARGE INSTRUCTIONS|The patient was originally on Zantac, and this was changed to propranolol because of possible cerebral effects. DISCHARGE INSTRUCTIONS: 1. The patient will return to Augustana nursing home today at 2:00 PM. 2. The patient will follow-up with Dr. _%#NAME#%_, University of Minnesota Physician's, Neurology in 1 month. 3. The patient will follow-up with Dr. _%#NAME#%_ in 2 weeks.
PM|afternoon|PM|207|208|DISCHARGE INFORMATION|Feedings were started on _%#DDMM2007#%_ of Enfamil Lipil with Iron on an ad lib on demand schedule. He was subsequently switched to PM 60/40. At the time of discharge, he was bottling all of his feedings of PM 60/40 ad lib. His weight at the time of discharge was 3710 gm. Problem #2: Sepsis. _%#NAME#%_'s mother was GBS negative. We treated _%#NAME#%_ with ampicillin and gentamicin for a total of 2 days.
PM|physical medicine and rehabilitation:PMR|PM|217|218|HOSPITAL COURSE|She underwent physical and occupational rehabilitation assessment in the hospital. PM and R assessment was also obtained during her hospital course to evaluate for transitional care placement following discharge. The PM and R consult on _%#MM#%_ _%#DD#%_, 2006, left recommendations for TCU placement. The patient was initially agreeable to this but later declined.
PM|afternoon|PM,|115|117|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Aspirin 81 mg daily. 2. Colace 100 mg 3 times a day. 3. Diovan 160 mg b.i.d. 4. Excedrin PM, 1-2 capsules at bedtime p.r.n. 5. Magnesia one tablespoon daily as needed. 6. Nephrocaps 1 daily. 7. Nitropatch 0.4 mg on 8 a.m., off 8:00 p.m.
PM|afternoon|PM|194|195|ASSESSMENT AND PLAN|_%#NAME#%_ should be seen in audiology clinic after discharge for further workup of the left side hearing. Immunizations: Hepatitis B vaccine was not given. _%#NAME#%_ was discharged on Similac PM 60/40 and breast feeding taking 70 ml every 3 hours and/or breast-feeding every 3 hours ALD. The parents were asked to make an appointment for their child to see you this week.
PM|physical medicine and rehabilitation:PMR|PM|196|197|PROBLEM #2|Once out of the Intensive Care Unit, Mr. _%#NAME#%_'s mental status improved significantly. At the time of discharge, he was nearly back to his usual functioning status. It was recommended by the PM and R Service that he have cognitive testing prior to returning to work. This will need to be arranged at discharge from Rehab.
PM|afternoon|P.M.|151|154|DISCHARGE MEDICATIONS|4. Calcium 250 mg p.o. daily 5. Enteric coated aspirin 325 mg p.o. daily 6. Multi-vitamin one tab p.o. daily 7. Omega-3, 2000 mg p.o. daily 8. Tylenol P.M. one tab p.o. daily q.h.s. p.r.n.
PM|afternoon|PM|212|213|HOSPITAL COURSE|Otherwise, the patient did quite well. He was tolerated a diet, working well with rehab, ambulating and improvement in both his wrist drop and his voice were noted. He was evaluated by both PT, OT as well as the PM Nurse Service and recommendations for acute rehab was made. The patient was able to be discharged to acute rehab on _%#DDMM2007#%_.
PM|afternoon|PM|164|165||_%#NAME#%_ _%#NAME#%_ is a 55-year-old female who was admitted to the Emergency Room with a 30 hour history of lower abdominal pain. The pain started suddenly at 1 PM yesterday. There has never been localization of the discomfort to right versus left side. This is worse with movement. She describes anorexia but no nausea, vomiting, diarrhea, dysuria.
PM|afternoon|PM|205|206|HOSPITAL COURSE BY SYSTEM|EXTREMITIES: Warm and well perfused with no edema. NEUROLOGIC: Moving all extremities equally. HOSPITAL COURSE BY SYSTEM: 1. Fluids, electrolytes and nutrition. _%#NAME#%_ was started on her home feeds of PM 60/40 plus Neutra-Phos at 52 mL/hour x17 hours. She received hemodialysis the day of admission. On hospital day #3, her potassium increased to 6.6. She received 2 doses of Kayexalate and Kayexalate was added to her feeds and the problem resolved.
PM|afternoon|PM.|111|113|HOSPITAL  COURSE|Most of this history was received from her mother. She apparently did an impulsive thing and took some Tylenol PM. She said she took half a bottle and then she took several tablets, possibly 80 of Flexeril. She initially was found by her neighbors crawling outside in the pouring rain only wearing a dress and crawling on the ground.
PM|afternoon|PM|149|150|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 17-year-old male transferred from Unity emergency room after overdose with approximately 8 g of Tylenol PM at 11:30 p.m. on _%#MMDD#%_. The patient reportedly had had an argument with his girlfriend, was upset and took the pills, mentioned to her over the phone that he had done it.
PM|physical medicine and rehabilitation:PMR|PM|139|140|HOSPITAL COURSE|5. History of V-tach. The patient is on amiodarone. 6. Hyperlipidemia. The patient is on atorvastatin. 7. The patient was evaluated by the PM and R team, and it was decided that he qualifies for acute rehabilitation. The patient will be transferred to Fairview Acute Rehab today.
PM|physical medicine and rehabilitation:PMR|PM|290|291|BRIEF SUMMARY OF HOSPITAL COURSE|One change in his medications this hospitalization was the discontinuation of simvastatin which his daughter felt had caused him some problems in the past and as such because of concerns of this possibly contributing to decreased mental status that was discontinued. It was felt overall by PM and R that the patient would likely do better in a familiar environment and as such, physical therapy and occupational therapy will continue at the patient's assisted living.
PM|afternoon|PM|197|198|DISCHARGE MEDICATIONS|This was discussed with the patient, who stated that she had not had intercourse in approximately 14 years. DISCHARGE MEDICATIONS: 1. Colace 100 mg p.o. b.i.d. 2. Senokot 1-4 p.o. b.i.d. 3. Lantus PM 25 units q.h.s. 4. Percocet 1-2 p.o. q.4-6h. p.r.n. FOLLOW-UP: She was instructed to follow up with her primary physician for staple removal approximately seven days postoperatively.
PM|afternoon|P.M.|206|209|REVIEW OF SYSTEMS|No strong odor to the urine. No burning or stinging and no control problems. MUSCULOSKELETAL: Positive for arthritis. GENERAL: Positive for a little bit of fatigue and insomnia, for which she takes Tylenol P.M. The rest of the review of systems is normal or negative. PHYSICAL EXAMINATION: GENERAL: The patient is delightfully chipper. VITAL SIGNS: Afebrile.
PM|afternoon|PM.|129|131|DISCHARGE MEDICATIONS|MAJOR PROCEDURES THIS ADMISSION: None. DISCHARGE MEDICATIONS: 1. Prednisone 20 mg PO q.d. 2. Lasix 140 mg PO q AM and 60 mg PO q PM. 3. Spironolactone 150 mg PO q AM and 50 mg PO q PM. 4. Oral potassium 80 mg PO b.i.d. 5. Combivent 120/21 mcg, 2 puffs q 6 H.
PM|afternoon|PM|242|243|HOSPITAL COURSE|HOSPITAL COURSE: Problem #1: CHF. Lungs cleared on 80 mg of Lasix PO b.i.d. Symptoms likely secondary to worsening CHF from sarcoidosis, complicated by a URI/pneumonia. The patient was treated by increasing the total Lasix dose from 80 AM/80 PM to 140 AM/60 PM, and spironolactone from 100 AM/100 PM to 150 AM/50 PM; the reason being the patient complains of going to the washroom many times at night and on occasion that discourages her from taking her evening dose of diuretic.
PM|afternoon|PM|297|298|HOSPITAL COURSE|HOSPITAL COURSE: Problem #1: CHF. Lungs cleared on 80 mg of Lasix PO b.i.d. Symptoms likely secondary to worsening CHF from sarcoidosis, complicated by a URI/pneumonia. The patient was treated by increasing the total Lasix dose from 80 AM/80 PM to 140 AM/60 PM, and spironolactone from 100 AM/100 PM to 150 AM/50 PM; the reason being the patient complains of going to the washroom many times at night and on occasion that discourages her from taking her evening dose of diuretic.
PM|afternoon|P.M.|143|146|DISCHARGE MEDICATIONS|Creatinine level to be done every two days until off antibiotics. Vancomycin troph level to be done after third dose which would be after 8:00 P.M. dose of _%#DDMM2002#%_. Patient is a 78-year-old male with multiple medical problems. Who was admitted on _%#MMDD#%_ with hematuria, fever, possible UTI.
PM|physical medicine and rehabilitation:PMR|PM|214|215|HOSPITAL COURSE|She maintained a consensual right pupillary reflex; however, she had lost her direct reflex. Due to concerns for her po intake, a nasojejunal tube was placed for overnight supplemental feeding. She was seen by the PM and R service in consultation who felt that she was an excellent rehabilitation candidate. At the time of discharge, she was awake, alert, and had right-sided ptosis.
PM|afternoon|P.M.|167|170|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: The patient is actually afebrile. She is well alert. She seems to be oriented but is very peculiar or stubborn. She tells me "I want two Tylenol P.M. soon and I don't need anything else". She seems to mean what she says. She denies other problems. VITAL SIGNS: Stable, with blood pressure of 120/80, pulse 80, respirations are normal.
PM|afternoon|PM.|141|143|DISCHARGE MEDICATIONS|6. Levothyroxine 100 mcg PO q.d. 7. Neurontin 1200 mg PO b.i.d. 8. Metoprolol 75 mg PO b.i.d. 9. Spironolactone 50 mg PO q AM and 25 mg PO q PM. 10. Zocor 80 mg PO q.d. 11. Trazodone 50 mg PO q.h.s. 12. Aspirin 1/2 to 1 tablet PO q.d. 13. Losartan 25 mg PO q.d.
PM|afternoon|PM.|158|160|DISCHARGE MEDICATIONS|14. Peri-Colace 2 tablets PO b.i.d. 15. Calcium carbonate with vitamin D 500 mg PO t.i.d. 16. Sodium bicarbonate 1.3 grams PO q.i.d. 17. Maxitrol 1 drop OS q PM. 18. Refresh tears 1 drop OS q.i.d. 19. Paxil 40 mg PO q day. 20. Amitriptyline 50 mg PO q day. 21. Aspirin 81 mg PO q day.
PM|afternoon|PM,|140|142|HISTORY OF PRESENT ILLNESS|She just saw Rheumatology yesterday to evaluate this and the results of the blood testing and workup are pending. Last night at about 10:00 PM, she took her first dose of Tylenol #3 to ease the joint pain, but then at midnight was awakened with severe epigastric pain that radiated into her back.
PM|afternoon|PM|190|191|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Autosomal recessive polycystic kidney disease diagnosed at 35 weeks gestation. 2. Chronic hyperkalemia treated with Kayexalate. 3. Chronic hypocalcemia treated with PM 6040. 4. Chronic decreased bicarb treated with Bicitra. 5. Chronic hypertension treated with atenolol 4 mg by mouth twice a day and nifedipine 0.37 mg by mouth 4 times a day.
PM|physical medicine and rehabilitation:PMR|PM|219|220|PLAN|They will also be looking into someone for help at home for 24 hour supervision, along with his wife. The patient will follow up with Dr. _%#NAME#%_, a psychologist, and his local physician. He will also follow up with PM and R in approximately 4 weeks' time. DISCHARGE CONDITION: Good.
PM|afternoon|PM.|155|157|DISCHARGE MEDICATIONS|The patient showed steady progress and was soon discharged to home. DISCHARGE MEDICATIONS: 1. Enteric-coated aspirin 325 mg PO q day. 2. Imuran 75 mg PO q PM. 3. Neoral 75 mg in the AM and 50 mg in the PM PO.
PM|afternoon|PM|134|135|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Enteric-coated aspirin 325 mg PO q day. 2. Imuran 75 mg PO q PM. 3. Neoral 75 mg in the AM and 50 mg in the PM PO. 4. Prednisone 10 mg PO q day. 5. Metoprolol 50 mg PO b.i.d. 6. Multivitamin 1 tab PO q day. 7. NPH insulin 8 units q AM subcu and 12 units q PM subcu.
PM|afternoon|PM.|148|150|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old woman who ingested at least two alcoholic drinks the night before last and had two Tylenol PM. She apparently got up during the night and fell down the stairs. She suffered fractures of her left fifth metatarsal and a comminuted fracture of her proximal left humerus.
PM|afternoon|P.M.|128|131|FOLLOW UP|It was recommend that the patient continue a low salt, cardiac diet and supplement his nutrition with Boost HP, one can at 3:00 P.M. daily. He is to check his weight daily and call his physician with a weight gain of two pounds or more.
PM|afternoon|PM.|177|179|MEDICATIONS|He does admit to cigarette smoking since high school. ALLERGIES: No known drug allergies. MEDICATIONS: He denies any medications, although he does take over-the-counter Tylenol PM. SOCIAL HISTORY: He is single. He is currently unemployed but he works in delivery.
PM|afternoon|PM|602|603|SOCIAL HISTORY|He was formerly _%#NAME#%_ _%#NAME#%_. Home meds are Serevent 2 puffs b.i.d., Lasix 10 mg q.i.d., vitamin C 0.4 ml G-tube q.d., Prevacid 10 mg G-tube q.d., Synthroid 62.5 mcg G-tube q.d., Bactrim suspension 90 mg G-tube every Monday, Wednesday, Friday, Benefiber 2.3 g G-tube over 1 hour with feeds, acidophilus 1 capsule per G-tube q.d., Crytic aid paste to diaper area p.r.n. LABS ON ADMISSION: Blood culture from 1050 a.m. on _%#MM#%_ _%#DD#%_, 2002, grew Gram negative rods, later identified as pseudomonas aeruginosa. Sputum culture drawn at the same time grew Gram negative bacilli with moderate PM enzyme Gram stain and then cultured and grew 2 strains of pseudomonas aeruginosa and light growth of Enterobacter cloacae from _%#MM#%_ _%#DD#%_, 2002, and _%#MM#%_ _%#DD#%_, 2002.
PM|afternoon|P.M.|184|187|DISCHARGE MEDICATIONS|e. Mild infiltrate left upper lobe inferiorly. DISCHARGE MEDICATIONS: Same as on admission and include: 1. Norvasc 2.5 mg po bid. 2. Neurontin 300 mg po bid. 3. Extra-Strength Tylenol P.M. 500/25 po qhs. 4. BuSpar 10 mg po bid. 5. Depakote 250 mg po bid. 6. Pepcid 20 mg po qd. 7. Atacand 60 mg po bid. 8. Betapace 120 mg po bid.
PM|afternoon|PM|217|218|MEDICATIONS|SURGICAL HISTORY: Includes hysterectomy, rectocele, and a cystocele repair, and cholecystectomy. MEDICATIONS: Carbatrol 300 mg twice a day, Prilosec 20 mg/day as needed, Celebrex 200 mg twice a day as needed, Tylenol PM as needed, Actonel 35 mg weekly on Monday, Citrucel twice a day. ALLERGIES: Ciprofloxacin. Intolerant to MACROBID itself. HABITS: She does not smoke or drink alcohol.
PM|afternoon|P.M.|256|259|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 54-year-old gentleman who was out of town for a wedding on Saturday night, acutely developed dizziness and then epigastric pain. He went to bed that night with Tylenol P.M. and a couple of aspirin and his pain felt better. The next day his pain returned and at that time developed a low-grade fever and shaking chills and was taken to the ER in _%#CITY#%_, New Mexico.
PM|afternoon|PM.|161|163|PAST MEDICAL HISTORY|Lasix - the dose recently increased to 80 mg p.o. b.i.d. Zaroxolyn - dose recently increased to 5 mg p.o. b.i.d. NPH insulin 32 units each AM and 16 units every PM. Digitek 0.125 mg p.o. daily. Flovent 220 two puffs b.i.d. Albuterol nebulizations b.i.d. Thyroxine 88 mcg p.o. daily. Avandia 8 mg p.o. daily. ALLERGIES ARE NOTED TO TETRACYCLINE; ACTUALLY IT IS MORE OF A SENSITIVITY CAUSING GI UPSET.
PM|afternoon|PM|284|285|HOSPITAL COURSE|Last chemotherapy was approximately seven days ago. Over the last seven days she had felt weak, lethargic and had noted some dizziness and fullness in her head. She presented to Oncology Clinic with these symptoms. She appeared to be neurologically intact at that time; however, at 6 PM which was several hours after leaving the clinic she noted acute onset of right lower extremity weakness, her foot was dragging, and her right upper extremity was weak with right-sided numbness.
PM|physical medicine and rehabilitation:PMR|PM|143|144|OPERATIONS/PROCEDURES PERFORMED|Grade 3 atherosclerotic plaque of the ascending aorta. 3. Upper GI endoscopy. Normal esophagus, normal stomach, normal exam of the abdomen. 4. PM and R consultation. 5. Cardiology consultation. HISTORY OF PRESENT ILLNESS: This is an 82-year-old Korean female with a history of coronary artery disease status post PTCA in _%#MM#%_ of 2003 who was brought to the emergency department by her family with acute confusion.
PM|afternoon|PM|146|147|HISTORY OF PRESENT ILLNESS|She used to drink a lot of beer, but in the last couple of years she just drinks Jack Daniels. She will have 3-4 Jack Daniels drinks from about 5 PM until midnight. She is cared for by her husband. She has not been functioning mentally or functioning in any kind of independent way for a number of years, but has gotten a lot worse probably in the last year.
PM|afternoon|PM|156|157|DIAGNOSTIC STUDIES|Repeat electrolytes done at 8 o'clock are entirely normal with the sodium now 133, potassium dropped to 3.9, and CO2 up to 25. Her blood gases done at 2:40 PM show pH of 7.45, pO2 elevated, bicarbonate down to 15, pCO2 27. ASSESSMENT: 1. Uncontrolled Type I diabetes. This is now much better, and she never really was acidotic, although she certainly had a very elevated blood sugar and ketones in the serum.
PM|afternoon|P.M.|233|236|HOSPITAL COURSE|She continues on Sinemet which she takes 25/100 orally t.i.d. and 50/200, one tablet orally q.h.s. Neurology also recommended Amaryl to be eventually added to her medications. 4. Restless leg syndrome. Patient was started on Tylenol P.M. and continues on Sinemet. 5. History of headache. A sed. rate was obtained to evaluate for possible giant cell arteritis but her sed.
PM|afternoon|P.M.|170|173|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1. Synthroid 0.05 mg daily 2. Lasix 20 mg Q day 3. Metoprolol 50 mg b.i.d. 4. Lisinopril 5 mg at HS 5. Klor-Con 10 mEq. Q day 6. Tylenol and Tylenol P.M. on a prn. basis. 7. Hydroxyzine 25 mg at HS 8. Glucosamine 500 mg b.i.d. 9. Allopurinol 100 mg b.i.d. 10. Sucralfate 1 gram q.i.d. SOCIAL HISTORY: Widowed, lives now at a nursing home, _%#CITY#%_ Care Center.
PM|afternoon|P.M.|121|124|HOSPITAL COURSE|The patient continued to receive IV fluids and IV antibiotics but continued to decline and was found dead in bed at 4:30 P.M. on _%#DDMM2004#%_. Cause of death is aspiration pneumonia.
PM|afternoon|P.M.,|289|293|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|She wants to go home and stay with her daughter for a while and follow-up with Dr. _%#NAME#%_ in 1-2 weeks. Her medications are as follows: Actonel 35 mg once a week, lisinopril dose uncertain but she thinks maybe 10 mg p.o. daily, Ritalin 10 mg p.o. every 7:00 A.M., 11:00 A.M., and 3:00 P.M., enteric coated aspirin 325 mg p.o. daily, Antivert 25 mg p.o. every eight hours as needed.
PM|afternoon|PM|153|154|HOSPITAL COURSE|Physical therapy, occupational therapy and PM and R saw the patient. He was scheduled for surgery on _%#MM#%_ _%#DD#%_, 2004 to resect his pontine mass. PM and R arranged placement at Walker Methodist from the time of discharge until the time of his surgery. He was discharged in good condition on _%#MM#%_ _%#DD#%_, 2004.
PM|afternoon|P.M.,|230|234|MEDICATIONS|11) Previous complete hysterectomy. MEDICATIONS: Her usual medications had been one aspirin daily, Aricept 10 mg daily, lisinopril 10 mg daily, Zantac 150 mg b.i.d., Zoloft 50 mg daily, Seroquel 25 mg in the A.M. and 50 mg in the P.M., Actonel 35 mg weekly, and Toprol XL 50 mg daily. Note that most of her medicines have been held for the past several days due to her failing course.
PM|afternoon|PM.|157|159|MEDICATIONS|4) Lopressor 50 mg twice a day. 5) Aspirin 81 mg daily. 6) Ditropan 5 mg twice a day. 7) Fibercon on a regular basis. 8) Tylenol as needed including Tylenol PM. 9) Colace 100 mg twice a day. 10) Multivitamin. 11) Calcium 1 gram orally daily. 12) Levaquin, unclear dose, but not well documented that he has been on just for a few days.
PM|afternoon|P.M.|126|129|DISCHARGE MEDICATIONS|5) Aricept 10 mg p.o. daily. 6) Citrucel three teaspoons in 8 ounces of fluid p.o. daily. 7) Ativan 0.5 mg p.o. daily at 8:00 P.M. as a substitution for previous Seroquel. 8) Two-percent Micatin powder to skin folds and gluteal crease b.i.d. 9) Neurontin 800 mg p.o. t.i.d. 10) Nasonex two puffs each nostril daily.
PM|afternoon|P.M.|242|245|HISTORY OF PRESENT ILLNESS|She has had a decreased appetite over the last 3 days and has been able to keep in very little p.o. She denies any diarrhea or constipation. Denies any fevers or chills. Over the last three days she states that she bought a bottle of Tylenol P.M. and was taking this to help with her pain, however, it made it little improvement. She states that she continued to take the medication throughout the day and over a period of approximately 30 hours believes she took an entire bottle of the Tylenol P.M. or approximately 50 pills.
PM|physical medicine and rehabilitation:PMR|PM|248|249|HOSPITAL COURSE|Although the patient did well with cardiac rehab, she still had a poor appetite and was slightly unclear on why some of her medications had been changed. For this reason, we felt that she was appropriate for subacute rehabilitation and requested a PM and R consult. They assisted in arranging for a transitional care facility. By postoperative day number 8 the on-call intern was notified due to some arm heaviness the patient was reported.
PM|afternoon|P.M.|130|133|MEDICATIONS|4. Lisinopril 10 mg b.i.d. 5. Zoloft 100 mg daily 6. Levothyroxine 0.025 mg daily 7. Pulmicort Respules 0.25 mg b.i.d. 8. Tylenol P.M. each day at bed-time 9. Coreg 12.5 mg b.i.d. 10. Metamucil b.i.d. 11. Albuterol via nebulization q.i.d. p.r.n. 12. Coumadin 5 mg Monday and Friday
PM|physical medicine and rehabilitation:PMR|PM|117|118|FOLLOW UP|1. It is recommended he follow up with his primary care physician in 2 to 3 weeks. 2. Follow up with Dr. _%#NAME#%_, PM and R, in 4 to 6 weeks.
PM|afternoon|PM|170|171|MEDICATIONS|3. Avandia 4 mg p.o. daily. 4. Ferrous gluconate 325 mg p.o. daily. 5. Lasix 40 mg p.o. daily. 6. Lisinopril 20 mg p.o. daily. 7. Multivitamin one p.o. daily. 8. Tylenol PM one p.o. q h.s. p.r.n. 9. Sodium bicarbonate 1950 mg p.o. t.i.d. 10. Tylenol #3 one to two q 4-6h p.r.n. pain. 11. Sliding-scale insulin FAMILY HISTORY: Father died of prostate cancer, otherwise negative.
PM|physical medicine and rehabilitation:PMR|PM|134|135|REHABILITATION DISCHARGE RECOMMENDATIONS|REHABILITATION DISCHARGE RECOMMENDATIONS: In-home physical therapy assistance with her medications and ILS activities. Follow up with PM and R on a p.r.n. basis.
PM|physical medicine and rehabilitation:PMR|PM|156|157|PHYSICAL EXAMINATION|2. Continue same medications. Increase Ceftin 500 mg b.i.d. for a total of a 10-day antibiotic course. 3. Continue present Glucotrol/Glucophage regimen. 4. PM and R input while on acute rehab. 5. Repeat brain MRI with neurology. FOLLOW UP: Followup by Dr. _%#NAME#%_.
PM|afternoon|P.M.|187|190|DISCHARGE MEDICATIONS|8. Simvastatin 40 mg p.o. daily. 9. Coumadin 7.5 mg on Monday and Thursday, and 5 mg on Tuesday, Wednesday, Friday, Saturday, and Sunday. 10. Sotalol 80 mg p.o. twice daily. 11. Excedrin P.M. p.r.n.
PM|physical medicine and rehabilitation:PMR|PM|154|155|HOSPITAL COURSE|We have asked her to employ the help of family members and consider full-time care for Mr. _%#NAME#%_. The patient has had difficulty with sialorrhea and PM and R doctor, Dr. _%#NAME#%_, was consulted for parotid Botox injections. Dr. _%#NAME#%_ met with the patient, and the patient declined this procedure.
PM|afternoon|PM|182|183|BRIEF HOSPITAL COURSE|Complaint was joint pain, as well as diarrhea for 5 days, per review of the ER records. The patient eventually was admitted to the Heme/Onc Service and arrived on the floor at 11:00 PM on _%#DDMM2006#%_. The patient was briefly interviewed. Prior to admission orders being written, the patient had left the floor and was not found for the remainder of the admission.
PM|afternoon|PM|200|201|HISTORY|He had a ventriculoperitoneal shunt placed in Children's Hospital in _%#CITY#%_ by Dr. _%#NAME#%_ _%#NAME#%_ when he was 5 days old and has had no revision. He was doing well until approximately 4:00 PM on _%#DDMM2006#%_ when the parents noticed swelling in the posterior right scalp, as well as lethargy and vomiting. There has been no fever. PHYSICAL EXAMINATION: GENERAL: _%#NAME#%_ _%#NAME#%_ is awake, eyes open, and responsive to stimuli.
PM|afternoon|PM|148|149|MEDICATIONS|7. Flonase 2 sprays in each nare as needed. 8. Azmacort 4 puffs twice daily. 9. Extra Strength Tylenol 2 tabs in the morning as needed. 10. Tylenol PM 3 tabs at night. 11. Multivitamin 1 tab daily. 12. Multi mineral 1 tab daily. 13. Vitamin C1 tab daily 14. Flax oil 2 capsules twice daily. 15. Vitamin E 400 international units daily.
PM|afternoon|PM|141|142|HISTORY OF PRESENT ILLNESS|She admits that she was rushing. She could not stand up but crawled up the stairs of the porch and then crawled to bed. She took two Tylenol PM and this morning still could not walk and was brought to the emergency room by her daughters. The patient says that she does not have pain when she moves her legs, however, when she stands on her legs it hurts and she is not able to walk.
PM|afternoon|P.M.|149|152|HISTORY OF THE PRESENT ILLNESS|He has had a long history of urinary urgency but no change and has had some sleep disturbance after his wife's death and his has been taking Tylenol P.M. or Advil which has not worked. He was to start taking some Ambien tonight. PAST MEDICAL HISTORY: 1. Coronary artery disease last 15 years ago. No recent evaluation.
PM|afternoon|PM.|227|229|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Overdose. HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ is a 31-year-old woman who earlier tonight had 3-4 drinks alcohol. She subsequently took about 20-30 pills of a mixture of Unisom with Benadryl and Tylenol PM. She typically takes Unisom to sleep but has not taken Tylenol PM prior to tonight. She called her husband from whom she is separated and he called police.
PM|afternoon|PM|131|132|HISTORY OF PRESENT ILLNESS|A biopsy was obtained at that time. Also patient there had paracentesis and 4000 mL of fluid was removed. The fluid showed WBC 77, PM 3 and culture was negative. His hemoglobin has been stable. The patient was transferred today to the University of Minnesota Medical Center, Fairview, for evaluation of a transplant and end-stage liver disease treatment.
PM|afternoon|PM|119|120|MEDICATIONS|5. Isosorbide mononitrate 120 mg p.o. daily. 6. Centrum Silver one p.o. daily. 7. Norvasc 10 mg p.o. daily. 8. Tylenol PM one to two tabs p.o. each day at bed time p.r.n. 9. Colace p.o. b.i.d. p.r.n. 10. Percocet one p.o. q.6h. p.r.n. pain ALLERGIES: No known drug allergies.
PM|afternoon|PM|189|190|HOSPITAL COURSE|On the medical floor, an endocrinology consultation was obtained. Initially, there was some sort of hyperaldosteronism, however, through the workup she was found to have an elevated AM and PM cortisol. At the time of discharge, she had a dexamethasone suppression test. The results are pending. She was also found to be thrombocytopenic on her stay here.
PM|afternoon|PM.|160|162|MEDICATIONS|4. Docusate sodium capsule 100 mg p.o. b.i.d. 5. Enalapril 10 mg p.o. daily. 6. Calcium supplement. 7. Meclizine 1/2 tablet p.o. b.i.d. 8. Citrucel. 9. Tylenol PM. 10. Plavix 75 mg p.o. daily. ALLERGIES: She has allergies or drug intolerances to Demerol, Darvon, morphine, Donnatal and questionably to aspirin.
PM|afternoon|PM|179|180|ADMISSION MEDICATIONS|14. TOBI neb 300 mg b.i.d. alternating monthly with coly 15. Tramadol 50 mg p.o. t.i.d. 16. Tylenol Arthritis pain medication 650 mg two tablets b.i.d. 17. Tylenol Extra Strength PM 2 tablets at bedtime 3 times per week. 18. Vitamin K 5 mg p.o. daily. 19. Azithromycin 250 mg p.o. daily.
PM|afternoon|PM|142|143|HOME MEDICATIONS|4. Albuterol MDI. 5. Ranitidine as needed. 6. Effexor 150 mg p.o. each day at bedtime. 7. Nortriptyline 50 mg each day at bedtime. 8. Tylenol PM as needed. DISCHARGE MEDICATIONS: 1. Lyrica 200 mg p.o. t.i.d. 2. Lortab 5 mg p.o. q.6 p.r.n. pain.
PM|afternoon|PM.|199|201|MEDICATIONS|12. Vitamin E 400 units b.i.d. 13. Multivitamin q.d. 14. Ambien 5 mg at bedtime. 15. Morphine Sulfate 15 mg breakthrough pain. 16. Morphine Sulfate Extended Release 120 mg t.i.d. 17. Bisacodyl 10 mg PM. 18. Senna prn. ALLERGIES: The patient has adverse reactions to penicillin, Tetracycline, Erythromycin, Dilaudid, Vasotec, Tetanus, Compazine.
PM|afternoon|P.M.|184|187|HISTORY OF PRESENT ILLNESS|DOB: _%#DDMM1986#%_ HISTORY OF PRESENT ILLNESS: This 15-year-old male was admitted through the emergency room for appendicitis. He developed the onset of lower abdominal pain at 07:30 P.M. last evening. This was following him pitching a full game of baseball without difficulty. The pain has progressed over the last 10 hours and is associated with anorexia and chills.
PM|afternoon|PM|217|218|PROCEDURES PERFORMED DURING THIS ADMISSION|Small right pleural effusion. Please see the admission history and physical for further details. Briefly, the patient is a 19-year-old female with no significant past medical history who reportedly took a few Tylenol PM for a headache. She continued to take these pills during the course of the night and was found by her mother next morning confused and with slurred speech.
PM|afternoon|PM|148|149|CURRENT MEDICATIONS|2. Aspirin 81 mg p.o. daily. 3. Propafenone 300 mg p.o. daily. 4. Potassium chloride 10 mEq p.o. daily. 5. Simvastatin 40 mg p.o. daily. 6. Tylenol PM 2 p.o. each day at bedtime. 7. Lunesta 2 mg 1 p.o. each day at bedtime. 8. Prednisone 10 mg p.o. daily. 9. Augmentin 875 mg p.o. b.i.d. IMMUNIZATION STATUS: He is current on his flu shot and pneumovax within the past year.
PM|afternoon|PM.|129|131|PLAN|Will continue with sub-Q insulin at this point and IV fluids. Will await ketones, serum lactate, and repeat electrolytes at 6:00 PM. Pulmonary to follow-up regarding pneumomediastinum.
PM|afternoon|PM.|80|82|DISCHARGE MEDICATIONS|2. Ferrous gluconate 325 b.i.d. 3. Insulin 26 units Novolin 26 q AM, 12 units q PM. 4. Combivent 2 puffs q.i.d. 5. Cozaar 50 mg q day. 6. __________1 gram PO q day. 7. Lopressor 50 mg b.i.d.
PM|afternoon|PM.|194|196|DISCHARGE MEDICATIONS|The decision was made to discharge her to home. DISCHARGE MEDICATIONS: 1. Prenatal vitamins. 2. Insulin 20 units NPH and 10 units regular in the AM, and 14 units NPH and 10 units regular in the PM. FOLLOW-UP: She was instructed to follow-up with her primary doctor in six weeks and to follow-up with Endocrine regarding her blood sugars.
PM|afternoon|P.M.|153|156|HISTORY OF PRESENT ILLNESS|The first two were not helpful, so a couple of hours later, he took two more. Over the course of the next day, he thinks that he took perhaps 12 Tylenol P.M. He also took some of his girlfriend's trazodone to help him sleep. He denies that there was ever any suicidal ideation or intention.
PM|afternoon|P.M.|132|135|HOSPITAL COURSE|This resulted in delivery of a viable female infant from the frank breech position, left sacrum anterior. Delivery occurred at 4:00 P.M. The infant had one and five minute Apgars of 8 and 9, and weighed 5 lb 9 oz. Operative procedure was uncomplicated with estimated blood loss of 700 cc.
PM|physical medicine and rehabilitation:PMR|PM|263|264|HOSPITAL COURSE|By the time of discharge, the patient was tolerating regular diet, voiding spontaneously, having good bowel function, had fairly good pain control, and was wearing his TLSO brace and ambulating appropriately. The patient was seen by home health care services and PM and R, PT and OT during his hospital stay. DISCHARGE EXAMINATION: Vital signs: He is afebrile. His vital signs are stable.
PM|afternoon|P.M.|227|230|ENDOCRINE AND DIABETES|This pattern was causing problems with overnight coverage by other physicians who would give very large doses of Regular insulin which would then cause the patient to go low with sugars in the 50's at midnight. By breaking the P.M. high peaks I have been able to maintain sugars in the 100 range for the past 24 hours. The Lantus insulin dose was increased to 35 units at HS.
PM|afternoon|PM|181|182|DISCHARGE INSTRUCTIONS|6. Provera 2.5 mg PO q.d. 7. ASA 81 mg PO q.d. DISCHARGE INSTRUCTIONS: 1. The patient is discharged to home. 2. Follow-up appointment with Diabetic Teaching Nurse on Monday at 1:30 PM at the Learning Center. 3. Follow-up care with her primary physician, Dr. _%#NAME#%_ _%#NAME#%_, in approximately one month. 4. Draw a TSH level in approximately one month, to follow-up high normal TSH serum levels.
PM|afternoon|P.M.,|314|318|MEDICATIONS|PAST MEDICAL HISTORY: Aortic stenosis, mental retardation, Down's syndrome, obsessive compulsive features and oppositional behavior improving on Risperdal, talipes equinovarus, intermittent urinary incontinence, edentulous state, chronic constipation. MEDICATIONS: Paxil 30 mg p.o. daily, Risperdal 1 mg p.o. each P.M., Cetaphil to arms, hands, and feet after shower, Silicone ear plugs to wear during shower and when in water, Senokot tablets one p.o. on alternate days for constipation, atenolol 25 mg p.o. daily.
PM|afternoon|P.M.,|235|239|PLAN|PLAN: Will admit to Fairview Ridges Hospital for pain management, IV Dilaudid 1 to 2 mg IV q 3 hours p.r.n., IV hydration normal saline 150 an hour. Also, continue with the Dilantin - she is taking 200 mg in the A.M. and 250 mg in the P.M., and Zofran 4 mg q.6.h.
PM|afternoon|P.M.|154|157|MEDICATIONS|7. Celexa 20 mg p.o. q.day. 8. Colace 100 mg p.o. b.i.d. 9. GenTeal eye drops one drop into both eyes q.i.d. 10. Metformin 500 mg p.o. b.i.d. 11. Refresh P.M. eye drops to both eyes q.h.s. 12. Senokot two tablets q.day. 13. Sorbitol 70% solution 30 cc p.o. q.day. 14. Zyprexa 2.1 mg p.o. q.12h. and 7.5 mg p.o. q.h.s.
PM|afternoon|P.M.|215|218|DISCHARGE MEDICATIONS|The patient's right shin abrasion requires no dressing and the right lateral malleolus wound will be cleansed daily with soap and water and then dressed with Allevyn foam dressing. DISCHARGE MEDICATIONS: 1. Tylenol P.M. 500 mg p.o. q.h.s. 2. Allopurinol 100 mg p.o. q.d. 3. Buspar 10 mg p.o. b.i.d. 4. Advair (100/50), one puff b.i.d. 5. Paxil 40 mg p.o. q.d.
PM|afternoon|P.M.|313|316|HOSPITAL COURSE|Family was present most of the morning. When they returned on _%#DDMM2002#%_ at 1:25 P.M., the patient was found with no spontaneous respirations or heart sounds, did not respond to painful stimuli, pupils were fixed and dilated. She was documented to be a DNR/DNI. Death was pronounced on _%#DDMM2002#%_ at 1:25 P.M. Family was notified by the nursing staff and the primary physician's office was notified.
PM|afternoon|PM|199|200|HISTORY OF PRESENT ILLNESS|She reports that the current headache started around _%#MM#%_ _%#DD#%_ and has been fairly constant. It has not remitted, but the intensity has waxed and waned intermittently. She used some Excedrin PM without success for the first week, then was started on Ultram and Tylenol by her primary physician with some improvement getting her pain from 10/10 to around 7/10.
PM|afternoon|P.M.|229|232|HISTORY OF PRESENT ILLNESS|DOB: _%#DDMM1941#%_ CHIEF COMPLAINT: Severe dizziness and nausea. HISTORY OF PRESENT ILLNESS: This 61-year-old woman had been in her usual health until she noted a very abrupt onset of profound dizziness and nausea at about 6:30 P.M. She had been seated in a rocking chair in her home doing some hand stitching on a craft type of project. She attempted to get up and felt severe dizziness, nausea, and a sense of visual spinning and "staggered" right back into her chair.
PM|afternoon|P.M.|257|260|HOSPITAL COURSE|On the evening of _%#DDMM2003#%_, the patient underwent primary low segment transverse cesarean section under spinal anesthetic. Operative findings included clear amniotic fluid and infant presenting direct occiput posterior with delivery occurring at 8:51 P.M. on _%#DDMM2003#%_, eleven minutes following skin incision. The infant delivered as a male and had one and five minute Apgars of 9 and 9, weighing 8 lb 2 oz.
PM|afternoon|PM|141|142|ALLERGIES|Lopid 600 bid and Atenolol 50 daily. ALLERGIES: ASPIRIN - ULCER. TEQUIN - LOW BLOOD SUGAR. CEPHALOSPORINS - DIARRHEA, AMITRIPTYLINE, TYLENOL PM AND LATEX. PAST FAMILY HISTORY: The patient notes that her daughter has diabetes.
PM|afternoon|PM.|211|213||He had loss of bowel and bladder function. He was treated in the hospital with t-PA and subsequently Heparin and improved rapidly. He was on no medications as an outpatient other than p.r.n. Centrum and Tylenol PM. The patient has a history of smoking. He had pneumonia in the past. He had no prior history of deep venous thrombosis or family history of PE.
PM|afternoon|P.M.|146|149|MEDICATIONS|6. Potassium 10 mEq q.day. 7. Flomax 0.4 mg two q.day. 8. Combivent two puffs q.i.d. 9. Aspirin 81 mg q.day. 10. Lipitor 40 mg q.day. 11. Tylenol P.M. p.r.n. 12. Guaifenesin 200 mg one b.i.d. HABITS: Does not smoke or drink. FAMILY HISTORY: Mother had MI, daughter and sister with diabetes.
PM|afternoon|PM|481|482|DISCHARGE MEDICATIONS|Atenolol was stopped and she was placed on diltiazem. By day #5 of hospitalization, her breathing improved significantly and it was decided to transfer her to transitional care to improve her weakness with physical therapy and continued cares. DISCHARGE MEDICATIONS: ____________ 8 70 mg one p.o. q week, aspirin 325 mg p.o. q day, cefuroxime 250 mg p.o. b.i.d., diltiazem SR 240 p.o. q day, __________ 220 mcg two puffs with spacer p.o. b.i.d., Lasix 40 mg p.o. q day, __________ PM one neb p.o. t.i.d., Xopenex one neb p.o. t.i.d., _________ 50 mg p.o. q day, ____________ 10 mg p.o. q.P.M., nicotine gum 4 mg p.r.n., Tylenol 500 mg one to two q 4-6 hours p.r.n. for arthritis.
PM|afternoon|PM.|161|163|MEDICATIONS|2. Xanax 0.50 mg PO t.i.d. prn anxiety. 3. Klonopin 0.50 mg PO q.h.s. prn insomnia. 4. Digoxin 0.125 mg PO q day. 5. Spironolactone 50 mg PO q AM and 25 mg PO q PM. 6. Norvasc 5 mg PO b.i.d. 7. Cozaar 50 mg PO b.i.d. 8. Aspirin 325 mg PO q day. 9. Amiodarone 200 mg PO b.i.d.
PM|afternoon|P.M.|265|268|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|She also was no longer conversant. At this time, we all decided that it was time to discontinue her dopamine and antibiotics and direct her care only at comfort measures. Over the next 1-1/2 days, she continued to decline and she passed away this afternoon at 1:05 P.M. Her family was present at the time of her passing. Time and cause of death are mentioned above.
PM|afternoon|PM|174|175|CURRENT MEDICATIONS|1. Mastoid surgery almost 80 years ago. 2. Vertebroplasty. ALLERGIES: The patient reports she is allergic to codeine. CURRENT MEDICATIONS: 1. Lisinopril 5 mg q.d. 2. Tylenol PM 2 p.o. q.h.s. 3. Aleve 2 p.o. q.d. FAMILY HISTORY: Unremarkable. SOCIAL HISTORY: The patient is widowed x 8 years.
PM|physical medicine and rehabilitation:PMR|PM|172|173|HOSPITAL COURSE|The patient was started on Neurontin, which provided significant relief of his symptoms. The patient was evaluated by Physical Therapy and Occupational Therapy, as well as PM and R Service while in the hospital, who recommended the patient undergo further rehabilitation. By the time of discharge, the patient demonstrated 5/5 strength in the biceps, triceps, hand intrinsics, and wrist flexion and extension bilaterally.
PM|afternoon|PM|155|156|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Lexapro 10 mg p.o. q day. 2. Lisinopril/HCTZ 20/25 one tablet p. o. q day. 3. Ativan prn as dosed prior to admission. 4. Tylenol PM q h.s. prn. 5. Zocor 20 mg, 0.5 tab p.o. q h.s. DISPOSITION: The patient is to follow up with her primary care MD, Dr. _%#NAME#%_ in one week, earlier prn.
PM|afternoon|PM|208|209|DISPOSITION|Antibiotics and Acyclovir were stopped after 48 hours. Ongoing problems and suggested management: 1. Nutrition: _%#NAME#%_ was discharged on PM 60/40 formula and breastmilk. If her phosphorus normalizes, the PM 60/40 may be discontinued. 2. Endocrine: _%#NAME#%_ is being sent home on Calcium and Vitamin D supplements. Her calcium and phosphorus levels should be rechecked within 2 -3 days of discharge.
PM|physical medicine and rehabilitation:PMR|PM|266|267|ADMISSION PHYSICAL EXAMINATION|HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted to the Neurology Service, and his first dose of Tegretol was held because of an elevated level of 13.9. He did show very gradual improvement throughout his stay. He was seen by Occupational Therapy, Physical Therapy, and PM and R. Further examination and history taking revealed that these spells had happened every few months over the past 10 years, and he was usually left with some degree of residual weakness at least for a few days thereafter.
PM|afternoon|P.M.|183|186|CURRENT MEDICATIONS|4. Calcium carbonate with vitamin D 600/200 mg international units one tablet p.o. b.i.d. 5. Vitamin B12 1000 mcg/1-mL injections every Tuesday. 6. Fish oil 1000 mg capsule b.i.d. 7. P.M. compound nutrient six capsules p.o. q.h.s. (it is composed of 2 mg of folic acid, 400 mg of magnesium oxide, 500 mg of niacin, and 400 international units of vitamin E).
PM|afternoon|P.M.|111|114|MEDICATIONS|MEDICATIONS: Medicines prior to admission included: 1. Zantac 150 mg b.i.d. 2. Ativan 0.5 mg t.i.d. 3. Tylenol P.M. 2 tablets q.h.s. 4. An over-the-counter estrogen, Estroven 1 tablet q.h.s. (apparently a synthetic soy product). FAMILY HISTORY: Family history of mental health and chemical dependency problems is denied.
PM|afternoon|PM,|424|426|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Reveals hypertension, a history of cerebrovascular accidents, adult asthma, long history of cigarette smoking until _%#MM#%_ of 2001, a tremor in the right hand reduced by Sinemet, status post hysterectomy, new and progressive incontinence, borderline hypothyroidism, "weak joints", dentures, macular degeneration, cataract in the left, and chronic insomnia. Nonpsychiatric medications include Tylenol PM, Premarin, prenatal vitamins, Tylenol Extra Strength, Sinemet CR 25/100 b.i.d., aspirin, Imdur, Azmacort inhaler, Ditropan, atenolol. FAMILY HISTORY: Of mental health and chemical dependency problems reveals a strong family history of suicide in a sister, a maternal aunt, a maternal great uncle, and a stepbrother, biological relationship, if any, unclear.
PM|afternoon|PM.|153|155|HISTORY OF PRESENT ILLNESS|She has had recent suicidal without a plan. She denies suicidal ideation currently. She did state that at the age of 17 years, she took too many Tylenol PM. She was not treated. She often has anxiety after drinking. She has been increasingly worried, restless and agitated. She has a history of panic attacks that occur mainly after a day of drinking.
PM|afternoon|PM|173|174|CURRENT MEDICATIONS|3. Fosamax 75 mg once a week. 4. Vitamin A 8000 International Units one tablet daily. 5. Vitamin B6 50 mg p.o. b.i.d. 6. Melatonin one to two tablets p.o. q.h.s. 7. Tylenol PM one to two tablets p.o. q.h.s. 8. Calcium one tablet p.o. daily. ALLERGIES: 1. Penicillin causes swelling in the fingers and feet.
PM|afternoon|PM.|251|253|NONPSYCIATRIC MEDICATIONS|PAST MEDICAL HISTORY: Pertinent for vascular dementia, anemia, multinodular goiter, abdominal pain, history of frequent urinary tract infections, incontinence of stool and urine. NONPSYCIATRIC MEDICATIONS: 1. Aspirin. 2. Multiple vitamins. 3. Tylenol PM. 4. Metamucil. FAMILY HISTORY: None known of mental health and chemical dependency problems.
PM|afternoon|PM|152|153|DISCHARGE  MEDICATIONS|8. Synthroid 88 mcg p.o. q. Monday, Tuesday, Wednesday, Thursday, Friday, Saturday and 132 mcg p.o. on Sundays. 9. Cozaar 50 mg p.o. daily. 10. Tylenol PM 1-2 tabs p.o. each day at bedtime p.r.n. for insomnia. 11. Prednisone 5 mg p.o. daily. 12. Compazine 5-10 mg p.o. q.6 h. p.r.n. for nausea or vomiting.
PM|afternoon|PM.|196|198|HISTORY OF PRESENT ILLNESS|She also began to have frequent falls and was facing several stressors, was evicted, car was repossessed yesterday and decided to get help for herself. She also has been taking Ativan and Tylenol PM. She also has long-standing history of depression even before she started she drink and she reports when she is depressed she has problems with sleep, energy, appetite, interest, motivation and concentration.
PM|afternoon|PM|246|247|HISTORY|Discharge diagnoses of Posttraumatic Stress Disorder, Major Depressive Disorder versus Bipolar Disorder and Borderline Personality Disorder. Approximately 2 months ago admitted to the Intensive Care Unit at North Memorial subsequent to a Tylenol PM overdose. The patient indicates she did receive an acetylcysteine. No apparent lingering sequela. Indicates that she has been off her medications for approximately 1 week.
PM|afternoon|P.M|232|234|ASSESSMENT|TSH reflex of 2.34. ASSESSMENT: 36-year-old female admitted with the following: 1. Major depressive disorder versus bipolar illness admitted with decompensation. Issue of medication noncompliance. Deferred to Psychiatry. 2. Tylenol P.M overdose 2 months ago with apparent hepatotoxicity without lingering clinical sequela. 3. Morbid obesity with gastric bypass 1999 followed by revision x2.
PM|afternoon|P.M.|127|130|MEDICATIONS|MEDICATIONS: 1. Allegra 180 a day 2. Crestor 10 mg a day 3. Vitamin E 4. Multi-vitamin 5. Aspirin, which is on hold 6. Tylenol P.M. PAST SURGICAL HISTORY: 1. Appendectomy at age 19.
PM|afternoon|PM.|188|190|NEUROLOGY CONSULTATION|His Gabitril level at this point is pending. The patient is admitted because of a prolonged postictal state post seizure. He was described as combative. He had a seizure on _%#DDMM2003#%_ PM. He was found by his roommate around 2200 drowsy and combative. He was given Ativan. His medications include Zyprexa, trazodone, Paxil, Gabitril, and Effexor.
PM|afternoon|PM.|307|309|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 36-year-old female admitted to station 22 for evaluation and treatment of depression following a suicide attempt by ingesting Tylenol. The patient had been in her hometown of _%#CITY#%_, Nebraska, when she overdosed on approximately 14 tablets of 500 mg Tylenol PM. Then 12 or more hours passed between the time of her ingestion and her presentation to the emergency room at which time she was noted to have markedly elevated liver function tests and was admitted to the ICU to begin Mucomyst.
PM|afternoon|PM|131|132|HISTORY OF PRESENT ILLNESS|The patient says that over the last week he took a single dose of Percocet, a single dose of Vicodin, and a single dose of Tylenol PM at different times during the last week. He does, as mentioned, use IV heroin daily and has used intermittent IV cocaine, most recently being 3 nights ago, the night before being admitted here.
PM|afternoon|P.M.|168|171|HISTORY  OF PRESENT ILLNESS|I was asked by Dr. _%#NAME#%_ to see the patient for internal medicine consult. The patient was hospitalized at Mercy Hospital on _%#DDMM2007#%_ secondary to a Tylenol P.M. overdose. The patient states he took a large amount of Tylenol P.M. and does not remember the exact dose. He was treated with Mucomyst per the documentation that was sent with the patient from Mercy Hospital.
PM|afternoon|PM.|172|174|CURRENT MEDICATIONS|2. Hysterectomy. CURRENT MEDICATIONS: 1. Fosamax. 2. Nexium. 3. Triamterene/hydrochlorothiazide. 4. Os-Cal. 5. Multivitamin. 6. Zocor. 7. Trazodone. 8. Reglan. 9. Excedrin PM. ALLERGIES: Codeine. SOCIAL HISTORY: She denies use of tobacco.
PM|afternoon|PM.|254|256|HISTORY OF PRESENT ILLNESS|She has had 6 mental health hospitalizations at University of Minnesota Medical Center, _%#COUNTY#%_ _%#COUNTY#%_ Medical Center, and Mercy Medical Center. Medication compliant. Approximately 6 days prior to admission the patient overdosed on 13 Tylenol PM. She indicates that she slept for 27 hours; subsequent nausea with dry heaves, since resolved. No other active self-harm. PAST MEDICAL HISTORY: 1. Motor vehicle accident _%#DDMM2003#%_ with the following sequelae: A) Multiple fractures involving the right ankle, left upper extremity, pelvis, and left hip (question dislocated).
PM|afternoon|PM|243|244|MEDICATIONS AT HOME|LYMPHATIC: Negative for known adenopathy and negative for lymphedema. PSYCHOLOGICAL/SOCIAL: Negative for depression or seizure disorder. MEDICATIONS AT HOME: 1. Glyburide 0.625 mg. 2. Metformin 1000 mg b.i.d. 3. Zocor 80 mg daily. 4. Excedrin PM 2 tabs p.r.n. 5. Excedrin 2 tabs p.r.n. 6. Multivitamins 1 tab daily. 7. Aspirin 81 mg daily. 8. Lisinopril 10 mg daily.
PM|physical medicine and rehabilitation:PMR|PM|103|104|FOLLOW UP|9. Senokot-S 1 to 3 p.o. daily to b.i.d. p.r.n. 10. Hydrochlorothiazide 12.5 mg p.o. daily. FOLLOW UP: PM and R followup will be on an as needed as basis.
PM|afternoon|PM|203|204|HISTORY|Fever is largely resolved on Tequin, and with leg elevation the leg edema has improved slightly and the erythema has improved as well. He still has some low grade fever with temp up to 100.3, brief last PM for example. No significant other new symptoms have occurred. He has a urinary catheter in place currently. PAST MEDICAL HISTORY: Pancytopenia as described above under workup, hypertension under good control, stroke in _%#MM#%_, 2001.
PM|afternoon|PM|202|203|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 17-year-old female admitted to station 4B for evaluation and treatment of depression. The patient describes overdosing o approximately 20 tablets of Tylenol PM on _%#DDMM2006#%_. She states about half an hour passed between the time of her ingestion until her arrival at the emergency department.
PM|afternoon|PM|155|156|MEDICATIONS|He does not use any tobacco or alcohol. ALLERGIES: Roxicet causes a rash. MEDICATIONS: 1. Lipitor 10 mg daily. 2. Metoprolol 50 mg twice daily. 3. Tylenol PM as needed for sleep. 4. Zantac 150 mg p.o. twice daily. 5. Lexapro 10 mg p.o. daily. 6. Senokot-S twice daily.
PM|afternoon|PM,|187|189|ALLERGIES|Novolin 70/30, 44 units in the morning and 22 in the evening. Lopid 600 mg b.i.d. Atenolol 50 q.d. ALLERGIES: SHE HAS ALLERGIES TO ASPIRIN, TEQUIN, CEPHALOSPORINS, AMITRIPTYLINE, TYLENOL PM, AND TO LATEX. SOCIAL HISTORY: She quit smoking many years ago. She denies any significant alcohol abuse.
PM|afternoon|P.M.|172|175|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ was admitted through the emergency room after developing acute abdominal pain. This pain began yesterday at about noon and worsened significantly about 7:00 P.M. last night after the patient attempted to eat dinner. Upon presentation to the emergency room at about 2:30 A.M. today, the patient had laboratories drawn which showed a hemoglobin which was elevated at 18.8, and a white count normal at 9300.
PM|afternoon|P.M.|181|184|INDICATIONS|Her GI history also includes a ruptured appendectomy with peritonitis in 2003 which required a long hospitalization, but ultimately she recovered. She has been taking both Excedrin P.M. and ibuprofen for migraine headaches for a longer period of time. MEDICATIONS: Her medicine list reveals also a variety of other medications including Prilosec.
PM|afternoon|PM|138|139|MEDICATIONS|3. Amitriptyline 5 mg q h.s. since 1984 for sleep. 4. Risperdal 3 mg q h.s. to help sleep since 1995. 5. Topamax 100 mg b.i.d. 6. Tylenol PM q h.s. ALLERGIES: Vicodin causes severe gastric distress.
PM|afternoon|P.M.|8|11|TIME|TIME: 4 P.M. REQUESTING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_. CHIEF COMPLAINT: Acute onset of left sided numbness with MRI evidence of right C3 intramedullary spinal cord inflammation. HISTORY OF THE PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 49-year- old right handed white female.
PM|afternoon|P.M.|239|242|HISTORY OF PRESENT ILLNESS|She has been afebrile. There are no obvious sources of infection except for a chest x-ray showing a questionable right middle lobe density. Her daughter-in-law indicates that she did complain of some left lateral abdominal/flank pain last P.M. which had not been an issue before, but her abdominal exam had been quite benign. An echocardiogram showed a 55% EF with no WMA's despite a slight rise in troponin to 0.45. The urine has been clear, although the urine output has diminished.
PM|afternoon|P.M.|201|204|MEDICATIONS|4. He had a DVT 10 years ago. MEDICATIONS: 1. Allopurinol. 2. Aranesp. 3 Avandia. 4. Ferrous gluconate. 5. Kayexelate. 6. Lasix. 7. Lisinopril.. 8. Multiple vitamins. 9. Sodium bicarbonate. 10.Tylenol P.M. SOCIAL HISTORY: He drinks a couple of beers a day.
PM|afternoon|PM|203|204|CURRENT MEDICATIONS|PAST SURGICAL HISTORY: 1. Cholecystectomy. 2. Cataract extraction. CURRENT MEDICATIONS: 1. Aspirin. 2. Celluvisc. 3. Doxycycline. 4. Enoxaparin. 5. Gatifloxacin. 6. Losartan. 7. Pantoprazole. 8. Refresh PM ointment. 9. Tizanidine. 10. Ceftazidime. 11. Acetaminophen. 12. Diazepam. 13. Diphenhydramine. 14. Senna. 15. Sorbitol. 16. Potassium. ALLERGIES: Augmentin. LABORATORY DATA: Prior urine culture was positive for Pseudomonas which was susceptible to ceftazidime.
PM|afternoon|PM.|420|422|ALLERGIES|She has chronic obstructive pulmonary disease, chronic renal failure, CHF, gout, impaired fasting glucose, CABG x2 vessels in 1986, stent placement in 1999, saphenous graft in 2000, TAH in 2004 and cholecystectomy in 1968. FAMILY HISTORY: Noncontributory. HEALTH HABITS: Nonsmoker, no alcohol. ALLERGIES: Vicodin with dizziness, adhesives with itching, penicillin with rash, codeine and tramadol with nausea and Tylenol PM. MEDICATIONS: 1. Zyloprim 100 mg once a day. 2. Colchicine 600 mcg p.o. once a day.
PM|afternoon|PM.|296|298|IMPRESSION/REPORT/PLAN|I discussed the case with Dr. _%#NAME#%_. Addendum: Dr. _%#NAME#%_ and I have a lengthy conversation with the family and patient regarding the above. They will discuss if further this evening. In addition, we have asked for an EP consult to go over things and provide their input on the need for PM.
PM|afternoon|PM.|144|146|MEDICATIONS|2. Imdur 30 mg a day. 3. Aciphex 30 mg daily. 4. Zyban one tablet b.i.d. 5. Premarin 1.25 mg a day. 6. Mysoline 100 mg in the AM, 250 mg in the PM. Since admission she has had a controlling of her heart rate.
PM|afternoon|PM|166|167|DISCUSSION|_%#NAME#%_ was transferred here from Fairview Ridges Hospital emergency room, where she was assessed after she drank four large drinks of vodka, and took ten Tylenol PM and seven trazodone. She was hemodynamically stable throughout. She had a non-toxic post-ingestion Tylenol level. _%#NAME#%_ has complained intermittently of pain in her nose and the back of her head since admission here.
PM|afternoon|PM|128|129|MEDICATIONS AT TIME OF ADMISSION|1. Aspirin 81 mg p.o. daily. 2. Senokot p.r.n. 3. Multiple vitamins 1 tablet p.o. daily. 4. Ultram 50 mg p.o. daily. 5. Tylenol PM p.r.n. 6. Lasix 40 mg p.o. b.i.d. 7. Hydralazine 10 mg p.o. daily. 8. Allopurinol 100 mg p.o. b.i.d. 9. KCL 10 mEq p.o. b.i.d.
PM|afternoon|PM|264|265|MEDICATIONS|2. D and C endometrial biopsy, as above. SOCIAL HISTORY: The patient lives with her son and daughter. She requires a great deal of care, as she seems to be physically impaired from what her son describes today as "arthritis in her left knee." MEDICATIONS: Tylenol PM p.r.n. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: GENERAL: The patient was an obese woman. It was difficult to ascertain her mental state given the language barrier.
PM|afternoon|PM|187|188|ADMISSION MEDICATIONS|ADMISSION MEDICATIONS: 1. Effexor. 2. Seroquel. 3. Trazodone. 4. Zyprexa. 5. Flovent 110 mcg 2 puffs b.i.d. 6. Albuterol inhaler 2 puffs q.i.d. p.r.n. for shortness of breath. 7. Tylenol PM for sleep. ALLERGIES: Penicillin causes anaphylactic reaction.
PM|afternoon|PM|186|187|HISTORY OF ALCOHOL AND DRUG USE|His heaviest use has been the last 5 years. He drinks at least 6 drinks 4 nights-plus per week. His last reported use was _%#DDMM2007#%_. He smoked marijuana in college. He uses Tylenol PM occasionally at night. SUMMARY OF CHEMICAL DEPENDENCY SYMPTOMS ACKNOWLEDGED BY CLIENT: This client believes he has a problem with chemicals and that it has been a problem for around 5 years.
PM|afternoon|P.M.|168|171|CURRENT MEDICATIONS|No alcohol or drug use. ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: 1. Aldomet 250 mg p.o. daily. 2. Prevacid 1 tablet as needed for heartburn. 3. Tylenol P.M. as needed for sleep. PHYSICAL EXAMINATION: VITAL SIGNS: The patient is afebrile, 98.2, blood pressures ranging from 142/87 to 129/67 during her admit here.
PM|afternoon|PM|166|167|MEDICATIONS|MEDICATIONS: Prior to surgery: 1. Fosamax 70 mg once a week. 2. Calcium supplements 600 mg, 2 daily. 3. Glucosamine 1000 mg, 2 daily. 4. Fish oil 1 daily. 5. Tylenol PM 2 at h.s. 6. Vicodin 1-2 q. 4-6 hours p.r.n. pain. 7. Darvocet 2 q. 4-6 hours p.r.n. pain. 8. Multivitamins once a day.
PM|physical medicine and rehabilitation:PMR|PM|150|151|ASSESSMENT/PLAN|6. History of cholecystectomy in the past. 7. Autoimmune hepatitis in the past. 8. Cognitive deficits secondary to #1: Speech Therapy, as well as the PM and R team will evaluate and treat/manage as needed. 9. Fall risk secondary to #1. 10. Deconditioning and left-sided weakness secondary to #1: Again, PM and R and Rehab will begin today.
PM|afternoon|P.M.|162|165|MEDICATIONS|4. Glucophage 500 mg p.o. b.i.d. 5. Aspirin 81 mg p.o. q. day. 6. Prozac 20 mg p.o. q. day. 7. Ibuprofen 400 mg p.o. b.i.d. 8. Ultracet 1 p.o. q. day. 9. Tylenol P.M. 2 p.o. q.h.s. FAMILY HISTORY: Noncontributory. HABITS: She does not smoke but does drink one alcohol drink per day.
PM|afternoon|P.M.,|233|237|MEDICATIONS|His wife, a son and a daughter are present during this visit. MEDICATIONS: Per the medication administration records from the care center, the patient received hydrocortisone cream as needed, Tylenol as needed, iron sulfate, Tylenol P.M., prednisone 5 mg daily, Seroquel 25 mg every evening, multivitamins. ALLERGIES: HE IS ALLERGIC TO PENICILLIN. REVIEW OF SYSTEMS: Not obtainable from the patient but the information was obtained as above from the family.
PM|physical medicine and rehabilitation:PMR|PM|237|238|HISTORY OF PRESENT ILLNESS|The patient has several medical complaints. The patient states she has been suffering from chronic radicular low back pain since suffering a fall at work in _%#DDMM2006#%_. She states she was seen by a chiropractor and was referred to a PM and R physician. She had been treated sporadically with Tylenol No. 3 and Vicodin, although it is not clear to me how recently she may have used these medications.
PM|afternoon|PM|269|270|MEDICATIONS|FAMILY HISTORY: Significant for heart disease in her father at age 64. Her mother had heart failure later in life. MEDICATIONS: Prior to admission included Prinivil 10 mg q.d., Lipitor 10 mg p.o. q.d., Celebrex 200 mg p.o. p.r.n., Prilosec 20 mg p.o. q.d., and Tylenol PM one to two p.o. q.h.s. p.r.n. sleep. ALLERGIES: She has allergies to sulfa and to Percocet. EXAMINATION: Today, her blood pressure is 145/70, heart rate 80.
PM|afternoon|PM|466|467|CURRENT MEDICATIONS|Father has atherosclerotic cardiovascular disease at age 81. The patient has two sons, ages 24 and 26, one who smokes and the younger one has type II diabetes mellitus. ALLERGIES: Codeine. CURRENT MEDICATIONS: Methotrexate 2.5 mg, six tablets p.o. q Sunday, Vioxx 25 mg q.d., artificial tears p.r.n., Zestril 5 mg q.d., Pravachol 20 mg q h.s., Prilosec 20 mg q.d., Miacalcin nasal spray one spray in one nostril q.d. when she remembers, calcium 500 mg q.d., Tylenol PM p.r.n. PAST MEDICAL HISTORY: 1. Rheumatoid arthritis diagnosed when the patient was 14 years of age.
PM|afternoon|PM.|125|127|MEDICATIONS|MEDICATIONS: 1. Triamterene once a day. 2. Oscal. 3. Glucosamine. 4. Levaquin and Flagyl po. 5. Reglan. 6. Tylox. 7. Tylenol PM. HEALTH HABITS: She is a non-smoker. She has no history of alcoholism.
PM|afternoon|PM,|260|262|HISTORY OF PRESENT ILLNESS|History is provided by the mother and the chart. _%#NAME#%_ has a past medical history of eczema, recurrent otitis media with a sixth episode onset last night, and sickle cell trait. He was in his usual state of health last night and put to bed, when around 8 PM, the mother noted rhythmic leg movement with rapid extension, typically together but occasionally with either leg not in synchrony and rare occasional movements of the shoulder with a slight tendency to turn to one side.
PM|afternoon|P.M.|181|184|ASSESSMENT/PLAN|Otherwise, she has no physical complaints regarding her left breast. Her hair has grown in nicely. Her medications are Tamoxifen 20 mg q. day, melatonin at h.s., occasional Tylenol P.M. p.r.n. and Pepcid on rare occasions, as well. On exam today, she weighed 203 pounds. Blood pressure was 124/86.
PM|afternoon|PM|231|232|DISCUSSION|Detailed attention has to be paid to allowing him to sleep at night without interruption and to minimize sound and light stimulation. One simple recommendation might be the use of an eye mask at night. The use of prednisone in the PM is a possible issue and using it as early in the afternoon as possible might be another minor suggestion. The other issue that Dr. _%#NAME#%_ made reference to in my conversation with her today had to do with the patient's wife's problems in dealing with this chronic illness and it was requested that possibly we provide some forms of support for the wife.
PM|afternoon|PM|192|193|HISTORY OF PRESENT ILLNESS|She was discharged approximately two weeks ago. She has been compliant with her medication regimen. At approximately 9 p.m. on _%#DDMM2005#%_, the patient ingested an entire bottle of Tylenol PM tablets consisting of approximately 50 grams of acetaminophen. She has been increasingly obtunded with decreased responsiveness. She is tachycardic and normotensive with marked tachypnea.
PM|afternoon|P.M.|285|288|DISCUSSION|Please see Dr. _%#NAME#%_'s notes and the charting for details regarding the patient's psychiatric history and the circumstances leading up to admission. _%#NAME#%_ denies acute concerns, denies past hospitalizations. He stated after admission that he took approximately eight Tylenol P.M. approximately two nights ago. There is some question that he may have actually taken these pills last night. _%#NAME#%_ denies nausea, vomiting, abdominal pain. PAST MEDICAL HISTORY: _%#NAME#%_'s past medical history is remarkable for depression, for which he takes Wellbutrin 150 mg 1 to 2 times per day.
PM|afternoon|P.M.,|114|118|CURRENT MEDICATIONS|5. Oxybutinin, 10 mg at breakfast and at bedtime. 6. Tylenol, two at breakfast and one in the evening. 7. Tylenol P.M., two at night. 8. Stool softeners and liquid which sounds like lactulose. ALLERGIES: None. SOCIAL HISTORY: He lives with his wife. He is a retired farmer.
PM|afternoon|PM,|196|198|HISTORY OF THE PRESENT ILLNESS|She was received in transfer from _%#COUNTY#%_ _%#COUNTY#%_'s Hospital where she had been observed overnight in the ICU following a multi-substance ingestion, including Zoloft, ibuprofen, Tylenol PM, and minocycline. Her labs are reviewed from her presentation and revealed a four hour Tylenol level of 15.4 and salicylate level was less than 0.5. She developed no other metabolic derangement.
PM|afternoon|PM|113|114|ADMISSION MEDICATIONS|8. Digoxin 0.125 mg q. day. 9. Centrum silver. 10. Tricor 145 mg q. day. 11. Valsartan 80 mg q. day. 12. Tylenol PM p.r.n. 13. Furosemide 40 mg tablets one and a half in the morning, one-half in the evening. 14. Glipizide 5 mg q. day. PHYSICAL EXAMINATION: GENERAL: This is a pleasant elderly patient appearing his stated age.
PM|afternoon|PM|216|217|IMPRESSION|IMPRESSION: This gentleman presents with transient episode of unsteadiness without any other accompaniment of neurologic symptoms and stable blood pressure. I wonder if he may have had drug intoxication with Tylenol PM rather than true transient ischemic attack. At this point, given the presence of the risk factor such as hypertension, I would like to obtain carotid ultrasound to make sure that he does not have carotid stenosis.
PM|afternoon|PM|224|225|HISTORY OF PRESENT ILLNESS|The patient's friend called the police who came to her house and then transferred her to Fairview _%#CITY#%_ emergency department for further evaluation. The patient also admitted at her intake that she had taken 10 Tylenol PM on _%#DDMM2005#%_. That had not been reported and there were no issues after the attempted overdose. She has had some self-injurious behavior, cutting her arms. Internal Medicine consultation was requested to follow this patient medically and for a routine history and physical.
PM|afternoon|P.M.|196|199|MEDICATIONS|1. "Thirty eight gastrointestinal surgeries." She at one time, did have a cholecystectomy but no longer has that. 2. Bladder repair. MEDICATIONS: 1. Lithium. 2. Trazodone. 3. Klonopin. 4. Tylenol P.M. p.r.n. 5. Imodium p.r.n. ALLERGIES: Betadine. SOCIAL HISTORY: The patient admits to smoking four packs per day, and drinks one-half to one quart of alcohol per day.
PM|afternoon|P.M.|144|147|DISCUSSION|6) Gabapentin 600 mg twice a day. 7) Isosorbide 30 mg daily. 8) Nitroglycerin 0.4 mg sublingually p.r.n. 9) Senokot one tablet every day in the P.M. 10) Tricor 145 mg daily. 11) Zetia 10 mg daily. 12) Ativan 1 mg twice a day. It is unknown whether the patient has a history of gout in the past.
PM|afternoon|P.M.|191|194|MEDICATIONS|Please refer to our original consultation note dated _%#DDMM2005#%_ for further details. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Multivitamin. 2. Supplemental calcium. 3. Tylenol P.M. PHYSICAL EXAMINATION: Weight 126.5 pounds; height 5 feet 2 inches. Blood pressure 127/72, pulse 82. GENERAL: Thin, alert, pleasant female in no distress.
PM|afternoon|PM.|139|141|HISTORY|He indicates a DWI in _%#MM#%_ of this year and again on _%#DDMM2004#%_. On _%#DDMM2004#%_, the patient overdosed on 12 tablets of Tylenol PM. He had subsequent nausea and vomiting with production of pill fragments. He did not seek medical attention at that time. Clinically, he did well without further nausea, vomiting, or abdominal pain.
PM|afternoon|PM|167|168|ASSESSMENT|TSH 0.92 with GGT of 20. ASSESSMENT: This is a 23-year-old female admitted with the following: 1. Major depressive disorder. Details per Psychiatry. 2. Recent Tylenol PM (?) overdose without significant lingering clinical sequelae. No indication by labs of hepatotoxicity. 3. Sinus bradycardia clinically on exam.
PM|afternoon|PM|242|243|PAST MEDICAL HISTORY|Internal Medicine consult was requested for a general medical evaluation to follow this patient regarding her history of amenorrhea. PAST MEDICAL HISTORY: 1. Bipolar disorder, diagnosed in _%#MM#%_. 2. History of overdose x2, once on Tylenol PM and once on her prescription drugs. 3. History of a Staph infection in her right arm at age 10 where she underwent an I&D.
PM|afternoon|PM|144|145||5. His immunosuppression regimen has been CellCept 750 mg PO BID and prednisone 25 mg PO BID. - Decrease prednisone to 25 mg PO AM and 20 mg PO PM - Zenapax 1 mg/kg today 6. Overall, he has made significant progress.
PM|afternoon|PM|254|255|LABORATORY STUDIES|Glucose on admission in the hospital was 100. BUN was 34 and creatinine was 1.12. Phosphorus was slightly elevated at 4.9 and magnesium was normal. Amylase and lipase were both increased, significantly with lipase to 826 (reference range of 20-250). Her PM cortisol was elevated at 320.3 (reference range of 1.4-14). She had not had any imaging studies. MEDICATIONS ON ADMISSION TO HOSPITAL: Vancomycin, Compazine, Protonix, Ativan, CellCept and prednisone 5 mg per day.
PM|afternoon|PM|125|126||Review of urine output in the last hours 5 AM 425, 6 AM 475, 8 AM 160, 9 AM 375m 10 AM 850, 11 AM 950, noon 950, 2 PM 900, 3 PM 1200, 4 PM 900, 5 PM 100. She got DDAVP 0.5 mcg iv between the 4 and 5 PM urine output. We have no urine osmolality or serum Na data still.
PM|afternoon|PM|225|226|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is an 18-year-old female admitted to station 22 after being transferred from the medical unit at University of Minnesota Medical Center, Fairview, University Campus status post Tylenol PM and Celexa overdose. An internal medicine consultation was ordered by Dr. _%#NAME#%_ for a general medical evaluation. PAST MEDICAL HISTORY: 1. Major depressive disorder. 2. History of anxiety disorder.
PM|afternoon|PM,|283|285|HISTORY OF PRESENT ILLNESS|3. Premenstrual syndrome, on Mirapex. PATIENT IDENTIFICATION: This is a 39-year-old Caucasian woman. HISTORY OF PRESENT ILLNESS: Yesterday at about 3:00, the patient drank a large quantity of vodka, reportedly about a fifth, and shortly thereafter she took about 10 pills of Tylenol PM, which contains Tylenol 500 mg and Benadryl 25 mg in each pill. This was an attempt to commit suicide. In the original report, the overdose was listed as being around noon or 1:00.
PM|afternoon|P.M.|153|156|HISTORY OF PRESENT ILLNESS|She has not eaten since Saturday. There has been no urinary tract symptoms. Interestingly, the patient did have an attempt at endometrial biopsy at 3:00 P.M. on Friday. Apparently, the uterus could not be entered due to some problem with the cervix. On examination now, the patient is comfortable when she is not moving, but is in obvious distress if she moves or takes a deep breath.
PM|afternoon|PM|164|165|OUTPATIENT MEDICATIONS|5) Kidney bleed approximately 15-20 years ago which the patient states he has no residual symptoms. OUTPATIENT MEDICATIONS: 1) Sominex 3-4 tablets q hs. 2) Tylenol PM 3-4 tablets q hs. Patient states that he takes only one type of sleep aid at night. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: Patient reports drinking approximately a 12-pack of beer a day and has done so for the past 8-9 months.
PM|afternoon|PM|253|254|INDICATIONS|She tells me this bout started about 4 weeks ago with what she characterized as the viral GI symptoms and then and then resulted in intermittent vomiting and chest burning. Since she had no medication she did not take it, but she took up to #30 Tylenol PM a day. She had denies any Advil or aspirin use. PAST MEDICAL HISTORY: Her physical is complicated By her social history.
PM|afternoon|P.M.|175|178|MEDICATIONS|2. Hernia surgery. 3. Appendectomy. ALLERGIES: No known drug allergies. MEDICATIONS: Prior to hospital admission include: 1. Ambien, unknown dose. 2. Multivitamin. 3. Tylenol P.M. 4. Diovan 80 mg p.o. daily. 5. Lipitor 40 mg p.o. daily. 6. Coreg 25 mg p.o. daily. 7. Amiodarone 100 mg p.o. b.i.d. 8. Coumadin. 9. Sublingual nitroglycerin.
PM|afternoon|P.M.|210|213|MEDICATIONS|3. He has been treated for hypertension and hyperlipidemia. MEDICATIONS: At the time of admission included: 1. Atenolol. 2. Lovastatin. 3. Lasix. 4. A baby aspirin. 5. He also notes that he began using Tylenol P.M. over the past two weeks. FAMILY HISTORY: Negative. SOCIAL HISTORY: The patient is married. He has smoked up to three-packs per day for many years.
PM|afternoon|PM|133|134|CURRENT MEDICATIONS|3. Calcium 1200 mg p.o. daily. 4. Vitamin D 60 mg p.o. daily. 5. Aspirin 325 mg p.o. daily. 6. Tylenol 500 mg p.o. b.i.d. 7. Tylenol PM p.r.n. ALLERGIES: No known drug allergies. SOCIAL HISTORY: She is retired. She used to work as a bookkeeper.
PM|afternoon|PM.|186|188|ADMISSION MEDICATIONS|6. Left knee arthritis. 7. Hysterectomy. 8. Traumatic brain injury 1992 secondary to assault while hospitalized. ADMISSION MEDICATIONS: 1. 70/30 NPH/insulin 20 units q AM and 20 units q PM. 2. Aspirin 325 mg PO q AM. 3. Ativan 0.5 mg q AM. 4. Chlor-Trimeton 10 mg q AM. 5. Clozaril 100 mg b.i.d.
PM|afternoon|P.M.,|87|91|HISTORY OF PRESENT ILLNESS|That evening he ate at Taco Johns and then had ice cream following this. At about 8:00 P.M., he developed crampy abdominal pain that was diffuse and nonlateralizing. He initially felt the pain was tolerable, however around 1:00 A.M. it became much more severe and he presented to the emergency room for evaluation.
PM|afternoon|PM|143|144|HISTORY OF PRESENT ILLNESS|She has been on 5 mg of methadone q.i.d., oxycodone/acetaminophen 5/325 mg, 1-2 tablets every 6-8 hours. In addition, she also takes a Tylenol PM and Tylenol Arthritis 650 mg q. day p.r.n. The patient tells me that her low back pain has been still severe, on an average is 4/10 level, occasionally getting to an 8-9/10, particularly when she has been up and walking.
PM|afternoon|PM|171|172|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1. Cardizem CD 240 mg q.d. 2. Atenolol 50 mg q.d. 3. Glucophage 500 mg b.i.d. 4. Niaspan 1500 mg p.o. q.h.s. 5. Aspirin 325 mg p.o. q.h.s. 6. Tylenol PM 1-2 p.o. q.h.s. 7. Ocuvite 2 tabs p.o. b.i.d. PAST MEDICAL HISTORY: 1. Hypertension as above. 2. Tobacco abuse, quitting in 1986 after a 90-pack-year history.
PM|afternoon|P.M|277|279|HISTORY OF PRESENT ILLNESS|She is managed by Dr. _%#NAME#%_ with an estimated blood loss of 500 cc I was asked by Dr. _%#NAME#%_ to see this patient to evaluate her INR status, and manage her hypertension, rheumatoid arthritis, and osteoporosis. It was stated by the patient, and per nursing report last P.M that the patient received 10 mg of Coumadin. However, this is not charted in her medical administration records, and therefore we are unable to verify if she did in fact receive the Coumadin.
PM|afternoon|PM.|173|175|REVIEW OF SYSTEMS|She denies chest pain, shortness of breath, cough, diarrhea, constipation, melena, hematochezia, and urinary symptoms. She does report mild nausea. and no emesis since last PM. PHYSICAL EXAMINATION: In general she is in no acute distress.
PM|afternoon|PM|110|111|ADMISSION MEDICATIONS|3. Daypro 600 mg bid. 4. Ocuvite with lutein one bid. 5. Proscar 5 mg daily. 6. Toprol 25 mg one daily in the PM (this must be extended release). 7. Digoxin 0.25 mg daily. 8. Coumadin 2 mg daily. 9. Aldactone 25 mg daily. 10. Darvocet prn. 11. Extra Strength Tylenol prn.
PM|afternoon|P.M.|142|145|HISTORY OF PRESENT ILLNESS|He had two units of packed red blood cells transfused in a routine fashion yesterday, according to his wife. His transfusion lasted from 2:00 P.M. to 10:00 P.M. at night and when he arrived home he went straight to bed. His wife describes him as sleeping restlessly and muttering all night as if he could not get comfortable.
PM|afternoon|PM,|147|149|HISTORY OF PRESENT ILLNESS|The patient was examined on _%#DDMM2004#%_. The patient states she has been having difficulty sleeping and has been using over-the-counter Tylenol PM, Benadryl and ibuprofen, as sleep aids. Her only medical complaint today is menstrual cramps and is currently having her menstrual period.
PM|afternoon|PM|141|142|DISCUSSION|_%#NAME#%_ was transferred here from Methodist Hospital where she presented on _%#DDMM2000#%_ after ingesting approximately 30 to 40 Tylenol PM tablets. She had a significantly elevated Tylenol level but had normal liver function tests throughout. She was treated with Mucomyst and was transferred here for further psychiatric assessment.
PM|afternoon|P.M.|138|141|ASSESSMENT|Alkaline phosphatase 81, total bilirubin of 0.6. GGT of 100. ASSESSMENT: 29-year-old male admitted with the following: 1. Serious Tylenol P.M. overdose: A. Hepato toxicity, gradually improving with serial reduction in transaminase levels. B. No other significant lingering clinical sequela. 2. Major depressive disorder with history of ADHD.
PM|afternoon|PM.|150|152|HISTORY OF PRESENT ILLNESS|I was asked by Dr. _%#NAME#%_ to see this patient to address medical concerns. She stated that she had a sore throat and large amounts of emesis last PM. She was given some Zofran which did offer some improvement. She has not had any emesis today and she denies any current feelings of nausea.
PM|afternoon|PM|108|109||It is important that her oral intake be covered with novolog sq as ordered. 2. Tube feeling, cycling from 8 PM to 8AM. Last night, she required 19.5 extra units of IV insulin to cover this. She might have needed less than this had we prevented the initial spike with the start of the TF—by virtue of the way the orders were written the iv insulin rate didn’t increase until after she had a high glucose one hour into the TF.
PM|afternoon|PM|161|162||Change glucose monitoring to before meals, HS and 3 AM after IV insulin is stopped. b. Increase Lantus dose to 7 units/day, given at HS, lst dose _%#DDMM2007#%_ PM c. Increase NPH/Regular 70/30 insulin dose to 8 units sq to be given 10 minutes after start of nightly tube feeding, lst dose _%#DDMM2007#%_ PM
PM|afternoon|PM|271|272||Endocrine Attending note Gucose and insulin levels as indicated below are again located on multiple different areas of electronic chart, including clinical summary sheet and flow-sheet. Neither location has complete data set. 12 hour cyclinc TF continues, roughly 8 or 9 PM to 8 or 9 AM. _%#DDMM2007#%_ 183 at 0700 Novolog 2 at 0830 Novlog 5 prandial 183 at noon Novolog 2 138 at 1600 Novolog 4 at 2000 70/30 10 units at 2100 Lantus 7 units Novolog 3 units at 2141 _%#DDMM2007#%_ 394 at 0125- notation made that HS glucose not checked, 3 AM done early Novolog 3 at 0125 – this was given earlier than it should have been 253 at 0400—this was not covered as it should have been 316 around 0700 ?? I am getting this from the insulin record, I can’t find it on any glucose records Novolog 3 at 0707 Current orders are for Lantus 7 units q HS 70/30 10 units 10 minutes after start of TF Novolog 3 units 10 minutes after start of TF Novolog 1 unit/carb Novolog correction scale < 200 mg/dl 0 units 201-250 1 units 251-300 2 units >300 3 units Assessment /Plan 1.
PM|afternoon|PM,|134|136|MEDICATIONS|15. Papaya enzymes, seven tablets per day, for stool softening and digestive aid. 16. Ranitidine 75 mg p.o. b.i.d. p.r.n. 17. Tylenol PM, one to two tablets q.h.s. p.r.n. 18. Extra-strength Tylenol, one to two tablets q4h p.r.n. 19. Rolaids or Tums, one to two tablets p.r.n. dyspepsia.
PM|afternoon|PM.|234|236|OUTPATIENT MEDICATIONS|4. Depression with suicidal attempt. 5. Arthritis of the right knee, shoulder, with arthroscopy of the right knee secondary to torn meniscus, and ACL tear. 6. Tonsillectomy. 7. Hysterectomy in 1993. OUTPATIENT MEDICATIONS: 1. Tylenol PM. 2. Sodium 100 mg three tablets p.o. q.h.s. for constipation. 3. Methadone 5 mg b.i.d. for pain. 4. Prilosec 20 mg p.o. daily.
PM|afternoon|PM.|117|119|OUTPATIENT MEDICATIONS|6) Albuterol/ipratropium nebs q.i.d. 7) Multivitamins. 8) Calcium with D. 9) Vitamin A, E, C, B-12, B-6. 10) Tylenol PM. 11) Combivent metered-dose inhaler two puffs p.r.n. 12) Serevent metered-dose inhaler two puffs b.i.d. PAST MEDICAL HISTORY: 1) Chronic obstructive pulmonary disease; severe.
PM|afternoon|P.M.|180|183|HISTORY OF PRESENT ILLNESS|The patient also complains of occasional headache which Excedrin and Advil has helped with the migraines. The patient has also been having difficulty sleeping and she uses Tylenol P.M. or Benadryl. The patient also complains of sinus drainage, and palpitation. She states that her heart feels like it is racing while she is laying down.
PM|afternoon|P.M.|353|356|HISTORY OF PRESENT ILLNESS|REQUESTED BY: _%#NAME#%_ _%#NAME#%_, MD HISTORY OF PRESENT ILLNESS: The patient is a 31-year-old female admitted to station 10 for evaluation and treatment of depression and suicidal ideation. She was received in transfer from Fairview Lakes Hospital, where she had been admitted since _%#DDMM2004#%_ following a suicide attempt by ingestion of Tylenol P.M. Apparently was noted to be unresponsive and incoherent or thrashing while in bed with her boyfriend, after they had been drinking 8 or 9 glasses of wine.
PM|afternoon|PM.|213|215|CURRENT MEDICATIONS|Denies gallbladder disease, thyroid disease, seizure, tuberculosis or anemia. Unaware of diabetic retinopathy, peripheral neuropathy or retinopathy. ALLERGY: NKDA. CURRENT MEDICATIONS: 1. Geodon 20 mg 1 q AM, 1 q PM. 2. Nadolol 160 mg q day. 3. Amaryl 8 mg q AM. 4. Lamivudine 150 mg b.i.d. 5. Starvidine 40 mg b.i.d.
PM|afternoon|PM.|239|241|REVIEW OF SYSTEMS|The patient denies diarrhea, nausea, vomiting, or possible pregnancy. The patient is experiencing headaches everyday. Headaches appear to be consistent with tension headaches as they are pressure-like bilaterally and improved with Tylenol PM. The patient has been experiencing chest pain on her left side for the past 6 months to 1 year. It is noticeable when the patient is having difficulty breathing or with coughing.
PM|afternoon|PM,|124|126|NURSING HOME MEDICATIONS|ALLERGIES: No known drug allergies. NURSING HOME MEDICATIONS: 1. Sinemet 25/100 one tab q. 7:00 AM, 11:00 AM, 3:00 PM, 5:00 PM, 7:00 PM, and 10:00 PM. 2. Multivitamin one tab p.o. daily. 3. Vitamin B12 1000 mcg IM q. month. 4. Calcium carbonate 650 mg p.o. b.i.d. with meals.
PM|afternoon|P.M.|265|268|ADMISSION MEDICATIONS|2. Cardiomyopathy diagnosed in 1997. The patient has had three echocardiograms, each done every year, and has resulted with no abnormalities. 3. Gastric bypass surgery 18 months ago. ADMISSION MEDICATIONS: 1. Wellbutrin for decreased appetite sensation. 2. Tylenol P.M. q.h.s. for sleep. 3. Albuterol inhaler p.r.n. for wheezing. 4. Robitussin with codeine p.r.n. for cough. 5. Ferrous sulfate 325 mg every other day. 6. Multivitamin one tablet q. day.
PM|afternoon|PM,|186|188|MEDICATIONS|SURGICAL HISTORY: Past surgeries include surgery on her hand and appendectomy. There is no history of anesthetic complications. MEDICATIONS: Medications preoperatively were only Tylenol PM, Flonase nasal spray and multivitamins. She had been on Relafen up until 8 days prior to surgery. SOCIAL HISTORY: The patient denies cigarette or alcohol use. PHYSICAL EXAMINATION: GENERAL: On examination she is a pleasant female who is in no acute distress.
PM|afternoon|P.M.|182|185|HISTORY|Diagnosis of schizoaffective disorder, followed I believe at the _%#COUNTY#%_ Clinic. Recent hospitalization at Regions on _%#DDMM2002#%_ following overdose on 50 tablets of Tylenol P.M. Records not available. Apparent discharge to _%#CITY#%_ Crisis Residence, who contacted police over a concern regarding increasing suicidal ideation.
PM|afternoon|PM.|88|90|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Patient came in yesterday having had an overdose of Tylenol PM. She states that she took 5 pills of Tylenol so that she could go to sleep because she states she has not been sleeping for many days due to a lot of problems going on, i.e. her car broke and she did not have money to pay for her apartment.
PM|afternoon|P.M.,|250|254|PLAN|PLAN: Neosporin ointment with a pressure patch was placed. Instructions were given to leave this pressure patch in place for at least 24 hours, after which time it can be removed and lubrication with artificial tears or bland ointment (e.g., Refresh P.M., Lacrilube, Duo- Lube or Genteel gel) can be commenced. The patient will be observed in the Emergency Room until morning to be sure he has no side effects from narcotic analgesics he received in the Emergency Room.
PM|afternoon|P.M.|148|151|MEDICATIONS PRIOR TO ADMISSION|PAST MEDICAL HISTORY: 1. Supraventricular tachycardia. 2. Status post cholecystectomy and herniorrhaphy. MEDICATIONS PRIOR TO ADMISSION: 1. Tylenol P.M. p.r.n. 2. Prempro. ALLERGIES: She has a history of intolerance to epinephrine due to hyperventilating, but no other medication allergies or intolerances.
PM|afternoon|PM|191|192||He is currently AV sequentially paced at a rate of 80 bpm. 1. OHTx with excellent immediate surgical results. 2. Immunosuppression: - MMF 1500 mg PO BID - Prednisone 35 mg PO AM and 30 mg PO PM - Prograf 0.5 mg PO BID.
PM|afternoon|P.M.|244|247|REASON FOR CONSULTATION|REASON FOR CONSULTATION: Ms. _%#NAME#%_ _%#NAME#%_ is a 31-year-old female admitted to inpatient psychiatry, through the emergency department, where she was referred by her gynecologist for worsening depression with concern regarding a Tylenol P.M. excess. We were asked by admitting psychiatrist, Dr. _%#NAME#%_ _%#NAME#%_, to see patient for a general medical evaluation. Details regarding psychiatric illness and circumstances leading up to present hospitalization as per psychiatry.
PM|afternoon|PM|155|156|OUTPATIENT MEDICATIONS|OUTPATIENT MEDICATIONS: 1. Zyprexa 10 mg p.o. at bedtime, last taken _%#DDMM2007#%_. This medication was discontinued at the time of admission. 2. Tylenol PM p.r.n. for sleep. This is per patient. ALLERGIES: No known drug allergies. FAMILY HISTORY: Father is a diabetic and also had bypass surgery age 65.
PM|afternoon|PM|153|154||We are asked to help with the management of her cardiomyopathy and recommend the following: 1. Wean milrinone to off today. 2. Start carvedilol 3.125 mg PM today, then BID starting tomorrow, _%#DD#%_ _%#MM#%_, 2007. 3. Hold lisinopril. Rationale: to avoid unpredictable injury to the kidneys in this particular patient.
PM|afternoon|P.M.|290|293|ADMISSION MEDICATIONS|Her friend apparently went into shock. PAST MEDICAL HISTORY: Hyperlipidemia diagnosed 2001, history of polio with left lower extremity atrophy and weakness, urinary stress incontinence. ALLERGIES: No known drug allergies. ADMISSION MEDICATIONS: Lipitor, Detrol, CombiPatch, Motrin, Tylenol P.M. FAMILY HISTORY: Breast cancer and diabetes. REVIEW OF SYSTEMS: She has some discomfort under the right rib cage in the area of her right hemidiaphragm.
PM|afternoon|P.M|158|160|HISTORY OF PRESENT ILLNESS|Details regarding circumstances leading up to present hospitalization as per Psychiatry. Past history of depression. Hospitalized at age 16 following Tylenol P.M overdose in _%#CITY#%_ _%#CITY#%_. Subsequent outpatient management on regimen of Effexor, Seroquel and Klonopin on which the patient has been compliant.
PM|afternoon|P.M.|264|267|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old female admitted to station 30 voluntarily status post hospitalization at University of Minnesota Medical Center, Fairview, University campus approximately 2 weeks for overdose on approximately 50-70 Tylenol P.M. tablets secondary to increasing depression. An Internal Medicine consultation was ordered by Dr. _%#NAME#%_ for a general medical evaluation and to follow this patient's recovery from fulminant hepatic failure secondary to Tylenol overdose.
PM|afternoon|PM,|165|167||A/P: 1. POD #9. 2. S/p LVAD explant. 3. S/p OHTx. 4. Immunosuppression: - Prograf 2 mg PO BID; - MMF 1500 mg PO BID; - Prednisone 35 mg PO this AM and 30 mg PO this PM, to be decreased to 30 mg PO BID tomorrow.
PM|afternoon|PM|161|162|HOSPITAL COURSE|The patient is to have an electrolyte panel rechecked on Monday at home by the home heath care nurse. 2. Nutrition. At the time of admission, the patient was on PM 60/40 that was mixed 1 cup formula to 2 cups water. Nutrition consultation was obtained to make sure the patient was not receiving too much free water, and during this consult, it was determined that this formula mixture mom had been using actually gave the patient 32.8 kcal/ounce rather than the 28 kcal/ounce that is desired.
PM|afternoon|PM|143|144|DISCHARGE MEDICATIONS|23. Biotene mouthwash 5 mL swish and spit q.i.d. 24. GenTeal eye gel as needed for dry eyes. 25. Lotemax eye drops each eye q.i.d. 26. Refresh PM ointment each eye daily. 27. Miconazole nitrate powder as needed. 28. Dulcolax 5 mg p.o. p.r.n. 29. MiraLax 17 gm p.o. p.r.n. 30. Ambien 10 mg p.o. p.r.n.
PM|afternoon|P.M.|405|408|HISTORY OF PRESENT ILLNESS|DOB: _%#DDMM1931#%_ CHIEF COMPLAINT: Syncope. HISTORY OF PRESENT ILLNESS: This 71-year-old woman is well known to me from previous care and presents to the emergency department twice within the last 24 hours, this second time this early afternoon after an episode of syncope this morning. The patient first presented to the emergency department last night after awakening abruptly at about 10:30 or 11:00 P.M. from sleep, noting significant dyspnea and orthopnea, needing to sit up to breath and having a sense that "I was dying". She describes feeling "like I was going over a hill".
PM|afternoon|P.M.|406|409|MEDICATIONS|11. Small abdominal aortic aneurysm, stable on follow-up CT imaging. ALLERGIES: None known. MEDICATIONS: Medications prior to admission included Prinivil 15 mg daily, Celexa 20 mg q.day, Coumadin as above, multivitamin q.day, Prevacid 30 mg q.day, aspirin 325 mg q.day, metoprolol 50 mg b.i.d., Lipitor 10 mg q.day, Cardura 1 mg q.h.s., Atrovent 2 puffs q.i.d., Flovent 220 mcg 2 puffs b.i.d., and Tylenol P.M. at h.s. FAMILY HISTORY: (Per prior records). HABITS: He is a remote smoker, quit 25 years ago.
PM|afternoon|P.M.|151|154|HOSPITAL COURSE|Eventually, she was started on NPH on a twice daily basis to help better cover her elevated glucose. Her current dose of NPH is 10 mg sub-Q q.A.M. and P.M. which has improved her blood glucose, but they still continue to be quite elevated in the 200 range. This can be adjusted as the patient, perhaps, becomes more active upon discharge and adjusted by her primary care physician.
PM|afternoon|PM.|242|244|HISTORY OF PRESENT ILLNESS|During the process of her evaluation in the emergency department she was medically stabilized, including receiving intravenous fluids and swallowing charcoal. Her acetaminophen level was initially found to be elevated at 31; this was at 7:40 PM. At 9:35 PM her acetaminophen level had returned to 19, which in the normal range. Of note, a careful review of the medications she brought in shows that she has multiple bottles with different tablets in them.
PM|afternoon|PM|205|206|HOSPITAL COURSE|At the time of his discharge, _%#NAME#%_ was feeding Similac PM 60/40 with Kayexalate added as per his home routine with 4 teaspoons added to his feeds. At the time of his discharge, _%#NAME#%_ was eating PM 60/40 Similac feeds 200 mL 4 times a day bolus as p.o./NG gavage during the day, and the remaining volume of his feeds was fed at 63 mL per hour as a continuous drip for 8 hours overnight by his NG.
PM|afternoon|PM|95|96|MEDICATIONS|She drinks a vodka at night to help her cope with the loss of her son. MEDICATIONS: 1. Tylenol PM p.r.n. 2. Avapro q.a.m. unknown dose. 3. Hydrochlorothiazide 50 mg q.a.m. 4. Tylenol p.r.n.. 5. Calcium daily. 6. Aspirin 81 mg daily. 7. Toprol-XL 50 mg q.a.m.
PM|afternoon|PM;|174|176|DISCHARGE INSTRUCTIONS|5. Tylenol 50 mg GT q. 4h. p.r.n. fever. DISCHARGE INSTRUCTIONS: 1. Follow up with: Dr. _%#NAME#%_ on _%#DDMM2003#%_; Dr. _%#NAME#%_, Pediatric Surgery, _%#DDMM2003#%_, 2:15 PM; Dr. _%#NAME#%_, Cardiology, three weeks after discharge. 2. Nurse visits through Fairview Home Infusion (phone _%#TEL#%_) were set up three times a week with the first visit being on _%#DDMM2003#%_.
PM|afternoon|PM|138|139|DISCHARGE DIET|Outpatient laboratories that include a basic metabolic panel on _%#MM#%_ _%#DD#%_, 2004, to follow up his sodium. DISCHARGE DIET: Similac PM 60/40 at 26 kcal/ounce with 5 teaspoons of kayexalate in 840 mL of formula per day. DISCHARGE ACTIVITY: Ad lib. DISCHARGE INSTRUCTIONS: 1. The patient's mother was told not to give sugar water at home.
PM|afternoon|PM.|133|135|PAST MEDICAL HISTORY|3. History of pleural effusion. 4. Insomnia, chronic. She is better with starting Ambien. Also is helped by over-the-counter Tylenol PM. 5. Mild hypertension. 6. Subdural hematoma, this is felt to be acute although the CT scan felt that it was probably chronic.
PM|afternoon|PM|130|131|HOSPITAL COURSE|He had multiple attempts to begin enteral feeds but had trouble tolerating. He was eventually advanced to oral feeds with Similac PM 60/40 at 22 Kcal per ounce plus Promod to equal 3 g/kg per day of protein. During his hospitalization, he did continue to require intermittent gavage feedings, as he was not taking enough oral feedings to get him up to his full caloric needs per day.
PM|afternoon|PM|215|216|HOSPITAL COURSE|Speech Therapy worked with them in helping to pace his feeds and also in finding the appropriate nipple. Nutrition followed patient, as well, through his stay, and they did recommend changing his formula to Similac PM 60/40 with fortification to 24 Kcal per ounce for additional calories. Parents were trained in gavage feedings. However, by discharge, he had not required any gavage feeds since _%#MM#%_ _%#DD#%_, 2004.
PM|physical medicine and rehabilitation:PMR|PM|162|163|PRINCIPLE DIAGNOSIS|She completed a 10-day course of IV antibiotics and was placed on a prophylactic dose of nitrofurantoin. 3. Spasticity: This issue was addressed with the help of PM and R physician Dr. _%#NAME#%_, and first a pharmacological approach was chosen with increasing the dose of Zanaflex and oral Baclofen.
PM|afternoon|PM|101|102|MEDICATIONS|No elicit drug use. She is a homemaker and she lives with her husband. MEDICATIONS: She took Tylenol PM q.h.s. p.r.n. She also took calcium and vitamins. ALLERGIES: No known drug allergies. HEALTH MAINTENANCE: She never had abnormal Pap smear prior to her recent one.
PM|physical medicine and rehabilitation:PMR|PM|160|161|HOSPITAL COURSE|2. An 11 mm of right-to-left subfalcine herniation as well as right-sided uncal and parahippocampal gyrus herniation. Radiation Oncology, Medical Oncology, and PM and R consults were obtained the next day as well as CT Surgery consult. On _%#MM#%_ _%#DD#%_, 2005, a CT of chest, abdomen, and pelvis with contrast was done at the request of Dr. _%#NAME#%_, the medical oncologist on the case with the following findings.
PM|afternoon|PM|189|190|DISCHARGE MEDICATIONS|25. Bacitracin ophthalmic ointment to the left eye q.h.s. 26. Ocuflox drops 1 drop q.12h. in the right eye. The patient was instructed that these drops need to be refrigerated. 27. Refresh PM drops 1 drop to the right eye b.i.d. 28. Lamisil cream 1% apply to toenails b.i.d. DISCHARGE PLANNING: 1. The patient is to follow up in Bone Marrow Transplant Clinic tomorrow, _%#DDMM2003#%_.
PM|physical medicine and rehabilitation:PMR|PM|281|282|PROBLEM #6|The Urology Service was consulted, and they attributed the hematuria to irritation of the mucosal lining of the urinary tract with the Foley catheter. The hematuria has cleared. PROBLEM #6: Physical Therapy, Occupational Therapy, and PM and R. These three services were consulted. PM and R has recommended subacute rehabilitation in the rehab of a nursing home. The patient has also been receiving physical therapy and occupational therapy during his hospital stay.
PM|physical medicine and rehabilitation:PMR|PM|172|173|PHYSICIAN FOLLOW UP|1. The patient will follow up with her primary neurologist, Dr. _%#NAME#%_ _%#NAME#%_, on _%#MM#%_ _%#DD#%_, 2005. 2. The patient will follow up with Dr. _%#NAME#%_ in the PM and R department on _%#MM#%_ _%#DD#%_, 2005. Please page me at _%#TEL#%_ if there are any further questions.
PM|physical medicine and rehabilitation:PMR|PM|245|246|IMPRESSION AND PLAN|9. Dysphagia secondary to respiratory failure in the trach as-well-as esophageal dysmotility, which is thought related to radiation therapy in the past. Again, Speech Therapy will be working with this patient. 10. Deconditioning: PT, OT and the PM & R team will see the patient and follow. 11. Infectious Disease: Klebsiella pneumonia, which was treated and resolved as well as coag negative staph pneumonia, which is thought to be a contaminant, however she was on 3 days of vancomycin and will now continue with linezolid per Pulmonary, but there is no stop date on that medication so we will have to clarify that.
PM|afternoon|PM|137|138|RAPID CITY HOSPITAL COURSE|Gastrointestinal: _%#NAME#%_ does have a right inguinal hernia which was repaired _%#DDMM2005#%_, after which he was started on feeds of PM 60/40 with Polycose, to give 24 kcal/ounce. He was generally drip fed at night and received some boluses during the day.
PM|afternoon|PM|104|105|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Cortef 1 mg p.o. q. 8h. 2. Lasix 4 mg p.o. daily. 3. Viagra 3 mg p.o. q. 4:00 PM and 10:00 PM daily. 4. Synthroid 50 mcg p.o. daily. 5. Genotropin 0.3 mg subcu daily. 6. Prevacid 15 mg p.o. daily.
PM|afternoon|PM|65|66|DIET|The patient is not yet sitting. IMMUNIZATIONS: Up to date. DIET: PM 60/40 with additive microlipids and Polycose at 20 calories. FAMILY HISTORY: Neurologic disease, renal disease, and hypertension. Patient's mother with similar manifestations of brachio- otorenal syndrome.
PM|afternoon|PM|226|227|FOLLOWUP|He was subsequently switched to Enfamil premature formula fortified to 24 kcal/oz and supplemented with beneprotein. At the time of discharge, he was breastfeeding minimally, and was reliant on gavage feedings of Breastmilk + PM 60/40 to 26 kcal/oz, 40 mL every 3 hours. His weight at the time of discharge was 2040 gm (50%). Problem #2: Cardiovascular. Samuel had an echocardiogram on _%#DDMM2007#%_ due to prenatal diagnosis of congenital heart disease.
PM|afternoon|PM|271|272|DIETARY MIXING INSTRUCTIONS|DISCHARGE DIET: Similac PM 60/40 30 kcal/oz plus metaprotein 3 g per kilo per day to run at 30 mL an hour continuous with the exception of Sundays and Wednesdays when it should be 20 mL an hour for 24 hours. DIETARY MIXING INSTRUCTIONS: One and three-fourth cups Similac PM 60/40 powder plus 1-1/2 teaspoons metaprotein plus 3 cups, plus 3 tablespoons of water to make 900 mL of formula. OTHER DISCHARGE INSTRUCTIONS: 1. Home ventilator setting: LTV home vent with the rates 25, tidal volume of 65, PEEP 8, pressure support 10, FIO2 to keep sats greater than 92%.
PM|afternoon|PM|187|188|MEDICATIONS|18. Oxycodone/acetaminophen 5/325 mg 1-2 tabs as needed for pain. 19. Plavix 75 mg q.a.m. 20. Prevacid 30 mg b.i.d. 21. Tricor 145 mg q.p.m. 22. Tylenol extra strength p.r.n. 23. Tylenol PM p.r.n. 24. Ursodiol 300 mg t.i.d. 25. Zetia 10 mg q.p.m. 26. Ambien 10 mg each day at bedtime p.r.n. for insomnia.
PM|physical medicine and rehabilitation:PMR|PM|141|142|HOSPITAL COURSE|The patient attributed her improvement primarily to rest and due to the patient's improved gait and level of function. It was recommended by PM and R that the patient could be discharged home. The patient expressed interest in appointment followup with her pain management specialist Dr. _%#NAME#%_.
PM|afternoon|PM|184|185|DISCHARGE MEDICATIONS|5. Lisinopril 5 mg p.o. daily. 6. Coumadin 3 mg p.o. Monday and Friday and 4 mg p.o. Sunday, Tuesday, Wednesday, Thursday and Saturday. 7. Multivitamin 1 tablet p.o. daily. 8. Tylenol PM 1 tablet each day at bedtime p.r.n. insomnia. 9. Ibuprofen 600 mg p.o. q. 6h. p.r.n. pain. 10. Colace 100 mg p.o. b.i.d. 11. Lovenox 120 mg subcutaneously b.i.d. until INR therapeutic on Coumadin.
PM|afternoon|P.M.,|344|348|DISCHARGE MEDICATIONS|DISCHARGE PLANS: The patient is discharged home. Prior to discharge, I will get a CT scan looking particularly at the adrenal glands, suspicion for atrophy or infection particularly with TB. She will liberally salt her food. Activities as tolerated. DISCHARGE MEDICATIONS: Prevacid 30 mg A.M., Prozac 20 mg A.M., cortisone 20 mg A.M. and 10 mg P.M., Florinef 0.1 mg A.M. Follow-up through Park Nicollet Endocrinology within the next couple of weeks which should allow them to proceed with the cosyntropin stimulation test and all follow-up will then be through Park Nicollet.
PM|physical medicine and rehabilitation:PMR|PM|161|162|PROBLEM #4|The wound nurse followed Ms. _%#NAME#%_ during her hospitalization, and her decubitus ulcer responded to therapy. She is currently scheduled to follow up in the PM and R Clinic with Dr. _%#NAME#%_ for pressure mapping on _%#DDMM2006#%_ at 9:00 on the 1st floor of _%#ADDRESS#%_ Building, Clinic 1A.
PM|afternoon|PM|131|132|MEDICATIONS|11. Metoprolol 100 mg by mouth each night and 50 mg by mouth every day at noon. 12. Tylenol 1000 mg by mouth each noon and Tylenol PM 1000 mg at bedtime. 13. Calcium 600 mg by mouth each p.m. 13. Amitriptyline 50 mg by mouth at bedtime. 14. Aciphex 20 mg by mouth at bedtime. 15. Simvastatin 40 mg by mouth each p.m
PM|afternoon|PM.|137|139|ADMISSION MEDICATIONS|6. Synthroid 0.3 mg q AM. 7. Citracal plus D 2 tabs t.i.d. 8. EASA 325 mg PO q day. 9. Lasix 40 mg PO q day. 10. Medrol 16 mg q AM and q PM. 11. Neurontin 400 mg PO t.i.d. 12. Zinc oxide topical wound care. 13. Regular insulin sliding scale. 14. Rocaltrol 0.25 micrograms PO q day.
PM|physical medicine and rehabilitation:PMR|PM|180|181|HOSPITAL COURSE|The patient was continued on antiplatelet therapy with aspirin throughout her hospitalization, and had no recurrence or escalation of her symptoms. She was evaluated by PT, OT and PM and R, and was found to have some spasticity of her right leg and some mild difficulty with gait. It was felt the patient would benefit from an acute rehab stay to return her to her baseline.
PM|physical medicine and rehabilitation:PMR|PM|214|215|ASSESSMENT AND RECOMMENDATIONS|I was unable to actually measure these lengths because I did not have a tape measure at my disposal; however, this should be something investigated further either through Physical Therapy or with a clinic visit to PM and R. In addition, the patient has complaints of low-back pain. At this time, I recommend: 1. The patient is not an acute rehab candidate because of her high level of function; however, she would benefit from outpatient physiotherapy to work on stretching and cervical traction initially to help control her dystonic and persistent head movements.
PM|afternoon|P.M.|160|163|DEMOGRAPHIS AND BACKGROUND INFORMATION|Her thoughts have included "I'm not worth being here." And "Things would be better without me." On Monday she overdoses on generic Nyquil in pill form, Tylenol P.M. and Aleve. She stated she felt tired when her best friend talked to her on the phone, she eventually came to the house and the patient revealed to her what she had done.
PM|afternoon|P.M.|261|264|MEDICATIONS ON ADMISSION|4. Aspirin 81 mg q.d. 5. Prinivil 20 mg b.i.d. 6. Nephrocaps one tablet q.A.M. 7. Toprol XL 50 mg p.o. q.A.M. Sunday, Tuesday, Thursday, Saturday; 50 mg q.P.M. Monday, Wednesday and Friday, Imdur 30 mg p.o. q.A.M. Saturday, Tuesday, Thursday, Sunday; and 30 mg P.M. Monday, Wednesday, and Friday, Zocor 40 mg q.h.s. PAST MEDICAL HISTORY: 1. Chronic renal insufficiency felt secondary to hypertensive nephropathy. She has been on hemodialysis three times a week for three years.
PM|afternoon|PM.|136|138|MEDICATIONS PREOPERATIVE|2. Nexium 20 mg daily. 3. Aspirin 325 mg daily, discontinued 1 month ago. 4. Lipitor 10 mg daily. 5. Fish oil. 6. Melatonin. 7. Tylenol PM. 8. Chondroitin/glucosamine. FAMILY HISTORY: Mother is _%#1914#%_ and died of renal failure.
PM|afternoon|PM,|200|202|DEMOGRAPHICS AND BACKGROUND INFORMATION|She was referred for a psychological evaluation by _%#NAME#%_ _%#NAME#%_, MD, to aid with diagnostic impressions and treatment recommendations. This patient noted that she took 6 Ambien and 4 Tylenol PM, but knew that it was not going harm herself too much. She noted "I wanted to go to sleep for a long time." Overall, she has felt guilty about "cheating on her boyfriend." She stated that she kissed this other boy.
PM|afternoon|PM.|202|204|MEDICATIONS|3. Thyroxine. 4. Lisinopril. 5. Aciphex. 6. Hydrochlorothiazide. 7. Nasacort. 8. Fosamax. 9. Caltrate. 10. Albuterol inhaler. 11. Baby aspirin. 12. Glucosamine chondroitin. 13. Prometrium.. 14. Tylenol PM. 15. Multivitamin. 16. Metamucil. 17. Advil as needed. Currently taking 2 tablets nightly. SOCIAL HISTORY: The patient lives alone in _%#CITY#%_, Minnesota.
PM|afternoon|PM|210|211|BACKGROUND INFORMATION|Overall he believes that this started this year. This patient drank a glass of wine at a wedding and has had wine coolers and Mike's Hard Lemonade on occasion in the past. He has also tried Vicodin and Tylenol PM to "stop feeling bad," but this was not a suicide attempt. In his leisure time he likes to talk on the phone, hang out with his friends, and work on the computer.
PM|afternoon|PM|214|215|ASSESSMENT|Urinalysis unremarkable, specifically no evidence of hematuria. ASSESSMENT: 21-year-old male admitted with the following: 1. Depression/suicidal ideation (defer to Dr. _%#NAME#%_). 2. Status post non-toxic Tylenol PM overdose. No lingering clinical sequelae. 3. History of headaches, likely mixed, with tension/muscle contraction component escalating into a migraine event when severe.
PM|afternoon|PM|142|143|HISTORY|Significant recent history of the patient's husband allegedly leaving her on _%#DDMM2005#%_. The patient subsequently overdosed on 50 Tylenol PM tablets on _%#DDMM2005#%_. Hospitalized at Fairview Ridges. Treated with activated charcoal and a full course of intravenous Mucomyst. Record review indicates that liver enzymes remained normal. Repeat acetaminophen level 15 hours post ingestion was undetectable.
PM|afternoon|PM|130|131|ASSESSMENT|ASSESSMENT: A 35-year-old male admitted with the following: 1. Alleged suicidal threat in the setting of a recent serious Tylenol PM overdose. Depressive disorder not otherwise specified per psychiatry. 2. Cannabis abuse (suspected). 3. Status post cervical spine fracture with C7 level.
PR|pulmonary regurgitation|PR.|122|124|PLANNED DISCHARGE DATE|There was aortic leaflet sclerosis, trace TR and the right heart pressures could not be assessed. There was trace to mild PR. There was mild LVH. There was diastolic dysfunction of the LV and moderate mitral annular calcification. While he was in the hospital, his dyspnea improved, as he was treated with ACE, beta blocker and diuretic therapy, but then around _%#DDMM2007#%_ to _%#DDMM2007#%_, he developed what seemed like a viral gastroenteritis and flu.
PR|per rectum|PR|148|149|DISCHARGE MEDICATIONS|2. Lorazepam 0.5 mg tablet 0.25-0.5 mg p.o. sublingual q.4h. p.r.n. 3. Haldol 0.5-1 mg p.o. sublingual q.6h. p.r.n. 4. Tylenol 650 mg suppository 1 PR q.4h. p.r.n. 5. OxyFast 20 mg per mL. to be used only when the pump failure. 6. The patient was discharged on PCA Dilaudid pump as per TLC nurse practitioner orders.
PR|per rectum|PR|149|150|DISCHARGE MEDICATIONS|7. Fludrocortisone 0.1 mg q.Tuesday and q.Friday. 8. Insulin sliding scale q.6h. p.r.n. 9. Augmentin 875 mg b.i.d. x7 days. 10. Acetaminophen 650 mg PR b.i.d. 11. Ocuvite one tablet daily. 12. Lexapro 15 mg daily. 13. Miacalcin 200 units, puffed into nostril daily, alternating nostrils every day.
PR|per rectum|PR|339|340|DISCHARGE MEDICATIONS|Her phone number is _%#TEL#%_. 4. Patient was instructed that once she returned home, if she happened to develop any problems to include increased pain, fever over 101, increased drainage from her wounds, or any other concerns that she should contact Dr. _%#NAME#%_ at his pager _%#TEL#%_. DISCHARGE MEDICATIONS: 1. Dulcolax suppository 1 PR daily p.r.n. for constipation. 2. Fibercon 1 tablet p.o. daily for constipation. 3. Diltiazem ER 120 mg p.o. daily. 4. Benadryl 25 mg p.o. each day at bedtime.
PR|per rectum|PR|190|191|DISCHARGE MEDICATIONS|12. Sinemet 25/100 mg 3 tabs p.o. t.i.d. during the day for Parkinson's. 13. Sinemet CR 25/100 mg 1 tab p.o. each day at bedtime for Parkinson's. 14. Beano suppository 30/16 one suppository PR q.4-6h. p.r.n. bladder spasm. 15. Vicodin 1 to 2 tablets 5/500 mg p.o. q.4-6h. PR pain. 16. Enoxaparin 30 mg subcutaneously daily DVT prophylaxis to start on _%#DDMM2006#%_.
PR|per rectum|PR|123|124|MEDICATIONS|8. Valium 5 to 10 mg p.o. q.6h p.r.n. vertigo or dizziness. 9. Percocet one to two p.o. q.4h p.r.n. pain. 10. Tigan 200 mg PR q.6h p.r.n. nausea. FOLLOW-UP: 1. Wound care none. 2. Diet regular. 3. Weight bearing status is full weight bearing.
PR|progesterone receptor|PR|221|222|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ had a breast cancer on _%#DDMM2001#%_ on the right breast, infiltrating ductal carcinoma grade I of III with 0 of four lymph nodes involved. It was ER positive at 82% and PR positive at 14.1. She then developed a second breast cancer in her left breast on _%#DDMM2003#%_. It was grade III of III. She had one of 15 lymph nodes involved.
PR|progesterone receptor|PR|263|264|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 54-year-old woman who is in today for followup of her infiltrating carcinoma, DCIS, of the right breast, status post right mastectomy, _%#DDMM1997#%_, grade 2 of 3, with 13 of 14 lymph nodes positive, ER and PR positive. REVIEW OF SYSTEMS: GENERAL: She has occasional sweats. EYES: Negative.
PR|per rectum|PR|154|155|DISCHARGE MEDICATIONS|2. Flagyl 500 mg p.o. q.i.d. x6 weeks. 3. Multivitamin one tablet p.o. q. day. 4. Senokot-S two tabs p.o. q.h.s., hold p.r.n. diarrhea. 5. Dulcolax 10 mg PR q. day p.r.n. 6. Toprol XL 25 mg p.o. q. day. 7. Plavix 75 mg p.o. q. day. The patient to resume use when okayed per Orthopedic Surgery.
PR|per rectum|PR,|114|116|TRANSFERRING MEDICATIONS|8. Compazine 10 mg p.o. or IV q.8 h. p.r.n. 9. Reglan 10 mg p.o. or IV q.6 h. p.r.n. 10. Tigan 200 mg suppository PR, p.r.n. nausea. 11. Vitamin B12 100 mcg IM q. month, next due _%#DDMM2005#%_. 12. Total parenteral nutrition (TPN), currently provided on a cyclic basis.
PR|per rectum|PR|126|127|DISCHARGE MEDICATIONS|4. Tylenol, 1,000 mg q. 6 hours p.r.n. 5. Tylenol Suppositories, 650 mg PR q. 6 hours p.r.n. 6. Compazine Suppositories, 5 mg PR q. 6 hours p.r.n. nausea. 7. Compazine, 5 mg p.o. q. 6 hours p.r.n. nausea. 8. Roxanol, 20 mg/cc 10-20 mg p.o. ________ q. 1 hour p.r.n. pain or respiratory distress.
PR|pr interval|PR|236|237|HOSPITAL COURSE|The patient did well throughout his hospital course. He had no further episodes of palpitations, and the telemetry monitor demonstrated no evidence of tachyarrhythmias. His ECG demonstrated the patient was in sinus rhythm with a normal PR interval and a normal EKG. The patient was ambulating the following day and did not have any evidence of hematoma or bleeding from his right groin where the vascular sheaths were placed.
PR|pr interval|PR|290|291|LABORATORY DATA ON ADMISSION|Neurologic exam: nonfocal. LABORATORY DATA ON ADMISSION: White count 11.4, hemoglobin 14.8, platelets 302, sodium 135, potassium 3.9, chloride 94, bicarbonate 29, BUN 12, creatinine 0.9, ABG 7.32, PC02 65, PO2 68, bicarbonate 33 on 2 liters nasal cannula. EKG: sinus tachycardia with short PR and frequent consecutive PVCs and fusion complexes. CT scan of chest, abdomen and pelvis showed emphysema with no pulmonary infiltrates; prominent ductal system probably physiological following gallbladder removal; left renal cyst; and some nonspecific cul-de-sac fluid.
PR|per rectum|PR|157|158|MEDICATIONS ON DISCHARGE|1. End-stage congestive heart failure with mitral regurg. 2. Dementia. MEDICATIONS ON DISCHARGE: 1. Senokot S two tabs per os twice a day. 2. Dulcolax 10 mg PR twice a day times one week, and then as occasion requires. 3. Fleets enema q 3 days as occasion requires. 4. Lasix 20 mg per os every day. 5. ASA 81 mg per os every day.
PR|per rectum|PR|145|146|DISCHARGE MEDICATIONS|7. Calcium carbonate 1.25 gm p.o. b.i.d. 8. Calcitrol 0.5 mcg p.o. q.d. 9. Peri-Colace 1 - 2 p.o. b.i.d. prn constipation. 10. Fleet's enema one PR q.d. prn constipation. 11. Hydrocodone (5 mg) 1 - 2 p.o. q. 4 - 6 hours prn incision pain. DISPOSITION AT DISCHARGE: _%#NAME#%_ _%#NAME#%_ was discharged to home in stable condition.
PR|pulmonary regurgitation|PR,|134|136|PROCEDURE|2. Echocardiogram dated _%#DDMM2005#%_ preliminary results show normal left ventricular function, EF of 55%, trace MR, mild AI, trace PR, no obvious clots or shunts. 3. EGD _%#DDMM2005#%_ shows a large hiatal hernia. 4. Non-bleeding crater gastric ulcers with no stigmata of bleeding.
PR|progesterone receptor|PR|144|145|PAST MEDICAL HISTORY|Re-vascularization of ramus intermedius lesion. 2. Paroxysmal atrial fibrillation previously on anticoagulation. 3. Left breast cancer in 1992. PR negative. Lymph nodes all negative. 4. Congestive heart failure, details unknown. 5. Hypertension. 6. Previous remote history of tobacco abuse.
PR|progesterone receptor|PR|197|198|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her right-sided infiltrating ductal carcinoma diagnosed _%#DDMM2001#%_, grade 2 of 3 with 3 of 13 lymph nodes, ER and PR positive, HER-2/neu positive. REVIEW OF SYSTEMS: GENERAL: She has hot flashes. She has right-sided pain with inspiration earlier this winter with a cough.
PR|per rectum|PR|118|119|DISCHARGE MEDICATIONS|9. Protonix 40 mg G-tube q. day. 10. Zetia 10 mg G-tube q.h.s. 11. Tylenol 650 mg PR q.4 h. p.r.n. 12. Dulcolax 10 mg PR q. day p.r.n. 13. Benadryl 25 mg IV q.4 h. p.r.n. 14. Hydralazine 10 to 20 mg IV q.6 h. p.r.n. for systolic blood pressures greater than 150.
PR|pr interval|PR|171|172|PHYSICAL EXAMINATION|Bowel sounds present. EXTREMITIES: No edema, sign of DVT. NEUROLOGIC: Nonfocal. EKG by my reading reveals sinus rhythm with a rate of 65, good R wave progression, axis 0, PR interval 0.20, QT 0.36. There are no diagnostic or acute ischemic changes, nonspecific ST-T wave changes and no previous EKGs for comparison.
PR|per rectum|PR|108|109|CURRENT MEDICATIONS|2. Aminophylline 360 mg ST q.6 h. 3. Aspirin 81 mg NG daily. 4. Baclofen 30 mg NG q.8 h. 5. Bisacodyl 10 mg PR every other day. 6. Soma 350 mg NG q.6 h. 7. Dantrium 25 mg NG t.i.d. 8. Docusate 100 mg NT b.i.d. 9. Estradiol/norgestimate 1 mg NG q.24 h.
PR|pr interval|PR|196|197|PHYSICAL EXAMINATION|Bowel sounds are present. EXTREMITIES: No edema. No sign of deep venous thrombosis of either leg. NEUROLOGICAL: Exam was non-focal. EKG by my reading today reveals sinus rhythm with a rate of 75. PR interval is 0.18, QT interval 0.38 and there is good R-wave progression. Axis is 0. There are no ischemic changes and no significant change compared with EKG of _%#DDMM1999#%_, sinus rhythm has replaced atrial fibrillation and the rate is improved and slower.
PR|per rectum|PR|187|188|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Prevacid 30 mg p.o. q.d. 3. Lanoxin 0.25 mg p.o. q.o.d. 4. Norvasc 2.5 mg p.o. q.d. 5. Senna 2 p.o. b.i.d. 6. Dulcolax suppository 1 PR q.d. p.r.n. constipation. DISCHARGE STATUS: Stable. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a _%#1914#%_-year-old female who was admitted on _%#DDMM2002#%_ by Dr. _%#NAME#%_ _%#NAME#%_.
PR|per rectum|PR|226|227|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Sinemet 25/100 po tid 30 minutes prior to meals, Xalatan 0.005% 1 drop OU q hs, ibuprofen 600 mg po tid prn, Tylenol #3 1 or 2 tablets po q 4-6 hours prn, Senna 2 tablets po q hs, Dulcolax suppository 1 PR q 6 hours prn and Mr. _%#NAME#%_ will follow up with his primary care provider at Fairview _%#CITY#%_ Clinic in the next two weeks.
PR|per rectum|PR|178|179|HOSPITAL COURSE|1. Ibuprofen 200 mg PO q 6 hours p.r.n. 2. Oxycodone 2.5 mg PO q 4-6 hours p.r.n. 3. Tylenol 325 mg PO q 4-6 hours p.r.n. 4. Macrobid 50 m PO q day. 5. ______suppositories 30 mg PR 12 hours p.r.n. bladder spasms. The patient is to follow-up with Dr. _%#NAME#%_ in one to two weeks in Pediatric Urology Clinic as well as follow-up with Peds Nephrology, Dr. _%#NAME#%_ or another staff nephrology physician in six to eight weeks for follow-up.
PR|pr interval|PR|147|148|HISTORY OF PRESENT ILLNESS|Repeat EKG an hour later shows only mild ST elevation consistent with improved ischemic picture and persistence of the first grade AV block with a PR interval of 210 microseconds. The patient was therefore transferred to the Intensive Care Unit on the ventilator. Currently, she is not responsive. Per nurse's notes, there was slight decerebrate posturing with painful stimuli.
PR|pr interval|PR|159|160|HOSPITAL COURSE|4. History of MI. No EKG changes, troponins x 2 negative. 5. Chronic intermittent atrial fibrillation, patient presently in normal sinus rhythm with prolonged PR interval. She is on low dose beta blockers as well as amiodarone. TSH is 2.17. DISPOSITION: The patient is discharged to her nursing home.
PR|pr interval|PR|295|296|STUDIES|There are chronic arthritic changes noted in the digits of both hands. DERM: No obvious ulcers, lesions or rash. STUDIES: EKG shows normal sinus rhythm, normal axis, normal intervals, no acute ST- or T-wave changes consistent with ischemia, no elevation by volts, no global T-wave inversions or PR depression is noted. CT: CT scan of the head, preliminary, demonstrates no mass, bleed or other focal findings.
PR|pr interval|PR|148|149|HOSPITAL COURSE|His heart rate was 160 bpm in atrial flutter. He converted spontaneously. After floor walking he developed significant first-degree AV block with a PR interval of greater than 300 msec. After extensive discussion with the patient and family we agreed on implantation of a pacemaker.
PR|per rectum|PR|133|134|DISCHARGE MEDICATIONS|12. Tylenol 325 mg by mouth every 6 hours. 13. Colace 100 mg by mouth twice daily, hold for loose stools. 14. Dulcolax suppository 1 PR daily as needed for constipation (10 mg suppository). 15. Amaryl 1 mg p.o. each morning. 16. Regular insulin twice daily before breakfast and dinner by sliding scale.
PR|pr interval|PR|100|101||Of note, there is some PR depression in lead I. There also appears to be a bit in lead II, there is PR elevation in lead AVR, findings that are consistent with probable pericarditis. However, given patient's multiple risk factors, ST segment elevation, it was decided to initiate the ST segment elevation protocol.
PR|pr interval|PR|169|170|HOSPITAL COURSE|1. Upon admission, the patient was evaluated with serial EKGs and troponins. Serial EKGs remained unchanged and revealed consistent left bundle branch block with slight PR prolongation. There were no significant ST or T-wave changes. Serial troponins x3 were negative. Nevertheless, the patient had significant persistent dyspnea with ambulation. She was a poor candidate for adenosine nuclear stress testing given her underlying COPD and had relatively poor echo windows making her poor dobutamine stress echo candidate.
PR|pr interval|PR|189|190|LABORATORY DATA|Sodium is 136, potassium 4.3, chloride 100, bicarb 27, BUN 19, and creatinine 0.8, and glucose 88. Calcium was 8.7. Electrocardiogram shows evidence of sinus tachycardia with possibly some PR interval depression in lead II which might be exacerbated by the tachycardia. The patient had an MRI of her neck and that showed no evidence of diskitis.
PR|per rectum|PR|154|155|MEDICINES AT THE TIME OF DISCHARGE|11. Lidocaine patch to the abdomen twelve hours on and twelve hours off. 12. Ativan 0.5 to 1 mg p.o. q.6h p.r.n. (this is an elixir). 13. Fleet enema one PR t.i.d. p.r.n. constipation. 14. Pink Lady enema one PR t.i.d. p.r.n. constipation. The patient is to be discharge to N C Little Memorial Hospice.
PR|progesterone receptor|PR|170|171|HISTORY OF PRESENT ILLNESS|The patient also had a mammogram, which was abnormal, and left breast cancer was subsequently diagnosed. This turns out to be an invasive lobular carcinoma. It is ER and PR positive. She had an abnormal EKG preoperatively, so a cardiac workup was performed and angiogram was done. She then was scheduled for bilateral oophorectomy, as well as lumpectomy by Dr. _%#NAME#%_.
PR|per rectum|PR|149|150|DISCHARGE MEDICATIONS|3. Compazine 10 mg p.o. q.6h. p.r.n. nausea. 4. Senna 2 tablets p.o. each day at bedtime continue while on Percocet. 5. Dulcolax 10 mg suppository 1 PR q. day p.r.n. constipation. 6. Calcium 1200 mg p.o. q. day. 7. Vitamin C 1000 mg p.o. q. day. 8. Emergen-C 1 tablet p.o. q. day. FOLLOWUP APPOINTMENT: The patient all the time was instructed to follow up with her identified physician in Indiana to follow up nephrectomy in the next 10-14 days.
PR|pr interval|PR|161|162|ELECTROCARDIOGRAM|pH 7.4, pO2 564, pCO2 32. Bicarbonate 20. FiO2 200. Oxygen saturation 99%, most likely venous. ELECTROCARDIOGRAM: Normal sinus rhythm. Rate 77 beats per minute. PR interval 200 milliseconds. Electrocardiogram is otherwise normal. RADIOLOGY: Chest x-ray shows endotracheal tube in good position above the carina.
PR|pr interval|PR|205|206|HISTORY OF MAIN COMPLAINT|The anesthesiologist or at least someone in the operating room, felt she had Mobitz type 1. They did put a rhythm stripes in the chart which showed sinus rhythm with one rhythm stripe that show a constant PR interval then then one p wave with no QRS following in other words Mobitz type two II. The patient's EKG at 12 lead right now shows normal sinus rhythm, again with no evidence of heart block.
PR|pr interval|PR|152|153|LABORATORY DATA|Chest x-ray demonstrates no effusion or infiltrate. EKG demonstrates the initial slow rhythm. It appears to be junctional or perhaps an extremely short PR interval without ischemic changes. ASSESSMENT: 1. Symptomatic bradycardia 1 week after starting beta blockade for paroxysmal atrial fibrillation with rapid ventricular response.
PR|per rectum|PR|149|150|MEDICATIONS|7. Hemorrhoid, myalgia and myositis. Discharge was to nursing home. MEDICATIONS: Lanoxyl ____ once a day, Prevacid 30 mg once a day, Proctofoam HC 1 PR bid x 14 days. COPD was treated with nebs, presumptive vasculitis with acute renal failure treated with Prednisone. She was on tapering dose 20 mg for 7 days, then 10 for 7 days, Darvocet-N 100 for pain, Artificial Tears.
PR|per rectum|PR|147|148|MEDICATIONS|10. Senna 2 tablets p.o. daily. 11. Zofran 8 mg p.o. q.6 h. p.r.n. nausea. 12. Compazine 5-10 mg p.o. q.6 h. p.r.n. nausea. 13. Promethazine 25 mg PR daily p.r.n. nausea. 14. Tylenol 650 mg p.o. daily p.r.n. pain. PHYSICAL EXAMINATION: VITAL SIGNS: On admission temperature was 98.6, blood pressure 125/63, pulse 85, respiratory rate 16, sats 97% on room air.
PR|progesterone receptor|PR|122|123|PAST MEDICAL HISTORY|1. Stage IIB infiltrating ductal carcinoma right breast with 2.7-cm primary and 2 of 16 lymph nodes positive, both ER and PR positive. 2. Migrainous headache. 3. Osteoarthritis. 4. Hypothyroidism. 5. Hypertension. 6. Trigeminal neuralgia. SOCIAL HISTORY: The patient is a pharmacy tech.
PR|pr interval|PR|142|143|DISCHARGE MEDICATIONS|His AV delay will be kept at 300 msec to allow _______ conduction. There is actually significant latency in the atrial lead and the patient's PR interval measured from onset of his atrial electrocardiogram, and his 12-lead is actually much less than 300 msec. ADDENDUM: Prior to discharge yesterday the patient became somewhat short of breath and with supine position developed some basilar rales.
PR|pr interval|PR|114|115|LABORATORY DATA|His EKG showed a sinus tachycardia at 111. He had diffuse ST elevation in 2, 3, F, V3, V4, V5 and V6. He also had PR depression in leads 2, 3, F and V2-V6. HOSPITAL COURSE: PROBLEM #1: Pericarditis. The patient was admitted to the hospital and started on indomethacin at 50 mg p.o. every eight hours.
PR|per rectum|PR|134|135|DISCHARGE MEDICATIONS|11. Viva-Drops eye drops, one to two drops both eyes p.r.n. 12. Dilaudid 4 to 8 mg through feeding tube q1h p.r.n. 13. Dulcolax 10 mg PR q. day p.r.n. DISPOSITION: Discharge to home in the care of family.
PR|pr interval|PR|239|240|LABORATORY DATA|Liver function tests are within normal limits. BUN 14, creatinine 0.8, blood sugar 123, potassium 3.5. EKG reveals normal sinus rhythm with mild flattening of the T-waves. There is on increase in the QRS complex duration. She has a normal PR interval. IMPRESSION: This is a 19-year-old Caucasian lady admitted with complaints of polysubstance overdose.
PR|per rectum|PR.|216|218|HISTORY|He was given a Tigan suppository after being given a history of 24 hours of vomiting with no history of diarrhea. Mother stated child was unable to keep fluids down, hence the reason for the Tigan 100 mg suppository PR. The child was admitted to the Children's Care Center approximately 21:00. An IV was started. Dr. _%#NAME#%_ was the attending physician.
PR|per rectum|PR|122|123|DISCHARGE MEDICATIONS|He was rehydrated, in stable condition with good prognosis. DISCHARGE MEDICATIONS: Tigan 100 mg suppositories to be given PR q 6-8 hours. The Rx prescription was issued from the Emergency Department the evening before. No consultations at this point. No procedures at this point.
PR|pr interval|PR|165|166|LABORATORY DATA|Grade 2 atheroma in the descending aorta. DC cardioversion was performed on _%#DDMM2004#%_. She received three shocks, 120, 200 and 200 joules. Effective. Increased PR intervals. The procedure was tolerated well. She remained in normal sinus rhythm. An EKG was performed. She was converted to oral diltiazem, long-acting Cardizem CD 240 mg p.o. daily which she tolerated well with rate control.
PR|progesterone receptor|PR|83|84|HISTORY OF PRESENT ILLNESS|It is a grade 3/3 with _%#DDMM#%_ lymph nodes positive. She is ER positive at 87%, PR positive at 80.2% and HER2/neu negative. She felt some pain in her axilla. She never did feel a lump in the breast. She went in to be evaluated and had surgery within two weeks of feeling this area of abnormality.
PR|progesterone receptor|PR|242|243|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her infiltrating ductal carcinoma of the left breast treated with lumpectomy _%#DDMM2001#%_, Nottingham grade I of III, 0 of five lymph nodes, ER positive at 30%, PR at 80%. REVIEW OF SYSTEMS: GENERAL: No fevers, sweats, weight change or fatigue.
PR|progesterone receptor|PR|124|125|HISTORY OF PRESENT ILLNESS|Bilateral mastectomies with expanders in place. She had a grade 2/3 cancer, 0 of 5 lymph nodes, greater than 90% ER and 20% PR positivity. The patient had some close margins with her microinvasion. Hence the patient was presented at the conference. REVIEW OF SYSTEMS: GENERAL: Fatigue is not bad. EYES: Negative, no blurred or double vision EARS: Negative.
PR|progesterone receptor|PR|280|281|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her infiltrating ductal carcinoma of the left breast, diagnosed _%#DDMM1994#%_, status post mastectomy with reconstruction, grade 2/3, with 1 of 16 lymph nodes positive. She was ER positive at 30% and PR negative at 0. REVIEW OF SYSTEMS: GENERAL: She has hot flashes every once in a while.
PR|progesterone receptor|PR|246|247|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her metastatic infiltrating ductal carcinoma diagnosed initially _%#DDMM2002#%_, with a right mastectomy. She had a grade 3/3 with 0 lymph nodes. She was ER positive, PR negative and 2+ HER-2/neu positive. REVIEW OF SYSTEMS: GENERAL: Weight is about the same. Energy is better.
PR|progesterone receptor|PR|157|158|HISTORY OF PRESENT ILLNESS|She has had bilateral mastectomies. Grade 1 of 3 cancer, with 0 of 6 lymph nodes positive, but with some extension. The patient is ER positive at 87.7%, and PR positive at 77.4%. HER-2/neu was negative. REVIEW OF SYSTEMS: GENERAL: Her taste is down. Her energy is down.
PR|progesterone receptor|PR|217|218|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for consultation regarding left-sided infiltrating ductal carcinoma diagnosed _%#DDMM2005#%_. She had a needle biopsy done. It was grade 1/3, ER negative, PR focally positive, HER-2/neu negative. FAMILY HISTORY: The patient has a mother who is 52 with skin cancer and depression, some thyroid problems.
PR|pr interval|PR|171|172|LABORATORY DATA|Chest CT is unremarkable. Negative for adenopathy or pulmonary embolism. CT of the head is negative, preliminary report. EKG shows sinus tachycardia initially with normal PR intervals. The patient has T wave inversion in III and AVF. It is unclear whether this has previously been noted as there is no baseline EKG for comparison.
PR|per rectum|PR|137|138|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1. Lisinopril 5 mg p.o. q.24 h. 2. Metoprolol 12.5 mg p.o. twice a day. 3. Senokot 2 tabs q.24 h. 4. Dulcolax 10 mg PR p.r.n. 5. Lasix 20 mg p.o. q.24 h. 6. Plavix 75 mg p.o. q.24 h. 7. Ranitidine 150 mg p.o. twice a day.
PR|per rectum|PR|154|155|MEDICATIONS|4. Albuterol 2.5 mg 1-2 tablets inhaled q.4h. p.r.n. shortness of breath or wheezing. 5. Colace 200 mg p.o. b.i.d. p.r.n. constipation. 6. Dulcolax 10 mg PR daily p.r.n. constipation. FOLLOWUP: 1. Dr. _%#NAME#%_ in Thoracic Surgery for followup on tissue expander removal and subcutaneous emphysema in 3 weeks.
PR|per rectum|PR|144|145|MEDICATIONS ON DISCHARGE|1. Zofran ODT 4 mg p.o. q. 6 hours p.r.n. nausea. 2. Roxanol 20 mg per mL, 0.25 mL p.o. q. 3 hours p.r.n. pain. 3. Dulcolax 10 mg suppository 1 PR daily p.r.n. constipation. 4. Nitroglycerin patch 0.4 mg per hour daily. 5. Pilostat 4% eyedrops both eyes daily at bedtime. HOSPITAL COURSE: Mrs. _%#NAME#%_ _%#NAME#%_ is a _%#1914#%_-year-old female who was admitted on _%#DDMM2007#%_ after being found down.
PR|per rectum|PR.|153|155|HOSPITAL COURSE|In order to avoid the nausea and vomiting the patient was experiencing with Dilaudid, the medication was dosed concomitantly with Phenergan or Compazine PR. The pain team had recommended using Zofran for nausea and vomiting; however, the patient states she prefers Compazine or Phenergan.
PR|per rectum|PR|285|286|DISCHARGE MEDICATIONS|8. Lidoderm patches, apply to affected area daily. 9. Dilaudid 8 mg p.o. q.4.h. x 5 days, to be tapered to 2 mg p.o. q.4.h. for the following days, and then 2 mg q.6.h x 5 days. The patient will then be provided with 15 doses of 2 mg p.o. q.4.h. p.r.n. thereafter. 10. Phenergan 25 mg PR or Compazine 25 mg PR to be taken with Dilaudid to prevent nausea. 11. Vicodin 1 tab p.o. q.6.h as needed for breakthrough pain.
PR|pr interval|PR|139|140|PROCEDURES PERFORMED|4. G.I. appointment for an upper endoscopy within the next week. PROCEDURES PERFORMED: EKG (_%#DDMM2002#%_). Results: Normal sinus rhythm, PR interval 172, left bundle branch block with QRS duration 124. HISTORY OF PRESENT ILLNESS: Patient is an 80-year-old male admitted _%#DDMM2002#%_ for persistent diarrhea over the past 10 days.
PR|per rectum|PR|157|158|DISCHARGE MEDICATIONS|4. Allegra 60 mg p.o. b.i.d. 5. Flexeril 10 mg p.o. q8h p.r.n. 6. Ditropan 5 mg p.o. b.i.d. p.r.n. 7. Imitrex 25 mg p.o. q4h p.r.n. 8. B & O suppository one PR b.i.d. p.r.n. 9. Detrol 4 mg p.o. q.d.
PR|per rectum|PR|154|155|DISCHARGE MEDICATIONS|3. Zantac 150 mg down feeding tube b.i.d. 4. Dulcolax 1 tab PR q.h.s. p.r.n. 5. Valium 5 mg down feeding tube or IV t.i.d. p.r.n. vertigo. 6. Tylenol 650 PR or down feeding tube q.6 h. p.r.n. Tylenol dose not to exceed 4 gm per day. 7. Metoprolol 5 mg IV q.6 h. p.r.n. to keep blood pressure less than 140.
PR|per rectum|PR|151|152|OPERATIONS/PROCEDURES PERFORMED|Her symptoms very much resolved, and upon discharge she was tolerating PO intake well. DISCHARGE MEDICATIONS: 1. Miralax 17 g daily. 2. Dulcolax 10 mg PR daily p.r.n. for constipation. 3. Estrace 0.5 mg daily. 4. Advair 250/50 1 puff b.i.d. 5. Combivent MDI 2 puffs q.i.d. p.r.n. 6. Prednisone 5 mg daily.
PR|per rectum|PR|122|123|DISCHARGE  INSTRUCTIONS|DISCHARGE INSTRUCTIONS: The patient will be transferred to NC Little on the following medications: 1. Tylenol 650 mg p.o. PR q.4h. p.r.n. 2. Duonebs q.4h. p.r.n. 3 Celexa 30 mg p.o. q day 4. Senokot 2 tabs p.o. q.h.s. 5. Lasix 40 mg p.o. b.i.d.
PR|per rectum|PR|179|180|DISCHARGE MEDICATIONS|3. Aspirin 81 mg p.o. daily. 4. Diovan 160/12.5 mg p.o. q.d. Could consider increasing to two tablets daily. 5. Colace 200 mg p.o. q.d. 6. Lexapro 5 mg p.o. q.d. 7. Fleet's enema PR q.72h p.r.n. 8. For her vertiginous symptoms, she has scheduled meclizine 25 mg p.o. q.6h, with alternating Benadryl 25 mg p.o. q.6h. These are to be alternated q.3h for vertigo.
PR|per rectum|PR|142|143|DISCHARGE MEDICATIONS|12. Tylox 1 to 2 p.o. q.4-6h. p.r.n. pain. 13. Colace 100 mg p.o. b.i.d. p.r.n. constipation. Hold for diarrhea. 14. Dulcolax suppository one PR q.d. p.r.n. constipation. 15. Fleet enema 1 PR q.d. p.r.n. constipation. DISPOSITION AT DISCHARGE: The patient was discharged from the hospital in stable condition.
PR|per rectum|PR|120|121|DISCHARGE MEDICATIONS|9. Zofran 4 to 8 mg p.o. q8h p.r.n. 10. Coumadin 2.5 mg p.o. q.h.s. 11. Vitamin C 500 mg p.o. q.day. 12. Dulcolax 10 mg PR every other day p.r.n. 13. Celexa 40 mg p.o. q.day. 14. Dantrolene 50 mg p.o. b.i.d. 15. Colace 100 mg p.o. q.day.
PR|progesterone receptor|PR|222|223|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of a well differentiated, infiltrating lobular carcinoma and LCIS, diagnosed _%#DDMM2004#%_, grade 1/3, lymph node negative, ER greater than 90%, PR greater than 80%. REVIEW OF SYSTEMS: GENERAL: No fevers, sweats, weight change, or fatigue.
PR|progesterone receptor|PR|238|239|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her left infiltrating ductal carcinoma with status post left lumpectomy diagnosed _%#DDMM2005#%_, grade 3 of 3, 0 of five lymph nodes with ER positive at 75%, PR negative at 4% and HER-2/neu positive at 5.5. REVIEW OF SYSTEMS: GENERAL: She has hot flashes at night. Appetite is good. Energy is better than on Adriamycin and cyclophosphamide.
PR|pr interval|PR|193|194|PROCEDURES PERFORMED|HOSPITAL COURSE: 1. Chest pain. The patient was seen in the emergency room where initial ECG showed a normal sinus rhythm with rate of 75. There did appear to be diffuse ST elevation with some PR elevation and AVR consistent with pericarditis. Serial troponins were obtained which were negative. The patient was transferred to the telemetry floor where no arrhythmias were noted.
PR|pr interval|PR|216|217|LABORATORY AND DIAGNOSTIC DATA|EXTREMITIES: Lower extremities with no edema. LABORATORY AND DIAGNOSTIC DATA: Comprehensive metabolic profile is normal. Complete blood count is normal. Troponins are normal. EKG shows sinus rhythm with normal axis. PR interval is normal. QRS duration is normal. ST segment is normal. There is no ST segment depression or elevation. T waves have normal configuration.
PR|per rectum|PR|170|171|DISCHARGE MEDICATIONS|4. Aquaphor ointment applied topically b.i.d. to his left ear, skull, and neck surgical incisions. 5. Floxin Otic suspension 4 drops to left ear b.i.d. 6. Dulcolax 10 mg PR daily p.r.n. constipation. 7. OxyContin taper; please see prescription for full details. WOUND CARES: The patient may clean his surgical incisions as needed with normal saline and Q-tips to remove any forming crusts.
PR|per rectum|PR|133|134|DISCHARGE MEDICATIONS|14. Sucralfate 20 mL via J-tube b.i.d. 15. Acetaminophen 325 to 650 mg via J-tube q.4-6 h. p.r.n. pain or fever. 16. Bisacodyl 10 mg PR each day. 17. Lorazepam 1 mg via J-tube q.6 h. p.r.n. 18. Ondansetron 4 mg via J-tube q.4 h. p.r.n. 19. Oxycodone 15 mg via J-tube q.4 h. p.r.n. pain.
PR|pr interval|PR|171|172|LABORATORY DATA|PELVIC/RECTAL: Deferred. NEUROLOGIC: Grossly negative. Babinskis are plantar flexion. PULSES: Good posterior tibial and pedal pulses LABORATORY DATA: EKG shows borderline PR interval, otherwise normal EKG. Hemoglobin 13.1, potassium 4.5, prothrombin time 12.1, INR 1.00, urinalysis negative. DIAGNOSTIC IMPRESSION: 1) Severe degenerative arthritis of right knee with almost complete loss of cartilage.
PR|pr interval|PR|150|151|LABORATORY DATA|LABORATORY DATA: Electrocardiogram shows a rapid tachycardia alternating with sinus rhythm. The tachycardic has a rate of about 140, there is a short PR interval with an abnormal P-wave associated with this. Sinus rhythm looks unremarkable. ASSESSMENT: 1. Persistent supraventricular tachycardia.
PR|per rectum|PR|592|593|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Tylenol 650 mg q. 4 hours p.r.n., Optivar 0.05% drops 1 drop b.i.d., Protonix 40 mg p.o. b.i.d., Lactulose syrup 30 cc each day at bedtime p.r.n., guaifenesin 5 cc p.o. 4 times daily p.r.n. cough, Haldol 0.5 to 1 mg q. 2-4 hours p.r.n., Claritin 10 mg p.o. daily, Ativan 0.25 mg p.o. t.i.d. p.r.n. anxiety, vitamin B12 1000 mcg p.o. daily, Lasix 20 mg p.o. daily, Seroquel 25 mg p.o. b.i.d., Haldol 0.5 mg p.o. t.i.d., iron sulfate 325 mg p.o. t.i.d., MiraLax 17 grams p.o. b.i.d. p.r.n. constipation, senna one tab p.o. each day at bedtime, Dulcolax suppository 10 mg PR q. day p.r.n., TED hose, Protonix 40 mg p.o. b.i.d. for one month - then daily thereafter, Levaquin 250 mg p.o. daily.
PR|per rectum|PR|156|157|DISCHARGE MEDICATIONS|8. Fosamax 70 mg p.o. q. week on Monday. 9. OxyContin 20 mg p.o. q.12h. 10. Oxycodone 5-10 mg p.o. q.3h. p.r.n. pain. 11. Dulcolax 10 mg rectal suppository PR every other day p.r.n. no stool.
PR|pr interval|PR.|178|180|STUDIES AND IMAGING|2. Lower extremity Dopplers were done which were negative. 3. Echocardiogram done and that showed ejection fraction of 55-60%. Right ventricular hypertrophy by 2-D, trace MR and PR. No shunts or clots are seen. A mild left atrial enlargement. 4. Spiral CT and VQ scan were ordered. The patient repeatedly declined these tests.
PR|pr interval|PR|210|211|LABORATORY FINDINGS|Serum potassium was 4.2, serum creatinine 1.3. Incidentally, his cholesterol was 250, HDL 41, LDL 164 similar to the past, PSA was 1.9. Electrocardiogram showed a normal sinus rhythm with a first degree block, PR interval, 0.232 seconds. There is no evidence of injury or ischemia. Copy was made and sent with the patient. A chest x-ray appeared to be within normal limits for age.
PR|pr interval|PR|160|161|LABORATORY DATA|Calcium 9.5. Total bilirubin 0.3. Albumin 4.5. Total protein 8.5. Alkaline phosphatase 81. ALT 21. AST 46. Electrocardiogram is normal sinus rhythm with normal PR interval and no features suggestive of ischemia. ASSESSMENT AND PLAN: The patient is a 72-year-old Caucasian gentleman admitted with acute alcohol intoxication and minor head trauma.
PR|pr interval|PR|231|232|PHYSICAL EXAMINATION|EXTREMITIES: No significant edema. NEUROLOGIC: Cranial nerves II-XII, strength and reflexes appear grossly intact. Her EKG showed normal sinus rhythm, rate 87, there is no appreciable ST-abnormalities, QT is 348, corrected is 418, PR interval is 178. The strip from the field shows normal sinus rhythm. Chest x-ray is unremarkable. Troponin is less than 0.07, platelets are 252, urinalysis shows trace leukocyte esterase, 0-2 white cells.
PR|pr interval|PR,|173|175|MEDICATIONS|6. Vitamin C, Vitamin E, Zinc and garlic. Electrocardiogram showed sinus rhythm with very small inferior Q waves and very slight J point depression in precordial leads. The PR, QRS, and QT intervals within normal limits. Subsequent electrocardiogram showed resolution of the ST segment changes. There was still persistent left axis deviation with suggestion of small Q waves inferiorly.
PR|per rectum|PR|129|130|DISCHARGE MEDICATIONS|11. Oxycodone 5 mg p.o. q. 4h p.r.n. pain. 12. Colace 100 mg p.o. b.i.d. 13. Senna 2 tablets p.o. once daily. 14. Dulcolax 10 mg PR suppository once daily p.r.n. constipation. 15. Insulin sliding scale. FOLLOW UP: 1. The patient is being discharged to transitional care unit for further rehab.
PR|pr interval|PR|270|271||He developed more shortness of breath, chills, diaphoresis, ultimately developed chest discomfort and bilateral arm discomfort and was seen in the emergency room where it was noted that he had ST segment elevations, but what was not noted initially was that he also had PR depressions. His troponin was elevated at 14 and he was admitted to the hospital. He was admitted to the cardiology service and it was felt that his symptom complex is most consistent with a mild pericarditis and that this did not represent an acute coronary syndrome or acute myocardial infarction.
PR|progesterone receptor|PR|188|189|HISTORY OF PRESENT ILLNESS|CODE STATUS: DNR/DNI with comfort care as priority. HISTORY OF PRESENT ILLNESS: A 49-year-old female diagnosed in _%#DDMM2004#%_ with infiltrating breast carcinoma grade 3/3, ER negative, PR negative, T=2.7 cm, T2 N1, HER2NEU FISH. On _%#DDMM2004#%_ she began dexamethazone, adriamycin and Cytoxan which she continued through _%#DDMM2004#%_.
PR|pr interval|PR|170|171|EKG|EXTREMITIES: She has no peripheral edema, and her peripheral pulses are normal. EKG: I reviewed the EKG performed on _%#MMDD#%_, which showed normal sinus rhythm, normal PR interval, and normal QRS morphology, although precordial lead approached low voltage criteria, and there was T-wave inversion in V 1 through V 6.
PR|per rectum|PR|214|215|DISCHARGE MEDICATIONS|2. Ativan oral - 2 mg/mL. The patient is to receive 1 to 2 mg p.o. q.6 h. p.r.n. anxiety or nausea, vomiting. 3. Zofran ODT - 4 mg p.o. q.8 h. scheduled for nausea. 4. Phenergan 25 mg suppositories - 1 suppository PR q.4 h. p.r.n. nausea, vomiting. 5. Reglan solution 5 mg/mL. The patient is to receive 10 mg p.o. q.6 h. p.r.n. nausea, vomiting. 6. Miconazole powder topical b.i.d. p.r.n. for rash discomfort.
PR|per rectum|PR|166|167|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Amlodipine 2 mg p.o. q.8 h. 2. Atenolol 6 mg p.o. q. day. 3. Neoral 35 mg p.o. q.8 h. 4. Colace 20 mg p.o. b.i.d. 5. Glycerin suppository 1 PR q. day p.r.n. 6. Prevacid 8 mg p.o. b.i.d. 7. Synthroid 40 mcg p.o. q. day. 8. Simethicone 20 mg p.o. q.i.d. p.r.n. gastrointestinal.
PR|per rectum|PR|170|171|DISCHARGE MEDICATIONS|1. Tylenol 650mg PO/PR Q 4 hrs PRN. 2. Compazine 10mg PR Q 6hrs PRN. 3. Roxinol 5-10mg SL Q4 hrs PRN. 4. Ativan 0.25mg-0.5mg SL Q4-6 Hrs PRN of anxiety. 5. Dulcolax 5 mg PR Q3 days PRN.
PR|progesterone receptor|PR|616|617|HISTORY OF PRESENT ILLNESS|They represent residual or recurrent metastatic disease. 2. On _%#DDMM2007#%_, CT of the chest PE protocol shows no evidence of pulmonary emboli in this technically adequate exam, bibasilar segmental atelectasis right greater than left, indeterminate mediastinal and right hilar lymphadenopathy, which are suspicious for neoplasia given the history of metastatic breast carcinoma, several thoracic vertebral bodies demonstrate irregular sclerosis, lucency and suspicious for skeletal metastasis. HISTORY OF PRESENT ILLNESS: Briefly, a 54-year-old female with advanced stage metastatic breast carcinoma, ER negative, PR positive, HER-2 negative with known brain and bone metastasis, hilar lymphadenopathy with previous treatment strategies including conservative surgery, dose-dense AC and dose-dense Taxol completed in _%#DDMM2005#%_, subsequent Herceptin therapy for 6 months, she was then treated with Navelbine and Herceptin and started on lapatinib plus Xeloda study, which was subsequently stopped due to onset of brain metastasis.
PR|progesterone receptor|PR|286|287|HISTORY OF PRESENT ILLNESS|SURGEON: _%#NAME#%_ _%#NAME#%_, MD. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 50-year-old female with diagnosis of stage 3 infiltrating ductal carcinoma of the left breast. Her tumor was staged 3 with extensive lymphovascular invasion and inflammation. Her tumor was ER negative, PR negative and HER-2 negative. She underwent neoadjuvant chemotherapy with CALGB _%#PROTOCOL#%_ protocol. She has finished her neoadjuvant course and now presents for surgical resection.
PR|pr interval|PR|400|401|HOSPITAL COURSE|Notably, Maxzide and Coreg were both stopped this admission. To further control her blood pressure, enalapril was therefore increased to 10 mg b.i.d. She should follow up with her primary care doctor later on this week to recheck blood pressure and further titrate medications as needed. 4. First-degree AV block: The patient was noted incidentally to have a significant first-degree AV block with a PR interval near 300. I did review a previous EKG from a recent hospitalization 2 weeks ago, which showed a PR interval also near 300.
PR|per rectum|PR|164|165|MEDICATIONS|11. Bactrim SS 1 tablet p.o. each day. 12. Actigall 300 mg p.o. t.i.d. 13. Valcyte 450 mg p.o. each day. 14. Oxycodone 5 mg p.o. q.4 h. p.r.n. pain. 15. Dulcolax 1 PR p.r.n. 16. Colace 100 p.o. b.i.d. p.r.n. SOCIAL HISTORY: The patient is married and lives with her husband in _%#CITY#%_, Minnesota.
PR|per rectum|PR|313|314|PAST MEDICAL HISTORY|Upon discharge, the patient's pain was controlled with OxyContin 20 mg p.o. b.i.d. and oxycodone 10 to 15 mg p.o. q.4-6h. p.r.n. Her bowel regimen includes senna 2 tablets p.o. b.i.d., Colace 100 mg p.o. b.i.d., Zantac 150 mg p.o. b.i.d., castor oil 30 mL p.o. b.i.d. p.r.n. constipation, Dulcolax suppository x1 PR q. day p.r.n. constipation, and Fleet Enema once PR q. day p.r.n. for constipation. She is also being discharged on Compazine and Zantac for nausea and vomiting, as well as ulcer prophylaxis.
PR|progesterone receptor|PR|270|271|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her infiltrating lobular carcinoma with left modified radical mastectomy, diagnosed in 1999. She had a grade 2/3, with 5 of 10 lymph nodes positive. She was focally ER positive and diffusely PR positive. REVIEW OF SYSTEMS: GENERAL: She has hot flashes on and off.
PR|progesterone receptor|PR|224|225|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her infiltrating ductal carcinoma of the right breast with DCIS, status post mastectomy diagnosed in 2003 with 2 of 15 lymph nodes, ER positive, PR negative, HER2/neu negative. REVIEW OF SYSTEMS: GENERAL: She gets occasional hot flashes. Her weight is up four pounds.
PR|progesterone receptor|PR|291|292|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 71-year-old woman who is in today for followup her right-sided infiltrating ductal carcinoma, status post mastectomy, diagnosed _%#DDMM2005#%_, Nottingham grade 2 of 3, with 1 of 6 lymph nodes positive, ER positive at greater than 90%, PR negative at less than 5%, HER-2/neu negative. REVIEW OF SYSTEMS: GENERAL: She has night sweats on and off.
PR|pr interval|PR|185|186|HOSPITAL COURSE|On telemetry monitoring, the patient remained in sinus rhythm with an occasional PAC noted. His ECG the following day demonstrated a sinus rhythm and a rate of 80 beats per minute with PR interval of approximately 150 milliseconds and otherwise normal ECG. The patient did not exhibit any evidence of peripheral or neurologic deficits as well.
PR|per rectum|PR|184|185|DISCHARGE MEDICATIONS|At the time of discharge, the patient's hemoglobin was 10.1. He was tolerating an age appropriate diet. His wound was healing well. DISCHARGE MEDICATIONS: 1. Tylenol suppository 80 mg PR q.4h p.r.n. 2. Tylenol #3 elixir 1-2 ccs p.o. q.4h p.r.n. pain. DISCHARGE DIET: Regular. SPECIAL INSTRUCTIONS: The wound should be kept covered and dry until suture removal.
PR|per rectum|PR|124|125|DISCHARGE MEDICATIONS|13. Colace 100 mg p.o. b.i.d. for constipation. 14. Zofran 4 mg p.o. every 6 hours as needed for nausea. 15. Dulcolax 10 mg PR daily as needed for constipation. The patient should stop taking her metoprolol at this time.
PR|pr interval|PR|151|152|PHYSICAL EXAMINATION|EKG shows sinus rhythm. There is first degree AV block. There is also a nonspecific intraventricular conduction delay with a QRS duration of 116 Msec. PR interval is 214 Msec. LABORATORIES: So far show a hemoglobin of 11. A sodium of 135, a potassium of 4.1, chloride 100, bicarb 26 and anion gap of 8.
PR|per rectum|PR|124|125|MEDICATIONS ON DISCHARGE|5. Ferrous sulfate 325 mg p.o. daily. 6. Colace 100 mg b.i.d. 7. Percocet 2 tabs while awake q. 4 hours. 8. Bisacodyl 10 mg PR p.r.n. 9. Compazine 10 mg q. 6 hours p.r.n. 10. Lasix 20 mg p.o. q. day. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 69-year-old male who has a history of metastatic prostate cancer.
PR|per rectum|PR|138|139|DISCHARGE MEDICATIONS|3. Percocet 1-2 tablets q.4-6h. p.r.n. pain. 4. Senna 2 tabs p.o. daily at bedtime, continue while on Percocet. 5. Dulcolax suppository 1 PR daily p.r.n. constipation. FOLLOW-UP APPOINTMENT: _%#NAME#%_ _%#NAME#%_ M.D. in the transplant clinic in the next 10-14 days to follow-up laparoscopic donor nephrectomy.
PR|pr interval|PR|177|178|BRIEF HISTORY AND HOSPITAL COURSE|His EKG would vary between a normal PR interval and a very long PR interval of 0.4, and this is basically proof of a dual AV node pathway, with the fast pathway being the short PR interval, and the long PR interval consistent with a slow pathway. This is a normal variant that we never document in AV node reentry tachycardia, and therefore this dual AV node pathway probably is an incidental finding.
PR|per rectum|PR|121|122|MEDICATIONS|Reason is constipation 9. Ambien 5 mg p.o. each day at bedtime. The reason is insomnia. 10. Acetaminophen 650 mg p.o. or PR q.4h p.r.n. pain. The reason is pain. 11. Vancomycin 1 gram IV to be given with dialysis with levels drawn prior to dialysis and to be followed by Dr. _%#NAME#%_.
PR|per rectum|PR|164|165|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Synthroid 88 mcg p.o. daily. 2. Pravastatin 20 mg p.o. daily. 3. CellCept 1 g p.o. b.i.d. 4. Protonix 40 mg p.o. daily. 5. Dulcolax 10 mg PR p.r.n. for constipation. 6. Senokot 2 tablets p.o. b.i.d. for constipation. 7. Benadryl 50 mg p.o. q.4 hours for pruritus. 8. Neoral 200 mg p.o. q.12 hours. 9. Norvasc 10 mg daily.
PR|pr interval|PR|217|218|PHYSICAL EXAMINATION|ABDOMEN: Positive bowel sounds, soft, and nontender. EXTREMITIES: No edema. His radial pulses are 3+ bilaterally. His ECG from the emergency room showed ST elevation in II, III, and F and first degree AV block with a PR interval of 264 and T wave inversions in V1 and V2 as well as ST depression in lead I. His labs on admission are as follows. Total protein 6.7, sodium 139, paroxysmal 3.6, glucose 181, creatinine 1.1, C02 26, chloride 104, calcium 8.2, BUN 20, bili of 0.3, AST of 21, ALT of 24, alk phos 87, albumin 3.1, platelet count 200.
PR|per rectum|PR|145|146|DISCHARGE MEDICATIONS|2. Clindamycin 300 mg q.i.d. times eight days (patient does not tolerate Flagyl). 3. Lactulose 30 cc qd prn. 4. Hydrocortisone suppositories one PR qd prn. 5. Prevacid 30 mg p.o. qd. Discharge followup will be with Dr. _%#NAME#%_ in 1-2 weeks. Discharge followup with Dr. _%#NAME#%_ in one month or prn.
PR|per rectum|PR|174|175|DISCHARGE MEDICATIONS|2. Atenolol 50 mg p.o. daily. 3. Cogentin 1-2 mg p.o. t.i.d. p.r.n. extra pyramidal effects. 4. Lumigan 0.03% drops one drop each eye each day at bed-time. 5. Dulcolax 10 mg PR q.12h. p.r.n. 6. Alphagan 0.15% one drop each eye t.i.d. 7. Aricept 5 mg p.o. daily. 8. Haldol 0.5-1 mg p.o. q.6h. p.r.n. severe agitation.
PR|pr interval|PR|276|277|LABORATORY DATA|LABORATORY DATA: Include a potassium 3.3, sodium 138, creatinine 0.9, troponin 0.31. D-dimer 0.2, white blood cell count 7.2, platelets 189,000, hemoglobin 15.2. His ECG initially shows inferior ST elevations of less than 1 mm. Repeat ECG shows diffuse ST elevations and mild PR depression in lead V3. IMPRESSION REPORT AND PLAN: 1. Exertional chest pain with typical features.
PR|per rectum|PR|134|135|DISCHARGE  MEDICATIONS|She was given nutritional supplements. DISCHARGE MEDICATIONS: 0. Enteric-coated aspirin 81 mg p.o. daily.1. 2. Tylenol 650 mg p.o. or PR q.6h. p.r.n. 3. Dulcolax 10 mg per rectum daily p.r.n., 4. Calcium carbonate 250 mg 1 tablet p.o. t.i.d., 5. Ciprofloxacin 500 mg p.o. b.i.d. through _%#DDMM2005#%_
PR|UNSURED SENSE|PR|128|129|DISCHARGE MEDICATIONS|2. Vicodin. 3. Doxycycline 100 mg p.o. twice a day for 14 days. Of note, she did receive 1 dose of ceftriaxone 250 mg IM in the PR immediately following surgery.
PR|pulmonary regurgitation|PR|231|232|HOSPITAL COURSE|Repeat echocardiogram on _%#DDMM2006#%_ showed an ejection fraction of 50-55% with elevated filling pressures strongly suggestive of diastolic dysfunction. She had mild mitral regurgitation, trace tricuspid regurgitation and trace PR also noted and the right ventricular systolic pressure was 55 mm. plus right atrial pressure. The patient improved nicely over the next several days.
PR|pulmonary regurgitation|PR,|125|127|PROCEDURES|PROCEDURES: 1. Administration of botulism immunoglobulin. 2. Echocardiogram. Results: Normal LV function, RV function, trace PR, small PFO left to right, aortic arch appears within normal limits. No pericardial effusion. 3. Ophthalmologic evaluation. 4. Lumbar puncture.
PR|pr interval|PR|176|177|LABORATORY|LABORATORY: Her admission laboratory data was significant for BNP of 826 and negative troponins. Her initial EKG showed a left anterior fascicular block, atrial rate of 101, a PR interval of 160, a QRS of 114, a QTC of 484, with an axis of negative 50. HOSPITAL COURSE: Her hospital course was characterized by aggressive diuresis and reinstitution of her medications.
PR|pr interval|PR|146|147|PHYSICAL EXAMINATION|Bowel sounds are present. EXTREMITIES: No edema. No signs of DVT. NEUROLOGIC: Nonfocal. EKG by my reading reveals sinus rhythm with a rate of 65. PR 0.16, QT 0.38. There is good R wave progression, the axis is normal. No ischemic changes. No previous EKGs available for comparison. ASSESSMENT/PLAN: There is no contraindication to this procedure assuming CBC and comprehensive metabolic panel drawn today are acceptable.
PR|per rectum|PR|252|253|DISCHARGE MEDICATIONS|She also needs further assistance with her ADLs. Arrangements are being made for her to go to transitional care at the time of discharge to further her rehabilitation after the stroke. DISCHARGE MEDICATIONS: 1. Senna 2 tabs at night. 2. Dulcolax 10 mg PR q.24h. as needed. 3. Lipitor 40 mg daily. 4. Paxil 10 mg daily. 5. Isosorbide mononitrate 30 mg daily. 6. Plavix 75 mg daily.
PR|per rectum|PR|196|197|DISCHARGE MEDICATIONS|She will have q.i.d. Accu-Cheks along with sliding scale along with her scheduled insulin. DISCHARGE MEDICATIONS: 1. Ventolin 2 puffs inhaled q.i.d. 2. Aspirin 81 mg p.o. daily. 3. Dulcolax 10 mg PR p.r.n. for constipation. 4. Wellbutrin 150 mg p.o. b.i.d. 5. Peridex 15 mg swish and spit b.i.d., stop after 14 doses. She did have 4 wisdom teeth extracted preoperatively in preparation for her valve surgery.
PR|per rectum|PR|182|183|DISCHARGE MEDICATIONS|4. Oyster-Cal-D, 500 mg, one p.o. t.i.d. 5. Synthroid, 88 mcg p.o. q.d. 6. Colace solution, 100 mg p.o. b.i.d. p.r.n. 7. Trazodone, 50 mg p.o. q.h.s. 8. Bisacodyl suppository, 10 mg PR q.o.d. 9. Milk of Magnesia, 30 ccs p.o. q.h.s. 10. Ativan, 0.5 to 1.0 mg p.o. t.i.d. p.r.n. DISCHARGE PLAN: 1. The patient will be transferred back to her nursing home for continued care.
PR|per rectum|PR|189|190|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Sinemet ER 50/200, 1/2 tablet 5 times per day, and Sinemet 10/100, 7 x per day. 2. Zantac 150 mg p.o. b.i.d. 3. Baclofen 10 mg p.o. q.d. 4. Dulcolax suppository 1 PR q.d. 5. Amantadine 100 mg p.o. b.i.d. 6. Seroquel 12.5 mg p.o. q.h.s. 7. Celexa 40 mg p.o. q.a.m. 8. Ativan 1 mg p.o. q.h.s. p.r.n. 9. Vicodin 1 to 2 tablets p.o. q.4h. p.r.n.
PR|UNSURED SENSE|PR|180|181|HISTORY OF PRESENT ILLNESS|Initial care was at 12 weeks. A total of 3 visits. Total weight gain unavailable. Blood pressure 100/60. Prenatal labs A positive, antibody negative, HIV negative, Rubella immune, PR negative, hepatitis negative. Hemoglobin 12.7. Ultrasound none. Medications include Zoloft 50 mg p.o. b.i.d. and prenatal vitamins. PAST MEDICAL HISTORY: Significant for manic depression and PTSD. PAST SURGICAL HISTORY: Status post classical Cesarean section in _%#MM#%_ 2002, status post tonsillectomy and adenoidectomy, status post lithotripsy.
PR|pr interval|PR|272|273|LABORATORY|ABDOMEN: Soft, nontender, no hepatosplenomegaly. EXTREMITIES: No pedal pitting edema. LABORATORY: electrocardiogram shows sinus tachycardia, first-degree AV block, left bundle branch block and he has got a suggestion of ST elevation in 3 and AVF, however, with respect to PR segment only there is a 30 second ST segments are not elevated. He does have Q-waves in III and AVF which are quite significant.
PR|pr interval|PR|200|201|HISTORY|Postoperatively, he had problems with atrial fibrillation and was on amiodarone and Coumadin. The patient was maintained in sinus rhythm although he had a bundle branch block pattern with a prolonged PR interval at over 300 milliseconds. The patient was seen in clinic at the end of _%#DDMM2007#%_. The patient was desiring to be off medications and therefore his amiodarone was stopped.
PR|per rectum|PR|142|143|DISCHARGE MEDICATIONS|7. Milk of Magnesia 30 mL p.o. daily p.r.n. constipation. 8. Tylenol 650 mg p.o. q.4 h. p.r.n. pain or fever. 9. Dulcolax 1 10-mg suppository PR daily p.r.n. constipation. 10. Cepacol lozenge 1 p.o. q.2 h. p.r.n. sore throat. 11. Prilosec 20 mg p.o. daily. 12. Effexor XR 75 mg p.o. 2 tablets q.a.m. and 1 tablet q.p.m.
PR|progesterone receptor|(PR)|174|177|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Breast cancer, infiltrating, stage III, lobular adenocarcinoma of the right breast. This was estrogen-receptor (ER) positive, progesterone- receptor (PR) negative, HER-2/neu negative. She had a bilateral mastectomy in _%#MM#%_ 1999. She also received chemotherapy and radiation therapy.
PR|pr interval|PR|193|194|DIAGNOSTIC STUDIES|NEUROLOGIC: Symmetric cranial nerves, strength and reflexes, with downgoing toes bilaterally. DIAGNOSTIC STUDIES: EKG shows sinus rhythm, and a minor nonspecific ST and T wave abnormality. Her PR interval has actually improved from _%#MM#%_, but otherwise there is no change from a _%#MM#%_ EKG. Hemoglobin is 14.8. ASSESSMENT: 1. Bilateral eyelid dermatochalasis, with planned surgery on _%#DDMM2002#%_.
PR|pr interval|PR|198|199|PHYSICAL EXAMINATION|Lungs: Left basilar rales. Abdomen: Soft, nontender, nondistended, normal bowel sounds. Extremities: No clubbing, cyanosis, or edema. No rashes. EKG shows atrial fib with a rate of 77, normal axis, PR interval of 146, QRS of 88, Q waves in 3 and AVF. LABORATORY: Sodium 142, potassium 4.5, chloride 110, bicarb 23, glucose 118, calcium 8.9, BUN 27, creatinine 1.1, hemoglobin 13.4, platelets 223, INR 1.01, white count 8.2, TSH less than .01, troponins negative x 3, total cholesterol 85, LDL 43, VLDL 15.
PR|pr interval|PR|295|296|IMAGING|Sodium 143, potassium 4.3, chloride 106, bicarb 27. BUN 18, creatinine 0.9, glucose 85, calcium 8.7. IMAGING: A chest x-ray showed mild cardiomegaly, normal pulmonary venous markings, and no infiltrate. A calcified RV-to-PA conduit was noted. EKG showed normal sinus rhythm at a rate of 79 with PR interval 0.14, right atrial enlargement and right bundle branch block. HOSPITAL COURSE: PROBLEM #1: Surgical procedure. The patient underwent change of her homograft pulmonary conduit on _%#DDMM2004#%_.
PR|per rectum|PR.|200|202|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 46-year-old male with a 7-day history of constipation with continuing urges to defecate. For this, he did digital rectal stimulation and Dulcolax p.o. and PR. The patient does not complain of any nausea, vomiting, or decreased appetite, though he has recently decreased his p.o. intake for fear of becoming obstructed.
PR|pr interval|PR|203|204|HOSPITAL COURSE|The patient is a 52-year-old white male with a history of liver transplant who was on Prograf. He presented after he had developed chest pain that was pleuritic, associated with position. His EKG showed PR depression, sloping ST elevation. He was seen by Cardiology who agreed with the diagnosis of pericarditis. The patient did have cardiac enzymes that were negative x3.
PR|per rectum|PR|144|145|TRANSFER MEDICATIONS|Mother died at age 78 secondary to pulmonary fibrosis. TRANSFER MEDICATIONS: 1. Vitamin C 500 mg p.o. daily. 2. Dulcolax suppository 10 mg p.o. PR daily prn. 3. Lovenox 30 mg subcutaneously daily. 4. Ferrous sulfate 325 mg p.o. daily. 5. Lisinopril 20 mg p.o. daily. 6. Megace 400 mg suspension p.o. q.a.m.
PR|per rectum|PR|148|149|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Nexium 40 mg p.o. b.i.d. for 6-8 weeks. 2. Percocet 1-2 tabs p.o. q.4-6h. p.r.n. pain. 3. Dulcolox suppository one tablet PR daily p.r.n. constipation. FOLLOW-UP APPOINTMENT: 1. Dr. _%#NAME#%_ in the transplant clinic in approximately one week to follow up his nephrectomy in recent admission.
PR|pr interval|PR,|190|192|DIAGNOSTICS|MUSCULOSKELETAL: Without synovitis. PELVIC/RECTAL: Deferred. NEUROLOGIC: Nonlateralizing. DIAGNOSTICS: Electrocardiogram demonstrating normal sinus rhythm with heart rate in the 70s. Normal PR, QRS, and QT interval. There are nonspecific ST-T changes V2-V6 as well as inferiorly which actually appear less prominent particularly in the lateral leads when compared with tracing _%#DDMM2006#%_.
PR|pr interval|PR|143|144|PHYSICAL EXAMINATION|EKG shows a left bundle branch configuration with uncertain rhythm. I cannot make out a definite P-wave although I believe there is one with a PR interval of approximately 0.12. Chest x-ray showed increased fluid ______________ventricle. LABORATORY DATA: Will be done in the hospital.
PR|pr interval|PR|311|312|PAST MEDICAL HISTORY|1. COPD with exacerbation in _%#MM#%_ 2004. A mini-chest x-ray also showed mild congestive heart failure but a cardiac echo during the _%#MM#%_ admission showed moderate to moderately severe biatrial enlargement with normal LV size and systolic function without regional wall motion abnormality. There was mild PR with RV systolic pressure estimated at 30 + RA pressure. No thrombus was seen. 2. Atrial fibrillation. I have been very hesitant to put her on Coumadin because of her history of alcohol use and abuse in the past.
PR|pr interval|PR|178|179|ASSESSMENT/PLAN|We will hold that as she has had the hip contusion, at least for one day and then likely re-start her aspirin. She looks like she is beta blocked. In fact she does have a slight PR prolongation and first degree AV block. She gives no history of feeling dizzy or any orthostatic type symptoms. This seems simply like she tripped and fell because she could not see.
PR|pulmonary regurgitation|PR,|124|126|PROCEDURES AND OTHER TESTS DONE|Echocardiogram showing LV function with estimated EF of 60%, atrial fibrillation, no clots were seen. Some mild MR and mild PR, mild TR, right ventricular systolic pressure 21. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a _%#1914#%_-year-old female who was admitted on _%#DDMM2004#%_.
PR|per rectum|PR|152|153|DISCHARGE MEDICATIONS|Their plan was to have him follow up in approximately 2 weeks for repeat pullback nephrostomy and ureterogram. DISCHARGE MEDICATIONS: 1. Dulcolax 10 mg PR p.r.n. constipation. 2. Lasix 40 mg b.i.d. 3. Zinc sulfate 220 mg p.o. daily. 4. Bactrim Single Strength 1 tab p.o. daily. 5. Darbepoetin 100 mcg subcutaneous q. week.
PR|pr interval|PR|264|265|EKG|Abdomen: Copious gas, biliary ductal air (has been seen on prior film), and the small bowel needs to be further identified and compared to prior CTs. EKG: EKG is a pattern consistent with pericarditis. This is prominent in the inferior leads, II, III and aVF with PR depression and .........elevation with early repolarization in a pattern consistent with pericarditis. This is most prominent in lead II, which is greater than III.
PR|per rectum|PR|113|114|DISCHARGE MEDICATIONS|2. Ativan 1 mg p.o. IV q.2-4h. 3. Scopolamine patch 1.5 mg patch q 3 days for secretions. 4. Aspirin 325 mg p.o. PR p.r.n. for fevers. 5. Tylenol 650 mg p.o. PR q.4-6h. p.r.n. for fever. 6. Demerol 150 mg p.o. IM q.3-4h. p.r.n. for rigors.
PR|pulmonary regurgitation|PR.|187|189|HISTORY OF PRESENT ILLNESS|3. Hospitalized for atherosclerotic coronary vascular disease in _%#MM#%_ of 2001 at which time she had an echo which showed left ventricular ejection fraction of 55% to 60%, mild MR and PR. No prolapse. 4. Back injury in 1968 with residual chronic neck pain. This has been evaluated by Dr. _%#NAME#%_ and has been considered nonoperable.
PR|per rectum|PR|140|141|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prednisone 40 mg PO q. day. 2. Senna 2 tabs PO at bedtime. 3. Colace 100 mg PO b.i.d. 4. Dulcolax suppositories 1 PR b.i.d. p.r.n. 5. Zantac 150 mg PO b.i.d. 6. Artificial Tears 2 or 3 drops to right eye q.2-3 hours and p.r.n.
PR|pr interval|PR|171|172|DISCHARGE DIAGNOSIS|His troponins were negative. His chest x-ray was negative for any acute pathology. EKG showed diffuse ST-segment elevation throughout the limb and precordial leads with a PR depression. The EKG was classic for pericarditis. Patient also underwent an echocardiogram as well as a stress echocardiogram, the results of which have been dictated above.
PR|pr interval|PR|146|147|ELECTROCARDIOGRAM|ALT 8. Total bilirubin 0.3. Albumin 3.6. Total protein 6.9. Alkaline phosphatase 79. INR 1.15. ELECTROCARDIOGRAM: Sinus rhythm with a rate of 90. PR interval 0.16. QRS 0.09. ? left anterior fascicular block. Possible old septal infarct. ASSESSMENT: 1. New onset seizure. 2. Abnormal electrocardiogram with ? septal infarct with elevated troponin.
PR|pr interval|PR|346|347|LABORATORY|Abdomen: Soft, non-tender, with no mass or organomegaly. Extremities: Normal, except for diminished posterior tibialis pulse, right foot. Skin: Benign. Neurologic: Intact. LABORATORY: Hemoglobin 12.9, WBC 7.8, platelets count 241,000, potassium 4.5, creatinine 1.4. Electrocardiogram: Sinus rhythm with first-degree atrial-ventricular block with PR interval of 0.34 seconds, which is similar to his previous recent electrocardiograms. ASSESSMENT: Mr. _%#NAME#%_ is medically stable for esophageal surgery. Ongoing medical problems include history of coronary artery disease, chronic obstructive pulmonary disease, benign prostatic hypertrophy, glaucoma, mitral valve insufficiency, and cigarette smoking.
PR|per rectum|PR|171|172|DISCHARGE MEDICATIONS|6. Protonix 40 mg p.o. or NG b.i.d. 7. Ursodiol 300 mg p.o. or NG t.i.d. 8. Spironolactone 25 mg p.o. or NG b.i.d. 9. Duo-neb 3 cc q4h p.r.n. 10. Dulcolax one suppository PR q.d. p.r.n. 11. Percocet elixir 5 ml/325 mg Tylenol/5 mg Oxycodone, 5 to 10 ml elixir in J-tube q4-6h p.r.n. 12. Dilaudid 0.1 to 0.3 mg IV q1h p.r.n. for breakthrough pain.
PR|(drug) PR|PR|137|138|IDENTIFICATION|The MSSA rating scale was used with Ativan to cover withdrawal symptoms. On admission Buspar 30 mg t.i.d. was reordered as well as Paxil PR 37.5 mg daily, Gedeon 20 mg at bedtime. Seroquel 25 mg twice a day and 50 at bedtime was also started for anxiety and sleep.
PR|pr interval|PR|167|168|PHYSICAL EXAMINATION|Bowel sounds are present. Extremities: No edema, no signs of DVT or cellulitis. Neurologic: Non-focal. EKG by my reading today reveals sinus rhythm with a rate of 60, PR 0.16, QT 0.40, Axis, normal. Good R-wave progression. No ischemic changes and no significant change compared with _%#DDMM2004#%_. ASSESSMENT/PLAN: Hip pain. There is no contraindication to this procedure, assuming CBC and basic metabolic panel are acceptable.
PR|pr interval|PR,|148|150|HISTORY OF PRESENT ILLNESS|Remaining liver function studies were normal. Ammonia less than 1. INR minimally elevated at 1.16. EKG demonstrated normal sinus rhythm with normal PR, QRS, and QT intervals. Nonspecific T-wave abnormality. Prior question of TIA-like event for which patient had been placed on Plavix. A Proteus mirabilis urinary tract infection, _%#MM#%_ _%#DD#%_, 2004, for which patient was treated with Cipro.
PR|progesterone receptor|PR|253|254|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her left-sided lumpectomy with infiltrating lobular carcinoma and LCIS, diagnosed _%#DDMM2004#%_ with grade 2/3 cancer, with 0 of 3 lymph nodes positive. ER positive at 90%, PR at 5%, HER-2/neu negative. REVIEW OF SYSTEMS: GENERAL: She had a low grade fever with a bad cold.
PR|pr interval|PR|161|162|HISTORY OF THE PRESENT ILLNESS|When he arrived here, his troponin I was repeated. It was again less than 0.07. His EKG at Fairview Lakes showed normal sinus rhythm at 65 beats per minute. His PR interval, QRS duration and QT interval corrected were within normal limits. He had Q-waves in leads 3 and AVF suggestive of an old inferior wall infarct.
PR|progesterone receptor|PR|238|239|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her right-sided infiltrating ductal carcinoma diagnosed _%#DDMM2002#%_ with metastatic disease. This is a grade 3 of 3 with 0 of one lymph nodes, ER positive, PR negative, HER-2/neu 2+. REVIEW OF SYSTEMS: GENERAL: Appetite is better. She has some days where she is not feeling so well.
PR|per rectum|PR|112|113|DISCHARGE MEDICATIONS|The family is in agreement that the patient will be made comfort care. DISCHARGE MEDICATIONS: 1. Tylenol 650 mg PR q.4-6 h. for fever and comfort. 2. Morphine 20 to 30 mg sublingual or suppositories q.2 to 4 hours p.r.n. The patient is now DNR/DNI and is made comfort care.
PR|per rectum|PR|307|308|DISCHARGE MEDICATIONS|10. Malnutrition requiring tube feedings. 11. Depression. DISCHARGE DISPOSITION: _%#NAME#%_ _%#NAME#%_ will be going over to Fairview University Transitional Care Center for ongoing rehabilitation. DISCHARGE MEDICATIONS:. 1. Dilantin suspension 400 mg down feeding tube b.i.d. 2. Dulcolax suppository 10 mg PR q day. 3. Digoxin 250 mcg down feeding tube q day. 4. Lasix 20 mg down feeding every other day. 5. Lantus insulin 45 units subcu q h.s. 6. Regular insulin sliding scale with q.i.d. Accu-Cheks.
PR|progesterone receptor|PR|136|137|HISTORY OF PRESENT ILLNESS|The patient had bilateral mastectomies. She had a grade 3 of 3 cancer, with 1 of 15 lymph nodes positive. She was ER positive at 43.3%, PR positive at 68.8%, and she was HER-2/neu positive. REVIEW OF SYSTEMS: GENERAL: Appetite is good. Energy is good.
PR|progesterone receptor|PR|141|142|HISTORY OF PRESENT ILLNESS|She had one cancer which was an infiltrating ductal with grade 2 out of 3. The other cancer was grade 1. They were both ER positive at 100%, PR at 30- 35%, 0 of 2 lymph nodes, HER-2/neu negative. REVIEW OF SYSTEMS: GENERAL: Hot flashes, but they are much better now that her thyroid is under good control.
PR|progesterone receptor|PR|193|194|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her infiltrating ductal carcinoma diagnosed _%#DDMM2005#%_ with grade 2/3, 0 of 1 lymph nodes. She is ER 100% and PR 85%, HER-2/neu negative. Her cancer was 4 cm in size. REVIEW OF SYSTEMS: GENERAL: Weight is up 35 pounds. She has increasing fatigue.
PR|progesterone receptor|PR|312|313|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her metastatic infiltrating ductal carcinoma and DCIS of the left breast, diagnosed _%#DDMM2000#%_, with recurrence on _%#DDMM2005#%_. She had a grade 2/3 cancer. She had 1 of 4 lymph nodes positive. She was ER positive at 80.9% and PR borderline at 7.2. HER-2/neu negative. REVIEW OF SYSTEMS: GENERAL: No fevers, sweats, weight change, or fatigue.
PR|progesterone receptor|PR|294|295|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 53-year-old woman who is in today for followup of her left-sided modified radical mastectomy for infiltrating ductal carcinoma diagnosed on _%#DDMM2005#%_. She had a Nottingham grade 3 of 3, with 3 of 20 lymph nodes positive, ER negative, PR negative, and HER-2/neu negative. REVIEW OF SYSTEMS: GENERAL: The patient has a little fatigue.
PR|progesterone receptor|PR|208|209|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her infiltrating ductal carcinoma , diagnosed _%#DDMM2005#%_, 1.7 cm in size, 0 of 1 sentinel lymph nodes positive, ER positive, PR negative, HER-2/neu positive. REVIEW OF SYSTEMS: GENERAL: Weight is down 2 pounds but her appetite is good.
PR|progesterone receptor|PR|148|149|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her left-sided DCIS diagnosed _%#DDMM2004#%_, ER positive at 90% and PR negative at 5%. REVIEW OF SYSTEMS: GENERAL: No fevers, sweats, weight change, or fatigue.
PR|per rectum|PR|190|191|DISCHARGE MEDICATIONS|6. Amaryl 2 mg one p.o. daily. 7. Lidoderm patch 5% on at 9 p.m. and off at 9 a.m. applied to starred area on right flank between blisters and not over blisters. 8. Dulcolax suppository one PR daily p.r.n. 9. Actos 30 mg p.o. daily. 10. Pred Forte 1% one drop in the right eye four times a day. 11. Ranitidine 150 mg p.o. b.i.d. 12. Senokot two p.o. q.h.s.
PR|progesterone receptor|PR|255|256|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her infiltrating ductal carcinoma and DCIS of the right breast, status post lumpectomy, treated in _%#DDMM#%_. She had a Nottingham grade 2/3, ER positive at greater than 90%, PR less than 5%, HER-2/neu negative. REVIEW OF SYSTEMS: GENERAL: She gets tired a lot. Pain when she eats in the mid back.
PR|pulmonary regurgitation|PR,|196|198|HOSPITAL COURSE|Echocardiogram was done, showing ejection fraction of 10%, four-chamber cardiac dilatation, trivial pericardial effusion, moderate plus mitral regurgitation, moderate plus TR and mild to moderate PR, with significant elevation of pulmonary pressures. Dr. _%#NAME#%_ picked up the service and recommended inotropic support, right and left heart catheterization, possible transplant referral.
PR|per rectum|PR|207|208|IMPRESSION AND PLAN|I did discuss this with the father, and we will obtain a urine toxicology screen as well as acetaminophen and aspirin levels. Plan at this point includes the following: 1. Check a Dilantin level. 2. Aspirin PR daily. 3. We will avoid heparin given her elevated INR. 4. We will obtain a chest, abdomen and pelvic CT to evaluate for pulmonary embolism and evaluate her abdominal distention in light of her anemia to rule out bleed.
PR|pr interval|PR|223|224|LABORATORY|LABORATORY : Labs from Ridges are reviewed, which include a troponin of 0.34, and a second one of 0.76. His chest x-ray showed no abnormalities. His EKG shows sinus rhythm with a first-degree AV block, a slightly prolonged PR interval of 0.21, and what appears to me to be some biphasic T waves in V 1 and V 2, really more in V 2 and V 3, and some flattening of the ST-T wave segments in I and II and III as well as aVF, slightly flattened.
PR|per rectum|PR|129|130|PHYSICAL EXAMINATION|Bedside ultrasound shows vertex, but no fluid. The patient was given magnesium sulfate 2 mg IV x3 with no relief. Indocin 100 mg PR was given, no change in her symptoms. ASSESSMENT AND PLAN: A 36-year-old G2, para 0-0-1-0 at 23 plus 2 weeks with suspected preterm premature rupture of membranes and preterm labor.
PR|pr interval|PR|112|113|LABORATORY DATA|INR 1.09. D-dimer 2.8. Urine pregnancy test negative. EKG shows normal sinus rhythm with first-degree AV block. PR interval of 210 milliseconds. No acute ST/T changes. CT of the chest shows bilateral predominantly basilar pulmonary emboli.
PR|per rectum|PR|199|200|DISCHARGE MEDICATIONS|2. Multiple lab tests. 3. Chest x-ray which shows a very large right-sided infiltrate, atelectasis, and bilateral pleural effusions, right greater than left. DISCHARGE MEDICATIONS: 1. Tylenol 650 mg PR q. 4 hours p.r.n. fever. 2. Atropine 1% 1-2 drops sublingual q. 30-50 minutes p.r.n. secretions. 3. Haldol 1-2 mg p.o. q. 6 hours p.r.n. agitation.
PR|pulmonary regurgitation|PR.|209|211|IMAGING|IMAGING: Cardiac echo shows prominent right pulmonary artery flow with very mild increased velocities, prominent pulmonary artery size, left and right. No clots were seen. She has mild MR, mild TR and trivial PR. Aortic valve is sclerotic with very small mobile echoes seen - strands. She has a normal LV and mild hypo right ventricular function.
PR|pr interval|PR|230|231|HOSPITAL COURSE|HOSPITAL COURSE: The patient tolerated surgery and anesthesia well. Minimal blood loss was found, less than 20 mL during surgery. Postoperatively the patient was noted to have, on the night of _%#MM#%_ _%#DD#%_, 2004, a prolonged PR interval and a question of Wenckebach type 2 heart block was considered. On _%#MM#%_ _%#DD#%_, 2004, cardiology was consulted regarding this. Cardiology found that this was likely a benign rhythm and indicated that this was very common in endurance athletes.
PR|progesterone receptor|PR|204|205|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 54-year-old man who is in today for followup of his male breast cancer, diagnosed _%#DDMM2004#%_, grade III of III, 1 of 5 lymph nodes, ER positive, PR negative, HER-2/neu positive. REVIEW OF SYSTEMS: GENERAL: Hot flashes on and off. Energy is down.
PR|pr interval|PR|214|215|LABORATORY DATA|LABORATORY DATA: Unremarkable with normal D-dimer. CBC unremarkable. First troponin less than 0.07, myoglobin 47. ____________ unremarkable. Chest x-ray unremarkable. INR 0.98. EKG shows first degree AV block with PR interval of 232 ____________. There is some T wave flattening in the inferior leads, otherwise no other abnormalities.
PR|pr interval|PR,|228|230|AVAILABLE LABORATORY DATA|Urinalysis: Unremarkable. White count 7100, hemoglobin 15.6 gm%, MCV 95.2, platelet count 267,000. Negative chest x-ray, _%#DDMM2005#%_. Electrocardiogram, _%#DDMM2006#%_, demonstrates a normal sinus rhythm, normal axis, normal PR, QRS, and QT interval, no ischemic change, tracing within normal limits. ASSESSMENT: 67-year-old female to undergo elective left total knee arthroplasty with the following problems: 1. Bilateral osteoarthritis of the knees.
PR|pr interval|PR|349|350|LABORATORY|LABORATORY: Hemoglobin today is 14.8, white blood count 8500, red blood cell indices were normal, platelet count 362,000, basic metabolic profile showed BUN of 14, creatinine of 0.88, blood sugar of 94, sodium was 140, calcium 4.2. His chest x-ray was satisfactory for surgery and his EKG showed a normal sinus rhythm with a QRS axis of -4 degrees. PR interval was 0.132 msec, QT 396 msec. He has a minimal intraventricular conduction delay noted but no significant findings.
PR|progesterone receptor|PR|239|240|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her infiltrating ductal carcinoma and DCIS and LCIS diagnosed in _%#DDMM#%_, grade 3/3, with 2 of 6 lymph nodes positive. She was ER positive at 71.6 and trace PR positive at 6.4, HER-2/neu 1+ (negative). REVIEW OF SYSTEMS: GENERAL: Weight is up 2 pounds. EYES: Negative, no blurred or double vision EARS: Negative.
PR|progesterone receptor|PR|356|357|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her infiltrating ductal carcinoma of the right breast, status post left mastectomy with lymph node dissection in the right axilla diagnosed _%#DDMM1999#%_ with recurrence in _%#MM2001#%_. The patient had grade II of III cancer with 26 of 34 lymph noes positive. She was ER and PR positive at 70.6% and 63.3%, respectively and 3+ HER-2/neu positive. REVIEW OF SYSTEMS: GENERAL: Her appetite is better but not great.
PR|progesterone receptor|PR|229|230|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 57-year-old woman who is in today for followup of her infiltrating ductal carcinoma, diagnosed _%#DDMM2001#%_. It was grade 1 of 3, 0 of 5 lymph nodes, ER positive at 78.5%, PR positive at 70.8%. REVIEW OF SYSTEMS: GENERAL: Occasional hot flashes.
PR|pr interval|PR|150|151|HISTORY OF PRESENT ILLNESS|His blood pressure was 110/60 with a pulse of 79. He appeared comfortable. An ECG done here at 9:50 this morning showed normal sinus rhythm with mild PR depressions in II, III and AVF and minimal ST elevations in V2, V3 which resemble an early repolarization variant.
PR|progesterone receptor|PR|238|239|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her infiltrating ductal carcinoma with DCIS diagnosed _%#DDMM2001#%_, grade 1/3, with 1 of 1 lymph nodes positive microscopically. She was ER negative at 2.4, PR 24 and HER-2/neu negative. Largest size of metastasis was 0.15 cm. REVIEW OF SYSTEMS: GENERAL: Hot flashes continued.
PR|pr interval|PR|161|162|HOSPITAL COURSE|No vegetations were seen in the valves. There was moderate aortic stenosis with an estimated valve area of 0.9 sq cm and a peak gradient of 35. Trace MR, TR and PR were noted. Left atrial enlargement was noted along with some LVH. PICC line was placed and the patient will require total of 14 days of vancomycin therapy for the Staph bacteremia.
PR|pr interval|PR,|315|317|ADMISSION LABORATORY|Sodium 137, potassium 3.9, chloride 87, CO2 greater than 40, glucose 144, BUN 23, creatinine 0.57, elevated ALT of 214 with AST of 73, INR 2.21 with troponin less than 0.07. Arterial blood gas: pH 7.45, pCO2 57, pO2 67, bicarb 39, FiO2 of 40%. Electrocardiogram demonstrated a normal sinus rhythm with PACs. Normal PR, QRS and QT intervals. No ischemic change. Chest x-ray demonstrated flat diaphragms with hyperlucent Lungs. No obvious infiltrate. HOSPITAL COURSE: The patient admitted to the intensive care unit where he was seen in consultation by University of Minnesota Pulmonary Service.
PR|per rectum|PR|145|146|DISCHARGE MEDICATIONS|21. Nizoral 2% shampoo every other day to sleep. 22. Fuzeon 90 mg subcu q.12 h. 23. Ethambutol 400 mg p.o. q.day. 24. Docusate suppository 10 mg PR every other day. 25. Milk of magnesia 1 to 2 tablets p.o. every other day. Again, the patient is to be discharged to home. She is having home health nurse palliative care stop by.
PR|per rectum|PR|132|133|DISCHARGE MEDICATIONS|6. Tylenol 650 mg p.o. q.4h. p.r.n. pain/fever. 7. Benadryl 25 mg p.o. each day at bedtime p.r.n. allergy. 8. B/O suppository 60 mg PR q.4h. p.r.n. constipation. 9. Lortab 7.5/500 mg 1-2 tablets p.o. q.4h. p.r.n. anxiety. 10. Milk of magnesia 10 mL p.o. daily p.r.n. constipation. MEDICATIONS DISCONTINUED THIS ADMISSION: Uroxatral.
PR|per rectum|PR|129|130|DISCHARGE MEDICATIONS|10. Sodium chloride 5 mEq p.o. daily. 11. Multivitamin 1 mL p.o. daily. 12. MiraLax 8.5 g p.o. daily. 13. Glycerin suppository 1 PR daily. 14. Calcium carbonate 1000 mg p.o. t.i.d. DIET: Similac Advance 150 mL t.i.d., then 70 mL per hour x12 hours overnight.
PR|pr interval|PR|246|247|DISCHARGE MEDICATIONS|Studies included an echocardiogram which showed diminished ejection fraction but no significant valvular disease that might account for her syncope. She was found to have a low magnesium level and this was treated with magnesium supplementation. PR interval seemed to shorten as her magnesium level increased. No advanced AV block was noted per cardiac monitoring. The patient also had a CT scan of the head which showed some expected atrophic changes but no evidence of a subdural hematoma related to her fall.
PR|per rectum|PR|344|345|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: The same, except the patient had been on erythromycin oral or bowel regimen and I felt this may be contributing to her abdominal pain, so that was discontinued. She also had a full bowel regimen upon discharge, including Maalox 30 mg p.o. q.i.d., Reglan 10 mg p.o. daily, Senokot 1-2 tabs p.o. b.i.d., and Dulcolax 10 mg PR daily, all p.r.n. Additionally, her hydrochlorothiazide was increased to 25 mg p.o. daily.
PR|per rectum|PR|174|175|MEDICATIONS|14. Simvastatin 20 mg p.o. each day at bedtime. 15. Augmentin 500 mg p.o. q. day x8 days, on hemodialysis days, please dose after hemodialysis. 16. Fleet mineral oil enema 1 PR q. day p.r.n. constipation. 17. Metamucil powder 1 tablespoon p.o. q. day, mixed with fluid. INSTRUCTIONS: 1. Activity level as tolerated. 2. Continue working with physical and occupational therapy.
PR|per rectum|PR|154|155|DISCHARGE MEDICATIONS|5. Kayexalate three teaspoons added to feeds daily. 6. Bactrim prophylaxis 16 mg NJ daily. 7. Calcium carbonate 500 mg NJ t.i.d. 8. Ferrous sulfate 22 mg PR NJ daily. 9. Discharge formula of Similac PM 60/40, 27 kcal 24-hour continuous drip feeds at a rate of 44 ml/hour. DISCHARGE HOME CARE: Children's Home Care skilled nursing visits one time a week to assess respiratory and cardiac status, as well as feeding tolerance and medication adherence.
PR|per rectum|PR|138|139|DISCHARGE MEDICATIONS|6. Sonata 5 mg p.o. each day at bedtime. 7. Senokot 2 tabs p.o. b.i.d. 8. Alendronate 70 mg p.o. q. weekly. 9. Dulcolax suppository 10 mg PR b.i.d. p.r.n. constipation. 10. K-Dur 10 mEq p.o. b.i.d. 11. Os-Cal with vitamin D 1 tablet p.o. daily.
PR|pr interval|PR|232|233|HISTORY AND HOSPITAL COURSE|Over the next 4-5 days, his AV conduction improved to the point that he was in a junctional rhythm at 60-65 beats per minute and the temporary wires were removed. Chest tubes were removed. His AV conduction system normalized with a PR interval of under 200 milliseconds. He had sustained atrial flutter with this and he was seen by Dr. _%#NAME#%_ who I think appropriately recommended an atrial flutter ablation and this was indeed performed on _%#DDMM2007#%_.
PR|per rectum|PR|156|157|DISCHARGE MEDICATIONS|24 Multivitamin by mouth 3 times daily. 25 Zofran 4 mg by mouth every 6 hours as needed for nausea. 26 Protonix 40 mg by mouth daily. 27 Fleet enema 133 mL PR daily as needed for constipation. 28 Mirapex 0.25 by mouth twice daily to be given every morning, each p.m. and may repeat x1 during the day.
PR|pr interval|PR|231|232|IMPRESSION AND PLAN|She will be placed on telemetry for overnight monitoring. We will also check orthostatic heart rate and blood pressure. 2. First, degree atrioventricular (AV) block: The patient does have a significant first degree AV block with a PR interval of 254. She is on atenolol and propafenone, both of which can prolong the PR interval. Given her significantly prolonged PR interval, it makes one wonder if perhaps this was also a contributing factor with increasing risk for development of a second or third degree heart block given the duration of her AV block.
PR|per rectum|PR|142|143|DISCHARGE MEDICATIONS|2. Keflex 250 mg b.i.d. while drain is in place. 3. Percocet 1 to 2 tablets p.o. q.4-6 h. p.r.n. pain. 4. Tylenol 650 mg 1 tablet p.o. q.6 h. PR pain. She is not to exceed greater than 4 g of acetaminophen in 24 hours.
PR|pr interval|PR|227|228|HOSPITAL COURSE|This was thought to be of benefit by raising her systolic pressure as she had been hypotensive both after the blood draws and then at Mercy hospital. 2. LGL phenomenon. The EKG examined from Mercy hospital demonstrated a short PR interval and a widened QRS complex. This rhythm was constant during this EKG finding. However, during her stay at University of Minnesota Medical Center, Fairview, this rhythm was intermittent and quite often done in bigeminy.
PR|per rectum|PR|210|211|MEDICATIONS|14. Tylenol 325 mg tablets, 2 tablets down the feeding tube presumably p.r.n. No frequency is listed. 15. Baclofen 15 mg t.i.d. p.r.n. 16. Lorazepam p.o. or IM p.r.n. seizures. 17. Dulcolax suppositories 10 mg PR daily p.r.n. 18. Nizoral cream to the scrotum and groin t.i.d. as needed. 19. Desitin cream topically to the G tube site as needed.
PR|pr interval|PR|138|139|PHYSICAL EXAMINATION|EXTREMITIES: No edema, no sign of deep venous thrombosis. NEUROLOGIC: Nonfocal. EKG by my reading reveals sinus rhythm with a rate of 90, PR 0.16, QT 0.32. There is good R-wave progression; there are nonspecific repolarization changes. There is slight left axis deviation. No diagnostic acute ischemic changes.
PR|pr interval|PR|143|144|PHYSICAL EXAMINATION|Bowel sounds present. EXTREMITIES: No edema and no sign of DVT. NEUROLOGIC: Nonfocal. EKG by my reading revealed sinus rhythm with rate of 75. PR 0.16, QT 0.36, axis 0. There is good R wave progression, no diagnostic or acute ischemic changes and no significant change compared with _%#DDMM2005#%_.
PR|pr interval|PR|177|178|HISTORY|Today, she became acutely more ill and was brought in to the emergency room. Initial observations indicated a blood pressure of 80/60, a heart rate of only about 40 with a wide PR interval, a digoxin level elevated at 3.6, and the patient looks extremely ill. She has also been noted to have lots of involuntary shaking of her limbs.
PR|per rectum|PR|198|199|DISCHARGE MEDICATIONS|Because of his increased stool output, he did develop a diaper rash. _____ cream was used as needed with diaper changes. DISCHARGE MEDICATIONS: Topamax 75 mg via J-tube every 12 hours, Diastat 5 mg PR every 4 hours as needed for seizure lasting greater than 5 minutes, lansoprazole 15 mg J-tube every 12 hours, enalapril 5 mg J-tube every 12 hours, Lamictal 75 mg J-tube q.p.m., Lamictal 50 mg J-tube q.a.m., _____ cream apply topically to the diaper area as needed with diaper changes if rash persists, vitamin E 30 mL J-tube q.12 hours, folic acid 1000 mcg J-tube daily, amlodipine 2 mg J-tube daily, vitamin C 1250 mg J-tube daily, calcitriol 0.2 mL J-tube daily, phytonadione 5 mg J-tube daily, calcium citrate 950 mg J-tube every 8 hours, Bicitra 20 mL J-tube every 8 hours, normal saline plus 10 mEq of KCl 450 mL IV every morning over 4.5 hours, normal saline 450 mL IV every p.m. and each day at bedtime over 4.5 hours and carnitine 650 mg J-tube q.8h. DIET: _____ 160 g plus EleCare 130 g plus Benefiber 8 g plus water 2323 mL, all ingredients mixed to run at a rate of 92 mL/hour via J-tube.
PR|per rectum|PR|191|192|OUTPATIENT MEDICATIONS|1. Xanax 0.5 mg p.o. q.p.m. p.r.n. anxiety. 2. Artificial tears 0.5%, 1-2 drops in both eyes q. 2 p.r.n. dryness. 3. Azelastine 1 spray to both nares b.i.d. p.r.n. dryness. 4. Dulcolax 10 mg PR suppository daily p.r.n. constipation. 5. Cyclosporine 0.05%, 1 drop in both eyes b.i.d. per Ophtho recommendations. 6. Lasix 20 mg p.o. b.i.d. 7. Guaifenesin 600 mg p.o. b.i.d. p.r.n. coughing.
PR|pr interval|PR|148|149|LABORATORY DATA|BUN is 73. CBC is notable for hemoglobin 10.2. EKG shows sinus bradycardia with a heart rate of 52 and what appears to a right bundle branch block. PR interval is 248 indicating a first-degree AV block. QRS is 146 and QT corrected is 437. I do not have a previous EKG to compare to at this time.
PR|per rectum|PR|186|187|MEDICATION|2. Ativan 0.5-1 mg p.o. or sublingually every 1 hour as needed for anxiety or dyspnea. 3. Atropine eye drops 1% 1-2 drops sublingually every 2 hours as needed. 4. Tylenol 650 mg p.o. or PR every 6 hours as needed for fever or pain. He is going to discharge home with hospice care. He will have a hospital bed; he will have oxygen at 5-10 liters per minute by Oxymizer as needed for dyspnea.
PR|per rectum|PR|154|155|DISCHARGE MEDICATIONS|2. NaCl tablet 2 gram per os three times a day with meals. 3. Colace 100 mg per os twice a day. 4. Senna tabs two per os q bedtime. 5. Therevac enema one PR q am. 6. Zantac 150 mg per os twice a day. 7. Decadron taper 4 mg per os q 6 hours times two days, and then 2 mg per os q 6 hours times two days, and then 2 mg per os q 12 hours times two days, and then 2 mg per os q day times two weeks, and then discontinue.
PR|pr interval|PR|129|130||The flutter episode he had was pace terminated and the patient was offered a flutter ablation. In addition, the patient's native PR interval has lengthened. In order to have intrinsic conduction, the patient requires extension of his AV delay out to 350 milliseconds.
PR|per rectum|PR|151|152|DISCHARGE MEDICATIONS|_%#NAME#%_ is to receive his fluconazole IV via home care. 3. Glutamine 1 gm/G tube t.i.d. 4. Lactobacillus 2 capsules/G tube q.i.d. 5. Tylenol 160 mg PR or G tube q.4h p.r.n. fever. 6. Benafiber 5 gm q.d. mixed in feeds. 7. Short chain fatty acid protocol 15 ccs via G tube q.d. The recipe is as follows: Sodium acetate 60 mmol plus sodium propionate 30 mmol plus sodium-N-butyrate 40 mmol plus sodium chloride 22 mmol.
PR|pr interval|PR,|220|222|LABORATORY DATA|He has bilateral withdrawal with Babinski testing. LABORATORY DATA: In addition to the above, an electrocardiogram demonstrated baseline artifact with what appears to be a normal sinus rhythm with heart rate in the 60s. PR, QRS, and QT intervals are normal. There is right bundle branch block pattern and minor nonspecific T wave abnormality.
PR|progesterone receptor|PR|181|182|PAST MEDICAL HISTORY|MRI revealed a herniated disc at C5-6 with a left-sided predominance. The patient presented for elective decompression. PAST MEDICAL HISTORY: Metastatic breast cancer, ER positive, PR negative, HER2 negative, with multiple bony metastases, status post chemo Adriamycin x 6; modified radical mastectomy on _%#MM#%_ _%#DD#%_, 2001; 4 cycles of Taxol; and then treatment with tamoxifen.
PR|pr interval|PR|146|147|OPERATIONS/PROCEDURES THIS ADMISSION|DISCHARGE DIAGNOSIS: Noncardiac chest pain. OPERATIONS/PROCEDURES THIS ADMISSION: 1. EKG revealed a rate of 73, normal sinus rhythm, normal axis, PR interval of 146, QRS interval 86; no ST, T-wave or Q-wave changes. 2. Chest CT was negative for pulmonary embolism. 3. Chest x-ray revealed clear lung fields and mild cardiomegaly.
PR|pr interval|PR,|151|153|LAB DATA, 6/13/03|Potassium was 4.2. Serum iron was 90. EKG on _%#DDMM2003#%_ demonstrated a normal sinus rhythm with heart rate in the 60s. Left axis deviation. Normal PR, QRS and QT interval. No ischemic change. Negative stress echocardiogram (by history) as above. DISCUSSION: No complaints of findings to contraindicate proceeding with surgery as planned.
PR|per rectum|PR|162|163|HISTORY OF PRESENT ILLNESS|Neuro observation, blood pressure watch, observation, and monitoring, and IV fluids due to continuing emesis. Anticipate patient needing Plavix and aspirin. Give PR if unable to keep down p.o. ALLERGIES: The patient has no known drug allergies.
PR|pr interval|PR|192|193|HOSPITAL COURSE|She did not have any chest pain, shortness of breath, and her palpitation disappeared with _______________. She also did not complain of any problem in the right groin vascular exit site. Her PR interval has normalized on all rhythm strips and no _________ T waves are detected. The echocardiogram from _%#DDMM2004#%_ revealed normal LV contractility and no pericardial fluid.
PR|per rectum|PR|197|198|COURSE IN HOSPITAL|Activities as tolerated. Medications really continue unchanged on Lantus plus q.i.d. sliding scale Humalog insulin. The Lantus, I believe, is at 45 units nightly. Aciphex 20 mg daily. Promethazine PR 25 mg p.r.n. nausea. Ambien 10 mg q.h.s. p.r.n. Creon 10-mg tablets 3 to 4 with each meal. His previously prescribed pain medications. Follow up with Dr. _%#NAME#%_, his regular primary provider, within one week of discharge.
PR|per rectum|PR|698|699|DISCHARGE MEDICATIONS|Also was to follow up with physical therapy and OT to have treatment particularly to neck. DISCHARGE MEDICATIONS: Protonix 40 mg p.o. daily, Seroquel 100 mg p.o. q.a.m. and 200 mg p.o. q.h.s., Neurontin 300 mg p.o. b.i.d., Paxil 40 mg p.o. q.a.m., lisinopril 10 mg p.o. daily, Flovent 110 mcg 2 puffs b.i.d., albuterol MDI 2 puffs q.1h. p.r.n., Combivent metered dose MDI 2 puffs b.i.d., Metamucil 1 packet p.o. q.h.s., BuSpar 30 mg p.o. b.i.d., hydrochlorothiazide 50 mg p.o. q.a.m., nystatin ointment to buttock t.i.d. until clear, Ambien 10 mg p.o. q.h.s. p.r.n., Risperdal 1 mg p.o. b.i.d., Vistaril 50 mg p.o. q.6h. p.r.n., multivitamin 1 p.o. daily, Senna-S 2 tabs p.o. daily, Dulcolax 10 mg PR p.r.n., Zithromax 250 mg p.o. daily x3 days, as well as TED hose to bilateral legs. PRIMARY DIAGNOSIS: Pneumonia. SECONDARY DIAGNOSES: 1. Depression/anxiety. 2. History of alcohol abuse.
PR|per rectum|PR|153|154|DISCHARGE MEDICATIONS|14. Normal saline nasal spray 0.65% at 1-2 sprays bilateral nostrils daily. 15. Acetaminophen 325 mg 1-2 tabs p.o. q. 4h. 16. Dulcolax suppository 10 mg PR b.i.d. p.r.n. 17. Lactulose 15 mL p.o. daily p.r.n. 18. Pimecrolimus 1% cream applied to back topically b.i.d. p.r.n. rash.
PR|per rectum|PR|161|162|DISCHARGING AND TRANSFER MEDICATIONS|11. Senokot S one to two tablets p.o. t.i.d., hold for loose stools. 12. Glucotrol 10 mg p.o. q.a.m. and Glucotrol 5 mg p.o. q.p.m. 13. Dulcolax suppository one PR q. 3 days p.r.n. no BM. 14. Milk of magnesia 15 to 30 mL p.o. q. 3 days no BM. 15. Fleets enema one per rectum q. day p.r.n.
PR|pr interval|PR|146|147|PHYSICAL EXAMINATION|EXTREMITIES: No edema. No deep venous thrombosis. NEURO: Non-focal. Electrocardiogram by my reading today reveals sinus rhythm with a rate of 55. PR is 0.16. QT is 0.40. There is good R wave progression. Axis is normal. No ischemic changes. No significant change compared with electrocardiogram of _%#DDMM2000#%_.
PR|progesterone receptor|PR|121|122|HISTORY OF PRESENT ILLNESS|The patient has an infiltrating lobular cancer grade I of III, 1.4 cm in size. Lymph node negative. ER positive at 100%, PR positive at 35%. She has only had the breast biopsy. No other surgery.
PR|progesterone receptor|PR|153|154|LABORATORY DATA|She is using trazodone for sleep. PAIN: She is taking ibuprofen for pain. LABORATORY DATA: Labs were done today. Her tumor has a lot of necrosis and ER, PR and HER/2-neu are not necessarily accurate. FAMILY HISTORY/SOCIAL HISTORY: The patient has no family history of breast cancer.
PR|per rectum|PR,|195|197|HISTORY OF PRESENT ILLNESS|The patient also had fevers at home of 100-101, taking Tylenol, and responding well to this. The parents brought the patient to urgent care yesterday, at which time she was given an anti- emetic PR, with good effect. In the emergency room today, the patient presented with a temperature of 101.8. Other vital signs were stable.
PR|per rectum|PR|200|201|MEDICATIONS|13. Lasix 40 mg P.O. q.a.m. 14. Miacalcin nasal spray, 1 spray alternating nostrils each day. 15. DuoNeb 1 neb q.4 h. p.r.n. 16. Tylenol 1000 mg P.O. q.6 h. p.r.n. pain. 17. Dulcolax suppository10 mg PR every other day p.r.n. 18. Magnesium oxide 400 mg P.O. b.i.d. ALLERGIES: No known drug allergies. CODE STATUS: DNR/DNI. FAMILY HISTORY: The patient's parents both had strokes.
PR|progesterone receptor|PR|185|186|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her infiltrating ductal carcinoma diagnosed in _%#MM#%_ 2000, grade 2, negative lymph nodes, ER positive, PR negative. REVIEW OF SYSTEMS: GENERAL: She occasionally has some hot flashes.
PR|per rectum|PR|151|152|DISCHARGE MEDICATIONS|12. Lipitor 40 mg p.o. q.h.s. 13. Ambien 5 to 10 mg p.o. q.h.s. p.r.n. insomnia. 14. Levaquin 250 mg p.o. daily for 8 days. 15. Dulcolax suppository 1 PR daily p.r.n. HISTORY AND PHYSICAL: Please see dictated history and physical by Dr. _%#NAME#%_.
PR|progesterone receptor|PR|180|181|HISTORY OF PRESENT ILLNESS|She had a lumpectomy, _%#DDMM1997#%_, and had recurrent disease, _%#DDMM2002#%_, T11 vertebral lesion. Her cancer was grade 3 of 3, with 0 of 10 lymph nodes, ER positive at 70.7%, PR positive at 69.2%, HER-2/neu positive. REVIEW OF SYSTEMS: GENERAL: The patient has a good appetite.
PR|per rectum|PR|117|118|DISCHARGE MEDICATIONS|14. Senna 2 tablets p.o. b.i.d. 15. Clonazepam 0.25 mg p.o. b.i.d. 16. Neurontin 1200 mg p.o. t.i.d. Phenergan 25 mg PR q.8 h. p.r.n. 1. Benadryl 25 mg p.o. b.i.d. p.r.n. 2. Morphine short acting 15 to 30 mg q.4 h. p.o. p.r.n. pain.
PR|pr interval|PR|160|161|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. The patient has a history of Lyme disease for which he was treated. At that time, he had characteristic skin rash. 2. History of short PR intervals on EKG and an incomplete right bundle- branch block which has been evaluated by cardiology and remained stable.
PR|per rectum|PR|179|180|DISCHARGE MEDICATIONS|5. Fosamax 10 mg p.o. daily. 6. Vicodin 1 to 2 tabs p.o. q.6 hours p.r.n. for pain. 7. Senna 1 to 2 tabs p.o. b.i.d. 8. Milk of magnesia 30 mL p.o. q.h.s. 9. Dulcolax suppository PR 10 mg p.r.n. 10. Maalox 30 mL p.o. p.r.n. gastric distress. 11. Temazepam 7.5 mg p.o. q.h.s. p.r.n. sleep. 12. DuoNeb t.i.d. p.r.n. shortness of breath.
PR|pr interval|PR|171|172|PHYSICAL EXAMINATION|Bowel sounds present. EXTREMITIES: No edema, no sign of deep venous thrombosis NEUROLOGIC EXAMINATION: Non-focal EKG by my reading reveals sinus rhythm with a rate of 50. PR interval 0.16, QT 0.44, there is good R-wave progression, left axis deviation, no ischemic changes and no significant change compared with _%#DDMM2003#%_ ASSESSMENT AND PLAN: There are no contraindications to the procedure assuming CBC and comprehensive metabolic panel are drawn today and acceptable.
PR|pr interval|PR|325|326|LABORATORY DATA|LABORATORY DATA: White blood cell count 4.7, hemoglobin 11.4 with an MCV of 96, INR 2.15, sodium 137, potassium 4.9, chloride 102, bicarbonate 26, BUN 45, creatinine 2.2, glucose 99, troponin less than 0.07 and BNP is 74. Chest x-ray shows some hyperinflation. EKG shows normal sinus rhythm with first-degree AV block with a PR interval of 220, evidence for early repolarization in V1 through V3. ASSESSMENT AND PLAN: Mr. _%#NAME#%_ is an 82-year-old man presents with atypical chest pain.
PR|pr interval|PR|179|180|PRIMARY CARE PHYSICIAN|His chest x-ray showed some small apical left-sided pneumothorax approximately 5%, and his EKG showed some ST elevations in II, III, aVF, as well as V2 through V6 and downsloping PR segments in some of the anterior leads. He had a TTE which was performed that showed normal EF with no evidence of wall motion abnormalities.
PR|per rectum|PR|182|183|DISCHARGE MEDICATIONS|9. Morphine 2-4 mg IV q.1h p.r.n. breakthrough pain. 10. Colace elixir 100 mg down NG b.i.d. for constipation. 11. Senna 1-2 tabs down NG q.h.s. for constipation. 12. Dulcolax 1 tab PR q.h.s. p.r.n. constipation. FOLLOW-UP APPOINTMENT: Dr. _%#NAME#%_ with ENT in 1-2 weeks.
PR|per rectum|PR|157|158|DISCHARGE MEDICATIONS|15. Paroxetine 40 mg p.o. q. day. 16. Doxycycline 100 mg p.o. b.i.d. x6 days. 17. Phenergan 25 mg p.o. q.8 hours for nausea. 18. Compazine suppository 25 mg PR q.12 hours p.r.n. for nausea. 19. Tums 2 tablets p.o. t.i.d with meals. 20. Neutra-Phos 1 packet p.o. q.i.d. 21. Bisacodyl suppository 10 mg PR q. day p.r.n. for constipation.
PR|pr interval|PR|165|166|PHYSICAL EXAMINATION|Finger-to-nose is normal with no cerebellar sign. Romberg is negative. A basic metabolic panel and a CBC were both normal. EKG showed sinus bradycardia with a short PR interval, otherwise no signs of arrhythmia. IMPRESSION AND PLAN: This is a 58-year-old man with a syncopal episode, most likely vasovagal in nature by the description, bradycardia and hypotension when the paramedic arrived to the scene.
PR|pr interval|PR|142|143|HISTORY|It has two RR intervals which alternate and it is a paroxysmal atrial tachycardia, probably a reentrant rhythm. In addition, he displayed two PR intervals with similar P-wave axes (from a single lead electrocardiogram) and the prolonged PR interval followed the administration of intravenous diltiazem which resulted in a resolution of the paroxysmal atrial tachycardia at a rate of 150 beats per minute with which he presented to the Emergency Room.
PR|pr interval|PR|237|238|HISTORY|It has two RR intervals which alternate and it is a paroxysmal atrial tachycardia, probably a reentrant rhythm. In addition, he displayed two PR intervals with similar P-wave axes (from a single lead electrocardiogram) and the prolonged PR interval followed the administration of intravenous diltiazem which resulted in a resolution of the paroxysmal atrial tachycardia at a rate of 150 beats per minute with which he presented to the Emergency Room.
PR|per rectum|PR|190|191|DISCHARGE MEDICATIONS|10. Prednisone 5 mg per feeding tube daily. 11. Seroquel 25 mg feeding tube daily. 12. Senokot S one tablet feeding tube b.i.d. p.r.n. for constipation. 13. Oxycodone 30 mg extended release PR q.12 hours. 14. Aspirin 81 mg feeding tube daily. 15. Bactrim double strength one tablet feeding tube daily. Start once patient is off all other antibiotics. 16. Glyburide 2.5 mg per feeding tube daily.
PR|pr interval|PR.|161|163|LABORATORY DATA|LABORATORY DATA: Chest x-ray reported some volume loss, right lung. No acute changes, unchanged since _%#MMDD#%_. EKG shows probably a junctional rhythm - short PR. No acute changes. Labs show white count 19,000, hemoglobin 11.7, INR 3.2. Sodium 139, potassium 3.6, chloride 102, CO2 34, urea nitrogen 33, creatinine 0.8. Normal liver function tests, low albumin.
PR|pr interval|PR|208|209|SOCIAL HISTORY|After discussion with Dr. _%#NAME#%_ between Dr. _%#NAME#%_ and Dr. _%#NAME#%_ and the emergency room, urgent catheterization seems more appropriate. EKG is reviewed and shows sinus bradycardia with a normal PR interval and mild ST elevation in lead 3 and perhaps a subtle elevation in II and F that were nonetheless slightly upsloping.
PR|per rectum|PR|245|246|1. FEN|The most likely etiology for the hyperbilirubinemia was physiologic. This problem has resolved. Transfer medications, treatments and special equipment: * Caffeine Citrate 9mg PO/NG every 24 hours (being given at 0200) * Glycerin 1/4 suppository PR every 12 hours PRN no stool Transfer measurements: Weight 1823 gm; length 42 cm; OFC 30 cm.
PR|per rectum|PR|202|203|DISCHARGE MEDICATIONS|Her LDL was less than 70. She was started on a low dose of a statin due to her protection study results. DISCHARGE MEDICATIONS: 1. Zocor 10 mg p.o. daily. 2. Norvasc 10 mg p.o. daily. 3. Dulcolax 10 mg PR daily p.r.n. 4. Colace 100 mg p.o. b.i.d. 5. Trusopt 2% 1 drop OS b.i.d. 6. Tambocor 50 mg p.o. q 12 hours.
PR|per rectum|PR|146|147|MEDICATIONS|3. Advair 50/500 mg 2 puffs b.i.d. 4. Celexa 20 mg daily. 5. Norvasc 5 mg daily. 6. Ambien 10 mg p.o. at bedtime for insomnia. 7. Trazodone 50 mg PR at bedtime p.r.n. insomnia. 8. Singulair 10 mg p.o. daily. 9. Protonix 40 mg p.o. daily. 10. Nicotine patch 7 mg. 11. Coumadin 5 mg daily.
PR|pr interval|PR|138|139|LABORATORY|Repeat ECG here, done at 1524 shows an electronic atrial paced rhythm with a right bundle branch block, QRS duration of 140 milliseconds. PR interval is paced at 120 milliseconds. IMPRESSION/REPORT/PLAN: 1. Paroxysmal atrial fibrillation.
PR|pr interval|PR|189|190|OBJECTIVE|OBJECTIVE: Generally healthy-appearing young adult male in no distress. Alert and oriented. Appropriate affect. Blood pressure 114/54. Heart rate has been in the 50-70s. Normal QRS, QT and PR intervals. Respirations normal. O2 sat 95% on room air. Maximum temperature 99.8 degrees, since normalized. HEENT exam: Extraocular movements full.
PR|per rectum|PR|146|147|DISCHARGE MEDICATIONS|7. Riopan 15-30 cc q.2-3 hours p.r.n. 8. Robitussin 5-10 cc q.4-6 hours p.r.n. 9. Salicylate 500-1000 mg t.i.d. p.r.n. 10. Dulcolax suppository 1 PR q.day 11. Lovenox 30 mg subcu q.12 hours until INR is therapeutic. 12. Percocet 5/325, 1-2 p.o. q.4-6 hours p.r.n. pain #50, no refills.
PR|pr interval|PR|185|186|LABORATORY DATA|LABORATORY DATA: (_%#DDMM2002#%_) BUN 25, creatinine 0.8, sodium 138, potassium elevated at 6.7, chloride 95, bicarbonate 38. EKG shows normal sinus rhythm at 76 with a widened QRS and PR interval of 130. There is poor R wave progression. In _%#DDMM2002#%_ her BUN was 25 and creatinine 0.9. IMPRESSION: 1. Shortness of breath. She has a history of congestive heart failure.
PR|UNSURED SENSE|PR|205|206|HOSPITAL COURSE|Platelets were 204. The patient's blood type is A positive, antibody negative, Rubella immune. Urine tox and urine culture screen were both negative during this admission, and at the time of discharge are PR and hepatitis B surface antigen are both pending. The patient will be discharged to home. She was told to continue her prenatal vitamins and to take them every day, as well as, Iron supplementation secondary to her anemia.
PR|per rectum|PR|171|172|SUMMARY|At discharge, the left testicle was felt high in the inguinal canal. Discharge medications, treatments and special equipment: Reglan 0.2mg PO QID Glycerin suppository 1/4 PR PRN no stool Discharge measurements: Weight 2870 gms; length 50 cm; OFC 34 cm.
PR|per rectum|PR|100|101|DISCHARGE MEDICATIONS|2. She is to resume her usual nursing home orders. DISCHARGE MEDICATIONS: 1. Dulcolax suppository 1 PR qd prn constipation. 2. Lasix 40 mg po qam. 3. Vistaril 10 mg po tid, this is a 2 mg/ml syrup. 4. Lisinopril 5 mg po qam. 5. Prevacid granules 30 mg po qd.
PR|per rectum|PR|157|158|DISCHARGE MEDICATIONS|OPERATIONS/PROCEDURES THIS ADMISSION: Adhesion take- down surgery. DISCHARGE MEDICATIONS: 1. Aspirin 300 mg p.o. q.d. 2. Dulcolax suppository, 1 suppository PR b.i.d. p.r.n. 3. Zantac 150 mg p.o. b.i.d. 4. Lasix 40 mg p.o. q.d. 5. Ceftriaxone 1 gm IV q.d. X2 weeks.
PR|per rectum|PR|464|465|HISTORY OF PRESENT ILLNESS|She was afebrile, vital signs were stable. Her discharge hemoglobin was 9.5, her creatinine was 0.5. DISCHARGE PLAN: Given the hemoglobin of 9.5 most likely secondary to hydration, however, she is receiving chemo, she was given 40,000 units subcutaneously Procrit prior to her discharge. She will receive that on a weekly basis. DISCHARGE MEDICATIONS: Include Esterase 1 mg p.o. q.d., Zantac 150 mg p.o. b.i.d., Celebrex 200 mg p.o. b.i.d., Dulcolax suppository 1 PR q.d. p.r.n., Senna 2 to 3 tablets p.o. b.i.d. p.r.n., Celexa 20 mg p.o. q.d., Procrit 40,000 units subcutaneously every Wednesday, Niferex 50 mg p.o. b.i.d. DISCHARGE INSTRUCTIONS: The patient was instructed on proper bowel management to include Colace, Senna, and Smooth Move and also Dulcolax to help her bowels move.
PR|pulmonary regurgitation|PR|207|208|ELECTROCARDIOGRAM|BUN 39, creatinine 1.3, troponin is negative x3. ELECTROCARDIOGRAM: No significant STT changes from her previous EKG. Echocardiogram done on _%#MM#%_ _%#DD#%_, 2003, shows hypercontractile LV with LVH, mild PR and MR. Right ventricle normal. Epicardial fat pad was fairly prominent. Estimated ejection fraction 70%. Patient had a coronary angiogram _%#MM#%_ _%#DD#%_, 2003, which showed diffuse coronary arteriosclerosis without focal stenosis, and there was no significant change from films on _%#MM#%_ _%#DD#%_, 2003.
PR|per rectum|PR|226|227|DISCHARGE PLANS|5. Seasonal allergies. DISCHARGE PLANS: The patient is being transferred to Walker Methodist Health Care Center today. She is being discharged on Citrucel one package q.d., ferrous sulfate 325 mg p.o. b.i.d., Cortenema 100 mg PR q.h.s. x 6 days, and loratadine 10 mg p.o. q.d. She already has a pre-made follow up appointment with Dr. _%#NAME#%_ _%#NAME#%_ from Gastroenterology next week, which she will keep.
PR|pr interval|PR|150|151|ELECTROCARDIOGRAM|EXTREMITIES: No cyanosis, clubbing or edema. LABORATORY DATA: Pending. ELECTROCARDIOGRAM: Rate 78. Rhythm normal sinus rhythm. Axis minus 15 degrees. PR 0.15, QRS 0.09, QTc is normal. Electrocardiogram is normal.
PR|per rectum|PR|183|184|DISCHARGE MEDICATIONS|10. Lasix 40 mg p.o. b.i.d. 11. Acyclovir 400 mg p.o. t.i.d. for oral stomatitis. This will continue for 12 days post-discharge. 12. KCL 20 mEq p.o. b.i.d. 13. Tylenol 650 mg p.o. or PR q.4h. p.r.n. 14. Colace 100 mg p.o. b.i.d. p.r.n. ALLERGIES: Penicillin.
PR|pr interval|PR|143|144|STUDIES|LOWER EXTREMITIES: No swelling or color change. Peripheral pulses are palpable. NEUROLOGIC: Nonfocal. STUDIES: 12-lead EKG shows sinus rhythm, PR interval 202, no signs of acute ischemic changes (i.e., no ST elevation or depression). No old EKG for comparison. Chest x-ray shows no active infiltrate.
PR|pr interval|PR|222|223|LABORATORY STUDIES|Chest x-ray review reveals right middle lobe and a possible left lower lobe infiltrate. No effusions noted. No pneumothorax. LABORATORY STUDIES: Unremarkable. EKG reveals normal sinus rhythm. No ST segment changes. Normal PR interval. No notable Q waves. She does have a left axis deviation. ASSESSMENT AND PLAN: Pneumonia complicated by COPD exacerbation and diabetes.
PR|per rectum|PR|138|139|DISCHARGE MEDICATIONS|5. Benadryl 50 mg p.o. b.i.d. 6. Hydroxyzine 10 mg p.o. q6h p.r.n. 7. Albuterol inhaler two puffs q.i.d. 8. Bisacodyl 10 mg suppositories PR q12h p.r.n. 9. Docusate p.r.n. 10. Senokot p.r.n. 11. Fluoxetine 30 mg p.o. q.day. 12. Combivent two puffs q.i.d. 13. Pantoprazole 40 mg p.o. q.day.
PR|per rectum|PR|224|225|DISCHARGE MEDICATIONS|3. Isosorbide 20 mg q.i.d. 4. Lisinopril 40 mg per day. 5. Glyburide 5 mg per day. I wrote prescriptions for Roxanol 20 mg per cc, 10-20 mg buccally q.2h. p.r.n. shortness of breath or pain and Compazine suppositories 25 mg PR q.12h. p.r.n. DISCHARGE FOLLOW-UP: Follow-up with Hospice Of The _%#CITY#%_ _%#CITY#%_.
PR|pr interval|PR|147|148|HISTORY OF PRESENT ILLNESS|He has had spells while sitting; more typically they are while he is standing. His monitoring here has shown sinus rhythm with first degree block, PR interval of 240 milliseconds, and a left bundle branch block. He has also had mild sinus bradycardia with pauses of 1 to 1.5 seconds.
PR|pr interval|PR|87|88|PROCEDURES PERFORMED|PROCEDURES PERFORMED: 1. EKG. This showed the patient to be in sinus rhythm with short PR interval. 2. CT of the head without contrast. This examination appeared radiographically within normal limits, with no mass, bleed, or midline shift identified.
PR|pr interval|PR|328|329|LAB|LAB: White count 7800, anemic with hemoglobin 10.2. This is compared to CBC done _%#DDMM2004#%_ with a white count of 8400 and a hemoglobin 11.3. Differential with 82 percent PMNs, 25 percent lymphs today. EKG is with T wave inversion, leads I, aVL, Precordial leads VI-VI, and this was changed from previous (copies attached). PR interval is greater than 0.3. Chest x-ray is remarkable for a cardiomegaly. ASSESSMENT: Lyme disease with high-grade first degree block. History of coronary artery disease, chronic obstructive pulmonary disease, expiratory wheeze, hyperlipidemia, tinea.
PR|per rectum|PR|141|142|DISCHARGE MEDICATIONS|4. Lasix 20 mg intravenous each day. 5. Lantus insulin 10 units subcutaneously q.h.s. 6. Benadryl 25 mg p.o. q.8 h. p.r.n. 7. Tylenol 650 mg PR q.6 h. p.r.n. 8. Nystatin suspension p.o. q.i.d. 9. Insulin sliding scale with regular insulin. 10. Pantoprazole 40 mg p.o. each day.
PR|pr interval|PR|206|207|LABS|ABDOMEN: Is benign. No hepatosplenomegaly. LABS: Are notable for a white blood cell count of 16.1. Troponin is 0.07, D-dimer is 0.4. Chest x-ray per emergency department staff is unchanged. EKG shows short PR interval with no signs of any acute ischemia. IMPRESSION: A 65-year old white female with complaints of abdominal pressure, diaphoresis, and just generalized malaise.
PR|per rectum|PR|247|248|DISCHARGE MEDICATIONS|She remained very brittle and it was recommended she start with growth hormone replacement as this may contribute to insulin sensitivity and her frequent problems with hypoglycemia. DISCHARGE MEDICATIONS: 1. Norvasc 10 mg p.o. q. day. 2. Dulcolax PR daily p.r.n. constipation. 3. Wellbutrin 300 mg p.o. daily. 4. Calcitriol 0.25 mcg p.o. daily. 5. Aranesp 125 mcg subq once a week on Fridays.
PR|per rectum|PR|158|159|ASSESSMENT AND PLAN|The patient had taken milk of magnesia this AM and is awaiting results. Will write for Senokot-S 2 tablets PO q.h.s. scheduled and Dulcolax suppository 10 mg PR prn for constipation. 5. Hypertension. The patient did have an episode of his blood pressure decreasing to 68/38. Will change his Lisinopril to 5 mg PO q.d. and write to hold Lisinopril and Lasix for systolic pressure less than 100.
PR|per rectum|PR|127|128|DISCHARGE MEDICATIONS|4. Valcyte 650 mg p.o. daily. 5. Mycelex 10 mg p.o. t.i.d. 6. Bactrim single strength one tablet p.o. daily. 7. Dulcolax 10 mg PR p.r.n. for no stools daily. 8. Calcium plus vitamin D 1250 mg p.o. b.i.d. 9. Percocet one to two tablets p.o. q. 4 h p.r.n. for pain, quantity 15.
PR|pr interval|PR|180|181|ELECTROCARDIOGRAM|Urinalysis showed 1 white blood cell and 1 red blood cell with mucus present and a few bacteria with 3 epithelial cells present. ELECTROCARDIOGRAM: Shows a sinus rhythm with short PR interval. CHEST X-RAY: Negative. ASSESSMENT AND PLAN: 1. Depression, per Dr. _%#NAME#%_. 2. Diarrhea chronic, likely secondary to dumping syndrome.
PR|pr interval|PR,|180|182|OBJECTIVE|On _%#DDMM2006#%_, hemoglobin 11.4 gm percent with potassium 4.6. Unremarkable urinalysis. Electrocardiogram demonstrated a normal sinus rhythm and axis. Baseline artifact. Normal PR, QRS and QT interval. No ischemic change. Tracing not significantly changed when compared to that from _%#DDMM2003#%_.
PR|pr interval|PR|132|133|PHYSICAL EXAMINATION|He has good pedal pulses with no edema. As I review the EKG post cardioversion, it does show sinus rhythm with a slightly prolonged PR interval of 0.24 and anterior Q-waves throughout. Small R-waves are identified in II, III and AVF. He has a bradycardia in the 50s.
PR|pr interval|PR|153|154|IMPRESSION|He had an ectopic atrial rhythm, which may suggest atrial infarct. Also has a proximal RCA lesion, but the initial ECG with a normal P wave did not have PR changes. The patient appears to have clinically lysed with lytic therapy. I would recommend adding Plavix to his current medications on beta blocker and aspirin.
PR|pr interval|PR|150|151|EKG|No cyanosis or erythema. Moves all extremities with grossly normal strength to command. EKG: EKG on admission demonstrated sinus rhythm with a normal PR interval. There was an intraventricular conduction defect (IVCD) of left bundle branch block type. There was rather prominent voltage. There were no acute ST changes.
PR|pr interval|PR|135|136|PERTINENT LABORATORY VALUES|Sodium 143, potassium 5.6, creatinine 2.32, BUN 78. Hemoglobin 7.9. BNP 2760. EKG, as read by me, shows sinus tachycardia, with normal PR and QRS and QT intervals. There are no ST changes. IMPRESSION: 1. Acute lupus nephritis, likely diffuse proliferative type, in light of large protein and blood in the urine.
PR|pr interval|PR|161|162|IMPRESSION, REPORT AND PLAN|He is on higher dose of Rythmol at 225 mg 3 times daily. I have reviewed his ECG which revealed a first degree AV block and QRS interval of 108. I note that his PR interval was 220, even prior to increasing the dose of Rythmol to 225 mg 3 times daily. Since the patient has not been on the higher dose of Rythmol for very long and his episodes of atrial fibrillation occurred in the setting of his new medical problems (GI bleed), I would not change the dose of Rythmol at this time.
PR|pr interval|PR,|142|144|PHYSICAL EXAMINATION|NEUROLOGIC: He does appear alert and oriented. He displays normal judgment and insight. His electrocardiogram today shows a sinus rhythm. The PR, QRS and QT intervals are normal. No signs of chamber hypertrophy or prior infarction are evident.
PR|pr interval|PR|153|154|IMPRESSION/RECOMMENDATIONS|There were no dynamic ST-T changes and no Q waves were seen. Her electrocardiogram from this morning shows sinus bradycardia at 51 beats per minute. Her PR interval QRS duration, QT interval corrected, are within normal limits. The patient will have a transthoracic echocardiogram to further assess her valves.
PR|progesterone receptor|PR|221|222|HISTORY OF PRESENT ILLNESS|Her right axillary node was examined and only two lymph nodes showed low- grade ductal carcinoma or infiltrating lobular carcinoma without extranodal extension. Each lymph node measured less than 2 cm in size. The ER and PR receptor was positive. HER2/neu was 2/3, however, FSH was negative. Therefore, the patient has bilateral breast cancer of the right side, T4, N1, M0 stage IIIB cancer, and left-sided T2, N1, M0 stage IIB breast cancer with both ER, PR positive and HER2/neu negative.
PR|pr interval|PR.|112|114|LABORATORY DATA|NEUROLOGIC: Symmetric cranial nerves. She is moving all four extremities well. LABORATORY DATA: EKG shows short PR. There is T-wave inversion in 1 and V2-6 and a Q in F. CT is reported as showing free air, gallstones, liver metastases, normal kidneys with no hydronephrosis.
PR|pr interval|PR,|405|407|ELECTROCARDIOGRAM|LABORATORY DATA: From _%#DDMM2003#%_, includes low sodium 131, potassium 4.4, chloride 95, cO2 of 29, anion gap of 8, glucose 111, BUN 12, creatinine 0.8, calcium 9.5, normal liver profile; white count 5700, hemoglobin 15.3, MCV of 92, platelet count 241,000 with unremarkable differential. Thyroid stimulating hormone of 2.19. ELECTROCARDIOGRAM: EKG demonstrates a normal sinus rhythm and axis. A normal PR, QRS, and QT interval. Right bundle branch block configuration to QRS; however, there is not a clear R-wave in V1. No old tracing for comparison.
PR|pr interval|PR|211|212|REASON FOR CONSULTATION|I have not had access to the them, but am told that they show a narrow complex regular tachycardia with a cycle length of approximately 320 Msec and abrupt onset and abrupt offset. It is not clear if there were PR prolongations proceeding the tachycardias or if premature atrial contractions were responsible for the onset The patient was asked to increase his Atenolol but he has not done so.
PR|pr interval|PR|176|177|REASON FOR CONSULTATION/HISTORY OF PRESENT ILLNESS|She was given an IV amiodarone bolus and infusion is being started. With that, her heart rate decreased to approximately 130. It shows what appeared to be P waves with a short PR interval, but there is no isoelectric segment inferiorly and thus this may represent atrial flutter. She is very anxious and nervous, but at this heart rate.
PR|pr interval|PR|132|133|LABORATORY EXAMINATION|He has nonspecific ST segmented elevation across the entire precordium. There is no significant change from previously. There is no PR depression. Troponins are negative x2. ASSESSMENT/PLAN: 1. I suspect Mr. _%#NAME#%_'s chest discomfort is possibly pericarditis, may be pleuritis.
PR|pr interval|PR,|258|260|ELECTROCARDIOGRAM|Unremarkable differential. Normal complete metabolic profile with mildly elevated GGT of 107, suppressed TSH of 0.31 with normal free thyroxin of 0.81. ELECTROCARDIOGRAM: Demonstrates a sinus bradycardia with heart rate in the upper 50s. Normal axis. Normal PR, QS and QT interval. Minor nonspecific T-wave abnormality. No old tracing on record for comparison.
PR|pr interval|PR|188|189|HISTORY OF PRESENT ILLNESS|In the emergency room, her head CT showed evidence of an old small vessel stroke in the left head of the caudate. Her EKG showed bradycardia with a rate of 50 and subtle evidence for LVH. PR interval was 212 indicating first-degree heart block. I do not know if this is a new finding or not. REVIEW OF SYSTEMS: Complete review of systems was performed including constitutional, gastrointestinal, respiratory, musculoskeletal, skin, hematologic, psychiatric, genitourinary, ophthalmologic, cardiovascular, neurologic and appeared all normal except as above.
PR|progesterone receptor|PR|279|280|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her infiltrating ductal carcinoma diagnosed on _%#DDMM2000#%_, with recurrent disease in the bones and the lymph nodes on _%#DDMM2005#%_. It is grade 2/3 with 1 of 4 lymph nodes, ER positive at 80.9, PR negative and HER-2/neu negative. REVIEW OF SYSTEMS: GENERAL: She notes she is a little tired on the second day after treatment.
PR|pr interval|PR|282|283|ASSESSMENT/PLAN|I will need to talk with the surgeon tomorrow, have one of my partners talk with the surgeons to see exactly what happened and whether there is any documentation of this block. Her problems are as follows: 1. Second-degree AV block, currently in sinus rhythm; she has a high normal PR interval. No further treatment at this point; she is max doses of beta blocker. I will ask the surgeon if there is any documentation to find out what type of second-degree block, but no further workup at this point.
PR|pr interval|PR,|431|433|LABORATORY DATA|GENITALIA/RECTAL: Deferred. NEUROLOGIC: Grossly nonfocal. LABORATORY DATA: In addition to the above lab data includes unremarkable basic metabolic profile _%#DDMM2006#%_, with BUN of 18, creatinine 1.0, sodium 142, potassium 4.3. Follow-up labs _%#DDMM2006#%_ show white count 9600, hemoglobin 13.4, platelet count 489,000. Unremarkable basic metabolic profile. EKG _%#DDMM2006#%_ demonstrated normal sinus rhythm and axis. Normal PR, QRS and QT interval. No ischemic change.
PR|pr interval|PR,|462|464|LABORATORY DATA|LABORATORY DATA: Available laboratory data from _%#MM#%_ _%#DD#%_, 2004 includes unremarkable urinalysis, normal basic metabolic panel with sodium 141, potassium 4.0, chloride 108, CO2 of 22, anion gap of 11, glucose 99, BUN 13, creatinine 0.91. White count 6,600, hemoglobin 17.1 gm %, MCV of 86, platelet count of 232,000 with INR of .98, PTT of 32, Sed Rate of 1. Electrocardiogram on _%#MM#%_ _%#DD#%_, 2004 demonstrated normal sinus rhythm and axis, normal PR, QRS and QT interval. No ischemic change. Tracing essentially within normal limits. Obtained for lower substernal/epigastric discomfort.
PR|pr interval|PR|143|144|FAMILY HISTORY|White count was 7000, hemoglobin 15.2, MCV of 80, platelet count 300,000. EKG demonstrated a sinus bradycardia with a normal axis and a normal PR and QT interval. No ischemic change. ASSESSMENT: A 25-year-old male admitted with the following: 1. Acutely psychotic behavior with a record indication of prior schizophrenia.
PR|pr interval|PR,|146|148|AVAILABLE LABORATORY DATA|White count 7700, hemoglobin 17.7 g%, MCV 90, platelet count 209,000. TSH reflex was 0.6. EKG demonstrates a normal sinus rhythm and axis, normal PR, QRS and QT interval. No ischemic change.
PR|pr interval|PR,|165|167|HISTORY|He had mild blood pressure elevation of 156/86, heart rate 70s, temperature normal, O2 sats 95% on room air. EKG demonstrated a normal sinus rhythm and axis, normal PR, QRS, and QT interval, no ischemic change. Lithium level was 0.4. Troponin less than 0.01. He has a history of medication noncompliance, which prompted referral to inpatient psychiatry for further treatment adjustment/intervention.
PR|progesterone receptor|PR|59|60|PROBLEM|PROBLEM: Left breast ductal carcinoma in situ, grade 3, ER PR positive. The patient was seen in the Radiation Oncology Clinic by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ at the request of Dr. _%#NAME#%_ _%#NAME#%_.
PR|progesterone receptor|PR|164|165|ASSESSMENT|No focal deficits. LABORATORY STUDIES: We reviewed all of the old records including her mammogram. ASSESSMENT: 45-year-old, premenopausal female with T1s N0 M0, ER PR positive, ductal carcinoma in situ of the left breast. PLAN: We recommend postoperative external beam radiation therapy. Our recommended dose is 5040 cGy in 28 fractions to the left breast.
PR|pr interval|PR|154|155|LAB DATA|Initial ECG showed junctional rhythm, nonspecific T wave changes. Subsequent ECG shows a normal QT interval. Subsequent ECG shows sinus rhythm with short PR interval, normal QTc, and nonspecific ST-T changes. IMPRESSION, REPORT AND PLAN: Out-of-hospital cardiac arrest. We will admit to the Intensive Care Unit.
PR|progesterone receptor|PR|203|204|ASSESSMENT|The pathology report is mentioned in the HPI. She also had 3 sentinel nodes removed and they were all negative for malignancy. It is ER positive, PR negative. ASSESSMENT: Stage I, T1B N0 M0 ER positive, PR negative, invasive ductal carcinoma of the left breast. PLAN: We recommend radiation therapy to the left breast. We recommend a dose of 5040 cGy followed by an electron boost of 1400 cGy.
PR|pr interval|PR|191|192|ASSESSMENT AND PLAN|He had recurrent worsening of his pain this morning and repeat EKG now shows ST elevation in anterior as well as probably in the inferior leads. This has a concavity of upwards with possible PR segment depression. Given the patient's character of the pain and the EKG, this could be related to pericarditis.
PR|pr interval|PR,|227|229|ELECTROCARDIOGRAM 8/9/03|Romberg negative. Cerebellar function intact. There is minimal tremor of the head and distal upper extremities. No rigidity. ELECTROCARDIOGRAM _%#DDMM2003#%_: Sinus bradycardia with a heart rate in the 50s. Normal axis. Normal PR, QRS, and QT intervals. No ischemic change. LABORATORY DATA: Other labs to be reviewed. ASSESSMENT: 1. Alcohol dependency.
PR|pr interval|PR|137|138|PHYSICAL EXAMINATION|I reviewed the EKG performed in _%#MM#%_ _%#DD#%_, 2006 at 7 a.m. which showed sinus rhythm, sinus bradycardia, heart rate of 54 and his PR interval is normal. His QRS duration is prolonged mostly consistent with a not very typical right bundle branch block morphology.
PR|progesterone receptor|PR|216|217|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her infiltrating ductal carcinoma, well differentiated, with lumpectomy, diagnosed _%#DDMM1998#%_ with 0 of 24 lymph nodes, ER positive, PR negative. REVIEW OF SYSTEMS: GENERAL: She has fatigue, but it is not increasing.
PR|progesterone receptor|PR|166|167|PLAN|She will most likely benefit from adjuvant chemotherapy. She will discuss this further with her medical oncologist. She also asked about tamoxifen. We do not have ER PR receptor status at this point. She will discuss tamoxifen further with Medical Oncology as well. We discussed this case with Dr. _%#NAME#%_ and the recommendation was to get a repeat mammogram and MRI.
PR|progesterone receptor|PR|241|242|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her right infiltrating ductal carcinoma 2.7 cm diagnosed _%#DDMM2004#%_. It is a grade 3 of 3 with two of 23 lymph nodes. She is ER positive at greater than 90%, PR weakly positive at 5-10 and HER-2/neu negative. REVIEW OF SYSTEMS: GENERAL: She has hot flashes. Energy is okay.
PR|progesterone receptor|PR|247|248|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her infiltrating ductal carcinoma of the left breast with DCIS diagnosed _%#DDMM2003#%_, grade 3 of 3 with one of 11 lymph nodes positive. She was ER positive at 85.4, PR negative at 3.6 and HER- 2/neu 3+ positive. REVIEW OF SYSTEMS: GENERAL: She has rare hot flashes. Her weight is up 3 pounds.
PR|pr interval|PR,|242|244|LABORATORY DATA|LABORATORY DATA: Complete metabolic panel was unremarkable. White count 7500, hemoglobin 13.7, MCV 88, platelet count 266,000. TSH 1.57. GGT 13. Chest CT as above. EKG on _%#DDMM2005#%_ demonstrated a normal sinus rhythm, normal axis, normal PR, QRS, and QT intervals. Mild interventricular conduction delay.
PR|pr interval|PR|321|322|IMPRESSION|Bowel sounds are quite active. Posterior tibial pulses are difficult to feel, but he has faint dorsalis pedis pulses and no edema at his ankles. IMPRESSION: Syncope x 3 over the last six or seven years, without obvious etiology, perhaps related to intermittent heart block, as his EKG suggests trifascicular block with a PR interval of 0.27, right bundle and left anterior fascicular block. I very much agree with repeating his echo, which he states was done several years ago without unusual findings for a murmur that he has had all of his life.
PR|pr interval|PR|153|154|PHYSICAL EXAMINATION|NEUROLOGICAL: Was not done in detail. The patient was able to move all extremities and respond to sensory stimuli. EKG shows a sinus rhythm with a short PR interval, a wide QRS complex, consistent with left bundle branch block pattern and also Wolff-Parkinson-White pattern type B. LABORATORY DATA: White blood count 13.7, hemoglobin 11.7, hematocrit 34.7, sodium 132, potassium 3.9, chloride 98, cO2 26, glucose 103, BUN 118, creatinine 1.19. Alkaline phosphatase 294, ALT 26, AST 147.
PR|progesterone receptor|PR|144|145|HPI|Tumor from the right breast was still 6.5 cm in size, which was associated with DCIS. Margins were negative. Tumor again showed ER positive and PR negative, and HER2/neu negative. She also had 5 of 15 right axillary nodes positive. MRI of the spine confirmed that she has spine metastases at the level of T4 and T6.
PR|pr interval|PR,|268|270|LABORATORY DATA|LABORATORY DATA: Sodium 139, potassium 3.9, chloride 106, cO2 28, glucose 96, BUN 25, creatinine 0.9, calcium 8.8, hemoglobin 12.5, hematocrit 36.1, white blood count 6.1. EKG: Baseline EKG demonstrated a normal sinus rhythm with no significant ST-wave abnormalities. PR, QRS and QT intervals within normal limits. A second EKG showed a normal sinus rhythm with a left bundle branch block pattern.
PR|pr interval|PR,|208|210|LABORATORY DATA|Urinalysis was unremarkable. Chest x- ray _%#DDMM2004#%_ demonstrated left lower lobe atelectasis versus fibrosis. EKG dated _%#DDMM2004#%_ demonstrated a normal sinus rhythm with left axis deviation. Normal PR, QRS, and QT interval. Loss of R-wave progression V1 through V2, consistent with possible old anteroseptal MI versus lead placement.
PR|progesterone receptor|PR|133|134|HISTORY OF PRESENT ILLNESS|In the spring of 2003 she developed a metastases to her liver and lung. This was biopsied and found to be HER2 strongly positive, ER PR negative. Her initial tumor was ER positive PR negative. She was treated with Herceptin and Taxol every 3 weeks initially and then switched to Herceptin alone.
PR|progesterone receptor|PR|155|156|HISTORY OF PRESENT ILLNESS|There was positive lymphatic invasion. There was associated DCIS. The margins were negative with the closest margin being 1 cm. The tumor was ER positive, PR negative. HER-2/neu was 2+. There were 5/10 positive lymph nodes in the axillary dissection. There was extracapsular extension present. The patient had a bone scan on _%#DDMM2003#%_ which was negative.
PR|pr interval|PR|363|364|LABORATORY DATA|Chest x-ray (report) shows heart and pulmonary vasculature considered normal, normal cardiac silhouette, no acute pulmonary infiltrate, congestion or pleural effusion. EKG showed normal sinus rhythm, rate of 70, with first-degree AV block, low QRS voltage, no acute ST abnormalities noted; this was very similar to that done in _%#MM#%_, 2001 other than that the PR interval appears slightly shorter. CLINICAL IMPRESSION: 1) Near syncope/repeated lightheadedness with brief, momentary visual loss.
PR|pr interval|PR|199|200|LABORATORY DATA|Denies feeling anxious. Cranial nerves II to XII are intact. She denies feeling homicidal or suicidal. LABORATORY DATA: EKG shows patient to have a normal sinus rhythm with a ventricular rate of 88, PR interval was 126, QRS was 82, QTC was 428, no ST segment elevation, no ST segment depression. Chest x-ray reveals no acute abnormality. Urine pregnancy test was negative.
PR|pr interval|PR|105|106|PHYSICAL EXAMINATION|NEUROLOGICAL: Exam appeared to be grossly negative. Electrocardiogram shows a normal sinus rhythm with a PR and QRS and QT intervals within normal limits. There is no acute ST abnormality noted. A chest x-ray is not available for viewing.
PR|pr interval|PR|118|119|PHYSICAL EXAMINATION|The carotids are benign. Chest x-ray is unremarkable. EKG shows a regular rate of 60 beats per minute. She has normal PR interval and QRS duration of 112 milliseconds. She has a left anterior fascicular block but no evidence of ischemia. Poor R-wave progression is also present. Cardiac echo with bubble study is notable for an ejection fraction greater than 60%.
PR|per rectum|PR|234|235|MEDICATIONS|The saphenous vein graft to OM2 and the first diagonal vessel was widely patent and the ejection fraction was normal. MEDICATIONS: 1. Ferrous gluconate 324 mg p.o. b.i.d. 2. Micronase 2.5 mg p.o. daily. 3. Hydrocortisone enema 100 mg PR b.i.d. 4. Insulin by sliding scale. 5. Mercaptopurine 50 mg p.o. daily. 6. Glucophage 500 mg p.o. b.i.d. 7. Solu-Medrol injection every 12 hours (currently at 125 mg).
PR|pr interval|PR|151|152|LABORATORY DATA|EXTREMITIES: The legs showed 1+ bilateral edema. NEUROLOGIC: Unremarkable. LABORATORY DATA: EKG today showed sinus rhythm with normal QRS complex. The PR interval was significantly prolonged with a P wave forming onto the peak of the T wave of the previous cardiac cycle. His potassium is normal at 4.3, sodium is normal at 134, white count is normal at 6.6 and he does have moderate anemia with a hemoglobin of 9.3. The platelet was reduced at 96,000.
PR|progesterone receptor|PR|339|340|ASSESSMENT/RECOMMENDATIONS|This is a brief update on Ms. _%#NAME#%_. As you know she had a recurrence of her left breast cancer this past _%#MM2005#%_ and subsequently underwent a modified radical mastectomy, which revealed a 2.8 grade 3 infiltrating ductal carcinoma, sentinel and axillary lymph node dissection was negative of 17 lymph nodes. The tumor was ER and PR negative, and HER2 negative by FISH Analysis. The patient has undergone further chemotherapy receiving dose Adriamycin and Cytoxan on a q.2 week schedule starting on _%#DDMM2005#%_ and through _%#DDMM2005#%_ for four cycles.
PR|pr interval|PR,|190|192|LABORATORY DATA|GENITALIA/RECTAL: Deferred. NEUROLOGIC: Grossly nonfocal. LABORATORY DATA: Includes a preop urinalysis which was unremarkable. Electrocardiogram demonstrated a sinus bradycardia with normal PR, QRS and QT interval. Minor nonspecific T-wave flattening inferolaterally. White count 7500, hemoglobin 14.9 with MCV 96.8, platelet count 234,000.
PR|progesterone receptor|PR|158|159|HISTORY|Pathology reviewed from her breast cancer lumpectomy sample showed a 0.7 cm grade I invasive ductal carcinoma; margins are negative. The closest is 1 mm. ER, PR are pending. Her INR on admission was 2.87 and she was given a 2 mg dose of vitamin K last night. PAST MEDICAL HISTORY: 1) Deep venous thrombosis in 2000, 2002 and _%#MM#%_, 2003, on long- term anticoagulation with Coumadin.
PR|pr interval|PR|145|146|HISTORY OF PRESENT ILLNESS|While being in the hospital on the monitor, he has had several ECGs which nicely show his rhythm disturbances. He has severe first AV block with PR interval of 400 milliseconds. He has a baseline left bundle branch block which alternates with a right bundle branch block.
PR|pr interval|PR,|225|227|HISTORY|Normal AST of 36. ALT of 27. Sodium 146, potassium 4.0, chloride 106, CO2 24, glucose 75, BUN 16, creatinine 0.8. Tylenol level less than 1. Electrocardiogram demonstrated a normal sinus rhythm with sinus arrhythmias. Normal PR, QRS and QT intervals. No ST-T wave change. He was clinically felt to be stable with subsequent transfer to inpatient psychiatry.
PR|pr interval|PR|247|248|HISTORY OF PRESENT ILLNESS|He has been increasingly aggressive and out-of-control at home. I have been asked to see the patient regarding an abnormal EKG. Patient currently had an EKG in the Emergency Department for reasons, which remain unclear to me. There is a shortened PR segment of 84 milliseconds noted. There is no length in QRS complex and no sign of bundle branch block or other electrical abnormality.
PR|pr interval|PR|149|150|ASSESSMENT/PLAN|His gait appears normal. LABORATORY EVALUATION: Pending. ASSESSMENT/PLAN: 1. Bipolar disorder. This will be followed by Dr. _%#NAME#%_. 2. Shortened PR wave. It was difficult to obtain any clinical correlations, or possible episodes of palpitations, or tachycardia as one might expect from a Wolff-Parkinson white type of picture.
PR|pr interval|PR,|209|211|EKG, 8/25/03|Left leg is wrapped. NEUROLOGICAL: Grossly non-focal. LAB DATA: Preop CBC: White count 8500, hemoglobin 15.4 with MCV 83.9, platelet count 291,000. EKG,_%#DDMM2003#%_: Normal sinus rhythm and axis with normal PR, QRS, and QT interval; no ischemic change. ASSESSMENT: This is a 37-year-old male with the following: 1. Left quadriceps tendinoplasty with hardware removal, left knee.
PR|pr interval|PR,|159|161|LABORATORY DATA|TSH reflex 0.86. GGT 22. Total cholesterol 155 with triglycerides 145, HDL 38, LDL of 88. DIAGNOSTICS: EKG demonstrates a normal sinus rhythm and axis. Normal PR, QRS and QT interval. No ischemic change. ASSESSMENT: 29-year-old male admitted with the following: 1. History of bipolar illness with depression and alleged suicidal ideation.
PR|per rectum|PR|129|130|CURRENT MEDICATIONS;|7. Senokot-S two tabs q h.s. 8. Sliding scale insulin drip. 9. Nipride drip. 10. Tylenol 650 mg PR q4h p.r.n. 11. Dulcolax 10 mg PR q12h p.r.n. 12. Dilaudid 0.2 to 0.3 mg IV q2h p.r.n. pain. 13. Ativan 0.25 to 1 mg IV q4h p.r.n. agitation.
PR|pr interval|PR|187|188|LABS|LABS: Are as described above. I would add also that an electrocardiogram performed this morning reveals normal sinus rhythm with nonspecific ST-The changes. QT corrected is .401 seconds. PR interval is normal.
PR|pr interval|PR,|269|271|LABORATORY DATA|GENITALIA/RECTAL: Exam deferred. NEUROLOGIC: Grossly nonlateralizing. LABORATORY DATA: Includes preoperative CBC with white count 4300, hemoglobin 14.9, MCV 94.4, platelet count 231,000. Unremarkable urinalysis. EKG demonstrating a normal sinus rhythm and axis. Normal PR, QRS and QT interval. No ischemic change. Estimated blood loss with surgery 375 mL.
PR|progesterone receptor|PR|183|184|ASSESSMENT AND PLAN|No evidence of recurrent breast cancer. She wanted me to go over again why she was not on hormone therapy. She thought she was pretty sure that it was because she was ER negative and PR negative and had bilateral mastectomies which is the case. She will see ENT for her hoarseness. I will put her on Elavil for sleep.
PR|progesterone receptor|PR|182|183|HISTORY OF PRESENT ILLNESS|The pathology slides were sent to the Mayo Clinic for a second opinion. The results from Mayo suggested metastatic adenocarcinoma consistent with a breast primary. The cells were ER PR positive, but HER-2/neu negative. Mammogram at that time was negative. The patient underwent right sided modified mastectomy _%#DDMM2004#%_ under Dr. _%#NAME#%_.
PR|progesterone receptor|PR|296|297|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her infiltrating ductal carcinoma moderate to poorly differentiated with DCIS comedo type. It was 1.3 cm tumor diagnosed _%#DDMM2004#%_. She had bilateral mastectomies with 0 of four lymph nodes involved. She was ER, PR and HER-2/neu positive. REVIEW OF SYSTEMS: GENERAL: She has heartburn once in a while.
PR|progesterone receptor|PR|134|135|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: 1. Stage I infiltrating ductal carcinoma of the left breast, status post lumpectomy and sentinel node biopsy. ER PR positive and HER2-neu- negative. 2. The patient was recommended to receive post-lumpectomy radiation treatment. Her lumpectomy scar has healed nicely and we will plan to start radiation treatment planning.
PR|progesterone receptor|PR.|123|125|HISTORY OF PRESENT ILLNESS|The tumor was strongly positive for both ER and PR. It was biphasic with a lesser component, which was negative for ER and PR. The major component was equivocal for HER2 NEU staining and the patient's cyto hyberization revealed that the HER2 NEU was not amplified.
PR|pr interval|PR,|182|184|LABORATORY DATA|GENITALIA/RECTAL: Deferred. NEUROLOGIC: Grossly nonfocal. LABORATORY DATA: Postop blood glucose of 337. Preop EKG demonstrates a normal sinus rhythm with left axis deviation. Normal PR, QRS, and QT interval. No ischemic change. On _%#DDMM2005#%_, sodium was 137, potassium 4.4, chloride 97, CO2 25, anion gap 15, calcium 10, BUN 14, creatinine 1.1, glucose 443.
PR|pr interval|PR|251|252|EKG|His current work is in product development. He travels about the country, and was recently in China and Hong Kong for product development. EKG: His EKG is clearly normal. There is some mild diffuse ST elevation, compatible with normality. There is no PR segment depression. PHYSICAL EXAMINATION: GENERAL: This is a young man in no significant distress, although he seems a bit uptight.
PR|pr interval|PR|236|237|LABORATORY DATA|LABORATORY DATA: Total cholesterol 183, LDL 124, HDL 37, white blood cell count 6.4, hemoglobin 15, platelets 214,000, creatinine 0.9, potassium 4, sodium 142. ECG shows sinus rhythm, ventricular rate of 68, normal QRS duration, normal PR interval, there is no evidence of old infarction and no ST-T changes consistent with acute coronary syndrome. IMPRESSION REPORT AND PLAN: 1. Chest pain, progressive exertional chest pressure, CCS class 3.
PR|pr interval|PR|147|148|LABORATORY DATA|Her AST is slightly increased at 49 but this is after her fall. EKG demonstrates sinus rhythm. There are very small Q waves noted in lead 3 and F. PR interval is somewhat short but there is no delta wave. She has slightly prominent R wave in lead V2. Chest x-ray report is not in the chart.
PR|pr interval|PR,|297|299|LABORATORY DATA|LABORATORY DATA: From _%#MMDD#%_ includes urinalysis remarkable for glucosuria. White count 10,100 with hemoglobin of 13.4 grams percent, MCV 90.3, platelet count 304,000, potassium of 5.2, creatinine of 1.5. Preop EKG _%#DDMM2007#%_ demonstrated a sinus bradycardia with heart rate of 58. Normal PR, QRS and QT interval. Possible left atrial abnormality. No ischemic change. No apparent change when compared to tracing _%#DDMM2006#%_.
PR|pr interval|PR|157|158|CHIEF COMPLAINT|Hemoglobin was normal at 13.3, white count mildly elevated at 12,000, creatinine elevated at 2.7, BUN 50. Glucose was 104. An EKG showed sinus rhythm with a PR interval of 122 msec and a heart rate of 42 beats/min. Remarkably, he had no QRS or T wave abnormalities, although the T waves uniformly are a bit peaked.
PR|pr interval|PR,|397|399|LABORATORY DATA|No edema. PELVIC/RECTAL: Deferred. NEUROLOGIC: Grossly nonfocal. LABORATORY DATA: Preop INR 1.0 with PTT of 27.8. Unremarkable urinalysis with white count of 5700, hemoglobin 15 grams percent, MCV 90, platelet count 290,000, sodium 145, potassium 4.4, chloride 102, CO2 32, anion gap 16, glucose 110, BUN 12, creatinine 0.8. EKG demonstrated a normal sinus rhythm with left axis deviation, normal PR, QRS and QT interval. No ischemic change. ASSESSMENT: Pleasant 64-year-old female admitted with the following: 1. L1-L2 decompressions/fusion.
PR|progesterone receptor|PR|285|286|HISTORY OF PRESENT ILLNESS|The patient underwent a scheduled lumpectomy performed by Dr. _%#NAME#%_ _%#NAME#%_ on _%#DDMM2003#%_, which showed a 3.6 x 1.8 x 1.2 cm Nottingham grade 3 infiltrating ductal carcinoma. There was associated DCIS, solid and cribriform grade 3 with necrosis. The tumor was ER positive, PR negative, and positive for HER-2/neu overexpression. Including the sentinel lymph node, there were 5 out of 7 lymph nodes positive. The patient has been to see Dr. _%#NAME#%_ regarding chemotherapy, which we understand will be four cycles of Adriamycin and Cytoxan which will then be followed by external beam radiotherapy.
PR|progesterone receptor|PR.|252|254|HISTORY OF PRESENT ILLNESS|The specimen showed infiltrating lobular carcinoma, which measured about 0.7 x 0.6 x 0.4, grade 2, with angiolymphatic invasion and associated LCIS. The margin was clear with 6.0 mm from nearest margin. Tumor revealed strongly positive ER and negative PR. Her ......was negative. Two sentinel nodes were taken, which showed no tumor. The patient is staged at stage 1 breast cancer, left sided T1 N0 M0 infiltrating lobular carcinoma with an ER receptor positive.
PR|pulmonary regurgitation|PR|126|127|LABORATORY DATA|Hemoglobin 12.1, hematocrit 36.9, white count 7.5 and platelets 202. Echo showed normal LV function with borderline LVH, mild PR and mild aortic valve sclerosis with a trace of mitral regurgitation. ASSESSMENT AND PLAN: 1. Somnolence. Patient had one episode which was not similar to when her pacemaker was implanted.
PR|pr interval|PR|159|160|IMPRESSION|IMPRESSION: This is a patient who presents with signs and symptoms consistent with acute pericarditis. Her EKG shows some subtle ST elevation with some subtle PR depression. There is a small to moderate pericardial effusion on echo and CT scan. There is no tamponade physiology. The etiology is unclear. This is probably idiopathic or viral, pericardial effusion.
PR|pr interval|PR|114|115|LABORATORY INVESTIGATIONS|LABORATORY INVESTIGATIONS: His EKG shows a normal sinus rhythm with a very prominent first degree AV block with a PR interval of 448 milliseconds. He has nonspecific ST-segment changes, fairly occasional PACs are seen. Nonspecific intraventricular conduction delay in the inferior leads. All troponins are negative.
PR|per rectum|PR|160|161|PREADMISSION MEDICATIONS|5. Paxil 10 mg p.o. each day. 6. Vitamin C 500 mg p.o. each day. 7. Propranolol hydrochloride 10 mg p.o. t.i.d. 8. Synthroid 137 mcg p.o. each day. 9. Dulcolax PR 10 mg suppository p.r.n. 10. Ambien 10 mg p.o. q.h.s. 11. Lorazepam 1 mg p.o. q.6 h. p.r.n. anxiety. 12. Prevacid 30 mg p.o. b.i.d.
PR|progesterone receptor|PR|240|241|HISTORY OF PRESENT ILLNESS|She had serous ovarian tumor in 1998. She had recurrent disease on _%#DDMM2004#%_ and then on _%#DDMM2004#%_ had gastric metastases. Her cancer was an infiltrating lobular. She had 17 of 21 lymph nodes involved. She was ER positive at 90%, PR negative and HER-2/neu negative. REVIEW OF SYSTEMS: GENERAL: Appetite is not good. Energy is fair.
PR|pr interval|PR|267|268|HISTORY OF PRESENT ILLNESS|She did not hit anything. She states that the discomfort was transient and she has had no recurrence since being admitted to the hospital. Her first 2 sets of troponin I's are negative. The patient was noted to have Q-waves inferiorly and had significantly prolonged PR interval. There was also poor R-wave progression seen. When comparing this to the patient's previous EKG, there really was no significant change other than she was in the Wenckebach second-degree heart block on the previous tracing.
PR|progesterone receptor|PR|272|273|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for consultation and second opinion regarding her infiltrating ductal carcinoma of the left breast. She is undergoing cytoreductive therapy. She was diagnosed _%#DDMM2005#%_, grade 3/3, ER positive at 90%+ and PR negative at less than 1%. HER-2/neu positive at 11.1. FAMILY HISTORY: The patient has a family history of a mother who is 53, alive and well.
PR|pr interval|PR|212|213|PHYSICAL EXAMINATION|ABDOMEN: Soft. EXTREMITIES: Lower extremities, no edema. His blood glucose level was 128 this morning, potassium 4.3. Hemoglobin 13.7, white blood cell count 11.5. EKG this morning shows normal sinus rhythm. The PR interval is normal. QRS shows a Q-wave in lead III which is old and unchanged from previous. Precordial leads appear normal. There is no ST segment change.
PR|pr interval|PR|150|151|LABORATORY DATA|I do not see clear cut P-waves, but the P-waves do seem somewhat high in V2 and there appears to be something of a negative P-wave in lead V1, a long PR interval. EKG while giving Adenosine does show regular P-waves, however, but not as rapid. ASSESSMENT: There is a 70-year-old female most likely with supraventricular tachycardia.
PR|pr interval|PR|284|285|HISTORY OF PRESENT ILLNESS|She had 4-5 episodes of short-lived paroxysmal supraventricular tachycardia. Upon reviewing some of the notes it looks like her heart rate got to about 160 beats per minutes. These were self-terminating. An EKG was performed this showed sinus tachycardia at 131 beats per minute. Her PR interval and QRS duration were normal. Her QT intervals were corrected with slightly prolonged at 454 msec, however, this is within normal limits for woman.
PR|pr interval|PR,|178|180|LABORATORY DATA|Cerebellar function intact. No tremor or rigidity. LABORATORY DATA: Labs from _%#MMDD#%_ include an electrocardiogram with sinus tachycardia, heart rate 103, normal axis. Normal PR, QRS, and QT intervals. No ischemic change. Comprehensive metabolic panel normal with sodium 138, potassium 3.6, chloride 102, CO2 27, anion gap 9, glucose 71, BUN 11, creatinine 1.2, calcium 9.4, albumin 3.7, normal liver profile.
PR|progesterone receptor|PR|133|134|HISTORY OF PRESENT ILLNESS|This demonstrated a 2 cm tumor grade 3/3 with associated extensive DCIS. The margins were negative, but within 1 mm for the DCIS. ER PR receptors were negative and the HER-2/neu was 3+. She had a sentinel node biopsy and 2 nodes were negative. The patient underwent chemotherapy with CEF for the first 2 cycles, but developed neutropenic fevers with both cycles.
PR|pr interval|PR|159|160|LABORATORY|They could not exclude an aortic aneurysm. EKGs have demonstrated sinus rhythm without acute changes. There is nonspecific flattening of the T-wave laterally. PR interval is 0.23 consistent with a first degree heart block. IMPRESSION: This patient has had multiple episodes of syncope recently and also a history of a syncope going back to her youth usually brought on by a painful stimulus.
PR|pr interval|PR|169|170|INDICATION FOR ADMISSION|He was admitted to the hospital where he was seen in the ER after chest pain. His EKGs were morphologically normal, albeit there was a mild first-degree AV block with a PR interval of 230 milliseconds. No acute ST-T changes were noted. Subsequently troponins were normal x3. Lipase and amylase were normal, electrolytes normal, potassium 4.2, creatinine 0.8, BUN 14, hemoglobin 14.3 grams.
PR|progesterone receptor|PR|126|127|HISTORY OF PRESENT ILLNESS|I called the pathologist assigned to the case and the final margins after re-excision are unclear. The tumor was ER positive, PR positive HER-2/neu 3+. There are two sentinel lymph nodes that were negative by both H and E and immunoperoxidase. The patient began CEF chemotherapy. She was also planned for Arimidex.
PR|pr interval|PR|142|143|LABORATORY|Troponins less than 0.04, 0.12 and 0.18. Hemoglobin A1C is 5.8. Her chest x-ray was negative for infiltrates. ECG does show sinus rhythm with PR interval of 0.152, QRS is 0.96. She is in a sinus rhythm. There is subtle ST depression in V2 to V6. ASSESSMENT/PLAN: Chest pain resolved with nitro and heparin.
PR|pr interval|PR|460|461|HISTORY OF PRESENT ILLNESS|She does not recall having fallen. She presented with initial studies that showed a mildly elevated D-dimer of 1.2, as well as a mildly elevated serum troponin of 0.86 which subsequently rose to 3.6 and 6.8, and then 7.1, suggesting a myocardial infarction, and the presumption is that an arrhythmia was present and/or significant hypotension associated with an acute coronary syndrome. Her initial electrocardiogram shows right bundle branch block and a long PR interval of 0.26. EKG changes on the electrocardiogram are otherwise related to a right bundle branch block, with a normal axis deviation.
PR|pr interval|PR|232|233|REFERRING PHYSICIAN|Over the next couple days AV Wenckebach persists. Again, the patient mostly asymptomatic during these episodes. Pre-surgery EKG as read by me showed a normal sinus rhythm with a PR interval of 210 milliseconds. Postoperatively, his PR interval has lengthened to approximately 350 milliseconds. A postoperative echocardiogram shows normal RV and LV function with appropriate mitral valve structure and function as well.
PR|pulmonary regurgitation|PR.|158|160|SUMMARY OF ILLNESS AND HOSPITAL COURSE|An echocardiogram done at Northland showed normal left ventricular systolic function with concentric left ventricular hypertrophy. There was only mild MR and PR. Given the likelihood that this sudden decompensation was on an ischemic basis, the decision was made to transfer here for further evaluation.
PR|pr interval|PR,|135|137|HISTORY OF PRESENT ILLNESS|Chest x-ray demonstrated no active disease. Electrocardiogram demonstrated a sinus tachycardia with heart rate in the low 100s. Normal PR, QRS, and QT interval. No significant ST T wave change. MEDICAL HISTORY: No serious illness. He denies heart disease, diabetes, asthma, hypertension, renal disease, peptic ulcer disease, hepatitis, gallbladder disease, thyroid disease, seizure, tuberculosis, or anemia.
PR|pr interval|PR,|196|198|LABORATORY DATA|BUN 12, creatinine 1.39. Normal liver profile. Normal electrolytes. WBC 7000, hemoglobin 16.6, MCV 91, platelets 233,000. TSH 1.03, GGT 65. EKG demonstrates a normal sinus rhythm and axis. Normal PR, QRS and QT interval. Minor non- specific T wave abnormality inferolaterally. ASSESSMENT: 36-year-old male admitted with the following: 1. Polydrug overdose without lingering clinical sequelae.
PR|per rectum|PR|277|278|DISCUSSION|There was some concern that the dose was causing nausea and he received Compazine with some relief. Since he is going toward a nursing home it would be preferable to have him off IV opioid therapy and I suggested that a long acting opioid, either morphine slow release p.o. or PR or methadone p.o., PR or SL be considered and made the appropriate equianalgesic calculations from his current 24 hour Dilaudid dose.
PR|per rectum|PR|164|165|DISCUSSION|In making this conversion I am more comfortable in reducing the calculated dose by approximately 50% and therefore suggested either MS Contin 30 mg q.12 h. p.o. or PR or a methadone 5 mg q.8 h. p.o., PR or SL and that for the time over the weekend they continue with the Dilaudid IV q.10 minutes p.r.n. The methadone dose should not be readjusted until early next week if it requires increasing, but the morphine dose, if that is the agent selected, can be increased after 24 hours, depending on his response.
PR|pr interval|PR,|254|256|LABORATORY DATA|Sodium 140, potassium 4.4, chloride 101, CO2 29, anion gap 10, glucose 164 (? non-fasting), BUN 15, creatinine 1.28, reduced GFR of 47 (?). Calcium and liver function tests normal. TSH 0.53.. EKG demonstrates normal sinus rhythm with normal axis, normal PR, QRS, and QT intervals, minor non-specific T-wave abnormality inferolaterally. ASSESSMENT: 49-year-old female admitted with the following: 1. Bipolar illness (from record), depressed, defer to Dr. _%#NAME#%_.
PR|pr interval|PR,|228|230|LABORATORY DATA|Sodium 146, potassium 3.9, chloride 112, CO2 26, anion gap 8, glucose 104, BUN 7, creatinine 0.7. Normal liver profile. GGT 16. TSH reflex 1.27. Electrocardiogram demonstrates a normal sinus rhythm with sinus arrhythmia. Normal PR, QRS, and QT interval. No ischemic change. ASSESSMENT: A 32-year-old female admitted with the following: 1. Alleged worsening depression and auditory hallucinations, psychiatric impression of schizoaffective disorder, depressed.
PR|pr interval|PR,|282|284|PHYSICAL  EXAMINATION|Bowel sounds are present. EXTREMITIES: Without cyanosis or edema. Pulses were 1-2+ below the femorals, 2+ above. NEUROLOGIC: Grossly intact not done in great detail. Electrocardiogram showed nonspecific ST-T wave changes primarily T-wave changes with borderline tachycardia, normal PR, QRS and QT interval. LABORATORY DATA: Demonstrated troponin less than 0.04, myoglobin 33, WBC 8.3, hemoglobin 12.7, hematocrit 38.5, platelet count 226,000, sodium 137, potassium 4.8, chloride 105, CO2 25, glucose 197, BUN 27, creatinine 1.12. Alkaline phosphatase 167, ALT 23, AST 34.
PR|progesterone receptor|PR|150|151|ASSESSMENT|LABORATORY STUDIES: We reviewed the old records including her ultrasound and mammogram. ASSESSMENT: 55-year-old physician with T1c N0 M0 ER positive, PR positive, HER-2/neu negative breast cancer. PLAN: We recommend external beam radiation therapy. We recommend a dose of 5040 cGy using 180 cGy fractions to the entire left breast.
PR|per rectum|PR|122|123|ACTION AND PLAN|2. Consider change of meds for pain and neuropathic pain to methadone 0.5 mg every 8 hours. This may be given tablet as a PR medication. Methadone will address the neuropathic pain as well. 3. We will address code and disposition after son is present and biopsy results are known.
PR|pr interval|PR|191|192|PHYSICAL EXAMINATION|Pulses were 2+ above the femorals. NEUROLOGICAL: Exam appeared to be grossly intact. Electrocardiogram shows a normal sinus rhythm with a slight leftward axis. No significant ST abnormality, PR QRS and QT intervals within normal limits. Chest x-ray is not available for viewing. LABORATORY DATA: Sodium 125, later sodium was 119, potassium 4.1, chloride 88, CO2 25, glucose 87, BUN 9, creatinine 0.6. Troponin is less than 0.3 twice, WBC 5.5, initial hemoglobin 13.4, second hemoglobin was actually 11.4. Hematocrit 38.9.
PR|pr interval|PR|178|179|PREOPERATIVE LABORATORY DATA|GENITALIA/RECTAL: Deferred. NEUROLOGIC: Grossly Nonlateralizing. PREOPERATIVE LABORATORY DATA: Included an electrocardiogram demonstrating a normal sinus rhythm and axis, normal PR and QRS and QT interval. There is no ischemic change. Equivocal T-wave flattening laterally. White count 5000 with hemoglobin of 15.5 grams percent, MCV 91, platelet count 262,000.
PR|pr interval|PR,|193|195|PLAN|4. Avoid nonsteroidals for now. 5. Increase Senokot with tendency toward constipation. 6. Clinical observation. 7. EKG obtained on _%#DDMM2007#%_ reviewed. Normal sinus rhythm and axis. Normal PR, QRS and QT interval. Minor nonspecific T-wave abnormality. No associated symptoms to suggest cardiac ischemia. Okay to proceed with ECT as above.
PR|pr interval|PR,|339|341|LABORATORY DATA|Large leukocyte esterase screen with negative nitrates. On _%#DDMM2006#%_ white count was 4600 with hemoglobin of 12.4 grams percent, platelet count 278,000, sodium 135, potassium 3.7, chloride 95, CO2 of 33, anion gap of 7, glucose 97, BUN 30, creatinine 1.20. EKG dated _%#DDMM2006#%_ demonstrated a normal sinus rhythm and axis normal, PR, QRS, and QT interval. No ischemic change. ASSESSMENT: 1. Revision left total hip arthroplasty (as above).
PR|pr interval|PR,|199|201|LABORATORY DATA|Sodium 146 with potassium of 4.6 (?), chloride 106, CO2 30, anion gap 10, glucose 82, BUN 19, creatinine 1.20. Electrocardiogram from this morning demonstrates a normal sinus rhythm, in axis, normal PR, QRS, and QT interval. No ischemic change. ASSESSMENT: 44-year-old male admitted with the following: 1. Anterior cervical decompression/fusion at C6-7 for left posterolateral C6-7 disk hernia.
PR|pr interval|PR|149|150|HISTORY OF PRESENT ILLNESS|An EKG was done in the emergency room during her episode of substernal chest pressure. This revealed normal sinus rhythm at 93 beats per minute. Her PR interval, QRS duration was within normal limits. her QT interval was slightly prolonged at 450 milliseconds. The patient had very small Q waves in leads 2, 3, AVF, V4 through V6.
PR|pr interval|PR|170|171|PHYSICAL EXAMINATION|She is alert and oriented with no gross motor defects. ECGs show SVT as described in history of present illness and sinus rhythm with a long first-degree AV block with a PR interval of 304 msec at baseline, but otherwise normal. An echocardiogram was apparently performed during her recent admission on _%#DDMM2005#%_ and shows a normally functioning mechanical aortic valve with an aortic valve area of 1.4 cm2 and a mean gradient of 14 mmHg.
PR|pr interval|PR,|222|224|LABORATORY DATA|NEUROLOGIC: Grossly nonlateralizing. LABORATORY DATA: Includes hemoglobin preop of 15.3 mg/%, potassium 3.8 with creatinine of 0.7, BUN of 16, INR 1.04. PTT of 30. EKG demonstrated normal sinus rhythm, normal axis, normal PR, QRS and QT interval. No ischemic change. ASSESSMENT: A 61-year-old female admitted with the following: 1. Right total hip arthroplasty, minimally invasive technique.
PR|progesterone receptor|PR|175|176|HISTORY OF PRESENT ILLNESS|She had 1 of 12 lymph nodes positive. There was no extranodal extension of the tumor, but the focus measured about 1.1 cm. The patient was ER positive at greater than 90% and PR positive at greater than 75%. She was HER-2/neu negative. The patient has been relatively healthy in her life. She has had a dilation and curettage for a miscarriage, otherwise no other surgery and no other medical problems.
PR|pr interval|PR|214|215|ASSESSMENT|He has no cardiovascular risk factors. His EKG shows early repolarization. His echocardiogram shows mild-to-moderate anterolateral hypokinesis without pericardial effusion, or aortic enlargement or dissection. His PR interval was prolonged, which he notes is chronic. His sedimentation rate is only minimally elevated at 17, with his first cardiac enzymes normal as well.
PR|pr interval|PR|156|157|LABORATORY DATA|LABORATORY DATA: Available laboratory includes preoperative EKG, demonstrating a sinus bradycardia with a heart rate in the 40s. First degree AV block with PR interval of .226. Incomplete right bundle branch block pattern. Occasional PACs indicated on readout but not appreciated on tracing. Preoperative hemoglobin of 13.5, potassium of 4.2.
PR|pr interval|PR,|213|215|LABORATORY DATA|Calcium 9.3. INR 0.93, PTT 26. Troponin was less than 0.07. Chest x-ray was negative. Urine tox screen positive for cocaine. Electrocardiogram from _%#DDMM2004#%_ demonstrated normal sinus rhythm and axis. Normal PR, QRS, and QT interval. No ischemic change. ASSESSMENT: This is a 49-year-old female admitted with the following: 1. Major depressive disorder (defer to psychiatry).
PR|progesterone receptor|PR|133|134|HISTORY OF PRESENT ILLNESS|She is Ukrainian origin. She was diagnosed with right-sided breast cancer in _%#DDMM2003#%_. At that time her tumor was ER positive, PR weakly positive, Her-2 negative. She had invasive carcinoma grade III, dimensions 1.6 x 1.5 x 1.8 cm. She had excision but margins positive. Extensive DCIS and angiolymphatic invasion.
PR|progesterone receptor|PR|210|211|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ was seen today for follow-up of her left lumpectomy for infiltrating lobular carcinoma, LCIS and DCIS, diagnosed _%#DDMM2004#%_. She had grade 2/3 ER positive, PR and HER2/neu negative. REVIEW OF SYSTEMS: GENERAL: Her weight is up a pound.
PR|pulse rate|PR:|140|142|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: T: 98.2. He is currently afebrile. He had a low-grade temperature of 100.1 yesterday. RR: In the mid 20s. BP: 103/55. PR: 71, down from 114. Saturations 955 on 6 liters of oxygen. WT: He weighed 72.4 kg, down from 73.5 on admission. Reveals a pleasant, frail elderly gentleman who is cheerful and alert, but when I embark upon the subject of home oxygen, he refuses to look at me and gives a clear indication that he is not interested in this subject.
PR|pr interval|PR|139|140|ASSESSMENT/PLAN|The patient electrocardiogram was read by computer as MOBITZ type 1. I did not feel that this is the case. There is no prolongation of the PR interval. She is in normal sinus rhythm and there is no evidence for nonconducted P waves. I feel this is secondary to a normal variant due to respiration and the patient is completely asymptomatic of any cardiac symptoms.
PR|progesterone receptor|PR|200|201|HISTORY OF PRESENT ILLNESS|The tumor was grade 3/3 with lymphatic invasion. There was associated ductal carcinoma in situ. The margins were clear. Sentinel lymph node identified 3 nodes which were all negative. The tumor is ER PR negative, and HER-2/neu 3+ positive on immunostaining. _%#NAME#%_ went onto complete four cycles of Adriamycin and Cytoxan. She also received 4 cycles of Taxol. There was a discussion of putting her on a trial that included her Herceptin.
PR|pr interval|PR,|173|175|LABORATORY DATA|CT scan of the head _%#MMDD#%_ was normal (unenhanced). B12 level 377. Electrocardiogram from _%#MMDD#%_ demonstrated normal sinus rhythm with heart rate in the 70s. Normal PR, QRS and QT interval. No ischemic change. There is an RSR prime in V1 through V2 consistent with an incomplete right bundle branch block pattern.
PR|pr interval|PR,|138|140|LABORATORY DATA|Normal liver profile. BUN is 9, creatinine is 0.9. EKG demonstrated a sinus bradycardia with a heart rate in the 50s. Normal axis, normal PR, QRS and QT interval. No ST-T wave change. ASSESSMENT: A 41-year-old male admitted with the following: 1. Proctocolectomy with loop ileostomy and Parks pouch.
PR|per rectum|PR|116|117|CURRENT OUTPATIENT MEDICATIONS|13 Iron tablets 325 mg p.o. daily. 14 Pergolide 0.5 mg p.o. daily. 15 Quinine sulfate 260 mg p.o. daily. 16 Tylenol PR q.p.m. as needed. REVIEW OF SYSTEMS: Other than the symptoms noted above in HPI, the patient does note no fever however he has felt cold over the last 1 month, especially in the evening.
PR|progesterone receptor|PR|294|295|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a pleasant 54-year- old lady with a history of hypercholesterolemia and hypothyroidism She also has a history of a left partial mastectomy and axillary node dissection performed on _%#DDMM2001#%_ for a T2, N0, M0 poorly differentiated ER negative, PR negative, HER-2/neu negative infiltrating ductal carcinoma. She received four cycles of AC, and also radiation therapy that was completed in _%#DDMM2002#%_.
PR|pr interval|PR|214|215|LABORATORY DATA|Blood cultures have been negative at day 1. EKG although the computer read it as atrial fibrillation in fact is a very, very poor baseline but I have circled that there is a P wave in front of every QRS with short PR interval, but no actual delta waves. The QRS has mildly increased duration of approximately 0.10 but again no delta wave. There are no ST-T changes. Preliminary transthoracic echo, mild MR, mild TR, normal LV function, no clot and borderline LVH.
PR|pr interval|PR,|159|161|PHYSICAL EXAMINATION|NEUROLOGIC: Exam was not done in detail, but appeared to be grossly intact. Electrocardiogram is pending. Rhythm strips demonstrate a sinus rhythm with normal PR, QRS and QT intervals. 12-lead is ordered. Chest x-ray demonstrates a pacemaker in place. Heart was large. There was prominence of central pulmonary vasculature, mild congestive heart failure, no obvious infiltrate.
PR|pr interval|PR|199|200|NEUROLOGICAL EXAM|Finger-nose-finger is performed quickly and accurately. Chest x-ray is unremarkable, showing no evidence of infiltrates or aspiration pneumonia. EKG shows a normal sinus rhythm, 79 beats per minute. PR interval and QRS duration are normal. She has no ischemic changes. On V2, there is prominence of the initial P wave suggestive of left atrial enlargement.
PR|progesterone receptor|PR.|145|147|HISTORY OF PRESENT ILLNESS|The patient underwent a biopsy which was read as grade 2 infiltrating ductal carcinoma with extensive DCIS. ER was strongly positive, as well as PR. HER-2/neu was negative. Since that time, the patient was evaluated with an MRI at Fairview-University Medical Center as part of a research program.
PR|pr interval|PR|165|166|IMPRESSION, REPORT AND PLAN|IMPRESSION, REPORT AND PLAN: 1. Chest pain. 2. Murmur suggestive of aortic stenosis. Given duration of symptoms, negative enzymes, diffuse ST segment elevation with PR depression and normal preliminary echo left ventricular function, I suspect this is pericarditis and not occlusive coronary artery disease.
PR|pr interval|PR|167|168|LABORATORY DATA|Electrolyte panel was unremarkable. This morning, _%#MMDD#%_, her potassium is 4.1, creatinine 1.2, BUN 17. Reviewing her ECGs from _%#DDMM2006#%_, it was normal. Her PR interval was 150 milliseconds, her QRS 88 milliseconds, QTC 430 milliseconds. On _%#MMDD#%_, she has sinus bradycardia with a first degree AV block.
PR|pr interval|PR,|182|184|ELECTROCARDIOGRAM, 3/4/05|CHEST X-RAY, _%#DDMM2005#%_: Demonstrated no active disease. Heart size was normal. ELECTROCARDIOGRAM, _%#DDMM2005#%_: Demonstrated sinus bradycardia, heart rate in high 40s. Normal PR, QRS, and QT intervals. No ischemic change. ASSESSMENT: The patient was a 67-year-old male with the following: 1. Right total hip arthroplasty using minimally invasive technique.
PR|pr interval|PR|163|164|LABORATORY DATA|Postoperatively, he has developed Q waves in the anterior precordial leads. We have documentation of a narrow QRS tachycardia with an RP interval greater than the PR interval. Multiple examples have occurred. They have been terminated with cardioversion or burst atrial pacing. During the administration of adenosine, he developed transient AV block which demonstrated the atrial tachycardia.
PR|pr interval|PR,|132|134|PHYSICAL EXAMINATION|ABDOMEN: Soft, nontender. No hepatosplenomegaly. EXTREMITIES: No pretibial or pitting edema. EKG is normal sinus rhythm with normal PR, QRS and QT intervals. No abnormalities whatsoever. LABORATORY: Fifty percent carotid stenosis on the left side and 50 to 70% carotid stenosis in the right internal carotid artery.
PR|pr interval|PR,|205|207|AVAILABLE LABORATORY DATA|Aortic sclerosis without hemodynamically-significant aortic stenosis. There was mild mitral, aortic and tricuspid insufficiency. EKG from _%#DDMM2004#%_ demonstrated a normal sinus rhythm and axis, normal PR, QRS and QT interval. RSR' consistent with incomplete right bundle branch block pattern. No ischemic change. Preoperative hemoglobin 13 gm with creatinine 1, PTT 24 (potassium ?).
PR|pr interval|PR,|205|207|ELECTROCARDIOGRAM(10/10 2006)|Otherwise is nonfocal. LABORATORY DATA: Preop hemoglobin 14.6, potassium 4.4, platelet count 200,000, white count 6200. ELECTROCARDIOGRAM(_%#DDMM2006#%_): Demonstrates normal sinus rhythm and axis. Normal PR, QRS and QT intervals. Loss of R-wave V1 through V2 consistent with anteroseptal MI versus lead placement. No change indicative of ischemia. Tracing not significantly changed when compared with that from _%#DDMM2006#%_.
PR|pr interval|PR|141|142|LABORATORY DATA|There is again a Q-wave present in lead III, which was present in her preop EKG. No significant ST changes. QTC on this EKG is for 42 with a PR interval of 168. IMPRESSION AND PLAN: Ms. _%#NAME#%_ is a 52-year-old female with a complicated history, including chronic thoracic back pain with multiple previous procedures, Sjogren syndrome, irritable bowel, reflex sympathetic dystrophy, and hypertension, admitted following an elective spinal fusion performed by Dr. _%#NAME#%_ and the staff.
PR|progesterone receptor|PR|177|178|PHYSICAL EXAMINATION|Extremities were without clubbing, cyanosis, or edema. TED stockings were in place. There are no laboratory values for my interpretation. Histopathology to review, ER positive, PR negative. HER2 negative (1+ by IHC). Final pathology from the lymph node dissection is pending. Impression is a 48-year-old white female with recently diagnosed invasive breast cancer.
PR|pr interval|PR|272|273|INDICATION FOR CONSULTATION|In the emergency room, he had an electrocardiogram. This study showed a sinus rhythm at 80 beats per minute and a fixed 2:1 AV block with a ventricular rate of 39-40 beats per minute. He also had a complete right bundle branch block. There were no acute ST-T-changes. The PR interval when he was conducting was about 210 Msec. He had no ST elevation or ST depression and no Q-waves. In the emergency room, he had laboratory information obtained. This showed that his potassium was 4.5, creatinine 1.0, troponins were normal x 2, myoglobin was normal, INR was 0.96, hemoglobin 16.6 grams, white count 5,000.
PR|pr interval|PR|173|174|HISTORY OF PRESENT ILLNESS|Heart rate was in the 50-beat-per-minute range, blood pressures in the 114-133 systolic range. In the ER, he was in sinus rhythm with frequent PACs and occasional PVCs. The PR interval was around 190-200 milliseconds. QRS was wide and compatible with a left bundle branch block. EKGs from Methodist Hospital showed that this intraventricular conduction defect was not new.
PR|pr interval|PR|167|168|LABORATORY DATA|NEUROLOGIC: Facies were symmetric. Patient moved all extremities without limitation. LABORATORY DATA: Electrocardiogram demonstrated normal sinus rhythm with a normal PR interval. There were only very small R waves in leads V1-V3 and there were Q waves in leads II, III and aVF consistent with a prior inferior infarction.
PR|progesterone receptor|PR|129|130||The patient underwent a lumpectomy on _%#DDMM2005#%_. Primary tumor was 2.5 cm with evidence of focal DCIS. Her tumor was ER and PR negative and by FISH analysis was also HER-2 negative. A bone scan was normal. Beginning on _%#DDMM2005#%_, the patient was started on combination chemotherapy in adjuvant setting and she received regimen which compromised of 5FU, epirubicin, and Cytoxan.
PR|per rectum|PR|133|134|CURRENT MEDICATIONS|11. Protonix 40 mg IV q.12 h. 12. Tylenol 325 to 650 p.o./NJ q.4 h. p.r.n. 13. _______ 3 mL inhaled q.4 h. p.r.n. 14. Dulcolax 10 mg PR daily p.r.n. constipation. 15. Benadryl 25 mg p.o./IV q.4 h. p.r.n. 16. Dilaudid 0.5 to 1 mg IV q.1-2 h. p.r.n. pain. 17. Combivent 2 puffs inhaled q.4 h. p.r.n.
PR|pr interval|PR|192|193|LABORATORY  DATA|From her electrocardiogram on _%#DDMM2007#%_ the patient is in a regular rhythm with a right bundle branch block pattern and left axis deviation. I suspect it is sinus rhythm with a very long PR interval. There is a rhythm strip from the paramedics which I agree shows an irregular rhythm that is suspicious for an atrial fibrillation.
PR|pr interval|PR|190|191|ASSESSMENT AND RECOMMENDATIONS|Atrial fibrillation or Wenckebach and intermittent heart block with first degree heart block is possible. Again, the P- waves are difficult to visualize but I suspect the patient has a long PR interval. 4. I would recommend avoiding beta blockers at this time and monitoring her rhythm. We will repeat an EKG. She may need event recorders or Holter monitor after discharge if no diagnosis can be made by the telemetry strips.
PR|pr interval|PR|118|119|EKG|He is alert and oriented x 3. PSYCH: Mood and affect were appropriate. EKG: EKG shows normal sinus rhythm with normal PR interval, QRS duration and QT interval. There is minimal ST elevation, particularly in the inferior leads; this is likely a normal variant and consistent with early repolarization.
PR|pr interval|PR,|266|268|LABORATORY DATA|NEUROLOGIC: Grossly non-focal. LABORATORY DATA: Preoperative white blood count 7400, hemoglobin 15.5 on _%#DDMM2006#%_, platelet count this morning 171,000. Serum potassium 4.2. Electrocardiogram on _%#DDMM2006#%_ demonstrated a normal sinus rhythm and axis, normal PR, QRS, and QT interval, no ischemic change. ASSESSMENT: 53-year-old male with the following: 1. Right total hip arthroplasty, minimally invasive technique.
PR|pr interval|PR|101|102|DATA|ABDOMEN - benign. EXTREMITIES - no clubbing, cyanosis, or edema. DATA: EKG shows sinus rhythm with a PR interval close to 360 milliseconds. QRS shows left bundle branch block and a QRS duration of near 160 milliseconds. On telemetry monitoring, she is noted to have episodes of second-degree type I AV block.
PR|pr interval|PR|139|140||The ventricular response is narrow. I do not see any obvious progressive increase in TP interval in association with the 2:1 AV block. The PR interval in the beat that precedes the first blocked beat is somewhat shorter than the subsequent beat during the AV block and the second PR interval after recovery of consistent conduction is somewhat prolonged.
PR|pr interval|PR|174|175|PHYSICAL EXAMINATION|The EKG is reviewed and shows sinus rhythm with a very long first degree AV block, possibly retrograde P-waves with an accelerated junctional rhythm with intermittent normal PR intervals noted. Nonspecific ST-T changes are present compatible with hypertension, but he does not have much voltage for the diagnosis of hypertension nor does he have a prolonged intrinsicoid.
PR|pr interval|PR|321|322|HISTORY|HISTORY: I was asked by Dr. _%#NAME#%_ to visit _%#NAME#%_ _%#NAME#%_ in the Emergency Department, when he presented with a couple of days of chest discomfort in the central chest moderately severe. An EKG suggested either pericarditis or acute myocardial process with moderately elevated ST segments in most leads, with PR depression. EKG showed up to 4 mm of elevation and was thought to be quite unusual for simple early repolarization, although the ST segments were upward coved and Dr. _%#NAME#%_ ordered an echocardiogram and I was lucky enough to see it being done at the time when the EKG's were as described.
PR|pr interval|PR|214|215|INDICATIONS FOR CONSULTATION|These symptoms lasted for 5-8 minutes. She was most light-headed when she stood up. She came to the Emergency Department. EKG showed sinus rhythm. She had periods with monitoring of intermittent 2:1 AV conduction; PR interval was 208 milliseconds, QRS was normal, QT interval normal. Since admission to the hospital she has had episodes of sinus rhythm with 2nd degree AV block with 3:2 and 2:1 AV conduction This was Winckebach type mechanism.
PR|pr interval|PR|144|145|STUDIES|The atrial pacing unit was then turned down to 45. She had an underlying narrow complex rhythm at a rate of 60. There were P waves with a short PR interval present on the monitor. These were upright in lead II. The PDA appeared to move in and out of the initial portion of the QRS interval, suggesting the possibility of competing atrial and junctional rhythms.
PR|pr interval|PR|342|343|LABORATORY|ECG shows inferolateral ST depression. Yesterday from admission until now, the three electrocardiograms show significant improvement in this ST depression so that she qualifies by Lyon-Sokolow criteria for LVH, but it is obvious that she is thin chest-walled and is a younger person, and therefore this criteria does not apply. There is some PR depression in some of the leads. There is no ST elevation. Chest x-ray is normal. Chest CT is normal. Echocardiogram was personally reviewed by me, and is essentially normal, with mild TR.
PR|per rectum|PR|163|164|HOME MEDICATIONS|2. Right carpal tunnel surgery. 3. Hysterectomy. ALLERGIES: No known drug allergies. HOME MEDICATIONS: 1. Tylenol 650 mg p.o. four times a day. 2. Compazine 25 mg PR q. 12 hours p.r.n. nausea. 3. Multivitamin 1 p.o. daily SOCIAL HISTORY: The patient is from South Dakota.
PR|pr interval|PR|183|184|INDICATIONS FOR CARDIOLOGY CONSULTATION|Since admission, she has continued to be in a paced rhythm that is associated with a supraventricular rhythm approximately every third or every fourth beat. Her sinus node fires. Her PR interval is approximately 200 milliseconds. QRS is narrow. PAST MEDICAL HISTORY: 1. Pacemaker placement 11 years ago for bradycardia with heart rates in the 20s.
PR|pr interval|PR,|120|122|ELECTROCARDIOGRAM|LABORATORY DATA: Preop hemoglobin 14.8 grams percent. ELECTROCARDIOGRAM: Demonstrates a normal sinus rhythm with normal PR, QRS and QT interval. No ischemic change. ASSESSMENT: Fifty-eight-year-old male admitted with the following: 1. Right total hip arthroplasty, minimally invasive technique.
PR|pr interval|PR,|203|205|OBJECTIVE|Return of lower extremity sensation with regard to epidural. LAB DATA (pre-operatively): Hemoglobin 17.4 gm %. EKG from _%#DDMM2003#%_ demonstrated a normal sinus rhythm with left axis deviation. Normal PR, QRS, and QT interval. No ischemic change. ASSESSMENT: 6-year-old male with the following: 1. Manipulation of left total knee arthroplasty under epidural anesthesia.
PR|pr interval|PR|158|159|PHYSICAL EXAMINATION|The bowel sounds were normal. EXTREMITIES: Legs showed no pedal edema. NEUROLOGIC: Unremarkable. The EKG showed a sinus rhythm with 2:1 AV conduction. He had PR interval of about 600 milliseconds for the conducted QRS complex. In addition, his QRS showed right bundle branch block. Since his admission, the troponin has been negative.
PR|(drug) PR|PR|217|218|HOSPITAL COURSE|Several changes were made to the patient's pain regimen. She was initially placed on fentanyl patch, however, with PO pain medicine for breakthrough pain. However, the patient requested to be placed back on methadone PR which in addition to morphine PCA controlled the patient's pain at the time of discharge. She will be discharged to home with TLC care where they will be able to administer morphine PCA as well as give her methadone PR.
PR|per rectum|PR|109|110|DISCHARGE MEDICATIONS|9. Protonix 20 mg p.o. b.i.d. 10. Tylenol Elixir 650 mg p.o. or down G-tube q.6 h. p.r.n. 11. Tylenol 650 mg PR q.6 h. p.r.n. 12. Compazine 10 mg p.o. q.6 h. p.r.n. nausea. 13. Methadone 10 mg PR q.8 h. p.r.n. pain.
PR|pr interval|PR,|184|186|HISTORY OF PRESENT ILLNESS|Significant fatigue. ER evaluation included electrocardiogram which demonstrated voltage consistent with patient's COPD. Normal sinus rhythm with premature atrial contractions. Normal PR, QRS, and QT interval. No ischemic change. A chest x-ray demonstrates flat diaphragms with hyperlucent lungs. No obvious infiltrate. PAST MEDICAL HISTORY: 1. Severe end-stage COPD, is BiPAP, steroid and O2 dependent, as above.
PR|per rectum|PR|194|195|DISCHARGE MEDICATIONS|The patient will follow up with Dr. _%#NAME#%_ _%#NAME#%_ in Neurosurgery next Tuesday and Dr. _%#NAME#%_ _%#NAME#%_ at Smiley's Clinic in 2 to 3 weeks. DISCHARGE MEDICATIONS: 1. Dulcolax 10 mg PR q. day. 2. Lisinopril 20 mg p.o. q. day. 3. Metoprolol 100 mg p.o. b.i.d. 4. Zantac 150 mg p.o. b.i.d.
PR|pr interval|PR|121|122|LABORATORY AND DIAGNOSTIC DATA|There is mild increase in cephalization, otherwise normal. EKG reviewed by myself shows normal sinus rhythm with a short PR interval and left atrial enlargement. There is no evidence for ischemia, otherwise a normal EKG. IMPRESSION/PLAN: This is a 60-year-old male with a complicated history, now admitted with a recurrent right leg cellulitis.
PR|per rectum|PR|111|112|DISCHARGE MEDICATIONS|21. Dilaudid 2-4 mg p.o. q.6 h. p.r.n. pain. 22. Valium 10 mg p.o. q.6 h. p.r.n. agitation. 23. Dulcolax 10 mg PR daily p.r.n. constipation. 24. Insulin NovoLog sliding scale p.r.n. for fingersticks between 120-149 2 units, 150-199 3 units, 200-249 4 units, 250-299 7 units, 300-349 10 units, greater than or equal to 350 12 units.
PR|progesterone receptor|PR|158|159|HISTORY OF PRESENT ILLNESS|In _%#DDMM1995#%_, she underwent a right modified radical mastectomy and axillary dissection. Pathology confirmed invasive ductal carcinoma, which was ER and PR positive. Eight axillary lymph nodes were involved with tumor. She went on to receive chemotherapy and radiation therapy to the right chest wall, axilla and supraclavicular area.
PR|per rectum|PR|119|120|DISCHARGE MEDICATIONS|15. Ambien 5 mg orally nightly p.r.n. 16. Ativan 0.5 to 1 mg orally or IV every 4 to 6 hours p.r.n. 17. Dulcolax 10 mg PR daily as needed. 18. Senokot S one to two tablets orally b.i.d. p.r.n. FOLLOW UP: There will be one future appointment that is on _%#MM#%_ _%#DD#%_, 2005, with Dr. _%#NAME#%_ for chemotherapy.
PR|pr interval|PR,|156|158|X-RAY|X-RAY: Chest x-ray PA and lateral on my review demonstrated no active disease. EKG dated _%#DDMM2006#%_ demonstrates a normal sinus rhythm and axis, normal PR, QRS, and QT interval. Mild baseline artifact. There is downward sloping of the complexes associated with less than 1 mm ST depression/straightening in V3 through V6.
PR|per rectum|PR|380|381|MEDICATIONS ON DISCHARGE|5) Roxicodone 5 mg p.o. q.4-6h. p.r.n. (Note: Roxicodone, Lidoderm, Neurontin, and Duragesic patches all to be distributed only by Pain Clinic.) 6) Ibuprofen 800 mg p.o. t.i.d. p.r.n. 7) Miconazole vaginal cream, 2%, apply q.h.s. times 7 days (end _%#DDMM2002#%_). 8) Celexa 40 mg p.o. q.d. 9) Clindamycin 300 mg p.o. q.i.d. times 7 days (end _%#DDMM2002#%_). 10) Compazine 25 mg PR q.8h. p.r.n. 11) Lansoprazole 30 mg p.o. q.d. 12) Colace 100 mg p.o. q.d. 13) Reglan 10 mg p.o. 30 minutes before meals p.r.n. 14) Insulin sliding scale.
PR|per rectum|PR|140|141|TRANSFERRING MEDICATIONS|12. Colace 100 mg b.i.d. 13. Lasix 20 mg b.i.d. 14. Albuterol 2.5 mg in 3 cc nebulized b.i.d. 15. Dulcolax suppository p.r.n. constipation, PR each day. 16. Seroquel 25 mg p.o. q.h.s. p.r.n. sleep disturbance. 17. DuoNeb 3 mL nebulized q.2 h. p.r.n. shortness of breath.
PR|per rectum|PR|221|222|PRESENT MEDICATIONS|9. Seroquel 50 mg b.i.d. (to help weaning of sedation, while in ICU and may not need to continue long term). 10. Sildenafil citrate 75 mg down NG-tube t.i.d. 11. Albuterol inhaler 4 puffs q.2 h. p.r.n. 12. Dulcolax 10 mg PR q.24 h. p.r.n. 13. Senna 2 tablets per G-tube b.i.d., hold for loose stools. 14. Colace 100 mg per G-tube b.i.d., hold for loose stools.
PR|per rectum|PR|152|153|DISCHARGE MEDICATIONS|He will have a video swallow on Friday, _%#DDMM2005#%_. DISCHARGE MEDICATIONS: Are as follows: 1. DuoNebs every four hours as needed. 2. Aspirin 300 mg PR Q day. It is difficult to down the tube feeds. 3. Lipitor 10 mg down feeding tube QHS 4. Plavix down feeding tube Q day 5.
PR|per rectum|PR|178|179|DISCHARGE MEDICATIONS|10. Ferrous sulfate 25 mg G-tube daily. 11. Vitamin E 800 unit 1 cap G-tube daily. 12. Enalapril 5 mg G-tube daily. 13. Carnitine 650 mg G-tube 5 times per day. 14. Diastat 5 mg PR q. 10 minutes p.r.n. seizure. 15. Vitamin K 5 mg G-tube daily. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 4-year 6-month-old male with methylmalonic acidemia, who presented via ambulance to Fairview Medical Center from _%#CITY#%_ _%#CITY#%_, Minnesota with a few days history of fever to 102 degrees Fahrenheit and cough.
PR|per rectum|PR|150|151|DISCHARGE MEDICATIONS|12. Percocet 1 to 2 tablets p.o. q. 4 to 6 hours p.r.n. pain. 13. Tylenol 325 to 650 mg p.o. q. 4 to 6 hours (do not exceed 4 gm). 14. Dulcolax 10 mg PR daily. 15. Actos 45 mg p.o. daily. 16 . Lasix 20 mg p.o. q. a.m. and 20 mg q. 3 p.m. DISCHARGE INSTRUCTIONS: 1. Follow up in Dr. _%#NAME#%_'s clinic within 2 weeks on Thursday (_%#TEL#%_ _%#TEL#%_).
PR|pr interval|PR|283|284|LABORATORY DATA|LABORATORY DATA: White count 7000, hemoglobin 10.7 grams percent with MCV of 86.7, platelet count 444,000, sodium 138, potassium 4.3, chloride 105, CO2 of 20. BUN 74 with a creatinine of 2.9. Glucose 117. Magnesium 4.7. Electrocardiogram demonstrates a normal sinus rhythm and axis. PR interval of 0.214 consistent with first degree AV block. Loss of R-wave progression V1 through V2 consistent with possible old anteroseptal MI (no clinical correlation).
PR|per rectum|PR|120|121|5. ID|7. Kayexelate 2 gm/650 ml formula 8. NaCl 5 mEq PO/NG q3h w/ feeds 9. Tylenol 50 mg PO/PR q4h PRN 10. Glycerin 1/4supp. PR PRN q12h 11. Sucrose 0.5 cc PRN 12. EMLA cream PRN Discharge measurements: Weight 3590 gms; length 46 cm; OFC 34 cm.
PR|per rectum|PR|187|188|DISCHARGE MEDICATIONS|5. CellCept 200 mg per G-tube b.i.d. 6. Delatestryl 200 mg per 5 mL, 0.25 mL IM q. month. 7. Diastat 50 mg p.r.n. for seizures greater than 2 minutes in duration. 8. Enemeez Mini Enema 1 PR nightly. 9. Fosamax 35 mg tablet q. week. 10. Reglan 5 mg per G-tube q.i.d. 11. Neutra-Phos-K 1 packet daily per G-tube mixed in 60 mL of water, with a 120 mL of water flush.
PR|UNSURED SENSE|PR,|181|183|HOSPITAL COURSE|The wound and fascia were sharply debrided and the fascia was reapproximated. Please see dictated operative report for details of the surgery. The patient did well initially in the PR, however then desaturated and was brought to the FICU overnight, where she did well and was transferred back to the floor on the morning of postoperative day 1.
PR|pr interval|PR|133|134|PHYSICAL EXAMINATION|DP pulses are difficult to palpate, however, he has good radial and femoral pulses. His EKG shows sinus bradycardia with a prolonged PR interval. Chest x-ray shows cardiomegaly but no pulmonary infiltrate or pulmonary vascular congestion. LABORATORY DATA: Digoxin 3.6, BNP 212, amylase 86, white count 13.4, hemoglobin 12.5. He had a differential of 80 neutrophils, 10 lymphs, 6 monos, 4 eosinophils and 0 basophils.
PR|pr interval|PR|153|154|ASSESSMENT AND PLAN|The patient had a 12-lead EKG, which showed A-fib with wide QRS complexes. No sign of ischemia or new cardiac injury has been seen on EKG. The patient's PR interval could not be evaluated. Her QRS complexes are widened. IV fluids were started on the patient, running at the rate of 100.5 ml/hour for the first liter, and then switched to 100 ml/hour for another 2 liters.
PR|pr interval|PR|210|211|ELECTROCARDIOGRAM|Troponin was less than 0.07. INR 1.16. PTT 31. Total bilirubin 0.8. Albumin 3.7. Protein 7.5. Alkaline phosphatase 63. ALT 39. AST 31. ELECTROCARDIOGRAM: Sinus tachycardia with a paced rhythm. Mildly shortened PR interval. No changes of acute ischemia present. RADIOLOGY: Chest x-ray revealed a right middle to lower lobe infiltrate with no pleural effusions noted.
PR|pr interval|PR|543|544|HOSPITAL COURSE|A cause for this was never determined and this can be followed up with her primary on an outpatient basis. 8. Cardiovascular: _%#NAME#%_ had some episodes of sinus pause on _%#MMDD#%_ and since then she appeared to have numerous instances of sinus arrhythmia where she would have a normal heart rate followed by a slightly increased gap between 2 successive heart beats, but she also had occasional dropped beats where P wave was seen and there is no QRS as well as one time when it was noted on telemetry that she appeared to have increasing PR interval followed by a drop beat consistent with a type 1 second-degree block. Cardiology was consulted, and we obtained an echo, which was normal and EKG which was normal as well.
PR|progesterone receptor|PR|249|250|HISTORY OF PRESENT ILLNESS|She underwent lumpectomy and axillary lymph node dissection. Lumpectomy demonstrated an infiltrating ductal adenocarcinoma Nottingham grade III, Nottingham score 9 of 9 with angiolymphatic invasion. The patient was HER II new negative, ER negative, PR negative. She had 4 of 18 lymph nodes positive with tumor with the largest lymph node measuring 1.5 cm. It is not clear how large her primary tumor was.
PR|per rectum|PR|140|141|DISCHARGE MEDICATIONS|10. Colace 100 mg p.o. b.i.d. 11. Percocet 1 to 2 tabs p.o. q.4-6 h. p.r.n. 12. Ativan 1 mg p.o. q.4-6 h. p.r.n. 13. Tylenol 650 mg p.o. or PR q.4 h. p.r.n. 14. Compazine 10 mg p.o. q.6 h. p.r.n. 15. Reglan 10 mg IV q.6 h. p.r.n. 16. Ambien 10 mg p.o. q.h.s. p.r.n. 17. Dulcolax 10 mg PR each day p.r.n.
PR|progesterone receptor|PR|211|212|PAST  MEDICAL HISTORY|Patient is on Taxol and dexamethasone chemotherapy, which she is getting approximately every 2 weeks. She does have a Port-A-Cath and has had no problems with this. The cancer is HER-2/Neu receptor negative and PR and ER receptor positive. 2. Hypertension well controlled with Norvasc therapy. 3. Anxiety treated with lorazepam. 4. Nausea secondary to chemo. 5. Tingling in extremities secondary to chemo.
PR|per rectum|PR|157|158|MEDICATIONS|13. Dilaudid 2-4 mg p.o. q. 2 h p.r.n. pain. 14. Senna-S 1-4 tablets p.o. daily titrated to 1 bowel movement per day. 15. Dulcolax suppository 1 suppository PR daily p.r.n. constipation. 16. Trazodone 25 mg p.o. each day at bedtime p.r.n. insomnia. 17. Vicodin 1-2 tablets p.o. q. 4 h p.r.n. pain.
PR|per rectum|PR|129|130|DISCHARGE MEDICATIONS|10. Lisinopril 2.5 mg q. day. 11. Haldol 0.5 mg, 1-2 tablets p.o. or IM q.4-6h. p.r.n. agitation. 12. Dulcolax suppository 10 mg PR q. day p.r.n. constipation. 13. Acetaminophen 500 mg, 1-2 tablets q.i.d. p.r.n. arthritis pain or fever. DISCHARGE FOLLOW UP: 1. A follow up appointment will be scheduled at my office in four to six weeks.
PR|pr interval|PR,|244|246|LABORATORY DATA|Urinalysis was unremarkable. A PTT of 24.9. Electrocardiogram demonstrated normal sinus rhythm. Loss of R-wave V1 through V3 consistent with possible anterior myocardial infarction, age indeterminate. Possibly related to lead placement. Normal PR, QRS and QT interval. No ST-T wave change to suggest cardiac ischemia. Record indicates no change since tracing on _%#DDMM2006#%_.
PR|pr interval|PR|160|161|STUDIES|Electrocardiogram of _%#DDMM2005#%_ at 0723 showed sinus rhythm, normal axis, with anterolateral T wave inversion. Telemetry shows intermittent prolongation in PR interval up to 0.48. IMPRESSION/PLAN: 1. Non-ST elevation myocardial infarction. The patient sustained a non- ST elevation myocardial infarction.
PR|pr interval|PR|125|126|LABORATORY DATA|The EKG from 5 this morning shows predominantly 2:1 AV block. There is sequence of 2 conducted P waves without change in the PR interval. All of the above strongly suggest AV block infrahisian intermittent due to an AV block. The preliminary report on her echocardiogram shows normal LV function and left ventricular hypertrophy and left atrial enlargement.
PR|pr interval|PR|136|137|EKG|Cranial nerves II-XII are grossly intact. Affect is normal. EKG: Normal sinus rhythm without ST or T wave abnormalities. QRS is normal. PR interval is normal. LABORATORY: Myoglobin is 39, troponin 0.17. Platelet count 207,000.
PR|pr interval|PR|176|177|LABORATORY DATA|Extraocular muscles are intact. LABORATORY DATA: Her EKG on admission was reviewed by me and revealed right bundle branch block with left anterior fascicular block with normal PR interval. Sinus tachycardia was noted on admission. No ischemic changes noted. Other labs include an INR of 2.15, hemoglobin 11.8, hematocrit 37.
PR|progesterone receptor|PR|173|174|IMPRESSION|The patient is status post wide excision with pathology showing high grade infiltrating carcinoma, extensive endolymphatic invasion, negative but close margin, ER positive, PR negative HER-2 negative. The patient is currently on Faslodex q. monthly injection. In addition to the punch biopsy of the erythematous lesion, there is another suspicious area identified lateral to that.
PR|pr interval|PR|504|505|LABORATORY DATA|Urinalysis was unremarkable, although the patient tells me she was found to have a urinary-tract infection in the Emergency Department at Fairview Northland Hospital; I am not sure what this diagnosis is based upon; the patient did not have any dysuria or fevers. CBC is unremarkable with hemoglobin of 15.5, platelets 275 and white blood count 6.5. I have reviewed the patient's EKG from _%#MM#%_ _%#DD#%_ and _%#MM#%_ _%#DD#%_; they show rare sinus beats conducted to the ventricles mostly with normal PR interval, although there is borderline prolongation after termination of atrial tachycardia runs, and frequent but nonsustained runs of atrial tachycardia with somewhat variable cycle lengths, approximately 300 msec, although some are a little bit longer.
PR|progesterone receptor|PR|324|325|HISTORY OF PRESENT ILLNESS|She was initially thought to have a gynecologic malignancy. She was transferred to Fairview-University Medical Center in _%#DDMM2004#%_ and she had breast biopsies on _%#DDMM2004#%_ and _%#DDMM2004#%_ (case _%#MRN#%_). The left breast biopsy showed invasive cancer with mixed ductal/lobular features grade 2/3, ER positive, PR negative. The mass measured 1.1 cm and was in the 7 o'clock position. She had a head CT on _%#DDMM2004#%_ and an MRI of the head on _%#DDMM2004#%_ which both revealed bony metastases to the right temporal lobe.
PR|progesterone receptor|PR|256|257|HPI|No other evidence of abnormal palpable lymphadenopathy. Assessment and Plan: The patient will be seen by Medical Oncology for discussion regarding systemic treatment. Her histopathology shows aggressive tumor with high grade and HER-2/neu positive with ER PR negative. She probably will go onto some sort of systemic treatment before radiation treatment. We will discuss this issue after she sees Dr. _%#NAME#%_ in Medical Oncology.
PR|pr interval|PR|196|197|LABORATORY DATA|The patient moved all extremities without focal limitation. LABORATORY DATA: EKG demonstrated sinus rhythm with a left bundle branch block, premature ventricular contractions and a left axis. The PR interval was borderline abnormal. Other laboratories include an echocardiogram which has demonstrated an ejection fraction of 40% with global hypokinesis and increased hypokinesis of the posterior wall.
PR|pr interval|PR,|328|330|LABORATORY DATA|Unremarkable urinalysis. On _%#DDMM2007#%_ sodium is 137 with a potassium of 4.0, chloride 98, CO2 28, anion gap 12, glucose 114, BUN 26, creatinine 0.8, calcium 9.5, magnesium 2.2, hemoglobin 13.7, hemoglobin A1c of 5.2. Electrocardiogram from this morning demonstrates a normal sinus rhythm with a left axis deviation. Normal PR, QRS and QT interval. Loss of R-wave across the anterolateral precordium consistent with anterolateral infarct, age indeterminate. Also, Q-waves in 3 and AVF consistent with possible old inferior myocardial infarction.
PR|pr interval|PR,|180|182|PHYSICAL EXAMINATION|EXTREMITIES; Without cyanosis or edema. Pulses were 1 to 2+ below the femorals, 2+ above. NEUROLOGIC: Grossly intact. EKG from the stress test showed a normal sinus rhythm, normal PR, QRS and QT intervals, no acute ST abnormalities. LABORATORY DATA AND CHEST X-RAY: Pending. CLINICAL IMPRESSION: 1) Chest discomfort, ? rule out possible angina pectoris.
PR|per rectum|PR|177|178|MEDICATIONS|MEDICATIONS: 1. Allopurinol 100 mg p.o. daily. 2. Ambien 5 mg p.o. each day at bedtime p.r.n. 3. Amitriptyline 50 mg p.o. daily. 4. Aspirin 81 mg p.o. daily. 5. Bisacodyl 10 mg PR p.r.n. constipation. 6. CellCept 500 mg p.o. t.i.d. 7. Compazine 10 mg p.o. q.6h. p.r.n. 8. Florinef 0.1 mg b.i.d. 9. Folic acid 5 mg p.o. q. day. 10. Metoprolol 12.5 mg p.o. b.i.d.
PR|pr interval|PR|114|115|HISTORY OF PRESENT ILLNESS|Her QT interval is slightly prolonged at 415 ms. There were no dynamic STT changes and no Q waves were noted. Her PR interval and QRS restoration were within normal limits. She was ruled out for a myocardial infarction with serial cardiac enzymes and electrocardiograms.
PR|pr interval|PR|173|174|LABORATORY DATA|No documented history of diabetes mellitus or known hypertension. LABORATORY DATA: is pending. Electrocardiogram showed a normal sinus rhythm with a mild sinus dysrhythmia. PR QRS and QT intervals were within normal limits. No acute ST abnormality noted. Chest x-ray is pending. CLINICAL IMPRESSION: 1. Chest discomfort consistent with possible unstable angina pectoris 2.
PR|progesterone receptor|PR|210|211|HPI|The patient underwent biopsy of the lesions on _%#DDMM2004#%_, which showed infiltrating ductal carcinoma in both sites, Nottingham grade 3/3, highly suspicious for angiolymphatic invasion. ER was positive and PR was negative. HER2/neu was positive. Metastatic workup showed no other findings, including PET scan. The patient underwent neoadjuvant chemotherapy with Adriamycin and Cytoxan until _%#DDMM2005#%_, then Taxol, carboplatin and Herceptin, of which she received 8 cycles until _%#DDMM2005#%_.
PR|pr interval|PR,|219|221|PHYSICAL EXAMINATION|Bowel sounds are present. EXTREMITIES: Without cyanosis or edema. Pulses were 2+ throughout. NEUROLOGIC: Appeared to be grossly intact. Electrocardiogram demonstrated a normal sinus rhythm with no acute ST abnormality. PR, QRS, and QT intervals within normal limits. Chest x-ray is not available for viewing. LABORATORY DATA: Showed a sodium 141, potassium 4.0, chloride 107, C02 28, glucose 96, BUN was 16, creatinine 1.0, calcium 8.4. WBC was 7.8, hemoglobin 14.7, and hematocrit 43.4. Myoglobin 62.
PR|progesterone receptor|PR|220|221|HISTORY  OF PRESENT ILLNESS|Initial margins of the tumor were positive so a reexcision was performed and all final margins were negative. The stage is T2, N1a, MX infiltrating ductal carcinoma of the left breast. Tumor was found to be ER positive, PR positive and HER-2/neu positive. The patient reports that she healed well from the surgery and went on to receive 4 cycles of AC chemotherapy followed by 12 cycles of Taxol.
PR|pr interval|PR,|180|182|ELECTROCARDIOGRAM, 5/5/05|Subsequent followup BMP normal. WBC 9300, hemoglobin 13.1 with MCV of 93, platelet count 233. ELECTROCARDIOGRAM, _%#DDMM2005#%_: Demonstrated sinus arrhythmia, normal axis, normal PR, QRS and QT intervals. No ischemic change. LABORATORY DATA, from this morning: Comprehensive metabolic profile was unremarkable except for mildly reduced albumin of 3.0. WBC 4600, hemoglobin 13, MCV 94.
PR|pr interval|PR|133|134|IMPRESSION AND PLAN|The patient with myotonic dystrophy and also may have a propensity toward intra-Hisian block or AV block. There has been a prolonged PR interval and borderline interventricular conduction defect on the admission EKG. Nevertheless, this was in the setting of pneumonia and/or hypoxemia and has since normalized.
PR|progesterone receptor|PR|162|163|HISTORY OF PRESENT ILLNESS|She did have a biopsy of 3 of the sites in the left breast that did show invasive ductal carcinoma with a micropapillary pattern of growth that were ER positive, PR negative. She then had a modified radical mastectomy of the left breast on _%#DDMM2005#%_ performed by Dr. _%#NAME#%_. All areas under suspicion were removed. The patient did have one sentinel node that was positive in addition to a second axillary node that was positive, for a total of 2 positive out of 25 lymph nodes.
PR|pr interval|PR|450|451|LABORATORY DATA|LABORATORY DATA: No labs have been done here. There are labs that were done on _%#MM#%_ _%#DD#%_ including a hemoglobin of 14.8, a white count of 6,800 with 71.6 neutrophils and 19.5 lymphocytes and 6.1 monocytes. Platelet count is 265,000. The glucose was 133, BUN was 22, creatinine was 1.1 and sodium was 139, potassium 3.3, chloride 99, CO2 30, calcium 9.5. protime was 0.9, a PPT was 25.5 and EKG was done and shows a normal sinus rhythm with a PR interval of 0.15, QRS of 0.09, QT of .42 with no evidence of acute ischemia. There were some nonspecific T-wave changes, no evidence of left ventricular hypertrophy by EKG.
PR|pr interval|PR,|249|251|PREOPERATIVE LABORATORY DATA|Normal global LV systolic function. Moderate right ventricle dilatation. RV systolic pressure was mildly increased. Mild to moderate tricuspid regurgitation. EKG I believe from _%#DDMM2004#%_ demonstrated rightward axis, normal sinus rhythm, normal PR, QRS, and QT interval. Decreased R- wave progression over the anterior precordium. No old tracing for comparison. ASSESSMENT: 66-year-old male with the following: 1. Right total hip arthroplasty.
PR|pulmonary regurgitation|PR|215|216|PHYSICAL EXAMINATION|The right ventricular function appears severely decreased with an enlarged right ventricle. Biatrial enlargement noted. Dilated IVC suggestive of increased right atrial pressures. Moderate TR and moderate to severe PR were noted. The right ventricular systolic pressure was 70 plus right atrial pressure, consistent with severe pulmonary hypertension.
PR|pr interval|PR|182|183|CLINICAL IMPRESSION|6. Obesity 7. History of hypothyroidism 8. Status post cholecystectomy 9. History of nephrolithiasis. 10. Abnormal electrocardiogram with transient mild diffuse ST elevation, slight PR depression presently resolved. DISCUSSION The patient's symptoms are somewhat atypical for pericarditis or unstable angina pectoris.
PR|pr interval|PR|167|168|LABORATORY|Wound culture from _%#DDMM2003#%_ demonstrated 4+ coagulase negative staph, with 3+ enterococcus. EKG from _%#DDMM2003#%_ demonstrates a normal sinus rhythm and axis. PR interval .272 consistent with first- degree AV block. Minor non-specific ST-T wave changes inferolaterally. ASSESSMENT: 1. Infected left prepatellar bursa with I & D (as above).
PR|pr interval|PR|245|246|PHYSICAL EXAMINATION|She was in rapid atrial fibrillation in the ambulance and in the ER she got a dose of Cardizem 20 mg followed by profound asystole and bradycardia which was treated with atropine. Subsequently she went back into sinus rhythm as noted above. Her PR interval was normal. QRS is normal. This is a complex combination of events. I believe this woman has paroxysmal atrial fibrillation, likely sick sinus syndrome and a tendency both to tachycardia and bradycardia.
PR|pr interval|PR|359|360|STUDIES|At 9:53 p.m., there continues to be a borderline right bundle branch block; however, there is a narrower QRS, Q waves persist inferiorly, and there is R wave in V 1 and V 2. EKG at 11:33 p.m. now demonstrates Q waves inferiorly, QRS duration of 0.116, QTc remains quite prolonged at 0.61, and there even appear to be delta waves, although I do not perceive a PR interval to substantiate that. On telemetry, she now has gone back into normal sinus rhythm.
PR|pr interval|PR|158|159|CURRENT MEDICATIONS|NEUROLOGIC: The patient was alert and oriented x3. No focal neurologic deficits were appreciated. The EKG shows sinus bradycardia at 53 beats per minute. The PR interval, QRS duration and QT interval corrected are within normal limits. There were no dynamic ST-T changes seen. No Q waves were noted.
PR|pr interval|PR,|493|495|LABORATORY DATA|LABORATORY DATA: Comprehensive metabolic panel with sodium 142, potassium 4.5, chloride 105, CO2 33, anion gap 5, glucose 97, BUN 13, creatinine 1.1, calcium 8.9, normal liver profile and TSH 1.77. Lanoxin level from _%#DDMM2003#%_ was 0.6, lipase 116, white count mildly elevated at 13,800 with hemoglobin 15.3, MCV 91, platelet count 109,000. Electrocardiogram fr om _%#MMDD#%_ demonstrated normal sinus rhythm and axis and insignificant Q wave in inferior leads, no ischemic change, normal PR, QR.....interval. ASSESSMENT: 58-year-old male with the following: 1. Major depressive disorder/panic disorder, as per Psychiatry.
PR|pr interval|PR,|178|180|LABORATORY DATA|GENITALIA AND RECTAL: Exam deferred. NEUROLOGIC: Grossly nonlateralizing. LABORATORY DATA: Preop electrocardiogram _%#DDMM2000#%_ demonstrating a normal sinus rhythm with normal PR, QRS and QT interval. Minor nonspecific T-wave abnormality inferolaterally. Hemoglobin was 12.6 grams percent with potassium 4.0. Follow-up potassium on _%#MMDD#%_ of 3.8. Urinalysis unremarkable.
PR|pr interval|PR,|314|316|AVAILABLE LABORATORY DATA|On _%#DDMM2005#%_: sodium 136, potassium 4.1, chloride 101, CO2 31, BUN 11, creatinine 1.1, calcium 9.0, phosphorus 3.9. Iron 44, transferrin 225, iron-binding capacity 335, percent saturation 13, ferritin 46. PTH mildly elevated at 84. EKG dated _%#DDMM2005#%_ demonstrated a normal sinus rhythm and axis. Normal PR, QRS, and QT intervals. Minor non-specific T-wave abnormality inferiorly as well as over the anterior precordium. ASSESSMENT: 58-year-old female with the following: 1. Right total shoulder arthroplasty.
PR|pr interval|PR|163|164|LABORATORY DATA|The differential diagnosis would be ventricular tachycardia versus a preexcited SVT. There is a question of P-wave following the QRS complex with a possibly short PR interval, but it is difficult to be certain about this. On one occasion the tachycardia at the cycle lengths shortens to as low as 200 milliseconds with a moderate degree of change in the QRS morphology.
PR|pr interval|PR,|218|220|AVAILABLE LAB DATA|NEUROLOGIC: No gross localizing abnormalities. Lower extremity motor strength, presently not tested. AVAILABLE LAB DATA: EKG preop, _%#DDMM2005#%_, demonstrated a sinus bradycardia with a heart rate in the 50s. Normal PR, QRS, Q-T interval. Right axis deviation (?). Low voltage in the limb leads. No ischemic change. Today, glucose was 146 this morning, with hemoglobin of 9.2 gm% (?).
PR|pr interval|PR|258|259|LABORATORY DATA|His ventricular rate slowed down to approximately 50. I can now probably map out P-waves at roughly 100 with a 2:1 block. Since the initial EKG actually had a ventricular rate of 97, I suspect what the original rhythm was sinus tachycardia with a very short PR interval, since again after the pause I am because able to map out P-waves at a rate of 100. The interesting thing though is the P to QRS interval is changing so this may actually be iso-rhythmic accelerated junctional tachycardia which is what I think we are seeing with the intermittent capture from the SA node.
PR|progesterone receptor|PR|185|186|CURRENT MEDICATIONS|4. Premarin 0.625 q. day. 5. Advair b.i.d. At today's visit the patient was scheduled for a whole body PET scan along with a bone scan. We also requested the pathology lab to do ER and PR staining on the patient's lymph node. In addition, a CEA and CA27-29 tumor marker was ordered. Finally, the patient has been advised to return to see me in ten days for follow-up.
PR|pr interval|PR,|358|360|PREOP EKG|PELVIC/RECTAL: Exams deferred. NEUROLOGIC: Grossly nonfocal. AVAILABLE LABORATORY DATA (from this morning): Hemoglobin 8.6, reduced platelet count of 68,000, sodium 134, potassium 3.2, chloride 107, CO2 25, anion gap 3, glucose 130, BUN 10, creatinine 0.83, calcium low at 6.3. INR 1.43. Magnesium low at 1.4. PREOP EKG: Normal sinus rhythm and axis; normal PR, QRS, and QT interval. No ischemic change. Unremarkable preop urinalysis. ASSESSMENT: This is a pleasant 63-year-old female with the following: 1. Bilateral total knee arthroplasty, in general doing well.
PR|pr interval|PR,|256|258|ELECTROCARDIOGRAM|Cerebellar function intact. There is no tremor or rigidity. LABORATORY DATA (_%#DDMM2003#%_): Sodium 136, potassium 3.8, chloride 98, CO2 29, anion gap 9. CHEST X-RAY: Demonstrated no active disease. ELECTROCARDIOGRAM: Normal sinus rhythm and axis. Normal PR, QRS and QT intervals. No ischemic change. ASSESSMENT: The patient is a 50-year-old female admitting with the following: 1. Major depressive disorder, details per Psychiatry.
PR|progesterone receptor|PR|225|226|PATHOLOGY|Findings: Invasive ductal carcinoma, Nottingham grade 2 of 3. DCIS present, solid and cribriform, intermediate grade without necrosis. Vascular invasion absent. Calcifications absent. ER positive with more than 90% of cells. PR negative with 0% of cells. HER2/neu negative. Case _%#MRN#%_, collected _%#DDMM2005#%_, lymph node sentinel, left axillary and breast lump, left.
PR|pr interval|PR|180|181|PHYSICAL EXAM|His electrocardiogram from today shows sinus tachycardia with right bundle branch block and occasional APC's and PVC's. There appears to be at least borderline prolongation of the PR interval and partial effusion of the ______ waves. The left bundle branch block has been already present in _%#DDMM2004#%_ and is not new.
PR|pr interval|PR,|152|154|LABORATORY DATA|Troponin less than 0.07. Urinalysis unremarkable. EKG, _%#DDMM2006#%_, demonstrated a normal sinus rhythm with a normal axis. Baseline artefact. Normal PR, QRS, and QT interval without ischemic change. ASSESSMENT: The patient is a 57-year-old female admitted with the following: 1. Behavioral disturbance (as above).
PR|pr interval|PR|142|143|LABORATORY RESULTS|The QRS duration is approximately 120 milliseconds on the ectopic beats. Otherwise, his electrocardiogram shows sinus bradycardia with normal PR interval, right-sided axis, as described above in _%#MM#%_. On some of the electrocardiograms, there is a negative T wave in lead 3, and also there appears to no specific D1 from this morning.
PR|pr interval|PR,|193|195|LABORATORY DATA|Follow-up pending at 900. The patient has put out approximately 100 cc in the Hemovac since 2:00 a.m. Preop urinalysis unremarkable. Preop EKG demonstrated normal sinus rhythm and axis. Normal PR, QRS and QT interval. Minor nonspecific T-wave abnormality inferolaterally. ASSESSMENT: 71-year-old female with the following: 1. Complex orthopedic history involving left hip with left total hip arthroplasty, as above.
PR|pr interval|PR|239|240|IMPRESSION AND RECOMMENDATIONS|I would recommend reimaging the carotid arteries. Finally, the patient's potassium and creatinine are normal, I would advocate restarting her Avapro; I would hold her carvedilol for now as it may be contributing to her prolongation of the PR interval. I would recommend checking a TSH level and supplementing her magnesium to keep the magnesium level above 2. It wa s my pleasure to see this very nice woman in consultation.
PR|progesterone receptor|PR|185|186|HISTORY  OF PRESENT ILLNESS|The ultrasound showed a 4 x 5 x 2 cm mass on the right as well as the right enlarged axillary node. Ultrasound-guided biopsy showed infiltrating ductal carcinoma grade II, ER positive, PR positive, HER-2/neu positive. Axillary node sampling also showed invasive ductal carcinoma. A PET CT scan performed on _%#MMDD#%_ revealed a 4.7 cm right breast mass and 2 adjacent satellite lesions as well as disease in the right axillary lymph nodes.
PT|physical therapy|PT,|158|160|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: Discharge status is improving. Her diet is 2 grams sodium, avoid aspirin, citrus juices and fruit and coffee. Activity aspirin as per PT, OT. DISCHARGE MEDICATIONS: 1. Protonix 40 mg daily. 2. Zyloprim 100 mg daily. 3. Colace 100 mg daily p.r.n. for constipation.
PT|physical therapy|PT|212|213|HOSPITAL COURSE|On PET scan in _%#DDMM2007#%_ multiple hypermetabolic enhancing lesions were found on the right hemithorax area and right ribs and the patient underwent Taxotere chemotherapy by Dr. _%#NAME#%_. She came here for PT and OT which she has progressed though it initially has been difficult secondary to her dropping oxygen levels. She still does need oxygen though she is much more stable since her pneumonia has resolved and she is much more active.
PT|prothrombin time|PT|183|184|LABORATORY DATA|Able to recognize himself and his date of birth. SKIN: No significant bruises noted. LABORATORY DATA: CBC is normal. Electrolytes are normal as well. Creatinine of 1.21, BUN 22. INR, PT INR was normal. CT with contrast is appropriate, without contrast is appropriate for age, no acute changes. EKG shows old MI changes, old Q-waves. ASSESSMENT AND PLAN: A 90-year-old Caucasian male who is being admitted for bilateral lower extremity weakness.
PT|physical therapy|PT|174|175|PLAN|We will obtain a rheumatology consultation to help us in this unusual case of this older lady being diagnosed with scleroderma at such a late age. Will obtain speech, OT and PT evaluation. We note that the patient had refused a G-tube for nutrition in the past. Will also obtain a first step mattress.
PT|physical therapy|PT,|116|118|RECOMMENDATION|Oxygen saturations will be monitored, diuretics will be held for the time being. Her GI symptoms will be monitored. PT, OT evaluation will be requested. Social Service will be asked to see the patient as is not clear how safe her living situation is both on a chronic and acute basis.
PT|physical therapy|PT|181|182|ASSESSMENT AND PLAN|At this time, we will offer her some gentle IV fluids for rehydration with normal saline and antiemetics as needed. Start with clears and advance as tolerated to a regular diet. 2. PT and OT evaluation and treat: Suspect disposition to TCU in a.m. if she is stable. 3. Nutritional consult with calorie counts. 4. Hypertension. 5. History of MRSA precautions per routine.
PT|physical therapy|PT|135|136|DISPOSITION|DISPOSITION: Hopefully to TCU soon. I did discuss all this with the daughter who is unable to provide cares at her house at this time. PT and OT input to help in assisting disposition.
PT|physical therapy|PT|197|198|DISPOSITION|The patient's son is to discuss further anticoagulation and risk/benefits with primary MD within 1 week. DISCHARGE DIET: Cardiac. DISPOSITION: Discharge to Regent for higher skilled level of care. PT and OT at the facility. Follow-up with primary MD within 1 week.
PT|physical therapy|PT|237|238|PERTINENT LABORATORY TESTS|His hemoglobin was 12.8 with a white count of 4.7 thousand. He has been seen by occupational therapy and physical therapy and noted that he requires significant assistance for ambulation and requires both cognitive as well as his OT and PT therapies and recommended acute rehab, as patient is an excellent candidate to return home. His long-term prognosis is guarded as with the cerebral amyloid disease he will continue to have recurrent small bleeds and infarctions, as the MRIs have shown without any measures available to prevent these.
PT|physical therapy|PT|165|166|IMPRESSION/PLAN|9. _%#DDMM2006#%_: Head CT showed atrophy but otherwise no acute changes. IMPRESSION/PLAN: 1. Frequent falls with weakness: He was admitted here for rehabilitation, PT and OT. He may need a nursing home placement after rehab rather than an assisted-living setting, as he appears to be becoming more debilitated.
PT|physical therapy|PT|138|139|HOSPITAL COURSE|The transplant team was also comfortable with stopping the subcu heparin prior to discharge. Otherwise, this patient has met the goals of PT and OT. His goal now is to be home with his wife who is dying. He has a family member picking him up today.
PT|physical therapy|PT|219|220|PLAN|Will check liver function tests. Would not repeat his TFTs, as the patient just had these checked recently in _%#MM#%_, and they were within normal limits and will maintain the patient's DNR/DNI status. Will get OT and PT to evaluate the patient. Will get Social Work involved. The patient is having recurrent admissions and is of advanced age.
PT|physical therapy|PT,|168|170|ASSESSMENT AND PLAN|Will monitor his hemoglobin had hematocrit and will stop vitamin K and watch his INR. 4. Prophylaxis: Will start him on Lovenox for DVT prophylaxis. 5. Rehabilitation: PT, OT, and PMR consultations are pending. 6. CODE STATUS: Patient requested "DO NOT INTUBATE" but he wants resuscitation in case of cardiac arrest or arrhythmias.
PT|physical therapy|PT|237|238|PLAN|We will get a fasting lipid profile study. I believe the family would not be necessarily open to any kind of surgical intervention or Coumadin if she was found to have a cardioembolic phenomena. We will do frequent neuro checks and have PT and OT and Speech assess the patient. 2. Hypertension. We will follow the CVI protocol, as well as continue on her Cozaar.
PT|physical therapy|PT|157|158|PLAN|4. Social. PLAN: The patient will be admitted for further evaluation and treatment. She will be given IV morphine as needed, Percocet or Vicodin. I will ask PT and OT to see her and Social Service. Currently, she will need to go to a nursing home on discharge, but we will need to stabilize her in the hospital first.
PT|physical therapy|PT|134|135|DISCHARGE INSTRUCTIONS|CODE STATUS: Full code. ALLERGIES: ASPIRIN. DISCHARGE INSTRUCTIONS: 1. See Dr. _%#NAME#%_ next week. Call for an appointment. 2. Home PT and OT referral. 3. Diet: Regular. 4. Activity: As tolerated. 5. Call if pain, swelling, fever or confusion. Note to Dr. _%#NAME#%_: Please check on blood cultures and urine cultures.
PT|physical therapy|PT|163|164|HOSPITAL  COURSE|For example, she had a poor five-minute recall on simple mini mental status evaluation and recommended really 24 hour supervision. In addition, she needed further PT and OT for her generalized weakness. The patient should continue on multivitamin, folic acid and thiamin.
PT|physical therapy|P.T.|132|135|PROBLEM #5|It was felt that he should continue on herpes prophylaxis on an outpatient basis. PROBLEM #5: Debilitation. The patient was seen by P.T. and O.T. during his hospital stay and was able to meet his goals of independent ambulation and independence with his activities of daily living.
PT|physical therapy|PT|160|161|DISCHARGE MEDICATIONS|5. Oscal-D 500 mg, 1 p.o. t.i.d. 6. Combivent, 2 puffs 4 times daily. 7. Albuterol MDI, 1 to 2 puffs every 4 to 6 hours as needed for shortness of breath. Home PT and OT will arrange for evaluation and treat. The patient is to follow up with her primary physician at Quello Clinic in 7 to 10 days.
PT|physical therapy|PT|114|115|PLAN|3. Recent gastrointestinal stromal tumor which has been stable. 4. Hypertension. PLAN: 1. As above. 2. Admit with PT and social service. 3. P.r.n. Vicodin. 4. Check urine culture.
PT|physical therapy|PT|131|132|FOLLOW-UP CARE|2. Keep Miami-J collar on at all times until clinic visit. 3. Keep sutures clean, dry, and intact. 4. Out of bed and exercise with PT and assist. DISCHARGE PHYSICAL EXAMINATION: The patient was awake, alert, oriented x 3.
PT|physical therapy|PT|248|249|ASSESSMENT/PLAN|We will monitor for possible withdrawal, and we will need to consider possibility of ETOH withdrawal if she develops signs or symptoms of agitation, hypertension, tachycardia, etc. 5. Disposition. We will obtain social work consult. We will obtain PT and OT consults if x-ray does not show evidence of fracture.
PT|physical therapy|PT,|154|156|OPERATIONS/PROCEDURES PERFORMED|He is on antibiotic prophylaxis. 3. Developmental delay. His mother reports that he is behind 1 year on speech and also has "low tone." He is followed by PT, OT, and speech. 4. Gastroesophageal reflux. 5. History of oral aversion, although he will now currently drink PediaSure without difficulty and take some solids as well.
PT|physical therapy|PT,|255|257||The patient transferred from subacute rehab stay to acute rehab with plans to discharge to home with husband when through with this program. Bed mobility is assist of one. Two to transfer. Assist of one to ambulate and toileting with assist of two. Needs PT, OT, and speech treatment. PAST MEDICAL HISTORY: 1. Hypertension. 2. Rheumatoid arthritis. 3. ASD repair. 4. Osteoporosis.
PT|physical therapy|PT,|94|96|PLAN|ASSESSMENT: As above, status post motor vehicle accident with trauma, deconditioned. PLAN: 1. PT, OT, Speech treatment. 2. Strength and coordination equipment. 3. Needs ADLs. 4. Endurance and cognitive evaluation. 5. Social Service to help with discharge planning.
PT|physical therapy|PT|262|263|ASSESSMENT AND PLAN|5. Elevated BUN and creatinine. We do not have any previous labs to know whether this is a recent phenomenon, however, likely related to his dehydration and will rehydrate and reassess. 6. Right leg pain. Concerning for claudication. Will check ABIs and consult PT to assist ambulation and safety. 7. Disposition. Will consult PT and OT to assist with evaluation.
PT|physical therapy|PT|163|164|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old woman whom I was asked to see the day after total knee arthroplasty, when she had a syncopal episode when PT attempted to get her up after surgery. She had tolerated the surgery previously well up to that point. She was assessed at that time and thought to have postural hypotension, though no blood pressure was recorded at the time of the episode.
PT|physical therapy|PT|346|347|HISTORY OF PRESENT ILLNESS|She was also started on IV steroids and a mild bump in her Lasix was done for the first two days for some mild fluid overload. She responded at first somewhat slowly, mostly due to the fact that she was quite fatigued and would not get out of bed, but once she increased her activity her breathing improved, and with regular treatment as well as PT and TO she got to the point where she was ambulating without significant dyspnea, and without having any significant desaturations in O2.
PT|physical therapy|PT.|146|148|DISCHARGE MEDICATIONS|Will be set up with home O2 for activity. Home nurse to see patient daily with measurements of O2 saturation with walking and document this. Home PT. Patient is to follow up with Dr. _%#NAME#%_ Monday at 9:00 a.m. Patient will be on tube feeds as she was prior to admission.
PT|physical therapy|PT|155|156|PHYSICAL EXAMINATION|Genitalia, testes, penis normal. No inguinal hernia. RECTUM: Deferred. EXTREMITIES: No cervical, axillary or femoral nodes. Femoral pulses present. No DP, PT pulses present. Ortho, joints without inflammation. NEUROLOGIC: Patellar reflexes trace. SKIN: Scattered thinning and redness of the lateral ankles, mainly on the left.
PT|physical therapy|PT|208|209|IMPRESSION AND PLAN|IMPRESSION AND PLAN: Back pain secondary to a fall. In the emergency room, she was given some Vicodin with good relief of her symptoms. I am going to go ahead and admit her to the general medical floor, have PT assess her, continue the Vicodin and Zofran and also her home meds as needed. Further management will depend on her response to the above.
PT|physical therapy|PT|140|141|DISPOSITION|DISPOSITION: Discharge to home in stable condition. Follow up with Dr. _%#NAME#%_ in 2 weeks. Return for any worsening abdominal pain. Home PT was also order at discharge.
PT|physical therapy|PT|160|161|DISCHARGE FOLLOW-UP|She will need weekly hepatic function panel testing and prealbumin. Her Mycophenolic acid level will be checked q. Monday and Thursday. She will need continued PT and OT until cleared to go home. She will need finger sticks q.i.d. for being on tube feedings. DISCHARGE MEDICATIONS: 1. Aspirin enteric-coated 81 mg p.o./J-tube daily.
PT|physical therapy|PT,|176|178|ASSESSMENT AND PLAN|CMS otherwise intact. LABORATORY DATA: Hemoglobin is 8.7. ASSESSMENT AND PLAN: 1. Degenerative joint disease postop day zero for left elective total hip arthroplasty. Continue PT, OT per routine. DVT prophylaxis as written with Lovenox. Caution with narcotic sensitivity as she tends to get delirious with oxycodone, morphine and Percocet.
PT|physical therapy|PT|194|195|ASSESSMENT AND PLAN|Continue Levaquin which was started in the ER, especially with her positive UA. Check sputum cultures. Nebulizers p.r.n. 2. Generalized weakness. Suspect secondary due to acute infection. Start PT and OT. 3. History of hypertension. Resume atenolol as well as Norvasc. 4. History of hypothyroidism. 5. Urinary tract infection. Continue Levaquin as above.
PT|physical therapy|PT|143|144|IMPRESSION|In regards to falls, the patient does have orthopedic issues with history of foot surgery which could be causing gait disturbance. We will ask PT and OT to get involved for assessment. The patient has some evidence of accelerated hypertension will need to recheck blood pressures here.
PT|physical therapy|PT|147|148|PLAN|4. We will give him a couple extra doses of IV Lasix to help in mobilizing some of his fluids and to ease up on his respiratory status. 5. Consult PT for strengthening exercises in order to equip the patient to be able to be discharged home. If the patient is quite weak at the end we might want to consider offering him the option of a nursing home.
PT|physical therapy|PT.|118|120|HOSPITAL COURSE|INR and PTT normal. Medications were resumed and the patient is being discharged back to the nursing home with OT and PT. The family and patient are both interested in evaluation for the possibility of liver transplant. Appropriate screening would need to be accomplished at the University of Minnesota.
PT|physical therapy|PT|182|183|IMPRESSION AND PLAN|6. Hyperlipidemia, gemfibrozil therapy. 7. Peripheral edema. This is probably secondary to post-surgery, and we will continue the Lasix therapy and also add TEDs. 8. Rehabilitation. PT and OT probably about 1-2 weeks. The patient wishes to return home as soon as possible. 9. Fall risk. The patient did have her last fall in _%#MM#%_.
PT|physical therapy|PT|156|157|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: 1. Follow up with primary physician next week. 2. Follow up with Dr. _%#NAME#%_ for quadriceps biopsy on _%#MM#%_ _%#DD#%_. 3. Home PT which has been arranged. ALLERGIES: Sulfa. CODE STATUS: Full code. CONSULTATIONS: 1. Dr. _%#NAME#%_ of Neurosurgery. 2. Dr. _%#NAME#%_ of Neurology.
PT|physical therapy|PT|115|116|DISCHARGE INSTRUCTIONS|3. Mestinon 60 mg p.o. t.i.d. DISCHARGE INSTRUCTIONS: 1. The patient is full code. 2. Activity is as tolerated. 3. PT and OT to evaluate and treat at Transition Services. FOLLOW-UP APPOINTMENTS: 1. _%#NAME#%_, _%#CITY#%_ _%#CITY#%_ Ophthalmology, next available for follow-up of cataract surgery.
PT|physical therapy|PT|170|171|HOSPITAL COURSE|PROBLEM #1. Status post fall with resulting weakness, resolving. The patient is doing well with physical therapy/occupational therapy. Fur recommendations for outpatient PT and OT will be discussed with his primary care physician in the future. PROBLEM #2. Cardiovascular: The patient has a history of hypertension and will continue on the above medications for this condition, and will follow up with his primary care physician for further management.
PT|physical therapy|PT|177|178|HOSPITAL COURSE|PROBLEM #5. Chronic low back pain with DJD of the lumbar spine and history of laminectomy: The patient was started on Vioxx 25 mg p.o. daily with good relief of pain. Extensive PT and OT rehab was also performed with good results. DISCHARGE CONDITION: Stable. DISPOSITION: The patient will be discharged to the assisted living home, as he has completed physical therapy and occupational therapy, and is also stable at this time.
PT|physical therapy|PT|234|235|HOSPITAL COURSE|HOSPITAL COURSE: 1. Left hip fracture: The patient underwent a closed reduction and internal medullary nailing performed by Dr. _%#NAME#%_. In regards to the patient's surgery, she did quite well postoperatively. She was working with PT and OT following surgery, and she will be discharged to a transitional care unit for further rehabilitation. The patient will followup with Dr. _%#NAME#%_ 2 weeks postop.
PT|physical therapy|PT|98|99|PLAN|She also has significant peroneal fungal infection. PLAN: At this time we will admit her and have PT and OT assess her. Pain control with either IV morphine or p.o. Vicodin. I would favor trying p.o. narcotics first.
PT|physical therapy|PT,|118|120|DISCHARGE  INSTRUCTIONS|She needs dressing changes to her left knee twice a day. She is on a reduced sodium diet, she is full code, she is on PT, OT. She is on p.r.n. oxygen, q.i.d. Accu-Cheks. Follow up with Dr. _%#NAME#%_ _%#NAME#%_ of _%#COUNTY#%_ Faculty Associates in one week and continue to follow blood sugars and adjust as needed.
PT|physical therapy|PT|127|128|HOSPITAL COURSE|She otherwise was in stable condition and was transferred to rehabilitation. HOSPITAL COURSE: The patient did well with OT and PT allowing for continued improvement in her mobility at the time of discharge. She was doing well with her ADLs. She was discharged home to follow up with orthopedic surgeon and her primary care physician.
PT|physical therapy|PT.|215|217|HISTORY|She will require ear stress doses of prednisone at 5 mg b.i.d. for three days followed by 5 mg q.a.m. and 2.5 mg q.p.m. for 3 days and eventually returning to her 5 mg a day dosing. She was then evaluated by OT and PT. They felt that she could return home with home therapies and home safety evaluation. Her blood cultures are negative so far and urine cultures growing out E coli.
PT|physical therapy|PT|194|195|BRIEF HISTORY AND HOSPITAL COURSE|She denies any localizing pain on presentation. Her initial head CT was negative. No evidence of fracture on her radiographic films. She had no focal findings. No other evidence to support CVA. PT and OT were consulted and agreed that she was still quite unsteady with her feet. She was still one-person assist with transfers as well as gait and would benefit from further TCU.
PT|physical therapy|PT|143|144|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|We are going to discharge her home with today with five more days of Levaquin. Physical therapy and occupational therapy are recommending home PT and OT at the time of discharge. I am also recommending that she hold her Lasix and potassium at least until seen by Dr. _%#NAME#%_ in 1-2 weeks.
PT|physical therapy|PT.|333|335|HOSPITAL COURSE|23. Heparin 5000 units subcutaneously b.i.d. He has been on this since Friday with his last dose last evening on _%#DDMM2007#%_ at 9:00 p.m. It has now been on hold in anticipation of the kidney biopsy. HOSPITAL COURSE:_%#NAME#%_ _%#NAME#%_ was admitted here mostly for antibiotic therapy which finished today. He also did have some PT. He was discharged from OT upon evaluation. He did have problems with constipation which are now resolved with the lactulose and MiraLax regimen.
PT|physical therapy|PT|127|128|PLAN|Will consider nipride drip if unable to control BP with hydralazine. I will check electrolytes and CBC as well. I will consult PT and OT for possible placement issues. The patient expressed her wishes of DNR/DNI during this interview and her son was in the room who concurred with the patient.
PT|physical therapy|PT|293|294|HOSPITAL COURSE|3. Delirium and dementia. The patient had an OT evaluation, but however the patient has been very stable all throughout her hospital course and she has maintained a fair cognitive function and she has been pretty oriented and alert. PT and OT was consulted and at the time of discharge as per PT the patient is up with minimal supervision to independent, she ambulated 400 inches with walker and did 6 steps with supervision.
PT|physical therapy|PT|176|177|HOSPITAL COURSE|Follow-up CBC on the 16th showed a hemoglobin of 11, platelet count of 112. White count 5000. TSH was 0.93. Vitamin B12 was 443 and INR was 168. The patient was seen by OT and PT who recommended, based on cognitive impairment, for the patient to go to _%#CITY#%_ Care Facility for concerns regarding her ability to care for herself.
PT|physical therapy|PT|115|116|HOSPITAL COURSE|This was confirmed on his angiogram. He also underwent an MRA of his neck, no signs of aortic dissection was seen. PT and OT consults were obtained as well as aggressive diabetic control. The patient did quite well, and in fact his neurologic symptoms improved dramatically.
PT|physical therapy|PT|111|112|FOLLOW UP|At this point, he will also have a basic metabolic panel to check sodium level. 2. He will follow up with home PT and OT in order to continue rehabilitation. He also will have a home health nurse referral.
PT|physical therapy|PT|194|195|DIAGNOSTIC IMPRESSION|10. Post five episodes of deep vein thrombosis in the past with extensive thrombosis of deep veins in both legs. Further orders include diabetic diet, weightbearing status advance as tolerated, PT and OT to evaluate and proceed, activity level as tolerated. The patient is full resuscitation at this time.
PT|physical therapy|PT|216|217|IMPRESSION|She received PT and OT and at the time of discharge was seizure-free and clinically doing fairly well, up ambulating with assistance. She was eager to go home. The patient was discharged, to continue with outpatient PT and OT and continue with outpatient radiotherapy. DISCHARGE MEDICATIONS: 1. Decadron, 4 mg 3 times daily.
PT|physical therapy|PT|202|203|ASSESSMENT AND PLAN|At this point we will give her IV pain medications with Vioxx for now, and give her scheduled Tylenol around the clock. Perhaps Orthopedics may suggest a joint injection, and she will also need to have PT evaluation and treatment. At this point I do not think there is anything more sinister, as her pain is relegated completely to the right shoulder and she has great pain with movement of the shoulder in any way, shape or form.
PT|physical therapy|PT|254|255|HOSPITAL COURSE|He did undergo an LVAD Heartmate 2 on _%#DDMM2007#%_. As of that time and now per the LVAD coordinator, he is considered a bridge to heart transplantation. There were no complications. He was sent here for rehabilitation. He has quickly met the goals of PT and OT. He has had no sequelae or complications. He did come to us initially to us on Lasix b.i.d. which has been decreased to once daily throughout his stay.
PT|physical therapy|PT|212|213|DISCHARGE INSTRUCTIONS|For this he underwent a temporal artery biopsy to evaluate for giant cell arteritis, result of which is still pending at this time. DISCHARGE INSTRUCTIONS: The patient was discharged to acute rehabilitation with PT and OT to evaluate his activity level and weight bearing status. He is discharged on a regular diet. He is to follow up with _%#NAME#%_ _%#NAME#%_ of neurosurgery on _%#DDMM2007#%_ at 9 a.m. to discuss the results of his C-spine and L-spine MRI.
PT|physical therapy|PT|186|187|HOSPITAL COURSE|She is otherwise doing fine we will continue all preoperative prehospital care plans, diet, medications when she gets home. CPM will be used at the nursing home as well as being seen by PT b.i.d. for possibly t.i.d. OT will evaluate her as well. Anticipate seven day stay there. We will see her back in the office two weeks postop.
PT|physical therapy|PT|207|208|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: 1. Status post corpectomy for acute spinal cord compression from osteomyelitis. The patient will remain in TLSO whenever she is up or whether head of bed is elevated. She will work with PT and OT until she is independent with ADLs, follow up with Dr. _%#NAME#%_ in 2 weeks. 2. Osteomyelitis without bacteriologic identification.
PT|physical therapy|PT|177|178|OBJECTIVE|Some voluntary guarding. Difficult to get a good examination. GU: Pelvic and rectal deferred. EXTREMITIES: No cervical or axillary femoral nodes. Femoral pulses present. No DP, PT pulses present. Right leg is markedly edematous to the thigh. Left is thin, some excoriations. ORTHO: She has a 2 cm laceration left humeral head, no bone is visible at this time.
PT|physical therapy|PT|129|130|ALLERGIES|There was some question of the patient being able to transfer in the home as he lives by himself and is wheelchair bound. OT and PT consults were obtained to get recommendations for patient's home care. At the time of discharge, he was eating, drinking, ambulating and had good evidence of bowel function.
PT|physical therapy|PT,|216|218|DISCHARGE AND FOLLOW-UP PLANS|4. Patient will go home on a sliding scale of Lispro, unless otherwise dictated by Endocrinology prior to discharge. 5. The patient should continue fluid restriction of 1000 cc per 24 hours. 6. The patient will have PT, a home safety evaluation, and a home RN for home care. HOSPITAL COURSE: The patient was admitted to the hospital on _%#MMDD#%_ with increasing shortness of breath, abdominal pain, and leukocytosis.
PT|physical therapy|PT|443|444|FOLLOW UP|DISCHARGE MEDICATIONS: Keflex 500 mg p.o. b.i.d. for five additional days, Coumadin 5 mg one tablet p.o. q.d., Percocet one to two tablets p.o. q.6h p.r.n., Prozac 20 mg p.o. q.d., trazodone 100 mg p.o. q.h.s., albuterol MDI with spacer two puffs q.4h p.r.n., BuSpar 15 mg p.o. t.i.d., Nasonex two puffs in each nostril q.d., Advair 250/50 one inhalation b.i.d. FOLLOW UP: Patient is to follow up tomorrow at Fairview Cedar Ridge Clinic for a PT INR check and in one week with Dr. _%#NAME#%_ for follow up.
PT|physical therapy|PT|107|108|HOSPITAL COURSE|Distal pulses intact. Motor and sensation intact. HOSPITAL COURSE: The patient continued to participate in PT and OT . There was marked improvement over her hospital stay. Decreased pain with weight-bearing. The patient's pain resolved over the course of this visit.
PT|physical therapy|PT|125|126|PLAN|PLAN: The patient will have Coumadin. We will avoid heparin at this point. The patient will have repeat labs in the morning. PT and OT will evaluate and treat. We will hold the Lasix today secondary to mild renal insufficiency, and we will request the social worker to see the patient for discharge planning.
PT|physical therapy|PT,|120|122|PLAN|We will defer on sinusitis treatment, given the impression that this appears to be resolving at this time. We will have PT, OT and Speech meet with the patient as per routine. I will ask Neurology to visit with the patient prior to discharge.
PT|physical therapy|PT,|189|191|ASSESSMENT AND PLAN|5. Hypertension. Resume atenolol. 6. History of atrial fibrillation. Clinically in normal sinus rhythm. I would not suspect she would be a Coumadin candidate secondary to her fall risk. 7. PT, OT, and Speech for ADLs, gait and possible dysphagia. 8. Dehydration. Clinically dry. Normal saline fluids to rehydrate patient. 9. DNR/DNI. This was reconfirmed with the daughter.
PT|physical therapy|PT|161|162|BRIEF HISTORY AND HOSPITAL COURSE|PT and OT was consulted and tried treating her per routine but she required great assistance just to ambulate. In fact she was unable to participate actively in PT for the first few days on her hospitalization. It was suspected that she would need at least short term rehab for possibly returning home after she has gained some improvement in muscle strength, endurance and stability of gait.
PT|physical therapy|PT,|117|119|ACTIVITY|Transfer form filled out. No discharge instructions. CONDITION ON DISCHARGE: Patient stable. ACTIVITY: As tolerated. PT, OT to evaluate and treat. MEDICATIONS: 1. Continue Lasix 20 mg one tablet twice a day.
PT|physical therapy|PT|208|209|HOSPITAL COURSE|However, the patient was strongly adamant that he be discharged to home as compared to rehab or to stay in the hospital. We could see no medical reason not to do that. Therefore, he was mobilized safely with PT and discharged to home. DISPOSITION: Home. DIET: Regular. DISCHARGE MEDICATIONS: 1. OxyContin 30 mg p.o. b.i.d.
PT|physical therapy|PT|227|228|HOSPITAL COURSE|Overall reduction in degree of dyspnea. As of _%#MM#%_ _%#DD#%_, 2005, with continued prompting by the patient, it was felt reasonable to discharge the patient home with home health care and close followup with RN visits. Home PT and OT avail as well as home health aid. BiPAP was discontinued as the patient was not using. Significant reduction of lower extremity edema for which Lasix was discontinued.
PT|physical therapy|PT.|189|191|DISCHARGE SUMMARY|They felt given the level of osteoporosis that she has if they pinned it, the bone might in fact just crumble rather than heal. Therefore, they have put her in a leg splint and recommended PT. Her first day or so in the hospital she did have significant increase in muscle spasms, but those seemed to resolve down to baseline after about 48 hours.
PT|physical therapy|PT,|175|177|ASSESSMENT/PLAN|A urinalysis was negative for leukocyte esterase or nitrates, but was noted to have greater than 100,000 bacteria. ASSESSMENT/PLAN: 1. Cerebral vascular accident. Plan is for PT, OT, nutrition, tube feeds, and general reconditioning. We will continue the patient's Plavix and we will hold the aspirin because of his recent small intracerebral hemorrhage and his generalized increased bleeding risk at this time.
PT|physical therapy|PT|195|196|HISTORY OF PRESENT ILLNESS|She underwent a total knee arthroplasty with Dr. _%#NAME#%_. Her postoperative course was uncomplicated. She was transferred to FUDS for rehabilitation. HOSPITAL COURSE: Patient received routine PT in FUDS. She had no complications during her FUDS stay. She was discharged home in the care of her parents for follow up with Dr. _%#NAME#%_ and her primary care physician.
PT|physical therapy|PT|214|215|SUMMARY OF HOSPITAL COURSE|_%#NAME#%_ _%#NAME#%_ presented confused. She was very hot. She was not using her air conditioning. She appeared dehydrated. She got some IV fluids and with this her mental status improved, the patient was seen by PT and OT and they both recommended short-term nursing home stay and she was agreeable to this and therefore we helped facilitate this and she is discharged.
PT|physical therapy|PT|290|291|ASSESSMENT AND PLAN|Given the degree of the pain and the fact that it is making it hard for her to live alone, I do agree that she needs to come in and because she has no neurologic symptoms I do not think she meets criteria for inpatient admission and therefore she will be on observation status. I will have PT and OT evaluate and treat her and have social work involved. For her pain, I will use Tylenol and Aleve sparingly and oxycodone for severe break through pain.
PT|physical therapy|PT|234|235|REHABILITATION COURSE|REHABILITATION COURSE: In short, _%#NAME#%_ _%#NAME#%_ came to us on _%#DDMM2007#%_ for rehabilitation as he was quite deconditioned and weak after his extensive hospitalization, which I previously stated. He quickly met the goals of PT and OT. His cognition has continued to improve and they believe he is at baseline with a CPT of 5.5. He has been medically stable.
PT|physical therapy|PT|169|170|FOLLOWUP VISITS|He will have a TSH with free T4 checked in 2 weeks for followup of his abnormal TSH during his hospital stay. He also should have a PT INR checked in 1 week with a goal PT INR between 2 and 3. The patient should have also have an outpatient formal sleep study as he does have nocturnal hypoxia and concern for underlying obstructive sleep apnea.
PT|physical therapy|PT|159|160|DISCHARGE MEDICATIONS|Her TSH level was 0.38, which was good control and her B12 level was normal. The patient will be on a 2 gram sodium diet. Activity level per progress with OT, PT and speech therapy. Blood pressure medicine is titrated as needed and patient's lungs have decreased breath sounds but clear. No respiratory distress on her present COPD management and her gastroesophageal reflux disease has no significant dysphagia problems at this time and will continue on her present management.
PT|physical therapy|PT|191|192|PLAN|I am going to start him on Ancef prophylactically because he had a white count of 15,000 with a left shift. _%#NAME#%_ is comfortable holding his Adderall for now. Incidentally, we did check PT and PTT, which were within normal limits.
PT|physical therapy|PT|228|229|7. GERD|7. GERD: This is controlled. We will monitor. For further in depth information, please refer to the copies of several consultants that did see the patient up in _%#CITY#%_ prior to transfer here. Further follow-up plans will be PT and OT here as she tolerates in the bed. Also, she will follow-up when she does go home with her primary care physician who is Dr. _%#NAME#%_ _%#NAME#%_ at _%#COUNTY#%_ Clinic in _%#CITY#%_ _%#CITY#%_ _%#CITY#%_.
PT|physical therapy|PT|168|169|HOSPITAL COURSE|Postoperatively, the patient's head CT showed pneumocephalus, and the patient was placed on bed rest for about two days after the operation. He then began working with PT and OT. On the day of discharge, the patient had a repeat head CT that still showed pneumocephalus in the left frontal area, which was minimally decreased from his postoperative head CT.
PT|physical therapy|PT|123|124|DISCHARGE INSTRUCTIONS|He will follow up with Dr. _%#NAME#%_, his primary care doctor, as needed. 2. The patient will have Fairview home care and PT on discharge. Fairview home care will check his INR at home on _%#MM#%_ _%#DD#%_, 2003, and call to the University of Minnesota Coumadin Clinic who will direct his Coumadin therapy.
PT|prothrombin time|PT|231|232|RELEVANT LABS|Her MCV was 89. The differential on WBC was 91% neutrophils with an absolute neutrophil count of 14.6. Her chem panel revealed a sodium of 135, potassium of 4.1, BUN of 30 and creatinine of 1.38. Her blood glucose was 144. INR and PT were within normal limits. Her LFTs were otherwise normal. Troponin I was less than 0.07. A chest x-ray revealed clear lungs with a large hiatal hernia.
PT|physical therapy|PT,|143|145|HISTORY OF PRESENT ILLNESS|IV antibiotics will be continued as appropriate. Cultures will be definitive tomorrow and will confirm that. See copy of the referral form for PT, OT, nursing home coverage, etc. She understands reason for the rehabilitation center is that medications are not covered as an outpatient by Medicare and can be costly.
PT|prothrombin|PT|223|224|HISTORY|Her workup has been relatively unrevealing so far. Her standard coagulation tests were normal (INR and PTT). She did not have a more extensive hypercoagulable workup study such as protein C, protein S, lupus anticoagulant, PT mutation, factor 5 Leiden, etc. Her MRI study shows moderate nonspecific chronic white matter disease, small areas of recent infarction of the left cerebellar hemisphere and left superior cerebellar vermis.
PT|physical therapy|PT|144|145|PLAN|Continue the patient's home medications once doses are known and give her prescription of thyroxine before she leaves. Check TSH. Obtain OT and PT evaluation and hopefully discharge the patient home by the end of tomorrow. CODE STATUS: The patient is going to be do not resuscitate, do not intubate.
PT|physical therapy|PT|112|113|HOSPITAL COURSE|Since he has had such significant improvement, I will hold off on using a steroid course for him. He did have a PT evaluation prior to discharge and was felt safe to go home; however, he should have a home safety evaluation as he does not have safety bars in the bathroom, etc.
PT|physical therapy|PT,|255|257|HISTORY OF PRESENT ILLNESS|She had some confusion about her medications at the University Center; therefore, she was transferred to Fairview Acute Rehab Center on _%#DDMM2007#%_ for further physical and occupational therapy and also nursing cares. She was seen in consultation with PT, OT, PMR at the rehab center. The patient was insistent to go home and physical therapy felt that the patient was okay from a physical point of view to be discharged home.
PT|physical therapy|PT|139|140|HOSPITAL COURSE|MRI ruled out a tumor or acute infarct. The patient is going to be discharged in satisfactory state. She will continue to have home OT and PT as an outpatient.
PT|physical therapy|PT|145|146|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: 1. The patient should follow up with primary care physician, Dr. _%#NAME#%_, in one to two weeks. 2. He should have home PT and OT if he goes home.
PT|physical therapy|PT|129|130|ASSESSMENT/PLAN|I in addition cannot rule out a peripheral neuropathy, however, at this point in time, the most important thing is to get OT and PT to evaluate and consult, falls precautions. The patient has possibly got some kind of progressive issues which may not be able to treat at this point in time.
PT|physical therapy|PT|198|199|PROCEDURES|1. Intrauterine pregnancy at 40 plus 4 weeks, delivered. 2. Postop day #3, status post primary cesarean section. PROCEDURES: 1. IV antibiotics. 2. Primary cesarean section. 3. Spinal anesthesia. 4. PT consults. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 36-year-old gravida 1, para 0 who presented at 40 plus 4 weeks with contractions and slight bloody show.
PT|physical therapy|PT|208|209|HOSPITAL COURSE|She was continued on her usual medicines without problem. She underwent surgery and tolerated this well. She was restarted on her Coumadin once Orthopaedics felt this would be safe and she was initiated into PT and OT without a problem. The patient continued to improve. The day before discharge, she did fall and initially complained of left hip pain as well.
PT|physical therapy|PT|318|319|DISCHARGE AND FOLLOW-UP PLANS|She also is to see her nephrologist, Dr. _%#NAME#%_ _%#NAME#%_, on _%#DDMM2004#%_ at 1000 hours in Iowa. _%#NAME#%_ _%#NAME#%_ from the Transplant team will call the patient to make a follow-up appointment for Dr. _%#NAME#%_ and Dr. _%#NAME#%_. 2. Trinity Home Care and KCI to provide wound vac. The patient will have PT and home health aide. 3. She should have a comprehensive metabolic profile, CBC, amylase, lipase, and urine amylase on Friday, and then Monday and Thursday, and the patient will call these results to the transplant team, _%#NAME#%_ _%#NAME#%_, at _%#TEL#%_.
PT|physical therapy|PT|188|189|ASSESSMENT AND PLAN|Await her INR and will adjust her Coumadin appropriately. 4. Atrial fibrillation, suspect intermittent. Given that she is currently regular, continue her current medications. 5. Weakness. PT eval. to insure safety after discharge when the patient's diarrhea is improving and she is maintaining her fluid status orally.
PT|physical therapy|PT,|193|195|ASSESSMENT AND PLAN|We will also restart his Lunesta for p.r.n. use for insomnia. 5. Fluid, electrolytes, and nutrition. The patient has folic acid and multivitamin supplements. 6. Deconditioning. We will consult PT, OT, and physical medicine and rehab for evaluation.
PT|physical therapy|PT|146|147|HISTORY OF PRESENT ILLNESS|The right leg was affected greater than the left. He also complained of urinary incontinence, and was most likely incontinent of stool initially. PT and OT did consult, and provided assistance with his strengthening of the lower extremities. In order to decrease his inhibitor load, Rituxan was also used, I believe the first dose was on _%#MM#%_ _%#DD#%_, 2005, the second dose was on _%#MM#%_ _%#DD#%_, 2005.
PT|physical therapy|PT|248|249|HOSPITAL COURSE|Pain was well controlled. Patient was ambulating with assistance and will likely go home with a mechanical assistance such as a walker. HOSPITAL COURSE: Postoperatively, the right lower extremity remained warm. Sensation was grossly intact. DP and PT pulses were dopplerable and the patient continued to do well. On _%#MM#%_ _%#DD#%_, 2005, the patient is ready to be discharged in stable condition.
PT|physical therapy|PT,|216|218|FOLLOW UP|She should have a hemoglobin in 3 days. She should have a mechanical soft diet as noted above. Weight-bearing status as tolerated. Activity level as tolerated. Oxygen (_______) nasal canula as needed. She should get PT, OT, and speech evaluations at the rehab facility. Of note, a couple of changes in her medications include decreased doses of atenolol from 25 down to 12.5, and decreased doses of Ramipril as well.
PT|physical therapy|PT,|151|153|DISPOSITION|3. The patient will follow up with his primary care doctor in one to two weeks for monitoring of chronic medical issues. 4. The patient will have home PT, OT and nursing care and will be able to return home today. Inpatient physical therapy evaluation has been performed and he is felt to be safe to return home with these home services.
PT|physical therapy|PT,|209|211|HOSPITAL COURSE|Gallbladder was judged to be normal. There was a small dilated aorta measured at 2.7 cm, none of these were felt to be related to the patient's pain. Patient was admitted for conservative treatment, including PT, OT, he was given one dose of Toradol. Patient progressed slowly. Chronic pain management team consult was obtained and the patient's medications were adjusted.
PT|physical therapy|PT.|145|147|DISCHARGE PLAN|He should keep the knee in full extension with no range of motion for one week. He can start prone knee flexion 0 to 90 degrees in one week with PT. He should continue to use the cryocuff for his right knee. He will be in the right knee immobilizer except for range of motion exercises at the conclusion of one week.
PT|physical therapy|PT|179|180|PLAN|4. Check carotid ultrasound scan and get echocardiogram of his heart. 5. Continue with aspirin and his Plavix. 6. Will use insulin to aggressively bring down his sugar. 7. OT and PT and speech therapy to evaluate the patient. 8. I think the patient should be able to eat. 9. Will check cholesterol in the morning.
PT|physical therapy|PT|127|128|HOSPITAL COURSE|At the time of discharge the patient remained disoriented, confused, but otherwise stable with his underlying dementia. OT and PT evaluated the patient, and it became clear the patient's wife was no longer able to care for him. He was discharged home to a rehabilitation facility, with plans to follow up with Dr. _%#NAME#%_ in one to two weeks.
PT|physical therapy|PT|164|165|DISCHARGE PLAN|It is likely that she will not need surgery and will be cast at that time. 2. Inability to care for self and ADLs. Recommend transfer to Rehab facility for further PT and OT until the patient is able to manage in assisted living independently. 3. Activity as tolerated. 4. Diet, regular. 5. Transfer to Rehab facility.
PT|physical therapy|PT|263|264|HOSPITAL COURSE|Upon further review, the patient stated that her house is currently in state of disarray as she is in the process of moving and has been unable to use her walker around the home and it also sounds like she was eating or drinking well at home. While hospitalized, PT and OT were consulted for evaluation and treatment and she was hydrated. Over the ensuing few days with proper hydration and p.o. intake.
PT|physical therapy|PT|142|143|ASSESSMENT AND PLAN|This is a bit stricter than typical, but she has had the recent subarachnoid hemorrhage. In addition, I will continue her aspirin and statin. PT and OT will evaluate her as well. 2. Diabetes mellitus type 2. I will continue her metformin. 3. Subarachnoid hemorrhage. This was recent. She is only due to keep to stay on her Keppra for a couple more days and I will ask neurology if they think she should stay on it longer.
PT|physical therapy|PT|140|141|HOSPITAL COURSE|Her hospital course was uncomplicated, though she was slow with physical therapy. She did transfer here for rehab. She has met the goals of PT and OT quickly. She has no further issues except some mild and intermittent constipation which is now controlled with prunes, as well as Senokot.
PT|physical therapy|PT,|222|224|HOSPITAL COURSE|This medicine does seem to be helping. Discharge plan is for the outpatient radiation therapy as mentioned above. Diet is soft mechanical as tolerated. Activity is up with assist. Routine nursing home orders are approved. PT, OT evaluate and treat is approved. At this point, the patient remains full code. This under active discussion with her oncologist.
PT|physical therapy|PT|204|205|ASSESSMENT AND PLAN|The CMS otherwise remained intact. At this time the pain control includes continue Oxycodone 20 mg b.i.d. with Dilaudid for break through pain. May need to increase basal rate of the oxycodone. Will have PT and OT to evaluate. Did discuss with the patient that she may need TCU at discharge. 2. Hyponatremia. She appears dry. She reports poor p.o. intake the past week.
PT|physical therapy|PT|119|120|MEDICATIONS|19. Trazodone 50 mg p.o. at night. 20. Seroquel 12.5 mg at night. Diet: Cardiac diet. Activity with assistance. OT and PT may evaluate and treat the patient. CODE STATUS: Do Not Resuscitate/Do Not Intubate. SUMMARY OF HOSPITALIZATION: _%#NAME#%_ _%#NAME#%_ is an 86-year-old gentleman who was hospitalized for decompensated heart failure, as well as poor mobility and some right-sided hip discomfort.
PT|physical therapy|PT|128|129|IMPORTANT LABS AND X-RAYS DONE|2. Dehydration: Patient is at risk for dehydration. She will have a nutritional supplement with meals. She will continue OT and PT in the TCU setting to regain her strength. 3. Weakness: The patient's weakness is most likely due to acute illness and deconditioning.
PT|physical therapy|PT|181|182|ASSESSMENT/PLAN|7. Hyperglycemia. She does not carry a diagnosis of diabetes, but blood sugar was 150. We will check some blood sugars and follow as needed. 8. Deconditioning. Will be evaluated by PT and OT. CODE STATUS: Reported as full.
PT|physical therapy|PT|171|172|FOLLOWUP|DISCHARGE INSTRUCTIONS: The patient is to follow up with Dr. _%#NAME#%_ _%#NAME#%_ in one week and follow up with Dr. _%#NAME#%_ in 1-3 weeks. The patient is to have home PT and OT. The patient will discuss Effexor with either Dr. _%#NAME#%_ or his psychiatrist.
PT|physical therapy|PT|157|158|DISPOSITION|DISPOSITION: Expect a 5-7 day hospitalization stay as we try to stabilize the patient with new onset congestive heart failure and new lung mass. We will get PT and OT involved as well as social services for possible placement into Rehab or nursing home.
PT|physical therapy|PT,|226|228|HOSPITAL COURSE|Postoperatively, the course was complicated by rebleeding, vasospasms and she was placed on nimodipineand transferred to acute rehab for rehabilitation. HOSPITAL COURSE: Following admission to acute rehab, she participated in PT, OT and speech language pathology b.i.d. In physical therapy, at the time of discharge, she was independent with her transfer.
PT|physical therapy|PT|177|178|HOSPITAL COURSE|2. Dementia. The patient has a history of dementia. The patient was tentatively scheduled to enter VA nursing home in one month. 3. Deconditioning. Patient will continue OT and PT at the rehab. 4. History of zoster. Patient's zoster showed evidence of healing at the time of discharge. 5. Hypothyroidism. The patient will continue his Synthroid. 6. History of seizure disorder.
PT|physical therapy|PT|132|133|INSTRUCTIONS|1. Topamax 75 mg p.o. q. day. 2. Atenolol 25 mg p.o. q. day. INSTRUCTIONS: 1. Activity restrictions none. 2. Diet, regular diet. 3. PT to evaluate and treat. 4. Occupational therapy to evaluate and treat. 5. Speech therapy to evaluate and treat. FOLLOWUP: After discharge, the patient should follow up with his primary care physician in 2-4 weeks.
PT|physical therapy|PT|200|201|HOSPITAL COURSE|Therefore, the patient has been deemed appropriate for discharge to home. She will be transferred to a nursing home for convalescence. She will be discharged with routine ostomy cares and request for PT and OT evaluation. The patient will be discharged on her outpatient medications along with the addition of, 1. Compazine 5 mg p.o. q.6h. p.r.n. 2. Bisacodyl suppositories p.r.n. daily.
PT|physical therapy|PT|147|148|DISCHARGE DISPOSITION|6. Restoril 50 mg at bedtime. 7. Protonix 40 mg daily. DISCHARGE DISPOSITION: _%#NAME#%_ _%#NAME#%_ will be going to a rehab center. She will have PT and OT evaluate and treat her. DIET: No added salt, moderate carb control. She is weightbearing.
PT|physical therapy|PT|136|137|COURSE OF HOSPITALIZATION|As the patient's condition was stable, the patient was transferred to regular cardiology floor for further management and evaluation by PT and OT. During the course of hospitalization, it was also noted that the patient had elevated blood sugar levels and an endocrine consult was obtained as a part of workup for newly diagnosed diabetes.
PT|physical therapy|PT|149|150|IMPRESSION AND PLAN|We will start Nystatin that he has been on in the past per his mother. 9. Anxiety. Zoloft therapy which appears to be effective. 10. Deconditioning. PT and OT. 11. Disposition: The goal of his mother is to transfer to the _%#CITY#%_ area where they live when a bed is available at a facility there.
PT|physical therapy|PT|211|212|ALLERGIES|DISPOSITION: To Robbinsdale Rehabilitation Center. DISCHARGE INSTRUCTIONS: 1. The incision with staples in place should be kept clean and dry. Wash with soap and water, but do not soak the incision. 2. Continue PT and OT therapy. 3. Lifting limitations: No greater than 10 pounds. Activity otherwise as tolerated. 4. Regular diet.
PT|physical therapy|PT|150|151|PLAN|Will continue her on her DuoNebs but will start her on Spiriva 1 puff q. day, Advair Diskus 250/50 one puff b.i.d. Will check daily INRs. Will obtain PT and TO evaluations. I did discuss code status with the patient and her son.
PT|physical therapy|PT|306|307|HOSPITAL COURSE|She had some falls at home due to her weakness and so we got a femur x-ray which showed the possibility of a fracture but followup MRI did not confirm this. She was not quite ready to go back home at the end of this admission so she was transferred over to the Fairview Transitional Care services for more PT and OT. DISCHARGE MEDICATIONS: 1. Viagra 25 mg PO t.i.d. for peripheral vascular disease.
PT|physical therapy|PT|106|107|HOSPITAL COURSE|Under spinal anesthesia, had a left total hip arthroplasty. Cemented stem, _________ cup. Please refer to PT notes, labs, medications, etc. in the computer and on the chart. No complications noted. She is doing fine. POSTOPERATIVE DIAGNOSIS: Acute blood loss anemia.
PT|physical therapy|PT,|176|178|DISCHARGE INSTRUCTIONS|Weightbearing is currently none. Activity level is advance as tolerated. Care level is skilled. Rehabilitation potential is fair. Code status is full. The patient will require PT, OT, and speech therapy assistance. The patient is on .....FIO2 per trach dome. Tube feeding is impact with glutamine at 60 cc/hour.
PT|physical therapy|PT,|183|185|HOSPITAL COURSE|In the interim, the patient is to maintain a regular diet with nectar thickened liquids. As per patient's advanced directives he is DNR/DNI. At the TCU it is recommended that he have PT, OT and speech therapy. DISCHARGE MEDICATIONS: 1. Dilantin 400 mg p.o. each day at bed-time.
PT|physical therapy|PT|188|189|PLAN|ABDOMEN: Obese, nontender, no mass or organomegaly. Straight leg range was positive and reflexes normal. ASSESSMENT: Acute lumbar strain. PLAN: Continue the PCA for pain care. We will get PT and OT evaluation and treatment. MRI to evaluate extent of treatment necessary.
PT|physical therapy|PT|216|217|HOSPITAL COURSE|When admitted she was found to be in rapid atrial fib which was her normal rhythm but it was greater than 100. She also had evidence of a UTI. This was treated with Levaquin 250 mg daily. She was placed at bed rest. PT and OT consults obtained. She is a candidate for acute rehab and will be going to an ECF on discharge prior to return to her apartment.
PT|physical therapy|PT,|186|188|MEDICATIONS|11. Cytomel 25 mcg p.o. q.d. She was again told to follow up with Dr. _%#NAME#%_ on _%#DDMM2002#%_ and continue with her radiation therapy as scheduled. She had home health arranged for PT, OT evaluation and for general assessment and pain control. She was again told not to drive while taking narcotics, no lifting greater than 10 pounds, and to watch for signs and symptoms of infection.
PT|physical therapy|PT|184|185|PLAN|1. Pain control with scheduled Tylenol. Also add Flexeril. Will have opioids available for breakthrough pain. 2. Hold Lasix for now. 3. Hydrate with IV fluids. 4. Check FENA level. 5. PT and OT consult. 6. Social work consult. 7. MRI of the back and hip to evaluate for any fractures, compression fractures.
PT|physical therapy|PT.|97|99|CONSULTATIONS|FOLLOW UP: With primary physician in one week. Vitamin B 12 level pending. CONSULTATIONS: OT and PT. with home OT PT ordered. SUMMARY OF HOSPITALIZATION: _%#NAME#%_ _%#NAME#%_ is an 87-year-old female admitted by myself for observation.
PT|physical therapy|PT|224|225|HOSPITAL COURSE|She was admitted for pain. We started her on calcitonin nasal spray, lidoderm patch, and p.r.n. medications. We did get a pain consult. The pain team was very helpful in making recommendations to control the patient's pain. PT and OT also worked with the patient gently to try to keep her moving. The patient's pain was improved prior to discharge and she will continue on the current pain medications.
PT|physical therapy|PT|288|289|PROBLEM #1|The patient said that she felt like there was a foreign body in her foot and on further examination, there appeared to be a splinter and a large fluid collection on the plantar surface of her foot. We did have Orthopedics come to remove the splinter and debride her wound which they did. PT came, looked at the patient and ordered her an orthotic. She will be discharged to rehab since we feel it is very important that the patient not do any weightbearing for several weeks so that the wound can heal.
PT|physical therapy|PT|211|212|HOSPITAL COURSE|The patient is discharged to the nursing home on a low sodium diet with 1500 cc fluid restriction. Routine standard nursing home orders are approved. It was felt the patient's rehabilitation potential was fair. PT and OT are asked to evaluate and treat the patient, as well as speech therapy. The patient is asked to follow up with Dr. _%#NAME#%_ in 1-2 weeks' time and Dr. _%#NAME#%_ at Minnesota Heart within 1-2 weeks' time.
PT|physical therapy|PT|78|79|CONSULTS|2. Curettage of right proximal tibial lesion and allograft packing. CONSULTS: PT and OT. BRIEF HISTORY AND EXAMINATION: Mrs. _%#NAME#%_ is a 34-year-old female with a 6 month history of right knee pain which has become progressively worse.
PT|physical therapy|PT|266|267|HOSPITAL COURSE|Urology at this point did not feel that a stent was needed and at the present time, no further diagnostic evaluation has been recommended in regards to his renal failure. The patient's hospital course was also notable for generalized weakness for which he underwent PT and occupational therapy. He also had some mild difficulty with swallowing and was seen by speech pathology. He underwent a video swallow study on _%#DDMM2001#%_ demonstrating a recommendation for thin and thickened foods in an upright position with no straws and slow chewing and swallowing.
PT|physical therapy|PT|125|126|ASSESSMENT AND PLAN|We will continue Accu-Cheks and insulin as ordered. 4. Deconditioning. The patient has a right hemiplegia. We will work with PT and OT daily.
PT|physical therapy|PT|120|121|MEDICATIONS|MEDICATIONS: Oxycodone, Colace, Percocet and probably on the Coumadin for 10-14 days. Home care will be set up for home PT INR checks and wound management. I will see him back in the office three to four weeks postop. He understands the body mechanics what not to do particularly.
PT|physical therapy|PT|254|255|HOSPITAL COURSE|Pacemaker interrogation was done and proved to be normal without evidence of arrhythmias. In review it was felt that the patient's medication was likely responsible for this problem, thus his medication regimen was adjusted and the patient was tested by PT and OT for the next several days. On the day of discharge and the day before discharge the patient was doing well.
PT|physical therapy|PT|209|210|BRIEF HISTORY AND HOSPITAL COURSE|Prior to discharge, she had been complaining of some neck tension and pain as well as stiffness. No obvious meningismus reproducible with palpation to the paraspinous muscles in the cervical region. I did ask PT to perform some myofascial tension release as well as instruct the patient on certain exercises at home. Massage at home was also encouraged. DISPOSITION: Discharged to home in a stable condition.
PT|physical therapy|PT|240|241|HOSPITAL COURSE|She did not require any blood transfusion. She was given some IV fluids as she was mildly orthostatic which was felt to be related to her blood loss anemia and use of atenolol. The following morning she was ambulating well. She was seen by PT who had no further recommendations. At time of discharge, her hemoglobin has stabilized at 8.4 with a previous hemoglobin being 8.2. Her hyponatremia is improved from 130 up to 132 and she is deemed a stable candidate for discharge with above follow-up.
PT|physical therapy|PT.|213|215|ASSESSMENT/PLAN|If her mental status does not improve, will proceed with more aggressive treatment of blood pressure control as she may have had hypertensive encephalopathy. Will get a speech pathology consult and consult OT and PT. The patient will be placed on aspirin 2. Accelerated hypertension. The patient will be treated with clonidine in the patch form until she is able to take p.o.. Will adjust IV medications as needed.
PT|physical therapy|PT,|177|179|DISCHARGE MANAGEMENT PLAN|8. MRSA pneumonia. 9. Aspiration pneumonia. 10. Septicemia. 11. History of nocardiosis. DISCHARGE MANAGEMENT PLAN: The patient will be transferred to _%#COUNTY#%_ for continued PT, OT and pulmonary rehabilitation. The patient is on gastric feeding tube and n.p.o. The patient requires frequent suctioning. DISCHARGE MEDICATIONS: 1. For hypertension, Norvasc 5 mg per the feeding tube daily.
PT|physical therapy|PT|85|86|CODE STATUS|DIET: Diabetic qualitative diet. ACTIVITY: Ad lib. CODE STATUS: Code status DNR/DNI. PT and OT evaluation at TCU. MEDICATIONS: 1. Calcitonin 1 spray to alternating nostrils daily.
PT|physical therapy|PT|172|173|SPECIAL INSTRUCTIONS|The idea of the patient getting aggressive rehab was focused on that the patient would be able to return home. SPECIAL INSTRUCTIONS: None. OT and PT: Patient will have OT, PT and speech pathology at the nursing home. PROCEDURES AND OPERATIONS: On _%#DDMM2007#%_ as well as on _%#DDMM2007#%_, the patient had 2 CT scans, which showed a large parietal lobe hemorrhagic infarct.
PT|physical therapy|PT|187|188|DISCHARGE RECOMMENDATIONS|Activity is as tolerated. Restrictions of no driving, no alcohol, and continue sternal precautions. Her pacemaker precautions were recommended. It is recommended that she receive in-home PT and Home Health aid until her endurance and function improves to the point where she can tolerate an outpatient cardiac rehab program.
PT|physical therapy|P.T.|218|221|HOSPITAL COURSE|Patient was in stable condition upon discharge. HOSPITAL COURSE: The patient was transferred to the Fairview- University Transitional Services on _%#MMDD#%_ from Fairview _%#CITY#%_. Patient was initially started with P.T. and O.T. Initially, it was thought patient would be able to make progress with therapy, but after 2-1/2 weeks of therapy it was shown that patient made very little progress.
PT|physical therapy|PT|212|213|ASSESSMENT AND PLAN|At this point, considering her age and lack of focal neurologic deficits, we will attempt conservative management with p.o. pain medications. We may consider a Pain Team consult. We will have the patient seen by PT and OT to assess her safety for eventual discharge to home. 2. Musculoskeletal. In regards to her osteoporosis, she was previously on calcitonin and calcium plus vitamin D.
PT|physical therapy|PT|156|157|DISCHARGE PLAN AND FOLLOWUP|DISCHARGE PLAN AND FOLLOWUP: 1. The patient will be transferred to Fairview University Transitional Care unit for a short rehab stay. 2. She is to continue PT and OT for balance as well as endurance and ADLs. 3. The patient is on a regular diet with Ensure t.i.d. for additional nutrition supplementation.
PT|physical therapy|PT,|251|253|HOSPITAL COURSE|The patient was seen by Dr. _%#NAME#%_ of Neurology. EMG was ordered but is pending at the time that this discharge summary is being dictated. Dr. _%#NAME#%_ thought that the patient's weakness may be related to the laminectomy. The patient underwent PT, OT and has made marked improvement. At time of discharge the patient is felt to be stable and ready for discharge pending Dr. _%#NAME#%_'s visitation today and approval for discharge: DISCHARGE DISPOSITION: The patient will go home with outpatient physical therapy.
PT|physical therapy|PT|245|246|ASSESSMENT AND PLAN|2. Hypertension. We will observe the patient off her ACE inhibitor and just the hydrochlorothiazide and Dr. _%#NAME#%_ will probably have to re-titrate that after discharge. 3. General deconditioning postoperatively. The patient will be seen by PT and OT with the restrictions on heavy lifting noted but no other restrictions. 4. Osteoporosis. Resume calcium supplements. 6. Postop anemia. The patient would probably benefit from some iron supplementation.
PT|physical therapy|PT|181|182|PLAN|When she is able we will try to transition her to oral did Dilaudid, perhaps ibuprofen and Zofran and Compazine orally as well. We will try Lidoderm in the morning. We will request PT and OT to evaluate and see the patient. Also, will talk with my partner about discussing the CT findings with radiology to see if vertebroplasty may be appropriate.
PT|physical therapy|PT.|172|174|DISCHARGE INSTRUCTIONS|She was discharged with Fairview Home Care Services to assess incision, pain control as well as lab draws for INR. She will continue with physical therapy at home per Home PT. WOULD CARE: The patient should cover the incision on a p.r.n. basis.
PT|physical therapy|PT,|205|207|DISCHARGE MANAGEMENT PLAN|2. Critical aortic stenosis. 3. Cardiac myopathy. 4. Atrial fibrillation now converted to sinus rhythmn. DISCHARGE MANAGEMENT PLAN: _%#NAME#%_ _%#NAME#%_ is being transferred to _%#CITY#%_ Care Center for PT, OT and then a decision on most appropriate long-term care situation possibly back to her apartment with home nursing. DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg p.o. b.i.d. through _%#MM#%_ _%#DD#%_ and then 200 mg daily.
PT|physical therapy|PT|182|183|PLAN|We will maintain her on her other chronic outpatient medications for her diabetes, her hypertension, and other chronic medical conditions. We will also have the patient evaluated by PT and OT with plans to return to her apartment when she is strong enough and stable.
PT|physical therapy|PT,|176|178|MEDICATIONS|The last complete formal examination on the _%#MM#%_ _%#DD#%_, at 09:00 was 16 out of 30 indicating severe cognitive impairment. It is hoped that with abstinence from alcohol, PT, OT and speech therapy, that this will improve. She will have to be evaluated further to see the appropriateness of her long term living situation, giving this level of impairment.
PT|prothrombin time|PT,|153|155|ISSUES AT THE TIME OF DISCHARGE|This will be restarted. Her INR will need to be rechecked on Monday. If the INR is low, her Coumadin will need to be restarted on Monday. The results of PT, PTT, INR and CBC and platelets will be faxed to Dr. ...........on _%#DDMM2003#%_ and _%#DDMM2003#%_. The patient will follow up with Dr. _%#NAME#%_ _%#NAME#%_.
PT|physical therapy|PT|132|133|STUDIES|Prior issue of diarrhea, thought related to alcohol effect on the bowel, had essentially resolved. The patient had stable gait with PT assessment, and was felt appropriate for discharge to outpatient followup. She was to see her primary care provider within the next week.
PT|physical therapy|PT,|164|166|DISCHARGE INSTRUCTION|He was discharged to Ebenezer Ridges Care Center for short rehab. CONDITION OF PATIENT ON DISCHARGE: Stable. DISCHARGE INSTRUCTION: Activity as tolerated. Continue PT, OT. MEDICATION: As filled in the nursing home form and also continue Levaquin 500 mg 1 tablet q d for 7 days.
PT|prothrombin time|PT|202|203|LAB  DATA|Hemoglobin is 11.6, white count 13,700, with no differential. Platelets 505,000. Sodium 128, potassium 3.3, chloride 95, bicarbonate 28, BUN is 7, creatinine 0.6, glucose is 190, calcium 8.1, INR 1.10, PT 26. IMPRESSION: 1. Dehydration secondary to decreased PO intake, vomiting and diarrhea.
PT|physical therapy|PT|202|203|IMPRESSION|I think this is probably due to the hydrochlorothiazide or Hydrodiuril and this will be held. We will cautiously give the patient some saline, watching for congestive heart failure. Also, we will get a PT and OT evaluation. Discussions with the husband and the daughter indicate that the patient may have to be placed in a nursing home facility.
PT|physical therapy|PT.|149|151|REHAB COURSE|She denies any difficulty with urination or bowel movements. She is steady on her feet, though activity is minimal bed to chair and a few steps with PT. Her appetite has improved. In regards to her diabetes, we have been slowly titrating her Lantus insulin up. Of interest, her sugars have been somewhat difficult to control secondary to her frequently nibbling on junk food snacks.
PT|physical therapy|PT.|97|99|CONSULTATIONS|Urine culture revealed greater than 100,000 colonies of Klebsiella pneumoniae. CONSULTATIONS: 1. PT. 2. Occupational therapy. 3. Physical medicine and rehabilitation. HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old right handed female who noticed on the night prior to admission at approximately 8:30 p.m. acute onset of right handed weakness.
PT|physical therapy|PT|318|319|DISCHARGE PLAN AND FOLLOWUP|She will be discharged to her home. 2. The patient will be receiving Fairview Home Care and Hospice for skilled nursing for initial home safety evaluation in 1-3 times weekly to evaluate her neurostatus, nutrition and medication management as well as general status post rehab stay. In addition, the patient will have PT and OT to evaluate and recommend plan of treatment in the home setting. 3. The patient will be receiving interpreter through _%#NAME#%_ _%#NAME#%_ Agency.
PT|physical therapy|PT|384|385|ASSESSMENT AND PLAN|SKIN: no rashes RECENT LABORATORY STUDIES: Today's BMP within normal limits with a creatinine of 1.2, White count of 10.4. INR 2.15, having recently started Coumadin for DVT prophylaxis Hemoglobin 10.2 (8.7 on _%#DDMM2007#%_ before she received packed red blood cells). ASSESSMENT AND PLAN: 1. Status post left total knee arthroplasty. - good pain control with Flexeril and Vicodin - PT and OT - Coumadin for DVT prophylaxis with a goal of 1.5-2.2. Clarify with Dr. _%#NAME#%_ how long he wants the patient to be on Coumadin.
PT|physical therapy|PT|153|154|ACTIVITY|DIET: Regular diet as requested by the patient even though dysphagia diet was recommended by speech and language therapy. ACTIVITY: As tolerated. OT and PT as tolerated, but may be discontinued if the patient declines. First step mattress. Notify physician if significant amount of bleeding is noted, the patient should be brought back to the hospital for possible blood transfusion or radiation treatment to the bladder.
PT|physical therapy|PT|193|194|PROBLEM #2|During this hospitalization, the patient did not have any significant problems with hypoxia and had ambulated with physical therapy without significant problems. However, it was recommended by PT that the patient should go to a short-term rehabilitation. The patient declined this and wanted to be discharged home. PROBLEM #3: Leukopenia: The patient was found to have leukopenia with increased monocytes.
PT|physical therapy|PT,|164|166|DISCHARGE DISPOSITION|This is yet to be determined but the social worker is working these details with his son. Diet is mechanical soft with thin liquids. Activity as able. He will have PT, OT and speech therapy working with him. He will also have home health if he goes back home. He will go home with a Foley catheter and he will see urology in two weeks to discuss removing his catheter.
PT|physical therapy|PT,|180|182|HISTORY OF PRESENT ILLNESS|MRI showed small subacute ischemic stroke involving he left posterior limb of the internal capsule. The patient was treated medically with aspirin and Plavix. He was seen by PM&R, PT, OT, and Speech therapy service. He underwent video swallowing study which he failed. Speech therapy then recommended NPO and tube feed which the patient refused.
PT|physical therapy|PT|198|199|HOSPITAL COURSE|The patient was discharged to _%#CITY#%_ Care Center on _%#DDMM2006#%_. Discharge diet is regular since this is the diet she takes at home. Weightbearing and activity level are without restriction. PT and OT will be continued at _%#CITY#%_ Care Center. The patient will continue to use oxygen supplementation at two liters per nasal cannula as needed for shortness of breath.
PT|prothrombin time|PT,|195|197|HOSPITAL COURSE|He was discharged to Rehab with instructions to follow up with Dr. _%#NAME#%_ in clinic after discharge from rehab. At rehab we will follow his labs including CBC, chem-10, liver function panel, PT, PTT, INR and prograf level every Monday, Wednesday and Friday, and NPA levels every Monday. He is weight-bearing as tolerated, but should not lift more than 10 pounds for the following 6 weeks.
PT|prothrombin time|PT|234|235|FOLLOW-UP|6. Zonegrem 300 mg PO b.i.d. 7. Tylenol 325 mg 1-2 tabs PO q 4 hours p.r.n. FOLLOW-UP: The patient is to follow-up with Dr. _%#NAME#%_ _%#NAME#%_ in one to two weeks and should have drawn CBC with platelets and differential. I and R, PT and chem 10 prior to his appointment.
PT|physical therapy|PT|396|397|DIAGNOSES AT DISCHARGE|She is discharged now on her previous medications which include Zanaflex 4 mg at bedtime, amantadine 100 mg twice a day, Wellbutrin 200 mg twice a day, Tofranil 25 mg a day, Effexor XR 150 mg twice a day with 75 mg twice a day, totalling 225 mg a day, methotrexate 7.5 mg every Wednesday, Neurontin 300 mg six times a day, Premarin 0.625 mg a day and a one-month Medrol taper. She will have some PT and OT at home. She will be seen in the office in six weeks.
PT|physical therapy|PT|144|145|PLAN ON ADMISSION|3. History of hypertension. 4. Hyperlipidemia. PLAN ON ADMISSION: 1. We will review this patient's hospital records and current medications. 2. PT and OT evaluation will be conducted. 3. Follow cardiac status closely. 4. Orthopedic follow-up per plans. 5. We will repeat a urine culture in deference to her fever.
PT|posterior tibial|PT|237|238|OBJECTIVE|BREASTS: No nodules or discharge. ABDOMEN: Soft and nontender. No organomegaly, rigidity, masses or tenderness. Normal bowel sounds. PELVIC/RECTAL: Deferred. EXTREMITIES: No cervical or axillary or femoral nodes. Femoral pulses present. PT pulses on right, none on left. Extremities warm, pink, dry, no edema. ORTHO: Joints, no inflammation. NEURAL: Cranial nerves II-XII normal. Reflexes, biceps, patella 2+. Babinski downgoing.
PT|physical therapy|PT|159|160|IMPRESSION/PLAN|She will have no treatment for now. 5. History of pulmonary fibrosis. 6. Questionable dementia per report from the transferring physician. We will have OT and PT do evaluations. 7. Urinary frequency and nocturia. The patient did have a UTI in the hospital with greater than 100,000 group D Enterococcus.
PT|physical therapy|PT|137|138|ADDENDUM|He is in good spirits. Will have the leg maker see him once we are absolutely certain the wound is healing. Will do dressing changes and PT for guidance, bed to chair, etc. He is diabetic. He will resume all pre-hospital care diabetic plan, etc.
PT|physical therapy|PT|217|218|SIGNIFICANT FINDINGS|2. Chronic anemia. 3. Dementia, multiinfarct. REASON FOR ADMISSION: Rehabilitation. SIGNIFICANT FINDINGS: After this patient was stabilized on the medical floor, he was transferred to rehab for assistance with OT and PT due to his COPD. He was continued on doxycycline 100 mg b.i.d., his Flovent and Combivent inhalers and albuterol, as well as a tapering dose of prednisone starting at 40 mg daily x 3 days, then every 3 days tapering down by 10 mg, and then by 5 mg for the last 3 days.
PT|physical therapy|PT|165|166|ASSESSMENT AND PLAN|We will hold the diuretics. Will continue to hold the Toprol as he is having a reaction to this. Will give him gentle hydration, as well as encourage p.o. Will have PT and OT again see patient. Will have a cardiology consult regarding adjustment of his medications and plan pending upcoming interventions.
PT|physical therapy|PT|213|214|HISTORY OF PRESENT ILLNESS|She seems forgetful, which seems to be her baseline. She was placed on Tylenol and Ultram only for pain control given the potential likelihood of delirium with narcotics. She was doing fairly well and will resume PT and OT at discharge. In regards to her diabetes, she was placed on a Novolog sliding scale.
PT|physical therapy|PT,|84|86|HOSPITAL  COURSE|He subsequently underwent an amputation of toes 2-5 on left foot and has been doing PT, OT since. He needs to go to a TCU. He was followed by Dr. _%#NAME#%_ in the hospital, he has been placed on linezolid and Augmentin for antibiotic coverage.
PT|physical therapy|PT,|166|168|ASSESSMENT AND PLAN|Additionally, I will get an MRI of her brain and I will allow the neurologist to decide whether or not they think she needs to have a transthoracic echo. I will have PT, OT and speech see her. It looks as though she is no longer pooling secretions and therefore I will make a dysphagia diet one available to her, but if she shows signs of aspiration, will make her n.p.o. I will also check her lipids.
PT|physical therapy|PT,|162|164|HOSPITAL COURSE|PT, OT evaluations were accomplished. It was felt the patient required rehabilitation before returning home and thus he is transferred to a TCU. It is asked that PT, OT and speech therapy evaluate and treat the patient. It is asked that the patient be fitted for TED hose, thigh high, which is hopeful to prevent syncopal episodes in the future.
PT|physical therapy|PT|214|215|HOSPITAL COURSE|Dr. _%#NAME#%_ of Orthopedic Surgery was kind enough to see the patient and recommended nonoperative management. The patient responded well to therapy. She was able to ambulate with assistance in the hallways with PT and OT. Pain was controlled well with Vicodin alone. She appears stable for discharge to transitional care unit today. 2. Urinary tract infection: The patient was diagnosed with UTI on admission.
PT|physical therapy|PT,|76|78|DISPOSITION|6. History of Parkinson's. Continue home medications. DISPOSITION: Will get PT, OT and social worker involved for discharge planning. He is DNR/DNI.
PT|physical therapy|PT|174|175|SPECIFIC DISCHARGE INSTRUCTIONS|5. Aspirin 81 mg daily for antiplatelet therapy. SPECIFIC DISCHARGE INSTRUCTIONS: 1. Code status is full 2. Diet is regular. 3. Physical activity instructions. 4. Ad lib per PT recommendations. 5. Oxygen requirements: none. 6. Wound care: none. 7. Followup appointments, primary care provider in 1-2 weeks and the patient is to follow up with Dr. _%#NAME#%_ _%#NAME#%_.
PT|physical therapy|PT|198|199|ADDENDUM|ADDENDUM: The patient did not get discharged to home with her daughter due to concerns over wound care with patient having active bleeding from her wound and requiring anticoagulation. In addition, PT worked with the patient and had concerns over her strength and mobility and thought she would benefit from short-term rehabilitation.
PT|physical therapy|PT|175|176|PLAN|Then she is to be started on aspirin 325 mg p.o. daily. 4. Pain: She is currently on Percocet. We will titrate the medication to control pain optimally as she participates in PT and OT. 5. Bowels: We will place her on an aggressive bowel program and initiate rehab nursing. 6. Incision. Clean, dry and intact currently. We will change dressings daily.
PT|physical therapy|PT|191|192|DISCHARGE RECOMMENDATIONS|DISCHARGE RECOMMENDATIONS: Follow up with her primary care physician Dr. _%#NAME#%_ _%#NAME#%_ in 2 weeks, Dr. _%#NAME#%_ she has appointment on Monday, Dr. _%#NAME#%_ in 1 month, outpatient PT and home health aide and nurse. Regular diet. Weightbear as tolerated. Bilateral Velcro shoes. No driving. No use of alcohol. Dressing change to left foot, bacitracin, Vaseline gauze and dry dressing every day to every other day, and to right posterior thigh, bacitracin with dry bulky dressing daily.
PT|physical therapy|PT|206|207|HOSPITAL COURSE|DIAGNOSIS: Severe osteoarthrosis, left hip. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ underwent primary arthroplasty left hip. Pain management has been good. Describes no pain but he does take Percocet before PT and home PT and INRs will be checked there. INR yesterday was 1.95, waiting for today's. PLAN is to see him back in three to four weeks, sooner if the visiting nursing cannot take the staples out.
PT|physical therapy|PT,|139|141|DISCHARGE PLAN|They have agreed to provide ongoing care and support for him at home. He will be followed by HealthPartners home care including a home RN, PT, OT. He has the need for scheduled followups with Dr. _%#NAME#%_ _%#NAME#%_ of the Liver Transplant Service and also with Mr. _%#NAME#%_ _%#NAME#%_ , transplant coordinator.
PT|physical therapy|PT,|181|183|ASSESSMENT AND PLAN|Will rehydrate with IV fluids. With elevated creatinine, hold her Metformin and gentle sliding scale insulin coverage t.i.d. as needed. Monitor INR, resume rest of her medications. PT, OT for therapy. Her living will is in front of the chart and says DNR/DNI. When talking this over with the patient, she is not quite clear if she wants chest compressions or not but has said no for the most part.
PT|physical therapy|PT,|124|126|ASSESSMENT AND PLAN|Given that he is having a little bit more difficulty with his speech, will also have speech eval. his swallowing. Will have PT, OT work with him since he does have the fairly significant weakness in the right leg now and plan pending this. Will also have _%#CITY#%_ Clinic of Neurology see him given the stroke through adequate anticoagulation on Coumadin and aspirin.
PT|physical therapy|PT,|208|210|DOB|His INR, however, was only 0.93. It was felt that the patient had a CVA and he was admitted to the hospital for this. He was initially admitted to intensive care, a neuro consult was obtained on the patient. PT, OT, as well as speech evaluation was performed. Speech therapist felt the patient had a moderate pharyngeal dysphagia, he was started on speech therapy.
PT|physical therapy|PT|188|189|HOSPITAL COURSE|8. Activity: As tolerated. Assist the patient with eating. HOSPITAL COURSE: PROBLEM #1: Weakness; dehydration. Ms. _%#NAME#%_ was admitted to the floor. She was rehydrated with IV fluids. PT and OT were consulted. Her history in the last two or three months has been one of repeated hospitalizations.
PT|physical therapy|PT|216|217|DISPOSITION|The patient was admitted to the station for observation. On the station, the patient's further hospital course was uneventful. He gradually improved and started feeling more confident and stronger. He was started on PT and actually did very well. He was walking with a walker and his confidence improved and he started feeling stronger.
PT|physical therapy|PT|180|181|DISCHARGE ORDERS|DISCHARGE ORDERS: Patient is discharged to transition care at _%#CITY#%_ Care Center. Regular diet, activities as tolerated. He is being fitted for the back brace and will receive PT and also an OT evaluation. CURRENT MEDICATIONS: Levothyroxine 75 mcgs, Atenolol 25 mg, increase dose of Lisinopril to 40 mg q.a.m., along with his other a.m. meds.
PT|physical therapy|P.T.|259|262|HOSPITAL COURSE|On postoperative day x 3 and 4. By postoperative day x 5, she was deemed appropriate for transfer to acute rehabilitation facility. Hemoglobin had remained stable. Her wound was clean, dry and intact. Drains removed. Foley discontinued. Progressing well with P.T. PLAN: Will be for the patient to maintain ...... weight bearing status of the right lower extremity over the next six weeks.
PT|physical therapy|PT|172|173|DISCHARGE INSTRUCTIONS|She may shower now, but she should not take a bath for at least a week. Ms. _%#NAME#%_ is to follow up in clinic with Dr. _%#NAME#%_ in two weeks. She will have an in-home PT and OT consult to evaluate and treat. She will also have a skilled nurse visit to review home nebulizer treatments, and she will receive a suction machine for home use.
PT|physical therapy|PT,|205|207|DOB|_%#NAME#%_ _%#NAME#%_ was brought in on _%#DDMM2003#%_, had a surgical procedure (left total knee arthroplasty, cemented Biomet knee). She has been doing well postoperatively. Please see the chart for all PT, OT, nursing care plans. When she gets home from the nursing home, she will continue with the same medications. She is going to the nursing home; see the referral sheet.
PT|physical therapy|PT|133|134|PLAN|This is to be done daily with .........., fluffs, and normal saline with dry change b.i.d. 2. PT and OT. The patient participated in PT and OT scheduling here, and so far she is going fine. 3. We will continue ..........closely monitor the patient.
PT|physical therapy|PT|181|182|ASSESSMENT/PLAN|We will try to control her pain by giving her oral Dilaudid and can add some Vistaril as needed. The patient will be seen for a pain consultation in the next couple of days and has PT and OT to evaluate. Given the confusing history of this patient and the confounding factors, I will ask Neurology to stop by and see her to see if they have any other ideas of approach to this patient.
PT|physical therapy|PT|215|216|REASON FOR ADMISSION|Also she needed nursing home disposition on admission. She was found to have a right humerus neck fracture. Orthopedic consultation was obtained and the patient is currently wearing a sling, but continued doing her PT and OT therapy while she is in the hospital and plans to have the patient follow up with Dr. _%#NAME#%_, Orthopedics, outpatient in a couple of weeks per Ortho recommendation.
PT|prothrombin time|PT|171|172|DISPOSITION|21. Glucerna one can p.o. t.i.d. DISPOSITION: 1. Follow up with TCU MD upon transfer to rehabilitation. 2. Hold Coumadin today, _%#DDMM2004#%_ and _%#DDMM2004#%_. Recheck PT INR on Sunday, call results to TCU MD for Coumadin dosing. 3. Follow up with ID per Dr. _%#NAME#%_'s recommendations.
PT|physical therapy|PT|137|138|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: Ms. _%#NAME#%_ may bear weight as tolerated on both legs. She should do as much activity as tolerated. She needs PT for gait training, range of motion exercises that she should do at home, quad sets and CPM. The goal is for 8 hours of CPM per 24 hours on each leg with goal maximum of 110 degrees.
PT|physical therapy|PT|92|93|PLAN|She also received some Ativan due to some shakes from the extra Seroquel. PLAN: 1. Will ask PT to assess the patient and will send home; she states she is able to ambulate. 2. Will continue on her current dose of mediations.
PT|physical therapy|PT|161|162|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: The patient has no known allergies. Diet: The patient requires a kosher diet. Activity is as tolerated with assisted needs determined by PT and OT. Follow up with Dr. _%#NAME#%_ _%#NAME#%_, the patient's primary care doctor in 1 week at which time family can also evaluate any interest in anticoagulation therapy.
PT|physical therapy|PT|203|204|PROBLEM # 4|Will start nystatin. PROBLEM # 4: Miscellaneous: The patient is markedly deconditioned and requires extensive care at home which is provided by his personal care attendant who is also his wife. Will get PT and OT to evaluate. May need short stay at acute rehabilitation. He is DNR/DNI.
PT|physical therapy|PT,|145|147||Please see history by hospitalist for details of this hospital stay involving the patient's medical issues. Her rehabilitation stay consisted of PT, OT, speech treatment and evaluation. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 70-year-old female atrial fibrillation developed difficulty with speech and right-sided weakness on _%#DDMM2007#%_ taken to _%#CITY#%_ _%#CITY#%_ Hospital diagnosed with acute infarct in the left basal ganglia and left periventricular front white matter transferred to the University of Minnesota underwent stroke protocol.
PT|posterior tibial|PT|231|232|FAMILY HISTORY|Heart: Normal rate and rhythm, no murmur, no gallop. Lungs: Clear to auscultation and percussion on both sides. Abdomen: Soft, nontender, nondistended, normal bowel sounds, no organomegaly. Extremities: No edema, no pain, palpable PT and DP pulses. Neurology: The patient is awake, alert and oriented x 3. She had some problems with serial 7's and backwards spelling.
PT|physical therapy|PT,|242|244|PLAN|We will consider discontinuation of Glucophage with the risk of lactic acidosis, and the patient is elderly. We will obtain psychiatric consultation for medication adjustment. The patient may need inpatient treatment. Also, the patient needs PT, OT and a swallowing evaluation during her stay here. The patient is clinically stable at this time. We will continue other home medications.
PT|physical therapy|PT|162|163|PLAN|Blood cultures X 2 and urine cultures have been done. He will empirically be started on Flagyl and Tequin IV. The delirium protocol will be instituted. Tomorrow, PT and OT evaluations will be done. If the patient has temperatures of 101 or above, we will re-culture him and start Tylenol.
PT|prothrombin time|PT,|207|209|DISCHARGE MEDICATIONS|8. Keflex 500 mg q six hours for 14 days. Orders for physical therapy and occupational therapy were given. He will be following up with his hematologist within a week for his factor X labs and coag studies, PT, PTT, INR and factor X chromogenic studies. This would be under the care of Dr. _%#NAME#%_ _%#NAME#%_. DISCHARGE CONDITION: Satisfactory.
PT|physical therapy|PT|103|104|REHAB COURSE|Since that time, his hemoglobin has been quite stable. REHAB COURSE: The patient did meet the goals of PT and OT. He was able to continue with his dressing change, as well as the application of his lower right leg lymphedema splint, with re-teaching by Nursing.
PT|physical therapy|PT|229|230|ASSESSMENT AND PLAN|In the meantime, we will initiate maintenance IV fluids and adjust all medications to IV that are needed urgently, and hold other non-urgent medications. We will update his albumin status with next blood draw. 4. Rehabilitation. PT and OT are to evaluate and treat, and eventually Speech Therapy will see him. 5. Psychosocial. I see a note on transfer that the patient requires a fair amount of emotional support, given the life changes going on with being widowed and his recent surgery.
PT|physical therapy|PT|253|254|HOSPITAL COURSE|He continued to do well until approximately postoperative day #3, at which time he developed a fever and was noted to have very coarse rhonchi bilaterally. Chest x-ray revealed postoperative pneumonia. He was started on antibiotics and aggressive chest PT and incidental spirometry. His condition continued to improve over time and with the removal of his drains and stitches approximately five and seven days out, respectively, he was ready for discharge.
PT|physical therapy|PT|192|193|IMPRESSION|1. Depressed mental status. The CT is negative. He may have had some head trauma. He has a right periorbital hematoma. We will hold his narcotics and other psychoactive medications. Will have PT and OT evaluate him. Will get a neuro consult. I'll check a B-12, TSH and VDRL. 2. Question UTI. Cultures are pending. Will treat him with Rocephin meanwhile.
PT|physical therapy|PT,|194|196|INSTRUCTIONS FOR DISCHARGE|INSTRUCTIONS FOR DISCHARGE: Increasing the amount of fluids that he drinks. He should take at least 2 L q.24 hours and his diet should be renal. He was weightbearing as tolerated and we ordered PT, OT and speech therapy evaluate and treat at his nursing home.
PT|physical therapy|PT|207|208|HOSPITAL COURSE|3. Chronic sinusitis. The patient was treated with Nasonex nasal spray. 4. Hyperlipidemia, diabetes, and hypertension, remained stable on outpatient medications. 5. Disposition. The patient was evaluated by PT who felt the patient was stable for discharge to home. The patient is encouraged to get her medications filled in advance so that this does not happen again.
PT|physical therapy|PT|183|184|HOSPITAL COURSE|She made minimal progress in PT and was not able to return to independent or semi-independent living and was therefore discharged to a nursing home for ongoing care. She will receive PT and OT there. She is in stable condition, but is now requiring oxygen, low flow at 1 to 2 liters to maintain her saturations in the 90s.
PT|physical therapy|PT|150|151|HISTORY OF PRESENT ILLNESS|She had an uncomplicated postoperative course, was transferred to (_______________) for ongoing rehabilitation. HOSPITAL COURSE: The patient received PT and OT. She was (_______________) successfully without any recurrent medical problems. She was stable and did well in therapy. She was able to be discharged home for followup with orthopedic surgeon, primary care physician, and to receive ongoing physical therapy.
PT|physical therapy|PT,|252|254|DISCHARGE INFORMATION|3. Followup Dr. _%#NAME#%_ renal appointment _%#MM#%_ _%#DD#%_, 2005. Dr. _%#NAME#%_ _%#MM#%_ _%#DD#%_, 2005, endocrinology approximately 2 weeks after discharge. Serology, Dr. _%#NAME#%_. Bladder scan in a month to a month and a half. Speech therapy, PT, OT. SPECIAL INSTRUCTIONS: Diet: He is discharged on a diet of Similac PM 60/40 plus Beneprotein, add Kayexalate and let sit for 4 hours then pour off formula to use feeds 250 mL boluses 4 times a day and then 65 mL per hour for 8 hours at night.
PT|physical therapy|PT|243|244|HOSPITAL COURSE|The patient was discharged back to the _%#CITY#%_ Care Center on a 1200 cc fluid restriction, exercise as tolerated. The patient was full code, still deciding on her advanced directives. It was felt that her rehabilitation potential was fair, PT and OT were asked to consult and treat. DISCHARGE MEDICATIONS: 1. Flagyl 500 mg p.o. t.i.d. for ten days.
PT|physical therapy|PT|155|156|DISPOSITION|4. Diabetes mellitus with poor control. 5. Status post CVA with mild expressive aphasia. 6. Dehydration, resolved. DISPOSITION: Based on recommendation of PT and OT, the patient will be transferred to a transitional care unit prior to his return to assisted living with his wife.
PT|physical therapy|PT,|179|181|LUNGS|Heart percusses to normal size. LUNGS: Clear anteriorly and posteriorly. Respiratory rate 12 per minute auscultation and at rest there is no distress. LEGS: No pre-tib edema. DP, PT, popliteal, radial pulses are all 4/4+. BREASTS/RECTAL/PELVIC: Deferred. IMPRESSION: 1. Acute GI bleed for one week with hemoglobin from 11.5 down to 7.5.
PT|posterior tibial|PT|205|206|PHYSICAL EXAMINATION|He has no streaking erythema up his leg. He has no edema in his right lower leg at this time. There is a trace amount of edema over this dorsal foot. He has sensation intact in his toes throughout and his PT pulse is 2+ and symmetric bilaterally. Erythema and edema much improved from several days ago. RECENT LABS/STUDIES: 1. On _%#DDMM2004#%_: CBC 7.7, hemoglobin 8.9, platelets 434, 81 neutrophils.
PT|physical therapy|PT|151|152|DISCHARGE MEDICATIONS|Wound is healing nicely. Acute blood loss anemia, but most likely will not need a transfusion. Today's hemoglobin is pending. Otherwise doing well. In PT is doing well. Please refer to the chart for PT, OT notes. All other care plans will be continued as same postoperatively.
PT|physical therapy|PT|241|242|HOSPITAL COURSE|Serotonin syndrome has resolved. She was re- evaluated by orthopaedics and did have, on the _%#DD#%_, a revision and repair of the nonunion of her left hip. She then did return to us on the _%#DD#%_ of _%#MM#%_. She has progressed well with PT and OT. The pain in her left hip is minimal. She did complain of pain in both of her arms and shoulders secondary to increased activity and degenerative joint disease.
PT|physical therapy|PT.|315|317|HOSPITAL COURSE|6. DVT prophylaxis. The patient was discharged on _%#MM#%_ _%#DD#%_, 2005, with improvement in ataxia and with the therapeutic level of her Depakote with recommendation to follow up with her primary physician. Follow up with neurologist and the hematologist. We had arranged a sick home care for the patient OT and PT. In the time of discharge, the patient's last Depakote level was 85, MRI was within normal level without any new change.
PT|physical therapy|PT|222|223|IMPRESSION AND PLAN|4. Nutritional issues and dysphagia: He has a feeding tube, however, speech therapy is working with patient and will continue to do swallow studies. At this point, he is still aspirating with thin liquids. 5. Decondition: PT and OT will commence today. 6. Nicotine addiction: Will continue with nicotine patch.
PT|physical therapy|PT|178|179|ASSESSMENT/PLAN|The patient's wife is accepting of this. While he is hospitalized she wishes to revisit this issue upon discharge. 5. Deconditioning. This is secondary to his failure to thrive. PT and OT will be undertaken. We will continue rehab placement at discharge.
PT|posterior tibial|PT.|208|210|PHYSICAL EXAMINATION|LUNGS: Clear to auscultation. ABDOMEN: Soft. No hepatosplenomegaly, normal bowel sounds. EXTREMITIES: No pedal edema in bilateral lower extremities, decreased pulses, +1 in bilateral lower extremities DP and PT. NEUROLOGIC: The patient has decreased mental status and is confused, however, he has no focal symptoms moving his 4 extremities. He has no facial asymmetry on skin exam. No rash or ulcer.
PT|physical therapy|PT|180|181|HISTORY OF PRESENT ILLNESS|Orthopedics were consulted and he was treated with a boot. He is to weight bear as tolerated currently. Given his functional limitations secondary to the right hemiplegia and pain PT and OT were consulted and he was thought to be a good candidate for rehab. He was then transferred to acute rehabilitation _%#CITY#%_ for further rehabilitation.
PT|physical therapy|PT,|215|217|FINAL DIAGNOSIS|FINAL DIAGNOSIS: Severe osteoarthrosis of her left knee. _%#NAME#%_ _%#NAME#%_ underwent left total knee arthroplasty under spinal anesthesia. She has been doing well postop. She was discharged home with outpatient PT, home CPM and Coumadin checks. We will keep her on an antibiotic for 10 to 14 days total. Revaluation will be made in the office two weeks postop.
PT|physical therapy|PT,|159|161|DISCHARGE MANAGEMENT PLAN|DISCHARGE DIAGNOSES: 1. Urinary tract infection. 2. Atrial fibrillation. 3. Diabetes mellitus. DISCHARGE MANAGEMENT PLAN: The patient is discharged to TCU for PT, OT. The patient is on: 1. Nitrofuradantin 50 mg p.o. b.i.d.
PT|physical therapy|PT|130|131|HOSPITAL COURSE|Arrangements were made for the patient to resume attending adult day care at Ebenezer Day Care Health Center. She was to continue PT at adult day care. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg daily. 2. Calcium carbonate 1250 mg t.i.d.
PT|physical therapy|PT|162|163|IMPRESSION|Will get his home medications and continue those. Will ask neurology to review his antiepileptic regimen and have spoken with Dr. _%#NAME#%_. We will have OT and PT evaluate the patient. Suspect that he may need a TCU versus home with additional services. LABORATORY DATA: That was performed here includes the following laboratory tests.
PT|physical therapy|PT|193|194|HISTORY|She was transferred to acute rehab to improve functional ability. Past medical history (as above). While on rehab, the patient remained clinically stable. Progressed satisfactorily with OT and PT as well as speech therapy. She was seen and followed by PMR staff. Addition of Lasix for increasing blood pressure as well as leg edema.
PT|physical therapy|PT|251|252|DISCHARGE PLAN|DISCHARGE PLAN: She was discharged to home on postoperative day #2 with the following medications, Percocet 1-2 tablets p.o. q. 4-6 hours p.r.n. pain. She was instructed to resume her preoperative medications. She will have home health nurse and home PT evaluation.
PT|physical therapy|PT|206|207|HOSPITAL COURSE|HOSPITAL COURSE: The patient is a 68-year-old woman who was admitted to Fairview University Transitional Services after a total knee arthroplasty which was quite uncomplicated. The patient was treated with PT and OT and was progressively mobilized. She had a low-grade temperature throughout her Fairview University Transitional Services stay that was thought to be due to inflammation.
PT|physical therapy|PT|144|145|DISCHARGE MEDICATIONS|She was transferred to FUTS for further rehabilitation. FUTS COURSE: The patient was stable throughout her rehabilitation course. She underwent PT and OT with improvement in her functional status. She developed some numbness in her leg that was thought to be cutaneous nerve compression.
PT|physical therapy|PT|240|241|PHYSICAL EXAMINATION|Bowel sounds present. No tenderness at this time. GENITALIA: Testes atrophic left not palpable right, no inguinal hernia, penis normal. RECTAL: Deferred. EXTREMITIES: No cervical, axillary or femoral nodes. Femoral pulses present, no DP or PT pulses present. Extremities warm, pink, dry and no edema. Joints without inflammation. NEUROLOGIC: Patellar reflexes unobtainable. Left knee scar present. SKIN: Benign.
PT|physical therapy|PT|151|152|HISTORY|She will be kept on Coumadin as prophylaxis against DVT until rehab is progressing. Right now the calves are benign. Please see the computer for labs, PT and OT values and nursing follow- ups. Complex medical issues are unchanged. She will follow-up. Postop with Dr. _%#NAME#%_ and myself. She had a spontaneous _____ spread to only infection many weeks ago.
PT|physical therapy|PT|171|172|DISCHARGE INSTRUCTIONS|2. Follow up with Dr. _%#NAME#%_, psychiatrist at Park Nicolette Clinic in 2-3 weeks. 3. Fairview Home Care will do home medication management, home safety evaluation and PT evaluation. 4. Please clarify with Dr. _%#NAME#%_ is you are to continue on Lasix and potassium. CONSULTS: Psychiatry, _%#NAME#%_ _%#NAME#%_, MD.
PT|physical therapy|PT,|158|160|DEVELOPMENT|2. Digoxin. 3. Lasix. 4. Reglan. 5. Zantac. 6. Aspirin. ALLERGIES: NO KNOWN DRUG ALLERGIES. DEVELOPMENT: _%#NAME#%_ has delayed development. She receives OT, PT, and speech therapy. Her immunizations include Synagis that she gets monthly. Her diet Nutramigen 28 k calories of bolus feeds of 60 mL 5 times a day and drip feeds 26 mL per hour x9 hours at night.
PT|physical therapy|PT|132|133|DISCHARGE PLANS|He is also to have lab followups on _%#MM#%_ _%#DD#%_ to check his INR and his potassium. Home nursing and home health aid and home PT were all set up for the patient. DISCHARGE MEDICATIONS: 1. Coumadin 5 mg p.o. q. day.
PT|physical therapy|PT.|227|229|BRIEF HISTORY AND HOSPITAL COURSE|In discussing options at disposition, the patient would prefer to go home. This was felt to be okay by Orthopaedics. He was evaluated by PT and they will determine whether or not he would benefit from either home or outpatient PT. DISPOSITION: Discharge to home in stable condition.
PT|physical therapy|PT,|185|187|ASSESSMENT AND PLAN|Will place on empiric alcohol withdrawal protocol. 5. Depression. Patient agrees to Psychiatry and Social Work consults. 6. Hypothyroidism. Will check TFTs. 7. Disposition: Will obtain PT, OT and Social Work consults.
PT|physical therapy|PT|141|142|PLAN|We will ask Neurology to consult. Questioned whether or not the patient may benefit with the addition of Plavix. Neurochecks q. shift. Asked PT and OT to evaluate and treat and start rehab therapy. At this time, we will also order MRI to assess the severity of her stroke.
PT|physical therapy|PT|135|136|DISCHARGE PLANNING|She will need to follow up on the diabetes as an outpatient. DISCHARGE PLANNING: Probably will be discharged to TCU soon. We will have PT and OT see her while here.
PT|physical therapy|PT,|258|260|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: Daily weights; if weight is up by 2 pounds from one day to the next or if 5 pounds within one week please call the Cardiology clinic. He is on a low-salt, low-fat diet. HE IS FULL CODE. He should be up with assistance. He should have PT, OT. He has an appointment with Minnesota Heart Clinic with _%#NAME#%_, Nurse Practitioner, on _%#MMDD#%_, also with Dr. _%#NAME#%_ in Cardiology at the Ridges Clinic on _%#MMDD#%_. He should have his next INR on _%#MMDD#%_ and check daily accordingly.
PT|physical therapy|PT,|182|184|FOLLOW-UP|2. The patient will follow up with Dr. _%#NAME#%_ in the Rheumatology Clinic in 2 to 3 weeks. 3. The patient will be discharged to a nursing home for subacute rehab and will require PT, OT, and Speech Therapy.
PT|posterior tibial|PT|156|157|HOSPITAL COURSE|HOSPITAL COURSE: The patient was admitted for thrombolysis. On hospital day 1, the patient did admit to feeling better. Upon admission the patient's DP and PT were nonpalpable but the PT was dopplerable. Post thrombolysis the patient's DP and PT on the right foot was dopplerable and the right foot was warm.
PT|physical therapy|PT|200|201|PLAN|His primary provider is Dr. _%#NAME#%_ _%#NAME#%_ at Health Partners, _%#CITY#%_ Clinic. Anticipate brief stay if cultures are negative and the patient defervesces with adequate oral intake. Will ask PT to do an assessment.
PT|physical therapy|PT,|215|217|ATTENDING PHYSICIAN|OPERATIONS/PROCEDURES PERFORMED: 1. Mandibular resection and fibular free flap reconstruction on _%#MM#%_ _%#DD#%_, 2006. 2. DP flap on _%#MM#%_ _%#DD#%_, 2006. ATTENDING PHYSICIAN: Dr. _%#NAME#%_. CONSULTS: 1. OT, PT, speech and language pathology, pain consult. 2. Hyperbaric oxygen team at _%#COUNTY#%_ _%#COUNTY#%_ Medical Center. HISTORY OF PRESENT ILLNESS: For full details, please admission H and P.
PT|physical therapy|PT.|244|246|HOSPITAL COURSE|Follow-up chest x-ray showed no pneumothorax. There was still some residual left-sided pleural effusion, which was small in size on the chest x-ray. This was stable on follow-up films. Mr. _%#NAME#%_ was able to ambulate with the assistance of PT. He was able to tolerate a soft diet without any difficulty. He was able to void independently. Mr. _%#NAME#%_ had adequate pain control without the use of any oral pain medications by request.
PT|physical therapy|PT|181|182|ASSESSMENT/PLAN|She is unable to manage at home and I think she is going to need nursing home placement and that may be even long term. She is hopeful that she can be in assisted living. Will have PT and OT work with her and will see where things go. 3. Diabetes, generally well controlled. 4. Hypertension, generally well controlled.
PT|physical therapy|PT|144|145|PLAN|PLAN: 1. The patient reiterates her desire for DNR/DNI status, and this will be continued. 2. Will resume her usual medications. 3. Will obtain PT and OT evaluations and treatment. 4. Social Service evaluation for transitional care unit placement; the patient probably needs long-term care as I believe she is very marginal for continued independent living despite the assisted living.
PT|physical therapy|PT|174|175||X-rays of the knee did not reveal anything specific. The patient was seen by Dr. _%#NAME#%_ and we agreed on continued conservative treatment. The patient was seen by OT and PT and made slow progress. The patient was fitted with a knee brace and seen regularly by Dr. _%#NAME#%_. The patient showed slow but definite improvement from day to day and she was finally able to be discharged on the _%#DD#%_ of _%#MM#%_, to continue treatment as an outpatient.
PT|physical therapy|PT|165|166|HISTORY|Subsequently the patient had an MFR scan which showed some evidence of small vessel disease, previous CVA, but no additional changes. The patient was seen by OT and PT and felt to be unsafe regarding ambulation. During his hospital stay, his diabetic medications were adjusted.
PT|physical therapy|PT|130|131|SECONDARY DIAGNOSES|She will resume all prehospital care plans, diets and medications. Questions were answered. Please refer to the discharge form or PT and OT notes for any specifics.
PT|physical therapy|PT,|160|162|HOSPITAL COURSE|It was recommended that he be maintained on a dysphagia diet 2 with thin liquids due to a positive speech therapy evaluation for aspiration while hospitalized. PT, OT and speech therapy were ordered. DISCHARGE MEDICATIONS: Coumadin 4 mg p.o. q. day. Lovenox 60 mg subq b.i.d. to be discontinued once INR exceeded 2.0, metoprolol 25 mg p.o. b.i.d., to be held for systolic blood pressure less 110, Prilosec 20 mg p.o. q. day, albuterol inhaler 2 puffs q.i.d. p.r.n.
PT|physical therapy|PT|202|203|DISPOSITION|He was also given a one refill option to get it refilled and taken if the erythema has not receded completely at the end of the week. DISPOSITION: Discharge to home with Home Health Care Services, home PT and OT as well as a visiting RN. He is to follow with his primary care physician at the VA within one week to ensure that his cellulitis is improving.
PT|prothrombin time|PT|158|159|OPERATIONS/PROCEDURES PERFORMED|2. _%#MM#%_ _%#DD#%_, 2006, chest x-ray: Stable interstitial disease of the lungs. 3. Mixing study. Results: PT 1:2 INR was 1.30, PT patient INR equals 4.99. PT normal INR equals 1.01. That mixing study was done on _%#MM#%_ _%#DD#%_, 2006. 4. Histone antibody study result, 1.2 (interpretation is inconclusive)
PT|physical therapy|PT|279|280|HOSPITAL COURSE|2. Deconditioning: The patient had seen physical therapy and occupational therapy during her stay, and those two services were recommended a TCU replacement for acute rehab. However, in discussion with the patient and her husband, they elected to be discharged to home with home PT followup. The patient will have this set up upon discharge, and treatment will be up to the evaluation of the home physical therapist and occupational therapist.
PT|physical therapy|PT|211|212|HOSPITAL COURSE|The patient was evaluated by PT and OT. They had advised rehab, but the patient did not want to go there and wanted to try to go back home with a friend. She was discharged to home with home health care and OT, PT evaluation. DISCHARGE MEDICATIONS: 1. Geocillin 382 mg tablets, 2 tablets orally 4x daily for 7 days
PT|physical therapy|PT|204|205|ASSESSMENT/PLAN|___________ anticoagulation with Coumadin, status post exploration of hematoma. He was admitted to acute rehab for reconditioning and rehab, including the PT and OT program. We will obtain a PM and R and PT and OT program. We will continue a tapering dose of Decadron, GI prophylaxis with Zantac. We will follow up blood sugars without coverage. The patient is to follow up in the Neurosurgery Clinic as scheduled.
PT|physical therapy|PT|222|223|PLAN|PLAN: Admission to Obs. Start PT and OT in the morning to ensure that the patient will be safe to go home. Last time TCU was stressed, but the patient was adamant about going home. She will need to go home with outpatient PT and OT as well as home health care as previously ordered.
PT|prothrombin time|PT|151|152|OBJECTIVE|He has a gastrostomy tube present. No inflammation. GENITORECTAL: None indicated. EXTREMITIES: No cervical, axillary or femoral nodes. Femoral, DP and PT pulses normal. Warm, pink, dry, no edema. Ortho normal. Patellar reflexes unable to obtain. SKIN: No lesions. ASSESSMENT: 1. Squamous cell carcinoma metastatic to cervical lymph nodes with primary possibly involving nasopharynx but not documented.
PT|physical therapy|PT,|132|134|PROCEDURE PERFORMED|He has a tube feeding which he is getting all his nutrition for. He has been able to get up with physical therapy. He is working in PT, OT and speech and his Parkinson's medicines have been adjusted to 25:100 1 1/2 tablets every 6 hours. The patient will be discharged to home, he will follow up with Dr. _%#NAME#%_ in 3-4 weeks regarding the liposarcoma.
PT|posterior tibial|PT|177|178|PHYSICAL EXAMINATION|BREASTS, PELVIC, RECTAL: Not done. EXTREMITIES: There is some slight calf tenderness bilaterally. I do not see any pitting edema. There is a strong right DP pulse and a 2+ left PT pulse. Skin is intact. No rashes. LABORATORY DATA: Hemoglobin and white count are normal.
PT|physical therapy|PT|185|186|ASSESSMENT AND PLAN|Start Flagyl 500 mg t.i.d. 6. Malnutrition. Continue the patient on TPN and lipids and advance diet as tolerated. 7. GI prophylaxis. Will continue Protonix. 8. Deconditioning. Will get PT to evaluate and treat the patient.
PT|physical therapy|PT|184|185|MEDICATIONS|X-ray would reveal a stable peri-acetabular fracture. This was evaluated by Dr. _%#NAME#%_ of orthopedics who felt this was a stable fracture and that he could weight bear and advance PT as tolerated.
PT|physical therapy|PT|135|136|IMPRESSION|The patient is clinically dehydrated on her physical examination. We will start some gentle IV fluids. Also check a UA and UC. We will PT and OT see her for further assessment. Will check an echocardiogram to rule out significant aortic stenosis which could be contributing to her dizziness.
PT|physical therapy|PT|111|112|PLAN|PLAN: Will try to arrange for short-term nursing home stay or perhaps with enough help she can be at home. OT, PT will be doing an evaluation in helping to decide that. I think we should limit her long-acting narcotics to 1 agent, so will increase her oxycodone CR to 2 q.12 hours and discontinue her fentanyl.
PT|physical therapy|PT|162|163|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|He was immediately ambulatory and most difficult part of his admission was pain control. On _%#DDMM2007#%_ he was in and out of bed on his own and was cleared by PT for discharge home. He was fitted for TLSO brace and was using this. His incision was without erythema, and he had a normal neurologic examination.
PT|physical therapy|PT|176|177|HOSPITAL COURSE|During her hospital stay, the patient's mood improved dramatically, and physical therapy, occupational therapy, and orthotics consults were obtained. The patient did well with PT and OT. Orthotics has arranged for the patient to receive an ASO for her left footdrop. After finding out the diagnosis of brain cancer, plasma exchanges were discontinued.
PT|physical therapy|PT|228|229|DISCHARGE MEDICATIONS|Nexium 40 mg p.o. b.i.d. 10. Augmentin 250/125 mg 1 tablet p.o. b.i.d. for 3 days and discontinue. The patient was recommended to go to a TCU, however, she is refusing and, therefore, will try to set up with home care, probably PT and OT.
PT|physical therapy|PT,|162|164|PLAN|5. Continue PPI at this time. 6. Transfuse to hemoglobin greater than 8.5. 7. Potassium protocol. 8. When the patient's hemoglobin is improved will continue with PT, OT.
PT|physical therapy|PT|156|157|IMPRESSION|At this point, I see no compelling reason to look for hypercoagulable states or other underlying processes which could be driving her DVT I will ask OT and PT to see the patient tomorrow. We should also check a UA, UC and check place her on the delirium protocol. Her blood pressure now is creeping up into the 160s and 170s and we will place her on empiric metoprolol intravenously with holding parameters.
PT|physical therapy|PT|168|169|SOCIAL HISTORY|Generally lives with his wife and a fairly sedentary lifestyle. He has been in the _%#CITY#%_ Care Center since discharge from the hospital here in _%#MM#%_ undergoing PT and OT and has not been strong enough to return home yet. ALLERGIES: NONE KNOWN. CURRENT MEDICATIONS: 1. He is on a prednisone taper would appear to be down to 1 mg a day
PT|physical therapy|PT,|138|140|PLAN|6. Foley catheter will be left in tonight given urinary retention noted in the emergency room, post void residual greater than 500 cc. 7. PT, OT for ADLs low back pain evaluation in the morning. 8. This patient does need a flexible sigmoidoscopy and/or anoscopy to rule out the possibility of a low obstructing lesion.
PT|physical therapy|PT|583|584|DISCHARGE MEDICATIONS|The patient at present will be discharged on his usual medications which include: DISCHARGE MEDICATIONS: Aricept 5 mg daily, Avandia 8 mg daily, glipizide 10 mg b.i.d., Crestor 10 mg daily, Zetia 10 mg daily, lisinopril 5 mg daily, Aggrenox 200/25 one orally b.i.d., Neurontin 100 mg at bed-time, Lantus 26 units insulin subcu daily, Ocuvite one daily, vitamin D 400 units daily, vitamin C 500 mg daily, Vicodin one orally q.4 hours p.r.n. for pain, high-dose sliding scale insulin coverage with Accu-Cheks q.i.d., Metamucil 2 teaspoons in water or juice daily. He is to have OT and PT at the TCU and will hopefully improve enough to possibly be discharged in the next 2 weeks with a followup appointment to see me in 2-3 weeks.
PT|posterior tibial|PT|219|220|EXTREMITIES|Femoral, DP and PT pulses are normal. Stool guaiacs in the emergency room were checked and were negative. Gastrostomy tube was negative for blood. EXTREMITIES: Warm, pink and dry; no edema. Patellar reflexes 2+. DP and PT pulses reduced. ORTHOPEDICS: Normal. SKIN: Without lesions. ASSESSMENT: 1. Anemia, probably chronic. 2. High INR due to stopping his vitamins.
PT|prothrombin time|PT|190|191|LABS|She also has a dermatitic rash on bilateral elbows. Neurologic: Intact, with nonfocal signs. LABS: CBC has a white count of 4.1, hemoglobin of 13.1, with a normal differential. INR is 0.95, PT is 29, chem 7 is within normal limits, with a BUN of 14, a creatinine of 0.6, and a sodium of 144. Her type and screen is O positive. She is guaiac positive in the ER.
PT|physical therapy|PT.|146|148|ASSESSMENT AND PLAN|I think he is at high risk to fall as he has some difficulty simply standing here in the office. Will have him started on antibiotics, see OT and PT. I will ask the surgeons to see him and make plans from there. 2. History of hypertension; follow. 3. History of benign prostatic hypertrophy; continue medications.
PT|prothrombin time|PT|174|175|PAST SURGICAL HISTORY|15. Tylox 1 to 2 tablets q.4-6h. as needed orally for pain. 16. Coumadin 1 mg q.o.d. to start on _%#MM#%_ _%#DD#%_, 2002 and the dosage needs to be adjusted based on INR and PT values. 17. Prednisone 25 mg q.d. until _%#MM#%_ _%#DD#%_, 2002; then reduce to 15 mg q.d. from _%#MM#%_ _%#DD#%_, 2002 to _%#MM#%_ _%#DD#%_, 2002; then further reduced to 10 mg q.d. from _%#MM#%_ _%#DD#%_, 2002 to _%#MM#%_ _%#DD#%_, 2002; then maintain at 5 mg q.d. after that.
PT|physical therapy|PT|145|146|DISCHARGE DIAGNOSIS|4. Hypertension. Blood pressures high end of normal of felodipine 5 mg p.o. q.d. 5. Physical therapy and occupational therapy were completed per PT and OT. 6. Low back pain. The patient developed complaints of low back pain, primarily on the right side. LS spine x-rays were obtained which indicated spondylosis, scoliosis, and disk disease on the lumbar spine.
PT|physical therapy|PT|125|126|PHYSICAL EXAMINATION|The patient continued to do well after that and was placed on medication for his leg pain. His CK's were also normal. OT and PT was consulted, and he again continued to do well and improved with their help. On _%#DDMM2002#%_, however, the patient had a worsening of his thigh and leg pain.
PT|posterior tibial|PT|130|131|OBJECTIVE|Inguinal creases have slight erythema under the fat folds. No cervical, axillary or femoral nodes. Femoral pulses present. No DP, PT palpable EXTREMITIES: Warm, pink dry. Has an IV in the right ankle. ORTHO: No inflammation. NEURO: Reflexes intact. SKIN: No other lesions other than rash.
PT|physical therapy|PT|142|143|SYNOPSIS OF HISTORY AND PHYSICAL|IV fluids were decreased. The chest x-ray showed developing infiltrate on the left mid and lower lung. On _%#DDMM2002#%_ the patient also had PT and OT evaluation done. At 3:45 p.m. the patient also had a speech evaluation done and they recommended stage 2 diet, pureed and thin liquids.
PT|physical therapy|PT|89|90|DISCHARGE PLANS|He has an INR check on _%#DDMM2002#%_. The patient will receive Fairview Home Care, with PT home safety evaluation. There should be no pending labs or studies at the time of discharge.
PT|physical therapy|PT|148|149|DISCHARGE PLANS|4. Increase celexa to 40 mg p.o. q.d. in the a.m. 5. Continue Xanax 0.5 mg p.o. q.d. p.r.n. 6. Decrease Decadron to 4 mg p.o. q.d. 7. Ambulate with PT b.i.d. 8. Levaquin 500 mg p.o. q.a.m. 9. Discontinue Rocephin in the a.m. 10. Continue Prevacid 30 mg p.o. q.d. 11. Lovenox 40 mg subcutaneously q.d. 12. Bactrim DS one tablet p.o. b.i.d. Saturday and Sunday only.
PT|physical therapy|PT,|148|150|DISCHARGE DIAGNOSES|He may wish to either change, adjust, or discontinue any pain medicines at that time and reassess if any nausea still exists. 3. She will have home PT, OT, and a home health aide. 4. The patient has been instructed and encouraged to use ice frequently for her left knee discomfort, as this seems to afford her the most relief.
PT|physical therapy|PT|424|425|DISCHARGE DIAGNOSES|FOLLOW UP: The patient will follow up with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2003, at 1:30 p.m. She will have a CT scan of the abdomen on _%#MM#%_ _%#DD#%_, 2003, at 8:30 a.m. Outpatient labs including comprehensive metabolic panel, CBC, diff, and platelet, INR, and PTT will be drawn when she sees Dr. _%#NAME#%_. Fairview TLC Homecare will follow for PICC dressing changes. QuickPoint teaching, IV antibiotic teaching, PT and home health aide, home equipment including a wheelchair, a bedside commode, a walker, and tub transfer will be delivered to her home.
PT|posterior tibial|PT|150|151|PHYSICAL EXAMINATION|No tenderness. GENITAL/RECTAL: Deferred. EXTREMITIES: Legs reveal severe 4+ or more pre-tib pitting, all the way up to below the knee. Otherwise, DP, PT and popliteal pulses are 3/4+. He has the site medial right calf of the graft from his coronary artery bypass graft.
PT|physical therapy|PT|160|161|HOSPITAL COURSE|Patient did have normal return of his bowel function. On discharge he was tolerating a regular diet, normal bowel function, and ambulating several times a day. PT and OT was involved with the patient and it was decided that he should go to rehab for further rehabilitation.
PT|physical therapy|PT|188|189|HOSPITAL COURSE|This showed atrophy, mild nonspecific white matter change, likely chronic small vessel ischemic disease and no evidence of a recent infarct. The patient was seen in consultation by OT and PT and did quite well with plan to discharge her to an acute rehab center before eventually going to live with her daughter.
PT|prothrombin time|PT|238|239|LABORATORIES|Total bilirubin 0.6, direct 0.1. Alkaline phosphorus 58, total protein 7.8, albumin 5.1. Uric acid is 4.6, LDH is 138. Chemistry: Sodium 146, potassium 3.8, chloride 109, bicarb 23, BUN 7.5, creatinine .8, glucose 97, calcium 9.9, Coag's PT 13.6, INR .97, PTT 26.8, fibrinogen 388, immunoglobulins, immunophenotyping are pending. ASSESSMENT: Hodgkin's disease. DISCUSSION: Thirty-nine-year-old female with a recent diagnosis of Hodgkin's disease, non-sclerosing, Stage 2B.
PT|physical therapy|PT|159|160|HOSPITAL COURSE|2. Multiple Sclerosis. This was evaluated by Dr. _%#NAME#%_ and the patient did not require treatment for her Multiple Sclerosis during her stay. She did have PT and OT evaluation and treatment. DISCHARGE MEDICATIONS: Discharge medications and dosages per chart.
PT|physical therapy|PT,|125|127|DISCHARGE AND FOLLOW-UP PLAN|Dr. _%#NAME#%_ may then follow the patient's calcium/metabolic values as he sees fit. 3. The patient will be discharged with PT, OT, speech therapy, social worker, and home RN. 4. Family has agreed that the patient will go to daughter's home over the weekend, and they will check on him at least every 24 hours.
PT|physical therapy|PT|340|341|SUMMARY OF HOSPITAL STAY|Because her pain seemed to be persistent, Orthopedics were again requested to come see her, and they recommended Vioxx as needed for pain relief, as well as possibly an outpatient consultation with Dr. _%#NAME#%_, who is a spinal surgeon, to consider treatment of the compression fracture. Follow-up was as above. She had met enough of her PT and OT goals to go home safely.
PT|physical therapy|PT|149|150|HOSPITAL COURSE|PT and OT consults were obtained and they felt the patient would benefit. However, because of his mentation, he was unable to cooperate with intense PT and OT. He will likely need further PT and OT upon discharge to the skilled nursing care facility. He is to ambulate with assistance. 3. CHF. Given his dehydration, his Lasix was held.
PT|physical therapy|PT|163|164|PLAN|3. Neurology consultation for further workup of his syncopal episodes. 4. CT scan of brain without contrast and EEG in a.m. 5. Continue outpatient medications. 6. PT and OT evaluations once the etiology for syncope is noted or neuro/cardiovascular causes are ruled out. 7. The patient will be seen in the a.m. by Dr. _%#NAME#%_ _%#NAME#%_ as well as the consultants as noted above.
PT|posterior tibial|PT,|164|166|PHYSICAL EXAMINATION|ABDOMEN: Liver 10 cm height by percussion. Scaphoid. No LKKS, mass or tenderness. Normal bowel sounds. No bruit. LEGS: Excellent nutrition. No pretibial edema. DP, PT, popliteal and femoral pulses 4/4+. RECTOPELVIC: Deferred. IMPRESSIONS: 1. Severe acute onset of headache, left greater than right, occipital, neck up to crown, onset _%#DDMM2003#%_.
PT|physical therapy|PT|203|204|ASSESSMENT AND PLAN|X-ray of the L spine is negative. ASSESSMENT AND PLAN: Intractable low back pain with intermittent pain on and off for two months since fall. The patient will be admitted for pain control. She will have PT evaluation and treat. We will get her on a muscle relaxant to try to help calm some of this spasm. We will have her ice for 30 minutes several times.
PT|physical therapy|PT.|149|151|PROCEDURE|The patient was transferred to post anesthesia care unit and later taken to the floor. The patient's stay was uncomplicated and the patient received PT. The patient was discharged to TCU on _%#DDMM2004#%_.
PT|posterior tibial|PT|138|139|OPERATIONS/PROCEDURES PERFORMED|There was a small hematoma at the right groin of less than 1 cm, and no bruit was appreciated. His distal pulses of both the right TP and PT site were +4/4. The laboratories showed a white count of 7900, hematocrit 42.6, platelet count of 253,000. His potassium was 3.9. BUN and creatinine were 10 and 0.8, respectively, and his troponin-I was slightly elevated at 0.47. His electrocardiogram was completely normal.
PT|physical therapy|PT|161|162|HOSPITAL COURSE|She was on TPN for some time and transferred over here for pain management, TPN and to begin her p.o. diet, as well as deconditioning. She did meet the goals of PT and OT rapidly. She frequently did go outside to smoke. Her pain control has been adequate and decreasing. Consequently, I have been able to decrease her Fentanyl, as well as her Dilaudid.
PT|prothrombin time|PT,|184|186|HOSPITAL COURSE|Dr. _%#NAME#%_ was the staff that attended this delivery. Patient also had a complete blood work up for etiology for a second trimester loss. This included a UTOX, CBC with platelets, PT, and PTT, Kleihauer-Betke, serum glucose, hemoglobin A1c, TORCH titer, FANA, lupus anticoagulant, and anticardiolipin antibodies, a CMV titer as well as Parvovirus, and type and screen performed.
PT|physical therapy|PT|125|126|ASSESSMENT/PLAN|2. Weakness. This is secondary to pneumonia, we will have PT/OT. Family hopes to be able to take him home possibly with home PT as needed, as he does have a daytime caregiver. 3. Tinea pedis. I will treat him with ketoconazole cream to his feet.
PT|physical therapy|PT,|199|201|HOSPITAL COURSE|She further states that her mother has had psychiatric problems throughout her life and is not really able to care for herself. The patient was admitted. She was started on Levaquin 500 mg IV a day, PT, OT were consulted. Additionally psychiatric consultations were obtained. Please see separately dictated notes in this regard. The patient did gradually improve and was felt most prudent that she go to an adult psychiatric center.
PT|physical therapy|PT,|253|255|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 72-year-old gentleman who underwent an elective left total knee arthroplasty on _%#MM#%_ _%#DD#%_, 2005. Postoperatively, his course was without significant complications, yet with participation in OT and PT, he was unable to transfer and ambulate, and was dependent with ADLs, so he was admitted to the acute inpatient rehab unit on _%#MM#%_ _%#DD#%_, 2005.
PT|UNSURED SENSE|PT.|234|236|SOCIAL HISTORY|FAMILY HISTORY: Significant for hypertension in her father. There is no family history of breast cancer. SOCIAL HISTORY: She is married. She has two living children. She works for Check Point Security system, HR benefits coordinator, PT. She does not smoke. She drinks wine two to three times a week. MEDICATIONS: Flonase as needed. She takes a variety of vitamins.
PT|physical therapy|PT|122|123|HOSPITAL COURSE|4. Alzheimer disease. He does have evidence of some confusion that has continued through the hospital stay. He had OT and PT evaluations done; they recommended home care with PT home safety evaluation. DISCHARGE MEDICATIONS: 1. Glipizide ER 20 mg p.o. daily.
PT|physical therapy|PT|189|190|DISCHARGE MEDICATIONS|He recovered uneventfully from that but was transferred to FUTS for ongoing rehabilitation due to his increased weakness after his respiratory infection. FUTS course: The patient underwent PT and OT. He was medically stable throughout his time in FUTS. He showed improvement in his functional status and was therefore discharged home for ongoing followup with his wife, primary physician, and neurologist, Dr. _%#NAME#%_.
PT|physical therapy|PT|232|233|ASSESSMENT/PLAN|5. Tobacco use. The patient encouraged at length to quit smoking as this does not help with his issues of recurrent clotting. 6. Dyspnea on exertion. Probable deconditioning. Lung exam clear and O2 sats 100% on room air. Will start PT for strengthening. 7. Weight loss/nutrition consult. 8. HIV. Will continue highly active antiretroviral therapy. 9. Left upper quadrant pain.
PT|physical therapy|PT,|161|163|HOSPITAL COURSE|Her heart rate was controlled, she felt near her baseline. She had PT and OT evaluations done, which recommended either a short-term rehabilitation stay or home PT, OT. She is considering moving to more of an assisted living from her house. DISCHARGE MEDICATIONS: 1. Diltiazem CD 120 mg p.o. daily.
PT|physical therapy|PT,|174|176|ASSESSMENT|Will do Duonebs. Levaquin has been started as well as prednisone. Will continue both of those, prednisone in a tapering fashion. Advised against smoking, offered assistance. PT, Social Service evaluations. Begin Advair. Dr. _%#NAME#%_, our hospital physician, will follow.
PT|physical therapy|PT|169|170|PLAN|Dr. _%#NAME#%_ advised that the patient should consider being seen at the Mayo Clinic as an outpatient regarding her unusual condition. The patient will be evaluated by PT and OT to assess for safety. Most likely, she will be transferred to the floor tomorrow pending no changes in neurological status.
PT|physical therapy|PT,|180|182|PLAN|I will hydrate her with normal saline. I will also give her Kayexalate for the hyperkalemia. I will put her on Maxzide for hypertension with holding parameters. I will also obtain PT, OT consult. I will check her fingersticks, as she is on steroids. Dr. ________ has left a message for the neurologist on call regarding the patient's admission to the hospital.
PT|physical therapy|PT|175|176|DISCHARGE MANAGEMENT PLAN|DISCHARGE DIAGNOSES: 1. Ataxia, multifactorial. 2. Chronic atrial fibrillation. 3. Hypertension. DISCHARGE MANAGEMENT PLAN: The patient is discharged to transitional care for PT and OT. DISCHARGE MEDICATIONS: 1. Warfarin, which will be at 2.5 mg daily.
PT|physical therapy|PT,|157|159|HOSPITAL COURSE|All suggested further cares. The patient does not want to go to a nursing home. She does have PCAs at home. We will continue with their help as well as home PT, OT and Speech Path referrals. 7. Hepatitis C. The patient's LFTs were elevated chronically. She did have a slight rise in her total bilirubin, likely related to the acute alcoholic episode.
PT|physical therapy|PT|253|254|SOCIAL HISTORY|The patient's pain improved daily, and 24 hours prior to discharge the patient has only required 2 doses of oxycodone for breakthrough pain and was able to tolerate walking with her walker during therapies. The patient will be discharged home with home PT and OT to evaluate, Social Work did assist in attempts to get a stair-lift for the granddaughter's home. 2. Cardiovascular with atrial fibrillation. The patient was continued on digoxin.
PT|prothrombin time|PT,|194|196|PRIMARY CARE PHYSICIAN|A CAT scan was performed. A renal cyst was identified but there is no other abnormal lesions in the abdomen. Other lab tests were ordered including comprehensive metabolic panel, CBC with diff, PT, INR, amylase, lipase, C-reactive protein. Iron, TIBC, ferritin, alpha 1 antitrypsin, serum alpha 1 antitrypsin phenotype ceruloplasmin, antimitochondrial antibody, immunoglobulins, smooth muscle antibody, antinuclear antibodies and celiac sprue panel.
PT|physical therapy|PT|176|177|HOSPITAL COURSE|Her laboratory studies were followed closely. She was given diuresis. Her chest tubes were removed at which time the output had diminished. She underwent therapy consisting of PT and OT. A speech pathology evaluation was obtained and a dysphagia level 1 diet was recommended. A pulmonary consult was then obtained and the patient was felt to be close to her baseline.
PT|physical therapy|PT|156|157|DISCHARGE AND FOLLOW UP PLANS|5. He will have Fairview Home Care to do an RN evaluation in regards to his medications and oxygen and overall independent functioning. He will also have a PT and OT evaluation. 6. He needs to have a basic metabolic panel drawn _%#DDMM2006#%_ at home and called to Dr _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ nurse _%#NAME#%_ _%#NAME#%_ at _%#TEL#%_ tomorrow.
PT|physical therapy|PT,|237|239|PLAN|PLAN: Will obtain old records, MRI and ask interventional radiology if she is a possible candidate for vertebroplasty for definitive treatment. Otherwise, will continue with her current medications, start a Medrol Dosepak. Will also ask PT, OT and social services to evaluate and treat. May need short-term nursing home care.
PT|physical therapy|PT,|131|133|ASSESSMENT AND PLAN|4. Dementia; I question whether she has dementia. I think she needs a psychiatric evaluation. She will need placement and probably PT, OT evaluations as well. 5. Hypertension; we will watch her blood pressures; if they start to be elevated we will then treat. 6. Tobacco dependence. Smoking cessation. Part two job
PT|physical therapy|PT,|165|167|DISCHARGE INSTRUCTIONS|This has been done at the hospital for the last two days and seems to have work well. DISCHARGE INSTRUCTIONS: Discharge diet is 1800 calorie ADA diet. We have asked PT, OT and Speech Therapy to evaluate and work with the patient. DISCHARGE MEDICATIONS: 1. Colace 100 mg p.o. b.i.d.
PT|physical therapy|PT|179|180|DISCHARGE AND FOLLOW-UP PLANS|3. Follow up with Dr. _%#NAME#%_, Renal Service at the University of Minnesota Medical Center, Fairview, in 1-2 weeks. The patient is to make this appointment. 4. She will have a PT and an OT evaluation at home. 5. She should have an abdominal CAT scan in 3 months to follow up on her abdominal pain.
PT|physical therapy|PT,|142|144|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: 1. Patient is Full Code status. 2. Activity and weightbearing as tolerated. 3. C. difficile precautions if needed. 4. PT, TO to evaluate and treat at the nursing home. 5. Accu-Chek q.i.d. FOLLOW-UP APPOINTMENTS: 1. Dialysis at the _%#CITY#%_ Dialysis Unit on a Monday-Wednesday-Friday basis as previously scheduled.
PT|prothrombin time|PT|214|215|LABORATORY DATA|Blood cultures pending. Basic metabolic with sodium 144, potassium 4.3, chloride 103, bicarb 33, BUN 30, creatinine 1.23, glucose 166, calcium 8.9. CBC with white count 15.2, hemoglobin 13.2, platelets 310. INR 1, PT 34, BNP elevated at 294, troponin elevated at 1.31, myoglobin normal at 51. EKG demonstrates sinus rhythm at 77 with normal axis and intervals and no change from previous.
PT|physical therapy|PT|213|214|HOSPITAL COURSE|Problem #6. Physical therapy: The patient had physical therapy during this stay on our service due to ataxic gate and inability to walk initially. He was steady with walker before going to MI/CD. He needs further PT care over there. DISPOSITION: Mr. _%#NAME#%_ was stable on _%#DDMM2006#%_ and we are trying to transfer him to MI/CD.
PT|physical therapy|PT,|177|179|FUNCTIONAL HISTORY|She does have a daughter in the area. FUNCTIONAL HISTORY: Prior to admission, she was being seen by me in my Physical Medicine and Rehabilitation Clinic where I had recommended PT, to and speech/language pathology. She had been walking inside the house without any assistive devices and doing activities of daily living.
PT|physical therapy|PT|257|258|ASSESSMENT|3. High alkaline phosphatase. We will follow up with repeating that and also would do right upper quadrant ultrasound to make sure there is no gallbladder disease. 4. General weakness, most likely secondary to age and multiple medical problems and continue PT and OT and monitor patient's improvement. At this time the patient meets criteria for transfer to skin care unit for evaluation and treatment.
PT|physical therapy|PT|213|214|HOSPITAL COURSE|Patient to have total knee surgery on the left, did not want to start any injection therapy at this time. She will follow-up with her orthopedic surgeon regarding this. Outpatient therapies were suggested for OT, PT and Speech. TODAY'S EXAM: VITAL SIGNS: Blood pressure 127/79, respirations 16, pulse 67, temperature 98, 95% sats on room air.
PT|physical therapy|PT|179|180|DISCHARGE MEDICATIONS|She is requested to follow up with Dr. _%#NAME#%_ in clinic in 2 weeks with a chest x-ray before that appointment. She will continue her home oxygen and I am also requesting home PT to evaluate and treat her as clinically indicated.
PT|physical therapy|PT.|173|175|TCS COURSE|She was in stable condition other than for blood sugar elevation and was transferred to Transitional Care Services for ongoing care. TCS COURSE: The patient received OT and PT. She had adjustment of her oral hypoglycemic program to bring her diabetes under control. Her pain was brought under control with a combination of OxyContin and oxycodone.
PT|physical therapy|PT|129|130|ASSESSMENT/PLAN|Regarding her hip pain I will plan on using oral OxyContin and oxycodone and p.r.n. Dilaudid. Tomorrow I plan on starting her on PT and OT. 2. Possible splenomegaly with an enlarged lymph node. I will do a peripheral smear and noncontrast CT scan of her abdomen and likely an FNA of her lymph node also an SPEP and UPEP for multiple myeloma.
PT|physical therapy|PT,|154|156|DISCHARGE PLAN|7. She is to be repositioned every 1 hours. 8. She is to follow up with Dr. _%#NAME#%_ in Neurosurgical Clinic in 2 weeks. 9. She is to receive extensive PT, OT and speech therapy. 10.Infectious disease clinic for follow-up in 4 weeks. DISCHARGE MEDICATIONS: 1. Prednisone 5 mg p.o. daily. 2. Multivitamin one tablet p.o. daily.
PT|physical therapy|PT|96|97|DISCHARGE PLAN|22. Albuterol two puffs every four hours p.r.n. for shortness of breath. DISCHARGE PLAN: OT and PT to evaluate and treat the patient. CODE STATUS: The patient is do not resuscitate, do not intubate.
PT|physical therapy|PT|231|232|HOSPITAL COURSE|He is using his crutches to increase his distance. Will go outside to work on uneven surfaces today. As noted, has difficulties with stairs, fatigues after 4 stairs. Probable discharge _%#DDMM2006#%_. May suggest one home visit by PT after discharge. Discussed his need for home IV therapies today. The patient will go to the Learning Center to make sure he understands the IV therapies.
PT|physical therapy|PT|214|215|ASSESSMENT  AND PLAN|Given the patient does have atrial fibrillation, a sub therapeutic transvenous ischemic attack could have occurred. At this point we have a negative head CT, unable to do an MRI because of his pacemaker. I will do PT and OT and certainly watch her further neurologic events. At this point, however, I believe TIA is unlikely. His confusion is probably related to urinary tract infection or possibly developing sepsis.
PT|physical therapy|PT,|148|150|DISCHARGE MANAGEMENT PLAN|2. Severe emphysematous lung disease. 3. Dementia. 4. Chronic alcoholism. DISCHARGE MANAGEMENT PLAN: _%#NAME#%_ _%#NAME#%_ is discharged to TCU for PT, OT and chemical dependency evaluation and treatment. DIET: Low-fat. ACTIVITY: As tolerated. DISCHARGE MEDICATIONS: 1. Albuterol MDI 2 puffs q.i.d. as needed for shortness of breath.
PT|physical therapy|PT,|123|125|DISCHARGE  MANAGEMENT PLAN|3. Cardiac myopathy with chronic congestive heart failure. DISCHARGE MANAGEMENT PLAN: The patient is discharged to TCU for PT, OT and speech therapies. She is on a dysphagia level 1 diet. DISCHARGE MEDICATIONS: Chronic medicines of 1. Lipitor 20 mg daily, 2. Digoxin 125 mcg daily, for a fib and cardiac myopathy.
PT|physical therapy|PT|199|200|ASSESSMENT/PLAN|6. Deep venous thrombosis prophylaxis. The patient does have limited mobility because of her previous left MCA infarct. Therefore she is certainly at increased risk for DVT. Would recommend SCDs and PT and OT postoperatively to increase mobility. Strongly suspect Lovenox would be contraindicated in this setting. However, will defer to Neurosurgery.
PT|physical therapy|PT|214|215|HOSPITAL COURSE|A Foley Catheter was placed. He was transferred to acute rehabilitation for further rehabilitation. HOSPITAL COURSE: Following admission to acute rehabilitation on _%#DDMM2007#%_. He did fairly. He participated in PT OT. OT b.i.d. and showed good progress. Right hip dislocation and acetabular fracture, status post ORIF. On _%#MMDD#%_ his incision at the time of discharge was clean dry and intact.
PT|physical therapy|PT.|141|143|HOSPITAL COURSE|She tolerated the surgery well and was transferred to transitional care unit for rehabilitation HOSPITAL COURSE: The patient received OT and PT. She tolerated this well. She was able to improve over the course of her stay her mobility. She was discharged home to continue home physical therapy to be followed by followed by Dr. _%#NAME#%_ as an outpatient.
PT|physical therapy|PT|435|436|HOSPITAL  COURSE|Secondary to his other chronic medical processes including a previous CVI with dementia, obesity, coronary disease, osteoarthritis the patient was no longer able to care for himself and had lost his abilities in the activities of daily living. The patient was seen and evaluated by physical therapy, occupational therapy and social service and it was determined the most appropriate situation would be transitional care with continued PT and OT to try to regain skills in the activities of daily living and ambulation. The patient is transferred to a TCU for this. The patient additionally had periods of sedation and some mild agitation; this is related to the previous CVI and dementia and possibly underlying developing senile dementia of the Alzheimer's type.
PT|physical therapy|PT|142|143|DISPOSITION|4. Divalproex ER 2000 mg p.o. each day at bed-time. 5. Tylenol 650-975 mg p.o. q.4-6h. p.r.n. pain. DISPOSITION: Discharge to TCU for further PT and OT. She was assessed by PT and felt that she would benefit from a wheeled walker with chair. She is to continue psychiatric and CD treatment for her bipolar disorder, severe anxiety and prescription drug abuse from a CD standpoint.
PT|physical therapy|PT|177|178|PRINCIPAL  PROCEDURES|4. Chest x-ray which showed interstitial infiltrates, likely secondary to pulmonary edema. 5. Medication titration for blood pressure control. 6. Cardiac rehab consultation. 7. PT and OT consultation. REASON FOR ADMISSION: Please see dictated history and physical.
PT|physical therapy|PT,|314|316|DISCHARGE RECOMMENDATIONS|Please the hospitalists' discharge summary for further medical information regarding the patient as this discharge summary addressed only the rehabilitation aspects of his acute rehabilitation stay. DISCHARGE RECOMMENDATIONS: 1. The patient is transferred to skilled nursing facility. 2. Fairview Lakes Home Care, PT, OT, Speech and Language Pathology as well as Home Health assistance has been setup. 3. Followup appointment with Neurosurgery to re-evaluate cervical spine setup.
PT|physical therapy|PT|168|169|DISCHARGE INSTRUCTIONS|Other problems are stable. The patient was continued with her all other medications. DISCHARGE INSTRUCTIONS: Discharge home, activity as tolerated with continuation of PT and OT. Diet 1800 calorie ADA, low-salt, low-fat diet. Follow up with Dr. _%#NAME#%_ _%#NAME#%_ at Fairview _%#CITY#%_ _%#CITY#%_ Clinic in 1 week or sooner if worse.
PT|physical therapy|PT.|170|172|HOSPITAL  COURSE|She was seen by occupational and physical therapy who felt the patient would benefit from further physical therapy in a TCU versus home with 24 hour observation and home PT. Beds were not available at the Minnesota Masonic Home which is the only TCU site the patient wished to consider. I discussed the case with patient's daughter, _%#NAME#%_, who assured me that she would be able to stay with the patient over the next 3-4 days at least while further assessment was undertaken.
PT|physical therapy|PT|153|154|DISCHARGE DISPOSITION|DISCHARGE DISPOSITION: Patient was discharged to TCU for continued rehabilitation. The patient should be on a low-salt, low-fat diet. Should have OT and PT evaluate. HOSPITAL COURSE: 1. Left pubic ramus fracture. The patient's pubic ramus fracture improved with conservative pain management on Percocet.
PT|physical therapy|PT|234|235|PROBLEM #5|Physical therapy did some teaching and developed a home exercise program for _%#NAME#%_ that he can continue during this next week at home. When he is re-admitted on the _%#DD#%_, we will reassess his foot pain and gait and reconsult PT as necessary. Overall, the paresthesias have improved. The main issue now is with walking. DISCHARGE MEDICATIONS: 1. Bactrim DS 1 tab p.o. twice a day, Monday and Tuesday.
PT|physical therapy|PT|224|225|HOSPITAL COURSE|At L1, there is a lesion that is consistent with an atypical hemangioma in the vertebral body. L3-5, L4-5, L5-S1 showed disk dehydration, L4-5 herniation, L5-S1 herniation with caudal extension, all unchanged from previous. PT evaluated and treated the patient while in the hospital. Orthopedic spine surgery evaluated the patient and recommended an epidural steroid injection at L5-S1.
PT|physical therapy|PT|139|140|IMPRESSION/PLAN|We will repeat the TEE, check an electrocardiogram and a sedimentation rate. 2. Weakness, generalized, likely secondary to #1. We will use PT and OT. 3. Urinary tract infection. This may be secondary to endocarditis with seating to the bladder. Vanco and gent as above. 4. Abdominal pain, acute and chronic, mild.
PT|physical therapy|PT|138|139|PERTINENT RADIOLOGICAL EXAMINATIONS|Unfortunately, the patient is more stiff with decreased activity secondary to his parkinsonism, so this may limit or slow his progress in PT and OT. 3. Constipation. This is controlled. 4. Pain control secondary to the right hip ORIF and fracture. Pain control is adequate at this time. We will continue to monitor and make changes as needed.
PT|prothrombin time|PT|212|213|EXAMINATION|Chest x-ray - reveals a right lower lobe pneumonia, questionable cardiomegaly. Electrolytes were within normal limits. BNP 73, myoglobin normal, troponin was normal. White count 10.7 with hemoglobin 14.0. Normal PT and PTT. We will admit the patient to ICU on a nitro drip as chest pressure has been relieved.
PT|physical therapy|PT|164|165|HOSPITAL COURSE|5. Diabetes. 6. Hypertension. 7. Deconditioning. The patient due to a prolonged hospitalization did develop quite severe deconditioning and will be transferred for PT and OT to _%#CITY#%_ Care Center. 8. Anemia and GI bleed. The patient did have some guaiac positive stools during this hospitalization, and her anemia was felt to be secondary to this as well as her pseudoaneurysm as well as her renal insufficiency.
PT|physical therapy|PT|150|151|PROBLEM LIST|We will continue the patient on a Decadron tapering dose, to be tapered over a week. The stop date is _%#DDMM2003#%_. The patient will participate in PT and OT per neurosurgical recommendations. The patient had a temperature of 101.4 early this a.m. per her vital signs, but the patient does not recall having that kind of temperature or feeling febrile.
PT|physical therapy|PT|296|297|HOSPITAL COURSE|She also had variable levels of consciousness and mental status during her stay in the hospital, and was seen by Dr. _%#NAME#%_ _%#NAME#%_ from psychiatry who did evaluate all of her psychiatric medications, and decided to make no changes at that time. At different points, she had been refusing PT and OT while in the hospital, and had been somewhat "cantankerous" according to his consultation write-up. She was found to have a urinary tract infection while in the hospital, and was treated with Cipro for Klebsiella.
PT|physical therapy|PT.|162|164|HOSPITAL COURSE|The duodenal bulb, the second part of the duodenum were normal. The patient was discharged back to the floor. She was placed on iron. She was also seen by OT and PT. Dr. _%#NAME#%_ noted that the patient was obstipated and treated her with a regimen of Colace, Metamucil, Sorbitol, and had the ET nurse irrigate her colostomy site.
PT|physical therapy|PT|123|124|DISPOSITION AND FOLLOW-UP|DISPOSITION AND FOLLOW-UP: 1. The patient will plan to be discharged to either transitional care unit or to home with home PT and OT evaluation. 2. She will follow up with her primary-care physician Dr. _%#NAME#%_ _%#NAME#%_ at the _%#CITY#%_-Lake Clinic in the next one to two weeks, after discharge from Transitional Care Unit.
PT|physical therapy|PT|223|224|REHAB COURSE|REHAB COURSE: The patient was quite weak and a little slower with responses cognitively when he arrived at rehab. He has cleared, though, at times, is a little forgetful. He is safe with transfers, and has met the goals of PT and OT. He does have nausea, at times, especially in the morning, intermittently, prior to radiation, for which we are giving Zofran, and it is effective.
PT|posterior tibial|PT|193|194|PHYSICAL EXAMINATION|No guarding, rigidity or organomegaly. Soft. GENITAL/RECTAL: Pelvic and rectal deferred. EXTREMITIES: No cervical, axillary or femoral nodes. Femoral pulses are present, DP bilaterally, but no PT present. Extremities have trace edema of the left calf but legs are very cool to touch on the left from the mid-calf to the foot, slight darker, both had marked varicosities.
PT|physical therapy|PT,|217|219|HOSPITAL COURSE|HOSPITAL COURSE: The patient was transferred to Fairview University Transitional Services after inpatient stay. Please see discharge summary from hospitalization for details of that. In transitional services, she had PT, OT therapy. She was noted to have some hematoma on her incision site. She was also noted to have some anemia and was started on iron for it.
PT|physical therapy|PT|111|112|DISCHARGE SERVICES|2. Follow up with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2004, at 1:15 p.m. DISCHARGE SERVICES: Home nursing and PT has been arranged for the patient. CODE STATUS: FULL CODE.
PT|physical therapy|PT,|178|180|PLAN|PLAN: 1. Diarrhea:. At this point in time I will go ahead and send C- difficile and stool cultures. If sounds like his wife was not able to take good care of him and I will have PT, OT and social worker see him as well, with the idea being that if he continues to have diarrhea, he may need to go to a nursing home setting.
PT|physical therapy|PT|148|149|DISCHARGE MEDICATIONS|Dressing change every day until staples are out. Remove staples _%#DDMM2004#%_. The patient is full code for now. The patient will continue to have PT and OT at rehab. DISCHARGE EXAMINATION: No new concerns. My friend broke his hip and he is at rehab also.
PT|physical therapy|PT|201|202|ADMISSION MEDICATIONS|Obesity and her deconditioning are also certainly playing a role. Would recommend a sleep study and pulmonary function tests as an outpatient. The patient will receive rehabilitative therapy including PT and OT in FUTS. 2. Lymphedema/cellulitis. The lymphedema and cellulitis have both improved over the course of her hospital stay. We stopped her Avandia due to its contraindication in people with lymphedema because it can cause swelling.
PT|physical therapy|PT|264|265|ASSESSMENT AND PLAN|Check sputum cultures first. I would start her on stress dose steroids - prednisone 40 mg p.o. every day and consider a 5-day course. 2. Weakness. Generalized at this point. Nonfocal exam. I suspect probably secondary to dehydration or deconditioning. I would ask PT and OT to see her. Hold her Lasix as she appears a little dry. 3. Acute-on-chronic renal failure. I suspect prerenal from Lasix. I would hold her Lasix and give her a gentle IV fluid challenge with normal saline at 50 mL/hr for 1 liter.
PT|physical therapy|PT|215|216|BRIEF HISTORY AND HOSPITAL COURSE|During his stay, however, he had gotten severely deconditioned and weak secondary to his pneumonia. He also had this recent fall and was pretty unsteady and required assistance with transfers as well as ambulation. PT and OT did see him and did recommend the patient would benefit from at least short term TCU before final disposition to home.
PT|physical therapy|PT|104|105|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: 1. Check hemoglobin every other day for a week and call MD if less than 9.0. 2. PT and OT to evaluate and treat. DIET: Regular. CODE STATUS: DNR/DNI.
PT|physical therapy|PT|167|168|HISTORY|HISTORY: This is a 52-year-old female, status post right total knee arthroplasty on _%#DDMM2006#%_ with chronic knee pain. The patient was admitted to acute rehab for PT and OT treatment prior to discharge home. Maximum amount of assist with transfers. PAST MEDICAL HISTORY: 1. Obesity. 2. Osteoarthritis. 3. Partial oophorectomy. ALLERGIES: Penicillin. Bee venom.
PT|physical therapy|PT,|187|189|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: 65-year-old with history of stroke, CAD and hypertension, dysphagia, nausea, hiccups, dizziness, depression, admitted to TCU _%#DDMM2006#%_. Patient receiving PT, OT, speech and TCU, making gains, 150 feet with walker standby assist, standby assist with transfers. The patient needs rest in between therapies. Asked to see patient for transfer to Acute Rehab for continued therapies.
PT|physical therapy|PT,|256|258|RECOMMENDATIONS|RECOMMENDATIONS: I think an MRI scan of the brain would be more informative than a CT scan, and I have taken the liberty of ordering that and cancelling the CT order. We will get a carotid ultrasound study. He will continue on aspirin therapy for now, get PT, OT and Speech Therapy to evaluate and treat this gentleman's symptoms. Thank you for the consult. Neurology will follow with you.
PT|posterior tibial|PT|143|144|PHYSICAL EXAMINATION|It is also moderately diffusely tender. No rebound is present. A few bowel sounds are present. EXTREMITIES: No peripheral edema. Normal DP and PT pulses. NEUROLOGIC: Intact. INITIAL LABORATORY DATA: Chest x-ray is clear. The hemoglobin 10.7, white count 6100, platelets 237,000. Sodium 136, K 3.8, chloride 111, CO2 11, glucose 83, BUN 111, creatinine 3.3 mg/dl.
PT|physical therapy|PT,|158|160|SUMMARY|We will do an MRI of the brain with and without diffusion and an MRA of the neck vessels. He may need further evaluation depending on the results. We will do PT, OT and speech. He is on an aspirin at this point. I think we will add Plavix to his regimen. Thank you for this consult.
PT|physical therapy|PT|145|146|REVIEW OF SYSTEMS|She has not had any back pain. She is having pain in her hip just today but feels it is due to the increased as she has been seen by both OT and PT this morning. She denies any numbness in her hands or feet but does have a heavy or full sensation in her left leg so that her entire left leg does not feel the same as her right.
PT|physical therapy|PT|153|154|RECOMMENDATIONS|With regard to his low back pain, I would recommend initial 48 hours of bedrest, which he has already started, followed by mobilization. Would recommend PT consult for back and abdominal strengthening, and range of motion. Continue pain medications and muscle relaxants. Heat and ice as needed.
PT|physical therapy|PT|285|286|HISTORY OF PRESENT ILLNESS|He is also on Coumadin for atrial fibrillation and reports that he was seen by a cardiologist about 6 weeks ago and at that time was in sinus rhythm for which he has been in sinus rhythm for a long time but was advocated to continue with the Coumadin at that time. He has been seen by PT and OT and speech. Speech has him on a regular diet. Physical therapy has found him to have needing modified independence for his sit to supine and sit to stand and requiring contact guard to standby assist for his chair to bed and mat transfers.
PT|physical therapy|PT|144|145|HISTORY OF PRESENT ILLNESS|The patient was found to have to have a large left ventricular clot with an injection fraction of 25%. She has malignant pleural effusion also. PT and OT evaluations were completed. The patient had a bedside swallow on _%#DDMM2007#%_ and was cleared for a soft, moist diet with thins.
PT|physical therapy|PT|224|225|IMPRESSION|Carotid ultrasound suggests some moderate stenosis bilaterally. EEG has been ordered and is pending. This will obviously be helpful to see if there is anything to suggest seizure-like activity. B12 and TSH are unremarkable. PT and OT are going to be involved in his assessment in part because of safety, and then we should also do a cognitive evaluation to see where things stand in terms of memory and so forth.
PT|posterior tibial|PT|192|193|PHYSICAL EXAMINATION|ABDOMEN: Nontender. Bowel sounds are present. EXTREMITIES: The right leg is wrapped in a dressing. Previous exam has shown no extension of the erythema or infection since surgery. Good DP and PT pulses. NEUROLOGIC: No focal motor signs. LABORATORY DATA: Hemoglobin 13.3, white count 8800, platelets 37,000. Sodium 128, K 4.2, chloride 104, CO2 19, BUN 56, creatinine 4.19. Calcium is 6.0. The ALT and AST both slightly elevated (175 and 162), alkaline phosphatase 89, albumin 2.3. Bilirubin total 1.6 mg/dl.
PT|physical therapy|PT|211|212|ASSESSMENT AND PLAN|Patient had an MRI of the brain that showed acute infarct in the left internal capsule area affecting the posterior limb of the left internal capsule. I will switch her aspirin to Aggrenox p.o. b.i.d. She needs PT and OT evaluation. Will also add Lipitor 10 mg p.o. daily.
PT|physical therapy|PT|147|148|ASSESSMENT|3. Chronic back pain. This patient has had difficulty with chemical abuse in the past and given the chronicity of this back pain, I will recommend PT evaluation and consultation. He may use low-dose Soma p.r.n. He should also use ibuprofen or Tylenol as needed. I will be available to follow up with other concerns as they may arise.
PT|physical therapy|PT,|181|183|RECOMMENDATIONS|At that time, I would consider discharge to Fairview Transitional Care if they would be willing to transport him back and forth to the University for therapy. He also could receive PT, OT, and speech in that setting as he tolerated and benefited. We will continue to follow for further disposition recommendations. Total time spent was 45 minutes; 15 minutes in physical exam and 30 minutes in case management and chart review.
PT|physical therapy|PT|234|235|HISTORY OF PRESENT ILLNESS|He underwent surgery on _%#DDMM2007#%_. Postoperatively, he had a fall and hurt his right ankle. X-rays of the right ankle have shown no fractures. The patient's PT and OT postoperatively are pending but patient has been evaluated by PT in the past and OT and has been recommended for subacute /TCU rehab. Patient on questioning today complained of pain across the back 8.5/10 and reported morphine is not lasting long enough.
PT|prothrombin time|PT,|235|237|ASSESSMENT/PLAN|The patient will be transferred to Fairview Southdale Hospital under the care of Quello Clinic who is his primary care physician. We will continue to follow him there. I will keep him n.p.o. for consideration of pacemaker later today. PT, INR and PTT will be sent. 2. Coronary artery disease. Remote history of coronary artery disease and is having no chest pain.
PT|physical therapy|PT|153|154|ASSESSMENT AND RECOMMENDATIONS|After much discussion and explanation of rehabilitation, the patient agreed that he would go to an acute rehabilitation program to continue working with PT and OT on these problems. Please see the resident's note for other issues addressed. The patient and his wife both would prefer to transfer to University of Minnesota Medical Center, Fairview _%#CITY#%_ as the patient is primarily concerned about his wife's situation while he is in rehabilitation.
PT|physical therapy|PT|245|246|ASSESSMENT|The patient is oriented to time, place and date. ASSESSMENT: Left distal femur fracture status post ORIF _%#DDMM2007#%_. Nonweight bearing on the left. Decreased ADLs. Glaucoma. Rotator cuff injury on the left. Suggest acute rehab placement for PT and OT treatment prior to discharge home. Spoke with therapist and the patient and they agree. Estimated length of stay 10 days to 2 weeks.
PT|physical therapy|PT|157|158|ASSESSMENT AND PLAN|On _%#DDMM2006#%_, hemoglobin 15.6. ASSESSMENT AND PLAN: 1. Left knee degenerative joint disease, status post total knee arthroplasty. Per primary team with PT and OT. DVT prophylaxis with Lovenox. Pain control with oxycodone p.r.n. Depending on his condition, he will undergo short-term rehab.
PT|physical therapy|PT,|144|146|RECOMMENDATIONS|He refused rehabilitation and if he continues to refuse, I recommend that he receive home services, including home health nurse, social worker, PT, OT, home-health aide, and also Lifeline. He may also benefit from having a personal care attendant. I would be happy to follow him again in clinic, if he returns to see Neurology.
PT|posterior tibial|PT|192|193|PHYSICAL EXAMINATION|EXTREMITIES: Her left leg is wrapped. Her right leg has a large deformity on the lateral shin from her prior surgeries. There is no edema. Her radial pulse on the left was Dopplerable. DP and PT pulses on the right were Dopplerable but not palpable. EKG shows a sinus rhythm with T-wave flattening in aVL.
PT|physical therapy|PT,|128|130|HISTORY OF PRESENT ILLNESS|MRI was also negative for bleed. It is presumed that she has had a small infarct of the posterior limb of the internal capsule. PT, OT, and speech evaluations are underway. PAST MEDICAL HISTORY 1. Coronary artery disease, status post non-Q-wave MI in 1990.
PT|physical therapy|PT|214|215|SUBJECTIVE|The patient was seen on rounds. No new problems. Working on e-stem to left lower extremity today. Transfers independent. He uses a walker for ambulation. Urology evaluation Thursday for Foley removal. We will have PT and RN to home for continued treatment after discharge. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.4; pulse 100; blood pressure 102/72; respiratory rate 16; oxygen saturations at 98% on room air.
PT|physical therapy|PT|203|204|PLAN|She will get a copy of her laboratories when she leaves, and I will be notified if the hepatitis or HIV laboratories are positive. We will change Motrin to 600 mg q.i.d. scheduled. The patient will have PT evaluation and treatment of the low back pain. In addition, the patient will have lidocaine patches for her back pain at night.
PT|physical therapy|PT|218|219|RECOMMENDATIONS|Gait is not observed. ASSESSMENT: Patient is a 70-year-old female with multiple medical problems, and right hemiparesis and diffuse ataxia with etiology unclear. RECOMMENDATIONS: 1. Dependent mobility. We will consult PT for you for mobility evaluation and treatment. 2. Dependent activities of daily living. We will consult occupational therapy for you for ADL's, adaptive equipment, and safety and energy saving conservations.
PT|physical therapy|PT|209|210|RECOMMENDATIONS|RECOMMENDATIONS: 1. Await Neurology consultation. 2. Cognitive deficits. Await OT assessment. Will consult Speech for you to complete cognitive assessment. 3. Mobility and activities of daily living. Continue PT and OT as you are. DISPOSITION: Depending upon the results of the rehab assessments, I anticipate that Mr. _%#NAME#%_ could be discharged home under his wife's supervision.
PT|prothrombin time|PT|190|191|RECOMMENDATIONS|Mechanism is most likely related to atherosclerosis. RECOMMENDATIONS: 1. Plavix. 2. Check fasting cholesterol and lipid panel. 3. Check sedimentation rate. 4. Check echocardiogram. 5. Check PT and PTT. 6. Occupational, physical and speech therapy will address what deficit she has related to the pelvic fracture and her recent stroke.
PT|posterior tibial|PT|171|172|EXAMINATION|LUNGS: Clear. HEART: Sinus rhythm; no murmur. ABDOMEN: Midline scar; no masses or tenderness. Bowel sounds are active. EXTREMITIES: No peripheral edema. Cannot feel DP or PT pulses. NEUROLOGIC: No obvious focal signs. RECTAL not done; the patient has been incontinent of dark brown stool. LABORATORY DATA: Hematocrit 55 percent. Hemoglobin 18.9 grams on _%#DDMM2003#%_.
PT|prothrombin time|PT|157|158|CURRENT MEDICATIONS|2. Coumadin. 3. Lisinopril. 4. Prilosec. 5. Metoprolol. 6. Diltiazem. The patient was on chronic Coumadin therapy and had an INR of 2.4 on admission, with a PT of 52 seconds. There was no thrombin time, so I am not sure whether the PTT which is longer than expected for this INR, was simply due to heparin contamination, or might e due to an alternative cause such as lupus inhibitor.
PT|physical therapy|PT|324|325|ADDENDUM|The social worker is checking with the patient's facility to clarify their position and whether she will be allowed back in if she does not go to chemical dependency treatment after she is done with physical rehabilitation. Given the uncertainties regarding this and also the previously documented varied participation with PT and OT, I recommended a trial of a transitional subacute rehab and then if it is appropriate, the patient should be reassessed in another week for transfer to the acute rehab ward.
PT|physical therapy|PT|343|344|PHYSICAL EXAMINATION|HEENT: Negative. URINARY: Negative. ENDOCRINE: Negative. LYMPHATICS: Negative. HEMATOLOGICAL: He does take Coumadin as postoperative for that AAA, but does not have any bleeding or bruising disorders. PHYSICAL EXAMINATION: VITAL SIGNS: His baseline blood pressure was 122/60, after PTT he was 86/79, heart rate before was 71, heart rate after PT was 79, temperature 99.8, respirations 20 and O2 sats are 98% on 2 liters of O2. He rates his pain at a 3-4 at rest and had a 7-8 with activity.
PT|physical therapy|PT|151|152|PLAN|Review of progress with Dr. _%#NAME#%_ would be appropriate, and I have requested charts to be FAX'd. We will be following this patient. At this point PT and OT should be involved, and consideration of placement would be appropriate.
PT|physical therapy|PT|312|313|HISTORY OF PRESENT ILLNESS|Again she was able to provide only very limited information as her speech was also dysphonic and as she reported that her speech has also been affected as part of her sickness and it is not related to her effort, particularly today, or is note related to sedation effect. The patient is still being evaluated by PT and OT. PAST MEDICAL HISTORY: 1. History of depression. 2. History of chronic pain.
PT|physical therapy|PT|189|190|RECOMMENDATIONS|Psychiatry consultation for management of his behavior could also be considered. Would check EEG and if negative for any epileptiform activity could then discontinue Dilantin. Continue OT, PT and speech therapy. Dr. _%#NAME#%_ to follow on _%#DDMM2007#%_. Case discussed with Dr. _%#NAME#%_
PT|physical therapy|PT|312|313|PLAN|2. Pain management issues. 3. Chronic obstructive pulmonary disease. She currently seems to be a bit short of breath on trinasal cannula tube, and I think she just is guarding because it hurts to deep breathe. 4. Hypertension. 5. Depression. 6. Osteoporosis. PLAN: 1. Bed rest. 2. Mobilize as is comfortable. 3. PT and OT consultation. 4. Very likely, she will require rehab center. With remote history of lung cancer, we must always be concerned about the possibility of occult malignancy.
PT|physical therapy|PT|138|139|ASSESSMENT|7. TLC inpatient consult team will continue to follow this patient until discharge. Anticipate discharge home to TLC home care. Recommend PT and OT at home to increase her independence in the home. Recommend hospital bed. Recommend bedside commode.
PT|physical therapy|PT|303|304|SUMMARY OF HOSPITAL COURSE|This may be just due to his resolving encephalopathy but I do think that given his atrial fibrillation postoperatively, we should do a head CT scan to rule out new strokes, particularly frontal lobe infarcts. We will do that tonight. We will also just continue to follow him neurologically and continue PT and OT and also obviously he will be continued on Coumadin. Thank you for this consult.
PT|physical therapy|PT|132|133|HISTORY OF PRESENT ILLNESS|He underwent manipulation at bedside today with flexion from approximately 5-95. He continues to complain of pain. He has initiated PT and a CPM machine will be used for passive range of motion. As he is below his functional baseline, a Physical Medicine and Rehabilitation consult was requested.
PT|physical therapy|PT|157|158|PLAN|7. Renal insufficiency with mildly elevated creatinine of 1.24. PLAN: Postop pain management per Orthopedic Surgery. Anticoagulation per Orthopedic Surgery. PT and OT will monitor hemoglobin, will check basic metabolic panel. I agree with withholding Toradol or other nonsteroidal anti-inflammatory drugs at this time.
PT|physical therapy|PT|179|180|PLAN|I do not see much loss of sensation in pain and temperature in his upper extremities. We will initiate physical therapy, occupational therapy and speech language pathology b.i.d. PT to focus on preservation of the range of motion and enhancement of mobility skills. Safe transfers as well as initiation of gait training. OT to work on upper extremity weakness through strengthening and stretching exercises as well as range of motion exercises.
PT|physical therapy|PT,|85|87|HISTORY OF PRESENT ILLNESS|She denies any neck pain for now, though she carries a history of C-spine arthritis. PT, OT and speech evaluation have been recommended and are in process. Physical Medicine and Rehabilitation consult has been requested per protocol.
PT|prothrombin time|PT,|130|132|LABS|No carotid bruit. COR: S1, S2, irregular. ABDOMEN: Soft, nontender. LUNGS clear to auscultation. LABS: Sodium 138, potassium 3.2. PT, PTT normal. Glucose, 109, creatinine 0.83, white count 9.6. CT head scan done on admission revealed no acute changes of mass effect or hemorrhage.
PT|physical therapy|PT|208|209|IMPRESSION|His cardiac echo is pending. The plan is to start him on anticoagulation and long-term Coumadin would be appropriateand review by cardiology. I will request a coagulopathy panel including homocysteine level. PT and OT and stroke protocol should be used. This was discussed with the patient and his wife. He has a vacation planned to Arizona in a week which I advised him to postpone if able.
PT|physical therapy|PT|174|175|PAST MEDICAL HISTORY|He has a wound VAC in place, and his abdominal wound is improving. His kidney function improved from admission. His creatinine is currently 2.44. The patient has worked with PT and OT. From a functional standpoint, he is going to the bathroom independently. He ambulated 200 feet yesterday with Occupational Therapy to the 7th floor rehab satellite station using the IV pole.
PT|physical therapy|PT|257|258|IMPRESSION|We will hold on that at this time due to the fact that she may be a surgical candidate and we will follow up. Other things I would recommend to keep this patient's pain managed during the time that she is waiting for a second opinion for surgery is to have PT followup and do a TENS unit which she has used in the past and does want have one at home so if they can reactivate that TENS therapy for her back that would be helpful as well.
PT|physical therapy|PT|183|184|ASSESSMENT AND PLANNING|OT evaluation is still pending for any impairment with his ADLs and any cognition concerns. He is still requiring oxygen at around 3 liters with no oxygen prior to admission. For now PT should be continued while the patient is still in the acute phase. OT evaluation will be available. We will be able to get a full picture once we have OT evaluation.
PT|physical therapy|PT|136|137|HISTORY OF PRESENT ILLNESS|There was some slowing seen on an EEG. The patient had an NG tube placed yesterday and tube feedings are advancing. She was written for PT and OT who have attempted to work with this patient. Her participation with PT and OT has been inconsistent. PAST MEDICAL HISTORY/PAST SURGICAL HISTORY: Status post gastric bypass, as stated above, at _%#COUNTY#%_ _%#COUNTY#%_ Medical Center in 2004.
PT|posterior tibial|PT|128|129|PHYSICAL EXAMINATION|Lungs - He did have expiratory wheezing. Heart regular rate without S3, S4, or murmur. There is no peripheral edema. DP is 4/4, PT is 4/4. Ankle jerks were normal. LABORATORY: From _%#DDMM2002#%_ at 1300 hours sodium 136, potassium 4.6, chloride 101, bicarb 26, anion gap 9, creatinine 1.3, calcium 9.1. Alk phos normal.
PT|physical therapy|PT|301|302|PLAN|Given the stool that is coming out from her fistula areas, we have decided that we will place on nothing by mouth to give facilitate healing of the fistula and to place her nothing by mouth. PLAN: 1. Admit to acute rehab. PT and OT b.i.d. working on gait, transfer training, stairs and car transfers. PT also to check balance. Check oxygen saturations during therapies. OT to work on ADLs and IADLs. 2. Nutrition. Currently, the patient is n.p.o. to facilitate the healing of the fistula.
PT|physical therapy|PT|158|159|HISTORY OF PRESENT ILLNESS|They also recommend ophthalmology exam and diabetes training. Prosthetics fit the patient on _%#DDMM2007#%_ with a removable cast. The patient is followed by PT and OT. He transferred to a chair with a one leg pivot with minimal assistance, and he was moderately independent for going from sit to standing at the edge of the bed and back to sitting.
PT|physical therapy|PT,|77|79|HISTORY OF PRESENT ILLNESS|She also required inpatient rehab 5 years ago after a brain tumor resection. PT, OT, and Speech Therapy have been consulted. PAST MEDICAL HISTORY: 1. History of multiple cardiovascular accidents with residual left facial droop.
PT|physical therapy|PT|206|207|ASSESSMENT AND PLAN|4. Will also check BMP, hemoglobin and TSH on _%#DDMM2004#%_to check electrolytes, kidney, thyroid function, and evaluate for anemia. 5. Will order Protonix 40 mg p.o. q.a.m. for heartburn. 6. Will request PT consult to evaluate need for additional cushion over tender areas for CAM walker. Thank you for this consultation.
PT|physical therapy|PT|178|179|RECOMMENDATIONS|She should be watched carefully for recurrent retention. I would also recommend that a urinalysis and urine culture be sent at that time to rule out a UTI. 2. Mobility: Continue PT as you are to address balance, fall prevention, gait, and stability. She may also require a gait aid upon discharge. 3. Activities of daily living: Continue OT as you are to address simple and instrumental activities of daily living.
PT|physical therapy|PT|163|164|RECOMMENDATIONS|This reaffirms for me that the patient would be best served in a subacute facility at this time, until his pain issue resolves. We will follow closely with OT and PT and adjust the recommendations as indicated in this patient. Thank you for this consultation. Please call with any questions or concerns.
PT|physical therapy|PT|230|231||The patient was found on CT scan to have an intracranial bleed at the right posterior parietal lobe with edema. Found to have decreased attention, concentration, and left hemianopsia. No decrease in strength or sensation. Seen by PT and OT/Speech. Suggest acute rehab stay for cognition and safety, balance, and ADLs before discharge home with family. PAST MEDICAL HISTORY: 1. Hypertension. 2. Morton's neuropathy. 3. Peripheral neuropathy.
PT|physical therapy|PT|161|162|FAMILY HISTORY|If these studies are negative then an MRI of his cervical and thoracic spine would be appropriate. Depending on his course cardiac echo will be required. An OT, PT evaluation will also be requested. My partners will be following this patient over the weekend.
PT|physical therapy|PT|184|185|PHYSICAL EXAMINATION|MUSCULOSKELETAL: Normal. The right knee is perhaps a little enlarged. There appears to be a mild effusion of the patient's right knee. Range of motion is intact. The patient is seeing PT for this. NEUROLOGIC: Cranial nerves II-XII are grossly intact. Sensation is intact to light touch. Strength is 5/5 bilaterally with no involuntary movements in the upper or lower extremities.
PT|physical therapy|PT|193|194|RECOMMENDATIONS|Dilantin level is 11.6. ASSESSMENT: A 78-year-old male status post bilateral frontal lobar hemorrhages, status post left CVA with history of brain aneurysm. RECOMMENDATIONS: 1. Mobility. Await PT assessment. 2. Activities of daily living. Continue OT as you. 3. Speech, language, cognition, and swallow. Await Speech Therapy evaluation. DISPOSITION: Anticipate patient will need placement.
PT|posterior tibial|PT|189|190|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_'s sutures were still in place. There was no drainage or bleeding noted on the dressing. Mr. _%#NAME#%_ was neurovascularly intact distal to the site of his operation with 2+ PT pulse and 5/5 strength, and plantar and dorsiflexion on the left foot. ASSESSMENT AND PLAN: Mr. _%#NAME#%_ is 2 weeks out from his revision of left patellar open reduction and internal fixation.
PT|physical therapy|PT|140|141|ASSESSMENT|ASSESSMENT: Status post numerous medical problems and recent spinal stenosis with laminectomies C3 to 5 with decreased ADL, increased pain. PT and OT evaluation, and treatment. Estimated length of stay, 2 weeks. PROGNOSIS: Good. Medicine to follow for medical issues.
PT|physical therapy|PT|118|119|ASSESSMENT AND RECOMMENDATION|From a functional standpoint she is quite good. At this point she does not need acute rehab placement for her ongoing PT or OT. Primarily she needs nutritional support to increase her bulk and an overall strength for activities. If you have any questions or concerns regarding my consultation, please feel free to call me.
PT|posterior tibial|PT|161|162|PHYSICAL  EXAMINATION|Apical impulse does not appear to be enlarged. ABDOMEN: Soft, nontender with no hepatosplenomegaly. EXTREMITIES: He does not have any lower extremity edema. His PT and DP pulses are 2/4. He has symmetrical and full radial artery pulses. SKIN: No obvious lesions. MUSUCLOSKELETAL: No findings. NEUROLOGIC: His cranial nerves are negative on brief exam, no neurologic deficits.
PT|physical therapy|PT,|228|230|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: 70-year-old admitted _%#DDMM2005#%_ with right-sided weakness and decreased balance, slurred speech, questioned accentuation of prior deficits. No change on acute MRI. The patient was seen by Speech, PT, and OT and found to have mild to moderate cognitive impairment. She required minimum assist with sit to stand and ambulate with wheeled walker, and mid to moderate assist with weight shift and leg advancement, difficulties with stairs, stand-by assist with putting on socks.
PT|physical therapy|PT|81|82|PHYSICAL EXAMINATION|He has social worker involved in his case. A social worker consult was obtained. PT and OT evaluations are pending. PAST MEDICAL HISTORY: Atypical Parkinson's disease, possible mood disorder.
PT|physical therapy|PT|245|246|IMPRESSION/RECOMMENDATIONS|IMPRESSION/RECOMMENDATIONS: This is a pleasant 63-year-old right-handed female who is status post decompressive cervical laminectomy C3 through C6 with postoperative pain and constipation and residual functional deficit. She is participating in PT and OT. Pain in his her major limitation. She needs to do some steps before she goes to home and also needs to work on her endurance and mobility.
PT|physical therapy|PT|217|218|MEDICATIONS|Functionally, the patient demonstrated going from a supine to a sitting at the edge of the bed to a standing position with stand-by assistance. To go from a standing to a sitting position, he falls back into bed. His PT evaluation is pending , I do not attempt to walk with the patient in the hallway. Functionally, the patient demonstrates going from a standing to a sitting and reclining position with stand-by assistance again.
PT|physical therapy|PT|208|209|DISPOSITION|I will rewrite an order. DISPOSITION: There is family to supervise the patient 24 hours a day. We recommend that he discharge home with family. I would recommend no driving. I would also recommend outpatient PT and OT at Sister Kinney Institute, as this is several blocks away from his home. I would be happy to follow him in clinic for these issues.
PT|physical therapy|PT|181|182|PLAN|No meniscus or ligament tears. Complained of deep pain. Has an immobilizer now. Because of decreased ADLs, function and pain, the patient was suggested to have an acute rehab stay. PT and OT note show a transfer with modest assist of one, ambulates 20 feet with rolling walker, notes pain in her knee at rest and with activity.
PT|physical therapy|PT|107|108|HISTORY OF PRESENT ILLNESS|She has had a relatively stable medical course acutely. From a rehab standpoint please refer to the OT and PT notes. On acute side she is unsafe ambulating alone let alone independently and tolerating aggressive therapy and has a reasonable expectation of being discharged home and there was admitted to the in-hospital rehab unit.
PT|physical therapy|PT|103|104|HISTORY OF PRESENT ILLNESS|His LVAD implantation is being considered as a bridge to transplantation. The patient has been seen by PT and OT. He has ambulated around 80 feet in hallway with frequent stops due to fatigue and poor endurance. He is noted to be mid assist for sit-to-stand and is standby assist for his ADLs.
PT|physical therapy|PT,|146|148|PLAN|Her rehabilitative course is complicated by possible mild gout in her left toe, her obesity, her age. PLAN: Her rehab program will consist of OT, PT, speech pathology, rehab nursing and social service intervention. The goals will be for her to be independent with her basic ADLs, to establish a safe system of nutrition and teach her to use PEG, if needed; to be independent with pads with her bladder, to be continent and voluntary of stool.
PT|physical therapy|PT,|173|175|PLAN|Gait is stable without assist. Coordination is good in both lower extremities on toe tap and the left upper extremity rapid alternating fingers. ASSESSMENT: As above. PLAN: PT, OT, Speech treatment for strength, coordination, ADLs, endurance, equipment needs, cognition, safety, communication skills. ESTIMATED LENGTH OF STAY: 2 weeks. PROGNOSIS: Good. Will follow and set up team conference as soon as possible.
PT|physical therapy|PT|171|172|PLAN|He also sustained an MI leading to further deconditioning. He is being admitted to acute rehab for further rehabilitation. PLAN: 1. Admit to acute rehab, PT and OT b.i.d. PT and OT both to emphasize on weight restrictions as well as precautions. PT to work on strengthening and stretching exercises as well as gait training and transfer training.
PT|physical therapy|PT,|258|260|ASSESSMENT AND PLAN|He has not had any cardiac transplantation, etc. done. Due to his complex medical course, he has been significantly impaired in function, but appears to have evaluated in participating in physical therapy and speech. For now will we should continue with the PT, OT and speech for his aspiration risk. He has a GJ tube now. His tube feeds should be continued and he should her post-discharge have a speech evaluation and treatment at regular intervals.
PT|physical therapy|PT|123|124|HISTORY OF PRESENT ILLNESS|She is up ambulating and holding onto her IV pole to the bathroom with standby assist. She was seen by PT and OT today. On PT evaluation, she was independent with bed mobility, sit to stand, and back. She was standby assistance chair to bed and back. She was standby assistance for gait.
PT|physical therapy|PT,|211|213|ASSESSMENT/RECOMMENDATIONS|He has a history of lung CA and hypertension. Overall, he has impaired gait, balance, and transfers, although this is improving. This patient would benefit from an acute rehab admission to continue working with PT, OT, and speech therapy. Given my exam today I anticipate that he would need at least 2-3 weeks in an acute rehab facility and be able to discharge home following that.
PT|physical therapy|PT|172|173|ASSESSMENT/RECOMMENDATIONS|The patient would benefit from placement in an acute rehabilitation facility for ongoing PT/OT therapies to increase his functional ADLs and mobility. Please continue with PT and OT services and speech therapy services as currently ordered while in hospital. We will follow up with this patient, but at this point I recommended placement in an acute rehab facility once he is medically stable for transfer.
PT|physical therapy|PT,|479|481|ASSESSMENT/RECOMMENDATIONS|ASSESSMENT/RECOMMENDATIONS: Mr. _%#NAME#%_ is a 64-year-old right-handed individual who is status post severe acute MI with poor cardiac function, status post right BKA secondary to right foot gangrene and MSSA sepsis, status post tracheostomy, status post PEG placement, status post decannulation of trach, improved swallow function, resolving pneumonia and coccyx wound issues, overall deconditioned. The patient would benefit from going to an acute rehab facility for ongoing PT, OT, and speech therapy. Estimated length of stay is approximately two to three weeks in acute Rehab. Goal is to achieve independence with ADLs and ambulation. Also to eventually be fitted for a right prosthetic leg.
PT|physical therapy|PT|202|203|PROBLEM #12|She is to receive skilled nursing care, and she has a good potential for rehabilitation. Her CPR status is full resuscitative measures, and she does have standing nursing home orders. She is to receive PT and OT evaluate and treat. She is to follow up with Dr. _%#NAME#%_ in 1 to 2 weeks. Nutrition is to continue following this patient after her discharge.
PT|physical therapy|PT|272|273|7.  FEN/GI|8. PT/OT/Rehab Service: The patient was initially evaluated on _%#DDMM2006#%_ and postoperatively received therapy with neck range of motion and mobility for her stiffness; Rehab Service was provided to assist in therapy for grooming, hygiene. The patient was followed by PT 5-7 times a week to work with transferring and ambulating. Upon readmission, PT OT may be consulted if necessary.
PT|physical therapy|PT|142|143|IMPRESSION AND PLAN|15. Insomnia: Ambien p.r.n. 16. Nausea: Compazine p.r.n., though this does not seem to be a serious problem at this time. 17. Deconditioning: PT and OT will commence tomorrow morning.
PT|physical therapy|PT,|117|119|PROBLEM #10|She will have an ophthalmology examination as an outpatient at her current ophthalmology clinic. PROBLEM #10: Rehab, PT, and OT. PT, OT and speech therapy were consulted during this admission. Speech therapy found no evidence of swelling problems or with textures.
PT|physical therapy|PT|169|170|PRINCIPAL  PROCEDURES|3. Carotid ultrasound study which showed less than 50% stenosis bilaterally. 4. Heparin drip with initiation of Coumadin. 5. ICU admission with telemetry monitoring. 6. PT and OT consultations. 7. Speech and swallow evaluation. The patient was placed on a dysphagia type II diet. REASON FOR ADMISSION: Please see dictated history and physical.
PT|physical therapy|PT,|133|135|IMPRESSION|6. Disposition. Patient was hospitalized twice within a month and at discharge last time did not do very well at first. We will have PT, OT evaluate. May consider Neurology consult if her weakness persists, and will require Social Work service to evaluate; her husband may need some respite time.
PT|physical therapy|PT|110|111|IMPRESSION|We will also need to rule out the possibility of an MI by getting a troponin in the morning. We will have OT, PT and speech see the patient. Will check a lipid panel and will also add a sed rate. We will check a urinalysis and urine cultu re. ADDENDUM: _%#NAME#%_ _%#NAME#%_'s laboratory results showed a hemoglobin of 10.5, a white count of 6400 with 78 neutrophils, 12 lymphs, 7 monocytes.
PT|physical therapy|PT|230|231|IMPRESSION AND PLAN|She is currently on Replete at 120 cc/hr. If we need, we will decrease this back down to her previous rate, which was 100/hr. This will run from 6 p.m. to 0800 hours. We will have dietitian follow here as well. 7. Deconditioning: PT and OT will commence in the morning. 8. Pain secondary to #1 above: Will continue with pain regimen of Percocet as needed.
PT|physical therapy|PT|124|125|PLAN|She will need muscle strengthening exercises of the large muscles especially of the pelvis, as well as the smaller muscles. PT to work on transfer training. She will need a wheelchair. 2. OT to work on ADLs and IADLs training. Assess the need for adaptive equipment.
PT|physical therapy|PT|200|201|PLAN|4 Infectious disease consultation with Dr. _%#NAME#%_ _%#NAME#%_. 5 Review/resume home meds as appropriate. 6 Accu-Cheks q.i.d. a.c. and h.s. with subcutaneously insulin coverage using a low scale. 7 PT to help with mobilization/strengthening. 8 Serial follow-up labs. 9 Parameters for which nursing staff should call.
PT|prothrombin time|PT|166|167|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Coumadin 3 mg p.o. q.d. A prescription was given for three days; however, he needs to go to Dr. _%#NAME#%_'s office in two days to have his PT and INR checked, and any modification of the Coumadin disease will be deferred to Dr. _%#NAME#%_'s discretion. 2. Altace 2.5 mg p.o. q.d. 3. Artificial Tears OU q.2-4h. p.r.n.
PT|physical therapy|PT,|173|175|OTHER DISCHARGE INSTRUCTIONS|4. _%#NAME#%_ care and flushing per dialysis. 5. G-tube cares b.i.d. with soap and water, the G-tube is a 14 French PEG. 6. Tracheostomy cares b.i.d. with sterile water. 7. PT, OT, speech to evaluate and treat through University of Minnesota Children's Hospital. 8. Hom e care agency as caregiver's network, phone number is _%#TEL#%_ for 24 hours a day nursing care.
PT|physical therapy|PT|153|154|PLAN|3. Recent CVA thought to be embolic in nature with some residual right-sided weakness. The patient is now essentially wheelchair bound and does not like PT according to the family. We will consider PT and OT consult. We will need to be careful not to completely reverse her anticoagulation unless she has a significant GI bleed as she is at risk for recurrent embolic stroke.
PT|physical therapy|PT,|172|174|FOLLOW-UP INSTRUCTIONS|11. Iron 160 mg p.o. b.i.d. 12. Fish oil 2000 mg p.o. daily. FOLLOW-UP INSTRUCTIONS: 1. The patient is to be transferred to the Fairview Acute Rehabilitation to be seen by PT, OT, and Cardiac Rehabilitation. Continue medications as written in this discharge summary. 2. Primary care physician: Should be seen by primary care physician in 2-3 weeks.
PT|physical therapy|PT|173|174|HOSPITAL COURSE|She was continued on Lexapro orally here. She does certainly need a lot of encouragement and admits to feeling frustrated with this hospital stay. I would recommend ongoing PT and OT for her. PHYSICAL EXAMINATION: VITALS: On discharge examination, her weight is 130.6 kg, temperature 100, blood pressure 116/73, pulse 87, respiratory rate 20, O2 sat 93% on room air.
PT|physical therapy|PT|163|164|DISCHARGE INSTRUCTION|Her stooling might need to be monitored and start antidiarrhea as needed due to the change of formula. 3. Activity - the patient should continue to receive OT and PT as tolerated. She should when able not lift greater than 10 pounds for 6 weeks. 4. Her trach. may be weaned as tolerated per protocol at the new hospital.
PT|physical therapy|PT|237|238|IMPRESSION/PLAN|5. ETOH abuse. The patient did withdraw in the hospital, and he eventually will need chemical dependency treatment if he is amenable to this in the future. His B-12 and folate levels are okay. These have been checked. 6. Deconditioning, PT and OT as needed. 7. Malnutrition. He is NPO, and he has TPN lipids, and after discussion with Dr. _%#NAME#%_ and the dietitian, the D5W will be stopped.
PT|physical therapy|PT|185|186|PROBLEM #6|PROBLEM #6: Anxiety. She may benefit from getting p.r.n. benzo and sublingual morphine. She may need a short term stay at Fairview- University Transitional Services as according to the PT recommendation and over there they can follow up her for her PT and OT evaluations and work up. PLAN: The patient needs PT and OT evaluation and treatment.
PT|physical therapy|PT|276|277|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|She also had a parathyroid hormone levels checked, which came back elevated, thus a nuclear medicine parathyroid scan was performed, which did not show any focal areas of abnormal activity. It was recommended that she see the endocrinologist as an outpatient. She was seen by PT and OT and deemed to be an candidate for acute rehab. PROBLEM #2: The patient was transferred to the acute rehab unit on _%#DDMM2007#%_ for continued rehab needs for her right hip fracture and general deconditioning.
PT|physical therapy|PT|193|194|IMPRESSION AND PLAN|12. Constipation. We will increase the Colace. 13. Urinary incontinence. Ditropan probably related to her diabetes. 14. Hypothyroidism. The patient has Synthroid treatment. 15. Deconditioning. PT and OT; though the patient does not feel she needs these, she is willing to have the evaluations done. 16. Elevated LFTs and a positive hepatitis B core antibody.
PT|physical therapy|PT|250|251|HISTORY OF PRESENT ILLNESS|At that time, the patient underwent repeat MRI imaging of the brain, which showed no evidence for recurrent infarct. The patient was again seen in consultation by Neurology. Stammering-type speech felt to be non-organic. Transfer to acute rehab with PT and OT with ultimate improvement in gait and speech pattern. The patient then did well from a neurologic standpoint until approximately the last two months when subsequent to the loss of her close companion, she again developed difficulty with altered gait with episodes of recurrent falls, reduced upper extremity coordination and stammering/stuttering-like speech.
PT|physical therapy|PT,|168|170|PLAN|We will continue on Bactrim and Valcyte for prophylaxis treatment. 2. For deconditioning, we will obtain Physical Medicine and Rehabilitation consultation for adequate PT, OT program and patient's goal is to go back home when he meets his rehab goals. 3. For DVT prophylaxis in patient's lower abdomen as well as ecchymoses secondary to heparin and subcutaneous injection t.i.d. Will change to Lovenox 40 mg subcutaneous daily.
PT|physical therapy|PT|205|206|HISTORY OF PRESENT ILLNESS|She has had multiple falls at home secondary to difficulty walking as well as some of her vertigo, which occasionally does occur. She was transferred to rehab from the hospital for pain control as well as PT and OT. Today, upon questioning the patient, she complains of severe pain, 10/10, on her left buttocks, extending down the back of her leg, with numbness down the back of her leg as well from her buttocks down to her foot.
PT|physical therapy|PT,|177|179|HOSPITAL COURSE|Neurology thought the patient had a low normal B12 level and recommended maybe she would benefit from B12 injections monthly. It was decided that the patient should have a home PT, OT evaluation for home safety as the patient lives independently in a town home. The patient had electrolytes done which were all normal. At the time of discharge, her methylmalonic acid and homocysteine levels were pending.
PT|physical therapy|PT,|189|191|PLAN|9. Chronic anemia. 10. History of left fibula and bone graft with cast placement. PLAN: The patient was admitted to Fairview-University Transitional Services for re-conditioning, including PT, OT, continuation of medical care and wound care. 1. For wound infection, we will continue with current antibiotics: Bactrim DS 1 tablet down G-tube b.i.d., fluconazole 100 mg down G- tube daily and ampicillin 500 mg down G-tube q.i.d. until seen by the ID team.
PT|physical therapy|PT|296|297|HISTORY OF PRESENT ILLNESS|His workup has included so far a CT chest, abdomen and pelvis,which has not shown any tumor but there is an infrarenal aortic occlusion with a distended bladder and distended stomach and moderate amount of stool in colon. He also has a left-sided heel wound and some pressure sores in both feet. PT and OT has evaluated the patient and he is noted to be min assist for transfers, max assist with his ADLs, especially feeding due to his hand weakness.
PT|physical therapy|PT,|157|159|PLAN|He is admitted to acute rehab being well below his baseline functionally. He has PT, OT, and help he needs. PLAN: 1. We will admit to acute rehab. Will need PT, OT, and Speech Language Pathology. Given his impulsive nature and the site of his subdural hematomas he is bound to have cognitive deficits including increased risk for falls.
PT|physical therapy|PT|148|149|REASON FOR CONSULTATION|There is considerable fatigue and debility with patient requiring assist to some degree with most activities and mobility. The patient is receiving PT and OT services. Gyn/Onc has previously recommended Megace for a trial of appetite stimulation, and the patient is agreeable to trying this.
PT|physical therapy|PT|151|152|ASSESSMENT/PLAN|1. Postoperative day number 2 revision of her right total hip arthroplasty, treatment to be continued per Dr. _%#NAME#%_. The patient will have OT and PT postoperatively. 2. Antiphospholipid antibody syndrome. The patient was on anticoagulants as an outpatient, receiving Coumadin 3.75 mg every day, with a goal INR of 2.5 to 3.5 and a goal factor 2 of 15 to 257.
PT|posterior tibial|PT|121|122|PHYSICAL EXAMINATION|His ABDOMEN is soft, nontender, with no hepatosplenomegaly. There is no lower extremity edema, and his pulses are 3/3 on PT and DP. There is a status post traumatic amputation of his fourth finger on the left side. His electrocardiogram shows full ventricular pacing, in the setting of atrial fibrillation.
PT|physical therapy|PT|121|122|HISTORY OF PRESENT ILLNESS|The patient has also been treated with some normal saline boluses and Lasix. He had a PICC line placed in his right arm. PT and OT have been ordered, and OT assessment is available in his chart. Today they note that he was contact-guard assist, sit-to-stand. He was independent with dynamic and static sitting.
PT|physical therapy|PT,|214|216|IMPRESSION/RECOMMENDATION|The left diaphragm was documented to be elevated. IMPRESSION/RECOMMENDATION: This is a 81-year-old gentleman with a history of frequent falls and some mental status changes currently being evaluated and treated by PT, OT and Speech. He was found to have significant functional limitations and also a significant fall risk. Neurosurgery has evaluated and does not find any surgical remediation for his fall risk or his C2 fracture.
PT|posterior tibial|PT|147|148|PHYSICAL EXAMINATION|ABDOMEN: Soft, nontender with no hepatosplenomegaly. EXTREMITIES: He has only trace lower extremity edema at this moment and his pulses are 2/2 on PT and DP. He has mild osteoarthritis of the hand joints and his radial artery pulses are full and symmetrical. There are no evident skin changes or musculoskeletal issues or definite neurologic deficits except for Parkinsonian tremor and hypokinesis described above.
PT|physical therapy|PT|261|262|MEDICATIONS|At this time, I am unable to make the recommendation that he be transferred to an acute rehab hospital to address these problems of ambulation and decreased lower extremity strength. We will continue to follow his progress in the hospital. Please continue with PT and OT as currently ordered. Please call with any questions. Thank you for this consultation. Time for consultation was 1 hour with 35% in patient examination and 65% in chart review and case management.
PT|physical therapy|PT.|269|271|HISTORY OF PRESENT ILLNESS|She was admitted because of increased weakness in her right lower extremity greater than right upper extremity, dysarthria, difficulty with coordination on the left and an inability to transfer. She received five doses of methylprednisolone and was evaluated by OT and PT. She was initially evaluated on _%#DDMM2007#%_ by OT; that was at the start of her IV steroid therapy. Her strength in her upper extremities was deemed to 4 /5.
PT|physical therapy|PT|177|178|TIME OF CONSULTATION|I encouraged her to follow up with him regarding botulinum toxin injections for spasticity. In addition, I think this patient would benefit from a referral to outpatient OT and PT since it has been quite some time since she has seen anyone in a therapeutic setting. We assessed her ability to function and do her ADLs.
PT|physical therapy|PT.|231|233|HISTORY OF PRESENT ILLNESS|She was extubated on _%#DDMM2006#%_. She was initially evaluated by Speech Therapy, on _%#DDMM2006#%_, and their recommendation at time was that she be n.p.o. Over the last few days, she has improved and is now working with OT and PT. She was reevaluated by Speech Therapy on _%#DDMM2006#%_, and they recommended a dysphagia 3 diet with thin liquids. She was on tube-feedings until her tube fell out sometime last night.
PT|physical therapy|PT|288|289|PALLIATIVE ASSESSMENT AND RECOMMENDATIONS|5. Debility. The patient's functional status may be at significant risk for decline postoperatively given multiple comorbidities that may make it difficult for her to successfully rehabilitate and become ambulatory again after surgery. This needs to be determined pending her course with PT and OT involved as will be routine postoperatively. Thank you for the opportunity to participate in this complex patient and family's care.
PT|physical therapy|PT|169|170|HOSPITAL COURSE|This was followed by CT. It measured 4 cm, with associated adjacent area adenopathy. This patient was discharged to home with a home health aide, home nursing, and home PT on _%#DDMM2002#%_. DISCHARGE DIAGNOSES: 1. Status post appendectomy. 2. COPD. 3. Left lung mass.
RA|room air|RA|146|147|HOSPITAL COURSE BY PROBLEM|Chest tube was successfully clamped and pulled the day of discharge. A small area of loculated effusion remains but the pt was ambulating well on RA by the time of discharge. 2) Pain Pt has left neck pain from her known cancer, and had significant lower chest wall pain from coughing, which was much improved by the day of discharge.
RA|right atrium|RA|172|173|HISTORY|This was repeated in followup on _%#MM#%_ _%#DD#%_ with relatively similar findings; once again the pericardial effusion was moderate in size. There was compression of the RA and RV which appeared to be real and did once again suggest early, mild characteristics of compression and tamponade.
RA|right atrium|RA,|163|165|DIAGNOSTIC STUDIES|Iron studies are okay. Iron sats are little elevated at 60%. DIAGNOSTIC STUDIES: 1. Echocardiogram shows some moderate severe pulmonary hypertension of 46-55 plus RA, mild LVH, diastolic dysfunction, moderate mitral regurg 2+ and right atrial pressures estimated at 5-10 as greater than 50% IVC collapse with respirations noted.
RA|right atrium|RA|180|181|HISTORY|The right ventricle was not well seen. There was mild mitral stenosis with a mean gradient of 12. There was moderate pulmonary hypertension with RV systolic pressure estimated 46+ RA pressure. There was trace tricuspid insufficiency. The aortic valve replacement was not well seen but the gradients were thought to be normal for the valve.
RA|right atrium|RA|167|168|LABORATORY AND DIAGNOSTIC DATA|There is moderate mitral insufficiency, moderate to severe tricuspid valve insufficiency, moderately severe to severe pulmonary hypertension with RVSP at 56 mmHg plus RA pressure. There is no pericardial effusion. EKG demonstrates atrial fibrillation with controlled ventricular response and some PVCs.
RA|right atrium|RA|155|156|HISTORY|Again, noted was moderate pulmonary hypertension RV dysfunction and moderately severe to severe TR with mild to moderate MR. Her RVSP was estimated at 42+ RA pressure. Apical clot could not be excluded. No obvious shunt was identified. She was again treated for the same. Her next admission was on _%#MMDD#%_ when she was again seen for her chronic renal insufficiency and edema.
RA|right atrium|RA|159|160|LABORATORY/DIAGNOSTIC DATA|There was noted to be moderate TR and the transthoracic echo showed moderate to moderately severe TR. There was pulmonary hypertension with RVSPF 57 mmHg plus RA pressure. The left heart was normal. The right heart was enlarged with decreased RV function. The mitral valve showed that it was structurally normal with mild MR.
RA|rheumatoid arthritis|RA.|175|177|REVIEW OF SYSTEMS|She denies dyspnea. GASTROINTESTINAL: Per HPI. GENITOURINARY: No dysuria. Hematologic, integumentary and endocrine review of systems are negative. MUSCULOSKELETAL: History of RA. NEUROLOGIC: No focal complaints. PSYCHIATRIC: She denies depressive symptoms. PHYSICAL EXAMINATION: VITAL SIGNS: She is afebrile, blood pressure is 135/73, heart rate 60s, respirations 20, 02 saturation 98% on 1 liter.
RA|right atrium|RA,|255|257|MANAGEMENT BY SYSTEM|MANAGEMENT BY SYSTEM: 1. Cardiovascular: She had a troponin leak in the setting of viral gastroenteritis, strep throat and right middle lobe pneumonia. Left heart cath showed no significant stenosis. Right heart cath showed marked TR and elevation of the RA, PA and wedge pressures. Moreover, her echocardiogram showed decrease in LV function. She was diuresed during her admission with good response.
RA|right atrium|RA|141|142|* FEN|Good LV and RV size and function. Bright echogenic 'dot' on ventricular septum. Normal valves. No PDA. Small PFO left to right. PICC line in RA and RV". No further follow-up is recommended. Problem #12: Screening Examinations/Immunizations. * PKU, galactosemia, hypothyroidism, hemoglobinopathy, adrenal hyperplasia screening was sent on _%#MMDD#%_ and the results were normal at the time of discharge.
RA|right atrium|RA|145|146|HISTORY OF PRESENT ILLNESS|Chest x-ray was done which was negative except for degenerative changes. Mild pulmonary hypertension was noted with the PA pressure of 39x19 and RA pressure of 9. LVADP was 20. Wedge was not obtained. The patient was continued on Lasix for his lower extremity edema and the elevated ADP.
RA|right atrium|RA|156|157|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Significant pulmonary hypertension with a right heart cath done on _%#DDMM2006#%_ with a PA pressure of 85/36, a wedge of 25 and an RA of 16. Etiology of her pulmonary tension was thought related to possible volume overload secondary to her end-stage kidney disease as well as diastolic dysfunction and a component of underlying lung disease from a history of a BOOP and interstitial lung disease.
RA|room air|RA|183|184|1. FEN|2. GI: _%#NAME#%_'s bilirubin was elevated at 11.4 this morning; he may benefit from phototherapy if a repeat check shows persistent elevation. 3. Resp: _%#NAME#%_ has been stable on RA since his chest tube was removed yesterday (_%#DDMM2004#%_). Crepitus is still palpable on his thorax, shoulders and neck; CXR this morning showed resolution of his pneumothoraces with persistence of the pneumomediastinum and subcutaneous air up to the shoulders and neck.
RA|right atrium|RA.|144|146|PAST MEDICAL HISTORY|There was mild LV dilatation, mild MR, and mild left atrial enlargement. Her right ventricular systolic pressure was mildly elevated to 29 plus RA. 2. Asthma. 3. Status post cesarean section. 4. History of meningitis as a child. 5. Status post septoplasty.
RA|room air|RA|154|155|* FEN|She actually did remarkable well thereafter and did not require any more doses of surfactant. She was extubated on DOL 2 without complication, and was on RA throughout the rest of her hospital stay. * CV: She initially had suspected pulmonary hypertension. She also initially required pressor support (dopamine and dobutamine).
RA|right atrium|RA|208|209|PROCEDURES PEFORMED|DISCHARGE DIAGNOSES: 1. Congestive heart failure exacerbation. 2. Anemia. 3. Steroid-induced diabetes. PROCEDURES PEFORMED: The patient underwent a right heart catheterization on _%#DDMM2006#%_, which showed RA pressure of 18, RV pressure of 55/22, PA pressure of 55/22 with a mean of 36 mm Hg. She had a wedge of 24 and elevated left ventricular pressure of 180/16 mm Hg.
RA|right atrium|RA|190|191|HOSPITAL COURSE|Therefore, it was determined that she had an idiopathic nonischemic cardiomyopathy. Her right heart cath was also done, which showed a pulmonary capillary wedge pressure of 11 to 12 with an RA pressure of 4. Her creatinine on admission was 2.2 with a previous baseline creatinine of 1.3 and therefore, she received maintenance IV fluids to increase her intravascular volume.
RA|right atrium|RA|145|146|OPERATIONS/PROCEDURES PERFORMED|No pericardial effusion. 2. A right heart catheterization which showed a pulmonary artery pressure of 43/15, mean pulmonary pressure of 30, mean RA pressure of 13, and a pulmonary capillary wedge pressure of 16. Her fixed cardiac index was 2.2.
RA|right atrium|RA|213|214|DISCHARGE DIAGNOSIS|The patient had a pericardiocentesis performed under echocardiographic guidance; 1810 mL of sanguinous blood were drained from the pericardial space with immediate clinical and hemodynamic improvement. The RV and RA were fully expanded at the end of this procedure. The patient had the drain left in for 2 days and had another 500 mL of fluid drained out of it.
RA|right atrium|RA|222|223|TESTS DONE DURING THIS HOSPITAL STAY|On the right there was a proximal in mid calf and on the left there is a clot in the posterior tibial vein. 5. Echocardiogram done on _%#DDMM2005#%_ showed acute right-sided decompensation with a pulmonary pressure of 30+ RA pressure, normal LV function. A repeat echocardiogram was done on _%#DDMM2005#%_ which did not show significant change from the previous echocardiogram.
RA|right atrium|RA|151|152|PROCEDURES PERFORMED|7. Chronic renal insufficiency. Baseline creatinine 1.5. PROCEDURES PERFORMED: 1. Right heart catheterization which showed elevated filling pressures. RA 10, PA 74/35, wedge 35, cardiac index 1.6, PA sat 61%. 2. Chest x-ray which showed cardiomegaly. 3. X-rays of the thoracic spine, lumbar spine, and pelvis.
RA|right atrium|RA|289|290|OPERATIONS/PROCEDURES PERFORMED|2. Ischemic cardiomyopathy with ejection fraction of 10%. 3. Status post BiV pacemaker with underlying rate of atrial fibrillation. 4. Hypothyroidism. 5. Hyperlipidemia. OPERATIONS/PROCEDURES PERFORMED: 1. Right heart catheterization was performed to look at the hemodynamics which showed RA pressure of 6, right ventricular pressure of 35/6, PA pressure of 35/20 with wedge of 21. The patient had Swan-Ganz catheter placed, and he was transferred to ICU for optimization before his mediastinoscopy and lymph node resection.
RA|rheumatoid arthritis|RA|200|201|ASSESSMENT AND PLAN|As I review some of the other laboratory studies that I do not quite understand, done I think from an infectious disease perspective, the hepatitis B surface antigen was 1.1, in the normal range. The RA factor was less than 20. Hepatitis C antibody was negative. Hepatitis B surface antigen was in the normal range. The ANA was less than 1, also normal, and the C3 and C4 were also in the normal range.
RA|right atrium|RA|131|132|HOSPITAL COURSE|He has a central venous catheter extending to the right atrium. There are mobile echos attached to the distal aspects of the right RA catheter. These most likely represent nonspecific stent, but regular lead vegetation cannot be completed excluded. There is a chance that it is a ______ echocardiography normal global LV systolic function.
RA|rheumatoid arthritis|RA.|158|160|PAST MEDICAL HISTORY|PROCEDURES: 1. Cardiac echo. 2. Chest x-ray x 2. 3. Troponins. PAST MEDICAL HISTORY: 1. COPD. 2. BPH. 3. Anemia. 4. Depression. 5. Arthritis, possible OA and RA. PRIMARY MD: Dr. _%#NAME#%_ at Smiley's. ALLERGIES: No known drug allergies.
RA|rheumatoid arthritis|RA.|105|107|PROBLEM #3|PROBLEM #2: COPD. The patient was stable throughout hospitalization. Discontinued ibuprofen. PROBLEM #3: RA. The patient's pain was treated with Tylenol and Tylenol #3. It is unclear whether he has RA and OA. He says that he had been followed by a rheumatologist in Wilder.
RA|rheumatoid arthritis|RA|198|199|PROBLEM #3|PROBLEM #2: COPD. The patient was stable throughout hospitalization. Discontinued ibuprofen. PROBLEM #3: RA. The patient's pain was treated with Tylenol and Tylenol #3. It is unclear whether he has RA and OA. He says that he had been followed by a rheumatologist in Wilder. Stable throughout hospitalization. PROBLEM #4: BPH. The patient straight caths three times, but is also on Flomax.
RA|right atrium|RA|223|224|BRIEF HISTORY OF PRESENT ILLNESS & HOSPITAL COURSE|She had an echocardiogram done to evaluate her hypoxia and shortness of breath, which showed a low-normal ejection fraction of 50-55%, severe pulmonary hypertension with right ventricular systolic pressure of 55 mm Hg plus RA pressure. The right ventricular function was a little decreased, and she was thought to be in some right ventricular failure. Pulmonary function tests were also ordered, but the patient was not able to completely perform these well.
RA|right atrium|RA.|213|215|PROCEDURES/TREATMENT PERFORMED|3. Atrial fibrillation. PROCEDURES/TREATMENT PERFORMED: 1. Transthoracic echo on _%#DDMM2005#%_ revealed normal global LV systolic function with moderately decreased RV function. RV systolic pressure was 36 above RA. 2. Coronary angiogram on admission: Revealed 100% mid RCA stenosis, .........% right PDA stenosis, ... ......worse than right PDA stenosis of 50% proximal and mid LDA stenosis and 70% ..........??(DUN), 50% proximal left circumflex stenosis.
RA|right atrium|RA|142|143|HOSPITAL COURSE|She presented and continued to have marked shortness of breath. She underwent a coronary angiogram and evaluation which showed severe AS with RA pressure of 4, RV pressure of 52/22 with a wedge of 12. She had an echocardiogram that also showed severe aortic stenosis with a elevated mean gradient of 50 mmHg.
RA|room air|RA,|236|238|DISCHARGE MEDICATIONS|_%#NAME#%_ was a Term-term AGA male infant, 3374 gm at 39 weeks plus 3 days gestation, with a length of 49.5 cm and head circumference of 33.25 cm. He was transferred to the NICU for tachypnea beginning 3 hours and saturation of 90% on RA, which improved to 100% with blow-by oxygen. The admission physical examination was normal newborn male.
RA|right atrium|RA.|285|287|HOSPITAL COURSE|In addition, her BNP was mildly elevated. She went on to have a transthoracic echocardiogram revealing that she had an ejection fraction of 60%, prolapse of her mitral valve with mitral regurgitation, listed as moderate. Severe tricuspid regurgitation with pulmonary pressures of 30 + RA. It was also noted that she had atrial fibrillation with rapid ventricular rate.
RA|right atrium|RA|311|312|OPERATIONS/PROCEDURES PERFORMED|HOSPITAL COURSE: 1. Chest pain and lower extremity edema. An echocardiogram was performed, which revealed normal global LV systolic function, mild mitral regurgitation, a large pericardial effusion, measuring 3 cm laterally, 3.2 cm anterior to the RV, 2 cm posterior to the RV, and 3.5 cm at the apex. There is RA collapse and diastole, but diastolic RV collapse is small. IVC dilated without respiratory variation, and a significant respiratory variant in the mitral inflow pattern, suggestive of tamponade physiology.
RA|right atrium|RA.|469|471|HOSPITAL  COURSE|He is actually eating much better, in addition. Because he was complaining of shortness of breath and not actually some chest pain in addition, he did have a cardiac evaluation which included transthoracic echocardiogram and this revealed an ejection fraction of approximately 55%, low to normal, hypokinetic area of the basilar inferior and apical septal wall. His aortic valve area is 1.5 cm squared with mild to moderate mitral regurg and pulmonary pressures of 33+ RA. He then went on to have a stress test, specifically adenosine thallium, and he had no inducible ischemia. Therefore, we are reassured that there was no evidence of any cardiac cause of this presyncopal episode and again seemed presumably from dehydration.
RA|right atrium|RA.|415|417|MEDICATION WERE|She is completely dependent on the prednisolone, and it is very difficult to taper down, even 2.5 mg p.o. Most recent pulmonary function shows an FVC at 1.69 liters, (59% of predicted value); FEV1 1.40 liters, (64% of predicted value); FEV1/FVC was 87 on _%#DDMM2005#%_. She also had right heart catheterization, PA pressure 59/13 with cardiac index 1.9, echo showed ejection fraction 70%, PA systolic 64mm Hz plus RA. She was from _%#CITY#%_, Minnesota, and was on a 300-mile trip yesterday.
RA|right atrium|RA.|162|164|OPERATIONS AND PROCEDURE PERFORMED|2. TPA lytic therapy for acute bilateral pulmonary artery and embolus. 3. 3. Echocardiogram dated _%#DDMM2006#%_. Findings: Poor views but notably dilated RV and RA. No obvious clots and in the RA. Estimated EF approximately 50-55%. No wall motion abnormalities. 4. 4. Follow-up echo on _%#DDMM2006#%_.
RA|right atrium|RA.|123|125|OPERATIONS AND PROCEDURE PERFORMED|3. 3. Echocardiogram dated _%#DDMM2006#%_. Findings: Poor views but notably dilated RV and RA. No obvious clots and in the RA. Estimated EF approximately 50-55%. No wall motion abnormalities. 4. 4. Follow-up echo on _%#DDMM2006#%_. Improved RV and RA function which also appears smaller in size.
RA|right atrium|RA|153|154|OPERATIONS AND PROCEDURE PERFORMED|No obvious clots and in the RA. Estimated EF approximately 50-55%. No wall motion abnormalities. 4. 4. Follow-up echo on _%#DDMM2006#%_. Improved RV and RA function which also appears smaller in size. BRIEF HISTORY AND HOSPITAL COURSE: A 73-year-old male with known history of DVT as well as pulmonary embolus in the past with previous hypercoagulable workup, who presents here with increasing dyspnea on exertion.
RA|right atrium|RA|133|134|DISCHARGE DIAGNOSES|b. CT scan of the head was unremarkable. b. Mc. RI/MRA of the brain was unremarkable showing no evidence of acute infarction. c. Md. RA of the neck showed no evidence of stenosis and the vessels appeared normal. e. Echocardiogram showed normal EF.
RA|right atrium|RA|196|197|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1: Mild congestive heart failure. The patient was diuresed at the outside hospital of unknown amount. The right heart cath reveals unremarkable hemodynamic numbers of an RA of only 7 and wedge of 17. The patient will likely need this high filling pressure to maintain an adequate cardiac output.
RA|rheumatoid arthritis|RA|198|199|PLAN|Will check amylase and lipase first thing in the morning. Will have Dr. _%#NAME#%_ or one of her partners see the patient in the hospital for further recommendations regarding treatment of both her RA and her SLE.
RA|right atrium|RA,|204|206|PAST MEDICAL HISTORY|11. History of rejection x2. 12. Osteonecrosis of the right hip. 13. Hemorrhoids. 14. Plantar fasciitis. 15. Echocardiogram unknown day with normal LV function, right ventricular systolic pressure of 34+ RA, mild to moderate left atrial enlargement, and mild mitral regurgitation. BRIEF HISTORY OF PRESENT ILLNESS AND PHYSICAL EXAM: Mr. _%#NAME#%_ is a 60-year-old male status post single lung transplant and above past medical history who developed chest palpitations while on dialysis on the day of admission.
RA|room air|RA.|157|159|DISPOSITION|_%#NAME#%_ was weaned off of ventilatory support and extubated at 1700 on _%#DDMM2002#%_. O2 sats initially were 80% on RA but quickly stabilized to >90% on RA. We recommend continued O2 sat monitoring. 3. Prematurity: 34 weeks gestation. 4. Hematology: Initial bilirubin at Fairview-_%#CITY#%_ was 9.9. _%#NAME#%_ received continuous Bililights.
RA|right atrium|RA|253|254|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: Pre heart transplant evaluation. OPERATIONS/PROCEDURES PERFORMED: Coronary catheterization performed on _%#MM#%_ _%#DD#%_, 2003, shows diffuse mild coronary artery disease without good target lesions. Cardiac index was 1.87 by FIC. RA pressure of 11, RV pressure 11, PA pressure of 42/22 with a mean of 30 and wedge pressure of 21. Bilateral carotid ultrasounds did not show any evidence of hemodynamically significant stenoses.
RA|right atrium|RA|135|136|HOSPITAL COURSE|Estimated EF is 25%. 5. Moderate to severe degree of mitral regurg. 6. The mitral valve inflow pattern suggests restriction. 7. RV and RA appear normal in size. 8. Mild tricuspid regurg with estimated RV pressure of 30 mmHg plus right atrial pressure. 9. Aortic valve is mildly sclerotic. There is mild to moderate degree of central aortic insufficiency.
RA|right atrium|RA|289|290|OPERATIONS/PROCEDURES PERFORMED|Psoriasis, rheumatoid factor positive. OPERATIONS/PROCEDURES PERFORMED: Procedure/Tests 1. Transthoracic echocardiogram on _%#MM#%_ _%#DD#%_, 2005, showed small pericardial effusion, loculated in the AV groove predominantly, minimal amount of fluid at the apex. No evidence for tamponade. RA and RV are fully expanded without RA or RV collapse. LV not underfilled. IVC is not dilated. 2. CT scan of the chest on _%#MM#%_ _%#DD#%_, 2005, showed large pericardial effusion, no PE, possible left lower lobe pneumonia.
RA|rheumatoid arthritis|RA|282|283|HOSPITAL COURSE|3. Rheumatoid arthritis. Because primary team recommended rheumatoid arthritis be discontinued, I contacted the doctor covering her primary rheumatologist in _%#CITY#%_ _%#CITY#%_. He agree with discontinuing the methotrexate and recommended that if the patient has flare up of her RA off the methotrexate that she should call and possibly be started on low-dose prednisone. DISCHARGE MEDICATIONS: At the time of discharge, aspirin 81 mg p.o. q. day, folate 1 mg p.o. q. day, Toprol 37.5 mg p.o. q. day, multivitamin 1 tablet p.o. q. day, Protonix 20 mg p.o. q. day, Pravachol 40 mg p.o. q. day, Tylenol No. 3 two tablets p.o. each evening and q.6 h. p.r.n. pain, Avapro 150 mg p.o. q. day, and Lasix 40 mg p.o. b.i.d. Methotrexate was discontinued.
RA|right atrium|RA|177|178|OPERATIONS/PROCEDURES PERFORMED|Hence, the patient will be sent home with a prescription. OPERATIONS/PROCEDURES PERFORMED: On _%#MM#%_ _%#DD#%_, 2006, the patient did have a right heart catheterization with a RA of 17, RV of 32/5 with an end of 15, pulmonary artery wedge pressure of 26, PA pressures of 42/23 with a mean of 32, and a Fick cardiac index was 2.75.
RA|right atrium|RA|360|361|PROCEDURES PERFORMED|DISCHARGE DIAGNOSES: 1. Primary pulmonary hypertension. 2. Hypertension. PROCEDURES PERFORMED: A transthoracic echo was performed on admission which showed normal global LV systolic function, mild increase in LV wall thickness, severe right ventricular dilatation, moderate right ventricular hypertrophy, RV systolic pressure severely increased at 81 mg above RA pressure, severe right atrial dilatation, no evidence of right to left shunt, severe tricuspid regurgitation. A right heart catheterization was performed on admission which showed a mean RA pressure of 11, RV pressure of 57/17, PA pressure of 60/16, and wedge pressure of 2.
RA|right atrium|RA|181|182|SUMMARY OF HOSPITAL COURSE|He does not drink or smoke. He takes good care of himself. He had a pacemaker placed yesterday Dr. _%#NAME#%_. He received a Medtronic Versa _%#DEVICE#%_ pacemaker with both RV and RA leads in place. Good pacemaker functions were noted. Because of his decreased ejection fraction, he was placed on metoprolol 25 mg b.i.d. We will have him follow up with both the device and heart failure clinics for titration of his heart medications gently.
RA|rheumatoid arthritis|(RA)|191|194|BRIEF HISTORY|She had a past medical history of some kind of bladder surgery and hysterectomy, also chronic recurrent cystitis, chronic obstructive lung disease (COLD) in a nonsmoker, rheumatoid arthritis (RA) with lupus erythematosus (LE). She stated she had been ill for at least a month prior to admission. No nausea, vomiting, or constipation. She denies any past medical history of hypertension (HTN) or phlebitis.
RA|right atrium|RA|205|206|PAST MEDICAL HISTORY|2. Coronary artery disease 1990, angioplasty for chest pain, no recent stress test. Echo in _%#MMDD#%_ showing mild LVH with normal global systolic function, increased pulmonary artery pressure of 49 plus RA with mild tricuspid regurgitation. 3. History of ischemic colitis. 4. Hypothyroidism. 5. Depression. 6. Recent C difficile infection. 7. Aspergillus of lung, last cultured in _%#DDMM2000#%_, status post fluconazole and itraconazole treatment.
RA|room air|RA.|163|165|1. FEN|She was diagnosed with respiratory distress syndrome. Since she was extubated she has not had any problems with breathing and continue to have saturations >92% on RA. 3. CV: No murmurs were appreciated and blood pressures remained stable throughout her admission. 4. Neuro: _%#NAME#%_ has a sacral hair tuft and dimple.
RA|right atrium|RA.|119|121|OPERATIONS/PROCEDURES PERFORMED|There is moderate to severe MR, moderate to severely decreased RV function, and moderate to severe TR. RVSP is 41 plus RA. 2. Right heart catheterization with Swan-Ganz catheter placement, dated _%#MM#%_ _%#DD#%_, 2006. Significant findings include a right ventricular pressure of 60/15 mmHg, PA pressure of 60/36 mmHg, and a mean pulmonary artery wedge pressure of 30 mmHg.
RA|UNSURED SENSE|RA|172|173|HOSPITAL COURSE|She was seen in consultation by both ophthalmology and neurology. The patient was evaluated with TFTs that showed free thyroxine to be 1.70. Her TSH was less than 0.03. T3 RA was unremarkable. The patient had an ear culture from drainage that grew pseudomonas that was pansensitive. She underwent a CT scan of her orbits which showed edema or inflammatory process involving the preseptal and post-septal soft tissues of the left orbit.
RA|right atrium|RA|166|167|HOSPITAL  COURSE|The permanent pacemaker is a St. Jude medical Victory XLDR model _%#DEVICE#%_, serial _%#DEVICE#%_, RV pacing lead, serial _%#DEVICE#%_ TC/52 serial _%#DEVICE#%_ and RA pacing lead 1688 TCx/46, serial _%#DEVICE#%_. The patient tolerated the procedure well without complications. She was then started on sotalol 120 mg p.o. b.i.d. and maintained normal sinus rhythm.
RA|right atrium|RA|199|200|HOSPITAL COURSE|During that right heart catheterization, they had also used Nipride to assess vasodilator responsiveness of his pulmonary vasculature. The right heart cath on _%#DDMM2006#%_ showed that his baseline RA pressure was 24, PA pressure was 77/41, mean PA pressure of 57 and wedge of 30. His baseline cardiac output was 5 with an index of 3.4. After giving Nipride, the patient's PA pressures decreased to 52/30 with a mean of 41 and the wedge pressure decreased to 22.
RA|right atrium|RA|198|199|KEY IMAGING STUDIES AND PROCEDURES PERFORMED DURING THIS HOSPITALIZATION|Interpretation summary: The RV systolic pressure was approximated at 36 mmHg plus the right atrial pressure. Mild concentric LVH. EF was estimated at 65-70%. LA is moderate to severely dilated. The RA is moderate to severely dilated. There is mild 1 aortic regurgitation. Rhythm was noted to be rapid atrial fibrillation.
RA|right atrium|RA.|301|303|PROCEDURES PERFORMED|ADMISSION DIAGNOSIS: CHF with atrial fibrillation. DISCHARGE DIAGNOSIS: Same. PROCEDURES PERFORMED: Transthoracic cardiac echo, which showed mildly decreased LV function with biatrial enlargement, mild MR, TR, and TI, with an EF of approximately 45%, with an estimated RV systolic pressure of 29 plus RA. HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old female with COPD, hypertension, atrial fibrillation, recurrent DVT's, on Coumadin, with a history of CHF, who presented with increased shortness of breath over one month, associated with some chest tightness with pain, radiating to the left shoulder, which was relieved with nitroglycerin.
RA|right atrium|RA,|249|251|PROCEDURES PERFORMED|ADMISSION/DISCHARGE DIAGNOSES: Flolan pump malfunction, with rebound pulmonary hypertension. PROCEDURES PERFORMED: Cardiac echo which showed normal LV function, decreased RV function, RV dilatation, with a right ventricular systolic pressure of 81+ RA, mild MR, moderate RA dilation. BRIEF HISTORY OF PRESENT ILLNESS: The patient is a 47-year- old female with scleroderma causing pulmonary fibrosis and pulmonary hypertension, who has been on Flolan therapy for the last 2-1/2 years.
RA|right atrium|RA,|139|141|PAST MEDICAL HISTORY|3. Laparoscopic cholecystectomy. 4. Last echo done in 2002 showed mild to moderate right atrial dilation, with RV systolic pressure of 71+ RA, with RV dilation, RVH, and moderate DR. The patient had previous cardiac catheterization in _%#DDMM2002#%_ which showed normal coronary, severe pulmonary hypertension with PA pressures of 75.
RA|right atrium|RA.|417|419|PROCEDURES PERFORMED|Pulmonary function tests revealed an FVC of 1.76, which is 68% of predicted; an FEV1 of 1.16, which is 56% of predicted, and FEF 25/75% of 0.59, which is 28% of predicted; and a DLCO of approximately 6.8, which is 31% of predicted. An echocardiogram performed during this hospitalization also revealed an ejection fraction that was visually estimated at 15%, a severe mitral regurgitation, and RV pressure of 58 plus RA. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 70-year-old woman with a long-standing history of smoking, who presents with three months of increasing dyspnea and weight loss.
RA|right atrium|RA|179|180|HISTORY OF PRESENT ILLNESS|Recommended dosage at this time would be Viagra 25 mg p.o. t.i.d. to be titrated accordingly. His repeat echocardiogram this admission revealed pulmonary artery pressures of 110+ RA which is not significantly changed from previous. The patient was treated with his usual dose of Lasix with a mild amount of diuresis.
RA|right atrium|RA|161|162|HOSPITAL COURSE|However a CMV antigenemia and a CMV rapid-shell culture were both negative in the hospital. Therefore, this was discontinued. AFB was negative. Admission ABG on RA 71/7.37/30/53 pO2. CBC 2.8/13.7/111, ANC 1.4. PROBLEM #2: Malnutrition. The patient's nutritional state was considered fairly poor by both the Cardiology Transplant Service and the Nutrition Service.
RA|right atrium|RA.|347|349|CHIEF COMPLAINT|He has had left lung lobectomy in 1996. His past medical history is significant for atrial fibrillation, farmer's lung in 1996, idiopathic cardiomyopathy, congestive heart failure with an ejection fraction of 25 percent, with a history of nonsustained Vtach. He is noted to have cor pulmonale and pulmonary hypertension with a pressure of 53 plus RA. He has had pulmonary nodules diagnosed initially in _%#DDMM2003#%_ which are indeterminate. Followed by Dr. _%#NAME#%_. Severe chronic obstructive pulmonary disease (COPD).
RA|right atrium|RA|208|209|HOSPITAL COURSE|1. Ischemic cardiomyopathy, congestive heart failure. The patient had a right heart catheterization on _%#MM#%_ _%#DD#%_, 2004, which showed severe pulmonary hypertension, congestive cardiomyopathy, elevated RA pressures at 50 mmHg, and left-sided filling pressures. wedge pressure 30. Severe pulmonary hypertension. Pulmonary artery pressure 85/25.
RA|right atrium|RA|149|150|HISTORY OF PRESENT ILLNESS|The left atrium was mildly dilated with mildly increased filling pressure. Tricuspid regurg grade with 1+ on a scale of 0-4+. PA pressure is 42 plus RA and RA pressures were elevated. Left- sided pleural effusion. The patient had a resting thallium done on _%#DDMM2004#%_. This showed a small anteroapical infarction with viability demonstrated in the remainder of the myocardium.
RA|right atrium|RA,|110|112|HOSPITAL COURSE|It says .....................systolic LVF seen. Mild MR sclerotic AOV, mild MAC, mild TR, dilated RV, oblique RA, normal PAP, mild prolapse of anterior MVA leaflet. EF is 55 plus percent. HOSPITAL COURSE: The patient, while he was in the hospital, continued to improve.
RA|right atrium|RA,|423|425|HOSPITAL COURSE|HOSPITAL COURSE: Patient had clinical signs of biventricular failure. This was confirmed by transthoracic echocardiogram that showed severely decreased LV function with estimated EF of 20%, mild increase in LV wall thickness, mild MR, moderate left atrial enlargement, mild RV dilatation, and moderate RA dilatation, moderate severe decrease in RV function, mildly increased RV systolic pressure, approximately 36 mm above RA, moderate TR and mild to moderate LV dilatation. Patient was initially aggressively diuresed with Lasix with an excellent clinical response.
RA|right atrium|RA|293|294|HOSPITAL COURSE|The remaining vessels were normal. His EF confirmed by V-gram, was again approximately 20% with portal hypokinesis suggestive of non-ischemic elevated function. A right heart cath was performed as well on _%#DDMM2002#%_, which showed mild secondary pulmonary arterial hypertension with a mean RA pressure of 14. RV pressure was 36/14; PAA pressure 36/24 - mean 28; and wedge pressure was 20. Cardiac output of 4.6 with an index of 1.9 L/min/M2.
RA|room air|RA|178|179|HOSPITAL COURSE|Baseline hemodynamics were done, which revealed a mean of 15, RV pressure of 36/12, PA pressure of 35/14, with a mean of 24, and left atrial pressure of 16. An SVC sat was 72.9, RA sats 82.4, RV sats 90, PA sat 92.8, and pulmonary vein sats of 99.5%. ASD was crossed using a 4-French multi-purpose catheter.
RA|right atrium|RA;|336|338|PROCEDURES PERFORMED DURING THIS HOSPITALIZATION|9. Deconditioning. 10. Malnutrition. PROCEDURES PERFORMED DURING THIS HOSPITALIZATION: 1. Transthoracic echo on _%#MM#%_ _%#DD#%_, 2004, which is suggestive of diastolic dysfunction, moderate RV dilatation, and RV pressure 49 plus RA. 2. Transesophageal echocardiogram that showed mild MR, moderate TR, RV pressure estimated at 44 plus RA; no evidence of thrombus; no ASD, including bubble study; no evidence of vegetation, but significant atheromatous disease in descending aorta.
RA|right atrium|RA,|232|234|HOSPITAL COURSE|This would be consistent by the less than rebuffed response noted to large platelet transfusion. 4. Cardiomegaly. Mr. _%#NAME#%_ received an echocardiogram while he was inpatient which noted mild LVH, moderately dilated LV, LA, and RA, mild MR, a mildly stenotic aortic valve that was bicuspid without any sort of vegetation. No AI was detected. He also had mild TR and overall normal LV function with an estimated EF of approximately 60%.
RA|right atrium|RA|250|251|HISTORY OF PRESENT ILLNESS|At followup prior to this admission, the patient was found to continue to have a decreased ejection fraction with an elevated wedge pressure. For this reason, he was admitted. On the patient's right heart catheterization on the day of admission, his RA pressure was 17, PA systolic pressure was 36, and his wedge was 28. His echocardiogram on the same day is as above, demonstrating an ejection fraction of about 15%.
RA|right atrium|RA.|271|273|PROCEDURE|2. Head CT showed old infarct in the left occipital lobe and right thalamus, and otherwise atrophy and small ischemic changes. 3. Transthoracic echocardiogram showed ejection fraction of 55%, mild mitral regurg, moderate tricuspid regurg with pulmonary pressures of 65 + RA. HOSPITAL COURSE: 1. Hypoglycemic episode. The patient presented with an episode of some altered mental status which appeared to be secondary to hypoglycemic episode.
RA|right atrium|RA|144|145|PROCEDURES AND IMAGING|DISCHARGE DIAGNOSES: 1. Sustained monomorphic ventricular tachycardia. 2. Ischemic cardiomyopathy. PROCEDURES AND IMAGING: 1. Right heart cath: RA of 5, PA of 23/11, PCWP of 12. 2. Intraaortic balloon pump placement. 3. Cardiopulmonary stress test on _%#DDMM2007#%_.
RA|right atrium|RA|172|173|LABORATORY|Chest x-ray has been personally reviewed by me, and shows all of the leads in adequate position. There is no evidence of heart failure. LV is borderline enlarged. There is RA enlargement. This chest x-ray is not significantly different from before. Electrocardiogram was personally reviewed by me. It is not significantly different from the electrocardiogram done on _%#DDMM2007#%_.
RA|room air|RA.|200|202|DISCHARGE CONDITION|They are consistent with alcoholic liver disease. Titers for hepatitis B and hepatitis C were both negative during this hospitalization. DISCHARGE CONDITION: Stable. T94.5 P55 BP120/65 R16 Sat 95% on RA. In no acute distress. HEENT sclera nonicteric neck no lymphadenopathy. COR Reg s MRG. Chest CTA bilaterally. Abd soft NTND no hepatosplenomegaly.
RA|right atrium|RA|127|128|SUBJECTIVE|His gradient across the aortic valve is only 16.2 mean gradient. He did have elevated right ventricular pressure of 51/10 with RA pressure of 15. He has not had any syncope, angina or marked shortness of breath but has had progressive decrease in his aortic valve area etc.
RA|right atrium|RA.|207|209|OPERATIONS AND PROCEDURE PERFORMED|Posterior lateral basal segments contracts but anterior septal worse. There is some septal lateral dyssynchrony. RV borderline dilated. There is moderate pulmonary hypertension with RV systolic pressure 43+ RA. BRIEF HISTORY: _%#1914#%_-year-old female who presents here with some shortness of breath.
RA|right atrium|RA|210|211|PHYSICAL EXAMINATION|His INR is 4.2. I do not know what it was yesterday but apparently was not dramatic. Echocardiogram done in the emergency room shows a small seemingly compressed cardiac anatomy. The right ventricle was small. RA is small. There was not definite compression, but these chambers appear compressed. There is a loculated pericardial effusion of the apex, the anterior wall, lateral wall, less so on the inferior wall.
RA|room air|RA.|216|218|1. FEN|Oxygen requirements subsequently increased and she placed on nasal CPAP again for a short while on _%#DDMM2003#%_ _%#DDMM2003#%_ (DOL 3-4). She was weaned to room air on _%#DDMM2003#%_ (DOL 8) and has been stable on RA. 3. ID: _%#NAME#%_ was initially placed on empiric antibiotics of Ampicillin and Gentamicin until blood cultures were negative for 48 hours.
RA|room air|RA|202|203|1. FEN|2. CV- _%#NAME#%_ had a gr 11/VI SEM along the LSB on admission thought to be a PDA murmur that was NOT present on the discharge exam. 3. Resp- _%#NAME#%_ was able to maintain adequate O2 saturation on RA (96-99%). 4. GI- _%#NAME#%_ had mild jaundice from the head to trunk with a bilirubin of 9.6 on day of discharge. 5. Neuro- _%#NAME#%_ likely developed a mild left Erb's palsy from the difficult delivery.
RA|room air|RA,|211|213|1. FEN|_%#NAME#%_ was allowed to breastfeed on an ad lib demand schedule. He is currently working on improving his breastfeeding efforts. 2. Respiratory- On admission _%#NAME#%_ was maintaining adequate oxygenation on RA, but he soon had a desaturation episode to the mid 80's requiring supplemental O2. He was kept on supplemental O2 to keep his saturation >95% and weaned to RA.
RA|room air|RA.|229|231|1. FEN|Mom plans to breastfeed and bottle-feed. 2. Respiratory: An ABG and CXR were obtained on admission due to _%#NAME#%_'s respiratory status and found to be normal. _%#NAME#%_ was placed on supplemental O2 and was weaned quickly to RA. She was able to maintain adequate oxygenation on RA. It is likely that the initial respiratory distress was due to delayed intrauterine transition.
RA|room air|RA.|282|284|1. FEN|Mom plans to breastfeed and bottle-feed. 2. Respiratory: An ABG and CXR were obtained on admission due to _%#NAME#%_'s respiratory status and found to be normal. _%#NAME#%_ was placed on supplemental O2 and was weaned quickly to RA. She was able to maintain adequate oxygenation on RA. It is likely that the initial respiratory distress was due to delayed intrauterine transition. She had no respiratory distress with feedings. 3. ID: A sepsis evaluation was done on admission.
RA|right atrium|RA.|184|186|PROCEDURES|Left ventricular ejection fraction is 45 to 50%. Aortic stenosis with a valve area of 0.7 cm and mild aortic insufficiency. Pulmonary artery systolic pressure is 33 mm of mercury plus RA. TSH upon discharge is 1.27 and INR is 2.21. HOSPITAL COURSE: 1. Atrial fibrillation with rapid ventricular response. Mr. _%#NAME#%_ is a 64-year-old male with a known history of paroxysmal atrial fibrillation who was admitted for rapid heart rate and found to be back into atrial fibrillation with rapid ventricular response.
RA|right atrium|RA|147|148|STUDIES DURING THIS HOSPITALIZATION|RFA demonstrated the in-stent restenosis was not significant. STUDIES DURING THIS HOSPITALIZATION: 1. Right heart cath on _%#MM#%_ _%#DD#%_, 2006: RA pressure 2, PA pressure 33/12 with mean of 20, veg of 8. 2. Left heart cath: Please see above text for result.
RA|right atrium|RA|386|387|PROCEDURES AND TESTS DONE WHILE HOSPITALIZED HERE INCLUDE|1. Echocardiogram, _%#DDMM2006#%_, was a technically difficult study, although did show some normal global LV systolic function, moderate increase in LV wall thickness, mild-to-moderate right ventricular dilatation, moderate mitral stenosis, as well as aortic stenosis, RV systolic pressures mildly increased approximately 31 mmHg. 2. Right heart cath done _%#DDMM2006#%_, which showed RA pressure mean of 18, RV pressures of 53/6 with an end RV pressure of 20, a pulmonary artery wedge pressure mean of 19, PA pressure of 58/9 with a mean of 35, a FICK cardiac output of 10.96 with a FICK cardiac index of 4.52, PA saturations 68.9. HOSPITAL COURSE: This lady was admitted orally with shortness of breath, dyspnea on exertion, which had been worsening for about a week.
RA|rheumatoid arthritis|RA.|130|132|HOSPITAL COURSE|TB was felt to be unlikely considering its appearance and that she was PPD negative 2 years ago when Remicade was started for her RA. 3. Atypical pulmonary fibrosis: The patient is believed to have atypical pulmonary fibrosis based on imaging and history of rheumatoid arthritis.
RA|right atrium|RA|178|179|DIAGNOSTIC STUDIES|4. Chronic atrial fibrillation. 5. Cellulitis in right lower extremity. 6. Clostridium difficile infection. DIAGNOSTIC STUDIES: 1. Right heart catheterization on _%#DDMM2007#%_: RA pressure with a mean of 8, PA pressure 39/15 with a mean of 26, PCWP with mean of 13, PVR of 3.1, thick cardiac output of 4.2 and thick cardiac index of 2, thermodilution cardiac output of 3.4 and thermodilution index of 1.6. Findings consistent with mild secondary pulmonary arterial hypertension, mild reduction in cardiac output, mild elevation in PCWP and mild increase in PA pressures.
RA|right atrium|RA|181|182|PROCEDURES|Right atrial size is normal. Mitral valve leaflets appeared normal. No evidence of stenosis or prolapse. There is mild regurgitation of mitral valve. RVSP is equal to 39 mmHg, thus RA pressure. Tricuspid valve is mild regurgitation. Trace aortic regurgitation. The pulmonic valve is not well seen, but grossly normal. 3. Repeat coronary angiogram on _%#DDMM2007#%_. Findings: Normal filling pressure, mean right atrial pressure was 4, RV was 30/4, PA 24/12 with a mean PA pressure of 18, mean PCWP was 8.
RA|right atrium|RA|237|238|MAJOR PROCEDURES DONE DURING THIS ADMISSION|There is normal left ventricular wall thickness. Left ventricular systolic function is normal. Ejection fraction more than 55%. There is no regional wall motion abnormality. There is moderate pericardial effusion predominantly above the RA and in the AV groove between the RA and RV work measures 1.3-1.5 cm and to a lesser degree around the lateral wall (1.5 cm).
RA|right atrium|RA|178|179|MAJOR PROCEDURES DONE DURING THIS ADMISSION|Ejection fraction more than 55%. There is no regional wall motion abnormality. There is moderate pericardial effusion predominantly above the RA and in the AV groove between the RA and RV work measures 1.3-1.5 cm and to a lesser degree around the lateral wall (1.5 cm). The RV is normal in size and function. The RV is fully expanded.
RA|right atrium|RA.|226|228|PROCEDURES|10. EKG showing normal sinus rhythm, no ST-T wave abnormalities or conduction abnormalities. 11. Cardiac echo showing normal LV function, EF 65-70%, no wall motion abnormality, normal chamber sizes, moderate TR, pressures 36+ RA. HISTORY OF PRESENT ILLNESS: Please see admission H&P. PAST MEDICAL HISTORY: Please see admission H&P.
RA|right atrium|RA|336|337|PRINCIPAL PROCDURES|3. Right heart catheterization and biopsy on _%#DDMM2005#%_ demonstrating grade 3A rejection with a PA pressure of 32/23, pulmonary capillary wedge pressure 20, and pulmonary artery saturation of 49%. 4. Repeat right heart catheterization and biopsy on _%#DDMM2005#%_ demonstrating no evidence of rejection with a PA pressure of 51/24, RA pressure of 18/22, pulmonary capillary wedge pressure, with a pulmonary artery saturation of 63% and a cardiac index of 2.5. 5. Echocardiogram transplanted heart demonstrating normal global left ventricular systolic function with mild aortic regurgitation with ejection velocity of ________ meters per second.
RA|right atrium|RA|175|176|HISTORY OF PRESENT ILLNESS|There was an FFR performed of the proximal circ which was 0.83. The LAD and RCA had no significant stenosis. She also had a right heart catheter that showed a wedge of 14, an RA of 7, and a PA of 40/19. She was admitted to the floor and continued on conservative medical therapy and antibiotics for her Streptozocin viridans bacteremia.
RA|right atrium|RA.|201|203|PROCEDURES|Severely decreased LV function with visually estimated ejection fraction of 25%. Mild increase in LV wall thickness. Mild left atrial enlargement and mitral regurgitation. RV systolic pressure is 29 + RA. RV size and function normal. Compared to transthoracic echocardiogram from 2003, this represented no change. HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old female with a history of ischemic cardiomyopathy and one prior heart failure exacerbation in 2003.
RA|right atrium|RA|257|258|HISTORY OF PRESENT ILLNESS|The patient was then transferred here. A stat echo here showed a small pericardial effusion without any tamponade physiology, normal LV function, severe pulmonary hypertension with pulmonary depresses at 70+ RA. The patient had hypertension, RV dilatation, RA dilation, decreased RV function, and 4+ TR. On admission, the patient's blood pressure was 101/70. Pulse was in the 110s. The patient was started on a Lasix drip. Continued on Flolan and Viagra as well as Coumadin.
RA|right atrium|RA|174|175|DISCHARGE DIAGNOSIS|She has Eisenmenger physiology. She is continuous Flolan. Her last right heart catheterization was done in _%#MM#%_ of 2004 for Flolan initiation. At that point in time, her RA pressure was 12 mm. Mean PA pressure was 112. Her pulmonary capillary wedge pressure was 9. Her cardiac index was 10 L per minute.
RA|right atrium|RA|196|197|PAST MEDICAL HISTORY|History of coronary artery disease, status post myocardial infarction and status post coronary artery bypass graft in 2000. Echocardiogram in 2003 showed an ejection fraction of 65% and increased RA pressure, consistent with moderate pulmonary hypertension. History of hyperlipidemia. History of hypothyroidism. Parkinson disease. Depression. PAST SURGICAL HISTORY: Bilateral hip replacements.
RA|right atrium|RA.|179|181|HOSPITAL COURSE|May consider starting salmeterol in the future. Problem #2. Pulmonary hypertension: The patient has significant pulmonary hypertension with a RV systolic pressure of 88 above the RA. Cardiology and Pulmonology consults were obtained and they suggested starting the patient on Viagra 20 mg p.o. q.8 hours for pulmonary hypertension.
RA|rheumatoid arthritis|RA|448|449|HEENT|Exam: Gen: lying in bed, tired appearing, alopecia HEENT: EOMI, PERRLA, A&Ox3 Pulm:CTABL CV:nl s1s2 no m/r/g Abd:soft nt/nd nl bs Neuro: 3/5 strength with eye closure, 4/5 shoulder shrug, cranial nerves otherwise intact, 3/5 proximal UE strength, 3/5 proximal and distal LE strength, 1+ left patellar refelx, no reflex on right, no ankle jerks,no clonus Labs, radiology studies, and medications reviewed. Assessment and Plan: 47 yo woman with SLE, RA now with relatively rapid onset weakness. Ddx includes toxins (medications, organophosphates, steroid myopathy, botulism), autoimmune process (Myasthenia Gravis, paraneoplastic syndrome, MS), Miller-Fisher variant of GBS, myopathy, syringomyelia.
RA|rheumatoid arthritis|RA,|98|100|FAMILY HISTORY|10. Glucosamine sulfate. 11. Metoprolol 50 mg b.i.d. ALLERGIES: None. FAMILY HISTORY: Cousin with RA, no other autoimmune diseases in the family. SOCIAL HISTORY: Lives independently in a condominium in _%#CITY#%_. No tobacco, alcohol or illicits currently, did quit smoking at age 40.
RA|rheumatoid arthritis|RA|190|191|PHYSICAL EXAMINATION|LUNGS: Clear to auscultation bilaterally without wheezes or crackles. ABDOMEN: Positive bowel sounds, nontender, nondistended, no hepatosplenomegaly. She is cachectic. EXTREMITIES: Positive RA changes of upper and lower extremity joints. She does have redness, warmth and some ulcers which are dressed at this time of her right lower extremity.
RA|right atrium|RA|206|207||His atrial flutter was first detected in _%#DDMM2007#%_. He does not have any history of syncope. On _%#DDMM2007#%_, he had undergone ablation procedure at EP lab. A radiofrequency ablation was done to the RA isthmus. The patient went in to the lab in atrial flutter and it was diagnosed to be counter clockwise atrial flutter.
RA|room air|RA|318|319|PE|Mr. _%#NAME#%_ lives with his wife in _%#CITY#%_. They have two sons _%#NAME#%_ and _%#NAME#%_, all present at hospital today. No sick contacts FH: Mother- stroke in 70's; HTN Father: Died of MI at 92 Sister: Mi at 83 Brother: Died of asthma attack at 74 PE: Vitals: T- 98.9, P- 88, BP- 147/79, RR- 24, 02 sat: 94% on RA General: NAD, mild resp distress Head: NT/NC Eyes: PERRL, EOMI OP: no erythema/exudate Neck: w/o LAD or thryomegaly CV: RRR; exam comp.
RA|right atrium|RA|212|213|BRIEF HOSPITAL COURSE|His history also revealed that he is eating significantly salty food lately as well as not adhering to a recommended fluid restriction. Admission echocardiogram revealed a right ventricular systolic pressure 44+ RA and his prosthetic aortic valve had a mean gradient of 33 mmHg. This gradient across the aortic valve was similar to gradient seen in echocardiogram in _%#DDMM2007#%_.
RA|right atrium|RA|243|244|MAJOR PROCEDURES DONE DURING HOSPITALIZATION|Ejection fraction is more than 55%. Paradoxical septal motion is consistent with right ventricular volume overload. The right ventricle is moderately dilated. The right ventricular systolic function is moderately reduced. RVSP is 67 mmHg plus RA pressure. 2. Upper GI endoscopy. Findings: The esophagus was normal. The examined duodenum was normal. Two pedunculated medium polyps with a bleeding and stigmata of recent bleeding were found on the lesser curvature of the stomach.
RA|UNSURED SENSE|RA|235|236|LABORATORY DATA|CK 185, LD 464, magnesium 2.9, phosphorus 4.1. TSH 1.17, some labs from _%#MMDD#%_ from the clinic at _%#CITY#%_ Family Physicians show a creatinine at that time of 1.10. Alkaline phosphate of 148. Hemoglobin of 12.4, white count 6.5, RA of 9, ESR 38, A1c 5.4. ASSESSMENT/PLAN: 1. Proximal muscle weakness with also some hand grip weakness and decreased ability to write, unclear etiology.
RA|right atrium|RA|149|150|PERTINENT PROCEDURES AND INVESTIGATIONS|Peak velocity is 0.8 m/sec. Severely decreased right ventricular function. Moderate right ventricular dilatation. Normal PA pressure at 23 mmHg plus RA pressure. 2. CT of the head, dated _%#MM#%_ _%#DD#%_, 2006. No significant interval change. No evidence for acute hemorrhage. 3. CT of the neck without contrast, dated _%#MM#%_ _%#DD#%_, 2006.
RA|right atrium|RA,|286|288|OPERATIONS/PROCEDURES PERFORMED|2. Chest pain, unlikely cardiac. 3. Atrial fibrillation. OPERATIONS/PROCEDURES PERFORMED: 1. Transthoracic echo with the following findings: Mild increase in LV wall thickness, normal global systolic function, RV systolic pressure significantly increased at approximately 58 mmHg above RA, moderate left atrial enlargement, moderate right atrial dilatation, mild mitral regurgitation, prosthetic aortic valve function normal, mean gradient 7 mmHg.
RA|right atrium|RA|209|210|ECHOCARDIOGRAM|ECHOCARDIOGRAM: Urgent bedside echo showed large pericardial effusion. Estimated pericardial fluid above 500-600 cc at least, with some sign of tamponade. There is some collapsing sign during diastole both in RA and RV. Dr. _%#NAME#%_ was called. Because of increased INR, we will reverse the patient with FFP, as well as with the factor VII, also typing and cross, and we will give two units of blood transfusion.
RA|right atrium|RA|129|130|PAST MEDICAL HISTORY|The defect was crossed and the balloon sized to 21 mm. A 24 mm Amplatzer device was used to occlude the defect with no problems. RA angiogram follow-through showed the device to be in a stable position. The procedure was uncomplicated. The sheaths were left in and were pulled after the ACT fell to below 180 seconds.
RA|right atrium|RA|368|369|PAST  MEDICAL HISTORY|She otherwise does have a loose cough but denies any fever or chills, she also denies any chest pain and denies any lower extremity edema. PAST MEDICAL HISTORY: Is significant for Alzheimer dementia, COPD, chronic left knee pain, history of knee surgeries, hypertension, cervical cancer status post hysterectomy, pulmonary hypertension with pulmonary pressures of 44+ RA and some mild decreased left ventricular systolic function estimated by an echocardiogram on _%#DDMM2006#%_. She otherwise had normal LV size and function. She also had a CT of the chest at that point that was negative for PE, however, did show a small left lung nodule that needs to be followed up in a few months.
RA|right atrium|RA|162|163|BRIEF HISTORY OF PRESENT ILLNESS|The patient describes increasing dyspnea with activity as well as occasional chest tightness with shortness of breath. Right heart cath on _%#DDMM2007#%_ showing RA pressure of 9, PA pressure 90/40 with a mean of 56, wedge pressure 40 _____ and right ventricular pressure 90/7.
RA|right atrium|RA|199|200|HOSPITAL COURSE|He had an ablation procedure performed after which he had his pacer turned off secondary to a pacer-induced (_______________) atrial arrhythmia after he had ablation burns after cardiomapping of the RA to a large area in the right septal area. He had a transseptal puncture and cardiomapping of the LA with burns in the root of the LA appendage.
RA|right atrium|RA|225|226|PAST MEDICAL HISTORY|There is severe biatrial enlargement with atria appearing larger than two ventricles. There are moderate to heavy mitral annular calcifications. Patient's peak velocity tricuspid regurgitation is 3.2 mm per second. Estimated RA pressure of 15 to 20 mm of mercury and estimated PA systolic pressure is in the region of 60 to 65 mm of mercury, which was consistent with moderate to severe pulmonary hypertension.
RA|right atrium|RA.|157|159|PROCEDURES|Trace aortic insufficiency. Mild left atrial enlargement. Normal right ventricular systolic function and size. Mild ventricular systolic pressure of 28 plus RA. Left ventricular hypertrophy and diastolic dysfunction suggested. 3. Chest x-rays which showed prominent congestive heart failure initially and improved after the thoracentesis.
RA|rheumatoid arthritis|RA|351|352|HISTORY OF PRESENT ILLNESS|This also complicates her social situation. For these reasons, the patient is being admitted for pain management, for an evaluation of her narcotic use and an attempt once again to come up with a better plan for her pain management and narcotic care plan. Possibility also is that she has worsening costochondral/sternal RA involvement or generalized RA flare and an attempt will be made to determine if she would benefit from both local cortisone injections, as well as an approach to her RA management.
RA|rheumatoid arthritis|RA|210|211|HISTORY OF PRESENT ILLNESS|She has had success with Kineret in the past. She has never been able to qualify for Embral in the past due to supply/production problems and her MA status. Perhaps she would be a candidate for more aggressive RA treatments. PHYSICAL EXAMINATION: GENERAL: The patient is sobbing during the entire examination.
RA|right atrium|RA|150|151|HISTORY OF PRESENT ILLNESS|The catheterization procedure was uneventful, and her right heart catheterization revealed moderate pulmonary hypertension with a PA mean of 39 mmHg, RA mean of 5, and a PA saturation of 72%. SVC saturation of 64%, aortic saturation of 94%, right atrial saturation of 75%, systemic flow of 3.92, pulmonary flow is 5.25, and Qp/Qs ratio 1.36. Her Fick cardiac index based on the SVC saturation is normal at 2.7. Her pulmonary angiogram revealed dilated pulmonary artery and severe biatrial enlargement, exact location of the shunt could not be visualized.
RA|right atrium|RA,|162|164|DISCHARGE DIAGNOSIS|Severe TR. Moderate pulmonary regurgitation. Small pericardial effusion. 2. Right heart catheterization performed on the _%#MM#%_ _%#DD#%_, 2005, showed elevated RA, RV, PA, and pulmonary capillary wedge pressure. Her cardiac output by Fick was 1.8 while her cardiac index was 1.2. 3. Ultrasound of her carotids showed no evidence for hemodynamically significant stenosis in the bilateral internal carotid arteries by velocity criteria.
RA|right atrium|RA,|173|175|HISTORY OF PRESENT ILLNESS|Right femoral venous access was obtained, and an 8-French sheath was placed. Right heart hemodynamic measurements were made which were in normal limits. Oximetry run on the RA, SVC, and IVC were done. Amplatz wire was placed with the help of 7-French Berman wedge catheter. Sizing balloon was inserted over the wire which measured 14.5 mm.
RA|right atrium|RA.|181|183|PROCEDURES PERFORMED|There was mild to moderate right ventricular dilatation with moderately decreased right ventricular function. Right ventricular systolic pressure was severely increased to 61 above RA. There was moderate mitral regurgitation and moderate tricuspid regurgitation. 4. A coronary angiogram was performed on _%#DDMM2006#%_ which showed mild to moderate coronary artery disease without hemodynamically significant lesions and out of proportion to the severity of her heart failure and cardiomyopathy.
RA|right atrium|RA|157|158|HOSPITAL  COURSE|An echocardiogram revealed that she has an ejection fraction of 55-60%. However, she has mild concentric LVH. She has some pulmonary hypertension with a 60+ RA and actually has fairly severe pulmonary hypertension and mild right ventricular hypertrophy with normal right ventricular systolic function. However, the patient clinically appeared to have congestive heart failure with a mildly elevated BNP and chest x-ray that showed pulmonary edema with mild pleural effusions.
RA|right atrium|RA.|189|191|OPERATIONS/PROCEDURES PERFORMED|5. Transthoracic echo. _%#MM#%_ _%#DD#%_, 2006. Significant findings included severely decreased LV function with EF 15%, moderate to severe MR, mild to moderate TR, and an RVSP of 31 plus RA. 6. Chest PA and lateral on _%#MM#%_ _%#DD#%_, 2006. Findings included small bilateral pleural effusions with (_______________) lateral atelectasis.
RA|right atrium|RA.|252|254|PAST MEDICAL HISTORY|8. Congestive heart failure with ejection fraction of 25%. She has had coronary angiograms before showing no significant coronary artery disease. 9. Mitral valve replacement with porcine valve. 10. Moderate pulmonary hypertension with pressures of 48+ RA. 11. History of obstructive sleep apnea uncertain, however, if she is on BiPAP. 12. Osteoarthritis. 13. Herpes zoster. 14. History of meningitis. ALLERGIES: Sulfa and penicillin.
RA|right atrium|RA.|308|310|HOSPITAL COURSE|Despite not receiving the full dose of TPA, he did certainly have good results with this in that he became much less short of breath, less symptomatic and had less lower extremity edema. In addition, a follow-up transthoracic echocardiogram revealed that he does have improved pulmonary pressures at 29 plus RA. Right ventricle is still dilated, however, it has decreased right ventricular systolic function. He did continue, however, to have left-sided systolic dysfunction and inferior wall motion abnormality.
RA|room air|RA.|235|237|HISTORY OF PRESENT ILLNESS|She presented to the F- UMC _%#MMDD#%_ with shortness of breath and light-headedness. The patient denied melanic stools or BRBPR. Within a year, blood pressure was 95/60, heart rate 130, temperature 97.5, respiratory rate 16, SPO 299% RA. PHYSICAL EXAMINATION: Remarkable for the presence of bilateral diffuse rales, tachycardia, splenomegaly.
RA|right atrium|RA,|138|140|HISTORY OF PRESENT ILLNESS|There was a large respiratory variation of PA wedge pressure measurement. There is equialization of RA, RV and LV diastolic pressure. The RA, LVEDP and wedge pressure were also significantly elevated with a wedge of approximately 20. This improved postnitro infusion. Findings are suggestive of possible constriction versus restriction.
RA|rheumatoid arthritis|RA,|161|163|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Subcutaneous abscess, mid left sternum within the soft tissue, not involving any bony structures as seen in the clinic ten days ago. 2. RA, longstanding on prednisone, methotrexate, and Aredia. 3. Melanoma, right leg with resection in her past. 4. Prosthetic right eye. 5. Atrial fibrillation. 6. History of recurrent pneumonia.
RA|right atrium|RA|847|848|PAST MEDICAL HISTORY|12. Coumadin 5 mg p.o. daily. 13. Oxycodone 10 mg p.o. twice daily. PAST MEDICAL HISTORY: Metastatic nonsmall cell lung cancer to pleura and mediastinum, diagnosed apparently almost four years back, status post chemo and radiation therapy in _%#DDMM2007#%_, history of GERD, high blood pressure, coronary artery disease, MI in _%#DDMM2006#%_, status post LAD stent x2, history of VT during that admission, chronic anemia, mediastinal lymphadenopathy, multiple tight pleurodesis procedure, malignant pericardial effusion, status post pericardial window, history of hit _____ in _%#DDMM2006#%_; history of PE, on Coumadin since _%#DDMM2007#%_; last echo on _%#DDMM2007#%_ showing EF of 75%, mild left ventricular concentric hypertrophy, borderline RV enlargement, moderate LAE, mild RA dilatation, dilated inferior vena cava suggestive of increased RA pressure, mild MR, mild TR, mild AS, gradient of 21 mmHg, mild aortic root dilatation. RSVP is 46 mmHg _____ _%#DDMM2006#%_ 100% LAD stenosis proximal collateral to mid RCA, 70% LAD mid to D1 and D2.
RA|right atrium|RA|304|305|HOSPITAL COURSE|The patient also had hemodynamics checked with the patient supine and sitting up for evaluating any significant changes in his cardiac index along with his orthostatic symptoms, however, the patient did not have any significant change in his hemodynamics with positional changes. Given the patient's low RA pressure it was thought that the patient's orthostasis is not significantly related to the volume of fluid removed during dialysis and was probably more related with the patient's severe dysautonomia Secondary to his diabetes.
RA|right atrium|RA.|196|198|IMPORTANT PROCEDURE AND INVESTIGATIONS DURING HOSPITALIZATION|An annuloplasty ring is noted in the mitral position. The mean gradient through mitral valve is 5.75 mmHg. An annuloplasty ring is noted in the tricuspid position. Estimated RVSP was 49 mmHg plus RA. There is no pericardial effusion. 2. CT chest without contrast. Impression: a. A stable bilateral pleural effusion with right greater than left.
RA|right atrium|RA.|185|187|HOSPITAL  COURSE|In addition, she had a transthoracic echocardiogram that showed an ejection fraction of 75-80%, moderate concentric LVH, RV function seems to be decreased. Pulmonary pressures were 38+ RA. Again, however, thromboembolic disease was ruled out and the pulmonary hypertension, decreased RV function may certainly be secondary to COPD. The patient fortunately improved, however, and now she is at her baseline of 3 liters of oxygen.
RA|right atrium|RA|133|134|STUDIES DURING HOSPITALIZATION|There is approximately 25% variation of Doppler signal across the mitral and aortic valves. The IVC appears dilated. This filling of RA and RV is preserved. 3. Large pleural effusion noted. Please refer to the patient's admitting history and physical, dated _%#DDMM2006#%_ for the patient's presenting exam, laboratory values and presentation.
RA|rheumatoid arthritis|RA|196|197|LABORATORY DATA|MRI of the lumbar spine on _%#DDMM2007#%_ showed a left psoas abscess and positive infected disk spaces at the T12-L1 and L3-4 and L4-5 levels. On _%#DDMM2007#%_, antinuclear antibodies were 5.6. RA factor was borderline elevated at 38, and potassium was 4.9. Left psoas abscess culture showed heavy growth of E. coli. Follow-up blood cultures were negative. On _%#DDMM2007#%_, follow-up MRI scan showed a T12-L1 disk space infection with accumulation of fluid in the disk.
RA|right atrium|RA|196|197|MAJOR IMAGING AND PROCEDURES|3. Chronic atrial fibrillation. 4. Congestive heart failure. 5. Hyperlipidemia. MAJOR IMAGING AND PROCEDURES: 1. A right and left heart cath, was done on _%#DDMM2007#%_. Right heart cath shows an RA pressure of 11, RV 31/11 with a mean of 19, PA pressure 31/11 with mean of 19, wedge pressure 12, cardiac index 1.5. Left heart cath was done which shows an ejection fraction of 48%.
RA|right atrium|RA|152|153|PROCEDURES AND TESTS|Resting LV was with an EF approximately 45%. Small PFO/ASD with left-to-right shunt was noted. 4. Moderate dilated RV with RV systolic pressures of 59+ RA pressure. 5. The patient underwent a cardiac catheterization on _%#DDMM2002#%_. This revealed, per attending oral report, clean coronaries. Unfortunately, the report is unavailable at this time. 6. The patient underwent an abdomen and pelvis CT with contrast on _%#DDMM2002#%_.
RA|right atrium|RA|127|128|HOSPITAL COURSE|The repeat echocardiogram on _%#DDMM2007#%_ showed ejection fraction of 50% and there is no pericardial effusion. RVSP 41 plus RA pressure. No evidence of pericardial effusion. FOLLOWUP APPOINTMENT: 1. Primary care clinic in _%#CITY#%_ _%#CITY#%_ within 1 week to follow up kidney function.
RA|right atrium|RA|252|253|MAJOR PROCEDURES|No further workup required with 2 years stability. 4. Right heart hemodynamic study: Left ventricular diastolic dysfunction. Orthotopic cardiac transplantation. Endomyocardial biopsy. The patient's right heart pressures were right atrium 25 mmHg mean, RA 23 mmHg end-diastolic pressure, PA 56/32 with a mean of 40 mmHg and a wedge pressure of 32. Histopathology of the endomyocardial biopsy showed no evidence of ejection with inflammatory grade IA.
RA|right atrium|RA|213|214|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Familial dilated cardiomyopathy currently New York Heart Association Class IV, inotropic dependent, EF 10%-15%, last echo on _%#DDMM2007#%_. Right heart catheterization on _%#DDMM2007#%_, RA pressure was 28, PAP 46/25 with a mean of 35, PCWP was 28 and cardiac index was only 1.3. 2. CVA on _%#DDMM2007#%_, nonhemorrhagic left parietal occipital area, currently on Coumadin, still has some degree of expressive aphasia, but improving.
RA|right atrium|RA|210|211|HISTORY|The right coronary artery had a 50% in the mid portion and an acute marginal branch had an 80-90% narrowing and the LV ejection fraction was 20-25% on catheterization. Hemodynamics were also severely abnormal. RA pressure 17. RV 61/20, PA 63/26. Wedge 31. LVEDP is between 32 and 38. It was thought that he had right heart findings of elevated right heart filling pressures and pulmonary hypertension, much of which may be due to left heart disease.
RA|rheumatoid arthritis|RA|94|95|HISTORY|The patient has ongoing pain. I will ask ortho to see her prior to discharge. The patient has RA and this has been stable during his stay here. The patient was discharged in stable condition to nursing home and follow up with Dr. _%#NAME#%_.
RA|right atrium|RA|250|251|HOSPITAL COURSE|5. Mild left atrial enlargement. 6. Mild mitral regurgitation. 7. RV systolic pressure increased to 31 mmHg above right atrial pressure. 8. She underwent right heart catheterization and coronary angiography, which provided the following information: RA mean 12; RV 48/12. PA 48/26. PCWP 26. PA saturation 70.7. FICK CO: 5.4/thermodilution 4.6. Tortuosity of the ascending aortic arch.
RA|right atrium|RA|273|274|PROCEDURES THIS ADMISSION|2. Status post biventricular pacemaker insertion. PROCEDURES THIS ADMISSION: 1. Biventricular pacemaker insertion on _%#MM#%_ _%#DD#%_, 2002. This was done by Dr. _%#NAME#%_ _%#NAME#%_. 2. Cardiac catheterization on _%#MM#%_ _%#DD#%_, 2002, showing a right heart cath with RA equal 14, PA equal 39, PAW equal 30, PVR equal 1.91, PA saturation 59.9 and CO equal 4.7. Left heart shows a right dominant RCA with a 50 percent proximal lesion, stent in the RCA which is widely patent, clear LMC, LAD mid section 100 percent occluded, circumflex 60-70 percent lesion in OM-1.
RA|room air|RA,|175|177|PHYSICAL EXAMINATION ON ADMISSION|The patient denies fevers, chills, nausea and vomiting, or chest pain. PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.5, blood pressure 175/79, heart rate 106, SpO2 91% on RA, RR 22. Head: ATNC. Eyes: PERRL. EOMI. Sclerae nonicteric. ENT: Mouth clear. Neck: Supple. Respiratory: A few crackles throughout with coarse breath sounds.
RA|room air|RA|128|129|IMPRESSION|2. Acute atrial flutter versus frequent PAC's, PVC's in the Emergency Department at around 10:30 a.m. 3. Hypoxia with 02 sat on RA 86% in the Emergency Department. 4. Acute glucose intolerance, new since last admission a year ago of 122. 5. Bilateral pleural effusions, left greater than right, chronic, of unknown etiology, though probably secondary to the mediastinal tumor radiation.
RA|right atrium|RA|177|178|HOSPITAL COURSE|He was transferred to the ICU in stable condition. He had diffuse oozing from his pericardium which required a return visit to the operating room. He had a clot compressing his RA which was evacuated. The rest of his postoperative course was complicated by his history of chronic renal failure. He was dialyzed and transfused with 1 unit packed red blood cells on postop day 1.
RA|right atrium|(RA|223|225|PROCEDURES PERFORMED|2. Echocardiogram _%#DDMM2007#%_: Heart transplant recipient with normal posttransplant anatomy. Ejection fraction greater than or equal to 55%. 3. Right heart catheterization: Normal right and left-sided filling pressures (RA mean pressure 10 mmHg and mean wedge pressure 18 mmHg) and mild pulmonary hypertension (PA pressures 45/25, mean 31 mmHg).
RA|right atrium|RA|163|164|PROCEDURES AND RESULTS|4. Hypothyroidism. 5. Tetralogy of fallot. PROCEDURES AND RESULTS: 1. Right heart catheterization, _%#DDMM2007#%_ shows RA pressure of 10 with V-waves at elevated RA pressure to 18, RV 55/10, PA 35/12, wedge 11, thick cardiac index 2.58, 20 mmHg gradient across the pulmonic valve.
RA|right atrium|RA,|370|372|PROCEDURES AND RESULTS|1. Right heart catheterization, _%#DDMM2007#%_ shows RA pressure of 10 with V-waves at elevated RA pressure to 18, RV 55/10, PA 35/12, wedge 11, thick cardiac index 2.58, 20 mmHg gradient across the pulmonic valve. 2. Pediatric echocardiogram _%#DDMM2007#%_ shows no mitral regurgitation, 2+ tricuspid regurgitation with a peak velocity of 3 meters per second, RVSP 36+ RA, normal flows in the left ventricular outflow tract in the ascending aorta. No pulmonary insufficiency identified, the peak velocity of flow through the ventricular outflow area is 2.7 meters per second (28 mmHg gradient).
RA|right atrium|RA|207|208|PROCEDURES PERFORMED|4. Draining groin cystocele. PROCEDURES PERFORMED: 1. Ultrafiltration. 2. Overnight oximetry showing desaturation below 89% of 2 minutes and 20 seconds. 3. Right heart catheterization _%#DDMM2007#%_ showing RA pressure of 24 with _____. RV 48/24. PA 48/25 with a mean of 36, but there was significant respiratory variation in the RV and PA pressures.
RA|right atrium|RA,|160|162|PROCEDURES PERFORMED|Injection of contrast documented no internal interatrial shunt. A highly mobile echodensity is seen in SVC approximately 3 cm proximal to its connection to the RA, highly consistent with a thrombus. The left ventricle is normal in size and has normal function with a greater than 55% ejection fraction.
RA|right atrium|RA.|414|416|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|Also, during his evaluation he had an evaluation for syncope which included an echocardiogram which showed a normal ejection fraction, an old inferior, well, almost abnormality consistent with his prior MI; but no significant left ventricular outlet obstruction or significant valve disease that would account for a syncopal event. He did have moderate pulmonary hypertension with pulmonary artery pressure of 31+ RA. Given, his history of cerebrovascular disease; TIA was also a consideration. A carotid artery ultrasound was obtained which showed some plaques in the bilateral carotids but no significant stenosis.
RA|right atrium|(RA)|569|572|HOSPITAL COURSE|The only flow-limiting lesion was the mid-LAD which was successfully stented using a balloon to pre-dilate and then eventually a 3.0- x 8.0-mm Express stent with less than 0% residual stenosis and no complications. The patient tolerated the procedure well. The following morning his hemoglobin was found to have dropped almost 4 points, but he was given a significant amount of fluids because his initial BUN was very high with a normal creatinine and he was felt to be dry; his hemodynamics confirmed that with a right ventricle (RV) pressure of 27 and a right atrial (RA) pressure of 2.0. His initial end- diastolic pressure (EDP) was 13, but he had already been given fluids by this time. DISPOSITION: The patient is discharged in satisfactory condition. It is unclear what the cause of his sudden left ventricle deterioration is; it does not appear to be coronary artery disease and may be idiopathic cardiomyopathy, but this patient also underwent chemotherapy many years ago.
RA|right atrium|RA|138|139|PROCEDURES PERFORMED DURING THIS ADMISSION|4. Admission EKG showing ST elevations in leads 2, 3 and aVF. 5. Right heart catheterization on admission, _%#DDMM2002#%_. A FICK of 2.9, RA 18, PA of 32, a wedge of 24. After diuresis, a PA of 20 and a wedge of 15. HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old male without prior cardiac history is admitted directly to the Cardiac Catheterization Laboratory from the ER for acute inferoposterolateral MI.
RA|right atrium|RA|303|304|PROBLEM #8|PROBLEM #6: History of vasovagal syncope. PROBLEM #7: Chronic renal insufficiency with baseline creatinine 1.5 to 2.0. PROBLEM #8: History of echocardiogram _%#DDMM2003#%_ at _%#CITY#%_ _%#CITY#%_ with ejection fraction of 15 to 20% and an apical thrombus along with pulmonary heart hypertension of 40+ RA and moderate mitral regurgitation. PROBLEM #9: History of apical thrombus, on Coumadin.
RA|right atrium|RA|281|282|PROCEDURES PERFORMED|Please note this was the secondary echocardiogram on the _%#DD#%_ of _%#MM#%_. Her preliminary echocardiogram on the _%#DD#%_ showed moderate LA enlargement, mild MR, normal LV systolic function, moderate-severe RS dilatation, severely decreased right ventricular function, severe RA dilatation, dilated pulmonary artery, severe TR, RV systolic pressure of 96, plus the right atrial pressure, large pericardial effusion.
RA|right atrium|RA|201|202|IMPRESSION|2. Coronary angiogram. IMPRESSION: 1. Severe three-vessel native coronary artery disease. 2. Patent grafts. 3. Patent stent to diagonal. 4. Normal left and right heart filling pressures. The patient's RA pressure was 4, PA pressure 20/11 with a pulmonary artery wedge pressure of 10 mmHg. The patient's Fick cardiac index was 2.6 liters per minute per meter square.
RA|right atrium|RA|188|189|HISTORY|No regional wall motion abnormality. Hyperdynamic precordium with left ventricular ejection fraction of 70%. There was severely increased right ventricular systolic pressure of 68 mm plus RA pressure consistent with severe pulmonary hypertension. Known underlying obstructive sleep apnea on CPAP thought to be a potential contributing factor.
RA|right atrium|RA|129|130|PROBLEM #4|A patent foramen ovale with a bidirectional shunt was seen. There was estimated right ventricular systolic pressure that was 34+ RA pressure. There was mild 1+ pulmonary insufficiency. Mild right ventricular outflow tract/infundibular flow acceleration. Flow acceleration continues to the atretic pulmonary valve to a peak velocity of 2.6 with a peak gradient of 27 mmHg.
RA|right atrium|RA|212|213|PAST MEDICAL HISTORY|3. History of atrioseptal defect which is noted to be moderate. Echocardiogram in _%#MM#%_ 2006 showed mild left atrial enlargement, normal LV size and function, estimated ejection fraction 60%, mild LVH, severe RA enlargement, moderate right ventricular enlargement with moderate decrease in right ventricular systolic contractility, moderate TR with evidence of pulmonary hypertension.
RA|right atrium|RA|298|299|PAST MEDICAL HISTORY|Probably mild decreased overall left ventricular systolic contractility with an estimated ejection fraction of 45% with hypokinesis of the inferior portion and posterior septal walls and moderate thickening of the mitral valve leaflets and annular calcification with probable mitral regurgitation. RA and RV enlargement and at least hypokinesis of the right ventricle, mild to moderate CR, mild mitral regurgitation and trace AI.
RA|right atrium|RA|250|251|HISTORY|She has not worked with toxic fumes, although for awhile she did work in a cleaning environment. She came to see me as directed because of an echocardiogram that was ordered in _%#MM#%_, 2003 that showed pulmonary hypertension, right ventricular and RA dilation and a PA pressure of greater than 60 plus right atrial pressure. Her left ventricle was normal and no significant left-sided abnormalities were noted.
RA|right atrium|RA|262|263|ECHOCARDIOGRAM|Troponin less than 0.07 x 3. BUN 9. Creatinine 0.6. ECHOCARDIOGRAM: Done this hospitalization showed a mild right atrial dilatation and mildly decreased LV function. The RV systolic pressure was moderately increased 41 mmHg above right atrial pressure, and mild RA and RV dilatation. LV function was normal. ECG: Atrial fibrillation with a rate of around 77.
RA|right atrium|RA.|347|349|PROCEDURES|2. Chest x-ray, unremarkable. 3. Echocardiogram with preliminary reading showing an ejection fraction of 55%, some distal septal inferior hypokinesis with mild to moderate mitral regurgitation, and a dilated aortic root to 4.2 cm. There is a mildly dilated right ventricle with mild tricuspid regurgitation. Pulmonary artery pressures are 22 plus RA. PAST MEDICAL HISTORY: 1. Questionable history of coronary artery disease. Angiogram in 1992 at _%#COUNTY#%_ _%#COUNTY#%_ Medical Center with unknown results.
RA|right atrium|RA.|401|403|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Hypertension, diabetes mellitus, rheumatoid arthritis, gout, colon cancer status post colectomy x2, cataracts, congestive heart failure with echocardiography in _%#MM#%_ of 2004 showing mild to moderate LV dilation, severe decreased left ventricular function with an EF of 15%, moderate left atrial enlargement, mild MR, and estimated right ventricular systolic pressure 29 plus RA. Coronary angiography in _%#MM#%_ of 2003 showing RA 26, wedge 38, pulmonary artery pressure 80/40 with a mean of 56, RV 80/4, and cardiac index 1.4 by _______.
RA|right atrium|RA|194|195|ADMISSION MEDICATIONS|Normal response exercise was increased approximately 65% to 70%. There was no EKG evidence of ischemia. Mild mitral regurgitation. However, pulmonary artery systolic pressures were 40 mmHg plus RA pressure. There was an atrial septal aneurysm with no shunt and there was normal functional capacity. 3. Musculoskeletal: The patient does have a history of chronic arthralgias which have been deemed osteoarthritis.
RA|right atrium|RA|256|257|HOSPITAL COURSE|10) Moderate mitral regurg present. 11) Moderate mitral annular calcification. 12) Tricuspid and aortic valve show age-related thickening. 13) Mild to moderate tricuspid regurg with peak velocity of the tricuspid regurg jet is at 3.7 mm/sec with estimated RA pressure of at least 15-20 mmHg with severe pulmonary hypertension likely present. 14) Pulmonic valve normal based on limited views, no pericardial effusion and aortic root size is normal.
RA|right atrium|RA|171|172|PAST MEDICAL HISTORY|She had trace to mild MR with mitral inflow suggesting diastolic dysfunction. She had an LA that was mildly enlarged, aortic valve slightly thickened with mild AI. RV and RA was normal size and function. She had a trace of TR and an estimated RVP of 38 mmHg plus the right atrial pressure which was mildly elevated.
RA|right atrium|RA|140|141|PROCEDURES PERFORMED|3. Transthoracic echocardiogram showed good systolic function, no mitral regurgitation, 1+ tricuspid regurgitation with RVSP of 22 mmHg and RA clot measures 8 mm. There is mild mitral gradient. Ultrasonographer was _%#NAME#%_ _%#NAME#%_. HISTORY OF PRESENT ILLNESS: The patient is an 8-year-old male well known to the Pediatric Cardiology Service with Brachio-otorenal syndrome, status post five days of mitral valve cleft heart repair who returns the same day of discharge with a fever to 101.8 and dysuria.
RA|right atrium|RA|189|190|OPERATIONS/PROCEDURES PERFORMED|3. Coronary angiogram _%#MM#%_ _%#DD#%_, 2003, reveals left dominant coronary system. Heart is dilated. Left main is normal. LAD with mild diffuse distal disease. Right heart cath revealed RA pressure 16, PA 45/20, mean 30, wedge 25. Cardiac output by assumed 5.6. 4. Overnight oximetry _%#MM#%_ _%#DD#%_, 2003. A number of desaturations, 330. Average 91%. Low 71%. Average pulse rate 86 beats per minute.
RA|right atrium|RA|145|146|HISTORY OF PRESENT ILLNESS|Moreover, diastolic pressures within the heart were severely elevated in each chamber. The LV EDP was about 40, the LA mean pressure was 25, the RA mean pressure was 20, and the RV EDP was 30. Coronary artery angiography was also performed (by Dr. _%#NAME#%_). This showed reasonably normal coronary arteries without evidence of ischemic heart disease.
RA|right atrium|RA|153|154|PROCEDURES PERFORMED|DISCHARGE DIAGNOSIS: CHF decompensation. PROCEDURES PERFORMED: 1. Right heart catheterization with Swan-Ganz placement on _%#DDMM2004#%_ which showed an RA pressure of 8, PA pressure 64/40, wedge of 34, cardiac index by Fick 1.8 L/min/m2. 2. ICD interrogation on _%#DDMM2004#%_ showed no atrial or ventricular tachyarrhythmias since the patient was discharged from the hospital on _%#DDMM2004#%_.
RA|right atrium|RA.|168|170|RELEVANT LABORATORY DATA|An echocardiogram, at the time of admission, showed septal akinesis, inferior hypokinesis with ejection fraction of 45%. Right ventricular systolic pressures were 39 + RA. Chest x-ray at the time of admission showed mild right-sided congestion. The results of the renal ultrasound with Doppler and nuclear medicine scan have been dictated above.
RA|right atrium|RA|123|124|HOSPITAL COURSE|There was a moderate 50% stenosis in the proximal OM1 and circumflex. The RCA is nondominant with possible conus branch to RA fistula. Hypertension. The patient's antihypertensive, Diltiazem and ACE inhibitor were doubled to better control his hypertension. The patient tolerated this quite well and is discharged on this dose.
RA|right atrium|RA|242|243|PRIMARY PROCEDURES|PRIMARY PROCEDURES: 1. Right heart catheterization on _%#MM#%_ _%#DD#%_, 2005, with a PA pressure of 70/30, pulmonary capillary wedge pressure of 28, and cardiac index of 2.4 by FIC. 2. Right heart catheterization on _%#MM#%_ _%#DD#%_, 2005, RA pressure of 8, PA pressure of 68/32, pulmonary capillary wedge pressure of 28. 3. Plasmapheresis including a series of 3 consecutive treatments with 4 further intermittent treatments.
RA|right atrium|RA|319|320|HOSPITAL COURSE|Beta type natriuretic peptide on _%#MMDD#%_ was 245, ASO was elevated at 151 (although this is close to normal), D-dimer was slightly elevated at 1.6, echocardiogram done on _%#MMDD#%_ showed left ventricular function with an ejection fraction of 60 to 65%, trace TR, small to moderate size pericardial effusion noted. RA mildly collapses. Patient was placed on ibuprofen, steroids and symptoms improved significantly, so that by _%#MM#%_ _%#DD#%_, was basically asymptomatic.
RA|right atrium|RA.|199|201|PAST MEDICAL HISTORY|Pulmonary artery pressure of 55/26. Pulmonary capillary wedge pressure of 33. 3. Coronary artery disease status post RCA stent. TTE in _%#DDMM2006#%_: Increased left ventricular thickness. RVSP 54 + RA. Left atrial enlargement. Mitral regurgitation. Tricuspid regurgitation. 4. BOOP. 5. Hypertension. 6. Breast cancer status post lumpectomy. 7. Total abdominal hysterectomy/bilateral salpingo-oophorectomy 2002. 8. VRE urosepsis.
RA|right atrium|RA.|302|304|OPERATIONS/PROCEDURES PERFORMED|4. Polymyalgia rheumatica. OPERATIONS/PROCEDURES PERFORMED: Transesophageal echo showing a normal ejection fraction with mild diastolic dysfunction along with mild to moderate mitral regurgitation. The mitral valve is imaged and without any vegetations. There is pulmonary hypertension of 41 mmHg plus RA. HISTORY OF PRESENT ILLNESS: This is a 70-year-old female with a history of mitral valve repair secondary to mitral stenosis with pulmonary hypertension, paroxysmal atrial fibrillation, polymyalgia rheumatica, and diabetes with pacemaker who presents with dehydration.
RA|right atrium|RA.|223|225|HISTORY OF PRESENT ILLNESS|She was seen at Fairview Ridges Emergency Department and underwent a chest CT with findings of an SVC stent occlusion with some recanalization of the left SVC on venous flow down to the azygous vein and into the IVS to the RA. This does create some suboptimal opacification of the pulmonary arteries but no PE definitely is seen. Her case was discussed with Dr. _%#NAME#%_ who wants to transfer the patient here for a possible angiogram in the morning.
RA|right atrium|RA|172|173|PROCEDURES PERFORMED|LAD had mild diffuse disease with 40% in-stent re-stenosis of the LAD stent. The OM stent was patent. No focal lesions were noted. 2. Right heart catheterization: Revealed RA pressure of 8, PA of 64/19, wedge pressure 23, mixed venous O2 62%. 3. Echocardiogram: Showed mildly decreased LV systolic function with ejection fraction of approximately 40%.
RA|right atrium|RA|225|226|PROBLEM #2|PROBLEM #2: Cardiovascular. He received a cardiac catheterization on _%#DDMM2004#%_ via right and antegrade left catheterization, with results as follows: MPA 115/59, LV 122/0 to 18, RV 124/0 to 17, AAo 104/48, RPA 45/31/39, RA x equals 4, LA x equals 8. He tolerated his catheterization and had no complications. He was continued on his home medications.
RA|right atrium|RA|160|161|HOSPITAL COURSE|Her ejection fraction was 55%. She had mild mitral regurgitation, aortic sclerosis. She had some left ventricular hypertrophy. Pulmonary pressures were 41 plus RA as incidental pulmonary hypertension, which may be causing a little bit of the lower extremity edema. Again, she will be started on a low dose of hydrochlorothiazide for her blood pressure, which may help.
RA|right atrium|RA.|180|182|PROCEDURE LIST AS FOLLOWS|No wall motion abnormalities. EF of 60%. Normal right ventricular size and function. Normal mitral valve. Mild tricuspid regurg. Trace pulmonic regurg. Pulmonary pressures of 32 + RA. 4. CT of the abdomen and pelvis revealing multiple small indeterminate liver lesions and 2 cm retroperitoneal medial left upper quadrant nodule, which is new since _%#MM#%_ of 2004.
RA|right atrium|RA.|148|150|HOSPITAL COURSE|In addition, she had a transthoracic echocardiogram that has normal left ventricular function. EF is 55%. Trace TR and pulmonary pressures are 13 + RA. 2. Acute renal failure, resolved. The patient had mildly acute renal failure upon admission. This, however, has resolved. Initially was 1.42 and is down to 1.14. This seemed to just actually resolve on its own.
RA|right atrium|RA|200|201|PAST MEDICAL HISTORY|1. Idiopathic dilated cardiomyopathy with heart failure. Most recent echocardiogram in _%#DDMM2003#%_ showed ejection fraction of 45% with diastolic dysfunction. Pulmonary artery pressures of 36 plus RA and left ventricular heart flow gradient 14 mmHg. There also is aortic root dilatation of 4.5 cm. 2. Hypertension. 3. History of left bundle branch block. 4. History of benign prostatic hypertrophy with mild retention.
RA|right atrium|RA.|202|204|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|Echocardiogram was obtained which showed normal ejection fraction without wall motion abnormalities but did show pulmonary hypertension with pulmonary artery pressure estimated at 36 mm of mercury plus RA. Over the next day, she improved significantly and at the time of discharge she is saturating about 91% at rest. When she ambulates on room air, however, her O2 sats dip down to the 86-88% range.
RA|room air|RA;|159|161|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|She remained peripherally cyanotic at 10 minute Apgar; however, respiratory effort had improved significantly. O2 sat at that time was noted to be 86 - 94% on RA; BB O2 was given intermittently and infant was transferred the NICU at that time. _%#NAME#%_ was a preterm AGA infant with a length of 48 cm and head circumference of 35 cm.
RA|right atrium|RA|236|237|PROCEDURES PERFORMED|5. CT of the chest demonstrating mild left basilar atelectasis. 6. Echocardiogram demonstrating hyperdynamic left ventricular function with an estimated ejection fraction of 70% with mildly elevated RV systolic pressure of 31 mmHg plus RA with mild left atrial enlargement. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 30-year-old female who is status post hepatic transplant for biliary atresia in 1994, who now has chronic hepatic rejection.
RA|right atrium|RA|450|451|LABORATORY DATA|LABORATORY DATA: Relevant laboratory data, creatinine at the time of discharge is 1.7, BUN is 66 and potassium is 5.6. Echocardiogram performed on _%#DDMM2005#%_ demonstrated normal left ventricular size and function, mild concentric left ventricle hypertrophy, mild left atrial enlargement, normal right ventricular size and systolic function, no intracardiac thrombus, mildly dilated ascending aorta, right ventricular systolic pressure of 43 plus RA consistent with moderate pulmonary hypertension. TSH was 2.14. Lower extremity venous Dopplers performed on _%#DDMM2005#%_ showed no evidence of deep venous thrombosis, beta-natriuretic peptide on admission was well within normal range at 19.
RA|rheumatoid arthritis|RA.|197|199|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|She did have a therapeutic paracentesis with removal of 8.3 liters of fluid. She felt much better. She also has rheumatoid arthritis and history of breast cancer. She takes pain medication for her RA. She had been taking Vicodin with her cirrhosis. I have recommended that she not take with Tylenol. We tried some codeine here and it has been effective.
RA|right atrium|RA|313|314|PROCEDURES|PROCEDURES: 1. Patient did have a right heart catheter _%#DDMM2006#%_ with the following results: Mean RA pressure was 26, RV pressure is 37/2 with an end of 22, mean wedge of 22, PA pressures of 35/22 with a mean of 28, thick cardiac output 2.76/cardiac index thick 1.48. 2. Right heart catheter _%#DDMM2006#%_: RA mean pressure 14, RV 31/1 with an end of 12, PA 29/12 with a mean of 20, pulmonary artery wedge pressure mean 13, cardiac output thick 3.10/cardiac index thick 1.66.
RA|right atrium|RA.|275|277|LABORATORY  DATA|(Also recent labs show normal LFTs.) INR 1.56, white count of 17.1, hemoglobin 13.6, platelets 240, transthoracic echocardiogram here revealed an ejection fraction of 40-45% with inferior akinesis. She has a porcine aortic valve. She has mild pulmonary hypertension with 34+ RA. EKG reveals atrial fibrillation with Q-waves inferiorly and mild ST elevation in II and III.
RA|right atrium|RA|516|517|HOSPITALIZATION|1. Right heart catheterization performed on _%#MM#%_ _%#DD#%_, 2006: Shows biventricular diastolic dysfunction and moderate pulmonary hypertension with PA pressure of 57/26 and a pulmonary artery wedge pressure of 35 with a cardiac index of 1.8. 2. Swan-Ganz catheter measurements. 3. Transthoracic echocardiogram performed on _%#MM#%_ _%#DD#%_, 2006, shows severely decreased LV systolic function with visually estimated ejection fraction of 20%, moderate to severe LV dilation, moderate MR, moderate LAE, moderate RA dilation, moderate RV dilation, moderate to severely decreased right ventricular function, moderate to severe tricuspid regurgitation. RV systolic pressure severely increased approximately 55 mmHg above the mean right atrial pressure, dilated IVC without respiratory collapse.
RA|right atrium|RA|256|257|HOSPITAL COURSE|That catheterization revealed severe AI and he has been placed on the 1A transplant list, because of that problem. A subsequent catheterization done on _%#DDMM2006#%_ revealed pulmonary hypertension, secondary to AI and elevated filling pressures, but his RA pressure was able to come down to 8 mmHg with a Nipride trial. Unfortunately, he was unable to tolerate a Nesiritide drip, having a very woozy-lightheaded feeling with it, as well as much ectopy.
RA|right atrium|RA.|240|242|PAST MEDICAL HISTORY|5. Congestive heart failure, with ejection fraction of 50% (this was in _%#MM#%_ 2006), with moderate LVH, left atrium was enlarged, right atrium was also enlarged, moderate degree of tricuspid regurgitation, and pulmonary pressures of 51+ RA. 6. Obesity. 7. Hypothyroidism. 8. History of right middle lobe lung nodule, seen on CT of _%#MM#%_ 2006. 9. Questionable history of obstructive sleep apnea. 10. Questionable history of cognitive impairment.
RA|right atrium|RA|181|182|PROCEDURES PERFORMED|3. Thrombocytopenia. PROCEDURES PERFORMED: 1. Chest x-ray _%#DDMM2007#%_: Marked pulmonary artery enlargement. Prominent heart size. 3. Right heart catheterization, _%#DDMM2007#%_: RA 21/12, RV 131/27, mean wedge 14, PA 133/51/91, thick cardiac output 2.4, thick cardiac index 1.5, pulmonary vascular resistance 2594.
RA|right atrium|RA|244|245|HOSPITAL COURSE|Despite improvement of his EF, the patient's heart failure and volume balance have been difficult to control secondary to his chronic renal failure and hypotension with afterload reduction. On admission, the patient was in volume overload with RA pressure of 18 and a pulmonary capillary wedge pressure estimated at 24 by right heart catheterization. He was admitted to the inpatient service and diuresed with IV nesiritide and Bumex.
RA|right atrium|RA|163|164|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: CMV infection. OPERATIONS/PROCEDURES PERFORMED: 1. Right heart biopsy and catheterization on _%#MM#%_ _%#DD#%_, 2004. Hemodynamic data showed RA mean of 2, PA of 32/10, with a wedge of 10, cardiac index of 3.2. Biopsy taken revealed inflammatory grade IB.
RA|right atrium|RA|221|222|HOSPITAL COURSE|The patient did have successful replacement of her dialysis catheter on _%#MM#%_ _%#DD#%_, 2004. She had dialysis via that catheter on _%#MM#%_ _%#DD#%_, 2004, prior to discharge. Additionally, she had angioplasty of her RA and SVC thrombosis as she will continue on Warfarin therapy for this. Her Coumadin is dosed on dialysis to help ensure compliance for this.
RA|right atrium|RA|272|273|PAST MEDICAL HISTORY|4. AICD implantation, 2003. 5. Last coronary angiogram _%#MM2004#%_: Showed normal left main, 95% proximal LAD, diffuse moderate disease of mid-circumflex, occluded RCA, LIMA to LAD was patent. SVG to RCA was occluded. 6. Right heart catheterization, _%#MM2004#%_: Showed RA of 4, PA 30/14, PCW 16, cardiac index 2.7 x 6. 7. Last echocardiogram _%#DDMM2004#%_: Showed EF of 15 to 20%, mild to moderate LV dilatation, diffuse hypokinesis, diastolic dysfunction, normal RV size and function, and no valvular abnormalities.
RA|right atrium|RA|198|199|HOSPITAL COURSE|3. Cardiac. The patient was found to be bradycardic. She was on 100 mg of atenolol, this was stopped and her heart rate went from 46 to 63. She also had an echocardiogram that showed ______ 4.2 cm, RA generous sclerotic AO with trileaflet mild to moderate AI, P 1/2 T with LV systolic function appears within normal limits, EF of 55% to 60%, mild mitral regurgitation, mild tricuspid regurgitation 2.7 mm per second, 29+ ______, no shunts or clots were noted.
RA|right atrium|RA,|190|192|DOB|She was treated with Solu-Medrol, heparin and Zosyn, switched to Levaquin, Lovenox and then placed on Coumadin. Electrocardiogram showed normal ejection fraction, echogenic mass seen in the RA, possibly a clot for which she was anticoagulated, no pulmonary embolism seen. She had a decubitus ulcers in the presacral area which is being treated.
RA|right atrium|RA|217|218|PHYSICAL EXAMINATION|Her mother is with her. LUNGS: Clear. ABDOMEN: Soft. Bowel sounds are ______active, yet present. There is diffuse abdominal discomfort without marked pain. No rebound. JOINTS: Unchanged from baseline. She has diffuse RA involvement through all of the axial as well as peripheral skeleton. Pupils are 2 mm and round. Gaze is normal. speech pattern and content are appropriate given her affect and discomfort.
RA|rheumatoid arthritis|RA.|166|168|ASSESSMENT/PLAN|Due to the cryoglobulins and recent pulmonary emboli, it will be important to keep her on anticoagulation as soon as possible. 2. Seizures. Continue the Tegretol. 3. RA. Continue pain management with morphine. I will ask the pain service to advise as to how to convert her best over to oral/IV administration of narcotics.
RA|right atrium|RA|167|168|PROCEDURES|The SVG to PDA of the RCA has a 90% proximal stenosis and has 75% distal stenosis inside the vein graft. 3. Right heart catheterization dated _%#MM#%_ _%#DD#%_, 2006: RA mean 28, PA pressure 70/32 with a mean of 43, wedge 28, cardiac index by Fick 1.8. 4. Resting thallium: Moderate sized left ventricular apical infarct, not reversible.
RA|right atrium|RA|182|183|HISTORY OF PRESENT ILLNESS|Hepatitis panels were negative. Of note, the patient's INR increased mildly during his hospitalization, even while holding the Coumadin. This was thought to be secondary to elevated RA pressures. An attempt was made to get a diagnostic paracentesis; however, the patient refused this test. The patient was discussed at transplant conference. It was felt that since the patient's PA pressures were (_______________) as well as his renal insufficiency, we will see how he does while on p.o. medications, and have him return for right heart catheterization at a later date.
RA|right atrium|RA|213|214|PROCEDURES PERFORMED WHILE HOSPITALIZED|Moderate-to-severe left atrial enlargement. Moderate-to-severe right ventricular dilatation. Moderately-to-severely decreased right ventricular function. RV systolic pressure moderately increased at 46 above mean RA pressure which was unchanged from prior. 2. Transesophageal echocardiogram on _%#MM#%_ _%#DD#%_, 2006, with successful cardioversion to normal sinus rhythm.
RA|right atrium|RA.|342|344|PROCEDURES|Left ventricular systolic function appears to be global and presumably not an ischemic cause for his cardiomyopathy. 6. Transthoracic echocardiogram; ejection fraction estimated about 20%. He has moderate mitral regurgitation, aortic sclerosis, trace pulmonary insufficiency, moderate tricuspid regurgitation with pulmonary pressures of 22 + RA. HOSPITAL COURSE: 1. Acute oliguric renal failure with history of chronic renal failure.
RA|right atrium|RA|205|206|HOSPITAL COURSE|She has several wall motion abnormalities in the mid and distal anterior septal walls, distal anterior wall, and portions of apex. She has normal right ventricular chamber size, pulmonary pressures of 24+ RA but chest x-ray did not appear to be volume overload. BNP was actually normal at 97 and she did not have any lower extremity edema.
RA|right atrium|RA|247|248|BRIEF HISTORY|The patient was scheduled for further PCI of the RCA on _%#MM#%_ _%#DD#%_, 2006, with wiring of the RCA and successful stenting of the stenotic lesion. At that time, they also did right heart catheterization which demonstrated PCWP of 25 mmHg and RA pressure of 12 mmHg and a reduced cardiac output. At the end of intervention, the PCWP was 17 mmHg. Transthoracic ECHO done after emergent stenting of the LAD demonstrated a reduce LV function with an EF of 20%.
RA|right atrium|RA|192|193|PROCEDURE PERFORMED|DISCHARGE DIAGNOSES: 1. Myalgias, probably secondary to medications. 2. Annual transplantation evaluation. PROCEDURE PERFORMED: 1. A right heart catheterization was performed that showed mean RA pressure of 6, RA pressure of 32/6, PA pressure of 32/18, and wedge pressure of 16. 2. A left heart catheterization was also performed, which showed normal coronary arteries.
RA|room air|RA.|130|132|OBJECTIVE|Coreg 25 mg twice daily with meals, lisinopril 5 mg once daily. OBJECTIVE: He is comfortable wearing his oxygen. Sats were 85% on RA. BP:80/44, HR: 76 b/min, Weight: 159 lb. (decreased from 170 last month) Lungs with few diffuse crackles. Heart reveals a regular rate and rhythm without murmur. There is a crisp mechanical aortic valve sound.
RA|right atrium|RA.|340|342|OPERATIONS/PROCEDURES PERFORMED|OPERATIONS/PROCEDURES PERFORMED: 1. Transthoracic echo: Mild to moderate left ventricular hypertrophy, mildly dilated left ventricle and left atrium, normal left ventricular systolic function with ejection fraction 50% to 55%, mild tricuspid regurgitation, moderately dilated right ventricle and right atrium, right atrial pressure 36 plus RA. 2. Video swallow revealing dysphagia, the patient on dysphagia-3 diet with nectar and thick liquids. 3. Chest x-ray: Left pleural effusion with atelectasis, no infiltrate.
RA|right atrium|RA|239|240|OPERATIONS/PROCEDURES PERFORMED|2. Transthoracic echocardiography dated _%#MM#%_ _%#DD#%_, 2005, showed mild increase in LV wall thickness, normal global LV systolic function. Her LV systolic pressure moderately increased, 46 mm above RAP. A mild LV enlargement and mild RA dilatation. Mild MR. Mild to moderate tricuspid regurgitation. No cause of syncope identified. HISTORY OF PRESENT ILLNESS: This is an 87-year-old female with a history of tachybrady syndrome status post dual-chamber pacing in 2004 with a history of hypertension, and positive family history of coronary artery disease, and no prior history of CAD, comes in with an episode of syncope.
RA|rheumatoid arthritis|RA|172|173|PROBLEM #3|She saw the patient and per her recommendation, the patient was started on Colchicine in an attempt to suppress recurrence of a pericardial effusion in the future. From an RA standpoint, the patient was continued on _________________ 75 mg p.o. b.i.d. and her outpatient prednisone dose was increased to 50 mg per day.
RA|right atrium|RA.|144|146|PAST MEDICAL HISTORY|Her cardiac output was 4.7. Her PDR was 5.3 and TPR is 6.6. Wedge was 6. Echo in _%#DDMM2005#%_ showed normal LV function with an RV of 81 plus RA. Moderate RV hypertrophy and RV dilation. 2. Anxiety. MEDICATIONS: 1. Flolan 35 ng/kg/min IV drip.
RA|right atrium|RA,|248|250|SIGNIFICANT STUDIES AND PROCEDURES|3. MRSA pneumonia. SIGNIFICANT STUDIES AND PROCEDURES: 1. Transthoracic echocardiogram _%#MM#%_ _%#DD#%_, 2007: Moderately-to-severely decreased LV function with EF 35%, normal function of prosthetic valve with mean gradient of 4, RV pressure 31 + RA, severe tricuspid regurgitation. 2. Sputum culture positive for MRSA _%#MM#%_ _%#DD#%_. Susceptibility includes vancomycin, linezolid, tetracycline and Bactrim.
RA|rheumatoid arthritis|RA|229|230|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSES: 1. Urinary tract infection. 2. Altered mental status secondary to encephalopathy from urinary tract infection. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 81-year-old female with known history of RA and seizure disorder who was diagnosed with CNS vasculitis, the year previous and presented to emergency department with confusion and weakness with a serious onset.
RA|retinoic acid|RA|129|130|MEDICATIONS|4. No history of anesthesia reaction in self or family. MEDICATIONS: 1. Provigil 400 mg daily. 2. NuvaRing for contraception. 3. RA lotion and Retin-A 0.1% cream at bedtime p.r.n. for acne. 4. Ibuprofen 800 mg t.i.d. p.r.n. ALLERGIES: None. PHYSICAL EXAMINATION: GENERAL: No distress.
RA|right atrium|RA.|193|195|OPERATIONS/PROCEDURES PERFORMED|OPERATIONS/PROCEDURES PERFORMED: 1. Transthoracic echocardiogram (_%#MM#%_ _%#DD#%_, 2006): The TTE demonstrates no change in the patient's pulmonary pressures which were approximately 31 plus RA. 2. Right upper quadrant ultrasound (_%#MM#%_ _%#DD#%_, 2006): The right upper quadrant ultrasound demonstrates a mildly enlarged hyperechoic liver which is consistent with diffuse fatty infiltration.
RA|right atrium|RA|489|490|PROCEDURES/INVESTIGATIONS|PROCEDURES/INVESTIGATIONS: 1. Transthoracic echocardiogram which showed ejection fraction of 10%, severe LV dilatation, moderate to severe mitral regurgitation, RV systolic pressure, 27 mm ________ pressure, mild RV dilatation, moderate to severe left atrial enlargement, moderate to severe right atrial dilation, moderate tricuspid regurgitation, and there was no pericardial effusion. 2. Chest x-ray which showed cardiomegaly. 3. Right heart catheterization done in the ICU which showed RA pressure of 20 mmHg, primary artery pressure of 40/32, PCWP 30 mmHg, and cardiac index of 2.5. Large _____________________.
RA|right atrium|RA.|190|192|DISCHARGE DIAGNOSIS|The EF was estimated at 65-70%. Moderate 2+ tricuspid regurgitation. Right ventricular systolic pressure is elevated consistent with severe pulmonary hypertension. PA systolic pressures 67+ RA. There is moderate 2+ mitral regurgitation. Mild valvular aortic stenosis. CONSULTATIONS OBTAINED: Gastroenterology.
RA|right atrium|RA|121|122|LABORATORY DATA|The left ventricle is normal in size. LV systolic function is normal. There is no pericardial effusion. RVSP was 25 plus RA pressure. ASSESSMENT AND PLAN: 1. Pseudoaneurysm of the right femoral artery confirmed by ultrasound: This aneurysm was diagnosed with a color Doppler study.
RA|right atrium|RA|149|150|HOSPITAL COURSE|HOSPITAL COURSE: 1. Congestive heart failure: The patient was scheduled for a heart cath on _%#MMDD#%_ with the results as noted above. Although her RA and wedge pressures were in the normal range, was significantly higher than previous cath on _%#DDMM2007#%_ for which her RA was 3 and her wedge was 9 with an index of 1.6. Around that time, she had an infusion of milrinone for 2 days which made her symptomatically significantly improved and the plan was to treat the patient as such following this finding in her right heart cath.
RA|right atrium|RA|275|276|HOSPITAL COURSE|There was moderate MR. His coronary showed minimal disease, his hemodynamics demonstrated LV pressure of 105/5 with a mean of 23, aortic pressure of 102/85 with a mean of 94. PA pressure demonstrated 72/30 with a mean of 54. RV pressure demonstrated 70/70 with a mean of 22. RA pressure 22/18 with a mean of 15, unable to have a wedge. Subsequently he was admitted to the hospital where he was started on intravenous Lasix 20 mg b.i.d. With this, he had an approximately 15-pound diuresis in 36 hours.
RA|right atrium|RA.|177|179|PROCEDURES AND RESULTS|7. Echocardiogram _%#DDMM2007#%_ showing normal LV size and function. No regional wall motion abnormalities. Trace mitral regurgitation. Trace tricuspid regurgitation. RVSP 23+ RA. No pericardial effusion. 8. Chest x-ray _%#DDMM2007#%_ showing clear lungs. 9. Right amputation wound fluid _%#DDMM2007#%_ growing Enterobacter cloacae with same sensitivities as above, beta-hemolytic Streptococcus group B susceptible to ampicillin and cefotaxime, ceftriaxone, penicillin, Bactrim, vancomycin, levofloxacin, moderate growth Citrobacter freundii sensitive to ceftazidime, ceftriaxone, ciprofloxacin, gentamicin, imipenem, levofloxacin, Zosyn and Bactrim.
RA|right atrium|RA.|164|166|PROCEDURES AT THE TIME OF HOSPITALIZATION|There were no regional wall motion abnormalities noted. The right ventricle was normal in size and function. The right ventricular systolic pressure was 38-40 plus RA. There was no pericardial effusion. 2. Permanent pacemaker placement on _%#DDMM2007#%_. 3. CT of the abdomen and pelvis without contrast on _%#DDMM2007#%_: There was significant bladder distention with minimal collecting system prominence bilaterally.
RA|room air|RA.|166|168|HISTORY OF PRESENT ILLNESS|He went home and his brother brought him to the _%#CITY#%_ ED. In the ER his temperature was 99 Farenheit. Blood pressure 204/125. Heart rate 105. RR 24. SpO2 98% on RA. PHYSICAL EXAM: Remarkable for poor dentition, tachycardia and diaphoresis.
RA|right atrium|RA.|218|220|HOSPITAL COURSE|The echo that was done on the day of admission showed normal global LV function, mildly thickened aortic valve, moderate MR, mild to moderate TR. Right ventricular systolic pressure was moderately increased at 46 plus RA. Right ventricular hypertrophy and ejection fraction of 35%. HOSPITAL COURSE: The patient was sent to the cath lab that revealed clean coronaries.
RA|right atrium|RA|229|230|PAST MEDICAL HISTORY|An echo from 1996 is read from clinic records and this showed dilated four chamber cardiomyopathy and LV EF of 30%, diffuse hypokinesis, left atrial enlargement, moderate mitral valve insufficiency, mild tricuspid insufficiency, RA and RV enlargement. 3. Hypertension. 4. History of hernia operations times two. 5. History of tonsillectomy at age 19. ALLERGIES: None. MEDICATIONS: From clinic report.
RA|right atrium|RA.|293|295|OPERATIONS/PROCEDURES THIS ADMISSION|6. Discharge to hospice. OPERATIONS/PROCEDURES THIS ADMISSION: Echocardiogram was done when the patient had A-fib with RVR which revealed a hypokinetic septal region, mild MR, bilateral atrial enlargement, and moderate to severe right ventricular systolic pressures that were estimated at 55+ RA. Her EF was 55%. HISTORY OF PRESENT ILLNESS: Miss _%#NAME#%_ is an 89-year-old woman with metastatic adenocarcinoma of unknown primary who had been undergoing chemotherapy including irinotecan.
RA|right atrium|RA|148|149|PROCEDURES PERFORMED|2. Resolving cytomegalovirus colitis. PROCEDURES PERFORMED: 1. Right heart catheterization showing a PE of 49/25, a wedge of 24, an RV of 55/21, an RA of 21 mmHg, cardiac output of 3.3. 2. Left coronary angiogram showing a clockwise rotated heart of right dominance, LAD mid of 50%-60%, and an LAD distal of 60%-70%.
RA|right atrium|RA|360|361|PROCEDURES THIS ADMISSION|PROCEDURES THIS ADMISSION: 1. Echocardiogram, _%#MM#%_ _%#DD#%_, 2002, showing mild left atrial enlargement, ejection fraction 20%, severe left ventricular dilatation, mild mitral regurgitation, mildly decreased right ventricular function and globular shape to the left ventricle with global hypokinesis. 2. Cardiac catheterization of the right heart, showing RA of 2, PA of 27, PAW of 15, PVR of 3.0 and CO of 4. This is pre-exercise. The postexercise numbers include a PA of 40, PAW of 28 and CO of 4.
RA|right atrium|RA,|180|182|HOSPITAL COURSE|The patient subsequently underwent a transthoracic echocardiogram that showed normal LV function, mild MR, mild dilatation, mildly increased RV systolic pressures to about 76 mm + RA, mild RV dilatation. No cardiac source of embolus was identified, and there was no evidence of right-to-left shunt on the bubble study.
RA|right atrium|RA|269|270|DISCHARGE DIAGNOSIS|1. Right coronary artery catheterization on _%#MM#%_ _%#DD#%_, 2003, showed right atrial and ventricular pressures of 13, a cardiac index of 1.4 with thermodilution and 1.7 via Fick. Wedge pressure 16. 2. Right cardiac catheterization on _%#MM#%_ _%#DD#%_, 2003, shows RA pressure 16, PA pressure 26 and wedge pressure of 21. Cardiac index was 2.2 via thermodilution and via Fick. 3. Cardiopulmonary assessment with Naughton protocol showed a functional capacity of 32.8 ml/kg per minute.
RA|right atrium|RA|148|149|ALLERGIES|On _%#MM#%_ _%#DD#%_, 2003, the patient's shortness of breath became acutely worse. This prompted a right heart catheterization which showed a mean RA pressure of 18, an end-diastolic right ventricular pressure of 19, and a wedge pressure of 20. Pulmonary artery pressure was 47/23 with a mean of 31.
RA|right atrium|RA.|353|355|PROCEDURES|LV gram reveals an EF of 76%, with mild inferior hypokinesis. Mitral regurgitation was graded as moderate to severe. 2. Echocardiogram reveals normal global LV function, aortic regurgitation, mild aortic stenosis with a mean gradient of 16.4, moderate to severe mitral regurgitation and RV systolic pressure moderately increased, approximately 46 above RA. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 71-year-old woman followed by Dr. _%#NAME#%_ _%#NAME#%_ at Southdale Heart Clinic.
RA|room air|RA|168|169|1. FEN|2. Respiratory: The initial RDS has since resolved and he has maintained adequate oxygenation with minimal supplemental O2 (currently 1/4 L). _%#NAME#%_ should wean to RA without difficulty. 3. ID: The blood culture will be 48 hours late evening of _%#DDMM2003#%_ and he has received at total of 4 doses of Ampicillin and 2 doses of Gentamicin.
RA|right atrium|RA|155|156|PROCEDURES|3. Status post cardiac transplant. 4. Hypertension. PROCEDURES: On _%#DDMM2003#%_ the patient had a right and left heart cath. Right heart cath revealed a RA pressure of 8 PA 32/15 with a mean of 23, pulmonary capillary wedge pressure of 16, cardiac output of 4.8 liters per minute by thermal delusion.
RA|right atrium|RA.|174|176|PROCEDURES|PROCEDURES: 1. Cardiac echo on _%#DDMM2002#%_. Conclusions: 1) Normal global LV systolic function. 2) RV1 systolic pressure mildly increased approximately 31 mmHg above mean RA. 3) Mild to moderate right atrial dilatation. 4) Mild left atrial enlargement. 5) Trace aortic regurgitation. 6) Mild mitral regurgitation. 2. Coronary angiogram on _%#DDMM2002#%_.
RA|right atrium|RA.|193|195|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|I ruled her out for myocardial infarction, but she was found to be in severe right-sided heart failure with pulmonary hypertension. Echocardiogram revealed pulmonary artery pressure of 74 plus RA. LV function was normal with an EF of 60 to 65 percent. She did have concentric LVH and no other screening abnormalities.
RA|rheumatoid arthritis|RA,|247|249|ASSESSMENT|The patient does complain of fatigue, which I think is more likely secondary to a respiratory infection than to a GI process. 3. CHF, with chronic atrial fibrillation and severe mitral regurgitation. This appears to be well compensated. 4. Severe RA, with chronic steroid therapy. PLAN: The patient will be admitted to the medical unit.
RA|right atrium|RA|502|503|OPERATIONS/PROCEDURES PERFORMED|OPERATIONS/PROCEDURES PERFORMED: 1. Transthoracic echocardiography performed on _%#MM#%_ _%#DD#%_, 2004, showed normal antegrade flow across the aortic prosthesis, severely decreased LV function with an estimated EF of 30%, dyskinesis of the distal septal segment with possible inferior wall motion abnormality, this was a clear change from previous echo _%#MM#%_ _%#DD#%_, 2004, which showed a relatively normal LVEF. 2. Right heart catheterization performed on _%#MM#%_ _%#DD#%_, 2004, showed a mean RA pressure of 1, RV pressure systolic 22, end diastolic 2, PA pressure 17/5 with a mean of 9, and a mean wedge pressure of 6.
RA|rheumatoid arthritis|RA|127|128|PHYSICAL EXAMINATION|On hand examination she has very long, slender fingers. It is not apparent to me that she has obvious synovial thickening. Her RA predominantly affects her first IP joints and wrist and at the present time they are not significantly swollen, erythematous, or tender.
RA|right atrium|RA,|157|159|OPERATIONS/PROCEDURES PERFORMED|Left ventricular size is normal at rest. Ejection fraction was 59%. 2. Echocardiography. Normal left ventricular function, mild LV dilatation, mild MR, mild RA, mild TR. These are preliminary reports. 3. Chest x-ray. Clear-appearing lungs. HISTORY OF PRESENT ILLNESS: A 51-year-old female with a significant past medical history for asthma, who was complaining for the past 3 months of short of breath that increased over the past week.
RA|right atrium|RA|137|138|PROCEDURES PERFORMED|Large conus branch with distal aneurysmal dilatation and AV fistula to RV. Right heart cath hemodynamics; pulmonary vein 19/17, mean 16; RA 26/24, mean 20; AO sat 85.5%, SVC 54%, RA 75.7%, LA 82%, PV 97%, Fick cardiac output 3.32 with index of 1.75, QP 7.82, QS 3.32, QP/QS 2.35, PVR 3.3. HISTORY OF PRESENT ILLNESS: The patient is a 33-year-old male with complex congenital heart disease admitted with symptomatic atrial fibrillation with rapid ventricular response.
RA|right atrium|RA|184|185|PAST MEDICAL HISTORY|His last echocardiogram was on _%#DDMM2004#%_ and showed severely decreased RV function and an RVSP of 231 + RAP. Last right heart catheterization was on _%#DDMM2003#%_, and showed an RA pressure of 4, PA of 168/64, wedge 11, PVR 25.8, cardiac index of 2.2 (FICK). 2. Bicuspid aortic valve with no evidence of aortic stenosis.
RA|right atrium|RA|257|258|HOSPITAL COURSE|Mitral annular calcification, moderate to severe. Aortic stenosis with an area of 0.8 cm squared, with a mean gradient of 17 and a peak of 27. Tricuspid insufficiency, mild to moderate. Left ventricular systolic pressure 37 mmHg plus right atrial pressure. RA and RV pacing wires. Impression given by the cardiologist was normal overall LV systolic function with bi-atrial enlargement and evidence of pulmonary hypertension.
RA|room air|RA|150|151|HOSPITAL COURSE|_%#NAME#%_ _%#NAME#%_ was transferred to the NICU 4 hours after admission to the newborn nursery when his O2 saturations were noted to be 88 - 96% on RA after being in the headbox for that duration of time. _%#NAME#%_ _%#NAME#%_ was an AGA infant with a length of 49 cm and head circumference of 34.5 cm.
RA|right atrium|RA|115|116|OPERATIONS/PROCEDURES PERFORMED|2. RHC revealed mild secondary pulmonary hypertension. PA was 42/20 with a mean of 27. Wedge was approximately 16. RA was 4. RV was 42/9, a CO of 2.5. There were very calcified proximal vessels with no significant LM disease.
RA|right atrium|RA|236|237|HISTORY OF PRESENT ILLNESS|An echocardiogram showed mildly reduced LV function with very small effusion. The elevated function was felt to be more diastolic, given her high left and right filling pressures during the right heart biopsy in _%#MM#%_ 2004, when her RA pressures were noted to be high at 12 and a pulmonary capillary wedge was 20. Given her symptoms of chest pain and also hypotension, associated with mildly decreased LV function, the patient was admitted to the hospital overnight for diuresis.
RA|right atrium|RA.|140|142|OPERATIONS/PROCEDURES PERFORMED|She had a transesophageal echocardiogram that showed normal EF, moderate-to- severe MR at 3 to 4+, moderate AI, RV systolic pressure at 50+ RA. She also underwent pacer interrogation, Cardiology recommendations were to discontinue her rate-controlling agents including atenolol, Cardizem, due to the fact that she is status post AV nodal ablation.
RA|right atrium|RA|153|154|PHYSICAL EXAMINATION|EXTREMITIES: Trace edema bilaterally. Angiogram again is as stated above. She had a LAD 40% stenosis, first diagonal had 90% stenosis, her wedge was 15, RA 13, no evidence of tamponade. Normal left ventriculogram. CT of the abdomen showed a large pericardial effusion and no pleural effusion, degenerative changes of her lumbar spine and abdomen is otherwise unremarkable.
RA|right atrium|RA|404|405|MAJOR PROCEDURES AND TREATMENT PERFORMED DURING THIS HOSPITALIZATION|1. Biventricular lead placement. 2. Transthoracic echocardiogram performed on _%#MM#%_ _%#DD#%_, 2005, which was a technically difficult study showing mild LV dilation, mild increased LV thickness, severely decreased EF of 20%, mild-to- moderate LA enlargement, mild mitral annular calcification/fibrosis, mild MR, mild aortic dilation with a maximum of 4.3 cm, mild AR, and RV with 36 mmHg greater than RA pressure. No effusion noted. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. daily. 2. Atorvastatin 40 mg p.o. q. day.
RA|rheumatoid arthritis|RA|166|167|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Syncope. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 62-year-old woman with rheumatoid arthritis without known liver disease. She has had RA since 1992 and had been on methotrexate for less than two years, stopped because of some liver blood test abnormalities.
RA|right atrium|RA|448|449|STAFF|She was subsequently transferred to the Cardiology 1 Service for further management before she could undergo surgery. PAST MEDICAL HISTORY: 1. CHF: Echo in _%#MM#%_ 2004 showed low-normal LV systolic function with visually estimated EF in the 50% to 55% range; moderate region of akinesis is present along the inferior and posterior segments; mild RV dilatation; mild RV hypertrophy; mildly decreased RV function; moderate LA enlargement; moderate RA dilatation; RV systolic pressure moderately to severely increased (approximately 52 mm above mean right atrial pressure); no pericardial effusion.
RA|right atrium|RA.|210|212|OPERATIONS/PROCEDURES PERFORMED|3. Echocardiogram performed on _%#MM#%_ _%#DD#%_, 2005, showed normal LV size and function, mildly dilated right atrium, dilated inferior vena cava, and estimated right ventricular systolic pressure of 28 plus RA. His estimated LV ejection fraction was 60%, all based on the preliminary report currently available to me. HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old man status post bilateral single lung transplantation in 1996 due to bronchiectasis, which is related to an inhalational injury, but also he carries a diagnosis of cystic fibrosis.
RA|right atrium|RA.|325|327|PROCEDURE LIST|7. Echocardiogram reveals normal left ventricular size and function, ejection fraction of 50-55%, a normal right ventricle, moderate right mitral annular calcification, trivial mitral regurgitation, aortic valve is calculated at 1.6 cm. involved area. Mild to moderate tricuspid regurgitation with pulmonary pressures at 26+ RA. HOSPITAL COURSE: 1. Ataxia. The patient presented with some weakness and actually on exam had more of ataxia.
RA|right atrium|RA|310|311|ASSESSMENT/PLAN|She was put on O2 and azithromycin. There is no family or friend here but apparently the patient has been declining at Assisted Living at the Colony and they felt she could not handle her and, therefore, sent her to the Emergency Room. 1. Pneumonitis with normal WBC. Chest x-ray shows no apparent infiltrate, RA arterial blood gas is pending. At this point we will plan blood cultures times two, sputum for gram stain and culture.
RA|right atrium|RA,|172|174|PROBLEM #2|We will not plan on repeating echocardiogram as he has that one recently that showed this mild aortic stenosis. He also has a mildly dilated left atrium, left ventricular, RA, and right ventricular. His ejection fraction was normal at 60%. He does have some hypertension that is reportedly controlled normally on his medications, but his blood pressure is elevated here tonight.
RA|right atrium|RA.|234|236|HOSPITAL COURSE|He seems to be tolerating this well. Transthoracic echocardiogram done here shows an ejection fraction of approximately 15%, moderate mitral regurgitation, tricuspid regurgitation showing significant pulmonary hypertension of 70 plus RA. The patient did have an overnight sleep oximetry because of pulmonary hypertension. He did have ___desaturations and average O2 sats of 94%, as low as 69%.
RA|right atrium|RA|167|168|PROCEDURES/INTERVENTIONS THIS ADMISSION|PROCEDURES/INTERVENTIONS THIS ADMISSION: 1. Right heart catheterization, _%#DDMM2005#%_. Impression: Moderate secondary pulmonary hypertension and low cardiac output. RA 7, PA 41/19 (31), PAW 23, PA % saturation 45.3%, .......cardiac .........CO 2.5, CI 1.7. 2. Radiofrequency ablation of AV nodal reentrant tachycardia and Mahaim fiber on _%#DDMM2005#%_.
RA|right atrium|RA|300|301|FINAL DIAGNOSES|Dr. _%#NAME#%_ was asked to see her and has ordered tests looking for her rather esoteric causes of a stroke other than the high blood pressure to exclude anything else that might be correctable in this young woman. To date she has a sed rate of 11, normal electrolytes, a homocysteine level 6.2 and RA level less than 20 which is normal. Her antithrombin III is at 93%, she has an A1c of 5.8 with normal chemistries, normal TSH of 4.0. Blood pressure has been stable in the hospital at 118/76.
RA|right atrium|RA|234|235|DISCHARGE AND FOLLOWUP PLANS|7. He should continue his renal diet, low-fat, low-sodium, and low- potassium diet as before and increase his activity as tolerates. He has been advised to call if he has further chest pain. 8. Angiogram done _%#DDMM2006#%_ showed an RA pressure mean of 6, right ventricle pressures of 18/6, PA pressures of 24/14 with a mean of 18, wedge mean of 9, cardiac index not recorded.
RA|right atrium|RA.|290|292|IMAGING STUDIES|OTHER DIAGNOSES: History of DVT, rheumatoid arthritis, dyslipidemia and hypertension. CONSULTS: Cardiology. IMAGING STUDIES: She has an ejection fraction at 55%, borderline biatrial enlargement, mild concentric LVH, moderate tricuspid insufficiency, right ventricular systolic pressure 32+ RA. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 66-year-old woman with history proximal atrial fibrillation anticoagulated with Coumadin.
RA|right atrium|RA.|202|204|PAST MEDICAL HISTORY|She said she has had coronary angiograms before showing no significant coronary artery disease. 7. Mitral valve replacement with porcine valve. 8. Moderate pulmonary hypertension with pressures of 48 + RA. 9. History of obstructive sleep apnea uncertain, however, if she is on BiPAP. 10. Osteoarthritis. 11. Herpes zoster. 12. History of meningitis. ALLERGIES: Penicillin causes nausea and sulfa.
RA|right atrium|RA.|229|231|HOSPITAL  COURSE|Aortic valve morphology was not well defined, however she does have some stenosis, aortic valve aortic calculates to 0.8 square cm, mean gradient of 8 mmHg. She has severe tricuspid regurgitation, the pulmonary pressures 40 plus RA. After much discussion we would primarily treat her with rate control for her atrial fibrillation with Coreg, as this would certainly help with congestive heart failure along with her rate control.
RA|right atrium|RA|176|177|PROCEDURES PERFORMED DURING THIS STAY|4. Transthoracic echocardiogram dated _%#DDMM2006#%_ shows normal LV function, normal RV size and function, mild increase in the RVSP approximately 25 greater in the RAP, mild RA dilation, mild MR. 5. Cardiac catheterization dated _%#DDMM2006#%_ showed an RA pressure of 12, PA of 32/12 with a mean of 20 and pulmonary capillary wedge pressure of 17.
RA|room air|RA|158|159|ASSESSMENT/PLAN|She was overall stable on the vent and once hospice was decided upon, after a few days more she was extubated (extubated on DOL 10). She transitioned well to RA requiring no further ventilatory support. Problem #3: Cardiovascular: She was hemodynamically stable throughout her hospital stay requiring no pressor support.
RA|right atrium|RA,|109|111|PROCEDURES PERFORMED DURING THIS HOSPITALIZATION|Oximetry studies to exclude a shunt revealed saturation of 68.7 in the SVC, 71.1 in the IVC, 70.3 in the mid RA, 68 in the main PA and 98.3 in the wedge position. Aortic saturation was 90%. This was interpreted as no significant step up on oxygen saturation.
RA|right atrium|RA.|228|230|HOSPITAL  COURSE|He does have a known ischemic cardiomyopathy. Transthoracic echocardiogram was done here and an EF of 35%. He had several wall motion abnormalities in addition. He had just mild valvular disease and pulmonary pressures were 39+ RA. His BNP however, was significantly elevated at greater than 35,000. Chest x-ray revealed mild to moderate cardiomegaly, small bilateral pleural effusion, questionable infiltrate on the left lung.
RA|right atrium|RA|315|316|PROCEDURES|PROCEDURES: 1. A chest x-ray was unremarkable. 2. Adenosine thallium stress test, which showed no evidence of inducible ischemia and ejection fraction of 72% at rest and 74% post-stress. 3. Echocardiogram, which showed moderate to severe mitral regurgitation with severe pulmonary hypertension greater 55 mmHg plus RA and moderate tricuspid regurgitation. HOSPITAL COURSE: 1. Chest pain. Mrs. _%#NAME#%_ is an 85-year-old woman who came to emergency department with chest discomfort.
RA|right atrium|RA.|232|234|PROCEDURES PERFORMED|6. Oral thrush. PROCEDURES PERFORMED: 1. Echocardiogram _%#DDMM2007#%_ shows a hyperdynamic LV with dilated right ventricle and decreased RV ejection fraction with severe tricuspid regurgitation 2-3+ and RV systolic pressure of 64+ RA. 2. Echocardiogram _%#DDMM2007#%_, paradoxical septal motion is consistent with right ventricular volume and pressure overload, the right ventricle is mild to moderately dilated.
RA|rheumatoid arthritis|RA,|216|218|PAST MEDICAL HISTORY|Given her subjective fevers and chills and sweats; infectious etiologies must be considered as well. PAST MEDICAL HISTORY: Rheumatoid arthritis, kidney stones with lithotripsy, multiple hand surgeries related to her RA, recent diagnosis of breast cancer, history of esophageal diverticula treated with resection and complicated by perforation. She required a feeding tube for that in her recovery.
RA|right atrium|RA,|345|347|MAJOR PROCEDURES|3. Hypothyroidism. 4. Dyslipidemia. MAJOR PROCEDURES: 1. Echocardiogram, _%#DDMM2007#%_, as read by Dr. _%#NAME#%_ showed a moderately dilated left ventricle, severely reduced left ventricular systolic function, ejection fraction equals less than 25%, small circumferential pericardial effusion, moderate loculated effusion posteriorly and near RA, no evidence of tamponade apart from RA collapse due to localized effusion near RA. 2. EKG performed _%#DDMM2007#%_ and _%#DDMM2007#%_ showed normal sinus rhythm.
RA|right atrium|RA|349|350|MAJOR PROCEDURES|MAJOR PROCEDURES: 1. Echocardiogram, _%#DDMM2007#%_, as read by Dr. _%#NAME#%_ showed a moderately dilated left ventricle, severely reduced left ventricular systolic function, ejection fraction equals less than 25%, small circumferential pericardial effusion, moderate loculated effusion posteriorly and near RA, no evidence of tamponade apart from RA collapse due to localized effusion near RA. 2. EKG performed _%#DDMM2007#%_ and _%#DDMM2007#%_ showed normal sinus rhythm. HISTORY OF PRESENT ILLNESS: This patient is a 55-year-old female with history of hypertension and CHF who presented to her primary care physician with 2 episodes of chest pain.
RA|right atrium|RA.|154|156|HOSPITAL COURSE|2. Right-sided heart failure. She did have an echo done this admission which showed some elevated right-sided systolic pressure estimated at 27 mmHg plus RA. Her LV function appeared normal and function size. She did have some moderate trileaflet aortic sclerosis and moderate aortic stenosis.
RA|right atrium|RA|256|257|PROCEDURES PERFORMED DURING HOSPITAL STAY|4. Hyperlipidemia. PROCEDURES PERFORMED DURING HOSPITAL STAY: Echocardiogram, which shows no regional wall motion abnormalities, left ventricular systolic function normal, trace tricuspid regurgitation. Right ventricular systolic pressure 39 mmHg plus the RA pressure and an abdominal aorta that was 4.2 cm. The patient also had an MRI/MRA of her abdomen, which initially was read as diffuse ulceration of the aortic arch and a descending thoracic aorta with diffuse chronic intramural hematoma in the same distribution.
RA|right atrium|RA|168|169|PROCEDURES AND INVESTIGATIONS|4. Brain MRI, which showed mild-to-moderate cerebral and cerebellar volume loss without involvement of a predominant lobe. 5. Right heart catheterization, which showed RA mean pressure 14 mmHg, RV pressure 59/25 mmHg, PA pressure 57/33 mmHg with a mean of 43 mmHg and pulmonary artery wedge pressure of 35 mmHg mean.
RA|right atrium|RA|232|233|PROCEDURES AND OPERATIONS|2. Left and right heart catheterization performed on _%#DDMM2006#%_ demonstrated minimal angiographical coronary artery disease with no hemodynamically significant lesions. Moderate pulmonary artery hypertension was noted with mean RA of 26, RV of 43/26, PA of 58/29 and a pulmonary artery wedge pressure of 10. Fixed cardiac index was 1.3. 3. Flolan initiation and catheterization lab performed on _%#DDMM2006#%_.
RA|right atrium|RA,|161|163|SIGNIFICANT FINDINGS|SIGNIFICANT FINDINGS: Include severely decreased LV function with an EF of 20%, moderate LV dilatation. Moderately decreased LV function with an RVsP of 41 plus RA, moderate left atrial enlargement. There is moderate mitral regurgitation and trace aortic regurgitation. Patient had first known episode of Atrial Fibrillation while visiting in Florida last month.
RA|right atrium|RA|161|162|TESTS DONE DURING THIS HOSPITAL STAY|4. Echocardiogram showed an ejection fraction of 55-60%, her RV function was normal and her diastolic function was normal. Her pulmonary pressure was 30 mm plus RA pressure. REASON FOR ADMISSION AND HOSPITAL COURSE: A 27-year-old woman who presented to the emergency room complaining of shortness of breath and back pain.
RA|right atrium|RA.|228|230|PAST  MEDICAL HISTORY|8. Gastroesophageal reflux disease. 9. OSA. 10. Osteopenia. 11. Congestive heart failure with an EF of 35-40%. 12. Biatrial enlargement, mild LVH, moderate mitral regurg, mild aortic insufficiency and pulmonary pressures of 16+ RA. He does see someone at Minnesota Heart Clinic and is also followed up at the CORE Clinic. 13. Diverticulosis. 14. Hypothyroidism 15. Hypertension. 15. Glaucoma.
RA|right atrium|RA.|217|219|PAST MEDICAL HISTORY|A history of chronic obstructive pulmonary disease, prior myocardial infarction, congestive heart failure with his last ejection fraction being about 35% in _%#MM#%_. He does have some pulmonary hypertension with 46+ RA. Depression, atrial fibrillation chronically anticoagulated. Prior wound infections with methicillin resistant staphylococcus aureus as well as pseudomonas. ALLERGIES: Allergies to codeine. CURRENT MEDICATIONS: Current medications are quite extensive and at this time are not readily available.
RA|right atrium|RA|150|151|PAST MEDICAL HISTORY|5. Dyslipidemia. 6. GERD. 7. DNR/DNI 8. Echocardiogram on _%#DDMM2007#%_ showed mild left ventricular hypertrophy, elevated pulmonary pressure of 42+ RA with normal right ventricular systolic function. 9. Hospitalization in _%#MM#%_ and _%#MM#%_ of 2007 for pneumonia, treated. MEDICATIONS: 1. Evoxac AC 30 mg t.i.d. 2. Beclomethasone nasal spray 2 sprays each nostril b.i.d. p.r.n.
RA|right atrium|RA|154|155|MAJOR PROCEDURES|1. CT chest, _%#DDMM2007#%_ - no PE, extensive ground glass opacities. 2. Transthoracic echo on _%#DDMM2007#%_ - ejection fraction 55%, RVSP 32 mmHg plus RA pressure. 3. Pulmonary function tests _%#DDMM2007#%_ - mild airflow obstruction. 4. Bronchoscopy _%#DDMM2007#%_ - diffuse lung disease with collapse of the left lower lobe and right lower lobe.
RA|right atrium|RA|213|214|MAJOR IMAGING AND PROCEDURES|1. A right heart catheterization was done on _%#DDMM2007#%_, which showed RA pressure 18, RV pressure 17, PA pressure 42, wedge pressure 24, cardiac index 1.1. 2. Right heart catheterization done _%#MMDD#%_ shows RA pressure 1, RV pressure of 35/1, PA pressure 22, wedge pressure 15, cardiac index of 1.9. 3. Ultrasound of the abdomen done on _%#MMDD#%_ showed no evidence of cholecystitis, enlargement of the intrahepatic inferior vena cava consistent with cardiac status.
RA|rheumatoid arthritis|RA|169|170|PAST MEDICAL HISTORY|He required blood transfusions at that time. 3. Hypertension 4. Hyperlipidemia on treatment for several years. 5. History of rheumatoid arthritis with positive FANA and RA which was over 1,000. That was quite a number of years ago and then his RA became negative. 6. Chronic nonspecific abdominal pain since 1976, mostly involving the right upper quadrant.
RA|right atrium|RA.|243|245|PROCEDURES PERFORMED DURING THIS ADMISSION|Status post mitral valve repair with no significant mitral regurgitation and a median gradient of 3 mmHg. There was small to moderate pericardial effusion and large right pleural effusion. Estimated right ventricular systolic pressure was 28+ RA. 2. Chest tube placement on _%#DDMM2002#%_ with an 8-French nonlocking pigtail catheter advanced to the right pleural space, and 1300 cc of bloody fluid was drained over a 24-hour period.
RA|right atrium|RA.|216|218|HOSPITAL COURSE|The patient did have an echocardiogram which showed a decreased ejection fraction of approximately 20%. Also evident, was bi-atrial enlargement, left ventricular enlargement, and pulmonary artery hypertension of 51+ RA. It was thought that this patient's heart failure was multifactorial. There were some mild wall motion abnormalities and he does have a history of coronary disease.
RA|room air|RA.|189|191|2. CV|Due to concerns over earlier problems at the clinic the patient was admitted overnight for observation. Pt did well and did not require any oxygen supplementation. O2 sats remained high on RA. CXR was negative. 2. CV: Pt remained hemodynamically stable. All four extremities were checked for BP and found to be consistent, this was done to help rule out coarctation.
RA|right atrium|RA|357|358|HISTORY OF PRESENT ILLNESS|Abdomen was benign. Extremities showed no edema. PROCEDURES AND TESTS: On _%#MM#%_ _%#DD#%_, 2002, the patient had a transthoracic echocardiogram which showed mild decreased LV function with an EF of 45%, moderate region of hypokinesis in apical and septal segments, mild mitral regurgitation, trace aortic regurgitation, RV systolic pressure 36 above mean RA pressure. Of note, this is a marked change from recent transthoracic echocardiogram approximately 2 months ago in _%#MM#%_ of 2002. The patient had new hypokinesis in the apical and septal segments, as well as new decreased LV function previously described as normal.
RA|right atrium|RA|157|158|PLAN|PLAN: Atrial fibrillation/CHF. The patient is rate controlled. Will diurese gently. Will heparinize and begin Coumadin. Check echocardiogram to evaluate for RA and LA size. She should be a good candidate for cardioversion and after three weeks of anticoagulation, if her echo is normal, will check a TSH.
RA|right atrium|RA,|160|162|PROBLEMS|This was reevaluated. The patient had standard transplant workup performed. 2. CHF. The patient initially had a right heart catheterization with measurement of RA, RV, and PA pressures. The patient's pressures were markedly elevated consistent with CHF. The patient had a Swan-Ganz catheter placed and was placed on BNP with increased diuretics.
RA|right atrium|RA|163|164|PROBLEMS|On the day of discharge, the patient had a repeat right heart catheterization. On this occasion, the cardiac output had increased from 3.1 L/min to 3.6 L/min. The RA pressure was 1 mmHg, decreased from 12 mmHg. The RV pressure at time of discharge was 27/4 mmHg, improved from 61/34 mmHg.
RA|right atrium|RA|136|137|PROCEDURES PERFORMED THIS HOSPITALIZATION|1. Pulmonary angiogram. 2. Transesophageal echo which showed no right-to-left shunt. Moderate to severe RV dilatation, moderate to mild RA dilatation. Mild to moderate tricuspid regurgitation. Severely decreased right ventricular function and right ventricular systolic pressure of 58+RA. 3. Trial of Flolan. 4. Swan-Ganz catheter. 5. Bronchoscopy which was positive for Candida and felt to be clinically insignificant.
RA|right atrium|RA,|285|287|PAST MEDICAL HISTORY|Echocardiogram on _%#DDMM2003#%_ revealed left ventricular systolic function with severe right ventricular dilatation, severe right ventricular hypertrophy, and severely decreased right ventricular function, severe tricuspid regurgitation, right ventricular systolic pressure 112 plus RA, severe right atrial dilatation. 2. IVC Greenfield filter placed on _%#DDMM2003#%_. 3. Hypercoagulable workup negative for homocysteine, negative ANA, factor V negative, lupus inhibitor negative, protein CNS negative.
RA|rheumatoid arthritis|RA|139|140|HOSPITAL COURSE|No evidence of further bleeding after injection. The patient has tolerated po Protonix just fine without evidence for further bleeding. 2. RA stable. 3. RAI involvement stable. 4. Congestive heart failure, also stable. DISCHARGE MEDICATIONS: 1. Coreg 6.25 mg b.i.d. 2. Lasix 40 mg b.i.d.
RA|right atrium|RA.|184|186|PROCEDURES|There is anterior septal and apical akinesis. There is moderate to severe mitral regurgitation and severe tricuspid regurgitation. There is pulmonary hypertension at 48 cm of H2O plus RA. 4. Chest x-ray showing persistent, but not worsened left upper lobe infiltrate as seen in previous imaging studies. PAST MEDICAL HISTORY: 1. Coronary artery disease with recent myocardial infarction in _%#DDMM2003#%_.
RA|right atrium|RA|255|256|PROCEDURES|2. Cardiac echo, _%#DDMM2003#%_: Normal global LV systolic function, mild right ventricular hypertrophy, normal RV size and function. 3. DDDR pacemaker placement on _%#DDMM2003#%_: Pacemaker is a Guidant Insignia _%#DEVICE#%_. Bipolar leads placed in the RA and the RV. HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old male with history of lightheadedness, dizziness for the last three months.
RA|right atrium|RA|272|273|HOSPITAL COURSE|However, the conclusion was that would not be eligible for transplant for at least three months because she was still smoking and needed to quit that before she could be eligible for a transplant. A right heart catheterization was performed on hospital day #2 that showed RA systolic pressures in the 50s with PA pressures in the 50s and wedge pressures about 28 with a mean of 25. Her cardiac index was calculated to be 1.8. Her mixed venous O2 sat was 48%.
RA|right atrium|RA.|241|243|PAST MEDICAL HISTORY|Most recent echocardiogram, _%#MM#%_ _%#DD#%_, 2003, with ejection fraction of 15%, mild to moderate mitral regurgitation, moderate to severe tricuspid regurgitation, and mild to moderate RV dilatation with pulmonary artery pressures of 36+ RA. The patient's most recent coronary angiogram was _%#MM#%_ of 2001, with normal coronaries. 2. Chronic pancytopenia since a bone marrow transplant requiring platelet transfusions Monday, Wednesday, and Friday, and weekly packed red blood cell transfusions.
RA|right atrium|RA,|497|499|DISCHARGE DIAGNOSIS|He is an 83-year-old with a history of congestive heart failure and had a normal echocardiogram with a normal ejection fraction in _%#MM#%_ 2003. Progressively, he has been having this deterioration of ejection fraction with the current ejection fraction noticed on _%#MM#%_ _%#DD#%_, 2004, on an echocardiogram of 15%, with also mild moderate increased of LV wall thickness, moderate right ventricular dilatation, moderate severely decreased right ventricular function, RV systolic pressure 31 + RA, moderate LA enlargement, severe aortic stenosis with a mean gradient of 17.3 mmHg. On _%#MM#%_ _%#DD#%_, 2003, he had an ejection fraction of 20%.
RA|right atrium|RA.|159|161|HISTORY OF PRESENT ILLNESS|There was severe concentric left ventricular hypertrophy, bilateral atrial enlargement, and pulmonary hypertension with a pulmonary artery pressure of 29 plus RA. Adenosine/thallium scan on _%#MM#%_ _%#DD#%_ was negative for ischemia. PAST MEDICAL HISTORY: Coronary artery disease with three-vessel bypass in 1995.
RA|room air|RA|192|193|ASSESSMENT|He did well for the first 6.5 hours of life while rooming-in, then at 12:30 p.m. was noted to be cyanotic. He was stimulated and moved to the newborn nursery, where an initial SaO2 was 77% on RA then increased to 100% with blow-by O2, and the baby pinked up. A second desaturation episode down to 86% with shallow respirations was observed while in the newborn nursery at 13:15 while the patient was asleep; this spell also resolved with stimulation.
RA|right atrium|RA.|188|190|OPERATIONS/PROCEDURES PERFORMED|OPERATIONS/PROCEDURES PERFORMED: 1. Echocardiogram that demonstrated normal LV systolic function with moderately decreased right ventricular function. RV systolic pressure at 31 mmHg plus RA. 2. Right heart catheterization with pulmonary artery pressure at 27/12, pulmonary capillary wedge pressure 10, cardiac index 2.3, RV pressure 26/5, and RA pressure of 5.
RA|rheumatoid arthritis|RA|105|106|PLAN|1. Alcohol dependence. 2. Alcohol withdrawal. 3. Chronic joint pain. PLAN: 1. Check sed rate, uric acid, RA titer and FANA. 2. Detox from alcohol. 3. Evaluate for further treatment, possibly in Lodging Plus.
RA|rheumatoid arthritis|RA.|153|155|PAST MEDICAL HISTORY|1. Rheumatoid arthritis, treated with prednisone and methotrexate and Arava (he is receiving stress doses of steroids). 2. Sjogren syndrome secondary to RA. 3. Previous history of cardiomyopathy with a reported EF in the past in the 30s (echo this a.m. showed a 50+ percent EF).
RA|right atrium|RA.|141|143|DATA|BNP 643. Chest x-ray dated _%#DDMM2005#%_ shows normal heart size. Lungs are clear. Echocardiogram shows ejection fraction of 20%, RVSP 24 + RA. PHYSICAL EXAMINATION: He is afebrile, SpO2 98% on room air, blood pressure 87/67, pulse 100.
RA|rheumatoid arthritis|RA,|145|147|FAMILY MEDICAL HISTORY|FAMILY MEDICAL HISTORY: The patient's mother has had breast cancer. Several grandparents have had diabetes. There is no family history of lupus, RA, heart disease, strokes, or thyroid disease. ALLERGIES: The patient has a latex allergy, but has no known drug allergies.
RA|right atrium|RA.|158|160|FAMILY HISTORY|Chest x-ray shows mild cardiomegaly. There are no infiltrates. Echocardiogram shows ejection fraction of 35-40% with normal LV size, RV systolic pressure 30+ RA. HC03 is 31. PHYSICAL EXAMINATION: VITAL SIGNS: He is afebrile.
RA|rheumatoid arthritis|RA,|151|153|PAST MEDICAL HISTORY|No residual. History of myocardial infarction. Past history is pertinent for pneumonia multiple times. No TB. Negative PPD. Autoimmune such as gout or RA, denies any. GI and GU are negative. Pulmonary is as noted. Cardiovascular: Denies any recent changes. No infectious diseases such as HIV, hepatitis. Cancers or peripheral vascular disease, denies any.
RA|rheumatoid arthritis|RA.|134|136|FAMILY HISTORY|FAMILY HISTORY: Father died of myocardial infarction. Mother died at 82 of old age. No cancers or autoimmune problems such as gout or RA. No history of TB. PHYSICAL EXAMINATION: Alert and oriented, moderately obese.
RA|right atrium|RA|187|188|LABORATORY DATA|Albumin 2.4, total protein 5.7, troponins negative times two. Arterial blood gases - 7.40, 44, 164, 27 on rebreather face mask. Echocardiogram shows normal ejection fraction, with normal RA size and normal RV function. Sputum culture shows gram negative rods with gram positive cocci with greater than 10 epithelial cells, suggestive of contamination.
RA|right atrium|RA.|164|166|PAST  MEDICAL HISTORY|11. History of congestive heart failure and last echo was in _%#MM#%_ of 2005 showing LVH. She has an ejection fraction of 45% and her pulmonary pressures were 37+ RA. She had moderate mitral regurg and moderate aortic sclerosis with some insufficiency. ALLERGIES: She has no known true drug allergies.
RA|right atrium|RA,|179|181||Her CXR is mortly clear. Her TTE shows hyperdynamic and small LV, enlarged RV and mild PHT (RVSP in the 30-35 cmmHg + RAP). Her right heart catheterization data (_%#MMDD#%_) show RA, 5 mmHg; PAP, 47/23, mean 21 mmHg; PCWP, 14 mmHg. A/P: 1. Septic shock. 2. Profound hypotension secondary to #1 with evidence for end-organ hypoperfusion (cerebral and renal vascular beds).
RA|right atrium|RA|372|373|HISTORY|This showed an ejection fraction greater than 45%. Trivial mitral regurgitation, aortic stenosis, and severe three vessel coronary disease including subtotal occlusion of the proximal RCA, 50% followed by a 70% left main stenosis, proximal 70% LAD disease, mid 50% LAD disease, mild first diagonal disease, 80% first OM stenosis, more distal 50%. PA pressures were 40/14, RA was 9. She had surgical intervention performed by Dr. _%#NAME#%_ _%#NAME#%_ on _%#DDMM2003#%_. This included a LIMA to the LAD, saphenous vein grafts sequentially to OM1 and OM2 and saphenous vein graft to the RCA.
RA|right atrium|RA|248|249|SOCIAL HISTORY|Pulmonary function testing also appears to be satisfactory with what is called a minimal obstructive lung abnormality. Overnight the patient has been on generous IV fluids, Swan-Ganz catheter has revealed pressures of approximately 30-35/10-12 PA, RA less than 10 only recently approaching 10. Wedge pressure of about 12. Cardiac output of about 5.3 liters per minute with satisfactory SVR of about 800-900.
RA|right atrium|RA|202|203|HISTORY OF PRESENT ILLNESS|His urine demonstrates pyuria and bacteruria. He has been treated with dopamine drip currently at 5 mcg/kg/minute, a Swan-Ganz catheter was placed earlier today that shows a PA of 48/21, PCWP of 23 and RA of 15. Urine output has been fairly high with a total output on _%#MMDD#%_ of 3750 cc (intake 2298). Eight-hour overnight output was 1250 cc.
RA|right atrium|RA.|230|232|RELEVANT LABORATORY DATA|Left ventricle is normal in size. Moderate to severe aortic stenosis with aortic insufficiency, mild to moderate mitral regurgitation, moderate tricuspid regurgitation with estimated pulmonary pressures estimated at 73 mmHg. plus RA. The inferior vena cava is dilated and does not collapse with inspiration consistent with an elevated CVP. IMPRESSION/RECOMMENDATIONS: See above. It is likely that the patient has atypical pneumonia with an additional component of congestive cardiac failure possibly related to her anemia and underlying valvular abnormalities.
RA|rheumatoid arthritis|RA.|131|133|PLAN|For acute renal failure history. The patient's renal function needs to be closely monitored, especially as he is on glipizide. For RA. I agree with increasing the patient's prednisone 5 mg whilst he is off his disease modifying agent, but also instructed the patient to contact his rheumatologist as soon as possible when he leaves to tell him that he has changed his medication regime.
RA|UNSURED SENSE|RA|151|152|ADDITIONAL LABS|Normoactive bowel sounds. Healing surgical incisions. EXTREMITIES: Unremarkable. NEURO: Grossly intact. ADDITIONAL LABS: Reveal normal platelet count, RA less than 20, normal BMP, albumin of 3.1, ANA less than 1, ESR of 99, white blood cell count 9400, hemoglobin 12.1, MCV of 90, platelet count 361,000.
RA|rheumatoid arthritis|RA,|207|209|ASSESSMENT|ASSESSMENT: 1. Status post revision right THA. The patient had a significant estimated blood loss of 800 cc. She has been hemodynamically stable, however. 2. Connective tissue disease, including features of RA, lupus and Sjogren's syndrome for which the patient is on Plaquenil and chronic low dose Prednisone. 3. Hypertension. 4. No known coronary artery disease. RECOMMENDATIONS: The patient requires stress steroid coverage perioperatively.
RA|rheumatoid arthritis|RA|157|158|PAST  MEDICAL HISTORY|1. Multiple right hip arthroplasties with complication of methicillin resistant staph aureus. 2. History of connective tissue disease with manifestations of RA and lupus. She is on chronic prednisone therapy for this. Her dose preoperatively was 10 mg. 3. History of nonischemic cardiomyopathy, ejection fraction was 45-50% based on the recent echocardiogram.
RA|right atrium|RA|433|434|STUDIES|He also notes worsening lower extremity edema. STUDIES: 1. CT scan of the chest done in the emergency room to rule out PE showed no evidence of PE, though a moderate to large pericardial effusion, which is circumferential, measuring approximately 1.8 cm to 2 cm at its largest dimension, perpendicular from the heart. 2. Echo performed per Cardiology showed a 1.5 to 1 cm circumferential effusion with some thickened pericardium. No RA or RV collapse. He did have mitral variation of 30%. He had a normal EF, mild right ventricular hypertrophy, normal sized atriums, no evidence of ASD with color flow, and his IVC was dilated to 2 cm without respiratory changes.
RA|right atrium|RA|136|137|DIAGNOSTIC STUDIES|He also had zero to two hyaline casts. DIAGNOSTIC STUDIES: 1. Echo shows an LV function of 30% and severe pulmonary hypertension of 55+ RA AAA has increased in size to 6 cm and he has multiple wall motion abnormalities. 2. Head CT shows small vessel ischemic disease. There is a right parietal subcutaneous.
RA|right atrium|RA.|285|287|IMPRESSION|Current hypoxic/hypercapnic respiratory failure, as above. Also, likely pulmonary hypertension secondary to her underlying fibrotic lung process and there may be a component of volume overload as well. Apparently echo from previous admission has shown PA pressures of at least 48 plus RA. RECOMMENDATIONS: 1. Broad spectrum antibiotics for atypical organisms. 2. Nebs and attempt to pulmonary toilet and sputum sample, if able.
RA|right atrium|RA|170|171|LABORATORY EXAMINATION|Normal pulses. LABORATORY EXAMINATION: Right heart catheterization numbers were evaluated. Cardiac index was 3.9. _____ 80.7. PA pressure is 36/17, wedge pressure of 16, RA pressure mean was 3. EKG strips and total lead EKGs were reviewed. EKG strip showed narrow complex tachycardia with heart rate of 160 to 170 per minute, which abruptly terminated with adenosine administration.
RA|room air|RA|469|470|PHYSICAL EXAMINATION|MSK: no muscle aches or pains, weakness PAST MEDICAL HISTORY: 1. Diabetes mellitus. 2. Hypertension. 3. Depression. MEDICATIONS: Norvasc ASA Wellbutrin Enalapril Enozaparin Prozac Aspart SSI (24 hours - 58 Units) Lantus 20Units qpm Metformin 1000mg po bid D5, 1/2 NS (d/c yesterday) SOCIAL HISTORY: +occasional drinker no smoke + married carpentar, recently retired FAMILY HEALTH HISTORY: +DM2 +HTN no Cancer PHYSICAL EXAMINATION: VS: 90s, 110-120s/70s-80s, 14-17, 98% RA GENERAL: Alert and oriented X3, NAD, well dressed, answering questions appropriately, appears stated age. HEENT: OP clear, no LAD, no TM, non-tender, no exopthalmous, no proptosis, EOMI, no lig lag, no retraction CV: RRR, no rubs, gallops, no murmurs LUNGS: CTAB, no wheezes, rales, or ronchi ABDOMEN: soft, Nontender, nondistended, +BS, no organomegaly EXTREMITIES: no edema, +pulses, no rashes, no lesions, bandanges consistent with surgeries NEUROLOGY: CN grossly intact, + pinprick, + DTR upper and lower extremity MSK: grossly intact Labs: BS: 250-400s A/Plan Mr. _%#NAME#%_ is a 59yo male with DM2.
RA|room air|RA.|153|155|GENERAL PHYSICAL EXAMINATION|GENERAL PHYSICAL EXAMINATION: Alert and oriented x3. Neuropsych profile normal. Vital signs - 156/73, pulse 68, respirations 18, afebrile, 02 sat is 96% RA. Foley catheter in place. HEENT - Bruising left forehead and eyebrow. PERRLA. EOMs full. Neck supple without significant pain or crepitus.
RA|right atrium|RA|175|176|HISTORY OF PRESENT ILLNESS|He then had his cataract surgery and had an echocardiogram performed on the _%#DD#%_ of _%#MM#%_ which revealed severe pulmonary hypertension with estimated pressure of 123 + RA pressure. In addition, there was a large right ventricular apex mass consistent with a thrombus. This is a small posterior pericardiac effusion of uncertain significance.
RA|right atrium|RA.|323|325|PAST MEDICAL HISTORY|2. Type 2 diabetes for over 5 years. 3. Coronary artery disease, status post MIs in the past He recently had an adenosine stress test that showed an EF of 40% He also had severe hypokinesis in the mid and distal anterolateral, lateral and apical walls. 4. Hyperlipidemia. 5. Pulmonary hypertension with PA pressures of 75+ RA. 6. GERD with history of gastropathy. 7. Bilateral cataract surgery in _%#MM#%_ and _%#MM#%_ of 2006. 8. Anemia. 9. Barrett's esophagus. 10. Right heart failure.
RA|rheumatoid arthritis|RA|92|93|PAST MEDICAL HISTORY|Subsequent to chemotherapy she has retained some numbness in her feet. She has a history of RA which is now inactive. Osteoarthritis particularly of the right knee. She has a history of colitis with a GI bleed when she was taking aspirin reportedly many years ago for her arthritis.
RA|right atrium|RA.|136|138|IMPRESSION|IMPRESSION: 1. Pulmonary hypertension: Cardiac echo performed on _%#DDMM2005#%_ showed a right ventricular systolic pressure of 67 plus RA. Further the BNP is elevated at 561. Although right ventricular pressures have not been confirmed via right cath, qualitatively on the echo there is right ventricular enlargement and decreased RV function.
RA|right atrium|RA|202|203|HISTORY OF PRESENT ILLNESS|She has been hospitalized on previous occasions with similar symptoms. She is known to have pulmonary hypertension, and on echocardiogram this admission her estimated right-sided pressures were 53 plus RA pressure. She does have a little bit of systolic dysfunction of the left ventricle and EF of about 40-45%. Overall right ventricular function was thought to be within normal limits.
RA|right atrium|RA|369|370|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Significant for: 1. Long-standing hypertension. 2. Diabetes mellitus. 3. Hyperlipidemia. 4. Heart failure. Last echo reveals ejection fraction of approximately 28- 30% with moderately severe left atrial enlargement, moderate concentric LVH, moderate mitral valve insufficiency, moderately severe tricuspid insufficiency with RSVP estimated at 27+ RA pressure and moderate to moderately severe global decrease in LV systolic function. 5. Atrial fibrillation chronic. 6. Peripheral neuropathy. 7. Depression. PAST SURGICAL HISTORY/PROCEDURES: Significant for pacemaker implantation and percutaneous transluminal coronary angioplasty of the left anterior descending artery.
RA|rheumatoid arthritis|RA|216|217|HISTORY OF PRESENT ILLNESS|She had an EMG of 1 upper and right lower extremity which was normal CPKs and ANAs were unremarkable as well. She also had ANCA and Wegner's as well as ACE, Lyme's titers and Sjogren's panels done which were normal. RA was negative and electrophoresis of her proteins was done which was normal. She had a spinal study done in 2005, which showed 1 white blood cell and 0 red blood cells with negative cryptococcal antigen, negative oligoclonal bands, negative myelin basic proteins and normal IgGs.
RA|right atrium|RA|142|143|PHYSICAL EXAMINATION|Cardiac output is 9.2 liters per minute. Cardiac index is 5.0. SVR is 686. PA pressure is 49/23. Pulmonary capillary wedge pressure is 15 and RA pressure is 8. HEENT: He has no evidence of head trauma. Pupils are equal, round and reactive. Sclera are white. Conjunctiva are slightly injected. Ears and nose are unremarkable.
RA|rheumatoid arthritis|RA.|252|254|IMPRESSION|I agree with plans for CT scan of the chest and abdomen and also agree that bronchoscopy would be likely the next best step in diagnosis. 2. Rheumatoid arthritis. I doubt that her current flare of general joint pain and swelling is directly related to RA. This is more likely related to her infectious process. Methotrexate, especially in the setting of a low albumin could predispose her to atypical pulmonary infections.
RA|right atrium|RA|228|229|HISTORY OF PRESENT ILLNESS|His RV was moderately dilated. An RV thrombus was noted and he had moderate to severe reduction of RV function. His RA also showed moderate to severe dilation, and his RV systolic pressure was 60 + RA (with my estimation of his RA pressure is 15 mm of mercury, giving him an RV systolic pressure of 75 mm of mercury). He was to return to the clinic to see Dr. _%#NAME#%_ in the next couple of days before this event occurred.
RA|right atrium|RA|138|139|HISTORY OF PRESENT ILLNESS|Her LV function was normal at that time with an ejection fraction of 60%. She had pulmonary hypertension with PA pressure of 67 mmHg plus RA pressure. She also has chronic atrial fibrillation. The patient was admitted with heart failure at that time and required thoracentesis for her pleural effusion.
RA|rheumatoid arthritis|RA|167|168|REVIEW OF SYSTEMS|ERYTHROMYCIN. REVIEW OF SYSTEMS: Had no recent chest pain or CHF symptoms. She denies cough or respiratory symptoms. MUSCULOSKELETAL: Chronic diffuse joint pains from RA and fibromyalgia. GU: Dysuria pre-admission. NEURO: No focal neurologic complaints. The altered level of consciousness noted. LABORATORY DATA: Initial hemoglobin was 11.8, initial white count 2,100 now 35,500 on _%#MMDD2004#%_.
RA|room air|RA|186|187|HPI|She woke up and was foaming at the mouth. Pt's husband called 911 and she was brought to ER. Pt's O2 sats were in the mid 50's according to ER records initially. ABG done pressumibly on RA had a PaO2 in the 80's. Pt apparently had a PPD done when she migrated from Somalia and that was negative.
RA|right atrium|RA|201|202|PHYSICAL EXAMINATION|He is sedated on a ventilator. Blood pressure is 104/60 with the drips running as listed. He is in a sinus rhythm at 110, temperature is 99.2 degrees. Respirations 24, ventilator setting. PA is 30/18, RA 13, sats 96%. HEENT: Pupils react. There is no scleral icterus. NECK: Veins are flat. CHEST: Lungs are clear HEART: Sinus rhythm. No extra cardiac sounds.
RA|right atrium|RA|408|409|MEDICAL HISTORY|MEDICAL HISTORY: Significant for "depression" diagnosed in _%#MM#%_, atrial fibrillation status post AV nodal ablation and pacemaker, rheumatic fever, osteoporosis, chronic anisocoria with MRI showing small vessel ischemic disease, bilateral oophorectomy for benign cystadenomas, history of hemorrhoids. Echocardiogram in _%#MM#%_ of this year showed EF of 45-50% with a pulmonary artery pressure of 38 plus RA with moderate concentric LVH and biatrial enlargement. She also has history of herpes zoster. FAMILY HISTORY: Significant for a sister with ovarian cancer and another sister with history of thyroid cancer.
RA|rheumatoid arthritis|RA|221|222|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Hypertension for many years. This has been adequately treated with Hyzaar and atenolol. 2. Rheumatoid arthritis. The patient reports that she has been having several flare-ups since _%#MM#%_. Her RA was first diagnosed in 1991. It mostly affects her hands and knees. She has been taking prednisone almost daily since _%#MM#%_.
RA|right atrium|RA|131|132|PHYSICAL EXAMINATION|Her temperature is 99.6. She is in a sinus rhythm with rates in the 80s. Her cardiac output was 3.5, index 1.8, PA pressure 34/20, RA 18. She is currently receiving blood transfusion. She is intermittently been on Neo-Synephrine. SKIN: Relatively benign. HEENT: Relatively benign. NECK: Hard to assess due to thick neck.
RA|right atrium|RA.|227|229|LABORATORY AND DIAGNOSTIC DATA|There is left upper lobe pleural thickening and scar. There is severe emphysema throughout. Echocardiogram shows right atrial enlargement, right ventricular enlargement, trace mitral regurgitation, mild TR, PA pressure 37 plus RA. Ejection fraction 50- 55%. Arterial blood gases: 7.30, 63, 228, 32, 98. White blood count 7.6. EKG shows a normal sinus rhythm.
RA|right atrium|RA|236|237|HISTORY|Ascites and a pleural effusions were noted. She had another echo _%#DDMM2006#%_ which was again very similar, normal ejection fraction, aortic valve area 0.82 cm2. Now they list mild TR and only mild pulmonary hypertension, RVSP of 33+ RA pressure. Again pleural effusion is noted. A question was raised if there was soft tissue mass extrinsic to the left atrium.
RA|right atrium|RA|294|295|PAST MEDICAL HISTORY|PTCA on _%#DDMM2005#%_ with a drug eluting stent placed in the left anterior descending artery with a Cipher stent of 3.5 x 28, a right coronary artery Cipher stent of 3.5 x 23, and obtuse marginal Cipher stent of 2.5 x 18. 2. Pulmonary hypertension with PA pressures of 60 and noted increased RA pressures of 20. 3. Systemic hypertension with systolic pressures in the 170s. 4. Underlying COPD. 5. Hernia repair. 6. GI bleed with an esophagogastroduodenoscopy on _%#DDMM2005#%_ and an esophagogastroduodenoscopy done this hospitalization that shows no acute blood loss.
RA|rheumatoid arthritis|RA,|248|250|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: Vital signs - afebrile. LUNGS clear to auscultation. HEART -regular rate and rhythm. ABDOMEN was benign. EXTREMITIES - status post left TKA doing well, _____________________________ fluids; right knee pain secondary to severe RA, trace to 1+ edema bilaterally. LABORATORY: PTT 30, INR 0.09. UA was within normal limits.
RA|right atrium|RA|122|123|HISTORY OF PRESENT ILLNESS|She is in a sinus rhythm. She has had excellent urine output. Her PA pressures are 35/20 average with a PCWP of about 14, RA 11, cardiac output 8.1, index 4.4 and SVR 552 as of 06:00. PAST MEDICAL HISTORY: 1. Appendectomy. 2. Gastroesophageal reflux disease.
RA|right atrium|RA.|316|318|IMPRESSION|4. Ongoing and significant hemodynamic instability, as marked by systolic blood pressures in the range of 70-80 despite significant dopamine infusion, presumed secondary to sepsis syndrome and/or reaction from peritonitis. 5. Apparent decreased intravascular volume on the basis of decreased PA pressures, decreased RA. 6. Evidence of urine output at this point. 7. Combined metabolic and respiratory acidosis on the basis of a pH of 7.31 and PCO2 of 30.
RA|rheumatoid arthritis|RA.|105|107|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 62-year-old married female who has severe chronic RA. She is one day postop revision surgery on her right knee. She actually had a total knee replacement done this time.
RA|right atrium|RA|218|219|PHYSICAL EXAMINATION|ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: Warm, well-perfused. NEUROLOGIC: Alert and oriented with no focal deficits. Echocardiogram was performed on _%#DDMM2007#%_ showed normal LV function, normal RV, LV, RA and valvular function. EKG shows giant flutter waves in the limb leads 1, 3 and aVF with a 3:1 conduction of a atypical flutter pattern as noted in lead V1 to have large flutter waves that are predominantly positive which is not consistent with a classic flutter pattern.
RA|right atrium|RA|214|215|LABORATORY DATA|LABORATORY DATA: Echocardiogram preliminary shows left ventricular enlargement, biatrial enlargement, akinetic inferior wall and hypokinetic anterior wall, mild TR, moderate pulmonary hypertension with RVSP of 41+ RA pressure. EKG demonstrates rapid atrial fibrillation, very poor R-wave progression from V1-V4, slight leftward axis, nonspecific ST-T changes throughout.
RA|rheumatoid arthritis|RA.|206|208|REVIEW OF SYSTEMS|She denies cancers, peripheral vascular disease, Gyn, GI, GU problems. She denies any neurological things such as neuropathies, seizure, stroke, transient ischemic attacks. No infectious diseases, gout, or RA. She denies thyroid dysfunction. SOCIAL HISTORY: She is a retired physician. She was trained as an internist.
RA|right atrium|RA.|173|175|LABORATORY DATA|No infiltrates or effusions are appreciated. Echocardiogram dated _%#DDMM2003#%_ shows tiny posterior pericardial effusion, moderate anterior pericardial effusion of RV and RA. RV is compressed with no diastolic collapse of the RV. Ejection fraction is 35 to 40%. PHYSICAL EXAMINATION: VITALS: She is afebrile.
RA|right atrium|RA|248|249|PHYSICAL EXAMINATION|All other systems completely negative. PHYSICAL EXAMINATION: GENERAL: The patient is a pleasant female who is lying in bed comfortably. Chest tubes are still in place. VITAL SIGNS: Cardiac output earlier today was 3.2, SVR 1348. PA pressure 36/15, RA pressure was 12. Currently systolic blood pressure much better controlled although she has been on nitroglycerin. Blood pressures are 110 to 120. In fact earlier today she was actually on dopamine, but she has been off that.
RA|rheumatoid arthritis|RA.|231|233|GENERAL MEDICAL REVIEW OF SYSTEMS|GENERAL MEDICAL REVIEW OF SYSTEMS: Denies pulmonary, constitutional, vision, hearing, bleeding dyscrasias, or changes from what he has had. GI/GU unchanged. No history of infectious diseases, metabolic, autoimmune such as gout, or RA. No known diabetes or thyroid problems are negative. PHYSICAL EXAMINATION: Blood pressure 140/80, respirations 18, pulse is 72 and regular, afebrile.
RA|right atrium|RA.|191|193|IMPRESSION|IMPRESSION: 1. Bilateral alveolar infiltrates with bilateral effusions (right greater than left). A. Echocardiogram shows ejection fraction of 35% with moderate pulmonary hypertension of 56+ RA. B. He still hypoxemic with an ongoing diuresis. C. His symptoms started three weeks ago; no chronic dyspnea, he denies orthopnea and is feeling a bit better.
RA|rheumatoid arthritis|RA.|111|113|ASSESSMENT AND PLAN|This will be managed by Dr. _%#NAME#%_ as well as anticoagulation and physical therapy. 2. Arthritis, possibly RA. She will continue on her Plaquenil. 3. Chronic pain. In addition to the medications above, she continues on Mirapex.
RA|right atrium|RA|238|239|DOB|His evaluation also had included an echocardiogram at Mercy Hospital on _%#DDMM2004#%_ that demonstrated hyperdynamic LV function, diastolic relaxation, moderate tricuspid regurgitation with right ventricular systolic pressure of 38 plus RA estimating moderate pulmonary hypertension. He is in no acute respiratory distress when he is recumbent. He has had a little bit of a cough of yellowish sputum.
RA|right atrium|RA|238|239|DOB|His evaluation also had included an echocardiogram at Mercy Hospital on _%#DDMM2004#%_ that demonstrated hyperdynamic LV function, diastolic relaxation, moderate tricuspid regurgitation with right ventricular systolic pressure of 38 plus RA estimating moderate pulmonary hypertension. He is in no acute respiratory distress when he is recumbent. He has had a little bit of a cough of yellowish sputum.
RA|right atrium|RA|172|173|PHYSICAL EXAMINATION|Cardiac output 6.6 liters/minute with cardiac index 3.1, SVR 860. He is off all drips except Neo-Synephrine at 25 mcg/minute. Pulmonary capillary wedge pressure was 34/12, RA pressure 5, current weight 105.2 kg. HEENT: Normocephalic, atraumatic without xanthoma. No arcus senilis. No oral pharyngeal lesions. Moist mucous membranes. He wears a hearing aid in his right ear.
RA|right atrium|RA.|171|173|REASON FOR CONSULTATION|There was no evidence of infarct. Subsequent to the cardiac echo showed septal flattening with RV strain and decreased function and estimated PA pressures of 43 mmHg plus RA. The EF was estimated at 60 percent. The patient was always noted to be hemodynamically stable.
RA|rheumatoid arthritis|RA,|103|105|PM&R CONSULTATION FOLLOW-UP NOTE|PM&R CONSULTATION FOLLOW-UP NOTE The patient is a 75-year-old female who is status post left TKA, DJD, RA, hypertension, decreased ADLs, strength and endurance. The patient was seen on rounds. No new problems. Working with therapies. Needs assistance to sit up in bed and stand for platform walker.
RA|right atrium|RA|148|149|LABORATORY DATA|The left atrium was notably enlarged to 5 cm. The right atrium was moderately enlarged. There was mild tricuspid insufficiency with RVSP of 27 plus RA pressure. The right ventricular size and function was normal. Today, her sodium was 139, potassium 3.7, bicarbonate 28, creatinine 1.09, and INR was 1.03. She was just started on Coumadin yesterday.
RA|rheumatoid arthritis|RA|126|127|REASON FOR CONSULTATION|DOB: _%#DDMM1949#%_ REASON FOR CONSULTATION: Nausea and vomiting. The patient is a 49-year-old white female with a history of RA who was admitted to Fairview Ridges Hospital on _%#DDMM2003#%_ for elective right TKA. The surgery was uneventful. Postop day #1 the patient developed multiple episodes of emesis and this morning she was noted by the floor nurse after one episode of emesis to lose consciousness for approximately 30 seconds.
RA|right atrium|RA|293|294|LABORATORY DATA|Echocardiogram preliminary shows normal LV size and function, borderline LVH, mild aortic stenosis with aortic valve area of 1.2 cm squared, and a mean gradient across the aortic valve of 22 mmHg. The right heart was enlarged with decreased RV function, IVC was dilated. RVSP was 35 mmHg plus RA pressure. EKG demonstrates sinus rhythm, Q wave in II, III and F, poor R wave progression in V1 through V4, borderline low voltage is seen, axis is indeterminate.
RA|rheumatoid arthritis|RA|180|181|PHYSICAL EXAMINATION|EXTREMITIES: No digital clubbing, peripheral cyanosis, or edema. Relevant LABORATORY DATA: Outpatient ANA direct was positive at 186, anti double stranded DNA was positive at 107. RA titer was elevated at 18. Liver function studies were within normal limits. Chest x-ray from _%#MMDD#%_ shows a small right pleural effusion, otherwise normal.
RA|rheumatoid arthritis|RA.|220|222|ASSESSMENT AND PLAN|7. History of BOOP. 8. Chronic indwelling Foley since _%#MM#%_ 2006 after her coccyx debridement and flap placement. The patient states it has been difficult for her to get to the bathroom, especially with her disabling RA. She is on Macrobid prophylaxis. 9. Leukocytosis: At this time suspect either secondary to steroids +/- stress demargination. She does not appear septic or toxic at this time.
RA|right atrium|RA.|160|162|ASSESSMENT AND PLAN|They have frequently been associated with hemoptysis. 2. Severe pulmonary hypertension. The patient has had echocardiograms estimating her PA pressures at 117+ RA. 3. Pancreatic insufficiency secondary to problem #1. 4. CF-related diabetes. 5. Osteoporosis. The patient has been on Pamidronate therapy and is due for a repeat dose in _%#MM#%_.
RA|right atrium|RA|187|188|PHYSICAL EXAMINATION|5. Hydromorphone. 6. Acetaminophen. PHYSICAL EXAMINATION: VITAL SIGNS: Current temperature 100.0 to 101.0 degrees. Pulse 80 (paced rhythm). Blood pressure 110/70. PA is about 45/25. Mean RA is about 16. Most recent cardiac output is 3.9 liters per minute with a cardiac index of 1.8, SVR of about 1300. GENERAL: Mr. _%#NAME#%_ is sedated. He arouses promptly to verbal cues.
RA|rheumatoid arthritis|RA|324|325|IMPRESSION|These signs include fever, weight loss, and fatigue. Differential diagnosis here is large and would include most likely a vasculitic process since the skin is involved, polyarteritis nodosa, cryoglobulinemia, plus or minus hepatitis are definitely possible. Other candidates would be systemic lupus, unusual presentation of RA with vasculitis, or a prolonged viral illness with arthritis. Workup plan would have Dermatology biopsy the active lesion to see if this is indeed a vasculitis.
RA|right atrium|RA.|149|151|PAST MEDICAL HISTORY|6. Mitral valve replacement with porcine valve. History of bacterial endocarditis 7. Moderate pulmonary hypertension with pressures of ________ plus RA. 8. History of obstructive sleep apnea uncertain; however, she is using BIPAP 9. Osteoarthritis. 10. History of herpes zoster. 11. History of meningitis
RA|right atrium|RA.|240|242|IMPRESSION|5. Severe biventricular failure: On Lasix and dobutamine. Echocardiogram reveals an ejection fraction in the range of 25-30%. There was significant mitral regurgitation, as well as tricuspid regurgitation demonstrating a PA pressure of 59+ RA. 6. Significant thrombocytopenia: After workup by Hematology, this is felt to be presumed due to myelodysplastic syndrome and a bone marrow biopsy to confirm this has been deferred due to multiple other issues.
RA|right atrium|RA|420|421|HISTORY OF PRESENT ILLNESS|He underwent a coronary angiogram with a left heart and right heart catheterization consistent with increasing aortic valve stenosis area at 0.6 as well as increasing aortic mitral valve stenosis as well with a mean gradient of 16.9 with a valve area of 1.28 on the mitral valve and aortic valve area of 0.61 with a mean gradient of 32. Patient otherwise had normal coronary anatomy. He had an RV pressure of 51/10 with RA pressure of 15. Patient denies any chest pain or shortness of breath. PAST SURGICAL HISTORY: 1. Multiple surgeries for his shoulders. 2. Carpal tunnel surgery.
RA|rheumatoid arthritis|RA.|217|219|ASSESSMENT AND PLAN|With the degree of pain and the effusion present, the differential here would include acute gout attack, acute pseudo gout (less likely), infection, and less likely would something like an inflammatory arthritis like RA. Also less likely would be connective tissue disease and vasculitis, although we should consider these given the right arm pain and unusual symptoms that she has had over the last six months or so.
RA|rheumatoid arthritis|RA.|120|122|SUMMARY OF CASE|She has no identifiable medication allergies. She has a daughter and son. Her family history is reportedly negative for RA. MEDICATIONS ON ADMISSION: 1. Prednisone 5 mg daily. 2. Hydrochlorothiazide. 3. Enalapril. 4. Oxycodone on a p.r.n. basis.
RA|right atrium|RA|217|218|HISTORY|Borderline concentric LVH was seen. The right heart function and size was normal. Left atrium was mildly dilated. There was mild mitral regurgitation. There was moderate pulmonary hypertension with RVSP of 40-50 plus RA pressure. There was moderate to severe aortic stenosis which represents a progression from the previous year. The aortic valve area is estimated 0.8 cm2 with a mean gradient of 29 mmHg.
RA|right atrium|RA|207|208|HISTORY|Preliminary echocardiogram shows global hypokinesis of the left ventricle, ejection fraction 20%, moderate to severe mitral insufficiency, 4 chamber enlargement, mild pulmonary hypertension with RVSP of 36+ RA pressure, and mild LVH. Again, as I alluded to above, the last echo at Minnesota Heart Clinic was 2003. This was actually an outside echo not done at Minnesota Heart Clinic but only forwarded.
RA|right atrium|RA|169|170|PAST MEDICAL HISTORY|There was diastolic dysfunction of the left ventricle, and remarkably LVEF was visually approximated at 55% with no major wall motion abnormalities. The RV was dilated, RA was dilated, RV systolic function was mildly diminished. Since admission to the a.m. and Med Surge I at Ridges she has been asymptomatic and she has not had any reoccurrence of the symptoms she noted above.
RA|rheumatoid arthritis|RA|98|99|PAST MEDICAL HISTORY|FAMILY HISTORY: Positive for arthritis. She has a sister with osteoporosis. PAST MEDICAL HISTORY: RA with advanced hand deformities. Hard-of-hearing. Status post hysterectomy and bilateral salpingo-oophorectomy, kyphosis of the thoracic spine. History of oral candidiasis. Low-grade hypertension and status post appendectomy surgically.
RA|right atrium|RA.|197|199|PAST  MEDICAL HISTORY|6. Hypothyroidism. 7. History of skin cancer. 8. Status post varicose vein surgery in the 1970s. 9. Status post bilateral cataract surgery in 2006. 10. Pulmonary hypertension with pressures of 47+ RA. 11. Gout. 12. History of heavy alcohol use in the past. MEDICATIONS: 1. Aspirin 81 mg daily. 2. Warfarin 2.5 mg daily.
RA|rheumatoid arthritis|RA.|149|151|HISTORY|Denies fevers, sweats or chills at this time, other than fever on admission. Denies cough, recent URI, pneumonia. No medial problems such as gout or RA. No history of cancer or peripheral vascular disease. PAST MEDICAL HISTORY: Completely negative. FAMILY HISTORY: Outlined in the chart, but also completely not related.
RA|rheumatoid arthritis|RA.|162|164|PREADMISSION MEDICATIONS|4. Vicodin 1-2 tablets q.6h p.r.n. (he actually reports using this generally 2 times per week). 5. He also is on doxycycline but I do not believe that is for his RA. EXAMINATION: GENERAL: Mr. _%#NAME#%_ is currently lying comfortably in bed.
RA|rheumatoid arthritis|RA.|245|247|PHYSICAL EXAMINATION|ABDOMEN: No hepatosplenomegaly. EXTREMITIES: No clubbing, cyanosis, edema, nail, capillary changes or sclerodactyly. MUSCULOSKELETAL: No active synovitis. She does have detectable synovial thickening in multiple joints consistent with quiescent RA. The left olecranon bursa is somewhat enlarged but flaccid. She may have some very minute palpable rheumatoid nodules over the left forearm and in the left olecranon bursa.
RA|right atrium|RA,|338|340|HISTORY OF PRESENT ILLNESS|She is being followed at the Minnesota Heart Clinic and was last seen by Dr. _%#NAME#%_ two weeks ago. She underwent a transthoracic echocardiogram on _%#DDMM2005#%_, her ejection fraction was 55% with grade 2 diastolic dysfunction, no regional wall motion abnormalities, moderate mitral regurgitation and RV systolic pressure of 30 plus RA, and normal-sized atrium. She is being evaluated for lower extremity edema and some lower extremity paresthesias. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hyperlipidemia. 3. Remote myocardial infarction.
RA|right atrium|RA.|171|173|BRIEF HISTORY|Coronary angiography was done on _%#MMDD#%_ showing mild disease with a normal-appearing LV. The right ventricle however was dilated and there was evidence of clot in the RA. Subsequently, a CT of the chest showed multiple distal pulmonary emboli. Decision was made to pursue a surgical removal of the RA clot which was done by Dr. _%#NAME#%_ the evening of _%#MMDD#%_, early a.m. of _%#MMDD#%_.
RA|right atrium|RA,|203|205|LABORATORY  DATA|There was no pericardial effusion. Valvular structures are without significant abnormalities. There is trace tricuspid regurgitation with velocity of 3.1 meters per second, suggesting an RBSP of 39 plus RA, or mild to moderately elevated. IMPRESSION: 1. Shortness of breath. I think this is most likely related to his acute leukemia.
RA|right atrium|RA.|136|138|DIAGNOSTIC STUDIES|2. V/Q was "normal" and low probability. 3. Bilateral lower extremity ultrasound, no DVT. 4. Echo, pulmonary hypertension of 40-45 plus RA. Normal right ventricular, left ventricular size and function. PROCEDURE NOTE: Left IJ triple lumen catheter placed 18 cm.
RA|right atrium|RA|176|177|PAST MEDICAL HISTORY|2. Hypertension 3. Hypothyroidism 4. Pulmonary hypertension 5. Kyphosis 6. Echo showing diastolic dysfunction 7. Severe pulmonary artery hypertension with a PA pressure of 55+ RA 8. Diastolic CHF 9. Right arm lipoma 10. Renal insufficiency. 11. She is DNR/DNI. MEDICATIONS: On admission 1. Atenolol 40 mg a day
RA|rheumatoid arthritis|RA.|180|182|REVIEW OF SYSTEMS|REVIEW OF SYSTEMS: No recent constitutional, cardiac, or renal problems. No other new problems. She denies any GI/GU problems. No frequent urinary tract infections. Denies gout or RA. I guess she denies any known history of frequent falls or stumbles. Family members do not know that either. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure at this time is 168/78, pulse 92 and regular, respirations 19, pulse O2 sat 93% on room air.
RA|right atrium|RA|323|324|PHYSICAL EXAMINATION|FAMILY HISTORY: Unobtainable. REVIEW OF SYSTEMS: Unobtainable. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure in the range of 80-120/40-60, pulse is 60 and regular, respiratory rate 18, he is on the ventilator with good sats. He is febrile to 102. His PA pressure is 37/24. His peak pulmonary capillary wedge is 20. His RA is 11-14. His I's and O's are 730 in and 570 out for the day with a marked decrease in his urine output since approximately noon today subsequent to his procedure.
RA|right atrium|RA|262|263|PHYSICAL EXAMINATION|He underwent coronary angiography which revealed diffuse, mild coronary disease with the most severe being about 50% obtuse marginal branch stenosis in conjunction with some aneurysmal dilatation of the same branch. Right and left heart catheterization revealed RA of 19, PA 68/24 with a mean of 35 mm, pulmonary capillary wedge pressure of 23. No left ventriculogram was done. ASSESSMENT: 1) Severe aortic stenosis.
RA|right atrium|RA.|204|206|FAMILY HISTORY|She has a sister with an MI, a sister with lung cancer and a brother with lung cancer. They were both smokers. Echocardiogram shows mild pulmonary hypertension with mild RVH, RV systolic pressure 32 plus RA. White blood cell count 5.4, hemoglobin 10.5, MCV 91, INR 1.95, troponin negative and BNP 313. Echocardiogram shows bilateral pleural effusion, there are bilateral bronchiectatic changes.
RA|right atrium|RA|434|435|HISTORY OF PRESENT ILLNESS|Because of the observed dyspnea, troponins were checked and have increased to 0.79. Because of the troponins were elevated, she subsequently had a transthoracic echo done at bedside which showed preserved LV function with an ejection fraction of 55%, but she had RV enlargement with decreased RV systolic function, moderate pulmonary regurgitation, and moderate tricuspid regurgitation. Pulmonary pressures were 29 mmHg plus elevated RA pressures suggesting that it may be around 40 mmHg or more. She had no significant mitral or aortic valve disease.
RA|right atrium|RA,|177|179|PHYSICAL EXAMINATION|Interestingly, mean mitral valve gradient in diastole was 21 mmHg but the valve area by pressure half life is 1.4 cm square and is 1.5 by telemetry. RV systolic pressure is 47+ RA, pressure RV systolic function and size seems to be normal, left atrium size is only slight mildly enlarged. Chest x-ray showed bilateral pulmonary edema and infiltrate. EKG sinus rhythm.
RA|right atrium|RA|157|158|LABORATORY DATA|Chest x-ray is a portable film, somewhat poor quality, not full inspiration. There is most likely vascular redistribution. There is slight prominence of the RA in the ascending aorta, but it is probably because it is a rotated film. The right hemidiaphragm is elevated compared to the left. IMPRESSION: This is a patient who is having a large inferoapical and probably right ventricular infarct as demonstrated by elevated neck veins and ST elevation in V1 greater than V2.
RA|right atrium|RA.|278|280|RELEVANT LABORATORY DATA|Stool was positive for vancomycin resistant enterococcus. Echocardiogram on _%#MMDD#%_ showed a normal ejection fraction but significant left ventricular hypertrophy and moderate to severe pulmonary hypertension with significant tricuspid regurgitation and a PA pressure of 51+ RA. Chest x-ray today shows a further increase in bilateral patchy but diffuse pulmonary consolidation. IMPRESSION/RECOMMENDATIONS: See above. Case discussed extensively with the family and also reviewed by phone with Dr. _%#NAME#%_.
RA|right atrium|RA|134|135|LABORATORY DATA|Echocardiogram shows normal left ventricular function at 50% with no evidence of valvular heart disease. Right heart catheterization: RA pressure 11, right ventricular 56/6, PAWP 16, LVEDP 22, PAS/D 52/14. PHYSICAL EXAMINATION: VITAL SIGNS: He is afebrile, SpO2 96%, respiratory rate 16 to 18, blood pressure 127/69, pulse 67.
RA|right atrium|RA.|193|195|DIAGNOSTIC STUDIES|1. Chest x-ray showed pulmonary congestion and maybe a slight left pleural effusion. 2. Echocardiogram shows an ejection fraction of 10% despite the balloon pump. Pulmonary hypertension of 35+ RA. TOTAL CRITICAL CARE TIME: 60 minutes.
RA|right atrium|RA|161|162|HISTORY|Her arterial pressures were as high as 55 to 60 systolic. Pulmonary artery pressures at the time of her angiogram were 64/33, right ventricular pressure 65 with RA pressure mean of 11. Left ventricular pressures were normal. Pulmonary capillary wedge mean was 24 mmHg. The patient did not have severe mitral regurgitation. The patient did not have any coronary artery disease.
RA|right atrium|RA|154|155|IMPRESSION|5. Hemodynamically stable with blood pressure in the range of 90-100 systolic. 6. Hypothermic. 7. Known atherosclerotic coronary disease with an occluded RA managed medically. 8. Modest cardiomyopathy with an ejection fraction of 40-50%. 9. History of atrial fibrillation and associated sick sinus syndrome with previous AV nodal ablation and permanent VVIR pacemaker implantation.
RA|right atrium|RA|288|289|RELEVANT LABORATORY DATA|Electrolytes are within normal limits. White blood cell count is increased to 21,600 with a hemoglobin of 10.9, platelet count of 119,000. Cardiac echo shows an ejection fraction of 65% with mild MR, slight increased size of left atrium, pulmonary hypertension of a moderate degree [40 + RA IMPRESSION/RECOMMENDATIONS: See above.
RA|room air|RA.|124|126|PHYSICAL EXAMINATION|VITAL SIGNS: Temperature 98.7, pulse 71, blood pressure 122/68, respiratory rate 16. O2 sats have been in the upper 90's on RA. HEENT: Benign exam. NECK: Supple with no lymphadenopathy. LUNGS: Clear to auscultation bilaterally, anterior auscultation only. CARDIOVASCULAR: Regular rate and rhythm. No murmurs heard. There is mild tenderness with palpation over the left chest wall.
RA|right atrium|RA|111|112|HISTORY OF PRESENT ILLNESS|He had little flow to his left lung and some flow to his right lung. His PA pressures were estimated to be 60+ RA and he had a slightly dilated RV, but no RV hypertrophy. He had negative lower extremity Dopplers and an abdominal CT that was unremarkable.
RA|right atrium|RA.|299|301|DATA|There is extensive, loculated anterior hemithorax fluid collection anteriorly and superiorly, as well as posterior fluid collection and infiltrate on the left. White blood count 13.6. Preliminary echocardiogram shows an ejection fraction of 55%, moderate pulmonary hypertension with RVSP of 43 plus RA. PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile, pulse 69, respiratory rate 22, blood pressure 107/75, SpO2 96% on 2 liters.
RA|room air|RA|135|136|PE|Works as a construction worker. ROS: per HPI otherwise reviewed completely and was negative PE: BP 134/68 HR 87, RR 16, T 97.4, 96% on RA Gen: A and O x 3, very pleasant gentleman, NAD. Speaks in complete sentences HEENT: EOMI, MMM and pink, PERRL, no scleral icterus.
RA|room air|RA.|112|114|HPI|Pt otherwise denies SOB while on O2. I took off her O2 while I was interviewing her and her sats were 90-93% on RA. However, pt felt a little SOB, but was not in any distress. Denies CP or palpitations. Has no cough or hemoptysis.
RA|right atrium|RA.|162|164|PAST  MEDICAL HISTORY|2. Type 2 diabetes for over 15 years. 3. Hypertension. 4. Coronary artery disease. 5. Ischemic cardiomyopathy with an EF of 25-30%. 6. Pulmonary hypertension 52+ RA. 7. History atrial fibrillation. 8. Status post AICD and pacer placement in 1997. 9. Chronic low back pain. 10. L-spine central stenosis. 11. Status post cholecystectomy.
RA|right atrium|RA|229|230|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Please see admission history and physical for past medical history, social history, and family history. In brief, pertinent past medical history includes: 1. Renal failure. 2. MSSA bacteremia. 3. History of RA thrombus, documented by MRI on _%#MM#%_ _%#DD#%_, 2004. 4. Hyperlipidemia. 5. Cardiomegaly with decreased LV function on MRI, completed _%#MM#%_ _%#DD#%_, 2004.
RA|right atrium|RA,|286|288|HOSPITAL COURSE|The patient was continued on his antibiotics. After receiving dialysis, he improved and was stable on room air throughout the course of his hospitalization with sats greater than 92%. Our working diagnosis and most likely diagnosis is that the patient has the large clot in his SVC and RA, which is mostly likely seeded with the methicillin sensitive Staph aureus from his previous hospitalization, being discharged _%#MM#%_ _%#DD#%_, 2004, and this is occasionally flipping off septic emboli, causing the changing infiltrates on chest x-ray.
RA|right atrium|RA.|346|348|LABORATORY STUDIES|Chest CT angiogram shows large bilateral pulmonary embolus. Echocardiogram shows a large clot in the right atrium, significant dilatation of the right ventricle with significant decrease in right ventricular function and moderate tricuspid regurgitation. Normal LV function with an ejection fraction of 65- percent, pulmonary hypertension at 54+ RA. ASSESSMENT/PLAN: 1. Bilateral significant pulmonary embolus with associated hypotension and hypoxia.
RA|right atrium|RA|164|165|HOSPITAL COURSE|Circumflex had diffuse disease with 70% lesions in the OM1 and 75% in the OM2. The RCA had a mid-75% lesion. A right heart catheterization was also done showing an RA pressure of 10, a PA pressure of 24 and a PA wedge pressure of 20. Cardiac output was 5.4. The recommendations of the Interventional Cardiologist at this point was for coronary artery bypass grafting in the future.
RA|right atrium|RA|219|220|IMAGING AND PROCEDURE DONE DURING THE COURSE OF HOSPITALIZATION|For that, please refer to the report of the Interventional Radiology after the repeat stenting of the SVC stent). 3. Echocardiogram done on _%#DDMM2007#%_ showed ejection fraction of 55% with RVSP pressure 61 mmHg plus RA pressure. 4. Repeat Chest CT was done on _%#DDMM2007#%_ showed a patent SVC stent approximately 1.5 cm diameter. Persistent opacification of collateral vessels. No significant soft tissue edema.
RA|right atrium|RA)|159|161|OPERATIONS/PROCEDURES PERFORMED|A large area of akinesis was visualized on the septal, apical, and anterior segments. Moderate MR and a mildly increased RV systolic pressure, (RVSP = 34 plus RA) was also noted. BRIEF HISTORY OF PRESENT ILLNESS: The patient is a 54-year- old male with a history of CAD, status post recent acute myocardial infarction with LAD stenting x4 at an outside hospital, who presented the evening of admission with approximately 24 hours of increasing substernal chest pain.
RA|right atrium|RA|204|205|OPERATIONS/PROCEDURES PERFORMED|LV gram showed ejection fraction of 15% and there was mid-distal anterior apical and mid-distal inferior akinesis. 3. Right heart catheterization was also performed to evaluate hemodynamics, which showed RA pressure of 28, right ventricular pressure of 43/28, PA pressure of 43/27 with wedge of 27. HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old female with history of chronic obstructive pulmonary disease versus asthma, came to the hospital on _%#MM#%_ _%#DD#%_, 2005, with chief complaint of shortness of breath.
RA|right atrium|RA|153|154|PROCEDURES PERFORMED|Echocardiogram done on _%#DDMM2003#%_ showed severely decreased LV function, with mild LV dilatation, mildly thickened LV, mild MR, moderately decreased RA function, and an EF of 15-20%. 2. Right heart catheterization and angiograms. The patient had a coronary angiogram as well as right heart catheterization done on _%#DDMM2003#%_.
RA|right atrium|RA|208|209|HOSPITAL COURSE|At the time of transfer from pediatric intensive care unit to the floor, _%#NAME#%_ had right atrial line. This line was used until _%#MMDD#%_ when it was noted that by repeat echo with bubble study that the RA line was actually adjacent to the pericardium and no longer in the right atrium. CVTS did attempt to pull the RA line after withdrawing as much fluid as possible from the pericardium.
RA|right atrium|RA|439|440|STUDIES, PROCEDURES AND CONSULTS|4) Echocardiogram, _%#DDMM2004#%_ showing normal left ventricular size and systolic function with ejection fraction of 55 to 60%, normal left ventricular wall thickness, mild to moderate mitral annular calcification, no prolapse, mild mitral regurgitation, aortic valve trileaflet with heavy calcification, moderate aortic stenosis, gradient 33 mm, aortic valve area 1 cm. Pulmonary hypertension with right ventricular pressure of 48 plus RA and diastolic dysfunction, mild aortic insufficiency. 5) Follow-up chest x-ray showed improvement in interstitial infiltrates with persisting right base fibrosis.
RA|right atrium|RA.|235|237|LABORATORY RESULTS|There is mild-to-moderate right ventricular hypertrophy. Mild biatrial enlargement. Moderate to severely elevated RVSP at 60 mmHg plus RAP. A small pericardial effusion which is circumferential. Maximum dimensions of 1.4 cm around the RA. No obvious hemodynamic impact. Studies done on _%#DDMM2007#%_, renin activity 0.2, aldosterone level 3.9. Immunofixation electrophoresis, IgG 1040, IgA 169, IgM 81.
RA|right atrium|RA)|289|291|CONDITION UPON DISCHARGE|A post CDH repair echo on _%#MMDD#%_ had a new finding of a linear thrombus in the right atrium but this was resolved on a repeat echo on _%#MMDD#%_ and showed no evidence of thrombus. A repeat echocardiogram performed _%#MMDD#%_ showed near systemic levels of pressures (RVSP of 80mmHg + RA) and a nearly closed PDA. _%#NAME#%_ required multiple medications to treat both pulmonary and systemic hypertension including NO, nifedipine, enalapril, digoxin as well as nitroglycerin patch during his hospitalization.
RA|right atrium|RA|149|150|LABORATORY DATA AND IMAGING TESTS|Mild to moderate pulmonary hypertension with RVSP of 36 plus RAP. The patient underwent a right heart catheterization on _%#DDMM2007#%_ demonstrated RA of 8, pulmonary artery pressure of 34 and 19. Pulmonary capillary wedge pressure of 11, cardiac output of 6.3 and cardiac index of 2.8. The patient underwent endocardial biopsy on _%#DDMM2007#%_ demonstrating no evidence of inflammation or rejection.
RA|right atrium|RA|191|192|PHYSICAL EXAMINATION|Respirations 20 breaths per minutes, oxygen saturation 94% on 2 liters. GENERAL: The patient is an elderly female in no acute distress. NECK: JVP is elevated to her earlobe with an estimated RA pressure roughly 12 mm of water. There are no carotid bruits. LUNGS: Bilaterally show diffuse crackles and increasing bibasilar rales.
RA|right atrium|RA|308|309|HISTORY OF PRESENT ILLNESS|EKG revealed no evidence for acute myocardial ischemia. On _%#MM#%_ _%#DD#%_, 2003, patient was taken to the cardiac catheterization lab for hemodynamic evaluation and coronary arteriography. Right heart catheterization revealed pulmonary hypertension with elevated right- sided filling pressure with a mean RA of 20 and an elevated pulmonary capillary wedge pressure of 30 with a normal cardiac output. This may represent restrictive heart disease or constrictive pericarditis in the setting of pulmonary hypertension.
RA|rheumatoid arthritis|RA|184|185|PLAN|Primary tumor such as bronchoalveolar carcinoma, lymphoma or metastases, will also be considered. 3. Fibrotic lung disease: This CT from _%#MM#%_ does not have a typical appearence of RA or IPF because of the lack of architetural distortion normally seen in fibrosis. 4. Rheumatoid arthritis: It is recommended that the patient not continue Infliximab while the team is considering mycobacterium tuberculosis infection.
RA|right atrium|RA.|200|202|DIAGNOSTIC PROCEDURES|There is mild mitral regurgitation. Mild aortic root dilatation. No regional wall abnormalities noted. The right ventricle is mildly dilated. Severe pulmonary hypertension with estimated RVSP 56 plus RA. Of note, RA pressure is elevated with dilated IVC that does not collapse and is estimated at least 20 mmHg. The right atrium is moderately dilated. Moderate left atrial enlargement.
RA|room air|RA|154|155|1. FEN|He was completely weaned off oxygen prior to his ileostomy takedown, but post op extubation, he needed low flow NC oxygen. Later _%#NAME#%_ was weaned to RA and was able to maintain adequate O2 saturation. After the VPS placement (_%#DDMM2003#%_) _%#NAME#%_ was remained on ventilator support for a day post-op and since then has remained stable on RA with adequate O2 saturation.
RA|rheumatoid arthritis|RA|433|434|FAMILY HISTORY|PAST MEDICAL HISTORY: 1. hypertension, on treatment for several years 2. hypothyroidism, on levothyroxine 3. obesity 4. Lyme disease 3 years ago, treated with ciprofloxacin SOCIAL HISTORY: -formerly 25-30 pack year smoker, quit in _%#MM#%_ -occasional alcohol -no IV drug history -has numerous tattoos, has never received blood transfusions -works in a lumber yard FAMILY HISTORY: -Hypertension in several family members -mother has RA ALLERGIES: Sulfa MEDICATIONS: Inpatient meds on discharge _%#DDMM2006#%_: 1. Acetaminophen 650 q.4h. p.r.n.
RA|right atrium|R.A.|188|191|PAST MEDICAL HISTORY|The last echo on _%#DDMM2003#%_ demonstrated severe aortic regurgitation with mild decrease in left ventricular function with an estimated ejection fraction of 45%. There is some moderate R.A. dilatation and moderate TR. There is mild left ventricular dilatation with increase in aortic insufficiency and TR compared to the prior echo.
RA|right atrium|RA,|136|138|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Alzheimer's dementia. 2. Severe pulmonary hypertension. Last TTE in _%#DDMM2007#%_ revealed an RVSP of 49 plus RA, although the RVSP had been estimated as high as in the 80s on previous right heart catheterizations. 3. Coronary artery disease, status post CABG in 2003.
RA|right atrium|RA.|220|222|PLAN|The patient's last transthoracic echocardiogram in _%#DDMM2007#%_ revealed a normal left ventricular systolic function with an ejection fraction of greater than 55% but a moderately to severely increased RVSP of 49 plus RA. His current symptoms may be associated with some progressive right ventricular failure as well, although he does not have significant lower extremity edema, hepatomegaly, or ascites.
RA|right atrium|RA.|131|133|HOSPITAL  COURSE|She does, however, have aortic stenosis with aortic valve area of 1.34. She does have pulmonary hypertension, however, rated at 42 RA. She does appear to have some evidence of ventricular hypertrophy and failure and thus probably has right-sided heart failure causing the majority of this edema.
RA|right atrium|RA|156|157|LABORATORY DATA|Echocardiogram from _%#DDMM2007#%_ showed ejection fraction more than 55% with large pericardial effusion with early cardiac tamponade physiology. No RV or RA collapse. There is not any mitral regurgitation. RADIOLOGY: Chest x-ray from _%#DDMM2007#%_ shows a mild patchy area of opacity within the left lower lung, increased size of cardiac silhouette since _%#DDMM2007#%_, small bilateral pleural effusions.
RA|right atrium|RA|237|238|PROCEDURES PERFORMED|4. Ultrasound of abdomen on _%#DDMM2007#%_ demonstrating no evidence of splenomegaly. 5. Quinton placement. 6. ___________________ dialysis catheter placement on _%#DDMM2005#%_. 7. Swan catheter placement on _%#DDMM2005#%_ demonstrating RA pressure 30, PAP 75/25, wedge 35, cardiac index 1.9. HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old male with history of severe congestive heart failure secondary to tetralogy of Fallot, history of atrial flutter, and ventricular tachycardia, status post ICD placement in 2003.
RA|right atrium|RA|149|150|HOSPITAL COURSE|On the first postoperative day, the patient was transferred out of the PACU, still intubated to the Intensive Care Unit secondary to her high PA and RA pressures. She did well and the following day, she was able to be extubated and then brought to the floor later that same day.
RA|rheumatoid arthritis|RA|154|155|HOSPITAL COURSE|They felt that the patient had pulmonary fibrosis which was subacute in nature. They also felt that she needed to be on home oxygen. They checked an ESR, RA and FANA. The patient's sed rate came back as 48 on _%#DDMM2003#%_, rheumatoid factor was less than 20, and ANA was 8.0 (positive > 3.0). The patient also had a video swallow study done, and according to speech pathology's notes, "Meal follow up completed. Patient tolerated diabetic diet. Viewed some difficulty with coughing observed over consecutive swallows."
RA|right atrium|RA.|257|259|PROCEDURES|There is right ventricular hypertrophy. Intraventricular septum is flat in both systole and diastole consistent with right ventricular volume and pressure overload. Mild to moderate tricuspid regurgitation. Moderate to severe pulmonary hypertension 68 plus RA. No obvious intracardiac clots. Patient is in normal sinus rhythm. Aortic sclerosis without evidence of significant aortic stenosis. Moderate diastolic dysfunction.
RA|right atrium|RA|217|218|HOSPITAL COURSE|Problem #3. History of orthotopic heart transplant with severely reduced left ventricular function: The results of the echocardiogram are given above. Swan-Ganz catheter was placed in the Medical Intensive Care Unit. RA was 16, PA 40/28, wedge 22, cardiac index 1.95 on milrinone 0.2. He was given one dose of Lasix 40 mg IV and then placed on an insulin drip for elevated filling pressures.
RA|right atrium|RA.|209|211|PROCEDURES PERFORMED|2. Echocardiogram showing ejection fraction of 25% along with a large area of akinesis in the anterior septal regions. There is moderate mitral regurgitation and elevated RV systolic pressures of 41 mmHg plus RA. 3. Status post total hip arthroplasty on the left on _%#DDMM2003#%_. 4. Head CT on _%#DDMM2003#%_ showing multiple areas of low attenuation at the right caudate and right corona radiata regions.
RA|right atrium|RA),|220|223|PAST MEDICAL HISTORY|6. Congestive heart failure. An echocardiogram was performed in _%#DDMM2004#%_ which demonstrated an ejection fraction of 50%, mild left atrial enlargement, right ventricular systolic pressure moderately increased (44 + RA), mild to moderate mitral regurgitation, mild right ventricular hypertrophy, plus dilatation. 7. Status post cholecystectomy. 8. Status post right total knee arthroplasty.
RA|right atrium|RA|210|211|PROCEDURES PERFORMED|Atrial appendage emptying velocities were 40 to 50 cm per second. Moderate LV dilation, severely decreased LV function with visually estimated ejection fraction of 25%, moderate LAE, mild MR, mild AR, moderate RA dilation, and mild to moderate tricuspid regurgitation. HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old woman with a history of class 4 heart failure, history of DDDR pacer, initially inserted for a complete heart block in 1983 with a revision in 1991, and ICD upgrade in 2004, also with an EF of 20%, severely dilated LV, who came in to the hospital on _%#MM#%_ _%#DD#%_, 2005, with severe fluid overload, dyspnea on exertion, and paroxysmal nocturnal dyspnea symptoms.
RA|right atrium|RA|232|233|HOSPITAL COURSE|Right IJ Swan was placed on the first day. Initial reading was PE pressure of about 65/32 with a pulmonary capillary wedge pressure of 32. Venous O2 saturation was 34. According to the sick equation, the cardiac index was 0.92. The RA pressure was 18, right ventricular pressure was 65/18. Initially, the patient was placed on 68 mg of Lasix IV one q. day, carvedilol 3.125 mg b.i.d., and losartan 25 mg nightly.
RA|right atrium|RA,|330|332|PROCEDURES DONE THIS HOSPITALIZATION|5. Bilateral upper and lower extremity Doppler ultrasounds. No evidence of deep venous thrombosis. 6. Echocardiogram _%#MM#%_ _%#DD#%_ showing normal LV systolic dysfunction with an ejection fraction of 55%, increased LV wall thickness, mild PR, moderately increased right ventricular pressure with an RV systolic pressure of 53+ RA, small pericardial effusion without tympanum. HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old female who was on the Gynecology-Oncology Service for management of her cervical cancer.
RA|right atrium|RA,|200|202|PROCEDURES PERFORMED DURING THIS ADMISSION|4. The patient did have placement of Swan-Ganz catheter on _%#DDMM2006#%_ without adverse event. 5. Transthoracic echo on _%#DDMM2006#%_ showed LV dilation, increased RV pressure at 61 mmHg above the RA, decreased RV function, RV dilation, moderate MR and TR, as well as an ejection fraction of 35%. 6. An EKG did show prolonged QRS, intraventricular conduction delay, evidence of atrial hypertrophy and axis was otherwise normal.
RA|right atrium|RA,|566|568|MAJOR PROCEDURES|3. Ultrasound of the lower extremity, bilateral as well as ultrasound of the IVC/iliac artery on _%#DDMM2007#%_, which demonstrated negative for DVT in the lower extremities and no thrombosis within the bilateral external and common iliac veins or IVC. 4. Transthoracic echocardiogram on _%#DDMM2007#%_, which demonstrated A normal left ventricle in size, B mild concentric left ventricular hypertrophy, C normal left ventricular systolic function, D mild tricuspid regurgitation, E mildly-to-moderately increased right ventricular systolic pressure at 31 mmHg plus RA, F moderately dilated right ventricle, G moderately reduced right ventricular systolic function and H mildly dilated right atrium, HISTORY OF PRESENT ILLNESS: Please refer to admission H&P on _%#DDMM2007#%_ for historical details.
RA|right atrium|RA|531|532|PERTINENT PROCEDURES/TESTS|7. History of chronic anemia. PERTINENT PROCEDURES/TESTS: Echocardiogram done _%#DDMM2006#%_ showed moderate to severe LV dilatation, severely decreased LV function with an estimated ejection fraction of 15%, abnormal LV filling in _______ suggest diastolic dysfunction. No LV apical thrombus. Mild mitral regurgitation, moderate LA enlargement, moderate RV dilatation, moderate to severely decreased RV function, moderate to severe right atrial dilatation, and RV systolic pressures moderately increased at 46 mmHg above the mean RA pressures. DISCHARGING MEDICATIONS: 1. Aspirin 81 mg p.o. daily. 2. Coreg 6.25 mg p.o. b.i.d.
RA|right atrium|RA|221|222|PAST MEDICAL HISTORY|1. Hemoglobin A1c 9.0 _%#DDMM2002#%_. 2. Sarcoidosis, pulmonary. Reports occasional hemoptysis. Is on steroids. 3. Pulmonary hypertension, secondary. Is on Viagra. Last right heart cath _%#DDMM1999#%_. PA pressure 77/44. RA pressure 22. RV 73/18. PCW 32. Is on home 02 3 L nasal cannula. 4. Cor pulmonale. Echo _%#DDMM2002#%_: RV systolic pressure 58 mm above mean right atrial pressure, mild RV dilation.
RA|right atrium|RA|556|557|PROCEDURES PERFORMED|Labs at the time of discharge were white count 4, hemoglobin 10.3, platelets 249, BUN was 54, creatinine 1.8, INR 2.28. PROCEDURES PERFORMED: EKG was done during current hospitalization and showed a paced rhythm with no ST-T changes. The patient also underwent echocardiogram during current hospitalization that showed severely decreased LV function with estimated EF of 15%, severely decreased artery function, moderate RV dilatation, trace aortic regurgitation, moderate left atrial enlargement, mild-to-moderate mitral regurgitation, moderate to severe RA dilatation, and moderate tricuspid regurgitation. The patient underwent cardiac catheterization multiple times during current hospitalization.
RA|right atrium|RA|248|249|PAST MEDICAL HISTORY|Dr. _%#NAME#%_ follows the patient, and she has been managed on Flolan for the past six years, as the patient was unable to tolerated sildenafil. Her last right heart cath was in _%#DDMM2007#%_. PA pressure was found to be 75/20 with a mean of 44. RA pressure mean was 3. 2. Hepatitis C with cirrhosis. The patient has developed portal hypertension with ascites and splenomegaly.
RA|right atrium|RA|168|169|PROCEDURES PERFORMED DURING HOSPITALIZATION|Emphysema. Left coronary artery calcifications. A small hiatal hernia and fluid in the esophagus. 4. Right heart catheterization dated _%#DDMM2007#%_ which showed mean RA pressure of 11, RV pressure of 32/12, mean PA was 28, wedge was 14. Cardiac output was 6 and SVR was 140. 5. Echocardiogram dated _%#DDMM2007#%_ which showed normal LV size and function.
RA|room air|RA.|260|262|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|Extubated _%#MMDD#%_ with good ABGs. Caffeine changed to oral, level on _%#MMDD#%_ therapeutic at 19.1. Pt continued to have apnea and bradycardia spells through _%#DDMM2002#%_ and eventually required re-intubation. He eventually improved and was extubated to RA. He was stable for a while but then began to have an increased frequency of spells again. He was placed on oxygen via nasal cannula, which seemed to decrease the frequency of the spells.
RA|right atrium|RA|222|223|INVESTIGATION AND IMAGING|Ejection fraction is 50-55%. Left ventricle is normal in size with normal wall thickness. RV is normal in size and function. Mild left atrial enlargement. Right atrium not well visualized. A dilated IVC suggests increased RA pressure. There is mild mitral annular calcification with mild regurgitation. Tricuspid valve is normal. There is mild-to-moderate tricuspid regurgitation. The aortic valve is normal.
RA|right atrium|RA|181|182|PROBLEM #4|PROBLEM #4: Pulmonary hypertension: The patient does have a history of known pulmonary hypertension. During this admission, we did have a followup echocardiogram done, which showed RA pressures of 20-25 mmHg and pulmonary artery systolic pressures of 40-80 mmHg. After reviewing outside notes and discussing this with the patient's pulmonary hypertension nurse, _%#NAME#%_ _%#NAME#%_, it has been noted that she would like to initiate sildenafil tx as an outpatient; however, her insurance does not cover this.
RA|right atrium|RA|374|375|PROCEDURES PERFORMED|5. Deep venous thrombosis. PROCEDURES PERFORMED: 1. Cardiac echo which showed normal global LV systolic function, moderate left atrial enlargement, trace AR, mildly decreased RV function, and mild to moderate RA dilation, mild to moderate TR, RV systolic pressure mildly increased with no gradient across the pulmonic valve. 2. Right heart catheterization which showed mean RA pressure of approximately 6, and PA pressures of 20/18 with a mean of 21, a pulmonary capillary wedge pressure of 14, cardiac output of 4.4 with index of 2.8 by both thermal dilution and fixed methods.
RA|right atrium|RA|227|228|PROCEDURES PERFORMED|5. CT chest, abdomen and pelvis _%#DDMM2007#%_: No pulmonary emboli; bilateral pulmonary infiltrates; small bilateral pleural effusions. 6. Echocardiogram on _%#DDMM2007#%_: Severe pulmonary hypertension with RVSP 86 mmHg plus RA pressure. Left ventricle is normal in size, ejection fraction greater than 55%. No wall motion abnormalities. Right ventricle is normal in size and function.
RA|right atrium|RA|159|160|HISTORY OF PRESENT ILLNESS|The patient underwent to the right heart catheterization on the day of admission, which is _%#DDMM2007#%_. The right heart cath finding on _%#DDMM2007#%_ show RA pressure with a mean of 13, RV systolic pressure was 35, PA pressure was 34/11 with a mean of 22. The wedge pressure mean of 11. The patient was found to have low cardiac output of 2.1 by Fick and also the index was 1.3 by Fick.
RA|right atrium|RA|206|207|HOSPITAL COURSE|He was felt still be in decompensated failure. Therefore, he underwent a right heart catheterization for further evaluation and guidance of therapy. The right heart catheterization results were as follows: RA pressure 23, RV pressure 40/12, T pressure 39/24, ______________________ cardiac index 1.43. The recommendation from the congestive heart failure team who was following this patient during the hospital stay was to restart the milrinone drip and continue with percussive diuresis.
RA|right atrium|RA|124|125|HISTORY OF PRESENT ILLNESS|The patient was found not to be in CHF. His BMP level was low. An echo was done which revealed normal LV function with some RA dilatation, LA dilatation and otherwise normal. Pulmonary consult was obtained. They felt that he may have pulmonary etiology but were led to believe that he had pulmonary fibrosis CHF although data does not support it.
RA|room air|RA|243|244|DIET|_%#NAME#%_ was again re-intubated on _%#DDMM2006#%_ after having increasing apnea spells, worsening blood gases and thick green secretions. _%#NAME#%_ was successfully extubated to high flow nasal cannula on _%#DDMM2007#%_. This was weaned to RA on _%#MMDD#%_ and he is currently on 1/2 liter/ min low-flow nasal cannula at 21% FiO2. His course was complicated by: * treatment with steroids (Solumedrol, 4mg/kg/day divided into 4 doses for extubation) * diuretics (Lasix and Diuril) were started on _%#MMDD#%_.
RA|right atrium|RA|196|197|5. GI|This was also confirmed clinically with no evidence of pulsus paradoxus on exam. The echocardiogram did show, however, increased right-sided pressures of approximately 35 to 45 mmHg plus the mean RA pressure. Left ventricular ejection fraction was 60%. Cardiology was consulted regarding these increased pressures in order to evaluate for pulmonary hypertension versus PE as well as S3 on cardiac exam.
RA|rheumatoid arthritis|RA|310|311|HISTORY OF PRESENT ILLNESS|He did see an ophthalmologist for the redness of his eye and was diagnosed as having episcleritis. Orthopedic Surgery was involved for the hip drainage. Extensive workup was done which showed negative rheumatoid factor, negative ANA, negative HLAB27, negative CMV and EBV titers, negative HIV titers, negative RA rheumatoid factor, negative RPR, negative hepatitis B and C, negative couidio, negative blastomycosis, and negative Helicobacter pylori. He had an elevated ESR greater than 120, increased CRP about 15 on admission, leukocytosis, hypoalbuminemia, increased IgG ANM, and increased complements.
RA|right atrium|RA|122|123|LABORATORY & DIAGNOSTIC DATA|PA pressure was 47/19 with a mean of 27. Pulmonary capillary wedge pressure was 18 A wave, V wave of 20 and a mean of 15. RA pressure mean of 11. Cardiac output by thermodilution was 3.95 liters per minutes. Systemic vascular resistance was 830 and pulmonary vascular resistance was mildly elevated at 243.
RA|right atrium|RA,|276|278|HOSPITAL COURSE|This showed mild concentric left ventricular hypertrophy, ejection fraction 60-65%, mild right ventricular hypertrophy, right ventricular systolic function was normal and there was moderate biatrial enlargement. She had a right ventricular systolic pressure approximately 52+ RA, consistent with severe pulmonary hypertension. The etiology is likely related to acute illness and pneumonia. No evidence for left-sided heart failure at this time. I suspect underlying obstructive sleep apnea.
RA|right atrium|RA.|165|167|PROCEDURES PERFORMED|There was left ventricular hypertrophy and left atrial enlargement. Estimated ejection fraction of 65% with estimated right ventricular systolic pressure of 50 plus RA. 10. Repeat 2-D echocardiogram on _%#DDMM2003#%_: Normal left ventricular function with an EF of 65%. Right ventricular systolic pressure was 31 plus RA. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 44-year-old female with a history of multiple sclerosis x 20 years, as well as autoimmune hepatitis diagnosed six years ago, transferred from an outside hospital for possible liver transplant work-up.
RA|right atrium|RA|309|310|OTHER FOLLOW UP INSTRUCTIONS|The reason for the transesophageal echocardiogram was an attempt to delineate her VSD anatomy more precisely as in the past the question of diagnosis of Valsalva aneurysm, and aneurysm of the sinus of Valsalva communicating to the atrium was raised. On another occasion, she was diagnosed left ventricular to RA shunt. However, the VSD and preceding DDE seemed to have corresponded to classical membranous VSD defect of a 3 mm in size with mild to moderate left to right shunt and no right to left shunt.
RA|right atrium|(RA|151|153|PROCEDURES PERFORMED|Borderline aneurysmal dilatation of the right common iliac artery. 8. Right heart catheterization _%#DDMM2007#%_: Elevated RA, PA, and PA OP pressures (RA mean 7 mmHg, PA 49/19 and mean 29 mmHg, PA OP mean 23 mmHg). PA OP shows elevated V wave. Cardiac output performed by Fick and thermodilution methods are low (Fick cardiac output 3.6, thermodilution cardiac output 3.3).
RA|right atrium|RA|266|267|PROCEDURES PERFORMED THIS ADMISSION|1. Left heart catheterization showing 50-75% stenosis in the proximal LAD, 100% stenosis in the left circumflex marginal 1 but is filled by a graft. The patient has grafts from the LIMA to the MLAD, vein graft to the LCXM1. 2. Right heart catheterization showing an RA pressure of 36, PA pressure of 84/42, pulmonary capillary wedge pressure of 30, cardiac output 3.9 with a cardiac index of 1.8 liters/minute/m2.
RA|right atrium|RA|394|395|HISTORY|When Dr. _%#NAME#%_ saw her, he was referring back to an echocardiogram dated _%#MM2006#%_ that showed normal LV size, moderate LVH, moderate RVH, mildly decreased RV systolic function, biatrial enlargement, dilated inferior vena cava suggesting elevated right atrial pressures, mild to moderate MR, mild amount of TR with pulmonary hypertension of a moderate to severe degree with RVSP of 54+ RA pressure, and the RA pressure was elevated. She also had mild AI. The patient had an echocardiogram on this admission that was reported as severe biventricular hypertrophy, speculated appearance suggesting possible infiltrative cardiomyopathy.
RA|right atrium|RA.|326|328|HISTORY|She also had mild AI. The patient had an echocardiogram on this admission that was reported as severe biventricular hypertrophy, speculated appearance suggesting possible infiltrative cardiomyopathy. LV function again was 55-60%, mild to moderate MR, mild TR, moderate pulmonary hypertension with PA pressure estimated at 41+ RA. Mild aortic insufficiency was noted and a left pleural effusion was noted. The reader commented that these were dramatic change from an echocardiogram dated 2001 but the reader did not know that there was an office echocardiogram from 2006.
RA|room air|RA.|215|217|HISTORY OF PRESENT ILLNESS|She may have felt feverish, but denies chills. The patient was seen in the ER on _%#MM#%_ _%#DD#%_, 2002. At that time, vital signs included temperature 98, heart rate 116, blood pressure 144/95, RR 16, SPO2 98% on RA. Physical exam was unremarkable at that time. The patient was admitted to the medicine ward. PAST MEDICAL HISTORY: Multiple and complex. 1. Longstanding psoriatic arthritis.
RA|right atrium|RA|227|228|HISTORY|This prompted an echocardiogram which shows left ventricular ejection fraction of 30-35% with LVH but normal left ventricular dimension. There was moderate pulmonary hypertension with right ventricular systolic pressure of 50+ RA pressure and the RV systolic function was at least moderately decreased. Valvular function showed insignificant leakage in the aortic, mitral and tricuspid valve.
RA|right atrium|RA|186|187|HISTORY|The left atrium was dilated. The right atrium was mild to moderately dilated. There was mild to moderate mitral insufficiency. There was moderate pulmonary hypertension with RVSP of 46+ RA pressure. The patient has been having increasing chest pain for the past 6 weeks to the point now she states that even going to walk to the bathroom in her house causes chest pain.
RA|right atrium|RA|224|225|ALLERGIES|Ejection fraction was 55%. Pseudo-normal pattern was seen on his LV filling. Right ventricle was normal. Mild to moderate mitral regurgitation. Mild tricuspid regurgitation with moderate pulmonary hypertension, RVSP 50 plus RA pressure. PHYSICAL EXAMINATION: Reveals a pleasant gentleman in no apparent distress.
RA|right atrium|RA|312|313|DIAGNOSTIC STUDIES|9. Head wound culture was MRSA. DIAGNOSTIC STUDIES: 1. Echo shows an EF of less than 20%, severe diastolic and systolic dysfunction of the left ventricle, mild concentric LVH, severe global hypokinesia of the left ventricle, moderate decrease in the right systolic function, severe pulmonary hypertension of 60+ RA I believe, 1 to 2+ MR and 1 to 2+ TR. 2. Chest x-ray shows marked cardiomegaly and a right effusion.
RA|right atrium|RA|179|180|HISTORY|It showed left atrial enlargement, LVH, ejection fraction of 60%, normal right ventricular function. She did have moderate pulmonary hypertension with RVSP estimated 45 mmHg plus RA pressure. She had a pleural effusion noted, but no pericardial effusion. She has had intermittent episodes of congestive heart failure, usually due to noncompliance.
RA|rheumatoid arthritis|RA,|238|240|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: 1. Markedly elevated sedimentation rate. This is difficult to assess in a patient who makes unusual antibodies without the clinical picture of the diseases. She has had elevated rheumatoid factors without evidence of RA, and she has a positive Sjogren's antibody A without overt Sjogren's syndrome. She could have a subclinical syndrome, and this can raise the sedimentation rate because it is sensitive to antibody production.
RA|right atrium|RA|185|186|HISTORY|The mitral valve area was estimated at 1.6 cm2. Again, this is on the low end of what one would expect with a valve prosthesis. She had moderate pulmonary hypertension with RVSP of 44+ RA pressure. The patient, as I mentioned, also had radiofrequency ablation of a flutter pathway. She went on to have a dual-chamber ICD placed, although at her last check in our office she was actually in an underlying atrial fibrillation and at that time she was 86% paced.
RA|rheumatoid arthritis|RA.|186|188|PAST MEDICAL HISTORY|2. Non-Q-wave MI complicating the MSSA sepsis and hypotension. Angiography at that time did not reveal focal lesion for intervention. Her grafts were patent. 3. Status post CABG x 2. 4. RA. 5. DM. 6. Bilateral knee arthroplasty in the past. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Lantus 10 units subcu q.h.s.
RA|rheumatoid arthritis|RA.|238|240|ASSESSMENT/RECOMMENDATIONS|ASSESSMENT/RECOMMENDATIONS: This is an 80-year-old female with multiple comorbid conditions who should give serious thought to her code status, and she and her family are willing to do so. Co-morbid conditions include ASCVD, DM, CKD, and RA. 1. Respiratory status. We discussed the tracheostomy and the feeding tube may have reduced but not eliminated her risk of aspiration.
RA|right atrium|RA|182|183|HISTORY|Her echocardiogram was also performed and showed moderately severe tricuspid valve insufficiency with at least moderate pulmonary hypertension with an RVSVP of 55 mg of mercury plus RA pressure. Dr. _%#NAME#%_ felt that this degree of pulmonary hypertension also added to her risk for surgery. Ejection fraction was thought to be 30% with inferior wall severe hypokinetic to akinetic and the remainder of the heart hypokinetic.
RA|right atrium|RA|164|165|HISTORY|She had mild LVH, normal right ventricular size and function, mild mitral valve insufficiency. She had aortic valve sclerosis without stenosis. She had RVSP of 34+ RA pressure. It was felt that much of her congestive heart failure was due to diastolic dysfunction in addition to trivessel coronary disease and potential ischemia.
RA|right atrium|RA|152|153|LABORATORY DATA|Motor and sensory intact. LABORATORY DATA: Preliminary echocardiogram on this admission - severe TR with severe pulmonary hypertension, RVSP of 78 plus RA pressure. IVC is dilated, suggesting elevated right atrial pressure. Bi- atrial enlargement, mild to moderate aortic insufficiency, moderate to severe mitral insufficiency with questionable mobile echoes seen on the mitral valve leaflets.
RA|right atrium|RA|286|287|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Cardiac as above. His echocardiogram showed ejection fraction of 60% with inferior wall hypokinesis, mild to moderate LVH, normal right ventricle, trivial aortic valve insufficiency, mild mitral valve insufficiency, mild pulmonary hypertension with RVSP of 37+ RA pressure, mild tricuspid insufficiency, no pericardial effusion. 2. Heart catheterization as above 3. On the last admission T4 was 1.39. TSH was low at 0.02On the last admission, head CT scan showed small vessel ischemic or degenerative changes in both hemispheres, no acute changes.
RA|right atrium|RA.|150|152|REASON FOR CONSULTATION|There was moderate mitral valve insufficiency, moderate tricuspid valve insufficiency with moderate pulmonary hypertension, PA pressure of 55-60 plus RA. That represented a significant drop in ejection fraction from his old echocardiogram. The patient was treated last month for his congestive heart failure and discharged.
RA|right atrium|RA|175|176|PAST MEDICAL HISTORY|Last echocardiogram _%#DDMM2005#%_ demonstrated an EF of 25%. On _%#DDMM2006#%_, demonstrated normal LV function with elevated pulmonary artery pressures, which were 58 above RA pressures. 4. Peptic ulcer disease, status post surgery. 5. Atrial fibrillation with sick sinus syndrome, status post pacemaker implantation in 1994 with revision in 2002.
RA|rheumatoid arthritis|RA,|166|168|GENERAL MEDICAL REVIEW OF SYSTEMS|He has never had problems with Coumadin before. Denies pulmonary, GI or GU problems in the past. Neuro/psych - negative. Infectious diseases, cancers, cardiac, gout, RA, thyroid, diabetes all negative. No autoimmune diseases known. No peripheral vascular or neurologic diseases such as MS, CVA, seizure, stroke or TIA.
RA|right atrium|RA|198|199|PHYSICAL EXAMINATION|NEUROLOGICAL: His affect is appropriate. SKIN: He does not have any skin lesions. His electrocardiogram from yesterday shows normal sinus rhythm with no definite pathological Q waves, somewhat slow RA transition in the precordial leads and downsloping ST depression mostly in the lateral precordial leads, lead III to lead V of 2-3 mm amplitude associated with biphasic T waves.
RA|right atrium|RA|166|167|HISTORY|The initial filling pressures included a pulmonary capillary wedge pressure of 12, PA pressure of 35/14, right ventricular pressure of 38 with an end-diastolic of 8. RA pressure was 6, cardiac output 4.7. PAST MEDICAL HISTORY: 1) Previous left nephrectomy for transitional-cell carcinoma in 1998.
RA|right atrium|RA.|322|324|HISTORY OF PRESENT ILLNESS|Regardless, her ejection fraction had been relatively normal and, in fact, when I saw her in _%#MM#%_ of 2001, her Echocardiogram showed an ejection fraction of approximately 45-50% with normal functioning aortic prosthesis. She was noted to have mild to moderate pulmonary hypertension with RVSP of 38 mm of mercury plus RA. Her right heart size and function were normal. She had concentric left ventricular hypertrophy. The patient subsequently had breast cancer surgery since that time.
RA|right atrium|RA|183|184|IMPRESSION|Otherwise, no significant abnormalities. A small amount of pericardial fluid was noted. It was circumferential in nature and less than 1 cm, but no evidence of respiratory variation, RA buckling, and/or RV collapse to suggest pericardial tamponade. No evidence of clots was noted as well. It should also be noted the patient did rule out for a myocardial infarction.
RA|right atrium|RA|194|195|HISTORY|Ejection fraction was normal at 60%. The hemodynamic state, however, was the most important. At baseline, the patient had a wedge pressure of 14/14/9, PA pressure of 27/8, RV pressure 32/7, and RA pressure of 3. She had diastolic equalization of her left and right ventricular pressures. However, she was then given a fluid challenge. Her RV systolic pressure rose to 34, her wedge rose to 23 with a now prominent V wave of 44 and a mean of 26.
RA|rheumatoid arthritis|RA.|146|148|PAST MEDICAL HISTORY|X-rays were negative in the ER, there was a laceration over the elbow, treated appropriately at the ER. PAST MEDICAL HISTORY: 1. Hypertension. 2. RA. 3. Possible MI in 2003. MEDICATIONS: 1. Isosorbide. 2. Monopril. 3. Hydrochlorothiazide. ALLERGIES: No known drug allergies.
RA|room air|RA.|257|259|1. FEN|2. Respiratory: Shortly after admission, _%#NAME#%_'s respiratory status improved and he did not require any supplemental O2. The admission CXR showed a PTX on the left, however clinically the patient was asymptomatic and maintained adequate oxygenation on RA. The ABG on admission was normal. The most likely etiology for the respiratory distress is transient tachypnea of the newborn and this problem has resolved.
RT|respiratory therapy|RT|187|188|HOSPITAL COURSE|The patient remained asymptomatic after the MI event and she was stable. 3. COPD exacerbation on admission: She had COPD exacerbation, which was closely monitored. She was continued with RT evaluation and management along with that. She continued with her baseline home oxygen that she uses along with that. She was added a new medication, Spiriva and albuterol along with that.
RT|respiratory therapy|RT|162|163|PLAN|We will avoid any nephrotoxic drugs and monitor this quite closely. She has had a history of needing dialysis in the past. 6. Respiratory failure. We will get an RT consult and continue the patient on trach dome. 7. History of sepsis. We will monitor the patient closely and if she spikes a fever we will have a low threshold to start empiric antibiotics as she has a history of multiple infections in the past including VRE and MRSA.
RT|radiation therapy|RT.|167|169|HISTORY OF PRESENT ILLNESS|He was treated with 2 cycles of induction chemotherapy with good response and was admitted on _%#MM#%_ _%#DD#%_, 2005, for his second cycle of concurrent chemotherapy RT. He was admitted for the second cycle of cisplatin. On admission the patient reported that he felt dehydrated and has had problems with his G-tube functioning.
RT|respiratory therapy|RT|301|302|SUMMARY OF HOSPITAL COURSE|The patient was treated with intravenous and later oral corticosteroids, inhaled nebulizer treatments, humidified oxygen via a trachdome with Mucomyst near the end of his hospital stay to help to raise some secretions. He required episodic suctioning as well through his tracheal stoma which required RT assistance as the patient was not independent with this. The patient did have a brief setback in terms of some worsening dyspnea that prompted some additional workup on _%#MM#%_ _%#DD#%_.
RT|retrograde tachycardia|RT.|186|188|ADMISSION LABORATORY RESULTS|EKG normal sinus rhythm. A strip of tachycardia was reviewed. It showed a narrow-complex tachycardia and a rate of 200, with questionable retrograde P wave suggestive of possible AV and RT. HOSPITAL COURSE: The patient was admitted to a monitored bed and was ruled out for MI with serial troponins and EKGs.
RT|radiation therapy|RT|160|161|PAST MEDICAL HISTORY|The patient denied fevers or chills. PAST MEDICAL HISTORY: Infiltrating ductal carcinoma of the left breast 1997. Her nodes were positive, she received CAF and RT 1998. She was treated with tamoxifen for ER positive edema as well. PAST MEDICAL HISTORY: Includes back pain and depression.
RT|respiratory therapy|RT|188|189|ASSESSMENT AND PLAN|3) Diabetes mellitus. As she is NPO, we will start her on the standard intensive protocol. 4) History of peripheral vascular disease. 5) Chronic left lower extremity wound. I will ask the RT nurse to assist with treatment. 6) Methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci precautions. 7) Chronic pain syndrome. Was on fentanyl and oxycodone chronically. We will watch for withdrawal.
RT|respiratory therapy|RT|143|144|IMPRESSION|Patient's home medications will be continued. I have instructed her husband to call in her BiPAP settings and have the nursing staff work with RT in getting BiPAP set up for her. Patient does not appear to be overtly overloaded on physical examination or by BNP.
RT|respiratory therapy|RT|258|259|HOSPITAL COURSE|Ultimately, it was felt the cough and shortness of breath may have been due to mucous plugging versus pulmonary edema with pleural effusion, although pneumonia and bronchitis could not be completely ruled out. The patient's symptoms resolved with aggressive RT and quad cough and also with cessation of IV fluids. The plan was to cautiously diurese patient and follow up effusions with serial studies.
RT|respiratory therapy|RT|125|126|DISCHARGE MEDICATIONS|9. Neurontin 200 mg p.o. q.h.s. 10. Ocuvite 2 tabs p.o. b.i.d. 11. Aciphex 20 mg p.o. daily. The patient is to have home PT, RT and RN. The patient is to have a home RN check electrolytes, BUN, creatinine and INR on Monday with results to PMD.
RT|radiation therapy|RT|133|134|PAST MEDICAL HISTORY|1. Infiltrating ductal CA of the left breast in 1997, with nodes positive, status post left mastectomy, status post adjuvant CAF and RT in 1998, treated with tamoxifen for ER positive disease. 2. History of atypical chest pain, with normal coronary angiogram in 1996.
RT|respiratory therapy|RT,|186|188|HOSPITAL COURSE|However, the effusion had improved since prior chest x-ray. The lung fields were clear. The patient's rales were still present on hospital day #1. An arterial blood gas was attempted by RT, which was a venous source. The venous sat was 75%. An arterial ABG was performed by a house officer with resulting values of 7.45/35/71/26, with a sat of 93%.
RT|respiratory therapy|R.T.|127|130|PROBLEM #2|ENT was consulted and examination with oropharyngeal scope showed patent airways. The patient was started on mucomyst nebs per R.T. and 30% FIO2 with humidified air, and he did not have any further episodes of shortness of breath or mucus plug throughout hospitalization.
RT|respiratory therapy|RT|251|252||The patient was transferred to the ICU in stable condition where postop course renal consult was obtained for chronic renal failure, dialysis dependent anemia, volume overload, all secondary to chronic renal failure. Pulmonary toileting per EzPAP per RT recommended hemodialysis be initiated postop day two. He tolerated the procedure well. Pulmonary following with EzPAP for pulmonary toileting.
RT|radiation therapy|RT|398|399|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 69-year-old white male with a history of chronic alcohol abuse and alcoholic encephalopathy, COPD and significant continued cigarette abuse, a recent admission from _%#MMDD#%_ to _%#MMDD#%_ with a UTI with sepsis syndrome secondary Serratia marcescens, C. diff colitis, hypertension, history of squamous cell carcinoma of the nose status post RT and sensory neural hearing loss. The patient was discharged on _%#MMDD#%_ to a TCU with plans for subsequent chemical dependency treatment thereafter.
RT|respiratory therapy|RT|159|160|IMPRESSION|I suspect that the patient's fever is related to pneumonitis, possibly aspiration. We will begin Zosyn 3.375 grams IV q8h and observe the patient. We will ask RT to induce the sputum. We will start Albuterol nebulizers and monitor his blood pressure and start diuresis. The patient is not significantly overloaded and therefore we will start Lasix 40 mg po qday.
RT|respiratory therapy|RT|322|323|PROBLEM #2|With a history of positive meta______ challenge which was consistent with asthma; however, decreased lung volumes after one year, this was worrisome for neuromuscular weakness, diaphragm dysfunction plus/minus recent small bilateral pleural effusions which are too far to tap. The patient did have a six-mile walk test by RT during which patient did not desaturate at all off O2. The patient then also was arranged to have maximum expiratory and inspiratory test done in the lab as well as slow vital capacity standing in line and the PFTs as well.
RT|respiratory therapy|RT|169|170|HOSPITAL COURSE|She is a chronic asthma patient with poor compliance with medication. The patient stated at her nebulizer is broken, so before she goes home she should be instructed by RT in the use of nebulizer and a new machine will be prescribed. 2. Bibasilar infiltration with suspicious of infection. Stable hospital course, no fever, requesting antibiotics for the first 72 hours until radiological study shows no findings of inflammation.
RT|respiratory therapy|RT|161|162|DISCHARGE DISPOSITION|6. Gastroesophageal reflux disease, under control with PPI medication. DISCHARGE CONDITION: Stable and fit. DISCHARGE DISPOSITION: 1. Discharge home today after RT teaching how to use nebulizer. 2. The patient should followup with primary care doctor at Smiley's Clinic this coming week. Family member doctor opted to do the appointment.
RT|respiratory therapy|RT|195|196|SPECIAL INSTRUCTIONS|3. DRIVING RESTRICTIONS: None. RETURN TO WORK: As tolerated. ADVANCED DIRECTIVES/CODE STATUS: The patient is full code. SPECIAL INSTRUCTIONS: The patient to use O2 if her sats are less than 88%. RT qualified the patient for O2 prior to discharge. REASON FOR ADMISSION: Shortness of breath. SIGNIFICANT PHYSICAL EXAM FINDINGS: Please see the H&P done by Dr. _%#NAME#%_ on _%#MMDD2007#%_.
RT|retrograde tachycardia|RT|233|234|PAST MEDICAL HISTORY|Glucose intolerance. 4. Recurrent acute renal failure, baseline creatinine 1.0-1.1, this admission peak of 1.4. 5. Thyroid nodule, negative FNA. 6. Charcot-Marie-Tooth. 7. GERD. 8. Congenital cervical stenosis. 9. Status post AV and RT ablation. 10. PVD. 11. Major depressive disorder. 12. Anxiety disorder, NOS. 13. Status post tubal ligation. 14. Status post diskectomy. 15. History of migraines. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 46-year-old female with history of primary pulmonary hypertension on Flolan with multiple recent hospitalizations for shortness of breath and lower extremity edema presented on _%#MMDD2007#%_ to the emergency room for dyspnea.
RT|respiratory therapy|RT|254|255|PLAN|We will start a nitroglycerin drip to titrate to keep his systolic blood pressure between 120 to 150 and a diastolic blood pressure less than 95. The patient will have insulin sliding scale. We will continue intravenous Lasix. We will continue BiPAP and RT will manage the BiPAP. We will hold antibiotics for now since there is no source seen for any infection.
RT|respiratory therapy|RT.|161|163|ASSESSMENT AND PLAN|3. History of CVI with chronic left-sided paresis, stable at this time. 4. Hypertension. 5. Obstructive sleep apnea. Start CPAP at 5 cm of water and titrate per RT. 6. Code status: DNR/DNI. Reaffirm with patient as well as his advanced directives at Ebenezer.
RT|respiratory therapy|RT|233|234|HOSPITAL COURSE|She was actually given a dose of Solu-Medrol, but I did not suspect that she needed stress dose steroids at this point in time as there was no significant bronchospasms. Sputum cultures were attempted but not obtainable even despite RT induction. She had done quite well and her oxygen was tapered down. She was 98% on 1 liter on the day of discharge and will be discontinued completely off O2.
RT|respiratory therapy|RT,|151|153|PHYSICAL EXAMINATION|Ventilator set at assist control tidal volume 840, rate 12, PEEP 5, 100% FIO2 with 100% O2 saturation. This was subsequently weaned to 84% FIO2 by the RT, with resultant blood gas of 7.42, PO2 228, bicarbonate 18, FIO2 100%, PCO2 27. Placing patient on pressure support of 10, the patient has no spontaneous respirations, possibly because of alkalosis.
RT|respiratory therapy|RT.|124|126|PHYSICAL EXAM|He will be placed on IV Rocephin and Zithromax. He will be given O2 and nebs p.r.n. We will have aggressive therapy through RT. We will suction as needed until he is stronger to clear his secretions. We will watch for any signs or problems. For the low potassium, we will correct with potassium protocol.
RT|respiratory therapy|RT.|211|213|PLAN|PLAN: Admit for neb treatments, IV fluids, D5 one-half normal saline at 70 cc per hour, albuterol nebs every 3 to 4 as needed with pulse oximetry and peak flows q shift. Sputum culture and gram-stain induced by RT. Nasal swab for pertussis and RSV. Rocephin 1 gram IV q.d. Zithromax 250 mg p.o. q.d. Solu-Medrol 50 mg IV q 8 hours. Dr. _%#NAME#%_ aware that he will be accepting the patient.
RT|radiation therapy|RT,|531|533|HISTORY OF PRESENT ILLNESS|REVISED REPORT: CHIEF COMPLAINT: Severe upper respiratory symptoms for eight days with increasing shortness of breath. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 79-year-old, white male with a history of coronary artery disease, status post AVR for critical aortic stenosis in _%#MM2003#%_, congestive heart failure, atrial fibrillation/flutter in _%#MM2003#%_ prior to his valvular surgery and his bypass surgery, prostate cancer diagnosed in _%#MM2004#%_ and treated with radiation therapy, he is on treatment #35 of RT, elevated cholesterol, macular degeneration, who is being admitted as an unassigned to Fairview Southdale Hospital after presenting with upper respiratory symptoms for eight days and shortness of breath.
RT|respiratory therapy|RT|130|131|HISTORY OF PRESENT ILLNESS|There has been no hemoptysis, no pleuritic pain. He has no history of pulmonary embolus or deep venous thrombosis. He went to his RT appointment today and was sent over to the ER for evaluation. In the ER, he was evaluated by Dr. _%#NAME#%_ and was felt to have congestive heart failure and atrial fibrillation with rapid ventricular rate.
RT|respiratory therapy|RT|142|143|IMPRESSION AND PLAN|I will update _%#NAME#%_ _%#NAME#%_ from the Transplant Team as soon as my dictation is finished. 2. Bilateral pleural effusions. I will have RT start Duo-Nebs, as he is still requiring oxygen. No fevers currently. We will check a chest x-ray as needed. He also is on Lasix 50 mg p.o. q.12 h.
RT|respiratory therapy|RT|179|180|ASSESSMENT AND PLAN|Dr. _%#NAME#%_ elected to initiate treatment with intravenous azithromycin in addition to Zosyn and tobramycin. The patient will receive frequent vest therapy and hand therapy by RT 2x each day during her hospitalization. 2. Dyspnea on exertion: There seems to be some aspect of reactive airway disease in the patient's symptoms.
RT|respiratory therapy|RT|136|137|IMPRESSION|She will be started on IV ceftriaxone and azithromycin. Will use p.r.n. nebulizers and O2. I will continue the BiPAP as needed and have RT monitor the patient's progress. The patient does have uncontrolled diabetes. At this time she will be continued on her home oral agents.
RT|radiation therapy|RT|242|243|PROCEDURES DURING HOSPITALIZATION|Follow up with Dr. _%#NAME#%_ in 2-4 weeks. Follow up for radiation therapy Monday through Friday per Dr. _%#NAME#%_. CONSULTATIONS DURING HOSPITALIZATION: Dr. _%#NAME#%_ of radiation therapy. PROCEDURES DURING HOSPITALIZATION: Initiation of RT treatment. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is an 84-year-old male who presented to the Fairview Southdale emergency room with palpitations and irregular heart beat on _%#MMDD2007#%_.
RT|respiratory therapy|RT|107|108|PLAN|2. Clonidine patch will be discontinued. 3. Atenolol will be decreased to 50 mg p.o. q. day. 4. I will ask RT to evaluate patient's machine which he has brought with him to verify my suspicion that this machine is not functioning correctly.
RT|respiratory therapy|RT|317|318|IMPRESSION|At this point given her request for admission, I would propose that we switch her antibiotics around to azithromycin and ceftriaxone, start her on empiric steroids in the form of Solu-Medrol 60 mg IV q.6h. and start scheduled albuterol nebulizers. In the morning I would like to check PFTs for baseline and will have RT attempt to get a sputum culture. Will have the nurses obtain nasopharyngeal swab for pertussis culture and DNA PCR. Will ask the nurses to get her home medication list for review by our the rounding physician in the morning.
RT|respiratory therapy|RT|226|227|DISCHARGE DIAGNOSES|3. Respiratory distress. Due to thick secretions resolving at the time of discharge, although he always has secretions. 4. Hypokalemia resolved with potassium replacement. 5. Obstructive sleep apnea, Trach dependent. Frequent RT cares were needed. 6. Bipolar disorder, schizophrenia. He remained relatively stable during hospitalization and was continued on his medications.
RT|respiratory therapy|RT|204|205|LABORATORY DATA|ABDOMEN: Soft, nontender, positive bowel sounds. EXTREMITIES: No clubbing, cyanosis or edema. LABORATORY DATA: She did have blood cultures done which are no growth and she had a sputum culture induced by RT yesterday which had mixed gram-positive and gram-negative bacteria present but greater than 10 squamous epithelial cells which indicated oral contamination.
RT|respiratory therapy|RT,|173|175|HOSPITAL COURSE|It was also noted that she had an increase in her creatinine level. Therefore, the IV Lasix was discontinued. The patient did have a change in her oxygen delivery system by RT, who tried her on an Oxymizer, which she felt helped some. It was also elected to put her on a schedule of Roxanol every 4 hours for her air hunger.
RT|respiratory therapy|RT.|222|224|HISTORY OF PRESENT ILLNESS|In the emergency room this morning, he was seen by Dr. _%#NAME#%_ and noted to have inspiratory and expiratory wheeze. Chest x-ray was done with negative results. He was given three Albuterol nebs with not much change per RT. Neb times were 8:15, 8:30 and 11:30 this morning. He was noted to have good aeration throughout. Respiratory rate in the 40s went down to 38 and down again to 28 post nebs.
RT|respiratory therapy|RT|152|153|IMPRESSION|1. Pulmonary. The patient probably has mild asthma exacerbation. We will place him on on prednisone 40 mg p.o. daily and schedule duonebs. We will have RT check a sputum culture and based on the sputum culture consider antibiotic therapy. At this point, I do not feel that he has a pneumonia 2.
RT|respiratory therapy|RT|233|234|OTHER NEEDS|DISCHARGE FOLLOW-UP: She will follow up with Dr. _%#NAME#%_ next week. DIET: Cardiac with no added salt. ACTIVITY: No restrictions. OTHER NEEDS: She may qualify for home O2, her discharge O2 sats were 90% on room air, but I did have RT stop by to reassess her oxygen level to see if she would qualify. If she does qualify for home O2, RT will set her up with this.
RT|respiratory therapy|RT|163|164|ASSESSMENT|We will admit the patient initially to the Intensive Care Unit despite DNR/DNI status as she is receiving BiPAP, which seems new to her, and will require a lot of RT attention. She will also require frequent nebulizations along with intravenous antibiotics and corticosteroids, and pulmonary consultation will also be ordered.
RT|respiratory therapy|RT|173|174|HISTORY OF PRESENT ILLNESS|The patient had an acute episode of respiratory distress in the emergency room the night of admission, at which time anesthesia was called to intubate the patient. However, RT was able to suction a very long mucous plug, and she has been stable ever since. ALLERGIES: Penicillin, vancomycin, clindamycin, Ancef, IV contrast, Lopressor, and statins.
RT|respiratory therapy|RT|195|196|HOSPITAL COURSE|I should note that yesterday's nebulized treatment was ineffective. It is unclear whether the 6:15 neb was helpful. Yesterday's treatment included Pulmicort followed by vibratory vest t.i.d. The RT department at Ridges did not have the cough-assist device that is available at the ICU.
RT|respiratory therapist|RT|351|352|HOSPITAL COURSE|Therefore, her antibiotics were discontinued. She was able to come off the oxygen and was subsequently feeling much improved, was ambulating without difficulty, and at this point she felt eager to go home, although she was still somewhat wheezy on exam. She was having improvement in her peak flows from the 150s to the 200s, and given that she is an RT herself she was discharged. She will follow up with pulmonary rehabilitation as an outpatient and continue her nebulizers as well as Advair.
RT|respiratory therapy|RT.|149|151|SUMMARY OF HOSPITAL COURSE|With this he improved and was weaned off the vent. 4. Chronic tracheostomy secondary to vocal cord paralysis. He was working with speech therapy and RT. He was working well with the Passe-Muir valve and pulmonary was involved in trach cares. 5. Dysphagia. His swallowing improved during his stay and speech therapy should continue to work with him.
RT|respiratory therapy|RT|144|145|DISMISSAL SUMMARY|Her postoperative course was complicated by some initial mild respiratory distress. She did receive aggressive treatment with the assistance of RT and additional pulmonary toilet. She then improved aeration of her right lung as evidenced on her chest x-rays. Her chest tube output decreased and the chest tube was able to be removed on postoperative day #5.
RT|respiratory therapy|RT.|167|169|PLAN|3. We will start Rocephin 1 gram IV q.24 hours and Z-PAK. 4. We will use nebulizer q.2h. p.r.n. and q.i.d. scheduled. 5. Will request a smoking cessation consult from RT. 6. We will keep him on Lovenox 40 mg subcutaneously for DVT prophylaxis. 7. The diagnosis of PE was entertained by me in the emergency room, although his CT was suboptimal, however, did not show any embolus.
RT|respiratory therapy|RT,|159|161|HOSPITAL COURSE|He made rapid progression. He no longer was dyspnea on room air. He does desat to 88% with walking up and down the hall, but within a minute, according to the RT, his O2 sats are back above 94% with rest. When seen by me today, his blood pressure is 121/74, his temperature is 98, heart rate is 83, respiratory rate 18 and her O2 sats are 94% on room air.
RT|respiratory therapy|RT|162|163|ASSESSMENT AND PLAN|Will check blood cultures x 2, urinalysis, urine culture. 2) Chronic obstructive pulmonary disease exacerbation; will place the patient on IV steroids. Will have RT perform albuterol/Atrovent nebulizations q4h while awake. 3) Nausea and vomiting; will continue p.r.n. Zofran, most likely secondary to acute infection.
RT|respiratory therapy|RT|182|183|IMPRESSION|Will send this fluid off for analysis. Will also add some empirical diuretics, check an echocardiogram to assess his LV and the significance of his pericardial effusion. We will ask RT to work with the patient in regards to CPAP or BiPAP as needed. The patient's diabetes appears under fair control. Will continue with the Lantus insulin; I would hold his metformin for now and use NovoLog sliding scale.
RT|respiratory therapy|RT|155|156|DISCHARGE MEDICATIONS|11. Metoprolol 75 mg p.o. b.i.d. 12. Omeprazole 20 mg p.o. b.i.d. (increased dose). 13. CPAP machine was ordered for the patient and is being titrated per RT recommendations. DISCHARGE: The patient will be discharged back to his nursing home for further rehabilitation.
RT|respiratory therapy|RT|155|156|ASSESSMENT|She does have a known history of anxiety and panic attacks. Will have some Ativan available as needed, and given her obstructive sleep apnea, we will have RT set up a CPAP.
RT|respiratory therapy|RT|195|196|HOSPITAL COURSE|The patient was not allowed to refuse therapy, given that she was somewhat passively suicidal. The patient was noted to have improvement of symptoms; she was started on Advair and Combivent with RT instruction, starting on hospital day #2. On hospital day #3, the patient was switched to oral steroids and was documented to be doing well with MDI technique.
RT|radiation therapy|RT,|442|444|HISTORY OF PRESENT ILLNESS|PRIMARY CARE PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_ CHIEF COMPLAINT: Congestion since _%#MMDD2007#%_ with productive cough and increasing weakness. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 68-year-old white female with a history of hypertension, hyperlipidemia, alcohol abuse who was hospitalized in 2005 with an alcohol withdrawal seizure and subsequently placed in a treatment program, breast cancer, status post lumpectomy and RT, chronic kidney disease with renal insufficiency previously described, previous cholelithiasis, status post laparoscopic cholecystectomy. She reports that she was in _%#CITY#%_ from _%#MMDD#%_ to _%#MMDD#%_.
RT|radiation therapy|RT.|203|205|PAST MEDICAL HISTORY|1. History previously of hypertension on Cozaar. The patient states she is no longer on that medication. 2. Hyperlipidemia. The patient is on no medications. 3. Breast cancer, status post lumpectomy and RT. 4. Cholelithiasis, status post cholecystectomy. 5. History of depression. 6. History of alcoholism with alcohol withdrawal seizure in 2005.
RT|respiratory therapy|RT|164|165|IMPRESSION|1. Probable right lower lobe pneumonia based on history and physical examination. Start Tequin 200 mg intravenous Q day. We will obtain sputum culture, gram stain, RT to induce if necessary. Blood cultures have been sent from the emergency room. Certainly the pneumonia would cause her degree of hypoxia, however, we would need to be concerned about possible underlying pulmonary embolism.
RT|respiratory therapy|RT|163|164|HOSPITAL COURSE|Shortly after admission to the floor he needed to be transferred to the Intensive Care Unit. There was concern for mucous plugging. With significant suctioning by RT his respiratory distress improved, however, he was still requiring 15 liters face mask to maintain O2 sats in the mid 90 range. He was placed on vancomycin and Levaquin. There was concern for possible nosocomial pneumonia given his recent hospitalization.
RT|respiratory therapy|RT|144|145|DISCHARGE DIAGNOSES|6. Chronic pain syndrome with narcotic dependence, special care risk patient. 7. Gastroesophageal reflux disease 8. Prostate cancer status post RT treatment in 1997 with resultant indwelling Foley changed every 3 weeks, just changed today, _%#MMDD2007#%_ by Urology. 9. Bipolar, depression, anxiety. 10. History of colon cancer.
RT|respiratory therapy|RT,|204|206|IMPRESSION|LABORATORY DATA: To be ordered in hospital. IMPRESSION: 1. Recurrent locally advanced squamous cell carcinoma of tongue. Stage of IV-B at original diagnosis with lymph node positivity. Status post chemo, RT, finished _%#MMDD2007#%_. 2. Vomiting. 3. Dehydration. RECOMMENDATIONS: 1. For her symptoms of vomiting and dehydration will do the following: a. IV fluids.
RT|respiratory therapy|RT|249|250|IMPRESSION|At this point he has a slightly elevated BUN/creatinine ratio and will start him on some gentle normal saline hydration. The patient also has what appears to be underlying COPD with acute chronic obstructive pulmonary disease exacerbation. Will ask RT to attempt to induce sputum, will place him on empiric Levaquin and start him on albuterol nebs, empiric steroids and follow his clinical course.
RT|respiratory therapy|RT|137|138|HISTORY OF PRESENT ILLNESS|He quickly stabilized. He was treated with increasing doses of beta blockers for his blood pressure. He was transferred to the floor. An RT was called because of over sedation but with medical management this improved. Otherwise, his course was uncomplicated. He resumed normal bowel function and was discharged home on postoperative day 8, afebrile, with stable vital signs, positive bowel movement palpable dorsalis pedis and posterior tibial pulses.
RT|respiratory therapy|RT|98|99|PLAN|The patient will be maintained on her usual medications for chronic medical concerns. I will have RT perform nocturnal oximetry as a screen for sleep apnea. Further evaluation will be predicated on this. If problem primarily relates to frequent nighttime awakening secondary to urinary frequency, then patient may benefit from a trial of DDAVP at h.s. If the problem seems more likely to be related to a primary sleep disturbance then a Neurology evaluation may be helpful.
RT|respiratory therapy|RT|153|154|ASSESSMENT/PLAN|3. Chronic obstructive pulmonary disease exacerbation. The patient will continue to receive IV Solu-Medrol scheduled p.r.n, Albuterol and Atrovent nebs, RT to manage secretions. 4. Pneumonia. The patient received IV Ceftriaxone in ED. We will add IV Azithromycin. Sputum gram stain culture pending. Blood cultures pending. 5. Congestive heart failure.
RT|respiratory therapy|RT.|121|123|DISCHARGE MEDICATIONS|2. Vancomycin 1 gm q.24 h. 3. Cefotetan 1 gm q.12 h. 4. Lasix 20 mg scheduled daily. 5. Duo-Neb treatments 4 x daily per RT. 6. Accu-Cheks q.i.d. and is on a Regular insulin sliding scale coverage that requires 2 units subq for blood sugars between 150 to 200, 4 units for 201 to 250, 6 units for 251 to 300, 8 units for 301 to 350, 10 units for 351 to 400.
RT|UNSURED SENSE|RT,|128|130|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft in _%#MM#%_ 2003 (LIMA to LAD, SVG to RT, SVG to B1, SVG to OM1). 2. Angiography revealed right dominant system with a 60% left main lesion, LIMA to LAD, SVG to B1, and SVG to PDA were patent.
RT|respiratory therapy|RT|141|142|PLAN|Atrial fibrillation, hypertension, pancytopenia - All of these are stable. Low back pain. PLAN: Will observe him for now. Would like to have RT take a look and see if they can work with him regarding the hyperventilation. Will continue his inhalers and O2 as needed. Will discontinue antibiotics and try to wean him off of the Methadone.
RT|respiratory therapy|RT|201|202|DISCHARGE DIAGNOSES|Calcium level 8.8. She did meet her PT goals. Her O2 saturations generally stayed in the low 90s on room air and high 90s when on supplemental O2, which she does use on a p.r.n. basis. She did receive RT attention, nebulization therapy, and pulmonary exercise during her stay here. Her medications at the time of discharge included calcium with vitamin D 1250 mg daily, tiotropium capsule inhalation daily, prednisone 20 mg daily, Protonix 40 mg daily, Vasotec 10 mg daily, Lasix 20 mg daily, Serevent inhalation every 12 hours, multivitamin supplements daily, Pulmicort 0.5 mg inhaled twice daily, alprazolam 1 mg twice daily at a dose of 1 mg and twice daily at a dose of 0.5 mg.
RT|respiratory therapy|RT|209|210|PLAN|5. Migraine headache syndrome. 6. Obesity. PLAN: 1. We will admit her and keep her on a medicine unit in the medical ward for close observation. 2. I will provide supplemental O2 as necessary. 3. We will have RT evaluate and assist with nebulization treatments. 4. We will re-institute steroids with intravenous Solu-Medrol tonight and then resume oral prednisone afterwards.
RT|respiratory therapy|RT.|191|193|PROBLEM #3|She was extubated successfully the second time. The patient was given a burst of prednisone 40 mg daily. She was initiated on albuterol inhaler 2 puffs four times daily, Antabuse, as well as RT. On discharge we put her on Combivent 2 puffs four times daily using the pacer with that. She is discharged on ______ as she was on that before.
RT|respiratory therapy|RT|186|187|PROBLEMS|Fluid from this right upper lobe continued to be positive for 2 strains of Alcaligenes xylosoxidans subspecies, sensitivities as below. He was placed on aggressive pulmonary toilet with RT 4 times daily consisting of albuterol and Mucocyst and Atrovent, which was weaned to t.i.d. after discharge. Given his age, it was difficult to follow his pulmonary function tests throughout this admission.
RT|respiratory therapy|RT|182|183|PLAN|Decreased intake due to SIADH. 3. Severe peripheral vascular disease, stable. 4. Chest pain. PLAN: 1. Continue Rocephin IV and azithromycin p.o. 2. Repeat chest x-ray and chem-7. 3. RT to try albuterol nebs. 4. OT and PT to assess. 5. Continue aspirin, nifedipine, Viagra for PVD, check EKG.
RT|respiratory therapy|RT|246|247|HISTORY OF PRESENT ILLNESS|From 11:00 p.m. to 2:00 in the morning last night, his respiratory symptoms continued to worsen, where he presented this morning here to our ER at 4:00 a.m. Here, he got two nebs of epinephrine, which seemed to be beneficial, noted by mom and by RT assessment. The patient received dexamethasone and Tylenol for a temperature of 101.0. The patient has not had an O2 requirement and was satting 96-97% on room air.
RT|respiratory therapy|RT|272|273|7. CODE STATUS|It increased in size. ASSESSMENT AND PLAN: The patient is a 75-year-old gentleman who is being admitted with a left lower lobe pneumonia and COPD exacerbation. 1. Community-acquired pneumonia: The patient was initiated on IV Rocephin and also oral Zithromax. Will request RT to induce sputum with gram stain and cultures. 2. COPD exacerbation component: The patient was initiated on DuoNeb q.4 h. and Solu-Medrol 60 mg IV q.6 h. His saturating comfortably in the low 90 %, and respiratory rate came down to the normal range.
RT|respiratory therapy|RT|256|257|7. CODE STATUS|Will have continuous oximetry. 3. Will initiate patient on Advair 250/50 1 puff b.i.d. and with concerns of compliance he should also be on the long-acting spirea at time of discharge. He has been non-compliant with home nebulizer treatments. Will request RT to teach him how to use his metered dose inhaler and new discus. 4. Hypertension: The patient was placed on lisinopril 10 mg each day, will watch and increase if needed.
RT|respiratory therapy|RT|185|186|HOSPITAL COURSE|The patient required O2 until 24 hours before discharge. At the time she was sent home, she was maintaining 92% to 93% on room air. Her ABGs which were done once she was more stable by RT revealed chronic respiratory acidosis which was compensated and chronic hypoxia with PO2 of 50. The patient will benefit from repeat PFTs as an outpatient if not done recently within a month or 2.
RT|radiation therapy|RT|187|188|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 81-year-old white female with a history of hypertension, remote CVA, anemia, osteoporosis, status post right breast lumpectomy and RT for breast cancer many years ago. She is followed by Dr. _%#NAME#%_ _%#NAME#%_ and lives at Heritage of _%#CITY#%_. The patient reportedly developed nausea and vomiting on _%#MM#%_ _%#DD#%_, 2004 with some abdominal pain.
RT|respiratory therapy|RT|176|177|INSTRUCTIONS|C. Respiq once per month; and to help with meals, eating behaviors, ADL cares. D. RT in home 2 times per day, five days per week to administer vest therapy and nebulizers. The RT will continue with one time at school in a.m. and once at home after school. 3. Diet. _%#NAME#%_ is discharged on a p.o. ad lib high-calorie, high-protein diet with enzymes.
RT|respiratory therapy|RT|258|259|PLAN ON ADMISSION|She has a normal basic metabolic profile on _%#MMDD2005#%_, and the same date her hemoglobin was 14.1, white cell count 3.9, and platelet count 186,000. PLAN ON ADMISSION: 1. Will review her medication schedule and make appropriate adjustments. 2. Will have RT involved with VEST therapy, 3 times daily if necessary. 3. Will continue her current intravenous antibiotics with appropriate monitoring per admission plan.
RT|respiratory therapy|RT|260|261|IMPRESSION AND PLAN|3. Diabetes mellitus type 2. Will hold his scheduled insulin as long as he is n.p.o. Will use sliding scale, will hold metformin while he is in the hospital. 4. Chronic obstructive pulmonary disease. Will continue his oxygen supplementation. Will request from RT to give him nebulizer. I would use Xopenex instead of albuterol because of the patient's tachycardia. I would use Xopenex scheduled t.i.d. and q.3h p.r.n. I will change his ipratropium to Spiriva with his Xopenex.
RT|respiratory therapy|RT|226|227|PLAN|Protonix 40 mg b.i.d. Monitor for worsening clinical exam. Currently no evidence of surgical abdomen; however, will contact surgery should clinical status change. 2. Fluids and electrolytes. N.p.o. IV hydration. 3. Pulmonary. RT induced sputum. Will send for anaerobic/anaerobic culture given multiple past infections. 4. Infections Disease. Obtain blood cultures.
RT|radiation therapy|RT,|308|310|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Weakness, inability to ambulate or care for himself. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 82-year-old white male with a history of esophageal cancer status post resection in 2000, nasopharyngeal cancer diagnosed in _%#MM#%_ of 2005, status post resection and six weeks of RT, cerebellar mets diagnosed in _%#MM2005#%_ and status post gamma knife radiation by Dr. _%#NAME#%_ at Fairview University Medical Center and recurrent nasopharyngeal lesion on _%#MMDD2005#%_ which has been biopsied and the results are pending.
RT|radiation therapy|RT.|146|148|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Remarkable for: 1. Esophageal cancer in 2000. 2. GERD. 3. Nasopharyngeal cancer in _%#MM#%_ 2005, status post resection and RT. 4. Cerebellar metastases, presumed secondary to nasopharyngeal carcinoma status post gamma knife radiation in _%#MM2005#%_. 5. Hypertension. 6. Right Bell's palsy. 7. Remote history of peptic ulcer disease.
RT|NAME|_%#NAME#%_|52|61|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Fever. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a _%#1914#%_ male recently discharged from Southdale Hospital with urosepsis to _%#CITY#%_ Care Center. This morning was getting up to the bathroom trying to walk without his walker; he fell and bumped his head at that time.
RT|radiation therapy|RT.|163|165|IMPRESSION|Surgery has been consulted for the patient's hydrocephalus. Will defer Decadron and anti-seizure medications to them. Will get a Hem/Onc consultation for possible RT. Will need to get a biopsy diagnosis. It may be that the chest lesion is the most amenable, however, will get a CT of the abdomen and pelvis.
RT|respiratory therapy|RT|275|276|HOSPITAL COURSE|HOSPITAL COURSE: _%#NAME#%_ was admitted to the University of Minnesota Medical Center Children's Hospital and placed on q.2h. albuterol nebs along with oral prednisone. He was able to advance to q.4h. nebs within the next day. He was given a peak flow meter and teaching by RT along with an asthma action plan.
RT|respiratory therapy|RT|157|158|DISCHARGE MEDICATIONS|10. Zithromax 250 mg p.o. q. day for 3 days to finish off course of treatment of pneumonia. 11. Albuterol MDI 2 puffs q.i.d. x7 days. The patient to receive RT albuterol inhaler teaching prior to discharge.
RT|respiratory therapy|RT.|121|123|DISCHARGE MEDICATIONS|14. Bactrim 8 mg/mL, 10 mL p.o./n.g. daily. 15. Valtrex 1000 mg suspension p.o. q.12 h. 16. Albuterol 6 puffs b.i.d. per RT. DISPOSITION: The patient is awaiting a bed availability at a rehab facility.
RT|radiation therapy|RT|149|150|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Infiltrating ductal carcinoma of the left breast in 1997, as above. Her nodes were positive. She received postadjuvant CAF and RT in 1998. She was treated with tamoxifen for ER positive edema, as well. HOSPITAL COURSE: After obtaining consent for surgery, Ms. _%#NAME#%_ was taken to the operating room on _%#MMDD2002#%_ where a right simple mastectomy was performed by Dr. _%#NAME#%_.
RT|respiratory therapy|RT|125|126|PLAN|4. Increased tracheostomy secretions. PLAN: We will send trach secretions for Gram's stain and culture. We will consult with RT for tracheostomy care. Social worker to assist in placing the patient in skilled nursing facility. Nutrition consult will be requested to address nutritional need. For now, we will continue the patient on nutrient 1.5, 2 cans q.i.d. We will hydrate him with D5 one-half normal saline with 20 mEq potassium chloride at 120 ml per hour.
RT|respiratory therapy|RT,|182|184|PROBLEMS|The patient's mood was stable during the hospital course. She continued to take Remeron for this reason. 9. Disposition. On the date of discharge the patient was evaluated by PT and RT, and in stable condition was discharged home with recommendations. DISCHARGE MEDICATIONS: Fosamax 70 mg p.o.q.7 day, Decadron 4 mg p.o. t.i.d., Senokot 2 tablets p.o. b.i.d., Synthroid 75 mg p.o. q.d., amiodarone 20 mg p.o.q. evening, Protonix 40 mg p.o.q.d., Zocor 20 mg p.o.q.h.s., methadone 10 mg p.o. q.d., Xeloda 1500 mg p.o. in the morning and 1500 mg in the evening and starting in _%#MM#%_ _%#DD#%_, 2003 and to continue for 10 more days, Trileptal 150 mg p.o. q.d. until _%#MM#%_ _%#DD#%_, 2003.
RT|respiratory therapy|RT|145|146|ASSESSMENT/PLAN|RT to see to aid in possibly mobilizing the patient's secretions. 2. Respiratory distress. Hypoxia on room air. We will continue O2 support with RT therapies. He has good oxygenation with O2 supplementation. 3. Quadriplegia, step mattress, continue chronic meds and turn the patient q. 2 hours. No evidence of sacral decub currently. 4. UTI.
RT|respiratory therapy|RT|214|215|PLAN|No acute changes. ASSESSMENT: Chronic obstructive pulmonary disease exacerbation, congestive heart failure exacerbation, possible pneumonia. PLAN: 1. Pulmonary - Will treat with antibiotics at this time. Will have RT help with nebulization for chronic obstructive pulmonary disease. Recheck an a.m. x-ray. Also will obtain arterial blood gases to identify his acid base status.
RT|respiratory therapy|RT|136|137|PLAN|Will ask Orthopedic Surgery to see him tomorrow as well as Physical Therapy and Occupational Therapy for ambulation and ADLs. Will have RT set up the CPAP machine with the settings at 8 cm of water. Pending no surprises on his labs or EKG, he would be a good surgical candidate.
RT|respiratory therapy|RT|209|210|COURSE IN EMERGENCY ROOM|I did not feel that we really needed to do a full sedation with something like etomidate because I felt that we should be able to get this without too much problem. Dad was comfortable with this. We asked for RT to be here, put the patient on supplemental oxygen per nasal cannula, on continuous oximetry monitoring. We gave him 1.8 mg of Versed IV slowly over two to three minutes and about two minutes later gave him an additional 1 mg of Versed.
RT|respiratory therapy|RT|179|180|ASSESSMENT AND PLAN|4. Expiratory wheezing on lung exam. At this point will start out albuterol inhaler/nebs one to two puffs every 4-6 hours p.r.n. for shortness of breath/cough. I am going to have RT to evaluate and treat. I will also do a chest x-ray PA and lateral. Assessment and plan of care was discussed with patient and her husband.
RT|respiratory therapy|RT|145|146|COURSE IN THE EMERGENCY DEPARTMENT|We preoxygenated him with high flow O2 15 liters per minute per nonbreather mask, placed him on monitors, assembled the conscious sedation team, RT and the sedation nurse. Patient was given IV Versed and then IV etomidate with excellent results. The fracture was reduced by Dr. _%#NAME#%_ with two others of us assisting in holding counter- traction.
RT|respiratory therapy|RT|343|344|ASSESSMENT AND PLAN|Will hold potentially sedating medications, monitor status, and reassess in the a.m. Will not do head CT at this point due to no history of trauma and nonfocal neurologic exam and no evidence of trauma on exam as well. 3. COPD. Appears to be at baseline. Will continue medications. 4. Tobacco abuse. Encouraged smoking cessation. Will consult RT assist. 5. Thrush. Placed on nystatin.
RT|respiratory therapy|RT|233|234|HOSPITAL COURSE|By the time of discharge, the patient was able to ambulate without much difficulty and saturating well on the room air. The patient was assigned to be sent out on 5-day burst of steroids. The patient had also received education from RT on how to use her inhalers. It was questioned if the patient was using her inhalers right at home as lots of her medicine were still on the package and evidently had not been used.
RT|respiratory therapy|RT|162|163|HOSPITAL COURSE|On hospital day 1, she underwent a sleep study with pH probe monitoring. On the night of admission, _%#NAME#%_ had an episode of respiratory distress followed by RT aspiration of large volume of stomach contents from the trachea, and a chest x-ray revealing interval increase in extensive lung densities.
RT|respiratory therapy|RT.|210|212|ASSESSMENT AND PLAN|Will continue nebs. Will do Advair 500/50 1 puff b.i.d.. Will continue prednisone 60 mg and Zithromax to complete a 5-day treatment. Will started with q. 2 hour nebs with q. 1 p.r.n. as tolerated. Increase per RT. I anticipate a short stay. He may need a better allergy medicine as well. 2. Abdominal pain related to Efedron use. I advised him to quit this.
RT|respiratory therapy|RT|196|197|PAST MEDICAL HISTORY|Was transferred from the nursing home secondary to shortness of breath, hypoxia, and cough. HOSPITAL COURSE: Respiratory problems. From the day of admission he was started on Timentin IV and also RT was notified and consulted to start albuterol nebulizers and also inhaler and do deep suctioning for him. Also he was put on a face mask 5 L of oxygen but during the hospital course, even with getting antibiotics, his respiratory problem was getting worse and he was dropping O2 saturation to 75% even on oxygen mask.
RT|respiratory therapy|RT|143|144|HISTORY OF PRESENT ILLNESS|The patient was then given 4 mg of Dilaudid and 2 mg of Ativan IV for pain. The Dilaudid drip was then started at 2 mg an hour. At 1415 hours, RT stopped ventilation and tubing was removed. The patient displayed no audible respirations. No movement. No carotid pulse. Pupils became fixed and dilated. The patient did not respond to verbal or tactile stimulation and was pronounced dead by Dr. _%#NAME#%_ _%#NAME#%_ at 1430 hours.
RT|respiratory therapy|RT|138|139|HISTORY OF PRESENT ILLNESS|In the Emergency Room a chest x-ray was performed and is said to be normal. Lung sounds seemed to be clear, but tight. Nebs were given by RT and the child was admitted for observation. PAST MEDICAL HISTORY: Very benign with no surgeries, no major disease or hospitalizations.
RT|respiratory therapy|RT|198|199|ASSESSMENT AND PLAN|He is already on an ARB, and I am going to add some metoprolol to his regimen. 2. Respiratory. We will check his PFTs. I will give him Duo-Nebs and see if that improves. 3. Obstructive sleep apnea. RT will assist with CPAP. 4. Diabetes. Lantus. His last A1C was less than 7. I will do Accu- Cheks and his metformin. 5. Elevated cholesterol. Will continue Pravachol. 6. Gastroesophageal reflux disease.
RT|respiratory therapy|RT|176|177|PLAN|2. Depression with anxiety. PLAN: We will prescribe prednisone 40 mg daily and Duonebs 4 times a day. We will have albuterol nebs available on an as needed basis. We will have RT instruct on correct inhaler use and she will likely go home with a couple weeks of prednisone and albuterol inhaler for as needed use.
RT|respiratory therapy|RT|175|176|HOSPITAL COURSE|She was admitted and she was placed on 3L/minute oxygen via nasal cannula. When she was brought to the floor, she was given DuoNeb q.4h. and q.1h. p.r.n. shortness of breath. RT did come to see the patient and wean the patient from the O2 to room air. At the time of discharge, the patient was saturating at 90% on room air.
RT|respiratory therapy|RT|276|277|SUMMARY OF HOSPITAL COURSE|He did not have any fevers. He was not hypoxic and he was tolerating p.o. and thus it was felt safe to discharge him home on a 7 day course of Levaquin. He will follow up with Dr. _%#NAME#%_ _%#NAME#%_ at the end of this course. 2. Wheezing. He was wheezing a bit. Therefore, RT did show him how to an albuterol MDI. He was given a prescription for this as well. Likely with resolution of his infection, the wheezing wall resolved.
RT|respiratory therapy|RT|130|131|PROCEDURE|CONSULTATIONS: Pulmonary. PENDING TESTS: Spirometry. PROCEDURE: He had spirometry done, the formalized results are still pending. RT is going to assess him for home O2 and if he qualifies they will get him set up for home O2. DIET: Diabetic. ACTIVITY: No restrictions. FOLLOW-UP: He will follow up Dr. _%#NAME#%_ in two to three weeks.
RT|respiratory therapy|RT|289|290|HOSPITAL COURSE|For his obstructive lung disease, the patient was placed on Solu-Medrol 60 mg IV q.8h. for a total of 3 days and then changed to prednisone 40 mg p.o. q.d. to continue on a slow taper. The patient was placed on Pulmozyme nebulizers, albuterol nebulizers, chest physiotherapy treatment per RT and Azmacort. Eventually, he was changed to Xopenex nebulizers t.i.d. The patient's respiratory status seemed to improve throughout the hospital stay until on day of discharge, the patient appeared to be much improved, breathing well, satting 93% on 2 liters of oxygen per nasal cannula.
RT|respiratory therapy|RT.|108|110|DIAGNOSIS|She at that point in time was admitted to ICU. She was placed on Accolate 20 mg po q day. Continue nebs per RT. Allegra XR 100 mg po q day, Paxil 40 mg po q day, Trazodone 100 mg po q hs, Prevacid 30 mg po q day, Tequin 400 mg po q day, Solu-Medrol 125 mg IV initially and then 60 mg q 6 hours, Atrovent qid, Albuterol q 1-2 hours prn, Potassium protocol.
RT|respiratory therapy|RT|162|163|ASSESSMENT/PLAN|1. Chronic obstructive pulmonary disease exacerbation with hypoxia and possible pneumonia. Will provide 02 support, place the patient on IV steroid therapy, have RT perform scheduled Albuterol and Atrovent nebs and continue treatment with IV Tequin. Will await formal radiological report for chest x-ray reading. Most likely the exacerbation is secondary to pulmonary infection, whether pneumonia or bronchitis, increased activity and humidity.
RT|retrograde tachycardia|RT,|158|160|HOSPITAL COURSE|On review of her EKG on the night of admission, it was tachycardic, with a rate of 109, and the P waves were behind the QRS complexes, revealing possible AV, RT, or other non- sinus tachycardia. The morning of evaluation, her EKG had reverted back to a sinus rhythm, with a prolongation of the P-R interval into the 336 msec range.
RT|respiratory therapy|RT|178|179|PAST MEDICAL HISTORY|We will regive it today. He did have a flu shot already this year. 2. Trach dependent obstructive sleep. Again has profuse secretions when ill. Will need frequent suctioning but RT and staff know him well. 3. Chronic obstructive pulmonary disease. He has been stable for several months. Is on O2. Try keep his sats above 92, he tends to loose some of his respiratory drive so just try to keep sats above 88.
RT|respiratory therapy|RT|175|176|ASSESSMENT AND PLAN|2. Respiratory failure with COPD. Doing better this morning than he was yesterday. Continue O2 respiratory cares. Will need frequent suction due to his profuse secretions and RT knows that. 3. Congestive heart failure. Stable. We will hold Lasix at this point as he is getting high normal for sodium.
RT|respiratory therapy|RT|218|219|ASSESSMENT|At this point, we will closely monitor him overnight. It is possible that with a little bit of time, he will turn around and regain his gait. We will get a physical therapy assessment. Otherwise, the patient will have RT assist with nebulizations and management of his chronic obstructive pulmonary disease. We will continue his home medications.
RT|respiratory therapy|RT|193|194|ASSESSMENT/PLAN|Prior to obtaining another scan here, I will request a copy of this result from Dr. _%#NAME#%_'s office. I do not feel this is related to her presentation. 4. Obstructive sleep apnea. Will ask RT to supply a loaner while in hospital. 5. Frequent stool. Simple observation and p.r.n. Imodium. 6. Non-fasting hyperglycemia.
RT|respiratory therapy|RT|218|219|PLAN|4. Notify neurologist of this patient's presence. 5. Review her meds and modify them as appropriate to her situation. She will need serial chest x-rays and close pulmonary attention with excellent pulmonary toilet and RT involvement if necessary.
RT|respiratory therapy|RT|153|154|PLAN|Continue current meds. Note: Primary team needs to check meds/doses with Community University Health Care Clinic. 3. Haldol 2.5 mg PO bid. 4. C tap plus RT consult for settings. 5. Vegetarian diet, no fish. 6. Nicotine patch made available. 7. Primary team to reassess in the AM.
RT|respiratory therapist|RT|144|145|SOCIAL HISTORY|SOCIAL HISTORY: The patient is married. She has one nine-year-old son. She does not smoke. Uses one alcoholic beverage a month. She works as an RT in the NICU here, at _%#CITY#%_. ALLERGIES: Codeine upsets her stomach. MEDICATIONS: 1. Paxil 20 daily.
RT|respiratory therapy|RT|120|121|PLAN|3. Pulmonary: We will initiate overnight sleep oxymetry. If this does confirm the suspicion of sleep apnea we will have RT set him up for CPAP tomorrow. In an attempt to rule out secondary causes we will also check his cholesterol and his TSH.
RT|respiratory therapy|RT|203|204|PLAN|6. History of osteoarthritis. 7. History of gastroesophageal reflux disease. PLAN: 1. He will be admitted and treated as if for pneumonia by giving him intravenous antibiotics, incentive spirometer, and RT evaluation and management if necessary. 2. We will continue treating his congestive heart failure and cardiac problems, and adjust his medications as appropriate.
RT|respiratory therapy|RT|259|260|HOSPITAL COURSE|She was suctioned per RT and also given Albuterol nebulizer treatment at which time her oxygen level increased to 95% saturation. Given her history of laryngeal web, she does experience some difficulty with secretions and also mucus plugging postoperatively. RT continued to follow her to keep her airway clear. _%#MM#%_ _%#DD#%_, 2005 she did have a bowel movement noted the night before.
RT|radiation therapy|RT|68|69|HPI|My key findings: CC: T3, N2a, M0 SG larynx cancer. HPI: Status post RT and neck recurrence with partial resection; now with tumor mass in level IV on left. Exam: 2 x 2.5 area of firmness and nodularity at left level IV, about 1 cm above clavicle.
RT|radiation therapy|RT.|174|176|HPI|Assessment and Plan: I have offered the patient palliative radiation to this previously treated area. I have explained the increased risk of side effects due to his previous RT.
RT|radiation therapy|RT.|201|203|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Metastatic NSC lung cancer. HPI: Painful paraspinal mass - previous thoracic RT. Exam: Patient appears fatigued, on NC 02, decrease right BS.
RT|radiation therapy|RT|198|199|HPI|HPI: Patient presented with cough. X-rays showed lung mass. Exam: Lungs clear, no SC nodes. Assessment and Plan: Patient will be enrolling in clinical trial using chemotherapy and hyperfractionated RT with neoadjuvant, concurrent and adjuvant treatment. Side effects were explained.
RT|radiation therapy|RT|169|170|HPI|HPI: Patient noted mass in upper left neck. Exam: 5 cm mass BOT left neck shows L/CM and 3 cm nodes level II. Assessment and Plan: We have recommended concurrent CT and RT and have discussed possible side effects with him.
RT|radiation therapy|RT|177|178|HPI|My key findings: CC: Painful mass at T11 HPI: Multiple myeloma s/p BMT with TBI Exam: Tenderness in T11 area Assessment and Plan: We have offered palliative RT. Side effects of RT have been explained.
RT|radiation therapy|RT|177|178|HPI|My key findings: CC: Painful mass at T11 HPI: Multiple myeloma s/p BMT with TBI Exam: Tenderness in T11 area Assessment and Plan: We have offered palliative RT. Side effects of RT have been explained.
RT|radiation therapy|RT|174|175|HPI|__x__ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Metastatic melanoma. HPI: Status post whole brain RT and SRS boost. Exam: Large 4 x 6 x 3 cm mass extending from right maxilla.
RT|radiation therapy|RT.|169|171|HPI|My key findings: CC: Anaplastic oligodendroglioma. HPI: Status post resection. Exam: No neurologic deficits detected. Assessment and Plan: We have offered postoperative RT. Possible side effects were explained.
RT|radiation therapy|RT.|178|180|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Metastatic NSC lung cancer. HPI: Status post thoracic RT. Exam: Four cm left inguinal node. Tender, fixed mass left sc.
RT|radiation therapy|RT.|108|110|HPI|Exam: Four cm left inguinal node. Tender, fixed mass left sc. Assessment and Plan: We will offer palliative RT. We will take great care not to overlap with previous high-dose regions. Possible side effects including nerve and soft tissue damage were explained.
RT|respiratory therapy|RT|249|250|IMPRESSION|At this point we will obtain blood cultures, sputum cultures, and urine cultures will still empiric IV Levaquin and adjust her antibiotics based on the culture results. Despite her seemingly normal white count I do suspect that she has pneumonia as RT has been suctioning up sputum. The patient will require an aggressive pulmonary toilet to keep her airway clear of secretions. There is a high likelihood that she could require mechanical ventilation.
RT|respiratory therapy|RT.|214|216|ASSESSMENT  AND PLAN|At the surgeon's request, he will be kept intubated overnight with a plan to extubate early tomorrow. a. Continue T piece tonight. b. If any respiratory distress, then will put him on CPAP with pressor support per RT. c. If that fails, will put him on CMV overnight. d. Check chest x-ray in the morning as the patient did have some vomiting earlier.
RT|radiation therapy|RT|184|185|HPI|HPI: Patient noticed right neck mass. Exam: Mass 3.5 cm in right base of tongue, 5.5 x 5 cm mass right neck level II, 1.5 cm node right level III. Assessment and Plan: We have offered RT and explained possible side effects.
RT|radiation therapy|RT.|139|141|HPI|Exam: 5/5 muscle strength bilaterally. Cranial nerves II through XII intact. Assessment and Plan: We have offered the patient 3D conformal RT. Possible side effects were explained.
RT|radiation therapy|RT|165|166|HPI|X Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Metastatic prostate cancer. HPI: Status post RT to left scalp and L1-L2. Exam: Large left neck mass. Assessment and Plan: To better evaluate this mass we have ordered a CT scan.
RT|radiation therapy|RT|213|214|HPI|My key findings: CC: Stage IV prostate cancer. HPI: Patient treated with hormones, now reports "psoas pain on right." Exam: Pain increased in psoas area when lying down. Assessment and Plan: Await original pelvic RT fields for review. If no overlap, recommend RT. All side effects discussed with patient by me, including risks of damage to bone, bowel, bladder, and spinal cord.
RT|radiation therapy|RT.|260|262|HPI|My key findings: CC: Stage IV prostate cancer. HPI: Patient treated with hormones, now reports "psoas pain on right." Exam: Pain increased in psoas area when lying down. Assessment and Plan: Await original pelvic RT fields for review. If no overlap, recommend RT. All side effects discussed with patient by me, including risks of damage to bone, bowel, bladder, and spinal cord.
RT|radiation therapy|RT|96|97|HPI|My key findings: CC: Progressing previously treated lesion in pons brain stem. HPI: Status post RT and GammaKnife. Exam: Numbness and weakness on right. Assessment and Plan: We have gone over the risk of re-irradiation to this region which include the increased risk of normal brain damage.
RT|radiation therapy|RT.|166|168|HPI|My key findings: CC: Stage IV renal cell carcinoma. HPI: Brain metastases. Exam: Neural exam is within normal limits. Assessment and Plan: Patient offered palliative RT. All possible side- effects explained.
RT|radiation therapy|RT|122|123|HISTORY OF PRESENT ILLNESS|He was then seen by Radiation Therapy and Surgery. Surgery felt his lesion was unresedtable and he left the clinic before RT was started. He went to Parker-Hughes Cancer Center for a second opinion. He had a second biopsy which showed a malignant spindle and epithelioid tumor consistent with sarcomatoid carcinoma.
RT|radiation therapy|RT|215|216|HPI|My key findings: CC: Recurrent epithelioid sarcoma-type tumor. HPI: Originally diagnosed as MFH and treated with chemotherapy and maxillectomy. Pathology read as epithelioid tumor, sarcomatous type. Patient refused RT up to now. Exam: Patient blind in left eye. No tumor seen in maxillary defect.
RT|radiation therapy|RT|173|174|HPI|Exam: Patient blind in left eye. No tumor seen in maxillary defect. Assessment and Plan: MRI shows tumor in left cavernous sinus and brain stem. As patient has not received RT and is not operable, we will offer him RT. All possible side effects including brain damage and visual loss were discussed.
RT|radiation therapy|RT.|147|149|HPI|Assessment and Plan: MRI shows tumor in left cavernous sinus and brain stem. As patient has not received RT and is not operable, we will offer him RT. All possible side effects including brain damage and visual loss were discussed.
RT|radiation therapy|RT.|161|163|HPI|My key findings: CC: Small-cell lung cancer. HPI: Brain metastases. Exam: No focal neurologic deficit detected. Assessment and Plan: We have offered whole brain RT. Possible side effects have been explained.
RT|radiation therapy|RT.|212|214|HPI|My key findings: CC: Stage IV rectal carcinoma HPI: Status post chemotherapy and pelvic RT now with brain mets Exam: Right lower extremity weakness 4/5 Assessment and Plan: We have offered palliative whole brain RT. We have explained possible side effects including risk of damage to brain.
RT|radiation therapy|RT|177|178|HPI|My key findings: CC: Stage IV NSC lung cancer. HPI: Large neck mass and brain metastasis. Exam: Large right-sided neck mass Assessment and Plan: We have recommended whole brain RT and palliative neck RT. Side effects were discussed.
RT|radiation therapy|RT,|183|185|HPI|___x__ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Metastatic NSC lung cancer. HPI: S/P 3750 cGy whole brain RT, s/p residual brain mets. Exam: CN II-XII intact. Normal gait. Assessment and Plan: Patient is a good candidate for stereotactic RT.
RT|radiation therapy|RT.|211|213|HPI|My key findings: CC: Metastatic NSC lung cancer. HPI: S/P 3750 cGy whole brain RT, s/p residual brain mets. Exam: CN II-XII intact. Normal gait. Assessment and Plan: Patient is a good candidate for stereotactic RT. We have explained the procedure and side effects to her.
RT|radiation therapy|RT,|180|182|HPI|HPI: Status post biopsy followed by chemotherapy. Exam: Some numbness in left face. Assessment and Plan: We have explained potential options which include observation, whole brain RT, and fractionated stereotactic RT. The patient wishes to think about his options and will contact us if he wishes SRT.
RT|radiation therapy|RT|169|170|HPI|1st underwent chemotherapy. Now here for treatment of brain mets. Exam: Palpable nodes bilaterally in neck. Assessment and Plan: We have offered the patient whole brain RT and will consider neck RT. All complications were explained.
RT|radiation therapy|RT.|120|122|HPI|Exam: The patient still has some numbness of the face and some paresis. Assessment and Plan: We recommend postoperative RT. All possible side effects were discussed with the patient.
RT|radiation therapy|RT.|106|108|HPI|My key findings: CC: Metastatic rectal carcinoma with brain mets. HPI: 3 mets, now undergoing whole brain RT. Exam: Normal neurologic exam. Assessment and Plan: We have recommended stereotactic RT after whole brain RT is completed.
RT|radiation therapy|RT|128|129|HPI|HPI: 3 mets, now undergoing whole brain RT. Exam: Normal neurologic exam. Assessment and Plan: We have recommended stereotactic RT after whole brain RT is completed. Potential side effects were discussed.
RT|radiation therapy|RT|168|169|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Recurrent GBM. HPI: Status post surgery and RT 6000 cGy. Exam: Right-sided hemiparesis. Assessment and Plan: We have offered re-treatment with SRT.
RT|radiation therapy|RT|182|183|HPI|Presented with visual problem. She recently was found to have widespread disease including leg and brain. Exam: No gross disease on outside of skin. Assessment and Plan: Whole brain RT with possible SRS as needed was recommended. Side effects were discussed and patient signed a consent form.
RT|radiation therapy|RT.|132|134|HPI|MRI shows increased enhancement Exam: Left facial nerve weakness Assessment and Plan: We have recommended fractionated stereotactic RT. We have explained side effects.
RT|radiation therapy|RT|206|207|HPI|Exam: No neurologic deficit detected. Assessment and Plan: I am unclear at this time of whether the lesion near the brain stem is worth re-treating with SRS given its previous SRS treatment and whole brain RT as well as its asymptomatic nature. The patient will see Dr. _%#NAME#%_ later today.
RT|radiation therapy|RT.|229|231|HPI|__x__ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Stage IV non-small-cell lung cancer. HPI: Patient has brain metastasis, status post 4000 cGy whole brain RT. Exam: Nystagmus on lateral gaze. Assessment and Plan: Patient has been offered SRT.
RT|retrograde tachycardia|RT|209|210|HISTORY|Regarding his cardiac condition, he does have a known history of atrial flutter which on my review is typical counterclockwise atrial flutter and SVT with a short RP interval possibly typical slow fast AV and RT on electrocardiograms from Fairview Ridges Hospital from. 2005 and 2006. He tells me that he had his first episode of palpitations in 1994 and then again in 2005 and 2006.
RT|radiation therapy|RT|165|166|HPI|My key findings: CC: Renal cell and lung cancer. HPI: No with brain metastases. Exam: No neurologic deficits noted. Assessment and Plan: We have offered whole brain RT at this time. We have explained the possible side effects.
RT|radiation therapy|RT.|131|133|IMPRESSION AND PLAN|We did discuss that radiotherapy could be given postoperatively, but we feel that the best chance of cure is by using preoperative RT. Please see Dr. _%#NAME#%_'s note for final impressions. _%#NAME#%_ _%#NAME#%_, Resident Physician __x__Patient seen and examined by me and resident.
RT|radiation therapy|RT|184|185|HPI|__x____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Limited small-cell lung cancer. HPI: Status post thoracic RT and chemo. Exam: Lungs clear. Assessment and Plan: The patient has undergone a CR.
RT|radiation therapy|RT|110|111|HPI|HPI: Incidentally discovered on work up. Exam: Lungs clear, no SC nodes. Assessment and Plan: We have offered RT with concurrent CT. Possible side effects have been explained.
RT|respiratory therapy|RT|187|188|PLAN|Stool for ova and parasite bacterial culture if recurrent. 5. Ultimate follow-up at Smiley's Clinic (primary care provider) subsequent to discharge for lingering clinical concerns. 6. As RT to adjust CPAP machine (as at home). Thank you for the consultation. We will follow along as indicated.
RT|radiation therapy|RT.|162|164|HPI|My key findings: CC: Multiple myeloma. HPI: Painful lesion in left shoulder. Exam: Limited left arm movement. Assessment and Plan: We have recommended palliative RT. Possible complications were discussed.
RT|radiation therapy|RT.|204|206|HPI|My key findings: CC: Extensive small cell lung cancer. HPI: Painful mass in left scapula and humerus. Exam: Pain mass palpable on left scapula. Assessment and Plan: We have offered the patient palliative RT. Possible side effects were discussed.
RT|radiation therapy|RT,|142|144|HPI|My key findings: CC: Low grade astrocytoma. HPI: Status post biopsy. Exam: No neurologic deficits noted. Assessment and Plan: We have offered RT, possible side effects were explained.
RT|radiation therapy|RT.|162|164|HPI|My key findings: CC: Small cell lung cancer stage IV HPI: Multiple brain mets. Exam: R-sided SC mas, lung clear. Assessment and Plan: We have offered whole brain RT. All possible side-effects explained.
RT|radiation therapy|RT|148|149|HPI|No other mets found. Exam: Lungs clear; heart regular rate and rhythm; no SC nodes. Assessment and Plan: We feel it is reasonable to offer thoracic RT at this time given the circumstances. We have explained possible side effects as well as rationale.
RT|radiation therapy|RT|231|232|PROBLEM|PROBLEM: Small cell lung cancer, extensive. HISTORY: Resection of single brain met with whole brain. RT/CT to chest. PE: Lungs clear, no neurologic deficit. PLAN: We have explained to the patient that due to the previous high dose RT that he has received the fact that this residual mass is involving the great vessels and carina that re-irradiation would carry a substantial risk with little proven benefit.
RT|radiation therapy|RT.|363|365|PROBLEM|RT/CT to chest. PE: Lungs clear, no neurologic deficit. PLAN: We have explained to the patient that due to the previous high dose RT that he has received the fact that this residual mass is involving the great vessels and carina that re-irradiation would carry a substantial risk with little proven benefit. The patient at this time does not wish to proceed with RT.
RT|radiation therapy|RT.|201|203|HPI|My key findings: CC: Metastatic small cell lung cancer. HPI: Single brain metastasis status post resection. Exam: Some weakness in lower extremity. Assessment and Plan: We will plan whole brain postop RT. Possible further treatment in the future. Possible side effects discussed.
RT|radiation therapy|RT.|158|160|HPI|My key findings: CC: Metastatic melanoma. HPI: Multiple brain metastases. Exam: No weakness or sensory loss. Assessment and Plan: We have offered whole brain RT. Possible side effects were explained.
RT|radiation therapy|RT|137|138|HPI|Exam: Patient shows cup of red blood he has been coughing. Decreased left-sided lung sounds. Assessment and Plan: We will begin emergent RT to chest today.
RT|radiation therapy|RT.|196|198|HISTORY OF PRESENT ILLNESS|He was seen by Dr. _%#NAME#%_ _%#NAME#%_ for consideration of stereotactic radiosurgery and he has been referred to us today for evaluation for that procedure. The patient is refusing whole-brain RT. ALLERGIES: No known drug allergies. PAST MEDICAL HISTORY: No history of hypertension, diabetes, chronic obstructive pulmonary disease or coronary artery disease.
RT|radiation therapy|RT.|259|261|ASSESSMENT AND PLAN|We have contacted Dr. _%#NAME#%_ _%#NAME#%_ from Medical Oncology at Fairview-University Medical Center, and he will see the patient this week for evaluation. The patient will let us know if he wishes to proceed with the stereotactic procedure or whole-brain RT. Once again, thank you for allowing to participate in the care of Mr. _%#NAME#%_.
RT|radiation therapy|RT|190|191|HPI|Assessment and Plan: We have referred patient at his request to Dr. _%#NAME#%_ who will continue his overall workup and care. The patient is very frightened of and does not want whole-brain RT and we have offered up front stereotactic RT to his symptomatic lesion as an immediate palliative treatment. He will decide after seeing Dr. _%#NAME#%_. We have explained the possible complications of whole-brain RT and stereotactic RT.
RT|radiation therapy|RT.|126|128|HPI|My key findings: CC: NSCLC. HPI: No mets to spine. Exam: Pain palpable in neck. Assessment and Plan: We will offer palliative RT. Possible risks have been explained.
RT|radiation therapy|RT|210|211|PAST MEDICAL HISTORY|Apparently his baseline creatinine is in the 1.7 range, (last check in our records 1.7 on _%#MM#%_ _%#DD#%_, 2005). PAST MEDICAL HISTORY: 1. Chronic nasal and sinus congestion. 2. Radiation proctitis following RT to the prostate. 3. Herniated L4-5 disc, not requiring surgery. 4. Tonsillectomy. 5. Hernia repair. 6. Bladder stone removal. 7. Placement of artificial ureteral sphincter. 8. No known coronary heart disease, diabetes, or thyroid disease.
RT|respiratory therapy|RT|160|161|PLAN|4. Will obtain Physical Therapy consult to evaluate and treat right ankle and chronic back pain. 5. If okayed with Psychiatry will start CPAP machine at 5 with RT to titrate to comfortable level. 6. Will add onto laboratory studies already drawn a T3 and free thyroxine. 7. We will be happy to see her during her admission for any intercurrent medical issues.
RT|radiation therapy|RT.|112|114|HPI|Margins unclear. Exam: Left hemilarynx, palpable adenopathy. Assessment and Plan: We have offered postoperative RT. Possible side effects including risk of damage to the partial larynx were discussed.
RT|radiation therapy|RT.|121|123|HPI|No SC nodes. Assessment and Plan: We do not feel that RT would be helpful at this time due limitations given by previous RT. We will, however, review the United Hospital post and simulation films and records.
RT|radiation therapy|RT|313|314|HISTORY OF PRESENT ILLNESS|_%#NAME#%_ _%#NAME#%_ is a vibrant _%#1914#%_-year-old white male followed by a Dr. _%#NAME#%_ _%#NAME#%_ at Park Nicollet for a history of prostate cancer in 1994 status post bilateral orchiectomy with recent elevation of his PSA. Because of the elevation the patient was evaluated and subsequently underwent 28 RT treatments to the prostate. He states that at the time of the evaluation he had a questionable bone scan showing possible lesions in his hip and his neck, but CT scans did not demonstrate metastatic disease.
RT|radiation therapy|RT|186|187|HPI|My key findings: CC: Recurrent mediastinal and SC nodes. HPI: Status post resection of stage I NSC lung cancer. Exam: Palpable SC nodes. Assessment and Plan: We have offered the patient RT treatment to the regional disease and this is her only site at this time. Possible side effects were explained.
RT|radiation therapy|RT.|153|155|HPI|My key findings: CC: Glioblastoma. HPI: Gross resection. Exam: Blind in right eye, abnormal gait. Assessment and Plan: We have recommended 3-D conformal RT. Possible side effects were explained.
RT|radiation therapy|RT.|171|173|HPI|My key findings: CC: Apical, T4 N0 M0 NSCLC. HPI: 2 cycles cisplatin/gemcitabine Exam: No mass or node felt in SC. Assessment and Plan: We have offered to treat this with RT. Possible side effects were discussed.
RT|radiation therapy|RT|221|222|HPI|My key findings: CC: Small cell lung cancer. HPI: Status post lung transplant. Exam: Decreased breath sound both bases. Assessment and Plan: We have referred the patient to Medical Oncology for upfront chemo and possible RT later.
RT|radiation therapy|RT.|228|230|PAST MEDICAL HISTORY|Currently the patient denies headache, nausea, vomiting, vision changes. The patient does have complaint of decreased sensation on the left side. PAST MEDICAL HISTORY: Hodgkin lymphoma status post allogenic BMT 7 years ago, and RT. PAST SURGICAL HISTORY: Left inguinal herniorrhaphy with mesh on _%#MMDD2006#%_.
RT|respiratory therapy|RT|165|166|PLAN|4. Obstructive sleep apnea. 5. Bilateral knee pain. 6. History of unprotected sex. PLAN: 1. Ibuprofen 400 mg p.o. every 6 hours p.r.n. knee pain. 2. Nasal CPAP with RT to titrate to comfortable level. 3. STD testing including HIV, hepatitis B and hepatitis C. 4. Will encourage the patient to increased p.o. fluid intake.
RT|retrograde tachycardia|RT.|252|254|LABORATORY DATA|QTC interval was 476 milliseconds. EKG yesterday on arrival in the Emergency Room revealed SVT at a rate of 181 beats per minute. There is a hint of P wave but within the QRS in leads V3 V4 which would suggest a short RO tachycardia or possibly AV and RT. Other labs include troponin I of 0.34 and 0.49. First troponin was less than 0.04. BUN and creatinine are 20 and 1.09. CBC was within normal limits.
RT|radiation therapy|RT|185|186|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Small cell lung cancer, metastatic HPI: S/P definitive chest RT in 2000, since then multiple areas treated effectively with low-dose RT for palliation. Now presents with swallowing difficulties. Exam: Left paralaryngeal area full and hand Assessment and Plan: We will attempt to palliate this area.
RT|radiation therapy|RT.|197|199|HPI|Care will be given to avoid as much previously radiated area as possible. She will have a new staging CT. The patient understands that she is at a greater risk for side effects due to her previous RT.
RT|radiation therapy|RT.|160|162|HPI|Exam: Abdominal mass not easily palpated. Lungs clear. Assessment and Plan: We have reviewed previous treatment as well as recent CT and recommended palliative RT. The potential side-effects were discussed with the patient.
RT|radiation therapy|RT.|185|187|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Chordoma. HPI: Previously treated to sacrum with surgery and RT. Node with mass in T7/T8 resected. Exam: No lower extremity weakness or sensory loss.
RT|radiation therapy|RT|169|170|HPI|My key findings: CC: Stage IV SCCA of lung HPI: Left hilar residual progressing after CT Exam: Lungs clear, no SC nodes. Assessment and Plan: We have offered palliative RT to the left hilum. Possible side effects were explained.
RT|radiation therapy|RT|171|172|HPI|My key findings: CC: Stage T3N2bMO BOT cancer. HPI: Patient had lesion discovered by dentist. Exam: Large mass in BOT. Node on right. Assessment and Plan: We have offered RT with concurrent CT. Possible side effects were explained.
RT|radiation therapy|RT|211|212|HPI|__X___ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Stage IV ovarian cancer. HPI: Persistent metastasis in brain, status post whole brain RT and SRT to lesion. Exam: No neurologic deficits present. Assessment and Plan: Lesion has not changed in size.
RT|radiation therapy|RT.|170|172|HPI|Small nodule left lobe. Assessment and Plan: Radiation options discussed at length. Because of high AUA score, implant may worsen symptoms, and I personally recommend Im RT. Risks and benefits described at length.
RT|radiation therapy|RT.|161|163|HPI|HPI: Patient discovered to have lung mass after decreased sodium. Exam: Wheeze and rhonchi heard on right side. Assessment and Plan: We have offered the patient RT. Possible side effects were explained.
RT|radiation therapy|RT|165|166|HPI|My key findings: CC: Stage IV ovarian cancer. HPI: Brain metastases. Exam: No neurologic deficits seen. Assessment and Plan: We have offered the patient whole brain RT and explained possible side effects. She will begin treatment today.
RT|radiation therapy|RT|162|163|HPI|HPI: Patient has SVC and tracheal compression. Exam: Right SC node, wheezes and is breathing heavily during speech. Assessment and Plan: We have initiated urgent RT due to her SVC and tracheal compression. We have explained possible side effects.
RT|radiation therapy|RT|189|190|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: T1 tracheal squamous cell carcinoma HPI: Status post surgery and RT for both laryngeal and lung primary Exam: Tracheostomy, lungs clear, no SC nodes Assessment and Plan: We would like to offer endotracheal high-dose rate brachytherapy.
RT|radiation therapy|RT|119|120|HPI|R tibial mass status post resection. Exam: Lungs clear, normal heart sounds. Assessment and Plan: Recommend palliative RT to site of fixation and resection. Side-effects discussed.
RT|radiation therapy|RT|184|185|HPI|Exam: Pain elicited left lower rib cage. Assessment and Plan: We have identified the painful site on bone scan as well as a site in a nearby vertebral body. We have offered palliative RT to these lesions. Possible side effects were explained.
RT|radiation therapy|RT|280|281|PLAN|ASSESSMENT: Ms. _%#NAME#%_ is a 67-year-old female with stage IVA follicular lymphoma x9 years, status post Rituximab x4 in the spring 2003, now with recurrence and transformation to large B-cell lymphoma. PLAN: Ms. _%#NAME#%_ would make an excellent candidate for combined chemo RT for the treatment of the high grade component of her lymphoma. Dr. _%#NAME#%_ is considering a PET scan. We are recommending a repeat neck CT, as well as a mammogram.
RT|radiation therapy|RT|116|117|HPI|HPI: Status post biopsy. Exam: 4.5 cm MACS in right base of tongue. Assessment and Plan: We have offered definitive RT for this lesion in conjunction with CT. Possible side effects were explained.
RT|NAME|_%#NAME#%_|16|25|IDENTIFICATION|IDENTIFICATION: _%#NAME#%_ _%#NAME#%_ is a _%#1914#%_ male admitted from the _%#CITY#%_ Care Center through the emergency room on _%#MMDD2006#%_ in the setting of a fall. REASON FOR CONSULTATION: Evaluation assessment while ongoing marked hemodynamic instability, associated metabolic acidosis and acute renal failure.
RT|radiation therapy|RT|276|277|HPI|My key findings: CC: Metastatic breast cancer. HPI: Patient previously treated with whole brain and stereotactic, now 2 new lesions, one previously treated and enlarging. Exam: No neurologic deficits detected. Assessment and Plan: We discussed the possibility of stereotactic RT with the patient. She will be seen by Dr. _%#NAME#%_ for his evaluation and opinion.
RT|radiation therapy|RT|170|171|HPI|Exam: Weak LEU, palpable neck nodes. Assessment and Plan: Although there is no diagnosis at this time, the patient is scheduled for a biopsy of a lymph node not near the RT field. We will begin palliative RT on the patient's spine. This as well as possible side effects were discussed. Dr. _%#NAME#%_ was also spoken to to discuss the care and agrees.
RT|radiation therapy|RT|124|125|HPI|My key findings: CC: Brain metastases from small cell lung cancer, falling. HPI: Status post brain resection, partial brain RT to 5400 cGy, stereotactic RT x 2. Exam: No lymph nodes, lungs clear, no neuro findings. Assessment and Plan: We have offered stereotactic RT to her right parieto-occipital area.
RT|radiation therapy|RT|124|125|HPI|My key findings: CC: Brain metastases from small cell lung cancer, falling. HPI: Status post brain resection, partial brain RT to 5400 cGy, stereotactic RT x 2. Exam: No lymph nodes, lungs clear, no neuro findings. Assessment and Plan: We have offered stereotactic RT to her right parieto-occipital area.
RT|radiation therapy|RT|104|105|HPI|Exam: No lymph nodes, lungs clear, no neuro findings. Assessment and Plan: We have offered stereotactic RT to her right parieto-occipital area. She understands that she is at higher risk for side effects due to her previous RT.
RT|radiation therapy|RT.|182|184|HPI|CC: Fifty-four-year-old female with CNS lymphoma. HPI: Patient found unresponsive, biopsy showed NHL. Exam: Patient relatively oriented, CN normal. Assessment and Plan: We recommend RT. Side effects of treatment discussed with patient and son.
RT|radiation therapy|RT|112|113|HPI|Exam: Lung sounds clear, no evidence of tumor in head and neck. Assessment and Plan: We have offered palliative RT to mediastinum.
RT|radiation therapy|RT,|219|221|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old white female with a complicated medical history who is followed by Dr. _%#NAME#%_ _%#NAME#%_. She has a history of breast cancer, status post lung lumpectomy and RT, adult-onset diabetes mellitus requiring insulin, hyperlipidemia, aortic stenosis and tricuspid regurgitation with pulmonary hypertension and a normal ejection fraction, hypertension, remote DVT, cholelithiasis, cirrhosis presumed secondary to steatohepatitis and ascites and a liver mass that was biopsied during her last hospitalization, which was from _%#MM#%_ _%#DD#%_ until _%#MMDD2007#%_.
RT|radiation therapy|RT.|145|147|HPI|Exam: Patient in cervical collar. Normal movement of upper extremities and lower extremities. Assessment and Plan: We will treat with palliative RT. Possible side effects explained.
RT|radiation therapy|RT.|223|225|HPI|My key findings: CC: Craniopharyngioma. HPI: History of increasing headache and visual disturbance on left Exam: PERRL, some light sensitivity in left eye. Assessment and Plan: We have recommended fractionated stereotactic RT. We have explained possible side effects.
RT|radiation therapy|RT|178|179|HPI|My key findings: CC: Low-grade oligodendroglioma HPI: Status post partial excision, now with increased seizure Exam: No neurologic defects noted Assessment and Plan: The role of RT was discussed with the patient as well as possible side effects. The patient wishes to think over his choices.
RT|radiation therapy|RT.|214|216|HPI|My key findings: CC: Stage IV NSC lung cancer HPI: Diffuse pain cardiac in nature, MRI shows large retrocardiac mass Exam: Lungs clear, heart regular rate and rhythm Assessment and Plan: We have offered palliative RT. We have explained the possible side effects.
RT|radiation therapy|RT.|146|148|HPI|Assessment and Plan: We have discussed possible side effects which include risk of damage to brain and hair loss. We have recommended whole brain RT.
RT|radiation therapy|RT.|105|107|HPI|HPI: S/P resection. Exam: Loss of left 7th and 5th nerves. Assessment and Plan: I would recommend postop RT. I have explained the rational and potential side effects of this treatment.
RT|radiation therapy|RT|325|326|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Cancer of prostate HPI: Gradual increase in PSA with biopsy positive Exam: As above, prostate small and firm, no definite nodules Assessment and Plan: To have total hormonal blockade and external beam RT
RT|radiation therapy|RT|137|138|HPI|My key findings: CC: Stage I seminoma. HPI: Status post inguinal resection. Exam: Well-healed scar. Assessment and Plan: We have offered RT and explain side effects.
RT|radiation therapy|RT|186|187|HPI|My key findings: CC: Stage IV NSC lung cancer. HPI: Bone metastases, status post previous palliative RT. Exam: Pain elicited when pressing ribs. Assessment and Plan: Due to her previous RT it will not be possible to treat the rib lesion. The patient does not feel the femur to be bothersome at this time.
RT|radiation therapy|RT.|163|165|HPI|My key findings: CC: Metastatic NSC lung cancer. HPI: Brain metastases. Exam: No focal neurologic deficits noted. Assessment and Plan: We have offered whole brain RT. Possible side effects were explained.
RT|radiation therapy|RT.|215|217|HPI|HPI: Possible h/o malignant pleural effusion. COPD. FEV1 48%. Exam: Course breath sounds. Tachycardia, nasal O2. Assessment and Plan: Because of patient's poor respiratory status patient is not a good candidate for RT.
RT|radiation therapy|RT|301|302|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Probable lymphoma with SVC HPI: Patient seen emergently for fast-growing mediastinal mass Exam: Dilated chest veins Assessment and Plan: The patient was treated emergently with RT
RT|radiation therapy|RT|207|208|PLAN|ASSESSMENT: Ms. _%#NAME#%_ is a 74-year-old female with stage IVA T2-3 N2b M0 squamous cell carcinoma of the base of tongue. PLAN: Ms. _%#NAME#%_ would make an excellent candidate for recurrent chemotherapy RT for the treatment of her squamous cell carcinoma of the base of tongue. We have discussed the case with Dr. _%#NAME#%_ who is planning to do two cycles of chemotherapy, followed by concurrent chemotherapy RT.
RT|radiation therapy|RT.|290|292|PLAN|PLAN: Ms. _%#NAME#%_ would make an excellent candidate for recurrent chemotherapy RT for the treatment of her squamous cell carcinoma of the base of tongue. We have discussed the case with Dr. _%#NAME#%_ who is planning to do two cycles of chemotherapy, followed by concurrent chemotherapy RT. We have discussed the risks and benefits of radiation therapy with the patient today. The side effects include dryness of mouth, loss of taste, sore mouth and throat, difficulty swallowing, skin irritation, fatigue, weight loss, voice change, ear damage, hair loss, increased risk of dental disease, skin and muscle fibrosis, bone damage, spinal cord damage, and risk of secondary malignancy.
RT|radiation therapy|RT.|167|169|CC|My key findings: CC: Anaplastic oligodendroglioma. HPI: Status post resection. Exam: No neurologic deficit detected. Assessment and Plan: We have offered 3D conformal RT. Possible side effects were explained.
RT|radiation therapy|RT.|183|185|HPI|My key findings: CC: Stage IV neuroendocrine carcinoma. HPI: Left rib metastasis, painful. Exam: Minimal back tenderness to palpation. Assessment and Plan: We have offered palliative RT. Possible side effects were explained.
RT|radiation therapy|RT.|210|212|HPI|My key findings: CC: Extensive NSC lung cancer. HPI: Patient previously treated with PC1, no metastasis at T8. Exam: No lower extremity weakness of sensory loss. Assessment and Plan: We have offered palliative RT. Possible side effects were discussed.
RT|radiation therapy|RT.|101|103|HPI|My key findings: CC: Recurrent oral tongue cancer. HPI: Status post resection, with recurrence, with RT. Now with multiple skin nodules. Exam: Multiple skin nodules. Assessment and Plan: Due to the likeliness of further spread outside the field of RT, we have referred him to Dr. _%#NAME#%_ for possible chemotherapy at this time.
RT|radiation therapy|RT|207|208|PLAN|Gait is smooth and symmetric. ASSESSMENT: Mr. _%#NAME#%_ is a 38-year-old male with metastatic medullary carcinoma of the thyroid. PLAN: Mr. _%#NAME#%_ would make a reasonable candidate for concurrent chemo RT for the treatment of his metastatic medullary carcinoma of the thyroid. We are planning to treat both his neck and chest for alleviation of his symptoms.
RT|radiation therapy|RT.|158|160|HPI|My key findings: CC: Small cell lung cancer. Limited. HPI: Discover during abdominal workup. Exam: Lungs clear. Assessment and Plan: We have offered thoracic RT. Possible side effects were explained.
RT|radiation therapy|RT.|188|190|HPI|My key findings: CC: Extensive small cell lung cancer. HPI: Progressing thoracic mass. Exam: Lungs clear; abdomen soft, nontender. Assessment and Plan: We have offered palliative thoracic RT. Possible side effects have been explained.
RT|respiratory therapy|RT.|165|167|ASSESSMENT/PLAN|6. Bronchitis. Will discontinue azithromycin and start the patient on Tequin as above. 7. Sleep apnea. Will order overnight oximetry with recorder without alarm per RT. 8. Amenorrhea, most likely secondary to stress and drug use. Will continue to observe the patient. 9. Secondary lesion in the oropharynx, possibly due to previous trauma.
RT|respiratory therapy|RT|185|186|IMPRESSION|For now, the patient is reasonably stable. I would change his antibiotics to Zosyn to cover possible aspiration flora given his recent hospitalization and add azithromycin. We will ask RT to obtain a sputum culture and will set him up for ultrasound guided thoracentesis in the morning for further analysis and therapeutic purposes.
RT|radiation therapy|RT.|127|129|HPI|Exam: Thin appearing female; abdomen non-tender, no masses. Assessment and Plan: We have offered potential preoperative CT and RT. Possible side effects were explained.
RT|radiation therapy|RT|118|119|HPI|My key findings: CC: ALL. HPI: CNS relapse. Exam: No neurologic deficits seen. Assessment and Plan: We have discussed RT with the patient including side effects. At this point chemotherapy will be used with RT held in reserve if needed.
RT|radiation therapy|RT|128|129|HPI|Assessment and Plan: We have discussed RT with the patient including side effects. At this point chemotherapy will be used with RT held in reserve if needed.
RT|radiation therapy|RT.|155|157|HPI|My key findings: CC: Craniopharyngioma. HPI: Patient had left sided visual field loss. Exam: Left ptosis. Assessment and Plan: We have offered the patient RT. We have discussed possible side effects including blindness or visual change.
RT|radiation therapy|RT|135|136|HPI|Assessment and Plan: Given the fact that the patient has not received RT since _%#MMDD2004#%_ and has had a CR, we will not offer more RT at this time. I have referred her to Dr. _%#NAME#%_ for possible further CT management.
RT|radiation therapy|RT.|164|166|HPI|My key findings: CC: Endometrial cancer. HPI: S/P TAH/BSO nodes. FIGO IVB Exam: No adenopathy. Assessment and Plan: Good candidate for our local protocol chemo and RT. Risks and benefits outlined at length.
RT|radiation therapy|RT.|210|212|HPI|My key findings: CC: Pituitary macroadenoma. HPI: Light sensitivity. Exam: No defects seen in visual fields; pupils somewhat sluggish. Assessment and Plan: We have offered the patient fractionated stereotactic RT. Possible side effects were discussed including possible visual loss.
RT|radiation therapy|RT|177|178|HPI|__x__ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: MFH now with brain mets HPI: Status post surgery and RT to neck Exam: No neurologic deficits noted Assessment and Plan: We have offered stereotactic radiosurgery and have presented the possible side effects.
RT|radiation therapy|RT.|203|205|HPI|Discussed with resident and agree with note. My key findings: CC: Anaplastic astrocytoma. HPI: Status post biopsy. Exam: No neurologic deficits identified. Assessment and Plan: Recommended postoperative RT.
RT|radiation therapy|RT.|149|151|HPI|My key findings: CC: Glioblastoma multiforme HPI: S/p debulking. Exam: Right sided facial weakness. Assessment and Plan: We have offered the patient RT. Possible side effects were explained.
RT|radiation therapy|RT.|154|156|HPI|My key findings: CC: Glioblastoma multiforme. HPI: Status post resection. Exam: Mild left facial droop. Assessment and Plan: The patient has been offered RT. Possible side effects were explained.
RT|right|RT|187|188|HPI|My key findings: CC: Stage IIA NHL. HPI: Previously treated with chemo-radiation. Finished _%#MM1999#%_. She was asked to see us because of questionable lymph node in the mediastinum and RT side of pleural effusion. Exam: Essentially negative. Assessment and Plan: Chest CT from today shows no change since _%#MM2002#%_.
RT|radiation therapy|RT|174|175|IMPRESSION|CHEST TUBE: In place as previously mentioned. IMPRESSION: The patient is a 57-year-old male with adenocarcinoma of the GE junction diagnosed in _%#MM#%_ of 2004, status post RT and chemotherapy now with elective surgery consisting of esophagogastrectomy. The patient had an estimated blood loss of 200 cc and 600 cc of urine with 2900 cc of lactated ringers.
RT|radiation therapy|RT|218|219|HPI|My key findings: CC: Metastatic NSC lung cancer. HPI: Pain in the right shoulder radiating to arm. Exam: No mass palpated in right SC. Assessment and Plan: Because of lack of evidence of disease in this area, previous RT to this area and patient's history of this pain going back a long time, we do not recommend RT treatment to this area at this time.
RT|radiation therapy|RT,|207|209|HPI|Exam: Right eye blindness and unresponsiveness, left UE and LE 3/5, right 4/5 Assessment and Plan: We have offered the patient fractionated stereotactic radiation. We have explained that due to his previous RT, he is at higher risk for complications.
RT|respiratory therapy|RT|119|120|PLAN|PLAN: 1. Antibiotics for his new right lower lobe and left lower lobe pneumonia. 2. Sputum Gram Stain and culture with RT to induce. 3. We will have Speech do a video swallow to rule out aspiration given the locations of these new infiltrates.
RT|radiation therapy|RT.|193|195|HPI|HPI: Status post partial glossectomy and neck dissection. Exam: No new masses of nodes appreciated. Assessment and Plan: The patient is at high risk for recurrence. We have recommended post-op RT. We have explained possible side effects.
RT|radiation therapy|RT.|171|173|HPI|My key findings: CC: Breast cancer. HPI: Multiple metastatic lesions seen in brain on MRI. Exam: Right-sided paresis. Assessment and Plan: We have recommended whole brain RT. Possible side effects have been discussed.
RT|radiation therapy|RT.|188|190|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Stage IV lung cancer (NSC). HPI: Status post previous abdominal RT. Exam: Not able to elicit specific pain on palpation. Assessment and Plan: The source of pain is unclear.
RT|radiation therapy|RT|166|167|HPI|My key findings: CC: Renal cell carcinoma HPI: Now brain metastases Exam: Motor 5/55, DTR 2/2 Assessment and Plan: Dr. _%#NAME#%_ will treat patient with whole brain RT and we will see patient after that for possible SRS.
RT|radiation therapy|RT.|170|172|HPI|My key findings: CC: HPI: Metastatic renal cell cancer to brain status post whole brain radiation. Isolated lesions remaining in CNS. Here for evaluation of stereotactic RT. Exam: No significant neurologic abnormalities noted. Assessment and Plan: To be seen by Dr. _%#NAME#%_ and scheduled for stereotactic RT.
RT|radiation therapy|RT.|134|136|HPI|Exam: No significant neurologic abnormalities noted. Assessment and Plan: To be seen by Dr. _%#NAME#%_ and scheduled for stereotactic RT.
RT|radiation therapy|RT|137|138|HPI|My key findings: CC: Stage IV NSC lung cancer. HPI: Large hilar mass. Exam: Wheezes heard. Assessment and Plan: We will offer palliative RT to the right hilum. Possible side effects have been explained.
RT|radiation therapy|RT|210|211|PLAN|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: Exam: Lungs clear, no SC nodes. Assessment and Plan: We have offered the patient thoracic RT with b.i.d. radiation. Possible side effects as well as advantages and disadvantages of b.i.d. RT were explained.
RT|radiation therapy|RT.|105|107|HPI|Exam: Abdomen soft, nontender; scar healing well. Assessment and Plan: We have recommended postoperative RT. Possible side effects have been explained.
RT|respiratory therapy|RT|214|215|HISTORY OF PRESENT ILLNESS|The patient was put in a wheelchair and moved back to her room and continued to be examined. The patient continued in respiratory distress, contacted Dr _%#NAME#%_ who ordered 2.5 mg albuterol nebulizer treatment. RT and the house doctor were called stat. The patient was given the albuterol nebulizer however she developed an increasingly progressive cough as well as well as some nausea.
RT|respiratory therapy|RT.|180|182|ASSESSMENT AND PLAN|EKG was ordered and demonstrated right bundle branch block. ASSESSMENT AND PLAN: 1. Asthma exacerbation due to recent URI and anxiety. Patient given albuterol nebulizer 2.5 mg per RT. This made patient nauseous and increased her cough. Neb was stopped. Ordered Zofran 4 mg IV, Ativan 2 mg IV. Stat. EGK per house doctor. Dr _%#NAME#%_ arrived ordering troponins q.6 h. x3.
RT|radiation therapy|RT,|171|173|HPI|__x___ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: AV malformation. HPI: Previously treated with RT, continued HA. Exam: No neurologic deficits noted. Assessment and Plan: We have offered re-treatment.
RT|radiation therapy|RT.|177|179|HPI|__x__ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Recurrent oligodendroglioma HPI: Status post PVC and RT. Exam: No focal neurologic deficits detected. Assessment and Plan: We have offered SRT re-treatment and explained possible side effects.
RT|radiation therapy|RT.|249|251|HPI|Now tumor progression. Exam: No neurologic defects detected. Assessment and Plan: We have offered palliative re-treatment with fractionated stereotactic radiation. All possible side effects were explained including an increased risk due to previous RT.
RT|radiation therapy|RT|220|221|HPI|Reviewed PET, CTs. Assessment and Plan: Stage IVB Hodgkin's. He will receive combination chemotherapy if there is less than a CR. Would consider consolidative radiotherapy. He is not on a COG protocol. Discussed role of RT with _%#NAME#%_ and his mother.
RT|radiation therapy|RT.|108|110|HPI|Exam: No palpable adenopathy. Decreased BS right base. Assessment and Plan: We have recommended whole brain RT. Potential side-effects were discussed.
RT|radiation therapy|RT|166|167|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Cavernous sinus meningioma. HPI: Previous RT for hard palate cancer. Exam: Decreased left-sided facial sensation and lateral gaze. Assessment and Plan: We must review the patient's previous radiation records.
RT|radiation therapy|RT|191|192|HPI|My key findings: CC: Metastatic NSC lung cancer. HPI: Status post resection of brain metastasis. Exam: No gross neurologic deficits detected. Assessment and Plan: We have offered whole brain RT for her multiple brain metastases. We have explained possible side effects.
RT|radiation therapy|RT|160|161|HPI|HPI: Status post resection _%#MMDD2002#%_. Exam: No neurologic deficits noted. Assessment and Plan: Await final pathology. Recommend postoperative 3D conformal RT if high grade. Side effects discussed.
RT|radiation therapy|RT.|188|190|HPI|My key findings: CC: Parasellar meningioma. HPI: Partial resection. Exam: Non-reactive right pupil, blindness right eye. Assessment and Plan: We have recommended stereotactic fractionated RT. We have explained possible side effects.
RT|radiation therapy|RT|190|191|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Recurrent oligodendroglioma HPI: Status post surgery, status post RT for recurrence, now developed second recurrence. Exam: Difficulty with word finding. Assessment and Plan: Recommend SRS, all possible complications discussed with patient by me.
RT|radiation therapy|RT.|187|189|HPI|My key findings: CC: Recurrent anaplastic oligodendroglioma. HPI: Status post previous resection. Exam: No neurologic deficits detected. Assessment and Plan: We have offered 3D conformal RT. Possible side effects were explained.
RT|radiation therapy|RT|126|127|HPI|My key findings: CC: Patient with resistant stage IV prostate carcinoma with probable cerebellar metastasis. HPI: Status post RT to pelvis. Recent workup shows lung metastases and solitary cerebellar mass. Exam: Assessment and Plan: The patient is planning to enter hospice and I have offered him whole brain RT.
RT|respiratory therapy|RT|174|175|PLAN|PLAN: 1. Continue supplemental oxygen, bronchodilators, Solu-Medrol and levofloxacin. 2. Check sputum culture if the patient is able to produce. 3. BiPAP will be ordered per RT protocol. 4. Do not resuscitate. Do not intubate status. 5. No workup of lung nodule at this time unless patient clinically improves.
RT|radiation therapy|RT|126|127|PROBLEM|PROBLEM: Left iliac bony metastasis with a history of left T2 parotid tumor treated with surgical resection and postoperative RT in 2003. This patient was seen for consultation in the Radiation Oncology Clinic by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2007#%_.
RT|radiation therapy|RT|179|180|HPI|My key findings: CC: Limited small-cell lung cancer HPI: Status post one round of chemotherapy Exam: Lungs clear. No SC adenopathy Assessment and Plan: We have recommended b.i.d. RT and concurrent chemotherapy. Possible side effects have been explained.
RT|radiation therapy|RT.|197|199|HPI|__x___ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Recurrent oligodendroglioma astrocytoma. HPI: Status post resection and RT. Exam: Decreased strength in right upper extremity and lower extremity Assessment and Plan: It is our opinion that given the size of the tumor and location the patient's best option at this time is intraarterial chemotherapy.
RT|radiation therapy|RT.|218|220|HPI|My key findings: CC: T1, N3, M0 WHO 3 nasopharynx cancer HPI: Patient originally noted neck mass Exam: Mass seen on roof of NP, bilateral and SC nodes Assessment and Plan: We are planning to treat with combined CT and RT. We have discussed the possible side effects of treatment.
RT|radiation therapy|RT,|274|276|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Ostomy bleeding. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 81-year-old white female with a history of colon cancer diagnosed in 1976, status post colon resection and colostomy by Dr. _%#NAME#%_, breast cancer, status post right lumpectomy and RT, alcoholic cirrhosis, pancytopenia secondary to ETOH use, depression who was hospitalized in _%#MM#%_ of 2006 with bleeding ostomy. During that time it was felt secondary to her INR greater than 1.6 and her platelet count in the 60s and as well as the patient actively consuming alcohol.
RT|radiation therapy|RT.|200|202|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Metastatic NSC lung cancer. HPI: S/P 4600 cGy for bain metastases and chest RT. Exam: No neurologic deficits detected. Assessment and Plan: We have recommended SRS.
RT|radiation therapy|RT.|230|232|HPI|My key findings: CC: Metastatic NSC lung cancer. HPI: Status post initial surgical resection of stage II primary, now with brain mets. Exam: No gross hemologic deficits. Assessment and Plan: We have offered palliative whole brain RT. Possible complications were explained.
RT|radiation therapy|RT,|177|179|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Small cell lung cancer. HPI: S/P chemotherapy, chest RT, and PCI now with brain mets. Exam: LE 1+ edema bilat. Assessment and Plan: Recommend stereotactic surgery
RT|radiation therapy|RT,|175|177|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Metastatic NSC lung cancer. HPI: Status post chest RT, now with brain mets. Exam: Lymph nodes, right neck. Assessment and Plan: We have offered whole brain RT.
RT|radiation therapy|RT|119|120|HPI|My key findings: CC: Diagnosis of plasmacytoma of sphenoid and cavernous sinuses; loss of vision. HPI: Patient had one RT treatment and neurosurgeon did surgery and resected part of tumor. He had difficult postop course. Exam: Post craniotomy. Assessment and Plan: Resume radiation.
RT|radiation therapy|RT.|101|103|HPI|Exam: Mass in vagina emanating from cervix almost to introitus. Assessment and Plan: Recommend chemo RT. Risks and benefits outlined. She wishes to have the radiation given closer to home in _%#CITY#%_ _%#CITY#%_.
RT|radiation therapy|RT|179|180|HPI|My key findings: CC: Angioma. HPI: Headaches. Exam: No neurologic deficits seen. Assessment and Plan: We have discussed the case with Dr. _%#NAME#%_. We do not feel she is a good RT candidate at this time.
RT|radiation therapy|RT|134|135|HPI|HPI: Presented with Lambert Eaton syndrome. Exam: Node palpated, left SC. Assessment and Plan: We have offered the patient concurrent RT and CT. We have explained possible side effects.
RT|radiation therapy|RT.|166|168|HPI|My key findings: CC: Glioblastoma multiforme. HPI: Status post gross resection. Exam: No neurologic deficits seen. Assessment and Plan: We have offered postoperative RT. Possible side effects were explained. .
RT|radiation therapy|RT.|142|144|HPI|My key findings: CC: GBM HPI: Resection Exam: Well healed surgical scar, no focal neurologic deficits Assessment and Plan: We plan to give 3D RT. We have explained possible side effects.
RT|radiation therapy|RT.|200|202|HPI|__x___ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Glioblastoma multiforme, possible recurrence. HPI: Status post surgery and RT. Exam: No neurologic defects detected. Assessment and Plan: We will repeat the MRI and re-evaluate.
RT|radiation therapy|RT|193|194|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Metastatic melanoma. HPI: Long history of stage IV disease. Previous RT to sternal mass. Exam: Pain when walking. Assessment and Plan: We have offered to treat the SI metastasis, possible side effects were discussed.
RT|radiation therapy|RT|168|169|HPI|__X__ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Recurrent ependymoma HPI: S/P resection and RT 5400 cGy. Exam: Unable to move right brow. Assessment and Plan: We have recommended SRS.
RT|respiratory therapy|RT|181|182|RECOMMENDATIONS|RECOMMENDATIONS: Thyroid function tests will be obtained as well as a serum cortisol level. _%#NAME#%_ was encouraged to follow up with her gynecologist after discharge. I will ask RT to assist in the resumption of CPAP during this hospitalization. DISCUSSION: _%#NAME#%_ _%#NAME#%_ is a 32-year-old white female who currently is hospitalized on station 3B for evaluation of depression.
RT|radiation therapy|RT.|142|144|HPI|My key findings: CC: GBM. HPI: Status post biopsy. Exam: Decreased strength left side. Assessment and Plan: We have recommended 3-D conformal RT. Possible side effects were explained.
RT|respiratory therapy|RT|142|143|ASSESSMENT/PLAN|2. Hyperglycemia. While she is n.p.o, I would recommend changing her sliding scale insulin from Novolog to Regular insulin. 3. Wheezing. Have RT see her and administer some bronchodilators. 4. Peripheral arterial disease. She is status post aortic iliac bypass and is cared for by the vascular surgeon, Dr. _%#NAME#%_.
RT|radiation therapy|RT.|180|182|HPI|My key findings: CC: Metastatic carcinoma, probable lung cancer. HPI: Spinal metastases. Exam: Lower thoracic spine tenderness. Assessment and Plan: We have recommended palliative RT. Possible side effects were discussed.
RT|respiratory therapy|RT|198|199|ASSESSMENT|3. Status post thyroid cancer. The patient is on thyroid replacement with normal TSH currently. 4. Abnormal GGT with normal alkaline phosphatase, ALT, and AST. No current treatment is warranted. 5. RT will be consulted for assessment of nasal CPAP use at night. Setting will probably be at 9 mmHg. 6. Routine EKG. EKG will be done secondary to Geodon use for possible QT prolongation.
RT|radiation therapy|RT|146|147|HPI|HPI: Noted lump on right side of neck. Exam: Mass palpated in and scar in right tonsillar fossae. Assessment and Plan: We have offered concurrent RT and CT. The patient will be enrolling in RTOG protocol _%#PROTOCOL#%_.
RT|radiation therapy|RT|152|153|ASSESSMENT/PLAN|On careful review of her CT scan shows right pedicle destruction with normal spinal canal compromise of T11. Patient will be planned to have palliative RT to both areas.
RT|radiation therapy|RT.|268|270|HPI|My key findings: CC: Limited stage small-cell lung cancer. HPI: Status post CT/RT with complete local response Exam: Lungs clear, no SC nodes Assessment and Plan: We have discussed the pro's and con's of PCI and feel that we would like to get further staging prior to RT. The patient is unsure at this time whether she would like PCI _%#NAME#%_ _%#NAME#%_ _%#NAME#%_.
RT|radiation therapy|RT.|113|115|HPI|HPI: Patient presented with hemoptysis. Exam: Lungs clear, no SC nodes. Assessment and Plan: We have recommended RT. The patient will be treated on our local phase II protocol. Possible side effects as listed above were explained in detail.
RT|radiation therapy|RT|166|167|HPI|My key findings: CC: Suprasellar meningioma. HPI: Headache Exam: Normal appearing neurologic exam. Assessment and Plan: We have recommended fractionated stereotactic RT and with the help of an interpreter explained possible side effects.
RT|radiation therapy|RT|160|161|HPI|HPI: Status post Taxotere and Taxol. New pain in lower back. Exam: Mild tenderness in region of mass. Assessment and Plan: We will offer the patient palliative RT and have discussed, in detail, risks and benefits with him.
RT|radiation therapy|RT|167|168|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Stage IV NSC lung cancer HPI: S/P previous RT to same deltoid and right psoas Exam: 2.5 x 4 cm mass palpated right posterior deltoid Assessment and Plan: We have planned to irradiate the region again.
RT|radiation therapy|RT|165|166|HPI|___x__ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Stage IV NSC lung cancer. HPI: Previous RT to psoas. Hilar mass, right should pain. Exam: Lungs clear-small nodules in right post shoulder muscles.
RT|radiation therapy|RT|194|195|HPI|Exam: Difficulty moving LEFT LOWER EXTREMITY due to hip pain. Assessment and Plan: As patient wishes to return to _%#CITY#%_ as soon as possible and does not have adequate transportation to get RT there, we have offered 800 cGy in a single palliative fraction.
RT|radiation therapy|RT.|207|209|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Recurrent progressive anaplastic oligodendroglioma. HPI: Status post resection and RT. Exam: Left lower extremity and upper extremity 4/5. Assessment and Plan: We have discussed the option of SRT re- irradiation and explained possible side effects.
RT|radiation therapy|RT.|145|147|HPI|My key findings: CC: NSHD CS IIA with post chemo Rx. HPI: Had bulky mediastinal disease CS IIA NSHD and received 6x AVBD. Here for consolidation RT. Has residual small mass in anterior superior mediastinum. PGT is negative after 4x AVBD. Exam: Essentially negative. Assessment and Plan: Recommend consolidation radiation.
RT|radiation therapy|RT.|164|166|HPI|HPI: Presented with pain in axilla, PET and CT show no nodes. Exam: Decreased BS RUL Assessment and Plan: We have been asked by Dr. _%#NAME#%_ to give preoperative RT. We have explained possible side-effects to the patient.
RT|radiation therapy|RT,|173|175|HPI|A soft >1 cm node palpatedin level II Assessment and Plan: As Dr. _%#NAME#%_ does not feel surgery is the best option due to post-surgical morbidity and the good results of RT, I will treat the patient with RT. We will also treat the level I and II nodes. We have explained possible side-effects to the patient.
RT|radiation therapy|RT.|148|150|HPI|As Dr. _%#NAME#%_ does not feel surgery is the best option due to post-surgical morbidity and the good results of RT, I will treat the patient with RT. We will also treat the level I and II nodes. We have explained possible side-effects to the patient.
RT|radiation therapy|RT|183|184|HPI|Exam: Assessment and Plan: Plan is to treat left lung and mediastinum at 200 cGy fx daily for 3 days fx. Patient to be scheduled for planning CT on _%#MMDD2003#%_ for more definitive RT plan.
RT|radiation therapy|RT|164|165|HPI|Now has suprasellar mass with elevated beta hCG and alpha-fetoprotein. Exam: Patient is unresponsive. Assessment and Plan: We will begin treatment with whole brain RT and reassess after 2 weeks with new MRI. If disease is responding, recommend boost to 5400 cGy. Risks and permission discussed by telephone consent with patient's aunt.
RT|radiation therapy|RT|185|186|HPI|My key findings: CC: Large mediastinal mass. HPI: SVC syndrome and airway compression. Exam: Dilated left CW and jugular veins Assessment and Plan: We have offered several fractions of RT palliatively to mediastinal mass. We began treatment emergently. Possible side effects were explained to the patient's mother.
RT|respiratory therapy|RT|151|152|IMPRESSION|I suspect that some of her lower extremity edema may be related to this. She has left-sided atelectasis but cannot rule out an infiltrate. We will ask RT to attempt to get a sputum. For now I would hold off on any further broadening of her antibiotics as she is afebrile and has normal white counts.
RT|radiation therapy|RT|108|109|HPI|Exam: Craniotomy incision with staples; no neuro deficits. Assessment and Plan: We have offered whole brain RT and explained the possible side effects. The patient would like to consider his options at this time.
RT|radiation therapy|RT.|164|166|HPI|My key findings: CC: Cervix cancer IB1. HPI: Status post radical hysterectomy 8 + lymph nodes. Exam: Scar healing well. Assessment and Plan: Recommend postop chemo RT. Risks and benefits explained at length.
RT|radiation therapy|RT.|211|213|HPI|My key findings: CC: Low-grade ependymoma. HPI: Headache and decreased peripheral vision, occipital craniotomy. Exam: No deficits found on neurologic exam. Assessment and Plan: We have recommended postoperative RT. We have explained possible side effects.
RT|radiation therapy|RT.|182|184|HPI|__x___ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Metastatic NSC lung cancer. HPI: Status post whole brain RT. MRI shows several new mets. Exam: No neurologic deficits seen.
RT|respiratory therapy|RT|140|141|RECOMMENDATIONS|Her chest x-ray shows no acute infiltrates, therefore I think it is reasonable to start trying to wean her from the ventilator and will ask RT to do so. Will follow with you.
RT|respiratory therapy|RT|252|253|PLAN|7. Primarily open-angle glaucoma, stable. 8. History of positive PPD with subsequent negative chest x-ray, stable, no evidence to suggest current active disease. PLAN: 1. Will discontinue Azmacort and start Advair Diskus 250/50, 1 puff b.i.d. and have RT instruct patient on how to use. 2. Will continue with lisinopril as prescribed with parameters. 3. Will increase metformin from 1500 q. day to 2000 mg daily with parameters, as well as increase Actos from 15 mg to 30 mg p.o. daily.
RT|radiation therapy|RT.|171|173|HPI|My key findings: CC: Glioblastoma multiforme. HPI: Status post resection. Exam: No neurologic deficits detected. Assessment and Plan: We have offered the patient adjuvant RT. Possible side effects were explained.
RT|radiation therapy|RT.|195|197|HPI|HPI: Right-sided ear and throat pain Exam: Patient has fullness right thyrohyoid membrane. Fullness of right false cord and epiglottis Assessment and Plan: We have offered the patient definitive RT. Side effects were explained
RT|radiation therapy|RT|187|188|HPI|Now with progressing right hilar disease. Exam: Lungs clear, heart regular rate and rhythm, SC no adenopathy, no abdominal masses. Assessment and Plan: We will administer more palliative RT to the right hilum with care to avoid the spinal cord. Possible side effects were explained to the patient.
RT|radiation therapy|RT.|156|158|HPI|My key findings: CC: Metastatic melanoma. HPI: Patient with brain metastasis. Exam: No neurologic deficits seen. Assessment and Plan: Recommend whole brain RT. Have explained possible side effects.
RT|radiation therapy|RT.|311|313|HPI|My key findings: CC: Glioblastoma multiforme HPI: S/P resection and RT, now recurrent Exam: Decreased strength RLE, decreased DTR RLE, CNII-XII intact Assessment and Plan: We have offered fractionated stereotactic re- treatment. We have explained possible side effects as well as increased risk due to previous RT.
RT|radiation therapy|RT|139|140|HPI|HPI: Surgery performed with gross removal. Pathology shows metastatic carcinoma. Exam: No SC nodes. Lungs clear. Assessment and Plan: Plan RT for local control. All side effects discussed by me.
RT|radiation therapy|RT,|168|170|PLAN|ASSESSMENT: Mr. _%#NAME#%_ is a 62-year-old male with stage IIA (uT3 N0 M0) rectal adenocarcinoma. PLAN: We are planning to treat Mr. _%#NAME#%_ with neoadjuvant chemo RT, most likely followed with an abdominal perineal resection. We were unable to discuss the risks and benefits of radiation therapy with the patient today due to time constraints.
RT|retrograde tachycardia|RT.|431|433|PHYSICAL EXAMINATION|Her electrocardiogram shows normal sinus rhythm with T-waves which are diffusely flat and somewhat prolonged QT duration with QT shift of 460. As described above, her 12 lead electrocardiogram during the ventricular tachycardia episode shows narrow complex tachycardia with apparently little indication of atrial activity appreciable in the somewhat poor quality effects curve but certainly consistent with possible typical AV and RT. IMPRESSION AND PLAN: This is a pleasant 56-year-old lady with left ventricular dysfunction.
RT|retrograde tachycardia|RT|250|251|IMPRESSION AND PLAN|It also showed moderate mitral regurgitation. This is a very pleasant 56-year-old lady with a probable dilated cardiomyopathy and non-sustained ventricular tachycardia. She also had a documented narrow complex tachycardia consider most likely AV and RT . Although it is certainly conceivable that she might have tachycardia induced cardiomyopathy given her relatively mild symptoms during documented supraventricular tachycardia episodes, this doesn't appear very likely in general.
RT|respiratory therapy|RT|162|163|LABORATORY DATA|Potassium was 5.6. Chest x-ray shows an increased heart with a left ventricular pattern and the ET tube down the right mainstem bronchus. This was discussed with RT for pullback. IMPRESSION: 1. Seizures. CT scan was negative, it will be repeated in the morning.
RT|radiation therapy|RT.|158|160|HPI|My key findings: CC: Glioblastoma multiforme. HPI: Status post resection. Exam: Nasolabial droop on right. Assessment and Plan: We have offered postoperative RT. Possible side effects were discussed.
RT|respiratory therapy|RT|273|274|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 74-year-old female who was admitted to the sixth floor here for depression and has been complaining of some shortness of breath to the staff. Two days ago on the tenth they called RT due to complaints by the patient of some pain in her left chest area. She was seen by the house doctor here and EKG was normal sinus and he felt it was more of a musculoskeletal chest wall pain.
RT|radiation therapy|RT|135|136|HPI|Exam: Decreased BS at bases. Assessment and Plan: Patient will most probably be transferred to _%#CITY#%_. We will review his previous RT records.
RT|radiation therapy|RT.|186|188|HPI|Exam: Performance status (Karnofsky) 30-40. Assessment and Plan: Given the patient's poor Karnofsky status and small likelihood that SRS would reverse the SIADH, we are not recommending RT. We have discussed this with Dr. _%#NAME#%_.
RT|radiation therapy|RT,|198|200|HPI|__x___ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Recurrent glioblastoma multiforme. HPI: Status post resection and postop RT, now with recurrence and spread. Exam: No neurologic deficits seen. Assessment and Plan: We have discussed re-irradiation with tomotherapy.
RT|radiation therapy|RT.|161|163|HPI|My key findings: CC: Malignant glioma. HPI: Seizure, status post resection. Exam: Well healing surgical scar; fatigued. Assessment and Plan: We have recommended RT. Possible risks and side effects were explained.
RT|radiation therapy|RT.|108|110|HPI|My key findings: CC: History of metastasis in left cavernous sinus. HPI: BOT cancer status post surgery and RT. Exam: Left eye ptosis. Assessment and Plan: We have offered the patient SRS. Possible side effects were explained.
RT|radiation therapy|RT.|139|141|HPI|My key findings: CC: Metastatic melanoma. HPI: Retrocardiac mass. Exam: Lungs clear. Assessment and Plan: We will offer patient palliative RT. Possible side effects have been discussed.
RT|radiation therapy|RT|159|160|HPI|My key findings: CC: Stage IIIA NSC lung cancer. HPI: Presented with hemoptysis. Exam: No SC adenopathy, lungs clear. Assessment and Plan: We have recommended RT with concurrent CT. Possible side effects were explained.
RT|radiation therapy|RT.|197|199|HPI|My key findings: CC: Stage IV hepatocellular carcinoma HPI: Status post chemotherapy, now pain Exam: Patient is icteric in chest mass and right scapula Assessment and Plan: We will give palliative RT. Possible side effects have been explained.
RT|radiation therapy|RT.|174|176|HPI|My key findings: CC: Metastatic liver cancer HPI: Metastasis to L3 Exam: decreased lower extremity sensation and strength Assessment and Plan: We have recommended palliative RT. Possible side effects discussed.
RT|radiation therapy|RT|189|190|HPI|Exam: No gross neurologic disease noted. Assessment and Plan: We have offered re-irradiation. Possible side effects including brain damage and a greater likelihood of these due to previous RT were explained.
RT|radiation therapy|RT|242|243|HPI|Here to consider BMT. Exam: No masses or adenopathy. Assessment and Plan: She is responding to chemotherapy. Anticipate harvest of stem cells; chemotherapy (possible total marrow irradiation as part of the conditioning) then consider further RT to sites of previously unirradiated disease.
RT|radiation therapy|RT|256|257|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: NHL HPI: Previous treatment with RT and chemo Exam: Large mass left neck Assessment and Plan: We will treat the left neck mass with RT
RT|radiation therapy|RT,|176|178|HPI|__x__ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Recurrent GBM HPI: Status post surgery and 6000 cGy RT, now recurrence Exam: No focal neurologic problems seen Assessment and Plan: We have offered her fractionated stereotactic RT.
RT|radiation therapy|RT.|120|122|HPI|Exam: Recent craniotomy scars. No significant noticeable clinical neuro deficits. Assessment and Plan: Recommend CT and RT. Recommend Dr. _%#NAME#%_ in Pediatric Oncology to see patient. Patient wants to be treated in North Dakota.
RT|radiation therapy|RT.|214|216|HPI|My key findings: CC: Acoustic neuroma HPI: Right-sided hearing loss Exam: No functional neurologic deficits seen besides mild balance problems Assessment and Plan: We have recommended fractionated and stereotactic RT. Possible side effects were explained.
RT|radiation therapy|RT|169|170|HPI|__X__ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Non small cell lung cancer. HPI: Status post RT and CT. Exam: Palpation of ribs reveals no pain. Assessment and Plan: Although there appears to be a lesion on Bone Scan, we see nothing on recent CT and particular pain is going away.
RT|radiation therapy|RT.|208|210|HPI|HPI: Status post CT with mass in left hilum. Exam: Patient is currently oxygen-dependent on NCO2. Assessment and Plan: Because of the impending obstruction and present atelectasis, we have offered palliative RT. We have explained possible complications.
RT|radiation therapy|RT|157|158|HPI|Exam: Slight asymmetry of gland, no definite nodes or masses felt. Assessment and Plan: Stage T2a cancer of prostate, Gleason 3 + 3. Recommend external beam RT using conformal and IMRT to 74 cGy.
RT|respiratory therapy|RT|178|179|SUMMARY OF CASE|The patient actually was discharged briefly, but was called back when her HSV/PCR test was reported back as positive. This patient is an otherwise fairly healthy woman who is in RT school. She claims not to be sexually active and has never had HSV and has not known any partner that had this problem.
RT|radiation therapy|RT|91|92|PROBLEM|PROBLEM: Non-small-cell lung cancer with a single brain metastases, status post Cyberknife RT to this lesion. The patient has no other sites of known metastatic disease and presents for the possibility of concurrent thoracic chemoradiation.
RT|radiation therapy|RT.|205|207|IMPRESSION|EXTREMITIES: Without clubbing, cyanosis, or edema. IMPRESSION: 68-year-old male who has a history of non-small-cell lung cancer. There is a single metastatic brain lesion which was treated with Cyberknife RT. There are no other distant metastases identified. The patient has received 3 cycles of cisplatin and docetaxel. The patient presents today for the possibility of concurrent chemoradiation therapy.
RT|radiation therapy|RT.|148|150|HPI|My key findings: CC: GBM. HPI: S/P resection. Exam: No neurologic deficits detected. Assessment and Plan: We have offered the patient postoperative RT. Possible side effects were discussed.
RT|radiation therapy|RT|239|240|PAST MEDICAL HISTORY|The patient received chemotherapy after total abdominal hysterectomy bilateral salpingo-oophorectomy with Taxol and Carboplatin. 3. History of colon cancer. 4. History of glioblastoma diagnosed in _%#MM#%_ of 2001, for which she underwent RT and chemotherapy. 5. The patient has a history of a seizure disorder related to her brain tumor. 6. The patient has a history of a right DVT.
RT|respiratory therapy|RT|141|142|PLAN|3. We will encourage the patient to increase p.o. fluid intake. 4. Flonase 2 sprays per naris daily. 5. We will start CPAP machine of 8 with RT to titrate to comfortable level. 6. We will increase Protonix from 20 q. day to b.i.d. 7. We will start Claritin 10 mg p.o. daily. 8. We will get repeat fasting blood glucose tomorrow a.m.
RT|radiation therapy|RT.|118|120|HPI|Now mediastinal (left-sided) adenopathy. Exam: Lungs clear. No SC adenopathy. Assessment and Plan: We had recommended RT. All possible side effects were discussed.
RT|radiation therapy|RT.|113|115|HPI|My key findings: CC: Metastatic breast cancer with brain metastases. HPI: Brain metastases, previous whole brain RT. Exam: Left hand dysmetria. Assessment and Plan: We have offered SRS and explained possible side effects.
RT|respiratory therapy|RT|150|151|IMPRESSION|At this point I would switch his Levaquin to Zosyn for broader coverage and cover anaerobes. I agree with sputum culture and blood cultures. Will ask RT to induce if the floor cannot obtain a sample. The patient did have hyponatremia. I would switch his IV fluids to normal saline and will re-check sodium in the morning.
RT|radiation therapy|RT.|132|134|HPI|HPI: Presented with soreness. Exam: 1.5 cm ulcerated mass in left posterior buccal mucosa. Assessment and Plan: We have recommended RT. Side effects were explained.
RT|radiation therapy|RT|166|167|HPI|_____Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Astrocytoma HPI: Status post resection and RT 6000 cGy now progressive disease Exam: Normal CN II-XII except increase sensation right V Assessment and Plan: Patient has been offered stereotactic re-treatment.
RT|radiation therapy|RT|150|151|HPI|HPI: Retinal metastases. Exam: Patient had some difficulty with sight, but difficult to examine eyes. Assessment and Plan: We have offered palliative RT to the retina and orbit. We have explained all possible side effects.
RT|radiation therapy|RT|187|188|HPI|My key findings: CC: Adenocarcinoma unknown primary. HPI: Previous RT to T9-T11 and lumbar spine. Exam: Pain when lateral T11 rib pressed. Assessment and Plan: We have offered palliative RT to this rib. Outside records and films will be reviewed.
RT|radiation therapy|RT.|194|196|HPI|__x____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Pituitary adenoma. HPI: Status post several resections and previous RT. Exam: Loss of vision. Assessment and Plan: We have explained re-irradiation as well as the increased risk of side effects involved including complete blindness.
RT|radiation therapy|RT.|132|134|HPI|Exam: Patient only able to see light and shapes in the left eye. Assessment and Plan: We have recommended fractionated stereotactic RT. We have described possible side effects.
RT|radiation therapy|RT.|199|201|HPI|My key findings: CC: Metastatic NSC lung cancer. HPI: Multiple mets and history of pathologic fracture. Exam: Patient unable to move arms due to pain. Assessment and Plan: We have offered palliative RT.
RT|radiation therapy|RT.|118|120|HPI|Biopsy SCLC. Exam: Lungs showed mild basilar crackles bilaterally, no SC nodes. Assessment and Plan: Recommend CT and RT. Side effects discussed by me with patient.
RT|radiation therapy|RT.|111|113|HPI|Exam: Left protruding tongue, bilateral facial weakness. Wide-based gait. Assessment and Plan: We have offered RT. Possible side effects were discussed.
RT|respiratory therapy|RT|199|200|ASSESSMENT/PLAN|3. Hypertension, as above. 4. Diabetes type 2. We will plan q.i.d. Accu-Cheks with sliding scale regular insulin available for sugars greater than 200. 5. Sleep apnea. We will request a consult with RT to recommend CPAP and settings. 6. Hypothyroidism. Stable.
RT|radiation therapy|RT|161|162|HPI|My key findings: CC: Acoustic neuroma. HPI: Patient noticed decreased hearing. Exam: Decreased hearing on left. Assessment and Plan: We have offered the patient RT with tomotherapy.
RT|radiation therapy|RT.|185|187|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Recurrent anaplastic astrocytoma. HPI: Status post chemo and RT. Exam: Wide-based gait. Assessment and Plan: We have explained stereotactic re-treatment as a palliative treatment and stressed the higher risk of side effects.
RT|radiation therapy|RT.|267|269|EXAMINATION|She is undergoing an MRI of the brain for metastatic work up for the adenocarcinoma and I suggested a right brachioplexus MRI be done as well to see if there is evidence of compression of the nerve in the apex. Heme/Onc is following her for recommendations regarding RT. In the meanwhile I'll continue her on aspirin and Plavix.
RT|radiation therapy|RT|288|289|HPI|_____Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Metastatic breast cancer to brain HPI: Previous T1, N1, M0 (stage II) Exam: No focal neurologic deficits seen Assessment and Plan: Patient will continue whole brain RT and follow up in 1 month status post treatment with evaluation for stereotactic RT.
RT|radiation therapy|RT.|371|373|HPI|_____Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Metastatic breast cancer to brain HPI: Previous T1, N1, M0 (stage II) Exam: No focal neurologic deficits seen Assessment and Plan: Patient will continue whole brain RT and follow up in 1 month status post treatment with evaluation for stereotactic RT.
RT|radiation therapy|RT|177|178|HPI|HPI: History of CAD, diabetes, PVD, renal transplant, amputation of feet and hand. Exam: Multiple amputations, no SC nodes. Assessment and Plan: Will attempt to give concurrent RT and CT. I have explained all possible side effects.
RT|radiation therapy|RT.|184|186|HPI|My key findings: CC: Metastatic NSC lung cancer HPI: Pain in left shoulder; MRI shows mass Exam: Patient unable to lift arm with shoulder Assessment and Plan: We will offer palliative RT. Possible side effects have been explained.
RT|radiation therapy|RT.|115|117|HPI|Exam: Some decreased sensation of right hand and foot. Assessment and Plan: We have offered the patient definitive RT. Possible side effects were explained.
RT|radiation therapy|RT.|157|159|HPI|My key findings: CC: NSC lung cancer. HPI: Brain metastases. Exam: No neurologic deficits seen. Assessment and Plan: We have offered the patient whole brain RT. Possible side effects were explained.
RT|radiation therapy|RT.|147|149|HPI|HPI: Blurring of vision and visual loss of left eye. Exam: Decreased left lateral vision. Assessment and Plan: Recommend fractionated stereotactic RT. All side effects discussed with patient by me.
RT|radiation therapy|RT.|195|197|HPI|My key findings: CC: Limited small-cell lung cancer. HPI: Patient presented with shortness of breath. Exam: Lungs clear. No SC adenopathy Assessment and Plan: We have recommended combined CT and RT. Possible side effects were discussed. Case discussed with Dr. _%#NAME#%_.
RT|radiation therapy|RT|293|294|HPI|__x__Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: CAVD HPI: Patient with history of stents and previous brachytherapy Exam: Heart regular rate and rhythm; lungs clear Assessment and Plan: We will be available to deliver RT if needed
RT|radiation therapy|RT.|170|172|HPI|Assessment and Plan: She received periaortic radiation in 1989 up to bowel and spinal cord tolerance, which includes the area of the pancreas. She is not a candidate for RT.
RT|respiratory therapy|RT|176|177|PLAN|3. Allergic rhinitis, controlled on Nasacort. 4. History of constipation, stable on Colace. PLAN: 1. Continue with current medications as prescribed. 2. CPAP machine at 5 with RT to titrate until comfortable level. 3. We will be happy to see her during admission for any intercurrent medical issues.
RT|radiation therapy|RT|100|101|HPI|Exam: Patient has no specific joint tenderness, normal mobility. Assessment and Plan: We will offer RT to the mass. Side effects were explained.
RT|radiation therapy|RT.|100|102|HPI|Exam: Muscle strength 5/5 in left upper extremity. Assessment and Plan: We have offered whole brain RT. We have explained possible side effects.
RT|radiation therapy|RT|135|136|HPI|HPI: R/O GERD with worsening dysphagia. Exam: NG, CS nodes. Chest: Clear. Assessment and Plan: Patient will be treated with concurrent RT and chemotherapy concurrently. We have explained possible side effects and consented the patient.
RT|radiation therapy|RT.|230|232|HPI|Discussed with resident and agree with note. My key findings: CC: Metastatic esophageal cancer HPI: Pain in left posterior chest Exam: Mass palpated on left posterior chest wall Assessment and Plan: We have recommended palliative RT. We will take great care to avoid previously treated areas. Possible side effects were explained.
RT|radiation therapy|RT.|192|194|HPI|My key findings: CC: Stage IV rectal adenocarcinoma. HPI: Brain metastasis. Exam: CN II-XII intact; no focal neurologic deficits detected. Assessment and Plan: We have recommended whole brain RT. Side effects have been explained.
RT|radiation therapy|RT.|185|187|HPI|My key findings: CC: Non-small cell lung cancer. HPI: Brain metastasis. Exam: No neurologic complications or deficits seen. Assessment and Plan: We have offered the patient whole brain RT. We have explained possible side effects.
RT|radiation therapy|RT|197|198|HPI|__x__Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Recurrent glioblastoma multiforme HPI: Status post 6000 cGy 3-D conformal RT Exam: Minimal right sided weakness Assessment and Plan: We have offered palliative fractionated re- treatment with radiation.
RT|radiation therapy|RT.|98|100|HPI|Exam: Tenderness to palpation in SI joint region. Assessment and Plan: We have offered palliative RT. Side effects were explained.
RT|radiation therapy|RT|160|161|HPI|My key findings: CC: Metastatic NSC lung cancer. HPI: Brain metastases. Exam: No neurologic deficits detected. Assessment and Plan: We have offered whole brain RT and discussed possible side effects.
RT|radiation therapy|RT.|158|160|HPI|My key findings: CC: Metastatic renal cell cancer. HPI: Left femur met. Exam: Pain in left femur. Assessment and Plan: We have offered the patient palliative RT. Possible side effects were explained.
RT|radiation therapy|RT|168|169|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Metastatic renal cell carcinoma. HPI: Prior RT to left hip. Exam: Rib metastases. Assessment and Plan: The patient has been offered palliative RT.
RT|radiation therapy|RT|225|226|HPI|My key findings: CC: Recurrent stage II NSC LC. HPI: S/P resection, now with upper mediastinal nodal recurrence. Exam: Lungs clear. Assessment and Plan: We have offered RT to her recurrent adenopathy. We will obtain previous RT record and review so we can make sure we avoid any overlap. Possible side effects were discussed.
RT|radiation therapy|RT|151|152|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Seminoma S/P resection and RT _%#MM1985#%_. HPI: Recent problems with libido maintaining full erection. Exam: Testicle, no masses, non-tender.
RT|radiation therapy|RT.|90|92|HPI|Exam: Muscle weakness and lack of sensation on left. Assessment and Plan: We have offered RT. We have explained possible side effects.
RT|radiation therapy|RT.|102|104|HPI|Exam: Swelling and chest vein dilatation on right. Assessment and Plan: Recommend starting palliative RT. All side effects discussed.
RT|radiation therapy|RT.|165|167|HPI|HPI: Previous resection _%#MM2000#%_; second resection _%#MM2004#%_. Exam: Patient alert, no neurologic deficits. Assessment and Plan: We have offered postoperative RT. Possible side effects were explained.
RT|radiation therapy|RT.|146|148|HPI|No tumor or adenopathy. Assessment and Plan: We have explained to the patient that she is at high risk for recurrence and have recommended postop RT. Side effects were explained.
RT|radiation therapy|RT.|192|194|HPI|__x___ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Glioblastoma multiforme, recurrent. HPI: Status post resection and RT. Assessment and Plan: Possible side effects were discussed. We have offered the patient SRT re-treatment.
RT|radiation therapy|RT|193|194|HPI|My key findings: CC: Persistent CNS lymphoma HPI: Status post 4000 cGy Exam: Assessment and Plan: We have offered SRS re-treatment to the area. The patient understands that because of previous RT she is at greater risk for side effects such as brain necrosis.
RT|radiation therapy|RT|135|136|CC|Assessment and Plan: Due to the very low position of the patient's larynx and difficulty __________ the cricoid area with conventional RT we have offered IMRT. We have discussed possible side effects.
RT|respiratory therapy|RT|119|120|PLAN|3. Will place patient on 2 liters nasal oxygen and monitor O2 continuously. If he has any periods of hypoxia will have RT assess and initiate CPAP therapy. 4. Follow-up labs in the morning including hemoglobin and BMP. 5. Will follow closely with you for management of intercurrent medical issues.
RT|respiratory therapy|RT|155|156|PLAN|3. High protein, high calorie diet. 4. Endocrine follow-up regarding diabetic control with labile blood sugars. 5. Routine hypoglycemic protocol. 6. CPAP. RT to set up. 7. Recheck BMP if patient agrees. 8. Monitor clinically. Thank you for the consultation. We will follow along with you.
RT|respiratory therapy|RT|155|156|PLAN|3. High protein, high calorie diet. 4. Endocrine follow-up regarding diabetic control with labile blood sugars. 5. Routine hypoglycemic protocol. 6. CPAP. RT to set up. 7. Recheck BMP if patient agrees. 8. Monitor clinically. Thank you for the consultation. We will follow along with you.
RT|respiratory therapy|RT|174|175|RECOMMENDATIONS|3. Change his antibiotics to vancomycin, Flagyl, Levaquin, and fluconazole intravenously with appropriate monitoring. 4. We will add Mucomyst to his nebulization therapy per RT recommendation. SUMMARY OF THE CASE: This is an 80-year-old man who came in here for elective right total hip arthroplasty on the above-stated date.
RT|respiratory therapy|RT|150|151|HISTORY OF PRESENT ILLNESS|He initially was being treated for what sounds like COPD exacerbation. However, yesterday evening while in hospital developed 5/10 chest pressure. An RT was called. At that time, EKG demonstrated marked ST segment depression in V4 through V6 and in the inferior leads of which lead II was greater than lead III.
RT|respiratory therapy|RT|217|218|ASSESSMENT/PLAN|Will follow-up her beta type natriuretic peptide and her creatinine and initiate an ACE inhibitor if blood pressure tolerates later t oday. Will initiate Lasix 40 mg IV q. 8 hours. Will continue her BiPAP for now per RT with tidal volumes at 300 cc. Will check an ABG now and likely will be able to get her off the BiPAP. Advanced directives were discussed with the patient. She was alert and oriented and appropriate.
RT|respiratory therapy|RT|126|127|ASSESSMENT AND PLAN|We will obtain a follow-up chest x-ray following hydration to see if an infiltrate reveals itself. We will obtain peak flows. RT to instruct patient on inhaler technique. Continue albuterol nebs. 2. Murmur consistent with mitral regurgitation murmur.
RT|(drug) RT|RT|178|179|OPERATIONS|18. L5-S1 anterior discectomy, L5-S1 anterior lumbar interbody fusion with cages and bone, morphogenic protein and L5-S1 anterior lumbar instrumentation with Sofamor Danek brand RT cages, all done on _%#MMDD2003#%_ at _%#COUNTY#%_ _%#COUNTY#%_ Medical Center. 19. Bilateral simple mastectomy and left sentinel node biopsy and bilateral first stage reconstruction with fibromuscular tissue expanders bilaterally done on _%#MMDD2004#%_ at _%#COUNTY#%_ _%#COUNTY#%_ Medical Center.
RT|respiratory therapy|RT|311|312|PLAN|5. Diabetes. We will continue the patient on all his medications except hold his glipizide given that we are not sure what is going to come about tomorrow in terms of any investigative studies. 6. Depression. Will continue the patient on his Seroquel as well as his Prozac 7. Obstructive sleep apnea. Will have RT use a CPAP for him tonight. My impression was discussed with the patient and the patient understands the plan.
RT|respiratory therapy|RT|144|145|HOSPITAL COURSE|He will have BiPAP sent to his home. I have written a prescription for that. The patient had G-tube maintenance education, along with his wife. RT did perform NIFs and vital capacities, and they remained stable during the hospitalization. His NIFs were recorded to be -40, and -50. Vital capacities were 2.3 L and 3.0 L.
RT|respiratory therapy|RT|155|156|IMPRESSION|She will be maintained on her usual home therapy with vest and manual. We will try to achieve at least 3-4 hours of manual therapy per day as permitted by RT availability. In the past the patient's family has made up some of the difference in manual therapy due to the patient's extensive manual requirements.
RT|respiratory therapy|RT|215|216|HISTORY OF PRESENT ILLNESS|In the past, there have been discussions repeatedly regarding home care for the patient and respite care. The patient's daughter has not been interested in pursuing this, however, she has had concerns regarding the RT (Respiratory Therapy) expertise and competent with home care, given her mom's complex medical issues and was disappointed in her care at _%#COUNTY#%_ Hospital, which has precluded her considering respite care in the future.
RT|respiratory therapy|RT,|234|236|FOLLOW UP|FOLLOW UP: 1. _%#NAME#%_ _%#NAME#%_ in CF Clinic _%#MMDD2003#%_ at 10:30 in the morning with pulmonary function tests prior to this at 10:00 a.m. 2. Dr. _%#NAME#%_ of ENT in four to six weeks. 3. Home health care service include home RT, q. Monday - Friday and nursing. 4. School resources involved which was discussed at a care conference on the day prior to discharge including: 1) Hearing-impaired teacher services, 2) Social work to be involved in her IEP.
RT|radiation therapy|RT|533|534|HISTORY OF PRESENT ILLNESS|PRIMARY CARE PHYSICIAN: _%#NAME#%_ _%#NAME#%_, M.D. CHIEF COMPLAINT: Cough since _%#MMDD2007#%_ HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 85-year-old white female with a history of 50-pack-year of smoking and presumed COPD, peripheral vascular occlusive disease, hypertension, stroke, anemia, breast cancer, status post lumpectomy, hyperlipidemia, glaucoma, macular degeneration, osteoporosis, remote colon cancer, status post sigmoid resection, adenocarcinoma of the esophagus diagnosed in _%#MM#%_, 2007, status post RT and chemotherapy under the direction of Dr. _%#NAME#%_ _%#NAME#%_. The patient was due for a CT scan of the chest on _%#MM#%_ _%#DD#%_, per Dr. _%#NAME#%_'s orders.
RT|respiratory therapy|RT,|207|209|CONSULTS|This was discussed with his family and the medical team and the family wants to discuss among themselves before deciding further. 6. Other consults. Wound ostomy continence nurse consult, rheumatology, TLC, RT, PT/OT. PROCEDURES: 1. EKG showing sinus rhythm with nonspecific T-wave abnormality.
RT|respiratory therapy|RT|207|208|PROCEDURES|2. Pigtail placement by Interventional Radiology and fluid collection in right lung. 3. Attempted pigtail placement in second fluid collection by Interventional Radiology without success. 4. TLC consult. 5. RT consult. 6. Intravenous fluids. COMPLICATIONS: None apparent. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 36-year-old female with recurrent ovarian carcinoma who presented to University of Minnesota Medical Center, Fairview complaining of increasing shortness of breath.
RT|respiratory therapy|RT|232|233|PROBLEM #9|The patient did require O2 during her hospitalization and will be discharged to home with oxygen therapy to help ease her breathing. The patient also had a chest x-ray performed on _%#MMDD2007#%_ that was negative for pneumothorax. RT was consulted and attempts to provide recommendations for symptomatic control. They recommended oxygen and morphine for her air hunger symptoms. PROBLEM #10: Prophylaxis: The patient was encouraged to wear Pneumoboots while in bed.
RT|respiratory therapy|RT|144|145|IMPRESSION AND PLAN|10. Endotracheal tube placement: On chest x-ray review, it appears that the endotracheal tube is right at the level of the carina. We will have RT pulled back the tube 2-3 cm. 11. Prophylaxis: We will place patient on IV PPI and subcutaneous heparin.
RT|respiratory therapy|RT|204|205|ASSESSMENT AND PLAN|The patient may require transitional care unit stay. Will have Social Work involved. 4. Deep vein thrombosis prophylaxis. We will provide Lovenox scheduled each day. 5. Obstructive sleep apnea. Will have RT assist with CPAP. 6. Hypertension. Will hold his lisinopril for the time being. He has adequate blood pressure control at this time.
RT|radiation therapy|RT.|264|266|HPI|My key findings: CC: Epithelioid hemangioendothelioma, recurrent HPI: S/P surgical resection L2, now recurrent, s/p re-resection Exam: Surgical scan well healed, no lower spinal tract signs that are abnormal. Assessment and Plan: We have recommended postoperative RT. All risks and benefits have been explained.
RT|radiation therapy|RT|144|145|PAST MEDICAL HISTORY|2. Osteopenia. 3. Hypertension. 4. Immune mediated myopathy. Tapering steroid course for this. 5. Breast cancer status post wedge resection and RT therapy. 6. Heart murmur. The patient is unsure if this is significant heart murmur. She was told that it was not and she was told she did not need dental prophylaxis.
RT|radiation therapy|RT.|146|148|PROBLEM|Small superficial firm nodular area, midline superior BOT. HISTORY: Growing neck mass. PLAN: The patient will undergo neck dissection followed by RT. Possible side effects of RT were explained in detail.
RT|respiratory therapy|RT|170|171|PLAN|4. Continue Combivent metered dose inhaler 2 puffs q.i.d. with albuterol metered dose inhaler 2 puffs between Combivent p.r.n. 5. Start Flovent 110 mcg 2 puffs b.i.d. 6. RT followup regarding CPAP device. 7. Fioricet p.r.n. migraine headache. 8. Nicotine patch, reduce to 14 mg per day in that patient has been off cigarettes for 1 month.
RT|radiation therapy|RT|171|172|HPI|Resection on _%#MMDD2002#%_ showed T2 N1 M0 adenocarcinoma. Exam: Surgical scar well-healed. No SC nodules. No tenderness. Good BS. Assessment and Plan: Recommend post-op RT with concurrent chemotherapy. All potential side effects discussed with the patient and me.
RT|radiation therapy|RT|103|104|HPI|My key findings: CC: Metastatic small-cell lung cancer. Pain in chest. HPI: Status post treatment with RT and chemo to chest, status post palliative RT to abdomen. CT shows mass in posterior chest. Exam: Left SC nodes palpated.
RT|radiation therapy|RT|164|165|HPI|Exam: Bilateral foot drop. Weakness of both extremities which makes walking difficult. Assessment and Plan: Bone scan and MRI to be reviewed. Recommend palliation. RT although she has been treated with RT previously to her right chest wall and nodal chains.
RT|radiation therapy|RT.|149|151|HPI|My key findings: CC: Anaplastic astrocytoma HPI: Biopsied. Exam: No neurologic deficients detected. Assessment and Plan: We have offered the patient RT. Possible side effects were explained.
RT|radiation therapy|RT.|107|109|HPI|Exam: Normal pharyngeal pouch, neck without adenopathy. Assessment and Plan: We have offered postoperative RT. Possible side effects were explained.
RT|radiation therapy|RT.|165|167|HPI|My key findings: CC: NHL. Received post BMT. HPI: Stage IV B-cell NHL since _%#MM2001#%_. Refractory to chemotherapy and BMT. Asked to see if he needs consolidation RT. Exam: Palpable lymphadenopathy in SC, axillary and groin areas. Pale and chronically-ill appearing.
RT|radiation therapy|RT.|221|223|HPI|Assessment and Plan: CT scan shows multiple lesions in the mesentery and retroperitoneal areas besides multiple lymph nodes uptake. His blood count is also very low. We don't feel he is a good candidate for consolidation RT. Discussed with Dr. _%#NAME#%_ _%#NAME#%_.
RT|radiation therapy|RT|166|167|HPI|My key findings: CC: Stage IV NSC lung cancer. HPI: Status post CT, now with residual hilar mass. Exam: Lungs clear. Assessment and Plan: We have offered the patient RT to prevent further problems from developing in left hilum. The patient understands this is not curative and understands the risks.
RT|radiation therapy|RT|177|178|HPI|HPI: S/P 648OCGY from _%#MM2001#%_ - _%#MM2001#%_ for T2N2MO. Exam: Bilateral wheezes. No SC nodes. Assessment and Plan: Radiation not recommended because of previous high dose RT to this area.
RT|radiation therapy|RT|155|156|HPI|HPI: Patient has had previous surgery and bilateral neck dissection. Exam: No primary lesions identified. Assessment and Plan: We are offering the patient RT and concurrent chemotherapy. We have explained possible side effects.
RT|radiation therapy|RT|152|153|HPI|Exam: Normal neurologic exam. Assessment and Plan: We have ordered an MRI scan to better evaluate the brain disease. We have discussed both whole brain RT and SRS and their side effects.
RT|radiation therapy|RT|134|135|HPI|My key findings: CC: Glioblastoma multiforme. HPI: Status post resection. Exam: No neurologic deficits detected. Assessment and Plan: RT offered. Possible side effects discussed.
RT|radiation therapy|RT.|215|217|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Thymic carcinoma stage III. HPI: Status post gross resection and previous right chest wall RT. Exam: Radiation changes on right chest wall and axilla. Assessment and Plan: We have explained the risk of chest wall necrosis and the increase risk due to previous RT of this and other side effects.
RT|radiation therapy|RT|182|183|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Recurrent adenocarcinoma of GE junction. HPI: Status post RT and CT preop and surgery. Exam: Abdomen soft, non-tender. Assessment and Plan: Care will be further discussed at multidisciplinary conference.
RT|radiation therapy|RT.|145|147|HPI|My key findings: CC: Neuroendocrine tumor HPI: Large mediastinal mass Exam: Mass in left SC region Assessment and Plan: We will offer palliative RT. Possible side effects were explained.
RT|radiation therapy|RT|133|134|HPI|HPI: Chest wall recurrence. Exam: No SC nodes, no lung sounds, left side. Assessment and Plan: We have explained to the patient that RT is not likely to be curative. And with fact he has no present symptoms that it is controversial to give at this time.
RT|radiation therapy|RT.|185|187|HPI|My key findings: CC: Glioblastoma multiforme. HPI: Speech difficulties and right-sided hand difficulty. Exam: Right-sided facial droop. Assessment and Plan: We have offered the patient RT. Possible side effects were explained.
RT|radiation therapy|RT|155|156|HPI|My key findings: CC: Patient with symptoms of LE weakness and numbness. R/O radiation neuropathy. HPI: Patient is s/p sigmoid resection and post op pelvic RT of 4900 cGy in 175 cGy fx. Exam: Decreased LE strength Assessment and Plan: At this dose, with these low fraction sizes, the patient appears to be the generally accepted dose for peripheral nerve tolerance.
RT|radiation therapy|RT.|186|188|HPI|__x__ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Brain mets-esophageal carcinoma. HPI: Status post whole brain RT. Exam: Cranial nerves II through XII intact. No neurologic deficits seen.
RT|UNSURED SENSE|RT|220|221|REVIEW OF SYSTEMS|No smoking. No drinking. No drugs. FAMILY HISTORY: Non-contributory. REVIEW OF SYSTEMS: Mild pain. She has anxiety with procedures, but otherwise no anxiety. She has mild pain associated with decubitus ulcers related to RT placed for diarrhea. Mild nausea, status post G-tube placement responding to Compazine. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 95.2. Pulse 65.
RT|radiation therapy|RT|179|180|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Cervical esophagus carcinoma (squamous). HPI: Previous RT to region for FOM. Exam: No adenopathy or oral lesions. Assessment and Plan: We have offered re-irradiation to the area but await final decision from head and neck team.
RT|radiation therapy|RT|195|196|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Recurrent anaplastic astrocytoma. HPI: Status post resection X2 and 3D RT 6120 cGy now with disease progression. Exam: Difficulty with word-finding, paralysis of left forehead, loss of balance, loss of right visual field.
RT|radiation therapy|RT|104|105|HPI|Exam: Well healing tongue flap. NED in oral cavity. Assessment and Plan: We have recommended palliative RT to both the oral cavity and esophagus. Possible complications were explained.
RT|radiation therapy|RT,|205|207|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Grade III oligoastrocytoma. HPI: S/P resection x 2 and stereotactic fractionated RT, now with small recurrence Exam: No neurologic deficits seen Assessment and Plan: The patient will be discussed at multimodality conference with surgery, hem/onc and RT present to decide the best option at this time.
RT|radiation therapy|RT|374|375|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Grade III oligoastrocytoma. HPI: S/P resection x 2 and stereotactic fractionated RT, now with small recurrence Exam: No neurologic deficits seen Assessment and Plan: The patient will be discussed at multimodality conference with surgery, hem/onc and RT present to decide the best option at this time.
RT|radiation therapy|RT|178|179|CC|__x___ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Metastatic breast cancer, status post lumpectomy and RT to left breast. HPI: Mass in right lung and mediastinal lymph nodes. Exam: Right SC adenopathy.
RT|radiation therapy|RT|214|215|HPI|Assessment and Plan: The patient's daughter claims the patient has a very active bothersome cough. She is otherwise asymptomatic. We wil l review her previous radiation records and see if we can deliver palliative RT to her mediastinum. We have explained possible side effects.
RT|radiation therapy|RT.|299|301|HPI|__x__ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Stage IV adenocarcinoma of lung HPI: Par tial met in right ischium Exam: Pain on palpation Assessment and Plan: Patient will begin chemotherapy prior to initiating palliative RT.
RT|radiation therapy|RT.|150|152|HPI|My key findings: CC: Recurrent floor of mouth carcinoma in oral tongue. HPI: Status post resection of previous oral floor of mouth lesion with postop RT. Exam: 2.5 x 2 cm mass in oral tongue extends to root of tongue.
RT|radiation therapy|RT|222|223|HPI|HPI: See above. Exam: Nodule at 3 o'clock lateral to left areola. No other nodules or masses. Assessment and Plan: We recommended mastectomy and sentinel node evaluation or lymph node levels 1 and 2 left axilla dissection RT plan will follow surgical findings.
RT|radiation therapy|RT.|169|171|HPI|My key findings: CC: BOT cancer. HPI: Status post resection. Exam: No lesions seen in oropharynx or neck. Assessment and Plan: We have offered the patient postoperative RT. Possible side effects were discussed.
RT|radiation therapy|RT.|191|193|HPI|__x___ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Recurrent glioblastoma multiforme. HPI: Status post resection and RT. Exam: No neurologic deficit seen. Assessment and Plan: We have offered Rt-fractionated SRT.
RT|radiation therapy|RT,|100|102|HPI|My key findings: CC: Stage IV adenocarcinoma of the lung. HPI: Brain mets, s/p resection and postop RT, now new lesion. Exam: Visual field cut right both eyes. Assessment and Plan: Recommend stereotactic radiosurgery.
RT|radiation therapy|RT|113|114|HPI|HPI: Left lung collapse and right nodular. Exam: Absent breath sounds on left. Assessment and Plan: Due to prior RT it is unlikely we will be able to give more RT. We will review patient's previous RT records.
RT|radiation therapy|RT|170|171|HPI|My key findings: CC: Non small-cell lung cancer HPI: Post obstructive pneumonia on right. Exam: Decreased BS on right Assessment and Plan: We have recommended palliative RT to right hilum in attempt to relieve obstruction. Potential side effects were discussed.
RT|radiation therapy|RT.|169|171|PROBLEM|I discussed the case with the resident and agree with the findings and plan of care as documented in the resident's note. PROBLEM: Recurrent tongue cancer. HISTORY: S/P RT. PE: Tumor invading through skin. PLAN: It is our feeling that we have nothing special to offer the patient that will improve his condition or alter his course.
RT|radiation therapy|RT.|150|152|HPI|My key findings: CC: Lumbar ependymoma. HPI: Status post resection. Residual on MRI. Exam: Scar well healed. Assessment and Plan: We have recommended RT. Possible side effects were explained. .
RT|radiation therapy|RT.|228|230|HPI|My key findings: CC: Recurrent osteosarcoma HPI: Status post chemo and surgery Exam: Decreased left Cranial nerves II through XII are grossly intact. V and VII. Well healed incision. Assessment and Plan: Patient wishes to begin RT. We will wait for significant healing to take place. Possible side effects were discussed with the patient.
RT|respiratory therapy|RT|124|125|PLAN|The patient will have Valium per MSSA protocol. We will perform a sputum culture and gram stain. If this not passable, then RT does not need to induce the sputum at this time. We will obtain a repeat a chest x-ray to follow up pneumonia as well as abdominal flat plain to evaluate the left-sided pain.
RT|radiation therapy|RT.|180|182|HPI|My key findings: CC: Metastatic hepatic carcinoma. HPI: Back pain, met at L3. Exam: Palpable pain in mid-lumbar region. Assessment and Plan: We have offered the patient palliative RT. We have explained the possible side effects.
RT|radiation therapy|RT.|190|192|HPI|My key findings: CC: Stage IIIA NSC lung cancer. HPI: Status post resection. Exam: Absent breath sounds on left. Assessment and Plan: We have discussed possible benefits and risks of postop RT. The patient is going to consider her options.
RT|radiation therapy|RT|140|141|HPI|HPI: Patient presented with hoarseness. Exam: Right sided SG tumor involving the right pyriform sinus. Assessment and Plan: We have offered RT and explained possible side effects.
RT|radiation therapy|RT|203|204|PROBLEM|PROBLEM: Non small-cell lung cancer. HISTORY: Patient ignored lung mass, now presents with metastasis. Some are painful. PE: Lungs decreased BS on left. PLAN: We have referred the patient for palliative RT closer to home.
RT|radiation therapy|RT.|172|174|HPI|My key findings: CC: Stage IIB NSC lung cancer. HPI: Patient does not want resection. Exam: Lungs clear, no SC lymph nodes. Assessment and Plan: We have offered definitive RT. Possible side effects were explained.
RT|radiation therapy|RT|164|165|HPI|Exam: Lungs clear, no SC nodes. Assessment and Plan: We have explained that there is no evidence the radiation will improve survival, but that we believe a limited RT field may improve local control and reduce chances of lung collapse. We have explained the possible side effects.
RT|respiratory therapy|RT.|137|139|IMPRESSION|The patient's current chest x-ray shows no evidence of infiltration, and we are unable to _____ suction sputum at this time according to RT. Dr. _%#NAME#%_, the ER physician, did see some green sputum the patient had coughed up. Her airway pressures are high secondary to underlying COPD. For now the patient will be continued on empiric Levaquin, high dose Solu- Medrol, oxygen via ventilator, and we have asked Dr. _%#NAME#%_ to assist with vent management as her airway pressures are significantly high.
RT|radiation therapy|RT.|167|169|HPI|HPI: slight episodes of hemoptysis. Exam: Exam shows no evidence of SVC syndrome. Assessment and Plan: Because of the location of the tumor we have offered palliative RT. We have explained possible side effects.
RT|radiation therapy|RT.|180|182|HPI|Exam: Patient had normal examined CN except slight deviation of uvula to right and reported left cord paralysis. Assessment and Plan: We have recommended fractionated stereotactic RT. All side effects have been discussed.
RT|radiation therapy|RT|148|149|HPI|No mass, no lymphadenopathy. Assessment and Plan: With pN2 axillary disease she would need radiation postop after chemotherapy. Because of previous RT treatment, it will be difficult not to overdose. Side effects are a concern, especially to RT brachial plexus. Other complicated issues are going to be saline expander, which may create more to develop post-treatment fibrosis and contraction.
RT|radiation therapy|RT|242|243|HPI|No mass, no lymphadenopathy. Assessment and Plan: With pN2 axillary disease she would need radiation postop after chemotherapy. Because of previous RT treatment, it will be difficult not to overdose. Side effects are a concern, especially to RT brachial plexus. Other complicated issues are going to be saline expander, which may create more to develop post-treatment fibrosis and contraction.
RT|radiation therapy|RT|116|117|HPI|Subcutaneous nodules seen in left neck, largest 4 mm in anterior low neck. Assessment and Plan: We have recommended RT with concurrent chemotherapy given the aggressiveness of this tumor and the likelihood of residual disease. Possible side effects have been explained.
RT|radiation therapy|RT|126|127|HPI|Exam: Pain to palpation over ischial tuberosity and scapula and lumbar spine. Assessment and Plan: We have offered palliative RT to painful regions. Possible side effects were discussed.
RT|radiation therapy|RT.|124|126|HPI|Exam: Some tenderness left upper thigh, small plaque right groin. Assessment and Plan: We will offer the patient palliative RT.
RT|radiation therapy|RT|306|307|HPI|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Metastatic transitional cell kidney carcinoma HPI: Severe pain in sternum and other areas, neck mass Exam: Pain with palpation of sternum Assessment and Plan: We will treat him with RT to his painful regions
RT|radiation therapy|RT|177|178|HPI|__x___ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Metastatic breast cancer HPI: Previous stereotactic RT to brain and CVBRT, now with increasing met Exam: No focal neurological findings Assessment and Plan: We have offered the option of SRS but also explained the option of observation.
RT|radiation therapy|RT|240|241|HISTORY OF PRESENT ILLNESS|The lung mass was biopsied and the pathology revealed non- small-cell lung cancer consistent with a poorly differentiated adenocarcinoma. Pathology has interviewed here at Fairview-University Medical Center. The patient then had Cyberknife RT to isolated brain metastases. The patient received 2 cycles of cisplatin and a docetaxel. On _%#MMDD2004#%_, the patient had a CT scan of his chest which showed a 6.4 x 5.2 cm mass in the right lower lobe with a 1.9 cm right hilar lymph node.
RT|radiation therapy|RT,|164|166|HPI|He feels her to be a surgical candidate. I agree that a single procedure that is more likely to achieve local control is preferable in this patient than 7 weeks of RT, with its resultant side effects and daily anesthesia.
RT|respiratory therapy|RT|245|246|ASSESSMENT  AND PLAN|At the present time, the patient states he was told not to take aspirin for which I am unclear can only assume it is related to his asthma and I am going to hold any beta blocker therapy here because of his underlying asthma history. I will ask RT to set up the patient with his CPAP as per patient's home use.
RT|radiation therapy|RT.|171|173|HPI|My key findings: CC: Glioblastoma multiforme HPI: S/P excision Exam: No neurological defects detected, scar well healed Assessment and Plan: We have offered 3-D conformal RT. I have explained all side effects.
RT|radiation therapy|RT|282|283|HPI|__x__ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Stage IV non-small-cell lung cancer HPI: With brain metastasis Exam: No neurologic deficits seen Assessment and Plan: We have offered the patient whole brain RT and explained possible side effects.
RT|radiation therapy|RT.|199|201|HPI|_____Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Metastases of brain. HPI: History of breast cancer, status post whole brain RT. Exam: Lungs clear, heart regular rate and rhythm, weakness right lower extremity.
RT|radiation therapy|RT,|172|174|HPI|___x__ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Glioblastoma multiforme HPI: S/P resection and RT, now recurrent Exam: Decreased strength RLE, decreased DTR RLE, CNII-XII intact Assessment and Plan: We have offered fractionated stereotactic re- treatment.
RT|radiation therapy|RT|142|143|HPI|HPI: Patient noticed neck mass. Exam: 4 x 5 cm level II mass, 2.5 cm BOT irregularity, both on left. Assessment and Plan: We have recommended RT and have discussed possible side effects.
RT|respiratory therapy|RT|204|205|PLAN|3. Discontinue hydrochlorothiazide. Parameters for Lisinopril. 4. Protonix 40 mg daily. 5. Recheck a serum sodium. Will require fluid restriction p.r.n. progressive decline. Add CBC to screening labs. 6. RT to adjust CPAP mask. 7. Clinical observation. Thank you for the consultation. We will follow along as indicated.
RT|radiation therapy|RT.|118|120|HPI|Exam: Increased pigmentation, acromegalic features Assessment and Plan: We have recommended stereotactic fractionated RT. We have explained the procedure and possible side effects.
SA|slow acting/sustained action|SA|171|172|MEDICATIONS|3. Tamsulosin 400 mg p.o. b.i.d. 4. Salmeterol two puffs b.i.d. 5. Levaquin 250 mg p.o. q. daily x7 days total. 6. Hydrochlorothiazide 12.5 mg p.o. daily. 7. Guaiphenesin SA 1200 mg p.o. b.i.d. 8. Flovent two puffs b.i.d. 9. Fluticasone nasal spray one spray into each nostril daily. 10. Colazal 750 mg p.o. b.i.d. 11. Albuterol mini-nebs as needed q.i.d. for dyspnea.
SA|slow acting/sustained action|SA|175|176|DISCHARGE MEDICATIONS|13. Insulin aspart, NovoLog sliding scale, high insulin resistance dosing subcutaneously. 14. Lantus 100 units subcutaneously each day at bed-time. 15. Isosorbide mononitrate SA 120 mg p.o. daily. 16. Metformin 1000 mg p.o. b.i.d., first dose _%#MMDD2007#%_ (was held). 17. Altace 10 mg p.o. daily. 18. Zantac 75 mg p.o. b.i.d.
SA|slow acting/sustained action|SA|177|178|DISCHARGE MEDICATIONS|2. C. diff colitis. 3. Pneumonia. 4. Pain secondary to lung cancer. DISCHARGE MEDICATIONS: 1. Albuterol inhaler 2.5 mg/3 mL, neb q.4h. scheduled and q.2h. p.r.n. 2. Guaifenesin SA 600 mg p.o. b.i.d. 3. Flagyl 500 mg p.o. t.i.d. x10 days. 4. Acetaminophen 650 mg p.o./p.r. q.4h. p.r.n. 5. Robitussin AC 5-10 mL p.o. q.4h. p.r.n.
SA|slow acting/sustained action|SA|162|163|DISCHARGE MEDICATIONS|5. Omeprazole 20 mg p.o. daily. 6. Protonix 40 mg p.o. daily, dispense 14-day supply. 7. Levaquin 250 mg p.o. daily x three more days, then discontinue. 8. K-Dur SA 10 mEq p.o. b.i.d. DISCHARGE FOLLOWUP: The patient is advised to follow up with her primary physician, Dr. _%#NAME#%_ _%#NAME#%_, in five to seven days; at that time she will need a repeat urinalysis and urine culture.
SA|slow acting/sustained action|SA|110|111|PREVIOUS HOME MEDICATIONS|1. Colitis with bloody diarrhea. 2. Hypokalemia. PROCEDURES: None. PREVIOUS HOME MEDICATIONS: 1. Pseudo-Chlor SA 1 capsule p.o. daily. 2. Hydrochlorothiazide 50 mg p.o. daily. 3. Synthroid 75 mcg p.o. daily. 4. Atenolol 50 mg p.o. daily. 5. Simvastatin 80 mg p.o. daily. HOSPITAL DISCHARGE MEDICATIONS: Same as above.
SA|slow acting/sustained action|SA|106|107|MEDICATIONS|MEDICATIONS: These he brings in with him: 1. Cozaar 100 mg a day. 2. Glipizide 10 mg a day. 3. Felodipine SA 5 mg a day. 4. Hydrochlorothiazide 25 mg a day. 5. Omeprazole 40 mg a day. 6. Atenolol 50 mg a day. 7. Simvastatin 40 mg a day.
SA|slow acting/sustained action|SA|118|119|MEDICATIONS|3. Lisinopril 10 mg p.o. daily. 4. Potassium chloride 20 mEq p.o. daily. 5. Lescol 40 mg p.o. q.h.s. 6. Nitroglycerin SA 2.5 mg p.o. t.i.d. 7. Aspirin 81 mg daily. SOCIAL HISTORY: The patient lives in _%#CITY#%_, is formerly from _%#CITY#%_, Minnesota.
SA|sinuatrial|SA|144|145|MEDICAL PROBLEM LIST|2. Hypertension, presumably in part related to above and as an etiology for his end-stage renal disease. 3. History of atrial fibrillation with SA node dysfunction. 4. Blindness long-standing. 5. History of osteoarthritis. HISTORY: Mr. _%#NAME#%_ is a gentleman who lives at the _%#CITY#%_ Health Care Center and has been there for approximately three years.
SA|slow acting/sustained action|SA|151|152|LABORATORY DATA|Other therapy for lung disease includes Combivent inhaler two puffs four times a day, Advair 100/50 inhaler one puff twice a day. He is on guaifenesin SA 600 mg tablet twice a day, prednisone schedule currently is 20 mg daily for seven days and then 10 mg daily for seven days and then discontinue.
SA|slow acting/sustained action|SA|220|221|PAST SURGICAL HISTORY|MEDICATIONS: Buspar 15 mg p.o. b.i.d., calcium carbonate 1500 mg p.o. daily, Klonopin 0.5 to 1 mg p.o. every a.m., Lexapro 20 mg p.o. q. h.s., prednisone 40 mg p.o. daily, Mestinon 60 mg p.o. three times daily, Mestinon SA 180 mg o q. h.s., Trazodone 100 mg p.o. q. h.s. and lisinopril 10 mg p.o. daily. He also takes Ativan 1 mg at h.s. as needed as well as cyclosporin 200 mg p.o. q. h.s.
SA|slow acting/sustained action|SA|255|256|DISCHARGE MEDICATIONS|1. Buspar 50 mg p.o. b.i.d., calcium carbonate 1500 mg p.o. q. day, Klonopin 0.5 to 1 mg p.o. q. a.m., Lexapro 20 mg p.o. q. h.s., prednisone 40 mg p.o. q. day until seen by Dr. _%#NAME#%_ on an outpatient basis. 2. Mestinon 60 mg p.o. t.i.d. 3. Mestinon SA 180 mg p.o. q. h.s. 4. Trazodone 100 mg p.o. q. h.s. 5. Lisinopril, usual dose he is taking at home. He is discharged to home and should follow-up on Monday for every other day plasmapheresis.
SA|UNSURED SENSE|SA|212|213|HOSPITAL COURSE|The patient had an increased PTT on admission in the 50 range so a Lupus inhibitor study was sent for him. That is to be followed by his hematology/oncology doctor who was notified about the result. His factor 2 SA was 14 on admission and factor 12 SA was 62. FOLLOW-UP: The patient is to follow up with his primary physician on _%#MM#%_ _%#DD#%_ and by the hematology/oncology doctor for his scheduled routine visit.
SA|slow acting/sustained action|SA|173|174|DISCHARGE MEDICATIONS|1. L2. ipitor 20 mg daily. 2. F3. errous sulfate 325 mg p.o. daily. 4. Dyazide 50/25 1 tablet daily. 5. Tylenol 650 mg p.o. q.4h. p.r.n. 6. Aspirin 81 mg daily. 6. I7. mdur SA 60 mg daily. 8. Prevacid 30 mg daily. 9. Metoprolol 50 mg b.i.d. 10. New medication: Vicodin 5 mg 1-2 tablets q.4h. p.r.n. The patient is advised not to drive under the influence of Vicodin.
SA|slow acting/sustained action|SA|187|188|DISCHARGE MEDICATIONS|11. Percocet 1-2 tablets every 4-6 h. p.r.n. pain. 12. Enteric-coated aspirin 325 mg daily. 13. Levofloxacin 250 mg daily for five more days. 14. Regular insulin sliding scale. 15. K-Dur SA 10 mEq daily. 16. Albuterol nebulization q. 8 h. p.r.n. shortness of breath. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is an 82-year-old female who was doing well until five days prior to admission when she started to have dry heaves and nausea.
SA|sinuatrial|SA|140|141|IMPRESSION|Deep tendon reflexes are hypoactive throughout. IMPRESSION: Near syncopal event likely secondary to bradycardia. He may have some intrinsic SA node disease related to aging, combined with the impact of Atenolol inducing his symptomatic bradycardia. Alternate diagnoses would include a transient ischemic attack, vasovagal episode, Benzodiazepine misadventure (took extra Diazepam last night), orthostatic hypotension, or occult infection.
SA|slow acting/sustained action|SA|160|161|MEDICATIONS AT THE TIME OF DISCHARGE|3. Calcium plus vitamin D 500/200, 1 p.o. t.i.d. 4. Ocuvite 2 p.o. daily. 5. Flonase 1 spray intranasally b.i.d. 6. Advair 500/50, 1 puff b.i.d. 7. Guaifenesin SA 600 mg b.i.d. 8. Lisinopril 2.5 mg p.o. q. day. 9. Lasix 40 mg p.o. q. day. 10. Metoprolol 25 mg p.o. b.i.d. 11. Fosamax 70 mg weekly.
SA|sinuatrial|SA|244|245|IMPRESSION|This also could be related to just his respiratory arrest that could have been from a cardiac cause, as he does have a history of underlying tachycardia. At this time, he has no evidence, by his EKG or rhythm strips, of any sort of AV nodal or SA nodal dysfunction, or evidence for any reentrant tachycardia. There is no other prolongation of the QT. However, given his respiratory arrest, the likelihood of this either relating to his acute lung injury versus a specific cardiac issue, is one that needs to be delineated.
SA|slow acting/sustained action|SA|153|154|DISCHARGE MEDICATIONS|4. Pantoprazole 40 mg daily. 5. Colace 100 mg twice daily. 6. Flovent inhaler 220 mcg one puff twice daily. 7. Metoprolol 12.5 mg twice daily. 8. Niacin SA 500 mg twice daily. 9. Glucosamine 500 mg 3 times daily. 10. Albuterol inhaler 2 puffs q.6 h. 11. Os-Cal 500 mg daily. 12. Lasix 80 mg q.a.m.
SA|slow acting/sustained action|SA|255|256|CURRENT MEDICATIONS|1. Simvastatin 40 mg p.o. q.h.s. 2. Carbidopa/levodopa 25/100 mg one tablet p.o. q.p.m. in the afternoon at about 5:00 p.m. 3. Carbidopa 25 mg two tablets p.o. t.i.d. about 30 minutes prior to carbidopa/levodopa 50/200 mg. 4. Carbidopa/levodopa 50/200 mg SA one tablet p.o. t.i.d. 5. Terazosin 5 mg p.o. q.h.s. 6. Diltiazem SA 360 mg p.o. daily (resumed about 1-1/2 months ago).
SA|slow acting/sustained action|SA|200|201|CURRENT MEDICATIONS|3. Carbidopa 25 mg two tablets p.o. t.i.d. about 30 minutes prior to carbidopa/levodopa 50/200 mg. 4. Carbidopa/levodopa 50/200 mg SA one tablet p.o. t.i.d. 5. Terazosin 5 mg p.o. q.h.s. 6. Diltiazem SA 360 mg p.o. daily (resumed about 1-1/2 months ago). 7. Clonidine 0.1 mg p.o. b.i.d. (started as of _%#MMDD2005#%_). 8. Clotrimazole 1% cream applied to both ears b.i.d. p.r.n. for itching.
SA|slow acting/sustained action|SA|182|183|CURRENT MEDICATIONS|7) Atenolol 25 mg p.o. q day. 8) Coumadin 10 mg p.o. q Monday and 7.5 mg p.o. Tuesday, Wednesday, Thursday, Friday, Saturday and Sunday. 9) Celebrex 200 mg p.o. q day. 10) Oxycodone SA 40 mg p.o. q8h. 11) Percocet one to two tabs p.o. q6h as needed. 12) Multivitamin one p.o. q day. ALLERGIES: NO KNOWN DRUG ALLERGIES, ALTHOGH HE DOES REPORT BEING ON ANTIPSYCHOTICS AT ONE POINT FOR REPORTED HALLUCINATIONS FROM HIS PTSD, BUT DOES NOT REMEMBER THE NAME OF THE MEDICATIONS.
SA|slow acting/sustained action|SA,|132|134|DISCHARGE MEDICATIONS|2. Toprol XL 50 mg a day 3. Lisinopril 10 mg a day 4. Atorvastatin 80 mg at night 5. Nitroglycerin p.r.n. 6. Isosorbide mononitrate SA, slow-acting, 15 mg a day 7. Carbamazepine she will continue at 400 mg p.o. b.i.d. 8. Gabapentin 300 mg in the morning and at noon, 600 mg at night 9.
SA|sinuatrial|SA|201|202|BRIEF HOSPITAL COURSE|One episode lasted longer than 12 seconds. Reviewing this EKG strip also showed significant sinus node dysfunction, with a significantly slowing sinus node rate. It was unclear whether this was due to SA node dysfunction or just a vasovagal response. An electrophysiological study was recommended and performed the electrophysiology service here at the Fairview-University Medical Center.
SA|sinuatrial|SA|240|241|BRIEF HOSPITAL COURSE|An electrophysiological study was recommended and performed the electrophysiology service here at the Fairview-University Medical Center. His electrophysiologic study clearly demonstrated sinus node dysfunction, with significantly abnormal SA node recovery time. Given his presentation, his abnormal SA node recovery time, and his well-documented prolonged sinus pause, a decision was made to implant a permanent pacemaker.
SA|sinuatrial|SA|162|163|BRIEF HOSPITAL COURSE|His electrophysiologic study clearly demonstrated sinus node dysfunction, with significantly abnormal SA node recovery time. Given his presentation, his abnormal SA node recovery time, and his well-documented prolonged sinus pause, a decision was made to implant a permanent pacemaker. The patient underwent successful implantation of a dual-chamber pacemaker on _%#MM#%_ _%#DD#%_, 2005, here at Fairview-University Medical Center.
SA|slow acting/sustained action|SA|159|160|DISCHARGE MEDICATIONS|6. Prazosin 6 mg po bid. 7. Klor-Con ER 20 mEq po qd. 8. Premarin .625 mg po q M-F. 9. Nortriptyline 30 mg po qhs. 10. Albuterol 2 puffs q4h prn. 11. Theo-Dur SA 200 mg po bid. 12. Advair 100/50 one puff bid. 13. Vistaril 25-50 mg po prn for pain and spasm. 14. Percocet 1-2 po q4-6h prn for pain. 15. Hydrochlorothiazide 25 mg po qd.
SA|slow acting/sustained action|SA|228|229|DISPOSITION|The patient was comfortable. Her lungs were clear and vital signs were stable. DISPOSITION: The patient will be discharged home on Norvasc 5 mg daily, Esterase 1 mg daily, Allegra 60 mg b.i.d., Advair 250/50 b.i.d., guaifenesin SA 600 mg b.i.d., Synthroid 150 mcg daily, Provera 2.5 mg q day, prednisone 40 mg q day for three days then tapering by 10 mg every four days, Cipro 500 mg b.i.d. for ten days and Singulair 10 mg daily.
SA|slow acting/sustained action|SA|116|117|DISCHARGE MEDICATIONS|3. Lipitor 40 mg po qd. 4. Plavix 75 mg po qd. 5. Advair 250/50 one puff bid. 6. Lasix 40 mg po bid. 7. Imdur 60 mg SA po qd. 8. Prevacid 30 mg po qd. 9. Toprol XL 100 mg po qd. 10. Multiple vitamin with iron 1 po qd.
SA|slow acting/sustained action|SA|157|158|DISCHARGE MEDICATIONS|2. Rule-out myocardial infarction. DISCHARGE MEDICATIONS: 1) Levoxyl 0.1 mg p.o. daily. 2) Aspirin 81 mg p.o. daily. 3) Allegra 180 mg p.o. daily. 4) Niacin SA 1000 mg p.o. q.P.M. 5) Lovastatin 20 mg p.o. b.i.d. 6) Multivitamin one tablet p.o. daily. 7) Fibercon two tablets p.o. b.i.d. PROCEDURES: Adenosine thallium stress test - negative for interval change.
SA|sinuatrial|SA|215|216|PROBLEMS ADDRESSED DURING TRANSITIONAL CARE STAY|PREVIOUS HOSPITALIZATION DATES: University of Minnesota Medical Center, Fairview, _%#MMDD2005#%_ to _%#MMDD2005#%_. PROBLEMS ADDRESSED DURING TRANSITIONAL CARE STAY: 1. Peripheral vascular disease status post right SA to popliteal bypass, _%#MMDD2005#%_, for underlying right lower extremity ischemia with significant claudication. 2. Hypertension. 3. Hyperlipidemia. 4. Chronic tobacco use and abuse.
SA|slow acting/sustained action|SA|150|151|DICHARGE MEDICATIONS|2. Levoxyl 150 mcg daily (TSH was 0.01, so her dose was decreased to this). 3. Citalopram 40 mg daily. 4. Ferrous sulfate 325 mg daily. 5. Isosorbide SA 90 mg 3 times daily. 6. Cozaar 5 mg daily. 7. Prilosec OTC 20 mg daily. 8. Torsemide 40 mg twice daily. 9. Metoprolol 50 mg twice daily. 10. Metolazone 50 mg every other day.
SA|slow acting/sustained action|SA|161|162|MEDICATIONS|2. Aspirin 81 mg p.o. daily. 3. Atenolol 15 mg p.o. daily 4. Plavix 75 mg p.o. daily 5. Felodipine 5 mg p.o. daily 6. Lisinopril 5 mg p.o. q. day. 7. Omeprazole SA 20 mg p.o. b.i.d. 8. Ezetimibe tablets 10 mg p.o. daily 9. Lovastatin 40 mg p.o. q.h.s. 10. Senokot p.r.n. SOCIAL HISTORY: The patient is married. He does not drink alcohol.
SA|sinuatrial|SA|220|221|PROCEDURES PERFORMED DURING STAY|The patient large left circumflex has a 70% proximal stenosis, the remainder of the vessel is without significant disease. The right coronary artery is without angiographic disease except for an ostial lesion in a small SA nodal branch. 2. Percutaneous intervention: Anticoagulation with IV heparin and Abciximab. An 8 French GL-3.5 guide used with good support. The LAD and first diagonal were wired without difficulty. Predilatation of the LAD with a 2.5 x 12 mm Voyager balloon, subsequent D1 and LAD stenting with a 2.5 x 13 mm and 3.0 x 33 mm Cipher stent respectively.
SA|sinuatrial|SA|213|214|HISTORY|He had problems with atrial fibrillation and atrial flutter associated with junctional rhythm, during the first post MI day, which I speculated was due to transient ischemia involving the AV node and possibly the SA nodal artery. As expected, these rhythm abnormalities resolved on their own and on the day of discharge, he is in one-to-one sinus rhythm.
SA|slow acting/sustained action|SA|813|814|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|Otherwise, they include Hydroxyzine 25 mg p.o. q.h.s., Warfarin 2 mg p.o. q.d. This dose was decreased slightly during his hospitalization, and I will continue on this lower dose pending recheck INR as his INR was 3.06 during this hospitalization. Tylenol 650 mg p.o. q.6.h. p.r.n., enteric-coated aspirin 325 mg p.o. q.d., Ativan 2 mg p.o. q.h.s., Olanzapine 25 mg p.o. q.h.s., Atenolol 100 mg p.o. q.d., Nifedipine XL 30 mg p.o. q.d., Isosorbide Dinitrate 20 mg p.o. t.i.d. Nitroglycerin 0.4 mg sublingual as needed, Gemfibrozil 600 mg p.o. b.i.d., Simvastatin 40 mg p.o. at night, Lisinopril 5 mg p.o. q.d., psyllium one tablespoon with eight ounces of water p.o. q.d., Rabeprazol 20 mg p.o. b.i.d., Metformin 500 mg p.o. b.i.d., Beclomethasone nasal inhaler 42 mcg one puff in each nostril daily, Guaifenesin SA 600 mg p.o. b.i.d., Terazosin 2 mg p.o. q.h.s. This is being increased on a schedule by the patient's primary care physician, and I recommended that he continue this taper up.
SA|slow acting/sustained action|SA|159|160|MEDICATIONS|4. Procardia XL 30 mg a day. 5. Actos 15 mg a day. 6. Prednisone discontinued. 7. Lasix given up to 80 mg recently. Normally Lasix 40 mg q day. 8. Quaifenesin SA 600 mg qd. 9. Multiple vitamin. 10. Aspirin 325 mg q day. 11. Citrucel one packet q day. 12. Plavix 75 mg q day.
SA|slow acting/sustained action|SA|151|152|DISCHARGE MEDICATIONS|2. Reglan 10 mg p.o. t.i.d. with meals. 3. Megace 2 teaspoons q.a.m. 4. Multivitamin 1 tablet p.o. q.a.m. 5. Prednisone 10 mg p.o. q.a.m. 6. Verapamil SA 240 mg p.o. b.i.d. 7. Peri-Colace tablets 2 tablets p.o. b.i.d. 8. Serevent 21 mcg MDI 2 puffs b.i.d. 9. Prevacid 30 mg p.o. q.d.
SA|slow acting/sustained action|SA.|121|123|CURRENT MEDICATIONS|9. Zoloft 100 mg p.o. q.d. 10. Xalatan ophthalmic 0.005% at h.s. 11. Artificial Tears at h.s. 12. Liquibid 600 mg b.i.d. SA. 13. Demadex 50 mg p.o. b.i.d. 14. Combivent inhaler two inhalations q.i.d. 15. Ambien 5-10 mg p.o. at h.s. 16. Prinivil 5 mg p.o. b.i.d.
SA|UNSURED SENSE|SA|188|189|HOSPITAL COURSE|2. ID. He received cefotetan in the OR and was continued on his prophylactic gatifloxacin and Diflucan. He remained afebrile throughout this admission. 3. Neurologic. Given his history of SA toxicity-induced seizures, he was continued on Keppra per his home dosing. Postoperatively, he had pain requiring fentanyl and morphine, which was weaned to off on the day prior to discharge.
SA|slow acting/sustained action|SA|117|118|HOME MEDICATIONS|4. Lopid 600 mg p.o. 2 times per day 5. Synthroid 100 mcg p.o. q. day 6. Cozaar 25 mg p.o. 2 times per day 7. Niacin SA 250 mg p.o. 2 times per day 8. Zoloft 25 mg p.o. q. day 9. Coumadin 1 mg and 2 mg alternating days
SA|slow acting/sustained action|SA|140|141|MEDICATIONS|Recent PET scan is negative. MEDICATIONS: 1. Celexa 20 mg p.o. in the evening. 2. Morphine sulfate LA 60 mg p.o. b.i.d. 3. Morphine sulfate SA 30 mg p.o. t.i.d. p.r.n. pain. 4. Spironolactone 250 mg p.o. daily. 5. Lasix 80 mg p.o. daily. ALLERGIES: No known drug allergies. SOCIAL HISTORY: History of alcohol and drug use in the past.
SA|sinuatrial|SA|358|359|IMPRESSION|The fact that the ST segments are elevated more in lead V1 and V2 suggests to me that she probably is having a right ventricular infarct and this would also go along with her neck veins, however, see my discussion above regarding the exam. What my bigger concern is that she is in cardiogenic shock with an atrial fibrillation rhythm and she may have had an SA node infarct (atrial infarct) although again I do not know what her atrial arrhythmia is and exactly which taking the digoxin for.
SA|slow acting/sustained action|SA|138|139|DISPOSITION|5. The patient will have albuterol nebs dispensed for him as well, 1 q.i.d. p.r.n. 6. Advair 500/50 one inhalation b.i.d. 7. Guaiphenesin SA 1200 mg p.o. b.i.d. 8. Lisinopril 20 mg p.o. daily. 9. Zocor 40 mg p.o. a.m. 10. Spiriva 1 capsule inhaled daily. 11. The patient was also given a flutter valve to be used q.3-4h while awake to help secretions.
SA|slow acting/sustained action|SA|211|212|HOSPITAL COURSE|At the time of discharge, she is going home. She has 24-hour nursing and will have home PT and home OT. Her discharge medications are _________________ 20 mg p.o. q.d, metoprolol 12.5 mg p.o b.i.d., guaifenesin SA one tablet p.o. b.i.d., Prevacid 30 mg p.o. q day, lisinopril 2.5 mg p.o. q day - this is down from the 5 mg per day at the time of admission, Coumadin 5 mg p.o. q day - this is up from 4 mg per day at the time of admission, Celebrex 200 mg p.o. q day, Tylenol as needed, Levaquin 500 mg p.o. q day for five days, Aldactone 12.5 mg p.o. q day, and Lescol 40 mg p.o. q day.
SA|slow acting/sustained action|SA|150|151|MEDICATIONS ON DISCHARGE|6. Plavix 75 mg daily x 1 month. 7. Erythropoietin 10,000 units subcu q. Monday. 8. Folic acid 2 mg daily. 9. Lasix 80 mg p.o. b.i.d. 10. Guaifenesin SA 600 mg p.o. q. day. 11. Hydralazine 25 mg p.o. q.a.c. plus q.h.s. 12. Lispro insulin per home routine. 13. NPH insulin 10 units subcu q.a.m. and 5 units subcu q.p.m.
SA|slow acting/sustained action|SA|132|133|DISCHARGE MEDICATIONS|7. Hydrochlorothiazide 25 mg p.o. q. day 8. Lisinopril 20 mg p.o. b.i.d. 9. Zyprexa 10 mg p.o. q.h.s., 2.5 mg p.o. q.a.m. 10. K-Dur SA 20 mEq p.o. q. day 11. Prednisone 30 mg p.o. q. day times 2 days, 20 mg p.o. q. day times 3 days, 10 mg p.o. q. day times 3 days, then off
SA|slow acting/sustained action|SA.|147|149|MEDICATIONS AT THE TIME OF DISCHARGE|MEDICATIONS AT THE TIME OF DISCHARGE: 1. Ancef. 2. Protonix. 3. Coumadin. 4. Atenolol. 5. Calcium carbonate/vitamin D. 6. Flexeril. 7. Guaifenesin SA. 8. K-Dur. 9. Quinine. 10. Percocet. Please see the nursing home transfer summary for doses. Patient will be followed by Dr. _%#NAME#%_ for infectious disease problem.
SA|slow acting/sustained action|SA|183|184|ADMISSION MEDICATIONS|10. History of left upper lobe granuloma. 11. History of multiple recurrences of shingles in 1992 and 1993. 12. Dry eyes. ADMISSION MEDICATIONS: 1. Aspirin 81 mg daily. 2. Nifedipine SA 30 mg daily. 3. Hydroxyzine 25 mg t.i.d. p.r.n. 4. Multivitamin. 5. Vitamin C. 6. Sodium chloride tablets 1 gm b.i.d.
SA|slow acting/sustained action|SA|143|144|DISCHARGE MEDICATIONS|5. Flovent two puffs b.i.d. 6. Furosemide 20 mg p.o. b.i.d. 7. Glipizide 5 mg p.o. q.d. 8. Atrovent two puffs q.i.d. 9. Isosorbide mononitrate SA 60 mg p.o. q.d. 10. L-thyroxine 75 mcg p.o. q.d. 11. Metoprolol 12.5 mg p.o. b.i.d. 12. Miconazole 2% powder to groin b.i.d.
SA|slow acting/sustained action|SA|123|124|DISCHARGE MEDICATIONS|10. Synthroid 150 mcg p.o. daily. 11. Cozaar 50 mg p.o. daily. 12. Dalmane 15 mg p.o. q.h.s. p.r.n. sleep. 13. Guaifenesin SA 700 mg p.o. daily. 14. Dulcolax suppository 2 mg per rectum daily p.r.n. constipation. ALLERGIES: OxyContin, not aware of the reaction. The patient has been tolerating Percocet well without complications.
SA|slow acting/sustained action|SA|187|188|CURRENT MEDICATIONS|8. History of miscarriage. ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: 1. Aricept 10 mg p.o. daily. 2. Arimidex 1 mg p.o. daily. 3. Aspirin 5 grains p.o. daily. 4. Diltiazem SA 240 mg p.o. daily. 5. Allegra 180 mg p.o. daily. 6. Potassium chloride 20 mEq p.o. daily. 7. Prozac 20 mg p.o. daily. 8. Hydrochlorothiazide 25 mg p.o. daily.
SA|slow acting/sustained action|SA|180|181|DISCHARGE MEDICATIONS|1. Albuterol/ipratropium nebs 3 mL inhaled t.i.d. 2. Baclofen 25 mg p.o. 4 times a day. 3. Clonazepam 1 mg p.o. twice a day. 4. Enoxaparin 40 mg subcutaneous daily. 5. Guaifenesin SA 120 mg p.o. b.i.d. 6. Lantus 10 units subcutaneous q. h.s. 7. Magic Mouthwash 5 mL p.o. t.i.d.
SA|slow acting/sustained action|SA|202|203|DISCHARGE MEDICATIONS|2. Metoprolol 12.5 mg p.o. b.i.d. 3. Miconazole topical 2% b.i.d. to scrotum and penis. 4. Omeprazole 20 mg p.o. daily for acid reflux. 5. Prednisone 50 mg p.o. daily for endstage COPD. 6. Procainamide SA 750 mg p.o. twice daily for dysrhythmia. 7. Senna 1 tablet p.o. b.i.d. for constipation as needed only if no bowel movements over 48 hours.
SA|sinuatrial|SA|147|148|HISTORY|In return atrial fibrillation sometimes he would return with 1-2 sinus beats only to go back into atrial fibrillation such that this suggests both SA and AV node disease. He had a dual chamber pacemaker placed. He was then started on amiodarone for his rapid atrial fibrillation.
SA|slow acting/sustained action|SA|137|138|DISCHARGE  MEDICATIONS|DISCHARGE MEDICATIONS: 1. Coumadin 5 mg daily. 2. Aspirin 325 mg daily. 3. Furosemide 120 mg p.o. q.a.m., 80 mg p.o. q.p.m. 4. Diltiazem SA 120 mg daily. 5. Allopurinol 100 mg b.i.d. 6. Valsartan 160 mg daily. 7. Isosorbide 20 mg daily. 8. Serevent inhaler daily. 9. Aciphex 20 mg b.i.d. 10. Trileptal 300 mg b.i.d.
SA|slow acting/sustained action|SA|171|172|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Metformin 500 mg p.o. b.i.d. 2. Metoprolol XL 25 mg p.o. daily. 3. Pantoprazole 40 mg p.o. daily. 4. Sucralfate 1 gram p.o. b.i.d. 5. Tamsulosin SA or Flomax 400 mcg p.o. daily. 6. Celexa was stopped after admission. ADMISSION MEDICATIONS: Same as discharge medications except Celexa was stopped: 1. Metformin 500 mg p.o. b.i.d.
SA|slow acting/sustained action|SA|171|172|ADMISSION MEDICATIONS|DISCHARGE MEDICATIONS: 1. Metformin 500 mg p.o. b.i.d. 2. Metoprolol XL 25 mg p.o. daily. 3. Pantoprazole 40 mg p.o. daily. 4. Sucralfate 1 gram p.o. b.i.d. 5. Tamsulosin SA or Flomax 400 mcg p.o. daily. 6. Celexa was stopped after admission. ADMISSION MEDICATIONS: Same as discharge medications except Celexa was stopped: 1. Metformin 500 mg p.o. b.i.d.
SA|slow acting/sustained action|SA|125|126|ADDENDUM DISCHARGE MEDICATIONS|2. Lipitor 40 mg p.o. q. day 3. Coreg 25 mg p.o. b.i.d. 4. Lasix 20 to 40 mg p.o. q. day 5. Multivitamin 1 q. day 6. Niaspan SA 1500 mg p.o. q.h.s. 7. Sublingual nitroglycerin p.r.n. 8. Valsartan 80 mg p.o. b.i.d. 9. Coumadin 2.5 mg p.o. q. day 10. Tylenol p.r.n. The patient has pending pulmonary function tests prior to discharge.
SA|slow acting/sustained action|SA|116|117|DISCHARGE  MEDICATIONS|3. Lexapro 10 mg daily. 4. Zetia 10 mg daily. 5. Tricor 145 mg daily. 6. Hydrochlorothiazide 12.5 mg daily 7. Imdur SA 30 mg twice daily. 8. Lamictal 25 mg daily. 9. Reglan 5 mg daily. 10. Zaroxolyn 2.5 mg daily. 11. Metoprolol 50 mg daily. 12. Nitroglycerin 0.4 mg sublingually p.r.n. chest pain.
SA|slow acting/sustained action|SA|178|179|MEDICATIONS|14. Ipratropium two puffs inhaled b.i.d. 15. Isosorbide dinitrate 10 mg t.i.d. 16. Levalbuterol 15 mcg inhaled q.4 hours p.r.n. 17. Metoprolol 25 mg b.i.d. 18. Nifedipine 120 mg SA q. day. 19. Ocuvite two tablets b.i.d. 20. Omeprazole 20 mg b.i.d. 21. Doxycycline 100 mg twice a day for the first seven days of every other month, alternating with amoxicillin.
SA|slow acting/sustained action|SA|119|120|MEDICATIONS|15. Severe familial tremor. MEDICATIONS: 1. Allopurinol 100 mg p.o. b.i.d. 2. Atenolol 25 mg p.o. q. day. 3. Diltiazem SA 120 mg p.o. q. day. 4. Lasix 80 mg p.o. b.i.d. 5. Isordil 20 mg p.o. b.i.d. 6. Reglan 10 mg p.o. b.i.d. 7. Iron 65 mg p.o. q. day
SA|slow acting/sustained action|SA|149|150|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Atenolol 25 mg PO Q day 2. Atorvastatin 10 mg PO Q day 3. Gabapentin 300 mg PO QHS 4. HCTZ 12.5 mg PO QD 5. Pentoxifylline SA 400 mg PO t.i.d. 6. Senna/Docusate two pills PO QHS 7. Percocet 1-2 pills PO Q 4 hours for low back pain. 8. Flexeril 10 mg PO Q 6 hours prn. for low back pain.
SA|slow acting/sustained action|SA|138|139|CURRENT MEDICATIONS|2. Depakote EC 250 mg in the a.m. 3. Lasix 80 mg one p.o. daily. 4. Aspirin 81 mg p.o. daily. 5. Ibuprofen 600 mg p.o. b.i.d. 6. Klor-Con SA 10 mEq p.o. b.i.d. 7. Depakote EC 500 mg one o q.h.s. 8. Vicodin 5/500 one tab q.4h. p.r.n. pain. 9. Ranitidine 100 mg b.i.d. p.r.n. for influenza prophylaxis.
SA|slow acting/sustained action|SA|140|141|DISCHARGE MEDICATIONS|3. Ultram 50 mg every 6 hours p.r.n. pain, limited to just 30 pills. (This is a new medication). 4. Clonazepam 1 mg p.o. b.i.d. 5. Depakote SA 1000 mg a day. 6. Neurontin 300 mg p.o. t.i.d. 7. Wellbutrin 150 mg p.o. b.i.d. 8. Prozac 40 mg daily. 9. Metoprolol SR 25 mg p.o. a day. 10. Nitroglycerin 0.4 mg sublingually p.r.n. chest pain.
SA|slow acting/sustained action|SA|84|85|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Lopid 600 mg p.o. b.i.d. This is a new medicine. 2. Imdur SA 30 mg p.o. q. day. 3. Lisinopril 5 mg p.o. q. day, this is a new medicine as well. 4. Lopressor 25 mg p.o. b.i.d.
SA|slow acting/sustained action|SA|131|132|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Duonebs 4 times a day. 2. Albuterol nebs every 4 hours as needed for shortness of breath. 3. Guaifenesin SA 600 mg twice daily. 4. Xalatan eyedrops 0.005% one drop in left eye each night. 5. Fosamax 70 mg weekly. 6. Ambien 2.5 mg at night as needed for insomnia.
SA|UNSURED SENSE|SA,|135|137|DISCHARGE EXAMINATION|Muscles intact bilaterally. Tongue of normal bulk and movement. Motor exam with strength in the bilateral upper extremities, including SA, EE, EF, WE, WF, FE, DI all 5/5. Strength in the right lower extremity hip flexion 2, HE 3 /4, KF 4, KE 5, DF 5, PF 5.
SA|slow acting/sustained action|SA|276|277|DISCHARGE MEDICATIONS|10. NovoLog sliding scale insulin for blood sugar 120-149 one unit, for blood sugar 150-199 two units, for blood sugar 200-249 three units, for blood sugar 250-299 five units, for blood sugar greater than 300 eight units. 11. Zofran 4 mg through the G-tube q.4 h. 12. Trental SA 400 mg p.o. through the G-tube b.i.d. 13. Crestor 20 mg per the G-tube each day at bed-time. 14. Flomax 400 mcg through the G-tube daily. 15. Ambien 5 mg per the G-tube each day at bed-time.
SA|slow acting/sustained action|SA|189|190|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. daily. 2. Albuterol nebs q.i.d. 3. Colace 100 mg p.o. b.i.d. 4. Zetia 10 mg p.o. daily. 5. Zocor 40 mg p.o. each day at bedtime. 6. Guaifenesin SA 600 mg p.o. b.i.d. 7. HCTZ 12.5 mg p.o. daily. 8. Levaquin 500 mg p.o. daily x3 more days to complete a 14-day course of antibiotics for her pneumonia.
SA|slow acting/sustained action|SA|146|147|DISCHARGE MEDICATIONS|She had two sponsors. She planned to go back to her recovery program. DISCHARGE MEDICATIONS: 1. Lexapro 20 mg daily. 2. Maxzide 1 daily. 3. Sular SA 20 mg daily. 4. Prempro 0.3/1.5 one daily. DISCHARGE DIAGNOSES: 1. Alcohol dependence. 2. Hypertension. 3. Depression.
SA|slow acting/sustained action|SA|152|153|DISCHARGE MEDICATIONS|8. Lasix 60 mg p.o. daily for CHF/diuresis. 9. Neurontin 200 mg p.o. t.i.d. 10. Glipizide EX 10 mg p.o. q.a.m. for diabetes. 11. Isosorbide mononitrate SA for Imdur 30 mg p.o. daily hold if systolic blood pressure less than 95. 12. Lactulose 30 mL p.o. daily for constipation. 13. Lisinopril 10 mg p.o. daily for hypertension.
SA|slow acting/sustained action|SA|124|125|DISCHARGE MEDICATIONS|3. Mellaril 10 mg p.o. b.i.d. 4. Doxepin 10 mg p.o. b.i.d. 5. Zocor 10 mg p.o. h.s. 6. Lopid 600 mg b.i.d. 7. Nitroglycerin SA 2.5 mg b.i.d. 8. Lasix 20 mg 3 q.a.m. daily 9. Kay Ciel 20 mEq 1 p.o. daily 10. Prednisone 10 mg 2 q.a.m. times 2 days, 1 q.a.m. times 2 days.
SA|slow acting/sustained action|SA|130|131|DISCHARGE MEDICATIONS|3. Vytorin 10/80, one tab p.o. q. day. 4. Ferrous gluconate 300 mg t.i.d. 5. Furosemide 80 mg q.a.m., 60 mg q.h.s. 6. Guaifenesin SA 1200 mg q.12h. 7. Isordil 60 mg t.i.d. 8. Lisinopril 5 mg daily. 9. Diltiazem 120 mg daily. 10. Insulin to be restarted per previous orders using sliding scale.
SA|slow acting/sustained action|SA,|151|153|DISCHARGE MEDICATIONS|5. Estrace 2 mg a day. 6. Flovent two puffs b.i.d. 7. Prevacid 30 mg daily. 8. Meclizine 25 mg q.i.d. 9. Serevent two puffs b.i.d. 10. Theo-Dur 300 mg SA, one q.i.d. Followup in the clinic with Dr. _%#NAME#%_ in two weeks. Small bowel follow-through and upper GI are pending.
SA|slow acting/sustained action|SA|295|296|DISCHARGE MEDICATIONS|As far as smoking goes since she has quit, I told her to try to do without cigarettes but if she finds this very stressful to allow herself to go back to smoking until after her bypass in a few days. She has been started on Wellbutrin. DISCHARGE MEDICATIONS: 1. Aspirin one q day. 2. Wellbutrin SA one b.i.d. 3. Insulin, lente 10 subq b.i.d. and Novolin 3 units b.i.d. 4. Ramipril 5 mg q day. 5. Zocor 20 q day.
SA|slow acting/sustained action|SA|350|351|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Her medications at discharge were Pulmicort nebs b.i.d. after her albuterol and Atrovent nebs which she is taking q.i.d. She is tapering her prednisone from 20 mg to 0 over the next four days. She is taking Zantac 150 mg b.i.d., Xanax p.r.n., Ambien at h.s. p.r.n., diltiazem 30 mg q.i.d., flecainide 50 mg b.i.d., guaifenesin SA 600 mg b.i.d., MOM 10 cc daily, Dulcolax p.r.n., nortriptyline 10 mg at h.s., Zostrix Cream to her area of involvement of shingles.
SA|sinuatrial|(SA)|113|116|DISCHARGE DIAGNOSES|During this admission she had sinus pause that qualified for pacer placement. DISCHARGE DIAGNOSES: 1. Sinoatrial (SA) node dysfunction. 2. Angina. 3. Coronary artery disease. 4. Chronic ischemic heart disease. PROCEDURE: Pacer placement. DISCHARGE MEDICATIONS: 1. Lopressor 50 mg 1/2 b.i.d. 2. Aspirin 325 mg q.d.
SA|slow acting/sustained action|SA|367|368|HOSPITAL COURSE|Her discharge medications were fairly identical to what they were on admission, namely Synthroid 0.125 mg each day, Toprol XL 50 mg q. day, Nexium 40 mg each day or twice a day, Zoloft 150 mg q. day, Lipitor 40 mg q. day, Diovan 160 mg q. day, Xanax 0.5 mg q.h.s. as needed, Zetia 10 mg p.o. q. day, Lasix 20 mg p.o. q. day, Neurontin 100 mg p.o. q.h.s., Imdur 30 mg SA each day, KCl 20 mEq each day, Lac- Hydrin, Nizoral shampoo, Darvocet, Soma, and Miralax as before. Her condition at the time of discharge is good. She will have a home health aide, physical therapy, and home health nurse visits.
SA|sinuatrial|SA|191|192|ADDENDUM|She was started on heparin at that time. Electrophysiology came to see her in the morning following her afib- aflutter episode. It was determined that she would go to the Cath Lab to undergo SA node ablation and with a permanent pacemaker implantation for dysfunctional SA node. This was done. The patient tolerated the procedure well, and her heart rate has been a regular sinus rhythm, rate controlled at 60.
SA|sinuatrial|SA|142|143|ADDENDUM|It was determined that she would go to the Cath Lab to undergo SA node ablation and with a permanent pacemaker implantation for dysfunctional SA node. This was done. The patient tolerated the procedure well, and her heart rate has been a regular sinus rhythm, rate controlled at 60.
SA|slow acting/sustained action|SA|161|162|ADMISSION MEDICATIONS|13. Lexapro 20 mg a day. 14. Azmacort 2 puffs b.i.d. 15. Wellbutrin SR 150 mg twice daily. 16. Combivent 2 puffs t.i.d. 17. Neurontin 400 mg b.i.d. 18. Lithobid SA 600 mg at h.s. PAST MEDICAL HISTORY: 1. GERD symptoms. 2. Prior history of aspiration pneumonia. Please refer to previous hospital summaries and consultation notes concerning other elements of her complex history.
SA|slow acting/sustained action|SA|233|234|DISCHARGE MEDICATIONS|The patient also has a low testosterone level and will also discuss initiation of testosterone replacement with his primary endocrine specialist as outpatient. DISCHARGE MEDICATIONS: 1. Acetylcysteine 600 mg p.o. b.i.d. 2. Albuterol SA 4 mg p.o. b.i.d. 3. Ascorbic acid 500 mg p.o. t.i.d. 4. Beta-carotene 50,000 units p.o. everyday. 5. Biotin 5,000 mcg p.o. q. day. 6. Carnitine 500 mg p.o. q. day.
SA|sinuatrial|"SA|146|148|PAST  MEDICAL HISTORY|12. History of chronic rhinorrhea and nasal congestion. 13. history of C. difficile infection in _%#MM#%_ 2007. 14. The patient was noted to have "SA node dysfunction" per nursing home records. 15. Hypertension 16. also noted to have a history of diabetes type 2, per nursing home records.
SA|slow acting/sustained action|SA|239|240|DISCHARGE MEDICATIONS|I have also discussed with him that his lisinopril dose has been lowered otherwise all his medications are the same with a new prescription for his Plavix only. DISCHARGE MEDICATIONS: 1. Norvasc 5 mg daily. 2. Plavix 75 mg daily. 3. Imdur SA 45 mg b.i.d. 4. Lisinopril 40 mg, half tablet daily. 5. Metoprolol XL 50 mg daily. 6. Tylenol PM p.r.n. insomnia. 7. Nitrostat 0.4 mg sublingual p.r.n. chest pain. 8. Selenium 200 mcg daily.
SA|slow acting/sustained action|SA|140|141|DISCHARGE DIAGNOSES|Patient was discharged to home after being evaluated by Dr. _%#NAME#%_. His atenolol at discharge was 50 mg one-half tablet daily. Aggrenox SA 25/200 one tablet twice daily. Low cholesterol, low salt diet. Followup with _%#NAME#%_ his primary physician at Fairview _%#TOWN#%_ Clinic.
SA|slow acting/sustained action|SA,|186|188|DISCHARGE MEDICATIONS|3. Persantine, 25 mg twice daily. 4. Folic acid, 800 mcg daily. 5. Xalatan, 0.005% in her left eye q.h.s. 6. Methotrexate, 17.5 mg q. Wednesday. 7. Metoprolol, 25 mg b.i.d. 8. Nitro-Bid SA, 4 mg capsules b.i.d. 9. Nitrostat, 0.4 mg sublingual p.r.n. chest pain. 10. Deltasone, 5 mg daily. 11. Aspirin, 81 mg daily. 12. Vicodin p.r.n. pain.
SA|slow acting/sustained action|SA|151|152|DISCHARGE  MEDICATIONS|6. Citrucel one to two tabs p.o. each day at bed-time. 7. Multivitamin 1 tab p.o. q. day. 8. Nitroglycerin 400 mcg p.r.n. chest pain. 9. Nitroglycerin SA 6.5 mg p.o. b.i.d. 10. Pancrecarb EC cap MS-8, one cap p.o. b.i.d. with meals. 11. Zantac 75 mg p.o. b.i.d. 12. Simethicone 80 mg 4 times a day p.r.n.
SA|slow acting/sustained action|SA|240|241|DISCHARGE MEDICATIONS|The patient has the name for Minnesota Heart in case he has further episodes despite being on the verapamil and if he is interested in ablation therapy. DISCHARGE MEDICATIONS: 1. Tricor 50 mg p.o. b.i.d. 2. Lasix 40 mg p.o. daily. 3. Imdur SA 30 mg a day. 4. His usual Micardis 40 mg a day. 5. Zantac 150 mg p.o. b.i.d. 6. Zocor 10 mg p.o. each day at bedtime.
SA|slow acting/sustained action|SA|124|125|DISCHARGE MEDICATIONS|We will try and transfer him for acute rehab before continuing speech, PT and OT. DISCHARGE MEDICATIONS: 1. Aggrenox 25/200 SA one tab p.o. b.i.d. 2. Prozac 20 mg p.o. q.a.m. 3. Toprol-XL 50 mg p.o. daily. 4. Multivitamin 1 tab p.o. daily. 5. Protonix 40 mg p.o. daily.
SA|slow acting/sustained action|SA|202|203|DISCHARGE MEDICATIONS|14. Zocor 60 mg p.o. q.p.m. 15. Percocet 5/325 1-2 tablets p.o. q.4h. as needed. 16. Acetaminophen 325 mg 1-2 tablets p.o. q.4h. as needed. 17. Caltrate 600 2 tablets p.o. daily. 17. Potassium chloride SA 20 mEq p.o. daily. 18. DuoNeb 3 ml 4x a day as needed. 19. Azmacort 4 puffs twice daily. 20. Lantus 5 units subq each day at bedtime.
SA|slow acting/sustained action|SA|150|151|MEDICATIONS|7. History of ankle fracture requiring pins in the past. MEDICATIONS: 1. Coumadin 5 mg a day. 2. Lasix 40 mg a day. 3. Colace p.r.n. 4. Tiazac 120 mg SA t.i.d. (given to her by Dr. _%#NAME#%_). 5. Ferrous sulfate as needed. ALLERGIES: Penicillin. FAMILY HISTORY: Father died at 62 of an MI.
SA|slow acting/sustained action|SA|229|230|DISCHARGE MEDICATIONS|FAMILY HISTORY, SOCIAL HISTORY: Reviewed and without change. ALLERGIES: No known drug allergies. DISCHARGE MEDICATIONS: Celexa 20 mg p.o. q day, Advair Diskus one puff b.i.d., Tequin 400 mg p.o. q day for seven days, guaifenesin SA 1200 mg b.i.d., Prevacid 30 mg p.o. q day, Flagyl 500 mg p.o. t.i.d. times seven days, KCl 20 mEq p.o. q day, Colace 100 mg p.o. b.i.d. p.r.n., Flomax 0.4 mg p.o. q day, prednisone taper as per discharge medication sheet, albuterol and Atrovent metered dose inhalers, two puffs q.i.d., albuterol and Atrovent nebs q 2 hours p.r.n., oxygen 2 liters per nasal cannula.
SA|slow acting/sustained action|SA|219|220|DISCHARGE INSTRUCTIONS|Colace 100 mg p.o. b.i.d. Advair 100/50 one puff b.i.d. Tequin 400 mg p.o. qd times seven days. Glyburide 2.5 mg p.o. b.i.d. that was increased given her current blood sugars. That had been a qd medication. Guaifenesin SA 600 mg p.o. b.i.d. times ten days. Prednisone 20 mg p.o. qd times three days, 10 mg p.o. qd times three days and then off.
SA|slow acting/sustained action|SA|173|174|DISCHARGE MEDICATIONS|3. Calcium carbonate 500 mg two tabs p.o. b.i.d. 4. Colchicine 0.6 mg p.o. Monday, Wednesday, Friday. 5. Colace 100 mg p.o. b.i.d. 6. Amaryl 1 mg p.o. q.d. 7. Nitroglycerin SA 2.5 mg capsule 1 p.o. b.i.d. 8. Protonix 40 mg p.o. q.d. 9. Prednisone 20 mg p.o. q.d. 10. Vitamin D 400 units p.o. q.d.
SA|slow acting/sustained action|SA|186|187|DISCHARGE MEDICATIONS|5. Spiriva one capsule inhaled daily. 6. Demadex 40 mg p.o. b.i.d. 7. Aspirin 81 mg. 8. Atorvastatin 10 mg h.s. 9. Digoxin 0.125 mg daily. 10. Advair 500/50 one puff b.i.d. 11. Liquibid SA 600 mg b.i.d. 12. Paxil. 13. Xopenex 1.25 mg in 3-cc nebulizer q.2h. p.r.n. 14. Levaquin 500 mg daily x 7 days. 15. Ativan 0.5 mg b.i.d.
SA|slow acting/sustained action|SA|119|120|BRIEF HISTORY OF PRESENT ILLNESS|10. Lantus 50 units subcutaneously q.p.m. 11. Atropine eye drop 1 drop to the left eye nightly. 12. Potassium chloride SA 10 mEq p.o. b.i.d. 13. Metformin XR 500 mg p.o. nightly (resume taking on _%#MM#%_ _%#DD#%_, 2006). 14. Timolol eye drops 0.25% one drop to the right eye q. day.
SA|slow acting/sustained action|SA|143|144|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Will consist of: 1. Prednisone 40 mg p.o., for 3 days, then 20 mg p.o. for 3 days and 10 mg p.o. for 3 days. 2. Pentasa SA p.o. q.i.d. The patient needs to stop her Asacol. All the other medications are still the same, which are as following: 3. 6-mercaptopurine 50 mg p.o. b.i.d.
SA|methicillin-susceptible Staphylococcus aureus:MSSA|SA|227|228|LABORATORY TESTS|_%#MMDD#%_, hemoglobin was 9.8. _%#MMDD#%_, hemoglobin 10.7, potassium 4.0. Wound culture from the gangrenous foot showed MRSA susceptible to gentamicin, vancomycin and Septra and tetracycline. Culture from the nose reported M SA also sensitive to the same antibiotics. _%#MMDD#%_, sodium 128, potassium 3.9. Glucose on that day was 278. 05/01, sodium 130 HOSPITAL COURSE. The patient initially required control of her congestive heart failure in preparation for general anesthetic and BK amputation of the left leg.
SA|slow acting/sustained action|SA|145|146|MEDICATIONS ON TRANSFER|A Kin-Air pressure reduction mattress has been critical in alleviating her pain and helped with her skin care. MEDICATIONS ON TRANSFER: 1. Imdur SA 90 mg daily. 2. Nitrostat p.r.n. 3. Toprol-XL 150 mg daily. 4. Aspirin 81 mg daily. 5. Plavix 75 mg daily. 6. Zocor 40 mg daily.
SA|slow acting/sustained action|SA|125|126|DISCHARGING MEDICATIONS|5. Milk of magnesia 30 mL by mouth every day p.r.n. constipation. 6. Vitamin C 1000 mg tablets by mouth every day. 7. Flomax SA 400 mcg every day at bedtime for urinary retention as a smooth muscle relaxant. 8. OxyContin 10 mg by mouth every 12 hours.
SA|slow acting/sustained action|SA|166|167|DISCHARGE MEDICATIONS|His potassium was 4.4. Fasting total cholesterol 170, triglycerides 119, LDL 117, HDL 30. DISCHARGE MEDICATIONS: 1. Zetia 10 mg daily. 2. Lasix 40 mg b.i.d. 3. Imdur SA 30 mg daily. 4. Prinivil/Zestril 20 mg daily. 5. Toprol-XL 25 mg daily. 6. Prilosec 20 mg daily. 7. Nitrostat p.r.n. 8. Coumadin 2.5 mg q. Tuesday, Thursday, Saturday and Sunday and 1.25 mg q. Monday, Wednesday, Friday.
SA|slow acting/sustained action|SA|162|163|DISCHARGE MEDICATIONS|11. Ocuvite 2 capsules twice daily. 12. Nifedipine XL 120 mg each day at bedtime. 13. Nitrostat 400 mcg sublingual p.r.n. 14. Aspirin 81 mg p.o. daily. 15. K-Dur SA 24 mEq p.o. daily. PLAN: Follow up with PCP. Patient has an appointment tomorrow.
SA|slow acting/sustained action|SA|124|125|DISCHARGE MEDICATIONS|4. Lisinopril 5 mg by mouth daily. 5. Lopressor 25 mg by mouth twice daily. 6. Multivitamin 1 tab by mouth daily. 7. Niacin SA 500 mg by mouth daily. 8. Nitroglycerin 400 mcg under the tongue as needed for chest pain. 9. Protonix 40 mg by mouth daily, this is a new medication.
SA|slow acting/sustained action|SA|160|161|DISCHARGE MEDICATIONS|4. Triamcinolone metered dose inhaler two puffs q 6 hours. 5. Lovastatin 20 mg p.o. q p.m. 6. Coumadin as directed. 7. Effexor XR 75 mg p.o. q h.s. 8. Liquibid SA 600 mg p.o. b.i.d. p.r.n. cough. 9. Prednisone 40 mg p.o. q day times three days and then stop. 10. Vioxx 25 mg p.o. q day - new.
SA|sinuatrial|SA|168|169|IMPRESSION|Of interest the QRS complex is both in the _%#MMDD#%_ EKG, the _%#MMDD#%_ EKG and again with both the P wave or the junction are of the same morphology. IMPRESSION: 1. SA node suppression, probably secondary to the medications. 2. Anxiety. 3. Osteomyelitis of the left toe. PLAN: 1. Per patient request we will not address the osteomyelitis other than to keep her on her antibiotics.
SA|slow acting/sustained action|SA|139|140|SUMMARY|The pain resolved with one sublingual nitro. His medical management was changed by increase atenolol to 50 mg twice a day and adding Imdur SA 30 mg once a day. Patient had one episode of bradycardia down to 37, for which one dose of atenolol was held. Patient was monitored for additional 24 hours with no further episodes of significant bradycardia.
SA|slow acting/sustained action|SA|175|176|DISCHARGE MEDICATIONS|3. Norvasc 5 mg p.o. daily. 4. Lisinopril 20 mg p.o. daily. 5. Lipitor 40 mg p.o. daily. 6. Atenolol 50 mg p.o. b.i.d. (increased). 7. Plavix 75 mg p.o. daily (new). 8. Imdur SA 30 mg p.o. daily (new). DISCHARGE FOLLOW-UP: Patient will follow up with his primary care physician, Dr. _%#NAME#%_, in one week.
SA|slow acting/sustained action|SA|201|202|CURRENT MEDICATIONS|9. Severe bilateral venous insufficiency of the lower extremities with history of venous stasis dermatitis and non healing venous stasis ulcers. 10. Moderate depression. CURRENT MEDICATIONS: 1. Niacin SA 250 mg at bedtime. 2. Fluoxetine 40 mg daily. 3. Advair 250/50 1 puff b.i.d. 4. Oxycodone 10 mg at bedtime. 5. Acetaminophen 1000 mg q.i.d.
SA|slow acting/sustained action|SA|170|171|MEDICATIONS|MEDICATIONS: 1. Allopurinol 100 mg twice daily. 2. Atenolol 25 mg daily. 3. Furosemide 40, 200 mg a day total. He does 120 mg in the a.m. and 80 mg at noon. 4. Diltiazem SA 120 mg daily. 5. Valsartan 160 mg daily. 6. Isosorbide dinitrate 20 mg b.i.d. 7. Senokot-S, two in the morning and two in the evening, 8. Aciphex 20 mg b.i.d.
SA|slow acting/sustained action|SA|167|168|DISCHARGE MEDICATIONS|2. Questran light 1 scoop in fluid daily. 3. Metoprolol XL 50 mg once daily. 4. Lisinopril 20 mg daily. 5. Allegra 180 mg daily. 6. Aricept 10 mg daily. 7. Isosorbide SA 60 mg daily. 8. Trazodone 25 q.h.s. p.r.n. 9. HCTZ 12.5 mg daily. 10. KCl 20 mEq daily. 11. Imodium can be used p.r.n.
SA|slow acting/sustained action|SA|274|275|DISCHARGE MEDICATIONS|Activity as tolerated. He will resume home care. He will follow up with his PCP in 2 weeks with his oncologist next week as scheduled and with counseling as soon as he can. DISCHARGE MEDICATIONS: 1. Xanax 0.5 mg p.o. t.i.d. p.r.n. with #12 given, no refills. 2. Guaifenesin SA 1200 mg p.o. b.i.d. 3. Mylanta 30 cc p.o. q.4h. p.r.n. 4. Zofran 4 mg p.o. q.6h. p.r.n. 5. MiraLax 17 gram p.o. daily p.r.n.
SA|slow acting/sustained action|SA|150|151|DISCHARGE MEDICATIONS|5. Dilaudid 2-4 mg p.o. q. 4h. p.r.n. pain. 6. Amiodarone 200 mg p.o. b.i.d. 7. Aspirin 81 mg p.o. daily. 8. Colace 100 mg p.o. b.i.d. 9. Guaifenesin SA 600/120 p.o. b.i.d. for cough. 10. Ferrous sulfate 325 mg p.o. t.i.d. 11. Clotrimazole troche 10 mg p.o. 5 times daily p.r.n.
SA|slow acting/sustained action|SA|180|181|DISCHARGING MEDICATIONS|2. Lopressor 12.5 mg p.o. twice daily. This is a new medication. 3. Protonix 40 mg p.o. daily: He will return to taking his home medication of Prevacid 30 mg p.o. daily. 4. Flomax SA 400 mcg p.o. every day. 5. Hydrochlorothiazide 12.5 mg every morning. 6. Avodart 0.5 mg every morning for BPH. 7. Symmetrel 100 mg p.o. every morning for Parkinson's disease.
SA|slow acting/sustained action|SA|155|156|DISCHARGE MEDICATIONS|7. Mirtazapine 30 mg p.o. each day at bedtime. 8. Multivitamin. 9. Orajel to mouth sores q. 4h. p.r.n. pain. 10. Pantoprazole 40 mg p.o. daily. 11. Flomax SA 400 mcg capsule p.o. daily. 12. Trazodone 50 mg p.o. each day at bedtime p.r.n. insomnia. 13. Acetaminophen. 14. Lidocaine patch. 15. Nystatin.
SA|slow acting/sustained action|SA|126|127|DISCHARGE MEDICATION|Mobic 15 mg p.o. daily. Albuterol nebulizer every 4 hours while awake and q.2h. p.r.n. Percocet 1-2 tabs q.6h. p.r.n. Norflex SA 100 mg p.o. b.i.d., prednisone 20 mg p.o. q. a.m., Ranitidine 150 mg p.o. at bedtime. Senna 1 tab p.o. b.i.d. Ambien 5 mg p.o. at bedtime.
SA|slow acting/sustained action|SA|153|154|DISCHARGE  MEDICATIONS|5. Seldane as before 6. Omeprazole 20 mg p.o. b.i.d. 7. Phenergan 25 mg p.o. q.6h p.r.n. nausea 8. Percocet 1-2 tabs q.4h p.r.n., number was 10 9. K-Dur SA 40 mEq p.o. t.i.d. 10. Sodium bicarbonate 650 mg p.o. b.i.d. 11. Albuterol inhaler 2 puffs q.4h p.r.n. 12. Advair Diskus 500/50 mcg 1 puff inhaled b.i.d. DISPOSITION: Discharge to home in a stable condition.
SA|slow acting/sustained action|SA|122|123|DISCHARGE MEDICATIONS|8. Calcium carbonate 500 mg p.o. b.i.d. 9. Mycelex troche 1 p.o. 5 times a day. 10. Florinef 0.1 mg p.o. daily. 11. Imdur SA 60 mg p.o. daily. 12. Mag oxide 400 mg p.o. b.i.d. 13. Reglan 5 mg p.o. t.i.d. 14. Myfortic 540 mg p.o. b.i.d. 15. Protonix 40 mg p.o. b.i.d.
SA|UNSURED SENSE|SA,|225|227|DISCHARGE PHYSICAL EXAMINATION|Motor exam with normal bulk, normal resting tone of the upper extremities, significant spasticity of the bilateral lower extremities. Normal dexterity and speed. Strength is 5/5 in the upper extremities bilaterally including SA, EE, EF, WE, WF, FE, DI. Strength in the left lower extremity HF4, KE5, KF4+, PF5, DF4+. Strength of the lower extremity 4+HF, 5KE, 4+KF, 5PF, 5DF.
SA|slow acting/sustained action|SA|197|198|MEDICATIONS|9. Urinary retention. 10. Diverticulitis. 11. Prostate cancer, diagnosed one year ago. MEDICATIONS: 1. Alprazolam 0.25 mg 1 tablet p.o. in the morning and 2 tablets at bedtime. 2. Diltiazem 120 mg SA 1 capsule p.o. daily. 3. Isosorbide dinitrate 20 mg p.o. 3 tablets by mouth 3 times a day. 4. Nitroglycerin 0.4 mg sublingual p.r.n. 5. Ezetimibe 10 mg/simvastatin 80 mg 1 tablet p.o. daily.
SA|slow acting/sustained action|SA|177|178|MEDICATIONS|4. Nitroglycerin 0.4 mg sublingual p.r.n. 5. Ezetimibe 10 mg/simvastatin 80 mg 1 tablet p.o. daily. 6. Artificial tears. 7. Albuterol nebulizer solution. 8. Theophylline 300 mg SA one tablet at bedtime. 9. Ipratropium bromide 0.02% inhaler solution 2.5 mL to be used with nebulizer treatment. 10. Ferrous gluconate 300 mg 1 p.o. 3 times daily.
SA|slow acting/sustained action|SA|183|184|DISCHARGE MEDICATIONS|6. Prilosec 20 mg by mouth daily. 7. Lipitor 20 mg by mouth every other day. 8. Flomax 400 mcg by mouth daily. 9. Multivitamin 1 tab daily. 10. Slow iron 1 tab daily. 11. Guaifenesin SA 600 mg by mouth twice daily. 12. PhosLo 660 mg by mouth twice daily. 13. Glucosamine/chondroitin 500/400 one tab twice daily.
SA|sinuatrial|(SA)|262|265|IMPRESSION|IMPRESSION: 1. Progressive renal failure from chronic nephrosclerosis. 2. History of cardiomyopathy, question hypertrophic, possibly worsening. 3. Hypothyroidism--has been on adequate therapy. 4. Chronic atrial fibrillation on Coumadin. 5. History of sinoatrial (SA) node dysfunction--pacemaker. PLAN: 1. Will proceed with initiation of dialysis using a temporary tunneled catheter.
SA|slow acting/sustained action|SA|228|229|DISCHARGE MEDICATIONS|5. Calcium and vitamin D tablets p.o. t.i.d. 6. Neurontin 100 mg p.o. q.a.m. and 200 mg p.o. q.p.m. 7. NPH insulin/regular insulin 70/30 - 60 units subcutaneously q.a.m., 50 units subcutaneously q.p.m. 8. Isosorbide mononitrate SA 60 mg p.o. daily. 9. Nicotine patch 14 mg p.o. daily, not while smoking. 10. Nystatin swish and swallow one teaspoon p.o. q.i.d.
SA|slow acting/sustained action|SA|174|175|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Senokot-S one po b.i.d. 2. Lovenox 70 mg po b.i.d. until Coumadin therapeutic. 3. Lasix 20 mg in the morning. 4. Tequin 200 mg qday. 5. Guaifenesin SA 600 mg t.i.d. 6. Lantus 20 units in the morning with a sliding scale Regular. 7. Phenytoin 300 mg at hs. 8. Coumadin 5 mg.
SA|slow acting/sustained action|SA|146|147|DISCHARGE MEDICATIONS|6. Allegra 180 mg p.o. daily. 7. Lasix 60 mg p.o. every morning. 8. Lopid 600 mg with lunch and supper. 9. Toprol XL 75 mg p.o. daily. 10. Niacin SA 500 mg p.o. daily at bedtime. 11. Protonix 40 mg p.o. daily. 12. Senna-S 2 tablets p.o. daily. 13. KCl 20 mEq p.o. on Wednesday and Friday.
SA|slow acting/sustained action|SA|165|166|DISCHARGE MEDICATIONS|His INR on the day of discharge was 2.39 after receiving Coumadin 5 mg for the past three days. 5. Lasix 40 mg p.o. q.a.m. 6. Lisinopril 20 mg p.o. daily. 7. Flomax SA 0.4 mg p.o. daily. 8. Insulin 70/30 16 units in the morning, 11 units at night. 9. Cholestyramine 4 mg p.o. daily. 10. Prednisone 5 mg p.o. daily x4 days, then stop.
SA|slow acting/sustained action|SA|122|123|DISCHARGE MEDICATIONS|8. Osteopenia. DISCHARGE MEDICATIONS: 1. Levaquin 250 mg p.o. daily x10 days. 2. Colace 100 mg p.o. b.i.d. 3. Guaifenesin SA or Liquibid 600 mg p.o. b.i.d. 4. Tiazac 360 mg p.o. daily. 5. Lisinopril 40 mg p.o. daily. 6. Fosamax 10 mg p.o. daily. 7. Requip 2 mg p.o. t.i.d.
SA|slow acting/sustained action|SA|204|205|DISCHARGE MEDICATIONS|3. Gabapentin 400 mg p.o. t.i.d. for agitation. 4. Lorazepam 1 mg p.o. t.i.d. for muscle spasms and lorazepam 0.5 to 1 mg p.o. q. 3h. p.r.n. for anxiety. 5. Protonix 40 mg p.o. q. day for GERD. 6. Flomax SA 800 mcg p.o. q.p.m. for urinary retention. 7. Trazodone 100 mg p.o. each day at bedtime for depression. 8. Restoril 15 mg p.o. each day at bedtime p.r.n. for insomnia.
SA|slow acting/sustained action|SA|122|123|DISCHARGE MEDICATIONS|8. Reglan 5 mg p.o. q.i.d. before meals. 9. Toprol XL 50 mg p.o. in a.m., and 25 mg p.o. each day at bedtime. 10. Trental SA 400 mg p.o. t.i.d. 11. Prazosin 2 mg p.o. each day at bedtime. 12. Zocor 40 mg p.o. each day at bedtime.
SA|slow acting/sustained action|SA|146|147|DISCHARGE MEDICATIONS|4. Modafinil 100 mg p.o. q.a.m., 50 mg p.o. q. noon, and 50 mg p.o. q.p.m. 5. Multivitamin one tablet p.o. each day at bedtime. 6. Pentoxifylline SA 400 mg p.o. t.i.d. 9. Prednisone 12 mg p.o. every alternate day. 10. Imitrex and 6 mg subq p.r.n. for severe migraine headaches.
SA|slow acting/sustained action|SA|120|121|DISCHARGE  MEDICATIONS|ACTIVITY: As tolerated. To start cardiac rehab as an outpatient. DISCHARGE MEDICATIONS: 1. Plavix 75 mg daily. 2. Imdur SA 30 mg daily. 3. Claritin 10 mg daily. 4. Toprol-XL 50 mg daily. 5. Niacin 1,000 mg daily, which is SA. 6. Nitroglycerin p.r.n. sublingually.
SA|slow acting/sustained action|SA.|157|159|DISCHARGE  MEDICATIONS|DISCHARGE MEDICATIONS: 1. Plavix 75 mg daily. 2. Imdur SA 30 mg daily. 3. Claritin 10 mg daily. 4. Toprol-XL 50 mg daily. 5. Niacin 1,000 mg daily, which is SA. 6. Nitroglycerin p.r.n. sublingually. 7. Omeprazole 20 mg daily. 8. Zocor 40 mg daily 9. Aspirin 325 mg daily, which should be coated. 10. Glucotrol 10 mg b.i.d.
SA|slow acting/sustained action|SA|112|113|DISCHARGE MEDICATIONS|3. Senokot two tablets p.o. b.i.d. 4. Diltiazem ER 180 mg p.o. q. day. 5. Zocor 40 mg p.o. q. day., 6. Ditropan SA 10 mg p.o. q. day. 7. Micardis HCT 40/12.5 p.o. q. day. 8. Lipitor 10 mg p.o. q. day. 9. Prilosec 20 mg p.o. daily. 10. Multivitamin 1 p.o. q. day.
SA|slow acting/sustained action|SA|121|122|MEDICATIONS|5. Recent diagnosis of aspiration pneumonitis on Levaquin. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Phenytoin SA 100 mg capsules, 1 capsule by mouth every morning and 2 capsules by mouth in the evening. 2. Phenobarbital 100 mg tablets, half tablet (50 mg) by mouth every morning and 1 tablet (100 mg) in the evening orally.
SA|slow acting/sustained action|SA|119|120|DISCHARGE MEDICATIONS.|4. Diltiazem ER 120 mg daily. 5. Colace 100 mg daily. 6. Lidex cream p.r.n. 7. Neurontin 100 mg 3 times a day 8. Imdur SA 60 mg daily 9. Zaroxolyn 1.25 mg daily. 10. Milk of magnesia 30 cc p.r.n. daily 11. Ditropan-XL 15 mg daily. 12. Senokot 2 pills daily p.r.n. 13. Desyrel 12.5 mg to 25 mg 3 times a day p.r.n. for anxiety.
SA|slow acting/sustained action|SA|603|604|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|At the time of discharge, his medicine list is as follows: Flovent 220 2 puffs b.i.d., Combivent 2 puffs by metered dose inhaler every 8 hours, aspirin 325 mg p.o. daily, Zocor 20 mg p.o. daily, cimetidine 400 mg p.o. daily, Lasix 40 mg p.o. daily, metoprolol 25 mg p.o. b.i.d., Valtrex, which is given for cold sore that developed during this hospitalization 500 mg p.o. b.i.d. for five days, Ambien 5 mg p.o. q. h.s. as needed, Tylenol 1000 mg p.o. q. 6 hours as needed, Augmentin 875/125 1 tab p.o. b.i.d. for five days, digoxin 125 mcg p.o. daily, DuoNebs every 4 hours as needed p.r.n. and Humibid SA 600 mg 1 p.o. b.i.d.. He also is on Glivec 400 mg p.o. daily.
SA|slow acting/sustained action|SA|131|132|MEDICATIONS|He denies nausea and vomiting. ALLERGIES: NONE. MEDICATIONS: 1) Furosemide 40 mg q day. 2) Endocet 5/325 q.i.d. p.r.n. 3) Morphine SA 30 mg b.i.d. 4) Morphine 10 mg q4h p.r.n. 5) Ambien 10 mg h.s. p.r.n. 6) Aspirin 81 mg q day. 7) Ranitidine 150 mg b.i.d., but has not been using.
SA|sinus arrest|SA|128|129|HISTORY OF PRESENT ILLNESS|His TSH was 2.09. His electrolytes and creatinine were normal. On carotid sinus massage on the left side, he did have transient SA arrest for approximately 3 seconds. This was probably an incidental finding. Also of note, his fasting blood sugar was 129. Hemoglobin A1C was ordered, but is pending at the time of this discharge.
SA|sinuatrial|SA|352|353|HISTORY OF PRESENT ILLNESS|He is certainly at risk for this. I am going to recommend that he have a 30-day heart monitor with auto record function to make sure there is no more heart block, but again I suspect that he simply had a vasovagal reaction to the pain and the nitroglycerin that caused the transient heart block. There is no other reason to assume he should have AV or SA conduction disturbance. His sleep apnea workup and a possible biliary workup can be done at _%#NAME#%_'s Hospital. DISCHARGE MEDICATIONS: 1. aspirin 81 mg daily. 2. Lipitor 40 mg daily.
SA|slow acting/sustained action|SA|189|190|DISCHARGE MEDICATIONS|She is on allopurinol 100 mg daily, Coumadin 1 mg daily, Celebrex 200 mg daily, Diltiazem Extended Release 240 mg daily, Lasix 80 mg t.i.d. orally, Advair 250/50 1 puff b.i.d., Guaifenesin SA 1200 mg b.i.d., Lantus 50 units subcutaneous q. a.m. and Humalog 10 units subcutaneous q. a.m. with breakfast and then sliding scale of Humalog with her other meals, Isordil or Sorbitrate 5 mg orally b.i.d. Cozaar was increased from 50 mg daily to 100 mg daily, nadolol 20 mg daily, Prilosec 20 mg daily, potassium chloride 20 mEq daily, prednisone 10 mg daily.
SA|sinuatrial|(SA)|288|291|HOSPITAL COURSE|However, he went to cardiac rehabilitation and pushed to exercise maximum tolerance and he could only generate a heart rate of about 75- 80 beats per minute and this was an accelerated junctional rhythm. Therefore, I have speculated that he has had perioperative injury to the sinoatrial (SA) node. Whether he actually recovers insufficiently and gets sufficient chronotropic competence to avoid chronotropic competence is unknown right now.
SA|slow acting/sustained action|SA|260|261|DISCHARGE MEDICATIONS|Sensory exam showed decreased pinprick on the left as compared to the right in both upper and lower extremities with extinction of sensory stimuli on the left side. Gait was wide based and spastic. DISCHARGE MEDICATIONS: 1. Acyclovir 400 mg b.i.d. 2. Aggrenox SA 1 tablet b.i.d. 3. Lisinopril 5 mg daily. 4. Zetia 10 mg nightly. 5. Zocor 80 mg nightly. 6. Multivitamin 1 tablet daily. 7. Indometacin 50 mg q.8 h. as needed for gout.
SA|slow acting/sustained action|SA|182|183|DISCHARGE MEDICATIONS|16. Lasix 30 mg twice a day. 17. Neurontin 1,000 mg p.o. t.i.d. 18. Glyburide 10 mg once before lunch and 10 mg once before supper. 19. Lantus insulin 38 units at bedtime. 20. Imdur SA 30 mg once a day. 21. Lisinopril 40 mg once a day. 22. Metformin 500 mg one at lunch, one at 1800 hrs.
SA|sinuatrial|SA|165|166|IMPRESSION|At this time, I would like to do a coronary angiogram, first to determine the condition of his coronary arteries. I am going to hold all drugs that would affect the SA or AV node and will determine later if he needs a pacemaker as these drugs wear down. It is conceivable he may ultimately need a pacemaker for sick sinus syndrome and then medications for any rapid beats.
SA|slow acting/sustained action|SA|126|127|DISCHARGE MEDICATIONS|6. Colace 100 mg p.o. b.i.d. 8. Prozac 40 mg p.o. daily 9. Lasix 20 mg p.o. daily 10. Hydralazine 50 mg p.o. t.i.d. 11. Imdur SA 30 mg p.o. daily 12. The patient was instructed to use Fleet enema 1 PR per day p.r.n. 13. Prednisone 10 mg p.o. daily 14. Evista 60 mg p.o. daily.
SA|sinuatrial|SA|169|170|HOSPITAL COURSE|Please refer to the dictated H&P for details of the past medical history, exam findings and present illness. HOSPITAL COURSE: PROBLEM #1: Symptomatic bradycardia due to SA node dysfunction: The patient on admission was found to have a heart rate in the 20s documented by EKG. It appeared to be a ventricular escape sort of rhythm with a likely underlying atrial fibrillation.
SA|sinuatrial|SA|139|140|HOSPITAL COURSE|His followup EKG showed a ventricular rhythm in the 80s, which had an underlying pacing rhythm of 60. Because of the symptomatic is likely SA node dysfunction. He was on albuterol and digoxin at home. His digoxin level was 1.7, which is normal. Also, his atenolol was not apparently taken an overdose and several days into admission.
SA|sinuatrial|SA|167|168|HOSPITAL COURSE|However, the patient remained asymptomatic during the episodes. Cardiology Service was consulted, and they recommended an EP study to further evaluate the patient. An SA EKG was obtained, which showed no abnormality. As per Cardiology's recommendations, there is not sufficient indication for treatment of asymptomatic ventricular tachycardia in patient's with nonischemic cardiomyopathy.
SA|sinuatrial|SA|127|128|ASSESSMENT AND PLAN|As far as bradycardia is concerned, this is a known complication of inferior wall MI. This could be related to ischemia of the SA versus AV node or it could also be the neurocardiac reflex resulting in bradycardia. At present, the patient's heart rate is in 40s however his blood pressure is stable and he is tolerating that well.
SA|slow acting/sustained action|SA|140|141|DISCHARGE MEDICATIONS|4. Premarin 0.625 mg daily. 5. Synthroid 75 mcg daily. 6. Mesalamine 800 mg three times a day. 7. ProAir. 8. Multivitamin daily. 9. Trental SA 400 mg three times a day. 10. Calmoseptine ointment to the skin four times a day. 11. Travatan eye drops, 1 drop each eye daily at bedtime.
SA|slow acting/sustained action|SA|223|224|DISCHARGE MEDICATIONS|DISCHARGE DIET: 1800 calorie ADA diet, cardiac. ACTIVITY: As tolerated, and as per physical therapy/occupational therapy. DISCHARGE MEDICATIONS: 1. Norvasc 5 mg twice a day. 2. Hydralazine 50 mg three times a day. 3. Imdur SA 60 mg daily. 4. Prinivil 20 mg twice a day. 5. Metoprolol 100 mg twice a day. 6. Lantus insulin 45 units at bedtime, along with NovoLog 2 units with meals plus insulin sliding scale for blood sugars over 120.
SA|sinuatrial|SA|190|191|HISTORY OF PRESENT ILLNESS|The patient denied fever or nausea. She also denies ingestion of undercooked meat, fast food or pot pies. The patient has comorbidities of osteoporosis, depression, venous insufficiency, AV SA node dysfunction and pacemaker placement, constipation and generalized anxiety disorder. She was on no medications. The patient on exam was alert and oriented and afebrile but was felt to be mildly dehydrated.
SA|slow acting/sustained action|SA|190|191|CURRENT MEDICATIONS|2. Ancef 1 gram q.12 h. IV. 3. Cozaar 100 mg daily (auto substitution for her Avapro 150 mg at home). 4. Lopressor 5 mg IV q.8 h. (substituting for her atenolol 25 mg at home). 5. Nitro-Bid SA 2.5 mg b.i.d. 6. Dilaudid PCA. 7. Zantac 50 mg q.8 h. IV. Additional home meds that she is not receiving here include: 1. Zetia 10 mg a day.
SA|slow acting/sustained action|SA|195|196|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Amlodipine 5 mg p.o. daily. 2. Enteric-coated aspirin 81 mg p.o. daily. 3. Zetia 10 mg p.o. daily. 4. Lasix 60 mg p.o. t.i.d. 5. Glucosamine 500 mg p.o. b.i.d. 6. Imdur SA 30 mg p.o. daily. 7. Lopressor 12.5 mg p.o. q.8h. 8. Diovan 80 mg p.o. daily.
SA|slow acting/sustained action|SA|120|121|MEDICATIONS|9. Indeterminate troponin. 10. Recent tooth extraction. 11. Chronic oxygen as described above. MEDICATIONS: 1. Aggrenox SA 25/100 mg 1 tablet b.i.d. 2. Levaquin, completed course yesterday. 3. Synthroid 100 mg per day. 4. Nicotine patch 14 mg per day. 5. Sliding scale insulin.
SA|slow acting/sustained action|SA|179|180|DISCHARGE MEDICATIONS|2. Ventolin 2.5 mL nebulizer q.4h. 3. Pulmicort 1 puff b.i.d. 4. Synthroid 100 mcg p.o. daily. 5. Spiriva 1 cap inhaled daily. 6. Miconazole 2% powder to groin b.i.d. 7. Aggrenox SA 25/100 one p.o. b.i.d. 8. Prednisone 30 mg p.o. daily, taper 5 mg q.3 days till patient is at 10 mg p.o. daily. The patient needs to follow up with Dr. _%#NAME#%_, her primary care physician in 1 week in clinic.
SA|slow acting/sustained action|SA|143|144|DISCHARGE MEDICATIONS|He will be discharged today with the following. DISCHARGE MEDICATIONS: 1. Ciprofloxacin 500 mg p.o. twice a day for ten more days. 2. Aggrenox SA 25/200 mg 1 twice a day. 3. Dulcolax 10 mg p.r.n. for constipation. 4. Colace 100 mg once daily for constipation.
SA|slow acting/sustained action|SA|144|145|MEDICATIONS|MEDICATIONS: 1. Aspirin 325 mg. 2. Plavix 75 mg. 3. Advair 250/50 mg 1 puff b.i.d. 4. Glipizide 10 mg b.i.d. 5. Claritin 10 mg daily. 6. Niacin SA 1000 mg at h.s. 7. Toprol 50 mg a day. 8. Prilosec 20 mg a day. 9. Zocor 40 mg h.s. 10. Metformin 1000 mg b.i.d.
SA|slow acting/sustained action|SA|174|175|PRESENT MEDICINES|7. Vicodin p.r.n. She has been using that without a lot of success recently. 8. Lisinopril 10 mg q.a.m. and she took that this morning. 9. Nexium 40 mg q. day. 10. Bromophed SA 1 in the morning for persistent nasal congestion and runny nose. FAMILY HISTORY: Father died of chronic obstructive pulmonary disease at age 65, mother died of congestive heart failure at age 73, had multiple myocardial infarctions previous to that time.
SA|slow acting/sustained action|SA|172|173|CHRONIC MEDICATIONS|13. Beta carotene. 14. Vitamin B12 500 mg p.o. daily. 15. Folate 400 mcg p.o. daily. 16. Bee pollen 500 mg p.o. daily. 17. Glucosamine chondroitin. 18. Potassium chlorides SA 10 mEq daily. SOCIAL HISTORY: She is a resident of the _%#CITY#%_ _%#CITY#%_ Villa.
SA|slow acting/sustained action|SA|163|164|DISCHARGE MEDICATIONS|2. Vitamin A 25,000 units daily. 3. Nexium 40 mg daily. 4. Ginger root 550 mg b.i.d. 5. Mucomyst 600 mg p.o. daily. 6. Multivitamin with minerals daily. 7. Niacin SA 250 mg b.i.d. 8. Pancrease MT 16, 6-8 caps with meals and 4 with snacks. 9. Vitamin D 800 international units b.i.d. 10. Vitamin E 400 units daily.
SA|slow acting/sustained action|SA,|198|200|DISCHARGE MEDICATIONS|3. Toprol XL, 50 mg p.o. daily (new). 4. Nitroglycerin, 0.4 mg SL p.r.n. chest pain. 5. Lotrel, 10/20 mg p.o. daily. 6. Hyzaar, 12.5/100 mg p.o. daily. 7. Vytorin, 10/40 mg p.o. nightly. 8. Niaspan SA, 500 mg p.o. nightly. 9. Aspirin, 81 mg p.o. daily. DISCHARGE FOLLOW-UP: 1. _%#NAME#%_ _%#NAME#%_ will follow up with Dr. _%#NAME#%_ _%#NAME#%_ in 2-3 months at the Minnesota Heart Clinic.
SA|slow acting/sustained action|SA|130|131|MEDICATIONS|4. Xalatan eye drops - 1 drop each day at bedtime. 5. Restasis 1 drop both eyes b.i.d. 6. Timoptic - 1 drop b.i.d. 7. Guaifenesin SA 600 mg b.i.d. 8. Fleets enema p.r.n. 9. Lyrica 50 mg b.i.d. 10. Compazine 5 mg q.6 h. p.r.n. for nausea. 11. Senokot S - 1 or 2 tablets p.o. b.i.d.
SA|slow acting/sustained action|SA|803|804|MEDICATIONS|PAST MEDICAL HISTORY: Schizophrenia, eczema, anxiety, history of DVTs twice before, hypertension, coronary artery disease, hypercholesterolemia, gastroesophageal reflux disease, diabetes mellitus, hemorrhoids, BPH. MEDICATIONS: Hydroxyzine 25 mg at night, _________ 2 mg p.o. q.d., Tylenol as needed, enteric-coated aspirin 325 mg p.o. q.d., Ativan 2 mg at night, _________ 25 mg at night, Atenolol 100 mg per day, nifedipine XL 30 mg p.o. q.d., isosorbide dinitrate 20 mg p.o. q.d., nitroglycerin 0.4 mg sublingual p.r.n., gemfibrozil 600 mg p.o. b.i.d., Sandostatin 400 mg p.o. q.h.s., Lisinopril 5 mg p.o. q.d., __________ 1 Tbsp with 8 ounces of water p.o. q.d., Rabeprazole 20 mg p.o. b.i.d., Metformin 500 mg p.o. b.i.d., beclomethasone nasal inhaler 42 mcgs one to two puffs per day, Guaifenesin SA 600 mg p.o. b.i.d., and terazosin 2 mg p.o. q.h.s. he will be taking this for one week then increasing to 3 mg at night for a week, then 4 mg at night for a week, and continue at 5 mg at night.
SA|slow acting/sustained action|SA|102|103|MEDICATIONS|11. Status post ORIF. MEDICATIONS: 1. Artane 5 mg b.i.d. 2. Sinemet CR 25/100 2 tabs p.o. q day and 1 SA tablet q.h.s. 3. Catapres 0.2 mg b.i.d. 4. Trileptal 3 300 mg tablets, i.e. 900 mg b.i.d. 5. Risperdal 4 mg b.i.d., 2 mg p.r.n. agitation. 6. Metamucil 1 tbsp q day.
SA|slow acting/sustained action|SA,|182|184|MEDICATIONS|No cancer was mentioned as far as the final diagnosis. She also has had surgery on a breast abscess. MEDICATIONS: Monopril 20 mg daily, Premarin 0.3 mg daily, verapamil 180 mg daily SA, and Phenergan with codeine prescribed today. ALLERGIES: Notes possible allergy to penicillin - had a localized itchy rash at IM site.
SA|UNSURED SENSE|SA|120|121|HOSPITAL COURSE|At no point did it drop significantly. On the day of discharge it remained at 14. The lowest it went was 13.8. Factor A SA after transfusion was 105. He did receive factor A q. 6h. approximately one day, and this was changed to b.i.d. prior to discharge.
SA|slow acting/sustained action|SA|150|151|DISCHARGE MEDICATIONS|2. Colace 100 mg p.o. b.i.d. 3. Dulcolax 10 mg p.o./PR q. day p.r.n. 4. Flexeril 10 mg p.o. t.i.d. p.r.n. 5. Actonel 35 mg, 1 time per week. 6. Imdur SA 60 mg p.o. daily. 7. Norvasc 10 mg p.o. daily. 8. Labetalol 150 mg p.o. b.i.d. 9. Protonix 40 mg p.o. q. day. 10. Calcium plus vitamin D 600/250 1 p.o. b.i.d.
SA|slow acting/sustained action|SA|169|170|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Fish oil 1 gram capsule every morning. Two gram capsule every evening. 2. Lisinopril 5 mg p.o. daily. 3. Lopressor 50 mg p.o. b.i.d. 4. Niacin SA 500 mg p.o. q.h.s. 5. Zocor 10 mg p.o. q.h.s. 6. He is to stop his Diovan at this point since he will be treated with beta blockers and lisinopril.
SA|slow acting/sustained action|SA|133|134|DISCHARGE MEDICATIONS|6. Advair Diskus 500/50 one puff b.i.d. 7. Albuterol p.r.n. 8. Lantus 8 units subq q.p.m. 9. Coumadin 5 mg p.o. daily. 10. _________ SA 400 mcg p.o. daily at bedtime. 11. Protonix 20 mg p.o. daily. 12. Nitroglycerin sublingual 400 mcg q.5 minutes p.r.n. x3.
SA|UNSURED SENSE|SA|127|128|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 4-year-old male with history of pre-B cell ALL on protocol _%#PROTOCOL#%_, regimen SA status post his sixth maintenance course, who presents with new onset of low-back pain last night, new cough/rhinorrhea this morning and fever to 102 Fahrenheit at home. He first complained of midline low back pain last night and was restless overnight; however, by this morning his low back pain had improved.
SA|sinuatrial|SA|288|289|PROCEDURES PERFORMED DURING HOSPITALIZATION|PROCEDURES PERFORMED DURING HOSPITALIZATION: 1. Emergent coronary angiogram dated _%#MMDD2007#%_, which showed patent LAD with large D1, left circumflex was a small caliber vessel with large OM1 branch. The right coronary was also patent. There was a possible anomalous connection of the SA branch of the left circumflex with the PDA artery. LV gram was also done, which did not show any wall motion abnormality and EF was within normal limits.
SA|slow acting/sustained action|SA|117|118|DISCHARGE MEDICATIONS|To that end her discharge medications are as follows: DISCHARGE MEDICATIONS: 1. Cardizem 30 mg p.o. q. day. 2. Imdur SA 30 mg p.o. b.i.d., to be held for systolic blood pressure less than 100 3. Metoprolol 25 mg p.o. b.i.d., to be held for systolic blood pressure less than 110
SA|slow acting/sustained action|SA|123|124|ADMISSION MEDICATIONS|1. Prozac 20 mg daily. 2. Lasix 20 mg daily. 3. Lisinopril 40 mg daily. 4. Nitroglycerin 0.4 mg sublingual p.r.n. 5. Imdur SA 120 mg q.a.m. 6. Labetalol 100 mg b.i.d. 7. Micardis 20 mg daily. 8. Lovastatin 40 mg daily. 9. Glucophage 2000 mg extended release once daily. Last dose was this morning.
SA|slow acting/sustained action|SA|161|162|MEDICATIONS|MEDICATIONS: 1. Lioresal 30 mg q.i.d. for spasticity. 2. Lunesta 2 mg each day at bedtime may repeat x1. 3. Copaxone 20 mg subcutaneous every day. 4. Tamsulosin SA 400 mcg capsule by mouth every day. 5. Hydrocodone and acetaminophen 5/325 one to two q. 4-6 hours p.r.n. pain, maximum acetaminophen dose 4 g in 24 hours.
SA|slow acting/sustained action|SA|187|188|DISCHARGE  MEDICATIONS|DISCHARGE MEDICATIONS: 1. Glipizide extended release 10 mg in the morning, 5 mg in the evening. 2. Captopril 25 mg t.i.d. 3. Synthroid 0.15 mg daily. 4. Maxzide 1 tablet daily. 5. Niacin SA 500 mg daily. 6. Potassium. The patient will resume previous dose. 7. Calcium with vitamin D. 8. Darvocet for pain.
SA|slow acting/sustained action|SA|133|134|ADMISSION MEDICATIONS|13. Isordil 30 mg t.i.d. 14. Ferrous sulfate 325 mg b.i.d. 15. Lopressor 12.5 mg b.i.d. 16. Senokot 1 tablet b.i.d. 17. Procainamide SA 750 mg b.i.d. 18. Lisinopril 2.5 mg daily. 19. Miconazole cream 25 to affected areas b.i.d. FAMILY HISTORY: The patient does not know.
SA|slow acting/sustained action|SA|110|111|FOLLOW-UP|3. Lipitor 10 mg daily. 4. Nexium 40 mg daily. 5. Allegra 180 mg daily. 6. Prozac 10 mg daily. 7. Imdur 30 mg SA p.o. each day at bedtime. 8. Xalatan eye drops. 9. Prednisone 10 mg daily. 10. Aldactone 12.5 mg daily. 11. Demadex 40 mg p.o. b.i.d. 12. Coumadin currently getting 4 mg daily.
SA|slow acting/sustained action|SA|169|170|DISCHARGE MEDICATIONS|8. Prevacid 30 mg p.o. b.i.d., 9. Lisinopril 20 mg p.o. q.h.s. 10. Citracal 950 mg p.o. q. day. 11. Hexawit one cap daily. 12. Multivitamin one tablet daily. 13. Niacin SA 1000 mg p.o. b.i.d. 14. Simvastatin 10 mg q.h.s. 15. Vitamin E 1,000 units daily. 16. Glucotrol 5 mg p.o. b.i.d. MEDICATIONS DISCONTINUED: 1. Warfarin.
SA|slow acting/sustained action|SA|159|160|DISCHARGE MEDICATIONS|3. Lexapro 10 mg once a day. 4. Zetia 10 mg once a day. 5. Tricor 145 mg daily. 6. Lasix 40 mg once a day. 7. Hydrochlorothiazide 12.5 mg once a day. 8. Imdur SA 30 mg p.o. b.i.d. 9. Lamictal 25 mg every morning. 10. Reglan 5 mg p.o. t.i.d. 11. Zaroxolyn 2.5 mg once a day. 12. Metoprolol 50 mg p.o. b.i.d.
SA|sinuatrial|SA|146|147|PAST SURGICAL HISTORY|BRIEF PAST MEDICAL HISTORY: Includes chronic obstructive pulmonary disease oxygen dependent, asthma, depression. PAST SURGICAL HISTORY: She had a SA node electroablation and right hip fracture repair. Apparently, she was still smoking. I had no contact with her on the day of discharge.
SA|slow acting/sustained action|SA|118|119|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: 1. Discharge to rehab. 2. Discharge meds: a. Tequin 200 mg p.o. q.d. x10 days. b. Guaifenesin SA 600 mg p.o. b.i.d. indefinitely. c. Zocor 40 mg p.o. q.d. d. Do a neb one unit q.4h. p.r.n. e. Ativan 0.5 mg p.o. b.i.d. p.r.n. f. Combivent inhaler 2 puffs q.i.d.
SA|slow acting/sustained action|SA|142|143|DISCHARGE MEDICATIONS|2. Digoxin 62.5 mcg one tablet once a day. 3. Prevacid 30 mg one capsule once a day. 4. Remeron 15 mg one tablet at bedtime. 5. Nitroglycerin SA 6.5 mg capsule one capsule twice a day. 6. Coumadin per INR results. The patient will be given 2.5 mg p.o. today.
SA|slow acting/sustained action|SA|175|176|DISCHARGE MEDICATIONS|8. Left bundle branch block. 9. Osteochondroma, right knee. 10. Cerebrovascular accident. DISCHARGE MEDICATIONS: 1. Glipizide 10 mg q.d. 2. Prinivil 10 mg q.d. 3. Guaifenesin SA 600 mg q.d. 4. Procardia XL 30 mg q.d. 5. Actos 15 mg q.d. 6. Albuterol nebs 2.5 mg p.r.n. 7. Dyazide one q.d. Check creatinine, BUN and potassium.
SA|slow acting/sustained action|SA|284|285|PROBLEMS|This can be done as an outpatient. DISCHARGE MEDICATIONS: Flagyl 500 mg p.o. t.i.d. x26 days, lactobacillus 3 packets p.o. q.i.d. x26 days, cholestyramine 4 g p.o. t.i.d. x26 days. Those are his new medications. He is to resume his old medications, glipizide 5 mg p.o. b.i.d., niacin SA 500 mg p.o. q.h.s., levobunolol 0.5% eye drops as directed. FOLLOW UP: Followup with Dr. _%#NAME#%_ in 1 week and after 1 month for C-diff colitis.
SA|slow acting/sustained action|SA,|164|166|DISCHARGE MEDICATIONS|2. Enteric-coated aspirin 325 mg p.o. q.day. 3. Zithromax 250 mg one tablet p.o. q.day x 5 days. 4. Hydrochlorothiazide 25 mg p.o. q.day. 5. Isosorbide mononitrate SA, i.e. Imdur, 30 mg p.o. q.day. 6. Lisinopril 20 mg p.o. q.day. 7. Protonix 40 mg p.o. q.day. 8. Prednisone 40 mg p.o. q.day x 7 days, then discontinue.
SA|slow acting/sustained action|SA|205|206|CHRONIC MEDICATIONS|Other past medical history includes hypertension, hypercholesterolemia, degenerative disease and BPH. ALLERGIES: No known drug allergies. CHRONIC MEDICATIONS: 1. Metoprolol 50 mg p.o. daily. 2. Felodipine SA 10 mg p.o. daily. 3. Imdur 30 mg p.o. daily. 4. Simvastatin 20 mg p.o. q.h.s. 5. Aspirin 81 mg p.o. daily. 6. Hydrochlorothiazide 25 mg p.o. every other day. 7. Folate 1 mg p.o. daily.
SA|UNSURED SENSE|SA,|283|285|DISCHARGE PHYSICAL EXAMINATION|General physical exam including appearance, cardiovascular, respiratory, abdomen, and extremities are significant for a moderate amount of anxiety. NEUROLOGIC: A full neurologic exam was done and was normal including mental status, cranial nerves, motor; individual testing included SA, EE, EF, WE, SE, DI, HS, KE, KS, PF, DF, normal tone. There is a small drift on the right. Reflexes are brisk throughout with clonus at the ankles and in upgoing toe on the right.
SA|slow acting/sustained action|SA|192|193|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Gemfibrozil 600 mg p.o. daily. 2. Levothyroxine 175 mcg p.o. daily. 3. Multivitamin 1 tablet p.o. daily. 4. Chantix 1 mg p.o. b.i.d. for smoking cessation. 5. Niacin SA 500 mg p.o. each day at bedtime. 6. Lipitor 10 mg p.o. each day at bedtime. 7. Aspirin 325 mg p.o. daily, which we asked the patient to hold until he sees his primary care physician or _%#NAME#%_ considering that might be a reason for his chronic bleeding, although we do not have any evidence for that.
SA|slow acting/sustained action|SA|139|140|DISCHARGE MEDICATIONS|2. Wellbutrin-XL 150 mg p.o. daily. 3. Lovenox 60 mg subq q.12h. until INR greater than 2. 4. Vytorin 10/20 mg 1 p.o. at bedtime. 5. Imdur SA 60 mg p.o. daily. 6. Lisinopril/hydrochlorothiazide 10/12.5 mg p.o. daily. 7. Calcium and vitamin D as prior to admission. 8. Zegerid 40 mg p.o. b.i.d. (new medicine). 9. Nitroglycerin 0.4 mg q. 5 minutes x3 p.r.n. chest pain.
SA|slow acting/sustained action|SA|155|156|DISCHARGING MEDICATIONS|5. Neurontin 400 mg p.o. t.i.d. This is a new medication this hospitalization. 6. Hydrea 1000 mg p.o. daily. 7. Purinethol 50 mg p.o. daily. 8. Mesalamine SA 2000 mg p.o. twice daily. 9. Calcium 630 mg p.o. t.i.d. 10. Therapeutic multivitamin 1 tablet daily. 11. Protonix 40 mg daily.
SA|slow acting/sustained action|SA|151|152|DISCHARGE MEDICATIONS|1. Protonix 40 mg daily. 2. Lisinopril 10 mg daily. 3. Atenolol 25 mg daily. 4. Hydrochlorothiazide 12.5 mg daily. 5. Aspirin 81 mg daily. 6. Liquibid SA 1200 mg twice daily as needed. 7. Albuterol inhaler 2 puffs every 4 hours as needed. 8. Augmentin 500/125 one tab twice daily for 5 days.
SA|slow acting/sustained action|SA|163|164|TRANSFER MEDICATIONS|1. Vitamin B12 1 mg injected subq monthly 2. Aranesp 100 mcg weekly 3. Lovenox 80 mg injected subq q.12h until INR therapeutic 4. Allegra 100 mg daily. 5. Pentasa SA 2,000 mg capsules b.i.d. 6. Multivitamin 1 daily. 7. Protonix 40 mg daily. 8. Paxil 20 mg daily. 9. MiraLax 17 grams daily. 10. Prednisone 7.5 mg daily, with a new ose scheduled for _%#MMDD#%_ by Dr. _%#NAME#%_.
SA|slow acting/sustained action|SA|224|225|DISCHARGE MEDICATIONS|7. Glucose tablets 5 mg sliding scale every 15 minutes for glucose 60-70 give 3 tablets, glucose 45-59 give 4 tablets, glucose less than 45 give 6 tablets. Repeat blood glucose in 15 minutes after doses given. 8. Tamsulosin SA 400 mcg p.o. daily. 9. Bisacodyl 10 mg suppository 1 tablet p.r. daily as needed for constipation, dispensed 30. 10. Zofran 4-8 mg p.o. q.8h. as needed for nausea, dispensed 30.
SA|slow acting/sustained action|SA|139|140|DISCHARGE MEDICATIONS|5. Fish oil 1 gram every day. 6. Lisinopril 5 mg every day. 7. Singulair 10 mg every night. 8. Multivitamin 1 tablet every day. 9. Niaspan SA 500 mg every day. 10. Ranitidine 150 mg every day. 11. Vytorin 10/20 mg 1 tablet every day.
SA|slow acting/sustained action|SA|120|121|MEDICATIONS|2. Plavix 75 mg q. day. 3. Advair 250/50, one puff b.i.d. 4. Glipizide 10 mg b.i.d. 5. Claritin 10 mg q. day. 6. Niacin SA 1000 mg daily. 7. Toprol XL 50 mg a day. 8. Prilosec 20 mg a day. 9. Zocor 40 mg at bedtime. 10. Metformin 1000 b.i.d. 11. Albuterol inhaler, two puffs q. 4 h. p.r.n.
SA|slow acting/sustained action|SA|157|158|TRANSFERRING MEDICATIONS|14. Compazine 5 mg p.o. q.6h. p.r.n. 15. Lyrica 50 mg p.o. b.i.d. 16. Xalatan 0.005%, latanoprost, 1 drop both eyes at bedtime for glaucoma. 17. Guaifenesin SA 600 mg p.o. b.i.d. 18. Astelin 1 spray both nares b.i.d. p.r.n. dryness. 19. Extra strength Tylenol 500-1000 mg p.o. q.4-6h. p.r.n. pain.
SA|slow acting/sustained action|SA|119|120|DISCHARGE MEDICATIONS|7. Zetia 10 mg daily. 8. Tricor 145 mg daily. 9. Maxepa 1 gram daily. 10. Hydrochlorothiazide 12.5 mg daily. 11. Imdur SA 90 mg daily. 12. Lamictal 25 mg daily. 13. Ativan 0.5 mg at bedtime p.r.n. 14. Reglan 5 mg p.o. t.i.d.
SA|sinuatrial|SA|211|212|HOSPITAL COURSE|She is admitted for further evaluation. Please refer to the history and physical for details of the present illness, past medical history and exam findings. HOSPITAL COURSE: Symptomatic bradycardia secondary to SA node dysfunction. On admission, the patient was found on EKG to have a heart rate in the 40s, which did appear to be a junctional rhythm with a narrow complex QRS escape rate in the 40s.
SA|sinuatrial|SA|184|185|HOSPITAL COURSE|It is not completely clear if the patient's recent symptoms of presyncope and recent fall are from her bradycardia, although on review of the EKGs, there clearly is a documentation of SA node dysfunction. Per the report of the nursing home or group home staff also she has had low heart rate and low blood pressure for the preceding 1 week.
SA|slow acting/sustained action|SA|156|157|DISCHARGE MEDICATIONS|Hold for loose stools. 2. Coreg 25 mg p.o. b.i.d. 3. Cepacol one lozenge p.o. q. 1 h p.r.n. sore throat. 4. Cyclosporin 200 mg tablets p.o. b.i.d. 5. Imdur SA 30 mg tablets p.o. daily. 6. Melatonin 3 mg tablets p.o. each day at bedtime. 7. Cellcept 1 gram p.o. b.i.d. 8. Protonix 40 mg p.o. daily.
SA|slow acting/sustained action|SA|168|169|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Levaquin 250 mg po qday X 10 days. 2. Metoprolol XL 50 mg po qday. 3. Allopurinol 300 mg po qday. 4. Ranitidine 150 mg po qhs. 5. Guaifenesin SA 600 mg po b.i.d. prn cough. 6. Furosemide 20 mg po b.i.d.(new medication this admission). 7. Coumadin 4 mg po qday X 4 days until follow-up with Dr. _%#NAME#%_.
SA|slow acting/sustained action|SA|222|223|DISCHARGE MEDICATIONS|8. Sinusitis. 9. Hypoxia, resolved. DISCHARGE MEDICATIONS: 1. Asacol 400 mg three tabs or 1200 mg p.o. t.i.d. 2. Augmentin 500 mg p.o. b.i.d. for five days. 3. Ferrous gluconate 324 mg p.o. daily with food. 4. Guaifenesin SA 600 mg p.o. b.i.d. p.r.n. cough. In addition, she will stay on her regular medications that she was on prior to admission.
SA|slow acting/sustained action|SA|198|199|DISCHARGE MEDICATIONS|She made steady progress and was discharged on _%#MMDD2003#%_. DISCHARGE MEDICATIONS: 1. Plavix 75 mg p.o. q.d. for 2 months. 2. Aspirin 81 mg p.o. q.d. 3. Diltiazem 180 mg p.o. q.d. 4. Guaifenesin SA 600 mg p.o. b.i.d. 5. Levothyroxine 0.75 mg p.o. q.d. 6. Zyprexa 7.5 mg p.o. q.d. 7. Warfarin 2 mg p.o. q.d. 8. Simvastatin 40 mg p.o. q.h.s. She also will continue her home nebulizer.
SA|slow acting/sustained action|SA|131|132|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Aspirin 81 mg a day. 2. Plavix 75 mg a day. 3. Zocor 20 mg p.o. q.h.s. 4. Altace 5 mg p.o. q.d. 5. Imdur SA 30 mg p.o. q.d. 6. Atenolol 25 mg p.o. q.d. 7. Folgard one tab p.o. q.d. DISCHARGE PLAN: Follow up with Minnesota Heart.
SA|sinuatrial|SA|244|245|ASSESSMENT AND PLAN|Chest x-ray, which I have personally reviewed and interpreted, shows cardiomegaly on an AP projection, but is otherwise free of any acute infiltrates or effusions. ASSESSMENT AND PLAN: 1. Bradycardia. This is most likely a toxic suppression of SA node function by the Zanaflex. It has responded well to atropine. She certainly had a symptomatic bradycardia at the nursing home.
SA|slow acting/sustained action|SA|111|112|MEDICATIONS|ALLERGIES: 1. EES 2. Sulfa 3. Levaquin MEDICATIONS: 1. Lasix 120 mg q.a.m. 2. Lasix 80 mg q. noon 3. Diltiazem SA 180 mg q. day 4. Atenolol 50 mg daily 5. Aciphex 20 mg daily 6. Isosorbide dinitrate 20 mg b.i.d. 7. Senokot S 2 tabs twice per day
SA|slow acting/sustained action|SA|111|112|DISCHARGE MEDICATIONS|5. Hydrochlorothiazide 12.5 mg p.o. q. day. 6. Isosorbide 60 mg q.h.s. 7. Cozaar 100 mg p.o. q. day. 8. Niacin SA 500 mg tablet q.h.s. 9. Lipitor 20 mg p.o. q. day. DISCHARGE FOLLOW-UP: Recommend follow-up with Dr. _%#NAME#%_ in one to two weeks, follow up with Dr. _%#NAME#%_ in four to six weeks.
SA|slow acting/sustained action|SA|123|124|DISCHARGE MEDICATIONS|2. Atorvastatin 20 mg po. qd. 3. Clopidogrel 75 mg po. qd. 4. Folic acid 1 mg po. qd. 5. Lasix 40 mg po. qd. 6. Isosorbide SA 60 mg po. q.day. 7. Lisinopril 5 mg po. qd. 8. Toprol 50 mg po. qd. 9. Pantoprazole 20 mg po. qd. 10. Spironolactone 25 mg po. qd. She is to follow-up with her primary doctor at Quello Clinic in one week and with Minnesota Heme Oncology _%#MMDD2004#%_.
SA|slow acting/sustained action|SA|170|171|DISCHARGE MEDICATIONS|2. Colace 100 mg p.o. daily. 3. Vytorin 10/80 p.o. each day at bedtime. 4. Lasix 40 mg p.o. q.a.m. 5. Metoprolol 75 mg p.o. b.i.d. 6. Multivitamins 1 tab daily 7. Niacin SA 500 mg p.o. daily. 8. Albuterol 2.5 mg/3 mL q. 4 hours while awake. 9. Flomax SA 400 mcg p.o. daily. 10. K-Dur 20 mEq p.o. b.i.d.
SA|slow acting/sustained action|SA|120|121|DISCHARGE MEDICATIONS|6. Multivitamins 1 tab daily 7. Niacin SA 500 mg p.o. daily. 8. Albuterol 2.5 mg/3 mL q. 4 hours while awake. 9. Flomax SA 400 mcg p.o. daily. 10. K-Dur 20 mEq p.o. b.i.d. 11. Oxycodone 5-10 p.o. q. 3 hours p.r.n. for moderate pain. 12. Ativan 0.5 mg p.o. each day at bedtime x2 weeks.
SA|sinuatrial|SA|159|160|PAST MEDICAL HISTORY|4) History of supraventricular tachycardia, not further specified. 5) Right hip fracture. 6) Pelvic fracture. 7) Osteoporosis. Past surgical history: Includes SA node electric ablation and a right hip fracture repair. She also has a tonsillectomy in the past. Habits: The patient continues to smoke six cigarettes a day.
SA|sinuatrial|SA|310|311||Finally, she had the angiogram which showed multiple high grade lesions involving a very large and dominant right coronary artery that received a total of 5 stents to reconstruct the entire artery from ostium down to near the crux. Dr. _%#NAME#%_ apparently related to me that there was some compromise of the SA nodal artery. She also had multiple lesions involving the left anterior descending and circumflex, none of which were tight lesions.
SA|sinuatrial|SA|179|180|ASSESSMENT AND PLAN|I am not sure why she is on Lanoxin. I have asked her to see our nurse practitioner in follow up to see what rhythm looks like in the next couple weeks, expecting the AV node and SA node conduction to become more uniform. At her request, she will follow up with Dr. _%#NAME#%_ to see how we should best follow her coronary status given the fact that her previous stress test might have represented a false negative.
SA|slow acting/sustained action|SA|136|137|DISCHARGE MEDICATIONS|3. Lanoxin 0.125 mg p.o. daily to prevent rapid heartbeat if he should go into his paroxysmal atrial fibrillation again. 4. Guaifenesin SA 600 mg one capsule twice a day to help keep his lung secretions loose as he has chronic rhonchi from his rhinitis.
SA|slow acting/sustained action|SA|122|123|MEDICATIONS|4. Coenzyme 10, 30 mg PO t.i.d. 5. Lanoxin 125 mcg PO qd. 6. Neurontin 600 mg PO b.i.d. 7. Lantus 14 units q hs. 8. Imdur SA 30 mg PO qd. 9. Evista 60 mg PO qd. 10. Demadex 20 mg PO qd. 11. Coumadin 2.5 mg PO qd. 12. K-CL 20 mEq PO b.i.d. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Noncontributory.
SA|slow acting/sustained action|SA|211|212|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: The same as on admission: 1. Calcium carbonate plus vitamin D, two tabs p.o. t.i.d. 2. Coumadin as previously scheduled, 7.5 mg p.o. q Monday and Friday, 5 mg p.o. other days 3. Verapamil SA 240 mg p.o. daily 4. Fosamax 70 mg p.o. q Sunday 5. Methotrexate 15 mg p.o. q Thursday 6. Folic acid 1 mg p.o. daily The patient is to follow up with the VA for his regular care.
SA|slow acting/sustained action|SA|449|450|SURGICAL HISTORY|She did receive PT/OT therapy while hospitalized and they agreed with the rehab recommendation, but the patient will receive home care safety evaluation instead and will go home with a walker. DISCHARGE MEDICATIONS: Cipro 250 mg b.i.d. for 5 days, Lasix 40 mg daily, Nitrostat 300 mcg sublingual p.r.n. chest pain, quinine sulfate 260 mg p.o. at bedtime p.r.n. leg cramps, Ativan 0.5 mg p.o. t.i.d. p.r.n. anxiety, Toprol XL 25 mg p.o. daily, Imdur SA 60 mg p.o. daily, Protonix 40 mg p.o. daily, lisinopril 2.5 mg p.o. daily, Lipitor 80 mg p.o. daily, Effexor XR 75 mg daily, Azmacort 4 puffs MDI b.i.d., DuoNeb q.i.d. and p.r.n., Percocet 1-2 p.o. q.6h. p.r.n. pain.
SA|slow acting/sustained action|SA|151|152|DISCHARGE MEDICATIONS|7. Organic mood disorder secondary to chronic brain injury. DISCHARGE MEDICATIONS: Same as on admission, including 1. Aspirin 81 q.d. 2. Carbamazepine SA 200 mg sustained release b.i.d. 3. Depakote 500 mg t.i.d. 4. Lexapro 20 q.d. 5. Haldol 2 q.d. 6. Keppra 500 b.i.d. 7. Lisinopril 20 q.d. 8. Metoprolol 50 b.i.d.
SA|slow acting/sustained action|SA|244|245|MEDICATIONS|After several hours and some Demerol shots his stone passed and he has been symptom free then, maintaining on a low fat diet. PAST MEDICAL HISTORY: He has no known allergies. MEDICATIONS: 1. Aspirin which is currently on hold. 2. Diltiazem 120 SA once a day. 3. Lisinopril 20 mg one-half per day. 4. Omeprazole 20 mg delayed release one daily prn for heartburn.
SA|slow acting/sustained action|SA|192|193|DISCHARGE MEDICATIONS|1. Lipitor 40 mg p.o. each day at bedtime. 2. Benadryl 25 mg p.o. each day at bedtime. 3. Climara 0.1 mg applied to skin on Tuesday. 4. Fish oil 1 tablet daily. 5. Guaifenesin/pseudoephedrine SA 600/120 0.5 mg daily. 6. Metoprolol 25 mg p.o. b.i.d. 7. diabetic supplement 1 tablet daily. 8. Multivitamin 1 tablet daily. 9. Zantac 1 tablet 150 mg p.o. daily.
SA|slow acting/sustained action|SA|157|158|CURRENT MEDICATIONS|9. Chronic low back pain. FAMILY HISTORY: Noncontributory ALLERGIES: Sulfa and erythromycin CURRENT MEDICATIONS: 1. Furosemide 40 mg p.o. q.day 2. Diltiazem SA 180 mg daily. 3. Atenolol 50 mg daily. 4. Isosorbide dinitrate 20 mg b.i.d. 5. Senokot-S one b.i.d. 6. Enteric coated aspirin 81 mg q.day.
SA|UNSURED SENSE|SA.|142|144|DISCHARGE MEDICATIONS|7. Univasc 7.5 mg G-tube q.d. 8. Isosource cans 2.5 b.i.d. 9. Restart Coumadin 4 mg G-tube MWFSOU on _%#MMDD2003#%_, and 6 mg G- tube TU, TH, SA. DISCHARGE INSTRUCTIONS: 1. The patient is discharged to home to follow-up with his primary-care physician at Smiley's Clinic.
SA|slow acting/sustained action|SA|166|167|DISCHARGE MEDICATIONS|2. Zocor 5 mg p.o. q.h.s. (for peripheral vascular disease and history of cerebrovascular accident). 3. Dilantin 200 mg p.o. q. 9 p.m. (for seizures). 4. Propranolol SA 120 mg p.o. q.d. (for tremor). This has been controlling his tremors well. 5. Reglan 10 mg p.o. before lunch and dinner (for nausea and some postoperative terminal ileus).
SA|sinuatrial|SA|243|244|LABORATORY|The first EKG obtained showed normal sinus rhythm at the rate of 84 beats per minute with sinoatrial block versus frequent several ventricular premature complexes which comes one normal sinus rhythm on one ventricular premature complex versus SA block. There is also left axis deviation and left anterior vesicular block with no specific T-wave abnormalities. Chest x-ray shows no infiltrates and no changes when compared with prior chest x-rays.
SA|sinuatrial|SA|191|192|ADDENDUM|She was started on heparin at that time. Electrophysiology came to see her in the morning following her afib- aflutter episode. It was determined that she would go to the Cath Lab to undergo SA node ablation and with a permanent pacemaker implantation for dysfunctional SA node. This was done. The patient tolerated the procedure well, and her heart rate has been a regular sinus rhythm, rate controlled at 60.
SA|sinuatrial|SA|142|143|ADDENDUM|It was determined that she would go to the Cath Lab to undergo SA node ablation and with a permanent pacemaker implantation for dysfunctional SA node. This was done. The patient tolerated the procedure well, and her heart rate has been a regular sinus rhythm, rate controlled at 60.
SA|sinuatrial|SA|213|214|HISTORY OF PRESENT ILLNESS|6. Chronic back pain. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a _%#1914#%_ white female who was noted to have acute slurred speech associated with left-sided weakness. This was most likely related to SA node dysfunction with significant bradycardia. The patient was supported aggressively. She wished to be comfort care only and she was treated as such.
SA|slow acting/sustained action|SA|173|174|DISCHARGE MEDICATIONS|ALLERGIES: IVP DYE, PENICILLIN. DISCHARGE DIET: No added salt, low cholesterol. DISCHARGE MEDICATIONS:. 1. Aspirin 81 mg p.o. q day. 2. Digoxin 125 mcg p.o. q day. 3. Imdur SA 30 mg p.o. q day. 4. Lisinopril 5 mg p.o. q day. 5. Metoprolol 12.5 mg p.o. b.i.d. 6. Protonix 40 mg p.o. q day. 7. Zocor 40 mg p.o. q day.
SA|slow acting/sustained action|SA|128|129|IDENTIFICATION|12. Lovenox 60 mg subcu twice daily. 13. Advair Discus inhaler 500/50 two times daily. 14. Tequin 400 mg daily. 15. Guaifenesin SA 600 mg twice daily. 16. Levothyroxine 175 mcg daily. 17. Milk of magnesia 30 mL daily. 18. Singulair 10 mg daily at bedtime. 19. DuoNebs at 2.5-0.5 mg 4 times daily from respiratory therapy were also ordered.
SA|slow acting/sustained action|SA|143|144|DISCHARGE MEDICATIONS|3. Lipitor 20 mg at h.s. 4. Colace 100 mg daily. 5. Lasix 20 mg b.i.d. She had been on 40 mg daily. 6. Lisinopril 5 mg daily. 7. Nitroglycerin SA 6.5 mg b.i.d. before meals. 8. Protonix 40 mg daily. 9. She will resume her normal insulin, which is 70/30 mixed, 45 units in the a.m. and 27 units in the p.m. FOLLOW-UP PLAN: She is due to follow up with Dr. _%#NAME#%_ from urology for an office cysto.
SA|slow acting/sustained action|SA|150|151|ADMISSION  MEDICATIONS|4. Lipitor 10 mg p.o. q.h.s. 5. Vitamin B12 IM 1000 mcg q. month. 6. Ranitidine 150 mg p.o. b.i.d. 7. Ditropan XL 10 mg p.o. once a day. 8. OxyContin SA 20 mg p.o. b.i.d. 9. Colace 100 mg p.o. b.i.d. 10. Ambien 10 mg p.o. q.h.s. 11. Vicodin 5/500 q.8 h. p.r.n. SOCIAL HISTORY: He quit smoking 20 years back. There is a past history of alcohol abuse.
SA|slow acting/sustained action|SA|132|133|DISCHARGE MEDICATIONS|8. Omeprazole 20 mg PO daily. 9. Digoxin 0.25 mg PO daily. 10. Atenolol 25 mg PO daily. 11. Celebrex 200 mg PO daily. 12. Oxycodone SA 40 mg PO q.8h. p.r.n. 13. Percocet 1-2 tabs PO q.6h. p.r.n. 14. Multivitamin one PO daily. 15. Albuterol MDI 2 puffs q.i.d. p.r.n.
SA|slow acting/sustained action|SA|281|282|DISCHARGE DIAGNOSES|His laboratory work showed a GGT of 167, but normal ALT and AST. His glucose was 119. His blood sugars were stable. DISCHARGE MEDICATIONS: He was discharged to Lodging Plus on the following medications: Multivitamin 1 daily, Depakote 250 mg t.i.d., Protonix 40 mg daily, diltiazem SA 120 mg 1 b.i.d., Toprol XL 200 mg 1 daily, albuterol MDI 2 puffs q.i.d., Metformin 500 mg b.i.d., lisinopril 40 mg daily, allopurinol 300 mg daily, aspirin 81 mg daily, hydrochlorothiazide 25 mg daily, Seroquel 300 mg at h.s. and Seroquel 25 mg b.i.d. p.r.n.
SA|slow acting/sustained action|SA|177|178|DISCHARGE MEDICATIONS|We are treating this with a Desitin cream and with Tucks pads as needed. DISCHARGE MEDICATIONS: Azathioprine 50 mg p.o. daily, methotrexate 5 mg p.o. each Thursday, Guaifenesin SA 1200 mg p.o. b.i.d., Combivent inhaler two puffs q six hours, albuterol nebs q four hours as needed, Protonix 40 mg p.o. daily - would continue this indefinitely with this episode of probable upper GI bleed and what I assume will be lifelong or at least extended prednisone therapy, Tequin 200 mg p.o. daily for three more days, prednisone 40 mg a day for three days, then 20 mg daily for four days, then 15 mg daily for four days, then 10 mg daily until follow up with Dr. _%#NAME#%_ or Dr. _%#NAME#%_.
SA|slow acting/sustained action|SA|138|139|HOSPITAL COURSE|He is discharged on atenolol 25 mg a day, Prozac 20 mg a day, Betaseron, Synthroid 0.2 mg a day, Prevacid 30 mg a day, cilium, tamsulosin SA 400 mcg a day and Dyazide. He will be seen in the office in 2 weeks and in 6 weeks or there about.
SA|slow acting/sustained action|SA|125|126|MEDICATIONS|4. Plavix 75 a day. 5. Hydrochlorothiazide 12.5 mg a day. 6. Isosorbide mononitrates 60 at bedtime. 7. Cozaar 100. 8. Niacin SA 500. 9. Lipitor 20. HEALTH HABITS: Smoking history none. Alcohol use none. FAMILY HISTORY: Unchanged as reviewed and unchanged from dictation by Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2004.
SA|slow acting/sustained action|SA|281|282|MEDICATIONS AT THE TIME OF DISCHARGE|However, we will need to resume that at some point in the future as he does have a history of recurrent pulmonary emboli and deep vein thrombosis. MEDICATIONS AT THE TIME OF DISCHARGE: Augmentin XR 2 grams b.i.d. times 10 days, DuoNeb by home nebulizer machine q.i.d., guaifenesin SA 1200 mg b.i.d., Flonase nasal inhaler two puffs each nostril b.i.d., Celexa 40 mg daily, Zyprexa 15 mg pill taking two pills daily, ferrous sulfate 325 mg daily, Salsalate 750 mg taking two pills t.i.d., Reglan 10 mg b.i.d., prednisone taking 5 mg in the morning and 1 mg in the evening, vitamin C 500 mg b.i.d., Levoxyl taking one 200 mcg pill plus one 25 mcg pill daily, Foltyx one pill daily, Avodart 1.5 mg daily, K-Dur 20 meq taking two pills daily, Lasix (furosemide) 40 mg daily, Prilosec 20 mg b.i.d. Coumadin and aspirin remain on hold at this time.
SA|sinus arrest|(SA)|130|133|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: 1. Acute inferior wall myocardial infarction (MI) complicated by mitral valve insufficiency and sinus arrest (SA) and AV node arrest. 2. Hyperlipidemia. 3. Noncompliance. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a lovely 70-year-old white female with a history of hyperlipidemia.
SA|slow acting/sustained action|SA|115|116|DISCHARGE MEDICATIONS|2. Hypertension. DISCHARGE MEDICATIONS: 1. Metoprolol 50 mg p.o. b.i.d. 2. Lisinopril 20 mg p.o. q. day. 3. Niacin SA 500 mg p.o. q.h.s. 4. Aspirin 81 mg p.o. q. day. DISCHARGE INSTRUCTIONS: 1. Follow up with primary care doctor in one to two weeks, either during or after discharge from transitional care unit.
SA|saturation|SA|182|183|ADMISSION PHYSICAL EXAMINATION|He does have trouble sleeping at night and requires Ativan for this. ADMISSION PHYSICAL EXAMINATION: Vitals: Temperature 99.7, heart rate 94, blood pressure 142/76, respirations 18, SA O2 is 98% on room air. GENERAL: Patient is alert and oriented, in mild discomfort. HEENT: Extraocular motions intact.
SA|slow acting/sustained action|SA|153|154|DISCHARGE MEDICATIONS|C. diff. and routine stool cultures were negative. DISCHARGE MEDICATIONS: 1. Doxycycline 100 mg p.o. b.i.d. x 3 days, stop _%#MMDD2005#%_. 2. Wellbutrin SA 200 mg p.o. b.i.d. 3. CellCept 250 mg p.o. b.i.d. 4. Gabapentin 300 mg p.o. t.i.d. 5. Neomycin 2000 mg p.o. q.i.d.
SA|slow acting/sustained action|SA|191|192|DISCHARGE  MEDICATIONS|DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. daily. 2. Metoprolol 50 mg p.o. b.i.d. 3. Lipitor 60 mg p.o. at bed-time 4. Ticlid 250 mg p.o. b.i.d. 5. Ambien 10 mg p.o. at bed-time 6. Niacin SA 500 mg p.o. each day at bed-time />
SA|slow acting/sustained action|SA|128|129|DISCHARGE MEDICATIONS|8. Prevacid 30 mg daily. 9. Trazodone 50 mg nightly. 10. Flovent 220, 2 puffs b.i.d. 11. Toprol XL 25 mg daily. 12. Guiafenesin SA 600 mg b.i.d. for 9 days. 13. Ativan 1 mg q. 6 hours p.r.n. 14. Prednisone, very slow wean. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a very pleasant 58-year-old gentleman who unfortunately had worsening shortness of breath over time before his hospitalization to the point where, when he got to the emergency room, he was having extreme difficulty breathing, and he did intubation.
SA|slow acting/sustained action|SA|139|140|DISCHARGE MEDICATIONS|7. Furosemide 20 mg p.o. daily. 8. Glyburide 1.25 mg p.o. b.i.d. 9. Nitroglycerin 0.4 mg SL p.r.n. x3 for chest pain. 10. Omeprazole 20 mg SA tablets 2 tablets p.o. q.a.m. 11. Simethicone 80 mg p.o. 4 times daily p.r.n. 12. Simvastatin 40 mg p.o. nightly. 13. Temazepam 15 mg p.o. nightly p.r.n.
SA|slow acting/sustained action|SA|171|172|DISCHARGE  MEDICATIONS|Postoperative hemoglobin 9.8, serum creatinine 1.85. DISCHARGE MEDICATIONS: 1. Coumadin per home schedule. 2. Toprol-XL 75 mg daily. 3. Norvasc 5 mg daily. 4. Isosorbide, SA 90 mg daily. 5. Furosemide 20 mg daily. 6. Prinivil 10 mg daily. 7. Lanoxin 125 mcg daily with two tablets q Sunday and Wednesday.
SA|sinuatrial|SA|175|176|PREVIOUS MEDICAL HISTORY|There is no evidence of diarrhea while the patient is here. REVIEW OF SYSTEMS: Is unable to be obtained. PREVIOUS MEDICAL HISTORY: 1. Alzheimer's disease 2. Hyperlipidemia 3. SA node dysfunction, details unclear 4. Hyperlipidemia 5. Constipation PREVIOUS SURGICAL HISTORY: 1. Bilateral cataract extractions 1995
SA|slow acting/sustained action|SA|158|159|CURRENT MEDICATIONS|14. Oxycodone 10-15 mg orally every 4 hours as needed. 15. Tylenol 650 mg orally as needed every 6 hours. 16. Lomotil 2 tablets orally q.i.d. 17. Guaifenesin SA 600 mg orally twice daily. 18. Singulair 4 mg twice daily. 19. Lyrica 50 mg orally every a.m., 100 mg every afternoon, and 100 mg orally every evening.
SA|slow acting/sustained action|(SA)|303|306|CURRENT MEDICATIONS|At that time the patient was found to have a UTI with pyelonephritis, nephrolithiasis, and had the procedures done on _%#MMDD2004#%_ as described above.) CURRENT MEDICATIONS: His medications on discharge included: 1. Aspirin 81 mg q.d. 2. Digoxin 125 mcg p.o. q.d. 3. Isosorbide mononitrate slow-acting (SA) 30 mg p.o. q.a.m. 4. Lisinopril 5 mg p.o. q.d. 5. Metoprolol XL 12.5 mg p.o. q.d. 6. Miconazole powder. 7. Simvastatin 40 mg p.o. q.h.s. 8. Ciprofloxacin 250 mg b.i.d. x 2 days.
SA|slow acting/sustained action|SA|109|110|CURRENT MEDICATIONS|1. Aspirin 81 mg a day. 2. Plavix 75 mg a day. 3. Folic acid 1 mg a day. 4. Lasix 40 mg daily. 5. Isosorbide SA 60 mg a day. 6. Lisinopril 5 mg daily. 7. Metoprolol 50 mg daily. 8. Protonix 20 mg daily. 9. Spironolactone 25 mg daily. 10. Colace 100 mg b.i.d. p.r.n.
SA|slow acting/sustained action|SA|125|126|CURRENT MEDICATIONS|ALLERGIES: None. CURRENT MEDICATIONS: 1. Coumadin 5 mg daily except for Monday and Friday when he takes 7.5 mg. 2. Verapamil SA 240 mg p.o. daily. 3. Fosamax 70 mg p.o. q. Sunday. 4. Methotrexate 15 mg p.o. q. Thursday. 5. Folic acid 1 mg p.o. daily.
SA|American Society of Anesthesiologists:ASA|SA|157|158|PLAN|We are currently holding her aspirin and have discontinued her Detrol secondary to no real benefit seen in this with her. She is otherwise doing well in the SA Class II to III for surgery. Would follow her fluid status and cardiac status closely. Basic metabolic panel is pending; we will fax when back from the lab.
SA|UNSURED SENSE|SA|142|143|HOSPITAL COURSE|That is to be followed by his hematology/oncology doctor who was notified about the result. His factor 2 SA was 14 on admission and factor 12 SA was 62. FOLLOW-UP: The patient is to follow up with his primary physician on _%#MM#%_ _%#DD#%_ and by the hematology/oncology doctor for his scheduled routine visit.
SA|slow acting/sustained action|SA|140|141|DISCHARGE MEDICATIONS|11. Ibuprofen 600 mg t.i.d. 12. Fentanyl patch 25 micrograms every three days. 13. Lidoderm patch 5% patch three patches daily. 14. Quassin SA 600 mg b.i.d. 15. Levaquin 250 mg x 10 more days. 16. Percocet one to two tablets p.o. q.6 h. p.r.n. pain. 17. Senokot one to two tablets q.h.s. p.r.n. for constipation.
SA|slow acting/sustained action|SA|117|118|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. His new medicine will be Klonopin 0.5 mg b.i.d. 2. His new doses of medicine will be Imdur SA 30 mg once a day. 3. Hydralazine 50 mg q.i.d. 4. We will hold Lasix until he is seen by cardiology on Thursday.
SA|slow acting/sustained action|SA|196|197|DISCHARGE INSTRUCTIONS|The urine culture grew out 50-100,000 Staphylococcus aureus. It was felt she was ready for discharge. DISCHARGE INSTRUCTIONS: Discharged back to nursing home, her dementia care unit on Isosorbide SA 30 mg daily, ASA 81 mg daily, Lasix 20 mg daily, atenolol 50 mg b.i.d., Avapro 150 mg each day at bed-time, Catapres patch 0.2 mg every 72 hours, cyanocobalamin 1000 mcg IM q. month, Tylenol 500 mg p.o. q.4h. p.r.n., Seroquel 12.5 mg p.o. b.i.d. and Bactrim DS 1 tablet for 5 days.
SA|slow acting/sustained action|SA|119|120|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Vasotec 5 mg p.o. b.i.d. 2. Digoxin 125 mcg p.o. daily. 3. Plavix 75 mg p.o. daily. 4. Imdur SA 120 mg p.o. daily. 5. Metoprolol XL 25 mg p.o. daily. 6. Aspirin 81 mg p.o. daily. The patient was instructed to call his cardiologist on Monday to follow up on the stress test result and the possibility of having an angiogram.
SA|slow acting/sustained action|SA|115|116|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Albuterol 90 mcg, 2 puffs inhaled q.2 h. as needed for shortness of breath. 2. Diltiazem SA 120 mg p.o. every day. 3. Phenobarbital 60 mg p.o. twice a day. 4. Simvastatin 80 mg p.o. q.h.s. 5. Afrin 81 mg p.o. every day.
SA|sinuatrial|SA|228|229|PROBLEM #2|The EKG telemetry monitor documented short periods of second degree AV block followed by a complete heart block followed by asystole for 15 seconds. It was believed that this was due to chronotropic incompetence or drug-induced SA node dysfunction. The patient was seen by Dr. _%#NAME#%_ _%#NAME#%_ from Electrophysiology who decided that the patient needs a permanent cardiac pacemaker.
SA|slow acting/sustained action|SA|140|141|CURRENT MEDICATIONS|6. Aortofemoral bypass in 2002. CURRENT MEDICATIONS: 1. Furosemide 40 mg three tablets in the a.m. and two tablets in the p.m. 2. Diltiazem SA 120 mg daily. 3. Candesartan 16 mg daily. 4. Isosorbide dinitrate 20 mg b.i.d. 5. Aciphex 20 mg b.i.d. 6. Senokot-S b.i.d. 7. Coumadin daily (usual dose 2.5 mg daily).
SA|slow acting/sustained action|SA|684|685|DISCHARGE MEDICATIONS|Chronic renal insufficiency. Patient has been seen by renal consult in _%#MM#%_ during her hospital stay and it was felt that her renal insufficiency is explained by her chronic diabetes mellitus. DISCHARGE MEDICATIONS: Patient will be discharged home on the following medication: Augmentin 500/125 p.o. b.i.d. for 12 days, Lasix 40 mg p.o. b.i.d. for three days, then 40 mg p.o. daily, ferrous sulfate 325 p.o. b.i.d., gabapentin 100 mg p.o. t.i.d., PhosLo 667 p.o. t.i.d. with meals, atenolol 25 mg p.o. daily, aspirin 325 p.o. daily, Lipitor 10 mg p.o. at bedtime, insulin Novolog 12 units t.i.d. five minutes before meals, Lantus 35 mg subcutaneously b.i.d., isosorbide sustained SA 60 mg p.o. daily. Patient needs a follow-up with her primary care clinic at _%#CITY#%_ _%#CITY#%_ Medical Center in one week on her hospitalization.
SA|slow acting/sustained action|SA|134|135|DISCHARGE MEDICATIONS|7. Bacitracin b.i.d. to right great toe and scrotal ulcer. 8. Lisinopril 20 mg p.o. daily. 9. Synthroid 125 mcg p.o. daily. 10. Imdur SA 60 mg p.o. daily. 11. Iron Niferex 150 mg p.o. b.i.d. 12. Glucotrol-XL 10 mg p.o. daily. 13. Lasix 60 mg p.o. b.i.d.
SA|slow acting/sustained action|SA|136|137|MEDICATIONS|7. Bacitracin ointment to the right great toe and scrotal ulcer b.i.d. 8. Lisinopril 20 mg a day. 9. Synthroid 125 mcg a day. 10. Imdur SA 60 mg a day. 11. Iron 150 mg twice a day. 12. Glucotrol XL 110 mg a day. 13. Lasix 60 mg twice a day.
SA|slow acting/sustained action|SA|144|145|DISCHARGE MEDICATIONS|3. Atenolol 50, a 50/50 mg p.o. daily. 4. Plavix 75 mg p.o. q. day. 5. Felodipine 5 mg p.o. daily. 6. Lisinopril 5 mg p.o. daily. 7. Omeprazole SA 20 mg p.o. b.i.d. 8. Ezetimibe tablets 10 mg p.o. daily, 9. Lovastatin 40 mg p.o. q.h.s. 10. Senokot p.r.n.
SA|slow acting/sustained action|SA|124|125|CURRENT MEDICATIONS|1. Allopurinol 100 mg b.i.d. 2. Atenolol 25 mg daily. 3. Furosemide 40 mg 3 tablets a.m. and 2 tablets at noon 4. Diltiazem SA 120 mg daily. 5 Valsartan 160 mg daily. 6. Isosorbide, dinitrate 20 mg b.i.d. 7. Zocor 40 mg daily. 8. Coumadin 5 mg daily. 9. Trileptal 150 mg b.i.d.
SA|UNSURED SENSE|SA|247|248|PROBLEM #4|She does have stool cultures pending, though she did not have a stool during this hospitalization, so collection of these specimens were not done. Of note, her lipase was normal at 133, TSH was 2.75. She does have a C. difficile culture and toxin SA pending, along with fecal leukocytes and stool culture for SSCE. Again, her diarrhea did resolve during this hospitalization. If it does return, the patient may benefit from either a colonoscopy or an EGD to work up this history of chronic diarrhea.
SA|sinuatrial|SA|158|159|IMPRESSION|He almost certainly is having an associated right ventricular infarct. His neck veins are markedly distended. There are no P-waves. He probably had atrial or SA node infarct also. I am concerned that he may have Osborn waves on his EKG and his clinical story was he was shoveling snow and collapsed outside and therefore he may also be hypothermic.
SA|sinuatrial|SA|136|137|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Urinary tract infection. 2. Down syndrome. 3. Ventricular septal defect status post repair in _%#MM#%_ 2006. 4. SA node dysfunction status post implantable pacer, _%#MM#%_ 2006. 5. Aortic insufficiency. 6. Hypothyroidism. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 6-month-old female with Trisomy 21, hypothyroidism, and status post VSD repair on _%#MM#%_ _%#DD#%_, 2006.
SA|slow acting/sustained action|SA|130|131|DISCHARGE MEDICATIONS|10. Aspart NovoLog insulin sliding scale. 11. Lamictal 100 mg p.o. daily. 12. Nicoderm patch 14 mg transdermal daily. 13. Ritalin SA 60 mg p.o. in the morning daily. 14. Senokot 2 tabs p.o. daily. 15. Desyrel 200 mg p.o. every evening for depression.
SA|slow acting/sustained action|SA|166|167|DISCHARGE  MEDICATIONS|DISCHARGE MEDICATIONS: 1. Aspirin 81 mg daily. 2. Plavix 75 mg daily. 3. Advair 250/50, 1 puff b.i.d. 4. Lisinopril 40 mg p.o. daily. 5. Lasix 20 mg daily. 6. Niacin SA 500 mg p.o. daily. 7. Protonix 40 mg daily., 8. Simvastatin 80 mg p.o. q.p.m. 9. Carafate 1 gram p.o. daily. 10. Septra-DS 1 p.o. b.i.d. x10 days.
SA|sinuatrial|SA|66|67|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Near syncopal episode due to AV nodal and SA nodal disease with bradycardia and long AV block. 2. Renal insufficiency. Probably chronic. Workup in progress, but maybe due to diabetic nephropathy, but other causes need to be evaluated for.
SA|slow acting/sustained action|SA|199|200|MEDICATIONS|He denies dysuria. REVIEW OF SYSTEMS: Otherwise negative. ALLERGIES: He is allergic to erythromycin and sulfa, Levaquin and adhesive tape. MEDICATIONS: 1. Allopurinol 100 mg p.o. b.i.d. 2. Diltiazem SA 120 mg p.o. q. day. 3. Valsartan 160 mg p.o. q. day. 4. Isordil 20 mg p.o. b.i.d. 5. Aciphex 20 mg p.o. b.i.d. 6. Trileptal 300 mg p.o. b.i.d.
SA|slow acting/sustained action|SA|124|125|DISCHARGE MEDICATIONS|1. Arimidex 1 mg p.o. q. day. 2. Lasix 40 mg p.o. q. day 3. Hydralazine 50 mg o. t.i.d., which is a new medication 4. Imdur SA 30 mg p.o. q. day. 5. Cozaar 50 mg p.o. q. day. 6. Metoprolol 50 mg p.o. b.i.d.
SA|slow acting/sustained action|SA|160|161|DISCHARGE/TRANSFER MEDICATIONS|3. Colace 100 mg b.i.d. 4. Prozac 20 mg capsules, one capsule daily. 6. Apresoline 25 mg tablets t.i.d. Hold if systolic blood pressure less than 100. 7. Imdur SA 60 mg tablets daily. 8. Ativan 0.25-0.5 mg (1/2-1 tablet) q.6h. p.r.n. anxiety. 9. Reglan 5 mg tablets 1 tablet q.i.d. p.r.n. for GERD symptoms.
SA|slow acting/sustained action|SA|145|146|MEDICATIONS|3. Lasix 40 mg b.i.d. 4. Metoprolol XL 50 mg daily. 5. Zinc oxide topically/ 6. Phoslo one tablet with each meal 7. Multivitamin daily. 8. Imdur SA 60 mg daily. ALLERGIES: None known. SOCIAL HISTORY: He is married, lives in an assisted living with his wife at _%#CITY#%_ _%#CITY#%_.
SA|sinuatrial|SA|187|188|PAST  MEDICAL HISTORY|Primary physician is Dr. _%#NAME#%_ _%#NAME#%_. The patient has also followed by Dr. _%#NAME#%_ _%#NAME#%_ of the orthopedic service previously. PAST MEDICAL HISTORY: 1. Hypertension. 2. SA node dysfunction. 3. Left ventricular hypertrophy. 4. Glaucoma. 5. Osteoarthritis. 6. History of breast cancer status post left modified radical mastectomy.
SA|slow acting/sustained action|SA|122|123|CURRENT MEDICATIONS|3. Lexapro 10 mg p.o. daily. 4. Zetia 10 mg p.o. daily. 5. Tricor 145 mg p.o. daily. 6. HCTZ 12.5 mg p.o. daily. 7. Imdur SA 30 mg p.o. daily. 8. Lamictal 25 mg p.o. q.a.m. 9. Reglan 5 mg p.o. t.i.d. 10. Zaroxolyn 2.5 mg given 30 minutes prior to Lasix dose daily.
SA|slow acting/sustained action|SA|169|170|MEDICATIONS|10. Lisinopril 2.5 mg daily. 11. Clonazepam 0.5 mg at bedtime. 12. Simvastatin 20 mg daily at bedtime. 13. Metformin 800 mg twice daily. 14. Aspirin/dipyridamole 200 mg SA one pill twice daily. ALLERGIES: None. PAST SURGICAL HISTORY: Prostate surgery. MEDICAL PROBLEMS: 1. Parkinson's disease with associated dementia.
SA|slow acting/sustained action|SA|154|155|DISCHARGE MEDICATIONS|5. Dilantin 100 mg 3 times a day. 6. Zithromax 250 mg daily for 2 more days. 7. Augmentin 875/125 one tablet daily for 9 more days. 8. Potassium chloride SA 20 mEq daily. He is requested to follow up with Dr. _%#NAME#%_ in 2 weeks and with Dr. _%#NAME#%_ on an as-needed basis.
SA|slow acting/sustained action|SA|126|127|DISCHARGE MEDICATIONS|5. Nexium 40 mg p.o. q. day. 6. Zetia 10 mg p.o. q. day. 7. Lasix 20 mg p.o. q. day. 8. Neurontin 300 mg p.o. b.i.d. 9. Imdur SA 30 mg p.o. q. day. On hold. 10. Cozaar 25 mg p.o. q. day. Hold for systolic blood pressure less than 90.
SA|sinuatrial|SA|167|168|DISCHARGE INSTRUCTION AND FOLLOWUP ARRANGEMENT|However, his presentation is also suggestive of inappropriate sinus tachycardia, which was supported by the findings of the electroanatomical mapping during EP study. SA modification can be considered in the future, however, given his young age we believe that a more conservative approach would be more appropriate initially for him.
SA|slow acting/sustained action|SA|158|159|DISCHARGE MEDICATIONS|8. Lasix 80 mg p.o. daily. 9. Gemfibrozil 600 mg p.o. b.i.d. 10. Lisinopril 2.5 mg p.o. daily. 11. Multivitamin with minerals, one tab p.o. daily. 12. Niacin SA 500 mg p.o. daily. 13. Warfarin variable dose daily. 14. Oxycodone 5 mg p.o. q. 4-6 hours p.r.n. 15. Tylenol 650 mg p.o. q. 4 hours p.r.n.
SA|slow acting/sustained action|SA|169|170|DISCHARGE MEDICATIONS|DIAGNOSES: 1. Sinusitis. 2. Pancytopenia. 3. Mildly elevated blood sugars. 4. Labial abscess. DISCHARGE MEDICATIONS: 1. Flonase 2 sprays in each nostril daily. 2. Entex SA 1 tablet p.o. b.i.d. p.r.n. cough. 3. Levaquin 500 mg p.o. daily for 14 days. 4. Mupirocin topical cream 2% to apply to the labial abscess area t.i.d. as needed.
SA|slow acting/sustained action|SA|144|145|DISCHARGE MEDICATIONS|8. Ferrous sulfate 325 mg p.o. b.i.d. 9. Furosemide 80 mg p.o. b.i.d. 10. Slo-bid 300 150 mg p.o. b.i.d. 11. Avapro 75 mg p.o. daily. 12. Imdur SA 90 mg p.o. daily. 13. Synthroid 150 mcg p.o. daily. 14. Lantus 32 units in the morning and 25 units at bedtime. 15. Humalog sliding scale. 16. Zoloft 200 mg p.o. daily.
SA|slow acting/sustained action|SA|169|170|DISCHARGE MEDICATIONS|Otherwise, her hospital stay was unremarkable. DISCHARGE MEDICATIONS: 1. Coreg 25 mg p.o. b.i.d. 2. Lisinopril 20 mg p.o. b.i.d. 3. Norvasc 10 mg p.o. daily. 4. Mucinex SA 600 mg p.o. b.i.d. 5. Renagel 3 tablets or 2400 mg p.o. t.i.d. with meals. 6. Genahist which is Benadryl 25 mg p.o. 3 times weekly after hemodialysis.
SA|sinuatrial|SA|140|141|HOSPITAL COURSE BY PROBLEM|So, this tachybrady new finding with couple of seconds pauses could be secondary to synergistic effects of AV nodal blocker versus inherent SA nodal disease. However, since that event she remained asymptomatic and she is in sinus rhythm. She is able to ambulate without having dizziness, chest pain, lightheadedness or palpitations.
SA|UNSURED SENSE|SA,|196|198|PLAN|IMPRESSION: 1. Weakness, ? secondary to dehydration. 2. Chronic diarrhea, unknown etiology with history of Crohn's. PLAN: IV fluids. Will check stools for culture, O&P, and Clostridium difficile, SA, and culture. Will obtain GI consultation. The patient may require endoscopy and/or imaging studies to clarify etiology of diarrhea.
SA|slow acting/sustained action|SA|138|139|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: He will be discharged home on his usual home medications which are as follows: 1. Lasix 40 mg p.o. b.i.d. 2. Imdur SA 60 mg p.o. daily. 3. Metoprolol XL 50 mg p.o. daily. 4. Renagel one tablet daily. 5. Flomax 400 mcg daily. 6. Hytrin 10 mg p.o. each day at bedtime.
SA|slow acting/sustained action|SA|125|126|DISCHARGE MEDICATIONS|2. Lotensin 20 mg daily, 3. Pletal 50 mg b.i.d., 4. Imdur 30 mg daily, 5. Synthroid 50 mcg daily, 6. Nasonex p.r.n. 7. Sular SA 10 mg daily. 8. Zocor 5 mg, 9. Simvastatin 5 mg at h.s., 10. Aspirin 325 mg a day. The patient was discharged in stable condition with follow-up to be as indicated.
SA|slow acting/sustained action|SA|151|152|DISCHARGE MEDICATIONS|3. Albuterol inhaler 2 puffs q.i.d. 4. Other medications include Lipitor 10 mg per day 5. Wellbutrin ________ mg in the morning, 150 mg in the evening SA 6. Calcium carbonate 1 tablet daily 7. Neurontin 100 mg t.i.d. 8. Ibuprofen 800 mg t.i.d. 9. Prevacid 30 mg in the morning
SA|slow acting/sustained action|SA|178|179|DISCHARGE MEDICATIONS|Patient is improving at the time of discharge. DISCHARGE MEDICATIONS: 1. Fosamax 70 mg once weekly. 2. Os-Cal 500 mg daily. 3. Tums Extra Strength 500 mg b.i.d. 4. Carbamazepine SA 300 mg b.i.d. 5. Lanoxin 250 mcg (patient had been on a full tablet daily, dose decreased to one-half tablet daily).
SA|slow acting/sustained action|SA|259|260|DISCHARGE MEDICATIONS|He was subsequently discharged home on _%#MMDD2002#%_, following a significant inferior wall myocardial infarction. DISCHARGE MEDICATIONS: Aspirin, Coreg 6.25 mg p.o. b.i.d., Plavix 75 mg p.o. q day, furosemide 20 mg p.o. q day, _____ 4 mg p.o. q day, Niacin SA 500 mg p.o. q h.s. and Zocor 40 mg p.o. q h.s. Nitroglycerin tablets p.r.n. Follow up with Dr. _%#NAME#%_ in one to two weeks.
SA|slow acting/sustained action|SA|174|175|DISCHARGE MEDICATIONS|2. PhosLo 667 mg p.o. t.i.d. with meals. 3. Peri-Colace p.o. b.i.d. 4. Epoetin 10,000 units SQ q. Friday. 5. Ferrous gluconate 125 mg IV q.8h. until _%#MMDD2002#%_. 6. Imdur SA 30 mg, 3 p.o. q.h.s. 7. Prevacid 30 mg p.o. q.d. 8. Metoprolol 25 mg p.o. b.i.d. 9. Silvadene cream, apply daily to lower extremity ulcers until healed.
SA|slow acting/sustained action|SA|128|129|DISCHARGE MEDICATIONS|4. Cyclosporine 0.5% 1 drop OS b.i.d. 5. Tambocor 100 mg p.o. q.d. 6. FML Forte 0.25% eye drops 1 drop OU q.a.m. 7. Guaifenesin SA 600 mg p.o. 2 tabs b.i.d. 8. Xopenex q.4h. while awake. 9. Atrovent q.4h. while awake. 10. O2 1-2 liters per nasal cannula (continuous).
SA|slow acting/sustained action|SA|153|154|DISCHARGE MEDICATIONS|2. Aspirin 81 mg p.o. q.d. 3. Flovent 110 micrograms two puffs b.i.d. 4. Lasix 20 mg p.o. b.i.d. 5. Tequin 400 mg p.o. q.d. times 7 days. 6. Imdur 30 mg SA one p.o. q.d. 7. Serevent two puffs b.i.d. The patient did have some mildly elevated blood sugars on his steroids but they have dropped rapidly as the steroids have been tapered off.
SA|slow acting/sustained action|SA|135|136|DISCHARGE MEDICATIONS|11. Combivent inhaler two puffs q.i.d. p.r.n. 12. Heparin 5000 units subq q.12h. 13. Vitamin D 800 units daily. 14. Potassium chloride SA 20 mEq daily. 15. Triamterene/hydrochlorothiazide 37.5/25 mg daily. 16. Vitamin E 400 units daily. 17. Senokot-S 1 tab daily. 18. Dulcolax suppository 1 per rectum q.12h. p.r.n.
SA|slow acting/sustained action|SA|156|157|ADMISSION MEDICATIONS|ADMISSION MEDICATIONS: Duragesic 100 mcg per hour to be changed q. 3 days, lorazepam 1 mg q. 3 to 4 hours p.r.n., Fosamax 70 mg p.o. q. Thursday, Verapamil SA 240 mg p.o. q.d., ipratropium and albuterol nebulizers q.i.d., digoxin 250 mcg q.d., metoclopramide 10 mg p.o. t.i.d. before meals, MS-04 immediate-release 15 mg p.o. b.i.d. p.r.n., Combivent 2 puffs b.i.d., Flovent 220 mcg 2 puffs b.i.d., Serevent 21 mcg 2 puffs b.i.d., Miacalcin 200 IU q.d., Peri-Colace _%#MMDD#%_ two tablets p.o. b.i.d., Prevacid 15 mg q.d., calcium with vitamin D 1500 mg p.o. q.d., ASA 81 mg p.o. q.d., prednisone 10 mg p.o. q.d., multivitamin 1 tablet p.o. q.d., megestrol 400 mg p.o. q.d. REVIEW OF SYSTEMS: Review of systems was negative for chest pain on exertion or orthopnea.
SA|slow acting/sustained action|SA|328|329|DISCHARGE MEDICATIONS|It was planned to return for repeat attempted kyphoplasty. DISCHARGE MEDICATIONS: Duragesic 100 mcg patch change q. 3 days, Megace 40 mg/ml 2 teaspoons p.o. q.a.m., multivitamin 1 tablet p.o. q.a.m., morphine immediate-release 15 mg p.o. q.4h. p.r.n., prednisone 10 mg p.o. q.a.m., Peri-Colace 2 capsules p.o. b.i.d., Verapamil SA 240 mg p.o. q.a.m., Serevent 21 mcg MDI 2 puffs b.i.d., Flovent MDI 2 puffs b.i.d., Combivent MDI 2 puffs b.i.d., lorazepam 1 mg p.o. q. 4 to 6 hours p.r.n., Fosamax 70 mcg p.o. q. Thursday a.m., Prevacid 15 mg p.o. q.a.m., metoclopramide 10 mg p.o. t.i.d., Miacalcin nasal spray q.a.m., ipratropium 0.5 mg neb q.i.d. and albuterol neb q.i.d., aspirin 81 mg p.o. q.d., K-Phos tablets p.o. q.i.d., testosterone 400 mg IM q. 4 weeks started on _%#MM#%_ _%#DD#%_, 2002, due to a total testosterone level of less than 4 ng/dl measured on _%#MM#%_ _%#DD#%_, 2002.
SA|sinuatrial|(SA)|200|203|HOSPITAL COURSE|The distal circumflex remained widely patent once it was recanalized. Dr. _%#NAME#%_ tried to angioplasty the proximal circumflex trunk but with this he compromised the blood supply to the sinoatrial (SA) nodal artery and each time the balloon was inflated there was profound sinus bradycardia with a heart rate in the 20s such that Dr. _%#NAME#%_ felt that he should not intervene on this segment further.
SA|slow acting/sustained action|SA|225|226|DISCHARGE MEDICATIONS|7. Nicotine nasal spray two sprays every hour as needed for nicotine withdrawal with maximum of 40 sprays per day. 8. Fluoxetine 40 mg p.o. q. day for depression. 9. Effexor 75 mg p.o. q. day for hot flashes. 10. Guaifenesin SA 600 mg p.o. b.i.d. for congestion/cough. 11. Trazodone 30 mg p.o. q.h.s. p.r.n. sleep. 12. Prednisone taper with 60 mg p.o. on the first day; 50 mg on the second; 40 mg on the third; 30 mg on the fourth; 20 mg on the fifth;, 10 mg on the sixth;, and off on day #7.
SA|slow acting/sustained action|SA|296|297|DISCHARGE MEDICATIONS|He is going to be discharged to a rehab facility for PT and OT, and also to get work on the memory unit, given the fact that he had some delirium which is improving but still present. DISCHARGE MEDICATIONS: 1. Biaxin 500 mg po b.i.d. for seven days. 2. Albuterol neb 2.5 mg q.i.d. 3. Guaifenesin SA 600 mg po b.i.d. 4. Imdur 90 mg po daily. 5. Lopressor 25 mg po b.i.d. 6. Risperdal 500 mg po q.p.m. 7. Sorbitol 70%, 20 cc po daily.
SA|sinuatrial|SA|219|220|IMPRESSION|Hemoglobin 12.9, white count 600. BNP is 292. IMPRESSION: 1. History of palpitations. Symptoms suggestive of intermittent supraventricular tachycardia. Since on the monitor the patient has shown a couple of episodes of SA block with approximately 2-3 second pause, because of this I will ask Cardiology to see her and evaluate for possible sick sinus syndrome.
SA|slow acting/sustained action|SA|130|131|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Coumadin 3.5 mg p.o. q.d. until Friday, then per primary MD. 2. Combivent 2 puffs q.i.d. 3. Guaifenesin SA 600 mg p.o. b.i.d. 4. Vicodin 1-2 tablets p.o. q.6h. p.r.n. pain. 5. Nystatin 5 cc p.o. q.i.d. x3 days. 6. Metoprolol 50 mg p.o. b.i.d. 7. Azmacort 4 puffs b.i.d. Rinse mouth after each use.
SA|slow acting/sustained action|SA|116|117|MEDICATIONS|6. Neurontin 300 mg four times a day. 7. Rebif 44 mcg three times a week. 8. Macrodantin 100 mg a day. 9. Potassium SA 20 mEq twice a day. 10. Pramipexole 0.125 mg twice a day. 11. Restoril p.r.n. 12. Zanaflex 2 mg twice a day and 4 mg at bedtime.
SA|slow acting/sustained action|SA|114|115|DISCHARGE MEDICATIONS|8. Fluoxetine 20 mg p.o. every day. 9. Multivitamin one tablet p.o. every day. 10. ________ 25 mg p.o. b.i.d. 11. SA 400 mcg p.o. every day. 12. Ferrous sulfate 325 mg p.o. every day. 13. OxyContin SR 20 mg p.o. every day. 14. Dilaudid 2 mg p.o. q4h p.r.n. 15. Zantac 150 mg p.o. b.i.d. DISCHARGE INSTRUCTIONS: The patient is to follow up with Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2004#%_ at 3:00 p.m.
SA|slow acting/sustained action|SA|172|173|MEDICATIONS|4. Lisinopril 5 mg p.o. b.i.d. 5. Lipitor 10 mg p.o. q.h.s. 6. Nitroglycerin p.r.n. 7. Amiodarone 400 mg tablets x 2 weeks, then 200 mg daily. 8. Wellbutrin. 9. Isosorbide SA 30 mg daily. 10. Protonix. 11. Motrin. I recommend follow-up with Dr. _%#NAME#%_ in one week.
SA|slow acting/sustained action|SA|142|143|DISCHARGE MEDICATIONS|4. Lipitor 10 mg q.h.s. 5. Dyanacobalamine 1000 mcg IM qmonth. 6. Ranitidine 150 mg p.o. b.i.d. 7. Ditropan XL 10 mg p.o. daily. 8. OxyContin SA 20 mg p.o. b.i.d. per his outpatient routine. 9. Colace 100 mg p.o. b.i.d. 10. .....powder to skin as needed t.i.d.
SA|slow acting/sustained action|SA|182|183|MEDICATIONS|PAST SURGICAL HISTORY: 1. Status-post hysterectomy in 1955. 2. Status-post appendectomy in 1957. 3. Status-post cystoscopies. MEDICATIONS: 1. Plavix 75 mg p.o. q day 2. Theophylline SA 200 mg q day. The patient did not take her theophylline dose this morning. 3. Norvasc 10 mg p.o. q day 4. Synthroid 0.025 mg p.o. q day
SA|slow acting/sustained action|SA|189|190|DISCHARGE MEDICATIONS|2. Phenobarbital 32.4 mg t.i.d. 3. Dilantin 350 mg p.o. daily script and 325 mg daily. 4. Neurontin 100 mg p.o. t.i.d. 5. Synthroid 300 mcg daily. 6. Protonix 40 mg daily. 7. Nitroglycerin SA 2.5 mg t.i.d. 8. Combivent MDI 2 puffs q.i.d. 9. Ferrous gluconate 325 mg daily. 10. Allegra 180 mg daily. 11. Cipro 500 mg p.o. b.i.d. Separate from iron, aspirin, and calcium by at least 3 hours.
SA|slow acting/sustained action|SA|118|119|DISCHARGE MEDICATIONS|6. Toprol XL 150 mg p.o. q. 09:00. 7. Protonix 40 mg p.. q. 09:00. 8. Isordil 10 mg p.o. t.i.d. 9. Potassium chloride SA 20 meq b.i.d. 10. Calcium carbonate with vitamin D b.i.d. 11. Mephyton 2.5 mg p.o. daily. 12. Lasix 20 mg p.o. b.i.d. 13. Trazodone 25 mg p.o. q.h.s. for insomnia.
SA|slow acting/sustained action|SA|100|101|CURRENT MEDICATIONS|11. History of MI 2000. 12. History of hypertension. ALLERGIES: None. CURRENT MEDICATIONS: 1. Imdur SA 60 mg p.o. daily. 2. Torsemide 10 mg p.o. daily. 3. Potassium 20 mEq p.o. daily. 4. Propranolol 40 mg p.o. b.i.d. 5. Os-Cal with D b.i.d.
SA|slow acting/sustained action|SA|114|115|DISCHARGE DIAGNOSES|4. Gabapentin 1000 t.i.d. 5. Gemfibrozil 600 b.i.d. 6. Omeprazole 20 twice a day. 7. Losartan 50 a day. 8. Niacin SA two at bedtime. 9. Trazodone 50 at bedtime. 10. Simvastatin 40 mg 1/2 at bedtime. 11. Nortriptyline 50 at bedtime. The patient presented with symptoms of chest pain in the left sternal area to the left chest that raised the possibility of ischemia.
SA|slow acting/sustained action|SA|127|128|DISCHARGE MEDICATIONS|6. Digoxin 125 mcg p.o. q other day 7. Lasix 40 mg p.o. q day 8. Zocor 20 mg p.o. q day 9. Klor-Con 8 mEq p.o. q day 10. Imdur SA 30 mg p.o. q day 11. Glipizide 2.5 mg p.o. q a.m. FOLLOW-UP: 1. Chem-7 in three to five days. 2. Quello physician in one to two weeks.
SA|slow acting/sustained action|SA|115|116|DISCHARGE MEDICATIONS|3. Neurontin 400 mg p.o. twice a day. 4. Haldol 0.5 mg p.o. twice a day. 5. Albuterol neb twice a day. 6. Lithobid SA 600 p.o. q.h.s. 7. Protonix 40 mg p.o. every day. 8. Synthroid 75 mcg p.o. every day. 9. Simvastatin 80 mg p.o. every day. 10. Nystatin swish 5 cc p.o. four times daily after meals.
SA|sinuatrial|SA|209|210|PAST MEDICAL HISTORY|Again, no focal neurologic symptoms that are new. He has not had any other recent changes in his medications. PAST MEDICAL HISTORY: Hypertension, history of stroke with a right-sided weakness nearly resolved, SA node dysfunction with pacemaker placement, depression, history of hydronephrosis treated with stenting, history of GI bleed in _%#MM2003#%_ related to aspirin and Vioxx, hypothyroidism, cardiac valve disease with moderate aortic stenosis and mitral regurgitation, history of some dysphagia, esophageal motility problems, irritable bowel, spinal stenosis, left heel arthritis, chronic anemia, hemoglobin 10, chronic renal failure with baseline creatinine of 2.2, mildly elevated potassium, bicarbonate consistent with mild RTA.
SA|slow acting/sustained action|SA|173|174|DISCHARGE MEDICATIONS|His fasting blood sugar this morning was 164. He will be discharged on sliding scale insulin as well at the Transitional Care Facility. DISCHARGE MEDICATIONS: 1. Felodipine SA 5 mg per day. 2. Gemfibrozil 600 mg b.i.d. 3. Simvastatin 10 mg a day (this was decreased due to concerns of interaction with gemfibrozil).
SA|slow acting/sustained action|SA|137|138|DISCHARGE MEDICATIONS|5. Prilosec 20 mg daily. 6. Synthroid 150 mcg daily. 7. Aspirin 81 mg daily. 8. Ambien 5 mg at night as needed to help sleep. 9. Effexor SA 150 mg each morning. 10. Metoprolol 75 mg twice daily. 11. Felodipine 5 mg daily. 12. Lasix 20 mg daily. 13. Losartan 100 mg daily. 14. Ursodiol 900 mg each morning.
SA|slow acting/sustained action|SA|200|201|DISCHARGE MEDICATIONS|7. Erythropoietin per Dr. _%#NAME#%_ of Intermed Consultants. 8. Phos-Lo 667 mg p.o. t.i.d. with meals. 9. Atenolol 25 mg daily. 10. Aspirin 325 mg daily. 11. Lipitor 10 mg at bedtime. 12. Isosorbide SA 60 mg daily. 13. Avandia 4 mg daily. 14. Norvasc 5 mg daily. 15. Triamterene, unknown dose. 16. Heparin 5000 units subcutaneous b.i.d. until patient is ambulating regularly.
SA|slow acting/sustained action|SA|142|143|DISCHARGE MEDICATIONS|We asked him to follow up with his primary physician within 2 weeks of leaving the detoxification center. DISCHARGE MEDICATIONS: 1. Diltiazem SA 120 mg p.o. b.i.d. 2. Chlorthalidone 50 mg p.o. daily. 3. Lisinopril 40 mg p.o. daily. 4. Toprol XL 200 mg p.o. daily. 5. Aspirin 81 mg p.o. daily.
SA|slow acting/sustained action|SA|299|300|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prednisone taper 60 mg p.o. daily for 3 days, then 40 mg p.o. daily for 3 days, then 20 mg p.o. daily for 3 days, then 10 mg p.o. daily for 2 days, then 5 mg p.o. daily for 2 days. 2. Levofloxacin 500 mg p.o. daily for 4 days to complete a seven day course. 3. Guiafenesin SA 600 mg p.o. b.i.d. 4. Duonebs q.6h. and q.2h. p.r.n. 5. Tessalon Perles 100 mg p.o. t.i.d. Patient is to continue her prior medications as on admission which include the following: 1. Advair 250/50, one puff b.i.d.
SA|slow acting/sustained action|SA|218|219|MEDICATIONS|The patient was admitted for further evaluation and I was asked to see him in surgical consultation. ALLERGIES: Sulfa, Levaquin, E.E.S. MEDICATIONS: 1. Allopurinol 100 mg b.i.d. 2. Furosemide 40 mg daily. 3. Diltiazem SA 120 mg daily. 4. Isosorbide dinitrate 20 mg b.i.d. 5. Atenolol 25 mg daily. 6. Zocor one tablet daily. 7. Coumadin. 8. Zoloft 100 mg daily.
SA|sinuatrial|SA|168|169|IMPRESSION|I did teach her how to do carotid sinus massage and Valsalva but I suggested it would probably be ineffective for what might be either a sinus tachycardia from pain or SA node reentry tachycardia or other high ectopic focus. I will draw a TSH today and those results will be pending. The patient does not have a primary care physician, but I will have her make an appointment with Minnesota Heart Clinic electrophysiology service to be seen by one of our doctors.
SA|slow acting/sustained action|SA|240|241|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prednisone 30 mg daily for 3 days, then 20 mg daily for 3 days, then 10 mg daily (until follow-up appointment). 2 Lexapro 5 mg daily 3. Flonase 2 sprays each nostril daily. 4. Furosemide 40 mg daily. 5. Isosorbide SA 30 mg daily. 6. Ketoprofen 10% gel apply to the back of the shoulders and upper back 3 times daily. 7. Levaquin 250 mg daily (stop after _%#MMDD2006#%_). 8. Metformin 1000 mg twice daily.
SA|slow acting/sustained action|SA|374|375|FINAL DIAGNOSES|Improved mobility to the point where she was ambulatory without overt clinical compromise. Felt stable at that point for discharge to home. DISCHARGE MEDICATIONS: Elavil 25 mg daily, Lipitor 20 mg daily, Cymbalta 60 mg daily, Flovent 220 mcg 2 puffs b.i.d. followed by rinse, Neurontin 800 mg t.i.d., Xalatan 1 drop both eyes at bedtime, Spiriva inhaler once daily, Norflex SA 100 mg b.i.d., Protonix or Nexium 40 mg p.o. daily, and Senokot-S 1 or 2 tablets 1 to 2 times daily b.i.d. FOLLOW UP: Recommended to follow up with primary care provider, Dr. _%#NAME#%_ _%#NAME#%_ the week following discharge.
SA|slow acting/sustained action|SA|162|163|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Tessalon Perles 100 mg p.o. q.4h. p.r.n. for cough. 2. Nexium 40 mg p.o. daily. 3. Guiafenesin 5-10 ml p.o. q.4h. p.r.n. 4. Guiafenesin SA 1200 mg p.o. b.i.d. 5. ___ mg p.o. q.6h. p.r.n. 6. Prednisone tapering dose, 60 mg for three days and then 50 mg for three days and then 40 mg for three days, then 30 mg for three days, then 20 mg for three days, and then 10 mg for three days and then discontinue.
SA|slow acting/sustained action|SA|101|102|DISCHARGE MEDICATIONS|4. Parkinsonism secondary to #1. 5. Bilateral groin yeast infection. DISCHARGE MEDICATIONS: Aggrenox SA (25/200 mg) orally twice daily. Corgard 40 mg orally daily. Lipitor 40 mg orally in the evening. Niaspan 1000 mg orally at bedtime.
SA|slow acting/sustained action|SA|125|126|MEDICATIONS|6. Lasix 60 mg by mouth twice daily. 7. Lisinopril 20 mg by mouth twice daily. 8. Synthroid 125 mcg by mouth daily. 9. Imdur SA 60 mg by mouth daily. 10. Glucotrol-XL 10 mg by mouth daily. 11. Lipitor 10 mg by mouth daily. 12. Allopurinol 100 mg by mouth daily. 13. Iron.
SA|slow acting/sustained action|SA|138|139|DISCHARGE MEDICATIONS|3. Nexium 20 mg daily. 4. Gabapentin 300 mg daily. 5. Flonase 0.05%, 1-2 sprays in each of the 2 nares daily for rhinitis. 6. Guaifenesin SA 600 mg twice a day. 7. Lisinopril 10 mg daily. 8. MS Contin 15 mg twice a day. 9. Vicodin 1-2 tablets every 4 hours p.r.n.
SA|UNSURED SENSE|SA,|243|245|FOLLOWUP PLANS|2. He should have a chest CT done to follow up on his pneumonia in approximately 2 to 3 weeks' time. 3. He should have his INR checked on Monday, _%#MMDD2006#%_. 4. Pending labs, ANCA, cryptococcal antigen test, histoplasma capsulatum antigen SA, aspergillus galactomannan antigen, and acid fast bacillus culture. It has been a pleasure to be involved in Mr. _%#NAME#%_ care.
SA|UNSURED SENSE|SA|258|259|PHYSICAL EXAMINATION|ENDOCRINE: Positive for possible pre-diabetes. MUSCULOSKELETAL: Positive for surgeries mentioned above. NEUROLOGIC: Negative for seizures. Cognitive is normal. PHYSICAL EXAMINATION: Temperature is 98.1, heart rate 98, blood pressure 109/64, respirations 20, SA of 2, 95% on room air. LABORATORY DATA: Urine is consistent with a stone, with 36 RBCs, 1 WBC, and moderate blood.
SA|sinuatrial|SA|227|228|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. See also previous dictations (admission in 2004 for COPD exacerbation). 2. End-stage renal disease, presumably nephrosclerosis. 3. Hypertension in the past, difficult to manage. 4. Atrial fibrillation, SA node dysfunction, not on Coumadin because of fall risk. 5. Longstanding blindness. 6. Osteoarthritis. MEDICATIONS: From the dialysis unit list: 1. Advair 250/50 one puff b.i.d.
SA|slow acting/sustained action|SA|159|160|DISCHARGE MEDICATIONS|13. Allegra 180 mg p.o. daily. 14. Flonase spray, 2 sprays to both nares p.r.n. daily. 15. Robitussin-AC 1-2 teaspoon q.8h. p.r.n. for cough. 16. Imdur 120 mg SA daily. 17. Mevacor 40 mg p.o. daily. 18. Actos 15/850 b.i.d. 19. Nitroglycerin p.r.n. 20. Protonix 40 mg p.o. daily. 21. Permax 250 mcg p.o. at bedtime.
SA|slow acting/sustained action|SA|135|136|DISCHARGE MEDICATIONS|7. Lisinopril 2.5 mg p.o. daily. 8. Oxycodone 5-10 mg q.4h. p.r.n. for pain. 9. Levaquin 250 mg p.o. daily for 10 days 10. Guaifenesin SA 600 mg p.o. b.i.d. 11. Demadex 20 mg p.o. daily. 12. K-Dur 10 mEq p.o. daily. 13. Actos 15 mg p.o. daily. 14. Combivent 2 puffs q.i.d.
SA|slow acting/sustained action|SA|123|124|DISCHARGE MEDICATIONS|5. Aspirin 81 mg p.o. daily. 6. Augmentin 500/125 mg p.o. b.i.d. x9 days. 7. Diltiazem ER 240 mg p.o. daily. 8. Tamsulosin SA 0.4 mg p.o. each day at bedtime. 9. Benefiber 1 packet p.o. daily. 10. Zocor 40 mg p.o. b.i.d.
SA|sinuatrial|SA|200|201|PAST MEDICAL HISTORY|8. Macular degeneration. 9. Glaucoma. 10. Hydrocephalus of unknown etiology. Status post VP placement for treatment of obstructive hydrocephalus in 1996. 11. History of bladder cancer. 12. History of SA node dysfunction, status post DDDR placed for sick sinus syndrome in _%#MM#%_ of 2005. PAST SURGICAL HISTORY: 1. Nasal polypectomy in 1992. 2. VP shunt placement in 1994.
SA|slow acting/sustained action|SA|146|147|DISCHARGE MEDICATIONS|11. Tylenol Extra Strength 1000 mg p.o. t.i.d. p.r.n. pain. 12. Aspirin 81 mg p.o. q. day. 13. Levaquin 250 mg p.o. daily x5 more days. 14. K-Dur SA 20 mEq tablets p.o. b.i.d. DISCHARGE FOLLOW-UP: 1. _%#NAME#%_ _%#NAME#%_ will need follow-up with her primary physician in 5-7 days.
SA|slow acting/sustained action|SA.|205|207|DISCHARGE MEDICATIONS|4. Betagan 0.5% 1 drop b.i.d. for ocular hypertension. 5. Lopressor 75 mg p.o. b.i.d. for coronary artery disease, hold if systolic blood pressure less than 90 or heart rate less than 55. 6. Nitroglycerin SA. 7. Nitro-bid b.i.d. 2.5 mg capsule p.o. each day at bedtime for coronary artery disease. 8. Zyprexa 5 mg p.o. each day at bedtime, dose to be decreased to 2.5 mg p.o. each day at bedtime on _%#MMDD2007#%_.
SA|slow acting/sustained action|SA|167|168|DISCHARGING MEDICATIONS|10. MiraLax 8.5 to 17 grams powder each day at bedtime p.r.n. constipation. 11. Zoloft 125 mg p.o. daily: This is an increase from his home dose of 100 mg. 12. Flomax SA 400 mcg p.o. daily. 13. Ambien 5 mg p.o. p.o. each day at bedtime p.r.n. 14. Tylenol 650 mg p.o. q. 6 h p.r.n. 15. Aspirin 325 mg p.o. daily.
SA|slow acting/sustained action|SA|181|182|DISCHARGE MEDICATIONS|3. Hypertension. This remains stable during hospitalization. He is to remain on his usual dose of lisinopril. DISCHARGE MEDICATIONS: 1. Gabapentin 250 mg p.o. t.i.d. 2. Guaifenesin SA 1200 mg p.o. b.i.d. 3. Ketoconazole 2% cream, apply topically to affected area 2 times a day. 4. Lisinopril 20 mg p.o. daily. 5. Sudafed syrup 30 mg p.o. t.i.d.
SA|slow acting/sustained action|SA|117|118|MEDICATIONS|2. Aspirin 325 mg p.o. q. day. 3. Seroquel 25 mg in a.m. and 50 mg in h.s. 4. Namenda 10 mg daily. 5. Sinemet 50/200 SA 1 p.o. q.i.d. 6. Tramadol 50 mg p.o. q.4h. 7. Albuterol inhaler 2 puffs q.2h. p.r.n. 8. Clonazepam 0.5 mg p.o. q.h.s. SOCIAL HISTORY: Cannot obtain except that we know that he is a nursing home resident in a memory unit.
SA|slow acting/sustained action|SA|130|131|TRANSFERRING MEDICATIONS|8. Protonix 20 mg p.o. b.i.d. 9. Compazine 5 mg p.o. q.6h. p.r.n. 10. Zofran 4 mg dissolvable tablets before meals. 11. Albuterol SA 4 mg p.o. each day at bedtime. 12. Baza cream applied to perineal area daily p.r.n. 13. Mylanta 30 mL p.o. q. 4 hours p.r.n. 14. Culturelle 1 capsule p.o. b.i.d.
SA|sinuatrial|SA|163|164|IMPRESSION/PLAN|He has been on AV nodal blocking agents in the past. On recent EP study, there was noted to be significant scarring in the right atrium, with the exception of the SA node. As such, it is easy to see how he could demonstrate pauses from time to time. Unfortunately, these are symptomatic from a standpoint of feeling flushed and presyncopal.
SA|slow acting/sustained action|SA|141|142|DISCHARGE MEDICATIONS|3. Tenormin 25 mg p.o. q. day. 4. Plavix 75 mg p.o. q. day. 5. Lopid 600 mg p.o. b.i.d. 6. Hydrochlorothiazide 12.5 mg p.o. q. day. 7. Imdur SA 60 mg p.o. q. day. 8. Benicar 20 mg p.o. q. day. 9. Caltrate Plus 600/200 one tab p.o. q. day. 10. Caduet 5/20 one tablet p.o. each day at bedtime.
SA|slow acting/sustained action|SA|115|116|DISCHARGE  MEDICATIONS|5. Leuprolide injection every 4 months. 6. Hexavitamin one tab p.o. q. day. 7. Lyrica 50 mg p.o. q. day. 8. Flomax SA 400 mcg p.o. q. day. 9. Ambien CR 12.5 mg p.o. daily at bedtime. 10. Mobic 15 mg p.o. q. day. 11. Calcium carbonate plus vitamin D 1,500 mg tablets, 2 tabs daily.
SA|slow acting/sustained action|SA|171|172|DISCHARGE MEDICATIONS|5. Prilosec 40 mg p.o. b.i.d. 6. Synthroid 224 mcg p.o. daily. 7. Lipitor 10 mg p.o. daily. 8. Losartan 50 mg p.o. daily. 9. Folic acid 400 mcg p.o. daily. 10. Isosorbide SA for Imdur 60 p.o. daily. 11. Reglan 10 mg p.o. q.i.d. DISCHARGE DIAGNOSES: 1. Right hemispheric stroke.
SA|slow acting/sustained action|SA|116|117|DISCHARGE MEDICATIONS|During this admission, we continued her Lantus as well as short-acting insulin. DISCHARGE MEDICATIONS: 1. Albuterol SA 8 mg p.o. q. 12 h. 2. Creon 20 five to six capsules p.o. with meals for pancreatic enzyme insufficiency p.r.n. with meals and snacks.
SA|slow acting/sustained action|SA,|166|168|DISCHARGE MEDICATIONS|3. Digoxin, 0.125 mg q.o.d. 4. Docusate, 100 mg b.i.d. 5. Calcium tablets, 1.25 mg q.h.s. 6. Ferrous gluconate, 324 t.i.d. 7. Lisinopril, 10 mg q.d. 8. Nitroglycerin SA, 2.5 b.i.d. 9. Demadex, 10 b.i.d. 10. Zyprexa, 2.5 q.h.s. 11. Seroquel, 25 q.h.s. DISCHARGE CONDITION: Markedly improved and stable.
SA|slow acting/sustained action|SA|240|241|MEDICATIONS|He is admitted for further treatment and evaluation. PAST MEDICAL HISTORY: Again from the chart: Significant history of strokes, congestive heart failure, diabetes. ALLERGIES: None. MEDICATIONS: From the nursing home include 1. Guaifenesin SA 600 mg p.o. q. day. Apparently he has a history of chronic obstructive pulmonary disease (COPD). 2. Glipizide 10 mg per day 3. Prinivil 10 mg per day
SA|slow acting/sustained action|SA|114|115|DISCHARGE MEDICATIONS|2. Enbrel 25 mg twice weekly. 3. Lasix 40 mg p.o. q.d. 4. Tequin 400 mg p.o. q. 24 h. x two weeks. 5. Guaifenesin SA 600 mg p.o. b.i.d. 6. Lisinopril 2.5 mg p.o. q.d. 7. Glucophage XR 1000 mg p.o. q.d. 8. Actos 15 mg p.o. q.d. 9. Multivitamin. 10. DuoNeb q.i.d. and p.r.n. 11. Amaryl per sliding scale blood sugars greater than or equal to 130 up to 160 she is to take 1 mg.
SA|sinuatrial|SA|236|237|PROBLEM #2|Although dehydration was thought to be the principle cause of her symptoms, this could be another cause causing bradycardia to mimic these symptoms. Diltiazem was discontinued secondary to its bradycardic effects and the effects on the SA node. PROBLEM #3: The patient does have a history consistent with postoperative atrial fibrillation lasting for approximately five to six months after discharge.
SA|slow acting/sustained action|SA|253|254|REASON FOR ADMISSION|He was later discharged to home with home physical and occupational therapy after he had refused nursing home placement. DISCHARGE MEDICATIONS: Aldactone 125 mg p.o. b.i.d., Atrovent 12.5 mg p.o. b.i.d. p.r.n., Neurontin 300 mg p.o. t.i.d., propranolol SA 80 mg p.o. q.a.m., theophylline 500 mg p.o. q.d., Lasix 60 mg p.o. q.d., oxycodone 20 mg p.o. q.i.d. p.r.n., KCL 20 mEq p.o. q.a.m., lansoprazole 30 mg p.o. q.a.m., tramadol 50 mg p.o. b.i.d. p.r.n., Zoloft 100 mg p.o. q.h.s., Tylenol 650 mg p.o. q. 4 to 6 hours p.r.n., lactulose 20 g p.o. t.i.d., testosterone patch 5 mg transdermal q.24h.
SA|slow acting/sustained action|SA|91|92|MEDICATIONS|PAST MEDICAL HISTORY: 1. Borderline personality. 2. Arthritis. MEDICATIONS: 1. Venlafaxine SA 35 mg po qday. 2. Risperidone 1 mg po qday. 3. Ibuprofen 400 mg po q.i.d. prn. 4. Gabapentin 100 mg po t.i.d. FAMILY HISTORY: Unknown.
SA|slow acting/sustained action|SA|142|143|DISCHARGE MEDICATIONS|2. Aspirin 81 mg p.o. q.d. 3. Lasix 40 mg p.o. q.d. 4. Tequin 200 mg p.o. q.d. x 2 additional days. 5. Isosorbide mononitrate. 6. Imdur 60-mg SA tablet q.a.m. 7. Multivitamin 1 p.o. q.d. 8. K-Dur 40 mEq p.o. q.d. 9. Tamoxifen 10 mg p.o. b.i.d. 10. Vitamin E 400 International Units (IU) p.o. q.a.m. The patient will also be discharged on oxygen.
SA|slow acting/sustained action|SA|147|148|DISCHARGE INSTRUCTIONS|4. Ceftin 500 mg p.o. b.i.d. times seven days. 5. Premarin 0.625 mg p.o. qd. 6. Allegra 180 mg p.o. qd. 7. Aerobid two puffs b.i.d. 8. Guaifenesin SA 600 mg p.o. two tabs b.i.d. 9. Bumex 1 mg p.o. qd. 10. Serevent one puff of a Diskus p.o. b.i.d.
SA|slow acting/sustained action|SA|139|140|MEDICATIONS|6. Synthroid .1 mg per day. 7. Lasix 20 mg per day. 8. Aspirin 325 mg per day. 9. Zantac 150 mg b.i.d. 10. Effexor 75 mg b.i.d. 11. Niacin SA 1000 mg p.o. h.s. ALLERGIES: None. There was some concern in the past about Novocain although she has had lidocaine without problems.
SA|slow acting/sustained action|SA|140|141|DISCHARGE MEDICATIONS|2. Combivent inhaler two puffs q.i.d. 3. Lasix 40 mg po q.d. 4. Tequin 200 mg po q.d. times 7 days. 5. Hydralazine 25 mg po t.i.d. 6. Imdur SA 60 mg po q.d. 7. Metoprolol XL 25 mg po q.d. 8. K-Dur 10 mEq po q.d. 9. Altace 10 mg po q.d.
SA|slow acting/sustained action|SA|168|169|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|Upon discharge, his medications are as follows: 1. Metoprolol 12.5 mg p.o. b.i.d. 2. Lisinopril 10 mg p.o. q day. 3. Plavix 75 mg p.o. q day. 4. Isosorbide mononitrate SA 90 mg p.o. q day. 5. Lasix 20 mg daily as needed for weight gain of more than 4 lb. I have recommended that he follow-up with Dr. _%#NAME#%_ in the Cardiology Clinic in one to two months and with Dr. _%#NAME#%_ at the Allina _%#CITY#%_ _%#CITY#%_ Clinic in two weeks.
SA|sinuatrial|SA|189|190|HOSPITAL COURSE|He also had asymptomatic bradycardia in-hospital after starting labetalol. This medication was discontinued, and his heart rate is in the 50's upon discharge. He does undoubtedly have some SA node dysfunction, but does not appear to meet criteria for a pacemaker at this time. DISPOSITION: This patient is sent home on a no added salt, qualitative diabetic diet.
SA|saturation|SA|153|154|OBJECTIVE|Her daughter is involved with her care. She does not drink alcohol. She is a nonsmoker. OBJECTIVE: Temperature 96, heart rate 97, blood pressure 170/89. SA O2 94% on 2 liters. General: The patient is a pleasant elderly woman in no distress, who is eating dinner. HEENT: Sclera anicteric, conjunctiva pink. Oropharynx is clear. Neck is without adenopathy.
SA|slow acting/sustained action|SA|174|175|DISCHARGE MEDICATIONS|6. Pneumothorax after pacemaker resolved. 7. Allergy to Amoxicillin. DISCHARGE MEDICATIONS: 1. Ferrous gluconate 324 mg one po t.i.d. 2. Lisinopril 10 mg po daily. 3. Niacin SA 500 mg po qhs. 4. Dilantin 200 mg po b.i.d. 5. Zantac 150 mg po b.i.d. 6. Zocor 40 mg po qhs. 7. Coumadin 7.5 mg qafternoon. PLAN: He will be discharged to Masonic nursing home.
SA|slow acting/sustained action|SA|137|138|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. q.d. 2. Calcium carbonate 500 mg p.o. b.i.d. 3. Cardizem CD 120 mg p.o. q.d. 4. Guaifenesin SA 600 mg p.o. b.i.d. x five more days. 5. Motrin 600 mg p.o. q.i.d. 6. Lactobacillus, one p.o. t.i.d. 7. Metoprolol 50 mg p.o. b.i.d. 8. Prednisone 10 mg p.o. q.d. x 3 days, 5 mg p.o. q.d. x 3 days then discontinue.
SA|slow acting/sustained action|SA|364|365|DISCHARGE MEDICATIONS|We will be having her activity ad lib with assistance, and her diet can be regular at this time. No added salt. DISCHARGE MEDICATIONS: Include Tylenol 325-650 mg p.o. q.6h. p.r.n., calcium carbonate 500 mg p.o. t.i.d. with meals, Lasix 10 mg p.o. q.d. in the a.m., Synthroid 125 mcg p.o. q.d., lisinopril 5 mg p.o. b.i.d., metoprolol 12.5 mg p.o. b.i.d., Kay-Ciel SA do not crush 20 mEq p.o. q.d. She is to have potassium and thyroid levels done in 1 week and results called to Dr. _%#CITY#%_.
SA|slow acting/sustained action|SA|496|497|DISCHARGE MEDICATIONS|BUN and creatinine also remained stable, and on discharge, her BUN was 27, creatinine 1.63. Her INR was checked and was 2.14. She was to follow up with the below plan. DISCHARGE MEDICATIONS: Combivent metered dose inhaler 2 puffs q.i.d.; Advair 100/50, 1 puff b.i.d.; carvedilol 3.125 mg p.o. b.i.d.; Colace 100 mg p.o. b.i.d.; furosemide 40 mg p.o. t.i.d. until followup with primary physician, hydralazine 10 mg p.o. t.i.d.; hydrocortisone 1% cream to rash b.i.d.; isosorbide mononitrate 30 mg SA p.o. daily; Lorazepam 0.5 mg p.o. t.i.d. as needed for anxiety; and Protonix 40 mg p.o. daily; Ultracet 1 to 2 tablets p.o. q. 6 hours p.r.n. pain; and warfarin 3 mg p.o. daily.
SA|slow acting/sustained action|SA|116|117|MEDICATIONS|7. Iron 325 mg p.o. t.i.d. (Patient does not recall if she is still taking this.) 8. Lasix 80 mg p.o. q.d. 9. Imdur SA 30 mg p.o. q.h.s. 10. Synthroid 100 mcg p.o. q.d. 11. Metoprolol 25 mg p.o. q.h.s. 12. Risperdal 25 mg p.o. q.h.s.
SA|UNSURED SENSE|SA,|182|184|PROBLEM #4|PROBLEM #4: Thrombocytopenia. The patient developed during hospitalization low platelet counts of 30,000. Heparin inducing antibody was negative, as well as a platelet serotonin and SA, which were ruled out heparin induced thrombocytopenia. The etiology most likely is multifactorial with a combination of splenic sequestration, drug effect, or Flolan, as well as post-transfusion purpura.
SA|slow acting/sustained action|SA|154|155|DISCHARGE MEDICATIONS|2. Celecoxib 200 mg p.o. q.d. 3. Flexeril (cyclobenzaprine) 10 mg p.o. t.i.d. 4. Docusate 100 mg p.o. b.i.d. 5. Lisinopril 40 mg p.o. q.d. 6. Nisoldipine SA 10 mg p.o. q.d. 7. Potassium gluconate 550 mg p.o. q.d. 8. Raloxifene 60 mg p.o. q.d. 9. Quinine sulfate 200 mg p.o. q.h.s.
SA|sinuatrial|SA|139|140|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: 1. Congestive heart failure. 2. Hypovolemia. 3. Mild renal acute failure. 4. Atrial fibrillation. 5. Malnutrition. 6. SA node dysfunction. 7. Coronary artery disease. 8. Ischemic cardiomyopathy. 9. Hyperlipidemia. 10. Hypertension. 11. Urinary tract infection. 12. Hypothyroidism. 13. Status-post coronary artery bypass.
SA|slow acting/sustained action|SA|175|176|DISCHARGE MEDICATIONS|17. Nitroglycerin 0.4 mg sublingually prn. 18. Tranxene 7.5 mg q8h prn anxiety. 19. Quinine 324 mg qd prn leg cramps. 20. Kay Ciel 10 mEq, five tablets q.i.d. 21. Guaifenesin SA 600 mg, two po b.i.d. 22. Singulair 10 mg qd. 23. Lanoxin 0.125 mg po qd. 24. Tricor 160 mg po qd. 25. Coumadin to begin 48 hours after surgery. 26. Multi-vitamins one po qd.
SA|slow acting/sustained action|SA|131|132|DISCHARGE PLAN|6. Proscar 5 mg p.o. q.d. 7. Advair (250/50) 1 puff b.i.d. 8. Folic acid 1 mg p.o. q.d. 9. Tequin 400 mg p.o. q.d. 10. Guaifenesin SA 600 mg p.o. t.i.d. 11. Lisinopril 5 mg p.o. q.d. 12. Multivitamin 1 p.o. q.d. 13. Protonix 40 mg p.o. 30-60 minutes before first meal daily.
SA|UNSURED SENSE|SA,|196|198|FOLLOW UP|2. Bone marrow biopsy on _%#MM#%_ _%#DD#%_, 2004, at Masonic Day Hospital. 3. Bone survey on _%#MM#%_ _%#DD#%_, 2004. 4. Patient will go to Masonic Cancer Clinic for labs including immunoglobulin SA, beta 2 microglobulin. SPEP and UPEP, CBC, LFTs and chemistries. 5. CBC, diff, platelet every Monday and Thursday at Fairview _%#CITY#%_.
SA|slow acting/sustained action|SA|319|320|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1) Prednisone 60 mg p.o. q.d. x one week then 40 mg p.o. q.d. x one week, then 20 mg p.o. q.d. x one week. 2) Toprol XL 25 mg p.o. q.d. 3) Spiriva one puff p.o. q.d. 4) Elavil 25 mg p.o. q.d. 5) Singulair 10 mg p.o. q.d. 6) Protonix 40 mg p.o. q.d. 7) Albuterol two puffs p.o. q.i.d. 8) Liquibid SA 600 mg p.o. b.i.d. p.r.n. 9) Albuterol nebs one q4h p.r.n. DISPOSITION: The patient was discharged home in the care of herself as well as her mother, who was present today.
SA|slow acting/sustained action|SA|137|138|DISCHARGE MEDICATIONS|We will send a faxed copy of this dictation to Dr. _%#NAME#%_. DISCHARGE MEDICATIONS: 1. Synthroid 0.075 mg p.o. daily. 2. Nitroglycerin SA 2.5 mg p.o. b.i.d. 3. Alphagan 0.15% eye drops, one drop to the left eye twice a day. 4. Gatifloxacin 200 mg p.o. daily times three days for urinary tract infection.
SA|slow acting/sustained action|SA|282|283|DISCHARGE MEDICATIONS|ABDOMEN: Benign. DISCHARGE LABS: White count 8.5, hemoglobin 13.6, platelets 217,000, sodium 142, potassium 5, chloride 112, bicarb 24, BUN 12, creatinine 0.65. DISCHARGE MEDICATIONS: 1. Calcium carbonate one tablet p.o. q day. 2. Multivitamin one tablet p.o. q day. 3. Guaifenesin SA 600 mg p.o. b.i.d. 4. Ambien 5-10 mg p.o. q h.s. prn. 5. Levofloxacin 500 mg p.o. q day times seven days.
SA|slow acting/sustained action|SA|313|314|PLAN|Attention and concentration adequate. Poor insight and judgment. The patient has no gait problems.no language problems DIAGNOSIS: The patient has methamphetamine dependence, alcohol dependence, Marihuanadependence. The patient has major depressive disorder, recurrent. PLAN: Patient will be started on Wellbutrin SA 100 mg b.i.d. for depression Patient was also started on Topamax 25 mg a day and 50 mg at night to target patient's symptoms of cocaine craving, methamphetamine craving.
SA|slow acting/sustained action|SA|165|166|PLAN|Axis II: Deferred. Axis III: None. Axis IV: Severe homelessness, unemployed. Axis V: 50. PLAN: The patient will continue treatment. He will be started on Wellbutrin SA to target symptoms of low motivation and also to improve his concentration. The patient will be seen in 1 week. The patient will continue Phase II here.
SA|slow acting/sustained action|SA|179|180|DISCHARGE MEDICATIONS|4. Valcyte 900 mg p.o. daily. 5. Sodium bicarbonate 1300 mg p.o. b.i.d. 6. Protonix 40 mg p.o. daily. 7. Aspirin 81 mg p.o. daily. 8. Mycelex Troche 10 mg p.o. q.i.d. 9. Aggrenox SA 1 capsule p.o. b.i.d. 10. Folic acid 400 mg p.o. b.i.d. 11. Lantus 20 units subcutaneously q.h.s. 12. Humalog sliding-scale subcutaneously: 120-149, 1 unit; 150-199, 2 units; 200-249, 3 units; 250-299 5 units; 300-349, 7 units; greater than 350, 8 units.
SA|slow acting/sustained action|SA|194|195|PLAN|The patient has 4 children. At this time she denied any thoughts to hurt them. She will work with DCFS. 2. At this time was seeking medication for stopping cocaine use. Will give her Wellbutrin SA to target both her symptoms of cocaine craving and smoking 100 mg b.i.d. The patient will return in 7 days. 3. The patient will work with her case manager regarding disposition/after care.
SA|slow acting/sustained action|SA|192|193|PLAN|Dysthymia . Social anxiety disorder. Axis II: Cluster C. Axis III: Asthma. Axis IV: Moderate. Axis V: GAF: 50. PLAN: Patient will continue Lexapro 20 mg, Seroquel 50 mg, started on Wellbutrin SA 100 mg and increased up to 200 mg a day to increase symptoms of amotivation. The patient will follow up with Dr. _%#NAME#%_ in 3 weeks and he will have aftercare in Fairview.
SA|slow acting/sustained action|SA|167|168|PLAN|Axis II: Deferred. Axis III: Asthma, hay fever, status post partial hysterectomy. Axis IV: Moderate. Axis V: GAF = 50. PLAN: The patient will be started on Wellbutrin SA 100 mg 1 tablet in the morning for 3 days and then increase to 200 mg. The patient will return to the clinic in 1 week.
SA|slow acting/sustained action|SA|99|100|PLAN|Axis III: None. Axis IV: Moderate. Axis V: GAF 45. PLAN: The patient will be started on Wellbutrin SA 100 mg a day. The patient will complete Lodging Plus Program. He will follow up according to the recommendations of the counselors for aftercare.
SA|slow acting/sustained action|SA|165|166|MEDICATIONS|He denies alcohol and drug use. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Wellbutrin SR 200 mg bid (am/hs). 2. Depakote 750 mg q am, 1000 q hs. 3. Lithium SA 300 mg q hs. 4. Neurontin 300 mg q am, 400 mg q hs. 5. Celexa 60 mg q am. 6. Remeron 45 mg q hs.
SA|slow acting/sustained action|SA|114|115|PLAN|Axis II: Deferred. Axis III: None. Axis IV: Moderate. Axis V: 50. PLAN: The patient will be started on Wellbutrin SA 100 mg for 4 days and then increased to 200 mg. The patient will return in 1 week for follow uo. At the time of interview, the patient denied any suicidal or homicidal ideation, plan, or intent.
SA|slow acting/sustained action|SA|147|148|CURRENT MEDICATIONS|4. NitroQuick 0.4 mg under the tongue q.5h. minutes for up to three doses p.r.n. pain. 5. Temazepam 15 mg p.o. q.h.s. 6. Potassium chloride 10 mEq SA one by mouth daily. 7. Prednisolone 1% drops in both eyes daily. 8. Toprol-XL 100 mg p.o. daily. 9. Vitamin D 400 international units two tablets by mouth daily.
SA|slow acting/sustained action|SA|126|127|TRANSFER MEDICATIONS|4. Calcitonin nasal spray 1 spray daily. 5. Sinemet CR 50/200 one tablet p.o. b.i.d. 6. Colace 100 mg p.o. b.i.d. 7. Liquibid SA 600 mg p.o. b.i.d. 8. Insulin sliding scale. 9. Lisinopril 20 mg p.o. daily. 10. Remeron 30 mg p.o. q.h.s. 11. Morphine, appears to be 4 mg IV q.4 hours.
SA|slow acting/sustained action|SA.|135|137|MEDICATIONS|3. Endocet prn. 4. Magnesium oxide. 5. Compazine prn. 6. Zofran prn. 7. Anzemet prn. 8. MS-Contin SR. 9. Senokot. 10. Morphine sulfate SA. 11. Neurontin. HABITS: No history of cigarette smoking or alcohol abuse.
SA|slow acting/sustained action|SA|149|150|CURRENT MEDICATION|CURRENT MEDICATION: 1. Fentanyl patch 25 mcg started yesterday. 2. Actiq transmucosal fentanyl 400 mcg q.4 h. p.r.n., as per pain team 3. Wellbutrin SA 200 mg b.i.d. 4. CellCept 250 mg b.i.d. 5. Gabapentin 300 mg t.i.d. 6. Neomycin 200 mg 4x daily. 7. Prednisone 7.5 mg b.i.d. 8. Prograf 1.5 mg b.i.d.
SA|slow acting/sustained action|SA|134|135|OUTPATIENT  MEDICATIONS|8. Ambien. 9. Ecotrin 81 mg p.o. q. daily. 10. Glipizide EL 2.5 mg p.o. q. daily. 11. Ventolin inhaler 2 puffs q.i.d. 12. Guaifenesin SA 600 mg p.o. b.i.d. ALLERGIES: Trazodone. FAMILY HISTORY/SOCIAL HISTORY: Reviewed and per documentation on FCIS.
SA|sinuatrial|SA|177|178|ASSESSMENT/PLAN|SKIN: No obvious lesions or rashes. ASSESSMENT/PLAN: 1. Sinus bradycardia, sinus block, junctional escape. The etiology of this is unclear. Differential diagnosis would include SA or AV nodal ischemia, possibly due to right coronary artery lesion. Other differential diagnoses would include congenital conduction system disease, Lyme disease, sarcoid, thyroid disorder.
SA|slow acting/sustained action|SA|174|175|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1. Glargine 76 units at bedtime. 2. Novolog sliding scale. 3. Aspirin 1 daily. 4. Calcium carbonate 1250 mg a day. 5. Lithium 60 mg a day. 6. Isosorbide SA 30 mg a day. 7. Lisinopril 40 mg a day. 8. Metoprolol XR 75 mg a day. 9. Protonix 40 mg a day. 10. K-Dur 10 mg a day.
SA|slow acting/sustained action|SA.|685|687|MEDICATIONS|PAST MEDICAL HISTORY: Significant for coronary vascular disease, anterior myocardial infarction, transient ischemic attack, with carotid artery disease of no more than 70%, hypertension, dyslipidemia, macular degeneration, constipation, post-traumatic stress disorder, chronic kidney disease, status post left-sided surgery due to war injuries in the brachial plexus on the left and the left leg, with residual weakness and numbness in those extremities. MEDICATIONS: On admission include Ocuvite, potassium chloride, Remeron, cider vinegar tablet daily, lovastatin, metoprolol, acidophilus, Fibercon, minoxidil, lisinopril, Aggrenox twice a day, baby aspirin daily, Lasix, nifedipine SA. ALLERGIES: Codeine, and malaria medication. FAMILY HISTORY: He has no family history of seizure disorder.
SA|MISTAKE:Oncotype DX|SA|191|192|HISTORY OF PRESENT ILLNESS|The patient did not have any lymphovascular invasion however the margins were positive. The patient underwent reexcision. Her primary pathology reveals negative HER2 receptor. Her uncle type SA showed low risk of recurrence to be about 5% over the next 10 years according to Dr. _%#NAME#%_. It was decided to not proceed chemotherapy and use Arimidex after her radiation is finished to her right breast.
SA|MISTAKE:Oncotype DX|SA|212|213|ASSESSMENT AND PLAN|No swelling. ASSESSMENT AND PLAN: 62-year-old postmenopausal ER PR positive graded II right breast cancer with a stage T2 N0 M0. The patient is elected not to proceed with chemotherapy because of high uncle type SA value and will plan to use Arimidex instead. The patient is here for right breast radiation. The possible benefit reducing local recurrences, as well as benefit to the survivor has been discussed.
SA|UNSURED SENSE|SA.|89|91|HISTORY OF PRESENT ILLNESS|The patient has worked in the veterinary field in the past. She also has been working at SA. She may have lost her job. She has been living with her parents recently. The patient enters Fairview Recovery Services at this time with an addiction to opiates.
SA|slow acting/sustained action|SA|148|149|MEDICATIONS|5. COPD 6. Bladder outlet obstruction. 7. History of increased lipids. MEDICATIONS: 1. Citalopram hydrobromide 40 mg once a day. 2. _________ 10 mg SA once a day. 4. Zocor 80 mg 1/2 tablet at bedtime. 5. Hydrochlorothiazide/lisinopril 12.5 mg/20 mg p.o. daily. 6. Ibuprofen 800 mg p.o. daily.
SA|sinuatrial|SA|204|205|IMPRESSION|A year and a half ago it was mild, although on exam it seems to be at least moderate. She has multiple pauses, some of which were no doubt brought on by beta blocker but she obviously shows an unreliable SA node for small amount of beta blocker to do this and she had multiple falls in 2005 which in retrospect may have been due to the same problem and she has chest pain.
SA|sinuatrial|SA|164|165|ASSESSMENT/PLAN|What is more difficult is the etiology of his sinus arrest and complete heart block. One must assume in his age and with a history of chest pressure that it may be SA nodal or AV nodal ischemia until proven otherwise, possibly a right coronary artery lesion or a left circumflex left dominant system lesion.
SA|sinuatrial|SA|264|265|IMPRESSION|This slowly improved from a creatinine of 17 and BUN of 101, I am sure partially related to blood absorption, to a most recent creatinine of 1.3 with a BUN of 46. The EKG is reviewed and shows left bundle branch block with evidence of bradycardia and intermittent SA block. IMPRESSION: My impression is on review of the echo report that she probably has a form of Tako-Tsubo's, and that often is associated with a mild troponin bump.
SA|sinuatrial|SA|229|230|PAST MEDICAL HISTORY|The colonoscopy was suboptimal due to inadequate prep. EGD showed gastric ulcer, which was then treated with PPI medication. Medical problems include hypertension, hypothyroidism, CVA with mild residual weakness, diverticulosis, SA node dysfunction, peptic ulcer disease and dysphasia, possible Parkinson's disease as well. Also, the patient reports having had rectal prolapse surgery at Mayo Clinic and may have had his hernia repair at that time.
SA|slow acting/sustained action|SA|172|173|MEDICATIONS|3. Hydrochlorothiazide 12.5 mg daily. 4. Terazosin 5 mg q.h.s. 5. Omeprazole 20 mg twice daily. 6. Pepto-Bismol 1 tsp. daily p.r.n. abdominal discomfort. 7. Lithium 450 mg SA 1 tablet q.h.s. 8. Gemfibrozil 600 mg twice a day. 9. Melatonin 3 mg at night p.r.n. SOCIAL HISTORY: The patient lives with this 40-year-old son.
SA|sinuatrial|SA|200|201|ASSESSMENT/PLAN|ASSESSMENT/PLAN: 1. Bradycardia, unclear etiology. The patient has no obvious medication cause. This is probably secondary to vagal stimulation from gastric pouch fullness or possibly could be due to SA node dysfunction such as sick sinus syndrome. Will plan to have her on tele. TSH was checked in the emergency room and was normal at 0.72. Will also check a cardiac echo and add troponin to the pending one in the ER and also have one in the morning.
SA|slow acting/sustained action|SA|145|146|CURRENT MEDICATIONS|9. Tonsillectomy/adenoidectomy. ALLERGIES: Vicodin. CURRENT MEDICATIONS: 1. Aspirin 81 mg p.o. q. day. 2. Tequin 400 mg p.o. q.d. 3. Guaifenesin SA 600 mg p.o. q. 12 h. 4. Hydrochlorothiazide 25 mg p.o. q.d. 5. Lisinopril 2.5 mg p.o. q.d. 6. Solu-Medrol 125 mg IV q. 6 h. 7. Multivitamin.
SA|slow acting/sustained action|SA|143|144|MEDICATIONS|MEDICATIONS: 1. Aspirin 81 mg p.o. daily, which is on hold. 2. Zocor 80 mg p.o. daily at bedtime. 3. Glipizide 10 mg p.o. b.i.d. 4. Metoprolol SA 100 mg p.o. b.i.d. 5. Isosorbide mononitrate 30 mg p.o. daily. 6. Hydralazine 50 mg p.o. t.i.d. 7. Lasix 60 mg in the morning and 40 mg at night.
SA|slow acting/sustained action|SA|215|216|MEDICATIONS|MEDICATIONS: He is on a variety of medications, including albuterol nebulization therapy, Symmetrel, vitamin C, Lioresal, Pulmicort, Respules, Valium, Pulmozyme inhaling twice daily, Prozac 40 mg daily, guaifenesin SA twice daily, Zestril twice daily, multivitamins. Relafen is also on schedule. Roxicodone twice daily and on Protonix, Mirapex and Lyrica. He is also on Senokot as part of his bowel program.
SA|sinuatrial|SA|170|171|PAST MEDICAL HISTORY|We were asked to see in regards to any symptom management as well as any supportive care that we could offer the family. PAST MEDICAL HISTORY: 1. Atrial fibrillation. 2. SA node dysfunction, status post pacemaker insertion. 3. Hypothyroidism with ablation. 4. Dementia. 5. Prostate cancer. 6. TIA. 7. Bilateral sensorineural hearing loss. 8. Hypertension. 9. Chronic ischemic heart disease.
SA|slow acting/sustained action|SA|152|153|MEDICATIONS|MEDICATIONS: 1. Docusate 100 mg BID 2. Mucomyst 2 ml inhaler solution every 4 hours 3. Avdair Diskus 500/50 one BID 4. Lasix 60 mg 1 BID 5. Guaifenesin SA 1200 mg BID 6. Heparin 5,000 units sub Q every 12 hours 7. Vicodin 1 or 2 a day 8. Insulin 9. Atrovent nebulizer
SA|slow acting/sustained action|SA|149|150|MEDICATIONS|2. Imdur 30 mg q h.s. 3. Levaquin 500 mg t.i.d. 4. Lexapro 20 mg every other day. 5. Lipitor 10 mg p.o. q.i.d. 6. Lisinopril 40 mg q day. 7. Mucinex SA 600 mg b.i.d. 8. Neurontin 200 mg p.o. q a.m. 9. Neurontin 300 mg p.o. q h.s. 10. Advair discus. 11. Aspirin 81 mg daily. 12. Lasix 40 mg b.i.d.
SA|slow acting/sustained action|SA|189|190|MEDICATIONS|5. Ferrous gluconate 324 mg once a day. 6. Advair 250/50 1 puff b.i.d. 7. Lasix 40 mg once a day. 8. Liquibid 600 mg b.i.d. 9. Novolog insulin. 10. Lantus insulin. 11. Isosorbide monitrate SA 60 mg once a day. 12. Synthroid 100 mcg once a day. 13. Nasonex one spray once a day. 14. Protonix 40 mg once a day. 15. Deltasone 5 mg once a day.
SA|sinuatrial|SA|298|299|PAST MEDICAL HISTORY|She states she only takes Tylenol for arthritis pains. Her husband states she has had black outs for at least a year, felt to be secondary to orthostatic hypotension. She has had a pacemaker for about 5 years. PAST MEDICAL HISTORY: Notable for recurrent syncopal episodes, history of pacemaker for SA node dysfunction, autonomic neuropathy, hypertension, osteoporosis, polymyalgia rheumatica, macular degeneration, hearing loss, peptic ulcer disease and remote history of a diverticular bleed status post left hemicolectomy.
SA|sinuatrial|SA|134|135|IMPRESSION|I am going to switch her IV diltiazem to oral diltiazem and continue her on her regular medications. Will have to watch for worsening SA or AV block; she is now Lopressor and low dose diltiazem; I will use 120 mg a day. If she breaks through on this we would either consider amiodarone, or talking to her once again about invasive procedures such as EP study and possible ablation, which at this point she does not necessarily want.
SA|sinuatrial|(SA)|390|393|IMPRESSION AND RECOMMENDATIONS|She is doing well postoperatively. She does have heart block and I would note that her EKG prior to surgery showed a left bundle-branch block with left axis deviation and this on top of the aortic valve surgery would suggest that she may ultimately need a pacemaker but we will see if she makes recovery of her A-V node. As I mentioned, she actually had atrial standstill so her sinoatrial (SA) node also needs to be watched also. She was a smoker and I do not know if she was evaluated for emphysema but that will have to be watched as we try to wean her from the ventilator.
SA|slow acting/sustained action|SA|210|211|MEDICATIONS|History of depression, anxiety. History of alcohol abuse. Possible history of a seizure disorder. Status post cholecystectomy. MEDICATIONS: Include Flexeril 10 mg tid, Zestril 10 mg a day, Seroquel 200 mg bid, SA 325 mg a day, Colace 100 mg a day, Neurontin 300 mg tid, Zantac 150 mg bid and Trileptal 900 mg bid. He has no known drug allergies. FAMILY HISTORY: Significant for a father with heart disease, mother with cancer.
SA|sinuatrial|SA|144|145|IMPRESSION|IMPRESSION: This patient is status post large ASD repair. She is having junctional rhythms, this is probably due to edema and irritation of the SA AV node area from the large defect and repair. Her blood pressure is a bit low on dopamine, but is relatively stable.
SA|slow acting/sustained action|SA|140|141|MEDICATIONS|1. Plavix 75 mg daily. 2. Digoxin 0.0625 mg daily. 3. Allegra 180 mg daily. 4. Vitamin C 500 mg daily. 5. Lasix 40 mg daily. 6. Guaifenesin SA 600 mg p.r.n. 7. Robitussin-AC 5 mL q.6 h. p.r.n. 8. Hydralazine 25 mg t.i.d. 9. Imdur 30 mg daily. 10. Betagan eye drops 0.5% both eyes daily.
SA|UNSURED SENSE|SA|124|125|PHYSICAL EXAMINATION|Knees negative. Feet negative. Ankles: Left normal, right ankle lateral malleolus is tender in the ATF and CF areas. Stable SA grade 1 to 2.sprain. Achilles intact both sides. Babinski's negative. UPPER EXTREMITIES: Negative upper extremities. LAB DATA: Sodium 139, potassium 3.3, calcium 9.6. Urinalysis shows trace hematuria.
SA|sinuatrial|(SA)|185|188|IMPRESSION|He is not on nitrates at this time. His heart rhythm is unstable. He may be actually reperfusing already, or alternatively this may be a very proximal lesion and he may have sinoatrial (SA) node ischemia. RECOMMENDATIONS: We will need to take the patient directly to the Heart Catheterization Laboratory.
SA|UNSURED SENSE|SA|275|276|ASSESSMENT AND PLAN|Currently patient is on Lovenox 20 mg q.12 h. and since possible DVT is very high with knee surgery, will continue Lovenox for now until we get repeat hemoglobin, or if stool returns positive for occult bleed, then we may hold Lovenox. 4. Diarrhea; will check C. diff toxin, SA and culture, abnormal LFT or secondary to Lipitor. 5. Hypertension, under good control, but will hold Ziac if blood pressure is less than 100/60.
SA|UNSURED SENSE|SA|227|228|SUMMARY  OF CASE|S she is alert, oriented, and interactive. She and is not febrile at this time, but does have leukocytosis with a white cell count of 16,600 this morning. sShe remains in good. She she ccontinues to retain good renal function. SA she had a flat plate of . Of her abdomen today that showed some abnormal small bowel loops in the left abdomeabdomen.
SA|sinuatrial|SA|186|187|LABORATORY DATA|Otherwise normal EKG. Chest x-ray report is not yet on the chart. When I saw the patient, I rubbed on his neck and he had a very, very long pause with occasional P-waves suggesting both SA and AV block. Interestingly, this did not make the patient dizzy although he was supine when I did it. This was a very impressive hypersensitive carotid sinus syndrome on the left side only, not the right side.
SA|slow acting/sustained action|SA|172|173|MEDICATIONS|4. Ankylosing spondylitis 5. Hypertension 6. Status post appendectomy 7. Status post ventral hernia repair 8. Status post TURP MEDICATIONS: At this time include 1. Pentasa SA 1000 mg p.o. q.i.d. 2. Solu-Medrol 15 mg IV q6 hours 3. Procardia 30 mg p.o. q.day 4. Protonix 40 mg p.o. q.day 5. K-Dur 20 mEq p.o. t.i.d.
SA|slow acting/sustained action|SA|145|146|CURRENT MEDICATIONS|1. Aspirin 325 mg daily. 2. Plavix 75 mg daily. 3. Advair 250/51 puff b.i.d., 4. Glipizide 10 mg p.o. b.i.d. 5. Claritin 10 mg daily. 6. Niacin, SA 1,000 mg p.o. q.h.s. 7. Toprol XL 50 mg daily. 8. Prilosec 20 mg daily. 9. Zocor 40 mg q.h.s. 10. Metformin 1,000 mg p.o. b.i.d.
SA|UNSURED SENSE|SA|148|149|ASSESSMENT|ASSESSMENT: 1. Depression with thoughts of self-harm. 2. Intermittent headaches, likely muscle-contraction related. 3. Sexual assault; she received SA FER evaluation at the time. RECOMMENDATIONS: Routine labs were ordered and will be followed if results abnormal.
SA|UNSURED SENSE|SA|159|160|REVIEW OF SYSTEMS|No TB. Nonsmoker, worked in banking, no known environmental exposure, no pets, hobbies, travel. No seasonal allergies. Had a flu shot and a pneumonia shot. No SA symptoms at baseline. No shortness of breath, no dyspnea on exertion, no nocturnal symptoms. Triggers are smoke, dust, cold air. She does not normally wheeze.
SA|sinuatrial|SA|266|267|LABORATORY DATA|The underlying QRS complex, however, is completely normal. Telemetry also shows a rare episode where he does the same thing with a dropped beat and the dropped beat interval is roughly twice the P to P interval from the previous beats. Again, I suspect that this is SA exit block and it may represent SA node Wenckebach. IMPRESSION: This patient had a dizzy spell, but no syncope.
SA|sinuatrial|SA|301|302|LABORATORY DATA|The underlying QRS complex, however, is completely normal. Telemetry also shows a rare episode where he does the same thing with a dropped beat and the dropped beat interval is roughly twice the P to P interval from the previous beats. Again, I suspect that this is SA exit block and it may represent SA node Wenckebach. IMPRESSION: This patient had a dizzy spell, but no syncope.
SA|sinuatrial|SA|158|159|IMPRESSION|Again, I suspect that this is SA exit block and it may represent SA node Wenckebach. IMPRESSION: This patient had a dizzy spell, but no syncope. He has shown SA exit block, this occurring in the setting of a fractured wrist and pain. This is probably a variation of a vasovagal episode. I did do carotid sinus massage, it was negative.
SA|slow acting/sustained action|SA|121|122|MEDICATIONS|3. Zocor 20 mg daily. 4. Regular insulin 15 units daily. 5. Singulair 10 mg daily. 6. Risedronate 35 mg weekly. 7. Imdur SA 60 mg daily. 8. Diovan/hydrochlorothiazide daily. 9. Aspirin 81 mg daily. 10. Calcium with vitamin D supplement.
SA|slow acting/sustained action|SA|549|550|CHIEF COMPLAINT|2. Appendectomy. 3. Rotator cuff repair. 4. Herniorrhaphy. MEDICATIONS: Synthroid 75 mcg per day, albuterol nebulizers twice a day, Zyprexa 40 mg at hour of sleep, Zocor 80 mg per day, Haldol 0.5 mg t.i.d., Lidoderm patch, Dilaudid p.r.n., Protonix 40 mg every day, Ativan 0.5 mg every 6 hours, Prilosec 20 mg per day, sliding scale NovoLog schedule, fentanyl patch 125 mcg every 72 hours, Lexapro 20 mg daily, Azmacort 2 puffs b.i.d., Wellbutrin sustained release 150 mg twice a day, Combivent 2 puffs t.i.d., Neurontin 400 mg b.i.d., and Lithobid SA 600 mg at hour of sleep. ALLERGIES: PENICILLIN, MORPHINE, AND IVP DYE. SOCIAL HISTORY: The patient is disabled, lives in the Episcopal Nursing Home.
SA|saturation|SA|195|196|PHYSICAL  EXAMINATION|Other organ systems were reviewed and are noncontributory. PHYSICAL EXAMINATION: GENERAL: Sedated, intubated. VITAL SIGNS: Temperature 37.5, pulse 80, blood pressure 113/60, respiratory rate 12, SA O2 sats 100% on 70% FIO2. Chest x-ray - no pneumothorax postoperatively, no focal infiltrates. Arterial blood gas this morning pH of 7.37, pCO2 of 37, pO2 of 62 on, I believe, 45% FIO2.
SA|UNSURED SENSE|SA|163|164|SOCIAL HISTORY|HABITS: Nonsmoker, alcohol history as above. FAMILY HISTORY: Negative for alcoholism. SOCIAL HISTORY: The patient lives with her sister. She works part-time at an SA gas station. She also works part-time housecleaning at a hotel. REVIEW OF SYSTEMS: GI as noted, otherwise negative for ten-point system review.
SA|slow acting/sustained action|SA|102|103|MEDICATIONS|8. History of Parkinson's disease for which he has been on Sinemet and Namenda. MEDICATIONS: 1. Imdur SA 60 mg daily 2. Lisinopril 20 mg a day 3. Metoprolol XL 50 mg a day 4. Aspirin 325 mg a day which was held starting _%#MM2008#%_.
SA|UNSURED SENSE|SA|391|392|PAST MEDICAL HISTORY|Flomax was started to help him empty his bladder, and Nystatin was started because his mother wanted him on something that would prevent yeast infections while he was on antibiotics because he was prone to them in the past, and he decompensates when he does have yeast infections. An Infectious Disease consult was obtained at that time. A throat culture, UA/UC, quantitative immunoglobulin SA EBV antibody titer screen, Lyme disease titer screen, ASO titer, ESR, and C-reactive protein were all done and were within normal limits.
SA|sinuatrial|SA|228|229|PAST MEDICAL HISTORY|1. Parkinson's disease. 2. Inguinal hernia. 3. Mild thrombocytopenia which has been stable. 4. Mild anemia which has been stable. 5. Borderline hypertension. 6. Labyrinthitis. 7. Hypothyroidism. 8. Dyslipidemia. 9. Syncope with SA nodal dysfunction 10.Benign prostatic hypertrophy. 11.Cervical disk disease. 12.Previous patellar fracture. MEDICATIONS: 1. Carbidopa/levodopa 25/100 1 b.i.d.
SA|sinuatrial|SA|330|331|IMPRESSION|Her medicines were recently changed. She now presents with hypotension and marked sick sinus syndrome with sinus bradycardia and sinus arrest. I suspect that this is a combination of an elderly woman with conduction disturbance as evidenced by the left anterior hemiblock, and then the addition of the beta blocker suppressed her SA node further, plus her blood pressure dropped probably from a combination of the Lotrel which is in a higher combination and the atenolol.
SA|slow acting/sustained action|SA|155|156|ADMISSION MEDICATIONS|ALLERGIES: He is intolerant of Bumex and mayonnaise. ADMISSION MEDICATIONS: 1. Prograf 0.5 mg b.i.d. 2. Hydralazine 25 mg q.i.d. 3. Isosorbide mononitrate SA 60 mg a day. 4. Multivitamin one a day. 5. Prednisone 5 mg a day. 6. Zocor 20 mg a day. 7. Single strength Septra 1 a day. 8. Aspirin 1 a day.
SA|slow acting/sustained action|SA|172|173|CURRENT MEDICATIONS|7. Metoprolol 25 mg p.o. b.i.d. 8. Remeron 30 mg p.o. q.h.s. 9. Vitamin ___ 50,000 IU p.o. twice a week on Monday and Thursday. 10. Nephrocaps one p.o. q.day 11. Oxycodone SA 10 mg q.a.m. It looks like this was discontinued on _%#MM#%_ _%#DD#%_. 12. Senokot two tablets p.o. b.i.d. 13. Trazodone 50 mg p.o. q.h.s.
SA|UNSURED SENSE|SA|186|187|LABORATORY DATA|Coordination was normal on screening exam today. LABORATORY DATA: Included a hemoglobin of 13.1, white cell count 6.6 and platelet count 373,000. Cultures are as reported above. His INR SA is susceptible to gentamicin, tetracycline, sulfa drugs, vancomycin and linezolid but resistant to others on this testing panel. Thank you very much for the opportunity to examine _%#NAME#%_ _%#NAME#%_ and to help with his care.
SA|slow acting/sustained action|SA|132|133|PRESENT MEDICATIONS|ALLERGIES: Codeine, erythromycin (GI upset). Environmental allergies, i.e., dust mites, trees, etc. PRESENT MEDICATIONS: 1. Sudafed SA 120 mg b.i.d. p.r.n. 2. Guaifenesin LA 600 mg b.i.d. p.r.n. 3. Simethicone 80 mg q.i.d. p.r.n. 4. Vioxx 25 mg daily. 5. Flonase 1 to 2 sprays each nostril b.i.d.
SA|slow acting/sustained action|SA|157|158|CURRENT MEDICATIONS|ALLERGIES: Cardura. CURRENT MEDICATIONS: 1. Albuterol nebulizer 2.5 mg q.i.d. 2. Diltiazem 120 mg p.o. daily 3. Advair 500/50 one puff b.i.d. 4. Guaifenesin SA 1200 mg p.o. b.i.d. 5. Methylprednisolone 50 mg IV q.8h. 6. Protonix 20 mg p.o. daily 7. Zosyn 3.375 mg IV q.8h. 8. Spiriva 18 mcg inhaled capsule daily 9. Dulcolax suppository 10 mg per rectum daily
SA|sinuatrial|SA|217|218|PAST MEDICAL HISTORY|Since admission, she has done well. This morning, she had one small formed bowel movement without blood. She denies any sick contacts. PAST MEDICAL HISTORY: 1. Osteoporosis. 2. Venous insufficiency. 3. Depression. 4. SA node dysfunction status post pacemaker placement. 5. History of constipation. 6. History of hemorrhoid surgery. 7. Appendectomy. 8. Gastric resection for peptic ulcer disease in 1974.
SA|slow acting/sustained action|SA|129|130|MEDICATIONS|5. Hypertension. 6. Hypercholesterolemia. MEDICATIONS: 1. Niacin SR 500 mg twice a day. 2. Adalat CC 60 mg daily. 3. Propranolol SA 60 mg daily. 4. Risperdal 6 mg in the evening. 5. Seroquel 100 mg in the morning, 200 mg at 8 p.m. 6. Zoloft 200 mg every morning. 7. Enteric-coated aspirin 81 mg a day.
SA|slow acting/sustained action|SA|150|151|MEDICATIONS|3. Recent tobacco dependence. 4. Hypothyroidism. 5. Macrocytosis. 6. Recent tooth extraction 1 week prior to last admission. MEDICATIONS: 1. Aggrenox SA 25/100 one tablet p.o. b.i.d. 2. Levaquin - completed course 2 days ago. 3. Synthroid 100 mcg p.o. daily. 4. Nicotine patch. 5. Prednisone taper. 6. Spiriva. 7. Budesonide inhaler.
SA|slow acting/sustained action|SA|142|143|MEDICATIONS|11. Prinivil 40 mg a day. 12. Lorazepam 1 mg daily p.r.n. anxiety. 13. Metformin 1000 mg twice a day. 14. Multivitamins 1 daily. 15. Prilosec SA 20 mg daily. 16. Seroquel 500 mg q.h.s. 17. Actonel 35 mg weekly. 18. Spiriva inhaler 1 puff daily. 19. Effexor XR 75 mg daily. 20. Ativan 1 mg each day at bedtime.
SA|sinuatrial|SA|175|176|PAST MEDICAL HISTORY|5. Morbid obesity. 6. GERD. 7. Renal cell carcinoma in 1990s, status post right nephrectomy. 8. Hypothyroidism. 9. Anemia of chronic disease. 10. Spinal stenosis of L3-4. 11. SA node dysfunction. Followed by a doctor at Methodist. 12. Incisional hernia. 13. Sciatica. 14. UTI diagnosed preoperatively on _%#MMDD2007#%_.
SA|sinuatrial|SA|345|346|PAST MEDICAL/SURGICAL HISTORY|The patient states she had no symptoms for this. Prior to the surgery, the patient denied decreased force of stream, hematuria, dysuria, prior bladder surgery, prior urologic radiation, infections, trauma, family history of urologic cancers, obstructive voiding symptoms or history of stones. PAST MEDICAL/SURGICAL HISTORY: Atrial fibrillation, SA node dysfunction, hypertension, depression, congestive heart failure, hypothyroidism, spinal stenosis, morbid obesity, esophageal reflux, AV node ablation, hysterectomy, bilateral TKA, gastric bypass, closed reduction of left distal femur, incisional hernia repair, and exploratory surgery of parathyroid glands.
SA|sinuatrial|SA|283|284|IMPRESSION/REPORT/PLAN|3. Elevated liver enzymes. Will order all the appropriate tests to be done to further evaluate this elevation of liver enzymes, which may be due to trauma/fall to the muscles. However we need to exclude hepatitis, hemachromatosis, etc. 4. Sinus pause due to overdrive suppression of SA node. I dont think that this constitutes an indication of pacer, but it will be reasonable to run it by an electrophysiologist after the weekend, as recommended by Dr _%#NAME#%_.
SA|saturation|SA|155|156|PHYSICAL EXAMINATION|She is a former smoker. REVIEW OF SYSTEMS: Negative. PHYSICAL EXAMINATION: VITAL SIGNS: She is on Bipap and cannot speak well with Bipap, pulse was 83 and SA O2 was 96%. Respiratory rate is in the high 20s. HEENT: Normocephalic, atraumatic. No rashes. EXTREMITIES: No cyanosis, clubbing or edema. Peripheral pulses are intact.
SA|slow acting/sustained action|SA|135|136|DISCHARGE MEDICATIONS|4. Proscar 5 mg p.o. daily. 5. Megace 400 mg solution p.o. daily. 6. Reglan 10 mg p.o. q.i.d. 7. CellCept 250 mg p.o. b.i.d. 8. Nicene SA 250 mg p.o. daily. 9. Protonix 40 mg p.o. daily. 10. Prednisone 5 mg p.o. daily. 11. Seroquel 100 mg p.o. each day at bedtime.
SA|slow acting/sustained action|SA|138|139|MEDICATIONS ON TRANSFER|7. Advair 500/50 one puff b.i.d. 8. Lorazepam 0.5 mg b.i.d. 9. Quinine sulfate 260 mg q.h.s. 10. Protonix 40 mg each day. 11. Guaifenesin SA 600 mg t.i.d. 12. Flonase 2 sprays each nostril each day. 13. Lexapro 10 mg each day 14. Vasotec 5 mg each day.
SA|slow acting/sustained action|SA|177|178|DISCHARGE MEDICATIONS|4. Seroquel 25 mg p.o. b.i.d. 5. Os-Cal vitamin D 1250 mg p.o. b.i.d. 6. Pantoprazole 40 mg p.o. q. day. 7. Senna/docusate 1 tab p.o. b.i.d. p.r.n. constipation. 8. Guaifenesin SA 600 mg p.o. q. day. 9. Fosamax 70 mg p.o. every Monday. 10. Aricept as previously prescribed, was not continued during hospitalization.
SA|slow acting/sustained action|SA|152|153|MEDICATIONS|10. Lisinopril 20 mg p.o. daily. 11. Aspirin/dipyridmole one tablet p.o. b.i.d. 12. Aspirin 81 mg p.o. daily. 13. Lasix 20 mg p.o. daily. 14 Nifedipine SA two 60 mg pills p.o. at nighttime ALLERGIES: Codeine and malaria medication. FAMILY HISTORY: No family history of seizure disorder. SOCIAL HISTORY: The patient does not smoke; he drinks about 4 ounces of brandy in the evening which was evaluated and discussed with him during his VA visit last time.
SA|slow acting/sustained action|SA|179|180|ADDENDUM|Mrs. _%#NAME#%_ brought in Mr. _%#NAME#%_'s medication list and they are as follows: 1. Acetaminophen with codeine 30 mg tablets, one p.o. q 6 hours prn pain. 2. Diltiazem 120 mg SA one p.o. q day. 3. Oxybutynin 5 mg one b.i.d. 4. Allegra 60 mg one b.i.d. 5. Temazepam 15 mg one q h.s. prn insomnia .
SA|slow acting/sustained action|SA|140|141|CURRENT MEDICATIONS|4. Ambien 5-10 mg orally q.h.s. p.r.n. insomnia. 5. Magnesium oxide 400 mg b.i.d. 6. Remeron 30 mg orally every h.s. 7. Potassium citrate - SA for Urocit-K 2160 mg tablets t.i.d. for potassium supplementation. Also, 2 tablets of 10 mEq total dose equals 20 mEq or 2160 mg. 8. Insulin Aspart Novolog sliding scale q.i.d. 9. Insulin Aspart Novolog 1 unit subcu t.i.d. before or immediately after meals.
SA|slow acting/sustained action|SA|154|155|DISCHARGE MEDICATIONS|7. Ferrous gluconate 325 mg p.o. b.i.d. 8. Fish oil, 1 gram p.o. daily. 9. Folic acid 1 mg p.o. daily. 10. Gemfibrozil 600 mg p.o. b.i.d. 11. Guaifenesin SA 600 mg p.o. b.i.d. for ten days. 12. Hydralazine 25 mg p.o. t.i.d. 13. Imdur 30 mg p.o. daily. 14. Imodium 4 mg capsules p.o. b.i.d. and p.r.n. for diarrhea.
SA|UNSURED SENSE|SA|155|156|LABORATORY|On discharge the patient's examination was basically unchanged. LABORATORY: Significant laboratory data showed the patient's INR to be 5.95. Her factor II SA was 18 with her goal being between 15 and 25%. Her white blood cell count was 10.8, hemoglobin was 14.5, and platelets were 268.
SA|slow acting/sustained action|SA|117|118|DISCHARGE INFORMATION|6. Neoral 200 mg p.o. b.i.d. 7. Pulmozyme 2.5 mg inhaled b.i.d. 8. Lactoba cillus 1 tablet p.o. t.i.d. 9. Mesalamine SA 750 mg p.o. b.i.d. 10. ADEK gel caps, 2 caps p.o. b.i.d. 11. Tazarotene 0.05% gel applied to arms and legs b.i.d.
SA|slow acting/sustained action|SA|145|146|DISCHARGE MEDICATIONS|10. Cosopt 1 drop OU b.i.d. 11. Refresh preservative free artifical tears, 2 drops OU q.i.d. 12. Docusate sodium 100 mg p.o. b.i.d. 13. Aggrenox SA 1 cap p.o. q.d. 14. Albuterol MDI, 2 puffs q.i.d. 15. Os-Cal Plus D 1 tab p.o. b.i.d. 16. Regular insulin sliding scale. HISTORY OF PRESENT ILLNESS: This is a 71-year-old female who was transferred from Nile Health Care Center with a three day history of increased confusion, decreased p.o. intake, and complaint of pain.
SA|slow acting/sustained action|SA|138|139|MEDICATIONS|11. 70/30 insulin 80 units subq q.a.m. and 38 units at 4:00 p.m. 12. Metformin 500 mg b.i.d. 13. Finasteride 5 mg daily. 14. Theophylline SA 300 mg tablet, 1 tablet b.i.d. 15. Oxygen 3-1/2 liters nasal cannula during the day, 3 liters at night. ALLERGIES: Augmentin, metoprolol. REVIEW OF SYSTEMS: RESPIRATORY: Stable, dyspnea on exertion, no recent cough, fevers, chills.
SA|slow acting/sustained action|SA|156|157|MEDICATIONS|11. Simvastatin 80 mg p.o. q.h.s. 12. Docusate sodium with Senna two tablets by mouth 3x a day. 13. Quinine 260 mg p.o. q.h.s. 14. Potassium chloride 8 mEq SA q.d. 15. Metoprolol 100 mg p.o. b.i.d. 16. Gabapentin 400 mg two capsule by mouth t.i.d. 17. Lasix 40 mg p.o. q.d. 18. Folic acid one tablet p.o. q.d.
SA|slow acting/sustained action|SA|120|121|DISCHARGE/TRANSFER MEDICATIONS|2. Nexium 20 mg capsules daily. 3. Ferrous sulfate 325 mg daily. 4. Robitussin-AC 5-10 cc q.h.s. p.r.n. cough. 5. Imdur SA 60 mg daily. 6. Culturelle 1 capsule b.i.d. for loose stools. 7. Synthroid, current dose 50 mcg 1 tablet daily. 8. Imodium 4-mg capsules q.6 h. p.r.n. loose stools, maximum 14 mg daily.
SA|UNSURED SENSE|SA|201|202|PROBLEM #6|A factor V Leiden was negative (_%#MMDD2002#%_). Antiphospholipid work up including cardiolipin, IgG, and IgM level was negative. Beta II glycoproteins IgG and IgM were negative. A lupus anticoagulant SA was also negative. The patient, nonetheless, was recommended to start empirically on vitamin B12 1 mg p.o. q.d., vitamin B6 50 mg p.o. q.d., and folic acid 1 mg p.o. q.d. Homocystine levels were not checked.
SA|UNSURED SENSE|SA|196|197|ASSESSMENT|There are blood and urine cultures pending at this time, and we will do a diagnostic paracentesis at the bedside in order to rule out SBP as a possible etiology. While we await the results of the SA fluid studies, we will start her empirically on antibiotic therapy for SBP with Cefotaxime. We will continue her doses of Lactulose and Rifaximin and ensure that she is having an adequate number of bowel movements while she is here in the hospital.
SA|slow acting/sustained action|SA|180|181|CURRENT MEDICATIONS|3. Coumadin (causes nausea). CURRENT MEDICATIONS: Her current medications per her assisted- living records include: 1. Norvasc 2.5 mg p.o. q.d. 2. Aspirin 81 mg p.o. q.d. 3. Imdur SA 60 mg p.o. q.d. 4. Toprol XL 100 mg p.o. q.d. 5. Protonix 40 mg p.o. q.d. 6. Potassium chloride 20 mEq p.o. q.d.
SA|slow acting/sustained action|SA|167|168|HOME MEDICATIONS|3. Calcium with vitamin D, 500 mg of calcium and 200 units of vitamin D one b.i.d. 4. Lasix 20 mg b.i.d. 5. Klor-Con 20 mEq t.i.d. 6. Protonix 20 mg daily. 7. Mucinex SA 600 mg b.i.d. 8. Verapamil extended release 180 mg daily. 9. Nasonex nasal spray two sprays to each nostril daily 10. Vitamin E 400 units daily 11. Vitamin D 400 units daily
SA|slow acting/sustained action|SA|166|167|CURRENT MEDICATIONS|2. Iron gluconate 325 mg b.i.d. 3. Neurontin 100 mg t.i.d. 4. Novolog insulin sliding scale with meals. 5. Aspirin 325 mg daily 6. Lipitor 10 mg q.h.s. 7. Isosorbide SA 60 mg daily 8. Avandia 4 mg daily 9. Norvasc 5 mg daily 10. Triamterene 37.5 mg daily 11. PhosLo 667 mg tab one tab t.i.d. with meals
SA|slow acting/sustained action|SA|158|159|MEDICATIONS|MEDICATIONS: 1. Vancomycin 1 gram Tuesday, Thursday, Saturday an on dialysis Coreg 25 mg b.i.d. 2. Lisinopril 20 mg b.i.d. 3. Norvasc 10 mg daily. 4. Mucinex SA 600 mg p.o. b.i.d. 5. Renagel 2400 mg t.i.d. with meals. 6. Benadryl 25 mg post-hemodialysis. 7. Plavix 75 mg daily.
SA|slow acting/sustained action|SA|109|110|MEDICATIONS|MEDICATIONS: 1. Lisinopril 10 mg b.i.d. 2. Furosemide 20 mg daily. 3. Fish oil 1 gram twice a day. 4. Niacin SA 250 mg daily. 5. Ranitidine 150 mg b.i.d. 6. Senokot-S two tablets q.p.m. 7. Latanoprost ophthalmic solution each eye for allergies. 8. Cosopt both eyes daily.
SA|slow acting/sustained action|SA,|221|223|DISCHARGE MEDICATIONS|5. Coumadin: We will restart her Coumadin after her outpatient esophagogastroduodenoscopy. 6. Erythromycin 500 mg p.o. t.i.d. times three days, per electrophysiology for her pacemaker placement. 7. Isosorbide mononitrate SA, 45 mg p.o. q day (increase from 30 mg). 8. Losartan 100 mg p.o. q day 9. Pantoprazole 40 mg p.o. q day
SA|slow acting/sustained action|SA|118|119|MEDICATIONS|1. Aspirin enteric-coated 81 mg p.o. daily. 2. Thiamine 100 mg p.o. daily. 3. Clonazepam 1 mg at bedtime. 4. Depakote SA 1000 mg at bedtime. 5. Prozac 40 mg p.o. q.a.m. 6. Gabapentin 300 mg p.o. t.i.d. 7. Vytorin 1 tablet p.o. daily. 8. Levalbuterol inhaler 1 puff q. 8 hours p.r.n. shortness of breath.
SA|slow acting/sustained action|SA|161|162|DISCHARGE RECOMMENDATIONS|3. Hydrochlorothiazide 12.5 mg p.o. q.a.m. 4. Doxazosin 2 mg p.o. daily. 5. Simvastatin 80 mg p.o. each day at bedtime. 6. Prednisone 5 mg p.o. daily. 7. Flomax SA 400 mcg p.o. daily. 8. Warfarin 4 mg p.o. daily. 9. Albuterol MDI 2 puffs q.4h. p.r.n. wheezing. FOLLOW-UP APPOINTMENTS: Mr. _%#NAME#%_ is to follow up with his primary care physician on Monday, _%#MMDD#%_ for a Coumadin management.
SA|slow acting/sustained action|SA|153|154|CURRENT MEDICATIONS|2. Aspirin 325 mg enteric-coated daily 3. Calcium 250 mg/vitamin D 125 tablet b.i.d. 4. Plavix 75 mg p.o. q. day. 5. Docusate b.i.d. 6. Felodipine 10 mg SA p.o. q. day. 7. Formoterol fumarate 12 mcg capsule inhaled one q.12h. 8. Lasix 40 mg tablets p.o. q. day. 9. Insulin NPH 20 units subq q.a.m. and 14 units subq q.p.m.
SA|slow acting/sustained action|SA|113|114|CURRENT MEDICATIONS|8. Lasix 40 mg tablets p.o. q. day. 9. Insulin NPH 20 units subq q.a.m. and 14 units subq q.p.m. 10. Imdur 60 mg SA tablet p.o. q. day. 11. Metoprolol 150 mg p.o. b.i.d. 12. Nitroglycerin tablets p.r.n. 13. Simvastatin 40 mg p.o. day.
SA|UNSURED SENSE|SA,|185|187|VITAL SIGNS|NEUROLOGIC MENTAL STATUS: Alert, oriented, attention, language, speech intact. Cranial nerves 2 through 12 normal. MOTOR: Diffusely decreased bulk, strength 5 out of 5 bilaterally with SA, EE, EF, WF, WE, FE, DI, HF, HE, HAB, HADB, KF, KE, PF, normal dexterity and speed in bilateral upper extremities.
SA|slow acting/sustained action|SA|139|140|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Rocaltrol 0.375 mcg q.d. 2. Os-Cal 1,000 mg b.i.d. 3. Synthroid 150 mcg q.d. 4. Metoprolol 25 mg b.i.d. 5. Imdur SA 30 mg q.d. 6. Furosemide 80 mg q.d. 7. Potassium chloride 20 mEq b.i.d. 8. Prednisone 5 mg q.d. 9. Prevacid 15 mg q.d. 10. Fosamax 70 mg once a week.
SA|slow acting/sustained action|SA|168|169|DISCHARGE MEDICATIONS|13. Pantoprazole 40 mg every 12 hours. 14. Dilantin 200 mg b.i.d. 15. Detrol-LA 4 mg every day. 16. Residronate 35 mg once a week on Fridays 16. Isosorbide mononitrate SA 30 mg daily. 17. Effexor 75 mg t.i.d. 18. Baclofen 10 mg q.i.d. 19. Plavix 75 mg daily. 20. Vitamin 500 mg twice a day. 21. Vitamin B12 1000 mcg every 4 hours.
SA|slow acting/sustained action|SA|154|155|DISCHARGE MEDICATIONS|6. Lasix 40 mg p.o. b.i.d. 7. Imodium 4 mg capsules p.o. t.i.d. p.r.n. diarrhea. 8. Lopressor 75 mg p.o. b.i.d. 9. Myfortic 360 mg p.o. b.i.d. 10. Niacin SA 250 mg p.o. daily. 11. Zofran 48 mg p.o. IV q.i.d. Give 30 minutes prior to meals and medications. 12. Protonix 40 mg p.o. daily. 13. Prednisone 5 mg p.o. daily.
SA|slow acting/sustained action|SA|158|159|TRANSFERRING MEDICATIONS|Please refer to review of systems for further data. TRANSFERRING MEDICATIONS: 1. Fosamax 70 mg p.o. weekly on Fridays. 2. Protonix 40 mg p.o. daily. 3. Imdur SA 90 mg daily. 4. Synthroid 88 mcg daily. 5. Toprol XL 150 mg p.o. daily. 6. Plavix 75 mg daily. 7. Multivitamin with minerals one tablet daily. 8. Colace 100 mg p.o. b.i.d. p.r.n.
SA|slow acting/sustained action|SA|206|207|TRANSFERRING MEDICATIONS|13. Actonel 35 mg weekly. 14. Spiriva daily. 15. Coumadin 5 mg daily x4 weeks with a goal INR of 2 to 3. 16. Tylenol 650 mg orally p.r.n. q.6h for pain.. 17. Lomotil 2 tablets orally q.i.d. 18. Guaifenesin SA 600 mg p.o. q.12h. 19. Ambien 10 mg q. h.s. p.r.n. 20. Nystatin 500,000 units p.o. x5 q. day.
SA|sinuatrial|SA|215|216|ASSESSMENT|His electrolytes are all normal. CBC is normal. The 12-lead EKG showed a right bundle branch block and marked sinus bradycardia down to 25 beats per minute. ASSESSMENT: 1. Cardiac dysrhythmia, bradycardia, question SA node dysfunction. 2. Syncope on collapse. 3. Palpitations, history of, with temporary transvenous pacer in 2006. 4. Asthma, severe, persistent with mild exacerbation currently. 5. Other unspecified sleep apnea.
SA|slow acting/sustained action|SA|200|201|MEDICATIONS AT DISCHARGE|7. Haldol 0.5 mg p.o. twice a day. 8. Lidoderm patch, apply 1 patch to pain site on for 12 hours, off for 12 hours as needed. 9. Duo-Neb 2.5/0.5, 1 neb treatment 4 times daily as needed. 10. Lithobid SA 600 mg p.o. q.h.s. 11. Protonix 40 mg p.o. daily. 12. Dilaudid 1 to 2 mg p.o. q.3 h. p.r.n. breakthrough pain. 13. NovoLog insulin sliding scale for blood glucose of 0 to 150 gives 0 units subcu; for blood glucose 151 to 200 give 1 unit subcu; for a blood glucose 201 to 250 give 2 units subcu; for a blood glucose 251 to 300 give 3 units subcu; for blood glucose 301 to 400 give 4 units subcu; if blood glucose is greater than 400 please recheck the glucose.
SA|slow acting/sustained action|SA|126|127|MEDICATIONS|5. Enalapril 20 mg b.i.d. 6. Lexapro 30 mg daily. 7. Advair 500/50, 1 puff b.i.d. 8. Folic acid 400 mcg daily. 9. Guaifenesin SA 1200 mg b.i.d. 10. Insulin p.r.n. 11. Metoprolol 50 mg b.i.d. 12. B complex vitamin daily. 13. Nasonex 2 sprays daily. 14. Singulair 10 mg q. p.m.
SA|slow acting/sustained action|SA|136|137|MEDICATIONS|ALLERGIES: None known about. MEDICATIONS: On admission: 1. Isosorbide mononitrate 30 mg one-half tablet daily. 2. Pentoxifylline 400 mg SA one tablet q.i.d. 3. Docusate 100 mg b.i.d. 4. Lisinopril 40 mg one-half tablet daily. 5. Metoprolol tartrate 100 mg b.i.d.
SA|slow acting/sustained action|SA|126|127|MEDICATIONS|5. Enalapril 20 mg b.i.d. 6. Lexapro 30 mg daily. 7. Advair 500/50, 1 puff b.i.d. 8. Folic acid 400 mcg daily. 9. Guaifenesin SA 1200 mg b.i.d. 10. Insulin p.r.n. 11. Metoprolol 50 mg b.i.d. 12. B complex vitamin daily. 13. Nasonex 2 sprays daily. 14. Singulair 10 mg q. p.m.
SA|slow acting/sustained action|SA|124|125|MEDICATIONS|5. Levothyroxine 75 mcg p.o. - extra on Saturday day and then he takes 75 mcg daily. 6. KCl 60 mEq p.o. daily. 7. Verapamil SA 120 mg p.o. daily. 8. Lisinopril 40 mg p.o. daily. 9. Cardura 4 mg p.o. daily at h.s. 10. Simvastatin 20 mg p.o. daily. 11. Aspirin 325 mg p.o. daily.
SA|sinuatrial|SA|198|199|PAST MEDICAL HISTORY|We are asked to see her by Dr. _%#NAME#%_ for additional suggestions on managing her severe emphysema. PAST MEDICAL HISTORY: Significant for severe emphysema as above, nicotine dependence, SVT with SA node ablation, pelvic fracture in 1999 with secondary leg weakness, apparently due to inactivity. In 1998, right hip fracture and repair. History of osteoporosis, history of anxiety and depression, history of tonsillectomy.
SA|slow acting/sustained action|SA,|127|129|MEDICATIONS|12. Status post spinal fusion, 1988. MEDICATIONS: 1. Lasix, 40 mg 3 tablets in the a.m. and 2 tablets in the p.m. 2. Diltiazem SA, 120 mg p.o. daily. 3. Candesartan, 16 mg p.o. daily. 4. Isordil, 20 mg p.o. b.i.d. 5. Aciphex, 20 mg p.o. b.i.d.
SA|sinuatrial|SA|268|269|IMPRESSION|He then has sinus arrest with a ventricular escape beat and likely some concealed conduction from the ventricular beat going back into the AV node and blocking the next P wave. IMPRESSION: This is an elderly gentleman who had a syncopal event. He has evidence of both SA node and AV node disease. SA disease is manifested by sinus arrest with ventricular escape AV node by the marked first degree heart block, left anterior hemiblock and right bundle branch block.
SA|sinuatrial|SA|120|121|IMPRESSION|IMPRESSION: This is an elderly gentleman who had a syncopal event. He has evidence of both SA node and AV node disease. SA disease is manifested by sinus arrest with ventricular escape AV node by the marked first degree heart block, left anterior hemiblock and right bundle branch block.
SA|slow acting/sustained action|SA|322|323|MEDICATIONS ON ADMISSION|ALLERGIES: Dipyridamole causing a headache and sulfa with nausea and vomiting. MEDICATIONS ON ADMISSION: Aspirin 81 mg q.d., Citrucel one- half pack p.o. q.d., clonazepam 12.5 mg q.d., Plavix 75 mg q.d., Flovent 2 puffs b.i.d., furosemide 20 mg b.i.d., glipizide 5 mg q.d., Atrovent 2 puffs q.i.d., isosorbide mononitrate SA 60 mg q.d., L-thyroxine 75 mcg p.o. q.d., metoprolol 12.5 mg p.o. b.i.d., increased to 25 mg b.i.d.; miconazole 2 percent powder to the groin b.i.d., Remeron 45 mg p.o. q.d., sertraline 200 mg q.d., Lipitor 40 mg q.d., timolol 0.5 percent eye drops, one drop in each q.d., Actos 30 mg q.d., albuterol nebulizer q.i.d. p.r.n., Atrovent nebulizer q.i.d. p.r.n., oxygen 2 percent by nasal cannula.
SA|sinuatrial|SA|145|146|HISTORY|It was felt initially that the pacemaker was not indicated. It was commented that if she is placed on any kind of medicines which can affect the SA node, she develops marked bradycardia into the 40s. As soon as those medicines are held, it jumps back up to 100, suggesting that she may have some form of sick sinus syndrome.
SA|slow acting/sustained action|SA|358|359|MEDICATIONS|LABORATORY DATA: Indicate a hemoglobin of 10.7, white blood cell count 25.6 as of today, creatinine 3.4 as of today. ALLERGIES: Penicillin and sulfa. MEDICATIONS: Mucomyst 20% nebs, albuterol t.i.d, Azactam 1 gram IV every 12 hours, calcium carbonate 1 a day, Decadron 10 mg IV once a day, Cymbalta 60 mg b.i.d., Advair 250 mg/50 2 puffs b.i.d., guaifenesin SA 600 mg b.i.d., heparin b.i.d., insulin regular, Levaquin 500 mg IV every other day, Synthroid 175 mcg p.o. once a day, OxyContin is now at 10 mg b.i.d., Protonix 40 mg once a day, K-Dur 20 mEq every 6 hours x3, Darvocet-N 100 - she can receive that 1 tablet every 4 hours and last received it at 1400, in fact that was the only dose today.
SA|sinuatrial|SA|147|148|IMPRESSION|As I mentioned, she is now in a junctional rhythm. IMPRESSION: This is a patient who has fascicular and AV node disease and probably an element of SA node disease and sick sinus syndrome. She previously on atenolol 25 mg a day she developed junctional rhythm. When that medicine was held she went into a sinus rhythm with sinus tachycardia.
SA|slow acting/sustained action|SA|267|268|PRESENT MEDICATIONS|ALLERGIES: None known. PRESENT MEDICATIONS: 1. Maalox p.r.n. 2. Baclofen 10 mg q.h.s. (to be discontinued after _%#MMDD2002#%_ dose). 3. Lexapro 5 mg q.a.m. (to be discontinued after _%#MMDD2002#%_ dose), with Lexapro 10 mg to begin on _%#MMDD2002#%_. 4. Guaifenesin SA 600 mg b.i.d. 5. Hydrochlorothiazide 25 mg q.a.m. 6. Prevacid 60 mg q.a.m. 7. Primidone 25 mg q.h.s. 8. Vioxx 25 mg q.a.m. 9. Septra DS b.i.d., with last dose on _%#MMDD2002#%_.
SA|slow acting/sustained action|SA|196|197|MEDICATIONS ON TRANSFER|10. Gemfibrozil 600 mg p.o. b.i.d. 11. Insulin. 12. Insulin sliding scale as previously mentioned. 13. Lisinopril 2.5 mg daily. 14. Lantus 90 units subq q.h.s. 15. Multivitamins 1 p.o. 16. Niacin SA 500 mg daily. 17. Actos 15 mg daily. 18. KCl 20 mEq daily. 19. Vancomycin 1,000 mg IV q.12h. 20. Heparin lock. 21. Normal saline 0.9 with 20 mEq of KCl at 600 cc per hour.
SA|sinuatrial|SA|156|157|LABORATORY DATA|There is also probably left anterior hemiblock, but the EKG could also be read as an inferior infarct along with the IVCD. The other problem is what is the SA node doing. There is 1 or 2 pauses on the 12-lead that shows P-waves. I then did a carotid massage and did a rhythm strip where his heart rate slows down.
SA|sinuatrial|SA|445|446|LABORATORY DATA|Since the initial EKG actually had a ventricular rate of 97, I suspect what the original rhythm was sinus tachycardia with a very short PR interval, since again after the pause I am because able to map out P-waves at a rate of 100. The interesting thing though is the P to QRS interval is changing so this may actually be iso-rhythmic accelerated junctional tachycardia which is what I think we are seeing with the intermittent capture from the SA node. Other labs from the outside hospital include a troponin today of 16.79. Amylase less than 30.
SA|sinuatrial|SA|134|135|IMPRESSION|He has a history of diastolic dysfunction due to heart failure. He has a history of what is probably sick sinus syndrome and not only SA node disease but AV node disease. He has been in sinus rhythm the whole time he was here, but we have documentation of atrial fibrillation/atrial flutter.
SA|sinuatrial|SA|362|363|IMPRESSION|His underlying EKG is right bundle branch block with left anterior hemiblock, therefore he is at significantly higher than average risk for third degree heart block, and there was a question raised in the past that he may have had third-degree heart block. At this point his blood pressure can probably be well controlled with medications that do not affect the SA node or AV node, but if he does have additional problems of atrial fibrillation or atrial flutter that would become a significant problem, to go on antiarrhythmics.
SA|sinuatrial|SA|251|252|IMPRESSION|He is at higher than average risk for going into third degree heart block and with a wide QRS this is not necessarily a reliable escape rhythm. If one wishes, in the interim one could consider starting theophylline 200 mg b.i.d. which may improve the SA and AV node conduction. I would be a bit concerned about causing some toxicity in an elderly gentleman. At this point, with his advanced age I would not do followup stress testing and I do not think he needs another echocardiogram at this time.
SA|slow acting/sustained action|SA|165|166|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Enteric-coated aspirin 81 mg p.o. daily. 1. Diltiazem ER 360 mg p.o. daily. 2. Ferrous gluconate 324 mg p.o. daily. 3. Isosorbide mononitrate SA 30 mg p.o. daily. 4. Senokot-S 1 to 2 tabs p.o. b.i.d. p.r.n. constipation. 5. Simvastatin 10 mg p.o. q.p.m. 6. Valsartan 80 mg p.o. daily.
SA|UNSURED SENSE|SA|300|301|ASSISTANT|PREOPERATIVE DIAGNOSES: Intrauterine pregnancy 39+ weeks gestation, mild pregnancy induced hypertension, lack of satisfactory progress in labor, fetal wellbeing. PROPOSED PROCEDURE: Primary low segment transverse cesarean section. SURGEON: _%#NAME#%_ _%#NAME#%_, MD ASSISTANT: _%#NAME#%_ _%#NAME#%_, SA PATIENT IDENTIFICATION: _%#NAME#%_ _%#NAME#%_ is a 29-year-old gravida 1, para 0 at 39+ weeks gestation who is admitted to Fairview Ridges Hospital for induction of labor on the morning of _%#MMDD2006#%_.
SBP|systolic blood pressure|SBP.|157|160|HOSPITAL COURSE|3. Hypertension. The patient had a persistently high blood pressure. His blood pressure optimized per CVTS consult, was determined to be below 120s-130s for SBP. The patient was placed on Lopressor and diltiazem very high dose. He was having blood pressure checks every 2 hours with hydralazine p.r.n. IV to maintain a systolic blood pressure of below 130.
SBP|spontaneous bacterial peritonitis|SBP|198|200|HISTORY OF PRESENT ILLNESS AND COURSE IN HOSPITAL|Gram stain did not show any infection. The cultures are still pending at the time of discharge. GI transplant team did see the patient during his stay in hospital and recommended to continue him on SBP treatment as he demonstrated classic symptoms of SBP, although his ascitic fluid analysis was not very conclusive. He received a dose of ceftriaxone IV in emergency room, and we continued his medication intravenously during his stay in the hospital and we switched him to oral ciprofloxacin upon discharge.
SBP|systolic blood pressure|SBP|172|174|PLAN|If the patient still has persistent symptoms, then will probably need to get cardiology consultation. Addendum After arrival on the floor the patient had maroon stool. His SBP dropped to 60 and he was transferred to ICU. He was given FFP and Hgb came back at 7. EGD was performed and a bleeding ulcer was noted and the junction of the bulb and 2 nd part of the duodenum.
SBP|spontaneous bacterial peritonitis|SBP|148|150|FOLLOW UP|Given that this patient has had multiple hospitalizations for spontaneous bacterial peritonitis, it is likely that he would be a good candidate for SBP prophylaxis with weekly levofloxacin. The patient also has follow-up with Dr. _%#NAME#%_ _%#NAME#%_ at the primary care center on _%#MMDD2006#%_ to follow up both this and his prior hospitalization.
SBP|spontaneous bacterial peritonitis|SBP|154|156|PROBLEMS|The patient was started on broad-spectrum antibiotics with Zosyn. The patient eventually did undergo diagnostic paracentesis, which was not suggestive of SBP and the cultures did not grow any organisms. The patient was seen by GI, who recommended a full course of treatment for spontaneous bacterial peritonitis.
SBP|spontaneous bacterial peritonitis|SBP.|180|183|PROBLEM #3|This will need to be followed in the outpatient setting. PROBLEM #3: End-stage liver disease secondary to alcohol abuse, with history of encephalopathy, coagulopathy, varices, and SBP. The patient will resume his medications regarding all these issues, which will include his Protonix, Inderal, Bactrim, lactulose, and Vitamin K.
SBP|spontaneous bacterial peritonitis|SBP.|200|203|ASSESSMENT|We will restart his Lactulose. I do not see any reason to pursue an infectious work up based on his current condition and examination, but if he does deteriorate further we should tap his abdomen for SBP. I think we should have Psychiatry evaluate him also when he clears as I think this is not just hepatic encephalopathy.
SBP|spontaneous bacterial peritonitis|SBP.|190|193|ASSESSMENT/PLAN|3. Metastatic breast cancer. Likely chemotherapy tomorrow will be on hold, given her acute illness. Oncology consult to follow. 4. Ascites, chronic. Soft abdomen with no evidence to suggest SBP. At this time, no report of abdominal pain, distention or discomfort prior to admission. May consider therapeutic paracentesis in the future. Would hold on diuretics given her severe pre-renal state.
SBP|spontaneous bacterial peritonitis|SBP|108|110|MEDICATIONS|1. Prevacid 30 mg per day 2. Lasix 120 mg b.i.d. 3. Spironolactone 50 mg per day 4. Cipro 750 mg per week ( SBP prophylaxis?) 5. Levothyroxine 100 mcg. per day 6. Neurontin 600 mg per day 7. Oxycodone 5 mg averaging about two tablets per day ALLERGIES: None.
SBP|spontaneous bacterial peritonitis|SBP.|186|189|ASSESSMENT/PLAN|I will hold off on antibiotics, but if any signs of diverticulitis or peritonitis are suggested on the CT, I would start antibiotics. If no other source is identified, I will reconsider SBP. Serial examinations of the abdomen will also prove helpful. Urinalysis has been ordered. 2. Chronic hyponatremia. Normal saline will be provided. 3. Alcoholism.
SBP|spontaneous bacterial peritonitis|SBP.|182|185|PROBLEM #2|PROBLEM #2: Cirrhosis. The patient underwent two large volume paracenteses while he was in the hospital. He tolerated these well. Analysis of the ascitic fluid showed no evidence of SBP. The patient was noted to have some encephalopathy during his hospital stay and was placed on lactulose. PROBLEM #3: Hepatic cancer. An abdominal CT was performed to evaluate any improvement in the size of his left adrenal metastasis.
SBP|spontaneous bacterial peritonitis|SBP.|218|221|HOSPITAL COURSE|There was concern for enterococcus. The patient has had enterococcus on _%#MMDD2006#%_ in his urine. However, on exam and by history he had no localizing infectious symptoms other than his recent diagnosis of possible SBP. Infectious Disease was consulted to see whether this was contaminant or representing true pathogenic bacteremia. They felt this was likely contaminant because enterococcus can be a contaminant and there is two different species also consistent with a contaminant.
SBP|spontaneous bacterial peritonitis|SBP.|130|133|HOSPITAL COURSE|Clinically there was no clear site of ongoing infection and his abdominal exam was benign making this very unlikely to be ongoing SBP. Lastly his urinalysis was also unremarkable showing only persistent hematuria. He was deemed appropriate for discharge home. A second set of blood cultures were obtained.
SBP|spontaneous bacterial peritonitis|SBP.|140|143|IMPRESSION|Will check some cell counts with the paracentesis fluid. If he has more pain, change in blood pressure, fever, would consider treatment for SBP. Otherwise, continue his usual prophylactic medications at this time. Will ask for GI to follow and assist with his management.
SBP|spontaneous bacterial peritonitis|SBP.|232|235|BRIEF HISTORY OF PRESENT ILLNESS|BRIEF HISTORY OF PRESENT ILLNESS: This is a 37-year-old female patient who was transferred here from _%#CITY#%_ _%#CITY#%_ for further evaluation of her liver disease. She had been admitted at _%#CITY#%_ _%#CITY#%_ for treatment of SBP. Her liver disease was noticed approximately 1 year ago. She had a 20-year history of alcohol abuse, with her heaviest drinking beginning about 2 years ago.
SBP|spontaneous bacterial peritonitis|SBP|264|266|BRIEF HISTORY OF PRESENT ILLNESS|Initially, her ascites had been controlled with diuretics until about 2 months ago, at which point she began needing paracentesis every 7 to 10 days. Prior to admission at _%#CITY#%_ _%#CITY#%_, she had abdominal pain, weakness, and fevers. She was diagnosed with SBP with a diagnostic and therapeutic paracentesis. She began IV antibiotics for that, and was transferred to the University of Minnesota Medical Center, Fairview for further evaluation.
SBP|spontaneous bacterial peritonitis|SBP.|149|152|DISCHARGE INSTRUCTIONS|8. Per discussion with GI patient is not a tips candidate given his frequent hepatic encephalopathy, frequent admissions for confusion, and risk for SBP. The patient will be placed on SBP prophylaxis at this time. It has been a pleasure participating in his care. Please contact me at _%#TEL#%_ with any further questions regarding this admission.
SBP|spontaneous bacterial peritonitis|SBP|180|182|MEDICATIONS AT THE TIME OF TRANSFER|She was transferred on _%#MMDD2006#%_ for continuation of her medical care and for rehabilitation. MEDICATIONS AT THE TIME OF TRANSFER: 1. Ciprofloxacin 750 mg by mouth weekly for SBP prophylaxis. 2. Chronulac 2 tablespoons daily. 3. Nystatin 500,000 units 4 times daily by mouth. 4. Protonix 40 mg b.i.d. 5. Inderal 40 mg b.i.d.
SBP|spontaneous bacterial peritonitis|SBP.|152|155|HOSPITAL COURSE|Per GI recommendation, the patient was started on norfloxacin for SBP prophylaxis; after he completes his course of ciprofloxacin, to treat the current SBP. This was decided since the patient is likely to require further large volume paracentesis in the future secondary to ascites.
SBP|spontaneous bacterial peritonitis|SBP|239|241|HOSPITAL COURSE|Clinically throughout, the patient remained relatively stable. Hemodynamics adequate with blood pressure 130/60s, heart rate 90s, O2 sat 97% on room air. Improved pulmonary status with tapping of ascitic fluid. Continued issue of possible SBP for which Cipro prophylaxis was recommended by GI. Hospice was briefly discussed which the patient declined. There was a newly diagnosed neoplasm.
SBP|spontaneous bacterial peritonitis|SBP|140|142|ASSESSMENT AND PLAN|Medications are reviewed and will be continued. He is on the transplant list and will follow at discharge. 2. Abdominal pain concerning for SBP clinically, although he does not have significant amount of fluid and therefore unable to obtain sample for diagnosis. His white count is normal and he has no fever, but will initiate IV antibiotics aimed at the treatment of SBP.
SBP|systolic blood pressure|SBP|220|222|DISCHARGE INSTRUCTIONS|Dry dressing change daily to the left knee wound. May shower as long as the left knee wound is covered with a plastic bag. DISCHARGE MEDICATIONS: Isosorbide mononitrate 30 mg p.o. q.d.; Prinivil 5 mg p.o. q.d., hold for SBP less than 110; Prozac 60 mg p.o. q.d.; Cipro 250 mg p.o. q.d.; Tranxene 7.5 mg p.o. q.d.; Natural Tears moisture drops to both eyes p.r.n.; Zyprexa 5 mg p.o. q.h.s.; albuterol nebulizers 2.5 mg/2 cc normal q.4h. p.r.n.; glyburide 5 mg p.o. b.i.d., hold for blood sugar less than 100; atenolol 25 mg p.o. q.d.; Ambien 5 mg p.o. q.h.s. p.r.n.; Percocet 1 to 2 tablets p.o. q.4h. p.r.n. pain; and insulin sliding scale.
SBP|spontaneous bacterial peritonitis|SBP|130|132|DISCHARGE MEDICATIONS|DIET: Recommend low-protein, low-potassium diet. ACTIVITY: As tolerated. DISCHARGE MEDICATIONS: 1. Cipro 750 mg p.o. q. week (for SBP prophylaxis). 2. Lactulose 45 mL p.o. q.i.d. 3. Folate 1 mg p.o. daily. 4. Lasix 20 mg p.o. daily. 5. Mirtazapine 15 mg p.o. nightly.
SBP|spontaneous bacterial peritonitis|SBP|313|315|HOSPITAL COURSE|As such, given her abdominal pain, she was started on empiric treatment for spontaneous bacterial peritonitis. She remained afebrile throughout the duration of the hospitalization, and will be continued on oral empiric antibiotics for a total of five more days after discharge, to be followed by weekly Cipro for SBP prophylaxis. The patient was never significantly encephalopathic during this hospitalization, she will continue on outpatient lactulose as previously, for a goal number of bowel movements of four per day.
SBP|spontaneous bacterial peritonitis|SBP|277|279|SECONDARY DISCHARGE DIAGNOSES|Her hemoglobin at discharge was stable at 8.4. Her INR was stable at 1.58. She was started on Claforan empirically at the time of admission, and her blood culture remained negative throughout her hospital course. She was, therefore, discharged on her routine dose of Cipro for SBP prophylaxis and the Claforan was discontinued. She never had any increased abdominal pain during her hospitalization. DISCHARGE MEDICATIONS: 1. Folate 1 mg p.o. q. day.
SBP|spontaneous bacterial peritonitis|SBP|187|189|HOSPITAL COURSE|She underwent large volume paracentesis by interventional radiology on _%#MM#%_ _%#DD#%_, 2006. Cell count and differential showed 10 nucleated cells; therefore, there was no concern for SBP based on this and also lack of symptoms. Therefore, no antibiotics were indicated. She was given albumin during and post paracentesis.
SBP|spontaneous bacterial peritonitis|SBP|165|167|ASSESSMENT AND PLAN|5. Abdominal pain, most likely secondary to increasing ascites and abdominal distension. TIPs procedure is planned for later this week. We will monitor for signs of SBP and sepsis. DISPOSITION: Thoracentesis later today. Possible discharge to home tomorrow with readmission for TIPS procedure later this week.
SBP|spontaneous bacterial peritonitis|SBP|176|178|ASSESSMENT|No obvious clinical features of SBP at this time. No splinter hemorrhages. His right lower extremity wounds appear well healed and his abdomen is nontender. Nothing to suggest SBP at this time. PLAN: The patient will be admitted for close observation.
SBP|spontaneous bacterial peritonitis|SBP|165|167|DISCHARGE MEDICATIONS|4. Propranolol 20 mg p.o. b.i.d. 5. Sucralfate 1 g p.o. q.6 h. 6. Compazine 5 to 10 mg p.o. q.6 h. as needed for nausea. 7. Ciprofloxacin 750 mg p.o. every week for SBP prophylaxis. 8. Ferrous sulfate 325 mg p.o. b.i.d. DISCHARGE DIET: Renal, low-protein diet. DISCHARGE ACTIVITY: As tolerated.
SBP|spontaneous bacterial peritonitis|SBP|192|194|DISCHARGE MEDICATIONS|The patient was told to follow with hematology as scheduled for further workup of anemia. DISCHARGE MEDICATIONS: 1. Ferrous sulfate 325 mg p.o. t.i.d. 2. Ciprofloxacin 750 mg p.o. q. week for SBP prophylaxis. 3. Ambien 5mg p.o. q. day. 4. Nephrocaps 1 tablet p.o. q. day. 5. Mirtazapine 30 mg p.o. q. day. 6. Protonix 40 mg p.o. b.i.d. Please note the ciprofloxacin was the new addition to his medications and Bactrim was discontinued during this hospitalization.
SBP|spontaneous bacterial peritonitis|SBP|148|150|DISCHARGE MEDICATIONS|2. Levofloxacin 750 mg p.o. q.48 h. x3 days. 3. Norfloxacin 400 mg p.o. daily. Start this after the levofloxacin course is finished and this is for SBP prophylaxis. 4. Spironolactone 100 mg p.o. b.i.d. 5. Zoloft 50 mg p.o. daily. 6. Nexium 40 mg p.o. daily. 7. Lactulose 30 mL p.o. t.i.d. to q.i.d. titrate to 3-4 loose stools per day.
SBP|spontaneous bacterial peritonitis|SBP|137|139|MEDICATIONS|5. Vitamin K 5 mg by mouth daily. 6. Colace 100 mg by mouth twice daily. 7. Bactrim DS 1 by mouth Monday, Tuesday, Wednesday, Friday for SBP prophylaxis. 8. Lasix 40 mg by mouth daily. 9. Spironolactone 50 mg by mouth daily. SOCIAL HISTORY: The patient denies tobacco abuse. He has not had any alcohol for 1-1/2 years and is currently unemployed.
SBP|spontaneous bacterial peritonitis|SBP,|193|196|ASSESSMENT AND PLAN|Abdominal pain, exact etiology unclear. Could be secondary to his recently performed paracentesis. There is concern for SBP. When looking through his chart he has history of being admitted for SBP, but when looking at his previous diagnostic paracentesis, he has not had paracentesis that showed SBP in the past. He was just treated empirically. Because he had a large volume paracentesis done yesterday, I is unclear, given the physical exam, how much fluid he actually has in his abdomen and therefore, will defer for an ultrasound-guided diagnostic paracentesis in the morning.
SBP|spontaneous bacterial peritonitis|SBP.|231|234|HISTORY OF PRESENT ILLNESS|He was started on a PPI continuous infusion and changed to IV Protonix and then to high-dose PPI p.o. and then via NJ. He did receive octreotide for 48 hours. He was started on antibiotics. His ascites were tapped and negative for SBP. His hemoglobin stabilized and he was transferred back to the floor. His hemoglobin did continue to slowly trend down. He has required weekly to every other week transfusions as an outpatient given his history of gastropathy and likely will continue to need weekly to every other week transfusion as this likely will not improve until he receives a transplant.
SBP|spontaneous bacterial peritonitis|SBP.|409|412|HISTORY OF PRESENT ILLNESS|His hemoglobin did continue to slowly trend down. He has required weekly to every other week transfusions as an outpatient given his history of gastropathy and likely will continue to need weekly to every other week transfusion as this likely will not improve until he receives a transplant. 2. Hepatic encephalopathy. He was started on lactulose and rifaximin in his hospitalization. There is no evidence of SBP. This was new for him and he did continue to improve. His lactulose was weaned to twice daily dosing prior to discharge and his mental status improved alert and oriented x3.
SBP|spontaneous bacterial peritonitis|SBP.|157|160|HOSPITAL COURSE|She did have diffuse abdominal tenderness on presentation. However, this could have been multifactorial. It is possible that she had active hepatitis versus SBP. The initial tap did grow out 1 out of the 4 blood cultures, something call proteus rettgeri which is normally associated with cystitis.
SBP|systolic blood pressure|(SBP|198|201|HISTORY OF PRESENT ILLNESS|The patient reported the onset of substernal chest pain while at rest shortly after eating breakfast. This was associated with nausea and several episodes of emesis, as well as relative hypotension (SBP 80-90). He was given nitroglycerin in the ambulance and in the emergency department without clear improvement. In the emergency department, he did receive Mylanta and nitroglycerin and had a small emesis as well as a bowel movement.
SBP|spontaneous bacterial peritonitis|SBP,|213|216|ASSESSMENT AND PLAN|We will then guide workup from there. Other possibilities include problems with blood sugars; though they were high today, certainly not in a nonketotic hyperosmolar range. Could be secondary to infection such as SBP, pneumonia, or urinary tract infection (URI). Could also be secondary maybe to some decreased oxygen, all levels from this upper respiratory infection and possibly worsening of COPD.
SBP|systolic blood pressure|SBP|204|206|HOSPITAL COURSE|Her platelet count remained in the upper 40,000 range, despite washed platelets, cross-matched platelets and, finally, regular platelets. Problem #4. Hypertension: Her hypertension improved and stayed in SBP 130 to 170 range. The addition of labetalol and p.r.n. clonidine, assisted with blood pressure control. Two days prior to her discharge, the p.r.n. clonidine was made scheduled, due to her need for this medication.
SBP|spontaneous bacterial peritonitis|SBP|105|107|DISCHARGE MEDICATIONS|9. Ciprofloxacin 500 mg p.o. b.i.d. for 5 days, then he will take ciprofloxacin 750 p.o. once a week for SBP prophylaxis. 10. Vitamin K 5 mg p.o. once a day. 11. Hydrocortisone cream 1% topically q.i.d. 12. Nystatin powder topically q.i.d. as needed for fungal infection.
SBP|spontaneous bacterial peritonitis|SBP|137|139|DISCHARGE MEDICATIONS|3. Nephrocaps 1 tablet p.o. daily. 4. Protonix 40 mg p.o. daily. 5. Vitamin K 5 mg p.o. daily. 6. Rifaximin 400 mg p.o. t.i.d. Alter for SBP prophylaxis. 7. Thiamine 100 mg p.o. daily.
SBP|spontaneous bacterial peritonitis|SBP.|192|195|CHIEF COMPLAINT|He has not been having a fever, has not had any changes in medications or diet recently. Three months ago he was admitted with similar abdominal pain and was treated and improved for presumed SBP. They could not get a sample of his ascites fluid because it was very minimum. PAST MEDICAL HISTORY: 1. Cirrhosis of the liver, on transplant list.
SBP|spontaneous bacterial peritonitis|SBP.|129|132|CURRENT MEDICATIONS|8. Vicodin 5/500 1 tablet 4-6 hours p.r.n. 9. Fosamax 70 mg weekly. 10. Septra double strength 1 tablet daily as prophylaxis for SBP. 11. Nizoral shampoo 3 times a week. 12. Flomax 0.4 mg daily. 13. Propranolol 20 mg b.i.d. 14. Multivitamins once a day.
SBP|spontaneous bacterial peritonitis|SBP,|290|293|MAJOR PROCEDURES AND TREATMENT PERFORMED|This was consistent with partial small-bowel obstruction. 4. Abdominal flat film was also performed, which showed findings consistent with partial small-bowel obstruction. No intraperitoneal free air. 5. Paracentesis was performed by interventional radiology and was sent for evaluation of SBP, which was ruled out. CONSULTS: GI consult was obtained as the patient has been on transplant list.
SBP|spontaneous bacterial peritonitis|SBP.|109|112|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Massive ascites from hepatocellular carcinoma and hepatitis C cirrhosis. 2. Possible SBP. PROCEDURES PERFORMED WHILE THE PATIENT WAS IN THE HOSPITAL: 1. MRI abdomen, which shows a poor study with evidence of liver mass measuring 5.9 cm in the largest dimension.
SBP|spontaneous bacterial peritonitis|SBP|283|285|HOSPITAL COURSE|The patient was adamant on leaving on the morning of _%#MMDD2006#%_ and we did mention to the patient that the patient may have to leave against medical advice. Since the patient requires pain medications for his hepatocellular cancer and ascites as well as he was being treated for SBP with levofloxacin, he touch base with the liver transplant coordinator and the multiple physicians as well as his caregiver at home.
SBP|systolic blood pressure|SBP|232|234|HISTORY OF PRESENT ILLNESS|He was then transferred to UMMC and arrived approximately 1400 on _%#MMDD2007#%_; transport was reportedly complicated by a number of episodes of tachyarrythmias requiring defibrillation. On arrival he was severely hypotensive with SBP 60's (MAP ~ 50) and required increasing dopamine as well as vasopressin; when sedation was lifted he was able to respond to verba; commands and move all extremities.
SBP|systolic blood pressure|SBP|165|167|NEW DISCHARGE MEDICATIONS|4. Bilateral pleural effusions. NEW DISCHARGE MEDICATIONS: none DISCHARGE MEDICATIONS, UNCHANGED DOSES: 1. Lipitor 20 mg daily 2. Coreg 3.125 mg p.o. b.i.d. hold if SBP less than 80. 3. Darbepoetin 25 mcg injection subcutaneous q. week. 4. Colace 100 mg p.o. b.i.d. 5. Imdur 30 mg p.o. q day. hold if SBP less than 85 6 Levothyroxine 75 mcg p.o. daily.
SBP|systolic blood pressure|SBP|118|120|NEW DISCHARGE MEDICATIONS|3. Darbepoetin 25 mcg injection subcutaneous q. week. 4. Colace 100 mg p.o. b.i.d. 5. Imdur 30 mg p.o. q day. hold if SBP less than 85 6 Levothyroxine 75 mcg p.o. daily. 7. Lorazepam 0.5 to 1 mg p.o. daily p.r.n. anxiety. 8. Remeron 50 mg p.o. q h.s. 9. I caps p.o. daily.
SBP|systolic blood pressure|SBP|134|136|ASSESSMENT/PLAN|I discussed the case with Dr. _%#NAME#%_ and hemodialysis will be continued. The patient will also have his blood pressure treated to SBP less than 180 and diastolic blood pressure less than 90. The patient's anticoagulation will be reversed rapidly with vitamin K, an INR will be checked in six hours, he will get 10 mg of IV vitamin K.
SBP|spontaneous bacterial peritonitis|SBP|137|139|HISTORY OF PRESENT ILLNESS|She has needed no paracenteses while here. She was treated for C. difficile, and there has been no recurrence. She is on prophylaxis for SBP with Levaquin. She had been progressing with PT and OT; however, did have decreased sensation in her feet and her hands, as well as ataxia.
SBP|spontaneous bacterial peritonitis|SBP|251|253|HISTORY OF PRESENT ILLNESS|Of note, his hepatitis C is of genotype 1B and he is treatment naive. His main problem from end-stage liver disease up to this point is mainly refractory ascites which is the main reason for the TIPS procedure insertion, and he also has an episode of SBP back in _%#MM2006#%_, esophageal varices, status post EGD with banding about two years ago and he was on propranolol, but he was being discontinued secondary to nausea and also dizziness.
SBP|spontaneous bacterial peritonitis|SBP.|142|145|HOSPITAL COURSE|She had a recent paracentesis which showed leukocytosis but cultures have been negative. There was no elevated neutrophil count suggestive of SBP. There is no gross bloody fluid suggestive of an exudate such as metastatic breast cancer. She complained of some increased abdominal pain. She did have a fever of 101 at the nursing home, but here at the hospital she has been afebrile.
SBP|spontaneous bacterial peritonitis|SBP.|169|172|HOSPITAL COURSE|She appeared grossly nontoxic. Vital signs were within normal limits. She was afebrile, satting oxygenating well. She was placed empirically on antibiotics, concern for SBP. However, again she had no leukocytosis or fever. This is predominantly because of her ascites history and recent paracentesis and temperature of 101 at the nursing home, this was for, I believe, for 2 days.
SBP|spontaneous bacterial peritonitis|SBP,|161|164|HOSPITAL COURSE|She was continued on Lyrica and codeine p.r.n. Also ketoprofen gel to her lower extremities. The patient will complete a course of antibiotics for possible mild SBP, as this can sometimes presents subtly, and since we are unable to obtain a paracentesis to rule out SBP. DISCHARGE INSTRUCTIONS: No NSAIDs. Advanced directives DNR/DNI. In chair t.i.d., ambulate t.i.d., low sodium diet, 1500 cc fluid restriction.
SBP|systolic blood pressure|SBP|217|219|MEDICATIONS|Discontinued because of risk of dehydration. Adjusted: 1. Lisinopril 10 mg p.o. b.i.d. The patient will have a BMP on _%#MMDD2007#%_ to assess for possible hyperkalemia. The patient's lisinopril should be held if his SBP is less than 90 of if he has dizziness 2. Prilosec 40 mg p.o. daily while on aspirin. New: 1. Aspirin 81 mg p.o. daily. 2. Colace 100 mg p.o. b.i.d.
SBP|systolic blood pressure|SBP|181|183|DISCHARGE DISPOSITION|The patient will continue on lisinopril. The patient's blood pressure was well-controlled in the hospital on lisinopril b.i.d. Instructions were given to hold the lisinopril if his SBP was less than 90 or he had dizziness. The patient is at risk for autonomic neuropathy from his Parkinson's.
SBP|spontaneous bacterial peritonitis|SBP|222|224|HISTORY OF PRESENT ILLNESS|He does have chronic abdominal pain but tells me that his abdominal pain is worse over the last few days and that his chills have existed throughout most of the last 24 hours. He was recently discharged on antibiotics for SBP including levofloxacin, linezolid, fluconazole and ampicillin. He reports that he is receiving and taking all of his scheduled antibiotics. He reports that his abdominal pain is currently a 9/10.
SBP|systolic blood pressure|SBP|238|240|ASSESSMENT/PLAN|Colonoscopy would be performed to look for microscopic colitis. I will not order a celiac panel at this time, as the patient has only had his symptoms for less than a month. 2. Hypertension. We will continue his atenolol, but hold if his SBP is less than 100. We will him on his other hypotensive medication if it is not an ACE inhibitor when the identity of that medication is known.
SBP|spontaneous bacterial peritonitis|SBP.|123|126|LABORATORY|5-10 RBCs and protein 30 mg/dl. There are 0 WBCs. ASSESSMENT and PLAN: 1. New onset ascites. There are no current signs of SBP. This is likely secondary to cirrhosis due to the cumulative effects of alcohol abuse, hepatitis B and hepatitis C. Large volume paracentesis will be undertaken in the morning with fluid sent for cytology, gram stain CNS, as well as albumin level.
SBP|spontaneous bacterial peritonitis|SBP|134|136|LABORATORY|4. Spironolactone 100 mg p.o. b.i.d. 5. Lactulose 1 ounce p.o. t.i.d. 6. Protonix 40 mg p.o. q. day. 7. Cipro 750 mg p.o. q. week for SBP prophylaxis. FOLLOW UP: The patient is to follow up with her primary care doctor, Dr. _%#NAME#%_ in gastroenterology for workup for her future liver transplant.
SBP|spontaneous bacterial peritonitis|SBP|159|161|DISCHARGE MEDICATIONS|3. Risperdal 1 mg p.o. daily. 4. Effexor 37.5 mg p.o. daily. 5. Propranolol 10 mg p.o. daily. 6. Gatifloxacin 200 mg p.o. daily (to be continued long-term for SBP prevention). 7. NPH 8 units subcu b.i.d. 8. Lactulose 30 cc p.o. q.6h. and one 300-cc retention enema daily. 9. Protonix 40 mg p.o. b.i.d. 10. Insulin sliding scale (for TCU use only).
SBP|spontaneous bacterial peritonitis|SBP,|212|215|HOSPITAL COURSE|The patient refused this procedure and, given the fact that the patient's white blood cell count was almost certainly elevated because of the receipt of Neulasta, and the patient had no abdominal pain to suggest SBP, it seemed very reasonable not to pursue this. The patient will follow up at the Parker Hughes Cancer Center on _%#MMDD2003#%_ to see Dr. _%#NAME#%_ _%#NAME#%_ at 12:00.
SBP|spontaneous bacterial peritonitis|SBP|206|208|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. End-stage liver disease secondary to cryptogenic cirrhosis on transplant list. 2. Status post TIPS on _%#MM2002#%_ which was revised and _#%MM2002#%_ and _%#MM2003#%_. 3. Recurrent SBP with history of VRG peritonitis. 4. History of multiple hepatic encephalopathy. 5. Schizophrenia. 6. Type 2 diabetes. 7. Esophageal varices.
SBP|spontaneous bacterial peritonitis|SBP.|191|194|ASSESSMENT AND PLAN|Laboratory studies are pending, however, given the patient's history of liver cirrhosis and history of portal hypertension, and concern of abdominal distention, the patient was suspected for SBP. However, other differential is the patient could be anemic. He does have a history of elevated ferratin and with history of alcohol abuse, the patient could be volume depleted and anemia secondary to possibly gastrointestinal bleed.
SBP|systolic blood pressure|SBP|164|166|MEDICATIONS|5. Hydrocodone/acetaminophen 5/325 mg p.o. t.i.d. p.r.n. pain. 6. Septra-DS 800/160 p.o. daily. 7. Warfarin 4 mg p.o. daily. 8. Lisinopril 5 mg p.o. daily, hold if SBP is less than 90. 9. ICAPS two tabs p.o. daily. 10. Digoxin 0.125 mg p.o. daily. 11. Glucosamine chondroitin 1,500 to 1,200, two teaspoons daily.
SBP|spontaneous bacterial peritonitis|SBP.|228|231|PROBLEM #3|He did have any evidence of spontaneous bacterial peritonitis. He did receive a paracentesis on _%#MMDD2007#%_. A total of 1 liter of ascites was drained in Interventional Radiology. Again, this was negative for any evidence of SBP. The patient had previously been on ceftazidime. PROBLEM #4: Hypoglycemia. The patient had been made n.p.o. for a day due to decreased and worsening mental status.
SBP|systolic blood pressure|SBP|145|147|ASSESSMENT/PLAN|2. Hypertension. Will continue his medications on a p.r.n. basis. The patient will be managed with nicardipine, labetalol or enalapril IV if his SBP is greater than 220. Will not aggressively control hypertension at this time as it might make any ischemia worse. 3. Type 2 diabetes. Will get Accu-Cheks and put him on low-resistance sliding scale.
SBP|spontaneous bacterial peritonitis|SBP.|193|196|4.  ID|4. ID: She had a T-max of 101 on the day of admission, her infectious work up was significant for UTI; her blood culture was negative. She also had a diagnostic ascites tap with no evidence of SBP. She was started on Levaquin which was continued for a total of 7 days. 5. Anemia: Anemia was believed to be secondary to her GI bleeding.
SBP|spontaneous bacterial peritonitis|SBP.|76|79|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Abdominal pain likely secondary to splenomegaly and SBP. 2. End-stage liver disease as previously diagnosed. 3. Chronic hypokalemia and hypomagnesemia as previously diagnosed. MAJOR PROCEDURES: 1. Abdominal x-ray on _%#MMDD2007%#_, which demonstrated massive splenomegaly.
SBP|spontaneous bacterial peritonitis|SBP,|330|333|HISTORY OF PRESENT ILLNESS|Briefly, Mr. _%#NAME#%_ is a 24 years old gentleman with end-stage liver disease secondary to congenital hepatitis B induced cirrhosis who presented to the emergency room on _%#MMDD2007#%_ with abdominal pain. Of note, he is currently on the liver transplant list and had multiple admissions in the last few months, including for SBP, ileus, and also increased lower extremity edema. At this point, the patient stated that the abdominal pain is no different from his previous episode of abdominal pain, which is located at left upper quadrant.
SBP|spontaneous bacterial peritonitis|SBP|241|243|COURSE IN HOSPITAL|We initially thought about proceeding with another paracentesis, but we decided not to do it as the last ascitic fluid culture did come back positive for alpha-hemolytic Strep. We decided to treat this presumed alfa-hemolytic streptococcus, SBP per liver transplant team's recommendations. We started him on Augmentin and he needs to complete a 2 weeks' course of these antibiotics upon discharge.
SBP|spontaneous bacterial peritonitis|SBP|201|203|MEDICATIONS|ALLERGIES: No known drug allergies. MEDICATIONS: 1. Tylenol 650 mg p.o. q.6 hours, max dose 2 grams per day. 2. Calcium with vitamin D 1250 mg 2 tablets b.i.d. 3. Ciprofloxacin 750 mg p.o. q. week for SBP prophylaxis. 4. Lasix 40 mg p.o. daily. 5. Lactulose 30 mL p.o. q.6-8 hours p.r.n., titrate for 4 loose stools daily.
SBP|spontaneous bacterial peritonitis|SBP.|156|159||He is near end-stage liver disease secondary to hepatitis B with chronic complications of ascites, status post variceal bleed, encephalopathy and recurrent SBP. He complains of increasing abdominal pain over the last 3-4 days located throughout the abdomen but perhaps worse in the left upper quadrant and left lower quadrant.
SBP|spontaneous bacterial peritonitis|SBP|405|407|BRIEF HISTORY OF PRESENT ILLNESS|3. End-stage liver disease with recurrent ascites. PROCEDURES PERFORMED DURING THIS HOSPITALIZATION: Bedside paracentesis done on _%#MMDD2007#%_ with removal of 2.2 liters of ascites. CONSULTS OBTAINED DURING THIS ADMISSION: GI Transplant Service. BRIEF HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 24-year-old male with a history of cirrhosis secondary to congenital hepatitis B with recurrent SBP and history of a recent Klebsiella UTI who was admitted from clinic with low magnesium and potassium. The patient has been admitted multiple times in the past due to this concern as he does have chronic diarrhea and loses his electrolytes through this manner.
SBP|systolic blood pressure|SBP|185|187|DISCHARGE MEDICATIONS|2. Lovenox 40 mg subQ q.d. for seven days total and then to start ECASA one tablet p.o. q.d. 3. Lasix 20 mg p.o. q.a.m. 4. Celexa 10 mg p.o. q.d. 5. Verapamil 240 mg p.o. q.d. Hold for SBP less than 110. 6. Colace 100 mg p.o. b.i.d. 7. Fosamax 70 mg p.o. q. week. Start this on Sunday, _%#MM#%_ _%#DD#%_, 2002. Have patient take this medication first thing in the morning on an empty stomach.
SBP|spontaneous bacterial peritonitis|SBP|119|121|HOSPITAL COURSE|The patient was discharged on a total of a 14-day course of gatifloxacin. After that she is to restart her bactrim for SBP prophylaxis. 2. 2. Anemia: The patient's initial hemoglobin on admission was 10.1, however, the day after admission, her hemoglobin was 9.2. Therefore, it was decided to keep the patient 1 more day and to watch her hemoglobin.
SBP|spontaneous bacterial peritonitis|SBP.|142|145|PLAN|4. Duodenal ulcer 5. Thrombocytopenia 6. Marked constipation PLAN: Our plan will be to initiate a therapeutic paracentesis. We will check for SBP. We will also start him on aggressive bowel regime with a Fleet's and Mineral Enemas as well as Senna Sorbitol and follow up with abdominal pain flat plate x-ray.
SBP|spontaneous bacterial peritonitis|SBP.|190|193|PROBLEM #5|She will continue that medicine. PROBLEM #5: ID: History of Staphylococcus infection in the stomach 2 years ago with mesh as well as potential chronic fluoroquinolone use for suppression of SBP. The patient had her most recent paracentesis _%#MMDD2005#%_ and this revealed no growth from the fluid. It is unclear to me if she requires chronic suppressive antibiotics, and at this time, we are not sending her home on this regimen as I do not see that she has had recurrent SBP documented.
SBP|spontaneous bacterial peritonitis|SBP|147|149|ASSESSMENT AND PLAN|3. Liver disease/ascites. It appears that her disease process has taken a turn for the worse in the past few months and at this time concern about SBP given her change in mental status and kidney failure. Would like to obtain acidic fluid before starting antibiotics, but all of her paracentesis have been done under ultrasound guidance to this point and unable to achieve that tonight.
SBP|spontaneous bacterial peritonitis|SBP|245|247|HOSPITAL COURSE|Blood cultures and peritoneal fluid cultures showed no growth. The patient was given narcotics for abdominal pain control. His pain improved considerably by the time of discharge. He was sent home on levofloxacin to complete a 10-day course for SBP and he was also given a prescription for ciprofloxacin 750 mg to be taken every week for SBP prophylaxis. PROBLEM #2: Hypokalemia: The patient's diuretics i.e. furosemide was held.
SBP|spontaneous bacterial peritonitis|SBP|338|340|HOSPITAL COURSE|Blood cultures and peritoneal fluid cultures showed no growth. The patient was given narcotics for abdominal pain control. His pain improved considerably by the time of discharge. He was sent home on levofloxacin to complete a 10-day course for SBP and he was also given a prescription for ciprofloxacin 750 mg to be taken every week for SBP prophylaxis. PROBLEM #2: Hypokalemia: The patient's diuretics i.e. furosemide was held.
SBP|systolic blood pressure|SBP|191|193|MEDICATIONS|14. Fluvoxamine 250 mg p.o. at q.h.s. 15. Lorazepam 1 mg p.o. q.6 hours p.r.n. anxiety, 16. Motrin 600 mg p.o. t.i.d. 17. Pseudoephedrine 30 mg 1-2 tablets p.o. q6h. p.r.n. congestion, DC if SBP is greater than 140. 18. Calamine lotion to the left leg daily. 19. Seroquel 400 mg p.o. q at bed time. 20. Triamcinolone 0.025% to affected area daily. 21. Acetaminophen 1,000 mg q.8h. p.r.n. pain.
SBP|systolic blood pressure|SBP|194|196|ADDENDUM|The patient's volume status should be followed closely and the need for Lasix as needed. ADDENDUM: The patient did have a spell before discharge; blood pressures were checked and apparently her SBP was in the 70's, but if this was completely accururate. Nonetheless, we will decrease her metoprolol to 50 mg XL q day. If she continues to have these spells after her sodium is corrected, or if she has more frequent spells, she will need more workup.
SBP|systolic blood pressure|SBP|162|164|DISCHARGE MEDICATIONS|11. Lasix 40 mg p.o. daily with instructions to hold if SBP less than 110 or heart rate less than 55. 12. Toprol-XL 25 mg p.o. daily with instructions to hold if SBP less than 110 or heart rate less than 55. HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ is a _%#1914#%_-year-old gentleman with previous history of congestive heart failure, pacemaker in place, who presented on _%#MMDD2007#%_ with leukocytosis, low-grade fevers, cough, and altered mental status.
SBP|spontaneous bacterial peritonitis|SBP.|189|192|PROBLEM #2|They did agree with treating with imipenem for a 14-day course. He also had ascites present and a leukocytosis, and so they also recommended treatment with imipenem as empiric coverage for SBP. No paracentesis was done because of his Factor VIII deficiency. They also felt that he had oral thrush, and yeast culture did grow out heavy growth of Candida glabrata.
SBP|systolic blood pressure|SBP|169|171|HISTORY OF PRESENT ILLNESS|Today, the patient became completely unresponsive in a whirlpool bath where it was witnessed that his eyes rolled back. At that time, no seizure activity was witnessed. SBP was in the 90's and O2 sats were 77% on room air. The patient was brought in to F-UMC ER. Vital signs were: blood pressure 103/75, pulse 89, respiratory 16, temperature 99.2, satting 97% on room air.
SBP|spontaneous bacterial peritonitis|SBP|271|273|HOSPITAL COURSE|Chemistries revealed a creatinine of 3.8, with a bicarbonate of 19, a potassium of 4.2, INR was 0.9, ammonia was 91, lipase 309, bilirubin 1.1, alkaline phosphatase 369, AST 148, ALT 69. HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted for abdominal paracentesis to rule out SBP in light of worsening mental status and increasing abdominal ascites. Gram stain of the peritoneal fluid revealed no organisms and a few neutrophils.
SBP|spontaneous bacterial peritonitis|SBP.|255|258|DISCHARGE DIAGNOSES|2. Pancytopenia secondary to interferon therapy. 3. Hepatic encephalopathy, mild. 4. Chronic renal insuffiency secondary to proliferative glomerulonephritis. 5. Status post abdominal paracentesis, consistent with transudative ascites, and no evidence for SBP. DISCHARGE MEDICATIONS: 1. Nadolol 80 mg b.i.d. 2. Norvasc 2.5 mg q.d.
SBP|spontaneous bacterial peritonitis|SBP.|243|246|HOSPITAL COURSE|Abdominal pain and tenderness started to improve. On discharge, the patient is afebrile and abdominal pain has been resolved. The patient was given 5 days of IV cefotaxime and on discharge the patient will continue on the prophylaxis dose for SBP. 2. End-stage liver disease secondary to the hepatitis C. The patient was diagnosed 10 years back and the patient was on the transplant list at Fairview University Medical Center, but after talking to GI, it was found out that the patient recently fired the transplant team here and the patient wanted to transfer his care to the Mayo building.
SBP|spontaneous bacterial peritonitis|SBP,|196|199|PROCEDURES PERFORMED|The patient did defervesce with Zosyn. A CT scan as well as GYN consult did not reveal any obvious source for her fever or her Gram-positive blood culture. The patient was started on a course for SBP, and we will continue her for a total of 14 days of antibiotics. She was converted to p.o. Augmentin prior to discharge. The patient's pain had diminished, and she was tolerating a regular diet.
SBP|spontaneous bacterial peritonitis|SBP.|204|207|HOSPITAL COURSE|The paracentesis was done to relieve his discomfort as his abdomen was protuberant. He had no abdominal pain, no shortness of breath, no changes in mental status. The paracentesis was not consistent with SBP. Six liters of straw-colored ascites were removed and he received albumin. Initially, he was started on ciprofloxacin and received ciprofloxacin for at least 3 days.
SBP|spontaneous bacterial peritonitis|SBP|166|168|REASON FOR ADMISSION|The patient remained in the ICU for approximately six days, slowly recovering. On admission, an abdominal ultrasound was obtained to evaluate for ascites to rule out SBP as a possible cause of his presentation. There was no ascites present. The patient was also empirically treated with antibiotics for possible pneumonia as well.
SBP|spontaneous bacterial peritonitis|SBP|157|159|REVIEW OF SYSTEMS|EXTREMITIES: Wife recognizes that he has had an increase in peripheral edema over the ankles bilaterally. MEDICATIONS include: 1. Rifampin, 300 mg daily for SBP prophylaxis. 2. Spironolactone, 25 mg daily, which I recognize as half the dose that he was on upon admission in _%#MM#%_. 3. Inderal LA, 60 mg daily. 4. Ciprofloxacin, 500 mg weekly on Mondays.
SBP|spontaneous bacterial peritonitis|SBP.|145|148|ASSESSMENT AND PLAN|Will have nursing resume routine tube cares. Will repeat ultrasound to evaluate for ascites and if present then perform paracentesis to rule out SBP. 4. Chronic pain syndrome with neuropathy. Will continue her chronic meds. 5. Headache. Head CT ordered in Emergency Department. Results are still pending at the time of this dictation.
SBP|spontaneous bacterial peritonitis|SBP|216|218|HOSPITAL COURSE|The patient was having several bowel movements already prior to transfer to the primary team. The exam was benign and not consistent with spontaneous bacterial peritonitis, so it was felt that further evaluation for SBP such as attempt to tap his abdomen was not needed at this time. The patient's white count was normal. The patient's white count was normal (5.8). The patient was feeling much better at the time of discharge.
SBP|spontaneous bacterial peritonitis|SBP|105|107|DISCHARGE MEDICATIONS|4. Metoprolol 25 mg through the G tube once a day. 5. Bactrim 1 tablet through the G tube once a day for SBP prophylaxis. 6. Ursodiol 300 mg p.o. G tube b.i.d. 7. Colace 100 mg through the G tube b.i.d. 8. Multivitamin 1 tablet through the G tube twice a day as a vitamin supplement.
SBP|spontaneous bacterial peritonitis|SBP.|111|114|BRIEF HISTORY AND HOSPITAL COURSE|A cell count and diff showed only 19 nucleated cells with only 9% neutrophils. Findings were not diagnostic of SBP. She was afebrile. She felt slightly better. She had not been on any diuretics in the past for her ascites, and I started her on a Lasix 20 mg p.o. b.i.d. as well as Aldactone 50 mg p.o. daily.
SBP|systolic blood pressure|SBP|203|205|HISTORY OF PRESENTING COMPLAINT|The patient's albumin is reasonable at 3.2. Hemoglobin here in the emergency room was 6.9, BUN 30, creatinine 0.7, suggestive of some dehydration and probably an upper GI bleed. Her heart rate is 40 and SBP about 90. PAST MEDICAL HISTORY: 1. Strep infection of the skin, on antibiotics for the last two weeks, discontinued yesterday.
SBP|spontaneous bacterial peritonitis|SBP|198|200|HOSPITAL COURSE|Physical examination was without changes. See admission history and physical without additions or deletions. HOSPITAL COURSE: The patient was gradually rehydrated. His rifampin was discontinued for SBP prophylaxis. Cultures were appropriately drawn and were found to be negative. Lab testing indicated on admission a creatinine of 1.94 and BUN of 34.
SBP|spontaneous bacterial peritonitis|SBP.|219|222|PROBLEM #2|We did consult the transplant gastroenterology team to let them know that the patient was being evaluated in the hospital. They did not feel that his symptoms were secondary to his liver disease or even possibly due to SBP. The patient does not have any history of having SBP and on exam did not have any notable ascites. At this time, it appears that his liver disease is stable and the patient should continue on all of his medications as previously ordered.
SBP|spontaneous bacterial peritonitis|SBP|149|151|PROBLEM #2|They did not feel that his symptoms were secondary to his liver disease or even possibly due to SBP. The patient does not have any history of having SBP and on exam did not have any notable ascites. At this time, it appears that his liver disease is stable and the patient should continue on all of his medications as previously ordered.
SBP|spontaneous bacterial peritonitis|SBP|211|213|BRIEF HISTORY OF PRESENT ILLNESS|Because of the temperature and the symptoms he visited the ER where he had some blood work drawn and after that he was referred to the GI clinic. In the GI clinic, he was evaluated and there was a concern about SBP and therefore the patient was admitted to emergency service for further workup. For detailed H&P please see the note in the chart, dated _%#MMDD2007#%_.
SBP|spontaneous bacterial peritonitis|SBP|325|327|PROBLEM#1|Therefore, the patient was instructed that when his 14-day course of ciprofloxacin finishes, he should start taking ciprofloxacin 250 mg p.o. once every week, so as to ensure that he does not get this infection again. He was also asked to follow up with the GI clinic with nurse practitioner in 2 weeks' time for followup of SBP and he was asked to retain his appointment with Dr. _%#NAME#%_ in _%#MM#%_ 2007. PROBLEM#2: Anemia. During the hospitalization, the patient was noted to be anemic.
SBP|spontaneous bacterial peritonitis|SBP.|168|171|HOSPITAL COURSE|A CT of the abdomen was obtained, which did not show any specific cause for the abdominal pain. Again, the patient's history of liver disease and him being at risk for SBP. We performed a bedside diagnostic paracentesis and obtained peritoneal fluid for analysis. The peritoneal fluid showed 4400 red blood cells, 1885 nucleated cells with 8% neutrophils and 74% lymphocytes.
SBP|spontaneous bacterial peritonitis|SBP|168|170|HOSPITAL COURSE|At the time of discharge, we decided to send the patient home on p.o. ciprofloxacin for 2 weeks. Based on the recommendations from GI, it was also recommended to start SBP prophylaxis after completion of the antibiotic course. Therefore, after 2 weeks of p.o. ciprofloxacin, the patient will start once a week p.o. ciprofloxacin for prophylaxis.
SBP|spontaneous bacterial peritonitis|SBP|178|180|PROBLEM #4|At the time of discharge, the patient was noted to have reduction in the lymphadenopathy and was feeling well. We sending the patient home on ciprofloxacin, which will cover his SBP and he did also have some activity against prior to that bacteria as well. The patient completed the course of ciprofloxacin as mentioned above.
SBP|spontaneous bacterial peritonitis|SBP,|349|352|HOSPITAL COURSE|No ecchymosis. Slightly warm to touch bilaterally. ADMITTING LABS: INR 1.93, T-bili 3.11, ammonium 43, ALT 19, AST 39, alkaline phosphatase 157, albumin 2.9. Sodium 138, potassium 3.9, 99 chloride, bicarb 34, BUN 13, creatinine 0.9, glucose 100, calcium 8.7. HOSPITAL COURSE: The patient was admitted into the Medicine Service. Because of suspected SBP, she was started on clindamycin and ceftazidime. After review of her skin findings, it is most likely that she has a bilateral cellulitis, but more likely that she has venostasis ulcerations explaining the multiple areas of lesions and indentations.
SBP|spontaneous bacterial peritonitis|SBP.|143|146|PROBLEM #3|Blood cultures at the end of his hospital course were negative. The patient also underwent two diagnostic paracentesis which were negative for SBP. DISCHARGE MEDICATIONS: 1. Propranolol 10 mg q.i.d. 2. Protonix 40 mg b.i.d.
SBP|spontaneous bacterial peritonitis|SBP.|288|291|HISTORY OF PRESENT ILLNESS|Patient was discharged from _%#CITY#%_ to home. Within 2-3 days of discharge from _%#CITY#%_, patient was taken to MeritCare Hospital on _%#MM#%_ _%#DD#%_, 2003, by his wife. On admission he was noted to have hepatic encephalopathy. Patient was resuscitated and started on cefotaxime for SBP. Patient developed acute renal failure with elevated creatinine 1 day prior to the transfer. Patient also became anuric, not responding to diuretics. Patient remained confused and obtunded.
SBP|spontaneous bacterial peritonitis|SBP.|253|256|LABORATORY|HOSPITAL COURSE: Patient was admitted with end-stage liver disease, hepatic encephalopathy, and acute renal failure suspicious for hepatorenal syndrome. Patient initially received supportive care for hepatic encephalopathy prophylaxis for treatment for SBP. Renal consult was obtained to evaluate for hepatorenal syndrome. Patient was electively intubated for airway protection in the ensuring hospital stay.
SBP|spontaneous bacterial peritonitis|SBP|230|232|HOSPITAL COURSE|After discharge, his influenza A virus was positive; however, the patient was recovering quite quickly. His chest x- ray was negative for any acute infiltrate and an abdominal examination was additionally done to evaluate for any SBP and there was no ascites present. The patient did spike a temperature again the first evening of admission and a repeat chest x-ray to evaluate any changes in his right pleural effusion was done and showed a small increase, but no obvious infiltrates.
SBP|spontaneous bacterial peritonitis|SBP.|251|254|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Pantoprazole 40 mg p.o. b.i.d. 2. Gastrointestinal can switch this to daily when they think the upper gastrointestinal bleed is healed. 3. Nadolol 20 mg p.o. q.h.s. for varices. 4. Levofloxacin 500 mg p.o. daily x 6 days for SBP. 5. Fluconazole 100 mg p.o. daily until _%#MMDD2005#%_ for urinary tract infection with yeast. 6. Lactulose 45 mL p.o. q.i.d., titrate to 3-4 loose stools per day.
SBP|spontaneous bacterial peritonitis|(SBP)|154|158|ASSESSMENT/PLAN|He will follow up with primary medical doctor. 3. End-stage liver disease. This appears to be stable, no ascites, doubt spontaneous bacterial peritonitis (SBP) as the cause of his pain. Again there is no ascites on CT. CT of the abdomen is unremarkable, and he has no fever or leukocytosis.
SBP|systolic blood pressure|SBP|167|169|DISCHARGE MEDICATIONS|3. Celexa 20 mg p.o. daily. 4. Hydrochlorothiazide 25 mg tablets p.o. daily. 5. Lisinopril 20 mg tablets p.o. daily. 6. Metoprolol 25 mg tablets p.o. b.i.d., hold for SBP less than 90. 7. Milk of magnesia 30 mL suspension p.o. daily p.r.n. constipation. 8. Cranberry tablet 1 tablet p.o. daily. 9. Multivitamin with minerals 1 tablet p.o. daily.
SBP|spontaneous bacterial peritonitis|SBP,|139|142|HOSPITAL COURSE|A diagnostic paracentesis was performed which revealed 146 nucleated cells, most of which were neutrophils. This did not meet criteria for SBP, however, the patient had been treated with Unasyn at outside hospital so it was felt that it was possible that the patient may have a partially treated SBP.
SBP|spontaneous bacterial peritonitis|SBP.|188|191|HOSPITAL COURSE|This did not meet criteria for SBP, however, the patient had been treated with Unasyn at outside hospital so it was felt that it was possible that the patient may have a partially treated SBP. Also, the patient had cellulitic appearing rash on his right flank and leg with the appearance of a vesicular lesion. It was felt that the patient may also have a skin infection related to this.
SBP|spontaneous bacterial peritonitis|SBP.|213|216|PROBLEM #2|PROBLEM #2: Abdominal pain. The patient currently does have some chronic abdominal pain and is on chronic oxycodone. There are no signs of ascites at this time. His abdomen is soft and nontender. I do not suspect SBP. He was recently tapped on _%#MMDD2006#%_ when he presented also with abdominal pain. This was negative for infection. The patient is afebrile and has a normal white count.
SBP|systolic blood pressure|SBP|137|139|DISCHARGE MEDICATIONS|3. Furosemide 40 mg p.o. daily. 4. Neurontin 100 mg p.o. q.a.m., 300 mg p.o. each day at bedtime. 5. Lisinopril 5 mg p.o. daily, hold if SBP is less than 90. 6. ICAPS two tabs p.o. daily. 7. Glucosamine/chondroitin 1500/1200; 30 mL oral liquid 2 tablespoons p.o. daily.
SBP|spontaneous bacterial peritonitis|SBP|204|206|HOSPITAL COURSE|With respect to her Levofloxacin she will receive 1 more dose of that for approximate total 14-day course of antibiotics between IV cefotaxime and oral Levofloxacin. She will be restarted on her previous SBP prophylaxis regimen of ciprofloxacin of 250 mg every week. She has follow up with her hepatologist on _%#MM#%_ _%#DD#%_.
SBP|spontaneous bacterial peritonitis|SBP,|190|193|PROCEDURES PERFORMED|DISCHARGE DIAGNOSES: 1. Encephalopathy, likely secondary to Ambien. 2. Urinary tract infection. PROCEDURES PERFORMED: Ultrasound-guided paracentesis on _%#MMDD2007#%_ showing no evidence of SBP, 1 L removed. BRIEF HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old female with a history of endstage liver disease secondary to alcohol abuse, type 2 diabetes, history of portal hypertension and grade 1 esophageal varices as well as chronic renal failure secondary to type 2 hepatorenal syndrome requiring dialysis.
SBP|spontaneous bacterial peritonitis|SBP|152|154|DISCHARGE MEDICATIONS|12. Ambien 5-10 mg p.o. each day at bedtime p.r.n. insomnia. 13. Vicodin one to two tabs p.o. q.6 hours p.r.n. pain. 14. Noroxin 400 mg p.o. q. day for SBP prophylaxis. Please note we discontinued Flagyl which had been at 500 mg p.o. q.i.d., and Lasix for the time being has been discontinued as well.
SBP|spontaneous bacterial peritonitis|SBP.|190|193|HOSPITAL COURSE|Hemoglobin was 9.7 down from 11 on _%#MM#%_ _%#DD#%_. Platelets were 73,000, creatinine 1.7. His ammonia was 44. HOSPITAL COURSE: Because of his weakness and fever, he was suspected to have SBP. Blood cultures were obtained and he was empirically started on Unasyn. Because of anemia, he was transfused with 2 units of packed red cells.
SBP|spontaneous bacterial peritonitis|SBP.|153|156|ASSESSMENT AND PLAN|Possible explanations include uremia, low likelihood of hepatic encephalopathy with low ammonia, and undiagnosed infection with most likely source being SBP. We will be attempting to treat any acute component of uremia (i.e. dehydration) as well hepatic encephalopathy with rehydration and with an increased dose of lactulose to promote increased bowel movement.
SBP|spontaneous bacterial peritonitis|SBP,|357|360|HISTORY OF PRESENT ILLNESS|Briefly, Mr. _%#NAME#%_ _%#NAME#%_ is a very pleasant 24-year-old gentleman, who was admitted on _%#MMDD2007#%_ with three days' history of nausea and nonbloody emesis in context of end-stage liver disease, secondary to congenital hepatitis B, awaiting transplant. He does have multiple features of portal hypertension and has a strong history of recurrent SBP, which was last being treated by IV vancomycin for group D enterococcus. He just finished this 2 weeks' course of IV vancomycin a day ago prior to admission.
SBP|spontaneous bacterial peritonitis|SBP|246|248|COURSE IN THE HOSPITAL|COURSE IN THE HOSPITAL: 1. End-stage liver disease. As mentioned above, he is high on the transplant list and we did get liver transplant team to assess him as an inpatient. The only medication change they suggested is to change his prophylactic SBP antibiotics from Levaquin to Bactrim. We will also continue his other GI medication upon discharge. Although Nh3 is 119 he is fully lucid. 2. Small bowel obstruction.
SBP|spontaneous bacterial peritonitis|SBP.|159|162|COURSE IN THE HOSPITAL|Due to his chronic history of recurrent SBP, we also ordered an imaging-guided paracentesis to sample his ascitic fluid for laboratory examination to rule out SBP. The ascitic fluid was sterile for bacteria with nucleated cell count of 118, 85% monocytes and macrophages. Working diagnosis of small bowel obstruction is likely secondary to either bowel edema or his hypomagnesemia as well as hypokalemia.
SBP|spontaneous bacterial peritonitis|SBP|200|202|IMPRESSION AND PLAN|We will rule out urinary tract infection with urine culture, although this seems less likely. I would doubt pneumonia. I would doubt any other significant infection. Certainly consider something like SBP given his cirrhosis history and we will check an abdominal ultrasound to evaluate for ascites. Notably this was checked during his last hospitalization and showed just a scant amount.
SBP|spontaneous bacterial peritonitis|SBP.|168|171|BRIEF HISTORY OF PRESENT ILLNESS|BRIEF HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 24-year-old male with a history of congenital hepatitis B, cirrhosis and multiple admissions for recurrent SBP. The patient presented with refractory emesis, inability to hold on medications along with increasing abdominal pain. He had been on ceftriaxone and vancomycin empirically for SBP prior to this.
SBP|spontaneous bacterial peritonitis|SBP|235|237|PLAN|BUN to creatinine ratio is difficult to assess with expected contribution from upper GI bleed. Bilateral renal ultrasound has been requested to consider hydronephrosis. FENA has been requested to confirm presumed prerenal etiology. 5. SBP (spontaneous bacterial peritonitis) prophylaxis: As this patient likely has variceal bleeding in a setting of cirrhosis SBP prophylaxis will be offered with levofloxacin.
SBP|spontaneous bacterial peritonitis|SBP.|184|187|HISTORY OF PRESENT ILLNESS|He was given scheduled lactulose and started to have bowel movements and did have improvement of his mental status. He also had a diagnostic tap of his ascites, which was negative for SBP. He remained stable and was seen by the PM&R who felt he is a good candidate for acute rehab. At the time of my questioning the patient denies hemoptysis, hematemesis, melena or hematochezia.
SBP|spontaneous bacterial peritonitis|SBP.|130|133|HOSPITAL COURSE|The hematocrit was also less than 2. Further studies are pending, however, it seems unlikely that the patient has any evidence of SBP. Of note, the patient is also on SBP prophylaxis and we recommended that patient continued that. Given the patient's increasing needs for regular paracentesis recently, we have decided to refer the patient to Intervention Radiology for scheduled periodic abdominal paracentesis.
SBP|spontaneous bacterial peritonitis|SBP|176|178|DISCHARGE MEDICATIONS|Depression: The patient was continued on her home doses of paroxetine. DISCHARGE MEDICATIONS: 1. Multivitamin 1 tab p.o. daily. 2. Bactrim double strength 1 tab p.o. daily for SBP prophylaxis. 3. Propranolol 40 mg p.o. b.i.d. 4. Ambien 10 mg p.o. each day at bedtime. 5. Paroxetine 40 mg p.o. daily. 6. Iron dextran IV monthly.
SBP|spontaneous bacterial peritonitis|SBP.|279|282|HOSPITAL COURSE|(Patient's prior EGD showed portal gastropathy and gastric ulcer, no varices, so he was not on a beta blocker and just on PPI which was switched to iv at time of transfer). -Assess for possible therapeutic and diagnostic paracentesis to improve respiratory distress and rule out SBP. -Assess antibiotic coverage, especially to consider adding empiric Flagyl because of recent broad spectrum antibiotics and worse diarrhea.
SBP|systolic blood pressure|SBP|205|207|ASSESSMENT/PLAN|3. Tobacco abuse. Patient will be encouraged to quit smoking. 4. Possible hypertension. The patient's blood pressures will be monitored. She will be placed on treatment for accelerated hypertension if her SBP is greater than 220.
SBP|spontaneous bacterial peritonitis|(SBP)|216|220|-2/2 PBC|5. Hypothyroidism: -She is currently on replacement therapy. 6. Gastrointestinal prophylaxis: -She is on Protonix 40 mg b.i.d. 7. Depressed mood: -She is on Zyprexa 2.5 mg daily. 8. Spontaneous bacterial peritonitis (SBP) prophylaxis: -She is on ciprofloxacin once weekly, held on admit. 9. Malnutrition: -Will keep NPO tonite -She is currently on a soft diet with supplements.
SBP|systolic blood pressure|SBP|145|147|PHYSICAL EXAMINATION|PSYCHIATRIC: Negative for anxiety or depression ENDOCRINE: Negative for polyuria, polyphagia, polydipsia. PHYSICAL EXAMINATION: Respirations 30, SBP is 116/72, T 99, O2 sats 94% on 2 liters. GENERAL APPEARANCE: Middle-age female lying in bed in no acute distress.
SBP|systolic blood pressure|SBP|170|172|MEDICATIONS ON DISCHARGE|4. Lidoderm patch 5% to each site of wound, 12 hours on, 12 hours off. 5. Dilaudid 2-4 mg p.o. q 4h p.r.n. 6. Valium 5 to 10 mg p.o. q 8h p.r.n. spasms. 7. Clonidine for SBP greater than 140. 8. Hydrochlorothiazide 25 mg p.o. daily. 9. Prednisone 7.5 mg p.o. daily. 10. Gabapentin 100 mg p.o. t.i.d.
SBP|spontaneous bacterial peritonitis|SBP.|242|245|PROBLEM #4|Biopsy is not necessary. Serologies including viral hepatitis and autoimmune as well as alpha 1 antitrypsin have all been normal. The patient underwent a diagnostic and therapeutic paracentesis during her admission. There was no evidence for SBP. This was complicated by persistent leak from the paracentesis site. This is now closed after DermaBond application. Her diuretic regimen is Lasix 60 mg p.o. twice a day and spironolactone 50 mg daily.
SBP|spontaneous bacterial peritonitis|SBP.|173|176|ASSESSMENT/PLAN|1. This is a 40-year-old end-stage liver failure patient with subacute hepatic encephalopathy in the setting of hyponatremia, with a recent paracentesis without evidence of SBP. 2. Persistent mild leukocytosis with left shift, cannot rule out remote but possible bacteremia. PLAN: We will fully culture this man with blood cultures x2, UA, UC, and do a chest x-ray.
SBP|spontaneous bacterial peritonitis|SBP.|270|273|HOSPITAL COURSE|He was also started on rifaxamin. There was some concern about spontaneous bacterial peritonitis given his relatively sudden change in mental status. A diagnostic paracentesis was not easily performed on the floor. He was started on ceftriaxone empirically for possible SBP. On hospital day #2, he went to Interventional Radiology for a paracentesis there. About, 1.8 L of fluid was successfully removed. Fluid analysis showed 120 nucleated cells, only 7% of which were neutrophils.
SBP|spontaneous bacterial peritonitis|SBP|192|194|HOSPITAL COURSE|2. Abdominal pain. No clear etiology was found for the patient's abdominal pain on previous admission and it had spontaneously self-resolved. Diagnostic paracentesis was performed to rule out SBP as described above. At the time of discharge, the abdominal pain had again resolved. 3. Review of studies from his previous admission showed that a VCV and HSV studies were positive only for IgG.
SBP|spontaneous bacterial peritonitis|SBP.|229|232|HOSPITAL COURSE|2. Spontaneous bacterial peritonitis. Since time of admission, the patient did say that he had increasing abdominal distention and also had abdominal pain as well. This time, it was suspected that the patient possibly might have SBP. The patient received paracentesis and his fluid was sent for cultures and also for fluid analysis as well. His fluid analysis revealed that he had RBC count of 2960, nucleated cells were 69, neutrophils were 6, lymphocytes 21, monocytes were 73 and the fluid was yellow and hazy.
SBP|spontaneous bacterial peritonitis|SBP.|150|153|DISCHARGE MEDICATIONS|5. Hydroxyzine 100 mg p.o. q.8h. p.r.n. 6. Lansoprazole 30 mg p.o. daily. 7. Ciprofloxacin 750 mg p.o. once a week. This was added for prophylaxis of SBP. 8. Percocet. The patient was given Percocet at the time of discharge for pain management. However, the patient was called back to discontinue the Percocet.
SBP|systolic blood pressure|SBP|230|232|DISCHARGE MEDICATIONS - UNCHANGED|2. Hypertension. 3. Dyslipidemia. DISCHARGE MEDICATIONS - UNCHANGED: 1. Alprazolam 0.5 mg p.o. each day at bed-time p.r.n. 2. BuSpar 10 mg p.o. daily 3. Hydrochlorothiazide 25 mg p.o. daily 4. Lisinopril 10 mg p.o. daily, hold if SBP is less than 90 5. Multivitamins with minerals p.o. daily 6. Simvastatin 80 mg p.o. q p.m. 7. Aspirin 81 mg p.o. daily 8. Ibuprofen 600 mg p.o. q.i.d. p.r.n. pain
SBP|systolic blood pressure|SBP|315|317|TREATMENT RENDERED|The patient will use Flexeril as needed. She also prefers to use hydromorphone, but I would use hydromorphone only if she truly does have significant nausea with Percocet and oxycodone. 3. Hypertension. She will continue to take her antihypertensive medicines with exclusion of lisinopril which will be held if her SBP is less than 90. 4. Dyslipidemia. The patient will continue her cholesterol medications.
SBP|spontaneous bacterial peritonitis|SBP|200|202|HOSPITAL COURSE BY PROBLEM|Labs drawn included a PSA, RPR, hepatitis A, hepatitis B, hepatitis C, CMV, IgG, EBV, HIV, cholesterol, triglycerides, TSH, T4, ferritin, iron saturation, and DEXA scan. As mentioned, he did not have SBP based on the outside labs. He did receive cefotaxime for possible SBP until we found out the results of the labs, and this was subsequently discontinued and he was discontinued on his vancomycin.
SBP|spontaneous bacterial peritonitis|SBP.|202|205|PROBLEM #5|PROBLEM #5: Infectious Disease. On admission, the patient was empirically started on cefotaxime for a possible spontaneous bacterial peritonitis. A diagnostic paracentesis the next day was negative for SBP. Her white blood count remained mildly elevated but was most likely due to her hepatitis. The patient was given a five-day course of antibiotics (levofloxacin and then ceftriaxone) after her colonoscopy to prevent transient feeding of the ascites from her bowel.
SBP|systolic blood pressure|SBP|177|179|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Lasix 40 mg p.o. daily. 2. Lisinopril 40 mg p.o. daily. 3. Lipitor 40 mg p.o. at bedtime. 4. Clonidine 0.3 mg to take 1/2 tablet p.o. daily p.r.n. for SBP greater than 180. 5. Metformin 1000 mg p.o. b.i.d. 6. Albuterol nebulizer every 2 hours as needed for wheezing and shortness of breath.
SBP|spontaneous bacterial peritonitis|SBP|161|163|PLAN|3. Ascites: Mild ascites is noted on physical exam as well. At this time since the patient is afebrile and there is no white blood cell count it is unlikely and SBP is not a concern. 4. Type 2 diabetes: As noted on the previous history. However, patient is not on any glycemic control medication. We will evaluate hemoglobin A1c and reassess.
SBP|spontaneous bacterial peritonitis|SBP|194|196|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: The patient's past medical history is significant for chronic hepatitis C which was diagnosed in 2001 and status post liver biopsy in 2001. The patient also has history of SBP and portal hypertension, grade I esophageal varices and questionable hematochromatosis from her liver biopsy done in 2001. It was then noted that she has stage 3 fibrosis and steatohepatitis.
SBP|spontaneous bacterial peritonitis|SBP.|147|150|ADDENDUM|The patient will be treated with Levaquin for a total of 14 days instead of the previously prescribed 10 days for her UTI. She will be treated for SBP. I spent more than 30 minutes reviewing and discussing the plan of discharge for this patient.
SBP|spontaneous bacterial peritonitis|SBP|193|195|HOSPITAL COURSE|Her mouth score in the past has been low, but in the hospital it was up to 28. GI recommended increasing her diuretics, continuing her propranolol. Continue on ciprofloxacin for prophylaxis of SBP and repeated diagnostic and therapeutic paracentesis to rule out spontaneous bacterial peritonitis which was done and there was no evidence of SPB on culture and sensitivities of the peritoneal fluid.
SBP|spontaneous bacterial peritonitis|SBP|203|205|PROBLEM 2|The patient had 2 episodes of paracentesis most recently on _%#MMDD2007#%_. Viral hepatitis serology is negative. He underwent diagnostic paracentesis, initially followed by therapeutic paracentesis, no SBP presently. The patient is on Cipro for prophylaxis for SBP. Mr. _%#NAME#%_ is also on Lasix and Aldactone. He may need repeat paracentesis in the future as ascitic fluid builds up.
SBP|spontaneous bacterial peritonitis|SBP.|167|170|DISCHARGE MEDICATIONS|2. Spironolactone 50 mg p.o. b.i.d. This was also doubled from the previous dose as recommended by transplant. 3. Ciprofloxacin 500 mg p.o. q. day for prophylaxis for SBP. 4. Lidoderm patch 5% skin 12 hours on and 12 hours off. 5. Quinine sulfate 260 mg p.o. q. day. 6. Percocet 7.5/500 p.o. b.i.d.
SBP|spontaneous bacterial peritonitis|SBP|148|150|ASSESSMENT/PLAN|Will continue her lactulose. Will check her liver function tests and INR to see if there has been any worsening in her status. Will continue weekly SBP prophylaxis for now. Will continue propanolol for varices. Will continue Lasix and spironolactone. 3. Rash: The patient had a diffuse erythematous rash on her abdomen and extremities.
SBP|spontaneous bacterial peritonitis|SBP|194|196|DISCHARGE MEDICATIONS|He will dialyze at _%#CITY#%_ DaVita Dialysis Unit on Mondays, Wednesdays and Fridays. DISCHARGE MEDICATIONS: Discharge medications are largely unchanged. He should get ciprofloxacin weekly for SBP prophylaxis and his PhosLo was switched to Renagel.
SBP|spontaneous bacterial peritonitis|SBP|291|293|HOSPITAL COURSE|White count remained stable at about 17. 2. GI. The patient was admitted with recurrent refractory ascites from end-stage liver disease secondary to alcoholic cirrhosis. She underwent large-volume paracentesis. The cultures were negative. Ascites fluid was low in protein, so GI recommended SBP prophylaxis. The patient developed mild encephalopathy and was started on lactulose with good results. She was continued on her diuretics.
SBP|spontaneous bacterial peritonitis|SBP.|252|255|HOSPITAL COURSE|Of note, because of the patient's renal insufficiency, the patient was given 3 days of IV albumin after her paracentesis. The patient will also be started on prophylactic antibiotics after this current antibiotic treatment, to avoid future episodes of SBP. The patient will be started on ciprofloxacin 750 mg p.o. q. week. 2. Urinary tract infection: The patient showed evidence of a urinary tract infection on her initial UA; however, her culture never grew a specific organism.
SBP|systolic blood pressure|SBP|150|152|DISCHARGE MEDICATIONS|Unchanged doses: 2. Loperamide 2 mg p.o. q.1 hour p.r.n. diarrhea, up to maximum of 8 mg a day. 3. Metoprolol 50 mg p.o. each day at bedtime, hold if SBP is less than 90. 4. Nitroglycerin take under the tongue 400 mcg q.5 minutes p.r.n. chest pain. 5. Pravastatin 10 mg p.o. each day at bedtime.
SBP|systolic blood pressure|SBP|189|191|PHYSICAL EXAMINATION|Denies tobacco, denies alcohol use. REVIEW OF SYSTEMS: A complete review of systems is performed and is negative with the exclusion of the ailments listed in the HPI. PHYSICAL EXAMINATION: SBP is 136/70. P 88. GENERAL: Elderly male lying in bed in no acute distress. HEENT: Pupils are equal and reactive to light and accommodation.
SBP|spontaneous bacterial peritonitis|SBP.|275|278|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old gentleman with a history of endstage liver disease secondary to hepatitis C, diagnosed in 2002, who was recently discharged in _%#MM2006#%_ from the University of Minnesota Medical Center, Fairview with a diagnosis of SBP. At that time, he presented with abdominal pain and fevers. He now presents to the emergency room today with right-sided abdominal pain, subjective fevers at home, nausea, vomiting and increased stool output.
SBP|spontaneous bacterial peritonitis|SBP|202|204|MEDICATIONS|6. L5/S1 fusion in 1991. ALLERGIES: Penicillin. MEDICATIONS: 1. Furosemide 40 mg daily. 2. Amiloride 10 mg b.i.d. 3. Protonix 40 mg b.i.d. 4. Lactulose 30 cc b.i.d. 5. Bactrim double-strength daily for SBP prophylaxis. SOCIAL HISTORY: He has a 60-pack-year smoking history. No alcohol for 3 years.
SBP|spontaneous bacterial peritonitis|SBP|268|270|HOSPITAL COURSE|Therefore, he has been requiring routine every other week paracentesis for fluid removal and presents with increasing edema and need for further paracentesis with some complaints of abdominal pain. Paracentesis was performed results as above. There is no evidence for SBP and the patient was continued on his ciprofloxacin for SBP prophylaxis. Following paracentesis, the patient had continued drainage from the paracentesis site, which throughout the course of the hospitalization did start to slow down.
SBP|spontaneous bacterial peritonitis|SBP|129|131|HOSPITAL COURSE|Paracentesis was performed results as above. There is no evidence for SBP and the patient was continued on his ciprofloxacin for SBP prophylaxis. Following paracentesis, the patient had continued drainage from the paracentesis site, which throughout the course of the hospitalization did start to slow down.
SBP|spontaneous bacterial peritonitis|SBP.|174|177|HOSPITAL  COURSE|Paracentesis was done and showed 3600 white blood cells with 89% neutrophils. Cultures were negative. With the leukocytosis, the patient was thought to have culture negative SBP. The patient was treated with ceftriaxone and will complete 14 days on _%#MMDD2007#%_. Thereafter, GI has recommended norfloxacin for SBP prophylaxis. Patient did have blood per rectum during the stay and was found to have c. diff colitis; she was started on treatment during this stay; GI has recommended 4 weeks of Flagyl.
SBP|spontaneous bacterial peritonitis|SBP|234|236|HOSPITAL  COURSE|Cultures were negative. With the leukocytosis, the patient was thought to have culture negative SBP. The patient was treated with ceftriaxone and will complete 14 days on _%#MMDD2007#%_. Thereafter, GI has recommended norfloxacin for SBP prophylaxis. Patient did have blood per rectum during the stay and was found to have c. diff colitis; she was started on treatment during this stay; GI has recommended 4 weeks of Flagyl.
SBP|spontaneous bacterial peritonitis|SBP|161|163|MEDICATIONS|5. Inderal 20 mg p.o. daily. 6. Ocean nasal spray 1 inhalation both nostrils b.i.d. 7. Aldactone 100 mg p.o. daily. 8. Ciprofloxacin 750 mg p.o. once weekly for SBP prophylaxis. 9. Rifaximin 400 mg p.o. t.i.d. 10. Albuterol inhaler 2 puffs q.i.d. p.r.n. 11. Advair 250/500, 1 inhalation daily. 12. Heparin solution to maintain patency of peripheral/PICC line.
SBP|spontaneous bacterial peritonitis|SBP|214|216|ASSESSMENT AND PLAN|2. Liver failure secondary to ETOH with recent ascites, portal hypertension, varices and synthetic dysfunction. Will continue lactulose, proton pump inhibitor, Questran, Aldactone and Inderal and also continue her SBP prophylaxis with Levaquin. The patient is at high risk for not metabolizing drugs well so monitor closely. 3. Anemia. Monitor closely, given her high risk for bleeding from portal hypertension, elevated INR, thrombocytopenia, and Lovenox therapy.
SBP|systolic blood pressure|SBP|141|143|MEDICATIONS|New medications: 1. Norvasc 10 mg p.o. daily. Reason: Hypertension, hold if his SBP is less than 90. 2. Hydroxyzine 10 mg p.o. t.i.d. p.r.n. SBP greater than 60. The reason is hypertension. 3. Labetalol 100 mg p.o. t.i.d., hold if heart rate is less than 60 or SBP is less than 95.
SBP|spontaneous bacterial peritonitis|SBP.|242|245|HOSPITAL COURSE|HOSPITAL COURSE: 1. Hepatic encephalopathy. The patient was started on lactulose titrated to 4 to 5 bowel movements per day. The patient had a ultrasound guided paracentesis on _%#MMDD2007#%_ and the fluid obtained from this was negative for SBP. His mental status continued to improve until he had a significant amount of cashews a few days before discharge. His mental status rapidly deteriorated and his ammonia rose to 281.
SBP|spontaneous bacterial peritonitis|SBP.|157|160|HOSPITAL COURSE|The patient was also given some IV fluids, D-5 half normal saline at 50 cc an hour. The patient was also started on ceftriaxone 2 grams IV q.d. for possible SBP. Vitamin K 5 mg p.o. q.d. was continued. Ammonia levels were followed q.d. The day after admission he remained confused and lactulose was increased to 45 cc q 3 hours.
SBP|spontaneous bacterial peritonitis|SBP,|146|149|ASSESSMENT AND PLAN|They also suggested we start octreotide, which I will do. Unknown INR, was also not checked and so we will be checking that. 4) Concern regarding SBP, spontaneous bacterial peritonitis. We will get a tap tonight through radiology, check for cells and after the tap get her started on antibiotics.
SBP|spontaneous bacterial peritonitis|SBP|281|283|PROBLEM #2|We did send the patient down for an ultrasound guided tap by Interventional Radiology, but they also thought that there was not enough fluid and with his dilated bowel, that it would be too risky procedure. We subsequently decided that we should treat him empirically for possible SBP or secondary peritonitis and we chose ceftriaxone. We then discharged the patient on levofloxacin with dosing for his renal insufficiency.
SBP|systolic blood pressure|SBP|169|171|DISCHARGE MEDICATIONS|4. Hypertension. 5. Dementia. 6. Depression 7. Anemia. 8. Neuropathy. 9. Gastroesophageal reflux disease DISCHARGE MEDICATIONS: 1. Norvasc 10 mg p.o. daily, hold if his SBP is less than 140 2. Abilify 10 mg p.o. daily. 3. Celexa 20 mg p.o. daily, 4. Darbepoetin 60 mcg injection every week with dialysis 5. Aricept 10 mg p.o. at q.h.s.
SBP|systolic blood pressure|SBP|138|140|DISCHARGE MEDICATIONS|6. Gabapentin 600 mg p.o. b.i.d. 7. Lisinopril 20 mg p.o. daily, hold if SBP is less than 130 8. Minoxidil 2.5 mg p.o. at q.h.s., hold if SBP is less than 160 9. Multivitamin p.o. daily. 10. Acetaminophen 1000 mg p.o. t.i.d. p.r.n. pain. 11. Aspirin 81 mg p.o. daily. 12. Levaquin 250 mg q.48h., give for six more doses
SBP|spontaneous bacterial peritonitis|SBP|324|326|ASSESSMENT|MRI shows some disk narrowing increased signaling in the .endplates at L2-3, and because of the ongoing fever and her main complaint, which is back pain, we have proceeded with diagnostic needling of that area. I think other possibilities, however, exist for infection, most particularly infection of her right IJ catheter. SBP has been ruled out with unremarkable paracentesis values The localized abdominal pain is difficult to explain but may simply be related to a small hematoma at the site of the paracentesis.
SBP|systolic blood pressure|SBP|111|113|MEDICATIONS|8. Travatan 0.004% one drop each eye q.h.s. 9. Aspirin 81 mg p.o. daily. 10. Atenolol 50 mg p.o. q. day p.r.n. SBP greater than 150. HISTORY OF PRESENT ILLNESS DISCHARGE FOLLOW-UP: The patient will follow up with her regular physician.
SBP|spontaneous bacterial peritonitis|SBP|116|118|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Abdominal pain, thought secondary to multiple etiologies including urinary tract infection, SBP and ascites. 2. Anemia. 3. Acute kidney insufficiency. 4. End-stage liver disease. IMAGING STUDIES PERFORMED DURING ADMISSION: On _%#MMDD2007#%_, ultrasound of the abdomen showed cirrhotic liver, enlarged main portal vein and ascites consistent with portal hypertension, coursing echogenicity of the spleen is unchanged compared to prior exam on _%#MMDD2007#%_.
SBP|systolic blood pressure|SBP|259|261|DISCHARGE MEDICATIONS|DISCHARGE CONDITION: Stable. DIET: As specified above. ACTIVITY: As tolerated. DISPOSITION: Homeward bound group home. DISCHARGE MEDICATIONS: 1. Atenolol 50 mg suspension through J-tube each day at bedtime, shake well and hold if pulse is less than 45 and/or SBP is less or equal to 90 and/or DBP is less or equal to 50. 2. Carbamide 6.5% ear drops instill 1-2 drops into both ears x3 days, flush with half-strength H2O2 on day #4 as needed.
SBP|spontaneous bacterial peritonitis|SBP.|163|166|ASSESSMENT AND PLAN|2. Acute-on-chronic kidney disease with worsening creatinine. Possible etiologies for this renal failure include hepatorenal syndrome or ATN secondary to possible SBP. Creatinine has not improved despite rehydration. Renal will be consulted tomorrow. It is possible that the patient's primary team at Fairview Southdale was considering both renal and liver transplant for this patient.
SBP|systolic blood pressure|SBP|149|151|ASSESSMENT/PLAN|The patient is not on any oral agents, so we will start her on Norvasc 10 mg a day, metoprolol 50 mg b.i.d. Will reserve IV hydralazine 10 mg IV for SBP more than 180 or DBP more than 110. Will consider using IV labetalol if the patient's blood pressure does not respond to the aforementioned medications.
SBP|spontaneous bacterial peritonitis|SBP|155|157|PROBLEM #2|He was not restarted on his spironolactone as spironolactone had caused gynecomastia in him. However, as stated he was started on levofloxacin for empiric SBP treatment. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. twice daily.
SBP|systolic blood pressure|SBP|154|156|PERTINENT LABORATORY TESTS|6. On _%#MMDD2007#%_, creatinine urine 63, sodium urine random 107 and percentage FENA was 1.8. _%#MMDD2007#%_: Today on exam, no changes from yesterday. SBP is in the 100's. No dizzyness. D/w with pt why HCTZ not restarted prior to dc home and he can f/u with PCP next week.
SBP|spontaneous bacterial peritonitis|SBP.|360|363|SECONDARY DIAGNOSES|PLANNED DISCHARGE DATE: Transfer to University Medical Center on _%#MMDD2007#%_ PRIMARY CARE PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD PRINCIPAL DIAGNOSIS: Decompensating cirrhosis (NASH), worsening status post large volume (15,600 mL) pleurocentesis, _%#MMDD2007#%_, with worsening total bilirubin, creatinine and ascites. SECONDARY DIAGNOSES: 1. Culture negative SBP. 2. Elevated lipase of unclear etiology. MRI done, results pending. 3. Acute on chronic kidney disease with creatinine worsening despite IV hydration.
SBP|spontaneous bacterial peritonitis|SBP|222|224|DISCHARGE MEDICATIONS|6. Levothyroxine 125 mcg p.o. daily. 7. Lactulose 30 mL p.o. 3 times daily, titrate to 3-5 bowel movements daily. 8. Lasix 40 mg p.o. daily. 9. Spironolactone 50 mg p.o. daily. 10. Avelox 400 mg p.o. weekly on Mondays for SBP prophylaxis. 11. Nystatin 5 mL oral q.i.d. swish and swallow for thrush, use for the next 5 days and then as needed. 12. Oxycodone 5 mg p.o. q. 6h. as needed for pain.
SBP|spontaneous bacterial peritonitis|SBP|255|257|HISTORY OF PRESENT ILLNESS|She had been there for several days prior to transfer to the University of Minnesota Medical Center, Fairview, and had a chest tube placed to drain her right-sided pleural effusion. Although there is no documentation of paracentesis and a big concern for SBP so the patient was started on antibiotics. She has had increasing confusion and weakness as well. On admission here the patient is somnolent, however does arouse to answer some questions.
SBP|spontaneous bacterial peritonitis|SBP|117|119|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Augmentin 875 mg p.o. b.i.d. for 14 days. 2. Begin Septra Double Strength 1 p.o. daily for SBP prophylaxis beginning _%#MMDD2006#%_. Further refills per Dr. _%#NAME#%_ at the Transplant Clinic. 3. Vicodin 1 p.o. q. 6-8 hours p.r.n. severe pain, #20.
SBP|spontaneous bacterial peritonitis|SBP,|284|287|BRIEF HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|BRIEF HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: Ms. _%#NAME#%_ is an unfortunate 59-year-old female with end- stage liver disease secondary to hepatitis C. She has actually just been discharged from the Medicine Service on _%#MMDD2006#%_ after being treated for encephalopathy, SBP, bacteremia, left perifusion, and MSSA urinary tract infection. She was readmitted to the Medicine Service on _%#MMDD2006#%_, because of increased confusion.
SBP|spontaneous bacterial peritonitis|SBP,|173|176|ASSESSMENT AND PLAN|6. Significant ascites. I think it reasonable to proceed with paracentesis both for diagnostic and therapeutic purposes. I would be somewhat surprised if he had evidence of SBP, but it is certainly possible and I think we need to exclude this given his somewhat decreased mental status. I think he would also benefit symptomatically from fluid removal, and if I am able to remove more than five liters I would replace him with some albumin.
SBP|spontaneous bacterial peritonitis|SBP.|227|230|HOSPITAL COURSE|This demonstrated over 2000 nucleated cells, 68% PMNs. Gram stain revealed no organisms and culture has been no growth to date. Given the number of PMNs in the peritoneal fluid, Mr. _%#NAME#%_ was started on IV antibiotics for SBP. He received 2 days of IV antibiotics and was then transitioned to oral ciprofloxacin. He remained afebrile on oral antibiotics and his abdominal exam improved significantly.
SBP|spontaneous bacterial peritonitis|SBP|152|154|HOSPITAL COURSE|He was oriented x place and person _____ stage I. He underwent an ultrasound-guided paracentesis to rule out SBP. The fluid analysis showed no signs of SBP and no signs of any other malignancies or _____. He had 5 L removed by an ultrasound-guided paracentesis. The patient was placed on high-dose lactulose and rifaximin.
SBP|spontaneous bacterial peritonitis|SBP.|237|240|PROBLEM #2|PROBLEM #2: SBP and E. coli bacteremia. Diagnostic and therapeutic paracenteses were performed on _%#MM#%_ _%#DD#%_, 2002. The fluid had 6160 white blood cells with 95% neutrophils. The patient was empirically started on ceftazidime for SBP. Later, his blood culture from admission and the ascites grew E. coli, which was pan sensitive. After his transfer to the floor, the patient spiked a temperature to 101.1. A diagnostic paracentesis showed 645 white blood cells with 81% neutrophils.
SBP|spontaneous bacterial peritonitis|SBP,|201|204|PLAN|We will start him on spironolactone for the ascites. We will restrict his dietary sodium. We will get GI consult for further advice regarding possible workup for varices, paracentesis, prophylaxis for SBP, and possible liver biopsy. 3. Hyperbilirubinemia. We will fractionate this. 4. Hypokalemia. This is secondary to the liver failure. We are starting him on spironolactone. 5. Hyponatremia. This is also secondary to the liver failure.
SBP|spontaneous bacterial peritonitis|SBP|142|144|HISTORY OF PRESENT ILLNESS|The patient has a history of refractory ascites and has been tapped the last time about 3 weeks ago. The patient does not have any history of SBP in the past and her last tap done 3 weeks ago also showed clear ascitic fluid. The patient's daughter stated that her primary-care physician was trying to arrange a tap once a week for her refractory ascites, but she has not been able to get one scheduled.
SBP|spontaneous bacterial peritonitis|SBP|282|284|ASSESSMENT AND PLAN|Her chest x-ray has been ordered and is pending. ASSESSMENT AND PLAN: The patient is a 47-year-old female with end-stage liver disease secondary to alcohol abuse and refractory ascites presenting with hyponatremia, confusion, and weakness with normal ammonia levels and no signs of SBP on clinical exam. 1. Hyponatremia: The patient has low sodium at 123 likely secondary to her diuretics that have been held in her last doctor visit.
SBP|spontaneous bacterial peritonitis|SBP.|93|96|DISCHARGE DIAGNOSES|2. Major hemorrhoidal bleeding - status post oversewing by a colorectal surgery. 3. Probable SBP. 4. Acute blood loss anemia - requiring transfusion. 5. Acute kidney failure - secondary to dehydration. MAJOR PROCEDURES: 1. Chest x-ray _%#MMDD2007#%_ - left lobe atelectasis versus pneumonia.
SBP|spontaneous bacterial peritonitis|SBP|149|151|DISCHARGE MEDICATIONS|12. Nystatin 5 mL p.o. q.i.d. x7 days. 13. Rifaximin 200 mg p.o. t.i.d. 14. Advair 250/50 mg 1 puff b.i.d. 15. Ciprofloxacin 750 mg p.o. q. week for SBP prophylaxis. FOLLOWUP: The patient is being set up for a TIPS procedure in interventional radiologist on Friday _%#MMDD2007#%_ at 8:00 a.m. He will be discharged home until that time and likely be readmitted following the procedure for observation and follow up ultrasound.
SBP|spontaneous bacterial peritonitis|SBP.|280|283|HOSPITAL COURSE|After the procedure, the patient's abdominal pain improved slightly. The fluid was also sent for Gram stain and culture, at which time the Gram stain came back negative for organisms but moderate PMNs were seen. At which time, it was decided to start the patient on treatment for SBP. The patient was started on Zosyn. Over the course of the hospitalization, the patient's ascites continued to reoccur. The patient had 2 more paracentesis done before discharge.
SBP|systolic blood pressure|SBP|233|235|PLAN|There is a high chance of death, however, his pre-clot cardiopulmonary profile was good and therefore he is in a relatively low risk category of death from a massive pulmonary embolus. Monitor troponin for and Echo for RV strain. If SBP low start levophed and dobutamine and then dopamine in that order. IVFluid. I will not insert a central or arterial line do not alteplase.
SBP|systolic blood pressure|SBP|356|358|DISCHARGE MEDICATIONS|_%#NAME#%_ should avoid lifting for 6 weeks. The patient's parents were instructed to report any increased drainage, pain, swelling or elevated temperature in excess of 100.5 to the transplant coordinator, their pediatrician or the University of Minnesota Medical Center Emergency Department. DISCHARGE MEDICATIONS: 1. Amlodipine 5 mg p.o. q. day hold for SBP less than 110. 2. Cyclosporine 175 mg twice a day. 3. Colace 50 mg p.o. b.i.d. p.r.n. constipation. 4. Prevacid 30 mg p.o. q. day.
SBP|spontaneous bacterial peritonitis|SBP|201|203|HISTORY OF PRESENT ILLNESS|He does take lactulose at home, however, would only take lactulose to have 1-2 stools a day. During his past hospitalization, he was started on IV antibiotics before paracentesis. Tap was negative for SBP and he was discharged after 2 days of antibiotics. HOSPITAL COURSE: 1. Abdominal pain. The patient complained of abdominal pain and developed worsening ascites during his hospitalization.
SBP|systolic blood pressure|SBP|290|292|A/P|I confirmed presentation, PMH, PSH, All, meds, FH, SH, ROS, vital signs, pertinent exam, labs and data and agree with findings as documented in housestaff H&P. A/P: 1. Hypertensive emergency with PRES (posterior reversible encephalopathy syndrome) - agree with IV labetolol to achieve goal SBP < 140. MRI findings reviewed. Appreciate neurology recommendations. To prevent seizures associated with this acute syndrome, patient will start on dilantin.
SBP|spontaneous bacterial peritonitis|SBP.|218|221|HOSPITAL COURSE|HOSPITAL COURSE: Hospital course was uneventful. Diagnostic and therapeutic paracentesis was performed on _%#MMDD2007#%_. Peritoneal fluid showed nucleated cell 397 and 4% of neutrophils, which was not consistent with SBP. Total 6.4 L of peritoneal fluid was removed and albumin was replaced appropriately. On the following day, her electrolytes were within normal limit and creatinine was 11.33, improved from time of admission.
SBP|spontaneous bacterial peritonitis|SBP|178|180|HOSPITAL COURSE|However, the patient was markedly confused with an elevated ammonia level of greater than 100. The patient was started on lactulose, and a paracentesis was performed to rule out SBP in the setting of hepatic encephalopathy despite the patient being afebrile. Because the patient was also sent here for evaluation for a possible TIPS, ultrasound of his abdomen was obtained to assess portal flow, the results as above.
SBP|spontaneous bacterial peritonitis|SBP|194|196|HOSPITAL COURSE|Her labs suggest a cholestatic picture and remain largely unchanged from previous admissions. The patient has baseline jaundice that has not changed on this admission. The patient is on chronic SBP prophylaxis with Bactrim Double-Strength twice a week. Although the patient has no history of SBP, it is felt at this time that she is tolerating the drug well and will be continued on this regimen.
SBP|spontaneous bacterial peritonitis|SBP,|198|201|HOSPITAL COURSE|The patient has baseline jaundice that has not changed on this admission. The patient is on chronic SBP prophylaxis with Bactrim Double-Strength twice a week. Although the patient has no history of SBP, it is felt at this time that she is tolerating the drug well and will be continued on this regimen. 4. Respiratory. The patient has a pulmonologist who follows her sarcoid of the lung.
SBP|spontaneous bacterial peritonitis|SBP|253|255|HOSPITAL COURSE|The etiology of cirrhosis was further evaluated. Patient's hepatitis panel was within normal limits as were his iron studies thereby ruling out viral hepatitis contributing to the cirrhosis as well as hemachromatosis. There was concern of his recurrent SBP and therefore it was decided that he would be put on prophylactic Bactrim after his antibiotic course was finished.
SBP|spontaneous bacterial peritonitis|SBP|179|181|MEDICATIONS AT TIME OF DISCHARGE|Ceftriaxone 2 grams IV q day times four days. Thiamine 100 mg per os q day. Folate 1 mg per os q day. Bactrim DS one tab per os q day after the antibiotic course was finished for SBP prophylaxis.
SBP|spontaneous bacterial peritonitis|SBP|152|154|HOSPITAL COURSE|She will go on a schedule either tomorrow or the following day. 3. ID: The patient was treated for a UTI briefly with ceftriaxone and also for presumed SBP briefly. At the time of this writing she is not on any antibiotics. 4. Thrombocytopenia: The patient's platelet count is usually at her baseline of approximately 50.
SBP|systolic blood pressure|SBP|144|146|DISCHARGE MEDICATIONS|401 - 450 - 12 units SC. Greater than 450 - call MD. 15. Thorazine 12.5 mg p.o. t.i.d. p.r.n. hiccups. 16. Labetalol 10-30 mg IV q2h p.r.n. for SBP greater than 140.
SBP|spontaneous bacterial peritonitis|SBP,|215|218|OPERATIONS/PROCEDURES PERFORMED|No organisms, no white blood cells seen. Anaerobic culture and peritoneal culture are pending. HOSPITAL COURSE: Ascites: Patient came in with significant ascites with positive tenderness, was suspected for possible SBP, however, patient did not have peritoneal signs. Patient was afebrile throughout hospital stay, never developed an elevated white count. Patient did have a 3-liter paracentesis on _%#MM#%_ _%#DD#%_, 2004, which cultures are pending and cytology is pending at the time of discharge.
SBP|spontaneous bacterial peritonitis|SBP|161|163|HOSPITAL COURSE|Blood pressures were monitored. He was also continued on rifaximin and his lactulose was titrated to about 4 stools a day. He was continued on ciprofloxacin for SBP prophylaxis. During his hospital course his mentation improved. His INR continues to be monitored. He was followed by the transplant surgeons by the Transplant Hepatology team during his hospitalization course and his liver disease appears stable at this time.
SBP|systolic blood pressure|SBP|195|197|DISCHARGE MEDICATIONS|11. Metoclopramide 40 mg p.o. q.6 hours x12 doses. 12 For chemotherapy prophylaxis, Zofran 8 mg p.o. q.8 hours, take for six days. 13. Lisinopril 20 mg p.o. daily, the patient can hold it if her SBP at home is less than 140. She should take her blood pressure readings for one week until she sees Dr. _%#NAME#%_. She can hold lisinopril if she has dizziness or a cough.
SBP|spontaneous bacterial peritonitis|SBP|163|165|PROBLEM #2|I will have liver transplant physician see him. PROBLEM #2: Left abdominal pain. Seems mild but I think in this setting we need to make sure that he does not have SBP particularly since he going to have a liver transplant next week . We will check to see if a paracentesis was done at St. Mary's and if not we will proceed to do that and treat with cefotaxime.
SBP|spontaneous bacterial peritonitis|SBP.|177|180|HISTORY OF PRESENT ILLNESS|Shortly thereafter the patient became apneic and required intubation. It was felt that it was secondary to benzodiazepines that he did receive. The temp was clear. Negative for SBP. After our intubation it was recommended that the patient be transferred to the Intensive Care Unit at Fairview-University Medical Center for further management of the dependent patient as well as his pneumonia and end stage liver disease.
SBP|spontaneous bacterial peritonitis|SBP|182|184|PROBLEM #2|Prior to discharge the patient underwent a second paracentesis. This time it was for diagnostic purposes and to ensure that the Klebsiella was absent given no clinical suggestion of SBP on initial presentation. The fluid withdrawn was also inconsistent with SBP, which was borne out by a subsequent culture. PROBLEM #3: Acute renal insufficiency. Her BUN and creatinine increased with the fluid shifts following her paracentesis.
SBP|spontaneous bacterial peritonitis|SBP.|190|193|HOSPITAL COURSE|HOSPITAL COURSE: The patient was admitted with a diagnosis of hepatic encephalopathy. Peritoneal fluid that was leaking from his prior paracentesis was sent and did not show any evidence of SBP. The patient was started on lactulose. On the morning following admission he was much clearer but still somewhat slow to respond and slightly confused.
SBP|spontaneous bacterial peritonitis|SBP|162|164|HISTORY OF PRESENT ILLNESS|Due to the fact that she is unable to maintain adequate oral p.o. intake, the decision was made to admit her for hydration and treatment of what is felt to be an SBP complicating her malignant ascites. The patient denies any fevers or chills. Nonetheless, she is noted to have a white blood cell count of 33,000 on her peripheral blood.
SBP|spontaneous bacterial peritonitis|SBP.|181|184|ASSESSMENT/PLAN|If, however, it continually re-accumulates, we will ask for assistance from Gastroenterology colleagues to set up a large volume outpatient paracentesis regimen for the patient. 2. SBP. The patient will be treated with cefotetan and Flagyl. Possible source for seeding of her peritoneal fluid could be her urinary tract, given the fact that her urine is positive for nitrites.
SBP|spontaneous bacterial peritonitis|SBP|111|113|PROBLEM #2|He was discharged on _%#MMDD2004#%_ to his nursing home. PROBLEM #2: Possible SBP. His past medical history of SBP diagnosed from a positive fluid culture in a fluid sample, showing no elevation of PMNs. Thoracocentesis fluid was obtained on _%#MMDD2004#%_. See above results. He was started on ciprofloxacin 500 mg b.i.d., received a 7-day course.
SBP|systolic blood pressure|SBP|246|248|HOSPITAL COURSE|The patient tolerated the procedure well and was moving all extremities to command in the recovery roo m after surgery. The patient was admitted to station 33 where, approximately 12 hours after the procedure, Ms. _%#NAME#%_ was hypotensive with SBP 50 and tachycardic with sinus rate of 180. Dr. _%#NAME#%_ was consulted and placed a left subclavian triple lumen catheter.
SBP|spontaneous bacterial peritonitis|SBP|202|204|HISTORY OF PRESENT ILLNESS|The patient was recently discharged from the hospital approximately two weeks ago for pneumonia at that time. He finished his course of levofloxacin, however, was not restarted on his ciprofloxacin for SBP prophylaxis at that time. PAST MEDICAL HISTORY: 1. Endstage renal disease secondary to hypertension on chronic hemodialysis.
SBP|spontaneous bacterial peritonitis|SBP|175|177|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Cefotaxime 2 grams IV every day to be given through _%#MMDD2002#%_. 2. Ciprofloxacin 750 mg per os/per G-tube every week start on _%#MMDD2002#%_ for SBP prophylaxis. 3. Nephrocaps one tab per os/G-tube every day. 4. Prevacid 30 mg per os/G-tube every day. 5. Celexa 5 mg per os/G-tube every day. 6. Labetalol 100 mg per os/G-tube every day.
SBP|spontaneous bacterial peritonitis|SBP|209|211|SUMMARY|He was then taken to a _%#CITY#%_ Hospital, where he had a CT of the head that was negative and he was diagnosed with hepatitic encephalopathy. He was stain cultured and his paracentesis did meet criteria for SBP by white cells, with just over 250 neutrophils, and he also grew E. coli out of his sputum. Otherwise, cultures were negative. He began to have progressive renal failure and was transferred to Fairview-University Medical Center for further management of his renal failure and liver issues.
SBP|spontaneous bacterial peritonitis|SBP.|185|188|PROCEDURES PERFORMED|Impression: Mild stenosis of the right internal carotid, moderate stenosis of the left internal carotid, and antegrade flow through both vertebral arteries. 2. Paracentesis to rule out SBP. No complications. Paracentesis fluid without evidence for infection. HISTORY OF PRESENT ILLNESS: This is a 63-year-old male with end-stage liver disease and end-stage renal disease, dialysis dependent, who was seen in dialysis, where he had an episode of hypotension measuring 62/28.
SBP|spontaneous bacterial peritonitis|SBP,|300|303|HOSPITAL COURSE|Calcium 8.3. Albumin 2.4. Lipase 273, alkaline phosphatase 130, total bilirubin 3.6. HOSPITAL COURSE: PROBLEM #1: Empiric treatment of spontaneous bacterial peritonitis (SBP). As on previous admissions, a diagnostic paracentesis on the day of admission did not exhibit a cell profile consistent with SBP, nor did a culture of the ascitic fluid reveal the presence of an organism (final culture results were negative for anaerobes, aerobes; a 30-day fungal culture was also negative).
SBP|spontaneous bacterial peritonitis|SBP|201|203|ASSESSMENT/PLAN|I do not feel inclined at this point to start her on antibiotics, however, I would wait for the results of the tap and send the cells for cell count and culture. It at that point she shows evidence of SBP I would definitely treat her. That could also be a comfort measure given her situation. As far as her metastatic breast cancer goes, I think it would be reasonable to continue to treat her pain with her current pain medications.
SBP|spontaneous bacterial peritonitis|SBP.|189|192|ADMITTING DIAGNOSES|PAST MEDICAL HISTORY: 1. Known permanent hepatic failure secondary to accidental carbon tetrachloride ingestion, associated portal hypertension and ascites in _%#MM#%_ 2003, complicated by SBP. 2. Acute renal disease secondary to the ingestion, treated with hemodialysis for 2 weeks. 3. Coagulopathy. 4. VRE cystitis. 5. Pancreatitis in _%#MM#%_ 2004, mild and resolved.
SBP|spontaneous bacterial peritonitis|SBP.|201|204|ASSESSMENT|There is no obvious precipitating cause. There is no concomitant GI bleed that may have precipitated his encephalopathy. He is diffusely tender on exam and we would need to consider the possibility of SBP. His head CT is negative. He has a non-gap acidosis on his lytes which is likely secondary to bicarb loss with lactulose.
SBP|spontaneous bacterial peritonitis|SBP|176|178|HISTORY OF PRESENT ILLNESS|At North Memorial Medical Center he was noted to have an ammonia level of 73. He was obtunded with ascites noted. He underwent paracentesis at that time and was diagnosed with SBP and started on treatment. He also developed respiratory failure and was intubated on _%#MMDD2004#%_, and the following day transferred to Fairview-University Medical Center for emergent liver transplant workup.
SBP|spontaneous bacterial peritonitis|SBP.|209|212|PROBLEM #4|PROBLEM #4: ID. The patient's initial peritoneal cultures from _%#MMDD#%_, obtained from Interventional Radiology revealed a negative gram stain as well as culture. However, the PMNN count was consistent with SBP. The patient was thus initially started on vancomycin and cefotax, which was changed out to Unasyn. She received a 10-day course of IV antibiotics, which finished on _%#MM2004#%_.
SBP|spontaneous bacterial peritonitis|SBP|152|154|DISCHARGE MEDICATIONS|3. Prevacid 6 mg p.o. b.i.d. 4. MCT oil 5 mg p.o. daily. 5. Lasix 10 mg p.o. b.i.d. 6. Aldactone 13 mg p.o. t.i.d. 7. Amoxicillin 200 mg p.o. daily for SBP and VUR prophylaxis.
SBP|systolic blood pressure|SBP|184|186|DISCHARGE MEDICATIONS|7. Code status DNR/DNI. DISCHARGE MEDICATIONS: 1. Albuterol nebs Q 4 hours while awake. 2. Zyrtec 10 mg PO q hs. 3. Digoxin 0.125 mg PO Q day. 4. Enalapril 20 mg PO Q day, holding for SBP less than 90. 5. Proscar 2.5 mg PO b.i.d. 6. Advair 500/50, one puff b.i.d. 7. Reminyl 8 mg PO b.i.d. 8. Regular insulin sliding scale.
SBP|spontaneous bacterial peritonitis|SBP.|173|176|ASSESSMENT|Urine hCG is negative. ASSESSMENT: 1. Liver failure, cirrhosis secondary to chronic hepatitis C. 2. Coagulopathy secondary to #1. 3. Abdominal pain secondary to ascites vs. SBP. 4. Iron deficiency anemia with history of prior peptic ulcer disease. 5. Hypokalemia. PLAN: 1. Patient will require a diagnostic as well as therapeutic paracentesis but in order to do this, will need to correct her coagulopathy first with use of fresh frozen plasma and vitamin K.
SBP|spontaneous bacterial peritonitis|SBP,|115|118|PLAN|Once done, the paracentesis may be done. 2. In doing so, if cell count, Gram stain is positive for any evidence of SBP, will start empiric antibiotics at that time. 3. Replace potassium. 4. Transfuse one unit of packed red blood cells. 5. Gastroenterology consultation in the a.m. 6. Dr. _%#NAME#%_ will round the patient in the a.m.
SBP|spontaneous bacterial peritonitis|SBP|115|117|CURRENT MEDICATIONS|CURRENT MEDICATIONS 1. Spironolactone 50 mg b.i.d. 2. Rifampin 300 mg daily. 3. Cipro 500 mg taken once a week for SBP prophylaxis. 4. Hytrin 2 mg at h.s. 5. Lasix 20 mg b.i.d. 6. Inderal Long Acting 60 mg daily. 7. Lactulose syrup 15 cc t.i.d. He is married and lives with his wife.
SBP|spontaneous bacterial peritonitis|SBP|142|144|ADMISSION PROBLEMS|ADMISSION PROBLEMS: 1. End-stage liver disease secondary to HCV status post orthotopic liver transplant. Date of procedure _%#MMDD2005#%_. 2. SBP prior to transplant with paracentesis performed _%#MMDD2005#%_ to _%#MMDD2005#%_. 3. Hepatorenal syndrome leading to renal failure with the patient requiring dialysis during hospitalization.
SBP|spontaneous bacterial peritonitis|SBP|188|190|1. FEN|He receives tri-vi-sol qd. He receives the following diuretics: aldactone 7.5 mg po q 12 hours, Chlorthiazide 75 mg po q 12 hours, and Lasix 7.5 mg po qd. 2. CV: _%#NAME#%_ should receive SBP for GI or GU procedures because of his PPS. He should follow up with pediatric cardiology within one year. 3. Respiratory: _%#NAME#%_ continues on beclomethasone for its anti- inflammatory effects.
SBP|systolic blood pressure|SBP|111|113|DISCHARGE MEDICATIONS|9. Percocet 1 to 2 tab p.o. q4-6h p.r.n. 10. Rocephin 1 g IV q12h. 11. Labetalol 10 to 40 mg IV q2h p.r.n. for SBP greater than 140. 12. Hydralazine10 to 40mg IV q2h p.r.n. for SBP greater than 140. 13. Zofran 48 mg IV q6h p.r.n. nausea. 14. Oxygen per nasal cannula.
SBP|systolic blood pressure|SBP|177|179|DISCHARGE MEDICATIONS|9. Percocet 1 to 2 tab p.o. q4-6h p.r.n. 10. Rocephin 1 g IV q12h. 11. Labetalol 10 to 40 mg IV q2h p.r.n. for SBP greater than 140. 12. Hydralazine10 to 40mg IV q2h p.r.n. for SBP greater than 140. 13. Zofran 48 mg IV q6h p.r.n. nausea. 14. Oxygen per nasal cannula. 15. Ativan 2 mg IV x1 p.r.n. for general tonic clonic seizures, or two or more complex partial seizures in 3 hours.
SBP|spontaneous bacterial peritonitis|SBP.|192|195|IMPRESSION/PLAN|2. Evaluation for SBP (spontaneous bacterial peritonitis). With his longstanding alcohol use, increasing in abdominal girth, and ongoing fevers and chills, the patient should be ruled out for SBP. He has already been on Cipro now for almost three weeks. We will get blood cultures, and wait for his abdominal CT scan.
SBP|spontaneous bacterial peritonitis|SBP,|154|157|HOSPITAL COURSE|The hepatitis viral studies were also negative and they were drawn for both hepatitis B and hepatitis C. It was suspected possibly that this could be for SBP, however, the patient did not present with a fever. The patient was started on metronidazole and cefixime. The ascites suspected to be multifactorial in picture was likely due may be a partially spontaneous bacterial peritonitis.
SBP|spontaneous bacterial peritonitis|SBP.|195|198|DISCHARGE PLANING|Last cardiology visit was _%#MM#%_ 2004. He had a GI bleed in _%#MM#%_ 2004 of unknown etiology. He has liver disease with new onset ascites; the etiology is unclear. He has not had a history of SBP. He also has hypertension and hyperlipidemia. The patient has been considered as a candidate for a kidney transplant and is currently listed.
SBP|spontaneous bacterial peritonitis|SBP.|193|196|PLAN|PLAN: 1. I will discuss further with Dr. _%#NAME#%_ _%#NAME#%_ who knows the patient well. He has never previously been hospitalized here. 2. Empiric antibiotics to start this p.m. Question of SBP. 3. Unfortunately, diagnostic paracentesis will not be possible prior to starting the antibiotics due to the late hour. 4. Hydration and continue Lactulose. Check INR. Recheck ammonia in the a.m.
SBP|spontaneous bacterial peritonitis|SBP,|200|203|PROBLEM #2|CMV IgM antibody was interpreted as equivocal. PROBLEM #2: Abdominal pain. The patient did complain of mild abdominal pain on admission and given fevers, we performed a paracentesis for evaluation of SBP, which did not yield any ascitic fluid. She subsequently underwent right upper quadrant ultrasound, which did not show ascites but did demonstrate stenosis of the IVC with marked IVC dilatation.
SBP|spontaneous bacterial peritonitis|SBP|177|179|PROBLEM #2|PROBLEM #2: Low-grade fevers: The patient was admitted with low- grade fevers and had a complete culture workup that showed no source. The fluid from her belly did not show any SBP at the time of her TIPS. She did spike a fever up to 101.8 on _%#MMDD2004#%_, and therefore, she was started on levofloxacin empirically.
SBP|spontaneous bacterial peritonitis|SBP|156|158|MEDICATIONS|MEDICATIONS 1. Levoxyl 50 mcg p.o. daily. 2. Multivitamin. Review of her records shows that in the past she has been on spironolactone as well as Cipro for SBP prophylaxis. She is not on those currently, nor is she on a proton pump inhibitor. ALLERGIES: No known drug allergies. HABITS: She smokes a half pack per day.
SBP|spontaneous bacterial peritonitis|SBP,|164|167|ASSESSMENT|He does have a mild flap and elevated lactulose, however, he is very oriented and does not appear clinically encephalopathic. He also does not have any evidence of SBP, acute GI blood loss, or hypotension.
SBP|spontaneous bacterial peritonitis|SBP|136|138|HOSPITAL COURSE|This was tapped on admission and 10L of fluid were obtained. She underwent albumin replacement. This was sent for cell count concern of SBP and this was ruled out. The patient felt significantly better after the paracentesis. Unfortunately her fluid re- accumulated pretty fast.
SBP|spontaneous bacterial peritonitis|SBP|132|134|SUMMARY|The patient resides in a nursing home with staff reporting worsening confusion and cognitive function. She was recently treated for SBP with aztreonam and levofloxacin based on sensitivity from outside hospital. The patient's lactulose dose was recently decreased. Working diagnosis of hepatic encephalopathy was established early on in admission based on clinical findings.
SBP|spontaneous bacterial peritonitis|SBP|137|139|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Protonix 40 mg p.o. q. day. 2. Levofloxacin 500 mg p.o. q. day, for a total of 3 days and then to continue her SBP prophylaxis dose. 3. Celexa 20 mg p.o. q. day. 4. Mephyton 10 mg p.o. q. day. 5. Nasonex nasal spray twice a day. 6. Nystatin 5 mL p.o. q.i.d.
SBP|spontaneous bacterial peritonitis|SBP,|248|251|PAST MEDICAL HISTORY|There is no nausea, vomiting or hematochezia. No obvious fever or abdominal pain had been noted by the family. He was brought in for further evaluation. PAST MEDICAL HISTORY: Alcohol related cirrhosis, history of hepatic encephalopathy, history of SBP, history of GI bleed secondary to varices, hypertension, chronic coagulopathy and chronic thrombocytopenia secondary to alcohol. FAMILY HISTORY: The family history is noncontributory. ALLERGIES: No known drug allergies.
SBP|spontaneous bacterial peritonitis|SBP|266|268|HOSPITAL COURSE|The family stated that he has been compliant with his lactulose treatment and that on admission, his ammonia level was found to be 18 and he did not appear to have any sign of hepatic encephalopathy. It was thought that his altered mental status might be due to the SBP as his mentation did clear with treatment. On discharge, he was fully alert and oriented and following conversation normally.
SBP|spontaneous bacterial peritonitis|SBP,|178|181|IMPRESSION|Head CT is negative. IMPRESSION: Hepatic encephalopathy. There does not appear to be a significant problem triggering this that is obvious at this time and possibilities include SBP, given her ascites, GI bleed, progressive liver failure. Overall, currently her vital signs are stable. Her initial NG did not show blood, she has some small amount at this time.
SBP|spontaneous bacterial peritonitis|SBP|149|151|ADDENDEUM|2. Renagel 800 mg p.o. with meals. 3. Rifamaxin 400 mg p.o. 4 times a day. 4. Ciprofloxacin 750 mg p.o. q week. He should take this every Monday for SBP prophylaxis. 5. Diflucan 100 mg p.o. daily. Last does _%#MMDD2005#%_. 6. Pantoprazole 40 mg p.o. 12 hours. 7. PhosLo 2 tabs p.o. with meals.
SBP|spontaneous bacterial peritonitis|SBP.|228|231|HOSPITAL COURSE|The patient is hyponatremic however his hyponatremia is currently at his baseline in the mid 120s upon presentation. He has been compliant with his fluid restrictions. Diagnostic paracentesis was obtained which was negative for SBP. Therapeutic paracentesis was performed. 10 liters were removed with the therapeutic paracentesis by Interventional Radiology. This was followed by intravenous infusion of albumin solution to prevent post-paracentesis circulatory dysfunction.
SBP|spontaneous bacterial peritonitis|SBP|208|210|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: 1. Patient is to follow up in the next 1-2 weeks in GI clinic with Dr. _%#NAME#%_ for a therapeutic paracentesis as needed. 2. Patient will continue on Cipro 750 mg p.o. q. weekly for SBP prophylaxis. 3. Patient will continue on Diflucan for 3 more days to treat his yeast urinary tract infection. 4. Patient will need to have a follow up CBC, INR, chem-10, and liver function tests within the next 3-5 days for follow up.
SBP|spontaneous bacterial peritonitis|SBP.|401|404|DISCHARGE INSTRUCTIONS|As such, would recommend that if patient is re-admitted prior to his Neuropsychiatric evaluation would have inpatient team or immediately order a Neuropsychiatry consult in order to evaluation the patient while he is an inpatient to complete his workup. 7. Patient is not a TIPS candidate given his history of frequent hepatic encephalopathy, frequent admissions for confusion, and increased risk for SBP. It has been a pleasure participating in his care. Please contact me at _%#TEL#%_ with any further questions regarding this admission.
SBP|spontaneous bacterial peritonitis|SBP|231|233|HOSPITAL COURSE|His mortality risk over the next 3 months, based on his MELD score is high, (greater than 50%, closer to 80%), and the patient is aware of this. He has ascites but did not require paracentesis during this hospitalization. He is on SBP prophylaxis with ciprofloxacin weekly. Problem #3. End-stage renal disease. The patient underwent dialysis as usual and tolerated it well. He still urinates, is on phosphate binder, and needs adequate blood pressure control should he become hypertensive in the future; however, given the severity of his liver disease, he has chronic hypotension as described below.
SBP|spontaneous bacterial peritonitis|(SBP|134|137|HOSPITAL COURSE|3. Nephrocaps 1 tablet p.o. q. day. 4. Pantoprazole 40 mg p.o. q. day. 5. Vitamin K 5 mg p.o. q. day. 6. Rifaximin 400 mg p.o. t.i.d. (SBP prophylaxis). 7. Thiamine 100 mg p.o. q. day. DISCHARGE INSTRUCTIONS/FOLLOWUP: Diet: Renal. Activity: As tolerated. 1. PT/OT as deemed appropriate by the TCU staff.
SBP|spontaneous bacterial peritonitis|SBP|389|391|PROBLEM #1|PROBLEM #1: Weakness. At this time differential diagnosis could be quite extensive, however, given recent marked decreased in oral intake and what appears to be dehydration on exam and history, I believe this is a likely etiology of the weakness. Additionally, the patient is more hyponatremic, which may also contribute to his weakness. Other differential includes infection specifically SBP in this type of patient, however, there are no symptoms or signs pointing to this as the cause. At this time, will tenuously rehydrate the patient, monitor sodium, and search for methods to improve nutrition.
SBP|spontaneous bacterial peritonitis|SBP|142|144|MEDICATIONS|10. Anemia. 11. Thrombocytopenia. 12. History of GI bleed with portal hypertensive gastropathy. MEDICATIONS: 1. Cipro 750 mg p.o. q. week for SBP prophylaxis. 2. Lactulose 30 cc p.o. b.i.d. 3. Oxycodone 5 mg p.o. q. 4 to 6 hours p.r.n.
SBP|systolic blood pressure|SBP|154|156|HISTORY OF PRESENT ILLNESS|It is not associated with diaphoresis or sweating. The patient does not have a history of hyperlipidemia, hypertension or high cholesterol. The patient's SBP on admission, though, was in the 150s. The patient has been experiencing a lot of stress at her job. ALLERGIES: ASPIRIN CAUSES GASTROINTESTINAL DISTRESS. PAST MEDICAL HISTORY: 1. Breast cancer.
SBP|spontaneous bacterial peritonitis|SBP|403|405|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSES: 1. End-stage liver disease secondary to nonalcoholic steatohepatitis. 2. Acute Hepatic encephalopathy. 3. Acute renal failure. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 57-year-old female with a history of end-stage liver disease secondary to NASH with MELD score of 27, 28 with a history of recurrent episodes of hepatic encephalopathy and also history of ascites and SBP who was initially treated at an outside hospital for encephalopathy and discharged on _%#MMDD2007#%_ with follow up with Dr. _%#NAME#%_ on _%#MMDD2007#%_. On the morning of admission, the patient had worsening encephalopathy with mental status changes, confusion and lethargy.
SBP|systolic blood pressure|SBP|133|135|DISCHARGE MEDICATIONS|7. Hydroxyzine 50 mg p.o. t.i.d. 8. Milk of magnesia 15-30 mL p.o. daily p.r.n. constipation 9. Atenolol 100 mg p.o. daily, hold for SBP less than 120 or pulse less than 60. (Continued) 1. Aspirin 325 mg p.o. daily. 2. Albuterol 2 puffs inhaled q.6 hours p.r.n. shortness of breath.
SBP|systolic blood pressure|SBP|35|37|CHIEF COMPLAINT|CHIEF COMPLAINT: Hypertension with SBP recorded at 220/90. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 73-year-old female who presented to the care suites with a systolic blood pressure that was elevated. The patient has a history of renal artery stenosis. Her blood pressures are usually well controlled on Imdur, clonidine, lisinopril as well as atenolol.
SBP|systolic blood pressure|SBP|166|168|PLAN|If blood pressure remains high by time of discharge would initiate Norvasc therapy and have the patient follow up with her outpatient doctor. Use hydralazine prn for SBP > 180. 6. The patient hopefully will be able to discharge after one to two days.
SBP|spontaneous bacterial peritonitis|SBP|260|262|ASSESSMENT/PLAN|b. For her end-stage liver disease secondary to autoimmune hepatitis with overlap syndrome with primarily biliary cirrhosis, we will continue her Lasix and spironolactone for her ascites. Continue propranolol for portal hypertension. Continue Cipro weekly for SBP prophylaxis. We will need to clarify with the GI Service the length of rifaximin use, which appears to be for her hepatitic encephalopathy.
SBP|spontaneous bacterial peritonitis|SBP|152|154|ASSESSMENT AND PLAN|We will place him on a lactulose enema and lactulose oral regimen q.2h. until he has several bowel movements. I do not think he has SVP. He has been on SBP prophylaxis. He is on an antibiotic from the Mayo Clinic. I have trying to two figure out which antibiotic. This could be an orphan antibiotic but will need to look this up.
SBP|spontaneous bacterial peritonitis|SBP.|147|150|CONSULTANTS|The patient was asymptomatic and denied significant cough. Regardless, the pneumonia is currently being covered by her ceftriaxone therapy for her SBP. 4. Anemia. The patient is found to have a low hemoglobin stay values ranging from 9 to 11. MCV was normal. Iron studies were obtained and were borderline low.
SBP|systolic blood pressure|SBP|198|200|HOSPITAL COURSE|8. Chronic anemia. The patient is reporting poor tolerance of her EPO, but I will defer to her primary nephrologist for managing this. 9. Hypertension: The patient had intermittent elevation of her SBP to 180 and DBP > 105. On the evening of her discharge, we found a large discrepancy between her automated and manual BP values with the manual values being substantially lower.
SBP|spontaneous bacterial peritonitis|SBP|146|148|HOSPITAL COURSE|Given the fact that the patient did not have any evidence of ascites, paracentesis was not performed to rule out SBP. However, we did not suspect SBP given no signs of ascites and no fevers or no high white count. 2. She was also continued on all her outpatient medications.
SBP|systolic blood pressure|SBP|340|342|HOSPITAL COURSE|3. Acute respiratory failure. Status post bowel section the patient developed acute respiratory failure and it was felt his respiratory failure was possibly due to hospital-acquired pneumonia with MRSA. He was treated with vancomycin and Levaquin. 4. Probable sepsis; the patient's vital signs prior to intubation showed a temperature 103, SBP of 80/40 and sinus tachycardia of approximately 130-140, it was felt the patient had probable sepsis, however his blood cultures were negative.
SBP|spontaneous bacterial peritonitis|SBP|319|321|HOSPITAL COURSE|He was receiving chemotherapy by Dr. _%#NAME#%_ with adriamycin. (Please see the admission H&P for the patient's family history, social history, admission medications, and physical examination). HOSPITAL COURSE: Hepatocellular carcinoma with increased abdominal pain: The patient underwent paracentesis to evaluate for SBP on his first hospital day. His peritoneal fluid returned negative for SBP. It was thought that his abdominal pain may be due to enlargement of his tumor.
SBP|spontaneous bacterial peritonitis|SBP.|167|170|MY INTERPRETATION, ASSESSMENT AND PLAN|1. At this point the etiology may be secondary to a recent TIPS procedure, may have had diet indiscretion. There is no evidence of ascites on exam. Therefore, I doubt SBP. Will assess her TIPS stent with ultrasound as it has been blocked in the past. However, blocking of the tips should not predispose her to encephalopathy but rather the contrary.
SBP|systolic blood pressure|SBP|150|152|CHANGED DOSES|9. Digoxin 125 mcg p.o. daily. 10. Colace 100 mg p.o. b.i.d. 11. Lexapro 20 mg p.o. daily. CHANGED DOSES: 1. Carvedilol 12.5 mg p.o. b.i.d., hold for SBP less than 110. PHYSICIAN FOLLOW-UP: The patient will follow up with hospice and Dr. _%#NAME#%_ as needed.
SBP|spontaneous bacterial peritonitis|SBP,|212|215|HOSPITAL COURSE|However, he did not improve significantly in terms of his leukocytosis and continued to run about 14 on _%#MMDD#%_ when he demonstrated significant respiratory decompensation. However, from the standpoint of the SBP, he did seem to improve in terms of his symptoms and tenderness. On _%#MMDD2007#%_ a repeat paracentesis was done, aspirating 6 liters of fluid.
SBP|spontaneous bacterial peritonitis|SBP|189|191|HOSPITAL COURSE|He is on lactulose 30 mL t.i.d. and has been regularly, in fact had 3 bowel movements on the 8th. I'm sorry could you please go back up, I apologize for this, I'm sorry, I guess we did the SBP and then we went to the acute kidney disease. Continuing in the acute kidney disease, I apologize for the interruption.
SBP|spontaneous bacterial peritonitis|SBP|137|139|HISTORY OF PRESENT ILLNESS|She has needed no paracenteses while here. She was treated for C. difficile, and there has been no recurrence. She is on prophylaxis for SBP with Levaquin. She had been progressing with PT and OT; however, did have decreased sensation in her feet and her hands, as well as ataxia.
SBP|systolic blood pressure|SBP|226|228|DISCHARGE  MEDICATIONS|5. Plavix (Discontinued because of anemia.) CONTINUED: 1. Albuterol 2.5 mg nebulizers q.i.d. and albuterol 2.5 mg q.4h. p.r.n. for shortness of breath. 2. Synthroid 25 mcg p.o. daily. 3. Hydralazine 50 mg p.o. b.i.d., hold if SBP less than 90. 4. Colace 100 mg p.o. b.i.d. 5. Diltiazem 180 mg p.o. daily. 6. Vitamin B12 IM q. four weeks, resume in three months.
SBP|spontaneous bacterial peritonitis|SBP.|574|577|PLAN|The patient's abdomen was 2.4. ASSESSMENT: This is a 52-year-old male with a past medical history significant for end stage liver disease secondary to alcoholic cirrhosis also with chronic renal failure, hemodialysis dependent secondary to IgA nephropathy and hepatorenal syndrome who was admitted to _%#CITY#%_ _%#CITY#%_ Emergency Department and transferred to University of Minnesota Medical Center, Fairview, for management of gram-positive septic shock. PLAN: 1. Septic shock: The patient will be continued on vancomycin and cefotaxime for empiric coverage of possible SBP. We will continue the patient on phenylephrine and levophed as needed and titrate this off as his pressures improve. Of note, the patient does seem to be much more alert than as previously billed and would expect him to rapidly improve.
SBP|spontaneous bacterial peritonitis|SBP|156|158|OPERATIONS/PROCEDURES PERFORMED|Although the patient has a history of SBP recently and has been on Cipro prophylaxis for this, the studies on the peritoneal fluid were not consistent with SBP on this occasion. His Augmentin that he was on, on transfer was discontinued as it did not appear that the patient had any evidence of SBP and he had already received a complete course of treatment for his previous episode.
SBP|systolic blood pressure|SBP|214|216|DISCHARGE MEDICATIONS|Patient will follow up with Dr. _%#NAME#%_ in one week. Patient was discharged in good condition. DISCHARGE MEDICATIONS: Neoral 200 mg PO/GT b.i.d., Cellcept 500 mg PO/GT q.i.d.; Norvasc 10 mg PO/GT q.d., hold for SBP less than 110; aspirin 81 mg PO/GT q.d., Bicitra 80 ml PO/GT t.i.d., Mycelex 1 tab or 1 troche PO q.i.d., fluconazole 400 mg PO/GT q.d., Prevacid 30 mg PO/GT b.i.d., Epogen 5,000 units subcu q. Monday and Thursday, Magace 600 mg PO/GT b.i.d.; metoprolol 75 mg PO/GT b.i.d., hold for heart rate less than 60 or systolic blood pressure less than 110; Zoloft 100 mg PO/GT q.d., Bactrim Single Strength 1 tab PO GT q.d., triamcinolone 1% cream to affected areas of rash b.i.d., Actigall 300 mg PO/GT t.i.d., valganciclovir 900 mg PO/GT q.d., oxycodone 5 mg PO/GT q6h PRN pain, Solu-Medrol 28 mg IV t.i.d. through _%#MM#%_ _%#DD#%_, 2002; then starting prednisone 85 mg PO/GT q.d. x 7 days, then start prednisone taper over 8 weeks, please see attached sheet for prednisone taper instructions.
SBP|spontaneous bacterial peritonitis|SBP.|141|144|HOSPITAL COURSE|The patient also gave a history of a distended abdomen over the last month. She had also been started recently on ciprofloxacin for presumed SBP. Therapeutic and diagnostic paracenteses were arranged. This was performed on hospital day #2, with approximately 2 L removed. This revealed 250 nucleated cells, 35 RBCs, with a differential showing 4% neutrophils, 40% leukocytes, 56% other nucleated cells.
SBP|systolic blood pressure|SBP|302|304|PROBLEM #5|PROBLEM #4: Hypothyroidism. Given the patient's somnolence, as noted above, TSH was rechecked and found to be normal at 2.07. No adjustment in Synthroid dose needed. PROBLEM #5: Hypertension. The patient is not currently on antihypertensive medications. Blood pressures were within normal limits, with SBP 101-130s and DBP 40s-80s.
SBP|spontaneous bacterial peritonitis|(SBP)|123|127|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Alcoholic cirrhosis. 2. Tense ascites secondary to #1. 3. Likely spontaneous bacterial peritonitis (SBP) secondary to #2. HOSPITAL COURSE: Please refer to my admission History and Physical _%#MMDD2003#%_ for full details concerning the patient's presentation on admission.
SBP|spontaneous bacterial peritonitis|SBP|149|151|PROBLEM #2|The patient was felt to be mildly edematous. Lasix dosage was increased from 10 - 20 and spironolactone 15 mg p.o. q.d. was introduced. Furthermore, SBP prophylaxis was instituted with ciprofloxacin 750 mg p.o. q. weekly. PROBLEM #3: Chronic hepatitis C. PROBLEM #4: Organic personality disorder.
SBP|spontaneous bacterial peritonitis|SBP|184|186|PROBLEM #2|If the patient tolerates clamping to allow sufficient episolization of the tract for later removal. PROBLEM #2: GI/end-stage liver disease. The patient was admitted and was started on SBP treatment. She was started on Ciprofloxacin and Flagyl. A GI consult was obtained. It was felt that the patient's liver disease may be reversible; if she were to stop drinking.
SBP|spontaneous bacterial peritonitis|SBP.|138|141|HOSPITAL COURSE|The cell count and dif on ascitic fluid demonstrates 140 enucleated cells up which 60% were monocytes. This would not meet a criteria for SBP. He was continued on his Lasix as well as Spironolactone. I was tempted to increase the Spironolactone to 200 mg po bid, however, he was slightly hyperkalemic on admission already.
SBP|spontaneous bacterial peritonitis|SBP.|80|83|PROBLEM #6|PROBLEM #5: PSC treatment continued, ursodiol per home dose. PROBLEM #6: Recent SBP. The patient finished a complete course of ceftriaxone, after which her PICC line was discontinued without difficulty. DISCHARGE INFORMATION: The patient should follow up with Dr. _%#NAME#%_ in the GI Clinic in one week.
SBP|spontaneous bacterial peritonitis|SBP.|332|335|HOSPITAL COURSE|6. Pulmonary hypertension with an echo in _%#MM2003#%_ which showed normal left ventricular function, mild LVH, right ventricular systolic pressure of 34, right atrial enlargement, left pleural effusion. 7. Benign prostatic hypertrophy. HOSPITAL COURSE: PROBLEM #1: Gastrointestinal. The patient's abdominal pain was concerning for SBP. He was given an empiric dose of ceftriaxone IV x 1. A blind attempt at paracentesis was unsuccessful, and therefore the patient underwent ultrasound-guided paracentesis with return of 7 L of fluid.
SBP|spontaneous bacterial peritonitis|SBP|152|154|HISTORY OF PRESENT ILLNESS|Therefore, the main history was obtained from old charts as well as nursing home personnel. She was given a dose of cefotaxime for empiric treatment of SBP prior to transfer here. PAST MEDICAL HISTORY: 1. End-stage liver disease, cryptogenic cirrhosis, diagnosed in 1998.
SBP|spontaneous bacterial peritonitis|SBP|222|224|PROBLEM #2|PROBLEM #2: End-stage liver disease with hepatic encephalopathy, recurrent ascites. The patient was given increased dose of lactulose for encephalopathy. Abdominal ultrasound was performed to provide evidence for possible SBP or other cause for confusion. No significant ascites. The patient was found to have a dilated common bile duct. Therefore, GI was consulted, and ERCP was performed to evaluate for possible obstructing stone.
SBP|spontaneous bacterial peritonitis|SBP|229|231|PLAN|We will continue present management with Glucotrol. Of note, her hemoglobin A1C was last 7.0 on _%#MMDD2003#%_. 5. End-stage liver disease. We will continue her present management with Lasix, spironolactone and ciprofloxacin for SBP prophylaxis. 6. Leukopenia and thrombocytopenia. These appear chronic and stable from her previous admission.
SBP|spontaneous bacterial peritonitis|SBP|162|164|HOSPITAL COURSE|The patient also had a Mallory-Weiss tear noted on EGD also on the day of admission. For much of the hospital course the patient was continued on antibiotics for SBP coverage and she received support for liver failure such as lactulose and correction for her coagulopathy. PROBLEM #2 : Pulmonary. The patient was intubated on _%#MMDD2003#%_ secondary to worsening mental status changes.
SBP|spontaneous bacterial peritonitis|SBP.|214|217|HOSPITAL COURSE|The abdominal CT was negative with the exception of some small hypodensities in the liver that were later found to be simple cysts on MRI. The patient did also undergo an ultrasound-guided paracentesis to look for SBP. The results of this were negative. The patient did have a suspicious urinalysis and was initially started on gatifloxacin.
SBP|spontaneous bacterial peritonitis|SBP|174|176|HOSPITAL COURSE|He had a follow-up x-ray, which showed stable amount of free air, which is most likely secondary to after surgical intervention. He likely had an ileus secondary to possible SBP and also secondary to recent surgery. On discharge he was taking an adequate oral intake with no nausea, vomiting, or abdominal discomfort.
SBP|spontaneous bacterial peritonitis|SBP|220|222|PLAN|It should be of note that the patient reports having seen and discussing liver transplantation with Dr. _%#NAME#%_ at Fairview University Medical Center at her most recent hospitalization. 3. Continue cefotaxime for the SBP though present cultures are negative. In all likelihood the patient will have a re-tap for ascites during this hospitalization and we can send this off for culture.
SBP|spontaneous bacterial peritonitis|SBP|148|150|DISCHARGE MEDICATIONS|12. Lipitor 10 mg p.o. daily. 13. Phenergan 12.5 mg p.o. q.6h p.r.n. 14. Imitrex 25 mg p.o. q.2h p.r.n. migraine headaches. 15. He is discharged on SBP prophylaxis, which is Bactrim Double Strength one tablet p.o. q.Monday and q.Friday. He will also be taking the following pain medications, which are the same on discharge as they were on admission.
SBP|spontaneous bacterial peritonitis|SBP.|400|403|PROBLEMS|NEUROLOGIC: Exam is grossly nonfocal. LABORATORY: Hemoglobin 12.9, white count 3.8, platelets 56, INR 1.59, bilirubin 3.6, albumin 2.6, alkaline phosphatase 156, ALT is 69, AST 217, sodium 136, potassium 3.4, chloride 103, bicarbonate 29, BUN 12, creatinine 0.88. PROBLEMS: Ascites. The patient did not have any new abdominal pain, fever, chills, or other systemic signs. It was doubtful that he had SBP. However, fluid was drawn in the ER and sent for lab studies. The lab studies subsequently came back negative for any signs of infection.
SBP|spontaneous bacterial peritonitis|SBP|198|200|ADDENDUM|He was given a 250 cc normal saline flush. The only additional medication change is a decrease in his lactulose dose to daily dosing. He will get a therapeutic and diagnostic paracentesis, although SBP is not suspected on the day of discharge. This will be done by Interventional Radiology. A medication added to his regimen is midodrine at a dose of 10 mg p.o. t.i.d.
SBP|spontaneous bacterial peritonitis|SBP,|135|138|ASSESSMENT/PLAN|Lastly, infectious it does not seem like he has any fevers or any other infections going on. Could consider getting a paracentesis for SBP, but he does not appear to have a significant of ascites, and again he is afebrile at this point. Therefore, again I would ask GI to follow up with him to help determine the cause of this recurrent hepatic encephalopathy and for further management.
SBP|spontaneous bacterial peritonitis|SBP|216|218|HOSPITAL COURSE|1. Abdominal pain. The patient was brought into the hospital and kept on his outpatient pain regimen of oxycodone and Tylenol. The patient did not have any changes other than the addition of antibiotics for possible SBP the night of admission. The abdomen was tapped, which showed peritoneal fluid that had 46 nucleated cells, less than 1 gm/dL of total protein, less than 1 of albumin.
SBP|spontaneous bacterial peritonitis|SBP.|228|231|OPERATIONS/PROCEDURES PERFORMED|Few small ulcerations in the mid esophagus and portal hypertensive gastropathy in the stomach. No stigmata of active bleeding. 2. Paracentesis performed on _%#MM#%_ _%#DD#%_, 2005 with removal of 3-1/2 liters and no evidence of SBP. HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old man status post liver transplant who presents with fatigue, decreasing urine output, low appetite, and tarry black stools.
SBP|spontaneous bacterial peritonitis|SBP.|225|228|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: Ms. _%#NAME#%_ is a 46-year-old woman with end-stage liver disease secondary to hep C cirrhosis here for a TIPS procedure for variceal bleeding and resistant ascites. No acute evidence for GI bleeding or SBP. 1. End-stage liver disease. The patient is to have TIPS procedure tomorrow. At this time will continue her Lasix, spironolactone, and lactulose.
SBP|spontaneous bacterial peritonitis|SBP.|109|112|ASSESSMENT AND PLAN|Will get ...........to evaluate for ascites and for possible diagnostic through paracentesis ........... for SBP. Will also take UA/UC. Increase his lactulose. Will likely cover empirically for SBP if unable to conduct diagnostic paracentesis.
SBP|spontaneous bacterial peritonitis|SBP,|208|211|HOSPITAL COURSE|The patient was discharged with wound cares by Methodist Hospital and to return to clinic in 1 or 2 weeks for evaluation of the wound. 2. End-stage liver disease. As noted, his course has been complicated by SBP, recent encephalopathy, and history of esophageal variceal bleeding, and portal hypertension. This was banded in 1999. The patient's end- stage liver disease was stable throughout his admission.
SBP|spontaneous bacterial peritonitis|SBP.|152|155|PAST MEDICAL HISTORY|3. History of lymphoma. 4. Coagulopathy. 5. Thrombocytopenia. 6. Type 2 diabetes. 7. GERD. 8. Trigeminal neuralgia. 9. History of ascites with a recent SBP. 10. History of facial tic. 11. Peripheral vascular disease. 12. Status post esophageal banding at Mayo Clinic.
SBP|spontaneous bacterial peritonitis|SBP|403|405|ASSESSMENT|NEUROLOGIC: Confused and in delirium. LABORATORY DATA: Ammonia level 60, sodium 127, potassium 5.8, chloride 99, bicarbonate 20, anion gap 8, glucose 148, BUN 82, creatinine 2.72. Conjugated bilirubin 1.3, INR 1.91. WBC 6600, hemoglobin 9.9, hematocrit 29, MCV 99, platelet 121,000. ASSESSMENT: 1. Hepatitic encephalopathy with ammonia level of 60. 2. Hypotension, possibly could be sepsis secondary to SBP or secondary to GI bleed. 3. GI bleed. Hemoglobin 9.9, history of esophageal varices. 4. Endstage liver disease secondary to alcoholic cirrhosis, leading to portal hypertension and varices.
SBP|spontaneous bacterial peritonitis|SBP,|226|229|HOSPITAL COURSE|HOSPITAL COURSE: 1. Ascites/alcoholic cirrhosis: The patient was admitted to medicine ward because of the significant history of alcohol abuse in the past. The patient was put on alcohol withdrawal protocol. For evaluation of SBP, paracentesis was performed, which showed WBC count of 103 and hence SBP was ruled out. To evaluate further cause of massive ascites, we performed ultrasound of abdomen as well as CT scan of abdomen and pelvis and results are noted above.
SBP|spontaneous bacterial peritonitis|SBP.|187|190|ASSESSMENT AND PLAN|2. Abdominal pain: At this point in time the differential diagnosis includes spontaneous bacterial peritonitis, peptic ulcer disease or pancreatitis. Ascites fluid will be sent to relied SBP. In the meantime we will continue treating with antibiotics. 3. Upper GI bleed: The patient presents with symptoms compatible with upper GI bleeding.
SBP|systolic blood pressure|SBP|112|114|DISCHARGE MEDICATIONS|6. Senokot two tabs p.o. q a.m. while on oxycodone 7. Colace 100 mg p.o. b.i.d. 8. Hydralazine 25 mg po tid prn SBP greater than 160. 9. Tramadol 25 mg po bid prn pain 10 oxycodone 2.5 to 5 mg po q 8 hours prn pain. 11. Plavix 75 mg po daily re stroke prevention
SBP|spontaneous bacterial peritonitis|SBP.|166|169|PROCEDURES|2. Therapeutic paracentesis performed on _%#MMDD2007#%_ and _%#MMDD2007#%_ by Interventional Radiology. Peritoneal fluid was sent for these and was also negative for SBP. 3. Renal ultrasound dated _%#MMDD2007#%_. Impression, no hydronephrosis. There was a small hyperechoic lesion in the midpole of the right kidney, possibly an angiomyolipoma.
SBP|spontaneous bacterial peritonitis|SBP|218|220|PMH|He was having pain with the procedure and there was concern for peritonitis, so the fluid was sent for culutre and cell count and admission to UMMC was arranged. PMH: 1. alcoholic cirrhosis - (+)h/o varices - no prior SBP 2. withdrawal seizures 3. obstructive sleep apnea 4. Raynaud's ROS/Meds/All/Fam/Soc: see resident H&P; pertinently, last drink in _%#MM2006#%_ PE: 99.6, 118, 121/88, 16, 99% Gen: cachectic 53yo male, appears chronically ill HEENT: MMM, anicteric Neck: no JVD Chest: clear bilat, small lung volumes CV: tachy, 2/6 flow murmur RUSB Abd: moderately distended abdomen with few bowel sounds, tenderness in epigastrium - no RUQ tenderness, liver not palpable Ext: trace LE edema, 1+ pedal pulses Skin: faint jaundice Pertinent labs and imaging: reviewed.
SBP|spontaneous bacterial peritonitis|SBP:|163|166|A/P|Patient is passing gas so this is not complete. No prior abd surgeries that I'm aware of to predispose, we will have to find out if he has had colonoscopy yet. 2. SBP: borderline criteria by PMNs in ascites, will treat with ceftriaxone while cultures pending 3. hyperkalemia: check ECG, plan for kayexelate. If truly obstructed will need to use non-GI measures to reduce.
SBP|spontaneous bacterial peritonitis|SBP.|163|166|ADMITTING DIAGNOSES|2. Upper GI bleed. 3. Hepatic encephalopathy. 4. Grade III esophageal varices. 5. Renal insufficiency secondary to hepatorenal syndrome. 6. Ascites. 7. History of SBP. 8. COPD. 9. Type 2 diabetes mellitus. DISCHARGE DIAGNOSES: 1. End-stage liver disease. 2. Alcoholic and hepatitis C cirrhosis.
SBP|spontaneous bacterial peritonitis|SBP.|176|179|HISTORY OF PRESENT ILLNESS AND BRIEF HOSPITAL COURSE|Due to significant ascites, a therapeutic tap was done and around 4.5 L were taken out with the 25 g albumin. We also sent a tap for workup and he did not have any evidence of SBP. The patient was put on alcohol withdrawal protocol and required only 2 doses of p.o. lorazepam during this admission. ISSUES: 1. GI. As described above, the patient has a history of end-stage liver disease.
SBP|spontaneous bacterial peritonitis|SBP|195|197|HOSPITAL COURSE|He was also seen by physical, occupational therapy is ambulating well upon discharge. 5. Infectious disease. The patient was treated empirically with antibiotics throughout his hospital stay for SBP prophylaxis. He did have a few low-grade temps several days ago, but these subsequently resolved. Cultures have all been negative. He had some loose stools and C.
SBP|spontaneous bacterial peritonitis|SBP|139|141|HISTORY OF PRESENT ILLNESS|He presented to the ED on the day admission with fever and abdominal pain. He has history of ascites for greater than 2 months and has had SBP previously in early _%#MM#%_. He was on prophylactic Cipro once weekly prior to admission and reports taking that and doing well for 4 days prior to admission when he had worsening abdominal pain.
SBP|spontaneous bacterial peritonitis|SBP.|140|143|HOSPITAL COURSE|Please see the admission H&P for details of the history of present illness, past medical history and exam on admission. HOSPITAL COURSE: 1. SBP. The patient was admitted and started on IV antibiotics. He was initially started on Zosyn and this was continued. He was not tapped prior to starting antibiotics. He was tapped about 24 hours into his admission and cultures were sent from the peritoneal fluid and cultures, however, were negative.
SBP|spontaneous bacterial peritonitis|SBP.|270|273|HOSPITAL COURSE|He also had a urine culture that was negative. He continued on Zosyn throughout his hospitalization and had improvement in his abdominal pain at the time of discharge. He was transitioned to Augmentin 4 g p.o. x6 days to complete 10 days of antibiotics for his presumed SBP. He previously had been on ciprofloxacin prophylaxis and this was changed to Bactrim DS 1 tab p.o. daily, Monday to Friday for SBP prophylaxis.
SBP|systolic blood pressure|SBP|138|140|DISCHARGE MEDICATIONS|4. Ferrous sulfate 325 mg p.o. daily. 5. Furosemide 20 mg p.o. b.i.d. Hold if SBP less than 100. 6. Lisinopril 2.5 mg p.o. daily. Hold is SBP less than 100. 7. Compazine 10 mg p.o. q 8 hours p.r.n. 8. Senokot 1 tablet p.o. b.i.d. 9. Vicks Vapor rub topical p.r.n. 10.Argenine 1 packet p.o. t.i.d. 11.Multiple vitamin 1 tablet p.o. daily.
SBP|systolic blood pressure|SBP|123|125|DISCHARGE MEDICATIONS|(Continued) 1. Allopurinol 300 mg p.o. G tube daily. 2. Atenolol 50 mg p.o. G tube daily, hold if pulse is less than 50 or SBP is less than 110. 3. Atorvastatin via G tube 10 mg p.o. daily. Patient should have fasting lipid profile repeated in 6 weeks.
SBP|spontaneous bacterial peritonitis|SBP.|205|208|HOSPITAL COURSE|He received a total of 50 g. GI was consulted and recommendations included starting weekly Cipro for SBP prophylaxis. Of note, ascites sample was sent during the admission and did not show any evidence of SBP. To better control the ascites, the patient was evaluated for TIPS procedure. This had been delayed in the past because of elevated pulmonary pressures.
SBP|spontaneous bacterial peritonitis|SBP.|141|144|DISCHARGE MEDICATIONS|2. Protonix 40 mg p.o. daily. 3. Paxil 20 mg daily. 4. Multivitamin 1 tab p.o. daily. 5. Moxifloxacin 400 mg daily to complete treatment for SBP. 6. Vitamin K 10 mg p.o. daily. 7. Rifaximin 400 mg p.o. t.i.d. FOLLOWUP INSTRUCTIONS: 1. The patient is to followup with Dr. _%#NAME#%_ in the liver transplant clinic within 1 to 2 weeks.
SBP|spontaneous bacterial peritonitis|SBP|249|251|ASSESSMENT|Problem #2. End-stage liver disease: The patient's ascites may be contributing to his decreased appetite. He has regularly been receiving paracenteses and anticipate performing therapeutic paracentesis tomorrow morning. Will continue patient on his SBP by continuing levofloxacin after his daily dialysis treatment and continue regular PPI. Problem #3. Chronic kidney disease. The patient received hemodialysis this morning prior to being evaluated in Primary Care Clinic.
SBP|spontaneous bacterial peritonitis|SBP.|185|188|HOSPITAL COURSE|However, the fluid analysis by cytology is pending at the time of discharge of this patient. The patient's examination was also very benign and it is very unlikely that the patient has SBP. In this hospital admission, we also increased her dose of Lasix to 60 mg from 40 mg p.o. q.day. We also increased the dose of spironolactone to 100 mg p.o. b.i.d. from 150 mg p.o. daily.
SBP|spontaneous bacterial peritonitis|SBP|230|232|PLAN|PLAN: 1. Abdominal ascites: Mr. _%#NAME#%_ and I talked last time about the option of doing a peritoneal dialysis catheter and he is open to his idea at this point in time. He is aware that that puts him at a much higher risk for SBP and I outlined this with him tonight. He needs to keep the catheter site clean and to do to self evacuations of his abdominal fluid as he sees fit.
SBP|spontaneous bacterial peritonitis|SBP.|165|168|PLAN|Certainly in the future if he comes in with any infections or any mental status changes, he will need to have that fluid evaluated and to make sure he does not have SBP. 2. Diabetes: Continue with his prior regimen.
SBP|spontaneous bacterial peritonitis|SBP|187|189||4. Respiratory failure most likely secondary to encephalopathy and requiring mechanical ventilation. 5. Candidemia treated with amphotericin B. 6. Staphylococcal and group D enterococcus SBP treated with linezolid. 7. Aspergillus and VRE pneumonia treated with amphotericin B and linezolid. 8. Right upper extremity thrombosis. The patient was not a candidate for anticoagulation due to his coagulopathy.
SBP|spontaneous bacterial peritonitis|SBP,|177|180|ADDENDUM|She had a feeding tube placed on 3/4, with initiation of NutriHep tube feeds. She tolerated her goal rate of 40 cc/hour. However, since she is on prophylactic ciprofloxacin for SBP, this will be increased to 45 cc/hour. The patient required no further transfusions, and her hemoglobin remained stable.
SBP|systolic blood pressure|SBP|159|161|DISCHARGE DIAGNOSIS|2. Accelerated hypertension with fluid overload, it is likely due to poorly controlled hypertension. 3. Syncope due to relative hypotension and venous pooling SBP 110 due to imdur and hydralazine. 4. Chest pain transient negative stress test _%#MMDD2007#%_. CHRONIC DIAGNOSES: 1. Hypertension. 2. Diabetes. DISCHARGE MEDICATIONS: New Medications: 1. Hydralazine, 50 mg p.o. b.i.d.
SBP|systolic blood pressure|SBP|158|160|SUMMARY OF HOSPITALIZATION|I observed her one more day and stress test was negative on _%#MMDD#%_. I stopped the nitrate. Maybe this could be added once she tolerates her new lower BP. SBP 140 by time of discharge. Her ACEI is now permanently discontinued but her ARB continues.
SBP|spontaneous bacterial peritonitis|SBP.|160|163|HOSPITAL COURSE|She may require further large volume paracentesis. However, she does have a TIPS placed a month or 2 ago that may now well be functioning. PROBLEM #2: Presumed SBP. On admission, the patient appeared septic was hypotensive and had leukocytosis. She had been on antibiotics 24 hours prior to admission and ascitic fluid was not diagnostic for SBP.
SBP|spontaneous bacterial peritonitis|SBP.|192|195|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Levofloxacin 750 mg p.o. daily for 7 days. 2. Bactrim DS 1 tab p.o. daily to be started after the patient completes 7-day course with levofloxacin for prophylaxis of SBP. 3. Lasix 40 mg p.o. daily. 4. Spironolactone 100 mg p.o. daily. 5. Propranolol 40 mg p.o. b.i.d. 6. Protonix 40 mg p.o. b.i.d.
SBP|spontaneous bacterial peritonitis|SBP.|152|155|HOSPITAL COURSE|The patient has no history of a GI bleed. No hepatic encephalopathy present. PROBLEM #2: Ascites. The patient underwent two paracenteses. No associated SBP. The patient is to continue SBP prophylaxis with Levaquin q.i.d. PROBLEM #3: Compression fracture of L1 with severe pain. The patient responded to high-dose narcotics but with complicating ileus.
SBP|spontaneous bacterial peritonitis|SBP.|224|227|HISTORY OF PRESENT ILLNESS|The patient was also noted to be confused. The patient was intubated at an outside hospital for respiratory distress and started on dopamine for hypotension. She was treated with cefotaxime, vancomycin, and levofloxacin for SBP. ALLERGIES: The patient has no known drug allergies.
SBP|spontaneous bacterial peritonitis|SBP.|134|137|HOSPITAL COURSE|She was started on Prisma for severe lactic acidosis. She was also started on antibiotics for broad-spectrum coverage of her presumed SBP. Her condition deteriorated despite blood pressure support, ventilatory support, and Prisma. The patient was initially evaluated for liver transplantation, but was later judged not to be a candidate because of her overall poor status.
SBP|spontaneous bacterial peritonitis|SBP.|123|126|PROBLEM #3|PROBLEM #3: Abdominal pain. During this admission, the patient had significant abdominal pain. It was possible that he had SBP. He was treated empirically with IV antibiotics. PROBLEM #4: Death. The patient died on _%#MMDD2003#%_ at 11:10 a.m. Cause of death was hepatocellular carcinoma and acute renal failure.
SBP|systolic blood pressure|SBP|167|169|DISCHARGE MEDICATIONS|10. Head of bed elevated to 30 degrees. Out of bed to chair three times a day with assist only. DISCHARGE MEDICATIONS: 1. Lopressor 50 mg down GJ-tube q.12h., hold if SBP less than 90. 2. Protonix 40 mg down GJ-tube q. daily. 3. Multivitamin one tablet down GJ-tube q. daily. 4. Albuterol nebs q.4h. p.r.n. 2 puffs. 5. Zofran 4-8 mg IV q.6h. p.r.n.
SBP|spontaneous bacterial peritonitis|SBP|340|342|ALLERGIES|Sodium 139, potassium 3.8, chloride 108, CO2 of 23, BUN 27, creatinine 1.3. Glucose 91, magnesium 147, phos 3.4. UA with a specific gravity of 1.014, pH 5.0, small leukocyte esterase, 7 white blood cells, 1 red blood cell, few bacteria. HOSPITAL COURSE: 1. Mental status changes. The differential for this was hepatic encephalopathy versus SBP infection versus seizure activity associated with hemochromatosis. We checked the patient's TIPS with an ultrasound as above, which showed that it was functioning normally.
SBP|spontaneous bacterial peritonitis|SBP.|167|170|ALLERGIES|2. Fatigue. The patient has reported some fatigue over the last month or so. A TSH was checked, and returned at 2.17. 3. ID. The patient was going to be evaluated for SBP. She had a paracentesis done, with no return. The scan showed that she had minimal ascites at that time. She did have a UTI at the time of admission, and was treated for this with ciprofloxacin as an inpatient.
SBP|spontaneous bacterial peritonitis|SBP.|175|178|PAST MEDICAL HISTORY|2. End-stage liver disease secondary to cystic fibrosis with refractory ascites. 3. History of mycobacterial infection. 4. Cystic fibrosis-related lung disease. 5. History of SBP. 6. Pancreatic exocrine insufficiency. 7. History of multiple episodes of DIOS (Distal Intestinal Obstruction Syndrome). PAST SURGICAL HISTORY: Living unrelated right lobe liver transplant _%#MMDD2007#%_.
SBP|spontaneous bacterial peritonitis|SBP.|178|181|HOSPITAL COURSE|4. Blood transfusions. HOSPITAL COURSE: 1. Abdominal pain. This is likely secondary to tense ascites. He was admitted and underwent an ultrasound-guided paracentesis to rule out SBP. He was placed empirically on Rocephin initially. The paracentesis labs were not consistent with SBP. Unfortunately, only 1500 cc were withdrawn. He was on a low-dose diuretic.
SBP|spontaneous bacterial peritonitis|SBP.|177|180|HOSPITAL COURSE|He was admitted and underwent an ultrasound-guided paracentesis to rule out SBP. He was placed empirically on Rocephin initially. The paracentesis labs were not consistent with SBP. Unfortunately, only 1500 cc were withdrawn. He was on a low-dose diuretic. I suspect that we may be able to help his abdominal pain by reducing the amount of ascites that he is accumulating.
SBP|spontaneous bacterial peritonitis|SBP|199|201|PAST MEDICAL HISTORY|However, the patient has been placed on antiepileptic medicines specifically Keppra after an allergic reaction to Dilantin. 3. Hypothyroidism. 4. Grade I esophageal varices on EGD _%#MMDD2004#%_. 5. SBP status post 2 weeks of ceftriaxone in _%#MM#%_ 2004. 6. Thoracentesis approximately 2 weeks ago. 7. History of acute renal failure secondary to over diuresis.
SBP|spontaneous bacterial peritonitis|SBP.|203|206|HISTORY OF PRESENT ILLNESS|He presented to Fairview Lakes Emergency Department on the morning of admission secondary to the above symptoms. He was found to have ascites and a 2 L paracentesis was performed, which was negative for SBP. The patient was then transferred to Fairview-University Medical Center for further care. PAST MEDICAL HISTORY: 1. Removal of a partial goiter in the 1950s.
SBP|spontaneous bacterial peritonitis|SBP,|308|311|PROBLEM #2|He did not have much of a response to this, so we therefore increased this to 100 of spironolactone and 40 mg of Lasix b.i.d. On the day of his discharge, he received a repeat paracentesis in which 2 L of bloody fluid were removed. There was no evidence of SBP or malignancy on the cytology. To help prevent SBP, we started ciprofloxacin 500 mg once per week. As an outpatient, this should probably be increased to 750 mg once weekly.
SBP|spontaneous bacterial peritonitis|SBP|161|163|ASSESSMENT|The patient currently is on Lasix and also Aldactone for her ascites. We will continue to monitor the patient's weight. The patient is also on ciprofloxacin for SBP prophylaxis. 4. Pancytopenia, this is likely secondary to 3. Hematology is following and will continue to monitor the patient's platelet count and white blood cell count.
SBP|spontaneous bacterial peritonitis|SBP|154|156|DISCHARGE MEDICATIONS|12. Neoral 75 mg p.o. q.a.m. and 50 mg p.o. q.p.m. to be adjusted for level between 75-100. 13. Dapsone 50 mg p.o. daily. 14. Cipro 500 mg p.o. daily for SBP prophylaxis. 15. Percocet 5/325 1-2 p.o. q.6h p.r.n. pain, dispense #20. 18. Senna S2 p.o. q day, to be held for loose stools.
SBP|spontaneous bacterial peritonitis|SBP|160|162|PROBLEM # 1|He is currently not on liver transplant list. He has had esophageal variocele bleed during his hospitalization requiring banding x two. He was also treated for SBP empirically and is currently on ciprofloxacin and rifaximin for prophylactic purpose. Treated for hepatitic encepholopathy with lactulose. He appears to be medically stable and his last hemoglobin was 10.3 gm on _%#MMDD2006#%_.
SBP|spontaneous bacterial peritonitis|SBP|241|243|ASSESSMENT AND PLAN|In terms of the liver disease given the patient is still actively drinking certainly would not be a candidate for liver transplantation unless he was abstinent for a minimum of 6 months, preferably up to a year. His ascites was negative for SBP and is likely due to his liver disease as the ascitic fluid albumin level is not available to us at this time.
SBP|systolic blood pressure|SBP|125|127|PHYSICAL EXAMINATION|ENDOCRINE: Negative for polyuria, polyphagia or polydipsia. Negative for thyroid disease. PHYSICAL EXAMINATION: VITAL SIGNS: SBP is 200-148 and diastolic blood pressure is 96, pulse is 108, and respiratory rate is 20. GENERAL: Cachectic-appearing, elderly female lying in bed in no acute distress.
SBP|spontaneous bacterial peritonitis|SBP|163|165|IMPRESSION|d. There is some evidence of a possible GI bleed with his 2 gram hemoglobin drop in two weeks. The patient does not look at his stools, and they could be dark. e. SBP is unlikely since there is no ascites. f. Congestive failure is a possibility since he does have trouble with progressive dyspnea on exertion and cholestasis.
SBP|spontaneous bacterial peritonitis|SBP.|188|191|PLAN|As far as the elevated ammonia levels, I would discontinue the lactulose as you have and begin Rifaximin as already currently being treated. Would do a diagnostic paracentesis to rule out SBP. 2. Hyponatremia likely secondary to end-stage liver disease: Would continue treating as you are with restricted free water. Continue to monitor closely. 3. Hypokalemia likely secondary to large bowel movements and Lasix: Continue to aggressively replace potassium per protocol as you are.
SBP|spontaneous bacterial peritonitis|SBP|143|145|RECOMMENDATIONS|Given that we do not want to be too aggressive we could potentially hold off on doing paracentesis for diagnosis. There is no real evidence of SBP at this time. 7. Consider holding diuretics. 8. For now, the patient's daughter does not want to pursue an EGD. Please contact the GI service if she changes her mind.
SBP|spontaneous bacterial peritonitis|SBP|250|252|SUMMARY  OF CASE|She admits to drinking vodka but only with meals and tells me that she "usually just drinks wine." The patient has numerous other medical issues for which she has received attention. She does carry diagnosis of mitral valve prolapse and does receive SBP prophylaxis for it. She also takes a diuretic on a daily basis for fluid retention. She is also on thyroid hormone replacement. She tells me that she is not a smoker.
SBP|spontaneous bacterial peritonitis|SBP.|197|200|PAST MEDICAL HISTORY|12. Chronic hyponatremia. 13. Chronic anemia. 14. Chronic back pain. 15. History of acute renal failure. 16. History of hepatic vein thrombosis. 17. Sigmoid diverticulosis. 18. Possible history of SBP. SOCIAL HISTORY: The patient lives in _%#CITY#%_ with her husband whom she married about 1 year ago.
SBP|spontaneous bacterial peritonitis|SBP|142|144|PLAN|The patient should be put on antibiotics to cover any infection for this time. Given that he has a GI bleed and is cerotic he should not have SBP prophylaxis during his hospitalization. The patient should receive fluids and pressors as needed to maintain a blood pressure greater than 50.
SBP|spontaneous bacterial peritonitis|SBP|132|134|PLAN|Correct the coagulopathy with FFP and vitamin K as able. PPI drip and octreotide drip. As mentioned above, the patient should be on SBP prophylaxis given the GI bleed in a cerotic patient. The patient should be made NPO until we are able to do an EGD.
SBP|spontaneous bacterial peritonitis|SBP|132|134|PLAN|Correct the coagulopathy with FFP and vitamin K as able. PPI drip and octreotide drip. As mentioned above, the patient should be on SBP prophylaxis given the GI bleed in a cerotic patient. The patient should be made NPO until we are able to do an EGD.
SBP|spontaneous bacterial peritonitis|SBP.|202|205|PAST MEDICAL HISTORY|2. Autoimmune hepatitis followed by Dr. _%#NAME#%_; last seen in _%#MM#%_; currently on Imuran and prednisone. She is up-to-date on hepatocellular cancer screening. No history of varices. No history of SBP. 3. Aspiration pneumonitis in _%#MM2006#%_. 4. Neurogenic bladder. 5. Recurrent urinary infection and urosepsis. 6. History of decubitus ulcers. 7. History of kidney stones bilaterally. 8. History of pancytopenia; had a bone marrow biopsy in 2005 with no evidence of myelodysplastic syndrome.
SBP|systolic blood pressure|SBP|123|125|PLAN|Per patient request, he will be placed on a regular diet. 5 Hypertension: Will start lisinopril 10 mg p.o. q.a.m. Hold for SBP less than 100 as patient was on this prior to admission. 6 History likely tension: Will start ibuprofen. 7 Mild onychomycosis: The patient instructed to follow up with primary medical doctor upon discharge.
SBP|spontaneous bacterial peritonitis|SBP|155|157|RECOMMENDATIONS|5. Suggest FANA to rule out autoimmune hepatitis and a ceruloplasmin level which I will order. 6. If the patient develops ascites, he would be at risk for SBP but I would suggest not prophylaxing him for this until he develops an initial episode of SBP.
SBP|spontaneous bacterial peritonitis|(SBP),|271|276|A/P|coagulopathy - please correct INR for possible biopsy on Friday if his renal function does not improve I participated in this evaluation and agree with the fellow's note above. The acute kidney injury is likely multifactorial, with causes including liver disease, sepsis (SBP), recent hypotension, or even acute renal allograft rejection. The latter we will need to rule out if function does not improve.--_%#NAME#%_
SBP|spontaneous bacterial peritonitis|SBP|214|216|ASSESSMENT|Transplant coordinator is aware of the patient. Recommendation to follow MELD lab. 2. Nephrology consultation. 3. Ascites secondary to underlying liver disease. Requiring paracentesis every 2 weeks. No evidence of SBP with paracentesis done yesterday. Depending on the renal recommendation the patient should have large volume paracentesis with albumin. Diuretics cannot be used because of his worsening renal function.
SBP|spontaneous bacterial peritonitis|SBP|113|115|IMPRESSION|There is no asterixis now, and there was certainly no focal neurologic findings. IMPRESSION: 1. Sepsis, possible SBP would explain the syndrome, with hypertension, confusion, hypovolemia and worsening liver function and rapid improvement, with fluid replacement, Dopamine, IV antibiotic and steroids.
SBP|systolic blood pressure|SBP|287|289|ASSESSMENT/PLAN|ASSESSMENT/PLAN: 1. Hypertension, we will start the patient on Metoprolol 25 mg p.o. b.i.d. Will hold the metoprolol if her SBP is less than 140 as I would not want to make any ischemic infarct worse by exacerbating possible watershed zone. The patient will be started on Norvasc if her SBP is greater than 160. She will continue her Benicar. We should try to avoid hypotensive encephalopathy if possible. 2. Left tendinitis. The patient will be given Vicodin for pain medication as needed.
SBP|spontaneous bacterial peritonitis|SBP.|145|148|IMPRESSION|IMPRESSION: 1. Early satiety with difficulty swallowing. 2. Nodular degenerative hyperplasia. 3. Ascites. 4. Fever. The concern at this point is SBP. The patient is to have a diagnostic paracentesis later toady. She is currently on a broad spectrum antibiotic. We will await those results and make further recommendations.
SBP|spontaneous bacterial peritonitis|SBP,|206|209|IMPRESSION|The patient had a recent upper endoscopy in _%#MM#%_ of 2006 that showed hypertensive gastropathy. I recommend a proton pump inhibitor for this. Also, the patient has a urinary tract infection and possible SBP, and is currently on an antibiotic. Infectious process may be contributing to these symptoms. Continue to monitor and await above studies.
SBP|spontaneous bacterial peritonitis|SBP,|231|234|PROBLEM #2|She is on Lactulose and rifaximin. We need to be more aggressive at this time and increase the dose of lactulose to have 5-6 loose stools and will need to continue with rifaximin 400 mg t.i.d. at this time. There is no evidence of SBP, and she is on antibiotics for that. PROBLEM #3: Ascites. We can adjust the dose of her Lasix and increase it from 40 to 60 mg twice a day.
SBP|spontaneous bacterial peritonitis|SBP,|190|193|RECOMMENDATIONS|RECOMMENDATIONS: 1. I agree with current measures; that is, central line, adjusting IV fluids, and judicious use of diuretics, as tolerated. 2. I agree with empiric antibiotics for possible SBP, and the use of vitamin K to try to reverse his coagulopathy. 3. Check liver function tests, which I ordered in case there is a reversible insult that can be corrected, leading to better synthetic function.
SBP|spontaneous bacterial peritonitis|SBP|199|201|IMPRESSION|2. History of hyperammonemia related to above. 3. Hypotension with blood pressures in the range of 50-60, presumed sepsis, question of underlying urinary tract source on the basis of UA and possibly SBP given her history and previous diagnosis in this regard. 4. Associated profound metabolic acidosis. 5. Hyperkalemia secondary to acidosis.
SBP|spontaneous bacterial peritonitis|SBP.|180|183|PAST MEDICAL HISTORY|She has been taking her medications as prescribed at home. PAST MEDICAL HISTORY: 1. Autoimmune hepatitis, as described above. 2. Insulin-dependent diabetes. 3. History of previous SBP. 4. Previous delivery. 5. Previous inguinal hernia repair.
SBP|systolic blood pressure|SBP|138|140|ASSESSMENT AND PLAN|3. Hypertension. He is on lisinopril 10 mg p.o. daily, hold for SBP less than 110. He is also on diltiazem CD 240 mg p.o. daily, hold for SBP less than 110. 4. Hyperlipidemia. He is on Simvastatin 20 mg p.o. q.p.m. 5. Dependent edema. He is on Lasix 40 mg p.r.n. approximately every other day with potassium 20 mEq approximately every other day with Lasix.
SBP|spontaneous bacterial peritonitis|SBP|222|224|IMPRESSION|IMPRESSION: 1. Insignificant upper GI bleed in a patient at risk for major upper GI bleeding and no history of an endoscopy. Rule out peptic disease and check variceal size. 2. Urinary tract infection (UTI), also possible SBP causing the elevated white count. 3. Renal insufficiency due to dehydration probably from diuresis. RECOMMENDATIONS: Liberalize fluid and culture.
SBP|spontaneous bacterial peritonitis|SBP.|182|185|HISTORY OF PRESENT ILLNESS|He would drink heavier in the summertime. He had been seeing Dr. _%#NAME#%_ _%#NAME#%_ at Minnesota Gastroenterology. Complications of cirrhosis for him have included (1) History of SBP. He apparently was not on prophylaxis for this. (2) Ascites. He has required multiple large volume paracenteses. The ascites began in the latter part of 2006/early part of 2007.
SBP|spontaneous bacterial peritonitis|SBP,|218|221|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 58-year-old Caucasian male with a past medical history significant for cirrhosis secondary to alcohol use. The patient's liver disease has been complicated by history of SBP, recurrent ascites requiring large volume paracentesis, hepatic encephalopathy, grade 3 esophageal varices found on EGD, and renal insufficiency. The patient was recently discharged from the hospital last week.
SBP|spontaneous bacterial peritonitis|SBP.|239|242|RECOMMENDATIONS|The patient needs to be seen by Chemical Dependency also as he minimally fulfilled the criteria for listing (he is sober for 6 months). RECOMMENDATIONS: 1. Nephrology consult. 2. Urinalysis and FENa. 3. Diagnostic paracentesis to rule out SBP. 4. IV fluids plus albumin. 5. No diuretics. 6. Will follow the MELD labs. 7. Will discuss him in Transplant meeting and try to expedite his listing on the transplant.
SBP|spontaneous bacterial peritonitis|SBP|369|371|HISTORY OF PRESENT ILLNESS|I was asked to see the patient for hepatic encephalopathy and acute-on-chronic liver failure and acute renal failure by Dr. _%#NAME#%_. HISTORY OF PRESENT ILLNESS: This is a lovely 45-year-old man with end-stage liver disease secondary to alcohol and hepatitis C complicated by ascites and recurrent hepatic encephalopathy, requiring multiple admissions and history of SBP who presented to the outside hospital with hepatic encephalopathy and acute renal insufficiency. His creatinine at that time was 1.62 from baseline of 1.
SBP|spontaneous bacterial peritonitis|SBP|205|207|CHIEF COMPLAINT|He underwent endoscopy showing no esophageal varices, and colonoscopy showed mixed old and new blood throughout the colon with large internal hemorrhoids. Octreotide was started as well as antibiotics for SBP prophylaxis. He was extubated 3 days ago and taken to the operating room for ligation of the hemorrhoids on _%#MM#%_ _%#DD#%_, 2003.
SBP|spontaneous bacterial peritonitis|SBP|145|147|MEDICATIONS|We will continue the octreotide. Keep his hemoglobin around 9 but be careful not to over- volume resuscitate him. Start antibiotics for possible SBP as his nucleated white cells are greater than 250. We will cautiously deflate the rectal balloon and remove it. Will continue the Neomycin and add back lactulose b.i.d. Slightly worsening renal insufficiency is most likely due to recent bleeding and will give albumin infusion because of the SBP and its benefits for preventing acute renal failure in the setting of end-stage liver disease with infection.
SBP|spontaneous bacterial peritonitis|SBP,|264|267|IMPRESSION|INR is 1.2, PTT 29 seconds, bilirubin 1.5 with a total protein of 5.8. Peritoneal fluid has 2000 nucleated cells of which 85% are polys. IMPRESSION: The patient has been having recurring episodes of encephalopathy. Possible precipitating factors might include: a. SBP, which has been proven this time despite his prophylaxis with one Double Strength Bactrim twice a week. Clearly a different regimen would be needed to prevent a future episode.
SBP|systolic blood pressure|SBP|177|179|HISTORY OF PRESENT ILLNESS|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_. REASON FOR CONSULTATION: Postop hypertension, COPD. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 59-year-old male with an SBP of 148 postoperative, now normotensive. The patient has a history of COPD but denies any wheezing or shortness of breath; the patient denies any chest pain or diaphoresis.
SBP|spontaneous bacterial peritonitis|SBP|200|202|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. End-stage liver disease secondary to cryptogenic cirrhosis on transplant list. 2. Status post TIPS on _%#MMDD#%_ which was revised and _%#MMDD#%_ and _%#MMDD#%_. 3. Recurrent SBP with history of VRG peritonitis. 4. History of multiple hepatic encephalopathy. 5. Schizophrenia. 6. Type 2 diabetes. 7. Esophageal varices.
SBP|spontaneous bacterial peritonitis|SBP.|288|291|PERTINENT PAST MEDICAL HISTORY|2. He is status post upper endoscopy by my partner, Dr. _%#NAME#%_ in _%#MM#%_ of 2006 which showed evidence of grade 2 esophageal varices and portal gastropathy. He has been on propranolol since. 3. Recent hospitalization for what was documented by the discharging physician as presumed SBP. Patient presented with elevated white count and responded well to antibiotics. He had no ascites to tap. He has been on prophylactic Bactrim for SBP.
SBP|spontaneous bacterial peritonitis|SBP.|145|148|PERTINENT PAST MEDICAL HISTORY|Patient presented with elevated white count and responded well to antibiotics. He had no ascites to tap. He has been on prophylactic Bactrim for SBP. 4. History of hypertension. 5. History of gastroesophageal reflux disease. 6. History of hyperlipidemia. 7. He also had surgery for sternoclavicular joint infection years ago at Fairview Southdale Hospital.
SBP|spontaneous bacterial peritonitis|SBP|234|236|IMPRESSION AND PLAN|IMPRESSION AND PLAN: The patient is a pleasant 54-year-old gentleman with end-stage liver disease on transplantation, has no evidence of decompensated cirrhosis at this time. I find it hard pressed to give this gentleman diagnosis of SBP and in retrospect, I have a hard time giving him a diagnosis of SBP in _%#MM#%_, especially with no ascites. His small bowel findings are concerning, although it does appear that they are stable, in reviewing the CT scans and will need to review these personally with the radiologist.
SBP|spontaneous bacterial peritonitis|SBP|207|209|HISTORY|He has had subacute bacterial peritonitis at least once in the last 4 months and it appears to me at least 2 or 3 episodes. He had vancomycin-resistant enterococcus in the blood, a recently presumably of an SBP basis and also had an Enterobacter SBP in _%#MM#%_. The current symptoms developed abruptly with fever going up to 102 degrees.
SBP|spontaneous bacterial peritonitis|SBP|483|485|IMPRESSION|His platelets are 53, hemoglobin of 10, and white blood cell count of 4.4. Chest x-ray showed bandlike opacity in the right lung base, which could be pneumonia versus atelectasis. His lipase was 262 and blood cultures are pending. IMPRESSION: This lovely 55-year-old man with end-stage liver disease secondary to NASH who presents with recurrent episode of hepatic encephalopathy of which he has had multiple bouts of hepatic encephalopathy in the past, as well as multiple bouts of SBP in the past. PLAN: 1. Medication: Will titrate his lactulose to 5 bowel movements a day.
SBP|spontaneous bacterial peritonitis|SBP|217|219|PLAN|2. End-stage liver disease with cirrhosis secondary to PBC. The patient is currently on the transplant list. Her MELD score is 38 and the transplant team is aware of her hospitalization. 3. The patient should receive SBP prophylaxis. 4. Ascites. The patient may have ascites, however, her abdomen is not tense and is not at the point where she would require therapeutic paracentesis.
SBP|systolic blood pressure|SBP|196|198|ASSESSMENT/PLAN|He also be placed on Norvasc. The patient will have available IV enalapril, IV labetalol available to use to control his hypertension if his SBP is greater than 170. Hypertension: Attempt to keep SBP less than 160. Will use Norvasc 5 mg p.o., will also use Metoprolol 25 mg p.o. daily. The patient will have her troponins x2 checked.
SBP|systolic blood pressure|SBP|311|313|ASSESSMENT/PLAN|On _%#MMDD2007#%_ if ok with Dr. _%#NAME#%_, increase Lovenox to 100 mg subcu b.i.d. Discontinue Lovenox 24 hours prior to next surgery on _%#MMDD2007#%_. Will hold aspirin and Coumadin until after next scheduled surgery on _%#MMDD2007#%_. 3. Hypertension, controlled. Hold Lopressor, Lasix, spironolactone for SBP less than 110. Hold metoprolol for pulse less than 55. 4. Diabetes type 2, currently controlled. Hold glyburide for blood sugar less than 100. Change IV fluid to normal saline plus 20 KCl at 125 ml per hour.
SBP|spontaneous bacterial peritonitis|SBP.|250|253|PROBLEMS|2. Acute hepatic decompensation. This is likely secondary to the infection of the SBP (spontaneous bacterial peritonitis). The patient will start ceftriaxone today. 3. Acute renal failure. This is likely secondary to acute hepatic decompensation 2/2 SBP. There could also be an element of ATN (acute tubular necrosis) versus HRS (hepatorenal syndrome). I would start albumin for some intravascular repletion in the patient.
SBP|systolic blood pressure|SBP|129|131|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 74-year-old female status post left knee arthroplasty who has been having SBP measurements in the 160s. The patient normally has a blood pressure in the clinic in 120s. The patient has had normal blood pressures her whole entire life.
SBP|spontaneous bacterial peritonitis|(SBP).|222|227|DOB|After hydration his anemia and thrombocytopenia worsened slightly (hemoglobin 7.9, platelets 35,000). He was given 4 units of FFP and platelets prior to abdominal paracentesis to rule out spontaneous bacterial peritonitis (SBP). He was also placed on empiric antibiotics for prophylaxis against SBP. REVIEW OF SYSTEMS: Today is notable for continued confusion, jaundice, some recent epistaxis and possible gingival bleeding, abdominal bloating with associated ascites, and a generalized abdominal tenderness.
SBP|spontaneous bacterial peritonitis|SBP|229|231|IMPRESSION|Ethanol less than 0.01 grams/dl. Lipase is normal. Chest x-ray, blood cultures, UA are all pending. IMPRESSION: This patient with cirrhosis, hepatic encephalopathy and ascites, now has a febrile illness with confusion. I suspect SBP since there are no other localizing features. Rule out other infectious source such as pneumonia, bronchitis or urinary tract infection.
SBP|spontaneous bacterial peritonitis|SBP.|188|191|IMPRESSION|INR 1.28. Electrolytes 136, 3.8, 103/26. Creatinine 0.6. Total protein 6.6. IMPRESSION: This patient presents with melena, low hemoglobin in addition to the abdominal pain. I doubt he has SBP. 1. Melena. This indicates a continued slow GI bleed, possibly from portal hypertensive gastropathy. Apparently he has not been on proton pump inhibitors.
SBP|spontaneous bacterial peritonitis|SBP.|173|176|ASSESSMENT  AND PLAN|This is likely on the basis of his liver disease as well as some possible intravascular depletion. a. Follow sodium. b. Will check urine studies to be complete. 4. Possible SBP. The patient has a high white count and has a lot of PMNS in his paracentesis fluid. a. The patient is on Zosyn. 5. Nutrition. The patient should be on a renal diet.
SBP|spontaneous bacterial peritonitis|SBP|206|208|HISTORY OF PRESENT ILLNESS|Ultimately, she was diagnosed with hepatitis. She was hospitalized at Fairview University Hospital just a little over one week ago for abdominal swelling and variceal bleeding. She had banding at the time. SBP was also found. She was started on IV antibiotics. She has been at the _%#CITY#%_ Health Center receiving IV antibiotics since then.
SBP|spontaneous bacterial peritonitis|SBP|137|139|RECOMMENDATIONS|2. May consider EGD and possible flex sig tomorrow to assess for ulcer disease and possibly for CMV disease. 3. Paracentesis to rule out SBP 4. Check MMF and cyclosporine levels. 5. If the above studies are unremarkable may need to consider CT versus even possible MR angiogram just to rule out mesenteric ischemia or other etiologies as a cause of the patient's pain and weight loss.
SBP|spontaneous bacterial peritonitis|SBP|190|192|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Alcoholic liver disease with cirrhosis and recent alcoholic hepatitis. 2. History of portal hypertension with ascites noted last admission. 3. Depression. 4. Recent SBP culture negative. 5. Recent C. diff positive culture. 6. Chronic arthritis. 7. Chronic constipation. 8. GERD. 9. Multiple admissions for alcoholism.
SBP|spontaneous bacterial peritonitis|SBP.|183|186|PAST MEDICAL HISTORY|Her white blood count today is 4.9. PAST MEDICAL HISTORY: 1. Alcoholic liver disease with cirrhosis, ascites and encephalopathy. 2. Depression. 3. Chronic constipation. 4. History of SBP. PAST SURGICAL HISTORY: Closed reduction and percutaneous pinning of left femoral neck fracture _%#MMDD2007#%_.
SBP|spontaneous bacterial peritonitis|SBP.|184|187|HISTORY|Of note, on admission her creatinine was elevated. This has been treated with volume resuscitation and has responded. Her creatinine is now 1.4. In addition, there was a concern about SBP. She has had an acidic tap and this is no growth so far. PAST MEDICAL HISTORY: Is significant for hepatitis C secondary to blood transfusion 10 to 25 years ago.
SBP|systolic blood pressure|SBP|185|187|ASSESSMENT AND PLAN|I would give him 25 mg of Metoprolol prior to surgery and 25 mg p.o. b.i.d. postop x 2 doses after surgery. It is okay to hold the Lopressor though if his pulse is less than 60 and his SBP is less than 80. If his rate were to go greater than 100, I would try intravenous Lopressor 5 mg q 6 hours to rate control his atrial fibrillation.
SBP|spontaneous bacterial peritonitis|SBP|233|235|ASSESSMENT AND PLAN|Problem #2. Cryptogenic cirrhosis. MELD score of 15. She was doing fine except for varices and therefore TIPS was placed. Her ascites and edema are also well controlled. We can slowly titrate her off diuretics. She needs to continue SBP prophylaxis until her ascites is completely resolved. Problem #3. Iron-deficiency anemia. Patient is to get IV iron q. monthly.
SBP|spontaneous bacterial peritonitis|SBP.|147|150|REASON FOR CONSULTATION|REASON FOR CONSULTATION: We are asked by the hospitalist service and Dr. _%#NAME#%_ to help to evaluate for the need for paracentesis and rule out SBP. PERTINENT PAST MEDICAL HISTORY: Significant for end-stage liver disease secondary to alcohol use and hepatitis C.
SBP|spontaneous bacterial peritonitis|SBP.|251|254|IMPRESSION AND PLAN|The yield on paracentesis at this time would be low given that he has been placed on antibiotics already by the primary admitting physician. I would recommend at discharge that the patient be sent out on SBP prophylaxis, given his previous history of SBP. In addition, he does have one blood culture that was positive.
SBP|spontaneous bacterial peritonitis|SBP.|178|181|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. End-stage liver disease secondary to hep C and alcohol. This has been complicated by: a) Coagulopathy. b) Thrombocytopenia. c) Ascites with a history of SBP. d) Esophageal varices, status post banding in _%#MM#%_ 2006. e) History of hepatic encephalopathy. 2. Type diabetes. 3. GERD. 4. Anemia. 5. PVD.
SBP|spontaneous bacterial peritonitis|SBP,|135|138|PLAN|PLAN: 1. Diagnostic paracentesis to be performed in the a.m. to check for fluid culture, cell count, etc. I doubt that the patient has SBP, most likely the fevers are due to her bronchitis. 2. Dietitian to educate the patient on two liters fluid restriction and 2 grams sodium intake.
SBP|systolic blood pressure|SBP|186|188|MEDICATIONS ON ADMISSION|7. Chronic pain syndrome. MEDICATIONS ON ADMISSION: 1. Prednisone 7.5 mg daily. 2. Coumadin 3. Ditropan 5 twice daily. 4. HCTZ 25 daily 5. Cozaar 50 daily 6. Clonidine 0.2 given only if SBP greater than 180 and not taking 7. Synthroid 0.075 daily 8. Protonix 40 mg daily 9. Multivitamins 10. Oxycodone 10 three times a day preadmission REVIEW OF SYSTEMS: Prior to surgery had no chest pain or congestive heart failure symptoms overtly.
SBP|spontaneous bacterial peritonitis|SBP.|129|132|IMPRESSION AND PLAN|Her abdominal pain is concerning for two reasons; 1)SBP in a patient with cirrhosis and possible ascites should be evaluated for SBP. Will proceed with ultrasound and if there is any evidence of ascites this will be tapped for diagnostic purposes. In addition, she does have a history of gallstones in the past, certainly she is at risk for cholecystitis, stone which could be lodged in her common bile duct.
SBP|systolic blood pressure|SBP|155|157|ASSESSMENT AND PLAN|EKG shows sinus tachycardia. ASSESSMENT AND PLAN: 1. Hypertension, consider pain or agitation as the etiology. Use intravenous hypertensive medications if SBP is greater than 180. Consider oral Norvasc or if no improvement consider Lisinopril as the patient is diabetic. He will have a BNP in the morning to assess his kidney function
SBP|spontaneous bacterial peritonitis|SBP.|114|117|PLAN|Unfortunately the patient has already been started on antibiotics, so we may not be able to ascertain if this was SBP. 3. EUS to be considered in this setting to see if there is any ability to intervene if there is ductal obstruction.
SBP|spontaneous bacterial peritonitis|SBP.|173|176|IMPRESSION|It might have been exacerbated by either dehydration (the patient's BUN and creatinine are elevated) or constipation. There is no evidence for infection, but she might have SBP. I do not see a significant bleed. PLAN: 1. We will cover with antibiotics. 2. Lactulose enemas and oral lactulose. 3. A TIPS is now out of the question in this patient.
SBP|spontaneous bacterial peritonitis|SBP|263|265|PLAN|She certainly does have gallstones, but given her clinical history and her physical findings, I think it is more likely that peritoneal infection is the likely cause of her current symptoms. PLAN: We certainly need to keep a close eye on her symptoms, and as her SBP treatment progresses, I can certainly evaluate if she has ongoing issues related to her right upper quadrant. I explained all of these issues to the patient, as she appears to understand well, and is in agreement with our plan to follow her symptomatology.
SBP|spontaneous bacterial peritonitis|SBP.|244|247|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Cirrhosis secondary to hepatitis B. The patient is currently #3 on the B-positive transplant list. 2. Splenomegaly with previous splenic infarct, chronic abdominal pain secondary to that. 3. Multiple bouts of recurrent SBP. Most recently cultures from _%#MM#%_ showed E. coli and group D enterococcus as well as alpha hemolytic strep. Recent paracentesis performed over the weekend showed no growth. The patient had a VRE UTI in _%#MM2007#%_.
SBP|spontaneous bacterial peritonitis|SBP|167|169|ASSESSMENT  AND PLAN|His lipase is also elevated, suggesting mild pancreatitis. The white count may be somewhat elevated due to hemoconcentration. a. Start Cipro and metronidazole for the SBP and diarrhea. b. Will check C. diff as well. 4. Hypotension. Again, this is mainly related to his hypovolemia, but absolutely cannot rule out sepsis syndrome.
SBP|spontaneous bacterial peritonitis|SBP|201|203|PHYSICAL  EXAMINATION|No recent other intervention has been in order. He had been evaluated at Mayo Clinic in the past. He has apparently also had treatment at Ridges. His course with the liver problem has been complicated SBP In talking to him today on review of systems, he denies to me that he is short of breath.
SBP|spontaneous bacterial peritonitis|SBP|271|273|MEDICALLY|MEDICATIONS: At time of admission include 40 of Lasix in the morning, 20 at night, 50 Aldactone, 20 b.i.d., Inderal, lactulose, vitamins, insulin. PAST MEDICAL HISTORY: Surgeries include thoracoscopy. MEDICALLY: He has been treated for cirrhosis, diabetes, hypertension, SBP GI bleeding. SOCIAL HISTORY: The patient is not a smoker or drinker.
SBP|spontaneous bacterial peritonitis|SBP|123|125|IMPRESSION|I doubt that the TIPS is clotted off in view of the history the family is giving me, but it should be ruled out. A TAP for SBP may be hazardous and might be prudent to cover the patient for this possibility especially with the left shift in her white count.
SBP|spontaneous bacterial peritonitis|SBP|205|207|IMPRESSION AND PLAN|Plan at this time as discussed with Dr. _%#NAME#%_ in the emergency room, the patient has been started and bolused on octreotide and continues at 50 mcg per hour, started on broad-spectrum antibiotics for SBP prophylaxis. We will proceed with upper endoscopy. Risks and benefits are explained at length to the patient. She is agreeable to proceed. Further recommendations pending endoscopy results.
SBP|spontaneous bacterial peritonitis|SBP|173|175|RECOMMENDATIONS|RECOMMENDATIONS: 1. EGD. 2. n.p.o. 3. Start Octreotide with a bolus of 50 mcg and followed by 50 mcg per hour for 2-3 days. 4. Protonix 40 mg IV b.i.d. 5. Start spontaneous SBP prophylaxis. 6. Monitor INR and platelets. 7. Further recommendations after the upper endoscopy. PROBLEM #2: End-stage liver disease secondary to alcohol. Because of recent endocarditis, the patient is deactivated on the liver.
SBP|spontaneous bacterial peritonitis|SBP|134|136|ASSESSMENT AND PLAN|Had worsening encephalopathy. At this time we agree with continuing with lactulose to have 4-5 bowel movements. Levaquin for possible SBP although if needed the patient should have paracentesis to further evaluate it. Based on low blood pressure one can consider stopping nadolol.
SBP|spontaneous bacterial peritonitis|SBP.|154|157|HISTORY OF PRESENT ILLNESS|He apparently fell on the day of admission because he was so weak. He recently had been started on levofloxacin by his primary care probably for possible SBP. In questioning the patient, he has had some chronic abdominal pain. Denies hematemesis or vomiting at all. Denies black stools. Denies bright red blood per rectum.
SBP|spontaneous bacterial peritonitis|SBP|181|183|PLAN|The Transplant coordinator should also see the patient in evaluation. 3. Medical treatment of acute liver failure. The patient should be put on a third generation cephalosporin for SBP prophylaxis. The patient should be put on a PPI drip for prophylaxis. There is no need at this point to start lactulose for his encephalopathy.
SBP|systolic blood pressure|SBP|220|222|ASSESSMENT/PLAN|7. Prenatal vitamin. LABORATORY: Sodium 141, potassium 3.9, chloride 108, BUN 25, glucose 103, creatinine 0.93, BUN 22, hemoglobin 14.3. ASSESSMENT/PLAN: 1. Hypertension. The patient will continue atenolol, notify MD if SBP is greater than 220 or diastolic blood pressure is greater than 130. Only notify MD if blood pressure is greater than 180 and patient has symptoms of headache or visual disturbance.
SBP|spontaneous bacterial peritonitis|SBP|163|165|ASSESSMENT AND PLAN|2. Hepatic encephalopathy, likely multifactorial: Recent urinary infection and now worsening hyponatremia are likely contributing factors. There is no evidence of SBP at the outside hospital. At this time, recommendation is to continue with lactulose aggressively to have 5-6 bowel movements, continue with rifaximin and Zinc sulfate (this was started while patient was in the hospital 2 days back), and correction of electrolytes.
SBP|spontaneous bacterial peritonitis|SBP|139|141|PLAN|11. Prophylaxis. The patient should be maintained on PPI given that he has a history of upper GI bleeds. 12. The patient should also be on SBP prophylaxis. I have discussed this patient with Dr. _%#NAME#%_ _%#NAME#%_ and he has participated in the decision making process.
SBP|spontaneous bacterial peritonitis|SBP.|134|137|ASSESSMENT|4. Abdominal distention and rule out acute abdomen plus minus ileus. 5. Ischemic lower extremities. 6. Leukocytosis. Rule out sepsis, SBP. 7. Respiratory failure 8. Decreased urine output. The patient presents with multiple organ failure.
SBP|spontaneous bacterial peritonitis|SBP;|242|245|OPERATIONS/PROCEDURES PERFORMED|7. Diagnostic paracentesis (_%#MM#%_ _%#DD#%_, 2004): No evidence for spontaneous bacterial peritonitis; fluid is transudate. 8. Diagnostic and therapeutic large volume paracentesis of ascites (_%#MM#%_ _%#DD#%_, 2004): Again, no evidence of SBP; fluid is transudative; 5760 mL of ascites fluid removed without complication. 9.EEG (_%#MM#%_ _%#DD#%_, 2004): Performed to evaluate mental status changes.
SBP|spontaneous bacterial peritonitis|SBP.|254|257|PROBLEM #3|She had multiple imaging studies during her hospital stay. Her most recent abdominal CT on _%#MMDD2003#%_ showed unremarkable liver, spleen, pancreas, and adrenal glands. There was a moderate amount of ascites, which had been tapped and was negative for SBP. Kidneys were normal except for extra-renal pelvis on the left. There was some mild sludge in her gallbladder. There was no abdominal wall thickening or dilatation of the small or large bowel.
SBP|spontaneous bacterial peritonitis|SBP.|188|191|PAST MEDICAL HISTORY|He has hemodialysis on Monday, Wednesday, and Friday. 3. History of ascites, recurrent. 4. History of heparin-induced thrombocytopenia. 5. History of hepatic encephalopathy. 6. History of SBP. 7. History of GI bleed secondary to portal gastropathy treated with cauterization. 8. History of endocarditis and coagulase negative Staph. 9. History of septic shock.
SBP|spontaneous bacterial peritonitis|SBP.|414|417|HISTORY OF PRESENT ILLNESS|6. End stage liver disease. HISTORY OF PRESENT ILLNESS: This is a 57-year-old male with history of end stage renal disease secondary to hypertension status post rejected renal transplant times two and end stage liver disease secondary to hepatitis C, with previous history of spontaneous bacteria peritonitis, who was recently discharged from Fairview University on _%#MM#%_ _%#DD#%_ 2002, secondary to episode of SBP. He presented again on the day of admission with some diffuse abdominal pain, temperature to 100.3, continued poor oral intake and was transferred to FUMC for mental status changes and fever work-up.
SBP|spontaneous bacterial peritonitis|SBP|158|160|ASSESSMENT AND PLAN|We will obtain serial hemoglobins. We will transfer her for a hemoglobin of 9. Given her ascites and her bleed, she will need 7 days of a fluoroquinolone for SBP prophylaxis. She will receive vitamin K. We will obtain a followup INR. No NSAIDs, heparin products or aspirin product, an order will be put in place.
SBP|spontaneous bacterial peritonitis|SBP,|203|206|ASSESSMENT AND PLAN|He also has associated coagulopathy. There may be a nutrition component, but I suspect this is solely related to his liver disease. He does not have renal failure and there appears to be no evidence for SBP, though he has been bleeding; he may have some degree of ascites and it may be prudent to have him on a fluoroquinolone for SBP prophylaxis.
SBP|spontaneous bacterial peritonitis|SBP|199|201|ASSESSMENT AND PLAN|He does not have renal failure and there appears to be no evidence for SBP, though he has been bleeding; he may have some degree of ascites and it may be prudent to have him on a fluoroquinolone for SBP prophylaxis. If there is ascites present on abdominal ultrasound, we could consider paracentesis. He may require a liver biopsy and I suspect, and upper endoscopy to evaluate varices or degree of varices to evaluate for underlying ulcers.
SBP|systolic blood pressure|SBP|152|154|DISCHARGE MEDICATIONS|9. Fluphenazine 50 mg p.o. b.i.d. 10. Lamictal 25 mg p.o. each day at bedtime. 11. Synthroid 75 mcg p.o. daily. 12. Lisinopril 5 mg p.o. daily, hold if SBP less than 90. 13. Mirtazapine dissolve tabs 45 mg p.o. each day at bedtime. 14. Zyprexa 20 mg p.o. daily. 15. Protonix 40 mg p.o. daily.
SBP|spontaneous bacterial peritonitis|SBP|140|142|DISCHARGE MEDICATIONS|9. Prevacid 30 mg p.o. b.i.d. 10. Tylenol 650 mg p.o. q.6h. p.r.n. pain with a max of 2 g per day. 11. Ciprofloxacin 750 mg p.o. weekly for SBP prophylaxis. The patient should take this on Fridays. 12. Zinc sulfate 220 mg p.o. b.i.d. 13. Oxycodone 5-10 mg p.o. q.6h. p.r. n. for pain.
SBP|spontaneous bacterial peritonitis|SBP|358|360|PROBLEMS|Since, according to the patient's daughter and according to the transplant care coordinator, the patient was more agitated and belligerent than what she is usually, even when she has exacerbation of her apathic encephalopathy, we decided to perform a more detailed work which included CT which was negative and diagnostic paracentesis which was negative for SBP and did not show any infection of the ascitic fluid. 2. UTI. From the previous admission, she had a urinary tract infection, and she was started on gatifloxacin to complete a 5-day course.
SBP|systolic blood pressure|SBP|134|136|HISTORY OF PRESENTING COMPLAINT|He did not appear to have any disorientation or any seizure activity. When the rescue squad arrived at 6:10 p.m., he apparently had a SBP of 99 and HR 44 later on blood pressure 107/76, pulse 84, respiratory rate 14, oxygen saturation 97%, and blood sugar was 142.
SBP|systolic blood pressure|SBP|66|68|HISTORY OF PRESENTING COMPLAINT|He did not seem to have any irregular heart rhythm. In the ER his SBP drop by ten points with standing SBP 139 to 129 and his heart increased by ten points. No alcohol this evening. PAST MEDICAL HISTORY: 1. Syncope, for which the patient has had an event monitor on for the month of _%#MM#%_, and he has had four syncopal episodes over the last year with apparently this one being his fourth.
SBP|spontaneous bacterial peritonitis|SBP|199|201|ASSESSMENT AND PLAN|We will work her up with for cirrhosis, including ANA, hepatitis A, B and C serologies, mitochondrial antibody, Tylenol level, ferritin, ceruloplasmin, etc. She will undergo paracentesis to rule out SBP and for cytology and further studies to evaluate for portal hypertension. She will undergo abdominal ultrasound to further characterize the liver and for Doppler flows of hepatic portal veins.
SBP|spontaneous bacterial peritonitis|SBP.|257|260|ASSESSMENT AND PLAN|She will undergo abdominal ultrasound to further characterize the liver and for Doppler flows of hepatic portal veins. Will check coagulation studies and treat for spontaneous bacterial peritonitis. Her low-grade fever and abdominal pain could certainly be SBP. She has a penicillin allergy, will treat with fluoroquinolone and Flagyl. If she does not respond or clinically deteriorates, we will need to cover enterococcus.
SBP|spontaneous bacterial peritonitis|SBP|232|234|ASSESSMENT AND PLAN|She should see either University gastroenterology or arrangements through her primary care clinic to have this paracentesis done. She will continue at this time on her Lasix, her Aldactone and her lactulose as well as rifaximin for SBP prophylaxis. 2. History of pneumothorax, which required initially chest tube treatment and eventually a VATS with anterior wedge resection procedure.
SBP|spontaneous bacterial peritonitis|SBP.|362|365|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 53-year-old male with past medical history significant for cirrhosis secondary to alcohol use, ascites, most prominent since _%#MM2007#%_ and a history of gastric varices and upper GI bleeding, who was initially admitted to the hospital on _%#MMDD2007#%_ after he had a large volume paracentesis and suspicion for SBP. He was transferred to the MICU for the first time on _%#MMDD2007#%_ with complaints of respiratory distress and was discovered to have a large bilateral pneumonia.
SBP|spontaneous bacterial peritonitis|SBP:|160|163|HOSPITAL COURSE|While we never identified a pathogen on sputum, we wanted to cover him for community-acquired pneumonia versus hospital-acquired pneumonia versus atypicals. b. SBP: On the patient's initial admission to the hospital on _%#MMDD#%_, he began a treatment course for SBP. His peritoneal fluids from that day showed 387 nucleated cells, 56% of which were neutrophils.
SBP|spontaneous bacterial peritonitis|SBP.|263|266|HOSPITAL COURSE|While we never identified a pathogen on sputum, we wanted to cover him for community-acquired pneumonia versus hospital-acquired pneumonia versus atypicals. b. SBP: On the patient's initial admission to the hospital on _%#MMDD#%_, he began a treatment course for SBP. His peritoneal fluids from that day showed 387 nucleated cells, 56% of which were neutrophils. The patient also had abdominal pain at that time. He was treated from _%#MMDD#%_-_%#MMDD#%_ with cefotaxime and was then covered with Zosyn until _%#MMDD#%_.
SBP|spontaneous bacterial peritonitis|SBP|310|312|PROBLEM #3|PROBLEM #3: Leukocytosis. Differential includes spontaneous bacterial peritonitis, cholecystitis, urinary tract infection, abdominal abscess, skin, or soft tissue infection. In this patient the most likely diagnoses would be either spontaneous bacterial peritonitis or cholecystitis. The patient was receiving SBP prophylaxis prior to transfer, however, she did not receive a paracentesis at the outside hospital. Again will plan for ultrasound guided paracentesis to evaluate for SBP.
SBP|spontaneous bacterial peritonitis|SBP.|197|200|PROBLEM #3|The patient was receiving SBP prophylaxis prior to transfer, however, she did not receive a paracentesis at the outside hospital. Again will plan for ultrasound guided paracentesis to evaluate for SBP. Will also obtain urinalysis, urine culture, and blood cultures. We will hold on antibiotic treatment at this time as the patient is afebrile and appears to be stable from a medical standpoint.
SBP|spontaneous bacterial peritonitis|SBP|145|147|HISTORY OF PRESENT ILLNESS|She was originally diagnosed with primary biliary cirrhosis in 2002. She has had a waxing and waning course involving encephalopathy, as well as SBP and chronic renal insufficiency secondary to hepatorenal syndrome. She had a history of intractable ascites that was requiring frequent paracentesis.
SBP|spontaneous bacterial peritonitis|SBP|236|238|PAST MEDICAL HISTORY|1. Recurrent ascites requiring repeat paracentesis, currently stable. 2. Varicose vein surgery. 3. Tubal ligation. 4. Anemia of chronic disease. 5. Recurrent urinary tract infection (VRE). 6. Hypothyroidism (on replacement therapy). 7. SBP prophylaxis (currently on rifaximin and ciprofloxacin weekly). 8. Hepatic encephalopathy (currently stable on low-dose lactulose). Her last serum ammonia level was 12, at the time of hospital admission.
SBP|spontaneous bacterial peritonitis|SBP.|135|138|ASSESSMENT AND PLAN|Will also investigate other causes of her altered mental status including infection. Due to her recent paracentesis she is at risk for SBP. We will perform a diagnostic tap while she is an inpatient and start antibiotics if this shows signs of SBP. There are no other concerning medications for these mental status changes on the patient's list but we will also obtain a urine toxicology screen and blood cultures.
SBP|spontaneous bacterial peritonitis|SBP|235|237|PROBLEM #3|The patient does have a history of a retroperitoneal bleed, and it was felt that this may be contributing to it. The patient at this time is on SBP prophylaxis with ciprofloxacin. All of her taps besides being bloody were negative for SBP during the hospitalization. The patient does not have history of SBP outside per patient and her fiance. The patient will continue to need a paracentesis done every 4-7 days depending on her discomfort.
SBP|systolic blood pressure|SBP|159|161|PLAN|6. The patient is a full code. He is medically optimized to go to the operating room, pending results of lipase. [ADDENDUM Lipase only 95 so ok for OR. Expect SBP to run low 90's. HR 50 to 60's
SBP|systolic blood pressure|SBP|263|265|3. CV|She remained on pressor support for 3 days post-operatively. A repeat echocardiogram post op showed 3 small VSD's and one 4-5mm VSD with a 8 mmHg gradient across the coarctation. Enalapril was started on POD #1 for hypertension and discontinued after 9 days when SBP was <85. Repeat echo on DOL 30 showed mild bilateral brachial pulmonary stenosis and 23 mmHg gradient across the coarctation repair.
SBP|spontaneous bacterial peritonitis|SBP.|143|146|HOSPITAL COURSE|The patient had just completed a two week course of Levaquin for cellulitis prior to admission. Paracentesis was performed without evidence of SBP. In addition, the patient probably has underlying renal failure, likely type 2 hepato-renal syndrome. After three days of continuous hemodialysis, the patient was transferred to the general ward.
SBP|spontaneous bacterial peritonitis|SBP.|216|219|HOSPITAL COURSE|All diuretics were discontinued and were not restarted. The patient's creatinine stabilized at 2.6. 2. End stage liver disease secondary to alcoholic cirrhosis. There was no evidence of hepatic encephalopathy and no SBP. The patient continued to receive Lactulose to achieve three to four bowel movements per day. Because of the acute renal failure, the patient was not given any diuretics during this hospital stay.
SBP|spontaneous bacterial peritonitis|SBP|314|316|PROBLEM #2|Patient also had abdominal supine and upright x-rays on _%#MM#%_ _%#DD#%_, 2002, to evaluate for possible small-bowel obstruction, which was negative, but the x-rays reveal an obstructive bowel-gas pattern. Patient was continued on ceftriaxone 2 g IV q.24h. upon discharge and ciprofloxacin 500 mg p.o. b.i.d. for SBP prophylaxis. Patient also to continue taking lactulose 30 cc p.o. q.d. p.r.n. Patient to follow up with primary doctor, Dr. _%#NAME#%_, and _%#COUNTY#%_ Walker Clinic in 1 week, who will be adjusting her antibiotic needs.
SBP|spontaneous bacterial peritonitis|SBP|276|278|HOSPITAL COURSE|Gram's stain negative with a normal glucose. HOSPITAL COURSE: PROBLEM #1: GI: The patient received a therapeutic and diagnostic peritoneal tap with 5.8 liters of fluid withdrawn and replaced with 25% albumin. The patient tolerated the procedure well. There was no evidence of SBP and symptomatically the patient was improved. Optimization of his medical management of his end-stage renal disease was attempted by increasing his spironolactone to 100 mg b.i.d. as well as increasing his Lasix to 120 mg p.o. b.i.d. The patient's lower extremity edema improved over the course of the hospitalization.
SBP|spontaneous bacterial peritonitis|SBP.|217|220|HISTORY OF PRESENT ILLNESS|Encephalopathy and three renal azotemia, C-difficile colitis, hyponatremia, malnutrition was other issues that the patient was challenged with both cognitively and functionally. She is also on antibiotic Levaquin for SBP. After medical stabilization she was transferred to DCU at _%#CITY#%_ where she underwent PT/OT b.i.d., as well as Speech Therapy.
SBP|spontaneous bacterial peritonitis|SBP,|252|255|PROBLEM #3|PROBLEM #3: Aneutrophilic bacterascites. The patient had a paracentesis on _%#MMDD2004#%_ which had a negative gram stain, but a positive culture. The patient also had symptomatic abdominal pain. For this reason, he was treated with Zosyn for possible SBP, although his labs were not completely consistent with this. The diagnosis per GI is aneutrophilic bacterascites. The patient will complete a seven day course of antibiotics.
SBP|spontaneous bacterial peritonitis|SBP|270|272|ASSESSMENT|There are blood and urine cultures pending at this time, and we will do a diagnostic paracentesis at the bedside in order to rule out SBP as a possible etiology. While we await the results of the SA fluid studies, we will start her empirically on antibiotic therapy for SBP with Cefotaxime. We will continue her doses of Lactulose and Rifaximin and ensure that she is having an adequate number of bowel movements while she is here in the hospital.
SBP|spontaneous bacterial peritonitis|SBP|121|123|PROCEDURES PERFORMED DURING THIS ADMISSION|1. Therapeutic and diagnostic paracentesis performed on _%#MMDD2007#%_ with removal of 6 liters of fluid, no evidence of SBP and cultures negative to date. 2. CT of the head done on _%#MMDD2007#%_ showed no evidence of acute disease. 3. Dobutamine stress echo done on _%#MMDD2007#%_. Interpretation shows that the patient failed to achieve heart rate that was targeted despite the use of dobutamine and atropine.
SBP|spontaneous bacterial peritonitis|SBP|171|173|BRIEF HISTORY OF PRESENT ILLNESS|Because of this, he has decided to had to come to the emergency room for further evaluation. In the ERER, he was thought to have a possible small bowel obstruction versus SBP and was admitted to the General Oliynyk Medical Service for further care. Please see the admission H&P for further information of the patient's presenting symptoms, past medical history, family history, social history and admission physical exam.
SBP|spontaneous bacterial peritonitis|SBP.|211|214|HOSPITAL COURSE|Please see the admission H&P for further information of the patient's presenting symptoms, past medical history, family history, social history and admission physical exam. HOSPITAL COURSE: PROBLEM #1: Probable SBP. The patient has a history of recurrent SBP and is on prophylactic medicines. MMedications at home, j Just prior to this admission, he had been on leave levofloxacin 750 mg p.o. weekly.
SBP|spontaneous bacterial peritonitis|SBP|255|257|HOSPITAL COURSE|Please see the admission H&P for further information of the patient's presenting symptoms, past medical history, family history, social history and admission physical exam. HOSPITAL COURSE: PROBLEM #1: Probable SBP. The patient has a history of recurrent SBP and is on prophylactic medicines. MMedications at home, j Just prior to this admission, he had been on leave levofloxacin 750 mg p.o. weekly.
SBP|systolic blood pressure|SBP|252|254|ATTENDING ADDENDUM|I. Acute renal failure. Differential diagnosis includes: A. Pre-renal. 1. Decreased cardiac output due to potential CHF corroborated by elevated BNP. Hold diuretics now. Check TEE for change in LV function. Likely needs better afterload reduction. Aim SBP approximately 100 with nitrate and hydralazine in setting of elevated creatinine. Will consult Cardiology after TEE. 2. Third spacing with decreased intravascular volume.
SBP|spontaneous bacterial peritonitis|SBP.|260|263|SUMMARY|SUMMARY: This is a 48-year-old female well known to this service because she has had two recent admissions in the last two weeks, first for thoracentesis of a symptomatic right pleural effusion and the second for nausea and vomiting, during which we ruled out SBP. She is now admitted _%#MM#%_ _%#DD#%_, 2002, the night prior to TIPS procedure arranged by Dr. _%#NAME#%_ through Dr. _%#NAME#%_. Since her last discharge, the patient states she has continued to have a bit of nausea at home.
SBP|spontaneous bacterial peritonitis|SBP|202|204|HOSPITAL COURSE|A diagnostic paracentesis was performed at bedside. Fluid sent for studies. There was no evidence of spontaneous bacterial peritonitis. The patient was restarted on ciprofloxacin 750 mg p.o. weekly for SBP prophylaxis. He was continued on his rifaximin and lactulose. An additional concern was his increased lower extremity edema and general anasarca.
SBP|systolic blood pressure|SBP|132|134|DISCHARGE MEDICATIONS|6. Therapeutic paracentesis, as needed. DISCHARGE MEDICATIONS: 1. Lactulose 13 mL p.o. t.i.d. 2. Lasix 40 mg p.o. each day; hold if SBP less than 100. 3. Spironolactone 100 mg p.o. each day; hold if SBP less than 100. 4. Voriconazole 250 mg p.o. b.i.d. for 4 weeks, to be completed _%#MMDD2004#%_.
SBP|systolic blood pressure|SBP|199|201|DISCHARGE MEDICATIONS|6. Therapeutic paracentesis, as needed. DISCHARGE MEDICATIONS: 1. Lactulose 13 mL p.o. t.i.d. 2. Lasix 40 mg p.o. each day; hold if SBP less than 100. 3. Spironolactone 100 mg p.o. each day; hold if SBP less than 100. 4. Voriconazole 250 mg p.o. b.i.d. for 4 weeks, to be completed _%#MMDD2004#%_. 5. Vancomycin 1 g IV q48h. 6. Magnesium oxide 400 mg p.o. b.i.d.
SBP|systolic blood pressure|SBP|312|314|PROBLEM #1|We will start lactulose to decrease his ammonia levels. If his mental status does not clear with lactulose administration in the morning we will delay paracentesis of the abdomen looking for SBP. Currently he is afebrile, he does not have an elevated white count and no abdominal tenderness, so my suspicion for SBP is low. The patient had been unable to tolerate lactulose at home due to nausea and vomiting, therefore, we will administer this with Compazine.
SBP|spontaneous bacterial peritonitis|SBP,|176|179|INFECTIOUS DISEASE|His tube feeds will be adjusted for a low sodium given his liver failure. INFECTIOUS DISEASE: Patient had occasional low-grade temperature. No clear evidence for infection. No SBP, no pneumonia. His urinalysis showed MSSA which is likely a contaminant, sensitive to Levaquin. He did receive several doses of Levaquin. DISCHARGE INSTRUCTIONS: Physical therapy, occupational therapy consult, no NSAIDS, no aspirin, advanced directives, DNR/DNI.
SBP|spontaneous bacterial peritonitis|SBP.|175|178|PROBLEM #2|The inguinal hernia was reducible and there is no evidence of bowel ischemia. The patient did undergo paracentesis x3 during his hospital stay, all of which were negative for SBP. He will likely need scheduled paracentesis until his transplant. The Transplant Team did follow the patient while inhouse and most of his transplant workup was completed including his chest CT and bone scan, however, he will need to follow up with his primary urologist regarding his extensive prostate cancer history for pretransplant clearance.
SBP|spontaneous bacterial peritonitis|SBP|299|301|PROBLEM #3|Review of his medications did show case studies of also medications causing pancytopenia, but most of which the patient needs to be on including his prostate cancer therapy, the Lupron and Casodex. The patient was started on both doxepin and ciprofloxacin during this hospital stay for pruritus and SBP prophylaxis respectively, so thought it was most reasonable to discontinue both of these in case they were contributing to the patient's decreased cell counts.
SBP|spontaneous bacterial peritonitis|SBP|171|173|DISCHARGE MEDICATIONS|2. Morbid obesity, status post gastric bypass. 3. Alcoholism. 4. Possible sleep-related breathing disorder. DISCHARGE MEDICATIONS: 1. Ciprofloxacin 750 mg once weekly for SBP prophylaxis. 2. Propanolol LA 60 mg p.o. q.h.s. for primary prevention of GI bleed. 3. Spironolactone 100 mg p.o. q.d. 4. Multivitamin one tablet p.o. q.d.
SBP|spontaneous bacterial peritonitis|SBP.|273|276|HOSPITAL COURSE|The patient did have crisper mentation, receiving lactulose 20 ml q.i.d. Care of this patient with end-stage liver disease included propanolol LA 60 mg p.o. q.d. for primary prevention of GI bleed, as well as ciprofloxacin 750 mg p.o. once weekly for primary prevention of SBP. Serologies for hepatitis A, B, and C were negative. The patient was vaccinated on _%#MMDD2003#%_ for hepatitis A, the first dose, with a booster dose at six months.
SBP|spontaneous bacterial peritonitis|SBP.|137|140|HISTORY OF PRESENT ILLNESS|No gross bleeding per family history. Head CT was unremarkable. He was admitted to the Intensive Care Unit. He was given antibiotics for SBP. According the family, he has denied any recent specific complaints of fevers, chills, though he has felt "cold," nausea, vomiting, diarrhea, bloody stools, hemoptysis, hematemesis.
SBP|spontaneous bacterial peritonitis|SBP.|131|134|ASSESSMENT AND PLAN|No NSAIDs, heparin products. He will undergo a diagnostic paracentesis, and he is getting cefotaxime 2 grams IV q.12h for possible SBP. We will follow up these tests later today. His acute renal failure may also be contributing to his hepatic encephalopathy.
SBP|spontaneous bacterial peritonitis|SBP|193|195|DISCHARGE MEDICATIONS|CONSULTANTS: 1. Gastroenterology, Dr. _%#NAME#%_. 2. Nephrology Dr. _%#NAME#%_. DISCHARGE MEDICATIONS: 1. Cipro 750 mg once a day until _%#MMDD#%_ for SBP. 2. Cipro 750 mg p.o. once a week for SBP prophylaxis. 3. Lasix 40 mg p.o. b.i.d. 4. Spironolactone 100 mg p.o. b.i.d. 5. Potassium chloride 40 mEq once a day. 6. Anusol cream applied to anal twice a day as needed.
SBP|spontaneous bacterial peritonitis|SBP|233|235|HOSPITAL COURSE|After an extensive workup for intrinsic causes of renal failure and review of the patient's history, the nephrology service felt that failure was most likely secondary to ciprofloxacin, which had been started several weeks prior for SBP prophylaxis. The nephrology service recommended supportive care. Over the course of her hospital stay, Ms. _%#NAME#%_'s creatinine continued to trend downward and her urine output increased.
SBP|spontaneous bacterial peritonitis|SBP|144|146|ASSESSMENT/PLAN|We will add Nystatin powder to this for management purposes. 6. Deconditioning debility: Physical and occupational therapy will be provided. 7. SBP prophylaxis: The patient is currently on Levaquin and will continue on this medication until surgical evaluation.
SBP|spontaneous bacterial peritonitis|SBP.|385|388|ASSESSMENT AND PLAN|We will monitor his mental status during his hospitalization. We will continue his spironolactone and Lasix for his history of ascites and we will consult with transplant GI for possible need of propanolol for esophageal variceal prophylaxis. After his paracentesis we will add ciprofloxacin 500 mg p.o. b.i.d. as prophylaxis due to his acute liver failure decompensation for possible SBP. 2. Hyponatremia significantly to 117: Likely chronic with no acute symptoms noted at this time though history is clouded with a possible history of hepatic encephalopathy.
SBP|spontaneous bacterial peritonitis|SBP|151|153|IMPRESSION AND PLAN|In addition, I also consider infectious etiologies. Chest CT scan shows ground glass opacities concerning for pneumonia. Also, consider something like SBP given his possible ascites. I will order an ultrasound to be performed tomorrow with paracentesis of ascites is present and send off the fluid to evaluate for infectious etiologies.
SBP|spontaneous bacterial peritonitis|SBP|160|162|PAST MEDICAL HISTORY|The patient is being evaluated by University of Minnesota Medical Center, Fairview, for pretransplant evaluation. According to the patient he has no history of SBP but did have a recent bout of hepatic encephalopathy for which he was on xifaxin and lactulose. He is on SBP prophylaxis with cipro q weekly.
SBP|spontaneous bacterial peritonitis|SBP.|143|146|PAST MEDICAL HISTORY|He receives hemodialysis through a tunneled Hickman three times a week. 2. End-stage liver disease secondary to hepatitis C, with a history of SBP. He was considered not a TIPS candidate secondary to his renal disease. 3. Diabetes mellitus secondary to prednisone. 4. History of DVT, status post IVC filter placement.
SBP|spontaneous bacterial peritonitis|SBP|201|203|MEDICATIONS|He was also found to have acute renal failure with a creatinine up to 3.57, when his baseline is 1.2 to 1.5. ALLERGIES: Codeine - he gets a rash. MEDICATIONS: 1. Ciprofloxacin 750 mg p.o. q. week (for SBP prophylaxis). 2. Lactulose 35 cc p.o. q.i.d. 3. Folate 1 mg p.o. daily. 4. Lasix 20 mg p.o. daily. 5. Mirtazepine 15 mg p.o. q.h.s.
SBP|spontaneous bacterial peritonitis|SBP.|163|166|IMPRESSION|The patient's symptoms may be from hepatic dysfunction with elevated ammonia level. Again, I do not think this is likely to be the case. It clinically is not from SBP. PLAN: 1. Hospitalize the patient. 2. For acute renal failure: I agree with giving the patient insulin and calcium chloride as well as fluid bolus here in the ER.
SBP|spontaneous bacterial peritonitis|SBP|270|272|PROBLEM #4|PROBLEM #4: Ascites and pleural effusion. The patient has had ascites present, which was drained at the time when the patient had the G-tube placement and then was also drained later on as well. About three and a half liters were taken off. There was no evidence of any SBP pres ent. The patient though has been started off on SBP prophylaxis with ciprofloxacin 750 mg p.o. or G-tube q.weekly. The patient will continue on this.
SBP|spontaneous bacterial peritonitis|SBP|132|134|PROBLEM #4|About three and a half liters were taken off. There was no evidence of any SBP pres ent. The patient though has been started off on SBP prophylaxis with ciprofloxacin 750 mg p.o. or G-tube q.weekly. The patient will continue on this. It was noted on previous CT scan that the patient does have pleural effusions present.
SBP|spontaneous bacterial peritonitis|SBP.|347|350|IMPRESSION|IMPRESSION: This patient has hepatitis B liver disease with cirrhosis, but what has changed now is he has developed decompensation of his cirrhosis with ascites, reduced hepatic synthetic function and an elevated pneumonia. Looking at a cause of the problem, it could be related to his treatment for pneumonia, i.e. superimposed infection such as SBP. Another possible underlying factor would be gallstone pancreatitis, since he does have pancreatitis, and according to his history, has not had significant alcohol intake.
SBP|spontaneous bacterial peritonitis|SBP,|235|238|ASSESSMENT/PLAN|ASSESSMENT/PLAN: The patient is a 52-year-old female with multiple medical issues, including end-stage liver disease secondary to autoimmune hepatitis, with sequelae of liver disease, including portal hypertension, ascites, history of SBP, peripheral edema, pancytopenia, and coagulopathy. She has currently been hospitalized for a left frontal lobe mass which is found to be brain abscess, although no organisms have grown.
SBP|spontaneous bacterial peritonitis|SBP|170|172|ASSESSMENT/PLAN|It is not clear when this was placed. 2. Portal hypertension with esophageal varices status post a GI bleed in _%#MM2006#%_. He has been on a beta-blocker. 3. History of SBP maintained in Cipro for prophylaxis. 4. Question of hepatic encephalopathy, but he has not been on anything previously. 5. Renal failure. The etiology and duration of this is unclear, but it seems to have been for less than a month.
SBP|spontaneous bacterial peritonitis|SBP.|130|133|RECOMMENDATIONS|She does have good drug coverage. 3. The patient does have a low-grade temps and I agree with the use of covering antibiotics for SBP. 4. Long-term followup with Dr. _%#NAME#%_ regarding these issues.
SBP|spontaneous bacterial peritonitis|SBP.|214|217|HISTORY OF PRESENT ILLNESS|This patient has had a complicated medical course. He was diagnosed with acute kidney insufficiency with a creatinine level of 5.45. After admission, he had a paracentesis. His peritoneal tap showed no evidence of SBP. He was on antibiotics. The following day he had a dobutamine stress echocardiogram as part of his transplant workup. The patient also became significantly hypotensive after his paracentesis the day of admission.
SBP|spontaneous bacterial peritonitis|SBP|282|284|ASSESSMENT/PLAN|1. Pain: According to the patient's husband, her pain responds quite well to Ativan but is also receiving Dilaudid PCA. It is difficult to assess how much of the pain may be due to muscle stiffness from lying in bed versus some type of possible bony pain versus abdominal pain from SBP versus abdominal pain from stretching of the liver and spleen capsules versus anxiety enhanced pain due to shortness of breath and being severely ill.
SBP|spontaneous bacterial peritonitis|SBP|164|166|HOSPITAL COURSE/PROBLEMS|Based on previous hospitalizations, the patient has normal mental status only when her ammonia is less than 10. A diagnostic paracentesis was performed to rule out SBP as a cause of the patient's encephalopathy. Fluid demonstrated only 14 nucleated cells and was therefore not consistent with SBP. Blood cultures, urine cultures, and chest x-ray were also obtained to evaluate for infection and were all unremarkable.
SBP|spontaneous bacterial peritonitis|SBP|196|198|PROBLEM #2|Because of this, he was started on levofloxacin 500 mg x 1 and then 250 mg daily x 10 days. He was also advised to stop his Bactrim for the time that he is on the levofloxacin. The Bactrim is for SBP prophylaxis. FOLLOW-UP: The patient tolerated the procedure well.
SMA|superior mesenteric artery|SMA|138|140|BRIEF HISTORY AND HOSPITAL COURSE|She will likely be intolerant of Ace inhibitors in the future. She does seem to have significant peripheral arterial disease including an SMA thrombosis also. 4. Hypothyroidism, she was resumed on Synthroid since she is she has been here. 5. Urinary tract infection. Her urine culture did demonstrate some significant pyuria with 20 white cells.
SMA|superior mesenteric artery|SMA|173|175|PAST MEDICAL HISTORY|ALLERGIES: No known drug allergies. SOCIAL HISTORY: History of 60 pack year history of tobacco, but she quit 30 years ago. No alcohol. PAST MEDICAL HISTORY: End stage COPD, SMA insufficiency/stenosis, chronic constipation, PVD, peripheral vascular disease, status post appendectomy, and status post right hip replacement. ADMISSION PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.3; pulse 83; blood pressure 162/68; respiratory rate 18; oxygen saturation at 95% on room air.
SMA|smooth muscle actin|SMA|185|187|PLAN|Will check an iron level as well as ceruloplasmin. Will check blood cultures times two. Will empirically cover the patient with Rocephin. Will check a Coombs antibody, FANA, as well as SMA antibodies. Will check a peripheral blood smear. Will have the patient started on daily INR's. Will recheck for comprehensive panel as well as a CBC in the morning.
SMA|superior mesenteric artery|SMA|272|274|HISTORY OF PRESENT ILLNESS|Ultrasound ankle, arm, index obtained in this hospitalization with segmental pressures stated that this was a nondiagnostic study due to his noncompressible vessels. MRI of his bilateral lower extremities, MRA with contrast showed aorta is patent and tortuous. The celiac SMA and IMA were just patent. There was a bilateral single renal artery and no origin stenosis was identified. In summary, the impression was that there was a limited study due to venous flow contamination.
SMA|sequential multiple autoanalyzer|SMA|171|173|FOLLOW UP|14. Ferrous sulfate 325 mg p.o. once a day. FOLLOW UP: The patient will follow up in with Dr. _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2005. The patient will have CBC, SMA 10 and Prograf level checked before clinic appointment with Dr. _%#NAME#%_. The patient will also follow up with the urology clinic in 2 weeks' time and prior to the visit, the patient will have CT abdominal renal protocol without contrast to look for ureteric stone.
SMA|superior mesenteric artery|SMA|223|225|HOSPITAL COURSE|ALLERGIES: THE PATIENT HAS NO KNOWN DRUG ALLERGIES. HOSPITAL COURSE: The patient was admitted and initially evaluated by the internal medicine team. She has had at that time full radiographic workup. This revealed that the SMA syndrome was persisting, causing her pain as well as some nausea and vomiting. General surgery consult was eventually obtained. The patient was eventually taken to the operating room for laparoscopic duodenojejunostomy.
SMA|superior mesenteric artery|SMA,|131|134|DATA|There is a right inguinal hernia which is probably the cause of the obstruction. Extensive calcification of the aorta in origin of SMA, a 2 cm left renal lesion, presumably a cyst. Sodium 136, potassium 3.5, chloride 97, bicarbonate 25, BUN 19, creatinine 1.1, glucose 175, protein 8.4, albumin 3.8, alkaline phosphatase 74, ALT 14, AST 23, bilirubin 1.0, calcium 9.3. White count 17.5, hemoglobin 13.0, platelet count 393,000, with 82% neutrophils, 9% lymphocytes, 2% monocytes, 1% eosinophils and 1% basophils.
SMA|superior mesenteric artery|SMA|14|16|DIAGNOSES|DIAGNOSES: 1. SMA syndrome. 2. Recent laparoscopic hemicolectomy for inflamed colonic polyp with chronic colitis. 3. History of Ewing's sarcoma diagnosed in _%#MM1995#%_, had relapse metastasis to the lungs after 2 months.
SMA|superior mesenteric artery|SMA|290|292|HOSPITAL COURSE|A small bowel follow through was obtained which showed no evidence for small bowel obstruction, mild holdup of barium in duodenum where the duodenum crosses over the thoracic spine and the superior mesenteric artery crosses over the duodenum. It was felt that this maybe a mild form of the SMA syndrome. There was no evidence for small bowel dilatation and barium reached the colon in 300 minutes. Pediatric GI was consulted and they recommended evaluating magnetic resonance imaging of the brain to look for metastasis as there maybe neurologic cause to the patient nausea.
SMA|superior mesenteric artery|SMA|199|201|HOSPITAL COURSE|There was one area of increased attenuation, however, this was noted be artifact from the plain sphenoidal. After discussion with the patient and her parents the patient agreed to continue workup of SMA syndrome versus gastroparesis as an outpatient and was discharged to home. Disposition: The patient is being discharged to home without any new medications.
SMA|superior mesenteric artery|SMA|130|132|BRIEF HISTORY OF ADMISSION|The patient underwent abdominal duplex ultrasound the day prior to admission for routine follow-up and was noted to have elevated SMA velocities. Angiography was arranged for the day of admission, but upon this admission, her creatinine was noted to be 2.9 whereas it had been 1.4 at discharge in _%#MM#%_.
SMA|superior mesenteric artery|SMA|219|221|BRIEF HISTORY OF ADMISSION|HOSPITAL COURSE: The patient underwent randomization into the fenoldopam trial by the interventional radiology service the night prior to her angiogram. The following day, she did undergo an angiogram at which time her SMA was angioplastied and re-stented at its takeoff. After the procedure, it was noted that she had lost her radial pulse in the left arm.
SMA|sequential multiple autoanalyzer|SMA|196|198|ADMISSION LABS|Genitalia/Spine/Lymphatics/ Musculoskeletal: Within normal limits. Skin: Dry, scaly over the face and much of the body consistent with eczema. Neurologic: Grossly intact. ADMISSION LABS: Included SMA 7 with a mildly elevated glucose at 126, otherwise within normal limits. CBC had clotted. UA was within normal limits. HOSPITAL COURSE: The patient was admitted to Smiley's team, was started on IV fluids with plan to continue breast feeding as tolerated.
SMA|sequential multiple autoanalyzer|SMA|170|172|LABORATORY DATA|Neurologic check unremarkable. I should comment that this patient is not known to be diabetic. LABORATORY DATA: Hemoglobin 10.2, white count 8.3, platelet count 458,000. SMA 6 panel was unremarkable. Blood sugar 102. IMPRESSION: 1. This 39-year-old woman with history of severe and right-sided headache, suspect a vascular headache.
SMA|sequential multiple autoanalyzer|SMA|137|139|DISCHARGE DIAGNOSIS|MRA of the abdomen showed no evidence of renal artery stenosis. There was a 50 to 60% narrowing at the celiac access, simple renal cyst, SMA appeared patent. 4. Probable dehydration on admission with mild renal failure with BUN of 43, creatinine of 1.63 and with discharge BUN 20, creatinine 1.23.
SMA|superior mesenteric artery|SMA|77|79|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1) Chronic mesenteric ischemia. 2) Selective celiac and SMA arteriograms, stenting of the celiac artery x 2, stenting of the SMA. 3) Acute renal failure, now resolved. 4) Hypertension. 5) Transient atrial flutter.
SMA|superior mesenteric artery|SMA|256|258|HISTORY OF PRESENT ILLNESS AND EXAM|An exploratory laparotomy was performed which showed extensive adhesions and tissue unable to be adequately separated to relieve the small bowel obstruction. A G tube was placed, and the patient was closed. There was some thought given to the diagnosis of SMA syndrome, but this was speculative only. The G tube drains over a liter of bilious fluid per 24 hours, with very little continuing down through the duodenum.
SMA|superior mesenteric artery|SMA|165|167|HISTORY OF PRESENT ILLNESS|He has documented involvement of AV malformations of the proximal small bowel. He has required periodic transfusion. He has actually on _%#MM#%_ _%#DD#%_, 2005, had SMA embolization done. Since through the following winter of 2005, the patient had no further episodes of bleeding. He was seen in urology in _%#MM#%_ for bladder problems and stent issues and is now on Flomax, and he is anticipating following with up urology in near future.
SMA|superior mesenteric artery|SMA|263|265|HOSPITAL COURSE|The patient was hemodynamically stable throughout his hospital course. The ischemic colitis was felt to be possibly due to embolic disease or thrombotic disease. There was no clots seen on echocardiogram, however. Other possible etiologies were thrombosis of the SMA or possible dissection. There were no stigmata of peripheral emboli. Should further bleeding occur, it appears that the family will likely opt to treat only conservatively with transfusions as needed.
SMA|sequential multiple autoanalyzer|SMA|140|142|DISCHARGE FOLLOW UP|The patient is able to tolerate oral intake okay. The patient will follow up with his GI doctor, Dr. _%#NAME#%_, and he will have a CBC and SMA 10 checked prior to his appointment. Also Dr. _%#NAME#%_ will decide about whether or not the patient needs an EGD workup for possible upper GI bleeding while he was in the hospital.
SMA|superior mesenteric artery|SMA|291|293|PAST SURGICAL HISTORY|8. Anemia. 9. Cerebrovascular disease. 10. Ischemic colitis. 11. Coronary artery disease; Non-Q-wave myocardial infarction in _%#MM#%_ 2002. 12. Pseudo thrombosis, left brachial artery. 13. Anxiety. PAST SURGICAL HISTORY: Significant for left axillobifemoral bypass, femoral-femoral bypass, SMA stent, right renal artery stent, and TAA repair in '96. ALLERGIES: None. ADMIT MEDICATIONS: Aspirin, Lipitor 10 mg per os every day, Zestril 20 mg per os every day, Lasix 20 mg per os twice a day, Imdur 60 mg per os every day, Paxil 50 mg per os every day, Flovent 2 puffs twice a day, Combivent two puffs twice a day, potassium chloride 20 mg per os every day, Prevacid 30 mg per os every day, Neurontin 300 mg per os twice a day, hydralazine 25 mg three times a day, iron sulfate 325 mg per os every day, Atenolol 100/50 per os every day.
SMA|superior mesenteric artery|SMA|129|131|ASSESSMENT/PLAN|Intestinal ischemia could explain this and the patient does have a long-standing history of hypertension. Will obtain MRA of the SMA and IMA to rule out stenosis. Another possibility is medication effect. Will hold her Glucophage and follow. 4. Diabetes mellitus, type II. Hold Glucophage and initiate insulin sliding scale.
SMA|superior mesenteric artery|SMA|420|422|CHIEF DIAGNOSIS|CT of the abdomen and pelvis on _%#MM#%_ _%#DD#%_, 2002, showed postoperative changes in the stomach with no evidence of lymphadenopathy or abscess. HISTORY OF PRESENT ILLNESS: This is a 55-year-old female previously followed for presumed chronic idiopathic intestinal pseudoobstruction with a 7-year history of chronic right-sided abdominal pain and postprandial vomiting and multiple surgical procedures for suspected SMA compression syndrome including duodenojejunostomy, gastrojejunostomy, and antrectomy, who was seen in clinic by Dr. _%#NAME#%_ with worsening pain and vomiting and an upper GI which showed gastric obstruction.
SMA|superior mesenteric artery|SMA|168|170|CHIEF DIAGNOSIS|PAST MEDICAL HISTORY: 1. Total hysterectomy in 1982. 2. Right thyroidectomy in 1980. 3. Lap chole in 1995. 4. Appendectomy in 1965. 5. Multiple operations for presumed SMA compression syndrome such as duodenojejunostomy in _%#MM#%_ 1998, exploratory laparotomy and lysis of adhesions, revisions of anastomosis in _%#MM#%_ 1999, ERCP that presumed the diagnosis pancreatic divisum in 1999, gastrojejunostomy in _%#MM#%_ 1999, repeated exploratory laparotomy in _%#MM#%_ of 1999, and exploratory laparotomy with lysis of adhesions and duodenojejunostomy takedown and sphincteroplasty, resection of jejunum, and enteroenterostomy and intraoperative cholangiogram were all done in _%#MM#%_ 2002.
SMA|sequential multiple autoanalyzer|SMA|122|124|DISCHARGE FOLLOW-UP|DISCHARGE FOLLOW-UP: The patient should follow up with the Transplant Center within a week of discharge to have follow-up SMA 7, white counts, and tacrolimus levels checked. Infectious Disease did recommend a follow-up CT scan approximately three weeks after discharge to evaluate the status of the patient's colitis.
SMA|superior mesenteric artery|SMA.|176|179||She has done well here in the hospital, but is going home today with home hospice. Abdominal CAT scan showed the following: Large pancreatic mass involving the celiac axis and SMA. This also appears to be causing occlusion of the splenic vein and SMV. The portal vein appears to be filling by collaterals and there is evidence of some portal cavernous transformation.
SMA|superior mesenteric artery|SMA.|252|255|HOSPITAL COURSE|The patient had MR angiogram of his abdomen as well as his chest to rule out for arteritis of the large vessels, as well as arteritis of his SMA and celiac trunk. The MR angiogram did not show any significant abnormality at the origin of the celiac or SMA. Further vasculitis workup was done, including a sed rate which was mildly elevated at 26. The patient's blood cultures were negative. His lactic acid level was normal.
SMA|superior mesenteric artery|SMA|201|203|HOSPITAL COURSE|On admission his INR was 3.47. He had a fairly acute abdomen and underwent emergency angiography. Angiography showed likely a retroperitoneal bleed from a branch pancreatic artery. A celiac access and SMA arteriogram was performed and was unable to embolize the branch of the pancreatic artery. His INR was corrected and he was stabilized and watched and observed since surgical approach to that appeared to be the procedure of choice.
SMA|superior mesenteric artery|SMA|315|317|HISTORY OF PRESENT ILLNESS|She is a complicated 55- year-old woman with a known history of fibromuscular dysplasia, renal artery stenosis, and a known 80% stenosis of both her celiac artery and superior mesenteric artery. In _%#MM2002#%_ she was admitted with an episode of ischemic colitis and underwent angioplasty of her celiac artery and SMA with good result. Since that time, she has done fairly well and tells me that she was eating normally with minimal pain at home.
SMA|superior mesenteric artery|SMA,|162|165|FOLLOW-UP|5. Imodium 2 mg p.o. p.r.n. after each episode of diarrhea. DIET: Regular. ACTIVITIES: Ad lib. FOLLOW-UP: The patient needs to get CBC with platelets, as well as SMA, done in one week's time, and follow up with Dr. _%#NAME#%_ in one week.
SMA|sequential multiple autoanalyzer|SMA|208|210|FOLLOW-UP INSTRUCTIONS|6. Octreotide 150 mcg subcu t.i.d. for abdominal pain and to decrease secretions. FOLLOW-UP INSTRUCTIONS: The patient will follow up with Dr. _%#NAME#%_ as an outpatient with CBC, cholesterol, triglycerides, SMA 10 before the next visit. He will also continue on with his home-care help to receive TPN from home services and appropriate labs for them.
SMA|superior mesenteric artery|SMA|224|226|RESULTS OF STUDY|3. Hypercholesterolemia. 4. Osteoporosis. STUDIES PERFORMED WHILE HOSPITALIZED: A CT angio of the abdomen and pelvis. RESULTS OF STUDY: 1. Patent bypass graft of the abdominal aorta to the gastroduodenal artery. 2. Occluded SMA stent. 3. No CT evidence of the bowel ischemia.
SMA|superior mesenteric artery|SMA|131|133|IMPRESSION|CT suggests her stomach is markedly distended without material moving into the duodenum, may have some type of pyloric stenosis or SMA syndrome or other process at this time. Plan is to place NG tube, keep her n.p.o. and use IV fluids. Will have GI consult and probably scope tomorrow if her stomach can be cleared.
SMA|superior mesenteric artery|SMA|427|429|HISTORY OF PRESENT ILLNESS|She finally was evaluated again after discharge from _%#COUNTY#%_ _%#COUNTY#%_'s Hospital because she was "sick and tired" of the Woodwinds Hospital still not being able to diagnose her. At _%#COUNTY#%_ _%#COUNTY#%_'s Hospital, the patient did have a CT scan with contrast which did show a probable clot in the superior mesenteric artery, and she did undergo angiogram by Interventional Radiology, which did show approximately SMA focal 80% stenosis proximally and small streaming linear defect downstream questionable clot or dissection. The clot was occlusive to the extension of the mid to distal SMA and some occlusion of some branches going down to the jejunum.
SMA|superior mesenteric artery|SMA|413|415|HISTORY OF PRESENT ILLNESS|At _%#COUNTY#%_ _%#COUNTY#%_'s Hospital, the patient did have a CT scan with contrast which did show a probable clot in the superior mesenteric artery, and she did undergo angiogram by Interventional Radiology, which did show approximately SMA focal 80% stenosis proximally and small streaming linear defect downstream questionable clot or dissection. The clot was occlusive to the extension of the mid to distal SMA and some occlusion of some branches going down to the jejunum. This was thought to be subacute mesenteric ischemia and they did consult Vascular Surgery who evaluated the patient.
SMA|superior mesenteric artery|SMA|150|152|PLAN|ASSESSMENT: 53-year-old Caucasian female with history of chronic abdominal pain secondary to superior mesenteric artery clot and dissection. PLAN: 1. SMA clot. The patient has evidence of an SMA clot both on CT scan, as well as angiography. For further evaluation of this, we will consult the Vascular Surgery Service, as well as the Hematology/Oncology Service to help us with further workup of possible hypercoagulable state or another reason for the patient's clot, as well as management of the acute clot.
SMA|superior mesenteric artery|SMA|231|233|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old female well known to the Colorectal Service for about a year now who has a history of fibromuscular dysplasia and renal artery stenosis as well as 80% stenosis of celiac and SMA arteries. She had undergone angioplasty in _%#MM2003#%_ for ischemic colitis with good success. Before this admission she had been eating normally and gaining weight.
SMA|superior mesenteric artery|SMA|186|188|HOSPITAL COURSE|A CT of the abdomen was obtained which showed thickened sigmoid colon and ascites, but no free air. A mesenteric angiogram was obtained and she underwent angioplasty and stenting of her SMA by Interventional Radiology. Post-stenting the patient's symptoms continued to improve and slowly her diet was advanced from clears to regular food.
SMA|superior mesenteric artery|SMA,|401|404|HISTORY OF PRESENT ILLNESS|3. CT angiogram failed to reveal pulmonary embolism. HISTORY OF PRESENT ILLNESS: This patient is a 34-year-old female with a history of sickle cell disease admitted with acute band-like chest pain and shortness of breath along with back pain similar to her previous sickle cell crisis. Symptoms preceded by cough productive of green sputum. Essentially normal oxygenation and respiratory exam. Normal SMA, total bilirubin 1.4, hemoglobin 8.4. PAST MEDICAL HISTORY: 1. Sickle cell anemia, phenotype SS. 2. History of miscarriage, but also 1 normal pregnancy.
SMA|superior mesenteric artery|SMA|211|213|HISTORY/HOSPITAL COURSE|Tagged red blood cell study was done on _%#MMDD2003#%_ which showed evidence of bleeding in the cecum. EGD was done which showed no varices, some old blood in the stomach. There was a duodenal ulcer present. An SMA arteriogram was done by interventional radiology with vasopressin infusion. A bleeding site was found in the cecum. Bleeding subsequently resolved.
SMA|superior mesenteric artery|SMA.|139|142|PAST MEDICAL HISTORY|8. Congestive heart failure with ejection fraction of 40%. 9. Atrial fibrillation. 10. History of mesenteric ischemia with stenting of the SMA. PHYSICAL EXAMINATION ON ADMISSION: Blood pressure 129/39, pulse of 50, temperature 96.0, respiratory rate 16.
SMA|sequential multiple autoanalyzer|SMA,|150|153|HISTORY OF PRESENT ILLNESS|The patient has a fast irregularly irregular heart rate and full neck veins. His skin was with ecchymoses and atrophic changes related to aging. CBC, SMA, and LFTs were all normal. An EKG confirmed atrial fibrillation with rapid ventricular response. PAST MEDICAL HISTORY: 1. Sigmoid volvulus first diagnosed in _%#MM2003#%_.
SMA|sequential multiple autoanalyzer|SMA|116|118|LABS|VITAL SIGNS: Stable on admission, and afebrile. LUNGS: Diffuse rales and egophony. LABS: WBC 16.8, hemoglobin 11.6. SMA normal for this patient. Creatinine 1.9 (baseline creatinine is 2). PAST MEDICAL HISTORY: 1. Atrial fibrillation. Coumadin was discontinued secondary to GI bleed in the past.
SMA|sequential multiple autoanalyzer|SMA,|162|165|FOLLOW-UP INSTRUCTIONS|She was going to continue her IV antibiotic treatment and TPN there. She was to get a vancomycin level on _%#MMDD2004#%_, as well as some blood work such as CBC, SMA, and albumin before her appointment with Dr. _%#NAME#%_. Dr. _%#NAME#%_ is her primary-care physician at _%#COUNTY#%_ Care North Clinic.
SMA|superior mesenteric artery|SMA|209|211|HISTORY OF PRESENT ILLNESS|A CAT scan was done as an outpatient basis the day prior to admission with result as above. An upper GI with Gastrografin solution was then performed with result as above. There was some initial concern about SMA syndrome. He was sent to emergency from Boynton Health Center. ER consulted surgery, especially as lactic acid level was slightly high at 3.1, who do not think that this finding represent SMA syndrome.
SMA|superior mesenteric artery|SMA|125|127|HISTORY OF PRESENT ILLNESS|ER consulted surgery, especially as lactic acid level was slightly high at 3.1, who do not think that this finding represent SMA syndrome. He was thus being for admitted for further evaluation and treatment for his abdominal discomfort. HOSPITAL COURSE: PROBLEM #1. Grade B reflux esophagitis as well as some nonbleeding erosive gastropathy: On admission he gave a very good history of symptoms suggestive of probable low-grade upper GI bleed.
SMA|sequential multiple autoanalyzer|SMA|157|159|FOLLOW-UP APPOINTMENTS|There is no lower extremity edema. Her strength in her bilateral lower extremities continues to improve. FOLLOW-UP APPOINTMENTS: She will get q. weekly CBC, SMA 7 which should be faxed to Dr. _%#NAME#%_. She should also follow up with him the second week in _%#MM#%_ to plan for further courses of chemotherapy for her recurrent lymphoma.
SMA|superior mesenteric artery|SMA|96|98|PAST SURGICAL HISTORY|6. Multinodular goiter. 7. Depression. 8. Hypercholesterolemia. PAST SURGICAL HISTORY: 1. Aorto SMA bypass graft. 2. Auto renal transplant for renal artery stenosis. 3. Right renal artery repair. 4. Left oophorectomy. 5. Nissan fundoplication.
SMA|sequential multiple autoanalyzer|SMA|211|213|LABORATORY ON ADMISSION|Bowel sounds positive. SKIN: Warm and moist. NEUROLOGICAL: Without gross focal deficits. LABORATORY ON ADMISSION: Complete blood count: white blood count 17,900, hemoglobin 11.4, MCV 85, platelet count 370,000, SMA 10, BUN 29, creatinine 1.5, glucose 177. LFTs normal. Urinalysis negative. Urine culture negative. Blood culture x 1 negative. TSH 0.67. Tacrolimus level 8.3. Cholesterol 125, LDL 37, triglycerides 134, HDL 61.
SMA|sequential multiple autoanalyzer|SMA|148|150|LAB  DATA|LAB DATA: CBC results are normal. Coags are normal. Myoglobin is 17, troponin I less than 0.07. Platelets 199. BNP is 8. D-Dimer is negative at .2. SMA 12 results are normal. EKG: Normal sinus rhythm. Heart rate of 63, no acute changes, no old EKG for comparison.
SMA|superior mesenteric artery|SMA,|309|312|LABS AND STUDIES|LABS AND STUDIES: CT of the abdomen and chest showed there is extensive thoraco-abdominal aortic dissection from the junction of the ascending aorta/arch to near the abdominal aortic bifurcation; dissection extends into the proximal innominate and left subclavian arteries with no dissection into the celiac, SMA, IMA or renals demonstrated. Prominent contrast in false lumen with prominent compression of true lumen, especially in the descending thoracic aorta and distal/small to moderate abdominal aortic aneurysm.
SMA|sequential multiple autoanalyzer|SMA|145|147|HISTORY OF PRESENT ILLNESS|Examination was negative but for palpable abdominal mass, tenderness and scrotal tubers. His WBC was 18.8, hemoglobin 8.2, INR 1.4, albumin 3.2, SMA normal and no renal failure. His EKG was normal. A chest x-ray revealed an enlarged heart silhouette.
SMA|sequential multiple autoanalyzer|SMA|182|184|HISTORY OF PRESENT ILLNESS|He had obtundation and weak gag reflex. He was initially admitted to the ICU. CBC revealed a hemoglobin 9.8, platelets 110 and normal WBC. Ammonia 73. Transaminases mildly elevated. SMA essentially normal. Abdominal CT showed ascites with no change from previous studies. PAST MEDICAL HISTORY: 1. End-stage liver disease secondary to HCV (IV drug use), alcoholism in remission.
SMA|sequential multiple autoanalyzer|SMA|209|211|LABORATORY DATA|She also has deviation in her feet. She has involvement of her rheumatoid arthritis in her shoulder. LABORATORY DATA: There is no laboratory data currently available. A CBC with diff blood cultures times two, SMA 7 have been ordered. IMPRESSION: 1. Cat bite in an immunosuppressed patient with garden exposure.
SMA|superior mesenteric artery|(SMA)|152|156|HISTORY OF PRESENT ILLNESS|The dissection starts distal to the left subclavian and goes to the level of the renal arteries. The true lumen supplies the superior mesenteric artery (SMA) and renal arteries. The iliac access arises off the false lumen. There was no extravasation of contrast or pleural effusions.
SMA|superior mesenteric artery|(SMA)|220|224|CT SCAN|Heart within normal size. No adenopathy. No pneumothorax. Descending thoracic aortic dissection starting distal to the left subclavian to the level of the renal arteries. Two lumens supply the superior mesenteric artery (SMA) and renal arteries. Iliac access arises off the false lumen. There was no extravasation of contrast or pleural effusions.
SMA|superior mesenteric artery|SMA|259|261|HOSPITAL COURSE|HOSPITAL COURSE: 1. Abdominal pain/ischemic bowel disease. She was admitted and given her history of thromboembolic events, quite concern for ischemic bowel from this. She was placed on Heparin and underwent an MRA of the abdomen. Findings demonstrated tight SMA and celiac artery Not quite sure whether or not this may have been embolic at this time, however given her history and the acute onset of her symptoms, suspect that this is probably thromboembolic.
SMA|superior mesenteric artery|SMA,|518|521|PAST MEDICAL HISTORY|CT scan of the abdomen and pelvic _%#MM#%_ _%#DD#%_, 2005 showed mild intra and extrahepatic bile duct dilatation after cholecystectomy and unchanged from previous CT an month prior to that, postoperative changes in the upper abdominal region of the esophagogastric junction, malrotated left kidney with prominent extra renal pelvis possibly peripelvic cyst which was seen previously and unchanged, small right and left ovarian cysts, otherwise unremarkable study. e. MRA of the abdomen showing normal celiac axis and SMA, renal arteries and iliac arteries were unremarkable. f. Hepatobiliary scan showed delayed emptying back in _%#MM#%_ of 2005. 2. History of vagotomy and antrectomy for apparent refractory peptic ulcer disease in 2003.
SMA|sequential multiple autoanalyzer|SMA|160|162|FOLLOW UP|2. The patient also will follow up with Dr. _%#NAME#%_ at Methodist Clinic in mid _%#MM#%_, for which appointment has already been made. Patient will have CBC, SMA 10, Prograf at the time when he will follow up with Dr. _%#NAME#%_.
SMA|superior mesenteric artery|SMA|124|126|DISCHARGE DIAGNOSE|The patient was not placed on Coumadin because of his recent history of GI bleed. 4. Abdominal pain evaluated with a MRA. A SMA stenosis was seen but it was felt that this should be treated medically as she did not have classic symptoms of ischemic bowel.
SMA|superior mesenteric artery|SMA|125|127|HISTORY OF PRESENT ILLNESS|The patient had abdominal pain on admission and this was worked up by the hospitalist. MRI/MRA was performed. There was some SMA stenosis but it was felt to be an incidental finding as the patient is not having postprandial pain and does not have typical symptoms to suggest ischemic bowel.
SMA|superior mesenteric artery|SMA|260|262|DISCHARGE DIAGNOSES|PENDING DISCHARGE _%#MMDD2007#%_ DISCHARGE DIAGNOSES: 1. Myocardial infarction non-ST elevation, peak troponin of 18.7. She is status post right coronary artery stent on _%#MM2006#%_. 2. Paroxysmal atrial fibrillation. 3. Diabetes mellitus. 4. Stenosis of the SMA artery. 5. Anemia with heme positive stools/GI bleeding. DISCHARGE MEDICATIONS: 1. Plavix 75 mg p.o. q. day. This is recommended to be continued for one month per cardiology given the balance of her needs post-stent and GI bleeding.
SMA|superior mesenteric artery|SMA|198|200|DISCHARGE SUMMARY|She was taken to the Cath lab on _%#MM2006#%_ and underwent right coronary artery stenting. She also had evaluations for her abdominal pain including MRI/MRA of the abdomen which showed evidence of SMA artery occlusion, 90% lesion stenosis of the superior mesenteric artery. It was discussed with interventional general radiology whether a stenting of this would be reasonable and ultimately her symptoms went away with treatment of her coronary artery disease and evolution of her myocardial infarction.
SMA|superior mesenteric artery|SMA.|140|143|DISCHARGE SUMMARY|In the absence of ongoing symptoms such as postprandial pain and weight loss, it is not recommended to have interventional procedure of the SMA. The patient recovered nicely, was briefly in atrial fibrillation but back in sinus after her myocardial infarction. She did have heme positive stools and was seen by gastrointestinal service.
SMA|superior mesenteric artery|SMA|177|179|HOSPITAL COURSE|The impression of the CT angiogram was that there is significant and focal stenosis of the origin of the celiac artery that could stem from the median arcuate ligament, and the SMA and IMA were demonstrated patent. The splenic vein and portal vein were demonstrated patent, too. Therefore, Surgery recommended an MRA, discontinuing the aspirin and Vioxx and starting on PPI.
SMA|sequential multiple autoanalyzer|SMA|135|137|DISPOSITION|This was set up by our discharge planning nurse. DISPOSITION: Follow up with Dr. _%#NAME#%_ in one to two weeks. CBC, platelets, diff, SMA 10, and LFTs. DISCHARGE MEDICATIONS: 1. OxyContin 40 mg p.o. t.i.d. 2. Octreotide 100 mcg subcutaneous t.i.d. from _%#MMDD#%_ to _%#MMDD#%_.
SMA|superior mesenteric artery|SMA|194|196|ADDENDUM|I feel the best course right now would be simply to control his lipids and blood pressure optimally. If he has recurrent symptoms could consider evaluation including MRA of the abdomen to check SMA etc. DISCHARGE MEDICATIONS: Metoprolol 25 mg b.i.d., Zocor 20 mg q h.s., aspirin 81 mg q.d., Wellbutrin 75 mg q.d., Plavix 75 mg q.d., Xanax p.r.n.
SMA|superior mesenteric artery|SMA,|166|169|HOSPITAL COURSE|There was concern for bowel ischemia on account of this abdominal pain and a CT angiogram of the abdomen was completed which showed patent arteries of celiac, trunk, SMA, and IMA. The patient's abdominal distention resolved with better ambulating and medical management. She was ultimately discharged on _%#MMDD2003#%_ with home health care and oxygen available at home for problems with desaturations.
SMA|sequential multiple autoanalyzer|SMA|168|170|DISCHARGE INSTRUCTIONS|7. He will also call if there is any increase in temperature or pain. 8. He will also have home health care followup and tomorrow, on _%#MMDD2004#%_, he should have an SMA drawn and these results will be called in to the renal fellow. DISCHARGE MEDICATIONS: He will go home on: 1. Zantac 150 mg p.o. daily.
SMA|sequential multiple autoanalyzer|SMA|176|178|FOLLOWUP|4. Colace 100 mg p.o. b.i.d. 5. Aspirin 325 mg p.o. daily. 6. Atenolol 50 mg p.o. q.p.m. FOLLOWUP: He should follow up with Dr. _%#NAME#%_, his primary care physician, with an SMA 7 this coming Monday, _%#MMDD2004#%_, as well as Dr. _%#NAME#%_ in the urology clinic with another SMA 7 next Thursday, _%#MMDD2004#%_, and with Dr. _%#NAME#%_ on Friday _%#MMDD2004#%_.
SMA|sequential multiple autoanalyzer|SMA|190|192|FOLLOWUP|FOLLOWUP: He should follow up with Dr. _%#NAME#%_, his primary care physician, with an SMA 7 this coming Monday, _%#MMDD2004#%_, as well as Dr. _%#NAME#%_ in the urology clinic with another SMA 7 next Thursday, _%#MMDD2004#%_, and with Dr. _%#NAME#%_ on Friday _%#MMDD2004#%_. Again, all of these instructions were discussed with the patient prior to discharge.
SMA|sequential multiple autoanalyzer|SMA|119|121|ADMISSION LABORATORY DATA|Admission exam reveals bilateral rales, tachycardia about 110. ADMISSION LABORATORY DATA: White blood cell count 11.2. SMA and liver function tests normal. Chest x-ray reveals infiltrate, as described above. PAST MEDICAL HISTORY: 1. Cystic fibrosis diagnosed in childhood, last hospitalization _%#MM2004#%_. 2. Mycobacterium avium complex cultured in _%#CITY#%_, North Dakota.
SMA|sequential multiple autoanalyzer|SMA|189|191|FOLLOW UP|2. Follow up for Avastin at Masonic Cancer Clinic on _%#MM#%_ _%#DD#%_, 2004, at 3:00 p.m. 3. Follow up with Dr. _%#NAME#%_ at Masonic Clinic at 3 p.m. on _%#MM#%_ _%#DD#%_, 2004. 4. LFTs, SMA 10 to be repeated as an outpatient in 4 days and results faxed to Dr. _%#NAME#%_. CODE STATUS: DNR/DNI.
SMA|sequential multiple autoanalyzer|SMA|205|207|DISCHARGE INSTRUCTIONS|3. Follow up with the GI Clinic within a week and to reassess need for paracentesis with Primary Care Medicine Clinic at Fairview-University Medical Center. He needs follow-up labs, which include INR, PT, SMA 10 and CBC. The patient will call.
SMA|sequential multiple autoanalyzer|SMA|233|235|ASSESSMENT|ASSESSMENT: A 51-year-old woman here for preoperative studies for a TIPS to be done tomorrow for resistant ascites. We will check a chest x-ray, EKG, dopplers of her upper extremity vessels. We will also check coagulations, CBC, and SMA 12. We will hold her short acting insulin tomorrow morning and give her 75 units of Lantus this evening. We will also increase her atenolol slightly to increase her beta blockade going into the surgery as she is at mild risk with her risk factors of diabetes, smoking, and hypertension.
SMA|sequential multiple autoanalyzer|SMA|253|255|PROBLEM #1|PROBLEM #1: Abdominal pain. As mentioned before, the patient has had multiple hospitalizations for this problem and had numerous imaging done. Her clinical presentation and history, we were concerned about possible chronic ischemic colitis and possible SMA syndrome. The patient underwent CT scan of the abdomen with angio. This study showed no pathology explaining her presenting symptoms. The patient was discharged with Zelnorm on her past hospitalization; however, she has not been taking it due to insurance problems.
SMA|superior mesenteric artery|SMA|296|298|HISTORY OF PRESENT ILLNESS|The patient has a history of ischemic colitis in the past but there was no evidence of that. The patient also had a nuclear medicine bleeding study done which showed possible active bleeding site within the right pelvis, she had a subsequent visceral angiogram which showed normal celiac, normal SMA and a very small but patent IMA which could not be selectively catheterized. After this workup was done, the patient's anemia was thought secondary to episodic diverticular bleeding.
SMA|superior mesenteric artery|SMA|249|251|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Postpartum cardiomyopathy with ejection fraction of 10% and an LVAD for destination therapy in _%#MM2005#%_. 2. Numerous postoperative complications, including ventilation support requiring tracheostomy for a period of time, SMA syndrome, T9 paralysis and paraplegia secondary to microemboli. The patient is not a heart transplant candidate secondary to PRA antibodies are 100%.
SMA|superior mesenteric artery|SMA|213|215|HISTORY OF PRESENT ILLNESS|Symptoms that came up included vomiting and intolerance of oral intake. He had a CT scan of the abdomen performed in the emergency department that demonstrated a large stomach with finding that were suggestive of SMA syndrome. HOSPITAL COURSE: 1. Gastric outlet obstruction secondary to SMA syndrome: As noted above, the patient was taken to the operating room on the _%#DD#%_ for a decompressive duodenojejunostomy.
SMA|superior mesenteric artery|SMA|215|217|HOSPITAL COURSE|He had a CT scan of the abdomen performed in the emergency department that demonstrated a large stomach with finding that were suggestive of SMA syndrome. HOSPITAL COURSE: 1. Gastric outlet obstruction secondary to SMA syndrome: As noted above, the patient was taken to the operating room on the _%#DD#%_ for a decompressive duodenojejunostomy.
SMA|superior mesenteric artery|SMA,|137|140|PAST MEDICAL HISTORY|FAMILY HISTORY: Daughter has melanoma at the age of 18. PAST MEDICAL HISTORY: Pancreatic cancer, no resection secondary to encasement of SMA, initially presented with abdominal pain and pancreatic cancer was diagnosed by CT and abdominal ultrasound findings at last showed adenocarcinoma, treatment with gemcitabine weekly, starting _%#MMDD2007#%_, last dose was given on _%#MMDD2007#%_.
SMA|sequential multiple autoanalyzer|SMA|215|217|ADMISSION LABORATORY|NEUROLOGIC: Alert and oriented x 3. No focal deficits. ADMISSION LABORATORY: White count 8.1, hemoglobin 12.3, platelets 286, amylase of 70, lipase 72, troponin less than 0.07, basic metabolic panel was 22,000. Her SMA 7 was 136, sodium 5.0, potassium 100, chloride 22, bicarbonate 47, BUN 9.1, creatinine 122, glucose. CHEST X-RAY: Abdominal x-ray showed no free-air, no air fluid levels.
SMA|sequential multiple autoanalyzer|SMA|157|159|FOLLOW-UP|9. Maxzide 50 - 75 mg one tablet p.o. q. daily. FOLLOW-UP: The patient is to follow up with Dr. _%#NAME#%_ within one week with follow up labs of lipase and SMA 10. The patient's primary- care physician, Dr. _%#NAME#%_ is on vacation, and hence to follow up with Dr. _%#NAME#%_. Follow up with ENT is also arranged within one to two weeks for chronic vertigo and dizziness.
SMA|sequential multiple autoanalyzer|SMA|171|173|PROBLEM #4|She was given alprazolam and BuSpar. PROBLEM #4: Hyperglycemia. The patient's glucose was 240 when she came in. Her initial urinalysis showed negative glucose. Her repeat SMA then showed a glucose level of 214. To diagnose diabetes the patient needs two readings of random blood glucose control greater than 200, and hence this will be deferred to the primary-care provider.
SMA|superior mesenteric artery|(SMA),|318|323|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a _%#1914#%_-year-old Caucasian female whose code status is Do Not Resuscitate (DNR)/Do Not Intubate (DNI) who lives independently. She has a complex and long medical history of severe peripheral arterial disease including disease in the superior mesenteric artery (SMA), celiac, left iliac, right renal as well as carotid stenosis, status post bilateral femoropopliteal bypass surgery in 1995 and 1995 with ongoing claudication symptoms.
SMA|superior mesenteric artery|SMA|301|303|HOSPITAL COURSE|The patient was put on liquid diet and his electrolytes were continued to be repleted. The CT of the abdomen showed mild dilatation of the second portion of the duodenum, likely from compression of the third portion by the pancreatic head mass, which was 4.7 x 4.3. Also, there was compression of the SMA and SMV, SMA appeared to be almost completely encircled by the mass. New pneumobilia was seen and decrease in intra and extrahepatic biliary dilatation was seen.
SMA|sequential multiple autoanalyzer|SMA,|201|204|HISTORY OF PRESENT ILLNESS|On presentation his blood pressure was 82/56 secondary to SL-NTG given by paramedics. His exam was positive only for bronchial breath sounds. Had some bruises on his back. D. dimer 0.9. Otherwise CBC, SMA, troponin negative. Ethanol level zero, although he reportedly drank earlier that day. A chest x-ray revealed blunting of the right costophrenic angle with hazy infiltrates.
SMA|superior mesenteric artery|SMA|376|378|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old female with a history of vertical banded gastroplasty in 1995, cholecystectomy in 1985, and hysterectomy, who was recently admitted on _%#MM#%_ _%#DD#%_, 2004, with partial small-bowel obstruction CT was initially read as negative and an addendum was added on the report indicating that the SMB was rotating around the SMA suggesting malrotation volvulus. The patient came back to FUMC on _%#MM#%_ _%#DD#%_, 2004, complaining of left-sided abdominal pressure and swelling, pain, nausea, and vomiting.
SMA|superior mesenteric artery|SMA|139|141|PAST MEDICAL HISTORY|10. History of acute renal failure, _%#MM#%_ 2003 and _%#MM#%_ 2003. 11. History of depression. 12. History of portal and splenic vein and SMA thrombosis. 13. History of seizures. 14. History of GERD. HOSPITAL COURSE: PROBLEM #1: GI. The patient was admitted with the diagnosis of pancreatitis. A CT scan showed a new pseudocyst versus possible infected pseudocysts around her pancreas.
SMA|UNSURED SENSE|SMA|160|162|DISCHARGE INSTRUCTIONS|The patient was told to follow up with interventional radiology for T-tag removal on _%#MM#%_ _%#DD#%_, 2004, at 8:00 a.m. The patient will be sent out with an SMA time to be performed on _%#MM#%_ _%#DD#%_, 2004. Fairview Home Infusion will help the patient with tube feeding and re- enforcement of teaching.
SMA|superior mesenteric artery|SMA.|199|202|PREOPERATIVE LABS|A CT angiogram on _%#MM#%_ _%#DD#%_, 2005, showed total liver volume of 1367 mL and right lobe of 888 mL. There was normal portal vein branching pattern. The right hepatic artery was replaced to the SMA. The left hepatic artery arises off the common hepatic artery which arises from celiac axis. There was irregular hypodense mass in segments 6 and 7 with peripheral globular enhancement, likely hemangioma.
SMA|superior mesenteric artery|SMA|146|148|LABORATORY DATA|Ethanol less than 0.1. UA with trace blood and 2-5 RBCs. CT of her abdomen and pelvis showed a suggestion of edema just above the pancreas around SMA origin. There is also a trace of fluid along the medial right lobe of the liver below clips which could be due to pancreatitis with mild to moderate dilatation of the small bowel loops with small air fluid levels.
SMA|superior mesenteric artery|SMA|121|123|DISCHARGE DIAGNOSIS|2. Congestive heart failure. 3. Paraplegia. 4. Recurrent episodes of ventricular tachycardia. 5. Respiratory failure. 6. SMA syndrome. 7. Decubitus ulcer. 8. Recurrent line infections. 9. Recurrent urinary tract infections, colonized with vancomycin- resistant enterococci.
SMA|superior mesenteric artery|SMA|215|217|HISTORY OF PRESENT ILLNESS|OPERATIONS/PROCEDURES PERFORMED: NJ replacement by interventional radiology. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is an 18-year-old female with a history of chronic vomiting, gastroparesis, and GI feed dependent, SMA syndrome, and type 1 diabetes mellitus. She presents acutely with vomiting and increased abdominal pain since prior afternoon. She was seen in clinic one day prior to admission for regular followup and no changes were made to the home routine.
SMA|superior mesenteric artery|SMA|238|240|HOSPITAL COURSE|She did start taking clears on hospital day #2 and then was tolerating small amounts of regular diet prior to discharge. 2. GI: _%#NAME#%_ has a known history of gastroparesis with recurrent nausea and vomiting. She also had a history of SMA syndrome, pancreatitis, and hepatitis. Her liver panel and lipase were normal here. Her NJ was replaced without difficulty by interventional radiology and her feeds were resumed.
SMA|superior mesenteric artery|SMA|316|318|PRIMARY DIAGNOSIS|2. There was a question of renal artery stenosis, however, on a repeat testing done during hospitalization CT angiogram showed right renal artery with fairly dense calcification without any definite stenosis. Two left renal arteries which were patent. There is high grade celiac access proximally but patency of the SMA and IMA is noted. I discussed the case with Dr. _%#NAME#%_. No intervention at this time from his standpoint. She does have the celiac artery, high grade stenosis proximally but does have a patent SMA and IMA.
SMA|superior mesenteric artery|SMA|179|181|PRIMARY DIAGNOSIS|I discussed the case with Dr. _%#NAME#%_. No intervention at this time from his standpoint. She does have the celiac artery, high grade stenosis proximally but does have a patent SMA and IMA. PROCEDURES OTHER TESTS DONE: 1. Cardiology consult. 2. CT angio of the abdomen as above.
SMA|superior mesenteric artery|SMA|177|179|PROCEDURES PERFORMED|REVISED _%#MMDD2007#%_jj DISCHARGE DIAGNOSES: 1. Chronic intestinal ischemia. 2. Viral gastroenteritis. PROCEDURES PERFORMED: MRA abdomen showing patent takeoffs of the celiac, SMA and the IMA with no evidence of occlusion in the proximal vasculature. However, the distal vasculature could not be evaluated further.
SMA|superior mesenteric artery|SMA|218|220|HISTORY OF PRESENT ILLNESS|At that time the patient had come in with postprandial abdominal pain associated with blood in her stools. At that time in _%#MM2006#%_ she also had an MRA of the abdomen which had shown normal takeoffs of the celiac, SMA and IMA. However, there were calcifications noted in the abdominal aorta and some of its branches. The patient presented on _%#MMDD2006#%_ after a history of 3 days of not tolerating any p.o. food due to postprandial pain.
SMA|superior mesenteric artery|SMA|328|330|PROCEDURES PERFORMED DURING HOSPITALIZATION|1. ERCP and EUS (endoscopic ultrasound) dated _%#MMDD2007#%_. The endoscopic ultrasound showed 34 x 26 mm hypoechoic mass in the head of pancreas with upstream dilation of the bile duct and pancreatic duct. The mass was noted to be partially encasing the SMV and loss of interfere with portal vein confluence. No involvement of SMA and hepatic artery was seen. The mass was also invading the duodenal wall. Multiple peripancreatic and celiac lymph nodes were noted. Needle aspiration from the mass showed malignant cell.
SMA|superior mesenteric artery|SMA.|146|149|HOSPITAL COURSE|The mass is abutting superior mesenteric vein, but does not appear to be infiltrating the vein. There is slightly less than 50% encasement of the SMA. No infiltration into the splenic and portal veins was noted. Enlarged retroperitoneal, celiomesenteric lymph nodes were noted. There was also intrahepatic biliary dilatation.
SMA|superior mesenteric artery|SMA|315|317|HOSPITAL COURSE|The patient's amoxicillin has been stopped and she was started on intravenous fluids, pain control and was maintained n.p.o. She underwent endoscopy the following day which was consistent with ischemic colitis. The biopsied portions of the colon showed changes consistent with ischemia. There was no evidence of an SMA thrombus on the CT scan and the patient's symptoms improved after colonoscopy. She was therefore advanced to a normal diet and tolerated this well.
SMA|sequential multiple autoanalyzer|SMA|215|217|DISCHARGE FOLLOW-UP|DISCHARGE DIET: Regular diet. DISCHARGE ACTIVITY: As tolerated. DISCHARGE FOLLOW-UP: The patient will follow up with _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ on _%#MMDD2007#%_. He should have CBC with differential, SMA 10, LFTs, INR and PTT, lactate dehydrogenase and uric acid at that time. It was a pleasure participating in the care of this patient during this admission.
SMA|superior mesenteric artery|SMA|251|253|HISTORY OF PRESENT ILLNESS|Given her known coronary artery disease and likely peripheral vascular disease, the patient was admitted for workup for mesenteric ischemia. HOSPITAL COURSE: 1. Mesenteric ischemia. MRA was performed and demonstrated stenosis of the celiac trunk, the SMA and IMA. There was some question of possibly stenting through these stenotic regions, but given the patient's recent bump in creatinine from the presumed contrast nephropathy, this was declined.
SMA|superior mesenteric artery|SMA|183|185|HOSPITAL COURSE|On _%#MMDD2006#%_, we performed an MR angiogram, which really did not show any difference. Still some wall thickening of the distal small bowel with no evidence of obstruction of the SMA or IMA vessels. The patient had diet advanced during her hospitalization and on _%#MMDD#%_ and _%#MMDD#%_, she was eating a regular diet with no increased pain following that.
SMA|spinal muscular atrophy|SMA|156|158|HISTORY OF PRESENT ILLNESS|11. Obstructive sleep apnea, ventilator dependent at night. SERVICE: Medicine Firm. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 29-year-old female with SMA who requires 24-hour nursing care. She has a tracheostomy and is ventilator dependent at night due to obstructive sleep apnea.
SMA|superior mesenteric artery|SMA;|253|256|IMAGING|Amylase 59. Sodium 143. Potassium 3.7. Chloride 106. CO2 27. BUN 14. Creatinine 0.9. Glucose 112. Calcium 8.5. IMAGING: CT scan done today report is 1) small amount of free air near the liver; 2) Malrotation with worsening volvulus and narrowing of the SMA; 3) small bowel dilation with extraluminal gas; 4) misty appearance of the mesentery possibly consistent with venous congestion.
SMA|superior mesenteric artery|SMA,|456|459|HISTORY OF PRESENT ILLNESS AND COURSE IN HOSPITAL|Her lactic acid normalized the next day. As mentioned above GI was consulted and performed an EGD on her, which did not show any evidence of gastritis or duodenitis; however, the result of EGD revealed that she had her moderate-to-large size hiatal hernia of which because of the size she has increased risk of getting a volvulus from hiatal hernia in the future. GI also recommended performing a Doppler ultrasound of the abdomen to assess the patency of SMA, IMA, and celiac trunk, result of which was dictated above. The patient's lactic acid did fluctuate a bit during her course in the hospital and we think this is most likely due to type D-lactic acid from possible small blind loop from her ventral hernia.
SMA|sequential multiple autoanalyzer|SMA|192|194|ASSESSMENT AND PLAN|Unclear whether this is a white-coat phenomenon or actually represents essential hypertension. We will continue to follow at home on Avastin to check it more on the right than the left, check SMA as well as urine protein. Had a normal EKG in 2004. We will plan for another next year. He will contact me if he has any values that are sustained with a diastolic greater than 90.
SMA|superior mesenteric artery|SMA|110|112|ADMISSION DIAGNOSIS|He did have a palpable pulse in his celiac access and he had Doppler signals which were easy to obtain in his SMA distribution. However, the colon which was supplied by the middle colic artery as well as the entire small bowel appeared somewhat dusky and of questionable viability.
SMA|spinal muscular atrophy|SMA|196|198|HISTORY OF PRESENT ILLNESS|8. History of recurrent aspiration pneumonia. 9. Respite care. PROCEDURES: None. CONSULTATIONS: None. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a pleasant 30-year-old female with a history of SMA type 2 and nighttime ventilator dependence via tracheostomy who was admitted for respite care and 24-hour nursing care. The patient usually lives at home with a personal care assistant but this PCA and abruptly left the patient.
SMA|sequential multiple autoanalyzer|SMA|435|437|PROBLEM #2|The patient has been afebrile for about 48 hours now and is ready for discharge based on that she will go home on IV antibiotics for 2 weeks as per ID recommendations. PROBLEM #2: Acute renal failure, stage III, creatinine has been generally up during her hospital course but the etiology is likely prerenal versus sepsis versus acute interstitial nephritis from her antibiotics for the eosinophilia, continued on IV hydration and her SMA 7 were assessed and electrolyte replacements protocols were in place. PROBLEM #3: Diabetes mellitus. The patient was placed on regular insulin sliding scale and her glucose was monitored every day at bedtime.
SMA|sequential multiple autoanalyzer|SMA|137|139|LABORATORY STUDIES|The patient did receive 20 mg of IV Lasix and a nitroglycerin patch at 0.4 mg per hour was applied. LABORATORY STUDIES: Returned showing SMA 7 to be within normal limits. Hemoglobin was 12.4, no evidence of anemia. White blood count is normal at 6.3. Troponin was less than 0.07. BNP was markedly elevated at 956.
SMA|superior mesenteric artery|SMA|111|113|HISTORY OF PRESENT ILLNESS|This revealed an active bleeding site and diverticula in the splenic flexure. The catheter was left within the SMA and Pitressin infusion started. This did stop bleeding. The patient received 2 units of packed red blood cells upon admission for acute blood loss anemia.
SMA|superior mesenteric artery|SMA|190|192|HOSPITAL COURSE|This required Hickman line placement. She tolerated the procedure well and was started on TPN. Of note, an abdominal CT was performed due to her positive EBV infection and was found to have SMA syndrome with distention of the stomach in the first and second portions of the small bowel with narrowing of the third section of the duodenum between the superior mesenteric artery and aorta.
SMA|superior mesenteric artery|SMA|351|353|HOSPITAL COURSE|Of note, an abdominal CT was performed due to her positive EBV infection and was found to have SMA syndrome with distention of the stomach in the first and second portions of the small bowel with narrowing of the third section of the duodenum between the superior mesenteric artery and aorta. An upper GI was performed which confirmed the presence of SMA syndrome. We consulted GI at that time, which recommended placing an NJ tube to initiate feeds along with decompression of the stomach.
SMA|sequential multiple autoanalyzer|SMA|195|197|LABORATORY DATA|BREASTS: Exam was normal. LABORATORY DATA: CBC obtained last night showed WBC of 11.2. Hemoglobin 14.1. Platelets 3000. Differential showed 71% neutrophils, 22% lymphocytes, 6% monocytes, 1 eos. SMA was reviewed and this revealed occasional large platelets without any abnormal red blood cells or white blood cells. INR is 1. PTT is 25. Chemistry profile is within normal limits including a creatinine of 0.7 and normal liver function tests.
SMA|sequential multiple autoanalyzer|SMA|131|133|FOLLOW-UP APPOINTMENTS|FOLLOW-UP APPOINTMENTS: Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ on Friday, _%#MMDD2003#%_, at noon. The patient was to follow up with SMA 10 and CBC with diff and platelets. Main issues at that time would be to evaluate the patient's HTN and to make sure the patient's electrolytes were stable in lieu of being started on lisinopril mainly (?) potassium and creatinine.
SMA|sequential multiple autoanalyzer|SMA|154|156|FOLLOW UP|9. Lisinopril 5 mg p.o. q.d. DIET: Regular. ACTIVITY: Ad lib. FOLLOW UP: He needs to follow up with his primary physician within one to two weeks with an SMA 10 and also with Dr. _%#NAME#%_ on _%#MMDD2003#%_. At the time of his follow up his BUN and creatinine needs to be checked as he has been started on Lisinopril during the current admission.
SMA|superior mesenteric artery|SMA|237|239|PAST  MEDICAL HISTORY|Unfortunately, the patient had a rising CA19-9 level and VATS procedure showed the pulmonary nodules were a recurrence of his pancreas cancer. He has follow up with Dr. _%#NAME#%_ to discuss chemotherapy. 1. Abdominal pain -- history of SMA stenosis of about 50% on an MRI.2. 3. Atrial fibrillation -- on Coumadin. 4. BPH. 4. Hypertension.5. 6. Head injury many years ago -- with a residual right 6th and 8th cranial nerve palsy.
SMA|superior mesenteric artery|SMA|305|307|LABORATORY  DATA|MSK: Severely kyphotic spine. LABORATORY DATA: EKG shows no acute ischemic changes, appears to have well controlled heart rate. No evidence of dysrhythmia. Chest x-ray is still pending. CT scan of abdomen and pelvis reveals significant calcification through the blood vessels of her abdomen with probable SMA plaque present. Serum labs: Hemoglobin 14, white count 9.6, platelet count 297,000.
SMA|superior mesenteric artery|SMA|124|126|IMPRESSION|IMPRESSION: An 83-year-old female who smokes. She has got oxygen dependent COPD, does have a right pleural effusion and has SMA clot with what appears to be mesenteric ischemia. She has had weight loss and most likely is going need revascularization to eliminate her symptoms.
SMA|superior mesenteric artery|SMA|205|207|HISTORY OF PRESENT ILLNESS|Unfortunately, she did not improve. She returned to Fairview Ridges ER where she underwent investigations and subsequent admission. Interestingly, the CT scan now shows thrombus within the proximal to mid SMA along with bilateral renal infarcts and equivocal thickening of the cecum. Because of this, the patient was transferred up to Fairview Southdale Hospital for consideration of an angiogram.
SMA|superior mesenteric artery|SMA|189|191|IMPRESSION|IMPRESSION: A 59-year-old woman with a constellation of symptoms, including abdominal pain, nausea and vomiting, as well as diarrhea, which I suspect is related to ischemic colitis and the SMA thrombus. I suspect that her hematuria was related to the renal infarctions. The patient is to be scheduled for an angiogram with Interventional Radiology to better look at her blood vessels.
SMA|superior mesenteric artery|SMA,|223|226|HOSPITAL COURSE|The patient subsequently had a nuclear medicine bleeding study done which showed possible active bleeding site within the right pelvis. The patient underwent subsequent visceral angiogram which showed normal celiac, normal SMA, a very small but patent IMA could not be selectively catheterized. After all this workup was thought that the patient's anemia is most likely secondary to episodic diverticular tic bleeding.
SMA|superior mesenteric artery|SMA|173|175|DISCHARGE DIAGNOSES|Cultures grew pseudomonas aeruginosa and Klebsiella pneumonia. b. The patient was seen in consultation by Dr. _%#NAME#%_ who treated her with a course of IV antibiotics. 2. SMA aneurysm repair _%#MMDD2006#%_ by Dr. _%#NAME#%_. 3. Clostridium difficile colitis. 4. Abnormal LFTs felt likely related to passing of gallbladder sludge with elevated LFTs which are decreasing at time of discharge.
SMA|superior mesenteric artery|SMA|366|368|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 71-year-old gentleman who has had a past history of CVA resulting in clumsiness in his hand and difficulty with his speech who was undergoing speech therapy since 2004 until about four months ago. He also has a history of hypertension, chronic stable extensive thoracic aortic dissection extending to below his SMA since about 6 years ago. His last CT was in _%#MM#%_ which was stable. The patient was recently treated for walking pneumonia when he presented with shortness of breath and fatigue and a chest x-ray showed pneumonia.
SMA|superior mesenteric artery|SMA|194|196|PAST MEDICAL HISTORY|1. Hypertension with his blood pressure running somewhat low and therefore his Norvasc was discontinued a week ago. 2. Chronic stable extensive thoracic aortic dissection extending to below his SMA in the past six years, but probably diagnosed only four years ago by a CT. He initially had back pain which was not evaluated with a CT, but 4 years ago when he had a widened mediastinum on a chest x-ray, was evaluated with a CT and was found to be diagnosed as chronic and the plan was to treat him medically.
SMA|superior mesenteric artery|SMA|364|366|LABORATORY  DATA|DTRs 1+ diffusely. Plantars are downgoing. LABORATORY DATA: Showed a white count of 4.3, hemoglobin 13.7, hematocrit 39.8, platelets 151, sodium 132, potassium 3.8, chloride 97, CO2 26, BUN 17, creatinine 1.03, hemoglobin A1c a week ago was 5.8. CT of the chest showed extensive descending thoracic aortic dissection, measuring about 6.3 cm extending to below the SMA with no change from _%#MMDD2006#%_. MRI of the head per ER report showed a significant small vessel disease. EKG is sinus rhythm and rate of 61 per minute, occasional PA-C, low voltage diffusely, more so in the limb leads with Q-waves in inferior leads consistent with possible old inferior infarct.
SMA|superior mesenteric artery|SMA|219|221|DISCHARGE PLAN|DISCHARGE PLAN: 1. Follow up with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2006, at 10 a.m. 2. Follow up with Dr. _%#NAME#%_, primary care doctor on _%#MM#%_ _%#DD#%_, 2006, at 3:20 p.m. 3. Ultrasound of arteries including SMA and celiac axis on _%#MM#%_ _%#DD#%_, 2006, at 10 a.m. No food or drink 8 hours prior to this study. 4. Restart MS Contin 15 mg p.o. b.i.d. for chronic abdominal pain with immediate release morphine p.r.n. as needed for increasing pain.
SMA|superior mesenteric artery|SMA|310|312||Also possible inappropriate use of alcohol as an etiology. The patient presented to hospital to make her comfortable and NPO order, IV fluids, and also upper gastrointestinal workup per consultant Gastroenterology. After reviewing her previous records and GI workups, Dr. _%#NAME#%_ recommended possibility of SMA Type Syndrome which has a difficult control prognosis, but decided to do CT of the abdomen and small bowel follow-through.
SMA|superior mesenteric artery|SMA|129|131|HOSPITAL COURSE|The patient had an unremarkable hospital course. He underwent a pancreas biopsy of the pancreatic tail. This was decided, as the SMA was narrow at the time of transplant. The tail was successfully biopsied and showed acute neutrophilic pancreatitis. The patient's amylase and lipase serum enzymes continued to increase during his hospitalization.
SMA|superior mesenteric artery|SMA|212|214|PROCEDURES|3. History of saphenous venous thrombus. 4. Ductal carcinoma in situ, breast cancer status post bilateral mastectomy. CONSULTS: Intervention radiology. PROCEDURES: 1. On _%#MMDD2007#%_, mesenteric angiography of SMA and celiac vessels showing no active GI bleed. 2. Blood transfusion. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 44-year-old female with recent workup for occult GI bleed including colonoscopy showing melena to the terminal ileum and normal EGD who underwent capsule endoscopy on _%#MMDD2007#%_, which was found to show an active jejunal bleed.
SMA|superior mesenteric artery|SMA|735|737|LABORATORY DATA|Troponin initially was 0.58 at 4:45 this morning, at 10:57 it was 0.46. INR was 1.82. Sodium 138, potassium 4.4, chloride 106, CO2 23, glucose 94, BUN 22, creatinine 0.8, calcium 9.1. Liver function tests were normal. White blood cell count 14.1, hemoglobin 13.2, hematocrit 40.4, platelets 294, absolute neutrophils 9.5. CT of the abdomen showed mildly dilated loops of fluid filled small bowel with normal caliber distal loops suggesting partial mechanical small-bowel obstruction, moderate amount of stool in the left colon, small periumbilical ventral hernia containing fat, multiple indeterminate small low density lesions in the liver, too small to characterize, possible small cyst, prominent calcification at the origin of the SMA with some atherosclerotic disease in the proximal SMA. ASSESSMENT AND PLAN: 1. Hypotension, unsure of etiology, associated with vomiting this a.m.; some concern for sepsis versus cardiac.
SMA|superior mesenteric artery|SMA,|278|281|PROCEDURES|2. Abdominal aortogram obtained on _%#MMDD2007#%_ showing a possible minimal angiodysplasia at the sigmoid and descending colon branches off of the IMA. There was irregular caliber and vasospasm with corkscrew aspect. No aneurysm or draining vein was identified. Patent celiac, SMA, IMA and iliac arteries and no renal artery stenosis. 3. CT enterogram, _%#MMDD2007#%_, results were pending at the time of discharge.
SMA|superior mesenteric artery|SMA|183|185|FOLLOW UP|DISCHARGE MEDICATIONS: 1. Glyburide 10 mg q.d. 2. Glucophage 500 mg p.o. q.d. 3. Lisinopril 5 mg p.o.q.d. 4. Aspirin 325 mg p.o. q.d. FOLLOW UP: As mentioned above within 1 week with SMA prior to evaluation by physician to rule out electrolyte abnormalities secondary to starting lisinopril.
SMA|superior mesenteric artery|SMA|157|159|HOSPITAL COURSE|She also had evidence of somewhat diffuse bleeding sites more than just at the splenic flexure and the MR angiogram that she had today shows a patent celiac SMA and IMA vasculature. For all of these reasons, I think we need to keep the differential diagnosis somewhat open.
SMA|superior mesenteric artery|SMA|306|308|HISTORY  OF PRESENT ILLNESS|CHIEF COMPLAINT: Slurred speech, hypoglycemia. HISTORY OF PRESENT ILLNESS: A 75-year-old female well known to us who was recently discharged last Friday after a prolonged hospitalization for newly diagnosed Crohn's with a proctocolectomy subsequently complicated by a proximal duodenal obstruction from an SMA syndrome who presents here with slurred speech. She reports poor p.o. intake since discharge. She has also had some urinary frequency.
SMA|superior mesenteric artery|SMA|147|149|KEY IMAGING STUDIES AND PROCEDURES PERFORMED THIS HOSPITALIZATION TO DATE|Findings: In the inferior mesenteric artery there was some stenosis at its origin. There was no bleeding identified along its distribution. In the SMA there was normal appearance. No bleeding identified along this distribution. 5. Ultrasound guided thoracentesis on _%#MMDD2008#%_. 6. Colonoscopy on _%#MMDD2008#%_ which showed probable ischemic colitis. Likely to be the site of bleeding.
SMA|superior mesenteric artery|SMA.|151|154|SUMMARY OF HOSPITAL COURSE|No evidence of hemorrhage. He was admitted. His electrocardiogram showed a sinus rhythm with sinus arrhythmia, left axis deviation, and some premature SMA. He was given insulin and over a period of time his sugars came down. His blood sugars have been nicely controlled. Nursing staff decided only to check them once a day now with sugar yesterday 135 in the morning, this morning 176, previous to that time his sugars have all been under the 200s with the exception of 1 in the last 15 determinations.
SMA|superior mesenteric artery|SMA|98|100|CHIEF COMPLAINT|CODE STATUS: Full code. INFORMATION: Patient, FCIS. CHIEF COMPLAINT: 53-year-old woman with known SMA thrombosis, here for follow up angiogram. HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old woman initially transferred to University of Minnesota Medical Center, Fairview, _%#MMDD2007#%_ from _%#COUNTY#%_ _%#COUNTY#%_'s Hospital where SMA occlusion was found to explain abdominal pain.
SMA|superior mesenteric artery|SMA|196|198|PAST MEDICAL HISTORY|There is no family history of bleeding problems, clots, strokes or miscarriages. PAST MEDICAL HISTORY: 1. Hypertension treated with clonidine and lisinopril prior to last admission. 2. Anemia. 3. SMA thrombosis with occlusion causing abdominal pain. 4. Right lower extremity hematoma attributed to lytic therapy and anticoagulation evacuated by vascular surgery on last admission.
SMA|superior mesenteric artery|SMA|151|153|ASSESSMENT|LABORATORY DATA: CBC, Chem 7, INR, PTT, AST, ALT, amylase, lipase, alkaline phosphatase pending on admission. ASSESSMENT: 53-year-old woman with known SMA thrombosis causing abdominal pain, treated with lytic therapy and anticoagulation with enoxaparin requiring follow up angiogram by Interventional Radiology.
SMA|superior mesenteric artery|SMA|211|213|PLAN|ASSESSMENT: 53-year-old woman with known SMA thrombosis causing abdominal pain, treated with lytic therapy and anticoagulation with enoxaparin requiring follow up angiogram by Interventional Radiology. PLAN: 1. SMA thrombosis: Enoxaparin will be held at this time. If IR procedure is not done today, the team will discuss anticoagulation with heparin with Interventional Radiology.
SMA|superior mesenteric artery|SMA|225|227|DISCHARGE DIAGNOSIS|At the mid-segment of the first diagonal branch there is a moderate 60-70% stenosis, probably 1.5-2 mm. The LAD then continues on with mild irregularity. The left ventriculogram revealed normal left ventricular function with SMA ejection fraction of 65-70%. The patient had a successful PTCA and stenting to OM-1 without complications. The day after his procedure the patient had complaints of chest pain or shortness of breath.
SMA|sequential multiple autoanalyzer|SMA|295|297|LABORATORY|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 101.0, otherwise normal vitals. HEENT: The patient had right facial swelling, erythema, calor, and tenderness over her right face extending from her lower eyelid through the buccal region with parotid swelling. LABORATORY: WBC 7.7, hemoglobin 9.7, SMA negative. Hepatitis serology negative. CT of the chest revealed bilateral small pleural effusions. PROBLEMS: 1. Facial Cellulitis: We continued azithromycin, clindamycin, ceftriaxone. Chest x-ray was subsequently normal and azithromycin and ceftriaxone were discontinued after a full 7-day course had been given.
SMA|superior mesenteric artery|SMA|147|149|PAST MEDICAL HISTORY|10. Bilateral cataract surgery. 11. Left herniorrhaphy. 12. Status post T&A. 13. Renal angiography _%#MM#%_ 1998. 14. Abdominal aortic aneurysm at SMA level 5 cm followed by Dr. _%#NAME#%_. 15. Atrophic left kidney. 16. Chronic obstructive pulmonary disease FAMILY HISTORY/SOCIAL HISTORY: Reviewed without change.
SMA|superior mesenteric artery|SMA|138|140|PAST MEDICAL HISTORY|Gastrografin enema was consistent with a dilated terminal ileum with no peristomal hernia. CT at that time was consistent with a possible SMA syndrome; however, subsequent CT scans have been negative. The last abdominal CT was in _%#MM#%_ 2002. 3. Hernias at her ostomy site.
SMA|superior mesenteric artery|SMA|150|152|HOSPITAL COURSE|Abdominal CT scan showed a soft tissue mass in the proximal transverse colon with direct pericolonic mesenteric induration and adenopathy towards the SMA and venous change. No focal liver or lung lesions were seen. The patient's CEA level was 24.5. On _%#MM#%_ _%#DD#%_, 2003, the patient had a segmental colectomy consisting of the right and transverse colon.
SMA|superior mesenteric artery|SMA,|187|190|OPERATIONS/PROCEDURES PERFORMED THIS ADMISSION|3. MRA of the abdomen dated _%#MMDD2004#%_. Findings: Celiac and superior mesenteric occlusion or thrombus. There is no renal artery stenosis. There is some reconstitution of flow in the SMA, a few centimeters beyond it's origin. There is a focal area of high T2 signal on the spleen, probably splenic infarct.
SMA|superior mesenteric artery|SMA|160|162|HOSPITAL COURSE|Given the constellation of his symptoms, we were concerned about mesenteric ischemia. He underwent MRA of the abdomen which demonstrates a thrombus of both the SMA and celiac access. There is some reconstitution of flow distal to the SMA as described above. A Vascular Surgery consult was obtained and it was felt that the patient should be transferred to Fairview Southdale for further care.
SMA|superior mesenteric artery|SMA|148|150|HOSPITAL COURSE|He underwent MRA of the abdomen which demonstrates a thrombus of both the SMA and celiac access. There is some reconstitution of flow distal to the SMA as described above. A Vascular Surgery consult was obtained and it was felt that the patient should be transferred to Fairview Southdale for further care.
SMA|superior mesenteric artery|SMA|471|473|PAST MEDICAL HISTORY|She experienced no chills, rigors, or change in bowel or bladder function. PAST MEDICAL HISTORY: She has a past medical history that includes chronic pancreatitis, status post cyst debridement, status post distal pancreatectomy, status post colonic perforation with colostomy, hyperlipidemia, status post splenectomy, diabetes mellitus, ERCP with multiple stent placements with an extra hepatic biliary obstruction, duodenal stricture, portal venous, splenic venous, and SMA thrombosis, acute renal failure, depression, cerebral vascular accident with seizure disorder, gastroesophageal reflux. The patient was admitted NPO. She was given IV hydration and IV pain control.
SMA|sequential multiple autoanalyzer|SMA|370|372|FOLLOW UP|3. Aerosolized pentamidine q. month for PCP prophylaxis. FOLLOW UP: Patient to follow up with his primary physician in 2-3 weeks for further evaluation, and patient needs also to be assessed by GI clinic and by the pathology general med clinic in 2 weeks. The clinic number was given to the patient, 625-5155, to make appointment (it should be in 2 weeks) with LFTs and SMA and CBC.
SMA|superior mesenteric artery|SMA.|210|213|HOSPITAL COURSE|Gastrografin enema revealed moderate retained stool in the colon with sigmoid colon diverticulum. Subsequent abdominal CT scan showed a normal appendix, densely calcified abdominal aorta and branches including SMA. However, the abdomen and pelvis was unremarkable. The patient subsequently began drinking fluids and tolerated this well. She had gradual improvement in her abdominal pain and was discharged in improved condition.
SMA|superior mesenteric artery|SMA|233|235|HISTORY OF PRESENT ILLNESS|He presented with all over body pain/bone pain. The patient was discharged from F- UMC (5B) on _%#MMDD2003#%_, with a discharge diagnosis of: 1. Candida pneumonia. 2. Vancomycin-resistant enterococcus bacteremia. 3. Hypertension. 4. SMA syndrome. 5. Hyperbilirubinemia. 6. Pansinusitis. 7. Immune hemolysis. 8. GVHD of liver and skin. 9. Depression. The patient went to his clinic on _%#MMDD2003#%_ to have a CBC checked and for follow-up.
SMA|superior mesenteric artery|SMA|149|151|PRIOR HOSPITALIZATIONS AND SURGERY|5. Depression. 6. Frequent ear infection, mastoiditis in _%#MM#%_ 2002. 7. History of Candida pneumonia. 8. History of VRE bacteremia. 9. History of SMA syndrome. 10. Pansinusitis. 11. Hypertension. SOCIAL HISTORY: He lives with his mother. PHYSICAL EXAMINATION: On exam in the ER his vitals were as follows: temperature 108, pulse 102, respirations 16, blood pressure 99/60, O2 sats 96%.
SMA|superior mesenteric artery|SMA|250|252||Because of this finding, she underwent a colonoscopy which came back normal. She was subsequently scheduled for an MRI of her abdomen which revealed a significantly appearing stenosis of the proximal superior mesenteric artery, and the origin of the SMA was felt to be small in caliber and just beyond the first mm. there was a high grade appearing SMA stenosis. The celiac as well as the internal mammary artery were patent.
SMA|superior mesenteric artery|SMA|272|274||She was subsequently scheduled for an MRI of her abdomen which revealed a significantly appearing stenosis of the proximal superior mesenteric artery, and the origin of the SMA was felt to be small in caliber and just beyond the first mm. there was a high grade appearing SMA stenosis. The celiac as well as the internal mammary artery were patent. Because of this, the patient is now scheduled for an angiogram with possible angioplasty to the SMA at Fairview Southdale Hospital on _%#MM#%_ _%#DD#%_.
SMA|superior mesenteric artery|SMA|114|116|DISCHARGE MEDICATIONS|She is going to follow-up with me next week and Dr. _%#NAME#%_ in a couple of weeks. She does need CT scan of the SMA artery to see how bad stenosis is and would she be a surgical candidate.
SMA|superior mesenteric artery|(SMA)|135|139|DOB|DOB: _%#MMDD1941#%_ FINAL DIAGNOSIS: Intestinal ischemia with occlusion of previously- placed hepatic aorto-superior mesenteric artery (SMA) bypass. PROCEDURE: 1. Visceral angiogram. 2. Right common iliac to right common hepatic bypass with 6 mm externally-supported polytetrafluoroethylene/Teflon graft (PTFE).
SMA|superior mesenteric artery|SMA|286|288|DOB|PROCEDURE: 1. Visceral angiogram. 2. Right common iliac to right common hepatic bypass with 6 mm externally-supported polytetrafluoroethylene/Teflon graft (PTFE). 3. Cholecystectomy. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 63-year-old male who previously had undergone a SMA and aorto-common hepatic bypass for intestinal ischemia. He returned with abdominal pain, nausea and vomiting. Angiography was obtained which showed occlusion of his previously placed graft.
SMA|superior mesenteric artery|SMA.|201|204|HISTORY OF PRESENT ILLNESS|At that time, she was placed on Gemzar times 3 cycles but had continued progression on _%#MMDD2005#%_. A CT scan showed an enlarging periaortic lymph node to just above the celiac as well as below the SMA. There was right hydronephrosis secondary to enlarged nodes and stents were placed. Patient initially presented to _%#CITY#%_ Hospital early in the morning on _%#MMDD2005#%_ with frequent falls, weakness, and disorientation.
SMA|sequential multiple autoanalyzer|SMA|193|195|LABORATORY DATA|CARDIOVASCULAR: S1, S2. No murmurs. CHEST AND LUNGS: Clear to auscultation bilaterally. ABDOMEN: Ileostomy and intact. Bowel sounds present. LABORATORY DATA: White count 16.2, hemoglobin 13.9. SMA 7 showed a creatinine of 1.39, baseline creatinine 0.9-1.0. HOSPITAL COURSE: PROBLEM #1: .......to rule out sepsis.
SMA|sequential multiple autoanalyzer|SMA|224|226|HISTORY OF PRESENT ILLNESS|No family history of clotting disorder or smoking/OCP use. Admitted for CT angiogram per above. Vitals on admission notable for pulse of 100, blood pressure 104/71. Cardiovascular and lung exam within normal limits. CBC and SMA both normal. D-dimer 3.5 and troponin negative. Chest x-ray showed line in SVC. EKG normal. CT per above. PAST MEDICAL HISTORY: 1. Irritable bowel syndrome.
SMA|superior mesenteric artery|SMA|161|163|HISTORY OF PRESENT ILLNESS|He had another tagged red blood cell which suggested a left upper quadrant source, possibly jejunum. On _%#MM#%_ _%#DD#%_, 2004, he underwent angiography of the SMA and IMA in _%#CITY#%_ with heparin provocation. No source of bleeding was found at that time. He subsequently developed acute cholecystitis by HIDA scan and underwent an open cholecystectomy.
SMA|spinal muscular atrophy|(SMA)|132|136|ADMISSION DIAGNOSES|DOB: ADMISSION DIAGNOSES 1. Pneumonia with respiratory distress and oxygen requirement. 2. Leukocytosis. 3. Spinal muscular atrophy (SMA) type 2. HISTORY OF PRESENT ILLNESS: The patient became ill with an upper respiratory infection six days ago.
SMA|spinal muscular atrophy|SMA|269|271|PAST MEDICAL HISTORY|Increased vibratory vest from baseline b.i.d. to q.i.d., and was seen in the Emergency Room early this morning for persistent respiratory distress. PAST MEDICAL HISTORY: Surgeries: None. Hospitalizations: None. Birth history: Term baby. Chronic illness: Diagnosed with SMA type 2 at approximately 8 to 9 months of age following a gastroenteritis, from which he remained quite weak with low tone.
SMA|spinal muscular atrophy|SMA|209|211|IMPRESSION AND ASSESSMENT|Hemoglobin 13. Hematocrit 39. Platelets 370,000. Calcium 9.9. Chest x-ray: Radiology result pending, and we will review with them. Electrolytes within normal limits. Calcium 9.9. IMPRESSION AND ASSESSMENT: 1. SMA type 2 patient with lower respiratory infection, reportedly pneumonia, with respiratory distress and oxygen requirement and leukocytosis without significant left shift.
SMA|superior mesenteric artery|SMA|223|225|HISTORY OF PRESENT ILLNESS|She has had a history of chronic abdominal pain for the past 5 years, and a recent history of 20 pounds of weight loss over approximately 5 months. She was transferred to the University of Minnesota for a second attempt at SMA stenting. As the previous attempt at stenting of the SMA was from a groin approach, we elected to perform a left upper extremity approach.
SMA|superior mesenteric artery|SMA|132|134|HISTORY OF PRESENT ILLNESS|She was transferred to the University of Minnesota for a second attempt at SMA stenting. As the previous attempt at stenting of the SMA was from a groin approach, we elected to perform a left upper extremity approach. Again, the superior mesenteric artery was noted to be occluded, but both the celiac access and the inferior mesenteric artery appeared patent.
SMA|spinal muscular atrophy|(SMA|218|221|FOLLOW UP|On discharge, he was instructed to follow-up in the Pediatric Neurology Clinic for further work-up of his hypotonia. He saw Dr. _%#NAME#%_ _%#NAME#%_ who gave him a probable diagnosis of Spinal Muscular Atrophy Type I (SMA I) given his clinical course and areflexia. Genetic testing was sent for SMA I and is pending at this time. Prior to admission, _%#NAME#%_ was seen in clinic for feeding intolerance with dysphagia.
SMA|spinal muscular atrophy|SMA|179|181|FOLLOW UP|He saw Dr. _%#NAME#%_ _%#NAME#%_ who gave him a probable diagnosis of Spinal Muscular Atrophy Type I (SMA I) given his clinical course and areflexia. Genetic testing was sent for SMA I and is pending at this time. Prior to admission, _%#NAME#%_ was seen in clinic for feeding intolerance with dysphagia.
SMA|superior mesenteric artery|SMA|197|199|HOSPITAL COURSE|We asked surgery to consult on the patient for further evaluation of this. They recommended doing a CT angiogram, which has an official read pending at this time. Unofficially, it appears that the SMA and IMA are wide open and patent. She did have an elevated lactate at 2.7, but this had normalized to 2.1 prior to discharge.
SMA|superior mesenteric artery|SMA|330|332|OPERATIONS/PROCEDURES PERFORMED|No obvious clot. 5. Echo bubble study dated _%#MMDD2005#%_; negative bubble study. 6. MR abdomen dated _%#MMDD2005#%_; findings, there is some left questionable significant stenosis at the origin of the left renal artery, severe stenosis at the origin of the left common ileac as well as possibly suspected severe stenosis of the SMA superior mesenteric. BRIEF HISTORY: A 62-year-old female who presents here with left- sided hand numbness and tingling that was persistent and had gotten worse to date.
SMA|superior mesenteric artery|SMA.|270|273|ADMISSION MEDICATIONS|Her abdomen is benign. LABORATORY: Preoperative hemoglobin 14.9, hematocrit 44.6. INR 1.07. CT angiogram on _%#MM#%_ _%#DD#%_, 2005, demonstrated a total liver volume of 1706 cc with the right lobe 1137 cc. There was a replaced right hepatic artery originating from the SMA. The left hepatic artery originates from the celiac axis. There is a normal portal-vein branching pattern and normal hepatic venous anatomy.
SMA|superior mesenteric artery|SMA|205|207|SURGEON|He was then referred to Fairview Southdale to undergo visceral angiography by Dr. _%#NAME#%_ _%#NAME#%_ and the angiogram did not show any bleed at that time. At that time, he had a catheter placed in the SMA superior mesenteric artery and was then sent to the intensive care unit. Gastroenterology was consulted for this as well as Dr. _%#NAME#%_ for surgical intervention.
SMA|superior mesenteric artery|SMA|162|164|HISTORY|However, due to lack of the displacement of the calcified intima, it was very low likelihood that any dissection was taking place. There was calcification of the SMA as well as gallstones and enlarged prostate noted. Please note this is a preliminary CT scan. His EKG is normal. The patient has had no significant chest discomfort or shortness of breath.
SMA|superior mesenteric artery|SMA,|135|138|ADDENDUM|You are referred to Dr. _%#NAME#%_'s previously dictated discharge summary. ADDENDUM The results of the MRI of the abdomen show patent SMA, patent IMA, mild stenosis celiac mesenteric artery; however, not significant enough to account for the patient's symptoms. No convincing evidence of intestinal ischemia.
SMA|superior mesenteric artery|SMA|327|329|GI|His UAC was removed on _%#MMDD2007#%_. At that time, his lactate bumped to 6.1. His last lactate acid level was done on _%#MMDD2007#%_, which is about 12 days prior to discharge and the lactate acid level was decreased nicely to 1.9, which is normal. Aorta and renal artery ultrasound showed a small clot in his aorta near the SMA with no visible clot in the renal arteries. He was briefly on heparin during this hospitalization. Renal: _%#NAME#%_ initially had a high creatinine level which is now normalized.
SMA|superior mesenteric artery|SMA.|336|339|HISTORY OF PRESENT ILLNESS|These gastrointestinal symptoms continued despite discontinuation of salicylate. Extensive workup at previous Emergency Department visits were negative, and include normal chest x-ray, normal right upper quadrant ultrasound, normal abdominal x-rays times three, and abdominal computed tomography which was normal except for an enlarged SMA. Patient reports no significant relief with Phenergan, Pepcid, Benadryl, or GI cocktail. On the day of admission the patient reports increasing nausea and vomiting which has now become chronic, rather than intermittent.
SMA|superior mesenteric artery|SMA|110|112|HISTORY OF PRESENT ILLNESS|She was transferred to University of Minnesota Medical Center, Fairview on _%#MMDD2007#%_ with a diagnosis of SMA thrombosis. The patient was started on anticoagulation with enoxaparin. After discharge on _%#MMDD2007#%_, the patient was asked to return for elective SMA angiogram to follow up known SMA clot.
SMA|superior mesenteric artery|SMA|173|175|HISTORY OF PRESENT ILLNESS|The patient was started on anticoagulation with enoxaparin. After discharge on _%#MMDD2007#%_, the patient was asked to return for elective SMA angiogram to follow up known SMA clot. Per discharge summary of _%#MMDD2007#%_, the patient had a Hematology workup for hypercoagulation stage, which was reportedly negative.
SMA|superior mesenteric artery|SMA|134|136|HOSPITAL COURSE|HOSPITAL COURSE: The patient was on low-intensity heparin protocol with enoxaparin held prior to SMA angiogram. The patient underwent SMA angiogram, which revealed patent SMA artery. No angioplasty or other intervention was done at that time. Per recommendations from Interventional radiologist, Dr. _%#NAME#%_, the patient was started on clears.
SMA|superior mesenteric artery|SMA|171|173|HOSPITAL COURSE|HOSPITAL COURSE: The patient was on low-intensity heparin protocol with enoxaparin held prior to SMA angiogram. The patient underwent SMA angiogram, which revealed patent SMA artery. No angioplasty or other intervention was done at that time. Per recommendations from Interventional radiologist, Dr. _%#NAME#%_, the patient was started on clears.
SMA|superior mesenteric artery|SMA|139|141|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Enoxaparin 70 mg subcutaneously q. 12h. until 24-48 hours after INR therapeutic. 2. Warfarin 2 mg p.o. daily for SMA clot, INR goal 2-3. 3. Prochlorperazine 10 mg p.o. q. 6h. p.r.n. nausea vomiting. 4. Pantoprazole 40 mg p.o. daily. 5. Oxycodone 5 mg p.o. q. 4h. as needed for pain.
SMA|superior mesenteric artery|SMA|286|288|DISPOSITION|The patient will follow up with new primary care provider, Dr. _%#NAME#%_ _%#NAME#%_ who is familiar with the patient from previous admission on _%#MMDD2007#%_ at 09:40 a.m. in the primary care clinic. Per recommendations from Dr. _%#NAME#%_, the patient will require ultrasound of the SMA in 1 month, 3 months, and 6 months to evaluate outflow arteries. In 6 months, if the patient's ultrasounds do not reveal progression of the clot and the patient is clinically doing well, INR goal should be reduced from 2-3 to 1.5-2. The patient should be continued on warfarin for approximately 5-10 units per Dr. _%#NAME#%_.
SMA|sequential multiple autoanalyzer|SMA|144|146|DISCHARGE MEDICATIONS|His symptoms were very much improved, and his mood is improved. The patient will schedule an appointment to see Dr. _%#NAME#%_ and will have an SMA planned just prior to Dr. _%#NAME#%_'s appointment. Dr. _%#NAME#%_ will adjust the KCl supplement and Lasix dose according to the patient's symptoms and lab results.
SMA|sequential multiple autoanalyzer|SMA|121|123|LABORATORY DATA|Neurologic exam: Normal cranial nerves. Normal motor exam. LABORATORY DATA: Hematocrit 40% normal. Urinalysis is normal. SMA 8 is pending. ASSESSMENT: 1. Markedly enlarged uterus due to multiple uterine fibroids.
SMA|superior mesenteric artery|SMA|287|289|LABORATORY DATA|CT scan of the abdomen is done which shows marked abnormality of the distal 20-25 cm of terminal ileum are markedly thickened of bowel wall with a proximal dilated loops of small bowel. Appears to be per Dr. _%#NAME#%_, a possible ischemic bowel, although, he sees good flow through the SMA and SMB. This likely represents infection versus ischemic bowel with small bowel obstruction. The patient will obviously require inpatient admission. I contacted her primary, Dr. _%#NAME#%_ _%#NAME#%_, and discussed the case with her.
SMA|superior mesenteric artery|SMA|188|190|PROCEDURES|The patient is to talk to Dr. _%#NAME#%_ about restarting _______. His previous dose was 0.25 mg q.d. PROCEDURES: 1. Exploratory laparoscopy. 2. Abdominal angiogram, which showed a patent SMA and patent left SMA branches displaced to the right, with no filling defects or ischemia. 3. Abdominal CT showed only mildly thickened loops of bowel.
SMA|spinal muscular atrophy|SMA|265|267|HOSPITAL COURSE|However, he had a completely normal neurologic exam, no focal findings, and was without emesis for 48 hours and so we decided to cancel the study, although this may be something that would be considered, if he becomes readmitted. The plan for managing _%#NAME#%_'s SMA at this point, was discussed at length with mom. At this point, she is avid about feeding _%#NAME#%_ by mouth, not by NG or NJ tube, or by TPN at this point.
SMA|sequential multiple autoanalyzer|SMA,|160|163|PHYSICAL EXAMINATION|NEUROLOGIC: The patient is intact. LABORATORY DATA: Laboratory exams were taken at the time of admission and are essentially normal. These tests include a CBC, SMA, and LFTs. Of note, his creatinine is 1.1, and his hemoglobin is 16.5 preoperatively. HOSPITAL COURSE: The patient was admitted for a lung transplant when a donor lung became available on _%#MMDD2003#%_.
SMA|superior mesenteric artery|SMA,|376|379|DISCHARGE DIAGNOSES|Indication: Abdominal pain. Results: No abdominal aortic aneurysm, significant atherosclerotic calcification throughout the abdominal aorta, status post fem-fem bypass, a low attenuation lesion of the left kidney suggestive of angiomyolipoma. 2. MRI/MRA of the abdomen (_%#MM#%_ _%#DD#%_, 2002). Indication: Evaluation for possible mesenteric ischemia. Results: Celiac trunk, SMA, and IMA are patent at their origins. No evidence of local stenosis in the proximal celiac or SMA. HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old woman presenting to an outside hospital after severe generalized abdominal pain.
SMA|sequential multiple autoanalyzer|SMA|150|152|FOLLOW-UP|The patient is advised outpatient cardiac rehab. FOLLOW-UP: The patient is to follow up with her primary practitioner in one week's time with CBC and SMA 10. She also needs to follow up with Dr. _%#NAME#%_ _%#NAME#%_ of Interventional Cardiology at Cardiac Clinic in four weeks time.
SMA|sequential multiple autoanalyzer|SMA|172|174|PLAN|9. Regular insulin sliding scale with q.i.d. finger sticks. PLAN: Follow-up will be with Dr. _%#NAME#%_ in three weeks, with Dr. _%#NAME#%_ in two weeks. He will have CBC, SMA 12 and ESR q Monday per Dr. _%#NAME#%_. Will see Dr. _%#NAME#%_ in follow-up in two weeks in his office. We as well discussed code status with the patient during his hospitalization with both him and his family.
SMA|sequential multiple autoanalyzer|SMA|143|145|PROBLEM #3|The plan is for her to follow with Dr. _%#NAME#%_ _%#NAME#%_ at her home clinic in _%#CITY#%_ as soon as possible after the discharge, with an SMA check if the patient has developed contrast nephropathy. Most likely it will resolve completely within two weeks. DISPOSITION: The patient was discharged to home in stable condition.
SMA|superior mesenteric artery|SMA|203|205|REASON FOR DEATH|Concern again was for an intraabdominal process and she was sent for CT scan. CT scan showed pneumatosis intestinalis including pneumatosis in the portal system. She underwent arteriogram that showed an SMA occlusion and was taken to the operating room and underwent an exploratory laparotomy and SMA revascularization. Her bowel was markedly ischemic and there was a significant concern for complete gut infarction.
SMA|superior mesenteric artery|SMA|329|331|REASON FOR DEATH|After discussing these issues with the family, it was elected to make the patient comfort care and she expired on _%#MM#%_ _%#DD#%_, 2003. The impression is that the patient did not have any evidence of torsion or bowel obstruction related to her Roux-en-Y hepaticojejunostomy but rather that she had undergone thrombosis of her SMA as a result of her underlying significant atherosclerotic vascular disease, possibly precipitated by her postsurgical state and possibly further precipitated by some dehydration from her antecedent 2 or 3 days of poor p.o. intake.
SMA|superior mesenteric artery|SMA.|148|151|PAST MEDICAL HISTORY|4. Diabetes. 5. Chronic renal insufficiency with a baseline creatinine of 1.5 to 1.7. 6. History of mesenteric ischemia status post stenting to the SMA. 7. Carotid artery stenosis status post stenting on the left and complete occlusion on the right. Most recent evaluation with an MRI and MRA in _%#MM#%_ of 2003 that showed significant stenosis on the left and complete occlusion on the right.
SMA|sequential multiple autoanalyzer|SMA|222|224|HISTORY OF PRESENT ILLNESS|No fever or jaundice. The patient presented with stable vital signs, very tender epigastric examination without rebound or guarding. Negative Murphy's sign. Amylase 88, lipase 303, alkaline phosphorus 66, ALT 60, AST 195. SMA and CBC normal. EKG normal and ultrasound as noted above. HOSPITAL COURSE: 1. Chronic cholecystitis. Due to absence of fever, antibiotic was not initiated and the patient was observed for presumed cholelithiasis with passed stone.
SMA|sequential multiple autoanalyzer|SMA,|211|214|LABORATORY AND X-RAY DATA|Physical examination is essentially normal, with difficult to assess breath sounds and multiple decubitus ulcers, including a stage III in his right flank. Most have healed over. LABORATORY AND X-RAY DATA: CBC, SMA, and EKG are normal. UA shows pyuria. Chest x-ray reveals the effusion. HOSPITAL COURSE: PROBLEM #1: Right-sided pleural effusion.
SMA|superior mesenteric artery|SMA.|196|199|HISTORY OF PRESENT ILLNESS|The patient was initially diagnosed with adenocarcinoma of the pancreas T4M0N0 locally advanced following a cholecystectomy where an endoscopic ultrasound revealed the 3 x 5 cm mass involving the SMA. The patient had a celiac plexus block to decrease low back pain as well as epigastric discomfort. She was started on chemotherapy on _%#MMDD#%_ as well as radiation on _%#MMDD#%_.
SMA|superior mesenteric artery|SMA|182|184|HOSPITAL COURSE|The MRI revealed a prominent bile duct and pancreatic duct with no stone or other obstructing lesion with an MRCP, and her MRA revealed extensive vascular disease. The origin of the SMA was occluded, there was reconstitution distally. The IMA is occluded, severe atherosclerotic disease involving the aorta and iliac arteries bilaterally.
SMA|superior mesenteric artery|SMA|183|185|PAST MEDICAL HISTORY|10) Bilateral cataract extractions. 11) Left herniorrhaphy. 12) Status post tonsillectomy and adenoidectomy. 13) Renal angiography in _%#MM#%_, 1998. 14) Abdominal aortic aneurysm at SMA level, 5 cm, followed by Dr. _%#NAME#%_. 15) Atrophic left kidney. 16) Chronic obstructive pulmonary disease. FAMILY HISTORY: One brother died of an abdominal aortic aneurysm rupture.
SMA|sequential multiple autoanalyzer|SMA|213|215|HISTORY OF PRESENT ILLNESS|Creatinine in the emergency room was about baseline and admitted for further workup. Vital signs stable on admission. No flank tenderness and otherwise normal exam. White count 17.4, hemoglobin 13, platelets 193. SMA 7 normal, BUN 26, creatinine 2.5. He had a renal ultrasound the day prior to admission revealing the 4 anechoic masses mentioned above.
SMA|superior mesenteric artery|SMA;|238|241|HOSPITAL COURSE|Colonoscopy was performed by Gastroenterology, which showed ischemic colitis extending from the splenic flexure to the cecum, several discontinuous areas were noted. Recommendations were that the patient have MR angiography of celiac and SMA; factor V Leiden levels, antiphospholipid antibodies were also ordered. His factor V Leiden mutation analysis is still pending, as well as cardiolipin; these need to be followed up as an outpatient.
SMA|superior mesenteric artery|SMA.|189|192|PERTINENT PROCEDURES|2. CT of the abdomen and pelvis with contrast on _%#MM#%_ _%#DD#%_, 2004, revealed: A. Distended gastric through 2nd portion of the duodenum with air fluids and possible compression of the SMA. B. Enlargement of the left gonadal vein with prominent parametrial vessels, which may represent pelvic congestion syndrome. 3. Complete urine drug screen. Findings were positive for cocaine, cocaine metabolites, and Benadryl.
SMA|superior mesenteric artery|SMA|160|162|PAST MEDICAL HISTORY|He underwent exploratory lap with right transverse wedge resection, in addition to removal of the primary mass an additional mass was identified encircling the SMA which was unresectable. On _%#MMDD2002#%_ he underwent external beam radiation and is currently undergoing chemotherapy with 5FU as well as a study drug.
SMA|superior mesenteric artery|SMA,|228|231|IMPRESSION|This is an extremely difficult situation and it has been discussed with the patient and his family with high risk of complications and possible extensive bowel infarction and perforation. However, with the extensive clot in his SMA, I do feel that TPA lytic therapy is the appropriate treatment. I do not feel that surgically we can even come close to removing this clot with mechanical thrombectomy.
SMA|superior mesenteric artery|SMA,|174|177|DISCHARGE DIAGNOSIS|10. Colonoscopy in 2001 showed 1 polyp. Otherwise normal per patient. 11. EGD showed hiatal hernia. 12. Abdominal MRI on _%#MM#%_ _%#DD#%_, 2004, showed no stenosis. Celiac, SMA, IMA, IVC, SVC were all patent. 13. Barium enema on _%#MM#%_ _%#DD#%_, 2004, showed malrotated right colon without small bowel obstruction.
SMA|superior mesenteric artery|SMA|176|178|HOSPITAL COURSE|The remainder of the exam was completely nonfocal. HOSPITAL COURSE: 1. Lymphadenopathy - although the patient does have a recent history of "clogged" eustachian tubes, and the SMA was consistent with a reactive lymphadenitis, we felt it necessary to proceed with an excisional biopsy given his past medical history of anaplastic large T-cell lymphoma.
SMA|superior mesenteric artery|SMA|197|199|HISTORY OF PRESENT ILLNESS|On surgery recommendation, the patient was discharged home on nasojejunal tube with the cyclic feeding. The patient will be seen in the surgery clinic on _%#MM#%_ _%#DD#%_, 2005, and she will have SMA syndrome surgery as an outpatient. 2. Infectious disease: ID was consulted for Entamoeba hartmanni trophozoites which were seen in _%#MM#%_ 2005 in stools.
SMA|superior mesenteric artery|SMA|322|324|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Postpartum cardiomyopathy with an ejection fraction of less than 10%, status post LVAD placement for destination therapy in _%#MM2005#%_. A. Very complicated postoperative course including bleeding, infection, requirement of massive blood transfusions, ventilatory failure requiring tracheostomy, SMA syndrome, T9 paralysis secondary to microemboli. B. The patient is not a heart transplant candidate as PRA antibodies are 100%.
SMA|superior mesenteric artery|SMA|132|134|PAST MEDICAL HISTORY|9. Hypertension. 10. Mitral and aortic valve repair in 2002. 11. Mesenteric stents placed secondary to postprandial pain in 2001 in SMA and celiac arteries. 12. Myelodysplastic syndrome with refractory anemia and pancytopenia. ALLERGIES: Penicillin, Benadryl, contrast dye. MEDICATIONS: 1. Folate 800 mcg p.o. q. day.
SMA|superior mesenteric artery|SMA|319|321|HOSPITAL COURSE|She also had an MRA of the abdomen to rule out stenosis which showed mild to moderate stenosis of the proximal superior mesenteric artery, celiac access and inferior mesenteric artery, appeared to be patent proximally. A vascular surgery consultation was obtained and the recommendation was asymptomatic with 30-40% of SMA stenosis. No surgical intervention needed. At present, she denies any complaint. Her blood pressure ranged between systolic of 145-183 and diastolic 75-88, pulse 80, respiratory rate 18/minute.
SMA|superior mesenteric artery|SMA|219|221|HOSPITAL  COURSE|Due to the relatively young age of the patient, hypercoagulable workup has been undertaken and are pending at the time of discharge. The patient also had an MRA of the abdomen to evaluate for any stenosis of the celiac SMA or IMA vessels. At the time of discharge, the patient was not tolerating a normal diet and was able to control her pain with oral pain medications.
SMA|superior mesenteric artery|SMA|239|241|OPERATIONS/PROCEDURES PERFORMED|1. Gastrointestinal bleed. 2. Posttransplant lymphoproliferative disorder. 3. Cystic fibrosis, status post bilateral lung transplantation. OPERATIONS/PROCEDURES PERFORMED: 1. On _%#MM#%_ _%#DD#%_, 2006, mesenteric angiogram of the IMA and SMA with embolization of the jejunal branch and the left colonic branch of the IMA. 2. Transfusion; 13 units of packed red blood cells, 5 units of fresh frozen plasma, and three 5 packs of platelets.
SMA|superior mesenteric artery|SMA;|160|163|HOSPITAL COURSE|This was felt secondary to his small-bowel lymphoma, likely exacerbated by his anticoagulation. On _%#MM#%_ _%#DD#%_, 2006, mesenteric angiogram of the IMA and SMA; the IMA angiogram revealed an aneurysm of the branch supplying the left lower colon. SMA showed active extravasation of the proximal jejenum branch that was felt to lie close to an apparent bowel suture line from previous small-bowel resection.
SMA|superior mesenteric artery|SMA|154|156|HOSPITAL COURSE|On _%#MM#%_ _%#DD#%_, 2006, mesenteric angiogram of the IMA and SMA; the IMA angiogram revealed an aneurysm of the branch supplying the left lower colon. SMA showed active extravasation of the proximal jejenum branch that was felt to lie close to an apparent bowel suture line from previous small-bowel resection.
SMA|superior mesenteric artery|SMA.|266|269|LABORATORY DATA|UA is noted for ketones only. Troponin is less than 0.04, digoxin level 1.2. Electrolytes sodium 135, potassium 3.8, BUN 19, creatinine 0.64, glucose 181. CT scan shows bilateral infiltrates versus atelectasis of the lungs, diverticulosis and severe stenosis of the SMA. INR is 2.43. ASSESSMENT: 1. Infectious process, unknown source at this time.
SMA|superior mesenteric artery|SMA,|115|118|ISSUES|She underwent a mesenteric angiogram as described above. She was found to have aneurysm in the first branch of the SMA, but no SMA aneurysm. Third part of the duodenum was compressed and it was thought to be secondary to the peripancreatic fluid collection rather than the aneurysm.
SMA|superior mesenteric artery|SMA|127|129|ISSUES|She underwent a mesenteric angiogram as described above. She was found to have aneurysm in the first branch of the SMA, but no SMA aneurysm. Third part of the duodenum was compressed and it was thought to be secondary to the peripancreatic fluid collection rather than the aneurysm.
SMA|superior mesenteric artery|SMA|222|224|ISSUES|It was thought that the pancreatitis was secondary to the gallstone and the GI team recommended a cholecystectomy. The patient was seen by general surgery team and they also thought that the patient probably does not have SMA syndrome and should have a cholecystectomy as an outpatient. The compression of the third part of the duodenum was thought to be secondary to the peripancreatic fluid collection and NG was placed in the decompression for the first 3 days.
SMA|superior mesenteric artery|SMA|184|186|HOSPITAL COURSE|During her hospitalization infectious disease consultation from Dr. _%#NAME#%_ was obtained and he helped maintain her antimicrobial therapy. 2. Vascular: The patient has a history of SMA aneurysm and is followed by Dr. _%#NAME#%_. The date of her planned surgical correction was moved up and is now planned for _%#MMDD2006#%_.
SMA|superior mesenteric artery|SMA|244|246|PROBLEM #1|PROBLEM #1: GI: She has history of diverticulitis, chronic abdominal pain, and status post partial colectomy on _%#MM#%_ 2005. Most of her symptoms of abdominal pain and nausea after eating are explained due to mesenteric ischemia secondary to SMA stenosis. She was seen by the gastroenterology physicians, who performed a colonoscopy that was negative. Moreover, they recommended abdominal ultrasound with mesenteric Dopplers that showed the SMA stenosis.
SMA|superior mesenteric artery|SMA|264|266|FOLLOW UP|FOLLOW UP: 1. An appointment has been arranged with Dr. _%#NAME#%_ from neurology for followup of her lower extremity weakness on _%#MM#%_ _%#DD#%_, 2006, at 9:30 a.m. 2. An appointment has been arranged with Dr. _%#NAME#%_ from gastroenterology. To follow up her SMA stenosis within one month. 3. She will need to see her primary care physician within 2 weeks for followup on her secondary adrenal insufficiency, hypercholesterolemia, and hypokalemia.
SMA|superior mesenteric artery|SMA|262|264|LABORATORY DATA|UA is noted for ketone was only. Troponin is less than 0.04, digoxin level 1.2. Electrolytes sodium 135, potassium 3.8, BUN 19, creatinine 0.64, glucose 181. CT scan shows bilateral infiltrates versus atelectasis. Lungs diverticulosis and severe stenosis of the SMA INR is 2.43. Assessment. 1. Infectious process of unknown source at this time. 2. Atrial fibrillation with rapid ventricular response. She is has chronic a fib with feel be increased in rate is almost certainly due to the temperature as in.
SMA|superior mesenteric artery|SMA|153|155|HOSPITAL COURSE|After reviewing the films and speaking with the vascular attending, they stated that the imaging studies do not show that she has occlusive disease. The SMA of the celiac and IMA are open at their origins, which is the locations or intervention will need to be made if she did have occlusive ischemia in the mesenteric region.
SMA|superior mesenteric artery|SMA|223|225|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is an 8-year-old male with past medical history of cystic fibrosis who has a longstanding history of abdominal pain and poor appetite that began in _%#MM2006#%_. He was diagnosed with SMA syndrome by upper GI in _%#MM2006#%_ and NJ was placed and he has been gaining weight on home NJ feeds. The abdominal pain had resolved but returned 1 week prior to admission.
SMA|superior mesenteric artery|SMA|156|158|HISTORY OF PRESENT ILLNESS|Work-up has been somewhat elusive as is diagnosis but on hepatobiliary scan we found bile reflux. The diagnostic laparoscopy showed a thick band around the SMA that may or may not be obstructing the duodenum. There is concern for retrogastric colon based on CT findings and barium study.
SMA|superior mesenteric artery|SMA|216|218|PAST MEDICAL HISTORY|12. Methotrexate injections. PAST MEDICAL HISTORY: MAJOR DIAGNOSES: 1. Hyperlipidemia. 2. Hypertension. 3. Hypothyroidism. 4. Barrett's esophagitis with esophageal strictures. 5. Depression. 6. Meniere's disease. 7. SMA (superior mesenteric artery) stenosis. 8. Psoriatic arthritis. 9. Alcohol and chemical dependency. 10. Fibromyalgia. 11. Peripheral vascular disease 12. ASCVD. 13. Stress incontinence.
SMA|superior mesenteric artery|SMA.|236|239|HOSPITAL COURSE|She presents now for Whipple procedure. HOSPITAL COURSE: The patient was admitted on _%#MMDD2007#%_ for a Whipple procedure and at the time of laparotomy, the patient was found to have a large pancreatic mass, which was adjacent to the SMA. The Whipple procedure was accomplished; however, final pathology showed a positive margin with involvement of _____ nodes. Please refer to the operative report for further details of this procedure.
SMA|superior mesenteric artery|SMA.|212|215|HISTORY OF PRESENT ILLNESS|She was on Coumadin therapeutic levels at her house and she actually felt postprandial quite a significant amount of pain in the right upper quadrant that was presumed like her before and she had the clot in the SMA. She presented today and was admitted. HOSPITAL COURSE: Abdominal pain. The patient was admitted to the hospital. She had a negative lactate on admission.
SMA|sequential multiple autoanalyzer|SMA|150|152|PROBLEM #3|The patient was instructed to take a regular diet and to follow up with Dr. _%#NAME#%_ in the Heme/Onc Clinic in 6 weeks and to follow up with repeat SMA 10 to assess renal function prior to his appointment with Dr. _%#NAME#%_. The patient was instructed to notify medical doctor if he experienced chest pain, palpitations, shortness of breath, fever, chills, pain or cough.
SMA|sequential multiple autoanalyzer|SMA|163|165|LAB AND X-RAY DATA ON ADMISSION|The rest of the physical exam was otherwise unremarkable. LAB AND X-RAY DATA ON ADMISSION: Hemoglobin 10.3. White blood cell count 5.7. Platelets 296,000. MCV 72. SMA 7. Sodium 138. Potassium 2.8. Chloride 99. Bicarb 25. BUN 21. Creatinine 0.7. Glucose 95. Calcium 8.7. Amylase 103. T bili 0.2. Albumin 4. Total protein 6.9. Alk phos 49.
SMA|superior mesenteric artery|SMA.|276|279|PROCEDURES PERFORMED DURING ADMISSION|2. Mesenteric angiogram on _%#MMDD2007#%_. This study revealed a 4 cm stenosis of the superior mesenteric artery, it appeared to be a dissection. The initial angiogram demonstrated slow flow in the SMA, during the procedure, the dissection spontaneously extended into the mid SMA. Stent revascularization was undertaken with good resultant flow, with residual dissection of the distal SMA. REASON FOR ADMISSION: _%#NAME#%_ _%#NAME#%_ is a 73-year-old female who had recently undergone laparoscopic Nissen for repair of a large paraesophageal hiatal hernia, and had done well postoperatively until the evening prior to admission when she had sudden diffuse abdominal pain.
SMA|superior mesenteric artery|SMA.|239|242|PROCEDURES PERFORMED DURING ADMISSION|The initial angiogram demonstrated slow flow in the SMA, during the procedure, the dissection spontaneously extended into the mid SMA. Stent revascularization was undertaken with good resultant flow, with residual dissection of the distal SMA. REASON FOR ADMISSION: _%#NAME#%_ _%#NAME#%_ is a 73-year-old female who had recently undergone laparoscopic Nissen for repair of a large paraesophageal hiatal hernia, and had done well postoperatively until the evening prior to admission when she had sudden diffuse abdominal pain.
SMA|superior mesenteric artery|SMA|221|223|PROBLEM #1|Calcium 9.5. ERP is 6.2. Blood culture pending. Sputum culture Gram's stain revealed many PMNs and few gram-positive bacilli resembling diphtheroid. ASSESSMENT/PLAN: HOSPITAL COURSE: PROBLEM #1: A 24-year-old female with SMA type II, upper respiratory infection symptoms and probable sinusitis. The patient was admitted and continued on her normal medication regimen.
SMA|superior mesenteric artery|SMA,|198|201|FAMILY AND SOCIAL HISTORY|Abdominal CT on admission: Mass in the head of the pancreas, causing dilatation of both the intrahepatic and extrahepatic ducts. Mass is worrisome for adenocarcinoma of the pancreas, displacing the SMA, and is contiguous to it but not encasing it. No evidence for liver metastasis. There is a simple cyst in the right kidney.
SMA|superior mesenteric artery|SMA.|366|369|HOSPITAL COURSE|Consultation was obtained from the Interventional Radiology Service, and the afternoon of hospital day number one following admission she was taken to the Angio Suite where she underwent attempted thrombolysis of an occluded right limb of her aortobifem bypass graft. This procedure was complicated by multiple visceral emboli to the celiac access, left kidney, and SMA. After a period of approximately 1.5 hours of viscero-ischemia flow was ultimately re-established through the use of mechanical thrombolysis, and lytic therapy.
SMA|superior mesenteric artery|SMA|148|150|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Significant for coronary artery disease and a valve replacement in 1987. Shortly after that operation, she developed apparent SMA embolism and had a small bowel resection at that time. She, also, has a history of appendectomy, cholecystectomy, partial hysterectomy, history of a partial gastrectomy, ventral hernia repair, carotid stenosis, alcohol abuse.
SMA|sequential multiple autoanalyzer|SMA|234|236|DISCHARGE|DISCHARGE: The patient was discharged home in stable condition. He is to continue taking Lasix and metolazone and follow up as stated above with Dr. _%#NAME#%_ within one week. At that time, he should have Epogen level, CSA level and SMA 10 drawn.
SMA|superior mesenteric artery|SMA|319|321|DISCHARGE|Yesterday the patient underwent MRI performed by Dr. _%#NAME#%_, reviewed the study in detail with Dr. _%#NAME#%_ where there is an indication of a 90% focal stenosis of the proximal aspect of the celiac artery, there is web-like stenosis approximately 5-10 mm from the origin of the celiac access. It appears that the SMA and IMA were patent as were the renal arteries. The patient is currently asymptomatic. We anticipate discharge today. I will review the results of the hospitalization with Dr. _%#NAME#%_.
SMA|superior mesenteric artery|SMA|127|129|HOSPITAL COURSE|Findings were unremarkable. She had a normal-appearing colon. There was no evidence of leaks with intact anastomoses. Note the SMA limb of the Y graft to the pancreas transplant was noted to be partially thrombosed. Postoperatively, the patient continued to improve slowly. Abdominal pain slowly abated with course of Toradol.
SMA|sequential multiple autoanalyzer|SMA|238|240|ADMISSION LABORATORY DATA|ADMISSION LABORATORY DATA: His white count was 8.5 and hemoglobin 9.3. Of note, his hemoglobin was 12.2 on _%#MMDD#%_, ten days prior to admission. His platelets was 257, and troponin was less than 0.07. His INR was 1.14. He had a normal SMA 7. His calcium was decreased at 7.7 along with his albumin, which was decreased at 3.0. Again, he had a fecal occult blood test that was positive.
SMA|superior mesenteric artery|SMA|289|291|HOSPITAL COURSE|On _%#MMDD2003#%_ the patient underwent surgery specifically exploratory laparotomy with gastrojejunostomy, choledochojejunostomy, celiac lymph node, biopsy, cholecystectomy and gastrostomy. The patient's cancer was found to be unresectable at that time due to it involving the celiac and SMA vessels. Therefore palliative surgery was done to relieve patient's symptoms and allow him to be more comfortable. The patient had fairly unremarkable postoperative course. He had very slow return of bowel function.
SMA|superior mesenteric artery|SMA.|297|300|PROBLEM #1|The patient was treated supportively. Her case was discussed with vascular surgery, and the decision was made to discontinue her Coumadin, given that she would only likely benefit from continuation of her anticoagulant therapy. The patient underwent ultrasound for evaluation of celiac artery and SMA. Stenosis was seen in both celiac artery and SMA with possibility of SMA stent stenosis. However, given the patient had elevated creatinine and triple A, as well as severe vascular disease, Surgery felt that she will not benefit from revascularization, and revascularization is very risky in this patient.
SMA|superior mesenteric artery|SMA|142|144|PROBLEM #1|The patient underwent ultrasound for evaluation of celiac artery and SMA. Stenosis was seen in both celiac artery and SMA with possibility of SMA stent stenosis. However, given the patient had elevated creatinine and triple A, as well as severe vascular disease, Surgery felt that she will not benefit from revascularization, and revascularization is very risky in this patient.
SMA|superior mesenteric artery|SMA|167|169|FOLLOW-UP STUDIES|CONDITION AT DISCHARGE: Stable. DISPOSITION: Discharged to Innsbruck Health Care Center in _%#CITY#%_ _%#CITY#%_, Minnesota. FOLLOW-UP STUDIES: We are recommending an SMA with sodium checked _%#MMDD2003#%_ and at regular intervals to be determined by his follow-up providers. FOLLOW-UP APPOINTMENTS: 1. He needs to see Dr. _%#NAME#%_ in Cardiology at the Fairview-University Medical Center within one week; an appointment will be scheduled by our front desk on Monday.
SMA|sequential multiple autoanalyzer|SMA|177|179|ADMISSION LABS|Examination on admission revealed jaundice and a nontender belly. ADMISSION LABS: Total bilirubin 17, total protein 7.7, albumin 3.5, alkaline phosphatase 612. ALT, AST normal. SMA normal. CBC normal. INR 1.09. PAST MEDICAL HISTORY: 1. Cholecystectomy in 1990. 2. Status post duodenal surgery in 1950.
SMA|sequential multiple autoanalyzer|SMA|195|197|HISTORY OF PRESENT ILLNESS|PHYSICAL EXAMINATION: Admission vital signs stable, exam normal. EKG normal. Chest x-ray normal. LABORATORY: Admission Labs: Hemoglobin 13.6, platelets 287. D- dimer 1. Normal urinalysis. Normal SMA 7. HOSPITAL COURSE: 1. Pulmonary Embolism: The patient's history was very inconsistent with pulmonary embolism. He has had no recent surgeries. No known malignancy, and he is very active.
SMA|sequential multiple autoanalyzer|SMA|166|168|DISCHARGE MEDICATIONS|7. Tylenol No. 3 one to two tablets p.o. q.6h. His antibiotic was discontinued and he was told to see Dr. _%#NAME#%_ the _%#MM#%_ _%#DD#%_, 2004, and to have CBC and SMA obtained on Monday and Thursday at Masonic Day Hospital, start on _%#MM#%_ _%#DD#%_, 2004. He was also told to call to the hospital if he spikes fever more than 100.5.
SMA|spinal muscular atrophy|SMA|139|141|HOSPITAL COURSE|This diagnosis was discussed with both parents with the explanation that prognostication is difficult without knowing exactly what type of SMA _%#NAME#%_ has. 2. Respiratory distress: _%#NAME#%_ was monitored closely throughout her hospitalization. She did not require intubation. However, pulmonary consult was obtained and suggested to start her CPAP with PEEP of 7.
SMA|superior mesenteric artery|SMA|178|180|HOSPITAL COURSE|He was treated with rejection. Follow-up radiology studies showed there to be evidence of portal vein thrombosis. HOSPITAL COURSE: The patient underwent anticoagulation and then SMA angiogram. Thrombolytics were placed and he had follow-up studies. These showed continued clot. It was agreed that we should systemically anticoagulate him and follow up with potential portal venous study.
SMA|superior mesenteric artery|SMA.|193|196|HOSPITAL COURSE|Please refer to their notes for full details. This test revealed a fistula between his duodenum and pancreas allograft Y graft arterial connection. It appeared to originate from the transplant SMA. Coil embolization was performed on this lesion with restoration of normal blood flow. By hospital day #2 Mr. _%#NAME#%_ was feeling well and his hemoglobin was stable at 10.2. He was asymptomatic with stable vital signs and was discharged home.
SMA|superior mesenteric artery|SMA|291|293|DESCRIPTION OF PROCEDURE|The mesentery feeding this area was very foreshortened. The mass at the base of the mesentery was large and quite a bit larger than it seemed on CT scan for some reason. I felt it was worth trying to see if we could dissect down into this region to better understand its relationship to the SMA just to be sure that this wasn't potentially resectable. With that in mind, we identified the middle colic vessels and then stayed just to the left of that vessel.
SMA|superior mesenteric artery|SMA|202|204|HISTORY/HOSPITAL COURSE|2. _%#MMDD2005#%_: small bowel transplant enterectomy secondary to thrombosis. HISTORY/HOSPITAL COURSE: The patient is a very pleasant 33- year-old man who has a history of lupus inhibitor which led to SMA thrombosis and loss of almost his entire small bowel. He became TPN dependent and had complications with deep venous thromboses and line infections.
SMA|spinal muscular atrophy|(SMA)|307|311|FOLLOW-UP PLAN|She reported several members having cancer including her father with colon cancer in his 60s, a paternal uncle with pancreatic cancer in his 50s, and a paternal grandmother who had some sort of cancer in her 60s. _%#NAME#%_ reported that his brother had a son who was diagnosed with spinal muscular atrophy (SMA) in Colorado and passed away at 1 year of age. This occurred approximately 5 years ago. Both of them are of Northern European ethnicity.
SMA|spinal muscular atrophy|SMA)|194|197|FOLLOW-UP PLAN|If two parents are carriers then there is a 25% chance to have an affected child. Given that information this current pregnancy would have a 1/2 x 1:40 (which is the general population risk for SMA) x 1/4 which is approximately 1:320 risk to affected with spinal muscular atrophy. Carrier screening is available through the University of Pennsylvania which we can help make arrangements for this patient and her husband to have their blood drawn and analyzed.
SMA|spinal muscular atrophy|SMA|305|307|FOLLOW-UP PLAN|The patient stated that they were concerned about their risk of miscarriage associated with amniocentesis and decided to start with a Level II ultrasound, which was performed today by Dr. _%#NAME#%_. They will contact me with further information regarding their family members in terms of DNA testing for SMA and we can make arrangements for these parents to have their blood drawn to screen for this. If you have any further questions of which I can be of assistance please feel free to contact me at _%#TEL#%_.
SMA|superior mesenteric artery|SMA|246|248|PHYSICAL EXAMINATION|There was no pelvic fractures, nor obvious lumbar fractures. With these findings we were concerned about active bleeding and therefore Dr. _%#NAME#%_ of interventional radiology performed an aortogram with selective visualization of the celiac - SMA - left renal arteries. All these vessels were intact. There was no extravasation appreciated. The left kidney was well perfused. ADMISSION LABORATORY: Potassium is 5.2, sodium is 133, glucose is 135, creatinine 1.3, total bilirubin 2.4, albumin 3.8, alkaline phosphatase 46, ALT 19, AST 66, INR 1.04, amylase 100, hemoglobin 13.6, white blood cell count is 7,800, platelet count is 248,000.
SMA|superior mesenteric artery|SMA|182|184|PHYSICAL  EXAMINATION|There may be a small saccular aneurysm off the origin of the celiac artery, but there is no hemorrhage here. There are no other calcifications appreciated in the distribution of the SMA or celiac arteries to suggest other aneurysms. There is a large area of hemorrhage in the area of the head of the pancreas and in the duodenal sweep within the mesentery that displaces the duodenal sweep, inferiorly and laterally.
SMA|superior mesenteric artery|SMA.|273|276|REVIEW OF SYSTEMS|Her appetite has been good. She does have intermittent upper abdominal discomfort as noted, but had gastrointestinal evaluation in the past which she reports as negative. In addition, I note that she had had a MR angiogram of the gut that did show a patent celiac axis and SMA. No swelling in the legs, she does have easy bruising, no skin lesions or oral lesions have been noted.
SMA|superior mesenteric artery|SMA|258|260|IMPRESSION|I don't think we need to look for pulmonary embolism since she has been well anticoagulated, although I do realize the D-dimer test was slightly increased. We can discuss that with her primary care physician. We should probably reconsider repeating a stress SMA to make sure that this is not a coronary disease equivalent of flash pulmonary edema. We will also repeat her echocardiogram.
SMA|superior mesenteric artery|SMA|133|135|LABORATORY AND DIAGNOSTIC DATA|INR 0.95, lipase 146. CT of the abdomen and pelvis shows: 1. Type B aortic dissection with false lumen that is clotted to celiac and SMA are patent. 2. Dilated biliary tree. 3. Sigmoid diverticulosis. IMPRESSION: Abdominal pain. The patient did have dilated biliary tree on CT question the significance of this and this can be a normal finding in post-cholecystectomy patients, however, his LFTs have slightly increased.
SMA|superior mesenteric artery|SMA|227|229|HISTORY OF PRESENT ILLNESS|However, no new acute abdominal pathology was identified. Her aortic dissection did not appear different from previous CT on _%#MMDD2007#%_. It does not appear to extend above the renal arteries specifically. The origin of the SMA and celiac are not entirely clear due to the artifact from her VAD device; although, no obvious occlusions are identified.
SMA|superior mesenteric artery|SMA|140|142|LABORATORY DATA|LABORATORY DATA: CT scan of the abdomen which is read as normal except for food in the stomach. I have reviewed this, this is not a classic SMA syndrome but there is a fair amount of gastric distention. In addition, there is stool in the colon. Flat plate of the abdomen comments on moderate stool in the colon.
SMA|superior mesenteric artery|SMA|189|191|LABORATORY DATA|He is somewhat slow in response. LABORATORY DATA: Abdominal x-ray today shows residual barium in the colon, otherwise negative. CT scan shows fluid-filled distended stomach at the level of SMA as seen previously but to a slightly lesser extent. Findings suggest SMA syndrome. No obstructing lesions are noted. SMA 12.
SMA|superior mesenteric artery|SMA|182|184|LABORATORY DATA|CT scan shows fluid-filled distended stomach at the level of SMA as seen previously but to a slightly lesser extent. Findings suggest SMA syndrome. No obstructing lesions are noted. SMA 12. Albumin 5.3, calcium 10.5, BUN of 39, creatinine 1.1. WBC 8,700, hemoglobin 16.0. ASSESSMENT: 1. Recurrent nausea, emesis and abdominal distention. 2. CT of the abdomen with findings suggestive of SMA syndrome.
SMA|superior mesenteric artery|SMA|197|199|ASSESSMENT|Albumin 5.3, calcium 10.5, BUN of 39, creatinine 1.1. WBC 8,700, hemoglobin 16.0. ASSESSMENT: 1. Recurrent nausea, emesis and abdominal distention. 2. CT of the abdomen with findings suggestive of SMA syndrome. This is a rather unusual finding. There is no preceding risk factors such as eating disorder or weight loss. 3. We will advance diet as tolerated. Reglan has been started, but it the SMA syndrome is present, this will not help and surgery may be necessary.
SMA|superior mesenteric artery|SMA|186|188|LABORATORY DATA|INR 1.02, BUN 74, creatinine 1.3, sodium 140. CT scan from _%#MMDD2003#%_ shows that the ascites seen in _%#MM#%_ has resolved. Tissue indistinctness in the vessels with celiac axis and SMA is unchanged. No evidence for portal venous thrombosis. No specific signs of tumor, homogeneous liver texture and hiatal hernia.
SMA|sequential multiple autoanalyzer|SMA|126|128|LABS|NEUROLOGICALLY he's sleepy but is easily alerted. He's not tremulous. LABS: Obtained preoperatively included a normal CBC and SMA 7. As above, a TSH was elevated at 9.18. A chest x-ray revealed no acute process. EKG was normal.
SMA|spinal muscular atrophy|SMA|217|219|LABS|In addition, the patient's sister lost a pregnancy at 28 weeks gestation secondary to spinal muscular atrophy. The patient reports that her father as well as her sister and brother-in-law have had carrier testing for SMA and have all been found to be carriers. The patient's family history is also remarkable for her sister who has bipolar illness as well as her mother who has bipolar illness.
SMA|spinal muscular atrophy|SMA|257|259|LABS|Given the patient's family history of spinal muscular atrophy we briefly discussed the clinical features and genetics of SMA. SMA is an autosomal recessive genetic condition characterized by progressive muscle weakness. There are several different forms of SMA that are classified by both the age of onset and symptoms. In the patient's family it appears that the type of SMA has both a prenatal onset, as well as early infancy.
SMA|spinal muscular atrophy|SMA|148|150|LABS|In the patient's family it appears that the type of SMA has both a prenatal onset, as well as early infancy. The autosomal recessive inheritance of SMA was reviewed for the patient. Given the family history the patient has a 50% risk to be a carrier for SMA. We discussed that carrier testing through genetic analysis would be available to the patient given that the patient's family members have also had carrier testing for SMA.
SMA|spinal muscular atrophy|SMA.|167|170|LABS|We discussed that carrier testing through genetic analysis would be available to the patient given that the patient's family members have also had carrier testing for SMA. The risk for her husband, _%#NAME#%_, to be a carrier is about 1 in 50, based on his ethnic background. Thus the risk for the couple to have a child with SMA is approximately 1 in 400.
SMA|spinal muscular atrophy|SMA|154|156|LABS|The risk for her husband, _%#NAME#%_, to be a carrier is about 1 in 50, based on his ethnic background. Thus the risk for the couple to have a child with SMA is approximately 1 in 400. The patient indicated at the time of her visit that she was not interested in pursuing carrier testing for SMA.
SMA|spinal muscular atrophy|SMA.|188|191|LABS|Thus the risk for the couple to have a child with SMA is approximately 1 in 400. The patient indicated at the time of her visit that she was not interested in pursuing carrier testing for SMA. We discussed the availability of ultrasounds throughout the pregnancy to screen for clinical features of early onset SMA such as fetal arthrogryposis.
SMA|spinal muscular atrophy|SMA|229|231|LABS|The patient indicated at the time of her visit that she was not interested in pursuing carrier testing for SMA. We discussed the availability of ultrasounds throughout the pregnancy to screen for clinical features of early onset SMA such as fetal arthrogryposis. Specifically, we discussed the availability of first trimester screening. First trimester screening is typically used to screen for fetal chromosome issues, specifically Down syndrome and trisomy 18.
SMA|spinal muscular atrophy|SMA|308|310|LABS|Specifically, we discussed the availability of first trimester screening. First trimester screening is typically used to screen for fetal chromosome issues, specifically Down syndrome and trisomy 18. We discussed that case reports have shown an increased nuchal translucency ultrasound associated with fetal SMA thus we discussed the nuchal translucency ultrasound as a means to provide early information about possible SMA affecting this current pregnancy.
SMA|spinal muscular atrophy|SMA|220|222|LABS|We discussed that case reports have shown an increased nuchal translucency ultrasound associated with fetal SMA thus we discussed the nuchal translucency ultrasound as a means to provide early information about possible SMA affecting this current pregnancy. Additionally, ultrasounds would be available to the patient later on in the pregnancy around 18 to 20 weeks, as well as in her third trimester to again look for clinical ultrasound features of SMA.
SMA|spinal muscular atrophy|SMA.|315|318|LABS|Additionally, ultrasounds would be available to the patient later on in the pregnancy around 18 to 20 weeks, as well as in her third trimester to again look for clinical ultrasound features of SMA. It was stressed to the patient that a normal ultrasound cannot rule out the current pregnancy as being affected with SMA. Given the patient's European Caucasian and her husband's German ethnic background we also briefly discussed the availability of cystic fibrosis carrier testing.
SMA|superior mesenteric artery|SMA,|198|201|LABORATORY DATA|Dr. _%#NAME#%_ _%#NAME#%_ has also seen these studies and did raise the question of a possible focal area of narrowing at the level of the aortic bifurcation. The pancreas appears to be normal. The SMA, SMV and IMA are all patent. LABORATORY DATA: Hemoglobin 11.3, MCV is low at 74, white count 9700, platelet count is normal.
SMA|superior mesenteric artery|SMA|280|282||Unfortunately, by _%#MMDD#%_ she had worsening back pain and repeat scans showed a stable disease and she was started on Gemzar receiving 3 cycles with continue progression. In _%#MMDD#%_, a CT scan showed enlarged periaortic lymph node just above the celiac as well as below the SMA with right hydronephrosis which was new and stents were placed, and it was planned for her to see me for an opinion regarding palliative radiotherapy.
SMA|sequential multiple autoanalyzer|SMA,|211|214|RECOMMENDATIONS|5. If the small bowel obstruction continues to improve may consider upper endoscopy at a later time to look for varices or other evidence of portal hypertension. 6. Check serum protein electrophoresis. 7. Check SMA, antismooth muscle antibody, ANA, antinuclear antibody, antimitochondrial antibody. 8. Check hepatitis serologies. 9. Check ferritin and iron studies. 10. May be reasonable to try patient on a trial regimen of lactulose to see if this reduces his risk of recurrence of encephalopathy, however would not start this until after the small bowel obstruction is completely resolved.
SMA|spinal muscular atrophy|SMA|160|162|RECOMMENDATIONS|_%#NAME#%_ has 1 brother with 2 healthy children. She also apparently has a maternal first cousin once removed who was in his 20s who also was reported to have SMA as well. _%#NAME#%_ has a large family including 4 sisters who are living and 1 who is deceased from a car accident.
SMA|spinal muscular atrophy|SMA|79|81|RECOMMENDATIONS|There is variability among family members as well as individuals who have SMA. SMA is a common type of neuromuscular condition, which approximately 1 in 40 individuals are carriers. SMA is an autosomal recessive condition, which means that usually both parents of an affected child are carriers.
SMA|spinal muscular atrophy|SMA|182|184|RECOMMENDATIONS|There is variability among family members as well as individuals who have SMA. SMA is a common type of neuromuscular condition, which approximately 1 in 40 individuals are carriers. SMA is an autosomal recessive condition, which means that usually both parents of an affected child are carriers. Rarely, in approximately 2% of cases, it is a result of a de novo mutation.
SMA|spinal muscular atrophy|SMA|133|135|RECOMMENDATIONS|_%#NAME#%_ plans to come back on _%#MMDD2005#%_ for subsequent CVS, and direct sample will be sent to University of Pennsylvania for SMA analysis of the specific gene. Blood samples will also be obtained from her husband as well as the son for complete analysis.
SMA|spinal muscular atrophy|SMA|201|203|G  1  P	0000				LMP|When I used this term, _%#NAME#%_ seemed to recognize that this might be the diagnosis. Without records verifying the precise diagnosis, it is difficult to exclude a possible genetic risk. I did offer SMA carrier testing, which _%#NAME#%_ declined. * _%#NAME#%_ reported a maternal first cousin once removed with multiple congenital anomalies. He had 2-vessel umbilical cord, VSD, and at least 3 other major anomalies (_%#NAME#%_ is uncertain of what these were).
SMA|superior mesenteric artery|SMA|333|335|IMPRESSION|In association with this, her stomach appears somewhat increased in size, it is difficult to assess whether this is related to her small stature or whether this is really dilated. I do not see evidence of a distinct superior mesenteric artery syndrome, but this does raise the issue of if she has a proximal gut disorder vs possible SMA syndrome. Usually with intestinal pseudo-obstruction the small bowel may be more dilated.
SMA|superior mesenteric artery|SMA|126|128|RECOMMENDATIONS|RECOMMENDATIONS: 1. Agree with current management. 2. MR angiogram at some point in the near future to look at his celiac and SMA and evaluate for any critical stenosis. 3. I am contemplating an arterial angiogram looking for reversible small bowel vascular lesion.
SMA|superior mesenteric artery|SMA.|140|143|LABORATORY DATA|Occult blood in the stool is positive. CT scan of the abdomen with contrast is negative, with no sign of colitis. No comment is made on the SMA. IMPRESSION: This patient has a history of sudden abdominal pain associated with blood in the stools, a high white count and normal colonoscopy in _%#MM#%_, 2003; these are all suggestive of the possibility of ischemic colitis of the sigmoid and descending colon.
SMA|superior mesenteric artery|SMA|217|219|PHYSICAL EXAMINATION|CT scan was reviewed with Dr. _%#NAME#%_ and shows small bowel dilatation with some possible metastatic edema. He feels the wall of the small bowel is normal in thickness and therefore not suggestive of ischemia. The SMA appears to show good flow of contrast through it as far as can be followed. There are some distal decompressed small bowel loops, and this is all felt to be consistent with a partial or early mid small bowel obstruction.
SMA|smooth muscle antibody|SMA|190|192|HISTORY|She has been followed over the years by one of my partners, Dr. _%#NAME#%_ _%#NAME#%_. Generally, she has been found to have positive FANA, occasional positive anti-DNA antibodies, positive SMA antibodies, positive SSA autoantibodies, but she has been anticardiolipin negative. Clinically, she has had occasional serositis, occasional skin inflammation, sun sensitivity, mild arthritis.
SMA|superior mesenteric artery|SMA,|195|198|LABS|RECTAL: Exam is deferred. EXTREMITIES: Unremarkable NEUROLOGIC: Exam is grossly intact. LABS: Electrolytes unremarkable. Potassium of 4.1, MRI of the abdomen, 40-50% of celiac axis, unremarkable SMA, IMIA not identified. CT scan of the abdomen pending. Leiden mutation analysis is unremarkable. ASSESSMENT: 1. Severe colitis, presumably C-Difficile related, await old records.
SMA|sequential multiple autoanalyzer|SMA|136|138|LABS|Neurologic Exam: Grossly nonfocal. LABS: Thus far, an EKG reveals sinus bradycardia, but is otherwise normal. A chest x-ray is pending. SMA 7 is normal. Hemoglobin is 14.1, white count 8,800, platelet count is 168,000.
SMA|superior mesenteric artery|SMA|141|143|ASSESSMENT|ASSESSMENT: Abdominal pain, question related to triple A expansion. Rule out peptic ulcer disease. Complex triple A involving the renals and SMA with an elevated baseline renal function and history of congestive heart failure. RECOMMENDATIONS: Admission, GI evaluation, MRA of the abdominal aorta, possibly cardiology work up prior to triple A repair.
SMA|superior mesenteric artery|SMA|143|145|RECOMMENDATIONS|Repeat workup for bleeding was done in _%#CITY#%_ _%#CITY#%_ and once again the source was felt to be in the jejunum. Embolization of the same SMA branch was performed and he appeared stable. Two to three weeks after that he developed chest discomfort, light-headedness and maroon stools.
SMA|superior mesenteric artery|SMA|218|220|IMPRESSION|CT scan is reviewed in detail and shows significant edema of some small bowel segments possibly right colon also. There is air in the biliary tree. IMPRESSION: Probable ischemic bowel, cause not clear, celiac axis and SMA are both patent. PLAN: Urgent abdominal exploration.
SMA|superior mesenteric artery|SMA|166|168|PHYSICAL EXAMINATION|SKIN: Negative. All lab studies have been negative. She did undergo CT scan which shows a 1.3 cm area and halo around the aorta in the area of the renal arteries and SMA which appears to be a small bleed. I did discuss this with Dr. _%#NAME#%_ of radiology who felt that there was no evidence of extravasation when the dye was given.
SMA|superior mesenteric artery|SMA|135|137|HISTORY OF PRESENT ILLNESS|The patient was seen at the Mayo Clinic for a second opinion, and also saw Dr. _%#NAME#%_. Because of the questionable invasion to the SMA of this tumor, Dr. _%#NAME#%_ elected not to proceed with surgery, and considered preop chemoradiation treatment. The patient was seen by Dr. _%#NAME#%_, and was seen by us today with an interest in being treated under the same program as post-pancreatic cancer protocol by the surgical oncology group, which consists of daily radiation with concurrent continuous infusion of 5-FU and cisplatin on day 1, 8, 15, 22, 29 and 36, as well as interferon, 3 million-unit subcutaneous injection on day 1, 3, and 5 of each week for 5-1/2 weeks during the radiation treatment.
SMA|superior mesenteric artery|SMA|159|161|IMAGING|There is no loculation or abscess I can identify. The pancreas does appear to enhance normally with no evidence of necrosis or infarction. The portal vein and SMA appear patent, as does the middle colic artery. Dye does extend throughout the colon nearly to the rectum suggesting minimal or no ileus.
SMA|superior mesenteric artery|SMA|152|154|LABORATORY DATA|Her differential diagnoses in this setting includes ischemia, although pan colonic ischemia is somewhat unusual given the vascular supply from both the SMA and IMA. Another possibility would be infection especially C. difficile and stool cultures have been sent. Crohn's colitis is also possible in this patient with history of Crohn's disease, although she has never had any evidence of colitis in the past.
SMA|superior mesenteric artery|SMA|213|215|HISTORY OF PRESENT ILLNESS|She also felt like her energy level was dropping, her appetite was declining, and she had lost about 60 pounds. She had a CT scan of her abdomen performed which revealed extensive lymphadenopathy encompassing her SMA as well as the celiac axis. There was adenopathy posterior to the pancreas, elevating the pancreas away from the spine.
SMA|superior mesenteric artery|SMA|129|131|DOB|The presumed diagnosis was intestinal angina and an MRA was ultimately performed. The MRA revealed a 50 percent narrowing of the SMA and a right-sided approximate 4 cm mass in the liver, which was partially blocking the intrahepatic ducts. A CT-guided liver biopsy was then performed on _%#MMDD2003#%_. Pathology from the biopsy revealed infiltrative, moderately differentiated, mucin-producing adenocarcinoma.
SMA|superior mesenteric artery|SMA|174|176|ASSESSMENT|The CT was unrevealing and shows no major intra-abdominal pathology. Certainly this could be peptic ulcer disease or some other upper GI source. Another possibility might be SMA syndrome especially in light of her six-pound weight loss recently. However, the CT does not suggest a particularly dilated stomach.
SMA|superior mesenteric artery|SMA|172|174|IMPRESSION|Now she has developed abdominal pain with pain somewhat out of proportion to the physical findings, and perhaps some peritoneal signs; rule out ischemic small bowel due to SMA embolus or ischemic colon. The latter is possible because of the bloody stool. So far the amount of blood she has lost does not appear significant, so she does appear to have ischemia and anticoagulation may be favored, since it might prevent further emboli.
SMA|superior mesenteric artery|SMA|165|167|REASON FOR CONSULTATION|He proved to have some collateral circulation, so lysis and heparinization continued. However, while he did have some collateral circulation he continued to have an SMA occlusion and therefore earlier today he was taken to the operating room for exploratory laparotomy by Dr. _%#NAME#%_. Findings there included a gangrenous proximal jejunum, mid SMA thrombotic occlusion and Mr. _%#NAME#%_ underwent resection of the proximal jejunum as well as an SMA endarterectomy with vein patch angioplasty.
SMA|superior mesenteric artery|SMA|261|263|REASON FOR CONSULTATION|However, while he did have some collateral circulation he continued to have an SMA occlusion and therefore earlier today he was taken to the operating room for exploratory laparotomy by Dr. _%#NAME#%_. Findings there included a gangrenous proximal jejunum, mid SMA thrombotic occlusion and Mr. _%#NAME#%_ underwent resection of the proximal jejunum as well as an SMA endarterectomy with vein patch angioplasty.
SMA|superior mesenteric artery|SMA|178|180|IMPRESSION|IMPRESSION: 1) The patient is a 52-year-old white male status post exploratory laparotomy for mesenteric ischemia. He is status post resection of gangrenous proximal jejunum and SMA endarterectomy with vein patch angioplasty,. 2) He has respiratory failure postoperatively; this may be complicated by aspiration per history. He is certainly at risk for acute lung injury and ARDS given ischemic bowel, though no evidence for this at the present time.
SMA|spinal muscular atrophy|(SMA)|181|185|PHYSICAL EXAMINATION|As you know, she was seen here at the MFM Clinic specifically for chorionic villi sampling due to the fact that they had a daughter, _%#NAME#%_, who died of spinal muscular atrophy (SMA) infantile form. I spent approximately 60 minutes with this patient today. _%#NAME#%_ is a 32-year-old gravida 3, para 2-0-0-1, who is currently 11 weeks 4 days' gestation based on estimated date of delivery of _%#MMDD2008#%_.
SMA|spinal muscular atrophy|SMA|196|198|PHYSICAL EXAMINATION|She was seen by genetic counselor _%#NAME#%_ _%#NAME#%_. Subsequently both parents were tested for MCAD disease and _%#NAME#%_ is a carrier while _%#NAME#%_ is not. Then _%#NAME#%_ was tested for SMA due to her elevated CK and was found to be a carrier. Subsequently both parents were tested as well as blood from original newborn screening from _%#NAME#%_ where DNA was extracted and tested for SMA.
SMA|spinal muscular atrophy|SMA.|142|145|PHYSICAL EXAMINATION|Subsequently both parents were tested as well as blood from original newborn screening from _%#NAME#%_ where DNA was extracted and tested for SMA. It turned out that _%#NAME#%_ actually died from spinal muscular atrophy and had a homozygous deletion of the SMN gene as well as an NAIP.
SMA|spinal muscular atrophy|SMA|224|226|PHYSICAL EXAMINATION|It turned out that _%#NAME#%_ actually died from spinal muscular atrophy and had a homozygous deletion of the SMN gene as well as an NAIP. It turns out that both parents, _%#NAME#%_ and _%#NAME#%_, were heterozygous for the SMA gene. _%#NAME#%_'s testing was done at Niemers in _%#CITY#%_, and both _%#NAME#%_ and _%#NAME#%_'s testing was performed at Athena Diagnostic Laboratory.
SMA|spinal muscular atrophy|SMA|213|215|PHYSICAL EXAMINATION|We discussed the rare possibility of ambiguous results or the cells not growing and we could offer a follow-up amniocentesis in that particular instance. We discussed options available if a baby was found to have SMA prenatally, including continuation of pregnancy or termination of pregnancy. We thoroughly updated their family history during our genetic counseling session.
SMA|superior mesenteric artery|(SMA)|148|152|HISTORY OF PRESENT ILLNESS|The study does not include the infrarenal abdominal aorta or the lower abdomen or pelvis on the cuts. The celiac artery, superior mesenteric artery (SMA) and both renal arteries are filling well from the true lumen. The false lumen contains clot but only a tiny wisp of contrast was seen in the false lumen near the renal arteries.
SMA|superior mesenteric artery|SMA|182|184|RECOMMENDATIONS|He was finally admitted to Fairview Ridges Hospital and ultimately transferred to Fairview Southdale Hospital for further workup. He did undergo angiography which showed an occluded SMA as well as a high-grade stenosis of his celiac axis. PAST MEDICAL HISTORY: 1. Essential hypertension. 2. Gastroesophageal reflux disease.
SMA|superior mesenteric artery|SMA|156|158|HISTORY OF PRESENT ILLNESS|The patient's been on NG decompression for relief of symptoms. The leading thought this time, after discussion with Dr. _%#NAME#%_, is the patient may have SMA syndrome. The patient denies any nonsteroidals. He is reporting his abdominal discomfort is somewhat better. He still complains of occasional nausea. He denied any chest pain or shortness of breath.
SMA|superior mesenteric artery|SMA|261|263|HISTORY OF PRESENT ILLNESS|A biopsy revealed adenocarcinoma. On _%#MMDD2004#%_, the patient was seen by Dr. _%#NAME#%_ at _%#COUNTY#%_ _%#COUNTY#%_ Medical Center where an esophageal ultrasound showed that the lesion invaded into the muscularis propria and also had enlarged nodes at the SMA and SMD. Needle aspiration of the three largest nodes were negative for malignancy. Therefore, the patient is ultrasound staged T2 N0 M0. Symptomatically, the patient states that his diarrhea has improved now that he is on the gluten-free diet.
SMA|superior mesenteric artery|SMA|199|201|HPI|He had a gastroesophageal ultrasound on _%#MMDD2004#%_ by Dr. _%#NAME#%_. _%#NAME#%_ which showed a lesion penetrating through the muscularis propria. The patient also had enlarged lymph node at the SMA and SMD which showed negative findings on needle aspiration. He lost 30 pounds since _%#MMDD#%_ due to sprue.
SMA|superior mesenteric artery|SMA,|139|142|PLAN|Finally, because of this history, it might be worth obtaining an abdominal ultrasound to try to evaluate the patency of her celiac artery, SMA, and perhaps even the IMA, if it can be visualized. If she does appear to have compromised mesenteric vasculature, we could then consider asking one of the vascular surgeons to evaluate her for any further therapy.
SMA|spinal muscular atrophy|SMA.|181|184|MMC 295|As you know, it has been reported in literature approximately four times that with direct testing prenatal testing had shown a healthy baby, but when the baby was born, it did have SMA. Thus, the University of Pennsylvania offers linkage analysis to help rule out that rare possibility. _%#NAME#%_ stated that she was interested in pursuing both of these avenues.
SMA|spinal muscular atrophy|SMA|225|227|MMC 295|We had a consent form signed, and DNA was arranged from Nemours Clinic in _%#CITY#%_, Delaware, to be sent to the University of Pennsylvania for the linkage study. We discussed options available if the baby was found to have SMA prenatally, including continuation of a pregnancy or termination of a pregnancy. We thoroughly reviewed the remainder of the family history during our genetic counseling session.
SMA|spinal muscular atrophy|SMA|326|328|MMC 295|His mother may have some mental health issues. There were apparently some distant cousins that had two children die at ages 6 and 9 and that needed to be on a ventilator and had hypotonia and feeding difficulties. Without the specific records regarding these children, it is difficult to know whether there is any relation to SMA or if this is some unrelated genetic disorder. We would be happy to review records if needed. We recognize that this is a very difficult time for _%#NAME#%_ and her family given the recent loss of her daughter _%#NAME#%_ and this current pregnancy.
SMA|spinal muscular atrophy|SMA|348|350|MMC 295|According to University of Pennsylvania both DNA direct testing for spinal muscular atrophy, as well as linkage analysis involving DNA sample from their late daughter _%#NAME#%_ _%#NAME#%_, husband _%#NAME#%_ _%#NAME#%_, and _%#NAME#%_ _%#NAME#%_, both of these results were normal thus consistent with a developing baby not to be expected to have SMA or spinal muscular atrophy. Copies of these records were faxed to your office. These results were communicated to this patient by phone.
SMA|superior mesenteric artery|SMA|150|152|HISTORY OF PRESENT ILLNESS|On _%#MMDD#%_ she underwent mesenteric angiogram which revealed occluded IMA (known since she had an aortobiiliac bypass graft placed by myself). The SMA injection revealed no obvious site of ongoing bleeding. She did undergo a low dose pitressin treatment overnight and had stopped bleeding.
SMA|superior mesenteric artery|SMA|168|170|RECOMMENDATIONS|2. Would proceed to vascular studies at this point, although I expect these will be normal as well. Will obtain an MR angiogram as a screening procedure looking at her SMA and superior mesenteric arteries. 3. Factor V Leiden level. 4. Antiphospholipid antibody. 5. Do not see a need for colonoscopy at present. Would reconsider this, as well as obtain biopsies if she does not have rapid clinical resolution.
SMA|superior mesenteric artery|SMA,|193|196|HISTORY OF PRESENT ILLNESS|PET CT scan on _%#MMDD#%_ showed significant progression of the lymphadenopathy. In addition to the left supraclavicular and mediastinal lymph nodes, there were bulky gastroesophageal, celiac, SMA, periaortic, and bilateral iliac lymph nodes. We are asked by Dr. _%#NAME#%_ to see the patient for consideration of palliative radiotherapy.
SMA|superior mesenteric artery|SMA|236|238|DATA BASE|None on right renal artery. There was atrophy and decreased enhancement of the left kidney and poor visualization of the distal left renal artery suggesting renal artery stenosis. There was diffuse atherosclerotic disease involving the SMA and IMA was patent. Colonoscopy _%#MMDD2006#%_ for_______ screening showed a polyp in the cecum, 2 in the transverse colon, 1 in the sigmoid colon and sigmoid colon diverticulosis.
SMA|superior mesenteric artery|SMA|156|158|PAST MEDICAL HISTORY|He also had a defibrillator placed at some point. He just in _%#MM#%_ of 2005 had DFT testing. He has a history of hyperlipidemia, history of hypertension, SMA occlusion requiring resection of small bowel with an incidental cholecystectomy. Postop PT. He has been on anticoagulation since then. History of TIA in 1999, moderate carotid disease.
SMA|superior mesenteric artery|SMA.|117|120|PROBLEM LIST|Of concern is her comorbidity, baseline creatinine is greater than 2, she has multiple stents in her renal arteries, SMA. Overall, she presents malnourished, with a history of colon resection for colon cancer back in 1990. She has a history of ischemic colitis. She has severe lower extremity ischemia, a recently performed left axillary to bifemoral bypass graft.
SMA|sequential multiple autoanalyzer|SMA|132|134|LABS|She is not tremulous. Reflexes are normal. MENTAL STATUS EXAM: Per Dr. _%#NAME#%_. LABS: Prior to admission here, included a normal SMA 7. A positive urine pregnancy screen and negative urinalysis. A non-detectable salicylate and acetaminophen level.
SMA|superior mesenteric artery|SMA|250|252|LABORATORY DATA|White count was 8.2 with a normal differential. INR is 0.93. Alkaline phosphatase initially was 193, fell to 172, AST is 67, fell to 60, ALT has been normal. CT scan done _%#MMDD#%_ shows aortic dissection as described above, but the celiac axis and SMA feel normally. There is no change from two years ago. He apparently has an ileus on exam and he is status post cholecystectomy.
SMA|superior mesenteric artery|SMA|161|163|PAST MEDICATION HISTORY|PAST MEDICATION HISTORY: Her work up to date includes a CAT scan which suggests dilation of the second and third part of the duodenum secondary to the so called SMA syndrome. (It is unclear whether this exists at all). An endoscopy was done three or four weeks ago which was negative. She thinks she has lost approximately ten pounds. Significant in her history is that she takes ibuprofen for headaches which are frequent.
SMA|smooth muscle antibody|SMA,|172|175|IMPRESSION|The patient also has a long history of alcohol abuse so alcoholic liver disease is also a consideration, vs autoimmune disease. Recommend checking labs. Will check an ANA, SMA, GGT and ferritin, order an MRCP to further evaluate the liver and the biliary tree, continue to monitor. At some point the patient will need a liver biopsy once he is more stable.
SMA|spinal muscular atrophy|(SMA|176|179|IMPRESSION|She reports nausea and some early spotting and cramping in the current pregnancy. The focus of our discussion was _%#NAME#%_'s family history of spinal muscular atrophy type I (SMA type I). Therefore we began by obtaining a family history. _%#NAME#%_'s sister is 27 years old and was diagnosed with spinal muscular atrophy (SMA) in infancy.
SMA|spinal muscular atrophy|(SMA)|133|137|IMPRESSION|Therefore we began by obtaining a family history. _%#NAME#%_'s sister is 27 years old and was diagnosed with spinal muscular atrophy (SMA) in infancy. She is now wheelchair bound and _%#NAME#%_ reports that she was able to walk a little bit when she was younger.
SMA|spinal muscular atrophy|SMA.|146|149|IMPRESSION|_%#NAME#%_ is German, French, Irish and Welsh, and _%#NAME#%_ is Russian. The main concern for _%#NAME#%_ and _%#NAME#%_ is the family history of SMA. Therefore, we began by reviewing the natural history of SMA nad the genetics of this condition. SMA is a debilitating condition involving muscle weakness that progresses as motor neurons degenerate.
SMA|spinal muscular atrophy|SMA|133|135|IMPRESSION|The main concern for _%#NAME#%_ and _%#NAME#%_ is the family history of SMA. Therefore, we began by reviewing the natural history of SMA nad the genetics of this condition. SMA is a debilitating condition involving muscle weakness that progresses as motor neurons degenerate.
SMA|spinal muscular atrophy|SMA|173|175|IMPRESSION|The main concern for _%#NAME#%_ and _%#NAME#%_ is the family history of SMA. Therefore, we began by reviewing the natural history of SMA nad the genetics of this condition. SMA is a debilitating condition involving muscle weakness that progresses as motor neurons degenerate. In its most severe form, SMA is lethal. SMA is inherited in an autosomal recessive fashion, which means that both parents have to be carriers in order to have a chance of having a child affected with the condition.
SMA|spinal muscular atrophy|SMA|224|226|IMPRESSION|Therefore, we began by reviewing the natural history of SMA nad the genetics of this condition. SMA is a debilitating condition involving muscle weakness that progresses as motor neurons degenerate. In its most severe form, SMA is lethal. SMA is inherited in an autosomal recessive fashion, which means that both parents have to be carriers in order to have a chance of having a child affected with the condition.
SMA|spinal muscular atrophy|SMA|143|145|IMPRESSION|SMA is a debilitating condition involving muscle weakness that progresses as motor neurons degenerate. In its most severe form, SMA is lethal. SMA is inherited in an autosomal recessive fashion, which means that both parents have to be carriers in order to have a chance of having a child affected with the condition.
SMA|spinal muscular atrophy|SMA.|279|282|IMPRESSION|In its most severe form, SMA is lethal. SMA is inherited in an autosomal recessive fashion, which means that both parents have to be carriers in order to have a chance of having a child affected with the condition. We would not expect carriers themselves to have any features of SMA. _%#NAME#%_ reports that neither of her parents have had genetic testing, but it is quite likely that they are both carriers of this condition.
SMA|spinal muscular atrophy|SMA.|173|176|IMPRESSION|The likelihood that _%#NAME#%_ is a carrier is 1 in 50. That means that there is a 1 in 200, or 0.5% chance that _%#NAME#%_ and _%#NAME#%_'s pregnancy will be affected with SMA. After talking with _%#NAME#%_ and _%#NAME#%_, they felt that they would not alter the management of the pregnancy based on a diagnosis of SMA.
SMA|spinal muscular atrophy|SMA|186|188|IMPRESSION|Nevertheless, they were hoping to obtain information about _%#NAME#%_'s carrier status so that they could be prepared for the birth of a special needs child. _%#NAME#%_ wished to pursue SMA carrier testing today. However, insurance would not guarantee coverage, and a letter of medical necessity was sent to his insurance company.
SMA|spinal muscular atrophy|SMA|292|294|IMPRESSION|Amniocentesis involves taking a sample of amniotic fluid from around the fetus for genetic testing and is associated with a 1 in 200 or 0.5% risk of miscarriage in the pregnancy. I assured _%#NAME#%_ and _%#NAME#%_ that we could discuss this option further, if _%#NAME#%_ is identified as an SMA carrier. In summary: 1. We obtained confirmation of insurance coverage for SMA carrier testing in _%#NAME#%_'s boyfriend, _%#NAME#%_.
SMA|superior mesenteric artery|SMA|268|270|HISTORY OF PRESENT ILLNESS|An _%#MMDD2006#%_ CT of the chest and abdomen done at Fairview Southdale Hospital showed a 4.3 x 3.9 x 4.6 cm mass in the pancreatic head and neck causing biliary dilatation with extension of the tumor into the small bowel mesentery. There was no definite invasion of SMA or celiac artery and no evidence of distant metastases. A pancreatic biopsy was taken on _%#MMDD2006#%_, which showed moderately well-differentiated ductal adenocarcinoma of the pancreas.
SMA|sequential multiple autoanalyzer|SMA|184|186|LABORATORY DATA|RECTAL: Deferred. EXTREMITIES: Unremarkable. NEUROLOGIC: Grossly intact. LABORATORY DATA: WBC 27,300. Hemoglobin and hematocrit is 13.6 and 39.1, respectively. Platelet count 274,000. SMA 12: BUN 29, creatinine 1.8, amylase 245, lipase 1305, total bilirubin 1.5. No AST or ALT in the chart. CT SCAN: CT scan of the abdomen reveals nonspecific inflammatory changes and free fluid in the right upper quadrant area extending to the right pericolic gutter.
SMA|superior mesenteric artery|SMA|173|175|LABORATORY DATA|LABORATORY DATA: White blood cell count now is normal. She did undergo an MR angiogram which shows a high grade stenosis of the celiac access with occlusion of the IMA. The SMA appears to be normal to a limited amount due to this study, but the orifice was widely patent. At this point I would not consider visceral revascularization based on the patient's history and symptoms as well as her multiple other medical problems.
SMA|superior mesenteric artery|SMA|178|180|REASON FOR CONSULTATION|He states he has no appetite and just does not feel like eating. He did have an MR angiogram in the past with a high-grade stenosis of celiac artery, but reportedly had a patent SMA (superior mesenteric artery). He has an infrarenal aneurysm of about 4 cm. PAST MEDICAL HISTORY: 1. Gastroesophageal reflux disease. 2. Hypertension. 3. Elevated lipids. He denies any other surgery or hospitalizations.
SMA|superior mesenteric artery|SMA|231|233|IMPRESSION|REASON FOR CONSULTATION: Ongoing assessment and ventilator management in a patient immediately postop from an aortoceliac/SMA bypass procedure. REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_. IMPRESSION: 1. Postop from an aortoceliac SMA bypass with 12 x 6 mm Dacron graft. 2. Status post cholecystectomy. 3. Prolonged surgical time on the basis of discussion with anesthesiology and review of operative notes.
SMA|superior mesenteric artery|SMA|181|183|HISTORY OF PRESENT ILLNESS|She is followed also and being seen concurrently by the Gastroenterology service. Under the direction of Dr. _%#NAME#%_ she was taken to the operating room today for an aortoceliac SMA bypass with cholecystectomy. Indication for this procedure was presumed mesenteric ischemia and her bowel was all deemed to be viable. Her operative course can be reviewed. She was seen and examined in the PAC postprocedure.
SMA|superior mesenteric artery|SMA|206|208|IMPRESSION|Last arterial blood gas had a pH of 7.53, pCO2 of 29 and a pO2 of 69 yesterday morning. IMPRESSION: 1. Respiratory failure: Probable underlying COPD, also volume overload postoperatively. 2. Post-op day #5 SMA bypass. 3. Diffuse pulmonary infiltrates: These likely are a combination of ventilator-associated pneumonia and possible volume overload. 4. Respiratory alkalosis secondary to mechanical ventilation. RECOMMENDATIONS: 1. CPAP pressure support trials as tolerated.
SMA|superior mesenteric artery|(SMA)|211|215|RECOMMENDATIONS|This means the patient has had two significant attacks with hospitalization in one month. If further intervention is desirable one could consider angiogram looking specifically at the superior mesenteric artery (SMA) takeoff to see whether angioplasty of this area might be effective.
SMA|superior mesenteric artery|SMA|142|144|RADIOLOGICAL EXAM|For this reason, it is impossible to determine whether or not the patient has an arterial embolus. He does have a fairly large takeoff of his SMA and there is no plaque around it, but that is all that I can talk about it. There is no evidence of bowel wall thickening, no evidence of free air, no evidence of inflammatory change.
SMA|sequential multiple autoanalyzer|SMA,|154|157|IMPRESSION/PLAN|I did discuss this case event with this patient and also with her referral physician, Dr. _%#NAME#%_. I feel that we want to obtain liver function tests, SMA, uric acid, reticulocyte count, haptoglobin, and LDH. I also wanted pathologist to review her peripheral blood smear at this time so we can make a formal plan as to management.
SMA|superior mesenteric artery|SMA|313|315|CHIEF COMPLAINT|She was started on Pentasa and discharged to home. However, she has continued to worsen with increasing abdominal pain, nausea and vomiting and she finally came into Ridges late last night feeling very ill. She was found to have a white count 28,000. A final reading of the CT scan, however, showed a clot in the SMA and wedge-shaped densities in the kidneys. The patient does not know of any family history of any clotting disorders.
SMA|superior mesenteric artery|SMA.|182|185|LABORATORY DATA|Wedge shaped low attenuation abnormalities in the inferior pole of the right kidney and a few wedge shaped low attenuation regions and left kidney. There is the possible clot in the SMA. This is described as proximal-to-mid SMA. There is also a mild wall thickening of the cecum with known pericecal inflammatory changes.
SMA|superior mesenteric artery|SMA.|224|227|LABORATORY DATA|Wedge shaped low attenuation abnormalities in the inferior pole of the right kidney and a few wedge shaped low attenuation regions and left kidney. There is the possible clot in the SMA. This is described as proximal-to-mid SMA. There is also a mild wall thickening of the cecum with known pericecal inflammatory changes. IMPRESSION: I think we can unify the clinical presentation is being caused spine some type of proximal thrombosis with emboli of the SMA and renal arteries and the cecal inflammation is probably therefore due to ischemia rather than IBD.
SMA|superior mesenteric artery|SMA|226|228|IMPRESSION|There is also a mild wall thickening of the cecum with known pericecal inflammatory changes. IMPRESSION: I think we can unify the clinical presentation is being caused spine some type of proximal thrombosis with emboli of the SMA and renal arteries and the cecal inflammation is probably therefore due to ischemia rather than IBD. The patient does have a remote history of breast cancer and that would raise concern about recurrence.
SMA|sequential multiple autoanalyzer|SMA,|158|161|RECOMMENDATIONS|The patient was stabilized here in the Emergency Room. She had mild hypertension at 182/97 on admission. No other significant findings, with a normal CBC and SMA, normal sed rate. FAMILY HISTORY: Seems unremarkable/noncontributory. SOCIAL HISTORY: Includes her living alone.
SMA|superior mesenteric artery|SMA|221|223|HISTORY OF PRESENT ILLNESS|She underwent surgery at that time, but had a frozen abdomen due to adhesions, and a G-tube was placed. Subsequently, the G-tube was dislodged and had to be replaced. She underwent endoscopy, which did not demonstrate an SMA syndrome. She, therefore, started having jejunal feeds through the G-J tube. She was admitted to the hospital this week with nausea and vomiting and dehydration.
SMA|superior mesenteric artery|SMA.|183|186|HISTORY OF PRESENT ILLNESS|She had a CT scan of the abdomen, which I reviewed, but has not been read yet. On my evaluation, there is a dilated stomach and duodenum. It looks like the duodenum is dilated to the SMA. In fact, this looks like an SMA syndrome. The distal bowel is not dilated. There is no evidence of tumor recurrence on my evaluation.
SMA|superior mesenteric artery|SMA|137|139|HISTORY OF PRESENT ILLNESS|On my evaluation, there is a dilated stomach and duodenum. It looks like the duodenum is dilated to the SMA. In fact, this looks like an SMA syndrome. The distal bowel is not dilated. There is no evidence of tumor recurrence on my evaluation. PHYSICAL EXAMINATION: She does not appear toxic. Her abdomen is soft, nondistended, and nontender.
SMA|superior mesenteric artery|SMA|181|183|IMPRESSION|PHYSICAL EXAMINATION: She does not appear toxic. Her abdomen is soft, nondistended, and nontender. Incisions are healing well. IMPRESSION: Nausea and vomiting possibly secondary to SMA syndrome. PLAN: We will obtain an upper GI series to rule out this finding.
SMA|superior mesenteric artery|SMA.|221|224|PHYSICAL EXAMINATION|She did have two CT scans overnight. The second CT scan did show some moderate amount of peritoneal fluid present. No significant abnormalities were noted. It appears that she has good dye filling in her celiac access on SMA. No mass lesions are noted. There is some stranding on the small bowel mesentery. White blood cell count today is increased to 20,000. IMPRESSION: Abdominal pain of undetermined etiology.
SMA|spinal muscular atrophy|SMA|239|241|PHYSICAL EXAMINATION|This is characteristic of SMA, although, the autosomal dominant parents' pattern is not typical. Based upon his description of what he has been told by various neuromuscular neurologists, it appears that they concur that this is a form of SMA that is atypical, but that there is no other substantial diagnostic consideration. I explained the following with respect to his procedure: 1. His anesthesiologist needs to be aware that he has a neuromuscular disorder and that a genetically determined myopathy cannot be excluded at present.
SMA|sequential multiple autoanalyzer|SMA|217|219|RECOMMENDATIONS|RECOMMENDATIONS: As a precaution, I am going to obtain MRI of the brain with and without contrast to rule out infection as well as obtain basic studies such as sedimentation rate, CBC with differential, electrolytes, SMA 10, liver function tests, urinalysis. I would suggest that she have an Infectious Disease consultation to take a look at her.
SMA|sequential multiple autoanalyzer|SMA|131|133|LABS|LABS: At the time assessment at the Fairview Lakes ER included hemoglobin of 14.2, white count 14,000, platelet count was 748,000. SMA 7 revealed a BUN of 16, creatinine of 1.5. An EKG revealed normal sinus rhythm. There was a bifascicular block and no obvious acute appearing changes, no old EKG is currently available.
SMA|superior mesenteric artery|SMA,|246|249|LABORATORY & DIAGNOSTIC DATA|I also reviewed CT scan from _%#MMDD2005#%_. This shows no evidence for mass or tumor, there are a few prominent small bowel loops, but no clear sign of obstruction. Further review of the scan also shows focal calcifications at the origin of the SMA, fewer calcifications at the origin of the celiac, and an aneurysm in the lower abdominal aorta, which would include the origin of the IMA, although this vessel is not specifically seen.
SMA|UNSURED SENSE|SMA|175|177|IMPRESSION|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD IMPRESSION: 1. Chronic renal insufficiency with a baseline serum creatinine of approximately 2.0 mg per dl. On this basis, her SMA glomerular infiltration rate is approximately 25 milliliters per minute and based on this represents Stage 4 chronic kidney disease with severe documented glomerular infiltration rate.
SMA|superior mesenteric artery|SMA|157|159|LABORATORY DATA|CT scan of the abdomen is reviewed and reveals obvious distention of the stomach and duodenum. There is a prominent gallstone noted just at the level of the SMA with what appears to be obvious obstruction at this point. Comparison with previous CT scans reveals this large gallstone within the gallbladder last year.
SMA|superior mesenteric artery|SMA|231|233|LABORATORY & DIAGNOSTIC DATA|LABORATORY & DIAGNOSTIC DATA: Recent labs show electrolytes are normal, creatinine 0.6. The patient has undergone a CT of the abdomen with CT angiography. This was reported by Dr. _%#NAME#%_ as showing atheromatous change, but the SMA was patent and there was only 20-30% narrowing of the celiac axis. Therefore, the patient should not have intestinal angina. The CT did reveal a possible rectal versus perirectal mass, and accordingly we are proceeding with further endoscopic evaluation.
SMA|spinal muscular atrophy|SMA|149|151|LABORATORY & DIAGNOSTIC DATA|_%#NAME#%_ reported that he had a nephew who died at approximately two years of age of spinal muscular atrophy type I. _%#NAME#%_ also had undergone SMA carrier screening which was sent to the University of Pennsylvania which was reportedly negative, thus again reducing their chance to have a child with spinal muscular atrophy.
SMA|superior mesenteric artery|SMA|196|198|LABORATORY|Erythrocyte sedimentation rate was 12. CT scan of the abdomen reveals an unremarkable bowel gas pattern and otherwise felt to likely be negative. MR angiogram done today reveals patent celiac and SMA with presumed occlusion of IMA. Renal arteries were patent without evidence of stenosis. ASSESSMENT AND PLAN: A patient with intermittent crampy type abdominal pain of uncertain etiology.
SMA|superior mesenteric artery|SMA|145|147|ASSESSMENT AND PLAN|We would expect to see symptoms more relating to left colonic ischemia if that were a problem rather than anything more proximal. Also, with the SMA and celiac artery patent, it is unlikely that she should be having any ischemic change in any case. It is therefore likely that her symptoms are due to some other cause and consideration should be given to upper GI with small bowel follow through and possibly right upper quadrant ultrasound.
SMA|spinal muscular atrophy|SMA.|169|172|ASSESSMENT AND PLAN|Based on her family history, _%#NAME#%_ herself would have a 1/4 chance of being a carrier and an overall 1 in 640 chance to have a child that is actually affected with SMA. We discussed that carrier screening is available. However, it would be important to get a blood sample or molecular test results from these cousins.
SMA|spinal muscular atrophy|SMA.|322|325|ASSESSMENT AND PLAN|We discussed that carrier screening is available. However, it would be important to get a blood sample or molecular test results from these cousins. _%#NAME#%_ stated that after hearing the risks were quite low to this pregnancy, she stated that she was okay with not pursuing any further carrier screening or testing for SMA. We then also briefly discussed first trimester screening which can assess one's risk for Down syndrome, trisomy 13, trisomy 18, and congenital heart defects.
SMA|superior mesenteric artery|SMA.|317|320|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 71-year-old patient who, while being evaluated for an episode of loss of consciousness, was found to have a critical right renal artery stenosis by MRA at the Lee Memorial Health System in Florida. He was also noted to have a high grade stenosis of the celiac artery with a normal SMA. His blood pressure has been elevated and quite labile. It is felt that he most likely had renal vascular hypertension.
SMA|superior mesenteric artery|SMA|204|206|PHYSICAL EXAMINATION|Bowel sounds are normal. RECTAL: Deferred. EXTREMITIES: Normal with intact peripheral pulses. It is noted in the history that the patient has stenosis of the celiac axis, celiac artery, but the patient's SMA and IMA are widely patent. The above had been discussed by Dr. _%#NAME#%_ with Dr. _%#NAME#%_. LABORATORY & DIAGNOSTIC DATA: Laboratory studies on admission show hemoglobin of 12.6, MCV 90, the white count is 8200, platelet count is normal, electrolytes are normal.
SMA|superior mesenteric artery|SMA|211|213|DIAGNOSTIC STUDIES|We do not see free air. Pelvic portion of the exam is somewhat limited due to artifact caused by the recently-placed hip. The patient also has significant calcifications of the aorta involving the region of the SMA ostia. The IMA cannot be identified. IMPRESSION: 1. Probable ischemic colitis secondary to postoperative hypertension.
SMA|sequential multiple autoanalyzer|SMA|182|184|LABORATORY DATA|She is not tremulous. Motor, sensory and coordination are intact. MENTAL STATUS EXAMINATION: Per Dr. _%#NAME#%_. LABORATORY DATA: Laboratories are ordered and are pending, including SMA 18. T4 and TSH will also be obtained.
SMA|sequential multiple autoanalyzer|SMA|156|158|LABORATORY|EXTREMITIES: Unremarkable. NEUROLOGIC: Grossly intact. LABORATORY: Repeat labs today indicate WBC 6500, hemoglobin 11.0, MCV of 87, platelet count 401,000. SMA 12 unremarkable except for a nonfasting glucose of 168. INR is 1.05. ASSESSMENT: 1. Dark stool, heme negative. The patient denies iron or Pepto-Bismol, it is unclear why it does appear to be dark.
SMA|superior mesenteric artery|SMA.|137|140|PHYSICAL EXAMINATION|She also underwent MR angiography which showed a subtotal occlusion of her celiac axis as well as a possible significant stenosis in the SMA. The IMA was not visualized. IMPRESSION: Ischemic colitis. I believe that standard angiography is indicated to further delineate this patient's vascular disease.
SMA|superior mesenteric artery|SMA|230|232|LABORATORY DATA|I reviewed this. It does reveal a calcified 3 cm aneurysm to the right of the superior mesenteric artery with calcified vessel running around the head of the pancreas. Angiography today reveals occlusion of the celiac access. The SMA is patent and normal in its body but with a very short neck to the right side, and in the inferior pancreatic duodenal artery there is a 2.5 to 3 cm aneurysm.
SMA|superior mesenteric artery|SMA.|123|126|LABORATORY DATA|UA is negative. CT scan - I have had the chance to review with the radiologist and it looks as though he has a clot in his SMA. One wonders whether this clot is embolic in nature. There is an infarct on his kidney and with the history of murmurs, it could be that he has vegetation on his heart.
SMA|superior mesenteric artery|(SMA)|319|323|REASON FOR CONSULTATION|REASON FOR CONSULTATION: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 50-year- old man who was admitted to Fairview Southdale Hospital within the last 24 hours to Fairview Ridges Hospital complaining of about 10 days of vague abdominal pain. CT scan of the abdomen today is highly suspicious for an superior mesenteric artery (SMA) occlusion. He is transferred to Fairview Southdale Hospital for angiography. Angiography was performed revealing extensive SMA clot not amenable to surgical therapy and involving many secondary branches.
SMA|superior mesenteric artery|SMA|213|215|REASON FOR CONSULTATION|CT scan of the abdomen today is highly suspicious for an superior mesenteric artery (SMA) occlusion. He is transferred to Fairview Southdale Hospital for angiography. Angiography was performed revealing extensive SMA clot not amenable to surgical therapy and involving many secondary branches. He is currently on t-PA infusion with the hopes of inducing thrombolysis.
SMA|superior mesenteric artery|SMA.|394|397|LABS|LABS: From Fairview Ridges: Lactic acid 1.0, PTT 37, INR 1.01, sodium 143, potassium 4.2, chloride 102, bicarb 29, glucose 105, BUN 10, creatinine 0.8, bili 1.5, albumin 4.7, total protein 7.9, alkaline phosphatase 88, ALT 25, AST 18, white count 18.8, hemoglobin 15.3, platelet count 404, lipase 45. CT of the abdomen and pelvis was officially read as: 1) Marked narrowing or occlusion of the SMA. 2) No evidence for acute process. 3) Tiny indeterminate liver lesion. 4) Bilateral renal scarring and calcified granuloma at the right lung base.
SMA|superior mesenteric artery|SMA|158|160|LABS|2) No evidence for acute process. 3) Tiny indeterminate liver lesion. 4) Bilateral renal scarring and calcified granuloma at the right lung base. 5) Abnormal SMA was not described in the preliminary report; this is from CT of the abdomen and pelvis on _%#MM#%_ _%#DD#%_, 2004 at 3:23.
SMA|superior mesenteric artery|SMA|165|167|HISTORY OF THE PRESENT ILLNESS|He was started on TPA lytic therapy and over several days, his abdominal pain completely resolved. Mr. _%#NAME#%_ today underwent a stenting of his renal artery and SMA with good results. The thrombus has completely resolved, however, last evening, he developed an episode of atrial fibrillation which was completely asymptomatic.
SMA|sequential multiple autoanalyzer|SMA|150|152|PLAN|3. Vioxx, 25 mg now, then 50 mg daily, plus or minus Percocet p.r.n. for pain. 4. Metabolic stone evaluation through his primary care, including full SMA profile and 24-hour urines.
SMA|superior mesenteric artery|SMA|181|183|PAST MEDICAL HISTORY|He otherwise denies any other complaints. PAST MEDICAL HISTORY: 1. History of incarcerated hernia, status post right hemicolectomy and distal ileectomy _%#MM2007#%_. 2. Status post SMA jejunal branch embolization. 3. Status post IVC filter placement. 4. GI bleed. 5. PE. 6. Spontaneous pneumothorax. 7. Hypertension.
SMA|superior mesenteric artery|SMA.|227|230|LABORATORY DATA|CT scan of the abdomen was done and shows a focal area of low attenuation in the fat inferior to the body of the pancreas extending along the retroperitoneum just anterior to the retro-aortic left renal vein and lateral to the SMA. This surrounds a third portion of the duodenum and extends inferiorly to the left psoas muscle. There is a single cystic lesion in the central aspect of this region.
SMA|superior mesenteric artery|SMA|157|159|HOSPITAL COURSE|She also had evidence of somewhat diffuse bleeding sites more than just at the splenic flexure and the MR angiogram that she had today shows a patent celiac SMA and IMA vasculature. For all of these reasons, I think we need to keep the differential diagnosis somewhat open.
SMA|superior mesenteric artery|SMA|192|194|INDICATIONS|He underwent a MR angiogram and this showed dissection of celiac artery with occlusion of the splenic artery and common hepatic artery. The hepatic artery was supplied with a left gastric and SMA collaterals, the splenic field by the SMA. We have been asked to see him for the same. He is now anticoagulated, feels significantly better and mainly has residual soreness.
SMA|superior mesenteric artery|SMA.|234|237|INDICATIONS|He underwent a MR angiogram and this showed dissection of celiac artery with occlusion of the splenic artery and common hepatic artery. The hepatic artery was supplied with a left gastric and SMA collaterals, the splenic field by the SMA. We have been asked to see him for the same. He is now anticoagulated, feels significantly better and mainly has residual soreness.
SMA|superior mesenteric artery|SMA|253|255|HISTORY OF PRESENT ILLNESS|He has been receiving chemotherapy for this in the recent past, however, has continued to develop significant retroperitoneal adenopathy. This adenopathy appears to be obstructing the second to third portion of his duodenum as it crosses underneath the SMA pedicle. He has, for this reason, been constantly nauseous and unable to eat for approximately the last two to three weeks.
SMA|superior mesenteric artery|SMA|275|277|LABORATORY DATA|Psych: She appeared quite anxious. LABORATORY DATA: Sodium 132, BUN 4, white blood cell count is 15.1 with an MCV of 101, hemoglobin 15.3. Small bowel follow- through performed today shows that there is compression of the third portion of the duodenum, believed to be in the SMA area. The rest of the small bowel appears normal. ASSESSMENT/PLAN: Abdominal pain. She may actually have an SMA type syndrome which can be very difficult to control.
SMA|superior mesenteric artery|SMA.|146|149|ASSESSMENT|I would therefore at this time recommend continued observation and broad spectrum antibiotic coverage. I agree with the ordered MRA of her celiac SMA. We will continue to follow along with you.
SMA|superior mesenteric artery|SMA|155|157|HISTORY OF PRESENT ILLNESS|During the most recent hospital stay an MR angiography was performed revealing moderate to high-grade stenosis of the celiac artery and then open proximal SMA but high-grade distal obstruction of the SMA. She was also worked up with stool cultures on her last hospital stay with a negative C.
SMA|superior mesenteric artery|SMA.|200|203|HISTORY OF PRESENT ILLNESS|During the most recent hospital stay an MR angiography was performed revealing moderate to high-grade stenosis of the celiac artery and then open proximal SMA but high-grade distal obstruction of the SMA. She was also worked up with stool cultures on her last hospital stay with a negative C. difficile toxin. PAST MEDICAL HISTORY: 1) Hypertension. 2) End-stage renal disease, on dialysis for three years.
SMA|superior mesenteric artery|SMA|168|170|IMPRESSION|2) History of ischemic colitis x two; uncertain if this represents another episode. 3) Significant arteriosclerotic vascular disease with involvement of the celiac and SMA artery on MR angiography. Unclear if stenting would help. Was discussed with Dr. _%#NAME#%_, and Interventional Radiology would like to do a standard angiogram to further evaluate this.
SMA|superior mesenteric artery|SMA|178|180|IMPRESSION|She is intubated. ABDOMEN - soft, there is no guarding, rebound. Bowel sounds are decreased. IMPRESSION: CT scan shows no evidence of free air, pneumatosis intestinalis, and the SMA is reported as open. Although the patient has profound metabolic disorder, there is no evidence of intraperitoneal perforation or infarct.
SMA|superior mesenteric artery|SMA|216|218|REASON FOR CONSULTATION|Following this procedure Pitressin was infused but she developed very severe abdominal pain after 6-8 hours and this was stopped. Repeat angiogram showed that the catheter apparently had migrated into a small of the SMA and her pain resolved very quickly when this was pulled back. CT scan showed diverticulosis but nothing to suggest ischemia, no air in the portal tract and no air in the wall of the colon.
SMA|superior mesenteric artery|SMA.|277|280|PHYSICAL EXAMINATION|With this, a CT scan and upper GI revealed evidence of a duodenal obstruction, and because of this, the patient was taken to the operating room on _%#MM#%_ _%#DD#%_. At the time of surgery, the patient was found to have an unresectable mass in the pancreas that was around the SMA. There was local invasion into the duodenum, and metastases to a regional hepatic artery lymph node. The lymph node was biopsied, and the patient was surgically diverted.
SMA|superior mesenteric artery|SMA,|240|243|IMPRESSION|IMPRESSION: _%#NAME#%_ _%#NAME#%_ is a 57-year-old woman who has unfortunately developed an unresectable pancreatic cancer. I have discussed the prognosis with her, and that unfortunately she is unresectable given the tumor surrounding the SMA, invasion into the duodenum, and the metastatic spread to the regional lymph node bed. Options for further treatment include radiation, chemotherapy, or a combination of both.
SMA|superior mesenteric artery|SMA|128|130|LABORATORY DATA|This has a maximum diameter of 46.9 x 45.3 cm. The aneurysm starts just below the level of the widely patent celiac artery. The SMA and left renal artery are at the same plane with right renal artery being more distal. The maximum aneurysmal dilatation is just beyond the right renal artery.
SMA|superior mesenteric artery|SMA|165|167|LABORATORY DATA|The right renal artery has a calcific stenosis in the range of 50% by source images with only mild calcification and no stenosis of the left renal and widely patent SMA with minimal calcification. Both iliac arteries were quite calcified but appeared to be patent. There is no evidence of rupture of the aneurysm. Both kidneys appear to be normal with the right being quite ptotic.
SMA|superior mesenteric artery|SMA|192|194|IMPRESSION|It is improving somewhat because her white count is falling, hemoglobin is stable and there is no ileus. There is no obvious obstruction of major blood vessels in the proximal portion such as SMA or celiac arteries, by CT scan. The question is the cause of the ischemia. She has no evidence or family history for vascular disease; there has been no trauma or strenuous exercise.
SMA|sequential multiple autoanalyzer|SMA|189|191|SUBJECTIVE ASSESSMENT|1. Sutures out. 2. Discussion about decreased energy level. 3. Discussion of Decadron taper. 4. INR management. 5. Awaiting lab results for ........ Blood draws were done today for CBC and SMA 7. OBJECTIVE ASSESSMENT: The patient is doing quite well. He is here in a wheelchair for just decreased energy level.
SMA|sequential multiple autoanalyzer|SMA|93|95|LABORATORY|Normoactive bowel sounds. EXTREMITIES: Unremarkable. NEUROLOGIC: Grossly intact. LABORATORY: SMA 12. AST of 67. Albumin of 3.1. INR 1.16. Hemoglobin of 10.7. MCV of 91. Platelet count 170,000. CT scan of the abdomen revealed diverticulosis without changes of diverticulitis.
SMA|sequential multiple autoanalyzer|SMA|196|198|LABORATORY|UAC in the umbilical stalk. Large mucosal defect inferior to the omphalocele with abnormal genitalia and hemiscrotum. EXTREMITIES: Lower extremities demonstrate club feet. LABORATORY: PH of 7.39, SMA 6, normal hemoglobin of 16.2 yesterday. ASSESSMENT/PLAN: A 5-day-old infant with OEIS complex. Team plans for surgery as soon as they can stabilize his pulmonary status.
SMA|superior mesenteric artery|SMA|277|279|LABORATORY DATA|LABORATORY DATA: White count 20.5 thousand, dropping to 12.8 thousand, hemoglobin 11.0 dropping to 10.2, BUN, creatinine 34/1.45. INR is 1.39, going up to 2.04. Stool negative for C. diff and stool cultures are negative so far. CT scan: Multiple pulmonary emboli as above. The SMA and celiac arteries were seen. The SMA appears probably patent, celiac is calcified near the take off. IMPRESSION: 1. Pulmonary fibrosis. 2. Pulmonary emboli. 3. Probable ischemic colitis.
SMA|superior mesenteric artery|SMA|88|90|LABORATORY DATA|CT scan: Multiple pulmonary emboli as above. The SMA and celiac arteries were seen. The SMA appears probably patent, celiac is calcified near the take off. IMPRESSION: 1. Pulmonary fibrosis. 2. Pulmonary emboli. 3. Probable ischemic colitis.
SMA|superior mesenteric artery|SMA|174|176|CURRENT LABORATORY DATA|I discussed these results with Dr. _%#NAME#%_ _%#NAME#%_ who was the radiologist performing the study. In retrospect, I ask him to review the CT and he does believe that the SMA and SMV both run through the tumor mass directly. ASSESSMENT: Large intra-abdominal lymphoma with GI hemorrhage and contained perforation of the duodenal distal to the ampulla.
SMA|superior mesenteric artery|SMA|203|205|ASSESSMENT|ASSESSMENT: Large intra-abdominal lymphoma with GI hemorrhage and contained perforation of the duodenal distal to the ampulla. Because of the involvement of the duodenal wall and also the fact that both SMA and SMV vessels are enclosed within the tumor mass, resection is not reasonable or feasible here at Ridges Hospital. I suspect that she might need a vascular resection and/or revascularization.
SMA|superior mesenteric artery|SMA,|183|186|PHYSICAL EXAMINATION|NEURO: No focal motor signs. LABORATORY DATA at 0600: Hemoglobin 12 3, white count 14,300, platelets 186,000, sodium 139, K 4.4, chloride 107, CO2 27, magnesium 2.2. Angio of celiac, SMA, hepatic, gastroduodenal arteries all within normal limits per Dr. _%#NAME#%_. EKG preoperative showed normal sinus rhythm, essentially normal ECG.
SMA|superior mesenteric artery|SMA|270|272|HISTORY OF PRESENT ILLNESS|The rupture is contained within the mediastinum. The aortic arch is relatively normal diameter as is the very proximal descending thoracic aorta. The abdominal aorta is dilated to almost 5 cm including the celiac artery origin. The aorta becomes somewhat more normal at SMA and relatively normal at the renal arteries. Calcifications noted within these vessels. There is no evidence of a significant abdominal aortic aneurysm.
SMA|superior mesenteric artery|SMA,|227|230|IMAGING DATA|I reviewed the CT scan of _%#MMDD2007#%_, which shows a 3.2 cm abdominal aortic aneurysm, colon wall thickening of the distal transverse and descending colon and there is aortic calcification just cephalad to the origin of the SMA, but there is no clear stenosis of the SMA. The IMA itself was not visible. IMPRESSION: Ischemic colitis, possibly secondary to dehydration from a viral illness (versus viral colitis with bleeding secondary to anticoagulation).
SMA|superior mesenteric artery|SMA.|162|165|PLAN|There is certainly no indication for emergency surgery at this time. I will review and discuss the CT scan with Radiology to consider possible angioplasty of the SMA. However, to my review, it seems unlikely that this would be of benefit. If the SMA can be improved, this may help prevent further attacks, however.
SMA|spinal muscular atrophy|SMA|128|130|HISTORY OF PRESENT ILLNESS|She is referred to a pediatric neurologist, Dr. _%#NAME#%_, on the day of admission, who was concerned about the possibility of SMA (spinomuscular atrophy). _%#NAME#%_ was found to have some decreased tone but patellar reflexes were present (which is not consistent with SMA).
SMA|spinal muscular atrophy|SMA|230|232|HISTORY OF PRESENT ILLNESS|_%#NAME#%_ was found to have some decreased tone but patellar reflexes were present (which is not consistent with SMA). Dr. _%#NAME#%_ recommended hospitalization for further investigation and sent off a genetic test that detects SMA prior to admission. ALLERGIES: No known drug allergies.
SMA|spinal muscular atrophy|SMA,|137|140|PROBLEM #2|She had a genetic study done for SMA, which was still pending at the end of her hospitalization. Because her symptoms aren't typical for SMA, it was recommended that she get an MRI as an outpatient. Her tone was generally considered to be improved by the end of her hospitalization but was still lower than normal for her age.
SMA|superior mesenteric artery|SMA|116|118|PERTINENT INVESTIGATIONS|3. Diarrhea. PERTINENT INVESTIGATIONS: 1. MRI abdomen with contrast: Tortuous nonaneurysmal aorta. The celiac axis, SMA and IMA are patent without stenosis. Liver and right kidney cyst. Moderate right pleural effusion. 2. CT neck with contrast dated _%#MM#%_ _%#DD#%_, 2006. 3. There is a balloon type catheter through the left lower neck percutaneous tract which by surgical description likely extending to the esophagus.
SMA|superior mesenteric artery|SMA|146|148|PAST MEDICAL HISTORY|3. Status post autorenal transplant in 1997. 4. Bilateral carotid artery stenosis status post recent TIA. 5. Raynaud's phenomenon. 6. Status post SMA bypass secondary to mesenteric ischemia. 7. History of depression. 8. Status post left oophorectomy secondary to benign cystic mass.
SMA|superior mesenteric artery|SMA|200|202|PAST MEDICAL HISTORY|11. Abdominal aortic aneurysm with large amount of thrombus followed by Dr. _%#NAME#%_, measures 5.7 cm in AP diameter at the level of the lower kidneys and 5.3 cm in the upper abdomen just below the SMA by chest CT _%#MMDD2007#%_. 12. Recent patchy bilateral infiltrates treated for pneumonia, noted on chest CT _%#MM2007#%_, described as multifocal areas of infiltrate, airspace opacity throughout both lungs.
SMA|superior mesenteric artery|SMA|243|245|OPERATIONS AND PROCEDURES PERFORMED DURING THIS HOSPITALIZATION|5. Lumbar puncture performed on _%#MMDD2006#%_. 6. Percutaneous gastrojejunostomy tube placed on _%#MMDD2006#%_. 7. Upper GI performed on _%#MMDD2006#%_ showed no evidence of leak. Persistent pooling of contrast in the duodenum concerning for SMA syndrome. 8. Surgery consult because of acute abdomen. 9. ID consult. 10. Neurology consult. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 33-year-old woman with a past medical history of HIV/AIDS which is being treated with disseminated MAC and multiple recurrent hospital admissions for chronic recurrent nausea and vomiting assumed to be multifactorial in nature based on multiple medications and adrenal insufficiency.
SMA|superior mesenteric artery|SMA|156|158|PROBLEM #2|A CT of the abdomen and pelvis was obtained which demonstrated no evidence of metastatic disease with any compression along the bowel or any evidence of an SMA syndrome. She had no evidence of metastases in her abdomen and her liver was within normal limits, except for an attenuation region adjacent to the ligamentum teres certainly consistent with a fat accumulation.
SMA|superior mesenteric artery|SMA|231|233|SECTION #2|This improved after stopping the Voriconazole and spacing out her MMF to q.i.d. An upper GI was done on _%#MMDD#%_ due to concerns of superior mesenteric artery syndrome, and was negative for signs of gastric outlet obstruction or SMA syndrome. Endoscopy on _%#MMDD#%_ revealed delayed gastric emptying. An NJ was placed on _%#MMDD#%_ to aid in supplemental nutrition; however, the patient did not tolerate this, and it was removed that evening.
SMA|superior mesenteric artery|SMA|154|156|HOSPITAL COURSE|She was identified on nuclear scan to have a bleeding source either in her lower small bowel or proximal right colon, and this was further evaluated with SMA angiogram and continuous infusion therapy. She was maintained on Octreotide therapy as well, to decrease her gut secretions as her perineal care was compromised by a massive stooling.
SMA|superior mesenteric artery|SMA|126|128|HOSPITAL COURSE|The tagged red cell study came back and showed bleeding in her transverse colon. She underwent an angiogram of the celiac and SMA with embolization of the left gastric artery on _%#MMDD2002#%_. At this time, her Port-A-Cath became infected and it was removed.
SMA|superior mesenteric artery|SMA|247|249|HOSPITAL COURSE|On _%#MMDD2002#%_ the patient continued to have nausea and vomiting and a low grade temperature and increased white blood cell count at that time. Vac was changed. A CT was done on _%#MMDD2002#%_, which showed duodenal obstruction consistent with SMA syndrome. An NG was placed to help with the patient's nausea and vomiting and plans were made for PICC line placement and initiation of TPN.
SMA|superior mesenteric artery|SMA|206|208|HISTORY OF PRESENT ILLNESS|By the end of _%#MM#%_, the patient had increased her weight to 62 pounds but her p.o. intake continued to decrease. A repeat upper GI at the end of _%#MM#%_, also in North Dakota showed improvement of her SMA syndrome but showed an abnormal mucosal pattern in the stomach and duodenum with diffuse full thickening and irregularities. An NG tube with suction was then placed a week prior to admission.
SMA|superior mesenteric artery|SMA|220|222|PAST MEDICAL HISTORY|7. Status post laparoscopic cholecystectomy in _%#MMDD2007#%_. 8. Upper GI on _%#MMDD2007#%_ in _%#CITY#%_, North Dakota showed a dilated duodenum necking down near the area of superior mesenteric artery consistent with SMA syndrome. It is noted that images from the outside clinic and hospitals were sent which included images and reports at the end of _%#MM#%_, however, the images from _%#MMDD2007#%_ were not provided on admission.
SMA|superior mesenteric artery|SMA|181|183|PAST MEDICAL HISTORY|9. Strep pharyngitis, post rapid strep on _%#MMDD2007#%_. The patient recently completed a 10-day course of Omnicef. 10. Upper GI at the hospital at end of _%#MM#%_ showed improved SMA syndrome, abnormal mucus pattern with diffuse full thickening and irregularities suggested of gastritis, duodenitis and jejunitis. PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: Show a temperature of 98.7 degrees and weight of 28.1 kilograms, heart rate of 88 beats per minute, respiratory rate 24, blood pressure of 111/70, oxygen saturation 97% to 98% on room air.
SMA|superior mesenteric artery|SMA|137|139|DIET|15. Oxycodone 5-10 mg p.o. q.4h. p.r.n. pain. 16. Actigall 250 mg p.o. b.i.d. 17. Zofran 8 mg p.o. q.8h. p.r.n. nausea. DIET: Due to his SMA syndrome, _%#NAME#%_ is on Vivonex tube feedings by NJ tube at a continuous drip rate of 70 mL/hour. He may take p.o. feeds in addition to his tube feedings.
SMA|superior mesenteric artery|SMA|91|93|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Mesenteric angina with ischemia s/p dilation and stent of proximal SMA with resolution of symptoms. 2. Severe atherosclerotic disease. 3. Oliguria. 4. Metabolic acidosis. 5. Hematuria. HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old male with past medical history significant for severe atherosclerotic disease.
SMA|superior mesenteric artery|SMA|483|485|HISTORY OF PRESENT ILLNESS|While in the _%#CITY#%_ _%#CITY#%_ Hospital, the patient continued to have abdominal pain with meals, has been n.p.o. for further evaluation and an evaluation to evaluate for possible mesenteric ischemia was undertaken. The patient had multiple imaging studies eventually including an MRI/MRA of his abdominal vasculature, which showed evidence of 95% right renal artery stenosis, (4:53) 30% left renal artery stenosis, 70% stenosis of the celiac artery with severe narrowing of the SMA and IMA, occluded left common iliac and external iliac arteries and occlusion of the right common iliac and external iliac arteries.
SMA|superior mesenteric artery|SMA|177|179|HOSPITAL COURSE|Interventional Radiology was then contacted as the patient was not a surgical candidate who took the patient for interventional procedure with angiography of the celiac artery, SMA and IMA, results as above. Stent was placed across the SMA and following this, the patient's diet was advanced to clear liquids.
SMA|superior mesenteric artery|SMA|236|238|HOSPITAL COURSE|Interventional Radiology was then contacted as the patient was not a surgical candidate who took the patient for interventional procedure with angiography of the celiac artery, SMA and IMA, results as above. Stent was placed across the SMA and following this, the patient's diet was advanced to clear liquids. He did tolerate this well, had a transient rises in his lactate, however, with further advancement of his diet, the patient did not have any ongoing abdominal pain and the day before discharge had a lactate of 1.6 and the patient should continue a regular diet as an outpatient.
SMA|superior mesenteric artery|SMA|177|179|IMAGING STUDIES AND PROCEDURE PERFORMED DURING THIS HOSPITALIZATION|Essentially normal femoral, popliteal and trifurcation vessels bilaterally with the exception of mild disease involving the profunda femorus arteries. Apparent occlusion of the SMA at its origin. Probable origin stenosis of the celiac trunk. High grade stenosis of the origin of the inferior mesenteric artery with poststenotic aneurysmal dilatation as previously described on the study of _%#MMDD2007#%_.
SMA|superior mesenteric artery|SMA|191|193|HISTORY OF PRESENT ILLNESS|It was further complicated by dyspepsia and poor p.o. intake and weight loss. _%#NAME#%_ was recently admitted to F-UMC on _%#MM#%_ _%#DD#%_, 2002, with a weight of 25.1 Kg and found to have SMA syndrome. She was started on NJ tube feedings and tolerated these at a goal rate of 90 feces (?) per hour at the time of her discharge on _%#MM#%_ _%#DD#%_, 2002.
SMA|superior mesenteric artery|SMA|205|207|HOSPITAL COURSE|Both the cultures were sensitive to Bactrim. 5. Gastrointestinal. During this hospitalization, _%#NAME#%_ underwent two upper GIs with small bowel follow-throughs. Both tests revealed a persistence of her SMA but with interval improvement. They also revealed a distal ileal stricture of unknown significance. When this stricture was initially identified, a CT was performed.
SMA|sequential multiple autoanalyzer|SMA|227|229|LABORATORY DATA|The patient has decreased strength in his upper and lower extremities bilaterally secondary to back pain upon neurological exam. LABORATORY DATA: CBC revealed a white count of 6.8. Hemoglobin 10.7. MCV 59. Platelet counts 260. SMA chem panel revealed sodium of 141, potassium 3.3, chloride 108, bicarbonate of 26, BUN 8, creatinine 1.7. Calcium 8.3. Urine toxicology screen was positive for alcohol and her blood alcohol level is 0.29. D-dimer minimally elevated at 0.6. BMP normal at 81.
SMA|sequential multiple autoanalyzer|SMA|197|199|DISCHARGE INSTRUCTIONS|9. Lanoxin 0.12 mg p.o. q.d. 10. Insulin 70/30 and the dose is stated above. DISCHARGE INSTRUCTIONS: 1. The patient will follow up in the outpatient laboratory on Monday, _%#MM#%_ _%#DD#%_, for an SMA 10 and INR. 2. Nephrology clinic to see _%#NAME#%_ _%#NAME#%_ in the renal clinic at 1 p.m. She will make adjustments to the Lisinopril and Coumadin as needed at that point.
SMA|superior mesenteric artery|SMA,|174|177|PAST MEDICAL HISTORY|The patient had an MRI and MR angiogram of abdomen on _%#MMDD2006#%_ and repeated on _%#MMDD2006#%_, which showed widely patent origins and proximal segments of celiac axis, SMA, and IMA. Minimal narrowing of proximal celiac axis. 4. Hypertension. 5. History of multiple compression fractures in the thoracic.
SMA|superior mesenteric artery|SMA|156|158|RADIOLOGY|Cannot rule out possible diverticulitis versus colitis. There are simple cysts in the liver and kidneys which are otherwise unchanged from previous CT. The SMA and the celiac artery appear widely patent. ELECTROCARDIOGRAM: Normal sinus rhythm. Rate 60s. There is a T-wave abnormality in 3, AVF, V1 and V2 and Q waves inferiorly.
SMA|sequential multiple autoanalyzer|SMA|211|213|FOLLOW-UP PLANS|9. Docusate 100 mg p.o. q. day. FOLLOW-UP PLANS: 1. Dr. _%#NAME#%_ in one week. 2. Dr. _%#NAME#%_ at _%#COUNTY#%_ _%#COUNTY#%_ Medical Center endocrinology _%#MMDD2002#%_ with the patient to receive urinalysis, SMA 7 and hemoglobin A1C prior to appointment. 3. Home health care to be seen _%#MMDD2002#%_. 4. Diet: Diabetic 1800 kilocalorie.
SMA|sequential multiple autoanalyzer|SMA|195|197|FOLLOW-UP PLAN|The patient will be following up with Dr. _%#NAME#%_ and her primary physician. FOLLOW-UP PLAN: 1. Dr. _%#NAME#%_ from Heme/Onc in 3-4 weeks, _%#MM#%_ _%#DD#%_, 11:00 in the morning, with a CBC, SMA 10, and liver functions. 2. Dr. _%#NAME#%_ at _%#CITY#%_ _%#CITY#%_ who is the patient's primary physician.
SMA|superior mesenteric artery|SMA,|289|292|PROCEDURES THIS ADMISSION|5. Angio CT of the aorta (_%#MMDD2002#%_). Indication: evaluate type B aortic dissection, status post surgical repair of the ascending aorta and aortic arch. Results: descending thoracic and abdominal aortic dissection, descending down to the left common iliac artery, the splenic artery, SMA, and two left renal arteries supplied by the true lumen, common hepatic artery and right renal artery supplied by the false lumen.
SMA|superior mesenteric artery|SMA|244|246|HISTORY OF PRESENT ILLNESS|The patient has had weakness and fatigue ongoing for 1 month and worse so in the last week bu otherwise reported no new symptoms this morning. She was sent to interventional radiology from the ED where mesenteric angiogram was performed of the SMA and the celiac vessels. This study revealed no active bleeding, no AVM, no telangiectasias and no source of GI bleeding. She is admitted to medicine following the angiogram.
SMA|superior mesenteric artery|SMA|245|247|MESENTERIC ANGIOGRAM|Sodium 137, potassium 3.7, chloride 112, carbon dioxide 24, BUN 9, creatinine 0.69, glucose 73, calcium 7.3. Reticulocyte count was added and is 3.1. MESENTERIC ANGIOGRAM: Performed by interventional radiology. They performed angiography of the SMA and celiac vessels. There was no active bleeding, no AV malformation, no telangiectasias, no active source of bleeding. CBC following angiogram shows WBC 2.1 with 77% neutrophils and an ANC of 1600.
SMA|sequential multiple autoanalyzer|SMA|115|117|FOLLOW UP|22. Zofran 8 mg p.o. q.8h p.r.n. 23. Vicodin 1 to 2 tabs p.o. q.6h. p.r.n. FOLLOW UP: 1. Dr. _%#NAME#%_ in 1 week. SMA 7 INR in 4 to 5 days. 2. Dr. _%#NAME#%_, Urology in week. Renal ultrasound prior to visit. 3. Home healthcare service as previously.
SMA|superior mesenteric artery|SMA|166|168|HISTORY OF PRESENT ILLNESS|He was evaluated by MRI of the abdomen on _%#MMDD2004#%_ which showed a chronic dissection of the thoracic and abdominal aorta which was unchanged. The celiac access SMA right and left renal arteries arise from the true lumen. There is moderate to severe stenosis of the SMA which is unchanged from previous.
SMA|superior mesenteric artery|SMA|123|125|HISTORY OF PRESENT ILLNESS|The celiac access SMA right and left renal arteries arise from the true lumen. There is moderate to severe stenosis of the SMA which is unchanged from previous. He denies any melena, hematochezia, or hematemesis. No cough. Given his persistent symptoms, he was admitted for further medical management.
SMA|sequential multiple autoanalyzer|SMA|131|133|LABS ON ADMISSION|Funduscopic examination: Possible presence of small bleed at 10:00 the right eye; _______________ cone: Normal. LABS ON ADMISSION: SMA 10: Notable for BUN 35, creatinine 1.2. CBC: Wbc 2900, hemoglobin 9.3, platelets 139,000.
SMA|sequential multiple autoanalyzer|SMA.|295|298|ADMISSION DIAGNOSES|4. Hypercoagulable state associated with inflammatory bowel disease requiring chronic anticoagulation; S/P thrombotic stroke in 1985; S/P pulmonary emboli in 1999; S/P vena caval umbrella placement. 5. Malnutrition secondary to 1. above on TPN since Spring, 2006. 6. Current partial thrombus of SMA. 7. S/P internal iliac artery bleeding treated by intravascular arterial stent per interventional radiology at _%#COUNTY#%_ _%#COUNTY#%_'s Hospital in Fall, 2006. 8. Chronic depression
SMA|superior mesenteric artery|SMA.|208|211|DISCHARGE DIAGNOSES|4. Hypercoagulable state associated with inflammatory bowel disease with need for chronic anticoagulation; S/P thrombotic stroke; S/P pulmonary emboli; S/P vena caval umbrella. 5. Current partial thrombus of SMA. 6. S/P total proctocolectomy and Brooke ileostomy in 1985 for massive hemorrhage from chronic ulcerative colitis while on heparin for a thrombotic stroke.
SMA|superior mesenteric artery|SMA|185|187|PAST MEDICAL HISTORY|10. History of duodenal stricture. 11. History of acute renal failure in _%#MMDD#%_ and _%#MMDD#%_, requiring dialysis. 12. Major depression. 13. History of portal and splenic vein and SMA thrombosis in _%#MMDD#%_. 14. History of a seizure in _%#MMDD#%_. Last seizure _%#MMDD#%_. 15. Gastroesophageal reflux disease. PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: Temperature 97.8, pulse 69, blood pressure 105/59, respiratory rate 20, weight 51.6 kg.
SMA|superior mesenteric artery|SMA|249|251|ALLERGIES|GI and psychiatry consultations were obtained on admission. _%#NAME#%_ continued with some nausea and occasional vomiting for approximately 2 days. These symptoms then resolved. Gastroenterology was involved and recommended and upper GI to rule out SMA syndrome. The upper GI was normal. After that, they performed EGD which scheduled mild, erythematous gastropathy, duodenitis, and a small hiatal hernia.
SMA|superior mesenteric artery|SMA|258|260|PROCEDURES|PROCEDURES: On _%#MMDD2007#%_, the patient underwent an extended right hemicolectomy with distal ileectomy and intraoperative endoscopy by Dr. _%#NAME#%_ for gastrointestinal bleeding. On _%#MMDD2007#%_, the patient also underwent embolization of his second SMA jejunal branch by Interventional Radiology. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 66-year-old male who was transferred from an outside hospital on _%#MMDD2007#%_ due to multiple medical problems.
SMA|superior mesenteric artery|SMA|133|135|HOSPITAL COURSE|An angio was performed demonstrating bleeding from his jejunal branch. Due to this, the patient underwent embolization of his second SMA jejunal branch by Interventional Radiology on _%#MMDD2007#%_. This procedure was successful in providing hemostasis. There was no further blood out of this ostomy after this procedure.
SMA|superior mesenteric artery|SMA|176|178|HOSPITAL COURSE|Bilateral fallopian tubes and ovaries also appeared within normal limits. Smooth diaphragm, liver and gallbladder were noted. A mesenteric mass measuring 8 x 6 cm encasing the SMA was noted with gross lymphadenopathy above the lateral renal arteries, and there was also hepatic fossa lymphadenopathy with 3 x 4 cm nodules within the small bowel mesentery at the level of the ligament of Treitz.
SMA|sequential multiple autoanalyzer|SMA|131|133|DISCHARGE MEDICATIONS|Lipid solution should 20%, and it should be infused at 20 mL/hour for 12 hours. The patient should also get a CBC differential, an SMA 7, calcium, magnesium, and phosphorous level tomorrow in the Bone Marrow Transplant Clinic. He will also need to follow up on the vancomycin level as seemed appropriate, and his dose will be modified accordingly.
SMA|superior mesenteric artery|SMA|140|142|BRIEF HISTORY OF PRESENT ILLNESS|The lumen in this location measured 6 mm in diameter with a total diameter of the vessel measuring 10 mm. Distally the second branch of the SMA to the patient's right had some minimal narrowing of its takeoff; however, there was good opacification of the artery distal to this.
SMA|sequential multiple autoanalyzer|SMA|205|207|FOLLOW-UP|12. Combivent two puffs inhaled p.o. q.i.d. 13. Potassium chloride 20 mEq p.o. b.i.d. FOLLOW-UP: His follow-up is with the Electrophysiology Clinic with Dr. _%#NAME#%_ in three to four weeks with a repeat SMA -10 check in one week. The patient was hypokalemic during this hospitalization as he was getting IV Lasix, and it was replaced aggressively.
SMA|superior mesenteric artery|SMA|222|224|HISTORY OF PRESENT ILLNESS|He has had a complicated medical history including a stab wound and a serious fall at different times requiring multiple resections of his bowel and subtotal colectomy. He has a history of mesenteric venous thrombosis and SMA occlusion starting in _%#MM#%_ 2004. He has had multiple surgeries, subtotal colectomy, ileal resections, partial jejunal resections, jejunostomy.
SMA|superior mesenteric artery|SMA,|248|251|HISTORY OF PRESENT ILLNESS|She has not had an ultrasound of her lower extremities. As part of Dr. _%#NAME#%_'s workup for her renal failure, the patient underwent an MRA of her abdomen which showed significant atherosclerotic disease of her vessels including stenosis of the SMA, celiac, and left iliac arteries as well as significant stenoses to the right kidney with atheromatous plaque. In the Emergency Department today, the patient's vital signs were notable for blood pressure 180/104.
SMA|superior mesenteric artery|SMA,|248|251|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Renal failure, felt likely to be secondary to atherosclerotic disease as well as contribution from hypertension. 2. Extensive atherosclerotic disease of the abdominal vasculature with MRA in _%#MMDD#%_ with stenoses of the SMA, celiac, left ilea and right renal arteries. 3. Carotid artery stenosis greater than 70% bilaterally on recent ultrasound. 4. Left lower extremity calf pain felt secondary to claudication.
SMA|superior mesenteric artery|SMA|210|212|OPERATIONS/PROCEDURES PERFORMED|3. Atrial fibrillation, chronic. 4. Supratherapeutic INR. OPERATIONS/PROCEDURES PERFORMED: 1. Gastric emptying study - was within normal limits. 2. Doppler flow study of abdominal arteries: Showed narrowing of SMA and celiac arteries. 3. Pacer interrogation - showed no events, no arrhythmias. HISTORY OF PRESENT ILLNESS: An 81-year-old white female complains of abdominal pain and weakness.
SMA|sequential multiple autoanalyzer|SMA|162|164|FOLLOW-UP CARE|She is to follow up in Urology Clinic in one month. She is to follow up with Dr. _%#NAME#%_ in three weeks in renal clinic. On _%#MMDD#%_ the patient will have a SMA 10 drawn, which will be checked by Dr. _%#NAME#%_ from the Nephrology Department.
SMA|sequential multiple autoanalyzer|SMA|181|183|LABORATORY ON ADMISSION|NEUROLOGIC: Alert, oriented, motor strength is 5/5, intact sensation. LABORATORY ON ADMISSION: CBC, WBC 11,600, hemoglobin 10.4, MVC 92, platelets 200,000, lipase 193. INR is 0.96. SMA is 10. Creatinine is 1.2. BUN is 52. LFTs show albumin 2.5, protein total 5.7, ALT and AST 11/28. Troponins are negative. D-dimer is 1.9. UA showed proteins greater than 300.
SMA|superior mesenteric artery|SMA|322|324|PERTINENT INVESTIGATIONS|There is no evidence for ureteral dilatation. The mildly distended stomach and proximal small bowel may be related to distention from injection of oral contrast versus focal ________________. Small soft tissue density in the anterior mediastinum of uncertain clinical significance. 2. Renal ultrasound _%#MMDD2006#%_: The SMA and celiac trunk are patent with low resistance arterial waveforms at the origin. The IMA is difficult to visualize; consider an MRA for further evaluation.
SMA|superior mesenteric artery|SMA,|169|172|PERTINENT INVESTIGATIONS|Occluded left common iliac artery. Moderate to severe stenosis at the origin of the right common iliac artery. 3. MRI abdomen with MRA _%#MMDD2006#%_: The celiac trunk, SMA, and IMA are patent at their origins. Severe stenosis in the proximal right renal artery. Occluded left common iliac artery.
SMA|superior mesenteric artery|SMA|159|161|HOSPITAL COURSE|A celiac panel showed negative endomysial and gliadin antibodies. The tissue transglutaminase IgA was weekly positive though. An upper GI was done to rule out SMA syndrome, this was normal showing no evidence of SMA syndrome or small bowel obstruction. An MRI of the abdomen showed no ductal dilation and no evidence of sclerosing cholangitis.
SMA|spinal muscular atrophy|SMA|142|144|PAST MEDICAL HISTORY|Denies use over the last 6 months. No use of alcohol. PAST MEDICAL HISTORY: 1. Psychiatric illness (as above). Details per Dr. _%#NAME#%_. 2. SMA type 1 (as above). 3. Chronic upper respiratory infections (as above). On chronic BiPAP, presumably to help improve ventilation. 4. Mixed tension/muscle contraction and migraine headaches.
SMA|sequential multiple autoanalyzer|SMA|52|54|PHYSICAL EXAMINATION|Wall motion and heart function is otherwise normal. SMA 7 is unremarkable. CBC is also unremarkable with a normal H&H of 14 and 44 with platelets of 342,000. In summary, _%#NAME#%_ _%#NAME#%_ is a woman with an intermediate sized subcortical stroke on the left accounting for her facial, arm and leg weakness.
SMA|superior mesenteric artery|SMA,|117|120|HISTORY OF PRESENT ILLNESS|The sonographic finding was suggestive of a malignancy. The pancreatic mass did not appear to be in contact with the SMA, the SMV, portal vein, hepatic artery, or aorta. There was no definite contact with the IVC. The pancreatic body and tail had sonographic features of chronic pancreatitis.
SMA|superior mesenteric artery|SMA.|221|224|HISTORY OF PRESENT ILLNESS|There was irregular impression and filling defect along the adjacent second portion of the duodenum with possible invasion into the second portion of the duodenum. There was a replaced right hepatic artery rising off the SMA. The pancreatic mass was adjacent to approximately 40% of the circumference of the SMA. There was distinct fat planes between the mass and the celiac axis left hepatic artery and splenic artery.
SMA|superior mesenteric artery|SMA.|144|147|HISTORY OF PRESENT ILLNESS|There was a replaced right hepatic artery rising off the SMA. The pancreatic mass was adjacent to approximately 40% of the circumference of the SMA. There was distinct fat planes between the mass and the celiac axis left hepatic artery and splenic artery. SMV and portal veins were patent. There was a 1 cm small lymph node anterior to the left neck of the pancreas and an approximately 1 cm lymph node left of the SMA below the level of its origin just above the left renal vein.
SMA|superior mesenteric artery|SMA|266|268|HISTORY OF PRESENT ILLNESS|There was distinct fat planes between the mass and the celiac axis left hepatic artery and splenic artery. SMV and portal veins were patent. There was a 1 cm small lymph node anterior to the left neck of the pancreas and an approximately 1 cm lymph node left of the SMA below the level of its origin just above the left renal vein. The 5 mm lesion in the right lobe of the liver was consistent with a simple cyst.
SMA|superior mesenteric artery|SMA.|136|139|HPI|The patient was thought to be operable, however further examination revealed the mass is invading about 40% of the circumference of the SMA. The patient's disease course has been somewhat complicated with panc reatitis which he is being treated as an in-patient.
SMA|superior mesenteric artery|SMA|148|150|HISTORY OF PRESENT ILLNESS|The largest lesion was appreciated in the liver and was sized at 8 x 6 cm. Also, appreciated was a left periaortic soft tissue mass at the level of SMA as well as a left adrenal lesion. The patient has sought multiple second opinions and has been seen at Moral Sloan Kettering and MD _%#NAME#%_.
SMA|superior mesenteric artery|SMA|225|227|HISTORY OF PRESENT ILLNESS|This was confirmed by upper EUS reportedly. There was no evidence of metastatic disease at presentation. The patient was taken for a Whipple procedure by Dr. _%#NAME#%_ on _%#MMDD2007#%_. Unfortunately, there was evidence of SMA involvement at the time of surgery, and resection was aborted. He was then seen by Dr. _%#NAME#%_ at Abbott-Northwestern during his recovery.
SMA|superior mesenteric artery|SMA|366|368|HISTORY OF PRESENT ILLNESS|There is again noted a splenic infarct. Because of the finding of celiac and SMA occlusion, the patient was transferred up to Fairview Southdale Hospital to be evaluated by Dr. _%#NAME#%_ from vascular surgery, and to go to the interventional radiology department to have an angiogram by Dr. _%#NAME#%_ who I have spoken with. He found an occluded celiac artery and SMA which he placed a local lytic catheter to run TPN and SMA. The patient is to be sent for CT scan of the pancreas to rule out underlying malignancy.
SMA|smooth muscle actin|SMA,|183|186|LABORATORY STUDIES|It was reviewed by Dr. _%#NAME#%_ _%#NAME#%_ as a plasmacytoma with lambda light change restriction. Special immunohistochemical stains: RCD 45 positive, CD 99 positive. Cytokeratin, SMA, MSA, and myogen were all negative. CT scan of the chest shows no adenopathy. There is calcification of the right hilar node region.
SMA|superior mesenteric artery|SMA,|198|201|LABORATORY|No acute ST-T wave changes noted. The patient also had a CT scan of the abdomen done, which was negative for any abnormal findings except for a 2 cm collection, with air fluid levels just below the SMA, thought to be due to small bowel diverticulum. However, the patient was preliminarily noted to have a large gallbladder on the CT scan of the abdomen.
SMA|superior mesenteric artery|(SMA).|176|181|HOSPITAL COURSE|The patient was hemodynamically stable. He underwent an aortic angiogram specifically looking at the celiac artery and splenic artery along with the superior mesenteric artery (SMA). This revealed no evidence of a pseudoaneurysm. It was felt that with these findings the mass most likely was a pancreatic-type tumor that had internal necrosis with bleeding.
SMA|smooth muscle antibody|SMA,|254|257|PLAN|3. Current symptoms are not thought to be secondary to his blood pressure medication as typically with lisinopril there would be more of a cholestatic type picture with increased alkaline phosphatase. 4. We will, therefore, check iron studies, ANA, AMA, SMA, B12, and folic acid. 5. Viral serologies have already been requested. 6. Liver biopsy will be entertained, however, that after repeated liver studies over the next few weeks.
SMA|superior mesenteric artery|SMA.|138|141|IMPRESSION|After talking with _%#NAME#%_ and _%#NAME#%_, they felt that they would not alter the management of the pregnancy based on a diagnosis of SMA. Nevertheless, they were hoping to obtain information about _%#NAME#%_'s carrier status so that they could be prepared for the birth of a special needs child.
SMA|superior mesenteric artery|SMA|168|170|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Total hysterectomy in 1982. 2. Right thyroidectomy in 1983. 3. Lap chole in 1995. 4. Appendectomy in 1965. 5. Multiple operations for presumed SMA compression syndrome, such as a. duodenojejunostomy in _%#MM#%_ 1998; b. exploratory laparotomy, lysis of adhesions, revision of anastomosis in _%#MM#%_ 1999; c. ERCP that presumably diagnosed pancreatic division in 1999; d. gastrojejunostomy in _%#MM#%_ 1999; e. repeated exploratory laparotomy in _%#MM#%_ 1999; f. exploratory laparotomy with lysis of adhesions, duodenal jejunostomy, take-down, sphincteroplasty, resection of limp jejunum, enteroenterostomy, intraoperative cholangiogram was all done in _%#MM#%_ 2002.
SMA|superior mesenteric artery|SMA|180|182|PAST MEDICAL HISTORY|In _%#MM2006#%_, he had repeat GI bleed and he received a tagged red blood cell scan which was positive for jejunal cells of bleeding and he did undergo segment of embolization of SMA per Interventional Radiology. A follow-up capsule endoscopy done in _%#MM2006#%_ revealed resolution of his GI bleed. 3. History of small bowel obstruction in _%#MM2006#%_ which resolved with conservative management.
SMA|superior mesenteric artery|SMA|225|227|HISTORY OF PRESENT ILLNESS|Previously seen to have a venous malformation at the splenic flexure by colonoscope on _%#MM#%_ _%#DD#%_, 2002. Angiography on the day of admission, _%#MM#%_ _%#DD#%_, 2002, showed no abnormalities in the distribution of the SMA or IMA. He was admitted for overnight observation. PAST MEDICAL HISTORY: 1. GI bleed. 2. Myelofibrosis. 3. PTCA with stent 1995.
SMA|superior mesenteric artery|SMA|191|193|PLAN|ASSESSMENT: 53-year-old Caucasian female with history of chronic abdominal pain secondary to superior mesenteric artery clot and dissection. PLAN: 1. SMA clot. The patient has evidence of an SMA clot both on CT scan, as well as angiography. For further evaluation of this, we will consult the Vascular Surgery Service, as well as the Hematology/Oncology Service to help us with further workup of possible hypercoagulable state or another reason for the patient's clot, as well as management of the acute clot.
SMA|superior mesenteric artery|SMA|192|194|INDICATIONS|He underwent a MR angiogram and this showed dissection of celiac artery with occlusion of the splenic artery and common hepatic artery. The hepatic artery was supplied with a left gastric and SMA collaterals, the splenic field by the SMA. We have been asked to see him for the same. He is now anticoagulated, feels significantly better and mainly has residual soreness.
SMA|spinal muscular atrophy|(SMA)|273|277|PAST MEDICAL HISTORY|The patient had history of spinal muscular atrophy since her __________, and now she flaccid weakness of lower extremities, but she was able to use her electric wheelchair and drive. She is alert, oriented, and cooperative. PAST MEDICAL HISTORY: 1. Spinal muscular atrophy (SMA) possible type A, onset at birth. 2. Recurrent right pyelonephritis and urinary tract infection. 3. Atrophic right kidney with pyelonephritis.
SMA|superior mesenteric artery|SMA|127|129|HOSPITAL COURSE|Some mild calcifications. She does, however, have HIGH-GRADE STENOSIS OF CELIAC ACCESS PROXIMALLY but there was patency of the SMA and IMA proximally. We did not think that this needed to be pursued any further. That is an issue and Dr. _%#NAME#%_ can decide at some point whether she would need a vascular surgery referral.
SS|single strength|SS|134|135|DISCHARGE MEDICATIONS|3. CellCept 1000 mg p.o. b.i.d. 4. Dilaudid 2 mg to 4 mg p.o. q.3h. p.r.n. pain. 5. Tylenol 650 mg p.o. q.4h. p.r.n. pain. 6. Bactrim SS 1 p.o. q. day.
SS|single strength|SS|124|125|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prograf 1.5 mg p.o. b.i.d. 2. CellCept 1 gm p.o. b.i.d. 3. Prednisone 5 mg p.o. q day. 4. Bactrim SS one tablet p.o. q day. 5. Protonix 40 mg p.o. q day. 6. Valtrex 1 gm p.o. t.i.d. X28 days, then discontinue.
SS|single strength|SS|130|131|DISCHARGE MEDICATIONS|Her hemoglobin increased to adequate levels prior to discharge. DISCHARGE MEDICATIONS: 1. Fluconazole 100 mg PO daily. 2. Bactrim SS one tab PO daily. 3. Peridex rinse 10 mL swish and spit twice daily. 4. EMLA cream to port p.r.n. 5. MiraLax 17 grams PO daily p.r.n. for no stool.
SS|single strength|SS|160|161|DISCHARGE MEDICATIONS|He received IV fluids as well as vincristine, actinomycin and Cytoxan. DISCHARGE MEDICATIONS: 1. G-CSF 90 mcg subcu daily to start on _%#MMDD2005#%_ 2. Bactrim SS 5 mL p.o. b.i.d. every Monday and Tuesday 3. Fluconazole 50 mg p.o. daily 4. MiraLax 17 g p.o. daily 5. Zofran 4 mg oral dissolvable tabs q.6-8 h p.r.n. nausea
SS|single strength|SS|153|154|ADMISSION DIAGNOSIS|The patient was discharged home. DISCHARGE MEDICATIONS: 1. Prograf 2 mg p.o. b.i.d. 2. CellCept 1 g p.o. b.i.d. 3. Valcyte 450 mg p.o. daily. 4. Bactrim SS 1 tablet p.o. daily. 5. Protonix 40 mg p.o. daily. 6. Lipitor 10 mg p.o. daily. 7. Allopurinol 300 mg p.o. daily.
SS|single strength|SS|144|145|MEDICATIONS|3. Levothyroxine 112 mcg p.o. daily. 4. Metoprolol XL 12.5 mg p.o. q.a.m. 5. Cellcept 1 gm p.o. b.i.d. 6. Protonix 40 mg p.o. daily. 7. Bactrim SS p.o. daily. 8. Valcyte 450 mg p.o. daily. 9. Actigall 300 mg p.o. t.i.d. 10. Senokot two tablets p.o. q.h.s.
SS|single strength|SS|129|130|DISCHARGE MEDICATIONS|10. MMF 250 mg po qid. 11. Prednisone 30 mg po qd, then taper as per protocol. 12. Sodium bicarbonate 2 tabs po qid. 13. Bactrim SS 1 tab po qd. 14. Tylox 1-2 tabs po q4-6h prn. 15. Ganciclovir 1 gm po t.i.d.
SS|single strength|SS|160|161|PHYSICAL EXAMINATION ON ADMISSION|9. Metoprolol 25 mg twice a day. 10. Multivitamin once a day. 11. CellCept 1500 mg twice a day. 12. Prednisone 20 q.a.m. 13. Prednisone 17.5 q.p.m. 14. Bactrim SS one tablet p.o. two times a week. 15. Valcyte 900 mg p.o. once a day. 16. For the pain control, the patient will continue to the medications that he has taken at home as well as he will receive a prescription for Tylenol #3 and he will receive 50 of those tablets.
SS|single strength|SS|123|124|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prograf 3 mg p.o. b.i.d. 2. Cellcept 500 mg p.o. q.i.d. 3. Prednisone 15 mg p.o. q.d. 4. Bactrim SS 1 p.o. q.d. 5. Valcyte 900 mg p.o. q.d. 6. Mycelex troche 10 mg p.o. q.i.d. 7. Prevacid 30 mg p.o. q.d. 8. Sodium bicarbonate 1.3 gm p.o. q.i.d.
SS|single strength|SS|305|306|DISCHARGE MEDICATIONS|3. Prednisone 35 mg p.o. q.d. (divided dose) _%#MMDD#%_ through _%#MMDD#%_, 20 mg p.o. q.d. (divided dose) _%#MMDD#%_ through _%#MMDD#%_, 15 mg p.o. q.d. (divided dose) _%#MMDD#%_ through _%#MMDD#%_, 7.5 mg p.o. q.d. _%#MMDD#%_ through _%#MMDD#%_, then 5 mg p.o. q.d. beginning _%#MMDD2002#%_. 4. Bactrim SS 1 p.o. q.d. 5. Valcyte 450 mg p.o. q.d. (x 3 months, then discontinue). 6. Mycelex troche 10 mg p.o. q.i.d. (p.c. and h.s.)
SS|single strength|SS|189|190|DISCHARGE MEDICATIONS|12. Reglan 10 mg p.o./JT q.i.d. 13. Zofran 4-8 mg p.o./JT q4-6 hours prn nausea. 14. Lomotil one tablet p.o./JT b.i.d./q.i.d. prn diarrhea. 15. Mycelex troche 10 mg p.o. q.i.d. 16. Bactrim SS one p.o. q.d. 17. Vitamin C one gram p.o. b.i.d. 18. Accuzyme one smear topical to necrotic areas of heel ulcers b.i.d.
SS|single strength|SS|129|130|DISCHARGE MEDICATIONS|7. Colace 100 mg p.o. b.i.d. 8. Imdur 30 mg p.o. q.day. 9. CellCept 1500 mg p.o. b.i.d. 10. Valcyte 900 mg p.o. q.d. 11. Bactrim SS 1 tablet p.o. q. times per week. 12. Prograf 2 mg p.o. b.i.d. 13. Prednisone taper which we will taper down 5 mg every day.
SS|single strength|SS|181|182|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Vancomycin 1.5 gm IV q. 24 hours (_%#MM#%_ _%#DD#%_-_%#DD#%_, 2002, then discontinue). 2. Prograf 3.5 mg p.o. b.i.d. 3. Rapamune 4 mg p.o. q.d. 4. Bactrim SS 1 p.o. q.d. 5. Valcyte 900 mg p.o. q.d. 6. Mycelex troche 10 mg p.o. q.i.d. 7. Lopressor 50 mg p.o. b.i.d.
SS|single strength|SS|366|367|DISCHARGE MEDICATIONS|3. Prednisone 35 mg p.o. q.d. (divided dose) _%#MMDD#%_-_%#MMDD#%_, 30 mg p.o. q.d. (divided dose) _%#MMDD#%_-_%#MMDD#%_, 20 mg p.o. q.d. (divided dose) _%#MMDD#%_-_%#MMDD#%_, 15 mg p.o. q.d. (divided dose) _%#MMDD#%_-_%#MMDD#%_, 10 mg p.o. q.d. _%#MMDD#%_-_%#MMDD#%_, 7.5 mg p.o. q.d. _%#MMDD#%_-_%#MMDD#%_, then 5 mg p.o. q.d. beginning _%#MMDD2002#%_. 4. Bactrim SS 1 p.o. q.d. 5. Valcyte 900 mg p.o. q.d. (for three months, then discontinue). 6. Mycelex troches 10 mg p.o. q.i.d. (for six months, then discontinue).
SS|single strength|SS|149|150|ADMISSION MEDICATIONS|2. Left lower quadrant abscess, percutaneously drained in _%#MM2004#%_. ADMISSION MEDICATIONS: 1. Prograf 3.5 mg q.a.m., 3 mg p.o. q.p.m. 2. Bactrim SS one tablet p.o. every Monday and Thursday. 3. Prevacid 30 mg p.o. daily. 4. Multivitamin one tablet p.o. daily. 5. Aspirin 81 p.o. q.3 times a week. 6. Magnesium oxide 2 tablets p.o. t.i.d.
SS|single strength|SS|144|145|MEDICATIONS|2. Cellcept 250 mg p.o. b.i.d. 3. Prednisone 10 mg p.o. b.i.d. 4. Mycelex troche, 1 troche p.o. q.i.d. 5. Valcyte 900 mg p.o. daily. 6. Bactrim SS 1 tablet p.o. daily. 7. Voriconazole 200 mg p.o. b.i.d. 8. Lantus 20 units subq q.h.s. 9. NovoLog insulin sliding scale.
SS|single strength|SS|191|192|IMPRESSION AND PLAN|It was then decided that the patient would be discharged to home on _%#MM#%_ _%#DD#%_, 2005, on the following medications. 1. Neoral 225 mg p.o. b.i.d. 2. CellCept 1 g p.o. b.i.d. 3. Bactrim SS 1 tablet p.o. daily. 4. Valcyte 900 mg p.o. daily. 5. Mycelex troche 10 mg p.o. daily. 6. Catapres 0.1 mg p.o. daily.
SS|single strength|SS|124|125|REVIEW OF SYSTEMS|ADMISSION MEDICATIONS: 1. Protonix 40 mg p.o. b.i.d. 2. Calcium with vitamin D. 3. Wellbutrin 300 mg p.o. daily. 4. Bactrim SS 1 tablet p.o. daily. 5. Singulair 10 mg p.o. daily. 6. Nasonex 2 sprays daily. 7. Diltiazem 120 mg daily. 8. Advair 1 puff b.i.d.
SS|single strength|SS|143|144|DISCHARGE MEDICATIONS|6. Metoprolol XL 50 mg p.o. daily. 7. MS Contin 60 mg p.o. b.i.d. 8. Pantoprazole 40 mg p.o. daily. 9. Prednisone 5 mg p.o. daily. 10. Bactrim SS one p.o. daily. 11. Tacrolimus 2 mg p.o. b.i.d. (this dose should be adjusted for a goal tacrolimus level of 10-12).
SS|single strength|SS|145|146|SERVICE|5. Prevacid 300 mg p.o. daily. 6. CellCept 500 mg p.o. t.i.d., which is to be held until his clinic appointment on _%#MM#%_ _%#DD#%_. 7. Bactrim SS 1 tablet p.o. every other day. 8. Valcyte 450 mg p.o. daily. FOLLOWUP: The patient is to follow up with Dr. _%#NAME#%_ in transplant clinic on _%#MM#%_ _%#DD#%_, the day following discharge.
SS|single strength|SS|113|114|DISCHARGE MEDICATIONS|6. Prednisone 125 mg p.o. x1 on Saturday and 7.5 mg p.o. on Sunday. 7. K-Phos 1 tablet 5 times a day. 8. Bactrim SS 1 tablet p.o. b.i.d. Monday and Tuesday. INSTRUCTIONS: _%#NAME#%_ is to have a diet as tolerated. FOLLOW UP: _%#NAME#%_ is to follow up on Monday and Thursday via home health for a CBC with differential and platelets, to be faxed _%#NAME#%_ _%#NAME#%_ at _%#TEL#%_.
SS|single strength|SS|203|204|DISCHARGE MEDICATIONS|Dr. _%#NAME#%_ assessed her status during this hospitalization course and adjusted her brace and ordered physical therapy to improve the range of motion in her right knee. DISCHARGE MEDICATIONS: Bactrim SS 1 tablet p.o. b.i.d. Monday and Tuesday, Peridex rinse 10 mL swish and spit b.i.d., fluconazole 100 mg p.o. daily, Protonix 40 mg p.o. daily, OxyContin 10 mg p.o. b.i.d., oxycodone 5 to 10 mg p.o. q.4-6 h. p.r.n. for pain, MiraLax 17 g p.o. daily p.r.n. constipation, Colace 100 mg p.o. daily p.r.n. constipation, Zofran 4 to 8 mg p.o. q.6-8 h. p.r.n. for nausea, and leucovorin 10 mg to complete 20 total doses.
SS|single strength|SS,|181|183|DIAGNOSES|Otherwise, the patient will be informed of the test results on his followup clinic visit. DISCHARGE MEDICATIONS: 1. Neoral 125 mg p.o. b.i.d. 2. CellCept 1 g p.o. b.i.d. 3. Bactrim SS, 1 tablet p.o. every Monday, Wednesday, Friday for 3 weeks. 4. Valcyte 450 mg p.o. q.day. 5. Protonix 40 mg p.o. q.day.
SS|single strength|SS|185|186|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Neoral 225 mg p.o. b.i.d. 2. Prednisone 5 mg p.o. q.a.m. 3. Prednisone 7.5 mg p.o. q noon 4. MMF 500 mg p.o. b.i.d. 5. Mycelex troche 1 p.o. q.i.d. 6. Bactrim SS 1 tab p.o. q day 7. Ganciclovir 500 mg p.o. t.i.d. 8. Remeron 15 mg p.o. q.h.s. 9. Celexa 30 mg p.o. q day 10. Colace 50 mg p.o. q day p.r.n. constipation FOLLOW UP: The patient is to follow up with pediatric nephrologist Dr. _%#NAME#%_ and she is to call for an appointment.
SS|single strength|S.S.|170|173|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prograf 3 mg p.o. bid. 2. CellCept 500 mg p.o. bid. 3. Prednisone 5 mg p.o. qd. 4. Nafcillin 2 gm IV q4h X14 days, then discontinue. 5. Bactrim S.S. one p.o. qd. 6. Mycelex troche 10 mg p.o. qid (after meals and at bedtime). 7. Sodium bicarbonate 1.3 gm p.o. qid. 8. Calcium carbonate with vitamin D 500 mg p.o. tid.
SS|single strength|SS|220|221|DISCHARGE MEDICATIONS|30 mg p.o. q.d. [divided dose] _%#MMDD#%_ and _%#MMDD#%_. 20 mg p.o. q.d. [divided dose] _%#MMDD#%_ through _%#MMDD#%_. 10 mg p.o. q.d. _%#MMDD#%_ through _%#MMDD#%_, then 5 mg p.o. q.d. beginning _%#MMDD#%_. 8. Bactrim SS 1 p.o. q.d. 9. Valcyte 450 mg p.o. q.d. 10. Mycelex troche 10 mg p.o. q.d. 11. Zocor 30 mg p.o. q.h.s. 12. Aspirin 325 mg p.o. q.d. 13. Hydralazine 10 mg p.o. t.i.d.
SS|single strength|SS|204|205|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Primaxin 500 mg IV q12 hours (discontinue after first dose on _%#MMDD2002#%_). 2. Prograf 2 mg p.o. b.i.d. 3. Cellcept 1 gram p.o. b.i.d. 4. Prednisone 5 mg p.o. q.d. 5. Bactrim SS one p.o. q.d. 6. Lisinopril 10 mg p.o. q.d. 7. Clonidine 0.1 mg p.o. b.i.d. 8. Aspirin 81 mg p.o. q.d. 9. Sodium bicarbonate 3.9 grams p.o. q.i.d.
SS|single strength|SS,|162|164|DISCHARGE MEDICATIONS|5. Chlorthalidone 25 mg po qd. 6. Fluconazole 400 mg po qd. 7. Ganciclovir 1 g po tid. 8. Lansoprazole 30 mg po qd. 9. Magnesium oxide 400 mg po tid. 10. Bactrim SS, 1 tab po qd. 11. Tacrolimus 1.75 mg in morning; 2 mg in evening. 12. Prednisone taper 17.5 mg today, then one week of 15 mg, then one week of 12.5 mg, then one week of 10 mg, then one week of 7.5 mg; after that he will take 5 mg qd.
SS|single strength|SS|144|145|DISCHARGE MEDICATIONS|Mr. _%#NAME#%_ will be transferred to home on the following medications: 1. Neoral 200 mg p.o. b.i.d. 2. Cellcept 1 gram p.o. b.i.d. 3. Bactrim SS 1 p.o. q.d. 4. Valcyte 450 mg p.o. q. Monday/Wednesday/Friday x 3 months. 5. Mycelex Troches 10 mg p.o. q.i.d. x 6 months.
SS|single strength|SS|126|127|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Sandimmune 100 mg p.o. b.i.d. 2. Neurontin 900 mg p.o. q.h.s. 3. Imuran 100 mg p.o. q.d. 4. Bactrim SS 1 tab p.o. q.d. 5. Quinine 260 mg p.o. every other day on dialysis days. 6. Midodrine 2.5 mg p.o. t.i.d. 7. Epogen 10,000 units 3 times a week in dialysis.
SS|single strength|SS|142|143|DISCHARGE MEDICATIONS|Though she will continue Abelcet three times a week per infectious disease (Dr. _%#NAME#%_) recommendation. DISCHARGE MEDICATIONS: 1. Bactrim SS one p.o. Monday, Wednesday, Friday. 2. Prevacid 30 mg p.o. q.d. 3. Aspirin enteric-coated 81 mg p.o. q.d. 4. Voriconazole 300 mg p.o. b.i.d., discontinue it on _%#MMDD2003#%_.
SS|single strength|SS|258|259|DISCHARGE MEDICATIONS|Her tacrolimus level at discharge was 10.2 ng/L. She was switched from mycophenolate mofetil to enteric-coated mycophenolate sodium because of intractable nausea. DISCHARGE MEDICATIONS: 1. Prograf 2.5 mg p.o. b.i.d. 2. Myfortic 720 mg p.o. b.i.d. 3. Bactrim SS 1 p.o. daily. 4. Valcyte 900 mg p.o. daily. 5. Mycelex troche 10 mg p.o. q.i.d. 6. Aspirin 81 mg p.o. daily.
SS|single strength|SS|126|127|DISCHARGE MEDICATIONS|3. Flomax 0.4 mg p.o. daily. 4. Aspirin 81 mg p.o. daily. 5. Tylenol Extra Strength 750 mg p.o. daily p.r.n. pain. 6. Bactrim SS 1 p.o. b.i.d. x 5 days, #10, no refills. Prescription was sent home with the patient.
SS|single strength|SS|248|249|DISCHARGE MEDICATIONS|2. Cellcept 1 gram p.o. b.i.d. 3. Prednisone 17.5 mg p.o. q.d. until _%#MMDD#%_, 15 mg p.o. q.d. _%#MMDD#%_-_%#MMDD#%_, 12.5 mg p.o. q.d. _%#MMDD#%_-_%#MMDD#%_, 10 mg p.o. q.d. _%#MMDD#%_-_%#MMDD#%_, 5 mg p.o. q.d. beginning _%#MMDD#%_. 4. Bactrim SS 1 p.o. q.d. 5. Valcyte 900 mg p.o. q.d. x 3 months, then discontinue. 6. Mycelex Troches 10 mg p.o. q.i.d. x 6 months, then discontinue.
SS|single strength|SS|129|130|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Include: 1. Imuran 50 mg p.o. q.d. 2. Neoral 100 mg p.o. b.i.d. 3. Prednisolone 3 mg p.o. q.d. 4. Bactrim SS 5 ml p.o. q.d. 5. Enalapril 2.5 mg p.o. q.d. She was to follow up in clinic on _%#MMDD#%_ to recheck her potassium and CsA levels.
SS|single strength|SS|199|200|DISCHARGE MEDICATIONS|This can be followed as an outpatient. The patient was discharged to home on _%#MM#%_ _%#DD#%_, 2003. DISCHARGE MEDICATIONS: 1. Azathioprine 100 mg po q day. 2. Prednisone 10 mg po q day. 3. Bactrim SS one po q day. 4. Vasotec 5 mg po q day. 5. CSA 125 mg po bid. DISCHARGE FOLLOWUP: The patient is to follow up with primary physician within two to three days for recheck of electrolytes, notably watching his potassium as well as to obtain a CSA level.
SS|single strength|SS|455|456|DISCHARGE MEDICATIONS|The biopsy showed chronic allograft nephropathy. The patient was discharged home with medication change. DISCHARGE MEDICATIONS: Neoral 40 mg G-tube q.8h., Augmentin 400 mg G-tube b.i.d. x 20 days, Afrin 1 spray to each nostril b.i.d. x 5 days, Lotronex 1 eyedrop each eye b.i.d., Norvasc 2.5 mg G- tube b.i.d., bacitracin or Bactrim 10 cc G-tube t.i.d., Cosopt 1 drop each eye b.i.d., prednisone 5 mg to G-tube q.d., Zantac 15 mg G-tube q.d., and Bactrim SS 3 cc p.o. q.d. The patient should have a low potassium diet and no contact sports or heavy activity for 2 weeks.
SS|single strength|SS|148|149|DISCHARGE MEDICATIONS|5. Zosyn. This was stopped today, _%#MMDD2003#%_. 6. Multivitamin one tablet p.o. q.d. 7. Lasix 80 mg p.o. q.d. 8. Paxil 40 mg p.o. q.d. 9. Bactrim SS one tablet p.o. Mondays and Thursdays. 10. Ranitidine 150 mg p.o. b.i.d. 11. Metoprolol 25 mg p.o. b.i.d. 12. Colace 100 mg p.o. b.i.d.
SS|single strength|SS|129|130|DISCHARGE MEDICATIONS|3. Labetalol 400 mg p.o. b.i.d. 4. Prednisone 5 mg p.o. q.d. 5. CellCept 1 gm p.o. b.i.d. 6. Protonix 40 mg p.o. q.d. 7. Bactrim SS one tablet p.o. q.d. 8. Valcyte 450 mg p.o. qod. 9. Neoral 275 mg p.o. b.i.d.
SS|single strength|SS|228|229|DISCHARGE MEDICATIONS|After having her nausea and vomiting moderate controlled, she was discharged to home with TPN at home and IV medications per her mother. DISCHARGE MEDICATIONS: 1. Prograf 2.5 mg p.o. b.i.d. 2. Rapamune 3 mg p.o. q.d. 3. Bactrim SS 1 p.o. q.Monday and Thursday. 4. Valcyte 900 mg p.o. q.d. x 3 months. 5. Nystatin swish and swallow 10 cc p.o. q.i.d.
SS|single strength|SS|164|165|DISCHARGE MEDICATION|11. Kay Ciel 20 mEq b.i.d. 12. Prednisone 25 mg b.i.d., to be tapered. Details can be found in the discharge instructions in the patient's old records. 13. Bactrim SS one tablet q. Monday and Thursday. 14. Valcyte 450 mg q.d. 15. Tylox 1 to 2 tablets p.o. q. 4 to 6 h. p.r.n. pain. 16. Iron 325 mg p.o. t.i.d.
SS|single strength|SS|119|120|PAST MEDICAL HISTORY|His asthma is much improved and he is not wheezy or dyspneic. PAST MEDICAL HISTORY: 1. History of sickle cell disease, SS disease. He has had multiple admissions in the past. 2. History of a Perm-A-Cath catheter. 3. History of acute chest syndrome. 4. History of priapism status post surgery x 2.
SS|single strength|SS|280|281|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Aspirin 325 mg p.o. q.d., potassium carbonate/vitamin D 500 mg p.o. t.i.d., Mycelex one troche q.i.d., Neoral 150 mg p.o. b.i.d., Colace 100 mg p.o. b.i.d., multivitamin one tablet p.o. q.d., CellCept 1.5 g p.o. b.i.d., Pravachol 10 mg p.o. q.h.s., Bactrim SS one tablet p.o. q. Monday and Thursday, Zantac 150 mg p.o. b.i.d., terbutaline 10 mg p.o. q.d., Valcyte 900 mg p.o. q.d., Tylox 1 to 2 tablets p.o. q.4-6h. p.r.n. pain.
SS|single strength|SS|165|166|DISCHARGE MEDICATIONS|10. Maalox 30 mL p.o. q.i.d. 11. CellCept 250 mg p.o. b.i.d. 12. Zofran 4 mg p.o. t.i.d. 13. Protonix 40 mg q.a.m. 14. K-Phos neutral 500 mg p.o. t.i.d. 15. Bactrim SS one tab p.o. every day. 16. Prograf 0.5 mg p.o. b.i.d. 17. Demadex 50 mg p.o. every day. 18. Valcyte 450 mg p.o. every day. 19. Vancomycin 1.5 gm IV q. 48h.
SS|single strength|SS|118|119|DISCHARGE MEDICATIONS|6. Mycophenolate 500 gm p.o. q.i.d. 7. Pantoprazole 40 mg p.o. q. daily. 8. Neutra-Phos 500 mg p.o. t.i.d. 9. Bactrim SS 1 tab p.o. q. daily. 10. Prograf 1 mg p.o. b.i.d. 11. Valcyte 450 mg p.o. q. daily. 12. Zelnorm 6 mg p.o. t.i.d. 13. NPH Insulin 6 units subcu q.a.m.
SS|single strength|SS|146|147|DISCHARGE MEDICATIONS|7. CellCept one gram p.o. b.i.d. 8. Protonix 40 mg p.o. q. day. 9. Actos 60 mg p.o. q. day. 10. Senna one laxative p.o. b.i.d. p.r.n. 11. Bactrim SS one tablet p.o. q. day. 12. Valcyte 900 mg p.o. q. day. 13. Effexor 300 mg p.o. q.a.m. 14. Tylox one to two tablets p.o. q.4-6h p.r.n. for pain.
SS|single strength|SS|153|154|DISCHARGE MEDICATIONS|6. Effexor XR 150 a day. 7. Carbidopa/Levodopa 25/100 b.i.d. 8. CellCept 1 gm b.i.d. 9. Vitamin B12 100 mg a day. 10. OxyContin 10 mg b.i.d. 11. Bactrim SS one tablet p.o. daily. 12. Folate one tablet daily. 13. Protonix 40 mg a day. 14. Cozaar 50 mg b.i.d. 15. Neoral 150 mg q.a.m., q.p.m.
SS|single strength|SS|136|137|DISCHARGE MEDICATIONS|Prophylaxis: He was restarted on Bactrim SS 1 tablet by mouth daily. DISCHARGE MEDICATIONS: 1. Effexor 75 mg by mouth daily. 2. Bactrim SS 1 tablet by mouth daily. DISCHARGE FOLLOWUP: He will go to Masonic Day Center on Friday, _%#MMDD#%_, at 10:30 a.m. to be transfused 2 units of PRBCs if the patient has hemoglobin of less than 8.
SS|single strength|SS|198|199|DISCHARGE MEDICATIONS|4. The patient's report questions are concerned including increased drainage, increased pain, increased swelling or fever promptly. DISCHARGE MEDICATIONS: 1. Senokot-S 2 tabs p.o. b.i.d. 2. Bactrim SS 1 p.o. daily. 3. Prograf 2 mg p.o. b.i.d. 4. Valcyte 900 mg p.o. daily. 5. Norvasc 10 mg p.o. daily. 6. Bisacodyl 1 PR daily.
SS|single strength|SS|260|261|ADMISSION DIAGNOSIS|At this point, she was deemed ready for discharge. DISCHARGE INSTRUCTIONS: The patient was discharged to home in good condition with a good prognosis. She was given medications of Darvocet-N 100 one p.o. q.4-6h. p.r.n. pain, Colace 100 mg p.o. b.i.d., Bactrim SS 1 p.o. b.i.d. x 3 doses. She has no dietary restrictions. Her physical activity should be limited to lifting less than 10 pounds and no sit-ups for the next 6 weeks.
SS|single strength|SS|135|136|DISCHARGE DIET|2. Epogen 1,000 U subcu q. Monday, Wednesday, and Friday. 3. Cyclosporin 126 mg p.o. b.i.d. 4. CellCept 1.25 gm p.o. b.i.d. 5. Bactrim SS 1 tablet p.o. q. Monday and Thursday. 6. Aspirin 325 mg p.o. q. d. 7. Ferrous sulfate 324 mg p.o. q.d. 8. Multivitamins 1 tablet p.o. q.d 9. Zoloft 50 mg p.o. q.d.
SS|single strength|SS|299|300|MEDICATIONS|7. Prednisone from _%#MMDD2003#%_ to _%#MMDD2003#%_ 20 mg p.o. q.d., _%#MMDD2003#%_ to _%#MMDD2003#%_ 17.5 mg p.o. q.d., _%#MMDD2003#%_ to _%#MMDD2003#%_ 15 mg p.o. q.d., _%#MMDD2003#%_ to _%#MMDD2003#%_ 10 mg p.o. q.d., starting _%#MMDD2003#%_ 5 mg p.o. q.d. 8. Prograf 4 mg p.o. b.i.d. 9. Bactrim SS one tablet p.o. q.d. 10. Ursodiol 300 mg p.o. q.d. 11. .......100 mg p.o. q.d. 12. Tylox one to two tablets p.o. q.4 to 6h p.r.n. pain.
SS|single strength|SS|227|228|DISCHARGE MEDICATIONS|His only oral immunosuppressant is CellCept since he is on the Campath protocol and should be re-dosed when ALC is above 200. DISCHARGE MEDICATIONS: 1. CellCept 500 mg p.o. q.i.d. 2. Prednisone 2.5 mg p.o. q. daily. 3. Bactrim SS one p.o. q. daily. 4. Valcyte 900 mg p.o. q. daily. 5. Mycelex troche 10 mg p.o. q.i.d. 6. Lisinopril 10 mg p.o. q. daily.
SS|single strength|SS|129|130|DISCHARGE MEDICATIONS|3. Lasix 20 mg p.o. daily. 4. Cellcept 750 mg p.o. b.i.d. 5. Prednisone 10 mg p.o. daily 6. Zantac 150 mg p.o. b.i.d. 7. Bactrim SS one-half tab p.o. daily. DISCHARGE INSTRUCTIONS: 1. _%#NAME#%_ has been instructed to follow a regular diet as tolerated.
SS|single strength|SS|128|129|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Lantus 16 units subcu daily. 2. Norvasc 15 mg once a day. 3. Lovenox 40 mg subcu q. daily. 4. Bactrim SS 1 tablet twice a week. 5. Celexa 40 mg once a day. 6. Deprol 2 mg in the evening. 7. Prograf 1.5 mg twice a day. 8. Prednisone 5 mg daily.
SS|single strength|SS|158|159|DISCHARGE MEDICATIONS|8. OxyContin 20 mg in the evening before bedtime. 9. Protonix 40 mg q daily. 10. Paxil 10 mg q daily. 11. Senokot one to two tablets twice a day. 12. Bactrim SS one tablet daily. 13. Valcyte 450 mg daily. 14. Voriconazole 200 mg twice daily. 15. Neoral 50 mg twice daily. 16. CellCept 250 mg two tablets b.i.d. 17. Prednisone 5 mg daily.
SS|single strength|SS|157|158|DISCHARGE MEDICATIONS|1. Aspirin 81 mg daily. 2. Mycelex troche four times a day. 3. Multivitamin one tab daily. 4. Cellcept 1 gm twice a day. 5. Protonix 40 mg daily. 6. Bactrim SS one tablet daily. 7. Prograf 1.5 mg twice a day. 8. Actigall 300 mg three times a day. 9. Valcyte 900 mg daily. 10. Tequin 400 mg daily x 7 days.
SS|single strength|SS|121|122|DISCHARGE MEDICATIONS|3. Calcium with vitamin D 500 mg p.o. b.i.d. 4. Mycelex troche 1 tab p.o. q.i.d. 5. Protonix 40 mg p.o. daily 6. Bactrim SS 1 tab p.o. daily. 7. Valcyte 900 mg p.o. daily. 8. Colace 100 mg p.o. b.i.d. 9. Prednisone 20 mg p.o. daily x1 day. That dose is to be taken on _%#MMDD2004#%_ and then discontinued.
SS|single strength|SS.|160|162|ADMISSION MEDICATIONS|ADMISSION MEDICATIONS: 1. Prograf 1.5 mg p.o.q.a.m. and 1 mg p.o. q.h.s. 2. Metoprolol 50 mg p.o. b.i.d. 3. Prednisone 5 mg q.a.m. and 2.5 mg q.h.s. 4. Bactrim SS. 5. Prevacid. 6. Diflucan. 7. Imuran 50 mg p.o. b.i.d. 8. Humalog insulin p.r.n. 9. Endocet. 10. Glucotrol XL 10 mg p.o. daily.
SS|single strength|SS|132|133|DISCHARGE MEDICATIONS|3. Lipitor 10 mg p.o. q. day. 4. Celexa 20 mg p.o. q. day. 5. Prednisone 5 mg p.o. q. day. 6. Rapamune 2 mg p.o. q. day. 7. Bactrim SS one tablet q. Monday and Thursday. 8. Sodium bicarbonate 975 mg p.o. b.i.d. 9. Enalapril 5 mg p.o. q. day. 10. Os-Cal with vitamin D 500 mg p.o. b.i.d.
SS|single strength|SS|129|130|DISCHARGE MEDICATIONS|12. Protonix 40 mg p.o. daily. 13. Compazine 5-10 mg p.o. q.4 h p.r.n. nausea. 14. Sodium bicarb 1300 mg p.o. b.i.d. 15. Bactrim SS 1 tab p.o. daily. 16. Valcyte 450 mg p.o. daily. 17. Vitamin D 400 units p.o. daily. 18. Lactobacillus 1 tablet p.o. b.i.d. 19. Darbepoetin 60 mcg subcutaneous q. week injection.
SS|single strength|SS|238|239|DISCHARGE MEDICATIONS|3. Prednisone 30 mg p.o. q.d. (divided dose) _%#MMDD#%_ through _%#MMDD#%_; 20 mg p.o. q.d. (divided dose) _%#MMDD#%_ through _%#MMDD#%_; 10 mg p.o. q.d. _%#MMDD#%_ through _%#MMDD#%_; then 5 mg p.o. q.d. beginning _%#MMDD#%_. 4. Bactrim SS 1 p.o. q.d. 5. Valcyte 450 mg p.o. 6. Nystatin solution swish and swallow 10 mL p.o. q.i.d. 7. Ciprofloxacin 500 mg p.o. b.i.d. x 7 days. 8. Rocephin 1 gm IV q.24.h x 5 days.
SS|single strength|SS|344|345|DISCHARGE MEDICATIONS|4. Prednisone 35 mg p.o. q.d. (divided dose) _%#MM#%_ _%#DD#%_-_%#DD#%_, 2002, 20 mg p.o. q.d. (divided dose) _%#MM#%_ _%#DD#%_-_%#MM#%_ _%#DD#%_, 2002, 15 mg p.o. q.d. (divided dose) _%#MM#%_ _%#DD#%_-_%#DD#%_, 2002, 7.5 mg p.o. q.d. _%#MM#%_ _%#DD#%_-_%#MM#%_ _%#DD#%_, 2002, then 5 mg p.o. q.d. beginning _%#MM#%_ _%#DD#%_, 2002. 5. Bactrim SS 1 p.o. q.d. 6. Valcyte 900 mg p.o. q.d. 7. Mycelex troche 10 mg p.o. q.d. 8. Calcium carbonate with vitamin D 500 mg p.o. t.i.d.
SS|single strength|SS|162|163|DISCHARGE MEDICATIONS|12. Reglan 5 mg p.o. q.i.d. before meals and at nighttime. 13. Metoprolol 100 mg p.o. b.i.d. 14. CellCept 1 gm p.o. b.i.d. 15. Zoloft 50 mg p.o. q.d. 16. Bactrim SS 1 tab p.o. q.d. 17. Prograf 1 mg p.o. b.i.d. 18. Valganciclovir 450 mg p.o. q.d. 19. Ampicillin 2 gm IV q. 24 hours x 10 days.
SS|single strength|SS|141|142|OUTPATIENT MEDICATIONS|12. Cell-Cept 250 mg p.o. b.i.d. 13. Celexa 20 mg p.o. q day 14. Prednisone 7.5 mg p.o. q day 15. Prograf 3 mg q.a.m. and q.p.m. 16. Bactrim SS 1 tab p.o. q day Monday and Thursday 17. Albuterol MDI 2 puffs q.i.d. 18. Salmeterol MDI 2 puffs b.i.d. FAMILY HISTORY: The patient's mother had coronary artery bypass graft at age 37.
SS|single strength|SS|378|379|DISCHARGE MEDICATIONS|4. Prednisone 35 mg p.o. q.d. (divided dose) _%#MMDD#%_ - _%#MMDD#%_; 30 mg p.o. q.d. (divided dose) _%#MMDD#%_ - _%#MMDD#%_; 20 mg p.o. q.d. (divided dose) _%#MMDD#%_ - _%#MMDD#%_; 15 mg p.o. q.d. (divided dose) _%#MMDD#%_ - _%#MMDD#%_; 10 mg p.o. q.d. _%#MMDD#%_ - _%#MMDD#%_; 7.5 mg p.o. q.d. _%#MMDD#%_ - _%#MMDD#%_; then 5 mg p.o. q.d. beginning _%#MMDD2002#%_. 5. Bactrim SS 1 p.o. q.d. 6. Valcyte 900 mg p.o. q.d. x 3 months, then discontinue. 7. Nystatin (100,000 U/mL) 10 mL p.o. q.i.d. (swish/swallow p.c. and h.s.) x 6 months, then discontinue.
SS|single strength|SS|282|283|DISCHARGE MEDICATIONS|3. Prednisone 50 mg p.o. q.d. x 7 days; then 40 mg p.o. q.d. x 7 days; and then 30 mg p.o. q.d. x 7 days; and then 25 mg p.o. q.d. x 7 days; then 20 mg p.o. q.d. x 7 days; then 10 mg p.o. q.d. x 7 days; and then 7.5 mg p.o. q.d. x 7 days; then 5 mg p.o. q.d. thereafter. 4. Bactrim SS one p.o. q.d. 5. Valcyte 450 mg p.o. q.d. 6. Mycelex Troche 10 mg p.o. q.i.d. 7. Ciprofloxacin 250 mg p.o. b.i.d.
SS|single strength|SS|178|179|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Roxicet 5 to 10 mL q4h p.r.n. for pain. 2. Neoral elixir 175 mg q.a.m., 150 mg q.p.m. 3. Deltasone 5 mg q.a.m. 4. Fluorocortisol 1 mg q.a.m. 5. Bactrim SS 5 cc daily. 6. Zoloft 150 mg daily. 7. Zocor 20 mg q.p.m. 8. Reglan 1 cc p.o. b.i.d. 9. Aciphex currently held until patient can swallow pills. 10. Colace 100 mg liquid b.i.d.
SS|single strength|SS|123|124|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Lovenox 30 mg subcu per day. 2. Percocet 1-2 p.o. q.4 h. 3. Colace 100 mg p.o. b.i.d. 4. Bactrim SS 1 p.o. b.i.d.
SS|single strength|(SS)|179|182|DOB|_%#NAME#%_ is a 24-year-old black male of Nigerian descent who has immigrated to the United States and has been living here for the last one year. He is known to have sickle cell (SS) disease. His hematologic history is notable for two previous exchange transfusions at the time of surgeries for osteomyelitis (in both his hand and hip areas).
SS|single strength|SS|153|154|DISCHARGE MEDICATIONS|15. Dilaudid 2 mg to 4 mg p.o. q.i.d. p.r.n. pain. 16. Ceftazidime 2 g IV q.8h. 17. Biaxin 500 mg p.o. q.12h. 18. Levofloxacin 750 mg daily. 19. Bactrim SS p.o. twice weekly. 20. Tobramycin 180 mg IV q.24h. 21. Insulin Lispro one unit per carb for meals. 22. Insulin Lispro one unit if blood sugar level above 150.
SS|single strength|SS|148|149|DISCHARGING MEDICATIONS|22. Bacitracin ointment apply to the old Jackson-Pratt site left abdomen every day until that is healed and change this daily and p.r.n. 23. Septra SS 400/80 1 tablet every day p.o. 24. Valcyte 450 mg p.o. every day. 25. Mycelex 10 mg by mouth 4 times daily.
SS|single strength|SS|123|124|DISCHARGE MEDICATIONS|20. Valcyte 900 mg p.o. q.d. 21. Prograf 1 mg p.o. q.a.m., 0.5 mg p.o. q. p.m. 22. Actigall 300 mg p.o. t.i.d. 23. Bactrim SS one tab p.o. q.d. 24. Vitamin A 25,000 units p.o. q.d. 25. Vitamin E 800 units p.o. q.d. 26. Percocet one to two tabs p.o. q. 4 - 6 hours prn.
SS|single strength|SS|157|158|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Cipro 500 mg p.o. b.i.d. x7 days/14 doses, then discontinue. 2. Prograf 4 mg p.o. b.i.d. 3. Prednisone 5 mg p.o. q day. 4. Bactrim SS 1 p.o. q Monday and Thursday. 5. Metoprolol 100 mg p.o. b.i.d. 6. Lipitor 40 mg p.o. q p.m. 7. Aspirin 325 mg p.o. q day. 8. Prevacid 30 mg p.o. q day.
SS|single strength|SS|123|124|ADMISSION MEDICATIONS|ADMISSION MEDICATIONS: 1. Neoral 150 mg p.o. b.i.d. 2. Rapamune 2 mg p.o. q day. 3. Prednisone 5 mg p.o. q day. 4. Bactrim SS 1 p.o. q day. 5. Flagyl 500mg p.o. q.i.d. for 8 doses and then that will be discontinued. 6. Catapres 0.2 mg p.o. b.i.d. 7. Lopressor 100 mg p.o. b.i.d.
SS|single strength|SS|246|247|DISCHARGE MEDICATIONS|The patient met criteria for subacute rehabilitation and was transferred to Fairview- University Transitional Care Services at the _%#CITY#%_ Hospital. DISCHARGE MEDICATIONS: 1. Neoral 125 mg p.o. b.i.d. 2. Cellcept 1 gram p.o. b.i.d. 3. Bactrim SS 1 p.o. q.d. 4. Valcyte 900 mg p.o. q.d. (x 2 months, then discontinue). 5. Mycelex troches 10 mg p.o. q.i.d. x 5 months, then discontinue.
SS|single strength|SS|105|106|ADMISSION MEDICATIONS|4. Metoprolol 25 mg p.o. b.i.d. 5. Cardizem 240 mg p.o. q day 6. Lasix 40 mg p.o. q day 7. Bactrim 1 tab SS p.o. q day 8. Lipitor 40 mg p.o. q day 9. Glucotrol 10 mg p.o. q day 10. Calcium carbonate 500 mg p.o. q day 11. Multivitamin q day
SS|single strength|SS|517|518|DISCHARGE MEDICATIONS|3. Prednisone 30 mg p.o. q day, _%#MM#%_ _%#DD#%_ through _%#MM#%_ _%#DD#%_, 30 mg p.o. q day _%#MM#%_ _%#DD#%_ through _%#MM#%_ _%#DD#%_, 25 mg p.o. q day _%#MM#%_ _%#DD#%_ through _%#MM#%_ _%#DD#%_, 20 mg p.o. q day _%#MM#%_ _%#DD#%_ through _%#MM#%_ _%#DD#%_, 15 mg p.o. q day _%#MM#%_ _%#DD#%_ through _%#MM#%_ _%#DD#%_, 10 mg p.o. q day _%#MM#%_ _%#DD#%_ through _%#MM#%_ _%#DD#%_, 7.5 mg p.o. q day _%#MM#%_ _%#DD#%_ through _%#MM#%_ _%#DD#%_, then 5 mg p.o. q day beginning _%#MM#%_ _%#DD#%_, 2003. 4. Bactrim SS 1 p.o. q day. 5. Valcyte 900 mg p.o. q day. 6. Mycelex troche 10 mg p.o. q.i.d. 7. Enalapril 5 mg p.o. q day.
SS|single strength|SS|158|159|DISCHARGE MEDICATIONS|3. Mycelex troche 1 p.o. q.i.d. 4. Colace 100 mg p.o. b.i.d. 5. Prevacid 30 mg p.o. q.d. 6. Lopressor 50 mg p.o. b.i.d. 7. Rapamune 5 mg p.o. q.d. 8. Bactrim SS 1 tab p.o. q.d. 9. Prograf 10 mg p.o. b.i.d. 10. Valcyte 450 mg p.o. q.d. DISCHARGE INSTRUCTIONS: The patient was instructed regarding follow-up, and regarding diet and lifting.
SS|single strength|SS|120|121|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Neoral 150 mg p.o. b.i.d. 2. Cellcept 1 g p.o. b.i.d. 3. Prednisone 5 mg p.o. q.d. 4. Bactrim SS one p.o. q.d. 5. Sodium bicarbonate 1.95 g p.o. t.i.d. 6. Calcium carbonate with vitamin D 500 mg p.o. t.i.d. 7. Magnesium oxide 400 mg p.o. b.i.d. 8. Prinivil 5 mg p.o. q.d.
SS|single strength|SS|211|212|DISCHARGE MEDICATIONS|His amylase and lipase levels were 66 U/L and 205 U/L, respectively, with a urinary amylase level of 1,132 U/hour. DISCHARGE MEDICATIONS:: 1. Prograf 2.5 mg p.o. b.i.d. 2. Cellcept 750 mg p.o. q.i.d. 3. Bactrim SS 1 p.o. q. Monday and Thursday. 4. Valcyte 450 mg p.o. q.d. 5. Mycelex troche 10 mg p.o. q.i.d. 6. Sodium bicarbonate 1.3 grams p.o. b.i.d.
SS|single strength|SS|198|199|DISCHARGE MEDICATIONS|She was taking adequate amounts of oral fluids. She was discharged home to complete her intravenous antibiotic therapy as an outpatient. DISCHARGE MEDICATIONS: 1. Rapamune 1 mg p.o. q.d. 2. Bactrim SS one p.o. two times per week (Mondays and Thursdays). 3. Valcyte 450 mg p.o. q.d. 4. Mycelex troche 10 mg p.o. q.i.d.
SS|single strength|SS|170|171|DISCHARGE MEDICATIONS|She was afebrile and ambulating without any problems. DISCHARGE MEDICATIONS: 1. FK506 2 mg p.o. b.i.d. 2. MMF 500 mg p.o. q.i.d. 3. Valcyte 450 mg p.o. q.o.d. 4. Bactrim SS one tablet p.o. q.o.d. 5. Mycelex troches one tablet p.o. q.d. 6. Protonix 40 mg p.o. q.d. 7. Flagyl 500 mg p.o. t.i.d. x three days and then stop.
SS|single strength|SS|179|180|DISCHARGE DIAGNOSES|12. Aranesp 25 mcg subcutaneously weekly on Friday. 13. Premarin 0.625 mg daily. 14. Fluoxetine 60 mg daily. 15. Gabapentin 300 mg b.i.d. 16. Synthroid 100 mcg daily. 17. Bactrim SS 1 tablet every Monday and Thursday. 18. Zinc sulfate 220 mg daily. 19. Furosemide 20 mg daily with an additional 20 mg if weight increases 2 pounds in 2 days.
SS|single strength|SS|138|139|DISCHARGE MEDICATIONS|13. Senna S 2 tabs p.o. daily while taking narcotic pain medications, hold for loose stools. 14. Trazodone 100 mg p.o. q.h.s. 15. Bactrim SS 1 tab p.o. daily. 16. Valcyte 450 mg p.o. q.48h. 17. Percocet 1-2 tabs p.o. q.4h p.r.n. pain.
SS|single strength|SS|130|131|DISCHARGE MEDICATIONS|He should pack his wounds b.i.d. and has been instructed on this. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. q. day. 2. Bactrim SS 1 tablet p.o. q. day. 3. Calcium carbonate 1200 mg p.o. b.i.d. 4. CellCept 1000 mg p.o. b.i.d. 5. Multivitamin 1 tablet p.o. q. day.
SS|single strength|SS|161|162|DISCHARGE MEDICATIONS|7. CellCept 1 g p.o. b.i.d. 8. Zantac 150 mg p.o. b.i.d. 9. Valcyte 450 mg p.o. q.d. 10. Tylox one to two tablets p.o. p.o. q.4-6h. p.r.n. for pain. 11. Bactrim SS one tablet p.o. q.d. 12. Calcium carbonate with vitamin D 500 mg p.o. t.i.d. 13. K Phos neutral 250 mg p.o. t.i.d. FOLLOW-UP: The patient has an appointment on _%#MMDD2003#%_ at 2 p.m. with Dr. _%#NAME#%_, the transplant nephrologist.
SS|single strength|SS|158|159|DISCHARGE MEDICATIONS|8. Protonix 40 mg p.o. daily 9. Senokot-S one to two tabs p.o. b.i.d. p.r.n. 10. Renagel 1600 mg p.o. t.i.d. until kidney graft function improves 11. Bactrim SS one tab p.o. daily 12. Valcyte 450 mg p.o. two times weekly on Mondays and Thursdays until kidney graft function improves, then this dose can be increased in frequency and dosage
SS|single strength|SS|107|108|PAST MEDICAL HISTORY|ALLERGIES: MORPHINE sensitivity (rash and itching). PAST MEDICAL HISTORY: 1. Sickle cell anemia hemoglobin SS with history of the following: A. Multiple hospitalizations for sickle cell pain crises. B. History of acute chest syndrome x2-3 in the past.
SS|single strength|SS|190|191|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Bactrim SS 40, #20, 2 mg p.o. b.i.d. until _%#MM#%_ _%#DD#%_, 2005. 2. Lactobacillus, half pack mixed with formula t.i.d. until _%#MM#%_ _%#DD#%_, 2005. 1. Bactrim SS 100 mg p.o. q.24 hours to begin on _%#MM#%_ _%#DD#%_, 2005, after completion of 10-day course of Bactrim 20 mg. DISCHARGE INSTRUCTIONS: 1. Diet: Regular diet. 2. Activity: Ad lib as tolerated.
SS|single strength|SS|151|152|DISCHARGE MEDICATIONS|2. History of elevated liver enzymes. 3. Latent tuberculosis infection. DISCHARGE MEDICATIONS: 1. Isoniazid 300 mg by mouth every 24 hours. 2. Bactrim SS 1 tablet by mouth twice daily on Monday and Tuesday. 3. Compazine 5 mg tablets 5-10 mg by mouth every 8 hours as needed for nausea.
SS|single strength|SS|120|121|DISCHARGING AND TRANSFERRING MEDICATIONS|19. Valcyte 900 mg by mouth every day p.o. 20. Zithromax 250 mg every week on Monday, Wednesday, and Friday. 21. Septra SS 1 tablet every day. 22. Lantus insulin 38 units subcutaneously q.a.m. 23. NovoLog aspart insulin 3 units per carbohydrates unit breakfast, lunch, and supper.
SS|single strength|SS|141|142|DISCHARGE MEDICATIONS|At the time of discharge, he was afebrile, and his vital signs were stable. DISCHARGE MEDICATIONS: 1. CellCept 1 gram p.o. b.i.d. 2. Bactrim SS one p.o. q. daily. 3. Valcyte 450 mg p.o. two times per week (Mondays and Thursdays). 4. Nystatin solution 10 mL p.o. q.i.d. (swish/swallow p.c. nh. s).
SS|single strength|SS|127|128|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Neoral 100 mg p.o. b.i.d. 2. Cellcept 1.5 gm p.o. b.i.d. 3. Valcyte 450 mg p.o. 2 x week. 4. Bactrim SS 1 tab p.o. daily. 5. Protonix 40 mg p.o. daily. 6. Mycostatin 10 cc p.o. q.i.d. 7. Clonidine 0.3 mg p.o. b.i.d. 8. Calcium carbonate 1250 mg p.o. b.i.d.
SS|single strength|SS|176|177|DISCHARGE MEDICATIONS|8. Lopressor 25 mg p.o. b.i.d. 9. Colace 100 mg p.o. b.i.d. 10. Tylenol 325-650 mg p.o. q.6h. p.r.n. pain. 11. Valcyte 450 mg p.o. daily for transplant prophylaxis. 12. Septra SS 1 tablet p.o. daily for prophylaxis. 13. Mycostatin 10 mL p.o. t.i.d. for prophylaxis. 14. Albuterol Inderal nebulizers inhaled q.12 h. p.r.n. shortness of breath.
SS|single strength|SS|177|178|DISCHARGE MEDICATIONS|DISCHARGE DIAGNOSES: 1. Fever and neutropenia. 2. Retinoblastoma of the left eye, status post enucleation and four six rounds of chemotherapy. DISCHARGE MEDICATIONS: 1. Bactrim SS 4 mL or 32 mg p.o. b.i.d. on Monday and Tuesday. 2. Colace 40 mg p.o. daily to b.i.d. for constipation.
SS|single strength|SS|192|193|DISCHARGE MEDICATIONS|4. Prednisone 12.5 mg p.o. daily for 2 months until _%#MM#%_ _%#DD#%_, 2006. 5. Prednisone 10 mg p.o. daily afterwards. 6. Levaquin 500 mg p.o. daily until _%#MM#%_ _%#DD#%_, 2006. 7. Bactrim SS one tab p.o. daily. 8. Valcyte 900 mg p.o. daily. 9. Allopurinol 200 mg p.o. daily. 10. Norvasc 10 mg p.o. daily. 11. Calcium with vitamin D 1250 mg p.o. b.i.d.
SS|single strength|SS|117|118|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS 1. Prograf 2 mg p.o. b.i.d. 2. Rapamune 3 mg p.o. q.d. 3. Prednisone 5 mg p.o. q.d. 4. Bactrim SS 1 p.o. q.d. 5. Mycelex troche 10 mg p.o. q.i.d. 6. Valcyte 900 mg p.o. q.d. (x 1 month, then discontinue). 7. Cipro 500 mg p.o. b.i.d. (x 7 days, then discontinue).
SS|single strength|SS|169|170|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prograf 4 mg p.o. b.i.d. 2. Rapamune 4 mg p.o. q.d. 3. Prednisone 30 mg p.o. q.d. (divided dose), follow previous prednisone taper. 4. Bactrim SS 1 p.o. q.d. 5. Valcyte 450 mg p.o. q.d. 6. Nystatin solution 10 cc swish and swallow p.o. q.i.d. 7. Calcium carbonate with vitamin D 500 mg p.o. t.i.d.
SS|single strength|SS|205|206|DISCHARGE MEDICATION|DISCHARGE MEDICATION: 1. Prograf 2.5 mg p.o. b.i.d. 2. CellCept 1 gm p.o. b.i.d. 3. Prednisone 20 mg p.o. q.d., _%#MMDD2002#%_, and _%#MMDD2002#%_, then 5 mg p.o. q.d. beginning _%#MMDD2002#%_. 4. Bactrim SS 1 p.o. q.d. 5. Valacet 900 mg p.o. q.d. x 3 months, then discontinue. 6. Mycelex troche 10 mg p.o. q.i.d. 7. Aspirin 325 mg p.o. q.d.
SS|single strength|SS|115|116|ADMISSION MEDICATIONS|2. Prograf 1 mg q.a.m. and 0.5 mg q.p.m. 3. CytoGam 1 g p.o. q.i.d. 4. Mycelex troche 10 mg p.o. q.i.d. 5. Bactrim SS 40/800 mg p.o. q.d. 6. Levothyroxine 0.088 mg p.o. q.d. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: Weight 57.5 kg, height 166.1 cm, temperature 97.8, pulse 75, blood pressure 121/74, respirations 16 per minute.
SS|single strength|SS|142|143|ADMISSION MEDICATIONS|10. Pravachol 10 mg q. h.s. 11. Prednisone 15 mg q. h.s. (clarify to b.i.d.) 12. Zantac 150 mg b.i.d. 13. Senokot 1 tablet b.i.d. 14. Bactrim SS 1 tablet daily. 15. Prograf 2 mg daily. 16. Spiriva 18 mcg 1 inhalation daily. 17. Valganciclovir 900 mg daily. 18. Voriconazole 200 mg p.o. b.i.d.
SS|single strength|SS|118|119|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prograf 3 mg p.o. b.i.d. 2. Imuran 150 mg p.o. q.d. 3. Prednisone 5 mg p.o. q.d. 4. Bactrim SS 1 p.o. q. Monday and Thursday. 5. Valcyte 450 mg p.o. q.d. 6. Mycelex troche 10 mg p.o. q.i.d. 7. Linezolid 600 mg p.o. b.i.d. x 14 days/28 doses then discontinue.
SS|single strength|SS|157|158|DISCHARGE MEDICATIONS|1. Prograf 3 mg p.o. b.i.d. 2. Rapamune 3 mg p.o. q day 3. Heparin 5000 units subcu t.i.d. X2 weeks, then re-evaluate 4. Aspirin 81 mg p.o. q day 5. Bactrim SS 1 p.o. q day 6. Valcyte 450 mg p.o. q day X3 months, then discontinue 7. Mycelex troche 10 mg p.o. q.i.d. X3 months, then discontinue
SS|single strength|SS|164|165|MEDICATIONS ON THIS ADMISSION|3. NPH insulin 17 units subcu q.a.m. and 15 units subcu q.p.m. 4. Prevacid 30 mg p.o. q.d. 5. Lamivudine 100 mg p.o. q.d. 6. Cellcept 500 mg p.o. b.i.d. 7. Bactrim SS 1 tablet p.o. q.d. 8. Prograf 2 mg p.o. b.i.d. 9. Actigall 300 mg p.o. t.i.d. 10. Valcyte 900 mg p.o. q.d. 11. Prednisone tapering dose.
SS|single strength|SS|118|119|DISCHARGE MEDICATIONS|9. Senna 1-4 tabs p.o. b.i.d. 10. Valcyte 450 mg p.o. q. Monday, Thursday. 11. Rapamune 2 mg p.o. q. day. 12. Bactrim SS 1 tab p.o. q. day. 13. Prograf 1 mg p.o. b.i.d. 14. Lispro sliding scale insulin. He was discharged with home health care three times a week to help with medication education and management as well as to insure continuation of established transplant plan.
SS|single strength|SS|154|155|DISCHARGE MEDICATIONS|6. Imdur 60 mg p.o. q.d. 7. Lisinopril 20 mg p.o. q.d. 8. Prednisone 2.5 mg p.o. q.d. 9. Rapamune 1 mg p.o. q.d. 10. Zoloft 50 mg p.o. b.i.d. 11. Bactrim SS 1 p.o. 2 times per week. 12. Prograf 1 mg p.o. q.p.m. and 2 mg p.o. q.a.m. 13. Colchicine 0.6 mg p.o. q.2.h. p.r.n. 14. Insulin Regular subcutaneous.
SS|single strength|SS|134|135|DISCHARGE MEDICATIONS|3. Neoral 150 p.o. q.a.m., 125 p.o. q.p.m. 4. Lansoprazole 30 mg q.d. 5. Metoprolol 50 mg b.i.d. 6. Cellcept 500 mg q.i.d. 7. Bactrim SS 1 tab q.d. 8. Valsartan 80 mg q.d. 9. Percocet 1 to 2 tabs p.o. q.4-6h. p.r.n. pain. FOLLOW-UP: The patient will follow up with Dr. _%#NAME#%_ in his clinic in four weeks, and with Dr. __________in the Renal Clinic in two to four weeks.
SS|single strength|SS|201|202|DISCHARGE MEDICATIONS|_%#NAME#%_ was discharged in good condition. DISCHARGE MEDICATIONS: 1. Neoral 400 mg p.o. b.i.d. 2. Imuran 150 mg p.o. q.h.s. 3. Prednisone 5 mg p.o. q.d. 4. Erythromycin 500 mg p.o. b.i.d. 5. Bactrim SS 1 tablet p.o. q.d. 6. Lorazepam 0.5 mg p.o. b.i.d. p.r.n. 7. Amitriptyline 50 mg p.o. q.h.s. 8. Calcium with vitamin D 500 mg p.o. b.i.d. 9. Iron 324 mg p.o. q.d.
SS|single strength|SS|171|172|DISCHARGING MEDICATIONS|11. Protonix 40 mg p.o. twice daily. 12. Apresoline 100 mg 4 times daily. 13. Reglan 10 mg p.o. 3 times daily scheduled. 14. Tylenol 650 mg p.o. q.4 h. p.r.n. 15. Bactrim SS 1 tablet on Mondays and Thursdays. 16. Diflucan 100 mg p.o. daily until _%#MMDD2007#%_. 17. Lantus 16 units subcutaneously every morning (this was decreased from 20 units, which she did receive today).
SS|single strength|SS|147|148|DISCHARGE MEDICATIONS|7. CellCept 1 g p.o. b.i.d. 8. Nifedipine XL 65 mg p.o. daily. 9. Protonix 40 mg p.o. daily. 10. Sodium bicarbonate 650 mg p.o. t.i.d. 11. Bactrim SS 1 tab p.o. daily. 12. Valcyte 450 mg p.o. every other day. 13. Simethicone 80 mg p.o. q.6h. p.r.n. gas pain.
SS|single strength|SS,|158|160|ADDENDUM|It showed heavy growth of two strains of Methicillin-resistant staph aureus. Therefore, his discharge plan will be the same except for an addition of Bactrim SS, 1 tab p.o. b.i.d. x7 days. I did discuss the fact that the patient lists an allergy to sulfa with a reaction of depression.
SS|single strength|SS|118|119|DISCHARGE MEDICATIONS|10. Prevacid 30 mg p.o. q.d. 11. Prednisone 22.5 mg p.o. q.d. for 1 more day. 12. Rapamune 3 mg p.o. q.d. 13. Bactrim SS 1 tablet p.o. q.d. 14. Prograf 2 mg p.o. b.i.d. 15. Vitamin A 25,000 units p.o. q.d. 16. Percocet for pain control, 1-2 tablets p.o. q.4-6 hours p.r.n. pain.
SS|single strength|SS|96|97|DISCHARGE MEDICATIONS|2. CellCept 500 mg p.o. b.i.d. 3. Prednisone 5 mg p.o. q.d. 4. Zocor 20 mg p.o. q.d. 5. Bactrim SS one tablet p.o. q.d. on Monday and Thursday each week. 6. Prograf 10 mg p.o. q.d. 7. Lasix 80 mg p.o. q.d. 8. Colace 100 mg p.o. b.i.d. while taking Percocet. 9. Percocet 1-2 tabs p.o. q.4-6h. p.r.n. for pain.
SS|single strength|SS|150|151|DISCHARGE MEDICATIONS|12. Pravachol 10 mg p.o. q day 13. Prednisone taper 20/20, 20/15, 15/15, 15/10, 10/10, every day thereafter 14. Zantac 150 mg p.o. b.i.d. 15. Bactrim SS twice a week 16. Brethine 10 mg p.o. b.i.d. 17. Percocet 1-2 tabs p.o. q.4-6h p.r.n. 18. Lasix 40 mg p.o. q day 19. K-Dur 20 mEq p.o. q day
SS|single strength|SS|117|118|DISCHARGE MEDICATIONS|5. Lantis 10 units q.h.s. 6. Prevacid 30 mg p.o. q.a.m. 7. Lopressor 50 mg p.o. b.i.d. 8. MMF 1 gm b.i.d. 9. Bactrim SS 1 p.o. q.d. 10. Valcyte 450 mg p.o. q.o.d. 11. Lasix 20 mg p.o. b.i.d. 12. Percocet 1 to 2 tabs p.o. q.4h. p.r.n.
SS|single strength|SS|144|145|DISCHARGE MEDICATIONS|13. Lexapro 10 mg q.d. 14. Prednisone 7.5 mg p.o. q.a.m./5 mg p.o. q.p.m. 15. Synthroid 0.1 mg q.d. 16. Vitamin B1 100 mg p.o. q.d. 17. Bactrim SS one tablet p.o. q. Mondays and Thursdays. 18. CellCept 500 mg p.o. q.i.d. 19. Rapamune 1 mg p.o. q.d. 20. Genasyme 80 mg p.o. q.i.d. 21. Fosamax 40 mg p.o. q. Sunday.
SS|single strength|SS|159|160|DISCHARGE MEDICATIONS|3. Synthroid 100 mcg q.d. 4. Lopressor 25 mg q.d. 5. Paxil 10 mg q.d. 6. Neoral 225 mg b.i.d. 7. Cellcept 1000 mg b.i.d. 8. Prednisone 12 mg b.i.d. 9. Bactrim SS one tab q. Monday and Thursday. 10. Mycelex one troche q.i.d. 11. Valcyte 450 mg b.i.d. 12. Tylox one to two tablets q. 4-6h. p.r.n. pain.
SS|single strength|SS.|146|148|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 33-year-old African-American female with a history of sickle cell anemia. The patient has hemoglobin SS. She had been on routine exchange transfusions to try to reverse a recent trend of frequent hospitalizations. On the day of admission, the patient had her Quinton catheter placed and soon after that she reported significant pain.
SS|single strength|SS,|163|165|DISCHARGE MEDICATIONS|4. Labetalol 200 mg p.o. b.i.d. 5. CellCept 500 mg p.o. q.i.d. 6. Protonix 40 mg p.o. b.i.d. 7. Prednisone 5 mg p.o. q.d. 8. Senokot 2 tabs p.o. b.i.d. 9. Bactrim SS, one tab p.o. q.d. 10. Valcyte 450 mg p.o. two times a week on Mondays and Thursdays. Dose will have to be changed according to creatinine.
SS|single strength|SS|146|147|DISCHARGE MEDICATIONS|DIETARY RESTRICTIONS: None. DISCHARGE MEDICATIONS: 1. Tylenol #3 1 to 2 tablets p.o. q.4-6h. p.r.n. pain. 2. Colace 100 mg p.o. b.i.d. 3. Bactrim SS 1 tablet p.o. b.i.d. x 5 doses, then discontinue. The patient verbalizes understanding of her discharge instructions and knows how to contact me should she have any questions or concerns.
SS|single strength|SS|152|153|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Imipenem 250 mg IV q12h x 14 days, then discontinue. 2. CellCept 500 mg p.o. t.i.d. 3. Prednisone 5 mg p.o. q.i.d. 4. Bactrim SS one p.o. 2 times per week (Monday, Thursday). 5. Valcyte 450 mg p.o. 3 times per week (Monday, Wednesday, Friday).
SS|single strength|SS|170|171|DISCHARGE MEDICATIONS|The patient should stay in a sitting position for 30 minutes and should not lie down during this 30 minutes. 9. Tacrolimus 8 mg p.o. b.i.d. 8 a.m. and 8 p.m. 10. Bactrim SS 1 tablet p.o. daily. 11. Glipizide 10 mg p.o. b.i.d. 12. Calcium with vitamin D 1250 mg that contains 500 mg elemental calcium by mouth t.i.d.
SS|single strength|SS|131|132|DISCHARGE MEDICATIONS|9. Oxycodone 5-10 mg p.o. q. 6 h. 10. OxyContin ER (taper) 50 mg p.o. q. 12 h. 11. Tylenol 650 mg p.o. q. 4-6 h p.r.n. 12. Bactrim SS one tablet p.o. weekly Thursday and Friday at 0700 and 1900 13. Diflucan 100 mg p.o. daily. DISCHARGE FOLLOW-UP PLANS: 1. Oncology Clinic appointment with Dr. _%#NAME#%_ for labs, including CBC with differential, platelets, CMP, magnesium, phosphate, urinalysis, and admission for week 15 of chemotherapy with methotrexate on _%#MMDD2006#%_.
SS|single strength|SS|223|224|DISCHARGE MEDICATIONS|PROBLEM #4. Extravascular fluid overload: The patient's diuretics were increased during his hospitalization though, as mentioned, he will likely continue to require paracentesis as needed. DISCHARGE MEDICATIONS: 1. Bactrim SS 1 tablet by mouth daily on Wednesday and Friday. 2. Norvasc 10 mg by mouth daily. 3. Lasix 40 mg by mouth daily.
SS|single strength|SS|125|126|DISCHARGE MEDICATIONS|Her white count was 4.8 with an ANC of 4.3, hemoglobin was 9.5 and platelets were 135,000. DISCHARGE MEDICATIONS: 1. Bactrim SS one tab p.o. twice daily every Thursday and Friday. 2. Fluconazole 100 mg p.o. daily. 3. Peridex swish and spit 10 mg daily.
SS|single strength|SS|173|174|DISCHARGE MEDICATIONS|5. Prevacid 30 mg p.o. b.i.d. 6. Magnesium oxide 600 mg p.o. t.i.d. 7. Cell-Cept 1 g p.o. b.i.d. 8. Zosyn 3.375 g IV q.6h X14 days 9. Prednisone 5 mg p.o. q day 10. Bactrim SS 1 tab p.o. q day 11. Augmentin 500 mg p.o. b.i.d. X30 days to begin on _%#MMDD2002#%_ DISCHARGE INSTRUCTIONS: The patient is instructed to follow a regular diet as tolerated.
SS|single strength|SS|120|121|DISCHARGE MEDICATIONS|2. Prograf 0.5 mg p.o. b.i.d. (target levels 3-5). 3. CellCept 250 mg p.o. b.i.d. 4. Rapamune 2 mg p.o. q.d. 5. Bactrim SS 1 p.o. q. Monday and Thursday. 6. Valcyte 450 mg p.o. q. Monday, Wednesday, Friday x 3 months, then discontinue. 7. Mycelex troche 10 mg p.o. q.i.d. x 6 months, then discontinue.
SS|single strength|SS|462|463|DISCHARGE MEDICATIONS|3. Prednisone 180 mg per os every day (divided dose) _%#MM#%_ _%#DD#%_; 135 mg per os every day (divided dose) _%#MM#%_ _%#DD#%_ and _%#MM#%_ _%#DD#%_; 90 mg per os every day (divided dose) _%#MM#%_ _%#DD#%_ and _%#MM#%_ _%#DD#%_; 65 mg per os every day (divided dose) _%#MM#%_ _%#DD#%_ and _%#MM#%_ _%#DD#%_; 45 mg per os every day (divided dose) _%#MM#%_ _%#DD#%_ and _%#MM#%_ _%#DD#%_; then 5 mg per os every day beginning _%#MM#%_ _%#DD#%_, 2002. 4. Bactrim SS one per os every day. 5. Valcyte 900 mg per os every day times three months, and then discontinue. 6. Mycelex troche 10 mg per os four times a day times three months, and then discontinue.
SS|UNSURED SENSE|SS|182|183|HISTORY OF PRESENT ILLNESS|The patient stated that he perhaps had some dysuria and hesitancy. A UA was obtained which was completely normal. The patient was treated with (_______________) antibiotic. PROBLEMS SS DRAINAGES. OTHER DISCHARGE MEDICATIONS: 1. Chronic abdominal pain, multifactorial, post multiple abdominal surgical procedures including pancreatectomy and abscess drainages.
SS|single strength|SS|185|186|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Neoral 175 mg p.o. b.i.d. 2. CellCept 1 gram p.o. b.i.d. 3. Prednisone 15 mg p.o. q.d. on _%#MMDD#%_, then 5 mg p.o. q.d. beginning _%#MMDD2002#%_. 4. Bactrim SS 1 p.o. q.d. 5. Valcyte 900 mg p.o. q.d. X3 months, then discontinue. 6. Mycelex troche 10 mg p.o. q.i.d. X6 months, then discontinue.
SS|single strength|SS|123|124|DISCHARGE MEDICATIONS|9. Ranitidine 150 mg b.i.d. p.o. 10. Calcium with vitamin D 500 mg t.i.d. p.o. 11. Docusate 2 tabs b.i.d. p.o. 12. Bactrim SS 1 tab q day p.o. 13. Lipitor 20 mg q day p.o. 14. Sodium bicarbonate 1300 mg t.i.d. p.o. 15. Synthroid 0.2 mg q day p.o. DISCHARGE INSTRUCTIONS: The patient will go to the Transplant Center to receive four more doses of Thymoglobulin over the next four days.
SS|single strength|SS,|114|116|ADMISSION MEDICATIONS|ADMISSION MEDICATIONS: 1. Prograf 2 mg p.o. b.i.d. 2. Cellcept 1000 mg p.o. q.a.m., 750 mg p.o. q.p.m. 3. Bactrim SS, 1 tablet p.o. q.d. 4. Ranitidine 150 mg p.o. q.d. 5. Calcium carbonate 500 mg p.o. t.i.d. 6. Docusate p.r.n.
SS|single strength|SS|138|139|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: Cellcept 1 gram p.o. b.i.d. Prograf 5 mg p.o. b.i.d. Prednisone 15 mg p.o. q. am. Norvasc 2.5 mg p.o. q.d. Bactrim SS 1 tab p.o. q. Monday and Thursday. (?sp)Cenex .5 mg p.o. t.i.d. Flovent MDS 2 puffs b.i.d. Pancrease 3 caps p.o. with meals and snacks.
SS|single strength|SS|180|181|ADMISSION MEDICATIONS|8. Ear drum reconstruction. ADMISSION MEDICATIONS: 1. Prednisone 5 mg p.o. q day 2. Tacrolimus 2 mg p.o. b.i.d. 3. Sirolimus 5 mg p.o. q day 4. Clotrimazole p.o. q.i.d. 5. Bactrim SS one tab p.o. q day 6. Valganciclovir 450 mg two times per week 7. Lansoprazole 40 mg p.o. q day 8. Calcium carbonate with vitamin D 9. Valproic acid 250 mg p.o. b.i.d.
SS|single strength|SS|157|158|MEDICATIONS ON DISCHARGE|MEDICATIONS ON DISCHARGE: 1. Rapamune 10 mg p.o. q.d. 2. Prograf 1.5 mg p.o. b.i.d. 3. Cellcept 750 mg p.o. b.i.d. 4. Cytovene 1 gram p.o. t.i.d. 5. Bactrim SS p.o. q.d. 6. Metamucil 1 tablespoon p.o. b.i.d. 7. Ortho p.o. as directed. 8. Differin 0.1% gel topical as directed. 9. Aspirin 81 mg p.o. q.d.
SS|single strength|SS|137|138|DISCHARGING MEDICATIONS|11. Tylenol 325-650 mg p.o. q.4h. p.r.n. pain. 12. Augmentin 1 tablet p.o. q.12h for UTI with last dose to be on _%#MMDD#%_. 13. Bactrim SS 400/80 mg 1 tablet daily p.o. 14. Valcyte 450 mg p.o. daily. 15. Ocuflox 1 drop right eye 4 times daily. 12. Mycelex troche lozenge 10 mg 3 times a day.
SS|single strength|SS|169|170|DISCHARGE MEDICATIONS|17. Aquacel-E 400 mg p.o. daily. 18. Fentanyl patch 50 mcg an hour 19. Morphine immediate release 15-30 mg p.o. q.4-6h. p.r.n. 20. Aspirin 81 mg p.o. daily. 21. Bactrim SS 1 p.o. q. Monday and Thursday 22. Magnesium oxide 400 mg p.o. daily. The patient is to follow up with _%#NAME#%_ _%#NAME#%_ next week for hospital followup and he will get a CBC with diff and platelet at that time to check for blood dyscrasia.
SS|single strength|SS|159|160|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Atenolol 50 mg daily. 5. Celexa 40 mg daily. 3. Sustiva 600 mg at night. 4. Synthroid 75 mcg daily. 5. Sulfamethoxazole trimethoprim SS 400/80, 1 tablet daily. 6. Lantus discharge dose to be determined. She was on 15 units at night. 7. Trizivir 1 tablet twice daily.
SS|single strength|SS|165|166|DISCHARGE MEDICATIONS|3. Vasotec 20 mg p.o. b.i.d. 4. CellCept 750 mg p.o. b.i.d. 5. Minipress 1500 mcg p.o. t.i.d. 6. Senokot-S one tablet p.o. b.i.d., hold for loose stools. 7. Bactrim SS one tablet p.o. daily. 8. Clonidine 200 mcg transdermally apply a patch daily. 9. Valcyte 450 mg p.o. daily. 10. Calcium with vitamin D 1 tablet p.o. b.i.d.
SS|single strength|SS.|183|185|ADMISSION MEDICATIONS|SOCIAL HISTORY: No tobacco or drugs. Occasional alcohol. ADMISSION MEDICATIONS: 1. Lipitor. 2. Neoral. 3. ERL, which is a study drug. 4. Prednisone 7.5 mg q.d. 5. Aspirin. 6. Bactrim SS. 7. Magnesium oxide. 8. Multivitamins. 9. Celexa. 10. Lantus insulin. 11. Norvasc. 12. Toprol XL. 13. Humalog sliding scale. 14. Prilosec 20 mg p.o. q.d. 15. Os-Cal with vitamin D.
SS|single strength|SS|176|177|HOSPITAL COURSE|13. Magnesium oxide 400 mg p.o. q.d. 14. Toprol XL 50 mg p.o. q.d. 15. Multivitamin one tablet p.o. q.d. 16. Protonix 40 mg p.o. q.d. 17. Prednisone 5 mg p.o. q.d. 18. Bactrim SS one tablet p.o. q.d. 19. Coumadin 7.5 mg p.o. q.d. 20. Percocet one to two tablets p.o. q4-6h p.r.n. pain. FOLLOW-UP CARE: The patient is to see Dr. _%#NAME#%_, on _%#MM#%_ _%#DD#%_, in his follow-up clinic.
SS|single strength|SS|165|166|DISCHARGE MEDICATION|DISCHARGE MEDICATION: 1. Prograf 2 mg p.o. b.i.d. 2. CellCept 250 mg p.o. q.a.m. and q.p.m. 3. CellCept 500 mg p.o. q. noon. 4. Prednisone 5 mg p.o. q.d. 5. Bactrim SS 1 p.o. q.d. 6. Valcyte 450 mg p.o. 2 x week (Monday and Thursday). 7. Nystatin suspension 10 mL p.o. swish/swallow q.i.d. p.c. and h.s.
SS|single strength|SS|126|127|DISCHARGE MEDICATIONS|11. History of transient atrial flutter in the past. This was not a problem this admission. DISCHARGE MEDICATIONS: 1. Bactrim SS 1 p.o. q. Mondays and Thursdays. 2. Calcitonin nasal spray one spray q.d. 3. Lidoderm patch 5% one topically left shoulder on 10-12 hours and off 12 hours.
SS|single strength|SS|123|124|ADMISSION MEDICATIONS|ALLERGIES: No known drug allergies. ADMISSION MEDICATIONS: 1. Cell-Cept 1 g b.i.d. 2. Remeron 15 mg p.o. q.h.s. 3. Bactrim SS 1 tab q Monday and Thursday 4. Neurontin 300 mg p.o. t.i.d. 5. Deltasone 5 mg p.o. q day 6. Magnesium oxide 400 mg p.o. b.i.d. 7. Sodium bicarbonate 1300 mg p.o. b.i.d. PHYSICAL EXAMINATION: On exam, the patient is afebrile with a temperature of 97.8, blood pressure 116/78, pulse 84, respirations 20, weight 58.1 kg.
SS|single strength|SS|163|164|DISCHARGE MEDICATIONS|He will complete his course of Tequin for treatment of prostatitis. DISCHARGE MEDICATIONS: 1. Prograf 2.5 mg p.o. b.i.d. 2. Cellcept 1 gram p.o. b.i.d. 3. Bactrim SS 1 p.o. q.d. 4. Tequin 400 mg p.o. q.d. x 14 days, then discontinue. 5. Flomax 0.4 mg p.o. q.h.s. 6. Sodium bicarb 1.3 grams p.o. q.i.d.
SS|single strength|SS|123|124|DISCHARGE MEDICATION|DISCHARGE MEDICATION: 1. Prograf 2.5 mg p.o. b.i.d. 2. CellCept 250 mg p.o. q.i.d. 3. Prednisone 5 mg p.o. q.d. 4. Bactrim SS 1 p.o. q.d. 5. Flagyl 500 mg p.o. q.i.d. (x 14 days/56 doses, then discontinue). 6. Prevacid 30 mg p.o. q.d. 7. Celexa 20 mg p.o. q.d.
SS|single strength|SS|227|228|DISCHARGE MEDICATIONS|The patient was encouraged to contact the transplant coordinator with questions or concerns regarding care after the time of discharge. DISCHARGE MEDICATIONS: 1. Neoral 225 mg p.o. b.i.d. 2. CellCept 1 g p.o. b.i.d. 3. Bactrim SS 1 tablet p.o. q.day. 4. Valcyte 450 mg p.o. q.day. 5. Prevacid 30 mg p.o. q.day. 6. Mycelex 1 troche p.o. q.i.d.
SS|single strength|SS|146|147|DISCHARGE MEDICATIONS|4. Fentanyl patch 50 mcg topically - change every 72 hours and apply to a different body location each change. 5. Maalox 400 mg b.i.d. 6. Bactrim SS 1 tablet p.o. q day. 7. Valcyte 900 mg p.o. q day. 8. Mycelex troche 10 mg p.o. q.i.d. after meals, and at hs.
SS|single strength|SS|124|125|DISCHARGE MEDICATIONS|7. Procardia XL 60 mg q day 8. Sodium bicarbonate 1300 mg q.i.d. 9. Prograf 2 mg b.i.d. 10. CellCept 1 g b.i.d. 11. Bactrim SS 1 tab q day 12. Valcyte 900 mg q day; to stop in three month's time 13. Tylox 1-2 tabs q.4-6h p.r.n. pain 14. Prednisone taper 45 mg q day until _%#MMDD#%_; then 25 mg q day _%#MMDD#%_- _%#MMDD#%_; then 15 mg q day _%#MMDD#%_-_%#MMDD#%_; then 10 mg q day _%#MMDD#%_-_%#MMDD#%_; then 5 mg q day thereafter 15.
SS|single strength|SS|159|160|DISCHARGE MEDICATIONS|6. Aspirin 81 mg Monday, Wednesday, and Friday. 7. Insulin NPH 14 units a.m. and 10 units p.m. 8. OxyContin 1 to 2 tablets p.o. q.4-6h. p.r.n. pain. 9. Lispro SS q.p.m. 10. Percolate q.d. 11. Augmentin 875 mg p.o. b.i.d. 12. Epivir 100 mg p.o. q.i.d. 13. Prilosec 20 mg p.o. q.d.
SS|single strength|SS|156|157|MEDICATIONS|5. Lopressor 12.5 mg p.o. b.i.d. 6. Mineral oil 1 to 2 tablespoons p.o. t.i.d. mixed with olive oil prior to taking. 7. Multivitamin 1 p.o. q.d. 8. Bactrim SS 1 p.o. q.d. 9. OxyContin 60 mg p.o. q.a.m., 40 mg p.o. q.p.m. 10. Prograf: evening dose on _%#MMDD2002#%_ is to be held as well as a.m. dose on _%#MMDD2002#%_.
SS|single strength|SS|105|106|ADMISSION MEDICATIONS|4. Metoprolol 25 mg p.o. b.i.d. 5. Cardizem 240 mg p.o. q day 6. Lasix 40 mg p.o. q day 7. Bactrim 1 tab SS p.o. q day 8. Lipitor 40 mg p.o. q day 9. Glucotrol 10 mg p.o. q day 10. Calcium carbonate 500 mg p.o. q day 11. Multivitamin q day
SS|single strength|SS|124|125|ADMISSION MEDICATIONS|ADMISSION MEDICATIONS: 1. Tacrolimus 1.5 mg p.o. q.a.m. and 1 mg p.o. q.p.m. 2. Mycophenolate 500 mg p.o. b.i.d. 3. Bactrim SS one tab p.o. q day 4. Valganciclovir 450 mg p.o. q day 5. Clotrimazole troches 10 mg p.o. q.i.d. 6. Pantoprazole 40 mg p.o. q day HOSPITAL COURSE: The patient was admitted on _%#MMDD2003#%_ as work up for acute rejection.
SS|single strength|SS|110|111|DISCHARGE MEDICATIONS|8. Magnesium oxide 400 mg p.o. b.i.d. 9. Prilosec 20 mg b.i.d. 10. Prednisone 10 mg po every day. 11. Bactrim SS 1 tab q M, Th. 12. Prograf 1 mg b.i.d. 13. CellCept 250 mg b.i.d. 14. Effexor 75 mg p.o. q evening. 15. Multivitamins 1 every day.
SS|single strength|SS,|161|163|DISCHARGE MEDICATIONS|5. Lopressor 75 mg p.o. b.i.d. 6. CellCept 1 gm p.o. b.i.d. 7. Protonix 40 mg p.o. daily. 8. Paxil 10 mg p.o. daily. 9. Prednisone 10 mg p.o. daily. 10. Bactrim SS, one tab p.o. two times a week, on Mondays and Thursdays. 11. Ampicillin 500 mg p.o. q.i.d. x 14 days. 12. Lispro insulin for sliding scale coverage of high blood sugars.
SS|single strength|SS|166|167|DISCHARGE MEDICATIONS|The patient will be discharged on _%#MMDD2004#%_ in stable condition. DISCHARGE MEDICATIONS: 1. Prednisone 17.5 mg p.o. daily 2. Valcyte 450 mg p.o. daily 3. Bactrim SS 1 tab daily 4. Multivitamin 1 tab p.o. daily 5. Protonix 40 mg p.o. daily 6. Prograf 4 mg p.o. q.12h 7. Cell-Cept 1 g p.o. q.12h 8. Actigall 300 mg p.o. t.i.d.
SS|single strength|SS|166|167|DISCHARGE MEDICATIONS|Her wound looks clear, dry, and intact. There is minimal serous discharge in the distal incision area. DISCHARGE MEDICATIONS: 1. CellCept 1 Gm p.o. b.i.d. 2. Bactrim SS 1 Gm p.o. 2 x a week. 3. Valcyte 450 mg p.o. 3 x a week. 4. Mycelex troches 10 mg p.o. q.i.d. 5. Lopressor 12.5 mg p.o. b.i.d.
SS|single strength|SS|272|273|HISTORY OF PRESENT ILLNESS|His postoperative course was also characterized by aspiration pneumonitis as well as several episodes of ventilator associated pneumonia and pulmonary embolism, despite the use TED hose, pneumo-boots and subcutaneous heparin. He is currently finishing a course of Bactrim SS double strength for Stenotrophomonas ventilator- associated pneumonia as well as well as a course of linezolid for MRSA. He was recently discharged from the hospital on _%#MMDD2004#%_ to another facility.
SS|single strength|SS|165|166|MEDICATIONS|2. Prednisone 7.5 mg daily. 3. Azathioprine 100 mg daily. 4. Penicillin 250 mg daily. 5. Propanolol 20 mg daily. 6. Ursodiol 600 mg q.a.m., 300 mg q.p.m. 7. Bactrim SS one daily. 8. Nasonex for seasonal allergies. ALLERGIES: Amoxicillin, however, she is able to tolerate penicillin.
SS|single strength|SS|150|151|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prograf 3 mg p.o. b.i.d. 2. MMF 250 mg p.o. q.i.d. 3. Prednisone 10 mg p.o. q day 4. Potassium 20 mEq p.o. q day 5. Bactrim SS 1 p.o. q day 6. Valcyte 450 mg p.o. q.o.d. 7. Mycelex troche one p.o. q.i.d. 8. Clonidine 0.1 mg p.o. t.i.d.
SS|single strength|SS|245|246|HISTORY OF PRESENT ILLNESS|Impression: No change from previous exam. Bilateral bibasilar interstitial infiltrate remains. This appears to be chronic in nature. HISTORY OF PRESENT ILLNESS: A 27-year-old African-American male with history of sickle cell disease, Hemoglobin SS who presented on _%#MM#%_ _%#DD#%_, 2003, complaining of bilateral knee, back and elbow pain. The patient reported this is his typical sickle cell crisis pain.
SS|single strength|SS|135|136|DISCHARGE MEDICATIONS|7. CellCept 1 gram p.o. b.i.d. 8. Prilosec 20 mg p.o. q.d. 9. Prednisone 2.5 mg p.o. q.d. 10. Allopurinol 100 mg p.o. q.d. 11. Bactrim SS one tab p.o. q.d. 12. Aspirin 81 mg p.o. q.d. 13. Multivitamin one tab p.o. q.d. 14. Temazepam 15 mg p.o. q. 4-6h. p.r.n. 15. B-complex vitamin one tablet p.o. q.d.
SS|single strength|SS|130|131|DISCHARGE MEDICATIONS|7. Vitamin E 400 International Units p.o. every day. 8. Lantis 40 units subcu b.i.d. 9. Humalog 20 units subcu t.i.d. 10. Bactrim SS one tablet p.o. every day. 11. Oxycodone 5-10 mg p.o. q4-6h p.r.n. pain. DISCHARGE FOLLOW-UP: He will follow up with Dr. _%#NAME#%_ in approximately two weeks and the patient will make this appointment.
SS|single strength|SS|297|298|DISCHARGE MEDICATIONS|9. Protonix 40 mg p.o. daily. 10. Prednisone 25 mg p.o. _%#MMDD2004#%_ in the p.m. and _%#MMDD2004#%_ in the a.m., then 20 mg p.o. _%#MMDD2004#%_ in the p.m., then 20 mg p.o. b.i.d. 11. Lantus 50 units subcutaneously q.p.m. 12. Heparin flush 300 units IV q.24h for flushing PICC line. 13. Bactrim SS one tablet p.o. q.Mondays and Thursdays. 14. Valcyte 450 mg p.o. daily. 15. Vancomycin 1 gm IV q.12h via PICC line. Stop after 14 days. 16. Percocet one to two tablets p.o. q.3-4h p.r.n. pain.
SS|single strength|SS|157|158|DISCHARGE MEDICATIONS|She remained afebrile throughout this admission and no additional antibiotics were started. DISCHARGE MEDICATIONS: 1. OxyContin 10 mg p.o. b.i.d. 2. Bactrim SS one tablet p.o. b.i.d. on Mondays and Tuesdays. 3. Fluconazole 100 mg p.o. at bedtime daily. 4. Colace 100 mg p.o. b.i.d.
SS|single strength|SS|181|182|DISCHARGE MEDICATIONS|17. Tacrolimus 4 mg p.o. b.i.d. (adjust dose for tacrolimus level of 10- 12. 18. Nystatin 10 mL p.o. q.i.d. 19. Pantoprazole 40 mg p.o. daily. 20. Senokot 2 p.o. q.h.s. 21. Bactrim SS 1 p.o. daily. 22. Actigall 300 mg p.o. t.i.d. 23. Valcyte 450 mg p.o. every other day. 24. Zofran 4-8 mg p.o. q 6 hours p.r.n.
SS|sickle cell genotype SS|(SS)|36|39|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Sickle cell (SS) disease. 2. Fever. 3. Cough. DISCHARGE DIAGNOSES: 1. Sickle cell (SS) disease. 2. Atypical pneumonia.
SS|single strength|SS|143|144|DISCHARGE MEDICATIONS|14. CellCept 250 mg p.o. q.i.d. 15. Nystatin 10 mL p.o. q.i.d. 16. Protonix 40 mg p.o. daily. 17. Senokot 1 tablespoon p.o. b.i.d. 18. Bactrim SS 1 tablet p.o. daily. 19. Prograf 0.5 mg p.o. b.i.d. 20. Valcyte 450 mg p.o. daily 21. Zelnorm 6 mg p.o. t.i.d.
SS|sickle cell genotype SS|SS,|274|276|REASON FOR ADMISSION|REASON FOR ADMISSION: Chest pain, sickle cell crisis. OPERATIONS/PROCEDURES PERFORMED: CT angio performed on _%#MM#%_ _%#DD#%_, 2003, was negative for pulmonary embolism. HISTORY OF PRESENT ILLNESS: This is a 34-year-old female with a history of sickle cell anemia genotype SS, who has had frequent hospitalizations for sickle cell crises admitted from the emergency department on _%#MM#%_ _%#DD#%_, 2003, because of shortness of breath, achy arms, and hip pain, along with chest pain that is similar in nature to previous sickle cell crises per record and per patient.
SS|single strength|SS|146|147|DISCHARGE MEDICATIONS|3. Metoprolol 25 mg p.o. b.i.d. 4. Protonix 40 mg p.o. daily. 5. Prednisone 5 mg p.o. daily. 6. Sodium Bicarbonate 1300 mg p.o. b.i.d. 7. Bactrim SS one tablet p.o. daily. 8. Prograf 1.5 mg p.o. b.i.d. 9. Reglan 10 mg p.o. t.i.d. 30 minutes before meals. DISCHARGE INSTRUCTIONS: Mr. _%#NAME#%_ has been instructed to keep his Foley catheter in place for a total of six weeks to allowing healing of his epithelial layer in his bladder.
SS|single strength|SS|189|190|DISCHARGE MEDICATIONS|He will receive an additional dose of alemtuzumab as an outpatient in the Transplant Clinic. DISCHARGE MEDICATIONS: 1. CellCept 1 gram p.o. t.i.d. 2. Prednisone 5 mg p.o. daily. 3. Bactrim SS 1 p.o. daily. 4. Valcyte 450 mg p.o. 3 times per week (Mondays, Wednesdays, Fridays). 5. Mycelex troche 10 mg p.o. q.i.d. (p.c. and h.s.).
SS|single strength|SS|164|165|DISCHARGE MEDICATIONS|He was safely discharged on _%#MMDD2005#%_. DISCHARGE DIAGNOSES: 1. Fever and neutropenia. 2. Osteosarcoma of right distal femur. DISCHARGE MEDICATIONS: 1. Bactrim SS 1 tablet p.o. b.i.d. q. Mon, Tue. 2. Peridex 10 mL swish and spit b.i.d. 3. Mycelex troche, 1 p.o. q.i.d. 4. Emla cream, to apply to port site p.r.n. prior to port access.
SS|single strength|SS|148|149|DISCHARGE MEDICATIONS|He also will be given a reclining wheelchair for home, hospital bed, and a commode. DISCHARGE MEDICATIONS: 1. Valtrex 500 mg p.o. t.i.d. 2. Bactrim SS one tablet p.o. b.i.d. 3. Peridex rinse 10 mL swish and spit b.i.d. 4. MiraLax 17 g p.o. q. day and p.r.n. 5. Fluconazole 100 mg p.o. daily.
SS|single strength|SS|236|237|DISCHARGE MEDICATIONS|10. Protonix 40 mg p.o. b.i.d. 11. Prednisone taper 40 mg p.o. b.i.d. for 3 days, then 20 mg p.o. b.i.d. for 3 days, then 10 mg p.o. b.i.d. for 3 days, and then 10 mg p.o. per day. 12. Wellbutrin XL 300 mg p.o. q. 24 hours. 13. Bactrim SS 1 tablet p.o. daily. 14. Risedronate 35 mg p.o. q. week.
SS|single strength|SS|196|197|MEDICATIONS PRIOR TO ADMISSION|1. Prednisone 7.5 mg p.o. q. day. 2. Imuran 75 mg p.o. every other day with 50 mg every other day. 3. Carbatrol 400 mg p.o. b.i.d. 4. Clonazepam 0.5 mg p.o. q.a.m. and 1 mg p.o. q.p.m. 5. Bactrim SS 1 tab p.o. q. day. 6. Penicillin VK 250 p.o. b.i.d. 7. Acyclovir 400 mg p.o. b.i.d. 8. Lorazepam p.r.n.
SS|single strength|SS|166|167|DISCHARGE MEDICATIONS|3. Wellbutrin 300 mg p.o. b.i.d. 4. Sodium bicarbonate 2 tabs p.o. b.i.d. 5. Calcium with vitamin D one tab p.o. b.i.d. 6. Amitriptyline 75 mg p.o. q.h.s. 7. Bactrim SS one tab p.o. daily 8. Valcyte 450 mg p.o. daily 9. Lasix 20 mg p.o. every other day 10. Levaquin 500 mg p.o. daily, ending _%#MMDD2005#%_
SS|single strength|SS|528|529|DISCHARGE MEDICATIONS|She continued to have resolving partial small bowel obstruction, which was eventually resolved and she was able to be discharged on the _%#MM#%_ _%#DD#%_, 2005. DISCHARGE MEDICATIONS: Prograf 1 mg twice a day, prednisone 7.5 mg once a day, CellCept 750 mg three times a day, Coreg 12.5 mg b.i.d., Fosamax 70 mg once a week, calcium and vitamin D supplement, magnesium oxide supplement, Lomotil two tabs t.i.d., Lantus 20 units daily, Protonix 40 mg once a day, Vistaril 50 mg p.r.n., insulin sliding scale with NovoLog, Bactrim SS one tab twice a week, and Premarin cream p.r.n.
SS|single strength|SS|185|186|DISCHARGE MEDICATIONS|11. Levaquin, Linezolid and Zosyn discontinued yesterday. 12. Magnesium oxide 400 mg p.o. three times daily. 13. Myfortic 360 mg p.o. b.i.d. 14. Protonix 40 mg q. 24 hours. 15. Bactrim SS 1 p.o. daily. 16. Prograf 2 mg p.o. b.i.d. 17. Actigall 300 mg b.i.d. 18. Valcyte 900 mg daily.
SS|single strength|SS|307|308|DISCHARGE MEDICATIONS|11. Pravachol 20 mg p.o. q.p.m. 12. Prednisone taper as follows: _%#MM#%_ _%#DD#%_, 2005, 20 mg in the morning and 15 mg at night, _%#MM#%_ _%#DD#%_, 2005, 15 mg b.i.d. _%#MM#%_ _%#DD#%_, 2005, 15 mg in the morning and 10 mg at night, and from _%#MM#%_ _%#DD#%_, 2005, onward, 10 mg p.o. b.i.d. 13. Bactrim SS 1 tablet p.o. 2 times a week, Monday and Thursday. 14. ProGraf 1 mg p.o. b.i.d. 15. Terbutaline 5 mg p.o. b.i.d.
SS|single strength|SS|170|171|CURRENT MEDICATIONS|5. Tacrolimus 3 mg p.o. twice daily. 6. Nicotine transdermal patch 14 mg daily. 7. Nystatin 10 mL p.o. q.i.d. for thrush prophylaxis. 8. Protonix 40 mg daily. 9. Bactrim SS 1 tablet daily. 10. Ursodiol 300 mg b.i.d. 11. Oxycodone 10 mg p.o. q. 6 hours pan 12. Dilaudid 2 to 4 mg p.o. q. 6 hours p.r.n.
SS|single strength|SS|139|140|PAST MEDICAL HISTORY|_%#NAME#%_ also noted that he had not stooled in greater than 1 week. PAST MEDICAL HISTORY: Remarkable for: 1. Sickle cell with hemoglobin SS disease. 2. Left MCA ischemic event x2 in 1991, resulting in right hemiplegia. 3. Severe pneumonia in 1991, with pneumothorax requiring ECMO.
SS|single strength|SS|168|169|DISCHARGE MEDICATIONS|9. Allegra 180 mg p.o. daily. 10. Lasix 40 mg p.o. daily. 11. Cozaar 50 mg p.o. b.i.d. 12. Protonix 20 mg p.o. daily. 13. K-Phos Neutral 250 mg p.o. t.i.d. 14. Bactrim SS one tablet p.o. daily. 15. Valcyte 450 mg p.o. daily. FOLLOW UP: Discharge followup as following, _%#NAME#%_ will need daily plasmapheresis starting tomorrow, continuing on tomorrow until Saturday, every other day IVIG.
SS|single strength|SS|131|132|DISCHARGE MEDICATIONS|1. Neoral 225 mg p.o. q. aA.m. 2. Neoral 225 mg p.o. q.8h. p.m. 3. CellCept 1 gram p.o. b.i.d. next 13. 4. Bactrim single strength SS 1 tablet p.o. q. day. 5. Valcyte 900 mg p.o. q. day. 6. Mycelex troche 10 mg p.o. three 3 times a day after meals.
SS|single strength|SS|151|152|MEDICATIONS|2. Bumex 1 mg p.o. b.i.d. 3. Risperdal 3 mg p.o. each day at bedtime. 4. Zocor 20 mg p.o. each day at bedtime. 5. Coumadin 5 mg p.o. daily. 6. Bactrim SS one tablet p.o. every other day starting _%#MMDD2007#%_. 7. Synthroid 112 mcg p.o. daily. 8. Calcitriol 0.25 mg p.o. daily. 9. Calcium citrate 950 mg p.o. daily. 10. Prednisone 5 mg p.o. daily.
SS|single strength|S.S.|625|628|DISCHARGE MEDICATIONS|3. Prednisone 50 mg (divided dose) _%#MM#%_ _%#DD#%_, 45 mg p.o. qd (divided dose) _%#MM#%_ _%#DD#%_-_%#DD#%_, 35 mg p.o. qd (divided dose) _%#MM#%_ _%#DD#%_-_%#DD#%_, 30 mg p.o. qd (divided dose) _%#MM#%_ _%#DD#%_-_%#MM#%_ _%#DD#%_, 20 mg p.o. qd _%#MM#%_ _%#DD#%_-_%#MM#%_ _%#DD#%_, 15 mg p.o. qd _%#MM#%_ _%#DD#%_-_%#MM#%_ _%#DD#%_, 10 mg p.o. qd _%#MM#%_ _%#DD#%_- _%#MM#%_ _%#DD#%_, 7.5 mg p.o. qd _%#MM#%_ _%#DD#%_-_%#MM#%_ _%#DD#%_, then 5 mg p.o. qd beginning _%#MM#%_ _%#DD#%_, 2002. 4. Zenapax 90 mg IV on _%#MM#%_ _%#DD#%_, _%#MM#%_ _%#DD#%_, _%#MM#%_ _%#DD#%_, and _%#MM#%_ _%#DD#%_, then discontinue. 5. Bactrim S.S. one p.o. qd. 6. Mycelex troche 10 mg p.o. qid. 7. Valcyte 900 mg p.o. qd. 8. Metoprolol 25 mg p.o. bid. 9. Aspirin 81 mg p.o. qd. 10. Calcium carbonate with vitamin D 500 mg p.o. tid.
SS|single strength|SS|128|129|DISCHARGE MEDICATIONS|3. Lantus insulin 10 units subcutaneous q24h at bedtime. 4. Haldol 2.5 to 5.0 mg IM q6h prn. 5. Flomax 0.4 mg po qd. 6. Bactrim SS 1 tab po qd. 7. Seroquel 25 mg po b.i.d. 8. Metoprolol 25 mg po b.i.d. 9. Flagyl 500 mg po t.i.d. x 3 more days.
SS|single strength|SS|397|398|HOSPITAL COURSE|3. Prednisone 50 mg p.o. q.d. (divided dose), _%#MM#%_ _%#DD#%_ through _%#MM#%_ _%#DD#%_, 2002, 30 mg p.o. q.d. (divided dose) _%#MM#%_ _%#DD#%_ through _%#MM#%_ _%#DD#%_, 2002, 20 mg p.o. q.d. (divided dose) _%#MM#%_ _%#DD#%_ through _%#MM#%_ _%#DD#%_, 2002, 10 mg p.o. q.d. _%#MM#%_ _%#DD#%_ through _%#MM#%_ _%#DD#%_, 2002 and then 5 mg p.o. q.d. beginning _%#MM#%_ _%#DD#%_, 2002. 4. Bactrim SS one p.o. q.d. 5. Valcyte 450 mg p.o. q.d. 6. Mycelex troches 10 mg p.o. q.i.d. 7. Lopressor 100 mg p.o. b.i.d.
SS|single strength|SS|143|144|MEDICATIONS|10. Status post single parathyroidectomy. MEDICATIONS: 1. Lexapro 5 mg daily. 2. Cyclosporin 50 mg b.i.d. 3. Prednisone 5 mg daily. 4. Bactrim SS 1 daily. 5. Lantus insulin 20 units daily. 6. Glipizide 5 mg daily. 7. Nexium 40 mg daily. 8. Lasix 20 mg b.i.d. 9. Soriatane 10 mg daily.
SS|single strength|SS|157|158|MEDICATIONS ON TRANSFER|MEDICATIONS ON TRANSFER: 1. CellCept 100 mg p.o. q. day. 2. Prograf 5.5 mg p.o. b.i.d. 3. Prednisone 5 mg q. day until prograf is greater than 8. 4. Bactrim SS 1 q. day. 5. Valcyte 300 mg t.i.d. 6. Nystatin swish and swallow q.i.d. 7. Norvasc 10 mg q. day. 8. Lopressor 100 mg p.o. b.i.d.
SS|single strength|SS|117|118|DISCHARGE MEDICATIONS|4. Prozac 10 mg p.o. q. day. 5. Ritalin 5 mg p.o. q. day p.r.n. for focus. 6. Metadate 20 mg p.o. q. day. 7. Bactrim SS 1 tablet p.o. b.i.d. q. Monday and Tuesday. 8. VFEND 100 mg p.o. b.i.d. 9. Tylenol No.3 1 tablet p.o. q. 4h. p.r.n. pain. She was given 30 with no refills.
SS|single strength|SS|125|126|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prograf 1.5 mg p.o. b.i.d. 2. Cellcept 500 mg p.o. q.i.d. 3. Prednisone 10 mg p.o. q.d. 4. Bactrim SS 1 p.o. q.d. 5. Valcyte 900 mg p.o. q.d. 6. Mycelex troche 10 mg p.o. q.i.d. 7. Cipro 500 mg p.o. b.i.d. x 10 days/20 doses, then discontinue.
SS|single strength|SS|303|304|DISCHARGE MEDICATIONS|4. Prednisone 90 mg p.o. q.d. (divided dose) _%#MMDD#%_ and _%#MMDD#%_, 60 mg p.o. q.d. (divided dose) _%#MMDD#%_ and _%#MMDD#%_, 45 mg p.o. q.d. (divided dose) _%#MMDD#%_ and _%#MMDD#%_, 30 mg p.o. q.d. (divided dose) _%#MMDD#%_ and _%#MMDD#%_, then 5 mg p.o. q.d. beginning _%#MMDD2002#%_. 5. Bactrim SS 1 p.o. q.d. 6. Valcyte 450 mg p.o. q.d. x 3 months, then discontinue. 7. Mycelex troche 10 mg p.o. q.i.d. x 6 months, then discontinue.
SS|single strength|SS|181|182|DISCHARGE MEDICATIONS|Her serum pancreatic enzyme levels were within normal limits. DISCHARGE MEDICATIONS: 1. Prograf 5 mg p.o. b.i.d. 2. Rapamune 4 mg p.o. q.d. 3. Prednisone 10 mg p.o. q.d. 4. Bactrim SS 1 p.o. q.d. 5. Valcyte 450 mg p.o. q.d. 6. Fentanyl patch 25 mcg transdermal q. 72 hours. 7. Methadone 2.5 mg p.o. b.i.d. 8. Ativan 1 mg p.o. t.i.d.
SS|single strength|SS|176|177|DISCHARGE MEDICATION|4. Prednisone 10 mg p.o. b.i.d., _%#MMDD2002#%_ and _%#MMDD2002#%_, 10 mg p.o. q.d. _%#MMDD2002#%_ and _%#MMDD2002#%_, then 5 mg p.o. q.d. beginning _%#MMDD2002#%_. 5. Bactrim SS 1 p.o. q.d. 6. Valcyte 450 mg p.o. q.d. x 3 months, then discontinue. 7. Mycelex troche 10 mg p.o. q.i.d. x 6 months, then discontinue.
SS|single strength|SS|102|103|DISCHARGE MEDICATIONS|5. Nutra-Phos one packet p.o. t.i.d. 6. Plavix 75 mg p.o. q day 7. Norvasc 5 mg p.o. q day 8. Bactrim SS 1 tab p.o. q day 9. Mycelex troche one troche p.o. q.i.d. 10. Peri-Colace 2 tabs p.o. b.i.d. 11. Valcyte 900 mg p.o. q day 12. Calcium carbonate 1250 mg p.o. b.i.d.
SS|single strength|SS|131|132|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prograf 2.5 mg PO b.i.d. 2. Rapamune 4 mg PO q day. 3. Prednisone 5 mg PO q day times 7 days. 4. Bactrim SS 1 PO q day. 5. Itraconazole 100 mg PO q day. 6. Valcyte 450 mg PO q day. 7. Mycelex troches 10 mg PO q.i.d.
SS|single strength|SS|161|162|DISCHARGE MEDICATIONS|4. Desiccated thyroid 180 mg p.o. q.d. 5. Insulin NPH humulin 10 units subcutaneous b.i.d. 6. Prevacid 30 mg p.o. q.d. 7. Cellcept 1 gram p.o. b.i.d. 8. Bactrim SS 1 tablet p.o. q.d. 9. Prograf 2 mg p.o. b.i.d. 10. Actigall 300 mg p.o. t.i.d. 11. Valcyte 450 mg p.o. q.o.d.
SS|single strength|SS|182|183|DISCHARGE MEDICATIONS|2. Prednisone taper 15 am 15 mg p.m. on the _%#DD#%_, and then 15 mg am 10 mg p.m. on the _%#DD#%_, and then 10 mg a.m. 10 mg p.m. on the _%#DD#%_. 3. Rapamycin 2 mg q.d. 4. Bactrim SS one tablet twice a week. 5. Prograf 2.0 mg twice a day. 6. Terbutaline sulfate 10 mg twice a day. 7. Valcyte 450 mg q.d. 8. Calcium carbonate 500 mg three times a day.
SS|single strength|SS|141|142|DISCHARGE MEDICATIONS|3. Valcyte 900 mg p.o. q.d. x three months, then discontinue. 4. Mycelex troche 10 mg p.o. q.i.d. x six months, then discontinue. 5. Bactrim SS one tab p.o. q.d. 6. Sodium bicarbonate 1.3 gm p.o. b.i.d. 7. Calcium with Vitamin D 500 mg p.o. t.i.d. 8. Prevacid 30 mg p.o. q.d.
SS|single strength|SS|131|132|DISCHARGE MEDICATIONS|2. Mycelex one troche p.o. q.i.d. 3. Prevacid 30 mg p.o. q.d. 4. Lopressor 50 mg p.o. b.i.d. 5. Rapamune 2 mg p.o. q.d. 6. Bactrim SS one tab p.o. q.d. 7. Prograf 3 mg p.o. b.i.d. 8. Valcyte 900 mg p.o. q.d. x 3 months. 9. Tylox one to two tabs p.o. q. 4-6h. p.r.n. pain.
SS|single strength|SS|301|302|HOSPITAL COURSE|He did well and by postop day 4, his creatinine was 1.4. He continued to feel well and began to tolerate oral intake. Bowel function resumed and he was discharged home in stable condition with instructions to take Neoral 200 mg p.o. b.i.d., CellCept 1 g p.o. b.i.d., Valcyte 100 mg p.o. q.d., Bactrim SS 1 p.o. q.d., calcium carbonate with vitamin D 1250 mg p.o. t.i.d., clotrimazole Troche 1 tab p.o. q.i.d., furosemide 20 mg p.o. b.i.d., Prevacid 30 mg p.o. q.d., aspirin 325 mg p.o. q.d., atenolol 25 mg p.o. q.d. FOLLOW UP: He was instructed to follow up with Dr. _%#NAME#%_ in the clinic next week.
SS|single strength|SS|171|172|DISCHARGE MEDICATIONS|6. Prograf 2 mg p.o. b.i.d. 7. Valcyte 900 mg p.o. q.o.d. until white blood cell count is within normal limits, then dose should be changed to 900 mg p.o. q.d. 8. Bactrim SS 1 tab p.o. q. day. Medication is currently on hold secondary to leukopenia. It should be restarted at 1 tab p.o. q. day when white blood cell count is within normal limits.
SS|single strength|SS|124|125|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prograf 3 mg p.o. b.i.d. 2. Cellcept 250 mg p.o. q.i.d. 3. Prednisone 2.5 mg p.o. q.d. 4. Bactrim SS 1 p.o. q.d. 5. Prevacid 30 mg p.o. q.d. 6. Reglan 2 mg p.o. t.i.d. 7. Os-Cal With Vitamin D 500 mg p.o. t.i.d. 8. Magnesium oxide 800 mg p.o. b.i.d.
SS|single strength|SS|123|124|DISCHARGE MEDICATION|DISCHARGE MEDICATION: 1. Prograf 2.5 mg p.o. b.i.d. 2. CellCept 500 mg p.o. q.i.d. 3. Prednisone 5 mg p.o. q.d. 4. Bactrim SS 1 p.o. 2 x per week (Monday and Thursday). 5. Prevacid 30 mg p.o. q.d. 6. Colace 100 mg p.o. b.i.d. p.r.n. constipation.
SS|single strength|SS|134|135|DISCHARGE MEDICATIONS|10. Minoxidil 10 mg p.o. q day. 11. Prednisone 5 mg p.o. q day. 12. Paxil 30 mg p.o. q h.s. 13. Zantac 150 mg p.o. b.i.d. 14. Bactrim SS one tablet p.o. q day.
SS|single strength|SS|120|121|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Tylenol No. 3 one to two tabs p.o. q4-6h p.r.n. pain. 2. Colace 100 mg p.o. b.i.d. 3. Bactrim SS one tab p.o. b.i.d. x 3 doses. 4. Fleet enemas one p.r. q8h p.r.n. abdominal distention. 5. Dulcolax 10 mg suppository one p.r. q8h p.r.n. distention. DISCHARGE INSTRUCTIONS: 1. The patient had no dietary restrictions.
SS|single strength|SS|145|146|DISCHARGE MEDICATIONS|4. Colace 100 mg p.o. b.i.d. 5. Procardia XL 90 mg p.o. every day. 6. Protonix 40 mg p.o. every day. 7. Rapamune 1 mg p.o. every day. 8. Bactrim SS one tablet p.o. every day. 9. Prograf 2 mg p.o. b.i.d. 10. Valcyte 450 mg p.o. every day. DIET: Renal. ACTIVITIES: As tolerated.
SS|single strength|SS|166|167|DISCHARGE MEDICATIONS|6. Nystatin swish and swallow one million units p.o. q.i.d. 7. Protonix 40 mg p.o. b.i.d. 8. Prednisone 17.5 mg p.o. q.d. 9. Psyllium one tsp p.o. b.i.d. 10. Bactrim SS one tablet p.o. q. daily. 11. Prograf 1 mg p.o. b.i.d. 12. Actigall 300 mg p.o. t.i.d. 13. Val-Cyte 450 mg p.o. q. daily. 14. Vancomycin 750 mg IV q.12 times one week.
SS|single strength|SS|118|119|DISCHARGE MEDICATIONS|17. Oxybutynin chloride 50 mg p.o. daily. 18. Protonix 40 mg p.o. daily. 19. Prednisone 10 mg p.o. daily. 20. Bactrim SS one tablet p.o. daily. 21. Prograf 1 mg p.o. b.i.d. 22. Actigall 300 mg p.o. t.i.d. 23. Valcyte 450 mg p.o. daily. DISCHARGE INSTRUCTIONS: 1. Mr. _%#NAME#%_ was instructed to follow a regular renal diet as tolerated.
SS|single strength|SS|175|176|MEDICATIONS|MEDICATIONS: 1. Lipitor 10 mg p.o. q.d. 2. Catapres 0.1 mg p.o. b.i.d. 3. Mycelex one troche p.o. q.i.d. 4. Cellcept 750 mg p.o. b.i.d. 5. Prograf 1 mg p.o. b.i.d. 6. Bactrim SS one tab p.o. q.d. 7. Coumadin starting dose 2.5 mg q.d. to be dosed per clinic with a goal INR of 2-3. 8. Flovent two puffs INH b.i.d. 9. Albuterol MDI two puffs INH q.i.d. p.r.n.
SS|single strength|SS|110|111|DISCHARGE MEDICATIONS|2. Mycelex troche 1 tablet p.o. q.i.d. 3. Lisinopril 40 mg p.o. b.i.d. 4. CellCept 1 g p.o. b.i.d. 5. Bactrim SS 1 tablet p.o. 3 x per week. 6. Valcyte 450 mg p.o. q.i.d. 7. Os-Cal with vitamin D 500 mg p.o. t.i.d.
SS|single strength|SS,|222|224|DISCHARGE MEDICATIONS|He will continue to receive intravenous Campath when absolute neutrophil count are greater than, or equal to 0.2. His creatinine was 1.1 mg/dl at discharge. DISCHARGE MEDICATIONS: 1. CellCept 500 mg p.o. q.i.d. 2. Bactrim SS, one p.o. q.d. 3. Mycelex troche 10 mg p.o. q.i.d. 4. Prinivil 10 mg p.o. q.d. 5. Aspirin 81 mg p.o. q.d. 6. Calcium carbonate with vitamin D 500 mg p.o. t.i.d.
SS|single strength|SS,|194|196|ADMISSION MEDICATIONS|5. History of peptic ulcer disease. ALLERGIES: Toradol causing pulmonary edema and Compazine causing muscle spasm. ADMISSION MEDICATIONS: Lipitor, Prevacid, Prednisone, Keppra, Prograf, Bactrim SS, Cellcept, Actigall, and Lasix. REVIEW OF SYSTEMS: A 10-system review was negative, except for the findings noted above in the HPI.
SS|single strength|SS|164|165|DISCHARGE MEDICATIONS|5. Cellcept 1 gram p.o. b.i.d. 6. Protonix 40 mg p.o. q. daily. 7. Prednisone 10 mg p.o. q. daily to be tapered to 5 mg p.o. q. daily on _%#MMDD2003#%_. 8. Bactrim SS one tablet p.o. q. Monday and Thursday. 9. Prograf 1 mg q.a.m. and 2 mg q.p.m. 10. Ursodiol 300 mg p.o. b.i.d. 11. Valcyte 450 mg p.o. q. daily.
SS|single strength|SS|192|193|DISCHARGE MEDICATIONS|3. Neupogen 300 mcg subcutaneous one-time dose on _%#MMDD2003#%_ if white blood count less than 2000. 4. Solu-Cortef 15 mg p.o. q.a.m./5 mg p.o. q.p.m. 5. Florinef 0.1 mg p.o. q.d. 6. Bactrim SS 1 p.o. q.Monday and Thursday. 7. Valcyte 900 mg p.o. q.d. 8. Mycelex troche 10 mg p.o. q.i.d. 9. K-Dur 20 mEq p.o. q.d. 10. Magnesium oxide 400 mg p.o. t.i.d.
SS|single strength|SS|146|147|DISCHARGE MEDICATIONS|17. Nystatin 10 mL p.o. q.i.d. 18. Protonix 40 mg p.o. q.d. 19. Accuzyme ointment 30 mg to wound q.h.s. 20. Prednisone 5 mg p.o. q.d. 21. Bactrim SS 1 tablet p.o. q.d. 22. Coumadin 5 mg p.o. q.d. with a goal INR of 2 to 3. 23. Ferrous sulfate 225 mg p.o. q.d. 24. Tylox 1 to 2 tablets q.4-6h. p.o. p.r.n.
SS|single strength|SS,|268|270|DISCHARGE MEDICATIONS|Her serum creatinine was 1.0 mg/dL. She remains euglycemic, independent of exogenous insulin with amylase and lipase levels of 103 units per liter and 283 units per liter. DISCHARGE MEDICATIONS: 1. CellCept 1 gram p.o. b.i.d. 2. Prednisone 5 mg p.o. daily. 3. Bactrim SS, one p.o. two times per week (Mondays and Thursdays). 4. Valcyte 900 mg p.o. daily. 5. Mycelex troche 10 mg p.o. q.i.d.
SS|single strength|SS|179|180|DISCHARGE MEDICATIONS|4. Clotrimazole one troche p.o. q.i.d. 5. Lasix 40 mg p.o. b.i.d. 6. Mycophenolate 500 mg p.o. q.i.d. 7. Pantoprazole 40 mg p.o. q.d. 8. Neutra-Phos 500 mg p.o. t.i.d. 9. Bactrim SS one tab p.o. q.d. 10. Prograf 1 mg p.o. b.i.d. 11. Valcyte 450 mg p.o. q.d. 12. Zelnorm 6 mg p.o. t.i.d. 13. NPH insulin 6 units subcu q.a.m.
SS|single strength|SS|119|120|DISCHARGE MEDICATIONS|He was euglycemic independent of exogenous insulin. DISCHARGE MEDICATIONS: 1. CellCept one gram p.o. b.i.d. 2. Bactrim SS one p.o. two times per week (Mondays and Thursdays). 3. Valcyte 450 mg p.o. q. daily. 4. Mycelex troche 10 mg p.o. q.i.d.
SS|single strength|SS|147|148|DISCHARGE MEDICATIONS|16. Protonix 40 mg p.o. daily. 17. Penicillin VK 50 mg p.o. daily. 18. Prednisone 5 mg p.o. daily. 19. Prenatal Plus 1 tab p.o. daily. 20. Bactrim SS 1 tab p.o. b.i.d. 21. Warfarin 5 mg p.o. daily. DISCHARGE INSTRUCTIONS: 1. The patient was told to resume her previous diet and previous level of activity based on her instructions after her hysterectomy.
SS|single strength|SS|128|129|DISCHARGE MEDICATIONS|2. Keep incision clean and dry. DISCHARGE MEDICATIONS: 1. Lopressor 100 mg p.o. daily. 2. Protonix 40 mg p.o. daily. 3. Bactrim SS one tablet p.o. daily. 4. Tylox one to two tablets p.o. q. 4-6 h. p.r.n. pain. FOLLOW-UP: The patient will have follow-up appointment with Pediatric Nephrology as already arranged.
SS|single strength|SS|169|170|DISCHARGE MEDICATIONS|He has met the goals of physical therapy and occupational therapy and is progressing. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg daily. 2. Protonix 40 mg daily. 3. Bactrim SS one tablet daily. 4. Valganciclovir 900 mg daily. 5. Fiber-Con one tablet b.i.d. 6. Cellcept 1 gm b.i.d. 7. Actigall 300 mg t.i.d. 8. Mycelex troche one tablet q.i.d.
SS|single strength|SS|145|146|MEDICATIONS PRIOR TO ADMISSION|ALLERGIES: No known drug allergies. MEDICATIONS PRIOR TO ADMISSION: 1. CellCept 250 mg p.o. daily. 2. Voriconazole 200 mg p.o. b.i.d. 3. Bactrim SS 1 tab p.o. daily. 4. Norvasc 10 mg p.o. daily. 5. Lipitor 10 mg p.o. daily. 6. Asprin 81 mg p.o. daily. 7. Aranesp 40 mcg IV q. week. 8. Protonix 40 mg daily.
SS|single strength|SS|98|99|DISCHARGE MEDICATIONS|2. Left distal femur osteosarcoma. 3. Left heel pressure ulcer. DISCHARGE MEDICATIONS: 1. Bactrim SS one tab PO b.i.d. q. Monday and Tuesday. 2. Fluconazole 100 mg PO daily. 3. Zofran 8 mg PO q.6 hours p.r.n. nausea.
SS|single strength|SS|507|508|DISCHARGE MEDICATIONS|DISCHARGE CONDITION: Good. DISPOSITION: Patient was discharged to home. DISCHARGE INSTRUCTIONS: Patient's parents were instructed to call MD for a temperature greater than 101.4 or any other signs of infection including cough, diarrhea, or urinary complaints. DISCHARGE MEDICATIONS: Imuran 35 mg p.o. every day, prednisone 6 mg p.o. every day, cyclosporin 35 mg p.o. q.8h., vancomycin 200 mg intravenously q.8h. and home health is to follow the levels, Nystatin 10 mL p.o. q.i.d. swish and swallow, Bactrim SS 25 mg p.o. every day, Valcyte 140 mg p.o. every day, Prevacid 50 mg p.o. b.i.d., and aspirin 180 mg p.o. every day.
SS|single strength|SS|113|114|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Cellcept 750 mg p.o. q.a.m., 500 mg p.o. q.p.m. 2. Prograf 2 mg p.o. b.i.d. 3. Bactrim SS 1 p.o. daily. 4. Valcyte 450 mg p.o. daily. 5. Mycelex troche 10 mg p.o. q.i.d. 6. Flagyl 500 mg p.o. t.i.d. x10 days, then discontinue.
SS|single strength|SS|143|144|ADMISSION MEDICATIONS|One aunt had diabetes mellitus. One aunt had hypertension. ADMISSION MEDICATIONS: 1. Prograf 5 mg b.i.d. 2. Imuran 150 mg at night. 3. Bactrim SS 1 tablet daily. 4. Valcyte 900 mg daily. 5. Mycelex troche 10 mg t.i.d. 6. Ursodiol 300 mg b.i.d. 7. Aspirin 81 mg daily. 8. Tenormin 50 mg daily.
SS|single strength|SS|131|132|DISCHARGE MEDICATIONS|9. Oxycodone 5-10 mg p.o. q. 6 h. 10. OxyContin ER (taper) 50 mg p.o. q. 12 h. 11. Tylenol 650 mg p.o. q. 4-6 h p.r.n. 12. Bactrim SS one tablet p.o. weekly Thursday and Friday at 0700 and 1900 13. Diflucan 100 mg p.o. daily. DISCHARGE FOLLOW-UP PLANS: 1. Oncology Clinic appointment with Dr. _%#NAME#%_ for labs, including CBC with differential, platelets, CMP, magnesium, phosphate, urinalysis, and admission for week 15 of chemotherapy with methotrexate on _%#MMDD2006#%_.
SS|single strength|SS|169|170|DISCHARGE MEDICATIONS|12. Metamucil 1 tablespoon p.o. daily in orange juice or juice. 13. Kaletra 2 tablets p.o. b.i.d. 14. Myambutol 100 mg daily. 15. Emtriva 200 mg q. 72 hours. 16. Septra SS 1 tablet daily. 17. Zerit 20 mg at h.s. 18. Clotrimazole ointment apply to topical fungal infections p.r.n. 19. Mycostatin 10 ml swish and swallow q.i.d. 20. Zerit 40 mg p.o. q.a.m.
SS|single strength|SS|133|134|DISCHARGE MEDICATIONS|9. CellCept 1 g p.o. q.i.d. 10. Protonix 40 mg p.o. q. day. 11. Senokot 1 tab p.o. b.i.d. 12. Zoloft 150 mg p.o. q. day. 13. Bactrim SS 1 tab p.o. q. day. 14. Prograf 4 mg p.o. b.i.d. 15. Valcyte 450 mg p.o. q. day. 16. Vancomycin 1 g IV q.24. 17. Ambien 5 mg p.o. q.h.s. DISCHARGE INSTRUCTIONS: The patient was advised to follow up with Dr. _%#NAME#%_ in Transplant Clinic on Monday _%#MMDD2006#%_.
SS|single strength|SS|168|169|DISCHARGE MEDICATIONS|On week 16 will receive vincristine, actinomycin, and Cytoxan. With admission she will have an MRI, possible bone scan, and chest CT. DISCHARGE MEDICATIONS: 1. Bactrim SS 2 tablets p.o. b.i.d. every Monday and Tuesday. 2. Peridex 10 mL swish and spit b.i.d. 3. Fluconazole 100 mg p.o. daily.
SS|single strength|SS|130|131|DISCHARGE MEDICATIONS|1. Prograf 3 mg p.o. b.i.d. 2. CellCept 1 g p.o. b.i.d. 3. Valcyte 450 mg p.o. q. day. 4. Mycelex 1 troche p.o. t.i.d. 5. Bactrim SS 1 p.o. daily. 6. Actigall 300 mg p.o. t.i.d. 7. Aspirin 81 mg p.o. q. day. 8. Percocet 2 tabs p.o. q.4 hours p.r.n. pain.
SS|single strength|SS|188|189|DISCHARGE MEDICATIONS|Os-Cal with vitamin D one tab p.o. t.i.d., mycelex 10 mg p.o. daily, Colace 100 mg p.o. b.i.d., furosemide 20 mg p.o. daily, Protonix 40 mg p.o. daily, Pravachol 20 mg p.o. daily, Bactrim SS one tablet p.o. q. Tuesday and Thursday, Valcyte 450 mg p.o. daily, vancomycin 1650 mg p.o. IV q.12h, Lantus 18 units each day at bedtime.
SS|single strength|SS|151|152|MEDICATIONS|10. Acetaminophen 325-650 mg tablet p.o. q. 4 hours p.r.n. for fever greater than 101.5. 11. Clotrimazole 10 mg lozenge p.o. t.i.d. 12. Bactrim 400/80 SS 1 tablet p.o. daily. 13. Calcium carbonate 1250 mg p.o. daily. INSTRUCTIONS: Diet, regular diet. Activity is as tolerated. Restrictions, do not lift weight more than 10 pounds for about 2 months.
SS|single strength|SS|352|353|DISCHARGE MEDICATION|DISCHARGE MEDICATION: 1. Rapamune 3 mg p.o. q.d. 2. Prednisone 110 mg p.o. q.d. (divided dose), _%#MMDD2002#%_ and _%#MMDD2002#%_, 80 mg p.o. q.d. (divided dose), _%#MMDD2002#%_ and _%#MMDD2002#%_, 55 mg p.o. q.d., (divided dose), _%#MMDD2002#%_ and _%#MMDD2002#%_, then 10 mg p.o. q.d., beginning _%#MMDD2002#%_. 3. Imuran 150 mg p.o. q.d. 4. Bactrim SS 1 p.o. q.d. 5. Valacet 450 mg p.o. q.d. x 3 months, then discontinue. 6. Mycelex troche 10 mg p.o. q.i.d. 7. Norvasc 10 mg p.o. q.d.
SS|single strength|SS|155|156|DISCHARGE MEDICATIONS|3. Insulin sliding scale per patient. 4. Aciphex 20 mg po qd. 5. Catapres 0.2 mg po qd. 6. Mycelex 1 troche po qid. 7. CellCept 1000 mg po bid. 8. Bactrim SS 1 tab po qd. 9. Prograf 2 mg po bid. 10. Fosamax 10 mg po qd. 11. Alphagan eye drops both eyes bid. 12. Magnesium oxide 400 mg po qd.
SS|single strength|SS|736|737|DISCHARGE MEDICATIONS|3. Prednisone 170 mg p.o. q.d. (divided dose) _%#MM#%_ _%#DD#%_, 2001, 125 mg p.o. q.d. (divided dose) _%#MM#%_ _%#DD#%_ and _%#DD#%_, 2002, 85 mg p.o. q.d. (divided dose) _%#MM#%_ _%#DD#%_ and _%#MM#%_ _%#DD#%_, 2002, 60 mg p.o. q.d. (divided dose) _%#MM#%_ _%#DD#%_ and _%#MM#%_ _%#DD#%_, 2002, 40 mg p.o. q.d. (divided dose) _%#MM#%_ _%#DD#%_ and _%#MM#%_ _%#DD#%_, 2002, 15 mg p.o. q.d. (divided dose) _%#MM#%_ _%#DD#%_, 2002 through _%#MM#%_ _%#DD#%_, 2002, 10 mg p.o. q.d. _%#MM#%_ _%#DD#%_, 2002 through _%#MM#%_ _%#DD#%_, 2002, 7.5 mg p.o. q.d. _%#MM#%_ _%#DD#%_, 2002 through _%#MM#%_ _%#DD#%_, 2002, then 5 mg p.o. q.d. beginning _%#MM#%_ _%#DD#%_, 2002. 4. Valcyte 900 mg p.o. q.d. (x 3 months, then discontinue). 5. Bactrim SS 1 p.o. q.d. 6. Clotrimazole troche 10 mg p.o. q.i.d. 7. Metoprolol 25 mg p.o. b.i.d. 8. Aspirin 81 mg p.o. q.d. 9. Sodium bicarbonate 1.3 gm p.o. q.i.d. 10. Calcium carbonate with vitamin D 500 mg p.o. t.i.d.
SS|single strength|SS|174|175|DISCHARGE MEDICATIONS|3. Lasix 20 mg p.o. q day. 4. Ganciclovir 1 gram p.o. t.i.d. 5. Prevacid 30 mg p.o. q day. 6. Cellcept one gram p.o. b.i.d. 7. Nystatin 10 milliliters p.o. q day. 8. Bactrim SS one tab p.o. q day. 9. Percocet one to two tabs p.o. q4-6 hour's prn for pain. 10. Peri-Colace one to two tabs p.o. b.i.d. prn for constipation.
SS|single strength|SS|254|255|DISCHARGE MEDICATIONS|At discharge, Mr. _%#NAME#%_'s serum creatinine was 1.6 mg/dL. There was no evidence of hematuria, and his hemoglobin was stable. DISCHARGE MEDICATIONS: 1) Prograf 0.5 mg p.o. b.i.d. 2) Cellcept 500 mg p.o. b.i.d. 3) Prednisone 5 mg p.o. q.d. 4) Bactrim SS 1 p.o. q.d. 5) Norvasc 7.5 mg p.o. q.d. 6) Metoprolol 25 mg p.o. b.i.d. 7) Clonidine 0.1 mg p.o. b.i.d. 8) Lasix 40 mg p.o. b.i.d. 9) Prevacid 30 mg p.o. q.d. 10) Allopurinol 300 mg p.o. q.d. 11) Calcium carbonate with vitamin D 500 mg p.o. t.i.d. 12) Imodium 2 mg p.o. q.a.m. and p.r.n. diarrhea.
SS|single strength|SS|118|119|DISCHARGE MEDICATIONS|8. Lopressor 25 mg b.i.d. 9. CellCept 1000 mg b.i.d. 10. Kay Ciel 20 mEq b.i.d. 11. Senna 1-4 tabs b.i.d. 12. Bactrim SS 1 tab q.d. 13. Prograf 2 mg b.i.d. 14. Valcyte 900 mg q.d. 15. Vitamin A 25,000 U q.d. 16. Tylox 1-2 tabs q.6h. p.r.n.
SS|single strength|SS|168|169|DISCHARGE MEDICATIONS|DISCHARGE INFORMATION: Discharge date _%#MM#%_ _%#DD#%_, 2002. DISCHARGE DIAGNOSES: Chromic myelogenous leukemia, on Gleevec therapy. DISCHARGE MEDICATIONS: 1. Bactrim SS one p.o. b.i.d. q.Monday, q.Tuesday. 2. Gleevec 500 mg p.o. q.d. 3. Nystatin 5 cc, swish and swallow q.i.d. 4. Zofran 4 mg p.o. q.d. before Gleevec. 5. Colace 100 mg p.o. b.i.d.
SS|single strength|SS|134|135|DISCHARGE MEDICATIONS|3. Lisinopril 5 mg p.o. b.i.d. 4. Catapres 0.1 mg p.o. b.i.d. 5. Prednisone 5 mg p.o. q.d. 6. Fluconazole 400 mg p.o. q.d. 7. Bactrim SS 1 p.o. q.d. 8. Nystatin 10 ml p.o. q.i.d. swish-n-swallow. 9. Mycelex troche 10 mg p.o. q.i.d. 10. Calcium with vitamin D 1250 mg p.o. t.i.d.
SS|single strength|SS|253|254|PAST MEDICAL HISTORY|On _%#MM#%_ _%#DD#%_ she will begin 15 mg p.o. q.d. for 1 week, then the following week 12.5 mg p.o. q.d., then the following week 10 mg p.o. q.d. These dosages can be monitored by the Transplant Coordinator. 4. She will also be discharged with Bactrim SS 1 tab p.o. q.d., Valcyte 900 mg p.o. q.d., Mycelex Troche 10 mg p.o. b.i.d., aspirin 81 mg p.o. q.d. 5. She will also be discharged on her regular meds of Prozac 20 mg p.o. q.d., insulin 3 units subcutaneous b.i.d., Synthroid 100 mcg p.o. q.d., nystatin swish and swallow p.o. q.i.d., pilocarpine 5 mg p.o. t.i.d., multivitamin 1 tab p.o. q.d., and Roxicet elixir 5-10 cc q.4-6h. p.r.n. pain.
SS|single strength|SS|209|210|DISCHARGE MEDICATIONS|Her hemoglobin was stable at 10.2 gm/dL, and her white blood count was 6100 on a dose of Cellcept of 1 gm p.o. b.i.d. DISCHARGE MEDICATIONS: 1. Prograf 2 mg p.o. b.i.d. 2. Cellcept 1 gm p.o. b.i.d. 3. Bactrim SS 1 p.o. q.d. 4. Valcyte 450 mg p.o. q.d. 5. Mycelex troche 10 mg p.o. q.i.d. 6. Norvasc 10 mg p.o. q.d. 7. Atenolol 25 mg p.o. q.d. 8. Cardura 4 mg p.o. q.d.
SS|single strength|SS|245|246|PROBLEM #1|Also, the patient was continued with his medications for immunosuppression, including Cellcept 500 mg p.o. b.i.d., Prograf 2 mg p.o. b.i.d. and Prednisone tapering dose. The patient was receiving opportunistic infection prophylaxis with Bactrim SS and Ganciclovir. The patient remained stable. The patient was seen in Transplant Clinic today by Dr. _%#NAME#%_. The patient was stable to go home. The patient's incisional wound was clean.
SS|single strength|SS|231|232|DISCHARGE MEDICATIONS|He will continue to follow up with the transplant coordinator as previously indicated and will get Rapamune levels every Monday and Thursday for the next several weeks. DISCHARGE MEDICATIONS: 1. Rapamune 5 mg p.o. q day 2. Bactrim SS 1 p.o. two times per week 3. Prilosec 20 mg p.o. q day 4. Calcium carbonate with vitamin D 500 mg p.o. q day
SS|single strength|SS|162|163|DISCHARGE MEDICATIONS|2. Valcyte 900 mg p.o. q.d. to begin on _%#MMDD2002#%_ after the final dose of ganciclovir. 3. Prograf 2 mg p.o. b.i.d. 4. Cellcept 500 mg p.o. q.i.d. 5. Bactrim SS 1 p.o. q.d. 6. Zestril 5 mg p.o. q.d. 7. Lasix 20 mg p.o. b.i.d. 8. Prevacid 30 mg p.o. q.d. 9. Calcium carbonate with vitamin D 500 mg p.o. t.i.d.
SS|single strength|SS|128|129|ALLERGIES|3. Neoral 80 mg p.o. q.8h. 4. CellCept 125 mg p.o. q.i.d. 5. Prednisone 5 mg p.o. b.i.d. 6. Zantac 45 mg p.o. b.i.d. 7. Bactrim SS 80 mg p.o. q.d. 8. Valcyte 250 mg p.o. q.d. 9. Tylenol 325 mg p.o. q.6h. p.r.n. 10. Senna 1 to 4 tablets p.o. b.i.d. p.r.n. Most oral medications are going to be administered per gastrostomy tube.
SS|single strength|SS|165|166|DISCHARGE MEDICATIONS|9. Cellcept 500 mg p.o. q.i.d. 10. Nystatin 10 ml p.o. q.i.d. swish and swallow. 11. Neutra-Phos 1 packet p.o. b.i.d. x 7 days, then reassess with labs. 12. Bactrim SS 1 tablet p.o. q.d. 13. Valcyte 450 mg p.o. q.o.d., dosage will have to be adjusted according to creatinine level.
SS|single strength|SS,|122|124|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prograf 2 mg p.o. b.i.d. 2. CellCept 500 mg p.o. q.i.d. 3. Prednisone 5 mg p.o. q.d. 4. Bactrim SS, 1 p.o. q.d. 5. Valcyte 450 mg p.o. q.d. times three months, then discontinue. 6. Nystatin solution, 100,000 U/mL 10 cc p.o. q.i.d. (swish/swallow p.c. and h.s.)
SS|single strength|SS|132|133|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Insulin NPH 24 U subcu b.i.d. 2. Insulin regular, 12 U subcu b.i.d. 3. Aciphex 20 mg p.o. q.d. 4. Bactrim SS one tab p.o. q.d. 5. Lactulose two tabs p.o. b.i.d. 6. Propranolol 20 mg p.o. q.d. 7. Spironolactone 50 mg p.o. q.d.
SS|single strength|SS|119|120|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Neoral 100 mg p.o. b.i.d. 2. Rapamune 3 mg p.o. q.d. 3. Prednisone 5 mg p.o. q.d. 4. Bactrim SS 1 p.o. q.d. 5. Aspirin 81 mg p.o. q.d. 6. Protonix 40 mg p.o. q.d. 7. Demadex 100 mg p.o. q.d. 8. Synthroid 0.25 mg p.o. q.d.
SS|single strength|SS|189|190|DISCHARGE MEDICATIONS|He was ambulating well and tolerating p.o. intake well prior to the time of discharge. He was discharged in good condition. DISCHARGE MEDICATIONS: 1. Valcyte 450 mg p.o. q. day. 2. Bactrim SS 1 tab p.o. q. day. 3. Diltiazem 30 mg p.o. b.i.d. 4. Calcium with vitamin D 1.25 gm p.o. q. day. 5. Mycelex 1 troche p.o. q.i.d. 6. Neoral 350 mg p.o. b.i.d.
SS|single strength|SS|152|153|DISCHARGE MEDICATIONS|4. Lasix 40 mg p.o. b.i.d. 5. Lopressor 50 mg p.o. b.i.d. 6. Protonix 40 mg p.o. q.d. 7. Rapamune 2 mg p.o. q.d. 8. Prograf 2 mg p.o. b.i.d. 9. Bactrim SS one tab p.o. q.d. 10. Valcyte 900 mg p.o. q.d. 11. Tylox one to two tabs p.o. q. 4-6h. p.r.n. for pain. 12. Allopurinol 100 mg p.o. q.d.
SS|single strength|SS|167|168|DISCHARGE MEDICATIONS|3. Prednisone 20 mg p.o. b.i.d., as directed by the transplant team. 4. Zantac 150 mg p.o. b.i.d. 5. Metoprolol 25 mg p.o. b.i.d. 6. Norvasc 5 mg p.o. q.d. 7. Bactrim SS tab one tab p.o. q. Monday and Thursday. 8. Nystatin swish and swallow 5 cc p.o. q.i.d. 9. Fosamax 70 mg p.o. q. Saturday. 10. Calcium carbonate 500 mg p.o. q.d.
SS|single strength|SS|134|135|DISCHARGE MEDICATIONS|11. Nitroglycerin 0.2 mg q h transdermal q day 12. Protonix 40 mg q day 13. Paxil 10 mg q day 14. Prednisone 15 mg b.i.d. 15. Bactrim SS one tab q Monday and Thursday 16. Valcyte 900 mg q day 17. Tylenol 650 mg p.o. q.4-6h p.r.n. pain 18. Colchicine 0.6 mg b.i.d.
SS|single strength|SS|273|274|HOSPITAL COURSE|She was admitted overnight for observation. The following morning her Foley was discontinued and the patient's vitals, and exam were all within normal limits. She was tolerating p.o. and able to ambulate and void on her own. Therefore, she was discharged to home on Septra SS one tablet p.o. q.h.s., and Tylenol #3 one tablet p.o. q4-6h p.r.n. for pain control. She should follow up with Dr. _%#NAME#%_ in Pediatric Clinic and Urology Clinic in two weeks.
SS|single strength|SS|272|273|DISCHARGE MEDICATIONS|Her serum creatinine was 0.7 mg/dL. Of note, she is on the Campath protocol and is calcineurin-inhibitor free with CellCept and prednisone as the sole oral immunosuppressants. DISCHARGE MEDICATIONS: 1. Cellcept 1 gm p.o. b.i.d. 2. Prednisone 5 mg p.o. per day. 3. Bactrim SS 1 p.o. 2 times per week (Mondays and Thursdays). 4. Valcyte 900 mg p.o. per day. 5. Mycelex troche 10 mg p.o. q.i.d.
SS|single strength|SS|144|145|DISCHARGE MEDICATIONS|1. Amlodipine 10 mg q.d. 2. Atorvastatin 20 mg q.d. 3. Metoprolol 100 mg q.d.. 4. Metronidazole 500 mg t.i.d. 5. Prilosec 10 mg q.d. 6. Bactrim SS 1 tablet twice a week. 7. Prograf 1 mg b.i.d. 8. Valcyte 900 mg q.d.
SS|single strength|SS|251|252|DISCHARGE MEDICATIONS;|At the time of discharge from the hospital, Mr. _%#NAME#%_ was afebrile and his white blood count was 7,700 with an absolute lymphocyte count of 0.1. His serum creatinine was 0.9 mg/dL. DISCHARGE MEDICATIONS; 1. CellCept 750 mg p.o. t.i.d. 2. Bactrim SS one p.o. every day. 3. Valcyte 900 mg p.o. every day. 4. Mycelex troche 10 mg p.o. q.i.d. 5. Aspirin 81 mg p.o. every day. 6. Protonix 40 mg p.o. every day.
SS|single strength|SS|154|155|DISCHARGE MEDICATIONS|13. Procardia XL 60 mg p.o. b.i.d. 14. Protonix 40 mg p.o. q. daily. 15. Senokot S 2 tabs p.o. b.i.d. p.r.n. 16. Zoloft 200 mg p.o. q. daily. 17. Bactrim SS 1 tab p.o. q. daily. 18. Valcyte 900 mg p.o. q. daily. 19. K-Phos Neutral 250 mg p.o. t.i.d. x 2 weeks. 20. Mirapex 2-3 tabs p.o. t.i.d. p.r.n. 21. Tigan 200 mg p.r. q.8h. p.r.n. for nausea.
SS|single strength|SS|120|121|DISCHARGE MEDICATIONS|He was euglycemic, independent of exogenous insulin. DISCHARGE MEDICATIONS: 1. CellCept one gram p.o. b.i.d. 2. Bactrim SS one p.o. q day 3. Valcyte 900 mg p.o. q day 4. Mycelex troche 10 mg p.o. q.i.d. 5. Protonix 40 mg p.o. q day 6. Calcium carbonate with vitamin D 500 mg p.o. t.i.d.
SS|single strength|SS|162|163|DISCHARGE MEDICATION|Through the first year, she will continue on the Alemtuzumab protocol. DISCHARGE MEDICATION: 1. CellCept 500 mg p.o. t.i.d. 2. Rapamune 1 mg p.o. q.d. 3. Bactrim SS 1 p.o. q.d. 4. Valcyte 450 mg p.o. q.d. 5. Mycelex troche 10 mg p.o. q.i.d. 6. Pravastatin 10 mg p.o. q.h.s.
SS|single strength|SS|149|150|DISCHARGE MEDICATIONS|6. Prednisone 2.5 mg p.o. q.d. 7. Prograf 2.5 mg p.o. b.i.d. 8. Flomax 0.4 mg p.o. q.h.s. 9. Vicodin one - two tablets p.o. q4-6h p.r.n. 10. Bactrim SS one p.o. q.d. 11. Enteric-coated aspirin 81 mg p.o. q.d. FOLLOW-UP INSTRUCTIONS: He is to have a diet as tolerated, activity as tolerated, no lifting greater than ten pounds for six weeks.
SS|single strength|SS|125|126|ADMISSION MEDICATIONS|ADMISSION MEDICATIONS: 1. Prograf 2 mg p.o. b.i.d. 2. Advair 3. Albuterol 4. Effexor 5. Prilosec 20 mg p.o. daily 6. Bactrim SS 1 p.o. 2 times per week FAMILY HISTORY: The patient is adopted and does not know the family history of her father.
SS|single strength|SS|258|259|DISCHARGE MEDICATIONS|6. She was told to report erythema, increased drainage, pain, swelling, or fever of 101 degrees Fahrenheit or higher, to her transplant coordinator, _%#NAME#%_ (??_%#NAME#%_) _%#NAME#%_ (sp??) DISCHARGE MEDICATIONS: 1. CellCept 500 mg p.o. b.i.d. 2. Bactrim SS 1 p.o. 4x q. week. 3. Valcyte 450 p.o. 3x q. week. 4. Mycelex Troche 1 p.o. q.i.d. 5. Lopressor 25 mg p.o. b.i.d. 6. Aspirin 81 mg p.o. per day.
SS|single strength|SS|236|237|DISCHARGE MEDICATIONS|If he remains without fever for 4 days, his PICC line will be removed, and 6 days later he will electively have a Port-A-Cath placed. DISCHARGE MEDICATIONS: 1. Prograf 2 mg p.o. twice daily. 2. Rapamune 2 mg p.o. once daily. 3. Bactrim SS 1 p.o. once daily. 4. Fentanyl patch 150 mcg TD every other day (q.48h.). 5. OxyFAST 40 mg p.o. every 4-6 hours p.r.n. pain.
SS|single strength|SS|153|154|DISCHARGE MEDICATIONS|Please see below for details. DISCHARGE MEDICATIONS: 1. CellCept 500 mg p.o. daily. 2. Prograf 1 mg p.o. b.i.d. 3. Valcyte 900 mg p.o. daily. 4. Bactrim SS one tablet p.o. daily. 5. Colace 100 mg p.o. b.i.d. 6. Mycelex 10 mg p.o. q.i.d. 7. Calcium plus vitamin D 1250 mg p.o. b.i.d.
SS|single strength|SS|149|150|DISCHARGE MEDICATIONS|2. Mycelex troche 10 mg p.o. q.i.d. 3. CellCept 1 g p.o. b.i.d. 4. Senna 1 to 2 tabs p.o. b.i.d. 5. Sodium bicarbonate 650 mg p.o. b.i.d. 6. Bactrim SS 1 tablet p.o. each day. 7. Valcyte 900 mg p.o. each day. 8. Campath 30 mg IV a 2, 6 and 12 weeks and monthly thereafter for the first year whenever the absolute lymphocyte count is above 200.
SS|single strength|SS|146|147|DISCHARGE MEDICATIONS|5. Vicodin 1 to 2 p.o. q.6 h. 6. Tylenol 650 mg p.o. every day. 7. Prograf 1 mg p.o. twice a day. 8. CellCept 1 gram p.o. twice a day. 9. Bactrim SS 1 p.o. every day. 10. Hydrocortisone 20 mg p.o. twice a day. 11. Synthroid 0.125 mg p.o. every day. 12. Lopressor 75 mg p.o. twice a day.
SS|single strength|SS|138|139|MEDICATIONS|ALLERGIES: Phenobarbital. MEDICATIONS: 1. Neoral 125 mg p.o. b.i.d. 2. Imuran 50 mg p.o. daily. 3. Prednisone 5 mg p.o. daily. 4. Bactrim SS one tablet p.o. daily. 5. Aspirin 325 mg p.o. daily, on hold. 6. Plavix 75 mg p.o. daily, on hold. 7. Lipitor 10 mg q.h.s.
SS|single strength|SS|158|159|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Colace 100 mg p.o. b.i.d. 2. Norvasc 2.5 mg p.o. b.i.d. 3. Captopril 12.5 mg p.o. t.i.d. 4. Prednisone 35 mg p.o. daily. 5. Bactrim SS one tablet p.o. q. Monday and Wednesday b.i.d. 6. MiraLax 17 g p.o. daily p.r.n. 7. Magic mouthwash; apply with applicator p.r.n.
SS|single strength|SS|142|143|DISCHARGE MEDICATIONS|11. Mycelex troche one tablet q.i.d. 12. Os-Cal 500 mg t.i.d. 13. Darbepoetin 100 mg every Tuesday. 14. Metoprolol 12.5 mg q.12h. 15. Bactrim SS one every Monday, Wednesday, Friday. 16. Ery-Tab 500 mg q.12h stop after the am dose on _%#MMDD2004#%_. 17. Neoral 150 mg p.o. b.i.d. 18. Zofran 4 mg q.6h as needed.
SS|single strength|SS|123|124|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Neoral 150 mg p.o. b.i.d. 2. Imuran 125 mg p.o. daily. 3. Prednisone 5 mg p.o. daily. 4. Bactrim SS 1 p.o. daily. 5. Valcyte 900 mg p.o. daily. 6. Mycelex troche 10 mg p.o. q.i.d. 7. Lopressor 25 mg p.o. b.i.d. 8. Norvasc 5 mg p.o. b.i.d.
SS|single strength|SS|175|176|DISCHARGE MEDICATIONS|8. Flagyl 500 mg p.o. b.i.d. x 7 days. 9. Cellcept 1 gm p.o. b.i.d. 10. Protonix 20 mg p.o. daily. 11. Prednisone 5 mg p.o. daily. 12. Aldactone 25 mg p.o. b.i.d. 13. Bactrim SS 1 tab p.o. 3 x week. 14. Percocet 1 to 2 tabs p.o. q.4-6 h. p.r.n. pain. 15. Levaquin 500 mg p.o. daily x 7 days.
SS|single strength|SS|151|152|DISCHARGE MEDICATIONS|7. Iron standard 25 mg p.o. daily. 8. Folate 2 mg p.o. daily. 9. Miconazole cream to effected areas b.i.d. 10. Cellcept 500 mg p.o. b.i.d. 11. Bactrim SS 100 mg p.o. daily. 12. Torsemide 100 mg p.o. daily. 13. Urea cream 40% to effected areas daily. 14. Steroid taper as: Solu-Medrol 500 mg IV on _%#MMDD2005#%_, prednisone 45 mg p.o. b.i.d. _%#MMDD2005#%_, prednisone 35 mg p.o. b.i.d. _%#MMDD2005#%_-_%#MMDD2005#%_, prednisone 45 mg p.o. daily _%#MMDD2005#%_-_%#MMDD2005#%_, prednisone 25 mg p.o. daily from _%#MMDD2005#%_-_%#MMDD2005#%_, and finally prednisone 5 mg p.o. daily.
SS|single strength|SS|198|199|DISCHARGE MEDICATIONS|The patient tolerated the procedure without complication. She was discharged to home in stable condition. DISCHARGE MEDICATIONS: 1. Neoral 125 mg p.o. b.i.d. 2. Cellcept 1 gm p.o. b.i.d. 3. Bactrim SS 1 p.o. daily. 4. Valcyte 900 mg p.o. daily. 5. Mycelex troche 10 mg p.o. q.i.d. 6. Tequin 40 mg p.o. daily x2 days, then discontinue.
SS|single strength|SS|170|171|DISCHARGE MEDICATIONS|At the time of discharge, she was afebrile and her vital signs were stable. DISCHARGE MEDICATIONS: 1. Rapamune 2 mg p.o. daily 2. Prednisone 2.5 mg p.o. daily 3. Bactrim SS one p.o. daily 4. Valcyte 450 mg p.o. daily 5. Mycelex troche 10 mg p.o. q.i.d. 6. Celexa 10 mg p.o. daily 7. Lipitor 20 mg p.o. q.h.s. 8. Aspirin 81 mg p.o. daily
SS|single strength|SS|343|344|DISCHARGE MEDICATIONS|4. Prednisone taper 40 mg p.o. b.i.d. for 2 days (_%#MMDD2006#%_ and _%#MMDD2006#%_), 30 mg p.o. b.i.d. for 2 days (_%#MMDD2006#%_ and _%#MMDD2006#%_), 20 mg p.o. b.i.d. for 2 days (_%#MMDD2006#%_ and _%#MMDD2006#%_), 20 mg p.o. daily (_%#MMDD2006#%_ and _%#MMDD2006#%_), then 10 mg p.o. daily thereafter, beginning _%#MMDD2006#%_. 5. Bactrim SS 1 p.o. daily. 6. Coumadin 3.75 mg p.o. q.p.m. (hold Coumadin dose beginning Friday, _%#MMDD2006#%_). 7. Aspirin 325 mg p.o. daily (hold aspirin dose).
SS|single strength|SS|236|237|DISCHARGE MEDICATIONS|At the time of discharge, her creatinine was 0.6 mg dL, her fasting blood glucose was 84 mg/dL, and her amylase and lipase levels were less than 30 and 18, respectively. DISCHARGE MEDICATIONS: 1. Cell-Cept 500 mg p.o. b.i.d. 2. Bactrim SS 1 p.o. daily 3. Valcyte 450 mg p.o. daily 4. Mycelex troche 10 mg p.o. q.i.d. (p.c. and h.s.) 5. Zelnorm 6 mg p.o. t.i.d. 6. Pancrease 2 tablets p.o. a.c.
SS|single strength|SS|181|182|DISCHARGE MEDICATIONS|She may need evaluation by Colorectal Surgery as well. DISPOSITION: Home. DISCHARGE MEDICATIONS: 1. Ceftazidime 1 g IV q.12 hours x 13 days, to complete a 14-day course. 2. Bactrim SS 1 p.o. daily. 3. Neoral 100 mg p.o. q.a.m. and 75 mg p.o. q.p.m. 4. Prednisone 2.5 mg p.o. daily. 5. Valcyte 450 mg p.o. q. Monday, Wednesday, and Friday.
SS|sickle cell genotype SS|SS.|101|103|PAST MEDICAL HISTORY|She did not have any diarrhea or any further symptoms. PAST MEDICAL HISTORY: 1. Sickle cell with Hgb SS. She had been hospitalized on _%#MM#%_ 2004 and _%#MM#%_ 2004, with sickle cell crisis. 2. She was hospitalized 2 to 3 times with acute chest syndrome, history of admission for pneumonia previously.
SS|single strength|SS|132|133|DISCHARGE MEDICATIONS|9. Nystatin 1 mL p.o. q.i.d. 10. Protonix 8 mg p.o. daily. 11. Zosyn 750 mg IV q.8. 12. Prednisolone 2.5 mg p.o. b.i.d. 13. Bactrim SS 30 mg p.o. daily. 14. Valcyte 80 mg p.o. daily. 15. Tylenol 120 mg p.o. q.4 h. p.r.n. pain. FOLLOW-UP: 1. He will follow up with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2004, at 11:30.
SS|single strength|SS|179|180|DISCHARGE MEDICATIONS|His serum creatinine was 1.76 mg/dL, his baseline with chronic renal insufficiency. DISCHARGE MEDICATIONS: 1. Prograf 1.5 mg p.o. b.i.d. 2. CellCept 500 mg p.o. t.i.d. 3. Bactrim SS one p.o. daily. 4. Valcyte 450 mg p.o. daily. 5. Mycelex troche 10 mg p.o. t.i.d. 6. Atenolol 50 mg p.o. daily. 7. Clonidine 0.1 mg p.o. b.i.d. 8. Dynacirc 10 mg p.o. b.i.d.
SS|single strength|SS|228|229|DISCHARGE MEDICATIONS|The patient wanted to be discharged so he could go back to trucking and stated that he would follow up as an outpatient. DISCHARGE MEDICATIONS: 1. Prograf 2 mg by mouth every morning and 1 mg by mouth in the evening. 2. Bactrim SS 1 tablet by mouth daily. 3. Aspirin 81 mg by mouth daily. 4. Hytrin 2 mg by mouth each day at bedtime.
SS|single strength|SS|184|185|DISCHARGE MEDICATIONS|5. Mycelex one tablet p.o. q.i.d. 6. CellCept 1000 mg p.o. b.i.d. 7. Protonix 40 mg p.o. daily. 8. Prednisone 5 mg p.o. daily. 9. Renagel 1600 mg p.o. t.i.d. before meals. 10. Bactrim SS 1 tablet p.o. daily. 11. Valcyte 450 mg p.o. Tuesday and Friday. 12. Lipitor 40 mg p.o. daily. 13. Sirolimus 1 mg p.o. daily. 14. IVIg schedule: Polygam or equivalent IV in Transplant Center after pheresis on _%#MMDD#%_, _%#MMDD#%_, and _%#MMDD2005#%_.
SS|single strength|SS|189|190|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Mycelex troche 1 p.o. q.i.d. 2. Lantus 40 units subq q.a.m. 3. Multivitamin 1 p.o. q. daily. 4. CellCept 1 gm p.o. b.i.d. 5. Protonix 40 mg p.o. daily. 6. Bactrim SS 1 p.o. daily. 7. Prograf 2 mg p.o. b.i.d. 8. Actigall 300 mg p.o. t.i.d. 9. Valcyte 900 mg p.o. daily. 10. Percocet 1 to 2 tablets q.4-6 h. p.r.n. for pain.
SS|single strength|SS|150|151|DISCHARGE MEDICATIONS|4. Neoral 100 mg p.o. q.12 h. 5. Prevacid 20 mg p.o. daily. 6. CellCept 500 mg p.o. twice a day. 7. Mucostatin 5 mL oral four times daily. 8. Bactrim SS 40 mg p.o. daily. 9. Valcyte 300 mg p.o. daily. 10. Hurricane spray 1 to 2 sprays q. hour p.r.n. 11. Benadryl 12.5 mg p.o. q.4-6 h. p.r.n. itching. 12. Colace 50 mg oral twice a day p.r.n. constipation.
SS|single strength|SS|199|200|DISCHARGE MEDICATIONS|For maintenance immunosuppression, he was started on a 2-drug protocol with Tacrolimus and mycophenolate. DISCHARGE MEDICATIONS: 1. Prograf 2 mg p.o. b.i.d. 2. Cellcept 1 gram p.o. b.i.d. 3. Bactrim SS 1 p.o. daily. 4. Valcyte 900 mg p.o. daily. 5. Mycelex troche 10 mg p.o. t.i.d. 6. Aspirin 325 mg p.o. daily. 7. Plavix 75 mg p.o. daily. 8. Coreg 12.5 mg p.o. b.i.d.
SS|single strength|SS|132|133|DISCHARGE MEDICATIONS|His serum creatinine was 1.18 mg/dL. DISCHARGE MEDICATIONS: 1. Cellcept 500 mg p.o. q.i.d. 2. Prograf 3.5 mg p.o. b.i.d. 3. Bactrim SS 1 p.o. daily. 4. Valcyte 900 mg p.o. daily. 5. Mycelex troche 10 mg p.o. t.i.d. 6. Aspirin 81 mg p.o. daily. 7. Lipitor 40 mg p.o. daily.
SS|single strength|SS|166|167|DISCHARGE MEDICATIONS|4. Prednisone taper. 5. Pravachol 40 mg every day. 6. Metoprolol 25 mg twice a day. 7. Prinivil 10 mg every day. 8. Insulin NPH 15 units q.a.m. and q.p.m. 9. Bactrim SS one tab every day. 10. In addition, we have started sodium bicarbonate 1300 mg three times per day.
SS|single strength|SS|162|163|DISCHARGE MEDICATIONS|2. Keflex 500 mg p.o. t.i.d. for an additional week (for presumed E. coli pneumonia). 3. Prednisone 5 mg p.o. q. day. 4. Sirolimus 0.5 mg p.o. q. day. 5. Bactrim SS one tablet twice weekly. 6. Tacrolimus 0.5 mg p.o. b.i.d. DISCHARGE INSTRUCTIONS: 1. He will continue on TPN for the next week.
SS|single strength|SS|181|182|DISCHARGE MEDICATIONS|At the time of discharge, Mr. _%#NAME#%_ was afebrile, and his vital signs were stable. DISCHARGE MEDICATIONS: 1. Prograf 2 mg p.o. b.i.d. 2. Cellcept 500 mg p.o. b.i.d. 3. Bactrim SS 1 p.o. two times per week (Mondays and Thursdays). 4. Mycelex troche 10 mg p.o. q.i.d. 5. Norvasc 10 mg p.o. daily. 6. Aspirin 81 mg p.o. daily. 7. Protonix 40 mg p.o. b.i.d.
SS|single strength|SS|215|216|DISCHARGE MEDICATIONS|9. Lantus insulin 34 units subcutaneously b.i.d. 10. Humalog insulin per self regulations subcutaneously. 11. Lisinopril 20 mg p.o. daily. 12. Toprol XL 50 mg p.o. daily. 13. Prednisone 5 mg p.o. daily. 14. Bactrim SS one tablet p.o. daily. 15. __________ 150 mg p.o. daily. 16. Warfarin 7.5 mg p.o. daily. 17. Zetia 10 mg p.o. daily. 18. Darvocet one to two tablets p.o. q. 4-6 h. p.r.n. pain.
SS|single strength|SS|124|125|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS 1. Prograf 0.5 mg p.o. b.i.d. 2. CellCept 500 mg p.o. b.i.d. 3. Prednisone 5 mg p.o. q day 4. Bactrim SS 1 p.o. q day 5. Valtrex 1 g p.o. b.i.d. X7 days 6. Valcyte 450 mg p.o. q day X2 months once Valtrex has been completed
SS|single strength|SS|127|128|DISCHARGE MEDICATIONS|She was afebrile with a WBC 3600. DISCHARGE MEDICATIONS: 1. Prograf 2 mg p.o. b.i.d. 2. CellCept 500 mg p.o. b.i.d. 3. Bactrim SS one p.o. daily. 4. Prevacid 30 mg p.o. daily. 5. Reglan 10 mg p.o. b.i.d. 6. Senokot one to two p.o. b.i.d. p.r.n. constipation.
SS|single strength|SS|109|110|DISCHARGE MEDICATIONS|6. CellCept 750 mg p.o. b.i.d. 7. Protonix 40 mg p.o. b.i.d. 8. Senna 1 to 2 tablets p.o. q. day. 9. Bactrim SS 1 tablet p.o. q. day. 10. Prograf 1.5 mg p.o. b.i.d. 11. Tylox 1 to 2 tablets p.o. q. 4 hours p.r.n. pain. FOLLOW-UP: The patient will follow up with Dr. _%#NAME#%_ on _%#MMDD2005#%_.
SS|single strength|SS|142|143|DISCHARGE  MEDICATIONS|7. Lexapro 10 mg p.o. daily. 8. Synthroid 88 mcg p.o. daily. 9. Imodium 2 mg p.o. q.a.m. 10. Actonel 35 mg p.o. weekly on Sunday. 11. Bactrim SS strength 1 tab p.o. daily. 12. Coumadin 2 mg p.o. on Mondays and Thursdays and 1 mg p.o. on Tuesday, Wednesday, Friday, Saturday and Sunday.
SS|single strength|SS|110|111|DISCHARGE MEDICATION|15. Pravastatin 10 mg p.o. q. h.s. 16. Prednisone 5 mg p.o. q. day. 17. Zoloft 25 mg p.o. q. day. 18. Bactrim SS 1 tablet p.o. x 2 a week. 19. Sodium bicarbonate 1.3 gm p.o. q.i.d. 20. Coumadin 5 mg p.o. q day. DISCHARGE INSTRUCTIONS: The patient is to be discharged to home today.
SS|single strength|SS|235|236|DISCHARGE MEDICATIONS|His INR was 2.35. His abdominal pain had decreased significantly and his amylase and lipase levels were 92 and 145 units/liter, respectively. DISCHARGE MEDICATIONS: 1. Prograf 2 mg p.o. b.i.d. 2. CellCept 500 mg p.o. q.i.d. 3. Bactrim SS 1 p.o. daily. 4. Valcyte 450 mg p.o. b.i.d. 5. Mycelex troche 10 mg p.o. q.i.d. 6. Miconazole powder, topical application to abdominal folds q.i.d. p.r.n.
SS|single strength|SS|164|165|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Cipro 500 mg p.o. twice daily x14 days then discontinue. 2. Prograf 1 mg p.o. twice daily. 3. CellCept 250 mg p.o. once daily. 4. Bactrim SS 1 p.o. 3 times weekly. 5. Valcyte 450 mg p.o. daily. 6. Mycelex troche 10 mg p.o. 4 times daily. 7. Octreotide LAR Depo 20 mg IM monthly. 8. Flomax 0.4 mg p.o. daily.
SS|single strength|SS|176|177|DISCHARGE MEDICATIONS|His amylase was 73. Mr. _%#NAME#%_'s staples from his original transplant were removed prior to his discharge. DISCHARGE MEDICATIONS: 1. Cellcept 750 mg p.o. q.i.d. 2. Bactrim SS 1 tab p.o. daily. 3. Valcyte 900 mg p.o. daily. 4. Mycelex 10 mg p.o. q.i.d. 5. Augmentin 875 mg p.o. b.i.d. x 14 days for pneumonia.
SS|single strength|SS|118|119|DISCHARGE MEDICATIONS|He was euglycemic, independent of exogenous insulin. DISCHARGE MEDICATIONS: 1. Cellcept 750 mg p.o. q.i.d. 2. Bactrim SS 1 p.o. daily. 3. Valcyte 450 mg p.o. 2 times per week (Mondays and Thursdays). 4. Mycelex troches 10 mg p.o. q.i.d. 5. Atenolol 25 mg p.o. daily.
SS|single strength|SS|111|112|DISCHARGE MEDICATIONS|5. CellCept 750 mg p.o. q.a.m., 500 mg p.o. q. noon, 750 mg p.o. q.p.m. 6. Prograf 1 mg p.o. b.i.d. 7. Bactrim SS 1 p.o. each day. 8. Mycelex Troche 10 mg p.o. q.i.d. 9. Protonix 40 mg p.o. each day. 10. Colace 100 mg p.o. b.i.d.
SS|single strength|SS|103|104|DISCHARGE MEDICATION|8. CellCept 1 gm p.o. b.i.d. 9. Protonix 40 mg p.o. q. day. 10. Rapamune 3 mg p.o. q. day. 11. Bactrim SS 1 tablet p.o. q. day. 12. Tequin 200 mg p.o. q.d. x 6 days. DISCHARGE DISPOSITION: He was doing well. He will follow up with lab draws with the Some Care Agency on Monday, Wednesday, and Friday, and he will follow up with Dr. _%#NAME#%_ in one to two weeks.
SS|single strength|SS|275|276|DISCHARGE MEDICATIONS|Coumadin was started. At the time of discharge, she had not reached her target INR of 2-2.5, so she was started on Lovenox until her INR reaches 1.9. DISCHARGE MEDICATIONS: 1. Prograf 2 mg p.o. b.i.d. 2. Cellcept 1.5 g p.o. b.i.d. 3. Prednisone 2.5 mg p.o. daily. 4. Bactrim SS 1 p.o. daily. 5. Valcyte 900 mg p.o. daily. 6. Mycelex Troche 10 mg p.o. q.i.d. 7. Cipro 500 mg p.o. b.i.d. (discontinue after 2nd dose on _%#MMDD2005#%_).
SS|single strength|SS|141|142|DISCHARGE MEDICATIONS|5. Neoral 100 mg p.o. b.i.d. 6. Cell-Cept 1 gram p.o. b.i.d. 7. Protonix 20 mg p.o. q.a.m. 8. Valcyte 450 mg p.o. every other day 9. Bactrim SS one tab p.o. daily 10. Prednisone 100 mg p.o. Monday; 75 mg p.o. Tuesday and Wednesday, 50 mg Thursday and Friday, 25 mg Saturday and Sunday
SS|single strength|SS|164|165|DISCHARGE MEDICATIONS|2. Aspirin 81 mg p.o. daily 3. Neoral 150 mg p.o. b.i.d. 4. Cell-Cept 1 g p.o. b.i.d. 5. Prednisone 10 mg p.o. daily on _%#MMDD2004#%_, then discontinue 6. Bactrim SS one p.o. daily 7. Valcyte 900 mg p.o. daily 8. Mycelex troche 10 mg p.o. q.i.d. 9. Prevacid 30 mg p.o. daily
SS|single strength|SS|123|124|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prograf 3 mg p.o. b.i.d. 2. CellCept 1.5 g p.o. b.i.d. 3. Prednisone 5 mg p.o. daily. 4. Bactrim SS 1 tablet p.o. daily. 5. Valcyte 450 mg p.o. daily. 6. Mycelex troche 10 mg p.o. t.i.d. after meals. 7. Clonidine 0.1 mg p.o. t.i.d. 8. Lopressor 100 mg p.o. b.i.d.
SS|single strength|SS|142|143|DISCHARGE MEDICATIONS|9. NovoLog sliding scale. 10. Multivitamin 11. Protonix 20 mg b.i.d. 12. Paxil 30 mg p.o. q.h.s. 13. Ribavirin 600 mg p.o. q.a.m. 14. Bactrim SS 1 p.o. q.a.m. 15. Actigall 300 mg p.o. b.i.d. 16. Viread 300 mg p.o. q.a.m. 17. Percocet 1 to 2 p.o. q.4 h. p.r.n. 18. Colace 100 mg p.o. b.i.d.
SS|single strength|SS|200|201|DISCHARGE MEDICATIONS|2. Prednisone 40 mg p.o. X1, Thymoglobulin premedication 3. Tylenol 650 mg p.o. Thymoglobulin premedication 4. Benadryl 25-50 mg Thymoglobulin premedication 5. Cell-Cept 500 mg p.o. q.i.d. 6. Bactrim SS one p.o. three times weekly 7. Valcyte 450 mg p.o. daily 8. Seroquel 100 mg p.o. q.h.s. 9. Wellbutrin XL 150 mg p.o. daily
SS|single strength|SS|146|147|DISCHARGE MEDICATIONS|2. Xanax 0.5 mg p.o. q.h.s. 3. Amiodarone 200 mg p.o. q. day. 4. Aranesp 60 mcg subcu one time q.2 weeks. 5. Aspirin 81 mg p.o. daily. 6. Bactrim SS one tablet p.o. daily. 7. Calcium with vitamin D 1250 mg p.o. b.i.d. 8. CellCept 500 mg p.o. b.i.d. 9. Ferrous Sulfate 325 mg p.o. b.i.d.
SS|single strength|SS|141|142|DISCHARGE MEDICATIONS|11. Rapamune 1 mg p.o. daily - to be held until levels are rechecked. 12. Zantac 150 mg p.o. b.i.d. 13. Zoloft 50 mg p.o. daily. 14. Bactrim SS tablet 1 tab p.o. daily. 15. Torsemide 20 mg p.o. b.i.d. 16. Valcyte 450 mg p.o. q.o.d. 17. Robitussin 5 ml p.o. q.4-6h p.r.n. for cough.
SS|single strength|SS|131|132|DISCHARGE MEDICATIONS|She was free of nausea and pain. DISCHARGE MEDICATIONS: 1. CellCept 500 mg p.o. t.i.d. 2. Prednisone 2.5 mg p.o. daily. 3. Bactrim SS one tablet p.o. daily. 4. Valcyte 450 mg p.o. daily. 5. Mycelex troches one p.o. q.i.d. 6. Protonix 40 mg p.o. daily.
SS|single strength|SS|144|145|DISCHARGE MEDICATIONS|8. Magnesium oxide 400 mg p.o. b.i.d. 9. Metoprolol 100 mg p.o. b.i.d. 10. Protonix 40 mg p.o. daily. 11. Rapamune 3 mg p.o. daily. 12. Bactrim SS one tablet twice weekly. 13. Prograf is to be decreased to 3 mg p.o. b.i.d. 14. Ditropan 5 mg p.o. t.i.d. DISCHARGE INSTRUCTIONS: 1. Diet is renal
SS|single strength|SS|136|137|DISCHARGE MEDICATIONS|9. Mycelex troche 1 p.o. q.i.d. 10. Lopressor 50 mg p.o. b.i.d. 11. Protonix 40 mg p.o. daily. 12. Zoloft 50 mg p.o. daily. 13. Bactrim SS one tab p.o. daily. 14. Valcyte 450 mg p.o. q. two times per week. DISCHARGE INSTRUCTIONS: The patient is discharged from unit 6B to home on _%#MMDD2004#%_.
SS|single strength|SS|153|154|DISCHARGE MEDICATIONS|Her urinary amylase level was 5314 U/hour. DISCHARGE MEDICATIONS: 1. Prograf 3 mg p.o. q.a.m./2 mg p.o. q.p.m. 2. Cellcept 1 gram p.o. b.i.d. 3. Bactrim SS one tablet p.o. q.day. 4. Valcyte 900 mg p.o. b.i.d. x 14 days, then 900 mg p.o. q.day for three months. 5. Florinef 0.3 mg p.o. b.i.d. 6. Flomax 0.4 mg p.o. q.day.
SS|single strength|SS|191|192|DISCHARGE MEDICATIONS|He was afebrile with a white blood count of 4,800, and his hemoglobin was stable at 9.8 grams/dL. DISCHARGE MEDICATIONS: 1. Prograf 3 mg p.o. b.i.d. 2. Cellcept 1 gram p.o. b.i.d. 3. Bactrim SS one p.o. daily. 4. Valcyte 450 mg p.o. daily. 5. Mycelex troch 10 mg p.o. t.i.d. (after meals). 6. Aspirin 81 mg p.o. daily. 7. Cozaar ON HOLD.
SS|single strength|SS|183|184|DISCHARGE MEDICATIONS|2. Clonidine 0.2 mg transdermal patch q. week. 3. Mycelex one troche p.o. q.i.d. 4. CellCept 1.5 g p.o. b.i.d. 5. Protonix 40 mg p.o. daily. 6. Prednisone 5 mg p.o. daily. 7. Bactrim SS one tab p.o. daily. 8. Prograf 2 mg p.o. q.a.m. 9. Prograf 1 mg p.o. q.p.m. 10. Valcyte 450 mg p.o. every other day. 11. Tigan 25 mg p.o. q.6 hours p.r.n. nausea.
SS|single strength|SS|143|144|DISCHARGE MEDICATIONS|6. Lantus 10 units subcutaneous b.i.d. 7. Lopressor 75 mg p.o. b.i.d. 8. CellCept 200 mg p.o. b.i.d. 9. Protonix 40 mg p.o. daily. 10. Bactrim SS 1 tab p.o. daily. 11. Valcyte 900 mg p.o. daily. 12. Senna 2 tabs p.o. b.i.d. 13. Tylenol 650 mg p.o. q. 4-6 hours p.r.n. pain. FOLLOW UP: Patient should follow up with her primary care physician, Dr. _%#NAME#%_ in 1 to 2 weeks.
SS|single strength|SS|264|265|DISCHARGE INSTRUCTIONS|2. Immunosuppression: She will be discharged on Cellcept 250 mg p.o. q.i.d., a prednisone taper, (she is not a candidate for prednisone withdrawal secondary to her primary disease), and tacrolimus 1.5 mg p.o. b.i.d. 3. Other discharge medications include: Bactrim SS one p.o. daily, calcium carbonate/vitamin D 500 mg one p.o. b.i.d., Celexa 30 mg once daily, Colace 50 mg once daily, Prevacid 30 mg one capsule once daily, Remeron 15 mg p.o. once daily, senna 8.6 mg once daily, Valcyte 450 mg once daily, Norvasc 10 mg p.o. daily.
SS|single strength|SS|141|142|DISCHARGE MEDICATIONS|It appeared that the hydronephrosis was the cause of her increased creatinine. DISCHARGE MEDICATIONS: 1. Cellcept 1 g p.o. b.i.d. 2. Bactrim SS 1 tablet p.o. daily. 3. Valcyte 900 mg p.o. daily. 4. Mycelex troche 10 mg p.o. q.i.d. 5. Protonix 40 mg p.o. daily. 6. Diltiazem 150 mg p.o. b.i.d.
SS|single strength|SS|167|168|DISCHARGE MEDICATIONS|2. Celexa 40 mg p.o. each day. 3. Mycelex troche 10 mg p.o. q.i.d. 4. Kytril 1 mg p.o. b.i.d. 5. Prevacid 30 mg p.o. b.i.d. 6. Rapamune 1 mg p.o. each day. 7. Bactrim SS 1 p.o. each day. 8. Valcyte 450 mg p.o. each day. 9. Ativan 2 mg p.o. q.h.s. 10. Domperidone 5 mg p.o. t.i.d. 11. Fluconazole 400 mg p.o. each day.
SS|single strength|SS|224|225|DISCHARGE MEDICATIONS|Her serum creatinine was 1.47 mg/dL. Amylase and lipase levels were 95 and 236 units/L, respectively, and she was euglycemic independent of exogenous insulin. DISCHARGE MEDICATIONS: 1. Myfortic 360 mg p.o. b.i.d. 2. Bactrim SS 1 p.o. daily. 3. Valcyte 450 mg p.o. daily. 4. Mycelex troche 10 mg p.o. q.i.d. 5. Prevacid 30 mg p.o. b.i.d. 6. Ranitidine 150 mg p.o. b.i.d.
SS|single strength|SS|138|139|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prograf 5 mg p.o. twice daily. 2. Rapamune 5 mg p.o. once daily. 3. Prednisone 5 mg p.o. once daily. 4. Bactrim SS 1 p.o. 3 times weekly. 5. Valcyte 450 mg p.o. 3 times weekly. 6. Mycelex troche 10 mg p.o. 3 times daily.
SS|single strength|SS|208|209|DISCHARGE MEDICATIONS|Her fasting blood glucose was 92 mg/dL with amylase and lipase levels of less than 30 and 193 units/L, respectively. DISCHARGE MEDICATIONS: 1. Prograf 4 mg p.o. b.i.d. 2. Rapamune 5 mg p.o. daily. 3. Bactrim SS 1 p.o. 3 times weekly. 4. Valcyte 450 mg p.o. 3 times weekly. 5. Coumadin 7.5 mg/5 mg alternate daily. 6. Flagyl 500 mg p.o. 3 times daily x 10 days, then discontinue.
SS|single strength|SS|171|172|DISCHARGE MEDICATIONS|Mycophenolate doses may require adjustment for gastrointestinal intolerance. DISCHARGE MEDICATIONS: 1. Rapamune 3 mg p.o. daily. 2. Cellcept 500 mg p.o. q.i.d. 3. Bactrim SS 1 p.o. three times weekly. 4. Valcyte 450 mg p.o. three times weekly. 5. Mycelex troche 10 mg p.o. q.i.d. 6. Protonix 40 mg p.o. daily.
SS|single strength|SS|189|190|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Coumadin 3 mg p.o./J-tube daily. 2. Aranesp 60 mcg subcutaneously q. week. 3. Rapamune 2 mg p.o./J-tube daily. 4. Prograf 3 mg p.o./J-tube twice daily. 5. Bactrim SS 10 mL p.o./J-tube daily. 6. Valcyte 900 mg p.o./J-tube daily. 7. Mycelex troche 10 mg p.o./J-tube three times per day. 8. Seroquel 50 mg p.o./ J-tube at bedtime. 9. Protonix 20 mg per J-tube twice daily.
SS|single strength|SS|167|168|DISCHARGE MEDICATIONS|She was afebrile and vital signs were stable. DISCHARGE MEDICATIONS: 1. Prograf 2 mg p.o. b.i.d. 2. CellCept 1 g p.o. b.i.d. 3. Prednisone 5 mg p.o. daily. 4. Bactrim SS one p.o. daily. 5. Valcyte 900 mg p.o. daily. 6. Mycelex troche 10 mg p.o. q.i.d. 7. Synthroid 50 mcg p.o. daily. 8. Lantus insulin 10 units subcu q. h.s.
SS|single strength|SS|180|181|DISCHARGE MEDICATIONS|12. Protonix 40 mg p.o. daily. 13. Prednisone 5 mg p.o. daily. 14. Zoloft 50 mg p.o. daily. 15. Prograf 0.5 mg p.o. b.i.d. 16. Sodium bicarbonate 3 tablets p.o. q.i.d. 17. Bactrim SS 1 tablet p.o. daily. 18. Percocet 1 to 2 tablets p.o. q. 4-6h. p.r.n. pain. DISCHARGE INSTRUCTIONS: The patient will schedule a followup appointment with the transplant coordinator for further instructions.
SS|single strength|SS|140|141|DISCHARGE MEDICATIONS|7. Prednisone taper as instructed on discharge orders given to the patient at the time of discharge. 8. Zoloft 25 mg p.o. daily. 9. Bactrim SS p.o. daily. 10. Prograf 1 mg p.o. b.i.d. 11. Actigall 300 mg p.o. t.i.d. 12. Valcyte 450 mg p.o. daily. 13. Dilaudid 1 mg p.o. q. 4-6h. p.r.n. for pain.
SS|single strength|SS|189|190|DISCHARGE MEDICATIONS|2. Calcium with vitamin D 1250 mg p.o. b.i.d. 3. Mycelex troche 10 mg p.o. q.i.d. 4. Myfortic 360 mg p.o. b.i.d. 5. Protonix 40 mg p.o. q. day 6. Sodium bicarb 1.3 g p.o. b.i.d. 7. Bactrim SS one tablet p.o. q. day. 8. Vancomycin 800 mg IV q.12h times 14 days. DISCHARGE INSTRUCTIONS: 1. The patient will follow up with her primary transplant physician as previously ordered on her previous discharge.
SS|single strength|SS|114|115|DISCHARGE MEDICATIONS|9. Morphine 0.1% gel to incisions t.i.d. 10. CellCept 1 gm p.o. b.i.d. 11. Protonix 40 mg p.o. daily. 12. Bactrim SS 1 tablet p.o. daily. 13. Valcyte 900 mg p.o. daily. 14. Coumadin 7.5 mg p.o. daily X6 months. 15. Dilaudid 4 to 8 mg p.o. q. 4 hours p.r.n. pain.
SS|single strength|SS|139|140|DISCHARGE MEDICATIONS|3. Magnesium oxide 800 mg b identified 4. Meropenem 1 gm IV q. 8. 5. Tobramycin 220 mg IV daily. 6. MS-Contin 50 mg p.o. b.i.d. 7. Bactrim SS 1 p.o. daily. 8. Tacrolimus 1 mg p.o. b.i.d. 9. Ursodiol 300 mg p.o. b.i.d. 10. Valcyte 900 mg p.o. daily. DISCHARGE INSTRUCTIONS: 1. On _%#MMDD2005#%_, he will go to a transitional care facility near his home in _%#CITY#%_.
SS|single strength|SS|171|172|DISCHARGE MEDICATIONS|15. CellCept 1.5 mg p.o. b.i.d. 16. Zofran 8 mg p.o. t.i.d. 17. Protonix 40 mg p.o. daily. 18. Senna 2 tabs p.o. b.i.d. 19. Spironolactone 12.5 mg p.o. daily. 20. Bactrim SS 1 tab p.o. daily. 21. Valcyte 450 mg p.o. q.48 hours. 22. Coumadin 1 mg p.o. daily. 23. Percocet 1 to 2 tabs p.o. q.4-6 hours p.r.n. pain.
SS|single strength|SS|162|163|DISCHARGE MEDICATIONS|10. Prednisone 5 mg p.o. daily. 11. Senna one to two tablets p.o. b.i.d. for constipation postoperatively. 12. Sodium Bicarbonate 1300 mg p.o. b.i.d. 13. Bactrim SS one tablet p.o. daily. 14. Prograf 2 mg p.o. b.i.d. 15. Restoril 30 mg p.o. q.h.s. 16. Valcyte 450 mg p.o. daily. 17. Vicodin one to two tablets p.o. q. 4-6 h. p.r.n. pain.
SS|single strength|SS|182|183|DISCHARGE MEDICATIONS|Her absolute lymphocytes count was 0.1 after two doses of Thymoglobulin. DISCHARGE MEDICATIONS: 1. Rapamune 2 mg p.o. daily. 2. Neoral on hold until creatinine decreases. 3. Bactrim SS one p.o. twice weekly (Monday and Thursday). 4. Valcyte 450 mg p.o. daily. 5. Mycelex troche 10 mg p.o. q.i.d. 6. Levaquin 250 mg p.o. daily (discontinue after dose on _%#MM#%_ _%#DD#%_, 2005).
SS|single strength|SS|314|315|DISCHARGE MEDICATIONS|The patient did have delayed pancreas graft function and was placed on Lantus with a sliding scale with the plan for the patient to be weaned off insulin as the pancreas graft function increases over the next 2 to 4 weeks. DISCHARGE MEDICATIONS: 1. CellCept 1 mg p.o. b.i.d. 2. Prograf 3 mg p.o. b.i.d. 3. Bactrim SS one tablet p.o. daily. 4. Mycelex one troche p.o. t.i.d. 5. Valcyte 900 mg p.o. daily. 6. Aspirin 81 mg p.o. daily. 7. Calcium with vitamin D one tab p.o. b.i.d.
SS|single strength|SS|163|164|DISCHARGE MEDICATIONS|4. MMF 1 gram p.o. b.i.d. 5. Prednisone 5 mg p.o. daily (he will be on this indefinitely due to the fact that he has PSC). 6. Senokot-S two p.o. b.i.d. 7. Bactrim SS one p.o. daily. 8. Ursodiol 300 mg p.o. b.i.d. 9. Valcyte 450 mg p.o. daily. 10. Tacrolimus 1 mg p.o. q.a.m. and 0.5 mg p.o. q.p.m.
SS|single strength|SS|107|108|DISCHARGE MEDICATIONS|10. Protonix 40 mg p.o. daily. 11. Repaglinide 0.5 mg p.o. b.i.d. 12. Senna 2 tabs p.o. b.i.d. 13. Bactrim SS 1 tab p.o. daily. 14. Flomax 0.4 mg p.o. daily. DISPOSITION: The patient is discharged from unit 6B to home on _%#MM#%_ _%#DD#%_, 2004.
SS|single strength|SS|155|156|DISCHARGE MEDICATIONS|2. Metronidazole 500 mg p.o. b.i.d. X1 week, then discontinue. 3. Fluconazole 400 mg p.o. daily X1 week, then discontinue. 4. CellCept ON HOLD. 5. Bactrim SS 1 three times weekly. 6. Aranesp 200 mcg subcu weekly. 7. Ferrous sulfate 325 mg p.o. t.i.d. 8. Coumadin 3 mg p.o. q. p.m. 9. Imodium 2 mg p.o. q.i.d. p.r.n. diarrhea.
SS|single strength|SS|143|144|DISCHARGE MEDICATIONS|10. Ambien 10 mg p.o. q.h.s. 11. Ferrous sulfate 325 mg p.o. q.day. 12. Zoloft 100 mg p.o. q.day. 13. Synthroid 0.1 mg p.o. q.day. 14. Bactrim SS 1 tablet p.o. q. Wednesday and q. Saturday. 15. Prevacid 30 mg p.o. daily. DISCHARGE INSTRUCTIONS: 1. The patient will have labs drawn q. Monday, Wednesday, and Friday x 2 weeks.
SS|single strength|SS|419|420|DISCHARGE MEDICATIONS|Her white blood cell count was 3000 with an absolute lymphocytes count of 0.1 and an absolute neutrophil count of 2.7. Her serum creatinine remained elevated at 1.47 mg/dL with a tacrolimus level of 9.2. She was discharged from the hospital in stable condition to continue follow-up as an outpatient in the Transplant Center. DISCHARGE MEDICATIONS: 1. Prograf 0.5 mg p.o. b.i.d. 2. Rapamune 1 mg p.o. daily. 3. Bactrim SS one p.o. daily. 4. Valcyte 900 mg p.o. daily. 5. Mycelex troche 10 mg p.o. q.i.d. 6. Lopressor 50 mg p.o. b.i.d.
SS|single strength|SS|143|144|DISCHARGE MEDICATIONS|9. Senna S 1 to 2 tablets p.o. each day while taking narcotic pain medications. Hold for loose stools. 10. Zocor 20 mg p.o. q.p.m. 11. Bactrim SS 1 tablet p.o. q.24 h. 12. Valcyte 900 mg p.o. each day. 13. Percocet 1 to 2 tablets p.o. q.4 h. p.r.n. pain.
SS|single strength|SS|156|157|DISCHARGE MEDICATIONS|6. Calcium carbonate with vitamin D 1250 mg p.o. b.i.d. 7. Mycelex 10 mg p.o. q.i.d. 8. Senna S 2 tabs p.o. daily. 9. Cellcept 1 gm p.o. b.i.d. 10. Bactrim SS 1 tab p.o. daily. 11. Valcyte 900 mg p.o. daily. 12. Prograf 2.5 mg p.o. b.i.d. 13. Percocet 1-2 tabs p.o. q.4h. p.r.n. pain. The patient has just stopped taking all medications that were taken prior to this hospital admission: Lasix, sodium bicarbonate and Phoslo.
SS|single strength|SS|123|124|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prograf 1.5 mg p.o. b.i.d 2. Rapamune 3 mg p.o. daily. 3. Prednisone 5 mg p.o. daily. 4. Bactrim SS 1 p.o. 3 times weekly. 5. Valcyte 450 mg p.o. daily. 6. Mycelex troche 20 mg p.o. t.i.d. 7. Lopressor 25 mg p.o. b.i.d. 8. Norvasc 10 mg p.o. daily.
SS|single strength|SS|137|138|DISCHARGE MEDICATIONS|11. Cellcept 500 mg p.o. q.i.d. 12. Narcan 1 mg p.o. q.i.d. 13. Protonix 40 mg p.o. daily. 14. Senokot 2 tablets p.o. b.i.d. 15. Bactrim SS one p.o. daily. 16. Valcyte 900 mg p.o. daily. 17. Vitamin E 400 units p.o. b.i.d. 18. Zelnorm 600 mg p.o. daily.
SS|single strength|SS|112|113|DISCHARGE MEDICATIONS|8. Protonix 40 mg p.o. each day. 9. Prednisone 5 mg p.o. each day. 10. Rapamune 1 mg p.o. each day. 11. Bactrim SS 1 tablet p.o. each day. 12. Prograf 1.5 mg p.o. b.i.d. 13. Valcyte 90 mg p.o. each day. 14. Tylenol #3 1 to 2 tablets p.o. q.4-6 h. p.r.n. pain.
SS|single strength|SS|126|127|DISCHARGE MEDICATIONS|2. Lovenox 40 mg subcu daily until INR greater than or equal to 2 (target 2 to 3). 3. Coumadin 7.5 mg p.o. q. day. 4. Bactrim SS one p.o. q. day. 5. Atenolol 50 mg p.o. q. day. 6. Lasix 60 mg p.o. b.i.d. 7. Zocor 10 mg p.o. q. h.s. 8. K-Dur 10 mEq p.o. q. day.
SS|single strength|SS|156|157|MEDICATIONS|5. Nystatin 10 cc swish and swallow q.i.d. 6. Protonix 40 mg p.o. daily. 7. Senna 2 tablets p.o. b.i.d. 8. Sodium bicarbonate 650 mg p.o. daily. 9. Bactrim SS 1 tablet p.o. daily. 10. Valcyte 900 mg p.o. daily. 11. Tylenol No. 3 one to two tablets p.o. q. 4-6h. p.r.n. pain. 12. Phenergan 12.5 to 25 mg p.o. q. 4-6h. p.r.n. for nausea.
SS|single strength|SS|191|192|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Klonopin 0.5 mg p.o. t.i.d. 2. Mycelex troche 10 mg p.o. q.i.d. 3. Lantis Insulin 20 units q.a.m. 4. CellCept 1 gm p.o. b.i.d. 5. Zocor 40 mg p.o. q.p.m. 6. Bactrim SS one tablet p.o. daily. 7. Prograf 1 mg b.i.d. 8. Trazodone 150 mg q.h.s. 9. Valcyte 450 mg p.o. daily. 10. Humalog Insulin Sliding Scale less than 150, 0 units.
SS|single strength|SS|239|240|DISCHARGE MEDICATIONS|On the day of discharge, the patient was afebrile with a white blood cell count of 7.5, a hemoglobin of 10.7, and a serum creatinine of 1.48 mg/dL. DISCHARGE MEDICATIONS: 1. Cellcept 1 gm p.o. b.i.d. 2. Program 2 mg p.o. b.i.d. 3. Bactrim SS 1 tab p.o. daily. 4. Valcyte 450 mg p.o. daily. 5. Levaquin 500 mg p.o. daily x 7 days. 6. Aspirin 81 mg p.o. daily. 7. Calcium with vitamin D 500 mg p.o. b.i.d.
SS|single strength|SS|122|123|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prograf 1 mg p.o. b.i.d. 2. CellCept 1 gm p.o. b.i.d. 3. Prednisone 5 mg p.o. daily. 4. Bactrim SS 1 p.o. daily. 5. Metoprolol 100 mg p.o. b.i.d. 6. Clonidine transdermal patch TTS1 q. weekly. 7. Voriconazole 300 mg p.o. b.i.d. 8. Levaquin 750 mg p.o. daily.
SS|single strength|SS|135|136|DISCHARGE MEDICATIONS|She was afebrile and her vital signs were stable. DISCHARGE MEDICATIONS: 1. Myfortic 720 mg p.o. b.i.d. 2. Prograf ON HOLD. 3. Bactrim SS 1 tablets p.o. daily. 4. Valcyte 450 mg p.o. twice weekly. 5. Mycelex troche 10 mg p.o. q.i.d. 6. Metoprolol 50 mg p.o. b.i.d.
SS|single strength|SS|185|186|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Linezolid 600 mg p.o. b.i.d. x27 doses, then discontinue. 2. Prograf 3 mg p.o. b.i.d. 3. CellCept 1 gram p.o. b.i.d. 4. Prednisone 5 mg p.o. daily. 5. Bactrim SS 1 p.o. daily. 6. Coreg 25 mg p.o. b.i.d. 7. Aspirin 81 mg p.o. daily. 8. Prilosec 20 mg p.o. b.i.d. 9. Zelnorm 6 mg p.o. b.i.d.
SS|single strength|SS|195|196|DISCHARGE MEDICATIONS|7. Metoprolol 75 mg p.o. b.i.d. 8. Flagyl 500 mg p.o. t.i.d. x 4 days, then discontinue. 9. Cellcept 750 mg p.o. b.i.d. 10. Protonix 40 mg p.o. daily. 11. Senna 2 tablets p.o. b.i.d. 12. Bactrim SS 1 tablet p.o. daily. 13. Valcyte 900 mg p.o. daily. 14. Vancomycin 750 mg IV q. 24 h. x 3 days, then discontinue. 15. Tylenol 325 to 650 mg p.o. q.4-6 h. p.r.n. pain or fever.
SS|single strength|SS|113|114|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. CellCept 500 mg p.o. q.i.d. 2. Prograf 2 mg p.o. q.a.m., 1.5 mg p.o. q.p.m. 3. Bactrim SS 1 p.o. each day. 4. Valcyte 900 mg p.o. each day. 5. Mycelex troche 10 mg p.o. t.i.d. 6. Diflucan 200 mg p.o. q. week.
SS|single strength|SS|240|241|DISCHARGE MEDICATIONS|At the time of discharge she was afebrile, with a white blood count of 7000, and an absolute lymphocyte count of 0.7. Her cyclosporine level was 86. DISCHARGE MEDICATIONS: 1. Neoral 125 mg p.o. b.i.d. 2. Cellcept 1 g p.o. b.i.d. 3. Bactrim SS 1 p.o. daily. 4. Valcyte 900 mg p.o. daily x 3 months, then discontinue. 5. Nystatin solution 10 mL p.o. swish-and-swallow q.i.d. x 3 months, then discontinue.
SS|single strength|SS|161|162|DISCHARGE MEDICATIONS|7. Flagyl 500 mg p.o. t.i.d. to complete a three-week course 8. Reglan 10 mg p.o. q.i.d. 9. Cell-Cept 1 mg p.o. b.i.d. 10. Protonix 40 mg p.o. daily 11. Bactrim SS one tab p.o. every other day 12. Valcyte 900 mg p.o. daily 13. Coumadin 2 mg p.o. q.h.s.
SS|single strength|SS|168|169|MEDICATIONS|3. Clonidine patch 0.3 once a week. 4. Lopressor 100 b.i.d. 5. Multivitamin q. day. 6. CellCept 1 g q. day. 7. Protonix 40 q. day. 8. Senna/Zocor 20 q. day. 9. Bactrim SS once a day. 10. Valcyte 900 q. day. 11. Zelnorm 6 t.i.d. PAST MEDICAL HISTORY: 1. Diabetes mellitus type 1.
SS|single strength|SS|139|140|DISCHARGE MEDICATIONS|7. CellCept 250 mg p.o. b.i.d. 8. Prograf 1 mg p.o. b.i.d. 9. Prednisone 5 mg p.o. daily. 10. Sodium bicarb 3.25 g p.o. q.i.d. 11. Bactrim SS 1 tab p.o. daily. 12. Prograf 100 mg p.o. b.i.d. 13. Tylox 1 to 2 tabs p.o. q.4-6 hours p.r.n. for pain. DISCHARGE INSTRUCTIONS: The patient is to leave the Foley catheter in for 3 weeks.
SS|single strength|SS|163|164|ADMISSION MEDICATIONS|4. Protonix 40 mg p.o. each day. 5. Calcium with vitamin tablets 500 mg t.i.d. 6. ................... 20 mg b.i.d. 7. Sodium bicarbonate 1950 mg q.i.d. 8. Bactrim SS 1 tablet p.o. each day. 9. Prednisone 10 mg po each day. SOCIAL HISTORY: The patient denied tobacco, alcohol, or other drug use.
SS|single strength|SS|173|174|DISCHARGE MEDICATIONS|5. Tequin 400 mg p.o. daily. 6. Lopressor 25 mg p.o. b.i.d. 7. Cellcept 500 mg p.o. q.i.d. 8. Zantac 75 mg p.o. daily. 9. Sodium bicarbonate 1300 mg p.o. t.i.d. 10. Bactrim SS one tablet p.o. daily. 11. Valcyte 900 mg p.o. daily. 12. Prednisone 5 mg p.o. daily. DISCHARGE INSTRUCTIONS: 1. Diet: Regular as tolerated. 2. Activity: As tolerated.
SS|single strength|SS|144|145|DISCHARGE MEDICATIONS|She was euglycemic, independent of exogenous insulin. DISCHARGE MEDICATIONS: 1. Prograf 2 mg p.o. b.i.d. 2. CellCept 1 g p.o. b.i.d. 3. Bactrim SS 1 p.o. daily. 4. Valcyte 900 mg p.o. daily. 5. Nystatin liquid 10 mL p.o. q.i.d. (swish and swallow after meals and at bedtime).
SS|single strength|SS|125|126|DISCHARGE MEDICATIONS|2. Sandimmune 125 mg p.o. q.a.m./100 mg p.o. q.p.m. 3. Imuran 100 mg p.o. daily. 4. Prednisone 7.5 mg p.o. daily. 5. Bactrim SS 1 p.o. daily. 6. Coreg 12.5 mg p.o. twice a day. 7. Hydralazine 25 mg p.o. twice a day. 8. Lasix 80 mg p.o. daily.
SS|single strength|SS|179|180|MEDICATIONS|No changes to his pre- admission outpatient insulin regimen were made. MEDICATIONS: 1. Sandimmune 100 mg p.o. b.i.d. 2. Imuran 100 mg p.o. q. day. 3. Prednisone 7.5 mg 4. Bactrim SS one tablet p.o. q. day. 5. Ciprofloxacin 250 mg p.o. b.i.d. for ten days. 6. Coreg 12.5 mg p.o. b.i.d. 7. Lipitor 20 mg p.o. q.h.s.
SS|single strength|SS|185|186|DISCHARGE MEDICATIONS|5. Atenolol 100 mg p.o. daily. 6. Calcium carbonate 1250 mg p.o. b.i.d. 7. Mycelex troche, one troche p.o. q.i.d. 8. Colace 100 mg p.o. b.i.d. 9. Protonix 40 mg p.o. daily. 10. Bactrim SS one tablet p.o. daily. 11. Tamsulosin 0.4 mg p.o. daily. 12. Valcyte 450 mg p.o. q. Wednesday and Saturday. 13. Zelnorm 6 mg p.o. b.i.d.
SS|single strength|SS|145|146|DISCHARGE MEDICATIONS|3. Synthroid 125 mcg p.o. daily. 4. Magnesium oxide 400 mg p.o. b.i.d. 5. Cellcept 1 gm p.o. b.i.d. 6. Pantoprazole 40 mg p.o. b.i.d. 7. Bactrim SS 1 p.o. daily. 8. Prograf 7 mg p.o. t.i.d. (goal level will be at least 8). 9. Valcyte 450 mg p.o. daily. 10. Percocet 1-2 p.o. q.6h. p.r.n.
SS|single strength|SS|139|140|DISCHARGE MEDICATIONS|Immunosuppression was discontinued and the patient was discharged to home on Lantus and Humalog insulin. DISCHARGE MEDICATIONS: 1. Bactrim SS 1 p.o. each day x3 months, then discontinue. 2. Valcyte 450 mg p.o. each day x3 months, then discontinue. 3. Mycelex troche 10 mg p.o. q.i.d. x3 months, then discontinue.
SS|single strength|SS|175|176|DISCHARGE MEDICATIONS|She was euglycemic independent of insulin therapy. DISCHARGE MEDICATIONS: 1. Prograf 2 mg p.o. b.i.d. 2. Cellcept 1 gram p.o. b.i.d. 3. Prednisone 5 mg p.o. daily. 4. Bactrim SS one p.o. daily. 5. Valcyte 450 mg p.o. daily. 6. Mycelex troch 10 mg p.o. q.i.d. 7. Aspirin 81 mg p.o. daily. 8. Plavix 75 mg p.o. daily.
SS|single strength|SS|152|153|DISCHARGE MEDICATIONS|7. Magnesium oxide 400 mg p.o. b.i.d. 8. Cellcept 1 gm p.o. b.i.d. 9. Protonix 40 mg p.o. daily. 10. Sodium bicarbonate 1500 mg p.o. t.i.d. 11. Bactrim SS 1 tab p.o. daily. 12. Prograf 1.5 mg p.o. b.i.d. 13. Valcyte 450 mg p.o. daily. 14. Prednisone taper per coordinator.
SS|single strength|SS|148|149|DISCHARGE MEDICATIONS|8. Insulin Lantus 10 units subcu q.h.s. 9. Lopressor 50 mg p.o. b.i.d. 10. CellCept 750 mg p.o. q.i.d. 11. Zoloft 150 mg p.o. each day. 12. Bactrim SS 1 tablet p.o. each day. 13. Valcyte 900 mg p.o. each day. 14. NovoLog insulin per sliding scale. 15. Percocet 1 to 2 tablets p.o. q.4-6 h. p.r.n. pain.
SS|single strength|SS|141|142|DISCHARGE MEDICATIONS|2. Lantus 75 units subcutaneous q.h.s. 3. Lopressor 50 mg p.o. b.i.d. 4. CellCept 1 gm p.o. b.i.d. 5. Protonix 40 mg p.o. q. day. 6. Bactrim SS one tablet p.o. q. day. 7. Valcyte 450 mg p.o. q. day. 8. Mycelex troche 10 mg p.o. q.i.d. 9. Campath 30 mg IV x 1 on _%#MMDD2004#%_. 10. Solu-Medrol 100 mg IV x 1 on _%#MMDD2004#%_.
SS|single strength|SS|151|152|DISCHARGE MEDICATIONS|He was euglycemic, independent of exogenous insulin. His serum creatinine was 1.2 mg/dL. DISCHARGE MEDICATIONS: 1. CellCept 1 g p.o. b.i.d. 2. Bactrim SS 1 p.o. every day. 3. Valcyte 450 mg p.o. b.i.d. 4. Mycelex troche one p.o. q.i.d. 5. Diflucan 200 mg p.o. every day. 6. Tylox 1 to 2 p.o. q4-6h p.r.n. pain.
SS|single strength|SS|168|169|DISCHARGE MEDICATIONS|2. Calcitriol 0.5 mcg p.o. 3 x week. 3. Concerta 54 mg p.o. daily. 4. Genotropin 1 mg subq daily. 5. Gengraf 75 mg p.o. b.i.d. 6. Melatonin 9 mg p.o. daily. 7. Bactrim SS 2.5 mL daily. 8. Prednisone 20 mg p.o. daily for 2 days, then 15 mg p.o. daily for 2 days, then 10 mg p.o. daily for 2 days, then 5 mg p.o. daily for 2 days, then 4 mg p.o. daily thereafter.
SS|single strength|SS|129|130|DISCHARGE MEDICATIONS|3. Valcyte 450 mg p.o. daily x3 months (begin in 14 days). 4. Prograf 3 mg p.o. b.i.d. 5. Myfortic 720 mg p.o. b.i.d. 6. Bactrim SS 1 p.o. daily. 7. Aspirin 325 mg p.o. daily. 8. Lipitor 10 mg p.o. daily. 9. Lasix 20 mg p.o. daily p.r.n., ankle swelling.
SS|single strength|SS|143|144|DISCHARGE MEDICATIONS|6. Magnesium oxide 400 mg p.o. b.i.d. 7. CellCept 1 g p.o. b.i.d. 8. Protonix 40 mg p.o. each day. 9. Senokot 1 tablet p.o. b.i.d. 10. Bactrim SS 1 tablet p.o. each day. 11. Valcyte 900 mg p.o. each day. 12. Calan Extended Release 240 mg p.o. each day.
SS|single strength|SS|156|157|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prograf 1 mg p.o. b.i.d. 2. Myfortic 720 mg p.o. b.i.d. 3. Vancomycin 1.2 gm IV q. 24 hours X3 days, then discontinue. 4. Bactrim SS 1 daily. 5. Aspirin 325 mg p.o. daily. 6. Colace 100 mg b.i.d. 7. Protonix 20 mg p.o. b.i.d. 8. Reglan 5 mg p.o. b.i.d. 9. Lasix 20 mg p.o. daily.
SS|single strength|SS|182|183|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prograf 0.5 mg p.o. b.i.d., which the patient will restart on a.m. _%#MMDD2004#%_. 2. CellCept 500 mg p.o. b.i.d. 3. Prednisone 5 mg p.o. daily. 4. Bactrim SS one tablet p.o. q. Monday and Thursday. 5. Valcyte 450 mg p.o. q. Monday and Thursday. 6. Mycelex troche 10 mg p.o. q.i.d. 7. Oral nystatin swish and swallow 10 cc p.o. q.i.d.
SS|single strength|SS|127|128|DISCHARGE MEDICATIONS|5. Multivitamin one tablet p.o. q. day. 6. Mycostatin 1 mL swish and swallow q.i.d. 7. Ranitidine 15 mg p.o. b.i.d. 8. Bactrim SS 32 mg p.o. q. day. 9. Valcyte 80 mg p.o. q. day. 10. Vancomycin 100 mg IV q.12h. 11. Tylenol 120 mg p.o. q.6h p.r.n. for pain. 12. Codeine phosphate 4 mg p.o. q.4h p.r.n. for breakthrough pain.
SS|single strength|SS|139|140|DISCHARGE MEDICATIONS|2. Cozaar 50 mg p.o. q. h.s. 3. Metoprolol XL 25 mg p.o. q. day. 4. Prevacid 30 mg p.o. q. day. 5. Prednisone 5 mg p.o. q. day. 6. Bactrim SS 1 tablet p.o. q. day. 7. Azithromycin 250 mg p.o. 3 times weekly. 8. Triazolam 62.5 mcg p.o. q. h.s. 9. Magnesium oxide 800 mg p.o. q. day.
SS|single strength|SS|152|153|DISCHARGE MEDICATIONS|3. Tylox one to two tablets p.o. q.4-6 h p.r.n. pain. 4. Colace 100 mg p.o. b.i.d. 5. Rapamune 2 mg p.o. q. day. 6. Prograf 1 mg p.o. b.i.d. 7. Bactrim SS one tablet p.o. q. day. 8. Valcyte 900 mg p.o. q. day. 9. Lipitor 10 mg p.o. q. day. 10. Humulin NPH 20 units subcu in the morning and 10 units subcu in the evening.
SS|single strength|SS|160|161|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. daily. 2. Mycelex one troche p.o. q.i.d. 3. Cellcept 1 gm p.o. b.i.d. 4. Pantoprazole 40 mg p.o. daily. 5. Bactrim SS one p.o. daily. 6. Prograf 3.5 mg p.o. b.i.d. 7. Ursodiol 300 mg p.o. t.i.d. 8. Valcyte 450 mg p.o. daily. 9. Tylox one to two p.o. q. 6h. 10. Colace 100 mg p.o. b.i.d.
SS|single strength|SS|170|171|DISCHARGE MEDICATIONS|3. Cozaar 50 mg p.o. b.i.d. 4. Lopressor 50 mg p.o. b.i.d. 5. Cellcept 1 gm p.o. b.i.d. 6. Prevacid 30 mg p.o. daily. 7. Sodium bicarbonate 350 mg p.o. daily. 8. Bactrim SS 1 tab p.o. daily. FOLLOW-UP: The patient was instructed to follow up with Dr. _%#NAME#%_ in Transplant Clinic on Tuesday, _%#MMDD2005#%_.
SS|single strength|SS|164|165|DISCHARGE MEDICATIONS|6. Ferrous sulfate 325 t.i.d. 7. Protonix 40 mg p.o. daily. 8. Rapamune 1.5 mg p.o. daily. 9. Prograf 1.5 mg p.o. b.i.d. 10. Valcyte 900 mg p.o. daily. 11. Bactrim SS one tablet p.o. daily. 12. Senna one tablet p.o. b.i.d. 13. Aranesp 60 mcg subcu Monday, Wednesday, and Friday for 9 days.
SS|single strength|SS|171|172|DISCHARGE MEDICATIONS|6. Colace 100 mg p.o. b.i.d. 7. Cellcept 1 gm p.o. b.i.d. 8. Protonix 40 mg p.o. daily. 9. Prednisone 2.5 mg p.o. daily. 10. Sodium bicarb 1300 me p.o. b.i.d. 11. Bactrim SS 1 tab p.o. daily. 12. Valcyte 450 mg p.o. daily. 13. Nitrofurantoin 100 mg p.o. q.6 h. x 10 day course.
SS|single strength|SS|180|181|DISCHARGE MEDICATIONS|8. Linezolid 600 mg p.o. b.i.d. for a month. 9. Toprol XL 100 mg p.o. q.a.m. 10. Protonix 40 mg p.o. daily. 11. Prednisone 5 mg p.o. daily. 12. Zocor 40 mg p.o. q.p.m. 13. Bactrim SS 1 tablet p.o. daily. 14. ______________ 450 mg p.o. q.4-8h. 15. Tylenol 650 mg p.o. q.4-6h. p.r.n. pain. FOLLOW-UP: The patient will have a follow-up appointment on Tuesday afternoon with the Transplant Clinic.
SS|single strength|SS|155|156|DISCHARGE MEDICATIONS|3. Neoral 250 mg p.o. b.i.d. (held for high cyclosporin levels) 4. Colace 100 mg p.o. b.i.d. (hold if diarrhea occurs) 5. Zocor 5 mg p.o. daily 6. Bactrim SS 1 tab p.o. daily 7. Valcyte 900 mg p.o. daily 8. Tylox 1 to 2 tabs p.o. q.6 h p.r.n. pain DISPOSITON: The patient is discharged to home with his wife.
SS|single strength|SS|134|135|DISCHARGE MEDICATIONS|She was voiding and stooling spontaneously. DISCHARGE MEDICATIONS: 1. Rapamune 3 mg p.o. daily 2. Prograf 1 mg p.o. b.i.d. 3. Bactrim SS 1 tab p.o. daily 4. Valcyte 900 mg p.o. daily 5. Atenolol 50 mg p.o. daily 6. Calcium carbonate 1250 mg p.o. b.i.d. 7. Mycelex troche, one troche p.o. q.i.d.
SS|single strength|SS|146|147|DISCHARGE MEDICATIONS|7. CellCept 1000 mg by mouth twice daily. 8. Protonix 40 mg by mouth daily. 9. Senna S 2 by mouth daily, to be held for loose stools. 10. Bactrim SS 1 by mouth daily. 11. Actigall 300 mg by mouth three times per day. 12. Valcyte 450 mg by mouth daily. 13. Prograf 2 mg by mouth twice daily to be adjusted to keep level between 10-12.
SS|single strength|SS|127|128|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prograf 1.5 mg p.o. b.i.d. 2. CellCept 500 mg p.o. q.i.d. 3. Prednisone 5 mg p.o. q. day. 4. Bactrim SS one p.o. q. day. 5. Cipro 500 mg p.o. b.i.d. x10 days (20 doses), then discontinue. 6. Protonix 40 mg p.o. q. day. 7. Senna one to two p.o. b.i.d. p.r.n. constipation.
SS|single strength|SS|167|168|DISCHARGE MEDICATIONS|On the day of discharge, blood glucoses ranged between 110 and 125 mg/dL. DISCHARGE MEDICATIONS: 1. Prograf 2 mg p.o. b.i.d. 2. Cellcept 500 mg p.o. q.i.d. 3. Bactrim SS one p.o. daily. 4. Valcyte 450 mg p.o. daily. 5. Nystatin solution 10 mL p.o. (swish and swallow) q.i.d. (p.c. and h.s.).
SS|single strength|SS|164|165|DISCHARGE MEDICATIONS|3. Coumadin 5 mg p.o. every day. 4. Prograf 1 mg p.o. q.a.m. 5. Prograf 0.5 mg p.o. q.p.m. 6. CellCept 500 mg p.o. twice a day. 7. Valcyte 450 mg q.a.m. 8. Bactrim SS 1 tab p.o. q.a.m. 9. Protonix 40 mg p.o. twice a day. 10. Multivitamin 1 tablet p.o. every day. 11. Calcium 500 mg p.o. q.a.m. 12. Senokot 2 tabs p.o. q.h.s.
SS|single strength|SS|216|217|DISCHARGE MEDICATIONS|A Psychiatry consultation was obtained and at their recommendation her Zoloft dose was increased and Seroquel was started. DISCHARGE MEDICATIONS: 1. Prograf 2 mg p.o. b.i.d. 2. CellCept 1 gram p.o. b.i.d. 3. Bactrim SS 1 p.o. three times weekly (Monday, Wednesday, and Friday). 4. Valcyte 900 mg p.o. daily. 5. Mycelex troche 10 mg p.o. q.i.d.
SS|single strength|SS|122|123|DISCHARGE MEDICATIONS|His urinary amylase level remained low at 100 units/ hour. DISCHARGE MEDICATIONS: 1. CellCept 1 gm p.o. b.i.d. 2. Bactrim SS 1 p.o. daily. 3. Valcyte 450 mg p.o. twice weekly. 4. Mycelex troche 10 mg p.o. q.i.d. 5. Lipitor 10 mg p.o. daily. 6. Aspirin 162 mg p.o. daily.
SS|single strength|SS|144|145|DISCHARGE MEDICATIONS|3. Calcitrol 0.25 mcg p.o. daily. 4. Mycelex troche 10 mg p.o. t.i.d. 5. Multivitamin 1 tab p.o. daily. 6. Cellcept 1 gm p.o. b.i.d. 7. Bactrim SS 1 tab p.o. daily. 8. Vitamin C 500 mg p.o. daily. 9. Prograf 6 mg p.o. b.i.d. 10.Dilaudid taper 6 mg p.o. q.i.d., taper 1 tablet every 3 days; then 1 tablet t.i.d. for 3 days; then 1 tablet b.i.d. for 3 days.
SS|single strength|SS|103|104|CURRENT MEDICATIONS|5. Itraconazole 100 mg p.o. each day 6. Ciprofloxacin 500 mg q.2 h. 7. Flagyl 500 mg q.6 h. 8. Bactrim SS 1x each day 9. Nystatin powder for pressure sores b.i.d. 10. Detrol 1 mg b.i.d. 11. Azithromycin 1200 mg q. week. 12. Factor VIII bolus 3000 units each day.
SS|single strength|SS|162|163|ASSESSMENT AND PLAN|Creatinine 1.53. ASSESSMENT AND PLAN: A 59-year-old gentleman status post HeartMate XVE Left Ventricular Assist Device placed following explantation of temporary SS device support. The patient has remained hemodynamically stable over the last 24-48 hours with excellent LVAD flows. His CVP has discontinued and we will start him on a Bumex drip.
SS|single strength|SS|132|133|CURRENT MEDICATIONS|CURRENT MEDICATIONS: 1. Rapamune 0.25 mg q.d. 2. Prednisone 5 mg q.a.m. and 2.5 mg q.p.m. 3. Cellcept 250 mg p.o. b.i.d. 4. Bactrim SS 1 tablet qMonday and Thursday. 5. Itraconazole 10 cc b.i.d. 6. Aciphex 20 mg q.d. 7. Hexavitamin. 8. Os-Cal with vitamin D. 9. Azithromycin 500 mg q.d.
SS|single strength|SS|171|172|MEDICATIONS|PAST MEDICAL HISTORY: Acute myeloid leukemia as described above. Otherwise healthy. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Dulcolax. 2. Lactulose. 3. Bactrim SS 1 tab po bid q Mon, Tues. 4. Murelax. 5. Colace. 6. Prevacid. 7. Senna. 8. Zofran. SOCIAL HISTORY: The patient's home town is _%#CITY#%_, South Dakota where he lives with his parents and siblings.
SS|single strength|SS|175|176|MEDICATIONS|3. Levaquin 125 by mouth daily. 4. Reglan 2.5 mg by mouth daily. 5. MiraLax 17 g by mouth daily. 6. Nystatin 1 mL by mouth daily. 7. Protonix 15 mg by mouth daily. 8. Bactrim SS 3 mL by mouth daily. 9. Valcyte 75 mg by mouth daily. PHYSICAL EXAMINATION: GENERAL: Atraumatic normocephalic, does not appear to be in any acute distress.
SS|single strength|SS|172|173|SCHEDULED MEDICATIONS|6. Calcium carbonate 1 tab p.o. b.i.d. 7: Neurontin 100 mg t.i.d., 8. NovoLog insulin sliding scale. 9. Lantus. 10. Nifedipine XL 90 mg extended release daily. 11. Bactrim SS daily. 12. Valganciclovir 450 mg q.48h. 13. CellCept 1 gram p.o. b.i.d. 14. Lopressor 100 mg b.i.d. 15. Sodium bicarbonate 1300 mg b.i.d. 16. Prograf 1.5 mg b.i.d.
SS|single strength|SS|190|191|IMPRESSION|Lower extremities show no pedal edema. Extremities are warm. LABORATORY DATA: White count 8.9, hemoglobin 10, platelets 65. Creatinine 1.6. IMPRESSION: Status post biventricular Levatronics SS device insertion. The patient is stable. I discussed the risks and benefits of bridging the patient to a HeartMate left ventricular assist device with the family.
SS|single strength|SS.|141|143|ADMISSION MEDICATIONS|16. Lactose intolerant. ADMISSION MEDICATIONS: 1. Docusate sodium. 2. Acyclovir. 3. Aspirin EC. 4. Effexor XR. 5. Lactase enzyme. 6. Bactrim SS. 7. Benadryl. 8. Prevacid. 9. Dyazide. 10. Calcium carbonate. 11. Trazodone. 12. Fish oil. ALLERGIES: No known drug allergies. SOCIAL HISTORY/FAMILY HISTORY: Reviewed as documented per FCIS and per chart.
SS|single strength|SS.|129|131|CURRENT MEDICATIONS|7. Colace. 8. Lasix. 9. Reglan. 10. Nystatin. 11. Oxycodone ER. 12. Protonix. 13. Zosyn. 14. Prednisone. 15. Zoloft. 16. Bactrim SS. 17. Vancomycin. SOCIAL HISTORY: The patient quit smoking tobacco in 1996 and carries a 20-pack year history.
SS|single strength|SS|123|124|ASSESSMENT|No peripheral edema. Brisk capillary refill. Skin: Free from rash. Neurologic: Grossly nonfocal. ASSESSMENT: 1. Hemoglobin SS disease. 2. Acute pneumonia. 3. Moderate persistent asthma with less than optimal control. 4. At this time he is not showing features of acute chest syndrome, but he is certainly at risk for this.
SS|single strength|SS|134|135|DISCHARGE MEDICATIONS|9. Lactobacillus 1 cap p.o. b.i.d. after antibiotics. 10. Nystatin 4 to 6 mL p.o. q.i.d. 11. Prednisone 5 mg p.o. q. day. 12. Bactrim SS 1 tablet twice a week. 13. Prevacid 30 mg p.o. q. day.
SS|single strength|SS|246|247|DISCHARGE MEDICATIONS|18. Protonix 40 mg G-tube b.i.d. 19. Prednisolone 50 mg G-tube b.i.d. with next tapered dose on _%#MMDD2005#%_ with ongoing taper per attached schedule. 20. Simethicone 80 mg G-tube b.i.d. with dose prior to initiation of tube feeds. 21. Bactrim SS 1 tablet G-tube daily. 22. Tacrolimus 5 mg G-tube b.i.d. with dose adjustment p.r.n. with levels per Transplant coordinator.
SS|single strength|SS|147|148|TRANSFER MEDICATIONS|5. Prednisone 5 mg p.o. q.d. 6. Valcyte 900 mg p.o. q.d. x 2 months, then this will be discontinued: This is for CMV viral prophylaxis. 7. Bactrim SS 1 p.o. q.d.: This is long term for pneumocystic prophylaxis. 8. Chlortrimazole (?) troche 10 mg p.o. q.i.d. a.c. and h.s.: This is for thrush and candida esophagitis prophylaxis.
SS|single strength|SS|141|142|DISCHARGE MEDICATION|3. Tacrolimus 6 mg p.o. q.a.m. 4. Tacrolimus 5 mg p.o. q. p.m. 5. Mycophenolate 500 mg p.o. q.i.d. 6. Prednisone 5 mg p.o. daily. 7. Bactrim SS 1 tablet p.o. Mondays and Thursdays. 8. Dulcolax 5 to 10 mg p.o. q.h.s. 9. Protonix 40 mg p.o. daily. 10. Reglan 10 mg p.o. t.i.d. AC. 11. Imdur 60 mg daily.
SS|single strength|SS,|164|166|DISPOSITION MEDICATIONS|6. Methiodal 20 mg p.o. twice a day. 7. Trazodone 25 mg p.o. q.h.s. 8. Pen-Vee K 250 mg p.o. every day to begin after she is finished with the Rocephin. 9. Bactrim SS, 1 tab p.o. q. Monday and Wednesday. 10. Imodium 2 mg p.o. three times a day p.r.n. for diarrhea. 11. Allegra 30 mg p.o. every day. 12. Melatonin 3 mg p.o. q.h.s.
SS|single strength|SS|125|126|DISCHARGE MEDICATIONS|10. Seroquel 25-50 mg p.o. q.h.s. 11. Renal multivitamin one tablet p.o. daily. 12. Rifaximin 200 mg p.o. t.i.d. 13. Bactrim SS one tablet p.o. daily. 14. Prograf 1 mg p.o. b.i.d. 15. Valcyte 450 mg p.o. q. 48 h. 16. Zelnorm 18 mg p.o. t.i.d. 17. Tylenol 325 mg p.o. q. 4 h. one to two tablets p.r.n. pain.
SS|single strength|SS|168|169|TRANSFERRING MEDICATIONS|6. Methylphenidate 5 mg p.o. t.i.d. 7. Cellcept 1 gm p.o. b.i.d. 8. Protonix 40 mg p.o. b.i.d. 9. Prednisone 7.5 mg p.o. daily. 10. Zoloft 25 mg p.o. daily 11. Bactrim SS one tablet p.o. twice weekly 12. Prograf 2 mg p.o. b.i.d. 13. Actigall 300 mg p.o. b.i.d. 14. Valcyte 450 mg p.o. daily 15. Miconazole cream 1% topically p.r.n.
SS|single strength|SS|144|145|PROBLEM #2|ID consult was obtained, and approval was given for IV vancomycin with a suggested course through _%#MMDD2006#%_, then changing over to Bactrim SS b.i.d. for a 10-day course. The patient continues to have a Foley catheter in place due to her poor level of transfers and amount of pain that occurs with transfers to commode.
SS|single strength|SS|119|120|DISCHARGE MEDICATIONS|5. Bactroban ointment 2% to both nares b.i.d. 6. Protonix 40 mg p.o. daily. 7. Senokot-S 2 tabs p.o. daily. 8. Bactrim SS 1 p.o. b.i.d. to start _%#MMDD2006#%_ through _%#MMDD2006#%_. 9. Vancomycin 700 mg IV q.24 h. Last dose to be given on _%#MMDD2006#%_. 10. Tylenol 325 to 650 mg p.o. q.6-8 h. p.r.n.
SS|single strength|SS|142|143|DISCHARGE MEDICATIONS|However, no pathology was seen during colonoscopy done three days later. DISCHARGE MEDICATIONS: 1. Cyclosporine 200 mg p.o. b.i.d. 2. Bactrim SS 1 tab p.o. b.i.d. qMonday and Tuesday. 3. Voriconazole 150 mg p.o. b.i.d. 4. Ganciclovir 180 mg IV q.d. Monday through Friday until _%#MMDD2003#%_.
SS|single strength|SS|159|160|DISCHARGE MEDICATIONS|9. Prednisone 5 mg p.o. daily. 10. MiraLax 17 g p.o. b.i.d. as needed for constipati on. 11. Oxycodone 5 mg p.o. every 4 hours as needed for pain. 12. Bactrim SS one tablet p.o. daily. 13. Fluconazole 100 mg p.o. daily. 14. Levaquin 500 mg IV daily through _%#MMDD2007#%_. 15. Lantus 3 units subcu at bedtime.
SS|single strength|SS|164|165|MEDICATION|9. Combivent 4 puffs q.i.d. 10. Lopressor 100 mg p.o. b.i.d. 11. CellCept 250 mg p.o. b.i.d. 12. Protonix 40 mg p.o. q.d. 13. Prednisone 5 mg p.o. q.d. 14. Bactrim SS 1 tablet p.o. q.d. 15. Prograf 1 mg p.o. b.i.d. 16. Valcyte 450 mg p.o. x 2 a week. 17. Vitamin E 400 U p.o. q.a.m. 18. Percocet 1 or 2 tablets p.o. q. 4 to 6 h. p.r.n. for pain.
SS|single strength|SS|122|123|TRANSFERRING MEDICATIONS|15. Percocet 5/325 mg 1-2 tablet by mouth every 4 hours as needed for pain. 16. Ecotrin 81 mg by mouth daily. 17. Bactrim SS 1 tablet by mouth daily. 18. Valcyte 450 mg by mouth daily. 19. Diflucan 400 mg by mouth daily x7 days, to finish on the _%#MMDD2006#%_.
SS|single strength|SS|154|155|DISCHARGE MEDICATIONS|May be restarted as renal function returns. 9. Oxybutynin 5 mg p.o. b.i.d. 10. Amiodarone 100 mg p.o. b.i.d. 11. Metoprolol 25 mg p.o. b.i.d. 12. Bactrim SS one tab p.o. q.h.s. 13. Augmentin 250 mg p.o. q.i.d. 14. Prednisone 7.5 mg p.o. daily. 15. Cyclosporin 75 mg p.o. b.i.d.
SS|single strength|SS|168|169|DISCHARGE MEDICATIONS|18. Prevacid 30 mg p.o. daily. 19. Pen-Vee K 250 mg p.o. daily. 20. Prednisone 5 mg p.o. daily. 21. Prograf 1.5 mg p.o. b.i.d. 22. Zelnorm 6 mg p.o. b.i.d. 23. Bactrim SS 1 tab p.o. daily. DISPOSITION AT DISCHARGE: The patient, _%#NAME#%_ _%#NAME#%_, was discharged from the University of Minnesota Medical Center, Fairview, in stable condition.
SS|sickle cell genotype SS|SS|148|149|PAST MEDICAL HISTORY|ADMISSION MEDICATIONS: 1. Folic acid 0.5 mg p.o. daily. 2. Penicillin G solution 125 mg p.o. b.i.d. PAST MEDICAL HISTORY: 1. Sickle cell hemoglobin SS (disease). 2. No prior hospitalizations, no surgeries, and no injuries. ALLERGIES: No known drug allergies. FAMILY HISTORY: Negative for allergies, birth defects, cancer, leukemia, lymphoma, cardiac disease, diabetes, mental illness, chemical dependency, neurologic disease, sudden or early infant death, thyroid disease, or tuberculosis.
SS|single strength|SS|193|194|PROBLEM #2|The patient was continued on her hydroxyurea and folic acid during her hospital stay. PROBLEM #2: Left shoulder pain. Due to localization of the left shoulder pain and the patient's hemoglobin SS status osteomyelitis had to be ruled out. A bone scan was obtained. There is a focal area of decreased uptake distal to the metaphysis of the left humeral bone.
SS|single strength|SS|200|201|TRANSFER MEDICATIONS|FAMILY HISTORY: Significant for diabetes. TRANSFER MEDICATIONS: 1. CellCept 1000 mg p.o. b.i.d. 2. Prograf 3 mg p.o. b.i.d. 3 Mycelex troche 10 mg p.o. t.i.d. 4. Valcyte 450 mg p.o. daily. 5. Bactrim SS 1 tablet p.o. daily. 6. Calcitriol 0.25 mcg p.o. daily. 7. Calcium with vitamin D 1250 mg p.o. daily. 8. Clobetazole topical 0.05% transdermal to dermatosis 2-3 times daily.
SS|single strength|SS|155|156|TRANSFERRING MEDICATIONS|8. Rapamune 1.5 mg p.o. q. daily, and this dose has been increased today. 9. Protonix 40 mg p.o. q. daily. 10. Prednisone 10 mg p.o. q. daily. 11. Bactrim SS one p.o. q. Monday and Thursday. 12. Valcyte 450 mg p.o. q. daily. 13. Photophoresis two consecutive days per month, with the last treatments being _%#MMDD#%_ and _%#MMDD2003#%_.
SS|single strength|SS|166|167|DISCHARGE MEDICATIONS|A repeat ultrasound is planned. 2. Voriconazole 200 mg q. am. and q. p.m. for prophylaxis of fungal infections. 3. Nasonex one spray both nostrils q. a.m. 4. Bactrim SS 80 mg Mondays and Thursdays. 5. Prednisone 7.5 mg q. a.m. 6. Valcyte 450 mg q. a.m. 7. Protonix 40 mg q. a.m. daily. 8. Creon enzyme 3 tablets 3 times daily with meals.
SS|single strength|SS|168|169|MEDICATIONS|3. Sandimmune 150 mg p.o. b.i.d. 4. Lantus 70 units subcu b.i.d. 5. Lisinopril 20 mg p.o. daily. 6. Cell Cept 1 gm p.o. b.i.d. 7. Protonix 40 mg p.o. daily. 8. Bactrim SS one tablet p.o. daily. 9. Valcyte 900 mg p.o. daily. 10. Coumadin 5 mg p.o. daily. 11. Tylox one to two p.o. q.4-6 h. p.r.n. for pain.
SS|single strength|SS|78|79|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 19-year-old male with sickle cell SS disease with history significant for multiple hospitalizations, transfusions and exchange transfusions. He was in his normal state of health until the day prior to admission.
SS|single strength|SS|229|230|DISCHARGE MEDICATIONS|The patient's serum creatinine was 1.35 mg/dL. INR was 1.89. The patient's last tacrolimus level was 4.6. DISCHARGE MEDICATIONS: 1. Prograf 1 mg p.o. q.a.m. 2. Prograf 0.5 mg p.o. q.p.m. 3. CellCept 250 mg p.o. b.i.d. 4. Bactrim SS one p.o. daily. 5. Valcyte 450 mg p.o. daily. 6. Mycelex troche 10 mg p.o. t.i.d. 7. Coumadin 3 mg p.o. q. day, Monday, Wednesday, Friday, Sunday.
SS|single strength|SS|156|157|MEDICATIONS ON ADMISSION|5. Cozaar 100 mg q. daily. 6. Megestrol acetate 800 mg q. daily. 7. Reglan 10 mg q.i.d. 8. Lopressor 100 mg b.i.d. 9. Prednisone 5 mg q. daily. 10. Bactrim SS 1 tablet twice weekly. 11. Prograf 1 mg p.o. b.i.d. 12. Valcyte 400 mg q. daily. 13. Fentanyl patch 100 mcg 72-hours. 14. Fentanyl 25 mcg IV p.r.n. q.1h.
SS|single strength|SS|129|130|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: The patient was discharged on: 1. Colace 100 mg p.o. b.i.d. 2. MiraLax 17 g p.o. b.i.d. p.r.n. 3. Bactrim SS 1 tablet p.o. b.i.d. every Thursday and Friday. 4. Fluconazole 100 mg p.o. daily. 5. G-CSF 150 mcg subcutaneously daily.
SS|single strength|SS|150|151|MEDICATIONS|MEDICATIONS: 1. Pancrease vitamin 6 with meals and 3 with snacks. 2. Prilosec 20 mg p.o. each day. 3. Calcium carbonate 600 mg p.o. b.i.d. 4. Bactrim SS 1 tablet p.o. Mon, Thurs. 5. Nasonex 2 sprays b.i.d. 6. Darbopoietin 20 mcg q. week. 7. Ambien 10 mg p.o. q.h.s. p.r.n.
SS|single strength|SS|121|122|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Prograf 4 mg p.o. b.i.d. 2. Imdur 300 mg p.o. daily. 3. Prednisone 5 mg p.o. daily. 4. Bactrim SS 1 tab p.o. daily. 5. Valcyte 450 mg p.o. on Mondays and Thursdays. 6. Mycelex troche 10 mg p.o. t.i.d. after meals. 7. Norvasc 10 mg p.o. daily.
SS|single strength|SS|126|127|DISCHARGE MEDICATIONS|10. Zantac 40 mg p.o. b.i.d. 11. Flovent MDI 44 mcg 1 puff b. i.d. 12. Multivitamin with iron, 1 tablet p.o. q.d. 13. Bactrim SS 1 tab p.o. q.Saturday and Sunday. 14. K-Dur 5 mEq p.o. q.d. 15. Depakote 375 mg p.o. q.a.m. until _%#MMDD2003#%_; Depakote 250 mg p.o. q.h.s. until _%#MMDD2003#%_.
SS|single strength|SS|86|87|TRANSFER MEDICATIONS|ALLERGIES: 1. Codeine. 2. Erythromycin. 3. Prinivil. TRANSFER MEDICATIONS: 1. Bactrim SS 1 tablet p.o. q. Mondays and Thursdays. 2. Reglan 10 mg p.o. t.i.d. 3. Multivitamin 1 tablet p.o. daily. 4. Guaifenesin 15 mL to 30 mL p.o. q.6 hours.
SS|single strength|SS|188|189|TRANSFER MEDICATIONS|5. NovoLog as per sliding scale. 6. Calcium with vitamin D 1250 mg p.o. t.i.d. 7. Magnesium oxide 800 mg p.o. b.i.d. 8. Linezolid 600 mg p.o. b.i.d. (stop date _%#MMDD2007#%_). 9. Bactrim SS 1 tablet daily. 10. Valcyte 400 mg p.o. daily 11. Tylenol p.r.n. 1-2 tablets p.o. q.4 h. p.r.n. 12. Oxycodone 5-10 mg p.o. q.4 h. p.r.n.
SS|single strength|SS|142|143|DISCHARGE MEDICATIONS|7. Ganciclovir 110 mg IV push q. day times 13 more doses. 8. Torsemide 10 0 mg p.o. q. day. The patient should adjust per weights. 9. Bactrim SS one tablet p.o. q.a.m. DISCHARGE INSTRUCTIONS: 1. The patient is instructed to follow a diabetic diet.
SS|single strength|SS|259|260|DISCHARGE INSTRUCTIONS|1.10. Lansoprazole 30 mg p.o. q.d. 1.11. Magnesium oxide 800 mg p.o. q.h.s. 400 mg p.o. q.a.m. 1.12. Metoprolol 25 mg p.o. b.i.d. 1.13. Multivitamin 1 tablet p.o. q.d. 1.14. Cellcept 500 mg 2 tablets p.o. b.i.d. 1.15. Prednisone 10 mg p.o. q.d. 1.16. Bactrim SS 1 tablet p.o. twice per week. 1.17. Ipratropium/albuterol 4 puffs inhaled q.4h. 1.18. Home oxygen. 1.19. Potassium chloride 20 mEq packet for use as replacement as needed with Abelcet.
SS|single strength|SS.|144|146|MEDICATIONS ON ADMISSION|ALLERGIES: Codeine, penicillin, and morphine. All give her GI upset. MEDICATIONS ON ADMISSION: 1. B6. 2. Cyclosporin. 3. Prednisone. 4. Bactrim SS. 5. Prevacid. 6. B12. 7. Lasix. 8. Os-Cal. 9. Iron. 10. Cellcept. 11. Folic acid. 12. Fosamax. 13. Potassium 14. Cardura. 15. Evista. 16. Diltiazem. 17. Amitriptyline.
SS|single strength|SS|136|137|ADMISSION MEDICATIONS|11. Ferrous sulfate 325 t.i.d. 12. Folate 1 g q day 13. Multivitamin one q day 14. Pravachol 40 q day 15. Protonix 40 q day 16. Bactrim SS q day PHYSICAL EXAMINATION: Initial physical exam revealed blood pressure 196/57; pulse 81; respirations 18; temperature 98.4. There was jugular venous distention to 4 cm above the sternal angle at 45 degrees.
SS|UNSURED SENSE|(SS|241|243|ACADEMIC ACHIEVEMENT|ACADEMIC ACHIEVEMENT: _%#NAME#%_'s academic achievement skills were briefly screened as part of this assessment in the hospital using selected subtests from the WIAT-II. She obtained average scores on tasks assessing her single-word reading (SS = 97, 42nd percentile) and phonetic decoding skills (SS = 93, 32nd percentile) in comparison to age mates. Scaled scores between 90 and 109 are considered to be within the broadly average range.
SS|UNSURED SENSE|(SS|171|173|RECOMMENDATIONS|_%#NAME#%_'s broad independent score was in the borderline range (SS = 74). He obtained the highest score in a subscale assessing his communication and social interaction (SS = 90), and the lowest score in an area of his personal living skills (SS = 54). _%#NAME#%_'s executive functioning skills were assessed using a parent-rating scale (BRIEF), as well as the Wisconsin Card-Sorting Test (WCST).
SS|UNSURED SENSE|(SS|208|210|TEST RESULTS|Academic achievement skills. _%#NAME#%_'s academic achievement skills were assessed using selected subtests from the WIAT - II. She obtained a low-average score on a measure of her single word reading skills (SS equals 84, 14th percentile) consistent with a mid 6th grade level. She obtained a borderline score on a task assessing her phonetic decoding skills (SS equals 79, 8th percentile) consistent with an early 3rd grade level.
SS|UNSURED SENSE|(SS|155|157|ACADEMIC ACHIEVEMENT|His performance is consistent with a mid-second grade level (2:5). Within the written language domain, _%#NAME#%_ obtained a low average score in spelling (SS = 82, 12th percentile) for his age. _%#NAME#%_' spelling skills are consistent with a mid-second grade level (2:6). Overall, a review of _%#NAME#%_' performance across the intellectual achievement domain indicates that he exhibits mild delays in reading and written language, consistent with his mildly delayed verbal intellectual abilities.
SS|UNSURED SENSE|(SS|206|208|SENSORY PERCEPTUAL, AND VISUAL MOTOR INTEGRATION SKILLS|_%#NAME#%_' visual motor integration skills were assessed using the Beery VMI, fifth edition. He was asked to copy a series of increasingly complex geometric designs. _%#NAME#%_ obtained a borderline score (SS = 74, 13th percentile) for his age. Results are consistent with an age equivalent of a 6-year 3-month-old child on a structured measure of visual motor integration skills.
SS|UNSURED SENSE|(SS|160|162|ACADEMIC ACHIEVEMENT|His performance is consistent with an early first grade level (1:1). Within the mathematics domain, _%#NAME#%_ obtained a low average score in math calculation (SS = 89) at the 23rd percentile for his age. His performance in math calculation is consistent with a late kindergarten level (K:8).
SS|UNSURED SENSE|(SS|241|243|FINE AND VISUOMOTOR INTEGREATION SKILLS|_%#NAME#%_'s visual motor integration skills were assessed using the Buktinica developmental test of visual motor integration. He was asked to copy a series of geometric designs. _%#NAME#%_ obtained an overall score within the average range (SS = 102) and at the 55th percentile, consistent with an age equivalent of a 7 year, 1-month-old child. It is important to note that this was a non-timed task.
SS|UNSURED SENSE|(SS|237|239|MEMORY AND LEARNING SKILLS|Scales scores between 9 and 11 are considered average. _%#NAME#%_'s ability to recall verbal information presented in the context of short stories was well below average, both immediately after exposure (SS = 4) and after a longer delay (SS = 5). However, _%#NAME#%_ was able to retain a limited amount of information that she initially recalled after a delay.
SS|UNSURED SENSE|(SS|272|274|MEMORY AND LEARNING SKILLS|_%#NAME#%_'s visual memory skills were assessed using a picture memory subtest, in which she was shown pictures of everyday scenes and then asked to immediately note any changes in similar pictures after the exposure. She obtained a well below average score on this tasks (SS = 1) and only benefited slightly from visual cues on a picture memory recognition subtest (SS = 6). SENSORY PERCEPTUAL AND VISUAL MOTOR INTEGRATION SKILLS: _%#NAME#%_'s sensory perceptual skills were assessed, using the Lafayette G rooved Pegboard Test.
SS|UNSURED SENSE|(SS|206|208|SENSORY PERCEPTUAL AND VISUAL MOTOR INTEGRATION SKILLS|_%#NAME#%_'s visual motor integration skills were assessed using the Beery VMI - 5th Edition. She was asked to draw a series of geometric designs. She obtained an overall score within the low average range (SS = 82) and 19th percentile for her age. In general, this score is consistent with an age-equivalent of a 7 year 1 month old child.
SS|UNSURED SENSE|(SS|263|265|ACADEMIC ACHIEVEMENT|ACADEMIC ACHIEVEMENT: _%#NAME#%_'s academic achievement skills were assessed using the WIAT-II. Standard scores between 90 and 109 are considered average. Within the reading domain, _%#NAME#%_ obtained average scores on subtests assessing his single word reading (SS = 96, 39th percentile) and phonetic decoding skills (SS = 94, 34th percentile). His performance in these areas is consistent with an early 5th (5:2) to early 3rd grade (3:1) level, respectively.
SS|UNSURED SENSE|(SS|223|225|ACADEMIC ACHIEVEMENT|Standard scores between 90 and 109 are considered average. Within the reading domain, _%#NAME#%_ obtained average scores on subtests assessing his single word reading (SS = 96, 39th percentile) and phonetic decoding skills (SS = 94, 34th percentile). His performance in these areas is consistent with an early 5th (5:2) to early 3rd grade (3:1) level, respectively.
SS|UNSURED SENSE|(SS|154|156|TEST RESULTS|_%#NAME#%_'s visual-motor integration skills were assessed using the Beery VMI - Fifth Edition. He obtained an overall score within the low-average range (SS = 81) and 10th percentile for his age. His performance is mildly delayef for his age and consistent with that of a 6-year, 3-month-old child.
SS|UNSURED SENSE|(SS|169|171|TEST RESULTS|Results from a screening of _%#NAME#%_'s academic achievement skills reflect average performance in the area of mass calculation in comparison to other children his age (SS equals 95, 37th percentile). _%#NAME#%_ had more difficulty on tasks involving reading and spelling, in which his scores ranged from low average to lower average levels.
SS|UNSURED SENSE|(SS|354|356|MEMORY AND LEARNING SKILLS|Scaled scores between 9 and 11 ar4e considered average. _%#NAME#%_'s ability to recall verbal information presented in the context of short stories was age-appropriate, both immediately (SS = 11) and after a longer delay (SS = 11). His ability to learn a discreet word list (16 words) over 4 consecutive trials was also average. After immediate exposure (SS = 9) and again after a longer delay (SS = 9). _%#NAME#%_'s visual memory skills were assessed using a subtest entitled Picture Memory, in which he was shown pictures of everyday scenes and then shown a similar picture and asked to mark any changes between the pictures.
SS|UNSURED SENSE|(SS|241|243|ACADEMIC ACHIEVEMENT|Her reading comprehension skills are within the high-average range for age (SS = 113, 81st percentile), consistent with an upper 2nd-grade level (2:8). In regard to math, _%#NAME#%_ obtained a math calculation score within the average range (SS = 95, 37th percentile), consistent with a mid-kindergarten level (K:5). In regard to written language skills, _%#NAME#%_ obtained a score in spelling within the high-average range (SS = 110, 75th percentile), consistent with an early 1st-grade level (1:3).
SS|UNSURED SENSE|(SS|224|226|ADAPTIVE FUNCTIONING SKILLS|It is important to note that this score was inflated to a certain degree by _%#NAME#%_'s strong written language skills. Within the daily living skills domain, _%#NAME#%_ obtained a score within the well-below-average range (SS =42, less than 1st percentile), consistent with a 2-year 4-month-old child. Within the socialization domain, _%#NAME#%_ obtained an overall score within the well-below-average range, as well (SS = 52, less than 1st percentile), consistent with a 1-year 6-month-old child.
SS|UNSURED SENSE|(SS|185|187|TEST RESULTS|Academic Achievement: Results from an assessment of _%#NAME#%_'s academic achievement skills using the WIAT-II reflects an average reading score for age within the mildly delayed range (SS = 89) and 23rd percentile. _%#NAME#%_'s single word reading (SS = 03) and reading comprehension (SS = 95) scores ranged from low average to average levels.
SS|UNSURED SENSE|(SS|204|206|REFERRAL AND BACKGROUND INFORMATION|The results reflected broad reading skills within the high- average range (SS = 112), broad math skills within the average range (SS = 99), and broad written language skills within the high-average range (SS = 112). As such, the results were not consistent with a learning disability. The results from the Behavioral Assessment System for Children (BASC) using teacher, parent, and some self-report ratings reflected a number of concerns in the areas of inattention, hyperactivity, impulsivity, conduct problems (E.G., aggression), and depression.
SS|UNSURED SENSE|(SS|229|231|ACADEMIC ACHIEVEMENT|She had no reported history of academic challenges in reading or written language. Standard scores between 90-109 are considered average. Within the mathematics domain, _%#NAME#%_ obtained a low average score in math calculation (SS = 89, 23%), consistent with mid 4th grade level (4:6). Overall, due to the significant discrepancy between _%#NAME#%_'s performance in math calculation (mildly delayed skills) and her average intellectual abilities, results are consistent with a learning disability affecting math.
SS|UNSURED SENSE|(SS|258|260|SUMMARY AND CLINICAL IMPRESSIONS|In regard to _%#NAME#%_'s intellectual functioning, he shows a relative strength on nonverbally as compared to verbally mediated measures. As previously reported, _%#NAME#%_ obtained an overall nonverbal reasoning score within the high average range for age (SS = 115, 84th percentile). These results indicate that _%#NAME#%_ is able to express himself and process information without words more effectively than with words.
SS|UNSURED SENSE|(SS|136|138|ACADEMIC ACHIEVEMENT SKILLS|Within the reading domain, _%#NAME#%_ obtained a high-average score (SS equals 110) in single word reading skills, and an average score (SS equals 98) in phonemic awareness skills. Within the mathematics domain, _%#NAME#%_ demonstrated a weakness on a math calculation task, in which he obtained a low-average score (SS equals 82), reflecting a mild delay and possible learning disability in this area.
SS|UNSURED SENSE|(SS|316|318|ACADEMIC ACHIEVEMENT SKILLS|Within the reading domain, _%#NAME#%_ obtained a high-average score (SS equals 110) in single word reading skills, and an average score (SS equals 98) in phonemic awareness skills. Within the mathematics domain, _%#NAME#%_ demonstrated a weakness on a math calculation task, in which he obtained a low-average score (SS equals 82), reflecting a mild delay and possible learning disability in this area. Within the written language domain, _%#NAME#%_ obtained a spelling score within the average range (SS equals 101).
SS|UNSURED SENSE|(SS|179|181|BACKGROUND INFORMATION|_%#NAME#%_'s cognitive functioning was assessed using the Wechsler Intelligence Scale for Children, 3rd edition (WISC-III). Results reflected a Verbal IQ within the average range (SS = 98), a Performance IQ within the low average range (SS = 80), and a Full Scale IQ within the low average range (SS = 88).
SS|UNSURED SENSE|(SS|162|164|TEST RESULTS|This is a non-timed task in which a child is asked to copy geometric forms using a pencil. Results reflect mildly delayed visual motor integration skills for age (SS = 84) at the 14th percentile. Results are consistent with an age equivalent of an 8-year, 4-month-old child. Social, emotional, and behavioral functioning: _%#NAME#%_'s social, emotional and behavioral functioning were assessed using self-rating scales, a projective measure, and a non-standardized child-based assessment.
SS|UNSURED SENSE|(SS|545|547|PROBLEM|Due to the significant amount of variability between _%#NAME#%_'s index scores, his Full Scale IQ (FSIQ = 86), which is low average for age, should be interpreted with caution. Index scores between 90 and 109 are considered average. Results from the assessment of _%#NAME#%_'s achievement skills through the school, as measured by the Woodcock-Johnson - 3rd Edition Tests of Achievement (WJ-III) on _%#MM#%_ _%#DD#%_, 2005, reflected a broad reading score within the average range (SS = 96), a broad math score within the mildly deficient range (SS = 63), and a broad written language score within the low average range (SS = 88). In reviewing _%#NAME#%_'s developmental history section of the school evaluation, in which school professionals gathered information regarding his prenatal and birth history as well as early developmental history, it was documented that _%#NAME#%_ has always needed reminders to make and sustain eye contact with others.
SS|UNSURED SENSE|(SS|183|185|DEMOGRAPHICS AND BACKGROUND INFORMATION|Previous testing reflects academic achievement scores as follows: Cluster scores on the Woodcock-Johnson III in oral language (SS equals 82), broad reading (SS equals 56), broad math (SS equals 88) and broad written language (SS equals 62). These test results are from _%#MM#%_ _%#DD#%_, 2005. Nonverbal reasoning subtest from WISC-III was also administered on _%#MM#%_ _%#DD#%_, 2004, with results described to be within the broadly average range (no score was given).
SS|UNSURED SENSE|(SS|147|149|TEST RESULTS|_%#NAME#%_'s visuomotor integration skills were assessed using the Berry-BMI-5th Edition. He obtained an overall score within the borderline range (SS = 73) at the 4th percentile, consistent with an age equivalent of a 6 year, 7-month-old child. Social, emotional and behavioral functioning: _%#NAME#%_'s functioning across these areas was assessed using a Sentence Completion Test (SCT), as well as a projective measure entitled the Roberts Apperception Test for Children (RATC).
SS|UNSURED SENSE|(SS|339|341|BACKGROUND AND REFERRAL INFORMATION|An assessment through the school district of _%#NAME#%_'s academic achievement skill, as measured by the Woodcock-Johnson III Test of Achievement, Form A, reflexed lower average broad reading skills (SS = 96) at the 26th percentile, borderline broad math skill (SS = 79) at the 8th percentile and low average broad written language skills (SS = 88) at the 21st percentile. Overall, results from the school evaluation indicated that _%#NAME#%_ did not demonstrate a severe enough discrepancy between his intellectual and academic achievement skills and therefore was not eligible to receive special education support to address learning difficulties.
SS|UNSURED SENSE|(SS|243|245|MEMORY AND LEARNING SKILLS|VISUAL MOTOR INTEGRATION: _%#NAME#%_'s visual-motor integration skills were assessed Beery-Buktenica Developmental Test of Visual- Motor Integration (Beery VMI), fifth edition. _%#NAME#%_ obtained an overall score within the low average range (SS = 88) at the 21st percentile. His performance was consistent with an age equivalent of a 9-year-old child. EMOTIONAL, SOCIAL, AND BEHAVIORAL FUNCTIONING: _%#NAME#%_'s emotional, social, and behavioral functioning was assessed using several Self-Rating Scales, a projective measure, a sentence completion test, and a clinical interview.
SS|UNSURED SENSE|(SS|190|192|SENSORY PERCEPTUAL AND VISUAL MOTOR INTEGRATION|_%#NAME#%_'s visual motor integration skills were assessed using the Beery-Buktenica Developmental Test of Visual-Motor Integration. He obtained an overall score within the borderline range (SS equals 77 at the sixth percentile for age). His score is consistent with an 6-year-3-month- old level. SOCIAL, EMOTIONAL, AND BEHAVIORAL FUNCTIONING: _%#NAME#%_'s social, emotional, and behavioral functioning were assessed using self-report measures, a Sentence Completion Test, a projective measure (RATC), and a clinical interview.
SS|UNSURED SENSE|(SS|332|334|MEMORY AND LEARNING|Scaled scores between 9 and 11 are considered average. In the area of verbal memory, _%#NAME#%_ obtained a low-average score on a task assessing his ability to immediately recall verbal information presented in the context of short stories. He obtained a borderline score when asked to recall story information after a longer delay (SS equals 6). He also obtained a borderline score on a story memory recognition task (SS equals 5). _%#NAME#%_'s ability to learn a list of 16 words after 4 consecutive exposures was also assessed (verbal learning).
SS|UNSURED SENSE|(SS|160|162|MEMORY AND LEARNING|His performance on this task improved slightly (SS equals 6) after a longer delay. He obtained a well-below average score on a verbal learning recognition task (SS equals 3). Overall, results from an assessment of _%#NAME#%_'s verbal memory and learning skills suggest that his ability to learn and recall verbal information is well below average for his age.
SS|UNSURED SENSE|(SS|158|160|ACADEMIC ACHIEVEMENT|His performance was compared to other individuals approximately his age. Within the reading domain, _%#NAME#%_ obtained average scores in single word reading (SS = 104) and phonetic decoding (SS = 108). However, he worked at a significantly slower rate than expected in both areas.
SS|UNSURED SENSE|(SS|167|169|ACADEMIC ACHIEVEMENT|His performance is consistent with an 8-10th grade level, respectively. In the mathematics domain, _%#NAME#%_ obtained a w ell below average score in math calculation (SS = 68). His performance is consistent with a mid third grade level. Within the written language domain, _%#NAME#%_ obtained an average score in spelling (SS = 98), consistent with an upper sixth grade level.
SS|single strength|SS.|115|117|MEDICATIONS|He recently graduated from high school. Substances are negative x3. ALLERGIES: Vancomycin. MEDICATIONS: 1. Bactrim SS. 2. Fluconazole. 3. Valganciclovir. 4. Enalapril. 5. Cortef. 6. Levothyroxine. 7. Ambien. 8. Peridex. 9. Coreg. REVIEW OF SYSTEMS: A 10-point review of systems at this time is significant for the left-sided visual loss and the left retro-orbital headache as described in history of present illness.
SS|UNSURED SENSE|(SS|204|206|FINE AND VISUAL MOTOR INTEGRATION SKILLS|_%#NAME#%_ was given the Beery-VMI-5th Edition to assess his visual motor integration skills. He was asked to copy a series of increasingly complex visual designs. _%#NAME#%_ obtained a low average score (SS = 81, 10th percentile), which is consistent with an age-equivalent of a 7-year, 6-month-old child. PSYCHOLOGICAL FUNCTIONING: _%#NAME#%_'s psychological functioning was assessed using self-rating scales, a Sentence Completion Test (SCT), a projective measure (RATC) and a clinical interview.
SS|UNSURED SENSE|(SS|178|180|ACADEMIC ACHIEVEMENT|His reading skills are consistent with a mid to late 4th grade level (4:7, 4:6), respectively. Within the math domain _%#NAME#%_ obtained a low average score in math calculation (SS equals 85) for age. His performance is consistent with a late 5th grade level (5:8). Within the language domain _%#NAME#%_ obtained a borderline score in spelling (SS equals 70, 2nd percentile) for his age.
SS|UNSURED SENSE|(SS|258|260|MEMORY|His performance improved on a story memory recognition subtest (SS equals 8) to the low average range indicating that he had encoded more information than he could recall without contextual cues. _%#NAME#%_ also obtained a below average and borderline score (SS equals 6) on a verbal learning subtest in which he was exposed to a 16-word list over 4 consecutive trials and asked to recall as many words as possible after each exposure.
SS|UNSURED SENSE|(SS|244|246|ACADEMIC ACHIEVEMENT|Within the mathematics domain, _%#NAME#%_ obtained a low average score in math calculation (SS =81, 10th percentile), consistent with a mid 5th grade level. Within the written language domain, _%#NAME#%_ obtained a borderline score in spelling (SS = 73, 4th percentile), consistent with a mid 3rd grade level. Overall, assessment of _%#NAME#%_'s performance across the intellectual and achievement measures indicates that he demonstrates a relative stregnth in reading comprehension, in which he obtained an average score.
SS|UNSURED SENSE|(SS|200|202|ACADEMIC ACHIEVEMENT|Standard scores between 90 and 109 are considered average. His performance was compared to other children his age. Within the reading domain, _%#NAME#%_ obtained average scores in single word reading (SS = 96, 39th percentile) and Phonetic Decoding (SS = 95, 37th percentile) for his age. His performance in these areas was consistent with an early third (3:2) to late second (2:9) grade level respectively.
SS|UNSURED SENSE|(SS|512|514|TEST RESULTS|Attempted to administer memory functioning tests TEST RESULTS: Results from the WAIS-III reflected a verbal IQ within the mildly deficient range (VIQ equals 69; 2nd percentile), a performance IQ within the borderline range (PIQ equals 77; 6th percentile), and a full-scale IQ within the borderline range (FSIQ equals 70; 2nd percentile). _%#NAME#%_'s verbal comprehension index was within the borderline range (VCI equals 67; 1st percentile), his perceptual organizational index was within the low-average range (SS equals 84; 14th percentile), and his working memory index was within the mildly deficient range (SS equals 61; less than the 1st percentile).
SS|UNSURED SENSE|(SS|196|198|ACADEMIC ACHIEVEMENT|_%#NAME#%_ obtained an average score on a task assessing his single word reading skills (SS equals 95, 37th percentile) and a low average score on a measure assessing his phonetic decoding skills (SS equals 84, 14th percentile). He obtained an average score on a measure of his math calculation skills (SS equals 95, 37th percentile) sphere.
SS|UNSURED SENSE|(SS|281|283|BACKGROUND AND REFERRAL INFORMATION|_%#NAME#%_ obtained a full scale IQ of 120, which is in the superior range. Results from the assessment, academic achievement using the Woodcock-Johnson Test of Achievement - third edition (WJ-III), conducted in _%#MM2006#%_, reflected average reading Broad Average Reading Skills (SS equals 102), high-average overall math skills (SS equals 116), and high-average overall written language skills (SS equals 110). As such, even though _%#NAME#%_'s academic achievement skills are not as fully developed as his intellectual abilities, results are not consistent with a learning disability.
SS|UNSURED SENSE|(SS|286|288|ACADEMIC ACHIEVEMENT|ACADEMIC ACHIEVEMENT: _%#NAME#%_'s academic achievement skills were briefly assessed using selected subtests from the WAIT-II. Results from an assessment of his math calculation skills on a subtest entitled Numerical Operations reflected a standard score within the lower average range (SS = 91) at the 27th percentile for age, consistent with a mid 6th grade level. As such, results are significantly lower than his nonverbal intellectual abilities and therefore, it is suggested that his math skills be further assessed to determine if he meets criteria for a learning disability in math.
SS|UNSURED SENSE|(SS|228|230|ACADEMIC ACHIEVEMENT|ACADEMIC ACHIEVEMENT: Selected subtests from the WIAT-II were administered to _%#NAME#%_ to assess his current academic achievement skills. _%#NAME#%_ obtained an average score on a task assessing his single word reading skills (SS equals 95, 37th percentile) and a low average score on a measure assessing his phonetic decoding skills (SS equals 84, 14th percentile).
SS|UNSURED SENSE|(SS|278|280|BACKGROUND AND REFERRAL INFORMATION|His early academic achievement skills were assessed using the Woodcock Johnson-Third Edition Test of achievement (WJ-III). He obtained a broad reading score within the upper average range (SS = 109, 73rd percentile), a broad written language score within the high average range (SS = 119, 90th percentile) and a broad math score within the very superior range (SS = 135, 99th percentile). Assessment of emotional, social and behavioral development reflected clinically significant concerns across raters (_%#NAME#%_'s mother, teacher and daycare provider) in the areas of externalizing behavior.
SS|UNSURED SENSE|(SS|409|411|BACKGROUND AND REFERRAL INFORMATION|Academic achievement testing was also conducted through the school in late _%#MM2005#%_ in the areas of reading and written language. _%#NAME#%_'s reading skills were assessed using the Woodcock-Johnson III Test of Achievement (WJ-III), with results reflecting a broad reading cluster score within the lower average range (SS = 93, 34th percentile), basic reading cluster score within the lower average range (SS = 89, 23rd percentile), and the reading comprehension cluster score was in the solidly average range (SS = 100, 50th percentile).
SS|UNSURED SENSE|(SS|514|516|BACKGROUND AND REFERRAL INFORMATION|Academic achievement testing was also conducted through the school in late _%#MM2005#%_ in the areas of reading and written language. _%#NAME#%_'s reading skills were assessed using the Woodcock-Johnson III Test of Achievement (WJ-III), with results reflecting a broad reading cluster score within the lower average range (SS = 93, 34th percentile), basic reading cluster score within the lower average range (SS = 89, 23rd percentile), and the reading comprehension cluster score was in the solidly average range (SS = 100, 50th percentile). _%#NAME#%_'s written language skills were assessed using the Wechsler Individual Achievement Test - second edition (WIAT-II).
SS|UNSURED SENSE|(SS|186|188|BACKGROUND AND REFERRAL INFORMATION|_%#NAME#%_'s written language skills were assessed using the Wechsler Individual Achievement Test - second edition (WIAT-II). He obtained a spelling score within the lower average range (SS = 92) and a written expression score within the average range (SS = 97). Overall, he obtained a written language composite score within the lower average range (SS = 93, 32nd percentile).
SS|UNSURED SENSE|(SS|195|197|BACKGROUND AND REFERRAL INFORMATION|_%#NAME#%_'s intellectual functioning was assessed using the Kaufman Assessment Battery for Children - Second Edition (KABC-II). He obtained a sequential index score within the low average range (SS = 88), a simultaneous index score within the low average range (SS = 89), a learning index within the average range (SS = 100) and a knowledge index within the high average range (SS = 118).
SS|UNSURED SENSE|(SS|315|317|BACKGROUND AND REFERRAL INFORMATION|_%#NAME#%_'s intellectual functioning was assessed using the Kaufman Assessment Battery for Children - Second Edition (KABC-II). He obtained a sequential index score within the low average range (SS = 88), a simultaneous index score within the low average range (SS = 89), a learning index within the average range (SS = 100) and a knowledge index within the high average range (SS = 118). He obtained a fluid crystallized index score within the average range (SS = 96).
SS|UNSURED SENSE|(SS|173|175|BACKGROUND AND REFERRAL INFORMATION|His academic skills were assessed using the Kaufman Test of Educational Achievement - Second Edition (KTEA-II). He obtained a lower average score in letter word recognition (SS = 91), low average scores in math concepts and application (SS = 87) and math computation (SS = 81), and a borderline score in written expression (SS = 73).
SS|UNSURED SENSE|(SS|399|401|BACKGROUND AND REFERRAL INFORMATION|She obtained an overall full scale IQ within the lower average range (FSIQ = 92, 30th percentile). Results from an assessment through the school of _%#NAME#%_'s academic achievement skills in _%#MM#%_ of 2005 using the Woodcock-Johnson III Achievement Test reflected a broad reading score within the average range (SS = 103, 59th percentile), a broad written language score within the average range (SS = 105, 62nd percentile), and a broad math score within the average range (SS = 96, 40th percentile). In reviewing the results from an assessment of _%#NAME#%_'s intellectual and academic achievement skills through the school, findings are not consistent with learning disabilities in any tested areas.
SS|UNSURED SENSE|(SS|312|314|ACADEMIC ACHIEVEMENT SKILLS|_%#NAME#%_'s processing speed skills were average for age. ACADEMIC ACHIEVEMENT SKILLS: _%#NAME#%_'s academic achievement skills were assessed using selected subtests from the WIAT-II. He obtained average scores on subtests on assessing his single-word reading skills (SS equals 99) and phonetic decoding skills (SS equals 101), which correspond with an upper 4th to upper 5th grade level. _%#NAME#%_ obtained an average score on a measure of his math calculation skills (SS equals 95), which corresponds with an early 5th grade level.
SS|UNSURED SENSE|(SS=104,|255|262|SOCIAL REASONING|Her general performance on this measure is consistent with an age equivalent of a 17-year, 5-month-old adolescent. Standard scores between 90 and 109 are considered average. She obtained the following scores on indices from the TOPS-II: Making Inferences (SS=104, 61st percentile), Determining Solutions (SS=112, 78th percentile), Problem Solving (SS=106, 65th percentile), Interpreting Perspectives (SS=108, 70th percentile) and Transferring Insight (SS =111, 76th percentile).
SS|single strength|SS|176|177|DISCHARGE MEDICATIONS|At the time of discharge, she was afebrile, and her vital signs were stable. DISCHARGE MEDICATIONS: 1. Prograf 2 mg p.o. b.i.d. 2. CellCept-ON HOLD for neutropenia. 3. Bactrim SS 1 p.o. 3 x weekly. 4. Valcyte 450 mg p.o. daily. 5. Mycelex troche 10 mg p.o. q.i.d. 6. Lisinopril 10 mg p.o. daily.
SS|single strength|SS|169|170|DISCHARGE MEDICATIONS|The patient was notified that he may have to have removal of his Port-A-Cath. DISCHARGE MEDICATIONS: 1. Rapamune 2 mg p.o. daily. 2. Prograf 3 mg p.o. b.i.d. 3. Bactrim SS 1 tablet p.o. daily. 4. Vancomycin 1 g IV b.i.d. until _%#MMDD2006#%_, then reassessment. 5. Elavil 75 mg p.o. q. h.s. 6. Pancrease 6-10 tablets p.o. t.i.d. with meals and snacks.
SS|UNSURED SENSE|(SS=85,|147|153|TEST RESULTS|_%#NAME#%_ demonstrated a relative weakness on a measure of her math calculation skills in which she obtained a score within the low average range (SS=85, 16th percentile). Her performance in math calculation is consistent with an upper 5th grade level. It is important to note that some of _%#NAME#%_'s errors appeared to be related to carelessness and others more related to lower math skills.
T1|tumor stage 1|T1,|106|108|FINAL DIAGNOSIS|FINAL DIAGNOSIS: Moderately differentiated adenocarcinoma of the left upper lobe lung, pathological stage T1, N0, M0. PROCEDURE: On _%#MMDD2006#%_, left thoracotomy with a wedge resection of the left upper lobe lung nodule was performed.
T1|tumor stage 1|T1,|162|164|PROCEDURE|Several mediastinal lymph nodes were sent to pathology for diagnostic purposes and for staging. They were all found to be benign. The final pathological stage is T1, N0, M0. The patient's postoperative course was complicated with a total below knee amputation of the right lower extremity.
T1|tumor stage 1|T1|112|113|RADIOLOGY|There is significant surrounding edema. These findings are confirmed by the MRI that I reviewed as well. on the T1 weighted image there is a homogeneously hyperintense lesion in the left centrum semiovale which corresponds to the CT lesion. There is extensive edema seen around this on the FLAIR imaging.
T1|thoracic (level) 1|T1,|272|274|HOSPITAL COURSE|The MRI of the C-spine showed a destructive lesion involving the C6 vertebral body with a compression fracture, so there was a pathologic compression fracture of C6, some moderate spinal canal stenosis but no epidural tumor. He also did have some subtle metastasis in C5, T1, T3 and T4. The MRI of the chest was significant for a necrotic tumor in the upper left lung but it was not affecting the brachial plexus.
T1|thoracic (level) 1|T1|222|223|LABORATORY DATA|LABORATORY DATA: Her CT scan of the head did not show any evidence of intracranial pathology except that she did have a left small, thin, left frontal subdural hematoma. CT scan of the spine showed degenerative disease in T1 with no evidence of fracture, and CT scan of her right hip showed no evidence of fracture. Her white count was 8.2, hemoglobin was 11.5. Platelet count was 157.
T1|tumor stage 1|(T1,|127|130|ASSESSMENT AND PLAN|5. Further electrolytes are pending. Hemoglobin 12.1, white count 4.4, platelets 141. ASSESSMENT AND PLAN: 1. Laryngeal cancer (T1, N0, M0). Plan surgical resection. Needs INR recheck prior to surgery to evaluate anticipated normal result. The patient has been instructed to hold Coumadin five days prior to surgery.
T1|tumor stage 1|T1,|164|166|DISCHARGE DIAGNOSIS|He will follow as an outpatient. He is taking Tylenol for pain and Percocet for more severe pain and clindamycin 150 mg q.i.d. as prophylaxis. DISCHARGE DIAGNOSIS: T1, N0, M0 invasive squamous cell carcinoma of the floor of the mouth. OPERATIVE PROCEDURE: Excision of invasive squamous cell carcinoma of the floor of the mouth with bilateral supraomohyoid neck dissections.
T1|thoracic (level) 1|T1|256|257|HISTORY OF PRESENT ILLNESS|This led to an evaluation by Dr. _%#NAME#%_ at the Noran Neurologic Clinic including imaging studies that included MRI scan of the thoracic and lumbar spine. These studies performed in early _%#MM#%_ demonstrated metastases at T9 and T10 and also possibly T1 and T3. She then had a CT scan of her chest which confirmed the presence of a mass lesion in the left upper lobe as well as mediastinal adenopathy.
T1|thoracic (level) 1|T1|180|181|HISTORY OF PRESENT ILLNESS|A brain and spine MRI was done within a few hours after her presentation and was consistent with extensive increased T2 signal within the cervical spinal cord extending from C3 to T1 levels. Her brain MRI was normal. HOSPITAL COURSE: _%#NAME#%_ was initially admitted to the Intensive Care Unit for close monitoring.
T1|tumor stage 1|T1|187|188|ASSESSMENT AND PLAN|The remainder of his physical exam is unchanged from the previous exam _%#MMDD2005#%_. ASSESSMENT AND PLAN: Mr. _%#NAME#%_ is a 63-year-old male with adenocarcinoma of the prostate stage T1 C with a history of rising PSA and biopsy proven with a Gleason 3 + 3 = 6. The patient was seen and examined by Dr. _%#NAME#%_ and myself.
T1|tumor stage 1|T1|98|99|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Squamous cell carcinoma of the left tonsil with metastasis to the left neck, T1 N1 M0 squamous cell carcinoma of the left tonsil. DISCHARGE DIAGNOSIS: Squamous cell carcinoma of the left tonsil with metastasis to the left neck, T1 N1 M0 squamous cell carcinoma of the left tonsil.
T1|tumor stage 1|T1|249|250|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Squamous cell carcinoma of the left tonsil with metastasis to the left neck, T1 N1 M0 squamous cell carcinoma of the left tonsil. DISCHARGE DIAGNOSIS: Squamous cell carcinoma of the left tonsil with metastasis to the left neck, T1 N1 M0 squamous cell carcinoma of the left tonsil. OPERATIONS/PROCEDURES PERFORMED: Left tonsillectomy plus left modified radical neck dissection, _%#MM#%_ _%#DD#%_, 2005.
T1|tumor stage 1|T1,|188|190|BRIEF ADMISSION SUMMARY|He was discovered to have a transitional cell carcinoma of the left renal pelvis and left ureter and underwent a left nephroureterectomy on _%#MM#%_ _%#DD#%_, 2001. Pathology showed stage T1, TCC of the kidney, grade 2. Further workup showed a large right sided renal pelvis filling defect. Retrograde pyelogram and biopsy in outside hospital showed papillary tumor which was transitional cell carcinoma, grade 2, noninvasive.
T1|tumor stage 1|T1|149|150|IMPRESSION/PLAN|ECG sinus bradycardia with no signs of any acute or chronic ischemia. IMPRESSION/PLAN: _%#NAME#%_ _%#NAME#%_ is a 56-year-old White male with a left T1 and 2A squamous cell carcinoma of the piriform sinus scheduled to undergo a left modified radical neck dissection. At a later date this will be followed by radiation therapy and possibly chemotherapy.
T1|thoracic (level) 1|T1|160|161|OPERATIONS/PROCEDURES PERFORMED|4. Cardiac catheterization, which revealed congestive cardiomyopathy and focal coronary artery disease without hemodynamically significant lesion. 5. Lesion in T1 25 to 50% instant restenosis. Otherwise, the LAD stent is patent. LCX and OM, no significant disease and RCA without significant disease.
T1|tumor stage 1|T1|190|191|SUMMARY|On that basis, three days later she underwent a right thoracotomy, right lower lobectomy. All mediastinal lymph nodes were negative as well as the margins. The final pathological stage is a T1 N0 M0. She was dismissed on postoperative day is in good condition. Instructions were given. The patient will follow up in my office in ten days with followup chest x-ray.
T1|tumor stage 1|T1,|146|148|INDICATIONS FOR SURGERY AND HISTORY OF PRESENT ILLNESS|INDICATIONS FOR SURGERY AND HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 55-year-old male with a past medical history significant for a T1, N0 squamous-cell carcinoma of the right tongue. This was treated in 2002, by Dr. _%#NAME#%_ with a partial glossectomy and ipsilateral modified radical neck dissection.
T1|tumor stage 1|T1,|168|170|ADMISSION DIAGNOSIS|DISCHARGE DIAGNOSIS: Metastatic squamous cell carcinoma from left base of tongue. HISTORY OF PRESENT ILLNESS: This patient is a 78-year-old female who has a history of T1, N0 squamous cell carcinoma of the left base of tongue. She had undergone radiation therapy for this completed in _%#MM#%_ 2005.
T1|thoracic (level) 1|T1|52|53|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: 1. Vertebral wedge fracture at T1 level. 2. Hyponatremia. SECONDARY DIAGNOSIS: 1. Hypertension. 2. Gastroesophageal reflux disease.
T1|thoracic (level) 1|T1|332|333|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Please see the detailed discharge summary by Dr. _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2006, and the history and physical at the time of admission by Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2006. Briefly, Mrs. _%#NAME#%_ _%#NAME#%_ was presented initially secondary to the vertebral wedge fracture at T1 level and was in the Fairview _%#CITY#%_ Hospital from _%#MM#%_ _%#DD#%_, 2006, to _%#MM#%_ _%#DD#%_, 2006, and then she was transferred to the (_______________) for further physical therapy and occupational therapy.
T1|tumor stage 1|T1,|176|178|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 55-year-old female with stage IIA infiltrating ductile carcinoma involving the left breast. She was diagnosed in _%#MM#%_ 2006; T1, M0, N0; 3 positive lymph nodes which were ER positive; PR and HER-2 negative. She is status post mastectomy. She is receiving adjuvant dose-dense chemotherapy with AC.
T1|UNSURED SENSE|T1|155|156|PROCEDURES|There was a distal LAD stenosis that ranged 50%. The vein graft to the posterior distal artery is open with a distal anastomosis stenosis. There is SVG to T1 which was open with good flow. There was an SVG to OM which was closed at the proximal segment. Impression: 1. Three vessel cardiovascular disease without a left main lesion.
T1|thoracic (level) 1|T1|442|443|HISTORY OF PRESENT ILLNESS|2. Abdominal pain. 3. Metastatic small cell lung cancer. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a very pleasant 61- year-old female who was diagnosed with metastatic small cell lung cancer in _%#MM#%_ 2001 with a mass in the left upper lobe bronchus with increased intense activity along the left paratracheal area extending superior towards the left lung apex. At that time, the patient was found to have metastatic disease to T1 vertebra and possible involvement of left adrenal gland. The patient was then seen at Parker Hughes Cancer Center on _%#MMDD2001#%_ for a second opinion and was recommended to start chemotherapy with a combination of cisplatin and VP-16.
T1|thoracic (level) 1|T1.|191|193|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Metastatic adenocarcinoma of the tongue with pathological fracture of C7. OPERATIONS/PROCEDURES PERFORMED: C7 vertebrectomy with anterior cervical fusion from C6 through T1. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 69-year-old gentleman with mucinous cystadenocarcinoma of the tongue. He presented with severe neck pain and radicular symptoms. MRI scan demonstrated pathological fracture of T7 with canal compromise and a vertebrectomy at the C7 level was elected.
T1|T1 (MRI)|T1|187|188|ADMISSION LABORATORY DATA|An MRI of the brain done on _%#MMDD2005#%_ revealed no interval changes as compared with similar examination of _%#MMDD2005#%_. The MRI noted extensive white matter T2 hyperintensity and T1 hypointensity within the posterior half of both cerebral hemispheres and involving the posterior third of the corpus callosum. The corticospinal tracts bilaterally are also involved through the brain stem.
T1|T1 (MRI)|T1|217|218|LABORATORY  DATA|LABORATORY DATA: Pending. Her MRI of her brain as in the history of present illness shows infiltrative lesion in the right petrous apex extending to the right cavernous sinus and right clivus best seen on precontrast T1 weighted images, suspicious for metastatic breast cancer. Bone scan per Dr. _%#NAME#%_ three weeks ago was negative per Dr. _%#NAME#%_'s report to her. ASSESSMENT/PLAN: A 52-year-old patient with probable metastatic lesion from breast cancer which now is in a difficult spot to biopsy.
T1|thoracic (level) 1|T1|209|210|HOSPITAL COURSE|She was seen by the Pain Service. She failed a test dose of intrathecal analgesia, presumably, in retrospect, due to the fact that she has nearly complete block of the spinal canal at C4 through approximately T1 or T2. This was demonstrated on MRI of the chest on _%#MMDD2003#%_. The patient was subsequently transferred to the Medical Intensive Care Unit, where she was started on a ketamine drip.
T1|T1 (MRI)|T1|151|152|PERTINENT LABORATORY TESTS|No evidence of pneumonia. MRI of the lumbar spine with and without contrast. Interval increase in compression fractures of L4-L5. Diffuse reduction of T1 signal likely secondary to involvement of the lumbar spine with multiple myeloma. No evidence of spinal cord or thecal sac, or neuro-foraminal compromise.
T1|tumor stage 1|T1,|230|232|HISTORY OF PRESENT ILLNESS|The tumor penetrated into the submucosa, but there was no evidence of invasion into the muscularis propria and no evidence of any vascular invasion. Twelve pericolic lymph nodes were negative for metastasis. This is, therefore, a T1, N0, M0 adenocarcinoma of the cecum. The patient postoperatively had a relative smooth postoperative course. On the second postoperative day, his Foley catheter was discontinued, and he was started on sips of clear liquids.
T1|tumor stage 1|T1,|153|155|EXAMINATION|The ulcer did not resolve, and therefore he underwent a biopsy of this, which was positive for an invasive squamous cell carcinoma. Mr. _%#NAME#%_ has a T1, N0 squamous cell carcinoma of the left lateral tongue. I discussed with him at length the findings and options of therapy.
T1|tumor stage 1|T1,|256|258|DISMISSAL SUMMARY|6. History of smoking. PROCEDURE: _%#MMDD2003#%_ - Left thoracotomy, mediastinal lymph node dissection, left upper lobectomy. DISMISSAL SUMMARY: Mr. _%#NAME#%_ _%#NAME#%_ is a 78-year-old gentleman who underwent seven years ago a right upper lobectomy for T1, N0, M0 non-small cell carcinoma of the right upper lobe lung. More recently he has been complaining of some cough. A CT scan showed a mass in the left upper lobe lung.
T1|tumor stage 1|T1,|162|164|FINAL DIAGNOSIS|FINAL DIAGNOSIS: Well-differentiated squamous cell carcinoma, right upper lobe lung. Status post induction chemotherapy and radiation therapy. Pathological stage T1, N0, M0. OTHER DIAGNOSES: History of smoking. PROCEDURE: _%#MMDD2003#%_ 1. Diagnostic flexible bronchoscopy.
T1|T1 (MRI)|T1|252|253|PHYSICAL EXAMINATION|LABORATORY DATA (from Allina Medical Clinic): Pertinent positives shows ESR of 50, negative serum protein electrophoresis, LDH of 301, PSA of 0.5, white count 7.5, hemoglobin 14.1, and platelet count of 306. MRI scan from Allina, also showed increased T1 signal in L5, with epidural soft tissue enhancement. HOSPITAL COURSE: Problem #1. Bone mass: The patient underwent a fluoroscopic-guided biopsy, performed by Dr. _%#NAME#%_, on _%#MMDD2003#%_.
T1|thoracic (level) 1|T1|193|194|PROCEDURE PERFORMED|ADMISSION DIAGNOSIS: Multiple enhancing lesions of vertebral bodies in the cervical and thoracic area. DISCHARGE DIAGNOSIS: Same. PROCEDURE PERFORMED: Anterior approach to open biopsy of C7 to T1 disk and vertebral body lesion. HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old woman with a history of thyroid papillary carcinoma, status post treatment with surgery and radioiodine in the 1980s, with a recurrence in the right neck in 2001 that was followed by I-131.
T1|thoracic (level) 1|T1|148|149|HISTORY OF PRESENT ILLNESS|None of these studies have been definitive. The patient had an MRI in _%#MM2003#%_ that showed multiple small enhancing lesions, with the lesion at T1 being the largest. She had another MRI in _%#MM2003#%_ that showed an increasing number and size of some of the lesions.
T1|thoracic (level) 1|T1|204|205|HOSPITAL COURSE|SOCIAL HISTORY: She denies alcohol or smoking. HOSPITAL COURSE: Negative for neurological, hematological, or infectious complications. The patient was admitted and had the biopsy performed, both from the T1 vertebral body as well as the disk space from C7 to T1. At the time of this dictation, the pathology report had not come back.
T1|thoracic (level) 1|T1.|124|126|HOSPITAL COURSE|The patient was admitted and had the biopsy performed, both from the T1 vertebral body as well as the disk space from C7 to T1. At the time of this dictation, the pathology report had not come back. Otherwise, the patient tolerated the procedure well. Postoperatively, she had some hoarseness in her voice, but good strength in her extremities.
T1|tumor stage 1|T1|220|221|HISTORY OF PRESENT ILLNESS|A core needle biopsy of this was performed on _%#MM#%_ _%#DD#%_, 2006, and revealed a moderately differentiated adenocarcinoma. He also underwent preoperative PET scan and by clinical staging criteria was felt to have a T1 and 0 lesion. He had preoperative pulmonary function test. His medical history is notable for coronary artery disease, however, did have an angiogram in the past which was unremarkable.
T1|T1 (MRI)|T1,|316|318|RADIOLOGY|Likewise, his sensation appears grossly intact but it is not possible to quantify due to the patient's inability to communicate. RADIOLOGY: An MRI from _%#MMDD2006#%_ reveals a cerebellopontine angle mass extending from the right medullar up to the right uncus, possibly cystic, which appears heterogeneous, dark on T1, and bright on T2 signal, possibly representing a dermoid tumor. PRELIMINARY ASSESSMENT/DIAGNOSIS: The patient has a cerebellopontine angle mass and will require a biopsy for tissue diagnosis.
T1|tumor stage 1|T1,|186|188|PATHOLOGY RESULTS|The patient was passing gas from her stomach. No stools have been reported at the time of discharge. PATHOLOGY RESULTS: Pathology results from the patient's resection were notable for a T1, N0, M0 finding. This was communicated to patient. The patient was discharged to home in good condition. DISCHARGE MEDICATIONS: 1. Multivitamins 1 tablet p.o. q. day.
T1|tumor stage 1|T1,|263|265|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSES: 1. Mucositis. 2. Candidiasis. 3. Status-post PEG-tube placement. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is a pleasant 32-year-old gentleman with past medical history significant for squamous-cell carcinoma of the head and neck T1, status post left modified radical neck dissection and posterior lung biopsy who presents with severe mouth pain and dehydration. The patient denied any fever or chills but after his last round of chemotherapy and radiation he noted that he developed severe mouth sores and pain and he was unable to keep food down or eat secondary to this.
T1|thoracic (level) 1|T1|226|227|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old right-handed female with a history of known tonsillar adenoma with metastases to the T2 vertebral body, status post corpectomy with cage and pedicle screw fixation from T1 to T3 by Dr. _%#NAME#%_ _%#NAME#%_ in _%#MM2006#%_. She did well postoperatively and was last seen by Neurosurgery in _%#MM2006#%_ with a complication of a postoperative seroma and epidural extension with mild spinal cord compression causing urinary retention, also status post wound washout for that situation.
T1|tumor stage 1|T1|191|192|PAST MEDICAL HISTORY|She otherwise denies chest pain, sinus pain or congestion. No history of fevers, chills or weight loss. PAST MEDICAL HISTORY: Anxiety, hypertension, stage 1 adenocarcinoma of the right lung, T1 N0 M0 COPD, history of alcohol abuse and osteoporosis. PAST SURGICAL HISTORY: Cholecystectomy, history of breast biopsy x2, history of intraabdominal adhesions 1972, right lower lobe lobectomy 2001.
T1|tumor stage 1|T1,|108|110|FINAL DIAGNOSIS|FINAL DIAGNOSIS: Moderately differentiated adenocarcinoma of the distal esophagus. Final pathological stage T1, N0, M0. OPERATIVE PROCEDURE: On _%#MMDD2007#%_ abdominal exploration with distal esophagectomy and proximal gastrectomy, intraabdominal end-to-side esophagogastric anastamosis, pyloromyotomy, and placement of feeding tube jejunostomy was performed.
T1|tumor stage 1|T1|252|253|OPERATIVE COURSE|The surgeons were Drs. _%#NAME#%_, _%#NAME#%_, and _%#NAME#%_. The left lower lobe was submitted, with the nodule inside. This was submitted to formal pathology. The pathology demonstrated adenocarcinoma of the lung, without nodal disease, designating T1 N0 tumor classification for this patient. POSTOPERATIVE COURSE: The patient's postoperative course was unremarkable. She was slow to progress, with respect to physical therapy and occupational therapy, and it was recommended that she continue these at home.
T1|T1 (MRI)|T1|186|187|PERTINENT LABS AND X-RAYS|MRI with and without contrast, MRI/MRA of the head with and without contrast done _%#MMDD2003#%_ - new focal lesion in the left anterior body of the corpus callosum, high signal on both T1 and T2 weighted images suggesting a small hematoma. Otherwise, unremarkable diffusion images. Areas of presumed old infarction, right globus pallidus and periventricular white matter are again seen.
T1|tumor stage 1|T1,|110|112|FINAL DIAGNOSIS|FINAL DIAGNOSIS: Moderately differentiated squamous cell carcinoma, right upper lobe lung. Pathological stage T1, N0, M0. OTHER DIAGNOSES: 1. History of Hodgkin's lymphoma with residual subcarinal mass negative for malignancy.
T1|tumor stage 1|T1,|148|150|PLAN|IMPRESSION: Biopsy was reviewed, demonstrating microinvasive squamous cell carcinoma of the left anterior tongue. PLAN: _%#NAME#%_ _%#NAME#%_ has a T1, N0 squamous cell carcinoma of the left anterior tongue. I reviewed the findings and pathology reports with Ms. _%#NAME#%_. CT scan of the neck was performed, demonstrating no enlarged or necrotic-appearing lymph nodes and no mandibular erosion.
T1|tumor stage 1|T1|101|102|FINAL DIAGNOSIS|DOB: _%#MMDD1941#%_ FINAL DIAGNOSIS: Non-small-cell carcinoma right middle lobe lung, surgical stage T1 N0 N0. OTHER DIAGNOSIS: Smoking history. PROCEDURE: _%#MMDD2003#%_: Right thoracotomy and right middle lobectomy.
T1|tumor stage 1|T1|283|284|PAST MEDICAL HISTORY|He was initially hospitalized several times with dehydration and hypokalemia secondary to a rectosigmoid secretory villous adenoma in _%#MM#%_/_%#MM#%_ of 2002. He subsequently underwent ileostomy and anterior resection of the rectosigmoid villous adenoma which did show evidence of T1 carcinoma in _%#MM2002#%_ at Southdale. He subsequently developed problems with small bowel obstruction, pneumonias, dehydration and hypokalemia again and had an MRSA pneumonia as well.
T1|tumor stage 1|T1|138|139|IMPRESSION|2. Chronic lymphocytic leukemia, stage 0, not symptomatic and untreated. 3. Chronic anemia. 4. Status post secretory villous adenoma with T1 carcinoma of rectosigmoid, resected. 5. Mild dehydration. 6. Diarrhea, probable viral illness. 7. History of MRSA. PLAN: Initiate albuterol/Atrovent nebs, will start Zithromax to cover for bacterial bronchitis, watch for fever or other signs of possible development of pneumonitis, initiate IV fluids and oral fluids as tolerated, advance diet as tolerated depending on whether or not he develops diarrhea, repeat nares and sputum culture to see if he has cleared his MRSA.
T1|T1 (MRI)|T1|153|154|HOSPITAL COURSE|Also it is important to mention, that on the CT scan done on _%#MMDD2004#%_; in retrospect the MRI of the head done on _%#MMDD2004#%_, blood was seen on T1 images. This blood was absent on the MRI of the brain done on _%#MMDD2004#%_. It was thought that the bleeding occurred between the on _%#MMDD2004#%_ and _%#MMDD2004#%_, and that was when the lumbar puncture was performed.
T1|tumor stage 1|T1,|179|181|HISTORY OF PRESENT ILLNESS|2. Clostridium difficile colitis. 3. Hyperbilirubinemia. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 43-year-old female with AML. She was diagnosed in _%#MM2003#%_ with stage II, T1, N1, M0 breast cancer of the right breast. She had advanced local disease and received adjuvant chemotherapy with adriamycin, Cytoxan, and Taxol x 4 cycles.
T1|thoracic (level) 1|T1|148|149|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Significant for, 1. Hypertension. 2. Gastroesophageal reflux. 3. Hyperlipidemia. 4. History of wedge pressure at the level of T1 at 2006, she was hospitalized at that time and she was transferred to the FUTS. 5. Constipation. 6. Mild COPD. REVIEW OF SYSTEMS: A 10-point review of systems including psych was evaluated and it was negative except for the notes mentioned in above.
T1|thoracic (level) 1|T1|174|175|HISTORY OF THE PRESENT ILLNESS|4. Lipoma located mid back. He is interested in pursing removal. HISTORY OF THE PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ has a 2 cm. lipoma versus sebaceous cyst overlying the T1 process in the upper thoracic spine. He currently denies fever or chills, no nausea, vomiting, no gastrointestinal, genitourinary or respiratory symptoms of infection.
T1|thoracic (level) 1|T1.|169|171|PRINCIPAL DIAGNOSIS|PRINCIPAL DIAGNOSIS: 1. Syncopal episode, probably vasovagal in nature. 2. Central spinal canal stenosis at C6-C7 level, severe. 3. Spondylolisthesis of 5.0-mm of C6 on T1. 4. Bilateral leg paralysis secondary to above. 5. Diarrhea during hospitalization. 6. Hyponatremia. 7. Hypertension. 8. Rheumatoid arthritis. 9. Osteoarthritis.
T1|tumor stage 1|T1,|177|179|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSES: 1. Neutropenic fevers. 2. Anal carcinoma. 3. Diarrhea. 4. Radiation burns to perineum. HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old female with T1, N1, M0 squamous cell carcinoma of the anal canal. The patient has gone through 5 weeks of chemoradiation treatment with 5-FU with mitomycin and states that she has not felt well for the week leading up to her admission.
T1|tumor stage 1|T1,|198|200|HISTORY OF PRESENT ILLNESS|She denies any cough, sputum production, or vomiting. No change in her urination but has had diarrhea for the past several weeks and some associated nausea. PAST MEDICAL HISTORY: 1. Anal carcinoma, T1, N1, M0 squamous cell of the anal canal, stage IIIa. 2. Status post chemoradiation, most recently on _%#MM#%_ _%#DD#%_, 2005, currently on week 5 of 6.
T1|thoracic (level) 1|T1|193|194|OBJECTIVE|GENITOURINARY exam, RECTAL exam, BREAST exam, all not done. EXTREMITIES have no edema, good pulses. NEUROLOGIC exam: Skin is intact. BACK exam: She does have slight amount of swelling over the T1 vertebrae and there is no obvious other deformity or redness noted. ASSESSMENT: L1 compression fracture with moderate amount of pain. PLAN: We will get her out of bed this morning and see how she manages with walking the halls.
T1|tumor stage 1|T1|220|221|HISTORY OF PRESENT ILLNESS|The patient underwent transrectal needle biopsy of prostate gland positive for Gleason 3 + 3 = 6 adenocarcinoma of the prostate. Pathology report MS07-10276 and reviewed at Mayo Clinic HR07-27651. The patient reportedly T1 C tumor. Metastatic workup was negative. Prostate gland volume 37.1 cc. Following discussion of the options for therapy and after reviewing them at length in detail, the patient is most interested in prostate brachytherapy.
T1|thoracic (level) 1|T1|193|194|LABORATORY DATA|Sodium 124, potassium 3.9, creatinine 0.57, glucose 105. WBC 5, hemoglobin 12.3, platelets 103,000. CT scan of the lumbosacral spine showed no evidence of acute vertebral compression, previous T1 and T11 and T12 vertebroplasty. L4-L5 spondylolysis and marked degenerative changes and postoperative changes in the lower lumbar spine. IMPRESSION AND PLAN: A _%#1914#%_ woman with: 1. Back pain secondary to degenerative disk disease and compression fracture: There is no evidence of acute finding on the CT scan.
T1|T1 (MRI)|T1|220|221|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|1. Interval evolution and increase in extent of abnormal T2 signal hyperintensity in the white matter of the left frontoparietal convexity. There is now a large confluent area of ill-defined T2 signal hyperintensity and T1 signal hypointensity, which shows patchy curvilinear contrast enhancement. The subcortical T2 hyperintensity is now also present in the subinsular white matter.
T1|thoracic (level) 1|T1.|171|173|HISTORY OF PRESENT ILLNESS|She also has abnormal signal in the thoracic region compatible with areas of demyelinization. She also had a cervical MRI which indicated lesions at C2, C6, C7 as well as T1. These MRIs were back in _%#MM2006#%_ and _%#MM2006#%_. She has previously received other multiple sclerosis treatments with _%#NAME#%_, which she could not tolerate as well as a chemotherapeutic agent which she did progress well but was discontinued due to potential for side effects.
T1|tumor stage 1|T1,|166|168|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Generalized weakness, lethargy. Suspect multifactorial with poor p.o. intake and progressive cancer. 2. CML. 3. Non-small cell adenocarcinoma T1, N0, M0. HISTORY: A 60-year-old female with a history of CML, which was diagnosed 6 years ago.
T1|thoracic (level) 1|T1|114|115|PROCEDURES PERFROMED WHILE IN THE HOSPITAL|2. Posterior spinal fusion revision with lateral mass plates from C3 to T1 and inner spinous process cables C7 to T1 and C6-7. 3. Left posterior iliac crest bone graft. CONSULTS PERFORMED WHILE IN THE HOSPITAL: 1. Internal medicine. 2. Neurology. HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old female with the above mentioned diagnosis.
T1|tumor stage 1|T1,|254|256|HOSPITAL COURSE|The postoperative course was uneventful. She was advanced up to a regular diet and discharged on postoperative day #5 in good condition. She will follow up with us in three to four weeks or sooner should problems develop. The pathology report revealed a T1, N0, M0 moderately differentiated mucinous adenocarcinoma of the cecum. Because of the early stage, she will probably not require adjuvant therapy.
T1|thoracic (level) 1|T1,|252|254|HISTORY OF PRESENT ILLNESS|He was found on imaging to have a significant amount of spinal canal compromise due to the size of the tumor. In a combined procedure with Dr. _%#NAME#%_ and Dr. _%#NAME#%_, this tumor was resected and the spine was fixated, as described above, at the T1, T3 and T4 levels. HOSPITAL COURSE: Mr. _%#NAME#%_ had an uneventful course at first after surgery.
T1|thoracic (level) 1|T1,|155|157|PAST MEDICAL HISTORY|7. History of Sjogren's syndrome, I do not have full details. 8. Gastroesophageal reflux disease (GERD). 9. Depression. 10. Osteoporosis with fractures of T1, T2 and T3, status post vertebroplasty. 11. History of lumbar fusion. 12. Cholecystectomy. 13. Restless leg syndrome. 14. Total hip arthroplasty. ALLERGIES: None. CURRENT MEDICATIONS: 1. Zoloft 150 mg.
T1|thoracic (level) 1|T1|218|219|PROBLEM #8|The white blood cell count was 11.9; hemoglobin 10.2, hematocrit 30.7; platelets 96; 1 lymphocyte, 97 neutrophils, 11.7 absolute neutrophils, 1 monocyte, and 1 eosinophil. He has received irradiation of his spine from T1 through T9. He will also be treated at home with oral VP-16 for two more weeks. His platelets and hemoglobin drifted to below 50 and below 10 the day prior to discharge and platelet as well as red cell transfusions were given.
T1|tumor stage 1|T1,|221|223|PAST MEDICAL HISTORY|By the way, he was also informed about the admission of this patient, and he was following her during her entire stay. Second diagnosis is pulmonary embolism and is on warfarin since _%#MM#%_ 2003. She had adenocarcinoma T1, N0, M0, status post right upper lobectomy in 1999. She was followed by Dr. _%#NAME#%_ _%#NAME#%_ and reportedly had a PET scan which revealed a hot spot on the L3 spine.
T1|T1 (MRI)|T1|202|203|HOSPITAL PROCEDURES|HOSPITAL PROCEDURES: Patient had an MRI on _%#MMDD2006#%_ that showed a lateral disk protrusion at L3-L4 on the right, mild grade I degenerative anterolisthesis on L4-L5. There was a focus of decreased T1 and T2 signal within the medullary cavity of the right iliac bone but this is likely a large but benign bone island.
T1|tumor stage 1|T1,|46|48|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: Squamous cell carcinoma, T1, of the left posterior tongue. OPERATIONS/PROCEDURES PERFORMED: 1. Left modified radical neck dissection. 2. Left posterior tongue biopsy.
T1|tumor stage 1|T1|212|213|HISTORY OF PRESENT ILLNESS|OPERATIONS/PROCEDURES PERFORMED: 1. Left modified radical neck dissection. 2. Left posterior tongue biopsy. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 32-year-old gentleman who presented with a diagnosis of T1 squamous cell carcinoma of the left posterior tongue. This was excised at a previous surgery. The depth of invasion was found to be at least 5 mm.
T1|tumor stage 1|T1|130|131|FINAL DIAGNOSIS|FINAL DIAGNOSIS: 1. Moderately differentiated adenocarcinoma superior upper lobe of the left upper lobe; final pathological stage T1 N0 M0. 2. Moderately differentiated squamous cell carcinoma in the inferior upper lobe of the left upper lobe; final pathological stage T1 N0 M0.
T1|thoracic (level) 1|T1|350|351|IMAGING|Most recent magnesium 2.0, phosphorus 4.1, sodium 140, potassium 3.6, chloride 102, carbon dioxide 27, BUN 15, creatinine 0.64, glucose 96, calcium 8.5. White blood cell count 5.4, hemoglobin 9.3, hematocrit 27.4, platelets 303. IMAGING: 1. An MRI of the T-spine performed _%#MMDD#%_: Showed severe compromise of the upper thoracic spinal canal from T1 through T4 due to compression fractures and extensive epidural tumor without any significant compression of the thoracic spinal canal below the T4 level; right paramedian disk protrusion at the T12-L1 level effacing the ventral subarachnoid space.
T1|tumor stage 1|T1.|209|211|HISTORY OF PRESENT ILLNESS|Based on the size of her tumor, it was felt that this was a T2. There were no lymph nodes on imaging studies, but she did have right neck fullness and/or tenderness and it was therefore felt that she may be a T1. The patient received radiation therapy along with cisplatin and 5-FU.
T1|T1 (MRI)|T1|276|277|MAJOR PROCEDURES|Biliary and pancreatic ducts are not well visualized. No mass in the cirrhotic liver, splenomegaly and cholelithiasis without evidence of cholecystitis. 5. MRI of brain on _%#MMDD2007#%_: No evidence for acute ischemic cerebral or cerebellar infarction, bilateral symmetrical T1 shortening within the deep grey nuclei, which was consistent with manganese deposition in the setting of liver failure and hepatic encephalopathy.
T1|thoracic (level) 1|T1|173|174|DISCHARGE DIAGNOSIS|2 . Stress ulcer right foot, mild, healing. 3. Nonhealing sacral wound, chronic. 4. History of T4 paraplegia after a motor vehicle accident with history of fractures of C7, T1 and T4. 5. Neurogenic bladder. 6. History of depression.
T1|thoracic (level) 1|T1,|179|181|HOSPITAL COURSE|There was also a hemangioma on the liver. The patient underwent a CT of the spine also which showed diffuse sclerotic and lytic metastases throughout the thoracic spine involving T1, T2, T3, T4, T5 and T10. The patient was admitted for pain control. Urinalysis was unremarkable. Fractional excretion of sodium was 6.4. Urine culture was negative.
T1|thoracic (level) 1|T1.|127|129|HOSPITAL COURSE|Multiple osseous metastases involving C7, T1, T2, T3, T4, T5, T10, with a small amount of left anterolateral epidural tumor in T1. There was a small central right paramedian disk protrusion or osteophyte at T7-T8. There was no lumbar spine lesions on the MRI of the spine.
T1|thoracic (level) 1|T1,|173|175|REASON FOR CONSULTATION|He was seen by his family practitioner earlier today who obtained an MRI/MRA at the T2 level what appears to be non-enhancing mass involving the T2, as well as parts of the T1, and T3 vertebra. There is a mass effect upon the thecal sac in a somewhat circumferential fashion. After the scan was performed apparently the family physician by report talked to a Neurosurgeon up in _%#CITY#%_.
T1|thoracic (level) 1|T1|211|212|HOSPITAL COURSE|This had substantial effect on the underlying spinal cord and the patient was emergently taken to surgery. HOSPITAL COURSE: Unfortunately, the first surgery which was an anterior approach with fusion from C6 to T1 did not substantially change his neurologic status. After careful consideration, the patient was then returned to the operating room for a posterior decompression with laminectomy at that level as well.
T1|thoracic (level) 1|T1|169|170|OPERATIONS/PROCEDURES PERFORMED|ADMISSION DIAGNOSIS: Cervical stenosis with C8 radiculopathy. DISCHARGE DIAGNOSIS: Cervical stenosis with C8 radiculopathy. OPERATIONS/PROCEDURES PERFORMED: Right C7 to T1 minimally invasive posterior decompression. HOSPITAL COURSE: Mr. _%#NAME#%_ is a pleasant gentleman well- known to Dr. _%#NAME#%_.
T1|T1 (MRI)|T1|254|255|OPERATIONS/PROCEDURES PERFORMED|3. MRI of right knee and right proximal tibia. Impression: Interval decrease in size of enhancing interosseous lesion in the proximal lateral tibial metaphysis in comparison to the MRI from CDI dated _%#MM#%_ _%#DD#%_, 2006. Scattered areas of decreased T1 signal and increased T2 signal on fat saturation sequences in the femoral metadiaphyseal and diaphyseal regions. The findings were most consistent with hemopoietic marrow change versus less likely metastatic disease.
T1|tumor stage 1|(T1|152|154||I have been asked to see _%#NAME#%_ by his primary colorectal operative surgeon, Dr. _%#NAME#%_ _%#NAME#%_, regarding his diagnosis of likely stage III (T1 and 2 MX) rectal carcinoma. _%#NAME#%_ is a kind 51-year-old white male with a fairly unremarkable past medical history who was in his usual state of health until a recent colonoscopy which was requested for screening purposes by his primary care physician (Dr. _%#NAME#%_).
T1|tumor stage 1|T1|194|195|DISCHARGE MEDICATIONS|On _%#MMDD2007#%_, _%#NAME#%_ had a low anterior resection (LAR surgery) with fairly few complications. He is now at postoperative day 3 and doing well. Pathology from that procedure revealed a T1 lesion of moderately differentiated adenocarcinoma measuring 1.9 cm, invading into the submucosa. Somewhat surprisingly, however, 4 of the 12 submitted perirectal lymph nodes were positive for local metastatic spread (N2 nodal status).
T1|tumor stage 1|(T1|135|137|ASSESSMENT  AND PLAN|His electrolyte panel was normal with a creatinine of 0.94. A CEA level is pending from tonight. ASSESSMENT AND PLAN: Likely stage III (T1 N2 MX) rectal cancer. _%#NAME#%_ is at postoperative day #3 and doing well from his recent LAR surgery. Unfortunately, his localized spread of tumor to the perirectal lymph nodes indicates a need for systemic chemotherapy to maximize the chance that his disease does not recur in the near future (3-5 years).
T1|T1 (MRI)|T1|216|217|HISTORY OF PRESENT ILLNESS|This was confirmed here at the University of Minnesota Medical Center, Fairview, by an MRI on _%#MMDD2007#%_, which showed a large mass measuring 16 cm x 11.8 cm x 11 cm in size. This mass is slightly hypointense on T1 weighted images and slightly hyperintense on T2 weighted images. This mass was thought to have areas of apparent septation, which do no enhance.
T1|thoracic (level) 1|T1.|217|219|SYNOPSIS OF HISTORY AND PHYSICAL|Neurology consultation was obtained and Dr. _%#NAME#%_ ordered an MRI of the cervical spine which showed a solid fusion from C4 through C7 and mild degenerative retrolisthesis of C3-C4 and anterior subluxation C7 and T1. During the hospital course, the patient started feeling much better. The fullness of her head had resolved. The patient had also had a physical therapy evaluation during the hospital stay, and neurology recommended to discharge patient home, and PT recommendation was to discharge with home physical therapy.
T1|thoracic (level) 1|T1,|166|168|PAST MEDICAL HISTORY|8. History of right hip osteopenia. 9. History of scoliosis. 10. History of MRI at outside hospitalon _%#MMDD2000#%_ showing increased enhancement of left occipital, T1, and craniocervical junction area. 11. An echocardiogram obtained at the outside hospital on _%#MMDD2000#%_ showed left ventricle size and function with small MR and small pericardial effusion.
T1|thoracic (level) 1|T1|151|152|MAJOR PROCEDURES|4. Constipation. 5. Neutropenic fevers. MAJOR PROCEDURES: 1. MRI, C spine and L spine, _%#MMDD2007#%_ - slight progression of metastatic lesion in the T1 vertebrae. Compression fracture at T5. L1 vertebral body that appears abnormal. 2. MRI, L spine, _%#MMDD2007#%_ - worsening of metastatic disease in the L2 vertebrae and sacrum.
T1|thoracic (level) 1|T1|202|203|HOSPITAL COURSE|HOSPITAL COURSE: On _%#MMDD2007#%_, the patient underwent a right VATS drainage of his paraspinal abscess. Findings included a very thick capsule with overlying area in the upper thoracic spine between T1 and T4. This area was drained and only scant thick purulent fluid was obtained. The cavity was found to have communicated with the previously placed drain.
T1|tumor stage 1|T1|171|172|HISTORY OF PRESENT ILLNESS|1. Flexible bronchoscopy. 2. EGD with esophageal stent placement. 3. Esophagram. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 58-year-old male with a history of T1 esophageal cancer, status post esophagectomy on _%#MMDD2006#%_, was seen for increasing dysphasia. This has been a recurrent problem for the patient since esophagectomy.
T1|thoracic (level) 1|T1|335|336|ALLERGIES|Chemistries: Sodium 140, potassium 3.9, chloride 99, CO2 28, BUN 38, creatinine 1.05, glucose 131, calcium 9.6. LFTs: Total bilirubin 1.0, albumin 4.6, alkaline phosphatase 83, ALT 13, AST 25, amylase 56, lipase 81. IMAGING STUDIES: CT scan of the abdomen on admission showed dilated loops of bowel with apparent transition point near T1 with loops of bowel protruding beyond mesh which appears to be completely folded up onto itself. Findings were consistent with a small bowel obstruction. HOSPITAL COURSE: After admission and initial workup, on hospital day 2 the patient was taken to the operating room for repair of her ventral hernia.
T1|thoracic (level) 1|T1|149|150|HISTORY OF PRESENT ILLNESS|In _%#MM#%_ 2004, she had a new brain metastasis, received whole brain radiation and sterotactic radiation. She had metastatic disease to C7 through T1 and received radiation therapy. She was also started on temozolomide and then most recently received Tarceva, topotecan and Avastin.
T1|thoracic (level) 1|T1,|134|136|OPERATIONS/PROCEDURES PERFORMED|3. MRI of the spine. Findings; C-spine with multilevel disc disease and mild spinal stenosis of C3-C4, lumbar spine S2 with increased T1, T2 signal suggesting post trauma versus marrow replacement versus neoplasm. HOSPITAL COURSE: The patient is a 60-year-old woman who was transferred to Fairview University Medical Center following presentation for nonspecific symptoms of malaise, fatigue, and nausea which she attributed to having recent dental work.
T1|thoracic (level) 1|T1|294|295|STUDIES AND PROCEDURES THIS ADMISSION|2. The patient had a Doppler ultrasound of both his lower extremities on _%#MMDD2006#%_ which showed no evidence of deep venous thrombosis. 3. The patient had an MRI of his spine on _%#MMDD2006#%_ which showed compression fractures at T1, T6, T9, and T12 with evidence of osseous metastases at T1 with an extrusion to the posterior aspect of the T1 vertebral body into the anterior epidural space. The lumbar spine, however, showed no enhancement of abnormal signal intensity.
T1|tumor stage 1|T1,|86|88|FINAL DIAGNOSIS|FINAL DIAGNOSIS: Well to moderately differentiated adenocarcinoma, pathological stage T1, N0, M0. OTHER DIAGNOSES: 1. Waldenstrom's macroglobulinemia. 2. History of malignant melanoma.
T1|tumor stage 1|T1.|107|109|DISCHARGE DIAGNOSES|ADMISSION DATE: _%#MMDD2006#%_ DISCHARGE DATE: _%#MMDD2006#%_ DISCHARGE DIAGNOSES: 1. Head and neck cancer T1. 2. Severe symptomatic anemia secondary to bone marrow suppression by chemoradiation. BRIEF HISTORY: The patient is a 32-year-old gentleman with head and neck cancer T1, of the tongue, status post left radical neck dissection being treated with RTOG protocol 0234, including Cisplatin, and Erbitux, and ongoing external beam radiation, who presented to Radiation Oncology Clinic with a hemoglobin of 5, complaining of fatigue.
T1|thoracic (level) 1|T1|189|190|NEUROLOGIC EXAMINATION|There were some other intermittent patchy areas of an inability to localize light touch from pinprick in his right upper extremity. However, he can localize sensation in the C5, C6, C7 and T1 distribution bilaterally. He can also differentiate light touch from pinprick in the L5 and S1 distribution bilaterally. Reflexes: He has 1+ biceps and brachioradialis reflex bilaterally. He has 3+ with crossed extensor reflexes from patellar reflexes bilaterally.
T1|thoracic (level) 1|T1.|107|109|HISTORY OF PRESENT ILLNESS|She also underwent emergency decompression surgery at T6 and T7. She also had cervical syrinx at C7-C8 and T1. Since this accident she has had intractable left double pain refractory to multiple braces and she sustained flexion of the left elbow since the injury.
T1|thoracic (level) 1|T1|142|143|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Hypertension. 2. Longstanding angina that was evaluated by Cardiology with stress test. 3. Recent symptoms of C6-C7, T1 pain that was evaluated by MRI. 4. Denies any history of surgeries. PAST FAMILY HISTORY: Father: Cancer. Mother with diabetes PAST SOCIAL HISTORY: The patient denies any IV drug use or tobacco.
T1|thoracic (level) 1|T1,|172|174|PHYSICAL EXAMINATION|She has normal tone in her upper extremity and lower extremity muscle groups bilaterally. Sensation intact to light touch and pinprick without a sensory level in the C6-7, T1, L5 and S1 distribution bilaterally. She has good rectal tone, which increases upon Valsalva and once again there is no saddle anesthesia.
T1|tumor stage 1|T1|219|220|HISTORY OF PRESENT ILLNESS|This has been a recurrent problem since his esophagectomy. Patient was diagnosed with Barrett's in _%#MM2006#%_ and is status post esophagectomy with feeding tube removal on _%#MMDD2007#%_. Previous biopsies revealed a T1 esophageal cancer with 24 negative lymph nodes. Patient's last CT scan in _%#MM2007#%_ shows no recurrence. On _%#MMDD2007#%_, patient was diagnosed with dysphagia secondary to anastomotic stricture and is now status post dilation.
T1|T1 (MRI)|T1,|181|183|NEUROLOGICAL EXAMINATION AT TIME OF DISCHARGE|He also has 5/5 strength in his hip flexion, knee extension, knee flexion, dorsiflexion and plantar flexion bilaterally. Sensation is intact to light touch and pinch in the C6, C7, T1, L5 and S1 distribution bilaterally. He has a 3+ patellar reflexes bilaterally. No clonus bilaterally, but he does have up going toes bilaterally.
T1|T1 (MRI)|T1|131|132|HISTORY OF PRESENT ILLNESS|We were worried about ovarian neoplasm and wanted to watch her until the second trimester. She had an ultrasound again, MRI with a T1 analysis to look for fat and possibilities of dermoid cyst. We did not see these findings at approximately 15 weeks when there was no other findings other than these large ovarian masses.
T1|tumor stage 1|T1,|280|282|DISMISSAL SUMMARY|In the hilum there is an enlarged malignant appearing lymph node at the bifurcation of the 3 lobes and based on the location and appearance of this node the only option for resection would be a pneumonectomy. We then proceeded with pneumonectomy. The final pathological stage was T1, N1, M0. Postoperatively the patient was cared for on station 33. She did experience postop complication of some pneumonia in her left upper lobe.
T1|tumor stage 1|T1|108|109|FINAL DIAGNOSIS|FINAL DIAGNOSIS: Poorly differentiated adenocarcinoma of right lower lobe lung. Final pathological stage is T1 N0 M0. OPERATIVE PROCEDURE: On _%#MMDD2007#%_ a right video-assisted thoracoscopy and wedge resection of right lower lobe lung nodule and right thoracotomy, right lower lobectomy with mediastinal lymph node dissection was carried out.
T1|tumor stage 1|T1|56|57|FINAL DIAGNOSIS|FINAL DIAGNOSIS: Adenocarcinoma, right upper lobe lung, T1 N1 M0. SECONDARY DIAGNOSES: 1. Emphysema. 2. History of deep venous thrombosis.
T1|T1 (MRI)|T1|269|270|INTERVENTIONS/STUDIES/PROCEDURES|2. Transplant kidney ultrasound dated _%#MMDD2006#%_ - Impression: Left lower quadrant renal transplant with no hydronephrosis or perinephric fluid collection with satisfactory Doppler evaluation. 3. MRI of the cervical spine dated _%#MMDD2006#%_ - Impression: Foci of T1 and T2 hypointensity within the C3, C7 and possibly within the T5 vertebral body which show contrast enhancement and likely representing metastatic lesions.
T1|T1 (MRI)|T1|221|222|IMAGING STUDIES|Impression: A. No interval changes compared to previous examinations from _%#MM#%_ _%#DD#%_, 2006, and _%#MM#%_ _%#DD#%_, 2006. B. Extensive mucosal thickening involving paranasal sinuses. C. Subtle enhancement and vague T1 prolongation in right anterior upper parapharyngeal fat adjacent to right pterygoid musculature is unchanged. D. Bilateral mastoiditis, left greater than right. 2. Nuclear medicine gastric emptying study.
T1|thoracic (level) 1|T1|165|166|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 45-year-old patient with a history of an epidural esophageal fistula status post C7 infusion in 2004. He underwent a T1 to T12 laminectomy for evacuation of an epidural abscess in 2007. He is well known to the Thoracic service for esophageal leak, and despite multiple stent placements, he has had a persistent esophageal cutaneous fistula.
T1|tumor stage 1|T1|178|179|HISTORY OF PRESENT ILLNESS|2. Bilateral pelvic lymph node dissection. 3. Lysis of adhesion. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 74-year-old gentleman, who was recently diagnosed with grade III T1 bladder cancer with sarcomatoid features. A CT scan of the abdomen in _%#MM2007#%_ showed no definite suspicion of extravesical disease and no hydroureter or hydronephrosis.
T1|tumor stage 1|T1|123|124|PAST MEDICAL HISTORY|She was admitted for laryngopharyngectomy with flap coverage. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypothyroidism. 3. T1 or T2 squamous cell carcinoma of the larynx, status post chemoradiation. ADMISSION MEDICATIONS: 1. Zestril. 2. Synthroid. 3. Atenolol. 4. Norvasc.
T1|thoracic (level) 1|T1|65|66|PROCEDURES PERFORMED|ADMISSION DIAGNOSIS: Cervical dystonia. PROCEDURES PERFORMED: 1. T1 laminotomy for intrathecal catheter placement. 2. Intrathecal drug delivery system connection to the catheter. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 49-year-old female with diagnosis of cervical dystonia, which has been present for some time now.
T1|T1 (MRI)|T1|180|181|HISTORY|He underwent MRI scan of the abdomen and pelvis. No pelvic or periaortic lymph nodes were identified. There was low attenuation of the right side of the prostate at the base and a T1 lesion at the apex on the left side, and a T2 lesion with increased attenuation on the left. Prostate gland was reportedly mildly enlarged although non-impressive. The prostatic acid phosphatase was 0.5. Following discussion of the options for therapy the patient was interested in prostate brachytherapy.
T1|T1 (MRI)|T1|267|268|PROCEDURES|2. MRI of the brain with and without contrast, which revealed the presence of a rounded sharply defined mass that appears to be dural based on the right posterior frontal convexity with invagination into the underlying cortex. The lesion was centrally hypointense on T1 weighted imaging and hypertensive on T2 weighted imaging. On T2 gradient echo imaging, there was a central isointensity with peripheral irregular hypointensity consistent with calcification or hemorrhage following intravenous gadolinium this peripheral contrast enhancement around the margin of this lesion was measured 11 mm x 10 mm x 0.9 mm based on the MR characteristics that the lesion was most likely representing meningioma with calcific rim.
T1|T1 (MRI)|"T1|208|210|PROCEDURES|1. CT of the abdomen and pelvis, dated _%#MMDD2007#%_. Impression "right paraspinal soft-tissue mass, which appears inflammatory extending from T10-L1." 2. MRI of the abdomen dated _%#MMDD2007#%_. Impression "T1 hypointense and T2 hyperdense soft-tissue mass and left paraspinal soft tissue, is extending from T10-L1. No evidence for abscess or other complications. Neoplasm is felt less likely."
T1|thoracic (level) 1|T1,|396|398|NEUROLOGICAL EXAMINATION AT TIME OF DISCHARGE|Her tongue was midline on protrusion and she is moving all of her extremities with 5/5 strength in her deltoid, biceps, triceps, wrist extension, wrist flexion and intrinsic muscles of the hand and 5/5 strength in her hip flexion, knee extension, knee flexion, dorsiflexion and plantar flexion bilaterally. Sensation is intact to light touch and pinprick without a sensory level in the C6-C7 and T1, L5 and S1 distribution bilaterally. She has 2+ patellar reflexes bilaterally. There is no Achilles reflex bilaterally. There are equivocal toes bilaterally. Her gait is within normal limits and narrow based and she has normal tandem walking.
T1|thoracic (level) 1|T1|381|382|INVESTIGATIONS|INVESTIGATIONS: Reviewed. White count 5.1, hemoglobin of 10.3, platelets 67,000, sodium 130, potassium of 4, BUN 28, creatinine 1.59. Calcium is elevated at 11.9, total bilirubin is 1.7. Albumin is 2.8, alkaline phosphatase 156, AST 98, ALT 36, INR elevated at 1.64. CT spine done shows a few small bone metastases present, possibly the right base of the occiput, posterior C7 and T1 as well as the right first rib. Multiple level DJD. CT of the head done without contrast shows no acute intracranial process but there is significant heterogenicity of the bones with possible metastatic bone disease.
T1|tumor stage 1|T1,|109|111|SURGICAL PATHOLOGY|Her incision is healing well, and her pain is well controlled with oral pain medication. SURGICAL PATHOLOGY: T1, N0, Mx. The patient is ready for discharge home. DIET: Soft, low-residue diet. Advance as tolerated. ACTIVITY: Advance as tolerated.
T1|thoracic (level) 1|T1|410|411|HISTORY OF PRESENT ILLNESS|At followup, there was noted to be progressive subluxation and a fracture and therefore recommended admission to the University of Minnesota Medical Center, Fairview. On _%#MMDD2007#%_, he underwent a decompressive posterior cervical laminectomy, revision of an old decompression including removal of old bone fusion, posterior spinal cord and nerve root decompression, segmental instrumentation of C4 through T1 with pedicle screws, rods and cross connectors and anterior cervical C6 corpectomy with an anterior cervical spinal cord decompression and nerve root decompression at C5-C6 and C6-C7 bilaterally, structural allograft for anterior cervical arthrodesis of C5 through C7, anterior cervical plating of C5 through C7.
T1|thoracic (level) 1|T1|284|285|PROBLEMS ADDRESSED DURING TRANSITIONAL CARE STAY|She has a history of chronic pain syndrome and has had increasing discomfort associated with a neck injury that she relates to a motor vehicle accident in _%#MM2006#%_. She had cervical fusion in 2005. She comes in at this time for an elective decompressive laminectomy at C7 through T1 to assist with pain as well as right upper extremity myelopathy. She underwent a surgery on _%#MMDD2006#%_. Postoperatively, the most significant problem was ongoing pain management.
T1|T1 (MRI)|T1|151|152|HOSPITAL COURSE|Basic labs were checked. An MRI/MRA of the brain was performed. There was no evidence of acute infarction. There was increased T2 signal and decreased T1 signal throughout a petrous segment of the right internal carotid artery causing a moderate grade stenosis. There was mild dilatation of the lumen distal to the narrowing with concern for an intimal flap.
T1|tumor stage 1|T1,|166|168|HOSPITAL COURSE|The patient's labs were normal, and he was afebrile. His creatinine was 1.5 on discharge. His pathology report showed a 5 cm low grade organ confined papillary stage T1, N0, M0, renal cell carcinoma which is a favorable pathology report. The patient will be discharged from the hospital and scheduled to follow up with Dr. _%#NAME#%_ in 7 to 10 days.
T1|T1 (MRI)|T1|284|285|HISTORY OF PRESENT ILLNESS|It was consistent with a diagnosis of melanoma. There was no evidence of intracranial metastases, although, portions of the posterior brain were not included. Because of this, the patient was advised to return for additional images throughout the brain including pre-gadolinium axial T1 and post gadolinium axial and ______ sequences. There was enlargement of the adenoids, retropharyngeal and possibly internal jugular change lymphadenopathy.
T1|tumor stage 1|T1,|136|138|DISCHARGE DIAGNOSIS|He is able to keep up with his oral intake. He has also noted some left ear irritation. PAST MEDICAL AND SURGICAL HISTORY: 1. Stage III T1, N2 squamous cell carcinoma of the left tonsil status post a left neck mass excision, random biopsies, and left tonsillectomy on _%#MM#%_ _%#DD#%_, 2003.
T1|thoracic (level) 1|T1|233|234|PHYSICAL EXAMINATION|Lower extremities are without cyanosis or edema. Upper extremities are remarkable for clubbing in several digits. NEUROLOGIC: Grossly intact with the exception of sensory diminishment across the upper left torso in approximately the T1 through T4 dermatomes. DERMATOLOGIC: Unremarkable. PSYCHIATRIC: Affect is full range. LABORATORY DATA: White count 9.3, hemoglobin 11.9, platelets 354.
T1|tumor stage 1|T1|151|152|HISTORY OF PRESENT ILLNESS|An MRI was done that showed no vaginal masses or inguinal lymphadenopathy. The uterus was unremarkable. Further biopsies were undertaken and she had a T1 stage I adenocarcinoma of the distal vagina and further therapy was considered to be useful in the form of definitive radiation.
T1|thoracic (level) 1|T1|262|263|HISTORY OF PRESENT ILLNESS|See HPI. PAST SURGICAL HISTORY: Right inguinal hernia repair. HISTORY OF PRESENT ILLNESS: The patient presented approximately 3 weeks ago with weakness and some pain in the right upper extremity. He was found to have a large lung mass and a metastatic lesion to T1 vertebra. Lung biopsy demonstrated poorly differentiated non-small cell carcinoma end-stage IV disease. Palliative treatment was initiated with Decadron and radiation therapy to the T1 lesion.
T1|thoracic (level) 1|T1|172|173|HISTORY OF PRESENT ILLNESS|Lung biopsy demonstrated poorly differentiated non-small cell carcinoma end-stage IV disease. Palliative treatment was initiated with Decadron and radiation therapy to the T1 lesion. Since that time pain and paresthesias in the right upper extremity have largely resolved, but the patient continues to have some weakness in the right hand.
T1|thoracic (level) 1|T1|177|178|HOSPITAL COURSE|This demonstrated multiple metastatic lesions in the thoracic spine. No cord compression. There are microfractures of the superior endplate region of T12 of the above-mentioned T1 findings as previously known. IMPRESSION: 1. Severe back pain, which required narcotics and admission.
T1|tumor stage 1|T1,|287|289|DISMISSAL DIAGNOSIS|ADMITTING DIAGNOSIS: Right renal pelvic mass. PROCEDURE: _%#MMDD2007#%_, Right laparoscopic nephrectomy, ureterectomy. SURGEON: Dr. _%#NAME#%_ and Dr. _%#NAME#%_. DISMISSAL DIAGNOSIS: High-grade urothelial cell carcinoma of the right renal pelvis, superficial invasive, pathologic Stage T1, NX, MX. HOSPITAL COURSE: Uneventful. Prescription for Percocet, #36. Routine followup. _%#NAME#%_ _%#NAME#%_'s dismissal labs are recorded in the chart.
T1|thoracic (level) 1|T1|192|193||She had an MRA of the head without contrast, obtained _%#MM#%_ _%#DD#%_, 2001 showing tight stenosis of the proximal M2 segment, anterior and posterior branches, and mild stenosis of the left T1 segment. She had a carotid ultrasound study obtained on _%#MM#%_ _%#DD#%_, 2001 demonstrating left than 40% stenosis in the carotid bifurcation.
T1|thoracic (level) 1|T1.|244|246|SECONDARY DIAGNOSIS|PRINCIPAL DIAGNOSIS: Syncopal event. SECONDARY DIAGNOSIS: History of stage IVB adenocarcinoma of the tongue base with metastases to the cervical and thoracic spine. Recently status post C7 vertebrectomy with anterior cervical fusion from C6 to T1. DISCHARGE MEDICATIONS: 1. Zantac. 2. Colace. 3. Roxicet. 4. Increase potassium to 20 ml q.d.
T1|tumor stage 1|T1|94|95|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is a 58-year-old male with a history of T1 esophageal cancer, status post esophagectomy on _%#MMDD2006#%_. The patient was hospitalized in early _%#MM2007#%_ and found to have a gastrobronchial fistula for which a stent had been placed.
T1|thoracic (level) 1|T1|82|83|ADMITTING DIAGNOSIS|ADMITTING DIAGNOSIS: Cervical radiculopathy, left greater than right at C6-7, C7- T1 and severe spinal stenosis at C7-T1 with spondylolisthesis. PROCEDURE: C6-7, C7-T1 anterior cervical diskectomy and fusion. Mr. _%#NAME#%_ _%#NAME#%_ is a 61-year-old gentleman who developed worsening radicular symptoms in both arms, much worse on the left than the right.
T1|thoracic (level) 1|T1|117|118|HISTORY|Sensation was present in the left paraspinal area. However, it was absent in the left arm, including the C6,7,8, and T1 dermatomes. The T2 dermatome in the axilla was intact. She had no C-spine discomfort. She had full active range of motion of her C-spine, and had no midline tenderness of her C-spine.
T1|tumor stage 1|T1|217|218|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|ADMISSION DIAGNOSIS: Bladder cancer. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE: Radical cystectomy with Studer pouch neobladder. HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: This is 72-year-old male with history of T1 Grade III transitional carcinoma of the bladder with history of recurrence after a course of BCG who was admitted for a radical cystectomy and a neobladder.
T1|thoracic (level) 1|T1|235|236|LABORATORY DATA|CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: Without cyanosis, clubbing or edema. LABORATORY DATA: Lumbar spine MRI shows a large expansive lesion involving the central and left side of T1 vertebral body extending to the left posterior elements. CT of the chest reveals 2 x 1.3 cm left upper lobe ill-defined mass along with tiny 4 mm nodule on the major fissure superiorly.
T1|T1 (MRI)|T1|149|150|LABORATORY STUDIES|There is mild pretumoral edema in the larger mass within the deep white matter. The MRI finding consists of four high signal T1 and T2 and enhancing T1 lesions consisting of a left brain stem (pons) with mild mass affect measuring 2.3 cm, right cerebellar mass measuring 1 cm, as well as two lesions in the posterior right periventricular deep white matter measuring 1.8 cm and 0.9 cm.
T1|tumor stage 1|T1|176|177|COMPLICATIONS|OPERATIONS/PROCEDURES PERFORMED: Direct laryngoscopy plus KTP laser resection of the right tongue base lesion. COMPLICATIONS: None. The patient presented with a diagnosis of a T1 lesion of the base of the tongue. The patient was taken to the operating room on _%#MM#%_ _%#DD#%_, 2005, and underwent the procedures described above.
T1|thoracic (level) 1|T1,|162|164|HISTORY OF PRESENT ILLNESS|His most recent oncology follow-up was approximately 10 days ago. He underwent a repeat MRI of his spine in _%#MM2003#%_ which demonstrated metastatic lesions at T1, T2, T7, T12, L1, L2, L3, L4. There was also evidence of prominent epidural extension tumor, as well as encroachment on the thecal sac and question of epidural extension.
T1|thoracic (level) 1|T1|258|259|MAJOR PROCEDURES PERFORMED|MAJOR PROCEDURES PERFORMED: 1. Posterior partial vertebrectomy and rib resection T3 through T5 performed by Dr. _%#NAME#%_, on _%#MM#%_ _%#DD#%_, 2003. 2. Closure of large back wound by Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2003. 3. Segmental instrumentation T1 through T7 and facette fusion T1 through T2 and T6 through T7 performed on _%#MM#%_ _%#DD#%_, 2003. HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: Ms. _%#NAME#%_ is a 65-year-old female who had recurrence of a fibrosarcoma involving the posterior chest wall.
T1|thoracic (level) 1|T1|281|282|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ was admitted on _%#MM#%_ _%#DD#%_, 2004, with the diagnosis of congenital-acquired cervical stenosis. HOSPITAL COURSE: On the day of admission he underwent an uncomplicated canal expanding cervical laminoplasty from inferior C3 through upper T1 and a segmental plate fixation at each level. He also underwent a foraminotomy at the left C6-C7 for decompression of the C7 nerve root.
T1|thoracic (level) 1|T1,|268|270|STUDIES DURING THIS HOSPITAL STAY|1. MRI of the head, cervical spine, thoracic spine, and lumbar spine: There is moderatespinal stenosis at C5 to 6, with slight flattening of the right ventral spinal cord due to severe disk bulging with degenerative changes, not metastases. Metastases are seen at C7, T1, and T2. Known abnormal marrow in the sacrum and iliac bones is again seen. 2. Chest film: Large mass in the left lung, retraction of inferior pleura, opacity in the right lower lobe and minor fissure, small left pleural effusion, unchanged from prior.
T1|thoracic (level) 1|T1|188|189|PROCEDURE/STUDIES PERFORMED|7. No evidence of spinal cord or nerve root compression. 8. Sclerotic focus in the anterior aspect of the T2 vertebral body. 9. C-spine showed abnormal contrast enhancement throughout the T1 vertebral body and posterior elements. 10. Broad-based posterior disk bulge with superimposed focal disk herniation and posterior osteophyte formation in C4 and C5 resulting in mild spinal cord impingement.
T1|thoracic (level) 1|T1|155|156|PROCEDURE PERFORMED|ADMISSION DIAGNOSIS: Cervical medullary cavernous malformation. DISCHARGE DIAGNOSIS: Cervical medullary cavernous malformation. PROCEDURE PERFORMED: C6 to T1 posterior cervical laminectomy and resection of intramedullary cavernous malformation. HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old woman who was seen in the Neurosurgery Clinic with complaints of dysesthetic pain.
T1|T1 (MRI)|T1.|192|194|RADIOLOGY|The components extend from the lower pontine region in the fourth ventricle superiorly to the midbrain. The tumor does brightly enhance with contrast. It is bright on T2. It is hypointense on T1. The patient does have significant ventriculomegaly but no sign of transependymal cerebrospinal fluid flow. On the axial cuts it does appear that her fourth ventricle is nearly entirely obstructed by the mass.
T1|tumor stage 1|T1,|171|173|OPERATIONS/PROCEDURES PERFORMED|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 52-year-old male well known to Dr. _%#NAME#%_ in the otolaryngology service. He has a past medical history significant for T1, N0 squamous cell carcinoma of the right lateral tongue, for which he underwent a marginal resection by Dr. _%#NAME#%_ of oral surgery in _%#MM#%_ of 2002. The patient was followed by Dr. _%#NAME#%_ postoperatively and presented with a recurrence in the right lateral tongue and floor of mouth in the autumn of 2003.
T1|tumor stage 1|T1|213|214|HOSPITAL COURSE|She was given prescription for Vicodin and told to follow-up with us in two to three weeks. The pathology report from the specimen revealed a moderately differentiated adenocarcinoma within the polyp. There was a T1 N0M0 carcinoma. The CEA level at the time of admission was 1.5. This corresponds to a Stage I cancer. No adjuvant therapy was offered to patient.
T1|tumor stage 1|T1|206|207|ADMITTING SURGEON|HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old gentleman who has a very complex past medical history. He is a patient with a really bad peripheral vascular disease. The patient had a diagnoses of T1 carcinoma of the floor of the mouth. He has only 1 functioning carotid artery because the right carotid artery is totally occluded.
T1|T1 (MRI)|T1|153|154|HISTORY|That study demonstrated multiple hyperintensities in T2-weighted sequences. Some of the areas showed ring-enhancing qualities in the gadolinium-enhanced T1 sequences. The patient was advised to come to the emergency department at Fairview- University Medical Center from which she was admitted for assessment.
T1|tumor stage 1|(T1,|181|184|HOSPITAL COURSE|This was discussed with the patient and his family. The final pathology report on his colon revealed a well-differentiated adenocarcinoma of the cecum with 0/5 lymph nodes positive (T1, N0, M0). No further treatment would be required for this except for follow- up colonoscopy in one year along with a CT scan of his liver to ensure there is no metastatic disease.
T1|thoracic (level) 1|T1|52|53|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Vertebral wedge fracture at T1 level. 2. Hyponatremia. SECONDARY DIAGNOSES: 1. Hypertension. 2. Gastroesophageal reflux disease.
T1|thoracic (level) 1|T1|163|164|ADMISSION HISTORY OF PRESENT ILLNESS|Briefly, this is an 88-year-old female with a history of a fall. She was referred from Smiley's Clinic secondary to the fall and a vertebral wedge fracture at the T1 level. While she was in the clinic 2 days after the fall, basic labs were done which showed the hyponatremia with a sodium of 121.
T1|T1 (MRI)|T1|252|253|PROCEDURES PERFORMED|5. MRI of the brain with and without contrast. This demonstrated 5-10 foci of T2 hyperintensity within the cerebral white matter, consistent with a clinical suspicion of demyelinating disease. Also, no contrast- enhancing lesions present and symmetric T1 hyperintensity of the head with a caudate nuclei on the anterior putamen bilaterally, consistent with long-standing hypercalcemia.
T1|term 1|T1,|98|100|DOB|DOB: This is a 35-2/7 week estimated gestational age male, delivered vaginally at 2215 g to a G3, T1, P1, AB0, white female. The mother is A-, hepatitis B negative, GBS pending and the patient's mother had been given RhoGAM on _%#MMDD2005#%_.
T1|tumor stage 1|T1.|152|154|FOLLOW UP|She will then followup with Dr. _%#NAME#%_ at Lakes Clinic in the future. Ultimately, a pathology showed papillary RCC, grade 2 to 3 Fuhrman. Stage was T1. She was sent home with prescription for Colace, Percocet, told her we are to be informed if she has fever greater than 101.5 or any problems with symptoms of anemia.
T1|thoracic (level) 1|T1.|219|221|OPERATIONS/PROCEDURES PERFORMED|ADMISSION DIAGNOSIS: Herniated nucleus pulposus, C7-T1. DISCHARGE DIAGNOSIS: Status post anterior cervical diskectomy and fusion, C7-T1. OPERATIONS/PROCEDURES PERFORMED: Anterior cervical diskectomy and fusion of C7 to T1. HOSPITAL COURSE: The patient was admitted after his ACDF on _%#MM#%_ _%#DD#%_, 2005.
T1|tumor stage 1|T1|116|117|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ is a 46-year-old woman with a remote history of transanal excision of a T1 rectal cancer by Dr. _%#NAME#%_ in 1988. She had been followed regularly for this and did develop a recurrent polyp at the site, which had in situ carcinoma.
T1|tumor stage 1|T1|182|183|FINAL DIAGNOSES|FINAL DIAGNOSES: 1. Well differentiated bronchoalveolar carcinoma, right upper lobe lung. Pathological stage T1 N0 M0. 2. Carcinoid tumor, right middle lobe lung. Pathological stage T1 N0 M0. PROCEDURE: Right thoracotomy, wedge resection of right middle lobe lung nodule.
T1|thoracic (level) 1|T1.|244|246|HOSPITAL COURSE|MR angiogram was essentially normal. There may have been mild narrowing of the left vertebral artery at its origin, although it was felt this could be artifact. Cervical MRI did reveal evidence of apparent hydromyelia or syrinx from C2 through T1. Other moderate degenerative changes were seen in the mid cervical level. Echocardiogram did not reveal any embolic source or endocarditis. Blood cultures were unremarkable.
T1|tumor stage 1|(T1,|244|247|HISTORY OF PRESENT  ILLNESS|CHIEF COMPLAINT: GI bleeding. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 79-year-old patient who is well known to me. He has severe COPD and underwent a right hemicolectomy with ileal transverse colostomy for a cecal adenocarcinoma (T1, N0, M0) on _%#MMDD2005#%_. This had been a bleeding tumor. Postoperatively the course was complicated by fascial dehiscence requiring re-exploration and placement of retention sutures.
T1|thoracic (level) 1|T1|256|257||Ms. _%#NAME#%_ _%#NAME#%_ is an 83-year-old female admitted on _%#MMDD2006#%_ with intractable back pain. The patient has long-standing history of chronic back pain with an exacerbation in _%#MM#%_ after following a fall, documented compression fractures, T1 and T3, but increasing pain recently. PAST MEDICAL HISTORY: Essential hypertension and gastroesophageal reflux. INITIAL PHYSICAL EXAMINATION: Multiple areas of point tenderness on palpation of the back.
T1|tumor stage 1|T1|101|102|FINAL DIAGNOSIS|FINAL DIAGNOSIS: Moderately differentiated adenocarcinoma, right lower lobe lung, pathological stage T1 N0 M0. OTHER DIAGNOSIS: 1. Hypertension 2. Hyperlipidemia 3. History of smoking
T1|thoracic (level) 1|T1.|102|104|PAST SURGICAL HISTORY|The patient is currently undergoing cycle analysis. PAST SURGICAL HISTORY: Osteoblastoma removed from T1. This presented as pain under her shoulder blade. FAMILY HISTORY: Aunt had migraines, grandmother had stroke, grandfather had cancer.
T1|thoracic (level) 1|T1|239|240|LABORATORY|Given the history of pattern, this most likely represents active demyelination. Minimum nonspecific biventricular white matter changes. MRI of cervical spine with and without contrast shows subtle area of increasing ___in thoracic cord at T1 level which is nonspecific, could be small area of myelitis and demyelination. MRI of thoracic spine with and without contrast showed increasing ____thoracic cord at T1 level suggestive of small area of myelitis or demyelination.
T1|tumor stage 1|T1|21|22|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: T1 N0 M0 left upper lobe lung cancer. DISCHARGE DIAGNOSIS: T3 N2 M0 left upper lobe lung squamous cell cancer. OPERATIONS/PROCEDURES PERFORMED: VATS left upper lobectomy. HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old woman who was diagnosed with left upper lobe non-small-cell lung cancer.
T1|thoracic (level) 1|T1|112|113|OPERATIONS/PROCEDURES PERFORMED|ADMISSION DIAGNOSIS: T2 pathologic fracture secondary to head and neck cancer. OPERATIONS/PROCEDURES PERFORMED: T1 through T3 pedicle fusion with T2 instrumentation and corpectomy. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is 59-year-old female with a history of head and neck cancer that has metastasized to T2 vertebral body.
T1|thoracic (level) 1|T1|195|196|HOSPITAL COURSE|He had a negative CT of the cervical C-spine; however, he had a tender lower cervical spine, and therefore, underwent flexion and extension views in radiology. These did not adequately visualize T1 due to the patient's size. He therefore went to an MRI which was negative, and the cervical collar was removed.
T1|T1 (MRI)|T1|150|151|HISTORY|He denies any pain or constitutional symptoms. MRI showed a large anterior medial thigh consistent with intramuscular lipoma. There is intense fat on T1 and T2 imaging. It is intermittently associated with femoral vessels, but does not encase these structures. It is likely an intramuscular lipoma. This may be an atypical presentation that has recurred significantly over a relatively short period of time.
T1|tumor stage 1|T1,|226|228|DISMISSAL SUMMARY|Mediastinal lymph node dissection was initially negative but on permanent section there was some small microscopic foci of metastatic disease in the subcarinal and right paratracheal lymph nodes. Final pathological stage is a T1, N2, M0 and the resection is complete. The final pathological stage is stage III-A. The patient's postoperative course was uneventful.
T1|thoracic (level) 1|T1|156|157|HISTORY OF PRESENT ILLNESS|OPERATIONS: Cystectomy with continent catheterizable stoma. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 66-year-old female with a history of T1 spinal cord injury due to MVA in 1980 resulting in bilateral lower extremity paralysis. Previously, the patient was spontaneously voiding and using a Crede maneuver.
T1|thoracic (level) 1|T1|217|218|HOSPITAL COURSE|PROBLEM #2. Cord compression: Patient did have signs and symptoms of acute spinal cord compression with lower extremity weakness and bladder/bowel incontinence. MRI demonstrated obliteration of the spinal column from T1 to T3. Patient was started on Decadron 6 mg IV q. 6 hours along with localized radiation therapy to the lesion in the spine.
T1|tumor stage 1|T1,|113|115|FINAL DIAGNOSIS|FINAL DIAGNOSIS: Grade 3 neuro-endocrine carcinoma, large cell type, left lower lobe lung. Final pathology stage T1, M0, N0. OPERATIVE PROCEDURE: On _%#MMDD2007#%_ a left thoracotomy, left lower lobectomy with mediastinal lymph node dissection was carried out.
T1|thoracic (level) 1|T1|253|254|IMPORTANT STUDIES|He was admitted with progressive weakness and worked up. IMPORTANT STUDIES: CT of his cervical, thoracic, and lumbar spines which showed a significant increase in size of the soft tissue mass involving the spinal canal and tracing for the distortion at T1 and T3 vertebrae. These were almost completely destroyed by tumor. It also appeared that the right T1 screw appeared unstable because of the destructive mass.
T1|T1 (MRI)|T1|240|241|PROCEDURES PERFORMED|1. Lumbar x-ray (_%#MMDD2006#%_): Severe degenerative disk disease of L3-4 and L4-5, unchanged from previous examination on _%#MMDD2004#%_. No acute osseous abnormality in the lumbar spine. 2. MRI lumbar spine (_%#MMDD2006#%_): Two foci of T1 hypointensity within the L1 vertebral body that enhances with IV gadolinium. This is suspicious for metastatic disease. Correlation with bone scan recommended.
T1|tumor stage 1|T1|224|225|DISMISSAL SUMMARY|The thoracotomy, left upper lobectomy was performed. The final pathology showed a 2.2 cm moderately differentiated adenocarcinoma. All mediastinal and peribronchial lymph nodes were negative. The final pathological stage is T1 N0 M0. The patient's postoperative course was uneventful. The patient was in good condition.
T1|thoracic (level) 1|T1|178|179|PAST MEDICAL HISTORY|2. History of migraine. 3. History of asthma. 4. History of motor vehicle accident in _%#MM#%_ of this year. He has been on fentanyl for neck pain for broken vertebra; C6, 7 and T1 per his report. They have been trying recently to taper his fentanyl and now he is down to 25 mcg q.3 days of fentanyl.
T1|tumor stage 1|T1|151|152|DISCHARGE DIAGNOSIS|PROCEDURE: _%#MMDD2007#%_ - Enterolysis, laparoscopic right radical nephrectomy. HOSPITAL COURSE: Uneventful. DISCHARGE DIAGNOSIS: Grade 4, pathologic T1 N0 M1, Stage IV renal cell carcinoma. _%#NAME#%_ _%#NAME#%_ was dismissed with routine followup. To be evaluated by oncology as an outpatient.
T1|thoracic (level) 1|T1|129|130|PROCEDURES PERFORMED DURING THIS HOSPITALIZATION|2. CT of the neck to evaluate for cervical stenosis. There was significant loss of disk space height at C4-5, C5-6, C6-7, C7 and T1 levels. Overall, this was interpreted as diffuse degenerative changes with no significant spinal cord impingement, mild-to-moderate neuroforaminal narrowing throughout the cervical spine and nerve root impingement cannot be completely excluded by this exam.
T1|T1 (MRI)|T1|212|213|DIAGNOSTIC PROCEDURES|Thin linear band of the right frontal region showing the same signal characteristic of the cerebral cortex in all sequences suggestive for gray matter heterotopia. A 2.7 x 1 cm fusiform shaped slightly lobulated T1 hypointense and T2 hyperintense mass in the cistern of the velum interpositum probably an arachnoid cyst. 2. Chest x-ray on _%#MMDD2006#%_. Findings: The lungs and pleural spaces are clear.
T1|T1 (MRI)|T1|146|147|IMAGING STUDIES|There is mild mass effect on the dural sac. Central canal and neural foramen are adequate. 3. MRI of the brain shows high signal basil ganglia on T1 weighted images which can be consistent with liver disease; otherwise, normal study. 5. EEG is unremarkable. No gross seizure-like activity.
T1|tumor stage 1|T1|101|102|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 63-year-old white woman who has a previous history of stage I, T1 N0 M0, non-small-cell lung cancer of the left lower lobe, for which she underwent resection approximately 5 years ago. She is from the _%#CITY#%_ area and was recently visiting family and friends when she was brought to the emergency room at Fairview Southdale Hospital due to complaints of nausea, weakness in her left arm, difficulty with her walking and speech and mental cognition.
T1|T1 (MRI)|T1|246|247|IMPRESSION/PLAN|Chemistry profile is pending. IMPRESSION/PLAN: _%#NAME#%_ is an unfortunate woman with metastatic extensive stage small cell lung cancer, status post two cycles of chemotherapy and radiation to the brain, left shoulder and humerus, including the T1 region with good response to her fist two cycles of chemotherapy. Unfortunately, she has not been able to restart chemotherapy, which was due about a week ago.
T1|tumor stage 1|T1,|127|129|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 55-year-old male who had recent transurethral resection of a bladder tumor showing grade T1, grade 3 bladder cancer. Options were discussed with the patient, and he elected to undergo re-resection of the prostatic tissue which had also showed some minimal invasion in the prostate.
T1|thoracic (level) 1|T1.|173|175|FOLLOW-UP  INSTRUCTIONS|On the day of admission, he underwent an uncomplicated revision anterior exposure, and extensive and somewhat tedious removal of the cervical plate in place from C3 through T1. A nonunion was identified, resected, and bone grafted with autogenous iliac crest bone graft. The patient tolerated the procedure well. He was mobilized slowly and deliberately.
T1|tumor stage 1|T1|72|73|FINAL DIAGNOSES|ADMITTING DIAGNOSIS: Polypoid lesion, splenic flexure. FINAL DIAGNOSES: T1 carcinoma of the splenic flexure. PROCEDURE: Colonoscopy, insertion of double lumen venous catheter and partial left colon resection with a left transverse to descending, 4-0 silk one layer anastomosis.
T1|tumor stage 1|T1|294|295|BRIEF HISTORY|No evidence of malignancy. BRIEF HISTORY: This is a 51-year-old male who presented with gross hematuria on _%#MMDD2003#%_ to Dr. _%#NAME#%_ at Fairview Lakes Hospital. The patient underwent transurethral resection of a bladder tumor after that presentation, with pathology showing a high grade T1 lesion involving an extensive part of the posterior wall of the bladder. The risks and benefits of radical cystectomy with neobladder construction were discussed with the patient and he agreed to proceed after appropriate counseling.
T1|thoracic (level) 1|T1|120|121|PAST MEDICAL HISTORY|He had two separate surgeries in 2002, initially a C3 through C7 laminectomy and then a second surgery involving C7 and T1 for spinal stenosis and apparently a cyst that had formed. He was left with some weakness on his left side, as mentioned above.
T1|tumor stage 1|T1|11|12|DIAGNOSIS|DIAGNOSIS: T1 rectal cancer, removed by polypectomy procedure. Exploratory laparotomy extended low anterior resection. Ureteral stent placement. HISTORY OF PRESENT ILLNESS: This is a 30-year-old woman who experienced some rectal bleeding some time ago.
T1|thoracic (level) 1|T1|147|148|HISTORY OF PRESENT ILLNESS|She denies pain with movement. She has no difficulty swallowing or breathing. Previous MRIs in _%#MM#%_ showed a mass at the C2 vertebral body and T1 vertebral body. The MRI was consistent with extensive mets to the skeleton, subcutaneous tissue, and adrenal glands. Since her diagnosis on _%#MMDD#%_, she has been treated with one cycle of Taxol and carboplatin.
T1|T1 (MRI)|T1|276|277|LABORATORY STUDIES|No extremity edema. LABORATORY STUDIES: Pending at this time. MRI of the brain shows a 7 x 8 mm mass in the superior left temporal lobe with no significant mass effect. There is a surrounding rim of hypointensity, suggestive of a hemosiderin rim. This mass is hyperintense on T1 and hyperintense on T2 sequences. There is no midline shift. MRA shows normal anatomy of cerebral arteries. IMPRESSION: The patient is a 22-year-old right-handed African American female with a family history of aneurysm who presents with a one-day history of headache and nausea, as well as a transient episode of blurry vision.
T1|tumor stage 1|T1|100|101|FINAL DIAGNOSIS|FINAL DIAGNOSIS: Moderately differentiated adenocarcinoma, left lower lobe lung, pathological stage T1 NO, MO. OTHER DIAGNOSIS: COPD. PROCEDURE: _%#MM#%_ _%#DD#%_, 2004: Left thoracotomy, left lower lobectomy, and mediastinal lymph node dissection.
T1|tumor stage 1|T1,|215|217|HOSPITAL COURSE|OPERATIONS/PROCEDURES PERFORMED: 1. Gastrostomy tube placement. 2. Upper GI endoscopy. HOSPITAL COURSE: Mr. _%#NAME#%_ is a 75-year-old gentleman with a history of squamous cell carcinoma of the supraglottis, stage T1, N1, who is status post an endoscopic laser supraglottic laryngectomy on _%#MM#%_ _%#DD#%_, 2004, as well as a right modified radical neck dissection.
T1|thoracic (level) 1|T1|208|209|PAST MEDICAL HISTORY|Lipase is normal. UA showed moderate leukocyte esterase and 2-5 white blood cells. PAST MEDICAL HISTORY: Surgery: Right knee arthroscopy for cartilage removal in 1997 and she had a cervical fusion from C4 to T1 she states in 1999 after trauma. Major Disease: She has not had any major medical disease processes, but has had mild left-sided weakness after her trauma.
T1|tumor stage 1|T1|180|181|FINAL DIAGNOSIS|FINAL DIAGNOSIS: Non-small cell carcinoma, right lower lobe lung, with metastases to the subcarinal, tracheobronchial angle, and right paratracheal lymph nodes. Pathological stage T1 N2 M0. OTHER DIAGNOSES: 1. Hypertension. 2. Stable ascending thoracic aneurysm. 3. History of smoking. PROCEDURES: On _%#MM#%_ _%#DD#%_, 2005: Right exploratory thoracotomy with mediastinal lymph node dissection.
T1|T1 (MRI)|T1|218|219|DISCHARGE DIAGNOSIS|Following admission the patient underwent an MRI of the abdomen which revealed a diffuse neoplasm involving the left lobe of the liver, heterogeneous and diffuse homogeneous, increased T2 weight signals with decreased T1 weighted signal involving the medial and lateral segments of the liver. Some involvement of the medial aspect of segment VIII of the right lobe of the bladder.
T1|tumor stage 1|T1|237|238|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 38-year-old gentleman who was found to have a left testicular mass, status post left radical orchiectomy via inguinal incision. Pathology revealed a pure seminoma and was considered T1 disease. As a staging workup, CT of the abdomen revealed a 3 x 3-cm mass surrounding the right common iliac artery.
T1|tumor stage 1|T1|27|28|PRINCIPAL DIAGNOSIS|PRINCIPAL DIAGNOSIS: Stage T1 papillary renal cell carcinoma. OTHER DIAGNOSES: 1. Chronic obstructive pulmonary disease. 2. Urethral stricture. 3. Backache.
T1|tumor stage 1|T1,|21|23|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: T1, N1, M0 infiltrating ductal carcinoma of the left breast. OPERATIONS/PROCEDURES PERFORMED: Lymphatic mapping, left axillary sentinel lymph node biopsy, left axillary lymph node dissection, and left breast lumpectomy on _%#MM#%_ _%#DD#%_, 2005.
T1|tumor stage 1|T1|360|361|BRIEF HISTORY|The patient saw Dr. _%#NAME#%_ in consultation and discussed the risks and benefits of having a re-resection of the site to look for any residual disease that may or may not be muscle invasive with approximately 20% to 30% chance of this. The patient originally was scheduled for a cystectomy with the outside urologist, but due to the fact that it was just a T1 tumor he did discuss the possibility of just doing a re-resection and proceeding with BCG therapy. At this point, the patient presents now for a re-resection of his tumor.
T1|tumor stage 1|T1|81|82|FINAL DIAGNOSIS|FINAL DIAGNOSIS: Multiple squamous cell carcinoma right lung, pathological stage T1 NXM0. OTHER DIAGNOSES: 1. History of testicular lymphoma. 2. History of smoking.
T1|thoracic (level) 1|T1|72|73|ADMITTING DIAGNOSIS|Consulting Neurosurgeon: Dr. _%#NAME#%_ _%#NAME#%_ ADMITTING DIAGNOSIS: T1 spinous process fracture. _%#NAME#%_ _%#NAME#%_ is a 30-year-old gentleman who was seen in neurosurgical consultation on _%#MMDD2006#%_ following a bicycling accident in which he was riding home from the bar and went down an embankment and flipped over the handlebars.
T1|thoracic (level) 1|T1|165|166|PAST MEDICAL HISTORY|She had been symptom free since that time. 2. Hyperlipidemia. 3. Hypertension. 4. Recently diagnosed diabetes, diet controlled. 5. Postherpetic neuralgia, the right T1 distribution since _%#MM2006#%_. ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: 1. Nifedipine XL 90 mg p.o. daily.
T1|T1 (MRI)|T1|207|208|HISTORY OF PRESENT ILLNESS|This was confirmed at the University of Minnesota Medical Center, Fairview, by an MRI, which was done in _%#MM2007#%_. This showed a large mass measuring 16 cm x 12 cm x 11 cm in size and was hypointense on T1 weighted images and hyperintense on T2 weighted images. No extracapsular invasion was seen. A differential diagnosis based on the imaging available was focal nodular hyperplasia versus fibrolamellar variant of hepatocellular carcinoma.
T1|tumor stage 1|T1,|124|126|HISTORY OF PRESENT ILLNESS|He has no evidence of mediastinal adenopathy or other metastatic disease by either history or CT. His tumor at this time is T1, N0. HOSPITAL COURSE: The patient was admitted to the hospital on _%#MMDD2007#%_ for an elective right upper lobectomy and a mediastinoscopy with lymphadenectomy.
T1|thoracic (level) 1|T1|185|186|DISCHARGE MEDICATIONS|Plain films of _%#NAME#%_'s cervical spine showed a deformity of C1 with fused additional vertebral body and platyspondyly (i.e. flatness) of the cervical spine. In the thoracic spine, T1 and T2 were fused on the right, and T9 and T10 were fused centrally. These abnormalities are consistent with a diagnosis of OAV syndrome.
T1|thoracic (level) 1|T1|273|274|ASSESSMENT AND PLAN|MRI of the cervical spine shows probable metastatic disease to the T1 vertebra with epidural tumor compression of the spinal cord, as well as multilevel degenerative disc disease. ASSESSMENT AND PLAN: A 67-year-old male with what appears to be metastatic lung cancer, with T1 vertebral involvement and spinal cord compression with subacute neurologic compromise. Will admit the patient to expedite workup and therapy of his spinal metastatic lesion.
T1|thoracic (level) 1|T1|239|240|HISTORY OF PRESENT ILLNESS|Given his history of tobacco use, a chest x-ray was performed which revealed a very large, right perihilar mass suspicious for neoplasm. Given this, an MRI of the cervical spine was performed which showed an infiltrative process above the T1 vertebrae suspicious for metastatic disease. Given this, urgent neurosurgical and oncology consultation was obtained. The patient was admitted for further treatment.
T1|T1 (MRI)|T1|235|236|MAJOR IMAGING AND INVESTIGATIONS DONE DURING HOSPITALIZATION|Impression: Lucent lesions within thoracic vertebral bodies.(the right pedicle of T5 as well as posterior centrally within the T11 vertebral body.) 3. MRI spine with and without contrast, _%#MMDD2007#%_. Impression: Areas of increased T1 and T2 signal in several thoracic vertebra which do not demonstrate definite contrast enhancement. These are likely hemangiomas. The thoracic vertebra and spinal cord otherwise appears grossly within normal limits.
T1|thoracic (level) 1|T1|80|81|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: Left upper extremity weakness and numbness superimposed on T1 distribution, left upper extremity pain. PAST MEDICAL HISTORY: Notable for rheumatoid arthritis, tobacco abuse and alcohol use.
T1|thoracic (level) 1|T1|172|173|HOSPITAL COURSE|He noted some sensation in his hands, no pain. His whole arm felt numb and weak. It was not cyanotic or cold. He had no other signs or symptoms. He had no worsening of the T1 dermatomal pain that he had earlier. The weakness apparently lasted for approximately 45 minutes. He went to _%#CITY#%_ _%#CITY#%_ Medical Center clinic.
T1|thoracic (level) 1|T1|261|262|HOSPITAL COURSE|No other neurologic abnormalities. The patient no longer had symptoms at _%#CITY#%_ _%#CITY#%_ Medical Center Urgent Care in the emergency room. On exam his neurologic exam was persistently normal except for decreased grip strength. He also had increase in his T1 dermatomal like pain with abduction of the arm. Procedures for thoracic outlet obstruction including wrist chest and modified tests were unremarkable.
T1|thoracic (level) 1|T1.|348|350|ASSESSMENT|He has 2+ bilateral patellar reflexes with downgoing toes. RADIOLOGY: Images reviewed include an x-ray and a CT scan as well as an MRI, which demonstrate a compression fracture of T11 and the MRI scan demonstrates that this is an acute fracture. LABORATORY DATA: Pending. ASSESSMENT: This is a 77-year-old man with an acute compression fracture at T1. RECOMMENDATIONS: 1. Pain control. 2. TLSO. 3. Physical Therapy, Occupational Therapy, and Physical Medicine and Rehabilitation consultation.
T1|tumor stage 1|T1,|147|149|HOSPITAL COURSE|Final pathology revealed renal cell carcinoma, grade II, measuring 3.0 cm by 3.2 cm and confined to the kidney. Her pathologic state was therefore T1, NX, M0.
T1|tumor stage 1|T1|141|142|HISTORY OF THE PRESENT ILLNESS|The patient was referred to Dr. _%#NAME#%_ due to the elevated prostate specific antigen. Ultrasound and biopsy was done with a diagnosis of T1 tumor, I do not have the pathology report. PAST MEDICAL HISTORY: 1. Hypertension 2. Migraine 3. Recently diagnosed with prostate cancer.
T1|thoracic (level) 1|T1|139|140|HISTORY OF PRESENT ILLNESS|Otherwise, the patient tolerated her chemotherapy well. Her prior courses of chemotherapy have also been complicated by bony metastases to T1 through T12. She is now status post an anterior L1 vertebrectomy with allograft and plate fixation on _%#MMDD2002#%_. Postoperatively the patient developed a left empyema which required surgical drainage.
T1|tumor stage 1|T1,|198|200|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Adenocarcinoma of the lung. Status post right upper lobectomy at Regions Hospital in _%#MM2001#%_. Pathology revealed one positive lymph node, giving the tumor a stage IIA, T1, N1, M0. Official pathological report reads right upper lobectomy with mediastinal lymphadenectomy, 1.75 x 1.5 x 1 cm right upper lobe mass. Adenocarcinoma histologic grade 2, moderately differentiated. Lymph nodes positive for metastases: one of 26 nodes.
T1|thoracic (level) 1|T1|222|223|FINAL DIAGNOSES|Echocardiogram was negative. FINAL DIAGNOSES: 1. Acute infarction in the middle carotid area, leading to left facial drooping and mild weakness of the left arm and left leg barely detectable. 2. Herpes zoster in the right T1 to T4 area, including the arm and mid- back. 3. Type 2 diabetes mellitus, poorly controlled. 4. Obesity.
T1|thoracic (level) 1|T1|196|197|HISTORY OF PRESENT ILLNESS|UA showed clumps of white blood cells and bacteria with minimal red blood cells. White blood count 20,800 with a left-shift. Hemoglobin 12.5. CT scan of the spine showed possible lytic lesions in T1 and T2. He has a history of an elevated PSA and a significantly enlarged prostate. HOSPITAL COURSE: The patient was treated with Tequin with gradual improvement in his symptoms.
T1|T1 (MRI)|T1,|227|229|HISTORY OF PRESENT ILLNESS|The patient was thoroughly evaluated and then the decision was made to get an MRI scan of the brain, which revealed a nonenhancing lesion of the left parietal posterotemporal region. This lesion was bright on T2, isointense on T1, and did not enhance with contrast, and the decision was made after consultation with Dr. _%#NAME#%_ about possible etiologies to perform an MRI guided brain biopsy for diagnosis.
T1|T1 (MRI)|T1|480|481|DISCHARGE INSTRUCTIONS|A portable cranial ultrasound on _%#MMDD2004#%_ was negative for intraventricular hemorrhage, but showed "increased periventricular echogenicity and paucity of lateral ventricle fluid consistent with known hypoxemia." Follow-up cranial ultrasounds on _%#MMDD#%_, _%#MMDD#%_, and _%#MMDD#%_ continued to be negative for bleed and showed improvement in periventricular edema. A MRI on _%#MMDD2004#%_ showed a suggestion of a subacute severe asphyxia episode with abnormal increased T1 and T2 signal in the bilateral periolandic cortices and lateral putamina (from formal report - Dr. _%#NAME#%_ _%#NAME#%_)." Neurology was consulted regarding the abnormal MRI. They did not note any abnormality on exam and simply recommended follow-up with Dr. _%#NAME#%_ in _%#MM#%_ of 2005.
T1|thoracic (level) 1|T1,|245|247|LABORATORY & DIAGNOSTIC DATA|Bone scan from _%#MMDD#%_ shows scattered foci of abnormal radiotracer localization, suspicious for metastatic deposits. These involve the upper outer left scapula, small tiny focus of abnormal activity in the upper sternum, several foci at the T1, T9 and T10 levels, small amount of activity in the left paraspinal location at L4-5 level. IMPRESSION: 1. Nausea/vomiting, dehydration, malnutrition and weight loss associated with cancer and chemotherapy.
T1|UNSURED SENSE|T1|288|289|FAMILY HISTORY|The patient presented for baseline on _%#MM#%_ _%#DD#%_, 2005. She, at that time, discontinued her pancreatic enzymes and was put on a controlled diet which she tolerated well for 3 days. She also ingested a dye marker, and we did a dye-to-dye stool collection without difficulty. On day T1 which was _%#MM#%_ _%#DD#%_, 2005, the patient began Oral TheraCLEC/Total. She did tolerate her doses well prior to discharge. On _%#MM#%_ _%#DD#%_, 2005, she did pass her second dye marker and was discharged to home.
T1|type 1 (diabetes mellitus)|T1|112|113|PAST MEDICAL HISTORY|Of note, he is not on calcineurin- inhibitors and is on the Campath/CellCept protocol. PAST MEDICAL HISTORY: 1. T1 diabetes mellitus, onset age 31. 2. Proliferative retinopathy. 3. Glaucoma. 4. Peripheral neuropathy. 5. Diabetic gastroparesis with gastroesophageal reflux disease.
T1|thoracic (level) 1|T1|180|181|PHYSICAL EXAMINATION|Her grip strength has minor deficits. REFLEXES: Symmetrical in upper and lower. There is no clonus. Hoffmann's is negative. SENSORY EXAM: Reveals intact sensation throughout C3 to T1 in the right upper extremity. Left upper extremity reveals diminished sensation along the ulnar border of her forearm and also the last 2 digits of her left hand.
T1|tumor stage 1|T1|185|186|ASSESSMENT|NEUROLOGIC: Cranial nerves II-XII are grossly intact, with no focal deficits. EXTREMITIES: No cyanosis, clubbing or edema. ASSESSMENT: Ms. _%#NAME#%_ is a 69-year-old female with stage T1 N0 M0 (stage 1) infiltrating ductal carcinoma of the left breast, status post lumpectomy on _%#MMDD2007#%_. PLAN: We have recommended postlumpectomy radiation to decrease the risk of local recurrence.
T1|tumor stage 1|(T1|177|179|ASSESSMENT|There is some edema in the inguinal area. There is a 1 residual testicle without palpable mass. ASSESSMENT: In summary, Mr. _%#NAME#%_ is a 55-year-old gentleman with stage IIB (T1 N2) pure seminoma of the left testicle, status post left orchiectomy, who is here for a consultation of the further therapy.
T1|tumor stage 1|T1|173|174|HISTORY|His weakness has improved, although he overall has deteriorated since late _%#MM#%_. My involvement in this patient was five years ago when I resected a left upper lobe for T1 N0 M0 poorly differentiated squamous cell carcinoma of the lung. He had no therapy after that, nor should he have. CT done in _%#MM#%_ of 2002 looked good, but since then, things have worsened.
T1|tumor stage 1|T1,|152|154|ASSESSMENT AND PLAN|Ms. _%#NAME#%_ is a 60-year-old female with recurrent squamous-cell carcinoma to right submandibular region, approximately one year post resection of a T1, N0, M0 oral tongue cancer. The patient was left with positive margins at her most recent surgery. We therefore the patient should receive postoperative radiation therapy. We feel both sides of her neck would be at risk at this point, and would recommend radiation therapy to the bilateral neck, as well as supraclavicular region and would include the oral tongue and the field.
T1|thoracic (level) 1|T1,|272|274|REQUESTING PHYSICIAN|Mr. _%#NAME#%_ is a 73-year-old gentleman who was admitted on _%#MM#%_ _%#DD#%_, 2005 with increasing complaints of pain in his back with some weakness in his left hand and the fourth and fifth fingers. MRI of the spine indicates multiple osseous metastasis involving C7, T1, T2, T3, T4, T5 and T10 with a small amount of left anterolateral epidural tumor at T1 without evidence of cord compression.
T1|T1 (MRI)|T1|212|213|RADIOGRAPHS|There was no significant scoliosis or listhesis. MRI of the lumbar spine was reviewed from _%#MMDD2002#%_, which shows compression fractures of L2 and L3. The L3 compression fracture has high signal intensity of T1 images consistent with tumor. There is an epidural extension to the right side of her spinal canal. He has mild central stenosis at the L4-5 and multilevel degenerative changes.
T1|tumor stage 1|T1|174|175|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Infiltrating ductal carcinoma of the left breast, T1 N0 (I positive) M0, stage II breast cancer, status post lumpectomy and chemotherapy. HPI: This is a 57-year-old female patient who was diagnosed to have breast cancer at the end of 2003.
T1|tumor stage 1|T1,|122|124|HISTORY OF PRESENT ILLNESS|I was asked to see the patient to evaluate left tonsil swelling. The patient is known to me as she does have a history of T1, N0, M0 squamous cell carcinoma of the left oral tongue which is status post wide local excision by me approximately 1 month ago.
T1|thoracic (level) 1|T1|140|141|HISTORY OF PRESENT ILLNESS|He was able to ambulate with a walker or cane. He was re-admitted on _%#MMDD2002#%_ for re-do of tumor resection. He underwent a C6 through T1 laminectomy. Postoperatively he has developed weakness of wrist, flexors, extensors and finger intrinsics. He also has increased weakness of lower extremities, left greater than right.
T1|thoracic (level) 1|T1|247|248|IMAGING|The vocal cords are fully mobile without any lesions. IMAGING: On _%#MMDD2003#%_, the patient had an MRI of the spine which demonstrated metastatic lesions involving C6, C7 and T1. The C7 vertebra was fractured with compression of C7-C8 and C8 to T1 neural foramina, likely contributing to his symptoms. IMPRESSION: 69-year-old with stage IVB adenocarcinoma of the base of tongue, status post two sessions of chemotherapy in _%#MM2002#%_, and status post herbal remedies at the Bruzynski Institute.
T1|thoracic (level) 1|T1,|294|296|HISTORY OF PRESENT ILLNESS|The patient has also had an increasing history of falls fundamentally related to his lack good position sense, his numbness, and some reported weakness at the ankle, as well. An MRI of the thoracic and lumbar spine was done per the Neurology Clinic. This showed a cystic-type lesion from above T1, which is a limited scan, to T9-10 disk space. It also shows substantial compression of the spinal cord in that area.
T1|thoracic (level) 1|T1|276|277|HISTORY OF PRESENT ILLNESS|PET CT scan from _%#MMDD2006#%_ revealed decrease in the amount of enhancement and size of the thoracic primary, cervical and perihilar disease. Noted was a right axillary foci. Repeat CT PET on _%#MMDD2006#%_ revealed increasing metastatic burden with new bony metastasis at T1 and L3. The patient was then administered Zometa. The patient was then offered several studies due to progressive disease.
T1|tumor stage 1|(T1|178|180|ASSESSMENT|EXTREMITIES: 2+ left upper extremity edema. NEUROLOGIC: Cranial nerves II-XII are grossly intact. Gait is smooth and symmetric. ASSESSMENT: An 84-year-old female with stage IIIA (T1 N2) non- small-cell lung carcinoma. Her primary measures 2.5 cm in the left hilum with a 1.4-cm precarinal node. She is not a surgical or chemotherapy candidate and presents with a 2-month history of increased dyspnea on exertion.
T1|T1 (MRI)|T1|172|173|HISTORY OF PRESENT ILLNESS|He was admitted to the hospital for formal evaluation of the back pain, and we were consulted for the findings on the MRI scan. Specifically, this shows both a significant T1 lesion with mild compression of the thecal sac posteriorly. It has completely displaced and degenerated the vertebral body. Also, he has systemic disease now both with skin lesions at the site of the old resection and resection in the right neck, as well as lung metastasis.
T1|T1 (MRI)|T1|195|196|HISTORY OF PRESENT ILLNESS|An MRI was then accomplished in the evening of _%#MMDD2006#%_, which showed a mass in the midline anterosuperior cerebellar vermis which was hyperintense on T2 weighted images and hypointense on T1 weighted images, measuring 3.2 x 2.4 x 2.7 cm. There was another focal area of enhancement lateral to this mass in the right cerebellar hemisphere measuring 2.6 x 1 x 0.8 cm, which was not well-identified on the unenhanced images.
T1|tumor stage 1|T1|171|172|IMPRESSION|EXTREMITIES: No clubbing, cyanosis, or edema. IMPRESSION: Mr. _%#NAME#%_ is a 74-year-old male with 2 lung nodules, 1 biopsy-proven non-small cell lung cancer staged as a T1 N0 M0 (stage IA) right upper lobe non-small-cell lung cancer. The left lower lobe lesion has not been biopsied; however, it is likely a synchronous lesion rather than a metastatic lesion secondary to the fact that there is no mediastinal hilar disease on PET.
T1|T1 (MRI)|T1,|228|230|HISTORY OF PRESENT ILLNESS|The patient then had a MRI scan performed that showed mildly enlarged ventricles with some transient ependymal edema. There was also an abnormality noted in the third ventricle, and left lateral ventricle that was isointense on T1, and hyperintense on flare. There was also a parenchymal abnormality in the right basal ganglion that was hyperintense on T2.
T1|tumor stage 1|T1|149|150|HISTORY OF PRESENT ILLNESS|The hormonal receptor was positive and HER2/neu was negative. The patient was seen by Dr. _%#NAME#%_ and discussed the options for treatment of this T1 N0 M0 breast cancer with positive hormonal receptor. Patient was recommended to have hormonal adjuvant treatment following radiation treatment to the left breast.
T1|thoracic (level) 1|T1|288|289|PAST MEDICAL HISTORY|At this point, his scrotum is very edematous and he has been having some spasmodic issues around that in his lower extremities that is new and different from his quadriplegic-related spasticity. PAST MEDICAL HISTORY: Bladder calculus, anxiety, constipation, urinary tract infections, his T1 spinal cord injury and neurogenic bladder and he does do self-cathing. CURRENT MEDICATIONS: Baclofen 20 mg t.i.d., Celexa 20 mg daily, Levaquin 500 mg q. 24 hours IV, Protonix 40 mg daily, Senokot one tablet b.i.d. and some Vicodin.
T1|tumor stage 1|T1|188|189|RECOMMENDATIONS|3. Will add West Nile serologies. 4. She is scheduled for MRI scan of the spine looking for tumor recurrence or abscess. This is a 29-year-old female with previous history significant for T1 angiosarcoma which was resected in 1992. She says that she had many follow-up scans over the years without evidence of recurrence.
T1|thoracic (level) 1|T1|149|150|PHYSICAL EXAMINATION|Head CT shows a large area of hypoattenuation of the right frontal temporal regions with a small amount of midline shift. The head CT confirms a low T1 lesion in the right frontal temporal lobes involving the insula and a small 1.5 cm area of contrast enhancement in the medial frontal region of this tumor.
T1|tumor stage 1|T1,|249|251|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: This is a 36-year-old female patient who has right parotid gland adenoid cystic carcinoma, status post right parotidectomy with wide local excision and questionable close margin with residual lymph node in the right upper neck, T1, N1, M0. Status post neutron-beam radiation treatment at the University of _%#CITY#%_, finished on _%#MMDD2002#%_. The patient apparently is doing well as of now. We will review her neck CT as well as follow up on the CT scan of the chest.
T1|tumor stage 1|T1,|236|238|ASSESSMENT AND PLAN|There are comparison CT scans performed after chemotherapy with good response, with decrease in size of the lymph node disease. ASSESSMENT AND PLAN: Mr. _%#NAME#%_ is a 62-year-old gentleman presenting with nonsmall-cell lung carcinoma T1, N2 disease, status post chemotherapy with cisplatin and gemcitabine. We obtained his previous medical records from Florida and also we have obtained x-rays performed previously.
T1|T1 (MRI)|T1,|167|169|X-RAYS|MRI of her left knee shows a diffuse increased signals in the patella. There are no discreet fracture lines; however, there is some increased in the signal changes on T1, consistent with significant microtrabecular fracturing. There is a large effusion. No ligamentous abnormalities. ASSESSMENTS: 1. Left knee nondisplaced patellar fracture. 2. Left wrist displaced distal radius fracture.
T1|tumor stage 1|T1,|91|93|PROBLEM|PROBLEM: Breast cancer, left side status post lumpectomy and axillary node dissection with T1, N1, M0 poorly-differentiated adenocarcinoma. Status post six cycles of AC chemotherapy. The patient came to initiate consolidation radiation treatment.
T1|tumor stage 1|T1|115|116|SOCIAL HISTORY|There is no evidence on chest films or the remainder of the CT of any metastatic disease. This is probably a stage T1 renal-cell carcinoma. She has been asymptomatic as far as having no flank or back pain and no gross hematuria. ASSESSMENT: 5.5 cm solid right renal mass. PLAN: I spoke with the patient today and her daughter over the phone.
T1|thoracic (level) 1|T1|213|214|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old gentleman with metastatic lung carcinoma. He was admitted recently because of decreased strength in his lower extremities. He has metastatic disease to his T1 and T2, which involves the spinal cord with resultant bilateral lower extremity paralysis. He was seen by Neurosurgery, and it was felt that he was not a candidate for surgical intervention, and I have been asked to see him regarding whether a brace would be of any benefit.
T1|thoracic (level) 1|T1|176|177|PAST SURGICAL HISTORY|She has been diabetic since age 11. She denies hypertension or thyroid disease. PAST SURGICAL HISTORY: She has had the above-mentioned anterior cervical fusion from C6 through T1 done in 1992. She has had four surgeries for thoracic scoliosis in 1998, 1999 and two operations in 2000.
T1|T1 (MRI)|T1|202|203|DOB|He has been stable as far as his vital signs are concerned but is quite distressed and full of self reproach. Mr. _%#NAME#%_ has had multiple sclerosis since 1973. A recent brain MRI showed mild T2 and T1 lesion burden and no enhancing lesions. Only mild atrophy was present. He has long-standing weakness and numbness in his left leg that causes him to fall.
T1|tumor stage 1|T1|9|10|PROBLEM|PROBLEM: T1 N1 seminoma who presents for the possibility of radiation therapy. The patient was seen in consultation by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_.
T1|UNSURED SENSE|T1.|228|230|PHYSICAL EXAMINATION|Elbows: Normal. Left shoulder normal. Right shoulder has S2 swelling and T3 pain, decreased range of motion. C-spine is normal. Hips: Tender over trochanteric areas. Knees: 1+ effusion with mild warmth. Ankles: Normal. MTPs S1, T1. Soft tissue exam shows active fibromyalgia tender points. Muscle exam is unremarkable. LABORATORY: Sed. rate 18, AST 19, creatinine 0.55, platelet count 235,000, hemoglobin 11.9, WBC 15.7 after steroids.
T1|T1 (MRI)|T1|209|210|HISTORY OF PRESENT ILLNESS|The patient was again partially controlled up until recently. She decided to ask to have re-imaging of her brain to help with possible control of her seizures. The MRI showed a lesion that was isointense with T1 and hyperintense with T2 weighted imaging. It did not enhance with gadolinium contrast, and she has a swollen hippocampal lobe.
T1|T1 (MRI)|T1|156|157|SOCIAL SITUATION|Karyotype has been performed and is normal. No other reason for developmental delay has been identified. MRI scan was personally reviewed. It showed normal T1 images but T2 images demonstrate normal myelination in the rostrum and the finding of the corpus callosum, mildly delayed myelination and thinning of the intra and posterior limb of the internal capsule bilaterally and significant decreased significant on flare and T2 weighted image only in the centrum semiovale.
T1|T1 (MRI)|T1|373|374|SOCIAL SITUATION|MRI scan was personally reviewed. It showed normal T1 images but T2 images demonstrate normal myelination in the rostrum and the finding of the corpus callosum, mildly delayed myelination and thinning of the intra and posterior limb of the internal capsule bilaterally and significant decreased significant on flare and T2 weighted image only in the centrum semiovale. The T1 image looks normal. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 111/77.
T1|tumor stage 1|(T1|140|142|DIAGNOSIS|The consult was requested by Dr. _%#NAME#%_ _%#NAME#%_. Chart, radiographic reports/films, and pathology were reviewed. DIAGNOSIS: Stage 4A (T1 N2a M0) squamous cell carcinoma of the right tonsil. REASON FOR CONSULTATION: Consideration for definitive radiotherapy.
T1|tumor stage 1|T1|132|133|ASSESSMENT|NEUROLOGIC: Cranial nerves II through XII are grossly intact. Gait is smooth and symmetric. ASSESSMENT: 59-year-old male with stage T1 N2a M0 tonsillar carcinoma with minimal invasion of the base of tongue status post level I-IV neck dissection. A single 4.1 cm lymph node is involved with malignancy, no extracapsular extension present.
T1|tumor stage 1|T1|170|171|HISTORY OF PRESENT ILLNESS|REASON FOR CONSULTATION: Consideration for external beam radiotherapy. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 80-year-old male who was found to have synchronous T1 N0 M0 right oral tongue squamous cell carcinoma and a T1 N0 M0 squamous cell carcinoma of the left supraglottis in 2005.
T1|thoracic (level) 1|T1|318|319|PAST MEDICAL HISTORY|On _%#MM2005#%_, she presented with left pelvic bone pain with lytic lesion on the left iliac crest and, therefore, underwent biopsy, with the lesion showing metastatic head and neck cancer with the same histology. She had a wound seroma evacuation, including posterior spinal fusion with segmental instrumentation of T1 through 3 transpedicular spinal cord compression and corpectotomy. 2. The patient had an appendectomy at age 16. ADVANCED DIRECTIVES: The patient is currently full code, but does realize her prognosis is not good at this point.
T1|thoracic (level) 1|T1.|216|218|REASON FOR CONSULT|PHYSICAL EXAMINATION: Temperature 98.1, pulse 82, blood pressure 104/63, respirations 16, and saturation 100%. He is awake, alert, and oriented, in no acute distress. His upper extremity sensation is intact at C5 to T1. Strength is 5/5 in the bilateral deltoids, biceps, triceps, wrist flexors, wrist extensors with finger abduction, grip strength, (_______________) sign, and thumb strength.
T1|tumor stage 1|(T1|20|22|PROBLEM|PROBLEM: Stage IIIA (T1 N2) nonsmall cell lung cancer (adenocarcinoma), status post left lower lobectomy. Mr. _%#NAME#%_ was seen for initial consultation in the Department of Therapeutic Radiology on _%#MMDD2007#%_ by Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ at the request of Dr. _%#NAME#%_ _%#NAME#%_.
T1|thoracic (level) 1|T1|172|173|PHYSICAL EXAMINATION|He is appropriate and communicative. He has unlabored breathing. EXTREMITIES: RIGHT UPPER EXTREMITY: The patient is right hand dominant. His sensation is intact from C5 to T1 and sensation is normal over the thumb, palmar, radial, and ulnar surfaces. He has 5/5 strength in his biceps, wrist extension, and flexion of triceps.
T1|thoracic (level) 1|T1|169|170|PAST MEDICAL HISTORY|She is hoping to eventually move back to Wyoming where her 2 children live. PAST MEDICAL HISTORY: 1. T6 paraplegia secondary to MVA as stated above. 2. History of C7-C8 T1 cervical syrinx. 3. Right BKA secondary to gangrene. 4. Morbid obesity. 5. Neurogenic bowel. 6. Neurogenic bladder. 7. Status post colostomy. 8. Multiple decubitus ulcers, status post multiple debridements, last debridement _%#MMDD2007#%_.
T1|thoracic (level) 1|T1|152|153|PAST MEDICAL HISTORY|17. Hypertension. 18. Dyslipidemia. 19. Osteoporosis. 20. History of herpes. 21. History of partial small-bowel obstruction. 22. Status post C5, C6 and T1 laminectomy. SOCIAL HISTORY: The patient does not smoke and does not drink any alcohol.
T1|thoracic (level) 1|T1|208|209|PAST MEDICAL HISTORY|He is normally 171 pounds. PAST MEDICAL HISTORY: Diabetes mellitus type I for 32 years. Status-post right BKA for vascular disease. Chronic back pain, status- post spine fusion in 1995. Compression fractures T1 through T6. There is some component of an old motorcycle accident with his back injures. Has had cataract OS, history of depression, paranoia and anxiety.
T1|thoracic (level) 1|T1|244|245|IMPRESSION|Gross sensation is intact throughout the lower extremities. IMPRESSION: 22-year-old white male status post resection of ependymoma of the cervical spinal cord. MRI now shows residual lesion stretching from approximately the bottom of T3 to mid T1 with recent expansion of the cystic region. ORIGINAL PATHOLOGY: This is a University of Minnesota Medical Center, Fairview, PUHS00-07596 spinal cord tumor C3-T1 ependymoma (frozen sections resembled pilocytic astrocytoma).
T1|tumor stage 1|T1|133|134|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Stage I, T1 N0 M0 infiltrating ductal carcinoma of the left breast. HPI: This is a 36-year-old female patient who was diagnosed to have left breast cancer, stage I in _%#MM2004#%_.
T1|thoracic (level) 1|T1|175|176|HISTORY OF PRESENT ILLNESS|It also demonstrated increase of a right-sided pleural effusion. A right hilar soft-tissue mass was seen which was decreased in size. Metastatic disease was also noted in the T1 vertebral body, lower thoracic vertebral body, left iliac wing, and left sacrum. Currently Ms. _%#NAME#%_ reports that she has not noticed any new neurologic symptoms, although she did have a headache for the first time last evening.
T1|T1 (MRI)|T1|227|228|PHYSICAL EXAMINATION|MRI of his left foot was reviewed and there are changes in the soft tissues of the left great toe, consistent with inflammation or cellulitis. There is also increased edema in the bone of the distal phalanx and changes on both T1 and IR images, consistent with an osteomyelitis picture. ASSESSMENT: Left great toe osteomyelitis with resolving cellulitis. PLAN: I discussed with the patient his options, believe this to be his source of infection.
T1|thoracic (level) 1|T1|204|205|HISTORY|Significant history of a cervical facet joint ganglion with marked facet destruction and C8 radiculopathy for which the patient underwent decompression with posterior cervical fusion at C7 through T1 and T1 through T2 by Dr. _%#NAME#%_ _%#NAME#%_ from Spine Surgery on _%#MMDD2007#%_. Unremarkable postoperative course. Subsequent development of intractable cervical pain for which removal of instrumentation was planned.
T1|thoracic (level) 1|T1.|171|173|SOCIAL HISTORY|He has staircase degenerative spondylolisthesis at 2-3, 3-4, and 4-5. He is relatively kyphotic from C3 to C6. He appears to have early grade 1 spondylolisthesis of C7 on T1. He has intraparenchymal high signal intensity at the C4-5 level. His plain films are not available for review.
T1|tumor stage 1|T1|124|125|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: T1 tracheal squamous cell carcinoma HPI: Status post surgery and RT for both laryngeal and lung primary Exam: Tracheostomy, lungs clear, no SC nodes Assessment and Plan: We would like to offer endotracheal high-dose rate brachytherapy.
T1|tumor stage 1|T1|197|198|HISTORY OF PRESENT ILLNESS|Her primary tumor revealed estrogen receptor positive, progesterone receptor negative, and no HER-2/neu amplification. The patient is staged as right breast infiltrating ductal carcinoma, stage I, T1 N0 M0. The patient was seen by Dr. _%#NAME#%_ and Aromasin was started. The patient is seen by us for post-lumpectomy radiation to her right breast.
T1|tumor stage 1|T1|117|118|ASSESSMENT AND PLAN|NEUROLOGIC EXAMINATION. No motor or sensory weakness. CNS II-XII within normal limits. ASSESSMENT AND PLAN: Stage I, T1 N0 M0 infiltrating ductal carcinoma of the right breast, status post lumpectomy and sentinel node examination. The patient is on Aromasin hormonal management. The patient was recommended to receive radiation to her right breast.
T1|tumor stage 1|T1|157|158|DISCUSSION|She had good pulses in her arms. There was no lymphedema in the left lower leg. DISCUSSION: Ms. _%#NAME#%_ appears to have an early stage lung cancer with a T1 lesion. There is no evidence that there is, at present, mediastinal involvement. However, the full work up is in process and the PET scan will be of a great interest.
T1|tumor stage 1|(T1|209|211|ASSESSMENT|NEUROLOGIC: Cranial nerves II-XII are grossly intact. Muscle strength is 5/5 throughout. Gait and station are normal. ASSESSMENT: In summary, Ms. _%#NAME#%_ is a 63-year-old female with a history of stage IIA (T1 N1 M0) squamous cell carcinoma of the left lower lobe, status post external beam radiation (6300 cGy), who now presents with recurrence at the primary site.
T1|thoracic (level) 1|T1|150|151|HISTORY OF PRESENT ILLNESS|MRI scan was performed and demonstrated multiple metastatic foci involving the cervical, thoracic, and lumbar spine. Epidural compression was seen at T1 and T2, with mild compression of the spinal cord, and a mass extending into the left T1 and T2 neural foramina.
T1|tumor stage 1|T1,|120|122|IMPRESSION|Lungs are essentially clear. Heart is regular sinus rhythm. Abdomen unremarkable. IMPRESSION: Breast cancer, right side T1, N1, M0 status post four cycles of AC. RECOMMENDATIONS: We will consider post chemotherapy radiation treatment to her right breast and supraclavicular area.
T1|thoracic (level) 1|T1|119|120|RADIOGRAPHIC EXAMINATION|RADIOGRAPHIC EXAMINATION: Review of the CT scan shows that he has a transverse process avulsion fracture at the C7 and T1 levels. This is consistent with a muscular avulsion type process. ASSESSMENT: Transverse process avulsion fracture, stable.
T1|tumor stage 1|T1,|194|196|HPI|_____Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Right breast cancer. HPI: Had lumpectomy and sentinel lymph node exam. T1, N0, M0 infiltrating ductal cancer. ER + PR HER2/neu. Exam: Post lumpectomy and sentinel lymph node exam. Scars well healed.
T1|tumor stage 1|T1|38|39|PROBLEM|DOB: _%#MMDD1930#%_ PROBLEM: Probable T1 N3 MX adenocarcinoma of the lung. HISTORY OF THE PRESENT ILLNESS: The patient is a very pleasant 73-year-old woman who has had a nonproductive cough over the last three months or so.
T1|tumor stage 1|T1|233|234|ASSESSMENT AND PLAN|There is extrinsic compression of the right upper lobe bronchus with several enlarged lymph nodes noted in the mediastinum. Biopsies were obtained with preliminary pathology demonstrating adenocarcinoma. The patient is tentatively a T1 N3 MX stage 3B adenocarcinoma of the lung. The patient has possible metastasis to the liver. A PET scan could be obtained for further evaluation.
T1|thoracic (level) 1|T1|197|198|PHYSICAL EXAMINATION|NEUROLOGIC: Cranial nerves II through XII intact, strength is 5/5 in all four extremities. Light touch is symmetric and intact in all four extremities, gait was not tested. Pinprick and dermatomes T1 through L2 intact. IMPRESSION: Ms. _%#NAME#%_ is a 54-year-old female with pancreatic endocrine carcinoma, metastatic to her left posterior rib at T10/T11.
T1|T1 (MRI)|T1,|214|216|PHYSICAL EXAMINATION|She does have tenderness to palpation along the right inferior rib cage that extends to the sternum. On review of her MRI scan, she has an approximate 15% compression of the T8 vertebral body with hypointensity on T1, isointensity on T2. She has preservation of the disk spaces above and below, and with contrast the T8 vertebral body enhances.
T1|T1 (MRI)|T1|122|123|IMAGING|Residual defect in the posterior mid brain from the previous mass effect was seen. There is a minimal amount of increased T1 signal along the right lateral wall of the resection cavity, which was thought to represent a small amount of postoperative blood.
T1|tumor stage 1|T1,|198|200|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: Ms. _%#NAME#%_ is a 68-year-old lady with a floor of mouth squamous-cell carcinoma which has been resected, status post left radical neck dissection. The lesion was found to be T1, N2b, M0. Postoperative external-beam radiation therapy is indicated for Ms. _%#NAME#%_.
T1|tumor stage 1|T1|316|317|HPI|An ultrasound performed on _%#MM#%_ _%#DD#%_, 2005, when she was 21 weeks gestational age revealed a viable intrauterine fetus as well as a 2 x 3-cm mass on the right wall of the bladder. She subsequently met with Dr. _%#NAME#%_ _%#NAME#%_ who transurethrally resected most of the mass, and she was diagnosed with a T1 grade 2 out of 3 transitional cell carcinoma of the bladder. This was non-invasive at this time.
T1|thoracic (level) 1|T1,|207|209|RADIOGRAPHIC IMAGING|RADIOGRAPHIC IMAGING: Cervical spine CT demonstrates a large destructive mass in the left paraspinous region, extending into the left apex of the lung. Some involvement of the left lateral mass is at C7 and T1, and there appears to be some epidural extension at these levels as well. IMPRESSION: Large left apical and paraspinous muscle likely neoplasm. Etiology at this point unknown.
T1|tumor stage 1|T1|87|88|IMPRESSION|She has no cyanosis, clubbing, or edema. Mammograms did not accompany her. IMPRESSION: T1 N0 M0 infiltrating ductal carcinoma high grade with a positive margin with her first excision attempt. RECOMMENDATION: I discussed her care with Dr. _%#NAME#%_ in _%#CITY#%_ _%#CITY#%_ who called after the patient had left.
T1|thoracic (level) 1|T1.|246|248|IMPRESSION|He was found to have bacteremia, strep pneumonia, meningitis. He is improved clinically on vancomycin with ceftriaxone initially and now ceftriaxone alone. MRI scan from _%#MMDD2004#%_ revealed a small (3x5 mm) possible epidural abscess from C7- T1. Repeat MRI today shows no definite fluid collection in this area. 2. Multiple myeloma. 3. Hypertension. RECOMMENDATIONS: 1. Continue ceftriaxone 2 g IV q 12 hours.
T1|tumor stage 1|T1|134|135|ASSESSMENT|The top few slices of the lungs were clear. ASSESSMENT: Mr. _%#NAME#%_ is a 45-year-old gentleman with what appeared to be a possibly T1 base of tongue versus T0 N1 unknown primary of the head and neck. Given the greater likelihood that this a base of tongue lesion, the patient is a candidate for external beam radiotherapy to the head and neck with boost treatment to the base of tongue, as well as concurrent chemotherapy given his likely stage III status.
T1|tumor stage 1|T1|135|136|ASSESSMENT|She also has a cervical lymph node that is positive on a PET scan and, with cytology, also suspicious for malignancy. She has clinical T1 N0 M1a disease. Ms. _%#NAME#%_ has poor performance status (ECOG 3). She is not a candidate for surgical resection. She is also not felt to be able to tolerate chemotherapy.
T1|thoracic (level) 1|T1,|173|175|REASON FOR CONSULTATION|He was seen by his family practitioner earlier today who obtained an MRI/MRA at the T2 level what appears to be non-enhancing mass involving the T2, as well as parts of the T1, and T3 vertebra. There is a mass effect upon the thecal sac in a somewhat circumferential fashion. After the scan was performed apparently the family physician by report talked to a Neurosurgeon up in _%#CITY#%_.
T1|T1 (MRI)|T1|238|239|PHYSICAL EXAMINATION|I believe the headache is paroxysmal hemicrania. This is a indomethacin responsive headache, and we will prescribe extended release indomethacin for control. We will also perform somewhat more workup with MR angiogram to include an axial T1 fat saturated sequence through the neck to exclude carotid dissection.
T1|thoracic (level) 1|T1|134|135|IMPRESSION REPORT AND PLAN|His symptoms recently are consistent with an acute cervical radiculopathy in the lower cervical T1-C7 region affecting the C7, C8 and T1 nerves. This may be contributed to or due to his rheumatoid arthritis. There is no evidence of any vascular incidence.
T1|T1 (MRI)|T1|145|146|PHYSICAL EXAMINATION|Radiographic studies were reviewed. Yesterday's MRI scan of the brain was without contrast from Fairview Southdale Hospital. Axial post contrast T1 images are available. These reveal two small metastases of about 1 cm in size. One is in the region of the left cerebellum at about the level of the internal auditory canal.
T1|T1 (MRI)|T1|194|195|IMAGES REVIEWED|IMAGES REVIEWED: An MRI of the head is available on the PACS system which showed a ring-enhancing lesion medial left cerebellar hemisphere, measuring approximately 1.03 cm. This was seen on the T1 axial post-gadolinium images. LABORATORY DATA: Sodium 137, potassium 4.3. White blood cells 2.9, hemoglobin 9.2, platelets 278.
T1|tumor stage 1|(T1|191|193|HISTORY OF PRESENT ILLNESS|REASON FOR CONSULTATION: Consideration for whole brain radiotherapy. HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ is a 63-year-old female with a past medical history significant for a stage 1 (T1 N0 M0) nonsmall cell lung carcinoma that underwent resection 5 years ago in the _%#CITY#%_ area. Recently, she was visiting family in _%#CITY#%_ when she presented to the emergency room with left hemi body weakness, nausea and altered mental status.
T1|T1 (MRI)|T1|230|231|SOCIAL HISTORY|I did review the patient's recent MRI of the brain, as well as the forwarded report from early this month. Here we see the patient to have a quite stable radiographic appearance with no new areas of enhancement or evidence of new T1 change. IMPRESSION: Astrocytoma, grade II, bifrontal/gliomatosis cerebri with good control of the patient's circumstance on chemotherapy. I would like to complete at least 12 cycles of Temodar if possible.
T1|thoracic (level) 1|T1|225|226|HISTORY OF PRESENT ILLNESS|He was found to have metastatic disease now involving his spine as well as liver, abdomen and brain. The weakness was felt to be related to the cervical and thoracic metastases with spinal cord compression, with fractures at T1 through T4, also severe canal stenosis into the cervical spine. He had been treated with high dose steroids and his weakness is likely secondary to steroid myopathy with acute myelopathic changes as well.
T1|tumor stage 1|T1|137|138|DIAGNOSIS|The consult was requested by Dr. _%#NAME#%_ _%#NAME#%_. Chart, radiographic reports/films, and pathology were reviewed. DIAGNOSIS: Stage T1 N1 M0 squamous cell carcinoma of the nasopharynx. REASON FOR CONSULTATION: Consideration for definitive chemoradiation.
T1|tumor stage 1|T1|174|175|PHYSICAL EXAMINATION|LUNGS: Clear to auscultation bilaterally. NEUROLOGIC: Cranial nerves II through XII are grossly intact. Gait is smooth and symmetric. ASSESSMENT: 68-year-old male with stage T1 N1 M0 squamous cell carcinoma of the nasopharynx. RECOMMENDATIONS: We concur with Dr. _%#NAME#%_ and Dr. _%#NAME#%_'s recommendations for concurrent chemotherapy and radiation.
T1|thoracic (level) 1|T1|231|232|PHYSICAL EXAMINATION|X-rays: I reviewed her cervical MRI scan from _%#MMDD2005#%_. It showed a pathologic compression fractures of C6 and C7 but at least 50% loss of height of the vertebral segments. She had some marrow signal abnormality in C5 and in T1 as well and a little bit in T4. On the axial images, she did not appear to have any significant central stenosis with spinal cord compression.
T1|T1 (MRI)|T1,|132|134|OBJECTIVE/PHYSICAL EXAMINATION|There is a kyphotic deformity in this region. MRI dated _%#MMDD2002#%_ demonstrates dural ectasia. The L1 vertebral body is dark on T1, bright on T2 consistent with acute process. There is a fragment of bone or osteophytic disc at the 12-1 level over the superior end plate at 1, which does efface the cord.
T1|thoracic (level) 1|T1,|165|167|HISTORY OF PRESENT ILLNESS|The patient had new imaging studies on _%#MMDD2004#%_ including MRI of cervical, thoracic and lumbar spine. This shows progression of the disease. He has lesions in T1, T2, T3 and T12. There is also a paraspinal mass in L2-L3 and L4. There is no spinal cord compression. The patient is having significant back pain radiating to his right hip at this time.
T1|T1 (MRI)|T1,|119|121||Reviewing the patient's MRI of the brain from just several days ago, we see no evidence of increased tumor with stable T1, T2 and flair images. No gadolinium enhancement of any significance is seen of new onset. The patient does have some minor old enhancement. IMPRESSION: The patient's oligodendroglioma, grade 2, appears stable radiographically and clinically the patient appears somewhat improved.
T1|T1 (MRI)|T1|163|164|LABORATORY DATA|ASSESSMENT and RECOMMENDATIONS: This is a 51-year-old woman who presents with weakness. Her cervical spine MRA shows slightly decreased marrow signal intensity on T1 weighted images. With regard to the above I would check serum and urine protein electrophoresis to evaluate for myeloma or indeed a blood cell dyscrasia in the first instance.
T1|thoracic (level) 1|T1,|345|347|HPI|The patient was offered to have a biopsy which she declined and finally came to the emergency room because of worsening of pain. On MRI, she was found to have extensive metastases of the cervical and upper thoracic spine with multiple pathology compression of the spine causing severe spinal cord stenosis and impingement at the level of C4 and T1, as well as between C3 and C4. The patient was seen for possible palliative radiation treatments. Exam: Well-developed, moderately nourished Ethiopian female patient who is in no acute distress.
T1|thoracic (level) 1|T1|151|152|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: She is resting comfortably in her bed and is pleasant and cooperative with the exam. She is tender with palpation over the C6-7, T1 intraspinous ligaments and paraspinal muscles. She has no palpable muscle spasm. Her trapezii are nontender, as are her parascapular muscles.
T1|thoracic (level) 1|T1|162|163|HISTORY|She was appropriately transferred to the emergency room where an MRI scan was obtained. The MRI scan reveals an epidural hematoma that extends from approximately T1 to L1 with varying degrees of spinal cord impingement ranging from mild to moderately severe. Since her transferred to the emergency room, her clinical status has continued to improve dramatically.
T1|thoracic (level) 1|T1|130|131|HISTORY|An MRI scan is reviewed. It reveals an epidural hematoma and some free air within the spinal canal. It extends from approximately T1 to L1. There are varying degrees of compression ranging from extremely mild compression of the thecal sac with maintained CSF spaces to moderate compression.
T1|thoracic (level) 1|T1|113|114|PHYSICAL EXAMINATION|Plantar reflexes are upgoing bilaterally. Sensory examination to light touch is symmetric in the C5, 6, 7, 8 and T1 dermatomes. Passive range of motion reveals some limitations with left shoulder abduction and external rotation. Right is within functional limits. ASSESSMENT: Non-traumatic spinal cord injury with polyradiculopathy secondary to cervical kyphosis and myelopathy.
T1|T1 (MRI)|T1|216|217|IMPRESSION/PLAN|Full active motion of both knee joints. MRI examination is notable for diffuse osteonecrosis throughout both femurs as well as proximal tibia. Specifically, the femoral head has areas of involvement as noted on both T1 and T2 imaging studies involving over 180 degrees of the arc on both APA and sagittal views of the femoral head. No evidence of subchondral collapse is seen on radiographs or on MR.
T1|thoracic (level) 1|T1|253|254|HISTORY OF PRESENT ILLNESS|REASON FOR CONSULTATION: Rehabilitation. Needs evaluation for a patient with status post laminectomy and wound infection. Physician Requesting consult: Dr. _%#NAME#%_ HISTORY OF PRESENT ILLNESS: This is a 63-year-old female with a history of C6, C7 and T1 laminectomy and pedicle screw fixation on _%#MMDD2006#%_ for cervical myelopathy on _%#MMDD2006#%_ with postoperative cellulitis and later VE urinary tract infection requiring debridement and washout on _%#MMDD2007#%_.
T1|thoracic (level) 1|T1|242|243|HISTORY OF PRESENT ILLNESS|Her history began on _%#MMDD2007#%_ where she received a diagnosis of cervical spondylosis, stenosis and myelopathy and underwent reexploration of a previous cervical fusion, revision of the fusion and extension so it now involves C5 through T1 with screws and rods placed. Postoperative course was complicated by cellulitis and spread to the wound. On _%#MMDD#%_ she required surgical debridement and washout, again on _%#MMDD#%_ and on _%#MMDD#%_ underwent I&D, washout and removal of all hardware and placement of a vacuum dressing.
T1|thoracic (level) 1|T1,|167|169|IMAGING|Sensation to pain was also intact. Gait was slow but normal. IMAGING: MRI from _%#MMDD#%_: 1. Patchy areas of increased and decreased signal along the thoracic spine, T1, T9 and L4 vertebrae, likely consistent with myelomatous involvement. There is also a collapse seen at T7 and varying degrees of compression of T5 and T9-12 vertebral bodies.
T1|T1 (MRI)|T1|126|127|IMAGING|There is a complex abnormality in the superior aspect of the right cerebellar hemisphere which has multiple round foci of low T1 and high T2 signal. The diffusion-weighted images show no diffusion abnormality to suggest an acute infarct. There may have been some suggestion of an old hemorrhage at the superior aspect of the abnormality.
T1|tumor stage 1|(T1|82|84|IMPRESSION|The pathology from the procedure is as described above. IMPRESSION: 1. Stage IIIA (T1 N1 M0) adenocarcinoma of the right colon. Because of the patient's young age (45) and evidence of lymph node involvement by her primary cancer, adjuvant systemic chemotherapy is certainly indicated in an effort to decrease the chance of micrometastasis and/or disease recurrence.
T1|tumor stage 1|T1,|179|181|ASSESSMENT|This shows a mass confined to the nasopharynx. There is also multiple lymph nodes in the left neck. ASSESSMENT: Ms. _%#NAME#%_ is a 39-year-old female with nasopharynx carcinoma, T1, N3, M0 which makes her a stage IVB. PLAN: _%#NAME#%_ _%#NAME#%_ has supraclavicular adenopathy noted on the CT scan on the left.
T1|T1 (MRI)|T1|145|146|LABS|CT scan showed no evidence of bleed. MRI of the brain with diffusion-weighted images showed no evidence of stroke, no hypoxic ischemic regions,. T1 and T2 signal images showed no evidence of abnormalities. This was an essentially normal MRI. IMPRESSION: _%#NAME#%_ _%#NAME#%_ presented with a possible seizure and posturing which I think occurred as a result of the cardiac arrest and hypoxic ischemic brain injury.
T1|tumor stage 1|T1|139|140|ASSESSMENT AND PLAN|HISTORY OF CHEMOTHERAPY: None. KPS score: Approximately 90. ASSESSMENT AND PLAN: Mr. _%#NAME#%_ is a 67-year-old Caucasian male with stage T1 N2 BM 9 (IVA) moderately differentiated squamous cell carcinoma of the base of tongue. He has minimal medical comorbidities and his performance status is excellent.
T1|tumor stage 1|T1|152|153|HISTORY OF PRESENT ILLNESS|She was previously seen for us by consultation on _%#MMDD2007#%_. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 79-year-old female with initial stage T1 and N2 M0 (stage III A) squamous cell carcinoma of the right upper lobe, status post chemoradiation. She received a total of 6360 cGy in 34 fractions to the lung, completing treatment on _%#MMDD2007#%_.
T1|thoracic (level) 1|T1.|142|144|PHYSICAL EXAMINATION|C5 x-ray suspicious for x-ray; CAT scan, films not available for review. CT head negative. ________ fractures, left transverse process C7 and T1. Mild degenerative changes diffusely in the cervical spine. LABORATORY DATA: Electrolytes normal. Calcium 8.8, alkaline phosphatase 102. Liver function tests are normal.
T1|tumor stage 1|(T1|17|19|PROBLEM|PROBLEM: Stage 1 (T1 N0 M0) infiltrating ductal carcinoma of the left breast. The patient had a lumpectomy and finished her chemotherapy. Her last Taxol treatment was today and she came to set up her radiation treatment.
T1|tumor stage 1|(T1|156|158|ASSESSMENT|NEUROLOGIC: Cranial nerves II through XII are grossly intact. Gait is smooth and symmetric. ASSESSMENT: 78-year-old female with newly diagnosed stage III A (T1 N2 M0) squamous cell carcinoma of the right upper lobe. \n RECOMMENDATIONS: Our recommendation is to undergo definitive current chemotherapy and radiation.
T1|T1 (MRI)|T1|162|163|INFORMANT|The scan I reviewed again showed bilateral increased signal in the basal ganglion on flare images and decreased symmetrical signal attenuation in the thalamus on T1 image. EEGs were normal x 2, and ABR was failed. Because of persistent problems with no brainstem function returning, she was transferred here for additional care.
T1|T1 (MRI)|T1|187|188|PHYSICAL EXAMINATION|He has extensive osteoarthritic changes. The axial images are compromised secondary to motion artifact, although they do demonstrate primarily foraminal rather than central stenosis. His T1 images do not demonstrate significant central stenosis, particularly at the level of his cord atrophy. The area of most stenosis centrally appears to be C3-4.
T1|thoracic (level) 1|T1|84|85|ADDENDUM|ADDENDUM: Under radiology the discussion of the level of the disc thought to be C7- T1 needs to be changed to level C6-C7 (everywhere in the report it needs to be changed from C7-T1 to C6-C7) - also found in Assessment and Plan section at the end of the report......
T1|T1 (MRI)|T1|207|208|HISTORY OF PRESENT ILLNESS|The report of the MRI indicated that meningitis should also be considered given the mild restrictive effusion in the posteromedial parietal-occipital sulci and rapid onset of symptoms. There was extra-axial T1 hyperintensity in the left posterior fossa, which might represent hemorrhage. A lumbar puncture was performed. There were 463 white blood cells and 4225 red blood cells.
T1|thoracic (level) 1|T1.|188|190|DIAGNOSIS|He was seen by Dr. _%#NAME#%_ for these problems. X-ray of the chest showed a lung tumor. MRI of the cervical spine was done secondary to his weakness and showed an infiltrating lesion of T1. We were consulted secondary to this lesion at T1, which has some cord compression involved with it. I reviewed the films with Dr. _%#NAME#%_ _%#NAME#%_ and there is a fair amount of edema around this lesion.
T1|thoracic (level) 1|T1,|148|150|DIAGNOSIS|MRI of the cervical spine was done secondary to his weakness and showed an infiltrating lesion of T1. We were consulted secondary to this lesion at T1, which has some cord compression involved with it. I reviewed the films with Dr. _%#NAME#%_ _%#NAME#%_ and there is a fair amount of edema around this lesion.
T1|T1 (MRI)|T1,|186|188|HISTORY OF PRESENT ILLNESS|Skull x-rays revealed no metal in the head. MRI scan showed enlargement of the lateral ventricles and cortical sulci but no parenchymal signal abnormalities. Technique included sagittal T1, axial T2, axial FLAIR and axial diffusion studies. Repeat blood studies included albumin of 3 and ammonia of less than 1. Maroon stool was observed and patient was on ICU care for over 24 hours.
T1|tumor stage 1|T1|253|254|IMPRESSION|Gait is not evaluated. LABORATORY DATA: The pathology report is as already stated. A CBC from _%#MMDD2005#%_ shows a white count of 6000, hemoglobin 15.0, platelet count 282,000, INR 0.98, potassium 4.1. IMPRESSION: The patient has recent findings of a T1 N2 M0 stage III a nonsmall cell lung carcinoma arising the right upper lobe. She appears to have tolerated the surgery well, and given her generally good health, I think she could potentially benefit from adjuvant therapy.
T1|T1 (MRI)|T1|183|184|MRI SCAN|All extremities move normally. MRI SCAN: Performed today and official report reveals left temporal horn cyst and normal gray-white junction. My review did not find any comments about T1 hyperintensities in the periventricular area, most prominent on the coronal view which appeared to have cystic changes. IMPRESSION: 1. Sarnat stage I neonatal encephalopathy with improvement after delivery, normal eye findings, mildly abnormal EEG, and questionably abnormal MRI scan.
T1|tumor stage 1|T1|181|182|HISTORY OF PRESENT ILLNESS|The chart, radiographic reports/films, and pathology were reviewed. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 35-year-old female with a past medical history significant for a T1 N0 M0 right breast infiltrating ductal carcinoma, status post lumpectomy and radiation therapy on _%#MMDD2000#%_ to _%#MMDD2000#%_ to 6440 cGy. She is also a type 1 diabetic, status post two pancreatic and two left sided renal transplants on immunosuppressants.
T1|T1 (MRI)|T1|159|160|HISTORY OF PRESENT ILLNESS|The CT scan of the head revealed a normal exam. The MRI of the thoracic and lumbar spine revealed a thin epidural fluid collection that appeared bright on the T1 and T2 sequences. The Neuroradiology fellow thought this was consistent with an epidural hematoma but because of the contrast agent given could not rule out completely an epidural abscess.
T1|tumor stage 1|T1|152|153|RECOMMENDATIONS|RECOMMENDATIONS: I will await final pathology report, but based on my initial discussion with the pathologist, it appears to be early disease, possibly T1 N0 N0. Therefore, prognosis is generally good and systemic or radiation adjuvant therapy is not recommended. I will await final pathology report. I will see him back upon recovery in three weeks.
T1|thoracic (level) 1|T1|160|161|HISTORY OF PRESENT ILLNESS|He had decreased light touch over the C8 distribution of bilateral upper extremities. He was felt to be an appropriate patient for C7 corpectomy and C6 through T1 fusion. He had surgery on _%#MMDD2005#%_. There were no intraoperative complications. He was found to have a soft tumor in C7 and pre-vertebral tissue which was sent for pathology.
T1|tumor stage 1|(T1,|17|20|PROBLEM|PROBLEM: Stage 1 (T1, N0, M0) Right breast cancer, status post lumpectomy and central node sampling. HISTORY OF PRESENT ILLNESS: This is a 55-year-old female patient, three years postmenopausal and was found to have a microcalcification of her right breast on a screening mammogram.
T1|thoracic (level) 1|T1|273|274|HISTORY OF THE PRESENT ILLNESS|Of note: On her cervical CT imaging, there appears to be mass behind more prominently the body of C4 through the superior portion of the body of T1. In order to clarify this, emergent MRI scanning was done, there is certainly a mass from C4 through the superior portion of T1 that has a consistency of that of acute blood by MRI imaging. A differential diagnosis would, however, include a spontaneous cervical epidural hematoma versus cervical epidural empyema versus a possible extramedullary tumor that has possibly bled.
T1|thoracic (level) 1|T1|182|183|HISTORY|There does appear to be some blood layering out in the thoracic spine below that. Her initial examination was reported at no movement of the lower extremities from approximately the T1 level down. Currently, she had 2-5 strength in all muscle groups of the lower extremity except 1/5 in plantar flexion.
T1|tumor stage 1|T1|181|182|ADDENDUM|3. The patient was just placed on broad-spectrum antibiotics by the primary team. Thank you for this interesting consultation. ADDENDUM: The patient has a history of clinical stage T1 C Gleason 4+4 adenocarcinoma of the prostate on the left side and 10% with a PSA of 24.7 at the time of diagnosis. Per outside records, they were considering the patient to have brachytherapy plus supplemental external beam radiation therapy, and he received some Lupron at the time of the diagnosis.
T1|tumor stage 1|T1|87|88|CHIEF COMPLAINT|The patient was seen and examined by Dr. _%#NAME#%_ _%#NAME#%_. CHIEF COMPLAINT: Stage T1 N2 M0 non-small-cell lung cancer. HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old female with a history of limited-stage small-cell carcinoma treated with chemotherapy and radiation _%#MM2002#%_.
T1|tumor stage 1|T1|158|159|HISTORY OF PRESENT ILLNESS|She is also status post wedge resection of two well-differentiated adenocarcinomas 4 mm in size in the left upper lobe. More recently, she was diagnosed with T1 N2 M0 large-cell carcinoma of the left upper lobe, status post six cycles of carboplatin and etoposide and recurrence in the AP window.
T1|tumor stage 1|T1|9|10|PROBLEM|PROBLEM: T1 versus T2 N0 M0 invasive ductal carcinoma of the left breast. Ms. _%#NAME#%_ was seen in the Department of Therapeutic Radiology on _%#MMDD2007#%_ by Dr. _%#NAME#%_ and Dr. _%#NAME#%_ at the request of Dr. _%#NAME#%_ for adjuvant radiation.
T1|tumor stage 1|T1|201|202|ASSESSMENT AND PLAN|EXTREMITIES: No edema in the lower extremities was noted. NEUROLOGIC: Cranial nerves II-XII are grossly intact. Normal gait. ASSESSMENT AND PLAN: Ms. _%#NAME#%_ is a 54-year-old female with a stage I, T1 N0 M0 invasive ductal carcinoma of the left breast. It was our recommendation that the patient should go on to receive adjuvant radiation to the left breast.
T1|tumor stage 1|T1,|137|139|ASSESSMENT AND PLAN|The lymph node was 8 mm and would not be classified as suspicious for malignancy. ASSESSMENT AND PLAN: This is a 41-year-old female with T1, N0, M0 squamous cell carcinoma of the buccal mucosa. We agree that radiation therapy is warranted in this case.
T1|tumor stage 1|T1,|9|11|PROBLEM|PROBLEM: T1, N3, M0 non-small cell lung cancer. This patient was seen in the Radiation Oncology Clinic on _%#MM#%_ _%#DD#%_, 2002 by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ for initial consultation at the request of Dr. _%#NAME#%_ _%#NAME#%_ from the Department of Medical Oncology.
T1|tumor stage 1|T1,|202|204|ASSESSMENT|Extremities are without cyanosis, clubbing or edema. ASSESSMENT: Mr. _%#NAME#%_ is a 48-year-old with biopsy-proven squamous cell carcinoma of base of tongue with a left neck mass. He appears to have a T1, 2B, stage III base of tongue squamous cell carcinoma. The patient's case is being presented to Tumor Conference tomorrow.
T1|T1 (MRI)|T1|268|269|REASON FOR CONSULTATION|The patient underwent a routine MRI today, which showed an approximately 4 x 3 cm lesion in the right frontal region with what looks like a cystic component with mass effect and surrounding edema. This lesion is hyperintense on the unenhanced, as well as the enhanced T1 sequences. There is no midline shift. The patient denies any headaches, nausea, vomiting or difficulty with speech or vision. She denies any blurry vision, double vision, bladder or urinary incontinence or walking difficulties.
T1|tumor stage 1|(T1|37|39|PROBLEM|PROBLEM: Left parotid adenocarcinoma (T1 N2b M0) stage IVA, status post total parotidectomy and left neck dissection. Mr. _%#NAME#%_ was seen on _%#MMDD2004#%_ in the Radiation Oncology Clinic by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ for a consultation at the request of Dr. _%#NAME#%_.
T1|thoracic (level) 1|T1|120|121|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old male who presents for medical follow-up following a C7 through T1 laminoplasty, posterior. The patient also had a C7/T1 foraminotomy on the left. The patient had an estimated blood loss of 500 mL at surgery, with no complications noted.
T1|thoracic (level) 1|T1|141|142|HISTORY OF PRESENT ILLNESS|A week to ten days ago the patient also developed marked tenderness over the posterior aspects of her lower neck at about the level of C7 or T1 spinous process. This area became over a few days exquisitely tender and firm, and reddened. Because of unbearable pain that prevented her from sleeping at night, the patient was eventually seen in the emergency room here and elsewhere.
T1|tumor stage 1|T1,|290|292|IMPRESSION|EXTREMITIES: Without clubbing, cyanosis or edema. IMAGING: The patient had a CT scan of the neck on _%#MMDD2003#%_ which showed a 1.4 cm mass in the left base of tongue and a 2.3 cm left jugulodigastric node. IMPRESSION: 49-year-old with prior radiation therapy for ALL who presents with a T1, N1 left base of tongue cancer. PLAN: We have discussed with the patient the possibility of radiation therapy for the treatment of his cancer.
T1|tumor stage 1|T1,|176|178|CC|_____Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Right base of tongue with left neck lymphadenopathy, T1, N1, M0 HPI: Has history of ALL and had TBI with chest wall and testicular boost and also whole brain radiation.
T1|T1 (MRI)|T1|186|187|LABORATORY DATA|2. MRI of the brain, _%#MMDD2005#%_: 5 to 10 foci of T2 hyperintensity within the cerebral white matter consistent with demyelinating disease. No contrast-enhancing lesions, symmetrical T1 hyperintensity of the heads of the caudate nuclei and the anterior basal ganglia consistent with hypercalcemia. 3. _%#MMDD2005#%_: WBC 7.1, hemoglobin 11.7, MCV 91, platelets 436, sodium 141, potassium 4.5, chloride 103, CO2 25, glucose 102, BUN 41, creatinine 2.2, calcium 13.1, albumin 4.2, alkaline phosphatase 112, ALT 29, AST 54, INR 2.96, a PTT is 31, TSH 1.17. Urine calcium is 22.7. CK is 123, magnesium 1.7, phosphorus 3.
T1|tumor stage 1|T1|182|183|ASSESSMENT AND PLAN|LUNGS: Essentially clear. HEART: Regular sinus rhythm. ABDOMEN: Unremarkable. EXTREMITIES: Unremarkable and without evidence of swelling. ASSESSMENT AND PLAN: Right breast Ca, stage T1 N0 M0 with two histopathology status post lumpectomy and sentinal lymph node exam. The patient wishes to discuss more about the options of chemotherapy after Onco type Dx result.
T1|thoracic (level) 1|T1,|157|159|ASSESSMENT|10. Normal coags with platelet count of 269,000. ASSESSMENT: The patient is a 48-year-old female with the following: 1. Anterior spinal fusion of C7 through T1, with posterior spinal fusion revision, as above, for cervical spondylosis/pseudoarthrosis associated with bilateral upper extremity radicular pain, weakness, and paresthesias.
T1|T1 (MRI)|T1|123|124|IMPRESSION|Here, we see excellent results with no evidence of tumor enhancement and no evidence of new areas of abnormality on either T1 or T2 signal assessment. IMPRESSION: Glioblastoma involving the left temporal region with remarkably good response to multimodality intervention including initial surgery, radiotherapy and Temodar x 12 cycles.
T1|thoracic (level) 1|T1|272|273|HISTORY OF PRESENT ILLNESS|Dense consolidation was seen in the lower lobe. The following day she underwent a CT scan of the chest, abdomen, and pelvis which showed an extensive cavity mass involving the left upper lobe. It involved the posterior chest wall, ribs, and the vertebral bodies of C7 and T1 causing narrowing of the spinal canal to approximately 50 percent. Also seen was extensive soft tissue thickening in the left lung base.
T1|thoracic (level) 1|T1|258|259|HISTORY OF PRESENT ILLNESS|PROBLEM: Multiple myeloma. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 53-year-old who presented in _%#MM#%_, 2001 with left-arm pain and numbness. He was found to have a mass on the sternum and MRI scan of the spine revealed a destructive lesion at the T1 vertebral body with compression fracture. A biopsy of the sternum revealed plasmacytoma. Urine protein was 2.2 g. Bone marrow biopsy revealed 69% plasma cells. Lytic lesions were also detected in the right ischium and left humerus.
T1|thoracic (level) 1|T1,|130|132|PROBLEM|The patient had repeated MRI on _%#MMDD2007#%_ which again showed multiple metastatic area, especially in the area of the pain at T1, T2, T4 and T6. She has a mild bulging posteriorly at the level of T4, which is probably due to compression fracture.
T1|thoracic (level) 1|T1|212|213|PHYSICAL EXAMINATION|He has tenderness along his left chest wall. He has 5 out of 5 wrist flexion, wrist extension, and intrinsics. He is able to supinate and pronate with pain though no mechanical block. He has full sensation C5 to T1 dermatomes bilaterally. He has 2+ radial and ulnar pulses bilaterally. He has no tenderness to palpation the entire aspect of his spine.
T1|thoracic (level) 1|T1|276|277|REQUESTING PHYSICIAN|She was hospitalized for deep venous thrombosis, and during this hospitalization she has undergone an MRI scan of the cervical spine carried out on _%#MMDD2004#%_. This study demonstrates diffuse bony metastasis with tumor involvement of the C2, C6 and C7 vertebrae, and also T1 and T2 vertebral bodies with some evidence of tumor along the right neural foramen at C2-C3. The patient's pain and discomfort has been quite pronounced. She has been started on MS Contin 30 mg t.i.d. She is seen at this time for consideration of palliative radiation treatment to the cervical spine region.
T1|tumor stage 1|T1,|193|195|ASSESSMENT/PLAN|Sentinel lymph node, 2 of the lymph nodes were taken out and we doubt any of them suffer tumor. ERPR positive. ASSESSMENT/PLAN: A 71-year-old female patient with a recent diagnosis of stage 1, T1, N0, M0, breast cancer on the right side with enteral lymphatic invasion. The patient is going to be placed on Arimidex. She will need right breast radiation post lumpectomy status.
T1|tumor stage 1|(T1|212|214|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Left breast cancer, status post lumpectomy and axillary lymph node dissection, stage II (T1 N1 M0). HPI: Patient is receiving chemotherapy and last one will be on _%#MM#%_.
T1|T1 (MRI)|T1|259|260|HISTORY OF PRESENT ILLNESS|She was brought to the emergency room where studies have revealed an epidural mass versus potential hematoma in the mid thoracic region, which resulted in some impingement on the subarachnoid space. A correlation with the MRI on _%#MMDD#%_ showed a decreased T1 and increased T2 signal at the T7 vertebral body, with some enhancement, suggestive of an acute process; and the differential was a fracture versus metastases.
T1|tumor stage 1|T1|180|181|PROBLEM|Date of Service: _%#MMDD2007#%_ Patient was asked to see ua per Drs. _%#NAME#%_ and _%#NAME#%_. PROBLEM: Left breast cancer, status post lumpectomy and sentinel node biopsy, stage T1 N0 M0 infiltrating mucinous adenocarcinoma. HISTORY OF PRESENT ILLNESS: This is a 67-year-old female patient who had a yearly mammogram in 2005 and a lesion was found in the left breast thought to be a cystic lesion, which she has been followed.
T1|tumor stage 1|T1|141|142|HPI|Exam: The scar over the medial right knee area is well healed without mass or modularity. There is no groin adenopathy. Assessment and Plan: T1 N0 M0 MHF of the right medial knee. In this situation, it is our policy to proceed with preoperative radiotherapy, followed by tumor bed re-excision.
T1|T1 (MRI)|T1|194|195|HISTORY OF PRESENT ILLNESS|He has multiple bilateral cervical lymphadenopathy, as well as retropharyngeal lymphadenopathy. He also has pituitary macroadenoma on the left side of the pituitary area. He also has changes of T1 signal in the clivus which may indicate marrow replacement of the tumor. The patient was consulted to Dr. _%#NAME#%_ _%#NAME#%_ of ENT at Fairview-University Medical Center who found abnormal findings in the nasopharyngeal area where a biopsy was taken and showed squamous cell carcinoma, accelerated type.
T1|T1 (MRI)|T1|185|186|HISTORY OF PRESENT ILLNESS|Possibility of sepsis was raised. She had an oral temperature of 92.7 at that time. An MRI scan of the brain was obtained on _%#MMDD2006#%_ showing stable MRI scan with multiple T2 and T1 lesions felt to be moderate to severe. There is a single enhancing lesion in the left frontal subcortical white matter.
T1|T1 (MRI)|T1.|124|126|IMAGING REVIEWED|IMAGING REVIEWED: She had an MRI of the T-spine which shows a right T5 lesion that is hypointense and contrast enhancing on T1. It involves the pedicle and the right posterior vertebral body measuring approximately 22 mm x 11 mm. She also has a left T10 lesion that is 8.3 mm round, posterior left vertebral body where the body meets the pedicle.
T1|thoracic (level) 1|T1|263|264|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Metastatic renal cancer. HISTORY OF PRESENT ILLNESS: This is a 49-year-old female with long-standing history of chronic neck pain, which had gradually been worsening. She underwent evaluation and was thought to have metastases to the C3, C7, and T1 vertebra with a possible fracture of the T1 vertebra. The patient had a prior MRI in _%#MM2004#%_, which was negative. On the most recent evaluation, it showed the pathological fracture at T1.
T1|thoracic (level) 1|T1,|169|171|HISTORY OF PRESENT ILLNESS|He was recently assessed for back pain at Unity Hospital and found to have metastatic spread of his tumor to the level of T3. Further, this month, the patient underwent T1, T3, and T4 pedicle screw fixation with tumor resection. Unfortunately, the patient had a hematoma formation postoperatively and had a hematoma evacuation performed on _%#MMDD2005#%_.
T1|thoracic (level) 1|T1|307|308|REQUESTING PHYSICIAN|There was no evidence of metastasis at this point. However, this gentleman's weakness has continued to progress, showing central paresis of his right lower extremity and fairly well-preserved, 4+/5 on his left side. Because there was no clear etiology of this, work-up included a thoracic MRI which shows a T1 metastatic lesion intramedullary. In light of that he was started on radiation therapy. He has received eight of 23 radiation treatments but has had progression of his neurological deficits.
T1|thoracic (level) 1|T1|112|113|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 63-year-old female who has a history of osteosarcoma. She had a T1 to T9 posterior spinal fusion done on _%#MMDD2006#%_ by Dr. _%#NAME#%_. Her preoperative hemoglobin was 12. Estimated blood loss was 2100 cc.
T1|thoracic (level) 1|T1|164|165|PAST MEDICAL HISTORY|3. The osteosarcoma metastasized to her lungs. She had 16 tumors within her lungs that were treated and resolved. 4. In 2002, her osteosarcoma came back. She had a T1 through T4 removed. 5. In 2005, Ms. _%#NAME#%_ had additional metastasis to her ribs and lung. 6. No asthma, no coronary artery disease, no hypertension.
T1|T1 (MRI)|T1.|189|191|HISTORY OF PRESENT ILLNESS|It was a hypodensity on CT. He was then transferred to _%#CITY#%_ _%#CITY#%_ Hospital for follow-up MRI. This was done with gadolinium contrast. It showed the same area enhancing lesion on T1. He was brought to the University Hospital with consult by Dr. _%#NAME#%_, pediatric neurologist. We were called by him for a work-up of possible differential including aspergillosis secondary to prior transplant history, meningioma, and possible lymphoma recurrence.
T1|tumor stage 1|T1,|111|113|HISTORY OF PRESENT ILLNESS|Previous colonoscopy was at least 5 years ago. He was operated for lung cancer in _%#MM#%_ of this year. Had a T1, N0 lesion removed and felt to be a curative resection. This was a left upper lobe resection. There is current chest x-ray demonstrating a 3 cm right infrahilar mass, but I am uncertain of the significance of this, as it was present in _%#MM#%_ as well.
T1|thoracic (level) 1|T1,|139|141|HISTORY|The patient was started on IV Rocephin and ceftazidime. Today repeat MRI scan has been done and he has evidence of inflammation from C2 to T1, suggestive of transverse myelitis. No other history is obtainable from the patient at present. PAST MEDICAL HISTORY: 1. Peripheral vascular disease with bilateral fem/pop bypass _%#MMDD2002#%_.
T1|tumor stage 1|T1,|76|78|HPI|My key findings: CC: Breast CA. Sternal or parasternal metastasis. HPI: Had T1, N0, M0 left breast CA 21 years ago. Had mastectomy and silicone reconstruction. Now has single site recurrence lesion in the parasternal area at 1st intercostal space at the area of internal mammary lymph node.
T1|T1 (MRI)|T1|211|212|IMAGING DATA|IMAGING DATA: We reviewed a head CT scan which shows generalized volume loss as well as an MRI scan. The latter shows quite significant hyperintensity in the globus pallidus and lentiform nucleus bilaterally on T1 weighed images, suggestive of manganese deposition and hepatic encephalopathy. There is also a hyperintense area in the basis pontis. ASSESSMENT/PLAN: The findings are those of global cognitive dysfunction, presumably a delirium.
T1|thoracic (level) 1|T1|129|130|HISTORY OF PRESENT ILLNESS|MRI scan of the C-spine was done which was unremarkable. MRI scan of the T-spine was done which showed a compression fracture of T1 and T5. She was treated appropriately with TLSO with a C-extension. This has been difficult for her. Unfortunately, she has developed what is believed to be aspiration pneumonia and is admitted at this time.
T1|T1 (MRI)|T1|226|227|REVIEW OF RADIOLOGIC EXAMINATIONS|It was compared to the prior study from _%#COUNTY#%_ _%#COUNTY#%_ Medical Center and had decreased from its initial size of 3.9 x 4.2 x 4.2 to the current size. Additionally, there was resolution of the hydrocephalus. A round T1 hyperintense structure with central hypointensity measuring 8 mm was present at the pineal gland without contrast enhancement and it was unchanged from the _%#COUNTY#%_ _%#COUNTY#%_ Medical Center examination of _%#MMDD2004#%_.
T1|T1 (MRI)|T1|264|265|PROCEDURES PERFORMED DURING THIS HOSPITALIZATION|1. On _%#MM#%_ _%#DD#%_, 2006, MRI of the brain. Impression was few scattered foci of T2 hyperintensities in the periventricular white matter which are nonspecific and could represent postchemotherapy changes. Heterogeneous hypointense appearance in the clivus on T1 weighted images with possible enhancement that could be secondary to regenerative bone marrow or infiltrative process. 2. CT of the head without contrast on _%#MM#%_ _%#DD#%_, 2006.
T1|T1 (MRI)|T1|87|88|PHYSICAL EXAMINATION|There is also anterior to the lateral to this focus there is a second hyper density on T1 voided imaging that measures about 4 x 6 mm in transverse and the AP diameter. She also has fibrocystic changes throughout the breast. Follow-up MRI was recommended.
T1|tumor stage 1|(T1|133|135|ASSESSMENT AND PLAN|Lungs essentially clear. Heart regular sinus rhythm. Extremity no evidence of arm swelling. ASSESSMENT AND PLAN: Right breast cancer (T1 N0 M0) status post lumpectomy, status post bilateral breast augmentation with saline implant 4 years ago. The patient would need radiation treatment to her right breast after her chemotherapy.
T1|thoracic (level) 1|T1,|157|159|HISTORY OF PRESENT ILLNESS|In late _%#MM2006#%_, the patient developed lower thoracic back pain. On _%#MMDD2006#%_ a cervical spine MRI was done which showed metastases in the C5, C7, T1, T2, T3, and T4 vertebrae. Lumbar spine MRI on _%#MMDD2006#%_ showed diffuse bone metastases throughout the lower thoracic and lumbar spine consistent with metastatic disease.
T1|tumor stage 1|T1|281|282|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: Ms. _%#NAME#%_ is a 65-year-old female with a newly diagnosed squamous-cell carcinoma of the left base of tongue with a leve 2 necrotic lymph node, also on the left. We are unable to visualize her primary lesion in the base of tongue, so likely the stage is a T1 (Tx?) N1 M0 squamous-cell carcinoma of the left base of tongue. The patient was seen and examined with Dr. _%#NAME#%_ _%#NAME#%_.
T1|T1 (MRI)|T1|145|146|RADIOGRAPHIC STUDIES|Patient's tumor is hormone-receptor positive. RADIOGRAPHIC STUDIES: 1. MRI scan of spine (_%#MMDD2002#%_) revealed multiple hypointense areas on T1 and T2-weighted images consistent with metastases. These lesions are present in vertebrae T2, T4, T5, T7, T9, T10, T12, and L3. 2. MRI scan of brain (_%#MMDD2002#%_): Showed multiple enhancing lesions throughout brain and cerebellum consistent with metastatic breast cancer.
T1|tumor stage 1|T1|219|220|IMPRESSION|Muscle strength is 5/5 in all muscle groups in upper and lower extremities. The patient has normal gait. IMPRESSION: 75-year-old white female with history of right lung transplant for COPD, now presents with left-sided T1 lesion with metastases to bone adenocarcinoma and some pain in the C6 region. I discussed the patient's situation with her, as well as the possible options open to her.
T1|thoracic (level) 1|T1|302|303|HISTORY OF PRESENT ILLNESS|He had a herniated disk at L5-S1 creating right leg pain and had titanium implants for fusion at T3-5 and a right diskectomy at L5-S1 He had been on up to 100 mcg of fentanyl, that was for a chronic neck pain that occurred secondary to a motor vehicle accident last _%#MM#%_ 2006 resulting in C6-7 and T1 compression fracture from a rollover accident. Two kids were in the car, 10 and 15 years old and they were not injured. He was actually resolving pretty well on his neck pain and tried tapering the fentanyl patch but ended up having quite a bit of difficulty because of withdrawal symptoms.
T1|thoracic (level) 1|T1|208|209|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Parkinson's disease. 2. Orthostatic hypotension secondary to Parkinson's disease. 3. Mild dementia, most likely Lewey body dementia 4. Cataract extraction. 5. Compression fracture at T1 through L1. 6. Migraine headaches. 7. Rotator cuff injury. 8. Glaucoma. 9. Allergic rhinitis. 10. Gastroesophageal reflux disease. MEDICATIONS: 1. Amitriptyline 100 mg p.o. q h.s.
T1|tumor stage 1|T1|218|219|HISTORY OF PRESENT ILLNESS|On serial CT scanning, the lung nodule increased in size and on _%#MMDD2003#%_ he underwent right lower lobe wedge resection followed by right lower lobe lobectomy with lymph node dissection for what was found to be a T1 N0 M0 non-small cell carcinoma of the right lower lobe. Postoperatively, he has had a small pneumothorax on the right. Yesterday evening, he took a pain pill p.o. and shortly thereafter developed some mild "itching all over." He received IV Benadryl.
T1|thoracic (level) 1|T1|128|129|HISTORY  OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 65-year-old gentleman who presents after a roughly 3-month history of pain in a T1 radicular distribution. The pain got significantly worse in the last 4 days. This caused him to seek attention by his primary physician, and he was referred to the Emergency Department at the University of Minnesota Medical Center, Fairview.
T1|thoracic (level) 1|T1|173|174|IMAGING|Babinski sign is negative bilaterally. There is no clonus. IMAGING: MRI of the thoracic spine with and without contrast performed _%#MMDD2007#%_ shows metastatic lesions at T1 and T5. The T1 lesion demonstrates retropulsion with canal narrowing. There is mild to moderate canal narrowing with no compression of the cord.
T1|thoracic (level) 1|T1|260|261|IMAGING|MRI of the lumbar spine with and without contrast performed _%#MMDD2007#%_ shows metastatic lesions at L1 and L2 with no extension into the epidural space. MRI of the cervical spine with and without contrast performed _%#MMDD2007#%_ shows metastatic lesion at T1 which demonstrates a pathologic fracture and retropulsion posteriorly causing moderate canal stenosis with no cord compression. CT of the head with and without contrast performed on _%#MMDD2007#%_ shows no abnormal intracranial enhancing lesions noted, persistent enlargement of the lateral and 3rd ventricles which was present on the CT report from _%#MMDD2003#%_.
T1|thoracic (level) 1|T1.|257|259|DISCUSSION|Please see Dr. _%#NAME#%_'s notes and the charting for details regarding the indication for surgery and the events of surgery. The patient did undergo an anterior cervical decompression infusion C3 through C7 as well as a posterior spinal fusion C2 through T1. Estimated blood loss was approximately 450 cc. He did receive 5,000 cc of lactated Ringer's.
T1|tumor stage 1|T1|100|101|IMPRESSION|There is no evidence of lymph node metastasis and he is now in remission after resection. This is a T1 N0 M0 with stage I adenocarcinoma of the colon. His prognosis with surgery alone is excellent and I would not suggest any further therapy.
T1|tumor stage 1|T1,|176|178|PAST MEDICAL HISTORY|At this time the patient states that the discomfort is keeping her from getting any meaningful sleep and she reports she is feeling exhausted. PAST MEDICAL HISTORY: 1. Stage I T1, N0, M0 adenoid cystic carcinoma of right parotid gland treated surgically and with postoperative radiation, as described above.
T1|tumor stage 1|(T1,|147|150|DOB|3) Evidence of angiolymphatic invasion without surgical margin positivity (i.e. clear margins). Therefore, Aloma has been deemed to have Stage III (T1, N1, M0) adenocarcinoma of the colon given her recent CT scans without evidence of metastasis. I am now asked to address the pathology and recommend adjuvant treatment options.
T1|tumor stage 1|(T1,|119|122|ASSESSMENT AND PLAN|LABORATORY: None. But, a recent CEA level was obtained in our clinic on _%#MMDD2005#%_. ASSESSMENT AND PLAN: Stage III (T1, N1, M0) adenocarcinoma of the colon. Based on the surgical pathology and the recent CT scan imaging, _%#NAME#%__has now had a second bout with colon cancer, and I am confident that her Stage III diagnosis is correct.
T1|thoracic (level) 1|T1|236|237|ASSESSMENT|3. Neck CT scan: It appears that he has a C7 spinous process fracture as well as an approximately 2-3 mm anterolisthesis of C7 on T1. ASSESSMENT: Mr. _%#NAME#%_ is a 75-year-old male with a C7 spinous process fracture and a small C7 on T1 anterolisthesis. This is not a fracture, which is likely to destabilize the spine and the patient additionally has severe degenerative disease.
T1|tumor stage 1|T1|269|270|PHYSICAL EXAMINATION|ABDOMEN: Unremarkable. EXTREMITIES: Unremarkable. She has subtle tightening of the left arm, however, on measurement there is only 1 cm difference in circumference. ASSESSMENT/PLAN: This is a 57-year-old female patient with metastatic breast cancer with original stage T1 CN1 breast cancer status post lumpectomy and status post lumpectomy axillary dissection status post chemotherapy status post radiation treatment.
T1|tumor stage 1|T1|233|234|HISTORY OF PRESENT ILLNESS|PROBLEM: Metastatic breast cancer with brain metastases. HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old white female who presented in _%#MM2003#%_ with a right sided breast mass with 2/21 nodes positive and was staged as a T1 N2 breast cancer. She was treated postoperatively with radiation therapy between _%#MM2003#%_ and _%#MM2003#%_, receiving a total of 6020 cGy. She also received 4 cycles of Cytoxan, adriamycin, and 4 doses of........, which ended in _%#MM2003#%_.
T1|tumor stage 1|T1|277|278|ASSESSMENT|3) Chronic obstructive pulmonary disease; it is mild at baseline and I do not think this is the primary problem but it certainly does limit his pulmonary reserve from the above problems. 4) Non-small-cell lung cancer, status post right lower lobectomy _%#MM#%_ _%#DD#%_, 2003, T1 N0 M0. PLAN: 1) Consider checking echocardiography given his BNP. 2) Agree with Lasix, and I would consider even a little bit more.
T1|tumor stage 1|T1|161|162|ASSESSMENT AND PLAN|We are unsure if that was metastasis or not. PATHOLOGY: Non-small cell lung adenocarcinoma. ASSESSMENT AND PLAN: Mrs. _%#NAME#%_ is an 83-year-old female with a T1 non-small-cell lung carcinoma and questionable brain metastasis. At this time, we are not sure if the lesion in the vertex of her brain is a metastasis.
T1|tumor stage 1|T1|9|10|PROBLEM|PROBLEM: T1 N0 S0 pure seminoma. The patient was seen in consultation by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_. This consultation was requested by Dr. _%#NAME#%_.
T1|tumor stage 1|T1|167|168|HISTORY OF PRESENT ILLNESS|The chart was reviewed. Radiological reports were reviewed. Pathology reports were reviewed. HISTORY OF PRESENT ILLNESS: The patient is a 34-year-old gentleman with a T1 N0, S0 pure seminoma who presents for the possibility of radiation therapy. He felt a firmness in his right testicle in _%#MM#%_.
T1|tumor stage 1|T1|183|184|IMPRESSION|LYMPHATICS: The patient is without any preauricular or postauricular, cervical, supraclavicular, infraclavicular, or axillary lymphadenopathy or inguinal lymphadenopathy. IMPRESSION: T1 N0, S0 pure seminoma in a 34-year-old, status post inguinal orchiectomy who presents for the possibility of radiation therapy.
T1|tumor stage 1|T1|9|10|PROBLEM|PROBLEM: T1 N0 S0 pure seminoma. The patient was seen in consultation by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_. This consultation was requested by Dr. _%#NAME#%_.
T1|tumor stage 1|T1|218|219|IMPRESSION|No other palpable abnormalities. NEUROLOGICAL: Cranial nerves II through XII grossly intact with no focal deficits. EXTREMITIES: No cyanosis, clubbing, or edema. IMPRESSION: Ms. _%#NAME#%_ is a 59-year-old female with T1 N0 M0 (stage I) invasive adenocarcinoma arising in a villous adenoma that has been transanally excised on _%#MMDD2006#%_ with negative but close margins as well as angiolymphatic invasion.
T1|T1 (MRI)|T1|196|197|HISTORY OF PRESENT ILLNESS|There was severe dilation of the body and atrium of the left lateral ventricle with encephalomalacia of the overlying frontoparietal cortex. The peripheral ventricular rim of T2 hypointensity and T1 hyperintensity suggested that these findings were secondary prior grade IV germinal matrix hemorrhage on the left with intraventricular hemorrhage and left frontoparietal cortical insult.
T1|tumor stage 1|T1|9|10|PROBLEM|PROBLEM: T1 N2B M0 squamous cell carcinoma of the left tonsillar bed. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 52-year-old gentleman who in _%#MM#%_ noticed a left-sided mass, which he describes as being in level 3.
T1|tumor stage 1|T1|115|116|IMPRESSION|There is no evidence of any induration or pain in the base of tongue or oral tongue or floor of mouth. IMPRESSION: T1 N2B M0 squamous cell carcinoma of the left tonsillar bed, status post modified left neck dissection and biopsy of small nodule with no extracapsular extension.
T1|thoracic (level) 1|T1.|149|151|HISTORY OF PRESENT ILLNESS|Final pathology results are pending, however, it is presumed to be an posterior element bone cyst. She had posterior instrumentation from C4 through T1. She is now in a neck brace. Neurologically the strength in her arms have improved since her surgery 5 days ago. Also, the numbness and tingling is improving. She has had pain issues and is receiving narcotic medication for this.
T1|thoracic (level) 1|T1|282|283|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: He had two cervical disk surgeries, one was on _%#MMDD2007#%_ and was anterior at C4-T1 fusion and then yesterday with posterior fusion same level. He has a history of a mild grade stenosis from C5-C7 with a large disk herniation at both C4-5 and at C7, T1 there is severe spinal stenosis. The patient presented with significant changes: walking and balance, difficulty with fine motor movements, upper extremity deficits, and significant neck pain.
T1|tumor stage 1|T1,|207|209|HISTORY|REASON FOR CONSULTATION: Bacteremia. HISTORY: PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 71-year-old gentleman who I have known for many years. The patient has a history of bladder cancer, pathologic stage T1, status post partial cystectomy by me in 1997. He has not had a recurrence since and was actually seen in _%#MM#%_ of this year with a negative cystoscopy and a negative urinalysis.
T1|thoracic (level) 1|T1|194|195|HISTORY OF PRESENT ILLNESS|REQUESTING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_, on 10A. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 59-year-old male who underwent a posterior cervical laminoforaminotomy C7 through T1 right side earlier today by Dr. _%#NAME#%_ _%#NAME#%_ from Spine Surgery. We were asked to see the patient postoperatively for general medical care with particular regard to known history of reactive airway disease and obstructive sleep apnea.
T1|thoracic (level) 1|T1|119|120|OBJECTIVE|He does have intact sensation; however, it is diminished in the right upper extremity, primarily in the C6, C7, C8 and T1 dermatomes. He also has intact sensation in bilateral lower extremities, however, impaired primarily into the L2-L3 dermatomes. He has a negative Babinski test bilaterally with downgoing toes.
T1|tumor stage 1|T1|169|170|IMPRESSION|On bimanual examination you can ballot it between the rectum and the vagina but it is ill appreciated. EXTREMITIES: She has no cyanosis, clubbing, or edema. IMPRESSION: T1 N0 M0 villoglandular adenocarcinoma of the distal vagina, presumably of cloacogenic origin. RECOMMENDATIONS: I asked Dr. _%#NAME#%_ to examine her today. He saw her last about six weeks ago and agrees that this lesion now has some size associated with it.
T1|T1 (MRI)|T1|133|134|IMAGING STUDIES|Extensive calcification and plaque in the thoracic aorta and upper abdominal aorta. MRI of the T-spine and L-spine showing decreased T1 and increased T2 signal at T11 vertebral body presumably representing acute or semi-acute compression fracture. MRI of the L-spine showing grade I anterior slip L6 on S1 with bilateral pars defects.
T1|T1 (MRI)|T1|193|194|HISTORY OF PRESENT ILLNESS|Lumbar MRI was performed which showed diffuse metastatic disease through the vertebrae as well as 60% compression fracture of L1. Thoracic MRI also revealed intramedullary mass at the level of T1 through T2 as well as extramedullary mass a the level of T7. The patient was subsequently started on radiation therapy. He reportedly has received 1 treatment of radiation therapy this past Sunday.
T1|T1 (MRI)|T1|132|133|PROBLEM #5|The etiology for these findings is unclear at this time. The patient has had an MRI which reveals a large central area of decreased T1 signal in the liver which on repeat scanning 2-1/2 weeks apart did not change significantly. It is possible that a biopsy directed at this site, an external core biopsy, may be of higher yield in terms of proving that this patient has recurrent cholangiocarcinoma.
T1|T1 (MRI)|T1|308|309|LABORATORY DATA ON ADMISSION|This may represent metastases or postinfectious process. An MRI of the right left was done, which showed 4.6 x 4.7 x 7.5 cm high-grade tumor consistent with high grade osteosarcoma. There were 2 subcutaneous lymph nodes within the popliteal fossa. There was an ill-defined focal patchy T2 hyperintensity and T1 hypointensity within the medial femoral condyle of the right knee of uncertain clinical significance. HOSPITAL COURSE: 1. Fluids, electrolytes and nutrition. _%#NAME#%_ was maintained on a regular diet.
T1|thoracic (level) 1|T1|155|156|PHYSICAL EXAMINATION|ABDOMEN: Obese, positive bowel sounds in all four quadrants. No palpable hepatosplenomegaly. BACK: He does have a scar on his back over the vertebrae from T1 to T4. NEUROLOGIC: His cranial nerves II through XII are intact and his neuro exam is nonfocal. LABS: On day of admit, white count is 9.3, hemoglobin is 12.5, platelets are 352, 000.
T1|T1 (MRI)|T1|208|209|FAX (952) 985-8299|However, this is vastly in excess of that and needs to be considered in counseling the family. Clinical correlation is required". A head MRI without contrast on _%#MMDD2006#%_ showed "small foci of increased T1 signal in the right germinal matrix consistent with a small germinal matrix hemorrhage". We consulted with our pediatric neurologist, Dr. _%#NAME#%_. The most likely etiology for the seizures was hypoxic ischemic encephalopathy.
T1|thoracic (level) 1|T1|146|147|PAST MEDICAL HISTORY|7. Status post fall _%#MM2003#%_ resulting in scalp laceration and traumatic brain injury. No alteration ultimately in mental status. Did develop T1 and T5 compression fractures which are presently asymptomatic. 8. History of bilateral pulmonary infiltrates/effusion during hospitalization in _%#MM#%_ of 2004.
T1|thoracic (level) 1|T1.|128|130|LABORATORY FINDINGS/DIAGNOSTICS|In addition, there was made note of a paravertebral node near the first thoracic vertebra which appears to have some erosion to T1. There is no other dramatic mediastinal or hilar lymph adenopathy noted. There are some small lesions in the liver that are felt to be too small to characterize at the time of that scan.
T1|T1 (MRI)|T1|398|399|STUDIES|2. MRI of L-spine with and without contrast on _%#MMDD2007#%_ reveals broadbased disc bulging at L4-5 level causing mild spinal canal bilateral neural foraminal narrowing and no abnormal signal or contrast enhancement in the cord. 3. MRI of T-spine with and without contrast on _%#MMDD2007#%_, revealing normal thoracic spine and no areas of abnormal contrast in the cord, focal areas of increased T1 and T2 signal and T5, T8, T10 and T11 which do not enhance likely representing hemangiomas. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 50-year-old female with history of progressive relapsing form of multiple sclerosis who is followed by Dr. _%#NAME#%_ _%#NAME#%_ at the University of Minnesota.
T1|thoracic (level) 1|T1:|207|209|IMAGING|Anteriorly there is a fibular strut graft at levels 4 and 5 where corpectomies were done. There is also a kick plate that was placed at C6 with only inferior screws. 2. CT scan of the cervical spine through T1: This shows more detail than just the lateral and AP x-rays described above. There again is this concern for a fluid collection just off to the right side posteriorly at the C7 spinous process.
T1|T1 (MRI)|T1|220|221|IMAGING STUDIES PERFORMED DURING ADMISSION|This lesion is not identified on the noncontrast T1 or T2 images ______ liver parenchyma on delayed contrast images, it is likely benign and may represent an adenoma, FNH or transient perfusion defect. Second 1.5 cm low T1 signal intensity lesion within the right lobe of the liver correlates with the stable hypodensity seen on T2 since _%#MMDD2005#%_.
T1|T1 (MRI)|T1|209|210|ALLERGIES|The result of the MRI scan with multiple sclerotic lesions in the thoracic spine and a sclerotic lesion on L4 vertebral body. There were also multiple foci of hypointensity in the post contrast fat saturation T1 weighted images in the sacrum and the iliac mantle. So, on _%#MM#%_ _%#DD#%_, 2004, the patient underwent CT-guided bone biopsy from the iliac bone, the results of which are pending at the time of dicta tion.
T1|T1 (MRI)|T1|230|231|IMAGING RESULTS|2. Biopsy from right shoulder mass on _%#MM#%_ _%#DD#%_, 2006 consistent with Ewing sarcoma with strongly CD99/cytokeratin. 3. Molecular studies positive for EWF. 4. MRI of upper extremity joint: Nonspecific ill-defined decreased T1 and increased T2 signal in the operative site region, which is likely postop edema. Difficult to exclude residual tumor. No focal masses. 5. Chest, abdomen, pelvis CT: Bilateral lung clear of nodules or air space opacities.
T1|T1 (MRI)|T1,|157|159|PAST MEDICAL HISTORY|No nausea, vomiting, constipation, diarrhea. No dysuria, hematuria, joint pains, or headaches. No rash, no vaginal bleeding. PAST MEDICAL HISTORY: She had a T1, P1, high cholesterol, hypertension, and aortic regurgitations. No valve replacement has been done. She says that she had an echo done on _%#MM#%_ _%#DD#%_, 2006.
T1|thoracic (level) 1|T1|278|279|HISTORY OF PRESENT ILLNESS|Bilateral hip x-ray done on _%#MMDD2002#%_ that reveals multiple lytic lesions involving both iliac bones, sacrum, femoral neck on the right. HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old man with multiple myeloma diagnosed in _%#MM#%_ of 2001 when he presented with T1 compression fracture with C7 and C3 lytic lesions visualized on x-ray with normal SPEP and positive UPEP with light chains 2.23 grams in 24 hours.
T1|T1 (MRI)|T1,|177|179|IMAGING|Soft, nontender, nondistended. GYNECOLOGICAL EXAM: Deferred. IMAGING: MRI: The patient had an MRI on _%#MM#%_ _%#DD#%_, 2004. The patient had too-numerous-to count abnormal low T1, high T2, and contrast enhancing lesions throughout the bilateral cerebellar and cerebral hemispheres and the brain stem. Also lesions within the temporal horn of the lateral ventricle on the left.
T1|T1 (MRI)|T1|210|211|KEY IMAGING STUDIES AND PROCEDURES PERFORMED DURING THIS HOSPITALIZATION|Left lung remains clear. 6. MRI of the abdomen performed on _%#MMDD2006#%_. Conclusion is a quiet hemachromatosis of the liver and spleen. Possible hepatic cirrhosis with multinodular appearance on noncontrast T1 weighted images that may represent regenerating nodules. Cannot evaluate the liver for advancing nodules, however. If clinically indicated, a contrast enhanced CT could be performed prior to a planned dialysis.
T1|thoracic (level) 1|T1,|488|490|HISTORY OF PRESENT ILLNESS|When she was admitted to the neurology service, examination was consistent with T5 paraplegia with a sensory level and no movement of bilateral lower extremities. She had MRI of the brain, C,T and L-spine done the morning of admission showed greater than than 25 foci of T2 hyperintensities within the cerebral white matter,diffuse atrophy of the cervical cord most prominent at C7 through mid T2, multiple foci of irregular contrast enhancement in the cervical spinal cord at C7 through T1, diffuse atrophy of the thoracic spinal cord and focal region of circumferal enhancement at T7. She was initially started on methylprednisolone 1 mg daily. First day of treatment was on _%#MMDD2007#%_.
T1|thoracic (level) 1|T1.|262|264|LABORATORY DATA|The heads of these screws were interconnected with a metallic rod bilaterally. No evidence of impingement. There is also evidence of wide midline hemilaminectomies from C3 through C7, and residual subchondral and sclerotic changes in vertebral bodies C7 through T1.
T1|thoracic (level) 1|T1|159|160|HISTORY OF PRESENT ILLNESS|The patient has appointment on _%#MMDD2007#%_, with Dr. _%#NAME#%_ in oncology. 2. T1 vertebral fracture. The patient had an MRI of his spine which revealed a T1 vertebral fracture. Please see the report as noted above. Neurosurgery was consulted and felt that the patient needed a sedated MRI of the cervical, thoracic and lumbar spine, as the patient did not tolerate his previous MRI well.
T1|thoracic (level) 1|T1.|136|138|REASON FOR ADMISSION|Sleep architecture normal. Interictal activity consisted of spikes present occasionally over the left temporal leads, maximal at F7 and T1. No ictal activity seen. Impression: Interictal transience in the left temporal region. Video EEG monitoring from _%#MM#%_ _%#DD#%_, 2003, to _%#MM#%_ _%#DD#%_, 2003: Background alpha of 10 hertz which is bilaterally and symmetrically seen, and of the highest voltage posteriorly.
T1|thoracic (level) 1|T1|181|182|HISTORY OF PRESENT ILLNESS|A head CT without contrast demonstrated no acute abnormality. Cervical spine films raised a question of soft tissue swelling posteriorly. A CT through the cervical spine from C2 to T1 demonstrated no apparent fracture or subluxation per ER physician. It is noted that the patient underwent a brain MRI with and without contrast earlier today apparently to evaluate a movement disorder.
T1|thoracic (level) 1|T1,|236|238|H&P/ID|Since early _%#NAME#%_ he has had increasing pain and increase in opiate requirement, certainly over the last 1-2 weeks. He has had subsequent investigations and an MRI now demonstrating involvement in other thoracic vertebra including T1, T5, T7 and T9. MRI investigations apparently done in _%#CITY#%_ and sent to Dr. _%#NAME#%_ at Abbott Northwestern for reinterpretation with what I understand is clear disease progression.
T1|T1 (MRI)|T1|669|670|RADIOLOGY|An ultrasound of her transplanted kidney on _%#MMDD2006#%_ was significant only for persistent low resistance wave form in the iliac artery below the renal artery anastomosis of unknown significance. An MRI of the abdomen on _%#MMDD2006#%_ was significant for widely patent left lower quadrant transplant renal arteries and veins without stenosis, widely patent right lower quadrant pancreas transplant artery and veins without stenosis, bilateral native renal arteries without stenosis, a long mild to moderate irregular narrowing of the left external iliac throughout the majority of its course, multiple hypointense lesions throughout the pancreas seen primarily on T1 weighted images similar to those seen on CT exam from _%#MMDD2006#%_, which may represent complex fluid collections consistent with graft pancreatitis.
T1|T1 (MRI)|T1|220|221|HISTORY OF PRESENT ILLNESS|During that hospitalization, he received chemotherapy with methotrexate followed by leucovorin rescue for week 21 of that cycle. During that hospitalization, he had an MRI scan, which showed a concern for a nonenhancing T1 hypointense lesion in the lesser trochanter of the right femur. As this was not clearly consistent with his recent nuclear medicine scans, which had shown no skeletal metastasis.
T1|T1 (MRI)|T1|196|197|PROBLEM #2|He had been completely ambulatory upon admission to the Loyola. The patient was unable to tolerate an MRI and was electively intubated. MRI on _%#MMDD2007#%_ showed diffusely borderline decreased T1 signal in the vertebral bod ies throughout the vertebral column becoming progressively more apparent from the upper cervical region to the sacrum, focal areas of abnormal T1 signal and T5-L1, possibly L4 and S2 vertebral bodies, right iliac weighing and probably left sacrum (felt to represent a diffuse marrow replacement disorder), diffuse areas of dural/epidural enhancement throughout the length of the spinal canal with relatively focal areas of dural/epidural enhancement in the lumbar spinal canal at L3-L5 downward into the sacrum.
T1|T1 (MRI)|T1|190|191|IMAGING|No significant side batch visualization, filling defects or stricturing. There are no enhancing lesions. I did find about the liver and pancreatic head, there is a decrease in the signal on T1 images of the upper pelvis probably related to marrow reactivation from long-standing anemia. 2. An ultrasound of the abdomen _%#MMDD2006#%_ with the impression of an unremarkable exam of the abdomen.
T1|thoracic (level) 1|T1|139|140|LABORATORY DATA|Coagulation studies are, INR 1.21 and PTT 44. Imaging studies include a C-spine MRI, which shows focal bone marrow abnormalities at C6 and T1 suspicious for metastatic lesion. A neck MRA shows a 90% stenosis of the left internal carotid artery. Blood cultures x2 has been negative. Brain MRI shows a small left infarct of the left precentral gyrus.
T1|thoracic (level) 1|T1,|209|211|HISTORY OF PRESENT ILLNESS|No evidence of spinal cord compression was seen. There is also a mass seen at the level of S1 and S2, although this is not reported in the official radiology report. C-spine MRI showed abnormal enhancement in T1, as well as a C4-5 osteophyte with herniation and mild cord impingement. Symptomatically, the patient continues to have urinary retention, as well as pain in her bilateral ribs.
T1|T1 (MRI)|T1|255|256|HISTORY OF PRESENT ILLNESS|She underwent MRI scanning on _%#MMDD2007#%_, and this revealed 2 small foci of enhancement in the cerebellum, 1 at the right peduncle and 1 in the left body of the cerebellum. The size of these lesions was approximately 3 mm. There was also questionable T1 hypointensity at the posterocentral clivus, which has not been further characterized at this time. With regards to her current and recent symptomatology, the patient states that her weight has been stable, and she has not endorsed constitutional symptoms.
T1|tumor stage 1|T1|205|206|HPI|LUNGS: Essentially clear on auscultation. HEART: Regular sinus rhythm. ABDOMEN: Soft, no palpable organomegaly. EXTREMITIES: Unremarkable without arm swelling. Assessment and Plan: Stage II breast cancer, T1 N1 M0, infiltrating ductal carcinoma, with lobular feature. Status post bilateral mastectomy with a tissue expander. The patient is under chemotherapy with Adriamycin and Cytoxan, and planned Taxol.
T1|tumor stage 1|T1|188|189|HPI|My key findings: CC: Recurrent cancer of the left breast with metastases. HPI: This is a 77-year-old female patient who had left breast cancer since 1992. The original cancer was stage I, T1 N0 M0 and most likely infiltrating ductal or lobular carcinoma. The patient had a lumpectomy and radiation therapy to her left breast with adjuvant tamoxifen.
T1|T1 (MRI)|T1|145|146|LABORATORY|2. 1.5 enhancing lesion within the right lobe of the liver, which correlates to the findings on CT. Lesion is not identified on the non-contrast T1 or T2 images and blends in with liver parenchyma on delayed contrast images, likely benign and may represent an adenoma or a nodular hyperplasia or transient perfusion defect that recommend follow-up MRI.
T1|T1 (MRI)|T1|329|330|DIAGNOSTICS|Tandem walking, toe walking, and heel walking are normal. DIAGNOSTICS: MRI of brain _%#MMDD2007#%_: No enhancing lesions, no diffusion-weighted abnormalities, approximately 6 bihemispheric subcortical white matter lesions. Three of them are periventricular. Brain stem and cerebellum are normal. Several are of reduced signal on T1 images. LABORATORY DATA: On _%#MMDD2007#%_: TSH normal at 0.57. Chem 10 normal including BUN 10, creatinine 0.7. Normal LFTs with AST 25, ALT 22, alkaline phosphatase 93.
T1|T1 (MRI)|T1,|308|310|HISTORY OF PRESENT ILLNESS|That study showed a 5 x 4 x 4 cm mass located in the region of the suprasellar cistern which was hypodense without any notable surrounding edema or calcifications. There was a notable mass effect, however. An MRI was done subsequently which showed this mass to be effacing the third ventricle, isointense on T1, hyperintense on T2, displacing the pituitary stalk medially and possibly the optic chiasm slightly anteriorly. On that same day, the patient was taken to the operating room and Dr. _%#NAME#%_ performed a ventriculoperitoneal shunt.
T1|tumor stage 1|T1|9|10|PROBLEM|PROBLEM: T1 N0 squamous cell carcinoma of the left lateral oral tongue S/p resection with 5 cm of invaion and no neck disection now with recurence in left neck This patient was seen for consultation in the Radiation Oncology Clinic on _%#MMDD2007#%_ by Dr _%#NAME#%_ _%#NAME#%_ and Dr _%#NAME#%_ _%#NAME#%_. The consultation was at the request of Dr _%#NAME#%_ _%#NAME#%_.
T1|tumor stage 1|T1|115|116|HISTORY OF PRESENT ILLNESS|PROBLEM: Acute myeloid leukemia. HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ is a 68-year-old who has a history of T1 N0 left breast cancer diagnosed in 2000. She underwent lumpectomy, radiation and chemotherapy with Adriamycin and Cytoxan. She has had no recurrence of her breast cancer, however, in _%#MM2005#%_ she was found to have falling blood counts.
T1|tumor stage 1|T1,|244|246|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 55-year-old gentleman status post right single-lung transplant in 1993 followed by a left single-lung transplant in 1997 after first transplant was rejected. He also has a history significant for T1, N0, M0 squamous cell carcinoma of the right tongue treated in 2002 by Dr. _%#NAME#%_ with a partial glossectomy and a modified radical neck dissection of the right side.
T1|T1 (MRI)|T1|140|141|HISTORY OF PRESENT ILLNESS|During that admission, she also had an MRI of her head that showed an interval progression in white matter abnormalities. She had increased T1 signal in the posterior left periventricular white matter and in the pons. Radiology reports dictate that this is consistent with a primary demyelinating process.
T1|T1 (MRI)|T1|250|251|HISTORY OF PRESENT ILLNESS|The patient had a CT of the chest again on _%#MMDD2004#%_ which showed a large left pleural effusion occupying most of the left hemithorax. MRI of the spine on _%#MMDD2004#%_ showed compression of T7 through T12. T7 appeared diffusely hypointense on T1 and with contrast enhanced in the body and into the right pedicle. There was expansion of the vertebral body into the spinal canal with mild spinal stenosis.
T1|tumor stage 1|T1,|338|340|ASSESSMENT AND PLAN|Gait and balance are normal. ASSESSMENT AND PLAN: In summary, this patient is a 44-year-old gentleman with squamous cell carcinoma of the right lateral tongue, status post resection, left radial forearm free-flap repair, and neck dissections. Originally, he was felt to have a clinical T3, N1 lesion. Pathologically, he appears to have a T1, N0 lesion (stage I). Our current interpretation of the pathology report indicates that there maybe a deep/lateral mucosal margin that is within 2 mm.
T1|T1 (MRI)|T1|355|356|LABORATORY  DATA|MRI of the brain without and with contrast, MRA of the circle of Willis without contrast and MRV of the brain without contrast all done on _%#MMDD2006#%_. Impressions from the above include the following: 1. Cystic peripherally enhancing lesion with central hypo intensity and peripheral hyper intense and T2 weighted images and central hyperintensity on T1 weighted images in the mid posterior left cerebellar hemisphere consistent with an early subacute intraparenchymal hemorrhage. No definite evidence of mass, arteriovenous malformation, aneurysm, or venous sinus thrombosis.
T1|tumor stage 1|T1,|168|170|HISTORY OF PRESENT ILLNESS|She is a former smoker. Records do not indicate to what extent she may have emphysema but she has previously had resection of the left upper lobe in _%#MM2006#%_ for a T1, NO, MO, nonsmall cell carcinoma of the lung. She did not receive any postoperative adjunctive therapy so far as I know.
T1|thoracic (level) 1|T1|303|304|PHYSICAL EXAMINATION|EXTREMITIES: No pedal edema noted and no calf tenderness. MUSCULOSKELETAL: Examination shows functional cervical spine range of motion, though the quality of the motion is abnormal with a flat C-spine during her flexion of the neck, and bony prominence at the lower end of the incision in the region of T1 and T2 for the thoracic spinous processes. The results are mild scoliosis but increased lumbar lordosis. There is decreased range of motion at both the hips due to spasticity and also right fingers in flexed position due to increased tone and hand intrinsic wasting and deformity.
T1|thoracic (level) 1|T1|162|163|HISTORY OF PRESENT ILLNESS|She had an MRI on _%#MMDD#%_ at Unity Hospital, which revealed cord compression from T1-T3 level due to epidural mass, which extends from the upper margin of the T1 to upper margin of T4. There was metastatic involvement of multiple neural foramina on the left from the T1-T2 level to the T4-T5 level.
T1|T1 (MRI)|T1|218|219|HISTORY OF PRESENT ILLNESS|He was followed by neurology, infectious disease, surgery and the internal-medicine service during his stay. He underwent head CT as well as MRI scan. The latter showed multiple T2 hyperintense lesions as well as some T1 hypointense lesions, also known as black holes. In comparison to MRI exam in 2003, this burden was unchanged. In addition there were not particular enhancements post gadolinium. He had several studies establishing his cholecystitis leading to cholecystectomy.
T1|tumor stage 1|T1|218|219|HISTORY OF PRESENT ILLNESS|The consult was requested by Dr. _%#NAME#%_. The chart, radiographic reports/films and pathology reports were reviewed. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 52-year-old male who was initially diagnosed with T1 N0 M0 squamous cell carcinoma of the right lateral tongue and underwent resection with Dr. _%#NAME#%_ in _%#MM2002#%_. The lesion was noted to be superficially invasive, less than 0.1 mm.
T1|tumor stage 1|T1|178|179|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Left breast infiltrating ductal carcinoma, stage IIA, T1 N1 M0. HPI: This is a 52-year-old female patient who was found to have abnormal mammogram with multiple densities in the left breast on routine examination in _%#MM#%_ 2005.
T1|thoracic (level) 1|T1|173|174|CURRENT PALLIATIVE ISSUES|It has been present previously and is consistent with known lower cervical foraminal stenosis due to degenerative arthropathy with possible but not likely contribution from T1 metastatic disease. This pain is present intermittently, occurs frequently, and is never less than a 6/10 level. The patient does get temporary relief from a dose of morphine 15 mg given q.4 h. p.r.n. break-through pain.
T1|thoracic (level) 1|T1,|149|151|PHYSICAL EXAMINATION|She misses by about 10 degrees. The left elbow is completely normal. Wrists are normal. MCPs are normal. PIPs have synovitis. The left second is S1, T1, L1; left third S1+, T1, L1. Other PIP joints are all normal. DIP joints are without synovitis. The hips are nontender and move well. The knees are cool and have no effusions.
T1|tumor stage 1|(T1,|17|20|PROBLEM|PROBLEM: Stage I (T1, N0, M0) invasive ductal carcinoma of the left breast. This patient was seen in the Radiation Oncology Clinic on _%#MM#%_ _%#DD#%_, 2002, by Drs. _%#NAME#%_ _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_ for consultation at the request of Dr. _%#NAME#%_ _%#NAME#%_ in the Department of Medical Oncology.
T1|thoracic (level) 1|T1|142|143|HISTORY OF PRESENT ILLNESS|Right frontal skull and right parietal skull lytic lesions were also noted. An MRI scan of the cervical spine demonstrated again C2, 4, 5 and T1 metastases and soft- tissues masses in the prevertebral regions between C2 and C5. There is also an epidural mass extending from C2 to C5 with cord compression.
T1|thoracic (level) 1|T1,|188|190|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: In summary, Ms. _%#NAME#%_ is a 38-year-old female with carcinoma of the breast which is now metastatic to the cervical spine and skull. There may also be a lesion at T1, and further evaluation for other sites of metastatic disease will be forthcoming. Before we proceed with radiation to the cervical spine for treatment of cord compression, and for palliation, we would like Neurosurgery to evaluate the patient to determine if any structural intervention is required in order to stabilize the spine.
T1|thoracic (level) 1|T1,|200|202|HISTORY OF PRESENT ILLNESS|She goes on to receive whole brain radiation 3750 cGy, completed in _%#MM2007#%_. 3. _%#MMDD2007#%_: Follow-up MRI of the axial spine reveals progression of disease with specific noted disease at C2, T1, T2, and diffuse involvement of the lumbar vertebra. Of note, there is also high-grade canal stenosis at L2-L3, which is thought to be related to degenerative disk disease.
T1|thoracic (level) 1|T1|134|135|HISTORY OF PRESENT ILLNESS|He also was found to have a mass on his sternum. He underwent MRI scan of the spine and was found to have a destructive lesion at the T1 vertebra with a compression fracture. He also had small destructive lesions at C7 and T3. Biopsy of the sternal mass revealed plasma-cytoma. Biopsy of a left axillary mass revealed a benign lipoma.
T1|tumor stage 1|T1,|152|154|IMPRESSION|2. History of recurrent bronchitis. 3. History of right lower lobectomy for stage I adenocarcinoma of the lung in 2001, at Fairview Southdale. This was T1, N0, M0 disease per the admission history and physical. 4. Two pulmonary nodular densities in the right lower lung zone, one was 2.3 cm and one was 2.5 cm, question focal rounded infectious infiltrate versus tumor densities.
T1|thoracic (level) 1|T1|216|217||Had physical therapy and medications for one year, nothing helped, the incident occurred in 1999. She ended up having fusion in the cervical area, C6-7 and she said actually she had nerve root impingement from C3 to T1 on the left side but it was worse at C6-7 and then cadaver and metal was used for the fusion. She continued to decline, no help with pain. She had a collar on which actually threw her jaw out of the position and she became very tender in the left TMJ.
T1|tumor stage 1|T1,|125|127|IMPRESSION|IMPRESSION: Mr. _%#NAME#%_ has recent findings of two separate synchronous colon cancers. The lesion in the right colon is a T1, N0, M0 and the lesion in the sigmoid colon appears to be a T1, N1, M0 cancer. His greatest risk of relapse is from the sigmoid colon lesion.
T1|tumor stage 1|T1,|62|64|PROBLEM|PROBLEM: Squamous cell carcinoma of the base of tongue, stage T1, N2c, M0. Mr. _%#NAME#%_ was seen in the Department of Radiation Oncology on _%#MMDD2005#%_ by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ at the request of Dr. _%#NAME#%_ _%#NAME#%_.
T1|tumor stage 1|T1,|125|127|CC|__x___ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: T1, N2c, M0 BCT carcinoma. HPI: Status post resection of primary. Exam: Bilateral neck nodes, no primary seen or palpated. Assessment and Plan: We have offered the patient concurrent RT/chemotherapy.
T1|thoracic (level) 1|T1|206|207|HISTORY OF PRESENT ILLNESS|MRI of the thoracic spine on _%#MMDD2005#%_ showed multiple scattered lesions in the thoracic spine, with the largest being in T7 and T11. A PET scan on _%#MMDD2005#%_ showed increased uptake in the C7 and T1 vertebral bodies, as well as in the left anterior fifth rib. There are also increased bilateral pretracheal nodes, which were not specific for malignancy.
T1|tumor stage 1|T1|9|10|PROBLEM|PROBLEM: T1 N0 M0 vaginal cancer, status post partial vaginectomy with close deep margins. Ms. _%#NAME#%_ was seen for initial consultation in the Department of Therapeutic Radiology on _%#MMDD2005#%_ by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ at the request of Dr. _%#NAME#%_ _%#NAME#%_.
T1|tumor stage 1|T1|180|181|ASSESSMENT AND PLAN|NEUROLOGIC: Cranial nerves II through XII intact. The muscle strength is 5/5 throughout. Gait and stations are normal. ASSESSMENT AND PLAN: This is a 52-year-old female with stage T1 N0 M0 squamous cell carcinoma of the vagina, status post partial radical vaginectomy and bilateral inguinal femoral lymph node dissection in _%#MM2004#%_.
T1|tumor stage 1|T1|157|158|ASSESSMENT|Final Diagnosis: Fibrofatty tissue with single benign lymph node; no evidence of malignancy. ASSESSMENT: Ms. _%#NAME#%_ is a 72-year-old female with stage I T1 N0 M0 invasive ductal carcinoma of the left breast, completely excised with negative margins. Greatest diameter is 0.9 cm. ER positive, PR negative, HER2/neu negative.
T1|tumor stage 1|T1|332|333|IMPRESSION|EXTREMITIES: No cyanosis, clubbing or edema. IMAGING: We have reviewed her recent imaging including her _%#MMDD2005#%_ neck CT and _%#MMDD2005#%_ PET scan from Regions Hospital. IMPRESSION: Ms. _%#NAME#%_ is a 72-year-old female with recurrent squamous cell carcinoma of the left oral tongue, status post partial glossectomy, stage T1 N2b Mx. PLAN: We recommend external beam radiation therapy. Given the anterior location of the lesion, we discussed treating level 1 nodes, as well as the involved level 3 and 4 nodes.
T1|tumor stage 1|(T1|322|324|ASSESSMENT|NEUROLOGIC: Cranial nerves II through XII are grossly intact, strength is 5/5 in all 4 extremities, light touch is symmetric and intact, the gait is aided by use of a walker. ASSESSMENT: Ms. _%#NAME#%_ is a 46-year-old female under chronic immunosuppression, status post renal transplant times 2, presents with a stage IV (T1 N1 M0) malignant fibrous histiocytoma of the left middle thigh versus 2 separate primaries, stage II (T1 N0 M0) of malignant fibrous histiocytoma in the left middle thigh.
T1|tumor stage 1|(T1|252|254|ASSESSMENT|ASSESSMENT: Ms. _%#NAME#%_ is a 46-year-old female under chronic immunosuppression, status post renal transplant times 2, presents with a stage IV (T1 N1 M0) malignant fibrous histiocytoma of the left middle thigh versus 2 separate primaries, stage II (T1 N0 M0) of malignant fibrous histiocytoma in the left middle thigh. She is status post a radical resection of one of the masses with a less than 1 mm deep margin, and status post excisional biopsy of the other mass with positive margin.
T1|thoracic (level) 1|T1|208|209|HISTORY OF PRESENT ILLNESS|However, deletion 20q was still identified. Chemotherapy was complicated with infectious complications. On _%#MM#%_ _%#DD#%_, 2005, he developed right upper back pain. An MRI revealed cord impingement from a T1 lesion. He was otherwise neurologically intact. The patient was treated with high-dose Ara-C, as well as radiation. He received radiation to C6 through T2. He received 200 cGy a day for 12 days for a total dose of 2400 cGy.
T1|thoracic (level) 1|T1|146|147|HISTORY OF PRESENT ILLNESS|Impression of these films was that: 1. Post surgical changes in the lower cervical and upper thoracic spine with destructive lytic lesions in the T1 vertebral body. 2. Soft tissue mass along the posterior and right lateral aspect of the trachea measuring at its largest 3 x 2 cm.
T1|T1 (MRI)|T1|188|189|HOSPITAL COURSE|HOSPITAL COURSE: In the hospital, he was loaded with Dilantin and an MRI was obtained which showed a negative MR of the brain, no structural abnormalities are identified. Finding sagittal T1 weighted images are normal. T2 weighted images appear normal. Flare images are unremarkable. Post gadolinium weighted imaging is also unremarkable.
T1|thoracic (level) 1|T1|454|455|HOSPITAL COURSE|Cranial nerves II-XII are intact bilaterally. He had 5/5 strength in his right deltoid bicep, tricep, wrist extensor, wrist flexor and intrinsic muscles of the hand as well as 5/5 strength in the left deltoid, bicep, tricep, wrist extension, flexion, and intrinsic muscles of the hand and 5/5 strength in lower extremity muscle groups bilaterally. The incision looked clean, dry and intact. He had normal sensation in the upper extremity, C6, C7, C8 and T1 dermatomal distribution bilaterally. At this point in time, the patient was appropriately ready for discharge. DISCHARGE MEDICATIONS: 1. The patient is being sent home on Percocet 1-2 pills p.o. q.4-6h. p.r.n. for pain of which 30 pills were written for with 1 refill.
T1|tumor stage 1|T1,|254|256|IMPRESSION|Specifically, there is no evidence of recurrent or residual tongue mass or lesion. IMPRESSION: This is a 50-year-old white female with a history of breast cancer on recent chemotherapy, who was admitted for neutropenic fever, also with a history of left T1, N0, M0 squamous cell carcinoma of the tongue, status post wide local excision with signs and symptoms consistent with mild pharyngotonsillitis, improving on IV antibiotics.
T2|tumor stage 2|T2,|170|172|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Squamous cell carcinoma of the lung, newly diagnosed. 2. HIV/AIDS, previously diagnosed. 3. History of squamous cell carcinoma of piriform sinus, T2, N1, M0 status post radiation and chemotherapy, previously diagnosed. MAJOR PROCEDURES: 1. Chest CT with IV contrast on _%#MMDD2007#%_ which demonstrated no pulmonary emboli, but it showed multiple new nodular lesions in both lungs, with encasement of the central right lower lobe bronchovascular bundles.
T2|T2 (MRI)|T2|127|128|HISTORY OF PRESENT ILLNESS|This showed a large mass measuring 16 cm x 12 cm x 11 cm in size and was hypointense on T1 weighted images and hyperintense on T2 weighted images. No extracapsular invasion was seen. A differential diagnosis based on the imaging available was focal nodular hyperplasia versus fibrolamellar variant of hepatocellular carcinoma.
T2|tumor stage 2|T2,|109|111|FINAL DIAGNOSIS|FINAL DIAGNOSIS: Moderately differentiated squamous cell carcinoma, left lower lobe lung, pathological stage T2, N0, M0. OPERATIVE PROCEDURE: On _%#MMDD2007#%_ left video-assisted thoracoscopy, wedge resection, left lower lobe lung nodule and left thoracotomy, left lower lobectomy and mediastinal lymph node dissection was carried out.
T2|tumor stage 2|T2|237|238|BRIEF HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSES: 1. Oropharyngeal cancer. 2. Chemoradiation. MAJOR IMAGING AND PROCEDURES: None. BRIEF HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is a 62-year-old gentleman with a history of stage IVA oropharyngeal cancer T2 N2 M0 who has completed 2 cycles of cisplatin, Doxil and 5-FU. He is admitted for another cycle of cisplatin infusion.
T2|tumor stage 2|T2|71|72|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Stage 4A oropharyngeal squamous cell carcinoma T2 N2C MX. 2. Nausea. 3. Constipation. HISTORY OF PRESENT ILLNESS: Briefly, this is a very pleasant 62-year-old gentleman with a past medical history significant for GERD and hypertension who presents for induction chemotherapy for a newly-diagnosed stage 4A oropharyngeal cancer, T2, N2C, MX.
T2|tumor stage 2|T2,|253|255|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Squamous cell carcinoma of the larynx. DISCHARGE DIAGNOSIS: Squamous cell carcinoma of the larynx. OPERATIONS/PROCEDURES PERFORMED: Total laryngectomy. HOSPITAL COURSE: Mr. _%#NAME#%_ is a 57-year-old gentleman who had a history of T2, N1 squamous cell carcinoma of the right piriform sinus that was treated with radiation therapy and a right modified radical neck dissection in _%#MM#%_ 2004.
T2|T2 (MRI)|T2|146|147|ADMISSION MEDICATIONS|ALLERGIES: None. REVIEW OF SYSTEMS: Mid and low back pain, no headaches. HOSPITAL COURSE: The patient was admitted and underwent MRI that shows a T2 hyperintensity at the T5 vertebral body indicating likely acute event. On further review it was found that he has very minimal if any blood behind the T5 vertebral body.
T2|tumor stage 2|T2|118|119|FINAL DIAGNOSIS|FINAL DIAGNOSIS: Moderately- to poorly-differentiated adenocarcinoma right upper lobe of the lung, pathological stage T2 N0 M0. OTHER DIAGNOSES: 1) Hypertension. 2) Hyperlipidemia. PROCEDURE: _%#MM#%_ _%#DD#%_, 2005: 1) Diagnostic flexible bronchoscopy.
T2|T2 (MRI)|T2|166|167|PROCEDURES|Some increased signal in the central mid brain, questionable artifact, although there was a similar abnormality noted on CT scan. Several foci of abdominal increased T2 signal scattered throughout the subcortical white matter of both cerebral hemispheres, consistent with chronic small vessel ischemic disease. No gadolinium enhancement and no intracranial mass. PERTINENT LABORATORY: Obtained _%#MMDD2005#%_, total cholesterol 134, triglycerides 103, LDL 78, HDL 35, glucose 117, A1C 5.6.
T2|T2 (MRI)|T2|239|240|HISTORY OF PRESENT ILLNESS|There were no movements in her legs. Since her examination was consistent with a level at approximately to T1, T3 levels. A brain and spine MRI was done within a few hours after her presentation and was consistent with extensive increased T2 signal within the cervical spinal cord extending from C3 to T1 levels. Her brain MRI was normal. HOSPITAL COURSE: _%#NAME#%_ was initially admitted to the Intensive Care Unit for close monitoring.
T2|T2 (MRI)|T2|149|150|PROCEDURES/TREATMENT PERFORMED|3. Lumbar puncture: Negative for cryptococcal antigen, EBV, toxoplasma, bacteria, fungus, cytology. 4. MRI scan of brain: Revealed areas of abnormal T2 hyperintensive and T1 hypointensity and punctate focal areas of abnormal T2 hyperintensity scattered throughout the cerebral hemispheres, bilaterally.
T2|T2 (MRI)|T2|144|145|IMAGES REVIEWED|The patient had no pronator drift. IMAGES REVIEWED: MRI with third ventricular mass, although possibly a thalamic mass. It was non-enhancing on T2 but hyperdense with contrast. The head CT showed no ventriculomegaly; however, it did indicate the third ventricle cyst. LABORATORY DATA: Labs are pending. ASSESSMENT: Mr. _%#NAME#%_ is a 37-year-old right-handed male who presents with approximately a 20-day history of worsening symptoms related to third ventricular mass.
T2|UNSURED SENSE|T2,|211|213|HISTORY OF PRESENT ILLNESS|The patient does have a brother who is a completely-matched donor. As stated above, patient was diagnosed in early _%#MM#%_ 2005 with acute myelogenous leukemia with a Chromosome 5 deletion and translocation of T2, 11 was given round of chemotherapy with cytarabine, etoposide, and doxorubicin that started on _%#MM#%_ _%#DD#%_, 2005 discharged from the hospital in complete remission.
T2|tumor stage 2|T2,|223|225|HISTORY OF PRESENT ILLNESS|3. Sleep apnea. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 51-year-old male, diagnosed with stage 4A squamous cell carcinoma involving the right base of the tongue in _%#MM#%_ 2005. His disease stage was classified as T2, N2b, M0. He began a study protocol on _%#MM#%_ _%#DD#%_, 2005 with an induction of cisplatin, docetaxel, and 5-FU. He has been admitted on _%#MM#%_ _%#DD#%_, 2005 for a second cycle of chemo induction.
T2|T2 (MRI)|T2|224|225|OPERATIONS/PROCEDURES PERFORMED|ADMISSION DIAGNOSIS: Dizziness. DISCHARGE DIAGNOSIS: Demyelinating disease, etiology uncertain. OPERATIONS/PROCEDURES PERFORMED: 1. Magnetic resonance imaging of the brain on _%#MM#%_ _%#DD#%_, 2006, which revealed multiple T2 hyperintensities throughout the white matter of the brain, consistent with multiple sclerosis. 2. Magnetic resonance imaging of cervical and thoracic spines _%#MM#%_ _%#DD#%_, 2006, official report pending.
T2|T2 (MRI)|T2|266|267|FINAL DIAGNOSIS|She has known metastatic breast cancer to bone and as part of her hospital workup, we did proceed to do an MRI of her brain. The findings showed diffuse metastatic involvement in the visualized portions of the skull, particularly near the clivis with some increased T2 activity consistent with either adjacent meningeal enhancement either due to local irritation or perhaps direct involvement. The patient was not of the mind set to consent to a spinal tap.
T2|T2 (MRI)|T2|194|195|HOSPITAL COURSE|During the EEG monitoring, the patient had several stars, when she gave us a signal, but they have never seen any clinical EEG change during the event. The MRI showed a few non-specific foci of T2 signal hyperintensity in the cerebellar white matter; otherwise unremarkable. DISCHARGE PLAN: The patient was loaded with Depakote before she left the hospital.
T2|tumor stage 2|T2,|201|203|HISTORY OF PRESENT ILLNESS|There were no complications. Findings were perianastomotic recurrence of colon cancer. HISTORY OF PRESENT ILLNESS: This is a 73-year-old woman, who underwent a sigmoid resection in _%#MM#%_ 2002 for a T2, N0 carcinoma of the sigmoid, with a 13 of 13 nodes negative for tumor. All resection margins were normal including distal resection margin and a cut specimen of 3.5 cm.
T2|T2 (MRI)|T2|289|290|ADMISSION LABORATORY DATA|The MRI noted extensive white matter T2 hyperintensity and T1 hypointensity within the posterior half of both cerebral hemispheres and involving the posterior third of the corpus callosum. The corticospinal tracts bilaterally are also involved through the brain stem. There was a focus of T2 hyperintensity and T1 hypointensity involving the middle cerebral peduncle on the right. All of these findings are unchanged compared to the earlier examination.
T2|tumor stage 2|T2,|169|171|ADMITTING PHYSICIAN|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 49-year-old male with squamous cell carcinoma of the left tonsil, diagnosed in _%#MM#%_ 2005. He has been staged as IVa, T2, N2b, M0. He is currently undergoing concurrent chemoradiation with his first dose of cisplatin given on _%#MM#%_ _%#DD#%_, 2005, and second dose given on _%#MM#%_ _%#DD#%_, 2005.
T2|T2 (MRI)|T2|199|200|PROCEDURES PERFORMED DURING THIS ADMISSION|6. End-stage kidney disease. PROCEDURES PERFORMED DURING THIS ADMISSION: 1. MRI brain, _%#MMDD2006#%_. Impression: a. Overall no significant change in the bilateral periventricular deep white matter T2 hyperintensities, which may represent small vessel ischemic disease. b. Old infarct in the right MCA distribution. c. No evidence for restricted diffusion to suggest ischemia.
T2|T2 (MRI)|T2|185|186|HOSPITAL COURSE|One punctate lesion was noted in the right parietal region, second lesion was in the right frontal area and the third lesion was in the left posterior white matter. There was confluent T2 hyperintensity compatible with multiple sclerosis. T2 hyperintensity was seen perpendicular to the lateral ventricles and the corpus callosum. Corpus callosum was mildly thinned. There were several lesions noted also within the corpus callosum itself.
T2|tumor stage 2|T2|237|238|HOSPITAL COURSE|His postoperative course was uneventful. The patient was discharged on _%#MMDD2004#%_ which was postoperative day #6 in good condition. He was told to follow-up with us in two to three weeks for follow-up and pathology report revealed a T2 N0M0 carcinoma of the splenic flexure. Because of the patient's previous history of malignant polyps, he needs to be seen frequently for colonoscopy.
T2|T2 (MRI)|T2|169|170|HOSPITAL COURSE|On admission, the patient also obtained an MRI scan to ensure that there was nothing else occurring. The MRI scan was read out as there being a small focus of increased T2 hyperintensity and enhancement at the right anterior horn of the right lateral ventricle along the tract of the previous ventriculostomy catheter as well as stable postoperative changes of a partial right cerebellar hemispheric resection.
T2|T2 (MRI)|T2|273|274|CURRENT LABORATORY WORK|CURRENT LABORATORY WORK: 1. _%#MMDD2006#%_: INR 1.04, WBC 6.5, hemoglobin 12.9, MCV 97, platelets 294, sodium 132, potassium 3.6, BUN 6, creatinine 0.66, IgM 51. 2. _%#MMDD2006#%_: MRI results as follows: There has been marked interval improvement in multiple areas of the T2 signal abnormality. Only mild residual abnormal T2 signal is present in the bilateral medial temporal lobes. The findings are most consistent with a resolving inflammatory or infectious process.
T2|tumor stage 2|T2|66|67|FINAL DIAGNOSIS|FINAL DIAGNOSIS: Adenocarcinoma of the cardia. Pathological stage T2 BN1M0. OTHER DIAGNOSIS: Crohn's disease. PROCEDURE: On _%#MMDD2006#%_, transhiatal esophagectomy with left cervical end-to-side esophagogastrostomy, pyloromyotomy, placement of feeding tube jejunostomy, and bilateral tube thoracostomy.
T2|tumor stage 2|T2|259|260|DISMISSAL SUMMARY|This was performed. The final pathology showed a poorly differentiated adenocarcinoma measuring 1.5 cm. All margins were negative. Unfortunately, there was metastatic carcinoma of _%#MMDD#%_ periesophageal/perigastric lymph nodes. Final pathological stage is T2 BN1 M0. The patient's postoperative course was uneventful.
T2|tumor stage 2|T2|233|234|HISTORY OF PRESENT ILLNESS|She was diagnosed with a lower esophageal adenocarcinoma via endoscopy after presenting to her physician with dysphagia. She was seen by Dr. _%#NAME#%_ at _%#COUNTY#%_ _%#COUNTY#%_ and had an EUS. The findings were consistent with a T2 N1 M0 cancer. The patient did not want chemotherapy. She initally saw Dr. _%#NAME#%_ for an endoscopic resection but theis was not technically feasible.
T2|thoracic (level) 2|T2|240|241|HISTORY OF PRESENT ILLNESS|REASON FOR CONSULTATION: Multiple brain metastases with known metastatic, systemic primary tumor. HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old right-handed female with a history of known tonsillar adenoma with metastases to the T2 vertebral body, status post corpectomy with cage and pedicle screw fixation from T1 to T3 by Dr. _%#NAME#%_ _%#NAME#%_ in _%#MM2006#%_. She did well postoperatively and was last seen by Neurosurgery in _%#MM2006#%_ with a complication of a postoperative seroma and epidural extension with mild spinal cord compression causing urinary retention, also status post wound washout for that situation.
T2|thoracic (level) 2|T2|152|153|PAST SURGICAL HISTORY|6. Schizoaffective disorder. 7. Chronic lower extremity neuropathy. 8. Gastroreflex disease. 9. Tobacco use. PAST SURGICAL HISTORY: 1. Hysterectomy. 2. T2 spinal surgery. ALLERGIES: No known drug allergies. ADMISSION MEDICATIONS: 1. Thorazine 250 mg each day at bedtime.
T2|tumor stage 2|(T2,|141|144|BRIEF HISTORY|2. Mucositis. 3. Clostridium difficile. BRIEF HISTORY: The patient is a 60-year-old gentleman with history of stage IVA oropharyngeal cancer (T2, N2c, Mx) status post 2 cycles of cisplatin, Doxil, and 5-FU. Second cycle administered week of _%#MMDD2006#%_. The patient was admitted for nausea, vomiting, diarrhea and hypotension.
T2|thoracic (level) 2|T2|151|152|HISTORY OF PRESENT ILLNESS|She was found to have an apical tumor of the chest with impingement of the spinal vertebral column, marrow replacement at T2 with complete collapse of T2 vertebral body. There was also moderate involvement of T5 with slight collapse of the disk and subluxation. On _%#MMDD2006#%_ the patient had a C7 through T3 posterior fusion and pedicle screws with kyphoplasty and C-arm implants for treatment of her deformities.
T2|T2 (MRI)|T2|180|181|HISTORY OF PRESENT ILLNESS|She had an MRI during the previous hospitalization in _%#MM2005#%_ showing lesion in the posterior corpus collosum as well as white matter lesions and diffuse areas of spinal cord T2 signal intensity. Her laboratory findings in addition to the autoantibodies also include decreased levels of compliment 3 and compliment 4.
T2|T2 (MRI)|T2|170|171|DIAGNOSTIC STUDIES|1. Head CT done _%#MMDD2007#%_. Impression: Negative CT of the head. 2. Brain MRI done _%#MMDD2007#%_. Formal reading is pending. Preliminary review by me revealed small T2 white matter hyperintensities, but no diffusion abnormality and no abnormality by MR angiography of the carotid, vertebral, or Circle of Willis vessels.
T2|thoracic (level) 2|T2|187|188||There were scattered white matter lesions in the right frontal lobe that were nonspecific. Eight days prior to admission, the patient developed a vesicular rash in approximately the left T2 distribution primarily anteriorly. He had had a previous history of herpes zoster in the same distribution in 2004, two days prior to admission, the patient became aware of some numbness in the left lower face.
T2|thoracic (level) 2|T2|129|130|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Above-mentioned coronary artery disease status post stenting 1999. 2. MVC with compression fractures of T2 and L1 and fracture to lower femur secondary to this car accident. 3. Patient is ETOH dependent, has gone through withdrawals in the past (patient states that he has never gone through withdrawals, however, reports a history of seizures, which seem to be associated with stopping drinking).
T2|thoracic (level) 2|T2|135|136|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ _%#NAME#%_ is a 47- year-old gentleman with an approximate 4-day history of progressive weakness and MRI that a shows a T2 mass with impingement on his cord. His initial findings show a positive Babinski on both sides, weakness of the right lower extremity 4/5.
T2|T2 (MRI)|T2|491|492|HOSPITAL COURSE|HOSPITAL COURSE: 1. The patient was admitted to Neurology Service on _%#MM#%_ _%#DD#%_, 2005, head CT obtained that evening showed small-vessel ischemic disease of the white matter, right parietal encephalomalacia, no evidence of intracranial hemorrhage, high-grade frontal calcified meningiomas overlying hyperostosis. An MRI of the brain was obtained subsequent day on _%#MM#%_ _%#DD#%_, 2005, that showed deep white matter infarctions in the left frontoparietal region, extensive foci of T2 hyperintensity and the periventricular white matter consistent with severe small-vessel ischemic disease, 18-mm extraaxial enhancing right parietal mass consistent with meningioma, severe narrowing of the distal right common carotid artery, proximal right internal carotid artery, irregularity of the middle cerebral arteries and posterior cerebral arteries bilaterally consistent with atherosclerotic disease.
T2|thoracic (level) 2|T2|438|439|OPERATIONS AND  PROCEDURES PERFORMED|OPERATIONS AND PROCEDURES PERFORMED: Transpedicular vertebrectomy of T3, with interbody fusion and posterior fixation from C7 through T6. The interbody fusion utilized Pyramesh cage and methyl methacrylate from T2 through T4, with hook and rod construct using Legacy hooks and rods from C7 through T6 with compressive hooksfolks at C7 through T1, a small hook onand C7, medium hooks on the remainder of the construct, compressive hook at T2 through T4, and T5 through T6 and cross- length link at T2 through T4 interval and at T5 through T6 interval.
T2|T2 (MRI)|T2|345|346|PROCEDURE|1. MRI brain, stroke protocol _%#MMDD2007#%_: Impression: Likely early subacute stage infarct in the right hemipons, this could involve locations including the corticospinal tracts, potentially the MLF and potentially the course of the cranial nerve six. Likely, chronic focus of hemorrhage in the right thalamus related to old infarct. Chronic T2 hyperintensities throughout the basal ganglia and surrounding the ventricles likely related to small vessel ischemic disease. Head MRA demonstrate multifocal stenosis most prominent in the left M1 segment of MCA.
T2|thoracic (level) 2|T2|242|243|REASON FOR ADMISSION AND HOSPITAL COURSE|She is morbidly obese and is mostly in her bed, so what she is on Coumadin per Mayo for deep venous thrombosis prophylaxis until she resumes ambulation. 6. Shingles. The patient developed shingles during her hospital stay at the right T1 and T2 dermatome. She was started on antiviral with Valtrex and Lyrica for herpetic neuralgia and on Vicodin. She did well. She needs to finish her antiviral medication course.
T2|T2 (MRI)|T2|124|125|HISTORIAN|A MRI scan was also performed, the images from that were not sent with them. The technique showed sagittal one flare, axial T2 diffusion weighted imaging with ADC mapping and an axial T2 haste imaging without contrast and was reportedly normal without evidence of stroke.
T2|T2 (MRI)|T2|213|214|PROCEDURES AND STUDIES PERFORMED DURING THIS HOSPITALIZATION|Findings include enhancing lesion, which appears to compress the left temporal lobe and is suspicious for dural base metastasis despite the fact this is unusual nasopharyngeal carcinoma. 2. Patchy enhancement and T2 hyperintensity extending from the pontomedullary junction to the pontomesencephalic junction. This would be exceedingly unusual presentation for metastasis and likely represents radiation necrosis.
T2|T2 (MRI)|T2|213|214|HOSPITAL COURSE|An EEG was obtained on _%#MM#%_ _%#DD#%_, 2002 and revealed a normal awake and drowsy study. MRI of the brain without contrast was obtained on _%#MM#%_ _%#DD#%_, 2002 and revealed several focal areas of prolonged T2 relaxation in the central white matter of the parietal lobes, greater on the left, as well as to a lesser extent in the periventricular white matter adjacent to the anterior aspects of the lateral ventricles.
T2|T2 (MRI)|T2|350|351|PROCEDURES DONE DURING THIS ADMISSION|2. Head CT without contrast dated _%#MM#%_ _%#DD#%_, 2002 that showed minimal sinus disease in the ethmoid and maxillary sinuses, otherwise negative. No evidence of herpes encephalitis. 3. MRI with and without contrast dated _%#MM#%_ _%#DD#%_, 2002 that showed scattered sinus disease in the ethmoid and right maxillary sinus and nonspecific foci of T2 signal in deep white matter with no evidence of tumor or changes consistent with herpes or encephalitis. PAST MEDICAL HISTORY: For a thorough past medical history, please see prior discharge summary dated _%#MM#%_ _%#DD#%_, 2002.
T2|T2 (MRI)|T2|268|269|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|It appears that he had a central cord syndrome and an MRI of the cervical spine on _%#MMDD2002#%_ was accomplished which did reveal a very moderate broad-based central disk herniation that was effacing the thecal sac creating spinal cord compression. There was no any T2 signal changes in the spinal cord itself. Postoperatively, Mr. _%#NAME#%_ _%#NAME#%_ is doing very well. He has had virtually no pain complaints.
T2|T2 (MRI)|T2|238|239|RADIOGRAPHIC PROCEDURES|OT did notice some deficits in speech. A swallowing study was done which was normal and will work with her on her speech. RADIOGRAPHIC PROCEDURES: MRI of the brain with and without contrast - multiple small white matter foci of increased T2 seemingly related to ischemic change from small vessel disease. No evidence of acute infarct. Head CT showed no evidence of acute hemorrhage.
T2|T2 (MRI)|T2|199|200|HISTORY OF PRESENTING ILLNESS|In follow-up on _%#MMDD2005#%_ she complained of new left leg spasticity and weakness. The repeat MRI performed on that day revealed slight worsening of the abnormalities in the brain including high T2 signal in the right side of the pons, left temporal lobe, and also abnormalities on the flare images. A conference with staff neurologists in an outpatient setting felt that this was likely to be consistent with progressive multifocal leukoencephalopathy based on her presentation and her recent imaging and CSF studies.
T2|thoracic (level) 2|T2|215|216|PAST MEDICAL HISTORY|1. Chronic obstructive pulmonary disease. 2. History of depression. 3. History of anxiety disorder. 4. History of fibromyalgia. 5. History of "chronic fatigue". 6. History of degenerative joint disease, status post T2 to T12 fusion in the past. 7. History of hyperlipidemia. 8. History of hypothyroidism. 9. Questionable history of obstructive sleep apnea.
T2|T2 (MRI)|T2|266|267|HOSPITAL COURSE|These findings were suspicious for vascular malformation. The patient also underwent EEG which was abnormal with excessive slowing in the left temporal region. A post-ictal state appears possible to account for the EEG changes. Following hyperventilation a spike at T2 was seen. The findings support a diagnosis of localization-related epilepsy. The patient was started on albendazole to extirpate the parasites and prednisone to forestall cerebral edema around dying parasites.
T2|T2 (MRI)|T2|242|243|FINDINGS|DISCHARGING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, M.D. DISCHARGE DIAGNOSIS: Spells consistent with complex partial seizures. PROCEDURES: 1. Video EEG. 2. MRI brain. FINDINGS: Minimally increased nonspecific bilateral periventricular white matter T2 hyperintensities. DIFFERENTIAL DIAGNOSIS: Includes, vasculitis, Lyme and demyelinating disease. HISTORY AND PHYSICAL: The patient is a 27-year-old veterinary medical resident who has a history of spells dating back to approximately mid _%#MM2007#%_.
T2|T2 (MRI)|T2|173|174|PHYSICAL EXAMINATION|Her evaluation has included zero white blood cells on her urine, pregnancy test negative, tox screen was negative. MRI of the brain does reveal some subtle areas of altered T2 signal change in the right subinsular white matter and external capsule. The radiologist indicated that there was no enhancement and no mass effect.
T2|T2 (MRI)|T2|137|138|PROCEDURES|2. Depression. DISCHARGE DIAGNOSES: 1. Chronic daily headaches, in exacerbation. 2. Depression. PROCEDURES: 1. MRI of brain: This showed T2 hyperintense subcortical white matter lesions bilaterally in the frontal lobes and right cerebellar hemisphere, which were nonspecific. There was no evidence of infarction or hemorrhage, aneurysms or stenosis to the intracranial arteries.
T2|tumor stage 2|(T2|82|84|IMPRESSION|Abnormality on digital exam felt to be biopsy related. IMPRESSION: 1. Stage B III (T2 C) adenocarcinoma of the prostate. 2. History of arthritis. 3. Rising PSA. 4. Abnormal digital rectal exam. TREATMENT/RECOMMENDATIONS: Following long detailed discussion with the patient regarding the options for therapy including the rationale risks, goals, side affects, and/or alternatives and again following discussion and review on _%#MMDD2007#%_ the patient was most interested in proceeding with prostate brachytherapy for the primary treatment of his prostate cancer.
T2|tumor stage 2|T2|110|111|FINAL DIAGNOSIS|FINAL DIAGNOSIS: Poorly differentiated squamous cell carcinoma left lower lobe lung. Final pathological stage T2 N0 M0. OPERATIVE PROCEDURE: On _%#MMDD2007#%_, diagnostic flexible bronchoscopy, mediastinoscopy, left thoracotomy with left lower lobectomy and mediastinal lymph node dissection was carried out.
T2|tumor stage 2|T2|21|22|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: T2 metastatic lesion with spinal cord instability and compression. OPERATIONS/PROCEDURES PERFORMED: 1. Posterior instrumented spinal fusion C5-T2 with segmental instrumentation.
T2|thoracic (level) 2|T2|217|218|HOSPITAL COURSE|HOSPITAL COURSE: Patient was admitted on _%#MM#%_ _%#DD#%_, 2004, to the surgical intensive care unit for monitoring. CT of the chest, abdomen and pelvis was undertaken which showed again a large mass at the level of T2 extending into the spinal canal with compression of the thecal sac on the right. This MRI also showed a large heterogenous mass in the right kidney which was concerning for renal cell carcinoma.
T2|thoracic (level) 2|T2|276|277|HOSPITAL COURSE|Radiation/oncology was consulted _%#MM#%_ _%#DD#%_, 2004, and their recommendations were to consider radiation to the T2 area after surgery at that level was undertaken. After consultation between the neurosurgery and orthopedic spine services, decision was made to undertake T2 corpectomy and instrumented fusion. Given the high likelihood that the lesion at T2 was metastatic renal cell carcinoma, the decision was made to undertake a preoperative embolization of feeding arteries.
T2|tumor stage 2|(T2|174|176|FINAL DIAGNOSIS|5. Aspirin 81 mg p.o. q.d. 6. Ibuprofen p.r.n. FINAL DIAGNOSIS: 1. Infiltrating ductal carcinoma, right breast. a. Status post right modified radical mastectomy, stage III-A (T2 N2 M0) 2. History of hypertension. 3. History of coronary artery disease. 4. History of hypothyroidism. PLAN: The patient is discharged to home with her family.
T2|thoracic (level) 2|T2|273|274|DISCHARGE PLANS AND FOLLOW-UP CARE|There was also a low attenuation lesion in the left lobe of the liver and a soft tissue mass within the mesentery with displacement of surrounding bowel loops, also, worrisome for malignancy. MRI scanning demonstrated demultiple bony lesions as outlined above. However, at T2 there was a large epidural mass comprising the central canal and compressing the cord. It measured 4.1 x 1.5 x 1.2 cm. The patient had a needle biopsy of an expansile left rib lesion which showed a plasma cell myeloma.
T2|thoracic (level) 2|T2,|184|186|IMPRESSION|However, we will hold off on addition Flutamide at this point until his current problem is evaluated. He will however be started on Zometa for his bony disease. 2. Cord compression at T2, currently receiving radiation therapy by Dr. _%#NAME#%_ _%#NAME#%_ at Fairview Ridges. We will ask Dr. _%#NAME#%_ or Dr. _%#NAME#%_ to evaluate the patient while here at Fairview Southdale Hospital.
T2|thoracic (level) 2|T2,|184|186|HISTORY OF PRESENT ILLNESS|2. Return to the operating room on _%#MMDD2005#%_ for hematoma evacuation. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 72-year-old male with renal cell carcinoma metastasis to the T2, T3 level of the spine. He was found on imaging to have a significant amount of spinal canal compromise due to the size of the tumor.
T2|T2 (MRI)|T2|185|186|LABORATORY DATA|There is intrahepatic biliary duct dilatation. There is also dilation of common bile duct. The common bile duct has a maximum diameter of 14 mm. Within the common bile duct, there is a T2 and T1-hypointense calculus obstructing the common bile duct. UA on admission was negative for any infection. A diagnostic tap was done on admission, which showed serum alphafetoprotein of less than 1.5. The ascitic fluid diagnostic tap was done, which showed an RBC count of 1990, nucleated cell 78%, neutrophil 13%, lymphocyte 48% and other cells 39%.
T2|T2 (MRI)|T2|171|172|PROCEDURES|PROCEDURES: 1. MRI obtained _%#MMDD2007#%_ - demonstrating diffuse T2 enhancement of the left medial temporal lobe. 2. Repeat MRI, _%#MMDD2007#%_- slightly more extensive T2 hyperintensity involving the left medial temporal lobe with new enhancement. 3. Lumbar puncture _%#MMDD2007#%_ - demonstrating 2 white cells, 187 red cells, glucose 70, protein 63.
T2|T2 (MRI)|T2|207|208|FAMILY HISTORY|An MRI was obtained on the second day of hospitalization which showed some old, right-sided periventricular white matter changes consistent with small-vessel ischemic disease. However, diffusion imaging and T2 could not show a new lesion. The transesophageal echocardiogram obtained showed a moderate size but significant patent foramen ovale, normal left ventricular function, and no clot.
T2|thoracic (level) 2|T2.|184|186|DISCHARGE DIAGNOSES|2. Lumbar disc herniation, central disc herniation L4-L5 with spinal stenosis centrally. 3. L3-L4 disc herniation posterior/lateral. 4. L5 superior endplate, anterior intra-body edema T2. DISCHARGE MEDICATIONS: 1. Celexa 20 mg p.o. daily. 2. Bromfenex one tablet p.o. daily, as previously prescribed.
T2|T2 (MRI)|T2|219|220|HOSPITAL COURSE|HOSPITAL COURSE: In the hospital, he was loaded with Dilantin and an MRI was obtained which showed a negative MR of the brain, no structural abnormalities are identified. Finding sagittal T1 weighted images are normal. T2 weighted images appear normal. Flare images are unremarkable. Post gadolinium weighted imaging is also unremarkable. No abnormal parenchymal, mesial or vascular enhancement is seen. He was noted to be subtherapeutic initially when he presented to the emergency room and on date of discharge, his phenytoin level was 12.2, a CT of his head was also obtained.
T2|T2 (MRI)|T2,|149|151|HISTORY OF PRESENT ILLNESS|She had an MRI of the brain which demonstrates isointense mass in the left posterior superior temporal lobe. It is isointense on T1, hyperintense on T2, brightly enhancing gadolinium what appears to be dural based lesion. Looks like there is preservation of underlying neuro-structures that are consistent with meningioma.
T2|T2 (MRI)|T2|289|290|PROCEDURES|5. History of hypercalcemia. 6. Chronic malnutrition. PROCEDURES: 1. CT of the head (_%#MMDD2005#%_): Interpretation limited by significant motion artifact. No interval change. 2. MRI of the brain with and without contrast (_%#MMDD2005#%_): This study demonstrated greater than 10 foci of T2 hyperintensity within the cerebral white matter, consistent with a clinical suspicion of demyelinating _________ disease. Post contrast images are degraded by significant motion artifact. There is progression of disease as compared with a prior study.
T2|tumor stage 2|T2,|167|169|PAST MEDICAL HISTORY|He denied fevers, chills, or other complaints. The patient was admitted to the Thoracic Surgery Service for further evaluation and treatment. PAST MEDICAL HISTORY: 1. T2, N0, M0 squamous cell carcinoma of the upper lobe of the right lung. 2. Chronic obstructive pulmonary disease. 3. Gastroesophageal reflux disease.
T2|T2 (MRI)|T2|204|205|HOSPITAL COURSE|It was thought that it was unlikely that this was CNS lupus and did discuss the abnormal T2 hyperintensity with neuroradiology and upon further review; I thought that this was likely artifact or that the T2 hyperintensity was due to the degenerative changes. The paresthesias that she is describing are consistent with Lhermitte's syndrome and that could be due to the degenerative changes seen on MRI.
T2|T2 (MRI)|T2|124|125|HISTORY OF PRESENT ILLNESS|Of note, he was previously followed by Dr. _%#NAME#%_ and Dr. _%#NAME#%_. Recent MRIs within the last year showing multiple T2 hyperintensities and a few hypointensities bilaterally in the brain and multiple cervical and thoracic hyperintensities. FAMILY HISTORY: Significant for a sister with MS, other family members with type 2 diabetes, hypertension and heart disease.
T2|UNSURED SENSE|T2|204|205|OPERATIVE PROCEDURE|PREOPERATIVE DIAGNOSIS: Aortic regurgitation, mitral regurgitation and Adriamycin-induced cardiomyopathy. OPERATIVE PROCEDURE: 1. Mitral valve repair using 23 mm Duran ring and closure of a cleft between T2 and P3. 2. Aortic valve replacement using a 19 mm St. Jude region mechanical valve. HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ is a 35-year-old woman who has a history of AAL diagnosed in _%#MM1981#%_.
T2|T2 (MRI)|T2|260|261|HOSPITAL PROCEDURES|HOSPITAL DIAGNOSES: 1. Falls at home due to gait instability. 2. Status post lung transplant. HOSPITAL PROCEDURES: 1. Head MRI, _%#MMDD2007#%_ showing no acute ischemic cerebellar infarctions, diffuse cerebellar volume loss are stable and nonspecific focus of T2 prolongation in the centrum semiovale of the right frontal lobe possibly secondary to early small vessel ischemic disease. 2. Neurology consult. 3. Psychiatry consult.
T2|T2 (MRI)|T2|164|165||Cortical grey matter, however, was non-effaced. There is no diffusion abnormality and no abnormal enhancement identified; however, there was confluent pericallosal T2 hyperintensities noted bilaterally. It demonstrated projections into the subcortical white matter. There was also a separate less than 5 mm foci of T2 hyperintensity noted in the area of the U fibers bilaterally and abnormal signal intensity was noted in the callosal septal interface as well as the splenium.
T2|T2 (MRI)|T2|258|259|PROCEDURES PERFORMED|8. _%#MMDD2004#%_, nephrostogram demonstrating good position of nephrostomy tube. 9. _%#MMDD2004#%_, unsuccessful attempt at MRA of right upper extremity (suboptimal exam). 10. _%#MMDD2004#%_, MRI of brain with contrast demonstrating minimal periventricular T2 hyperintensities consistent with minimal small vessel ischemic disease and some tiny foci of restricted diffusion in the right and left frontal lobes, consistent with tiny acute lacunar type infarctions.
T2|T2 (MRI)|T2|159|160|HOSPITAL COURSE|Unchanged finding of a left mastoidectomy and associated mass. The mass likely represents tumor although (_______________) is still a consideration. Scattered T2 hypointensities consistent with chronic small-vessel disease. There was discussion with the radiologist regarding these films. The patient had had only 2 radiation treatments to her head prior in _%#MM#%_, so it seemed unlikely that this would be from radiation treatment.
T2|thoracic (level) 2|T2,|163|165|HOSPITAL COURSE|The patient subsequently underwent an MRI of the C-spine, L-spine and T-spine which revealed the following findings. Multiple osseous metastases involving C7, T1, T2, T3, T4, T5, T10, with a small amount of left anterolateral epidural tumor in T1. There was a small central right paramedian disk protrusion or osteophyte at T7-T8.
T2|T2 (MRI)|T2|347|348|OPERATIONS/PROCEDURES PERFORMED|2. Atrial fibrillation. 3. Palindromic rheumatism. OPERATIONS/PROCEDURES PERFORMED: 1. Left lower extremity Doppler on _%#MM#%_ _%#DD#%_, 2005, occlusive deep venous thrombosis of left popliteal and distal left superficial femoral vein just above the knee. 2. MRI of the brain. No evidence of atrioventricular malformation. 3. Nonspecific foci of T2 hyperintensity in the periventricular white matter likely related to minimal small vessel ischemic disease. 4. Right lower extremity Doppler. No evidence for deep venous thrombosis.
T2|T2 (MRI)|T2|182|183|OPERATIONS/PROCEDURES PERFORMED|3. Magnetic resonance imaging of the brain, _%#MM#%_ _%#DD#%_, 2005, showing no evidence of a mass, mass effect, or abnormal areas of enhancement; also showing nonspecific scattered T2 hyperintensities, likely representing small-vessel ischemic disease; pansinusitis. 4. Electroencephalogram, _%#MM#%_ _%#DD#%_, 2005: Official dictation is not on the computer system yet; however, Dr. _%#NAME#%_ did call the neurology resident team, and reported that the electroencephalogram was normal.
T2|tumor stage 2|T2|133|134|PAST MEDICAL HISTORY|He, however, states that he has been treated for it at the VA Hospital. 2. Esophageal cancer diagnosed in _%#MM2005#%_ and staged at T2 N1 M0, stage IIb, moderately differentiated, status post chemotherapy and XRT. 3. Cigarette abuse, long-standing, a 45-pack-year history and still smoking five cigarettes per day.
T2|T2 (MRI)|T2|243|244|DISCHARGE MEDICATIONS|A CT scan of the head without contrast showed no significant changes since prior exam on _%#MMDD2005#%_, no acute changes. MRI of the head and MRA showed no evidence for recent infarct with moderate atrophy with moderate nonspecific increased T2 signal in the subcortical white matter which is consistent with small vessel ischemic disease. He had an echocardiogram which showed normal LV function, mild LVH and diastolic mild findings consistent with diastolic dysfunction.
T2|T2 (MRI)|T2|288|289|PROCEDURES|5. Hypertension. 6. Recent hospitalization for esophagitis. PROCEDURES: 1. Head CT: Showing an old lacunar infarct in the right caudate, internal capsule, left subinsular white matter, and left cerebellum; no evidence of blood. 2. MRI, brain: Showing scattered foci of abnormal increased T2 signal which is nonspecific. 3. Dialysis run per usual regimen on Tuesday, _%#MMDD2007#%_. 4. Chest x-ray, which was clear. 5. EEG - results pending.
T2|T2 (MRI)|T2|151|152|PROCEDURES|Diffuse involvement of the L2 and L4 vertebral bodies, but these vertebral bodies are at high risk for subsequent fracture. Increased area of abnormal T2 signal and enhancement in the subcutaneous tissues from the approximate level of L1 through the level of the sacral spine with a focal nodule enhancement more posteriorly at the level of L3.
T2|T2 (MRI)|T2|229|230|PROCEDURES|PROCEDURES: 1. MRI obtained on _%#MMDD2007#%_ demonstrated T2 hyperintensity in the mostly subcortical white matter of the posterior frontal lobes of the brain. There was no evidence of acute infarction and no enhancement of the T2 hyperintensity. 2. Dialysis per patient's schedule. HISTORY OF PRESENT ILLNESS: Please see admission history and physical for complete details.
T2|T2 (MRI)|T2|145|146|HOSPITAL COURSE|In further workup for malignancy, a CT of the abdomen, pelvis and chest was completed and was negative for malignancy. MRI of the brain showed a T2 hyperintense lesion in the left posterior frontal white matter, with incomplete ring enhancement. There were also chronic, small pontine and cerebellar infarcts on MRI.
T2|tumor stage 2|T2|280|281|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSIS: Left facial cellulitis with history of left tonsillar cancer, treated with radiation therapy, with osteoradionecrosis. OPERATIONS/PROCEDURES PERFORMED: Intravenous antibiotics. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ was seen in clinic in followup for her T2 N0 M0 left tonsillar squamous cell carcinoma, for which she underwent radiation therapy, and she has had a history of an exposed left mandible with osteoradionecrosis.
T2|thoracic (level) 2|T2|279|280|DISPOSITION|FOLLOW UP: The patient should follow up in the orthopedic surgery clinic with Dr. _%#NAME#%_ _%#NAME#%_ in 6 weeks for postoperative check and evaluation. DISPOSITION: _%#NAME#%_ _%#NAME#%_ was taken to the operating room on _%#MM#%_ _%#DD#%_, 2005, for decompression C7 through T2 and posterior fusion of C7 through T2. She had an uneventful hospital course and fulfilled the requirements of physical therapy and was subsequently discharged to home.
T2|tumor stage 2|T2|336|337|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old white male who was transferred directly to Fairview University Intensive Care Unit on _%#MM#%_ _%#DD#%_, 2005, from _%#CITY#%_ _%#CITY#%_ Hospital for evaluation and management of hemoptysis. The patient at time of admit was 3 months status post left pneumonectomy for stage IB, T2 N0 M0, nonsmall cell lung cancer, and was currently undergoing adjuvant chemotherapy with Taxol, carboplatin. The patient had been in his normal state of health and had not had postoperative complications (operative procedure was performed at outside hospital), until _%#MM#%_ _%#DD#%_, 2005, while the patient was having a bout of coughing when he suddenly experienced chest pain, shortness of breath, and hemoptysis.
T2|T2 (MRI)|T2|298|299|PROBLEM #4|This area of induration extends from the superficial fascia anteriorly and medially to the intermuscular septums separating the lateral triceps from the brachialis and extends to a branch of one of the veins accompanying the radial collateral artery. The region of induration is of low T1 and high T2 intensity. There is associated enhancement. Additionally the origin of the left brachioradialis is slightly hyperintense on STIR and demonstrates faint enhancement post contrast no discreet intramuscular mass is seen.
T2|tumor stage 2|T2,|201|203|HISTORY OF PRESENT ILLNESS|Ms. _%#NAME#%_ is a 56-year-old female with a history of non-small cell lung carcinoma with metastases to the brain, liver, bilateral lung, and bone. She initially was diagnosed in _%#MM#%_ 2000, with T2, N2 tumors. She had resection followed by radiation. She did well until _%#MM#%_ 2001, and new pulmonary nodules were noted in both the right and left lungs.
T2|T2 (MRI)|T2|196|197|DIAGNOSTIC STUDIES|4. Repeat head CT without contrast _%#MM#%_ _%#DD#%_, 2006. No interval change. Finding of scleral buckle of the right eye globe. 5. MRI of brain _%#MM#%_ _%#DD#%_, 2006. Findings: Focal areas of T2 hyperintensity within the subcortical white matter centrum semiovale and periventricular white matter consistent with small vessel ischemic disease. No evidence of acute infarction. Right A1 segment hypoplasia versus stenosis.
T2|T2 (MRI)|T2|181|182|PROCEDURES|Impression, area of restricted diffusion and corresponding hyperintensity on T2-weighted image consistent with acute infarction. Small area of restricted diffusion corresponding to T2 hyperintensity in the subcortical white matter of the posterior left occipital lobe suggesting subacute embolic infarction or early metastasis.
T2|tumor stage 2|T2,|142|144|FINAL DIAGNOSES|FINAL DIAGNOSES: Poor differentiated squamous cell carcinoma, right lung, with metastases to the peribronchial lymph node, pathological stage T2, N1, M0. SECONDARY DIAGNOSES: Emphysema and smoking history. Complications: Acute renal failure.
T2|tumor stage 2|(T2|135|137|DISCHARGE X-RAYS|Lastly, possible microsatellite instability (MSI) was described (see below). Therefore, _%#NAME#%_ is deemed to have a likely stage II (T2 N0 MX) adenocarcinoma of the colon. I am now asked for oncologic consultation and management recommendations. REVIEW OF SYSTEMS: Notable for some confusion, generalized malaise and fatigue since surgery.
T2|T2 (MRI)|T2|245|246|MAJOR IMAGING/PROCEDURES|1. CT of head. Impression: No acute changes seen. Overall, there is no interval change since the early study in _%#MM2006#%_. 2. MRI of the brain with and without contrast. Impression: A. No evidence of acute ischemia. B. Multiple areas of mild T2 hyperintensity within the deep cerebral white matter, nonspecific, but likely represent small-vessel ischemic disease. C. There were temporal arteries and the internal carotid arteries are patent.
T2|T2 (MRI)|T2|174|175|DIAGNOSTIC PROCEDURES|1. Chest x-ray showed stable bibasilar density, left greater than right, most likely represents atelectasis. 2. MRI/MRA of the brain showed no change in previously described T2 hyperintensities involving left optic radiation, right cerebellar hemisphere, and periventricular white matter. Also, attenuation of M1 segment of the right middle cerebral artery.
T2|thoracic (level) 2|T2|123|124|ASSESSMENT|Urinalysis shows no protein, no glucose, and 1+ bacteria. ASSESSMENT: 1. Preoperative examination for thoracic fusion from T2 to T10 in a patient with a remote history of neuroblastoma. 2. History of mild renal insufficiency secondary to chemotherapy with cisplatin.
T2|T2 (MRI)|T2|151|152|IMAGING STUDIES|Impression: 1. A 3.2 by 4.0 by 6.0 cm mass, dorsal to olecranon. Appearance consistent with hemorrhagic bursitis versus hematoma. 2. Diffuse increased T2 signal in subcutaneous tissue of the volar aspect of the forearm, demonstrating minimal enhancement, likely representing cellulitis.
T2|thoracic (level) 2|T2|52|53|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Nonsmall cell carcinoma of the T2 vertebral body. DISCHARGE DIAGNOSIS: Nonsmall cell carcinoma of the T2 vertebral body.
T2|thoracic (level) 2|T2|102|103|MAJOR PROCEDURE AND TREATMENT|DISCHARGE DIAGNOSIS: Nonsmall cell carcinoma of the T2 vertebral body. MAJOR PROCEDURE AND TREATMENT: T2 corpectomy with placement of intervertebral body cage and fusion C7 to T3. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 65-year-old male who previously underwent resection of the upper lobe of his left lung with upper lobectomy and excision of tumor at that T1 to T5 level.
T2|thoracic (level) 2|T2|143|144|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1: The patient was admitted on _%#MMDD2007#%_. He was taken to the operating room on the same day where he underwent T2 corpectomy and fusion. See operative note for details. The patient tolerated this procedure without complication. He was monitored in the Intensive Care Unit before being transferred to the general neurosurgery floor.
T2|T2 (MRI)|T2|160|161|IMAGING STUDIES|Sodium is 130, potassium is 3.4, and BUN and creatinine are 14 and 0.9. IMAGING STUDIES: MRI of the brain is reviewed from _%#MMDD2007#%_. This shows bilateral T2 hyperintensity in the basal ganglia particularly the globus pallidus. There are lesions appreciated in the right frontal lobe and left cerebellar hemisphere, which are enhancing.
T2|T2 (MRI)|T2|120|121|HOSPITAL COURSE|A Neurology consult was placed, and an MRI and EEG were obtained. Her MRI of the brain showed diffuse scattered foci of T2 hyperintensity in the white matter adjacent to the atrium of the left ventricle that are nonspecific. Her EEG was read as moderately abnormal with focal slowing and epileptiform discharges emanating from the left temporal and central area.
T2|T2 (MRI)|T2|315|316|PROCEDURES|4. Left-sided numbness and weakness. PROCEDURES: 1. MRI of the lumbar spine showing diffuse disc bulge at L4-L5 with no narrowing, mild posterior right paracentral bulge at L5-S1, mild narrowing, bilateral pars interarticularis defect in L5. 2. MRI of the brain showing periventricular and subcortical white matter T2 hyperintensities in the right corona radiata. Differential includes tumefactive multiple sclerosis. No stenoses or aneurysms of the major artery seen. Lumbar puncture: Protein mildly elevated at 74, white count 10 and glucose 54.
T2|tumor stage 2|T2|241|242|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 48-year-old gentleman, who was diagnosed with rectal cancer and preoperative staging suggested an early lesion. He decided to undergo TEM excision and the final pathology demonstrated a T2 lesion with negative margins and infiltrating tumor border. We had several discussions regarding further treatment options and the patient decided to proceed with anterior resection.
T2|thoracic (level) 2|T2|254|255|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ is a 65-year-old pleasant gentleman with history of nonsmall cell lung cancer status post lobectomy in _%#MM2007#%_ along with multiple left upper rib resections. He was found to have recurrence of tumor in T2 vertebral body and underwent T2 corpectomy with C7 through T3 fusion by Dr. _%#NAME#%_ on _%#MMDD2007#%_. This was an incidental finding on screening PET scan and he did not have new myelopathy symptoms.
T2|UNSURED SENSE|T2|201|202|PROCEDURES PERFORMED|1. Access right brachial artery due to pyoderma gangrenosum in lower extremities. 2. Limited coronary angiography showing no significant left main disease, two sequential 70% mid-LAD lesions involving T2 and first septal (FFR across the LAD on previous angiography demonstrated hemodynamic significance). No significant circ disease. Anticoagulation with IV heparin. 6 FR-GLGL-3.5 guide was used with good support.
T2|T2 (MRI)|T2|262|263|OPERATIONS/PROCEDURES PERFORMED|OPERATIONS/PROCEDURES PERFORMED: 1. MRI/MRA of the brain on _%#MM#%_ _%#DD#%_, 2006, showing 2 small foci of abnormal contrast enhancement within the right temporal lobe. Differential diagnoses of these include PRES, vasculitis, infection. Also showing abnormal T2 signal hyperintensity in the cortical and subcortical regions of the posterior frontal and posterior midline occipital lobes bilaterally consistent with PRES.
T2|thoracic (level) 2|T2|318|319|ONCOLOGY HISTORY|ONCOLOGY HISTORY: His duodenal adenocarcinoma was diagnosed in _%#MM2007#%_. He visited his primary care physician's office complaining of neck and shoulder pain in _%#MM2007#%_. MRI of cervical spine was obtained, which showed bony metastatic lesions involving C6-C7 and another metastatic lesion involving posterior T2 vertebral body. CT scan and PET scan were obtained, which showed several hypermetabolic lymph node in the left cervical chain.
T2|term 2|T2,|211|213|HISTORY OF PRESENT ILLNESS|1. Ultrasounds 2. Fetal fibronectin test. 3. External fetal monitors. 4. Betamethasone therapy. 5. Penicillin. DISCHARGE DIAGNOSIS: Prenatal vitamins. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 20-year-old G3, T2, P0, A0, L2, presenting at 33-weeks, 3 days to MFM Clinic for NST/BPP for her twin gestation. She claims to have had increased contractions 6 to 8 per hour x1 week on and off, and her cervix was 1.5 cm open ten days ago, as measured by Dr. _%#NAME#%_ at Smiley's Clinic.
T2|T2 (MRI)|T2|132|133|HISTORY OF PRESENT ILLNESS|At that time in her workup, an electroencephalogram was done, which was essentially normal, and an MRI showed multiple non-specific T2 hyper-densities. The patient stated that her headache had been present since her workup at the hospital last week, performed her new-onset seizure disorder.
T2|T2 (MRI)|T2|331|332|PROCEDURES|2. MRI of the brain with and without contrast, which revealed the presence of a rounded sharply defined mass that appears to be dural based on the right posterior frontal convexity with invagination into the underlying cortex. The lesion was centrally hypointense on T1 weighted imaging and hypertensive on T2 weighted imaging. On T2 gradient echo imaging, there was a central isointensity with peripheral irregular hypointensity consistent with calcification or hemorrhage following intravenous gadolinium this peripheral contrast enhancement around the margin of this lesion was measured 11 mm x 10 mm x 0.9 mm based on the MR characteristics that the lesion was most likely representing meningioma with calcific rim.
T2|T2 (MRI)|T2|127|128|IMAGING STUDIES PERFORMED DURING ADMISSION|Second 1.5 cm low T1 signal intensity lesion within the right lobe of the liver correlates with the stable hypodensity seen on T2 since _%#MMDD2005#%_. This lesion demonstrates minimal gradual peripheral enhancement ______ atypical hemangioma or regional scar considering mild adjacent catheter retraction, large amount of ascites.
T2|T2 (MRI)|T2|477|478|HOSPITAL COURSE|The rest of her hospital course was uncomplicated and on _%#MMDD2007#%_ she was ambulating on her own and voiding without any problems, tolerating her diet and also had no further drainage from the left ear and had almost no pain on oral pain medications and at this point in time she was appropriately ready for discharge. The patient and also had an MRI of her brain done postoperatively, on _%#MMDD2007#%_, which showed no residual contrast enhancing lesion, however stable T2 hyperintensity in the left frontal temporal lobes, signifying vasogenic edema. NEUROLOGICAL EXAMINATION AT TIME OF DISCHARGE: Her incision is clean, dry and intact and there is no drainage that can be expressed from the wound.
T2|tumor stage 2|T2|163|164|PAST MEDICAL HISTORY|The patient gave her informed consent following complete discussion of the risks, benefits and alternatives with Dr. _%#NAME#%_. PAST MEDICAL HISTORY: 1. Stage II T2 N0 Mx infiltrating ductal carcinoma of the left breast status post radiation and chemotherapy in 1998. 2. Stage I infiltrating ductal carcinoma of the right breast, status post radiation and Taxotere, Cytoxan chemotherapy x4 cycles.
T2|T2 (MRI)|T2|153|154|IMAGING|There appears to be several cystic components to this lesion. The 2 spherical components of the lesion, which are contrast enhancing, are hypointense on T2 weighted image, and the portions of the lesions that are not contrast enhancing are hyperintense on T2 weighted images.
T2|T2 (MRI)|T2|192|193|HOSPITAL COURSE|The patient's symptoms had been resolved and did not recur during his hospital stay. An MRI/MRA was performed and did not show any evidence of acute or previous stroke or hemorrhage. Multiple T2 hyperintensities suggested chronic small vessel ischemic disease. MRA did not show any significant stenosis or aneurysm in the major vasculature of the head and neck.
T2|tumor stage 2|T2|149|150|HOSPITAL COURSE|HOSPITAL COURSE: Chemotherapy induction for squamous cell carcinoma of the head and neck. The patient was admitted for induction chemotherapy of his T2 N2c mildly differentiated squamous cell carcinoma of his head and neck on _%#MMDD2006#%_. The patient was started on cisplatin and docetaxel for the first day and also was started on a 5-FU continuous pump throughout his hospitalization.
T2|thoracic (level) 2|T2|174|175|HISTORY OF PRESENT ILLNESS|He was seen by Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2006#%_ and found to have an odontoid fracture. He underwent open fixation of the fracture on _%#MMDD2006#%_, occipital to T2 fusion, halo application. Postoperatively, he was seen by physical therapy, occupational therapy, and speech/ language pathology.
T2|thoracic (level) 2|T2,|162|164|HISTORY OF PRESENT ILLNESS|During her hospitalization at the University of Minnesota Medical Center, Fairview, she had an MRI of the brain and cervical spine which showed multiple areas at T2, hyperintense activity, along with cervical and thoracic spine. She was given a 5-day burst of Solu-Medrol, ending on _%#MMDD2006#%_.
T2|T2 (MRI)|T2|271|272|IMAGING|There was also slight nodular enhancement along the superior lateral margin of the dominant lesion that could be due to smaller satellite lesions. There was also a 1.6 cm enhancing lesion in the right hepatic lobe medially, which also was felt to be indeterminant. Other T2 hyperdensities were felt to be likely hepatic cysts, and there was minimal fluid and stranding adjacent to the right hepatic mass compatible with interval biopsy.
T2|T2 (MRI)|T2|127|128|HOSPITAL COURSE|Basic labs were checked. An MRI/MRA of the brain was performed. There was no evidence of acute infarction. There was increased T2 signal and decreased T1 signal throughout a petrous segment of the right internal carotid artery causing a moderate grade stenosis.
T2|thoracic (level) 2|T2|167|168|DISCHARGE PHYSICAL EXAM|Her hand grip is 5/5 bilaterally as well as her biceps and triceps strength. She has full range of motion of her upper extremities. Her sensation is intact C4 through T2 distribution bilaterally and she has strong radial pulses bilaterally. She has a negative Homans. PENDING TEST RESULTS: None. DISCHARGE MEDICATIONS: The patient will continue her preoperative medications which included 1. Neurontin 1200 mg p.o. t.i.d.
T2|T2 Nodes|T2,|349|351|HISTORY OF PRESENT ILLNESS|ADMITTING DIAGNOSES: 1. Squamous cell carcinoma of the tongue, with mets to cervical nodes, diagnosed in _%#MM2002#%_. 2. Presents for chemotherapy. HISTORY OF PRESENT ILLNESS: This is a 59-year-old male who presents with a history of squamous cell carcinoma of the tip of the tongue, diagnosed in _%#MM2002#%_, with mets to trochlear nodes, T3 and T2, status post radiation therapy, 17 out of 30, and chemo with cisplatin therapy. The patient denies any new symptoms, or any other problems.
T2|thoracic (level) 2|T2|180|181|HISTORY OF PRESENT ILLNESS|10. Hyperimmune state with increased tumor necrosis factor alpha. 11. Chronic steroid use. 12. Multiple line infections and clots. 13. History of MRSA. 14. Decreased bone mass and T2 compression fracture. 15. History of hypertension. 16. Chronic sinusitis. ADMISSION MEDICATIONS: For home medications, please see the list of discharge medications at the end of this dictation.
T2|T2 (MRI)|T2|144|145|ADMITTING LABS|MRI of the pelvis showed a 3.5 x 1.7 x 3.2 cm destructive mass within the right superior pubic ramus and acetabulum. Marked amount of increased T2 signal within the adductor muscle. The proximal right thigh and right obturator internus may represent denervation edema and right hip synovitis inflammatory versus reactive.
T2|tumor stage 2|T2|111|112|BRIEF ONCOLOGICAL HISTORY|4. MRI of the pelvis showed rectal tumor which was 1.6 x 2.7 cm in size and a 1.6-cm lymph node. She was stage T2 N1 rectal cancer. 5. CT scan of the chest, abdomen and pelvis showed no evidence of distant disease. CURRENT TREATMENT: The patient is currently on a continuous 5-FU and radiation treatment.
T2|tumor stage 2|T2,|80|82|FINAL DIAGNOSIS|FINAL DIAGNOSIS: Adenocarcinoma, left upper lobe lung. Final pathological stage T2, Nx, M0 OPERATIVE PROCEDURE: On _%#MMDD2007#%_ a left video-assisted thoracoscopy and wedge resection of left upper lobe lung mass was performed. DISMISSAL SUMMARY: _%#NAME#%_ _%#NAME#%_ is a 76-year-old woman with a history of smoking.
T2|T2 (MRI)|T2|548|549|SOCIAL HISTORY|2. Subtle cognitive deficits. Because of her family's concerns, a head CT was obtained on _%#MM#%_ _%#DD#%_, 2003, which showed extensive diffuse small vessel ischemic disease of the white matter. To further investigate possible acute stroke or insult, an MRI/MRA was done on _%#MM#%_ _%#DD#%_, 2003, which showed severe stenosis of the right internal carotid at the origin, moderate stenosis of the origin of the left internal carotid, a small stable aneurysm in the supraclinoid portion of the right internal carotid, extensive deep white matter T2 hyperintensities bilaterally most consistent with severe small vessel ischemic disease, but no evidence for acute infarction. It is unclear the etiology of the subtle changes; however, could be an acceleration of her small vessel ischemic disease.
T2|T2 (MRI)|T2|166|167|PHYSICAL EXAMINATION|To review, she did have extensive MRI imaging when she was in the hospital last week, which included an MRI of the brain which reveals only a tiny focus of increased T2 signal in the left frontal lobe, of essentially no significance. MRI of the thoracic spine revealed no abnormality. MRI of the cervical spine revealed minimal disk bulges.
T2|thoracic (level) 2|T2|225|226|PAST MEDICAL HISTORY|He was admitted with some fevers, chills, no hemoptysis. He also complained of significant abdominal pain and had not had a stool in 3 days. PAST MEDICAL HISTORY: 1. Cystic fibrosis. 2. Hemoptysis status post embolization of T2 and T3 intercostal arteries _%#MM#%_ _%#DD#%_, 2004. 3. Cystic fibrosis related bronchiectasis with mild obstruction baseline. His pulmonary function tests during this admission showed an FEV1 of 2.71 (64%) and an FVC of 4.56 (90%).
T2|T2 (MRI)|T2|216|217|PROCEDURES PERFORMED DURING THIS ADMISSION|Findings were consistent with punctate focus of restricted diffusion with left frontal white matter with minimal corresponding T2 signals and new enhancement. This was suggestive of hyperacute infarct. It was due to T2 hyperintensities within the right periventricular and supraventricular white matter extending to the insular cortex and right frontal cortex. This corresponds to the acute infarct as presented on previous MRI on _%#MMDD2007#%_.
T2|tumor stage 2|T2,|236|238|DISCHARGE DIAGNOSIS|ADMITTING DIAGNOSIS: Localized adenocarcinoma of the prostate. PROCEDURE: Bilateral pelvic lymph node dissection, bilateral nerve- sparing radical retropubic prostatectomy. DISCHARGE DIAGNOSIS: Gleason grade III plus V pathologic stage T2, N0, M0. HOSPITAL COURSE: Uneventful. Mr. _%#NAME#%_ did not require transfusion. Post-operative hemoglobin 11.
T2|T2 (MRI)|T2|140|141|IMAGING DONE DURIING HOSPITALIZATION|DISCHARGE DIAGNOSIS: Seizure disorder. IMAGING DONE DURIING HOSPITALIZATION: 1. MRI of the head done _%#MMDD2004#%_: (A) Unchanged areas of T2 hyperintensity with decrease in the T2 hyperintensity within the left parietal occipital cortical region. Post biopsy changes with no new areas of contrast enhancement over the left frontal lobe convexity.
T2|tumor stage 2|T2,|144|146|DISCHARGE DIAGNOSIS|The patient has completed 5 cycles of capecitabine and lapatinib as well since _%#MM#%_ _%#DD#%_, 2004. Briefly, the patient was diagnosed with T2, N1 with 4 of 23 nodes positive, ER/PR negative, HER-2 three positive breast cancer in _%#MM#%_ 2000. She received Taxol and Herceptin prior to SC. She was then found to be disease-free until _%#MM#%_ 2003 when she had facial pain and numbness and was unfortunately found to have metastases in these areas as well as in her lung and liver.
T2|T2 (MRI)|T2|253|254|HOSPITAL COURSE|She had mild instability during tandem walking. HOSPITAL COURSE: During her Emergency Department stay, she underwent MRI of the brain. This showed no evidence of an acute stroke or significant vascular stenosis. It showed non-specific foci of increased T2 signal involving the white matter and subcortical white matter of the corona radiata and centrum semiovale . PROBLEM #1: Neurological deficit.
T2|UNSURED SENSE|T2,|175|177|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|At approximately 5:30 p.m. the evening of admission, he had acute onset of chest pain in the CCU. It appeared the chest pain was associated with ST segment elevation in leads T2, 3, and aVF on the EKG. The patient was symptomatic with his chest pain and diaphoresis. The chest pain radiated to his left arm and to his jaw.
T2|tumor stage 2|T2|127|128|PAST MEDICAL HISTORY|See specific operative note for details. PAST MEDICAL HISTORY: 1. Colon cancer, which in _%#MM1977#%_ resected and noted to be T2 N0M0. During patient's follow-up visits for history of colon cancer the liver metastases were discovered. PET scan revealed no other areas of metastasis. 2. Nephrolithiasis.
T2|T2 (MRI)|T2|188|189|HISTORY OF PRESENT ILLNESS|She had no vesicles, but was treated with Valtrex for this, and the rash has recently resolved. The patient underwent an MRI of the brain while still in the emergency department. Sagittal T2 images showed no white matter lesions suspicious for multiple sclerosis, and there were no enhancing lesions post-gadolinium. However, the diffusion studies showed a small diffusion abnormality in the right frontal lobe in the area of the motor strip at approximately the gray-white matter junction.
T2|thoracic (level) 2|T2,|166|168|HISTORY OF PRESENT ILLNESS|His most recent oncology follow-up was approximately 10 days ago. He underwent a repeat MRI of his spine in _%#MM2003#%_ which demonstrated metastatic lesions at T1, T2, T7, T12, L1, L2, L3, L4. There was also evidence of prominent epidural extension tumor, as well as encroachment on the thecal sac and question of epidural extension.
T2|T2 (MRI)|T2|206|207|DISCHARGE DIAGNOSIS|He has had increasing problems as of late and has become a new patient to me. His MRI scan is quite consistent with multiple sclerosis with significant abnormalities with contrast enhancement and extensive T2 abnormalities. He had become increasingly weak, depressed, and fearful. His ability to walk was significantly compromised, but let alone his activities of daily living being compromised.
T2|T2 (MRI)|T2|188|189|OPERATIONS AND PROCEDURES PERFORMED|The largest of these were in the central aspect of the right temporal lobe with an appearance suggesting hemorrhage. It had a high T1C node before contrast with a rim-like globe signal on T2 weighted images and mild diffuse gadolinium enhancement. This is lobulated in nature and measures approximately 1.9 cm x 0.9 cm transverse x 1.4 cm in a craniocaudal diameter.
T2|tumor stage 2|T2|128|129|SECONDARY DIAGNOSES|2. Fever secondary to mucositis. 3. Mild ileus, now resolved. SECONDARY DIAGNOSES: 1. Hypertension. 2. Erectile dysfunction. 3. T2 N2b squamous cell carcinoma of the right piriform sinus diagnosed in _%#MM#%_ of 2004. DISCHARGE MEDICATIONS: Discharge medications include fentanyl patch 75 mcg q.72, oxycodone 5 to 10 mg tablets p.o. q.2-4 hours p.r.n., lisinopril 20 mg, Diflucan tablets, and Colace and Senna.
T2|thoracic (level) 2|T2|148|149|PHYSICAL EXAMINATION|NECK: Supple without lymphadenopathy. No evidence of head trauma. LUNGS: Clear. BREASTS: Small without masses. There is shingles type rash over the T2 dermatome. HEART: Regular rate and rhythm without murmurs, rubs or gallops. ABDOMEN: Soft, nondistended, nontender. EXTREMITIES: No edema. Distal pulses are 2+.
T2|tumor stage 2|T2,|255|257|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSIS: Tonsillar carcinoma. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 47-year-old male who was diagnosed with moderately differentiated squamous cell carcinoma of the right tonsil in _%#MM#%_ of 2005. He was staged as a 4A with T2, N2, MX tumor. The patient was seen by Dr. _%#NAME#%_ and subsequently enrolled in the RTOG study with concurrent chemoradiation therapy.
T2|T2 (MRI)|T2|214|215||When she was admitted she had a work up which included an MRI scan of her brain which showed several areas of demyelinating lesions. She had MRI of her cervical spine which also revealed several areas of increased T2 signal in the cervical and upper thoracic spine consistent with demyelinating lesions. She had a negative Lyme titer. She had a negative FANA.
T2|thoracic (level) 2|T2|186|187|HOSPITAL COURSE|GU: Normal. Renal: Normal. Musculoskeletal: Normal. Endocrine: Normal. Hematologic: Normal. HOSPITAL COURSE: The patient presented in stable condition. She was taken to the OR where the T2 thoracic sympathetic flapping was performed by Dr. _%#NAME#%_ without complication. We anticipated a discharge that same day. However, she developed significant face and upper extremity edema. This did not present any complications from a respiratory standpoint.
T2|thoracic (level) 2|T2|195|196|HISTORY OF PRESENT ILLNESS|He now presents with extensive herpes zoster that extends on the posterior aspect of his neck at the level of C3 and C4. This does extend to his right shoulder and into his chest at the level of T2 anteriorly. He also has extensive involvement across the T12 that has now progressed on his left side and does extend into the anterior portion of his groin and to the level of L1.
T2|T2 (MRI)|T2|205|206|PROCEDURES PERFORMED|2. MRI of lumbar spine by primary physician, Dr. _%#NAME#%_ of Smiley's Clinic, as an outpatient on _%#MMDD2003#%_. This showed some reactive degenerative changes in the end plate of L4-L5; marked loss of T2 signal in L4 and L5 disk consistent with degenerative changes; L3-L4 broad- based central disk herniation causing mild central spinal stenosis; L4-L5 moderate-sized broad-based central disk herniation causing moderate central spinal stenosis with marked impression on the thecal sac; bony neural foramen below the left L4 pedicle with mild-to-moderate foraminal stenosis.
T2|thoracic (level) 2|T2|204|205|OPERATIONS/PROCEDURES PERFORMED|These findings were consistent with metastatic disease. 3. Bone scan dated _%#MM#%_ _%#DD#%_, 2004: Multiple foci on the left posterolateral chest wall. There was also increased radiotracer uptake in the T2 and L3 vertebral bodies, left sacrum, and right pelvis. There was also uptake in the occiput and the 7th rib on the right posteriorly.
T2|tumor stage 2|T2|145|146|PAST MEDICAL HISTORY|4. Hyperlipidemia. 5. Valvular heart disease. 6. GERD. 7. History of cholecystectomy 2001. 8. Stage III squamous cell carcinoma of right tonsil, T2 2MO, tonsillectomy in 1996 with lymph node dissection and post surgical irradiation. 9. Anemia of chronic disease. 10. AML-M2 ALLERGIES: No known drug allergies.
T2|T2 (MRI)|T2|158|159|HISTORY OF PRESENT ILLNESS|She had also been admitted earlier in _%#MM#%_ when she had a syncopal spell and weakness. Had MRI of her brain which revealed only a tiny focus of increased T2 single in the left frontal lobe of essentially no significance. During her work-up in _%#MM#%_ she also had an MRI of her thoracic spine which revealed no abnormalities.
T2|T2 (MRI)|T2|124|125|HOSPITAL COURSE|Although the images were not directly comparable, the size of the lesion appears the same. All characteristics of flare and T2 signal change seem similar. The radiologist thought that perhaps there might be slight enhancement of the lesion, but this was not clear.
T2|T2 (MRI)|T2|186|187|PRINCIPAL DIAGNOSIS|Of note during this hospitalization, the patient complained of headaches, which were new to her. For this reason, an MRI of the head was obtained, which demonstrated nonspecific foci of T2 hypodensity of the frontal lobes bilaterally. It was the impression that these are nonspecific and that the differential diagnosis includes vascular disease, vasculitis, demyelination, or sequela from a previous infectious or inflammatory disease.
T2|T2 (MRI)|T2|128|129|SOCIAL HISTORY|His workup included a CT scan of the brain which was negative. He had an MRI scan of the brain showing nonspecific white matter T2 uptake lesions, either small vessel in origin or unknown. His carotid ultrasound was negative. Chest x-ray was normal. His routine labs were normal.
T2|tumor stage 2|T2|168|169|HISTORY OF PRESENT ILLNESS|COMPLICATIONS: None. HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old woman, a nonsmoker and nondrinker, with recurrent tongue cancer. Her original tumor was a T2 of the left tongue. She had a left neck dissection for which the pathology was negative. However, she presented with a right-sided neck mass which was FNA positive for squamous cell carcinoma.
T2|thoracic (level) 2|T2,|139|141|HISTORY OF PRESENT ILLNESS|She also has a history of cervical spinal fusion. She underwent a bilateral C7-T1 foraminotomies revision of her posterior fusion of C5 to T2, segmental instrumentation, allograft bone, and BMT by Dr. _%#NAME#%_ and Dr. _%#NAME#%_. Postoperatively, she remained quite stable, however, was not at her baseline with mobilities and ADLs, tolerating the rehab process and, recommendation for admission to the inpatient rehab unit.
T2|tumor stage 2|T2,|192|194|PAST  MEDICAL HISTORY|His most recent hemoglobin prior to this was 11.9 on _%#MMDD2006#%_ approximately 7 days postoperatively. PAST MEDICAL HISTORY: 1. Adenocarcinoma of the lung, right upper lobe, surgical stage T2, N2 with right paratracheal lymph node and metastases. 2. Ventricular fibrillation cardiac arrest intraoperatively thought secondary to coronary vasospasm.
T2|T2 (MRI)|T2|179|180|HOSPITAL COURSE|There was right temporooccipital arteriovenous malformation fed by branches of both the right, middle, and posterior cerebral arteries. There was (_______________) 10-mm focus of T2 hyperintensity in the left (_______________). There is a suggestion of a flow void in this area on the coronal (_______________) area images, but this is seen maybe a second small AVM.
T2|tumor stage 2|T2|163|164|HISTORY OF PRESENT ILLNESS|2. Severe mucositis. 3. Fever secondary to mucositis. 4. Nutritional deficit. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 51-year-old gentleman diagnosed with T2 N2b squamous cell carcinoma of the right piriform sinus in _%#MM#%_ 2004. He received 2 cycles of chemotherapy with carboplatin and Taxol.
T2|UNSURED SENSE|T2.|158|160|PLAN|5. Hypertension stable 6. Mitral valve prolapse stable 7. A patient with osteoarthritis and osteoporosis. PLAN: The patient was cleared for surgery. She is a T2.
T2|T2 (MRI)|T2|303|304|HOSPITAL COURSE|They recommended that the patient should have oligoclonal bands measured in her cerebrospinal fluid as well as basic myelin protein, both of which are pending at the time of this dictation. Because of their recommendations she also underwent MRI of her lumbar spine which revealed a focus of low T1 and T2 signal within the anterior aspect of T10 which, by their dictation, revealed hematopoietic marrow replacement versus osteoplastic metastases.
T2|T2 (MRI)|T2|284|285|OPERATIONS/PROCEDURES PERFORMED|3. Non-small cell lung cancer. 4. Right hand cellulitis. 5. Altered mental status. OPERATIONS/PROCEDURES PERFORMED: 1. MRI brain on _%#MM#%_ _%#DD#%_, 2005, that showed no evidence of intracranial metastasis, normal MRI of the brain for the patient's age, although there were several T2 hyperintensities scattered foci throughout the matter of both cerebral hemispheres. HISTORY OF PRESENT ILLNESS: A 57-year-old female with well- differentiated squamous cell carcinoma of the lung diagnosed in _%#MM#%_ 2005 by CT scan that was done as part of in evaluation for pneumonia.
T2|thoracic (level) 2|T2|181|182|BRIEF HISTORY OF ADMISSION|Further workup with MRI of thoracic spine showed syrinx-type cavity from C6 to about C12, and there was apparent solid tissue enhancing mass, intramedullary location extending from T2 to T4. On _%#MM#%_ _%#DD#%_, 2005. The patient underwent MRI-guided intramedullary spinal cord lesion biopsy, T3 laminectomy, T2 and T4 laminotomies, and duraplasty with patch graft by neurosurgery at the University of Minnesota Medical Center.
T2|thoracic (level) 2|T2|304|305|BRIEF HISTORY OF ADMISSION|Further workup with MRI of thoracic spine showed syrinx-type cavity from C6 to about C12, and there was apparent solid tissue enhancing mass, intramedullary location extending from T2 to T4. On _%#MM#%_ 19, 2005. The patient underwent MRI-guided intramedullary spinal cord lesion biopsy, T3 laminectomy, T2 and T4 laminotomies, and duraplasty with patch graft by neurosurgery at the University of Minnesota Medical Center. Postoperative course was significant with tingling of the right leg and foot and also some numbness in that area and extending also to the right lower abdomen on the right side.
T2|T2 (MRI)|T2,|348|350|HOSPITAL COURSE|She did undergo an MRI and MRA overnight which showed a new lacunar infarct in the left basal ganglia which is not entirely consistent with her symptoms, but was bright on diffusion-weighted imaging and dark on ADC map indicating that it is a lesion of less than 2 weeks in nature. She did have significant and diffuse white matter changes seen on T2, which would likely be associated with a small- vessel disease. She was seen and evaluated by physical therapy and was judged to be capable of returning to her home.
T2|tumor stage 2|T2,|143|145|HOSPITAL COURSE|Her abdomen was soft and her incision was healing nicely. She was tolerating the diet. She was discharged to home. Pathology report revealed a T2, N0 poorly differentiated adenocarcinoma. Follow up will be with her primary care physician, Dr. _%#NAME#%_ and Dr. _%#NAME#%_. FINAL DIAGNOSIS: Incontinence of stool with anal sphincter defect.
T2|T2 (MRI)|T2|182|183|OPERATIONS/PROCEDURES PERFORMED|OPERATIONS/PROCEDURES PERFORMED: On _%#MM#%_ _%#DD#%_, 2005, the patient had an MRI of the brain which yielded the following results: 1. Focus of restricted diffusion with increased T2 signal, and mild enhancement in theleft corticospinal tract. This may represent a subacute phase of an injury to the corticospinal tract such as infarct versus intramyelinic edema possibly due to graft-versus-host disease versus much less likely lymphoma.
T2|tumor stage 2|T2,|24|26|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. T2, N0, M0, stage IB squamous cell carcinoma of the lung. 2. Persistent air leak with pleural effusions, right hemithorax.
T2|tumor stage 2|T2|164|165|HISTORY OF PRESENT ILLNESS|She had a left mastectomy with axillary sentinel lymph node biopsy and also right total mastectomy. Records from the Mayo Clinic indicate that she had a multifocal T2 N0 M0 breast cancer with negative lymph nodes. A synchronous stage I invasive breast cancer was noted in the left breast.
T2|T2 (MRI)|T2|316|317|ADMISSION DIAGNOSIS|As mentioned above, LP results did reveal WBCs 19, RBCs 10 x1, glucose 79, protein 43, negative Gram stain, negative cultures, negative cytology, 75% lymphocytes, 5% neutrophils, negative AFB, and negative cryptococcal antigen. Also as mentioned above, MRI from outside hospital on _%#MM#%_ _%#DD#%_, 2005, did show T2 white matter hyperintensities with a bilateral midcerebellar peduncles bilaterally, right superior parietal lobe, pons (left of midline), and degenerative joint disease in the L-spine.
T2|tumor stage 2|T2,|153|155|DISMISSAL SUMMARY|The patient underwent an esophagectomy on _%#MMDD2005#%_. The final pathology showed a 2.7 cm tumor. All the nodes were negative. The final pathology is T2, N0, M0. The patient's postoperative course was uneventful. Patient was dismissed on postoperative day #8 in good condition. DISCHARGE PLAN: Instructions regarding his diet were given. All the other instructions were also given.
T2|thoracic (level) 2|T2|21|22|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: T2 pathologic fracture secondary to head and neck cancer. OPERATIONS/PROCEDURES PERFORMED: T1 through T3 pedicle fusion with T2 instrumentation and corpectomy.
T2|thoracic (level) 2|T2|146|147|OPERATIONS/PROCEDURES PERFORMED|ADMISSION DIAGNOSIS: T2 pathologic fracture secondary to head and neck cancer. OPERATIONS/PROCEDURES PERFORMED: T1 through T3 pedicle fusion with T2 instrumentation and corpectomy. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is 59-year-old female with a history of head and neck cancer that has metastasized to T2 vertebral body.
T2|T2 (MRI)|T2|234|235|HOSPITAL COURSE|The patient's metastasis gradually started to improve with the steroid treatment. The patient was then transferred to neurology service. A repeat MRI study on _%#MM#%_ _%#DD#%_, 2006, showed slight progression of the diffuse abnormal T2 hyperintensity involving subcortical and periventricular white matter as well as cerebral hemispheres throughout his basal ganglia and cerebellum. A repeat MRI study on the _%#MM#%_ _%#DD#%_, 2006, with the clinical improvement after steroid treatment showed no significant change in the bilateral diffuse subcortical and deep white matter T2 of hyperintensity.
T2|tumor stage 2|T2|201|202|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: She was diagnosed back in _%#MM2003#%_ with a non-small cell lung cancer. It was located in the right lower lobe. On _%#MMDD2003#%_ she had a right lower lobe lobectomy. It was a T2 lesion with 2/6 positive peribronchial lymph nodes. The primary tumor measured 3.4 cm. It was poorly differentiated. In addition, she had loculated right pleural fluid. Following recovery from her surgery, she was treated with adjuvant chemotherapy.
T2|tumor stage 2|T2|117|118|DISCHARGE DIAGNOSES|ADMISSION DATE: _%#MMDD2006#%_ DISCHARGE DATE: _%#MMDD2006#%_ DISCHARGE DIAGNOSES: 1. Stage IVA oropharyngeal cancer T2 N 2 C. 2. Malnutrition. 3. C-difficile. BRIEF HISTORY: The patient is a 60 -year-old gentleman with a history of stage IVA oropharyngeal cancer T2 N2C MX status post two cycles of cisplatin, Doxil, and 5FU admitted for poor p.o. intake, nausea, vomiting, and G tube placement.
T2|T2 (MRI)|T2|240|241|PROBLEM #4|PROBLEM #4: MRA findings of avascular necrosis. The patient had an MRA performed during the hospital course to evaluate for any renal artery stenosis contributing to her hypertensive crisis. That MRA did show evidence of possible increased T2 signal in femoral heads, which was possibly related to marrow re-conversion versus avascular necrosis. This will be followed up as an outpatient with the primary care physician.
T2|tumor stage 2|(T2|135|137|IMPRESSION|Prostate gland BII nodule noted, right base and left apex. Lateral sulci and seminal vessicles WNL. IMPRESSION: 1. Clinical stage BIII (T2 C) adenocarcinoma of the prostate, pathologic stage BII disease. 2. History of rising PSA. 3. History of skin cancer. 4. Actinetic keratosis. 5. Hyperlipidemia. 6. Abnormal digital rectal exam.
T2|T2 (MRI)|T2|297|298|PROCEDURES|CONSULTATIONS: 1. Neurology _%#MMDD2006#%_. PROCEDURES: 1. CT scan of head without contrast _%#MMDD2006#%_: no acute intracranial pathology demonstrated, unchanged left maxillary sinus mucus retention cyst. 2. MRI/MRA of head: no evidence of acute ischemic infarct, scattered foci of white matter T2 hyperintensity (nonspecific). HOSPITAL COURSE: The patient was hospitalized for observation. CT and MR studies are noted above.
T2|tumor stage 2|T2,|546|548|PROCEDURE|PROCEDURE: Left internal jugular double lumen venous catheter per anesthesia services, vertical laparotomy, moderately extensive small bowel lysis of adhesions, partial right colon resection to include the terminal ileum, cecum, ascending colon up to the distal ascending colon near the hepatic flexure, stapled GIA 75 and TA60, side-to-side ileal distal ascending anastomosis. Pathology detected: Adenocarcinoma, moderately differentiated at the junction between the cecum and ascending colon, into but not through the muscularis propria deemed T2, N0, MX. DETAILS: _%#NAME#%_ _%#NAME#%_ was admitted electively for this procedure. At the time of her request, she was brought to the operating room on the date of her admission, _%#MMDD2006#%_.
T2|thoracic (level) 2|T2|226|227|HISTORY OF PRESENT ILLNESS|Workup revealed a pathologic fracture at T12 and pathologic lesions at T5 that had not yet fractured. Per Dr. _%#NAME#%_, he underwent a posterior fusion of C5-T7 transpedicular corpectomy of T2 on the left, a hemilaminectomy T2 on the left, and posterior spinal fusion with instrumentation and bone allograft. Postoperatively, he had difficulties with postoperative anemia and hypocalcemia. He has noticed significant improvements in the pain in his right upper extremity.
T2|T2 (MRI)|T2|177|178|PROCEDURES/STUDIES|5. Diabetes mellitus. PROCEDURES/STUDIES: 1. MRI of the brain. Findings: No masses or contrast-enhancing lesions identified in the brain. Stable, nonspecific focus of increased T2 signal in the right posterior frontal lobe. 2. Whole body PET scan, official reading pending.
T2|T2 (MRI)|T2|208|209|PROCEDURES PERFORMED|1. CT head without contrast on _%#MMDD2006#%_ shows no definite acute intracranial pathology or intracranial mass effect. 2. MRI of the brain with and without contrast on _%#MMDD2006#%_ shows single focus of T2 hyperintensity in the right frontal white matter. This is nonspecific. Possible etiologies include: a. Infectious/inflammatory or demyelinating process of indeterminate chronicity.
T2|tumor stage 2|T2|75|76|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Squamous cell carcinoma of the base of the tongue, T2 N2 M0. 2. Status post cycle #3 of induction chemotherapy with cisplatin. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 67-year-old male who was recently diagnosed with squamous cell carcinoma of the tongue.
T2|tumor stage 2|T2|329|330|HISTORY OF PRESENT ILLNESS|2. History of stage II breast cancer. DISCHARGE DIAGNOSES: 1. Breast cancer gene 1 mutation variant, status post prophylactic total laparoscopic hysterectomy and bilateral salpingo-oophorectomy. 2. History of stage II breast cancer. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 53-year-old woman who was diagnosed with T2 lobular left breast carcinoma which was ER/PR positive and HER-2/neu negative. She underwent 2 left lumpectomies and subsequently bilateral mastectomies with sentinel lymph node dissection, _%#MMDD#%_.
T2|thoracic (level) 2|T2|225|226|PAST MEDICAL HISTORY|1. Cervical dysplasia. 2. Mitral valve regurgitation. She then was scheduled for mitral valve repair and that was carried out on _%#MMDD2002#%_ by Dr. _%#NAME#%_ at Fairview Southdale Hospital. He did a subtotal resection of T2 and also placed a #34 C-E Physio-Ring annuloplasty. Postoperatively she required some temporary pacing and that was subsequently resolved.
T2|thoracic (level) 2|T2|261|262|HOSPITAL COURSE|PAST MEDICAL HISTORY: 1. Severe mitral regurgitation. 2. Status post knee surgery under spinal anesthesia. ADMISSION MEDICATION: Lisinopril 5 mg q.d. HOSPITAL COURSE: On _%#MMDD2003#%_, the patient underwent mitral valve repair with triangular resection of the T2 segment of the posterior leaflet, with a sliding posterior annular repair and placement of a 28 mm Cosgrove-Edwards annuloplasty ring, on cardiopulmonary bypass.
T2|T2 (MRI)|T2|270|271|HOSPITAL COURSE/SUMMARY|Her calcium was noted to be normal. In addition, the week prior she had been seen by her primary doctor and was given calcium for the cramps with no relief. A full workup ensued, including MRI with MRA, and with a questionable lesion in the anterior medullary area with T2 linear hyperintensity. The significance of this, however, could not be correlated to her physical findings. In addition, the idea of a stiff-man's syndrome was entertained, however, antibody for glutamic acid decarboxylase was negative.
T2|thoracic (level) 2|T2|183|184|HISTORY OF PRESENT ILLNESS|He was diagnosed metastatic hepatocellular carcinoma in _%#MM#%_ 2003. He is status post liver transplant in _%#MM#%_ 2002 and has a history of chronic hepatitis C. He recently had a T2 to T4 effusion with T3 tumor excision on _%#MM#%_ _%#DD#%_, 2003, at Abbott Northwestern Hospital. PAST MEDICAL HISTORY: 1. Metastatic hepatocellular carcinoma with lung and spinal metastases status post chemotherapy and radiation therapy.
T2|tumor stage 2|T2|133|134|FINAL DIAGNOSIS|FINAL DIAGNOSIS: Squamous cell carcinoma of left lower lobe lung with metastases to one peribronchial lymph node, pathological stage T2 N1 M0. SECONDARY DIAGNOSIS: Other diagnoses: 1. Post-obstructive pneumonectomy consolidation, left lower lobe lung.
T2|tumor stage 2|T2|169|170|DISMISSAL SUMMARY|The final pathology showed a squamous cell carcinoma with metastases to one peribronchial lymph node. All mediastinal lymph nodes were negative. The final pathology was T2 N1 M0 and resection is complete. Her postoperative course was uneventful until postoperative day 6 where she had some mild hypoxemia and the chest x-ray showed some atelectasis to the right base.
T2|T2 (MRI)|T2|457|458|LABORATORY DATA ON ADMISSION|_%#NAME#%_ was in place without erythema or infection. LABORATORY DATA ON ADMISSION: Sodium 138, potassium 4.5, chloride 111, bicarb 21, BUN 14, creatinine 0.38, glucose 98, anion gap 7, calcium 9.2, albumin 3.5, total bilirubin 0.4, total protein 5.8, alkaline phosphatase 338, ALT 59, AST 83, white blood cell count 9.6, hemoglobin 11.3, platelets 457, neutrophils 67%, lymphocytes 24%, monocytes 8%, ANC 6.5. Imaging: An MRI was obtained which showed no T2 signal in the optic nerve track. No pineal abnormalities. HOSPITAL COURSE: The patient was admitted to 5B, Hematology/Oncology Pediatric Unit, under the care of Dr. _%#NAME#%_.
T2|T2 (MRI)|T2|153|154|HISTORY|He has been seen by Dr. _%#NAME#%_, and had an MRI of the lumbar spine on _%#MMDD2004#%_ which showed multiple foci of decreased T1 signal and increased T2 signal scattered throughout the spine, raising the question of neoplasm. There was a partial compression superior to the endplate of L5, with increased T2 signal, with suspicion for a compression fracture.
T2|tumor stage 2|T2,|89|91|HOSPITAL COURSE|The patient was admitted to Fairview for initiation of chemotherapy. HOSPITAL COURSE: 1. T2, N2B, M0 head and neck squamous cell carcinoma. The patient received 1 dose of cisplatin during the hospitalization. He tolerated chemo well and only suffered mild nausea and headache.
T2|T2 (MRI)|T2|174|175|HISTORY OF PRESENT ILLNESS|There were areas in the lung with mixed nodularity and ground-glass opacities suspicious for lymphoma. An MRI scan of the head on _%#MM#%_ _%#DD#%_, 2004, revealed increased T2 signal in the deep white matter of the bilateral corona radiata and centrum semiovale consistent with leukoencephalopathy.
T2|T2 (MRI)|T2|162|163|PHYSICAL EXAMINATION|His right toe is upgoing and his left toe is downgoing. Cerebellar tests performed were negative. The patient's MRI of his L spine was reviewed revealing no cord T2 hyperintensities or contrast enhancement. Chest x-ray revealed no infiltrate. EKG revealed normal sinus rhythm. LABORATORY EXAMINATION: The patient's sodium is 145, potassium 3.9, chloride 105.
T2|tumor stage 2|T2|160|161|INDICATIONS FOR PROCEDURE|INDICATIONS FOR PROCEDURE: Ms. _%#NAME#%_ is a _%#1914#%_ woman with a noted left retromolar and trigone squamous cell carcinoma which was noted to be at least T2 on clinical examination. She had had a history of pain for approximately 2 years. She was seen in the Otolaryngology Clinic where discussion of operative resection of this was undertaken with the patient.
T2|tumor stage 2|T2|165|166|HISTORY OF PRESENT ILLNESS|DIAGNOSIS: T2 N2 tonsillar carcinoma with cervical mass, status post chemotherapy. HISTORY OF PRESENT ILLNESS: The patient is a 45-year-old gentleman diagnosed with T2 N2 tonsillar carcinoma and was admitted to the hospital for elective chemotherapy and radiation treatment. The patient is in a study where he will be in an arm which receives both high dose cisplatin and radiation treatment.
T2|tumor stage 2|T2|102|103|FINAL DIAGNOSIS|FINAL DIAGNOSIS: Poorly differentiated adenocarcinoma of the left lower lobe lung, pathological stage T2 N1 M0, stage IIB. OTHER DIAGNOSIS: None. PROCEDURE: On _%#MM#%_ _%#DD#%_, 2005, the patient underwent left thoracotomy, left lower lobectomy, and mediastinal lymph node dissection.
T2|tumor stage 2|T2|186|187|OPERATIONS/PROCEDURES PERFORMED|3. MRI, MRA of the brain did not show any small vascular lesions. 4. MRI per seizure protocol with sections through the neck for dissection protocol. This revealed a nonspecific foci of T2 hyperintensity in the left frontal lobe just superior to the sylvian fissure as well as a T2 hyperintensity in the subcortical white matter of the left frontal lobe.
T2|tumor stage 2|T2,|114|116|HOSPITAL COURSE|ALLERGIES: THE PATIENT HAS NO KNOWN DRUG ALLERGIES. HOSPITAL COURSE: 1. Esophageal carcinoma stage IIB which is a T2, N1, M0 disease. Upon admission, the patient received the usual free cisplatin IV fluid flushes. He then received cisplatin 150 mg IV followed by additional fluid flushes.
T2|T2 (MRI)|T2|241|242|HOSPITAL COURSE|She was able to converse in a normal manner and states that she feels much better and does not seem to be having problems with her memory. MRI showed no evidence for metastatic disease or other abnormal enhancement. She had some nonspecific T2 hyperintense foci in the cerebrum, really not typical for small vessel ischemic disease. PROBLEM #2: Hyponatremia. Upon admission the patient was euvolemic, so questionable etiology of hyponatremia would be syndrome of inappropriate secretion of antidiuretic hormone secondary to drugs.
T2|T2 (MRI)|T2|145|146|MAJOR IMAGING AND PROCEDURES|d. Focal stenosis in the mid portion of the left vertebral artery. e. Findings suggestive of chronic small vessel ischemic disease. f. Increased T2 signal intensity along the sulci of the posterior parietal and occipital lobe, which could represent subarachnoid proteinaceous debris and less likely exudate such as inflammatory cells or pus but cannot exclude subarachnoid blood.
T2|T2 (MRI)|T2|269|270|IMAGING STUDIES PERFORMED DURING ADMISSION|5. Two views of the right elbow on _%#MM#%_ _%#DD#%_, 2006, showed a limited study of the right elbow which demonstrated no evidence of acute fractures. 6. MRI/MRA of the brain and carotid arteries on _%#MM#%_ _%#DD#%_, 2006, showed no evidence of acute infarction but T2 hyperintensities in the periventricular and subcortical white matter and within the decussating fibers of the pons which may be related to chronic small-vessel ischemic changes.
T2|T2 (MRI)|T2|199|200|OPERATIONS/PROCEDURES PERFORMED|It may represent small vessel ischemic disease. Brain MRI for stroke was done on _%#MM#%_ _%#DD#%_, 2006, with the following findings. 1. Focal subacute infarction in the right putamen. 2. Extensive T2 hyperintensities in the periventricular and supraventricular white matter suggestive of chronic small vessel ischemic changes. 3. The MRI images of the head are interpretable, likely due to technical limitations.
T2|thoracic (level) 2|T2|306|307|HOSPITAL COURSE|Her workup additionally included echocardiogram with no evidence of clot and ejection fraction of 55 to 60%. She also had MR angiogram of the neck which showed no evidence of stenosis and she did have MR angiogram of the circle of Willis which showed occlusion of the left posterior cerebral artery at the T2 segment. The patient is discharged in improving condition with anticipated discharge on _%#MMDD2006#%_ to subacute rehab.
T2|T2 (MRI)|T2|140|141|ASSESSMENT/PLAN|Ophthalmologic exam was completed with normal ocular anatomy. A brain MRI was notable for right and left periventricular focus of increased T2 signal likely sequelae of prior hemorrhage. No definitive brain anomalies were identified. The diagnosis of Stickler syndrome was entertained, but collagen gene studies were normal.
T2|tumor stage 2|T2|81|82|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is 68-year-old gentleman with history of T2 N0, left true vocal cord tumor; squamous cell carcinoma status post endoscopic CO2 laser assisted excision, left radical hemilaryngectomy and planned tracheotomy on _%#MMDD2006#%_. Several days prior to admission, the patient developed increasing respiratory distress with stridor.
T2|thoracic (level) 2|T2|192|193|FOLLOWUP APPOINTMENTS|Plain films of _%#NAME#%_'s cervical spine showed a deformity of C1 with fused additional vertebral body and platyspondyly (i.e. flatness) of the cervical spine. In the thoracic spine, T1 and T2 were fused on the right, and T9 and T10 were fused centrally. These abnormalities are consistent with a diagnosis of OAV syndrome.
T2|thoracic (level) 2|T2|256|257|INDICATIONS AND HOSPITAL COURSE|The patient was taken to the operating room on _%#MMDD2006#%_ where a Smith-Peterson osteotomy as well as a posterior spinal fusion was performed. Smith-Peterson osteotomy was performed from T9 through L1 and the posterior spinal fusion was performed from T2 through L1. The surgery was very significant in that the patient lost a significant amount of blood intraoperatively, most likely consistent with his entire blood volume.
T2|T2 (MRI)|T2|249|250|PROCEDURES|2. MRI of the brain done on _%#MMDD2007#%_ was essentially normal except for old left cerebellar lacunar infarct. 3. Incidental bilateral hippocampal cyst of doubtful clinical significance was also seen. 4. Finally, mild nonspecific periventricular T2 hyperintensity was seen. HISTORY AND PHYSICAL EXAM: Mr. _%#NAME#%_ is a 68-year-old right-handed gentleman with a history of spells consisting of diaphoresis followed by confusion.
T2|T2 (MRI)|T2|247|248|HISTORY OF PRESENT ILLNESS|However, the pain did continue to worsen and he did have an MRI done on _%#MMDD2007#%_ which did show extensive disc space destruction and end-plate destruction of the C6-C7 level in the adjacent vertebral bodies, and the diffuse enhancement with T2 signal was compatible with infection. There was also mild spread to the epidural space. It was thought the patient would best be served by having a biopsy done of this likely infectious process to make a diagnosis as well as facilitate treatment.
T2|T2 (MRI)|T2|220|221|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Vertigo, nausea and vomiting. 2. History of atypical migraine phenomenon without headache. 3. History of common migraine. 4. History of abnormal MRI with pontine lesion characterized by increased T2 signal and gadolinium enhancement that has been stable over serial MRIs. DISCHARGE DIAGNOSES: Vertigo with nausea and vomiting that has resolved, unclear if atypical migraine phenomenon versus symptomatic vascular malformation seen on MRI.
T2|T2 (MRI)|T2|222|223|HOSPITAL COURSE|She was given IV fluids and Compazine suppositories. Her symptoms slowly resolved over the following 2 days. MRI scan of the brain was performed with and without contrast. It revealed a small focus of T1 hypointensity and T2 hyperintensity within the belly of the pons. The lesion enhanced with gadolinium. These findings are essentially unchanged in size compared with prior studies dating back to 2003.
T2|tumor stage 2|T2,|21|23|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: T2, N0 squamous cell carcinoma, right floor of mouth. DISCHARGE DIAGNOSIS: T2, N0 squamous cell carcinoma, right floor of mouth. PROCEDURES PERFORMED: 1. Transoral excision of squamous cell carcinoma from right floor of mouth with reconstruction using platysma flap.
T2|tumor stage 2|T2,|168|170|HISTORY OF PRESENT ILLNESS|3. Platysma myocutaneous flap. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 56-year-old female who presented with squamous cell carcinoma of the floor of the mouth; T2, N0. She was scheduled for the above procedure. She was brought to the OR where she underwent the above procedure without any complication.
T2|UNSURED SENSE|T2,|117|119|LABS|No No lymphadenopathy. NEUROLOGIC - nonfocal and symmetric. SKIN - intact. LABS: EKG - NSR with inverted T waves and T2, otherwise nospecific ST-T changes. Chest x-ray: Negative. Myoglobin initial 27, troponin-I 0.07. Sodium 140, potassium 4.0, chloride 101, bicarbonate 26, BUN 9, creatinine 0.7, glucose 101, white blood cell count 8.4, normal differential, hemoglobin 12.2, platelets 309,000.
T2|tumor stage 2|T2,|234|236|HOSPITAL COURSE|On the _%#DD#%_, patient had been tolerating regular diet, was voiding without Foley, and was using only p.o. pain medication. The path report, which came back on the _%#DD#%_, showed proximal large polyp with invasive adenocarcinoma T2, as well as a distal large polyp with intramucosal adenocarcinoma, which was T0. All of the 16 lymph node samples were negative. Therefore, it was determined stage 1 proximal retrosigmoid carcinoma.
T2|thoracic (level) 2|T2|194|195|HOSPITAL COURSE|HOSPITAL COURSE: The patient is a 14-year-old boy with ___________ idiopathic scoliosis, which was unresponsive to TLSO treatment. He was admitted on _%#MMDD2003#%_, had a posterior fusion from T2 to L3 with synergy instrumentation (6.35 stainless steel), with hook screws and sublaminar wire. This was augmented with iliac bone and AGF. The patient had an uncomplicated postoperative course and was discharged on _%#MMDD2003#%_ ambulatory, without a brace.
T2|thoracic (level) 2|T2|151|152|HISTORY OF PRESENT ILLNESS|When he arrived at Fairview-University Medical Center, he was noted to be paraplegic. His sensory level to both light touch and pain was approximately T2 through T3. He did state he could feel pressure, however. Neurosurgery was consulted but felt nothing could be done from their standpoint.
T2|T2 (MRI)|T2|225|226|HEENT|NEUROLOGICALLY she is intact. Her initial laboratory evaluation showed a hemoglobin of 13, electrolytes were within normal limits. X-ray of her hip showed no fracture but the subsequent MRI of her hip showed subtle increased T2 signal and decreased T1 signal inferior aspect of the right femoral neck subcapital region 1 cm in size most consistent with a stress fracture or incomplete insufficiency fracture.
T2|T2 (MRI)|T2|259|260|PROCEDURES|PROCEDURES: 1. MRI/MRA showing subacute infarction of the right middle cerebral artery distribution, in the right frontotemporal opercula, and more acute infarction in the left middle cerebral artery, in the left centrum semiovale. Additionally, non-specific T2 hyperintensity is consistent with small-vessel ischemic disease. MRA showed mild stenosis of the A1 segment of the right anterior cerebral artery.
T2|T2 (MRI)|T2|185|186|IMAGING STUDIES|6. MRI brain _%#MMDD2003#%_: New area of restricted diffusion in the right temporal lobe. No significant change in the posterior T2 hyperintensity in the supratentorial brain. Improved T2 hyperintensity in the cerebellum. 7. EEG _%#MMDD2003#%_: Focal right frontotemporal rhythmic slowing. LABORATORY DATA: 1. Admission labs _%#MMDD2003#%_: White blood cells 18.3, hemoglobin 12.6, 89% neutrophils, 8% lymphocytes.
T2|tumor stage 2|T2,|141|143|PAST MEDICAL HISTORY|3. History of infiltrating ductal carcinoma, left breast, 1998. Status post lumpectomy and radiation therapy. The tumor was ER, PR positive, T2, N0, M0. 4. Macular degeneration. 5. Status post TAH-BSO. 6. History of endometriosis. 7. Status post left patellar fracture, left wrist fracture, right knee arthroscopy.
T2|T2 (MRI)|T2|345|346|HISTORY OF PRESENT ILLNESS|The patient does have a history of previous cervical surgery by Dr. _%#NAME#%_ which involved a fusion from C3 to C7. On examination in clinic, the patient was found to have full strength with normal sensation in both upper and lower extremities and on review of the MRI, he was found to have a significant stenosis at the C2-C3 level with some T2 signal change in the spinal cord at that level. After a discussion with the patient, the decision was made to perform a cervical laminectomy at that level of C2-C3 for decompression of the spinal cord.
T2|tumor stage 2|T2|146|147|PAST MEDICAL HISTORY|See specific pathology results for details. (The patient had negative lymph nodes after resection. The patient originally had been diagnosed with T2 N0 M0 non-small-cell cancer in _%#MM#%_ 2004.) The patient will follow up with the oncologist and see if any additional studies or treatments are needed.
T2|T2 (MRI)|T2|244|245|HOSPITAL COURSE|Neurology was consulted and an MRI was obtained which showed mild diffuse dural thickening and contrast enhancement maybe secondary to intracranial hypertension; however, an infectious or inflammatory process is not excluded. Markedly abnormal T2 signal hyperintensity within the posterior internal capsule, consistent with a demyelination process. The etiology is uncertain. An MRI of the cervical spine showed abnormal signal intensity in the cervical spinal cord from C2 through the top of C7 with a differential diagnosis including infectious disease, vascular ischemia, degenerative syndrome, or inflammatory or toxic or metabolic process.
T2|thoracic (level) 2|T2|149|150|HISTORY OF PRESENT ILLNESS|The initial examination of her lymph nodes showed no evidence of involvement. She was subsequently, however, found to have an invasive lesion of the T2 vertebral body and underwent 4000 cGy of radiation to this area, which was considered by the radiation oncologist to be the maximum acceptable dose.
T2|T2 (MRI)|T2|334|335|RECOMMENDATIONS|It is otherwise quite small and manageable. Review of the magnetic resonance scan demonstrates scattered large vessels in the lumbar region around the central lump, which is the primary area of the patient's pain. The lump itself has no large vessels, but does have microscopic vascular tissue as noted by the increased signal on the T2 weighted scans. However, there is also a large amount of non-vascular signal in the same lump, some of which appears to have signals consistent with fat and other parts of which have signals consistent with fibrous or other soft tissues.
T2|thoracic (level) 2|T2,|201|203|IMPRESSION AND PLAN|At that time, it measured 5 x 5 cm in the upper lobe, at the apex region, and extended posteriorly and medially to involve several adjacent vertebral bodies. In fact, there was complete replacement of T2, and partial replacement of the T3 vertebral body. There was no impingement on the spinal cord. At that time, he was admitted to the hospital with alcohol-related problems, which have subsequently periodically cropped up, but basically he has been alcohol- free since.
T2|tumor stage 2|T2,|206|208|HISTORY OF PRESENT ILLNESS|Mrs. _%#NAME#%_ is a pleasant 52-year- old lady who works as a nursing supervisor at Fairview-University Medical Center. She was diagnosed in 1994 with breast carcinoma on the right side, which seems to be T2, N1, with _%#MMDD#%_ positive lymph nodes. She underwent right mastectomy with lymph node dissection followed by CAF chemotherapy for four months.
T2|tumor stage 2|T2|144|145|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Coronary artery disease, status post angioplasty in 1987 and 1985. 2. Cataract surgery bilaterally. 3. Prostate cancer T2 PSA 6, Gleason 9, treated initially with Lupron and recently _%#MMDD#%_ with cryotherapy. MEDICATIONS: 1. Stool softener over the counter laxative. 2. Herbal Life Fiber.
T2|T2 (MRI)|T2|112|113|RADIOGRAPHIC STUDIES|Mr. _%#NAME#%_ indicated, understood, and consented to proceed. In terms of the right frontal area of increased T2 signal, I am suspicious of tumor. I would not recommend simple biopsy because of risk of sampling error. I think Mr. _%#NAME#%_ best opportunity would be for excision of this area with intraoperative MRI scanning.
T2|T2 (MRI)|T2|145|146|HISTORY OF PRESENT ILLNESS|She did have an MRI and MR angiogram this morning. I was able to review the MRI. To my eye it does not look like there is any acute infarct. The T2 sequences revealed some white matter changes consistent with small vessel changes due to her diabetes. PAST MEDICAL HISTORY: 1. Type 2 diabetes mellitus. 2. Partial hepatectomy just this _%#MM#%_ because of an abscess.
T2|T2 (MRI)|T2|198|199|CURRENT RECOMMENDATIONS|These were more prominent on the right but also involved the left side of the vermis and superior aspects of the cerebellar hemispheres. The lesions were irregular in shape and were hyperintense in T2 weighted sequences and hypointense in T1 sequences. The lesions contained tissue with restricted proton diffusion. There was also intermixed areas of darkness on gradient echo sequences.
T2|tumor stage 2|(T2,|215|218|REFERRING PHYSICIAN|The patient did undergo lymph node retrieval and although the major number of 10 lymph nodes were not recovered, nine were found and they were all negative for tumor. The patient would thus be a clinical stage II-A (T2, N0, M0). He has previously in the past undergone an ultrasound of his abdomen which included examination of the liver and there was no evidence of hepatic metastases.
T2|thoracic (level) 2|T2.|188|190||Therefore, instructed to come into the emergency room. She was seen by Dr. _%#NAME#%_. He had contacted me. I requested cervical spine series. She does have an extensive fusion from C3 to T2. She was hydrated with 1 liter of normal saline. We discussed possible admission. However, it was not clear that we would be able to do anything more for her.
T2|tumor stage 2|(T2|273|275|HISTORY OF PRESENT ILLNESS|A biopsy of the left mainstem bronchus mass, _%#MMDD2005#%_, showed non-small-cell carcinoma, which did not appear to be adenocarcinoma or squamous cell carcinoma. A PET scan in _%#MM#%_ 2005 showed increased uptake in the left hilum only, and the patient was staged as IB (T2 N0). She was not felt to be a surgical candidate due to her age and poor pulmonary status. She has severe COPD, and the location of the tumor would have required a pneumonectomy.
T2|tumor stage 2|T2|147|148|ASSESSMENT|KPS SCORE: Approximately 100. ASSESSMENT: Dr. _%#NAME#%_ is a 38-year-old Asian female who is status post lumpectomy and adjuvant chemotherapy for T2 N0 M0 (2a) medullary carcinoma of the left breast. She has essentially no medical comorbidities and her performance status is excellent.
T2|tumor stage 2|T2|28|29|PROBLEM|PROBLEM: Pancreatic cancer, T2 N0. The patient was seen in the Radiation Oncology Clinic by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ at the request of Dr. _%#NAME#%_.
T2|tumor stage 2|T2|64|65|ASSESSMENT|This does show a small mass in the pancreatic head. ASSESSMENT: T2 N0 M0 adenocarcinoma of the pancreas. PLAN: We recommend concurrent chemoradiation therapy.
T2|T2 (MRI)|T2|174|175|HISTORY OF PRESENT ILLNESS|She has received Ativan this morning prior to her MRI as she was very agitated. The MRI of her brain showed multiple diffusion without imaging signal changes in the areas of T2 signal prolongation in both hemispheres. The patient also had a venogram that was negative. PAST MEDICAL HISTORY: There is history of migraines.
T2|tumor stage 2|(T2,|270|273|ASSESSMENT AND PLAN|Her lymph node dissection recovered 17 lymph nodes, 14 of which were positive with a maximum size of metastasis at 1.8 cm; extracapsular extension was present. At the time of her surgery, she did undergo a right breast expansion. The patient is thus surgical stage IIIC (T2, T1b, T1b, N3 M0). She is making a reasonable postoperative recovery. This was initially complicated by bleeding from the surgical site, which did require her to stay in the hospital and she did receive some blood products.
T2|tumor stage 2|T2|9|10|PROBLEM|PROBLEM: T2 N2B MO squamous cell carcinoma of the floor of mouth, status post resection with partial mandibulectomy and left modified neck dissection. The patient was seen in consultation by _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_.
T2|T2 (MRI)|T2|353|354||He has spastic paresis of the upper and lower extremities with bowel and bladder dysfunction. He has an MRI as well as CT scan of the cervical spine which demonstrates a congenitally tight canal at C3-C4 with accompanying severe degenerative disc disease at C3-C4 with herniated disk which is causing a significant degree of spinal cord compression and T2 signal changes within the cord itself. I had a long discussion with _%#NAME#%_ and his family which regards to the operative plan.
T2|T2 (MRI)|T2|213|214|RADIOGRAPHIC EVALUATION|Her strength is 5/5 and symmetric. RADIOGRAPHIC EVALUATION: Brain MRI demonstrates a homogenetically contrast-enhancing olfactory groove mass, 2.5 cm, slightly eccentric to the right. There is increased flare and T2 signal within the right frontal lobe, traveling in the corpus callosum, and to a small extent the left frontal lobe. IMPRESSION: Imaging characteristics consistent with a moderately- sized frontal floor meningioma, with significant associated edema in the right frontal lobe.
T2|tumor stage 2|T2,|181|183|ASSESSMENT|Lungs are essentially clear. Heart has regular sinus rhythm. Breasts reveal no palpable mass. Abdomen is unremarkable and extremities are unremarkable. ASSESSMENT: This patient has T2, N1 breast cancer with poor congruency factors being with lymphatic invasion and close margins. She is presently undergoing chemotherapy. RECOMMENDATIONS: We recommend radiation therapy after completion of chemotherapy to her breast and lymph node chains, in view of 5 positive axillary lymph nodes and the larger primary size of tumor with lymphatic invasion.
T2|T2 (MRI)|T2|217|218|HISTORY OF PRESENT ILLNESS|Her workup at the time of admission to the hospital included a normal CT scan of the head. MRI scan of the head was unremarkable for any significant findings. There was a nonspecific unrelated 5 mm focus of increased T2 signal on the left posterior parietal subcortical area which is an incidental finding. MR angiography of the circle of Willis was normal. Specifically, there was no aneurysm.
T2|T2 (MRI)|T2|344|345|EXAMINATION|No carotid bruits. Phenytoin 21.9 today. EEG revealed left-sided slowing with occasional sharp waves on the right hemisphere and associated slowing but no active electrographic seizure discharges. Sodium is stable. CT head scan is pending. Recent MRI scan on _%#MMDD2004#%_ revealed evolving meningitis over the right hemisphere with increased T2 signal in the cortical regions compared to a prior scan. IMPRESSION: 1. Seizures associated with right epidural abscess, status post evacuation with associated MRI changes consistent with evolving meningitis.
T2|tumor stage 2|(T2,|250|253|ADDENDUM|ADDENDUM: After further review of available oncology records from _%#MM2005#%_, it has become apparent that _%#NAME#%_ was appropriately treated with initially Arimidex (this was poorly tolerated) and later tamoxifen. Her disease was in fact stage I (T2, N0, M0) ER-positive infiltrating ductal carcinoma of the breast, as described above. It appears that she may have been lost to oncologic followup, as the last available note is from _%#MM#%_ 2005.
T2|tumor stage 2|T2,|81|83|PROBLEM|PROBLEM: Squamous cell carcinoma of the left oral tongue and floor of the mouth, T2, N2, BM0. Ms. _%#NAME#%_ was seen in the Department of Therapeutic Radiology on _%#MMDD2007#%_ by Dr. _%#NAME#%_ and Dr. _%#NAME#%_ at the request of Dr. _%#NAME#%_ _%#NAME#%_ for the possibility of postop radiation.
T2|tumor stage 2|T2,|93|95|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old male who in 1994 was diagnosed with T2, grade 3, pleomorphic liposarcoma of his right calf. He underwent surgery followed by radiation therapy. From _%#MM1994#%_ to _%#MM1995#%_ radiation therapy consisted of 4500 cGy followed by a boost to 1800 cGy to a total dose of 6300 cGy.
T2|tumor stage 2|T2|168|169|HISTORY OF PRESENT ILLNESS|PROBLEM: Breast cancer. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is well-known to me. I gave her both pre and postoperative radiotherapy in 1993 for her stage T2 N0 M0 grade 3 posterior shoulder liposarcoma. She has had no recurrences from that. Unfortunately, in _%#MM2003#%_ she felt a lump in her right breast.
T2|thoracic (level) 2|T2|189|190|PROBLEM|Bone scan was performed on _%#MMDD2003#%_. Bone scan reported no evidence for metastatic disease to bone. There was some indeterminate uptake at the superior aspect of the left scapula and T2 vertebral body. Both areas were felt to be too subtle to suggest metastatic disease. The patient did have x-rays of the left tibia, fibula, and left knee, and all sites were felt to be negative for metastatic disease.
T2|T2 (MRI)|T2|132|133|DIAGNOSTIC STUDIES|There is also enhancement in the left side of the sphenoid sinus and the maxillary sinus along with some bright signal intensity on T2 in the left maxillary and sphenoid sinus. On the contrasted MRI studies, the cavernous sinus does not appear to have a significant filling defect.
T2|thoracic (level) 2|T2|173|174|DIAGNOSTICS|We could not ambulate the patient. DIAGNOSTICS: MRI performed this morning was reviewed extensively with Dr. _%#NAME#%_. We reviewed this study and there is evidence of the T2 and T3 vertebral bodies and extension into the canal. There is some canal compromise. The tumor also involved the pedicle and a portion of the spinous processes posteriorly.
T2|thoracic (level) 2|T2|252|253|ASSESSMENT|He is tender over his upper thoracic spine. MRI scan of the thoracic spine reveals metastatic disease involving the body and posterior elements of T2 and T3 with some involvement of the spinal cord at that level with edema within the cord. ASSESSMENT: T2 and T3 pathologic compression fractures with resultant paralysis in this 71-year-old gentleman with metastatic lung cancer. I had a long discussion with him regarding this situation.
T2|thoracic (level) 2|T2|373|374|IMPRESSION|A prostate specific antigen has been sent and is pending and a bone scan has already been obtained this afternoon, the results of which are still pending. IMPRESSION: _%#NAME#%_ _%#NAME#%_ is a very pleasant 70-year-old gentleman with a history of prostate cancer treated by prostatectomy eight years ago now with what appears to be bony metastases and an epidural mass at T2 and T3 by recent MRI scanning. I will track down his prior CT scans, prior MRI scans and will track down the results of the bone scan done today.
T2|thoracic (level) 2|T2|250|251|PERTINENT LABS|PERTINENT LABS: Today blood sugar was 136 and 175. White count 8.5, hemoglobin 11.8, platelets 192, sodium 137, BUN 21, creatinine 0.71, calcium 8.2. Spine CT done on _%#MM#%_ _%#DD#%_ indicates several thoracic spine metastatic lesions that involve T2 and T3 with pathological compression fractures of these vertebra. There is significant cord compression; cord edema has increased as compared to _%#MM#%_ _%#DD#%_.
T2|tumor stage 2|T2|165|166|IMPRESSION|Exam today reveals some persisting tenderness in the low mid abdomen, right lower quadrant area consistent with the documented apparent abscess. IMPRESSION: 1. Deep T2 or early T3 N0 moderately differentiated adenocarcinoma of the rectum, with ulcerated lesion noted posteriorly and located in the distal third of the rectum.
T2|T2 (MRI)|T2|92|93|PHYSICAL EXAMINATION|Deep tendon reflexes are symmetric with no drift. MRI scan: Revealed a left ........?? with T2 hyperintensity of about 1 cm in diameter. There is no edema, no evidence of hydrocephalus or mass effect. The basal cisterns are open. ASSESSMENT AND PLAN: The patient is a 24-year-old female with headache and incidental T2 enhancing left temporal lesion.
T2|T2 (MRI)|T2|179|180|ASSESSMENT AND PLAN|There is no edema, no evidence of hydrocephalus or mass effect. The basal cisterns are open. ASSESSMENT AND PLAN: The patient is a 24-year-old female with headache and incidental T2 enhancing left temporal lesion. Films were shown to Dr. _%#NAME#%_ and the case was discussed and when she presented to the Neurosurgery clinic, it was felt this most likely is an incidental lesion, not contributing to her headache as there was no real mass effect.
T2|tumor stage 2|T2,|156|158|IMPRESSION/PLAN|Sensation is otherwise grossly intact. IMPRESSION/PLAN: Squamous cell carcinoma of the base of tongue with 6 of 29 involved lymph nodes. Stage 4A (clinical T2, pathologic N2BM0). I agree with radiation therapy to the primary tumor and bilateral neck with concurrent chemotherapy. Studies have shown a significant benefit for patients receiving concurrent chemoradiation for stage 3 and 4 tumors of the head and neck region.
T2|tumor stage 2|T2|124|125|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: T2 N+ carcinosarcoma of left mouth. HPI: Status post resection. Exam: Flap well healed. NED. Assessment and Plan: We are waiting on further information on primary tumor location and neck pathology before making final decisions.
T2|tumor stage 2|T2,|164|166|IMPRESSION|There is no preauricular, postauricular, cervical, supraclavicular, infraclavicular or axillary lymphadenopathy. IMPRESSION: Mr. _%#NAME#%_ is a 68-year old with a T2, N1 adenocarcinoma of the distal esophagus who presents for the possibility of concurrent chemoradiotherapy. PLAN: The risks, benefits, and alternatives to chemoradiotherapy were discussed with the patient.
T2|tumor stage 2|T2|161|162|ASSESSMENT|KPS SCORE: Approximately 90. ASSESSMENT: Ms. _%#NAME#%_ is a very healthy 89-year-old Caucasian female who is status post mastectomy with a 2 mm deep margin for T2 N0 M0 adenoid cystic carcinoma of the left breast. Her performance status is excellent. She has essentially no medical comorbidities.
T2|T2 (MRI)|T2|153|154|HISTORY OF PRESENT ILLNESS|The patient had short-term steroids without any response. In the middle of _%#MM#%_ his right eye became blind. At that time he was found to have a 9 mm T2 hypodense contrast enhancing lesion in the right high frontal convexity. Other areas showed no evidence of recurrent disease. His MRI was again repeated.
T2|thoracic (level) 2|T2|140|141|HISTORY OF PRESENT ILLNESS|She was originally seen in our department on _%#MMDD2006#%_, at which time she was found to have a painful met in the right pelvis and also T2 vertebral body. Due to the fact that she has had previous head and neck radiation, it was decided to refer her for surgery for her T-spine metastasis.
T2|thoracic (level) 2|T2|198|199|SUBJECTIVE|She is status post treatment with cisplatin and radiation. She sustained a sensory peripheral neuropathy as a side effect of her cisplatin. On _%#MMDD2006#%_ she underwent debulking of her tumor at T2 with a posterior spinal fusion instrumentation of T1 to T3. A T2 corpectomy with CAGE placement. She was discharged home.
T2|thoracic (level) 2|T2|169|170|HISTORY OF PRESENT ILLNESS|Since that time, she has been on chemotherapy with Taxol and carboplatin under the care of Dr. _%#NAME#%_ in Medical Oncology. She also had surgery for her spine at the T2 level by Dr. _%#NAME#%_ _%#NAME#%_ for stabilization of the spine. At this time, the patient is seen by us with multiple brain metastases on MRI done on _%#MMDD2006#%_.
T2|thoracic (level) 2|T2|278|279|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This 59-year-old female with history of Stage III tonsillar carcinoma was seen by Dr. _%#NAME#%_ in Neurosurgery for debridement of wound and thoracic washout of wound seroma, performed on _%#MMDD2006#%_. She has a history of metastatic carcinoma of T2 thoracic body and is status post posterior vertebrectomy and posterior T1-3 pedicle screw fusion on _%#MMDD2006#%_. The patient did well postoperatively, but her MRI showed some epidural fluid collection.
T2|tumor stage 2|T2|251|252|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 70-year-old gentleman who was diagnosed with non-small cell lung cancer in _%#MM2005#%_. He had a 3.2 cm right upper lobe mass along with PET positive ipsilateral hilar and mediastinal adenopathy (stage T2 N2). He received 2 cycles of induction therapy consisting of Carbo and Taxol, however, he was not deemed to be resectable.
T2|thoracic (level) 2|T2|314|315|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old right-handed individual with history of nonsmall cell lung carcinoma who is status post chemoradiation therapy, who 4 months ago underwent mediastinoscopy and excision of left ribs 1-4. He is also status post T1-T5 vertebrectomy with recurrence of tumor at T2 PET scan was positive for recurrence of tumor in the left arm. He is now status post transpedicular vertebrectomy of T2 with a C7-T3 fusion for NSCLC metastasis.
T2|thoracic (level) 2|T2|296|297|ASSESSMENT/RECOMMENDATIONS|Reflexes 2/4 and symmetrical. Functional exam deferred. ASSESSMENT/RECOMMENDATIONS: This 65-year-old individual with history of nonsmall cell lung carcinoma with a history of rib resection, left lobectomy, left upper lobectomy and tumor resection. He is now status post complete vertebrectomy at T2 and posterior fusion of C7-T1 bilaterally T2 on the right and T3 bilaterally. His complex medical history. He requires CTLSO at all times when up.
T2|thoracic (level) 2|T2.|258|260|CT|In fact, the odontoid fragment is behind the body of T2, which is consistent with a diagnosis of spondyloptosis. Cervical spine CT scan confirms this posterior displacement of the fragment with retraction and pulling of that fragment down behind the body of T2. IMPRESSION: 1. Type 2 odontoid fracture. 2. Hypertension. 3. Alcoholism.
T2|T2 (MRI)|T2|233|234|HISTORY OF PRESENT ILLNESS|He has adrenal insufficiency secondary to metastatic renal cell carcinoma that has metastatic disease to his brain and adrenal glands. He is status post an adrenalectomy. He had a positive MRI on _%#MMDD2006#%_ that showed increased T2 signal in the posterior white matter bilateral occipital in his cerebellum and multiple contrast-enhancing nodular right cerebellar foci.
T2|tumor stage 2|T2|263|264|HISTORY OF PRESENT ILLNESS|The pancreatic duct had a positive in situ component. Three peripancreatic lymph nodes were removed and found to be benign. Gallbladder revealed chronic cholecystitis. She is presently postoperative and I was asked to see her regarding further management of this T2 or 3, N0, M0 pancreatic malignancy. I did take the opportunity to talk with the patient and her family about the fact that the news is quite good, that it was resectable and that lymph nodes were not involved.
T2|tumor stage 2|T2|327|328|HISTORY OF PRESENT ILLNESS|Ms. _%#NAME#%_ _%#NAME#%_ was seen for initial consultation in the Department of Therapeutic Radiology on _%#MMDD2007#%_ by Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ at the request of Dr. _%#NAME#%_ _%#NAME#%_. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 66-year-old female with a history of stage T2 N0 (2A) ductal carcinoma of the right breast diagnosed in 2002 status post modified radical mastectomy and sentinel lymph node biopsy.
T2|T2 (MRI)|T2|203|204|HISTORY OF PRESENT ILLNESS|She had an MRI of the head on _%#MMDD2003#%_. This was compared with an MRI of _%#MMDD2002#%_. There was an unchanged mass within increased signal in the brain stem and the pons region on turboFLAIR and T2 images. This mass is non-enhancing; size and appearance is unchanged. There is a new region of increased signal in the periventricular white matter, however, most prominently adjacent to the occipital horn of the left lateral ventricle and the body of the left lateral ventricle.
T2|T2 (MRI)|T2|296|297|HISTORY OF PRESENT ILLNESS|This mass is non-enhancing; size and appearance is unchanged. There is a new region of increased signal in the periventricular white matter, however, most prominently adjacent to the occipital horn of the left lateral ventricle and the body of the left lateral ventricle. There is also increased T2 signal in the corpus callosum. The patient underwent biopsy of the left periventricular region on _%#MMDD2003#%_. This demonstrated infiltrating anaplastic astrocytoma. The patient is now being sent to us regarding the possibility of re-irradiation for her anaplastic astrocytoma.
T2|T2 (MRI)|T2|470|471|HISTORY|Hospitalized at Fairview-_%#CITY#%_ from _%#MMDD2000#%_ through _%#MMDD2000#%_. Diagnosis at that time included organic mood disorder with depressed-like features including some "frontal lobe features." Question of mild cognitive impairment for which neuropsychological testing was performed which did show some features consistent with the patient's reported head injury. Brain MRI did show a frontal lobe abnormality consisting of a 1 cm oval-shaped area of increased T2 signal in the left midfrontal white matter, felt to be nonspecific. A small white matter infarct related to old trauma could not be excluded.
T2|T2 (MRI)|T2|129|130|RADIOLOGY|The mass does not appear to be extending into the bone. On T1 the mass appears homogeneous and isointense to the spinal cord. On T2 the mass appears hyperintense and homogeneous. No contrasted studies were obtained because of the comfort of the patient. ASSESSMENT: Ms. _%#NAME#%_ has an extraaxial mass that is causing a significant amount of pain and some possible mild neurologic deficit with lower extremity myelopathy.
T2|tumor stage 2|(T2,|66|69|PROBLEM|PROBLEM: T2B, N0, M0 bladder cancer, possible lung cancer primary (T2, N2, M0) of unknown histology. Mr. _%#NAME#%_ was seen in the Radiation Oncology Clinic on _%#MM#%_ _%#DD#%_, 2002 by Drs. _%#NAME#%_ _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_ for initial consultation at the request of Dr. _%#NAME#%_ _%#NAME#%_.
T2|tumor stage 2|T2,|157|159|HISTORY OF PRESENT ILLNESS|MRI scan was performed and demonstrated multiple metastatic foci involving the cervical, thoracic, and lumbar spine. Epidural compression was seen at T1 and T2, with mild compression of the spinal cord, and a mass extending into the left T1 and T2 neural foramina. The patient was admitted to the hospital for further evaluation.
T2|thoracic (level) 2|T2|195|196|NEUROLOGY CONSULTATION|Apparently his pain was so severe that he is readmitted today by Dr. _%#NAME#%_ and neurological consultation is requested. The question to us deals with whether Neurontin would be useful or the T2 cystic lesion on the thoracic spine is of a source of his difficulties. The balance of his neurological history is difficult to obtain as he is a bit demented and has quite a bit of difficulty tracking and recounting his history.
T2|tumor stage 2|T2|204|205|IMPRESSION|She is now in remission after resection, though does have a very high risk of potential recurrence given the positive pancreatic margin for ___________ invasion and the one positive lymph node. This is a T2 N1 adenocarcinoma of the head of the pancreas. At this point the patient clearly needs more time to recover from surgery.
T2|tumor stage 2|T2,|20|22|PROBLEM|PROBLEM: Stage IIB, T2, N0, M0 squamous cell carcinoma of the left neck with extracapsular extension and with subglottic extension of the glottic larynx, status post 7440 cGy to the larynx in 120 b.i.d treatments between the dates of _%#MMDD2002#%_ and _%#MMDD2002#%_, status post recent neck dissection (please see initial consultation from _%#MMDD2002#%_ and last clinic note from _%#MMDD2003#%_). HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ initially presented to us in _%#MM2002#%_ with a T2, N0, M0 squamous cell carcinoma of the true glottic larynx with subglottic extension of approximately 1 cm.
T2|tumor stage 2|T2,|325|327|IMPRESSION|No subglottic disease can be visualized. The piriform sinuses both appear normal and have no pooling or masses. IMPRESSION: Poorly differentiated squamous cell carcinoma of the right neck levels 2/3, with extracapsular extension and poorly differentiated, now almost six months status post completion of radiation therapy to T2, N0, M0 moderately differentiated squamous cell carcinoma of the subglottic larynx, now status post neck dissection. PLAN: This is an unusual case. It is highly unlikely that T2 larynx cancer would metastasize to neck nodes, with reported incidence being 5%, yet the time frame is correct.
T2|tumor stage 2|T2|9|10|PROBLEM|PROBLEM: T2 N2b M0 squamous cell carcinoma of the right base of tongue. Mr. _%#NAME#%_ was seen in the Department of Radiation Oncology on _%#MMDD2004#%_ by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ at the request of Dr. _%#NAME#%_ _%#NAME#%_.
T2|T2 (MRI)|T2|168|169|HPI|A recent MRI scan had been performed and was unfortunately obscured by movement artifact. Nevertheless, major structural lesions are excluded by the study. Also in the T2 weighted sequences, the findings of hypertensive encephalopathy (posterior T2 hyperintensity of white matter and gray matter) was not apparent. There was, however, fairly extensive white matter hyperintensity or leukoaraiosis.
T2|tumor stage 2|T2,|208|210|IMPRESSION|Other labs as charted. IMPRESSION: 1) Non-Hodgkin's lymphoma involving peripheral lymphadenopathy and ovarian deposits, stage unknown at the present time. 2) Right breast cancer status post lumpectomy, stage T2, N0, M0, ER/PR positive. Adjuvant therapy on hold. 3) Perforated duodenal ulcer status post surgery. PLAN: I discussed with _%#NAME#%_ that her non-Hodgkin's lymphoma is symptomatic and causes some narrowing of her ureters, according to Dr. _%#NAME#%_'s report when he operated.
T2|tumor stage 2|T2,|15|17|PROBLEM|PROBLEM: Stage T2, N1 base-of-tongue cancer. Ms. _%#NAME#%_ was seen in the Radiation Oncology clinic by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2002 for initial consultation at the request of Dr. _%#NAME#%_ _%#NAME#%_.
T2|T2 (MRI)|T2|166|167|HISTORY OF PRESENT ILLNESS|An MRI scan of the brain performed on _%#MMDD2002#%_ showed a midline shift to the left secondary to persistent tumor in the anterior right frontal lobe. The intense T2 signal abnormality crosses the corpus callosum. The radiologists feel this is consistent with persistent tumor. Since resection she has been on Decadron and Dilantin, but is just completing her dexamethasone taper.
T2|tumor stage 2|T2,|166|168|IMPRESSION|Cholesterol 166; HDL 51; triglycerides 158; LDL 83; lipase 1273. CA19-9 of 142 (normal less than 37 units/mL). IMPRESSION: Adenocarcinoma of the head of pancreas, CT T2, Nx, M0. RECOMMENDATIONS: The patient is a candidate for preoperative chemoradiation treatment.
T2|T2 (MRI)|T2|146|147|IMPRESSION|The occlusion is 2-3 cm above the bifurcation. The internal carotid is reconstituted in its petrous segment. The T1 sequence with enhancement and T2 studies show an enhancing lesion several centimeters in diameter in the left extracranial petrous area. The episodes probably qualify as vertigo. The examination fails to incriminate a central cause.
T2|T2 (MRI)|T2|200|201|HISTORY OF PRESENT ILLNESS|An AP and lateral x-ray was taken, which showed L1 compression fracture as well as old T12 and L2 compression deformities. An MRI was obtained to assess the age of the L1 compression fracture. On the T2 image there was evidence that this fracture was of either a subacute or acute nature. Orthopedics was not consulted at that time. A TLSO brace was ordered for the patient, and he has been wearing the brace since.
T2|thoracic (level) 2|T2|252|253|PAST MEDICAL HISTORY|4. History of recent rollover motor vehicle accident on _%#MMDD#%_, status post exploratory laparotomy and 1-week hospitalization at HCMC. The patient was found to have duodenal hematoma too small to evacuate, left suboccipital condyle fracture, and a T2 spinous process fracture. The patient currently on Percocet for pain. PAST SURGICAL HISTORY: Exploratory laparotomy approximately 1 week ago (as above).
T2|thoracic (level) 2|T2|130|131|ASSESSMENT|ASSESSMENT: 1. Polysubstance abuse and depression per Dr. _%#NAME#%_. 2. Acute pain secondary to left occipital condyle fracture, T2 spinous process fracture, and duodenal hematoma status post exploratory laparotomy as a result of rollover motor vehicle accident on _%#MMDD#%_.
T2|T2 (MRI)|T2|123|124|IMPRESSION|LUNGS: Including sedimentation rate, TSH, ANA are all normal. IMPRESSION: 1. MRI findings of six tiny subcortical areas of T2 signal change. These findings are entirely nonspecific and are unlikely to be related to any of her psychiatric symptoms. Her neurologic examination is otherwise normal. RECOMMENDATIONS: I explained to the patient that the MRI findings at this point are not concerning.
T2|thoracic (level) 2|T2,|145|147|REASON FOR CONSULTATION|He was seen by his family practitioner earlier today who obtained an MRI/MRA at the T2 level what appears to be non-enhancing mass involving the T2, as well as parts of the T1, and T3 vertebra. There is a mass effect upon the thecal sac in a somewhat circumferential fashion.
T2|thoracic (level) 2|T2.|135|137|HISTORY OF PRESENT ILLNESS|When the patient presented for his MRI on Monday, _%#MMDD2004#%_, he was unable to walk. The MRI showed a non-enhancing mass involving T2. At that point, he was sent to Fairview-University Medical Center to be seen in neurosurgery. The patient's history actually dates back to about 10 months ago when he starting having right shoulder pain.
T2|thoracic (level) 2|T2|193|194|IMPRESSION|NEUROLOGIC: Upper extremity strength is symmetric and intact. Lower extremity strength is a 2/4. IMPRESSION: Mr. _%#NAME#%_ is a 47-year-old male with likely renal cell carcinoma metastatic to T2 vertebral body. PLAN: We discussed the option of palliative radiation to his T2 vertebral lesion.
T2|tumor stage 2|T2|166|167|PLAN|At the time of this dictation, neurosurgery was still considering doing surgery on his T2 lesion. We will await their decision. We can do radiation treatments to his T2 lesion after surgery if they decide to proceed with that option. We discussed with the patient the indications for, as well as the risks and benefits of radiation therapy for his disease.
T2|tumor stage 2|T2|359|360|HISTORY OF PRESENT ILLNESS|On _%#MMDD2004#%_, the patient was seen by Dr. _%#NAME#%_ at _%#COUNTY#%_ _%#COUNTY#%_ Medical Center where an esophageal ultrasound showed that the lesion invaded into the muscularis propria and also had enlarged nodes at the SMA and SMD. Needle aspiration of the three largest nodes were negative for malignancy. Therefore, the patient is ultrasound staged T2 N0 M0. Symptomatically, the patient states that his diarrhea has improved now that he is on the gluten-free diet. He admits to a 30 pound weight loss since _%#MM#%_, but states he is gaining is weight back.
T2|thoracic (level) 2|T2|176|177|HISTORY OF PRESENT ILLNESS|From _%#MMDD#%_ to _%#MMDD#%_ he complained of some weakness and clumsiness in his lower extremities and by _%#MMDD#%_ he was unable to walk. He underwent an MRI that showed a T2 lesion. He then underwent a posterior laminectomy for decompression. Two weeks later, he underwent an anterior approach at which time he had a fusion.
T2|thoracic (level) 2|T2|148|149|PLAN|He was diagnosed in _%#MM#%_ of 2005, after he was noted to have weakness in his lower extremities, and was found to have a paraspinal tumor in the T2 paravertebral area. He was evaluated by a neurosurgeon, and underwent exploratory surgery to remove this tumor. However, a diagnosis was not achieved until the 2nd surgical procedure was performed in _%#MM#%_ of this year, and the pathology at that time showed Ewing's sarcoma.
T2|T2 (MRI)|T2|300|301|IMAGING|3. MRI subsequently done 11:30 a.m. on _%#MMDD2007#%_ shows small acute parenchymal hematoma with symmetric hyperintensities in the occipital, parietal and posterior frontal region, which is most likely PRES/posterior reversible encephalopathy syndrome. There is also several hyperintensities in the T2 images periventricularly, which is probably small-vessel ischemic disease. There does not appear to be any evidence of any tumor. LABORATORY DATA: Sodium 133 and it has been trending down as it was in the 140s a few days ago.
T2|thoracic (level) 2|T2.|259|261|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Patient with previous h/o fallopian tumor, s/p diagnosis of stage IV lung NSC cancer since 1999, now presents with paraspinal mass C6- T2. HPI: New neck pain. MRI shows mass. Exam: No decrease in UE, strength, or sensation.
T2|tumor stage 2|T2|19|20||PROBLEM: Recurrent T2 N0 M0 squamous cell carcinoma of the true vocal cord, status post initial laser assisted resection, status post recurrence, and status post resection of recurrence. HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old white male who originally presented in 2006 with left-sided T2 N0 M0 squamous cell carcinoma of the glottic larynx and underwent an endoscopic laser assisted resection.
T2|T2 (MRI)|T2|142|143|REFERRING PHYSICIAN|There was a bubble study which was negative. His carotid ultrasound study was felt to be normal. His MRI of the brain showed some nonspecific T2 changes but no acute infarcts were identified. Sed rate was 2. He was noted to have some elevation of LDL and reduced HDL.
T2|thoracic (level) 2|T2|307|308|HISTORY OF PRESENT ILLNESS|Back pain has been going on, he states, starting with the radiation therapy for his cancer, and he has a congenital malformation of the vertebral body which has been the origin, I believe, of his pain. He has a kyphosis 3 back surgeries by Dr. _%#NAME#%_. The last one was 6 years ago with a fusion between T2 through L2. He states that one of those surgeries (I think it was the second one) ended up having a nerve resection to correct his scapula winging.
T2|tumor stage 2|T2|196|197|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Invasive ductal carcinoma of the right breast with the original staging T2 N1 M0, now has recurrence and is status post bilateral mastectomy. HPI: This is a 40-year-old surgical resident who had breast cancer, on the right side in _%#MM2002#%_.
T2|tumor stage 2|T2|150|151|RECOMMENDATIONS|Underwent a right nephroureterectomy by Dr. _%#NAME#%_. Unfortunately, she continued to have local recurrences with biopsy in _%#MM#%_ 2003 showing a T2 muscle invasive high-grade bladder cancer. Workup at that time for metastatic disease was unremarkable. She was not felt to be a good candidate for systemic chemotherapy, so we did initiate local radiation therapy to her bladder, which was delivered between _%#MMDD2003#%_ and _%#MMDD2004#%_.
T2|thoracic (level) 2|T2|135|136|HISTORY OF PRESENT ILLNESS|She also had moderate involvement of T5 with slight collapse of the disk and subluxation. She underwent a decompression laminectomy of T2 with kyphoplasty with T2 partial corpectomy with instrumentation and rods, and arthrodesis of C7-T1, T1-T2, T2-T3 and T3-T4 facets by Dr. _%#NAME#%_ _%#NAME#%_ on again on _%#MM#%_ _%#DD#%_, 2006. A PT, OT evaluation has been recommended and PM and R consultation has been also asked, as the patient has also been advised to have a CT LSO in place for her external spinal support.
T2|thoracic (level) 2|T2|162|163|HISTORY OF PRESENT ILLNESS|The left foramen was more severe than the right. There was a tight spinal canal as well. There were also findings that involved an increased signal change in the T2 vertebral body and there was question of early metastasis at this level. PAST MEDICAL HISTORY: 1. Hypertension. 2. Coronary artery disease, status post CABG in 2003.
T2|tumor stage 2|T2|216|217|PATHOLOGY|The patient also has undergone a bone scan in _%#MM2007#%_, which showed no hydronephrosis and no bony metastasis. PATHOLOGY: Tissue pathology from _%#MM2007#%_ was reviewed and shows transducer cell carcinoma grade T2 with carcinoma in situ of the prostatic urethra. IMPRESSION: This is an 85-year-old gentleman with multiple medical problems admitted for dehydration and altered mental status in the setting of hyponatremia, is recently diagnosed with T2 of the bladder with carcinoma in situ of the prostatic urethra.
T2|T2 (MRI)|T2|138|139|HISTORY OF PRESENT ILLNESS|A _%#MMDD2004#%_ whole body bone scan shows no skeletal mets and a _%#MMDD2004#%_ brain MRI shows a single non-specific foci of increased T2 signal in the left periventricular white matter. She also had another CT of the chest, abdomen and pelvis done on that date which has not been officially read at the time of this dictation, but per our review, is comparable to a _%#MMDD2004#%_ chest CT.
T2|T2 (MRI)|T2|212|213|IMPRESSION/PLAN|The overlying skin on the external surface is normal. The magnetic resonance evaluation demonstrated that the majority of the lesion was definitely deep toward the buccal surface. The lesion had a high signal on T2 weighted images, and is therefore completely consistent with a lymphangioma or mixed lymphangioma and hemangioma. On the basis of the fact that the patient has definite worsening symptoms I think that a course of injection scleral therapy is indeed warranted.
T2|T2 (MRI)|T2|178|179|NEUROLOGIC EXAMINATION|My unofficial reading of the MRI shows an area of hyperintensity on diffusion-weighted imaging in the left mesocerebellar hemisphere. This area of abnormality is also visible on T2 imaging of the posterior fossa. In addition, there are multiple areas of increased T2 and flare signal in the periventricular cerebral hemispheric white matter, most suggestive of small-vessel ischemic changes.
T2|tumor stage 2|(T2,|264|267|HISTORY|No LCIS was seen away from the invasive tumor. All surgical margins were free of tumor, twelve lymph node were recovered along with the two sentinel lymph nodes, all fourteen of lymph nodes were negative for metastatic disease. The patient is a surgical Stage IIa (T2, N0, M0). PAST MEDICAL HISTORY: Noncontributory. She had benign essential hypertension for a few years.
T2|tumor stage 2|T2|160|161|HISTORY OF PRESENT ILLNESS|MRI of the cervical spine showed minimal disk bulge at C5, C6. Slightly decreased marrow signal intensity was noted on T1 weighted images, but no corresponding T2 segmental abnormality was noted, raising the question of the possibility of a myeloproliferative disorder or simply normal hemopoietic bone marrow.
T2|T2 (MRI)|T2|224|225|PHYSICAL EXAMINATION|There is no clonus at the knees. Radiographic imaging: Cervical spine MRI demonstrates significant cord progression of C4-5 due to a combination of a ventral disc herniation and dorsal ligamentous hypertrophy. There is high T2 signal within the spinal cord. Ms. _%#NAME#%_ does not have physical exam evidence of an overt myelopathy but a history and an MRI which are very suggestive of a progressive compressive myelopathy.
T2|tumor stage 2|T2,|9|11|PROBLEM|PROBLEM: T2, N2b, M0 poorly-differentiated squamous cell carcinoma of the right tonsil. Mr. _%#NAME#%_ was seen in the Radiation Oncology Clinic on _%#MM#%_ _%#DD#%_, 2002 by Drs. _%#NAME#%_ _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_ for initial consultation at the request of Dr. _%#NAME#%_ _%#NAME#%_.
T2|tumor stage 2|T2|124|125|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: T2 N2bMo squamous cell carcinoma of the right tonsil. HPI: Status post biopsy. Exam: 2.5 x 1 cm ulcerated (postop) induration right tonsil with bilateral neck disease.
T2|tumor stage 2|T2|132|133|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Sarcoma T2 No Mo HPI: S/P WLE with close margins (1 cm), outside chest CT negative Exam: Scar healing well Assessment and Plan: Recommend XRT to decrease risk of local recurrence Risks and benefits of XRT explained Planning session scheduled
T2|T2 (MRI)|T2|201|202|IMAGING|IMAGING: MRI scan of the cervical spine was accomplished, which demonstrates chronic changes of degenerative cervical spondylosis. There is moderate central stenosis at C3-4, yet nothing in the way of T2 changes in the T2 signals of this area that would indicate acute myelopathy. There are moderate to mild degenerative changes similarly at C6-7.
T2|T2 (MRI)|T2|162|163|HISTORY OF PRESENT ILLNESS|Later that day she was unable to urinate. Her numbness progressed. She returned to the hospital. She was noted to have urinary retention. MRI of the spine showed T2 signal abnormality in the thoracic cord consistent with transverse myelitis. She was also found to be pregnant. She has been treated with steroids.
T2|T2 (MRI)|T2|138|139|IMAGING|There is a complex abnormality in the superior aspect of the right cerebellar hemisphere which has multiple round foci of low T1 and high T2 signal. The diffusion-weighted images show no diffusion abnormality to suggest an acute infarct. There may have been some suggestion of an old hemorrhage at the superior aspect of the abnormality.
T2|T2 (MRI)|T2|152|153|LABS|CT scan showed no evidence of bleed. MRI of the brain with diffusion-weighted images showed no evidence of stroke, no hypoxic ischemic regions,. T1 and T2 signal images showed no evidence of abnormalities. This was an essentially normal MRI. IMPRESSION: _%#NAME#%_ _%#NAME#%_ presented with a possible seizure and posturing which I think occurred as a result of the cardiac arrest and hypoxic ischemic brain injury.
T2|T2 (MRI)|T2|236|237|HISTORY OF PRESENT ILLNESS|He was brought in for further evaluation. He has a history of a stroke a year ago with left-sided weakness. He had an MRI of his brain while in the hospital at that time that showed acute left frontal lobe ischemic changes and multiple T2 hyperintensities in both cerebral hemispheres. PAST MEDICAL HISTORY: History of high blood pressure, a stroke in the past, diabetes, cocaine abuse and ETOH abuse.
T2|T2 (MRI)|T2|235|236|HOSPITAL COURSE|Proprioception was intact in both toes. Casual gait is neuro based with symmetric arm swing. HOSPITAL COURSE: I reviewed the brain MRI today which demonstrates a heterogeneically enhancing temporal superficial lesion with a rim of low T2 signal consistent with hemosiderin. IMPRESSION: I agree with the radiologic diagnosis that this is a large cavernoma.
T2|tumor stage 2|T2|207|208|HISTORY|He underwent colonoscopy evaluation and was found to have malignancy in the transverse colon. He was hospitalized on _%#MM#%_ _%#DD#%_ and had initial surgery with colectomy. The pathology revealed a 2.1 cm T2 invasive into muscularis propria. There was no lymphatic or vascular invasion. The margins were negative. One lymph node was involved, N1 disease. He had primary anastomosis, subsequently developed leakage and required a second operation, which was done on _%#MM#%_ _%#DD#%_ with colostomy.
T2|tumor stage 2|T2,|174|176|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ is a very pleasant 75- year-old gentleman who was noted to have a right upper lobe mass on a chest x-ray in _%#MMDD#%_. He was diagnosed as having stage IIIB, T2, N3, M0, non-small cell carcinoma, probably adenocarcinoma of the right upper lobe of the lung. He was treated with chemoradiation at West Bank Radiation in _%#CITY#%_, receiving a total dose of 6120 cGy in 34 fractions.
T2|T2 (MRI)|T2|245|246|PAST MEDICAL HISTORY|The patient was therefore referred to our clinic and we are seeing him for initial consultation. The MRI done at Fairview-University Medical Center on _%#MMDD2003#%_ shows a 5.2 x 5.3 x 9.0 cm mass in the distal forearm with increased signal in T2 encasing the ulna and radius with some mass effect on the radius and somewhat lobulated in appearance. A chest x-ray done _%#MMDD2003#%_ was negative for evidence of pulmonary metastases.
T2|T2 (MRI)|T2|341|342|IMAGING|No other mass lymphadenopathy is identified within the neck. MRI of the brain with and without contrast performed _%#MM#%_ _%#DD#%_, 2005, for resection of the right parietal lobe lesion shows patient is status post right parietal craniotomy with surgical defect in the right parietal lobe and splenium of the corpus callosum. Large area of T2 hyperintensity seen in the right frontoparietal region and the splenium of the corpus callosum representing ________ edema. Small amount of the hemorrhage and air is noted in the surgical cavity.
T2|T2 (MRI)|T2|221|222|ASSESSMENT/PLAN|Antigens for Cryptococcus, Toxoplasmosis, and Aspergillus are negative. No fungus is growing from the culture. Blood cultures from _%#MMDD2005#%_ are also negative. ASSESSMENT/PLAN: The patient is a 59-year-old male with T2 hyperintense lesions on MRI performed as a workup for a first-time seizure. 1. We recommend repeating the MRI to assess for progression of lesions.
T2|tumor stage 2|T2|17|18|PROBLEM|PROBLEM: Initial T2 N1 left breast cancer with metastatic disease with extensive skin metastases. The patient was seen by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ on 7C the request of Dr. _%#NAME#%_.
T2|tumor stage 2|T2|163|164|HPI|She had whole brain radiation at Fairview-University Medical Center. She was initially diagnosed to have breast cancer in _%#MM2003#%_ and had a mastectomy with a T2 disease. Right after her surgery and chemotherapy with FAC she developed swelling of the left arm with pain. The patient was found to have a mass in the supraclavicular area and the neck area and received radiation with 6000 cGy in Illinois.
T2|tumor stage 2|T2|131|132|ASSESSMENT|LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, non-tender, non-distended. ASSESSMENT: 56-year-old gentleman with initial T2 N2b squamous cell carcinoma of the right base of tongue. He has completed one cycle of chemotherapy with partial response.
T2|T2 (MRI)|T2|240|241|HISTORY OF PRESENT ILLNESS|_%#NAME#%_ was last administered gammaglobulin on _%#MMDD2007#%_. _%#NAME#%_ has undergone Port-A-Cath placement. _%#NAME#%_ had a cranial MRI obtained on _%#MMDD2007#%_, which showed a small, abnormal enhancing focus with surrounding high T2 signal within the subcortical white matter of the right parietal lobe, near the vertex. There were 3 other tiny foci of high T2 signal within the subcortical and deep white matter.
T2|T2 (MRI)|T2|253|254|HISTORY OF PRESENT ILLNESS|_%#NAME#%_ had a cranial MRI obtained on _%#MMDD2007#%_, which showed a small abnormal enhancing focus with surrounding high T2 signal within the subcortical white matter of the right parietal lobe, near the vertex. There were 3 other tiny foci of high T2 signal within the subcortical and deep white matter. A bone scan was normal. Echocardiogram was normal. A PET scan showed no abnormal hypermetabolic activity.
T2|T2 (MRI)|T2|247|248|HISTORY OF PRESENT ILLNESS|His MRI of the brain from _%#MMDD2007#%_ have shown him to have a large subacute stroke involving the left frontal, temporal lobes within the distribution of left middle cerebral artery. There is superimposed scattered areas of gyriform decreased T2 signals present representing areas of acute petechial hemorrhage, edema is present within the involved area of stroke with minimal rightward midline shift and mass effect upon the body of left corpus collosum.
T2|T2 (MRI)|T2|244|245|ADDENDUM|Thank you very much for allowing me to participate in the care and evaluation of this very interesting, pleasant gentleman. ADDENDUM: I have just received a preliminary report on the cervical, thoracic and lumbar spine. There was a nonspecific T2 signal described on the right side of the cervical spine at the C3-C4 level. The possibility of a demyelinating disorder was raised. Interestingly, the thoracic cord did not reveal any abnormalities as identified by the preliminary report.
T2|tumor stage 2|T2|9|10|PROBLEM|PROBLEM: T2 N2b M0 squamous cell carcinoma of his right tonsil who presents for the possibility of radiation therapy. The patient was seen in consultation by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_.
T2|T2 (MRI)|T2|133|134|REASON FOR CONSULTATION|We reviewed the head MRI scans. There were a number of areas of parenchymal T2 hyperintensity. There was a cystic area surrounded by T2 hyperintensity in the left corona radiata. In the _%#MMDD2006#%_ MRI scan, there was area of T2 hypertensity as well as enhancement involving the dura on the left overlying the frontoparietal hemisphere.
T2|T2 (MRI)|T2|134|135|REASON FOR CONSULTATION|There was a cystic area surrounded by T2 hyperintensity in the left corona radiata. In the _%#MMDD2006#%_ MRI scan, there was area of T2 hypertensity as well as enhancement involving the dura on the left overlying the frontoparietal hemisphere. The medial border of this area did appear to feather into the sulci suggesting a leptomeningeal component.
T2|T2 (MRI)|T2|165|166|RECOMMENDATIONS|Babinski is absent. MRI from this morning is reviewed. Here, we see excellent stability with no evidence of new enhancing lesion and no evidence of changes in T1 or T2 signal abnormalities. Impression: 1. Oligodendroglioma with good response to radiotherapy and 12 cycles of Temodar. The treatment ceased in _%#MM#%_ of last year. We will continue to follow her with q.3 month studies.
T2|tumor stage 2|T2|36|37|PROBLEM|PROBLEM: Newly diagnosed stage IIA, T2 N0 M0, microscopically immunohistochemically-positive sentinel node biopsy, right breast cancer, status post lumpectomy. This patient was seen in consultation in the Radiation Oncology Clinic on _%#MMDD2006#%_ by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_.
T2|T2 (MRI)|T2|118|119|HISTORY OF PRESENT ILLNESS|The MRI of the thoracic and lumbar spine revealed a thin epidural fluid collection that appeared bright on the T1 and T2 sequences. The Neuroradiology fellow thought this was consistent with an epidural hematoma but because of the contrast agent given could not rule out completely an epidural abscess.
T2|thoracic (level) 2|T2|190|191|IMPRESSION|IMPRESSION: 1. Chronic lymphocytic leukemia. 2. Anemia, secondary to #1, with features of anemia of chronic illness and insufficient erythropoietin levels. 3. Recent episode of left C7, T1, T2 level herpes zoster. 4. Chronic fatigue and weakness. 5. Hyponatremia and hypoalbuminemia, with multifactorial features and evidence of syndrome of inappropriate antidiuretic hormone.
T2|tumor stage 2|T2|125|126|PROBLEM|Patient was seen in request by Dr. _%#NAME#%_ for breast consolidation radiation. PROBLEM: Left breast cancer, initial stage T2 N2 M0 infiltrating ductal carcinoma. The patient presented with multiple bony metastases with a painful metastasis in the left hip area. HISTORY OF PRESENT ILLNESS: This is a 47-year-old female patient who is known to have left breast cancer, initial stage IIIA, T2 N2 M0, with at least 8 of 12 positive lymph nodes, ER/PR positive and HER2/neu positive.
T2|thoracic (level) 2|T2|168|169|CC|_____Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Multiple myeloma, spinal cord compression at T2 HPI: Known to have MM since 1998 and presented with T2 spinal cord compression with numbness below T2.
T2|tumor stage 2|T2|19|20|PROBLEM|PROBLEM: T1 versus T2 N0 M0 invasive ductal carcinoma of the left breast. Ms. _%#NAME#%_ was seen in the Department of Therapeutic Radiology on _%#MMDD2007#%_ by Dr. _%#NAME#%_ and Dr. _%#NAME#%_ at the request of Dr. _%#NAME#%_ for adjuvant radiation.
T2|UNSURED SENSE|T2.|157|159|IMPRESSION|7. Hypertension, untreated prior to admission. 8. Morbid obesity. . 8. 8. RECOMMENDATIONS: 1. Will check urine sodium and fractional excretion of sodium. 1. T2. aper norepinephrine and other pressers as able. 2. A3. void contrast nonsteroidal anti-inflammatory drugs, ACE inhibitors and ARBs if possible.
T2|T2 (MRI)|T2|240|241|HISTORY OF PRESENT ILLNESS|Initial imaging performed _%#MMDD2001#%_ showed a left posterior orbital mass approximately 3 to 4 mm in size adjacent and inferior to the left optic nerve. This apparently intraconal mass was isointense to muscle on T1 and hyperintense on T2 with apparent contrast enhancement post- gadolinium. The patient's lesion was managed noninvasively, given her minimal symptoms at that time. However, over time Ms. _%#NAME#%_ developed headaches which she describes as alternating between pressure type and pulsating behind and surrounding the left eye.
T2|thoracic (level) 2|T2.|167|169|MEDICATIONS|Antibiotics were started in the emergency room. An MRI was done which revealed a pathologic fracture of the left clavicle. There were also worrisome lesions at T7 and T2. They were unable to tell whether this represented tumor, versus infection. She was admitted with this particular problem. REVIEW OF SYSTEMS: Is otherwise pretty unremarkable.
T2|T2 (MRI)|T2|393|394|NEUROLOGIC EXAMINATION|There is approximately six enhancing areas: one in the right frontal lobe that measures 2.5 cm in diameter, one in the right occipital lobe, one in the left temporal lobe, one in the left cerebellar ramus, one in the cerebellar hemisphere, and one large one in the left cerebellar hemisphere close to the midline. These lesions are associated with a moderate amount of edema as evident on the T2 sequence, and the diffusion-weighted images they are negative for diffusion abnormality. On review of the laboratory studies there are no significant abnormal findings.
T2|T2 (MRI)|T2|297|298|PHYSICAL EXAMINATION|Sensation is intact to light touch. She is diffusely hyperreflexic with upgoing toes bilaterally. Sustained clonus in bilateral ankles. MRI of the brain was available for review revealing stenosis at the cervicomedullary junction, abnormal sella turcica, pineal cystic lesion, and periventricular T2 hyperintensity. ASSESSMENT AND PLAN: The patient is a 13-year-old girl with a history of multiple sulfatase deficiency, tracheostomy dependency, cervicomedullary junction stenosis, and myelopathy.
T2|tumor stage 2|T2|9|10|PROBLEM|PROBLEM: T2 N2 B squamous cell carcinoma of the left tonsil. The patient was evaluated in the Department of Radiation Oncology by _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ at the request of Dr. _%#NAME#%_ _%#NAME#%_ of ENT.
T2|tumor stage 2|T2|243|244|ASSESSMENT AND PLAN|There is about 1.1 cm size low attenuation nodule within the left thyroid gland. Small Bochdalek hernia on the left side. ASSESSMENT AND PLAN: Gastric cancer, status post laparoscopy, gastrectomy, and Roux-en-Y with esophagojejunostomy, stage T2 N0 M0. The patient is seen by Dr. _%#NAME#%_ and was recommended neoadjuvant chemoradiation treatment although his lesion being T2, he has borderline disease to receive adjuvant treatment.
T2|tumor stage 2|T2|36|37|PROBLEM|PROBLEM: Newly diagnosed stage IIA, T2 N0 M0 infiltrating ductal carcinoma of the right breast, status post lumpectomy. This patient was seen for consultation in the Radiation Oncology Clinic on _%#MMDD2006#%_ by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_.
T2|tumor stage 2|T2|247|248|ASSESSMENT/PLAN|Lymphatic invasion is negative, and DCIS is negative. Margins are negative, but close within 1 mm in the anterior and posterior margins. The skin and nipple are not included. ASSESSMENT/PLAN: Ms. _%#NAME#%_ is a 39-year-old female with stage IIA, T2 N0 M0 infiltrating ductal carcinoma of the right breast, status post lumpectomy. She has yet to meet with Dr. _%#NAME#%_ _%#NAME#%_. He will likely recommend some chemotherapy given being premanopausal age, the hormone status and the size of tumor.
T2|tumor stage 2|T2|153|154|HISTORY OF PRESENT ILLNESS|She was evaluated with an MRI of the C-spine and T-spine on _%#MMDD2007#%_. This revealed diffuse lesions throughout the spine. The worse lesions are at T2 and T10. At T10, there was a compression fracture, and the epidural tumor has caused severe spinal canal compromise. There was also moderately severe spinal canal compromise at the T10 level.
T2|T2 (MRI)|T2|122|123|PHYSICAL EXAMINATION|However, a meningioma or leptomeningioma metastasis could not be ruled out. Otherwise, she has multiple hyperintensity on T2 weighted images on periventricular white matter which could be from inflammation, demyelination, infection or vascular disease. ASSESSMENT AND PLAN: A 55-year-old female patient with right ear hearing loss with enhancing lesion in the right cochlea area most likely from schwannoma.
T2|tumor stage 2|T2|154|155|IMPRESSION|IMPRESSION: Probable low rectal cancer. A CT scan today was also negative and chest x-ray is negative for metastases. This does appear to be clinically a T2 or T3 lesion. I believe I would start the workup at this point with a colonoscopy to evaluate the rest of the colon.
T2|tumor stage 2|T2|9|10|PROBLEM|PROBLEM: T2 N2b squamous cell carcinoma of the right piriform sinus, status post 2 cycles of chemotherapy. Mr. _%#NAME#%_ was seen for re-consultation in the Department of Therapeutic Radiology on _%#MMDD2004#%_ by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ at the request of Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_.
T2|thoracic (level) 2|T2,|134|136|PROBLEM|The patient had repeated MRI on _%#MMDD2007#%_ which again showed multiple metastatic area, especially in the area of the pain at T1, T2, T4 and T6. She has a mild bulging posteriorly at the level of T4, which is probably due to compression fracture.
T2|T2 (MRI)|T2|154|155|HISTORY OF PRESENT ILLNESS|Straight leg raising was negative for radicular pain in a seated position. MRI of the cervical spine from _%#MMDD2004#%_ was reviewed and showed abnormal T2 signal in the cervical and upper thoracic cord. A CT of the abdomen and pelvis was negative for abnormality. I felt that she should be seen by the Pain Management Clinic before pursuing further aggressive therapy.
T2|tumor stage 2|(T2,|234|237|IMPRESSION|PATHOLOGY: Report from the patient's right-sided mastectomy as reported in the Fairview-University Medical Center review is described above in history of present illness. IMPRESSION: The patient is a 44-year-old female with stage IIA (T2, N1, M0) right-sided breast cancer. She is on the NCIC MA-21 trial consisting of six cycles of epirubicin and Cytoxan, followed by four cycles of Taxol, and is scheduled to complete her last Taxol cycle in one week.
T2|T2 (MRI)|T2|166|167|HISTORY OF PRESENT ILLNESS|This is deemed to be of indeterminate significance, possibly representing a syrinx. The radiologist suggested a repeat imaging to examine the natural history of this T2 signal after about a three month interval. The patient herself has no sensory complaints at C7-T1. She has not had trouble with use of her legs.
T2|T2 (MRI)|T2|205|206|ASSESSMENT|Abdomen is soft. Extremities show no edema. ASSESSMENT: The MRI is not available, but this woman's physical examination is normal, and her chronic head and neck pain are unlikely to be related to a 0.5 mm T2 signal abnormality at the cervicothoracic cord junction. She has a substantial problem with chronic migraine. Present management includes relatively frequent injections of subcutaneous Imitrex.
T2|S2 (heart sound):S2|T2.|189|191|PHYSICAL EXAMINATION|Some residual scleral icterus, however. No thyromegaly. LYMPH: No cervical or supraclavicular lymphadenopathy. HEART: Normal first and second heart sounds with valve clicks and a prominent T2. LUNGS: Crackles in the mid zone, decreased breath sounds at the bases. ABDOMEN: Obese, soft and nontender, no organomegaly or masses. EXTREMITIES: No digital clubbing or peripheral cyanosis.
T2|T2 (MRI)|T2|95|96|IMAGING|No evidence for any masses or signs of infection. The MRI scan demonstrates, especially on the T2 images, an insufficiency-type fracture of the right parasymphyseal area. This is more consistent with an insufficiency fracture, although could be consistent with a nondisplaced acute injury.
T2|T2 (MRI)|T2|259|260|HISTORY OF PRESENT ILLNESS|MRI of the brain on _%#MMDD2006#%_ showed acute infarct in the left occipital lobe in the region of parahippocampal gyrus in the distribution of left PCA with decreased attenuation on P2 segment of the left-sided PCA compatible with occlusion. There was also T2 hypointensity within the left basal ganglia suggestive of hemorrhage likely evolving along with encephalomalacia of left temporal lobe and basal ganglia region compatible with old infarct.
T2|thoracic (level) 2|T2|154|155|HISTORY OF PRESENT ILLNESS|He was initially diagnosed in 2003 and had a left nephrectomy as treatment. The patient progressed to metastatic disease and was initially treated with a T2 laminectomy and transpedicular tumor resection in _%#MM#%_ 2005. His postoperative course was complicated by poor healing. The patient initially got a hematoma of the spinal canal.
T2|tumor stage 2|T2|206|207|ASSESSMENT AND PLAN|HEART: Regular sinus rhythm. ABDOMEN: Unremarkable. EXTREMITIES: Unremarkable. ASSESSMENT AND PLAN: Infiltrating ductal carcinoma of the right breast, status post lumpectomy and sentinel node biopsy, Stage T2 M0 N0. The patient is going to be on tamoxifen. The patient is recommended post-lumpectomy radiation treatment.
T2|tumor stage 2|T2,|153|155|HISTORY OF PRESENT ILLNESS|Dr. _%#NAME#%_ spoke directly with Dr. _%#NAME#%_ concerning this patient's care. HISTORY OF PRESENT ILLNESS: The patient is a 46-year old female with a T2, N1 infiltrating ductal carcinoma, status post lumpectomy with axillary node dissection, status post AC x 4 and two of planned 4 cycles of Taxol.
T2|tumor stage 2|T2,|174|176|IMPRESSION|There was some thickening below both of those scars. There was no other masses, nipple discharge, edema or erythema noted. IMPRESSION: Ms. _%#NAME#%_ is a 46-year old with a T2, N1 infiltrating ductal carcinoma, status post lumpectomy, followed by full axillary dissection. Status post four cycles of AC chemotherapy. The patient is currently in her second cycle of Taxol of a planned four cycles.
T2|tumor stage 2|T2,|144|146|HPI|Her previous lumpectomy scar in the left breast and axilla unremarkable. Assessment and Plan: Infiltrating ductal carcinoma of the left breast, T2, N1, M0, stage IIB disease. The patient is in her third course of chemotherapy and has two more cycles of Taxol to go.
T2|T2 (MRI)|T2|166|167|HISTORY OF PRESENT ILLNESS|He had the same sort of visual problem prior to his seizure on _%#MMDD2004#%_. He had an MRI of the head at Regions Hospital on _%#MMDD2004#%_ which showed extensive T2 signal change in the left hemisphere primarily involving the left temporal parietal and occipital lobes. This appears to be consistent with a diffusely infiltrating neoplasm.
T2|tumor stage 2|(T2,|20|23|PROBLEM|PROBLEM: Stage IIIB (T2, N3, M0) squamous cell carcinoma of the lung, now with brain metastasis. Mr. _%#NAME#%_ was seen in the Therapeutic Radiation Department on _%#MM#%_ _%#DD#%_, 2002, for reconsultation by Drs. _%#NAME#%_ _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_ at the request of Dr. _%#NAME#%_.
T2|tumor stage 2|T2,|203|205|IMPRESSION|The previously noted right apical spiculated lesion is obscured by post- radiation changes. Small pleural effusion is unchanged. IMPRESSION: Mr. _%#NAME#%_ is a 42-year-old male with initial stage IIIB, T2, N3, N0, squamous cell carcinoma of the lung; status post induction chemotherapy with Taxol and carboplatin x6 cycles, status post concurrent Taxol and radiotherapy to 6000 cGy in 30 fractions from _%#MMDD2001#%_ to _%#MMDD2002#%_, status post whole-brain radiation therapy to 3000 cGy in 10 fractions from _%#MMDD2002#%_ to _%#MMDD2002#%_.
T2|thoracic (level) 2|T2|292|293|OBJECTIVE|ABDOMEN: Soft, nontender, no hepatosplenomegaly. Bowel sounds are present. MUSCULOSKELETAL: Examination of his neck indicates no pain between the spinous process, no pain in the paraspinal muscles. Examination of the thoracic area indicates pain between the spinous processes at the level of T2 and then on the right paraspinal ligaments and then along the right midscapular border. No pain on the left at all. No pain in the lumbar area between the spinous processes or the paraspinal muscles or the paraspinal ligaments.
T2|thoracic (level) 2|T2.|189|191|HISTORY OF PRESENT ILLNESS|She has been using oxycodone and OxyContin for neck and back pain for approximately the past year. She states she has had imaging in the past, which showed her _________________ from C6 to T2. The patient recently took one tablet of naltrexone and unintentionally put herself into withdrawal. She denies any opiate abuse currently or in the past.
T2|T2 (MRI)|T2|167|168|ADDENDUM|We will follow up on the MRI scan. ADDENDUM: The MRI of the brain with and without contrast shows no enhancing masses in the right occipital area. There appears to be T2 hyperintensity in the bilateral occipital areas. This imaging characteristic is most consistent with PRES. A neurology consultation is recommended.
T2|T2 (MRI)|T2|293|294|PHYSICAL EXAMINATION|This lesion, however, did not enhance with gadolinium. There was no evidence for acute infarct on the diffusion-weighted imaging, and vasculature appeared patent with no significant stenosis. CT scan did show white matter lesions, which are likely to be related to multiple sclerosis shown on T2 and flare images. CT showed no acute bleed. ASSESSMENT: Multiple sclerosis exacerbation. No active lesions on MRI.
T2|tumor stage 2|T2|9|10|PROBLEM|PROBLEM: T2 N0 M0 squamous cell carcinoma of the left vallecula status post chemoradiation. DOSE: He was treated per ECOG protocol _%#PROTOCOL#%_ with concurrent chemoradiation.
T2|T2 (MRI)|T2|189|190|HISTORY OF PRESENT ILLNESS|There was no abnormal diffusion signal, and no local abnormality on SPECT scan. There were abnormal perivascular spaces that were prominent and some scattered subcortical foci of increased T2 signal intensity bilaterally of unclear etiology. Following the addition of aspirin and cyproheptadine, he has had no more episodes of slurred speech, right upper extremity weakness, or visual obscuration.
T2|T2 (MRI)|T2|239|240|PHYSICAL EXAMINATION|Radiographic examination from several days shows decreased disc height at L4-5, L5-S1 with sclerotic end _________ changes in vertebral body osteophytes at these two levels as well. An MRI dated _%#MM#%_ _%#DD#%_, 2001, is significant for T2 single chains consistent with disc dehydration at L4-5, L5-S1 with decreased disc heights, and plate changes at these levels as well.
T2|T2 (MRI)|T2|290|291|HISTORY OF PRESENT ILLNESS|Pathology confirmed a pineal cytoma. Postoperatively, she underwent rehabilitation and radiation therapy (5400 cGy completed _%#MMDD1998#%_ at _%#CITY#%_ Radiation Therapy Center under my supervision). She then did well for many years. In 2002, follow-up brain MRI showed some non-specific T2 changes near the tumor bed which were felt to be radiation effect. There was no evidence of recurrent tumor. In 2004, there was a shadow in the left frontal region which had not been previously irradiated.
T2|tumor stage 2|T2|168|169|HISTORY OF PRESENT ILLNESS|The chest CT was negative for any signs of malignancy in the lung. When seen by Dr. _%#NAME#%_ in Hematology Oncology the patient was clinically staged at a stage IIIC T2 N3c M0. Four cycles of AC, followed by 4 cycles of Taxol were given neoadjuvantly per the CALGB-_%#PROTOCOL#%_ protocol.
T2|T2 (MRI)|T2|151|152|DIAGNOSTIC DATA|Vibration sense is reduced on the right side but present in both hands. DIAGNOSTIC DATA: MRI head films are reviewed. This does reveal periventricular T2 and flair signal changes consistent with MS. There are no acute changes on diffusion weighted imaging to indicate any acute stroke and there is no enhancing lesions to indicate acute inflammation.
T2|tumor stage 2|T2|384|385|HISTORY OF PRESENT ILLNESS|At that time he underwent an endorectal ultrasound that showed an irregular polypoid hard mass on the left side of the rectum that was about half the circumference of the rectum, it was approximately 4 cm from the anal verge, the ultrasound was a T3, N1 lesion with seminal vesicles and prostate free but were very close. The lesion was thought to be a villous lesion that was mostly T2 though had areas of T3 depth into it. Again, at this time preoperative chemotherapy and radiation were recommended.
T2|T2 (MRI)|T2|153|154|HISTORY OF THE PRESENT ILLNESS|She has had retrograde amnesia from this to some extent. A head MRI done at the time of admission showed a 1.5 cm. area of mixed increased and decreased T2 signal in the left anterior frontal region consistent with hemorrhagic contusion which was also see on her head CT. Also noted was irregularity over a 4 cm. region in the posterior temporal region consistent with hemorrhagic contusion.
T2|T2 (MRI)|T2|266|267|FOLLOW UP|Orthostatic syncope could not be excluded. Objective evaluation was pursued with initial head CT without contrast on _%#MM#%_ _%#DD#%_, 2004, which was negative. A followup brain MRI without contrast on _%#MM#%_ _%#DD#%_, 2004, demonstrated 2 tiny foci of increased T2 signal in the left frontal white matter of uncertain clinical significance. The remainder of this exam was negative. A neurology consultation was requested from Fairview University.
T2|thoracic (level) 2|T2|145|146|PHYSICAL EXAMINATION|His tone appears normal in all extremities. Sensation, he can differentiate light touch from pinprick in the T4 area, T5 area, T6 area, T3 area, T2 area bilaterally and all extremities. REFLEXES: The biceps reflex was 2+ bilaterally. The brachioradialis reflex was 3+ on the right and 2+ on the left.
T2|T2 (MRI)|T2|198|199|LABORATORY DATA|FAMILY HISTORY: Not available. REVIEW OF SYSTEMS: Not available. LABORATORY DATA: Results of testing showed MRI of the brain which has considerable motion artifact. There is a question of increased T2 signal in the left thalamus and adjacent left cerebral peduncle ? more of infarction. The MRA of the circle of Willis is unremarkable. He has a blood sugar of 212, magnesium is 2.0 and phosphorus level is normal.
T2|tumor stage 2|(T2,|130|133|DISCUSSION|DISCUSSION: Ms _%#NAME#%_ is a pleasant 63-year-old female, the wife of a former patient of mine, and now presents with stage IIB (T2, N1, M0) (R1) pancreatic cancer. Her preoperative workup with CT did not show liver or nodal involvement, but she certainly is at high risk for occult metastases.
T2|T2 (MRI)|T2|189|190|PHYSICAL EXAMINATION|It is opened and reviewed. The diffusion weighted images suggest a new left superior frontal lesion. There also is a suggestion of possibility of 1 on the right frontal region as well. The T2 weighted images and actual flares seem to indicate a preponderance of small vessel ischemic disease on the bihemispheral basis.
T2|T2 (MRI)|T2|224|225|HISTORY OF PRESENT ILLNESS|He was then started on weekly topotecan, which he has been receiving since. MRI of the brain was obtained by Dr. _%#NAME#%_ to evaluate for possible brain metastasis, and this unfortunately did reveal numerous rim-enhancing T2 hyperintense lesions bilaterally, as well as a left pontine and right cerebellar lesion. He was promptly referred to our department. With regards to his current and recent symptomatology, the patient specifically denies any neurologic complaints and endorses no recent history of significant headache, vision changes, or other changes in sensorium.
T2|T2 (MRI)|T2|198|199|LABORATORY DATA|Albumin, protein, alkaline phosphatase, ALT and AST were normal. I reviewed reports and the images of head CT and MRI scan. I concur that there are non-specific white matter hyperintensities in the T2 signal seen in the posterior periventricular area and some scattered area in the cortex. These are non-specific. My interpretation is that they are not consistent with ADEM, multiple sclerosis or a metabolic disease and are not a feature of heavy metal intoxication.
T2|T2 (MRI)|T2.|249|251|REFERRING STAFF|He has no ataxia, no pronator drift. IMAGING AND EVALUATIONS: His EEG shows a subclinical bitemporal rhythmic EEG discharges. TEE showed no vegetations. His MRI of the brain shows multiple subcortical enhancing nodules and pontine hyperintensity on T2. LABORATORY VALUES: ESR 28, sodium 137, and white count 10.7. Chest x-ray is clear. His spinal fluid shows 56 white cells, 7 red cells, glucose 92, protein 113, and all cultures are negative to date including bacterial, fungal, viral, VDRL, and AFB.
T2|T2 (MRI)|T2|149|150|STUDIES|An MRI of the C-spine from _%#MMDD2006#%_ is within normal limits. An MRI of the head from _%#MMDD2006#%_ demonstrates a number of scattered foci of T2 hyperintensity which were found on a previous examination from 6 months ago as well as 2 new relatively well demarcated T2 hyperintense foci found bilaterally in the frontal convexity.
T2|T2 (MRI)|T2|136|137|RADIOGRAPHIC STUDIES|10. Multivitamin. 11. Zometa. 12. Decadron. 13. Doxil. 14. Prednisone. 15. Melphalan. RADIOGRAPHIC STUDIES: MRI scan of spine: Revealed T2 hyperintensity mass under the T12 vertebral body involving about half of the vertebral body at T12, and degenerative disk disease in the lumbar spine.
T2|tumor stage 2|T2|166|167|ASSESSMENT|She had a recent CT scan in _%#MM2004#%_ showed a mass in the sacral area consistent with some back pain. Dr. _%#NAME#%_ has ordered a follow-up CT scan. ASSESSMENT: T2 N2 M0 infiltrating lobular carcinoma of the left breast, status post chemotherapy and mastectomy bilaterally. PLAN: We would recommend post mastectomy chest wall radiation. This would certainly decrease her chance of local recurrence.
T2|tumor stage 2|T2|129|130|HPI|Radiographic findings: She has an abnormal soft tissue density in the presacral area on CT scan. Assessment and Plan: Stage III, T2 N2 M0 infiltrating lobular carcinoma of the left breast status post chemotherapy and mastectomy. Status post chemoradiation for rectal cancer and APR. Since the patient has a soft tissue density in the presacral area with pain, she needs to be further evaluated.
T2|tumor stage 2|T2,|122|124|IMPRESSION  AND PLAN|LABORATORY DATA: Hemoglobin obtained today is 12.7. IMPRESSION AND PLAN: The patient is a 78-year-old woman with stage I, T2, N0 colon cancer, status post right hemicolectomy. Given the low likelihood of recurrence of her cancer she will not need any adjuvant chemotherapy.
T2|T2 (MRI)|T2|358|359|HISTORY OF PRESENT ILLNESS|His last MRI of the brain of _%#MMDD2006#%_ showed heterogeneous mass occupying the sublentiform region in the left basal ganglia, infiltrating, and expanding the left cerebral peduncle with a small nodular focus of the hemorrhage in the center of the lesion, with surrounding edema involving the left basal ganglia and internal capsule. The results will be T2 hypertonicity and subtle contrast enhancement in the head of bold cardiac nuclei and the genu of corpus callosum suggestive of neoplastic involvement.
T2|tumor stage 2|T2|236|237|ASSESSMENT|ABDOMEN: Soft, nontender, no hepatosplenomegaly. EXTREMITIES: No edema. NEUROLOGIC: Cranial nerves II through XII intact. Muscle strength 5/5. Gait and station normal. ASSESSMENT: In summary, Ms. _%#NAME#%_ is a 69-year-old female with T2 N2 squamous cell carcinoma of the left upper lobe. The patient has ECOG performance status of 1. The patient is not interested in surgical resection.
T2|tumor stage 2|T2|210|211|IMPRESSION|CT guided chest wall biopsy revealed metastatic adenocarcinoma with necrosis. IMPRESSION: Mr. _%#NAME#%_ is a 65-year-old gentleman returning with past medical history significant for esophageal adenocarcinoma T2 N1 returning with metastatic disease to left posterior chest wall. He comes to Radiation Therapy for palliation of pain. The risks and benefits of radiation therapy were discussed with the patient including risk of damage to the lung, soft tissue, bone, spinal cord.
T2|tumor stage 2|T2|147|148|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ is a 54-year-old male who presented in _%#MM2005#%_ with a squamous cell carcinoma of the right oral tongue. He was initially stage T2 with nodal disease (we are unsure of the extent of nodal disease from the records at this time). He underwent excision of the oral tongue lesion with negative margins followed by chemoradiation in _%#CITY#%_ by Dr. _%#NAME#%_ _%#NAME#%_.
T2|T2 (MRI)|T2|228|229|IMPRESSION|There is no salient history of abnormality in the pregnancy or delivery. On initial inspection, cerebral imaging seemed unremarkable. Subsequently, there was an interpretation of the cranial MRI reporting an area of ill-defined T2 hyperintensity with corresponding restricted diffusion within the bilateral posterior limbs of the internal capsules, putamen and anterior and lateral anterior thalami.
T2|tumor stage 2|T2|108|109|HEART|LUNGS: Essentially clear. HEART: Regular sinus rhythm. Assessment and Plan: Adenocarcinoma of the pancreas, T2 NO M0, status post Whipple surgery with a close margin. The patient will be a candidate for postoperative chemoradiation therapy and she is seeking the treatment per surgical oncology group protocol which includes 5FU cisplatin and alpha interferon.
T2|tumor stage 2|(T2|174|176|ASSESSMENT|NEUROLOGIC: Cranial nerves II through XII intact, strength is 5/5 in all four extremities, light touch is symmetric and intact. ASSESSMENT: 83-year-old female with stage IVA (T2 N2 M0) poorly differentiated squamous cell carcinoma of the vulva. The tumor measured 3.3 cm in size with no lymphvascular invasion.
T2|T2 (MRI)|T2|217|218|HISTORY OF PRESENT ILLNESS|Initially, this was thought to be likely due to transient ischemic attacks. MRI scan was performed on _%#MMDD2005#%_. This showed no evidence of acute infarct, however, there were 2 patchy areas of abnormal increased T2 signal and abnormal contrast enhancement within the posterior-inferior aspect of the right cerebellar hemisphere suggestive of metastatic tumor.
T2|tumor stage 2|T2|125|126|CC|__x___ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: T2 N0 supraglottic larynx cancer. HPI: Patient presented with GI bleed and tumor seen on EGD. Exam: Low placed larynx with cricoid very low to shoulder mass seen on AE fold.
T2|thoracic (level) 2|T2|174|175|ASSESSMENT|Heart sounds are tachycardic, S1, S2 are present, no murmurs, no irregularity heard today. ASSESSMENT: Somatosensory and visceral pain with neuropathic features secondary to T2 through L2 spinal fusion with instrumentation for severe kyphosis and scoliosis. PLAN: 1. Right now there is an order to start IV, Toradol 30 mg IV every 6 hours, but I would like to put some parameters on that because of his large amount of blood loss.
T2|T2 (MRI)|T2|135|136|LABORATORY DATA|B12 level normal. TSH 3.98. Head CT scan without contrast negative. MRI of the brain reveal a few tiny nonspecific foci with increased T2 signal. The radiologist mentioned that this could be due to chronic hypertension. Her electrolyte panel is normal including a potassium that is normal at 3.8, creatinine is 0.76. Chest x-ray is negative.
T2|tumor stage 2|T2|294|295|HISTORY OF PRESENT ILLNESS|Additionally, the CT scan was reviewed and showed the aforementioned base of tongue mass, as well as a left-sided level-2 lymph node and a left-sided level-3 lymph node. No other lymphadenopathy was evident. The patient presents today for evaluation for external-beam radiation therapy for his T2 N2b M0 squamous-cell carcinoma of the left base of tongue. Earlier today, he was seen by audiology and by _%#NAME#%_ _%#NAME#%_ in, a research nurse in ENT.
T2|tumor stage 2|(T2,|118|121|HISTORY OF PRESENT ILLNESS|The margins were clear and lymph nodes at station 7R, 4R, and 10R were negative. She is therefore staged at stage I-B (T2, N0, Mx). She now presents to discuss her options for treatment. REVIEW OF SYSTEMS: She is a healthy woman in excellent performance status ECOG PS 0, works as a cath lab technician at the Marquette general hospital in Michigan.
T2|tumor stage 2|T2|169|170|HISTORY|HISTORY: This 47-year-old female seen in consultation with Dr. _%#NAME#%_ due to fever and diarrhea. The patient has a history of adenocarcinoma of the rectum which was T2 N1 stage 2A, no clear evidence of distant disease. She has had resection and subsequent chemo and radiation. She has done reasonably well with chemo, is now 4-1/2 weeks into it as of last Monday.
T2|T2 (MRI)|T2|137|138|HISTORY OF PRESENT ILLNESS|She did not follow-up on an outpatient basis as suggested. She then had increased dizziness on _%#MMDD2007#%_ and an MRI showed abnormal T2 weighted signal in the medullam and pons. She also had bifrontal lobe findings. An LP showed increased WBC, 97% lymphocytosis, glucose 58 and protein 153.
T2|T2 (MRI)|T2|215|216|HOSPITAL COURSE|Lumbar puncture and cerebrospinal fluid studies showed 75 white blood cells, glucose 64, and protein 297. Also magnetic resonance imaging of cervical spine, thoracic spine, and brain shows a questionable edematosis T2 enhanced lesion. He was sent to the operating room immediately for evaluation of cervical lesions. Preoperative diagnosis was C4 through C7 cervical stenosis. However, pus was identified during the operation.
T2|T2 (MRI)|T2|152|153|PROCEDURES PERFORMED|This is possibly suggestive of a paroxysmal disorder. 6. Non-contrast MRI of the brain was performed _%#MMDD2003#%_. Non-contrast sagittal MPRAGE axial T2 weighted, proton density, and diffusion weighted; coronal T2 weighted TIRM proton density TRM, and true IR sequences of the brain were obtained.
T2|T2 (MRI)|T2|186|187|OPERATIONS/PROCEDURES PERFORMED|This was repeated on _%#MM#%_ _%#DD#%_, 2005, and was unchanged. 3. MRI of the brain performed on _%#MM#%_ _%#DD#%_, 2005, which demonstrated nonspecific punctate foci of hyperintensity T2 signal in the peripheral white matter of the right and left frontal lobes consistent with small-vessel ischemic disease.
T2|T2 (MRI)|T2|215|216|OPERATIONS AND PROCEDURES|Day of discharge: _%#MMDD2006#%_. OPERATIONS AND PROCEDURES: 1. MRI of the brain with and without contrast on _%#MMDD2006#%_. Findings were large acute infarct left temporoparietal region; extensive patchy areas of T2 hyperintensity involving both cerebral hemispheres, predominantly occipitoparietal and temporal lobes and predominantly in white matter also extending into the cortical rim posteriorly.
T2|T2 (MRI)|T2|262|263|OPERATIONS/PROCEDURES PERFORMED|The bowel gas pattern is nonobstructive. On _%#MM#%_ _%#DD#%_, 2006, MRI of the C-spine and brain was performed with and without contrast with the following results: Suboptimal study due to significant patient motion. There is a questionable ill-defined area of T2 hyperintensity within the cervical spinal cord on STIR images at C3-C4 level. There is diminished diameter of the cervical spinal cord from C2 through C4 level.
T2|T2 (MRI)|T2|229|230|OPERATIONS/PROCEDURES PERFORMED|OPERATIONS/PROCEDURES PERFORMED: An MRI/MRA done on _%#MM#%_ _%#DD#%_, 2006, with the following findings: 1. No evidence of acute ischemic infarction or other acute abnormality within the brain parenchyma. 2. Mildly hyperintense T2 signal abnormality within the right dorsolateral medulla and inferior right cerebellar hemisphere without corresponding DWI abnormalities. This likely represents prior area of infarction. 3. Diffuse multifocal areas of lost signal within the extraosseous, foraminal, extraspinal, and intradural right vertebral artery.
T2|T2 (MRI)|T2|286|287|LABORATORY DATA ON ADMISSION|This may represent metastases or postinfectious process. An MRI of the right left was done, which showed 4.6 x 4.7 x 7.5 cm high-grade tumor consistent with high grade osteosarcoma. There were 2 subcutaneous lymph nodes within the popliteal fossa. There was an ill-defined focal patchy T2 hyperintensity and T1 hypointensity within the medial femoral condyle of the right knee of uncertain clinical significance. HOSPITAL COURSE: 1. Fluids, electrolytes and nutrition. _%#NAME#%_ was maintained on a regular diet.
T2|thoracic (level) 2|T2|301|302|HISTORY OF PRESENT ILLNESS|_%#NAME#%_ did fairly well for approximately 8 months when he was found to have multiple areas of bony involvement and he started a systemic therapy including Revlimid and Decadron in _%#MMDD2006#%_. In _%#MM2006#%_, he was admitted to the hospital with a vertebral fracture along with involvement of T2 through T4 with lytic lesions requiring radiation. The patient continued to have increased back pain requiring kyphoplasty at T4. Some time during this history, _%#NAME#%_ was found to have a serum lambda light chain in his urine.
T2|thoracic (level) 2|T2|235|236|HOSPITAL COURSE|The patient's MRI of cervical, thoracic, and lumbar spine were repeated after admission, and it was determined to have signal abnormality of the C4 to the T4 cord levels. Examination was significant for a decreased sensation below the T2 dermatomal level with flaccid tone in her lower extremities, with no movement in the left lower extremity and right lower extremity, being antigravity proprioception preserved in the left lower extremity but not present in the right.
T2|thoracic (level) 2|T2|402|403|HOSPITAL COURSE|5. Orthopedics/musculoskeletal. Given the findings upon admission, orthopedics was consulted and on a bone scan obtained found healing right clavicle fracture, lytic bone lesion of proximal left fracture, congenital hemivertebra between T1 and T2, with remainder of skeletal survey normal. This was followed up by MRI of the spine which revealed an accessory left-sided hemivertebra between the T1 and T2 vertebral bodies causing abrupt scoliosis with convexity to the left. To follow up the fracture a chest CT was obtained and found to have bilateral clavicular fractures with exuberant new bone formation at the site of these fractures.
T2|T2 (MRI)|T2|184|185|IMAGES|2. Aphasia likely secondary to diagnosis #1. 3. Urinary retention. 4. Constipation. 5. Hospital acquired pneumonia. IMAGES: 1. MRI of the brain on _%#MMDD2006#%_ which showed abnormal T2 hyperintensity of the lentiform caudate nuclei bilaterally with mild restricted effusion. 2. Video wallow study on _%#MMDD2006#%_ which showed: A. Marked oral phase dysmotility.
T2|T2 (MRI)|T2|153|154|IMAGING|Results: Areas of acutely restricted diffusion in the distribution of the left posterior cerebral artery, most consistent with an acute stroke. Areas of T2 hyperintensity in the periventricular white matter, suggestive of small-vessel ischemic disease bilaterally. Mild volume loss. 12. _%#MMDD2003#%_: MRA of the brain. Results: No areas of abnormal contrast enhancement within the orbits or intracranially.
T2|T2 (MRI)|T2|405|406|STUDIES|2. MRI of L-spine with and without contrast on _%#MMDD2007#%_ reveals broadbased disc bulging at L4-5 level causing mild spinal canal bilateral neural foraminal narrowing and no abnormal signal or contrast enhancement in the cord. 3. MRI of T-spine with and without contrast on _%#MMDD2007#%_, revealing normal thoracic spine and no areas of abnormal contrast in the cord, focal areas of increased T1 and T2 signal and T5, T8, T10 and T11 which do not enhance likely representing hemangiomas. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 50-year-old female with history of progressive relapsing form of multiple sclerosis who is followed by Dr. _%#NAME#%_ _%#NAME#%_ at the University of Minnesota.
T2|thoracic (level) 2|T2|49|50|PROBLEM|PROBLEM: Renal cell carcinoma with metastases to T2 vertebral body. Mr. _%#NAME#%_ was seen in the Department of Therapeutic Radiology on _%#MMDD2004#%_ by Dr. _%#NAME#%_ and Dr. _%#NAME#%_ at the request of Dr. _%#NAME#%_.
T2|T2 (MRI)|T2|234|235|HOSPITAL COURSE|2. No definite hemorrhage involved within the area of infarction, although a punctate focus is noted just inferior to that, which is indeterminant and could even represent an underlying tiny cavernoma. The previous study did not have T2 star weighted images for comparison. 3. Head MRA again demonstrates the occlusion or near occlusion of M1 segment of anterior and posterior temporal branch.
T2|T2 (MRI)|T2|145|146|PROCEDURES PERFORMED|10. MR of brain with and without contrast. The findings were no evidence for intracranial enhancing lesion. Nonspecific small focus on increased T2 signal in the right central semiovale and no definite evidence for mesial temporal sclerosis. 11. Chest AP portable x-ray on _%#MMDD2004#%_ before and after chest tube removal showed no change in any interim difference between the chest tube removal.
T2|T2 (MRI)|T2|238|239|MAJOR PROCEDURES|It also demonstrated enhancing mass in the midline suboccipital soft tissues with lush, dilated and tortuous vessels which could be consistent with metastatic disease or a vascular malformation. It also demonstrated scattered nonspecific T2 hyperintensities in the periventricular and supraventricular white matter consistent with a small vessel ischemic disease given the patient's age. 9. MRI of the C-spine, T-spine and also L-spine without contrast on _%#MMDD2006#%_ which demonstrated compression fracture of T12 vertebrae and degenerative changes involving the lumbar spine but no definite evidence of bony metastasis.
T2|T2 (MRI)|T2|216|217|OPERATIONS/PROCEDURES PERFORMED|3. _%#MM#%_ _%#DD#%_, 2004, the patient received a PIC line without any complications. 4. _%#MM#%_ _%#DD#%_, 2004, the patient had an MRI of the brain with and without contrast. Impression: A. Nonspecific changes of T2 hyperintensity within the deep white matter of the centrum semiovale and periventricular region bilaterally consistent with small vessel ischemic disease.
T2|thoracic (level) 2|T2|183|184|OPERATIONS/PROCEDURES PERFORMED|This is a change when compared to _%#MM#%_ _%#DD#%_, 2002, study and compatible with very mild cerebritis primarily involving right parietal region. No focal areas of abnormal T1 and T2 relaxation were identified. No parenchymal, meningeal, or vascular enhancements were seen. CSF studies were repeated with another LP and were remarkable for negative India ink, negative AFB stain and culture, negative stain for anti-amoeba, negative IgG and IgM for West Nile antibodies, negative HSV PCR.
T2|thoracic (level) 2|T2|170|171|HOSPITAL COURSE|A CT myelogram was obtained. There was no evidence of an epidural hematoma or spinal canal narrowing. The epidural catheter was removed. An MRI was obtained and abnormal T2 to T9 signal intensity within the spinal cord was noted, consistent with ischemia. In addition, chronic vertically oriented vertebral body fractures in T4, T5, and 6 were noted.
T2|T2 (MRI)|T2|194|195|MRI SCAN|There is significant mass effect and narrowing of the left intrahepatic portal vein as well. Also there is a new 2.1 x 1.4 cm arterial enhancing lesion on the right hepatic lobe associated with T2 hyperintensity as noted above, which is concerning for a second focus of hepatoma. There were also numerous small foci of arterial phase enhancement throughout the right hepatic lobe, but these cannot be excluded as additional foci of hepatoma and continued followup was indicated.
T2|T2 (MRI)|T2|132|133|PROCEDURES|There was essentially a normal circle of Willis. There were no T1 or T2 hyperintensities on diffusion-weighted images, and no T1 or T2 hyperintensities. 4. Electroencephalogram, _%#MMDD2003#%_. There was a background alpha rhythm of moderate voltage and a frequency of 10 Hz, which was symmetrical and synchronous.
T2|T2 (MRI)|T2|337|338|PROCEDURES|5. GJ tube placement done on _%#MMDD2003#%_. 6. Transthoracic echo (TTE) done on _%#MMDD2003#%_ showed normal left ventricular function, with an ejection fraction of 60% and no clot or vegetation. 7. Brain MRI per stroke protocol done on _%#MMDD2003#%_ showed extension of the right middle cerebral artery infarction with a tiny area of T2 hypointensity within the right putamen, which could represent partial hemorrhagic transformation of the infarct. Recannulization or improved flow was seen within the right distal internal carotid artery and the right middle cerebral artery, with some residual narrowing of the middle cerebral artery possibly due to spasm related to prior thrombus or embolus.
T2|T2 (MRI)|T2|128|129|HOSPITAL COURSE|The patient had another MRI on _%#MMDD2006#%_ which showed a new left frontal lesion as well as these previous diffuse punctate T2 lesions which continue to enhance. Based on this another CSF tap was done which showed a glucose of 114, protein 121, white cells 28, and red cells 31.
T2|T2 (MRI)|T2|187|188|HOSPITAL COURSE|The patient was then continued to be given IV steroids and had an MRI re-imaged of his spinal cord on _%#MM#%_ _%#DD#%_, 2002, at which time very little improvement was shown. He now had T2 changes from the level of T10 down. Hence, there was a small improvement over the preceding 7 days. At this time, it was determined appropriate to transfer the patient to our care at the Fairview University Medical Center where he could undergo further workup.
T2|thoracic (level) 2|T2.|161|163|HISTORY|C5-C6 mild annular bulge without focal protrusion, C6-C7 broad-based central disk protrusion without foraminal stenosis. No cord abnormalities were seen through T2. MRI of the thoracic spine was also attempted but incomplete due to motion artifact. No gross thoracic lesions were identified.
T2|tumor stage 2|T2,|156|158|PAST MEDICAL HISTORY|Abdomen was in general uncomfortable without unspecific pains, and the patient had no other symptoms or complaints. PAST MEDICAL HISTORY: 1. Breast cancer, T2, N2 diagnosed in 1990. For this, she is status post lumpectomy with adjuvant Adriamycin/Cytoxan and radiation therapy.
T2|T2 (MRI)|T2|200|201|PLAN|A cranial CT scan on _%#MMDD2004#%_, showed normal intracranial contents. _%#NAME#%_ had a cranial MRI and _%#MMDD2004#%_. This report describes "some scattered linear and punctate areas of increased T2 signal within the cerebral white matter." The report was found to indicate, "this may simply represent some dilated Virchow-Robin spaces.
T2|T2 (MRI)|T2|149|150|HISTORY OF PRESENT ILLNESS|CT scan of head completed on _%#MMDD2006#%_ showed hypoattenuation of right posterior parietal region. MRI of the brain did show a diffuse increased T2 signal essentially in the cerebrum and cerebellum consistent with edema. These findings are more suggestive of reversible encephalopathy of PRES.
T2|T2 (MRI)|T2|203|204|PROCEDURES PERFORMED|2. A PICC line was placed for vascular access, and discontinued prior to discharge. 3. MRI of the head _%#MMDD2003#%_ revealed evolution of multiple embolic infarcts, no new infarcts, and improvement in T2 hyperintensity from previous. 4. Ultrasound of the abdomen and pelvis _%#MMDD2003#%_ revealed normal bilateral renal ultrasound, including Doppler flow.
T2|T2 (MRI)|T2|137|138|PROBLEM #4|We obtained a Neurology consult who recommended several tests. An MRI of the brain and spine from _%#MMDD2007#%_ demonstrated multifocal T2 hyperintensities in the deep white matter without contrast enhancement. Findings are nonspecific. There was no infarct or acute ischemia. Of note, these findings were also demonstrated from previous MRIs at Barnes Jewish Hospital from _%#MM2005#%_.
T2|thoracic (level) 2|T2|256|257|ADMISSION HISTORY OF PRESENT ILLNESS|There was asymmetric increased FDG uptake in the upper chest wall. All of these areas were consistent with metastatic disease. MRI of the cervical thoracic and lumbar spine from _%#MMDD2003#%_ showed bone marrow abnormalities consistent with metastases at T2 and T10, S1 with nerve root compression of the right S1 and displacement of the right S2 nerve root. There were degenerative changes at other levels, including T2, T7, L5-S1, C-3, C-4, and C-5.
T2|T2 (MRI)|T2|186|187|HOSPITAL COURSE|There were two punctate enhancing foci at the level of the C3 vertebral body consistent with an active demyelinating process. The thoracic spine MRI showed multiple foci of hyperintense T2 signal throughout the thoracic cord. There were no areas of abnormal enhancement. However, the lesions were consistent with the patient's clinical history of multiple sclerosis.
T2|T2 (MRI)|T2|182|183|PROCEDURES PERFORMED|PROCEDURES PERFORMED: 1. MRI of the brain which showed small focal area of restricted diffusion in the left thalamus consistent with acute ischemia. There was also a noted increased T2 signal in the right occipital lobe posteriorly. This finding was more apparent on the post-contrast T2 sequence, and is likely due to venous flow.
T2|T2 (MRI)|T2|253|254|HOSPITAL COURSE BY PROBLEM|As above, Mr. _%#NAME#%_ first developed lower extremity weakness in _%#MM2005#%_. Prior to his hospital admission, he underwent an extensive evaluation, both as an outpatient and an inpatient. He has had multiple MRIs, which have demonstrated abnormal T2 enhancement within the internal capsule and corticospinal tracks. An LP was performed during his hospitalization in _%#MM#%_. Cerebrospinal fluid was remarkable for oligoclonal bands only.
T2|T2 (MRI)|T2|355|356|PROCEDURES|3. _%#MMDD2007#%_, x-ray of shoulder, humerus and elbow showing no acute abnormality. 4. _%#MMDD2007#%_, lumbar puncture. 5. _%#MMDD2007#%_, MRI brain patent venous sinuses, no evidence for cerebral infarct, focal encephalomalacia at the roof of the right lateral ventricle with resultant ex vacuo dilation possibly related to prior ischemia, nonspecific T2 hyperintensities in the white matter that could be secondary to demyelination versus sequelae of infectious or inflammatory process versus vasculopathy, 6. _%#MMDD2007#%_, echocardiogram, left ventricle normal in size, EF 45% to 50%, no significant valve disease.
T2|T2 (MRI)|T2|298|299|HISTORY OF PRESENT ILLNESS|The uterus and both ovaries otherwise appeared unremarkable. She went on to have an MRI of the pelvis on _%#MM#%_ _%#DD#%_, 2006, which confirmed the mass arising from the left lateral aspect of the uterine corpus which a smooth interface, without evidence of uterine invasion. There was increased T2 signaling on the ultrasound. There were no findings to suggest this mass was an uterine or broad ligament sarcoma. There was a small amount of fluid in the cul-de-sac and moderate diffuse sigmoid diverticulosis.
T2|tumor stage 2|T2,|9|11|PROBLEM|PROBLEM: T2, N0, M0 squamous cell carcinoma of the true vocal cords with subglottic extension. This patient was seen in the Radiation Oncology Clinic on _%#MM#%_ _%#DD#%_, 2002 by Dr. _%#NAME#%_ _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_ for initial consultation at the request of Dr. _%#NAME#%_ _%#NAME#%_ from the Department of Otolaryngology at Fairview-University Medical Center.
T2|thoracic (level) 2|T2|147|148|PHYSICAL EXAMINATION|Finger intrinsics are 3/5. Left upper extremity strength is 5/5. Bilateral lower extremity strength is 0/5. SENSATION: Sensation is decreased from T2 distal. TONE: Tone is increased to bilateral adductors. Ashworth 2/4. Hip flexor tone is 1/4. There is no clonus at the ankles. COORDINATION: Normal on the left side, decreased in the right upper extremity.
T2|tumor stage 2|T2|215|216|HPI|My key findings: CC: T3 N1 M0 GE junction adenocarcinoma, status post resection in 67-year-old man. HPI: Patient presented with food sticking. PET showed tumor at the GE junction. Resection on _%#MMDD2002#%_ showed T2 N1 M0 adenocarcinoma. Exam: Surgical scar well-healed. No SC nodules. No tenderness. Good BS. Assessment and Plan: Recommend post-op RT with concurrent chemotherapy.
T2|tumor stage 2|T2|133|134|ASSESSMENT AND PLAN|Patient has thick speech and some swallowing problems. ASSESSMENT AND PLAN: In summary, Mr. _%#NAME#%_ is a 25-year- old male with a T2 medulloblastoma, status post resection, and now presents for evaluation for postoperative radiation therapy. We agree that the patient would be a candidate for radiation, and Dr. _%#NAME#%_ personally led a discussion of the risks, benefits and alternatives to radiation therapy with the patient.
T2|T2 (MRI)|T2|244|245|PREVIOUS IMAGING|PREVIOUS IMAGING: MRI performed on _%#MMDD2003#%_ was reviewed by me and Dr. _%#NAME#%_ _%#NAME#%_, which showed contrast enhancement in the right frontal U-fibers, as well as hypointensities on T1 and correlated areas of abnormal T2 signal on T2 in the periventricular region, suggestive of demyelination. Evoke potentials performed on _%#MMDD2003#%_ were abnormal. The report showed 118 msec on the left and 141 msec on the right.
T2|T2 (MRI)|T2|148|149|MAJOR TESTS AND PROCEDURES PERFORMED SINCE 1/3/2007|Pansinusitis and mastoiditis, as above. 2. MRI of the brain with and without contrast showing scattered intracerebral and intrapontine white matter T2 hyperintensities consistent with small vessel ischemic disease of white matter. Pansinusitis, as above 3. Chest x-ray AP portable done on _%#MMDD2007#%_ shows differences in techniques.
T2|tumor stage 2|T2|9|10|PROBLEM|PROBLEM: T2 N2 Mx squamous cell carcinoma of the right tonsil (stage VIA). Mr. _%#NAME#%_ was seen in the Department of Therapeutic Radiology on _%#MMDD2005#%_ by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ at the request of Dr. _%#NAME#%_ _%#NAME#%_.
T2|T2 (MRI)|T2|132|133|HISTORY OF PRESENT ILLNESS|During this hospitalization she has had an MRI and the presumed diagnosis per Neurology is PRES. Her MRI was positive for PRES with T2 hyperintensity noted in the cortical and subcortical white matter of all lobes but most prominent posteriorly and in the left frontal lobe, also noted in the cerebellar region.
T2|T2 (MRI)|T2|185|186|STUDIES|There is presently no tremor or rigidity. STUDIES: MRI on _%#MM#%_ _%#DD#%_, 2003 compared with study _%#MM#%_ _%#DD#%_, 2002 demonstrating multiple small ill-defined foci of increased T2 signal in the mid pons bilaterally, unchanged and of uncertain significance. The patient is followed by Dr. _%#NAME#%_ _%#NAME#%_ from neurology at the _%#CITY#%_ Clinic.
T2|T2 (MRI)|T2|318|319|IMAGING|The right middle cerebellar peduncle appears thickened with a mild mass effect on the right lateral wall of the 4th ventricle There are focal areas of more greatly increased T2 signal that may represent focal necrotic spaces in the right paramedian mid pons there is a single small focus of increased T1 and decreased T2 signal that likely represents subacute blood products. After the IV injection gadolinium, there is a suggestion of supple enhancement posteriorly at the cervical medullary junction at the pontile medullary junction posteriorly, and at the pontile mesencephalic junction anteriorly.
T2|tumor stage 2|(T2,|19|22|PROBLEM|PROBLEM: Stage IIB (T2, N1, M0) infiltrating ductal carcinoma of the right breast. The patient is now status post lumpectomy and four cycles of Adriamycin, Cytoxan, followed by four cycles of Taxol.
T2|T2 (MRI)|T2|228|229|DWI.|In addition to his cognitive complaints, he stated that he has had back and knee pains as a result of the falls. He denied any previous head injuries or stroke. An MRI on _%#MMDD2002#%_ revealed numerous small foci of increased T2 signal in the periventricular and subcortical white matter bilaterally, with the largest lesion in the left posterior frontal subcortical white matter, with mild cortical atrophy.
T2|T2 (MRI)|T2|194|195|HISTORY OF PRESENT ILLNESS|She does not have any bladder or bowel incontinence or retention. The patient had an MRI of the brain on _%#MMDD2005#%_ which showed no enhancing lesions, however, there are persistent abnormal T2 weighted hyperintensity within the paraventricular and subcortical white matter bilaterally. MRI of the spine showed enhancing lesions in multiple vertebral bodies throughout the thoracic lumbar and throughout the lumbar spine, as well as sacrum.
T2|tumor stage 2|T2,|48|50|PROBLEM|PROBLEM: Metastatic non-small cell lung cancer, T2, N0, M0. Mrs. _%#NAME#%_ is seen today in consultation at the request of Dr. _%#NAME#%_ _%#NAME#%_.
T2|tumor stage 2|T2|186|187|IMPRESSION|There is no hepatosplenomegaly. The patient has positive bowel sounds. EXTREMITIES: Without clubbing, cyanosis or edema. IMPRESSION: The patient is a 49-year-old male who had an initial T2 N0 M0 squamous cell carcinoma of his right oral tongue, now recurrent, status post 2 surgeries and bilateral neck dissections.
T2|tumor stage 2|T2|145|146|ASSESSMENT|ASSESSMENT: Ms. _%#NAME#%_ is a 56-year-old Caucasian female who is status post lumpectomy and adjuvant chemotherapy (shortened to 2 cycles) for T2 N1 M0 (IIB) infiltrating ductal carcinoma of the right breast. She is currently recovering from the side effects of her chemotherapy regimen.
T2|tumor stage 2|T2|183|184|HPI|Exam: The scar over the resection site is healing well without nodularity or mass. There is no inguinal, axially or supraclavicular adenopathy. Assessment: Extraosseous Ewing sarcoma T2 N0 M0 status post induction chemotherapy and surgery. Recommendations: We are recommending adjuvant radiotherapy because of the large percentage of viable tumor.
T2|tumor stage 2|T2|77|78|HPI|CT chest shows small nodules too small to characterize. Assessment and Plan: T2 N1 M? chondrosarcoma. His Mayo surgeon plans to attempt wide local excision after a dose of 5040 cGy preoperative XRT. The nodes will be removed then, too. His lung nodules will be followed.
T2|tumor stage 2|(T2|191|193|PROBLEM|PROBLEM: Synchronous stage III (T3 N1 M0) rectal adenocarcinoma, status post neoadjuvant chemoradiation, APR and total colectomy, and postoperative hybrid CMF times six cycles and stage IIIA (T2 N2 M0) invasive lobular carcinoma of the left breast, status post lumpectomy and adjuvant hybrid CMF times six cycles. The patient was seen in consultation by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_.
T2|tumor stage 2|T2,|174|176||She eventually had a biopsy done which was consistent with a nonsmall cell carcinoma of the lung, after the immunostaining was done, it was adenocarcinoma. Her diagnosis was T2, N3, M0. She was given concurrent chemotherapy and radiation therapy. The chemotherapy used was Carboplatin along with Taxol. She finished that concurrent treatment and came to _%#CITY#%_ where she was seen at Hubert H. Humphrey Cancer Center and was given two cycles of consolidation chemotherapy with Carboplatin and Taxol which she finished on _%#MM#%_ _%#DD#%_.
T2|tumor stage 2|T2,|373|375|IMPRESSION|I see a last CBC done on _%#MM#%_ _%#DD#%_ which shows WBC 6.4, hemoglobin 11.4, platelet count 315,000, neutrophils 4.57. I do not have any chemistries available to me from that admission. Her chemistries on _%#MM#%_ _%#DD#%_ show creatinine 0.7, calcium 9.4, ALT 12, direct bilirubin 0.3, total bilirubin 0.6, total protein 7.5. IMPRESSION: The patient with a stage IIIB T2, N3, M0 nonsmall lung cancer, status post treatment with concurrent chemotherapy (Carboplatin and Taxol based treatment), followed by two cycles of consolidation chemotherapy with Carboplatin and Taxol, finished on _%#MM#%_ _%#DD#%_.
T2|tumor stage 2|T2,|319|321|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ was seen for initial consultation in the Department of Therapeutic Radiology on _%#MMDD2004#%_ by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ at the request of Dr. _%#NAME#%_ _%#NAME#%_. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 51-year-old Africa American male with recently diagnosed T2, N2b squamous cell carcinoma of the right piriform sinus. He was brought to the attention of ENT after a long history of a chronic cough.
T2|tumor stage 2|T2,|170|172|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Right piriform sinus squamous cell carcinoma, T2, N2b, M0. HPI: This is a 51-year-old African American male patient who had had a chronic cough and was evaluated by ENT.
T2|thoracic (level) 2|T2,|204|206|HISTORY OF PRESENT ILLNESS|She goes on to receive whole brain radiation 3750 cGy, completed in _%#MM2007#%_. 3. _%#MMDD2007#%_: Follow-up MRI of the axial spine reveals progression of disease with specific noted disease at C2, T1, T2, and diffuse involvement of the lumbar vertebra. Of note, there is also high-grade canal stenosis at L2-L3, which is thought to be related to degenerative disk disease.
T2|tumor stage 2|T2|192|193|HPI|My key findings: CC: Squamous cell carcinoma of the right floor of mouth, recurrent in the left neck, status post left neck dissection. HPI: This is a 61-year-old female patient who had stage T2 right floor of mouth cancer in _%#MM2002#%_ which was treated with surgery with a flap reconstruction and a right neck dissection.
T2|tumor stage 2|T2,|159|161|HISTORY OF PRESENT ILLNESS|The specimen was noted to have close 2 mm margins. His lymph node dissection was negative for any tumor. The patient was therefore a probable pathologic stage T2, N0, M0 (based on probable shrinkage of specimen). The patient was referred to Dr. _%#NAME#%_ to discuss postoperative radiation therapy.
T2|tumor stage 2|(T2|135|137|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 58-year-old female with a history of right invasive ductal breast carcinoma, stage IIA (T2 N1 M0), diagnosed in _%#MM2002#%_. She had a grade 2 invasive ductal carcinoma that was ER/PR negative and HER2/neu negative.
T2|T2 (MRI)|T2|217|218|DIAGNOSTIC TESTS|PAST MEDICAL HISTORY: 1. Self-described obstructive sleep apnea, untreated. 2. Borderline hypercholesterolemia, untreated. DIAGNOSTIC TESTS: 1. MRI, brain, seizure protocol and tumor protocol, _%#MMDD2007#%_: Diffuse T2 hyperintensity with faint enhancement, left medial temporal lobe. 2. Repeat MRI, seizure protocol, _%#MMDD2007#%_L Increasing extent and intensity of previously seen lesion in left medial temporal lobe with faint enhancement as part of the lesion.
T2|T2 (MRI)|T2|214|215|REVIEW OF RELEVANT AVAILABLE RECORDS|Lumbar puncture and other neurologic workups were at that time described as negative. There was slight elevation of CSF protein with unclear significance. A brain MRI of _%#MMDD2007#%_ revealed diffusely increased T2 signal intensity of the cerebral white matter, most prominent within the periatrial regions, the splenium of the corpus callosum and the bilateral parietal and occipital lobes, but also within the posterior and midfrontal paraventricular and subcortical regions.
T2|tumor stage 2|T2|139|140|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Base of tongue T2 NoMo, post-op with close margin (1mm). HPI: Had difficulty swallowing and speaking and was found to have squamous cell CA.
T2|tumor stage 2|(T2|19|21|PROBLEM|PROBLEM: Stage IIA (T2 N0 M0) invasive ductal carcinoma of the right breast, status post lumpectomy and four cycles of AC and one cycle of Taxol. The patient was seen in the Radiation Oncology Clinic by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_.
T2|T2 (MRI)|T2|222|223|ASSESSMENT|Behcets shows an incidence of not 21% but 5% with involvement of CNS over a course of 2 decades in males of up to 14% and some case series from Turkey. The moment of Behcet it is most likely in the brainstem lesion with a T2 hyperintense lesions with subacute onset and usuall y involving the brainstem, the mid brain, and the posterior thalamus.
T2|T2 (MRI)|T2|186|187|PROCEDURES PERFORMED DURING THIS HOSPITALIZATION|5. History of portal hypertension with ascites. PROCEDURES PERFORMED DURING THIS HOSPITALIZATION: 1. MRI of the abdomen on _%#MMDD2007#%_, which showed number of focal area of increased T2 signal within the right lobe of the liver _____ enhancement washout and is concerning for hepatocellular carcinoma. 2. Nodular fibrotic liver consistent with cirrhosis. 3. Splenomegaly with recanalized umbilicus, consistent with portal hypertension.
T2|thoracic (level) 2|T2|229|230|HISTORY OF PRESENT ILLNESS|Postoperatively, he has been unable to move his lower extremities and his upper extremities are weak. Apparently he has some biceps contraction and triceps function. Postop MRI recently showed increased T2 signal from C2 through T2 level and cord swelling from C4 through C6. The patient is currently still intubated. The plans include in the immediate future the patient will be receive a tracheotomy.
T2|T2 (MRI)|T2|205|206|HISTORY OF PRESENT ILLNESS|During her work up for a bone marrow transplant she was found to have a prolonged INR and PTT that was presumed to be do to a mild tumor-related DIC. On _%#MMDD2004#%_ brain and orbit MRIs showed abnormal T2 hyperintensity in the corpus medullare of the cerebellum bilaterally. This may represent hemartoma of neurofibromatosis. Normal optic pathways. ALLERGIES: No known drug allergies.
T2|thoracic (level) 2|T2|198|199|PROCEDURE PERFORMED|ADMISSION DIAGNOSIS: T2 epidural mass. DISCHARGE DIAGNOSIS: Benign and noninfectious thoracic epidural mass. Preliminary pathology is calcified amorphus debris. PROCEDURE PERFORMED: _%#MMDD2002#%_: T2 corpectomy with a T1-T3 fusion with allograft. HISTORY OF PRESENT ILLNESS: This is a 15-year-old African- American right-handed female who developed neck pain on 8/8, and progressed to sever pain between the scapulas.
T2|tumor stage 2|T2|37|38|PROBLEM|REVISED: _%#MMDD2007#%_/VAA PROBLEM: T2 N2 M0, IIIA squamous cell carcinoma of the right lung. The patient is referred for definitive radiotherapy. Ms. _%#NAME#%_ was seen for initial consultation in the Department of Therapeutic Radiology on _%#MMDD2007#%_ by Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ at the request of Dr. _%#NAME#%_ _%#NAME#%_.
T2|thoracic (level) 2|T2|48|49|PROBLEM|PROBLEM: Metastatic breast cancer to C2 through T2 vertebral bodies with spinal cord compression at C4. Ms. _%#NAME#%_ was seen in our Department of Therapeutic Radiology on _%#MMDD2005#%_ by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ at the request of Dr. _%#NAME#%_ _%#NAME#%_ in Neurosurgery.
T2|thoracic (level) 2|T2.|256|258|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: The patient has complete paresthesia and paraplegia bilaterally to the level of T4, with bilateral upper extremity weakness, right greater than left. There is a roughly 1 cm open wound above the previous surgical site at the level of T2. ASSESSMENT AND PLAN: Mr. _%#NAME#%_ is an 83-year-old male with progression of his metastatic disease in his low cervical and upper thoracic spine.
T3|thoracic (level) 3|T3.|130|132|HISTORY OF PRESENT ILLNESS|This progressed with some lower extremity weakness with gait instability. He was found to have pathologic compression fracture at T3. He underwent surgery with fusion from C7 through T6 _%#MMDD2007#%_ by Dr. _%#NAME#%_. He is recommended to continue with a CTLSO brace for 3 months.
T3|triiodothyronine|T3|204|205|HOSPITAL COURSE|_____________ were also sent for any evidence of Wegener's. An ANA was checked for any evidence of lupus. Lyme titers and ________ studies were also sent. The TSH came back low at 0.03 and therefore free T3 and T4 were sent as well as TSI which were pending at the time of discharge. The patient was initially treated with IV Solu-Medrol 250 q.6 hours which was titrated to oral steroids with significant improvement in the patient's symptoms.
T3|tumor stage 3|T3|21|22|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: T3 N1 squamous cell carcinoma of the tongue. DISCHARGE DIAGNOSIS: T3 N1 squamous cell carcinoma of the tongue.
T3|tumor stage 3|T3.|219|221||He had fallen once. He was found to have a fracture, compression of the superior plate of T6 and new areas of mild spinal cord edema at T3-T4 to the superior compression of the spinal cord caused by the tumor at T2 and T3. He was seen in consultation by Dr. _%#NAME#%_ who felt surgery offered virtually no chance of resolution of his problem and had high risk.
T3|tumor stage 3|T3|238|239|DOB|Unfortunately, the pathology from her procedure revealed a poorly differentiated adenocarcinoma measuring approximately 6 x 3 cm in dimension. This tumor has spread through the serosa and muscularis to involved the transmural fat, i.e. a T3 lesion. Additionally, 5 of the submitted 31 lymph nodes were positive for local metastatic spread. Therefore, _%#NAME#%_ has been deemed to have stage 3C (T3, N2, MX) adenocarcinoma of the colon.
T3|tumor stage 3|(T3,|116|119|ASSESSMENT/PLAN|A chest x-ray done in the postoperative setting appeared free of pulmonary metastasis. ASSESSMENT/PLAN: 1. Stage 3C (T3, N2, MX) adenocarcinoma of the colon. At present, _%#NAME#%_'s exact TNM staging is difficult to assess given that she has not had CT scans of the chest nor a PET scan.
T3|thoracic (level) 3|T3|144|145|CURRENT PROBLEMS|CURRENT PROBLEMS: 1. Neurogenic bladder, change in bowel continence, and decreasing ambulatory ability associated thoracic epidural lipoma from T3 to T8, status post MRI-guided decompressive laminectomy T3-8 and resection of lipoma on _%#MMDD2005#%_. 2. Underlying multiple sclerosis which has left her wheelchair bound, left greater than right-sided weakness.
T3|thoracic (level) 3|T3|149|150|ANCILLARY DATA|MRI of the thoracic spine shows abnormal T3, T6 and T7 vertebra. MRI of the cervical spine shows no cord compression but did show abnormality in the T3 and diffuse low signal intensity within bone marrow of the vertebral bodies. The MRI of the LS spine is not available, but reported over the phone by the radiologist on Saturday to have 1 cm epidural mass causing slight pressure on the spine at the level of L3, L4.
T3|triiodothyronine|T3,|251|253|DIAGNOSIS|The metabolic panel was unremarkable, but a TSH was low at .33. It was repeated, and was in the normal range but still very low at 0.65. She was seen in primary care consultation by her primary care physician, Dr. _%#NAME#%_ _%#NAME#%_, who ordered a T3, which was also low at 63, with the reference range being 70-170. Her cholesterol is very low, and a question of hyperthyroidism is being raised.
T3|tumor stage 3|T3,|39|41|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Rectal cancer, T3, N1, M0. 2. Incidental left ovary serous cystadenofibroma without evidence of malignancy. 3. Oxygen-dependent chronic obstructive pulmonary disease. 4. Anemia, transfusion one unit red cells.
T3|tumor stage 3|T3|355|356|DISCHARGE MEDICATIONS|Thus, the patient is discharged as noted above. We should note during her stay, her sodium was 137, potassium 3.8, chloride 101, C02 31, glucose 97, BUN 10, creatinine .7, calcium 8.6, liver profile was normal, TSH at first mildly suppressed at 0.28, but the repeat was 1.45, normal, along with a normal of free T4 at 1.10. T3 uptake was normal at 38 and T3 was normal at 122. B12 was normal at 463. Urinalysis was normal. hemoglobin 12.6, platelets 213,000 and white count was 7,900 with a normal differential.
T3|tumor stage 3|T3,|163|165|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: Colon cancer diagnosed with significant microcytic anemia with a hemoglobin of 6.9 and weight loss. The patient was found to have a stage II, T3, N0, M0 adenocarcinoma of the colon. The patient has chronic atrial fibrillation. His Coumadin was reversed. He was diagnosed with colonoscopy by GI. He was stabilized with 2 units of packed red blood cells and underwent surgery on _%#MMDD2002#%_ and had a transverse left colectomy.
T3|thoracic (level) 3|T3|215|216|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSIS: Paraplegia, neurogenic bladder. OPERATIONS/PROCEDURES PERFORMED: Augmentation cystoplasty, Mitrofanoff, and bladder neck closure. HISTORY OF PRESENT ILLNESS: A 59-year-old female with traumatic T3 spinal cord injury approximately 1-1/2 years ago. The patient has had multiple abdominal procedures since that time including a colostomy.
T3|tumor stage 3|T3|210|211|DETAILS|She was advised to eat whatever she wants but a minimum of three quarts of electrolyte solutions daily, and only one-third of it water. She was to call me if there were any problems. Her path report revealed a T3 N0 lesion, no sign of metastatic disease, and 0 out of 19 lymph nodes positive. She will be followed in the office for removal of skin staples.
T3|triiodothyronine|T3|231|232|HOSPITAL COURSE|Patient was discharged in a much improved condition. I have asked them to follow-up with me early this week for a recheck including check of her creatinine, her liver function tests and her hemoglobin. I asked them to add a T4 and T3 to the previous thyroid labs. I suspect she will need an Endocrinology consult for her thyroid mass and hyperthyroidism.
T3|tumor stage 3|T3|139|140|HOSPITAL COURSE|The patient's sepsis-like picture also gradually improved and he was treated with antibiotic therapy. Pathology came back revealing a 3-cm T3 tumor with 0 of 4 nodes positive for malignancy. The patient was maintained on TPN and Oncology consult was obtained.
T3|triiodothyronine|T3|206|207|HOSPITAL COURSE|She was noted to be hypertensive on admission with systolic pressures in the 170s-180s. Workup of her atrial fibrillation revealed a TSH which was suppressed. On repeat this was also suppressed. Her T4 and T3 were also elevated consistent with hyperthyroidism and suspect Graves' disease. Her presenting chronic symptoms seemed consistent with this. It was felt that the etiology to her atrial fibrillation was thought to be her hyperthyroidism, though could certainly be related to her age, left atrial enlargement, hypertension and subsequent mild LVH.
T3|triiodothyronine|T3|256|257|PERTINENT LABORATORY STUDIES|Rapid Strep culture is negative and rapid Strep screen is negative. Vitamin B12 level was negative. Mono screen was negative. T3 at146 is normal, free thyroxine at 1.02 is normal and C-reactive protein 4.2. Sed rate was 9, troponin negative x3, TSH, prior T3 was 190, minimally elevated, previous total thyroxine 9.9 and previous TSH 2.92. D-dimer is negative. Electrolyte panel is normal. IMAGING STUDIES: Stress echo was negative with negative EKG strip during stress test.
T3|tumor stage 3|T3,|263|265|PATHOLOGIC|FINAL DIAGNOSIS: Adenocarcinoma of the rectum, moderately differentiated, extending through the wall into the perirectal soft tissue with no definite angiolymphatic invasion identified, but with perineural invasion present. Five negative lymph nodes. PATHOLOGIC: T3, N0, M0 lesion. OPERATIONS/PROCEDURES: _%#MMDD2006#%_ exploratory laparotomy, extended low anterior resection with Hartmann pouch and sigmoid colostomy under general anesthesia.
T3|triiodothyronine|T3|213|214|HISTORY|A nuclear stress test was performed, it showed hyperdynamic ventricle and no ischemia. Echocardiogram showed normal LV size and function, no wall motion abnormality, no significant valvular problems. T4 was 1.58, T3 was 100, both in normal range, and her TSH was 3.4. Her CBC was normal. It is conceivable, since the patient just had an infection and a dental procedure on her jaw, that this may have somewhat contributed to orthostatic hypotension, although she states she was eating fully and was not dehydrated, and again here in the hospital was eating normally but was still a bit orthostatic, therefore I do not know if this potential jaw infection and dental procedure may or may not have contributed.
T3|triiodothyronine|T3|168|169|ASSESSMENT AND PLAN|3. Atrial fibrillation. Like secondary to his hyperthyroidism and possible thyrotoxicosis. It would be preferable for him to be on propranolol as this blocks the T4 to T3 conversion. However, last night due to his blood pressure being on the low side, we chose to use esmolol for rate control and that it was short-acting.
T3|triiodothyronine|T3|159|160|LABORATORY DATA|PT and PTT within normal limits. Troponin I less than 0.3 x 2. Sodium 137, potassium 4.4, chloride 103, CO2 17, BUN 8, creatinine 0.6, anion gap 18, TSH 0.14, T3 77. Urine tox screen is positive for alcohol and cannabinoids. Pregnancy test is negative. Urinalysis shows blood in urine moderate, protein trace, leukocyte esterase trace, nitrites negative.
T3|thoracic (level) 3|T3|161|162|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 52-year-old right-handed white male with a history of T5 paraplegia since 1985, secondary to a motor vehicle accident with T3 to T10 Harrington rods. He was recently discharged on _%#MM#%_ _%#DD#%_, 2002, after drainage of a paraspinous abscess and closure of the wound on _%#MM#%_ _%#DD#%_, 2002.
T3|tumor stage 3|T3|296|297|HISTORY OF PRESENT ILLNESS|The patient was diagnosed in _%#MM#%_ of 2002 with her moderately differentiated adenocarcinoma and underwent endorectal ultrasound which showed evidence of a 4 by 3 cm ulcerative lesion to the left and midline of the rectum, beginning at 9 cm and extending to 13 cm. The patient was staged as a T3 lesion. A CT scan of the chest, abdomen and pelvis in _%#MM#%_ of 2002 showed evidence of thickening of the rectal wall but no evidence of adenopathy.
T3|triiodothyronine|T3|146|147|HOSPITAL COURSE|CBC was normal with a hemoglobin of 12.12. CK was 238. ESR was 33. TSH was pending on admission, however, recently result came back at 0.36. Free T3 and T4 were not done. Calcium was 8.9, albumin was 3.7, and phosphate was 4.1. EKG was consistent with no change from her previous EKG.
T3|triiodothyronine|T3|179|180|HOSPITAL COURSE BY PROBLEM LIST|3. Hypothyroidism: The patient was on Synthroid 250 mg which was reduced from 300 mg per day earlier this month. However, this admission, her TSH was found to be 0.03 with normal T3 and T4 levels. Her TSH was 0.05 on last admission on _%#MM#%_ _%#DD#%_, 2005. Endocrine was asked to suggest dosing for now, and the dose was reduced from 250 to 200 mcg per day per endocrine recommendation, and to check the next TSH level only after 4 weeks at least.
T3|triiodothyronine|T3|178|179|HOSPITAL COURSE|She had a normal stress test. The patient did get started on some Toprol-XL for palpitations that she had. She did have a low TSH of less than 0.03. Her free thyroxine was 1.21. T3 was done and was normal at 114. Her Synthroid dose was decreased from 0.1-0.075 and she should have a follow-up TSH in six weeks.
T3|thoracic (level) 3|T3|219|220|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Parkinson's. 2. Myasthenia gravis. 3. Peptic ulcer disease. 4. Osteoarthritis. 5. Hypertension. 6. Allergic rhinitis. 7. Cholelithiasis. 8. Cervical spondylosis. 9. Osteoporosis. 10. L3-T12 and T3 vertebral compression fractures. 11. Lumbosacral spondylolisthesis. 12. Benign prostatic hypertrophy. 13. Right shoulder rotator cuff tear. 14. Gastroesophageal reflux disease. 15. Iron deficiency anemia, status post resolution, status post colonoscopy and EGD without findings suggestive of etiology.
T3|thoracic (level) 3|T3|238|239|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|Unfortunately, with his steroid therapy and radiation therapy, he had little improvement in his lower extremity weakness. He was evaluated by Dr. _%#NAME#%_ of neurosurgery and the patient did agree to a spinal decompression at the level T3 and T4. This was done 5 days ago. Unfortunately, he has shown little improvement of his lower extremity weakness.
T3|tumor stage 3|T3.|262|264||Pathology report showed papillary urothelial carcinoma, high grade. The tumor focally invades into the renal interstitium in the ureter. The tumor invades into the lamina propria and submucosa without evidence of smooth muscle involvement. Pathologic staging is T3. Surgical margins were negative. Prior to his surgery the patient did require a blood transfusion and was transfused 2 units of blood.
T3|triiodothyronine|T3|202|203|HOSPITAL COURSE|However, sphenoid sinus has some opacification. Mononucleosis screen test is negative. Her urine for VMA and HVA are also negative. Her thyroid function tests, TSH, and free T4 are within normal range. T3 also sent, however, is still pending at the time of the discharge (normal). We also sent urine PPG (normal) and ALA (elevated) to rule out acute intermittent porphyria, and this urine test is still pending at the time of discharge.
T3|triiodothyronine|T3.|338|340|MEDICATIONS ON ADMISSION|9. Hepatitis B positive. 10. Esophageal stricture dilatation. 11. Dilated cardiomyopathy, valvular heart disease with an ejection fracture of 15% to 20%. MEDICATIONS ON ADMISSION: Coumadin, aspirin, Lasix, Synthroid, Elavil, ferrous sulfate, Prevacid, Ditropan, Colace, Neurontin, lantis, lispro, Imdur, Prinivil, Coreg, hydralazine, and T3. ALLERGIES: Penicillin, oxycodone, Percocet, Percodan, and Darvocet. PHYSICAL EXAMINATION AT DISCHARGE: Temperature 99.2. Respirations 16.
T3|tumor stage 3|T3|228|229|DISCHARGE DIAGNOSIS|The patient is a 69-year-old female who on a screening colonoscopy was found to have a splenic flexure cancer. On the day of admission she underwent a left colectomy with a primary hand-sewn anastomosis. She was found to have a T3 N2 lesion without any evidence of intra- abdominal metastasis. The patient had an uncomplicated postoperative course and by the day of discharge she was tolerating a regular diet and moving her bowels.
T3|triiodothyronine|T3|423|424|LABORATORY DATA|LABORATORY DATA: Chest x-ray shows an enlarged cardiac silhouette with some increased pulmonary vascularization. Sodium 139, potassium 3.5, chloride 96, bicarb 33, BUN 36, creatinine 1.8, calcium 9.2, albumin 3.8, total bili 0.2, alkaline phosphatase 137, ALT 16, AST 22, INR 0.94, hemoglobin 12, white count 11,900 with no differential yet, platelet count 222,000, MCV 90, troponin less than 0.07, myoglobin 10, TSH 3.73, T3 1.62. EKG shows normal sinus rhythm with first-degree AV block.
T3|thoracic (level) 3|T3|384|385|BRIEF HISTORY OF PRESENT ILLNESS|PRIMARY DIAGNOSIS: Metastatic Ewing's sarcoma. SECONDARY DIAGNOSIS: Urinary tract infection with group D Enterococcus (2 strains) sensitive to ampicillin. TREATMENT/WOUND CARE: Ifosfamide, Mesna, Etoposide chemotherapy (IMV), cycle #2. BRIEF HISTORY OF PRESENT ILLNESS: The patient is a 31-year- old Hmong female with a history of Ewing's sarcoma with metastases to the thoracic body T3 through T10 as well as skull lesions for which he is status post craniotomy having had left frontotemporal tumor resection, numerous chemotherapy rounds, radiation, and laminectomy from T8 to T10.
T3|triiodothyronine|T3|124|125|PAST MEDICAL HISTORY|3. Diastolic heart failure 4. Previous atrial fibrillation 5. ?Gout 6. Hypertension with severe LVH 7. Normal Free T4, free T3 is pending, low TSH and normal thyroid uptake and scan raising the question of subclinical hyperthyroidism 8. Previous tobaccoism (discontinued in 1965) 9. Macular degeneration. ALLERGIES AND SENSITIVITIES: NOVOCAIN (CNS ) LATEX (RASH).
T3|tumor stage 3|T3,|129|131|OTHER DIAGNOSES AND PROCEDURES AS FOLLOWS|2. Exploratory laparotomy for suture ligation of gastrointestinal bleeding vessel. OTHER DIAGNOSES AND PROCEDURES AS FOLLOWS: 1. T3, N0, M0 pancreatic cancer. 2. Bile leak secondary to bile duct ischemia. 3. Gastrointestinal bleed hepaticojejunostomy. 4. Postoperative myocardial infarction. 5. Postoperative renal failure. 6. Postoperative pulmonary failure with prolonged intubation and need for tracheostomy tube.
T3|triiodothyronine|T3|212|213|PROCEDURES|2. Probable alcohol withdrawal. 3. Tobacco abuse. 4. Mildly elevated thyroid-stimulating hormone. PROCEDURES: 1. CT scan on _%#MMDD2007#%_: Unremarkable head except cerebellar _____. 2. TSH 5.07 mildly elevated. T3 and T4 are pending. PAST MEDICAL HISTORY: 1. Hypertension. 2. Gout. 3. Heel fracture.
T3|triiodothyronine|T3|113|114|PROBLEM #2|He will buy over-the-counter thiamine and folate by himself. Follow up by Dr. _%#NAME#%_ on _%#MMDD2007#%_ _____ T3 and T4, EEG. DISCHARGE MEDICATIONS: 1. Norvasc 10 mg daily. 2. Folic acid 1 g daily.
T3|triiodothyronine|T3|105|106|IMPRESSION|Heart rate was 140. Chest x-ray did not show any acute infiltrates. IMPRESSION: 1. Overdose with Cytomel T3 and Trazodone 2. Schizoaffective disorder with previous history of suicide attempts as documented in FCIS. History of electroconvulsive therapy 3. Tachycardia and altered mental status likely related to problem #1.
T3|triiodothyronine|T3|186|187|HOSPITAL COURSE|Normal electrolytes. Improvement in pre- renal azotemia preoperatively with a BUN of 13 and creatinine of 0.7. Off of diuretic therapy. Normal thyroid function as above including normal T3 of 2.5. Follow-up chest x-ray _%#MMDD#%_ demonstrating no active disease. Felt clinically stable for discharge back to the nursing home. MEDICATIONS AT DISCHARGE: 1. Senna one p.o. b.i.d. for constipation.
T3|triiodothyronine|T3|160|161|HOSPITAL COURSE|The patient was started on Synthroid 15 mcg p.o. q.d. which was discussed with the Endocrinology Fellow. It is planned that the patient should have a TSH, free T3 and free T4 checked at the end of _%#MM2003#%_ after six weeks of treatment. PROBLEM #5. Cardiac. The patient has history of sick sinus syndrome with pacer in place, and has not had any problems during this hospitalization.
T3|triiodothyronine|T3|185|186|FOLLOW UP|She will also follow up with Dr. _%#NAME#%_ from cardiology in the next 3-4 weeks. She is planning on having her INR checked within the next couple days and she will follow up with her T3 and T4 with her primary care physician in follow up.
T3|triiodothyronine|T3|152|153|LABORATORY DATA|Abdomen is soft with no organomegaly. Lower extremities have no edema, no masses. Neurologically the patient was intact. LABORATORY DATA: Free T4 0.49; T3 79; thyroid antibody of less than 10; TSH elevated at 21.52; ESR 34. WBC 16.6 (this was obtained after the patient was started on steroids); hemoglobin 12.7; ANC 13.2; ALC 2.2; absolute monocytes 1.2. Sodium 138; potassium 4.3; chloride 104; bicarbonate 21; glucose 201 (after steroids were started); creatinine 0.8; BUN 10; calcium 9.0; magnesium 2.2; phosphorus 2.7; uric acid 4.4; LDH 607.
T3|tumor stage 3|T3|375|376|DISCHARGE DIAGNOSIS|ADMITTING DIAGNOSIS: High grade adenocarcinoma of the prostate TYPE OF PROCEDURE: Bilateral pelvic lymph node dissection, non- nerve sparing radical retropubic prostatectomy SURGEON: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD ASSISTANT: _%#NAME#%_ _%#NAME#%_, MD HOSPITAL COURSE: Uneventful. DISCHARGE DIAGNOSIS: Grade 3+4 ductal adenocarcinoma of the prostate, pathological Stage T3 N0 TRANSFUSION: None. Postoperative hemoglobin was 11.9. Patient is scheduled for follow-up, staple removal at one week.
T3|triiodothyronine|T3|196|197|LABORATORY DATA|Platelets are 79. Sodium 132, potassium 2.9, chloride 95, C0 25, BUN 36, creatinine 1.49. Total bilirubin 8.6. Alkaline phosphatase 243, ALT 120, AST 195, ammonia 219. INR 3.27, PTT 62. TSH 66.4. T3 and T4 are pending. Urinalysis shows no white blood cells or red blood cells. A chest x-ray revealed clear lungs. ASSESSMENT/PLAN: The patient is a 58-year-old female with end-stage liver disease secondary to NASH.
T3|thoracic (level) 3|T3,|45|47|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Compression fracture of T3, due to lung cancer metastasis, with cord compression and paraparesis. OPERATIONS AND PROCEDURES PERFORMED: Transpedicular vertebrectomy of T3, with interbody fusion and posterior fixation from C7 through T6.
T3|thoracic (level) 3|T3|183|184|HISTORY OF PRESENT ILLNESS AND PAST MEDICAL HISTORY|HISTORY OF PRESENT ILLNESS AND PAST MEDICAL HISTORY: The patient is a 57-year-old male who presented to our service with progressive paraparesis due to spinal cord compression from a T3 vertebral body compression fracture and metastatic tumor of the lung. He is undergoing has undergone chemotherapy and radiation therapy for his luong tumor, which started a week before his presentation torsed to our service.
T3|tumor stage 3|T3,|182|184|FINAL DIAGNOSIS|DISCHARGE/TRANSFER SUMMARY FINAL DIAGNOSIS: Moderately-differentiated non-small cell carcinoma, mixed adenocarcinoma and squamous type of the right lung. Final pathological stage is T3, N2, M1 (M1 is due to the separate nodule in the lower lobe) OPERATIVE PROCEDURE: On _%#MMDD2007#%_ a right thoracotomy with right intrapericardial pneumonectomy and mediastinal lymphadenectomy was performed.
T3|tumor stage 3|T3,|93|95|HOSPITAL COURSE|She was sent home on postoperative day #5 in good condition. The pathology report revealed a T3, N0, M0 moderately differentiated adenocarcinoma of the cecum. The proximal, distal and radial margins appeared normal. She will follow up in our office in approximately three weeks or sooner should problems develop.
T3|triiodothyronine|T3|171|172|HOSPITAL COURSE|Blood cultures done on admission remained no growth to date. Urine culture showed no growth to date. The patient had a TSH which was mildly elevated at 5.28. However, her T3 and T4 were within normal range. This needs to be followed. She should have a repeat thyroid function test in approximately one month time.
T3|thoracic (level) 3|T3|260|261|PAST MEDICAL HISTORY|The patient did undergo a previous epidural injection several weeks prior, which did result in some relief of his chronic lower extremity pain. PAST MEDICAL HISTORY: 1. Paraplegia as above in 1985. The patient underwent stabilization with Harrington rods from T3 to T10 here at Fairview-University Medical Center by the Neurosurgery Service under Dr. _%#NAME#%_. Chronic lower extremity pain, treated at the Maps Center.
T3|tumor stage 3|T3,|260|262|FOLLOW-UP|She was admitted for elective surgery. She underwent a right hemicolectomy on the day of admission on _%#MMDD#%_ and her postoperative course was uneventful. She was discharged on _%#MMDD#%_ in good condition. The pathology report from the specimen revealed a T3, N1, M0, stage III adenosquamous carcinoma of the right colon. The tumor was a plaque- like lesion 3x3 cm in size. The tumor perforated the muscularis propria and 3 of 9 lymph nodes were positive for metastatic disease.
T3|thoracic (level) 3|T3|160|161|HISTORY|HISTORY: Mr. _%#NAME#%_ is a 52-year-old gentleman who had a T5 spinal cord injury in 1985 secondary to a motor vehicle accident and underwent the placement of T3 through T10 Harrington rods. He developed a seroma which required multiple incisional drainages secondary to thoracic paraspinal abscesses.
T3|tumor stage 3|T3,|164|166|DETAILS|The patient was sent home with a leg bag on _%#MMDD2004#%_ to be seen by Dr. _%#NAME#%_ _%#NAME#%_ in the near future in follow up. His path report revealed that a T3, N0, M0 lesion, which appears not to require any further treatment. He will be seen in the office in 2-3 weeks. DISCHARGE INSTRUCTIONS: 1. Foley catheter leg bag. 2. Avoidance of heavy lifting.
T3|triiodothyronine|T3|180|181|LABORATORY DATA|On discharge, that was noted to be 34 and 1.48 which is more at her normal range. She had a TSH also that was noted to be 6.18. A free thyroxin was within normal limits at 1.19. A T3 was done which was 119. A hemoglobin A1C is pending. FOLLOW UP PLAN: 1. The patient should be on a diabetic diet.
T3|triiodothyronine|T3|232|233|MEDICATIONS ON ADMISSION|2. Diabetes mellitus 3. Chronic obstructive pulmonary disease 4. Hypertension MEDICATIONS ON ADMISSION: 1. Were Xanax 2. Allegra 3. Lasix with potassium supplementation 4. Glyburide/insulin 5. Protonix 6. Prednisone 7. MS Contin 8. T3 9. Pulmicort 10. Xopenex inhalers. SOCIAL HISTORY: Was detailed in a previous history and physical in _%#MM#%_ of 2003 FAMILY HISTORY: Is noncontributory to the current admission.
T3|tumor stage 3|(T3,|188|191|ADMITTING PHYSICIAN|2. Status post implanted port placement. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 54-year-old gentleman who was initially diagnosed with adenocarcinoma of the GE junction stage III (T3, N1, M0) in 2002. The patient was treated with carbo-Taxol chemotherapy initially and then concurrently with radiation to a total dose of 45 grays in 25 fractions.
T3|thoracic (level) 3|T3|156|157|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Progressive adolescent idiopathic scoliosis. OPERATIONS/PROCEDURES PERFORMED: Posterior spinal fusion and extension thoracoplasty from T3 to L2. HISTORY OF PRESENT ILLNESS: The patient is an otherwise healthy 13-year-old female, who has rapid progression of her scoliosis to greater than 60 degrees.
T3|triiodothyronine|T3|210|211|HOSPITAL COURSE|In addition, her liver function tests would return to normal and hepatitis B and C serology would be negative. Also, initial TSH was low, but a repeat TSH was normal at 0.61 with a normal free T4 at 1.57 and a T3 of 116.
T3|triiodothyronine|T3|276|277|HISTORY ON ADMISSION|That admission she was diagnosed with congestive heart failure with an ejection fraction of 35%, BNP in the 500s, and a chest x-ray that showed a left-sided pleural effusion. She was admitted for further workup. During that stay, she had an undetectable TSH, with an elevated T3 and T4 consistent with hyperthyroidism. A chest CT showed hilar adenopathy and patchy bilateral infiltrates. The patient was treated with Lasix, Coreg, and lisinopril. Her symptoms improved, and she was sent home for follow- up.
T3|tumor stage 3|T3|253|254|DOB|The pathology from the procedure revealed a 2 cm primary tumor of adenocarcinoma that was invading into the muscularis propria and to the subserosa and pericolonic tissue. This tumor was described as moderately differentiated and was characterized as a T3 lesion. Additionally, 3 of the 12 resected lymph nodes were positive for local metastases. PAST MEDICAL HISTORY: 1. Hypothyroidism. 2. Atrial fibrillation. She had no known allergies.
T3|tumor stage 3|T3|191|192|HOSPITAL COURSE|He was taken to the operating room on _%#MMDD2007#%_ where he underwent a resection of descending colon for an obstructing adenocarcinoma: The patient did have positive lymph nodes. He was a T3 N2 M0 staging. During his postoperative stay he was seen by Dr. _%#NAME#%_ _%#NAME#%_ of oncology with regard to adjuvant chemotherapy. His hospital course was unremarkable and without complication.
T3|triiodothyronine|T3|131|132|DISCHARGE FOLLOW-UP|DISCHARGE ACTIVITY: As tolerated. DISCHARGE FOLLOW-UP: With endocrinology in 7-10 days. Recommend checking a TSH, free T4 and free T3 at the time of follow-up with endocrine. Of note is the fact that the patient did have abnormal levels of TSH during inpatient stay.
T3|triiodothyronine|T3,|220|222|PROBLEM #2|PTH levels came back below the normal values with TSH levels came back extremely low (less than 0.02), and patient's corrected calcium was found to be 12.8. Endocrinology service was consulted and further labs including T3, free T4, and thyroid antibody studies were sent off. Patient was placed on propranolol for symptomatic control of clinical hyperthyroidism and was instructed to follow-up for radioactive iodine therapy and subsequent outpatient management.
T3|triiodothyronine|T3|396|397|HOSPITAL COURSE|During the hospital course, the patient was found to have a sodium upon admission of 134 with a potassium of 4.2, chloride was 108 with a bicarbonate of 22, BUN and creatinine were 4 and 0.6 respectively, her white count was 6000 with a hemoglobin of 11.8. During the hospitalization, her electrolytes remained stable, her calcium was 8.1, a TSH was also obtained which was less than 0.2 but her T3 and T4 were essentially within normal limits. Her triiodothyronine was 171 which was within normal limits, total protein was 2.8, and her prealbumin was 0.5 with LFTs also being within normal limits.
T3|triiodothyronine|T3|193|194|HOSPITAL COURSE & LABORATORY DATA|Serum calcium was slightly low at 7.8-7.9. Thyrotropin and thyroxine free levels were normal. Arterial blood gases with a p02 of 52, bicarb of 30, and hemoglobin saturation on room air was 85. T3 uptake test was 38, which is high limits of normal. Serial hemoglobins were in the normal range. Red cell counts and hematocrit are normal.
T3|triiodothyronine|T3|400|401|LABORATORY DATA|His fibrinogen activity was 363. His dedimer was less than 0.2. Comprehensive metabolic panel - Sodium 142, potassium 4.0, chloride 108, bicarb 23, glucose 161, BUN 16, creatinine 0.89, calcium 9.8. Liver function tests - Bilirubin 0.4, albumin 4.6, total protein 7.5, alkaline phosphatase 66, ALT 27, and AST 20. We also did some thyroid function tests. His TSH was 0.52, thyroxin was 0.92, and his T3 was 76. His osmolality was 304. His urinalysis was remarkable for some glucose in the urine. HOSPITAL COURSE: PROBLEM #1: Fluids, electrolytes, and nutrition. _%#NAME#%_ was started on a regular diet and was also started on IV fluids.
T3|tumor stage 3|T3|278|279|HISTORY OF PRESENT ILLNESS|PROCEDURE PERFORMED: Not a transdural KTP laser, but a transoral KTP laser excision of recurrent squamous cell carcinoma of left hypopharyngeal wall. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 56-year-old gentleman who on _%#MMDD2003#%_ underwent a composite resection for T3 N1 squamous cell carcinoma of the left tongue base. The patient had reconstruction with a left radial forearm free flap reconstruction of the lateral pharyngeal wall.
T3|UNSURED SENSE|T3.|46|48|PRINCIPAL DIAGNOSIS|PRINCIPAL DIAGNOSIS: Adenocarcinoma of T2 and T3. ADDITIONAL DIAGNOSES: 1. Myelopathy. 2. Esophageal stricture. 3. Diabetes. PRINCIPAL PROCEDURE THIS ADMISSION: Anterior spinal reconstruction of T2 and T3 with complete corpectomy of T2 and T3 and replacement with SynMesh cage and bone cement with anterior spinal plating.
T3|triiodothyronine|T3|248|249|HOSPITAL COURSE|There is also probably moderate pulmonary hypertension noted. The patient had thyroid function tests done when she was in a fib. Her TSH was slightly elevated at 5.80 with normal being up to 5.0. Her free thyroxine, however, was normal at 1.14 and T3 was normal at 1.08. Given the fact that the patient just went through surgery with postop ileus, would like to repeat her TSH in two weeks.
T3|triiodothyronine|T3|155|156||These are suspicious for possible early hyperthyroidism. I would recommend that the patient have repeat thyroid function tests performed in two weeks. The T3 also needs to be followed up when it becomes available from here. Should her TSH remain depressed and her T4 remain elevated, the patient should undergo a thyroid scan with subsequent therapy dependent on the results.
T3|thoracic (level) 3|T3.|162|164|HISTORY OF PRESENT ILLNESS|When he arrived at Fairview-University Medical Center, he was noted to be paraplegic. His sensory level to both light touch and pain was approximately T2 through T3. He did state he could feel pressure, however. Neurosurgery was consulted but felt nothing could be done from their standpoint.
T3|thoracic (level) 3|T3.|150|152|ADMISSION DIAGNOSIS|3. Status-post suboccipital craniectomy, C1 laminectomy, duraplasty, mild Chiari I malformation on _%#MMDD2003#%_. 4. Central cord searing from C5 to T3. 5. Left leg phlebitis. 6. History of irritable bowel syndrome. HISTORY: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 44-year-old woman who is known to our practice for having presented with gait disturbances and neck discomfort and headache.
T3|tumor stage 3|T3,|280|282|HISTORY OF PRESENT ILLNESS|He was initially treated with external beam radiotherapy. During the summer of 2004, the patient developed some odynophagia and subsequent biopsy at the base of the patient's right tongue which revealed recurrent squamous cell carcinoma with localized metastasis, which was stage T3, N2B, M0. A CT scan of the chest was done for evaluation for more distal metastases at that time and CT scan revealed multiple pulmonary nodules.
T3|triiodothyronine|T3|179|180|LABORATORY|Repeat prolactin at the time of discharge was 27, which is in the high normal range. Her TSH was elevated at 5.06, but her thyroxine free was within normal limits at 0.94 and her T3 was elevated at 202. Patient had an EKG prior to initiation of Geodon which showed normal sinus rhythm. CONSULTATIONS: An internal medicine consultation was obtained and performed by Dr. _%#NAME#%_.
T3|triiodothyronine|T3|294|295|CONSULTATIONS|Included in his assessment and plan was her galactorrhea, which he suspects is related to her psychiatric regimen, as you can see hyperprolactinemia with Seroquel. Regarding her mildly elevated TSH, suspects that this is "subclinical hypothyroidism." He recommended rechecking her TSH, T4, and T3 in 3 months. The patient is also to follow up with her primary care provider on an as needed basis. HOSPITAL COURSE: The patient was admitted to station 20 under the care of Dr. _%#NAME#%_, which was then transferred to Dr. _%#NAME#%_.
T3|thoracic (level) 3|T3|120|121|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Wound breakdown. HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old right-handed man status post T3 to T7 laminectomy and spinal tumor resection in _%#MM2002#%_ by Dr. _%#NAME#%_ _%#NAME#%_ at North Memorial Medical Center. The patient had subsequent radiation treatment to that.
T3|tumor stage 3|T3|195|196|HOSPITAL COURSE|His postoperative course was uneventful. He was found to have a 3.6 cm renal cell carcinoma that had sarcomatoid features and there was focal involvement of the perirenal fat making this a stage T3 tumor. He was discharged on postoperative day #5 in excellent condition and will follow up with me in several days for staple removal.
T3|triiodothyronine|T3,|203|205|HOSPITAL COURSE|She does note that she had discontinued taking medication for a brief period of time during some periods of financial difficulty. She stated that at the time of admission, she was taking her medication. T3, free T4 were checked and both were within normal limits. She was given 1 dose of intravenous thyroid medication, otherwise she is discharged on 175 mcg daily and she will be checked again as an outpatient.
T3|triiodothyronine|T3|161|162|HOSPITAL COURSE|CBC normal. Chest x-ray: Mild vascular engorgement compatible with congestive heart failure but no pleural effusions. Thyroid studies including TSH, free T4 and T3 all normal. Cardiology consult was requested and the full note as in FCIS, basically the impression was some shortness of breath likely due to the patient's chronic poor cardiac function and possibly some deconditioning.
T3|tumor stage 3|T3|210|211|HOSPITAL COURSE|The patient proceeded to have an uncomplicated hospital course. The patient start clears on postoperative day 3 without any nausea or vomiting. The pathology reports from biopsies taken during surgery showed a T3 node negative adenocarcinoma that was well differentiated originating in a villous structure. The surgical margins were negative. On the day of discharge, the patient was tolerating a soft mechanical diet while her pain was managed by oral pain medications.
T3|thoracic (level) 3|T3|203|204|HOSPITAL COURSE|Her pupils are equal, round, and reactive to light. Her extraocular muscles are intact without nystagmus. She has facial sShe has facial ulcers. Sensation intact to light touch and in the VT11, V-T2 and T3 V3 distributions bilaterally. She has facial symmetry at rest and upon closing her eyes and arise and smiling. Her tongue is midline ofn protrusion and in her shoulder shrug is with good strength and full bilaterally.
T3|tumor stage 3|(T3|298|300|ASSESSMENT AND PLAN|2. Two small indeterminate left adrenal nodules (benign adenoma suspected, however metastasis cannot be excluded.) No other findings suspicious for metastatic neoplasm in the abdomen or pelvis. 3. A1 cm abdominal aortic aneurysm. ASSESSMENT AND PLAN: A 71-year-old white male with likely stage III (T3 N2 Mx) adenocarcinoma of the colon. _%#NAME#%_ is now at postoperative day 3, after his hemicolectomy. I discussed with him briefly the applications of his stage III colon cancer diagnosis.
T3|triiodothyronine|T3|135|136|DISCHARGE MEDICATIONS|3. Ambien 10 mg p.o. nightly. 4. Ativan 2 mg p.o. nightly. 5. Benadryl 50 mg p.o. q.4 hours p.r.n. 6. TPN 16 hours on, 8 hours off. 7. T3 elixir 5 mL p.o. q.4 hours p.r.n. FOLLOW UP: The patient is to follow up with Dr. _%#NAME#%_ _%#NAME#%_ p.r.n. She is to also visit the outpatient laboratory for TPN laboratory studies every week.
T3|triiodothyronine|T3|138|139|HOSPITAL COURSE|5. History of hypothyroidism. The patient did have thyroid studies done. These showed a TSH of 0.84 and a free thyroxin of 1.44. Her free T3 was 1.7. However, with her TSH being in the normal range, we will continue her on her same dose of thyroid hormone on discharge.
T3|thoracic (level) 3|T3|89|90|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old male with a history of previous T3 spine injury with triplegia and neurogenic bladder status post augmentation and ......cutaneous catheter stoma placement who presented to the emergency room with abdominal pain over the past 2 weeks associated with vomiting the last few days. The patient had gradual onset of diffuse abdominal pain that has been getting worse in the past 2 weeks.
T3|tumor stage 3|T3,|263|265|PATHOLOGIC|FINAL DIAGNOSIS: Adenocarcinoma of the rectum, moderately differentiated, extending through the wall into the perirectal soft tissue with no definite angiolymphatic invasion identified, but with perineural invasion present. Five negative lymph nodes. PATHOLOGIC: T3, N0, M0 lesion. OPERATIONS/PROCEDURES: _%#MMDD2006#%_ exploratory laparotomy, extended low anterior resection with Hartmann pouch and sigmoid colostomy under general anesthesia.
T3|triiodothyronine|T3|113|114|PROCEDURE AND OTHER TESTS DONE|Serum iron was 100, ferritin was 478, free thyroxine the day before discharge noted to be 11.15. Sed rate is 12. T3 was at 652. DISCHARGE MEDICATIONS: 1. Atenolol 100 mg p.o. q day.
T3|thoracic (level) 3|T3|238|239||An MRI performed: Found to have an apical tumor of the chest with impingement of the vertebral column, collapse of T2 vertebral body, some moderate involvement of T5, slight collapse of discs and subluxation. The patient had a C7 through T3 posterior fusion and pedicle screw with implants for treatment of her deformities. Placed in a Miami J-collar. Admitted to acute rehab for therapies prior to discharge.
T3|triiodothyronine|T3|181|182|HOSPITAL COURSE|We did do an EKG to evaluate her myocarditis given his metabolic disease. EKG, CK and BNP were also within normal limits. His bradycardia and hypotension did improve. 4. Endocrine. T3 and free T4 were sent to evaluate for hypothyroid given his bradycardia. These were normal as well. 5. ID. We discussed doing an LP to rule out viral encephalopathy, but the patient did begin to improve.
T3|triiodothyronine|T3|126|127|ASSESSMENT AND PLAN|Based on laboratory data from the outside hospital, she has hyperthyroidism. Hyperthyroidism: Based on decreased TSH and high T3 and T4, she has hyperthyroidism. Currently she is not in acute thyroid toxicosis. She has sinus tachycardia and does not have atrial fibrillation.
T3|thoracic (level) 3|T3|162|163|PHYSICAL  EXAMINATION|He has normal tone in all 4 extremities. Sensation is intact per the patient to pinprick and light touch. He denies any sensory levels or any sensory loss in the T3 dermatomal distribution. He has downgoing toes, 2+ bilateral patellar reflexes and no clonus. He has good rectal tone. IMAGING: There are no images available.
T3|triiodothyronine|T3|161|162|PROBLEM #3|PROBLEM #3: Thyroid disorder. We obtained a TSH and thyroid labs during the hospitalization. Her TSH was low, the total T3 was also low, however the normal free T3 was high. The etiology of this is unclear and we think that this could sick euthyroid syndrome, because if the patient is hypothyroid her TSH should be elevated.
T3|triiodothyronine|T3|227|228|LABS|LABS: Which were from _%#MMDD2007#%_, sodium 140, potassium 2.6, chloride 109, bicarb 25, BUN 9, creatinine 0.37, glucose 140, WBC 4.4, hemoglobin 12.4, hematocrit 37.7, platelets 120. Beta HCG negative. TSH is less than 0.03, T3 is 818 and thyroxine free is 7.26. A&P: This is a 33-year-old female with hyperthyroidism and atrial fibrillation with rapid ventricular response.
T3|tumor stage 3|T3|160|161|HISTORY OF PRESENT ILLNESS|He has a history complicated by neuropathy and underwent chemotherapy _%#MMDD2004#%_ through _%#MMDD2005#%_ with Navelbine and .....obine prior to that for his T3 N2 M.... non-small cell lung cancer. He underwent radiation therapy to a total of 161.2 gray from _%#MMDD2004#%_ to _%#MMDD2004#%_ at Mercy Radiation Therapy.
T3|tumor stage 3|T3,|153|155|PAST MEDICAL HISTORY|Complications include diabetic nephropathy and peripheral neuropathy. The patient is currently on hemodialysis 3 times a week. 3. Rectal carcinoma stage T3, N1, M0. The patient underwent chemotherapy and radiation therapy for this cancer. 4. IgG myeloma. 5. Asbestosis. 6. History of bladder cancer.
T3|triiodothyronine|T3|214|215|HOSPITAL COURSE|A urine Tox screen on the day of discharge, _%#MMDD2006#%_ was positive only for opiates and oxycodone. 5. Euthyroid sick syndrome: Due to symptoms of sweating and hot flashes, a TSH was checked and low at 0.06. A T3 was normal at 97 and free-T4 normal at 1.11. This is most consistent with a euthyroid sick syndrome. Followup is recommended. 6. History of PE: Mr. _%#NAME#%_'s INR remained therapeutic during this admission.
T3|triiodothyronine|T3|226|227|RECOMMENDATIONS|2. Thyroid mass, probably goiter with evidence of hyperthyroidism chemically but little evidence clinically. RECOMMENDATIONS: 1. We will check the patient's thyroid function tests again, including thyroid antibodies, free T4, T3 RIA. 2. We will obtain an ultrasound of her neck and then nuclear thyroid scan. 3. Concerning her chest pain, we will obtain serial troponin levels and EKGs and possibly pursue the workup further if symptoms warrant.
T3|triiodothyronine|T3|428|429|LABORATORY DATA|LUNGS: Clear bilaterally with no crackles or wheezes. ABDOMEN; Soft, nontender, nondistended with no organomegaly and no masses appreciated. There was no guarding or rebound. SKIN: Without rashes LABORATORY DATA: White blood cell count is 4.3, hemoglobin 13.2, hematocrit 40.7, platelets 178, GGT 21, total bilirubin is less than 0.1, albumen 3.7, total protein 6.6, alkaline phosphatase 43, ALT 40, AST 50, TSH is low at 0.12, T3 is normal at 88, T4 is normal at 1.04, a tox screen is positive for cocaine. Sodium is 143, potassium 4.3, chloride 110, bicarb 29, BUN 21, creatinine is 1.6 which is elevated.
T3|triiodothyronine|T3|217|218|HOSPITAL COURSE|Vital signs were within normal limits. She was afebrile. On presentation, she had a mild leukocytosis, likely stress response. This quickly resolved. All electrolytes are within normal limits. Free thyroxin was 0.94, T3 116, Cortisol level was 3.0. Urinalysis negative. Chest x-ray unremarkable. Follow-up CBCs were unremarkable. The patient's blood sugars remained within normal limits.
T3|term 3|T3,|65|67||Baby Girl _%#NAME#%_ was born on _%#MMDD2007#%_ at 1841 to a G3, T3, L3 mother by spontaneous vaginal delivery. Her Apgar scores were 8 and 9 at 1 and 5 minutes respectively. Her mother's blood group type is A positive, VDRL negative, HBSAG is negative, GBS is positive and the mother did get penicillin once prior to delivery; but that was only 2 hours before the baby was born.
T3|triiodothyronine|T3|110|111|COURSE IN HOSPITAL|She has no evidence to suggest hyperaldosteronism. Her TSH was found to be a fairly low at 0.15 but the total T3 and also free T4 was found to be in tachycardia. We believe her severe hypokalemia is the results of chronic ongoing diarrhea precipitated by her recent crash dieting.
T3|triiodothyronine|T3|256|257|PROBLEM #3|PROBLEM #3: Sick euthyroid syndrome. As part of workup of her hypokalemia, we obtained a TSH which was found to be slightly low at 0.15. We consulted Endocrinology which thought that this likely represents sick euthyroid syndrome based on the normal total T3 and free T4 levels. We do not think any further followup or investigation need to be done in addition to just a routine recheck of TSH in a couple of months' time.
T3|triiodothyronine|T3|150|151|ASSESSMENT AND PLAN|We will follow sed and CRT, an if those are significant elevated, we may contact Rheumatology and consultant. 4. Hypothyroidism. We ordered TSH, free T3 and T4. Since ......thyroid disease is related to urticaria, we may need order further workup if the thyroid screening labs tend to be abnormal.
T3|thoracic (level) 3|T3|277|278|REPAIR OF SCALP LACERATION|Admission laboratory: Hemoglobin 14.0. White count 9100, platelet count 254,000, sodium 139, potassium 3.7, glucose 139, serum creatinine 1.16. Liver function tests are normal with an albumin of 3.3. Lipase 41. Chest x-ray revealed evidence five right-sided rib fractures from T3 toT8. The upper three are displaced posterolaterally. There is no evidence of hemopneumothorax so subcutaneous emphysema is appreciated in the right chest wall.
T3|triiodothyronine|T3|408|409|HOSPITAL COURSE|The patient also had electrolytes that showed a sodium 135, potassium 3.3, chloride 101, bicarbonate 32, glucose 80, BUN 28, creatinine 0.77. The patient is having her potassium corrected per the pharmacy protocol. Erythropoietin level was pending at the time of discharge. Thyroxine free was 0.84. Her TSH was mildly depressed at 0.16, it was thought that this was related to sick thyroid syndrome, however T3 is pending at the time of discharge, which will need to be followed up by her primary physician. The patient is supposed to be going to a rehab center and Social Work will assist with that.
T3|triiodothyronine|T3|195|196|PLAN|3. Elevated erythrocyte sedimentation rate, likely related to underlying undiagnosed rheumatoid arthritis. PLAN: Differential diagnosis includes thyroiditis but TSH is normal. Free thyroxine and T3 are pending. Peritonsillar abscess and epiglottitis are very unlikely because of negative neck CT. The patient also does not have drooling, dysphagia or leukocytosis.
T3|thoracic (level) 3|T3|176|177|HISTORY OF PRESENT ILLNESS|Please see op report dated _%#MMDD2002#%_ for details. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 29-year-old who previously underwent anterior spine instrumentation from T3 to L3. This hardware was felt to be causing the patient some pain. He elected to have this particularly removed. HOSPITAL COURSE: His hospital course is unremarkable.
T3|UNSURED SENSE|T3|278|279|PROCEDURES PERFORMED DURING ADMISSION|3. Hypercholesterolemia. PROCEDURES PERFORMED DURING ADMISSION: 1. Coronary angiography was performed on _%#MM#%_ _%#DD#%_, 2002, that showed native three vessel disease, patent saphenous vein grafts to RCA OM1 and OM3 without significant lesions, and a patent LIMA to LAD with T3 flow with two sharp bends of "borderline significance." 2. Nuclear stress test performed on _%#MMDD#%_ showed no evidence of stress induced ischemia with no subjective worsening of symptoms.
T3|triiodothyronine|T3|35|36|ADDENDUM|ADDENDUM: Lab test results of free T3 on _%#MM#%_ _%#DD#%_, 2002, was 3.9, which is within normal limits. Random urine sample on _%#MM#%_ _%#DD#%_, 2002, for porphobilin was 7.8 which is within normal limits.
T3|thoracic (level) 3|T3.|199|201|HISTORY OF PRESENT ILLNESS|This appeared to be his only area of involvement of his nonsmall cell tumor. After explanation of the risks, benefits and alternatives, the patient elected to undergo T2 corpectomy with fusion C7 to T3. HOSPITAL COURSE: PROBLEM #1: The patient was admitted on _%#MMDD2007#%_.
T3|triiodothyronine|T3|197|198|DISCHARGE FOLLOW-UP|It has been a pleasure to participate in the care of this patient. If there are questions, please feel free to contact us. As mentioned above, investigation pending include HIV antibody screen and T3 and T4. Patient's TSH was found to be significantly depressed at 0.08. Revised: _%#MMDD2007#%_, sp
T3|triiodothyronine|T3|198|199|ASSESSMENT AND PLAN|We will also start him on some IV diltiazem to decrease the heart rate to less than 100. We will continue his metoprolol XL at 50. 2. A recently slightly increased TSH. We will recheck TSH and free T3 and free T4. 3. Acute on chronic renal insufficiency. Will hold his Bumex and gently hydrate. We can check his creatinine in the morning. We will also check a FENA.
T3|triiodothyronine|T3|151|152|HOSPITAL COURSE|No pleural or pericardial effusion was seen. Magnesium level was 2.3. Along with a TSH was trace elevated at 6.0, free thyroxine was normal at 1.0 and T3 was normal at 72. With 60-181 being normal limits. MEDICATIONS: Ultimately Mr. _%#NAME#%_'s heart rate was controlled with a combination of medicines including: 1. Digoxin 0.125 mg a day.
T3|tumor stage 3|T3|168|169|PLAN|The pathology report showed her to have no lymph node involvement. The tumor was through the abdominal wall without any signs of metastases which showed that she was a T3 N0. Postoperatively, the patient did well. She was noted to have significant fluid gain postoperatively associated with hypertension.
T3|thoracic (level) 3|T3|183|184|PAST MEDICAL HISTORY|8. Total knee arthroplasty. PAST MEDICAL HISTORY: 1. Type 2 diabetes mellitus on insulin. 2. Status post TIAs and CVIs. 3. History of polymyalgia rheumatica. 4. Compression fractures T3 and T11. 5. History of pneumonitis. MEDICATIONS: 1. Albuterol nebs t.i.d. 2. Ambien 5 mg at bedtime p.r.n.
T3|tumor stage 3|T3,|279|281|HISTORY OF PRESENT ILLNESS|In addition, there was a Gleason of 3+4=7 on 20% on the core specimen from the left apex. He was seen in consultation by Dr. _%#NAME#%_ for discussion of possible robotic-assisted prostatectomy, however, for fear that he would have high-volume diffuse disease and possibly stage T3, the decision was made to have an open radical retropubic prostatectomy with thorough pelvic lymph node dissection. COURSE OF HOSPITALIZATION: Mr. _%#NAME#%_ underwent a radical retropubic prostatectomy with bilateral pelvic lymph node dissection on _%#MM#%_ _%#DD#%_, 2006.
T3|tumor stage 3|T3,|65|67|FINAL DISCHARGE DIAGNOSIS|FINAL DISCHARGE DIAGNOSIS: Adenocarcinoma of the prostate, Stage T3, Gleason score of 7 ADDITIONAL DIAGNOSES: 1. Hypertension. 2. Hyperlipidemia. PRINCIPAL PROCEDURES: 1. Nerve sparing radical retropubic prostatectomy.
T3|triiodothyronine|T3|153|154|DISCHARGE MEDICATIONS|1. Coreg 6.25 mg b.i.d. 2. Demadex 10 mg every other day. 3. Lanoxin 0.125 mg daily. 4. Lotensin 5 mg daily. 5. Spironolactone 12.5 mg every evening. 6. T3 1-2 tabs every 4-6 hours p.r.n. 7. Completion of the azithromycin (just one remaining 250-mg tablet to take on _%#MMDD2002#%_).
T3|triiodothyronine|T3|248|249|HISTORY OF PRESENT ILLNESS|The patient is status post I-131 treatment for hypothyroidism in _%#MM2003#%_. She was recently re-evaluated by Dr. _%#NAME#%_ with thyroid function tests on _%#MMDD2003#%_ which showed a TSH of less than 0.011, a free T4 elevated at 4.61, a total T3 elevated at 3.34. Because of this the patient was started approximately three days ago on Methimazole 10 mg po bid by Dr. _%#NAME#%_ and her Lexapro was discontinued. The patient noted concurrent with initiation of the new medication (Methimazole) that she developed lower extremity edema and became more short of breath.
T3|triiodothyronine|T3|142|143|HOSPITAL COURSE|The patient has a history of hyperthyroidism and is followed by Dr. _%#NAME#%_. She recently had Tapazole started due to elevated Free T4 and T3 and depressed TSH. She is status post iodine ablation. The patient noted approximately two days prior to admission that her heart rate was very fast.
T3|triiodothyronine|T3|269|270|HOSPITAL COURSE|LFTs that were normal. N-terminal BNP was 275. Troponin was less than 0.4, myoglobin was 35, a TSH was mildly decreased at 0.3. The patient had a CT scan of the head which was negative for intracranial abnormality. The patient had a chest x-ray which was unremarkable. T3 free thyroxine was 0.93. The patient's EKG showed no acute changes. She was ruled out with serial troponins x3 which were negative.
T3|tumor stage 3|T3,|131|133|ADMISSION DIAGNOSES|ADMISSION DIAGNOSES: 1. Febrile neutropenia. 2. Chemotherapy-induced pancytopenia. 3. Transitional carcinoma of the bladder, stage T3, with invasion into perivesical sac and bilateral pelvic lymph nodes. 4. Status post radical cystoprostatectomy, distal urethrectomy, bilateral pelvic lymph node dissection and creation of an ileal conduit urinary diversion.
T3|triiodothyronine|T3,|123|125|DISCHARGE INSTRUCTIONS|DISCHARGE INSTRUCTIONS: 1. Followup with Dr. _%#NAME#%_ for her postop check in 2 weeks. She will have a beta-HCG and TSH, T3, and T4 before her visit. 2. Weekly beta-HCGs to be faxed to _%#NAME#%_ _%#NAME#%_, Dr. _%#NAME#%_'s nurse. 3. The patient was given instructions that she should not get pregnant for a year.
T3|UNSURED SENSE|T3|163|164|HISTORY OF PRESENT ILLNESS|Electrolytes were checked and are pending at the time of this dictation. An EKG was also obtained which showed no ST segment changes but does show perhaps S1, Q3, T3 pattern. REVIEW OF SYSTEMS: Includes no nausea, vomiting, chest pain, abdominal pain, diarrhea, melena, hematochezia, dysuria, hematuria, rash, skin lesions, weight loss, hot or cold intolerance, or psychiatric symptoms.
T3|triiodothyronine|T3|207|208|PROBLEM #1|A TSH was checked and was found to be abnormally low at 0.05. An endocrine consult was promptly obtained the morning of surgery. Free T4 and MP3 were obtained and were normal, with T4 at 5.6 , Free T4 1.02, T3 85. The endocrine consultation concluded that this is an abnormally low TSH, however, the patient was clinically euthyroid, and it would be okay to proceed with surgery from an endocrine standpoint.
T3|tumor stage 3|T3|179|180|HISTORY|HISTORY: Mr. _%#NAME#%_ _%#NAME#%_ was an 80-year-old man with known squamous cell carcinoma of the lung, for which he had undergone left upper lobe lobectomy with resection of a T3 lesion in _%#MM#%_ 2002. He had done reasonably well afterward. However, he developed a recurrent tumor of the brain, presumed to be squamous cell carcinoma, for which he undergoing radiation therapy and seemed to have a response.
T3|triiodothyronine|T3|359|360|HISTORY OF PRESENT ILLNESS|_%#NAME#%_ _%#NAME#%_ is a 71-year- old female whose PMD is Dr. _%#NAME#%_ _%#NAME#%_ at Oxboro Clinic with a history of breast cancer, status-post left modified radical mastectomy, admitted with fevers, chills and left axillary streaking erythema and edema. She has a history of hospitalization _%#MM#%_ 2002 with similar symptoms, treated with IV Ancef and T3 p.r.n. The patient states that she noticed a laceration on her thumb from several days ago and that yesterday after her evening meal she started noticing pain, erythema, warmth and redness with streaking up into her axilla in the left upper extremity.
T3|tumor stage 3|T3,|239|241|BRIEF HISTORY OF PRESENT ILLNESS|PROCEDURES PERFORMED DURING THIS ADMISSION: None. CONSULTS OBTAINED DURING THIS ADMISSION: None. BRIEF HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is 58-year-old gentleman with a history of supraglottic squamous cell carcinoma stage T3, N2C, M0, who presented for it in hospital for chemotherapy. He is status post treatment with 2 cycles of cisplatin was localized with radiation and with a history of a debulking resection.
T3|tumor stage 3|T3|137|138|HOSPITAL COURSE|Please follow his chest x-ray and respiratory symptom prior to cardiac surgery. 3. Oncology. He has a history of colon cancer, stage III T3 N2 M0 status post hemicolectomy and chemotherapy of Xeloda in _%#MM2006#%_. His followup abdominal CT scan did not reveal evidence of relapse or metastasis on _%#MM2006#%_.
T3|triiodothyronine|T3|202|203|SUMMARY OF HOSPITALIZATION|Echocardiography was unremarkable other than some elevated pulmonary hypertension. Stress test could not be obtained at this point. The patient had a TSH which was slightly low, however his free T4 and T3 levels were adequate. 7. Insomnia and depressive disorder. He was treated with trazodone and Prozac and should follow up later with his regular doctor to see how he does with his mood disorder.
T3|triiodothyronine|T3|184|185|PENDING RESULTS|PROBLEM #3: History of hyperthyroidism with multinodular goiter. The patient's TSH was 1.47. At the time of discharge, her T3 and T4 were both pending. PENDING RESULTS: 1. Followup of T3 and T4. 2. Followup of blood culture drawn on _%#MMDD2007#%_, which was no growth at 1 day. DIET: Will be regular. ACTIVITY: Will be as tolerated without restriction.
T3|thoracic (level) 3|T3|200|201|PHYSICAL  EXAMINATION|1. WBC 8.8, hematocrit 43, platelets 350. INR 3.86. CT scan: Abdomen and pelvis are negative for acute findings. MRI of the T spine shows acute versus subacute compression fracture of T8 with chronic T3 compression fracture. ASSESSMENT AND PLAN: Highly complex 82-year-old female with: 1. Subacute compression fracture at T8.
T3|tumor stage 3|T3|133|134|ADMITTING DIAGNOSIS|ADMITTING DIAGNOSIS: Hypernephroma of the right kidney, surgical stage to be determined. The patient is at least a T2 and probably a T3 primary tumor. The patient is medically clear for the upcoming surgery.
T3|triiodothyronine|T3|160|161|PROBLEM #4|PROBLEM #4: THYROID. We were requested by the patient's primary physician to get thyroid function studies, which revealed a TSH of 0.45, free T4 of 1.06, and a T3 of 92. All of these values are within normal limits. PROBLEM #5: PAIN. The patient complained of a non-specific abdominal pain, so we obtained a CT of the abdomen and pelvis which essentially came up negative, except for a right renal cyst and the appearance of diverticula in the sigmoid colon.
T3|triiodothyronine|T3|214|215||The patient initially required Foley catheterization. Norvasc was added for better hypertensive control. With improvement in patient's symptoms activity was increased. Solu-Medrol was changed to prednisone. A free T3 was found to be 241 with a normal range of 60-181 and I-123 thyroid uptake and scan has been scheduled for _%#MM#%_ _%#DD#%_ and _%#MM#%_ _%#DD#%_.
T3|triiodothyronine|T3.|141|143|HISTORY OF PRESENT ILLNESS|Upon discharge, the heparin and Coumadin were stopped. Endocrine/Hyperthyroidism: This patient had a low TSH, a high-normal T4, and a normal T3. The cause of the low TSH was not found. However, a thyroid ultrasound showed the presence of a thyroid nodule.
T3|tumor stage 3|T3,|164|166|PAST MEDICAL HISTORY|1. Rectal cancer diagnosed via colonoscopy after presenting with bloody stools in _%#MM#%_ of 2003. Biopsies showed mildly differentiated adenocarcinoma stage IIA, T3, N0, M0. Abdomen and chest CT of _%#MM#%_ of 2004 showed 2 nonspecific right liver lobe densities. Per patient, he is status post 6 rounds of chemotherapy with 5-FU along with another agent, as well as 25 rounds of radiation, with all ending last week.
T3|triiodothyronine|T3|144|145|1. GI|2. Cardiology: Repeat Echo and Cardiology clinic follow-up at 4-6 months of age for small ASD. 3. Endocrine: Recheck TSH, Free T4, Total T4 and T3 in 2 weeks after initial levels from _%#MMDD2004#%_. Discharge medications, treatments and special equipment: 1. G-tube equipment and routine cares including washing with warm, soapy water BID; sutures are absorbable
T3|thoracic (level) 3|T3|232|233|PAST MEDICAL HISTORY|He was admitted with some fevers, chills, no hemoptysis. He also complained of significant abdominal pain and had not had a stool in 3 days. PAST MEDICAL HISTORY: 1. Cystic fibrosis. 2. Hemoptysis status post embolization of T2 and T3 intercostal arteries _%#MM#%_ _%#DD#%_, 2004. 3. Cystic fibrosis related bronchiectasis with mild obstruction baseline. His pulmonary function tests during this admission showed an FEV1 of 2.71 (64%) and an FVC of 4.56 (90%).
T3|thoracic (level) 3|T3|223|224|PERTINENT STUDIES AND PROCEDURES|3. _%#MMDD2008#%_, status post bone marrow biopsy showed cellularity of 5-10% with 1.8% blasts representing residual leukemia. 4. _%#MMDD2008#%_, MRI of the thoracic spine showed abnormal signalling contrast enhancement of T3 and T9 as well as in the left transverse processes of T4 and T8 (stable compared with previous). 5. _%#MMDD2008#%_, MRI of the cervical spine showed slight interval increase in C6 vertebral body contrast enhanced focus with no extension into the epidural space; changes consistent with degenerative joint disease.
T3|tumor stage 3|T3,|191|193|HOSPITAL COURSE|She now presents for elective surgery. HOSPITAL COURSE: The patient underwent surgery on the day of admission, _%#MM#%_ _%#DD#%_. A right hemicolectomy was performed. The specimen revealed a T3, N0, M0 cancer of the colon. There is a palpable abnormality at the dome of the liver. This is not biopsied because of its location. Her postoperative course was uneventful.
T3|triiodothyronine|T3|256|257|LABORATORY|LABORATORY: On admission date, her sodium was 144, potassium 5, chloride 116, bicarbonate 23, BUN 75, creatinine of 3.21, GFR of 14, calcium level 7.7, BNP more than 5000. Her albumin is low at 2.9. Hemoglobin A1C was 7. She had a high TSH of 10, and free T3 of 2.1. MEDICATIONS: 1. Tamoxifen. 2. Prevacid. 3. Furosemide 20 mg b.i.d. 4. Hydrochlorothiazide 25 mg daily.
T3|triiodothyronine|T3|90|91|MEDICATIONS|9. Aspiration pneumonia. 10. Urinary tract infection. MEDICATIONS: 1. Xanax 0.5 q.i.d. 2. T3 t.i.d. 3. Lasix 80 q. day. 4. Metoprolol 12.5 b.i.d. 5. Compazine 10 mg p.r.n. 6. Protonix 40 q. day. 7. Zoloft 100 q. day. ALLERGIES: 1. Dilaudid. 2. Haldol.
T3|T3 (ECG pattern)|T3|196|197|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|He subsequently came to the emergency department, where he received nitroglycerine, metoprolol, and aspirin with some relief of the pain. His EKG revealed ST-segment changes, with ST elevation in T3 and AVF and ST depression in V1 and V2. The patient was subsequently taken to the Cath Lab, where he had 90% stenosis in the left circumflex.
T3|tumor stage 3|T3,|146|148|DISCHARGE DIAGNOSIS|ADMISSION DIAGNOSIS: Squamous cell carcinoma of the left base of tongue. DISCHARGE DIAGNOSIS: Squamous cell carcinoma of the left base of tongue. T3, N2b. PROCEDURES: 1. Diagnostic laryngoscopy with biopsy. 2. Left modified radical neck dissection.
T3|triiodothyronine|T3|157|158|PROCEDURES AND TESTS|PROCEDURES AND TESTS: 1. Admission chemistries remarkable for a CBC with a white count of 26,000, hemoglobin of 10.5. platelet count 139. TSH of 0.09 with a T3 of 124 and a free T4 of 1.78. 2. Electrocardiogram with findings of atrial flutter and rapid ventricular response.
T3|tumor stage 3|T3|163|164|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is well known to the Colorectal Surgery Service. He is a 75-year-old man with history of prostate cancer in 2000, and a T3 N1 rectal cancer in 2002, for which he underwent an extended low anterior resection and colostomy. Since that time, he has developed a large pelvic tumor recurrence, which is thought to be rectal in origin, and chemotherapy is currently planned.
T3|triiodothyronine|T3,|142|144|PLAN|We will check a comprehensive metabolic panel, a serum ammonia, B12, folate, rheumatoid factor, FANA, as well as sed rate and RPR, as well as T3, T4, and a TSH on the patient. We will continue her on her present drug regimen.
T3|T3 (ECG pattern)|T3.|189|191|PHYSICAL EXAMINATION|Sodium 146, potassium 3.7, chloride 109, CO2 28, BUN 17, creatinine 0.8, glucose 135, total bilirubin 0.5, INR 1. LFTs normal. EKG shows sinus tachycardia at a rate of 115 with and S1, Q3, T3. HOSPITAL COURSE: 1. Dyspnea. The patient was admitted to the medicine service and with S1, Q3, T3 on EKG, the patient underwent a CT pulmonary angiogram of the chest to rule out a pulmonary embolism.
T3|triiodothyronine|T3|160|161|ASSESSMENT/PLAN|I will also discuss with her daughter about her renal artery stenosis and see what past interventions were done. 5. Hyperthyroidism with a low TSH. We will add T3 and T4. We will start PTU and I will have endo see her with her complicated past history of colloid goiter.
T3|triiodothyronine|T3|150|151|SUMMARY OF HOSPITAL COURSE|She was treated with potassium supplements during her hospitalization as well as TPN. A TSH was found to be low but a concomitant free T4 and/or free T3 was not obtained. The patient subsequently was treated with 0.05 mg Synthroid rather than her usual 0.1 mg Synthroid. The patient had low back pain with sciatica which improved with conservative treatment during her hospitalization.
T3|thoracic (level) 3|T3|155|156|PAST MEDICAL HISTORY|9. Workup at Parker Hughes for abnormal liver enzymes included an abdominal ultrasound, which showed normal portal vein flow. MRI showed lesions in C7 and T3 in the vertebral bodies. MRI of the abdomen showed ascites around the liver and spleen in moderate amounts, and no liver masses.
T3|tumor stage 3|T3|205|206|ASSESSMENT/PLAN|He reports that he first became polyuric a few months ago and this led him to seek urological care. He was admitted on _%#MMDD2005#%_ and underwent nephroureterectomy on that day. His pathology revealed a T3 (through full thickness of ureteral wall) high grade urothelial carcinoma. There was also evidence of perineural invasion and the radial margin was positive for invasive cancer.
T3|thoracic (level) 3|T3|258|259|HISTORY OF PRESENT ILLNESS|She also complains of pain in the neck and occasionally has pain going between her shoulder blades as well as some arm pain from the neck to the hand. She relates that she occasionally drops things and has occasional falls. The patient also has a very small T3 through T6 syrinx that has been followed because for her persistent symptoms of the patient, as well as the pain and numbness of her upper torso and her arms.
T3|triiodothyronine|T3|147|148|LABORATORY DATA|Hemoglobin was monitored and stable. On the day before discharge, hemoglobin was 10.8. Due to low TSH, additional thyroid studies were ordered and T3 was 64 and free T4 1.12, both within normal limits. Due to anemia, iron studies were ordered and iron level was 97 which was normal, ferritin increased at 503, iron saturation 42% which was normal, TIBC 231 which is low.
T3|tumor stage 3|T3|165|166|HOSPITAL COURSE|Stool was sent for C-difficile which was negative, however, she has empirically improved on Flagyl. Pathology was obtained during the admission which demonstrates a T3 N0 colon cancer in the cecum with negative surgical margins and no positive lymph nodes. Oncologic evaluation was undertaken with Dr. _%#NAME#%_ for consideration of chemotherapy.
T3|triiodothyronine|T3|226|227|HISTORY OF PRESENT ILLNESS|He did receive blood transfusions. Sodium low at 132, ferritin 1,500, iron and iron binding capacity low at 15 and 216 respectively. He also had problems with hypothyroidism and TSH was 13. Repeat at 105. Dropping back to 72. T3 uptake was normal twice checked. B-12 folate level normal. Adrenal corticotropin normal. CRT elevated at 39, decreased to 29. Hemoglobin is low 6.2, 10.0 on discharge. Erythropoietin level 29, felt to be decreased.
T3|triiodothyronine|T3|211|212|PLAN|4. Hyperthyroidism with question of a large hot nodule, substernal goiter, on the left and a multinodular in the right lobe. PLAN: 1. The patient will be observed on the cardiac monitor. 2. We will check a free T3 and T4. 3. She is on Tequin IV 400 mg q.d. pending urine culture results. 4. Pulmonary consultation will be obtained. 5. Endocrinology consultation will be obtained.
T3|term 3|T3,|105|107|HOSPITAL COURSE|DOB: _%#MMDD2004#%_ HOSPITAL COURSE: Baby _%#NAME#%_ is twin #1, delivered by C-section, to a gravida 4, T3, A2, L2, mother who had an unknown GBS, negative VDRL, negative HIV, and Hepatitis B Surface Antigen negative. Mother's blood type was B positive and the infant was delivered at 37- 1/7-week's with a weight of 6 lb 1/2 oz and was vigorous with Apgars of 8 and 9.
T3|tumor stage 3|(T3,|175|178|HISTORY OF PRESENT ILLNESS|3. Port removal. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 54-year-old gentleman who was initially diagnosed with adenocarcinoma of the GE junction, which was stage III (T3, N1 M0) in 2002. The patient was treated with carbotaxol chemotherapy concurrently with radiation. The patient then underwent esophagraphic resection _%#MMDD2002#%_. Postoperatively, his course was complicated by sepsis, abscess formation, and fistulas of the site of surgical anastomosis.
T3|triiodothyronine|T3,|231|233|PLANS FOR DISCHARGE|There is no pitting edema noted. Neurovascular is intact. Neck reveals mildly enlarged thyroid with no nodule palpable on examination. PLANS FOR DISCHARGE: 1. Hyperthyroidism with TSH of less than 0.02. Labs pending include a free T3, free T4, and thyroid antibodies. The patient is to follow up with endocrinology at the University of Minnesota on _%#MM#%_ _%#DD#%_, 2005, at 10 a.m. This information was given to the patient and recommended to follow up there to discuss treatment options.
T3|tumor stage 3|T3,|245|247|ADMISSION DIAGNOSIS|A colonoscopy showed a tumor in the cecum and subsequent CT scan demonstrated bowel obstruction and isolated mass in the caudate lobe. A laparoscopic right hemicolectomy was performed on _%#MM#%_ _%#DD#%_, 2005. Her pathology report returned as T3, N2 colon cancer. A laparoscopic liver biopsy was performed at the time of surgery, which was positive for metastatic disease.
T3|triiodothyronine|T3,|169|171|FOLLOW UP|As for his heart failure he will follow up as routinely scheduled. Of note, the follow up labs and tests done on his initial Endocrinology visit should include a TSH, a T3, T4 and calcium levels.
T3|thoracic (level) 3|T3|290|291|HISTORY OF PRESENT ILLNESS|In the emergency department, the patient had a CT scan of the chest, abdomen and pelvis, which showed multiple bilateral older fractures, with two acute rib fractures on the right anterior ribs, no parenchymal injury. CT scan of the cervical spine showed DJD, and no fractures, with an old T3 area compression fracture. Head CT reconfirms a posterolateral right maxillary fracture with blood and fluid in it.
T3|triiodothyronine|T3|226|227|HOSPITAL COURSE|HOSPITAL COURSE: 1. Atrial fibrillation with rapid ventricular response. The patient had routine laboratory workup, including serial troponins which were negative. Thyroid function revealed a suppressed TSH, and elevated free T3 and T4. He was started on anticoagulation, and was started on beta blockers, and was placed on a dofetilide protocol.
T3|triiodothyronine|T3|178|179|HOSPITAL COURSE|2. Hyperthyroidism. The patient did not show any diffuse goiter or nodules on physical exam. The patient's TSH was severely suppressed. His free T4 was elevated to 2.50, and his T3 was also noted to be elevated. At the time of this dictation, TSH antibodies are pending. The patient was started on methimazole, and has a 2-week followup appointment with Dr. _%#NAME#%_.
T3|triiodothyronine|T3|157|158|PATIENT HISTORY|On the day of discharge, the patient's creatinine was 1, BUN 10 and potassium was 3.7. The patient's TSH level was abnormally low at 0.33, but a free-T4 and T3 level were both normal. Magnesium level was 2.1. The patient was in good condition. He was discharged with follow-up as arranged. Dr. _%#NAME#%_ recommended the follow-up with the Holter monitor in two weeks and the follow-up with him.
T3|triiodothyronine|T3|184|185|HOSPITAL COURSE|A goal LDL, given his diagnosis of diabetes would be 70 mg per deciliter. Additionally, the patient was noted to have an inappropriately suppressed TSH of 0.29. Free T4 was 0.73, free T3 is currently pending. Radioactive iodine uptake scan has been ordered on the patient. He will follow-up on the results of this with Dr. _%#NAME#%_ when he sees her in follow-up.
T3|triiodothyronine|T3|313|314|LABORATORY DATA|Negative urine pregnancy test. Urinalysis demonstrated presence of ketones and squamous epithelial cells consistent with vaginal contamination. Urine drug screen was negative. Further labs included normal B12 at 977, sed rate of 23, C-reaction protein normal at 4.4, rheumatoid factor less than 20, TSH 0.83 with T3 of 150, free T4 of 1.37. While on Psychiatry, the patient developed fever to 100 degrees with noted heart rate in the 160s.
T3|tumor stage 3|T3|201|202|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 52-year-old man who presented in _%#MM2005#%_ with abdominal pain and rectal bleeding. At that time a rectal cancer was diagnosed and staged as a T3 N1 lesion by ultrasound. He underwent preoperative chemotherapy and radiation therapy which had been recommended as an adjuvant to surgery; however, he declined surgery until recently.
T3|tumor stage 3|T3|266|267|HISTORY OF PRESENT ILLNESS|DIAGNOSES: 1. Wound dehiscence and probable infection. 2. Paraparesis secondary to incomplete spinal cord injury secondary to metastatic cancer of his spine. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 73-year-old gentleman with a metastatic renal cell tumor to T3 with pathologic fracture "compression." He is status post resection of his tumor and decompression of his spinal cord on _%#MM#%_ _%#DD#%_, 2005.
T3|triiodothyronine|T3|191|192|HOSPITAL  COURSE|Hemoglobin came up to the low 11 range and has remained stable since that time. Hemoglobin at the time of is 10.9. Thyroid studies showed an elevated TSH of 6.06. However, the patient's free T3 and free T4 were normal. Questionable true hypothyroidism versus a sick euthyroid. Thyroid studies will be repeated in a month. The patient was found to be iron deficient and will be started on iron therapy.
T3|tumor stage 3|T3|229|230|BRIEF HISTORY OF PRESENT ILLNESS|3. Bilateral lower extremity ultrasound performed on _%#MMDD2007#%_, which demonstrated no deep venous thrombosis. BRIEF HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a pleasant 33-year-old female, who is diagnosed with stage II T3 and 1 M0, ER PR positive left breast cancer in 2001. She was treated with bilateral mastectomy followed by chemotherapy and radiation.
T3|tumor stage 3|T3,|128|130|HOSPITAL COURSE|At that time a colonic tumor was removed and primary anastomosis was achieved. The tumor was felt to be an adenocarcinoma stage T3, N0, MX. Post-operative and pre-operative anemia. The patient's hemoglobin was stable both pre-operatively and post-operatively.
T3|tumor stage 3|T3,|183|185|MAJOR IMAGING AND PROCEDURES DONE DURING HOSPITALIZATION|No evidence of distant metastasis found on this exam. FNA of the pancreatic mass showed malignant cells. ( Final path = Positive for Malignancy. Adenocarcinoma.) This would be staged T3, Nx, M0 dilated bile duct with gallbladder with sludge. Atrophic pancreas with dilated pancreatic duct. 3. ERCP Impression of malignant-appearing biliary stricture from the pancreatic tumor was found in the bile duct with extreme dilatation of the bile duct.
T3|tumor stage 3|(T3|255|257|PAST MEDICAL HISTORY|His mother was recently diagnosed with diabetes. PAST MEDICAL HISTORY: He was diagnosed with pancreatic cancer in _%#MM#%_ 2002 after experiencing weight loss and abdominal pain. He underwent a Whipple procedure in _%#MM#%_ 2002. His cancer was a stage 3 (T3 N1 M0). In _%#MM#%_ 2002 he underwent incision and drainage for abdominal abscess. He had history of left knee surgery in 1977 and 1978.
T3|triiodothyronine|T3|143|144|MEDICATIONS ON ADMISSION|BUN a little elevated at 59 but it came down to 37, creatinine 2.8, came down to 1.9. Hemoglobin A1C was 8.1. Cholesterol 157, HDL 28, LDL 91, T3 2.8, triglycerides 187, hemoglobin 11.6, down from 13.7 after rehydration. Normal CBC. Normal abdominal ultrasound which was done because she had some vague pain but she denied pain, actually it was her relatives who wanted that done.
T3|tumor stage 3|T3,|162|164|DETAILS OF ADMISSION|Surgery was, therefore, delayed, and she was referred to Dr. _%#NAME#%_ for further evaluation. Endorectal ultrasound was obtained in _%#CITY#%_ which revealed a T3, N1 lesion beginning at the level of the internal anal sphincter and extending upwards for several cm. CT scans did not reveal any evidence of metastatic disease.
T3|UNSURED SENSE|T3,|208|210|ADMISSION LABORATORY DATA|Sodium 139, potassium 4.9, chloride 104, bicarb 18, BUN 17, creatinine 1.1, glucose 123, calcium 9.5. INR is 2.32. Anion gap is 17. EKG reveals normal sinus rhythm with T wave inversion of V1, V2, some Qs in T3, aVF, prolonged QT. ASSESSMENT: A 59-year-old female with past medical history of ASCVD, DVT, and history of pulmonary embolus on chronic Coumadin who presents with the sudden onset of abdominal cramping and hematochezia associated with one episode of syncope.
T3|triiodothyronine|T3|221|222|HOSPITAL COURSE|She remained afebrile during the course of her hospitalization. Blood pressures were all within normal limits. Oral intake was good. Abdominal exam remained benign. Thyroid level, free, was 1.27 and TSH 1.6, calcium 8.8, T3 was pending. Glucose 93, BUN 6, creatinine 0.6, potassium 3.6. Blood cultures negative. Urine culture pending, apparently negative. CT of the abdomen and pelvis showed a previous cholecystectomy, hysterectomy, sigmoid diverticulosis.
T3|triiodothyronine|T3|166|167|LABS AT FAIRVIEW LAKES|There was a slight neutrophilic left shift. Her LDH was 407. Reticulocyte count was 0.4% with an absolute retic value of 11.3. TSH was 6.36. Free thyroxine was 1.04. T3 was 103. Ferritin was elevated at 589. Her iron level was 12. Transferrin 131, transferrin binding capacity 195, and iron saturation of 6; all of the iron studies were low except for the ferritin, which was high.
T3|thoracic (level) 3|T3|114|115|PAST MEDICAL HISTORY|4. History of SVT status post ablation in _%#MM#%_ 2002. 5. T2 to T4 laminectomy and debulking of tumor and right T3 foraminotomy, _%#MM#%_ _%#DD#%_, 2003. 6. T2 to T4 fusion with T3 laminectomy and excision of T3 tumor on _%#MM#%_ _%#DD#%_, 2003. 7. Tricuspid valve repair, 1993. 8. History of appendectomy.
T3|triiodothyronine|T3|163|164|ASSESSMENT AND PLAN|B. Palpitations may be related to cardiac arrhythmia. The patient had sinus bradycardia and that may be attributed to a subclinical hypothyroidism. We will obtain T3 and T4 levels, and if markedly low, will consider Synthroid replacement. C. Also may be related to panic and anxiety disorders that would be considered if excluded all other causes as above.
T3|triiodothyronine|T3|187|188|ASSESSMENT AND PLAN|2. History of hyperthyroidism, status post radioactive iodine. The patient now had elevated TSH which is mildly related, and could be related to subclinical hypothyroidism. A. Will check T3 and T4 as above. We will follow up. B. There is no need for immediate start of Synthroid at this time.
T3|tumor stage 3|T3|196|197|HOSPITAL COURSE|Her pain and her incision was healing nicely. At her request, she was seen by cardiac rehab, smoking cessation consultation service and recommendations were removed. A pathology report revealed a T3 N0 lesion. By the time of discharge on the 8thx postoperative day, her rash was improving. Her abdominal pain was well controlled. She was tolerating a diet with good GI function.
T3|triiodothyronine|T3|135|136|ASSESSMENT AND PLAN|At this time the patient ...... The patient was also found to have an elevated TSH level at 8.62. We will check total T4, free T4, and T3 levels today. We most likely will start on Synthroid prior to her discharge.
T3|triiodothyronine|T3.|113|115|ASSESSMENT|2. Hypothyroidism. We note the TSH is 18.86 and she is on Synthroid 150 mcg per day. We will check a free T4 and T3. PLAN: 1. Intravenous fluids. 2. Intravenous insulin and then we will switch to subcutaneous insulin.
T3|triiodothyronine|T3,|182|184|PAST MEDICAL HISTORY|She has been treated, I believe, empirically with steroids intermittently. 2. Questionable hypothyroidism. Laboratory studies seem consistent with subclinical hypothyroidism, normal T3, T4, but slightly low TSH. She is being followed by endocrinology, they are checking follow-up thyroid studies. 3. History of rheumatoid arthritis. Again, unclear this is true diagnosis or not.
T3|triiodothyronine|T3|208|209|HOSPITAL COURSE|The patient reverted spontaneously back to a sinus rhythm. Workup for an atrial fibrillation include a lower extremity Doppler looking for DVT which was negative. TSH which was mildly reduced, but subsequent T3 and free T4 were normal. Cardiac enzymes were normal. The patient will remain on anticoagulation. DISCHARGE MEDICATIONS: 1. Fosamax 70 mg p.o. q. week.
T3|T3 (ECG pattern)|T3.|179|181|LABORATORY STUDIES|No abnormal movements. Normal speech. Normal mentation. Strength 5 out of 5 in extremities times four. LABORATORY STUDIES: ECG revealed by me shows a normal sinus rhythm, S1, Q3, T3. Chest x-ray PA and lateral: Initial study shows a large right pneumothorax. Followup chest x-ray following chest tube placement shows no clear residual pneumothorax.
T3|triiodothyronine|T3|143|144|HOSPITAL COURSE|EKG showed normal sinus rhythm with no ST/T changes. No delta wave. The work up for tachycardia included a TSH level which was normal at 0.71, T3 was within normal limits, free thyroxine was decreased at 0.66. Urine drug screen was negative. The patient was evaluated by Dr. _%#NAME#%_ _%#NAME#%_ for her supraventricular tachycardia.
T3|triiodothyronine|T3|191|192|IMPRESSION|CT scan of the chest is done. Preliminary reading is that this is normal as well. IMPRESSION: 1. Syncopal episode. Differential diagnoses at this point would include thyrotoxicosis, possibly T3 elevation. 2. Urinary tract infection 3. Anemia uncharacterized at this point PLAN: The patient will be admitted on Med-telemetry.
T3|thoracic (level) 3|T3|131|132|DISCHARGE DIAGNOSIS|2. Positive sagittal balance. 3. Previous back surgeries that resulted in T9 to pelvis fusion. Status post posterior spinal fusion T3 through sacrum with osteotomy of T7 to T10 vertebral bodies. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 66-year-old female who was seen by Dr. _%#NAME#%_ in the clinic for increasing pain in her back and leg, and she had had previous back surgeries that resulted in T9 through pelvis fusion.
T3|thoracic (level) 3|T3|265|266|PROCEDURE|It was recommended that she should have a revision of the posterior spinal fusion and osteotomies as needed at that time, and she was scheduled to have that procedure done electively. PROCEDURE: Revision of posterior spinal fusion with segmental instrumentation of T3 through pelvis using local spine autograft bone and allograft bone with BMP. Osteotomies at T7, T8, T9, and fusion mass osteotomy at T9 and T10.
T3|tumor stage 3|T3,|185|187|HOSPITAL COURSE|The Foley catheter was removed, as was his Jackson-Pratt drain from the pelvis. He was tolerating a regular diet at time of discharge. The pathology report from the specimen revealed a T3, N2, M1 stage IV adenocarcinoma of the rectosigmoid colon. He will follow up in our office in about 3-4 weeks or sooner should problems develop.
T3|tumor stage 3|T3|149|150|PHYSICAL EXAMINATION|There was a metastatic cancer on one lymph node out of 3 nodes. PRINCIPAL DIAGNOSIS. Adenocarcinoma of the upper rectum. Staging PT NM followed by a T3 N1. SECONDARY DIAGNOSIS includes 1. Diabetes mellitus type 2. 2. Hypertension.
T3|tumor stage 3|T3|264|265|HISTORY OF PRESENT ILLNESS|Her primary physician felt a rectal mass and sigmoidoscopy revealed an ulcerated rectal mass which on biopsy was an adenocarcinoma 4 cm proximal to the dentate line. Colonoscopy showed this mass with no evidence of obstruction. By transrectal ultrasound, it was a T3 N1 lesion. I saw the patient in consultation on _%#MMDD2006#%_ and we recommended that she begin appropriate chemo-radiation therapy.
T3|triiodothyronine|T3|137|138|LABORATORY DATA|His hemoglobin was noted to be about 11.8, platelet count 194,000, white count 5.5, and creatinine of 1.49. A free thyroxine was 0.19. A T3 is pending. TSH is 63.94. A PTT is noted to be prolonged at 69. A 1 to 2 battery showed the 1 to 2 second of 78 and the 1 to 4 was noted to be increased, and they recommended a lupus inhibitor, which is pending at this time, as well as a T3.
T3|triiodothyronine|T3.|174|176|LABORATORY DATA|A 1 to 2 battery showed the 1 to 2 second of 78 and the 1 to 4 was noted to be increased, and they recommended a lupus inhibitor, which is pending at this time, as well as a T3. Anticardiolipin antibody showed a positive IgM of 15.1. LFTs were all within normal limits. Fungal cultures, and anatomic pathology on the bronchoscopy biopsy are all pending at this time.
T3|tumor stage 3|T3,|200|202|DETAILS|The above operative procedure was carried out. Postoperatively, she did extremely well and had no untoward complications and by the 5th day was ready for discharge to home. Her path report revealed a T3, N1, M0 lesion. Because of the patient's advanced age and her desire to have no further chemo or radiation therapy, no adjuvant therapy was recommended or considered at this time.
T3|triiodothyronine|T3|143|144|ADDENDUM|ADDENDUM: The discharge summary was dictated today after Ms. _%#NAME#%_ left. Her labs were reviewed. Her TSH was 7.14 and free thyroxine 1.1, T3 of 103. So, these labs were consistent with a sick euthyroid syndrome. She was started on low dose thyroxine, which should be discontinued when she sees her primary care physician.
T3|triiodothyronine|T3|186|187|185 PPS.|Her electrolytes were normal. Her CBC was also normal. Her chest x-ray was clear. Her CK was 37. Her CRP was normal as was her ESR. Her thyroid stimulating hormone was low, however, her T3 and T4 levels were normal. The patient did have an elevated BNP. As a result, a cardiology consult was obtained. The transthoracic echocardiogram showed mild diastolic dysfunction. As a result, the patient was started on Norvasc per the cardiology recommendations.
T3|triiodothyronine|T3|143|144|HOSPITAL COURSE|Other medical issues that were addressed included probable mild hyperthyroidism related to thyroid replacement, TSH was less than 0.03. T4 and T3 were in the upper limits of normal. His levothyroxine dose will be, therefore, decreased. DISCHARGE DIAGNOSES: 1. Pneumonia, likely aspiration. 2. Dysphagia. 3. Dementia. 4. History of seizure disorder.
T3|triiodothyronine|T3|194|195|ANTEPARTUM COURSE SUMMARY|Endocrinology staff physician Dr. _%#NAME#%_ saw the patient and evaluated her past fibroid issues. Her thyroid hormone resistance had resulted in a goiter and also caused increased free T4 and T3 and normal TSH and so PTU will be continued at 150 mg daily to protect her baby and she will follow up with Dr. _%#NAME#%_, endocrinologist as previously described in her prenatal visits.
T3|triiodothyronine|T3.|264|266|HOSPITAL COURSE|With her failure to thrive workup, she had a very low prealbumin level and also her total protein level were low consistent with her less than _stellar nutritional status. She also has low TSH with normal thyroid peroxidase antibodies as well as free T4 and total T3. Due to the CAT scan that she received and having received iodine dye, she cannot get the thyroid scan done for 4 more weeks.
T3|tumor stage 3|T3,|228|230|ADDENDUM|ADDENDUM The results of pathology are as follows: The tumor measures 3 x 2 x 1 cm and infiltrates through the muscular wall into the serosal adipose tissue. There were 4 out of 19 positive lymph nodes. This is consistent with a T3, N2 lesion.
T3|tumor stage 3|T3|166|167|FOLLOWUP|Pathology from that procedure revealed a 3 cm primary tumor of adenocarcinoma invading through the muscularis propria and into the pericolonic fat/soft tissues (i.e. T3 lesion). However, 0 of 19 resected pericolonic lymph nodes were positive for localized spread (i.e. N0 status). Her metastatic status is unknown (Mx) but her initial CT scans of the abdomen and pelvis revealed no evidence of bulky metastatic disease.
T3|thoracic (level) 3|T3.|216|218|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ back in _%#MM#%_ with a sneeze felt a sudden electrical sensation shoot down both legs and into his chest area. He was evaluated by his physician and found to have a pathologic compression fracture of T3. This resulted in a workup which discovered a carcinoma, which is listed as unknown etiology. Apparently CT scanning of the chest done on _%#MMDD2007#%_ demonstrated an irregular mass posterior basal segment of the left lower lobe, a mass adjacent to the right posterolateral heart border, and several small pulmonary nodules.
T3|triiodothyronine|T3|217|218|ASSESSMENT/PLAN|Given the patient's abnormal ultrasound she may be a candidate for radioactive iodine uptake scan. However, if the patient's T4 level was within normal limits a conservative approach can be taken with a TSH level and T3 and T4 levels being drawn in one month to look for resolution of the symptoms. 3. Abnormal LFTs; the patient does have gallbladder thickening and fluid in the right upper quadrant.
T3|tumor stage 3|T3|44|45|FINAL DIAGNOSES|FINAL DIAGNOSES: 1. Colonic adenocarcinoma, T3 N2 M0, stage IIIC, status post hemicolectomy. 2. History of gastric carcinoid tumors, status post endoscopic resection. 3. Type 2 diabetes mellitus. 4. Hyperparathyroidism. 5. Hypertension.
T3|tumor stage 3|T3|215|216|HOSPITAL  COURSE|She underwent right hemicolectomy on _%#MMDD2007#%_ without complications, and fortunately had relatively rapid resolution of normal bowel function and an uneventful postoperative course. Her pathologic staging was T3 N2 M0, placing her at Stage IIIC. a. Oncology was consulted and at this point they have recommended adjuvant chemotherapy with FOLFOX versus research trial medication to start in the next 3-4 weeks.
T3|thoracic (level) 3|T3|159|160|PAST MEDICAL HISTORY|5. Traumatic brain injury (TIB), status post MVA at age 16. 6. Last MRI on _%#MMDD2007#%_ showed multiple metastatic lesions with mild cord compression in the T3 through T5 lesions with advanced compression at T10. ALLERGIES: 1. CT dye. Reaction is not known. 2. Lidocaine or Lanacane.
T3|thoracic (level) 3|T3|120|121|IMPRESSION AND PLAN|2. History of previous small-bowel obstructions with lysis of adhesions x2. 3. Metastatic breast cancer to the spine at T3 through T5 with mild compression, as well ad advanced compression at T10. We will consult Dr. _%#NAME#%_ _%#NAME#%_ who is her oncologist to see her here.
T3|tumor stage 3|T3.|150|152||Mr. _%#NAME#%_ _%#NAME#%_ is a 66-year-old gentleman with low to mid rectal cancer that on preoperative staging by MRI and ultrasound was noted to be T3. He underwent neoadjuvant chemoradiation and was then taken to the operating room for elective low anterior resection. He in addition had a cecal polyp that was removed partially on his preoperative colonoscopy.
T3|triiodothyronine|T3|118|119|PROBLEM #5|PROBLEM #5: Probable hypothyroidism. She complained of lethargy and weakness and we have ordered TSH, which was 15.2. T3 and T4 are pending on time of this dictation. Please follow these labs and repeat TSH 2 weeks later. I will put her on a low dose of Synthroid on time of discharge.
T3|triiodothyronine|T3|416|417|HISTORY OF PRESENT ILLNESS|LABORATORY: Sodium 143, potassium 4.3, chloride 104, bicarbonate 24, BUN 11, creatinine 0.3, glucose 88, calcium 9.9, magnesium 2.3, phosphorous 5.5, white blood cell count 10,900 with 57% neutrophils, 30% lymphocytes, hemoglobin 12.8, hematocrit 36.8, platelets 561, total protein 7.7, albumen 4.9. AST 30, ALT 21, alkaline-phosphatase 149, total bilirubin 0.2, INR 0.92, PTT 34. Fibrinogen 345. TSH 2.24, T4 2.04, T3 253. HOSPITAL COURSE: 1. Right optic glioma. _%#NAME#%_ was started on dexamethasone 4 mg IV q.6h. to decrease the swelling of the optic nerve.
T3|triiodothyronine|T3|397|398|HOSPITAL COURSE|2. Endocrine. _%#NAME#%_ was initially placed on insulin drip, and this was titrated, based upon her serum and fingerstick glucoses and eventually switched over to IM Glargine and Humalog as her blood glucose control improved. She had multiple endocrine labs drawn during her admission including an islet cell antibody of the less than 1:4 ratio, insulin antibodies less than 3, C-Peptide to 3.6, T3 less than 40, free T4 1.07 with a TSH of 1.16. 3. CV/Respiratory. Stable. 4. GI/GU. _%#NAME#%_ was continued on her tacrolimus with levels varying from 10.9-14.0 during her admission.
T3|tumor stage 3|T3|137|138|SUMMARY OF HOSPITAL COURSE|This rectal cancer was diagnosed by a colonoscopy done for rectal bleeding. A subsequent workup revealed that this is a locally advanced T3 lesion and that he had metastatic disease to the liver. _%#NAME#%_ had undergone preoperative chemo radiation therapy and on _%#MMDD2003#%_ he underwent a low anterior resection with diverting loop ileostomy.
T3|tumor stage 3|T3|157|158|BRIEF HISTORY|BRIEF HISTORY: The patient was an 84-year-old male with a history of squamous cell carcinoma who is status post a left pneumonectomy on _%#MMDD2003#%_ for a T3 N0 M0 cancer. He presented to clinic on _%#MMDD2003#%_ with increasing cough and labored breathing. It was decided the patient was to be admitted to the Surgical Intensive Care Unit.
T3|tumor stage 3|T3|213|214|HOSPITAL COURSE|Therefore, he will be discharged to home today on his home medication, in addition to Percocet for pain and Colace for constipation. Also, Dr. _%#NAME#%_ had discussed his pathology results with him, which showed T3 and 0 stage and some extracapsular invasion on the left, as well as a positive urethral margin, however, the lymph nodes were negative.
T3|triiodothyronine|T3|164|165|PLAN AT THIS TIME|2. We will place the patient on aspirin. In addition, we will order a chest CT scan to rule out pulmonary emboli as a cause for atrial fibrillation. 3. A TSH, free T3 and T4 will also be obtained. 4. She will be gently diuresed overnight with intravenous Furosemide.
T3|tumor stage 3|T3|198|199|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Status post resection of right upper lobe lung cancer in 1998. 2. Status post right completion pneumonectomy on _%#MM#%_ _%#DD#%_, 2005, for recurrent adenocarcinoma. 3. 2A T3 N0 (4.3 cm) with chest wall invasion. 4. 1B chest wall resection ribs 4, 5, and 6. 5. Postoperative atrial fibrillation, resolved. Currently on Coumadin. SOCIAL HISTORY: He is not a smoker or a drinker and he is currently retired.
T3|thoracic (level) 3|T3|136|137|DISCHARGE DIAGNOSIS|10. Benign prostatic hypertrophy. 11. Right shoulder rotator cuff syndrome. 12. Status-post prior surgeries from the meningiomas at the T3 and C4 level (uncertain if this includes the previously noted meningioma at T5). DISCHARGE MEDICATIONS: 1. Ultram 50 mg p.o. p.r.n. 2. Flomax 0.4 mg p.o. nightly
T3|triiodothyronine|T3|173|174|PERTINENT LABORATORY DATA|PRIMARY DIAGNOSIS: New onset atrial fibrillation, now in normal sinus rhythm, maintained on diltiazem. Her Norvasc was stopped. PERTINENT LABORATORY DATA: Her TSH was 1.30. T3 was 125. Free thyroxine was 1.61. Troponin times three were less than 0.07. On discharge her sodium was 131. Her potassium level was 3.3 which was corrected with potassium protocol.
T3|triiodothyronine|T3,|155|157|IMPRESSION|So far, the patient had sinus tachycardia and first degree AV block. She will be started on metoprolol 12.5 mg p.o. b.i.d. for symptom control. Will await T3, T4 levels. Also will obtain a thyroid peroxidase antibody level. The patient will be referred to the Endocrinology Clinic for further evaluation and treatment.
T3|triiodothyronine|T3,|228|230|PLAN|The fact that the patient has a nonpalpable, nontender thyroid is somewhat helpful, although a thyroid uptake scan will be more helpful along with the above-mentioned laboratory tests. If the T4 is normal, we will likely need a T3, as this would be somewhat unusual. We also can consider a thyroid-stimulating IG if the diagnosis continues to be in question. Dr. _%#NAME#%_ stated that they would be happy to consult on Monday as needed.
T3|thoracic (level) 3|T3|147|148|PAST MEDICAL HISTORY|This procedure was complicated by delayed renal function. The patient required an abdominal wash-out on _%#MMDD2004#%_ for bleeding. 7. History of T3 compression fracture. 8. Status post right fem-pop bypass. ALLERGIES: The patient has no drug allergies. His immunosuppression regimen is Neoral, prednisone, and Cellcept.
T3|triiodothyronine|T3,|139|141|ASSESSMENT AND PLAN|4. Constipation. Plan: Continue with MiraLax 17 gm p.o. in 8 ounces of water, hold if stools are loose. 5. Elevated TSH. Plan: Repeat TSH, T3, T4, and thyroid __________ autoantibodies tomorrow, _%#MMDD2005#%_. 6. Increased blood glucose. Plan: Check fasting blood glucose in the a.m. of _%#MMDD2005#%_.
T3|triiodothyronine|T3|219|220|LABORATORY INVESTIGATIONS|The left atrium is mild to moderately enlarged. There are no major valvular lesions. Pulmonary artery pressures are normal. His hemoglobin 11.9, white cell count 6.8, potassium 3.4, sodium 128, creatinine is 0.75. TSH, T3 normal. IMPRESSION AND PLAN: There are multiple reasons for this gentleman to have atrial fibrillation.
T3|tumor stage 3|T3,|46|48|PROBLEM|PROBLEM: Squamous cell carcinoma of the lung, T3, N3, M0. _%#NAME#%_ _%#NAME#%_ was seen in the Radiation Oncology Clinic on _%#MM#%_ _%#DD#%_, 2002 by Drs. _%#NAME#%_ _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_ for initial consultation at the request of Dr. _%#NAME#%_.
T3|triiodothyronine|T3|358|359|ASSESSMENT|The use of amiodarone is problematic in this setting as it can be associated with two different types of hyperthyroidism, so called destructive thyroiditis or in association with underlying Graves' thyroiditis however amiodarone in susceptible patients, particularly with Hashimoto's thyroiditis can actually cause hypothyroidism. It can also decrease T4 to T3 conversion associated with the high iodine load. Repeat TSH was still suppressed yesterday. Pending for tomorrow is a free T4. I have added a free T3 to this as well as a TSI and anti-TPO antibody.
T3|triiodothyronine|T3|156|157|PLAN|5. Copy of labs to patient at discharge with primary MD follow-up. 6. TSH suppressed at 0.16, possibly related to a sick euthyroid state. Will check T4 and T3 IRA to insure no evidence for hyperthyroidism. Thank you for the consultation. Will follow along as indicated.
T3|triiodothyronine|T3|138|139|LABORATORY DATA|The patient's BUN last month was 19 with a creatinine of 1.10 on _%#MMDD2007#%_. Her peak TSH was 0.08. Her T4 was 1.38, which is normal. T3 was 86, which is normal. It should be noted the patient's TSH on _%#MMDD2007#%_ was 1.09. Hemoglobin 12.3. MCV 91. The rest of the CBC was within normal limits. The comprehensive metabolic panel on _%#MMDD2007#%_ was remarkable for creatinine of 1.8, BUN 45, glucose 111 with a GFR 29.
T3|triiodothyronine|T3|177|178|LABORATORY  DATA|Denies methamphetamine use for the past 26 days. LABORATORY DATA: Laboratory tests on _%#MMDD2006#%_: Undetectable TSH. On _%#MMDD2006#%_: Free T4 1.02 (normal 0.7-1.85), total T3 164 (normal 60-181). No electrolytes or CBC information is available recently on the computer. REVIEW OF SYSTEMS: CARDIOVASCULAR: Recent tachycardia and anxiousness. Denies recent chest pain.
T3|triiodothyronine|T3|284|285|REQUESTING PHYSICIAN|He is not familiar with the recent obvious thyroid test results from the Fairview Oxboro Clinic. He did have laboratory tests completed this hospitalization _%#MM#%_ _%#DD#%_, 2003 revealing a normal TSH of 0.56(normal 0.4 to 5) with elevated free T4 2.29 (normal 0.7 to 1.8). A free T3 test was also ordered today and pending, but there was a I-123 thyroid uptake and scan scheduled but this was canceled due to the patient's recent iodine contrast dye exposure.
T3|tumor stage 3|T3|160|161|IMPRESSION|Most recent hemoglobin is 10 from today, white count 13, platelets 227. IMPRESSION: 1. _%#NAME#%_ _%#NAME#%_ is a 51-year-old woman with stage III colon cancer T3 N1 disease, status post sigmoid colectomy with end-to-end anastomosis and incidental appendicectomy, extensive lysis of intraabdominal adhesions 2. History of Hodgkin's lymphoma stage IIB treated with radiation therapy appears to be in remission
T3|tumor stage 3|T3|212|213|ASSESSMENT/PLAN|No other lesions are visible in the oral cavity or in the oropharynx. Examination of the left nasal cavity reveals crusting secretion. ASSESSMENT/PLAN: In summary, this patient is a 57-year-old female with stage T3 N0 squamous-cell carcinoma of the left maxillary sinus arising from an inverted papilloma, status post left maxillectomy. We agree that radiation therapy is indicated as adjuvant treatment.
T3|triiodothyronine|T3,|165|167|PLAN|PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Hepatitis A, B, and C studies. 3. Limited MRI of the liver to evaluate probable cavernous hemangioma. 4. T3, IRA, and T4. 5. Sudafed and nasal salt water irrigation prn congestion. 6. Follow-up Dr. _%#NAME#%_, Fairview-University Medical Center Infectious Disease as scheduled.
T3|triiodothyronine|T3|147|148|PLAN|4. Fractionate bilirubin. 5. Ophthalmology appointment at Fairview-University Medical Center for followup regarding question of glaucoma. 6. Check T3 and T4 with suppressed TSH. 7. Clinical observation. Thank you for this consultation. Will follow along as clinically indicated.
T3|tumor stage 3|T3|219|220|HISTORY OF PRESENT ILLNESS|She has had a moderate degree of initially left upper quadrant, and now right upper quadrant pain, but these have not been severe. She has had only low-grade fevers. Her pathology revealed 12 positive lymph nodes and a T3 primary tumor. PHYSICAL EXAMINATION: On exam, she is alert and well appearing.
T3|thoracic (level) 3|T3|160|161|HISTORY OF PRESENT ILLNESS|MRI of the thoracic spine on _%#MMDD2005#%_ showed cord compression at T9/T10, and neural foraminal narrowing at L1. Cervical spine MRI _%#MMDD2005#%_ showed a T3 compression fracture. MRI of the lumbar spine on _%#MMDD2005#%_ showed soft tissue masses at T12 and L1, as well as throughout the lumbar spine.
T3|triiodothyronine|T3,|132|134|HISTORY OF PRESENT ILLNESS|Her cultures have been negative. Her hyponatremia responded with 1500 fluid restriction. TSH was mildly elevated at 7 with a normal T3, T4, and she was discharged with low dose Synthroid. She was also initiated on Glyburide for her diabetes. She was discharged to Martin Luther Manor nursing home for transitional care.
T3|thoracic (level) 3|T3|144|145|ASSESSMENT AND PLAN|He would like to go ahead with radiation. We have arranged for simulation to be performed done today. Our plan is to perform simulation between T3 and L1 as well as treat pain in the left hip. These areas correlate with MRI scan and bone scan. After simulation, we can begin his treatment tomorrow.
T3|triiodothyronine|T3|199|200|LABORATORY DATA|Complete metabolic profile was unremarkable with a nonfasting glucose of 108. Normal electrolytes with BUN of 13, creatinine 1.2. Normal liver function. TSH reflux was suppressed at 0.34 with normal T3 of 121 and free thyroxin of 1.49. GGT of 56. ASSESSMENT: A 53-year-old male admitted with the following: 1. Major depressive disorder with paranoia (question major depression with psychotic features).
T3|triiodothyronine|T3.|169|171|ASSESSMENT|4. Urinary hesitancy with post-void dribbling possibly on the basis of BPH. 5. Low TSH, possibly related to sick euthyroid. Not hyperthyroid based on normal free T4 and T3. 6. Gastroesophageal reflux disease, symptomatically well controlled on Protonix. 7. Restless leg syndrome on Mirapex. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_ or associate.
T3|triiodothyronine|T3|169|170|ASSESSMENT AND PLAN|3. Facial acne. The patient will continue her topical clindamycin. 4. Hypothyroidism. The patient's TSH is slightly elevated at this time. We will check a free T4 and a T3 and consider readjusting and increasing her Synthroid if necessary. 5. Hypertension. She will continue her captopril. 6. PCOS. She will continue her birth control pills.
T3|triiodothyronine|T3|107|108|LABORATORY|Strength, sensory, and coordination appear to be intact. LABORATORY: TSH slightly elevated at 5.52. T4 and T3 are pending. CBC is without significant abnormality. CMP is completely within normal limits. ASSESSMENT/PLAN: 1. Depression. This is to be followed by Dr. _%#NAME#%_.
T3|triiodothyronine|T3|184|185|ASSESSMENT/PLAN|3. Asthma and allergies. These appear to be well-controlled presently. 4. Mildly elevated TSH. She does not appear to have physiologic signs of hypothyroidism. Recommended waiting the T3 and T4. If these are normal I would recommend a recheck through her primary care MD in a months' time to assure normal TSH.
T3|tumor stage 3|T3|160|161|IMPRESSION  AND PLAN|He does have two separate tumors which are also positive for MSI gene raising the possibility of any thyroid cancer. The stage of his disease is stage III with T3 N2 disease which has a high likelihood of systemic recurrence hence adjuvant chemotherapy will be highly recommended. I reviewed this with the patient at length. He would like to think this over, however, he feels that he will have to do what is recommended as a year ago he had to face a similar situation when adjuvant radiation was recommended and he could not make up his mind but finally did comply.
T3|triiodothyronine|T3|232|233|ASSESSMENT AND PLAN|This is likely due to the patient's lithium. It was noted in the chart that the patient had a history of this although I did not find record of this in previous old chart. At this point I would plan to recheck the TSH with the free T3 and T4 level and discuss with psychiatry whether lithium will be continued, if so we may need to consider thyroid replacement.
T3|tumor stage 3|T3|241|242|HISTORY OF PRESENT ILLNESS|The patient's chart, pathology and radiography were reviewed. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 63-year-old gentleman who has been previously treated with radiation and chemotherapy for a squamous cell carcinoma of the larynx, T3 N0 M0, and adenocarcinoma in the left hilar and mediastinal lymph nodes. His previous treatment was in _%#MM2004#%_. He received a total of 7000 cGy to the larynx and 6600 cGy to the mediastinal and left hilar lymph nodes.
T3|thoracic (level) 3|T3|145|146|BRIEF HISTORY|He was diagnosed a few months ago and subsequently received radiation therapy to his spine. He has known metastatic lesions involving the T2 and T3 vertebral bodies. He was previously seen and evaluated by my colleague, Dr. _%#NAME#%_ _%#NAME#%_, and nurse practitioner _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2005.
T3|thoracic (level) 3|T3|180|181|DIAGNOSTICS|We could not ambulate the patient. DIAGNOSTICS: MRI performed this morning was reviewed extensively with Dr. _%#NAME#%_. We reviewed this study and there is evidence of the T2 and T3 vertebral bodies and extension into the canal. There is some canal compromise. The tumor also involved the pedicle and a portion of the spinous processes posteriorly.
T3|thoracic (level) 3|T3,|167|169|REVIEW OF SYSTEMS|No nausea or vomiting. Significant decrease in appetite. Genitourinary - neurogenic bladder. No hematuria. Skeletal - no bone pain. He has spinal metastases at T2 and T3, received radiation therapy. Skin and integumentary - no ecchymosis or rash. Neurological - paraplegia due to metastatic cancer. No headache. His friend who is present during the interview today mentioned confusion earlier.
T3|tumor stage 3|T3,|229|231|HISTORY|There was also a right neck dissection, including levels 2, 3, 4, and 6 on the right, and also a right hemilaryngectomy with reported preservation of the right recurrent laryngeal nerve. The final pathology was consistent with a T3, grade 3, ie aggressive squamous cell carcinoma of the supraglottic larynx/piriform sinus and an N0 neck. The patient again had no previous radiation. The flexible laryngoscopy was difficult to perform, as the patient had a significant amount of saliva present in the oropharyngeal region, as well as in the supraglottic larynx region.
T3|triiodothyronine|T3|126|127|LABORATORY DATA 11/11/05|Alkaline phosphatase 121. ALT 9. AST 70. Troponin less than 0.07. _%#MMDD2005#%_: Basic metabolic panel within normal limits. T3 and T4 are pending. Folic acid level is pending. RPR is pending. Vitamin B12 level is pending.
T3|triiodothyronine|T3|280|281|ASSESSMENT|To be pursued with regular diet/good nutrition. 3. Mild elevation in albumin and hemoglobin consistent with probable mild volume depletion on presentation. 4. Suppressed TSH. A 10-pound weight loss since last spring. Consider hyperthyroidism, however, no other stigmata. Will add T3 and free T4 to labs. Copy of labs to patient at discharge for primary MD follow-up. 5. Nicotine addiction. PLAN: 1. Encourage fluids/good nutrition. 2. Primary MD follow-up at Park Nicollet Clinic regarding thyroid function (as above).
T3|triiodothyronine|T3|174|175|LABORATORY DATA|CBC normal with hemoglobin of 13.9, MCV of 90, platelet count 276,000. Complete metabolic profile was unremarkable with glucose of 165. TSH reflex 0.25 with free T4 of 1.28, T3 134. GTT 21. ASSESSMENT: A 42-year-old female admitted with the following: 1. Major depressive disorder. Deferred to Psychiatry.
T3|triiodothyronine|T3|116|117|PLAN|1. Advair Diskus in addition to albuterol inhaler as prescribed. 2. We will add onto labs free thyroxine as well as T3 give patient a copy of labs in order to have when following up with outpatient physician, who has monitored her hypothyroidism in the past.
T3|thoracic (level) 3|T3|172|173|PHYSICAL EXAMINATION|There are no chronic deformities noted. MCPs normal. Wrists: Grade 1 synovitis along with T2 pain. Elbows: Normal. Left shoulder normal. Right shoulder has S2 swelling and T3 pain, decreased range of motion. C-spine is normal. Hips: Tender over trochanteric areas. Knees: 1+ effusion with mild warmth. Ankles: Normal. MTPs S1, T1. Soft tissue exam shows active fibromyalgia tender points.
T3|triiodothyronine|T3.|127|129|RECOMMENDATIONS|I have recommended laboratory testing for the thyroid-stimulating immunoglobin (TSI) and a repeat test for a free T4 and total T3. We discussed the potential treatment option with propylthiouracil (PTU) antithyroid medication though it is important to clarify the abnormal liver tests and hepatic function first.
T3|tumor stage 3|T3,|178|180|HISTORY OF PRESENT ILLNESS|The patient was asked to bee seen for consideration of irradiation for recurrent disease. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 44-year-old gentleman with a history of T3, N2b squamous-cell carcinoma of the larynx. Originally, he was treated with a hemilaryngectomy followed by 6,000 cGy to the head and neck, which was completed on _%#MMDD2006#%_.
T3|triiodothyronine|T3|222|223|ASSESSMENT AND PLAN|We will check her for HIV, hepatis C, and also hepatis B surface antibody to assure that she has been previously inoculated against this. Will also check RPR, as well as serum pregnancy test. 3. Elevated TSH. Will check a T3 and T4. I will be available to follow should further issues arise during the hospitalization.
T3|tumor stage 3|(T3,|143|146|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a kind 86-year-old white male who I know from my outpatient clinic. He was diagnosed with Stage IIIB (T3, N3, M0) nonsmall cell lung cancer and felt to be a nonsurgical candidate. Therefore, he was initially treated with combination chemoradiation. He has been receiving weekly carboplatinum and Taxol chemotherapy through my clinic while he receives daily radiation treatments.
T3|triiodothyronine|T3|223|224|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: 1: Major depressive disorder, generalized anxiety disorder with panic attacks. Mental health issues managed by Dr. _%#NAME#%_. 2. Low TSH: This is probably secondary to sick euthyroidism. The patient's T3 and thyroxine levels were normal. She will follow up with her primary-care physician on one month. 3. Constipation. This may be secondary to her psychiatric medications.
T3|triiodothyronine|T3|158|159|PLAN|Suppressed TSH as above. Will check a T3 and T4 to ensure normal. 5. Acne, on minocycline. PLAN: 1. Resume home meds, i.e., Synthroid and minocycline. 2. Add T3 and T4 to screening labs. Consider adjustment in Synthroid dose. 3. Ventolin inhaler p.r.n. 4. Clinical observation. A copy of labs to patient at discharge for primary MD follow-up.
T3|triiodothyronine|T3,|182|184|HISTORY OF PRESENT ILLNESS|A general surgeon in _%#CITY#%_ _%#CITY#%_ performed an exploratory laparotomy, and did a left colectomy, with colostomy and Hartmann pouch procedure. Pathology showed that he had a T3, N1, N0 adenocarcinoma with lymph-vascular invasion. Postoperatively, he was treated with leucovorin and 5-FU for six months, and then subsequently had his colostomy reversed, with takedown of his Hartmann pouch.
T3|thoracic (level) 3|T3,|202|204|HISTORY OF PRESENT ILLNESS|Workup revealed relapse confirmed by a liver biopsy. He also had lung nodules at that time and 5% bone marrow involvement. Mr. _%#NAME#%_ required urgent radiation treatment due to the epidural mass at T3, T4, and T5. He received 15 radiation treatments from T2 to T6. He received a total of 3750 cGy. The radiation was effective at relieving associated pain, and he has gradually regained some of his motor function.
T3|tumor stage 3|T3,|143|145|HPI|The lung reveals decreased breath sounds in the left lower lung field, otherwise unremarkable. Assessment and Plan: Newly diagnosed stage IIB, T3, N0, M0 squamous cell carcinoma of the lung, left lower lung area with a previous history of ovarian cancer. The patient will be treated with chemoradiation therapy concurrently. The patient was explained the benefits, side effects and complications and consented for the treatment.
T3|triiodothyronine|T3|86|87|PLAN|4. Elevated total bilirubin, likely secondary to Gilbert's disease. PLAN: 1. Will get T3 from labs already drawn and repeat TSH on Thursday (_%#MMDD2007#%_). 2. Tylenol as needed for headaches. 3. Will give patient a copy of labs upon discharge in order to have for followup with primary care physician.
T3|triiodothyronine|T3|172|173|PLAN|The patient was referred to _%#NAME#%_ _%#NAME#%_, an endocrinologist, for consultation. At that time she was identified to have thyroid-stimulating immunoglobulin, a free T3 of 7.5 which is increased, a free T4 at 2.44 which is increased, and a suppressed TSH of 0.05. She has a tachycardia of 108.
T3|triiodothyronine|T3,|225|227|ASSESSMENT AND PLAN|The patient does have some physical characteristics including exophthalmia and has developed diplopia over the past several months. He does have a history of radiation treatments to the neck and a low TSH. I recommend adding T3, and T4, and likely will require Endocrinology Consultation. I will plan to add atenolol 25 mg to be used on a p.r.n. basis for heart rate greater than 120, and systolic blood pressure greater than 160.
T3|triiodothyronine|T3|228|229|LABORATORY DATA|Motor, sensory and coordination are grossly intact. MENTAL STATUS EXAMINATION: Mental status examination is per Dr. _%#NAME#%_. LABORATORY DATA: Labs on admission included an unremarkable CBC. Comprehensive metabolic profile. A T3 is 1.82, a TSH is 0.06. The thyroid function tests do raise the question of excessive thyroid replacement.
T3|triiodothyronine|T3|169|170|LABORATORY DATA|Chest x-ray reveals no active disease. Urinalysis: Nitrites negative. Leukocyte esterase small. WBC 2 to 5. Red blood cell negative. Mucus present. Thyroxine free 6.03. T3 675. T3 uptake 55 with reference range between 23 to 37. It should be noted that the above laboratories were drawn on _%#MMDD2003#%_.
T3|triiodothyronine|T3|169|170|LABORATORY DATA|Chest x-ray reveals no active disease. Urinalysis: Nitrites negative. Leukocyte esterase small. WBC 2 to 5. Red blood cell negative. Mucus present. Thyroxine free 6.03. T3 675. T3 uptake 55 with reference range between 23 to 37. It should be noted that the above laboratories were drawn on _%#MMDD2003#%_.
T3|triiodothyronine|T3|165|166|LABORATORY DATA|Comprehensive metabolic panel was completely within normal limits. A glucose level was at 75. TSH showed a decreased TSH at 0.03. The T4 was normal at 1.75, and the T3 was elevated at 185. The GGT was normal at 16. A CBC showed a mildly decreased platelet count at 148 and a left shift neutrophil percentage at 76 and lymphocyte percentage at 15.
T3|tumor stage 3|T3,|21|23|PROBLEM|PROBLEM: Lung cancer T3, N2A non-small cell cancer squamous cell carcinoma. Mr. _%#NAME#%_ is seen today for consultation by Drs. _%#NAME#%_ _%#NAME#%_ and _%#NAME#%_ _%#NAME#%_ in the Therapeutic Radiology Department at the request of Dr. _%#NAME#%_ from the Medical Oncology Department.
T3|tumor stage 3|T3|187|188|ASSESSMENT|Palpation of the neck revealed a level 2 lymph node measuring 2 x 1.5 cm which is slightly decreased compared to pre-chemotherapy size of 3 x 2 cm. ASSESSMENT: 74-year-old gentleman with T3 N2c M0 squamous cell carcinoma of the right base of tongue, status post 3 cycles of induction chemotherapy with partial response.
T3|triiodothyronine|T3|178|179|PAST SURGICAL HISTORY|Record review indicates issue of a prominent "stare" at time of evaluation by Dr. _%#NAME#%_ _%#NAME#%_ _%#MMDD2003#%_. Thyroid function testing at that time demonstrated a free T3 of 2.0, with free thyroxin of 1.1 and TSH of 1.67. ALLERGIES: Naproxen (rash, dyspnea) and cortisone (urticaria).
T3|triiodothyronine|T3|151|152|PLAN|9. Suppressed TSH. Possibly related to euthyroid syndrome. Will check T3 and T4 to ensure no evidence for hyperthyroidism (doubt clinically). PLAN: 1. T3 and T4. 2. Psychiatric intervention per Dr. _%#NAME#%_. 3. Albuterol metered-dose inhaler p.r.n. as ordered. 4. Clinical observation. No further medical intervention appears necessary at this time. Copy of labs to patient at discharge for primary physician follow-up.
T3|triiodothyronine|T3|168|169|ASSESSMENT|He is on ferrous sulfate 325 mg p.o. daily; we will increase this to b.i.d. and recheck a hemoglobin in the morning for stability. 4. Low TSH. We will check a free T4, T3 to rule out hypothyroidism and treat as necessary. 5. Gastroesophageal reflux disease. We will continue Protonix. We appreciate the consult.
T3|tumor stage 3|T3|132|133|DOB|The tumor was noted to invade through the entire thickness of the bowel muscularis and into the mesocolonic adipose tissue (i.e., a T3 lesion). Thankfully, his submitted lymph nodes (24 of 24) were negative for metastatic spread. No formal imaging studies (i.e., CT, bone scan, or PET scan) have been performed.
T3|thoracic (level) 3|T3|156|157|PHYSICAL EXAMINATION|She responded to sensation in arms and legs with crying. MRI scan showed thickening of the cervical cord from the level of the foramen magnum down to about T3 with obliteration of spaces around the cord and the cervical canal. There was no enhancement on the image done today and the one from _%#CITY#%_ _%#CITY#%_.
T3|tumor stage 3|T3,|226|228|ASSESSMENT AND PLAN|RADIOGRAPHIC STUDIES: 1. MRI scan (from outside): Unavailable for review at this time. 2. Chest x-ray (_%#MMDD2002#%_): Negative. ASSESSMENT AND PLAN: Mr. _%#NAME#%_ is 59-year-old male with extensive soft-palate cancer stage T3, N2b. He will be enrolled on Protocol ECOG _%#PROTOCOL#%_ which involves two cycles of neoadjuvant chemotherapy followed by concurrent chemoradiation therapy.
T3|triiodothyronine|T3,|361|363|LABORATORY  DATA|Sensation is intact to light touch. Strength 5/5 bilaterally. LABORATORY DATA: Depakote level was mildly decreased from therapeutic at 44, lithium level was therapeutic at 0.5. CBC was significant for a mildly elevated, white blood count at 11.1. Also a slightly decreased hematocrit 34.5, hemoglobin was normal at 11.7, TSH was mildly elevated at 5.72. Reflex T3, T4 pending. Comprehensive metabolic panel was all within normal limits. B12 level was pending. Serum hCG was negative. GGT was within normal limits.
T3|triiodothyronine|T3|266|267|LABORATORY DATA|LABORATORY DATA: Hemoglobin today 11.9. Labs from _%#MMDD2002#%_ show a sodium of 138, potassium 4.0, chloride 105, bicarbonate 26, BUN 14, creatinine 1.7, glucose 84. Alpha fetoprotein 4.5, beta HCZ less than 3, CEA 0.7, CA125 is 144. TSH is 7.56, free T4 0.56 and T3 of 118. Her creatinine on _%#MM2002#%_ was 1.6. ASSESSMENT/PLAN: 1. Post-operative day #1, exploratory surgery for possible adrenal mass.
T3|tumor stage 3|(T3,|45|48|PROBLEM|PROBLEM: Pancreatic adenocarcinoma stage III (T3, N1, M0). Mr. _%#NAME#%_ was seen in the Radiation Oncology Clinic on _%#MMDD2003#%_ by Dr. Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ initial consultation at the request of Dr. _%#NAME#%_ _%#NAME#%_ from the Department of Medical Oncology at Fairview-University Medical Center.
T3|thoracic (level) 3|T3|221|222|OBJECTIVE|He understands that that is not our goal to hasten that and that we would not do that ethically or legally. He does accept that. Examination of his back indicates allodynia at the thoracic region, actually extending from T3 down to T10 and in the paraspinal ligaments of the thoracic region as well he is quite tender there. The next area is around the right chest tube site.
T3|tumor stage 3|(T3,|19|22|PROBLEM|PROBLEM: Stage III (T3, N0, M0) squamous cell carcinoma of the right tonsil. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 66-year-old gentleman who reports that in the beginning of _%#MM#%_ he noticed the sensation of plugging in his right ear.
T3|triiodothyronine|T3|150|151|PLAN|4. Low back pain secondary to herniated disc. PLAN: 1. We will obtain a pain consult for the patient. 2. We will recheck the TSH and T4, as well as a T3 and thyroid peroxidase, and I will be notified if that is abnormal. 3. The patient will get a copy of his labs when he returns home.
T3|triiodothyronine|T3|173|174|HISTORY|The patient was followed subsequently with generally normal thyroid function since that time. She had last been seen by me on _%#MMDD2002#%_ and had normal values for a T4, T3 and TSH. She was to have seen me in the office this week for an annual reassessment. Apparently, the patient was found approximately two weeks ago or so to have again an elevation in her free T4 or suppression of her serum TSH.
T3|tumor stage 3|T3,|135|137|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Stage IVA, T3, N2b, M0 squamous cell cancer of the base of tongue. Status post induction chemotherapy following ECOG protocol _%#PROTOCOL#%_. HPI: This patient with stage IV base of tongue cancer is well-known to our department.
T3|triiodothyronine|T3|175|176|PLAN/SUGGESTIONS|6. Type 2 diabetes a. on oral agent therapy with sulfonylurea (glipizide). 7. History of tobacco abuse. PLAN/SUGGESTIONS 1. Repeat thyroid levels including a free T4 and free T3 2. Thyroid stimulating antibodies. 3. Interleukin 6. (IL6). This is often significantly elevated in a type II AIT. 4. Thyroid ultrasound with Doppler flow. Ultrasound can occasionally differentiate between the two types of AIT.
T3|tumor stage 3|(T3|19|21|PROBLEM|PROBLEM: Stage IIB (T3 N1 M0) ductal adenocarcinoma of the pancreas, status post pylorus sparing Whipple procedure. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 76-year-old female who initially presented to her primary care physician Dr. _%#NAME#%_ in Northwest Iowa with symptoms of jaundice, dark urine, and clay-colored stools.
T3|triiodothyronine|T3|128|129|ASSESSMENT/PLAN|2. Hematuria of unclear etiology one week ago. Plan to check a UA/UC to rule out infection. 3. Slight elevation of TSH. Check a T3 and T4. Thank you for this consultation. I would be happy to follow the patient should any other issues arise during the hospitalization.
T3|triiodothyronine|T3,|150|152|HISTORY OF PRESENT ILLNESS|The brain MR demonstrated a 3.5 cm metastatic lesion in the right brain parenchyma. The thoracic spine MR demonstrated metastatic tumor involving the T3, T7, T11 and T12 vertebrae, with pathological compression fractures and spinal cord impingement at these levels. Also noted in the lumbar spine was extensive metastatic tumor involving L5-L6, and severe central stenosis at T12 as well.
T3|triiodothyronine|T3|138|139|ASSESSMENT|1. Bipolar disorder. This will be followed by Dr. _%#NAME#%_. 2. Low TSH. I doubt this represents a hyperthyroid state. Will check a free T3 and T4 to confirm. 3. Weight loss of 10 pounds over about the past six weeks. No apparent metabolic derangement. Again, we will do further thyroid studies to confirm that this is not playing a role in her weight loss.
T3|triiodothyronine|T3|226|227|LABORATORY EVALUATION|Peripheral pulse is intact. No apparent trauma. LABORATORY EVALUATION: Reveals a sodium 141, potassium 3.3, chloride 106, CO2 21, BUN 5, creatinine 0.68, glucose 98. Hemoglobin 13, WBC 7.7, platelet 301. TSH elevated at 9.31. T3 and T4 were both within normal limits. ASSESSMENT AND PLAN: 1. Psychosis. This will be followed by Dr. _%#NAME#%_.
T3|tumor stage 3|T3|54|55|PROBLEM|PROBLEM: Ductal adenocarcinoma of pancreas, stage IIB T3 PN1a M0 status post Whipple procedure. Ms. _%#NAME#%_ was seen for initial consultation in the Department of Therapeutic Radiology on _%#MMDD2004#%_ by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ at the rest of Dr. _%#NAME#%_.
T3|tumor stage 3|T3|162|163|HPI|Abdomen is soft and has no organomegaly. Bowel sounds are within normal limits. Assessment and Plan: 56-year-old female patient with stage IIA pancreatic cancer, T3 N1a M0, status post Whipple surgery. The patient will be treated according to ACO SOG protocol with chemoradiation. The patient has been seen by Dr. _%#NAME#%_ and will be seen by Dr. _%#NAME#%_ for the abdominal wall wound.
T3|thoracic (level) 3|T3|201|202|PAST MEDICAL HISTORY|She states that it is burning and aching, but does not radiate down her back to her legs. PAST MEDICAL HISTORY: 1. Status post meningoma in the low back treated with resection with pedical screws from T3 to T8 on _%#MM#%_ of 2004 with revision in _%#MM#%_ of 2005. 2. Chronic low back pain secondary to back surgery.
T3|triiodothyronine|T3|104|105|IMPRESSION|The sodium electrolyte amount can be adjusted for the hyponatremia. I also recommend repeat free T4 and T3 level to reevaluate the unusual thyroid pattern. I suspect the patient has sick euthyroid syndrome, which is common for his significant illness.
T3|thoracic (level) 3|T3|171|172|HISTORY OF PRESENT ILLNESS|He was admitted for bilateral upper extremity weakness and numbness. MRI of the cervical spine indicates congenital spinal canal stenosis. There was edema from C4 through T3 secondary to arterial infarct to that area. He is rather difficult to evaluate on his pain because of the language barrier.
T3|triiodothyronine|T3|134|135|PLAN|2. BuSpar. 3. Treat constipation with lactulose 15 mg p.o. b.i.d. as well as Senokot S, 2 tabs p.o. b.i.d. 4. We will add onto labs a T3 and get repeat TSH reflex as well as AST and ALT on Monday a.m. (_%#MMDD#%_). 5. We will be happy to see her stay for any intercurrent medical issues.
T3|triiodothyronine|T3|184|185|ASSESSMENT/PLAN|3. Peptic ulcer disease. I would recommend discontinuing naproxen and ibuprofen. We should try Vioxx 12.5 mg p.o. b.i.d. for treatment of menstrual cramps. 4. Low TSH. Plan to check a T3 and T4. Thank you for this consultation.
T3|thoracic (level) 3|T3|181|182|REASON FOR CONSULTATION|He was seen by his family practitioner earlier today who obtained an MRI/MRA at the T2 level what appears to be non-enhancing mass involving the T2, as well as parts of the T1, and T3 vertebra. There is a mass effect upon the thecal sac in a somewhat circumferential fashion. After the scan was performed apparently the family physician by report talked to a Neurosurgeon up in _%#CITY#%_.
T3|triiodothyronine|T3|269|270|LABORATORY DATA|No organomegaly or mass. CHEST: Examination of the anterior chest reveals faint superficial appearing lacerations anteriorly, no sign of infection. LABORATORY DATA: At the present time includes a hemogram which is unremarkable. Comprehensive metabolic panel is normal. T3 is normal. Urine toxin screen negative for chemicals of abuse. ASSESSMENT AND PLAN: 1. Depression.
T3|triiodothyronine|T3,|186|188|ASSESSMENT|Associated with multiple PPIs. Rule out C. difficile with antibiotics (in Prevpac). 8. Hepatitis C. Status of liver function unclear. 9. Suppressed TSH, significance unclear. Will check T3, RIA, and free T4 to ensure no evidence of hyperthyroidism (doubt). PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. With increased albuterol requirement, start Advair 250/50 one puff b.i.d.
T3|triiodothyronine|T3|160|161|ASSESSMENT/PLAN|ASSESSMENT/PLAN: 1. Psychosis. The patient will be followed by Dr. _%#NAME#%_. 2. Mildly elevated TSH of uncertain significance. Recommend re-check of the TSH, T3 and T4 in one week's time. I doubt this represents a developing hypothyroid state. 3. Hypokalemia, mild, possibly secondary to muscular agitation.
T3|tumor stage 3|T3|144|145|DISCUSSION|DISCUSSION: This gentleman has evidence of progressive primary hepatocellular carcinoma. The lesion is large and would be considered at least a T3 lesion. There is no evidence that this is invading into adjacent structures. He has already been evaluated by a very competent hepatic surgeon and was not found to be an operative candidate back in the summer, and certainly at this point this should not be further considered.
T3|thoracic (level) 3|T3,|129|131|IMAGING|Images were accomplished. IMAGING: Imaging is involved with performance of a thoracic MRI scan. The scan notes tumor involvement T3, T4, T5, T6 and T11. At the T3 area there is moderate involvement anteriorly of the vertebral body at T3 without extension in the canal and without bony collapse.
T3|thoracic (level) 3|T3|401|402|REASON FOR CONSULTATION|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD REASON FOR CONSULTATION: I am asked by Dr. _%#NAME#%_ to see Ms. _%#NAME#%_ _%#NAME#%_ for a medical Oncology consultation regarding previous history of non-small cell lung cancer treated with surgery in _%#MM2004#%_ and with the recent findings of metastatic disease involving the thoracic spine at multiple levels and with compression fracture in the T3 and T4 area. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 75-year- old woman who has a history of non-small cell lung cancer diagnosed in _%#MM2004#%_ when she underwent left lower lobe wedge resection by Dr. _%#NAME#%_.
T3|triiodothyronine|T3|176|177|HISTORY OF PRESENT ILLNESS|Her Lipitor has been discontinued after admission and she has been switched to Zocor. The workup here has included thyroid function testing which had shown her TSH to be 0.13, T3 to be 138 and free T4 to be 1.23 which is normal. The patient has been on Haldol, which has had any beneficial effect so far.
T3|triiodothyronine|T3|198|199|LABORATORY DATA|LABORATORY DATA: Present laboratory studies shows CBC which is interesting with an MCV of 105, hemoglobin 13.3, B12 639, folic acid was on the lower side at 3.6 at an indeterminate level. TSH 7.51, T3 1.13, liver function studies were normal. PHYSICAL EXAMINATION: GENERAL: Patient is comfortable.
T3|tumor stage 3|T3|227|228|HISTORY OF PRESENT ILLNESS|Initial biopsies of this lesion were nondiagnostic, but the patient was referred to Dr. _%#NAME#%_, and an endorectal ultrasound confirmed a mass in the proximal rectum or distal sigmoid colon. This was clinically felt to be a T3 lesion, although the entire thickness of the tumor could not be visualized by ultrasound. Repeat biopsies revealed a moderated differentiated adenocarcinoma. A PET scan was performed preoperatively, and she was felt to have uptake at the rectal tumor, as well as a focus of perirectal uptake suggesting involvement of a regional lymph node.
T3|tumor stage 3|T3|124|125|PAST MEDICAL HISTORY|There was obvious general deconditioning. PAST MEDICAL HISTORY: Is dominated by the above mentioned lung cancer, at least a T3 N3 tumor. He had treatment with radiation and chemotherapy and had some underlying resultant esophagitis. There was also a history of emphysema and pulmonary fibrosis.
T3|tumor stage 3|T3|225|226|IMPRESSION|The tumor itself invaded into the perirectal tissue, there was evidence of seven positive lymph nodes with mesenteric deposits, there was venous and lymphatic invasion. The tumor was poorly differentiated. In total, this was T3 N2 M0 rectal cancer. The pathology from the prostate cancer revealed a Gleason's grade 4+3 T3A, N0, M0 prostate cancer.
T3|triiodothyronine|T3|130|131|LABORATORY DATA|Normal CBC with white count of 5300, hemoglobin 16.1, MCV 87, platelet count 281,000. GGT of 24, TSH 0.79. Free thyroxin of 1.03, T3 of 115. Sed rate of 7. B12 of 1098. Cholesterol of 177 with triglycerides 201, LDL 109, VLDL 40, HDL 27.
T3|thoracic (level) 3|T3|289|290|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old black male who was admitted to the hospital 3 days ago for cystectomy and ileal loop diversion for chronic urinary tract problems after having a spinal cord injury in 1990. The patient had an automobile accident in 1990, suffered a T3 spinal cord injury with residual paraplegia plus left upper extremity plegia-related associated injuries. He underwent bladder reconstruction on _%#MM2005#%_ and augmentation with a Monty stoma.
T3|thoracic (level) 3|T3|155|156|CHRONIC DISEASE/MAJOR ILLNESSES|ALLERGIES: None. CURRENT MEDICATIONS: Listed in medicine reconciliation list. CHRONIC DISEASE/MAJOR ILLNESSES: 1. Status post spinal cord injury 1990 with T3 transection and residual triplegia. 2. Small-bowel obstruction related to adhesions _%#MM2006#%_ treated with lysis of adhesions and bowel resection. 3. Hepatitis C secondary to blood transfusion in 1990.
T3|triiodothyronine|T3|237|238|ASSESSMENT|Rule out major depressive disorder. Deferred to psychiatry. 2. Status post colectomy for ulcerative colitis. 3. Mixed tension/muscle contraction and migraine headaches. 4. Status post treatment for Graves' disease. Suppressed TSH. Check T3 and T4 to ensure no evidence for lingering hyperthyroidism. 5. Anemia attributed to nutritional factors/iron deficiency. Normochromic normocytic. Present level actually quite adequate per patient.
T3|tumor stage 3|(T3|174|176|IMPRESSION|Circumferential wall thickening of the proximal transverse colon was identified, consistent with her malignancy. IMPRESSION: An 87-year-old female with Stage II colon cancer (T3 N0 M0). She has a modest risk of disease recurrence, in the range of 25-30% following surgery alone, but there is no clear benefit to adjuvant chemotherapy in this setting, especially in view of her multiple underlying medical problems.
T3|tumor stage 3|(T3|174|176|IMPRESSION|Circumferential wall thickening of the proximal transverse colon was identified, consistent with her malignancy. IMPRESSION: An 87-year-old female with Stage II colon cancer (T3 N0 M0). She has a modest risk of disease recurrence, in the range of 25-30% following surgery alone, and there is no clear benefit to adjuvant chemotherapy in this setting, especially in view of her multiple underlying medical problems.
T3|triiodothyronine|T3,|187|189|IMPRESSION|We also discussed pathophysiology, prognosis and therapies for Grave's disease. Patient will require additional laboratory tests to evaluate the thyroid condition. Labs pending include a T3, T4, TSI and thyroid antibodies. The patient's hyperthyroidism most likely is due to Grave's disease, although hyperthyroidism from amiodarone is a possibility, less likely subacute thyroiditis or a toxic nodule.
T3|tumor stage 3|T3,|217|219|REFERRING PHYSICIAN|Colonoscopy showed no other lesions. He was then referred here for further treatment and evaluation. Endorectal ultrasonography performed by my associate Dr. _%#NAME#%_ _%#NAME#%_ shows this to be an ultrasound stage T3, N0 carcinoma. The CT scan shows no sign of any distance spread to lung, liver, or abdomen. There is slight thickening on one side along the pelvic sidewall, but this is minimal and probably does not represent extensive tumor.
T3|thoracic (level) 3|T3|218|219|ASSESSMENT|Normal axis. Minor nonspecific T-wave flattening across the precordium. ASSESSMENT: Pleasant 65-year-old female with the following: 1. Fibrosarcoma involving the posterior chest wall/thorax: a. Thoracic laminectomy of T3 through T5, with initial diagnosis of fibrosarcoma in _%#MM2000#%_. b. Local recurrence in _%#MM2002#%_, with chemotherapy completed in _%#MM2003#%_. c. Wide excision, as above, including posterior elements of T3 through T5.
T3|thoracic (level) 3|T3|299|300|ASSESSMENT|1. Fibrosarcoma involving the posterior chest wall/thorax: a. Thoracic laminectomy of T3 through T5, with initial diagnosis of fibrosarcoma in _%#MM2000#%_. b. Local recurrence in _%#MM2002#%_, with chemotherapy completed in _%#MM2003#%_. c. Wide excision, as above, including posterior elements of T3 through T5. d. Left rib and chest tube placement. 2. Blood loss of 3200 cc (transfused). 3. Hypertension, with low-normal blood pressure. 4. Hiatal hernia, with presumed acid reflux.
T3|triiodothyronine|T3|123|124|PLAN|PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Recheck liver profile on the morning of _%#MMDD#%_. Add T4 and T3 and RIA to further screen for hyperthyroidism. 3. Copy of lab studies to po at discharge with recommendation that she make appointment as previously advised at the Fairview Redwing Medical Center with a primary care provider.
T3|triiodothyronine|T3|186|187|ASSESSMENT AND PLAN|3. Hyperlipidemia. The patient is currently on no medication and we will continue to have her follow with her primary MD. 4. Hypothyroidism. She clearly has a low TSH. We will check the T3 and T4 and continue her Cytomel and Synthroid at this time. 5. Gastroesophageal reflux disease. We will continue Prevacid. 6. Tremors.
T3|thoracic (level) 3|T3|219|220|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: The differential diagnosis for the right thoracic burning pain would include: 1. Post-herpetic neuralgia without any significant lesions. 2. Degenerative disk disease of thoracic spine, compressing T3 or T4 nerve root versus compression of the spinal cord. 3. Diabetic radiculopathy in the thoracic spine. I will recommend obtaining an MRI of his thoracic spine to rule out any degenerative disk disease compressing the T3-T4 nerve root.
T3|tumor stage 3|(T3,|175|178|IMPRESSION|PATHOLOGY: A CT guided biopsy of right upper lobe of lung revealed adenocarcinoma. IMPRESSION: The patient is a 51-year-old male with non-small cell lung carcinoma, stage IIB (T3, N0, M0) with right apical lung mass abutting, but not invading T2 vertebral body and head of first rib. RECOMMENDATIONS: We are planning to treat the patient with neoadjuvant chemoradiation, and have consented him this morning.
T3|triiodothyronine|T3|182|183|LABORATORY  DATA|LABORATORY DATA: Glucose 111, ALT 80. The rest of the comprehensive metabolic panel is negative. CBC remarkable for lymphocytes 19, otherwise normal. Reflex TSH 0.33. Otherwise, the T3 and T4 are pending. Magnesium, phosphorus and platelet count are normal. ASSESSMENT: 1. Depression. 2. Nausea. This is probably secondary to depression versus the patient's headache.
T3|tumor stage 3|T3|161|162|HOSPITAL COURSE|5. Coronary artery disease. 6. Hypertension. 7. Hypercholesterolemia. HOSPITAL COURSE: Patient underwent surgery where a sigmoid carcinoma was found. This was a T3 lesion with four positive lymph nodes, moderately differentiated. She also underwent a cholecystectomy for cholelithiasis and chronic cholecystitis.
T3|triiodothyronine|T3|99|100|LABORATORY TESTS|Dorsal pedal pulses are 3+. LABORATORY TESTS: Included a TSH of 0.22, a free T4 of 2.3 and a total T3 of 104. Normal 60 to 181. The sed rate was increased to 62. IMPRESSION: 1. Abnormal thyroid function tests, possible hypothyroidism 2. Recent acute illness, left cerebrovascular accident.
T3|triiodothyronine|T3|153|154|LABORATORY DATA|Strength 5/5 bilaterally. LABORATORY DATA: While at Regions on _%#MMDD2003#%_, phosphorus was 5.3, BUN was 4, cholesterol 246, TSH less than 0.03, total T3 was 213, total T4 was normal. Pregnancy test was negative. ASSESSMENT AND PLAN: 1. Opioid dependence, depression, anxiety (per Dr. _%#NAME#%_).
T3|triiodothyronine|T3,|69|71|PLAN|9. Low-grade anemia, potentially related to menstrual loss. PLAN: 1. T3, RIA and T4 labs. 2. Start Protonix 40 mg daily for reflux symptoms. 3. Monitor chest complaints for now. Will request labs obtained in the ER including CBC, CMP and troponin.
T3|tumor stage 3|T3|183|184|HPI|She was treated as pancreatitis. Further workup with endoscopic ultrasound of the pancreas showed a 2 cm mass at the head of the pancreas with EUA finding and a CT scan thought to be T3 lesion without any vascular invasion of the disease. The patient underwent stent placement for jaundice and had exploratory laparotomy on _%#MMDD2004#%_ which showed unresectable pancreatic cancer in the head of the pancreas.
T3|thoracic (level) 3|T3|83|84|ASSESSMENT|ASSESSMENT: 1. Status post posterior spinal fusion with segmental instrumentation, T3 through T7, for treatment of T5 burst fracture. The patient is hemodynamically stable. 2. Probable left calf cellulitis. 3. History of hypertension, stable. 4. Asthma, stable. 5. Morbid obesity.
T3|triiodothyronine|T3|218|219|ASSESSMENT|As the patient is denying any urinary concerns we will forego gonorrhea and chlamydia testing at this point. ADDENDUM CORRECTION: ASSESSMENT: "Change hypothyroidism to hyperthyroidism." We will check free T4 and total T3 today, and treat accordingly.
T3|tumor stage 3|T3|99|100|PROBLEM|PROBLEM: The patient is a 58-year-old white male with squamous cell carcinoma of the right tonsil, T3 N1 (?2c) Mx. Approximately 3 weeks ago, the patient noticed a sore throat.
T3|triiodothyronine|T3,|149|151|PLAN|1. Depression. 2. Asthma, quiescent. 3. Mildly depressed thyroid stimulating hormone; rule out hyperthyroidism. PLAN: 1. The patient will have a T4, T3, ______ uptake ordered. 2. The patient was told that she must remove her tampon this evening. She can do it on her own or with the assistance of the nursing staff, but it must come out this evening.
T3|tumor stage 3|(T3|247|249|ONCOLOGY CONSULTATION|I am asked to see the patient by Dr. _%#NAME#%_ and the primary medical team regarding his worrisome imaging studies which suggest metastatic cancer. In brief, the patient is a 75-year-old white male with a past medical history of a stage I to II (T3 N0 M0) right-sided colon cancer which was treated with hemicolectomy in 1999. He also has had prostate cancer and has underlying coronary artery disease, chronic obstructive pulmonary disease (COPD), and diabetes mellitus.
T3|tumor stage 3|T3|302|303|HISTORY OF PRESENT ILLNESS|PROBLEM: Non-small cell lung cancer with brain metastases, status post 1250 cGy in 250 cGy fractions, now being transferred to the Fairview-University Medical Center Radiation Oncology Department. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 75-year-old gentleman who was diagnosed initially with a T3 N0 M0 adenocarcinoma of the colon in 1997. He at that time underwent resection without any adjuvant treatment.
T3|tumor stage 3|T3,|9|11|PROBLEM|PROBLEM: T3, N0. M0 pancreatic adenocarcinoma who presents for the possibility of concurrent chemoradiotherapy. The patient was seen in consultation by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_.
T3|triiodothyronine|T3|743|744|CSF (12/11/2007)|Dilantin 250mg qday ALL: NKDA PExam: VS-37.1, 78, 146/51, 24, 98% on RA Very cachectic female, laying in bed, does not track, does not respond to stimulus, warm to touch OP clear, no LAD, dry MM, no TM appreciated, nontender Neck no goiter RRR no rubs, no gallops CTAB (anterior exam), no rales, no ronchi Schaphoid abdomen, no organomegaly, + BS, G-tube in place No cyanosis, clubbing, edema, warm to touch, moist. DTRs could not be eliciated due to positioning. Labs: EEG (_%#MMDD#%_) CSF (_%#MMDD2007#%_): Colorless/clear, WBC -2, RBC - negative, Lymph - 81, Mono -19, Cells - 100, Glucose - 81 **Please note there are not ranges or units from OSH** TSH (_%#MMDD2007#%_) - 5.58 T4 (_%#MMDD2007#%_) - 4.5 Free T3 - 228 (_%#MMDD2007#%_) Free T3 - 247 (_%#MMDD2007#%_) FreeT3 - 172 (_%#MMDD2007#%_) Microsomal Ab 1:1600 (_%#MMDD2007#%_) TPO > 950 (_%#MMDD2007#%_) MRI (_%#MMDD2007#%_) ? enlargement of third ventricle and lateral ventricle, homogenous mass within the cerevellopontine angle on the let side.
T3|tumor stage 3|T3,|148|150|IMPRESSION|INR 1.15, PTT 27. Pathology as detailed in HPI. IMPRESSION: 1. Metastatic adenocarcinoma of the colon with biopsy proven liver metastasis stage IV, T3, N1, M1 disease. The extent of liver metastasis is unclear at the present time. 2. History of iron deficiency anemia due to GI bleed.
T3|triiodothyronine|T3,|175|177|ASSESSMENT AND PLAN|1. Psychosis. This is to be followed by Dr. _%#NAME#%_. 2. Slightly low thyroid stimulating hormone (TSH) of uncertain etiology. I doubt this represents a hyperthyroid state. T3, T4 are pending at this time. 3. History of gunshot wound to the chest. I am not aware of sequelae of this incident. He appears hemodynamically stable presently.
T3|triiodothyronine|T3|205|206|ASSESSMENT AND PLAN|3. Mild gastroesophageal reflux disease, idiopathic. Will treat patient with Zantac as needed. 4. Low TSH possibly secondary to stress versus sic euthyroid syndrome. The patient is currently asymptomatic. T3 and T4 levels are normal. No further treatment needed at this time. Instructed patient to follow up with his primary care in approximately 6 weeks for recheck of TSH and T3 and T4 levels.
T3|triiodothyronine|T3|179|180|PLAN|9. Surgeries as above. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Consider resumption of low dose Elavil at h.s. if agreeable with Psychiatric Service. 3. Review T3 and T4 with regard to a low TSH. (rule out hyperthyroidism). 4. Check B12 level. 5. Request report from brain MRI allegedly obtained in _%#CITY#%_ in _%#MM#%_ of 2005.
T3|tumor stage 3|T3|15|16|PROBLEM|PROBLEM: Stage T3 N0 M0 adenocarcinoma of the head of the pancreas. DOSE: She received a total of 5040 cGy in 25 fractions to the abdomen between the dates of _%#MMDD2006#%_ and _%#MMDD2007#%_.
T3|tumor stage 3|T3,|129|131||Mr. _%#NAME#%_ is 63 years old. Last _%#MM#%_ he was found to have a sigmoid colon cancer and underwent a sigmoid colectomy of a T3, N0, M0 cancer. I do not have his actual pathology report from that procedure so I am unsure of other details of his cancer.
T3|tumor stage 3|T3|229|230|ASSESSMENT|HISTORY OF RADIATION: None HISTORY OF CHEMOTHERAPY: None. KPS score: Approximately 80-90 ASSESSMENT: Mr. _%#NAME#%_ is a 60-year-old African-American male who has biopsy proven squamous cell carcinoma of the mid esophagus, stage T3 N1 M0 (III). He is thought not to be a surgical candidate and does have moderate medical comorbidities. His performance status is good. PLAN: Dr. _%#NAME#%_ personally led a discussion with the patient in regard to the role of radiation and the management of esophageal cancer.
T3|tumor stage 3|(T3,|127|130|DOB|However, 6 of 6 lymph nodes resected were negative for metastatic disease. Thus, she was deemed to have a Stage II/Duke's B II (T3, NO, MX) adenocarcinoma of the colon. A CT scan of the abdomen and pelvis was essentially negative for metastatic disease.
T3|triiodothyronine|T3|254|255|ASSESSMENT AND PLAN|We will do an EKG today and consider an Endocrinology consult for evaluating her thyroid function or a Cardiology consult to possibly set up a Holter monitor for further workup. 3. History of abnormal thyroid function. She has a decrease TSH, but normal T3 and T4. At this time we will pan on having the patient follow up in three months with her primary care MD to recheck her thyroid function.
T3|thoracic (level) 3|T3|476|477|HISTORY OF PRESENT ILLNESS|REASON FOR CONSULTATION: Rehabilitation needs. REQUESTING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_ HISTORY OF PRESENT ILLNESS: This is a 57-year-old male who has a history of carcinoma of unclear origin diagnosed in _%#NAME#%_ 2006 following which he has reported to me that he has had 6 sessions of chemotherapy which ended in _%#MM#%_ 2006 and the follow-up CT scan had shown no progress but in _%#MM#%_ 2007 after sneezing he felt a jolt down his spine and was found to have a T3 compression fracture. His further work-up showed him to have a mass in the left lung in the lower field with a small pulmonary nodule.
T3|tumor stage 3|T3|295|296|ASSESSMENT AND PLAN|The patient also had a 4-cm soft tissue mass in the perirectal soft tissue bilaterality, which could be an abnormal lymph node and therefore patient is stage at T3 N2 M1 considering that liver lesion is a distant metastases. ASSESSMENT AND PLAN: Recently diagnosed adenocarcinoma of the rectum, T3 N2 M1 with a small liver metastasis. Options of treatment have been discussed with Dr. _%#NAME#%_ and us with options of neoadjuvant chemotherapy and then chemoradiation preoperatively or concurrent chemoradiation and watching liver lesion.
T3|triiodothyronine|T3|178|179|HISTORY OF PRESENT ILLNESS|She also had a CT angiogram, which shows a tiny anterior communicating artery aneurysm measuring 1-1.5 mm. Thyroid profile showed her TSH to be elevated at 15.5, otherwise, free T3 and thyroxin was was normal. Her echocardiogram done on _%#MMDD2007#%_ showed no significant abnormalities. She also had a stress test which was stopped due to nausea but the EKG portion was negative for any inducible ischemia.
T3|thoracic (level) 3|T3|312|313|HISTORY OF PRESENT ILLNESS|The patient also was noted to have a left forehead lesion which was biopsied with fine needle aspiration on _%#MMDD2003#%_ and also positive for squamous cell carcinoma. Also on _%#MMDD2003#%_, the patient underwent an MRI of the cervical and thoracic spine revealing metastatic disease in the vertebral body of T3 and T8 with encroachment on the thecal sac at the level of T3, but with no abnormal signal within the cord. Also, of note, was a probable hemangioma at T10 and C5 vertebral body compression fracture without cord impingement which was suspicious for malignancy, but due to motion artifact, somewhat indeterminate.
T3|triiodothyronine|T3|117|118|ASSESSMENT AND PLAN|The patient is to follow up with Ob-Gyn within 4 months if menses do not start to become regular. 5. Low TSH. T4 and T3 are pending. No history of thyroid problems. Will continue to follow clinically. We appreciate the consult.
T3|tumor stage 3|T3|191|192|HISTORY OF PRESENT ILLNESS|The final pathology report is not available, though Dr. _%#NAME#%_ comments that the tumor did not extend into the lymph nodes, but did grow through the wall of the colon. He therefore has a T3 N0 colon cancer or Duke's B2 colon cancer. He does have a risk of recurrence that is in the range of 30% to 35%.
T3|tumor stage 3|(T3|144|146|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: 63-year-old with T2 (T3 ?) N0, M0 NSC lung cancer RUL. HPI: Presented with pain in axilla, PET and CT show no nodes.
T3|tumor stage 3|(T3,|33|36|PROBLEM|PROBLEM: Rectal cancer stage III (T3, N1, M0). HISTORY OF PRESENT ILLNESS: The patient has a history of rectal cancer, stage III (T3, N1, M0). The patient received a total dose of 5040 cGy in 28 fractions between _%#MMDD2002#%_ and _%#MMDD2002#%_.
T3|triiodothyronine|T3|155|156|PERTINENT  LABORATORY VALUES|PERTINENT LABORATORY VALUES: White count 8.1, hemoglobin of 14.2, platelets 283,000. Sodium 136, potassium 4.2, creatinine 1.54, INR of 3.97, TSH of 6.51, T3 within normal range. IMPRESSION AND RECOMMENDATIONS: Mr. _%#NAME#%_ is a delightful 69-year-old gentleman with a history of lone persistent atrial fibrillation well-controlled on Rythmol who presented with dizziness and chest discomfort due to a narrow complex tachycardia.
T3|tumor stage 3|T3,|165|167|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Adenocarcinoma of the rectum, ultrasound T3, N1, M0. HPI: This is a 78-year old male patient who developed right groin pain since last winter.
T3|triiodothyronine|T3|187|188|HISTORY OF PRESENT ILLNESS|I am not aware of any intercurrent medical ailments since the time of his discharge. During his last hospitalization, the patient had been noted to have a mildly elevated TSH with normal T3 and T4. This was repeated several days later, and his TSH had improved to 5.1, with continued normal T3 and T4.
T3|triiodothyronine|T3|121|122|PLAN|She will also have folate 1 mg p.o. q. day. Will continue the multivitamin one tablet p.o. day. We will check a TSH, T4, T3 _%#MMDD#%_ and I will be notified if this is abnormal. The patient will be given a copy of her labs when she is discharged home.
T3|tumor stage 3|(T3|141|143|DIAGNOSIS|The consult was requested by Dr. _%#NAME#%_ _%#NAME#%_. Chart, radiographic reports/films, and pathology were reviewed. DIAGNOSIS: Stage IVA (T3 N2b M0) invasive moderately differentiated squamous cell of the supraglottis. REASON FOR CONSULTATION: Consideration for postoperative radiotherapy.
T3|triiodothyronine|T3|143|144|PLAN|Since amiodarone was also started this would make an I-123 scan and uptake difficult to interpret. PLAN: Will see if we can run total and free T3 lab today and TSI (thyroid stimulant immunoglobulin); if not will repeat her thyroids in the morning including free T4, free T3 and TSH.
T3|tumor stage 3|T3|9|10|PROBLEM|PROBLEM: T3 N3 M1 nonsmall cell carcinoma of the right upper lobe with SVC syndrome. SUBJECTIVE: Mr. _%#NAME#%_ was seen for initial consultation in the Mesonic Cancer Center on _%#MMDD2007#%_ by Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ at the requested of Dr. _%#NAME#%_ _%#NAME#%_.
T3|triiodothyronine|T3.|159|161|ASSESSMENT/PLAN|We will also check her for HIV 1 and 2. 3. Borderline low TSH which I doubt represents a hyperthyroid state. Recommend conservatory testing by checking T4 and T3. 4. Blurred vision. I suspect this is as a result of fatigue and possibly dry eyes. She will continue the moistening drops and will return for further evaluation as indicated.
T3|tumor stage 3|T3,|140|142|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Prostate cancer T3, N0, M0, Gleason 8, PSA 5.2. HPI: Was evaluated for seeds as monotherapy, but the ultrasound suggested extracapsular disease.
T3|tumor stage 3|T3|136|137|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Adenocarcinoma of the splenic flexure (T3) status post partial colectomy _%#MM#%_ 2004 2. Second occurrence of T3 adenocarcinoma in the cecum, status post laparoscopic cecal resection _%#MM#%_ 2004 3. Invasive lobular carcinoma of the left breast, status post left mastectomy with sentinel node biopsy _%#MM#%_ 2004, currently on Arimidex therapy and followed by Dr. _%#NAME#%_
T3|triiodothyronine|T3|155|156|CURRENT MEDICATIONS|1. Spiriva one capsule daily. 2. Starlix 120 mg twice daily. 3. Mobic 50 mg daily. 4. Zetia 10 mg daily. 5. Nexium 40 mg daily. 6. Xanax 0.25 mg q.h.s. 7. T3 one tablet every 4-6 hours. 8. Prozac 20 mg daily. 9. Restoril 30 mg daily. 10. Aspirin 81 mg daily. 11. Ambien 5 mg q.h.s. SOCIAL HISTORY: Nondrinker, nonsmoker. FAMILY HISTORY: Unremarkable.
T3|triiodothyronine|T3|177|178|LABORATORY DATA|BREASTS: Bilateral normal breast contour without any nipple discharge. No masses are appreciated. LABORATORY DATA: CBC and chemistry profile were within normal limits. Of note, T3 level was slightly low at 1.6. IMPRESSION/RECOMMENDATIONS: Mrs. _%#NAME#%_ is a 64-year-old woman with a history of chronic abdominal pain likely secondary to adhesions and a significant weight loss which is concerning.
T3|triiodothyronine|T3|147|148|IMPRESSION|She may also have iodine-induced hyperthyroidism from the MRI scan or CT scan contrast dye. I recommended additional lab tests or repeat TSH, free T3 and thyroid stimulating immunoglobulin (TSI). These tests will be ordered. In addition, I requested a thyroid ultrasound procedure and reviewed this plan with the patient.
T3|triiodothyronine|T3,|147|149|LABS|NEUROLOGIC: She is alert and fully oriented, though quite manicky. She moves all extremities. She is not tremulous. LABS: This far, include normal T3, normal liver function test. TSH was slightly low at 0.14. EKG revealed sinus tachycardia but, otherwise, was normal. Basic metabolic profile and CBC are normal.
T3|tumor stage 3|T3|190|191|ASSESSMENT AND PLAN|Her procedure was tolerated well and the pathology revealed a fairly large (8x6 cm) adenocarcinoma invasive through the colonic wall/muscularis propria and into the periadipose tissue (i.e. T3 lesion). However, 14/14 resected pericolonic lymph nodes were negative for local metastatic spread (N0 status). Her metastatic disease status is unknown as she has not had a CT scans, chest x-rays or PET scans yet.
T3|triiodothyronine|T3,|123|125|IMPRESSION|1. Multinodular goiter. 2. Probable mild hyperthyroidism. 3. Recent syncope. The laboratory tests pending including a free T3, free T4 and thyroid antibodies. The patient also will be started on a low dose of Tapazole for treatment of mild hyperthyroidism.
T3|triiodothyronine|T3|149|150|IMPRESSION|3. We will continue to check cardiac enzymes. I suspect his myoglobin is increased simply because of the seizure. I will repeat a TSH but also get a T3 and a T4 tomorrow to rule out thyroid disease. We will get an echocardiogram. I will place him on aspirin and Lovenox tonight on the off chance this is cardiac ischemia, although it seems less likely at his young age.
T3|tumor stage 3|T3|197|198|ASSESSMENT/PLAN|4. Procardia XL 30 mg p.o. daily. ASSESSMENT/PLAN: In summary, Mr. _%#NAME#%_ is an 81-year-old gentleman who has recently been diagnosed with sarcomatoid carcinoma involving the right lung, stage T3 N2. This lesion is felt to be unresectable, and given the pathology it is not felt to be likely to respond significantly to chemotherapy.
T3|thoracic (level) 3|T3|38|39|PROBLEM|PROBLEM: Metastatic liver cancer with T3 spinal cord compression. Mr. _%#NAME#%_ was seen on _%#MMDD2004#%_ by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ for consultation at the request of Dr. _%#NAME#%_ _%#NAME#%_.
T3|tumor stage 3|(T3|228|230|IMPRESSION|EXTREMITIES: Lower extremities reveal no edema. NEUROLOGIC: Nonfocal. LABORATORY DATA: Laboratory studies obtained at the time of admission included a normal CEA level. IMPRESSION: A 48-year-old female with stage 3 colon cancer (T3 N1 M0), presenting with a partial bowel obstruction. She underwent complete resection with diverting colostomy and she appears to be recovering well from surgery.
T3|tumor stage 3|T3|143|144|ASSESSMENT AND PLAN|The deep margin was 0.6 cm at least 2 cm in all other directions. ASSESSMENT AND PLAN: Mrs. _%#NAME#%_ is a 42-year-old female with stage IIIC T3 N3 M0 invasive ductal breast cancer of the right breast, status post mastectomy and adjuvant chemotherapy. Dr. _%#NAME#%_ personally led a discussion with Mrs. _%#NAME#%_ about the risks and benefits of radiation therapy for her disease.
T3|tumor stage 3|T3|195|196|ASSESSMENT|ABDOMEN: Thin. No masses appreciated. EXTREMITIES: Without edema or clubbing. CURRENT MEDICATIONS: None. ASSESSMENT: A 16-year-old male status post pneumonectomy, mediastinal lymphadenectomy for T3 N2 (stage IIIA), high-grade mucoepidermoid carcinoma of predominant squamous-cell features, status post 4 cycles of chemotherapy. PLAN: Dr. _%#NAME#%_ and I discussed with the patient the goals, risks, benefits, and alternatives to radiation therapy.
T3|tumor stage 3|T3,|133|135|ASSESSMENT|Light touch is symmetric and intact in all four extremities. Gait is smooth and symmetric. ASSESSMENT: 68-year-old female with stage T3, N1, M0 invasive lobular carcinoma of the right breast, status post four cycles of neoadjuvant Taxotere, modified radical mastectomy, and three cycles of adjuvant AC, with her last cycle scheduled for _%#MMDD2004#%_.
T3|triiodothyronine|T3|147|148|P - 99-102, BP 123/75,|Endocrine consult fu. Pt feeling better. Keeping down some food. Able to ambulate some now. P - 99-102, BP 123/75, Labs - _%#MMDD#%_ - FT$ - 3.07, T3 246, TSH < 0.01, TSI - pending. Thyroid scan/uptake - cannot be done until next week by nuc med due to holiday.
T3|triiodothyronine|T3|212|213||She was put on a fluid restriction and fosinopril and HCTZ were stopped. In the morning of _%#MMDD2007#%_ her sodium was 124 with glucose 111, creatinine 1.08, sed rate 40, A1c 7.6, TSH was less than 0.03, total T3 was 93 and normal 60-181 with a free T4 of 2.18, normal 0.7-1.85. A.M. cortisol was 21.9, triglycerides were 64.
T3|tumor stage 3|T3,|148|150|ASSESSMENT AND PLAN|Gait and balance appear to be normal, as is strength and sensation. ASSESSMENT AND PLAN: In summary, this patient is a 54-year old gentleman with a T3, N2b squamous cell carcinoma of the right tonsil, status post excisional biopsy of lymph nodes in the right neck. We agree that it is reasonable to pursue chemoradiation as detailed in ECOG protocol _%#PROTOCOL#%_.
T3|triiodothyronine|T3|213|214|LABORATORY DATA|Strength 5/5 bilaterally. LABORATORY DATA: Urine drug screen positive for cannabinoids and ethanol. Pregnancy test negative. White blood cell count 15.6, calcium level at 10.7. TSH mildly elevated at 5.56. T4 and T3 pending. Lithium level low at 0.3, total cholesterol 217, triglyceride level high at 514, HDL 29. All other labs normal. ASSESSMENT: 1. Psychiatric concerns, per Dr. _%#NAME#%_.
T3|triiodothyronine|T3|200|201|ALLERGIES|Please give a copy of the labs to the patient upon discharge home. Please call MD for any abnormal labs. 2. Elevated thyroid-stimulating hormone secondary to hypothyroidism versus stress. Waiting for T3 and T4 levels. Recheck thyroid- stimulating hormone on _%#MMDD2006#%_. 3. Elevated gamma-glutamyl transpeptidase and aspartate aminotransferase secondary to alcohol abuse/dependence.
T3|tumor stage 3|T3,|9|11|PROBLEM|PROBLEM: T3, N1, M1 squamous cell carcinoma of the floor of mouth, crossing midline, with 2 verified pulmonary metastases. HISTORY OF PRESENT ILLNESS: The patient originally presented in _%#MM#%_ 2006 with a 6-week history of slurred speech and mild left-sided tongue discomfort.
T3|triiodothyronine|T3.|233|235|PLAN|ASSESSMENT: 1. Psychiatric conditions per Dr. _%#NAME#%_. 2. Hypothyroidism with recent history of being on Synthroid. PLAN: 1. We will start Synthroid 25 mcg p.o. daily. 2. We will obtain thyroid studies including TSH, free T4, and T3. 3. We will be happy to see her during her admission for any intercurrent medical issues. We appreciate the consultation.
T3|triiodothyronine|T3|155|156|ASSESSMENT|Conceivably, hypothyroidism could aggravate his depression. We will simply follow his blood pressure and not add antihypotensive medications at this time. T3 and T4 are ordered. The patient appears to be on his usual dose of Synthroid S. As such, I would probably not make adjustments in his Synthroid dose, but instead would follow his thyroid function tests approximately every week to assure that his TFTs do normalize with consistent therapy.
T3|triiodothyronine|T3,|224|226|ASSESSMENT AND PLAN|Will start Vicodin 5/500, one tab p.o. q.i.d. p.r.n. for 2 days, and start ibuprofen 800 mg p.o. q.8 p.r.n. for pain. 3. Elevated TSH with a subsequent normal free thyroxine: Will get repeat thyroid studies including a TSH, T3, and a free thyroxine on Friday a.m. (_%#MMDD2007#%_). 4. Elevated liver enzymes: Most likely secondary to Vicodin use. Expect to resolve when Vicodin is discontinued. We will observe at this point.
T3|tumor stage 3|T3|163|164|ASSESSMENT|NEUROLOGIC: Cranial nerves II through XII intact. LABORATORY STUDIES: We reviewed the old records including a recent CT scan. ASSESSMENT: 81-year-old with initial T3 N1 colon cancer with now abdominal adenopathy causing compression of the portal vein. PLAN: We certainly can give Ms. _%#NAME#%_ radiation to the abdominal nodes.
T3|triiodothyronine|T3|162|163|LABORATORY DATA|Comprehensive metabolic panel within normal limits. Lipid panel showed total cholesterol 119, triglycerides 91, LDL 68, HDL 32. His TSH was 0.13. T4 was 1.76 and T3 124. His hepatitis B surface antigen was negative. Hepatitis C antibody negative. RPR negative. Urine gonorrhea and chlamydia were negative. Urine tox from this admission was negative.
T3|tumor stage 3|T3|159|160|REASON FOR CONSULTATION|The tumor extended to radial circumferential margin surface. The pathologist was not able to tell if this is a peritonealized margin. The tumor appeared to be T3 but T4 lesion cannot be excluded and 0 MX. Dr. _%#NAME#%_ discussed with the pathologist and he felt the tumor area extending to the superficial margin was not retroperitoneal and clinically was a peritonealized region.
T3|triiodothyronine|T3|179|180|ASSESSMENT AND PLAN|The patient's GGT was 94. ASSESSMENT AND PLAN: 1. Bipolar affective disorder, depression, polysubstance dependence per Dr. _%#NAME#%_. 2. Elevated TSH. Will recheck TSH and check T3 and T4 levels on _%#MMDD2003#%_. 3. Hepatomegaly with elevated ALT, AST and GGT levels. Possibly secondary to alcohol consumption versus hepatitis C.
T3|triiodothyronine|T3|218|219|ASSESSMENT|7. History of hypotension related to clonidine. 8. Isolated seizure event related to excessive Wellbutrin. 9. Minimal tremor potentially related to medication effect. 10. Low TSH, significance unclear. Will add T4 and T3 R.I.A. to labs. Copy of labs to patient at discharge with primary M.D. follow-up. Thank you for the consultation. No other medical intervention appears indicated at this time.
T3|tumor stage 3|T3|176|177|ASSESSMENT|This tumor was consistent with adenocarcinoma similar to the colonoscopy biopsy and was also found to invade through the muscularis propria and into the subserosal fat (i.e. a T3 lesion). However, none of the 16 resected lymph nodes were positive for localized metastatic spread (N0 nodal status). No lymphatic invasion was described and his CT scan of the abdomen and pelvis suggested no distant metastasis, (however, he did not have PET scanning or a CT scan of the chest.) Lastly, _%#NAME#%_'s surgical pathology revealed findings consistent with microsatellite instability (MSI), possibly indicating a lower grade and lower risk tumor histology.
T3|tumor stage 3|T3,|124|126|IMPRESSION|EXTREMITIES: There is no significant pedal edema. IMPRESSION: _%#NAME#%_ _%#NAME#%_ is a 65-year-old woman with a stage 3C, T3, N2, M0 colon cancer. She is now in remission after hemicolectomy, remains at high risk of recurrence. I suggested to the patient that at this point we get her home to recover from her surgery.
T3|triiodothyronine|T3|343|344|PLAN|3. New onset delirium. I suspect her effusions are mostly due to third space and secondary to low albumin; hypothyroidism certainly can cause or contribute to this but I think it is less likely, we should also rule out pancreatitis given bilateral effusions, given the most recent ERCP. PLAN: 1. Check amylase and lipase. 2. Check free T4 and T3 and replace if low. 3. Ultrasound guided tap for diagnostic and therapeutic purposes. 4. Consider enteral nutrition if there is no contraindication to this.
T3|tumor stage 3|T3|46|47|PROBLEM|PROBLEM: T3 N0 maxillary sinus tumor versus a T3 N0 gingival carcinoma. Mr. _%#NAME#%_ was seen in the Department of Therapeutic Radiology on _%#MMDD2007#%_ by Dr. _%#NAME#%_ and Dr. _%#NAME#%_ at the request of Dr. _%#NAME#%_.
T3|triiodothyronine|T3|162|163|PLAN|3. History of unprotected sex, patient declines STD testing on this admission. PLAN: 1. Resume Synthroid 100 mcg p.o. q.a.m. 2. We will get repeat TSH reflex and T3 on Monday (_%#MMDD#%_). 3. We will be happy to see her during her stay for any intercurrent medical issues. We appreciate the consultation
T3|triiodothyronine|T3|175|176|ASSSESSMENT AND PLAN|TSH elevated at 7.09. ASSSESSMENT AND PLAN: 1. Bipolar disorder. This will be followed by Dr _%#NAME#%_. 2. Mildly elevated TSH which may represent developing hypothyroidism. T3 and T4 have been ordered and are pending. We will review these and make further recommendations in this regard. 3. Psychomotor agitation which seems possibly secondary to his multiple stimulant medications.
T3|triiodothyronine|T3|227|228|PLAN|Typically, in that setting there is decreased conversion to free T4 to T3 with elevation in the T4 levels. PLAN: Await total T3. I would not intervene specifically at this point. Regarding thyroid, we will follow up when total T3 is available.
T3|triiodothyronine|T3|217|218|HISTORY OF PRESENT ILLNESS|Additional test information included abnormal thyroid tests, first noted _%#MM#%_ _%#DD#%_, 2006 with a low TSH 0.27 mu /per liter, mildly elevated free T4 1.96 nanogram per deciliter (normal 0.7-1.85), and low total T3 54 nanogram p/dL mg (normal 60-181). Repeat TSH testing today also confirmed low TSH 0.14 mu/per liter. The patient has no clear history of thyroid disease, denies previous problems with his thyroid gland during the interview, and has not been on any thyroid related medications at the time of his hospital admission, based on available medical information.
T3|tumor stage 3|T3|134|135|IMPRESSION|If she does recover from this insult we will then need to rediscuss our plans for her rectal cancer. She has a stage 2B lesion with a T3 N0 M0 adenocarcinoma. If she does recover she would be a candidate for postoperative radiation and chemotherapy. Thank you for allowing me to participate in _%#NAME#%_ _%#NAME#%_'s care.
T3|tumor stage 3|T3,|418|420|HISTORY|The lesion was consistent with invasive, moderately-differentiated adenocarcinoma in association with a villous carcinoma. This was a biopsy report with the colonoscopy. The surgery was actually on _%#MMDD#%_, the tumor was 7.5 cm in length, 16.5 cm in circumference, moderately differentiated adenocarcinoma, mucinous component 70%, solid pattern 10%, grade II invasive through muscularis propria into the subserosa, T3, no lymphatic or vascular invasion, negative lymph nodes, 25 sampled for metastatic carcinoma, mucinous component and tumor infiltrating lymphocytes suggests possible microsatellite instability.
T3|tumor stage 3|T3|187|188|ABDOMEN|LUNGS: Essentially clear. ABDOMEN: Soft and no palpable organomegaly with recent surgical scar and a colostomy bag which is functional. Assessment and Plan: Adenocarcinoma of the rectum, T3 N1 M0 status APR. The patient was recommended to have postop concurrent chemoradiation treatment. The patient is from the _%#CITY#%_, North Dakota area and she wishes to be treated near her home.
T3|triiodothyronine|T3|134|135|LABORATORY|Gait was not assessed. LABORATORY: Reveals a CBC and CMP without significant abnormality. TSH was marginally elevated at 5.63. A free T3 is pending at present. Serum pregnancy test was negative. ASSESSMENT/PLAN: 1. Bipolar disorder, currently in depressive phase.
T3|tumor stage 3|T3|220|221|IMPRESSION|RECTAL: The patient declined. NEUROLOGICAL: Cranial nerves II through XII grossly intact with no focal deficits. EXTREMITIES: No cyanosis, clubbing or edema. IMPRESSION: Ms. _%#NAME#%_ is a 51-year-old female with stage T3 N1 M0 (IIIB) adenocarcinoma of the rectum. PLAN: We have recommended neoadjuvant chemoradiation in order to decrease the risk of local recurrence and increase the chance of sparing sphincter function.
T3|triiodothyronine|T3|256|257|PLAN|No correlating symptoms to support obstructive sleep apnea. 8. Headache discomfort, likely mixed with tension/muscle contraction component becoming vascular when severe. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Recheck reflex TSH with a T3 and T4. 3. Clinical observation. 4. Consider Endocrine opinion if thyroid function studies remain abnormal. Thank you for the consultation. Will follow along as indicated.
T3|tumor stage 3|T3,|96|98|IMPRESSION|Chemistry study from today shows normal serum electrolytes, BUN 9, creatinine 0.76. IMPRESSION: T3, N2, M0 stage III colon cancer. I discussed the diagnosis of colon cancer as well as the potential risk for recurrence.
T3|tumor stage 3|T3,|212|214|IMPRESSION|h. Lymph nodes: 19 lymph nodes, no evidence of malignancy, pathologically staged at PT, 3P, N0, PMX and also omentum and appendix without evidence of malignancy. IMPRESSION: Stage 2A adenocarcinoma of the colon, T3, N0, MX. Status post hemicolectomy as described. RECOMMENDATIONS: 1. The patient does have excellent prognosis from his colon cancer.
T3|triiodothyronine|T3|129|130|ASSESSMENT/PLAN|6. Low thyroid. In addition, his free-thyroxine is also low. We will hold off treating for now. We will recheck TSH, free-T4 and T3 in 1 week. The purpose of this is this could be a pseudohyperthyroid state in light of the underlying stress, hence, it will be inappropriate to start him on methimazole, but we will not hesitate to do so if the need be.
T3|triiodothyronine|T3|162|163|ASSESSMENT|Presently patient appears stable hemodynamically. No symptoms to suggest cardiopulmonary compromise. 4. Hypothyroidism, on replacement. Low TSH noted. Will check T3 and T4 to insure that thyroid replacement, not excessive. 5. Generalized osteoarthritis. 6. Total abdominal hysterectomy for endometriosis.
T3|tumor stage 3|T3|107|108|HISTORY OF PRESENT ILLNESS|The patient had a rectal ultrasound and later had a MRI of the rectal area. It was felt that the tumor was T3 N2. The patient was referred to an oncologist for possible preoperative adjuvant chemoradiation treatment before surgery, but finally it was concluded the patient needs surgery for resectable rectal cancer.
T3|triiodothyronine|T3|131|132|ASSESSMENT|Possibly related to situational stress. Would monitor clinically for now. 5. Suppressed TSH with normal free thyroxine. Will check T3 to ensure not hyperthyroid (doubt clinically). 6. History of childhood seizure disorder, quiescent into adulthood. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Agree with workup for underlying organic cause for psychosis as I suspect this has not been done previously.
T3|tumor stage 3|(T3|167|169|ASSESSMENT AND PLAN|Her preoperative CT scans revealed a large pelvic mass but no evidence of distant metastatic disease. Therefore, it is presumed that _%#NAME#%_ has resected stage III (T3 N1 M0) invasive colon cancer. REVIEW OF SYSTEMS: Today is notable for frustration regarding her nasogastric tube (NGT) and a strong desire to eat and/or drink liquids despite her ongoing ileus.
T3|triiodothyronine|T3|187|188|PLAN|PLAN: 1. Continue with current outpatient medications as prescribed with parameters. 2. Zofran ODT 4 mg p.o. q.6h. p.r.n. nausea. 3. Will add onto labs already drawn a hemoglobin A1c and T3 and get the patient a copy of labs upon discharge in order to have when follow up with outpatient primary care physician.
T3|triiodothyronine|T3|215|216|LABORATORY DATA|CARDIAC: + tachycardia, no rubs, no gallops ABDOMEN: soft, NT/ND +BS. EXTREMITIES: + tremor with outstretched hands. No edema. NEUROLOGY: grossly intact, +hyper-reflex (+4/5) LABORATORY DATA: TSH < 0.03 freeT4 3.46 T3 351 EKG - sinus tachycardia (115s), LVH, biatrial enlargement (personally reviewed and read by me)
T3|triiodothyronine|T3|65|66|HISTORY OF PRESENT ILLNESS|Apparently, her TSH was less than 0.01, free thyroxine 3.4, free T3 7.4 normal range 2.4-4.2 and a thyroid scan showing diffuse uptake of 58%. Her TSI was also positive. The patient had been electively scheduled for a thyroidectomy on _%#MMDD2007#%_.
T3|tumor stage 3|T3|162|163|ASSESSMENT|CARDIOVASCULAR: Regular rate and rhythm without murmur. EXTREMITIES: Without cyanosis or edema. ASSESSMENT: Mr. _%#NAME#%_ _%#NAME#%_ is a 74-year-old man with a T3 N0 M0 squamous cell carcinoma of the supraglottic larynx. The rational for recommending concurrent chemotherapy and radiation for laryngeal preservation was discussed with the patient and his son-in-law.
T3|tumor stage 3|T3|229|230|HISTORY OF PRESENT ILLNESS|PHYSICAL. HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old Caucasian male who comes here from Unity Hospital. The patient is known to have metastatic renal cell carcinoma and over at Unity Hospital he was found to have a T3 mass which compromise of his vertical canal due to his metastatic renal cell carcinoma. This is currently going to be removed by Dr. _%#NAME#%_ and Dr. _%#NAME#%_.
T3|triiodothyronine|T3.|144|146|5.  HEMONC|8. Hypothyroidism: During her prior hospital admission, _%#NAME#%_ had had a workup for hypothyroidism which revealed a mildly low TSH, T4, and T3. Endocrinology was consulted who believed that she needed to be started on thyroid hormone supplementation. At the time of discharge, she was started on a dose of 50 mcg taken orally once a day.
T3|triiodothyronine|T3|136|137|5.  HEMONC|At the time of discharge, she was started on a dose of 50 mcg taken orally once a day. She was instructed to have her TSH, free T4, and T3 rechecked in 1 month's time. The etiology of her hypothyroidism is most likely mass effect from her tumor on her pituitary gland.
T3|triiodothyronine|T3.|207|209|DISCHARGE INSTRUCTIONS|6. To have repeat thyroid function checks in 1 month which will be approximately _%#MM#%_ _%#DD#%_, 2005, at her next scheduled admission for chemotherapy. Parameters to be checked include TSH, free T4, and T3. These results should be relayed onto the pediatric endocrinologist for their review. 7. Schedule admission for round number 5 of chemotherapy with ifosfamide, etoposide, and cisplatin at FUMC per the hematology- oncology service on _%#MM#%_ _%#DD#%_, 2005.
T3|triiodothyronine|T3|154|155|HOSPITAL COURSE|PROBLEM #1: Endocrine. Her low TSH at this time was further worked up with the ordering of a free T4, which was normal at 0.86; a T3, which is pending; a T3 uptake, which is pending. This patient had been worked up by Endocrinology in the past, and her first thyroid studies were in _%#MM#%_ of 2001, with a TSH of 0.46, a free T4 of 1.03, and a T3 of 160.
T3|triiodothyronine|T3|330|331|HOSPITAL COURSE|Also, an Endocrine consult was placed and Dr. _%#NAME#%_ saw this patient in consultation. Basic summary of his evaluation was at this time that the most likely explanation based on laboratory findings during this hospitalization including a mildly suppressed TSH level of 0.03 with a thyroglobulin antibody less than 20, reverse T3 of 350 and a free T4 of 1.51 with negative thyroid stimulating immunoglobulins that _%#NAME#%_ does not have Grave disease at this time.
T3|triiodothyronine|T3|210|211|OPERATIONS/PROCEDURES PERFORMED|This was done by Interventional Radiology, with local anesthesia only, on _%#MM#%_ _%#DD#%_, 2004. 9. Endocrinologic. _%#NAME#%_'s TSH was found to be markedly elevated at 16 during this admission. Free T4 and T3 were within normal limits. Endocrine Service was consulted, and thyroid ultrasound was done and was normal. _%#NAME#%_ was started on levothyroxine and will follow up with Endocrinology after discharge.
T3|triiodothyronine|T3|149|150|TRANSITIONAL UNIT COURSE|His AICD was evaluated during this visit by Cardiology, with no abnormalities. His TSH was elevated at 6.57. At the time of discharge, a free T4 and T3 were pending. His blood sugars were running in the 100s over his entire stay, and he did not require insulin. His urine amylase was followed by transplant, and on the latest value on _%#MMDD2004#%_ was 2645 units/hour.
T3|triiodothyronine|T3|135|136|LABORATORY TESTS|2. Chest x-ray showed bilateral pulmonary infiltrates, mostly alveolar with right lower lobe prominence. 3. Free thyroxine level 1.23, T3 104 with TSH 0.24. 4. Blood cultures are negative. 5. BAL negative for AFP, fungal and bacterial cultures. 6. Cytopathology is also negative. 7. Thyroid ultrasound showed two indeterminate nodules in the right lobe, both appear to be solid in nature.
T3|triiodothyronine|T3|245|246|LABORATORY DATA|INR 1.22, PTT 31, total bili less than 0.1, albumin 3.7 and total protein 79. Alkaline phosphatase 68, ALT 14 and AST 17. Sodium 138, potassium 3.5, chloride 99, bicarbonate 23, BUN of 19, creatinine 1.61, glucose 170 and calcium 10.5. TSH 4.3, T3 686 and T4 1.2. HOSPITAL COURSE BY SYSTEMS: 1. Oncology: An abdominal CT was done to evaluate the mass felt in _%#NAME#%_'s abdomen.
T3|triiodothyronine|T3|117|118|PROBLEM #4|Endocrinology was consulted regarding these findings. They recommended repeating the TSH with a free T4 as well as a T3 level. His T3 level was noted to be normal at 88. It was, therefore, the opinion of the Endocrinology Service that this likely represented euthyroid sick syndrome.
T3|triiodothyronine|T3|304|305|PROBLEM #5|At this point, there was no decision on what to do with his transplant medications, so he was scheduled and a followup appointment with Dr. _%#NAME#%_ for reevaluation of these issues. PROBLEM #5: Endocrine: The patient had a TSH checked here in hospital which returned mildly elevated at 5.39. He had a T3 returned at 109 and a free thyroxine returned at the low end of normal at 0.76. This will need to be followed up by his primary care provider as an outpatient.
T3|triiodothyronine|T3|132|133|ADMISSION PHYSICAL EXAMINATION|Lipase 11. Left ear fluid culture revealed E coli which is pansensitive. Troponin negative. Fibrinogen 421. BNP 518. TSH 37.2. Free T3 1.1. Free T4 0.56. Cholesterol 126. Triglycerides 174. LDL 82. HDL 9. Thyroid peroxidase antibody negative. Urine culture grew out 2 strains of Klebsiella. Strain #1 sensitive to Augmentin, cefazolin, ceftriaxone, ciprofloxacin, gentamicin, Timentin, tobramycin, and Bactrim.
T3|triiodothyronine|T3|100|101|DISCHARGE MEDICATOINS|10. Imodium liquid 2 mg per his G tube after each loose stool up to a maximum of 16 mg per day. 11. T3 elixir 5-10 milliliters per G tube q4-6 hours prn pain. FOLLOW-UP: 1. Dr. _%#NAME#%_ HIV Clinic in two weeks.
T3|triiodothyronine|T3|255|256|HOSPITAL COURSE|These findings were new since his last abdominal ultrasound. This patient's spleen was actually 16.3. The patient had additional studies, including hepatitis B surface antigen antibody and hepatitis B core antibody, which were negative. Ferritin was 223. T3 was 92. Free T4 was 0.63. Studies pending are a ceruloplasmin, alpha 1 antitrypsin, and antismooth muscle antibody. His sed rate was 48, and his C-reactive protein was 3.44. Because of the diagnosis of cirrhosis, based on ultrasound, GI was consulted regarding a liver biopsy.
T3|triiodothyronine|T3|235|236|HISTORY OF PRESENT ILLNESS|He also had increased sweating and dyspnea on exertion. He has lost a few pounds in the last few months and also has had anuresis. At that time in endocrine clinic, blood pressure was 144/70, heart rate was 144, TSH was less than 0.1, T3 was 15.85 and T4 was 9.75. Thyroid stimulating immunoglobulin was positive. Thyroglobulin antibody was positive and thyroid peroxidase antibody was positive.
T3|tumor stage 3|T3|24|25|ADMITTING DIAGNOSES|ADMITTING DIAGNOSES: 1. T3 N0 MX invasive urophilia carcinoma of the bladder. 2. Metastatic stage D adenocarcinoma of the prostate. 3. Chronic kidney disease secondary to obstruction from bladder tumor.
T3|triiodothyronine|T3|217|218|PROBLEM #6|We will continue to monitor her psychologic status as this medication takes effect during her rehabilitation stay. PROBLEM #6: Endocrine. TSH was significantly decreased, however, the patient ended up having a normal T3 and T4 (TSH 0.25), T3 80, and free thyroxine 1.66. We will continue to monitor this every couple of months to make sure that the patient does not develop frank hyperthyroidism.
T3|triiodothyronine|T3|122|123|5. ID|9. Hypothyroid: Thyroid studies done on _%#MMDD2002#%_ showed the TSH to be elevated at 6.59, the FT4 low at 0.54 and the T3 to be low at 78. Endocrine was consulted and requested a thyroid ultrasound and repeat of TSH, FT4 and T3. The repeat thyroid studies were consistent with hypothyroidism and _%#NAME#%_ was started on Synthroid 3 mcg per day.
T3|triiodothyronine|T3|132|133|PROBLEM #5|Endocrinology Service recommended discontinuing this after obtaining thyroid function tests. Her TSH was 1.13, free T4 was 1.04 and T3 was 124. All of these were in the normal range. In reviewing possible medication side effects, PTU has been known to cause interstitial pneumonitis.
T3|triiodothyronine|T3|260|261|LABORATORY|The urine culture on admission did show greater than 10,000 colonies of Corynebacterium and a repeat urine culture was done prior to discharge and the results are still pending at the time of discharge. 4. Endocrine. Given _%#NAME#%_'s short stature a TSH and T3 were checked during the hospital stay and were felt to be within normal limits. The TSH was 0.52 and the T3 was 1.76. Also a bone age x-ray was done of the hand and was found to have a bone age within 2 standard deviations of age 11.
T3|triiodothyronine|T3|203|204|DISCHARGE LABORATORY & DIAGNOSTIC DATA|NEUROLOGIC: Cranial nerves II-XII grossly intact. The patient was alert and oriented x3, but spoke no English, no focal deficit. DISCHARGE LABORATORY & DIAGNOSTIC DATA: Free thyroxin was 8.88, TSH 0.01, T3 was 266. On admission, TSH was less than 0.01 and free thyroxin was 9.07. The patient's EKG on admission showed sinus tachycardia with a heart rate of 127, otherwise no ST-T wave abnormalities, no Q waves.
T3|triiodothyronine|T3|224|225|ASSESSMENT AND PLAN|Endocrinology had recommended PTU at 100 mg q.i.d. and followup for radioactive iodine ablation in 2-4 weeks. There is no indication at this point for repeating her thyroid uptake scan or thyroid ultrasound. We will check a T3 and T4 level for completeness sake and will check a thyroid stimulating immunoglobulin and thyroid antibody tests. She will likely follow up with HealthPartners Endocrinology. 5. Hypertension which certainly could be contributing to her predisposition to atrial fibrillation.
T3|T3 (ECG pattern)|T3|155|156|LABORATORY DATA|Otherwise, there were no white cells, no nitrates, and no leukocyte esterase present. His electrocardiogram showed sinus tachycardia with an S1, Q3 but no T3 pattern. There was normal axis and no ST elevations were appreciated. His chest x-ray showed a right middle lobe infiltrate. ASSESSMENT/PLAN: This is a 40-year-old Type 1 diabetic with new onset DKA secondary to influenza A respiratory infection.
T3|thoracic (level) 3|T3.|145|147|IMAGING STUDIES|4. Bone scan, whole body, showing metastatic disease to the thoracic spine at approximately T6 and a probable second area of metastases at about T3. The T6 area is identified on the CT scan. Question of a third subtle metastasis at T11. 5. MRI of the T spine showing metastatic disease involving vertebral bodies from T2 through T6 and a small amount of metastatic disease in the pedicles of T7.
T3|triiodothyronine|T3|221|222|HOSPITAL COURSE|Mr. _%#NAME#%_' laboratory studies showed that the free T3 only came down slightly during his hospital stay to 8.88 at the time of his discharge. His total T3, however, did come down significantly from an admission total T3 of 516 to 266. His initial blood chemistries showed mildly abnormal liver chemistries, including a mildly elevated bilirubin.
T3|tumor stage 3|T3|122|123|ASSESSMENT AND PLAN|There is also an approximately 2 cm in length open site in the perineum area. ASSESSMENT AND PLAN: 1. Laryngeal carcinoma T3 N0 M0 status post laryngectomy _%#MMDD2006#%_. The patient is to follow up with Dr. _%#NAME#%_ from ENT and, according to discharge papers, an appointment should be made in the next week.
T3|triiodothyronine|T3.|290|292|ASSESSMENT AND PLAN|Initial draw here revealed a TSH of 14.8 and free T4 of 1.01. Repeat studies were drawn on _%#MMDD2007#%_ revealed a TSH of 7.32 and free T4 of 1.01. Pediatric endocrinology formally was consulted on _%#MMDD2007#%_ and recommended periodically following TSH and Free T4, as well as reverse T3. He was started on Synthroid 12.5 micrograms daily on _%#MMDD2007#%_, which was subsequently increased to alternating 12.5 microgram and 25 microgram doses.
T3|triiodothyronine|T3|257|258|PROBLEM #2|There was no hypokalemia. Rheumatology suggested checking ANA, which was negative, NDSCL 70, anticentromere antibodies, which are pending, repeat thyroid stimulating hormone (TSH), T4, free T index. These were checked. TSH was 1.38, thyroxin free was 0.97, T3 163. Aldolase was 8.2 elevated. Upper limit of normal is 8.1. Anticentromere IgG and scleroderma IgG were checked, and they were within normal limits.
T3|thoracic (level) 3|T3.|168|170|PAST MEDICAL HISTORY|Left ventricular ejection fraction was 58%. 2. MRI on _%#MMDD2005#%_ showed interval resolution of epidural mass. He does have loss of height of vertebra T10, T12, and T3. 3. CT completed on _%#MMDD2005#%_, which showed stable multiple bibasilar pulmonary nodules, with normal FDG uptake, stable pancreatic atrophy with multiple calcifications.
T3|triiodothyronine|T3|184|185|PROBLEM|Endocrine thought this could possibly be due to acquired antibody and recommended serial TSH dilutions in the future. Free T 4 and total T3 levels were checked. Free T4 was normal and T3 level was decreased. Her Synthroid was subsequently increased to 0.325 mg PO q day. Recommend recheck TSH and free T4 and T3 in three months.
T3|UNSURED SENSE|T3|188|189|REASON FOR ADMISSION|Drowsiness occurred early in the study, and this activated left temporal interictal discharges. Interictal activity consisted of fast spikes and spike-and-slow-wave potentials over F7 and T3 during drowsiness. No discharges were seen on the right. A dipole was identified, electrical negative in the left temporal and electrical positive in the right temporal region.
T3|triiodothyronine|T3|144|145|4. PULM|Pediatric Endocrine was consulted and requested a repeat of TSH, FT4, and total T3 on _%#MMDD#%_ with results of TSH 1.75, FT4 of 1.3 and total T3 of 3.4 all considered normal. All of these levels are normal. With the history of low calcium, a workup for adrenal function was done, with ACTH levels normal at 18.
T3|triiodothyronine|T3|170|171|FOLLOW UP|The circumcision was healing well. Problem #13: Endocrine. _%#NAME#%_ developed a mildly elevated TSH and a low normal T4. Endocrine consultation was obtained. A reverse T3 level was high, confirming the suspected sick euthyroid syndrome. Repeat thyroid functions were normal on _%#MMDD2007#%_ and _%#MMDD2007#%_. This problem has resolved.
T3|thoracic (level) 3|T3|361|362|H&P/ID|The patient's chronic pain persists and in the fall of 2006 he was seen by Dr. _%#NAME#%_/an orthopod at the Back and Neck Clinic in _%#CITY#%_ and apparently have the first time soft tissue masses diagnosed in the thoracic spine that has since gone on to be designated a spindle cell sarcoma. There had been significant progression of tumor at the site of T2, T3 and T4. Because of instability one of his ribs was harvested and wrapped with a titanium cage and attempt was made to stabilize his spine by Dr. _%#NAME#%_ again at Abbott Northwestern.
T3|triiodothyronine|T3|158|159|HISTORY OF PRESENT ILLNESS|FSH was normal at 4.9, with a mildly- reduced LH of 1.2. He had a normal total testosterone of 339. The basis for a low TSH is uncertain in light of a normal T3 and T4. He had been on Synthroid 0.1 mg chronically. No overt clinical stigmata of hyperthyroidism. He elected to continue his present regimen with recheck thyroid studies in approximately six weeks.
T3|triiodothyronine|T3|134|135|ASSESSMENT|The only clinical issue presently is the suppressed TSH, which could go along with hyperthyroidism not supported by previously normal T3 and T4. The patient does have somewhat of a "stare" to his gaze. He does note tremor, as above, which certainly may relate to Haldol effect.
T3|triiodothyronine|T3,|140|142|PLAN|5. History of peptic ulcer disease (clinically quiescent). 6. History of alcohol dependence with successful sobriety. PLAN: 1. Recheck TSH, T3, and T4. 2. Discuss once again with Endocrine. 3. Empiric aspirin 1 q.d. for antiplatelet effect. 4. Resume Senokot 2 p.o. b.i.d.
T3|triiodothyronine|T3,|166|168|IMPRESSION/RECOMMENDATIONS|Either may present with pericardial effusion. The hyperpigmentation on examination would be consistent with primary hypocortisolism. I would recommend sending a TSH, T3, and free T4. I would also recommend sending a morning cortisol and ACTH. If any of these is abnormal, I would recommend consulting Endocrinology.
T3|triiodothyronine|T3|176|177|IMPRESSION|Emergency thyroidectomy surgery is an unlikely possibility also. I would favor PTU since it is short-acting, may have benefits with thyroid hormone synthesis, as well as T4 to T3 conversion. The use of stable iodine such as SSKI may potentially cause acute exacerbation of the hyperthyroidism-I favor discontinuing this medication at the present time.
T3|tumor stage 3|T3|217|218|SUBJECTIVE|In addition, a rectal ultrasound showed that the outer serosal layer of the rectal sigmoid area was breached and that there were several enlarged lymph nodes in the area and it does appear that he is a clinical stage T3 N1 cancer. A biopsy was not apparently performed and will need to do so. The patient's CEA level was slightly elevated at 4.0. The patient is here to see me to discuss the next approaches regarding management and therapy.
T3|thoracic (level) 3|T3|169|170|ASSESSMENT|In talking to Dr. _%#NAME#%_, it looks like this tumor probably most likely given the circumstances of the way it looks and the invasion area is somewhat between T2 and T3 for practical purposes. Obviously there is no neck node involvement on CT scan or physical exam and the rest of the metastatic workup is also negative.
T3|tumor stage 3|T3|161|162|PAST SURGICAL HISTORY|Spontaneous conversion after 2 mg of IV metoprolol. PAST SURGICAL HISTORY: 1. Thoracic laminectomy, T3-T5, _%#MM#%_ 2000 as above. 2. Partial vertebrectomy from T3 through T5 with rib excision and chest tube placement (as above). 3. T3-4 fixation for fracture/subluxation (as above). 4. Rectocele repair.
T3|tumor stage 3|T3|27|28|PROBLEM|PROBLEM: Pancreatic cancer T3 N1 M0 stage IIB potentially resectable. Mr. _%#NAME#%_ was seen in the Radiation Oncology Department by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ for a consultation at the request of Dr. _%#NAME#%_.
T3|tumor stage 3|T3,|201|203|HISTORY OF PRESENT ILLNESS|There were no features of acute pancreatitis. A needle biopsy was done of the mass, which on pathology (UC04-1044) was positive for adenocarcinoma. By endoscopic ultrasound, the staging was felt to be T3, N1, M0. The patient underwent further staging with an MRI of the abdomen on _%#MMDD2004#%_. This showed again the mass in the head of the pancreas measuring 3.2 x 4.4 x 4.1 cm.
T3|tumor stage 3|T3.|222|224|PHYSICAL EXAM|The muscle cello exam was significant for severe tenderness with external rotation of the right hip. There was also mild tenderness with flexion to 90 degrees. Palpation of the cervical spine yielded exquisite tenderness, T3. The patient localized the site of this tenderness to approximately C6 or C7. There was point tenderness to palpation throughout the thoracic spine.
T3|triiodothyronine|T3.|153|155|PLAN|If abdominal symptoms persist, consider EGD if felt okay by Psychiatry. Avoid nonsteroidals. 5. With suppressed thyroid-stimulating hormone check T4 and T3. 6. Clinical observation. Thank you for the consultation. Will follow long with you.
T3|tumor stage 3|(T3|237|239|ASSESSMENT|Strength is 5/5 in all four extremities. Light touch is decreased in bilateral soles of the feet. Gait was not observed. ASSESSMENT: The patient is a 66-year-old male with locally advanced adenocarcinoma of the gastroesophageal junction (T3 N1 M0). He has significant medical comorbidities, which do not make him an ideal surgical candidate. He is status post recent J-tube placement _%#MMDD2005#%_.
T3|triiodothyronine|T3,|159|161|ASSESSMENT|6. Chronic renal insufficiency secondary to prior Vioxx. Stable certainly presently. 7. Hyperthyroidism, on replacement. Euthyroid based on normal free T4 and T3, as above. 8. History of asthma, presently well compensated. 9. History of hypertension with adequate blood pressure. 10. Question regarding remote history of peptic ulcer disease.
T3|triiodothyronine|T3|197|198|ADDENDUM|The patient also has iatrogenic hypoparathyroidism with hypocalcemia following thyroidectomy. The patient is currently without symptoms of hypocalcemia. The patient is currently being treated with T3 (Cytomel) for postoperative hypothyroidism. RECOMMENDATIONS: As above. 1. Incidental papillary thyroid cancer.
T3|triiodothyronine|T3.|163|165|PLAN|2. Mechanical soft diet. 3. Bone density x-ray. 4. Request urine culture data from Dr. _%#NAME#%_'s office. 5. Recheck thyroid function with a TSH, free T4, and a T3. Repeat liver profile as above. 6. Complete Cipro and amoxicillin. 7. Clinical observation. Thank you for the consultation. We will follow along with you.
T3|triiodothyronine|T3|254|255|IMPRESSION|The differential diagnosis would include a TSH-producing pituitary tumor or a combination of problems such as central or pituitary thyroid hormone resistance concurrent with hyperthyroidism. I will repeat the thyroid testing including TSH, free T4, free T3 and thyroid stimulating immunoglobulin. He should continue on beta blocker medication if tachycardia. There may be a connection between his hyperthyroidism and the ventricular tachycardia noted preadmission.
T3|triiodothyronine|T3|325|326|LABORATORY DATA|His T-cell subset on _%#MMDD2006#%_ showed a CD3 of 88, CD4 helper T-cell of 20, CD8 suppressor T of 65, CD19 B-cell antigen of 3, CD16 plus 56 natural killer cells of 8, CD4 to CD8 ration was 0.31 and his absolute CD4 count was 249. His reflex TSH was 0.15, HIV RNA quantitation by DNA was elevated at 5.0, his T4 was 0.86, T3 of 150. U. tox was positive for amphetamines and benzos. UA showed 30 protein. Urobilinogen of 4.0, trace leukocyte esterase, 10 white blood cells, 5 red blood cells and mucus present.
T3|triiodothyronine|T3|155|156|HISTORY OF PRESENT ILLNESS|An LP was done and a number of other labs as well, which are for the most part quite normal. Lyme screen, for instance, is negative, rheumatoid factor and T3 are normal. ESR is 3. Her CSF white blood cell count was 9 with a differential of 92% lymphocytes. The color was clear and colorless. HSV by PCR was also done and is negative.
T3|tumor stage 3|T3|160|161|HISTORY OF PRESENT ILLNESS|The patient has been well since without evidence of recurrence. The patient's current situation dates from _%#MM#%_ 2003. At that time, he was diagnosed with a T3 (palpable disease) Gleason 5 + 5 prostate carcinoma, which by imaging studies was associated with lymph node involvement. After obtaining several opinions, the patient chose to go with androgen deprivation therapy and chemotherapy.
T3|triiodothyronine|T3|165|166|PLAN|PLAN: 1. Start enteric coated aspirin 325 mg q.d. 2. Neurology consult ordered. Change the MRI to MRI/MRA to more specifically assess cerebral circulation. 3. Check T3 and T 4. 4. Nasal saline spray p.r.n. with p.r.n. Allegra and Cepacol lozenges.
T3|triiodothyronine|T3|247|248|LABORATORY  DATA|No cyanosis or clubbing. NEUROLOGIC: Alert and oriented x3. Cranial nerves II through XII grossly intact. Affect is normal. LABORATORY DATA: Sodium 142, potassium 4.4, chloride 115, CO2 total 19, glucose 187, BUN 35, creatinine 2.15, glucose 227, T3 62, free thyroxine 0.83. Rapid antigen for influenza A and B are negative. Hemoglobin 9.2. Vitamin B12 level 997. Folic acid 7.1. Chest x-ray from _%#MM#%_ _%#DD#%_ shows cardiomegaly, mild venous congestion, elevation of right hemidiaphragm.
T3|triiodothyronine|T3|141|142|PHYSICAL EXAMINATION|Sensory examination was grossly intact. Admission labs showed a sodium of 117 and osmolality of 239. Prethyroxin is mildly elevated to 2.13. T3 70 at the lower limits of normal. IMPRESSION: Hypothalamic syndrome as a consequence of the third ventriculostomy.
T3|triiodothyronine|T3|392|393|LABORATORY DATA|LABORATORY DATA: Includes a complete metabolic profile which is unremarkable with a serum sodium of 137, potassium of 4.1, chloride 109, CO2 of 24, anion gap of 5, glucose 84, BUN 18, creatinine 1.4, calcium 9.0. Normal liver profile with an albumin of 3.4. White count 9,500 with a hemoglobin of 15.1, MCV of 94, platelet count 179,000. Unremarkable differential. Free thyroxin of 1.10 with T3 of 86 and TSH of 2.34. Lithium level of 2.2. ASSESSMENT: Forty-six-year-old male is admitted with the following: 1. Bipolar affective disorder with decompensation manifested by depression, auditory hallucinations, and suicidal ideation.
T3|tumor stage 3|T3|286|287|HEENT|NEUROLOGIC: Cranial nerves II through XII within normal limits. Assessment and Plan: Stage IVA (T4a N0 M0) squamous cell carcinoma of the larynx, status post laryngectomy and right modified radical neck dissection. Previous radiation for squamous cell carcinoma of the right lower lip, T3 N0 M0. Status post chemoradiation treatment for lip cancer. On review of his previous radiation record, he probably will be able to be retreated to the area of the high risk.
T3|tumor stage 3|(T3|135|137|CC|______ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Stage IIA (T3 N0 M0) adenocarcinoma of the pancreatic head. HPI: This is a 67-year-old female patient who developed jaundice and pruritus in _%#MM2005#%_ while she was in Florida.
T3|triiodothyronine|T3,|86|88|PLAN|Would continue with antiplatelet therapy for now. 8. Surgeries as above. PLAN: 1. Add T3, T4 to labs. Decision on Synthroid dose. 2. Monitor blood pressure for now. 3. Continue antiplatelet therapy with one aspirin daily.
T3|triiodothyronine|T3|203|204|LABORATORY DATA|LABORATORY DATA: White blood cell count 9. Hemoglobin 9.7 (preoperatively 14.3). Platelets 292. Sodium 130. Potassium 4.5. Creatinine 0.55. ALT 21. AST 34. Alkaline phosphatase 71. Albumin 2.2. TSH 0.1. T3 92. Free T4 1.71. RADIOLOGY: Chest x-ray _%#MMDD2005#%_: Moderate bilateral layering effusions.
T3|tumor stage 3|T3,|242|244|ASSESSMENT AND PLAN|The pharynx and nasopharynx otherwise appeared unremarkable. He has a flap defect in the right chest wall, which is healing well at this time. ASSESSMENT AND PLAN: This is a 44-year-old male with oral tongue cancer, originally clinical stage T3, N1; pathologic stage T2, N0, M0. He is status post resection with initial positive and close margins which were rendered negative on re-resection.
T3|tumor stage 3|T3.|123|125|PLAN/SUGGESTIONS|The one advantage perhaps of PTU over Tapazole is the reduction of the T3 level by inhibiting the conversion of free T4 to T3. I would recommend 200 mg q.4.h. p.o. today, then 300 mg t.i.d. starting tomorrow. These are blocking doses. 6. At this point in time, since blood pressure is being maintained and since Ms. _%#NAME#%_ is clinically somewhat better on a beta blocker, I think we can hold on glucocorticoid therapy.
T3|triiodothyronine|T3|196|197|LABORATORY DATA|Romberg negative. Cerebellar function intact. There is mild tremor of the distal upper extremities with intent. No rigidity. LABORATORY DATA: In addition to the above: TSH reflex 0.21 with normal T3 69, free thyroxine 0.84. Glucose at noon today of 149. ASSESSMENT: 44-year-old male admitted with the following: 1. Depression with alleged suicidal ideation.
T3|triiodothyronine|T3|138|139|LABORATORY DATA|Peripheral pulses intact. Gait appears normal. No intention tremor is noted. LABORATORY DATA: Sodium 141, potassium 4.2, BUN 11, TSH 1.5, T3 1.26, magnesium 2.3. The rest of the laboratory evaluation, including liver function tests and CBC are pending. ASSESSMENT/PLAN: 1. Depression. This will be followed by Dr. _%#NAME#%_.
T3|tumor stage 3|T3|151|152|DISMISSAL DIAGNOSIS|1. Bilateral pelvic lymph node dissection. 2. Right nerve-sparing radical retropubic prostatectomy. DISMISSAL DIAGNOSIS: Gleason grade 3+3, pathologic T3 N0 MX adenocarcinoma of the prostate. HOSPITAL COURSE: Uneventful. _%#NAME#%_ _%#NAME#%_ is a 59-year-old male who did have some mild decrease in hemoglobin related to operative blood loss, as well as dilutional.
T3|triiodothyronine|T3|164|165|PLAN|Our plan for this, we will get a spot urine calcium and electrolytes, as well as send off a 24-hour urine collection for calcium. We will also check a PTH, TSH and T3 and T4 to elucidate any sort of ongoing hyperparathyroidism that would exacerbate this as well. We will also send for an ionized serum calcium, as this is mildly elevated, as well as serum phosphate.
T3|tumor stage 3|T3|277|278|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 78-year-old patient who had undergone an aorto, right common femoral, left profunda femoral bypass and a left graft to mid superficial femoral PTFE bypass on _%#MMDD2003#%_. He has also undergone a left pneumonectomy on _%#MMDD2004#%_ for a T3 N1 M0 small cell carcinoma. The patient has developed hip pain and CT scan is indicative of metastatic disease to his hip and pelvis.
T3|tumor stage 3|T3,|9|11|PROBLEM|PROBLEM: T3, N1, M0 left oral tongue cancer. Mr. _%#NAME#%_ was seen in the Radiation Oncology clinic by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2002 for consultation at the request of Dr. _%#NAME#%_.
T3|triiodothyronine|T3|127|128|PLAN|3. History of cervical cancer, status post vaginal hysterectomy, in full remission. PLAN: 1. We will obtain free thyroxine and T3 and give patient copy of labs to have with her when she follows up with her outpatient endocrinologist for further evaluation and management.
T3|tumor stage 3|T3,|248|250|ASSESSMENT AND PLAN|There is what seems to be an enlarged perigastric lymph node, more than 1 cm in diameter. There is no pleural effusion. ASSESSMENT AND PLAN: Mr. _%#NAME#%_ is a 67-year-old gentleman with history of smoking, who presented with esophageal carcinoma T3, N1, M90, status post resection with gastric pull-up. We believe the patient is a good candidate for chemoradiation therapy.
T3|tumor stage 3|T3|227|228|HISTORY OF PRESENT ILLNESS|On _%#MMDD2003#%_ he had a biopsy performed (S03-12648) which showed squamous cell carcinoma, well-to-moderately differentiated. He was referred to Dr. _%#NAME#%_ for treatment. On clinical exam, Dr. _%#NAME#%_ felt this was a T3 lesion, and he also palpated a 1.0 to 1.5 cm right jugulodigastric lymph node. Thus, it was diagnosed as T3, N1 squamous cell carcinoma of the right lateral tongue.
T4|thoracic (level) 4|T4|397|398|OPERATIONS/PROCEDURES PERFORMED THIS ADMISSION|OPERATIONS/PROCEDURES PERFORMED THIS ADMISSION: 1. On _%#MMDD2007#%_: Patient underwent a T1 through T7 pedicle screw fusion using the Medtronic Legacy system and a decompressive laminectomy and resection of tumor and decompression of spinal canal at T3, T4 and T5 with the use of intraoperative fluoroscopy. 2. On _%#MMDD2007#%_: Patient underwent a right lateral thoracotomy resection of T3 and T4 posterior ribs, complete corpectomy at T3 and T4 with interbody fusion using VERTESTACK cages 5 cm small cage with 4 degree lordotic curve cage at 20 mm.
T4|thyroxine|T4|208|209|DISCHARGE MEDICATIONS|It is important to note that on _%#MMDD2007#%_ when she was admitted, her thyroid functions were tested to ensure that she did not have subclinical hyperthyroidism precipitating atrial fibrillation. Her free T4 and TSH were in the normal range. 4. Metoprolol 50 mg p.o. b.i.d. 5. Coumadin 5 mg p.o. each day at bedtime.
T4|thyroxine|T4|178|179|HOSPITAL COURSE|Urinalysis did not show any evidence of nephrotic syndrome. LFTs were within normal limits without evidence of liver dysfunction. He had a low albumin of 2.6 and TSH, but T3 and T4 were within normal limits. Because the patient had edema of unknown etiology, most likely be iatrogenic with hospital admission and IV fluid administration and some hypoalbuminemia, he was started on diuretics and had a good response.
T4|thyroxine|T4.|239|241|HOSPITAL COURSE|Followup is arranged with Dr. _%#NAME#%_ of Endocrinology for outpatient evaluation and workup of the hyperthyroidism; at the care facility the patient will also have repeat labs, to include a CBC, basic metabolic panel, CPK, TSH and free T4. PT/OT will continue at the care facility as well.
T4|thyroxine|T4|289|290|HISTORY OF PRESENT ILLNESS|No nausea or vomiting, diaphoresis. No fevers. No coughing. In the Emergency Department his EKG showed new onset of atrial fibrillation with a slow ventricular response (heart rate around 52). Chest x-ray was benign. A urinalysis was benign. His TSH was mildly low at 0.23, however a Free T4 is 1.5 which is very normal. BNP is significantly elevated at the 1,040. Troponin and myoglobin were negative. Blood sugars mildly elevated at 188. Creatinine is 2.42 with a BUN of 81.
T4|thyroxine|T4|116|117|LABORATORY FINDINGS|Also her total bilirubin was 0.53; again in the normal range. Thyroid function normal with a TSH of 0.39 and a free T4 of 0.91. Electrocardiogram showed a normal sinus rhythm without evidence of injury or ischemia.
T4|thyroxine|T4|185|186|DISCHARGE INSTRUCTIONS|Psychological follow-up with primary-care physician in one to two weeks. Follow up with Dr. _%#NAME#%_ as scheduled on Friday, _%#MMDD2005#%_. Transplant labs as ordered. Check TSH and T4 in four weeks. DISCHARGE MEDICATIONS: 1. Prograf 5 mg p.o. t.i.d. 2. CellCept 1 gram p.o. b.i.d.
T4|thyroxine|T4|122|123|ADMITTING LABS|Electrolytes were essentially normal with the exception of slightly elevated sodium of 145 and chloride 112. TSH and free T4 were normal. Blood culture was drawn on admission, which remained negative. C. difficile also remained negative. HOSPITAL COURSE 1. FEN: Upon admission, _%#NAME#%_ was continued on her regular diet with calorie counts.
T4|thyroxine|T4|216|217|CARDIAC PLAN|5. The patient has been asked to call us in case there is a weight gain of more than 2-3 pounds than baseline. 6. At some point, a repeat TSH would be done as she had mildly elevated TSH, although with a normal free T4 in the hospital. 7. She will eventually need a nuclear study to assess for any ischemia, although clinical suspicion is low.
T4|thyroxine|T4|277|278|LABORATORY DATA|NEURO: Cranial nerves II-XII are intact. LABORATORY DATA: White cell count is 6.4, hemoglobin 11.5, platelet count 216, INR 1.01, sodium 141, potassium 3.8, chloride 106, bicarb 25, BUN 12, creatinine 0.9, glucose 160, BNP 537, troponin less than 0.07, myoglobin 34, TSH 0.05, T4 1.25, total bilirubin 0.5, alkaline phosphatase 104, ALT 35, AST 28. Electrocardiogram showed sinus tachycardia with left bundle branch block. Chest x-ray showed cardiomegaly with pulmonary venous congestion.
T4|thyroxine|T4|233|234|HISTORY|The patient developed atrial fibrillation. He was very well-controlled and asymptomatic on amiodarone; however, he developed amiodarone-induced hyperthyroidism. This has been treated by Dr. _%#NAME#%_, and is now stable. His TSH and T4 levels were normal on this admission. After he came off amiodarone, the patient went back into atrial fibrillation, and was symptomatic with shortness of breath and decreased exercise tolerance.
T4|thoracic (level) 4|T4|193|194|PHYSICAL EXAMINATION|No wheezes, rhonchi or crackles. CARDIOVASCULAR: Regular rate and rhythm, normal S1-S2. No murmurs, gallops or rubs. CHEST: There is tenderness over the anterior chest wall, approximately over T4 through T6, as well as under the right breast. The right breast is nontender. This tenderness is not reproduced in any other area of the chest wall.
T4|thyroxine|T4|147|148|FINAL DISCHARGE DIAGNOSES|Negative colonoscopy. Status post uterine biopsy, results pending. To be followed up by Gynecology as an outpatient. 2. Suppressed TSH with normal T4 to be followed up as an outpatient. DISPOSITION: Home. CONDITION: Stable. DISCHARGE MEDICATIONS: Iron sulfate 325 mg one q.d.. FOLLOW-UP: Follow-up with OB/GYN, Dr. _%#NAME#%_, Thursday.
T4|tumor stage 4|T4|114|115|HOSPITAL COURSE|He did have PET scan, which did not show any evidence of metastatic disease or tumor. It did appear to be a T3 or T4 lesion. He was started on chemotherapy and radiation with 5FU and cisplatin. He completed this course by radiation and was seen by Dr. _%#NAME#%_, and deemed to be acceptable candidate for minimally invasive esophagectomy.
T4|thyroxine|T4|120|121|PROBLEMS|Her urine osmolality was 256. Random urine sodium was 5. TSH was also checked, and this was normal, at 2.79, and a free T4 was normal, at 1.09. She was instructed on the importance of a low-salt diet, as well as fluid restriction, to keep her sodium within normal limits.
T4|thyroxine|T4|206|207|ADMISSION LABORATORY DATA|Other laboratory investigations, which she has had in the outside clinic have included HIV antibodies I and II both of which have been negative. Vitamin B12 and folate levels have been normal. TSH and free T4 levels have been normal as well. _____________ antibody and IgA screening was also negative. ASSESSMENT/PLAN: Ms. _%#NAME#%_ is a 20-year-old lady who has come in with hyponatremia and weight loss.
T4|thyroxine|T4|138|139|HISTORY OF PRESENT ILLNESS|3. Endocrine. The patient's presentation of microphallus plus borderline thyroid function tests done at 12 days of age (TSH 7.08 and free T4 of 1.97) warranted an endocrinology consult during this admission. Per the endocrinology recommendations, the patient did have a repeat TSH and T4 as well as a total T3, IgF-1, cortisol, growth hormone, and testosterone labs drawn.
T4|thyroxine|T4|128|129|HOSPITAL COURSE|She has been started on Norvasc and lisinopril. She is to have a basic metabolic panel in one week. 4. Hypothyroidism. Her free T4 was decreased 0.66. Therefore, her Synthroid was increased. Recommend repeat TSH in approximately one month. 5. Mild to moderate dementia with depression.
T4|thoracic (level) 4|T4.|203|205|MAJOR PROCEDURES DURING THIS STAY|9. _%#MM#%_ _%#DD#%_, 2005, anterior, posterior, and lateral x-rays showed no acute abnormalities. 10. _%#MM#%_ _%#DD#%_, 2005, thoracic spine AP and lateral showed questionable compression deformity at T4. Mild anterior compression deformity at T11. 11. _%#MM#%_ _%#DD#%_, 2005, lower extremity MR angiography showed _______ disease most pronounced below the ______origins.
T4|thyroxine|T4|173|174|HOSPITAL COURSE|The patient was to be discharged on methimazole 20 mg p.o. b.i.d. and propranolol 80 mg q.i.d. The patient was to follow up with endocrine within a week and have her T3 and T4 levels checked. She should have her free T4, total T3, and TSH levels checked 2 days prior to appointment. Propranolol was to be titrated to keep heart rate less than 100.
T4|thyroxine|T4|295|296|HOSPITAL  COURSE|He was maintained on sliding scale insulin. At the time of discharge the patient is starting to resume his normal diet and is therefore asked to resume his metformin and glipizide. 3. Hypertension. The patient was maintained on his Benicar. 4. Elevated TSH. The patient's TSH was elevated. Free T4 was within normal limits. 5. Ruled out for iron deficiency anemia. The patient's hemoglobin was 9.6 upon admission. There was no evidence of GI blood loss. Iron studies revealed a normal iron level as well as normal iron index saturation with mildly decreased iron binding capacity.
T4|thyroxine|T4|94|95|LABORATORY|Peripheral pulses are palpable. NEUROLOGIC: The patient is grossly nonfocal. LABORATORY: Free T4 is 0.87. TSH elevated at 106. ECG shows sinus tachycardia with Q-waves in leads III and AVF. White count 15.4 with left shift with absolute neutrophil count 12.4. Platelets 429.
T4|thyroxine|T4.|144|146|HOSPITAL COURSE|She did have a thyroid evaluation, which did reveal subclinical hypothyroidism. This should be followed. Currently, the patient has normal free T4. She will follow up with her primary care physician for management of her hypertension. PROBLEM #2: Status post right knee arthroscopy. The patient will follow up with her orthopaedist and continue her routine postoperative care, as prescribed by her orthopaedist.
T4|thyroxine|T4|135|136|DISCHARGE DIAGNOSIS|DOB: _%#MMDD1917#%_ DISCHARGE DIAGNOSIS: 1. Myasthenia gravis. 2. Status post plasmapheresis. 3. Mildly decreased TSH with normal free T4 and enlarged thyroid gland by outside imaging. HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is an 85-year-old female who presented to Dr. _%#NAME#%_ _%#NAME#%_, Neurology, at the _%#CITY#%_ Clinic with one year of diplopia, dysphagia and fatigue with chewing.
T4|thyroxine|T4|140|141|FOLLOW UP|3. The patient has an appointment to see Dr. _%#NAME#%_ in 4 weeks, on _%#MM#%_ _%#DD#%_, 2003. 4. The patient may need a follow-up TSH and T4 drawn with her primary care visit and may at some point need to be started on thyroid.
T4|thyroxine|T4.|225|227|IMPRESSION #1|IMPRESSION #1: Accelerated hypertension. I suspect that this patient may also have significant left ventricular hypertrophy. Plan: 1. Labetalol per p.o. protocol. 2. Check cardiac echo in the morning. 3. Recheck TSH and free T4. IMPRESSION #2: Pontine bleed secondary to accelerated hypertension as above.
T4|thyroxine|T4|271|272|HOSPITAL COURSE|This prompted us to increase her atenolol to 75 mg a day and decrease her isosorbide to 30 mg b.i.d. The patient will continue to take the rest of her home medications. The patient was instructed to follow up with her primary care physician. Her TSH was elevated, so her T4 was checked and this was within normal limits. This patient was seen and examined with Dr. _%#NAME#%_.
T4|thyroxine|T4|158|159|LABORATORY DATA|Significant pedal edema to knees bilaterally with erythema and marked onychomycosis of legs. LABORATORY DATA: EKG 100% paced. Labs, UA pending TSH 9.71, free T4 1.06, myoglobin 76, troponin less than 0.07, BNP 282, LFTs normal. INR 2.63, sodium 140, potassium 4.4, chloride 104, bicarbonate 28, BUN 24, creatinine 1.1. White count 10.3, hemoglobin 15.3, platelets 214,000.
T4|thyroxine|T4|137|138|ADMISSION LABS|BUN drawn initially was 93; creatinine of 4.87. With rehydration, the creatinine has come down to 2.16. Troponins were negative. TSH and T4 were okay. IMAGING: 1. CT of the head was negative except for an old basal ganglia infarct.
T4|thyroxine|T4|216|217|LABORATORY DATA|LABORATORY DATA: Sodium 142, potassium 4.8, chloride 106, CO2 32, glucose 78, BUN 23, creatinine 0.7, calcium 9.3, total protein 6.4, albumin 4, total bilirubin 0.6, alkaline phosphatase 88. GOT 26, SGPT 47, LDL 74, T4 8.7. White count 5,200, with 41% neutrophils, 47% lymphocytes, 8% monocytes, 3% eosinophils, hemoglobin 12.1, hematocrit 35.8, platelets 309,000.
T4|thyroxine|T4|258|259|HOSPITAL COURSE|The patient had been on an experimental protocol for her lung cancer and this drug was held while she was hospitalized. Problem 3: Hypothyroidism. The patient is on Synthroid medication and her TSH was suppressed during her hospitalization at 0.17. Her free T4 was 1.27. The patient's dose of Synthroid was decreased from 125 micrograms to 50 micrograms during this hospitalization and she is going to have a followup TSH done in six weeks to check her TSH and further dose changes depending on this followup lab.
T4|thyroxine|T4|174|175|HOSPITAL COURSE|However, sphenoid sinus has some opacification. Mononucleosis screen test is negative. Her urine for VMA and HVA are also negative. Her thyroid function tests, TSH, and free T4 are within normal range. T3 also sent, however, is still pending at the time of the discharge (normal). We also sent urine PPG (normal) and ALA (elevated) to rule out acute intermittent porphyria, and this urine test is still pending at the time of discharge.
T4|thyroxine|T4|247|248|PROBLEM #7|At that time, also, I would guaiac her stools and check a urinalysis. PROBLEM #7: Hypothyroidism. She was continued on Synthroid. Her TSH was slightly elevated, at 6.22, but her free thyroxin level was normal, at 0.79. I would recheck the TSH and T4 levels when she is not acutely ill. PROBLEM #8: History of anemia. With her significant GI bleed, as noted above, she will need further studies, such as a barium enema, to rule out any lesions, or consider repeat colonoscopy.
T4|thyroxine|T4|436|437|HOSPITAL COURSE|An echocardiogram revealed normal left ventricular size and function, ejection fraction of 60%, right ventricle was normal in size and function, atrial chambers were normal, there was no evidence of valvular abnormality, and estimated right ventricular pressures were minimally elevated at 29. After surgery, the patient had a mild dip in her hemoglobin to 7.6, and she was transfused back to 10.5. Her TSH was normal at 1.81, and free T4 was normal at 0.91. Her cholesterol returned as 104, triglycerides 82, HDL 45, LDL 42, and a ratio of 2. Chest x-ray was unremarkable. The patient was then stable throughout the rest of her hospital stay.
T4|thyroxine|T4|212|213|LABORATORY|1. Zoloft. 2. Zyprexa. 3. Clarinex. 4. Trazodone. LABORATORY: Labs on admission included a CBC, CMP, and LFTs which were all within normal limits. TSH level was 2.48, which was within normal limits, and a normal T4 level. Depakote level was 67 on _%#MM#%_ _%#DD#%_, 2003. HOSPITAL COURSE: On admission he was tapered off of Zoloft, and Depakote was started.
T4|thyroxine|T4|350|351|DISCHARGE PLANNING|He will resume his normal home insulin dose, subcutaneous NPH and regular at 36 units NPH and 28 units regular q.a.m., 28 units NPH and 12 units regular q.p.m. He will also go home on Dilaudid 1 mg down the NG q2h p.r.n. His home medications include Coumadin, metoprolol, Lasix, lisinopril, Xalatan, and Norvasc. Pending test results: A TSH and free T4 were drawn and are still pending at this time. The patient is also indicated to make an appointment with his primary-care physician so that he may follow-up with that physician and have his diabetes and coronary artery disease followed up.
T4|thyroxine|T4|159|160|HOSPITAL COURSE|There are no signs or symptoms of true peripheral neuropathy. There were no physical findings of same. A thyroid profile was measured with a TSH of 1.29, free T4 0.89 and a B12 of 346, all normal. Electrolytes were unremarkable. Calcium was normal at 9.5 as was the hemogram. The patient was instructed to follow with Dr. _%#NAME#%_ if symptoms were progressive in nature.
T4|thyroxine|T4|133|134|PROBLEM #3|He remains full code. Hospice was not brought up during this admission. PROBLEM #3: Hypothyroidism. TSH on admission was 23.42. Free T4 and total T3 were drawn on _%#MMDD2006#%_ and are pending. Levothyroxine was started at 50 mcg daily on _%#MMDD2006#%_. He should have follow up thyroid function tests in approximately 6 weeks.
T4|thyroxine|T4|219|220|HISTORY OF PRESENT ILLNESS|He really has no rebound, guarding or tenderness. Laboratory data available for review, his BUN and creatinine remained at his baseline of 17 and 1.8. Liver functions were normal. Sodium was 148, potassium was 4.0. His T4 levels 0.85, TSH is 2.63 and hemoglobin is 8.5. IMPRESSION AND PLAN: 1. Fecal infection, resolved. 2. History of hypothyroidism, stable. 3. History of recurrent otitis media.
T4|thoracic (level) 4|T4|203|204|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is well known to our Service, having been transferred back and forth to the University of Minnesota Medical Center, Fairview, for chemotherapy. She is status post T4 vertebral body laminectomy and surgical resection with cord compression for a recurrent spindle cell carcinoma. This was diagnosed approximately 25 years ago and treated surgically, as well as with radiation therapy, at that time.
T4|thyroxine|T4|155|156|LABORATORY  AND IMAGING STUDIES|Increased AP diameter with normal mediastinum and no acute infiltrates. Questionable fibrotic changes at the bases. BNP 7, troponin is 0.04. TSH 0.6. Free T4 1.21. White count is 10.4, hemoglobin 14.8, platelets 303. Electrolytes unremarkable. Hepatic panel normal. ASSESSMENT: 73-year-old admitted with COPD exacerbation and continued tobacco dependence and hypothyroidism.
T4|thyroxine|T4|226|227|HOSPITAL COURSE|She is being discharged to a rehab facility for rehabilitation given her injuries. 3. Subclinical hypothyroidism. During workup of her altered mental status, a TSH was checked and found to be elevated at 7.93. However, a free T4 was checked and found to be normal at 1.25. It is unlikely the subclinical hypothyroidism caused her fall. She was not started on thyroid replacement and this could be followed clinically by her primary care physician.
T4|tumor stage 4|T4|98|99|DISCHARGE DIAGNOSIS|DATE OF ADMISSION: _%#MMDD2006#%_ DATE OF DISCHARGE: _%#MMDD2006#%_ DISCHARGE DIAGNOSIS: Clinical T4 squamous cell carcinoma of the floor of mouth. PROCEDURES PERFORMED: Right composite resection, neck dissection, right pec flap reconstruction, tracheotomy.
T4|thyroxine|T4|147|148|HOSPITAL COURSE|A transthoracic echocardiogram, which showed normal LV function. No valve abnormalities. Thyroid workup showed a TSH, it was elevated but a normal T4 and she is taking Synthroid for hypothyroidism diagnosed at the age of 12. The attending staff on the Cardiology Service was Dr. _%#NAME#%_ _%#NAME#%_, an electrophysiologist after reviewing the ECG and symptoms with the patient, he felt quite certain that this was SVT secondary to AVNRT.
T4|thyroxine|T4,|206|208|PROBLEM #7|PROBLEM #7: Endocrine: The patient was seen during the hospitalization due to having problems with sweating throughout the day and night. Endocrine was consulted on _%#MMDD2007#%_ and recommended TSH, free T4, T3, total testosterone and pretestoterone and AM cortisol. The labs came back with a low AM cortisol and TSH. Endocrine is subsequently recommended checking an LH and FSH, which came back as high.
T4|thyroxine|T4|203|204|HOSPITAL COURSE|The patient was monitored on Telemetry for two days with no evidence of cardiac arrhythmia. Medicine consultation was obtained to help with further evaluation of the patient's slightly elevated TSH. The T4 was found to be acceptable and there were no further changes to her thyroid regiment. Evista was continued. The patient did have dyslipidemia and has not tolerated hypolipidemic agents in the past.
T4|thyroxine|T4.|214|216|DISCHARGE DIAGNOSES|1. Recurrent venous thrombosis, left lower extremity. 2. New diabetes mellitus. 3. Mediastinal lymphadenopathy, of undetermined significance, workup deferred. 4. Subclinical hypothyroidism, elevated TSH but normal T4. PROCEDURES & TESTS: 1. Admission chemistries with unremarkable CBC, platelet count, and liver function studies.
T4|thyroxine|T4|208|209|HOSPITAL COURSE|We will arrange for follow-up UA/UC in seven days, results to her private medical doctor or TDU doctor for follow-up. 5. Elevation in TSH. The patient has mild elevation in the TSH at 6.41. However, the free T4 is normal at 1.16 and patient is clinically euthyroid. Most likely this is euthyroid sick syndrome.
T4|thyroxine|T4|173|174|ASSESSMENT AND PLAN|Will hold Actose which the patient complains that is what is causing her blood glucose too high. Will check INR, electrolytes frequently if needed. Will obtain also TSH and T4 in the morning. Watch closely her Bg levels and avoid hypoglyceia, and use hypoglycemia protocol and discontinuation of insulin infusion.
T4|thyroxine|T4|116|117|LABORATORY DATA|Alkaline phosphatase 105. Amylase 60. AST 43. Bilirubin 2.5. Troponin was less than 0.3. A TSH was 1.35 with a free T4 of 1.55-both normal. Total protein is reduced at 6.3. Phosphorous 3.0. Repeat sodium on _%#MMDD2002#%_ was 136. Potassium 3.3. Chloride 104. Creatinine 0.6. Folic Acid was 9.6. Vitamin B-12 was 694.
T4|thyroxine|T4.|235|237|HISTORY|Plan was at some point in time in the near future to do a stress test and then carry out possible cardioversion after roughly six weeks of anticoagulation therapy. Thyroid function studies revealed a normal TSH and a slightly low free T4. Cholesterol levels were in excellent range. Renal function studies were normal including creatinines in the range of .7 to .8 and her blood sugars were normal.
T4|thyroxine|T4|180|181|CONSULTS|Pap: High-grade SIL. Colp done at approximately 27 to 28 weeks revealed CIN 2-3. No biopsies were done at that time given her late gestation. GCT 64, VDRL negative, TSH 0.21, free T4 0.56. Hepatitis B surface antigen negative. PAST MEDICAL HISTORY: Noncontributory. PAST GYNECOLOGIC HISTORY: No STDs. History of abnormal Pap smears for which she has not adequately been treated.
T4|thyroxine|T4|383|384|ADMISSION MEDICATIONS|3. Hypothyroidism. On admission, the patient was found to have subclinical hypothyroid with a TSH elevated at 9.58. However, his free T4 level was normal at 0.96. Given the setting of atrial fibrillation and the need for rate control, it was recommended that he not start oral thyroid replacement medications at this time given his normal T4 and recommend repeating the TSH and free T4 level in approximately 3-6 months by his primary care physician. 4. Alcohol abuse. The patient has a significant alcohol use history which is likely contributing to his overall medical conditions, including atrial fibrillation and heart failure.
T4|thyroxine|T4|121|122|HOSPITAL COURSE|Urine cultures pending. ENT was borderline elevated. WBC normal 9.5 at time. TSH was mildly low at 0.11, but with normal T4 at 1.26. Dosing of the patient's Levoxyl was not changed at this time. ENT consultation was obtained with Dr. _%#NAME#%_ and no significant findings were made.
T4|thyroxine|T4|141|142|1. FEN|6. Endocrine: _%#NAME#%_'s newborn screen that was drawn at less than 24 hours of life, was significant for a borderline TSH. Repeat TSH and T4 levels drawn here were within normal limits. A repeat newborn screen was also sent on _%#MMDD2005#%_ and results are pending. Ongoing problems and suggested management: 1. FEN: Current feeds are Enfacare 22 kcal/oz.
T4|thyroxine|T4|124|125|PAST MEDICAL HISTORY|13. Recent diagnosis of hyperthyroidism likely related to Graves' disease. a. He had a suppressed TSH with an elevated free T4 of 3.9 on _%#MMDD2005#%_. He then went on to have a thyroid uptake scan which showed a nodular thyroid gland.
T4|thyroxine|T4|193|194|HOSPITAL COURSE|In addition, her liver function tests would return to normal and hepatitis B and C serology would be negative. Also, initial TSH was low, but a repeat TSH was normal at 0.61 with a normal free T4 at 1.57 and a T3 of 116.
T4|thyroxine|T4|240|241|DISCHARGE DIAGNOSES|3. Goiter. a. Chest x-ray suggested a superior mediastinal mass with deviation of the trachea to the right and has been stable since _%#MMDD2003#%_ at which time she had previous chest x-ray which showed similar findings. b. TSH 0.58, free T4 1.33. c. Endocrine consultation in 2003. I believe culminated in an observation and management plan. 4. Hypertension for which she has not been treated for several years.
T4|thyroxine|T4|157|158|PROBLEM #2|His urine tox screen was completely negative. PROBLEM #2: Abnormal thyroid function test. The patient's TSH was low, as mentioned above. However, his T3 and T4 were within normal limits. An Endocrine consult was placed to determine the significance of his low TSH. Their opinion was that the atrial fibrillation was not likely related to this subtle thyroid abnormality.
T4|thyroxine|T4|172|173|FOLLOWUP VISITS|He will have home PT, OT and visiting nurse. He was discharged with home oxygen which he should wear at 4 liters nasal cannula while sleeping. He will have a TSH with free T4 checked in 2 weeks for followup of his abnormal TSH during his hospital stay. He also should have a PT INR checked in 1 week with a goal PT INR between 2 and 3.
T4|thyroxine|T4|133|134|HOSPITAL COURSE|She also had mentioned that she had a problem with her thyroid in the past. A TSH was checked which was slightly low at 0.24. A free T4 was then obtained which was normal at 1.21 and the question of possibly an early Hashimoto's thyroiditis or other problem was discussed and that she will need follow-up for this as an outpatient.
T4|thyroxine|T4|196|197|PROBLEM #3|However, he did have a free thyroxin level which was in the normal range at 1.32. Therefore, it was felt that he is a euthyroid sick patient or else may be becoming hypothyroid. However, his free T4 has not become low yet. We recommend that his primary physician follow this as an outpatient. PROBLEM #4: Mild left upper quadrant pain. Patient did complain of some mild left upper quadrant pain.
T4|thyroxine|T4|204|205|LABS|The patient was admitted to 3B West, with mental status exam significant for recall disorientation and impaired insight and judgment. LABS: Glucose 174, albumin 2.6, calcium 8.8, troponins negative. Free T4 1.94, otherwise normal CBC, electrolytes, UA, chest x-ray. She was continue on Celexa 10 mg p.o. q.d. and her Zyprexa was increased to 2.5 mg p.o. b.i.d. The patient appeared to tolerate this well during her stay.
T4|thyroxine|T4|128|129|LABS|Sodium is 139, potassium is 4.1, chloride is 112, bicarbonate is 29, BUN is 19, creatinine is 1.2. Glucose is 112. TSH is 1.72, T4 is 1.54, troponin is less than 0.07, myoglobin is 50. Urinalysis is negative. Chest x-ray shows no infiltrates. No pneumothorax is noted and no effusions are noted.
T4|thyroxine|T4|240|241|HOSPITAL COURSE|His blood counts, his hemoglobin was noted to be 8.1 on admission. He was transfused two units and by the time of discharge, his hemoglobin was stable at 10.5. We did also check thyroid studies which were noted to be 5.03, a TSH and a free T4 was 1.07. He also had findings consistent with congestive heart failure as he had some wheezing which seemed consistent with cardiac asthma on admission.
T4|thyroxine|T4.|198|200|HOSPITAL COURSE|3. Anemia. The patient's hemoglobin remained stable but low throughout her stay. Recommendation is for possible further workup per her private medical doctor (PMD). 4. Elevated TSH with normal free T4. Most likely this represents euthyroid sick syndrome, however, recommendation is for follow-up thyroid function tests at discretion of her PMD. 5. Chronic kidney disease. Remained stable throughout her stay.
T4|thyroxine|T4.|333|335|PAST MEDICAL HISTORY|Recent cardiac evaluation at Fairview Southdale Hospital with a negative adenosine thallium study showing an ejection fraction of 75%, no evidence for ischemia or prior MI. Echocardiogram showed LVH. History of diverticulosis and diverticulitis, degenerative joint disease, subclinical hyperthyroidism with suppressed TSH but normal T4. ALLERGIES: Intolerant to aspirin, she gets angioedema with lisinopril. PAST SURGICAL HISTORY: Hysterectomy, back surgery, hysterectomy, lumbar diskectomy x2.
T4|thyroxine|T4|128|129|HOSPITAL COURSE|Also, she was given a liter of normal saline yesterday and she will receive that today. A TSH was checked which was 15.8 with a T4 of 1.03. PERTINENT LABORATORY TESTS: 1. I would refer you to FCIS as noted T4 and TSH has been dictated.
T4|thyroxine|T4|291|292|PHYSICAL EXAMINATION|Hemogram is normal with white count 7.3, hemoglobin 11.9, platelets 239,000, MCV 85, sodium 142, potassium 4.0, chloride 104, carbon dioxide 28, BUN 14, creatinine 1.0, glucose 92, calcium 9.3, GFR 56, creatinine clearance 37 mL per minute, ALT 15, AST 22, T3 is 136 parenthetically normal, T4 of 1.22 parenthetically normal. Wound culture pending. DISCHARGE INSTRUCTIONS: 1. The patient is stay off her feet for extended period of time and not work for at least 1 week.
T4|tumor stage 4|(T4|163|165|PAST MEDICAL HISTORY|She has had intermittent relief after seeing the chiropractor, but again the pain has become severe. PAST MEDICAL HISTORY: 1. Stage IIIB nonsmall cell lung cancer (T4 N2 M0). T4 was based on 2 right upper lobe tumors. Status post neoadjuvant chemoradiation therapy followed by a right upper lobectomy on _%#MMDD2007#%_.
T4|thyroxine|T4|125|126|ADMISSION LABORATORY DATA|She does also continue to smoke. ADMISSION LABORATORY DATA: The patient's initial laboratory data on her admission she had a T4 and TSH pending. All troponins were normal. Her urinalysis was negative. Her sodium was 136, potassium of 3.3. Sed rate was 26.
T4|thoracic (level) 4|T4|257|258|HISTORY OF PRESENT ILLNESS|1. Thoracic spine MRI 2. Thoracic spine CT. 3. Cervicothoracic orthosis fitting and placement. HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old gentleman with history of multiple myeloma status post sacral region XRT and clavicle XRT, who underwent T4 kyphoplasty, which resulted in methacrylate infusion into the spinal canal necessitating a laminectomy in _%#MM2007#%_. He presented to the Emergency Department on _%#MMDD2007#%_ due to focal urgency and given his history, it was unsure whether if this was due to cord compression.
T4|thoracic (level) 4|T4|125|126|PROBLEM #3|An MRI was performed and showed a tumor growing into the spinal cord at the level of T5, as well as compression fractures of T4 and T12. The MRI also showed that his pulmonary lesions had doubled in size over the last month. He was treated with high-dose steroids over 48 hours, from which he is currently being weaned.
T4|thyroxine|T4|119|120|PRENATAL LABS|TSH was 0.93 with a free T4 1.47. Platelets were 323. TSH was rechecked on _%#MMDD2003#%_, and it was 1.23 with a free T4 of 0.69. Pregnancy was dated by an ultrasound at 9+6 weeks on _%#MMDD2003#%_. A repeat ultrasound was performed on _%#MMDD2003#%_ at 14+0 weeks.
T4|thyroxine|T4|213|214|HOSPITAL COURSE|A Neurology consult was obtained and they recommended continuation of antihypertensive medication and continuation of aspirin. During this admission, a thyroid ultrasound was obtained which was completely normal. T4 and TSH levels are pending at the time of this dictation. DISCHARGE MEDICATIONS: Atenolol 25 mg one p.o. q day, aspirin 325 mg one p.o. q day, Prilosec 20 mg one p.o. q day, nitroglycerin 0.4 mg sublingual tablets p.r.n. The patient is informed to follow-up with his primary physician in the next two weeks.
T4|thyroxine|T4|274|275|PROBLEM #7|We discontinued the Lipitor. PROBLEM #6: History of dyslipidemia. Fasting lipid panel in the hospital showed a total cholesterol of 110, HDL 43, LDL, 62, triglycerides 25. Statins were discontinued altogether. PROBLEM #7: Elevated TSH. TSH was mildly elevated at 6.28. Free T4 0.62. Suggest repeating this an outpatient after several months. PROBLEM #8: Pulmonary nodule. A 2-3 mm nodule was noted in recent chest CT in the right upper lobe.
T4|thyroxine|T4.|196|198|PLAN|PLAN: 1. Urgent neurology consultation. Specifically asking whether this patient is appropriate for TPA. Also subsequently asking if a C-Spine workup is warranted. 2. Tox screen. 3. TSH with Free T4. 4. MRI of the brain and C-spine. 5. Serum viscosity. 6. Sed rate. 7. Carotid ultrasound. 8. EEG if recommended by Neurology. 9. The non TPA CVI protocol will be started at this time subject to alteration by my Neurology consultant.
T4|thyroxine|T4.|162|164|ASSESSMENT|Will treat UTI with appropriate antibiotic but will avoid Levaquin for now. She has been loaded with Dilantin and is on seizure precautions. Will check a TSH and T4.
T4|thyroxine|T4|191|192|LABORATORY DATA|Patient is alert and oriented x3. LABORATORY DATA: UA is completely negative. White blood cell count 10.6, normal differential, hemoglobin 12.8. TSH is slightly elevated at 7.48 but the free T4 is normal at 0.87. Lithium level now is 0.9. EKG was obtained which demonstrates normal sinus rhythm at 71, this is a normal EKG.
T4|thyroxine|T4.|170|172|LABORATORY DATA|He will also be seen today by Endocrine prior to discharge to see whether or not the dose of Synthroid needs to be adjusted. He has an elevated TSH of 47 and normal free T4. He also wanted to see a social worker prior to discharge because he considers his 2 roommates are not good company for him and therefore he will decide to move to an assisted living facility where he will be less exposed to tobacco and alcohol.
T4|thyroxine|T4|247|248|HISTORY|EKG shows T-wave abnormalities in V3, V4 and 5. Her D-dimer slightly elevated at 0.8, so therefore, the patient underwent a chest CT which was negative for pulmonary embolus. Also, other labs that are significant was a TSH that is 0.04 and a free T4 of 1.55. Her CBC is normal. Her electrolytes are unremarkable. BNP is elevated at 3,270 with her previous BNP in _%#MM#%_ of 2007 of 1,440.
T4|thyroxine|T4.|167|169|DISCHARGE DIAGNOSES|3. Hyperglycemia occurring in a patient who received Solu-Medrol while hospitalized who has a history of gestational diabetes. 4. Mildly elevated TSH with normal Free T4. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was admitted on _%#MMDD2007#%_ by Dr. _%#NAME#%_ _%#NAME#%_.
T4|thyroxine|T4|184|185|LABORATORY DATA|Bone density from 2000 showed mild osteoporosis (no history of fracture). LABORATORY DATA: Recent labs: Lyme titer within normal range. Urinalysis, electrolytes, BUN, creatinine, free T4 and TSH within normal range since early this month. White blood count 6.8, hemoglobin 13.5 with no left shift. Blood sugar SBS 102, but A1C hemoglobin within normal range at less than 7.
T4|tumor stage 4|T4,|209|211|PROBLEM #2|She was tolerating this without discomfort. She was started on bolus feedings and was subsequently discharged to home. PROBLEM #2: Squamous cell carcinoma of the base of the right tongue. The patient is stage T4, N2b, currently undergoing a combination of weekly Taxol plus radiation therapy. She received radiation therapy throughout the hospital stay daily. She will continue on her weekly Taxol in the clinic on Mondays.
T4|thyroxine|T4|134|135|HISTORY OF PRESENT ILLNESS|Her serum glucose at that time was 939. The patient was subsequently found to have thyrotoxicosis with an initial TSH of 0.7 and free T4 of 5.68. She had negative thyroid stimulating immunoglobulins. Because of thyrotoxicosis, the patient also had atrial fibrillation. She was initially treated with iodine, propylthiouracil (PTU), steroids and a beta blocker.
T4|thyroxine|T4|129|130|PHYSICIAN|6. Need to have sodium levels checked at the time of next physician appointment. 7. Need to follow up on results of the TSH/free T4 thyroid function tests in the next physician visit. 8. Call endocrine physician on call for any question _%#TEL#%_, option number 3.
T4|thyroxine|T4|125|126|LABORATORY TESTS DURING HOSPITALIZATION|Her basic metabolic panel was normal with potassium of 3.9, sodium 141. Her thyroid function TSH was normal at 1.61 and free T4 1.28. anti cholinesterase antibody was positive reported as 70 on one occasion. A second determination was 75, normal is from 0-0.4. Acetylcholine blocking antibody one determination was 29 and the other one was 60, normal is from 0-20.
T4|thyroxine|T4|221|222|PLAN|3. Cardiovascular/respiratory. The patient will be continued on his captopril at 2.2 mg p.o. t.i.d. and he will be monitored for signs of cardiovascular and respiratory distress. 4. Endocrine. We will send a TSH and free T4 to ensure normal thyroid function. 5. Infectious disease. We will send a CBC and U/A to rule out any underlying infectious etiology including urinary tract infection.
T4|thyroxine|T4|260|261|HOSPITAL COURSE/PLAN|We will continue to monitor closely. Since the patient had one bowel movement, which is bright red we will continue to monitor closely, however, at this time the patient is stable for wards. 3. History of hypothyroidism. We will evaluate the patient's TSH and T4 levels. Given the patient is on levothyroxine and amiodarone this may or may not be attributed to her hypothyroidism state, however, the patient seems to be clinically euthyroid.
T4|thyroxine|T4|258|259|HOSPITAL COURSE|We should note patient had a TSH level of 0.20. She is on levothyroxine replacement at 100 mcg daily and it has been in the proper range in the past as she indicates without signs or symptoms of hyperthyroidism. We will have her get a follow-up TSH and free T4 in the next 2-3 weeks at Dr. _%#NAME#%_'s office. In addition, during the course of evaluation the patient had a biliary scan that showed uptake in the gallbladder and small bowel visualization although the gallbladder ejection fraction seem to be decreased.
T4|thyroxine|T4|157|158|ADMISSION DIAGNOSIS|Dr. _%#NAME#%_ _%#NAME#%_ is her endocrinologist and was contacted during the admission. She had seen Dr. _%#NAME#%_ in clinic earlier in the month. TSH and T4 were obtained during the hospitalization to assess this as an etiology and were normal. _%#NAME#%_ will follow up with Dr. _%#NAME#%_ to continue management of her diabetes.
T4|thyroxine|T4|199|200|POSTPARTUM COURSE|POSTPARTUM COURSE: Postpartum, the patient has done well. She was seen by endocrine and consultation for her hyperthyroidism. They did review her labs, which revealed a TSH of less than 0.03, a free T4 of 2.16, which was elevated, and a T3 of 281, which was also elevated. They recommended to continue propylthiouracil 100 mg p.o. t.i.d. The patient states, she is not experiencing any palpitations or noticeable tachycardia.
T4|thyroxine|T4|182|183|PROCEDURES|No evidence of any mass identified. No rib fracture. Some minimal atelectatic density at the very medial aspect of the posterior sulci. 5. Urine analysis was negative. TSH was 5.94, T4 was 1. Chest x-ray on _%#MM#%_ _%#DD#%_, 2006 was moderate cardiomegaly. 6. Nuclear bone scan showed compression fracture with moderate anterior wedging, to mid-thoracic vertebrae of uncertain age.
T4|thyroxine|T4|183|184|HISTORY OF PRESENT ILLNESS|She lives with her husband. The patient's family history is otherwise unknown. The patient's prior evaluation included a thyroid stimulating hormone level which was low at 0.01, free T4 which was 1.81, and a T3 level which was elevated at 7.2, date uncertain. She had a workup for syncope and weakness in _%#MM#%_ of this year and a brief hospitalization which included an EEG, CT scan of her head and MRI study all of which were negative or nondiagnostic.
T4|thyroxine|T4|214|215|LABORATORY TESTS|LABORATORY TESTS: Sodium 129, potassium 4.2, chloride 98, CO2 27, BUN 18, creatinine 0.7, glucose 119, calcium 8.4, hemoglobin 14.4, hematocrit 41.8, WBC 8, platelet count is 218. TSH 41.11, TSH reflex 35.17, free T4 0.88. ABG done on _%#MM#%_ _%#DD#%_ show a pH of 7.48, pCO2 of 37, pO2 of 81, bicarb of 27, and oxygen saturation of 96%.
T4|thoracic (level) 4|T4|161|162|HOSPITAL COURSE|HOSPITAL COURSE: PROBLEM #1: Back pain: The patient had imaging done in the emergency room. CT of the spine showed an acute T9 fracture with possible old T3 and T4 fractures. The patient was admitted for pain control. Her pain was relieved with morphine and lidocaine patch. She was also started on nasal calcitonin spray. Within 2 days, the patient's pain was improved but still present.
T4|thyroxine|T4|204|205|HOSPITAL COURSE|It should be noted that the patient was started on antibiotics on the day after admission by Dr. _%#NAME#%_, but cultures all returned negative and antibiotics will be discontinued. She also had a normal T4 during admission but her TSH was borderline low at 0.24. This may need to be repeated as an outpatient.
T4|thyroxine|T4|173|174|LABORATORY DATA|SKIN: Intact and normal. LABORATORY DATA: Remarkable for abnormal low sodium at 129, BUN 50 and creatinine 1.98. GFR variable between 22-25. TSH was elevated at 20.40. Free T4 was within normal range. Troponin I was elevated at 11. EKG showed very slow heart rate and complete AV heart block.
T4|tumor stage 4|T4|215|216|PHYSICAL EXAMINATION|We will most likely just have colorectal see her later today for a more definitive exam. As I mentioned she did have 17 lymph nodes that were positive for metastatic adenocarcinoma. She was pathologically staged at T4 N2 and MX. She has a stage II adenocarcinoma of the rectum, a T4 N2 MX classification. IMPRESSION AND PLAN: 1. Weakness, multifactorial secondary to diarrhea and possibly a lower GI bleed, decreased p.o. intake secondary to stomatitis.
T4|thyroxine|T4|141|142|HOSPITAL COURSE|HOSPITAL COURSE: His initial troponins were all negative, his INR was 1.26, white count on admission was 6.9, hemoglobin 13.3, TSH was 7.71, T4 0.27, sed rate 62. He had an MRI done of the thoracic and lumbar spine and impression was no evidence for metastases.
T4|thyroxine|T4,|179|181|FOLLOWUP LAB & X-RAY|8. Norvasc 5 mg p.o. q. day. 9. Lisinopril/hydrochlorothiazide 20/12.5 mg p.o. q. day. FOLLOWUP LAB & X-RAY: I have recommended a repeat UA/UC in one week, and a repeat TSH, free T4, and total T3, along with ACTH and cortisol levels in three weeks, per Dr. _%#NAME#%_'s note, as defined below. HOSPITAL COURSE: Mrs. _%#NAME#%_ _%#NAME#%_ is an 80-year-old white female who had recently been discharged from Fairview Ridges Hospital for sinus node dysfunction on _%#MMDD2005#%_.
T4|thoracic (level) 4|T4|340|341|PRIMARY ONCOLOGIST|The patient was doing well until _%#NAME#%_ 2004, when she started having right hip pain again and was admitted to University of Minnesota Medical Center, Fairview, after sustaining a hip fracture from a fall. She underwent right hip arthroplasty on _%#MM#%_ _%#DD#%_, 2005. She presented again with skeletal metastasis and underwent C2 to T4 fusion. She started having increasing lower back pain approximately in _%#MM#%_ 2005, and was treated with 15 fractions of radiation therapy to her T9 and T10 compression fracture that was found on imaging.
T4|thyroxine|T4|216|217|DISCHARGE MANAGEMENT PLAN|In addition, the patient has a history of a thyroid nodule which is hyper functioning suppressing the gland. She is followed at the University of Minnesota for this. The patient's TSH was suppressed at 0.01 and free T4 was in the normal range at 123 and T3 was in the normal range at 174. The patient's heart rate is normal throughout her hospital stay ranging 68-86, respirations were 18, blood pressure was normal.
T4|thyroxine|T4|123|124|HOSPITAL COURSE|6. Hypothyroidism. Due her high-output ostomy, thyroid function tests were checked. Her TSH was elevated to 5.58 with free T4 above 1.31. I adjusted her Synthroid to 100 mcg once p.o. daily. She will need a repeat TSH and free T4 in about 6 weeks.
T4|thyroxine|T4|143|144|HOSPITAL COURSE|Her TSH was elevated to 5.58 with free T4 above 1.31. I adjusted her Synthroid to 100 mcg once p.o. daily. She will need a repeat TSH and free T4 in about 6 weeks. 7. Osteoporosis. Continue on her Fosamax. 8. History of iron deficiency. Continue on her iron for her anemia. 9. Leg edema.
T4|thyroxine|T4|167|168|HOSPITAL COURSE|His diabetes mellitus was well controlled throughout his stay with fairly normal sugars. He had essentially normal TFTs with a TSH slightly elevated at 5.3 and a free T4 of 1.43. 4. Hematology: _%#NAME#%_'s hemoglobin was fairly stable throughout his stay and at discharge was 9.9. His platelets were also fairly stable and at discharge were 74.
T4|thyroxine|T4|152|153|ASSESSMENT/PLAN|History of anemia. We will check B12, folate, retic, iron, TIBC and ferritin. 7. Chronic pain from his left arm after multiple surgeries. Will hold the T4 due to the acetaminophen and his alcohol. Will try Oxycodone 5 mg p.o. q.6h. 8. History of complicated staph abscess in the cervical epidural space after his last cervical surgery requiring long-term antibiotics and a wound VAC.
T4|thyroxine|T4|222|223|PAST MEDICAL HISTORY|Type 2 diabetes mellitus on oral agents, and a recent hemoglobin A1c of 5.1 on _%#MMDD#%_. Hyperlipidemia with recent LDL of 63 on _%#MMDD#%_. Hypothyroidism with a slightly low TSH at 0.21 on _%#MMDD#%_ and a normal free T4 of 0.96 on the same date. PAST SURGICAL HISTORY: Remote tonsillectomy, also appendectomy, and hemorrhoidectomy. She had back surgery in early 1970s, hysterectomy and bladder repair in 1979.
T4|thyroxine|T4|186|187|HOSPITAL COURSE|He displayed no other signs of infection including fever or septic type picture in the hospital. 6. Endocrine: The patient had a slightly decreased TSA of 0.3 with a normal T3 of 98 and T4 of 1.19. It was felt that this did not represent a hypothyroid picture and should not be significantly contributing to his tachycardia.
T4|thyroxine|T4|131|132|ADDENDUM|As stated above, her TSH was found to be elevated at 8.29. Unfortunately, a T4 was not checked at that time. We attempted to add a T4 and TSH on to her labs prior to discharge, but this was not done. After discussion with her primary care provider, levothyroxine can begin versus repeating TSH with a T4 to see if the T4 is indeed suppressed or if this is subclinical hypothyroidism.
T4|thyroxine|T4|192|193|ADDENDUM|We attempted to add a T4 and TSH on to her labs prior to discharge, but this was not done. After discussion with her primary care provider, levothyroxine can begin versus repeating TSH with a T4 to see if the T4 is indeed suppressed or if this is subclinical hypothyroidism.
T4|thyroxine|T4|159|160|HOSPITAL COURSE|4. GI: The Prilosec was continued for GERD. He had no GI symptoms during his stay. 5. Endocrine: His Synthroid was continued throughout his stay. He had had a T4 and TSH checked in clinic on _%#MM#%_ _%#DD#%_, 2006. The T4 was 1.78. The TSH was 0.03. He should have this monitored per outpatient plan.
T4|thyroxine|T4|170|171|PLAN|In particular, the patient had complained of intermittent palpitations as well and will monitor for any dysrhythmias. His TSH is borderline suppressed. Will check a free T4 and monitor dysrhythmias. He will undergo serial troponins x3 and if unremarkable we will check a stress echo tomorrow. Meanwhile will also get a transthoracic echocardiogram to evaluate for left ventricular hypertrophy, chamber sizes and for ejection fraction.
T4|thyroxine|T4|204|205|PATIENT IDENTIFICATION|A Level II ultrasound was completely normal. The placenta was posterior. The patient had a quad screen that was normal. A 24-hour urine collection for protein and creatinine clearance were normal. A free T4 was also normal in the second trimester. The patient progressed to term. She was followed with antepartum testing, biophysical profile, non-stress testing weekly from 30 weeks.
T4|thyroxine|T4|127|128|LABORATORY DATA|CK 1020, protein 7.9, albumin 4.2, calcium 9.1, alkaline phosphatase 88, ALT 34, AST 66, total bilirubin 1.1, INR 1.1. PTT 22. T4 and TSH pending. Urinalysis had 40 ketones, specific gravity 1.023, pH 5, protein 100, urobilinogen 2, negative nitrites and leukocyte esterase, 3 red blood cells, positive mucus.
T4|thyroxine|T4|313|314|BRIEF HISTORY|A follow-up MRI scan was completed due to the onset of her headaches on _%#MMDD2001#%_ which did not reveal any change from the _%#MM#%_ MRI study. She underwent visual field testing preoperatively which was normal and initial endocrine evaluation was also normal with the following levels: prolactin serum 11.8; T4 5.3; TSH 0.96; and free cortisol 1.17. She underwent the aforementioned transsphenoidal excision of the pituitary tumor with frameless stereotaxy.
T4|thyroxine|T4.|160|162|ASSESSMENT/PLAN|Order physical therapy. Talk to the social worker about probable ECF placement. 2. Hypertension. Will follow. 3. Hypothyroidism. Her TSH is elevated with a low T4. Will adjust Synthroid accordingly. 4. Hypercholesterolemia. Will follow that closely as that certainly could impact on stroke. Will continue the Pravachol.
T4|thyroxine|T4,|197|199|LABORATORY DATA|The patient is discharged to be seen in followup by Dr. _%#NAME#%_ in 2 weeks to review these studies. Thyroid studies have also been ordered on the day of discharge including a TSH, free T3, free T4, and a thyroid ultrasound as well for evaluation of the thyroid mass. The patient is to be seen in followup at her primary clinic in one month or p.r.n. sooner.
T4|thoracic (level) 4|T4|222|223|ADMISSION HISTORY AND PHYSICAL EXAMINATION|ADMISSION HISTORY AND PHYSICAL EXAMINATION: The patient is a 25-year old female with complaint of 90% back pain, 10% left leg pain, who had had a previous spine fusion for scoliosis done at age 13. This had been done from T4 to L4. She had done well postoperatively from that surgery until a few years ago when she had a pregnancy, resulting in increased weight and onset of lower back pain.
T4|thyroxine|T4.|158|160|PAST MEDICAL HISTORY|To my knowledge, no cytogenic studies have been done. The patient is borderline hypothyroid. She has had a slightly elevated TSH but apparently normal T3 and T4. Also, she has had a relatively low platelet count with her last platelet count two days ago being 115 to 120,000.
T4|thyroxine|T4|156|157|PROBLEM #1|The remaining labs which were drawn on the patient were all within normal limits. The exception to this was a TSH which was noted to be low at 0.19. A free T4 was noted to be at the lower end or normal, reading 0.78, and a T3 was also read to be at the lower end of normal, reading 81.
T4|tumor stage 4|T4,|176|178|PAST MEDICAL HISTORY|She did have a low-grade temperature to 100.4 but denied any changes in her bowels or cough. PAST MEDICAL HISTORY: 1. Poorly differentiated squamous cancer of the oral cavity, T4, N2, M0, stage IV diagnosed _%#MM#%_ 2003 after failure of tooth extraction to heal in _%#MM#%_ of 2002. Patient was seen by ENT in _%#MM#%_ 2003 and noted to have a necrotic lesion, and biopsy revealed cancer.
T4|thoracic (level) 4|T4|168|169|REHABILITATION DIAGNOSES|REHABILITATION DIAGNOSES: 1. Incomplete T4 spinal cord injury ASIA classification D. 2. Pathological T4 compression fracture secondary to multiple myeloma, status post T4 kyphoplasty and T3-T6 laminectomy on _%#MMDD2007#%_. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 47-year-old right-handed male with a history of multiple myeloma and known T4 mass receiving radiation treatment as well as chemotherapy who developed weakness in his lower extremities and radicular pain and was admitted to the hospital on _%#MMDD2007#%_.
T4|thyroxine|T4|181|182|PROBLEM #1|A TSH was checked and was found to be abnormally low at 0.05. An endocrine consult was promptly obtained the morning of surgery. Free T4 and MP3 were obtained and were normal, with T4 at 5.6 , Free T4 1.02, T3 85. The endocrine consultation concluded that this is an abnormally low TSH, however, the patient was clinically euthyroid, and it would be okay to proceed with surgery from an endocrine standpoint.
T4|thyroxine|T4|57|58|LABORATORY DATA|Hemoglobin A1C done for hyperglycemia was normal at 5.9. T4 TSH was done. Follow-up history of ____ thyroid and these were normal. Serial troponins also done to rule out myocardial infarction, these were all less than 0.07. Phenytoin level on _%#MMDD2002#%_ was 12.5. The plan is to repeat this on _%#MMDD2002#%_ with LFTs.
T4|thyroxine|T4.|357|359|DISPOSITION|DISPOSITION: Patient to be discharged home to follow with primary- care provider, Dr. _%#NAME#%_ _%#NAME#%_ at the Primary Care Center in about one week and with Dr. _%#NAME#%_, her cardiologist in 2 to 4 weeks. Patient should have repeat TSH checked in approximately one month, as TSH during this admission was mildly elevated at 6.2, but she had a normal T4. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg qd. 2. Imdur 30 mg qd.
T4|thyroxine|T4|249|250|PLAN|2. Neurology consultation has been obtained. Dr. _%#NAME#%_ has already seen the patient and has outlined a plan of investigation, which will certainly be followed. 3. In regards to possible medical etiologies, I have recommended that the TSH, free T4 and phosphorus be rechecked ASAP. I am particularly interested in this patient's thyroid functionality.
T4|thyroxine|T4.|189|191|DISCHARGE DIAGNOSES|PLANNED DISCHARGE DATE: _%#MMDD2007#%_ DISCHARGE DIAGNOSES: 1. Weakness and fatigue. Multifactorial. Possibly related to anemia. 2. Subclinical hypothyroidism. Elevated TSH and normal free T4. 3. Anemia of chronic disease. Also could be related to hypothyroidism as well. 4. Congestive heart failure (CHF). 5. Hypertensive urgency.
T4|thyroxine|T4|299|300|LABORATORY STUDIES|RECTAL: Heme negative. LABORATORY STUDIES: White blood cell count of 10.5, hemoglobin 15.5, hematocrit of 45.5, platelets of 290, MCV of 87, sodium is 137, potassium is 3.7. Chloride is 103, CO2 of 26, BUN of 15, creatinine of 0.8, glucose of 93, calcium is 8.3, INR 1. PTT of 29, TSH is 1.54, free T4 is 1.27. EKG showed a sinus rhythm, T-wave inversions in AVL and flattening of T-waves in V6, otherwise completely normal.
T4|tumor stage 4|T4|183|184|PAST MEDICAL HISTORY|He tolerated his first round of chemotherapy without difficulty. This was considered to be an inoperable tumor by ENT. PAST MEDICAL HISTORY: 1. Squamous-cell carcinoma of the tonsil, T4 N0. 2. G-tube placed on _%#MMDD2003#%_. During the same hospitalization, the patient received chemotherapy and initiated radiation treatment.
T4|thyroxine|T4.|146|148|ASSESSMENT AND PLAN|Will discuss this with the family. 4. Hypertension. Monitor post Lasix. Continue other medications. 5. History of hypothyroid. Check TSH and free T4. 6. History of aspiration pneumonia and asymmetric pulmonary exam. Bedside swallow evaluation to insure that she is not aspirating.
T4|thyroxine|T4|201|202|PHYSICAL EXAMINATION|Our plan was to follow- up on those in the office, but the patient had spent some time in transitional care unit, and further workup was n ot done up to this date. The patient was found to have a free T4 of 2.5 and a TSH of 0._3, which would indicate hypothyroidism. It is possible that this has played a role in the osteoporosis.
T4|thyroxine|T4|212|213|PHYSICAL EXAMINATION|There was calcified granuloma of the left upper lobe. Comprehensive metabolic panel that was normal. She had normal cholesterol at 193, HDL was 46, LDL was 115. Thyroid tests in _%#MM#%_ 2004, TSH is 0.432, free T4 is 1.15, free T3 2.8. All this is within the normal range. PRINCIPAL DIAGNOSES: 1. Severe degenerative arthrosis of left knee.
T4|thyroxine|T4.|135|137|PLAN|PLAN: 1. The patient will be admitted to the CSC for rule out MI protocol. 2. Will recheck liver function tests. 3. Check TSH and free T4. 4. Abdominal ultrasound specifically to look for gallstones to be obtained. 5. Cardiac ultrasound to evaluate her mitral valve, as well as her ejection fraction will be obtained.
T4|thyroxine|T4|181|182|DISPOSITION|2. Follow up with Dr. _%#NAME#%_ _%#NAME#%_ in six weeks . 3. Eventual follow-up with patient's primary care physician, Dr. _%#NAME#%_, in _%#CITY#%_, Iowa. 4. Recheck TSH and free T4 in a few weeks' time. 5. Outpatient rehab p.r.n.
T4|thyroxine|T4|169|170|LABORATORY DATA|Deep tendon reflexes were within normal limits. LABORATORY DATA: WBC 6.9, hemoglobin 12.9, platelets 177, INR 0.97, PTT 35, D-dimer negative, TSH less than 0.02. T3 and T4 were ordered and pending at the time of admission. Troponin #1 was negative. Sodium 135, potassium 2.9, chloride 96, bicarbonate 28, BUN 10, creatinine 0.68, glucose 111.
T4|thyroxine|T4|139|140|LABORATORY|LABORATORY: Electrolytes, BUN and creatinine are all normal. TSH is slightly elevated at 10.8 which I think is not significant as her free T4 is normal. Blood sugars are elevated but not significantly so, in the 100s to 160 range. EKG shows junctional rhythm with a rate of about 78.
T4|thyroxine|T4|148|149|DISCHARGE MEDICATIONS|In any event, the patient's Synthroid will be held for three days and then he will resume at 0.075 mg a day. He will follow up with his PSA, T3 and T4 in two weeks with his primary care physician. A free T4 will also be added to the blood the patient had obtained yesterday and these results will be faxed to the patient's primary care physician to help guide his further therapy regarding this issue.
T4|thyroxine|T4|166|167|LABORATORY DATA|No bruits identified. EXTREMITIES: No edema. NEUROLOGIC: Reflexes normal. Cranial nerves II-XII are grossly intact. Strength is normal. LABORATORY DATA: TSH and free T4 were normal on _%#MM#%_ _%#DD#%_ when he required his cardioversion. On _%#MM#%_ _%#DD#%_ his white count was 5.7, hemoglobin 13.7, differential normal, INR 1.02, myoglobin 62, troponin less than .8 x 2.
T4|thyroxine|T4|267|268|DISCHARGE DIAGNOSES|The autonomic neuropathy does cause intermittent hypotension for which he was placed on Florinef, which is effective in controlling this symptom. 4. Hypertension. Controlled. 5. Coronary artery disease. Stable, no chest pain. 6. Hypothyroidism. His TSH was 0.65, and T4 was in a therapeutic range, so Synthroid dose has not been changed. 7. Gastroesophageal reflux disease. 8. Deep venous thrombosis prophylaxis for which he received Lovenox through _%#MMDD2004#%_.
T4|thyroxine|T4|247|248|PROBLEMS|2. The patient was edematous, puffy face. She had a history of hypothyroidism but she had not been taking any thyroid medicine for a significant period of time. An echocardiogram revealed a pleural effusion. Her TSH was markedly elevated and free T4 is markedly low as noted. The patient was felt to have myxedema. The patient was started on Levothyroxine 50 mcg the first day and increased to 75 mcg.
T4|thyroxine|T4|184|185|ASSESSMENT/PLAN|My suspicion is that she has some right-sided heart failure, and maybe some pulmonary hypertension. We will see what the findings are on that. 8. Hyperthyroidism. We will check a Free T4 and the likelihood is that we will need Endocrinology to see her at some point during this hospitalization.
T4|thoracic (level) 4|T4,|239|241|HOSPITAL COURSE|13. Pamidronate every other month in addition. HOSPITAL COURSE: Uneventful for hematological, neurological or infectious complications. After admission a magnetic resonance imaging of the thoracic spine revealed multiple metastasis at T2, T4, T7 with the most extensive disease at the T4 with epidural mass and spinal cord compression. On the examination the patient had spasticity of the lower extremities without any evidence of muscular weakness.
T4|thoracic (level) 4|T4|159|160|HOSPITAL COURSE|On _%#MMDD2002#%_ she presented to OR for extensive surgery which included: 1. T2, T4 and T6 laminectomies. 2. T4 pedicle substraction osteotomy. 3. Bilateral T4 costotransversectomies and T4 eggshell vertebrectomy. 4. T4 vertebroplasty with methylmethacrylate. 5. C7 through T8 segmental fusion with Medtronic titanium rod and sublaminar cables.
T4|thyroxine|T4|111|112|PLAN|2. Hyperthyroidism, that is to say hypothyroidism overtreated. 3. Elevated glucose. PLAN: 1. Will recheck free T4 and TSH, holding Synthroid for now. 2. Rule out myocardial infarction protocol. 3. Stress echocardiogram in the a.m. if myocardial infarction is ruled out.
T4|thyroxine|T4.|176|178|FINAL DIAGNOSES|2. Questionable ulcerative proctitis. 3. Traumatic brain injury with seizure disorder. 4. Acute renal failure, resolved. 5. Question of hyperthyroidism with low TSH but normal T4. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 64-year-old man who was admitted with nausea, vomiting, and diarrhea after a recent episode as an outpatient of acute renal failure with dehydration.
T4|thyroxine|T4,|175|177|HOSPITAL COURSE|Toxin was negative. Stool for O&P negative. There were a few PMNs in the stool. Other laboratories were relatively unremarkable, except for a borderline low TSH with a normal T4, at least suggesting hyperthyroidism. The patient is discharged to home. He will have follow-up with Dr. _%#NAME#%_ in one month and Dr. _%#NAME#%_ in two to three months.
T4|thyroxine|T4|131|132|DISCHARGE FOLLOW-UP|2. Follow-up with Dr. _%#NAME#%_ as previously scheduled. The patient was advised that her TSH level was low at 0.27 with a normal T4 of 1.26 and normal T3 of 75. Consideration may be made to reduce her thyroid medicine.
T4|thyroxine|T4|296|297|DISCHARGE MEDICATIONS|DISCHARGE INSTRUCTIONS: In investigating the patient's potentially modifiable risk factors, the patient indicated elevated blood sugars on bedside testing throughout the course of her stay, suggesting need for more rigorous blood sugar control. She also exhibited a markedly elevated TSH. T3 and T4 levels were pending at the time of her discharge. The patient is advised to follow up with her primary physician, Dr. _%#NAME#%_ _%#NAME#%_, at the Fairview _%#CITY#%_ Clinic within 1 week's time to follow up on rigorous management of her important risk factors for stroke, including her diabetes, her hypertension, any possible hypercholesterolemia, as well as follow up assessment of her hypothyroidism.
T4|thyroxine|T4|125|126|REVIEW OF SYSTEMS|LYMPHATIC: She has a little bit of lymphedema in the right upper extremity. ENDORINE: TSH is elevated even though the T3 and T4 are normal. That will be addressed by Dr. _%#NAME#%_. NEURO: Negative. No dizziness, headache, or weakness. IMMUNE: Negative. PSYCH: Negative. PAIN: She intermittently gets pain across her chest and takes over-the- counter medications.
T4|thyroxine|T4|166|167|HOSPITAL COURSE|She should have follow-up liver function tests in one month with her primary care physician. 4. Hypothyroidism. a. The patient had an elevated TSH of 16.11. Her free T4 level came back slightly less at 0.68. b. Her Synthroid dose was subsequently increased form 150-mcg to 200-mcg q.d. The patient should have a follow-up TSH level in one month with her primary care physician.
T4|thyroxine|T4|208|209|FOLLOW UP|FOLLOW UP: Follow up is with Dr. _%#NAME#%_ in the primary care center on _%#MM#%_ _%#DD#%_, 2005, at 9:00 a.m. with Dermatology Clinic on _%#MM#%_ _%#DD#%_, 2005, at 10:30 a.m. He should have a TSH and free T4 in 6 weeks with his appointment with Dr. _%#NAME#%_. Additionally, LFTs should be checked on _%#MM#%_ _%#DD#%_, 2005, with dermatology clinic with the initiation of fluconazole.
T4|thyroxine|T4|175|176|ASSESSMENT  AND PLAN|2. Hypokalemia. The patient was placed on potassium protocol and probably be needed to be discharged on potassium. 3. Hypothyroidism. Despite her TSH being elevated. Her free T4 is normal. ADDENDUM CODE STATUS: DNR/DNI.
T4|thyroxine|T4|213|214|ASSESSMENT|She remains tachycardic, which is notably primarily due to her dehydration status, but also to some extent could be due to oral replacement of her thyroid. In reviewing the clinic labs done 3 weeks ago, she had a T4 of 1.97 and TSH of 0.52. She is a candidate for beta blocker prophylaxis during surgery, but will defer this to anesthesia given the urgency of her need for surgery.
T4|thyroxine|T4|198|199|HOSPITAL COURSE|If she had a recent nuclear stress test then, that would likely be adequate, and she would not need further testing. Also during her hospitalization, she did have a very mildly low TSH but a normal T4 and T3. It makes sense to recheck a TSH in a couple of months to ensure that that is normal.
T4|thyroxine|T4|165|166|1. CV|We are now keeping _%#NAME#%_'s sats above 85%. 3. Endocrine: At risk of hypothyroidism secondary to Trisomy 21. _%#NAME#%_'s TSH was elevated at 15.6, and his free T4 was 2.61, which is also slightly elevated. This pattern is of unknown significance and he should have a TSH and free T4 repeated at one month of life.
T4|thoracic (level) 4|T4|266|267|PROBLEM #1|The patient was transferred to acute rehab for reconditioning. PHYSICAL EXAMINATION: Please refer to progress note dated _%#MM#%_ _%#DD#%_, 2005, and _%#MM#%_ _%#DD#%_, 2005. HOSPITAL COURSE: PROBLEM #1: Thoracic spinal cord tumor status post T3 laminectomy, T2 and T4 laminotomy, and the patient was admitted to acute rehab unit at University of Minnesota Medical Center, Fairview. Consultation with physical medicine and rehabilitation was obtained. The patient was started with PT/OT program, and the patient's progress totally improved, and the patient had paresthesia in right lower leg and right lower abdomen, and also some burning sensation pain in right upper quadrant area, which was decreased in intensity.
T4|thyroxine|T4|164|165|SUMMARY|There were no clinical signs of hyponatremia. 4. Hypothyroidism. The patient was found to have elevated TSH during her workup for euvolemic hyponatremia. Both free T4 and T3 were decreased. This may also partly explain her hyponatremia. Treatment with Synthroid was started to be advanced as needed outpatiently.
T4|thyroxine|T4|245|246|DISPOSITION|She was also seen by speech therapy for dysphagia and dietary suggestions were made as a result of an abnormal video swallow and a bedside swallow evaluation. The patient was found to have a TSH of 0.003 with a normal range at 0.4-5.0. Her free T4 was 1.08 with a normal range of 0.7-1.85 a free T3 is pending. The patient's sedimentation rate was 41. Her CRP was 0.2 with a normal range of 0-8.0. MRI of the head revealed chronic white matter disease, mild atherosclerotic disease of the carotid bifurcations, MRI of the neck revealed mild disease of the proximal right external carotid artery.
T4|thyroxine|T4|193|194|LABORATORY|INR of 2.14. Her chemistry showed a creatinine of 2.6 which was lower than the highest peak at 3.1 at Springfield the day prior to admission to our hospital. She also had a TSH of 0.8 and free T4 of 1.4. HOSPITAL COURSE: 1. Tachybrady syndrome. The patient had atropine and pressors placed at the bedside p.r.n., and she was placed on continuous EKG monitoring.
T4|thyroxine|T4|198|199|HOSPITAL COURSE|The patient was started on potassium supplements and her potassium improved on to 3.5 on the day of discharge. As part of her evaluation the patient had TSH which was decreased to 0.23 but her free T4 was normal at 1.32 and T3 normal at 103. The patient's cortisol was elevated at 118 but this was felt to be secondary to stress as per the Endocrine Teams opinion.
T4|thyroxine|T4|171|172|DISCHARGE DIAGNOSES|c. adenosine nuclear stress test showed no evidence of ischemia with an EF of 75%. 3. A4. bnormal TSH. . Ia. nitial TSH was 0.38. a. Fb. ollow-up TSH was 0.49 with a free T4 of 0.86. b. Cc. T scan of the chest to look at her lungs did demonstrate cysts suggesting cystic or nodular changes on the thyroid, which was further investigated with a thyroid ultrasound, which showed a multi-nodular thyroid gland.
T4|tumor stage 4|T4|292|293|POSTOPERATIVE COURSE|The margins were free of tumor but the tumor did invade through the muscularis propria into the pericolonic adipose tissue and visceral peritoneum and 3/12 lymph nodes were positive for metastatic adenocarcinoma, the largest node being 1 cm in diameter with extranodal extension. Staging was T4 N1 MX. CEA was 4.0 on _%#MMDD2006#%_. Final hemoglobin prior to discharge on _%#MMDD2006#%_ was 9.2 and stable at that level. The patient was given discharge instruction as to care of her incision and use of discharge medications including Darvocet as needed for pain.
T4|thyroxine|T4|141|142|PLAN|This includes insulin drip. 2. Vigorous rehydration. 3. Rule out myocardial infarction protocol. 4. CVP monitoring. 5. Will add TSH and Free T4 to admitting labs, as well as a Tox screen, EKG, and alcohol level. 6. The patient is pan-cultured. No antibiotics will be given at this time.
T4|thyroxine|T4|197|198|HOSPITAL COURSE|HOSPITAL COURSE: 1. Thyrotoxicosis. This is likely subacute thyroiditis. The patient had laboratory studies consistent with hyperthyroidism, specifically, her TSH was suppressed at 0.03 and T3 and T4 were elevated at 321 and 2.68 respectively. She also had elevated markers of inflammation. Her CRP was 62 and ESR was 127. Thyroid peroxidase antibody was negative. It was felt that she likely has subacute thyroiditis and therefore her prednisone dose was increased to 20 mg once a day.
T4|thoracic (level) 4|T4|161|162||_%#NAME#%_ _%#NAME#%_ is a 47-year-old female who underwent an endoscopically assisted anterior T8 to T12 spinal fusion with posterior spine reconstruction from T4 to T12 with augmentation to previous lumbar fusion. Her postoperative course and recovery included gradual progression of activity.
T4|thyroxine|T4.|190|192|OPERATIONS/PROCEDURES|3. Thyroid incidentaloma. The patient had a 1 mm enhancing area on an ultrasound, but a normal TSH and normal T3 and T4. She will follow up with her primary care physician for repeat T3 and T4. Of note, it was believed that the patient's abnormal LFTs which had resolved were related to passive liver congestion secondary to her tachycardia-induced cardiomyopathy.
T4|thyroxine|T4|223|224|OPERATIONS/PROCEDURES|4. False-positive TSH. Initially the patient's TSH prior to admission was determined to be low at 0.11. However, her T3 and T4 levels were normal. Subsequent recheck of her TSH revealed that her TSH was 0.79 and her T3 and T4 were 1.51 and 126 which were within normal limits. It was felt that her TSH elevation was due to either her ocular steroids or her acute illness, and not indicative of subclinical hyperthyroidism or hyperthyroidism.
T4|thoracic (level) 4|T4|117|118|SUMMARY OF HOSPITAL COURSE|However, he was ataxic on coordination testing. He was taken to surgery on _%#MM#%_ _%#DD#%_, 2007 and did undergo a T4 through 6 lumbar laminectomy for removal of the epidural tumor. Epidural tumor pathology did return with evidence of multiple myeloma.
T4|thyroxine|T4|155|156|HOSPITAL COURSE|He is aware of S-B prophylaxis for his valvular disease. #3: Question of hypothyroidism. The patient's TSH was noted to be 8.55, repeat 10.0. TSH, T3, and T4 were sent to confirm this. Results will be forwarded to Dr. _%#NAME#%_ for initiation of Synthroid should the patient need it for hypothyroidism.
T4|thyroxine|T4|157|158|1. FEN|Her urine, blood and CSF cultures were all negative. She remained stable, and her antibiotics were discontinued after 72 hours. 8. Endocrine: A TSH and Free T4 were checked on _%#NAME#%_ and were within the normal limits. Discharge medications, treatments and special equipment: Ferrous Sulfate (elemental iron) 3.5 mg PO BID _%#NAME#%_ is a good candidate to receive Synagis during the upcoming RSV season.
T4|thyroxine|T4,|103|105|DISCHARGE INSTRUCTIONS|Follow-up at Cedar Ridge Clinic on Monday _%#MMDD#%_ for repeat ALT, alkaline phosphatase, free T3 and T4, fax results to Dr. _%#NAME#%_'s office at _%#TEL#%_. Follow-up with Dr. _%#NAME#%_ in 2 weeks. DISCHARGE MEDICATIONS: 1. Propylthiouracil 50 mg 2 tablets p.o. daily.
T4|thyroxine|T4.|152|154|PAST MEDICAL HISTORY|4. Hypertension. 5. Persistently depressed TSH with normal radioactive iodine, uptake scan normal, thyroid antibody studies and normal free T3 and free T4. 6. The patient is labeled as having congestive heart failure, however, she has an ejection fraction of 60%. 7. Rotator cuff repair bilaterally in 1980. 8. Pneumonia. FAMILY HISTORY: Noncontributory.
T4|thyroxine|T4|127|128|DISCHARGE DIAGNOSES|Liver function tests revealed an elevated AST of 88 on admission and 79 on _%#MMDD2002#%_. TSH at admission was 3.07, and free T4 0.94. Vitamin B12 was within normal limits at 359. ANA screen was negative. Urinalysis showed a small amount of blood and few bacteria, otherwise normal.
T4|thoracic (level) 4|T4|135|136|PRINCIPAL DIAGNOSIS|Weight-bearing status partial, gait level as tolerated. PRINCIPAL DIAGNOSIS: 1. Left femoral neck fracture. 2. Compression fracture of T4 and T10, acute. 3. Postoperative anemia. 4. Postoperative subendocardial myocardial infarction. 5. Hypertension, severe. 6. Extensive _______ osteoporosis of the spine. 7. Severe degenerative arthritis of the spine.
T4|thyroxine|T4|151|152|HOSPITAL COURSE|The last TSH obtained on _%#MM#%_ _%#DD#%_, 2002 was normal. Prior to that the TSH was elevated to 8.41. On _____ it was mildly elevated, but the free T4 was normal at 1.06. Troponin I was less than .3 times three. Lipase 155, myoglobin 43. Liver function tests were within normal limits.
T4|thyroxine|T4,|129|131|ADMISSION LABS|The patient is crawling, with occasional falls. He can sit up unsupported. ADMISSION LABS: Normal electrolytes, CBC, urinalysis, T4, TSH, albumin, and normal plasma amino acids. Random urine amino acids showed elevated carnosine level of 480, which may be due to the patient's diet, and elevated hydroxyproline level of 105.
T4|thyroxine|T4|147|148|DISCHARGE MANAGEMENT PLAN|Ammonia less than 1. Hemoglobin A1C was normal at 5.8. Initial PSA slightly suppressed at 0.35, with a repeat it was 0.54 which was normal. A Free T4 was normal and a B-12 was 441. Blood cultures remained sterile. Chest x-ray showed postoperative bypass changes, some ectasia, and dilated thoracic arch in the bulb region but without other abnormality.
T4|thoracic (level) 4|T4,|103|105|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Metastatic breast cancer T4, T5, and T6. 2. Osteolytic osteoblastic lesions of T4, T5, and T6. 3. Insulin dependent diabetes. 4. Bradycardia, asymptomatic. 5. Chronic renal insufficiency. 6. History of DVT. 7. History of P-E. 8. Pulmonary fibrosis.
T4|thyroxine|T4,|285|287|PROBLEM #3|This diarrhea was C difficile negative. We are uncertain of what the etiology of the diarrhea was, it improved; however, prior to discharge. PROBLEM #3: Abnormal TSH. This was checked on admission as part of an evaluation for confusion, and was found to be elevated with a normal free T4, which was most consistent with euthyroid syndrome, which requires no further therapy. PROBLEM #4: To be continued on enoxaparin per home dose.
T4|thyroxine|T4|113|114|HOSPITAL COURSE|2. Graves disease. The patient was recently diagnosed with Graves disease. 3. Her TSH was pretty low with a free T4 more than 4. She was asymptomatic. Dr. _%#NAME#%_'s recommendations were to start methimazole 10 mg p.o. q. day until she sees Dr. _%#NAME#%_ in the near future.
T4|thyroxine|T4|240|241|PROBLEM #2|They also recommended avoidance of alcohol, caffeine and insomnia. Of note she had a MUGA scan after chemotherapy in the spring of 2001 which was normal. PROBLEM #2: Hypothyroid. During evaluation for her palpitations, she had TSH and free T4 done. TSH was 10, and free T4 0.78. The patient will be started on levothyroxine 50 mcg p.o. q.d., and labs should be rechecked in two months.
T4|thyroxine|T4|141|142|HOSPITAL COURSE|A renal consult was obtained and they suggested a captopril renogram, which was normal. They also did thyroid studies. TSH was 5.10 and free T4 was 1.26, both normal. A p.m. cortisol was 11.4, which is normal. Renin, aldosterone, and catecholamines were sent and are pending at the time of this dictation.
T4|thyroxine|T4|168|169|PROBLEM #2|The patient should continue on his Nexium and also prescribed a new medication called Librax to help with the frequent stooling. PROBLEM #2: Low TSH. However, the free T4 level is normal at 1.10. Recommend that he follow up with primary to recheck a thyroid level. No need for therapy at this time.
T4|thyroxine|T4|141|142|DISCHARGE FOLLOW-UP|The Cortisol was 7.4 in the a.m. We did give a Cortisol Cortrosyn Stimulation Test and it would rise to 37 which was a normal response. Free T4 was elevated at 2.0 and TSH was suppressed at 0.01. On _%#MMDD2004#%_, sodium was 136, potassium 3.3, chloride 106, C02 23, creatinine 1.23, BUN 6.
T4|thyroxine|T4|256|257|ASSESSMENT/PLAN|4. Hypertension. Blood pressure is up. Will stop the Norvasc due to leg swelling, increase lisinopril to 40 mg . 5. History of hypokalemia. Will change her to triamterene/hydrochlorothiazide to simplify the program. 6. Hyperthyroidism. Will recheck a TSH, T4 and have Endocrine see her if needed. 7. Gastroesophageal reflux disease. She is currently on Prilosec. 8. Asthma that is well-controlled. Will continue inhalers.
T4|thyroxine|T4|162|163||His initial CBC showed a slightly decreased platelet count of 128,000. This was otherwise unremarkable. Blood sugar was normal. TSH was elevated at 32.9 and free T4 was 2.25, which was normal. An echocardiogram showed BPH and no structural heart disease. The infant was also treated with phototherapy for hyperbilirubinemia.
T4|thyroxine|T4|221|222|PAST MEDICAL HISTORY|On discussions with her primary doctor, they were considering starting her on Namenda for her dementia recently. PAST MEDICAL HISTORY: Significant for hypertension, possible hypothyroidism (last TSH was 2003, recent free T4 was on the low side of normal), peripheral vascular disease with previous leg ulcers, dementia, endometrial carcinoma and edema.
T4|thyroxine|T4|128|129|IMPRESSION/PLAN|d. We will follow his daily weights. 3. Suppressed TSH. a. This may be the mechanism of his acute illness. b. I will add a free T4 to his laboratory tests drawn to further assess this. 4. Abnormal EKG. a. I will attempt to get old EKGs from the clinic.
T4|thyroxine|T4|314|315|MEDICATIONS ON ADMISSION|Neurological examination: Grossly intact. LABORATORY INVESTIGATIONS ON ADMISSION: CBC showed hemoglobin of 11.2, platelets of 529,000, and WBC of 7.7. Chem panel was remarkable for a creatinine of 1.48. His last creatinine was 1.38 on _%#MM#%_ _%#DD#%_, 2005. TSH was 6.17, which was mildly elevated, however, his T4 was 1.2, which was normal. INR was 2.01 and ESR was 67. His D- dimer was 2.5 and his BNP was 1370 increased from 351, which was on _%#MM#%_ _%#DD#%_, 2005.
T4|thyroxine|T4|120|121|HISTORY OF PRESENT ILLNESS|Presently, her labs are notable for extremely low potassium at 1.2. She also has a TSH of 0.02. We do not have the free T4 back yet. Specifically, when asking about thyroid, she has a sore throat, and is actually very tender over the thyroid. In addition, she has felt shaky in the past, and actually thought she may have Parkinson's because of the shakiness.
T4|thyroxine|T4|276|277|HOSPITAL COURSE|The patient's symptoms resolved after admission, his Toprol was adjusted to 75 mg to try and achieve an average heart rate of 70 in his atrial fibrillation, and Coumadin was started as stroke prophylaxis. In the course of evaluation, it was noted his TSH was suppressed, free T4 was up and T3 was up, given a diagnosis of hyperthyroidism, Graves' disease. He was seen in consultation by Dr. _%#NAME#%_. He is undergoing radioactive iodine scan and then a decision of most appropriate therapy will be in the office.
T4|thoracic (level) 4|T4;|126|128|PLAN|The patient underwent MRI of the cervical and thoracic spines which showed a paravertebral mass and also an acute fracture of T4; all this was consistent with myeloma. There were also degenerative changes in cervical spine and multiple other levels. The patient was admitted to the hospital for pain control and also for treatment of his myeloma and radiation therapy.
T4|thyroxine|T4|221|222|PROBLEM #3|It is not clear if this catatonic state was secondary to the hypernatremia or related to her psychiatric illness. PROBLEM #3: Sick euthyroid. We did check a TSH while the patient was here. Her TSH came back at 11.3. Free T4 was pending at the time of discharge. Again, this is likely sick euthyroid syndrome versus true hypothyroidism. Plan to recheck a TSH reflux in 3 weeks. If TSH is still elevated at that time would consider starting on Synthroid.
T4|thyroxine|T4|115|116|HOSPITAL COURSE|Because of this, admitting physician, Dr. _%#NAME#%_, obtained TSH and free T4. While the TSH was normal, the free T4 was significantly low at 0.6. Ultimately it was felt that the free T4 along with the patient's clinical symptomatology including muscle pain, weakness, depression and some constipation was most consistent with hypothyroidism.
T4|thyroxine|T4|170|171|HOSPITAL COURSE|At discharge, his BUN is 32 and his creatinine is 1.18. 4. Mild hypothyroidism, with question of if he had hypothyroidism upon admission. He had a TSH of 6.59, with free T4 of 1.08. Since he actually had a normal free T4, I would suggest checking a TSH in 6 weeks to make sure that he is not over-replaced.
T4|thyroxine|T4|338|339|HOSPITAL COURSE|2. Hypothyroidism: The patient is on Synthroid for hypothyroidism. Due to complaints of palpitations, TSH was checked and founded to be high at 10.03 with free thyroxine level of 1.06, and thyroxine total of 8.3, both of which were normal. The patient did not report complaints consistent with clinical hypothyroidism. Additionally, free T4 levels were within normal range. As such, in order to minimize exacerbating atrial fibrillation with an increased Synthroid dose at this time, this has been deferred.
T4|thyroxine|T4|288|289|LABORATORY DATA|No focal deficits. LABORATORY DATA: On admission: sodium 133, potassium 4.8, BUN 26, creatinine 0.7, calcium 8.7, total bilirubin 1.6, alkaline phosphatase 452, ALT 48, AST 78. PTT 52. Cholesterol 103, triglycerides 81. LDH 1529. Hemoglobin 8.8, WBC 2.4, platelets 162. INR 1.88. TSH and T4 within normal limits. ASSESSMENT AND PLAN: 63-year-old Caucasian male transferred from University of Minnesota Medical Center, Fairview, for rehabilitation and continuation of medical care after LVAD placement.
T4|thyroxine|T4|135|136|HOSPITAL COURSE|They also recommended Hurricaine spray for symptomatic relief. 3. HIV: Infectious Disease was consulted. They noted she has had stable T4 counts. They elected to redraw them as they had not been checked since _%#MM2006#%_. CD4 count was 33. They had no further recommendations regarding patient's pelvic inflammatory disease/tubular ovarian abscess nor her adenoiditis.
T4|thyroxine|T4|152|153||Early evaluations including thyroid, hormone, TSH and prolactin were produced. The patient has positive thyroid peroxidase antibodies, however her free T4 and TSH are well within normal limits. Semen analysis demonstrates a count of 37.5 million with 36% motility. Because of decreased motility, the semen analysis was repeated and in _%#MM#%_ of this year, the count was 104 million, 52% motility and 36% normal forms.
T4|thyroxine|T4|322|323|BRIEF HISTORY|Please see admission H and P for physical exam. Pertinent laboratory on this admission showed a parathyroid hormone level of 392, calcium 11.7, phosphorus 1.9, alkaline phosphatase 221, sodium 142, potassium 3.3, BUN 32, creatinine 1.61, glucose 178. CBC was within normal limits. Vitamin D, 25 hydroxy 14. TSH 1.81, free T4 1.37, hemoglobin A1c 5.7. HOSPITAL COURSE: Ms. _%#NAME#%_ was worked up for her hypercalcemia, was found to have primary hyperparathyroidism.
T4|thyroxine|T4|112|113|HOSPITAL COURSE|3. New hypothyroidism. Because of generalized weakness a TSH was checked and this was elevated at 146. His free T4 was undetectable. He was started on levothyroxine replacement. This will likely need further adjustment on an outpatient basis. This certainly could also be contributing to his generalized declined and he certainly may improve with treatment.
T4|thyroxine|T4|180|181|SUMMARY|She was evaluated here at this hospital, and it was determined that she would be unable to tolerate ERCP or surgery due to her hyperthyroid state. She had a TSH of 0.03 and a free T4 of 2.44. She had significant goiter on examination which did not seem to be causing any evidence of stridor or tracheal compression.
T4|thoracic (level) 4|T4|147|148|IMPRESSION|Care should be used in his fluid management as it may be harder for him to clear excess fluid postoperatively. 2. Motorcycle accident in 1972 with T4 paraplegia and below-the-knee amputation of the left leg due to infection related to the accident. 3. Chronic renal failure with creatinines in the range of 5.0.
T4|thyroxine|T4|251|252|HOSPITAL COURSE|With her failure to thrive workup, she had a very low prealbumin level and also her total protein level were low consistent with her less than _stellar nutritional status. She also has low TSH with normal thyroid peroxidase antibodies as well as free T4 and total T3. Due to the CAT scan that she received and having received iodine dye, she cannot get the thyroid scan done for 4 more weeks.
T4|thyroxine|T4|129|130|ASSESSMENT AND PLAN|We will monitor on tele. Her thyroid did come back a little bit low, asked her if she has had hyperthyroidism. However, her free T4 is initially normal. We will get her free T3 back and see what that shows and go from there. We will check her echocardiogram tomorrow just to recheck things to see if there are any signs of left atrial enlargement.
T4|thyroxine|T4.|179|181|ADMISSION EXAM|DISCHARGE: Is to home in stable condition. DIET: Is low fat and low sodium. ACTIVITY: Is no lifting more than 10 pounds for three weeks. Pending results are only the TSH and free T4. FOLLOW-UP: Is with primary Dr. _%#NAME#%_ _%#NAME#%_ at Fairview Northeast Clinic in the next week to two weeks. She should have a chemistry panel drawn at that time.
T4|thyroxine|T4|176|177|DISCHARGE LABORATORY DATA|DISCHARGE LABORATORY DATA: Sodium 143, potassium 3.4, chloride 104, bicarb of 34, B-12 295, white count 12.7, hemoglobin 12.5, platelets 297, TSH mildly elevated at 5.17, Free T4 1.09 normal. Urine cultures, blood cultures are negative. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg po qd. 2. OsCal 250/125 2 po tid. 3. Prednisone 20 mg po qd.
T4|tumor stage 4|T4,|21|23|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: T4, N2c, M0 squamous cell carcinoma of the oral cavity. DISCHARGE DIAGNOSIS: T4, N2c, Mo squamous cell carcinoma of the oral cavity.
T4|thyroxine|T4|161|162|LABS|PROCEDURES: Procedures performed during this stay include placement of a PPD which was negative. LABS: Pertinent lab values on _%#MMDD#%_, hemoglobin 11.2, free T4 1.37, TSH 0.15. On _%#MMDD#%_, hemoglobin 10.8, folate 5.5, B12 465. DISCHARGE DIAGNOSES: 1. Spinal stenosis status post L3-5 laminectomy with foraminotomies.
T4|thyroxine|T4,|140|142|PLAN|It certainly does not seem to be infectious. PLAN: We will get neurological consult. We will check a comp metabolic profile, hemogram, TSH, T4, CRP, and follow up as we start to get results back.
T4|thyroxine|T4.|151|153|HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE|She did have an echocardiogram that showed a normal ejection fraction without significant valve disease. Her thyroid was checked with a normal TSH and T4. She was seen by Neurology as this sounded more like a seizure than anything else and had an EEG that was less suggestive of ongoing seizure.
T4|thyroxine|T4|208|209|HISTORY|A central line was placed with some improvement in the patient's abdominal distention and pain. She was then transferred back to the nursing home. The patient's TSH level was mildly elevated at 5.66 and free T4 was borderline low normal at 0.74 with a normal range of 0.7 to 1.85. IMPRESSION: Constipation, hypothyroidism, renal failure, diabetes mellitus, status post replacement of tunnel dialysis catheter, MRSA, cellulitis improved, malnutrition, previous history of coronary artery disease status post status post coronary artery bypass graft X 4, hypertension, cerebrovascular accident, hyperlipidemia, osteoporosis, gastroesophageal reflux disease, restless leg syndrome, chronic obstructive pulmonary disease, left BKA, LS laminectomy, appendectomy, abdominal herniorrhaphy, left breast biopsy X 4, urethral stenosis with cystoscopy, laser treatment OU, atrial fibrillation, allergic rhinitis, herpes zoster, atrophic gastritis, pneumonia, peripheral neuropathy, fractured T-11, non-Q myocardial infarction, colon polyp and appendectomy.
T4|tumor stage 4|T4,|107|109|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 44-year-old woman with inflammatory right breast carcinoma T4, N1, NO, 3B. She had received chemotherapy in the recent past her cancer has metastasized to her rib for which she has undergone a rib resection.
T4|thyroxine|T4|211|212|ASSESSMENT|The patient does have a history of prematurity as a baby, but had no restrictions in exercise or athletics making this unlikely. We will proceed with CT. She has had long history of tachycardia. We will check a T4 and she could follow up with her primary doctor in regards to the tachycardia.
T4|thoracic (level) 4|T4|244|245|OPERATIONS/PROCEDURES|OPERATIONS/PROCEDURES: EGD dated _%#MM#%_ _%#DD#%_, 2004. Findings: Metastatic colon cancer and erosive pancreatic lesion into the body of the stomach. MRI of the thoracic spine. Findings concerning for a possible cord compression. There was a T4 epidural lesion extending with what appears to be some cord impression. There was, however, no abnormal cord signal to suggestive obvious cord compression.
T4|thyroxine|T4|143|144|PROCEDURES AND TESTS|PROCEDURES AND TESTS: 1. Admission chemistries remarkable for normal liver function, normal electrolytes, INR of 2.57, sed rate of 57. TSH and T4 normal. 2. Imaging studies with chest x-ray prior to admission showing chronic cardiomegaly and minimal left basilar infiltrate.
T4|thyroxine|T4|270|271|PROBLEM #4|Their recommendations were to follow up with Dr. _%#NAME#%_ within one week of discharge for a trial without the catheter and also to do further testing on bladder function. PROBLEM #4: Hypothyroidism: The patient's TSH was markedly elevated on admission; however, free T4 was within normal range. It is questionable whether or not the patient has been taking thyroid replacement. Given the fact that patient is going to be discharged on amiodarone it was felt that patient's dosage should be maintained at its current dose and TSH will be followed in 4 to 6 weeks.
T4|thyroxine|T4|176|177|LABORATORY/STUDIES|RPR pending. Urine culture pending. 2. Electrocardiogram normal sinus rhythm. 3. CAT scan showing some old infarct. 4. None of these studies need, therefore, to be repeated. A T4 will be obtained. PLAN: 1. _%#NAME#%_ is admitted to the Senior Treatment Program for ongoing assessment of her depression and anxiety.
T4|thoracic (level) 4|T4|226|227|HISTORY OF PRESENT ILLNESS|MRI scan revealed a tumor located at the T4 vertebral body and extending into the spinal canal. After receiving high-dose steroids, a decompression laminectomy was performed by Dr. _%#NAME#%_ on _%#MMDD2002#%_. He performed a T4 laminectomy, and describes a very vascular tumor. Pathology (case #U 02-8790) revealed metastatic carcinoid. The patient had CT scan of the thoracic spine on _%#MMDD2002#%_.
T4|thyroxine|T4|201|202|ASSESSMENT|May be reasonable for now to continue propoxyphene on a limited basis pending outside information if ok with Dr. _%#NAME#%_. 4. Suppressed TSH. May relate to a sick euthyroid status. Will check T3 and T4 to ensure no evidence for hyperthyroidism. 5. Mild hypotension earlier today potentially contributed to by Atenolol. Unclear why dispensed. No history of hypertension. Not aware of essential tremor.
T4|thyroxine|T4.|249|251|ASSESSMENT|5. Microhematuria (related to ongoing menses.) 6. Mild protein elevation consistent with probable mild volume depletion on presentation. 7. Elevated TSH of 6.01, likely lithium induced. No overt stigmata of hypothyroidism. Recommend check of T3 and T4. Defer Synthroid at this point. Will need close monitoring with recheck in the next few months. PLAN: 1. Follow-up thyroid function as above.
T4|thyroxine|T4|226|227|LABORATORY DATA|He has a fine resting tremor of both hands. There is no rigidity, and he moves all extremities equally. LABORATORY DATA: On admission a valproic acid level was 45, chem-18 was unremarkable, TSH slightly elevated at 5.27, free T4 at lower limits of normal at 0.9 (range of 0.7 to 1.85). Urine tox screen negative. CBC was normal. Thank you for this consultation.
T4|thyroxine|T4,|155|157|PAST MEDICAL HISTORY|7. Paroxysmal atrial fibrillation. 8. History of SVT. 9. Left CVA with residual right-sided weakness. 10. Chronic pain anemia. 11. Thyroid nodule with low T4, elevated TSH. 12. Sacral pressure ulcers. 13. PFO with a left to right shunt. 14. Hyperparathyroidism. PHYSICAL EXAMINATION: VITAL SIGNS (today): Temperature 36.3, respiratory rate 18, O2 saturations close to 100% on 30% on O2.
T4|thyroxine|T4|178|179|LABORATORY|Motor, sensory, and coordination are intact. MENTAL STATUS EXAMINATION: Per Dr. _%#NAME#%_. LABORATORY: Labs on admission included an unremarkable Chem- 18. A TSH was 7.50. Free T4 was ordered and is pending to follow this up.
T4|thyroxine|T4|103|104|LABORATORY DATA|Sensation intact to light touch. Strength 5/5 bilaterally. Gait deferred. LABORATORY DATA: EKG normal. T4 pending. TSH, CBC and CMP normal. ASSESSMENT: 1. Depression. 2. Right hand abrasion. This is stable at the present time.
T4|thyroxine|T4.|154|156|ASSESSMENT|3. Asthma. This is controlled. 4. Anemia. This is most likely secondary to anemia of chronic disease related to alcohol use. 5. Low TSH with slightly low T4. This is most likely secondary to sick euthyroidism. The patient's previous TSH was normal and I believe this is low because of all the stress that the patient is undergoing from his shoulder pain and alcohol withdrawal.
T4|thyroxine|T4,|115|117|LABS|Strength 5/5 bilaterally. Gait within normal limits. Reflexes 1+ bilaterally. LABS: TSH, phos, magnesium, calcium, T4, CBC, BMP all normal. EKG revealed sinus bradycardia with T wave inversion in V3, V4, F, and 3. No old EKG available. ASSESSMENT: 1. Acute schizophrenia. 2. Chest pains probably secondary to muscular causes but the EKG is suggestive of ischemia.
T4|thyroxine|T4|159|160|REQUESTING PHYSICIAN|She did maintain the Synthroid through last fall, but did run out of refills and did not call the office. Consistent with her hypothyroid status now is a free T4 from yesterday morning of 0.45 with a TSH of 18. I have since restarted her Synthroid IV at 0.075 mg per day.
T4|thyroxine|T4,|254|256|IMPRESSION|There are some signs of progression, however, of her cognitive disabilities, and the plan at this time is to obtain an MRI to sort out the part of dementia versus recurrent cerebrovascular disease. She has a significant aphasic component. MRI, EEG, B12, T4, and TSH will be requested. Social Services will need to be involved.
T4|thyroxine|T4|130|131|ASSESSMENT AND PLAN|We will repeat the TSH and T3 and T4 tomorrow before altering her Synthroid medication. If her TSH continues to be low and T3 and T4 are high we will alter her levothyroxine to 125 mcg each day at bedtime. 3. Nausea: This is most likely secondary to anxiety. This hopefully will be alleviated when the anxiety is better controlled.
T4|thyroxine|T4|187|188|PERTINENT LABORATORY DATA|ABDOMEN: Soft and nontender. EXTREMITIES: 1+ bilateral pedal edema. He has some chronic venous stasis changes. PERTINENT LABORATORY DATA: TSH that was significantly elevated at 34 with a T4 that is depressed at 0.66. Sodium is also a bit low at 131. Troponins are negative times three. He does have a low hemoglobin at 11.6 and his fasting lipid profile shows a total cholesterol of 114, HDL of 35, triglycerides of 64, LDL of 66.
T4|thyroxine|T4|261|262|LABORATORY DATA|LABORATORY DATA: Partially available to us at this stage. White cell count of 5.0, hemoglobin 10.9, indicating anemia. Platelets 421,000. INR is pending. On _%#MMDD2005#%_ her sodium was 137, potassium 4.1, creatinine 0.8, BUN 11, glucose 95, TSH was 2.0, free T4 1.2. Liver function tests were all normal. IMPRESSION: Obviously this is an extremely difficult situation. The patient is about to have bowel surgery which is semi urgent given that the sigmoid stenosis is quite tight and there is a risk of perforation above the stenosis if it is not relieved.
T4|thyroxine|T4|145|146|IMPRESSION|2. Thyrotoxicosis - untreated. He has been given beta blockers. I discussed his case with Dr. _%#NAME#%_ of endocrinology. She feels that with a T4 of only 4, the risk of thyroid storm is low with anesthesia. She would recommend beta blocker treatment for the hypertension and tachycardia as per anesthesiology.
T4|thyroxine|T4,|222|224|ASSESSMENT AND PLAN|1. Alcohol dependence per Dr. _%#NAME#%_. LFTs elevated. Comprehensive metabolic panel will be performed in the morning. There is no evidence of alcohol withdrawal, hepatomegaly, or jaundice. 2. Hypothyroidism. Will check T4, TSH in a.m. She has a history of using Synthroid but has not been using Synthroid for the past 2 weeks or so.
T4|thyroxine|T4|201|202|ASSESSMENT/PLAN|TSH was elevated at greater than 12. T4 was within normal limits. ASSESSMENT/PLAN: 1. Depression. Followed by Dr. _%#NAME#%_. 2. Possible developing hyperthyroidism. Recommended recheck of the TSH and T4 in the morning. 3. Recent diagnosis of HPV with abnormal Pap smear. She will undergo colposcopy with her primary gynecologist following discharge.
T4|tumor stage 4|T4|112|113|HISTORY OF PRESENT ILLNESS|A prostate biopsy was done demonstrating prostate cancer, Gleason 4 + 4. The tumor was felt to have stage T3 to T4 adenocarcinoma, and ultrasound at that time was felt to show prostate cancer involving the anterior rectal wall as well as extending up to the bladder.
T4|thyroxine|T4.|208|210|PLAN|2. Resume prenatal vitamins. 3. Bacitracin b.i.d. to upper extremity abrasions. 4. Follow-up labs. Suspect low TSH may represent a binding protein issue related to pregnancy. No intervention with normal free T4. Check T3 as above. Copy of labs to patient at discharge for followup through gynecologist. 5. Has not required albuterol metered dose inhaler recently.
T4|thyroxine|T4|238|239|ASSESSMENT/PLAN|2. Mild hypokalemia due to decreased p.o. intake. The patient to receive KCl 20 mEq p.o. x 1 dose on _%#MMDD2006#%_. 3. GGT elevation secondary to opiates and benzodiazepine use. 4. Low TSH, secondary to stress. Not hypothyroid since the T4 is normal. Thank you for this consultation. Dr. _%#NAME#%_ will follow the patient.
T4|thoracic (level) 4|T4.|183|185|PHYSICAL EXAMINATION|Sensation to light touch is intact on the plantar and dorsal aspects of the feet bilaterally. Patient does have a dressing over the spine on her back that extends up to approximately T4. Patient was able to wiggle her toes bilaterally. LABORATORY AND DIAGNOSTICS: Hemoglobin is 10.5 this morning.
T4|thoracic (level) 4|T4|191|192|ASSESSMENT|The T11 vertebra does not appear to be involved. The proximal thoracic fractures were not in this. ASSESSMENT: The patient is a 59-year-old man with probable new compression fractures at T3, T4 and T8 levels, with a burst fracture at the T12 level, with 50% canal compromise and no apparent neurologic deficit.
T4|thyroxine|T4,|135|137|RECOMMENDATIONS|RECOMMENDATIONS: Agree with fosphenytoin load given in the Emergency Room. Continue Dilantin 300 mg q.h.s. Workup to include EEG, TSH, T4, MRI scan. The plan and potential diagnosis was discussed with the patient and his family (spouse and daughters). I will follow his course with you.
T4|thyroxine|T4|170|171|ASSESSMENT|1. Paranoia in the setting of chemical use. This will be followed by Dr. _%#NAME#%_. 2. Mildly elevated TSH. I doubt this represents a hypothyroid state. We will check a T4 to rule this out. 3. Upper respiratory infection which has largely resolved. I will be available to follow up should other issues arise during the hospitalization.
T4|thoracic (level) 4|T4|188|189|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old man who transferred to Fairview-University Medical Center on _%#MMDD2002#%_ for long-term care of severe decubitus ulcers. He is a T4 quadriplegic after a motor vehicle accident in 2000. Early this morning, the patient developed respiratory distress felt possibly due to mucous plugging and was unable to oxygenate on the floor.
T4|thyroxine|T4.|146|148|PLAN|1. Staff to encourage p.o. fluids. 2. Recheck BMP presently with results called. Add magnesium. Replace potassium as appropriate. 3. TSH and free T4. 4. Hold Lisinopril for now. 5. Staff to call p.r.n. persistent blood pressure elevation. 6. Follow up BMP in the morning. Thank you for the consultation.
T4|thyroxine|T4|201|202|LABORATORY DATA|LUNGS: Clear to auscultation. ABDOMEN: Soft and nontender. There is no organomegaly. EXTREMITIES: Normal muscular bulk. LABORATORY DATA: CBC and CMP without abnormalities. TSH is slightly low at 0.34. T4 is still pending. ASSESSMENT AND PLAN: 1. Methamphetamine abuse.
T4|thyroxine|T4,|125|127|RECOMMENDATION|3. Ethanol abuse. There is no evidence of alcohol withdrawal. Liver function tests are normal. 4. Obesity. RECOMMENDATION: A T4, TSH will be obtained. I will be able to see this patient during his hospitalization for concurrent medical issues.
T4|thoracic (level) 4|T4|137|138|IMPRESSION|He also has significant abnormality in the cervical spine and T6, concerning for other lesions. IMPRESSION: Thoracic myelopathy due to a T4 compression fracture. This is an extremely difficult management condition. We discussed all the alternatives, including non-treatment which would unfortunately almost certainly result in progressive kyphotic deformity and paralysis, as renal cell is notoriously radio-resistant.
T4|thyroxine|T4|210|211|PLAN|She will plan followup with her primary care provider. Copy of labs will be provided at discharge for primary care provider review. Suppressed TSH noted. Does not appear to be hyperthyroid based on normal free T4 and T3. Thank you for consultation. Will follow up as indicated.
T4|thyroxine|T4|171|172|PLAN|3. Opportunistic infection in a patient on a T-cell modulating drug. PLAN: 1. CT scan of the abdomen. 2. C. difficile toxin. 3. Continue IV antibiotics. 4. Check T cells, T4 and T8. 5. Stool for Cryptosporidium. 6. Further recommendations to follow.
T4|thyroxine|T4|179|180|ASSESSMENT/PLAN|2. Ankle sprain. Recommend the use of ibuprofen p.r.n. He can also ice the ankle as needed. 3. Mildly decreased TSH of uncertain significance. Recommend a recheck of TSH, T3, and T4 in the morning. We will be happy to follow should further issues arise.
T4|thyroxine|T4|262|263|LABORATORY DATA|Strength 5/5 bilaterally in the upper and lower extremities. LABORATORY DATA: Comprehensive metabolic panel showed a sodium of 144, otherwise within normal limits. Hemogram differential: Red blood cell count of 5.39, otherwise within normal limits. TSH of 1.63. T4 is pending. U-tox was positive for marijuana. Urinalysis was within normal limits. DIAGNOSES: 1. Chemical-dependency with marijuana.
T4|thyroxine|T4|194|195|LABORATORY DATA|LABORATORY DATA: Comprehensive metabolic panel showed protein of 8.3, albumin of 5, otherwise within normal limits. Hemogram, differential, platelet count within normal limits. Reflex TSH 1.30, T4 is pending. Utox is positive for marijuana. ASSESSMENT AND PLAN: 1. Bipolar disorder. Treatment to be continued per Dr. _%#NAME#%_. 2. Headaches. Excedrin Migraine will be ordered on a p.r.n. basis.
T4|tumor stage 4|(T4|197|199|ASSESSMENT|ASSESSMENT: In summary, Mr. _%#NAME#%_ is a 65-year-old gentleman with a large nonsmall cell lung cancer in the right upper lobe, T4N3MX. It has extensively invaded the right hilum and mediastinum (T4 disease). He also has a large pretracheal lymph node, N2. Upon careful reviewing of his CT scan it appears that he might also have a right supraclavicular lymph node, N3(although this was not palpable upon physical examination)
T4|thyroxine|T4|194|195|RECOMMENDATIONS|The patient's swallowing function is normal. There is no evidence of airway obstruction. RECOMMENDATIONS: 1. There is no medical contraindication to ECT. 2. A urine culture will be obtained. 3. T4 will be obtained to compliment her TSH. 4. I will be able to see her during her hospitalization for concurrent medical issues.
T4|thyroxine|T4|134|135|ASSESSMENT|LABORATORY DATA: Pending. ASSESSMENT: 1. Depression. This will be followed by Dr. _%#NAME#%_. 2. Hypothyroidism. Will check a TSH and T4 to ensure appropriate replacement. 3. Occasional nausea and vomiting. I suspect this is functional in nature. Thank you for this consultation. We will be available to follow-up should any other medical concerns arise during this hospitalization.
T4|thyroxine|T4.|178|180|PAST MEDICAL HISTORY|3. Newly diagnosed diabetes mellitus. 4. Chronic anemia. 5. In the past she has had elevated liver enzymes of unknown etiology. 6. She has had an elevated TSH with normal T3 and T4. 7. Hypertension. 8. History of some liver toxicity secondary to amiodarone. 9. Laparoscopic cholecystectomy in _%#MM2005#%_. 10. She has previously had a period of hemodialysis for renal insufficiency although her creatinine is normal today.
T4|thyroxine|T4.|298|300|ASSESSMENT|Comprehensive metabolic battery revealed a high total bilirubin of 1.6. TSH elevated at 9.17. Subsequent free thyroxine was within normal limits at 1.05, vitamin B12 level within normal limits. ASSESSMENT: 1. Psychiatric conditions per Dr. _%#NAME#%_. 2. Borderline high TSH with subsequent normal T4. 3. Headaches, likely tension type, no evidence of neurological impairment. 4. Elevated total bilirubin, likely secondary to Gilbert's disease.
T4|thyroxine|T4|313|314|HISTORY|Her thyroid levels were borderline-low and therefore we recommended a small dose of thyroid hormone at 25 mcg a day which was started following her visit in _%#MM#%_. Ms. _%#NAME#%_ was seen most recently by me on _%#MMDD2003#%_ and her thyroid levels were good on 25 mcg a day with a TSH down to 2.63 and a free T4 1.03. I recommended an increase in dose to 37.5 mcg a day but Ms. _%#NAME#%_ developed other problems and stayed with the 25 mcg dose.
T4|thyroxine|T4|149|150|LABORATORY DATA|The rest of the patient's comprehensive metabolic profile was normal. The patient had a TSH in _%#MM2004#%_ that was elevated at 6.12. The patient's T4 was normal. ASSESSMENT: 1. Pervasive developmental disorder. 2. Asthma; this is stable.
T4|tumor stage 4|T4,|114|116|ASSESSMENT|Findings are as listed in History of Present Illness above. ASSESSMENT: Mr. _%#NAME#%_ is a 73-year-old male with T4, N0, M0 squamous cell carcinoma of the left piriform sinus. He is now 5-days status post total laryngectomy with left-neck dissection.
T4|thyroxine|T4|284|285|HISTORY OF PRESENT ILLNESS|She is followed by _%#NAME#%_ _%#NAME#%_, MD, of Prairie Family Practice, in _%#CITY#%_, Minnesota, and the patient lives in _%#CITY#%_, Minnesota. On _%#MMDD2004#%_, Dr. _%#NAME#%_ obtained thyroid levels, and those levels demonstrated mild subclinical hyperthyroidism, with a total T4 of 9.0 (4.5-10.9), and a TSH of 0.12 (range 0.25-5.0). At that point in time, there was no evidence of complications of subclinical hyperthyroidism and, therefore, no further evaluation was done or treatment recommended.
T4|thyroxine|T4|249|250|LABORATORY DATA|Stool culture is negative. The patient has laboratory evidence for syndrome of inappropriate antidiuretic hormone secretion (SIADH). Urinalysis did reveal 10-25 RBC. Liver function tests are normal. Amylase and lipase are normal. TSH level and free T4 are normal. Calcium 8.3, essentially a normal value, with an albumin of 3.1. Creatinine has remained normal at 0.7. Recent sodium 129, potassium 3.9. CT SCAN: The patient's outpatient abdominal CT scan is reported to be essentially within normal limits.
T4|thyroxine|T4|160|161|LABORATORY DATA|MENTAL STATUS EXAMINATION: Per Dr. _%#NAME#%_. LABORATORY DATA: On admission included a potassium 3.3. Upon repeat potassium this morning was 3.6, TSH is 0.11. T4 is normal. Serum pregnancy screen is negative. CBC is unremarkable. Urine tox screen was positive for cocaine.
T4|thyroxine|T4.|182|184|PAST MEDICAL HISTORY|1. Depression with anxiety. 2. History of chemical dependency involving alcohol and methamphetamines. 3. History of borderline hypothyroidism manifested by elevated TSH below normal T4. MEDICATIONS: 1. Celexa 40 mg a day. 2. Strattera I believe 20 mg every morning.
T4|thyroxine|T4|164|165|ASSESSMENT  AND PLAN|Will start albuterol inhaler one to two puffs q.4-6 h p.r.n. 6. Low TSH. This is most likely secondary to stress. I doubt the patient has hyperthyroidism. The free T4 still pending, and I will follow up on this and initiate further treatment if indicated.
T4|thyroxine|T4|324|325|PLAN|If the patient requires significant hospitalization, then we will look at initiating follow-up with the Fairview Hand Clinic, but if he is just here for a short time, it would be better to follow up with the clinics that the physician requested through the North Memorial Medical Center system. We will also check a TSH and T4 as well as baseline labs secondary to depression and mild thyromegaly. I will be notified if these labs are abnormal.
T4|thyroxine|T4|185|186|LABORATORY DATA|Urine toxicology screen is negative. TSH is elevated at 12.10. ESR is elevated at 31. Prolactin is elevated at 48. Free thyroxine is 0.95. Antithyroid antibodies, FANA, and free T3 and T4 results are pending. ASSESSMENT AND PLAN: 1. Bipolar affective disorder with psychotic features, per Dr. _%#NAME#%_.
T4|thyroxine|T4|336|337|LABORATORY DATA|NEUROLOGIC: Appeared to be grossly intact. Electrocardiogram demonstrated normal sinus rhythm with left bundle branch block pattern. Chest x-ray not available for viewing. LABORATORY DATA: Sodium 136, potassium 3.7, chloride 104, CO2 26, glucose 91, BUN 19, creatinine 1.3, calcium 8.4, myoglobin 54, troponin less than 0.07, TSH 2.22, T4 1.35, hemoglobin 9.7, hematocrit 29.5, WBC 38,000. IMPRESSION: 1. Apparent syncopal episode with isolated episodes of dizziness.
T4|thyroxine|T4|124|125|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: 1. Schizoaffective disorder, bipolar type, per Dr. _%#NAME#%_. A low TSH being 0.27. Will order a free T4 tomorrow in the a.m. 2. Hypertension, stable, for which she takes Zestril at 20 mg in the a.m. The patient's blood pressure is 105/66.
T4|thyroxine|T4|120|121|ASSESSMENT AND PLAN|We will check a fasting glucose. 4. Slightly low TSH. I doubt that this represents a hypothyroid state. We will check a T4 to confirm normal thyroid function. Thank you for the consult.
T4|thyroxine|T4,|205|207|RECOMMENDATIONS|However, we need to consider the possibility of paraneoplastic conditions, myasthenia, thyroid disease or neuropathy. RECOMMENDATIONS: Labs to include paraneoplastic antibody panel, myasthenia panel, TSH, T4, B12, CPK. Plan an EMG in early part of next week. I would also recommend an MRI of the head and cervical spine which the patient refuses at the present time.
T4|thyroxine|T4.|186|188|LABORATORY DATA|LABORATORY DATA: Urine tox screen done on _%#MMDD2007#%_ in the emergency department was negative. TSH level drawn on _%#MMDD2007#%_, the patient's last admission, was 6/6 with a normal T4. The TSH was repeated on _%#MMDD2007#%_ and was within normal range at 1.95. ASSESSMENT AND PLAN: 1. Schizoaffective disorder, bipolar type. The patient will be managed for all psychiatric needs by admitting psychiatrist, Dr. _%#NAME#%_.
T4|thyroxine|T4|266|267|LABORATORY DATA|REVIEW OF SYSTEMS: 10-point review of systems was done and pertinent findings mentioned in HPI LABORATORY DATA: Reveal a hemoglobin 10.8 with a normal MCV. WBC 10.2, platelet count 395. Ferritin was normal, iron levels were normal. B-12 and folate are pending. Free T4 was normal. TSH was 0.39. Troponin I less than 0.04 and subsequently 0.20. Chest x-ray shows no definitive infiltrate.
T4|thyroxine|T4|160|161|PLAN|3. COPD. This is stable. 4. Urinary tract infection. PLAN: The patient will have her cipro dose changed to 250 mg p.o. b.i.d. x 7 days. We will check a TSH and T4 on Wednesday and I will be notified with the results. At that time, I will determine what Synthroid dose to start.
T4|thyroxine|T4|256|257|LABORATORY DATA|Sodium 138, potassium 3.6, chloride 104, calcium 8.8, BUN 12, creatinine 0.7. Urine tox screen from _%#MMDD#%_ was negative. Urinalysis demonstrated many bacteria with 5-10 white cells. Negative leukocyte esterase screen. Magnesium today was 1.8 with free T4 of 1, TSH of 2.51, B12 was low at 182, with folic acid of 4.7. ASSESSMENT: A 47-year-old female admitted with the following: 1. Major depressive disorder (details per Psychiatry).
T4|thyroxine|T4|168|169|ASSESSMENT/PLAN|ASSESSMENT/PLAN: 1. Behavioral concerns. This will be followed by Dr. _%#NAME#%_. 2. Hypothyroidism, presumably associated with lithium therapy. Will recheck a TSH and T4 in the morning to confirm this. It is likely the patient will require Synthroid, which we can begin at a low dose.
T4|thyroxine|T4|174|175|LABORATORY RESULTS|Normal dorsalis pedis pulses. No pedal edema. No focal foot lesions or ulcers. LABORATORY RESULTS: AST 30, ALT 21, potassium 4.2, sodium 139, TSH 0.28 (normal 0.4-5.0), free T4 is 1.05 (normal 0.7-1.85), phosphorous 2.1, lipase 585 (normal 20-250), creatinine 1.3, hemoglobin 13.0, WBC 16,500. IMPRESSION: 1. Type 1 diabetes mellitus, with recent hyperglycemia.
T4|thyroxine|T4|198|199|HISTORY OF PRESENT ILLNESS|REASON FOR CONSULTATION: Locally advanced pancreatic cancer and lower GI bleed. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 81-year-old female with locally advanced pancreatic cancer, a T4 lesion with encasement of portal vein and luminal narrowing. This was determined to be inoperable, and was treated with combined chemotherapy which was completed in _%#MM#%_ 2002.
T4|thyroxine|T4|170|171|ASSESSMENT/PLAN|2. Hypothyroidism: The patient's TSH is currently elevated. As described above, the patient states he has been taking Synthroid as prescribed. We will not recheck a free T4 at this time because the patient has a known history of hypothyroidism. We will recheck a TSH in a few weeks while continuing his dose of Synthroid 25 mcg daily.
T4|tumor stage 4|T4,|9|11|PROBLEM|PROBLEM: T4, N0, M0 ameloblastic carcinoma with epidermoid transformation of the left mandible. The patient was seen in the Radiation Oncology Clinic by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ for initial consultation at the request of Dr. _%#NAME#%_ _%#NAME#%_ from the Department of Otolaryngology at Fairview- University Medical Center.
T4|thyroxine|T4|274|275|LABORATORY DATA|Motor, sensory and coordination appear normal. LABORATORY DATA: Labs on admission included a urine tox screen positive for barbiturates; perhaps this is likely representing Primidone. Urinalysis is negative. Sodium is 130, potassium 4.7, BUN 6, creatinine 0.6. TSH is 0.32, T4 is pending.
T4|thyroxine|T4|213|214|LABORATORY DATA|Extremities: no edema noted. Neurologic: cranial nerves II through XII grossly intact; sensation intact to light touch; gait deferred; reflexes 1+ bilaterally; strength 5/5 bilaterally. LABORATORY DATA: TSH 3.38, T4 low at 0.56 (with a reference range being between 0.7 to 1.85). WBC normal. Liver function tests done at the outside hospital reveal an AST of 68 (with a reference range being less than 40) and an ALT of 67 (with a reference range being less than 50).
T4|thoracic (level) 4|T4|246|247|ASSESSMENT AND PLAN|Recent CT also demonstrates a mass in the pancreas extending to the greater curvature of the stomach, which has been the source of a GI bleed. I would recommend a brief course of palliative therapy to the thoracic spine. I would include both the T4 and T10-T11 areas. I would also plan to include the abdominal masses as this may be accounting for some of the patient's pain.
T4|thyroxine|T4|107|108|HISTORY|Apparently, the patient was found approximately two weeks ago or so to have again an elevation in her free T4 or suppression of her serum TSH. She was begun on propylthiouracil for recurrence of thyrotoxicosis, presumably due to Graves' disease on _%#MMDD2003#%_, beginning propylthiouracil prescribed by Dr. _%#NAME#%_ at 100 mg p.o. b.i.d. and also commencing atenolol.
T4|thyroxine|T4|174|175|ASSESSMENT|3. Polysubstance abuse (ongoing), as above. No signs of drug withdrawal presently. 4. Facial acne. 5. Suppressed TSH. May relate to a sick euthyroid state. Will check T3 and T4 to ensure no evidence for hyperthyroidism. The patient otherwise appears stable. Thank you for the consultation.
T4|thyroxine|T4|161|162|LABORATORY DATA|HEART: Regular rate and rhythm ABDOMEN: Soft, nontender. EXTREMITIES: No edema. LABORATORY DATA: Sodium 137, potassium 3.8, glucose 130, calcium 8.8, TSH 10.13, T4 1.25. IMPRESSION: Hypothyroidism and Addison's disease.
T4|thyroxine|T4|130|131|PLAN|PLAN: 1. Psychiatric intervention, as per Dr. _%#NAME#%_. 2. Defer further thyroid replacement at this time. Recheck TSH, T3, and T4 in six weeks. 3. Heart murmur follow-up with primary-care provider. Consider echocardiogram. 4. Clinical observation. Thank you for the consultation.
T4|thyroxine|T4|169|170|ASSESSMENT/ PLAN|2. Hypothyroidism. She is clinically euthyroid but has features of hypothyroidism. She is on a high dose of L-T4 for her body weight. I recommend you check TSH and Free T4 _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD Endocrinology & Diabetes
T4|thyroxine|T4|142|143|ASSESSMENT AND PLAN|1. Depression. This will be followed by Dr. _%#NAME#%_. 2. Possible developing hypothyroidism. Recommend recheck of the TSH as well as T3 and T4 in the morning. 3. Mildly elevated blood pressure, which I suspect is secondary to stress. I recommend continuing to follow, and we can return for further workup if she continues to have blood pressures greater than 140/90.
T4|thyroxine|T4|410|411|ASSESSMENT AND PLAN|2. Somatic complaints, including fevers, chills, blurred vision, nausea, vomiting, abdominal pain, which has now resolved, urinary hesitancy, which has resolved, headache which has resolved; may be secondary to side effect of Effexor, which the patient is no longer taking at this time. Her vitals were stable, laboratories are within normal range. We will continue to monitor her clinically. 3. Elevated TSH. T4 is pending. We will recheck TSH. The patient has no history of thyroid disorder in the past. We will continue to follow. We appreciate the consultation.
T4|thyroxine|T4|190|191|PAST MEDICAL HISTORY|Rubella screen was indeterminate. PAST MEDICAL HISTORY: Her past medical history is documented in the prenatal notes as well. She has a history of a thyroid goiter, and her TSH was low, but T4 was normal at new-OB visit. FAMILY/SOCIAL HISTORY: Family history and social history are similarly documented in the prenatal sheets and are unremarkable.
T4|thyroxine|T4|323|324|DATA BASE|DATA BASE: Facsimile of office records from _%#MMDD2007#%_ note abdominal pain right upper quadrant, history of non-toxic uninodular goiter, hypercholesterolemia, allergic rhinitis, osteoporosis. There is a letter dated _%#MM#%_ _%#DD#%_, 2007 from _%#NAME#%_ _%#NAME#%_ that indicates follow up of her goiter and her free T4 is 1.3, TSH of 1.13, both within normal limits and a recommendation to continue on Synthroid 0.088 mg. daily. Abdominal ultrasound _%#MMDD2007#%_ for abdominal pain and nausea showed a simple cyst of the left kidney otherwise normal.
T4|thyroxine|T4|110|111|RECOMMENDATIONS|Suggest sputum culture which I ordered. 7. In view of the possibility of hyperthyroidism, check free T3, free T4 and TSH. 8. Appointment with Dr. _%#NAME#%_ _%#NAME#%_ in one month and the patient plans to keep this appointment.
T4|thyroxine|T4.|97|99|PLAN|There is no specific treatment per se. 5. History of methamphetamine dependence. PLAN: 1. T3 and T4. 2. Triamcinolone 0.1% cream b.i.d. to rash over dorsum of feet. 3. Zovirax ointment to left-sided lip lesion q3-4h while awake.
T4|thyroxine|T4|188|189|LABORATORY DATA|Gait is slow secondary to pain. LABORATORY DATA: Comprehensive metabolic panel is unremarkable except for a total protein slightly elevated at 8.3; otherwise, negative. TSH is low at 0.2. T4 is pending. CBC is normal. EKG shows occasional premature ventricular contractions noted; otherwise, negative. ASSESSMENT: 1. Status post polydrug overdose/depression. The patient is medically stable.
T4|tumor stage 4|T4|336|337|ASSESSMENT|CT scan with contrast shows very large oral cavity tumor completely eroding the left side of the mandible almost completely and involving full mouth, tongue and both submandibular triangles, the left neck node described earlier is also noted, as well as multiple subcentimeter nodes. ASSESSMENT: 55-year-old male with oral cavity tumor T4 N2 C MX consistent with squamous cell carcinoma. Due to radiologic, as well as physical exam findings, it seems to me that this is an unresectable tumor.
T4|thyroxine|T4|174|175|LABORATORY DATA|Motor, sensory and coordination are intact. LABORATORY DATA: Thus far include a white count 12,200. Hemoglobin was normal. Comprehensive metabolic panel is normal. TSH 0.39. T4 is ordered and is pending.
T4|tumor stage 4|T4,|132|134|ASSESSMENT/PLAN|Blood is on fingertips. The end of the tumor was not detected by distal examination. ASSESSMENT/PLAN: Adenocarcinoma of the rectum, T4, N1, M0. The patient was offered preop chemoradiation treatment.
T4|thyroxine|T4|166|167|LABORATORY  DATA|NEUROLOGIC: Cranial nerves II through XII are grossly intact. Sensation intact to light touch. Gait within normal limits. LABORATORY DATA: TSH less than 0.03, T3 87, T4 1.06. GGT normal. Total bilirubin less than 0.1. Rest of the comprehensive metabolic panel was normal. CBC normal. ASSESSMENT: 1. Depression. 2. Probable subclinical hyperthyroidism versus sick euthyroidism which is less likely.
T4|thyroxine|T4|202|203|ASSESSMENT|Diet will be advanced to solids. Will modestly restrict her free water intake. Certainly it would be appropriate to plan oral thyroid replacement therapy. We will not start such medication while a free T4 level has been ordered. Will check for appropriate urine sodium and osmolality levels to secure the SIADH diagnosis. As per your plan we will follow blood chemistries closely.
T4|thyroxine|T4.|165|167|PLAN|Most likely secondary to stress versus true hypothyroidism. PLAN: 1. Will get repeat TSH on Monday (_%#MMDD#%_). We will also add on the labs already drawn a T3 and T4. 2. Will give patient a copy of labs upon discharge. 3. We will be happy to see him during his stay for any intercurrent medical issues.
T4|thyroxine|T4|112|113|HISTORY OF PRESENT ILLNESS|The workup here has included thyroid function testing which had shown her TSH to be 0.13, T3 to be 138 and free T4 to be 1.23 which is normal. The patient has been on Haldol, which has had any beneficial effect so far. The patient has been evaluated by PT and OT and has been noted to be standby assist with bed mobility and minimal assist for sit to stand, moderate assist for her 90 foot ambulation.
T4|thyroxine|T4|185|186|LABORATORY DATA|Motor exam shows symmetric strength. Cerebellar exam is normal. Gait is normal. LABORATORY DATA: CBC is normal. Chemistry panel shows slightly low sodium at 132, TSH slightly elevated. T4 is normal. Urine tox is negative. EKG is within normal limits. ASSESSMENT: 1. Psychosis of uncertain duration with delusional thoughts and paranoia.
T4|thyroxine|T4|146|147|LABORATORY DATA|Hemogram, differential and platelet count were within normal limits. Comprehensive metabolic panel was within normal limits. Reflex TSH was 0.29. T4 is pending. Depakote level 36. ASSESSMENT/PLAN: 1. Bipolar affective disorder. Polysubstance dependence.
T4|thyroxine|T4|115|116|ASSESSMENT/PLAN|4. Occasional heartburn. I will order Prilosec 20 mg p.o. daily p.r.n. heartburn. 5. Low TSH. We will check a free T4 and follow if necessary.
T4|thoracic (level) 4|T4,|135|137|HISTORY OF PRESENT ILLNESS|The weakness was felt to be related to the cervical and thoracic metastases with spinal cord compression, with fractures at T1 through T4, also severe canal stenosis into the cervical spine. He had been treated with high dose steroids and his weakness is likely secondary to steroid myopathy with acute myelopathic changes as well.
T4|thyroxine|T4|200|201|HISTORY OF PRESENT ILLNESS|She has remained clinically euthyroid during the last few months, but during this hospitalization, was noted to have abnormal thyroid function tests. TSH was suppressed to less than 0.03 and the free T4 was high normal at 1.65. The patient states she has not had a goiter. She also denied having any dysphagia, voice change or cough.
T4|tumor stage 4|T4,|210|212|HISTORY OF PRESENT ILLNESS|The pathology reports were reviewed. Dr. _%#NAME#%_ spoke directly with Dr. _%#NAME#%_ concerning this patient's care. HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old female initially diagnosed with a T4, N2 infiltrating ductal carcinoma of her left breast. Her initial treatment was a neoadjuvant chemotherapy followed by bilateral mastectomy.
T4|tumor stage 4|T4,|124|126|CC|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: T4, N2B, M0 squamous cell carcinoma of oral tongue. HPI: Status post partial glossectomy and neck dissection. Exam: No new masses of nodes appreciated.
T4|thyroxine|T4|149|150|ASSESSMENT/PLAN|I would suggest that we increase the atenolol to 37.5 mg per day at the time of discharge. I suspect that the suppressed TSH despite the normal Free T4 may suggest early subclinical hyperthyroid state and may be contributing to her arrhythmia to a certain extent. I would suggest reducing the Synthroid dose and rechecking a TSH in follow-up.
T4|thyroxine|T4|252|253|LABORATORY DATA|NEURO: Nonfocal. LABORATORY DATA: Basic metabolic panel: Liver function tests within normal limits, CBC with differential reveals a white count of 4.6, hemoglobin 11.3, hematocrit 34.9, platelet count 267, troponin and myoglobin normal. TSH 11.5, free T4 0.65. EKG reveals sinus bradycardia, no acute ST/T-wave changes.
T4|thyroxine|T4|162|163|PHYSICAL EXAMINATION|Cranial nerves are symmetric. On _%#MMDD2002#%_ showed a right kidney 7.2, left 10.1. No hydronephrosis. On _%#MMDD2002#%_ the TSH was elevated at 7.49. The free T4 was low at 0.65. Urinalysis showed greater than 300 protein, trace blood, and no cells. Chest x-ray was negative for congestive heart failure. Hemoglobin was 13.3. The albumin was low at 2.3. Sodium was 128, which was low, and potassium 4.5.
T4|thyroxine|T4|149|150|LAB  AND DIAGNOSTIC DATA|Lipase is negative. INR 1.01. Serial troponins are negative. Pathology blood smear does not reveal cause of pancytopenia. TSH is low at 0.08, with a T4 of 1.29. B12 level 459. Follow-up white blood cell count 2.8. Platelets 137,000. Ferritin 52. Iron saturation index 17. TIBC 472. Iron level 80. Reticulocyte count 1.6%. Uric acid 7.8. EKG from the clinic showed normal sinus rhythm, borderline LVH with strain or nonspecific ST-T wave changes inferiorly laterally.
T4|thyroxine|T4|142|143|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Depression with psychotic features. 2. Cocaine dependence. 3. Chronic AST/ALT elevation. 4. Elevated TSH with normal T4 levels. 5. Alcohol withdrawal seizures last occurring in 2003. 6. Positive Mantoux test with negative chest x-ray having undergone two 6 month treatments of INH.
T4|thyroxine|T4,|191|193|IMPRESSION|We also discussed pathophysiology, prognosis and therapies for Grave's disease. Patient will require additional laboratory tests to evaluate the thyroid condition. Labs pending include a T3, T4, TSI and thyroid antibodies. The patient's hyperthyroidism most likely is due to Grave's disease, although hyperthyroidism from amiodarone is a possibility, less likely subacute thyroiditis or a toxic nodule.
T4|thyroxine|T4|135|136|PLAN|It is my understanding that the results from additional tests are pending. It is always helpful to see a free thyroid index and a free T4 in the process of assessing maternal thyroid function status in pregnancy. I spent at least 30 minutes with this couple discussing the various aspects of Mrs. _%#NAME#%_'s situation.
T4|thyroxine|T4|192|193|LABORATORY DATA|NEUROLOGIC: She is alert and fully oriented. She is not tremulous. MENTAL STATUS EXAMINATION: Per Dr. _%#NAME#%_. LABORATORY DATA: Sodium 138, BUN 14, and creatinine 0.8. CBC is unremarkable. T4 is 0.63. An EKG revealed left bundle branch block with a first-degree AV block.
T4|thyroxine|T4|136|137|ASSESSMENT/PLAN|We can return for further work-up if necessary. 3. Borderline low TSH. Possibly this represents a hyperthyroid state. I will review the T4 when it becomes available. I would add that the patient has no clinical symptoms at this time other than the tachycardia noted.
T4|thoracic (level) 4|T4|225|226|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: The differential diagnosis for the right thoracic burning pain would include: 1. Post-herpetic neuralgia without any significant lesions. 2. Degenerative disk disease of thoracic spine, compressing T3 or T4 nerve root versus compression of the spinal cord. 3. Diabetic radiculopathy in the thoracic spine. I will recommend obtaining an MRI of his thoracic spine to rule out any degenerative disk disease compressing the T3-T4 nerve root.
T4|thyroxine|T4|132|133|PLAN|4. Status post arthroscopic right elbow surgery. PLAN: 1. Chemical dependency intervention as per Dr. _%#NAME#%_. 2. Add T3 RIA and T4 to screening laboratories. 3. Clinical observation. 4. Further medical intervention does not appear required at this time. Thank you for the consultation. We will follow-up as indicated.
T4|tumor stage 4|T4|272|273|HISTORY OF PRESENT ILLNESS|Intraoperatively a rectal biopsy revealed moderately differentiated adenocarcinoma. The pelvic washings were negative for malignancy, but her primary pelvic mass was found to measure 3.9 cm in size and again was consistent with moderately differentiated adenocarcinoma (a T4 lesion). Specifically it extended through the muscularis propria into the mesenteric/subserosal surfaces and also to free peritoneal surface tissues. In particular she had 7 of 23 resected lymph nodes involved by metastatic adenocarcinoma (N2 nodal status) and localized metastasis to the left ovary (M1 metastatic status).
T4|thyroxine|T4|176|177|LABORATORY|NEUROLOGICAL: Cranial nerves II through XII are grossly intact. Sensation intact to light touch. Gait within normal limits. LABORATORY: Comprehensive metabolic panel, TSH, and T4 normal. Urine toxin screen positive for cannabinoids. Urinalysis negative. Complete blood count negative. ASSESSMENT: 1. Schizoaffective disorder. 2. Benign cervical adenopathy. PLAN: The patient is medically stable.
T4|thyroxine|T4|686|687|CSF (12/11/2007)|7. Dilantin 250mg qday ALL: NKDA PExam: VS-37.1, 78, 146/51, 24, 98% on RA Very cachectic female, laying in bed, does not track, does not respond to stimulus, warm to touch OP clear, no LAD, dry MM, no TM appreciated, nontender Neck no goiter RRR no rubs, no gallops CTAB (anterior exam), no rales, no ronchi Schaphoid abdomen, no organomegaly, + BS, G-tube in place No cyanosis, clubbing, edema, warm to touch, moist. DTRs could not be eliciated due to positioning. Labs: EEG (_%#MM2007#%_) CSF (_%#MMDD2007#%_): Colorless/clear, WBC -2, RBC - negative, Lymph - 81, Mono -19, Cells - 100, Glucose - 81 **Please note there are not ranges or units from OSH** TSH (_%#MMDD2007#%_) - 5.58 T4 (_%#MMDD2007#%_) - 4.5 Free T3 - 228 (_%#MMDD2007#%_) Free T3 - 247 (_%#MMDD2007#%_) FreeT3 - 172 (_%#MMDD2007#%_) Microsomal Ab 1:1600 (_%#MMDD2007#%_) TPO > 950 (_%#MMDD2007#%_) MRI (_%#MMDD2007#%_) ? enlargement of third ventricle and lateral ventricle, homogenous mass within the cerevellopontine angle on the let side.
T4|thyroxine|T4|124|125|PLAN|8. Status post venous ligation both lower extremities. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Add free T4 to screening laboratories. 3. Copy of laboratories to the patient at discharge for primary physician follow-up. If indeed iron deficient it may be reasonable to proceed with colonoscopy for completeness of workup.
T4|thyroxine|T4|189|190|LABORATORY DATA|Sensation intact to light touch. Strength 5/5 bilaterally in the upper and lower extremities. LABORATORY DATA: comprehensive metabolic panel: glucose 148, creatinine 0.76, reflex TSH 0.35, T4 1.16. U-tox positive for benzodiazepines, marijuana and opiates. Hemogram/differential/platelet count: Hemoglobin 12.9, hematocrit 38.7, RBC 4.14. Otherwise within normal limits.
T4|thyroxine|T4.|182|184|PLAN/RECOMMENDATIONS|2. I recommended additional lab tests if IV access is obtained with a PICC line or other peripheral access. Lab tests should be completed for repeat serum cortisol, IGF 1, TSH, free T4. 2. Furthermore, I recommend doing a midnight salivary cortisol test with 3. saliva sample at midnight tonight. I did call the UMMC Lab to confirm that they can do this test and requested appropriate sample container sent to the eighth floor nursing station for this test tonight or tomorrow night.
T4|thyroxine|T4|138|139|LABORATORY DATA|LABORATORY DATA: Chemistry panel is normal with the exception of slight elevation of GGT of 95. CBC is normal. TSH elevated at 22.4. Free T4 0.68. ASSESSMENT: 1. Depression with suicidal ideation. 2. Chronic alcohol abuse. 3. Hypothyroidism with inadequate replacement therapy due to noncompliance with moderate hypothyroidism based on current TSH level.
T4|thyroxine|T4,|214|216|SUMMARY|I would like to proceed with MRI of the brain as well both with and without contrast. EMG will be carried out to look for any evidence of myopathy and/or neuropathy. In addition, myasthenia gravis panel along with T4, vitamin B12 levels and sedimentation rate as well as Lyme disease will be checked. Further management depends on the outcome of the above measures.
T4|thyroxine|T4|222|223|REQUESTING PHYSICIAN|He was found to have hypertriglyceridemia in the past, two years ago, but with change of diet, that has improved. He has had weight loss in the past six months and was found to be hyperthyroid with numbers of TSH 0.02 and T4 of 7.48, with no other abnormality noted in his labs that I can identify. He is physically active and has essentially a negative review of systems, but has been hotter than his wife, needing fewer bed clothes in the last several months and has a fine tremor in his fingers that are outstretched, in addition to the weight loss, all of these findings likely related to hyperthyroidism, but he does not have muscle weakness and is physically active, walks all the time and looks actually quite fit and considers himself quite fit with no symptoms of exercise intolerance or discomfort with activity.
T4|thoracic (level) 4|T4|219|220|HISTORY OF PRESENT ILLNESS|This consultation is for exposed spinal hardware. HISTORY OF PRESENT ILLNESS: This is a 57-year-old T8 paraplegic secondary to a motor vehicle accident in 1966, which was treated with Harrington rod-type construct from T4 to his sacrum. He has approximately a 3-year history per the patient of chronic sacral decubiti, and both interventions for coverage and closure of this area in the past.
T4|thyroxine|T4|179|180|ASSESSMENT AND PLAN|1. Psychosis. This is to be followed by Dr. _%#NAME#%_. 2. Slightly low thyroid stimulating hormone (TSH) of uncertain etiology. I doubt this represents a hyperthyroid state. T3, T4 are pending at this time. 3. History of gunshot wound to the chest. I am not aware of sequelae of this incident. He appears hemodynamically stable presently.
T4|thyroxine|T4|136|137|LABORATORY DATA|Gait within normal limits. LABORATORY DATA: CBC and basic metabolic panel normal. TSH noted in _%#MM2003#%_ was slightly low at 0.24. A T4 on a prior check was normal. ASSESSMENT: 1. Depression. 2. Diarrhea probably secondary to stress. I doubt this is an infectious etiology.
T4|thoracic (level) 4|T4|247|248|IMPRESSIONS|2. He has a history of osteomyelitis involving the right femur, and is status post resection of the proximal femur. He also had pelvic and thigh abscesses drained. Coagulase-positive staph (2 strains) previously was isolated. 3. He is a long-term T4 paraplegic, having a motor vehicle accident occur at age 8. 4. He has chronic decubitus ulcers, a colostomy, and an ileal diversion.
T4|tumor stage 4|(T4|192|194|IMPRESSION|Examination of the exenteration site shows it to be well-healing. The nasal cavity can be seen clearly. IMPRESSION: 62-year-old white male with extensive apocrine carcinoma of the right orbit (T4 N0 M0 squamous cell carcinoma of the right eyelid) status post right orbital exenteration and right-sided ethmoidectomy with residual positive and close margins.
T4|thoracic (level) 4|T4|133|134|DISCUSSION|Patient has had periods of apnea in the recovery room. In addition, he has had a progression of his spinal level up to approximately T4 after surgery. Patient denies any pain, shortness of breath, or chest pain.
T4|thyroxine|T4|196|197|IMPRESSION|I would be most concerned about hypothyroidism in this setting, given the low voltage on his ECG, the cold intolerance, the bradycardia and heart failure. We will obtain a thyroid screen and free T4 measurement today. In the meantime, we need to treat the symptoms of his heart failure. It is going to be difficult to produce any effective diuresis, given his creatinine.
T4|thyroxine|T4|158|159|LABORATORY DATA|LABORATORY DATA: Labs on admission include a Chem-18 remarkable for BUN of 36, creatinine 1.12. CBC is essentially normal. Urinalysis is normal. TSH is 7.74. T4 is normal at 1.43. A chest x-ray and EKG are ordered and are pending.
T4|thyroxine|T4|502|503|LABORATORY DATA|Most recent arterial blood gases are satisfactory with pH 7.33, pO2 96, pCO2 45, hemoglobin as mentioned has fallen from 10.2-8.2. We note that earlier this year on an outpatient basis, hemoglobin was 12.3 with otherwise normal values. Otherwise, the CBC currently is normal. We note as well that other outpatient labs these are from ten days ago, show 1+ of protein on urinalysis and normal basic blood chemistries with a calcium of 8.9. There was a borderline elevated TSH of 6.07 with a normal free T4 of 0.9. Thank you for the opportunity to assist in Ms. _%#NAME#%_'s care. We will follow her with you as appropriate during the remainder of her hospital stay.
T4|thyroxine|T4|203|204|PLAN|The use of T3, which has a quicker onset of action versus T4 is controversial. Again, given the relatively compensated status, at this point albeit on low-dose dopamine, we will go with the conservative T4 IV dosing initially. ADDENDUM: PLAN: Await echocardiogram this morning to assess systolic and diastolic dysfunction as well as look for evidence for pericardial effusion.
T4|thyroxine|T4|168|169|IMPRESSION REPORT AND PLAN|His bradycardia now is most consistent with tachy-brady syndrome, and perhaps replacing his Synthroid has led to a masking of a sick sinus syndrome. He is currently on T4 replacement. I will check levels to ensure that we have done this sufficiently. Interestingly, he remains asymptomatic despite very low heart rates and very high heart rates.
T4|thoracic (level) 4|T4.|160|162|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. COPD - severe. a. O2 dependent. 2. History of T8 compression fracture by MRI, _%#MM#%_ 2003. 3. History of old compression fracture of T4. 4. Status post cataract surgery. SOCIAL HISTORY: He lives with his wife. He is retired.
T4|thyroxine|T4|211|212|ASSESSMENT AND PLAN|4. Irregular menses, likely secondary to recent chemical use. Her urine pregnancy test was negative. The patient is to follow up with Ob-Gyn within 4 months if menses do not start to become regular. 5. Low TSH. T4 and T3 are pending. No history of thyroid problems. Will continue to follow clinically. We appreciate the consult.
T4|tumor stage 4|T4,|171|173|PLAN|PLAN: We have discussed this case with Dr. _%#NAME#%_. It appears that he has a T4 tumor which invades the carina with bilateral supraclavicular disease. This makes him a T4, M3. This makes him a stage IIIB lung cancer. It is a very large tumor which invades the mediastinum and supraclavicular area.
T4|thyroxine|T4.|126|128|ASSESSMENT/PLAN|3. Question of hyperthyroidism. The patient has some nonspecific symptoms and a borderline low TSH, although she has a normal T4. I would recommend following up with the patient's primary MD regarding these studies and to follow her symptoms. It seems unlikely that the patient would have incidental hyperthyroidism in the setting of her recent pituitary surgery.
T4|thyroxine|T4|153|154|LABORATORY EVALUATION|Gait appeared normal. LABORATORY EVALUATION: Without significant abnormality, including CMP and CBC. His TSH was slightly low, at 0.3; however, his free T4 was within normal limits. ASSESSMENT AND PLAN: 1. Depression. This will be followed by Dr. _%#NAME#%_.
T4|thyroxine|T4|132|133|LABORATORY DATA|Neck veins are not distended. ABDOMEN: No hepatosplenomegaly, no tenderness. EXTREMITIES: No edema. LABORATORY DATA: TSH 1.91. Free T4 0.89. Electrolytes are normal. BUN and creatinine are normal. White count is low at 2.4, hemoglobin was 12.9, MCV is 102. Platelets 65,000. Electrolytes were normal on admission. Alcohol less than 0.01. IMPRESSION: 52-year-old woman with diarrhea.
T4|tumor stage 4|T4|256|257|HISTORY OF PRESENT ILLNESS|There was a clear break through the submucosal layer with ...............??extensions which maybe into the prostate. The patient presents to our clinic today for evaluation for possible neoadjuvant chemoradiation for the treatment of his ultrasound staged T4 N0 M0 rectal adenocarcinoma. DICTATION STOPPED AT THIS POINT...... PAST MEDICAL HISTORY: ?? MEDICATIONS: ??
T4|tumor stage 4|T4|189|190|HISTORY OF PRESENT ILLNESS|There appeared to be a clear break through the submucosal layer with lobular extension possibly into the prostate. No lymphadenopathy was seen. The patient was thus staged as an ultrasound T4 N0 M0. A CAT scan was performed the same day which showed non-specific hypodensity in the liver too small to characterize, a 9 mm hypodensity in the medial left liver lobe, likely hemangioma, multiple indeterminate small nodules within the lungs, renal stones, and an anterior mediastinal mass with thick rimmed calcifications benign in appearance.
T4|tumor stage 4|T4|206|207|ASSESSMENT|RECTAL: No mass is palpable on digital rectal examination. Stool is strongly hemoccult positive. Prostate is smooth and symmetric with no masses palpable. ASSESSMENT: 57-year-old male with ultrasound stage T4 N0 M0 adenocarcinoma of the rectum with questionable involvement of the prostate. RECOMMENDATIONS: Mr. _%#NAME#%_ is scheduled for a colonoscopy on _%#MMDD2004#%_ with Dr. _%#NAME#%_.
T4|thoracic (level) 4|T4|109|110|PAST MEDICAL HISTORY|Therefore, a urology consult was obtained for possible SP tube placement. PAST MEDICAL HISTORY: 1 History of T4 through T6 compression fractures secondary to fall from tree in 2002. 2 Status post baclofen pump placed _%#MMDD2003#%_. 3 History of multiple decubitus ulcers and history of surgical debridements for this condition.
T4|thyroxine|T4|128|129|PLAN|I suspect this may relate to subclinical hypothyroidism. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Add T3 and T4 to screening labs. 3. Milk of Magnesia p.r.n. 4. Resume Flonase two sprays each nostril daily. 5. Screening nocturnal oxymetry study to assess for periods of nocturnal desaturation.
T4|thyroxine|T4|220|221|ASSESSMENT|2. History of some type of thyroid surgery. She was on replacement at one time, but she has been off Synthroid for several months. Her current thyroid-stimulating hormone is 2.05, which is euthyroid. I will check a free T4 and T3 and continue to evaluate at this time. I will continue to hold they Synthroid and have the patient follow-up in 4 months if we do not restart of if we restart medications.
T4|thyroxine|T4.|181|183|LABORATORY DATA|There are no stigmata of chronic liver disease. There is no palpable lymphadenopathy or hepatosplenomegaly. LABORATORY DATA: CBC results are summarized above. Normal TSH and normal T4. Normal serum folate. Normal serum B12. Liver function tests and creatinine are also normal. Peripheral blood smear was not available for review at the time of this initial consult but will be reviewed subsequently.
T4|tumor stage 4|T4|91|92|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 52-year-old female with a recurrent T4 rectal cancer who presents for the possibility of radiation therapy. The patient initially presented approximately one year ago with vaginal bleeding.
T4|thyroxine|T4|177|178|LABORATORY DATA|Complete metabolic profile unremarkable except for a glucose 135, possibly nonfasting. TSH reflex low at 0.22 with a normal TSH reflux of 0.7 on _%#MMDD2007#%_. GGT of 29. Free T4 pending. ASSESSMENT: 26-year-old male admitted with the following: 1. Schizoaffective disorder, depressed.
T4|thyroxine|T4,|217|219|PLAN|1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Continue present meds and CPAP. 3. Add hemoglobin A1c to labs to assess for hyperglycemia over a protracted period consistent with type 2 diabetes. Follow-up free T4, however, doubt hyperthyroid based on recent normal TSH. Thank you for the consultation. Will follow along as indicated.
T4|thyroxine|T4|185|186|ASSESSMENT|4. Fatigue, multifactorial. The patient's labs studies other than her white count were unremarkable. Specifically, thyroid function tests are normal (a TSH is slightly elevated, with a T4 pending). PLAN: A free T4 will be obtained to compliment the TSH.
T4|thyroxine|T4|218|219|LABORATORY DATA|LABORATORY DATA: Comprehensive metabolic panel showed a glucose 113, AST 107, otherwise within normal limits. Hemogram differential platelet count showed a WBC 13.1, otherwise within normal limits. Reflex TSH is 0.37. T4 is pending. Urine tox positive for marijuana and PCP. Tylenol level less than 1. EKG showed normal sinus rhythm. ASSESSMENT: 1. Mood disorder, attention-deficit hyperactivity disorder, oppositional defiant disorder, bipolar disorder, and polysubstance abuse.
T4|thyroxine|T4|234|235|ASSESSMENT/PLAN|2. Goiter. The patient will have a chest x-ray which if it shows no signs of tracheal deviation and her T4 is not significantly elevated, she would be cleared for potential surgery if her hypothyroidism was treated. I will wait for a T4 before we begin any treatment. The patient's goiter is not substernal and I feel that no further imaging is needed. The patient would be at risk for acute hyperthyroidism if she received iodinated contrast.
T4|thyroxine|T4|361|362|LABORATORY DATA|Psychiatric negative. LABORATORY DATA: INR 1.15, PTT in 30s, sodium 140, potassium 3.8, BUN 32, creatinine 1.23, ESR 35, hemoglobin 12.5, hematocrit 37.1, white blood count 6.4. Her last lipid profile was in _%#MM#%_, with a total cholesterol of 186, triglycerides 125, LDL 102, VLDL 25, HDL 59. TSH done on _%#MM#%_ _%#DD#%_, 2005 was low normal at 0.59, free T4 mildly decreased at 0.60, ___________ antibody within normal limits. EKG done here revealed possibly a junctional rhythm. I could not appreciate any distinct P-waves, although the baseline is a bit of poor quality, nonspecific ST changes noted.
T4|tumor stage 4|T4,|150|152|HISTORY|The patient has a diagnosis of non-small cell lung cancer and had a wedge resection of the right upper lobe segment and lymph node biopsy and she was T4, N2, M0. At that time she received cisplatin sensitization and then radiation therapy to that area which was completed in _%#MM#%_.
T4|thyroxine|T4|129|130|IMPRESSION|This could be made worse by the current infection as noted in his WBC count and urinary discomfort. The plan is to obtain a B12, T4 and TSH. His history of gait disorder is probably multifactorial. However, his history of low back pain suggests the possibility of lumbar stenosis.
T4|thyroxine|T4|178|179|LABORATORY VALUES|If elevated, may consider propylthiouracil 100 mg t.i.d. and follow up with _%#CITY#%_ Physician in five to seven days. May also consider checking anti-thyroid antibodies if the T4 is elevated.
T4|thoracic (level) 4|T4|24|25|PROBLEM|PROBLEM: Second primary T4 pyriform sinus tumor, status post resection after original primary of the floor of mouth with 6000 cGy of postoperative radiation therapy given. (Please see initial consultation note by Dr. _%#NAME#%_ _%#NAME#%_ from _%#MMDD2001#%_).
T4|tumor stage 4|T4|167|168|IMPRESSION|Her speech is dysarthric, status post surgery. Her upper and lower extremity strength is symmetric and intact. IMPRESSION: Ms. _%#NAME#%_ is a 66-year-old female with T4 N2b M0 squamous cell carcinoma of base of tongue with metastases to left cavernous sinus. PLAN: We have recommended single shot stereotactic radiosurgery. We discussed with the patient the indications for, as well as the risks and benefits of radiation therapy for her disease.
T4|thoracic (level) 4|T4|213|214|HPI|Exam: 83-year-old male patient who is resting on his bed with great anxiety from the progression of his disease. The patient has complete paresthesia and paralysis of the bilateral lower extremities and below the T4 area on dermatome. He is experiencing some upper extremity weakness, especially on the right side. The patient's mental status is clear, and he is answering questions clearly.
T4|thyroxine|T4|96|97|LABORATORY  DATA|Motor, sensory and coordination are intact. She is not tremulous. LABORATORY DATA: TSH is 0.26, T4 is pending. Lithium level 0.2, nonfasting glucose is 152, potassium 3.6. CBC is unremarkable. Urine tox screen is negative. Urine pregnancy screen is negative.
T4|thyroxine|T4|126|127|PLAN|3. Elevated TSH of unclear etiology. This may be secondary to stress versus hypothyroidism. PLAN: Will recheck TSH as well as T4 in the morning. If it is elevated, will consider treatment. The patient will receive a copy of his labs when he is discharged.
T4|thyroxine|T4|160|161|LABORATORY|BUN and creatinine normal at 24 and 1.23. Bilirubin is 1.4. ALT and AST normal. Hemoglobin 10.6, hematocrit 31.7, platelet count 291,000. TSH is 5.63 with free T4 1.18, which is normal. BNP 1350. Troponin-I is 0.44. pH was 7.37, pCO2 45, pO2 306 and bicarbonate of 25. Pulse ox of 98% oxygen saturations. An EKG done revealed sinus rhythm with left bundle branch block and some nonspecific ST-T changes.
T4|thyroxine|T4|236|237|PLAN|She should have had symptoms prior to the surgery, and they would have also been exacerbated in the immediate postop period, which did not occur. PLAN: We have outlined a plan. This will include obtaining a CBC, chemistry profile, free T4 and C-reactive protein, also serum cortisol level-all of these to be drawn this coming Monday morning and, thereafter, we will obtain an imaging study with a CT scan of the abdomen and pelvis to be compared with previous CT scan from _%#MM#%_ of this year.
T4|thyroxine|T4|425|426|IMPRESSION|I recommended increasing the oral steroid dose to hydrocortisone 60 mg morning, and 30 mg evening today, though will taper tomorrow to 40 mg a.m. and 20 mg p.m. It will be important to track the sodium and potassium levels in the next few days, consider adding Florinef medication if persistent hyponatremia or hyperkalemia. I also requested lab tests for repeat cortisol, ACTH level, adrenocorticotropin antibody, TSH, free T4 and magnesium. I will also review the CT scan of the adrenals to look at the adrenal gland anatomy. I recommended post-hospital visit with me in two to three days to review the final cortisol and other laboratory test results and management plan.
T4|thyroxine|T4|158|159|IMPRESSION|She has an appointment with Neurology on Monday, from what I understand and I advised them to follow-up with this. The patient should have a B12, folic acid, T4 and TSH done for her dementia and consideration of Aricept can be discussed at the time of her outpatient appointment.
T4|thyroxine|T4|207|208|ALLERGIES|Please give a copy of the labs to the patient upon discharge home. Please call MD for any abnormal labs. 2. Elevated thyroid-stimulating hormone secondary to hypothyroidism versus stress. Waiting for T3 and T4 levels. Recheck thyroid- stimulating hormone on _%#MMDD2006#%_. 3. Elevated gamma-glutamyl transpeptidase and aspartate aminotransferase secondary to alcohol abuse/dependence.
T4|thyroxine|T4.|368|370|LABORATORY  DATA|Sensation intact to light touch. Strength 5/5 bilaterally. LABORATORY DATA: Labs obtained at Methodist reveal patient's eating disorder program include a CBC that was done on _%#MMDD2006#%_ that showed a hemoglobin of 11.5 and hematocrit 34.2. Also a sodium had been done there as well. The results were normal for the sodium. Labs on her admission here was a TSH and T4. The TSH was normal at 155. The T4 was normal at 1.02. ASSESSMENT AND PLAN: 1. Depression, managed per Dr. _%#NAME#%_. 2. Hypothyroidism, well controlled. TSH is 1.55, will continue on 100 mcg Synthroid q. daily.
T4|thyroxine|T4|161|162|LABORATORY DATA|ABDOMEN: Soft, nondistended, nontender. MENTAL STATUS EXAMINATION: Per Dr. _%#NAME#%_. LABORATORY DATA: Labs today included an unremarkable chem 18. TSH is 0.3. T4 is normal, CBC is unremarkable.
T4|thyroxine|T4|209|210|ASSESSMENT AND PLAN|She is to continue on iron supplements for anemia. Her anemia is most likely secondary to a combination of iron deficiency anemia and thalassemia. Since the patient is asymptomatic at this point, and her free T4 is normal, I will follow her clinically, and check free T4 periodically for evidence of hyperthyroid symptoms. I will ask the nurse to obtain the chart for her workup of hyperthyroidism.
T4|thyroxine|T4|219|220|RECOMMENDATIONS|Her abdominal examination is benign at this time. RECOMMENDATIONS: _%#NAME#%_ will be continued on Prevacid on a b.i.d. basis. I would add that a TSH obtained on admission was slightly low. We will, therefore, obtain a T4 to see if this does represent hypothyroidism. I will be able to see _%#NAME#%_ during her hospitalization for these and any other medical concerns.
T4|tumor stage 4|T4|408|409|ASSESSMENT AND PLAN|Electrolytes within normal limits. CEA 10.1, normal being up to 2.5. PATHOLOGY: From rectal mass biopsied on _%#MMDD2007#%_ at _%#COUNTY#%_ _%#COUNTY#%_ Medical Center reveals invasive, moderately-differentiated adenocarcinoma, extending to the muscularis propria and into the seminal vesicle, soft tissue and perineal tissue. ASSESSMENT AND PLAN: The patient most likely has adenocarcinoma of rectum, stage T4 N1 Mx cancer. As of now, until proven otherwise, he probably does not have distant metastases.
T4|thyroxine|T4|87|88|LABORATORY DATA|Left ankle has full strength and full range of motion. LABORATORY DATA: TSH 6.5 with a T4 of 1.07. CMP, CBC and UA are within normal limits. ASSESSMENT/PLAN: 1. Bipolar disorder. History and diagnosis per Dr. _%#NAME#%_.
T4|thyroxine|T4|164|165|IMPRESSION|Although this disorder usually appears as a goiter with or without hypothyroidism, iodine, may produce hypothyroidism unaccompanied by goiter. The low- normal free T4 blood test is characteristic of mild primary hypothyroidism. I have asked Mr. _%#NAME#%_ to have a family member bring and the iodine and kelp supplements.
T4|thoracic (level) 4|T4|142|143|HISTORY OF PRESENT ILLNESS|A suction catheter was placed and failed to drain any blood. Postoperative MRI demonstrated extensive epidural hematoma from level C2 through T4 after which Neurosurgery was consulted. At the time of consultation, the patient remained intubated and sedated under anesthesia. PAST MEDICAL HISTORY: 1. Anejaculation status post spinal cord injury on _%#MM#%_ _%#DD#%_, 2001.
T4|thyroxine|T4.|149|151|SUGGESTIONS|2. Start Methimazole 10 mg qd. 3. Repeat free T4 and TSH in three to four days just to be sure we are getting some early effect on at least the free T4. I do not expect the TSH to change for awhile. 4. Repeat free T4, TSH in two weeks along with a white count.
T4|thyroxine|T4|196|197|ASSESSMENT AND PLAN|2. Neck pain, likely musculoskeletal in etiology. Recommend the use of ibuprofen or Tylenol on a p.r.n. basis. 3. Mildly decreased TSH. I doubt this represents a hyperthyroid state. We will add a T4 to the labs to rule this out. 4. I will be happy to follow up should other issues arise during the hospitalization.
T4|thyroxine|T4|224|225|LABORATORY DATA|LABORATORY DATA: Comprehensive metabolic panel revealed sodium was 145, and otherwise was within normal limits. Hemogram, differential, platelet count showed RDW of 16.4, otherwise within normal limits. Reflex TSH was 0.29, T4 normal at 1.16, T3 normal at 108. U-Tox was positive for marijuana and cocaine. Urine pregnancy test was negative. ASSESSMENT AND PLAN: 1. Depression and polysubstance abuse, treatment per Dr. _%#NAME#%_.
T4|thyroxine|T4|186|187|LABORATORY DATA|Sensation intact to light touch. Gait within normal limits. LABORATORY DATA: Labs from _%#MMDD2007#%_ CBC normal, ALT 124, AST 73, GGT normal. Blood alcohol level 0.24. Reflex TSH 5.73, T4 normal. Sodium 145, total bilirubin zero less than 0.1. The rest of the comprehensive metabolic panel was normal. Urinalysis from _%#MMDD2007#%_ was normal. Urine tox screen from _%#MMDD2007#%_ positive for ethanol.
T4|thyroxine|T4|162|163|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: 1. Chemical dependency per Dr. _%#NAME#%_. 2. Hypothyroidism secondary to Graves. Consistently take Synthroid 100 mcg q.a.m. Recheck TSH and T4 in 3 weeks. Give the patient a copy of the labwork to take home with him. 3. Diarrhea. Imodium 4 mg p.o. x 1, then 2 mg p.o. after each loose stool; maximum of 16 mg per day.
T4|thyroxine|T4|142|143|PLAN|Will obtain urine analysis and urine culture today. Will follow up. 4. For hypothyroidism will resume Synthroid one dose. Will obtain TSH and T4 levels. 5. Will follow electrolytes and hemoglobin in the morning. The patient has chronic anemia with hemoglobin of 11.4. Will repeat postoperatively and follow up closely.
T4|thyroxine|T4|135|136|ASSESSMENT|We need to confirm that the patient is not menstruating. 5. Low TSH potentially related to a _____ thyroid state. We will check T3 and T4 to ensure she is not hyperthyroid. 6. Mildly-elevated GGT of questionable significance. This may relate to alcohol excess/fatty change. PLAN: 1. Psychiatric intervention as per Dr. _%#NAME#%_. 2. Recheck a urinalysis.
T4|thyroxine|T4|202|203|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Positive for exercise induced asthma. She has not used an inhaler recently. 2. Exophthalmus which necessitated a work up for thyroid function studies which revealed normal free T4 and normal sensitive TSH; however, her total T3 was elevated and the cardiologist performing both consultation and echocardiogram recommended that she see an endocrinologist.
T4|thyroxine|T4|240|241|ASSESSMENT|However, because the patient does have a history of intracranial surgery, it is possible that there could be a disconnect between the patient's hypothalamic-pituitary axis and her thyroid gland. As such, I think it is reasonable to check a T4 level on this patient to make sure that she truly has adequate blood levels of T4. 2. Flattened affect, fatigue complaints and self-destructive comments. The patient is avoiding stating that she is overtly suicidal; However, it is concerning that she states so many negative things about not wanting to be around all that long.
T4|tumor stage 4|T4|148|149|ASSESSMENT|LABORATORY STUDIES: We reviewed the old records including his endoscopic ultrasound and CT from Wyoming. The findings were noted above. ASSESSMENT: T4 N1 M0 differentiated invasive adenocarcinoma of the GE junction/stomach. PLAN: We recommend postoperative chemoradiation therapy. The McDonald trial did show a benefit for adjuvant chemoradiation therapy.
T4|thyroxine|T4|143|144|LABORATORY DATA|Urinalysis showed a moderate amount of leukocyte esterase, 4 white blood cells, few bacteria, otherwise within normal limits. Reflex TSH 6.49. T4 is pending. GGT 19. Urine toxicology positive for amphetamines, but the patient is on Adderall. Electrocardiogram showed normal sinus rhythm. ASSESSMENT AND PLAN: 1. Bipolar disorder, depression, panic attack, generalized anxiety disorder.
T4|thoracic (level) 4|T4,|197|199|HISTORY OF PRESENT ILLNESS|The outside records indicate a diagnosis of central cord syndrome with multilevel cervical stenosis, C3-C6, and disk herniation at C4-C5. The report also notes spinous process fractures at C6, T3, T4, T6, and T7, as well as comminuted fracture of the body of the scapula on the right, and multiple rib fractures that appear old.
T4|thyroxine|T4|205|206|RECOMMENDATION|3. Overall apparent good physical health. RECOMMENDATION: 1. Routine labs have been obtained and essentially normal. TSH is very slightly elevated at 5.4 which is likely not clinically significant. A free T4 will be obtained clarified this. 2. I will be able to see her during her hospitalization for concurrent medical concerns.
T4|thyroxine|T4|187|188|REQUESTING PHYSICIAN|We have elected to have her on a bisphosphate Actonel and have her observed as her calcium levels have only been minimally elevated. On _%#MM2001#%_, a TSH was normal at 2.76 with a free T4 of 1.26. Clinically, she is otherwise euthyroid. PAST MEDICAL HISTORY: 1. Diabetes mellitus. 2. Obesity. 3. Peripheral vascular disease.
T4|thyroxine|T4|242|243|ASSESSMENT|Heart rate was irregularly irregular. Breath sounds were decreased. LABORATORY DATA: Initial calcium level is 10.2, although on _%#MMDD2004#%_ calcium is 9.7. ASSESSMENT: Mild increase in free T4 with normal TSH. With repeat high-normal free T4 and normal TSH, total T3 pending. I do not believe she is hyperthyroid. The labs are more likely consistent with sick euthyroid illness, which in her case, could be exacerbation of her chronic obstructive pulmonary disease.
T4|thyroxine|T4|233|234|LABORATORY TESTS|No nodules or tenderness were noted. The patient did not have a fine tremor, and his deep tendon reflexes were normal. There was no edema, and no evidence of ophthalmopathy LABORATORY TESTS: On _%#MMDD2002#%_, TSH was 0.95, and free T4 was 1.16. IMPRESSION: 1. Amiodarone-induced hyperthyroidism, now controlled with propylthiouracil. 2. Atrial fibrillation.
T4|thyroxine|T4|201|202|IMPRESSION|He is not clinically symptomatic with the mild hyperthyroidism at the present time, and I doubt it has any relationship to the atrial fibrillation. As an outpatient, he should have repeat TSH and free T4 thyroid tests completed in 1 month and if persistently abnormal, I recommend follow-up endocrinology consultation. I would be happy to see the patient back for followup evaluation at our endocrinology clinic if this would be helpful.
T4|thyroxine|T4.|195|197|ASSESSMENT AND PLAN|He believes that he has had his dose adjusted once or twice although details are not available to me at present. Mother was not available for confirmation of this. We will plan to check a T3 and T4. Likely the patient will require decrease of his Levoxyl dosing and recheck of the TSH in a month's time. 3. Upper respiratory infection, likely viral in etiology. Recommend use of Sudafed on a p.r.n. basis as well as Robitussin p.r.n. I will be available to follow-up should further issues arise during hospitalization.
T4|thyroxine|T4|197|198|ASSESSMENT/PLAN|2. Thrombocytopenia. It is mild. This may be secondary to bone marrow suppression from his alcohol use. We will recheck a platelet count in the a.m. 3. Decreased TSH. We are following up on a free T4 and we will re- evaluate as necessary. 4. Hyperglycemia. This may be secondary to a non-fasting lab. The patient denies a history of diabetes. We will check a fasting blood sugar in the a.m. We appreciate the consult.
T4|thyroxine|T4|195|196|ASSESSMENT/PLAN|8. Smoking cessation. Patient uses nicotine gum currently. The patient is moving to Texas so she will not qualify for the Quit Plan. 9. Possible hyperthyroidism. We will await the results of the T4 and evaluate. Thank you for this consultation . We will continue to monitor the patient.
T4|thyroxine|T4|234|235|LABORATORY|NEUROLOGICAL: Non-focal. MENTAL STATUS EXAMINATION: As per Dr. _%#NAME#%_. LABORATORY: Prior to admission included normal liver function tests, normal electrolytes, BUN, and creatinine. TSH on admission was slightly elevated at 5.38. T4 ordered and is pending.
T4|thyroxine|T4|191|192|HISTORY OF PRESENT ILLNESS|Dr. _%#NAME#%_ also noted that he had a wide-based gait and a positive Romberg sign. His workup at that time also included thyroid function, which was unremarkable except for mildly elevated T4 of 11.5. Vitamin B12 level obtained on _%#MMDD2007#%_ was unremarkable at 1399. Her examination of him at that time did demonstrate a wide-based gait with a stocking glove distribution of sensory changes His past medical history is significant for serious closed head trauma a little over 30 years ago.
T4|thyroxine|T4|157|158|PAST MEDICAL HISTORY|He also denies heat intolerance, excess sweating, yet has had night sweats occasionally. PAST MEDICAL HISTORY: 1. Bipolar disorder, depression. 2. "Elevated T4 level." PAST SURGICAL HISTORY: Left wrist surgery, 1989. SOCIAL HISTORY: Single, though engaged to _%#NAME#%_, lives in _%#CITY#%_, Minnesota.
T4|thyroxine|T4|174|175|IMPRESSION|The distant history of thyroid medication treatment may relate to the early use of the lithium medication. I spoke with Dr. _%#NAME#%_ today and recommended repeat TSH, free T4 and TSI thyroid tests - the TSI thyroid antibody is a helpful screening for Graves' disease, hyperthyroidism since this illness typically involves the thyroid stimulating antibody.
T4|thyroxine|T4|167|168|LABORATORY DATA|It is soft, but appropriately tender. EXTREMITIES: There is no pedal edema. LABORATORY DATA: Review of the pathology reveals an adenocarcinoma of the colon. This is a T4 with perforation and a positive circumferential margin at the site of perforation, near the bladder. The distal margins were negative and 14 lymph nodes were negative.
T4|thyroxine|T4|76|77|LABS|Sensation intact to light touch. Gait within normal limits. LABS: TSH 8.73, T4 normal. BMP normal. Myoglobin 142, troponin less than 0.4. Sodium 132, potassium 3.3, glucose level 111, nonfasting rest of the comprehensive metabolic panel was normal.
T4|thyroxine|T4|118|119|RECOMMENDATION|The patient had a negative stress test a few years ago. RECOMMENDATION: We will clarify the patient's thyroxine dose. T4 and TSH be obtained. The patient will be maintained on metoprolol XL 50 mg a day. Blood pressure and heart rate will be monitored. I will be able to see _%#NAME#%_ during his hospitalization for these and any other medical issues.
T4|thyroxine|T4|320|321|LABS|Gait slightly unsteady. LABS: CBC normal. Blood alcohol on admission was 0.22, phosphorus level 2, magnesium 1.9. The labs today were remarkable for an anion gap of 4.8, calcium level 8.4, which has improved compared to yesterday's level of 8. The rest of the comprehensive metabolic panel was normal. TSH 39.5. GGT 61. T4 pending. Pregnancy test negative. Lipase level 291. ASSESSMENT: 1. Alcohol dependence. 2. Hypothyroidism, uncontrolled. The patient should benefit from switching to Cytomel since she does not have a functional thyroid to convert the T4 to T3.
T4|thyroxine|T4|176|177|HOSPITAL COURSE|This was done in all four quadrants, and after 72 hours resulted in _%#NAME#%_ being able to pass stool. Thyroid function tests were also obtained with a TSH of 3.9 and a free T4 of 1 as well as a sweat chloride, which was negative for cystic fibrosis. Problem #2: Fluid, electrolytes, and nutrition. As previously stated, _%#NAME#%_ did reportedly have a poor diet of mainly milk and noodles.
T4|thyroxine|T4|187|188|PROBLEM #3|PROBLEM #3: Endocrine: She has 12 units of insulin, her TPN, and a sliding scale. Follow blood glucose q.i.d. before meals and before bed. On home Synthroid dose with normal TSH and free T4 on _%#MM#%_ _%#DD#%_, 2006. PROBLEM #4: Respiratory: Developed pulmonary edema and pleural effusions when fluid balance was up. Went on oxygen on _%#MM#%_ _%#DD#%_, 2006, and BiPAP on _%#MM#%_ _%#DD#%_, 2006, and discontinued on _%#MM#%_ _%#DD#%_, 2006, in the morning.
T4|thyroxine|T4|132|133|NOTE|His newborn screen initially was borderline for hypothyroidism and the repeat was negative. His TSH was elevated at 210.16 and free T4 was low at 0.38. He was diagnosed with hypothyroidism and Pediatrics Endocrinology was consulted. They recommended starting Synthroid. The Synthroid dose was adjusted throughout his hospital stay and he went home on 75 mcg NG tube daily.
T4|thyroxine|T4|117|118|5. GYN|If the TSH is still elevated, she should increase her Synthroid dose to 112 mcg p.o. nightly and recheck her TSH and T4 in 3 to 5 days. 5. GYN: _%#NAME#%_ has a history of irregular periods and prolonged menses for which she was placed on oral contraceptive pills some time ago.
T4|thyroxine|T4|215|216|* FEN|Last Hgb/ RTC were 11.1/6.6 on _%#MMDD2007#%_. Her last ferritin level was 26 ng/mL on _%#MMDD2007#%_. * Endocrine: We have been following monthly thyroid functions on _%#NAME#%_. The last TSH was18.2 mU/L and free T4 was pending _%#MMDD2007#%_. No further follow-up is necessary. Discharge medications, treatments and special equipment: * Ferrous sulfate 8 mg po q 24 hours * Prevacid 1.5 mg po q 12 hours * Pear juice 5 mL po q 12 hours - to promote stooling.
T4|thyroxine|T4.|177|179|ASSESSMENT  AND PLAN|Occupational, Speech and Physical Therapy will be asked to see the patient. 6. Hypothyroidism. Review of labs from earlier this month showed a TSH of 7.75. Recheck TSH and free T4. If it is still abnormal, we will start Synthroid therapy. 7. History of partial aortic outflow tract obstruction and aortic insufficiency.
T4|thyroxine|T4,|107|109|FOLLOW-UP|Follow-up was also scheduled with Pediatric Endocrinology on _%#MMDD2004#%_ at 09:45, with TSH, 3T4, total T4, and total T3 to be drawn prior to this appointment. Finally a cardiac echocardiogram was set up to be completed in _%#CITY#%_ prior to Cardiology follow-up appointment on _%#MMDD2004#%_.
T4|thyroxine|T4|204|205|ASSESSMENT AND PLAN|We will hold hydrochlorothiazide for now. 3. Hypothyroidism secondary to total thyroidectomy: We will continue levofloxacin 50 mcg daily. The patient's last TSH on _%#MMDD2007#%_ was 6.8 with normal free T4 of .93. We will probably repeat TSH reflex on this admission. 4. Hyperlipidemia, stable and well controlled: The patient's last lipid profile on _%#MMDD2006#%_ showed cholesterol 121, triglyceride 117, LDL 71, HDL 27.
T4|thyroxine|T4|238|239|PROBLEM #8|PROBLEM #8: Hypothyroidism: Ms. _%#NAME#%_ has a history of subclinical hypothyroidism, which was considered to be a potential cause for her constitutional symptoms and failure to thrive. The TSH was slightly elevated at 5.35 with a free T4 of 0.78. Although, the free T4 was within normal limits; it was the recommendation of palliative care to administer a low dose of thyroid replacement to potentially improve her mood and energy level.
T4|thyroxine|T4|276|277|OPERATIONS/PROCEDURES PERFORMED|A bone marrow biopsy which was negative for fungal bacterial cultures showed severely hypocellular with microcytic hypochromic anemia. On day of admission, further labs were obtained which showed significantly elevated ESR of 98 and CRP of 9.4. The patient's TSH was 0.67 and T4 1.72. On _%#MM#%_ _%#DD#%_, 2002, the patient had a negative HIV 1 and 2. We also sent out perineoplastic antibiotics which are to date pending.
T4|thyroxine|T4|164|165|ALLERGIES|A basic metabolic profile was all within normal limits. A CBC was also within normal limits with a preoperative hemoglobin of 13.3. Her magnesium was 2.2. Her free T4 was 2.0. Her TSH was 0.31 which is slightly below normal. A chest x-ray was normal. HOSPITAL COURSE: The patient was admitted on _%#MM#%_ _%#DD#%_, 2004, she underwent the above-named procedures.
T4|thoracic (level) 4|T4|108|109|HOSPITAL COURSE|The patient was admitted to the Neurology Service. HOSPITAL COURSE: PROBLEM #1: Signal abnormality in C4 to T4 areas of the cord. The patient's MRI of cervical, thoracic, and lumbar spine were repeated after admission, and it was determined to have signal abnormality of the C4 to the T4 cord levels.
T4|thyroxine|T4:|163|165|PROBLEM #3|His heart rate will be monitored as an outpatient. PROBLEM #3: Endocrine. Hyperthyroidism, borderline. TSH: 0.18 (_%#MMDD2003#%_), and 0.45 (_%#MMDD2003#%_). Free T4: 1.86, upper limit of normal. Free T3: 2.5 (normal 2.2-4.0). Thyroperoxidase antibodies: negative. Thyroid stimulating immunoglobulins: negative.
T4|thyroxine|T4|167|168|ASSESSMENT AND PLAN|5. Hypothyroidism: As noted, we will check a TSH and keep her on her current dose of Synthroid at 200 mcg p.o. daily. If this is significantly elevated and her T3 and T4 are decreased, we will have to consider increasing her Synthroid, and maybe talk to Endocrinology about this as well. 6. Depression: The patient is currently on 1 depression medication and does show clinical signs of depression as well as bits of phrases such as, "I would like to die because of the pain." At this point, we will consider adding a psych consult onto her already large work-up at this time.
T4|thyroxine|T4|213|214|ACTIVITY|Problem #4: Endocrine. An extensive endocrine workup was performed. _%#NAME#%_ was found to have decreased pituitary function along several axes. His thyroid stimulating hormone was elevated despite a normal free T4 on several occasions. Otherwise, his ACTH was nearly immeasurable. His human growth hormone was low. His insulin growth factor was low, as well. MRI of the brain showed a normal-sized pituitary.
T4|thyroxine|T4|141|142|ADMISSION LABS|Her urinalysis showed many bacteria, and squamous epithelial cells, negative leukocyte esterase, nitrites, and protein. A TSH, CRP, and free T4 were sent. HOSPITAL COURSE: PROBLEM #1: Fluids, electrolytes and nutrition.
T4|thyroxine|T4|121|122|DISCHARGE FOLLOW-UP|2. _%#NAME#%_ will follow up in Pediatric Endocrinology Clinic in approximately two weeks. He does need a repeat TSH and T4 prior to that clinic visit. DIET: Low sodium diet. It was a pleasure to be involved in _%#NAME#%_'s medical care.
T4|thyroxine|T4|167|168|HISTORY OF PRESENT ILLNESS|The patient's thyroid function has been abnormal and she has been diagnosed with hypothyroidism initiated on methimazole. Her TSH is being grossly suppressed and free T4 and free T3 have being adequate in early _%#MM2007#%_. She did have atrial fibrillation and heart failure and I presume these were the reasons for her initiating methimazole.
T4|thyroxine|T4|284|285|ASSESSMENT/PLAN|We will check an Accu-Chek b.i.d. just to be on the safe side just to make sure that there are no new issues regarding her diet-controlled diabetes. 5. Hypothyroidism. Given the patient has not been checked on her TSH and T4 in more than a year, we will go ahead and obtain a TSH and T4 while she is in the hospital here to make sure that she is on the accurate dose of thyroid replacement at this time.
T4|thyroxine|T4|257|258|HOSPITAL COURSE|By the day of discharge, endocrinology had recommended checking blood glucose levels at least 3 times per day with 1 of these checks overnight. The patient was diagnosed with hypothyroidism during this hospitalization. She had previously had TSH levels and T4 levels that were normal. The patient was found to have normal TSH, but a low T4. The patient was started on levothyroxine. The patient is to have a repeat TSH and T4 on _%#MMDD#%_.
T4|thyroxine|T4|308|309|HOSPITAL COURSE|The hematology consultants were very helpful in that she was seen by Dr. _%#NAME#%_ _%#NAME#%_ and they suggested that she did in fact have vonWillebrand's disease, but was likely acquired and maybe mostly due to hypothyroidism inadequately treated potentially. Her TSH came back very elevated at 44, T3 and T4 levels are still pending at this time. Thus we upped her Synthroid from 100 micrograms to 125 micrograms daily and she should have repeat thyroid studies in two to three months to see the result of this change.
T4|thyroxine|T4|244|245|IMPRESSION|Now with the transplant, it should be correcting soon. Her albumin level is low normal and hopefully with replacing albumin cc for cc, per transplant orders, this should correct soon. 4. Hypothyroidism. The patient is on Synthroid, and TSH and T4 were fine on _%#MMDD2003#%_. 5. Steroid-induced diabetes: She is on prednisone taper, which should help. Also we will check Accu-Chek and cover with sliding-scale insulin p.r.n.
T4|thyroxine|T4|175|176|WORKUP TO DATE/MEDICAL HISTORY|WORKUP TO DATE/MEDICAL HISTORY: 1. On _%#MMDD2004#%_ ankyloglossia status post frenulectomy. 2. On _%#MMDD2004#%_ echocardiogram was performed. 3. On _%#MMDD#%_ TSH 8.8, free T4 1.5. 4. On _%#MMDD2005#%_ the child's liver function tests were within normal limits, with exception of an elevated alkaline phosphatase of 295.
T4|thyroxine|T4.|207|209|PROBLEM #4|An Endocrine Consultation was ordered to evaluate the child's elevated TSH in the context of a normal free T4. The Endocrinology Consultant stated that _%#NAME#%_'s elevated TSH may indicate a need for free T4. He presented the option of starting with 12.5 mg p.o. daily. It was thought that this might help improve _%#NAME#%_'s dry skin and slow bowel motility.
T4|thyroxine|T4|167|168|HOSPITAL COURSE|The patient remained in stable condition; however, developed total body shakes with a low TSH. The patient's tremor abated with increased Tapazole. The patient's free T4 level was normal. On postoperative day #2, the patient remained on esmolol drip, Isuprel, BNP, and Nipride.
T4|thyroxine|T4|269|270|1. FEN|Newborn screen results were normal for thyroid function. Thyroid ultrasound revealed normal anatomy. _%#NAME#%_ was started on replacement doses of Synthroid with monthly serial evaluations of his thyroid function showing appropriate response to therapy, his last free T4 and TSH were low normal on _%#MMDD2004#%_. Discharge medications, treatments and special equipment: 1. Diuril 60mg PGT Q12hrs
T4|thyroxine|T4|227|228|ACTIVITY|Problem #17: Hypothyroid. Salmo initially had her thyroid function followed closely during her hospitalization. She had high TSH and low normal T4 starting _%#MMDD#%_ which were followed until _%#MMDD#%_ when TSH was 9.86 with T4 of 1.39. At this time she was started on Synthroid with plans to follow with endocrinology after discharge. This problem is ongoing. Problem #18: Screening Examinations/Immunizations. * Newborn Screen: The Minnesota newborn metabolic screening examination was sent to the State Department of Health on _%#MMDD2007#%_and the results were normal.
T4|thyroxine|T4|259|260|ADMITTING LABORATORY|RBC indices were normal. Sodium was 136, potassium 4.1, chloride 106, bicarbonate 27, BUN 20, creatinine 0.85 and glucose 95. Ionized calcium 4.6, total calcium 8.3, magnesium 2.2, phosphorus 4.6, albumin 2.5, INR 1.06, PTT 30, fibrinogen 271, TSH 9.92, free T4 1.29, IgG 272 and AT3 113%. HOSPITAL COURSE: 1. CARDIOVASCULAR: _%#NAME#%_ was maintained on all of his cardiovascular medications, which he tolerated without difficulty.
T4|thyroxine|T4|315|316|LABORATORY DATA|The patient's most recent creatinine kinase total was 1764. The patient did have an elevated white blood cell count on _%#MMDD2005#%_ of 14.2, with an absolute neutrophil count of 11.0. The patient had a sodium on _%#MMDD2005#%_ of 133. All other labs were within normal limits, including a BMP that was normal and T4 that was also normal. MENTAL STATUS EXAMINATION: The patient was disheveled and in restraints at the time of the interview.
T4|thyroxine|T4|250|251|PROBLEM #5|PROBLEM #5: History of hyperthyroidism. The patient has been treated with PTU since her diagnosis of hyperthyroidism in _%#MM2002#%_. Endocrinology Service recommended discontinuing this after obtaining thyroid function tests. Her TSH was 1.13, free T4 was 1.04 and T3 was 124. All of these were in the normal range. In reviewing possible medication side effects, PTU has been known to cause interstitial pneumonitis.
T4|thyroxine|T4|128|129|HOSPITAL COURSE|7. Endocrine: Despite the Synthroid, the patient was found to still be hypothyroid. On admission her TSH was 7.71, and her free T4 was less than 0.0, suggesting under treatment, so we increased her Synthroid to 50 mcg p.o. q.d.
T4|thyroxine|T4|139|140|HOSPITAL COURSE|The patient was also noted to have repeat thyroid function tests which, of course, still remain abnormal. She had a TSH of 0.25 and a free T4 of 1.56. She was maintained on her methimazole. Her initial white count was noted to be 12.1, but by the time of discharge was noted to be 10.7. Hemoglobin remained at 10.8. Her bicarbonate was noted to be greater than 40 on her renal panel.
T4|thyroxine|T4|160|161|DISCHARGE INSTRUCTIONS|A deficiency of 5-alpha-reductase remains a possibility, and his gonadal function will need re-assessment at 3-months or older Problem #13: Hypothyroidis. Free T4 and TSH levels were indicative of hypothyroidism, and he was started on levothyroxine supplementation. He will need repeat TSH and free thyroxine measurements on the week of _%#MMDD2007#%_.
T4|thyroxine|T4.|108|110|PROBLEM #5|PROBLEM #5: Hypothyroidism. The patient was noted to have last TSH of 9.42 about a year ago with a low free T4. Therefore, considering the patient's osteopenia and general condition, he was started on a very low dose of levothyroxine at 50 mcg per day.
T4|thoracic (level) 4|T4|199|200|ADMISSION PHYSICAL EXAMINATION|Lungs are clear to auscultation bilaterally. Abdomen is soft, slightly tender to the right upper quadrant with no Murphy sign. There is no rebound or guarding. Spine: She had tenderness of the T1 to T4 area and had bilateral CVA tenderness. Skin was icteric. Neurologic exam was nonfocal. Extremities had no edema and 1+ bilateral pulses.
T4|thyroxine|T4|320|321|OPERATIONS/PROCEDURES PERFORMED|_%#NAME#%_ was initially treated with Zosyn until _%#MM#%_ _%#DD#%_, 2005, when he was switched to Augmentin to complete a total course of 14 days of antibiotics which was completed on _%#MM#%_ _%#DD#%_, 2005. Blood cultures from _%#MM#%_ _%#DD#%_, 2005, was negative. 5. Endocrine: _%#NAME#%_ has had high TSH and free T4 twice in the past. Endocrine has been involved. His TSH was as high as 9.28 on _%#MM#%_ _%#DD#%_, 2005 with free T4 at that time of 1.94. Repeat Endocrine consult was obtained, and was suggested to recheck a TSH and free T4.
T4|thyroxine|T4|226|227|OPERATIONS/PROCEDURES PERFORMED|Blood cultures from _%#MM#%_ _%#DD#%_, 2005, was negative. 5. Endocrine: _%#NAME#%_ has had high TSH and free T4 twice in the past. Endocrine has been involved. His TSH was as high as 9.28 on _%#MM#%_ _%#DD#%_, 2005 with free T4 at that time of 1.94. Repeat Endocrine consult was obtained, and was suggested to recheck a TSH and free T4. A TSH on _%#MM#%_ _%#DD#%_, 2005, showed 7.28 with free thyroxine of 2.15. Normal reference range of TSH is 0.4 to 5.0 and thyroxine normal reference range in 0.8 to 1.90. With _%#NAME#%_'s relatively normal free T4 despite elevated TSH, no specific treatment was recommended at this time, although he will need a close followup.
T4|thyroxine|T4|276|277|DISCHARGE MEDICATIONS|_%#NAME#%_ _%#NAME#%_ followup G-tube and probable Nicky button placement in 6 weeks, _%#MM#%_ _%#DD#%_, 2005, at 2 p.m. 4th floor, Phillip Wagenstein Building, Pediatric Endocrinology on _%#MM#%_ _%#DD#%_, 2005, at 10 p.m. with _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ for follow up T4 and TSH. _%#NAME#%_ is also to resume Children's Home Care Services. Mother was instructed to call MD if fever greater than 100.5 or oxygen saturation is less than 90% consistently.
T4|thyroxine|T4|187|188|HOSPITAL COURSE|The patient also had series of lab tests. She had a comprehensive urine drug screen which was negative. She had comprehensive metabolic panel which was unremarkable. She had TSH and free T4 levels checked and they were within normal limits. She had CBC with differential which was unremarkable. She had urinalysis which was significant only for some moderate bacteria and small amount of blood in the urine otherwise unremarkable.
T4|thyroxine|T4,|292|294|HISTORY OF PRESENT ILLNESS|Evaluation on _%#MMDD2007#%_ showed significant epigastric pain. Laboratory evaluation demonstrated hemoglobin 11.0 (new with severe iron deficiency anemia with a ferritin of two, iron is 7 and iron saturation 1%) Lipase was elevated at 748. Amylase 193, TSH was borderline low with a normal T4, calcium and triglycerides both normal. Chem-7 significant for sodium 132, WBC and differential normal. Since that time, the patient continues to have poor intake and has become more dehydrated and unable to manage at home.
T4|thyroxine|T4|152|153|PROBLEM #7|PROBLEM #7: Endocrine. _%#NAME#%_ has a history of hypothyroidism secondary to the thyroidectomy and has been maintained on Synthroid. A TSH and a free T4 level were checked on the date of discharge. The patient was also kept on calcium bicarbonate replacement for her history of hypocalcemia.
T4|tumor stage 4|T4|275|276|ASSESSMENT|There is also no evidence of any metastases in the chest, abdomen or pelvis, but there were some small regions of ground-glass opacities noted in the lower lung lobes of the lungs, possibly representing pneumonia. ASSESSMENT: 1. Squamous cell carcinoma of the left mandible, T4 with invasion of bone, now status post partial left mandibular composite resection tracheostomy and left pectoralis muscle flap reconstruction.
T4|thyroxine|T4|133|134|PLAN|10. Genetics - Chromosomes were sent due to the possibility of TE fistula. His karyotype was normal. 11. Endo/Metabolism - A TSH and T4 were checked on day 17 of life and were found to be normal. Serum amino acids were obtained and found to be normal.
T4|thyroxine|T4|173|174|ASSESSMENT AND PLAN|The patient's blood pressure is mildly elevated. Consider resuming the medication when the patient allows to be treated at this point. 5. Low TSH and mild elevation of free T4 consistent with a subclinical hyperthyroidism. With this clinical picture may also exacerbate the patient's congestive heart failure and cause a cardiomyopathy.
T4|thyroxine|T4|125|126|HOSPITAL COURSE|The patient is in significant risk of developing overt hypothyroidism should he receive iodinated contrast. His TSH and free T4 after giving the contrast material should be watched. If the TSH falls below 0.1, then initiate treatment with PTU at 300-600 mg per day.
T4|thyroxine|T4.|245|247|HOSPITAL COURSE|Next DVT prophylaxis. The patient will continue Lovenox for several days at the nursing home and call MD for further orders. 6. Macrocytic anemia. B12, folate, TSH and free T4 are all within normal limits. TSH was mildly suppressed. Normal free T4. She receives B12 injections 1 cc subq q.12h. q.2 weeks. 7. History of breast cancer followed by Minnesota Oncology. She is on Tamoxifen.
T4|thyroxine|T4|179|180|* IUGR|Results from the 14 day screen were abnormal for congenital hypothyroidism. Thyroid labs were obtained on _%#MMDD2007#%_ showed a minimally elevated TSH of 5.31 and a normal free T4 of 1.51. Repeat studies on _%#MMDD2007#%_ were nearly the same at TSH 5.98, free T4 1.50. No intervention is indicated at this time, as these values are not abnormal for newborn infants.
T4|thyroxine|T4.|162|164|LABORATORY DATA|We will follow the patient's BUN and creatinine. We will check his CBC again to see if with hydration, this drops significantly. We will check his THS and a free T4. We will maintain the patient AS DNR, DNI. We will have social work, occupational therapy and physical therapy eval uate the patient for nursing home placement.
T4|thyroxine|T4|169|170|LABORATORY & DIAGNOSTIC DATA|White count is elevated at 17,700 with increasing granulocytes, hemoglobin is 12.2, platelets are normal at 200,000, TSH remarkably elevated at 46.33, although the free T4 is low range to normal at 0.97. Urinalysis is normal. Chest x-ray is normal. CK is 1397. ASSESSMENT: 1. This is a 67-year-old female with chronic problems of inclusion body myositis, who presents with hypotension, generalized weakness, dry skin and a suggestion of inadequate thyroid replacement, possibly because of absorption, as it appears quite clear from the family that she has been taking her 100 mcg daily.
T4|thyroxine|T4|156|157|3. GU|His platelets have always been high- normal from 400to 750. No other heme issues. 7. Endocrine. He was admitted on 50 mcg of Synthroid and his TSH and free T4 were checked on admit on _%#MM#%_ _%#DD#%_ and were both found to be normal. They were repeated again on _%#MM#%_ _%#DD#%_ and his free T4 was borderline low and so his Synthroid was increased to 62.5 mcg q day, and his TSH and free T4 should be checked again in 2 to 3 weeks to make sure that he is now therapeutic.
T4|thyroxine|T4|428|429|FOLLOW UP|An upper GI study done on _%#MMDD#%_ revealed a "large amount of gastroesophageal reflux to the cervical esophagus." Because of his reflux, inability to take adequate feeding volumes without emesis and aversion to oral feeds a Nissen fundoplication with gastrostomy feeding tube placement was done on _%#MMDD2005#%_. Problem #8: Endocrine: _%#NAME#%_'s initial thyroid studies done on _%#MMDD#%_ showed an elevated TSH and free T4 at 7.38 and 2.79 respectively. Repeat studies on _%#MMDD#%_ were 4.16 and 2.16 i.e. within normal limits. Problem #9: Trisomy 21: chromosomes done _%#MMDD2005#%_ showed Trisomy 21, nondisjunction.
T4|thyroxine|T4|153|154|HOSPITAL COURSE|Ligation of the PDA should be done when she gains weight. 4. Endocrine: A endocrinology consult was obtained due to borderline TSH 5.01 (0.4-5) and free T4 0.77 (0.7 to 1.85). As per their recommendations, she was started on levothyroxine 37.5 mcg daily. Thyroglobulin and thyroid peroxidase antibodies were normal. 5. Infectious disease: Due to her PDA, SBE prophylaxis was given for all procedures involving the bowel.
T4|thyroxine|T4.|132|134|HOSPITAL COURSE|EKG unchanged compared to baseline. 3. Endocrine. Status post partial thyroidectomy. TSH was borderline low, but normal T3 and free T4. Sed rate was rechecked secondary to history of elevated sed rate and was within normal limits, though at the upper end of the range.
T4|thyroxine|T4.|194|196|DISCHARGE MEDICATIONS|The abdominal incision sites were clean, dry, and intact without erythema. The circumcision was healing well. Problem #13: Endocrine. _%#NAME#%_ developed a mildly elevated TSH and a low normal T4. Endocrine consultation was obtained. A reverse T3 level was high, confirming the suspected sick euthyroid syndrome. Repeat thyroid functions were normal on _%#MMDD2007#%_ and _%#MMDD2007#%_. This problem has resolved.
T4|thyroxine|T4|163|164|OB LABS|Gonorrhea negative. First trimester screen negative with negative AFP. Varicella immune. One-hour GCT of 155; 3-hour GTT abnormal. Negative GBS. TSH of 3.39. Free T4 and T4 within normal limits. OB ULTRASOUND: 1. _%#MM#%_ _%#DD#%_, 2005, first trimester screen, normal findings.
T4|thyroxine|T4|194|195|HOSPITAL COURSE|Tests were sent on _%#MMDD2003#%_. Results still pending at time of discharge. On _%#MMDD2003#%_ we sent a.m. cortisone level which was within normal limits. On _%#MMDD2003#%_ we sent TSH, free T4 and T3 which were all within normal range. On _%#MMDD2003#%_ fasting glucose level was 81, fasting ..........level was 9 and hemoglobin A1c on _%#MMDD2003#%_ was 5.4, all within normal range.
T4|thyroxine|T4|181|182|1. FEN|Repeat thyroid studies one week later again confirmed central hypothyroidism. He is currently being treated with 15 mcg/kg/day of Synthroid and will need monthly monitoring of free T4 until 6 months of age then q 3 month monitoring for life. He should follow-up with Endocrine clinic at four months of age.
T4|thyroxine|T4|136|137|HOSPITAL COURSE|The abnormal update in T9 and L1 corresponded to a fracture seen on plain film, but there was no correspondence with abnormal uptake in T4 and T5. An MRI of the spine was done to follow up bone scan results and to get a better visualization of the thorax.
T4|thyroxine|T4.|179|181|IMPRESSION/RECOMMENDATIONS|Either may present with pericardial effusion. The hyperpigmentation on examination would be consistent with primary hypocortisolism. I would recommend sending a TSH, T3, and free T4. I would also recommend sending a morning cortisol and ACTH. If any of these is abnormal, I would recommend consulting Endocrinology.
T4|thyroxine|T4|144|145|RECOMMENDATIONS|I have previously seen this patient for evaluation and management of type 2 diabetes mellitus. RECOMMENDATIONS: 1. I recommend repeat TSH, free T4 and free T3. She may have sick euthyroid syndrome which can cause problems with the T4 and T3 thyroid hormone conversion and metabolism.
T4|thyroxine|T4|136|137|RECOMMENDATIONS|RECOMMENDATIONS: 1. I recommend repeat TSH, free T4 and free T3. She may have sick euthyroid syndrome which can cause problems with the T4 and T3 thyroid hormone conversion and metabolism. I doubt she has Graves' disease-she has a normal thyroid gland on examination.
T4|thyroxine|T4,|200|202|REASON FOR CONSULTATION|In addition, she was started on the IV insulin infusion protocol with improvement in her blood glucose trends and electrolytes. Additional lab tests completed on _%#MMDD2005#%_ included elevated free T4, thyroid level of 5.68 (normal 0.7-1.85). Hemoglobin A1C 12.6%. The preliminary hyperglycemia diagnosis was hyperosmolar nonketotic acidosis and subsequent diagnosis hyperthyroidism with "thyroid storm".
T4|thyroxine|T4|158|159|IMPRESSION|In addition, I recommended additional thyroid tests with Free T4, Free T3, total T3, and thyroid stimulating immunoglobulin (TSR). We should recheck the Free T4 and ALT test daily while she is critically ill. I agree with the plan to use aggressive beta blocker medication, though, suggest switch to intravenous infusion of beta blocker such as Esmolol as noted by the hospitalist.
T4|tumor stage 4|T4|271|272|HEENT|He has a plastic salivary bypass tube (apparently this was attempted to be removed which the patient could not tolerate). Assessment and Plan: Large recurrence after extensive surgery and 2 occasions of flap reconstruction for the base of tongue squamous cell carcinoma, T4 N2b M0 initial staging. With this large recurrence, we would probably consider chemoradiation for palliation.
T4|thyroxine|T4|134|135|PREVIOUS EVALUATIONS|Coxsackie serologies were not definitive. Hepatic panel showed an albumin of 3.3, bilirubin 1.3, ALT 15, and AST 25. TSH was 3.63 and T4 was 0.89. Drug screen was unremarkable. Echocardiogram showed moderate to large effusion. Parvovirus PCR is still pending. AFE, gram stain, fungal culture, bacterial culture were all unremarkable.
T4|thyroxine|T4|113|114|ASSESSMENT|He has some documented alcohol abuse and has been diagnosed with hepatitis C. His TSH is elevated as is his free T4 consistent with "thick hyperthyroid." The patient is status post stenting of unknown coronary arteries with his nuclear stress test not showing significant cardiac ischemia in _%#MM#%_ o f 2006.
T4|tumor stage 4|T4|145|146|CC|My key findings: CC: Recurrent squamous cell carcinoma in the right tonsillar area. She has a previous history of supraglottic laryngeal cancer, T4 N2c M0 in 1985 and had another recurrence in 2003 in the base of tongue. HPI: This is a 51-year-old female patient who has a previous history of squamous cell carcinoma of the supraglottic larynx, T4 N3d M0.
T4|thyroxine|T4|324|325|LABORATORY DATA|LABORATORY DATA: EKG is as above. On _%#MM#%_ _%#DD#%_, sodium 134, potassium 3.6, chloride 101, glucose 192, creatinine 1.4, calcium 7.4, INR 1.46, hemoglobin A1-C 5.5%, glucoses have ranged between 100- 300. Blood cultures are negative to date. Platelet count 215,000, hemoglobin 11.9, MCV 101, white count 13.6, TSH 7.4, T4 1.19. Total cholesterol 169, LDL 56, HDL 37, triglycerides 375. ALT and AST were normal on _%#MM#%_ _%#DD#%_, alkaline phosphatase increased to 201.
T4|thyroxine|T4|119|120|ASSESSMENT|Again, medication effect is a possibility. 8. Suppressed TSH. May relate to a sick euthyroid status. Will check T3 and T4 to ensure not thyrotoxic. PLAN: 1. Discuss case with Neurosurgery at the University of Minnesota, with regard to seizure risk, the patient's complaint of persistent pain, and hyponatremia, as it relates to potential increased seizure risk.
T4|thyroxine|T4|128|129|LABORATORY  DATA|Morning blood sugar is 83, phenytoin level is 11.6 after a load of phenytoin in the ER. Calcium level is 8.9. TSH is 0.97. Free T4 is 1.1. Troponin has been less than 0.04. Two sets of urinalysis have been negative. Hemoglobin on admission was 11.2, white count 8.4, MCV was 97, platelet count 289,000.
T4|thyroxine|T4|110|111|ASSESSMENT|Care for a patient with such a viral infection is typically supportive. At this time I will order a TSH and a T4 to rule out a thyroid dysfunction as an etiology for this patient's pauciarticular arthritis. I will also reorder the Parvovirus B 19, as the IgM may not have been present when the patient was seen in h er primary clinic, as it may have been too soon after the acute infection.
T4|thyroxine|T4|305|306|LABORATORY DATA|Echocardiogram as noted above. Other labs, troponin I of 0.06 0.16 and 0.15. Hemoglobin is 13.6, WBC count 8.8, platelet count 147,000, BUN and creatinine of 18 and 1.18. ALT and AST were 49 and 60. UA showed WBCs with large leukocyte esterase but negative nitrites. TSH was less than 0.03, however, free T4 was normal at 0.88, valproic acid is mildly decreased at 16. IMPRESSION: 1. Episode of unresponsiveness as witnessed by a nurse, however, with an unrecorded blood pressure with initially recordable pulse.
T4|thyroxine|T4,|235|237|SUGGESTIONS|The goal was to get the TSH greater than 1.0. Once the thyroid levels are normal the dose can be reduced to a maintenance dose which I suspect will be probably 2.5-5.0 mg a day. 5. Thyroid levels that will be obtained including a free T4, total T3 and another TSH. I will also obtain thyroid antibodies including thyroid stimulating immunoglobulin, TBII, and antiTPO antibodies.
T4|tumor stage 4|T4|185|186|HISTORY OF PRESENT ILLNESS|The patient followed up with Dr. _%#NAME#%_ who then ordered an EUS biopsy by Dr. _%#NAME#%_. The biopsy showed ductal adenocarcinoma of the pancreas. By EUS, her tumor was staged as a T4 N0 M0. The patient has since been seen by Dr. _%#NAME#%_ and Dr. _%#NAME#%_. The current plan is transplant with continuous 5-FU, weekly cisplatin and interferon 3 times per week with re-evaluation on 4 to 6 weeks along with concurrent radiation therapy.
T4|thyroxine|T4|230|231|LABORATORY  DATA|He denies recent seizures and seizure history information difficult to obtain today. Additional ROS including skin, psychiatric and eyes is unremarkable. LABORATORY DATA: Thyroid test _%#MMDD2007#%_: TSH 8.19 (normal 0.4-5), free T4 2.98 (normal 0.7-1.85). Initial creatinine 3.24 mg/dL and BUN 31 mg/dL at admission, recent creatinine 3.0 and BUN 43 today.
T4|thyroxine|T4|181|182|HISTORY OF PRESENT ILLNESS|The tumor size was somewhat nonspecific given the multifocal nature of the lesion. However, the depth of invasion through the colonic wall (through the serosal surface) indicated a T4 lesion. Two of 19 sampled pericolonic lymph nodes were positive for a local metastatic spread (N1 nodal disease) and both resected ovaries were also found to be involved by metastatic adenocarcinoma (i.e., M1 status; local metastasis).
T4|thyroxine|T4|268|269|TSH = 0.15|_%#NAME#%_ could have pituitary disease. Alternatively, she may simply have narcotic induced suppression of ACTH. _%#NAME#%_ _%#NAME#%_, MD Endocrinology and Diabetes __________________________________________ Labs reviewed. FSH and LH low, Prolactin 70, TSH and free T4 WNL. It remains unclear whether she has pituitary disease or narcotic related suppression of ACTH and cortisol. Would recommend pituitary MRI, stopping opium and narcotic s and checking morning cortisol and ACTH.
T4|thyroxine|T4|86|87|PLAN|10. History of TSA elevation off levothyroxine replacement. PLAN: 1. Add TSH and free T4 to screening labs. 2. Continue with home medications as ordered. Add multivitamin daily, vitamin E, B12, omega-3, glucosamine/chondroitin. 3. Insulin pump to be managed by the patient.
T4|thyroxine|T4|234|235|HISTORY OF PRESENT ILLNESS|The patient was started on levothyroxine 0.15 mg p.o. q.d. on _%#MMDD2004#%_ for thyroid mass suppression. He then had an episode of tachycardia and persistent diarrhea. Repeat thyroid tests completed on _%#MMDD2004#%_, showed a free T4 greater than 12 (normal 0.7 to 1.85), and a suppressed TSH of 0.07. The levothyroxine medication was discontinued today.
T4|thyroxine|T4.|143|145|IMPRESSION|3. History of chronic lower extremity edema. 4. Hypertension. 5. Normal ejection fraction in the past. 6. Mildly elevated TSH with normal free T4. HISTORY OF PRESENT ILLNESS: This is a pleasant 83-year-old female with past medical history of hypertension, chronic lower extremity edema and diabetes, who is a patient of Dr. _%#NAME#%_ _%#NAME#%_ and was seen recently by Dr. _%#NAME#%_ on _%#MMDD2005#%_.
T4|thoracic (level) 4|T4|219|220|HISTORY OF PRESENT ILLNESS|Biopsy of this mass on that date, demonstrated infiltrating ductal carcinoma grade 3, ER positive, PR positive. On _%#MMDD2003#%_, the patient had a head MRI which was normal. The patient had a spine x-ray which showed T4 compression fracture. This was done on _%#MMDD2003#%_ at Fairview- University Medical Center. She describes the pain as worse than when she first presented.
T4|thoracic (level) 4|T4.|210|212|HPI|CC: Painful abnormal lesion of the T4 vertebral body and a recent diagnosis of breast cancer. HPI: 42-year-old pre-menopausal female patient who presented with severe upper back pain with an abnormal lesion at T4. The patient was found to have an abnormal lump in the right breast which was biopsied and revealed breast cancer with ER PR positive.
T4|thyroxine|T4,|118|120|ASSESSMENT AND PLAN|2. Low TSH level. The patient states that previous TSH levels were all normal. Will recheck TSH and get a free T3 and T4, and will follow up and treat accordingly after receiving the results of these labs. 3. Constipation, suspect secondary to pregnancy. Will order Colace 100 mg p.o. b.i.d. and Metamucil 1 Tbsp p.o. b.i.d. in 8 ounces of water or juice to regulate bowel movements.
T4|thyroxine|T4|357|358|RECOMMENDATIONS|5. Although he has no cardiac symptoms of angina, no previous cardiac problems and his echo shows normal ejection fraction, an outpatient stress study can be considered in the future given his risk factors for coronary artery disease and stenosis in the cerebral arteries. RECOMMENDATIONS: 1. Avoid AV nodal blockers or clonidine. 2. Make sure TSH and free T4 are normal. 3. Since he is asymptomatic with no significant pauses, I would continue conservative management. There is no absolute indication for a pacemaker at this time.
T4|tumor stage 4|T4.|289|291|ASSESSMENT|She has several additional right upper lobe nodules, most of which are not PET avid; however, at least 1 nodule in the posterior segment of the right upper lobe shows high SUV. Thus, she has at least 2 tumor masses within the same lobe, namely right upper lobe, making her disease a stage T4. Although her mediastinoscopy revealed no malignancies at station 7, 4R and 4L, her PET CT scan did appear to show evidence of of station 4L involvement, suspicious for N2 disease.
T4|tumor stage 4|T4,|9|11|PROBLEM|PROBLEM: T4, N0, M0 squamous cell carcinoma of the left tonsil. The patient was seen in the Radiation Oncology Clinic by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ for initial consultation on _%#MMDD2003#%_ at the request of Dr. _%#NAME#%_ _%#NAME#%_ from the Department of Otolaryngology at the Fairview-University Medical Center.
T4|thyroxine|T4,|147|149|ASSESSMENT|7. Bilateral breast discomfort with reduction in axillary/pubic hair, etc. Reviewed with Endocrine. Will check prolactin, LH, FSH, estradiol, free T4, and free testosterone and beta HCG. 8. Gastroesophageal reflux disease. Continue with Zantac p.r.n. 9. Bilateral upper extremity eruption, exact etiology unclear.
T4|thyroxine|T4|144|145|PLAN/SUGGESTIONS|They understand and the pharmacist will also review this prior to initiating PTU therapy. 9. Start PTU 50 mg tabs 100 mg t.i.d. 10. Repeat free T4 within six days after starting therapy 11. Follow WBC weekly for 4-6 weeks. 12. Follow up with endocrinologist in one week or so.
T4|thyroxine|T4|180|181|PLAN  AND SUGGESTIONS|Therefore, I would continue Amiodarone for now. 5. Fortunately, Mr. _%#NAME#%_ is only mildly hyperthyroid. His TSH is 0.16, so minimally below the lower limit of normal. The free T4 is close to 3.0 but amiodarone itself can raise the level of free T4 and Mr. _%#NAME#%_ has been on a small dose of thyroid hormone which probably is raising free T4 even higher although not obviously to this hyperthyroid range.
T4|thyroxine|T4|175|176|IMPRESSION|I recommended rechecking the thyroid tests for recheck on the TSH, free T4, total T3 and the thyroid stimulating immunoglobulin (TSI). He should also have repeat TSH and free T4 in 2 months for comparison and I will defer this testing to Dr. _%#NAME#%_. Since the patient had an intravenous contrast load with his coronary angiogram, I would not arrange any radioiodine thyroid scanning for at least 3 months duration, though this would be a helpful diagnostic test if he does not have any additional angiograms in the near future.
US|United States|US|248|249|SOCIAL HISTORY/HEALTH HABITS|SOCIAL HISTORY/HEALTH HABITS: The patient is a social drinker and has a significant tobacco history of over 22 years smoking, less than one pack per day. She has no illicit drug use history. Her occupation is as an auditory or financial manager at US Bank. She is married and previously divorced with 2 children and 2 stepchildren. Her husband accompanies her to the emergency room. FAMILY HEALTH HISTORY: The patient has 4 sisters and 1 brother.
US|United States|U.S.|211|214|SOCIAL HISTORY|REVIEW OF SYSTEMS: Head, ears, eyes, nose, throat, heart, lung, abdomen, neuro, musculoskeletal, integument, extremities otherwise unremarkable. FAMILY HISTORY: Negative. SOCIAL HISTORY: She works full-time for U.S. Bank. PHYSICAL EXAMINATION: GENERAL: Pleasant female in no acute distress. VITAL SIGNS: Height of 5'10", weight 203, blood pressure 116/70 and hemoglobin 12.7. HEENT: Pupils equally accommodate.
US|United States|US|164|165|SOCIAL HISTORY|4. Allopurinol 300 mg daily. 5. Prednisone 5 mg daily. SOCIAL HISTORY: Mr. _%#NAME#%_ denied tobacco or alcohol use. He is married with 2 children and retired from US Bank. FAMILY HISTORY: Significant for breast cancer of his maternal grandmother, mother, and aunt.
US|United States|U.S.|94|97|SOCIAL HISTORY|PAST SURGICAL HISTORY: None. FAMILY HISTORY: Unremarkable. SOCIAL HISTORY: He has been in the U.S. for the past nine years and lives with a girlfriend. He has two children back in Mexico. He denies tobacco use, alcohol use.
US|United States|U.S.|217|220|SOCIAL HISTORY|Father died at age 79 in his sleep of a "respiratory blockage." Review of the clinic records suggests that this was pulmonary embolism. SOCIAL HISTORY: The patient is married and has five adult children. He works for U.S. Furniture Service in charge of refurbishing furniture. He estimates two to three alcoholic beverages consumed daily of liquor. He smokes about a half pack of cigarettes daily now and has smoked since the age of 16.
US|UNSURED SENSE|US|240|241|PROCEDURES PERFORMED|PROCEDURES PERFORMED: 1. Coronary arteriography _%#MMDD2004#%_: Revealed acute instant thrombotic occlusion with incomplete loss of distal flow to the LAD, TIMI 3flow was zero. percutaneous coronary intervention (PCI) was performed with IV US and 2 drug eluting stents were placed, 1 proximal and 1 distal in the mid-LAD with good results. There was TIMI 3 flow post PCI, there was distal LAD disease that was not amenable to intervention.
US|United States|US|113|114|HISTORY OF PRESENT ILLNESS|The patient is divorced. She has been living with somebody, a friend. She has four grown children. She works for US Bank as a teller and has been there for several years. The patient enters Fairview Recovery Services at this time with an addiction to benzodiazepines.
US|United States|U.S.|162|165|HISTORY OF PRESENT ILLNESS|She describes her general health as good with a well controlled rheumatoid arthritis on Plaquenil and Relafen and hypertension. She has had no travel outside the U.S. in the last year and the only trip has been to California. She lives in an apartment. She has no exposures to pets or animals.
US|United States|U.S.|173|176|SOCIAL HISTORY|He works as a writer. He overall generally feels well and has no chronic medical problems. They have two pets at home, a dog and a cat. There has been no travel outside the U.S. FAMILY HISTORY: Unremarkable. REVIEW OF SYSTEMS: Vision without complaint. ENT: Without complaint. Respiratory: Without complaint.
US|United States|U.S.|129|132|SOCIAL HISTORY|2. Osteoarthritis. 3. History of migraines. SOCIAL HISTORY: Ms. _%#NAME#%_ is divorced, and has lived alone. She is retired from U.S. West. She is currently living with one of her daughters. FAMILY HISTORY: Mother had migraines and a stroke. ALLERGIES: Sulfa.
US|United States|U.S.|97|100|SOCIAL HISTORY|HABITS: Nonsmoker. MEDICATIONS: None. FAMILY HISTORY: Negative. SOCIAL HISTORY: She works at the U.S. postal service, computer. She is married. She has a child. REVIEW OF SYSTEMS: As above and otherwise negative cardiac, genitourinary, gastrointestinal, respiratory, integument, constitutional, heme, lymph, and endocrine.
US|United States|US|101|102|SOCIAL HISTORY|9. Metformin 1000 mg p.o. b.i.d. 10. Zocor 40 mg p.o. q.d. SOCIAL HISTORY: The patient works for the US Military as a marine engineer. History of polysubstance abuse in the past to prescription narcotics and history of cocaine use in the past.
US|United States|U.S.|127|130|SOCIAL HISTORY|Family history is positive for colon cancer and prostate cancer. SOCIAL HISTORY: Married, lives with her husband. She works at U.S. Bank. She does drink a little coffee but doesn't smoke, never has, but will have a rare drink. Little or no exercise. She does wear her seat belt.
US|ultrasound|US|213|214|DISCHARGE FOLLOW UP|During the 24 hours prior to discharge, she was breastfeeding well, and gaining weight. * Subgaleal hemorrhage: Significant soft tissue swelling and increasing OFC were concerning for subgaleal hemorrhage. A head US was performed but did not adequately visualize the scalp to definitely identify the hemorrhage as subgaleal. Initial hemoglobin was 13.4 and steadily declined to 9.5. Due to borderline hypotension and concern for possible ongoing hemorrhage, she received a transfusion of red blood cells.
US|United States|U.S.|171|174|FAMILY HISTORY/SOCIAL HISTORY|The patient's wife died many years ago of unknown cause. He is a nonsmoker. He retired as an inventory control specialist from some local manufacturing firm. He is also a U.S. Air Force veteran. He had three sisters; one died from complications of diabetes. He has one brother, who is alive and well, an older brother.
US|United States|U.S.|144|147|HISTORY OF PRESENT ILLNESS|DOB: _%#MMDD1922#%_ HISTORY OF PRESENT ILLNESS: This 80-year-old gentleman is a citizen of Taiwan, who spends several months of the year in the U.S. visiting his sons. He normally spends his winters in Taiwan. He is living with his son here in Minnesota currently. He was riding his bicycle when a car ran into him; he sustained a few minor abrasions and a bimalleolar fracture of the left ankle.
US|United States|U.S.|175|178|SOCIAL HISTORY|1. Right rotator cuff repair _%#MM#%_ 1992. 2. Foreign body removal left wrist _%#MM#%_ of 1993. SOCIAL HISTORY: The patient does not smoke. He is married. He has been in the U.S. for 20 years. He has children. He is from Southern India originally. He is currently doing assembly work at apothecary products in _%#CITY#%_.
US|United States|U.S.|282|285|PAST MEDICAL HISTORY|________________ subcapital fracture of the left hip. PAST MEDICAL HISTORY: 1) Previous right hip fracture in Copenhagen in 1985 and was cared for in that hospital. I did happen to be with her on a trip at that time and she was out of the hospital within a week and returned to the U.S. 2) The patient has glaucoma and has had some eye drops for that. 3) Elevated cholesterol, controlled by diet. 4) Actinic keratoses on the back.
US|ultrasound|US|236|237|HOSPITAL COURSE|The patient was instructed to have follow-up with Dr. _%#NAME#%_ _%#NAME#%_ as previously scheduled. The patient will also be followed by transplant coordinator. The patient was given numbers for the thoracic transplant coordinator and US Heart. She also had PRA antibody sent which were negative zero. The patient will follow-up with Dr. _%#NAME#%_ as previously scheduled.
US|United States|US.|196|198|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 30-year- old woman who has been experiencing right calf pain for the past two days. Her pain actually started before flying from Asia to the US. She was in Singapore on a business trip. She noted some pain in her right calf before the flight started. The pain has increased and she was seen in the office on the morning of admission.
US|United States|US|117|118|HISTORY OF PRESENT ILLNESS|The pain has increased and she was seen in the office on the morning of admission. She had taken a flight out of the US to Singapore approximately five days before this. On that flight she noted some soreness in her left leg. She has been on oral contraceptives and thinking about coming off the pill because of worries about her veins.
US|United States|U.S.|195|198|FAMILY HISTORY|She uses occasional alcohol and caffeine. FAMILY HISTORY: The patient's mother has a history of diabetes and obesity. The patient's father died at age 41 from lung cancer after having worked for U.S. Steel. REVIEW OF SYSTEMS: EYES: Review is negative for vision changes.
US|United States|US.|125|127|SOCIAL HISTORY|SOCIAL HISTORY: The patient chews tobacco. Social alcohol drinker. Works as an engineer of robots. Travels frequently in the US. He was last in Maryland. FAMILY HISTORY: Significant for mother with breast cancer and father with non-Hodgkin lymphoma.
US|United States|U.S.|211|214|REVIEW OF SYSTEMS|He has felt well. He says that he is swallowing better and better now but still has to take it easy on his diet. He said he has had a colonoscopy and he has been okay. He usually gets his healthcare through the U.S. Embassy in whichever country he happens to be in. ALLERGIES: None. MEDICATIONS: 1. Flomax 0.4 mg daily. 2. Zocor 20 mg daily.
US|United States|US|194|195|HOSPITAL COURSE|5. Social Work: Social work became involved in the patient's care in attempts to obtain a travel visa for the patient's mother who is living in Mexico. Attempts were made to mail letters to the US Embassy in Acapulco to obtain this visa for her. DISCHARGE INFORMATION: 1. Discharge date was _%#MM#%_ _%#DD#%_, 2006.
US|United States|U.S.|243|246|HOSPITAL COURSE|The patient was started on Sinemet. MRA provided an excellent study of the patient's distal intracranial vasculature and does show a somewhat distal MCA stenosis on the left. Currently there is no available stenting procedure available in the U.S. for such distal stenosis. Decision was made to continue medical management. Physical Therapy, Occupational Therapy, Speech Therapy, and PMNR were consulted; and short stay in Acute Rehab recommended by PMNR.
US|United States|U.S.|189|192|SOCIAL HISTORY|FAMILY HISTORY: States that her mother had arthritis. SOCIAL HISTORY: No tobacco, no alcohol, no drug use. She is married for 31 years. She has eight children, five of whom are here in the U.S. REVIEW OF SYSTEMS: Ten point review of systems was completed and she reports dry nose and mouth and chronic blurred vision.
US|ultrasound|US|191|192|LABORATORY DATA UPON ADMISSION|Urine was clear, protein 30 mg/dL. Large amount of leukocyte esterase with negative nitrites, white counts in the urine was 21 and red blood cells 10. Urine culture was pending on admission. US of abdomen negative. HOSPITAL COURSE: 1. Urinary tract infection. The patient was treated with ceftriaxone.
US|United States|US|163|164|SOCIAL HISTORY|HEALTH HABITS: No smoking for two weeks, prior to that 4-5 cigarettes a day. No alcohol use. SOCIAL HISTORY: The patient lives with his friend. He has been in the US for four years. He is currently unemployed. His family is here in the _%#CITY#%_ _%#CITY#%_. He also apparently has some family in _%#CITY#%_.
US|ultrasound|US|219|220|PLAN|Problems during the hospitalization included the following: 1. Neuro-Since it was thought that Rain's apnea was centrally mediated and she had other neurologic abnormalities (hypertonicity, high pitch cry, ect), a head US was performed on day of life #1, which was normal. Neurology was consulted and had recommended a head CT and head MRI, which were both normal.
US|United States|US|157|158|SOCIAL HISTORY|He owns his own business and still works part time. He has three kids; most of them are in the area. He lost a 27-year-old son to a lightening strike at the US Open back in 1991, the same year his first wife died of brain cancer. He has recently traveled south with his family, where he picked up over ten pounds; he said he drank a lot of alcohol.
US|United States|U.S.|146|149|SOCIAL HISTORY|She has no children. She is not a smoker. She does not consume alcohol. She lives alone at home in _%#CITY#%_ _%#CITY#%_, Minnesota. She works at U.S. Bank in downtown _%#CITY#%_. PHYSICAL EXAMINATION: GENERAL: Alert, awake and oriented x 3. She appears slightly uncomfortable but in no acute distress.
US|United States|US|158|159|SOCIAL HISTORY|He is not currently working. He had previously worked at the Goodwill in _%#CITY#%_ _%#CITY#%_. He aspires to be a truck driver. The patient emigrated to the US from Kenya in 2003, lived initially in _%#CITY#%_. PAST MEDICAL HISTORY: 1. Seizure disorder, recurrent breakthrough seizures.
US|United States|U.S.|194|197|SOCIAL HISTORY|SOCIAL HISTORY: The patient I believe is widowed. She has one daughter who looks after her. She grew up in Russia, was there throughout the war and has immigrated I believe more recently to the U.S. She speaks primarily Russian. Her daughter can interpret though FAMILY HISTORY: Really unremarkable. REVIEW OF SYSTEMS: HEENT: Vision without complaint.
US|ultrasound|US|177|178|PLAN|Problem #8: Renal. _%#NAME#%_ had a renal ultrasound on _%#MMDD#%_, which revealed bilateral mild hydronephrosis. She had no urinary tract infections. She had a follow-up renal US on _%#MMDD#%_, which revealed persisting prominence of renal collecting systems, with no change compared to _%#MMDD#%_. VCUG is recommended and should be completed at your discretion.
US|United States|US|174|175|ASSESSMENT|Would recommend rechecking the hemoglobin to be sure there is no significant drop and obtaining a echinnococcal serology given the patient's history of recent immigration to US as well as the CT appearance. Also will obtain an infectious disease consultation for their input.
US|United States|US|207|208|PAST MEDICAL HISTORY|4. Fractured lower back as above. SURGERY: 1. Skin graft procedure of right hand at age 34 due to a significant burn injury. 2. Tonsillectomy as a child. 3. Left hernia repair with incarcerated bowel in the US Army at age 19 4. Two orthopedic surgeries as above. 5. Right meniscectomy at age 39. 6. Orchiectomy on the left side secondary to an undescended left testicle.
US|ultrasound|US|224|225|DISCHARGE DIAGNOSES|2. Flexible sigmoidoscopy performed on _%#MMDD2007#%_. Findings: Diffuse pseudomembranous colitis was found in the sigmoid colon and in the descending colon. Biopsies with cold forceps was performed. 3. Left upper extremity US on _%#MMDD2007#%_: Final dictation pending. Preliminarily, this showed a small cephalic vein thrombus. ADMISSION HISTORY: Please see the H&P that I dictated on _%#MMDD2007#%_ for complete details.
US|ultrasound|US|287|288|HOSPITAL COURSE|A pulmonary consult was placed prior to possible colonoscopy. Pulmonary Consult felt that colonoscopy could be performed if needed with minimal sedation. However, colonoscopy was not pursuedas outoined above Problem #3. Ovarian Cyst -likely benign in a woman this age but needs followup US in 2 menstral cycles. CONDITION ON DISCHARGE: Stable. DISCHARGE INSTRUCTIONS: PHYSICAL ACTIVITY: Up as tolerated.
US|United States|U.S.|183|186|REVIEW OF SYSTEMS|No numbness or weakness. No fever or chills. PERSONAL and SOCIAL HISTORY: He occasionally uses alcohol; he smokes an occasional cigar. He is married, has 3 children and works for the U.S. Post Office. PHYSICAL EXAMINATION: Alert, no acute distress. Temperature 98.2, pulse 62 and regular, respirations 16, blood pressure 156/98.
US|United States|U.S.|210|213|HISTORY|He is uncircumcised. Despite treating with antibiotics, there is no evidence of cellulitis or inflammation, and edema has been fairly persistent. He is southeast Asian in origin, but has been a resident in the U.S. for at least 20 years now. PAST MEDICAL HISTORY: 1. Type 2 diabetes diagnosed within the last year.
US|United States|U.S.|113|116|SUBJECTIVE|SUBJECTIVE: _%#NAME#%_ _%#NAME#%_ is a 53-year-old male from _%#CITY#%_. He works as an investment counselor for U.S. Bank. He lives alone in _%#CITY#%_. He enters Fairview Recovery Services at this time with a several year history of alcohol dependence.
US|United States|US|197|198|SOCIAL HISTORY|They live in California. The patient was in California from _%#MM#%_ _%#DD#%_ until one week ago. She has had no outside travel. She does not use any intravenous drug use and she immigrated to the US in 1978. REVIEW OF SYSTEMS: Constitutionally, she denies any fever or chills.
US|United States|U.S.|176|179|HOSPITAL COURSE|HOSPITAL COURSE: Please refer to Dr. _%#NAME#%_ _%#NAME#%_'s admission History and Physical. Briefly, _%#NAME#%_ _%#NAME#%_ is a 64-year-old Egyptian female who is here in the U.S. to attend her daughter's wedding who is getting married this coming weekend. She reports being under a lot of stress arranging for this wedding.
US|United States|U.S.|213|216|SOCIAL HISTORY|The patient has been using sublingual nitroglycerin 1-2 tablets at least once or twice a week with improvement of her chest pain. SOCIAL HISTORY: She is from Russia, from the state of Georgia. She has been in the U.S. for the past twelve years. She has three sons. Denies tobacco or alcohol use. Drinks coffee occasionally. MEDICATIONS: Isosorbide mononitrate 60 mg b.i.d, aspirin 81 mg daily, Nitro-Quick p.r.n., spironolactone 50 mg daily.
US|United States|US|140|141|FAMILY, PERSONAL, AND SOCIAL HISTORY|He has had some sinus problems. FAMILY, PERSONAL, AND SOCIAL HISTORY: He is married and has a 13-year-old son. He is employed in finance at US Bank. Family history is positive for his parents being diabetic, and his father has arthritis. PHYSICAL EXAMINATION: GENERAL: This patient is 6 feet 4 inches, and 205 pounds.
US|United States|U.S.|168|171|HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE|3. Constipation. 4. Bradycardia. HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: The patient is a 76-year-old female, originally from Ethiopia who has lived her in the U.S. for more than a year. She has been generally healthy without any chronic medical problems or chronic medications. She presented to the Emergency Department yesterday for evaluation of headache.
US|ultrasound|US|199|200|PLAN|Antibody screening tests were negative. Bilirubin today is 4.2 and phototherapy was begun. Problem #6: At Risk for Intraventricular Hemorrhage. Baby Boy _%#NAME#%_ will need to have a screening head US at 7 days of age and again at one month of age. Problem #6: Access. Baby Boy _%#NAME#%_ had the following lines placed: umbilical arterial catheter (discontinued today) and double-lumen umbilical venous catheter (remains in place).
US|United States|US|207|208|SOCIAL HISTORY|2) History of back surgery with rods implanted. SOCIAL HISTORY: The patient lives alone, but remains close with his siblings (who are present in the Emergency Room) and his father. The patient works for the US Government in the Food Safety Department, and has held this position since _%#MM#%_ 2001. ALLERGIES: No known drug allergies. MEDICATIONS: Lithium 600 mg p.o. q.a.m. and 900 mg p.o. q.h.s. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 133/72.
US|United States|U.S.|145|148|SOCIAL HISTORY|He was not treated for H. pylori. He has no history of abdominal surgery. No known drug allergies. SOCIAL HISTORY: Significant for moving to the U.S. 4-5 months prior from South Africa. PHYSICAL EXAMINATION: His abdominal exam was significant for mild epigastric tenderness to deep palpation.
US|United States|US|115|116|TBA|DOB: _%#MMDD1951#%_ TBA: _%#MMDD2002#%_ _%#NAME#%_ _%#NAME#%_ is a 51-year-old white male purchasing agent for the US Navy. He is scheduled to undergo umbilical hernia repair on Wednesday, _%#MMDD2002#%_, by Dr. _%#NAME#%_ _%#NAME#%_. The patient presented to the clinic this morning complaining of some abdominal pain.
US|ultrasound|US|326|327|IMPRESSION AND PLAN|None of the results was positive. The course of the hyperbilirubinemia, despite the negative Coombs and peripheral smear, was felt to be most consistent with ABO or minor blood group incompatibility. Max bili was 18.9 on _%#MMDD#%_. Phototherapy was discontinued on _%#MMDD#%_. Bilirubin on discharge was 13.0 7. Neuro - Head US on _%#MMDD#%_ to negative for IVH. Clinically stable. 8. MS - Due to breech birth, consider hip US at 4 weeks age, or hip X- ray at 4-6 mo to evaluate for DDH.
US|United States|U.S.|121|124|SOCIAL HISTORY|SOCIAL HISTORY: The patient is originally from Somalia and several years in a refugee camp in Kenya before coming to the U.S. with her family. She does not smoke or drink alcohol. REVIEW OF SYSTEMS: According to husband she has been getting along fairly well, dialysis seems to be going satisfactorily.
US|United States|U.S.|183|186|PRIMARY DIAGNOSIS|PAST SURGICAL HISTORY: Vasectomy and tonsillectomy. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Smokes one pack per day since college age. Married and has children. Works for U.S. Steel as an engineer. Drinks an occasional beer socially. HOSPITAL COURSE: The patient was admitted to the hospital on _%#MM#%_ _%#DD#%_, 2004.
US|United States|U.S.|468|471|HISTORY|CHIEF COMPLAINT: Possible seizure. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 48-year-old white male with no significant medical history, not on any medications, with occasional sinus allergies, that have been bothering him for the past four to five weeks, but not on any medications for this, who presents to the hospital with a witnessed episode of possible seizure. The patient works in Kuwait in the oil refinery industry and works there five weeks and comes back to the U.S. for five weeks for a holiday. The patient had finished his five weeks here in the U.S. and was flying from _%#CITY#%_, Texas and en route had this episode of possible seizure.
US|United States|U.S.|193|196|HISTORY|The patient works in Kuwait in the oil refinery industry and works there five weeks and comes back to the U.S. for five weeks for a holiday. The patient had finished his five weeks here in the U.S. and was flying from _%#CITY#%_, Texas and en route had this episode of possible seizure. The patient states that he has had a fairly good visit and had an alcoholic drink before he got on.
US|United States|US|142|143|SOCIAL HISTORY|6) Toprol XL 100 mg daily. ALLERGIES: NONE TO MEDICATIONS. SOCIAL HISTORY: The patient is originally from the Philippines. He has been in the US 17 or 18 years. He has worked in electronic assembly. He is married. He lives with his wife. They have five children. He used to smoke until ten years or so ago.
US|United States|U.S.|255|258|HISTORY OF THE PRESENT ILLNESS|He has problems with urinary obstructive symptoms of frequent urination, however, no dysuria, no cloudiness to his urine. He has had no cough, no changes in his bowel habits, no sick contacts, no unusual exposure to pets or animals, no travel outside the U.S. He has had no unusual skin tears, he has not had any unusual exposures and he has had no recent dental or monitor surgical procedures.
US|United States|US,|246|248|ADMISSION HISTORY AND PHYSICAL|5. Placement of PICC line. ADMISSION HISTORY AND PHYSICAL: _%#NAME#%_ _%#NAME#%_ is a 65-year-old male with history of hypertension presented initially Thailand with his rectal bleeding and was diagnosed with rectal cancer. Upon returning to the US, rectal MRI revealed a T3 N0 lesion total of 16 cm in upper rectum. The patient decided to forgo new adjuvant chemoradiation and elected for resection.
US|United States|US|223|224|SOCIAL HISTORY|PAST MEDICAL HISTORY: No prior hospitalizations; prior diagnosis of major depression after 2 prior suicidal gestures. ADMISSION MEDICATIONS: None. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient came to the US from China in 2000, lives with her mother and stepfather and a 3-1/2-year-old brother with their maternal grandmother.
US|United States|U.S.|163|166|HISTORY  OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 56-year-old gentleman with no major medical problems in the past, is a citizen Moldova, residing now in the U.S. for at least five years. He is a construction worker by profession and has retired since the past three years. He has been divorced for at least 13 years, has a son and daughter who live in Minnesota but the patient lives alone.
US|United States|U.S.|352|355|SOCIAL HISTORY|He did have a chest x-ray back in _%#MM#%_ of 2007 which was a follow-up from an abnormal chest x-ray in the past which showed chronic elevation of right diaphragm which apparently was benign but there were incidental findings of two small lymph nodules. PAST SURGICAL HISTORY: None. SOCIAL HISTORY: He is a citizen of _%#CITY#%_, Russia living in the U.S. for the past five years. Retired for the past three years, a construction worker by profession, smokes, occasionally drinks alcohol.
US|United States|US|129|130|SOCIAL HISTORY|SOCIAL HISTORY: The patient is a nonsmoker. She drinks alcohol occasionally. The patient lives with a roommate. She had a job at US Bank in product advertisement management. REVIEW OF SYSTEMS: In general, the patient denies any weight loss, weight gain, fevers or chills.
US|United States|U.S.|148|151|SOCIAL HISTORY|Family history unremarkable. SOCIAL HISTORY: He is married, with two children. Tobacco denied. Alcohol: Two to three drinks per month. He works for U.S. Foods and is doing light duty at this time. PAST MEDICAL HISTORY: Medications: None. Allergies: None. Hospitalizations: Left ankle fracture surgery in _%#MM#%_ of 2002.
US|United States|U.S.|153|156|SOCIAL HISTORY|He does have a drink per night. He has a history of smoking but has not smoked for several years. No drugs. He is originally from Canada and came to the U.S. as a young man. REVIEW OF SYSTEMS: Cardiovascular - negative. He denies any chest pain, heart pain.
US|United States|U.S.|243|246|HISTORY OF PRESENT ILLNESS|She also has the complaint of polyuria and polydipsia and general malaise for a few days. Her social situation is complicated by the death of her father about 1 1/2 years ago secondary to myocardial infarction, with no family currently in the U.S. The patient has been in and out of multiple foster homes, and has a long-term history of non-compliance with meds.
US|United States|US|236|237|SOCIAL HISTORY|6. Vitamin D. 7. Os-Cal. DRUG ALLERGIES: DEMEROL, which caused nausea and vomiting and CAFFEINE, which causes palpitations. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Patient is widowed, lives alone in Rosemount. She works at the US Bank at an office job. She is a nonsmoker. She drinks one beer per month and has not had any recent alcoholic binges or recent alcohol ingestion.
US|United States|U.S.|177|180|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is 71-year-old woman who was in France in _%#MM#%_ and while walking incurred acute low back pain and when she returned to the U.S. she went to an urgent care and was given some Vicodin. She then followed up with her regular physician, Dr. _%#NAME#%_, who did further investigations including an MRI of the lumbar spine.
US|United States|U.S.|193|196|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This is a 16-year-old female who returned from Nigeria 2 weeks ago, where she had been living with her uncle for 5 years. She was born in Texas and had lived in the U.S. until 5 years ago. She had recently been doing well prior to this illness. She does report previous malaria episodes. PAST MEDICAL HISTORY: Negative except as above.
US|United States|U.S.|125|128|HISTORY OF PRESENT ILLNESS|Risk factors include age, hypertension, and hyperlipidemia. There is no family history of heart disease. He has lived in the U.S. since 1994. EKG - T waves inferiorly were down on some of the EKGs done today and flat on others.
US|United States|US|214|215|HABITS|HABITS: The patient was an occasional cigar smoker in the 1940's, but has not been a smoker for many years. The patient drinks alcohol on a social basis. He is physically active and exercises 4-5 times per week at US Swim and Fitness. ALLERGIES: Penicillin FAMILY HISTORY: Is remarkable for prostate cancer in the patient's brother.
US|United States|U.S.|113|116|SOCIAL HISTORY|He describes this as a fairly stressful, very demanding job with quite a bit of physical activity. He was in the U.S. Army between 1965 and 1972 and served over a year in Vietnam. MEDICATIONS: Atenolol 25 mg, Allegra 180 mg, Nasonex 2 puffs each nostril, all on a daily basis, plus ASA at least 325 mg daily.
US|ultrasound|US|125|126|1. FEN|Blood pressures have remained stable since this time. 4. NEURO: Ativan and morphine were used for agitation and pain. A head US was obtained on DOL #15 which showed a linear echogenicity in the thalamus The significance of the echodensity is not clear at this time, but a small hemorrhage cannot be ruled out.
US|United States|US|278|279|DISCHARGE DIAGNOSIS|The patient had AFB stains and AFB cultures. Preliminary AFB stains showed no acid-fast bacilli on the concentrated smear, and this was shown on 3 consecutive days of the smears. HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old female from Cambodia who emigrated to the US in 2001. The patient was admitted with a 3-day history of cough and new onset of hemoptysis with fever and chills and a sore throat.
US|United States|U.S.|148|151|HISTORY OF PRESENT ILLNESS|He had three of these fixed by Dr. _%#NAME#%_ _%#NAME#%_, beginning in the late 80s. Subsequently had one fixed in England. He then returned to the U.S. and had another repair done in 1999 by Dr. _%#NAME#%_. He had been doing well, but over the last couple of weeks began to notice some slight discomfort at the inferior portion of his incision, all of which is supraumbilical.
US|United States|U.S.|224|227|SOCIAL HISTORY|ALLERGIES: He has no known allergies. SOCIAL HISTORY: He is a long-term one pack per day smoker but quit about a year ago. He does not drink alcohol. He is married. He has six kids and is retired. He does volunteer work for U.S. Baseball Programs. REVIEW OF SYSTEMS: Mild hearing loss. Vision is fairly good. No respiratory complaints. No chest pains.
US|United States|U.S.|265|268|PLAN|Preoperative consultation was requested by Dr. _%#NAME#%_ for surgery this coming Wednesday, _%#MMDD2005#%_, regarding right ankle talus fracture, nonhealing; and cardiac status. _%#NAME#%_ _%#NAME#%_ is a very pleasant 53-year-old accountant, whose firm is in the U.S. Bank building in _%#CITY#%_. He has been suffering from a fractured right talus bone, which has been very slow to heal. He has tried immobilization and reduction of weight, without particular benefit to date.
US|United States|U.S.|113|116|SOCIAL HISTORY|She is an immigrant from Kenya who was reportedly married to her husband for about a year prior to coming to the U.S. No alcohol. No tobacco or IV drug use. She is employed at a bakery in _%#CITY#%_, Minnesota where she worked the 3-11 p.m. shift.
US|United States|US|242|243|SOCIAL HISTORY|She is pretty adamant that she is not taking her Maxzide, Flonase, or any other medicines that have been listed for her, including potassium. SOCIAL HISTORY: The patient is retired, allegedly an engineer, working for outdoor plant design for US West for many years. Two cups of coffee per day, no pop, half a glass of milk on cereal. No alcohol. She says she smokes about four cigarettes a day, chart indicates that she smokes much more than that.
US|United States|U.S.|197|200|SOCIAL HISTORY|He lives alone. He does not have any children of his own, however, he does have two stepsons, one in France and one in Arizona. He does not have any pets at home. He is retired from working at the U.S. Postal Service since 1986. FAMILY HISTORY: Mother with hypertension and coronary artery disease in her 80s.
US|United States|US|302|303|SOCIAL HISTORY|FAMILY HISTORY: Noncontributory. MEDICATIONS: Celebrex p.r.n., Tylenol she takes 1 tablet a day, blood pressure medicine and "a water pill" for lower extremity edema. SOCIAL HISTORY: Followed by Dr. _%#NAME#%_ _%#NAME#%_, North Memorial _%#CITY#%_ _%#CITY#%_ Clinic. Lives alone in an apartment in the US x12 years, speaks Ukrainian Russian only. She does not smoke or drink alcohol. No significant secondhand smoke history.
US|United States|US|124|125|SOCIAL HISTORY|She used to do childcare, however, is currently unemployed. She has 2 children in Utah and 2 in Mexico. She has been in the US for approximately 6-1/2 years. HEALTH MAINTENANCE: Her Pap smear in _%#MM2007#%_ was within normal limits.
US|ultrasound|US:|149|151|OPERATIONS AND PROCEDURES|Biopsy was done. Roux-en-Y surgery seen. No tear. Small intestine normal. EGD findings are consistent with likely related to gastritis. 2. Abdominal US: Nnormal with mildly echogenic kidney suggesting medical renal disease. No hydronephrosis. There could be complex cyst or solid lesion in the left kidney.
US|United States|U.S.|153|156|SOCIAL HISTORY|New med: Percocet 1-2 po q 4-6 hours prn, #20 dispensed. Senna-S 1-2 tabs bid while taking narcotics. SOCIAL HISTORY: The patient is an immigrant to the U.S. Her primary language is Oromo. She has several children that live abroad. She denies any tobacco, alcohol or drug use. FAMILY HISTORY: Unable to obtain/patient unable to recall.
US|ultrasound|US|239|240|DISCHARGE INSTRUCTIONS|After ther patient's workup was complete, and he remained afebrile on his antibiotics, and he was diet adequately, it was deemed he was ready to be discharged. DISPOSITION: To home. DISCHARGE INSTRUCTIONS: The patient will have a followup US performed within the next week. He will be called with the date and time. He will follow up with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2004. The patient will resume activity as tolerated.
US|United States|US|143|144|AMMENDMENT TO PREVIOUS DICTATION|I dictated the previous treatment that Mr. _%#NAME#%_ _%#NAME#%_ had received. Mr. _%#NAME#%_ was randomized for second-line chemotherapy in a US Oncology trial evaluating Taxotere and Pemetrexed and with a second randomization to observation or cetuximab. The original dictation had the agents Taxol, methotrexate, and rituximab which are incorrect.
US|United States|US.|159|161|SOCIAL HISTORY|She is a Cambodian immigrant since 1983. She is legally separated, was married for only 2 years. She has no children. She has 6 sisters who are now all in the US. No brothers. Parents are not living. She works as a patient advocate at the University Minnesota Community Heath Center.
US|United States|US|162|163|SOCIAL HISTORY|12. Glucosamine chondroitin one p.o. daily. 13. Vitamin B12 1 gm p.o. daily. SOCIAL HISTORY: The patient is chairman of Bachman's Florist. He is a Veteran of the US Air Force and was a B24 Bomber Pilot during World War 2. He does not smoke. He is married. FAMILY HISTORY: Positive for hypertension in mother, who also had coronary artery disease.
US|United States|US|138|139|PAST MEDICAL HISTORY|Her energy level is significantly lower and she has been sleeping more than usual. PAST MEDICAL HISTORY: The patient was born here in the US via term vaginal delivery. Mother had a GBS infection and there is some question of the infant having some sepsis at birth.
US|ultrasound|US|167|168|PERTINENT IMAGING PERFORMED DURING THIS ADMISSION|PERTINENT IMAGING PERFORMED DURING THIS ADMISSION: 1. Chest x-ray dated _%#MMDD2006#%_. Impression: Chronic changes of cystic fibrosis, no acute pulmonary process. 2. US abdomen, dated _%#MMDD2006#%_. Impression: No acute intraabdominal pathology. Abdomen is flat and upright, dated _%#MMDD2006#%_. Large amount of stool in the colon, no obstruction or free air.
US|United States|U.S.|158|161|SOCIAL HISTORY|The rest of the ROS is negative. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Married. He does not smoke. He is originally from Syria but has been in the U.S. for many years. Prior to dialysis, he operated a convenience store in _%#CITY#%_, which he subsequently sold. PHYSICAL EXAMINATION: GENERAL: 64-year-old man is seen in his hospital bed at Fairview Southdale Hospital.
US|ultrasound|US|122|123|DISCHARGE INSTRUCTIONS|17. Oxygen at 1.5 liters p.r.n. with activity at home. DISCHARGE INSTRUCTIONS: 1. The patient needs to follow up with the US study on Friday at Abbott Northwestern Hospital as scheduled with Dr. _%#NAME#%_ at 11:30 p.m. 2. The patient needs to follow up with his primary care next week with a basic metabolic panel, Dr. _%#NAME#%_.
US|United States|US|145|146|SOCIAL HISTORY|PAST MEDICAL HISTORY: See above. ALLERGIES: Dust and tree pollen. MEDICATIONS: Omeprazole 20 mg b.i.d. SOCIAL HISTORY: The patient is working at US Bank. He is single. He does not smoke. Drinks a couple of times a week but no excessive alcohol consumption and denies alcohol consumption since discharge from the hospital.
US|ultrasound|US|204|205|KEY IMAGING STUDIES AND PROCEDURE PERFORMED DURING THIS HOSPITALIZATION|The right ventricle was mild to moderately dilated. Mild decreased right ventricular systolic function. 3. Renal ultrasound on _%#MMDD2007#%_. Impression: Normal renal ultrasound. 4. Bilateral LE doppler US on _%#MMDD2007#%_. No DVT. ADMISSION HISTORY: Please see the H&P by Dr. _%#NAME#%_ on _%#MMDD2007#%_ for complete details. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was admitted with tachycardia.
US|United States|US|146|147|SOCIAL HISTORY|He had been working in the food service industry, however, was laid off as the contract was lost. He is originally from Kenya. He has been in the US at least eight years. He denies any recent travel history. FAMILY HISTORY: Is noncontributory, specifically no history of gout.
US|United States|US|107|108|SOCIAL HISTORY|The patient has never been intubated. ALLERGIES: No known drug allergies. SOCIAL HISTORY: She moved to the US about eight years ago with five children. No pets. She does not smoke cigarettes or drink alcohol. She denies other illicit drug use.
US|United States|U.S.|189|192|FAMILY HISTORY/SOCIAL HISTORY|FAMILY HISTORY/SOCIAL HISTORY: He is married. He has been a volunteer for many years at Fairview Ridges Hospital. He is also retired from the postal service and he was a paratrooper in the U.S. Army. ALLERGIES: He has no known allergies. MEDICATIONS: 1) Prednisolone - originally 10 mg a day, now 5 mg.
US|United States|U.S.|160|163|SOCIAL HISTORY|His father owns a Chinese restaurant. He was born in the U.S. and then has been living with his grandmother in China for the past 2 years. He moved back to the U.S. about 2 months ago. REVIEW OF SYSTEMS: Review of systems as per the history of present illness, no rashes, but he does have some dry and itching skin at times.
US|United States|US|191|192|SOCIAL HISTORY|Dad with colon cancer at 60s and asthma. Paternal grandmother with pancreas cancer. Maternal grandmother is a smoker. SOCIAL HISTORY: No tobacco. Occasional alcohol but no drugs. He works at US Bank. He is married. REVIEW OF SYSTEMS: Negative for bleeding or previous anesthesia problems.
US|United States|U.S.|301|304|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ as well known to me as a kind but unfortunate 51-year-old white female with a diagnosis of metastatic colorectal carcinoma (with known liver metastasis) on admission _%#MMDD2006#%_. _%#NAME#%_ was initially treated with FOLFOX 6 plus Avastin chemo biotherapy on U.S. Oncology Clinical Trial 05009, but ultimately discontinued her care and was lost to follow up for a period of 2 months while she was seeking second opinions at outside oncology clinics.
US|ultrasound|US|278|279|FOLLOW UP|Straight catheterization returned 90 mL of dark urine. UA was significant for trace protein, 2-5 hyaline casts, few epithelial and renal tubular epithelial cells, and few amorphous phosphate crystals. Culture results were negative. BUN 8, creatinine 0.55, Na and K WNL. A renal US was performed and demonstrating only bladder distension without hydroureter or hydronephrosis. Urology was consulted, and _%#NAME#%_ was transferred to the NICU for placement and management of a foley catheter.
US|United States|U.S.|188|191|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Light-headed, dizzy and black stools. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 63-year-old female who is originally from Cambodia. She moved here to the U.S. 23 years ago. She currently lives in _%#CITY#%_, California, and is visiting her family here. She was due to return to California in 4 days.
US|United States|U.S.|195|198|PAST MEDICAL HISTORY|This bone biopsy showed a granulomatous inflammatory lesion, which was suspicious for tuberculosis osteomyelitis. PAST MEDICAL HISTORY: He was born in Somalia and immigrated through Kenya to the U.S. He did have a positive PPD upon immigration here in _%#MM2006#%_ and completed 9 months of INH for latent TB. There is notable history that he did have malaria at age 14 years old.
US|ultrasound|US|193|194|HISTORY OF PRESENT ILLNESS|His hospital course was fairly unremarkable except for acute-on-chronic renal failure with peak creatinine of 2.0 and minimal oropharyngeal dysphagia. His baseline creatinine is 1.4-1.7. Renal US suggested medical renal disease. He was hydrated with IV fluids with complete resolution of his renal failure. Creatinine is back to baseline of 1.7. His blood pressure was an issue but he responded appropriately to antihypertensive medications.
US|ultrasound|US|148|149|TREATMENT PLAN AND RECOMMENDATION|This was then discussed more at length and in detail. All his questions were answered. Patient consents to proceed with prostate brachytherapy with US and fluoro guidance. Patient received preoperative XRT prior to brachytherapy; this to reduce risk of tracking the cancer cells along the needle path.
US|United States|US|123|124|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a pleasant 50-year-old white male, a US Customs Service Agent at the airport. First Fairview Ridges admission, the patient noted yesterday when he got home from work around 7:00 that he had some vague right lower quadrant abdominal pain.
US|ultrasound|US,|119|121|HOSPITAL COURSE|On the CT scan, there is still some fullness in the wall of the distal esophagus, and there was some thickening on the US, as well as minimal activity on PET scan. There was no evidence of distal metastases. ________________ on pre-treatment EUS have resolved.
US|United States|US|275|276|SOCIAL HISTORY|Home medications, no regular medications (she has been using Vicodin, since the _%#MM#%_ _%#DD#%_, 2005). ALLERGIES: No known drug allergies. FAMILY HISTORY: Uncertain. SOCIAL HISTORY: She is a Somalian female, who has been living in Kenya for the last 15 years, came to the US along with her husband and 5 grown children on _%#MM#%_ _%#DD#%_, 2005. She is living with her step-son currently, and she is a home maker.
US|United States|U.S.|175|178|SOCIAL HISTORY|11. Ambien 10 mg in the evening. ALLERGIES: None. PAST SURGICAL PROCEDURES: None. SOCIAL HISTORY: He is a nonsmoker. Rarely drinks alcohol. Caffeine occasional. Works for the U.S. Post Office in Deliveries. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: His weight has been stable. His general energy level has improved from two years ago.
US|United States|US|232|233|HISTORY OF PRESENT ILLNESS|The patient will follow up with Smiley's Clinic on _%#MM#%_ _%#DD#%_, 2005 for the level as well as for PPD read was placed on _%#MM#%_ _%#DD#%_, 2005. HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old female who came to the US from Kenya 3 days ago. This morning at 8 a.m. she began to start having seizures which did not stop. They were grand mal, they were generalized tonic clonic, and she was brought to the ER after having seizures for a total of 7 hours per family.
US|United States|US|148|149|SOCIAL HISTORY|ALLERGIES: MORPHINE-Gives her hives and itching. SOCIAL HISTORY: The patient does not smoke or drink. She has 8 children and has been living in the US for the last 2 years. She is originally from Somalia. ADMISSION MEDICATIONS: 1. Protonix 40 mg b.i.d.
US|United States|U.S.|123|126|SOCIAL HISTORY|SOCIAL HISTORY: The patient denies any tobacco, alcohol or illicit drugs. He lives in _%#CITY#%_, Minnesota. He works as a U.S. Customs and Border protection officer. FAMILY HISTORY: Father had coronary artery disease at age 50.
US|United States|U.S.|184|187|SOCIAL HISTORY|ALLERGIES: Noted to aspirin, penicillin. She had adverse reaction to Coreg; she did not tolerate a trial of this. SOCIAL HISTORY: She is a widow. She is Vietnamese and has been in the U.S. for 20 years. She does not drink or smoke. FAMILY HISTORY: Parents died of old age. REVIEW OF SYSTEMS: See history of present illness above. In addition, no nausea, vomiting, fever, chills, chest pain, abdominal pain.
US|United States|U.S|136|138|PLAN|We will have some Robitussin-AC available for cough. We will continue her metoprolol and Cozaar. The dose of clonidine available in the U.S a slightly different than what she gets in Columbia, so we will substitute the 150 mcg twice daily with 100 mcg 3 times daily.
US|United States|US|122|123|SOCIAL HISTORY|Also he said his wife lives in ______________ and after being married 10 years ago, he said he could not bring her to the US because he did not fill out any paperwork. That story is a little odd and he is not a good story giver. MEDICATIONS: The patient does not take any medications. PHYSICAL EXAMINATION: GENERAL: The patient alert and well oriented.
US|United States|US,|212|214|HISTORY OF PRESENT ILLNESS|The patient returned 3 weeks ago from a trip to Somalia where they had stayed for 1-1/2 years on vacation. She had lived in Minnesota prior to her trip to Africa. Just prior to leaving Africa to come back to the US, _%#NAME#%_ came down with an illness which mom describes as tonsillitis with vomiting, fever and stomach ache. She did go to a doctor in Africa and received some antibiotics.
US|United States|U.S.|162|165|SOCIAL HISTORY|5. Hyperlipidemia. 6. GERD. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient is married, lives with her husband. She is a Laotian immigrant, moved to U.S. in 1980. She smokes tobacco, half pack per day. No alcohol or drug use. MEDICATIONS: 1. Plavix 75 mg/day 2. Lipitor 40 mg/day.
US|United States|US|198|199|SOCIAL HISTORY|8. Status post right shoulder arthroplasty. 9. Status post left knee arthroplasty. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: He is a nonsmoker, social drinker. He currently still works at US Bank part-time. FAMILY HISTORY: Unremarkable. REVIEW OF SYSTEMS: Negative for any angina or anginal equivalence.
US|United States|U.S.|188|191|SOCIAL HISTORY|She was able to immigrate to the U.S. in 1995 directly and her son, who is with her today, was only able to come here in 2003. She has 2 children remaining in Cambodia and 5 living in the U.S. Finished fifth grade and speaks very little English and is able to read Cambodian somewhat. MEDICATIONS: 1. Lasix 20 mg q a.m. 2. ASA 81 mg q a.m.
US|ultrasound|US|199|200|PLAN|He had intermittent tachypnea but remained on room air with O2 sats greater than 95%. He was tolerating oral feeds. He also had hyperbilirubinemia which resolved with UV lights. He had a normal head US on _%#MMDD2002#%_ and a normal abdominal US on _%#MMDD2002#%_. _%#NAME#%_ was transferred to the Fairview-_%#CITY#%_ NICU on _%#MMDD2002#%_ for further cardiovascular observation with a possible need for cardiovascular surgery if unstable.
US|United States|US|203|204|SOCIAL HISTORY|PAST MEDICAL HISTORY: Otherwise very benign. He has no known other medical problems and is not on other treatment or medications. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: He is married, works at US Bank, has two children, ages 12 and 8. He doesn't smoke and uses no alcohol. ALLERGIES: None known. REVIEW OF SYSTEMS: Was not possible in this intubated sedated man.
US|United States|U.S.,|157|161|1. FEN|Their father is in Yemen, and their parents have not seen each other in about 7 months. Their mother is unsure when their father will be able to come to the U.S., though she thinks it may be in the next few months. 2. Anemia: _%#NAME#%_ will need to be on iron supplementation.
US|United States|US|99|100||Mr. _%#NAME#%_ _%#NAME#%_ is a 53-year-old gentleman who recently arrived here from Egypt. He is a US citizen. He has bi-citizenship and travels between Egypt and the United States quite frequently. He is back from the Egypt and looking for a job here in the States.
US|United States|U.S.|113|116|HISTORY OF PRESENT ILLNESS|Prior to his trip to Nebraska and in the weeks preceding that, he had also been on a trip to the far west of the U.S. with a 23-hour drive that was a round trip. Has had a history of pulmonary emboli in the past when he was actually in the hospital for a back fusion surgery, spinal fusion surgery, developed a few days after surgery.
US|ultrasound|US|118|119|CONSULTS|CONSULTS: None. CT scan chest _%#MMDD2007#%_ shows a definite small subsegmental pulmonary embolus on the right side. US scan of lower extremities was negative. bhcg test negative. Urinalysis negative. TSH 1.9. Lipase 35. BNP 21. Troponin less than 0.04. EKG shows normal sinus rhythm and no axis deviation, no evidence of tachycardia.
US|ultrasound|US|184|185|DISCHARGE DIAGNOSES|2. Gallstones. Coincidental finding of gallstones in the gallbladder with an enlarged common bile duct to approximately 12 mm, as well as benign kidney cysts and diverticular disease. US reveals a 2 cm gallstone in the gallbladder no GB wall thickening, fluid or tenderness. 3. Uterine fibroids. Coincidental finding of uterine fibroids on CT scan.
US|United States|U.S.|102|105|SOCIAL HISTORY|Denied any problems with depression in his family. SOCIAL HISTORY: The patient is retired, working as U.S. West Cable maintenance. He has 12th grade level of education. He is divorced once and he is presently married and he has 3 biological children of his own.
US|ultrasound|US|156|157||My key findings: CC:Abd pain HPI:24 yo woman with abd pain. Pt had a daughter 4 weeks ago. She has had sudden onset RUQ abd pain for the last 1-2 days. RUQ US showed dilated common bile duct. No fevers, chills, N/V. PMH, FH, SH, ROS as per resident note. Exam: VSS as per EMR Gen:NAD Pulm:CTABL CV:nl s1s2 no m/r/g brady Abd:soft nt/nd nl bs Labs, radiology studies, and medications reviewed.
US|United States|US|130|131|HISTORY OF PRESENT ILLNESS|The patient tells me that he was flying from _%#CITY#%_, Netherlands to the United States earlier this morning at about 4 o'clock US standard time in the morning. He was served some meals on board, after that soon thereafter he started developing extreme significant amount of nausea, which was associated with some substernal pressure discomfort, also followed by lots of diaphoresis and sweating.
US|United States|U.S.|241|244|HISTORY OF PRESENT ILLNESS|She received 2 doses of doxorubicin, ARA-C in Cambodia, however, it turned out that it seems _____ (1:50) her doses for the chemotherapy were inadequate. Her repeated bone marrow biopsy revealed 43% of blasts, so since then she moved to the U.S. for treatment on _%#MMDD2006#%_. She began with idarubicin plus ARA-C 7+3. A repeated bone marrow biopsy on day 14 revealed 7% blasts, so she received second induction chemotherapy with mitoxantrone, VP/16 on _%#MMDD2006#%_.
US|ultrasound|US|227|228|HOSPITAL COURSE|The patient had a repeat CT of the abdomen, which showed area on the right kidney consistent with pyelonephritis and some mild bilateral pleural effusions and a question of some fluid around the gallbladder. Followup abdominal US the next day was normal, except for the previously noted bilateral pleural effusions. The patient tests in the hospital included check for C. diff., which was negative.
US|ultrasound|US|170|171|DISPOSITION|She was scheduled for another bilirubin check _%#MMDD2007#%_. Problem #4: Intraventricular Hemorrhage. _%#NAME#%_ was born at less than 34 weeks, so she will need a head US at 1 week of age. This has not yet been done at time of transfer. Problem #5: Retinopathy of Prematurity. A baby born <32 weeks and/or <1500 grams should have their first eye exam at 4-7 weeks of age.
US|United States|U.S.|145|148|SOCIAL HISTORY|2. Levofloxacin 500 mg PO Q day He has NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: This gentleman is a retired Ford auto mechanic. He served in the U.S. Military in World War II, was a tank driver in an M5 light Stewart tank. He did not see any combat in Africa secondary to a ruptured right tympanic membrane.
US|United States|U.S.|124|127|SOCIAL HISTORY|CABG in 1998. SOCIAL HISTORY: The patient is single and has no children. He lived in Korea for 23 years and returned to the U.S. in 1998. History of 15- pack-per-year history of smoking. He still smokes occasionally. His alcohol consumption, in the past, was 4 ounces of hard liquor per week, but presently not drinking.
US|United States|U.S.|156|159|DOB|He did take some sulfa for two days a couple of days ago. The patient has a history of remote tonsillectomy and appendectomy. He has been a resident of the U.S. for 11 years. The car accident occurred at _%#CITY#%_ _%#CITY#%_ _%#CITY#%_, Wisconsin ten years ago. The patient is married and lives with his wife. The patient is a nonsmoker.
US|United States|US|122|123|SOCIAL HISTORY|ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient uses no alcohol or tobacco. She works as a researcher for US Bank. Positive regular exercise. No recent trauma. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Review of systems is negative for constitutional, ID, HEENT, cardiovascular, respiratory, upper gastrointestinal, genitourinary, musculoskeletal, neurologic, or dermatologic symptoms.
US|ultrasound|US.|157|159|FOLLOWUP CARE|He was withdrawn from support on _%#MMDD2003#%_. The mother's pregnancy was complicated by GBS positive status. By mother's report, she had a normal 20-week US. The infant was delivered NSVD with Apgar scores of 1 at one minute , 4 at five minutes, and 7 at 10 minutes. There was some reported polyhydramnios. _%#NAME#%_ was a term male infant, 3765 gm at 38 5/7 weeks gestation, with a length of 51 cm and head circumference of 35.5 cm.
US|ultrasound|US|234|235|1. FEN|He was supported with TPN during this time. Since _%#MMDD2004#%_ he tolerated BF+ENFAMIL20 with iron very well. 2. Renal-The initial creatinine-1.9, BUN-21 on admission, this improved significantly after 2 days, _%#MMDD2004#%_-.Renal US was done which showed no abnormalities. The Bun and Cr had normalized by the time of discharge. Bun 5. Cr 0.83. It was unclear the etiology of the initial elevations, but they may have been due to decreased renal blood flow associated with the mild polycythemia.
US|United States|U.S.|163|166|SOCIAL HISTORY|8. Etodolac 9. Advair. SOCIAL HISTORY: She is widowed. Her husband died in a civil war in their country in Africa. She has multiple children that live here in the U.S. and in Africa and divides her time between them. She is not a smoker, does not drink alcohol. REVIEW OF SYSTEMS: CONSTITUTIONAL: She denies fevers, chills, change in weight.
US|United States|US|122|123|CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS|Upon having chest tightness today, he presented to Smiley's Clinic, where he was instructed to go the ED. He moved to the US 4 months ago and was on antihypertensive outside. ALLERGIES: No known drug allergies. MEDICATIONS: Lisinopril/hydrochlorothiazide. SOCIAL HISTORY: Moved to Minnesota 4 months ago.
US|GENERAL ENGLISH|US,|331|333|AFTER DICTATING THE DISCHARGE FOR THIS ADMISSION ON|FOR THIS REASON, ALL FUTURE QUESTIONS REGARDING THIS PATIENT ARE TO BE DIRECTED TO Dr. _%#NAME#%_ _%#NAME#%_'S OFFICE, NOT TO OXBORO CLINIC. DESPITE THE FACT THAT THE PATIENT IS COMPETENT TO MAKE HER OWN DECISIONS, AND CHOSES TODAY TO NOT HAVE FURTHER HOSPITALIZATIONS, SHOULD SHE AT SOME POINT IN THE FUTURE RESCIND THAT ORDER TO US, SHE SHOULD NOT BE ADMITTED TO THE OXBORO CLINIC SERVICE AS SHE IS A PATIENT OF Dr. _%#NAME#%_'S.
US|United States|U.S.|118|121|SOCIAL HISTORY|SOCIAL HISTORY: He is married. He was born in Australia, lived in England until 1949, then has been in Canada and the U.S. since. He does not smoke or drink and stays fairly active. REVIEW OF SYSTEMS: Otherwise negative throughout including cardiovascular, pulmonary, GI, and GU.
US|United States|US.|195|197|HISTORY|I saw the patient on _%#MMDD2003#%_ at which time she had mentioned about a one week history of a fairly non-specific febrile illness. This occurred while she was on vacation in the southeastern US. She had symptoms of nausea, vomiting, chills, fever, and then had some slight discomfort under the right axilla with slight cough.
US|United States|US|146|147|SOCIAL HISTORY|SOCIAL HISTORY: She smoked for 20 years; however, has recently stopped smoking. Caffeine: One pop per day. Alcohol: Rare. She presently works for US Bank. ALLERGIES: Penicillin and cephalosporin cause hives. MEDICATIONS: Nexium 40 mg daily, and Yasmine oral contraceptive.
US|United States|US|130|131|SOCIAL HISTORY|SOCIAL HISTORY: This is, I believe, Mung female, I am not sure from the evaluation or Vietnamese but is living with family in the US now. She does not smoke. She uses no alcohol. She lives with her husband and two daughters. FAMILY HISTORY: Really unobtainable. REVIEW OF SYSTEMS: With the interpreter.
US|United States|U.S.|168|171|HISTORY OF PRESENT ILLNESS|DOB: _%#MMDD2006#%_ CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 36-year-old female originally from Vietnam. She has been in the U.S. for 14 years. She presents with 2-3 weeks of left-sided chest pain radiating to her left shoulder and somewhat to her left upper extremity.
US|United States|US|191|192|SOCIAL HISTORY|SOCIAL HISTORY: Nonsmoker. No alcohol use. Occasional caffeine use with ice tea. Has been married for 22 1/2 years. Children - _%#NAME#%_ 18, _%#NAME#%_ 15, and _%#NAME#%_ 12 1/2. Banker for US Bank Corporation. Senior credit officer real estate. FAMILY HISTORY: Father died of a cerebral hemorrhage. Negative otherwise for cancer.
US|United States|U.S.|145|148|ADMISSION HISTORY|PAST OB HISTORY: In 1992, she had a cesarean section in Iran. In 1996, she underwent a vaginal birth after cesarean without complications in the U.S. GYN HISTORY: She has monthly periods. No STDs or PID history. No abnormal Paps. PAST MEDICAL HISTORY: Negative. PAST SURGICAL HISTORY: Cesarean section. ADMISSION MEDICATIONS: No medications. ALLERGIES: No allergies.
US|United States|U.S.|241|244|STAFF ADDENDUM|More recent, subcutaneous metastasis was resected and since then the patient has gone on to develop further evidence of progression. Because of this, a Port-A-Cath was placed and yesterday he was started on further Salvage chemotherapy on a U.S. Oncology study, receiving Taxotere and either Apotsyn or placebo, given orally. The patient had started the study drug on Monday and then received the Taxotere yesterday.
US|United States|U.S.|203|206|SOCIAL HISTORY|3. Nexium 4. Fosamax 5. Levaquin ALLERGIES: No known drug allergies, until recently a rash caused by Leukine. SOCIAL HISTORY: She is a non-smoker or drinker. Married, lives with her family. Retired from U.S. Army office work. FAMILY HISTORY: Her father had cardiac problems as well as her mother.
US|United States|US|226|227|DISCHARGE DIAGNOSIS|C spines were negative and a troponin was negative. She was given 1 liter of normal saline and Toradol for her headache. She went to a wedding on Saturday and she got a little bit dehydrated. She has had no travel outside the US since 1985. SOCIAL HISTORY: She has a dog and 2 cats. PHYSICAL EXAMINATION: On admission, significant for a temperature of 98.6, pulse 75, blood pressure 129/70, respiratory rate 16, sats 100% on room air.
US|United States|US|105|106|SOCIAL HISTORY|No children, no known history of bleeding diathesis or anesthesia reactions. SOCIAL HISTORY: Came to the US one year ago was doing nails as a shop. Married. REVIEW OF SYSTEMS: No chest pain or shortness of breath.
US|United States|U.S.|128|131||He states recently he was in Sri Lanka which he is originally from. He was there for the past couple weeks. He came back to the U.S. last Friday and noted that today is Wednesday. He noticed since he was back home in Sri Lanka, he notices increasing amount of abdominal pain.
US|United States|US|210|211|DISCHARGE DIAGNOSIS|On _%#MM#%_ _%#DD#%_ she returned to Haiti. At that time, she developed increased thirst, jaundice, right upper quadrant pain, night sweats, and malaise. She presented to an outside hospital upon return to the US on the _%#DD#%_ for recurrent symptoms. She had more procedures done up there, had an ultrasound which showed a thickened gallbladder and a CT scan which showed abnormally thickened wall of the transverse colon, abnormal gallbladder surrounded by fluid, a horseshoe kidney, a small amount of free air in the pelvis.
US|United States|U.S.|232|235|SOCIAL HISTORY|No regular scheduled medications. ALLERGIES: No known drug allergies. FAMILY HISTORY: Remarkable for two brothers with asthma and a sister with migraine headaches. SOCIAL HISTORY: She is originally from Mexico, she has lived in the U.S. for about twenty years but often travels back and forth between here and Mexico. She is here with her boyfriend who helps interpret. REVIEW OF SYSTEMS: No cardiac symptoms, no pulmonary symptoms, GI symptoms of nausea and vomiting as mentioned above, as well as significant nonsteroidal anti-inflammatory medication use.
US|United States|US|172|173|PROCEDURES PERFORMED|ADMISSION MEDICATIONS: Prenatal vitamins. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient denied alcohol, tobacco or illicit drug use. The patient works at US Bank. ISSUES THIS PREGNANCY: Close spacing. The patient's last delivery was in _%#MM#%_ 2002. The patient also had infrequent prenatal care.
US|United States|U.S.|146|149|SOCIAL HISTORY|7. History of trigeminal neuralgia. 8. Cataract. 9. Status post hernia repair. 10. History of hepatitis in 1943 in Italy. SOCIAL HISTORY: Retired U.S. Air Force engineer. He is a non- smoker. No alcohol. Daily workout and walking. FAMILY HISTORY: Positive for breast cancer in his mother. Negative for colon cancer and hypertension.
US|ultrasound|US|162|163|ASSESSMENT|Initially, the goal was to encourage bladder training by clamping and unclamping the catheter every 6 hours. By DOL #30, the catheter was removed. A repeat renal US was performed just prior to discharge and was within normal limits. 2. Musculoskeletal: A pelvic x-ray was done and revealed abnormalities in the connections between the pubic bones.
US|United States|U.S.|162|165|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ _%#NAME#%_ is a pleasant 41-year-old Hindu priest from India. He speaks some English, but his niece is helping to translate. He is visiting in the U.S. and developed a spontaneous hemorrhagic stroke on _%#MM#%_ _%#DD#%_, 2005. He was treated at _%#CITY#%_ Clinic. According to his niece and the patient, he did not require any intervention.
US|United States|U.S.|217|220|SOCIAL HISTORY|SOCIAL HISTORY: The patient is a former heavy smoker who has abstained from tobacco since his surgery two months ago. He is a former drinker who has not consumed alcohol for three years. He formerly was employed as a U.S. Food Service worker, although he has not been able to work since this summer. He is single. REVIEW OF SYSTEMS: GENERAL: He denies any unexplained fever, chills or weight loss.
US|United States|US|139|140|SOCIAL HISTORY|FAMILY HISTORY: Her father died of complications of diabetes, but otherwise no specific history. SOCIAL HISTORY: She works as a banker for US Bank. REVIEW OF SYSTEMS: Patient is too impaired to given accurate information.
US|United States|U.S.|138|141|HISTORY OF PRESENT ILLNESS|He has chronic pain in the right knee going back years and years. He played college basketball at _%#CITY#%_ and spent three years in the U.S. Marine Corps. He complains of his right knee swelling, giving way, locking up, and left knee being unstable. An MRI done at the VA dated _%#MMDD2003#%_ showed ACL tear from condyle with bone contusion, osteochondral defect along the lateral femoral condyle as well.
US|United States|U.S.|192|195|FAMILY HISTORY|He is an immigrant from Laos, is married, and has children that live in the area. FAMILY HISTORY: The patient's parents passed away in Laos with unclear medical problems. He immigrated to the U.S. in 1980 and is a retired janitor. PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: Unremarkable. GENERAL: HEENT: His exam was significant for fibrotic changes over his right eye through which he is blind.
US|United States|US|137|138|SOCIAL HISTORY|FAMILY HISTORY: Mother recently diagnosed with kidney cancer. SOCIAL HISTORY: Does not smoke or drink significant alcohol. He works as a US marshall. He is married and has a son. ALLERGIES: None. MEDICATIONS: Ibuprofen, Tylenol, dose of Rocephin earlier today, prescription for Levaquin.
US|United States|U.S.|183|186|HISTORY OF THE PRESENT ILLNESS|The patient was recently in Puerto Rico due to his employment for Office Max. He resided there for five weeks, stayed mainly in his hotel and at corporate offices. He returned to the U.S. with stay in _%#CITY#%_ planned for the next two weeks also for employment reasons. The patient states that upon return to the U.S. is when he symptoms began.
US|United States|US,|183|185|PROCEDURE|She also noticed sore throat and sinus congestion. Since that time, her throat has gone more painful and swollen. During this time, she flew back to the US. On her flight over to the US, she noticed a maculopapular pruritic rash on her ankle and abdomen which she describes as if similar to the rash she has had in the past.
US|United States|U.S.|128|131|SOCIAL HISTORY|He denies any kind of drug use. He drinks alcohol socially only. SOCIAL HISTORY: The patient is married. He is a worker for the U.S. postal service for over 21 years. He has two children that are grown and out of the house. FAMILY HISTORY: Two brothers, one sister. Father died of lymphoma, mother died of some sort of esophageal carcinoma.
US|United States|US.|155|157|SOCIAL HISTORY|OBSTETRIC HISTORY: None. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: None. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Recent immigrant to the US. She is here with her husband. ADMISSION PHYSICAL EXAMINATION GENERAL: Afebrile.
US|United States|US|106|107|SOCIAL  HISTORY|FAMILY HISTORY: Really unclear. No real contributing factors. SOCIAL HISTORY: The patient has been in the US for 10 years. He is living with his wife. They both speak very little English and translator was present today to help out.
US|United States|US|144|145|SOCIAL HISTORY|She has 2 brothers who are healthy without any cardiac disease. SOCIAL HISTORY: She is a nonsmoker. Originally from Thailand, immigrated to the US 12 years ago. Occasional caffeine intake. PHYSICAL EXAMINATION: On admission, she is afebrile.
US|United States|US|120|121|SOCIAL HISTORY|3. Protonix 40 mg p.o. daily. SOCIAL HISTORY: She lives with her husband. She says she feels safe at home. She works at US Bank. She smokes more than a pack a day. She uses a 6-pack of beer a day and smokes pot daily. PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile. Blood pressure in the 120s to 150s/70s to 90s.
US|ultrasound|US|126|127|DISCHARGE INSTRUCTIONS|Mother is a 19-year-old, O positive, gravida 1, para 0, single Caucasian female whose LMP was _%#MMDD2005#%_ and whose EDC by US was _%#MMDD2006#%_. The infant was delivered by emergent Caesarian section with Apgar scores of 8 at one minute and 9 at five minutes. _%#NAME#%_ was a pre-term AGA male infant, 2050 gm at 34+5 weeks gestation, with a length of 44 cm and head circumference of 32.25 cm.
US|United States|US|246|247|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a kind 78-year-old white male with an unfortunate diagnosis of limited stage IV bronchioalveolar nonsmall cell lung cancer. _%#NAME#%_ has been receiving carboplatin, Abraxane and Avastin chemotherapy on US Oncology Clinical Trial 03022. He has now completed 3 cycles of such treatment with his last treatment occurring on _%#MMDD2006#%_.
US|United States|U.S.|280|283|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSIS: Pneumonia. HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old male who had been traveling for the last 4 weeks to Ethiopia and Saudi Arabia. He had a complaint of a dry cough for approximately 3 weeks with decreased appetite. He had just arrived in the U.S. the day prior to admission and was on his way back to California. However, he decided to be seen in the hospital emergency room.
US|United States|US|205|206|HISTORY OF PRESENT ILLNESS|A CT scan of the chest demonstrated mediastinal adenopathy and also a mass in the right hilum. After discussion of options, she was begun on chemotherapy using Abraxane, carboplatinum and bevacizumab on a US Oncology trial. She received her first dose of this approximately one week ago. She relates no significant problems with myalgias or paresthesias. Over the last three to four days, she has developed significant diarrhea and relates having up to 5-7 loose watery bowel movements per day.
US|United States|U.S.|118|121|DISCHARGE FOLLOW-UP|DISCHARGE FOLLOW-UP: 1. Follow up with regular physician. He has been advised to find a regular physician here in the U.S. 2. Follow up stool cultures. At time of discharge, he is no longer having diarrhea. He has also been advised to quit drinking alcohol. He reports that he finds himself in situations in Bulgaria where it is expected that he drink heavily.
US|United States|U.S.|258|261|DOB|The patient presented to the emergency room this morning with a one-week history of abdominal pain in the lower abdomen, a little tender in the epigastric region. It started on Thursday last week. He drives 18 wheelers to _%#CITY#%_ five days a week for the U.S. Postal Service and stated last Thursday on the _%#DD#%_ he developed so much abdominal pain that he actually was barely able to "complete my drive" and then on Sunday night had so much pain and Monday morning he presented to the emergency room.
US|United States|U.S.|168|171|FAMILY HISTORY/SOCIAL HISTORY|Allergies/immunology: No history of deep vein thrombosis. FAMILY HISTORY/SOCIAL HISTORY: Married. Worked in real estate for many, many years and then has been with the U.S. Postal Service for the past seven years. He has seven children, all adults. His father died of "old age" in his 90s. His mother died in her 50s of complications from "acidosis".
US|United States|US|118|119|SOCIAL HISTORY|MEDICATIONS: Occasional aspirin. ALLERGIES: None known. SOCIAL HISTORY: Mr. _%#NAME#%_ works as a mail sorter for the US Postal Service. He denies any tobacco or alcohol use. Denies any drug use. He lives independently and lives alone. FAMILY HISTORY: The patient states that his parents both died when they were well into their 90s due to old age.
US|United States|U.S.|131|134|HISTORY OF PRESENT ILLNESS|About a week ago he was in New Zealand golfing and again experienced a similar symptom. Over the last week since being back in the U.S. he has noted more and more chest discomfort with less and less exertion. He states initially he started out with a long walk and then a short walk and this morning was just walking around his office and began having the chest discomfort.
US|ultrasound|US|199|200|IMPRESSION AND PLAN|Mild septal hypertrophy was noted. A TSH was ordered and returned at 408 mU/L. The free thyroxine level was 0.92 ng/dL. Endocrinology was consulted, and recommended synthroid at 50mcg/day. A thyroid US revealed material in that was consistent with either thyroid or thymus in the area of expected thyroid. No cystic or solid masses were identified. There was no lingual thyroid material.
US|United States|US|149|150|HISTORY OF PRESENT ILLNESS|She has been able to keep anything down as it just goes straight through her. She has had some tactile fevers at home. She denies travel outside the US in the last couple of months. A month ago she was seen for upper respiratory infection with some pleuritic chest pain and dry cough and was treated with a Z pack.
US|United States|US|201|202|HISTORY OF PRESENT ILLNESS|6. Morbid obesity. 7. HTN. HISTORY OF PRESENT ILLNESS: History of present illness on admission, please see admission note for details. This is a 74-year-old male originally from Ethiopia living in the US for over 20 years who came to the emergency department on the _%#DD#%_ complaining of increasing shortness of breath, wheezing, coughing, and unable to go up the stairs in his house secondary shortness of breath.
US|United States|U.S|124|126|SOCIAL HISTORY|He works as a personal care attendant and also as a gas station attendant. He lives with his wife. He has immigrated to the U.S from Yemen 8 years ago. REVIEW OF SYSTEMS: A 10-point review of systems was completed, and patient has notable positives for shortness of breath, subjective fevers, chills, cough.
US|ultrasound|US|128|129|PHYSICAL  EXAMINATION|The patient is currently with a KCI VAC in place. White count 7.8,000 with a hemoglobin 11.7. Sed rate is 64, INR was 1 and the US ankle arm index, there is a resting left ankle brachial disease. There are moderate to severely reduced range of 4.54 the dorsal pedis level and a 0.66 at the posterior tibial level.
US|United States|US|210|211|HISTORY OF PRESENT ILLNESS|Patient did not achieve remission with that subtherapeutic dosing. She then traveled to the United States for further treatment in _%#MM2006#%_. The patient received her first round on induction therapy in the US consisting of IDA/Ara-C 3 7. On day 14, marrow demonstrated 7% blasts, at that point the patient required a second round of induction chemotherapy on _%#MMDD2006#%_ consisting of mitoxantrone and VP16.
US|ultrasound|US|134|135|ASSESSMENT AND PLAN|In summary, I will follow up with _%#NAME#%_ as an outpatient to discuss with him the MRI of the abdomen, outpatient PET scan and his US findings with Dr. _%#NAME#%_. If he is still in hospital, my partner (Dr. _%#NAME#%_ _%#NAME#%_) may see him to discuss the MRI results prior to his discharge.
US|United States|U.S.|162|165|SOCIAL HISTORY|PAST MEDICAL HISTORY: Stomach ulcers. PAST SURGICAL HISTORY: None. FAMILY HISTORY: None SOCIAL HISTORY: The patient is from Ecuador. She has been residing in the U.S. since 1998. No tobacco or alcohol. ALLERGIES: No known drug allergies. MEDICATIONS: None. REVIEW OF SYSTEMS: Temporary review of systems was obtained.
US|United States|U.S.|124|127|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: The patient is a 45-year-old female from Ethiopia visiting the U.S. She presents with 2 days of lower abdominal pain. This is more prominent left lower quadrant. She had an episode of diarrhea this morning but otherwise her stools have been unremarkable.
US|ultrasound|US|240|241|HOSPITAL COURSE|GI was consulted to help us to manage her pancreatitis and they decided not to do any endoscopic ultrasound or ERCP during this hospitalization as she has significant evidence of pancreatitis apparent on the CT scan. We decided to hold off US and we arranged for an endoscopic ultrasound procedure for her on _%#MMDD2006#%_ with Dr. _%#NAME#%_. At that time, her pancreatitis should have settled down and it would be easier to assess any structural abnormalities, which could have caused her to have this episode of pancreatitis.
US|ultrasound|US|157|158|HOSPITAL COURSE|We do not know whether or not she needs insulin in the long run and this could only be determined after her active pancreatitis subsides. After she gets her US procedure by Dr. _%#NAME#%_ on _%#MMDD2006#%_, Dr. _%#NAME#%_ can determine whether or not she needs to be placed on pancreatic enzyme supplements.
US|ultrasound|US|132|133|FOLLOWUP PLANS|6. Aspart insulin sliding scale. FOLLOWUP PLANS: 1. She is to be followed up by Dr. _%#NAME#%_ from gastroenterology to perform the US procedure on _%#MMDD2006#%_. The nurse coordinator for Dr. _%#NAME#%_ is _%#NAME#%_ _%#NAME#%_ who can be reached at _%#TEL#%_. She will call the patient regarding this appointment and the US procedure.
US|United States|US|112|113||Mr. _%#NAME#%_ is admitted with a complaint of pain in his right shoulder. He has been recently employed by the US Postal Service. However, on _%#MMDD#%_, he was hanging a cabinet in his garage. He was supporting the cabinet with his right arm and in the process of positioning the cabinet, was aware of a sharp painful sensation in his right shoulder.
US|United States|US|167|168|SOCIAL HISTORY|ALLERGIES: No medication allergies, but has an allergies to shrimp, no other shellfish. SOCIAL HISTORY: No smoking. No significant alcohol use. He is retired from the US Fish and Wildlife Service, lives with his wife, has 2 daughters. FAMILY HISTORY: Remarkable for mother who died of an MI in her 80s.
US|United States|US|152|153|SOCIAL  HISTORY|His parents had no coronary disease. SOCIAL HISTORY: He is married and has children in this area and is retired. He grew up in Germany and moved to the US in 1953. He smokes up to 3/4 of a pack per day but denies alcohol abuse. PHYSICAL EXAMINATION: VITAL SIGNS: Initial blood pressure is 80 systolic.
US|United States|US|214|215|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: This 38-year-old previously healthy male presents with fevers, chills and rigors that began on _%#MM#%_ _%#DD#%_, 2002, after he arrived home from a trip to Central America. He left the US on _%#MM#%_ _%#DD#%_, 2001, to travel to Guatemala. From there, he went to El Salvador and finished in Honduras. He was traveling alone. He did a lot of backpacking.
US|ultrasound|US|171|172|ASSESSMENT AND PLAN|_%#NAME#%_ was scheduled for another bilirubin check on _%#MMDD2007#%_. Problem #6: Intraventricular Hemorrhage. _%#NAME#%_ was less than 34 weeks, so he will need a head US at 1 week of age. This has not yet been done at the time of transfer. Problem #7: Access. _%#NAME#%_ had the following lined placed: percutaneously inserted central venous catheter in right arm and peripheral IVs.
US|ultrasound|US|147|148|* FEN|A home care nurse will visit within 48 hours of discharge. Appointments not scheduled at the time of discharge that need to be scheduled: 1. Renal US at 1 week of age. 2. Repeat head US at 2 weeks of age. Thank you again for allowing us to share in the care of your patient.
US|United States|US.|253|255|HISTORY|3. Peritracheal mass with mediastinal lymphadenopathy, status post bronchoscopy and mediastinoscopy with lymph node biopsy. 4. Iron deficiency anemia. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 49-year-old Southeast Asian female who recently immigrated to the US. She was found by her family in the morning of _%#MMDD2007#%_ unable to be aroused. The patient denies history of anxiety and had been more depressed lately.
US|United States|U.S.|230|233|SOCIAL HISTORY|ALLERGIES: She has no known allergies. She was started on Cipro 500 mg twice daily on the _%#DD#%_ as noted previously and has been using Tylenol for pain. SOCIAL HISTORY: The patient works at a laboratory testing for HIV for the U.S. government. This job has been performed for the last year. Previously she had been a biology major at Gustavus Adolphus College receiving her bachelor's degree.
US|United States|U.S.|146|149|ALLERGIES|He uses no tobacco and has never smoked. Caffeine rare. Alcohol rare. No drug use. He has had no history of reaction to anesthesia. He was in the U.S. Navy during World War II. SOCIAL & FAMILY HISTORY: He is a retired mining engineer.
US|ultrasound|US|145|146|1. F/E/N|Two more doses were given during the next two days. An ultrasound was obtained on _%#MMDD2002#%_ showed no evidence of significant bleed. A head US on _%#MMDD#%_ was negative for abnormalities. 6. Hematology: _%#NAME#%_ presented with an elevated INR and PTT as well as a low fibrinogen.
US|United States|U.S.|116|119|DISCHARGE DIAGNOSIS|SOCIAL HISTORY: The patient chews tobacco and occasionally uses alcohol. He does not use any illicit drugs. He is a U.S. bank trust administrator. PHYSICAL EXAMINATION: Temperature 97.8, pulse 74, blood pressure 146/84, respiratory rate 22, oxygen saturation 95%. In general, the patient was in moderate distress, lying in bed, appearing mildly warm.
US|GENERAL ENGLISH|US|163|164|DISCHARGE MEDICATIONS|6. Colace 100 mg p.o. b.i.d. p.r.n. constipation. ALLERGIES: BETA BLOCKERS CAUSE BRADYCARDIA. PLEASE CHECK LIST PATIENT FOR FURTHER ALLERGY DOCUMENTATION. HE TOLD US NO KNOWN DRUG ALLERGIES AT ONE POINT. CODE STATUS: Needs further discussion. DISCHARGE INSTRUCTIONS: 1. Schedule thyroid ultrasound for _%#MM#%_ _%#DD#%_, 2002.
US|United States|U.S.|189|192|SOCIAL HISTORY|SOCIAL HISTORY: The patient is a retired Army sergeant. He has been married for multiple decades now. He quit smoking in 1998. He has not had anything to drink since 1995. He served in the U.S. Army in Korea and in Vietnam. He is retired, having earned a pension through them. PHYSICAL EXAMINATION: Weight 190 pounds, blood pressure 148/80.
US|United States|U.S.|101|104|SOCIAL HISTORY|11. Ferrous Sulfate 324 mg PO Q day 12. Flomax 0.4 mg PO Q day SOCIAL HISTORY: Lives alone. Retired. U.S. Ary Veteran World War I. No smoking, no drinking. FAMILY HISTORY: Is noncontributory. PHYSICAL EXAMINATION: The patient is afebrile.
US|United States|US|130|131|SOCIAL HISTORY|He quit drinking alcohol a number of years ago. He has no history of alcohol abuse. SOCIAL HISTORY: He is a former executive with US Bank. He is married, and his wife is here with him tonight. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: CONSTITUTIONAL: He admits to some chills, but denies any sweats or fever.
US|United States|US|147|148|PLAN|He will need an increased dose of the Coumadin. As well, the multi-vitamin should probably be modified, as it contains vitamin K, with 100% of the US RDA. 2. Cardiac. The patient has stable LV function with good blood pressure. The patient is somewhat tachycardic. This may be concerning for tamponade.
US|United States|U.S.|117|120|SOCIAL HISTORY|ALLERGIES: There are no known drug allergies. SOCIAL HISTORY: He is married and he is Cambodian. He has lived in the U.S. since 1981. He does not drink, nor does he smoke. FAMILY HISTORY: The family history was unremarkable per patient. REVIEW OF SYSTEMS: He has had the nausea and vomiting as mentioned above as well as intermittent abdominal pain and diarrhea.
US|United States|U.S.|195|198|SOCIAL HISTORY|PAST MEDICAL HISTORY: Healthy. PAST SURGICAL HISTORY: Open cholecystectomy at age 13. SOCIAL HISTORY: She is married and works as a seamstress. No alcohol, drugs, or tobacco. She has been in the U.S. for seven years. MEDICATIONS: Prenatal vitamins. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Blood pressure 101/53, pulse 68, respirations 16, temperature 98.5. Abdomen gravid, soft, nontender, estimated fetal weight of 3000 grams.
US|ultrasound|US|182|183|PLAN|An initial set of coags demonstrated an INR of 1.7, PTT of 38, TT of 19 and Fibrinogen of 303. He was started on Vitamin K and after three doses his repeat INR was 1.4. An abdominal US was performed which showed gallstones vs. sludging in the gallbladder. This finding is not thought to have contributed to his hematochezia, but should be followed up with another abdominal US in 6 months.
US|ultrasound|US|164|165|PLAN|1. Hematochezia-_%#NAME#%_'s hematochezia is of unknown etiology and has spontaneously resolved during his hospital course. We recommend getting a repeat abdominal US in 6 months to reevaluate the gallstones vs sludging. _%#NAME#%_ needs to follow up with peds GI if the abdominal US is abnormal or if he again becomes symptomatic with bloody stools.
US|ultrasound|US|157|158|PLAN|We recommend getting a repeat abdominal US in 6 months to reevaluate the gallstones vs sludging. _%#NAME#%_ needs to follow up with peds GI if the abdominal US is abnormal or if he again becomes symptomatic with bloody stools. 2. _%#NAME#%_ had a slight Hyperbilirubinemia and continued to be mildly jaundiced at the time of discharge.
US|United States|US|192|193|SOCIAL HISTORY|She has two grown daughters, ages 34 and 37. Both of her pregnancies were normal vaginal deliveries. She did receive a blood transfusion with her second delivery. The patient is employed with US Bank Corporation, _%#NAME#%_ _%#NAME#%_. FAMILY HISTORY: The patient's mother died of an acute myocardial infarction at age 72.
US|United States|US|139|140|SOCIAL HISTORY|He marks the pain scale an 8/10. SOCIAL HISTORY: He is married with two children. He completed two years of college. He is employed by the US Postal Service as a letter carrier. He has been employed there for 16 years and plans to continue for 23 more years.
US|United States|US|155|156|SOCIAL HISTORY|1. Astigmatism. 2. Headaches. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is married. She lives with her husband and son. She works at US Bank. She denies tobacco, alcohol, or illicit drug use. FAMILY HISTORY: The patient's mother has diabetes.
US|ultrasound|US|160|161|ASSESSMENT AND PLAN|Apgar scores were 6 at one minute and 8 at five minutes. _%#NAME#%_ was a pre-term male infant, 2270 gm (<50%) at 34 weeks (Ballard) gestation (third trimester US arrived at 33 +6 and 36+6 by EDC), with a length of 47.5 (50%) cm and head circumference of 29.5 (<5%) cm.
US|United States|U.S.,|258|262|DISCHARGE DIAGNOSES|The culvert was filled with stagnate water. He struck the right shin on concrete and sustained a wound to the anterior right lower leg with a laceration in the skin flaps. This was debrided in Nigeria. He was treated with oral Augmentin. After return to the U.S., he noted increasing pain, swelling, and redness of the right lower extremity. He had fever and chills. After admission, Dr. _%#NAME#%_ took him to the Operating Room and performed debridement of eschar and evacuation of the abscess along with packing of the wound.
US|ultrasound|US|160|161|PLAN|Total Bili level 11.8. Recommend following levels and starting phototherapy if Hyperbilirubinemia persists. 12. Left Hip click on persistent on exam. Recommend US to evaluate for congenital dislocation. Discharge medications, treatments and special equipment: None Discharge measurements: Weight 2175 gms; length 43 cm; OFC 31 cm.
US|United States|U.S.|156|159|SOCIAL HISTORY|8. Chronic tinnitus. SOCIAL HISTORY: The patient is married. He has two children. He quit smoking after many years in _%#MM#%_ 2001. He is retired from the U.S. Navy. FAMILY HISTORY: Notable for mother with cataracts, father with hypertension and a deep venous thrombosis, and paternal uncle died from a pulmonary embolism at age 72.
US|United States|U.S.|145|148|SOCIAL HISTORY|REVIEW OF SYSTEMS AND FAMILY MEDICAL HISTORY: Are noncontributory SOCIAL HISTORY: The patient did smoke heavily in the past. She has been in the U.S. with her son for three years. She is now in a nursing home PHYSICAL EXAMINATION: Vital signs, temperature is 101.5 rectally.
US|United States|US|146|147|SOCIAL HISTORY|SURGICAL: I believe none. MEDICATION ALLERGIES: NONE. SOCIAL HISTORY: Smoking: None. Alcohol use: None. The patient is Somalian, emigrated to the US four years ago. I believe he lives with his daughter. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Vision is without complaint. Ears, nose, throat without complaint.
US|United States|U.S.|284|287|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Significant for SLE lupus diagnosed two months ago with history of being PPD positive, history of having BCG and was placed on INH with non-compliancy after three weeks of treatment. Ms. _%#NAME#%_ _%#NAME#%_ is a 23-year-old Somali female who immigrated to the U.S. six months ago with a past medical history significant for lupus diagnosed two months ago with a history of being PPD positive.
US|United States|U.S.|168|171|SOCIAL HISTORY|His oldest brother at 55 developed some heart condition of unclear etiology or what this is. SOCIAL HISTORY: The patient is married. He is from Somalia and came to the U.S. via Syria. He has been in the U.S. for about five years. He has 14 children. He works currently at a housekeeping job.
US|United States|US|237|238|HISTORY OF PRESENT ILLNESS|Ms. _%#NAME#%_ is a 57-year-old female with a history of hypertension and nephrolithiasis, who comes to the Ridges ER complaining of left flank pain. The patient is from Hawaii and visiting the mainland United States. She arrived to the US approximately five days ago. She was visiting in _%#CITY#%_ _%#CITY#%_ and developed left flank pain approximately three days prior to admission.
US|United States|U.S.|187|190|SOCIAL HISTORY|2) Quadriceps tendon rupture repair. 3) Tonsillectomy. 4) Varicose vein repair. SOCIAL HISTORY: He is married and has two children who are grown. He works in building maintenance for the U.S. Postal Service. Does not smoke. Does drink approximately one ounce of alcohol per week, 4-5 cans of soda per day. PHYSICAL EXAMINATION ON ADMISSION: Vitals - T-max 99.4, pulse 83-90, respirations 18, blood pressure 148/79, satting 99% on room air.
US|United States|US|176|177|ALLERGIES|10. Neurontin 300 mg t.i.d. 11. Nadolol 40 mg p.o. daily. ALLERGIES: No known drug allergies. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Immigrant from Somalia, moved to US in 2000. Lives with daughter. Ten-pack-year history tobacco use, quit in 1975. No alcohol or other drug use. PHYSICAL EXAMINATION: Vital signs: Temp 97.7, pulse 71, resps 16, BP 120/75, O2 sat.
US|ultrasound|US,|213|215|FOLLOW UP|Parents have been working with OT on range of motion exercises and will be seen in NICU follow-up clinic at 4 months of age corrected for further neurological evaluation. Because of the abnormalities seen on head US, _%#NAME#%_ is at high risk for future motor problems. Problem #6: Sepsis. We treated _%#NAME#%_ with ampicillin and gentamicin for a total of 2 days.
US|United States|US|117|118|SOCIAL HISTORY|CODE STATUS: Full code. SOCIAL HISTORY: She is a smoker. She drinks four to six beers per day. She has worked at the US Bank. She lives with her husband and has one grandchild. FAMILY HISTORY: Family health history includes her mother and grandmother both having had diabetes and congestive heart failure.
US|United States|U.S.|99|102|HISTORY OF THE PRESENT ILLNESS|He does not speak English and his daughter acted as the interpreter. Mr. _%#NAME#%_ arrived in the U.S. on Thursday and developed diarrhea the following day. He has had approximately three days of 5-6 watery bowel movements per day.
US|United States|U.S.|192|195|SOCIAL HISTORY|6. Lisinopril, 2.5 mg daily. 7. Nitroglycerin as needed. ALLERGIES: No known drug allergies. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She is originally from Peru. She has lived in the U.S. for 6 or 7 years. She has children who live here and are supportive. REVIEW OF SYSTEMS: No cardiac symptoms.
US|United States|US|136|137|HISTORY OF PRESENT ILLNESS|She stated that she did want to end her life at that time, but does not currently have any suicidal ideation. She recently moved to the US from Sierra Leone approximately 9 months ago and is married. She met her husband in 1996 and has been trying to get here since then.
US|United States|US|207|208|HISTORY OF PRESENT ILLNESS|He first presented with swelling of the whole body and according to him he had some kind of renal biopsy but there is no record or evidence of that biopsy. Since then, he has been back and forth between the US and Mexico and was noted to have chronic renal failure without any specific diagnosis. He was recently hospitalized about a month ago and at that point dialysis and transplant were offered, but the patient refused dialysis.
US|United States|US|185|186|HISTORY OF PRESENT ILLNESS|Early in _%#MM#%_ 2005 in Latvia, a renal biopsy provided tissue showing possible focal sclerosis but insufficient tissue for full testing. _%#NAME#%_ immigrated with his family to the US 5 months prior to this admission. _%#NAME#%_ proteinuria had been asymptomatic until approximately 3 months ago, at which time he began to have occasional flank pain.
US|United States|U.S.|143|146|ADMISSION MEDICATIONS|ADMISSION MEDICATIONS: Unknown, something for blood pressure. SOCIAL HISTORY: The patient currently lives with his wife and 1 daughter. In the U.S. a year and a half from Somalia. Denies tobacco, alcohol, or other drug use. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 115/73.
US|United States|US|115|116|SOCIAL HISTORY|4. Spironolactone 25 mg p.o. q. day 5. Navane 6. Trazodone 100 mg p.o. q. day SOCIAL HISTORY: Used to work for the US mail. He denies any alcohol or tobacco. FAMILY HISTORY: Noncontributory at this time. PHYSICAL EXAMINATION: GENERAL: The patient is very pleasant 50-year-old gentleman, no apparent distress.
US|United States|US|159|160|SOCIAL HISTORY|No nausea or vomiting. Extremities: denies swelling. SOCIAL HISTORY: He denies smoking and has 1-2 beers on weekends. He is a native of India and moved to the US in 1999. He just traveled back to India in 2002. He works in radiology oncology at Fairview-University. FAMILY HISTORY: Father with diabetes. No cancer in family. PHYSICAL EXAMINATION: Temperature 101.3, heart rate 99, blood pressure 112/70, respiratory rate 18, oxygen saturation 96% on room air.
US|United States|US|170|171|SOCIAL HISTORY|8. Glipizide ER 10 mg daily. FAMILY HISTORY: Unknown. SOCIAL HISTORY: The patient smokes 1 pack per day for 40 years. He denies alcohol or other medications. He moved to US from Somalia 6 years back and lives alone, and he is unemployed. He has close family members around, living in cities. REVIEW OF SYSTEMS: He denies shortness of breath, or PND, or orthopnea.
US|United States|US|180|181|SOCIAL HISTORY|7. Prevacid 30 mg daily. 8. Albuterol inhaler p.r.n. ALLERGIES: Anacin. SOCIAL HISTORY: The patient is married, lives with her husband. She is a Laotian immigrant and moved to the US in 1980. She smokes tobacco, about 1/2 pack per day and has smoked for over 50 years. No alcohol or drug use. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: CARDIOVASCULAR: The patient does have a history of cardiovascular disease and hypertension.
US|United States|U.S.|188|191|SOCIAL HISTORY|His wife has end-stage renal disease and is on dialysis three times a week, leaving him essentially unattended during her dialysis visits. He previously worked as a civil servant with the U.S. Air Force Reserve and retired a number of years ago. CURRENT MEDICATIONS PRIOR TO HOSPITALIZATION: Unchanged, at least in the last month or so.
US|United States|US|166|167|REASON FOR ADMISSION AND HOSPITAL COURSE|REASON FOR ADMISSION AND HOSPITAL COURSE: The patient is a 45-year-old woman who was visiting her family from Ethiopia. She lives in Ethiopia and is currently in the US visiting. She started having abdominal pain with tenderness over her abdomen and recurrent vomiting. She has history of hernia repair in the past but no prior history of small-bowel obstruction.
US|United States|U.S.|220|223|SOCIAL HISTORY|FAMILY HISTORY: Negative for GI disease. SOCIAL HISTORY: The patient is married and is accompanied by his wife today. He works as a chemical engineer for Interplastics Corporation. He does frequent travel throughout the U.S. He is a nonsmoker. Alcohol intake is perhaps 2 glasses of wine a month. He did use some Motrin over the weekend, i.e. 2 tablets t.i.d. on Saturday and Sunday because of the chest pain.
US|United States|US|222|223|HISTORY OF PRESENT ILLNESS|MAJOR PROCEDURES PERFORMED: None. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is a 32-year-old gentleman with previous history of asthma and premature heartbeats as a child, was diagnosed in China. He shifted to US in 2000, presented here because he was feeling that his lungs were not filling completely, and then, he also had an episode which lasted about 30 seconds of chest pain/chest pressure.
US|United States|U.S.|220|223|HISTORY OF PRESENT ILLNESS|DISCHARGE DIAGNOSIS: Atypical chest pain-musculoskeletal. OPERATIONS/PROCEDURES PERFORMED: Adenosine thallium: Normal. HISTORY OF PRESENT ILLNESS: Briefly, the patient is a 58-year- old Somali female who has been in the U.S. for 9 years. The patient's daughter reports that the patient described "heart squeeze" that lasted less than 1 minute. It was associated with shortness of breath, diaphoresis, and dizziness.
US|United States|US|152|153|SOCIAL HISTORY|Her husband and a friend are present with her in the emergency room. Her husband seems somewhat impaired at present. The patient works at a desk job at US bank. FAMILY HISTORY: Noncontributory. ALLERGIES: Listed as sulfa and amoxicillin. MEDICATIONS: P.r.n. inhaler.
US|United States|US|143|144|SOCIAL HISTORY|11. Noninvasive ASD repair _%#MM2000#%_. SOCIAL HISTORY: She has never smoked. No alcohol use, no other drug use. She is single, works for the US Attorney's office. Lives alone, does have a boyfriend. REVIEW OF SYSTEMS: In general, she has had the fever, chills, malaise as above.
US|United States|US|158|159|SOCIAL HISTORY|ALLERGIES: He has no known drug allergies, but does not use heparin secondary to religious issues. SOCIAL HISTORY: _%#NAME#%_ is from Somalia and came to the US in _%#MM2006#%_ by way of a refugee camp in Kenya. He lives with his mother, four sisters and two brothers. His father died of unknown causes.
US|United States|U.S.|139|142|SOCIAL HISTORY|3. Levaquin 500 mg daily. 4. Ativan p.r.n. SOCIAL HISTORY: Mr. _%#NAME#%_ lives in _%#CITY#%_ and has 2 grown children. He is retired from U.S. Bank. He denies alcohol or tobacco use. FAMILY HISTORY: His maternal grandmother, mother and aunt all have breast cancer.
US|United States|U.S.|216|219|HISTORY OF PRESENT ILLNESS|2. Hypertension. 3. Hyperlipidemia. DISPOSITION: Going to Sister Kenny Institute for rehabilitation. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 71-year-old gentleman, a native of Guyana, who lives in the U.S. for the past many decades. He was in good state of health, but woke up with sudden severe headache and vomiting on _%#MMDD2007#%_.
US|United States|U.S.|164|167|HISTORY OF PRESENT ILLNESS|It appears that the abdominal pain has been going on for several years and the chest pain also for a significant period of time. Mr. _%#NAME#%_ tar has been in the U.S. for one month now. The patient has been Somalian, he spent some time in Kenya, it appears he was in _%#CITY#%_ for a period of time and then to the U.S. In _%#CITY#%_, he was told he had fluid around the heart.
US|United States|U.S.|157|160|SOCIAL HISTORY|5. Chloromycin 6. amoxicillin 7. lactulose, although it is unclear that he has been taking these medications. SOCIAL HISTORY: The patient is visiting in the U.S. He is single. HABITS: Smoking history, never. Alcohol use never. FAMILY HISTORY: Unobtainable.
US|ultrasound|US|295|296|ASSESSMENT AND PLAN|I did not elicit any CVA tenderness. EXTREMITIES: No edema. SKIN: No rashes. LABORATORY DATA: White count 9.9, hemoglobin 13.4. ASSESSMENT AND PLAN: Acute onset of mid to left-sided lower abdominal pain in a 23-year-old with a early pregnancy (2 weeks gestation with positive pregnancy test and US negative for ectopic) and slightly abnormal urinalysis but unimpressive exam & renal ultrasound for pyelonephtritis. Continue Rocephin that she was started on in the emergency room for possible pyelonephritis.
US|United States|U.S.|161|164|SOCIAL HISTORY|She has two sons, _%#NAME#%_ and _%#NAME#%_. She lives independently. She denies alcohol or cigarette use. She denies recreational drug use. She is retired from U.S. Bank. FAMILY HISTORY: Negative. She states that she is half Norwegian and German.
US|United States|US|117|118|SOCIAL HISTORY|10. Lasix 40 mg p.o. q. day. SOCIAL HISTORY: The patient is married and is a retired postal worker. He served in the US Military, US Navy, in World War II. He was aboard a PBY reconnaissance airplane in the Pacific. No alcohol use, no smoking for several years. FAMILY HISTORY: Noncontributory.
US|United States|US|109|110|SOCIAL HISTORY|History of GI bleeds from peptic ulcer disease in 1993 and 1995. SOCIAL HISTORY: Patient is retired from her US West job. She is divorced, has no children but does have dogs. She was last seen in our office in _%#MM#%_ of 1998.
US|United States|US|210|211|SOCIAL HISTORY|20. Prednisone 80 mg every day times five days with taper as written for transfer order. ALLERGY: NKDA. SOCIAL HISTORY: He is Nigerian gentleman, he has lived between Nigeria and U.S. permanently moving to the US in 1996. He speaks fluent English. He is divorced. His most recent occupation was as bus driver in _%#CITY#%_. He lives in a house with his girlfriend. He has six children which are grown.
US|United States|U.S.|149|152|DIAGNOSIS|DIAGNOSIS: Elective kidney donation. PROCEDURE: Right laparoscopic hand-assisted donor nephrectomy. The patient is a 28-year-old Spanish male in the U.S. for approximately 17 years who presents for kidney donation. He has no fevers, chills, nausea, vomiting, diarrhea. No sick contacts.
US|United States|U.S.|138|141|SOCIAL HISTORY|Both are in good health. SOCIAL HISTORY: He does not smoke. He uses alcohol occasionally. Caffeine scant. He is presently a member of the U.S. Armed Forces. ALLERGIES: None. MEDICATIONS: Depakote 750 mg daily. Presently, he is on Vicodin for pain.
US|ultrasound|US|92|93|LABORATORY FINDINGS|Mild Chronic Lung Disease - Continue diuretics as needed to maintain lung functioning. Head US - he will need a follow-up head ultrasound at one month of age. Discharge medications, treatments and special equipment: Caffeine citrate 6 mg NG Q24 hrs Diuril 25 mg NG Q12 hrs Aldactone 2.5 mg NG Q12 hrs Sodium Chloride 1.2 mEq Q3 hrs _%#NAME#%_ is a good candidate to receive Synagis during the upcoming RSV season.
US|United States|U.S.|136|139|HISTORY OF PRESENT ILLNESS|This is because of his vision. He says that he coughs every morning for many years. He denies feeling short of breath. The patient is a U.S. citizen and lives in Norway. PAST MEDICAL HISTORY: 1. Type II diabetes mellitus for several years.
US|United States|US|157|158|FAMILY HISTORY, SOCIAL HISTORY|Neuroendocrine, neuromuscular - positive for polymyalgia rheumatica. FAMILY HISTORY, SOCIAL HISTORY: He is married, has two adult daughters. He is a retired US postal service worker, he did that for over 33 years. ALLERGIES: Only allergy is to codeine. CURRENT MEDICATIONS: Zestril 5 mg one-half tab per day, prednisone 7.5 mg p.o. q.d., vitamin E, calcium, and vitamin D.
US|United States|US|159|160|PLAN|Prenatal labs were incomplete; however Mom was Hep B negative with B + blood type, also with a history of positive PPD. Mom is from Honduras, has lived in the US for 9 years, and has not been back to Honduras since. The infant was delivered by C section for failure to progress with Apgar scores of 9 at one minute and 9 at five minutes.
US|United States|US|209|210|HE IS ALLERGIC TO THIAZIDE-TYPE DIURETICS.|NovoLog 5, 5, and 9 units spread with meals. Demadex 100 mg orally b.i.d. Aspirin 81 mg daily. HE IS ALLERGIC TO THIAZIDE-TYPE DIURETICS. The patient is a nonsmoker and nondrinker who is married. He works for US West or Quest in office-type work, but has been disabled recently due to his illness. He is married and lives with his wife. The patient on review of systems has had no other major symptoms.
US|ultrasound|US|275|276|PLAN|The mother's pregnancy was complicated by reported cigarette and alcohol use prior to knowledge of this pregnancy, preterm labor, IUGR, and polyhydramnios. The infant was delivered by cesarean section secondary to deep variable decelerations, late decelerations, and Doppler US that showed poor placental flow. Apgar scores were 7 at one minute and 8 at five minutes. _%#NAME#%_ was a term AGA female infant, 2293 gm at 37+4 weeks gestation, with a length of 48.5 cm and head circumference of 33.5 cm.
US|ultrasound|US|191|192|PLAN|4. Renal-On day of life #1 _%#NAME#%_ had a renal U/S which showed a minimal amount of fluid noted in the collecting system on the left. She was on ampicillin for prophylaxis. A repeat renal US performed on day of life #10 was normal. 5. Neuro-_%#NAME#%_ has been noted to have occasional twitching episodes of all 4 extremities without loss of consciousness.
US|United States|U.S.|157|160|SOCIAL HISTORY|ALLERGIES: A HERBAL ROOT CALLED KACHAI, AND NOW A QUESTION OF NUTS. SOCIAL HISTORY: This is a Cambodian female who now resides with her daughter here in the U.S. since 1985. SOCIAL HISTORY: Tobacco use: None. Alcohol use: None. FAMILY HISTORY: Noncontributory.
US|United States|U.S.|297|300|HISTORY OF PRESENT ILLNESS|The patient is being admitted to the Neurology Service for an admission diagnosis of first-time seizures. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 20-year-old young female who has recently migrated to the United States under the sponsorship of a host family and is currently present in the U.S. under a diversity visa and is anticipated to gain her American citizenship shortly. She recently hails from Sierra Leone and has been, as mentioned, sponsored by a host family, who is in fact currently responsible for the patient's care as well.
US|ultrasound|US|152|153|1. FEN|An anal reanastomosis is planned for 3 months of age. Pt should schedule follow up with Dr. _%#NAME#%_ upon discharge. 5. Renal: A normal initial renal US was obtained at birth but a renal ultrasound on DOL 20 revealed a new left hydronephrosis. A UA was normal at that time and a VCUG demonstrated moderate post void residuals consistent with neurogenic bladder but no vesicoureteral reflux.
US|United States|U.S.|168|171|SOCIAL HISTORY|No chronic medications. No prior surgical procedures or underlying medical problems. SOCIAL HISTORY: Is a nonsmoker. He was born in _%#CITY#%_, Mexico. Has been in the U.S. for several years. He works as a baker at General Mills. He has no family in town. REVIEW OF SYSTEMS: Completely unremarkable.
US|United States|U.S.|115|118|SOCIAL HISTORY|He lives with a new partner the last two months, who has also been a friend for about five years. He works for the U.S. Post Office as a mail carrier. FAMILY HISTORY: Mother with history of diabetes and hypertension. Father with Parkinson's disease.
US|United States|US|137|138|PRESENT ILLNESS|_%#NAME#%_ _%#NAME#%_ is a 45-year-old male from _%#CITY#%_ _%#CITY#%_. He is single and lives alone. He works as a mail carrier for the US Post Office. The patient enters Fairview Recovery Services at this time on his own volition.
US|United States|US|187|188|SOCIAL HISTORY|SOCIAL HISTORY: _%#NAME#%_ is divorced. She lives at the _%#CITY#%_ _%#CITY#%_ _%#CITY#%_ Plaza Nursing Home. She has a daughter who lives in _%#CITY#%_ _%#CITY#%_ area who works for the US Government - AID. She has a master degrees in music. She describes herself as a retired musician. MENTAL STATUS: _%#NAME#%_ _%#NAME#%_ presents as an awake, alert, petite woman with rapid speech.
US|United States|U.S.|157|160|HISTORY OF PRESENT PROBLEM|She frequently is given oxygen. She also has comorbid asthma, which complicates the presentation. Recent stressors include worry about her son who is in the U.S. Navy, progressive obesity and adult onset diabetes mellitus, worry about her asthma, the death of an uncle two months ago, and the theft of some money by a relative from _%#NAME#%_ and her husband.
US|United States|U.S.|280|283|HISTORY OF PRESENT PROBLEM|He believed he would be convicted at a trial and that this would cause harm to many people, including people in Iraq who might be laughing at him. He further told his wife that he thought the computer was communicating with him in special ways about the impending collapse of the U.S. economy. PAST CHEMICAL DEPENDENCY HISTORY: Nicotine, caffeine, and several gin and tonics a day.
US|United States|US|271|272|PRESENT ILLNESS|CHIEF COMPLAINT: "I was lied to./> < CHIEF COMPLAINT: "Alcohol dependence." PRESENT ILLNESS: This is the first FUMC admission for _%#NAME#%_ _%#NAME#%_, who is a 53-year-old male from _%#CITY#%_. The patient is single. He lives alone. He works as a financial adviser for US Bank.
US|United States|US.|157|159|SOCIAL HISTORY/FAMILY HISTORY|For a time she states that they lived on the streets in Iraq (about two years) until her maternal grandfather took them in just prior to their coming to the US. She speaks English very well. She will be a sophomore this year and describes no learning disabilities. She is in ELL Programming. PHYSICAL STATUS: See internist note for details.
US|United States|US|172|173|SOCIAL HISTORY|SOCIAL HISTORY: The patient is under an incredible amount of stress. She is currently going through her second divorce. Her husband is incarcerated. She has worked for the US Postal Service for the last 20 years. She denies any alcohol, tobacco, or IV drug use. FAMILY HISTORY: History of diabetes and gout.
US|United States|U.S.|128|131|SOCIAL HISTORY|6. Atrial fibrillation. SOCIAL HISTORY: This is not obtainable from the patient. Old records indicate this woman worked for the U.S. Postal Service. She has been retired since 1980. She is widowed. She has four children. She previously denied using alcohol and smoking. FAMILY HISTORY: The patient has two sisters with cancer, and one brother with colon cancer.
US|United States|U.S.|147|150|SOCIAL HISTORY|No medical allergies. FAMILY HISTORY: Negative for IBD or colon cancer. SOCIAL HISTORY: Married. He works as a building maintenance person for the U.S. Postal Service. He has two children who are grown. REVIEW OF SYSTEMS: Cardiovascular: Negative. Pulmonary: Nonsmoker; otherwise negative. Gastrointestinal: Heartburn once in awhile. No significant alcohol.
US|United States|US|246|247|NEUROLOGIC EXAMINATION|HIGHER CORTICAL FUNCTIONS: The patient is awake and alert, knows her name and knows she is in the hospital, but cannot identify the name of the hospital. She knows it is _%#MM#%_ of 2007, but does not know the specific day. She knows the current US president, but not the previous US president. She has mild to moderate difficulties with 2-part commands. Speech and speech content are normal.
US|United States|U.S.|169|172|SOCIAL HISTORY|SOCIAL HISTORY: The patient is a 50-year-old Caucasian female. She is married. She has two children. She works full time as a supervisor and hires border patrol for the U.S. She works out at _%#CITY#%_ _%#CITY#%_. She is a nonsmoker, occasional alcohol use. No other drug use is noted. REVIEW OF SYSTEMS: GENERAL: This is a 50-year-old Caucasian female who denies any recent histories of fevers, chills or night sweats.
US|United States|U.S.|107|110|SOCIAL HISTORY|Atenolol 25 mg p.o. b.i.d. No NSAIDs. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He is retired, a U.S. Army veteran. He is married. No alcohol use. No active tobacco use. FAMILY HISTORY: Negative for any GI malignancy per patient.
US|United States|US|162|163|SOCIAL HISTORY|SOCIAL HISTORY: The patient is a 27-year-old Caucasian female who is single and currently engaged. She has two children of her own and she works full time at the US Distillery in the filling department. She is a former smoker who quit last year. No alcohol use, and no other drug use is noted.
US|United States|US.|161|163|SOCIAL HISTORY|SOCIAL HISTORY: He is from _%#CITY#%_, Russia and has been in the US about five years. He had done construction work. He is divorced but has two children in the US. He smokes about a pack a day. He drinks and is a little bit evasive about how much he uses and a little bit defensive about it.
US|United States|US|235|236|SOCIAL HISTORY|No other history. FAMILY HISTORY: Negative for colon or rectal cancer, polyps, Crohn's disease, ulcerative colitis, liver disease, gallbladder disease or ulcer disease. SOCIAL HISTORY: The patient is a Somali male who has lived in the US for the last 8 years. He is single and lives with his brother. He is currently unemployed. Tobacco use is 1/2 to 1 pack per day. Alcohol use is 1 pint daily for the last two months secondary to some depression and stress that he is having.
US|United States|U.S.|145|148|HISTORY|He has not had constant headache and there has been no persistent neck stiffness. There is no history of trauma. He has not traveled outside the U.S. as has been noted by Dr. _%#NAME#%_. He did have a hepatitis A vaccination approximately 8 to 10 years ago according to Dr. _%#NAME#%_, with no intermittent such difficulties.
US|United States|U.S.|232|235|RECOMMENDATIONS|It was my pleasure to see Mrs. _%#NAME#%_ _%#NAME#%_ today request of Dr. _%#NAME#%_ _%#NAME#%_ for evaluation of questionable congestive heart failure. Mrs. _%#NAME#%_ is a delightful 45-year-old Sudanese woman who has been in the U.S. for the past 14 years, previously healthy without any significant cardiac history who presented with progressive exertional dyspnea along with the sensation of "choking" in the middle of the night for the past few months.
US|United States|U.S.|167|170|SOCIAL HISTORY|PREADMISSION MEDICATIONS none. ALLERGIES: NONE. FAMILY HISTORY: Premature CAD, mom died in her 50s, diabetes. SOCIAL HISTORY: Emigrated from Sudan and has been in the U.S. for the past 14 years. No tobacco or alcohol use. REVIEW OF SYSTEMS: As in HPI, otherwise 10 systems were negative.
US|United States|U.S.|248|251|SOCIAL HISTORY|PAST MEDICAL HISTORY: 1. Rheumatoid arthritis. 2. Previous stress fractures to right lower leg and right ankle, with ORIF to the ankle in _%#MM2005#%_. ALLERGIES: Penicillin- rash. SOCIAL HISTORY: Married and lives at home. Works as a secretary at U.S. Bank, downtown _%#CITY#%_. REVIEW OF SYSTEMS: No fevers, chills, cough, dyspnea, dysuria, diarrhea.
US|United States|US|179|180|REQUESTING PHYSICIAN|She then returned to Minnesota and was admitted here at Fairview Southdale Hospital per Dr. _%#NAME#%_. She is single but is involved in a long-term relationship. She is a former US Bank employee and is now retired. No past chronic history of pulmonary problems or cardiac problems.
US|United States|US|143|144|SOCIAL HISTORY|No recent change in doses. ALLERGIES: He has had adverse reactions to tetanus. SOCIAL HISTORY: He does not use tobacco or alcohol. He works at US Bank and is married. FAMILY HISTORY: Positive for migraine in his mother. He is not aware of any family history of strokes.
US|United States|US|132|133|SOCIAL HISTORY|MEDICATIONS: 1. Aspirin 162 mg a day. 2. Atenolol 25 mg p.o. b.i.d. SOCIAL HISTORY: The patient is a retired paramedic. He works at US Bank. He does not smoke. He consumes alcohol on a social basis, about 6-8 beers on a weekly basis. Last night, he had about 5 alcoholic beverages while he was out dancing.
US|ultrasound|US,|216|218|ASSESSMENT AND PLAN|We will most likely proceed with endoscopic ultrasound. Dr. _%#NAME#%_ _%#NAME#%_ will be covering the hospital and he will discuss the case with Dr. _%#NAME#%_ at Abbott Northwestern. If he agrees to proceed with a US, then we will try to get this done tomorrow afternoon. Further recommendations will follow. Thank you very much for asking us to participate in the care of this patient.
US|United States|US|121|122|SOCIAL HISTORY|SOCIAL HISTORY: The patient is widowed with her husband dying of lung cancer. She has had 3 children. She worked for the US government as a secretary, retiring in her 60s. No significant alcohol consumption. No significant caffeine consumption. She does not smoke.
US|United States|US|150|151|SOCIAL HISTORY|FAMILY HISTORY: The patient is adopted. MEDICATION: Refer to above. ALLERGIES: No history of allergies. SOCIAL HISTORY: The patient has served in the US Navy, he was stationed in _%#CITY#%_, CT. The patient does use tobacco products, approximately 1/2-3/4 pack of cigarettes per day.
US|United States|U.S.|149|152|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 27-year-old female, who emigrated from India, who experienced earlier today near drowning. She immigrated to the U.S. only within the last several years and was leaning how to swim after arriving here. Today she was in a pool with friends, fully clothed, practicing her swimming when she moved to a deeper part of the pool to practice holding her breath under water.
US|United States|U.S.|95|98||Mr. _%#NAME#%_ _%#NAME#%_ is a 53-year-old patient originally from Mexico. He has lived in the U.S. now for over 30 years. The patient is seen at this time by our service for continued evaluation of the patient's chronic liver disease, Laennec's cirrhosis and bacterial peritonitis.
US|United States|US|148|149|SOCIAL HISTORY|The remainder of review of systems is negative. SOCIAL HISTORY: The patient denies alcohol use. He smokes cigars. He is a retired machinist for the US Navy and has been exposed to multiple chemicals as well as asbestos. PHYSICAL EXAMINATION: GENERAL: This is a pleasant, older patient appearing his stated age.
US|United States|U.S.|133|136|SOCIAL HISTORY|No other significant history of family illnesses of any similar type. No major gastrointestinal family illnesses. SOCIAL HISTORY: In U.S. since nine months. He does smoke cigarettes, 1+ pack a day. Social alcohol use. No other illicit drug use. No recent travel history. REVIEW OF SYSTEMS: Currently feeling very nauseated, makes it difficult for him to communicate with me as he is concerned he is going to have emesis soon.
US|United States|US|156|157|HISTORY|She has had no particular workup but has had a negative PPD in the past and no obvious tuberculosis exposure. They go to Florida periodically. No Southwest US travel recently. No animal exposures. She has been around some children over Christmas with colds but nothing else significant.
US|United States|US|175|176|SOCIAL HISTORY|3. Fish oil. ALLERGIES: No known drug allergies. PAST SURGICAL HISTORY: None. FAMILY HISTORY: Non-contributory. SOCIAL HISTORY: He denies tobacco or alcohol use. He works for US Bank. He is married and has 2 children who are with him today. PHYSICAL EXAMINATION: The patient is alert, oriented, appears younger than his stated age.
US|United States|US|143|144|SOCIAL HISTORY|It should be recalled that she is an avid smoker. SOCIAL HISTORY: She lives with her husband. She tells me that she is a retired engineer from US West. She also tells me that she was recently involved in a group of senior engineers and she was supposed to lead this group of senior engineers.
US|United States|US|158|159|SOCIAL HISTORY|PAST MEDICAL HISTORY: 1. Seizure disorder. 2. No previous history of pneumonia, bronchitis, asthma. SOCIAL HISTORY: He is a life-long nonsmoker. He works for US Bank in investments and has quite a stressful job. He has two children, ages 12 and 8. No travel history. No occupational exposures. He does have a cat at home but he does not have any respiratory symptoms with exposure to the cat.
US|United States|U.S.|133|136|SOCIAL HISTORY|There has been no history of thyroid disease in the family. SOCIAL HISTORY: The patient is from the Philippines. He has lived in the U.S. for 17 years. The patient is married and has five children. Other social and family is as per the admitting physician.
US|United States|US|188|189|PHYSICAL EXAMINATION|Deep tendon reflexes are 2+ throughout. PSYCHIATRIC: Mood and affect are euthymic. The patient seems confused. Mini-mental exam: Did not know date, month, day, present location or current US President. ASSESSMENT/PLAN: Ms. _%#NAME#%_ is a 55-year-old female with a low- grade astrocytoma, status post resection.
US|United States|US|216|217|SOCIAL HISTORY|Mr. _%#NAME#%_ quit cigarette smoking in 1985. He has a 20-pack-year history. SOCIAL HISTORY: Mr. _%#NAME#%_ is married and has no children. They live in _%#CITY#%_ _%#CITY#%_ _%#CITY#%_, Minnesota. He works for the US Custom in Border Protection Services. He was assigned to work in Aruba for 6 years but because of his diagnosis was only there for 45 days.
US|United States|U.S.|193|196|SOCIAL HISTORY|ALLERGIES: Augmentin. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Unobtainable. SOCIAL HISTORY: The patient lives with his daughter. Retired. Originally from Korea but has lived in the U.S. for 20 years. PHYSICAL EXAMINATION: VITAL SIGNS: Please see nursing notes from today.
US|United States|U.S.|164|167|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a pleasant 64-year- old Caucasian male who presented in early _%#MM2005#%_ to his physician in _%#CITY#%_ _%#CITY#%_, U.S. Virgin Islands, with 3 months of right-sided nose bleeds and some fullness in his right nasal area. On exam, a mass in his right nasal cavity was seen and biopsied.
US|United States|U.S.|204|207|SOCIAL HISTORY|PAST SURGICAL HISTORY: None. FAMILY HISTORY: There is no family history of skin cancer or any other cancer. SOCIAL HISTORY: The patient lives with wife and owns a hardware store in _%#CITY#%_ _%#CITY#%_, U.S. Virgin Islands. He has lived there for the past 30 years. He has 2 sons who are also in the U.S. Virgin Islands.
US|United States|U.S.|76|79|SOCIAL HISTORY|He has lived there for the past 30 years. He has 2 sons who are also in the U.S. Virgin Islands. He is a smoker of pipes for 25+ years, and just recently quit in _%#MM2005#%_. He drinks about a glass of wine per day. MEDICATIONS: None currently.
US|United States|U.S.,|194|198|ASSESSMENT|Recommended an appointment with urology, also starting Cipro, perspectively awaiting the urine culture. Also, recommended they establish an internist to manage her cirrhosis while she is in the U.S., they will consider that, but she would rather return to China for ongoing medical care. At the time the patient and her husband have elected to leave, will follow up with urology as needed, they would like to try the antibiotic to see if that will clear the hematuria, they will consider returning to the University of Minnesota for further evaluation of her cirrhosis, but have not made a firm decision on that yet.
US|United States|US,|122|124|PHYSICAL EXAMINATION|Her speech is fluent. She has good current knowledge and is alert and oriented x3. She knows the current president of the US, but not the previous one. HEENT: Her pupils are equally reactive to light. Extraocular movements are full without nystagmus.
US|United States|US|163|164|SOCIAL HISTORY|PAST MEDICAL HISTORY/PAST SURGICAL HISTORY: None. ALLERGIES: None. MEDICATIONS: None. SOCIAL HISTORY: He is a Mexican immigrant. Former smoker. He has been in the US for three months. FAMILY HISTORY: Review of systems unobtainable. The patient is sedated on the ventilator.
US|United States|U.S.|161|164|REVIEW OF SYSTEMS|ALLERGIES: None. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Does have animals at home, but no significant bird exposures, etc. No significant Southwest U.S. travel other than the _%#CITY#%_ _%#CITY#%_ trip, as above. The review of systems is largely as listed above. In addition to those symptoms, he has also had some prominent skin changes over the last several months with a scaling, eczematous-type reaction, occurring primarily on his legs.
US|United States|US|157|158|SOCIAL HISTORY|He is in the skating club and has a lot of friends through this including a coach whom the family is very close to. He is an only child. His father works at US Bank. His mother was working as a teacher's assistant, however, is not now secondary to her son's illness and setbacks. They have a large social support network. In addition, he has an aunt who comes in from _%#CITY#%_ once a month to be with the family.
US|United States|U.S.|291|294|HISTORY OF PRESENT ILLNESS|_%#NAME#%_ _%#NAME#%_ is a 48-year-old Russian American woman, referred by Dr. _%#NAME#%_ _%#NAME#%_ at _%#CITY#%_ Family Physicians to Dr. _%#NAME#%_ _%#NAME%#_ of Southdale Weight Loss Surgery. The patient has lived in the United States for approximately 8 years. The patient moved to the U.S. from Russia. The patient does report that she speaks English (primarily broken English) and does not need an interpreter. The patient reports she has noticed significant increase in weight gain since a vaginal hysterectomy ten years ago.
US|United States|US|153|154|FAMILY HISTORY|Her two children; ages 8 and 6, have both had flu-like symptoms in the last 7 days, her husband has as well. Incidentally, this patient did serve in the US Army from 1990 to 1992 and she states that she received some hepatitis shots at that time. REVIEW OF SYSTEMS: HEENT: History of migraine headaches in the past.
US|United States|U.S.|189|192|SOCIAL HISTORY|Two children are well. SOCIAL HISTORY: The patient does not use tobacco products. He has not used alcohol to excess. He has had 20 years in the military including the army, coast guard and U.S. Air Force and a reserve unit. The patient has worked in a warehouse unit. REVIEW OF SYSTEMS: HEENT: Unremarkable.
US|United States|US|206|207|II.|7. Cozaar 8. Humalog insulin 9. Lipitor 10. Neurontin ALLERGIES: Codeine, Altace and latex I believe the patient had smoked approximately 1 pack of cigarettes a day for 60 years. He served two years in the US Navy during World War II. PHYSICAL EXAMINATION: Blood pressure is 173/75, pulse 72. O2 sats 94% on room air.
US|United States|US|165|166|IMPRESSION|Asked by Dr. _%#NAME#%_ to provide antibiotic recommendations. IMPRESSION: 1. _%#NAME#%_ _%#NAME#%_ is a 26-year-old female, native of Somalia, who has lived in the US x8 years. She was admitted with acute right wrist pain and swelling and at surgery was found to have cloudy fluid suggesting septic wrist.
US|United States|US|160|161|SOCIAL HISTORY|SOCIAL HISTORY: Married and is vice-president in general contractor, quit smoking 20 years ago. Travel history as above. No recent foreign travel. No Southwest US travel recently. REVIEW OF SYSTEMS: No significant abdominal symptoms, diarrhea, nausea, vomiting, skin rashes, musculoskeletal symptoms.
US|United States|US|145|146|SOCIAL  HISTORY|FAMILY HISTORY: Negative. SOCIAL HISTORY: The patient is an assistant manager of the employee cafeteria in Mystic Lake Casino. His wife works at US Bank, and they have two children. The patient smokes 5-6 cigarettes per day. He smoked from the age of 19-35, quit for four years and has been smoking again since that time.
US|United States|U.S.|144|147|SOCIAL HISTORY|They are Somali and two of his older siblings were born in Kenya and two more of them were born in Somalia. The other children were born in the U.S. REVIEW OF SYSTEMS: No fever for the last 24 hours, but intermittent low-grade fevers on previous days.
US|United States|U.S.|144|147|SOCIAL HISTORY|CURRENT MEDICATIONS: In the hospital include Protonix drip 8 mg per hour. SOCIAL HISTORY: The patient works in assembly line, immigrated in the U.S. in 1979. He smokes 2 cigars per day. History of heavy alcohol abuse for many years, but only drank on the weekend.
US|United States|US|191|192|HISTORY|He has no particular history of major parasitic infections or other exposures he knows. He has no history of family or him of tuberculosis. He apparently had a negative PPD on immigration to US from Liberia in 2002. PAST MEDICAL HISTORY: Comes from Liberia. Did not have major illnesses there prior to transfer and in general, he has not had major medical problems.
US|United States|U.S.|130|133|HISTORY|No significant unexplained febrile illnesses in the past. No history of tuberculosis or exposure is known. No travel to Southwest U.S. No travel within Minnesota to any typical Lyme's endemic areas. He has had no recent insect bites, tick bites, or similar problems.
US|United States|US|227|228|SOCIAL HISTORY|The patient denied abdominal pain with this episode. His weight, appetite, and bowel function had been completely stable. SOCIAL HISTORY: The patient went to _%#CITY#%_ _%#CITY#%_ State. He is a computer programmer, working at US Bank, I believe, in _%#CITY#%_ _%#CITY#%_. He is from _%#CITY#%_. FAMILY HISTORY: Mother had peptic ulcer disease. There are no other major medical problems identified. REVIEW OF SYSTEMS: The patient's review of systems is essentially negative except, of course, for GI where the patient has experienced the vomiting with coffeegrounds material, melena, and the lightheadedness.
US|ultrasound|US,|213|215|HPI|Tumor on left by ultrasound extends through capsule. Assessment and Plan: We are recommending combined modality therapy for Mr. _%#NAME#%_. Locally advanced prostate cancer although SV involvement was not seen by US, an MRI may be reasonable. Risks and benefits of this approach were discussed at length.
US|United States|US|125|126|SOCIAL HISTORY|2) No other significant illnesses. 3) No history of hepatitis. 4) No major surgery. SOCIAL HISTORY: Again, he is employed at US Bank in _%#CITY#%_. He is a graduate of the University of Kansas. FAMILY HISTORY: Parents are well. A sister died of pneumonia. A brother died in an automobile accident.
US|United States|U.S.|244|247|PHYSICAL EXAMINATION|Mr. _%#NAME#%_ is a 34-year-old gentleman seen in my office at the request of Dr. _%#NAME#%_ _%#NAME#%_ for my initial orthopedic consultation with regard to his right arm. He is a left-hand-dominant marshall arts instructor. He is also on the U.S. Kickboxing team and is expected to participate in the Kickboxing Word Championships in _%#MM#%_, 2004. He apparently took a silver last year in these world championship competitions.
US|United States|US|188|189|SOCIAL HISTORY|PAST SURGICAL HISTORY: None. ALLERGIES: No known medication allergies, though she may have had a recent cephalosporin reaction per patient. SOCIAL HISTORY: Married. Recently served in the US Army and plans to move to _%#CITY#%_ _%#CITY#%_ in upstate _%#CITY#%_ _%#CITY#%_ in one month. Alcohol and tobacco: None. FAMILY HISTORY: Diabetes mellitus, diabetes insipidus, thyroid disease: None reported.
US|United States|U.S.|129|132|SOCIAL HISTORY|FAMILY HISTORY: Significant for a son and a daughter who have what sound like febrile seizures. SOCIAL HISTORY: He works for the U.S. Postal Service as a letter carrier. He does drive as part of his work as well. PHYSICAL EXAMINATION: Patient is a well-developed, well- nourished, pleasant white male, resting comfortably in the hospital bed.
US|United States|US|140|141|SOCIAL HISTORY|A maternal grandmother had a similar event. Mother has no history of seizure, headaches, or staring spells. SOCIAL HISTORY: _%#NAME#%_ is a US citizen; he was born here. Mother was born in the Bahamas, educated in Nebraska and in England, and is a graduate of Buckingham Law School there.
US|United States|US|120|121|SOCIAL HISTORY|SOCIAL HISTORY: Smokes 2 packs per day, occasional alcohol. SOCIAL HISTORY: He lives with his niece. He has been in the US for 26 years, Laotian descent. Worked on assembly line here. Is single. ALLERGIES: None. MEDICATIONS: 1. Duonebs 3 cc every 4 hours for shortness of breath.
US|United States|US|154|155|SOCIAL HISTORY|SOCIAL HISTORY: The family lives in _%#CITY#%_ _%#CITY#%_, the mother worked at IDS tower at American Express prior to raising a family. Father works for US Bank as an analyst. There is an older 2 year old sister in good health. No tobacco exposure. REVIEW OF SYSTEMS: Finds the child has passed meconium, she is remaining n.p.o. and starting on fluid 60 cc/kilo, there has been urine output, blood pressures have been stable, no problems with skin have been identified.
US|United States|U.S.|201|204|SOCIAL HISTORY|ALLERGIES: Penicillin and Prevacid. FAMILY HISTORY: She states she does not know of anyone in her family with mental health or chemical dependency problems. SOCIAL HISTORY: She works currently for the U.S. Postal Service. She states that she has not had any problems regarding her work until just this past week. For the rest of her social history see current chart notes.
US|United States|U.S.|176|179|SOCIAL HISTORY|ALLERGIES: He has no known drug allergies. SOCIAL HISTORY: He is a nonsmoker, nondrinker, is a painter by occupation. He is married and lives with his wife. He has been in the U.S. for 7 years. Married for 12 years. He has 4 children, ages 7, 5, 3 and 1. He has some family back in Kazakhstan. FAMILY HISTORY: Malignancy in a sister, but he is unclear of what type.
US|United States|U.S.|209|212|SOCIAL HISTORY|FAMILY HISTORY: Reviewed per the chart and is noncontributory to his genitourinary presentation. SOCIAL HISTORY: The patient is Laotian American heritage. He lives in _%#CITY#%_, Minnesota. He was born in the U.S. He has no recent travel. PHYSICAL EXAMINATION: VITAL SIGNS: Reviewed per the electronic record and afebrile, stable and normal for age.
US|United States|U.S.|197|200|HISTORY OF PRESENT ILLNESS|He has a history of Alzheimer's dementia. He has a history of hypertension and hypercholesterolemia. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a very pleasant 80-year-old veteran of the U.S. Army who served in World War II in the artillery who presented to the emergency room with failure to thrive. He was found down at his assisted living facility on _%#MMDD2006#%_.
US|United States|US.|230|232|PMH|Family History: This is the first child to this couple of African descent, recent immigrants. Social History: The father is a physician trained abroad, and currently pursuing additional training locally to obtain a license in the US. ROS: Question of immunizations. Physical Examination: Caleb appears alert, happy, and well developed in no apparent distress in his parent's arms.
US|United States|US|215|216|SOCIAL HISTORY|FAMILY HISTORY: Patient's mother suffered from high cholesterol. She has siblings with high blood pressure and high cholesterol. SOCIAL HISTORY: The patient is married. She has two children. She works full-time for US Banks. She is a nonsmoker with rare alcohol use. REVIEW OF SYSTEMS: GENERAL: This is a 54-year-old Caucasian female who denies any recently history of fevers, chills, or night sweats.
US|United States|U.S.|169|172|SOCIAL HISTORY|SOCIAL HISTORY: The patient has not used tobacco products nor alcohol to excess. He served in the Army Air Corps for five years in World War II. He was stationed in the U.S. and taught flying. The patient's surgery consists of shoulder surgery.
US|United States|U.S.|177|180|SOCIAL HISTORY|PAST MEDICAL HISTORY: No previous hospitalizations, surgeries or chronic medical problems. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Married and lives at home. Works for U.S. Bank corporate offices. ALLERGIES: None known. REVIEW OF SYSTEMS: Intermittent fevers as described above.
US|United States|US|147|148|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 26- year-old female native of Germany who recently returned from Germany to work in the US as an au-pair. She developed some light-headedness at the home she is living at, fell and apparently fractured her ankle.
US|ultrasound|US|144|145|IMPRESSION|Her duct had been noted to be about 7 mm in the past, I think this bears further workup. I will do an MR. We can consider whether she needs any US or ERCP to follow. I will repeat her LFTs, looking for evidence of common duct process.
US|United States|US|139|140|SOCIAL HISTORY|SOCIAL HISTORY: The patient lives in a house in _%#CITY#%_ _%#CITY#%_ with his brother. He has no children. He is a computer specialist at US bank. He is an immigrant from Thailand 32 years ago. REVIEW OF SYSTEMS: Currently, is dominated by postsurgical pain, otherwise a 10 review of systems is entirely negative.
US|United States|U.S.,|102|106|SOCIAL HISTORY|He apparently does not have any other major health problems, however. SOCIAL HISTORY: He lives in the U.S., at the present time in _%#CITY#%_. He has traveled and lived in many parts of the world but is originally from Somalia.
US|United States|U.S.|131|134|SOCIAL HISTORY|PAST SURGICAL HISTORY: Appendectomy. He has never had a blood transfusion. SOCIAL HISTORY: He is an accountant. He has worked with U.S. Bank for the past seven years. He rents a dwelling. He has been separated from his wife for the past three years.
US|United States|US|150|151|SOCIAL HISTORY|FAMILY HISTORY: No inherited diseases. She has one child who is a 4-year-old boy who is alive and well. SOCIAL HISTORY: She is married. She works for US Bank. She has one son. REVIEW OF SYSTEMS: As indicated above. PHYSICAL EXAMINATION: GENERAL: Young female lying in bed. She is awake, alert, arousable, answers questions appropriately.
US|United States|U.S.|106|109|SOCIAL HISTORY|However, at Ridges, she was listed to be on Tylenol, Paxil and Prilosec. SOCIAL HISTORY: She lives in the U.S. She does not smoke, and she does not drink. FAMILY HISTORY: Unknown per the patient. REVIEW OF SYSTEMS: Complete review of systems was performed with the interpreter present and is negative with the exclusion of the elements listed in the HPI.
US|United States|US|197|198|SOCIAL HISTORY|9. Avandia 4 mg p.o. daily. FAMILY HISTORY: Negative per patient for any history of GI malignancies. SOCIAL HISTORY: No alcohol or tobacco. The patient was a veteran of World War II, served in the US Army Medical Corps, was involved with the linkup with the Soviet Union at _%#CITY#%_. Worked in the ____________. PHYSICAL EXAMINATION: VITAL SIGNS: His vital signs are stable.
US|United States|US|176|177|SOCIAL HISTORY|There has been no history of blood transfusions, nor needle stick exposure. There has been no tattoos and no use of intravenous drugs. The patient incidentally has been in the US for now 11 years. FAMILY HISTORY: Parents apparently are in good health. Siblings are well.
US|United States|U.S.|231|234|SOCIAL HISTORY|7) OxyContin. 8) Senna-S. 9) Fosamax. 10) Caltrate. 11) No obvious medications to cause drug fever, but certainly has to be a consideration as well. SOCIAL HISTORY: No significant travel recently. She has not been to the Southwest U.S. in any recent times. Has had extensive foreign travel previously but not to any third-world countries. She previously worked as a school teacher but never had any significant exposure, including negative PPDs throughout that time.
US|United States|U.S.|239|242|ALLERGIES|PAST MEDICAL HISTORY: 1. B cell lymphoma. 2. Carcinoma of the prostate with previous prostatectomy. SOCIAL HISTORY: Married and lives at home. ALLERGIES: His immigrant Korean daughter had active pulmonary tuberculosis when she came to the U.S. in 1979. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Recent recently discovered fever in the hospital, malaise.
US|United States|US|140|141|SOCIAL HISTORY|He is adopted. SOCIAL HISTORY: He smokes 1/2 pack per day. He lives with his wife, 2 stepdaughters, and 1 son. He is a shift supervisor for US Steel. PHYSICAL EXAMINATION: He is a healthy appearing male, in no acute distress.
US|United States|US|212|213|SOCIAL HISTORY|PAST SURGICAL HISTORY: Appendectomy 20 years ago. PAST MEDICAL HISTORY: Kidney stone passed four or five years ago. No recurrences of it. SOCIAL HISTORY: Stay-at-home dad with four children. He used to work with US Banks. He is basically on a Sabbatical. His partner is not here. Children include twins age 8, 6 and 2. Nonsmoker. Social drinker only. REVIEW OF SYSTEMS: Denies any pulmonary, cardiac or renal problems.
US|ultrasound|US|159|160|PLAN|2. Repeat liver tests within one week. 3. Upper endoscopy to be scheduled. 4. If all the above is otherwise unremarkable will then proceed with either MRCP or US versus proceed directly to ERCP to rule out common duct stones or pathology. Obviously the above will be predicated on an unremarkable cardiac evaluation.
US|United States|U.S.|158|161|SOCIAL  HISTORY|No home medications. ALLERGIES: None. FAMILY HISTORY: Noncontributory. No history of renal disease. SOCIAL HISTORY: The patient is Hmong. He has lived in the U.S. for 28 years. He is married with children in town. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.4, blood pressure 160s/80s-90s, heart rate in the 70s.
US|United States|U.S.|140|143|SOCIAL HISTORY|No other family history is available. SOCIAL HISTORY: She lives with her mother and sister in _%#CITY#%_. Mother is Somali, has been in the U.S. since 1997. Father lives in Canada. No other information is available. CURRENT MEDICATIONS: 1. Amphotericin B. 2. Cefotaxime. 3. Protonix. 4. Bactrim. 5. Vancomycin.
US|United States|U.S.|116|119|FAMILY HISTORY|The patient is awake and alert to person only. He does not recall easily the date or the place. He cannot state the U.S. president. His memory is 0 out of 3 objects at five minutes. He is able to repeat. His speech is fluent. NEUROLOGICAL: His pupils are 3.5 mm, equal, and reactive bilaterally.
US|United States|US.|179|181|DOB|There is no family history of any inflammatory bowel disease of which she is aware. She has had no contact with anyone with any similar illness. She has had no travel outside the US. She has not been on any antibiotics in the recent past. Her current medications include Zoloft for depression and also a diet pill, which she has been taking for the past month.
US|United States|U.S.|185|188|HISTORY OF PRESENT ILLNESS|The patient said that she has been in the United States for about 10 years and has not had any medical care prior. She said today was her first physical examination since coming to the U.S. She had not had a pelvic examination prior to today, and has not been sexually active in a number of years. The patient had come in for routine physical examination in Dr. _%#NAME#%_'s office.
US|United States|U.S.|230|233|PAST MEDICAL HISTORY|He sought medical attention. Repeat scans and intervention showed obvious osteomyelitis at the area of old fracture, and surgical intervention is now planned. PAST MEDICAL HISTORY: From Somalia. Known PPD positive on entry to the U.S. here with negative chest x-ray, treated with a course of INH. He has had no suggestions of active tuberculosis since that time.
US|United States|US|132|133|SOCIAL HISTORY|Negative family history for liver disease or inflammatory bowel disease. SOCIAL HISTORY: The patient lives independently, works for US Banksystems. She does not use tobacco or alcohol, only uses aspirin on a p.r.n. basis, no NSAIDs. REVIEW OF SYSTEMS: Negative for headache, seizure, syncope. She does wear glasses.
US|United States|US|163|164|SOCIAL  HISTORY|FAMILY HISTORY: His father had colon cancer and died from it. SOCIAL HISTORY: The patient is married. He has a grown son and daughter. He is a systems analyst for US Bank. He lives with his wife in _%#CITY#%_ _%#CITY#%_, Minnesota. He comes to today's appointment by himself. REVIEW OF SYSTEMS: Fully documented in the nurse's notes of _%#MMDD2006#%_ and is otherwise negative.
US|United States|U.S.|90|93|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 53-year-old Egyptian male who is a U.S. citizen. Seven years ago, the patient had moved back to Egypt. He recently returned from Egypt two weeks ago and has been staying with a friend.
US|United States|US|39|40|SOCIAL HISTORY|SOCIAL HISTORY: He is a veteran of the US Air Force, retired in 1972 and was a professional truck driver. No smoking since 1976. Social alcohol consumption once or twice a weekend.
US|ultrasound|US|341|342|PAST SURGICAL HISTORY|PAST MEDICAL HISTORY: Significant for stroke, hypertension, coronary artery disease, chronic obstructive pulmonary disease, chronic anemia, prostate cancer, hilar hernia, erosive gastritis, tobacco use, and distant alcohol use. PAST SURGICAL HISTORY: Radical prostatectomy in 1998, left shoulder surgery in 1995, appendectomy in 1956, and a US procedure both in 1999 and approximately 2002. MEDICATIONS: Medications are reviewed in the chart. ALLERGIES: None. PHYSICAL EXAMINATION: The patient is lying comfortably in bed in no acute distress.
US|United States|U.S.|210|213|SOCIAL HISTORY|FAMILY HISTORY: There is no change in the family history from previous consultations. SOCIAL HISTORY: Social history has changed in that father is now asking for social service help for the sister who may be a U.S. citizen because of prolonged hospitalization and cost. LABORATORY DATA: Laboratory studies show good oxygenation and no active sepsis.
US|United States|U.S.|156|159|HISTORY OF PRESENT ILLNESS|She feels that the IV medication for pain helps her better than the Vicodin she was getting. She also admits to feeling depressed. She has just been in the U.S. for one month and came to the U.S via Egypt where she went after her flight from Somalia during the war.
US|United States|US|133|134|SOCIAL HISTORY|Two daughters live close by and a son lives outside of the _%#CITY#%_ _%#CITY#%_. She has been widowed for many years. She worked at US Bank for several years before she became ill. SPIRITUAL BACKGROUND: The patient describes her spirituality as "private." She was raised Methodist but has not been to the institutional church in some time.
US|United States|US|147|148|SOCIAL HISTORY|She is married to an American who is now a missing person. His mother is still involved in her care. She has two children. Her son has been in the US for three weeks, her daughter for two weeks. Everyone speaks French only. The patient has been able to interact somewhat with conversation until today; she has been unable to communicate at all today regarding her wishes for care or her ability to communicate discomfort.
US|United States|US|280|281|HISTORY OF PRESENT ILLNESS|She is not complaining of neck pains or stiffness. The patient stated that she fell to the floor after being struck, but there was no head injury or loss of consciousness. The patient is currently having personal problems with relationship and has been depressed. She came to the US about 2 years ago from Ethiopia. She denies alcohol and drug use. She has no other neurological complaints at this time.
US|United States|U.S.|145|148|SOCIAL HISTORY|There are no known drug allergies. FAMILY HISTORY: The family history is remarkable for diabetes in her mother. SOCIAL HISTORY: She lives in the U.S. and has supportive family. She does not use alcohol, tobacco, or caffeine. REVIEW OF SYSTEMS: Before surgery, she was feeling fine without nausea, vomiting, fever or chills, chest pain, shortness of breath, cough, sore throat, rhinorrhea, or headache.
US|United States|US|190|191|FAMILY HISTORY|No history of cancer. He has been divorced. He has 3 children whom he has lost contact with, but knows they live in Oregon. He is a nonsmoker. Alcohol use is minimal. He is retired from the US Air Force. He also worked at the FAA for a period of time, fully retired in 1996. He has an interesting fellow and is involved in paranormal investigations.
US|United States|U.S.|168|171|HISTORY|He has had no significant travel history recently. Not been out of the country in recent years. No significant Northern Minnesota travel. Has not been to the Southwest U.S. in recent times. No other exposures, although he was at a wedding where there were 600 people just prior to the onset of this illness.
US|United States|US|138|139|SOCIAL HISTORY|SOCIAL HISTORY: The patient has not used tobacco products nor alcohol. The patient worked approximately 30 years at Northwestern Bell and US West. MEDICATIONS: The patient is on numerous medications, as follows: 1) Vitamin B-12.
US|United States|U.S.|181|184|HISTORY|It sounds like he may have had a similar infection years ago, which was treated bluntly with a "fingernail" to the back of the throat. He is a citizen of Nigeria but is here in the U.S. as a resident worker. PAST MEDICAL HISTORY: No ongoing medical problems. MEDICATIONS: Takes no medicines routinely.
US|United States|U.S.|191|194|SOCIAL HISTORY|He has no abdominal pain. PAST MEDICAL HISTORY: His past medical history includes coronary artery bypass surgery. SOCIAL HISTORY: He is retired and lives with his family. He has lived in the U.S. for 10 years. REVIEW OF SYSTEMS: His review of systems otherwise is negative, as best I can tell.
US|United States|U.S.|193|196|SOCIAL HISTORY|Autoimmune: Negative. Neurologic: Negative. ALLERGIES: NONE known. MEDICATIONS: Ibuprofen, Cefzil and Premarin 0.625. SOCIAL HISTORY: The patient is married and has two children. She works for U.S. Banks. She denies smoking or drinking. She has lived in Minnesota for 23 years. She is a native of the Soviet Union and speaks fluent English.
US|United States|US|109|110|SOCIAL HISTORY|FAMILY HISTORY: Apparently no other heart or kidney history. Mother has asthma. SOCIAL HISTORY: Moved to the US two years ago from Bosnia, lives in Idaho. Was a miner and may have developed some pulmonary disease related to that.
US|United States|U.S.|177|180|SOCIAL HISTORY|SOCIAL HISTORY: The patient does not use tobacco products. He rarely uses alcohol. He has one cup of coffee per day. The patient served in the military from 1978 to 1981 in the U.S. Navy. The patient is currently employed in heating and air conditioning. FAMILY HISTORY: Father had prostate cancer. Mother is well. Siblings are well.
US|United States|US|103|104|SOCIAL HISTORY|PAST MEDICAL HISTORY: Asthma, negative PPD skin test upon immigration. SOCIAL HISTORY: She has been in US for 12 years. There is no seasonal allergy. In Somali she was exposed to smoke from wood for cooking. She has no pets at home. FAMILY HISTORY: Negative for asthma or eczema in the family.
US|United States|U.S.|168|171|SOCIAL HISTORY|There is no documented past history of peptic ulcer disease or prior gastrointestinal blood loss. SOCIAL HISTORY: The patient moved from Vietnam with his family to the U.S. in 1991. The patient is married. He has three children. He smokes 2-3 cigarettes a day. He does not use alcohol to excess. PAST SURGICAL HISTORY: None.
US|United States|U.S.|132|135|SOCIAL HISTORY|SOCIAL HISTORY: The patient was born in mainland China and moved to _%#CITY#%_ until about 15 or 16 years ago when she moved to the U.S. She was working as an accountant prior to her diagnosis. She is married and her husband is an engineer. She lives in _%#CITY#%_ _%#CITY#%_ and has one child in college.
US|United States|US|143|144|SOCIAL HISTORY|The radiologist felt it was compatible with possible pericardial metastases. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She is a retired US Postal supervisor. She is a very independent and active lady who has been retired now for about 5 years and normally provides day care for 2 of her young grandchildren.
US|ultrasound|US|117|118|PLAN|2. Gastric polypoid lesion at the EG junction of uncertain significance as the bleeding source. PLAN: 1. We will get US and pill cam reports. 2. Consider enteroscopy, although prior upper endoscopy and pill cam studies negative for duodenal AVMs. 3. Consider repeat colonoscopy as last done in 2004.
US|United States|U.S.|150|153|RECOMMENDATIONS|RECOMMENDATIONS: 1. Check Lyme titer. 2. Watch off systemic antibiotics. This is a 30-year-old male Jordanian immigrant physician who has been in the U.S. for two years. About four days ago he began to note the above symptoms. He was seen in the emergency room where on _%#MMDD#%_ he underwent lumbar puncture with finding of a 5 white blood cells.
US|United States|US|117|118|SOCIAL HISTORY|She exercises regularly, and she felt well until ten days ago. She drives a car. She works as a marketing person for US Bank. REVIEW OF SYSTEMS: Until the last ten days was entirely negative.
US|United States|US|162|163|SOCIAL HISTORY|MEDICATIONS: Lisinopril, Zantac, chlorpropamide. SOCIAL HISTORY: He has seven children, lives with his wife and daughter. He does church work. He has been in the US for 22 years. REVIEW OF SYSTEMS: Positive for cough and sputum and some mild shortness of breath, nausea and vomiting, but is otherwise negative.
US|United States|US|282|283|DOB|DOB: _%#MMDD1962#%_ Mr. _%#NAME#%_ _%#NAME#%_ is a 43-year-old, who has been seen by the Allergy Clinic in the past and reports over the past four weeks chest tightness and cough productive of some sputum when would first get up in the morning. This quickly cleared. He went to the US Open Tennis Tournament in _%#CITY#%_ _%#CITY#%_, and both he and his wife and children returned with colds. Saturday, he noted clear runny nose, postnasal drip, itching of the throat, but not the nose or the eyes, sneezing, nasal congestion, sore throat, chest tightness, and dry cough with no wheeze.
US|United States|U.S.|199|202|SOCIAL HISTORY|REVIEW OF SYSTEMS: The patient denies paroxysmal nocturnal dyspnea, orthopnea, claudication, peripheral edema or syncope. SOCIAL HISTORY: The patient is single. He is currently not employed. He is a U.S. veteran and gets most of his care at the VA Hospital. It sounds like his life centers around his medical care.
US|United States|U.S.|157|160|HISTORY|The patient has a history of being a Nigerian immigrant and travels frequently back to Africa including essentially over the last year. She came back to the U.S. on _%#MMDD#%_ at which time she had been off many of her diabetes meds and had poorly-controlled diabetes.
US|ultrasound|US|195|196|HISTORY OF PRESENT ILLNESS|With this episode with this episode, he also noted some preceding gas and diarrhea, but that has totally resolved and that was approximately 5-6 days ago. The patient is scheduled for outpatient US with Dr. _%#NAME#%_ on _%#MMDD2006#%_. The patient is still having considerable pain today as well as some nausea, no current emesis.
US|ultrasound|US|175|176|ASSESSMENT|Today, the amylase 191 and lipase is 11/06. ASSESSMENT: Recurrent pancreatitis of unclear etiology. No readily evident risk factors noted. No evidence for obvious gallstones. US has already been scheduled. PLAN: 1. Supportive care to be administered with pain control, IV fluids, n.p.o.
US|ultrasound|US|217|218|PLAN|US has already been scheduled. PLAN: 1. Supportive care to be administered with pain control, IV fluids, n.p.o. 2. Call will be placed to Dr. _%#NAME#%_ regarding this interim change in status, but expect the date of US will remain the same, pending outcome of this current hospitalization.
US|United States|US|154|155|FAMILY HISTORY|Mother died at 84 of uterine cancer. A sister is in a home in _%#CITY#%_ with multiple sclerosis. The patient has step-children. He has not served in the US Military. REVIEW OF SYSTEMS: HEENT: Negative. Cardiorespiratory: Negative. Gastrointestinal: See history of the present illness.
US|United States|US|162|163|HISTORY OF PRESENT ILLNESS|REASON FOR CONSULTATION: Mental status changes and edema on head CT. HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old Ethiopian male who has lived in the US for the last 8 years, who was noted by his family to have altered mental status over the last 2 weeks.
US|United States|US|212|213|HISTORY OF PRESENT ILLNESS|REASON FOR CONSULTATION: Consideration for radiotherapy. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is an 80-year-old male with a past medical history significant for testicular carcinoma, treated in 1961 at the US Naval Hospital in _%#CITY#%_, Maryland with orchiectomy followed by external beam radiation; prostate cancer, Gleason 3+3, diagnosed in _%#MM1999#%_, treated with watchful waiting; high-grade adenoma of the colon, status post right hemicolectomy; basal cell carcinoma of the lower abdominal skin, status post excision _%#MMDD2007#%_.
US|United States|US|132|133|SOCIAL HISTORY|HABITS: One pack per day smoker. Alcohol use as above. No other chemical use. SOCIAL HISTORY: Married. Three children. Retired from US West. REVIEW OF SYSTEMS: Night sweats one to two times monthly, nonprogressive.
US|United States|U.S.|127|130|HISTORY|He does travel around the U.S. and in fact has been in _%#CITY#%_ recently, but has not had any recent travel to the southwest U.S. and has had no significant foreign travel. No significant risk factors from an HIV standpoint, hepatitis or other risk factors.
US|United States|U.S.|150|153|SOCIAL HISTORY|SOCIAL HISTORY: _%#NAME#%_ lives with his mother and three siblings and cousin in _%#CITY#%_. His father lives in Somalia. _%#NAME#%_ was born in the U.S. and his family emigrated here 6-1/2 years ago from Somalia. FAMILY HISTORY: No family history of ALD. REVIEW OF SYSTEMS: General: _%#NAME#%_ currently has a cold, and otherwise feels well.
US|United States|U.S.|240|243|SOCIAL HISTORY|MEDICATIONS: As an outpatient include Glucovance, Actos, Hyzaar and Toprol, Plavix, Zocor, Furosemide and potassium chloride. SOCIAL HISTORY: Obtained in her records once again shows that she is widowed and has previously lived in southern U.S. She has smoked cigarettes in the past but quit several years ago after approximately 40-pack-year of cigarette use.
US|ultrasound|US.|140|142|RECOMMENDATIONS|Will discuss with ultrasonographer if some local treatment such as alcohol injection would be reasonable presuming the mass is confirmed at US. Other possibility would be radiation therapy to the head of the pancreas. Lastly, pancreatic stenting generally not done for malignant processes. I believe it okay to discharge from out standpoint except for recently noted fever.
US|ultrasound|US|158|159|PLAN|PLAN: At this time support fluid wise. Advance diet as tolerated. Observe lipase as it seems to be climbing. Will not advance diet currently. Plan outpatient US within the next 1-2 weeks. Colonoscopy within the next 6-8 weeks. Will review MRCP results of _%#MM#%_ with Dr. _%#NAME#%_ further after reevaluation with Dr. _%#NAME#%_.
US|United States|US|249|250|SOCIAL HISTORY|Reportedly, his mother had a history of CNS vasculitis. MEDICATIONS: Medications on admission include Altace, aspirin, Plavix, Lipitor, metoprolol, ibuprofen 150 mg SR b.i.d. SOCIAL HISTORY: Notable for him living with his mother. He is back in the US now for only a month. Prior to that, he was unable to leave Korea because of legal problems. He denies any history of chemical abuse, alcohol abuse. He reportedly drinks only socially.
US|United States|U.S.|178|181|RECOMMENDATIONS|5. If she is not improved with the above, would consider bronchoscopy. _%#NAME#%_ _%#NAME#%_ is an 80-year-old female who is originally from Afghanistan but who has lived in the U.S. for eight years. She was visiting a grandson here in the _%#CITY#%_ _%#CITY#%_ and usually resides in _%#CITY#%_ _%#CITY#%_. She was doing well until the day prior to admission when she developed fever to 103 degrees with cough productive of yellow sputum, increasing shortness of breath and some right sided neck pain.
US|United States|U.S.|133|136|SOCIAL HISTORY|FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Widowed. Lives in _%#CITY#%_ _%#CITY#%_. Native of Afghanistan who has lived in the U.S. for over eight years. REVIEW OF SYSTEMS: Unobtainable. PHYSICAL EXAM: VITALS: Temperature 100.4, blood pressure 127/74, heart rate 88 and regular.
US|United States|US|127|128|HISTORY OF PRESENT ILLNESS|Off medication for approximately 3 months. Associated issue of PTSD when the patient involved in an explosion while working at US Steel. Resultant burns to her face, extremities, and "lungs." Incident occurred in 1996. No lingering clinical sequela otherwise. She has had ongoing insomnia with reduced appetite and fatigue.
US|United States|U.S.|195|198|RECOMMENDATIONS|This is a 28-year-old male, native of India who has worked in the United States as a software engineer and in the month of _%#MM#%_ had returned to India where he was married. He returned to the U.S. on _%#MMDD2007#%_. A few days later he began to note headaches and fever. The headaches have subsequently resolved, but fevers have persisted. He went to urgent care where he was given nonsteroidal anti-inflammatory.
US|United States|U.S.|192|195|ASSESSMENT/PLAN|4. Disposition: The patient wants to go home after her antibiotics are finished. Her daughter is coming from Korea today to take care of her. Patient stated that her daughter came back to the U.S. to also care for her husband before he died. Recommend care conference with primary physician, TLC team, and patient's children to discuss plan of care.
US|ultrasound|US|90|91|HPI|My key findings: CC: 62-year-old male with L2 metastases. HPI: Diagnosed 1998. Treated by US to T3-T6 region, now diagnosed with mass at L2, L3 region. Exam: No muscle weakness in LE. Patient has pain radiating down L LE.
US|United States|U.S.|151|154|HISTORY|He does not go to lake places. He has not cleaned out any sheds or similar type areas. He is an over-the-road trucker, so he has been to the southwest U.S. on a number of occasions, and all areas of the United States at one point or another. No recent particular exposures, although he has taken some storage bins as part of travel recently that had bird droppings, feces, and similar things associated with them.
US|ultrasound|US|178|179|IMPRESSION/PLAN|1. Hepatic Encepalopathy- Likely 2/2 to medication non-compliance. The patient was not taking her lactulose as an outpatient. Plan: A. Complete Infection work-up: Please arrange US guided paracentesis and send for cell count and culture. Send CXR, BC, UC and UA. The patient is currenltly being for cellulitis and this may have pushed her over to HE as well.
US|United States|U.S.|158|161|SOCIAL HISTORY|She has had a hysterectomy and tonsillectomy in the past. SOCIAL HISTORY: This lady does continue to smoke. She drinks as outlined above. She was born in the U.S. as has the rest of the family. FAMILY HISTORY: Positive for father dying of liver cancer. Apparently she has one sister who also has hepatitis B.
US|United States|U.S.|177|180|SOCIAL HISTORY|SOCIAL HISTORY: The patient lives alone in an apartment with an elevator. There are no step issues to be concerned with. There is a ramp up to the building. He emigrated to the U.S. from Libya in 1987. His family still lives in Libya. Review of his chart show he had some problem with managing the upkeep of his home.
US|United States|U.S.|181|184|HISTORY|There were definite chills and sweats as part of this, along with a general malaise and fatigue that persisted right to the present time. He was actually scheduled to return to the U.S. and on return here sought medical attention. He has now been admitted ot the hospital where his temperature was 101.8 degrees and imaging studies revealed significant myocardial dysfunction and mild pericarditis.
US|ultrasound|US|218|219|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: No apparent distress, alert and oriented, and very fluent in her speech. ABDOMEN: soft, nontender, and nondistended. No hepatosplenomegaly and no masses. PELVIC: External genitalia is normal. The US appears normal. Bimanual exam reveals a deeply retroflexed, retroverted uterus. Normal size throughout. No cervical motion tenderness. No mass can be felt in either adnexa, and both are nontender.
US|ultrasound|US|293|294|IMPRESSION AND PLAN|She has been complaining of early satiety and I would like to evaluate the second portion of the duodenum near the ampulla to make sure we do not have an obstructing process that has developed or is extending out from the pancreas. We will proceed with upper endoscopy tomorrow, then consider US after.
US|United States|U.S.|130|133|SOCIAL HISTORY|There is a younger brother who has biochemical ALD, but has a normal MRI scan. SOCIAL HISTORY: Father is a flight engineer in the U.S. Navy of the rank Chief Petty Officer flying P3 _%#NAME#%_. Mother was educated as a kindergarten teacher, currently does not work outside the home.
US|United States|US|93|94|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 36-year-old male immigrant from Laos (in the US since childhood) who presents to the University of Minnesota Medical Center, Fairview, Intensive Care Unit for evaluation of worsening liver failure.
US|United States|US,|117|119|HISTORY|The patient has a history of being a Sri Lankan immigrant, came to United States about 15 years ago. On entry to the US, he had a PPD done, which was negative and had no particular history of major illnesses prior to that other than malaria, which has not recurred or been a problem since coming to United States.
US|United States|U.S.|261|264|PAST MEDICAL HISTORY|Findings were felt to be consistent with sigmoid volvulus. PAST MEDICAL HISTORY: The mother states she has no other medical problems and takes no medications. She has completed high school and is going to college. She was born in Kenya apparently living in the U.S. for some time. ALLERGIES: No allergies. REVIEW OF SYSTEMS: Cardiovascular, pulmonary, gastrointestinal, hematologic are all negative.
US|United States|US|130|131|SOCIAL HISTORY|Alcohol, 10 beers a day average. Crack and heroin use. He lives in an apartment, currently, in New Jersey, and he has been in the US since the age of 8. He has 2 children with 2 different mothers, and the kids live with their mothers. FAMILY HISTORY: The patient's father died; he was shot when the patient was 6 years old.
US|ultrasound|US|184|185||He managed to avoid hospitalization. We saw him on Monday, the day before yesterday in clinic to discus endoscopic options which was planned to be endoscopic pancreaticogastrostomy by US guidance. We recommended that he repeat a CT scan yesterday, particularly because he looked so poorly and he was in pain and had been losing weight.
US|United States|U.S.|135|138|SOCIAL HISTORY|She lived in Great Britain for many years and, before coming here, in _%#NAME#%_ _%#NAME#%_ and then eventually traveling all over the U.S. She worked as a secretary in the past. She quit smoking 10 years ago, and she is not an active drinker. She is otherwise very active and enjoys swimming and outdoor activities.
US|United States|US|140|141|SOCIAL HISTORY|10. Oxycodone 15-30 mg. FAMILY HISTORY: Remarkable for father who died in Russia of cancer, type unknown. SOCIAL HISTORY: Immigrated to the US 8 years ago. He lives with his family including mother and siblings. REVIEW OF SYSTEMS: Not possible from the patient. He is anemic, receiving fluid support, having increasing urine output.
US|United States|U.S.|178|181|SOCIAL HISTORY|3. Mitral valve prolapse. 4. Sinus surgery. 5. Cholecystectomy. ALLERGIES: None known. SOCIAL HISTORY: Married and lives at home. Retired salesman, born in Portugal, came to the U.S. at age 7. FAMILY HISTORY: Father with congestive heart failure and Parkinson's disease, mother with coronary artery disease.
US|United States|U.S.|196|199|SOCIAL HISTORY|4. Gastric ulcer currently managed just with Maalox. SOCIAL HISTORY: The patient is married. She just arrived from Kenya on _%#MM#%_ _%#DD#%_, 2002. She is a public health nurse. Her husband is a U.S. citizen. She denies any tobacco or alcohol use. MEDICATIONS: Prenatal vitamins. ALLERGIES: Plasil (antiemetic which causes convulsions in the patient).
US|United States|U.S.|191|194|HISTORY OF PRESENT ILLNESS|6. VCUG showed no evidence of reflux. HISTORY OF PRESENT ILLNESS: The patient is a 3-1/2-year-old Somali female with tetralogy of Fallot first diagnosed at 2 months of age who arrived in the U.S. one week prior to admission from Kenya. She has had increased exercise intolerance and multiple episodes of cyanosis and fainting since birth.
US|ultrasound|US|221|222|NICU|Problem #4: Intraventricular Hemorrhage. A portable cranial ultrasound on DOL 2 revealed Bilateral Grade 2 intraventricular hemorrhages. Follow-up cranial ultrasound on DOL #9 revealed Bilateral grade 3 IVH. DOL #16 head US revealed post-hemorrhagic hydrocephalus. On the DOL 24 head US the hydrocephalus had worsened. She was then transferred to FUMC on DOL 27 for neurosurgical management.
US|ultrasound|US|147|148|NICU|Follow-up cranial ultrasound on DOL #9 revealed Bilateral grade 3 IVH. DOL #16 head US revealed post-hemorrhagic hydrocephalus. On the DOL 24 head US the hydrocephalus had worsened. She was then transferred to FUMC on DOL 27 for neurosurgical management. The next day, _%#MMDD#%_ a ventricular-subgaleal shunt on the left was placed.
US|United States|US|150|151|IMPRESSION AND PLAN|IMPRESSION AND PLAN: 1. Mr. _%#NAME#%_ has known diagnosis of metastatic prostate cancer with extensive bony metastasis. He most recently has been on US Oncology clinica l trial 03085 evaluating satraplatin versus placebo plus prednisone.
US|United States|U.S.|185|188|SOCIAL HISTORY|He has no history of biopsying. He has not been treated for his hepatitis. SOCIAL HISTORY: He is a driver recently employed several weeks prior, lives with his wife; he has been in the U.S. for 10 years. He has no primary MD, he is married. He smokes 1 pack per day, roughly he binge drinks heavily on weekends as described above.
US|United States|U.S.,|157|161|SOCIAL HISTORY|PAST MEDICAL HISTORY: Otherwise negative, except for cervical spine discectomy at Abbott Northwestern Hospital 2 years ago. SOCIAL HISTORY: She lives in the U.S., _%#CITY#%_, for the last 5 years. She is originally from Somalia, separated from her husband 4 years ago. She has 5 adult children in the area. She lives with young niece and nephew, and 24-year-old daughter.
US|ultrasound|US|155|156|* FEN|Follow-up cranial ultrasound on _%#MMDD2004#%_ revealed a grade 2 IVH on the left, grade 1 IVH on right, and increased ventricle size. A follow-up cranial US done on _%#MMDD2004#%_ showed unchanged ventricle size but decreased bilateral germinal matrix hemorrhages. The last head ultrasound showed normal size of both ventricles and resolving grade 1 bilateral IVH.
US|United States|U.S.|121|124|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 77-year-old female. She is originally from Lebanon. She has lived in the U.S. for several years. She has a history of chronic renal insufficiency, presumably secondary to hypertension. She also has history of hypertension, history of gout, history of high cholesterol.
US|ultrasound|US|188|189|1. FEN|This echo was also normal. He has been hemodynamically stable since. 5. Neuro: _%#NAME#%_ received one dose of indomethacin for IVH prophylaxis. However, on day one, _%#NAME#%_ had a head US revealing a grade I IVH on the left. Follow up at one week revealed that the bleed had progressed to a grade II.
US|ultrasound|US|169|170|1. FEN|However, on day one, _%#NAME#%_ had a head US revealing a grade I IVH on the left. Follow up at one week revealed that the bleed had progressed to a grade II. Follow up US one week later revealed presence of old blood without progression of the IVH. He continued to have weekly follow up head ultrasounds (last one on _%#MMDD2003#%_3, 1 month of age) which demonstrated improvement and resolving IVH.
US|ultrasound|US|124|125|1. FEN|He was treated with prophylactic amoxicillin. Most recent BUN and Creatinine were normal at 16 and 0.8 respectively. Repeat US on day 15, revealed normal kidneys and amoxicillin was discontinued. BUN and creatinine were followed and remained normal. 7. ID: On day 5, _%#NAME#%_ had some blood pressure instability overnight that did not respond well to fluid flushes and transfusions of PRBC's.
US|ultrasound|US|369|370|DISCHARGE MEDICATIONS|At the time of discharge, the infant's corrected gestational age was 42 weeks and 0 days. He was the 906 gm, 25+5 week gestational age male infant born at University of Minnesota Medical Center at _%#CITY#%_, Fairview to a 20- year-old, O positive, gravida 4, para 1-1-1-2, single Native American female whose LMP was _%#MMDD2005#%_ and whose EDC was _%#MMDD2005#%_ by US on _%#MMDD2005#%_. The mother's pregnancy was complicated by minimal prenatal care. Her first visit was for ruptured membranes on _%#MMDD2005#%_.
US|United States|US|167|168|SOCIAL HISTORY|Her mother suffers from hypertension. Other female relatives suffer from endometriosis. SOCIAL HISTORY: The patient is married. She works as an account coordinator at US Bank. She denies use of tobacco, alcohol, or drugs. ADMISSION PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 136/80 to 147/106.
US|United States|US|166|167|SOCIAL HISTORY|HABITS: Quit smoking 12 years ago. Denies alcohol or other chemical use. SOCIAL HISTORY: Married, two children. Presently off work. Was a special projects manager or US Bank previously. REVIEW OF SYSTEMS: Remarkable for chronic chills and sweats attributed to pain.
US|United States|US,|150|152|SOCIAL HISTORY|He does have a primary health care agent who helps manage medical decisions. The patient's son is currently in India, and is trying to make it to the US, where they can do further assessment of the patient's long-term health care plan. The patient was originally Pakistani-speaking, but since the cerebrovascular accident, he has been non-communicative.
US|ultrasound|US|332|333|XY.|Insulin-like growth factor BF3 was slightly low at 0.85 (normal 0.94-1.79). For this, pre- prandial blood sugars were followed for several days after the steroids and TPN were weaned off, but he did not become hypoglycemic again. He is currently maintaining his sugars well on normal breast milk and 20 kcal formula. 9. Neuro- Head US on day of life 2 revealed some cerebral edema but no evidence of bleed. Head MRI on _%#MMDD2004#%_ showed moderate-sized right parietal cephalohematoma and a pituitary within normal limits.
US|GENERAL ENGLISH|US|141|142|CODE STATUS|At this time, I have him as full code, but this may be discussed again with the family. I did discuss this with the patient and HE DOES WANT US TO RESUSCITATE HIM IN AN EVENT WHERE HIS HEART STOPS OR HE STOPS BREATHING. His understanding seems fair with regard to the question on code status.
US|United States|US|145|146|SOCIAL HISTORY|He plans on setting up residency here. He has no apartment, friends, or family here. The patient also does not have insurance. He was working at US Energy Saving Corporation in sales in _%#CITY#%_, but quit last Monday. He has received his associate's degree in accounting at a community college in _%#CITY#%_.
US|ultrasound|US|225|226|DISCHARGE STATUS|The mother's pregnancy was complicated by intermittent placental absent end diastolic flow (AEDF) and reverse end diastolic flow (REDF) on ultrasound. Onset was at 22 weeks gestation and worsened with subsequent ultrasounds. US also showed two vessel cord and IUGR with cranial sparing. She was hospitalized for 26 days prior to delivery, from 29 5/7 to 33 3/7 weeks.
US|ultrasound|US|115|116|4. GI|Liver may be damaged due to lack of oral feedings early in life vs. liver AVM. On _%#MMDD#%_ a repeat of the Liver US was obtained, and it noted that while the AVM was stable from the previous evaluation, the ascites is increased significantly, which correlated with increasing abdomin al girth.
US|ultrasound|US|148|149|5. ID|Dr. _%#NAME#%_ to follow as outpatient. Urology will perform circumcision when appropriate. Amoxicillin prophylaxis was restarted. 6. Neuro: A head US obtained showed cavum septum pellucidum. Repeat HUS on _%#MMDD#%_ showed some small echogenic foci in the periphery of the caudate of unclear significance.
US|United States|US|144|145|SOCIAL HISTORY|ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives with her husband. She is a nonsmoker and nondrinker. She has lived in the US for eight years. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION ON ADMISSION: Blood pressure 147/52, pulse 72, O2 sats 98% on room air, respiratory rate 20.
US|United States|U.S.|165|168|ADMISSION DIAGNOSIS|MEDICATIONS: Prenatal vitamins, Diflucan, and Zantac. FAMILY HISTORY: Noncontributory except for diabetes in the father. SOCIAL HISTORY: The patient has been in the U.S. for 3 years. She is married and lives with her husband and 2-year-old child. She denies any tobacco, alcohol, or drug use and has been married for 5 years.
US|ultrasound|US|198|199|1. FEN|On _%#MMDD#%_, she returned to Amoxicillin prophylaxis. Bacitracin ointment is used BID on ostomy sites. Antibacterial soap can be used for cleaning before catheterization. 8. NERO: An initial head US revealed mild echo densities probably representing mineralizing vasculopathy. There was no evidence for IVH and no other changes on _%#MMDD2003#%_. 9. GENETICS: Genetics consult was obtained. Did not believe baby is syndromatic or that there is a syndrome association consistent with current presentation.
US|ultrasound|US|199|200|HISTORY OF PRESENT ILLNESS|He normally tries to lie on his side. His bone scan on _%#MMDD2007#%_ was negative for bony mets and more favorable for degenerative disease. MRI at that time also showed evidence of brain mets. His US at bedside is negative for AAA. PAST MEDICAL HISTORY: 1. Myocardial infarction with severe hypokinetic left ventricle in the summer of 2007.
US|United States|U.S.|135|138|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: High glucose and elevated liver enzymes. HISTORY OF PRESENT ILLNESS: This is a 16-year-old male who immigrated to the U.S. from Liberia two years ago (_%#MM2000#%_), who presented to Fairview Crosstown on the day of admission with complaints of diarrhea of at least one year duration and some visual changes. Labs done at Crosstown Clinic revealed elevated glucose and elevated liver enzymes.
US|ultrasound|US|198|199|PLAN|A urine culture revealed E. coli infection and antibiotics were subsequently switched to Cefotaxime monotherapy for a total course of 10 days. Repeat urine culture on _%#MMDD#%_ was negative. Renal US was done on _%#MMDD2007#%_ and was normal. A VCUG was done on _%#MMDD2007#%_ and showed bilateral grade 3 vesicoureteral reflux.
US|ultrasound|US|191|192|DIET|The hemoglobin was stable for a while but did trend slowly down, requiring another transfusion 6. Neuro - Head ultrasound on _%#MMDD#%_ showed possible Grade I IVH on right side. Repeat head US at one week of age was wnl, and showed no evidence of periventricular leukomalacia at 1 month. 7. GI - total bilirubin on _%#MMDD#%_ of 7.0, phototherapy started _%#MMDD#%_ thru _%#MMDD#%_ when T bili decreased to 2.5 and stabilized.
US|ultrasound|US|143|144|DISCHARGE INSTRUCTIONS|A repeat follow-up ultrasound on _%#MMDD2006#%_ was unchanged. A repeat ultrasound on _%#MMDD2006#%_ revealed bilateral Grade II IVH. A repeat US on _%#MMDD2006#%_ revealed no change in bilateral Grade II IVH with slight decrease in size of the ventricular system. US on _%#MMDD2006#%_ revealed normal evolution of bilateral Grade II IVH.
US|ultrasound|US|131|132|DISCHARGE INSTRUCTIONS|A repeat US on _%#MMDD2006#%_ revealed no change in bilateral Grade II IVH with slight decrease in size of the ventricular system. US on _%#MMDD2006#%_ revealed normal evolution of bilateral Grade II IVH. US On _%#MMDD2006#%_ revealed further evolution, and normal periventricular white matter.
US|ultrasound|US|118|119|HOSPITAL COURSE|7. NEURO - An initial head US initially showed no IVH. On DOL2 however, a repeat US showed a grade I IVH. A follow up US on DOL#9 showed a stable grade I IVH. 8. HEME - Patient initially was severely coagulopathic with prolonged clotting times.
US|ultrasound|US|170|171|3. RESP|5. HEME- _%#NAME#%_ should continue on iron replacement (2 mg/kg/d of elemental iron) while he is receiving MBM since he is a premature infant. 6. Neuro- The second head US done on _%#MMDD2003#%_ was normal and did not show any signs of IVH or PVL. 7. Ophtho - _%#NAME#%_ should have a retinal exam to evaluate for retinopathy of prematurity at 5-6 weeks of age.
US|ultrasound|US|158|159|3. RESP|Problem #3: Ventricular Septal Defects: Two VSDs were noted on _%#MMDD2005#%_ on a screening echocardiogram performed secondary to abnormal antenatal cardiac US findings. A repeat echocardiogram performed on _%#MMDD2005#%_ demonstrated a small ASD with left to right shunting, 1.6 mm mid-muscular VSD, 2.2-2.8 mm peri-membranous VSD, and PA pressures 2/3 of systemic pressures, with good biventricular function.
US|ultrasound|US|146|147|PLAN|7. For chronic kidney disease, hold Diovan in the setting of her acute diuresis and attempt to obtain old creatinines and monitor renal function. US renals with arteries. 8. For glaucoma, continue eye drops. 9. For mood and dementia, continue celexa. The patient is going to continue to be a do not resuscitate, do not intubate.
US|ultrasound|US|139|140|PLAN|From a neurological standpoint, _%#NAME#%_ had a tonic clonic seizure on _%#MMDD#%_. She was loaded with 20 mg/kg of Phenobarbital. A Head US was WNL. On _%#MMDD2003#%_, she was transferred to the NICU at Fairview-University Children's Hospital for management of ARDS and possible ECMO treatment.
US|ultrasound|U.S.|294|297|2.  GERD|So patient was admitted for further evaluation. The patient had a history of positive PPD in the past in 2005 for which she was treated with INH for six to nine months. The patient is a nonsmoker and did not have any significant medical history in the past. She immigrated from Cambodia to the U.S. about sixteen years ago. 1. Dyspnea: The patient had an extensive workup done during hospitalization and all workup was negative.
US|United States|US|216|217|SOCIAL HISTORY|There is one railing for each flight of stairs. The patient is on long-term disability as of the summer of 2006. She was on short-term disability beginning since the beginning of 2006. She was previously employed at US Bank, and I believe her work involved scanning a lot of numbers and digits. She has been married I believe for three years. She is originally from the _%#CITY#%_ area.
US|United States|US.|213|215|SOCIAL HISTORY|He has been here for about 12 years. He studies political science at TSU and is due to graduate within the next year. He never smoked. He denies any alcohol use. He is divorced. He has some children living in the US. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Attempted, however, were of limited time because the interpreter had other commitments.
US|United States|US|126|127|PHYSICAL EXAMINATION|He is mildly obese and well hydrated. He has mild to moderate pleasant dementia. He knows the date, but does not remember the US President or the name of the hospital. VITAL SIGNS: His temperature is 36.3. His heart rate is 70 beats per minute and his blood pressure is 132/74.
US|United States|US|167|168|SOCIAL HISTORY|SOCIAL HISTORY: The patient denies any substance abuse. Never smoked, although has some second hand smoking exposure. Occasionally, drinks wine. Works as a mailman in US Postal Service. FAMILY HISTORY: CVA and MI. OUTPATIENT MEDICATIONS: Aspirin 81 mg daily, calcium 600 mg daily, and multivitamins one tablet daily.
US|United States|U.S.|189|192|SOCIAL HISTORY|SOCIAL HISTORY: The patient lives with her husband in a 40+ foot motorhome. They have owned this for 3 years. They have traveled extensively, usually going down to southeastern part to the U.S. during the wintertime. She has 6 steps to enter the motorhome. There are rails on both sides. Her husband is available to help all 24 hours. He is retired.
US|United States|U.S.|217|220|SOCIAL HISTORY|SOCIAL HISTORY: He is a single, professional long-haul truck driver who owns his own truck which he leases to a company in _%#CITY#%_ MN. This is why he did not wish to stop when he was short of breath in the Western U.S. He was afraid the truck would be unguarded while he was ill. He has until recently been a 2-1/2-pack-per-day smoker which he reports was to maintain his alertness while driving.
US|United States|US|196|197|ALLERGIES|He also has 2 sons who live in Alabama. One of those sons returned to Alabama just yesterday. It is reported that his wife splits her time between Florida and Minnesota. The patient immigrated to US in 1994 from Vietnam. He became US citizen in 2002. Functionally, prior to the operation, he was driving and doing his ADLs, and he was completely normal.
US|United States|US|322|323|SUMMARY OF CURRENT FINDINGS|He has had a history of suicidal ideation in the 6th grade, but denied current suicidal ideation, even with a note that he wrote his family stating "goodbye." He has had a history of Asperger's disorder diagnosis. In addition, he has an IEP at _%#CITY#%_ High School to reflective this and his ADHD diagnosis. He is an AP US history and plans on going to college to study math or science and a couple years. There still is some concern about his interactive style and possible difficulty accurately assessing the actions of others.
US|United States|US|156|157|SOCIAL HISTORY|2. No previous hospitalizations or surgeries. SOCIAL HISTORY: The patient is going into the 2nd grade in _%#CITY#%_. He is a good student. Father works for US Cable Company. Mother is a middle school counselor at the _%#CITY#%_ Middle School with a master's degree in counseling. Their dog died about 3 weeks prior to admission that he has had since he was 2 or 3 years of age.
US|United States|US|199|200|SOCIAL HISTORY|SOCIAL HISTORY: Mr. _%#NAME#%_ is widowed. His wife died in 1996 associated with Alzheimer's disease. He currently lives with 2 of his 3 adult children. Mr. _%#NAME#%_ is retired and was employed by US Steel as a mechanical engineer. He lives in _%#CITY#%_, Minnesota. FAMILY HISTORY: Father died of lung cancer after a history of cigarette smoking in 1960 at the age of 57.
US|United States|U.S.|122|125|TEST FINDINGS|She was able to correctly state the year, month, date, and day of the week on several occasions. She correctly stated the U.S. President, and the previous president. Simple auditory attention, as measured by the ability to recite digit sequences, was within the average range (6 digits forward, 3 digits backward).
US|ultrasound|US|119|120|CV|It is unclear if she has pancreatitis -- her lipase is climbing but is not very high. She likely has NASH according to US and her history, but we will get records from La Clinica to confirm this and to get a better sense of her work up, as well as to find out what "liver inflammation" refers to.
US|United States|US|136|137|BRIEF HISTORY|There was some difficulty getting the patient admitted to the hospital due to the patient's lack of insurance and the fact he was not a US citizen. However, he was admitted to the hospital for evaluation. The patient has a history of heart failure managed in Argentina and as an outpatient was on digoxin.
US|United States|US|125|126|DISCHARGE DIAGNOSES|_%#NAME#%_ _%#NAME#%_ is a 56-year-old female. She lives with a roommate. She has 4 grown children. She works as a teller at US Bank. Patient entered with an addiction to benzodiazepines. She has a previous history of a similar addiction. She has had some sober time in the past. Recently, she was having problems with a relationship; she went to a doctor and got benzodiazepines again.
US|United States|US|229|230|HISTORY OF PRESENT ILLNESS|OPERATIONS/PROCEDURES PERFORMED: 1. Cardioversion. 2. Diuresis. 3. Transesophageal echocardiogram. HISTORY OF PRESENT ILLNESS: This is a 23-year-old female with a history of partial AV canal repaired in 2003 when she came to the US from Vietnam. At the time of surgery, a pacemaker was also placed to treat AV block. Her postoperative course was complicated by AV block and recurrent pericardial effusions.
US|ultrasound|US|197|198|GU|_%#NAME#%_ had a percutaneous endoscopic gastrostomy tube placed for feedings on _%#MMDD2002#%_ by Dr. _%#NAME#%_ _%#NAME#%_. GU: Bilateral undescended testicles were noted on admission. Abdominal US on _%#MMDD2002#%_ showed mild hydronephrosis of the left kidney. The undescended testicles were identified just above the iliac vessels next to the bladder.
US|United States|U.S.|160|163|HISTORY OF PRESENT ILLNESS|This has not been treated. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 32-year-old man who is originally from the Czech Republic and has been in the U.S. for the last couple of years. He works in landscaping and has been under a fair amount of financial stress lately.
US|United States|US|172|173|SOCIAL HISTORY|He works as a waiter at a very well-known, high-end restaurant in _%#CITY#%_. He restores Victorian homes, and builds and restores grandfather clocks. He has served in the US Military. REVIEW OF SYSTEMS: GENERAL: No unexplained weight loss, fevers, etc.
US|United States|U.S.|148|151|HOSPITALIZATIONS AND SURGERIES|PAST MEDICAL HISTORY: MEDICATIONS: None. ALLERGIES: None. MAJOR DIAGNOSES: None. HOSPITALIZATIONS AND SURGERIES: She has never seen a doctor in the U.S. FAMILY HISTORY : Reportedly her brothers and sisters all lived into their 80s and 90s.
US|United States|U.S.|155|158|SOCIAL HISTORY|MEDICATION: Topical Rogaine for hair loss for the past one year. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Ms. _%#NAME#%_ has been living in the U.S. since the past one year. She is an immigrant from Iran and is currently doing her Ph.D. in industrial engineering.
US|United States|US|142|143|SOCIAL HISTORY|ALLERGIES: No known drug allergies. MEDICATIONS: No outpatient medications. SOCIAL HISTORY: The patient works in assembly line. Immigrated to US in 1979. Smokes 2 cigarettes per day. History of heavy alcohol abuse for many years, but only drank on the weekend, none during the week.
US|ultrasound|US|150|151|1. FEN|6. Renal: _%#NAME#%_ had a continual rise in BUN and creatinine to a max of 89 and 1.8 respectively on day 11. It began to decline on day 12. A renal US was performed on day 7 showed mild hydronephrosis. He was treated with prophylactic amoxicillin. Most recent BUN and Creatinine were normal at 16 and 0.8 respectively.
US|United States|U.S.|133|136|ADMISSION MEDICATIONS|3. Prilosec 20 mg daily. 4. Senna 2 tablets at bedtime. SOCIAL HISTORY: Patient does not smoke or drink alcohol. She has been in the U.S. for the last 6 years, and she lives with her grandson. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 95.7, pulse 79 blood pressure 154/93, and respiratory rate 18.
US|United States|US|207|208|SOCIAL HISTORY|7. TMP/SMX for rare recurrent UTIs. FAMILY HISTORY: Negative for allergic reaction to anesthesia, father diseased 70s oral CA, mother diseased 89 heart disease. SOCIAL HISTORY: Married, retired from work at US Bank of _%#CITY#%_. REVIEW OF SYSTEMS: Denies chest pain, shortness of breath, polyuria, polydipsia, other systems negative.
US|United States|US|173|174|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Headache and vertigo. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 52-year-old, right-handed female who is employed at an e-commerce group at US Bank Incorporated here in the _%#CITY#%_ _%#CITY#%_ area. The patient had recently had a physical examination done by her primary care physician and had subsequently received a clear bill of health except as outlined below in the past medical history.
US|ultrasound|US|197|198|1. FEN|Because of preterm birth, we worked her up to EPF 24 kcal or fortified breast milk to 26 kcal. On day of discharge she was tolerating 28 cc Q3h. 2. Neuro: It would be our recommendation for a head US on or around _%#MM#%_ _%#DD#%_ for evaluation of any hemorrhage. Discharge medications, treatments and special equipment: None. _%#NAME#%_ is a good candidate to receive Synagis during the upcoming RSV season.
US|United States|US|139|140|SOCIAL HISTORY|2. Prevacid. 3. Iron. 4. Albuterol. SOCIAL HISTORY: She used no tobacco, ethanol or other medication. The patient is widowed, immigrant to US in 1994, living with children. FAMILY HISTORY: No known family history. INITIAL PHYSICAL EXAMINATION: The patient was also on exam found to be thin, cachetic and elderly female who is responsive.
US|ultrasound|US|236|237|1. FEN|Continue Nystatin while antibiotics and lines continue. 4. Hyperbilirubinemia: Continue single bank bili lights. Check a bilirubin on _%#MMDD#%_ AM to determine further treatment. 5. GU: Final ultrasound reading needed. Follow-up renal US with or without VCUG and Amoxicillin prophylaxis may be indicated based on these. Discharge medications, treatments and special equipment: Amipicillin 300mg q12 at 700, 1900 Gentamycin 9mg q24 at 2100 Nystatin 50,000 units po q6 Discharge measurements: Weight 2910gms; length 47cm; OFC 32.5cm. Physical exam was normal except for mild jaundice, two-vessel umbilical cord with a UVC in place and a left calcanus valgus.
US|United States|US|153|154|PLAN|Staging studies at that time included evidence of bony metastatic disease. He was ultimately started on chemotherapy using docetaxel and prednisone on a US oncology clinical trial. He received several cycles of treatment. He had reimaging studies in late _%#MM#%_, which demonstrated an increasing bony metastatic disease.
US|United States|US|245|246|HISTORY OF PRESENT ILLNESS|1. CT of the head without contrast on _%#MM#%_ _%#DD#%_, 2005: No acute intracranial findings, moderate atrophy greater than expected for age. CONSULTS OBTAINED: Neurology. HISTORY OF PRESENT ILLNESS: A 39-year-old man who recently moved to the US from Zimbabwe 15 years ago and a history of alcoholism, presents with new onset of "spells." At 6 p.m. on _%#MM#%_ _%#DD#%_, 2005, his wife saw him have a spell that lasted approximately 1-2 minutes.
US|United States|US|151|152|HISTORY OF PRESENT ILLNESS|He was looking for heroin or benzodiazepines. It sounds like somebody else gunshot but the rikashade ended up in his back. The patient has been in the US Army. The patient had 4 to 5 visits after his tour of duty mostly related to anxiety and stress after serving.
US|United States|US|102|103|SOCIAL HISTORY|His grandfather had ulcers and an unknown cancer. SOCIAL HISTORY: He lives with his wife. He works at US Bank. He does not smoke. He occasionally drinks alcohol. REVIEW OF SYSTEMS: He denies any cardiovascular, respiratory, urinary, musculoskeletal, neurologic, cognitive or constitutional symptoms.
US|United States|US|143|144|COMPLICATIONS|SOCIAL HISTORY: Father of the baby is her husband. She denies use of alcohol, drugs, or tobacco products. She is a mongolian. She has lived in US since _%#MM#%_ 2004. On review of systems, the patient denies headache, nausea, vomiting, fevers, chills, or right upper quadrant pain.
US|United States|U.S.|169|172|SOCIAL HISTORY|9. Corneal transplant. 10. Nonsmall cell carcinoma of the lung. 11. History of pneumonias. ALLERGIES: Cyclosporin. SOCIAL HISTORY: Native of Ukraine. He has been in the U.S. for about 15 years. He lives with his wife in assisted living. Tobacco, none. REVIEW OF SYSTEMS: Unobtainable. FAMILY HISTORY: Unobtainable. PHYSICAL EXAMINATION: VITAL SIGNS: Please see nursing notes from today.
US|ultrasound|US|144|145|HISTORY OF PRESENT ILLNESS|The patient claims that he urinates twice a day. He stopped urinating at nighttime, but has a large amount of urine whenever he goes. His renal US in this month showed some cortical atropy but with borderline normal size. It appears that the patient is not on Epogen. He does have some medication he takes for his Billroth II procedure.
VAD|vincristine adriamycin and dexamethasone|(VAD)|194|198|DOB|DOB: _%#MMDD1932#%_ _%#NAME#%_ is a 72-year-old white male who I have recently diagnosed with multiple myeloma. He was admitted for his first cycle of vincristine, Adriamycin, and dexamethasone (VAD) systemic chemotherapy in anticipation of the eventual autologous bone marrow transplant. _%#NAME#%_ was admitted on _%#MM#%_ _%#DD#%_, 2004 and had a Port-A-Cath placed followed by a MUGA test indicating normal cardiac function with an ejection fraction of 51%.
VAD|vincristine adriamycin and dexamethasone|VAD|289|291|IMPRESSION|No laboratories were available today but the CBC performed yesterday on _%#MMDD2004#%_ revealed a normal white blood cell count of 3700, a hemoglobin of 9.4 with an MCV of 96, platelets of 155,000. IMPRESSION: A 72-year-old white male with multiple myeloma, status post his first cycle of VAD systemic chemotherapy. PLAN: 1) Discharge to home today on routine outpatient medications.
VAD|vincristine adriamycin and dexamethasone|VAD|133|135|HISTORY OF PRESENT ILLNESS|She was treated with thalidomide and her N-spike reduced to 0.98. she was found to have a pleural plasma cytoma and was treated with VAD x 4 cycles in _%#MM2004#%_. This was complicated by deep venous thrombosis and pulmonary embolism. In _%#MM2004#%_ she had a pelvic mass that was 7 cm and underwent surgery to remove this mass with an oophorectomy.
VAD|vincristine adriamycin and dexamethasone|VAD|232|234||_%#NAME#%_ _%#NAME#%_ is a 65-year-old man with a diagnosis of mantle cell lymphoma, Stage 4, with bulky adenopathy, splenomegaly, and bone marrow involvement. He is admitted today for continuation of chemotherapy using the Hyper-C VAD regimen. The patient was diagnosed earlier this year and underwent two cycles of R-Chop chemotherapy.
VAD|vincristine adriamycin and dexamethasone|VAD|215|217|DISCHARGE INSTRUCTIONS|His follow-up CT scans after two cycles demonstrated a mild decrease in his lymph nodes, although, he continued to have bulky adenopathy and splenomegaly. He has since been started on chemotherapy using the Hyper-C VAD regimen. He has completed two cycles of treatment, along with Rituxan therapy. He has undergone follow-up CT scans which demonstrated a moderate interval decrease in the size of enlarged lymph nodes in the chest, abdomen, and pelvis, and an interval decrease in moderate splenomegaly and small bilateral pleural effusions which have slightly decreased in size.
VAD|vincristine adriamycin and dexamethasone|VAD.|330|333|DISCHARGE INSTRUCTIONS|He has undergone follow-up CT scans which demonstrated a moderate interval decrease in the size of enlarged lymph nodes in the chest, abdomen, and pelvis, and an interval decrease in moderate splenomegaly and small bilateral pleural effusions which have slightly decreased in size. He is now being admitted for Cycle 3 of Hyper-C VAD. PAST MEDICAL HISTORY: 1. Nonhodgkin's lymphoma, mantle cell type as outlined above.
VAD|vincristine adriamycin and dexamethasone|VAD|95|97|ALLERGIES|5. Ativan as needed. ALLERGIES: No known drug allergies. The patient has tolerated his Hyper-C VAD reasonably well. He was hospitalized last week with nose bleeds. He was pancytopenic at that point. His INR was prolonged. He had been on Coumadin for a prior thrombosis related to a PICC line.
VAD|vincristine adriamycin and dexamethasone|VAD|221|223|IMPRESSION|IMPRESSION: 1. Mr. _%#NAME#%_ is a 65-year-old man with a mantle cell lymphoma, Stage 4, status post two cycles of R-CHOP. He did not have a significant response and he has gone on to begin chemotherapy using the Hyper-C VAD regimen plus Rituxan. He has tolerated his first two cycles reasonably well. 2. He has had the expected pancytopenia and has received Neulasta for neutropenia prevention.
VAD|vincristine adriamycin and dexamethasone|VAD|195|197|HISTORY OF PRESENT ILLNESS|3. _%#NAME#%_ _%#NAME#%_ proteinuria of near-nephrotic degree. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 49-year-old man who had multiple myeloma diagnosed in 2001. He received 4 cycles of VAD chemotherapy, followed by a stem cell autograft in _%#MM#%_ 2002. He enjoyed about 2 years of good disease control, then had renewed bone pain in _%#MM#%_ of 2004.
VAD|vincristine adriamycin and dexamethasone|VAD,|166|169|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Patient is a 49-year-old gentleman with a history of multiple myeloma originally diagnosed in 2003. In that year, he received 3 cycles of VAD, which was followed a non- myeloablative stem cell allograft. The patient did well until 2004, when a bone marrow biopsy showed monotypic plasma cells.
VAD|vincristine adriamycin and dexamethasone|VAD|212|214|HOSPITAL COURSE|His admission lab work was significant for an ionized calcium of 6.6 and creatinine of 2.41. HOSPITAL COURSE: PROBLEM #1: Multiple myeloma. Given his relapsed disease, we opted to start him on his first cycle of VAD (vincristine, adriamycin and dexamethasone). Prior to the initiation of chemotherapy, he had a MUGA, which showed a left ventricular ejection fraction of 59.9%. He tolerated the chemotherapy well.
VAD|vincristine adriamycin and dexamethasone|VAD|230|232|HISTORY OF PRESENT ILLNESS|CHIEF COMPLAINT: Seizure. HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old female, status post autologous peripheral stem cell transplant for multiple myeloma diagnosed in _%#MM#%_ 2001. She initially received 4 cycles of VAD and had a bone marrow transplant in _%#MM#%_ 2002. She has been in clinical remission since that time. Today, she was in clinic for a 3- year follow-up bone marrow biopsy.
VAD|vincristine adriamycin and dexamethasone|VAD,|159|162|PAST MEDICAL HISTORY|Mr. _%#NAME#%_ received radiation therapy to the left femur and humerus. He was treated with one cycle of melphalan and prednisone followed by three cycles of VAD, ending in _%#MM#%_ 2001. Follow-up bone marrow showed 5-8% plasma cells. He underwent autologous peripheral blood stem cell transplant on _%#MMDD2002#%_.
VAD|vincristine adriamycin and dexamethasone|VAD.|154|157|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 36-year-old female with a history of multiple myeloma, IgG restricted, diagnosed in 2003. She is status post VAD. Her clinical course in the past was complicated by a ruptured diverticulum and she also recently had a pathology fracture requiring open reduction and fixation of a lower extremity.
VAD|vincristine adriamycin and dexamethasone|VAD|386|388|HISTORY OF PRESENT ILLNESS|REASON FOR HOSPITAL ADMISSION: _%#NAME#%_ _%#NAME#%_ is admitted for further evaluation of fever and progressive dyspnea with probable pneumonia and with a known history of multiple myeloma. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 63-year-old woman who has a history of myeloma dating back several years for which she has had extensive treatment, most recently using the VAD (vincristine, Adriamycin and dexamethasone) regimen; her last cycle of this was given approximately 2 weeks ago. Her health has also been complicated by pathologic fracture of the right femur.
VAD|vincristine adriamycin and dexamethasone|VAD|163|165|PLAN|The patient was diagnosed in 1998 and has been extensively treated over time. She has been treated with melphalan and prednisone as well as chemotherapy using the VAD regimen. She has also received thalidomide and Velcade. Approximately one month ago, she was started on melphalan and prednisone once again because of a rising monoclonal protein.
VAD|vincristine adriamycin and dexamethasone|VAD|119|121|HISTORY OF PRESENT ILLNESS|The patient had UPEP with 6 grams of lambda light chain. According to his treatment plan, he is to undergo 4 cycles of VAD chemotherapy followed by allogeneic sibling bone marrow transplant. The patient was currently undergoing second cycle of VAD chemotherapy. He was 18 hours into the cycle. The patient had Hickman catheter placed 4 weeks ago.
VAD|vincristine adriamycin and dexamethasone|VAD|187|189|HISTORY OF PRESENT ILLNESS|According to his treatment plan, he is to undergo 4 cycles of VAD chemotherapy followed by allogeneic sibling bone marrow transplant. The patient was currently undergoing second cycle of VAD chemotherapy. He was 18 hours into the cycle. The patient had Hickman catheter placed 4 weeks ago. It has been malfunctioning since the time of placement and the use of it was positional.
VAD|vincristine adriamycin and dexamethasone|VAD|302|304|MEDICATIONS|At the time of admission, the patient's review of systems is negative except for back pain that has been present for many months and worked up with a diagnosis of multiple myeloma lesions in his spine and scapula. ALLERGIES: No known drug allergies. MEDICATIONS: Flonase and Percocet p.r.n. as well as VAD chemotherapy. PAST MEDICAL HISTORY: Multiple myeloma as above. SOCIAL HISTORY: Does not smoke.
VAD|vincristine adriamycin and dexamethasone|VAD|132|134|IMPRESSION|3. Multiple myeloma with clear-cut evidence of progression of disease, onset Cytoxan and prednisone. She is not a candidate for the VAD regimen based on problems with recurrent hyperglycemia as well as underlying heart disease. An alternative to this would be thalidomide. We discussed the side effects as well as benefits of thalidomide and will set in motion the registration process to obtain this.
VAD|vincristine adriamycin and dexamethasone|VAD|50|52|FINAL DIAGNOSES|FINAL DIAGNOSES: 1. Multiple myeloma, status post VAD chemotherapy. 2. Left upper extremity deep venous thrombosis, induced by port, treated with anticoagulation, therapeutic on Coumadin. FOLLOW UP APPOINTMENTS: 1. The patient is to call Dr. _%#NAME#%_ _%#NAME#%_'s office for follow up appointment.
VAD|vincristine adriamycin and dexamethasone|VAD|141|143|HOSPITAL COURSE|The marrow biopsy had nearly 70% plasma cells and the urinary protein was 2.2 grams. He received localized radiation and then four cycles of VAD chemotherapy with a good partial response. He unfortunately was recognized to develop herpes zoster retinitis with bilateral retinal necrosis and had nearly complete loss of his vision.
VAD|vincristine adriamycin and dexamethasone|VAD.|247|250|HISTORY OF THE PRESENT ILLNESS|A repeat bone marrow in _%#MM#%_ 2002, showed 55 to 40% cellularity with 1% atypical cells consistent with good response to chemotherapy. An autologous bone marrow transplant was recommended as a first line approach. The patient responded well to VAD. The patient will be admitted to receive intravenous cyclophosphamide, dexamethasone, MESNA and mitoxantrone for chemo priming prior to autologous stem cell transplantation.
VAD|vincristine adriamycin and dexamethasone|VAD|178|180|IMPRESSION|A 24-hour urine protein electrophoresis, as well as serum electrophoresis and quantitative immunoglobulins are pending. IMPRESSION: 1. Multiple myeloma, status post one cycle of VAD which was well- tolerated. The patient will be re-admitted on _%#MMDD2003#%_ for cycle #2. He did experience some constipation with chemotherapy and we will use Senokot-S on a prophylactic basis.
VAD|vincristine adriamycin and dexamethasone|VAD.|145|148|HISTORY OF THE PRESENT ILLNESS|By _%#MM#%_, patient's IgG level went up to 7.7 gm. _%#MM#%_ _%#DD#%_, 2002, the patient received cycle #1 of VAD. On _%#MMDD2002#%_ cycle #2 of VAD. Patient's IgG decreased to 4.8 gm in _%#MM2002#%_ and then 3.1 gm in _%#MM2002#%_. The latest IgG was 1.7 gm in _%#MM2002#%_. The patient is being admitted for cycle #3 of VAD today on _%#MMDD2002#%_.
VAD|vincristine adriamycin and dexamethasone|VAD|207|209|HISTORY OF THE PRESENT ILLNESS|On _%#MMDD2002#%_ cycle #2 of VAD. Patient's IgG decreased to 4.8 gm in _%#MM2002#%_ and then 3.1 gm in _%#MM2002#%_. The latest IgG was 1.7 gm in _%#MM2002#%_. The patient is being admitted for cycle #3 of VAD today on _%#MMDD2002#%_. REVIEW OF SYSTEMS: Essentially negative. PAST MEDICAL HISTORY: 1. Multiple myeloma with plasmacytoma as above.
VAD|vincristine adriamycin and dexamethasone|VAD.|190|193|HOSPITAL COURSE|LDH 627. ALP normal at 65. ALK and AST normal. Total bili .5. HOSPITAL COURSE: 1. Relapsed IgG multiple myeloma. Between _%#MMDD2002#%_ and _%#MMDD2002#%_, patient received a third cycle of VAD. Patient received vincristine .4 mg per day by continuous IV infusion q day, days #1 through day #4 to a total cycle dose of 1.6 mg.
VAD|vincristine adriamycin and dexamethasone|VAD|165|167|HOSPITAL COURSE|The left ventricular assist device was placed on hospital day #15. LVAD placement went well, and the patient had good flows up until postoperative day #5. Decreased VAD flows were thought to be due to right ventricular compensation, and Milrinone was started. On postoperative day #6, the chest tubes were discontinued. The patient continued to do well.
VAD|vincristine adriamycin and dexamethasone|VAD|185|187|HISTORY OF PRESENT ILLNESS|Beta II microglobulin was 3.1. He was diagnosed with multiple myeloma and started therapy with Zometa and VBMCP. He received only one course for which he was followed by five cycles of VAD with resolution of his bone pain. Chemotherapy priming consisted of cytotoxin on _%#MM#%_ _%#DD#%_ with hydration and mesna along with mitoxantrone on _%#MM#%_ _%#DD#%_ and _%#MM#%_ _%#DD#%_.
VAD|vincristine adriamycin and dexamethasone|VAD|126|128|PAST MEDICAL HISTORY|She was then referred to the University in _%#MM#%_ of 2002 for autologous transplant. She was treated with several cycles of VAD chemotherapy, with recent bone marrow biopsy showing 8% plasma cells. 2. History of migraine headaches. 3. Status post vaginal hysterectomy.
VAD|vincristine adriamycin and dexamethasone|VAD.|218|221|PAST MEDICAL HISTORY|He initially presented with left arm and leg pathologic fractures, requiring surgical correction. He underwent radiation of the left femur and humerus and one cycle of melphalan/prednisone. He also had three cycles of VAD. The treatment ended in _%#MM2001#%_. He underwent autologous peripheral blood stem cell transplant _%#MMDD2002#%_. 2. History of coag-negative bacteremia. 3. Mucositis last admission, _%#MM2002#%_.
VAD|vincristine adriamycin and dexamethasone|VAD.|115|118|PAST MEDICAL HISTORY|3. Cholecystectomy. 4. Minor trauma to thumb and index finger in the past. 5. History of shingles on the back with VAD. 6. History of steroid-induced hypoglycemia. 7. Chest pain thought secondary to dyspepsia. 8. History of reflux since chemotherapy started. 9. History of vascular ablation of a mole on the tongue 20 years ago.
VAD|vincristine adriamycin and dexamethasone|VAD|211|213|HISTORY OF PRESENT ILLNESS|A lymph node biopsy revealed nodular sclerosing Hodgkin's disease. A CT scan revealed large mediastinal mass without disease below the diaphragm. The bone marrow pathology was negative at that time. He received VAD x 4 cycles, followed by mediastinal radiation through _%#MM1996#%_. He did well for a year, and then presented with right axillary node enlargement.
VAD|ventricular assist device|VAD|160|162|HOSPITAL COURSE|The patient was having very little ectopy at the time of discharge. Throughout the rest of the hospital stay, the patient was anticoagulated with Coumadin. His VAD teaching was finished and he continued to progress. At the time of discharge, the patient was ambulating, voiding without difficulty, and having bowel movements.
VAD|ventricular assist device|VAD|249|251|DISCHARGE MEDICATIONS|8. Protonix. 9. Senokot p.r.n. 10. Coumadin 4 mg q. day, again with followup INR scheduled for tomorrow. The patient was instructed on signs and symptoms to warrant further followup and he and his wife appeared to have good understanding of how the VAD functioned and how to troubleshoot issues that could arise.
VAD|ventricular assist device|VAD|183|185|HOSPITAL COURSE|During the TEE, the patient converted to sinus. He was started on mexiletine and amiodarone and anticoagulated, and continued to stay in sinus rhythm. The patient progressed with his VAD teaching and cardiac rehab. He also was noted to have serous fluid draining from one of his left chest tube sites. This fluid was collected and it was noticed to be decreasing during his hospital stay.
VAD|ventricular assist device|VAD,|143|146|DISCHARGE INSTRUCTIONS|He is not to drive for 4 weeks after surgery. Avoid any strenuous activities. At the time of discharge, the patient had no questions about his VAD, felt he was adequately trained in troubleshooting the care and management of issues that might arise while he is at home. He also was informed about signs and symptoms to warrant further followup.
VAD|vincristine adriamycin and dexamethasone|VAD|66|68|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: Status post first cycle of chemotherapy with VAD for myeloma PROCEDURES DURING THIS ADMISSION: PICC line placement in left arm. HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old male with a history of myeloma diagnosed in 2001.
VAD|vincristine adriamycin and dexamethasone|VAD.|213|216|HISTORY OF PRESENT ILLNESS|Given this, the patient received the melphalan/prednisone chemotherapy in _%#MM#%_, but had disease progression through treatment at the end of two cycles. He was admitted for his first cycle of chemotherapy with VAD. REVIEW OF SYSTEMS: The review of systems is significant for a history of easy fatigability, decreased appetite, and a weight loss of about 5-10 pounds.
VAD|vincristine adriamycin and dexamethasone|VAD|160|162|HISTORY OF PRESENT ILLNESS|She also had an elevated beta 2 microglobulin at 8.2. She had several bony lesions, including T6 and T9 compression fractures. She was treated with 4 cycles of VAD and did quite well. She had excellent response to this therapy and her urine protein was markedly decreased. Her follow-up bone marrow biopsy showed only 5% residual plasma cells.
VAD|vincristine adriamycin and dexamethasone|VAD|180|182|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Progressive IgG, multiple myeloma, first diagnosed in 2001, status post melphalan and prednisone from _%#MMDD#%_ to _%#MMDD#%_, status post three cycles of VAD on _%#MMDD2002#%_, _%#MMDD2002#%_, _%#MMDD2002#%_. Thalidomide treatment since _%#MMDD2002#%_. 2. Status post herpes zoster left leg, _%#MM2002#%_. 3. Status post radical prostatectomy for prostate carcinoma in 1995.
VAD|vincristine adriamycin and dexamethasone|VAD|186|188|HISTORY OF PRESENT ILLNESS|In _%#MM#%_ 2002 he had a left orbital mass leading to a sixth nerve palsy. He also had a 2.2 cm tumor at the T5 with epidural extension. He had Decadron radiotherapy and four cycles of VAD at that time. In _%#MM#%_ 2002 he underwent related matched peripheral stem cell transplant from his sister. The patient is 100% donor as of day #21. On admission, the patient had nausea and vomiting with back pain.
VAD|vincristine adriamycin and dexamethasone|VAD|293|295|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 69-year- old woman with a diagnosis of multiple myeloma made originally in _%#MM#%_, 2000, when she presented with hypercalcemia and compression fractures involving the lumbar spine. Following diagnosis, she had chemotherapy with the VAD regimen with obtainment of a very good partial remission. She went on to have autologous stem cell harvest followed by transplant was accomplished at Abbott Northwestern Hospital.
VAD|vincristine adriamycin and dexamethasone|VAD.|125|128|DISCHARGE DIAGNOSES|PAST MEDICAL HISTORY: 1. Significant for multiple myeloma diagnosed in _%#MM#%_ 2002. The patient is status post 5 cycles of VAD. He is currently undergoing a workup for a possible bone marrow transplant. 2. GERD. 3. Right inguinal hernia repair. 4. Hypertension.
VAD|vincristine adriamycin and dexamethasone|VAD|152|154|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ was initially observed, but his IgG increased to approximately 7500 and his hemoglobin dropped to 10.7. He then received three cycles of VAD chemotherapy. Follow up evaluation of IgG was 4000. In _%#MM#%_ of 2002 Mr. _%#NAME#%_ was referred to Fairview-University Medical Center to discuss treatment options.
VAD|vincristine adriamycin and dexamethasone|VAD|189|191|HISTORY OF PRESENT ILLNESS|Follow up evaluation of IgG was 4000. In _%#MM#%_ of 2002 Mr. _%#NAME#%_ was referred to Fairview-University Medical Center to discuss treatment options. The patient received an additional VAD cycle and is now here for chemo priming prior to an autologous bone marrow transplant. PAST MEDICAL HISTORY: 1. Schizophrenia. 2. Irritable bowel syndrome. ALLERGIES: No known drug allergies.
VAD|vincristine adriamycin and dexamethasone|VAD|203|205|HISTORY OF THE PRESENT ILLNESS|Her serum protein electrophoresis, however, remained essentially stable. Because of these findings, she was felt to have progressive disease. She was therefore started on systemic chemotherapy receiving VAD chemotherapy. She has now completed three cycles and is here to initiate cycle #4. She has continued to tolerate her treatments extremely well. Many of her clinical symptoms have largely improved including her back pain.
VAD|vincristine adriamycin and dexamethasone|VAD|172|174|IMPRESSION AND PLAN|1. The patient has a known diagnosis of multiple myeloma. Again she had recent evidence of disease progression and was therefore started on systemic chemotherapy receiving VAD chemotherapy. She has now completed three cycles and is being admitted for cycle #4. We will continue to follow her clinical status as well as her serum protein electrophoresis to evaluate her overall response.
VAD|vincristine adriamycin and dexamethasone|VAD.|169|172|HOSPITAL COURSE|HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ is a 67-year-old gentleman with a new diagnosis of multiple myeloma. He was admitted for his first cycle of chemotherapy with VAD. He tolerated his chemotherapy very well. DISCHARGE PLANS: The patient will be discharged to home today in stable condition.
VAD|vincristine adriamycin and dexamethasone|VAD|239|241|HISTORY OF PRESENT ILLNESS|The patient also describes having a cough for a day, productive of clear sputum, with associated fever and rigors earlier on the day of admission. He has a history of advanced multiple myeloma, IgG kappa light chain. He has four cycles of VAD on _%#MMDD2003#%_ and is currently receiving Velcade, status post two doses, with the last one on _%#MMDD2003#%_. ALLERGIES: Sulfa. ADMISSION MEDICATION: 1. Metoprolol 75 mg b.i.d.
VAD|vincristine adriamycin and dexamethasone|VAD,|240|243|PAST MEDICAL HISTORY|1. Multiple myeloma, IgG kappa light chain, diagnosed in _%#MM2000#%_. The patient was treated in the past with melphalan and prednisone for about a year before he saw Dr. _%#NAME#%_. His most recent chemotherapy regimen was four cycles of VAD, which ended in _%#MM#%_, and he is currently receiving Velcade, status post two doses. The last dose was on _%#MMDD2003#%_. 2. Chronic renal insufficiency, with a baseline creatinine of 2.5.
VAD|vincristine adriamycin and dexamethasone|VAD|118|120|HISTORY OF PRESENT ILLNESS|The patient was initially diagnosed in _%#MM#%_ 2000 with IgG multiple myeloma. At that time, he received 6 cycles of VAD followed by an auto stem cell transplant on _%#MMDD2001#%_. The patient did well and was in remission until _%#MMDD2005#%_, when he had a bone marrow biopsy, which showed recurrent disease with 4% plasma cells and a total protein of 8.6. At that time, he was started on salvage chemotherapy with dexamethasone and thalidomide.
VAD|vincristine adriamycin and dexamethasone|VAD|166|168|HISTORY OF PRESENT ILLNESS|Initially, Mr. _%#NAME#%_ was observed, but his IgG was found to have increased to 7500, and his hemoglobin dropped to 10.7. He subsequently received three cycles of VAD chemotherapy. A follow-up evaluation found that his IgG was 4000 at that time. In _%#MM2002#%_, Mr. _%#NAME#%_ was referred to Fairview-University Medical Center to see Dr. _%#NAME#%_ _%#NAME#%_ to discuss treatment options.
VAD|vincristine adriamycin and dexamethasone|VAD|195|197|HISTORY OF PRESENT ILLNESS|In _%#MM2002#%_, Mr. _%#NAME#%_ was referred to Fairview-University Medical Center to see Dr. _%#NAME#%_ _%#NAME#%_ to discuss treatment options. Dr. _%#NAME#%_ felt that the IgG response to the VAD chemotherapy was suboptimal, so he received an additional cycle of VAD. He was subsequently enrolled on protocol for autologous transplantation.
VAD|vincristine adriamycin and dexamethasone|VAD|141|143|HISTORY OF PRESENT ILLNESS|She was enrolled in ECOG protocol (Decadron only). She was referred in _%#MM2000#%_ for a bone marrow transplant. She has had four cycles of VAD chemotherapy, with her most recent bone marrow biopsy showing 8% plasma cells. PAST MEDICAL HISTORY: 1. Multiple myeloma. 2. Status post vaginal hysterectomy.
VAD|vascular access device|VAD|168|170|PROBLEMS|The patient's symptoms resolved. 4. Positive blood cultures: The patient grew ou coagulase-negative Staphylococcus sensitive only to vancomycin. Due to the presence of VAD in line, we put her on vancomycin. Dr. _%#NAME#%_ was notified of this patient's discharge. Dr. _%#NAME#%_ on service during this patient's admission.
VAD|vincristine adriamycin and dexamethasone|VAD|257|259|DOB|Given these findings and his relatively good performance status despite being 72 years old, I recommended a marrow sensitive chemotherapeutic regimen with vincristine, adriamycin, and dexamethasone (VAD). He is now being admitted for his first cycle of the VAD regimen with plans for referral to our fellow group physicians for consideration of autologous bone marrow transplant (BMT) at Abbott-Northwestern Hospital in the coming months.
VAD|vincristine adriamycin and dexamethasone|VAD|191|193|IMPRESSION|IMPRESSION: A 72-year-old white male with recently diagnosed multiple myeloma. With bone marrow plasmacytosis and a monoclonal protein spike. As mentioned above. _%#NAME#%_ will initiate the VAD chemotherapeutic regimen today. He is scheduled to receive his chemotherapy over the next four days and hopefully will be discharged shortly thereafter.
VAD|vincristine adriamycin and dexamethasone|VAD|115|117|CONSULTS|Had significant back pain since _%#MM#%_ 2003 where IgA was found to be elevated to 4120. He underwent 4 cycles of VAD with bone marrow down to 33%. Subsequently got dexamethasone and thalidomide with good response. Plasma cells down to 35%. His complications from chemotherapy include DVT of lower extremity requiring Lovenox, constipation, muscle weakness prior to flutamide in 3 weeks prior.
VAD|ventricular assist device|VAD|275|277|HISTORY OF PRESENT ILLNESS|ADMISSION DIAGNOSIS: Diaphragmatic hernia. DISCHARGE DIAGNOSIS: Diaphragmatic hernia status post repair, history of heart transplant. PROCEDURE: Laparoscopic repair of diaphragmatic hernia. HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old male who has had a previous VAD and a heart transplant and subsequent to these procedures developed a hernia through his diaphragm which is a known complication with the VAD procedure.
VAD|ventricular assist device|VAD|283|285|HISTORY OF PRESENT ILLNESS|PROCEDURE: Laparoscopic repair of diaphragmatic hernia. HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old male who has had a previous VAD and a heart transplant and subsequent to these procedures developed a hernia through his diaphragm which is a known complication with the VAD procedure. The hernia has become significant and extensive occupying over half of his left chest and leading to symptoms of discomfort in his left chest and abdomen.
VAD|vascular access device|VAD|345|347|DISCHARGING MEDICATIONS|1. Decadron taper as follows: Decadron 6 mg p.o. q.i.d. continuing through _%#MM#%_ _%#DD#%_, 2007, then decrease to Decadron 6 mg p.o. t.i.d. through _%#MM#%_ _%#DD#%_, 2007, and then decrease the Decadron 6 mg p.o. b.i.d. indefinitely until seen by Dr. _%#NAME#%_. 2. Senokot S 2 tablets p.o. daily, hold for loose stools. 3. Lidocaine 1% for VAD protocol p.r.n. when accessing port. 4. Dulcolax suppository 10 mg per rectum q. 48 hours p.r.n. constipation. 5. Protonix 40 mg p.o. daily. 6. MiraLax 17 g p.o. daily in 8 ounces of fluid.
VAD|vascular access device|VAD.|138|141|CLINICAL NOTE|He has issues of secondary pulmonary hypertension and those became much less in the immediate postoperative period after placement of the VAD. He was started on remodulin therapy during this time period as well, very slowly turned around and was extubated and improved to the point where he will be transferred to the floor as he stabilized in rehab nicely and once all the pieces were in place, he was discharged home with his family after all the instruction had been carried out.
VAD|vascular access device|VAD|309|311|HOSPITAL COURSE|Upon arriving to the surgical ward, the patient continued to have reimplantation as well as education on the device's working. The patient continued to improve clinically each day and upon discharge, the patient was ambulating freely tolerating diet and was well versed with the operation and function of the VAD device and was given instruction on proper wound care and management. Follow-up appointments were scheduled with the patient including Coumadin clinic as well as follow up with the heart failure and surgical services.
VAD|vincristine adriamycin and dexamethasone|VAD|325|327|SUMMARY OF HOSPITAL COURSE|1. Chemotherapy administration. 2. Placement of PICC catheter on _%#MMDD2002#%_. SUMMARY OF HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 58-year-old man who has a known diagnosis of chronic renal insufficiency, as well as recent diagnosis of multiple myeloma and was admitted on _%#MMDD2002#%_ to begin chemotherapy using the VAD regimen. Please refer to Dr. _%#NAME#%_'s history and physical for further details. At the time of admission, he was noted to have creatinine of 7.0 and in view of this chemotherapy was placed on hold.
VAD|vincristine adriamycin and dexamethasone|VAD|149|151|SUMMARY OF HOSPITAL COURSE|After review of his studies, it was felt that the precipitating cause of acute renal failure was do to an underlying myeloma and he was begun on the VAD regimen. He began this on _%#MMDD2002#%_ and tolerated the treatment well. His renal function was monitored closely and he did have some slow steady improvement in creatinine down to a value of 4.5 prior to discharge.
VAD|vincristine adriamycin and dexamethasone|VAD|50|52|FINAL DIAGNOSES|FINAL DIAGNOSES: 1. Multiple myeloma, status post VAD chemotherapy. 2. History of MRSA pneumonia. 3. Clotted PICC line removed during this admission for infection control. DISCHARGE MEDICATIONS: 1. Decadron 40 mg q.d. x4 days, to repeat four days on, four days off, to start three days from now.
VAD|vincristine adriamycin and dexamethasone|VAD|147|149|HISTORY|Follow-up tests, CBC next week and twice a week until AMC over 10,000. HISTORY: This patient is a 61-year-old female with multiple myeloma who had VAD treatment a month ago and admitted here for another course of VAD. She has done well and being discharged today to follow up as an outpatient for additional treatments.
VAD|vincristine adriamycin and dexamethasone|VAD.|142|145|HISTORY|HISTORY: This patient is a 61-year-old female with multiple myeloma who had VAD treatment a month ago and admitted here for another course of VAD. She has done well and being discharged today to follow up as an outpatient for additional treatments.
VAD|vincristine adriamycin and dexamethasone|VAD|185|187|HISTORY OF PRESENT ILLNESS|Repeat bone marrow biopsy in _%#MM#%_ 2000 showed 20-25% plasma cells. The patient was then referred to the University for further treatment. She subsequently underwent three cycles of VAD recently completed. A repeat bone marrow showed improvement. The patient was then referred for auto BMT. PAST MEDICAL HISTORY: 1. Multiple myeloma, status post radiation therapy and three cycles of VAD.
VAD|vincristine adriamycin and dexamethasone|VAD|200|202|HISTORY OF PRESENT ILLNESS|At the time of diagnosis in _%#MM#%_ 2003, the patient had an IgG kappa spike in the urine, but no serum protein spike. He received radiation therapy T4 to T8 and T10 to L2 followed by four cycles of VAD chemotherapy, ending in _%#MM#%_. He is now being admitted for an autologous peripheral blood stem cell transplant following priming chemotherapy with Cytoxan, mitoxantrone and dexamethasone.
VAD|vincristine adriamycin and dexamethasone|VAD|168|170|IMPRESSION|LABORATORY DATA: Glucose 178, it has been in the high 100 to 200 range. His CBC is unremarkable. IMPRESSION: 1. Multiple myeloma, due for cycle #4 of chemotherapy with VAD regimen. 2. Right foot weakness, etiology unclear. Could be related to sensory and motor neuropathy due to vincristine chemotherapy.
VAD|vincristine adriamycin and dexamethasone|VAD|131|133|REVIEW OF SYSTEMS|No shortness of breath, chest pain, cough or wheezing. GASTROINTESTINAL: Nausea comes about four to seven days, and she was on the VAD drip this last cycle. GENITOURINARY: Negative. No urgency, frequency or hematuria. CHEST WALL: Chest tenderness secondary to her expanders.
VAD|vincristine adriamycin and dexamethasone|VAD,|126|129|PLAN|NEUROLOGIC: Cranial nerves II-XII are intact. PLAN: The patient will finish her fourth cycle of AC. We will try to do an oral VAD, but if she starts getting nauseated, we have talked to home care about starting her up if she calls them. She will get radiation, followed by tamoxifen, once she is done.
VAD|vincristine adriamycin and dexamethasone|VAD|302|304|BACKGROUND HISTORY|BACKGROUND HISTORY: The patient is 76-year-old woman with a history of multiple myeloma, IGg kappa, initially diagnosed in _%#MM#%_ 2003 with presenting symptoms consistent with hyperviscosity syndrome. She required emergent plasmapheresis and treatment of hypercalcemia. She is initially treated with VAD and did have good responses. This was complicated by an episode of neutropenia and a colonic diverticular perforation which required colostomy.
VAD|ventricular assist device|VAD|117|119|DISCHARGE INSTRUCTIONS|This is going to be per her VAD coordinator, who was going to call her at home, this message was relayed to her. The VAD coordinator is _____. />
VAD|vincristine adriamycin and dexamethasone|VAD.|145|148|HISTORY OF PRESENT ILLNESS|He was previously treated with radiotherapy to the L5 compression fracture followed by two cycles of Melphalan and prednisone, and two cycles of VAD. He then underwent autologous bone marrow transplant at Abbott-Northwestern Hospital in 1999. After the transplant, the patient was started on thalidomide for one year, and the course ended in _%#MM2002#%_ with stabilization of disease.
VAD|vincristine adriamycin and dexamethasone|VAD.|170|173|HISTORY OF PRESENT ILLNESS|The patient also had a 2.3 cm tumor mass at T5 with epidural extension. He underwent a cycle of Decadron and radiotherapy, and he also underwent four further cycles with VAD. The last chemotherapy was performed in _%#MM2002#%_ before the allogeneic peripheral blood stem cell transplant. PAST MEDICAL HISTORY: Positive for GERD. PHYSICAL EXAMINATION: HEAD: Normal, non-tender, no sinus tenderness.
VAD|vincristine adriamycin and dexamethasone|VAD|221|223|HISTORY OF PRESENT ILLNESS|Details of the work-up are in prior dictations. At diagnosis, bone marrow biopsy showed 30% plasma cells with an M-spike of 3.2 gm IgG kappa. Records indicate no evidence of lytic bone lesions. He received four cycles of VAD chemotherapy without significant problems. However, work-up after completion of this therapy showed residual 13% plasma cells in this bone marrow, and continued M-spike of 3.1 gm on _%#MMDD2002#%_.
VAD|UNSURED SENSE|VAD|167|169|PAST MEDICAL HISTORY|The patient had a lot of low back pain. PAST MEDICAL HISTORY: 1. Multiple myeloma, diagnosed in 1995. Extensive disease of the lumbar spine and back pain. Status post VAD at that time with continued back pain. In _%#MM1996#%_ the patient went for an autologous bone marrow transplant. The patient received 990 rads in six fractions between _%#MMDD1996#%_ and _%#MMDD1996#%_.
VAD|vincristine adriamycin and dexamethasone|VAD|191|193|IMPRESSION AND PLAN|1. _%#NAME#%_ _%#NAME#%_ has a known diagnosis of multiple myeloma. Again she has recent evidence of disease progression and therefore she has been started on systemic chemotherapy receiving VAD chemotherapy. She has now completed two cycles and she is being admitted for cycle #3 of her treatment. We will continue to follow her clinical status as well as her serum protein electrophoresis to evaluate her overall response.
VAD|vincristine adriamycin and dexamethasone|VAD|297|299|HOSPITAL COURSE|Upon recovery from her surgery, she was given her first dose of Doxil salvage chemotherapy for her recurrent disease on _%#MMDD2004#%_ (Doxil 50 mg/meters squared, total dose 90 mg). She was maintained on TPN. Tube feeding was attempted; however, she tolerated that very poorly. She was placed on VAD infusion which helped modestly in control of her nausea; however, it made her significantly confused, and this was tapered down.
VAD|vincristine adriamycin and dexamethasone|VAD.|194|197|HISTORY OF PRESENT ILLNESS|4. Hypocalcemia. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 50-year-old gentleman with IgG lambda multiple myeloma diagnosed _%#MM#%_ 2004 who was admitted for cycle 3 of chemotherapy with VAD. The patient presented in _%#MM#%_ with pathological fracture of the right hip. His bone marrow, at that time, showed 40% involvement of plasma cells.
VAD|vincristine adriamycin and dexamethasone|VAD|145|147|HISTORY OF PRESENT ILLNESS|2. Malignant myeloma. HISTORY OF PRESENT ILLNESS: This is a 57-year-old female with a history of multiple myeloma diagnosed in 1997, status post VAD cycle and autologous transplant x2. She has been in good remission. Recently, she has been having relapsing disease with increased monoglobin spikes from 1.3 to 2.2 and restarted on a cycle Velcade, completed _%#MM#%_ _%#DD#%_, 2005, which was the day prior to admission.
VAD|vincristine adriamycin and dexamethasone|VAD|176|178|PAST MEDICAL HISTORY|Bone marrow biopsy showed 50% involvement with plasma cells. She was initially treated with thalidomide, dexamethasone in _%#MM2005#%_ but developed a DVT, and was switched to VAD chemotherapy for 3 cycles in _%#MM2005#%_. The patient did well subsequently and was worked up for an autologous bone marrow transplant.
VAD|vincristine adriamycin and dexamethasone|VAD|290|292|BRIEF HISTORY OF PRESENT ILLNESS|BRIEF HISTORY OF PRESENT ILLNESS: The patient is a 77-year- old female with a history of multiple myeloma diagnosed in 2003, initially presenting with a hyperviscosity. The multiple myeloma was found to be an IgG kappa and required emergent plasmapheresis. Initially, this was treated with VAD followed by 4 cycles of melphalan and prednisone. Initial hospital course was complicated by diverticulitis. In the spring of 2004, the melphalan and prednisone were held due to leukopenia, treatment was resumed in _%#MM#%_ 2004 until _%#MM#%_ 2004.
VAD|vincristine adriamycin and dexamethasone|VAD|209|211|PAST MEDICAL HISTORY|Myeloma is an IgG kappa. Bone marrow biopsy at that time showed 30% kappa-restricted plasma cells. She then had 4 cycles of Revlimid and dexamethasone which caused a partial remission, followed by 2 cycles of VAD which ended in _%#MM#%_ 2006. She was referred to the University of Minnesota for evaluation for possible transplant and a tandem autologous transplant course was decided on, on the CT and protocol.
VAD|vincristine adriamycin and dexamethasone|VAD|254|256|PAST MEDICAL HISTORY|She was referred to the University of Minnesota for evaluation for possible transplant and a tandem autologous transplant course was decided on, on the CT and protocol. Of note, her ejection fraction was noted to have decreased from 60% to 45% following VAD therapy and then after priming with cyclophosphamide her ejection fraction had decreased to 45%. Autologous transplantation was temporarily delayed; however, more recent cardiac evaluation showed a negative stress test and estimated ejection fraction of 52%.
VAD|vincristine adriamycin and dexamethasone|VAD|168|170|HISTORY OF PRESENT ILLNESS|Bone marrow biopsy at that time showed 60% plasma cells. IgG at that time was elevated to 2760 mg/dl with a monoclonal protein spike of 2.3 gm/dl. The patient received VAD chemotherapy for four cycles and tolerated the therapy well although she had two upper respiratory infections during treatment.
VAD|vincristine adriamycin and dexamethasone|VAD|137|139|HISTORY OF PRESENT ILLNESS|Of note, the patient has history of multiple myeloma. He was diagnosed in _%#MM2003#%_, and he has subsequently undergone four cycles of VAD chemotherapy, and is being prepped for an autotransplantation at this time. He had been admitted to the hospital on _%#MMDD2003#%_ for priming at which time he received Cytoxan, mesna, mitoxantrone, and dexamethasone.
VAD|vincristine adriamycin and dexamethasone|VAD|129|131|PAST MEDICAL HISTORY|He had IGT mono-spike in the blood of 1.7 with an elevated LD. He had multiple lytic lesions on his skull. He received cycles of VAD chemotherapy, and subsequent being evaluated for priming and stem cell collection for autotransplantation. Please note the patient had a bone marrow biopsy on _%#MMDD2003#%_ revealing 30% cellularity and one single cluster of plasma cells.
VAD|vincristine adriamycin and dexamethasone|VAD|248|250|PLAN|2. Hypertension. 3. Chronic renal failure, improved post-chemotherapy. 4. Cough without evidence of respiratory infection. 5. Anemia, associated with myeloma. PLAN: Mr. _%#NAME#%_ will be admitted to Oncology floor and started on chemotherapy with VAD regimen. I will obtain a protein electrophoresis to follow up on his myeloma protein and will start him on IV fluids and monitor electrolytes.
VAD|vincristine adriamycin and dexamethasone|VAD|215|217|HISTORY OF PRESENT ILLNESS|As you will see from the initial discharge diagnosis, subsequent investigations including a bone marrow biopsy confirmed that _%#NAME#%_ _%#NAME#%_ has an IgA myeloma. HOSPITAL COURSE: She has had a 4-day course of VAD chemotherapy and this was tolerated with little ill effects. It was completed on _%#MM#%_ _%#DD#%_, 2003, and we anticipate that her hemoglobin, white cells, and platelets may drop over the next 10 days.
VAD|vincristine adriamycin and dexamethasone|VAD|224|226|HISTORY OF PRESENT ILLNESS|Followup has been arranged for _%#NAME#%_ with Dr. _%#NAME#%_ locally in Fairview _%#CITY#%_ and she is due to have a CBC and liver function test checked twice weekly until her next course of chemotherapy. Her 2nd course of VAD chemotherapy will be scheduled for _%#MM#%_ _%#DD#%_, 2003. She will have a Hickman line placed on this day and chemotherapy will be commenced the following day.
VAD|vincristine adriamycin and dexamethasone|(VAD)|150|154|HISTORY OF PRESENT ILLNESS|The patient was diagnosed with multiple myeloma roughly 4-5 years ago. She received initially vincristine, doxorubicin (Adriamycin) and dexamethasone (VAD) chemotherapy and then received high dose chemotherapy with stem cell support. Unfortunately, she had relapsed and has required therapy with flutamide and dexamethasone, Velcade and then a second auto stem cell transplant.
VAD|ventricular assist device|VAD|148|150|DISCHARGE RECOMMENDATIONS|Her course was complicated by cardiogenic shock requiring persistent leaving open of the sternum and subsequent transfer to us for consideration of VAD insertion. Fortunately, she did not require this after a long, slow convalescence in the hospital, and was able to be stabilized and discharged.
VAD|ventricular assist device|VAD|148|150|DISCHARGE RECOMMENDATIONS|Her course was complicated by cardiogenic shock requiring persistent leaving open of the sternum and subsequent transfer to us for consideration of VAD insertion. Fortunately, she did not require this after a long, slow convalescence in the hospital, and was able to be stabilized and discharged.
VAD|ventricular assist device|VAD|137|139|HOSPITAL COURSE|Despite her impulsivity, the patient is an appropriate candidate for discharge, as she has been able to tolerate all of her Coumadin and VAD teaching. She has undergone the appropriate VAD education, has taken a test and passed it without complications. Prior to discharge, the patient has been home on 2 passes, first for 4 hours and the second for 8 hours, which she tolerated well.
VAD|ventricular assist device|VAD|185|187|HOSPITAL COURSE|Despite her impulsivity, the patient is an appropriate candidate for discharge, as she has been able to tolerate all of her Coumadin and VAD teaching. She has undergone the appropriate VAD education, has taken a test and passed it without complications. Prior to discharge, the patient has been home on 2 passes, first for 4 hours and the second for 8 hours, which she tolerated well.
VAD|ventricular assist device|VAD|175|177|HOSPITAL COURSE|He was diagnosed as class IV heart failure at that time and was known to be candidate for destination therapy LVAD placement. The patient underwent the appropriate workup for VAD placement, which included a right heart catheterization as well as an echocardiogram. He was started on Lasix drip in an attempt to maximize his cardiac function and fluid status.
VAD|ventricular assist device|VAD|220|222|HOSPITAL COURSE|He is tolerating a regular diet, voiding, ambulating, stooling and participating in therapy and daily cares as he is able. His discharge creatinine is 1.68, which is at or below his presenting baseline. The flows on his VAD has been stable throughout his hospitalization. The patient has excellent rehabilitation potential at this time. DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg twice daily. 2. Aspirin 81 mg daily.
VAD|vincristine adriamycin and dexamethasone|VAD|218|220|HISTORY|Bone survey also showed multiple areas of involvement consistent with myeloma. Initially, he had left shoulder pain, and x-ray showed numerous discrete punched out lesions. He subsequently received chemotherapy with a VAD regimen x 2 cycles, and his creatinine improved. The reason for the admission on _%#MMDD2003#%_ was for the third cycle of the VAD regimen.
VAD|vincristine adriamycin and dexamethasone|VAD|176|178|HISTORY|He subsequently received chemotherapy with a VAD regimen x 2 cycles, and his creatinine improved. The reason for the admission on _%#MMDD2003#%_ was for the third cycle of the VAD regimen. HOSPITAL COURSE: The patient tolerated the VAD regimen during this hospitalization quite well, and denied any symptoms other than some slight numbness in the distal upper extremities, which he describes as unchanged and chronic since starting chemotherapy.
VAD|vincristine adriamycin and dexamethasone|VAD,|189|192|IMPRESSION|LABS: Potassium was 3.5 at discharge. His most recent creatinine was 1.67 on _%#MMDD2003#%_. IMPRESSION: The patient is a 62-year-old male with multiple myeloma, status post third cycle of VAD, in preparation for an autologous bone marrow transplant. The patient did well during this hospitalization for VAD chemotherapy.
VAD|vincristine adriamycin and dexamethasone|VAD|211|213|IMPRESSION|IMPRESSION: The patient is a 62-year-old male with multiple myeloma, status post third cycle of VAD, in preparation for an autologous bone marrow transplant. The patient did well during this hospitalization for VAD chemotherapy. He finished his chemotherapy on _%#MMDD2003#%_, and was sent home with a prescription for prednisone (see discharge medications).
VAD|vincristine adriamycin and dexamethasone|VAD.|137|140|HISTORY OF PRESENT ILLNESS|In _%#MM#%_ 2004, he developed GI bleeding and was found to have recurrent plasmacytoma in the stomach. He has now completed 2 cycles of VAD. Today, he denies tarry stools and abdominal pain. No nausea or vomiting. His hemoglobin has been stable. The patient has been straight cathing himself for urinary retention which also recurred in _%#MM#%_ 2004.
VAD|vincristine adriamycin and dexamethasone|VAD|218|220|HOSPITAL COURSE|He did have mild hyperglycemia with dexamethasone and was controlled with a Lispro sliding scale. His finger stick glucose was in the 200 range. The patient will continue pulsed dexamethasone to complete this cycle of VAD at home. Because the hyperglycemia was mild, it was decided the patient did not need glucose coverage at this time. He was instructed to follow up with his primary physician for further hyperglycemia management.
VAD|vincristine adriamycin and dexamethasone|VAD|174|176|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ has a known diagnosis of multiple myeloma. She originally was diagnosed in _%#MM#%_ of 1999. She was initially treated with VAD chemotherapy and then underwent stem cell collection, followed by stem cell transplant in _%#MM#%_ of 2000. She remained in remission until the spring of 2001 when she was found to have a small amount of monoclonal Lambda light chain detectable in the urine but was observed off treatment until _%#MM#%_ of 2002 when her urine protein increased significantly.
VAD|ventricular assist device|VAD|228|230|PHYSICAL EXAMINATION|His mean blood pressures have been running in the 60s and 70s with his HeartMate II pump and flows have been in the 5 L range. His heart rate has been stable in the 80s and 90s. HEART: He has no rub or murmur, only HeartMate II VAD sounds. LUNGS: Now clear to auscultation with very fine crackles in the lower left lobe. O2 saturations on room air are 99%. His respiratory rate is 18-20.
VAD|vincristine adriamycin and dexamethasone|VAD|209|211|HISTORY OF PRESENT ILLNESS|He has undergone treatment with thalidomide and dexamethasone in the past and also has received therapy for a lytic lesion in the femur with a total of 3500 Centigray to his left femur followed by 4 cycles of VAD chemotherapy. He has now been referred for autologous peripheral blood stem cell transplant. PAST MEDICAL HISTORY: 1. Chronic low back pain for decades.
VAD|video-assisted thoracic surgery:VATS|VAD|131|133|HISTORY OF PRESENT ILLNESS|Patient was admitted on _%#MM#%_ _%#DD#%_ of this year and was worked up for COPD and pulmonary fibrosis. This eventually led to a VAD lung biopsy that showed evidence for underlying fibrosis and scar. He has been followed by pulmonology for continued assessment and management of this possible pulmonary fibrosis/COPD.
VAD|ventricular assist device|VAD|218|220|ADMISSION DIAGNOSIS|We did keep him one extra day until his potassium had resumed to 3.8, and we will be rechecking it in the clinic tomorrow. GI-wise, he has had a bowel movement. He is 100% ventricularly paced with occasional PVCs. His VAD flows on the day of discharge have been running approximately 4.8. He has a fixed RPM set at 90 to 100 RMPs. His incisions are dry and intact, and his drive line line site is healing appropriately.
VAD|vincristine adriamycin and dexamethasone|VAD|210|212|HISTORY OF CURRENT ILLNESS|She was diagnosed with multiple myeloma in _%#MM2003#%_ with bone marrow biopsy showing 50% involvement of plasma cells. She suffered an L5 compression fracture and had a vertebroplasty followed by 4 cycles of VAD chemotherapy. She had partial remission with a bone survey showing lytic changes. She underwent an auto PBSCT in _%#MM2003#%_ with partial remission again.
VAD|vincristine adriamycin and dexamethasone|VAD.|114|117|HISTORY OF CURRENT ILLNESS|_%#NAME#%_ _%#NAME#%_ is a 61-year-old with multiple myeloma, admitted to the hospital to begin chemotherapy with VAD. She did have lab work that showed a white count of 2900, hemoglobin 9.8 and platelet count of 101,000. She had a 24-hour urine protein excretion of 4 gm% which had increased rather markedly in the last 2-3 weeks.
VAD|vincristine adriamycin and dexamethasone|VAD.|190|193|PAST MEDICAL HISTORY|He was found to have lytic lesions to the sacrum on MRI and 5% atypical plasma cells in his bone marrow. IgG at the time of diagnosis was 2230 and M spike of 2.3. He received five cycles of VAD. He then received an autologous peripheral blood stem cell transplant on _%#MMDD2001#%_. He is also status post palliative radiation therapy to the sacrum ending in _%#MM#%_ 2001.
VAD|vincristine adriamycin and dexamethasone|VAD|199|201|PAST MEDICAL HISTORY/HISTORY OF PRESENT ILLNESS|Workup included a bone scan in _%#MM#%_, which was negative for lytic lesions, and we do not have the details of the results of his plain films skeletal survey. He is now status post three cycles of VAD chemotherapy (_%#MMDD2002#%_ and _%#MMDD2002#%_ and then in early _%#MM#%_). He is admitted for cycle 4 of VAD. REVIEW OF SYSTEMS: Essentially negative, except for eye swelling and visual disturbances, which had been previously worked up by Ophthalmology and thought they are related to his chemotherapy.
VAD|vincristine adriamycin and dexamethasone|VAD.|149|152|PAST MEDICAL HISTORY/HISTORY OF PRESENT ILLNESS|He is now status post three cycles of VAD chemotherapy (_%#MMDD2002#%_ and _%#MMDD2002#%_ and then in early _%#MM#%_). He is admitted for cycle 4 of VAD. REVIEW OF SYSTEMS: Essentially negative, except for eye swelling and visual disturbances, which had been previously worked up by Ophthalmology and thought they are related to his chemotherapy.
VAD|vincristine adriamycin and dexamethasone|VAD|216|218|HISTORY OF PRESENT ILLNESS|At that time, he had an M-spike of 2000 mg, light chain proteinuria of 4.2 gm, T12 vertebral body fracture, and normal calcium, creatinine and hemoglobin. He had 16% marrow involvement with plasma cells. He received VAD x four cycles with a good response. His M-spike dropped to 100 mg. He comes now for an autologous peripheral blood stem cell transplant for multiple myeloma.
VAD|vincristine adriamycin and dexamethasone|VAD|306|308|HISTORY OF PRESENT ILLNESS|He had a number of additional evaluations, however, which showed the presence of multiple myeloma present in the bone marrow as well as probable cerebrospinal fluid involvement as well. He was transferred from Fairview Ridges Hospital to Fairview Southdale Hospital, and was begun on chemotherapy, using a VAD regimen. He had substantial improvement in his status, including resolution of fevers, and he was discharged from the hospital five days ago (_%#MMDD2002#%_).
VAD|vincristine adriamycin and dexamethasone|VAD|265|267|SUMMARY OF HOSPITAL COURSE|At the time of admission he was quite lethargic. He was seen by a number of consultants and he had previous documentation of myeloma cells present in the spinal fluid. It was felt that this represented at least part of the explanation. He was begun on chem using a VAD regimen which he tolerated quite well and had steady improvement in his mental status during the hospitalization. He did have serum viscosity study done to help evaluate for hyperviscosity.
VAD|ventricular assist device|VAD.|210|213|ACTIVE ISSUES BY SYSTEM AT THE TIME OF DISCHARGE ARE AS FOLLOWS|There is no sign of systemic hypoperfusion. There have been no trouble with his ventricular assistive device reads. He is on appropriate medications, and is on low dose anticoagulation therapy secondary to his VAD. He has a goal INR of 1.5-2.0. PROBLEM #2: Respiratory: Stable at the time of discharge.
VAD|ventricular assist device|VAD|215|217|PHYSICAL EXAMINATION ON DISCHARGE|Saturations of 99-100% on room air. GENERAL: He is alert and awake, oriented and in no distress. He is pleasant and cooperative. NECK: No obvious jugular venous distention. LUNGS: Clear to auscultation bilaterally. VAD sounds. ABDOMEN: Soft, non-tender. EXTREMITIES: Mild pedal edema. LVAD function: Flow rate fixed at about 5 L/minute, 2200 rpm/minute.
VAD|vincristine adriamycin and dexamethasone|VAD|136|138|HISTORY OF PRESENT ILLNESS|At the time of diagnosis, he had an M spike of 4.3, calcium 10.2, IgG of 6370, with 60-90% plasma cells in his bone marrow. He received VAD x 4 cycles with a decrease in his M spike to 0.9 grams, and no evidence of myeloma in his bone marrow.
VAD|vincristine adriamycin and dexamethasone|VAD|309|311|HISTORY OF PRESENT ILLNESS|2. Blindness due to HZV retinitis and retinal necrosis. HISTORY OF PRESENT ILLNESS: This is a 53-year-old man with multiple myeloma diagnosed in _%#MM#%_ of 2001 after presenting with a sternal mass and a vertebral fracture. He had localized radiation in _%#MM#%_ 2001 of his vertebrae. He had four cycles of VAD chemo from _%#MM#%_ 2001 to _%#MM#%_ 2002 with good partial response. He did have myopathy secondary to Decadron and mild peripheral nephropathy secondary to vincristine.
VAD|vincristine adriamycin and dexamethasone|VAD|257|259|HOSPITAL COURSE|She did have an ultrasound during this hospitalization which showed a normal concordantly grown twin pregnancy, size appropriate for dates. The patient additionally underwent a GI consultation during this hospitalization. They made a recommendation for the VAD (vincristine, Adriamycin, dexamethasone) protocol but the patient declined this intervention. They had no further recommendations at this time. _%#NAME#%_ was ultimately discharged to home on _%#MMDD2002#%_.
VAD|vincristine adriamycin and dexamethasone|(VAD)|194|198|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ will be admitted to Fairview Southdale Hospital today for his third cycle of chemotherapy with vincristine, Adriamycin, and Decadron (VAD) for his multiple myeloma. Mr. _%#NAME#%_ _%#NAME#%_ is a 63-year-old gentleman who was initially seen in the hospital after being admitted for workup of peripheral neuropathy and anemia and was found to be hypercalcemic.
VAD|vincristine adriamycin and dexamethasone|VAD|120|122|HISTORY OF PRESENT ILLNESS|His first chemotherapy cycle was complicated by oral candidiasis and constipation. He then received his second cycle of VAD in _%#MM#%_ of 2003 and this cycle was complicated by a cerebrovascular accident (CVA) of the vertebral basilar arteries from which he rapidly recovered with mild residual aphasia.
VAD|vincristine adriamycin and dexamethasone|VAD|104|106|HISTORY OF PRESENT ILLNESS|He also had herpes simplex of his lower lip which was treated adequately. His response to two cycles of VAD was supplemented by a beta-2 microglobulin that went down from 1.75 to less than 0.22 and an IgG level that went down from 4.4-g to 1.1-g which is normal.
VAD|vincristine adriamycin and dexamethasone|VAD|186|188|HISTORY OF PRESENT ILLNESS|Beta II microglobulin was 3.1. He was diagnosed with multiple myeloma and started therapy with Zometa and VBMCP. He received only one course of this which was followed by five cycles of VAD with resolution of his bone aches. He is being admitted for chemotherapy priming in preparation for peripheral blood stem cell collection and otologist bone marrow transplant.
VAD|ventricular assist device|VAD|160|162|HOSPITAL COURSE|Ultimately, his symptoms continued to worsen and an echocardiogram revealed a left ventricular thrombus. This thrombus was felt to be limiting the flows to his VAD and his LVAD flows were indeed depressed as expected. He was started on a thrombolytic infusion of tissue plasminogen activator.
VAD|ventricular assist device|VAD|141|143|HOSPITAL COURSE|The patient presented with well- compensated CHF. His outpatient medications remained the same during the course of his hospitalization. His VAD rates will remain the same. DISCHARGE MEDICATIONS: 1. Vancomycin 1 g IV daily times 14 days. 2. Amiodarone 200 mg p.o. q. day.
VAD|vincristine adriamycin and dexamethasone|VAD|129|131|PROCEDURES|This patient is a 40-year-old white male with multiple myeloma, diagnosed in _%#MM#%_ 2001, who presents for his second cycle of VAD chemotherapy. The patient had his first treatment from _%#MM#%_ _%#DD#%_, 2002 through _%#MM#%_ _%#DD#%_, 2002 without complication. The patient does not describe any positive review of systems, except for a "chest cold" x 1 week; however, he felt that this was improving.
VAD|vincristine adriamycin and dexamethasone|VAD|212|214|PAST MEDICAL HISTORY|1. Multiple myeloma, which was diagnosed in _%#MM#%_ 2001 with an F-PAP revealing an M spike and a bone marrow biopsy which revealed hypercellular marrow with 70-90% plasma cells. He underwent his first cycle of VAD chemotherapy from _%#MM#%_ _%#DD#%_, 2002 to _%#MM#%_ _%#DD#%_, 2002 without difficulty. He matched a sibling donor and is followed by Dr. _%#NAME#%_ as an outpatient, with the plan in the future for him to have a bone marrow transplant.
VAD|vincristine adriamycin and dexamethasone|VAD|156|158|FAMILY HISTORY|Urine culture was negative. Chest x-ray as mentioned above. HOSPITAL COURSE: PROBLEM #1: Multiple myeloma. The patient had a PICC line placed and underwent VAD chemotherapy. He received vincristine (total of 2 mg), Adriamycin (total of 80 mg) and dexamethasone (total of 160 mg). The patient tolerated this well. He did demonstrate minimal side effects of blurry vision, likely secondary to the dexamethasone and glucose side effects.
VAD|vincristine adriamycin and dexamethasone|VAD|201|203|DISCHARGE DIET|The patient tolerated this well. He did demonstrate minimal side effects of blurry vision, likely secondary to the dexamethasone and glucose side effects. The patient is to receive two more courses of VAD chemotherapy. The goal is to eventually get him to bone marrow transplant and he apparently now has a matched sibling donor.
VAD|vincristine adriamycin and dexamethasone|VAD|69|71|ADMISSION/DISCHARGE DIAGNOSIS|ADMISSION/DISCHARGE DIAGNOSIS: Elective admission for third cycle of VAD (vincristine, adriamycin, dexamethasone) chemotherapy. PROCEDURES: 1. PICC line placement performed on _%#MM#%_ _%#DD#%_, 2002. 2. Chest x-ray performed on _%#MM#%_ _%#DD#%_, 2002. HISTORY OF PRESENT ILLNESS: The patient is a 40-year-old man who was admitted electively for the third cycle of his VAD chemotherapy that he is receiving for his multiple myeloma in preparation for an autologous transplant.
VAD|vincristine adriamycin and dexamethasone|VAD|242|244|HISTORY OF PRESENT ILLNESS|PROCEDURES: 1. PICC line placement performed on _%#MM#%_ _%#DD#%_, 2002. 2. Chest x-ray performed on _%#MM#%_ _%#DD#%_, 2002. HISTORY OF PRESENT ILLNESS: The patient is a 40-year-old man who was admitted electively for the third cycle of his VAD chemotherapy that he is receiving for his multiple myeloma in preparation for an autologous transplant. Please see the discharge summary from _%#MM#%_ _%#DD#%_, 2002 for the history of his multiple myeloma as well as other past medical history.
VAD|vincristine adriamycin and dexamethasone|(VAD),|144|149|HISTORY OF PRESENT ILLNESS|His workup revealed IgG titer for multiple myeloma, stage 3b. The patient was started on chemotherapy with vincristine, Adriamycin and Decadron (VAD), with plans of going on to an autologous stem cell transplant after going into remission. Unfortunately, his first cycle of chemotherapy was complicated by oral candidiasis and constipation which were treated appropriately.
VAD|vincristine adriamycin and dexamethasone|VAD|192|194|HISTORY OF PRESENT ILLNESS|He also developed herpes simplex of his lower lip, for which he was treated adequately, and he has been maintained on prophylaxis in his midcycle of chemotherapy. Overall, his response to the VAD was excellent, with his beta 2-microglobulin going to 1.7, which is within the normal range, and his IgG level going down from 4.4 gm to 1.1. Reevaluation of his staging workup after his third cycle of VAD shows IgG down to 1.07, and beta 2-microglobulin down to 1.5. IgM and IgA are still low at 17 and 37, respectively.
VAD|vincristine adriamycin and dexamethasone|VAD|398|400|HISTORY OF PRESENT ILLNESS|He also developed herpes simplex of his lower lip, for which he was treated adequately, and he has been maintained on prophylaxis in his midcycle of chemotherapy. Overall, his response to the VAD was excellent, with his beta 2-microglobulin going to 1.7, which is within the normal range, and his IgG level going down from 4.4 gm to 1.1. Reevaluation of his staging workup after his third cycle of VAD shows IgG down to 1.07, and beta 2-microglobulin down to 1.5. IgM and IgA are still low at 17 and 37, respectively.
VAD|vincristine adriamycin and dexamethasone|VAD.|149|152|IMPRESSION/PLAN|I discussed this with Dr. _%#NAME#%_, who will be proceeding with an autologous stem cell transplant. He agrees in proceeding with a fourth cycle of VAD. He will restage with a bone marrow biopsy and a skeletal survey prior to him following up with him by the end of next month.
VAD|ventricular assist device|VAD|189|191|HOSPITAL COURSE|4. Celexa 5. Synthroid 6. Nexium 7. Torsemide 8. Vitamins 9. Potassium chloride supplement HOSPITAL COURSE: PROBLEM #1: Status post orthotopic heart transplant. Status post explantation of VAD and AICD. The patient did exceptionally well postoperatively. He was randomized to the Fuji (?) study and also CellCept and cyclosporin.
VAD|vincristine adriamycin and dexamethasone|VAD.|171|174|HISTORY OF PRESENT ILLNESS|He was initially treated with melphalan and prednisone from _%#MM#%_ of 2001 through _%#MM#%_ of 2002. From _%#MM#%_ through _%#MM#%_ of 2002, he received three cycles of VAD. Then, in _%#MM#%_ of 2003, he was started on thalidomide with pulse Cytoxan. He received Cytoxan on _%#MM#%_ 15 and _%#MM#%_
VAD|vincristine adriamycin and dexamethasone|VAD.|162|165|HISTORY OF PRESENT ILLNESS|He had a poor response to that, and was found to have 25% atypical plasma cells on bone marrow biopsy; this was in _%#MM2002#%_. He then underwent four cycles of VAD. His chemotherapy course was complicated by pneumonia in _%#MM2003#%_. Approximately one week prior to admission, the patient had been diagnosed with C.
VAD|vincristine adriamycin and dexamethasone|VAD|281|283|HISTORY OF PRESENT ILLNESS|In _%#MM#%_ 2002 the patient was diagnosed with pneumonia as well as a pulmonary embolus and subsequently treated with two months of pulse dexamethasone which he had a near partial response, with an IgG paraprotein dropping to 2 g. The patient subsequently underwent two rounds of VAD chemotherapy without complications, while continuing his anticoagulation. The patient was evaluated by Dr. _%#NAME#%_ _%#NAME#%_ for work up for autologous bone marrow transplant.
VAD|vincristine adriamycin and dexamethasone|VAD|165|167|HISTORY OF PRESENT ILLNESS|The patient was subsequently found to have plasmacytoma in the left iliac region. This was needle biopsied, and shown to be 100% plasma cells. The patient underwent VAD chemotherapy, with quick response in terms of pain. The patient is a non-secretor/minimal secretor. She has a trace lambda light chain expression.
VAD|vincristine adriamycin and dexamethasone|VAD|175|177|BRIEF HISTORY|BRIEF HISTORY: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 63-year-old man with a history of rheumatoid arthritis and recently diagnosed multiple myeloma, status post two cycles of VAD (vincristine, Adriamycin, dexamethasone), presenting with an acute cerebrovascular accident (CVA) with ataxia, nystagmus, and left-sided weakness. HOSPITAL COURSE: He was seen by Neurology who recommended aspirin.
VAD|ventricular assist device|VAD|168|170|HISTORY OF PRESENT ILLNESS|During this hospitalization, the patient was started on dobutamine and nitroglycerin drips. He was transferred to Fairview University Medical Center for evaluation for VAD or transplant. At the time of admission, the patient was feeling very well with minimal dyspnea and no chest pain symptoms.
VAD|ventricular assist device|VAD|142|144|HOSPITAL COURSE|Due to the patient's comorbidities including diabetes, he was considered not an excellent transplant candidate, but a very good candidate for VAD as destination therapy. This workup was initiated. Bilateral carotid ultrasound and screening labs were obtained. Cardiopulmonary stress testing and neuropsychiatric evaluation are pending. The patient received some VAD education.
VAD|ventricular assist device|VAD|214|216|HOSPITAL COURSE|The patient worked with cardiac rehabilitation throughout the hospitalization and did very well, able to tolerate the treadmill for 30 minutes per day. It is hoped that the patient will recover and will not need a VAD or transplant; however, it is difficult to know what the outcome will be a transplant evaluation was initiated including Neuropsychiatric evaluation and screening labs.
VAD|vincristine adriamycin and dexamethasone|VAD|336|338|HISTORY OF PRESENT ILLNESS|4. Mucositis. 5. Neutropenic fevers. HISTORY OF PRESENT ILLNESS: The patient is a 46-year-old female with IgA multiple myeloma diagnosed in _%#MM#%_ 2001 with an IgA spike of 2.7, 5% plasma cells, kappa light chain restricted, normal creatinine and no bone lesions. That is Stage 1A disease. The patient was treated with four cycles of VAD with good response with a decrease in the IgA spike to 1.2 and 2% plasma cells in the bone marrow. The patient's pretransplant workup showed a normal SPEP with normal clonal spike in _%#MM#%_ 2002 and 5% atypical plasma cells in the bone marrow.
VAD|vascular access device|VAD|95|97|PROCEDURES|6. End stage renal failure secondary to congenital urologic disease. PROCEDURES: Hemodialysis. VAD insertion. _%#NAME#%_ _%#NAME#%_ is a 29-year-old chronic dialysis patient was transferred from Fairview Ridges Hospital for placement of a dialysis access.
VAD|vincristine adriamycin and dexamethasone|VAD|52|54|ADMISSION DIAGNOSIS|ADMISSION DIAGNOSIS: Multiple myeloma, admitted for VAD chemotherapy. DISCHARGE DIAGNOSIS: Same. PROCEDURES PERFORMED DURING ADMISSION: Cycle #2 of VAD chemotherapy. HISTORY OF PRESENT ILLNESS: Dr. _%#NAME#%_ is an 81-year-old male with a history of multiple myeloma which was diagnosed in the spring of 2001.
VAD|vincristine adriamycin and dexamethasone|VAD|148|150|PROCEDURES PERFORMED DURING ADMISSION|ADMISSION DIAGNOSIS: Multiple myeloma, admitted for VAD chemotherapy. DISCHARGE DIAGNOSIS: Same. PROCEDURES PERFORMED DURING ADMISSION: Cycle #2 of VAD chemotherapy. HISTORY OF PRESENT ILLNESS: Dr. _%#NAME#%_ is an 81-year-old male with a history of multiple myeloma which was diagnosed in the spring of 2001.
VAD|vincristine adriamycin and dexamethasone|VAD|126|128|HISTORY OF PRESENT ILLNESS|He had 2 additional cycles of melphalan and prednisone, with only limited response. Currently, he is admitted for cycle #2 of VAD chemotherapy. He was noted to have a good response with a previous dose that was given between _%#MMDD2002#%_ and _%#MMDD2002#%_.
VAD|vincristine adriamycin and dexamethasone|VAD.|149|152|DIAGNOSIS|There was nothing particularly remarkable on examination and nothing is really new since his previous admission. He is here for his second course of VAD. He did have an elevated blood glucose with the Decadron, but he controlled this himself by regulating his insulin.
VAD|vincristine adriamycin and dexamethasone|VAD|126|128|PLAN|2. Hypertension. 3. Glaucoma. 4. Chronic renal failure. PLAN: The patient will be admitted to the hospital today for starting VAD continuous infusion chemotherapy. We discussed the complications of chemotherapy in detail which may rarely include fatality. We will start him on IV fluids and obtain MUGA scan to evaluate left ventricular ejection fraction for pre-anthracycline treatment baseline.
VAD|vincristine adriamycin and dexamethasone|VAD|174|176|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 62-year- old male with a recent diagnosis of multiple myeloma, admitted for his second cycle of chemotherapy using the VAD regimen. The patient presented with pain in his left shoulder. He ultimately underwent x-rays which demonstrated numerous discreet punched-out lytic lesions consistent with myeloma.
VAD|vincristine adriamycin and dexamethasone|VAD|125|127|HISTORY OF PRESENT ILLNESS|Immunophenotyping on plasma cells with monoclonal for lambda light chains. The patient has since received his first cycle of VAD which he tolerated well. Mr. _%#NAME#%_ did not notice any significant nausea or vomiting with chemotherapy.
VAD|vascular access device|VAD|181|183|DISCHARGE DIAGNOSIS|ADMITTING DIAGNOSIS: Severe heart failure with ischemic and valvular cardiomyopathy DISCHARGE DIAGNOSIS: Severe heart failure with ischemic and valvular cardiomyopathy, status post VAD placement. PROCEDURES: On _%#MMDD2007#%_, the patient underwent a heart catheterization with intraaortic balloon pump on _%#MMDD2007#%_.
VAD|vincristine adriamycin and dexamethasone|VAD|254|256|HISTORY OF PRESENT ILLNESS|PROCEDURES DURING ADMISSION: PA and lateral chest x-ray on _%#MM#%_ _%#DD#%_, 2002, which revealed a right middle lobe infiltrate. HISTORY OF PRESENT ILLNESS: This is a 40-year-old white male with a history of multiple myeloma, status post two cycles of VAD chemotherapy, who presents with an approximately one day history of increasing shortness of breath and increasing cough which was mostly nonproductive.
VAD|vincristine adriamycin and dexamethasone|VAD|214|216|PAST MEDICAL HISTORY|1. Multiple myeloma which was diagnosed in _%#MM#%_ 2001, with an SPEP revealing an M-spike and a bone marrow biopsy which revealed hypercellular marrow with 70% to 90% plasma cells. He has undergone two cycles of VAD chemotherapy, with the last being _%#MM#%_ _%#DD#%_, 2002, to _%#MM#%_ _%#DD#%_, 2002. He is followed by Dr. _%#NAME#%_ as an outpatient and the plan is for him to possibly undergo bone marrow transplant in the future.
VAD|vincristine adriamycin and dexamethasone|VAD|131|133|HISTORY OF PRESENT ILLNESS|Ms. _%#NAME#%_ is a 58-year-old woman with multiple myeloma that was diagnosed in _%#MM2002#%_. The patient has had four cycles of VAD with good response. She is now admitted for chemotherapy priming. She currently has no active symptoms with the exception of some low back pain and slight peripheral neuropathy in her fingers.
VAD|vincristine adriamycin and dexamethasone|VAD,|150|153||The patient presented with 4.9 gm of monoclonal protein and a beta-2 microglobulin level of 9.3. She had no bony disease. She received six courses of VAD, which resulted in a drop in her M spike to 2.2 gm, and a drop in her beta-2 microglobulin to 4.2. The patient's other medical problems include adult onset diabetes mellitus, treated with glyburide.
VAD|vincristine adriamycin and dexamethasone|VAD|196|198|DISCHARGE DIAGNOSIS|She originally presented with fatigue in _%#MM#%_ 2003 with fevers. Bone marrow biopsy showed a large number of atypical plasma cells that were kappa restricted and alpha restricted. She received VAD first around _%#MM#%_ _%#DD#%_, 2004, developed polyneuropathy, received second, third and fourth cycles with just Adriamycin and dexamethasone alone.
VAD|vincristine adriamycin and dexamethasone|VAD|230|232|IMPRESSION|2. Multiple myeloma. In view of the recurrence of thrombosis while on thalidomide and dexamethazone, she will need to be taken off the thalidomide. Options for treatment will include pulse dose dexamethazone or treatment with the VAD regime. 3. Pain due to compression fractures. We have discussed having her increase her use of Vicodin on a more regular basis.
VAD|vincristine adriamycin and dexamethasone|VAD|160|162|HISTORY OF PRESENT ILLNESS|On presentation, he had 80% plasma cells in his bone marrow and a 3.1 gm and spike on serum electrophoresis. He has received four cycles of chemotherapy with a VAD regimen with a complete response. He now presents for priming chemotherapy for an autologous transplant for multiple myeloma. His pretransplant workup shows less than 5% plasma cells in the bone marrow and a beta 2 microglobulin of 2.5 and a serum protein electrophoresis showing a faint protein band in the gamma fraction (0.8). His calcium and creatinine have been stable and normal.
VAD|ventricular assist device|VAD|168|170|DISCHARGE INSTRUCTIONS|Note that his INR goal from this point forward will be 2.5-3.5. This is anticoagulation for the RVAD, which he has had implanted. He should direct all questions to his VAD coordinator who will be _%#NAME#%_ _%#NAME#%_. Her phone number is _%#TEL#%_. She will make his appointment with Dr. _%#NAME#%_ and Dr. _%#NAME#%_ and let him know when this appointments are.
VAD|vincristine adriamycin and dexamethasone|VAD,|259|262|BRIEF HISTORY OF PRESENT ILLNESS|BRIEF HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 64-year-old male with history of refractory progressive multiple myeloma, IgG who is status post autologous stem cell transplant in 2001, status post multiple cycles of chemotherapy, which included VAD, modified hyper-CVAD, Velcade and Revlimid. Last dose of Revlimid was on _%#MMDD2007#%_, but in spite of all the therapy, his myeloma continued to progress and he was referred to Mayo Clinic, but he was not eligible for the phase 1 trial of clinical research over there due to elevated liver function test and that is why the patient came back and was admitted on the Hematology/Oncology floor for another cycle of chemotherapy, which would be VBMCP.
VAD|ventricular assist device|VAD.|194|197|PROCEDURES|PROCEDURES: On _%#MMDD2007#%_, the patient underwent the following procedures by Dr. _%#NAME#%_ _%#NAME#%_: 1. Laparoscopic lysis of adhesions. 2. Laparoscopic diaphragm fundoplication. 3. Left VAD. For details regarding these procedures, please refer to Dr. _%#NAME#%_'s dictation located in Allscripts.
VAD|vincristine adriamycin and dexamethasone|VAD|192|194|HISTORY OF PRESENT ILLNESS|Results: Normal chest x- ray. HISTORY OF PRESENT ILLNESS: The patient is a 46-year-old man with multiple myeloma (IgG lambda) diagnosed in _%#MM2001#%_. The patient was initially treated with VAD x 4 cycles. The patient had a good response, and a bone marrow biopsy in _%#MM2002#%_ showed hypocellular marrow without dystrophic plasma cells.
VAD|vincristine adriamycin and dexamethasone|VAD|167|169|PAST MEDICAL HISTORY|1. Multiple myeloma diagnosed in _%#MM#%_ of 2001. His presenting symptoms, included fatigue and arthralgias for approximately one year. He was initially treated with VAD times four cycles. He was then treated with BCNU in _%#MM#%_ of 2002. He also was treated with VPMCP prior to his transplant.
VAD|vincristine adriamycin and dexamethasone|VAD,|180|183|HISTORY OF PRESENT ILLNESS|24-hour urine collection showed 1254 mg protein. B2 equals 0.1. The patient diagnosed with multiple myeloma. WBC, and RBC counts were normal. She presented status post 4 cycles of VAD, the last dose _%#MM#%_ 2002 with improvement in bone marrow and 1% plasma cells. Some improvement in bony pain as well. Tenckhoff catheter was placed on _%#MM#%_ _%#DD#%_, 2002, status post cyclophosphamide and mesna, mitoxantrone, and dexamethasone _%#MM#%_ _%#DD#%_, 2002, through _%#MM#%_ _%#DD#%_, 2002.
VAD|vascular access device|VAD|122|124|HISTORY OF PRESENT ILLNESS|Bone marrow biopsy performed and showed an aspirate with 64% plasma cells and nearly 100% plasma cell bone marrow biopsy. VAD chosen to preserve option of BMT at later time, without apparent complications. 2. Hyperviscosity syndrome. Patient developed chest pain on the night of admission, viscosity index was elevated.
VAD|vincristine adriamycin and dexamethasone|VAD|152|154|HISTORY OF PRESENT ILLNESS|Mrs. _%#NAME#%_ is a 57-year-old female with a history of plasma cell leukemia diagnosed in _%#MM2000#%_. She was initially treated with four cycles of VAD and then underwent a non- myeloablative unrelated donor transplant in _%#MM2000#%_. Unfortunately, she relapsed in _%#MM2003#%_ with bone marrow involvement and plasmacytoma involving T8 with a compression fracture.
VAD|vincristine adriamycin and dexamethasone|VAD|194|196|HISTORY OF PRESENT ILLNESS|Unfortunately, she relapsed in _%#MM2003#%_ with bone marrow involvement and plasmacytoma involving T8 with a compression fracture. The T8 lesion was treated with local radiation and a cycle of VAD chemotherapy in _%#MM2003#%_. The bone marrow biopsy after the first cycle of VAD showed 50% plasma cells. She was subsequently treated with a cycle of EDAP on _%#MMDD2003#%_ and tolerated it well other than some nausea.
VAD|vincristine adriamycin and dexamethasone|VAD|144|146|HISTORY OF PRESENT ILLNESS|The T8 lesion was treated with local radiation and a cycle of VAD chemotherapy in _%#MM2003#%_. The bone marrow biopsy after the first cycle of VAD showed 50% plasma cells. She was subsequently treated with a cycle of EDAP on _%#MMDD2003#%_ and tolerated it well other than some nausea.
VAD|vincristine adriamycin and dexamethasone|VAD.|151|154|HISTORY OF PRESENT ILLNESS|She had to start taking oxycodone to relieve this pain. She continues to have some slight paresthesias of the fingers and toes since her last cycle of VAD. PAST MEDICAL/SURGICAL HISTORY: 1. Relapsed plasma cell leukemia as outlined in History of Present Illness.
VAD|vincristine adriamycin and dexamethasone|VAD|176|178|HISTORY OF PRESENT ILLNESS|She received treatment with high-dose Decadron followed by radiation therapy. Her symptoms improved, but she did have some residual lower extremity numbness. She then received VAD x 3 cycles with good response, verified by resolution of her MRI findings and protein down to 0.2 gm. She had chemotherapy priming with Cytoxan and mitoxantrone _%#MMDD2003#%_ and _%#MMDD2003#%_ followed by peripheral blood stem cell collection and autologous peripheral blood stem cell transplant.
VAD|vincristine adriamycin and dexamethasone|VAD|173|175|HISTORY OF PRESENT ILLNESS|He had a good response until _%#MM#%_ 2004, when he developed subsequent recurrent plasmacytoma in the stomach and recurrent urinary retention. He since has been started on VAD chemotherapy, and his urinary retention has resolved. HOSPITAL COURSE: The patient was admitted after being seen in the emergency room.
VAD|vincristine adriamycin and dexamethasone|VAD|229|231|HOSPITAL COURSE|Therefore, no antibiotics were started during the hospitalization. After discharge, he was instructed to call the on-call physician for a temperature greater than 100.5. He has plans to follow up with Dr. _%#NAME#%_ for cycle #4 VAD in a few weeks. DISPOSITION: The patient was discharged to home. DISCHARGE MEDICATIONS: 1. Protonix 40 mg p.o. daily. 2. Multivitamin 1 p.o. daily.
VAD|vincristine adriamycin and dexamethasone|VAD.|207|210|DISCHARGE MEDICATIONS|DISCHARGE MEDICATIONS: 1. Protonix 40 mg p.o. daily. 2. Multivitamin 1 p.o. daily. 3. Dexamethasone 40 mg p.o. daily on _%#MM#%_ _%#DD#%_, 2004, through _%#MM#%_ _%#DD#%_, 2004. This is to complete cycle #3 VAD. DISCHARGE FOLLOW-UP: 1. The patient is to follow up with Dr. _%#NAME#%_ on _%#MM#%_ _%#DD#%_, 2004, at 1 p.m. as previously scheduled.
VAD|vincristine adriamycin and dexamethasone|VAD|179|181|HISTORY OF PRESENT ILLNESS|4. Anxiety. 5. Multiple myeloma. HISTORY OF PRESENT ILLNESS: The patient is a 46-year-old female with a history of multiple myeloma diagnosed in _%#MM#%_ 2003. She is status post VAD chemotherapy. She is currently undergoing G-CSF treatment for upcoming stem cell harvesting for bone marrow transplant. The patient has received three doses of growth factor, last dose yesterday.
VAD|vincristine adriamycin and dexamethasone|VAD|156|158|HISTORY OF PRESENT ILLNESS|Of note, the patient complains of peripheral neuropathy secondary to VAD which had been slightly improving with time. The patient reports completion of the VAD about six weeks ago. She is currently being started for a tandem autologous then allogeneic sibling peripheral blood stem cell transplant.
VAD|vincristine adriamycin and dexamethasone|VAD|93|95|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Multiple myeloma. 2. Pathological fracture right hip. 3. Status post VAD chemotherapy during this admission with intractable nausea. BACKGROUND: Mr. _%#NAME#%_ is a 49-year-old gentleman who, in summary, presented on _%#MM#%_ _%#DD#%_, 2004, with a few-month history of right hip pain.
VAD|vincristine adriamycin and dexamethasone|VAD.|132|135||_%#NAME#%_'s brief history reveals that she was diagnosed with plasma-cell leukemia in _%#MM2000#%_ and treated with four cycles of VAD. She then underwent a non- myeloablative unrelated donor transplant in _%#MM2000#%_. Unfortunately, she relapsed in _%#MM2003#%_ with bone marrow involvement and a plasmacytoma of T8 manifesting as a compression fracture.
VAD|vincristine adriamycin and dexamethasone|VAD|139|141|OTHER PAST MEDICAL HISTORY|Was given Zometa and dexamethasone and that resulted in decreasing plasma cell count down to 75. He was then also treated with 2 cycles of VAD chemotherapy, which decreased amount of plasma cells again. At that point he was proposed autologous peripheral blood stem cell transplantation.
VAD|vincristine adriamycin and dexamethasone|VAD|192|194|HISTORY OF PRESENT ILLNESS|He was then seen at Fairview Ridge Medical Center for transplant evaluation at which time he had a protein spike of 0.3 gm and 7% plasma cells in his bone marrow. He then received 2 cycles of VAD (vincristine, Adriamycin and dexamethasone) ending in _%#MM#%_ 2004. Follow up marrow showed 15% plasma cells in the bone marrow. He was then admitted for priming chemotherapy and peripheral blood cell stem cell collection in preparation for auto PBSCT.
VAD|ventricular assist device|VAD.|208|211|ASSESSMENT/PLAN|Echo in _%#MM2004#%_ showed EF of 18%. Status post L-VAD placement on _%#MMDD2004#%_. The patient is still with shortness of breath with minimal exertion. We will continue aspirin, Lipitor, metoprolol and L- VAD. 2. Pulmonary. Shortness of breath secondary to ischemic cardiomyopathy. Continue albuterol neb. We will start O2 nasal cannula supplement to keep O2 sat greater than 94%.
VAD|vincristine adriamycin and dexamethasone|VAD|164|166|HISTORY OF PRESENT ILLNESS|She also had renal insufficiency with a creatinine of 3.4, a 4.3 gm IgG lambda M-spike, and normal cytogenetics. She was treated at the Humphrey Cancer Center with VAD x 3 cycles which went through _%#MM2004#%_. She was scheduled to have a fourth cycle of VAD chemotherapy. However, she developed PCP pneumonia and was hospitalized from _%#MMDD2004#%_ to _%#MMDD2004#%_ with this and treated with Bactrim and steroids.
VAD|vincristine adriamycin and dexamethasone|VAD|143|145|HISTORY OF PRESENT ILLNESS|She was treated at the Humphrey Cancer Center with VAD x 3 cycles which went through _%#MM2004#%_. She was scheduled to have a fourth cycle of VAD chemotherapy. However, she developed PCP pneumonia and was hospitalized from _%#MMDD2004#%_ to _%#MMDD2004#%_ with this and treated with Bactrim and steroids.
VAD|vincristine adriamycin and dexamethasone|VAD,|305|308|DISCHARGE DIAGNOSES|3. Nephrotic syndrome secondary to chronic kidney disease. HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old gentleman with multiple myeloma which is lambda light chain restricted, diagnosed in 2001. He is status post 4 cycles of vincristine, doxorubicin, and dexamethasone, which is also known as VAD, which was followed by an autologous stem cell transplant in _%#MM#%_ of 2002. Apparently the patient did well with this therapy regime and was in complete remission for about 2 years.
VAD|vincristine adriamycin and dexamethasone|VAD|195|197|PAST MEDICAL HISTORY|Bone marrow biopsy showed 50% involvement with plasma cells. She was initially treated with thalidomide and dexamethasone in _%#MM2005#%_, but developed a DVT and was switched in _%#MM2005#%_ to VAD for three cycles. The patient did well subsequently and was worked up for an autologous bone marrow transplant. Her follow-up _____________ showed monoclonal proteins of 0.2 gm/dL down from 3.1 gm/dL.
VAD|vincristine adriamycin and dexamethasone|VAD|236|238|HISTORY OF PRESENT ILLNESS|He was diagnosed with IgG kappa myeloma. Initial workup revealed an IgG of 4593, an M protein of 4.7 and a beta 2 microglobulin of 4.7. A bone marrow biopsy at the time of diagnosis revealed 12% plasma cells. He received four cycles of VAD chemotherapy ending in _%#MM#%_ 2003. After his second cycle, his IgG had dropped to 256, beta 2 down to 2.43, and he had resolution of his bone pain.
VAD|vincristine adriamycin and dexamethasone|VAD.|222|225|PAST MEDICAL HISTORY|Lichen kappa, monoclonal protein 3.1. Lumbar spine involvement, status post thalidomide and dexamethasone which was complicated by hemopathy. He received radiation therapy to femur lytic lesion. Status post four cycles of VAD. He was referred for auto stem cell transplant, received priming chemotherapy with Cytoxan, radiation, and dexamethasone in _%#MM#%_ 2004 and received the auto stem cell transplant on _%#MMDD2004#%_ in clinic.
VAD|ventricular assist device|VAD|149|151|PROBLEMS ADDRESSED DURING TRANSITIONAL CARE STAY|He is becoming more independent in mobility. His endurance is also improved. Between he and his spouse, they are independent in self-cares of his L- VAD and its associated support equipment. 3. Type 2 diabetes. The patient is currently on insulin therapy and has demonstrated his ability to manage his illness through participation in the Patient Learning Center.
VAD|ventricular assist device|VAD|319|321|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 74-year-old patient admitted to the University of Minnesota Medical Center, Fairview, in early _%#MM#%_ with non-ischemic cardiomyopathy resulting in Class IV heart failure. Despite maximum use of medications, biventricular pacing and ICD therapy, it was felt that an L- VAD would be necessary to support him. His ejection fraction pre-L- VAD placement was less than 15%. He tolerated L-VAD placement without significant difficulty. His prolonged hospital course included episodes of low-grade fever.
VAD|ventricular assist device|VAD|165|167|HISTORY OF PRESENT ILLNESS|Despite maximum use of medications, biventricular pacing and ICD therapy, it was felt that an L- VAD would be necessary to support him. His ejection fraction pre-L- VAD placement was less than 15%. He tolerated L-VAD placement without significant difficulty. His prolonged hospital course included episodes of low-grade fever.
VAD|vincristine adriamycin and dexamethasone|VAD,|170|173|DATE OF DEATH|DATE OF DEATH: _%#MM#%_ _%#DD#%_, 2006. The patient is a 63-year-old male with a history of multiple myeloma diagnosed in _%#MM#%_ 2001, heavily treated in the past with VAD, also status post autologous transplant relapsed in 2003, received dexamethasone with thalidomide, again relapsed in 2005, received a course of Velcade which was discontinued secondary to peripheral neuropathy. Workup for nonmyeloablative allogeneic bone marrow transplant was then initiated.
VAD|vincristine adriamycin and dexamethasone|VAD|193|195|HISTORY/HOSPITAL COURSE|HISTORY/HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a very pleasant 48-year-old woman with multiple myeloma. She has had multiple myeloma since _%#MM#%_ 1999. She has undergone chemotherapy with VAD followed by stem cell transplantation in _%#MM#%_ 2000. She has since relapsed and has required additional treatment with thalidomide, Velcade, Melphalan, and had an autotransplantation as well as another bone marrow transplantation with a matched donor.
VAD|vincristine adriamycin and dexamethasone|VAD|207|209|HISTORY|Home care was involved. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 63-year-old Caucasian woman with history of multiple myeloma treated by Dr. _%#NAME#%_ was hospitalized on _%#MM#%_ _%#DD#%_ to get treatment with VAD chemotherapy regimen. She had pain in the right knee, had an x-ray and ultrasound, eventually had MRI and evaluated by a doctor _%#NAME#%_ _%#NAME#%_.
VAD|vincristine adriamycin and dexamethasone|VAD|182|184|HISTORY|MRI was reviewed by Dr. _%#NAME#%_ who felt it was reasonable for her to discharge from the hospital. No surgical intervention was done during the hospitalization. Chemotherapy with VAD was administered without significant complications.
VAD|ventricular assist device|VAD)|123|126|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Acute blood loss anemia. 2. Ischemic cardiomyopathy status post left ventricular assist device (L- VAD) for bridge to transplant. 3. History of a bleeding diathesis after left ventricular assist device (L- VAD) placement. Workup started. OPERATIONS/PROCEDURES PERFORMED DURING THIS HOSPITALIZATION: 1. Upper endoscopy.
VAD|ventricular assist device|VAD)|230|233|DISCHARGE DIAGNOSES|DISCHARGE DIAGNOSES: 1. Acute blood loss anemia. 2. Ischemic cardiomyopathy status post left ventricular assist device (L- VAD) for bridge to transplant. 3. History of a bleeding diathesis after left ventricular assist device (L- VAD) placement. Workup started. OPERATIONS/PROCEDURES PERFORMED DURING THIS HOSPITALIZATION: 1. Upper endoscopy.
VAD|ventricular assist device|VAD|169|171|SSUES DURING HOSPITAL COURSE|8. At the time of discharge, the patient was ambulating, voiding without difficulty and tolerating a regular diet. He was having bowel movements. He was having adequate VAD teaching and was understanding it without difficulty. DISCHARGE INSTRUCTIONS: The patient is discharged to rehab in good condition.
VAD|vincristine adriamycin and dexamethasone|VAD|150|152|PAST MEDICAL HISTORY|Bone marrow biopsy 30% kappa-restricted plasma cells. Status post 4 cycles of Revlimid and dexamethazone with partial remission, status post 2 cycles VAD ending _%#MM2006#%_. 2. Hysterectomy at age 30 for fibroid tumor. 3. History of bilateral knee surgeries for sports injuries. 4. History of cervical fusion C5-6 and C7 for degenerative joint disease in 2001.
VAD|vincristine adriamycin and dexamethasone|VAD,|131|134|HOSPITAL COURSE|She is treated with Allegra 60 mg p.o. daily. PROBLEM #4. Constipation: She has constipation at her baseline. In the past with her VAD, she has had diarrhea; however, she is currently constipated. Senokot-S 2 tabs p.o. b.i.d. p.r.n. PROBLEM #5. Insomnia: At baseline the patient does not have insomnia, but when she was in the hospital in the past, she has benefited from Restoril 30 mg p.o. q.h.s. FOLLOW-UP: Follow-up is arranged at the Bone Marrow Transplant Clinic for _%#MMDD2006#%_ which is the day following her discharge from the hospital.
VAD|vascular access device|VAD|127|129|HOSPITAL COURSE|A chest x-ray was performed as well, which showed no acute airspace disease. She had her PICC line discontinued. She does have VAD port in her right upper chest, through which she can have further treatment if needed. At the present time the patient states that she is feeling fine and once again stated she wants to go home.
VAD|vincristine adriamycin and dexamethasone|VAD|176|178|PAST MEDICAL HISTORY|Bone marrow biopsy showed 50% involvement with plasma cells. She was initially treated with thalidomide, dexamethasone in _%#MM2005#%_ but developed a DVT, and was switched to VAD chemotherapy for 3 cycles in _%#MM2005#%_. The patient did well subsequently and was worked up for an autologous bone marrow transplant.
VAD|vascular access device|VAD,|132|135|HOSPITAL COURSE|The patient initially had blood cultures drawn upon arrival in the ER, and the blood culture from _%#MM#%_ _%#DD#%_, 2006, from his VAD, did grow coag-negative Staphylococcus which is susceptible to vancomycin. The patient's primary care physician, Dr. _%#NAME#%_ _%#NAME#%_, was consulted, as well as infectious disease here, to get their opinions as to how to manage this bacteremia.
VAD|vascular access device|VAD|217|219|HOSPITAL COURSE|The patient's primary care physician, Dr. _%#NAME#%_ _%#NAME#%_, was consulted, as well as infectious disease here, to get their opinions as to how to manage this bacteremia. The patient adamantly refuses to have the VAD port removed, so the patient was placed on vancomycin IV 1 g b.i.d. set up by home infusion, as well as an IV vancomycin lock for 12 hours on and 12 hours off per day.
VAD|vascular access device|VAD.|185|188|DISCHARGE DIAGNOSES|2. Possible sepsis. 3. Fever and neutropenia. DISCHARGE DIAGNOSES: 1. Gamma-delta T-cell lymphoma, recurrent after bone marrow transplant. 2. Coag-negative Staph sepsis due to infected VAD. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 12-year-old Caucasian male with hepatosplenic gamma-delta T-cell non-Hodgkin's lymphoma which was treated with bone marrow transplant on _%#MM#%_ _%#DD#%_, 2006, at Memorial Sloan-Kettering Cancer Center in _%#CITY#%_ _%#CITY#%_.
VAD|vincristine adriamycin and dexamethasone|VAD|228|230|HOSPITAL COURSE|3. Asthma. Please see the admission H and P for the patient's family history, social history, medications, allergies, and physical examination. HOSPITAL COURSE: Multiple myeloma. The patient had a PICC line placed and underwent VAD chemotherapy. The patient tolerated this well. He demonstrated very minimal side effects consisting of mild constipation. The patient will receive three more courses of VAD. The goal is to eventually get him to bone marrow transplant.
VAD|vincristine adriamycin and dexamethasone|VAD.|155|158|HOSPITAL COURSE|The patient tolerated this well. He demonstrated very minimal side effects consisting of mild constipation. The patient will receive three more courses of VAD. The goal is to eventually get him to bone marrow transplant. The patient will follow up with Dr. _%#NAME#%_ in the Hematology Clinic the Thursday before he is to be readmitted for his second cycle of VAD therapy.
VAD|vincristine adriamycin and dexamethasone|VAD|50|52|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: Multiple myeloma status post VAD treatment. OTHER DISCHARGE DIAGNOSES: 1. Multiple myeloma, IgA type, initially diagnosed in 1998. The patient was initially treated with melphalan and Prednisone.
VAD|vincristine adriamycin and dexamethasone|VAD|137|139|PROCEDURES PERFORMED|4. Appendectomy. 5. Surgical removal of left humerus. 6. Mitral valve prolapse. PROCEDURES PERFORMED: Treatment of multiple myeloma with VAD (vincristine, Adriamycin, dexamethasone). The patient started treatment on _%#MMDD2002#%_. The patient was treated with vincristine and Adriamycin from day #1 to day #4.
VAD|vincristine adriamycin and dexamethasone|VAD|203|205|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old female with multiple myeloma with IgA predominance. The patient was first diagnosed in 1998. She is now admitted by Dr. _%#NAME#%_ _%#NAME#%_ for VAD therapy for the first time. The patient's last S-PEP in _%#MM#%_ 2001 showed an IgA of 900 and an IgG of 400. The patient previously has had 10 cycles of melphalan and Prednisone and then oral dexamethasone for the duration of _%#MM2001#%_ until _%#MM2001#%_.
VAD|vincristine adriamycin and dexamethasone|VAD.|153|156|HOSPITAL COURSE|HOSPITAL COURSE: Multiple myeloma. The patient had IgA multiple myeloma and was essentially admitted to treat with her progressive multiple myeloma with VAD. The patient received VAD days #1-4. She tolerated the chemotherapy well and did not have any particular problems. The patient's bone pain was treated with Tylenol and did not require any further management.
VAD|vincristine adriamycin and dexamethasone|VAD|189|191|HISTORY OF THE PRESENT ILLNESS|Bone marrow biopsy had 50% plasma cells. X-ray showed involvement in bilateral humerus, left femur, right ischium, left clavicle and inferior part of the left scapula. She was treated with VAD chemotherapy. Now here for chemo-priming for autologous stem cell collection. ALLERGIES: Patient has allergy to Relafen.
VAD|vincristine adriamycin and dexamethasone|VAD|237|239|BRIEF HISTORY|After excessive workup, the patient was diagnosed with multiple myeloma with an IgA level of 2700 and a bone marrow biopsy showing 5% plasma cells but normal beta 2 microglobulins and no bony lesions. The patient received four cycles of VAD chemo ending in _%#MM2002#%_. Her IgA level dropped to 1200, and her bone marrow plasma cells percentage dropped to 2%.
VAD|vincristine adriamycin and dexamethasone|VAD|222|224|PAST MEDICAL HISTORY|The night before admission the patient noted some vesicles on his scalp and noted a burning sensation. PAST MEDICAL HISTORY: Significant for multiple myeloma was diagnosed in _%#MM#%_ of 2001. The patient was treated with VAD for four cycles. The patient is now status post autologous peripheral blood stem cell transplant on _%#MMDD2002#%_. PAST MEDICAL HISTORY: 1. The patient was diagnosed with multiple myeloma IgG in _%#MM#%_ of 2001.
VAD|vincristine adriamycin and dexamethasone|VAD|268|270|PAST MEDICAL HISTORY|The patient was treated with VAD for four cycles. The patient is now status post autologous peripheral blood stem cell transplant on _%#MMDD2002#%_. PAST MEDICAL HISTORY: 1. The patient was diagnosed with multiple myeloma IgG in _%#MM#%_ of 2001. The patient received VAD chemotherapy times four cycles with good response. The patient underwent autologous peripheral blood stem cell transplant on _%#MMDD2002#%_. 2. Depression. 3. Hypertension. 4. Status post appendectomy. 5. Status post recurrent pneumonias.
VAD|vincristine adriamycin and dexamethasone|VAD|191|193||_%#NAME#%_ _%#NAME#%_ is a 46-year-old man with a recent diagnosis of Burkitt's non-Hodgkin's lymphoma arising in the stomach, admitted for his second cycle of chemotherapy using the Hyper-C VAD regimen. He received his first cycle of treatment approximately three weeks ago using the treatment A portion of the regimen. He received Cytoxan with mesna, vincristine, Adriamycin, pulse dexamethasone and rituximab.
VAD|vincristine adriamycin and dexamethasone|VAD|237|239|IMPRESSION|Gait is steady. NEURO: Nonfocal. LABORATORY DATA: Labs drawn today demonstrate a white count 6.6, hemoglobin 9.9, platelets 277,000. IMPRESSION: 1. Burkitt's lymphoma arising in the stomach. The patient has completed cycle #1 of hyper-C VAD along with Rituxan. He will proceed with cycle #2 today using treatment B of the regimen which includes methotrexate and Ara-C.
VAD|vincristine adriamycin and dexamethasone|VAD.|150|153|HISTORY OF PRESENT ILLNESS|DOB: _%#MMDD1940#%_ HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 61-year-old female with multiple myeloma who was admitted for her fourth cycle of VAD. Please refer to my initial History & Physical for details of her recent medical course. HOSPITAL COURSE: Upon admission the patient was started on her treatment using Vincristine 0.4 mg intravenously over 24 hours x 4 days, Adriamycin 17 mg intravenous continuous infusion over 24 hours x 4 days, and Decadron 40 mg p.o. q.d. x 4 days.
VAD|vincristine adriamycin and dexamethasone|VAD|205|207|HISTORY OF PRESENT ILLNESS|X-ray of this area revealed a lytic lesion. Biopsy at that time revealed a plasmacytoma. He was also found to have a serum IgG of 7.8 gm. Bone marrow biopsy revealed 50% plasma cells. The patient received VAD x 4-6 cycles. After the fourth cycle, his total IgG level dropped to 1.1 gm and remained stable after 6 cycles. The plasmacytoma did decrease significantly in size and stabilized after six cycles of VAD.
VAD|vincristine adriamycin and dexamethasone|VAD.|185|188|HISTORY OF PRESENT ILLNESS|After the fourth cycle, his total IgG level dropped to 1.1 gm and remained stable after 6 cycles. The plasmacytoma did decrease significantly in size and stabilized after six cycles of VAD. He is admitted today for chemotherapy priming and preparation for an autologous peripheral blood stem cell transplant. He had no sibling matches. PAST MEDICAL HISTORY: 1. Adult-onset diabetes mellitus.
VAD|vincristine adriamycin and dexamethasone|VAD|171|173|SUMMARY|CONDITION UPON DISCHARGE: Stable. SUMMARY: Mr. _%#NAME#%_ is a 63-year-old male with a history of multiple myeloma, neuropathy and hypercalcemia. He has been treated with VAD chemotherapy. He received four cycles during this admission, tolerated it well, and is being discharged home. He had no nausea or vomiting, no shortness of breath or chest pain.
VAD|vincristine adriamycin and dexamethasone|VAD|216|218|PAST MEDICAL HISTORY|She had a trace paraprotein monoclonal protein detected on immunofixation, which was very low and not quantitated. She has multiple lytic lesions in the skull, humeri and pelvic bones. She was initially treated with VAD therapy for three cycles and had a great response clinically, much decreased pain. Follow up bone marrow biopsies revealed rare plasma cells. Biopsy was hypocellular.
VAD|vincristine adriamycin and dexamethasone|VAD|225|227|PAST MEDICAL HISTORY|Her pain is controlled with a fentanyl patch. She has been ambulating and able to go up and down stairs at home. Of note, she does have some bilateral lower extremity edema. She notes that this would flare with her cycles of VAD chemotherapy. She has taken Lasix before occasionally with minimal benefit. Medications include fentanyl patch. ALLERGIES: Penicillin. This causes a rash. She also noted that morphine caused mental status changes.
VAD|vincristine adriamycin and dexamethasone|VAD|150|152|ASSESSMENT|DLCO corrected was 51%, FEV1/FVC 64%. ASSESSMENT: The patient is a 59-year-old woman with multiple myeloma x 8 months. She has had a good response to VAD chemotherapy and is being accepted for autologous transplant program. The patient will be admitted for priming chemotherapy with Cytoxan and mitoxantrone for mobilization of stem cells and stem cell collection.
VAD|vincristine adriamycin and dexamethasone|VAD.|186|189|ASSESSMENT|The patient will receive IV hydration prior to chemotherapy. The patient does note a history of lower extremity edema which flared with withdrawal of dexamethasone after prior cycles of VAD. Of note, the patient also has decreased pulmonary function, will need to monitor closely. The patient is to be admitted _%#MMDD2003#%_ for hydration and IV chemotherapy.
VAD|vincristine adriamycin and dexamethasone|VAD|152|154|PAST MEDICAL HISTORY|2. Multiple myeloma diagnosed in _%#MM2002#%_. He has had subsequent chemotherapy. In _%#MM#%_ he was admitted for a second cycle of chemotherapy using VAD regime. 3. Hypertension. 4. Mitral and aortic regurgitation. 5. Left ventricular hypertrophy. 6. IgG lambda proteinuria. 7. Hypothyroidism. 8. Anemia secondary to multiple myeloma.
VAD|vincristine adriamycin and dexamethasone|VAD|139|141|HISTORY OF PRESENT ILLNESS|The patient has history of multiple myeloma, which was diagnosed in _%#MM#%_ of 2002. He has completed a second trial of chemotherapy with VAD treatment in _%#MM#%_ of 2003. Up until recently he has been on TPN. The patient has been doing well otherwise up until today.
VAD|vincristine adriamycin and dexamethasone|VAD.|220|223|HISTORY OF PRESENT ILLNESS|Ms. _%#NAME#%_ is a 57-year-old lady who was admitted on _%#MMDD2003#%_ for her third cycle of EDAP chemotherapy for plasma cell leukemia. She was initially diagnosed in _%#MM2000#%_, and was treated with four cycles of VAD. She then underwent a non-myeloablative unrelated donor transplant in _%#MM2000#%_. She had a relapse in _%#MM2003#%_, with bone marrow involvement and plasmacytoma involving T8 with a compression fracture.
VAD|vincristine adriamycin and dexamethasone|VAD|185|187|HISTORY OF PRESENT ILLNESS|She had a relapse in _%#MM2003#%_, with bone marrow involvement and plasmacytoma involving T8 with a compression fracture. The T8 lesion was treated with local radiation and a cycle of VAD chemotherapy in _%#MM2003#%_. A bone marrow biopsy after the first cycle of VAD showed 50% of plasma cells. She was subsequently treated with the first cycle of EDAP on _%#MMDD2003#%_, and is currently admitted for her third cycle.
VAD|vincristine adriamycin and dexamethasone|VAD|134|136||_%#NAME#%_ _%#NAME#%_ is a very pleasant 67-year-old gentleman with multiple myeloma. He was admitted for systemic chemotherapy using VAD using infusion vincristine, adriamycin, and oral Decadron. During the hospital course, the patient tolerated the chemotherapy extremely well and at the time of discharge was asymptomatic.
VAD|vincristine adriamycin and dexamethasone|VAD|138|140|HISTORY OF PRESENT ILLNESS|Bone marrow biopsy demonstrated 60% atypical plasma cells positive for monoclonal kappa light chains. He has since received two cycles of VAD and returns today for re-evaluation prior to his third cycle. Overall the patient continues to tolerate chemotherapy well. He has not had significant nausea or vomiting.
VAD|vincristine adriamycin and dexamethasone|VAD|156|158|IMPRESSION|3. He presented with a monoclonal protein in the urine which has normalized indicating a response to treatment. 4. He will proceed with this third cycle of VAD today. The patient does have a scheduled appointment with Dr. _%#NAME#%_.
VAD|vincristine adriamycin and dexamethasone|VAD.|286|289|IMPRESSION|The patient does have a scheduled appointment with Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ regarding the possibility of stem cell transplant and high dose chemotherapy. He will be returning to our clinic four weeks from now for reevaluation prior to his fourth of a planned four-cycles of VAD.
VAD|vincristine adriamycin and dexamethasone|VAD|126|128|SUMMARY|The patient was treated with high dose Decadron and radiation therapy to the spine. The patient then received three cycles of VAD consolidation chemotherapy. This was complicated by steroid induced diabetes mellitus for which the patient received insulin, but which resolved, and the patient has been off of insulin for about two weeks.
VAD|vincristine adriamycin and dexamethasone|VAD.|230|233|HOSPITAL COURSE|However, it was felt that this was not definite enough to explain the patient's urinary symptoms. These findings were discussed with Dr. _%#NAME#%_, the patient's primary oncologist. It was decided that the patient should receive VAD. Prior to this cycle, he had a MUGA with estimated EF of 61%. The patient completed cycle #1 VAD without complication. He will be followed by Dr. _%#NAME#%_ in clinic in 2 to 3 weeks.
VAD|vincristine adriamycin and dexamethasone|VAD|144|146|HOSPITAL COURSE|It was decided that the patient should receive VAD. Prior to this cycle, he had a MUGA with estimated EF of 61%. The patient completed cycle #1 VAD without complication. He will be followed by Dr. _%#NAME#%_ in clinic in 2 to 3 weeks. He will receive a Neulasta injection on _%#MM#%_ _%#DD#%_, 2004.
VAD|ventricular assist device|VAD|205|207|DISCHARGE INSTRUCTIONS|These appointments have been made and the patient will be given appropriate information regarding the time and place. DISCHARGE INSTRUCTIONS: 1. Regular diet as tolerated. 2. Call the Transplant Center or VAD coordinator or seek medical advice if there is any complaint of chest pain, shortness of breath, dizziness, or persistent nausea or vomiting.
VAD|vincristine adriamycin and dexamethasone|VAD|237|239|REASON FOR HOSPITALIZATION|HOSPITALIZATION: _%#NAME#%_ _%#NAME#%_ is a pleasant 72-year-old white male followed by myself and Dr. _%#NAME#%_ _%#NAME#%_ with a past medical history significant for multiple myeloma diagnosed in _%#NAME#%_ of 2004. He is status post VAD extended chemotherapy, diabetes mellitus type 2, hypertension, hyperlipidemia, and other history per the admission H&P. He had been hospitalized at Fairview Ridges Hospital on _%#MM#%_ _%#DD#%_, 2004, with hyperglycemia and a blood sugar of 832.
VAD|vincristine adriamycin and dexamethasone|VAD,|166|169|HISTORY OF PRESENT ILLNESS|At that time she had 25% to 30% plasma cells in her initial marrow including complex cytogenetics. She also had lytic lesions. She was treated with several cycles of VAD, which yielded a good partial response. The plan was to proceed promptly to transplant. However, due to insurance issues, her treatment was postponed.
VAD|vascular access device|VAD|256|258|PERTINENT LABORATORY TESTS|PERTINENT LABORATORY TESTS: 1. _%#MMDD2004#%_, anaerobic, fungal, Gram's stain and peritoneal cultures are still in the preliminary report phase from the ascites fluid. 2. _%#MMDD2004#%_, ammonia 24. 3. _%#MMDD2004#%_, blood cultures in the left arm and a VAD collection were negative. 4. _%#MMDD2004#%_, total bilirubin 1.9, albumin 2.7, protein 5.8, alkaline phosphatase 88, ALT 41, AST 71. 5. _%#MMDD2004#%_, WBC 8.6, hemoglobin 11.3, platelet count 159,000.
VAD|vincristine adriamycin and dexamethasone|VAD,|173|176|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Patient is a 49-year-old gentleman with a history of multiple myeloma originally diagnosed in 2003. In that year, he received 3 months' worth of VAD, which was followed a non- myeloablative stem cell allograft. The patient did well until 2004, when a positive bone marrow biopsy came back with plasma cells within his marrow.
VAD|vincristine adriamycin and dexamethasone|VAD|129|131|IMPRESSION|With regard to her nausea and vomiting, we will institute Zofran along with Decadron. If this does not work, we will institute a VAD drip. Code status was discussed with the patient, and she wishes to proceed with a full code, if that is necessary at this time.
VAD|ventricular assist device|VAD|170|172|HOSPITAL COURSE|The patient had a small pigtail catheter placed in the right pleural space. On _%#MM#%_ _%#DD#%_, 2005, the patient was started on (_______________) to help increase his VAD flows as these had been low despite decreasing the rate. On _%#MM#%_ _%#DD#%_, 2005, the patient's antibiotics were switched from Levaquin to Bactrim because his UTI was found to be resistant to Levaquin and the Bactrim was continued until the day of discharge at which point it was discontinued.
VAD|ventricular assist device|VAD.|112|115|HOSPITAL COURSE|On _%#MM#%_ _%#DD#%_, 2005, the patient was found to have slight serous drainage around his drive line from his VAD. The dressing around the drive line is now being changed 3 to 4 times a day to assess the fluid volume and character.
VAD|vincristine adriamycin and dexamethasone|VAD|133|135|HISTORY OF PRESENT ILLNESS|The patient was diagnosed with multiple myeloma in 1999 after presenting with a thoracic spine mass. She was originally treated with VAD and VBMCP prior to autologous stem cell transplantation in mid 2000. She relapsed a few years ago, and she has received additional salvage chemotherapy using Thalidomide and more recently, __________.
VAD|vincristine adriamycin and dexamethasone|VAD.|221|224|PAST MEDICAL HISTORY|She was started on thalidomide and dexamethasone. Her original bone marrow showed 85% plasma cells after the previous treatment. Repeat bone marrow showed 10-15% plasma cells. In _%#MM2005#%_ she underwent one cycle with VAD. Repeat bone marrow showed 5% plasma cells. She underwent her first autologous bone marrow transplant on _%#MMDD2005#%_. This was complicated by _________________ Her last protein electrophoresis done on _%#MMDD2005#%_ showed monoclonal protein seen.
VAD|vincristine adriamycin and dexamethasone|VAD,|175|178|HISTORY OF PRESENT ILLNESS|The patient has had a longstanding course of multiple myeloma, was initially diagnosed in 1998. She has received standard systemic chemotherapy with melphalan and prednisone, VAD, Velcade, as well as thalidomide, has received multiple courses of steroids and also Revlimid. More recently, the patient has been receiving palliative radiation, was completed about a week ago, and also has been receiving both Aredia and Aranesp for support of bone disease and anemia, receiving both last on _%#MMDD#%_.
VAD|ventricular assist device|VAD|207|209|SUMMARY OF EVENTS LEADING TO DEATH|He was transferred to University of Minnesota Medical Center, Fairview, on _%#MM#%_ _%#DD#%_, 2006, after spending 1 month in the intensive care unit of an outside facility. He was transferred for potential VAD workup and for possible transplantation. However, the patient was not a good transplant candidate given his poor lack of social support.
VAD|vincristine adriamycin and dexamethasone|VAD|294|296|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 72-year-old woman who lives in _%#NAME#%_, Minnesota, and who has a history of multiple myeloma, dating back to _%#MM#%_ 2000. At that time, she presented with anemia as well as multiple compression fractures. She was treated with the VAD regimen, and had attainment of remission, followed by high dose chemotherapy and a bone marrow transplant. Unfortunately, her myeloma has progressed over time, and she has subsequently been treated with a variety of agents, most recently using bortezomib (Velcade).
VAD|ventricular assist device|VAD|221|223|DISCHARGE PHYSICAL EXAMINATION|DISCHARGE PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 113/65, heart rate 88-110 per minute, temperature 99.1. GENERAL: He is alert and awake and extremely pleasant. NECK: No jugular venous distention. CHEST: Clear. VAD sounds. ABDOMEN: Soft, non-tender. Bowel sounds active. HeartMate XVE settings: Stroke volume of 80, flow of 4.8 L/minute, heart rate of 60 beats per minute.
VAD|ventricular assist device|VAD|309|311|HOSPITAL COURSE|Upon arriving to the surgical ward, the patient continued to have reimplantation as well as education on the device's working. The patient continued to improve clinically each day and upon discharge, the patient was ambulating freely tolerating diet and was well versed with the operation and function of the VAD device and was given instruction on proper wound care and management. Follow-up appointments were scheduled with the patient including Coumadin clinic as well as follow up with the heart failure and surgical services.
VAD|vincristine adriamycin and dexamethasone|VAD|183|185|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ received radiation therapy (3000 cGy in ten fractions) to the left femur and humerus. He was treated with cycle of melphalan and prednisone followed by three cycles of VAD ending in _%#MM#%_ 2001. Follow-up bone marrow showed 5 to 8% plasma cells. He received priming chemotherapy and stem cell collection in preparation for autologous peripheral blood stem cell transplant.
VAD|vincristine adriamycin and dexamethasone|VAD|257|259|BRIEF HISTORY AND PHYSICAL EXAMINATION|At the time of diagnosis he had an M- spike of 2000 mg, like chain proteinuria of 4.2 g, T12 vertebral body fracture, normal calcium, creatinine, and hemoglobin, 16% marrow involvement with myeloma plasma cells. He has had a good response to full cycles of VAD chemotherapy with reduction in his M-spike to 100 mg. He tolerated the chemotherapy well without any major complications. He has no full siblings and was offered autologous peripheral blood stem cell transplantation or unrelated donor non- myeloablative transplant or cord blood non-myeloablative transplant.
VAD|vincristine adriamycin and dexamethasone|VAD|210|212|HISTORY OF PRESENT ILLNESS|During the workup he was found to have also plasmocells replacing partially his bone marrow. Upon the diagnosis he was treated with radiation therapy to cervical spine and after that he received four cycles of VAD chemotherapy. He developed myopathy while on the Decadron and also had some mild peripheral neuropathy due to vincristine. He did well until _%#MM#%_ when he presented with progressive blindness.
VAD|vincristine adriamycin and dexamethasone|VAD.|101|104|DISCHARGE DIAGNOSIS|DISCHARGE DIAGNOSIS: Multiple myeloma. MAJOR PROCEDURES DURING HOSPITALIZATION: 1. Chemotherapy with VAD. 2. Hemodialysis. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 58-year-old female with a history of multiple myeloma admitted for her third cycle of VAD.
VAD|vincristine adriamycin and dexamethasone|VAD.|177|180|HISTORY OF PRESENT ILLNESS|1. Chemotherapy with VAD. 2. Hemodialysis. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 58-year-old female with a history of multiple myeloma admitted for her third cycle of VAD. She has a history of hypertension, asthma, seizures and bipolar disorder who was diagnosed with multiple myeloma in _%#MM#%_ 2002 after experiencing a compression fracture.
VAD|vincristine adriamycin and dexamethasone|VAD|160|162|HISTORY OF PRESENT ILLNESS|The patient underwent plasmapheresis x 5. She is now on hemodialysis secondary to multiple myeloma-induced renal failure and had undergone 2 previous cycles of VAD chemotherapy. REVIEW OF SYSTEMS: Her review of systems on admission was negative, except for multiple seborrheic keratoses and also basal cell carcinoma on the tip of her nose.
VAD|vincristine adriamycin and dexamethasone|VAD|227|229|HISTORY OF PRESENT ILLNESS|Her father has a history of prostate cancer. SOCIAL HISTORY: She is now widowed and lives with her mother. She has a remote history of tobacco. She does not drink any alcohol. HOSPITAL COURSE: 1. Myeloma. The patient underwent VAD chemotherapy which she tolerated well. During her hospitalization, she underwent a bone marrow biopsy for re-staging in order to assess her response to chemotherapy.
VAD|vincristine adriamycin and dexamethasone|VAD|178|180|FOLLOW UP|18. Neulasta 6 mg subcu q.d. for 1 day on _%#MM#%_ _%#DD#%_, 2002. FOLLOW UP: The patient was to follow up with Dr. _%#NAME#%_ in oncology in 2 weeks prior to her next scheduled VAD chemotherapy. The patient is to follow up with dermatology for a Mohs procedure on _%#MM#%_ _%#DD#%_, 2002, at 8:00 a.m. The patient was to follow up at the outpatient lab to check her CBC with differential, platelets and chemistry panel in 5 days.
VAD|vincristine adriamycin and dexamethasone|VAD.|159|162|HISTORY OF PRESENT ILLNESS|Peripheral blood showed 30-50% plasma cells. The bone marrow biopsy showed 95% plasma cell infiltrates. The patient underwent first cycle of chemotherapy with VAD. Bone marrow biopsy at that point showed persistent of 64% plasma cells. She subsequently underwent a dissect protocol (Cytoxan, VP-16, cisplatin). Repeat bone marrow on _%#MMDD2002#%_ showed 6% plasma cells.
VAD|vincristine adriamycin and dexamethasone|VAD|112|114|DISCHARGE DIAGNOSES|2. Dehydration due to acute infection and gastroenteritis. Prior to this discharge is: 1. Multiple myeloma, had VAD treatment which was diagnosed 15 years back, but now is being treated concomitantly with dexamethasone. 2. Hypertension. 3. Sarcoidosis which was pulmonary diagnosed in 1990 by bronchoscopy.
VAD|vincristine adriamycin and dexamethasone|VAD,|155|158|PAST MEDICAL HISTORY|The patient reports no confusion. PAST MEDICAL HISTORY: 1. Multiple myeloma, status post stem cell transplant and radiation treatment with three cycles of VAD, diagnosed in _%#MM#%_ of 2000 following plasmacytoma of the spine. 2. Status post cervical spine fusion after plasmacytoma. 3. Status post hysterectomy.
VAD|vincristine adriamycin and dexamethasone|VAD|135|137|PAST MEDICAL HISTORY|The patient was referred to the University in _%#MM#%_ 2000 for possible autologous transplant. She was treated with several cycles of VAD chemotherapy with most recent bone marrow biopsy showing 8% plasma cells. 2. Status post vaginal hysterectomy. 3. Migraine headaches.
VAD|ventricular assist device|VAD|247|249|PHYSICAL EXAMINATION|HEENT: pupils equal, round, react to light and accommodation; extraocular muscles were intact; anicteric sclerae. NECK: supple, non-tender. Bruits were not auscultated. LUNGS: clear to auscultation bilaterally. HEART: regular rate and rhythm with VAD sounds. ABDOMEN: soft, non-tender, non-distended, no masses, no hepatosplenomegaly. EXTREMITIES: No cyanosis, clubbing, or edema. Extremities had 1+ bilateral edema.
VAD|vincristine adriamycin and dexamethasone|VAD|191|193|HISTORY OF PRESENT ILLNESS|Morphology was quite immature, with a small, but significant percent of blasts. His IgG-K was greater than 4 gm. The patient had anemia. He had no urine protein. He had gotten four cycles of VAD beginning in _%#MM2002#%_, and the last one was in _%#MM2003#%_. He got monthly Zometa. In _%#MM2003#%_, he had PCP pneumonia after his fourth cycle of VAD, and that was diagnosed by bronchial lavage.
VAD|vincristine adriamycin and dexamethasone|VAD,|210|213|HISTORY OF PRESENT ILLNESS|He had no urine protein. He had gotten four cycles of VAD beginning in _%#MM2002#%_, and the last one was in _%#MM2003#%_. He got monthly Zometa. In _%#MM2003#%_, he had PCP pneumonia after his fourth cycle of VAD, and that was diagnosed by bronchial lavage. He was started on Bactrim but had switched to atovaquone because of nausea and vomiting.
VAD|vincristine adriamycin and dexamethasone|VAD|165|167|HISTORY OF PRESENT ILLNESS|In _%#MM#%_ 2002, he developed a pulmonary embolus that was treated for six months with heparin. Thalidomide was discontinued and he was treated with four cycles of VAD chemotherapy, which ended on _%#MM#%_ _%#DD#%_, 2003. He is currently status post chemo and priming an autologous stem cell collection.
VAD|vincristine adriamycin and dexamethasone|VAD|236|238|HISTORY OF PRESENT ILLNESS|He continued the treatment, but then developed neurologic symptoms and also some additional achiness in the left shoulder, which decreased after discontinuation of thalidomide. After that, the patient received a total of four cycles of VAD chemotherapy, and then he was admitted to the bone marrow transplant program at the University of Minnesota, to initiate priming chemotherapy.
VAD|vincristine adriamycin and dexamethasone|VAD|134|136|PAST MEDICAL HISTORY|He had multiple lytic lesions on his skull, scapula, sacrum, fevers, and was treated with Decadron and thalidomide. 3. Four cycles of VAD chemotherapy starting _%#MM2002#%_, ending on _%#MMDD2003#%_. 4. He received autologous bone marrow transplant on _%#MMDD2003#%_. Please note that priming for bone marrow transplant was complicated by multiple organ sepsis.
VAD|vincristine adriamycin and dexamethasone|VAD.|240|243|HISTORY OF PRESENT ILLNESS|The patient subsequently underwent six cycles of VAD. After the fourth cycle, total IgG level dropped to 1.1 gram and remained stable after the six cycles. The plasmacytoma decreased significantly in size and stabilized after six cycles of VAD. The patient had received Cytoxan _%#MMDD2003#%_ and mitoxantrone _%#MMDD2003#%_ through _%#MMDD2003#%_. In addition, he had dexamethazone and mesna. Mr. _%#NAME#%_ subsequently this admission for autologous bone marrow transplant.
VAD|vincristine adriamycin and dexamethasone|VAD|177|179|HISTORY OF PRESENT ILLNESS|3. Chemotherapy with VAD. 4. Crohn's disease. HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old female with history of recurrent plasma cell leukemia who is admitted for VAD treatment. She has also complained of back pain, worse with movement, for a number of weeks. She had a CT scan of her back that showed wedge compression at T8 with continuous spread and most likely consistent with plasmacytoma.
VAD|vincristine adriamycin and dexamethasone|VAD|223|225|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: 1. Crohn's disease, status post multiple abdominal surgeries in 1980s. 2. History of malignant melanoma in 1999 on abdomen. 3. Plasma cell leukemia originally diagnosed in _%#MM2000#%_. 4. Status post VAD x four cycles. 5. Unrelated bone marrow donor transplant _%#MM2000#%_. 6. Recurrent increasing back pain and found to have pancytopenia in _%#MM2003#%_.
VAD|vincristine adriamycin and dexamethasone|VAD.|142|145|HOSPITAL COURSE|8. Status post total abdominal hysterectomy and appendectomy. 9. History of basal cell cancer of the back. HOSPITAL COURSE: Chemotherapy with VAD. The patient was monitored closely during the administration of her chemotherapy with IV fluids, and electrolyte replacement. Overall, she tolerated the chemotherapy quite well. She continued on her radiation treatment to her back.
VAD|vincristine adriamycin and dexamethasone|VAD|290|292|HISTORY OF PRESENT ILLNESS|4. Right subclavian vein clot. 5. Nausea. HISTORY OF PRESENT ILLNESS: This is a 57-year-old woman with recurrent plasma cell leukemia who presents with fevers, pancytopenia, and nausea, vomiting. She was diagnosed with plasma cell leukemia in _%#MM#%_ 2001. She was status post 4 cycles of VAD and many allogeneic BMTs in _%#MM#%_ 2000. She was well for 2 years and in _%#MM#%_ 2003 recurred with increased back pain and pancytopenia.
VAD|vincristine adriamycin and dexamethasone|VAD|186|188|HISTORY OF PRESENT ILLNESS|CT revealed wedge compression fracture at T8 with a paraspinal soft tissue density. Bone marrow biopsy on _%#MM#%_ _%#DD#%_, 2003, revealed 52% plasma cells. She had received a cycle of VAD and radiation therapy. Repeat bone marrow biopsy on _%#MM#%_ _%#DD#%_, 2003, showed persistent plasma cells with 50% bone marrow involvement.
VAD|vincristine adriamycin and dexamethasone|VAD|64|66|FINAL DIAGNOSES|FINAL DIAGNOSES: 1. Multiple myeloma status post first cycle of VAD chemotherapy. 2. Anemia, required transfusion, packed cells. 3. Renal failure. 4. Hypertension. DISCHARGE MEDICATIONS: 1. Decadron 40 mg per chemo cycles, as detailed in the discharge sheet.
VAD|vincristine adriamycin and dexamethasone|VAD|235|237|HOSPITAL COURSE|PROCEDURE: Right arm PICC line placement and removal. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 62-year-old male with a history of hypertension and renal insufficiency diagnosed with myeloma recently and admitted to the hospital for VAD chemo regimen started on Monday the _%#DD#%_. He tolerated the treatment without any complications. His hemoglobin dropped significantly and he required transfusion on the _%#DD#%_.
VAD|vincristine adriamycin and dexamethasone|VAD|207|209|HISTORY|Bone survey showed multiple areas of involvement consistent with myeloma. He had initially left shoulder pain which showed numerous discrete punched out lytic lesions on x-ray. He received chemotherapy with VAD regimen, two cycles, and his creatinine has improved and he is being admitted to the hospital today for cycle #3. He complains of numbness in his fingertips, has been ongoing since he started chemotherapy.
VAD|vincristine adriamycin and dexamethasone|VAD|167|169|PLAN|5. Increased frequency of stool and mild sensory neuropathy related to chemotherapy. PLAN: 1. Will admit patient to Medical Oncology floor. 2. Start chemotherapy with VAD regimen. 3. Supplement potassium through K protocol. 4. Allopurinol was started initially to prevent tumor lysis. He had no evidence of that and medications will be discontinued at present time.
VAD|vincristine adriamycin and dexamethasone|VAD.|221|224|IMPRESSION|NEURO: Alert and oriented. Sensory, motor is grossly intact. LABORATORY DATA: Hemoglobin is 13.2, white count 5.9, platelets 296,000. IMPRESSION: 1. Multiple myeloma undergoing chemotherapy being admitted for cycle #2 of VAD. 2. Cough without significant findings on examination. It could be related to postnasal drip or primary pulmonary etiologies. 3. Mild anemia due to myeloma and treatment with chemotherapy.
VAD|vincristine adriamycin and dexamethasone|VAD|234|236|HOSPITAL COURSE|So, in essence, the patient had IgG multiple myeloma with a monoclonal spike of 8.4 and 80% plasma cells in the bone marrow. Cytogenetics are pending at the time of dictation. The patient was started with chemotherapy. She started on VAD (vincristine, adriamycin and dexamethasone). The patient tolerated the chemotherapy very well. Shortly after starting chemotherapy and steroids, the patient's headache did improve and she had no symptoms at the time of discharge.
VAD|vincristine adriamycin and dexamethasone|VAD|264|266|PLAN|Bone survey and protein electrophoresis are pending. IMPRESSION: Multiple myeloma with evidence of significant bone involvement and compression fracture of the back. PLAN: Will admit the patient to medical oncology floor starting on IV fluids and start regimen of VAD chemotherapy. I will have PICC line placed for chemotherapy and obtain blood count prior to starting. He will be placed on antiemetics and Decadron orally.
VAD|vincristine adriamycin and dexamethasone|VAD|157|159|HISTORY OF PRESENT ILLNESS|He then was treated with amprednisone with restaging in _%#MM2003#%_ showing decreased beta 2 microglobulin and IgG. He subsequently received four cycles of VAD through _%#MM2003#%_, which he tolerated well. A bone marrow biopsy from _%#MMDD2004#%_ showed slightly hypocellular marrow with no evidence of myeloma.
VAD|vincristine adriamycin and dexamethasone|VAD,|167|170|HISTORY OF PRESENT ILLNESS|He unfortunately relapsed in 2003 with plasmacytoma on his tongue and GI tract, also with cord compression. He is currently status post XRT and has received one cycle VAD, that is that he received one cycle of vincristine, adriamycin, and dexamethasone. He is now admitted for his second cycle. PHYSICAL EXAM ON DISCHARGE: VITAL SIGNS: Blood pressure 143/78, pulse 78, temperature 97.8, respirations 16, satting 94% on room air.
VAD|vincristine adriamycin and dexamethasone|VAD|129|131|DATE OF DEATH|DATE OF DEATH: _%#MMDD2004#%_. This is a 74-year-old male with ischemic cardiomyopathy who under prior rematch was randomized to VAD therapy, which was originally implanted for this patient's disease in _%#MM#%_ of 2001, and was later exchanged in _%#MM#%_ of 2003. The patient was admitted on _%#MMDD2004#%_ to the Cardiology Service with a 10 day history of fatigue, unrecognizable grinding noise in the VAD, and the patient was found to have a mechanically failing left ventricular assist device, although he was stable on pneumatic pump.
VAD|ventricular assist device|VAD,|406|409|DATE OF DEATH|DATE OF DEATH: _%#MMDD2004#%_. This is a 74-year-old male with ischemic cardiomyopathy who under prior rematch was randomized to VAD therapy, which was originally implanted for this patient's disease in _%#MM#%_ of 2001, and was later exchanged in _%#MM#%_ of 2003. The patient was admitted on _%#MMDD2004#%_ to the Cardiology Service with a 10 day history of fatigue, unrecognizable grinding noise in the VAD, and the patient was found to have a mechanically failing left ventricular assist device, although he was stable on pneumatic pump.
VAD|vincristine adriamycin and dexamethasone|VAD|122|124|DISCHARGE DIAGNOSIS|She was found to have IgA kappa myeloma with greater than 2 g IgA and a beta 2 microglobulin of 3.3. She was treated with VAD and developed severe peripheral neuropathy. Because of cytogenetic abnormalities and her age, she was evaluated for transplant and was found to be a candidate for a tandem autograft/allograft bone marrow transplant.
VAD|vincristine adriamycin and dexamethasone|VAD,|186|189|HISTORY OF PRESENT ILLNESS|This was treated with local radiation. His disease progressed to overt IgA lambda multiple myeloma approximately 18 months later and was treated with multiple cycles of chemo, including VAD, high-dose Cytoxan, and 2 cycles of ADAP with limited response. He is now status post 3.5 cycles of Velcade with a good PR.
VAD|vincristine adriamycin and dexamethasone|VAD|172|174|PAST MEDICAL HISTORY|He was therefore admitted to the ICU for treatment of hyperglycemia. PAST MEDICAL HISTORY: 1. Multiple myeloma diagnosed in _%#MM#%_, 2004. He has undergone four cycles of VAD therapy, the last ending three days ago. 2. History of hypertension. 3. Port-A-Cath placement. 4. MUGA in _%#MM#%_, 2004 showed ejection fraction of 51 percent.
VAD|vincristine adriamycin and dexamethasone|VAD.|133|136|ASSESSMENT AND PLAN|ASSESSMENT AND PLAN: This patient is a 72-year-old male with history of multiple myeloma, recently finishing his fourth treatment of VAD. He presents with marked hyperglycemia and ketosis. He, however, has a respiratory alkalosis without apparent significant metabolic acidosis.
VAD|vincristine adriamycin and dexamethasone|VAD|48|50|DISCHARGE DIAGNOSES|DOB: DISCHARGE DIAGNOSES: 1. New diabetes after VAD treatment for multiple myeloma. 2. Three episodes of supraventricular tachycardia. 3. Multiple myeloma. 4. Pancytopenia. 5. Mild hypomagnesemia. 6. Hypertension. CONSULTS: 1. Endocrinology.
VAD|vincristine adriamycin and dexamethasone|VAD|247|249|HOSPITAL COURSE|2. Cardiology. 3. Oncology. HOSPITAL COURSE: 1. New diabetes. Mr. _%#NAME#%_ is a 72-year- old male with a history of multiple myeloma who was admitted for elevated blood sugars in the 800 range. He also had some ketosis. He had just finished his VAD treatment, which includes steroids and went to his primary physician not feeling well. He had a blood sugar checked which was in the 800 range and he was admitted for blood glucose control.
VAD|vincristine adriamycin and dexamethasone|VAD|185|187|HISTORY OF PRESENT ILLNESS|Beta II microglobulin was 3.1. He was diagnosed with multiple myeloma and started therapy with Zometa and VBMCP. He received only one course for which he was followed by five cycles of VAD with resolution of his bone pain. Chemotherapy priming consisted of cytotoxin on _%#MM#%_ 4 with hydration and mesna along with mitoxantrone on _%#MM#%_ 4 and _%#MM#%_
VAD|ventricular assist device|VAD|138|140|ASSESSMENT/PLAN|Electrolytes within normal limits. Creatinine 1.1, which is decreased. BUN 37. ASSESSMENT/PLAN: 58-year-old woman, status post DeBakey L- VAD doing better. She has decreased the amount of lower GI bleeding. Hemoglobin has also remained stable over the last 24 hours. Her heparin is on hold, as we are awaiting upper GI endoscopy by the GI service.
VAD|vincristine adriamycin and dexamethasone|VAD|169|171|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 46-year-old male with multiple myeloma who initially presented with back pain in _%#MM2001#%_ He received four cycles of VAD chemotherapy. In _%#MM#%_, 2001 the patient was treated per our local protocol _%#PROTOCOL#%_ with cyclophosphamide and VP-16 along with total body irradiation in 8 fractions over 4 days to 1200 cGy.
VAD|vincristine adriamycin and dexamethasone|VAD|239|241|IMPRESSION|At intervertebral T11 there was an intense T1 contrast enhancement suggestive of neoplasm, given the patient's history of multiple myeloma. IMPRESSION: Mr. _%#NAME#%_ is a 46-year-old male with multiple myeloma, status post four cycles of VAD chemotherapy, status post autologous stem-cell transplant with T11 symptomatic bony lesion. PLAN: We have suggested possible radiation therapy to symptomatic lesion.
VAD|vincristine adriamycin and dexamethasone|VAD|216|218|HISTORY OF PRESENT ILLNESS|The chart, radiographic reports/films, and pathology were reviewed. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 49-year-old male with multiple myeloma diagnosed in 2001. He was initially treated with 4 cycles of VAD and total body irradiation, followed by autologous stem cell transplant in _%#MM2002#%_. He did well until relapse in _%#MM2004#%_. At that time he received 2000 cGy in 10 fractions to the T10 through T12 spine.
VAD|vincristine adriamycin and dexamethasone|VAD.|221|224|HISTORY OF PRESENT ILLNESS|PROBLEM: Multiple myeloma. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 62-year-old who presented in _%#MM2001#%_ with fatigue. His workup revealed multiple myeloma. He had no lytic lesions. His treatment consisted of VAD. He received three cycles which was effective at reducing his IgG, his 24- hour protein and his percentage of bone marrow involvement.
VAD|vincristine adriamycin and dexamethasone|VAD|164|166|HISTORY OF PRESENT ILLNESS|PROBLEM: Multiple myeloma. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 62-year-old who was diagnosed with multiple myeloma in _%#MM2001#%_. He was treated with VAD chemotherapy and had a good response. In _%#MM2002#%_ he was referred to our clinic to determine eligibility for total body irradiation prior to a transplant.
VAD|ventricular assist device|VAD|153|155|HISTORY OF PRESENT ILLNESS|It does not appear to extend above the renal arteries specifically. The origin of the SMA and celiac are not entirely clear due to the artifact from her VAD device; although, no obvious occlusions are identified. Beyond the orifice of these vessels, contrast can be seen clearly. I was asked by the medical team to see Ms. _%#NAME#%_ for surgical consultation for possible bowel ischemia.
VAD|vincristine adriamycin and dexamethasone|VAD|142|144|HISTORY OF PRESENT ILLNESS|She was found to have epidural masses in the thoracic and lumbar spine. Cerebrospinal fluid was negative. Ms. _%#NAME#%_ received 2 cycles of VAD chemotherapy, apparently had resolution of her ataxia. She chose to have her treatment continued at Abbott-Northwestern Hospital.
VAD|vincristine adriamycin and dexamethasone|VAD.|144|147|HPI|The patient had an epidural mass in the thoracolumbar spine on evaluation with symptoms of ataxia. The symptoms have resolved after 2 cycles of VAD. Her treatment was somewhat complicated with ARDS which required a prolonged hospitalization.
VAD|vincristine adriamycin and dexamethasone|VAD,|273|276|HISTORY OF PRESENT ILLNESS|LDH and liver function tests were within normal limits. The patient underwent four cycles of VAD chemotherapy with an approximately 40% decrease in the size of her liver lesion and a 50% decrease in her monoclonal spike. Her T12 lesion has been stable. After completion of VAD, the patient was placed on thalidomide, which she currently remains on. Her most recent CT of the abdomen and pelvis _%#MMDD2005#%_ shows a slight interval decrease in the mass in her liver.
VAD|vincristine adriamycin and dexamethasone|VAD|187|189|ASSESSMENT|ASSESSMENT: The patient is a 48-year-old female with stage II multiple myeloma located in her T12 vertebra, two axillary nodes, and portohepatis. She has been treated with four cycles of VAD chemotherapy with a 40% decrease in the size of her liver lesion, 50% drop in her monoclonal protein spike, and stabilization of her T12 lesion.
VAD|vincristine adriamycin and dexamethasone|VAD|131|133|HPI|A PET scan showed disease in the porta hepatis and celiac nodes, as well as liver. She has been receiving chemotherapy, first with VAD and more recently with thalidomide, with excellent response with shrinkage of this liver mass. She is referred now for discussion regarding consolidative radiotherapy to the initial sites of disease in preparation for an autologous and allogeneic tandem transplant.
VAD|ventricular assist device|(VAD)|215|219|ASSESSMENT AND PLAN|Except for his high pulmonary artery pressure, the patient is an excellent candidate with great family support and a very positive attitude. I also briefly discussed possible need for left ventricular assist device (VAD) if his pulmonary artery pressures remain high. I discussed risks and benefits of VAD implantation, including the risk of death, bleeding, stroke wound infection, renal failure.
VAD|ventricular assist device|VAD|161|163|ASSESSMENT AND PLAN|I also briefly discussed possible need for left ventricular assist device (VAD) if his pulmonary artery pressures remain high. I discussed risks and benefits of VAD implantation, including the risk of death, bleeding, stroke wound infection, renal failure. I also discussed that the LVAD will be used as a bridge to transplantation.
VAD|ventricular assist device|VAD|127|129|IMPRESSION|I have discussed the risk of these procedures and devices and also discussed the possible benefits. She wants to meet with the VAD coordinator, see the devices, and be prepared for whatever is needed. Thank you for asking us to see this patient in consultation.
VAD|vincristine adriamycin and dexamethasone|VAD|254|256|HISTORY OF PRESENT ILLNESS|He presents today with very limited medical records. At the time of diagnosis he presented with an enlarged mass in the left clavicle. Biopsy revealed a solitary plasmacytoma. His IgG level was determined to be 7.8. Mr. _%#NAME#%_ received six cycles of VAD chemotherapy with a drop in the IgG after the fourth cycle. He also experienced a decreased size in the plasmacytoma.
VAD|vincristine adriamycin and dexamethasone|VAD|223|225|HISTORY OF PRESENT ILLNESS|Dr. _%#NAME#%_ noted pronounced pectus excavatum and skeletal x-rays that revealed many lytic lesions. Dr. _%#NAME#%_ was concerned regarding his response to the dexamethasone, and wondered if he may benefit from receiving VAD chemotherapy. Since that visit, Mr. _%#NAME#%_ had continued with the dexamethasone which was discontinued two weeks ago. He indicates that his M-spike was reduced by 50%. He is now interested in pursuing an autologous peripheral blood stem-cell transplant.
VAD|vincristine adriamycin and dexamethasone|VAD|324|326|HISTORY OF PRESENT ILLNESS|This was complicated with bronchitis and severe constipation. Mr. _%#NAME#%_ was referred to the Fairview-University Medical Center in _%#MM#%_, after he had received two of the cycles of chemotherapy. He saw Dr. _%#NAME#%_ _%#NAME#%_ to discuss treatment options. At that time Dr. _%#NAME#%_ recommended two more cycles of VAD following by an autologous peripheral blood stem-cell transplant if he had a response. Response is being determined during this week's bone marrow transplant workup.
VAD|vincristine adriamycin and dexamethasone|VAD|202|204|HISTORY OF PRESENT ILLNESS|A hemoglobin of 10.6, 50% plasma cells in the bone marrow, multiple lytic lesions, normal creatinine. He was ultimately diagnosed with IgA lambda multiple myeloma. Mr. _%#NAME#%_ received two cycles of VAD chemotherapy ending in _%#MM#%_. On _%#MMDD2003#%_, he was referred to Fairview-University Medical Center where he saw Dr. _%#NAME#%_ _%#NAME#%_. Dr. _%#NAME#%_ recommended two additional cycles of chemotherapy avoiding vincristine because it may contribute to the neuropathy that he was experiencing from his thrombosis.
VAD|vincristine adriamycin and dexamethasone|VAD|155|157|HISTORY OF PRESENT ILLNESS|Mrs. _%#NAME#%_ was referred to the Fairview-University Medical Center where she saw Dr. _%#NAME#%_ _%#NAME#%_ in _%#MM2001#%_. Dr. _%#NAME#%_ recommended VAD chemotherapy followed by an autologous peripheral blood stem-cell transplant if there was a response. Mrs. _%#NAME#%_ indicates that she received chemotherapy. She completed three cycles recently and her IgA as well as her bone marrow involvement have improved.
VAD|vincristine adriamycin and dexamethasone|VAD|163|165|HISTORY OF PRESENT ILLNESS|She tolerated the radiation well. She eventually developed full-blown multiple myeloma and in _%#MM#%_, 2002 she underwent an autologous stem-cell transplant with VAD chemotherapy. She received 1200 cGy of total body irradiation as part of that protocol. She did have her neck blocked at that time because of the previous radiation it had received.
VAD|vincristine adriamycin and dexamethasone|VAD|226|228|HISTORY OF PRESENT ILLNESS|A bone marrow biopsy was performed and revealed 50% plasma cells (by history); she had no serum paraprotein elevation. Her beta2- microglobulin was 8.3, hemoglobin 9.4, creatinine 1.6. Mrs. _%#NAME#%_ received three cycles of VAD chemotherapy ending in _%#MM#%_, 2002. The VAD was tolerated well and her follow-up urine protein was normal. She was referred to the Fairview University Medical Center where she saw Dr. _%#NAME#%_ _%#NAME#%_ who recommended an autologous peripheral blood stem cell transplant after she had received an additional cycle of VAD.
VAD|vincristine adriamycin and dexamethasone|VAD|154|156|HISTORY OF PRESENT ILLNESS|Her beta2- microglobulin was 8.3, hemoglobin 9.4, creatinine 1.6. Mrs. _%#NAME#%_ received three cycles of VAD chemotherapy ending in _%#MM#%_, 2002. The VAD was tolerated well and her follow-up urine protein was normal. She was referred to the Fairview University Medical Center where she saw Dr. _%#NAME#%_ _%#NAME#%_ who recommended an autologous peripheral blood stem cell transplant after she had received an additional cycle of VAD.
VAD|vincristine adriamycin and dexamethasone|VAD|287|289|HISTORY OF PRESENT ILLNESS|She was referred to the Fairview University Medical Center where she saw Dr. _%#NAME#%_ _%#NAME#%_ who recommended an autologous peripheral blood stem cell transplant after she had received an additional cycle of VAD. Since that time Mrs. _%#NAME#%_ has received the additional cycle of VAD in _%#MM#%_, 2002, and had a continued response. She has never received radiation treatments. Mrs. _%#NAME#%_ presents to our clinic today at the request of Dr. _%#NAME#%_ _%#NAME#%_ for evaluation of the transplant and to discuss radiation conditioning.
VAD|vincristine adriamycin and dexamethasone|VAD|163|165|REVIEW OF SYSTEMS|Breasts: Mammogram in _%#MM#%_, 2001, reportedly normal. Respiratory: Some dyspnea on exertion. Cardiovascular: No chest pain. Gastrointestinal: Constipation with VAD which has resolved. Vascular access: Double-lumen Hickman catheter in place, will be replaced with a double-lumen Davol catheter. Musculoskeletal: Has some low back pain after a long active day, but does not require any medications.
VAD|vincristine adriamycin and dexamethasone|VAD|164|166|HISTORY OF PRESENT ILLNESS|A beta 2 microglobulins was 0.32. M- spike was 3.2. There were no lytic lesions. CSF was positive for immature plasma cells. Mr. _%#NAME#%_ received four cycles of VAD chemotherapy with resolution of his confusion. He tolerated the chemotherapy well except for some perirectal bleeding. Chemotherapy was completed in _%#MM#%_, 2002. Mr. _%#NAME#%_ was referred was referred to the Fairview-University Medical Center where he saw Dr. _%#NAME#%_ _%#NAME#%_ in _%#MM#%_, 2002.
VAD|vincristine adriamycin and dexamethasone|VAD|160|162|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ was observed initially, but his IgG increased to approximately 7500, and his hemoglobin dropped to 10.7. Mr. _%#NAME#%_ received three cycles of VAD chemotherapy; follow-up evaluation of his IgG was 4000. In _%#MM2002#%_, Mr. _%#NAME#%_ was referred to the Fairview-University Medical Center to see Dr. _%#NAME#%_ _%#NAME#%_ to discuss treatment options.
VAD|vincristine adriamycin and dexamethasone|VAD,|91|94|HISTORY OF PRESENT ILLNESS|Dr. _%#NAME#%_ was concerned about the IgG response to the VAD. She recommended additional VAD, followed by an autologous peripheral blood stem-cell transplant if he had a suitable response. Mr. _%#NAME#%_ has never received radiation treatments. When questioned as to whether he received additional chemotherapy after seeing Dr. _%#NAME#%_, he was unsure.
VAD|vincristine adriamycin and dexamethasone|VAD.|125|128|HISTORY OF PRESENT ILLNESS|His medical records from the referring physician are not available for our consultation to determine whether he received the VAD. He is currently asymptomatic. Mr. _%#NAME#%_ presents to our clinic today at the request of Dr. _%#NAME#%_ _%#NAME#%_ for evaluation of the transplant, and to discuss radiation conditioning.
VAD|vincristine adriamycin and dexamethasone|VAD|185|187|HISTORY OF PRESENT ILLNESS|IgG at that time was notably elevated at 2760 mg/dL, with monoclonal protein of 2.3 gm/dL, and immunofixation positive for IgG and lambda monoclonal protein. The patient was started on VAD therapy, the course of which was notable for at least two episodes of upper respiratory infection responsive to Zithromax and Avalox.
VAD|vincristine adriamycin and dexamethasone|VAD|235|237|HISTORY OF PRESENT ILLNESS|On bone survey, the patient was noted to have multiple areas of lytic lesions including the skull, bilateral acromion processes, as well as ribs, left humerus, and clavicle. The patient was started on Somata. The patient's response to VAD therapy after four cycles was suboptimal. Her monoclonal spike decreased from 2.3 to 1.3 gm/dL. Bone marrow biopsy from _%#MMDD2003#%_ showed plasma cells making up 36% of the marrow cellularity.
VAD|vincristine adriamycin and dexamethasone|VAD|278|280|ASSESSMENT|Additionally, there is an increase in size of ill- defined lytic areas within the iliac wings bilaterally, as well as stable lesions in the intertrochanteric left femur, right sacral ala and mid proximal left fibular diaphysis. ASSESSMENT: Progressing multiple myeloma while on VAD chemotherapy. Now being treated per stem cell transplant protocol _%#PROTOCOL#%_. Referred to our clinic for consideration of total body irradiation as part of that protocol.
VAD|vincristine adriamycin and dexamethasone|VAD|229|231|HISTORY OF PRESENT ILLNESS|PROBLEM: Multiple myeloma. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 50-year-old woman who was diagnosed with multiple myeloma in _%#MM2002#%_ when she presented with left rib and shoulder pain. She was treated with VAD times 4 with minimal response and then was changed to high-dose Cytoxan which resulted in a good response. On _%#MM2003#%_, she underwent autologous bone marrow transplant. Conditioning consisted of 990 cGy total body radiation with Cytoxan.
VAD|vincristine adriamycin and dexamethasone|VAD|277|279|HISTORY OF PRESENT ILLNESS|His IgG level was 4593. He had an M-protein level of 4.7. His beta 2 microglobulin level was 4.78. His creatinine 1.5. A bone marrow biopsy revealed 12% plasma cells. Bone survey was unremarkable. He was diagnosed with IgG kappa myeloma. Mr. _%#NAME#%_ received four cycles of VAD chemotherapy ending _%#MM2003#%_. He had a very good response. He had resolution of bone pain after his first cycle. After his second cycle, his IgG dropped from 4593 to 256.
VAD|vincristine adriamycin and dexamethasone|VAD|190|192|HISTORY OF PRESENT ILLNESS|The patient was seen at Fairview-University Medical Center by Dr. _%#NAME#%_ on _%#MMDD2003#%_. He has recommended an autologous bone marrow transplant. Of note, the patient's last cycle of VAD ended in early _%#MM#%_. The patient has now been referred to the Radiation Oncology Department to determine if he is appropriate for total body irradiation prior to his bone marrow transplant.
VAD|vincristine adriamycin and dexamethasone|VAD.|240|243|HISTORY OF PRESENT ILLNESS|She then had radiation treatments at Methodist Hospital, she received 3000 cGy in 10 fractions to the right and left humeri. She was treated with thalidomide and dexamethasone. She developed a significant rash. Her treatment was changed to VAD. She received her first course in _%#MM2005#%_, she has received a total of two courses. In _%#MM2005#%_, Ms. _%#NAME#%_ was referred to the University of Minnesota Medical Center for consideration of autologous peripheral blood stem cell transplant.
VAD|ventricular assist device|VAD|199|201||I was asked by Dr. _%#NAME#%_ _%#NAME#%_ of Cardiac Surgery to see Mr. _%#NAME#%_ in consultation for a possible necrotic lung and intrapulmonary abscess. Mr. _%#NAME#%_ is a gentleman who underwent VAD implantation for heart failure and has done well, but has had persistent intermittent septicemia with enterobacter in the blood.
VAD|vincristine adriamycin and dexamethasone|VAD|153|155|ASSESSMENT/PLAN|However, her heart rate and blood pressure are stable. She is in an intermittent sinus tachycardia that is associated with agitation. She is getting her VAD at a fixed rate. From a respiratory standpoint, the patient is in respiratory failure requiring full ventilatory support.
VAD|vincristine adriamycin and dexamethasone|VAD|278|280|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a very pleasant 63-year-old white female with a history of diabetes for the past eight years, and diagnosed with multiple myeloma in _%#MM#%_ 2004, status post five previous chemotherapeutic regimens, who is currently being admitted to undergo VAD regimen for the next four days. The patient is going to be on Decadron, and we are being asked to assist with her diabetes management.
VAD|vincristine adriamycin and dexamethasone|VAD|209|211|ASSESSMENT|3. Humalog 75/25 insulin, 15 units q.a.m. and 5 units q. 6 p.m. 4. Multivitamin tablet daily. ALLERGIES: Amoxicillin, Rocephin. ASSESSMENT: The patient is a 63-year-old with multiple myeloma who is undergoing VAD chemotherapy, and we are being asked to manage her diabetes. PLAN: 1. Diabetes. We will discontinue the metformin, and add Lantus insulin 10 units q.h.s. We will decrease her a.m. dose of Humalog 75/25 insulin from 15 to 10 units, and decrease her p.m. dose of Humalog 75/25 insulin down to 2.5 units.
VAD|vincristine adriamycin and dexamethasone|VAD|182|184|PLAN|It is unclear what the patient's nutritional status is going to be, given this three to four day chemotherapy regimen. 2. Multiple myeloma. The patient is currently about to undergo VAD chemotherapy. 3. Right knee pain. The patient currently has x-rays pending of the right knee. We will have her evaluated for any degenerative changes versus possible bony involvement of her multiple myeloma.
VAD|vincristine adriamycin and dexamethasone|VAD|189|191|HISTORY OF PRESENT ILLNESS|The whole leg seems to hurt. She denies burning or tingling. She has severe pain with weight-bearing. She did not get any relief with high doses of Decadron she went through as part of the VAD regimen. X-rays were taken which I reviewed. There are sclerotic areas in the tibia on both sides, much more on the asymptomatic left side than the right side based on some bone series done on the _%#DD#%_ of _%#MM#%_ here at Fairview Southdale.
VAD|vincristine adriamycin and dexamethasone|(VAD)|173|177|REASON FOR CONSULTATION|Mrs. _%#NAME#%_ is a 63-year-old woman with a history of multiple myeloma for which she was simply started on salvage chemotherapy with vincristine, Adriamycin and Decadron (VAD) in _%#MM#%_ of this year. The patient fell and sustained a nondisplaced right femoral fracture for which she is currently being admitted.
VAD|vincristine adriamycin and dexamethasone|VAD|295|297|PAST MEDICAL HISTORY|She has since been treated with dexamethasone alone followed by thalidomide and dexamethasone combination and was recently switched to Velcade after progressive disease. After moving to the _%#CITY#%_ _%#CITY#%_ she established care with Dr. _%#NAME#%_ _%#NAME#%_ and received her first dose of VAD as above in _%#MM#%_ of 2005. 2. Anemia related to her multiple myeloma for which she is on both Procrit and blood transfusion support.
VAD|vincristine adriamycin and dexamethasone|VAD|114|116|IMPRESSION/PLAN|Once the fracture has healed she may take full radiation treatment. For her myeloma, she has received one dose of VAD and is due for the next dose in the next week or so and Dr. _%#NAME#%_ will be following up with her tomorrow to address that.
VAD|vincristine adriamycin and dexamethasone|VAD,|170|173|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 63-year-old woman with multiple myeloma known for several years. She is status post multiple chemotherapeutic regimens, most recently VAD, the last dose of which was 2-1/2 weeks ago approximately. She was admitted on _%#MMDD#%_ with a one day history of shortness of breath and was noted to have problems with blood pressure as well.
VAD|vincristine adriamycin and dexamethasone|VAD|161|163|HISTORY OF PRESENT ILLNESS|Multiple lytic lesions were noted on plain film and an IgA was found to be 2.7 grams. The patient also developed pancreatitis at diagnosis. She was treated with VAD with 4 cycles ending _%#MM2004#%_. Her bone pain resolved, as did her IgA to 0.3 grams. The patient is now being considered for tandem bone marrow transplants with autologous, followed by a second autologous transplant.
VAD|vincristine adriamycin and dexamethasone|VAD|143|145|LABS|I have also read the hematology evaluation for his low platelets. We will perform a bone marrow biopsy at a later date and move ahead with the VAD as planned for tomorrow. FACILITY TIME: I spent a total of 2 hours with the patient.
VAD|ventricular assist device|VAD|70|72||Mr. _%#NAME#%_ is a 60-year-old gentleman status post HeartMate XP L- VAD placed as a bridge to transplant, as well as aortic valve patch closure. He is hemodynamically stable. He feels well. He has not passed gas yet.
VAD|ventricular assist device|VAD|286|288|IMPRESSION|I think there is no question that given his young age and the family's wishing to move ahead, we should place Levitronix ventricular assist devices in him, and then evaluate his neurological status, renal function and determine whether he could be a transplant candidate or a permanent VAD candidate. We will proceed on an emergent basis immediately. Thank you for asking us to see this patient in consultation .
VAD|vincristine adriamycin and dexamethasone|VAD|155|157|HISTORY OF PRESENT ILLNESS|Her bone marrow biopsy revealed 95% plasma cells. Chest x-ray revealed a fifth rib involvement by plasma-cell tumor. Mrs. _%#NAME#%_ received one cycle of VAD chemotherapy. Followup bone marrow biopsy revealed 64% plasma cells. Her chemotherapy was changed to Cytoxan, etoposide and cisplatin. After one cycle, her bone marrow biopsy revealed 6% plasma cells.
VAD|vincristine adriamycin and dexamethasone|VAD|146|148|HISTORY OF PRESENT ILLNESS|Beta 2 microglobulin was normal. Bone survey revealed lytic lesions in femoral shafts and in a right rib. Mr. _%#NAME#%_ received three cycles of VAD chemotherapy which was very effective at reducing his M spike. He was referred to the Fairview-University Medical Center in _%#MM#%_ for consideration of bone marrow transplant.
VAD|vincristine adriamycin and dexamethasone|VAD|130|132|HISTORY OF PRESENT ILLNESS|At that time it was felt he was in need of additional chemotherapy. Since that time Mr. _%#NAME#%_ has received a fourth cycle of VAD chemotherapy. He also has experienced a clotting problem related to an implanted port, has experienced thrombi in his neck and in his arm.
VAD|vincristine adriamycin and dexamethasone|VAD|191|193|HISTORY OF PRESENT ILLNESS|Dr. _%#NAME#%_ recommended an autologous peripheral blood stem-cell transplant. The patient wanted to wait until after the Christmas holidays. Therefore Dr. _%#NAME#%_ recommended additional VAD chemotherapy. Since that time Mr. _%#NAME#%_ indicates he received one addition cycle of VAD chemotherapy in _%#MM#%_, 2002. He has never received radiation treatments. Mr. _%#NAME#%_ has no siblings.
VAD|vincristine adriamycin and dexamethasone|VAD|141|143|HISTORY OF PRESENT ILLNESS|Therefore Dr. _%#NAME#%_ recommended additional VAD chemotherapy. Since that time Mr. _%#NAME#%_ indicates he received one addition cycle of VAD chemotherapy in _%#MM#%_, 2002. He has never received radiation treatments. Mr. _%#NAME#%_ has no siblings. Mr. _%#NAME#%_ presents to our clinic today at the request of Dr. _%#NAME#%_ consideration of the autologous transplant, and to discuss radiation conditioning.
VAD|vincristine adriamycin and dexamethasone|VAD|215|217|HISTORY OF PRESENT ILLNESS|He was treated initially with thalidomide which was complicated by lower extremity thrombosis. In _%#MM#%_ 2005, he transferred his care to the University of Minnesota Medical Center. In _%#MM#%_, he was started on VAD chemotherapy since he had achieved maximum benefit from thalidomide and dexamethasone. He received a total of 3 cycles of VAD chemotherapy which was effective at reducing his urine protein level.
VAD|vincristine adriamycin and dexamethasone|VAD|157|159|HISTORY OF PRESENT ILLNESS|In _%#MM#%_, he was started on VAD chemotherapy since he had achieved maximum benefit from thalidomide and dexamethasone. He received a total of 3 cycles of VAD chemotherapy which was effective at reducing his urine protein level. Chemotherapy was complicated with gastrointestinal discomfort and peripheral neuropathy. He is now ready to proceed to an autologous peripheral blood stem cell transplant.
VAD|vincristine adriamycin and dexamethasone|VAD|165|167|REVIEW OF SYSTEMS|No oral lesions or dental problems. Respiratory: No shortness of breath or cough. Cardiovascular: No chest pain. Gastrointestinal: Had abdominal discomfort with his VAD chemotherapy, which has resolved. Vascular access none. Musculoskeletal: Reports no bony pain at this time. Has a history of left shoulder discomfort which he associates with sports that he was involved with in his youth.
VAD|vincristine adriamycin and dexamethasone|VAD|167|169|ASSESSMENT AND PLAN|Otherwise no areas of other abnormality or pain detected. ASSESSMENT AND PLAN: Ms. _%#NAME#%_ is a 60-year-old female with multiple myeloma status post four cycles of VAD chemotherapy who is now being considered for autologous stem-cell transplant per protocol _%#PROTOCOL#%_. This protocol includes Cytoxan x2 followed by 3 days of total body irradiation 165 cGy b.i.d. 6990 cGy.
VAD|vincristine adriamycin and dexamethasone|VAD|223|225|HISTORY OF PRESENT ILLNESS|Skeletal survey revealed compression fractures, osteopenia of left humerus and pelvis and small lucency of the skull. His calcium was 7.6, hemoglobin 10.9, he had a normal creatinine. Mr. _%#NAME#%_ received five cycles of VAD chemotherapy ending in _%#MM2003#%_. He was re-staged after his fourth cycle and M-spike decreased to 1.3. He had follow-up bone marrow biopsy in _%#CITY#%_, details not available.
VAD|vincristine adriamycin and dexamethasone|VAD|220|222|HISTORY OF PRESENT ILLNESS|Dr. _%#NAME#%_ felt that she had a fairly-good response to the treatment, and recommended an autologous peripheral blood stem-cell transplant, however, he felt she needed to have a repeat bone marrow biopsy and consider VAD chemotherapy if she had a significant percentage of plasma cells. Since that time, Mrs. _%#NAME#%_ has received no additional Decadron or other chemotherapy.
VAD|vincristine adriamycin and dexamethasone|VAD|244|246|METABOLIC AND HEMATOLOGIC|METABOLIC AND HEMATOLOGIC: The patient's hemoglobin is 11. His chem-7 shows a hyperkalemia with a potassium of 5.5, and we will continue to monitor that. If necessary, the patient will get Kayexalate. The patient is on appropriate prophylactic VAD antibiotics. I should comment that the patient does have an intraaortic balloon pump in place which will be discontinued today (within 24 hours after the VAD has been placed).
VAD|ventricular assist device|VAD|248|250|METABOLIC AND HEMATOLOGIC|If necessary, the patient will get Kayexalate. The patient is on appropriate prophylactic VAD antibiotics. I should comment that the patient does have an intraaortic balloon pump in place which will be discontinued today (within 24 hours after the VAD has been placed).
VAD|ventricular assist device|VAD|283|285|HISTORY OF PRESENT ILLNESS|I was asked by Dr. _%#NAME#%_ to see Mr. _%#NAME#%_ in consultation for the evaluation and treatment of a loculated right pleural effusion and an intraparenchymal fluid collection. Mr. _%#NAME#%_ is a 67-year-old male with a complex medical history who has recently undergone a left VAD placement and has had multiple pulmonary complications. He initially had a left hemothorax, which I evacuated and now has developed right pleural effusions, a large intraparenchymal air fluid collection, and respiratory failure.
VAD|vincristine adriamycin and dexamethasone|VAD|115|117|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ returned to Methodist Hospital where he received 3500 cGy to his left femur followed by 4 cycles of VAD chemotherapy. He is now ready to pursue an autologous peripheral blood stem cell transplant and he is here to discuss any need for additional radiation consolidation after engraftment.
VAD|vincristine adriamycin and dexamethasone|VAD|162|164|IMPRESSION|PATHOLOGY: UHH04-2237 (_%#MMDD2004#%_) very minimal evidence of multiple myeloma, less than 1% on aspirate. IMPRESSION: Multiple myeloma, status post 4 cycles of VAD chemotherapy and radiation consolidation to the left femur, now with a good partial response. PLAN: Mr. _%#NAME#%_ was seen by Dr. _%#NAME#%_ and seems to be a suitable candidate for an autologous peripheral blood stem cell transplant per our local protocol _%#PROTOCOL#%_.
VAD|vincristine adriamycin and dexamethasone|VAD|133|135|HPI|The patient has large left proximal Femoral lytic lesion which may need radiation sooner or later. The patient also was treated with VAD chemotherapy, along with the radiation treatment to the left femur. The patient is here to discuss additional consolidation radiation after bone marrow transplantation and engraftment.
VAD|vincristine adriamycin and dexamethasone|VAD|148|150|HPI|Exam: Physical examination was not done in detail since this is a reconsultation. Assessment and Plan: Multiple myeloma, status post four cycles of VAD chemotherapy and radiation to the left femur with a good palliation. The patient will be receiving peripheral stem cell transplantation under MT protocol _%#PROTOCOL#%_.
VAD|vincristine adriamycin and dexamethasone|VAD|166|168|HISTORY OF PRESENT ILLNESS|An MRI and bone survey showed a T11 compression fracture. Bone marrow biopsy was 30% plasma cells. IgA was elevated at 579. Beta 2 microglobulin was elevated at 2.2. VAD chemotherapy was started in _%#MM2004#%_, and the patient received two cycles, with no response. In _%#MM2004#%_, the patient received radiation therapy to the T-spine.
VAD|ventricular assist device|VAD,|145|148|ASSESSMENT AND PLAN|INR 1.74. Electrolytes within normal limits. Creatinine 0.8. ASSESSMENT AND PLAN: The patient is a 55-year-old female, status post Heart Mate II VAD, is doing well on the floor. We will increase her Coumadin to maintain a therapeutic INR between 2 to 3. We will also remove her chest tube that was used to drain a left pleural effusion.
VAD|ventricular assist device|VAD|130|132|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 75-year-old male. He has history of ischemic cardiomyopathy. He is status post L- VAD placement x 3. He has history of subarachnoid hemorrhage in 2001. He evidently did well and was able to live independently.
VAD|vincristine adriamycin and dexamethasone|VAD|159|161|HISTORY OF PRESENT ILLNESS|Workup eventually lead to the diagnosis of multiple myeloma. She was found to have 53% plasma cells in her bone marrow biopsy. Ms. _%#NAME#%_ was treated with VAD chemotherapy which was effective at dropping her bone marrow involvement to 3%. In _%#MM2001#%_, Ms. _%#NAME#%_ was referred to the Fairview-University Medical Center for a workup for an autologous peripheral blood stem cell transplant.
VAD|vincristine adriamycin and dexamethasone|VAD|188|190|HISTORY OF PRESENT ILLNESS|Mrs. _%#NAME#%_ was referred to Fairview-University Medical Center shortly after diagnosis where she saw Dr. _%#NAME#%_ _%#NAME#%_ to discuss treatment options. Dr. _%#NAME#%_ recommended VAD chemotherapy and, if a response, then an autologous peripheral blood stem-cell transplant. Since that consultation, Mrs. _%#NAME#%_ indicates that she received 6 cycles of VAD chemotherapy ending in _%#MM2001#%_ and, that her IgG level decreased to 2000.
VAD|vincristine adriamycin and dexamethasone|VAD|219|221|HISTORY|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 64-year-old white male admitted on _%#MM#%_ _%#DD#%_ after presenting with fever, cough and hypoxia to Dr. _%#NAME#%_'s office. He has a history of multiple myeloma, was treated with VAD and ultimately autologous stem cell transplant in _%#MM#%_ of this year. He is now considered to be in remission. As his chest x-ray was relatively clear, thought turned to the possibility of a pulmonary embolus.
VAD|vincristine adriamycin and dexamethasone|VAD|161|163|IMPRESSION|Some bloody secretions from the ET tube noted. Currently being followed by pulmonary medicine. 3. Underlying and known multiple myeloma, previously treated with VAD chemotherapy and subsequent autologous bone marrow transplant, thought to be in remission, currently being followed by oncology. 4. Elevated temperature. Certainly at risk for aspiration. Sputum culture sent.
VAD|vincristine adriamycin and dexamethasone|VAD|168|170|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ _%#NAME#%_ is a very pleasant 46-year-old individual with a diagnosis of Burkitt's non-Hodgkin's lymphoma involving the gastric region. He is on hyper-C VAD chemotherapy. I am asked to see the patient for dialysis of his current CNS status. In reviewing the patient's situation, it does not appear that he has had definite CNS symptoms with the exception, however, of headaches which have been intermittent over this last month or so.
VAD|vascular access device|VAD|201|203|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ received two cycles of VAD chemotherapy. His interferon was held during that therapy, unfortunately, the chest wall mass has begun to enlarge. The interferon was recently restarted. The VAD was complicated with pneumococcal pneumonia for which he has recovered. He has had a good response to the VAD per the patient's wife.
VAD|vincristine adriamycin and dexamethasone|VAD|153|155|HISTORY OF PRESENT ILLNESS|The interferon was recently restarted. The VAD was complicated with pneumococcal pneumonia for which he has recovered. He has had a good response to the VAD per the patient's wife. Apparently his protein levels were half of what they were in _%#MM#%_. Mr. _%#NAME#%_ returns to our clinic today accompanied by his wife at the request of Dr. _%#NAME#%_ _%#NAME#%_ for re-evaluation of the umbilical cord blood transplant and to discuss the role of radiation in his transplant process.
VAD|vincristine adriamycin and dexamethasone|VAD|141|143|PATHOLOGY|IMPRESSION: Patient with history of metastatic renal cell carcinoma and recent diagnosis of multiple myeloma. He has had partial response to VAD chemotherapy. RECOMMENDATIONS: Mr. _%#NAME#%_ was seen and examined by Dr. _%#NAME#%_ and appears to be a suitable candidate for total body irradiation prior to an umbilical cord blood transplant per our local protocol _%#PROTOCOL#%_.
VAD|ventricular assist device|VAD|158|160|HISTORY OF PRESENT ILLNESS|She also required fasciotomy for the right upper extremity for compartment syndrome. Currently, she needs dialysis for her renal insufficiency. She underwent VAD explant on _%#MMDD2006#%_ for her cardiac support and a skin graft for her right arm fasciotomy. Her hospital course has been significant for mental status changes, including confusion and agitation, and she has required the need of a sitter until today.
VAD|vincristine adriamycin and dexamethasone|VAD|211|213|HISTORY OF PRESENT ILLNESS|He was found at that time to have multiple myeloma, at which time he had anemia and 30% plasma cells in his bone marrow. He was initially treated with melphalan and prednisone, and then received three cycles of VAD chemotherapy, ending in mid _%#MM#%_, 2001. He underwent 1200 cGy total body irradiation between _%#MMDD2002#%_ and _%#MMDD2002#%_ prior to autologous bone marrow transplant.
VAD|ventricular assist device|(VAD)|269|273|IMPRESSION|The colon is not obstructed, since contrast material passes through into the left side of the colon without difficulty. The patient's laboratory tests are essentially unremarkable. IMPRESSION: Mr. _%#NAME#%_ is a 45-year-old male, status post ventricular assist device (VAD) and heart transplant with a symptomatic retrosternal diaphragmatic hernia. PLAN: We plan to take him to the operating room urgently, in view of his symptoms.
VAD|vincristine adriamycin and dexamethasone|VAD|222|224|DISCUSSION/RECOMMENDATIONS|I agree with radiation therapy and Aredia infusion. I will start him on high-dose Decadron to start some effect on myeloma cells and will hold off chemotherapy until a definitive diagnosis is made. He may benefit from the VAD regimen. A MUGA scan evaluation will be required for left ventricular ejection fraction. I appreciate the opportunity to participate in the care of _%#NAME#%_ _%#NAME#%_.
VAD|vincristine adriamycin and dexamethasone|VAD|219|221|HISTORY OF PRESENT ILLNESS|On _%#MMDD2003#%_, Ms. _%#NAME#%_ was referred to the Fairview-University Medical Center where she saw Dr. _%#NAME#%_ _%#NAME#%_ to discuss treatment options. Dr. _%#NAME#%_ recommended that she received four cycles of VAD chemotherapy followed by an autologous peripheral blood stem cell transplant. The possibility of an allogeneic transplant was discussed, however she has no sibling matches.
VAD|vincristine adriamycin and dexamethasone|VAD|179|181|HISTORY OF PRESENT ILLNESS|The possibility of an allogeneic transplant was discussed, however she has no sibling matches. Since that visit, Ms. _%#NAME#%_ has received what she indicates as three cycles of VAD chemotherapy and had a good response with regards to her protein spike which was 2.0 prior to the chemotherapy, and a decrease to 0.2 after the first cycle.
VAD|vincristine adriamycin and dexamethasone|VAD|138|140|HISTORY OF PRESENT ILLNESS|No protein spike was seen. The patient had mild proteinuria. He was diagnosed as nonsecreting myeloma. He was treated with four cycles of VAD which help relieve his pain. He was sent for possible radiation therapy to United Hospital but at that time, it was decided not to treat, as he was responding so well to his medication.
VAD|vincristine adriamycin and dexamethasone|VAD|198|200|HISTORY OF PRESENT ILLNESS|On _%#MMDD2003#%_, Ms. _%#NAME#%_ was referred to Dr. _%#NAME#%_ _%#NAME#%_ at the Fairview-University Medical Center for a discussion of treatment options. Dr. _%#NAME#%_ recommended 2-4 cycles of VAD chemotherapy followed by an autologous peripheral blood stem cell transplant and a sibling allogeneic mini transplant. Since her visit with Dr. _%#NAME#%_, Ms. _%#NAME#%_ indicates that she received 3 cycles of VAD chemotherapy ending approximately 6 weeks ago in early _%#MM#%_.
VAD|vincristine adriamycin and dexamethasone|VAD|256|258|HISTORY OF PRESENT ILLNESS|Dr. _%#NAME#%_ recommended 2-4 cycles of VAD chemotherapy followed by an autologous peripheral blood stem cell transplant and a sibling allogeneic mini transplant. Since her visit with Dr. _%#NAME#%_, Ms. _%#NAME#%_ indicates that she received 3 cycles of VAD chemotherapy ending approximately 6 weeks ago in early _%#MM#%_. The chemotherapy was tolerated well. Ms. _%#NAME#%_ presents to our clinic today to determine her eligibility for total body irradiation prior to the allogeneic transplant which will be performed after the autologous transplant.
VAD|vincristine adriamycin and dexamethasone|VAD|209|211|HISTORY OF PRESENT ILLNESS|Therefore, he had a very good response. Mr. _%#NAME#%_ was referred to the Fairview-University Medical Center on _%#MMDD2004#%_ where he saw Dr. _%#NAME#%_ _%#NAME#%_. Dr. _%#NAME#%_ recommended two cycles of VAD chemotherapy, followed by an autologous peripheral blood stem cell transplant. Since that visit, Mr. _%#NAME#%_ indicated that he received the two cycles of VAD chemotherapy complicated by fatigue and nausea.
VAD|vincristine adriamycin and dexamethasone|VAD|238|240|HISTORY OF PRESENT ILLNESS|Since that visit, Mr. _%#NAME#%_ indicated that he received the two cycles of VAD chemotherapy complicated by fatigue and nausea. He is undergoing a bone marrow transplant workup this week during which they will determine response to the VAD chemotherapy. He is now being considered for an autologous peripheral blood stem cell transplant and he was referred to our clinic to determine the need for radiation in the transplant process.
VAD|ventricular assist device|VAD.|154|157|REVIEW OF SYSTEMS|5. Levaquin. 6. Protonix. REVIEW OF SYSTEMS: Constitutional: Fatigue. Respiratory: He feels decreased shortness of breath. Cardiovascular: Status post L- VAD. GU: Resolving renal failure. GI: Resolving ileus. Endocrine, musculoskeletal and neurologic: None. ENT: None. Integument: None. PHYSICAL EXAMINATION: VITAL SIGNS: On examination, he is afebrile.
VAD|ventricular assist device|VAD.|70|73||Mr. _%#NAME#%_ is a 74-year-old gentleman status post HeartMate XV L- VAD. He is doing well. He is tolerating his current rehab therapy. He is also started a regular diet. MEDICATIONS: 1. Aspirin.
VAD|vincristine adriamycin and dexamethasone|VAD|187|189|HISTORY OF PRESENT ILLNESS|A bone marrow biopsy was not repeated. In _%#MM#%_ of 2003, Mr. _%#NAME#%_ was referred to the Fairview-University Medical Center to discuss treatment options. Dr. _%#NAME#%_ recommended VAD chemotherapy, followed by an autologous peripheral blood stem cell transplant if there was a response. Since that time, Mr. _%#NAME#%_ indicates that he received four cycles of VAD chemotherapy ending in _%#MM#%_ of 2003.
VAD|vincristine adriamycin and dexamethasone|VAD|208|210|HISTORY OF PRESENT ILLNESS|Dr. _%#NAME#%_ recommended VAD chemotherapy, followed by an autologous peripheral blood stem cell transplant if there was a response. Since that time, Mr. _%#NAME#%_ indicates that he received four cycles of VAD chemotherapy ending in _%#MM#%_ of 2003. He indicates that he has had no follow-up bone survey or MRI. Mr. _%#NAME#%_ is now being considered for an autologous peripheral blood stem cell transplant and is referred to our clinic by Dr. _%#NAME#%_ _%#NAME#%_ to determine whether he is a candidate for total body irradiation.
VAD|vincristine adriamycin and dexamethasone|VAD|166|168|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ was then treated with thalidomide and dexamethasone that was complicated with a deep vein thrombosis on the right. He then was switched to 4 cycles of VAD chemotherapy with response. He was ini8tially seen in our department in _%#MM#%_ of 2004 to determine his eligibility for 990 cGy total body irradiation prior to an autologous bone marrow transplant per protocol _%#PROTOCOL#%_.
VAD|vincristine adriamycin and dexamethasone|VAD|183|185|HISTORY OF PRESENT ILLNESS|In _%#MM2004#%_ Mrs. _%#NAME#%_ was referred to Dr. _%#NAME#%_ _%#NAME#%_ in the Bone Marrow Transplant Clinic to discuss treatment options. Dr. _%#NAME#%_ recommended two additional VAD chemotherapy cycles, followed by tandem transplant where she will undergo an autologous followed by an allogeneic non-myeloablative transplant.
VAD|ventricular assist device|VAD|255|257||This has led to a sense of needing to vomit and vomiting, and ungulates, but does occur with any type of eating. Radiographic evaluation here has shown that he has a left diaphragmatic hernia which is related to the previous hole in the diaphragm for the VAD procedure. I spent a total of 45 minutes in counseling and coordination and care reviewing his history and his radiographic evaluations.
VAD|ventricular assist device|VAD|140|142|PAST MEDICAL HISTORY|She has been recently found to have gram-negative bacteremia. PAST MEDICAL HISTORY: Significant for: 1. Postpartum cardiomyopathy requiring VAD placement. 2. Decubitus ulcer. 3. Multiple episodes of bacteremia and drug-resistant infections. SURGICAL HISTORY: 1. Patient had an LVAD placed in 2005.
VAD|ventricular assist device|VAD|222|224|ASSESSMENT AND PLAN|They understand and are willing to proceed with surgery. I also extensively discussed with the family the options of bridging to a permanent LVAD support, if necessary, and also the possibility of myocardial recovery with VAD explant following a certain period of ventricular-assist device support. I have also discussed with the family the possibility for withdrawing support if there is evidence of severe neurological injury or severe end- organ dysfunction.
VAD|vincristine adriamycin and dexamethasone|VAD|221|223|HISTORY OF PRESENT ILLNESS|At that time, he had radiation therapy to an L5-S1 lesion at CentraCare to a total dose of 4000 cGy in 20 fractions. This was completed in _%#MM1998#%_. The patient then had melphalan and prednisone. This was followed by VAD chemotherapy. Ultimately, the patient had an autologous peripheral blood stem cell transplant at Abbott-Northwestern Hospital. The patient had TBI to 200 cGy on _%#MMDD2002#%_. The patient was on thalidomide for approximately one year.
VAD|vincristine adriamycin and dexamethasone|VAD|251|253|HISTORY OF PRESENT ILLNESS|This was completed in _%#MM#%_, 1998. He had good relief from his pain and did well until _%#MM#%_, 1999 when a skeletal survey showed progression in his skull. He was treated with melphalan and prednisone for two months. His treatment was changed to VAD chemotherapy. In 1999 Mr. _%#NAME#%_ underwent an autologous peripheral blood stem-cell transplant at Abbott Northwestern Hospital. He believes that the preparative regime was chemotherapy only. Unfortunately, after the transplant, his monoclonal protein was still detected and eventually began to rise.
VAD|vincristine adriamycin and dexamethasone|VAD.|200|203|REQUESTING PHYSICIAN|The patient's history as I understand it includes the diagnosis of multiple myeloma some time ago. The patient has been on chemotherapy which has included vincristine. I believe his regimen is really VAD. Over the last number of weeks to perhaps months, the patient has had some ongoing difficulty with mild numbness at the ankles and distally bilaterally.
VAD|vincristine adriamycin and dexamethasone|VAD|153|155|PAST MEDICAL HISTORY|PAST MEDICAL HISTORY: Notable of course for his multiple myeloma. He has been evaluated for possible stem cell transplant and is to continue on with his VAD chemotherapy if possible, although I believe the vincristine is planned to be ________ at this time. Otherwise the patient has GI reflux and compression fractures secondary to his multiple myeloma.
VAD|vincristine adriamycin and dexamethasone|VAD|125|127|HISTORY OF PRESENT ILLNESS|Bone marrow biopsy show aggregates of plasma cells. LDH was twice normal and IgG was 1.7 gm/dl. The patient was treated with VAD for four cycles with good response and the IgG decreased to 0.4 gm/dl. Chemotherapy was complicated with some fatigue and possible leg weakness and edema, as well as hyperglycemia.
VAD|vincristine adriamycin and dexamethasone|VAD|175|177|HISTORY OF PRESENT ILLNESS|The patient had increased beta 2 microglobulin. A bone survey revealed diffuse lytic lesions throughout, especially the skull and pelvis. The patient received three cycles of VAD with immediate relief of the pain in the left hip and the leg area, however she continued to have right groin pain, as well as right leg pain which required a fentanyl patch of 25 mcg with some break-through pain medication.
VAD|ventricular assist device|VAD|230|232|PHYSICAL EXAM|He has no thyromegaly. LUNGS: He has mildly diminished breath sounds on the left and otherwise clear auscultation. HEART: Heart sounds are faint. The ventricular assist device is heard. ABDOMEN: Soft, nontender, nondistended. His VAD drive line is bandaged. EXTREMITIES: He has 2+ bilateral lower extremity edema. NEUROLOGIC: The patient is intact without any focal deficits.
VAD|vincristine adriamycin and dexamethasone|VAD|153|155|HISTORY OF PRESENT ILLNESS|She had questionable liver involvement, a liver biopsy though revealed minimal lobular inflammation. By history, Mrs. _%#NAME#%_ received four cycles of VAD chemotherapy. She had significant peripheral neuropathy after her first cycle and by her report, she received no Vincristine for the additional cycles.
VAD|ventricular assist device|VAD.|226|229|ASSESSMENT AND PLAN|Over the last 24-hours her pressor requirements have slightly improved and she is currently only on 0.2 of epinephrine however if her pressor requirements worsen and her hemodynamics worsen one last resort is to place a right VAD. I have discussed this plan of option with Dr _%#NAME#%_ _%#NAME#%_ who is in agreement with this. I have spent a total of 1 hour with the patient which included reviewing investigations, examined the patient and 20 minutes just spent on coordination of care and discussion with the heart failure service.
VAD|ventricular assist device|VAD|309|311|ASSESSMENT AND PLAN|We plan to continue with Bumex today. 3. Neurological: The patient remains intubated and sedated and at least for the next 24 hours we do not plan to assess his neurological function. 4. Hepatic: His liver enzymes are resolving, which is suggestive of hepatic recovery. 5. Hematological: Because of excellent VAD flows, we will hold heparin for another 24 hours. We will check ACT and if it is less than 160, we will start him on low dose heparin.
VAD|vincristine adriamycin and dexamethasone|VAD;|138|141|SUMMARY|This is a relatively young woman (49) who was found to have multiple myeloma six years ago. She was initially treated with four cycles of VAD; she later was treated with the "M2" protocol; she reports having received for more than a year pulsed melphalan and prednisone; she had a period of therapy with pulsed dexamethasone.
VAD|vincristine adriamycin and dexamethasone|VAD|145|147|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ indicates that the radiation treatment significantly improved his arm pain. Mr. _%#NAME#%_ then went on to receive four cycles of VAD chemotherapy ending in _%#MM#%_, 2002 and this was effective at reducing his urinary protein level and the percentage of plasma cells in his bone marrow biopsy.
VAD|vincristine adriamycin and dexamethasone|VAD|166|168|DOB|Recent medications have included lisinopril 20 mg a day, hydrochlorothiazide, nifedipine 60 mg, and Lipitor 10 mg a day. He has received four course of chemotherapy, VAD therapy. The last was on the _%#DD#%_ of _%#MM#%_. SOCIAL HISTORY: The patient is married, lives with his wife.
VAD|vincristine adriamycin and dexamethasone|VAD|167|169|PAST MEDICAL HISTORY|That was likely performed prior to planned chemotherapy. PAST MEDICAL HISTORY: 1. Multiple myeloma diagnosed four months ago. The patient has undergone four cycles of VAD therapy. 2. Hypertension. 3. History of rotator cuff surgery. 4. History of two ankle fractures. 5. Hyperglycemia/diabetes mellitus. REVIEW OF SYSTEMS: The patient denies prior chest discomfort.
VAD|vincristine adriamycin and dexamethasone|VAD|192|194|HISTORY OF PRESENT ILLNESS|He was evaluated here for an autotransplant in _%#MM2003#%_, but was found to have transformed to a plasma cell leukemia; therefore, the transplant was delayed and since then, he has received VAD x2, and it is unclear if he has responded yet. This will be determined this week with marrows and scans. His sister is an HLA- match. In the interval since we last saw him, there are no new medical problems.
VAD|vincristine adriamycin and dexamethasone|VAD|214|216|HISTORY OF PRESENT ILLNESS|A bone marrow biopsy was 5% plasma cells (lambda light chain), a normal beta-2 microglobulin, normal hemoglobin, normal creatinine and no bony lesions. She was staged at IA. Mrs. _%#NAME#%_ received four cycles of VAD chemotherapy ending in _%#MM#%_, 2002. Her IgA level dropped to 1200. A bone marrow biopsy plasma-cell concentration decreased to 2%.
VAD|vincristine adriamycin and dexamethasone|VAD|130|132|HISTORY OF PRESENT ILLNESS|A bone marrow biopsy revealed 50% plasma cells. Mrs. _%#NAME#%_ underwent a vertebroplasty of L5 and then received four cycles of VAD chemotherapy, ending in _%#MM#%_ 2003. She has also received monthly Zometa. Chemotherapy was complicated with nausea and vomiting. Creatinine has returned to normal. By patient report, there has not been a followup bone marrow biopsy or urine protein evaluation until this week, while she is undergoing a bone marrow transplant workup.
VAD|vincristine adriamycin and dexamethasone|VAD|137|139|IMPRESSION|1. UHH 03-285: 2-4% atypical plasma cells. 2. Outside Materials: Status unknown. IMPRESSION: Multiple myeloma status post four cycles of VAD chemotherapy, currently undergoing evaluation of response to chemotherapy. RECOMMENDATIONS: Mrs. _%#NAME#%_ was seen and examined by Dr. _%#NAME#%_ _%#NAME#%_ and appears to be a potential candidate for total body irradiation (TBI) prior to an autologous peripheral blood stem-cell transplant per our local protocol _%#PROTOCOL#%_.
VAD|vincristine adriamycin and dexamethasone|VAD|133|135|HISTORY OF PRESENT ILLNESS|He was treated with the M2 protocol and had a good partial response. His disease progressed in 2000. He was treated with 4 cycles of VAD chemotherapy. Mr. _%#NAME#%_ then underwent an autologous peripheral blood stem cell transplant in 2001 at the University of Wisconsin _%#CITY#%_ with a chemotherapy only preparative regimen.
VAD|vincristine adriamycin and dexamethasone|VAD|140|142|HISTORY OF PRESENT ILLNESS|His IgA M spike was 4.2 He had normal renal function. Bone survey revealed no lytic lesions. Mr. _%#NAME#%_ was treated with four cycles of VAD chemotherapy with minimal response. He was treated then with EDAP chemotherapy for two cycles with minimal response. He was then treated with Velcade with a partial response per the patient.
VAD|vincristine adriamycin and dexamethasone|VAD|162|164|HISTORY OF PRESENT ILLNESS|Apparently a decision was made to pursue an allogeneic transplant, since the benefit of an autologous transplant would be impacted by his minimal response to the VAD and EDAP chemotherapy. He requires a cord blood transplant because he has no matched siblings. Mr. _%#NAME#%_ presents to our clinic today at the request of Dr. _%#NAME#%_ _%#NAME#%_ to determine his eligibility for 200 cGy total body irradiation prior to transplant.
VAD|vincristine adriamycin and dexamethasone|VAD|340|342|HISTORY OF PRESENT ILLNESS|He underwent protein electrophoresis showing 6.67 gram of IgG kappa monoclonal antibody with a beta G microglobulin with 7.58. A bone marrow biopsy was performed which revealed 75% plasma cells that showed kappa light chain. Chromosomal study showed 13 few minus T. The patient was treated with narcotics for pain and underwent 2 cycles of VAD with pain improvement. He was sent to Dr. _%#NAME#%_ _%#NAME#%_ for evaluation for possible bone marrow transplant. He has now been sent to the Radiation Oncology Department for evaluation of possible "Miniprep" total body irradiation for allo- autotransplant #2003-11.
VAD|ventricular assist device|VAD|195|197|PHYSICAL EXAMINATION|PHYSICAL EXAMINATION: GENERAL: 70-year-old woman who is unconscious (sedated) on a ventilator in the ICU. VITAL SIGNS: Blood pressure 114/40 with vasopressin, norepinephrine, epinephrine and the VAD device. HEENT: There is no obvious scleral icterus. Pupils are 3 mm and slow to react. NECK: No obvious JVD, difficult to assess. LUNGS: Few rhonchi bilaterally.
VAD|ventricular assist device|VAD|187|189|PHYSICAL EXAMINATION|HEENT: There is no obvious scleral icterus. Pupils are 3 mm and slow to react. NECK: No obvious JVD, difficult to assess. LUNGS: Few rhonchi bilaterally. HEART: Distant tones, mechanical VAD clicks. ABDOMEN: Large subxiphoid chest tube is present. Bowel sounds are absent. EXTREMITIES: Cool. Doppler pulses have been present for nursing.
VAD|vincristine adriamycin and dexamethasone|VAD|143|145|HISTORY OF PRESENT ILLNESS|She was found to have hemoglobin of 6.6 and an elevated M-spike. Bone marrow biopsy revealed 20% plasma cells. Ms. _%#NAME#%_ was treated with VAD chemotherapy. She received 4 cycles and had an improved M spike. In _%#MM1999#%_ Ms. _%#NAME#%_ underwent an autologous peripheral blood stem cell transplant at the University of Minnesota Medical Center, Fairview.
VAD|vincristine adriamycin and dexamethasone|VAD|234|236|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ was referred to the Fairview-University Medical Center shortly after diagnosis, where he saw Dr. _%#NAME#%_ _%#NAME#%_ to discuss treatment options. Dr. _%#NAME#%_ recommended that Mr. _%#NAME#%_ receive four cycles of VAD chemotherapy followed by an allogeneic peripheral blood stem-cell transplant with a myeloablative conditioning regimen because he was of standard risk and of young age.
VAD|UNSURED SENSE|VAD.|118|121|HISTORY OF PRESENT ILLNESS|The steroid dose of the third cycle was reduced because of the surgery. Mr. _%#NAME#%_ has had a good response to the VAD. His urine protein and beta 2 microglobulin have normalized and his bone marrow biopsy in _%#MM#%_, 2002 showed no evidence of residual myeloma.
VAD|vincristine adriamycin and dexamethasone|VAD|178|180|HISTORY OF PRESENT ILLNESS|He had an increase in his paraprotein to approximately 4 grams. He was anemic. He had normal creatinine and calcium. His pain required narcotics. Mr. _%#NAME#%_ was treated with VAD chemotherapy. He received four cycles, ending in _%#MM2003#%_. After two cycles, he was referred to the Fairview-University Medical Center where he saw Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2002#%_.
VAD|vincristine adriamycin and dexamethasone|VAD,|189|192|HISTORY OF PRESENT ILLNESS|After two cycles, he was referred to the Fairview-University Medical Center where he saw Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2002#%_. Dr. _%#NAME#%_ agreed with the plan for the additional VAD, followed by an allogeneic peripheral blood stem-cell transplant with a non-myeloablative conditioning regimen. As mentioned, the chemotherapy ended in _%#MM#%_. He was able to stop taking the narcotics for the pain control, therefore, his pain was resolved.
VAD|vincristine adriamycin and dexamethasone|VAD|107|109|HISTORY OF PRESENT ILLNESS|The IgG was greater than 4 grams at that time. He had anemia, but no urine paraprotein at the time. He had VAD x4 cycles beginning in _%#MM#%_ of 2002, last in _%#MM#%_ of 2003. He was getting monthly Zometa. In _%#MM#%_ 2003 with his last cycle of VAD he developed pneumochysis cornea pneumonia which was diagnosed on bronchial lavage.
VAD|vincristine adriamycin and dexamethasone|VAD|149|151|HISTORY OF PRESENT ILLNESS|He had VAD x4 cycles beginning in _%#MM#%_ of 2002, last in _%#MM#%_ of 2003. He was getting monthly Zometa. In _%#MM#%_ 2003 with his last cycle of VAD he developed pneumochysis cornea pneumonia which was diagnosed on bronchial lavage. He had Bactrim which caused nausea and vomiting. He was switched to atovaquone.
VAD|ventricular assist device|VAD|247|249|ASSESSMENT/PLAN|One could argue that the chance of HIT is great enough that a period of anticoagulation with fonduparinux (pentasaccaride) would be reasonable; one might even consider doing that solely on the basis of the past history of thrombosis with previous VAD devices. I do not think we have the evidence in hand that would say such anticoagulation is mandatory, however, so I leave that decision to the physicians directly caring for him.
VAD|vincristine adriamycin and dexamethasone|VAD|226|228|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ was referred to the Fairview- University Medical Center on _%#MMDD2003#%_ to discuss treatment options with Dr. _%#NAME#%_ _%#NAME#%_ in the Bone Marrow Transplant Clinic. Dr. _%#NAME#%_ recommended 4 cycles of VAD chemotherapy, followed by an autologous peripheral blood stem cell transplant. Since that time, Mr. _%#NAME#%_ has received 3 cycles of doxorubicin, vincristine and Decadron.
VAD|vincristine adriamycin and dexamethasone|VAD|276|278|HISTORY OF PRESENT ILLNESS|Ms. _%#NAME#%_ is a 76-year-old Caucasian female with a history of myeloma diagnosed in the spring of 2003, after presenting with hyperviscosity syndrome with a Kappa fraction, who required plasmapheresis and treatment for hypercalcemia. Since then, the patient has undergone VAD chemotherapy with complications including ruptured colonic diverticulum. Since late 2003, the patient has been on and off of melphalan and prednisone for bone pain, and hyper IgG.
VAD|ventricular assist device|VAD|118|120|ASSESSMENT/PLAN|She underwent immediate intubation in preparation for OR. ASSESSMENT/PLAN: 61-year-old woman status post HeartMate L- VAD now with hemothorax following a left thoracentesis with continued hemodynamic instability. We plan urgent thoracotomy and exploration. I will ask for an intraoperative evaluation/consultation from the Thoracic Surgery Service by Dr. _%#NAME#%_.
VAD|vincristine adriamycin and dexamethasone|VAD|190|192|HISTORY OF PRESENT ILLNESS|She has proteinuria and was 3.6 at diagnosis. She also had a compression fracture of T12 at diagnosis. LDH was elevated and renal function was normal. Mrs. _%#NAME#%_ received two cycles of VAD chemotherapy and was then referred to the Fairview-University Medical Center in _%#MM#%_, 2002 and she saw Dr. _%#NAME#%_ _%#NAME#%_. She was found to have good response to the two cycles with urine protein drop from 3.6 to 2.3. He recommended two additional cycles of VAD chemotherapy followed by autologous peripheral-blood stem-cell transplant.
VAD|vincristine adriamycin and dexamethasone|VAD|135|137|HISTORY OF PRESENT ILLNESS|She was found to have good response to the two cycles with urine protein drop from 3.6 to 2.3. He recommended two additional cycles of VAD chemotherapy followed by autologous peripheral-blood stem-cell transplant. Since that time, Mrs. _%#NAME#%_ indicates that she received one cycle of VAD chemotherapy in _%#MM#%_ and was unable to receive the fourth cycle in _%#MM#%_ because of her general health status.
VAD|vincristine adriamycin and dexamethasone|VAD|400|402|HISTORY OF PRESENT ILLNESS|He was found to have a lytic lesion in the right femoral neck, and on _%#MMDD2004#%_ went to the Operating Room for a biopsy and internal fixation. The pathology of this biopsy showed plasmacytoma. His bone marrow biopsy showed 30- 40% involvement by plasma cella, with a monoclonal spike of 5.5 grams, a calcium of 9.1 and a hemoglobin of 13.1 with a creatinine of 1.4. The patient was treated with VAD times 3 and this was complicated by severe constipation, however, the monoclonal spike decreased. The patient's hip pain improved with surgery, chemotherapy and narcotics, but it is still present.
VAD|vincristine adriamycin and dexamethasone|VAD|261|263|MEDICATIONS|His BUN is 80. Calcium is about 8.5. Phosphorus is approximately 8.5. The patient is anemic, as was the case before, with hemoglobin of 9.5, but with normal white blood cell count and essentially normal differential. The patient has been initiated again on the VAD chemotherapeutic protocol. He has been on half-normal saline IV fluid therapy. He has been requiring some nasal cannula oxygen for optimal oxygen saturation and has been receiving his other therapies for both hypertension and also obstructive lung disease as before.
VAD|vincristine adriamycin and dexamethasone|VAD|215|217||He was hospitalized _%#MM#%_ _%#DD#%_ to _%#MM#%_ _%#DD#%_ for a course of chemotherapy and hyperglycemia on Decadron. Blood gases showed a pH of 7.33, PCO2 of 53, PO2 of 72 on _%#MMDD2002#%_. He was readmitted for VAD chemotherapy on _%#MMDD2002#%_, but he had noted increasing weight gain of 4 kg, BUN and creatinine and worsening breathing. Dialysis has been started today. He had pulmonary infiltrates. Since last summer, the patient has had progressive worsening of his breathing throughout the fall.
VAD|ventricular assist device|VAD|312|314|HISTORY OF PRESENT ILLNESS|His troponins were noted to be 2.1 and his creatinine was 3.3. He had a stent placement done for his right coronary artery 100% stenosis, then he had a temporary pacemaker for bradycardia and was transferred to the University of Minnesota Medical Center, Fairview, on _%#MMDD#%_ in critical care. He had a right VAD placed on _%#MMDD#%_ and on _%#MMDD2007#%_ he had explantation of VAD. While in the hospital, he had hemoptysis and that was worked up.
VAD|ventricular assist device|VAD.|381|384|HISTORY OF PRESENT ILLNESS|His troponins were noted to be 2.1 and his creatinine was 3.3. He had a stent placement done for his right coronary artery 100% stenosis, then he had a temporary pacemaker for bradycardia and was transferred to the University of Minnesota Medical Center, Fairview, on _%#MMDD#%_ in critical care. He had a right VAD placed on _%#MMDD#%_ and on _%#MMDD2007#%_he had explantation of VAD. While in the hospital, he had hemoptysis and that was worked up. He also developed gangrene of the toes, left side more than right due to questionable embolic phenomena.
VAD|vincristine adriamycin and dexamethasone|VAD|173|175|HISTORY OF PRESENT ILLNESS|He was found to have extensive bone marrow involvement by plasma cell myeloma (68%). His IgA was elevated at 4120. He had hypercalcemia. Mr. _%#NAME#%_ received 4 cycles of VAD chemotherapy which brought his bone marrow involvement down to 33%. He had some relief from his back pain, although this may have been related to the narcotics.
VAD|ventricular assist device|VAD|157|159|ASSESSMENT/PLAN|We will also begin the patient on a heparin drip today as a low-intensity protocol without any heparin bolus. We will continue with the rehab program and L- VAD teaching for both him and his wife.
VAD|ventricular assist device|VAD|152|154||His PA pressures have improved significantly from a mean PA of 55 mmHg intraoperatively to the mid 20 mmHg now. His metabolic profile has improved. the VAD flows are stable. A/P: 1. S/p cardiac arrest 2. S/p CPR, multiple DC defibrillations 3. S/p 5 vessel CABG 4. S/p ECMO and IABP placement
VAD|ventricular assist device|VAD|144|146||His BP is stable and has required NTG for better control. His metabolic profile has improved, and his CK levels are considerably decreased. The VAD flows are stable. Per nursing report, he appears to follow commands. This morning he is sedated with Propofol. A/P: 1. S/p cardiac arrest
VAD|ventricular assist device|VAD|133|135||His BP is stable with a MAP arounf 65-68 mmHg. His metabolic profile has improved, and his CK levels are considerably decreased. The VAD flows are stable. He follows commands. He continues to be sedated with Propofol. He requires minimal ventilatory support. He is V-paced at a rate of 79 bpm with a large QRS complex.
VAD|ventricular assist device|VAD|366|368|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ is a 35-year-old Caucasian female with a difficult story of severe congestive heart failure status of undetermined etiology, question postpartum versus post mitral valve repair with biventricular failure who was transferred to the University of Minnesota Medical Center, Fairview, on _%#MMDD2007#%_ where she underwent BI VAD placement. This was complicated by respiratory failure presumably due to the congestive heart failure with chronic vent dependence, now status post tracheostomy.
VAD|ventricular assist device|VAD|146|148|PAST MEDICAL HISTORY|16. Octreotide infusion. 17. Isordil. 18. ........ 19. Lexapro. 20. Bumex. 21. Bacitracin ointment. 22. TPN. PAST MEDICAL HISTORY: 1. CHF with BI VAD as outlined in HPI. 2. History of SVT. 3. History of severe mitral regurgitation, status post mitral valve repair.
VAD|ventricular assist device|VAD|154|156|PHYSICAL EXAM|She is quite debilitated. HEAD AND NECK: No scleral icterus noted. LUNGS: Crackles bilaterally. HEART: Tachycardia. ABDOMEN: The patient does have the BI VAD through the abdomen. It is soft with the presence of BI VAD. EXTREMITIES: There is some 1-2+ lower extremity edema.
VAD|ventricular assist device|VAD.|177|180|ASSESSMENT AND PLAN|It is soft with the presence of BI VAD. EXTREMITIES: There is some 1-2+ lower extremity edema. LABORATORY DATA: Reviewed as per VCIS. ASSESSMENT AND PLAN: 1. Severe CHF with VI VAD. 2. History of severe upper GI bleeding secondary to diffuse upper GI ischemia. 3. Ongoing blood loss of undetermined source. 4. Acute renal failure, improving.
VAD|UNSURED SENSE|VAD.|226|229|REVIEW OF SYSTEMS|11. Ambien. 12. Darbepoetin. SOCIAL HISTORY: She is married. She has family who have been with her throughout this hospitalization in spite of living quite a distance away. REVIEW OF SYSTEMS: She feels fatigued. She is on the VAD. She is able to eat some food now, though has most of her food going through an NG tube. The rest of the 10-point review of systems was negative.
VAD|ventricular assist device|VAD.|177|180|PHYSICAL EXAMINATION|There is no bleeding from his nose, lips. There is obvious blood in his chest tube and Foley catheter. No bleeding from IV sites. LUNGS: Clear. CARDIAC: Mechanical sound of the VAD. EXTREMITIES: There is no discoloration, whiteness, or tenderness of the fingers or toes. No sign of any ischemic skin anywhere. LABORATORY DATA: White count 4700, platelets 76,000, hemoglobin 9.5, hematocrit 27.1, INR 1.46, PTT 67.
VAD|ventricular assist device|VAD.|178|181|HOSPITAL COURSE|2. Ischemic Cardiomyopathy: The patient has a severely decreased ejection fraction based on recent echo performed in _%#CITY#%_ _%#CITY#%_. He was transferred for evaluation for VAD. At this time, his chest pain symptoms seem to be improved and controlled with beta-blocker and ACE inhibitor therapy, as well as oxygen and transfusion to correct his anemia.
VAD|ventricular assist device|VAD|331|333|HOSPITAL COURSE|He was transferred for evaluation for VAD. At this time, his chest pain symptoms seem to be improved and controlled with beta-blocker and ACE inhibitor therapy, as well as oxygen and transfusion to correct his anemia. The patient's BMP on admission was 315, and he remained well compensated throughout his hospital course. Initial VAD evaluation was initiated. Further VAD workup will depend on his overall prognosis given his history of Pancoast tumor. The thoracic surgery service was consulted on this patient. The patient's oncologic records will also be faxed from _%#CITY#%_ _%#CITY#%_ to evaluate for his prognosis.
VAD|ventricular assist device|VAD|151|153|HOSPITAL COURSE|The patient's BMP on admission was 315, and he remained well compensated throughout his hospital course. Initial VAD evaluation was initiated. Further VAD workup will depend on his overall prognosis given his history of Pancoast tumor. The thoracic surgery service was consulted on this patient. The patient's oncologic records will also be faxed from _%#CITY#%_ _%#CITY#%_ to evaluate for his prognosis.
VAD|ventricular assist device|VAD|159|161|HOSPITAL COURSE|However, will need input from the patient's primary oncologist and the oncologic records to be reviewed by the thoracic surgery consult service before further VAD recommendations can be made at this time. The patient was continued on his oral CHF regimen, including aspirin, carvedilol, Lasix, digoxin, and lisinopril.
VAD|ventricular assist device|VAD|212|214|HOSPITAL COURSE|However, the patient will follow up with Dr. _%#NAME#%_ at a previously scheduled clinic appointment in next 2 to 3 weeks. The patient will need evaluation of his prognosis as it relates to his malignancy before VAD placement would be considered in the future. 5. Hyperlipidemia: The patient had a lipid panel on admission. Total cholesterol was 157, LDL was 100, HDL was 37.
VAD|ventricular assist device|VAD|168|170|FOLLOWUP APPOINTMENTS|2. Followup with Dr. _%#NAME#%_ within the next 4 weeks at a previously scheduled appointment. After review of the patient's oncologic record, further evaluation for a VAD placement will be made by Dr. _%#NAME#%_ _%#NAME#%_ of University of Minnesota Medical Center, Fair view, cardiology. 3. Followup with Dr. _%#NAME#%_, the patient's primary oncologist, at his next scheduled appointment.
VAD|vincristine adriamycin and dexamethasone|VAD,|185|188|BMT HISTORY|The patient was subsequently diagnosed with IgA multiple myeloma with poor risk factors which included an increased beta II microglobulin at the time of diagnosis. The patient received VAD, but had progressive disease by his IgA monoclonal proteins. The patient had 36% plasma cells prior to VAD. No bone marrow was documented post-VAD.
VAD|vincristine adriamycin and dexamethasone|VAD.|128|131|BMT HISTORY|The patient received VAD, but had progressive disease by his IgA monoclonal proteins. The patient had 36% plasma cells prior to VAD. No bone marrow was documented post-VAD. The patient then was treated with thalidomide and dexamethazone. The patient is currently undergoing an auto-peripheral blood stem cell transplant for multiple myeloma.
VAD|vincristine adriamycin and dexamethasone|VAD|234|236|HISTORY OF PRESENT ILLNESS|13. Cytoxan _%#MM#%_ _%#DD#%_, 2005. 14. TLC consult. 15. Placement of PICC line with removal prior to discharge. HISTORY OF PRESENT ILLNESS: A 49-year-old male diagnosed with multiple myeloma in 2003 and was treated with 3 months of VAD chemotherapy followed by nonmyeloablative allo-sib peripheral stem- cell transplant in _%#MM#%_ 2003 complicated by GVHD, particularly of the liver requiring chronic steroid use.
VAD|vincristine adriamycin and dexamethasone|VAD|186|188|BRIEF HISTORY OF PRESENT ILLNESS|10. Hematuria. 11. Constipation. 12. Deconditioning. 13. Nausea. BRIEF HISTORY OF PRESENT ILLNESS: A 49-year-old male with multiple myeloma diagnosed in 2001, status post four cycles of VAD and PVI followed by a stem cell transplant in _%#MM#%_ 2002. Relapse in _%#MM#%_ 2004. Received Velcade in _%#MM#%_ 2005 through _%#MM#%_ 2005, stopped _%#MM#%_ _%#DD#%_, 2005, because of acute on chronic renal failure (got 3/4 planned doses) as well as 2000 cGy in 10 fractions to the T10 through T12 spine.
VAD|vincristine adriamycin and dexamethasone|VAD|129|131|IMPRESSION|I also reviewed with her different treatment options for myeloma. These options include the use of melphalan and prednisone, the VAD regimen or alternatively using a thalidomide-based regimen. I also mentioned to her the agent Revimid (CC5013) which is still an investigational agent but sh e may be eligible for trials evaluating this agent.
VAD|vincristine adriamycin and dexamethasone|VAD|179|181|PLAN|A CT scan revealed a large mediastinal mass, without evidence of disease below the diaphragm. Bone marrow pathology was negative at that time. The patient received four cycles of VAD chemotherapy, followed by mediastinal radiation through _%#MM1996#%_. The patient did well for a year, and then re-presented with right axillary node enlargement.
VAD|vincristine adriamycin and dexamethasone|VAD|283|285|HISTORY OF PRESENT ILLNESS|Bone marrow biopsy revealed 50% of plasma cells. At the time of presentation, the patient presented with normal hemoglobin, normal creatinine, and hypercalcemia with calcium of greater than 10. The patient underwent radiation to spine in _%#MM#%_ of 2001. The patient also underwent VAD therapy for 4 cycles with good result with decrease in proteinuria. The patient has been on high- dose dexamethasone as part of the treatment throughout the treatment period.
VAD|vincristine adriamycin and dexamethasone|VAD|151|153|HISTORY OF PRESENT ILLNESS|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 50-year-old female with history of multiple myeloma diagnosed in _%#MM2002#%_. She had minimal response to VAD chemotherapy followed by 2-3 cycles of high-dose Cytoxan with a complete remission. She had an autologous stem cell transplant in _%#MM2003#%_. Her transplant course was complicated by hemorrhagic cystitis.
VAD|vincristine adriamycin and dexamethasone|VAD|143|145|MEDICAL HISTORY|She again underwent chemotherapy at Children's Hospital with Dr. _%#NAME#%_. The patient's second relapse in _%#MM#%_ of 2004 was treated with VAD and intrathecal methotrexate. After the patient was in complete remission, she underwent autologous peripheral blood stem cell transplant with VP16/TBI prep.
VAD|vincristine adriamycin and dexamethasone|VAD|156|158|HISTORY OF PRESENT ILLNESS|In _%#MM2003#%_ her M-spike was down to 0.48, however, she developed chest symptoms and was found to have a tissue plasmacytoma in the pleura. She received VAD x 4 cycles, and this was complicated by DVT and PE. In _%#MM2003#%_ a CT revealed a 7 cm pelvic mass. She underwent surgery to remove the mass and an oophorectomy was also done.
VAD|ventricular assist device|VAD|138|140|HOSPITAL COURSE|Cardiac Function: We performed serial ECHO studies and found no significant changes of bothe LV and RV function. The LVEF is about 2o% on VAD support. A coronary artery angiogram was performed which showed patent coronary artery. Hematology: _%#NAME#%_ had a history of HIT. She also has a PRA of over 90%.
VAD|ventricular assist device|VAD|167|169|FEN/GI|We have ordered for her to wear her right wrist brace at night and Orthotics has made a device for her right foot. As far as wound care, daily dressing changes to her VAD drive line per protocol and for her right lower extremity, apply Xeroform, Adaptic over the top of her right foot, use Telfa between toes and saline cream at the toes when dry, wrap the foot in Kerlix and then add two 4 x 4s underneath her foot daily for dressing changes.
VAD|ventricular assist device|VAD|158|160|DISCHARGE INSTRUCTIONS|She will follow a regular diet with snacks between meals. She can weight bear as tolerated without restrictions. Activity level as tolerated with assist with VAD belt. Please keep saturations above 93% and use nasal cannula oxygen as needed. For her chest, please perform daily dressing changes to VAD drive line per protocol and then for her right lower extremity, please apply Xeroform, Adaptic over top of right foot, use Telfa between toes and saline cream to toes when dry, wrap the right foot with Kerlix and then two 4 x 4s under the foot every day.
VAD|ventricular assist device|VAD|130|132|DISCHARGE INSTRUCTIONS|Please keep saturations above 93% and use nasal cannula oxygen as needed. For her chest, please perform daily dressing changes to VAD drive line per protocol and then for her right lower extremity, please apply Xeroform, Adaptic over top of right foot, use Telfa between toes and saline cream to toes when dry, wrap the right foot with Kerlix and then two 4 x 4s under the foot every day.
VAD|vincristine adriamycin and dexamethasone|VAD|243|245|HISTORY OF PRESENT ILLNESS|4. Renal insufficiency. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 50-year-old female with a diagnosis of multiple myeloma. She was diagnosed in _%#MM2002#%_ when she presented with left rib and shoulder pain. She was treated with VAD for 4 cycles with minimal response. This VAD was followed by high dose Cytoxan which resulted in complete remission.
VAD|vincristine adriamycin and dexamethasone|VAD|201|203|FELLOW|8. Graft-versus-host disease of the skin. 9. Gout attack. BRIEF HISTORY: The patient is a 62-year-old male with history of multiple myeloma diagnosed in _%#MM#%_ 2001, heavily treated in the past with VAD and also status post auto transplant. He did relapse in 2003 and received dexamethasone and thalidomide. Again relapsed in 2005 and received a course of Velcade which had to be discontinued due to peripheral neuropathy.
VAD|vincristine adriamycin and dexamethasone|VAD|265|267|HISTORY OF PRESENT ILLNESS|Labs at that time included total IgA of 2.02 g and beta microglobulin of 3.3. Her bone marrow at diagnosis showed 20 to 30% plasma cells with complex stereotyping. She had loss of chromosome #4, 8, 10, 13, 15 and .... ........ .........?? At that time she received VAD therapy with a side effect of lower extremity neuropathy. The patient then had delay in treatment because of insurance issues, and was found to have progressed.
VAD|vincristine adriamycin and dexamethasone|VAD|156|158|HISTORY OF PRESENT ILLNESS|A bone marrow biopsy that was performed revealed 50% plasma cells, and a diagnosis of myeloma was made. She proceeded to receive chemotherapy with 4 cycles VAD which was completely in _%#MM#%_ of 2003. She began her chemotherapy priming in early _%#MM#%_, and she was admitted on _%#MM#%_ _%#DD#%_, 2003, for autologous peripheral stem cell transplantation.
VAD|vincristine adriamycin and dexamethasone|VAD|151|153|HISTORY OF PRESENT ILLNESS|Unfortunately, she had developed chest symptoms in the fall of 2003 and was found to have a soft tissue plasmacytoma in her pleura. She was started on VAD chemotherapy in _%#MM2003#%_ and received 4 cycles ending in early _%#MM#%_. This was complicated by a deep vein thrombosis and pulmonary embolism.
VAD|vincristine adriamycin and dexamethasone|VAD|262|264|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ was treated with pulsed Dexamethasone which was effective at reducing his creatinine to 1.3. In _%#MM2004#%_, Mr. _%#NAME#%_ was referred to the Fairview-University Medical Center where he saw Dr. _%#NAME#%_ _%#NAME#%_. Dr. _%#NAME#%_ recommended VAD chemotherapy, followed by an autologous peripheral blood stem cell transplant. Since his visit with Dr. _%#NAME#%_, Mr. _%#NAME#%_ has received additional Decadron.
VAD|vincristine adriamycin and dexamethasone|VAD|127|129|HPI|The patient was treated with post Dexamethasone and his creatinine came down to 1.3 in _%#MM2004#%_. The patient also received VAD chemotherapy, by an autologous peripheral blood stem cell transplant. The patient is here for evaluation of possible consolidation radiation if there is any need.
VAD|vincristine adriamycin and dexamethasone|VAD|234|236|HISTORY OF PRESENT ILLNESS|She became anuric after her code and she had some respiratory failure, was intubated, and is currently on the ventilator. Prior to her code, she had been discussing with her cardiologist, Dr. _%#NAME#%_, whether or not she would want VAD as she was not a transplant candidate. PAST MEDICAL HISTORY: 1. Familial dilated cardiomyopathy with an ejection fraction of 10-1% and inotrope-dependent.
VAD|vincristine adriamycin and dexamethasone|VAD|172|174|HISTORY OF PRESENT ILLNESS|A bone survey was normal. Bone marrow biopsy revealed 35% involvement by plasma cell myeloma. She was found to have chromosome 13 deletion. Ms. _%#NAME#%_ was treated with VAD chemotherapy. She developed polyneuropathy from the vincristine. She received 3 additional cycles within the vincristine. Her bone marrow involvement from the plasma cell myeloma dropped, as well as her IgA.
VAD|vincristine adriamycin and dexamethasone|VAD|215|217|HPI|At that time, she presented with fatigue and fever of undetermined origin with a low hemoglobin and markedly elevated IgA with 2020. The patient had 35% plasma cells in the bone marrow. The patient was treated with VAD chemotherapy and stopped due to polyneuropathy from the Vincristine. In _%#MM2004#%_, the patient decided to have tandem autologous allogeneic transplant using her sister as a donor.
VAD|vincristine adriamycin and dexamethasone|VAD|171|173|HISTORY OF PRESENT ILLNESS|He was referred to Fairview-University Medical Center in _%#MM2002#%_ where he saw Dr. _%#NAME#%_ _%#NAME#%_. Dr. _%#NAME#%_ recommended systemic chemotherapy, preferably VAD chemotherapy, followed by an autologous peripheral blood stem cell transplant. Since that time, Mr. _%#NAME#%_ indicates that he started chemotherapy in _%#MM#%_.
VAD|vincristine adriamycin and dexamethasone|VAD|144|146|HISTORY OF PRESENT ILLNESS|Since that time, Mr. _%#NAME#%_ indicates that he started chemotherapy in _%#MM#%_. He received Dexamethasone only, followed by three cycles of VAD which was completed two weeks ago. Per Mr. _%#NAME#%_'s report, his IgA went up to an all-time-high of 3300 before starting the chemotherapy, decreased to 2500 after the Dexamethasone and has actually fluctuated up and down since starting the VAD with the most recent result on the outside evaluation being 2200.
VAD|vincristine adriamycin and dexamethasone|VAD|141|143|HISTORY OF PRESENT ILLNESS|She indicates this treatment has been effective at reducing her protein spike. There had been discussion in the fall about treating her with VAD chemotherapy. The decision was made to treat her with dexamethasone alone, since she was having some response, and because she had a planned autologous bone marrow transplant.
VAD|vincristine adriamycin and dexamethasone|VAD|174|176|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ indicates that the radiation was tolerated well. He had minimal skin breakdown and had a significant reduction in the pain. Mr. _%#NAME#%_ was also started on VAD chemotherapy during the radiation and monthly Zometa. He received a total of 3 cycles of VAD chemotherapy, ending in _%#MM#%_. After the second cycle his IgG level dropped to 1.8; therefore, he had a good partial response.
VAD|vincristine adriamycin and dexamethasone|VAD|128|130|HISTORY OF PRESENT ILLNESS|Mr. _%#NAME#%_ was also started on VAD chemotherapy during the radiation and monthly Zometa. He received a total of 3 cycles of VAD chemotherapy, ending in _%#MM#%_. After the second cycle his IgG level dropped to 1.8; therefore, he had a good partial response.
VAD|vincristine adriamycin and dexamethasone|VAD|179|181|HPI|He had radiation to the right humerus and then had internal fixation of the humerus and continued his radiation and received a total of 3600 cGy to that area. He was treated with VAD chemotherapy with good partial response. Chemotherapy, however, was complicated due to right lower extremity deep venous thrombosis and upper-respiratory infection.
VAD|vincristine adriamycin and dexamethasone|VAD|178|180|HISTORY OF PRESENT ILLNESS|In _%#MM#%_ he was referred to the Fairview-University Medical Center where he saw Dr. _%#NAME#%_ _%#NAME#%_ to discuss treatment options. Dr. _%#NAME#%_ recommended 4 cycles of VAD chemotherapy followed by an autologous peripheral blood stem cell transplant if there was response from the chemotherapy. Since that time, Mr. _%#NAME#%_ has received the 4 cycles VAD chemotherapy ending in _%#MM#%_.
VAD|vincristine adriamycin and dexamethasone|VAD|223|225|HISTORY OF PRESENT ILLNESS|Dr. _%#NAME#%_ recommended 4 cycles of VAD chemotherapy followed by an autologous peripheral blood stem cell transplant if there was response from the chemotherapy. Since that time, Mr. _%#NAME#%_ has received the 4 cycles VAD chemotherapy ending in _%#MM#%_. Response was noted by decrease in urinary protein, decrease in percentage plasma cells in his bone marrow biopsy, and a reduction in the size of his sternal mass.
VAD|vincristine adriamycin and dexamethasone|VAD|171|173|HISTORY OF PRESENT ILLNESS|In _%#MM#%_ 2005, Ms. _%#NAME#%_ was referred to the University of Minnesota Medical Center, Fairview, where she saw Dr. _%#NAME#%_ _%#NAME#%_ who recommended 2 cycles of VAD chemotherapy followed by tandem transplants. She has 5 siblings who are not HLA compatible. Therefore, she will be receiving tandem autologous transplants.
VAD|vincristine adriamycin and dexamethasone|VAD|203|205|HISTORY OF PRESENT ILLNESS|She has 5 siblings who are not HLA compatible. Therefore, she will be receiving tandem autologous transplants. Since her visit with Dr. _%#NAME#%_, Ms. _%#NAME#%_ indicates that she received 2 cycles of VAD chemotherapy ending in _%#MM#%_ 2006, and she had a good response. She was told that her urinary protein decreased to a range of 2000 after a peak of 5000 early in symptoms.
VAD|vincristine adriamycin and dexamethasone|VAD.|132|135|REVIEW OF SYSTEMS|No dental problems. She does indicate the presence of lesions on the roof of her mouth which developed after her mucositis from her VAD. Breasts: Recent mammogram revealed a cyst which was resected and the left breast was found to be benign. Respiratory: She has had a cough for the past several months associated with a sinus infection in _%#MM#%_.
VAD|vincristine adriamycin and dexamethasone|VAD|232|234|HISTORY OF PRESENT ILLNESS|This was diagnosed in _%#MM2000#%_. At the time of diagnosis, she had anemia, thrombocytopenia, and leukocytosis. Bone marrow biopsy was positive for IgG kappa subtype plasma cell leukemia. She underwent chemotherapy initially with VAD for four cycles, with a response in her bone marrow biopsy according to previous notes. Subsequently, she was referred to our Department for consideration of total body irradiation as part of conditioning for bone marrow transplant.
VAD|vincristine adriamycin and dexamethasone|VAD|268|270|HISTORY OF PRESENT ILLNESS|Bone marrow biopsy was reported as 15% plasma cells, beta 2 microglobulin was markedly increased at 13.1 with normal, less than 2.0. Creatinine was 3.4, bone survey revealed lesions in the left clavicle, right iliac crest ad skull. Ms. _%#NAME#%_ received 3 cycles of VAD chemotherapy and had a good partial response. Creatinine normalized. Bone marrow involvement decreased. Chemotherapy ended in _%#MM2004#%_ and was complicated with recurrent pneumonia, most recently hospitalized 3 weeks ago with pneumonia.
VAD|vincristine adriamycin and dexamethasone|VAD.|139|142|PAST MEDICAL HISTORY|1. Multiple myeloma, undergoing chemotherapy. He was evaluated for Dr. _%#NAME#%_ for stem cell transplant who recommended fourth cycle of VAD. 2. History of compression fracture due to myeloma. 3. History of gastroesophageal reflux disease, on H2 blocker. ALLERGIES: None. SOCIAL HISTORY: Does not smoke cigarettes, drinks alcohol rarely.
VAD|vincristine adriamycin and dexamethasone|VAD,|172|175|IMPRESSION|He has been receiving weekly Procrit injections. Serum creatinine is 2.2, down from 3.5 at the start of chemotherapy. IMPRESSION: Multiple myeloma status post one cycle of VAD, which was well tolerated. The patient has experienced an improvement in his hemoglobin which may be partially a result of the Procrit injections but could also represent an early response to chemotherapy.
VAD|vincristine adriamycin and dexamethasone|VAD|250|252|HISTORY OF PRESENT ILLNESS|Within a month, he developed recurrent hip pain. A spinal MRI revealed an L4 disk protrusion, degenerative disk disease, and areas of low signal intensity with marrow infiltration. Bone marrow biopsy revealed 2.8% plasma cells. He initially received VAD x 2 cycles, resulting in reduction of his IgG to 654 and monoclonal protein to 0.7. The second cycle of VAD was complicated by pneumonia, and subsequent cycles were delayed.
VAD|vincristine adriamycin and dexamethasone|VAD|181|183|HISTORY OF PRESENT ILLNESS|He had a serum protein electrophoresis with a protein of 10.3. Bone survey was negative. Bone biopsy was 50% infiltrated plasma cells. He was given VBMCP x 1 and Zometa followed by VAD x 5. He had chemotherapy priming on _%#MMDD2003#%_ with Cytoxan, mitoxantrone, and dexamethasone. PAST MEDICAL HISTORY: 1. Childhood asthma, resolved. 2. Sleep apnea with CPAP.
VAD|vincristine adriamycin and dexamethasone|VAD|60|62|PROCEDURES|DISCHARGE DIAGNOSES: Multiple myeloma. PROCEDURES: Infusion VAD chemotherapy. Specifically, that included vincristine 0.4 mg/m2, for an individual dose of 0.5 mg/day as a continuous IV infusion over 96 hours for a total dose of 2 mg. Also included was Adriamycin 10 mg/m squared for an individual dose of 20 mg/day by continuous IV infusion over 96 hours for a total cycle dose of 80 mg.